Goal attainment scaling as an outcome measure in rare disease trials: a conceptual proposal for validation.

BACKGROUND: Goal Attainment Scaling (GAS) is an instrument that is intended to evaluate the effect of an intervention by assessing change in daily life activities on an individual basis. However, GAS has not been validated adequately in an RCT setting. In this paper we propose a conceptual validation plan of GAS in the setting of rare disease drug trials, and describe a hypothetical trial where GAS could be validated. METHODS: We have used the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) taxonomy to deduce which measurement properties of GAS can be evaluated, and how. As individual GAS scores cannot be interpreted outside the context of a RCT, the validation of GAS needs to be done on trial as well as on individual level. RESULTS: The procedure of GAS consists of three steps. For the step of goal selection (step 1) and definition of levels of attainment (step 2), face validity may be assessed by clinical experts. For the evaluation of the goal attainment (step 3), the inter and intra rater reliability can be evaluated on an individual level. Construct validity may be evaluated by comparison with change scores on other instruments measuring in the same domain as particular goals, if available, and by testing hypotheses about differences between groups. A difference in mean GAS scores between a group who received an efficacious intervention and a control group is an indication of well-chosen goals, and corroborates construct validity of GAS on trial level. Responsiveness of GAS cannot be evaluated due to the nature of the construct being assessed. CONCLUSION: GAS may be useful as an instrument to assess functional change as an outcome measure in heterogeneous chronic rare diseases, but it can only be interpreted and validated when used in RCTs with blinded outcome assessment. This proposed theoretical validation plan can be used as a starting point to validate GAS in specific conditions.

The patient's view on rare disease trial design - a qualitative study.

BACKGROUND: Clinical trials in rare diseases are more challenging than trials in frequent diseases. Small numbers of eligible trial participants, often complicated by heterogeneity among rare disease patients, hamper the design and conduct of a 'classical' Randomized Controlled Trial. Therefore, novel designs are developed by statisticians. However, it is important to be aware of possible design aspects that may jeopardize the feasibility of trial conduct. If the burden of participation is considered out of proportion by patients or parents, recruitment may fail or participants may drop out before trial completion. In order to maximize the chance of success of trials in small populations, it is important to know which aspects of trial design are considered important by patients. RESULTS: We have interviewed all ten members of the Patient Think Tank (PTT) of the ASTERIX project, a European research consortium on methodology for clinical trials in small populations. The PTT members are rare disease patient representatives who have completed extensive training in clinical trial methodology. We have analyzed the interviews qualitatively according to Grounded Theory using a thematic analysis, and we structured the topics in four chronologically ordered themes: 1. Involvement in trial design; 2. Opinions on trial design; 3. Trial participation; 4. Phase after the trial. Our main findings are that the PTT-members recommend that patients are involved in trial design from an early stage on, and have influence on the outcomes and measurement instruments that are chosen in the trial, the length of the study, the choice of participants, and the information that is sent to potential participants. Also, according to the PTT-members, patient groups should consider setting up disease registries, placebo groups should be minimized, and more education on clinical trials is advised. CONCLUSIONS: Rare disease patient representatives who have been educated about clinical trial methodology think it is important to involve patient representatives in research at an early stage. They can be of advice in trial design in such a way that the ratio of potential benefit and burden of trial participation as well as the chosen outcome measures and in- and exclusion criteria are optimized.

The POWER-tool: Recommendations for involving patient representatives in choosing relevant outcome measures during rare disease clinical trial design.

In clinical trials, it is relevant to ask patients and/or their caregivers which aspects concerning their disease they consider important to measure when a new intervention is being investigated. Those aspects, useful as outcome measures in a trial, are of pivotal importance for the result of the trial and the subsequent decision-making. In rare diseases the choice of outcome measures may be even more important, due to the small numbers and heterogeneity of the patients that are included. We have developed a tool to involve patients in the determination of outcome measures and the choice of measurement instruments. This tool was developed together with a patient think tank, consisting of a group of rare disease patient representatives, and by interviewing end users. We have road-tested our tool in an ongoing trial, and evaluated it during a focus group meeting. The tool consists of three steps: 1) Preparation, 2) Consultation of patients, 3) Follow-up during which the consultation results are implemented in the trial design. The tool provides guidelines for researchers to include the patient's opinion in the choice of outcome measures in the trial design stage. We describe the development of the POWER-tool (Patient participation in Outcome measure WEighing for Rare diseases), and first experiences of the tool in an ongoing trial.

The negative predictive value of breast Magnetic Resonance Imaging in noncalcified BIRADS 3 lesions.

PURPOSE: The purpose of this study is to determine whether breast MRI can provide a sufficient NPV to safely rule out malignancy in mammographic BIRADS 3 lesions. MATERIALS AND METHODS: In a 3-year consecutive mammographic examination study 176 out of 4391 patients had a lesion classified as BIRADS 3. 76 out of 176 patients underwent breast MRI as diagnostic work-up. Lesions which MRI classified as BIRADS 1 or 2 were considered negative for malignancy. Sensitivity, specificity, PPV and NPV were calculated. RESULTS: In 27 out of 76 (35.5%) patients MRI showed no enhancement and was classified as BIRADS 1. In 25 (32.9%) patients MRI showed focal or mass enhancement classified as BIRADS 2. In these 52 (68.4%) patients no malignancy was found during at least 2 years study follow-up. The other 24 (31.6%) patients had a lesion classified as BIRADS ≥ 3. Thirteen of these 24 lesions were malignant by pathology. MRI had a sensitivity of 100% (95% CI: 75-100%), specificity of 82.5% (95% CI: 71-91%), PPV of 54.2% (95% CI: 33-74%) and NPV of 100% (95% CI: 93-100%). CONCLUSION: Breast MRI should be used in a diagnostic strategy for the work-up of noncalcified BIRADS 3 lesions. Malignancy is ruled out with a very high level of confidence in the majority of patients (68%), herewith avoiding invasive diagnostic procedures.

Comparison of (semi-)automatic and manually adjusted measurements of left ventricular function in dual source computed tomography using three different software tools.

To assess the accuracy of (semi-)automatic measurements of left ventricular (LV) functional parameters in cardiac dual-source computed tomography (DSCT) compared to manually adjusted measurements in three different workstations. Forty patients, who underwent cardiac DSCT, were included (31 men, mean age 58 ± 14 years). Multiphase reconstructions were made with ten series at every 10% of the RR-interval. LV function analysis was performed on three different, commercially available workstations. On all three workstations, end-systolic volume (ESV), end-diastolic volume (EDV), LV ejection fraction (LVEF) and myocardial mass (MM) were calculated as automatically as possible. With the same DSCT datasets, LV functional parameters were also calculated with as many manual adjustments as needed for accurate assessment for all three software tools. For both semi-automatic as well as manual methods, time needed for evaluation was recorded. Paired t-tests were employed to calculate differences in LV functional parameters. Repeated measurements were performed to determine intra-observer and inter-observer variability. (Semi-)automatic measurements revealed a good correlation with manually adjusted measurements for Vitrea (LVEF r = 0.93, EDV r = 0.94, ESV r = 0.98 and MM r = 0.94) and Aquarius (LVEF r = 0.96, EDV r = 0.94, ESV r = 0.98 and MM r = 0.96). Also, good correlation was obtained for Circulation, except for LVEF (LVEF r = 0.45, EDV r = 0.93, ESV r = 0.92 and MM r = 0.86). However, statistically significant differences were found between (semi-)automatically and manually adjusted measurements for LVEF (P < 0.05) and ESV (P < 0.001) in Vitrea, all LV functional parameters in Circulation (P < 0.001) and EDV, ESV and MM (<0.001) in Aquarius Workstation. (Semi-)automatic measurement of LV functional parameters is feasible, but significant differences were found for at least two different functional parameters in all three workstations. Therefore, expert manual correction is recommended at all times.

Semi-automatic measurement of left ventricular function on dual source computed tomography using five different software tools in comparison with magnetic resonance imaging.

PURPOSE: To compare left ventricular (LV) function assessment using five different software tools on the same dual source computed tomography (DSCT) datasets with the results of MRI. MATERIALS AND METHODS: Twenty-six patients, undergoing cardiac contrast-enhanced DSCT were included (20 men, mean age 59±12 years). Reconstructions were made at every 10% of the RR-interval. Function analysis was performed with five different, commercially available workstations. In all software tools, semi-automatic LV function measurements were performed, with manual corrections if necessary. Within 0-22 days, all 26 patients were scanned on a 1.5 T MRI-system. Bland-Altman analysis was performed to calculate limits of agreement between DSCT and MRI. Pearson's correlation coefficient was calculated to assess the correlation between the different DSCT software tools and MRI. Repeated measurements were performed to determine intraobserver and interobserver variability. RESULTS: For all five DSCT workstations, mean LV functional parameters correlated well with measurements on MRI. Bland-Altman analysis of the comparison of DSCT and MRI showed acceptable limits of agreement. Best correlation and limits of agreement were obtained by DSCT software tools with software algorithms comparable to MRI software. CONCLUSION: The five different DSCT software tools we examined have interchangeable results of LV functional parameters compared to regularly analysed results by MRI. The best correlation and the narrowest limits of agreement were found when the same software algorithm was used for both DSCT and MRI examinations, therefore our advice for clinical practice is to always evaluate images with the same type of post-processing tools in follow-up.

Breast magnetic resonance imaging as a problem-solving modality in mammographic BI-RADS 3 lesions.

The probability of a mammographic Breast Imaging Reporting and Data System (BI-RADS) 3 lesion being cancer is considered to be less than 2%. Therefore, the work-up of a mammographic BI-RADS 3 lesion should be biopsy or follow-up mammography after 6 months. However, most patients referred for biopsy have benign disease. Although the negative predictive value (NPV) of magnetic resonance imaging (MRI) is highest of all imaging techniques, it is not yet common practice to use breast MRI as a problem-solving modality to exclude patients for further diagnostic work-up. Therefore, in this meta-analysis the usefulness of breast MRI as a problem-solving modality in mammographic BI-RADS 3 lesions is investigated. After a systematic search only 5 out of 61 studies met the inclusion criteria. The NPV in 2 of those studies was reported to be 100%. It was concluded that MRI can be used as an adjunctive tool to mammographic BI-RADS 3 findings to exclude patients for further diagnostic work-up. The other 3 studies assessed the accuracy of MRI in mammographic BI-RADS 3 microcalcifications. These studies reported an NPV of MRI between 76% and 97%. Therefore, MRI cannot be implemented as a diagnostic tool to evaluate mammographic microcalcifications at this time. The first solid data indicate that breast MRI might be useful as a problem-solving modality to exclude patients with non-calcified mammographic BI-RADS 3 lesions for further diagnostic work-up. However, further research is needed to verify these results.

[Granted, undecided, withdrawn and refused requests for euthanasia and physician-assisted suicide in the Netherlands; 2000-2002]. / Ingewilligde, onbesliste, ingetrokken en geweigerde verzoeken om euthanasie en hulp bij zelfdoding in Nederland; 2000-2002.

OBJECTIVE: To determine the characteristics of patients who request euthanasia or physician-assisted suicide and whether these characteristics differ among those whose request is granted, those who die before the procedure, those who die before completion of the approval process, those who withdraw their request, and lastly, those whose request is refused by the physician. DESIGN: Questionnaire study. METHOD: All general practitioners in 18 of the 23 Dutch general practitioner districts received a written questionnaire in which they were asked to describe the most recent request for euthanasia or physician-assisted suicide that they had received (response 60%, n=3614). RESULTS: Of all explicit requests, 44% resulted in euthanasia or physician-assisted suicide. Thirteen percent of patients died before the procedure, 13% died before completion of the approval process, 13% withdrew their request and 12% were refused by the physician. The most prominent symptoms were 'feeling bad', 'tiredness', and 'lack of appetite'. The most frequently mentioned reasons for requesting euthanasia or physician-assisted suicide were 'pointless suffering', 'loss of dignity', and 'general weakness'. The patients' situation met the official requirements for accepted practice best in the group of requests that resulted in euthanasia or physician-assisted suicide and least in the group of refused requests. A lesser degree of competence and less unbearable and hopeless suffering had the strongest associations with the refusal of a request. CONCLUSION: The complexity of euthanasia or physician-assisted suicide decision-making is reflected in the fact that, besides granting and refusing a request, 3 other situations could be distinguished. The decisions physicians made, the reasons for their decisions and the way they arrived at their decisions appeared to be based on patient evaluations and on the official requirements for accepted practice.

Lower urinary tract symptoms after renal transplantation.

PURPOSE: We investigated the prevalence and nature of lower urinary tract symptoms after renal transplantation. In addition, we studied how these symptoms affect the quality of life and whether function of the lower urinary tract before transplantation was related to postoperative occurrence of lower urinary tract symptoms. MATERIALS AND METHODS: Data were gathered by a written questionnaire. The research group consisted of 63 patients who underwent renal transplantation in 1998 at the University Medical Center St Radboud Nijmegen. The control group consisted of 74 patients with nonurological complaints who visited an outpatient clinic at the same university. RESULTS: The most important finding was that patients who underwent renal transplantation needed to void more often than controls, both during the day and at night. After renal transplantation, almost 50% of the patients complained of frequency and 62% nocturia. Patients with a transplant had tended to perceive frequency and nocturia less as problems than those in the control group. CONCLUSIONS: No relation was found between the functioning of the lower urinary tract before transplantation, and occurrence of frequency and nocturia after. The amount of fluid intake at the interview was not related to the occurrence of frequency and nocturia. No abnormalities were found regarding bladder evacuation.

Development of a PCR-based line probe assay for identification of fungal pathogens.

We report on a reverse-hybridization line probe assay (LiPA) which when combined with PCR amplification detects and identifies clinically significant fungal pathogens including Candida, Aspergillus, and Cryptococcus species. DNA probes have been designed from the internal transcribed-spacer (ITS) regions of Candida albicans, Candida parapsilosis, Candida glabrata, Candida tropicalis, Candida krusei, Candida dubliniensis, Cryptococcus neoformans, Aspergillus fumigatus, Aspergillus versicolor, Aspergillus nidulans and Aspergillus flavus. The probes were incorporated into a LiPA for detection of biotinylated ITS PCR products, and the specificity of the probes was evaluated. We established LiPA detection limits for ITS 1 and for full ITS amplicons for genomic DNA from C. albicans, A. fumigatus, and C. neoformans. Further evaluation of the LiPA was carried out on clinical fungal isolates. One hundred twenty-seven isolates consisting of dimorphic yeasts and dermatophytic and filamentous fungi were tested by the LiPA, which correctly identified 77 dimorphic yeasts and 23 of the filamentous isolates; the remaining 27 isolates represented species of fungi for which probes were not included in the LiPA. The fungal-PCR-LiPA technology was applied to blood samples inoculated with Candida cells which were pretreated by minibead beating to mechanically disrupt the cells, with the DNA extracted by either a previously described guanidium thiocyanate-silica method or the commercially available QIAmp tissue kit. PCR amplification of the extracted DNA and subsequent DNA probe hybridization in the LiPA assay yielded detection limits of 2 to 10 cells/ml. An internal standard control was included in the PCR amplification to monitor for PCR inhibition. This fungal PCR-LiPA assay is robust and sensitive and can easily be integrated into a clinical-testing laboratory with the potential for same-day diagnosis of fungal infection.

Molecular characterisation of the Theileria buffeli/orientalis group.

Benign bovine Theileria parasites known as either Theileria buffeli, Theileria orientalis or Theileria sergenti are classified on basis of their morphology, vector specificity, pathogenicity and 18S small subunit ribosomal RNA or major piroplasm protein (MPSP) sequences. Since most isolates have been characterized on only some of these criteria and the existing confusion in nomenclature, an analysis was performed on eight different isolates to combine 18S rRNA data with MPSP data and the results were compared with available biological parameters. A polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) approach for both genes was used in combination with reverse line blot hybridisation for the 18S rRNA gene. Both MPSP and 18S rRNA genes were cloned and sequenced from parasites displaying aberrant MPSP RFLP profiles. Phylogeny based on published and determined 18S rRNA and MPSP sequences did correlate within the same isolate but there was no obvious correlation between molecular and biological data. Based on these findings, we suggest that the appropriate name for all these parasites is Theileria buffeli. A more specific nomenclature should be assigned when new molecular markers may become available.

Enrichment of an antigen-specific T cell response by retrovirally transduced human dendritic cells.

The superior ability of dendritic cells (DC) in triggering antigen-specific T cell responses makes these cells attractive tools for the generation of antitumor or antiviral immunity. We report here an efficient retroviral transduction system for the introduction of antigens into DC. A retroviral vector encoding several CTL epitopes in a string-of-beads fashion in combination with the marker gene green fluorescence protein (GFP) was generated. Polyepitope transduced EBV-LCL could be isolated on the basis of GFP expression and were found to be sensitive to lysis by antigen-specific cytotoxic T cells, demonstrating that antigens encoded by the retroviral construct were stably expressed, processed, and presented in the context of HLA class I molecules. CD34(+) cells isolated from G-CSF mobilized peripheral blood were transduced with high efficiency (40-60%) with this retroviral construct. These cells could be considerably expanded in vitro and differentiated into mature DC without loss of the transduced antigen. DC transduced with the polyepitope constructs were able to mount a CTL response against an influenza epitope in the context of HLA-A2, demonstrating the antigen-specific CTL priming capacity of retrovirally transduced DC. Staining of the T cells with tetramers of HLA-A2 and the influenza virus peptide demonstrated a marked antigen-specific CTL enrichment after 2 in vitro stimulations using DC transduced with the polyepitope. However, additional in vitro stimulations of the T cells with transduced DC did not result in a further enrichment of tetramer staining cells.

Simultaneous detection of bovine Theileria and Babesia species by reverse line blot hybridization.

A reverse line blot (RLB) assay was developed for the identification of cattle carrying different species of Theileria and Babesia simultaneously. We included Theileria annulata, T. parva, T. mutans, T. taurotragi, and T. velifera in the assay, as well as parasites belonging to the T. sergenti-T. buffeli-T. orientalis group. The Babesia species included were Babesia bovis, B. bigemina, and B. divergens. The assay employs one set of primers for specific amplification of the rRNA gene V4 hypervariable regions of all Theileria and Babesia species. PCR products obtained from blood samples were hybridized to a membrane onto which nine species-specific oligonucleotides were covalently linked. Cross-reactions were not observed between any of the tested species. No DNA sequences from Bos taurus or other hemoparasites (Trypanosoma species, Cowdria ruminantium, Anaplasma marginale, and Ehrlichia species) were amplified. The sensitivity of the assay was determined at 0.000001% parasitemia, enabling detection of the carrier state of most parasites. Mixed DNAs from five different parasites were correctly identified. Moreover, blood samples from cattle experimentally infected with two different parasites reacted only with the corresponding species-specific oligonucleotides. Finally, RLB was used to screen blood samples collected from carrier cattle in two regions of Spain. T. annulata, T. orientalis, and B. bigemina were identified in these samples. In conclusion, the RLB is a versatile technique for simultaneous detection of all bovine tick-borne protozoan parasites. We recommend its use for integrated epidemiological monitoring of tick-borne disease, since RLB can also be used for screening ticks and can easily be expanded to include additional hemoparasite species.

Detection of Theileria annulata by the PCR in ticks (Acari:Ixodidae) collected from cattle in Mauritania.

We report on the detection of Theileria annulata in infected Hyalomma ticks by the PCR using primers derived from the gene encoding the 30 kDa major merozoite surface antigen (TamsI-1). No inhibition of the PCR was observed and as little as 0.1 pg of parasite DNA, corresponding to 12 sporozoites, could be detected in non-infected tick DNA samples, spiked with T. annulata genomic DNA. Hyalomma dromedarii ticks, fed on a calf experimentally infected with T. annulata, were used to validate the PCR further. The infection rate in the adult ticks, fed as nymphs during the febrile reaction, was high (62%), dropped to zero for 1 day in tick batches that engorged after treatment with Butalex and increased to 30% 2 days later and 38% of the ticks acquired the infection after feeding as nymphs during a carrier state piroplasm parasitaemia of less than 0.1%. As an internal control, 16S tick rDNA sequences could be amplified from T. annulata-negative tick samples. Finally, 202 adult ticks from Mauritania, collected from zebu cattle carrying low levels of Theileria piroplasms, were tested by the PCR. Thirty-eight out of 52 (73%) and 17 out of 30 (57%) H. dromedarii from the Gorgol and Trarza regions, respectively and two out of 30 (7%) Hyalomma marginatum rufipes from the Gorgol region were positive. Hyalomma marginatum rufipes, Rhipicephalus evertsi evertsi and Rhipicephalus guilhoni from the Trarza region were negative. These findings confirm that H. dromedarii is the main vector of T. annulata in Mauritania and that the PCR is a useful method of determining the infection rates in ticks collected from cattle carrying low levels of T. annulata piroplasms.

Expression of genes encoding two major Theileria annulata merozoite surface antigens in Escherichia coli and a Salmonella typhimurium aroA vaccine strain.

The genes, Tams1-1 and Tams1-2, encoding the 30-and 32-kDa major merozoite surface antigens of Theileria annulata (Ta), have recently been cloned and characterized. Both genes encode a protein of 281 amino acids (aa) containing a putative hydrophobic N-terminal signal peptide. Another hydrophobic stretch is predicted at the C terminus which probably functions to anchor the protein in the membrane of the merozoite and piroplasm. Here, we report the successful expression of both Tams1-1 and Tams1-2 in Escherichia coli (Ec) using gene fragments lacking both hydrophobic domains. Attempts to produce high amounts of the entire recombinant (re-) protein, or a fragment containing the N terminus only, were unsuccessful. This is presumably due to the toxicity of these re-proteins. The internal part of both genes was also expressed in Salmonella typhimurium (St) aroA vaccine strain SL3261. We employed a dual-plasmid expression system based on an invertible promoter and selected the most stable St construct in vitro using liquid cultures and a macrophage-like cell line. The re-Tams1-1 protein produced in Ec, as well as in St, was recognized by monoclonal antibody (mAb) 5E1 specific to the 30-kDa protein. Both re-Tams1-1 and re-Tams1-2 were recognized by Ta immune calf serum.

Detection of Theileria annulata in blood samples of carrier cattle by PCR.

We report the detection of Theileria annulata, the causative agent of tropical theileriosis, by PCR in blood samples obtained from carrier cattle. The assay employs primers specific for the gene encoding the 30-kDa major merozoite surface antigen of T. annulata. A 721-bp fragment was amplified from blood samples taken monthly from calves experimentally infected with one of four different stocks of T. annulata originating in either Mauritania, Portugal, Spain, or Turkey. At the end of the experiment, five animals carried the infection for 12 months and two animals remained infected for 15 months. DNAs from six other Theileria species, T. parva, T. mutans, T. sergenti, T. buffeli, T. velifera, and T. taurotragi, were not amplified. Moreover, DNAs from four other hemoparasites (Anaplasma centrale, Anaplasma marginale, Babesia bovis, and Babesia bigemina) were also not amplified. As a control, primers derived from the small subunit rRNA gene of Theileria spp. amplified a 1.1-kb DNA fragment from all Theileria species examined but not from the other four hemoparasites. As few as two to three parasites per microliter of infected blood in a 50-microliters sample volume were detected by Southern or microplate hybridization with a T. annulata-specific cDNA probe. In addition, 92 field samples obtained from cattle in Spain were tested; 22% were positive in blood smears, 40% were positive by immunofluorescent antibody test, and 75% were positive for T. annulata by PCR. The method provides a useful diagnostic tool for detecting T. annulata carrier cattle.