Center-Related Determinants of VKA Anticoagulation Quality: A Prospective,Multicenter Evaluation

Background

Center-specific TTR (c-TTR) is a measure reporting the mean patient TTR within an anticoagulation clinic describing the quality of anticoagulant monitoring offered by that clinic. c-TTR has a considerable between-center variation, but its determinants are poorly understood.

Objectives

We aimed at evaluating which clinical, procedural or laboratory factors could be associated with c-TTR variability in a multicenter, observational cross-sectional study over a five-year period.

Patients/Methods

Data from 832,204 individual patients followed for VKA therapy in 292 Centers affiliated with the Italian Federation of Anticoagulation Clinics (FCSA) were analyzed. c-TTR was computed based on the TTR of patients followed at each Center, and a mixed linear regression model was used for a predefined set of explanatory variables.

Results

The Center next-visit interval ratio (the mean number of days after a visit with an INR outside the therapeutic range, divided by the days after a visit with an INR within the therapeutic range), the Center mean patient INR and the Center laboratory performance at EQA proficiency testing were the only variables that were independently associated with c-TTR (β-coefficients -17.32, 9.67, and -0.11, respectively; r ² = 0.635).

Conclusions

These findings suggest that c-TTR associates with proactive strategies aimed at keeping patients very close to their target INR with a prompt re-evaluation of those patients with under- or over-therapeutic INR.     

The carboxyl terminal extension of the Drosophila insulin receptor homologue binds IRS-1 and influences cell survival.

The Drosophila insulin receptor (INR) homolog includes an extension of approximately 400 amino acids at the carboxyl-terminal end of its beta subunit containing several tyrosine-based motifs known to mediate interactions with signaling proteins. In order to explore the role of this extension in INR function, mammalian expression vectors encoding either the complete INR beta subunit (beta-Myc) or the INR beta subunit without the carboxyl-terminal extension (betaDelta) were constructed, and the membrane-bound beta subunits were expressed in 293 and Madin-Darby canine kidney cells in the absence of the ligand-binding alpha subunits. beta-Myc and betaDelta proteins were constitutively active tyrosine kinases of 180 and 102 kDa, respectively. INR beta-Myc co-immunoprecipitated a phosphoprotein of 170 kDa identified as insulin receptor substrate-1 (IRS-1), whereas INR betaDelta did not, suggesting that the site of interaction was within the carboxyl-terminal extension. IRS-1 was phosphorylated on tyrosine to a much greater extent in cells expressing INR beta-Myc than in parental or INR betaDelta cells. Despite this, a variety of PTB or SH2 domain-containing signaling proteins, including IRS-2, mSos-1, Shc, p85 subunit of phosphatidylinositol 3-kinase, SHP-2, Raf-1, and JAK2, were not associated with the INR beta-Myc.IRS-1 complex. Overexpression of INR beta-Myc and betaDelta kinases conferred an equivalent increase in cell proliferation in both 293 and Madin-Darby canine kidney cells, indicating that this growth response is independent of the carboxyl-terminal extension. However, INR beta-Myc-expressing cells exhibited enhanced survival relative to parental and betaDelta cells, suggesting that the carboxyl-terminal extension, through its interaction with IRS-1, plays a role in the regulation of cell death.     

Calculating confidence intervals for prediction error in microarray classification using resampling

Cross-validation based point estimates of prediction accuracy are frequently reported in microarray class prediction problems. However these point estimates can be highly variable, particularly for small sample numbers, and it would be useful to provide confidence intervals of prediction accuracy. We performed an extensive study of existing confidence interval methods and compared their performance in terms of empirical coverage and width. We developed a bootstrap case cross-validation (BCCV) resampling scheme and defined several confidence interval methods using BCCV with and without bias-correction. The widely used approach of basing confidence intervals on an independent binomial assumption of the leave-one-out cross-validation errors results in serious under-coverage of the true prediction error. Two split-sample based methods previously proposed in the literature tend to give overly conservative confidence intervals. Using BCCV resampling, the percentile confidence interval method was also found to be overly conservative without bias-correction, while the bias corrected accelerated (BCa) interval method of Efron returns substantially anti-conservative confidence intervals. We propose a simple bias reduction on the BCCV percentile interval. The method provides mildly conservative inference under all circumstances studied and outperforms the other methods in microarray applications with small to moderate sample sizes.     

高温胁迫对白眉野草螟滞育幼虫存活特性的影响

【目的】白眉野草螟 Agriphila aeneociliella 是小麦上新发现的一种害虫,以滞育的老熟幼虫做土茧在土壤中越夏,研究明确滞育幼虫在夏季持续高温和极端高温条件下的存活率,为该害虫秋季虫源基数的预测预报和有效防控提供依据。【方法】以白眉野草螟带土茧滞育幼虫和不带土茧滞育幼虫为研究对象,在室内条件下设置43,46,49,52和55℃极端高温,分别处理0.5,1,2和4 h;设置35,37,39和41℃普通高温,分别处理1,2,4和8 d。【结果】极端高温处理2和4 h后,带土茧滞育幼虫半致死温度分别为50.04℃（95%置信区间: 49.36~50.47℃）和48.81℃（95%置信区间: 47.74~49.37℃）,去除土茧后分别为48.20℃（95%置信区间: 47.66~48.74℃）和47.36℃（95%置信区间: 47.08~48.37℃）;52℃温度条件下,带有土茧滞育幼虫半致死时间为1.29 h（95%置信区间: 1.17~1.44 h）,去除土茧后半致死时间为1.02 h（95%置信区间: 0.93~1.18 h）。普通高温处理41℃时,带有土茧滞育幼虫半致死时间为3.21 d（95%置信区间: 2.92~3.52 d）,去除土茧后半致死时间为2.66 d（95%置信区间: 2.33~3.02 d）。【结论】白眉野草螟滞育幼虫具有很强的耐高温能力,土茧对其具有一定的保护作用。小麦收割后深耕灭茬,使土茧或幼虫裸露到地表,利用夏季土表高温杀死滞育幼虫,可以作为一项有效的农业防治措施。     

On Parametric Confidence Intervals for the Cost‐Effectiveness Ratio

When comparing two competing interventions, confidence intervals for cost‐effectiveness ratios (CERs) provide information on the uncertainty in their point estimates. Techniques for constructing these confidence intervals are much debated. We provide a formal comparison of the Fieller, symmetric and Bonferroni methods for constructing confidence intervals for the CER using only the joint asymptotic distribution of the incremental cost and incremental effectiveness of the two interventions being compared. We prove the existence of a finite interval under the Fieller method when the incremental effectiveness is statistically significant. When this difference is not significant the Fieller method yields an unbounded confidence interval. The Fieller interval is always wider than the symmetric interval, but the latter is an approximation to the Fieller interval when the incremental effectiveness is highly significant. The Bonferroni method is shown to produce the widest interval. Because it accounts for the likely correlation between cost and effectiveness measures, and the intuitively appealing relationship between the existence of a bounded interval and the significance of the incremental effectiveness, the Fieller interval is to be preferred in reporting a confidence interval for the CER.     

Some Remarks on the Estimation of the Ratio of the Expectation Values of a Two-dimensional Normal Random Variable (Correction of the Theorem of Milliken)

It is possible to show that the theorem of Fieller yields an exact confidence region derivable from the likelihood ratio test. The statement of Milliken (1982) that this confidence region is conservative is refuted. Bounds for the conditional confidence coefficient under the condition that the confidence region is a “meaningful” confidence interval are given.     

An Improvement of the Westlake Symmetric Confidence Interval

A common statistical method for assessing bioequivalence of two formulations of a chemical substance is the symmetric confidence interval of WESTLAKE (1972). As mentioned by WEST -LAKE (1981) and SCHUIRMAN (1981) a more powerful method consists of two one-sided t-tests. An (1-α)-confidence interval consistent with the two one-sided t-tests procedure is given by [min(α, 0), max (0, b)] where [a, b] is the conventional (1–2α)-confidence interval of the t-test. This “central” confidence interval is always a strict subset of the symmetric confidence interval and thus has more power in proving bioequivalence. The central confidence interval has properties comparable with those of the conventional one-sided confidence intervals.     

Simple Methods of Determining Confidence Intervals for Functions of Estimates in Published Results

Often, the reader of a published paper is interested in a comparison of parameters that has not been presented. It is not possible to make inferences beyond point estimation since the standard error for the contrast of the estimated parameters depends upon the (unreported) correlation. This study explores approaches to obtain valid confidence intervals when the correlation is unknown. We illustrate three proposed approaches using data from the National Health Interview Survey. The three approaches include the Bonferroni method and the standard confidence interval assuming (most conservative) or (when the correlation is known to be non-negative). The Bonferroni approach is found to be the most conservative. For the difference in two estimated parameter, the standard confidence interval assuming yields a 95% confidence interval that is approximately 12.5% narrower than the Bonferroni confidence interval; when the correlation is known to be positive, the standard 95% confidence interval assuming is approximately 38% narrower than the Bonferroni. In summary, this article demonstrates simple methods to determine confidence intervals for unreported comparisons. We suggest use of the standard confidence interval assuming if no information is available or if the correlation is known to be non-negative.     

Mortality among oral contraceptive users: 20 year follow up of women in a cohort study.

OBJECTIVE--To see whether the use of oral contraceptives influences mortality. DESIGN--Non-randomised cohort study of 17,032 women followed up on an annual basis for an average of nearly 16 years. SETTING--17 Family planning clinics in England and Scotland. SUBJECTS--Women recruited during 1968-74. At the time of recruitment each woman was aged 25-39, married, a white British subject, willing to participate, and either a current user of oral contraceptives or a current user of a diaphragm or intrauterine device (without previous exposure to the pill). MAIN OUTCOME MEASURES--Overall mortality and cause specific mortality. RESULTS--238 Deaths occurred during the follow up period. The main analyses concerned women entering the study while using either oral contraceptives or a diaphragm or intrauterine device. The overall relative risk of death in the oral contraceptive users was 0.9 (95% confidence interval 0.7 to 1.2). Though the numbers of deaths were small in most individual disease categories, the trends observed were generally consistent with findings in other reports. Thus the relative risk of death in the oral contraceptive users was 4.9 (95% confidence interval 0.7 to 230) for cancer of the cervix, 3.3 (95% confidence interval 0.9 to 17.9) for ischaemic heart disease, and 0.4 (95% confidence interval 0.1 to 1.2) for ovarian cancer. There was a linear trend in the death rates from cervical cancer and ovarian cancer (in opposite directions) with total duration of oral contraceptive use. Death rates from breast cancer (relative risk 0.9; 95% confidence interval 0.5 to 1.4) and suicide and probable suicide (relative risk 1.1; 95% confidence interval 0.3 to 3.6) were much the same in the two contraceptive groups. In 1981 the relative risk of death in oral contraceptive users from circulatory diseases as a group was reported to be 4.2 (95% confidence interval 2.3 to 7.7) in the Royal College of General Practitioners oral contraception study. The corresponding relative risk in this study was only 1.5 (95% confidence interval 0.7 to 3.0). CONCLUSIONS--These findings contain no significant evidence of any overall effect of oral contraceptive use on mortality. None the less, only small numbers of deaths occurred during the study period and a significant adverse (or beneficial) overall effect might emerge in the future. Interestingly, the mortality from circulatory disease associated with oral contraceptive use was substantially less than that found in the Royal College of General Practitioners study.     

A Monte Carlo maximum likelihood method for estimating uncertainty arising from shared errors in exposures in epidemiological studies of nuclear workers

Errors in the estimation of exposures or doses are a major source of uncertainty in epidemiological studies of cancer among nuclear workers. This paper presents a Monte Carlo maximum likelihood method that can be used for estimating a confidence interval that reflects both statistical sampling error and uncertainty in the measurement of exposures. The method is illustrated by application to an analysis of all cancer (excluding leukemia) mortality in a study of nuclear workers at the Oak Ridge National Laboratory (ORNL). Monte Carlo methods were used to generate 10,000 data sets with a simulated corrected dose estimate for each member of the cohort based on the estimated distribution of errors in doses. A Cox proportional hazards model was applied to each of these simulated data sets. A partial likelihood, averaged over all of the simulations, was generated; the central risk estimate and confidence interval were estimated from this partial likelihood. The conventional unsimulated analysis of the ORNL study yielded an excess relative risk (ERR) of 5.38 per Sv (90% confidence interval 0.54-12.58). The Monte Carlo maximum likelihood method yielded a slightly lower ERR (4.82 per Sv) and wider confidence interval (0.41-13.31).     

Notes on interval estimation of the gamma correlation under stratified random sampling

We have developed four asymptotic interval estimators in closed forms for the gamma correlation under stratified random sampling, including the confidence interval based on the most commonly used weighted‐least‐squares (WLS) approach (CIWLS), the confidence interval calculated from the Mantel‐Haenszel (MH) type estimator with the Fisher‐type transformation (CIMHT), the confidence interval using the fundamental idea of Fieller's Theorem (CIFT) and the confidence interval derived from a monotonic function of the WLS estimator of Agresti's α with the logarithmic transformation (MWLSLR). To evaluate the finite‐sample performance of these four interval estimators and note the possible loss of accuracy in application of both Wald's confidence interval and MWLSLR using pooled data without accounting for stratification, we employ Monte Carlo simulation. We use the data taken from a general social survey studying the association between the income level and job satisfaction with strata formed by genders in black Americans published elsewhere to illustrate the practical use of these interval estimators.     

Blood Pressure Variability and Cardiovascular Risk in the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER)

Variability in blood pressure predicts cardiovascular disease in young- and middle-aged subjects, but relevant data for older individuals are sparse. We analysed data from the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) study of 5804 participants aged 70–82 years with a history of, or risk factors for cardiovascular disease. Visit-to-visit variability in blood pressure (standard deviation) was determined using a minimum of five measurements over 1 year; an inception cohort of 4819 subjects had subsequent in-trial 3 years follow-up; longer-term follow-up (mean 7.1 years) was available for 1808 subjects. Higher systolic blood pressure variability independently predicted long-term follow-up vascular and total mortality (hazard ratio per 5 mmHg increase in standard deviation of systolic blood pressure = 1.2, 95% confidence interval 1.1–1.4; hazard ratio 1.1, 95% confidence interval 1.1–1.2, respectively). Variability in diastolic blood pressure associated with increased risk for coronary events (hazard ratio 1.5, 95% confidence interval 1.2–1.8 for each 5 mmHg increase), heart failure hospitalisation (hazard ratio 1.4, 95% confidence interval 1.1–1.8) and vascular (hazard ratio 1.4, 95% confidence interval 1.1–1.7) and total mortality (hazard ratio 1.3, 95% confidence interval 1.1–1.5), all in long-term follow-up. Pulse pressure variability was associated with increased stroke risk (hazard ratio 1.2, 95% confidence interval 1.0–1.4 for each 5 mmHg increase), vascular mortality (hazard ratio 1.2, 95% confidence interval 1.0–1.3) and total mortality (hazard ratio 1.1, 95% confidence interval 1.0–1.2), all in long-term follow-up. All associations were independent of respective mean blood pressure levels, age, gender, in-trial treatment group (pravastatin or placebo) and prior vascular disease and cardiovascular disease risk factors. Our observations suggest variability in diastolic blood pressure is more strongly associated with vascular or total mortality than is systolic pressure variability in older high-risk subjects.     

Cardiovascular effects of training for a marathon run in unfit middle aged men.

The effects of a 30 week exercise programme on serum lipid values, blood pressure, and cardiac function were assessed in a group of sedentary men aged 35-50 training for their first marathon. Mean serum cholesterol concentration (n = 33) fell by 12% from 6.54 (SE 0.18) to 5.76 (0.15) mmol/l (mean fall 0.78 mmol/l; 95% confidence interval 0.52 to 1.04 mmol/l), serum triglyceride concentration (n = 33) by 22% from 1.56 (0.17) to 1.21 (0.09) mmol/l (mean fall 0.34 mmol/l; 95% confidence interval 0.12 to 0.56 mmol/l), and mean blood pressure (n = 27) by 10% from 102 (2) to 92 (2) mm Hg (mean fall 10 mm Hg; 95% confidence interval 7 to 13 mm Hg). These changes were not explained by changes in body composition. Peak exercise left ventricular end diastolic volume (n = 16) increased with training; as a result of this and an increased exercise left ventricular ejection fraction peak exercise cardiac output increased from 19.9 (1.2) to 23.1 (3.0) l/min (mean rise 3.2 l/min; 95% confidence interval 1.5 to 5.0 l/min). Maximum oxygen consumption increased from 33.9 (1.6) to 39.0 (1.3) ml/kg/min (mean rise 5.0 ml/kg/min; 95% confidence interval 1.8 to 8.2 ml/kg/min). This study showed favourable effects on coronary risk factors and cardiac function and supports the place of regular exercise in coronary prevention programmes.     

Development and validation of a computational method for assessment of missense variants in hypertrophic cardiomyopathy

Assessing the significance of novel genetic variants revealed by DNA sequencing is a major challenge to the integration of genomic techniques with medical practice. Many variants remain difficult to classify by traditional genetic methods. Computational methods have been developed that could contribute to classifying these variants, but they have not been properly validated and are generally not considered mature enough to be used effectively in a clinical setting. We developed a computational method for predicting the effects of missense variants detected in patients with hypertrophic cardiomyopathy (HCM). We used a curated clinical data set of 74 missense variants in six genes associated with HCM to train and validate an automated predictor. The predictor is based on support vector regression and uses phylogenetic and structural features specific to genes involved in HCM. Ten-fold cross validation estimated our predictor's sensitivity at 94% (95% confidence interval: 83%-98%) and specificity at 89% (95% confidence interval: 72%-100%). This corresponds to an odds ratio of 10 for a prediction of pathogenic (95% confidence interval: 4.0-infinity), or an odds ratio of 9.9 for a prediction of benign (95% confidence interval: 4.6-21). Coverage (proportion of variants for which a prediction was made) was 57% (95% confidence interval: 49%-64%). This performance exceeds that of existing methods that are not specifically designed for HCM. The accuracy of this predictor provides support for the clinical use of automated predictions alongside family segregation and population frequency data in the interpretation of new missense variants and suggests future development of similar tools for other diseases.     

Fenoldopam use in a burn intensive care unit: a retrospective study

Background

We sought to evaluate agreement between a new and widely implemented method of temperature measurement in critical care, temporal artery thermometry and an established method of core temperature measurement, bladder thermometry as performed in clinical practice.

Methods

Temperatures were simultaneously recorded hourly (n = 736 observations) using both devices as part of routine clinical monitoring in 14 critically ill adult patients with temperatures ranging ≥1°C prior to consent.

Results

The mean difference between temporal artery and bladder temperatures measured was -0.44°C (95% confidence interval, -0.47°C to -0.41°C), with temporal artery readings lower than bladder temperatures. Agreement between the two devices was greatest for normothermia (36.0°C to < 38.3°C) (mean difference -0.35°C [95% confidence interval, -0.37°C to -0.33°C]). The temporal artery thermometer recorded higher temperatures during hypothermia (< 36°C) (mean difference 0.66°C [95% confidence interval, 0.53°C to 0.79°C]) and lower temperatures during hyperthermia (≥38.3°C) (mean difference -0.90°C [95% confidence interval, -0.99°C to -0.81°C]). The sensitivity for detecting fever (core temperature ≥38.3°C) using the temporal artery thermometer was 0.26 (95% confidence interval, 0.20 to 0.33), and the specificity was 0.99 (95% confidence interval, 0.98 to 0.99). The positive likelihood ratio for fever was 24.6 (95% confidence interval, 10.7 to 56.8); the negative likelihood ratio was 0.75 (95% confidence interval, 0.68 to 0.82).

Conclusions

Temporal artery thermometry produces somewhat surprising disagreement with an established method of core temperature measurement and should not to be used in situations where body temperature needs to be measured with accuracy.     

Simple table for estimating confidence interval of discrepancy frequencies in microbiological safety evaluation

We provide a simple tool to determine discrepancies confidence interval (CI) in microbiology validation studies such as technical accuracy of a qualitative test result. This tool enables to determine exact confidence interval (binomial CI) from an observed frequency when normal approximation is inadequate, that is, in case of rare events. This tool has daily applications in microbiology and we are presenting an example of its application to antimicrobial susceptibility systems evaluation.     

Interval estimation of the LD50 based on an up-and-down experiment

It is well known that an up-and-down method can be more efficient than fixed-sample methods in estimating the LD50 of a quantal response curve. A problem that has not been addressed by many is that of obtaining a confidence interval for the LD50 from the up-and-down method. Dixon and Mood (1948, Journal of the American Statistical Association 43, 109-126) proposed a confidence interval using a maximum likelihood approach, but not much is known about its properties. In this paper, a new confidence interval for the LD50 based on turning points is obtained, which uses the concept of phi-mixing. Simulation results indicate that the coverage probabilities of both methods tend to be less than the nominal level unless the sample size is large. Even so, when the tolerance distribution is normal, the proposed confidence interval is found to be superior to Dixon's interval in terms of the coverage, the width, and stability. The advantages of the method do not appear to hold in the presence of nonnormal tolerance distribution.     

How Much Does a Verbal Autopsy Based Mortality Surveillance System Cost in Rural India?

ObjectiveThis paper aims to determine the cost of establishing and sustaining a verbal-autopsy based mortality surveillance system in rural India.ResultsVerbal-autopsies were completed for 96.7% (5786) of all deaths (5895) recorded. The annual cost in year 1 was INR 1,133,491 (USD 24,943) and the total cost per death was INR 757 (USD 16.66). These costs included training of NPHWs and physician reviewers Rs 67,025 (USD 1474), data collection INR 248,400 (USD 5466), dual physician review for cause of death assignment INR 375,000 (USD 8252), and project management INR 341,724 (USD 7520). The average annual cost to run the system each year was INR 822,717 (USD18104) and the cost per death was INR 549 (USD 12) for the next 3 years. Costs were reduced by using single physician review and shortened re-training sessions. The annual cost of running a surveillance system was INR 900,410 (USD 19814).DiscussionThis study provides detailed empirical evidence of the costs involved in running a mortality surveillance site using verbal-autopsy.     

Exact-corrected confidence interval for risk difference in noninferiority binomial trials

A novel confidence interval estimator is proposed for the risk difference in noninferiority binomial trials. The proposed confidence interval, which is dependent on the prespecified noninferiority margin, is consistent with an exact unconditional test that preserves the type-I error and has improved power, particularly for smaller sample sizes, compared to the confidence interval by Chan and Zhang. The improved performance of the proposed confidence interval is theoretically justified and demonstrated with simulations and examples. An R package is also distributed that implements the proposed methods along with other confidence interval estimators.