Analyzing change in medication use - statistical approaches

The objective of this study was to gain an understanding of the effects of population heterogeneity, missing data, and causal relationships on parameter estimates from statistical models when analyzing change in medication use. From a public health perspective, two timely topics were addressed: the use and effects of statins in populations in primary prevention of cardiovascular disease and polypharmacy in older population. Growth mixture models were applied to characterize the accumulation of cardiovascular and diabetes medications among apparently healthy population of statin initiators. The causal effect of statin adherence on the incidence of acute cardiovascular events was estimated using marginal structural models in comparison with discrete-time hazards models. The impact of missing data on the growth estimates of evolution of polypharmacy was examined comparing statistical models under different assumptions for missing data mechanism. The data came from Finnish administrative registers and from the population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly study conducted in Kuopio, Finland, during 2004–07. Five distinct patterns of accumulating medications emerged among the population of apparently healthy statin initiators during two years after statin initiation. Proper accounting for time-varying dependencies between adherence to statins and confounders using marginal structural models produced comparable estimation results with those from a discrete-time hazards model. Missing data mechanism was shown to be a key component when estimating the evolution of polypharmacy among older persons. In conclusion, population heterogeneity, missing data and causal relationships are important aspects in longitudinal studies that associate with the study question and should be critically assessed when performing statistical analyses. Analyses should be supplemented with sensitivity analyses towards model assumptions.

Testing mediation: The endogeneity problem and the solution

A mediator is a dependent variable, m (e.g., charisma), that is thought to channel the effect of an independent variable, x (e.g., receiving training or not), on another dependent variable (e.g., subordinate satisfaction), y. In experimental settings x is manipulated-subjects are randomized to treatment-to isolate the causal effect of x on other variables. If m is not or cannot be manipulated, which is often the case, its causal effect on other variables cannot be determined; thus, standard mediation tests cannot inform policy or practice. I will show how an econometric procedure, called instrumental-variable estimation, can examine mediation in such cases.

Cystatin C and cardiovascular disease : A mendelian randomization study

BACKGROUND: Epidemiological studies show that high circulating cystatin C is associated with risk of cardiovascular disease (CVD), independent of creatinine-based renal function measurements. It is unclear whether this relationship is causal, arises from residual confounding, and/or is a consequence of reverse causation. OBJECTIVES: The aim of this study was to use Mendelian randomization to investigate whether cystatin C is causally related to CVD in the general population. METHODS We incorporated participant data from 16 prospective cohorts (n ¼ 76,481) with 37,126 measures of cystatin C and added genetic data from 43 studies (n ¼ 252,216) with 63,292 CVD events. We used the common variant rs911119 in CST3 as an instrumental variable to investigate the causal role of cystatin C in CVD, including coronary heart disease, ischemic stroke, and heart failure. RESULTS: Cystatin C concentrations were associated with CVD risk after adjusting for age, sex, and traditional risk factors (relative risk: 1.82 per doubling of cystatin C; 95% confidence interval [CI]: 1.56 to 2.13; p ¼ 2.12 1014). The minor allele of rs911119 was associated with decreased serum cystatin C (6.13% per allele; 95% CI: 5.75 to 6.50; p ¼ 5.95 10211), explaining 2.8% of the observed variation in cystatin C. Mendelian randomization analysis did not provide evidence for a causal role of cystatin C, with a causal relative risk for CVD of 1.00 per doubling cystatin C (95% CI: 0.82 to 1.22; p ¼ 0.994), which was statistically different from the observational estimate (p ¼ 1.6 105 ). A causal effect of cystatin C was not detected for any individual component of CVD. CONCLUSIONS: Mendelian randomization analyses did not support a causal role of cystatin C in the etiology of CVD. As such, therapeutics targeted at lowering circulating cystatin C are unlikely to be effective in preventing CVD. 

Impact of Glycosyltransferases on the Phenotype, Signaling and Transcriptome of Colorectal Cancer Cell Lines. Focus on the role of glycosyltransferases B4GALNT2 and FUT6 and their cognate Sda and sLex antigens

In colorectal cancer (CRC), two carbohydrate structures are modulated: the Sda antigen, synthesized by B4GALNT2, and sLex antigen, mainly synthesized by FUT6. sLex antigen is often overexpressed and associated with worse prognosis; B4GALNT2/Sda antigen are dramatically downregulated but their role in tumor progression and development is not fully clear. TCGA interrogation revealed a dramatic down-regulation of B4GALNT2 mRNA in CRC, compared with normal samples. Patients with higher B4GALNT2 mRNA in CRC samples displayed longer survival. Yet, methylation and miRNA expression play a relevant role in B4GALNT2 downregulation in CRC. To clarify the mechanisms linking the B4GALNT2/Sda expression level to CRC phenotype, three different CRC cell lines were modified to express B4GALNT2: LS174T cell line, in which the constitutively expressed sLex antigen was partially replaced by Sda; SW480/SW620 pair, both lacking Sda and sLex antigens. In LS174T cells, the expression of B4GALNT2 reduced the ability to grow in poor adherence conditions and the expression of ALDH, a stemness marker. In SW620 cells, B4GALNT2 expression impacted on the main aspects of malignancy. In SW480 cells the expression of B4GALNT2 left unchanged the proliferation rate and the wound healing ability. To clarify the impact of sLex on CRC phenotype, the SW480/SW620 pair were permanently transfected to express FUT6 cDNA. In both cell lines, overexpression of FUT6/sLex boosted the clonogenic ability in standard growth conditions. Conversely, the growth in soft agar and the capacity to close a wound were enhanced only in SW620 cells. Transcriptome analysis of CRC cell lines transfected either with B4GALNT2 or FUT6 showed a relevant impact of both enzymes on gene expression modulation. Overall, current data may help to personalize therapies for CRC patients according to the B4GALNT2 levels and support a causal effect of this glycosyltransferase on reducing malignancy independently of sLex inhibition.

Effect of morphodynamics on annual average zonation pattern of benthic macrofauna of exposed sandy beaches in Santa Catarina, Brazil

This study investigated the effect of environmental factors on the annual average zonation pattern of benthic macrofauna of sub-aerial profile of three exposed sandy beaches of Santa Catarina with different morphodynamic characteristics. Sampling was carried out between March 2000 and March 2001, with monthly frequency on reflective and dissipative morphodynamic extremes and bimonthly frequency on the intermediate state. Results showed that macrobenthic zonation presented marked differences across the morphodynamic spectrum. The main differences observed from reflective to dissipative conditions were: a) increase in the number of species in lower zones of the beach; b) expansion of zones characterized by high water content of sediment and c) increase in the overlapping of zones, mainly on lower levels of the beach. Canonical Correspondence Analysis related these differences to distinctive cross-shore gradients in sediment moisture levels, sediment reworking and mean grain size that exist across the morphodynamic spectrum, showing that it is important to analyze these environmental factors in studies conducted to investigate zonation on microtidal exposed sandy beaches.

Direct Effect of Birth Weight on Childhood Blood Pressure: a Causal Mediation Analysis

Background: Numerous studies have shown a negative association between birth weight (BW) and blood pressure (BP) later in life. To estimate the direct effect of BW on BP, it is conventional to condition on current weight (CW). However, such conditioning can induce collider stratification bias in the estimate of the direct effect. Objective: To bound the potential bias due to U, an unmeasured common cause of CW and BP, on the estimate of the (controlled) direct effect of BW on BP. Methods: Data from a school based study in Switzerland were used (N = 4,005; 2,010 B/1,995 G; mean age: 12.3 yr [range: 10.1-14.9]). Measured common causes of BW-BP (SES, smoking, body weight, and hypertension status of the mother) and CW-BP (breastfeeding and child's physical activity and diet) were identified with DAGs. Linear regression models were fitted to estimate the association between BW and BP. Sensitivity analyses were conducted to assess the potential effect of U on the association between BW and BP. U was assumed 1) to be a binary variable that affected BP by the same magnitude in low BWand in normal BW children and 2) to have a different prevalence in low BW children and in normal BW children for a given CW. Results: A small negative association was observed between BW and BP [beta: -0.3 mmHg/kg (95% CI: -0.9 to 0.3)]. The association was strengthened upon conditioning for CW [beta: -1.5 mmHg/kg (95% CI: -2.1 to -0.9)]. Upon further conditioning on common causes of BW-BP and CW-BP, the association did not change substantially [beta: -1.4 mmHg/kg (95% CI: -2.0 to -0.8)]. The negative association could be explained by U only if U was strongly associated with BP and if there was a large difference in the prevalence of U between low BWand normal BW children. Conclusion: The observed negative association between BW and BP upon adjustment for CW was not easily explained by an unmeasured common cause of CWand BP.

The effect of combined antiretroviral therapy on the overall mortality of HIV-infected individuals.

OBJECTIVE: To estimate the effect of combined antiretroviral therapy (cART) on mortality among HIV-infected individuals after appropriate adjustment for time-varying confounding by indication. DESIGN: A collaboration of 12 prospective cohort studies from Europe and the United States (the HIV-CAUSAL Collaboration) that includes 62 760 HIV-infected, therapy-naive individuals followed for an average of 3.3 years. Inverse probability weighting of marginal structural models was used to adjust for measured confounding by indication. RESULTS: Two thousand and thirty-nine individuals died during the follow-up. The mortality hazard ratio was 0.48 (95% confidence interval 0.41-0.57) for cART initiation versus no initiation. In analyses stratified by CD4 cell count at baseline, the corresponding hazard ratios were 0.29 (0.22-0.37) for less than 100 cells/microl, 0.33 (0.25-0.44) for 100 to less than 200 cells/microl, 0.38 (0.28-0.52) for 200 to less than 350 cells/microl, 0.55 (0.41-0.74) for 350 to less than 500 cells/microl, and 0.77 (0.58-1.01) for 500 cells/microl or more. The estimated hazard ratio varied with years since initiation of cART from 0.57 (0.49-0.67) for less than 1 year since initiation to 0.21 (0.14-0.31) for 5 years or more (P value for trend <0.001). CONCLUSION: We estimated that cART halved the average mortality rate in HIV-infected individuals. The mortality reduction was greater in those with worse prognosis at the start of follow-up.

The causal surface and its effect on distribution transparency in a distributed virtual environment

One goal in the development of distributed virtual environments (DVEs) is to create a system such that users are unaware of the distribution-the distribution should be transparent. The paper begins by discussing the general issues in DVEs that might make this possible, and a system that allows some level of distribution transparency is described. The system described suffers from effects of inconsistency, which in turn cause undesirable visual effects. The causal surface is introduced as a solution that removes these visual effects. The paper then introduces two determining factors of distribution transparency relating to user perception and performance. With regard to these factors, two hypotheses are stated relating to the causal surface. A user-trial on forty-five subjects is used to validate the hypotheses. A discussion of the results of the trial concludes that the causal surface solution does significantly improve the distribution transparency in a DVE.

Maximising concurrency and scalability in a consistent, causal, distributed virtual reality system, whilst minimising the effect of network delays

The development of large scale virtual reality and simulation systems have been mostly driven by the DIS and HLA standards community. A number of issues are coming to light about the applicability of these standards, in their present state, to the support of general multi-user VR systems. This paper pinpoints four issues that must be readdressed before large scale virtual reality systems become accessible to a larger commercial and public domain: a reduction in the effects of network delays; scalable causal event delivery; update control; and scalable reliable communication. Each of these issues is tackled through a common theme of combining wall clock and causal time-related entity behaviour, knowledge of network delays and prediction of entity behaviour, that together overcome many of the effects of network delay.

Maximising concurrency and scalability in a consistent, causal, distributed virtual reality system, whilst minimising the effect of network delays

The development of large scale virtual reality and simulation systems have been mostly driven by the DIS and HLA standards community. A number of issues are coming to light about the applicability of these standards, in their present state, to the support of general multi-user VR systems. This paper pinpoints four issues that must be readdressed before large scale virtual reality systems become accessible to a larger commercial and public domain: a reduction in the effects of network delays; scalable causal event delivery; update control; and scalable reliable communication. Each of these issues is tackled through a common theme of combining wall clock and causal time-related entity behaviour, knowledge of network delays and prediction of entity behaviour, that together overcome many of the effects of network delays.

Controle biológico de Colletotrichum acutatum, agente causal da queda prematura dos frutos cítricos

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Effect of boron and zinc fertilization on white oats grown in soil with average content of these nutrients

The objective of this study was to evaluate the effect of fertilization with zinc or boron on the growth and dry matter production, nutritional value and accumulation of nutrients in white oats. The study comprised two experiments conducted in glasshouses, the first consisting of the application of four doses of zinc (0, 0.2, 0.4 and 0.6 mg/dm³) in the form of zinc sulphate (20% Zn), and the second consisting of the application of four doses of boron (0, 0.2, 0.4 and 0.6 mg/dm³) in the form of Borax (11% B). The experimental design in each case was a randomized block design, with five replicates. Fertilization with zinc and boron increased the growth of white oats, but had no significant effect on the nutritional value of the forage. Higher levels of absorption and accumulation of nutrients in plant tissues were observed following the application of boron and zinc at rates of up to 0.60 mg/dm³ of soil.

Leading particle effect, inelasticity, and the connection between average multiplicities in e+e- and pp processes

The Regge-Mueller formalism is used to describe the inclusive spectrum of the proton in pp collisions. From such a description the energy dependences of both average inelasticity and leading proton multiplicity are calculated. These quantities are then used to establish the connection between the average charged particle multiplicities measured in e+e- and pp/p̄p processes. The description obtained for the leading proton cross section implies that Feynman scaling is strongly violated only at the extreme values of xF, that is at the central region (xF≈0) and at the diffraction region (XF≈1), while it is approximately observed in the intermediate region of the spectrum. ©1999 The American Physical Society.

The Effect of Grade Point Average on Undergraduates' Understanding of Heat Transfer

Engineering students continue to develop and show misconceptions due to prior knowledge and experiences (Miller, Streveler, Olds, Chi, Nelson, & Geist, 2007). Misconceptions have been documented in students’ understanding of heat transfer(Krause, Decker, Niska, Alford, & Griffin, 2003) by concept inventories (e.g., Jacobi,Martin, Mitchell, & Newell, 2003; Nottis, Prince, Vigeant, Nelson, & Hartsock, 2009). Students’ conceptual understanding has also been shown to vary by grade point average (Nottis et al., 2009). Inquiry-based activities (Nottis, Prince, & Vigeant, 2010) haveshown some success over traditional instructional methods (Tasoglu & Bakac, 2010) in altering misconceptions. The purpose of the current study was to determine whether undergraduate engineering students’ understanding of heat transfer concepts significantly changed after instruction with eight inquiry-based activities (Prince & Felder, 2007) supplementing instruction and whether students’ self reported GPA and prior knowledge, as measured by completion of specific engineering courses, affected these changes. The Heat and Energy Concept Inventory (Prince, Vigeant, & Nottis, 2010) was used to assess conceptual understanding. It was found that conceptual understanding significantly increased from pre- to post-test. It was also found that GPA had an effect on conceptual understanding of heat transfer; significant differences were found in post-test scores onthe concept inventory between GPA groups. However, there were mixed results when courses previously taken were analyzed. Future research should strive to analyze how prior knowledge effects conceptual understanding and aim to reduce the limitations of the current study such as, sampling method and methods of measuring GPA and priorknowledge.