Prematurity and respiratory outcomes program (PROP): study protocol of a prospective multicenter study of respiratory outcomes of preterm infants in the United States

Background

With improved survival rates, short- and long-term respiratory complications of premature birth are increasing, adding significantly to financial and health burdens in the United States. In response, in May 2010, the National Institutes of Health (NIH) and the National Heart, Lung, and Blood Institute (NHLBI) funded a 5-year $18.5 million research initiative to ultimately improve strategies for managing the respiratory complications of preterm and low birth weight infants. Using a collaborative, multi-disciplinary structure, the resulting Prematurity and Respiratory Outcomes Program (PROP) seeks to understand factors that correlate with future risk for respiratory morbidity.

Methods/Design

The PROP is an observational prospective cohort study performed by a consortium of six clinical centers (incorporating tertiary neonatal intensive care units [NICU] at 13 sites) and a data-coordinating center working in collaboration with the NHLBI. Each clinical center contributes subjects to the study, enrolling infants with gestational ages 23 0/7 to 28 6/7 weeks with an anticipated target of 750 survivors at 36 weeks post-menstrual age. In addition, each center brings specific areas of scientific focus to the Program. The primary study hypothesis is that in survivors of extreme prematurity specific biologic, physiologic and clinical data predicts respiratory morbidity between discharge and 1 year corrected age. Analytic statistical methodology includes model-based and non-model-based analyses, descriptive analyses and generalized linear mixed models.

Discussion

PROP incorporates aspects of NICU care to develop objective biomarkers and outcome measures of respiratory morbidity in the <29 week gestation population beyond just the NICU hospitalization, thereby leading to novel understanding of the nature and natural history of neonatal lung disease and of potential mechanistic and therapeutic targets in at-risk subjects.

Trial registration

Clinical Trials.gov NCT01435187.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0346-3) contains supplementary material, which is available to authorized users.

Shorter time to target temperature is associated with poor neurologic outcome in post-arrest patients treated with targeted temperature management

INTRODUCTION

Time to achieve target temperature varies substantially for patients who undergo targeted temperature management (TTM) after cardiac arrest. The association between arrival at target temperature and neurologic outcome is poorly understood. We hypothesized that shorter time from initiation of cooling to target temperature ("induction") will be associated with worse neurologic outcome, reflecting more profound underlying brain injury and impaired thermoregulatory control.

METHODS

This was a multicenter retrospective study analyzing data from the Penn Alliance for Therapeutic Hypothermia (PATH) Registry. We examined the association between time from arrest to return of spontaneous circulation (ROSC) ("downtime"), ROSC to initiation of TTM ("pre-induction") and "induction" with cerebral performance category (CPC).

RESULTS

A total of 321 patients were analyzed, of whom 30.8% (99/321) had a good neurologic outcome. Downtime for survivors with good outcome was 11 (IQR 6-27) min vs. 21 (IQR 10-36) min (p=0.002) for those with poor outcome. Pre-induction did not vary between good and poor outcomes (98 (IQR 36-230) min vs. 114 (IQR 34-260) (p=ns)). Induction time in the good outcome cohort was 237 (IQR 142-361) min compared to 180 (IQR 100-276) min (p=0.004). Patients were categorized by induction time (<120min, 120-300min, >300min). Using multivariable logistic regression adjusted for age, initial rhythm, and downtime, induction time >300min was associated with good neurologic outcome when compared to those with an induction time <120min.

CONCLUSION

In this multicenter cohort of post-arrest TTM patients, shorter induction time was associated with poor neurologic outcome.

Monocular and binocular low-contrast visual acuity and optical coherence tomography in pediatric multiple sclerosis

BACKGROUND

Low-contrast letter acuity and optical coherence tomography (OCT) capture visual dysfunction and axonal loss in adult-onset multiple sclerosis (MS), and have been proposed as secondary outcome metrics for therapeutic trials. Clinical trials will soon be launched in pediatric MS, but such outcome metrics have not been well-validated in this population.

OBJECTIVES

To determine whether MS onset during childhood and adolescence is associated with measurable loss of visual acuity and thinning of the retinal nerve fiber layer (RNFL), whether such features are noted only in the context of clinical optic nerve inflammation (optic neuritis, ON) or are a feature of MS even in the absence of optic nerve relapses, and to define the optimal methods for such detection.

STUDY DESIGN

Cross-sectional study.

METHODS

Monocular and binocular high- and low-contrast letter acuity and contrast sensitivity were assessed in a cross-sectional cohort of children (ages 5 to 17 years) with MS (N=22 patients, 44 eyes; 8 patients with a history of ON) and disease-free controls (N=29 patients; 58 eyes) from three academic centers. Binocular summation was determined by calculating the number of letters correctly identified using the binocular score minus the better eye score for each visual test. RNFL thickness was measured using OCT (Stratus OCT-3). Results were analyzed in terms of "eyes" as: MS ON+, MS ON-, and control eyes. Generalized estimating equation (GEE) regression models were used to compare patients to controls.

RESULTS

Traditional high-contrast visual acuity scores did not differ between MS ON+, MS ON-, and controls eyes. MS ON+ eyes had decreased monocular (p<0.001) and decreased binocular (p=0.007) low-contrast letter acuity (Sloan 1.25% contrast charts) scores. Monocular visual acuity did not differ when comparing MS ON- and control eyes. The magnitude of binocular summation using low-contrast charts was similar for pediatric MS participants and controls and was not diminished in children with a history of ON. While the mean RNFL thickness for all MS eyes (103±17 μm) trended lower when compared to corresponding measures in control eyes (109±9 μm, p=0.085), we confirmed a highly significant reduction in mean RNFL thickness in MS eyes with a history of ON (86±22 μm, p<0.001). RNFL thickness of MS ON- eyes in pediatric MS patients (109±11 μm) did not differ from controls (p=0.994).

CONCLUSIONS

Low-contrast letter acuity detects subtle visual loss in MS patients with prior ON, consistent with incomplete recovery, a finding further supported by RNFL loss in ON affected eyes. In MS patients with prior unilateral ON, binocular acuity is decreased; however, the magnitude of binocular summation is preserved, unlike adult-onset MS who exhibit a reduced capacity for visual compensation in the context of unilateral injury. Also unlike findings in adult-onset MS, we did not demonstrate RNFL thinning in ON- eyes of children and adolescents with MS. Further validation is required to confirm whether neurodegeneration of visual pathways occurs in the absence of relapse, and thus whether OCT will serve as a sensitive metric for such pathology in the pediatric and adolescent MS context.

A pharmacogenetic versus a clinical algorithm for warfarin dosing

BACKGROUND

The clinical utility of genotype-guided (pharmacogenetically based) dosing of warfarin has been tested only in small clinical trials or observational studies, with equivocal results.

METHODS

We randomly assigned 1015 patients to receive doses of warfarin during the first 5 days of therapy that were determined according to a dosing algorithm that included both clinical variables and genotype data or to one that included clinical variables only. All patients and clinicians were unaware of the dose of warfarin during the first 4 weeks of therapy. The primary outcome was the percentage of time that the international normalized ratio (INR) was in the therapeutic range from day 4 or 5 through day 28 of therapy.

RESULTS

At 4 weeks, the mean percentage of time in the therapeutic range was 45.2% in the genotype-guided group and 45.4% in the clinically guided group (adjusted mean difference, [genotype-guided group minus clinically guided group], -0.2; 95% confidence interval, -3.4 to 3.1; P=0.91). There also was no significant between-group difference among patients with a predicted dose difference between the two algorithms of 1 mg per day or more. There was, however, a significant interaction between dosing strategy and race (P=0.003). Among black patients, the mean percentage of time in the therapeutic range was less in the genotype-guided group than in the clinically guided group. The rates of the combined outcome of any INR of 4 or more, major bleeding, or thromboembolism did not differ significantly according to dosing strategy.

CONCLUSIONS

Genotype-guided dosing of warfarin did not improve anticoagulation control during the first 4 weeks of therapy. (Funded by the National Heart, Lung, and Blood Institute and others; COAG ClinicalTrials.gov number, NCT00839657.).

Rationale and design of the Clarification of Optimal Anticoagulation through Genetics trial

BACKGROUND

Current dosing practices for warfarin are empiric and result in the need for frequent dose changes as the international normalized ratio gets too high or too low. As a result, patients are put at increased risk for thromboembolism, bleeding, and premature discontinuation of anticoagulation therapy. Prior research has identified clinical and genetic factors that can alter warfarin dose requirements, but few randomized clinical trials have examined the utility of using clinical and genetic information to improve anticoagulation control or clinical outcomes among a large, diverse group of patients initiating warfarin.

METHODS

The COAG trial is a multicenter, double-blind, randomized trial comparing 2 approaches to guiding warfarin therapy initiation: initiation of warfarin therapy based on algorithms using clinical information plus an individual's genotype using genes known to influence warfarin response ("genotype-guided dosing") versus only clinical information ("clinical-guided dosing") (www.clinicaltrials.gov Identifier: NCT00839657).

RESULTS

The COAG trial design is described. The study hypothesis is that, among 1,022 enrolled patients, genotype-guided dosing relative to clinical-guided dosing during the initial dosing period will increase the percentage of time that patients spend in the therapeutic international normalized ratio range in the first 4 weeks of therapy.

CONCLUSION

The COAG will determine if genetic information provides added benefit above and beyond clinical information alone.

Association between efavirenz-based compared with nevirapine-based antiretroviral regimens and virological failure in HIV-infected children

IMPORTANCE

Worldwide, the nonnucleoside reverse transcriptase inhibitors (NNRTIs) efavirenz and nevirapine are commonly used in first-line antiretroviral regimens in both adults and children with human immunodeficiency virus (HIV) infection. Data on the comparative effectiveness of these medications in children are limited.

OBJECTIVE

To investigate whether virological failure is more likely among children who initiated 1 or the other NNRTI-based HIV treatment.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of children (aged 3-16 years) who initiated efavirenz-based (n = 421) or nevirapine-based (n = 383) treatment between April 2002 and January 2011 at a large pediatric HIV care setting in Botswana.

MAIN OUTCOMES AND MEASURES

The primary outcome was time from initiation of therapy to virological failure. Virological failure was defined as lack of plasma HIV RNA suppression to less than 400 copies/mL by 6 months or confirmed HIV RNA of 400 copies/mL or greater after suppression. Cox proportional hazards regression analysis compared time to virological failure by regimen. Multivariable Cox regression controlled for age, sex, baseline immunologic category, baseline clinical category, baseline viral load, nutritional status, NRTIs used, receipt of single-dose nevirapine, and treatment for tuberculosis.

RESULTS

With a median follow-up time of 69 months (range, 6-112 months; interquartile range, 23-87 months), 57 children (13.5%; 95% CI, 10.4%-17.2%) initiating treatment with efavirenz and 101 children (26.4%; 95% CI, 22.0%-31.1%) initiating treatment with nevirapine had virological failure. There were 11 children (2.6%; 95% CI, 1.3%-4.6%) receiving efavirenz and 20 children (5.2%; 95% CI, 3.2%-7.9%) receiving nevirapine who never achieved virological suppression. The Cox proportional hazard ratio for the combined virological failure end point was 2.0 (95% CI, 1.4-2.7; log rank P < .001, favoring efavirenz). None of the measured covariates affected the estimated hazard ratio in the multivariable analyses.

CONCLUSIONS AND RELEVANCE

Among children aged 3 to 16 years infected with HIV and treated at a clinic in Botswana, the use of efavirenz compared with nevirapine as initial antiretroviral treatment was associated with less virological failure. These findings may warrant additional research evaluating the use of efavirenz and nevirapine for pediatric patients.

The association of cerebral palsy with birth asphyxia: a definitional quagmire

AIM

The aim of this study was to investigate whether current literature provides a useful body of evidence reflecting the proportion of cerebral palsy (CP) that is attributable to birth asphyxia.

METHOD

We identified 23 studies conducted between 1986 and 2010 that provided data on intrapartum risks of CP.

RESULTS

The proportion of CP with birth asphyxia as a precursor (case exposure rate) varied from less than 3% to over 50% in the 23 studies reviewed. The studies were heterogeneous in many regards, including the definitions for birth asphyxia and the outcome of CP.

INTERPRETATIONS

Current data do not support the belief, widely held in the medical and legal communities, that birth asphyxia can be recognized reliably and specifically, or that much of CP is due to birth asphyxia. The very high case exposure rates linking birth asphyxia to CP can probably be attributed to several factors: the fact that the clinical picture at birth cannot specifically identify birth asphyxia; the definition of CP employed; and confusion of proximal effects - results - with causes. Further research is needed.

Infusion of statistical science in comparative effectiveness research

PURPOSE

We present a general introduction to comparative effectiveness research (CER) from a statistician's viewpoint and focus on how statisticians can contribute to the methodology of CER.

CONCLUSIONS

The statistical science community needs to determine the priorities for methodological research in CER, in collaboration with our colleagues in the aligned medical fields. CER requires that we apply a new paradigm - a focus on the patient. The emphasis on the patient is driven by patients themselves, the federal government, and private payers, in addition to the fact that there is a rising chronic disease burden that is making patient populations more heterogeneous. The availability of new technology and data sources introduces not only complexity but also opportunity. Statistical scientists should rise to meet these new demands and develop optimal, statistically valid approaches to CER, just as they have in agriculture and clinical trials.

Abstract 2484: Validity and Reliability of Retrospective Scoring of the Pediatric NIH Stroke Scale

Background and Objectives: The Pediatric National Institutes of Health Stroke Scale (PedNIHSS), an adaptation of the adult NIH Stroke Scale, is a quantitative measure of stroke severity shown to be reliable when scored prospectively. The ability to calculate the PedNIHSS score retrospectively would be invaluable in the conduct of retrospective pediatric stroke studies. To this end, the objective of this study was to assess the validity and reliability of calculating the PedNIHSS score retrospectively from medical records.

Methods: Neurological examinations documented in medical records of 75 children from 9 institutions were deidentified and photocopied. All subjects had been previously enrolled in a prospective PedNIHSS validation study. Four neurologists of varying clinical training levels were given detailed instructions on how to translate the neurological examination into a PedNIHSS score. If an item was not recorded in the medical record, it was scored as 0 (normal) as was done in past adult studies. The raters were blinded to the PedNIHSS scores derived from the prospective study, reviewed the documented neurological examinations, and retrospectively assigned the PedNIHSS score. Each rater scored the 75 patients' examinations in the same order. Retrospective scores were compared among raters and to the prospectively measured scores.

Results: The mean prospective total PedNIHSS score for the 75 subjects was 8.2 (SD 7) with median 6 (IQR 3-12).The mean total retrospective PedNIHSS score was 7.6 (SD 7) with median 5 (IQR 3-11). The mean and median total prospective and retrospective PedNIHSS scores were not significantly different (p= 0.49 Student's t-test; p=0.37 Wilcoxon rank-sum). Total retrospective PedNIHSS scores correlated highly with prospectively assigned total scores (R 2 0.76, p<0.001). Eighty-nine percent of retrospective total scores were within 5 points of the prospectively scored totals. Using a pre-determined threshold PedNIHSS score ≤5, the sensitivity of retrospective assessment was 87% (95% CI: 81-92%) and the specificity was 81% (95%CI: 74-87%). Interrater reliability for the total retrospective scores among the four raters assessed with the intraclass correlation coefficient was 0.95 (95% CI: 0.94-0.97). Interrater reliability for the 15 item scores that comprise the total PedNIHSS score, assessed with weighted κ, ranged from 0.47 to 0.93. Interrater reliability for all but one item was “substantial” or “excellent.”

Conclusions: The PedNIHSS score can be assessed retrospectively from medical records with a high degree of validity and reliability. This tool, a stroke severity measure, can be used to improve the quality of retrospective pediatric stroke studies.

Concurrent validity and reliability of retrospective scoring of the Pediatric National Institutes of Health Stroke Scale

BACKGROUND AND PURPOSE

The Pediatric National Institutes of Health Stroke Scale (PedNIHSS), an adaptation of the adult National Institutes of Health Stroke Scale, is a quantitative measure of stroke severity shown to be reliable when scored prospectively. The ability to calculate the PedNIHSS score retrospectively would be invaluable in the conduct of observational pediatric stroke studies. The study objective was to assess the concurrent validity and reliability of estimating the PedNIHSS score retrospectively from medical records.

METHODS

Neurological examinations from medical records of 75 children enrolled in a prospective PedNIHSS validation study were photocopied. Four neurologists of varying training levels blinded to the prospective PedNIHSS scores reviewed the records and retrospectively assigned PedNIHSS scores. Retrospective scores were compared among raters and to the prospective scores.

RESULTS

Total retrospective PedNIHSS scores correlated highly with total prospective scores (R(2)=0.76). Interrater reliability for the total scores was "excellent" (intraclass correlation coefficient, 0.95; 95% CI, 0.94-0.97). Interrater reliability for individual test items was "substantial" or "excellent" for 14 of 15 items.

CONCLUSIONS

The PedNIHSS score can be scored retrospectively from medical records with a high degree of concurrent validity and reliability. This tool can be used to improve the quality of retrospective pediatric stroke studies.

Statistical design of personalized medicine interventions: the Clarification of Optimal Anticoagulation through Genetics (COAG) trial

Background

There is currently much interest in pharmacogenetics: determining variation in genes that regulate drug effects, with a particular emphasis on improving drug safety and efficacy. The ability to determine such variation motivates the application of personalized drug therapies that utilize a patient's genetic makeup to determine a safe and effective drug at the correct dose. To ascertain whether a genotype-guided drug therapy improves patient care, a personalized medicine intervention may be evaluated within the framework of a randomized controlled trial. The statistical design of this type of personalized medicine intervention requires special considerations: the distribution of relevant allelic variants in the study population; and whether the pharmacogenetic intervention is equally effective across subpopulations defined by allelic variants.

Methods

The statistical design of the Clarification of Optimal Anticoagulation through Genetics (COAG) trial serves as an illustrative example of a personalized medicine intervention that uses each subject's genotype information. The COAG trial is a multicenter, double blind, randomized clinical trial that will compare two approaches to initiation of warfarin therapy: genotype-guided dosing, the initiation of warfarin therapy based on algorithms using clinical information and genotypes for polymorphisms in CYP2C9 and VKORC1; and clinical-guided dosing, the initiation of warfarin therapy based on algorithms using only clinical information.

Results

We determine an absolute minimum detectable difference of 5.49% based on an assumed 60% population prevalence of zero or multiple genetic variants in either CYP2C9 or VKORC1 and an assumed 15% relative effectiveness of genotype-guided warfarin initiation for those with zero or multiple genetic variants. Thus we calculate a sample size of 1238 to achieve a power level of 80% for the primary outcome. We show that reasonable departures from these assumptions may decrease statistical power to 65%.

Conclusions

In a personalized medicine intervention, the minimum detectable difference used in sample size calculations is not a known quantity, but rather an unknown quantity that depends on the genetic makeup of the subjects enrolled. Given the possible sensitivity of sample size and power calculations to these key assumptions, we recommend that they be monitored during the conduct of a personalized medicine intervention.

Trial Registration

clinicaltrials.gov: NCT00839657

Prospective alpha allocation in the Clarification of Optimal Anticoagulation through Genetics (COAG) trial

BACKGROUND

The Clarification of Optimal Anticoagulation through Genetics (COAG) trial is a large, multicenter, double-blinded, randomized trial to determine whether use of a genotype-guided dosing algorithm (using clinical and genetic information) to initiate warfarin treatment will improve anticoagulation status when compared to a dosing algorithm using only clinical information.

PURPOSE

This article describes prospective alpha allocation and balanced alpha allocation for the design of the COAG trial.

METHODS

The trial involves two possibly heterogeneous populations, which can be distinguished by the difference in warfarin dose as predicted by the two algorithms. A statistical approach is detailed, which allows an overall comparison as well as a comparison of the primary endpoint in the subgroup for which sufficiently different doses are predicted by the two algorithms. Methods of allocating alpha for these analyses are given - a prospective alpha allocation and allocating alpha so that the two analyses have equal power, which we call a 'balanced alpha allocation.'

RESULTS

We show how to include an analysis of the primary endpoint in a subgroup as a co-primary analysis. Power can be improved by incorporating the correlation between the overall and subgroup analyses in a prospective alpha allocation approach. Balanced alpha allocation for the full cohort and subgroup tests to achieve the same desired power for both of the primary analyses is discussed in detail.

LIMITATIONS

In the COAG trial, it is impractical to stratify the randomization on subgroup membership because genetic information may not be available at the time of randomization. If imbalances in the treatment arms in the subgroup are found, they will need to be addressed.

CONCLUSIONS

The design of the COAG trial assures that the subgroup in which the largest treatment difference is expected is elevated to a co-primary analysis. Incorporating the correlation between the full cohort and the subgroup analyses provides an improvement in power for the subgroup comparison, and further improvement may be achieved via a balanced alpha allocation approach when the parameters involved in the sample size calculation are reasonably well estimated.

The National Children's Study (NCS): establishment and protection of the inferential base

The National Children's Study (NCS) is a unique study of environment and health that will follow a cohort of 100 000 women from prior to or early in pregnancy and then their children until 21 years of age. The NCS cohort will be a national multi-stage probability sample, using a U.S. Census Bureau geographic sampling frame unrelated to factors that might influence selection into the sample (e.g. access to health care). I present the case for the use of a national probability sample as the design base for the NCS, arguing that selection of the original cohort should be as free from selection bias as possible. The dangers of using a selected or nonprobability sample approach are demonstrated by an example of its use in outlining the clinical management of children with febrile seizures, an infrequent disorder, which was so wrong for decades. In addition, I stress the importance of and the NCS approach to avoiding selection bias that might occur after the initial selection of the cohort. The selection of and maintenance of an unselected cohort is an important element for the validity of inferences in this major undertaking.

Variation in receipt of opioids by pediatric oncology patients who died in children's hospitals

BACKGROUND

Opioids are a cornerstone of palliation of pain. We sought to assess variation in opioid prescription during the last week of life among a cohort of pediatric oncology patients who died while hospitalized.

PROCEDURE

We used detailed hospital administrative data from the Pediatric Health Information System (PHIS) regarding 1,466 subjects 0-24 years of age who were treated at 33 hospitals between 2001 and 2005.

RESULTS

Among the 1,466 subjects hospitalized at the time of their death, 56% received opioids every day during the hospitalized portion of their last week of life, while 44% did not. This proportion varied substantially across hospitals (range 0-90.5%). After multivariate adjustment for individual-level characteristics, the hospital-level effect on the odds of continuous prescription of opioids during the hospitalized portion of the last 7 days of life continued to vary significantly among hospitals, accounting for 10.5% of the variance in the receipt of daily opioid (P < 0.001).

CONCLUSION

Opioid prescription during the hospitalized portion of the last week of life varies substantially among hospitals, even after adjustment for clinical characteristics of the patients. The reasons for this significant variation, especially the component explained by hospital-level and not patient-level factors, warrant more scrutiny.

Use of the noninvasive components of the Mayo score to assess clinical response in ulcerative colitis

BACKGROUND

The Mayo score and a noninvasive 9-point partial Mayo score are used as outcome measures for clinical trials assessing therapy for ulcerative colitis (UC). There are limited data assessing what defines a clinically relevant change in these indices. We sought to assess what constitutes a clinically meaningful change in these indices using data from a recently completed placebo-controlled clinical trial.

METHODS

In all, 105 patients were enrolled in a 12-week randomized, placebo-controlled trial assessing rosiglitazone for treatment of mild to moderate UC. We compared the change in the Mayo score, the partial Mayo score, and a 6-point score composed just of the stool frequency and bleeding components of the Mayo score to the patient's perception of disease activity at week 0 and week 12. Optimal cutpoints were calculated as the maximal product of sensitivity and specificity.

RESULTS

Each index was strongly correlated with the patient's rating of disease activity at week 12 (Spearman correlations 0.61-0.71, P < 0.0001 for all correlations). The maximal product of sensitivity and specificity to identify patient reported improvement of disease activity was achieved using cutpoints for change of 2.5 for the Mayo score (sensitivity 88%, specificity 80%), 2.5 for the partial Mayo score (sensitivity 88%, specificity 87%), and 1.5 for the 6-point score (sensitivity 88%, specificity 80%).

CONCLUSIONS

The partial Mayo score and the 6-point score composed solely of the stool frequency and bleeding components performed as well as the full Mayo score to identify patient perceived clinical response.

Rosiglitazone for active ulcerative colitis: a randomized placebo-controlled trial

BACKGROUND & AIMS

Thiazolidinedione ligands for the gamma subtype of peroxisome proliferator-activated receptors (PPARgamma), widely used to treat type 2 diabetes mellitus, have been proposed as novel therapies for ulcerative colitis (UC).

METHODS

This multicenter, randomized, double-blind, placebo-controlled clinical trial compared the efficacy of rosiglitazone (Avandia; GlaxoSmithKline, Philadelphia, PA) 4 mg orally twice daily vs placebo twice daily for 12 weeks in 105 patients with mild to moderately active UC. Disease activity was measured with the Mayo score. The primary end point was clinical response (>/=2-point reduction) at week 12. Clinical remission (Mayo score </=2), endoscopic remission, and quality of life were secondary outcomes.

RESULTS

After 12 weeks of therapy, 23 patients (44%) treated with rosiglitazone and 12 patients (23%) treated with placebo achieved clinical response (P = .04). Remission was achieved in 9 patients (17%) treated with rosiglitazone and 1 patient (2%) treated with placebo (P = .01). Endoscopic remission was uncommon in either treatment arm (8% rosiglitazone vs 2% placebo; P = .34). Clinical improvement was evident as early as 4 weeks after beginning treatment (P = .049). Quality of life was improved significantly at week 8 (P = .01), but not at week 4 (P = .48) or week 12 (P = .14). Serious adverse events were rare.

CONCLUSIONS

Rosiglitazone was efficacious in the treatment of mild to moderately active UC.

Associations among body composition, androgen levels, and human immunodeficiency virus status in adolescents

PURPOSE

To investigate whether factors influencing body composition may be unique for male and female adolescents with horizontal transmission of human immunodeficiency virus (HIV).

METHODS

HIV infected and uninfected youth (aged 13-18 years) participating in the multi-center project REACH (Reaching for Excellence on Adolescent Health Care) had at baseline anthropomorphic measurements including height, weight, bicep, tricep, subscapular and suprailiac skinfold measurements and midarm circumference. Body mass index, muscle mass, fat free body mass, and fat mass were calculated and predictors of these measures were assessed using multiple variable linear regression. Predictors included contraception, HIV status and related variables (CD4 counts, treatment status, and viral load), substance use, androgen levels as well as appetite changes, and bone age.

RESULTS

In multiple variable linear regression analysis, female adolescents' body composition was associated with HIV status, CD4 + T cell counts, and free testosterone levels. HIV status was found associated with higher fat and lean body mass, however lower CD4+T cell counts were associated with lower fat and lean body mass. Higher testosterone levels were associated with higher lean and fat mass. For adolescent males, higher total testosterone levels but not free testosterone levels were associated with lower lean and fat mass.

CONCLUSIONS

HIV status was not associated with a lower muscle or fat mass. Different factors influenced body composition for females than males. Higher testosterone levels may be protective against loss in lean and fat mass in females.

A unified web-based query and notification system (QNS) for subject management, adverse events, regulatory, and IRB components of clinical trials

Even after intensive review, interpretative questions, ambiguities, contradictions, or errors, will arise once the protocol is scrutinized by site IRBs and implemented at sites. This will occur despite preparation and implementation of site protocol training, and provision of well crafted case report forms for the reporting of clinical and laboratory evaluations and adverse events. Since many staff are involved in each protocol, site investigators or study coordinators might direct protocol queries, participant management, or IRB queries to different network participants, resulting in inconsistent responses. It is important to establish a response mechanism that ensures consistent responses and their systematic documentation. For reporting of adverse events, and the submission of or documentation of completion of regulatory requirements, an easily accessible and structured communications system is also required. This paper describes the development and implementation of a user-friendly web-based query and notification system (QNS) for subject management, adverse events, regulatory, and IRB components. This system was created in the Adolescent Trials Network for HIV/AIDS Interventions (ATN), using existing web based tools with minor modifications and minimal cost. The query and notification system is interactive and allows for free flow of information among the site coordinators and both the protocol teams and the regulatory group. The process of the system is transparent to users at the sites, although its use and maintenance is controlled by Data Operations Center staff, to assure that ATN requirements for review and approval are met. This results in consistency of and timeliness of responses to queries, timeliness and accuracy of adverse event reporting and the ability for the data operations center regulatory staff to provide notification of pending or delinquent regulatory submissions.

Risk of High‐Grade Squamous Intraepithelial Lesion in HIV‐Infected Adolescents

BACKGROUND

The risk of developing the human papillomavirus (HPV)-associated precancer high-grade squamous intraepithelial lesion (HSIL) in human immunodeficiency virus (HIV)-infected adolescents is unknown. We examined the risk of developing HSIL among adolescents with and without HIV infection.

METHODS

HIV-infected (n = 172) and -uninfected (n = 84) girls aged 13-18 years who were participating in a multicenter study of primarily horizontally acquired HIV infections in adolescents (Reaching for Excellence in Adolescent Health Care) and who did not have HSIL on cytologic examination at study entry or at the first follow-up visit were followed at 6-month intervals. HIV-uninfected girls were recruited for comparison in a 2:1 ratio (HIV infected:HIV uninfected). The primary outcome was cytologic diagnosis of HSIL confirmed by expert review.

RESULTS

Incidence of HSIL by the end of follow-up was higher for HIV-infected girls than for HIV-uninfected girls (21.5% vs. 4.8%, respectively). In multivariate analysis, use of hormonal (either estrogen/progesterone oral combination or medroxyprogesterone acetate intramuscular) contraceptives, high cervical mucous concentrations of interleukin (IL)-12, a positive HPV test, and persistent low-grade squamous intraepithelial lesion (LSIL) were significantly associated with the development of HSIL.

CONCLUSIONS

The incidence of HSIL was alarmingly high in HIV-infected adolescent girls. However, when other predictors were considered in multivariate analysis, HIV status was not retained in the model. The heightened risk for HSIL associated with persistent LSIL underscores the need to closely monitor HIV-infected adolescents with LSIL. The risk for HSIL associated with high concentrations of IL-12 may be suggestive of a local immune dysregulation. The role of hormonal contraception as a risk factor deserves further investigation.

Persistence of human papillomavirus infection in HIV-infected and -uninfected adolescent girls: risk factors and differences, by phylogenetic type

BACKGROUND

High rates of persistence of human papillomavirus (HPV) infection have been reported for adult women with human immunodeficiency virus (HIV) infection. Although most women are first infected with HPV during adolescence, persistence of specific HPV types has not been carefully examined among HIV-infected adolescents. The objective of this study was to examine the rates of and risk factors for persistence of HPV types among HIV-infected and -uninfected adolescent girls.

METHODS

This is a prospective cohort study of female adolescents, aged 13-18 years, participating in the Reaching for Excellence in Adolescent Care and Health project, a national study of HIV-infected and -uninfected adolescents. The main outcome measured was type-specific loss of initial HPV DNA detected. Loss of HPV DNA was defined for the following categories of HPV DNA types: low risk, which included types 6, 11, 42, 44, 54, 40, 13, 32, 62, 72, 2, 57, and 55; and high risk, which included types 16-like (16, 31, 33, 35, 52, 58, and 67), 18-like (18, 39, 45, 59, 68, 70, 26, 69, and 51), and 56-like (56, 53, and 66).

RESULTS

Prevalent or incident HPV infection was detected in 334 girls. When type-specific loss of HPV was examined, HIV-uninfected girls had a shorter mean time to loss of initial infection than did HIV-infected girls (403 days vs. 689 days, respectively; P<.0001). By means of multivariate analysis, CD4 immunosuppression and the presence of multiple HPV-type subgroups were found to be associated with persistence of HPV.

CONCLUSION

Since persistence of high-risk HPV types has been strongly linked with the development of invasive cancer, the prolonged persistence of HPV observed among HIV-infected adolescents who are relatively healthy underscores the importance of prevention of HPV infection in this group.

CD8+CD38+ T cells but not HIV type 1 RNA viral load predict CD4+ T cell loss in a predominantly minority female HIV+ adolescent population

The purpose of this study was to evaluate predictors of HIV-1 disease progression in a cohort of predominantly female and minority adolescents who had acquired their HIV-1 infections through sexual risk behaviors. Subjects were identified from the REACH cohort who were not on antiretroviral therapy for at least 1 year and whose baseline CD4(+) T cells were >300 cells/mm(3). Biomedical and demographic characteristics of the subjects at the start of the study period were evaluated as predictors of CD4(+) T cell loss in univariate and multivariate models. Two-thirds of the 99 subjects meeting the selection criteria were female and 87% were black or Hispanic similar to the REACH cohort as a whole. Higher absolute CD8(+) CD38(+) T cell counts at the start of the assessment period were associated with a greater rate of loss of CD4(+) T cells. HIV-1 RNA viral load was among other potential predictors of HIV-1 disease progression that had no association with the rate of CD4(+) T cell loss in this cohort. This study extends the observed association of higher CD8(+) CD38(+) T cells numbers being predictive of HIV-1 disease progression into predominantly female, minority youth.

Recruitment and retention of adolescent participants in HIV research: findings from the REACH (Reaching for Excellence in Adolescent Care and Health) Project

PURPOSE

To evaluate the importance of 13 items in the recruitment and retention of HIV-positive and HIV-negative adolescent participants in a longitudinal study (REACH study).

METHODS

A confidential, self-administered, visual analog, cross-sectional survey was offered to active participants (November 1999-August 2000) with 438 subjects (86%) participating. Sixty-six percent of the cohort were HIV-positive and 34% were HIV-negative with a mean age of 17 years, and 76% were female. Subjects were asked to recall the importance they placed on 13 items in deciding to join the REACH study (recruitment) and to remain on study (retention). Factors that might explain the judgment placed on the items were analyzed using the nonparametric Wilcoxon Rank-Sum test or the Kruskall-Wallis test.

RESULTS

The five most important factors for study recruitment were identical to those chosen for retention by participants. The factors were: (a) quality medical care, (b) caring staff, (c) health education, (d) privacy/confidentiality, and (e) altruism. Items judged least important were social activities, compensation, transportation, and food/meals. Subject characteristics (gender, age, HIV status) were not associated with statistically different mean judgment scores at recruitment and retention, although clinical site showed significant variation. Factors that could render subjects vulnerable (health insurance, family finances) were not associated with related items.

CONCLUSIONS

Adolescents found quality health care and care team characteristics critically important in considering research participation. Attention to privacy and the opportunity to be altruistic were also important. Compensation for participation was not a significant factor for recruitment and retention of this adolescent cohort. This study demonstrates that adolescents apply sound criteria in evaluating research participation and do not appear to be unduly affected by compensation.

The risk of mortality or cerebral palsy in twins: a collaborative population-based study

The purpose of the paper was to describe demographic and clinical factors associated with fetal or neonatal death or cerebral palsy (CP) in twins. Vital statistics from five populations in the United States and Australia, which included information on CP diagnosed after 1 y of age. Information on zygosity was not available. In 1,141,351 births, 25,772 of whom were twins, significant secular trends from 1980 to 1989 included increasing prevalence of twins, increasing proportion of unlike-sex twins, and increasing maternal age. Overall, twins were at an approximately 5-fold increased risk of fetal death, 7-fold increased risk of neonatal death, and 4-fold increased risk of CP compared with singletons. However, at birth weight <2500 g, twins generally did better than singletons, both with respect to mortality and to CP rates. Second-born twins and twins from same-sex pairs were at increased risk of early death but not of CP. Twins from growth-discordant pairs and twins whose co-twin died were at increased risk of both mortality and CP. The highest rates of CP were in surviving twins whose co-twin was still-born (4.7%), died shortly after birth (6.3%) or had CP (11.8%). In this large data set spanning a 10-y period, overall rates of death or cerebral palsy were higher in twins than singletons, although small twins generally did better than small singletons. Co-twin death was a strong predictor of CP in surviving twins. This risk was the same for same- and different-sex pairs, and observed both for preterm and term infants.

The risk of mortality or cerebral palsy in twins: a collaborative population-based study

The purpose of the paper was to describe demographic and clinical factors associated with fetal or neonatal death or cerebral palsy (CP) in twins. Vital statistics from five populations in the United States and Australia, which included information on CP diagnosed after 1 y of age. Information on zygosity was not available. In 1,141,351 births, 25,772 of whom were twins, significant secular trends from 1980 to 1989 included increasing prevalence of twins, increasing proportion of unlike-sex twins, and increasing maternal age. Overall, twins were at an approximately 5-fold increased risk of fetal death, 7-fold increased risk of neonatal death, and 4-fold increased risk of CP compared with singletons. However, at birth weight <2500 g, twins generally did better than singletons, both with respect to mortality and to CP rates. Second-born twins and twins from same-sex pairs were at increased risk of early death but not of CP. Twins from growth-discordant pairs and twins whose co-twin died were at increased risk of both mortality and CP. The highest rates of CP were in surviving twins whose co-twin was still-born (4.7%), died shortly after birth (6.3%) or had CP (11.8%). In this large data set spanning a 10-y period, overall rates of death or cerebral palsy were higher in twins than singletons, although small twins generally did better than small singletons. Co-twin death was a strong predictor of CP in surviving twins. This risk was the same for same- and different-sex pairs, and observed both for preterm and term infants.

Serologic response to hepatitis B vaccine in HIV infected and high-risk HIV uninfected adolescents in the REACH cohort. Reaching for Excellence in Adolescent Care and Health

PURPOSE

To evaluate hepatitis B (HBV) vaccine response rates in HIV infected and high-risk HIV uninfected youth and examine associations with responsiveness in the HIV infected group.

METHODS

Cohorts within the Reaching for Excellence in Adolescent Care and Health (REACH) study population were defined based on receipt of HBV vaccine both retrospectively and prospectively. Sero-responsiveness was determined by HBsAb measurements. Testing was done for HBsAg, HBsAb, and HBcAb. For HBsAb, a value of > 10 International Units per liter was considered a positive response, and the data were collected as either positive or negative from each of the reporting laboratories. Covariates of responsiveness were explored in univariate and multivariate models for each cohort.

RESULTS

Sixty-one subjects had received a three-dose vaccination course at the time of entry into REACH. HIV uninfected subjects had significantly higher rates of response by serology compared with HIV infected subjects (70% vs. 41.1%; chi(2) = .05; RR = .586, 95% CI: .36-.96). By the time of an annual visit 43 subjects had received three vaccinations with at least one occurring in the study period. The rates of response were similar for the HIV infected and uninfected groups (37.1% vs. 37.5%) in this cohort. Univariate and multivariate analysis in the prospective HIV infected group (N = 35) found an association between elevated CD8(+)/CD38(+)/HLA-DR(+) T cells and lack of HBV vaccine responsiveness (6.7% vs. 60%; chi(2) = .03; RR = .12, 95% CI: .02- .55).

CONCLUSIONS

The poor HBV vaccine response rate in the HIV uninfected high-risk adolescents was unexpected and suggests that HBV vaccination doses have not been optimized for older adolescents. This is the first report of decreased responsiveness in HIV infected subjects being associated with elevated CD8(+)/CD38(+)/HLA(-)DR(+) T cells and suggests that ongoing viral replication and concomitant immune system activation decreases the ability of the immune system in HIV infected subjects to respond to vaccination.

Performance of antigens used in detecting delayed-type hypersensitivity in adolescents infected with the human immunodeficiency virus

We examined the performance of delayed-type hypersensitivity (DTH) antigens employing a new Candida albicans product in a human immunodeficiency virus (HIV)-infected and nonanergic adolescent population. Diameters of induration (in millimeters) for three intradermally applied antigens (C. albicans, tetanus toxoid, and mumps) were compared in a population of HIV-infected 12 to 18 year olds at study entry in a national multicenter study of HIV disease progression. CD4+ T-cell counts were measured in quality-controlled laboratories. The influence of past immunization, gender, and clinical status on antigen reactivity was evaluated with contingency table comparisons and relative risk estimation. Nearly one-half of the 123 eligible subjects were untreated, and almost three-quarters were early in HIV disease by clinical indicators. There was no statistically significant difference in reactivity by past immunization status. Candida antigen (CASTA; Greer Laboratories) evoked DTH response in a significantly higher number of males and females at every level of induration (largest P value, 0.049 for male comparisons; all P values, <0.001 for females) and in subjects with early and intermediate HIV disease at every level of induration (all P values, <0.0001) than either tetanus or mumps antigens. No two-antigen combination was as useful as all three antigens across either gender or clinical categories, although candida and tetanus was the most useful two-antigen combination at indurations of <3 mm. The superior performance of a new C. albicans antigen may extend the utility of DTH assessment in monitoring immune function.

The closeout process for a clinical trial terminated early for lagging enrollment and inadequate follow-up

Closeout of a clinical trial, whether carried out to its original completion of full accrual and attendant follow-up or stopped prematurely because of early indications of efficacy or adverse toxicity, presents challenges in many areas. Closing a clinical trial that fails to adequately accrue and/or successfully follow up patients may exacerbate these problems. The issues involved in the early termination of the Low-Dose Oral Alpha Interferon Trial are described. Control Clin Trials 2001;22:49-55

The prevalence of anergy in human immunodeficiency virus-infected adolescents and the association of delayed-type hypersensitivity with subject characteristics

PURPOSE

To examine the prevalence of anergy in HIV-infected adolescents and factors associated with its occurrence.

METHODS

Anergy was defined as less than 2mm induration to each of three intradermally applied antigens (Candida albicans, tetanus toxoid, and mumps) between 24 and 96 hours in a population of HIV-infected adolescents aged 12-18 at entry in a national multicenter study of HIV disease progression. CD4(+) T-cell counts and plasma HIV-1 RNA were measured in quality controlled laboratories. Factors associated with the probability of anergy were examined with contingency table comparisons, tree-structured classification, and logistic regression analyses.

RESULTS

Overall prevalence of anergy in this clinic-based population of 167 was 11% [7% in males and 12% in females (p = 0.57)]. The sole significant predictor of anergy was decreased CD4(+) T-cell count (p = 0.005).

CONCLUSION

The prevalence of anergy is low in this HIV-infected population compared to older infected cohorts. The occurrence of differential rates of anergy in particular age and sex groupings that may be related to intrinsic immunologic differences requires further study.

Relationship of CD4+ T cell counts and HIV type 1 viral loads in untreated, infected adolescents. Adolescent Medicine HIV/AIDS Research Network

The REACH Project (Reaching for Excellence in Adolescent Care and Health) of the Adolescent Medicine HIV/AIDS Research Network was designed as a study of an adolescent cohort composed of HIV-1-infected and -uninfected subjects. The goal of the analysis presented was to examine the relationship of CD4+ T cell counts and HIV-1 plasma viral loads in adolescents. The CD4+ T cell counts of 84 HIV+ subjects who were 13 to 19 years of age were measured at the clinical sites, using ACTG standardized techniques. HIV-1 viral loads in frozen plasma were determined by the NASBA/NucliSens assay at a central laboratory. Past and current treatment with antiretroviral drugs was determined by medical record abstraction and interview data. The slope of the line generated by regressing log10 HIV-1 RNA (copies/ml) versus CD4+ T cell counts of REACH subjects who are antiretroviral drug naive was negative and significantly different than zero. A negative association has also been reported for antiretroviral drug-naive, adult males in the Pittsburgh Men's Study, a component of MACS (Pitt-MACS) (Mellors J, et al.: Science 1996;272:1167). These data show that in adolescents, as in adults, HIV-1 RNA concentrations are correlated with corresponding absolute CD4+ T cell count. The slopes of the lines generated with data from each cohort were different (p = 0.003). In addition to age, there are sex and racial differences in the makeup of the two cohorts. Any or all of these differences may affect the slopes of the lines.

Cytokine profile in genital tract secretions from female adolescents: impact of human immunodeficiency virus, human papillomavirus, and other sexually transmitted pathogens

Quantitative enzyme-linked immunosorbent assays were used to measure interleukin (IL)-2, IL-10, and IL-12 in cervical secretions from female adolescents with and without sexually transmitted infections. Compared with human immunodeficiency virus [HIV]-negative patients, HIV-positive patients had higher concentrations of IL-10 (118.2 pg/mL vs. 34.5 pg/mL; P=.002) and IL-12 (175.5 pg/mL vs. 85.1; P=.03). IL-2 concentrations were not statistically different. Furthermore, genital tract infections were predictors of IL-10 and IL-12 concentrations. Coinfection with HIV and human papillomavirus predicted the highest IL-10 concentrations; coinfection with HIV, human papillomavirus, and other sexually transmitted pathogens predicted the highest IL-12 concentrations. The data indicate that concomitant infection of the genital tract with HIV and other viral, bacterial, or protozoan pathogens influences the local concentrations of some immunoregulatory cytokines.