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Internet in clinical research based on a pilot experience.

Computing has become an integral part of many disciplines nowadays, turning it into an evermore necessary working tool. Internet provides a fast and easy way to collect scientific data and is becoming a more and more effective and safe way to transmit data. It is also an efficient means for interaction and information sharing within a work group that provides the necessary flexibility. A pilot project was conducted replacing the traditional hardcopy version of the case report form for an electronic one (e-CRF) and with access to Internet within the Naturalistic Randomized Clinical Trial of the Effectiveness of Olanzapine and Risperidone in the Treatment of Schizophrenia. Carrying out this pilot project has given us the opportunity to determine the advantages electronic data collection (EDC) by Internet has to offer both researchers and sponsors. The results have optimized time management, since it is easier to work in real time; data quality is improved, since intermediates are eliminated, and it facilitates communication amongst the different parties involved in the project. The use of this technology requires updated Internet connections and adequate personal computers, since the possibilities offered by the computer system and high-speed connection are critical in conducting the project. Obviously, this may involve a higher initial investment, but the results have revealed to us that these start-up costs are later offset by lowering personnel costs or by decreasing the number of monitoring visits. On the basis of our experience and that of the participating investigators, certain recommendations for future clinical trials using e-CRF can be made. We will go into these recommendations in greater depth throughout this paper. In short, EDC can dramatically improve the clinical trial process, opening the door to new technologies in the world of clinical research, not only for sponsors, but also for clinicians.

Antipsychotic Agents↗

Projecting the sulcal pattern of human brains onto a 2D plane--a new approach using potential theory and MRI.

A new method is introduced to project the sulcal pattern of the brain surface onto a 2D plane. Twin brains are compared against each other using the planar representation. We obtained T1-weighted Flash-3D MRI volumes from 14 male twins (seven monozygotic, seven dizygotic) with 3 mm-thick coronal slices. The projection is based on potential theory: A virtual electrostatic field is calculated between the area of the segmented brain and a surrounding spherical electrode. Field lines starting from each border point of the segmented brain follow the gradient towards the sphere, leading to field line concentrations due to the underlying sulci. The unwrapped sphere surface with the number of field lines per area unit is used as the 2D representation of the sulcal pattern. The resulting brain projections show a distinctive pattern, and a visual assignment of the twin pairs from the unsorted set is possible because of a high similarity of the patterns between twin pairs. Global correlation coefficients for each pair of maps yield significantly higher values for matching monozygotic twin pairs (mean = 20.2, range 12.3-25.6) than for unmatched pairs (mean = 13.0, range 1.1-28.5). As a conclusion, our method allows us to map the location and depth of the sulci on a 2D plane. The resulting maps allow quantitative inter-individual comparisons on the entire brain or parts of the brain surface.

Adult↗

Final height in girls with Turner's syndrome treated with once or twice daily growth hormone injections. Dutch Advisory Group on Growth Hormone.

OBJECTIVES: To study final height in girls with Turner's syndrome treated with once or twice daily injections of growth hormone (GH) in combination with low dose ethinyl oestradiol. DESIGN: Until final height was reached, the effect of fractionated subcutaneous injections given twice daily was compared with once daily injections of a total GH dose of 6 IU/m2/day. Twice daily injections were given as one third in the morning and two thirds at bedtime. All girls concurrently received low dose oestradiol (0.05 microgram ethinyl oestradiol/kg/day, increased to 0.10 microgram/kg/day after 2.25 years). PATIENTS: Nineteen girls with Turner's syndrome aged > or = 11 years (mean (SD) 13.6 (1.7) years). MEASUREMENTS: To determine final height gain, we assessed the difference between the attained final height and the final height predictions at the start of treatment. These final height predictions were calculated using the Bayley-Pinneau (BP) prediction method, the modified projected adult height (mPAH), the modified index of potential height (mIPHRUS), and the Turner's specific prediction method (PTSRUS). RESULTS: The gain in final height (mean (SD)) was not significantly different between the once daily and the twice daily regimens (7.6 (2.3) v 5.1 (3.2) cm). All girls exceeded their adult height prediction (range, 1.6-12.3 cm). Thirteen of the 19 girls had a final height gain > 5.0 cm. Mean (SD) attained final height was 155.5 (5.4) cm. A "younger bone age" at baseline and a higher increase in height standard deviation score for chronological age (Dutch-Swedish-Danish references) in the first year of GH treatment predicted a higher final height gain after GH treatment. CONCLUSIONS: Division of the total daily GH dose (6 IU/m2/day) into two thirds in the evening and one third in the morning is not advantageous over the once daily GH regimen with respect to final height gain. Treatment with a GH dose of 6 IU/m2/day in combination with low dose oestrogens can result in a significant increase in adult height in girls with Turner's syndrome, even if they start GH treatment at a relatively late age.

Adolescent↗

Effective management of hospitalized patients--established role of hospitalists in the USA.

OBJECTIVES: Summarize and present benefits of effective management of inpatients in US hospitals by hospitalists and discuss the possible implications for healthcare system in Slovakia. BACKGROUND: Inpatient or hospital-based internal medicine started to separate from traditional office-based medicine about a decade ago. Today, hospitalist programs are an integral part of most progressive hospitals in the US and the value of such programs is well documented. METHODS: Literature review and analysis of Mercy Medical Center-North Iowa hospitalist program. RESULTS: Hospitalists improve the quality of care for hospitalized patients, use fewer resources and decrease the length of stay. In 1998 there were 2,000 hospitalists and in 2005 there were more than 15,000 hospitalists in more than 1,800 programs throughout the US. It is projected that by the end of the decade there will be more than 30,000 hospitalists in the US. Mercy Hospital started its hospitalist program in 1999 with one hospitalist and by July 2006 the program will expand to six physicians. The average daily census for a hospitalist is 20 patients and the average length of stay is 3 days. In 2003, with 874 median new admits and consults per year per hospitalist, one hospitalist was able to save approximately dollars 400,000/year compared to the traditional internal medicine model. CONCLUSION: Hospitalists are the fastest growing specialty in the US. In addition to the care of medical illnesses including subspecialty and surgical consults, hospitalists also serve as stewards of hospital systems. They improve quality, patient safety, efficient use of resources and reduce variation in diagnostic and therapeutic approaches (Tab. 2, Fig. 3, Ref. 10).

Hospitalists↗

[Optimum protocol of technetium-99m tetrofosmin myocardial perfusion imaging for the detection of coronary stenosis lesions in Kawasaki disease].

The clinical usefulness of a new myocardial perfusion imaging agent, technetium-99m tetrofosmin, was assessed in 58 patients for a total of 76 times (mean age 9.7 years, 1-15 years) including 20 with and 26 without significant coronary stenotic lesions in Kawasaki disease. Pharmacological (dobutamine or adenosine triphosphate disodium) or exercise stress technetium-99m tetrofosmin single photon emission computed tomography was performed under stress and at rest on the same day. The sensitivity for detection of stress-induced perfusion defects by this method was 90% (18/ 20) and the specificity was 85% (22/26). The dose was 9.3 +/- 2.5 MBq/kg under stress and 18.7 +/- 5.6 MBq/kg at rest. No significant correlation was recognized between the dose and the image quality. Adequate image quality was provided by projection time 20-40 sec per frame. Increased liver accumulation was seen in 24% (18/76), especially in younger and pharmacological stress cases. The acquisition starting time after tetrofosmin injection was 58.4 +/- 18.7 min in the negative increased liver accumulation group and 43.7 +/- 18.3 min in the positive group (p < 0.01). We recommend that the following protocol is used for pediatric imaging. 1) The standard tetrofosmin dose is rougly 10 MBq/kg (upper limit 370 MBq) at stress and the double dose for the rest imaging. 2) SPECT projection time of 20-40 sec per frame. 3) In practice, the patient should be fasting prior to stress injection, and the imaging should be done 1 hour after eating. The rest injection should be done immediately thereafter, and the rest image should be obtained 1 hour later.

Adolescent↗

Evidence of diffusion from a targeted HIV/AIDS intervention in the Dominican Republic.

The diffusion potential of a targeted HIV/AIDS intervention that enlisted peer educators to disseminate 'safer sex' messages and condoms among female commercial sex workers and their clients was evaluated in the Dominican Republic. Levels of interurban interaction potential were ascertained that linked the targeted city of La Romana with the proximate cities of San Pedro de Macoris and Guaymate. Weekly service statistics generated over an 8-month period were analysed to establish activity areas for the peer educators. Data were entered and analysed using a geographic information system and interurban linkages were established. Project outcomes were examined via a series of three cross-sectional Knowledge, Attitudes and Practices (KAP) surveys conducted among convenience samples of commercial sex workers at the start of the intervention and at 4 and 8 months. The results attest to a high degree of interconnectivity between the targeted and proximate cities, and a pattern of interurban mobility that links commercial sex workers, clients and establishments in all three cities. The examination of project outcomes revealed statistically significant changes in condom use in the targeted city of La Romana among commercial sex workers, as well as among their counterparts interviewed in the proximate cities of San Pedro de Macoris and Guaymate. These data suggest a diffusion effect. It is concluded that a targeted intervention may influence proximate cities within a relatively compressed period of time. The findings suggest the importance of considering geographic diffusion principles, such as urban hierarchies, regional nodes and transportation linkages, when designing HIV/AIDS prevention efforts. It also has important implications in the selection of control sites when conducting experimental studies of HIV/AIDS interventions.

Acquired Immunodeficiency Syndrome↗

Implementation of Fetal and Infant Mortality Review (FIMR): experience from the national Healthy Start program.

OBJECTIVES: The implementation of the Fetal and Infant Mortality Review (FIMR) process was examined as part of the evaluation of the national Healthy Start program, a federal program designed to reduce infant mortality in several communities. The implementation of the FIMR process over the 5-year funding period is described in terms of productivity, barriers and facilitators to implementation, and project expenditures. METHODS: Data were derived from grant continuation applications and personal interviews with program staff to produce a qualitative description. RESULTS: As of the summer of 1996, 14 of the 15 Healthy Start sites in the national evaluation had successfully implemented the FIMR process. Most sites had developed a two-tiered review process for examination of case data in which a review by health and social services professionals was followed by community review. In the period 1993 to 1995, the percentage of fetal and infant deaths reviewed had a median of 34% with a range of 4-79% across the sites at a cost of $600 to $3400 per death reviewed. Recommendations were variably implemented. CONCLUSIONS: The FIMR process provides an important opportunity to contribute to the knowledge base regarding infant mortality in these communities. The process, however, has important logistical requirements and may require substantial financial resources that may affect implementation of confidential inquiries into infant mortality and other health problems.

Data Collection↗

Birth of projection neurons in the higher vocal center of the canary forebrain before, during, and after song learning.

The higher vocal center (HVc) of the canary brain projects to two forebrain nuclei: robustus archistriatalis (RA) and area X of lobus parolfactorius. The time of birth of HVc neurons projecting to these two regions was determined by combining [3H]thymidine autoradiography and retrograde fluorogold uptake. Birds were sacrificed at 13 months of age, 4 days after fluorogold injections into area X or RA. A single injection of [3H]thymidine in ovo (embryonic day 9) labeled 76% of area X-projecting cells and 0.8% of cells projecting to RA. The great majority of RA-projecting cells were produced during posthatching development (posthatching day 10-240; P10-P240), with a peak at P60 and a hiatus at P120. HVc reaches full adult size by P240, yet at that age the production of new RA-projecting cells continued at a rate comparable to that recorded during posthatching development. Late production of neurons interconnecting two distant regions of the brain may regulate source to target cell population size. Male canaries start to sing at P40. During subsequent months, they imitate external models and their song becomes more structured and stereotyped. At sexual maturity (P240), song is stable. Three interpretations are offered: (i) neurogenesis of RA-projecting cells is related to learning, and learning continues even after achievement of pattern stability; (ii) neurogenesis of RA-projecting cells is not related to learning; (iii) the production of RA-projecting cells serves different purposes during development and after sexual maturity.

Aging↗

Getting started in research.

This paper introduces the preliminary steps in taking a clinical question or observation from practice and turning it into a potential research project. Future papers in this series will look at aspects of the research process in more detail.

Data Collection↗

Straight talk--new approaches in healthcare. The best starting point for performance improvement: a healthy bottom line. Panel discussion.

Bon Secours Health System's South Division launched a multitude of performance-improvement projects in 2004 even though it boasted a 9% margin. Why? Officials at the Catholic healthcare system wanted to increase the amount of money available for its nation-wide charitable commitments as well as to invest in capital projects critical to its mission. In this installment of Straight Talk, we look at the performance-improvement initiatives of the South Division of Bon Secours Health System, Inc., which saved $8 million in just five months and expects to gain a total of $41 million after it completes all projects. Modern Healthcare and PricewaterhouseCoopers present Straight Talk. The session on performance improvement was held on March 22, 2005 at Modern Healthcare's Chicago headquarters. Fawn Lopez, publisher of Modern Healthcare, was the moderator.

Catholicism↗

"Starting from scratch".

The process of establishing a new orthodontic service in any area requires a combination of patience and perseverance. It is a prolonged project littered with frustrating experiences, many of which we encountered. We endeavour to outline the pros and cons of such an undertaking and describe our experiences in implementing a marketing strategy prior to the practice opening. This was specifically geared to running a practice in a 'mixed' NHS/Private environment.

Humans↗

The postnatal spatial and temporal development of corticospinal projections in cats.

Orthograde labeling and immunocytochemical techniques were used to study the postnatal spatial and temporal development of corticospinal projections in cats. Findings from the orthograde labeling studies indicate that there are three major phases in the spatial development of corticospinal projections: an early period (1-10 postnatal days) when cortical axons grow into the spinal gray from the white matter; an intermediate period (2-5 postnatal weeks) where corticospinal axons develop terminal arborizations in a rostral to caudal, medial to lateral and intermediate gray to dorsal and ventral horn sequence; and, a late period (6-7 postnatal weeks) during which some corticospinal projections are eliminated. The time period over which cortical axons grow into the spinal cord was determined immunocytochemically using a monoclonal antibody against a microtubule associated protein (MAP 1B) present in growing axons. The corticospinal tracts were strongly immunoreactive for MAP 1B during the first three postnatal weeks. MAP 1B immunostaining of these tracts started to decline in the fourth postnatal week and was completely absent by five weeks of age. These findings indicate that the postnatal development of corticospinal projections is spatially and temporally protracted in cats.

Afferent Pathways↗

Evaluation of the use of health care assistants to support disadvantaged women breastfeeding in the community.

There is little experience of the use of health care assistants in the community to support breastfeeding in the UK. The aim of this project was to evaluate the implementation of a small-scale pilot project using health care assistants in the community to support disadvantaged women breastfeeding. The evaluation was funded as part of the Department of Health's Infant Feeding Initiative. A longitudinal observational and quasi-experimental design was used. The project involved women, who had recently given birth, living in an area of London identified by the government's Sure Start scheme as socio-economically disadvantaged. This paper focuses mainly on the findings drawn from the qualitative data focusing on the process of implementation, the role of the Support Worker and women's perceptions of the support. The findings suggest that the use of health care assistants in the community may offer a practical and encouraging approach in supporting breastfeeding which is acceptable to both breastfeeding women and health care professionals. More research is needed to establish whether the intervention significantly increases breastfeeding rates.

Adult↗

Self-organizing neural projections.

The Self-Organizing Map (SOM) algorithm was developed for the creation of abstract-feature maps. It has been accepted widely as a data-mining tool, and the principle underlying it may also explain how the feature maps of the brain are formed. However, it is not correct to use this algorithm for a model of pointwise neural projections such as the somatotopic maps or the maps of the visual field, first of all, because the SOM does not transfer signal patterns: the winner-take-all function at its output only defines a singular response. Neither can the original SOM produce superimposed responses to superimposed stimulus patterns. This presentation introduces a new self-organizing system model related to the SOM that has a linear transfer function for patterns and combinations of patterns all the time. Starting from a randomly interconnected pair of neural layers, and using random mixtures of patterns for training, it creates a pointwise-ordered projection from the input layer to the output layer. If the input layer consists of feature detectors, the output layer forms a feature map of the inputs.

Algorithms↗

Milestones in the Human Genome Project: genesis to postgenome.

The Human Genome Project (HGP) will change medicine and medical research irrevocably. The obvious gains in genetic knowledge from the HGP, together with the advances which will flow into bioinformatics, biotechnology and the potential for novel therapeutic agents, will ensure that the financial investment in the HGP is repaid many times over. The HGP's costs in terms of ethical and social issues remain to be determined, but it is to be hoped that these will not detract from the scientific and medical achievements. How did such an endeavour start, and what path did it follow?

History, 20th Century↗

[Inception cohorts for spondyloarthropathies].

The spondyloarthropathies (SpA) are important inflammatory rheumatic diseases--not only because patients of young age are frequently involved. Ankylosing spondylitis, reactive arthritis, and undifferentiated spondyloarthropathy are prototypes of SpA which share several clinical features and the strong association with HLA B27. Despite its high prevalence there are many shortcomings in early diagnosis and therapy of SpA. The same is true for the knowledge on course, prognostic factors, and the socioeconomic consequences of these diseases. Furthermore, our knowledge about pathogenesis and therapy is still limited. Due to the known deficiencies in rheumatologic education, there are clear-cut deficiencies in the health care provided by general practitioners. The aim of the project presented here is to built up a cohort of early SpA patients to learn about course and outcome of SpA. In this regard, special attention is paid to the inclusion of patients with juvenile SpA since AS starts frequently in the 2nd decade of life and because the clinical picture with more frequent peripheral joint involvement differs from AS of adult onset. Moreover, these cohorts play an essential role for other projects of the MedNet subdivision of infect-associated arthritides/spondyloarthropathies in which studies on diagnosis, therapy, immunology, and genetics of the SpA performed.

Adult↗

Comparing programs for rigid-body multiple structural superposition of proteins.

Different programs and methods were employed to superimpose protein structures, using members of four very different protein families as test subjects, and the results of these efforts were compared. Algorithms based on human identification of key amino acid residues on which to base the superpositions were nearly always more successful than programs that used automated techniques to identify key residues. Among those programs automatically identifying key residues, MASS could not superimpose all members of some families, but was very efficient with other families. MODELLER, MultiProt, and STAMP had varying levels of success. A genetic algorithm program written for this project did not improve superpositions when results from neighbor-joining and pseudostar algorithms were used as its starting cases, but it always improved superpositions obained by MODELLER and STAMP. A program entitled PyMSS is presented that includes three superposition algorithms featuring human interaction.

Amino Acid Sequence↗

The human mitochondrial translation initiation factor 2 gene (MTIF2): transcriptional analysis and identification of a pseudogene.

Mitochondrial translation initiation factor 2 (MTIF2) is nuclear-encoded and functions in mitochondria to initiate the translation of proteins encoded by the mitochondrial genome. To gain insight into mechanisms that regulate MTIF2 gene expression, the genomic copy and the 5' and 3' flanking regions of MTIF2 were isolated using a combination of genomic library screening and polymerase chain reaction (PCR). MTIF2 is approximately 33.5-kb long and contains 16 exons, confirming data from the Human Genome Project. With RNA ligase-mediated rapid amplification of cDNA ends (RLM-RACE), we mapped the transcription start point in human heart tissue to a cytosine residue 296 bp upstream from the translation initiation site. The region surrounding the transcription start point contains consensus binding sites for transcription factors Sp1, nuclear respiratory factor 2 (NRF-2) and estrogen receptor, while enhancer binding sites were identified upstream. Promoter constructs were prepared in a luciferase reporter vector and transiently transfected into 293T cells. The minimal promoter gave an expression level 3.5x higher than the SV40 control (P=0.001), while the construct containing the minimal promoter plus the enhancer region gave a 3.8x higher level of expression compared to the control (P<0.001). We also discovered a pseudogene of MTIF2 and mapped it to chromosome 1p13-12.

Base Sequence↗