Efficacy of tenofovir and efavirenz in combination with lamivudine or emtricitabine in antiretroviral-naive patients in Europe.

BACKGROUND: The combination of tenofovir and efavirenz with either lamivudine or emtricitabine (TELE) has proved to be highly effective in clinical trials for first-line treatment of HIV-1 infection. However, limited data are available on its efficacy in routine clinical practice. METHODS: A multicentre cohort study was performed in therapy-naive patients initiating ART with TELE before July 2009. Efficacy was studied using ITT (missing or switch = failure) and on-treatment (OT) analyses. Genotypic susceptibility scores (GSSs) were determined using the Stanford HIVdb algorithm. RESULTS: Efficacy analysis of 1608 patients showed virological suppression to <50 copies/mL at 48 weeks in 91.5% (OT) and 70.6% (ITT). Almost a quarter of all patients (22.9%) had discontinued TELE at week 48, mainly due to CNS toxicity. Virological failure within 48 weeks was rarely observed (3.3%, n = 53). In multilevel, multivariate analysis, infection with subtype B (P = 0.011), baseline CD4 count <200 cells/mm³ (P < 0.001), GSS <3 (P = 0.002) and use of lamivudine (P < 0.001) were associated with a higher risk of virological failure. After exclusion of patients using co-formulated compounds, virological failure was still more often observed with lamivudine. Following virological failure, three-quarters of patients switched to a PI-based regimen with GSS <3. After 1 year of second-line therapy, viral load was suppressed to <50 copies/mL in 73.5% (OT). CONCLUSIONS: In clinical practice, treatment failure on TELE regimens is relatively frequent due to toxicity. Virological failure is rare and more often observed with lamivudine than with emtricitabine. Following virological failure on TELE, PI-based second-line therapy was often successful despite GSS <3.

Effect and behaviour of different substrates in relation to the formation of aerobic granular sludge.

When aerobic granular sludge is applied for industrial wastewater treatment, different soluble substrates can be present. For stable granular sludge formation on volatile fatty acids (e.g. acetate), production of storage polymers under anaerobic feeding conditions has been shown to be important. This prevents direct aerobic growth on readily available chemical oxygen demand (COD), which is thought to result in unstable granule formation. Here, we investigate the impact of acetate, methanol, butanol, propanol, propionaldehyde, and valeraldehyde on granular sludge formation at 35 °C. Methanogenic archaea, growing on methanol, were present in the aerobic granular sludge system. Methanol was completely converted to methane and carbon dioxide by the methanogenic archaeum Methanomethylovorans uponensis during the 1-h anaerobic feeding period, despite the relative high dissolved oxygen concentration (3.5 mg O2 L(-1)) during the subsequent 2-h aeration period. Propionaldehyde and valeraldehyde were fully disproportionated anaerobically into their corresponding carboxylic acids and alcohols. The organic acids produced were converted to storage polymers, while the alcohols (produced and from influent) were absorbed onto the granular sludge matrix and converted aerobically. Our observations show that easy biodegradable substrates not converted anaerobically into storage polymers could lead to unstable granular sludge formation. However, when the easy biodegradable COD is absorbed in the granules and/or when the substrate is converted by relatively slow growing bacteria in the aerobic period, stable granulation can occur.

Evaluating the main and side effects of high salinity on aerobic granular sludge.

Salinity can adversely affect the performance of most biological processes involved in wastewater treatment. The effect of salt on the main conversion processes in an aerobic granular sludge (AGS) process accomplishing simultaneous organic matter, nitrogen, and phosphate removal was evaluated in this work. Hereto, an AGS sequencing batch reactor was subjected to different salt concentrations (0.2 to 20 g Cl(-) l(-1)). Granular structure was stable throughout the whole experimental period, although granule size decreased and a significant effluent turbidity was observed at the highest salinity tested. A weaker gel structure at higher salt concentrations was hypothesised to be the cause of such turbidity. Ammonium oxidation was not affected at any of the salt concentrations applied. However, nitrite oxidation was severely affected, especially at 20 g Cl(-) l(-1), in which a complete inhibition was observed. Consequently, high nitrite accumulation occurred. Phosphate removal was also found to be inhibited at the highest salt concentration tested. Complementary experiments have shown that a cascade inhibition effect took place: first, the deterioration of nitrite oxidation resulted in high nitrite concentrations and this in turn resulted in a detrimental effect to polyphosphate-accumulating organisms. By preventing the occurrence of the nitrification process and therefore avoiding the nitrite accumulation, the effect of salt concentrations on the bio-P removal process was shown to be negligible up to 13 g Cl(-) l(-1). Salt concentrations equal to 20 g Cl(-) l(-1) or higher in absence of nitrite also significantly reduced phosphate removal efficiency in the system.

Does EU legislation allow the use of the Benchmark Dose (BMD) approach for risk assessment?

Hazard characterisation is largely based on an approach of (statistically) comparing dose groups with the controls in order to derive points of departure such as no-observed-adverse-effect levels (NOAELs) or lowest-observed-adverse-effect levels (LOAELs). This approach suggests the absence of any relevant effect at the NOAEL. The NOAEL approach has been debated for decades. A recent Scientific Opinion by the European Food Safety Authority (EFSA) concluded that the Benchmark Dose (BMD) approach should be preferred over the NOAEL approach for deriving human (health-based) limit or guidance values. Nonetheless, the BMD approach is used infrequently within European regulatory frameworks. The reason for this may lie in legislation or guidelines requiring the use of the NOAEL approach. In this context, various EU regulatory frameworks were examined on such demands. Interestingly, no single legislation was identified containing statutory requirements in conflict with the use of the BMD approach.

Impact of the anaerobic feeding mode on substrate distribution in aerobic granular sludge.

There is a growing interest to implement aerobic granular sludge (AGS) in existing conventional activated sludge (CAS) systems with a continuous flow-through configuration. The mode of anaerobic contact of raw sewage with the sludge is an important aspect in the adaptation of CAS systems to accommodate AGS. It remains unclear how the distribution of substrate over the sludge by a conventional anaerobic selector compares to the distribution via bottom-feeding applied in sequencing batch reactors (SBRs). This study investigated the effect of the anaerobic contact mode on the substrate (and storage) distribution by operating two lab-scale SBRs; one with the traditional bottom-feeding through a settled sludge bed similar to full-scale AGS systems, and one where the synthetic wastewater was fed as a pulse at the start of the anaerobic phase while the reactor was mixed through sparging of nitrogen gas (mimicking a plug-flow anaerobic selector in continuous flow-through systems). The distribution of the substrate over the sludge particle population was quantified via PHA analysis, combined with the obtained granule size distribution. Bottom-feeding was found to primarily direct substrate towards the large granular size classes (i.e. large volume and close to the bottom), while completely mixed pulse-feeding gives a more equal distribution of substrate over all granule sizes (i.e. surface area dependant). The anaerobic contact mode directly controls the substrate distribution over the different granule sizes, irrespective of the solids retention time of a granule as an entity. Preferential feeding of the larger granules will enhance and stabilise the granulation compared to pulse-feeding, certainly under less advantageous conditions imposed by real sewage.

Aetiology of acute gastroenteritis in adults requiring hospitalization in The Netherlands.

SUMMARY Infectious gastroenteritis causes a considerable burden of disease worldwide. Effective control should be targeted at diseases with the highest burden and costs. Therefore, an accurate understanding of the relative importance of the different microorganisms is needed. The objective of this study was to determine the incidence and aetiology of gastroenteritis in adults requiring hospital admission in The Netherlands. Five hospitals enrolled patients admitted with gastroenteritis for about 1 year during the period May 2008 to November 2009. Participants completed questionnaires and provided a faecal sample. The hospital completed a clinical questionnaire. In total, 44 adults hospitalized for gastroenteritis were included in the study. The cases had serious symptoms, with 31% subsequently developing kidney failure. One or more pathogens were found in 59% of cases. Overall, rotavirus (22%) was the most common infection. Co-infections were observed relatively often (22%). This study emphasizes that rotavirus can also cause serious illness in adults.

Effect of elevated salt concentrations on the aerobic granular sludge process: linking microbial activity with microbial community structure.

The long- and short-term effects of salt on biological nitrogen and phosphorus removal processes were studied in an aerobic granular sludge reactor. The microbial community structure was investigated by PCR-denaturing gradient gel electrophoresis (DGGE) on 16S rRNA and amoA genes. PCR products obtained from genomic DNA and from rRNA after reverse transcription were compared to determine the presence of bacteria as well as the metabolically active fraction of bacteria. Fluorescence in situ hybridization (FISH) was used to validate the PCR-based results and to quantify the dominant bacterial populations. The results demonstrated that ammonium removal efficiency was not affected by salt concentrations up to 33 g/liter NaCl. Conversely, a high accumulation of nitrite was observed above 22 g/liter NaCl, which coincided with the disappearance of Nitrospira sp. Phosphorus removal was severely affected by gradual salt increase. No P release or uptake was observed at steady-state operation at 33 g/liter NaCl, exactly when the polyphosphate-accumulating organisms (PAOs), "Candidatus Accumulibacter phosphatis" bacteria, were no longer detected by PCR-DGGE or FISH. Batch experiments confirmed that P removal still could occur at 30 g/liter NaCl, but the long exposure of the biomass to this salinity level was detrimental for PAOs, which were outcompeted by glycogen-accumulating organisms (GAOs) in the bioreactor. GAOs became the dominant microorganisms at increasing salt concentrations, especially at 33 g/liter NaCl. In the comparative analysis of the diversity (DNA-derived pattern) and the activity (cDNA-derived pattern) of the microbial population, the highly metabolically active microorganisms were observed to be those related to ammonia (Nitrosomonas sp.) and phosphate removal ("Candidatus Accumulibacter").

Impact of aerobic availability of readily biodegradable COD on morphological stability of aerobic granular sludge.

Operational disturbances in aerobic granular sludge (AGS) systems can result in aerobic availability of readily biodegradable COD (rbCOD). Different from activated sludge, morphological consequences on the short and long term are not well described in literature. This study investigated the effect of incomplete anaerobic uptake of acetate on the morphological and process stability of AGS using a lab-scale reactor. A fraction of the total acetate load was dosed aerobically, which was increased stepwise while monitoring granular morphology. A good granular morphology and an SVI of 40 ml/g were obtained during initial enrichment and maintained for ≤20% aerobic acetate load dosed at 4 mg COD/g VSS/h. Biological phosphorus removal efficiency was initially unaffected, but the aerobic acetate dosage rate did decrease the aerobic phosphate uptake rate. This led to loss of phosphorus removal for >20% aerobic acetate load dosed at 8 mg COD/g VSS/h over the course of 12 days. Subsequently, significant outgrowth formed on the granular surfaces and developed over time into finger-like structures. Under these high aerobic acetate loads the SVI increased to 80 ml/g and resulted in significant biomass washout due to deteriorating settling properties of the sludge. The sludge settleability and biological phosphorus removal recovered 10 days after aerobic feeding of acetate was stopped. Aerobic presence of rbCOD can be tolerated if mostly anaerobic acetate uptake is maintained, thereby ensuring stable granular morphology and good settleability. The high enrichment of phosphate accumulating organisms in the granular sludge through bottom-feeding and selective wasting of flocs makes aerobic granular sludge resilient to morphological deterioration in aerobic presence of rbCOD.

Evaluation of certain food additives and contaminants.

This report represents the conclusions of a Joint FAO/WHO Expert Committee convened to evaluate the safety of various food additives, including flavouring agents, with a view to recommending acceptable daily intakes (ADIs) and to preparing specifications for identity and purity. The Committee also evaluated the risk posed by two food contaminants, with the aim of advising on risk management options for the purpose of public health protection. The first part of the report contains a general discussion of the principles governing the toxicological evaluation and assessment of intake of food additives (in particular flavouring agents) and contaminants. A summary follows of the Committee's evaluations of technical, toxicological and intake data for certain food additives (acidified sodium chlorite, asparaginase from Aspergillus oryzae expressed in Aspergillus oryzae, carrageenan and processed Eucheuma seaweed, cyclotetraglucose and cyclotetraglucose syrup, isoamylase from Pseudomonas amyloderamosa, magnesium sulfate, phospholipase A1 from Fusarium venenatum expressed in Aspergillus oryzae, sodium iron(III) ethylenediaminetetraacetic acid (EDTA) and steviol glycosides); eight groups of related flavouring agents (linear and branched-chain aliphatic, unsaturated, unconjugated alcohols, aldehydes, acids and related esters; aliphatic acyclic and alicyclic terpenoid tertiary alcohols and structurally related substances; simple aliphatic and aromatic sulfides and thiols; aliphatic acyclic dials, trials and related substances; aliphatic acetals; sulfur-containing heterocyclic compounds; aliphatic and aromatic amines and amides; and aliphatic alicyclic linear alpha, beta -unsaturated di- and trienals and related alcohols, acids and esters); and two food contaminants (aflatoxin and ochratoxin A). Specifications for the following food additives were revised: maltol and ethyl maltol, nisin preparation, pectins, polyvinyl alcohol, and sucrose esters of fatty acids. Specifications for the following flavouring agents were revised: maltol and ethyl maltol, maltyl isobutyrate, 3-acetyl-2,5-dimethylfuran and 2,4,5-trimethyl-delta-oxazoline (Nos 1482, 1506 and 1559), and monomenthyl glutarate (No. 1414), as well as the method of assay for the sodium salts of certain flavouring agents. Annexed to the report are tables summarizing the Committee's recommendations for intakes and toxicological evaluations of the food additives and contaminants considered.

The acid soluble extracellular polymeric substance of aerobic granular sludge dominated by Defluviicoccus sp.

A new acid soluble extracellular polymeric substance (acid soluble EPS) was extracted from an acetate fed aerobic granular sludge reactor operated at 35 °C. Acid soluble EPS dominated granules exhibited a remarkable and distinctive tangled tubular morphology. These granules are dominated by Defluviicoccus Cluster II organisms. Acetic acid instead of the usually required alkaline extraction medium was needed to dissolve the granules and solubilise the polymeric matrix. The extracted acid soluble EPS was analysed and identified using various instrumental analysis including 1H and 13C Nuclear Magnetic Resonance, Fourier Transform Infrared Spectroscopy and Raman spectroscopy. In addition, the glycoconjugates were characterized by fluorescence lectin-binding analysis. The acid soluble EPS is α-(1 â†’ 4) linked polysaccharide, containing both glucose and galactose as monomers. There are OCH3 groups connected to the glucose monomer. Transmission and scanning electron microscopy (TEM, SEM) as well as confocal laser scanning microscopy (CLSM) showed that the acid soluble EPS was present as a tightly bound capsular EPS around bacterial cells ordered into a sarcinae-like growth pattern. The special granule morphology is decided by the acid soluble EPS produced by Defluviicoccus Cluster II organisms. This work shows that no single one method can be used to extract all possible extracellular polymeric substances. Results obtained here can support the elucidation of biofilm formation and structure in future research.

Formation of aerobic granules and conversion processes in an aerobic granular sludge reactor at moderate and low temperatures.

Temperature changes can influence biological processes considerably. To investigate the effect of temperature changes on the conversion processes and the stability of aerobic granular sludge, an aerobic granular sludge sequencing batch reactor (GSBR) was exposed to short-term and long-term temperature changes. Start-up at 8 degrees C resulted in irregular granules that aggregated as soon as aeration was stopped, which caused severe biomass washout and instable operation. The presence of COD during the aerobic phase is considered to be the major reason for this granule instability. Start-up at 20 degrees C and lowering the temperature to 15 degrees C and 8 degrees C did not have any effect on granule stability and biomass could be easily retained in the system. The temperature dependency of nitrification was lower for aerobic granules than usually found for activated sludge. Due to decreased activity in the outer layers of granules at lower temperatures, the oxygen penetration depth could increase, which resulted in a larger aerobic biomass volume, compensating the decreased activity of individual organisms. Consequently the denitrifying capacity of the granules decreased at reduced temperatures, resulting in an overall poorer nitrogen removal capacity. The overall conclusion that can be drawn from the experiments at low temperatures is that start-up in practice should take place preferentially during warm summer periods, while decreased temperatures during winter periods should not be a problem for granule stability and COD and phosphate removal in a granular sludge system. Nitrogen removal efficiencies should be optimized by changes in reactor operation or cycle time during this season.

Effect of sludge age on methanogenic and glycogen accumulating organisms in an aerobic granular sludge process fed with methanol and acetate.

The influence of sludge age on granular sludge formation and microbial population dynamics in a methanol- and acetate-fed aerobic granular sludge system operated at 35°C was investigated. During anaerobic feeding of the reactor, methanol was initially converted to methane by methylotrophic methanogens. These methanogens were able to withstand the relatively long aeration periods. Lowering the anaerobic solid retention time (SRT) from 17 to 8 days enabled selective removal of the methanogens and prevented unwanted methane formation. In absence of methanogens, methanol was converted aerobically, while granule formation remained stable. At high SRT values (51 days), γ-Proteobacteria were responsible for acetate removal through anaerobic uptake and subsequent aerobic growth on storage polymers formed [so called metabolism of glycogen-accumulating organisms (GAO)]. When lowering the SRT (24 days), Defluviicoccus-related organisms (cluster II) belonging to the α-Proteobacteria outcompeted acetate consuming γ-Proteobacteria at 35°C. DNA from the Defluviicoccus-related organisms in cluster II was not extracted by the standard DNA extraction method but with liquid nitrogen, which showed to be more effective. Remarkably, the two GAO types of organisms grew separately in two clearly different types of granules. This work further highlights the potential of aerobic granular sludge systems to effectively influence the microbial communities through sludge age control in order to optimize the wastewater treatment processes.

Full scale performance of the aerobic granular sludge process for sewage treatment.

Recently, aerobic granular sludge technology has been scaled-up and implemented for industrial and municipal wastewater treatment under the trade name Nereda(®). With full-scale references for industrial treatment application since 2006 and domestic sewage since 2009 only limited operating data have been presented in scientific literature so far. In this study performance, granulation and design considerations of an aerobic granular sludge plant on domestic wastewater at the WWTP Garmerwolde, the Netherlands were analysed. After a start-up period of approximately 5 months, a robust and stable granule bed (>8 g L(-1)) was formed and could be maintained thereafter, with a sludge volume index after 5 min settling of 45 mL g(-1). The granular sludge consisted for more than 80% of granules larger than 0.2 mm and more than 60% larger than 1 mm. Effluent requirements (7 mg N L(-1) and 1 mg P L(-1)) were easily met during summer and winter. Maximum volumetric conversion rates for nitrogen and phosphorus were respectively 0.17 and 0.24 kg (m(3) d)(-1). The energy usage was 13.9 kWh (PE150·year)(-1) which is 58-63 % lower than the average conventional activated sludge treatment plant in the Netherlands. Finally, this study demonstrated that aerobic granular sludge technology can effectively be implemented for the treatment of domestic wastewater.

Reporting format for economic evaluation. Part I: Application to the Dutch healthcare system.

This article presents the first version of the reporting format for economic valuation that was created in 1995 by a multidisciplinary taskforce. The members of this taskforce come from a broad spectrum of backgrounds within the healthcare field and participated in the exercise voluntarily. The format presented should be understood as the preferred Dutch structure for the reporting of any study on economic evaluation. In view of the many areas of contention that exist within the field, this format only gives normative directions in those areas in which consensus exists, as evidenced by the current published international guidelines. A regular review and adaptation of this format will be needed to reflect advances in the field.

Reporting format for economic evaluation. Part II: Focus on modelling studies.

This article presents the first version of a reporting format for modelling studies which is based on a general reporting format by our taskforce, which was published in the previous issue of this journal. The use of decision-analytical models for economic evaluations is increasing because, in practice, it is not always possible to derive information from prospective studies. However, the acceptance of modelling studies is generally lower than prospective studies not only because of the use of secondary data, but also because the reports of modelling studies do not always have sufficient transparency. Hence, a standardised reporting format may improve the transparency and, consequently, the acceptance of modelling studies. This article presents an example of a reporting format for economic evaluation based on modelling studies, which may facilitate the development of future guidelines for modelling studies. The format consists of a number of headings, which are followed by a brief recommendation on the content. This format does not deal with methodology and data management, but especially addresses validation and quality assurance, which may increase the transparency of the report.

Introduction to the pharmacoeconomics of herbal medicines.

This article explores the need to perform pharmacoeconomic evaluations of herbal medicines and assesses the extent to which this approach has been applied so far to these products. There seems to be no compelling need for pharmacoeconomic analyses of herbal over-the-counter medicines, but such analyses are certainly warranted for herbal prescription medicines that have a high level of reimbursement. Such preparations are used in Germany, in particular, where physicians prescribed ginkgo, hawthorn, St John's wort, horse-chestnut and saw palmetto to a value of more than DM50 million each in 1996. In our survey, only a single pharmacoeconomic study, of uncertain quality, was found on these 5 herbs, whereas several pharmacoeconomic reports on synthetic competitors were retrieved. The time has come to submit highly reimbursed herbal prescription medicines to the same rigorous pharmacoeconomic evaluations as their synthetic competitors. At present, such studies are particularly important for Germany, but in the future they may also become relevant for other countries, inside as well as outside Europe.

The diffusion process of patient education in Dutch community pharmacy: an exploration.

Patient education activities in pharmacies are receiving much attention. These activities are relatively new and implementation requires individual and organisational change in pharmacies. The aim of this study is to identify barriers and facilitators to the implementation of patient education in community pharmacies and to classify these barriers and facilitators into the diffusion stages of Rogers' 'Innovations in Organisations' model [Rogers, EM. Diffusion of innovations. 4th ed. New York: The Free Press, 1995]. Six focus group interviews, three with pharmacists and three with pharmacy technicians (total n = 38) were carried out. The initiation phase has been dealt with by community pharmacies, whereas the implementation phase has not. The barriers and facilitators in the redefining/restructuring stage were mainly related to the organisation of patient education. In the clarifying and routinizing stages, barriers were related to repetition and knowledge transfer. The facilitators in these stages relate to performing and talking about patient education. Interventions for implementation of patient education should aim at these barriers and facilitating factors.

Evaluation of EU risk assessments existing chemicals (EC Regulation 793/93).

An evaluation was performed on the first group (41) of completed risk assessments for chemicals of the EU priority lists (Existing Chemicals; EC Regulation 793/93). The evaluation focussed on the conclusions of the risk assessments. The EU risk assessment process detected a high number of substances of concern. Furthermore priority chemicals may pose potential risks to the whole range of protection goals of the risk assessment. The predictability of the risk assessments for priority chemicals was investigated. Our a priori knowledge on possible risks of priority chemicals is found to be poor, especially for consumers. Both for environment and human health the potential risks were linked with a broad spectrum of use patterns. It is concluded that no industry category can in advance be excluded from performing risk assessments. For a great number of chemicals, additional testing was found to be needed to finalize the risk assessment. This evokes questions about the completeness of the current base-set, but also about the suitability of some of the submitted human health tests that should initially fulfil the base-set needs. The results of this evaluation are useful for ongoing discussions on risk assessment processes for chemicals.

[Activated charcoal as first-choice therapy in poisoning]. / Actieve kool als eerstekeustherapie bij intoxicaties.

In gastrointestinal detoxication, three methods are possible: ipecac induced emesis, gastric lavage and administration of activated charcoal. The method of treatment predominantly used in the Netherlands is gastric lavage in combination with activated charcoal. Published evidence suggests that activated charcoal not preceded by gastric emptying is preferred. Additional advantages of using activated charcoal alone as the method of choice for gastrointestinal decontamination are patient friendliness, low cost and time saving because quick intervention by general practitioners is possible.

[The budget control function of the Drug Reimbursement System]. / De budgetbeheersende functie van het Geneesmiddelenvergoedingssysteem.

We now have 10 years of experience with the Dutch Price Reference System (Dutch acronym GVS), which was instituted in order to reduce the growth of extramural pharmaceutical costs to 4.1% annually, assuming no loss of medical quality. The system focussed mainly on budget control rather than on increasing cost-effectiveness by substitution. The budget-control aims were not achieved. As epidemiological and demographic developments would account for about 3% annual budget growth given an unchanged individual consumption of pharmaceuticals, the 4.1% criterion left only 1% room for autonomous growth (price, volume). The current 8% average annual growth rate indicates 5% autonomous growth. This rate is low, however, compared to other European countries, where a number of autonomous growth factors are not systematically counterbalanced at the product level by substitution incentives and control over prices and indication by health-care authorities and health-insurance companies. The GVS and related administrative measures have therefore most likely exerted a significant budget-controlling influence. The current policy of the Dutch Ministry of Health, Welfare and Sports in terms of goals, actors' roles and incentives fits well with the GVS, which should therefore be continued.