Driving performance in persons with hemianopia and quadrantanopia assessed under in-traffic conditions

Purpose: To evaluate the on-road driving performance of persons with homonymous hemianopia or quadrantanopia in comparison to age-matched controls with normal visual fields. Methods: Participants were 22 hemianopes and eight quadrantanopes (mean age 53 years) and 30 persons with normal visual fields (mean age 52 years) and were either current drivers or aiming to resume driving. All participants completed a battery of tests of vision (ETDRS visual acuity, Pelli-Robson letter contrast sensitivity, Humphrey visual fields), cognitive tests (trials A and B, Mini Mental State Examination, Digit Symbol Substitution) and an on-road driving assessment. Driving performance was assessed in a dual-brake vehicle with safety monitored by a certified driving rehabilitation specialist. Backseat evaluators masked to the clinical characteristics of participants independently rated driving performance along a 22.7 kilometre route involving urban and interstate driving. Results: Seventy-three per cent of the hemianopes, 88 per cent of quadrantanopes and all of the drivers with normal fields received safe driving ratings. Those hemianopic and quadrantanopic drivers rated as unsafe tended to have problems with maintaining appropriate lane position, steering steadiness and gap judgment compared to controls. Unsafe driving was associated with slower visual processing speed and impairments in contrast sensitivity, visual field sensitivity and executive function. Conclusions: Our findings suggest that some drivers with hemianopia or quadrantanopia are capable of safe driving performance, when compared to those of the same age with normal visual fields. This finding has important implications for the assessment of fitness to drive in this population.

Motor conflict in Stroop tasks : direct evidence from single-trial electro-myography and electro-encephalography

Several brain imaging studies have assumed that response conflict is present in Stroop tasks. However, this has not been demonstrated directly. We examined the time-course of stimulus and response conflict resolution in a numerical Stroop task by combining single-trial electro-myography (EMG) and event-related brain potentials (ERP). EMG enabled the direct tracking of response conflict and the peak latency of the P300 ERP wave was used to index stimulus conflict. In correctly responded trials of the incongruent condition EMG detected robust incorrect response hand activation which appeared consistently in single trials. In 50–80% of the trials correct and incorrect response hand activation coincided temporally, while in 20–50% of the trials incorrect hand activation preceded correct hand activation. EMG data provides robust direct evidence for response conflict. However, congruency effects also appeared in the peak latency of the P300 wave which suggests that stimulus conflict also played a role in the Stroop paradigm. Findings are explained by the continuous flow model of information processing: Partially processed task-irrelevant stimulus information can result in stimulus conflict and can prepare incorrect response activity. A robust congruency effect appeared in the amplitude of incongruent vs. congruent ERPs between 330–400 ms, this effect may be related to the activity of the anterior cingulate cortex.

Aromatherapy for treatment of postoperative nausea and vomiting

Background: Postoperative nausea and vomiting is a common and unpleasant phenomenon and current therapies are not always effective for all patients. Aromatherapy has been suggested as a possible addition to the available treatment strategies. Objectives: This review sought to establish what effect the use of aromatherapy has on the severity and duration of established postoperative nausea and vomiting and whether aromatherapy can be used with safety and clinical effectiveness comparable to standard pharmacological treatments. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); MEDLINE; EMBASE; CINAHL; CAM on PubMed; Meditext; LILACS database; and ISI Web of Science as well as grey literature sources and the reference lists of retrieved articles. We conducted database searches up to August 2011. Selection criteria: We included all randomized controlled trials (RCTs) and controlled clinical trials (CCTs) where aromatherapy was used to treat postoperative nausea and vomiting. Interventions were all types of aromatherapy. Aromatherapy was defined as the inhalation of the vapours of any substance for the purposes of a therapeutic benefit. Primary outcomes were the severity and duration of postoperative nausea and vomiting. Secondary outcomes were adverse reactions, use of rescue anti-emetics and patient satisfaction with treatment. Data collection and analysis: Two review authors assessed risk of bias in the included studies and extracted data. As all outcomes analysed were dichotomous, we used a fixed-effects model and calculated relative risk (RR) with associated 95% confidence interval (95% CI). Results: The nine included studies comprised six RCTs and three CCTs with a total of 402 participants. The mean age and range data for all participants were not reported for all studies. The method of randomization in four of the six included RCTs was explicitly stated and adequate. Incomplete reporting of data affected the completeness of the analysis. Compared with placebo, isopropyl alcohol vapour inhalation was effective in reducing the proportion of participants requiring rescue anti-emetics (RR 0.30, 95%CI 0.09 to 1.00, P = 0.05). However, compared with standard anti-emetic treatment, isopropyl alcohol was not effective in reducing the proportion of participants requiring rescue anti-emetics (RR 0.66 95%CI 0.39 to 1.13, P = 0.13) except when the data from a possibly confounded study were included (RR 0.66, 95% CI 0.45 to 0.98, P = 0.04). Where studies reported data on patient satisfaction with aromatherapy, there were no statistically significant differences between the groups (RR 1.12, 95%CI 0.62 to 2.03, P = 0.71). Authors' conclusions: Isopropyl alcohol was more effective than saline placebo for reducing postoperative nausea and vomiting but less effective than standard anti-emetic drugs. There is currently no reliable evidence for the use of peppermint oil.

Do thermal agents affect range of movement and mechanical properties in soft tissues? A systematic review

OBJECTIVES: To examine the effect of thermal agents on the range of movement (ROM) and mechanical properties in soft tissue and to discuss their clinical relevance. DATA SOURCES: Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE) were searched from their earliest available record up to May 2011 using Medical Subjects Headings and key words. We also undertook related articles searches and read reference lists of all incoming articles. STUDY SELECTION: Studies involving human participants describing the effects of thermal interventions on ROM and/or mechanical properties in soft tissue. Two reviewers independently screened studies against eligibility criteria. DATA EXTRACTION: Data were extracted independently by 2 review authors using a customized form. Methodologic quality was also assessed by 2 authors independently, using the Cochrane risk of bias tool. DATA SYNTHESIS: Thirty-six studies, comprising a total of 1301 healthy participants, satisfied the inclusion criteria. There was a high risk of bias across all studies. Meta-analyses were not undertaken because of clinical heterogeneity; however, effect sizes were calculated. There were conflicting data on the effect of cold on joint ROM, accessory joint movement, and passive stiffness. There was limited evidence to determine whether acute cold applications enhance the effects of stretching, and further evidence is required. There was evidence that heat increases ROM, and a combination of heat and stretching is more effective than stretching alone. CONCLUSIONS: Heat is an effective adjunct to developmental and therapeutic stretching techniques and should be the treatment of choice for enhancing ROM in a clinical or sporting setting. The effects of heat or ice on other important mechanical properties (eg, passive stiffness) remain equivocal and should be the focus of future study.

Vestibular rehabilitation following the removal of an acoustic neuroma : a systematic review of randomized trials

An acoustic neuroma (also known as a vestibular schwannoma) is an intracranial tumour of the vestibular nerve that is commonly treated by surgical resection. Following resection of an acoustic neuroma, patients may experience a range of symptoms that include deficits in gaze stability, mobility and balance. Vestibular rehabilitation may be useful in reducing the severity and minimizing the impact of these symptoms.

The effects of exercise and adipose tissue lipolysis on plasma adiponectin concentration and adiponectin receptor expression in human skeletal muscle

Objective It has been suggested that adiponectin regulates plasma free fatty acid (FFA) clearance by stimulating FFA uptake and/or oxidation in muscle. We aimed to determine changes in plasma adiponectin concentration and adiponectin receptor 1 and 2 mRNA expression in skeletal muscle during and after prolonged exercise under normal, fasting conditions (high FFA trial; HFA) and following pharmacological inhibition of adipose tissue lipolysis (low FFA trial; LFA). Furthermore, we aimed to detect and locate adiponectin in skeletal muscle tissue. Methods Ten subjects performed two exercise trials (120 min at 50% VO2max). Indirect calorimetry was used to determine total fat oxidation rate. Plasma samples were collected at rest, during exercise and during post-exercise recovery to determine adiponectin, FFA and glycerol concentrations. Muscle biopsies were taken to determine adiponectin protein and adiponectin receptor 1 and 2 mRNA expression and to localise intramyocellular adiponectin. Results Basal plasma adiponectin concentrations averaged 6.57±0.7 and 6.63±0.8 mg/l in the HFA and LFA trials respectively, and did not change significantly during or after exercise. In the LFA trial, plasma FFA concentrations and total fat oxidation rates were substantially reduced. However, plasma adiponectin and muscle adiponectin receptor 1 and 2 mRNA expression did not differ between trials. Immunohistochemical staining of muscle cross-sections showed the presence of adiponectin in the sarcolemma of individual muscle fibres and within the interfibrillar arterioles. Conclusion Plasma adiponectin concentrations and adiponectin receptor 1 and 2 mRNA expression in muscle are not acutely regulated by changes in adipose tissue lipolysis and/or plasma FFA concentrations. Adiponectin is abundantly expressed in muscle, and, for the first time, it has been shown to be present in/on the sarcolemma of individual muscle fibres.

Isotonic designs for phase I trials

The purpose of a phase I trial in cancer is to determine the level (dose) of the treatment under study that has an acceptable level of adverse effects. Although substantial progress has recently been made in this area using parametric approaches, the method that is widely used is based on treating small cohorts of patients at escalating doses until the frequency of toxicities seen at a dose exceeds a predefined tolerable toxicity rate. This method is popular because of its simplicity and freedom from parametric assumptions. In this payer, we consider cases in which it is undesirable to assume a parametric dose-toxicity relationship. We propose a simple model-free approach by modifying the method that is in common use. The approach assumes toxicity is nondecreasing with dose and fits an isotonic regression to accumulated data. At any point in a trial, the dose given is that with estimated toxicity deemed closest to the maximum tolerable toxicity. Simulations indicate that this approach performs substantially better than the commonly used method and it compares favorably with other phase I designs.

Wood properties and processing outcomes for plantation grown African mahogany (Khaya senegalensis) trees from Clare, Queensland (18 and 20 year-old trees) and Katherine, Northern Territory (14 year-old trees).

Khaya senegalensis, African mahogany, a high-value hardwood, was introduced in the Northern Territory (NT) in the 1950s; included in various trials there and at Weipa, Q in the 1960s-1970s; planted on ex mine sites at Weipa (160 ha) until 1985; revived in farm plantings in Queensland and in trials in the NT in the 1990s; adopted for large-scale, annual planting in the Douglas-Daly region, NT from 2006 and is to have the planted area in the NT extended to at least 20,000 ha. The recent serious interest from plantation growers, including Forest Enterprises Australia Ltd (FEA), has seen the establishment of some large scale commercial plantations. FEA initiated the current study to process relatively young plantation stands from both Northern Territory and Queensland plantations to investigate the sawn wood and veneer recovery and quality from trees ranging from 14 years (NT – 36 trees) to 18-20 years (North Queensland – 31 trees). Field measures of tree size and straightness were complemented with log end splitting assessment and cross-sectional disc sample collection for laboratory wood properties measurements including colour and shrinkage. End-splitting scores assessed on sawn logs were relatively low compared to fast grown plantation eucalypts and did not impact processing negatively. Heartwood proportion in individual trees ranged from 50% up to 92 % of butt cross-sectional disc area for the visually-assessed dark coloured central heartwood and lighter coloured transition wood combined. Dark central heartwood proportion was positively related to tree size (R2 = 0.57). Chemical tests failed to assist in determining heartwood – sapwood boundary. Mean basic density of whole disc samples was 658 kg/m3 and ranged among trees from 603 to 712 kg/m3. When freshly sawn, the heartwood of African mahogany was orange-red to red. Transition wood appeared to be pinkish and the sapwood was a pale yellow colour. Once air dried the heartwood colour generally darkens to pinkish-brown or orange-brown and the effect of prolonged time and sun exposure is to darken and change the heartwood to a red-brown colour. A portable colour measurement spectrophotometer was used to objectively assess colour variation in CIE L*, a* and b* values over time with drying and exposure to sunlight. Capacity to predict standard colour values accurately after varying periods of direct sunlight exposure using results obtained on initial air-dried surfaces decreased with increasing time to sun exposure. The predictions are more accurate for L* values which represent brightness than for variation in the a* values (red spectrum). Selection of superior breeding trees for colour is likely to be based on dried samples exposed to sunlight to reliably highlight wood colour differences. A generally low ratio between tangential and radial shrinkages was found, which was reflected in a low incidence of board distortion (particularly cupping) during drying. A preliminary experiment was carried out to investigate the quality of NIR models to predict shrinkage and density. NIR spectra correlated reasonably well with radial shrinkage and air dried density. When calibration models were applied to their validation sets, radial shrinkage was predicted to an accuracy of 76% with Standard Error of Prediction of 0.21%. There was also a strong predictive power for wood density. These are encouraging results suggesting that NIR spectroscopy has good potential to be used as a non-destructive method to predict shrinkage and wood density using 12mm diameter increment core samples. Average green off saw recovery was 49.5% (range 40 to 69%) for Burdekin Agricultural College (BAC) logs and 41.9% (range 20 to 61%) for Katherine (NT) logs. These figures are about 10% higher than compared to 30-year-old Khaya study by Armstrong et al. (2007) however they are inflated as the green boards were not docked to remove wane prior to being tallied. Of the recovered sawn, dried and dressed volume from the BAC logs, based on the cambial face of boards, 27% could potentially be used for select grade, 40% for medium feature grade and 26% for high feature grades. The heart faces had a slightly higher recovery of select (30%) and medium feature (43%) grade boards with a reduction in the volume of high feature (22%) and reject (6%) grade boards. Distribution of board grades for the NT site aged 14 years followed very similar trends to those of the BAC site boards with an average (between facial and cambial face) 27% could potentially be used for select grade, 42% for medium feature grade, 26% for high feature grade and 5% reject. Relatively to some other subtropical eucalypts, there was a low incidence of borer attack. The major grade limiting defects for both medium and high feature grade boards recovered from the BAC site were knots and wane. The presence of large knots may reflect both management practices and the nature of the genetic material at the site. This stand was not managed for timber production with a very late pruning implemented at about age 12 years. The large amount of wane affected boards is indicative of logs with a large taper and the presence of significant sweep. Wane, knots and skip were the major grade limiting defects for the NT site reflecting considerable amounts of sweep with large taper as might be expected in younger trees. The green veneer recovered from billets of seven Khaya trees rotary peeled on a spindleless lathe produced a recovery of 83% of green billet volume. Dried veneer recovery ranged from 40 to 74 % per billet with an average of 64%. All of the recovered grades were suitable for use in structural ply in accordance to AS/NZ 2269: 2008. The majority of veneer sheets recovered from all billets was C grade (27%) with 20% making D grade and 13% B grade. Total dry sliced veneer recovery from the logs of the two largest logs from each location was estimated to be 41.1%. Very positive results have been recorded in this small scale study. The amount of colour development observed and the very reasonable recoveries of both sawn and veneer products, with a good representation of higher grades in the product distribution, is encouraging. The prospects for significant improvement in these results from well managed and productive stands grown for high quality timber should be high. Additionally, the study has shown the utility of non-destructive evaluation techniques for use in tree improvement programs to improve the quality of future plantations. A few trees combined several of the traits desired of individuals for a first breeding population. Fortunately, the two most promising trees (32, 19) had already been selected for breeding on external traits, and grafts of them are established in the seed orchard.

Evaluation of wood characteristics of tropical post-mid rotation plantation Eucalyptus cloeziana and E. pellita: Part (b) Accelerated seasoning of sawn timber.

Drying trials were conducted using two species of plantation grown eucalypt timbers: 19-year-old Eucalyptus cloeziana (Gympie messmate) and 15-year-old Eucalyptus pellita (red mahogany). The objective of this study was to gain an understanding of the drying potential of young plantation grown material using accelerated seasoning methods, a process expected to be critcal to the success of plantation hardwood products entering value added markets. The findings are encouraging, indicating that both species can be dried using conventional drying techniques much faster than industry is currently achieving when drying native forest timber. The results suggest that there is a definite drying time advantatge in vacuum drying over conventional methods for 19-year-old E. cloeziana. The findings have shown that through careful schedule manipulation and adjustment, the grade quality can be optimised to suit the desired expectation. As this study was limited to only a small number of trials, time and quality improvements are expected to be realised for both conventional and vacuum drying methods as more research is conducted.

Reduced fungicide use on a new Australian peanut cultivar, highly resistant to the late leaf spot and rust pathogens

Rust (caused by Puccinia arachidis) and late leaf spot (LLS, caused by Mycosphaerella berkeleyi) can cause significant yield losses in Australian peanut crops. Until recently, all commercial peanut varieties were highly susceptible to these pathogens, but the new Australian cultivar Sutherland has significantly higher levels of resistance than the older cultivars. Field trials were conducted at two sites in Queensland to (a) confirm the improved resistance of cv. Sutherland over another commercial cultivar, Menzies, (b) study the effects of timing of first spray, spray interval and cultivar on disease severity and yield, and (c) develop a suitable fungicide management program for cv. Sutherland. In the 2006 and 2007 trials, rust and LLS developed slower and had lower final disease ratings and AUDPC values on unsprayed plots of cv. Sutherland than on cv. Menzies. The timing of the first spray is critical in managing both rust and late leaf spot, with the results demonstrating that the first fungicide spray on cv. Sutherland should be applied as soon as rust and LLS are first seen on cv. Menzies. In most trials spray intervals of 14 days or 21 days were suitable to effectively control rust and LLS. In years with low disease pressure, few, if any, fungicide applications will be needed to manage the diseases, but in other years up to four sprays may be necessary. © Australasian Plant Pathology Society Inc. 2012.

Levels and predictors of exercise referral scheme uptake and adherence: A systematic review

Background The effectiveness of exercise referral schemes (ERS) is influenced by uptake and adherence to the scheme. The identification of factors influencing low uptake and adherence could lead to the refinement of schemes to optimise investment. Objectives To quantify the levels of ERS uptake and adherence and to identify factors predictive of uptake and adherence. Methods A systematic review and meta-analysis was undertaken. MEDLINE, EMBASE, PsycINFO, Cochrane Library, ISI WOS, SPORTDiscus and ongoing trial registries were searched (to October 2009) and included study references were checked. Included studies were required to report at least one of the following: (1) a numerical measure of ERS uptake or adherence and (2) an estimate of the statistical association between participant demographic or psychosocial factors (eg, level of motivation, self-efficacy) or programme factors and uptake or adherence to ERS. Results Twenty studies met the inclusion criteria, six randomised controlled trials (RCTs) and 14 observational studies. The pooled level of uptake in ERS was 66% (95% CI 57% to 75%) across the observational studies and 81% (95% CI 68% to 94%) across the RCTs. The pooled level of ERS adherence was 49% (95% CI 40% to 59%) across the observational studies and 43% (95% CI 32% to 54%) across the RCTs. Few studies considered anything other than gender and age. Women were more likely to begin an ERS but were less likely to adhere to it than men. Older people were more likely to begin and adhere to an ERS. Limitations Substantial heterogeneity was evident across the ERS studies. Without standardised definitions, the heterogeneity may have been reflective of differences in methods of defining uptake and adherence across studies. Conclusions To enhance our understanding of the variation in uptake and adherence across ERS and how these variations might affect physical activity outcomes, future trials need to use quantitative and qualitative methods.

Inventories and significance of the genetic resources of an African mahogany species (Khaya senegalensis (Desr.) A. Juss.) assembled and further developed in Australia.

The forest tree species Khaya senegalensis (Desr.) A. Juss. occurs in a belt across 20 African countries from Senegal-Guinea to Sudan-Uganda where it is a highly important resource. However, it is listed as Vulnerable (IUCN 2015-3). Since introduction in northern Australia around 1959, the species has been planted widely, yielding high-value products. The total area of plantations of the species in Australia exceeds 15,000 ha, mostly planted in the Northern Territory since 2006, and includes substantial areas across 60-70 woodlots and industrial plantations established in north-eastern Queensland since the early-1990s and during 2005-2007 respectively. Collaborative conservation and tree improvement by governments began in the Northern Territory and Queensland in 2001 based on provenance and other trials of the 1960s-1970s. This work has developed a broad base of germplasm in clonal seed orchards, hedge gardens and trials (clone and progeny). Several of the trials were established collaboratively on private land. Since the mid-2000s, commercial growers have introduced large numbers of provenance-bulk and individual-tree seedlots to establish industrial plantations and trials, several of the latter in collaboration with the Queensland Government. Provenance bulks (>140) and families (>400) from 17 African countries are established in Australia, considered the largest genetic base of the species in a single country outside Africa. Recently the annual rate of industrial planting of the species in Australia has declined, and R&D has been suspended by governments and reduced by the private sector. However, new commercial plantings in the Northern Territory and Queensland are proposed. In domesticating a species, the strategic importance of a broad genetic base is well known. The wide range of first- and advanced-generation germplasm of the species established in northern Australia and documented in this paper provides a sound basis for further domestication and industrial plantation and woodlot expansion, when investment conditions are favourable

Statistical methods for analysis of multi-harvest data from perennial pasture variety selection trials

Variety selection in perennial pasture crops involves identifying best varieties from data collected from multiple harvest times in field trials. For accurate selection, the statistical methods for analysing such data need to account for the spatial and temporal correlation typically present. This paper provides an approach for analysing multi-harvest data from variety selection trials in which there may be a large number of harvest times. Methods are presented for modelling the variety by harvest effects while accounting for the spatial and temporal correlation between observations. These methods provide an improvement in model fit compared to separate analyses for each harvest, and provide insight into variety by harvest interactions. The approach is illustrated using two traits from a lucerne variety selection trial. The proposed method provides variety predictions allowing for the natural sources of variation and correlation in multi-harvest data.

Clinical outcome of breast cancer patients with liver metastases alone in the anthracycline-taxane era: a retrospective analysis of two prospective, randomised metastatic breast cancer trials.

Liver metastases have long been known to indicate an unfavourable disease course in breast cancer (BC). However, a small subset of patients with liver metastases alone who were treated with pre-taxane chemotherapy regimens was reported to have longer survival compared with patients with liver and metastases at other sites. In the present study, we examined the clinical outcome of breast cancer patients with liver metastases alone in the context of two phase III European Organisation for Research and Treatment of Cancer (EORTC) trials which compared the efficacy of doxorubicin (A) versus paclitaxel (T) (trial 10923) and of AC (cyclophosphamide) versus AT (trial 10961), given as first-line chemotherapy in metastatic BC patients. The median follow-up for the patients with liver metastases was 90.5 months in trial 10923 and 56.6 months in trial 10961. Patients with liver metastases alone comprised 18% of all patients with liver metastases, in both the 10923 and 10961 trials. The median survival of patients with liver metastases alone and liver plus other sites of metastases were 22.7 and 14.2 months (log rank test, P=0.002) in trial 10923 and 27.1 and 16.8 months (log rank test, P=0.19) in trial 10961. The median TTP (time to progression) for patients with liver metastases alone was also longer compared with the liver plus other sites of metastases group in both trials: 10.2 versus 8.8 months (log rank test, P=0.02) in trial 10923 and 8.3 versus 6.7 months (log rank test, P=0.37) in trial 10961. Most patients with liver metastases alone have progression of their disease in their liver again (96 and 60% of patients in trials 10923 and 10961, respectively). Given the high prevalence of breast cancer, improved detection of liver metastases, encouraging survival achieved with currently available cytotoxic agents and the fact that a significant portion of patients with liver metastases alone have progression of their tumour in the liver again, a more aggressive multimodality treatment approach through prospective clinical trials seems worth exploring in this specific subset of women.

Economic return of clinical trials performed under the pediatric exclusivity program.

CONTEXT: In 1997, Congress authorized the US Food and Drug Administration (FDA) to grant 6-month extensions of marketing rights through the Pediatric Exclusivity Program if industry sponsors complete FDA-requested pediatric trials. The program has been praised for creating incentives for studies in children and has been criticized as a "windfall" to the innovator drug industry. This critique has been a substantial part of congressional debate on the program, which is due to expire in 2007. OBJECTIVE: To quantify the economic return to industry for completing pediatric exclusivity trials. DESIGN AND SETTING: A cohort study of programs conducted for pediatric exclusivity. Nine drugs that were granted pediatric exclusivity were selected. From the final study reports submitted to the FDA (2002-2004), key elements of the clinical trial design and study operations were obtained, and the cost of performing each study was estimated and converted into estimates of after-tax cash outflows. Three-year market sales were obtained and converted into estimates of after-tax cash inflows based on 6 months of additional market protection. Net economic return (cash inflows minus outflows) and net return-to-costs ratio (net economic return divided by cash outflows) for each product were then calculated. MAIN OUTCOME MEASURES: Net economic return and net return-to-cost ratio. RESULTS: The indications studied reflect a broad representation of the program: asthma, tumors, attention-deficit/hyperactivity disorder, hypertension, depression/generalized anxiety disorder, diabetes mellitus, gastroesophageal reflux, bacterial infection, and bone mineralization. The distribution of net economic return for 6 months of exclusivity varied substantially among products (net economic return ranged from -$8.9 million to $507.9 million and net return-to-cost ratio ranged from -0.68 to 73.63). CONCLUSIONS: The economic return for pediatric exclusivity is variable. As an incentive to complete much-needed clinical trials in children, pediatric exclusivity can generate lucrative returns or produce more modest returns on investment.