Population pharmacokinetic and pharmacogenetic analysis of 6-mercaptopurine in paediatric patients with acute lymphoblastic leukaemia

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • The cytotoxic effects of 6-mercaptopurine (6-MP) were found to be due to drug-derived intracellular metabolites (mainly 6-thioguanine nucleotides and to some extent 6-methylmercaptopurine nucleotides) rather than the drug itself. • Current empirical dosing methods for oral 6-MP result in highly variable drug and metabolite concentrations and hence variability in treatment outcome. WHAT THIS STUDY ADDS • The first population pharmacokinetic model has been developed for 6-MP active metabolites in paediatric patients with acute lymphoblastic leukaemia and the potential demographic and genetically controlled factors that could lead to interpatient pharmacokinetic variability among this population have been assessed. • The model shows a large reduction in interindividual variability of pharmacokinetic parameters when body surface area and thiopurine methyltransferase polymorphism are incorporated into the model as covariates. • The developed model offers a more rational dosing approach for 6-MP than the traditional empirical method (based on body surface area) through combining it with pharmacogenetically guided dosing based on thiopurine methyltransferase genotype. AIMS - To investigate the population pharmacokinetics of 6-mercaptopurine (6-MP) active metabolites in paediatric patients with acute lymphoblastic leukaemia (ALL) and examine the effects of various genetic polymorphisms on the disposition of these metabolites. METHODS - Data were collected prospectively from 19 paediatric patients with ALL (n = 75 samples, 150 concentrations) who received 6-MP maintenance chemotherapy (titrated to a target dose of 75 mg m−2 day−1). All patients were genotyped for polymorphisms in three enzymes involved in 6-MP metabolism. Population pharmacokinetic analysis was performed with the nonlinear mixed effects modelling program (nonmem) to determine the population mean parameter estimate of clearance for the active metabolites. RESULTS - The developed model revealed considerable interindividual variability (IIV) in the clearance of 6-MP active metabolites [6-thioguanine nucleotides (6-TGNs) and 6-methylmercaptopurine nucleotides (6-mMPNs)]. Body surface area explained a significant part of 6-TGNs clearance IIV when incorporated in the model (IIV reduced from 69.9 to 29.3%). The most influential covariate examined, however, was thiopurine methyltransferase (TPMT) genotype, which resulted in the greatest reduction in the model's objective function (P < 0.005) when incorporated as a covariate affecting the fractional metabolic transformation of 6-MP into 6-TGNs. The other genetic covariates tested were not statistically significant and therefore were not included in the final model. CONCLUSIONS - The developed pharmacokinetic model (if successful at external validation) would offer a more rational dosing approach for 6-MP than the traditional empirical method since it combines the current practice of using body surface area in 6-MP dosing with a pharmacogenetically guided dosing based on TPMT genotype.

Has DRG payment influenced the technical efficiency and productivity of diagnostic technologies in Portuguese public hospitals? An empirical analysis using parametric and non‐parametric methods

The use of Diagnosis Related Groups (DRG) as a mechanism for hospital financing is a currently debated topic in Portugal. The DRG system was scheduled to be initiated by the Health Ministry of Portugal on January 1, 1990 as an instrument for the allocation of public hospital budgets funded by the National Health Service (NHS), and as a method of payment for other third party payers (e.g., Public Employees (ADSE), private insurers, etc.). Based on experience from other countries such as the United States, it was expected that implementation of this system would result in more efficient hospital resource utilisation and a more equitable distribution of hospital budgets. However, in order to minimise the potentially adverse financial impact on hospitals, the Portuguese Health Ministry decided to gradually phase in the use of the DRG system for budget allocation by using blended hospitalspecific and national DRG casemix rates. Since implementation in 1990, the percentage of each hospitals budget based on hospital specific costs was to decrease, while the percentage based on DRG casemix was to increase. This was scheduled to continue until 1995 when the plan called for allocating yearly budgets on a 50% national and 50% hospitalspecific cost basis. While all other nonNHS third party payers are currently paying based on DRGs, the adoption of DRG casemix as a National Health Service budget setting tool has been slower than anticipated. There is now some argument in both the political and academic communities as to the appropriateness of DRGs as a budget setting criterion as well as to their impact on hospital efficiency in Portugal. This paper uses a twostage procedure to assess the impact of actual DRG payment on the productivity (through its components, i.e., technological change and technical efficiency change) of diagnostic technology in Portuguese hospitals during the years 1992–1994, using both parametric and nonparametric frontier models. We find evidence that the DRG payment system does appear to have had a positive impact on productivity and technical efficiency of some commonly employed diagnostic technologies in Portugal during this time span.

Stereotypes of salespeople in Taiwan:an empirical examination and research agenda

Stereotypes of salespeople are common currency in US media outlets, and research suggests that these stereotypes are uniformly negative. However there is no reason to expect that stereotypes will be consistent across cultures. The present paper provides the first empirical examination of salesperson stereotypes in an Asian country, specifically Taiwan. Using accepted psychological methods, Taiwanese salesperson stereotypes are found to be twofold, with a negative stereotype being quite congruent with existing US stereotypes, but also a positive stereotype, which may be related to the specific culture of Taiwan.

The valuation of travel time savings in least developed countries:theoretical and empirical challenges and results from a field study

In developed countries travel time savings can account for as much as 80% of the overall benefits arising from transport infrastructure and service improvements. In developing countries they are generally ignored in transport project appraisals, notwithstanding their importance. One of the reasons for ignoring these benefits in the developing countries is that there is insufficient empirical evidence to support the conventional models for valuing travel time where work patterns, particularly of the poor, are diverse and it is difficult to distinguish between work and non-work activities. The exclusion of time saving benefits may lead to a bias against investment decisions that benefit the poor and understate the poverty reduction potential of transport investments in Least Developed Countries (LDCs). This is because the poor undertake most travel and transport by walking and headloading on local roads, tracks and paths and improvements of local infrastructure and services bring large time saving benefits for them through modal shifts. The paper reports on an empirical study to develop a methodology for valuing rural travel time savings in the LDCs. Apart from identifying the theoretical and empirical issues in valuing travel time savings in the LDCs, the paper presents and discusses the results of an analysis of data from Bangladesh. Some of the study findings challenge the conventional wisdom concerning the time saving values. The Bangladesh study suggests that the western concept of dividing travel time savings into working and non-working time savings is broadly valid in the developing country context. The study validates the use of preference methods in valuing non-working time saving values. However, stated preference (SP) method is more appropriate than revealed preference (RP) method.

Pre-conception care : current practice and methods of provision

This thesis examines the present provisions for pre-conception care and the views of the providers of services. Pre-conception care is seen by some clinicians and health educators as a means of making any necessary changes in life style, corrections to imbalances in the nutritional status of the prospective mother (and father) and the assessment of any medical problems, thus maximizing the likelihood of the normal development of the baby. Pre-conception care may be described as a service to bridge the gap between the family planning clinic and the first ante-natal booking appointment. There were three separate foci for the empirical research - the Foresight organisation (a charity which has pioneered pre-conception care in Britain); the pre-conception care clinic at the West London Hospital, Hammersmith; and the West Midlands Regional Health Authority. The six main sources of data were: twenty five clinicians operating Foresight pre-conception clinics, couples attending pre-conception clinics, committee members of the Foresight organisation, staff of the West London Hospital pre-conception clinic, Hammersmith, District Health Education Officers working in the West Midlands Regional Health Authority and the members of the Ante-Natal Care Action Group, a sub-group of the Regional Health Advisory Group on Health Promotion and Preventive Medicine. A range of research methods were adopted. These were as follows: questionnaires and report forms used in co-operation with the Foresight clinicians, interviews, participant observation discussions and informal meetings and, finally, literature and official documentation. The research findings illustrated that pre-conception care services provided at the predominantly private Foresight clinics were of a rather `ad hoc' nature. The type of provision varied considerably and clearly reflected the views held by its providers. The protocol which had been developed to assist in the standardization of results was not followed by the clinicians. The pre-conception service provided at the West London Hospital shared some similarities in its approach with the Foresight provision; a major difference was that it did not advocate the use of routine hair trace metal analysis. Interviews with District Health Education Officers and with members of the Ante Natal Care Action Group revealed a tentative and cautious approach to pre-conception care generally and to the Foresight approach in particular. The thesis concludes with a consideration of the future of pre-conception care and the prospects for the establishment of a comprehensive pre-conception care service.

Reflection and reflexivity in reviewing and evaluating CDIO:an empirical approach to evaluation

Facilitated by an Engineer and a Social Scientist, both of whom have expertise in Engineering Education Research and Evaluation (EERE), this interactive workshop is divided into three main sections, each one focusing on a different area of evaluation. It will build on research conducted at Aston University School of Engineering and Applied Science to explore and critique the value of introducing CDIO across the first year undergraduate curriculum. Participants will be invited to consider the pedagogical and engineering related challenges of evaluating the academic and practical value of CDIO as a strategy for learning and teaching in the discipline. An empirical approach to evaluation developed by the researchers to provide empirically grounded evidence of the pedagogical and vocational value of CDIO will form the theoretical and conceptual basis of the workshop. This approach is distinctive in that it encapsulates both engineering and social science methods of evaluation. It is also contemporaneous in nature, with the researchers acting as a ‘fly on the wall’ capturing data as the programme unfolds. Through facilitated discussion and participation, the workshop will provide colleagues with the opportunity to develop a cross-disciplinary, empirically grounded research proposal specifically for the purposes of critically evaluating CDIO. It is anticipated that during the workshop, colleagues will work together in small groups. Suitable pedagogical approaches and tools will be suggested and a purposefully developed Engineering Education Research Guide, written by the workshop facilitators, will be given to all participants to inform and support the Workshop approach.

Comparing methods to separate treatment from self-selection effects in an online banking setting

The literature discusses several methods to control for self-selection effects but provides little guidance on which method to use in a setting with a limited number of variables. The authors theoretically compare and empirically assess the performance of different matching methods and instrumental variable and control function methods in this type of setting by investigating the effect of online banking on product usage. Hybrid matching in combination with the Gaussian kernel algorithm outperforms the other methods with respect to predictive validity. The empirical finding of large self-selection effects indicates the importance of controlling for these effects when assessing the effectiveness of marketing activities.

On the hydrophobicity of peptides:comparing empirical predictions of peptide log P values

Peptides are of great therapeutic potential as vaccines and drugs. Knowledge of physicochemical descriptors, including the partition coefficient logP, is useful for the development of predictive Quantitative Structure-Activity Relationships (QSARs). We have investigated the accuracy of available programs for the prediction of logP values for peptides with known experimental values obtained from the literature. Eight prediction programs were tested, of which seven programs were fragment-based methods: XLogP, LogKow, PLogP, ACDLogP, AlogP, Interactive Analysis's LogP and MlogP; and one program used a whole molecule approach: QikProp. The predictive accuracy of the programs was assessed using r(2) values, with ALogP being the most effective (r( 2) = 0.822) and MLogP the least (r(2) = 0.090). We also examined three distinct types of peptide structure: blocked, unblocked, and cyclic. For each study (all peptides, blocked, unblocked and cyclic peptides) the performance of programs rated from best to worse is as follows: all peptides - ALogP, QikProp, PLogP, XLogP, IALogP, LogKow, ACDLogP, and MlogP; blocked peptides - PLogP, XLogP, ACDLogP, IALogP, LogKow, QikProp, ALogP, and MLogP; unblocked peptides - QikProp, IALogP, ALogP, ACDLogP, MLogP, XLogP, LogKow and PLogP; cyclic peptides - LogKow, ALogP, XLogP, MLogP, QikProp, ACDLogP, IALogP. In summary, all programs gave better predictions for blocked peptides, while, in general, logP values for cyclic peptides were under-predicted and those of unblocked peptides were over-predicted.

The use of maturity models in improving project management performance:an empirical investigation

Purpose – The purpose of the paper was to conduct an empirical investigation to explore the impact of project management maturity models (PMMMs) on improving project performance. Design/methodology/approach – The investigation used a cross-case analysis involving over 90 individuals in seven organisations. Findings – The findings of the empirical investigation indicate that PMMMs demonstrate very high levels of variability in individual's assessment of project management maturity. Furthermore, at higher levels of maturity, the type of performance improvement adopted following their application is related to the type of PMMM used in the assessment. The paradox of the unreliability of PMMMs and their widespread acceptance is resolved by calling upon the “wisdom of crowds” phenomenon which has implications for the use of maturity model assessments in other arena. Research limitations/implications – The investigation does have the usual issues associated with case research, but the steps that have been taken in the cross-case construction and analysis have improved the overall robustness and extendibility of the findings. Practical implications – The tendency for PMMMs to shape improvements based on their own inherent structure needs further understanding. Originality/value – The use of empirical methods to investigate the link between project maturity models and extant changes in project management performance is highly novel and the findings that result from this have added resonance.

Cojumps in stock prices:empirical evidence

We examine contemporaneous jumps (cojumps) among individual stocks and a proxy for the market portfolio. We show, through a Monte Carlo study, that using intraday jump tests and a coexceedance criterion to detect cojumps has a power similar to the cojump test proposed by Bollerslev et al. (2008). However, we also show that we should not expect to detect all common jumps comprising a cojump when using such coexceedance based detection methods. Empirically, we provide evidence of an association between jumps in the market portfolio and cojumps in the underlying stocks. Consistent with our Monte Carlo evidence, moderate numbers of stocks are often detected to be involved in these (systematic) cojumps. Importantly, the results suggest that market-level news is able to generate simultaneous large jumps in individual stocks. We also find evidence of an association between systematic cojumps and Federal Funds Target Rate announcements. © 2013 Elsevier B.V.

Methods in mind

The evolution of cognitive neuroscience has been spurred by the development of increasingly sophisticated investigative techniques to study human cognition. In Methods in Mind, experts examine the wide variety of tools available to cognitive neuroscientists, paying particular attention to the ways in which different methods can be integrated to strengthen empirical findings and how innovative uses for established techniques can be developed. The book will be a uniquely valuable resource for the researcher seeking to expand his or her repertoire of investigative techniques. Each chapter explores a different approach. These include transcranial magnetic stimulation, cognitive neuropsychiatry, lesion studies in nonhuman primates, computational modeling, psychophysiology, single neurons and primate behavior, grid computing, eye movements, fMRI, electroencephalography, imaging genetics, magnetoencephalography, neuropharmacology, and neuroendocrinology. As mandated, authors focus on convergence and innovation in their fields; chapters highlight such cross-method innovations as the use of the fMRI signal to constrain magnetoencephalography, the use of electroencephalography (EEG) to guide rapid transcranial magnetic stimulation at a specific frequency, and the successful integration of neuroimaging and genetic analysis. Computational approaches depend on increased computing power, and one chapter describes the use of distributed or grid computing to analyze massive datasets in cyberspace. Each chapter author is a leading authority in the technique discussed.

The evolution of learning systems:to Bayes or not to be

Bayesian algorithms pose a limit to the performance learning algorithms can achieve. Natural selection should guide the evolution of information processing systems towards those limits. What can we learn from this evolution and what properties do the intermediate stages have? While this question is too general to permit any answer, progress can be made by restricting the class of information processing systems under study. We present analytical and numerical results for the evolution of on-line algorithms for learning from examples for neural network classifiers, which might include or not a hidden layer. The analytical results are obtained by solving a variational problem to determine the learning algorithm that leads to maximum generalization ability. Simulations using evolutionary programming, for programs that implement learning algorithms, confirm and expand the results. The principal result is not just that the evolution is towards a Bayesian limit. Indeed it is essentially reached. In addition we find that evolution is driven by the discovery of useful structures or combinations of variables and operators. In different runs the temporal order of the discovery of such combinations is unique. The main result is that combinations that signal the surprise brought by an example arise always before combinations that serve to gauge the performance of the learning algorithm. This latter structures can be used to implement annealing schedules. The temporal ordering can be understood analytically as well by doing the functional optimization in restricted functional spaces. We also show that there is data suggesting that the appearance of these traits also follows the same temporal ordering in biological systems. © 2006 American Institute of Physics.