Pharmacodynamic genome-wide association study identifies new responsive loci for glucocorticoid intervention in asthma.

Asthma is a chronic lung disease that has a high prevalence. The therapeutic intervention of this disease can be made more effective if genetic variability in patients' response to medications is implemented. However, a clear picture of the genetic architecture of asthma intervention response remains elusive. We conducted a genome-wide association study (GWAS) to identify drug response-associated genes for asthma, in which 909 622 SNPs were genotyped for 120 randomized participants who inhaled multiple doses of glucocorticoids. By integrating pharmacodynamic properties of drug reactions, we implemented a mechanistic model to analyze the GWAS data, enhancing the scope of inference about the genetic architecture of asthma intervention. Our pharmacodynamic model observed associations of genome-wide significance between dose-dependent response to inhaled glucocorticoids (measured as %FEV1) and five loci (P=5.315 × 10(-7) to 3.924 × 10(-9)), many of which map to metabolic genes related to lung function and asthma risk. All significant SNPs detected indicate a recessive effect, at which the homozygotes for the mutant alleles drive variability in %FEV1. Significant associations were well replicated in three additional independent GWAS studies. Pooled together over these three trials, two SNPs, chr6 rs6924808 and chr11 rs1353649, display an increased significance level (P=6.661 × 10(-16) and 5.670 × 10(-11)). Our study reveals a general picture of pharmacogenomic control for asthma intervention. The results obtained help to tailor an optimal dose for individual patients to treat asthma based on their genetic makeup.

A genome-wide association study of bronchodilator response in asthmatics.

Reversibility of airway obstruction in response to ß2-agonists is highly variable among asthmatics, which is partially attributed to genetic factors. In a genome-wide association study of acute bronchodilator response (BDR) to inhaled albuterol, 534 290 single-nucleotide polymorphisms (SNPs) were tested in 403 white trios from the Childhood Asthma Management Program using five statistical models to determine the most robust genetic associations. The primary replication phase included 1397 polymorphisms in three asthma trials (pooled n=764). The second replication phase tested 13 SNPs in three additional asthma populations (n=241, n=215 and n=592). An intergenic SNP on chromosome 10, rs11252394, proximal to several excellent biological candidates, significantly replicated (P=1.98 × 10(-7)) in the primary replication trials. An intronic SNP (rs6988229) in the collagen (COL22A1) locus also provided strong replication signals (P=8.51 × 10(-6)). This study applied a robust approach for testing the genetic basis of BDR and identified novel loci associated with this drug response in asthmatics.

HLA-DQ strikes again: genome-wide association study further confirms HLA-DQ in the diagnosis of asthma among adults.

BACKGROUND: Asthma is a common chronic respiratory disease in children and adults. An important genetic component to asthma susceptibility has long been recognized, most recently through the identification of several genes (e.g., ORMDL3, PDE4D, HLA-DQ, and TLE4) via genome-wide association studies. OBJECTIVE: To identify genetic variants associated with asthma affection status using genome-wide association data. METHODS: We describe results from a genome-wide association study on asthma performed in 3855 subjects using a panel of 455 089 single nucleotide polymorphisms (SNPs). RESULT: The genome-wide association study resulted in the prioritization of 33 variants for immediate follow-up in a multi-staged replication effort. Of these, a common polymorphism (rs9272346) localizing to within 1 Kb of HLA-DQA1 (chromosome 6p21.3) was associated with asthma in adults (P-value = 2.2E-08) with consistent evidence in the more heterogeneous group of adults and children (P-value = 1.0E-04). Moreover, some genes identified in prior asthma GWAS were nominally associated with asthma in our populations. CONCLUSION: Overall, our findings further replicate the HLA-DQ region in the pathogenesis of asthma. HLA-DQA1 is the fourth member of the HLA family found to be associated with asthma, in addition to the previously identified HLA-DRA, HLA-DQB1 and HLA-DQA2.

Summarizing methacholine challenges in clinical research.

In clinical trials in asthma, airway reactivity is commonly assessed by performing a methacholine challenge. Airway reactivity is thought to vary in proportion to asthma severity, and methacholine causes the airways of asthma subjects to constrict, thus lowering forced expiratory volume in 1 second (FEV(1)). A dose-response curve is obtained for each subject who meets standardized eligibility requirements to proceed with a methacholine challenge. When data from a methacholine challenge are used as an outcome variable in analysis, a univariate measure called the PC(20), the concentration of methacholine needed to produce a 20% fall in FEV(1) from baseline, is typically used to summarize the dose-response curve. Questions that arise regarding data generated from the methacholine challenge include: how to express data that do not yield a PC(20) value; whether PC(20) actually represents the best way to capture airway activity as expressed in a methacholine challenge; and whether the baseline FEV(1) is defined appropriately in calculation of PC(20). The impact of these issues on the statistical analysis of methacholine challenge data is described in this article. Some adjustments to the usual estimates of PC(20) and parametric modeling of the entire dose-response curve are proposed as alternatives that address some of the shortcomings of PC(20).

Transbronchial biopsy with virtual CT bronchoscopy and nodal highlighting.

Transbronchial biopsy to sample lymph nodes and tumors that are not visible at endoscopy has a poor (<50%) success rate. These nodes can be highlighted easily at virtual computed tomographic (CT) bronchoscopy to provide a guide. This study was performed to evaluate if the addition of this information to the bronchoscopist improved the success rate of transbronchial biopsy of subcarinal and aortopulmonary lymph nodes. The addition of virtual CT bronchoscopy with lymph node highlighting significantly (P < .5) increased biopsy success rates for pretracheal, hilar, and high pretracheal adenopathy.

Effect of alpha-difluoromethyl-ornithine on the expression and function of the epidermal growth factor receptor in human breast epithelial cells in culture.

We have previously shown that ornithine decarboxylase (ODC) overexpression enhances the transforming effects of HER-2neu and epidermal growth factor (EGF) in normal MCF-10A human breast epithelial cells. Our data suggest that such potentiation may be mediated by activation of the mitogen-activated protein kinase (MAPK) pathway and, possibly, STAT signalling. To further explore the interaction between the polyamine pathway and EGF/HER-2neu signalling in this system, we inhibited endogenous ODC activity with alpha-difluoromethylornithine (DFMO) and assessed the effects of this blockade on the expression of EGF receptors (EGFR) and HER-2neu as well as activation of downstream EGF target genes. We found that DFMO administration to MCF-10A cells increased EGF-R mRNA and protein levels in a dose-response fashion, while HER-2neu expression was not affected. The effect of DFMO was mediated through polyamine depletion since it could be reversed by exogenous putrescine administration. Our results also indicated that the increase in EGFR induced by DFMO was not a non-specific consequence of inhibition of cell proliferation. The upregulated EGFRs were functional since they could be phosphorylated by EGF and they were able to promote phosphorylation of downstream signalling molecules including ERK, STAT-3, and STAT-5. We propose that physiologic levels of ODC activity may be critical for regulation of a yet undefined signalling pathway, whose blockade by DFMO leads to a compensatory increase in functional EGFR.

CT angiography: in vitro comparison of five reconstruction methods.

OBJECTIVE: Five image reconstruction techniques have been used with CT angiography: axial (cross-sectional), maximum intensity projection (MIP), curved multiplanar reconstruction (MPR), shaded-surface display, and volume rendering. This study used a phantom to compare the accuracy of these techniques for measuring stenosis. SUBJECTS AND METHODS: A 19-vessel phantom containing various grades of concentric stenoses (0-100%) and three lengths (5, 7.5, and 10 mm) of stenoses was used for this study. Scans were obtained with a slice thickness of 2.0 mm, slice interval of 1.0 mm, pitch of 1.0, 120 kVp, 200 mA, and with the vessels oriented parallel to the z-axis and opacified with nonionic contrast material. CT angiography images were produced using five optimized techniques: axial, MIP, MPR, shaded-surface display, and volume rendering; and measurements were made with an electronic cursor in the normal lumen and mid stenosis by five separate investigators who were unaware of vessel and stenosis diameters. Each of the techniques was first optimized according to the radiology literature and our own preliminary testing. RESULTS: For vessels greater than 4 mm in diameter, axial, MIP, MPR, shaded-surface display, and volume-rendering CT angiography techniques all had a measurement error of less than 2.5%. However, axial, MIP, MPR, and shaded-surface display techniques were less accurate in estimating smaller (

An interactive computer program can effectively educate patients about genetic testing for breast cancer susceptibility.

As genetic testing for susceptibility to breast cancer becomes more widespread, alternative methods for educating individuals prior to testing will be needed. Our objective was to compare face-to-face education and counseling by a genetic counselor with education by an interactive computer program, assessing the effects of each on knowledge of breast cancer genetics and intent to undergo genetic testing. We used a randomized, controlled trial. Seventy-two self-referred women with a first-degree relative with breast cancer received outpatient education and counseling at the Clinical Center of the National Institutes of Health (NIH). Twenty-nine received individualized counseling from a genetic counselor (counseling group), 29 received education from an interactive computer program followed by individualized counseling (computer group), and 14 were controls. Both pre- and postintervention assessment of knowledge about breast cancer genetics and intent to undergo genetic testing were measured. The control group participants correctly answered 74% of the knowledge questions; the counselor group, 92%; and the computer group, 96% (P <.0001). Unadjusted mean knowledge scores were significantly higher in the computer group than the counselor group (P =.048), but they were equivalent when adjusted for demographic differences (P = 0.34). Intent to undergo genetic testing was influenced by the interventions: preintervention, a majority in all groups (69%) indicated that they were likely (definitely and most likely) to undergo testing; after either intervention coupled with counseling, only 44% indicated that they were likely to do so (P =.0002; odds ratio = 2.8, 95% CI = 1.7-4.9). We concluded that a computer program can successfully educate patients about breast cancer susceptibility, and, along with genetic counseling, can influence patients' intentions to undergo genetic testing.

Training in obstetric sonography for radiology residents and fellows in the United States.

OBJECTIVE: The purpose of our study was to assess the current experience of radiology residents and fellows in obstetric sonography. SUBJECTS AND METHODS: Written surveys were sent to the directors of 206 accredited radiology residency programs and 85 fellowship programs in the United States. The surveys encompassed obstetric sonographic experience during routine working hours and after hours, the level of supervision, the types of scanning performed, and the extent of formal lectures available during training. Additional questions concerned the relative knowledge of laboratory accreditation processes and training of faculty covering obstetric sonography. RESULTS: Sixty (29%) of 206 accredited radiology residency programs and 24 (28%) of 85 fellowship programs returned surveys. The experience among residency programs was similar, providing fewer than 4 weeks per year of obstetric sonography, usually within their own department of radiology. Residents were more likely to be sent to outside departments for second or third trimester sonography experience. A decrease in scanning assistance was reported for examinations performed after hours, more so for second or third trimester studies. Lecture topics revealed similar deficiencies for residency and fellowship programs. CONCLUSION: Greater emphasis on the performance of prenatal sonographic examinations may be warranted during formal sonography rotations. Current levels of experience in obstetric sonography may not be providing sufficient experience to allow residents to appropriately manage call cases or for practicing radiologists to provide such services after their training is completed.

Immunohistochemical detection of ornithine-decarboxylase in primary and metastatic human breast cancer specimens.

Increased ornithine decarboxylase (ODC) activity in human breast cancer specimens has recently been shown to be an independent adverse prognostic factor for recurrence and death. Biochemical measurement of ODC, however, is not practical for routine clinical use. Furthermore, it does not take into account the heterogeneous composition of human breast cancers which contain variable proportions of epithelial and stromal elements. Therefore, we developed an immunohistochemical method for ODC determination which can be applied to formalin-fixed, paraffin-embedded tissue sections. We report here our results in a series of 30 human breast cancer samples. ODC expression was detected most consistently in the malignant epithelial component of the tumors. Twenty-seven of 30 samples stained positive with intensities ranging from 1+ to 3+. The fraction of malignant epithelial cells expressing ODC varied among specimens between 10% and > 90%. When quantitated by H-SCORE, ODC expression was significantly higher in the malignant epithelial component than in normal appearing epithelial cells and stroma admixed within the tumor. Normal mammary tissue adjacent to the cancer was available for analysis in six cases. ODC expression was absent in two (while both cancers were positive) but present in four to a degree which was overall comparable to that observed in the corresponding tumors. We believe that this technique will be useful for future studies aimed at expanding our knowledge of the role of ODC and polyamines (PA) in breast cancer biology.

S-adenosylmethionine decarboxylase overexpression reduces invasiveness and tumorigenicity in nude mice of MCF-7 breast cancer cells.

To elucidate the role of S-adenosylmethionine decarboxylase (SAMDC) in breast cancer biology, we have generated SAMDC overexpressing MCF-7 breast cancer cells. SAMDC overexpression did not alter in a major way growth properties of MCF-7 cells in soft agar, either under basal conditions or in response to estrogen and antiestrogen administration. SAMDC-MCF-7 cells, on the other hand, exhibited a markedly reduced invasive ability in matrigel (p=0.013). Furthermore, they were less tumorigenic in nude mice. The odds for control clones to form tumors were 3.13 (C.1.1.2-8.2, p=0.0184) higher than those for SAMDC clones. The odds ratio were identical in the absence and in the presence of estradiol. In addition, the growth rate of established tumors was slower for SAMDC than for control clones. Overall, our results are consistent with the notion that these phenotypic changes induced by SAMDC overexpression are primarily mediated by suppression of cellular putrescine (and, possibly, spermidine) levels.

Reproducibility of motor unit number estimation in individual subjects.

Although the reproducibility of motor unit number estimation (MUNE) for groups of subjects has been studied, there is little such data for individuals. Prediction intervals represent a tool to study individual MUNE reproducibility and represent the range of values expected for a future MUNE if the true number of motor units remains unchanged. MUNE was performed using the statistical method on 48 normal individuals. The prediction interval was found to be a function of the intrasubject coefficient of variation. Using a commercial manufacturer's recommended technique and software, prediction intervals were found to be so broad as to be of uncertain value. We found that by averaging two MUNE observations for each determination, and using the method of weighted averages for calculating the size of an average single motor unit potential, the intrasubject coefficient of variation was reduced from 16.48% to 8.77%, and the 90% prediction interval became sufficiently narrow to be clinically useful. False-negative rates were also lowered substantially using these techniques. Thus, simple modifications of an existing MUNE program improved the clinical utility of this program for the longitudinal study of patients in whom changes in motor unit number over time are of importance, such as those with motor neuron diseases.

Comparative assessment of CT and sonographic techniques for appendiceal imaging.

OBJECTIVE: We performed a comparative assessment of CT and sonographic techniques used to assess appendicitis. MATERIALS AND METHODS: One hundred patients with clinically suspected acute appendicitis were examined with sonography, unenhanced focused appendiceal CT, complete abdominopelvic CT using IV contrast material, focused appendiceal CT with colonic contrast material, and repeated sonography with colonic contrast material. Each sonogram was videotaped for subsequent interpretation by three radiologists and two sonographers. The mean sensitivity, specificity, positive and negative predictive values, inter- and intraobserver variability, and diagnostic confidence scores of all observers were used for comparative performance assessments. The three CT examinations were filmed and interpreted separately by four radiologists. Patient discomfort was assessed on a 10-point scale for each radiologic study. Diagnoses were confirmed by pathologic evaluation of resected appendixes or clinical follow-up for a minimum of 3 months after presentation. RESULTS: Twenty-four of the 100 patients had positive findings for acute appendicitis. Both sonographic techniques had high specificity (85-89%) and comparable accuracy (73-75%) but low sensitivity (33-35%) and inter- and intraobserver variability (kappa = 0.15-0.20 and 0.39-0.42, respectively). Unenhanced focused appendiceal CT, abdominopelvic CT, and focused appendiceal CT with colonic contrast material all significantly outperformed sonography (p <0.0001), with sensitivities of 78%, 72%, and 80%; specificities of 86%, 91%, and 87%; and accuracies of 84%, 87%, and 85%, respectively. Abdominopelvic CT gave the greatest confidence in cases with negative findings (p = 0.001), and focused appendiceal CT with colonic contrast material gave the greatest confidence for cases with positive findings (p = 0.02). In terms of inter- and intraobserver variability, focused appendiceal CT with colonic contrast material yielded the highest, and unenhanced focused appendiceal CT the lowest, agreement (interobserver kappa = 0.45 vs. 0.36 and intraobserver kappa = 0.85 vs. 0.76, respectively) (p <0.05). Colonic contrast material was unsuccessfully advanced into the cecum in 18% of patients and leaked in another 24%. Patient discomfort was greatest with focused appendiceal CT using colonic contrast material and least with unenhanced focused appendiceal CT (p <0.05). CONCLUSION: A standard abdominopelvic CT scan is recommended as the initial examination for appendicitis in adult patients. However, focused appendiceal CT with colonic contrast material material should be used as a problem-solving technique in difficult cases.

Rationing HIV medications: what do patients and the public think about allocation policies?

BACKGROUND: New medications for treating HIV/AIDS are effective, but expensive, and funding shortfalls have led many state AIDS Drug Assistance Programs (ADAPs) to ration these drugs. Little is known about the views of those most directly affected by rationing policies. This study explores attitudes of patients with HIV and the general public toward specific rationing strategies. METHODS: A Likert-style, self-administered questionnaire about rationing expensive HIV medications in the context of a budget shortfall was administered to patients with HIV and shopping mall patrons in central Pennsylvania. Subjects were asked how much they agreed or disagreed with seven drug rationing policies. RESULTS: In all, 100 patients and 101 shoppers completed the survey (response rate = 89%). A majority in both groups "strongly" or "somewhat" disagreed with six of the seven rationing policies described, and patients more strongly disagreed with the policies than did the public. The five policies actually used by state ADAPs (first come first serve, limiting expensive medicines, limiting new patient enrollment, giving the expensive medicines to the sickest, using a spending cap) lacked support in either group. CONCLUSIONS: HIV drug rationing policies currently in use do not reflect the preferences of patients and the public. Integrating the views of those affected by the rationing decisions would raise difficult challenges to current programs.

CT angiographic measurement of the carotid artery: optimizing visualization by manipulating window and level settings and contrast material attenuation.

PURPOSE: To evaluate a broad range of window and level settings for various contrast material attenuation coefficients and degrees of vascular stenosis to obtain the most accurate computed tomographic (CT) angiographic measurements. MATERIALS AND METHODS: A total of 25, 480 measurements were made transversely (perpendicular to the lumen) and by means of maximum intensity projection (MIP) in a phantom with stenoses of 0%-100%, contrast material with attenuation coefficients of 150-350 HU, and 14 window and 13 level settings. Edge definition was also evaluated. RESULTS: There was an inherent relationship between the contrast material attenuation coefficient and the optimal window and level settings in the measurement of stenoses at both transverse and MIP CT angiography. This relationship between the contrast material attenuation coefficient D: and the optimal settings for window W: and level L: was represented by the following simple equations: W:/D: = [-2 x (L:/D:)] + 1.3, where -0.2 < L:/D: < 0.5, and W:/D: = [3.3 x (L:/D:)] - 1.3, where 0.5 < L:/D: < 1.0. With a vascular contrast material attenuation coefficient of 250-350 HU, the best transverse and MIP display settings for the window and level were 96 and 150 HU, respectively. CONCLUSION: The use of optimized window and level settings at CT angiography reduces measurement variability.

An alternative index for assessing profile similarity in bioequivalence trials.

In a typical bioequivalence trial, summary measures of the plasma concentration versus time profile are used to compare two formulations of a drug product. Commonly used measures include area under the curve (AUC), maximum plasma concentration (C(max)) and time to maximum concentration (T(max)). Equivalence of these summary measures, in general, does not guarantee equivalence of the entire profile. Rescigno and Chinchilli and Elswick propose indices which measure profile similarity, but can be overly sensitive to unimportant differences and are not easily interpreted pharmacologically. We propose an alternative index based on smoothing the relative difference between bioavailability profiles. This provides a method for assessing bioequivalence over the entire profile which has a familiar interpretation and can be tuned to provide a compromise between the insensitivity to pattern differences of summary measures and the oversensitivity of pointwise comparisons.

Impact of the Armed Forces Institute of Pathology Radiologic Pathology Course on radiology resident performance on the ACR In-Training and ABR written Examinations. American College of Radiology. American Board of Radiology.

RATIONALE AND OBJECTIVES: The purpose of this study was to assess resident scores on the American College of Radiology (ACR) In-Training Examination and on the written American Board of Radiology (ABR) Examination relative to attendance at and timing of the Armed Forces Institute of Pathology (AFIP) Radiologic Pathology Course. MATERIALS AND METHODS: A survey of 200 radiology residency program directors requested the type of residency program, whether the program sent residents to the AFIP course, dates of AFIP attendance for individual residents, percentile scores of residents on the ACR examination from 1995 through 1998, and ABR examination scores for 1997. Scores were analyzed before and after AFIP attendance and also temporally for examinations during or after AFIP attendance. Improvement in percentile scores for residents undergoing the ACR examination while attending the AFIP were compared with scores of matched residents from their programs who had not attended. RESULTS: Thirty-six (18%) program directors responded, providing data on 619 residents who underwent the ACR examination, ABR examination, or both. No significant improvement was found between pre- and post-AFIP ACR Examination scores for residents at university or military programs. There were statistically significantly improved scores for residents at community programs (mean percentile improvement, 8.1 points; P = .0064). Residents who underwent the ACR examination during the AFIP course improved their scores by 10.7 percentile points compared with matched residents who had not attended the AFIP course (P = .041). CONCLUSION: Residents undergoing the ACR examination while attending the AFIP improve their percentile scores more than residents who have not attended the AFIP.

Lying to each other: when internal medicine residents use deception with their colleagues.

BACKGROUND: While lying is morally problematic, physicians have been known to use deception with their patients and with third parties. Little is known, however, about the use of deception between physicians. OBJECTIVES: To determine the likelihood that resident physicians say they would deceive other physicians in various circumstances and to examine how variations in circumstances affect the likelihood of using deception. METHODS: Two versions of a confidential survey using vignettes were randomly distributed to all internal medicine residents at 4 teaching hospitals in 1998. Survey versions differed by introducing slight variations to each vignette in ways we hypothesized would influence respondents' willingness to deceive. The likelihood that residents say they would use deception in response to each vignette was compared between versions. RESULTS: Three hundred thirty surveys were distributed (response rate, 67%). Of those who responded, 36% indicated they were likely to use deception to avoid exchanging call, 15% would misrepresent a diagnosis in a medical record to protect patient privacy, 14% would fabricate a laboratory value to an attending physician, 6% would substitute their own urine in a drug test to protect a colleague, and 5% would lie about checking a patient's stool for blood to cover up a medical mistake. For some of the scenarios, the likelihood of deceiving was influenced by variations in the vignettes. CONCLUSIONS: A substantial percentage of internal medicine residents report they would deceive a colleague in various circumstances, and the likelihood of using deception depends on the context. While lying about clinical issues is not common, it is troubling when it occurs at any time. Medical educators should be aware of circumstances in which residents are likely to deceive, and discuss ways to eliminate incentives to lie.

Mucosal detail at CT virtual reality: surface versus volume rendering.

PURPOSE: To evaluate computed tomographic virtual reality with volumetric versus surface rendering. MATERIALS AND METHODS: Virtual reality images were reconstructed for 27 normal or pathologic colonic, gastric, or bronchial structures in four ways: the transition zone (a) reconstructed separately from the wall by using volume rendering; (b) with attenuation equal to air; (c) with attenuation equal to wall (soft tissue); (d) with attenuation halfway between air and wall. The four reconstructed images were randomized. Four experienced imagers blinded to the reconstruction graded them from best to worst with predetermined criteria. RESULTS: All readers rated images with the transition zone as a separate structure as overwhelmingly superior (P <.001): Nineteen cases had complete concurrence among all readers. The best of the surface-rendering reconstructions had the transition zone attenuation equal to the wall attenuation (P <.001). The third best reconstruction had the transition zone attenuation equal to the air attenuation, and the worst had the transition zone attenuation halfway between the air and wall attenuation. CONCLUSION: Virtual reality is best with volume rendering, with the transition zone (mucosa) between the wall and air reconstructed as a separate structure.