A "SMART" design for building individualized treatment sequences

Interventions often involve a sequence of decisions. For example, clinicians frequently adapt the intervention to an individual's outcomes. Altering the intensity and type of intervention over time is crucial for many reasons, such as to obtain improvement if the individual is not responding or to reduce costs and burden when intensive treatment is no longer necessary. Adaptive interventions utilize individual variables (severity, preferences) to adapt the intervention and then dynamically utilize individual outcomes (response to treatment, adherence) to readapt the intervention. The Sequential Multiple Assignment Randomized Trial (SMART) provides high-quality data that can be used to construct adaptive interventions. We review the SMART and highlight its advantages in constructing and revising adaptive interventions as compared to alternative experimental designs. Selected examples of SMART studies are described and compared. A data analysis method is provided and illustrated using data from the Extending Treatment Effectiveness of Naltrexone SMART study.

Diffusion tensor group tractography of the corpus callosum in clinically isolated syndrome

BACKGROUND AND PURPOSE

Many studies have observed atrophy and abnormal diffusion within the CC in MS. However, few studies have addressed whether such abnormalities appear at the earliest stage of MS, especially in CIS. In this study, we aimed to investigate the CC integrity and patterns of CC abnormalities in CIS with diffusion tensor group tractography.

MATERIALS AND METHODS

First, probability maps of the entire CC and its subregions (genu, body, and splenium) were created from 19 healthy subjects. Then these probability maps were used to evaluate diffusion within the entire CC and its segments in 19 patients with CIS. Five indices, including the midsagittal CC area, FA, MD, λ(1), and λ(23), were used to characterize CC integrity.

RESULTS

Significant differences were found between patients with CIS and healthy controls in the entire CC and its segments. For the entire CC, patients with CIS had a significantly lower midsagittal CC area and FA, higher MD and λ(23), with a trend toward higher λ(1). These 4 diffusion measures were correlated with T2 lesion volume. Moreover, abnormal white matter integrity was present in subregions of the CC; there was a robust significant increase in λ(23) in the body and splenium and no difference in λ(1) in the genu.

CONCLUSIONS

Our results suggest that atrophy and abnormal diffusion inside the CC appear at the stage of CIS and the severity of damage in the genu is milder than that in the body and splenium.

Genetic Etiology and Dental Pulp Cell Deficiency of Hypophosphatasia

Hypophosphatasia is caused by mutations of the tissue-non-specific alkaline phosphatase ( TNSALP) gene with deficiency of dentin structure. The aim of this study was to examine whether TNSALP mutation in dental pulp cells contributes to dentin dysplasia in hypophosphatasia. Mutation analysis showed that compound heterozygous mutations of TNSALP were identified in three hypophosphatasia patients, including 3 novel mutation sites. Exfoliated teeth from the patients showed abnormal dentin mineralization and loss of cementum, as assessed by ground sections and scanning electron microscope analysis. Dental pulp cells isolated from one of the patients showed a significantly reduced TNSALP activity and mineralization capacity when compared with those in dental pulp cells from the unaffected individuals. Our results suggested that dentin dysplasia in hypophosphatasia may be associated with the decreased mineralization ability of dental pulp cells.

Time-dependent oxidative stress responses of crucian carp (Carassius auratus) to intraperitoneal injection of extracted microcystins

This study was conducted to investigate time-dependent changes in oxidative enzymes in liver of crucian carp after intraperitoneally injection with extracted microcystins 600 and 150 microg kg(-1) body weight. The results showed that activities of antioxidant enzymes, including superoxide dismutase, catalase, glutathione peroxidase and glutathione reductase generally exhibited a rapid increase in early phase (1-3 h post injection), but gradually decreased afterwards (12-48 h) compared with the control, with an evident time-dependent effect. These zigzag changes over time contributed a better understanding on oxidative stress caused by microcystins in fish.

Therapeutic effects on experimental metastatic tumor-bearing mice by vaccination with GM-CSF gene-modified and tumor antigen-pulsed macrophages

Macrophages, with potent cytotoxic and antigen-presenting activities, can be used in cancer treatment. The biological characteristics and antitumor effect of GM-CSF gene-modified and tumor antigen-pulsed macrophages were investigated. The high levels of GM-CSF could be detected in the supernatants of macrophages after gene transfer. The cytotoxicity and the expression of MHC class II molecules of the gene-modified macrophages increased significantly and the antigen-presenting ability was enhanced. The gene-modified macrophages were then pulsed with tumor antigen and used to treat the experimental pulmonary metastastic mice. The number of pulmonary metastases was reduced significantly and the cytotoxicity of the CTL induced from the splenocytes of the tumor-bearing mice also increased. The results demonstrated that adenovirus-mediated GM-CSF gene transfer can activate macrophages to some extent and GM-CSF gene-modified, antigen-pulsed macrophages may be a new type of effective effector cells in the immunogene therapy of cancer.

Polymorphisms in the genes of the urokinase plasminogen activation system in relation to colorectal cancer

BACKGROUND

Extracellular matrix degradation, mediated by the urokinase plasminogen activation (uPA) system, is a critical step in tumor invasion and metastasis. High tumor levels of uPA and its inhibitor PAI-1 have been correlated with poor cancer prognosis. We examined four single nucleotide polymorphisms (SNPs) with a potential effect on expression of genes in the uPA system for their role in colorectal cancer susceptibility and prognosis.

PATIENTS AND METHODS

We genotyped the SNPs in 308 Swedish incident colorectal cancer patients with up to 16 years of follow-up and in 585 age- and sex-matched controls. We evaluated the associations between genotypes and colorectal cancer and Dukes' stage. Survival probabilities were compared between different subgroups.

RESULTS

Patients with PAI-1 -675 5G/5G genotype had better survival than patients with 4G/4G or 4G/5G genotypes when they had Dukes' stage A or B tumors (P = 0.023 and P = 0.015, respectively). No statistically significant association was observed between the SNPs and the risk of colorectal cancer or Dukes' stage.

CONCLUSIONS

Our results suggest a role for the PAI-1 genotype in colorectal cancer prognosis, but further studies are needed to evaluate the impact of our finding in the clinic.

Synthesis of tungsten nanoparticles by sonoelectrochemistry

Tungsten nanoparticles have been synthesized by the sonoelectrochemical method. The electrolyte contained the tri-sodium citrate, sodium tungstate, ferrous sulphate, and citric acid. A platinum slice was used as the anode and a titanium-alloy horn as the cathode. Twenty kilohertz ultrasound generated by an ultrasound generator was connected to the titanium-alloy horn as an amplitude converter. Due to the electrochemical reaction and the cavitation effect of the ultrasound, the iron-tungsten aggregates at the cathode were dispersed into the electrolyte and iron atoms were dissolved in the acidic environment. In this way, body-center-cubic (bcc) tungsten nanoparticles have been obtained by controlling the density of the electric current, the ultrasound pulse period and amplitude. Their morphology, structure, and chemical components have been characterized using transmission electron microscope (TEM) and X-ray photoelectron spectrometer (XPS).

Evaluation of an International Pharmacopoeia method for the analysis of indinavir sulfate by liquid chromatography

A gradient LC method for the determination of indinavir sulfate (IDV) and its impurities has been recently published in a consultation document of the International Pharmacopoeia, WHO Drug Information. The method uses a base-deactivated reversed-phase C18 column (25 cm x 4.6 mm i.d.), 5 microm kept at a temperature of 40 degrees C. The mobile phases consist of acetonitrile, phosphate buffer pH 7.5 and water. The flow rate is 1.0 ml/min. UV detection is performed at 220 nm. A system suitability test (SST) is described to govern the quality of the separation. The separation towards IDV components was investigated on 16 C18 columns and correlation was made with the column classification system developed in our laboratory. The method was evaluated using a Hypersil BDS C18 column (25 cm x 4.6 mm i.d.), 5 microm. A central composite design was applied to examine the robustness of the method. The method shows good precision, linearity, sensitivity and robustness. Six commercial samples were examined using this method.

Dynamic changes in orbitofrontal neuronal activity in rats during opiate administration and withdrawal

The orbitofrontal cortex is involved in the reinforcing effects of drugs of abuse. However, how the dynamic activity in OFC changes during opiate administration and withdrawal period has not been investigated. We first tested the effects of opiates and drug craving with the conditioned place preference paradigm, using manganese-enhanced magnetic resonance imaging and traditional electroencephalograph recording techniques in rats. T1-weighted 2D MRI (4.7 T) was used after unilateral injection of MnCl(2) (200 nL, 80 mM) into the right orbitofrontal cortex. The manganese-enhanced magnetic resonance imaging data suggested that the OFC activity decreased during the opiate administration period but recovered increasingly during the withdrawal period. Also, we found decreases and increases in gamma-band (20-100 Hz) activity during the opiate administration and withdrawal period, respectively. Our results showed that orbitofrontal cortex activity decreased during morphine administration and then went up progressively over several days during withdrawal. The time course of the recovery of orbitofrontal activity from inhibition during the withdrawal period may be related to the experience of drug craving.

Changes in axial length following trabeculectomy and glaucoma drainage device surgery

AIM

This study examines the changes in axial length (AL) after trabeculectomy and glaucoma drainage device (GDD) surgery and enabled an equation to be derived allowing prediction of AL change after filtering surgery.

METHODS

This was a prospective, interventional case series from the Glaucoma Service of the Doheny Eye Institute.

PATIENT POPULATION

One eye of 39 patients undergoing trabeculectomy and 22 undergoing Baerveldt tube shunt implantation for uncontrolled glaucoma.

INTERVENTION

These patients had AL measurements by non-contact, partial coherence interferometry preoperatively, at 1 week, 1 month, and >3 months after surgery.

MAIN OUTCOME MEASURES

Axial length and intraocular pressure were compared at preoperative and postoperative visits. Postoperative intraocular pressure (IOP) was categorised as hypotonous (0-4 mm Hg), low (5-9), normal (10-17), and high (18 or more).

RESULTS

There was a statistically significant reduction in IOP after 3 months of -12.8 (SD 1.5) mm Hg following trabeculectomy (p<0.001), and -10.7 (1.9) mm Hg after GDD (p<0.001). There was a statistically significant reduction in AL, which was similar after trabeculectomy and GDD at all time points (p<0.001), of -0.15 (0.03) and -0.21 (0.04) mm (1 week), -0.18 (0.02) and -0.10 (0.02) mm (1 month), and -0.16 (0.03) and -0.15 (0.03) mm (3 months). At 3 months or later the AL reduction was related to postoperative IOP and to the amount of IOP reduction (p<0.05, stepwise multiple regression). 10.2% (4/39) of trabeculectomy patients had hypotony after 3 months, with a mean AL reduction (-0.39 (0.11)) that was statistically significantly lower (p<0.01) than the other trabeculectomy eyes (-0.14 (0.15)).

CONCLUSIONS

There is a small but statistically significant decrease in AL after both trabeculectomy and GDD surgery, greater in eyes that are hypotonous after surgery. The authors suggest that AL reduction can be predicted after 3 months by the formula: AL reduction (mm) = -199+0.006 x IOP reduction+0.008 x final IOP.

Prevalence of Parkinson's disease in Sydney

OBJECTIVE

To examine the prevalence of Parkinson's disease (PD) in Bankstown, Sydney, using the same methodology as a previous study in Randwick, Sydney, Australia (1998-1999).

PARTICIPANTS AND METHODS

Twenty census districts (CDs) for the Bankstown local government area were randomly selected. Research personnel door-knocked every household within the CDs to locate people aged > or =55 years. A structured questionnaire (containing four screening questions for PD) was administered to those agreeing to participate. Screened positive participants were invited to come for a clinical examination. This is a continuation of the previous study and data have been combined.

RESULTS

Combining data for Bankstown and Randwick gave 1028 participants; crude prevalence, 780 per 100,000 (CI: 546-1077). In Bankstown, there were 501 participants aged > or =55 years (response rate 70%); 135 were screened positive with 101 (74.8%) agreeing to a clinical examination. The prevalence of PD in the Bankstown community was 3.4% (17 of 501) (95% CI: 1.98-5.43) for those aged > or =55 years; crude prevalence 776 per 100,000 (CI: 452-1241).

CONCLUSION

The combined results of two Sydney studies appear to indicate that Sydney has one of the highest prevalence estimates of PD in developed countries.

The release of cupric ion in simulated uterine: New material nano-Cu/low-density polyethylene used for intrauterine devices

With the development of IUDs, a number of copper-bearing devices are now commercially available, including the copper-T, the Multiload and the copper-T in various other forms, so-called "the second-generation" IUDs. In this article, we report on nano-Cu/low-density polyethylene composite as a potential copper carrier in IUD. Two issues for the new material are addressed: the effectiveness of polymers in reducing the initial burst in cupric ion release and the amount and pattern of continuing release. The aim of this study was to investigate copper ion release from this composite as a basis for considering its used in an IUD.

Patient Preference for Placebo, Acetaminophen (paracetamol) or Celecoxib Efficacy Studies (PACES): two randomised, double blind, placebo controlled, crossover clinical trials in patients with knee or hip osteoarthritis

BACKGROUND

Acetaminophen (paracetamol) is recommended as the initial pharmacological treatment for knee or hip osteoarthritis. However, survey and clinical trial data indicate greater efficacy for non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 specific inhibitors.

DESIGN

Two randomised, double blind, placebo controlled, crossover multicentre clinical trials, Patient Preference for Placebo, Acetaminophen or Celecoxib Efficacy Studies (PACES).

PATIENTS

Osteoarthritis of knee or hip.

INTERVENTION

"Wash out" of treatment; randomisation; 6 weeks of celecoxib 200 mg/day, acetaminophen 1000 mg four times a day, or placebo; second "wash out;" crossover to 6 weeks of second treatment.

MEASUREMENTS

Western Ontario McMaster Osteoarthritis Index (WOMAC), visual analogue pain scale, patient preference between two treatments.

RESULTS

Celecoxib was more efficacious than acetaminophen in both periods in both studies; WOMAC and pain scale scores differed at p<0.05 in period II and both periods combined of PACES-a and in periods I and II and both periods combined in PACES-b, but not in period I of PACES-a. Acetaminophen was more efficacious than placebo, generally p<0.05 in PACES-b, and >0.05 in PACES-a. Patient preferences were 53% celecoxib v 24% acetaminophen in PACES-a (p<0.001) and 50% v 32% in PACES-b (p = 0.009); 37% acetaminophen v 28% placebo in PACES-a (p = 0.340) and 48% v 24% in PACES-b (p = 0.007). No clinically or statistically significant differences were seen in adverse events or tolerability among the three treatment groups.

CONCLUSIONS

Greater efficacy was seen for celecoxib v acetaminophen v placebo, while adverse events and tolerability were similar. Variation in results and statistical significance in the two different trials are of interest.