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Madison AA, Burd CE, Andridge R, Wilson SJ, Bailey MT, Belury MA, Spakowicz DJ, Malarkey WB, Kiecolt-Glaser JK. Gut Microbiota Richness and Diversity Track With T Cell Aging in Healthy Adults. J Gerontol A Biol Sci Med Sci 2024; 79:glad276. [PMID: 38123141 PMCID: PMC10878250 DOI: 10.1093/gerona/glad276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND This study examined how gut microbiota diversity and richness relate to T cell aging among 96 healthy adults of all ages. It also explored whether these links differed throughout the lifespan. METHODS Peripheral blood was obtained from 96 study participants (N = 96, aged 21-72) to assess mRNA markers of T cell aging (p16ink4a, p14ARF, B3gat1, Klrg1) and DNA methylation. T cell aging mRNA markers were combined into an aging index, and the Horvath epigenetic clock algorithm was used to calculate epigenetic age based on DNA methylation status of over 500 loci. Participants also collected a stool sample from which the V4 region of the 16S rRNA gene was sequenced to derive the Shannon and Simpson diversity indices, and the total count of observed operational taxonomic units (richness). Models controlled for BMI, comorbidities, sex, dietary quality, smoking status, physical activity, and sleep quality. RESULTS Lower microbiota richness was associated with higher T cell age based on mRNA markers, but when probing the region of significance, this relationship was only significant among adults 45 years and older (p = .03). Lower Shannon diversity (p = .05) and richness (p = .07) marginally correlated with higher epigenetic age (ie, greater T cell DNA methylation). CONCLUSIONS Gut microbiota complexity may correspond with the rate of T cell aging, especially in mid-to-late life. These results suggest an interplay between the gut microbiome and immunological aging that warrants further experimental work.
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Affiliation(s)
- Annelise A Madison
- Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Christin E Burd
- Departments of Molecular Genetics, Cancer Biology and Genetics, The Ohio State University, Columbus, Ohio, USA
| | - Rebecca Andridge
- Division of Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Stephanie J Wilson
- Department of Psychology, Southern Methodist University, Dallas, Texas, USA
| | - Michael T Bailey
- The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Center for Microbial Pathogenesis and the Oral and Gastrointestinal Microbiology Research Affinity Group, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Martha A Belury
- The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Food Science and Technology, College of Food, Agriculture, and Environmental Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Daniel J Spakowicz
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - William B Malarkey
- The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Janice K Kiecolt-Glaser
- The Institute for Behavioral Medicine Research, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, Ohio, USA (Biological Sciences Section)
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2
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Luo J, Gao F, Liu J, Wang G, Chen L, Fagan AM, Day GS, Vöglein J, Chhatwal JP, Xiong C. Statistical estimation and comparison of group-specific bivariate correlation coefficients in family-type clustered studies. J Appl Stat 2021; 49:2246-2270. [PMID: 35755087 PMCID: PMC9225315 DOI: 10.1080/02664763.2021.1899141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Bivariate correlation coefficients (BCCs) are often calculated to gauge the relationship between two variables in medical research. In a family-type clustered design where multiple participants from same units/families are enrolled, BCCs can be defined and estimated at various hierarchical levels (subject level, family level and marginal BCC). Heterogeneity usually exists between subject groups and, as a result, subject level BCCs may differ between subject groups. In the framework of bivariate linear mixed effects modeling, we define and estimate BCCs at various hierarchical levels in a family-type clustered design, accommodating subject group heterogeneity. Simplified and modified asymptotic confidence intervals are constructed to the BCC differences and Wald type tests are conducted. A real-world family-type clustered study of Alzheimer disease (AD) is analyzed to estimate and compare BCCs among well-established AD biomarkers between mutation carriers and non-carriers in autosomal dominant AD asymptomatic individuals. Extensive simulation studies are conducted across a wide range of scenarios to evaluate the performance of the proposed estimators and the type-I error rate and power of the proposed statistical tests. Abbreviations: BCC: bivariate correlation coefficient; BLM: bivariate linear mixed effects model; CI: confidence interval; AD: Alzheimer's disease; DIAN: The Dominantly Inherited Alzheimer Network; SA: simple asymptotic; MA: modified asymptotic.
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Affiliation(s)
- Jingqin Luo
- Siteman Cancer Center Biostatistics Shared Resource, Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA, Jingqin Luo
| | - Feng Gao
- Siteman Cancer Center Biostatistics Shared Resource, Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jingxia Liu
- Siteman Cancer Center Biostatistics Shared Resource, Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Guoqiao Wang
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Ling Chen
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Anne M. Fagan
- Department of Neurology, Alzheimer Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Jonathan Vöglein
- Department of Neurology, Ludwig-Maximilians-Universität München, German Center for Neurodegenerative Diseases, Munich, Germany
| | - Jasmeer P. Chhatwal
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Chengjie Xiong
- Department of Neurology, Alzheimer Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA,Chengjie Xiong
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3
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Barthélemy NR, Li Y, Joseph-Mathurin N, Gordon BA, Hassenstab J, Benzinger TLS, Buckles V, Fagan AM, Perrin RJ, Goate AM, Morris JC, Karch CM, Xiong C, Allegri R, Mendez PC, Berman SB, Ikeuchi T, Mori H, Shimada H, Shoji M, Suzuki K, Noble J, Farlow M, Chhatwal J, Graff-Radford NR, Salloway S, Schofield PR, Masters CL, Martins RN, O'Connor A, Fox NC, Levin J, Jucker M, Gabelle A, Lehmann S, Sato C, Bateman RJ, McDade E. A soluble phosphorylated tau signature links tau, amyloid and the evolution of stages of dominantly inherited Alzheimer's disease. Nat Med 2020; 26:398-407. [PMID: 32161412 PMCID: PMC7309367 DOI: 10.1038/s41591-020-0781-z] [Citation(s) in RCA: 310] [Impact Index Per Article: 77.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 01/30/2020] [Indexed: 12/31/2022]
Abstract
Development of tau-based therapies for Alzheimer's disease requires an understanding of the timing of disease-related changes in tau. We quantified the phosphorylation state at multiple sites of the tau protein in cerebrospinal fluid markers across four decades of disease progression in dominantly inherited Alzheimer's disease. We identified a pattern of tau staging where site-specific phosphorylation changes occur at different periods of disease progression and follow distinct trajectories over time. These tau phosphorylation state changes are uniquely associated with structural, metabolic, neurodegenerative and clinical markers of disease, and some (p-tau217 and p-tau181) begin with the initial increases in aggregate amyloid-β as early as two decades before the development of aggregated tau pathology. Others (p-tau205 and t-tau) increase with atrophy and hypometabolism closer to symptom onset. These findings provide insights into the pathways linking tau, amyloid-β and neurodegeneration, and may facilitate clinical trials of tau-based treatments.
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Affiliation(s)
- Nicolas R Barthélemy
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Yan Li
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA.,Division of Biostatistics, Washington University School of Medicine, Saint Louis, MO, USA
| | - Nelly Joseph-Mathurin
- Department of Radiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Brian A Gordon
- Department of Radiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jason Hassenstab
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Tammie L S Benzinger
- Department of Radiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Virginia Buckles
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Anne M Fagan
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Richard J Perrin
- Department of Pathology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Alison M Goate
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John C Morris
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Celeste M Karch
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Chengjie Xiong
- Division of Biostatistics, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ricardo Allegri
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI) Instituto de Investigaciones Neurológicas Raúl Correa, Buenos Aires, Argentina
| | - Patricio Chrem Mendez
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI) Instituto de Investigaciones Neurológicas Raúl Correa, Buenos Aires, Argentina
| | - Sarah B Berman
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | | | | | | | - James Noble
- Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Martin Farlow
- Department of Neurology, Indiana University, Indianapolis, IN, USA
| | - Jasmeer Chhatwal
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Stephen Salloway
- Butler Hospital, Providence, RI, USA.,Brown University, Providence, RI, USA
| | - Peter R Schofield
- Neuroscience Research Australia, Sydney, New South Wales, Australia.,School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Colin L Masters
- The Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | | | - Antoinette O'Connor
- Dementia Research Centre, Institute of Neurology, University College London, London, UK
| | - Nick C Fox
- Dementia Research Centre, Institute of Neurology, University College London, London, UK
| | - Johannes Levin
- German Center for Neurodegenerative Diseases (DZNE) Munich, Munich, Germany.,Department of Neurology, Ludwig-Maximilians Universität München, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Mathias Jucker
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany.,Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Audrey Gabelle
- Laboratoire de Biochimie et Protéomique Clinique and CRB, INSERM-UM, CHU Montpellier, Montpellier, France, Montpellier, France
| | - Sylvain Lehmann
- Laboratoire de Biochimie et Protéomique Clinique and CRB, INSERM-UM, CHU Montpellier, Montpellier, France, Montpellier, France
| | - Chihiro Sato
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Randall J Bateman
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA.
| | - Eric McDade
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA.
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4
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Llibre-Guerra JJ, Li Y, Schindler SE, Gordon BA, Fagan AM, Morris JC, Benzinger TLS, Hassenstab J, Wang G, Allegri R, Berman SB, Chhatwal J, Farlow MR, Holtzman DM, Jucker M, Levin J, Noble JM, Salloway S, Schofield P, Karch C, Fox NC, Xiong C, Bateman RJ, McDade E. Association of Longitudinal Changes in Cerebrospinal Fluid Total Tau and Phosphorylated Tau 181 and Brain Atrophy With Disease Progression in Patients With Alzheimer Disease. JAMA Netw Open 2019; 2:e1917126. [PMID: 31825500 PMCID: PMC6991202 DOI: 10.1001/jamanetworkopen.2019.17126] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE The amyloid/tau/neurodegeneration (A/T/N) framework uses cerebrospinal fluid (CSF) levels of total tau (tTau) as a marker of neurodegeneration and CSF levels of phosphorylated tau 181 (pTau181) as a marker of tau tangles. However, it is unclear whether CSF levels of tTau and pTau181 have similar or different trajectories over the course of Alzheimer disease. OBJECTIVES To examine the rates of change in CSF levels of tTau and pTau181 across the Alzheimer disease course and how the rates of change are associated with brain atrophy as measured by magnetic resonance imaging. DESIGN, SETTING, AND PARTICIPANTS This cohort study was set in tertiary research clinics. Each participant was a member of a pedigree with a known mutation for dominantly inherited Alzheimer disease. Participants were divided into 3 groups on the basis of the presence of a mutation and their Clinical Dementia Rating score. Data analysis was performed in June 2019. MAIN OUTCOMES AND MEASURES Rates of change of CSF tTau and pTau181 levels and their association with the rate of change of brain volume. RESULTS Data from 465 participants (283 mutation carriers and 182 noncarriers) were analyzed. The mean (SD) age of the cohort was 37.8 (11.3) years, and 262 (56.3%) were women. The mean (SD) follow-up duration was 2.7 (1.5) years. Two or more longitudinal CSF and magnetic resonance imaging assessments were available for 160 and 247 participants, respectively. Sixty-five percent of mutation carriers (183) did not have symptoms at baseline (Clinical Dementia Rating score, 0). For mutation carriers, the annual rates of change for CSF tTau and pTau181 became significantly different from 0 approximately 10 years before the estimated year of onset (mean [SE] rates of change, 5.5 [2.8] for tTau [P = .05] and 0.7 [0.3] for pTau 181 [P = .04]) and 15 years before onset (mean [SE] rates of change, 5.4 [3.9] for tTau [P = .17] and 1.1 [0.5] for pTau181 [P = .03]), respectively. The rate of change of pTau181 was positive and increased at the early stages of the disease, showing a positive rate of change starting at 15 estimated years before onset until 5 estimated years before onset (mean [SE], 0.4 [0.3]), followed by a positive but decreasing rate of change at year 0 (mean [SE], 0.1 [0.3]) and then negative rates of change at 5 years (mean [SE], -0.3 [0.4]) and 10 years (mean [SE], -0.6 [0.6]) after symptom onset. In individuals without symptoms (Clinical Dementia Rating score, 0), the rates of change of CSF tTau and pTau181 were negatively associated with brain atrophy (high rates of change in CSF measures were associated with low rates of change in brain volume in asymptomatic stages). After symptom onset (Clinical Dementia Rating score, >0), an increased rate of brain atrophy was not associated with rates of change of levels of both CSF tTau and pTau181. CONCLUSIONS AND RELEVANCE These findings suggest that CSF tTau and pTau181 may have different associations with brain atrophy across the disease time course. These results have implications for understanding the dynamics of disease pathobiology and interpreting neuronal injury biomarker concentrations in response to Alzheimer disease progression and disease-modifying therapies.
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Affiliation(s)
| | - Yan Li
- Department of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | | | - Brian A. Gordon
- Department of Radiology, Washington University in St Louis, St Louis, Missouri
| | - Anne M. Fagan
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - John C. Morris
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
- Hope Center for Neurological Disorders, St Louis, Missouri
- Knight Alzheimer’s Disease Research Center, St Louis, Missouri
| | | | - Jason Hassenstab
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
| | - Guoqiao Wang
- Hertie Institute for Clinical Brain Research, Department of Cellular Neurology, University of Tübingen, Tübingen, Germany
| | - Ricardo Allegri
- Department of Cognitive Neurology, Institute for Neurological Research Fleni, Buenos Aires, Argentina
| | - Sarah B. Berman
- Department of Radiology, Washington University in St Louis, St Louis, Missouri
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - David M. Holtzman
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
- Hope Center for Neurological Disorders, St Louis, Missouri
- Knight Alzheimer’s Disease Research Center, St Louis, Missouri
| | - Mathias Jucker
- Hertie Institute for Clinical Brain Research, Department of Cellular Neurology, University of Tübingen, Tübingen, Germany
- DZNE-German Center for Neurodegenerative Diseases, Tübingen, Tübingen, Germany
| | - Johannes Levin
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
- DZNE-German Center for Neurodegenerative Diseases, Munich, Munich, Germany
- SyNergy, Munich Cluster for Systems Neurology, Munich, Germany
| | - James M. Noble
- Taub Institute for Research on Alzheimer’s Disease, Aging Brain G.H. Sergievsky Center, Department of Neurology, Columbia University Medical Center, New York, New York
| | - Stephen Salloway
- Memory & Aging Program, Butler Hospital, Brown University, Providence, Rhode Island
| | - Peter Schofield
- Neuroscience Research Australia, Randwick, Sydney, New South Wales, Australia
- School of Medical Sciences, UNSW Sydney, Sydney, New South Wales, Australia
| | - Celeste Karch
- Department of Psychiatry, Washington University in St Louis, St Louis, Missouri
| | - Nick C. Fox
- Dementia Research Centre, University College London, London, United Kingdom
| | - Chengjie Xiong
- Department of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | - Randall J. Bateman
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
| | - Eric McDade
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
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5
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Schindler SE, Li Y, Todd KW, Herries EM, Henson RL, Gray JD, Wang G, Graham DL, Shaw LM, Trojanowski JQ, Hassenstab JJ, Benzinger TLS, Cruchaga C, Jucker M, Levin J, Chhatwal JP, Noble JM, Ringman JM, Graff-Radford NR, Holtzman DM, Ladenson JH, Morris JC, Bateman RJ, Xiong C, Fagan AM. Emerging cerebrospinal fluid biomarkers in autosomal dominant Alzheimer's disease. Alzheimers Dement 2019; 15:655-665. [PMID: 30846386 PMCID: PMC6511459 DOI: 10.1016/j.jalz.2018.12.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/17/2018] [Accepted: 12/29/2018] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Four less well-studied but promising "emerging" cerebrospinal fluid (CSF) biomarkers are elevated in late-onset Alzheimer disease (AD): neurogranin, synaptosomal-associated protein-25 (SNAP-25), visinin-like protein 1 (VILIP-1), and chitinase-3-like protein 1 (YKL-40). METHODS CSF neurogranin, SNAP-25, VILIP-1, and YKL-40 were measured in families carrying autosomal-dominant AD mutations. RESULTS The four emerging CSF biomarkers were significantly elevated in the mutation carriers (n = 235) versus noncarriers (n = 145). CSF SNAP-25, VILIP-1, and YKL-40 were altered very early in the AD time course, approximately 15-19 years before estimated symptom onset. All CSF biomarkers predicted important AD-related outcomes including performance on a cognitive composite, brain amyloid burden as measured by amyloid positron emission tomography, and the estimated years from symptom onset. DISCUSSION Early abnormalities in CSF tTau, pTau, SNAP-25, VILIP-1, and YKL-40 suggest that synaptic damage, neuronal injury, and neuroinflammation begin shortly after the commencement of brain amyloid accumulation.
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Affiliation(s)
- Suzanne E Schindler
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Yan Li
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kaitlin W Todd
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Elizabeth M Herries
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Rachel L Henson
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA; Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Julia D Gray
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA; Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Guoqiao Wang
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Danielle L Graham
- Biomarkers, Research and Early Development, Biogen, Cambridge, MA, USA
| | - Leslie M Shaw
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John Q Trojanowski
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Neurodegenerative Disease Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason J Hassenstab
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Tammie L S Benzinger
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA; Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Carlos Cruchaga
- Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA; Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Mathias Jucker
- German Center for Neurodegenerative Diseases (DZNE), Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Johannes Levin
- German Center for Neurodegenerative Diseases (DZNE), Germany; Department of Neurology, Ludwig Maximilians University, Munich, Germany
| | - Jasmeer P Chhatwal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James M Noble
- Department of Neurology, Columbia University Medical Center, New York City, NY, USA
| | - John M Ringman
- Department of Neurology, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | | | - David M Holtzman
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA; Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Jack H Ladenson
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - John C Morris
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Randall J Bateman
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA; Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Chengjie Xiong
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA; Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Anne M Fagan
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Knight Alzheimer's Disease Research Center, Washington University School of Medicine, St. Louis, MO, USA; Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA.
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6
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Xu J, Slagle JM, Banerjee A, Bracken B, Weinger MB. Use of a Portable Functional Near-Infrared Spectroscopy (fNIRS) System to Examine Team Experience During Crisis Event Management in Clinical Simulations. Front Hum Neurosci 2019; 13:85. [PMID: 30890926 PMCID: PMC6412154 DOI: 10.3389/fnhum.2019.00085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/18/2019] [Indexed: 11/16/2022] Open
Abstract
Objective: The aim of this study was to investigate the utilization of a portable functional near-infrared spectroscopy (fNIRS) system, the fNIRS PioneerTM, to examine team experience in high-fidelity simulation-based crisis event management (CEM) training for anesthesiologists in operating rooms. Background: Effective evaluation of team performance and experience in CEM simulations is essential for healthcare training and research. Neurophysiological measures with wearable devices can provide useful indicators of team experience to compliment traditional self-report, observer ratings, and behavioral performance measures. fNIRS measured brain blood oxygenation levels and neural synchrony can be used as indicators of workload and team engagement, which is vital for optimal team performance. Methods: Thirty-three anesthesiologists, who were attending CEM training in two-person teams, participated in this study. The participants varied in their expertise level and the simulation scenarios varied in difficulty level. The oxygenated and de-oxygenated hemoglobin (HbO and HbR) levels in the participants’ prefrontal cortex were derived from data recorded by a portable one-channel fNIRS system worn by all participants throughout CEM training. Team neural synchrony was measured by HbO/HbR wavelet transformation coherence (WTC). Observer-rated workload and self-reported workload and mood were also collected. Results: At the individual level, the pattern of HbR level corresponded to changes of workload for the individuals in different roles during different phases of a scenario; but this was not the case for HbO level. Thus, HbR level may be a better indicator for individual workload in the studied setting. However, HbR level was insensitive to differences in scenario difficulty and did not correlate with observer-rated or self-reported workload. At the team level, high levels of HbO and HbR WTC were observed during active teamwork. Furthermore, HbO WTC was sensitive to levels of scenario difficulty. Conclusion: This study showed that it was feasible to use a portable fNIRS system to study workload and team engagement in high-fidelity clinical simulations. However, more work is needed to establish the sensitivity, reliability, and validity of fNIRS measures as indicators of team experience.
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Affiliation(s)
- Jie Xu
- Faculty of Science, Center for Psychological Sciences, Zhejiang University, Hangzhou, China.,Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jason M Slagle
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Arna Banerjee
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Matthew B Weinger
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States.,Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, United States
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Kinzy TG, Starr TK, Tseng GC, Ho YY. Meta-analytic framework for modeling genetic coexpression dynamics. Stat Appl Genet Mol Biol 2019; 18:/j/sagmb.ahead-of-print/sagmb-2017-0052/sagmb-2017-0052.xml. [DOI: 10.1515/sagmb-2017-0052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Methods for exploring genetic interactions have been developed in an attempt to move beyond single gene analyses. Because biological molecules frequently participate in different processes under various cellular conditions, investigating the changes in gene coexpression patterns under various biological conditions could reveal important regulatory mechanisms. One of the methods for capturing gene coexpression dynamics, named liquid association (LA), quantifies the relationship where the coexpression between two genes is modulated by a third “coordinator” gene. This LA measure offers a natural framework for studying gene coexpression changes and has been applied increasingly to study regulatory networks among genes. With a wealth of publicly available gene expression data, there is a need to develop a meta-analytic framework for LA analysis. In this paper, we incorporated mixed effects when modeling correlation to account for between-studies heterogeneity. For statistical inference about LA, we developed a Markov chain Monte Carlo (MCMC) estimation procedure through a Bayesian hierarchical framework. We evaluated the proposed methods in a set of simulations and illustrated their use in two collections of experimental data sets. The first data set combined 10 pancreatic ductal adenocarcinoma gene expression studies to determine the role of possible coordinator gene USP9X in the Hippo pathway. The second experimental data set consisted of 907 gene expression microarray Escherichia coli experiments from multiple studies publicly available through the Many Microbe Microarray Database website (http://m3d.bu.edu/) and examined genes that coexpress with serA in the presence of coordinator gene Lrp.
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Zuk M, Bailey NW, Gray B, Rotenberry JT. Sexual signal loss: The link between behaviour and rapid evolutionary dynamics in a field cricket. J Anim Ecol 2018; 87:623-633. [DOI: 10.1111/1365-2656.12806] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 12/21/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Marlene Zuk
- Department of Ecology, Evolution and Behavior University of Minnesota St. Paul MN USA
| | - Nathan W. Bailey
- School of Biology Centre for Biological Diversity University of St Andrews Fife UK
| | - Brian Gray
- Department of Biology University of California Riverside CA USA
- Columbia University New York NY USA
| | - John T. Rotenberry
- Department of Ecology, Evolution and Behavior University of Minnesota St. Paul MN USA
- Department of Biology University of California Riverside CA USA
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Xiong C, Luo J, Chen L, Gao F, Liu J, Wang G, Bateman R, Morris JC. Estimating diagnostic accuracy for clustered ordinal diagnostic groups in the three-class case-Application to the early diagnosis of Alzheimer disease. Stat Methods Med Res 2018; 27:701-714. [PMID: 29182052 PMCID: PMC5841923 DOI: 10.1177/0962280217742539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many medical diagnostic studies involve three ordinal diagnostic populations in which the diagnostic accuracy can be summarized by the volume or partial volume under the receiver operating characteristic surface for a diagnostic marker. When the diagnostic populations are clustered, e.g. by families, we propose to model the diagnostic marker by a general linear mixed model that takes into account of the correlation on the diagnostic marker from members of the same clusters. This model then facilitates the maximum likelihood estimation and statistical inferences of the diagnostic accuracy for the diagnostic marker. This approach naturally allows the incorporation of covariates as well as missing data when some clusters do not have subjects on all diagnostic groups in the estimation of, and the subsequent inferences on the diagnostic accuracy. We further study the performance of the proposed methods in a large simulation study with clustered data. Finally, we apply the proposed methodology to the data of several biomarkers collected by the Dominantly Inherited Alzheimer Network, an international family-clustered registry to study autosomal dominant Alzheimer disease which is a rare form of Alzheimer disease caused by mutations in any of the three genes including the amyloid precursor protein, presenilin 1 and presenilin 2. We estimate the accuracy of several cerebrospinal fluid and neuroimaging biomarkers in differentiating three diagnostic and genetic populations: normal non-mutation carriers, asymptomatic mutation carriers, and symptomatic mutation carriers.
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Affiliation(s)
- Chengjie Xiong
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO, U.S.A
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, U.S.A
| | - Jingqin Luo
- Division of Public health, Department of Surgery, Washington University in St. Louis, St. Louis, MO, U.S.A
- Biostatistics Core, Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, U.S.A
| | - Ling Chen
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO, U.S.A
| | - Feng Gao
- Division of Public health, Department of Surgery, Washington University in St. Louis, St. Louis, MO, U.S.A
- Biostatistics Core, Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, U.S.A
| | - Jingxia Liu
- Division of Public health, Department of Surgery, Washington University in St. Louis, St. Louis, MO, U.S.A
- Biostatistics Core, Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, U.S.A
| | - Guoqiao Wang
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO, U.S.A
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, U.S.A
| | - Randall Bateman
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, U.S.A
| | - John C. Morris
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, U.S.A
- Departments of Pathology and Immunology, Washington University in St. Louis, St. Louis, MO, U.S.A
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Mikulich-Gilbertson SK, Wagner BD, Grunwald GK, Riggs PD, Zerbe GO. Using empirical Bayes predictors from generalized linear mixed models to test and visualize associations among longitudinal outcomes. Stat Methods Med Res 2018; 28:1399-1411. [PMID: 29488446 DOI: 10.1177/0962280218758357] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medical research is often designed to investigate changes in a collection of response variables that are measured repeatedly on the same subjects. The multivariate generalized linear mixed model (MGLMM) can be used to evaluate random coefficient associations (e.g. simple correlations, partial regression coefficients) among outcomes that may be non-normal and differently distributed by specifying a multivariate normal distribution for their random effects and then evaluating the latent relationship between them. Empirical Bayes predictors are readily available for each subject from any mixed model and are observable and hence, plotable. Here, we evaluate whether second-stage association analyses of empirical Bayes predictors from a MGLMM, provide a good approximation and visual representation of these latent association analyses using medical examples and simulations. Additionally, we compare these results with association analyses of empirical Bayes predictors generated from separate mixed models for each outcome, a procedure that could circumvent computational problems that arise when the dimension of the joint covariance matrix of random effects is large and prohibits estimation of latent associations. As has been shown in other analytic contexts, the p-values for all second-stage coefficients that were determined by naively assuming normality of empirical Bayes predictors provide a good approximation to p-values determined via permutation analysis. Analyzing outcomes that are interrelated with separate models in the first stage and then associating the resulting empirical Bayes predictors in a second stage results in different mean and covariance parameter estimates from the maximum likelihood estimates generated by a MGLMM. The potential for erroneous inference from using results from these separate models increases as the magnitude of the association among the outcomes increases. Thus if computable, scatterplots of the conditionally independent empirical Bayes predictors from a MGLMM are always preferable to scatterplots of empirical Bayes predictors generated by separate models, unless the true association between outcomes is zero.
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Affiliation(s)
- Susan K Mikulich-Gilbertson
- 1 Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,2 Department of Biostatistics and Informatics, School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Brandie D Wagner
- 2 Department of Biostatistics and Informatics, School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gary K Grunwald
- 2 Department of Biostatistics and Informatics, School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Paula D Riggs
- 1 Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gary O Zerbe
- 2 Department of Biostatistics and Informatics, School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Bagegni N, Thomas S, Liu N, Luo J, Hoog J, Northfelt DW, Goetz MP, Forero A, Bergqvist M, Karen J, Neumüller M, Suh EM, Guo Z, Vij K, Sanati S, Ellis M, Ma CX. Serum thymidine kinase 1 activity as a pharmacodynamic marker of cyclin-dependent kinase 4/6 inhibition in patients with early-stage breast cancer receiving neoadjuvant palbociclib. Breast Cancer Res 2017; 19:123. [PMID: 29162134 PMCID: PMC5699111 DOI: 10.1186/s13058-017-0913-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/07/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Thymidine kinase 1 (TK1) is a cell cycle-regulated enzyme with peak expression in the S phase during DNA synthesis, and it is an attractive biomarker of cell proliferation. Serum TK1 activity has demonstrated prognostic value in patients with early-stage breast cancer. Because cyclin-dependent kinase 4/6 (CDK4/6) inhibitors prevent G1/S transition, we hypothesized that serum TK1 could be a biomarker for CDK4/6 inhibitors. We examined the drug-induced change in serum TK1 as well as its correlation with change in tumor Ki-67 levels in patients enrolled in the NeoPalAna trial (ClinicalTrials.gov identifier NCT01723774). METHODS Patients with clinical stage II/III estrogen receptor-positive (ER+)/HER2-negative breast cancer enrolled in the NeoPalAna trial received an initial 4 weeks of anastrozole, followed by palbociclib on cycle 1, day 1 (C1D1) for four 28-day cycles, unless C1D15 tumor Ki-67 was > 10%, in which case patients went off study owing to inadequate response. Surgery occurred following 3-5 weeks of washout from the last dose of palbociclib, except in eight patients who received palbociclib (cycle 5) continuously until surgery. Serum TK1 activity was determined at baseline, C1D1, C1D15, and time of surgery, and we found that it was correlated with tumor Ki-67 and TK1 messenger RNA (mRNA) levels. RESULTS Despite a significant drop in tumor Ki-67 with anastrozole monotherapy, there was no statistically significant change in TK1 activity. However, a striking reduction in TK1 activity was observed 2 weeks after initiation of palbociclib (C1D15), which then rose significantly with palbociclib washout. At C1D15, TK1 activity was below the detection limit (<20 DiviTum units per liter Du/L) in 92% of patients, indicating a profound effect of palbociclib. There was high concordance, at 89.8% (95% CI: 79.2% - 96.2%), between changes in serum TK1 and tumor Ki-67 in the same direction from C1D1 to C1D15 and from C1D15 to surgery time points. The sensitivity and specificity for the tumor Ki-67-based response by palbociclib-induced decrease in serum TK1 were 94.1% (95% CI 86.2% - 100%) and 84% (95% CI 69.6% -98.4%), respectively. The κ-statistic was 0.76 (p < 0.001) between TK1 and Ki-67, indicating substantial agreement. CONCLUSIONS Serum TK1 activity is a promising pharmacodynamic marker of palbociclib in ER+ breast cancer, and its value in predicting response to CDK4/6 inhibitors warrants further investigation. TRIAL REGISTRATION ClinicalTrials.gov, NCT01723774. Registered on 6 November 2012.
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Affiliation(s)
- Nusayba Bagegni
- Division of Oncology, Section of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Shana Thomas
- Division of Oncology, Section of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Ning Liu
- Division of Oncology, Section of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Jingqin Luo
- Division of Oncology, Section of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Jeremy Hoog
- Division of Oncology, Section of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | | | | | - Andres Forero
- University of Alabama at Birmingham, Birmingham, AL, 35294, USA
| | | | | | | | | | - Zhanfang Guo
- Division of Oncology, Section of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Kiran Vij
- Division of Oncology, Section of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Souzan Sanati
- Division of Oncology, Section of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | | | - Cynthia X Ma
- Division of Oncology, Section of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA.
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12
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Gao F, Philip Miller J, Xiong C, Luo J, Beiser JA, Chen L, Gordon MO. Estimating correlation between multivariate longitudinal data in the presence of heterogeneity. BMC Med Res Methodol 2017; 17:124. [PMID: 28818061 PMCID: PMC5561646 DOI: 10.1186/s12874-017-0398-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 08/02/2017] [Indexed: 11/24/2022] Open
Abstract
Background Estimating correlation coefficients among outcomes is one of the most important analytical tasks in epidemiological and clinical research. Availability of multivariate longitudinal data presents a unique opportunity to assess joint evolution of outcomes over time. Bivariate linear mixed model (BLMM) provides a versatile tool with regard to assessing correlation. However, BLMMs often assume that all individuals are drawn from a single homogenous population where the individual trajectories are distributed smoothly around population average. Methods Using longitudinal mean deviation (MD) and visual acuity (VA) from the Ocular Hypertension Treatment Study (OHTS), we demonstrated strategies to better understand the correlation between multivariate longitudinal data in the presence of potential heterogeneity. Conditional correlation (i.e., marginal correlation given random effects) was calculated to describe how the association between longitudinal outcomes evolved over time within specific subpopulation. The impact of heterogeneity on correlation was also assessed by simulated data. Results There was a significant positive correlation in both random intercepts (ρ = 0.278, 95% CI: 0.121–0.420) and random slopes (ρ = 0.579, 95% CI: 0.349–0.810) between longitudinal MD and VA, and the strength of correlation constantly increased over time. However, conditional correlation and simulation studies revealed that the correlation was induced primarily by participants with rapid deteriorating MD who only accounted for a small fraction of total samples. Conclusion Conditional correlation given random effects provides a robust estimate to describe the correlation between multivariate longitudinal data in the presence of unobserved heterogeneity (NCT00000125).
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Affiliation(s)
- Feng Gao
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA. .,Division of Biostatistics, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.
| | - J Philip Miller
- Division of Biostatistics, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Chengjie Xiong
- Division of Biostatistics, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Jingqin Luo
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.,Division of Biostatistics, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Julia A Beiser
- Department of Ophthalmology & Visual Sciences, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Ling Chen
- Division of Biostatistics, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Mae O Gordon
- Division of Biostatistics, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.,Department of Ophthalmology & Visual Sciences, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
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