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Using rare mutations to estimate population divergence times: a maximum likelihood approach.

In this paper we propose a method to estimate by maximum likelihood the divergence time between two populations, specifically designed for the analysis of nonrecurrent rare mutations. Given the rapidly growing amount of data, rare disease mutations affecting humans seem the most suitable candidates for this method. The estimator RD, and its conditional version RDc, were derived, assuming that the population dynamics of rare alleles can be described by using a birth-death process approximation and that each mutation arose before the split of a common ancestral population into the two diverging populations. The RD estimator seems more suitable for large sample sizes and few alleles, whose age can be approximated, whereas the RDc estimator appears preferable when this is not the case. When applied to three cystic fibrosis mutations, the estimator RD could not exclude a very recent time of divergence among three Mediterranean populations. On the other hand, the divergence time between these populations and the Danish population was estimated to be, on the average, 4,500 or 15,000 years, assuming or not a selective advantage for cystic fibrosis carriers, respectively. Confidence intervals are large, however, and can probably be reduced only by analyzing more alleles or loci.

Cystic Fibrosis↗

Some applications of the analysis of multivariate normal data with missing observations.

Methods are proposed for the analysis of data from a multivariate normal distribution when observations are missing completely at random on some of the variates. Park (1) proved the equivalence of the solutions given by maximum likelihood and generalized estimating equations when data are complete and an unstructured covariance is assumed. He suggested that generalized estimating equations may be used if sample sizes are large relative to the amount of missing data and the estimated covariance matrix is positive definite. We give several examples indicating that the estimating equations give results similar to those of maximum likelihood when smoothing of the covariance matrix to eliminate nonpositive definiteness is not encountered as, for example, under an assumption of exchangeable correlation. Generalized linear models are formulated that are appropriate for a wide class of experimental plans.

Blood Coagulation↗

Optimal batch size for estimation of the prevalence of a disease using combined samples.

Great attention has been given to the combined sample test for its high efficiency. Here a model of mathematical expectation for combined samples has been worked out and used for investigating the prevalence of HCV in serum from blood donors. It was shown that this model was valuable if the probability of a positive test, e.g. the prevalence, is less than 0.31.

Blood Donors↗

Costs and statistical power associated with five methods of collecting occupation exposure information for population-based case-control studies.

The ascertainment of information on past occupational exposure of study subjects is perhaps the main problem in case-control studies of occupational risk factors. Several methods have been proposed and used but little is known of their relative merits. The present study, undertaken in the context of a large ongoing case-control study of occupational cancer in Montreal, was designed to compare the costs of and statistical power to be derived from five plausible methods of data collection: 1) job titles abstracted from routine records, 2) job titles abstracted from routine records and processed through a job exposure matrix to derive exposure data, 3) job titles obtained by interview, 4) job titles obtained by interview and processed through a job exposure matrix to derive exposure data, and 5) job descriptions obtained by interview and processed by a team of experts to derive exposure data. Statistical power of the five methods was derived for 160 hypothetical risk factors, partly on the basis of empirical data from the data set and partly on the basis of some theoretical constructs. The design based on interview and expert evaluation was used as a reference, and the degree of misclassification of other methods was estimated in relation to this reference. For fixed sample size the interview and expert evaluation design was estimated to be much more costly than the others, but it provides much greater statistical power for detecting risks. Under the conditions of this investigation, this design was the most cost-effective. However, it is not clear to what extent this finding is generalizable.

Case-Control Studies↗

Management of sick children by health workers in Ballabgarh: lessons for implementation of IMCI in India.

The aim of this study was to determine the impact of training of health workers in the management of pediatric morbidity in terms of reduction in infant mortality rate (IMR) a 2-year period in rural Ballabgarh with a present IMR of 37 per 1000 live births. The study was designed as a pre- and post-intervention trial. The intervention was started in November 1999 and the outcome measured for the years 2000 and 2001. A sample size of 4000 was estimated for a power of 80 per cent at 5 per cent significance level. The training of the workers was for 4 days and included didactics, video-films, patient demonstrations, etc. Data on under-fives' deaths and their causes using a verbal autopsy tool was done as a part of the routine data collection system. The workers management of pediatric morbidity was assessed based on the post-training knowledge gain, forms filled by them, and referrals seen at the secondary level. The knowledge of the workers on disease and their management improved after the initial training but reached a plateau at a 50 per cent score. A review of 948 forms showed that the workers' disease classification and management was not satisfactory, especially for pneumonia and sick neonates. It was better for fever, measles, dysentery, and diarrhoea. A review of 11 cases referred by workers confirmed this. There was no impact on IMR. A look at the cause of death revealed that malnutrition, diarrhoea, and pneumonia to be the main causes among post-neonatal deaths and birth-asphyxia and prematurity as the main cause of deaths in the neonates. While implementing Integrated Management of Childhood Illnesses (IMCI) in India through the health workers, increased emphasis needs to be placed on training and supervision. Community level issues, such as healthcare seeking, female neglect, etc., may limit the scope of reduction in IMR due to implementation of IMCI.

Child, Preschool↗

Quality of controlled clinical trials on glaucoma and intraocular high pressure.

AIM: To study the quality of controlled clinical trials on glaucoma. METHODS: Two hundred and twenty-six clinical trials published between 1980 and 1999 were selected from seven international ophthalmological journals. Their quality was assessed by four researchers with epidemiological skills using a structured questionnaire. RESULTS: Sample size was pre-estimated in 34 (15.0%) papers, which were of greater size (P = 0.05). Randomization was performed in 98.2% of the trials, although the procedure of randomization was scarcely reported. Masking was reported in 56.6% of the papers, and was more frequent in medical treatments (P < 0.001). The basal characteristics of the groups were compared in 139 papers (61.5%). Patient losses during the follow-up period were fully described in only 27 trials. Intention-to-treat analysis was used in 17 (7.7%) papers. Most trials reported P values, but a measure of effect (mean, proportion, or relative risk) appeared in only 16 trials (7.7%). Trials performed in the US more frequently compared baseline characteristics of the groups (P = 0.03), described the patient flow (P = 0.04), and used adequate statistical procedures (P = 0.03). Those trials that included a statistician or an epidemiologist among the authors were more commonly blinded (P = 0.06) and they always avoided the analyses of subgroups (P = 0.006). Several methodological issues have improved throughout the studied period. CONCLUSIONS: Several methodological characteristics should be improved when reporting a clinical trial on glaucoma. Using a checklist like that suggested by the CONSORT can help to achieve this.

Controlled Clinical Trials as Topic↗

Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report.

The discovery of effective interventions to prevent or delay disability in older persons is a public health priority. Most likely to benefit from such interventions are frail individuals who are not yet disabled and those with early disability who are at high risk of progression. In spite of this frail older persons have often been excluded from research on the assumption that they would not tolerate testing or benefit from treatment. The Interventions on Frailty Working Group developed recommendations to screen, recruit, evaluate, and retain frail older persons in clinical trials. Specific recommendations are: Eligibility screening should include a multistage process, to quickly exclude those who are too well and those who are too sick. Inclusion criteria should target those most likely to benefit, be meaningful to clinicians, and reflect advancements in the frailty research area. Disability outcome measures should include self-reported, objective, and proxy measures. Strategies to improve retention and compliance and to monitor their effectiveness should be an integral part of the study design. Estimation of cost and sample size should contemplate high dropout rates and interference by competing outcomes. Additional research is needed to refine criteria for screening frail older persons, identify objective measures of disability that are reliable and valid in frail older persons, and improve the informed consent process for high-risk participants, recognizing that research in this subgroup is essential to improving their health outcomes.

Activities of Daily Living↗

A novel design for estimating relative accuracy of screening tests when complete disease verification is not feasible.

The accuracy (sensitivity and specificity) of a new screening test can be compared with that of a standard test by applying both tests to a group of subjects in which disease status can be determined by a gold standard (GS) test. However, it is not always feasible to administer a GS test to all study subjects. For example, a study is planned to determine whether a new screening test for cervical cancer ("ThinPrep") is better than the standard test ("Pap"), and in this setting it is not feasible (or ethical) to determine disease status by biopsy in order to identify women with and without disease for participation in a study. When determination of disease status is not possible for all study subjects, the relative accuracy of two screening tests can still be estimated by using a paired screen-positive (PSP) design in which all subjects receive both screening tests, but only have the GS test if one of the screening tests is positive. Unfortunately in the cervical cancer example, the PSP design is also infeasible because it is not technically possible to administer both the ThinPrep and Pap at the same time. In this article, we describe a randomized paired screen-positive (RPSP) design in which subjects are randomized to receive one of the two screening tests initially, and only receive the other screening test and GS if the first screening test is positive. We derive maximum likelihood estimators and confidence intervals for the relative accuracy of the two screening tests, and assess the small sample behavior of these estimators using simulation studies. Sample size formulae are derived and applied to the cervical cancer screening trial example, and the efficiency of the RPSP design is compared with other designs.

Biometry↗

An exact statistical test for the ABO system.

An exact test is proposed for the hypothesis stating that the ABO blood group distribution follows the Hardy-Weinberg law. The test is based on the conditional distribution of the observed phenotypic frequencies, given the estimated gene frequencies. For sample sizes of 20 or less, the exact test can be carried out with the aid of a table that lists the significant outcomes.

ABO Blood-Group System↗

Linkage analysis of malignancy-associated sarcoidosis.

STUDY OBJECTIVE: To determine whether a reported association between sarcoidosis and malignancy can be supported. DESIGN: In this retrospective survey in a general community setting, we crossmatched the Kaiser Permanente Northwest Region (KPNW) Tumor Registry comprising 3 x 10(4) cases observed over 32 years against a sarcoidosis registry of 243 cases observed over 24 years. We used linkage criteria, eg, previously reported associated malignancies, late age onset of sarcoidosis, and close temporal proximity, to identify joint occurrences suggesting an etiologic relationship. We assessed the feasibility of detecting an association of sarcoidosis and Hodgkins disease (HD) by computing the required sample size based on incidence estimates of sarcoidosis and HD in this population. Medical records of 241 persons identified by the Tumor Registry as having HD were reviewed. SETTING: KPNW, a health maintenance organization. POPULATION: We studied 6.8 x 10(6) KPNW member-years from 1960 to 1992 at risk for malignancy; 5.6 x 10(6) member-years from 1971 to 1992 at risk for sarcoidosis. RESULTS: Six of the 11 (55%; 95% confidence interval, 26 to 84) correctly classified sarcoidosis and malignancy (S&M) cases met two or more linkage criteria. A seventh case, incorrectly classified as sarcoidosis, exhibited a necrotizing systemic granulomatous process, believed to represent a response to a fatal lymphoproliferative disorder. The mean age (40 years) of the 11 patients with S&M was 9 years higher than the mean age of the patients with sarcoidosis in the population from which they were drawn. The stage of sarcoidosis at diagnosis among the 11 S&M cases was exclusively 0 and I and thus divergent from expected values in this population. We found no instances of sarcoidosis accompanying HD. CONCLUSION: Linkage analysis provides evidence that S&M may be etiologically related in at least a quarter of cases in which both are present.

Adult↗

Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis.

OBJECTIVE: To describe the relative risk for serious gastrointestinal complications due to non-aspirin nonsteroidal anti-inflammatory drug (NSAID) exposure among NSAID users as well as in selected subgroups. DESIGN: Overview and meta-analysis. DATA IDENTIFICATION: A literature search of English-language studies examining the association between NSAIDs and adverse gastrointestinal events for the period 1975 to 1990 identified using MEDLINE and communicating with three internationally recognized experts. DATA ANALYSIS: A qualitative summary of study characteristics and a critical appraisal of study quality were done. The results of 16 primary studies were selected and combined statistically. Summary estimates were weighted by sample size and quality score. MAIN RESULTS: The overall odds ratio of the risk for adverse gastrointestinal events related to NSAID use, summarized from 16 studies (9 case-control and 7 cohort) was 2.74 (95% Cl, 2.54 to 2.97). The summary odds ratios were as follows: elderly patients, (aged greater than or equal to 60 years), 5.52 (Cl, 4.63 to 6.60); patients under 65 years of age, 1.65 (Cl, 1.08 to 2.53); women, 2.32 (Cl, 1.91 to 2.82); and men, 2.40 (Cl, 1.85 to 3.11). The summary odds ratio for NSAID users receiving concomitant corticosteroids compared with NSAID users not receiving corticosteroids was 1.83 (Cl, 1.20 to 2.78). The summary odds ratio for the first gastrointestinal event was 2.39 (Cl, 2.16 to 2.65). The relative risk for a subsequent or unspecified gastrointestinal event was 4.76 (Cl, 4.05 to 5.59). The summary odds ratio for less than 1 month of NSAID exposure was 8.00 (Cl, 6.37 to 10.06); for more than 1 month but less than 3 months of exposure, the summary odds ratio was 3.31 (Cl, 2.27 to 4.82); and for more than 3 months of exposure, the summary odds ratio was 1.92 (Cl, 1.19 to 3.13). CONCLUSIONS: Users of NSAIDs are at approximately three times greater relative risk for developing serious adverse gastrointestinal events than are nonusers. Additional risk factors include age greater than 60 years, previous history of gastrointestinal events, and concomitant corticosteroid use. Another possible risk factor is the first 3 months of NSAID therapy. The risk for serious gastrointestinal events appears to be equal among men and women. These data represent summary statistics from 16 studies and cannot be considered generalizable to all NSAID users.

Anti-Inflammatory Agents, Non-Steroidal↗

[Bioequivalence and generic drugs. I. Studies of bioequivalence, considering the theoretical basis, design and use].

OBJECTIVES: To describe the studies done before a generic drug is marketed. DEVELOPMENT: We reflect on the concept of bioequivalence and its limitations, then describe the parameters on which a study of bioequivalence is based and explain the statistical hypothesis of bioequivalence. Finally, we explain the process of a clinical trial of bioequivalence and how the results are analyzed, using a clinical trial as an example. We show how 'carry-over', formulation and period effects are analyzed; and also how bioequivalence may be evaluated by using different approximations: construction of the confidence interval, confidence hypothesis and nonparametric approximations. Finally, we mention the methods used to estimate the size of the sample required in a study of this kind. CONCLUSIONS: Studies of bioequivalence, even the simplest, have peculiarities of design and statistical basis which are markedly different from other clinical trials. When generic drugs are marketed it is important to know about the peculiarities and characteristics of the studies on which affirmation of the bioequivalence of these products is based.

Clinical Trials as Topic↗

[Differences in the quality of Spanish clinical trials published in international periodicals and of the ones presented in general medicine periodicals with wide readership].

BACKGROUND: The assessment of the methodological quality of controlled clinical trials (CCTs) carried out in Spain and published in international journals and the comparison with those published in widely read general journals of medicine (N Engl J Med, Lancet, JAMA, BMJ) may help establishing their limitations and improving quality in future studies. METHODS: Search in Medline of CCTs. Studies were evaluated according to a structured questionnaire (J Clin Epidemiol 1992; 45:225-265). The odds ratio and their 95% confidence intervals were used to compare spanish studies with the remaining studies. The following variables were considered as confounders and controlled for by logistic regression analysis: number of participating centers, sample size, funding source, and the inclusion of epidemiologists in the research team. The journal's impact factor was taken into account. RESULTS: Spanish CTTs had a smaller sample size, were mostly monocentric, reported les frequently the source of funding, and exhibited a lower participation of epidemiologists. The informed consent and the approval by the ethics committee were more frequently omitted. The major methodological differences with the other studies were: lack of pre-study sample size and statistical power estimation, lack of inclusion criteria, poor explanation of patients' flow in the selection process, lack of explanation for unmasked procedures, poor description of methods to assess intervention compliance, under-reporting confidence intervals, and less frequent use of the intention-to-treat principle. The quality score of spanish studies was lower (9.4 +/- 1.7 vs 10.7 +/- 1.5; p < 0.001). These limitations improved with higher journal's impact factor, the quality score was 8.5 in journals with an impact factor < 1.5, and 10.6 in those with an impact factor > 4.5. This last figure is almost identical to the average of CCTs published in general journals of medicine. CONCLUSIONS: Most spanish studies achieved a good quality score. Nevertheless, there are still issues which can be overcome easily. If this goal is achieved, the results will obtain a higher repercussion, as a better quality is observed in those published in journals with the highest impact factor.

Clinical Trials as Topic↗

Myocardium tissue analysis based on textures in ultrasound images.

The heart disease is related to the alterations in the biological tissue of its muscles. The myocardium alterations have been analysed and evaluated on ultrasound images. The statistical parameters of the heart texture on the defined region of interest present information about the state of myocardium. There are hundreds of the texture parameters, which could be used to evaluate the heart tissue structure. The goal was to choose the most informative ones by applying the quantitative analysis technique. The Fisher statistics has been applied for hypothesis testing to define the most informative texture parameters. The quantitative analysis proved that the texture parameters of the myocardium tissue can be estimated significantly, when the sample size of ROI is not less than 900-1000 pixels. The sample cannot be enhanced by combining images on in the diastolic and systolic phases. To evaluate the state of the myocardium the following statistical parameters can be used on four chamber view images: the percentiles of order 0.01, 0.1, 0.5, grey level run length non-uniformity (in all directions: horizontally, vertically, 45(0), 135(0)), except a lateral wall of the left ventricle, the entropy of the two-dimensional probability distribution, the parameter of the two-dimensional probability distribution, which defines the mean distance between grey levels. On parasternal images the informative statistical parameters are: grey level run length non-uniformity (in all directions: horizontally, vertically, 45(0), 135(0)), grey level non-uniformity, the entropy of the two-dimensional probability distribution applied to the septum only.

Echocardiography↗

[A method of detecting conserved and variable segments in the amino acid sequences of homologous proteins].

A set of aligned homologous protein sequences is divided into two groups consisting of m and n sequences. Each group contains sequences from the most related organisms. Value of the position dissimilarity of proteins from different groups of m and n sequences is defined as a number of mismatches in comparison of all possible m X n pairs of amino acid residues in the position (each from different group) divided by m X n. Ten position average of dissimilarity values is plotted vs. the first position number. Area of the figure between the profile of dissimilarity values and its mean value line characterizes the overall irregularity of amino acid substitutions along the protein sequences. If the area is greater than the average area for 1000 random profiles by more than two standard deviation units, the profile extrema containing the "surplus" of area are cut off. The cut-off stretches are likely to be variable and constant regions. If necessary, each of stretches may be separately tested and statistically estimated using a standard size sample of artificial protein families. Intergroup comparison of protein sequences reveals high overall irregularity of amino acid substitutions and identifies variable and conservative regions for all considered families of proteins: phospholipases A2, aspartate aminotransferases, alpha-subunits of Na+, K(+)-ATPase, L- and M-subunits of photosynthetic bacteria photoreaction centre, human rhodopsins.

Amino Acid Sequence↗

[Prospective epidemiologic study on respiratory diseases in children in Cracow. Pilot study].

After introducing the main purpose of the project on the outdoor and indoor air quality and children's health in Cracow, the paper presents the results of the pilot study carried out in the higher polluted city area (suspended particulate matter: 51.5-74.5 micrograms/m3/year; SO2: 58.4-73.8 micrograms/m33/year) and in the less polluted area (suspended particulate matter: 31.7 micrograms/m3/year; SO2: 36.1 microgram/m3/year). The pilot study covered 171 children. There was an excess of chronic respiratory symptoms in children from the higher polluted area, but only the frequency of shortness of breath in boys and attacks of shortness of breath with wheezing in girls were significantly higher in those living in the polluted area. Spirometric indices were significantly lower in both boys and girls in the residence area with the higher air pollution level. The data on prevalence of respiratory diseases in the pilot study will be used to estimate the size of the sample needed in the other stages of the prospective study.

Air Pollution↗

Two-stage procedure for evaluating interassay carryover on random-access instruments.

A two-stage statistical procedure based on Dunnett's multiple comparison procedures with a control has been developed for detecting interassay carryover biases on the Abbott AxSYM(TM) System, a random- and continuous-access immunoanalyzer. With this procedure, every potential source of interassay carryover can be tested and estimated. In minimizing required sample sizes, the first stage is used primarily to detect and eliminate from further testing the assay reagent sources that do not cause carryover biases and the assay sources that cause very large carryover biases. Retested more extensively in the second testing stage are the cases where the data from the first testing stage are insufficient for judgment. An example data set from the Abbott AxSYM Free T4 assay is used to illustrate the methodology.

Autoanalysis↗

Performance estimation of diagnostic tests for cervical precancer based on fluorescence spectroscopy: effects of tissue type, sample size, population, and signal-to-noise ratio.

Fluorescence spectroscopy may provide a cost-effective tool to improve precancer detection. We describe a method to estimate the diagnostic performance of classifiers based on optical spectra, and to explore the sensitivity of these estimations to factors affecting spectrometer cost. Fluorescence spectra were obtained at three excitation wavelengths in 92 patients with an abnormal Papanicolaou smear and 51 patients with no history of an abnormal smear. Bayesian classification rules were developed and evaluated at multiple misclassification costs. We explored the sensitivity of classifier performance to variations in tissue type, sample size, tested population, signal to noise ratio (SNR), and number of excitation and emission wavelengths. Sensitivity and specificity could be evaluated within +/- 7%. Minimal decrease in diagnostic performance is observed as SNR is reduced to 15, the number of excitation-emission wavelength combinations is reduced to 15 or the number of excitation wavelengths is reduced to one. Diagnostic performance is compromised when ultraviolet excitation is not included. Significant spectrometer cost reduction is possible without compromising diagnostic ability. Decision-analytic methods can be used to rate designs based on incremental cost-effectiveness.

Algorithms↗