Nonproportional hazards and unobserved heterogeneity in clustered survival data: When can we tell the difference?

Multivariate survival data are frequently encountered in biomedical applications in the form of clustered failures (or recurrent events data). A popular way of analyzing such data is by using shared frailty models, which assume that the proportional hazards assumption holds conditional on an unobserved cluster-specific random effect. Such models are often incorporated in more complicated joint models in survival analysis. If the random effect distribution has finite expectation, then the conditional proportional hazards assumption does not carry over to the marginal models. It has been shown that, for univariate data, this makes it impossible to distinguish between the presence of unobserved heterogeneity (eg, due to missing covariates) and marginal nonproportional hazards. We show that time-dependent covariate effects may falsely appear as evidence in favor of a frailty model also in the case of clustered failures or recurrent events data, when the cluster size or number of recurrent events is small. When true unobserved heterogeneity is present, the presence of nonproportional hazards leads to overestimating the frailty effect. We show that this phenomenon is somewhat mitigated as the cluster size grows. We carry out a simulation study to assess the behavior of test statistics and estimators for frailty models in such contexts. The gamma, inverse Gaussian, and positive stable shared frailty models are contrasted using a novel software implementation for estimating semiparametric shared frailty models. Two main questions are addressed in the contexts of clustered failures and recurrent events: whether covariates with a time-dependent effect may appear as indication of unobserved heterogeneity and whether the additional presence of unobserved heterogeneity can be detected in this case. Finally, the practical implications are illustrated in a real-world data analysis example.     

Is the Swiss Society for Social and Preventive Medicine what it should be? An invitation to a discussion

Ohne Zusammenfassung     

Left ventricular pseudoaneurysm as a late complication of mitral annuloplasty

A 59-year-old hypertensive male, 1 year after uncomplicatedmitral annuloplasty for regurgitation with MAZE procedure, witha history of chronic obstructive pulmonary disease and repeatedpulmonary     

Long-term course of epilepsy in a large cohort of intellectually disabled patients.

This study was designed to describe the course of epilepsy (in terms of seizure frequency) and to assess the variables (antiepileptic therapy regimens and others) correlated to improvement. Seizure frequency (categories: seizure free, more than one seizure/year, monthly seizures, weekly seizures and daily seizures) and antiepileptic medication were retrospectively compared between 1992 and 2002 in a large cohort of 550 inpatients with chronic epilepsy and different degrees of intellectual disability or multiple handicaps. RESULTS: Seizure frequency decreased significantly (p<0.001). 218 of the 394 patients (55.3%) not seizure free in 1992 improved (changed into a better frequency category). The improvement rate was marginally higher in patients who had undergone a medication change (p=0.08). A high seizure frequency in 1992 (p=0.016) and older age (p=0.006), but not epilepsy syndrome or degree of intellectual disability, were predictors for improvement (stepwise logistic regression analysis). 56.4% of the improved patients were on combinations of two AEDs (17.4%, monotherapy; 20.2%, triple therapy). The most frequent therapy regimens in the improved patients were lamotrigine/valproate (48 patients), carbamazepine/phenobarbital (21) and carbamazepine only (19). Lamotrigine/valproate was effective in all kinds of epileptic syndromes. Most patients on lamotrigine had serum concentrations above 10microg/ml, approximately one half had dosages above 200mg/day. The rate of seizure freedom increased from 28.4 to 37.6%. The 84% of the patients seizure free in 1992 remained seizure free. Predictors for seizure freedom in 2002 were higher age (stepwise logistic regression, p<0.0005) and seizure freedom in 1992 (p<0.0005). CONCLUSIONS: Substantial improvement can be achieved even in intellectually disabled patients with chronic epilepsy. Although the rate of seizure freedom is reduced in comparison with a non-ID population, once seizure freedom has been achieved it is most likely to continue. For a majority of this patient population, monotherapy may not be sufficient. Lamotrigine/valproate appears to be a major therapeutic innovation.     

Immunological and respiratory reactions in workers exposed to organic dusts

The relationship of skin reactivity and serum immunoglobulin E (IgE) levels to the prevalence of chronic respiratory symptoms and to ventilatory capacity is examined in workers exposed to different organic aerosols. The results from group of control workers similarly tested are also presented. Workers exposed to occupational allergens had positive skin tests more frequently than did controls, except for soy bean workers. Workers with positive skin tests to occupational allergens had a higher prevalence of almost all symptoms than those with negative skin tests although the differences did not always reach statistical significance. Workers with positive skin reactions in general had significantly higher serum IgE levels than did workers with negative skin reactions. There were across-shift reductions of ventilatory capacity in all groups of exposed workers, varying for forced vital capacity from 1.7% to 13.3%, for forced expiratory volume from 0.4%–21.9%, for maximum flow rates at 50% from 1.5% to 16.1% and for maximum flow rates at the last 25% of control vital capacity from 0% to 24.9%. There was, however, no correlation between acute and chronic lung function changes and skin reactivity or IgE values. Our data suggest that although exposure to organic aerosols may be associated with frequent immunologic reactions, these findings do not predict objective respiratory impairment.The research was supported in part by grant no. JBP 733 from the National Institutes of Health, Bethesda, Md., USA, and by grant no. RO1 OHO-2593-04 from the National Institutes of Occupational Safety and Health, Centers for Disease Control, Atlanta, Ga., USA     

Stimulus-dependent modulation of smooth muscle intracellular calcium and force by altered intracellular pH

Measurements of simultaneous force and intracellular Ca²⁺ concentration ([Ca²⁺]_i) in rat uterine smooth muscle have been made to elucidate the mechanisms involved when force produced spontaneously, by high-K⁺ depolarization or carbachol is altered by a change of intracellular pH (pH_i). Rises in force and [Ca²⁺]_i were closely correlated for all forms of contraction, with the Ca²⁺ transient peaking before force. In spontaneously active preparations, alkalinization significantly increased, and acidification decreased, force and [Ca²⁺]_i. Inhibition of the sarcoplasmic reticulum ATPase (cyclopiazonic acid) did not affect these changes, whereas removal of external Ca²⁺ abolished both responses, suggesting that the effect of pH_i is on Ca²⁺ entry. Alkalinization caused a prolongation of the action potential complex, associated with a potentiation of contractile activity. Acidification produced hyperpolarization and abolition of action potentials and spontaneous activity, but did not prevent brief applications of carbachol or high-K⁺ from producing depolarization and increasing force, suggesting no impairment of the mechanism of generation of the action potential. For depolarized preparations, acidification increased tonic force and [Ca²⁺]_i; the increase in the calcium signal persisted in zero-external calcium. In the presence of carbachol, acidification transiently increased force and [Ca²⁺]_i, followed by a reduction in both. It is concluded that changes in pH_i act at more than one step in excitation-contraction coupling and that changes in [Ca²⁺]_i can account for most of the changes in uterine force. Received: 1 April 1996 /Accepted: 8 May 1996     

On the mechanism of anionic polymerization of maleic anhydride, 2

The triphenyl and tributyl phosphine initiated polymerization of maleic anhydride was investigated. The structure of the macro zwitterions, formed under the given reaction conditions, depended on the initiator employed. If the polymerization was initiated by triphenyl phosphine, the macromolecules contained succinic anhydride units and cyclopentanone derivatives, formed from further rearrangement. If, however, tributyl phosphine was employed as initiator, the polymers were mostly made up of conjugated ketoolefinic units. IR, NMR and mass spectrometric measurements were carried out to determine the structure of the polymers. Existence of the macro zwitterions was proved by high voltage electrophoresis. The semi-conductor properties of the polymers containing conjugated ketoolefinic units are discussed. Spectroscopic investigation of the kinetics of the triphenyl phosphine initiated polymerization of maleic anhydride showed that the initiation reaction of the ylide, formed with the monomer, proceeded about 90 times slower than the propagation reaction due to addition of the monomer to the growing chain-end.     

Laudationes

Ohne ZusammenfassungHerr Professor Dr.James E. Rothman wurde 1950 in Haverhill/Mass. geboren, studierte am Yale-College und am Department of Biological Chemistry, Harvard Medical School sowie am Department of Biology, Massachusetts Inst. of Technology von 1967–1978. Daraufhin wurde er Assistant Professor, 3 Jahre später Associate Professor und nach weiteren 3 Jahren Professor am Department of Biochemistry, Stanford University. Seit 1988 ist er Squibb Professor of Molecular Biology am Department of Biology an der Princeton University.Herr Prof. Dr.K.W.A. Wirtz wurde 1942 in Utrecht geboren, erhielt seine Ausbildung in Biochemie und Physiologie an den Universitäten von Utrecht und Cornell Univ. Ithaka und promovierte mit einer Arbeit unter Prof. L.L.M. van Deenen (Heinrich-Wieland-Preis 1971). Unterbrochen durch längere Aufenthalte im Ausland, wurde er 1973 Assistant Professor und 1980 Professor für Biochemie an seiner heutigen Wirkungsstätte.     

Zur Bestimmung des Kaliumspiegels im Blutplasma

Zusammenfassung Die Kaliumkonzentration im Blutserum nach der Gerinnung ist höher als im Blutplasma, dessen Gerinnung durch Heparin, Äthylendiamintetraessigsäure (EDTA) oder Citrat verhindert wurde. Die Differenz beträgt beim Hund 15–20%, beim Menschen 12–16% und beim Rind 8–10%.Der Unterschied wird durch den bei der Gerinnung des Blutes auftretenden Zerfall der Thrombocyten hervorgerufen, deren Kaliumgehalt überraschend hoch ist (mindestens das 10–20fache der Konzentration im Plasma).Aus diesem Grund geben Kaliumbestimmungen im Serum, bei denen das Blut während der Präparation der Proben gerinnt, zu hohe Werte gegenüber der tatsächlich in vivo herrschenden Konzentration im Plasma. Messungen der Kaliumkonzentration sollten immer im Plasma erfolgen, wobei als gerinnungshemmende Substanzen Heparin oder EDTA geeignet sind.