Reference interval estimation of small sample sizes: A methodologic comparison using a computer-simulation study

Randomized, crossover trial: comparing the effects of standardized egg-white meal and Vital® on global gastric emptying parameters and intragastric meal distribution in healthy Asian participants

BACKGROUND AND AIM

Measurements of gastric emptying and accommodation for alternative test-meal protocol during gastric emptying scintigraphy (GES), such as high-calorie nutrient drinks, are not fully established. We aimed to compare the effects of standardized egg-white meal (EWM) versus high-calorie nutrient drink (Vital®; Abbott Laboratories) on global GES parameters and intragastric meal distribution at immediate scan (IMD0h).

METHODS

Of 84 screened participants, 60 asymptomatic healthy Asian population (38 females; 24.0 ± 1.5 years; 23.8 ± 2.6 kg/m2) were recruited in this 2 × 2 (AB/BA) crossover trial. Participants were randomized to a 4-h GES with 99mTc-radiolabeled EWM (~255.8 kcal), followed by a 200 mL Vital® (300 kcal), or vice versa, separated by a 2-week washout period. Global meal retention (GMR), power-exponential model emptying parameters (half-emptying [T1/2], lag phases [Tlag2%, Tlag5%, Tlag10%]), and IMD0h were determined and compared.

RESULTS

GMRs for both test meals were within the international standard references for solid GES. Compared to EWM, Vital® exhibited significantly lower GMRs (faster emptying) from 0.5 to 3 h (all P < 0.001) but comparable at 4 h (P = 0.153). Similar observations were found for the model-based T1/2 and the different Tlag thresholds (all P < 0.001). Furthermore, IMD0h was found to be lower with Vital®, indicating lower gastric accommodation (faster antral filling) immediately post-ingestion (P < 0.001). Both test meals showed significant moderate-to-strong positive associations at the late-phase GE (GMR 2-4 h, T1/2) (all P < 0.05).

CONCLUSIONS

Overall, Vital® is an acceptable alternative test meal to the EWM for GES; however, exercise caution when interpreting early-phase GE. The normative values for global GES parameters and IMD0h are also established.

Establishing hematologic and biochemical reference intervals for the endangered Lear's macaw (Anodorhynchus leari)

BACKGROUND

The Lear's macaw, Anodorhynchus leari (Psittaciformes, Psittacidae), is an endemic species of the Caatinga region in Brazil. With only a few free-living individuals that are constantly under threat from agricultural clearance, hunting, and trapping, A. leari is classified as "endangered" by the Red Book of Endangered Brazilian Fauna and by the International Union for Conservation of Nature. At the same time, the number of individuals in captivity has been growing due to the efforts of biologists and veterinarians in zoological parks to reproduce this species. Thus, having species-specific reference intervals for hematologic and biochemical measurands is essential to assess the health status of these captive and wild birds and guarantee their reproductive success.

OBJECTIVES

This study aimed to determine reference intervals for hematologic and biochemical measurands for A. leari kept in captivity in São Paulo Zoo, Brazil.

METHODS

Blood samples from 32 individuals were selected based on inclusion and exclusion criteria. Only samples from adults and healthy individuals were included in this study. All statistical analyses were performed according to the American Society for Veterinary Clinical Pathology guidelines and available literature.

RESULTS

Reference values and reference intervals were determined for the captive population of Anodorhynchus leari.

CONCLUSIONS

This is the first study to establish reference intervals for A. leari, which can aid the veterinarian in the interpretation of laboratory test results, helping in the diagnosis, treatment, and monitoring of diseases of this endangered species of Brazilian fauna.

Exploring the Quantitative Assessment of Spatial Risk in Response to Major Epidemic Disasters in Megacities: A Case Study of Qingdao

With the global spread of various human-to-human epidemics, public health issues have become a focus of attention. Therefore, it is of great importance to improve the quantitative risk assessment of the construction of resilient cities in terms of epidemic disasters. Starting with the dimensions of social activities and material space, this paper took Qingdao, China, with a population of 5 million, as an example, and took its seven municipal districts as the research scope. In this paper, five risk factors, including the Population density index, Night light index, Closeness index of roads, Betweenness index of roads and Functional mixed nuclear density index were selected for weighted superposition analysis. We conducted a quantitative assessment of the spatial risk of epidemic disaster so as to obtain the classification and spatial structure of the epidemic disaster risk intensity. The results show that: ① The roads with a large traffic flow are most likely to lead to the risk of urban spatial agglomeration, and the areas with a large population density and large mixture of infrastructure functions are also important factors causing the risk of epidemic agglomeration. ② The analysis results regarding the population, commerce, public services, transportation, residence, industry, green space and other functional places can reflect the high-risk areas for epidemic diseases with different natures of transmission. ③ The risk intensity of epidemic disasters is divided into five risk grade areas. Among them, the spatial structure of epidemic disasters, composed of the first-level risk areas, is characterized by "one main area, four secondary areas, one belt and multiple points" and has the characteristics of spatial diffusion. ④ Catering, shopping, life services, hospitals, schools and transportation functional places are more likely to cause crowd gathering. The management of these places should be focused on prevention and control. At the same time, medical facilities should be established at fixed points in all high-risk areas to ensure the full coverage of services. In general, the quantitative assessment of the spatial risk of major epidemic disasters improves the disaster risk assessment system in the construction of resilient cities. It also focuses on risk assessment for public health events. It is helpful to accurately locate the agglomeration risk areas and epidemic transmission paths that are prone to outbreak or cause epidemic transmission in cities so as to assist the relevant practitioners in containing the epidemic from the initial stage of transmission in a timely manner and prevent the further spread of the epidemic.

Markers of inflammation in free-living African elephants (Loxodonta africana): Reference intervals and diagnostic performance of acute phase reactants

INTRODUCTION

Acute phase reactants (APRs) have not been investigated in free-living African elephants (Loxodonta africana), and there is little information about negative APRs albumin and serum iron in elephants.

OBJECTIVES

We aimed to generate reference intervals (RIs) for APRs for free-living African elephants, and to determine the diagnostic performance of APRs in apparently healthy elephants and elephants with inflammatory lesions.

METHODS

Stored serum samples from 49 apparently healthy and 16 injured free-living elephants were used. The following APRs and methods were included: albumin, bromocresol green; haptoglobin, colorimetric assay; serum amyloid A (SAA), multispecies immunoturbidometric assay, and serum iron with ferrozine method. Reference intervals were generated using the nonparametric method. Indices of diagnostic accuracy were determined by receiver-operator characteristic (ROC) curve analysis.

RESULTS

Reference intervals were: albumin 41-55 g/L, haptoglobin 0.16-3.51 g/L, SAA < 10 mg/L, and serum iron 8.60-16.99 μmol/L. Serum iron and albumin concentrations were lower and haptoglobin and SAA concentrations were higher in the injured group. Serum iron had the best ability to predict health or inflammation, followed by haptoglobin, SAA, and albumin, with the area under the ROC curve ranging from 0.88-0.93.

CONCLUSIONS

SAA concentrations were lower in healthy African vs Asian elephants, and species-specific RIs should be used. Serum iron was determined to be a diagnostically useful negative APR which should be added to APR panels for elephants.

An innovative approach based on real-world big data mining for calculating the sample size of the reference interval established using transformed parametric and non-parametric methods

Background

Currently, the direct method is the main approach for establishment of reference interval (RI). However, only a handful of studies have described the effects of sample size on establishment of RI and estimation of sample size. We describe a novel approach for estimation of the sample size when establishing RIs using the transformed parametric and non-parametric methods.

Methods

A total of 3,697 healthy participants were enrolled in this study. We adopted a two-layer nested loop sample size estimation method to determine the effects of sample size on RI, using thyroid-related hormone as an example. The sample size was selected as the calculation result when the width of the confidence interval (CI) of the upper and lower limit of the RI were both stably < 0.2 times the width of RI. Then, we calculated the sample size for establishing RIs via transformed parametric and non-parametric methods for thyroid-related hormones.

Results

Sample sizes for thyroid stimulating hormone (TSH), as required by parametric and non-parametric methods to establish RIs were 239 and 850, respectively. Sample sizes required by the transformed parametric method for free triiodothyronine (FT3), free thyroxine (FT4), total triiodothyronine (TT3) and total thyroxine (TT4) were all less than 120, while those required by the non-parametric method were more than 120.

Conclusion

We describe a novel approach for estimating sample sizes for establishment of RI. A corresponding open-source code has been developed and is available for applications. The established method is suitable for most analytes, with evidence based on thyroid-related hormones indicating that different sample sizes are required to establish RIs using different methods for analytes with different variations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01751-1.

Preoperative MRI for postoperative seizure prediction: a radiomics study of dysembryoplastic neuroepithelial tumor and a systematic review

OBJECTIVE

In this systematic review the authors aimed to evaluate the effectiveness and superiority of radiomics in detecting tiny epilepsy lesions and to conduct original research in the use of radiomics for preliminary prediction of postoperative seizures in patients with dysembryoplastic neuroepithelial tumor (DNET).

METHODS

The PubMed and Web of Science databases were searched from the earliest record, January 1, 2018, to December 29, 2021, for reports of the detection of epilepsy using radiomics, and the resulting articles were carefully checked according to the PRISMA 2020 guidelines. The authors then conducted original research by evaluating MR images in 18 patients, who were then separated into two groups, the epilepsy recurrence group (ERG) and the epilepsy nonrecurrence group. The tumor region and the edema region were segmented manually by 3D Slicer. The radiomics data were extracted from MR images by using “Slicer Radiomics” running on Mac OS X. Tumor regions were observed with T1-weighted imaging, and edema with FLAIR imaging. Radiomics features with significant differences were selected through comparison according to epilepsy relapses performed with the Mann-Whitney U-test. The edema and tumor regions were also compared within groups to identify their distinctive features. Radiomics features were tested to verify their ability to predict recurrence epilepsy by receiver operating characteristic curve.

RESULTS

This systematic review located 9 original articles related to epilepsy and radiomics published from 2018 to 2021. The reported studies demonstrated that radiomics is useful for detecting tiny epilepsy lesions. Among the radiomics features used, the predictive ability of the area under the curve was more than 0.8. The heterogeneity of the peritumoral edema region was found to be higher in the ERG.

CONCLUSIONS

Satellite lesions in the peritumoral edema region of DNET patients may cause epilepsy recurrence, and radiomics is an emerging method to detect and evaluate these epilepsy-associated lesions.

Prospective evaluation of 5 urinary biomarkers as predictors of acute kidney injury in nonazotemic, hospitalized dogs

BACKGROUND

Early recognition of acute kidney injury (AKI) is hindered by current definitions and use of traditional, insensitive markers.

HYPOTHESIS/OBJECTIVES

Urinary (u) activity of γ-glutamyl transpeptidase (GGT) and alkaline phosphatase (ALP), and concentrations of heat-shock protein 70 (HSP70) and interleukins (ILs) -6 and -18, are predictive biomarkers for AKI and survival.

ANIMALS

Nonazotemic, hospitalized dogs (n = 118) and healthy controls (n = 20).

METHODS

A prospective observational study. Nonazotemic dogs at risk of AKI were recruited and their urinary biomarker concentrations were measured at presentation. Serum creatinine (sCr) and symmetric dimethylarginine (sSDMA) were measured daily until discharge/death.

RESULTS

The overall case fatality rate was 18.6%. Fifteen dogs (12.7%) developed AKI, which was associated with death (relative risk, 3.2; 95% confidence interval [CI], 1.57-6.55). All 5 urinary biomarkers were significantly higher in hospitalized dogs compared to controls, with minimal overlap. uHSP70/uCr, uGGT/uCr, and uIL-6/uCr at presentation were higher in dogs which later developed AKI. Areas under the receiver operator characteristic curve (AUROC) (95% CI) for the 3 biomarkers as predictors of AKI were 0.67 (0.51-0.83), 0.68 (0.55-0.81), and 0.78 (0.65-0.91), respectively. When they were categorically classified as elevated/normal, each additional elevated biomarker increased the odds for AKI (OR, 2.83; 95% CI, 1.23-6.52, P = .01). Agreement between sCr and sSDMA was poor (Cohen's kappa = .071). The AUROC of SDMA at presentation for AKI prediction was 0.73 (0.51-0.95).

CONCLUSIONS AND CLINICAL IMPORTANCE

Kidney injury was common, irrespective of subsequent worsening of azotemia or death. The predictive value of individual urinary biomarkers was reduced by moderate sensitivities and specificities. SDMA showed moderate discriminatory utility for AKI prediction, and often displayed discordant results with sCr.

Subjective assessment of frequency distribution histograms and consequences on reference interval accuracy for small sample sizes: A computer-simulated study

BACKGROUND

Inaccuracy in estimating reference intervals (RIs) is a problem with small sample sizes.

OBJECTIVES

This study aimed to identify the most accurate statistical methods to estimate RIs based on sample size and population distribution shape. We also studied the accuracy of sample frequency distribution histograms to retrieve the original population distribution and compared strategies based on the histogram and goodness-of-fit test.

METHODS

The statistical methods that best enhanced accuracy were determined for various sample sizes (n = 20-60) and population distributions (Gaussian, log-normal, and left-skewed) were determined by repeated-measures ANOVA and posthoc analyses. Frequency distribution histograms were built from 900 samples of five different sizes randomly extracted from six simulated populations. Three reviewers classified the population distributions from visual assessments of a sample histogram, and the classification error rate was calculated. RI accuracy was compared among the strategies based on the histograms and goodness-of-fit tests.

RESULTS

The parametric, nonparametric, and robust methods enhanced lower reference limit estimation accuracy for Gaussian, log-normal, and left-skewed distributions, respectively. The parametric, nonparametric bootstrap, and nonparametric methods enhanced the upper limit estimation accuracy for Gaussian, log-normal, and left-skewed distributions, respectively. Regardless of sample size, sample histogram assessments properly classified the original population distribution 71% to 93.9% of the time, depending on the reviewers. In this study, the strategy based on histograms assessed by the statistician was significantly more precise and accurate than the strategy based on the goodness-of-fit test (P < 0.001).

CONCLUSIONS

A strategy based on histograms might enhance the accuracy of RI estimations. However, relevant inter-reviewer variations in histogram interpretation were detected. Factors affecting inter-reviewer variations should be further explored.

Hematologic and biochemical reference intervals and blood cell morphology in South American pit vipers (Bothrops pubescens)

BACKGROUND

The maintenance of snakes in captivity for venom extraction and antivenom production is essential due to the high incidence of snake envenomation in Latin America and the Caribbean. Hematology and biochemistry are valuable in the laboratory evaluation of these animals, which indirectly improves their health and welfare.

OBJECTIVES

The objective of this study was to determine the reference intervals for hematologic and plasma biochemistry variables in Bothrops pubescens snakes kept in captivity and to examine sex variation.

METHODS

Blood samples from 20 healthy B pubescens snakes were collected for hematologic and biochemistry evaluations and compared between sexes. The sample analysis consisted of a complete blood count using manual methods previously described, and blood cell morphology evaluation. Plasma biochemistry consisted of albumin, uric acid, aspartate aminotransferase, creatine kinase, and total plasma protein measurements.

RESULTS

Hematologic and biochemical variables were demonstrated to be different when compared with previously published values. A difference between the sexes was not observed for B pubescens.

CONCLUSIONS

Given that many illnesses can lead to laboratory alterations, knowledge about the reference intervals of healthy captive animals is essential to evaluate the health status and correct management of these snakes.

Reference Intervals for Selected Hematology and Clinical Chemistry Measurands in Temminck's Pangolin (Smutsia temminckii)

Pangolins are the world's most trafficked non-human mammals. A significant number of Temminck's pangolins (Smutsia temminckii) are presented for veterinary care and rehabilitation in southern Africa. Little is known about the physiology and normal health of this species, making diagnosis and medical management difficult. This study aimed to establish reference intervals (RIs) for hematology and plasma clinical chemistry in the Temminck's pangolin. RIs were generated according to international guidelines using samples from 27 healthy free-living (n = 18) and rehabilitated (n = 9) pangolins. Hematology was performed using the Abaxis VetScan HM5 analyzer with manual differentials; clinical chemistry was performed using heparin plasma on the Abaxis VetScan VS2 and Cobas Integra 400 Plus analyzers. Hematology RIs were: RBC 3.88-8.31 × 10¹²/L, HGB 73-150 g/L, HCT 26-51%, MCV 59-72 fL, MCH 15.6-21.4 pg, MCHC 257-325 g/L, RDW 14.3-19.1%, WBC 1.80-10.71 × 10⁹/L. Vetscan VS2 clinical chemistry RIs were: albumin 27-41 g/L, ALP 26-100 U/L, ALT 25-307 U/L, amylase 267-826 U/L, bilirubin 4-10 μmol/L, calcium 2.1-2.2 mmol/L, globulin 21-55 g/L, glucose 3.8-10.0 mmol/L, phosphate 1.3-2.6 mmol/L, potassium 3.6-5.9 mmol/L, sodium 132-140 mmol/L total protein 52-84 g/L, and urea 5.3-11.4 mmol/L. RIs for creatinine were not calculated as analytical imprecision exceeded analytical performance goals. Cobas Integra clinical chemistry RIs were: albumin 22-33 g/L, ALP 20-104 U/L, ALT 17-291 U/L, amylase 466-1,533 U/L, bilirubin 1-14 μmol/L, calcium 2.0-2.4 mmol/L, creatinine <58 μmol/L, globulin 23-49 g/L, glucose 3.6-10.1 mmol/L, phosphate 1.0-2.2 mmol/L, potassium 3.1-5.8 mmol/L, sodium 137-150 mmol/L, total protein 47-72 g/L, and urea 6.0-12.5 mmol/L. There was significant bias between the two chemistry analyzers for several measurands. Differences were found for some analytes between free-living and rehabilitated animals, probably reflecting differences in nutrition and hydration. These are the first RIs generated for Temminck's pangolin. These results will allow veterinarians to better determine pangolin health status, formulate optimal treatment plans and increase patient survival rates in this endangered species.

Serum iPTH range in a reference population: From an integrated approach to vitamin D prevalence impact evaluation

BACKGROUND

The iPTH upper reference limit (URL) reported by our laboratory provider (Abbott Laboratories) at Tor Vergata University Hospital was evaluated by internal verification procedures as not representative of our population and resulting as underestimated. In this study, a new reference interval has been investigated and established by comparing a direct and an indirect method based on a statistical reduction from results stored in the laboratory database.

METHODS

For reference interval calculation from the healthy population, we analyzed a cohort of 100 blood donors (84% males and 16% females) screened with no bone-related and malabsorption diseases. We analyzed a cohort of 495 patients retrieved from more than 800 iPTH results by excluding subjects with pathological measurement for calcium, phosphorus, and creatinine for the reference interval evaluation. Patients with vitamin D results were included in the analysis. Vitamin D sufficiency status during the period from January to September 2020 was also evaluated by investigating 3,050 patients.

RESULTS

The iPTH reference interval of a healthy blood donor population was measured as 25.2-109.1 pg/mL (2.7-11.6 pmol/L) at 2.5 and 97.5 distribution percentile. The iPTH reference interval from data stored in the laboratory database was 19.3-112.5 pg/mL (2.0-11.9 pmol/L). Furthermore, 60% of the whole population had prevalently insufficient vitamin D concentration (<30 ng/dL; <75 nmol/L). The impact of vitamin D concentration on the iPTH reference interval was measured for insufficient vitamin D (<30 ng/dL; <75 nmol/L) as 15.2-127.7 pg/mL (1.6-13.5 pmol/L), desirable vitamin D (30-40 ng/ml; 75-100 nmol/L) as 25.6-105 pg/mL (2.7-10.7 pmol/L) and optimal vitamin D (>40 ng/ml; >100 nmol/L) as 26.2-89.2 pg/mL (2.8-9.4 pmol/L), respectively.

CONCLUSIONS

The URL reported in manufacturer datasheets likely refers to a normal population with non-pathological vitamin D levels. On the contrary, the considered population was mostly vitamin D insufficient, resulting in a URL shift. On this basis, we suggest describing in medical reports the iPTH range for vitamin D deficiency for diagnosis of primary hyperparathyroidism even when a specific vitamin D request is lacking. On the other hand, reporting optimal vitamin D-based iPTH reference interval could be clinically relevant in supplemented patients as a marker of treatment efficacy.

Reference Intervals for Hematology and Clinical Chemistry for the African Elephant (Loxodonta africana)

The African elephant (Loxodonta africana) is listed as vulnerable, with wild populations threatened by habitat loss and poaching. Clinical pathology is used to detect and monitor disease and injury, however existing reference interval (RI) studies for this species have been performed with outdated analytical methods, small sample sizes or using only managed animals. The aim of this study was to generate hematology and clinical chemistry RIs, using samples from the free-ranging elephant population in the Kruger National Park, South Africa. Hematology RIs were derived from EDTA whole blood samples automatically analyzed (n = 23); manual PCV measured from 48 samples; and differential cell count results (n = 51) were included. Clinical chemistry RIs were generated from the results of automated analyzers on stored serum samples (n = 50). Reference intervals were generated according to American Society for Veterinary Clinical Pathology guidelines with a strict exclusion of outliers. Hematology RIs were: PCV 34–49%, RBC 2.80–3.96 × 10¹²/L, HGB 116–163 g/L, MCV 112–134 fL, MCH 35.5–45.2 pg, MCHC 314–364 g/L, PLT 182–386 × 10⁹/L, WBC 7.5–15.2 × 10⁹/L, segmented heterophils 1.5–4.0 × 10⁹/L, band heterophils 0.0–0.2 × 10⁹/L, total monocytes 3.6–7.6 × 10⁹/L (means for “regular” were 35.2%, bilobed 8.6%, round 3.9% of total leukocytes), lymphocytes 1.1–5.5 × 10⁹/L, eosinophils 0.0–0.9 × 10⁹/L, basophils 0.0–0.1 × 10⁹/L. Clinical chemistry RIs were: albumin 41–55 g/L, ALP 30–122 U/L, AST 9–34 U/L, calcium 2.56–3.02 mmol/L, CK 85–322 U/L, GGT 7–16 U/L, globulin 30–59 g/L, magnesium 1.15–1.70 mmol/L, phosphorus 1.28–2.31 mmol/L, total protein 77–109 g/L, urea 1.2–4.6 mmol/L. Reference intervals were narrower than those reported in other studies. These RI will be helpful in the future management of injured or diseased elephants in national parks and zoological settings.

Characterizing the Urban Mine—Simulation-Based Optimization of Sampling Approaches for Built-in Batteries in WEEE

Comprehensive knowledge of built-in batteries in waste electrical and electronic equipment (WEEE) is required for sound and save WEEE management. However, representative sampling is challenging due to the constantly changing composition of WEEE flows and battery systems. Necessary knowledge, such as methodologically uniform procedures and recommendations for the determination of minimum sample sizes (MSS) for representative results, is missing. The direct consequences are increased sampling efforts, lack of quality-assured data, gaps in the monitoring of battery losses in complementary flows, and impeded quality control of depollution during WEEE treatment. In this study, we provide detailed data sets on built-in batteries in WEEE and propose a non-parametric approach (NPA) to determine MSS. For the pilot dataset, more than 23 Mg WEEE (6500 devices) were sampled, examined for built-in batteries, and classified according to product-specific keys (UNUkeys and BATTkeys). The results show that 21% of the devices had battery compartments, distributed over almost all UNUkeys considered and that only about every third battery was removed prior to treatment. Moreover, the characterization of battery masses (BM) and battery mass shares (BMS) using descriptive statistical analysis showed that neither product- nor battery-specific characteristics are given and that the assumption of (log-)normally distributed data is not generally applicable. Consequently, parametric approaches (PA) to determine the MSS for representative sampling are prone to be biased. The presented NPA for MSS using data-driven simulation (bootstrapping) shows its applicability despite small sample sizes and inconclusive data distribution. If consistently applied, the method presented can be used to optimize future sampling and thus reduce sampling costs and efforts while increasing data quality.