Risk stratification for sudden cardiac death

Recent advances in pharmacological and device-based therapies have provided a range of management options for patients at risk of sudden cardiac death (SCD). Since all such interventions come with their attendant risks, however, stratification procedures aimed at identifying those who stand to benefit overall have gained a new degree of importance. This review assesses the value of risk stratification measures currently available in clinical practice, as well as of others that may soon enter the market. Parameters that may be obtained only by performing invasive cardiac catheterisation procedures are considered separately from those that may be derived using more readily available non-invasive techniques. It is concluded that effective stratification is likely to require the use of composite parameters and that invasive procedures might only be justified in specific sub-groups of patients.     

Balanced Sample Generation for Predicting the Mean of a Finite Population

Two algorithms for balancing samples are proposed. They permit to disminish the errors of a predictor. A simple linear regression superpopulation model generates the responses. The behavior of the predictor under two balancing algorithms is evaluated in a Montecarlo experiment. The data arose from the determination of the content of minerals and vitamins in feed.     

心衰生物标记物研究新进展

心力衰竭(心衰)是临床最常见的危重疾病之一,其致死率不低于某些癌症。随着现代医学进展,年龄依赖性死亡率明显下降,冠脉事件显著减少,患者生存时间延长,心衰患病率较前增加。针对心衰的研究不断更新,心衰的病理生理机制日益趋向完善,不仅仅涉及先前众所周知的心肌损伤或者心脏前后负荷增加,更多因素先后被发现参与心衰的发生、发展,包括神经内分泌机制、炎症反应,内分泌信号系统和生化因素等。伴随心衰病理生理过程产生了一系列的生物标记物,某些生物标记物在协助临床医生诊疗心衰患者方面发挥重要作用。具体包括神经激素类生物(例如:脑钠肽、氨基末端-pro BNP、心房钠尿肽前体中段、肾上腺髓质素前体中段和嗜铬素A),炎症因子类生物标记物(例如:CRP、IL-6和ST2),内分泌生物标志物(例如:脂联素、抵抗素、瘦素和醛固酮),其他生物标记物(包括:肌钙蛋白I/T、乳糖凝集素-3、胱氨酸蛋白酶抑制剂C、生长分化因子-15和基质金属蛋白酶)。生物标记物凭借其高度敏感性及特异性,在心衰的诊断、危险分层及评估预后等方面发挥重要作用。本文就心衰生物标记物最新研究进展做一综述。     

青檀种子休眠机理及发芽条件的探讨

对青檀 (PteroceltistatarinowiiMaxim .)种子的休眠机理和发芽条件进行了探讨。共设定 5个处理 :剪破种皮、热水处理 (4 0、5 0、6 0和 70℃ )、剪破种皮并变温层积 (0～ 4℃ 16h与 10～ 15℃ 8h)、低温层积 (0～ 4℃ )和变温层积(0～ 4℃ 16h与 10～ 15℃ 8h)。结果表明 ,剪破种皮、剪破种皮并变温层积和热水处理与对照的发芽率均无显著差异 ,说明青檀种子的休眠不是种皮限制所引起的。低温层积和变温层积处理均能打破种子的休眠 ,因而认为青檀种子休眠属于生理休眠。低温层积以 70d为最好 ,发芽率和发芽势分别达 6 7%和 5 5 % ;变温层积以 40d处理效果最好 ,发芽率和发芽势分别达 77%和 5 7%。同时还讨论了 2种层积处理的优缺点     

Longer duration of seasonal stratification contributes to widespread increases in lake hypoxia and anoxia

The concentration of dissolved oxygen (DO) is an important attribute of aquatic ecosystems, influencing habitat, drinking water quality, biodiversity, nutrient biogeochemistry, and greenhouse gas emissions. While average summer DO concentrations are declining in lakes across the temperate zone, much remains unknown about seasonal factors contributing to deepwater DO losses. It is unclear whether declines are related to increasing rates of seasonal DO depletion or changes in seasonal stratification that limit re-oxygenation of deep waters. Furthermore, despite the presence of important biological and ecological DO thresholds, there has been no large-scale assessment of changes in the amount of habitat crossing these thresholds, limiting the ability to understand the consequences of observed DO losses. We used a dataset from >400 widely distributed lakes to identify the drivers of DO losses and quantify the frequency and volume of lake water crossing biologically and ecologically important threshold concentrations ranging from 5 to 0.5 mg/L. Our results show that while there were no consistent changes over time in seasonal DO depletion rates, over three-quarters of lakes exhibited an increase in the duration of stratification, providing more time for seasonal deepwater DO depletion to occur. As a result, most lakes have experienced summertime increases in the amount of water below all examined thresholds in deepwater DO concentration, with increases in the proportion of the water column below thresholds ranging between 0.9% and 1.7% per decade. In the 30-day period preceding the end of stratification, increases were greater at >2.2% per decade and >70% of analyzed lakes experienced increases in the amount of oxygen-depleted water. These results indicate ongoing climate-induced increases in the duration of stratification have already contributed to reduction of habitat for many species, likely increased internal nutrient loading, and otherwise altered lake chemistry. Future warming is likely to exacerbate these trends.     

Sensitivity analysis for the assessment of causal vaccine effects on viral load in HIV vaccine trials

Vaccines with limited ability to prevent HIV infection may positively impact the HIV/AIDS pandemic by preventing secondary transmission and disease in vaccine recipients who become infected. To evaluate the impact of vaccination on secondary transmission and disease, efficacy trials assess vaccine effects on HIV viral load and other surrogate endpoints measured after infection. A standard test that compares the distribution of viral load between the infected subgroups of vaccine and placebo recipients does not assess a causal effect of vaccine, because the comparison groups are selected after randomization. To address this problem, we formulate clinically relevant causal estimands using the principal stratification framework developed by Frangakis and Rubin (2002, Biometrics 58, 21-29), and propose a class of logistic selection bias models whose members identify the estimands. Given a selection model in the class, procedures are developed for testing and estimation of the causal effect of vaccination on viral load in the principal stratum of subjects who would be infected regardless of randomization assignment. We show how the procedures can be used for a sensitivity analysis that quantifies how the causal effect of vaccination varies with the presumed magnitude of selection bias.     

Genome‐wide association study identifies genomic regions of association for cruciate ligament rupture in Newfoundland dogs

Cranial cruciate ligament rupture (CCLR) is the most common cause of pelvic limb lameness in dogs. To investigate the genetic basis of canine CCLR, we conducted a genome‐wide association study using a canine SNP array in Newfoundland pedigree dogs with and without CCLR (n = 96). We identified three main chromosomal regions of CCLR association (on chromosomes 1, 3 and 33). Each of these regions was confirmed by Sequenom genotyping in a further cohort of Newfoundlands (n = 271). The results, particularly SNPs identified in the SORCS2 and SEMA5B genes, suggest that there may be neurological pathways involved in susceptibility to canine CCLR.     

Skin tone,biracial stratification and tri-racial stratification among sperm donors

Abstract

Conception through donor insemination is an attractive option for many couples and single women in the USA, being a relatively simple and inexpensive way of having a baby by a biological birth. Sperm banks provide online catalogues in which sperm donors can be selected according to their physical and social characteristics. One sperm bank's catalogue was analysed based on the pregnancy of selected donors. Three hypotheses were tested related to colourism, biracial stratification and tri-racialism. Specifically, the selection of donors did not reflect: (1) any general preference for a lighter skin tone; (2) a black–white polarity; or (3) any trend towards tri-racialism. Donors who could be identified as Jewish or Muslim were more likely to be selected. Donors whose major was law were less likely to be selected.     

Valid Adjustment of Randomized Comparisons for Binary Covariates

In randomized trials, the treatment influences not only endpoints but also other variables measured after randomization which, when used as covariates to adjust for the observed imbalance, become pseudo‐covariates. There is a logical circularity in adjusting for a pseudo‐covariate because the variability in the endpoint that is attributed not to the treatment but rather to the pseudo‐covariate may actually represent an effect of the treatment modulated by the pseudo‐covariate. This potential bias is well known, but we offer new insight into how it can lead to reversals in the direction of the apparent treatment effect by way of stage migration. We then discuss a related problem that is not generally appreciated, specifically how the absence of allocation concealment can lead to this reversal of the direction of the apparent treatment effect even when adjustment is for a true covariate measured prior to randomization. (© 2004 WILEY‐VCH Verlag GmbH & Co. KGaA, Weinheim)     

A bayesian approach to improved estimation of causal effect predictiveness for a principal surrogate endpoint

Summary The literature on potential outcomes has shown that traditional methods for characterizing surrogate endpoints in clinical trials based only on observed quantities can fail to capture causal relationships between treatments, surrogates, and outcomes. Building on the potential-outcomes formulation of a principal surrogate, we introduce a Bayesian method to estimate the causal effect predictiveness (CEP) surface and quantify a candidate surrogate's utility for reliably predicting clinical outcomes. In considering the full joint distribution of all potentially observable quantities, our Bayesian approach has the following features. First, our approach illuminates implicit assumptions embedded in previously-used estimation strategies that have been shown to result in poor performance. Second, our approach provides tools for making explicit and scientifically-interpretable assumptions regarding associations about which observed data are not informative. Through simulations based on an HIV vaccine trial, we found that the Bayesian approach can produce estimates of the CEP surface with improved performance compared to previous methods. Third, our approach can extend principal-surrogate estimation beyond the previously considered setting of a vaccine trial where the candidate surrogate is constant in one arm of the study. We illustrate this extension through an application to an AIDS therapy trial where the candidate surrogate varies in both treatment arms.     

Evidence for hilltopping in bumblebees?

1. Male bumblebees are known to exhibit a range of mate‐location behaviours, including perching on prominent objects and darting at passing queens, patrolling of scent‐marked flight routes, and waiting outside nest entrances for virgin queens to emerge. Here we provide evidence for a fourth strategy, known as hilltopping. This behaviour is widely known from a range of invertebrates, but has not previously been described in bumblebees. 2. We studied the distribution of bumblebees along transects ascending four hills in Scotland and demonstrate that, relative to workers, males of four bumblebee species or species groups (Bombus lapidarius, B. monticola, B. pascuorum, and B. lucorum/magnus/cryptarum/terrestris) tend to congregate at or near the tops of hills. This is, to our knowledge, the first evidence for hilltopping in bumblebees and the first record of any putative mate‐locating behaviour for male B. pascuorum, a very common species in Europe. 3. We note that, in common with most previous studies of mate‐locating behaviour in bumblebees, attraction of virgin queens and mating were not observed.     

Risk stratification for sudden cardiac death in hypertrophic cardiomyopathy: Dutch cardiologists and the care of mutation carriers

Background. Patients with hypertrophic cardiomyopathy (HCM) and HCM mutation carriers are at risk of sudden cardiac death (SCD). Both groups should therefore be subject to regular cardiological testing – including risk stratification for SCD – according to international guidelines. We evaluated Dutch cardiologists' knowledge of and adherence to international guidelines on risk stratification and prevention of SCD in mutation carriers with and without manifest HCM. Methods. A questionnaire was sent to 1109 Dutch cardiologists (in training) containing case-based questions. Results. The response rate was 21%. Own general knowledge on HCM care was rated as insufficient by 63% of cardiologists. The percentage of correct answers (i.e. in agreement with international guidelines), on the case-based questions ranged from 37 to 96%, being lowest in cases with an unknown number of risk factors for SCD. A substantial portion of correct answers was based on the correct answer ‘ask an expert opinion’. Significantly more correct answers were provided in cases with manifest HCM. There was little difference between the answers of cardiologists with different self-reported levels of knowledge, with different numbers of HCM patients in their practice or with different numbers of carriers without manifest HCM. Conclusion. Knowledge on risk stratification and preventive therapy was mediocre, and knowledge gaps exist, especially on HCM mutation carriers without manifest disease. Fortunately, experts are frequently asked for their opinion which might bring patient care to an adequate level. Hopefully, our results will stimulate cardiologists to follow developments in this field, thereby increasing quality of care for HCM patients and mutation carriers. (Neth Heart J 2009:17:464–9.).     

Solutions for surrogacy validation with longitudinal outcomes for a gene therapy

Valid surrogate endpoints S can be used as a substitute for a true outcome of interest T to measure treatment efficacy in a clinical trial. We propose a causal inference approach to validate a surrogate by incorporating longitudinal measurements of the true outcomes using a mixed modeling approach, and we define models and quantities for validation that may vary across the study period using principal surrogacy criteria. We consider a surrogate-dependent treatment efficacy curve that allows us to validate the surrogate at different time points. We extend these methods to accommodate a delayed-start treatment design where all patients eventually receive the treatment. Not all parameters are identified in the general setting. We apply a Bayesian approach for estimation and inference, utilizing more informative prior distributions for selected parameters. We consider the sensitivity of these prior assumptions as well as assumptions of independence among certain counterfactual quantities conditional on pretreatment covariates to improve identifiability. We examine the frequentist properties (bias of point and variance estimates, credible interval coverage) of a Bayesian imputation method. Our work is motivated by a clinical trial of a gene therapy where the functional outcomes are measured repeatedly throughout the trial.     

Sensitivity analysis for principal stratum direct effects, with an application to a study of physical activity and coronary heart disease

Summary .  In many studies, the aim is to learn about the direct exposure effect, that is, the effect not mediated through an intermediate variable. For example, in circulation disease studies it may be of interest to assess whether a suitable level of physical activity can prevent disease, even if it fails to prevent obesity. It is well known that stratification on the intermediate may introduce a so-called posttreatment selection bias. To handle this problem, we use the framework of principal stratification ( Frangakis and Rubin, 2002 , Biometrics 58, 21–29) to define a causally relevant estimand—the principal stratum direct effect (PSDE). The PSDE is not identified in our setting. We propose a method of sensitivity analysis that yields a range of plausible values for the causal estimand. We compare our work to similar methods proposed in the literature for handling the related problem of "truncation by death."