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Biomedical subjects

M Townsend

Publications and source records attributed to M Townsend.

At least 19 recordsLinked to original sources

Overexpression of the retinoblastoma gene in a familial adrenocortical carcinoma.

Tumors derived from a Li-Fraumeni syndrome cancer-susceptible family were examined for expression of the retinoblastoma susceptibility gene (RB). Whereas RB expression was normal in a primary breast carcinoma and its metastases from one member of this family, overexpression of RB was found in an adrenocortical carcinoma from another family member. This was in contrast to normal RB expression in normal tissue of this patient, the adrenocortical adenocarcinoma cell line SW-13, and the fibroblast cell line MRC-5, and low level RB expression in normal adrenal tissue. The overexpression in the adrenocortical carcinoma resulted in increased synthesis of the RB-encoded protein and did not appear to be associated with RB amplification or rearrangement. This result is novel as it is usually the loss of expression or production of an altered RB transcript exhibiting deletions that is associated with carcinogenesis. In light of the recent discovery of p53 point mutations in the affected Li-Fraumeni syndrome family members tested, RB overexpression may constitute a secondary event in Li-Fraumeni syndrome tumorigenesis.

Adrenal Cortex Neoplasms

Measuring functional status in chronic lung disease: conclusions from a randomized control trial.

The optimal method of assessing the effect of treatment on the day-to-day function of patients with chronic airflow limitation has not yet been established. Therefore, we examined the performance of the 6-min walk test, a rating of dyspnea following the walk test, and three different questionnaires measuring dyspnea in daily activities, in a controlled trial of inhaled salbutamol and oral theophylline in 24 patients with primary fixed chronic airflow limitation. Clinically important and statistically significant effects of salbutamol and theophylline on dyspnea during the day-to-day activities were detected by each measure, but the Chronic Respiratory Questionnaire (CRQ) was more powerful than the other questionnaires, either the Oxygen Cost Diagram or the Medical Research Council Dyspnea Questionnaire as modified by the Rand Corporation. Changes in the CRQ dyspnea score showed a higher correlation with changes in spirometry, walk test score, dyspnea following the walk test, and global ratings of dyspnea than did the other two measures. We conclude that the CRQ is a responsive, valid measure of functional status for clinical trials in chronic lung disease.

Aged

Evaluation of the burden of illness for pediatric asthmatic patients and their parents.

To examine the quality-of-life burden of asthma in a pediatric population, we systematically surveyed 100 patients with moderate asthma and one parent of each patient to determine the impact of the disease on day-to-day life. We found that perceptions of burden of illness varied by viewpoint. For patients, the symptoms of asthma form the largest component of the burden of the disease; in addition, more than half of the sample listed various emotional function items that were of at least moderate bother to them. Parents cited worry and concern about the disease and the medications used to treat it and their inability to relieve their child's symptoms as the major components of the burden of the disease. We conclude that although pediatric patients with moderate asthma find the respiratory symptoms of the disease troublesome, few children perceive that their asthma poses a major disruption of their lives. For the parents of these patients, strategies could be implemented by clinicians to ease the common worries and concerns surrounding the child's asthma.

Adolescent

Should study subjects see their previous responses: data from a randomized control trial.

To test the relative merits of administering questionnaires with previous responses available (the informed condition) or unavailable (the blind condition), we administered blind and informed versions of a quality of life questionnaire (the Chronic Respiratory Disease Questionnaire, or CRQ) in a randomized, double-blind trial of bronchodilators in chronic airflow limitation. The responsiveness of the two methods, as reflected in the p-values associated with salbutamol and theophylline effects were comparable for three of the four dimensions of the CRQ. The data suggested possible increased responsiveness of the informed method for the emotional function dimension of the questionnaire. Changes in the informed CRQ dyspnea and fatigue dimensions showed stronger correlations with changes in spirometry, 6 minute walk distance, and rating of dyspnea after the walk test than did blind administration. Further, changes in all four CRQ dimensions showed stronger correlations with corresponding global ratings using the informed questionnaire. These results suggest that by letting study subjects see their previous responses the validity of subjective measures of health status in clinical trials can be improved.

Administration, Oral

Measuring functional status in chronic lung disease: conclusions from a randomized control trial.

The optimal method of assessing the effect of treatment on the day-to-day function of patients with chronic airflow limitation is not established. Therefore, we examined the performance of the Six Minute Walk test, a rating of dyspnea following the test and three different questionnaires measuring dyspnea in daily activities, in a controlled trial of inhaled salbutamol and oral theophylline in 24 patients with primarily fixed chronic airflow limitation. Clinically important and statistically significant effects of salbutamol and theophylline on dyspnea during day-to-day activities were detected by each measure, but the Chronic Respiratory Questionnaire (CRQ) appeared more powerful than either the Oxygen Cost Diagram or the Medical Research Council Dyspnea Questionnaire as modified by the Rand Corporation. Changes in the CRQ dyspnea score showed a higher correlation with changes in spirometry, walk test score, dyspnea following the walk test, and global ratings of dyspnea than did the other two measures. Results of the walk test demonstrated statistically significant salbutamol and theophylline effects, but suggested that no added benefit could be obtained with both drugs; the rating of dyspnea following the walk test, however, was consistent with an additive effect. We conclude that the CRQ is a responsive, valid measure of functional status for clinical trials in chronic lung disease, and that when the six minute walk is used as a measure of outcome, dyspnea following the walk test should be measured.

Albuterol

The epidemiology of pulmonary function and COPD mortality in the multiple risk factor intervention trial.

The potential determinants of the changes in chronic obstructive pulmonary disease (COPD) mortality were evaluated using both the Multiple Risk Factor Intervention Trial (MRFIT) screenees, the longitudinal analysis of the participants, and the differences in special intervention (SI) and usual care (UC) groups. COPD was the underlying cause for only one third of all death certificates listing COPD. Small changes in classification will have a major impact on reported COPD death rates. Cigarette smoking is clearly the primary determinant of COPD mortality. Decreased pulmonary function is an independent risk factor for coronary heart disease (CHD) mortality. Smoking cessation results in a slower rate of decline in pulmonary function over time, especially among heavy smokers. Careful evaluation of smoking cessation, including repeat chemical measures, suggest that the percentage of long-term quitters, especially among heavy smokers has been overestimated. The low percentage of quitters substantially reduced the power to detect an intervention effect. The increased cigarette smoking among recent older cohorts, and failure to substantially reduce smoking, especially among heavy smokers, may be an important factor accounting for the failure to note a decline in COPD mortality among older persons.

Adult

UDP-glucuronosyltransferases in the metabolic disposition of xenobiotics.

UDPGT isoenzymes are products of multiple gene families as demonstrated by sequence analysis of purified proteins and by molecular cloning experiments. These isoenzymes are relatively specific for endogenous substrates but have broad substrate specificities for xenobiotic substrates. They are important metabolic enzymes capable of converting exogenous and endogenous substances to more hydrophilic metabolites. Each species has its own pattern of UDPGTs and it is not possible at this time to extrapolate information directly from one species to another.

Animals

A controlled trial of digoxin in congestive heart failure.

Because of conflicting results from studies examining the usefulness of digoxin in congestive heart failure (CHF) patients in sinus rhythm, a cross-over trial was conducted in which 20 patients received 7 weeks of digoxin titrated to a level of 1.54 to 2.56 nmol/liter and 7 weeks of matched placebo. The order of treatments was determined by random allocation and patients, clinicians and research staff were blind to allocation. In patients with deteriorating condition, the treatment period was terminated and outcome measures were obtained. If deterioration occurred during the first period, the patient was crossed over without the code being broken. Seven patients required premature termination of study periods because of increasing symptoms of CHF. All 7 were taking placebo at the time (p = 0.016). Small differences in dyspnea (p = 0.044), walking test score (p = 0.055), clinical assessment of CHF (p = 0.036) and ejection fraction (p = 0.004) favored the digoxin treatment group. Patients with more severe CHF were more likely to benefit from digoxin administration. It was concluded that oral digoxin, in doses titrated to produce a serum level of 1.54 to 2.56 nmol/liter, improved quality of life and functional exercise capacity in some patients with CHF in sinus rhythm.

Aged

Acute response to bronchodilator. An imperfect guide for bronchodilator therapy in chronic airflow limitation.

We conducted a four-period cross-over randomized trial in which we found that patients with chronic airflow limitation demonstrated symptomatic improvement with both inhaled albuterol and oral theophylline. The response, however, was not uniform. We therefore tested the ability of acute change in forced expired volume in one second (FEV1) following inhaled beta agonist to predict long-term symptomatic response to albuterol and theophylline. We found that the reproducibility of acute change in FEV1 over three repetitions was poor (intraclass correlation 0.17). Furthermore, the mean improvement FEV1 following inhaled albuterol across the three repetitions did not relate closely to symptomatic response to either albuterol or theophylline. We conclude that acute response to inhaled beta agonist is not useful for identifying patients with chronic airflow limitation who are likely to benefit from bronchodilator treatment.

Administration, Inhalation

Long-term outcome after respiratory rehabilitation.

To determine the long-term effect of respiratory rehabilitation, we followed up for 6 months after discharge 31 consecutive patients enrolled in a multidisciplinary inpatient rehabilitation program lasting 4 to 6 weeks. Of the 31, 24 showed improvement in quality of life (as measured with a previously validated questionnaire) and in functional exercise capacity (as measured with the 6-minute walk test) 2 weeks after discharge. The improvement was sustained for 6 months in 11 of the 24. Other investigators have found higher response rates than those that we report. The differences are likely due to our enrolment of consecutive patients, the length and completeness of follow-up, and the objective measurement of quality of life by an interviewer not associated with the rehabilitation program. Controlled trials of respiratory rehabilitation measuring both costs and benefits are warranted. In the meantime, strategies to maintain the initial improvement seen after rehabilitation should be developed and studied.

Chronic Disease

Quality of life in patients with chronic airflow limitation.

One hundred patients with chronic airflow limitation (CAL) randomly selected from over 600 such patients seen in the previous 2 years at a respiratory referral centre were asked about the ways in which their lives were adversely effected by their lung problems. Major problem areas included dyspnoea on day-to-day activities, fatigue and certain areas of emotional function including embarrassment, depression, anxiety and frustration. Severity of airflow limitation was only weakly related to patients' problems. Patients did not volunteer items easily, and most problems were elicited by specific probes. In 36 subjects, relatives were asked about the patients' problems. Relatives tended to identify fewer items, but items identified were judged more important; there was a limited relation between spouses' and patients' assessment of CAL-related problems (Pearson's r = 0.42-0.60). These results suggest that physicians cannot rely on severity of airflow limitation as an indicator of the impact of CAL on patients' lives. Patients should be specifically asked about problem areas, especially emotional difficulties, and spouses' view of the problems should be obtained.

Aged

A comparison of Likert and visual analogue scales for measuring change in function.

Many controlled trials rely on subjective measures of symptoms or quality of life as primary outcomes. The relative merits of different response options for these measures is an important, but largely unexplored, issue. Therefore, we compared the responsiveness of seven-point Likert vs visual analogue scales (VAS) in a questionnaire measuring quality of life in chronic lung disease. The VAS and seven-point scale versions of the questionnaire were administered to 28 patients before and after completing an inpatient respiratory rehabilitation program of known benefit. For all four dimensions of the questionnaire (dyspnea, fatigue, emotional function, and mastery) the VAS showed a larger improvement than the seven-point scale when both were standardized on a scale of 0-10. However, in each case the variability of the improvement was greater using the VAS. The difference in improvement between the two scales was not statistically significant. We conclude that the two methods of presenting response options show comparable responsiveness. The ease of administration and interpretation of the seven-point scale recommend its use in clinical trials.

Clinical Trials as Topic

Treatment of cryptosporidiosis with spiramycin in AIDS. An "N of 1" trial.

We describe a randomized, double-blind, placebo-controlled, crossover trial with spiramycin in a single patient with acquired immune deficiency syndrome (AIDS) and a severe secretory diarrhea caused by cryptosporidium. Spiramycin, a potentially harmful antibiotic, had no clinical or microbiological effect in this patient. The application of the single patient (N of 1) trial to common clinical problems is a simple way to analyze the value of different therapeutic approaches. The time-consuming, expensive, multi-patient trial with ultimate extrapolation to the individual patient can be avoided. Single-patient trials can influence management and improve patient care and have potentially wide use in patients with gastrointestinal disease.

Acquired Immunodeficiency Syndrome

A measure of quality of life for clinical trials in chronic lung disease.

Since the relationships between pulmonary function, exercise capacity, and functional state or quality of life are generally weak, a self report questionnaire has been developed to determine the effect of treatment on quality of life in clinical trials. One hundred patients with chronic airflow limitation were asked how their quality of life was affected by their illness, and how important their symptoms and limitations were. The most frequent and important items were used to construct a questionnaire evaluating four dimensions: dyspnoea, fatigue, emotional function, and the patient's feeling of control over the disease (mastery). Reproducibility, tested by repeated administration to patients in a stable condition, was excellent: the coefficient of variation was less than 12% for all four dimensions. Responsiveness (sensitivity to change) was tested by administering the questionnaire to 13 patients before and after optimisation of their drug treatment and to another 28 before and after participation in a respiratory rehabilitation programme. In both cases large, statistically significant improvements in all four dimensions were noted. Changes in questionnaire score were correlated with changes in spirometric values, exercise capacity, and patients' and physicians' global ratings. Thus it has been shown that the questionnaire is precise, valid, and responsive. It can therefore serve as a useful disease specific measure of quality of life for clinical trials.

Clinical Trials as Topic

Bronchodilators in chronic air-flow limitation. Effects on airway function, exercise capacity, and quality of life.

We conducted a trial of inhaled salbutamol and orally administered theophylline in patients whose acute response to inhaled salbutamol was less than 25% of their baseline FEV1. Patients underwent 4 treatment periods, each of 2 wk duration, during which they received the following combinations: placebo-placebo, placebo-salbutamol, placebo-theophylline, and salbutamol-theophylline. The 19 patient who completed the study were all males with a mean age of 65 +/- 7.4 yr, mean FEV1 of 1.02 +/- 0.38, and mean VC of 2.73 +/- 0.19. Outcomes included twice-daily recordings of peak flow rates, spirometry, the distance patients could walk in 6 min, and clinical symptoms of dyspnea, fatigue, and emotional function. Clinically important and statistically significant differences between the 4 periods were noted on both physiologic and functional outcomes. For the group as a whole, improvement with inhaled salbutamol and orally administered theophylline was comparable, and additional benefit was gained from a combination of the 2 drugs. We conclude that both inhaled salbutamol and orally administered theophylline can improve airflow obstruction, functional exercise capacity, and quality of life in patients with primarily fixed air-flow limitation.

Aged

A controlled trial of ambroxol in chronic bronchitis.

Ambroxol is a mucolytic agent which is widely used in chronic bronchitis in Europe. We conducted a double-blind randomized controlled trial of ambroxol vs matched placebo in 90 patients with chronic bronchitis and difficulty clearing secretions. It was concluded that there was no advantage to taking ambroxol.

Ambroxol

How should we measure function in patients with chronic heart and lung disease?

To elucidate the characteristics of measures of function in patients with chronic heart failure and chronic lung disease we administered four functional status questionnaires, a 6-min walk test and a cycle ergometer exercise test, to 43 patients limited in their day to day activities as a result of their underlying heart or lung disease. Correlations between these measures were calculated using Spearman's rank order correlation coefficient. The walk test correlated well with the cycle ergometer (r = 0.579), and almost as well with the four functional status questionnaires (r = 0.473-0.590) as the questionnaires did with one another (0.423-0.729). On the other hand, correlations between cycle ergometer results and the questionnaires was in each case 0.295 or lower, and none of these correlations reached statistical significance. These results suggest that exercise capacity in the laboratory can be differentiated from functional exercise capacity (the ability to undertake physically demanding activities of daily living) and that the walk test provides a good measure of function in patients with heart and lung disease.

Activities of Daily Living

Should study subjects see their previous responses?

To test the relative merits of administering questionnaires with previous responses available (the informed condition) or unavailable (the blind condition), we administered blind and informed versions of a quality of life questionnaire to two groups of patients. One, a group of 43 stable subjects with chronic cardiorespiratory disease, were seen three times at fortnightly intervals; a separate series of 13 patients with chronic lung disease were evaluated before and after optimization of therapy. In the stable patients the informed strategy resulted in substantial decrease in the variance in the measurement of dyspnea, fatigue, and of emotional function. Large improvements in dyspnea, fatigue, and emotional function seen in patients undergoing treatment optimization were comparable using blind and informed methods. These results suggest that by letting patients see their previous responses we can decrease the sample size needed to detect changes in quality of life in clinical trials.

Aged