Mid-trial design reviews for sequential clinical trials

When sequential clinical trials are conducted by plotting a statistic measuring treatment difference against another measuring information, power is guaranteed regardless of nuisance parameters. However, values need to be assigned to nuisance parameters in order to gain an impression of the sample size distribution. Each interim analysis provides an opportunity to re-evaluate the relationship between sample size and information. In this paper we discuss such mid-trial design reviews. In the special cases of trials with a relatively short recruitment phase followed by a longer period of follow-up, and of normally distributed responses, mid-trial design reviews are particularly important. Examples are given of the various situations considered, and extensive simulations are reported demonstrating the validity of the review procedure in the case of normally distributed responses.

Exact sequential tests for single samples of discrete responses using spending functions

Sequential tests are increasingly used to reduce the expected sample size of trials in medical research. The majority of such methods are based on the assumption of normality for test statistics. In clinical trials yielding a single sample of discrete data, that assumption is often poorly satisfied. In this paper we show how a novel application of the spending function approach of Lan and DeMets can be used together with exact calculation methods to design sequential procedures for a single sample of discrete random variables without the assumption of normality. A special case is that of binomial data and the paper is illustrated by the design of a cytogenetic study which motivated this work.

New onset atrial flutter termination by overdrive transoesophageal pacing: effects of different protocols of stimulation

AIM

We evaluated the effect of different stimulation protocols on atrial flutter interruption by transoesophageal pacing.

METHODS AND RESULTS

Eighty patients with new onset atrial flutter were randomized into four groups. Pacing was attempted under the following conditions: with short bursts (5 s), without treatment (group A) and after oral administration of propafenone 600 mg (group B); with prolonged bursts (30 s), without treatment (group C) and after oral administration of propafenone 600 mg (group D). Pacing interrupted atrial flutter in 20% of patients in A, 55% in B, 50% in C and 85% in D. The use of longer bursts gave better results both in patients without treatment (P < 0.05: C vs A) and in patients with propafenone (P < 0.05: D vs B). Comparing groups with the same stimulation protocol, we observed a better response in patients treated with propafenone (P < 0.05: B vs A and D vs C). In the groups without treatment the use of shorter bursts was associated with a lower induction of stable atrial fibrillation (three vs nine episodes), in the groups on propafenone no differences were observed (one vs one episode).

CONCLUSIONS

We conclude that the association of propafenone with long bursts gives the best result for interruption of new onset atrial flutter by transoesophageal pacing.

Working in the public and private domains: staff management of community activities for and the identities of people with intellectual disability

In addition to describing how the concept of stigma continues to be a pervasive influence in encounters between people with intellectual disability and others, the present study suggests that the management of this situation has passed into the control of care staff. An ethnographic study of young adults and community relationships suggests that the activities of staff are crucial in shaping the social profile of people with intellectual disability. The views of care staff about the taken-for-granted rights which characterize presence and participation in the community domain encourage them to adopt a semi-insulation approach to their work. Staff extend this approach by adopting information control strategies to conceal important information from students. The present author argues that there is a need for on-going research into staff activity in the community domain.

Macromolecular inhibitors of HIV-1 protease. Characterization of designed heterodimers

Defective variants of human immunodeficiency virus type 1 (HIV-1) protease (HIV PR) have been engineered to inhibit wild-type (wt) HIV PR activity. These variants were designed to promote the formation of heterodimers and to destabilize the formation of inactive variant homodimers of HIV-1 protease through substitutions at Asp-25, Ile-49, and Gly-50 (Babé, L. M., Rosé, J., and Craik, C. S. (1995) Proc. Natl. Acad. Sci. U. S. A. 92, 10069-10073; McPhee, F., Good, A. C., Kuntz, I. D., and Craik, C. S. (1996) Proc. Natl. Acad. Sci. U. S. A. 93, 11477-11481). The mechanism of action of these dominant-negative inhibitors was established using recombinantly expressed defective monomers. The defective monomers were refolded in vitro in the presence of wt HIV PR and showed dose-dependent inhibition of proteolytic activity. This inhibition was shown to result from the formation of inactive heterodimers between defective and wt HIV PR monomers. Heterodimer formation was detected by (i) isolating refolded, inactive heterodimers using histidine-tagged defective monomers and (ii) isolating heterodimers from bacteria coexpressing both wt and defective variants of HIV PR. Single-chain variants of HIV PR, in which the C terminus of the wt HIV PR monomer was covalently tethered to the N terminus of the defective monomer, were also expressed and analyzed. Thermal denaturation of these single-chain heterodimers using differential scanning calorimetry revealed a 1.5-7.2 degrees C greater thermal stability than single-chain wt HIV PR. The thermodynamic trend shown by these three variants mirrors their relative inhibition in provirus transfection assays. These data support the model that the effects seen both in tissue culture and in vitro arise from an increase in stability conferred on these heterodimers by interface mutations and identifies heterodimer formation as their mechanism of inhibition.

HIV protease as a target for retrovirus vector-mediated gene therapy

The dimeric aspartyl protease of HIV has been the subject of intense research for almost a decade. Knowledge of the substrate specificity and catalytic mechanism of this enzyme initially guided the development of several potent peptidomimetic small molecule inhibitors. More recently, the solution of the HIV protease structure led to the structure-based design of improved peptidomimetic and non-peptidomimetic antiviral compounds. Despite the qualified success of these inhibitors, the high mutation rate associated with RNA viruses continues to hamper the long-term clinical efficacy of HIV protease inhibitors. The dimeric nature of the viral protease has been conducive to the investigation of dominant-negative inhibitors of the enzyme. Some of these inhibitors are defective protease monomers that interact with functional monomers to form inactive protease heterodimers. An advantage of macromolecular inhibitors as compared to small-molecule inhibitors is the increased surface area of interaction between the inhibitor and the target gene product. Point mutations that preserve enzyme activity but confer resistance to small-molecule inhibitors are less likely to have an adverse effect on macromolecular interactions. The use of efficient retrovirus vectors has facilitated the delivery of these macromolecular inhibitors to primary human lymphocytes. The vector-transduced cells were less susceptible to HIV infection in vitro, and showed similar levels of protection compared to other macromolecular inhibitors of HIV replication, such as RevM10. These preliminary results encourage the further development of dominant-negative HIV protease inhibitors as a gene therapy-based antiviral strategy.

Strategic planning and progress under the All Wales Strategy: reflecting the perceptions of stakeholders

Nominated representatives from the various stakeholder interests, i.e. social services, health, education, voluntary organizations, parent groups and self-advocacy groups, involved in the implementation of the All Wales Strategy for the development of services for people with intellectual disability were interviewed 2 years after the end of the initial 10-year phase. Interviewees were asked to reflect on the strengths and weaknesses of policy implementation, including: changing priorities, planning arrangements, agency roles, central guidance and financial mechanisms, consumer participation, and the impact of more recent policy or structural developments. Despite recognition of the leadership of the Welsh Office, the shift in thinking achieved, the developments made in joint agency collaboration and in consumer participation in planning, and an increasing competence to plan effectively over time, the overriding perception was that more could have been made of the opportunity afforded by the clearest and best resourced central government policy within the UK in this area. At the heart of this judgement lay concerns about pragmatic rather than strategic planning, a failure to link annual service developments to a final comprehensive end point and a related failure to integrate planning to meet community needs with hospital resettlement Factors which may have contributed to these weaknesses are discussed, as are lessons for subsequent community care policy.

Yeast two-hybrid assay for examining human immunodeficiency virus protease heterodimer formation with dominant-negative inhibitors and multidrug-resistant variants

The yeast two-hybrid assay was used to study the dimerization of engineered and naturally occurring variants of human immunodeficiency virus (HIV) protease (PR) monomers. Defective monomers that were previously shown to exhibit a dominant-negative (D-N) effect in cultured mammalian cells were tested for their ability to interact in the two-hybrid assay. Similarly, monomers with dimer-interface substitutions and monomers harboring in vivo selected mutations that confer multidrug resistance (mdr) in an AIDS patient were tested for interaction in yeast. Dimer formation between wt monomers with catalytic aspartates was not detected in yeast, whereas the dimerization of PR monomers harboring the acid active site substitution D25N was readily demonstrated. The use of inactive monomers harboring the D25N substitution as a genetic background for studying additional HIV PR mutations allowed for the probing of interactions between monomers with mdr-associated mutations with those based on the HIV-1 HXB2R sequence. The HTLVIII/HIV-1 HXB2R clone has been the basis for a large number of HIV-related plasmids, primers, antibodies, and other specific reagents throughout the HIV research community. The results of our assay suggest that HXB2R-based D-N PR inhibitors associate with variant monomers based on the recently obtained nucleotide sequence from an AIDS patient with a multidrug-resistant virus. These results further encourage the use of D-N PR inhibitors as antiviral agents which may complement existing small-molecule combination therapies.

Dietary antioxidant vitamins and fiber in the etiology of cardiovascular disease and all-causes mortality: results from the Scottish Heart Health Study

In this paper, data obtained between 1984 and 1993 from 11,629 men and women as part of the Scottish Heart Health Study (Scotland, United Kingdom) were used to investigate the relation between antioxidant vitamin and fiber intakes and both incident coronary heart disease (CHD) (649 events) and all-causes mortality (591 deaths). All age-adjusted mean intakes tended to be higher in the group that experienced no event. For men, increased fiber intake was associated with decreased risk of CHD even after adjustment for a host of other major coronary risk factors; hazard ratios relative to the lowest quarter were 0.68, 0.70, and 0.64 by increasing quarter. This relation was also observed for mortality (hazard ratios of 0.62, 0.66, and 0.62). Evidence was found that higher intakes of the antioxidants were also beneficial, although the associations were weaker. For women, fiber was the only obviously influential dietary factor, with hazard ratios of 0.94, 0.60, and 0.56 for CHD and 1.25, 0.82, and 0.65 for mortality. These results suggest that the current public health drive to increase the consumption of foods rich in antioxidant vitamins and (particularly) fiber will impact on both CHD risk and the general health of the population.

Colostrum intake by dairy calves

AIMS

To determine which clinical parameters could be used to identify calves with low serum immunoglobulin levels and to examine the influence of cow and calf behaviour on colostrum intake.

METHODS

Blood samples were taken from 74 dairy calves after they were separated from their dams, and analysed for serum gamma glutamyltransferase (GGT) activity. Physical and behavioural measurements were taken for 57 of these calves at this time. The behaviour of 2 1 dairy cows and their calves was observed between birth and the time the calves were separated when a blood sample was taken from 17 of them and analysed for GGT.

RESULTS

Low serum GGT activities (below 200 U/l GGT), indicating low serum immunoglobulin levels, were found in 45% of the group of 74 calves. The calves which had not received colostrum were not easy to distinguish from those that had on the basis of physical or behavioural features. The amount of time that the 2 1 calves spent with their dams before being separated ranged from 1.2 to 24.9 hours. Thirty-three per cent of these calves had not sucked within this time. Of the calves that did suck, 79% did so within 6 hours of birth.

CONCLUSIONS

About one half of New Zealand dairy calves may not receive colostrum from their dams even when they are together for up to 24 hours. Most calves that are going to suck of their own accord will do so within 6 hours of birth.

CLINICAL SIGNIFICANCE

Dairy calves should be removed from their dams after 6 hours and fed colostrum to guarantee that they receive sufficient immunoglobulins.

Mental health attrition from Air Force basic military training

The Department of Defense invests considerable money in recruiting and training new military recruits who are discharged for mental health reasons before completing their first enlistment, often within the first 6 months of active duty. The purpose of this study was to provide a description of 1,138 Air Force recruits referred for a mental health evaluation while in basic military training. Variables examined include dispositions, demographic features, diagnoses, mental health history, and attitude and motivation characteristics. Findings show that trainees recommended for discharge often had a history of depression, expressed a lack of motivation to continue in the military, were reporting suicidal ideation, and typically had withheld information on their mental health history during their Military Entrance Processing Station processing. The results are discussed in terms of potential strategies for reducing mental health attrition in Air Force basic military training.

Effect of sample volume location on Doppler-derived transmitral inflow velocity values in 288 normal subjects 20 to 80 years old: an echocardiographic, two-dimensional color Doppler cooperative study

The aims of the study were to evaluate in a population of 288 normal subjects 20 to 80 years old (1) the normal values of the indexes of the mitral flow velocity pattern measured either at the tips of the mitral leaflets or at the annulus; (2) whether there was a significant difference between the values obtained at the tips compared with those measured at the mitral annulus; (3) the correlation with aging between the indexes measured in the two different positions; and (4) whether certain physiological variables have different effects on diastolic function measured in the two different positions. The highest values were always measured at the tips of the mitral leaflets (p < 0.05); only atrial filling fraction, E acceleration time, and E deceleration velocity had higher values when measured at the level of the annulus (p < 0.05). The A-wave peak velocity had the same mean value when measured at both the tips and at the annulus. A significant difference in the correlation between parameters measured at the tips of the mitral leaflets with age and at the annulus (with age) was observed for the following parameters: (1) peak E velocity, E integral, total integral and E acceleration showed better correlation with age when measured at the annulus (p < 0.02); (2) peak A velocity and A integral showed better correlation with age when measured at the tips of the mitral leaflets (p < 0.001). Multivariate analysis showed that age was the variable that had the most influence on diastolic function parameters; heart rate had less influence on the diastolic function indexes.

Incorporation of sequential trials into a fixed effects meta-analysis

The technique of meta-analysis provides a systematic and quantitative approach to the summary of results from a collection of similar randomized studies. Comprehensive methodology exists for analysis when all trials are of a fixed sample size design, but this is based on assumptions which are no longer valid when incorporating sequentially designed studies. In this paper the effect of incorporating one or more sequential trials into a meta-analysis otherwise consisting of fixed sample size trials is investigated. The results from simulation studies of a variety of plausible scenarios are presented. The aim is to quantify the extent to which bias is introduced. It was found that when incorporating two alternative sequential designs, the triangular test and the O'Brien and Fleming procedure, the results of a conventional meta-analysis remain accurate.

Replication-competent picornaviruses with complete genomic RNA 3' noncoding region deletions

The genomic RNA 3' noncoding region is believed to be a major cis-acting molecular genetic determinant for regulating picornavirus negative-strand RNA synthesis by promoting replication complex recognition. We report the replication of two picornavirus RNAs harboring complete deletions of the genomic RNA 3' noncoding regions. Our results suggest that while specific 3'-terminal RNA sequences and/or secondary structures may have evolved to promote or regulate negative-strand RNA synthesis, the basic mechanism of replication initiation is not strictly template specific and may rely primarily upon the proximity of newly translated viral replication proteins to the 3' terminus of template RNAs within tight membranous replication complexes.

Parental work: an account of the day-to-day activities of parents of adults with learning disabilities

The parental role can be an enduring one for many people with sons or daughters with learning disabilities. Despite this, there has been little research on parents' experiences during their offspring's adult years. The present paper examines the different dimensions of work undertaken by parents in the care of their adult offspring and how they felt these had changed over the years. The paper also explores how parents seek to combine parental work with other aspects of their lives. Data for this study were derived from a qualitative, in-depth study of the experiences of parents of 33 co-resident adult offspring with learning disabilities. The data suggest that the long-term nature of parenting involves both stability and change. For example, some parents had experienced a depletion of physical resources and enthusiasm that made it difficult for them to carry out some aspects of parental work. Parents had also met new difficulties, such as the handling of the disclosure of learning disability to their offspring, as well as to members of the public. For all parents, parenting had remained an extensive involvement, so that they still found it difficult to meet the demands of parenting, and their own non-parental tasks and interests. The data also indicate that service intervention needs to be based on an appreciation of the temporal and personal difficulties in parents' lives, and that service intervention can add to the perceived burden of carers without such an appreciation.

Comparative evaluation of Wellhöfer ion chamber array and Scanditronix diode array for dynamic wedge dosimetry

Normalised profiles have been measured using the Scanditronix diode array and the Wellhöfer ion chamber array for the Varian dynamic wedge. Agreement was of the order of 0.1% of central axis peak dose for an open beam at depth, 0.3% for a dynamic wedge field at depth, and up to 0.6% at the peak depth. The use of the arrays for data acquisition is discussed, including user interface limitations. Data reproducibility is determined to be of the order of 0.1% for both systems. The issue of beam hardening within dynamic wedges is discussed and resolved in terms of the dose-gradient effect. A method for interpolation between dynamic wedge profiles using open beam data is presented that allows construction of isodoses to an estimated accuracy of 0.7%. Finally a benchmark for comparison of different measuring systems based on quality assurance requirements for the enhanced dynamic wedge is suggested.

Speech intelligibility of children with multichannel cochlear implants

The purpose of this longitudinal study is to document improvements in speech intelligibility in children who have received multichannel cochlear implants, to compare their performance to that of a matched group of children with different levels of hearing loss who use conventional hearing aids. Speech intelligibility was measured by panels of listeners who analyzed recorded speech samples preimplant and at 6-month intervals following implantation. The results of this study demonstrate that prelingually deafened children with the Nucleus multichannel cochlear implant achieved significant improvements in speech intelligibility. By the 4.5- to 7.5-year intervals, the speech intelligibility exceeded 40%.

Homozygous deletions of human chromosome 3p in lung tumors

Cytogenetic and loss of heterozygosity (LOH) studies have demonstrated that deletions of chromosome 3p occur at a high frequency in all forms of lung cancer. To clarify the role of 3p in lung tumorigenesis and to more precisely identify targets for positional cloning efforts, we have performed 3p deletion analyses (microsatellite and fluorescence in situ hybridization) in a series of lung cancer cell lines and uncultured tumor samples. Importantly, we identified homozygous deletions in four uncultured tumors and one cell line. Homozygous deletions were found in three squamous tumors within a region of 3p21 which had previously been described only in cell lines, a 1-2-megabase homozygous deletion in a small cell tumor at 3p12, and a 3p14.2 homozygous deletion in a non-small cell lung carcinoma cell line. The detection of homozygous deletions affecting these multiple regions in uncultured tumor cells substantiates the belief (previously based on deletions found only in tumor cell lines) that these sites contain important tumor suppressor genes. Along with previously reported homozygous deletions in a distal portion of 3p21.3, we now have evidence for four separate regions of 3p which undergo homozygous deletions in either uncultured lung tumors or cell lines.

Translation and replication properties of the human rhinovirus genome in vivo and in vitro

The poor translation efficiency of genome-length human rhinovirus RNA in vitro using HeLa cell extract-supplemented rabbit reticulocyte lysate has hampered the study of rhinovirus IRES-mediated translation and polyprotein synthesis in a cell-free system. In contrast, the efficient in vitro translation characteristics of poliovirus RNAs have ultimately allowed the programming of cell-free coupled translation/replication extracts which are able to produce infectious poliovirus particles in vitro. A possible explanation for the decreased burst size observed during the course of a rhinovirus infection, compared to poliovirus infection, is reduced levels of polyprotein synthesis in vivo. In order to test this hypothesis and extend in vitro translation/replication technology to the study of human rhinoviruses, a chimeric cDNA construct was engineered which allowed the in vitro synthesis of T7 transcripts containing the intact poliovirus type 1 (PV1) 5' noncoding region (5' NCR) and initiation codon upstream of the human rhinovirus 14 (HRV14) polyprotein-coding region and 3'-terminal sequences. These chimeric RNAs translated efficiently in vitro and were used successfully to program a cell-free replication extract. Unexpectedly, parental HRV14 RNAs also translated efficiently in the HeLa cell-free translation/replication extract but replicated less efficiently than the chimera in vitro. The chimeric HRV14/PV1 RNAs were infectious and gave rise to a virus with a growth phenotype similar to that of parental HRV14. Preliminary characterization of this chimeric virus suggests that the biological properties characteristic of rhinovirus in vivo are determined primarily by the rhinovirus gene products. Although the translation efficiency of the HRV14 5' NCR may be a limitation in rabbit reticulocyte lysate-based in vitro translation extracts, it does not appear to be a major limiting determinant for growth of rhinovirus in vivo or replication in the HeLa cell-free extract.

Chromosome 3p14 homozygous deletions and sequence analysis of FRA3B

Loss of heterozygosity (LOH) involving 3p occurs in many carcinomas but is complicated by the identification of four distinct homozygous deletion regions. One putative target, 3p14.2, contains the common fragile site, FRA3B, a hereditary renal carcinoma-associated 3;8 translocation and the candidate tumor suppressor gene, FHIT. Using a approximately 300 kb comsid/lambda contig, we identified homozygous deletions in cervix, breast, lung and colorectal carcinoma cell lines. The smallest deletion (CC19) was shown not to involve FHIT coding exons and no DNA sequence alterations were present in the transcript. We also detected discontinuous deletions as well as deletions in non-tumor DNAs, suggesting that FHIT is not a selective target. Further, we demonstrate that some reported FHIT aberrations represent normal splicing variation. DNA sequence analysis of 110 kb demonstrated that the region is high in A-T content, LINEs and MER repeats, whereas Alu elements are reduced. We note an intriguing similarity in repeat sequence composition between FRA3B and a 152 kb segment from the Fragile-X region. We also identified similarity between a FRA3B segment and a small polydispersed circular DNA. In contrast to the selective loss of a tumor suppressor gene, we propose an alternative hypothesis, that some putative targets including FRA3B may undergo loss as a consequence of genomic instability. This instability is not due to DNA mismatch repair deficiency, but may correlate in part with p53 inactivation.