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Internet based clinical trial protocols -- as applied to a study of warfarin pharmacogenetics.

AIMS: To describe and evaluate the use of an Internet-based study protocol in a multicentre study of genetic risk factors in anticoagulant treatment. METHODS: A web-based study protocol, similar to existing anticoagulation medical record systems, was developed for entry of clinical data. It was also supplied with a separate interface for study monitoring. Measures were taken to assure the confidentiality of transferred data. In addition, software modifications were made to enable automated transfer of clinical data from an existing medical record system to the study database. RESULTS: The system has been in use since March 2002, and at present 39 centres have included 909 patients with a dropout rate of 2.8%. The need for education of participating clinicians has been satisfactorily provided for by means of written instructions and telephone support. CONCLUSIONS: Our study demonstrates the usability of Internet-based data acquisition techniques in a full-scale multicentre clinical trial. The main advantages of such a protocol are automated data validation and standardization, fast data transfer independent of geographical distance, user feedback, synchronization of protocol updates and automatic data formatting facilitating statistical analyses. Safety and accessibility are possibly cumbersome areas and should be addressed duly.

Adult↗

Mechanisms of methicillin resistance in staphylococci.

The continuously high prevalence of methicillin-resistant staphylococci (MRS) throughout the world is a constant threat to public health, owing to the multiresistant characteristics of these bacteria. Methicillin resistance is phenotypically associated with the presence of the penicillin-binding protein 2a (PBP2a) not present in susceptible staphylococci. This protein has a low binding affinity for beta-lactam antibiotics. It is a transpeptidase which may take over cell wall synthesis during antibiotic treatment when normally occurring PBPs are inactivated by ligating beta-lactams. PBP2a is encoded by the mecA gene, which is located in mec, a foreign DNA region. Expression of PBP2a is regulated by proteins encoded by the plasmid-borne blaR1-bla1 inducer-repressor system and the corresponding genomic mecRl-mecl system. The blaRl-blal products are important both for the regulation of beta-lactamase and for mecA expression. Methicillin resistance is influenced by a number of additional factors, e.g. the products of the chromosomal fem genes which are important in the synthesis of normal peptidoglycan precursor molecules. Inactivation of fem-genes results in structurally deficient precursors which are not accepted as cell wall building blocks by the ligating PBP2a transpeptidase during antibiotic treatment. This may result in reduced resistance to beta-lactam antibiotics. Inactivation of genes affecting autolysis has shown that autolytic enzymes are also of importance in the expression of methicillin resistance. Methicillin resistance has evolved among earth microorganisms for protection against exogenous or endogenous antibiotics. Presumably the mec region was originally transferred from coagulase negative staphylococci (CNS) to Staphylococcus aureus (SA). A single or a few events of this kind with little subsequent interspecies transfer had been anticipated. However, recent data suggest a continuous horizontal acquisition by S. aureus of mec, being unidirectional from CNS to SA. Methicillin resistance may also be associated with mechanisms independent of mecA, resulting in borderline methicillin resistance. These mechanisms include beta-lactamase hyperproduction, production of methicillinases, acquisition of structurally modified normal PBPs, or the appearance of small colony variants of SA. Most MRS are multiresistant, and the mec region may harbour several resistance determinants, resulting in a clustering of resistance genes within this region.

Bacterial Proteins↗

An investigation of the differential-outcomes effect within sessions.

The differential-outcomes effect is manifest as more accurate performance of a delayed conditional discrimination when alternative choice responses are followed by different reinforcers than when they are followed by the same reinforcer. In Experiment 1, a differential-outcomes effect was demonstrated within sessions by signaling the duration of food access for correct responses with stimuli appearing in conjunction with the sample stimuli. The delayed matching-to-sample performance of 5 pigeons was more accurate when green choice responses (matching a green sample) were followed by 3.5-s food access and red choice responses (matching a red sample) were followed by 0.5-s food access (different-outcome trials) than when the correct choice responses were both followed by 1.5-s reinforcers (same-outcome trials). In Experiment 2, the acquisition of this differential-outcomes effect was characterized by a progressive decrease in rate of forgetting on different-outcome trials and no change in rate of forgetting on same-outcome trials. In addition, accuracy at the shortest delay intervals for both different-outcome and same-outcome trials increased over acquisition, but to a greater extent for different-outcome trials. These data suggest that both memorial and attentional (time-dependent and time-independent) factors contribute to the differential-outcomes effect.

Journal Article↗

Concomitant gradient field effects in spiral scans.

Maxwell's equations imply that imaging gradients are accompanied by higher order spatially varying fields (concomitant fields) that can cause artifacts in MR imaging. The lowest order concomitant fields depend quadratically on the imaging gradient amplitude and inversely on the static field strength. Time-varying concomitant fields that accompany the readout gradients of spiral scans cause unwanted phase accumulation during the readout, resulting in spatially dependent blurring. Concomitant field phase errors are independent of echo time and, therefore, cannot be detected using Dixon-type field map measurements that are normally used to deblur spiral scan images. Data acquisition methods that reduce concomitant field blurring increase off-resonant spin blurring, and vice versa. Blurring caused by concomitant fields can be removed by variations of image reconstruction methods developed to correct for spatially dependent resonance offsets with nonrectangular k-space trajectories.

Artifacts↗

Hemodialysis access fistula creation: preoperative assessment with MR venography and comparison with conventional venography.

PURPOSE: To prospectively evaluate magnetic resonance (MR) venography in the assessment of the adequacy of superficial veins for creation of hemodialysis access fistulas. MATERIALS AND METHODS: Twenty-eight upper limbs in 24 patients were imaged with MR and conventional venography. MR venography was performed with sequential multisection two-dimensional fast low-angle shot acquisitions in the axial plane from the wrist through the arm. Two observers independently evaluated MR venograms without knowledge of conventional venographic results. MR and venographic data were compared with each other and with surgical data in 21 patients. Diameters measured on MR and conventional venograms were compared by using linear regression analysis. Qualitative comparisons were performed with the kappa coefficient. RESULTS: Conventional and MR venographic diameter measurements were closely correlated overall (r = 0.91, P < .001) and on a vein-by-vein basis (r = 0.84-0.98, P < .001). MR and conventional venographic results were also well correlated in terms of demonstration of superficial veins (kappa = 0.83). MR venography demonstrated more patent veins than venography did, but the difference was not significant. The correlation between MR venographic and surgical findings (kappa = 0.78) was superior to that between conventional venographic and surgical findings (kappa = 056). CONCLUSION: MR venography is an accurate, noninvasive technique that is as useful as conventional venography for the planning of hemodialysis access fistula creation.

Adolescent↗

Cardiac diffusion MRI without motion effects.

We present a method for diffusion tensor MRI in the beating heart that is insensitive to cardiac motion and strain. Using a stimulated echo pulse sequence with two electrocardiogram (ECG) triggers, diffusion-encoding bipolar gradient pulses are applied at identical phases in consecutive cardiac cycles. In this experiment, diffusion is encoded at a single phase in the cardiac cycle of less than 30 ms in duration. This encoding produces no phase shifts for periodic motion and is independent of intervening strains. Studies in a gel phantom with cyclic deformation confirm that by using this sequence we can map the diffusion tensor free of effects of cyclic motion. In normal human subjects, myocardial diffusion eigenvalues measured with the present method showed no significant change between acquisitions encoded at maximum contractile velocity (peak) vs. at myocardial standstill (end-systole), demonstrating motion independence of in vivo diffusion measurements. Diffusion tensor images acquired with the present method agree with registered data acquired with a previous cardiac diffusion MRI method that was shown to be valid in the normal heart, strongly supporting the validity of MRI diffusion measurement in the beating heart. Myocardial sheet and fiber dynamics measured during systole showed that normal human myocardial sheet orientations tilt toward the radial during systole, and fiber orientations tilt toward the longitudinal, in qualitative agreement with previous invasive studies in canines. These results demonstrate the technique's ability to measure myocardial diffusion accurately at any point in the cardiac cycle free of measurable motion effect, as if the heart were frozen at the point of acquisition.

Diffusion↗

The cues that children use in acquiring adjectival phrases and compound nouns: evidence from bilingual children.

This study explores the cues used in acquisition of two semantically similar structures that are ordered differently in French and English: adjectival phrases and compound nouns. One possible prediction is that children attend primarily to meaning, so they should order both structures similarly. Another is that children attend primarily to structure, so they should learn these structures independently. Two kinds of data were obtained from eight 4-year old bilinguals: (1) spontaneous production and (2) experimental elicitation. The children were nearly perfect in their ordering of adjectival phrases, but less so in compounds. These results conform to neither prediction, leaving open the question of which cues children use in acquisition.

Child↗

Rapid magnetic resonance angiography for detection of atherosclerosis.

BACKGROUND: Choice of treatment for atherosclerosis depends on various clinical factors and radiological techniques. We aimed to assess the diagnostic accuracy of a new three-dimensional magnetic resonance angiography (3D MRA) strategy for the display of arterial vasculature from supra-aortic arteries to distal runoff vessels in 72 s. METHODS: We examined five healthy volunteers and six patients over 6 weeks. Conventional digital subtraction angiography (DSA) was available as reference standard in all six patients. Magnetic resonance imaging was done on a commercially available 1.5 Tesla scanner. The imaging technique was based on the acquisition of five 3D data sets in rapid succession with an optimum single injection protocol. FINDINGS: Compared with conventional catheter angiography, according to the findings of two independent and masked readers, whole-body MRA had overall sensitivities of 91% (95% CI 0.76-0.98) and 94% (0.8-0.99), and specificities of 93% (0.85-0.97) and 90% (0.82-0.96) for the detection of substantial vascular disease (luminal narrowing >50%), interobserver agreement for assessment of whole-body magnetic angiograms was very good (kappa=0.94; 95% CI 0.9-0.98). INTERPRETATION: The technique provides a comprehensive non-invasive approach for morphological screening assessment of the arterial vasculature from supra-aortic arteries to the distal runoff arteries.

Adult↗

Characterization of a programmed alteration in an 18S ribosomal gene that accompanies the experimental induction of drug resistance in Schistosoma mansoni.

Stable resistance to the anthelmintic hycanthone can be produced in the human blood fluke Schistosoma mansoni by exposing immature parasites in mice to the drug. Within a single generation, genomic rearrangements, detected as rRNA-encoding DNA restriction fragment length polymorphisms (RFLPs), accompany the appearance of resistance in this model. One of these RFLPs, an approximately 3.6-kilobase BamHI fragment, was shown previously to associate consistently with resistance in independent generations of the JHU strain of S. mansoni. To characterize the genetic changes responsible for this RFLP, the fragment was cloned and sequenced. A comparison of the cloned fragment with a normal 18S rRNA gene demonstrated that the drug resistance-associated RFLP fragment arises through the addition of 732 base pairs into an 18S rRNA gene, 134 base pairs downstream of the junction of the intergenic spacer and the mature 18S rRNA gene. The mutation is nonrandom, targets one, or a few only, of the 100 or so copies of the ribosomal genes, and may represent the incomplete duplication of the gene since the inserted element is identical in sequence to the region contiguous to it. The sequence spanning the junction of the insertion and the original 18S rRNA gene was used as a specific primer for the BamHI RFLP in PCR experiments. The analysis conclusively demonstrated that the mutation is induced rather than selected by the drug since the junctional sequence was not detectable in the drug-sensitive parent population of schistosomes. In addition, analysis of four, independently derived, resistant lines indicated that the same region of the gene was mutated each time. Together, these data demonstrate that reproducible changes are induced during the acquisition of resistance in schistosomes and suggest that the resistant phenotype is induced rather than selected from preexisting forms.

Animals↗

The mellow years?: neural basis of improving emotional stability over age.

Contrary to the pervasive negative stereotypes of human aging, emotional functions may improve with advancing age. However, the brain mechanisms underlying changes in emotional function over age remain unknown. Here, we demonstrate that emotional stability improves linearly over seven decades (12-79 years) of the human lifespan. We used both functional magnetic resonance imaging and event-related potential recording to examine the neural basis of this improvement. With these multimodal techniques, we show that better stability is predicted by a shift toward greater medial prefrontal control over negative emotional input associated with increased activity later in the processing sequence (beyond 200 ms after stimulus) and less control over positive input, related to a decrease in early activity (within 150 ms). This shift was independent from gray matter loss, indexed by structural magnetic resonance data. We propose an integrative model in which accumulated life experience and the motivation for meaning over acquisition in older age contribute to plasticity of medial prefrontal systems, achieving a greater selective control over emotional functions.

Adolescent↗

Identification of genes potentially involved in the acquisition of androgen-independent and metastatic tumor growth in an autochthonous genetically engineered mouse prostate cancer model.

BACKGROUND: A major focus of prostate cancer research has been to identify genes that are deregulated during tumor progression, potentially providing diagnostic markers and therapeutic targets. METHODS: We have employed serial analysis of gene expression (SAGE) and microarray hybridization to identify alterations that occur during malignant transformation in the Transgenic Adenocarcinoma of the Mouse Prostate (TRAMP) model. Many of these alterations were validated by real-time PCR (rtPCR). RESULTS: We identified several hundred mRNAs that were deregulated. Cluster analysis of microarray profiles with samples from various stages of the disease demonstrated that androgen-independent (AI) primary tumors are similar to metastases; 180 transcripts have expression patterns suggesting an involvement in the genesis of late-stage tumors, and our data support a role for phospholipase A2 group IIA in the acquisition of their highly aggressive characteristics. CONCLUSIONS: Our analyses identified well-characterized genes that were previously known to be involved in prostate cancer, validating our study, and also uncovered transcripts that had not previously been implicated in prostate cancer progression.

Adenocarcinoma↗

A JAVA-based DICOM server with integration of clinical findings and DICOM-conform data encryption.

The transfer of large amounts of medical data within heterogeneous hard and software infrastructures and the exploitation of distributed resources require a fast, secure, and platform-independent data exchange. To avoid costly vendor-specific solutions, a DICOM server was implemented in JAVA. Data access was enabled via internet browser technology. Relevant patient and image acquisition information was extracted from the DICOM images and stored into a relational database. Patient information such as radiological findings were transferred from the Radiological Information System into the database. Image data were accessed either by a fast preview tool or using a JAVA-based DICOM viewer. Since data security mechanisms are not yet part of the DICOM standard, a DICOM-conform encryption of sensitive patient data was implemented. The method allowed a dynamic selection of the data to be encrypted. Integrating this module into the image server enabled the fast and secure transfer of image data across insecure networks as well as long-term storage on CD-Recordables.

CD-ROM↗

Evaluation of retrospective multisector and half scan ECG-gated multidetector cardiac CT protocols with moving phantoms.

PURPOSE: We evaluated independently retrospective half scan and multisector mode manufacturer's protocols and compared them with modified acquisition protocols to determine optimal imaging parameters for cardiac scanning. MATERIALS AND METHODS: Data were acquired using two fabricated gated moving phantoms. In half scan mode, the manufacturer's recommended pitch values were compared with adjacent values at different motion rates. In multisector mode, the manufacturer's protocols were compared with ones with different gantry speeds and pitch values at the same motion rates. Weighted CT dose indexes (CTDI) were obtained for all protocols. Gated and reformatted reconstructed images of the moving phantoms were evaluated. RESULTS: In half scan mode, slightly better image quality was observed by lowering the pitch value, but with an increase of 6.3% of the weighted CTDI. Better results were obtained in multisector mode by lowering the pitch value up to 0.2, but with an increase of 14.3% of the weighted CTDI. Optimal images were obtained with the lowest temporal resolution. CONCLUSIONS: Gated moving phantom studies offer the advantage of testing acquisition protocols of complex motions and of helping to establish appropriate protocols.

Electrocardiography↗

The use of Apple Macintosh computers and Hypercard in teaching physiology laboratories.

A network of Apple Macintosh computers has been integrated into existing undergraduate physiology laboratories. Hypercard software programs replace the traditional laboratory handout; the text contains a number of buttons linked to cards that provide additional information on a particular subject. This additional information includes theory, the use of various instruments, expected results, and details on how to perform data analysis. This system of information layering allows students to work independently, at their own pace, and allows them to learn as much or as little as they consider necessary. Each computer is interfaced with a MacLab/4 data-acquisition unit, which permits the computer screen to display a four-channel chart recorder or a two-channel oscilloscope.

Computer Communication Networks↗

The utility of multi-detector row spiral CT for detection of coronary artery stenoses.

Contrast-enhanced multi-detector row spiral computed tomography (MDCT) was introduced as a promising noninvasive method for vascular imaging. This study examined the accuracy of this technique for detecting significant coronary artery stenoses. Both MDCT(Sensation 16, Siemens, Germany, 12x0.75 mm collimation and 0.42 sec rotation speed, 120 kV, 500 effective mA, and 2.7 mm/rotation table-feed) and invasive coronary angiography (CAG) were performed on 61 patients (mean age 59.2+/-10, 44 men) who were suspected of having coronary artery disease. All patients were treated with atenolol (25-50 mg) prior to imaging and the heart rate was maintained below 65 beats per minutes during image acquisition. The images were reconstructed in the diastole around TI-400 ms with a 0.5 mm increment and a 1.0 mm thickness. All coronary arteries with a diameter of 2.0 mm or more were assessed for the presence of a stenosis (>50% luminal narrowing). Two independent radiologists who were unaware of the results of the invasive CAG evaluated the MDCT data, and the results were compared with those from the invasive CAG (interval 1-27, mean 11 days). An evaluation of the CT coronary angiogram (CTCA) was possible in 58 of the 61 patients (95%). Image acquisition of the major coronary arteries including the left main trunk was available in 229 out of 244 arteries. Invasive CAG showed that 35 out of 58 patients had significant coronary artery stenoses by. patient analysis of those who could be evaluated showed that CT coronary angiography correctly classified 30 out of 35 patients as having at least 1 coronary stenosis (sensitivity 85.7%, specificity 91.3%, positive predictive value 93.8%, negative predictive value 80.8%). By analyzing each coronary artery, CAG found 62 stenotic coronary arteries in the 229 coronary arteries that could be evaluated. MDCT correctly detected 50 out of 62 stenotic coronary arteries and an absence of stenosis was correctly identified in 156 out of 167 normal coronary arteries (sensitivity 80.6%, specificity 93.4%, positive predictive value 81.9%, negative predictive value 92.8%). The non-invasive technique of MDCT for examining the coronary artery appears to be a useful method for detecting coronary artery stenoses with a high accuracy particularly with the proximal portion and large arteries.

Aged↗

Stages of smoking acquisition versus susceptibility as predictors of smoking initiation in adolescents in primary care.

We evaluated whether susceptibility, the stages of smoking acquisition, and socio-environmental factors can identify adolescents who will become smokers. Our data came from a randomized controlled trial of an intervention to prevent adolescent smoking. Subjects were adolescents (n=1955) ages 14-17 being seen for routine medical care. The dependent variable was 30-day smoking status at 2-year follow-up (89.6% response rate). Independent variables included susceptibility, the stages of acquisition, and socio-environmental factors. Susceptible adolescents were two to three times more likely to be smokers than non-susceptible adolescents. Compared to acquisition precontemplators, acquisition contemplators were three to five times more likely, and acquisition preparers were five to eight times more likely, to be smokers. When combined into a single measure, susceptible precontemplators were two times, contemplators were six times, and preparers were nine times more likely to be smokers than non-susceptible precontemplators. Our findings suggest that acquisition stage and susceptibility can independently predict smoking onset. They may be used together to target teens for smoking prevention efforts in the clinical setting.

Adolescent↗

Co-transcribed genes for long chain polyunsaturated fatty acid biosynthesis in the protozoon Perkinsus marinus include a plant-like FAE1 3-ketoacyl coenzyme A synthase.

The marine parasitic protozoon Perkinus marinus synthesizes the polyunsaturated fatty acid arachidonic acid via the unusual alternative Delta8 pathway in which elongation of C18 fatty acids generates substrate for two sequential desaturations. Here we have shown that genes encoding the three P. marinus activities responsible for arachidonic acid biosynthesis (C18 Delta9-elongating activity, C20 Delta8 desaturase, C20 Delta5 desaturase) are genomically clustered and co-transcribed as an operon. The acyl elongation reaction, which underpins this pathway, is catalyzed by a FAE1 (fatty acid elongation 1)-like 3-ketoacyl-CoA synthase class of condensing enzyme previously only reported in higher plants and algae. This is the first example of an elongating activity involved in the biosynthesis of a polyunsaturated fatty acid that is not a member of the ELO/SUR4 family. The P. marinus FAE1-like elongating activity is sensitive to the herbicide flufenacet, similar to some higher plant 3-ketoacyl-CoA synthases, but unable to rescue the yeast elo2Delta/elo3Delta mutant consistent with a role in the elongation of polyunsaturated fatty acids. P. marinus represents a key organism in the taxonomic separation of the single-celled eukaryotes collectively known as the alveolates, and our data imply a lineage in which ancestral acquisition of plant-like genes, such as FAE1-like 3-ketoacyl-CoA synthases, occurred via endosymbiosis. The P. marinus FAE1-like elongating activity is also indicative of the independent evolution of the alternative Delta8 pathway, distinct from ELO/SUR4-dependent examples.

3-Oxoacyl-(Acyl-Carrier-Protein) Synthase↗

Four-angle saturation transfer (FAST) method for measuring creatine kinase reaction rates in vivo.

A new fast method of measuring kinetic reaction rates for two-site chemical exchange is described. The method employs saturation transfer magnetic resonance spectroscopy (MRS) and acquisition of only four spectra under partially saturated, high signal-to-noise ratio (SNR) conditions. In two acquisitions one of the exchanging species is saturated; the other two employ a control saturation. Each pair of acquisitions is applied with two different flip angles, and the equilibrium magnetization, relaxation times, and reaction rates are calculated therefrom. This four-angle saturation transfer (FAST) method is validated theoretically using the Bloch equations modified for two-state chemical exchange. Potential errors in the rate measurements due to the effects of exchange are evaluated for creatine kinase (CK) metabolism modeled for skeletal and heart muscle, and are found to be < 5% for forward CK flux rates of 0.05 < or = k(f) < or = 1.0 s(-1), and up to a 90% depletion of phosphocreatine (PCr). The effect of too much or too little saturating irradiation on FAST appears to be comparable to that of the conventional saturation transfer method, although the relative performance deteriorates when spillover irradiation cuts the PCr signal by 50% or more. "FASTer" and " FASTest" protocols are introduced for dynamic CK studies wherein [PCr] and/or k(f) changes. These protocols permit the omission of one or two of the four acquisitions in repeat experiments, and the missing information is recreated from initial data via a new iterative algorithm. The FAST method is validated empirically in phosphorus ((31)P) MRS studies of human calf muscle at 1.5 T. FAST measurements of 10 normal volunteers yielded the same CK reaction rates measured by the conventional method (0.29 +/- 0.06 s(-1)) in the same subjects, but an average of seven times faster. Application of the FASTer algorithm to these data correctly restored missing information within seven iterations. Finally, the FAST method was combined with 1D spatially localized (31)P MRS in a study of six volunteers, yielding the same k(f) values independent of depth, in total acquisition times of 17-39 min. These timesaving FAST methods are enabling because they permit localized measurements of metabolic flux, which were previously impractical due to intolerably long scan times.

Algorithms↗