Estimating treatment effects in randomized clinical trials in the presence of non-compliance

In clinical trials where patients are randomized between two treatment arms, not all patients comply with the treatment they were randomly assigned to. The reasons for (non)compliance may be associated with the outcome variable and thereby act as confounders. The standard way of analysing such trials is by the 'intention-to-treat' principle, which allows the use of permutation tests. Conclusions drawn from such tests do not depend on untested assumptions such as absence of confounding. However, this approach may yield biased estimators for the causal effects of treatments. We consider the estimation of such effects for clinical trials where non-compliers can be considered to have switched to the other trial arm. The most important example of this is the placebo-controlled clinical trial where no substantial placebo effects are anticipated. We consider the situation where the relationship between compliance, and thus treatment received, and outcome is influenced by unobserved confounders. The residual of the regression of the actual treatment indicator variable on the randomization arm indicator variable is shown to 'intercept' the effect of such confounders. Inclusion of this residual in a multivariate analysis, in conjunction with the treatment indicator variable, should thus adjust for confounding. Examples are given. In those examples, the results are similar to those obtained by more complex methods.     

Immunity to hepatitis B, poliomyelitis and measles in fully vaccinated Aboriginal and Torres Strait Island children

Objective: To determine the immunity to hepatitis B, poliomyelitis and measles in fully vaccinated Aboriginal and Torres Strait Island children in north Queensland.
Methodology: A cross-sectional survey of immunity in a sample of children; 101 fully vaccinated Aboriginal and Torres Strait Island children, with a median age of 24.5 months, from 10 communities in North Queensland participated in this study. The main outcome measures were the prevalence of adequate antibody levels against hepatitis B, poliomyelitis and measles.
Results: Only 54% (95% Cl 44–63%) of the children had adequate immunity (10 m iu/mL) to hepatitis B, and one child had been infected despite vaccination. Although all the children (95% Cl 96–100%) had adequate immunity (i.e. neutralizing antibodies at a dilution of 1:8) to poliovirus 2, only 93% (95% Cl 86–96%) and 60% (95% Cl 50–69%) had adequate immunity to polioviruses 1 and 3, respectively. Nearly all (96%; 95% Cl 90–98%) of the children had adequate immunity (i.e. detectable IgG antibody) to measles.
Conclusions: Although a relatively low proportion of the children had adequate antibody levels against hepatitis B the clinical significance of this observation is uncertain. Further studies are needed to determine whether fully vaccinated Torres Strait Island children have been adequately protected and whether they require a booster dose of hepatitis B vaccine. A substantial proportion of fully vaccinated Aboriginal and Torres Strait Island children are inadequately protected against poliomyelitis, and therefore any such child with acute flaccid paralysis should be investigated fully for poliomyelitis. Vaccinated Aboriginal and Torres Strait Island children are well protected against measles, as are other Australian children.     

Apgar score, meconium and acidaemia at birth in relation to neonatal neurological morbidity in term infants

The relation between Apgar score, meconium and acidaemia at birth and neonatal neurological morbidity was investigated in 805 vaginally born term infants whose birthweight was appropriate-for-dates (AFD). Presence or absence of meconium stained amniotic fluid was not related to the neonatal neurological condition. The 1-min and 3-min Apgar scores and the umbilical artery pH were related, but the variances explained in neonatal neurological optimality score were very low (0.9 and 0.5% respectively). Combination of Apgar score and pH slightly increased these percentages to 1.5. The highest frequency of neurologically deviant infants was, on the other hand, found in the group with a normal pH but low Apgar score. It is concluded that in AFD term infants nowadays the predictive value of a low Apgar score, acidaemia at birth and/or presence of meconium for the neonatal neurological morbidity is poor. Most neonatal neurological abnormalities must be due to other factors.     

Traumatic flap displacement after LASIK

CASE REPORT: We present a case of traumatic displacement of corneal flap in the superior temporal quadrant 13 days after LASIK. The flap was repositioned after gentle irrigation of BSS, cleaned the interface and then drying the flap to verify its stability. In the next day the flap was adhered, clear cornea,smooth and visual acuity without correction was 1.00. DISCUSSION: We should try immediately to reposition the flap after traumatic displacement, as in this case.     

Proliferative ischaemic retinopathy in a case of systemic lupus erythematosus and antiphospholipidic syndrome

PURPOSE/METHODS: We report a 34-year-old woman with sytemic lupus erythematosus (S.L.E.) and antiphospholipidic syndrome which presented severe ischaemic retinopathy and neovascular proliferation. RESULTS/CONCLUSIONS: We achieved no progression of the disease and stabilization of visual acuity with panphotocoagulation. We recommend periodic ophtalmologic exams because of the scarce symptomatology.     

Injection timing determines whether intragastric ethanol produces conditioned place preference or aversion in mice

Previous studies have shown that mice develop conditioned place preference (CPP) when ethanol is administered by intraperitoneal (ip) or intravenous (iv) injection. The present studies examined CPP in mice using the intragastric (ig) route of administration. Inbred mice were surgically implanted with chronic intragastric cannulae and exposed to an unbiased place conditioning procedure in which infusion of ethanol (2 or 4 g/kg) was paired with a conditioned stimulus (CS+). A different CS was paired with water. In Experiments 1-2, ethanol was infused just before exposure to CS+. Contrary to previous studies involving intraperitoneal injection, infusion of 4 g/kg ig ethanol produced a significant conditioned place aversion (CPA). However, when a 5-min delay was inserted between infusion and CS exposure (Experiments 3-4), the same dose produced CPP. These outcomes are not consistent with expectations derived from a recent study in selectively bred rats, suggesting that sensitivity to ethanol reward is enhanced by intragastric administration. However, the finding that intragastric ethanol can produce either CPP or CPA depending on dose and injection timing is consistent with previous intraperitoneal ethanol studies in mice. Although the parameters differ for each route of administration, it appears that the same underlying processes can be invoked to explain how manipulation of injection timing affects the direction of ethanol-induced place conditioning. More specifically, in both cases, CPA can be attributed to an initial, short-lived aversive effect, whereas CPP can be attributed to a delayed rewarding effect of ethanol.     

Metastatic potential of human neoplasms

Primary human neoplasms are heterogeneous for a large number of properties that include invasion and metastasis. The process of metastasis consists of multiple selective steps. The outcome of metastasis is determined by the continuous interaction of metastatic cells with host homeostatic mechanisms. Since the outcome of metastasis is influenced by both the intrinsic properties of the tumor cell and host factors, the successful metastatic cell must be viewed as a cell able to manipulate its new microenvironment. For many years, our efforts to treat cancer have concentrated on the destruction of tumor cells. Strategies to treat tumor cells and to modulate the host organ microenvironment should provide an additional approach for cancer treatment. Recent advancements in our understanding of the biological basis of cancer metastasis present unprecedented possibilities for translating basic research to the clinical reality of cancer treatment.