Multiple imputation for estimating the risk of developing dementia and its impact on survival.

PubMed

Yu, Binbing; Saczynski, Jane S; Launer, Lenore

2010-10-01

Dementia, Alzheimer's disease in particular, is one of the major causes of disability and decreased quality of life among the elderly and a leading obstacle to successful aging. Given the profound impact on public health, much research has focused on the age-specific risk of developing dementia and the impact on survival. Early work has discussed various methods of estimating age-specific incidence of dementia, among which the illness-death model is popular for modeling disease progression. In this article we use multiple imputation to fit multi-state models for survival data with interval censoring and left truncation. This approach allows semi-Markov models in which survival after dementia depends on onset age. Such models can be used to estimate the cumulative risk of developing dementia in the presence of the competing risk of dementia-free death. Simulations are carried out to examine the performance of the proposed method. Data from the Honolulu Asia Aging Study are analyzed to estimate the age-specific and cumulative risks of dementia and to examine the effect of major risk factors on dementia onset and death.

Kaplan-Meier Survival Analysis Overestimates the Risk of Revision Arthroplasty: A Meta-analysis.

PubMed

Lacny, Sarah; Wilson, Todd; Clement, Fiona; Roberts, Derek J; Faris, Peter D; Ghali, William A; Marshall, Deborah A

2015-11-01

Although Kaplan-Meier survival analysis is commonly used to estimate the cumulative incidence of revision after joint arthroplasty, it theoretically overestimates the risk of revision in the presence of competing risks (such as death). Because the magnitude of overestimation is not well documented, the potential associated impact on clinical and policy decision-making remains unknown. We performed a meta-analysis to answer the following questions: (1) To what extent does the Kaplan-Meier method overestimate the cumulative incidence of revision after joint replacement compared with alternative competing-risks methods? (2) Is the extent of overestimation influenced by followup time or rate of competing risks? We searched Ovid MEDLINE, EMBASE, BIOSIS Previews, and Web of Science (1946, 1980, 1980, and 1899, respectively, to October 26, 2013) and included article bibliographies for studies comparing estimated cumulative incidence of revision after hip or knee arthroplasty obtained using both Kaplan-Meier and competing-risks methods. We excluded conference abstracts, unpublished studies, or studies using simulated data sets. Two reviewers independently extracted data and evaluated the quality of reporting of the included studies. Among 1160 abstracts identified, six studies were included in our meta-analysis. The principal reason for the steep attrition (1160 to six) was that the initial search was for studies in any clinical area that compared the cumulative incidence estimated using the Kaplan-Meier versus competing-risks methods for any event (not just the cumulative incidence of hip or knee revision); we did this to minimize the likelihood of missing any relevant studies. We calculated risk ratios (RRs) comparing the cumulative incidence estimated using the Kaplan-Meier method with the competing-risks method for each study and used DerSimonian and Laird random effects models to pool these RRs. Heterogeneity was explored using stratified meta-analyses and

Analyzing semi-competing risks data with missing cause of informative terminal event.

PubMed

Zhou, Renke; Zhu, Hong; Bondy, Melissa; Ning, Jing

2017-02-28

Cancer studies frequently yield multiple event times that correspond to landmarks in disease progression, including non-terminal events (i.e., cancer recurrence) and an informative terminal event (i.e., cancer-related death). Hence, we often observe semi-competing risks data. Work on such data has focused on scenarios in which the cause of the terminal event is known. However, in some circumstances, the information on cause for patients who experience the terminal event is missing; consequently, we are not able to differentiate an informative terminal event from a non-informative terminal event. In this article, we propose a method to handle missing data regarding the cause of an informative terminal event when analyzing the semi-competing risks data. We first consider the nonparametric estimation of the survival function for the terminal event time given missing cause-of-failure data via the expectation-maximization algorithm. We then develop an estimation method for semi-competing risks data with missing cause of the terminal event, under a pre-specified semiparametric copula model. We conduct simulation studies to investigate the performance of the proposed method. We illustrate our methodology using data from a study of early-stage breast cancer. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

[Use of bivariate survival curves for analyzing mortality of heart failure and sudden death in dilated cardiomiopathy].

PubMed

Gregori, Dario; Rosato, Rosalba; Zecchin, Massimo; Di Lenarda, Andrea

2005-01-01

This paper discusses the use of bivariate survival curves estimators within the competing risk framework. Competing risks models are used for the analysis of medical data with more than one cause of death. The case of dilated cardiomiopathy is explored. Bivariate survival curves plot the conjoint mortality processes. The different graphic representation of bivariate survival analysis is the major contribute of this methodology to the competing risks analysis.

A review of methods to estimate cause-specific mortality in presence of competing risks

USGS Publications Warehouse

Heisey, Dennis M.; Patterson, Brent R.

2006-01-01

Estimating cause-specific mortality is often of central importance for understanding the dynamics of wildlife populations. Despite such importance, methodology for estimating and analyzing cause-specific mortality has received little attention in wildlife ecology during the past 20 years. The issue of analyzing cause-specific, mutually exclusive events in time is not unique to wildlife. In fact, this general problem has received substantial attention in human biomedical applications within the context of biostatistical survival analysis. Here, we consider cause-specific mortality from a modern biostatistical perspective. This requires carefully defining what we mean by cause-specific mortality and then providing an appropriate hazard-based representation as a competing risks problem. This leads to the general solution of cause-specific mortality as the cumulative incidence function (CIF). We describe the appropriate generalization of the fully nonparametric staggered-entry Kaplan–Meier survival estimator to cause-specific mortality via the nonparametric CIF estimator (NPCIFE), which in many situations offers an attractive alternative to the Heisey–Fuller estimator. An advantage of the NPCIFE is that it lends itself readily to risk factors analysis with standard software for Cox proportional hazards model. The competing risks–based approach also clarifies issues regarding another intuitive but erroneous "cause-specific mortality" estimator based on the Kaplan–Meier survival estimator and commonly seen in the life sciences literature.

Kaplan-Meier survival analysis overestimates cumulative incidence of health-related events in competing risk settings: a meta-analysis.

PubMed

Lacny, Sarah; Wilson, Todd; Clement, Fiona; Roberts, Derek J; Faris, Peter; Ghali, William A; Marshall, Deborah A

2018-01-01

Kaplan-Meier survival analysis overestimates cumulative incidence in competing risks (CRs) settings. The extent of overestimation (or its clinical significance) has been questioned, and CRs methods are infrequently used. This meta-analysis compares the Kaplan-Meier method to the cumulative incidence function (CIF), a CRs method. We searched MEDLINE, EMBASE, BIOSIS Previews, Web of Science (1992-2016), and article bibliographies for studies estimating cumulative incidence using the Kaplan-Meier method and CIF. For studies with sufficient data, we calculated pooled risk ratios (RRs) comparing Kaplan-Meier and CIF estimates using DerSimonian and Laird random effects models. We performed stratified meta-analyses by clinical area, rate of CRs (CRs/events of interest), and follow-up time. Of 2,192 identified abstracts, we included 77 studies in the systematic review and meta-analyzed 55. The pooled RR demonstrated the Kaplan-Meier estimate was 1.41 [95% confidence interval (CI): 1.36, 1.47] times higher than the CIF. Overestimation was highest among studies with high rates of CRs [RR = 2.36 (95% CI: 1.79, 3.12)], studies related to hepatology [RR = 2.60 (95% CI: 2.12, 3.19)], and obstetrics and gynecology [RR = 1.84 (95% CI: 1.52, 2.23)]. The Kaplan-Meier method overestimated the cumulative incidence across 10 clinical areas. Using CRs methods will ensure accurate results inform clinical and policy decisions. Copyright © 2017 Elsevier Inc. All rights reserved.

Competing risk bias was common in Kaplan-Meier risk estimates published in prominent medical journals.

PubMed

van Walraven, Carl; McAlister, Finlay A

2016-01-01

Risk estimates from Kaplan-Meier curves are well known to medical researchers, reviewers, and editors. In this study, we determined the proportion of Kaplan-Meier analyses published in prominent medical journals that are potentially biased because of competing events ("competing risk bias"). We randomly selected 100 studies that had at least one Kaplan-Meier analysis and were recently published in prominent medical journals. Susceptibility to competing risk bias was determined by examining the outcome and potential competing events. In susceptible studies, bias was quantified using a previously validated prediction model when the number of outcomes and competing events were given. Forty-six studies (46%) contained Kaplan-Meier analyses susceptible to competing risk bias. Sixteen studies (34.8%) susceptible to competing risk cited the number of outcomes and competing events; in six of these studies (6/16, 37.5%), the outcome risk from the Kaplan-Meier estimate (relative to the true risk) was biased upward by 10% or more. Almost half of Kaplan-Meier analyses published in medical journals are susceptible to competing risk bias and may overestimate event risk. This bias was found to be quantitatively important in a third of such studies. Copyright © 2016 Elsevier Inc. All rights reserved.

Multilevel joint competing risk models

NASA Astrophysics Data System (ADS)

Karunarathna, G. H. S.; Sooriyarachchi, M. R.

2017-09-01

Joint modeling approaches are often encountered for different outcomes of competing risk time to event and count in many biomedical and epidemiology studies in the presence of cluster effect. Hospital length of stay (LOS) has been the widely used outcome measure in hospital utilization due to the benchmark measurement for measuring multiple terminations such as discharge, transferred, dead and patients who have not completed the event of interest at the follow up period (censored) during hospitalizations. Competing risk models provide a method of addressing such multiple destinations since classical time to event models yield biased results when there are multiple events. In this study, the concept of joint modeling has been applied to the dengue epidemiology in Sri Lanka, 2006-2008 to assess the relationship between different outcomes of LOS and platelet count of dengue patients with the district cluster effect. Two key approaches have been applied to build up the joint scenario. In the first approach, modeling each competing risk separately using the binary logistic model, treating all other events as censored under the multilevel discrete time to event model, while the platelet counts are assumed to follow a lognormal regression model. The second approach is based on the endogeneity effect in the multilevel competing risks and count model. Model parameters were estimated using maximum likelihood based on the Laplace approximation. Moreover, the study reveals that joint modeling approach yield more precise results compared to fitting two separate univariate models, in terms of AIC (Akaike Information Criterion).

The effect of delayed graft function on graft and patient survival in kidney transplantation: an approach using competing events analysis.

PubMed

Fonseca, Isabel; Teixeira, Laetitia; Malheiro, Jorge; Martins, La Salete; Dias, Leonídio; Castro Henriques, António; Mendonça, Denisa

2015-06-01

In kidney transplantation, the impact of delayed graft function (DGF) on long-term graft and patient survival is controversial. We examined the impact of DGF on graft and recipient survival by accounting for the possibility that death with graft function may act as a competing risk for allograft failure. We used data from 1281 adult primary deceased-donor kidney recipients whose allografts functioned at least 1 year. The probability of graft loss occurrence is overestimated using the complement of Kaplan-Meier estimates (1-KM). Both the cause-specific Cox proportional hazard regression model (standard Cox) and the subdistribution hazard regression model proposed by Fine and Gray showed that DGF was associated with shorter time to graft failure (csHR = 2.0, P = 0.002; sHR = 1.57, P = 0.009), independent of acute rejection (AR) and after adjusting for traditional factors associated with graft failure. Regarding patient survival, DGF was a predictor of patient death using the cause-specific Cox model (csHR = 1.57, P = 0.029) but not using the subdistribution model. The probability of graft loss from competing end points should not be reported with the 1-KM. Application of a regression model for subdistribution hazard showed that, independent of AR, DGF has a detrimental effect on long-term graft survival, but not on patient survival. © 2015 Steunstichting ESOT.

Estimation and comparison of cumulative incidences of biliary self-expandable metallic stent dysfunction accounting for competing risks.

PubMed

Hamada, Tsuyoshi; Nakai, Yousuke; Isayama, Hiroyuki; Togawa, Osamu; Kogure, Hirofumi; Kawakubo, Kazumichi; Tsujino, Takeshi; Sasahira, Naoki; Hirano, Kenji; Yamamoto, Natsuyo; Ito, Yukiko; Sasaki, Takashi; Mizuno, Suguru; Toda, Nobuo; Tada, Minoru; Koike, Kazuhiko

2014-03-01

Self-expandable metallic stent (SEMS) placement is widely carried out for distal malignant biliary obstruction, and survival analysis is used to evaluate the cumulative incidences of SEMS dysfunction (e.g. the Kaplan-Meier [KM] method and the log-rank test). However, these statistical methods might be inappropriate in the presence of 'competing risks' (here, death without SEMS dysfunction), which affects the probability of experiencing the event of interest (SEMS dysfunction); that is, SEMS dysfunction can no longer be observed after death. A competing risk analysis has rarely been done in studies on SEMS. We introduced the concept of a competing risk analysis and illustrated its impact on the evaluation of SEMS outcomes using hypothetical and actual data. Our illustrative study included 476 consecutive patients who underwent SEMS placement for unresectable distal malignant biliary obstruction. A significant difference between cumulative incidences of SEMS dysfunction in male and female patients via theKM method (P = 0.044 by the log-rank test) disappeared after applying a competing risk analysis (P = 0.115 by Gray's test). In contrast, although cumulative incidences of SEMS dysfunction via the KM method were similar with and without chemotherapy (P = 0.647 by the log-rank test), cumulative incidence of SEMS dysfunction in the non-chemotherapy group was shown to be significantly lower (P = 0.031 by Gray's test) in a competing risk analysis. Death as a competing risk event needs to be appropriately considered in estimating a cumulative incidence of SEMS dysfunction, otherwise analytical results may be biased. © 2013 The Authors. Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society.

Advantage of the modified Lunn-McNeil technique over Kalbfleisch-Prentice technique in competing risks

NASA Astrophysics Data System (ADS)

Lukman, Iing; Ibrahim, Noor A.; Daud, Isa B.; Maarof, Fauziah; Hassan, Mohd N.

2002-03-01

Survival analysis algorithm is often applied in the data mining process. Cox regression is one of the survival analysis tools that has been used in many areas, and it can be used to analyze the failure times of aircraft crashed. Another survival analysis tool is the competing risks where we have more than one cause of failure acting simultaneously. Lunn-McNeil analyzed the competing risks in the survival model using Cox regression with censored data. The modified Lunn-McNeil technique is a simplify of the Lunn-McNeil technique. The Kalbfleisch-Prentice technique is involving fitting models separately from each type of failure, treating other failure types as censored. To compare the two techniques, (the modified Lunn-McNeil and Kalbfleisch-Prentice) a simulation study was performed. Samples with various sizes and censoring percentages were generated and fitted using both techniques. The study was conducted by comparing the inference of models, using Root Mean Square Error (RMSE), the power tests, and the Schoenfeld residual analysis. The power tests in this study were likelihood ratio test, Rao-score test, and Wald statistics. The Schoenfeld residual analysis was conducted to check the proportionality of the model through its covariates. The estimated parameters were computed for the cause-specific hazard situation. Results showed that the modified Lunn-McNeil technique was better than the Kalbfleisch-Prentice technique based on the RMSE measurement and Schoenfeld residual analysis. However, the Kalbfleisch-Prentice technique was better than the modified Lunn-McNeil technique based on power tests measurement.

Impact of Competing Risk of Mortality on Association of Weight Loss with Risk of Central Body Fractures in Older Men: A Prospective Cohort Study

PubMed Central

Ensrud, Kristine E.; Harrison, Stephanie L.; Cauley, Jane A.; Langsetmo, Lisa; Schousboe, John T.; Kado, Deborah M.; Gourlay, Margaret L.; Lyons, Jennifer G.; Fredman, Lisa; Napoli, Nicolas; Crandall, Carolyn J.; Lewis, Cora E.; Orwoll, Eric S.; Stefanick, Marcia L.; Cawthon, Peggy M.

2017-01-01

To determine the association of weight loss with risk of clinical fractures at the hip, spine and pelvis (central body fractures [CBF]) in older men with and without accounting for the competing risk of mortality, we used data from 4,523 men (mean age 77.5 years). Weight change between baseline and follow-up (mean 4.5 years between examinations) was categorized as moderate loss (loss ≥10%), mild loss (loss 5% to <10%), stable (<5% change) or gain (gain ≥5%). Participants were contacted every 4 months after the follow-up examination to ascertain vital status (deaths verified by death certificates) and ask about fractures (confirmed by radiographic reports). Absolute probability of CBF by weight change category was estimated using traditional Kaplan-Meier method and cumulative incidence function accounting for competing mortality risk. Risk of CBF by weight change category was determined using conventional Cox proportional hazards regression and subdistribution hazards models with death as a competing risk. During an average of 8 years, 337 men (7.5%) experienced CBF and 1,569 (34.7%) died before experiencing this outcome. Among men with moderate weight loss, CBF probability was 6.8% at 5 years and 16.9% at 10 years using Kaplan-Meier vs. 5.7% at 5 years and 10.2% at 10 years using a competing risk approach. Men with moderate weight loss compared with those with stable weight had a 1.6-fold higher adjusted risk of CBF (HR 1.59, 95% CI 1.06–2.38) using Cox models that was substantially attenuated in models accounting for competing mortality risk and no longer significant (subdistribution HR 1.16, 95% CI 0.77–1.75). Results were similar in analyses substituting hip fracture for CBF. Older men with weight loss who survive are at increased risk of CBF, including hip fracture. However, ignoring the competing mortality risk among men with weight loss substantially overestimates their longterm fracture probability and relative fracture risk. PMID:27739103

The differential associations of preexisting conditions with trauma-related outcomes in the presence of competing risks.

PubMed

Calvo, Richard Yee; Lindsay, Suzanne P; Edland, Steven D; Macera, Caroline A; Wingard, Deborah L; Ohno-Machado, Lucila; Sise, Michael J

2016-03-01

Pre-existing chronic conditions (PECs) pose a unique problem for the care of aging trauma populations. However, the relationships between specific conditions and outcomes after injury are relatively unknown. Evaluation of trauma patients is further complicated by their discharge to care facilities, where mortality risk remains high. Traditional approaches for evaluating in-hospital mortality do not account for the discharge of at-risk patients, which constitutes a competing risk event to death. The objective of this study was to evaluate associations between 40 PECs and two clinical outcomes in the context of competing risks among older trauma patients. This retrospective study evaluated blunt-injured patients aged 55 years and older admitted to a level I trauma centre in 2006-2012. Outcomes were hospital length of stay (HLOS) and in-hospital mortality. Survivors were classified as discharges home or discharges to care facilities. Competing risks regression was used to evaluate each PEC with in-hospital mortality, accounting for discharges to care facilities as competing events. Competing risk estimates were compared to Cox model estimates, for which all survivors to discharge were non-events. Analyses were stratified using injury-based mortality risk at a 50% cutpoint (high versus low). Among 4653 patients, 176 died in-hospital, 3059 were discharged home, and 1418 were discharged to a care facility. Most patients (98%) were classified with a low mortality risk. Only haemophilia and coagulopathy were consistently associated with longer HLOS. In the low-risk subgroup, in-hospital mortality was most strongly associated with liver diseases, haemophilia, and coagulopathy. In the high-risk group, Parkinson's disease, depression, and cancers showed the strongest associations. Accounting for the competing event altered estimates for 12 of 19 significant conditions. Excess mortality among patients expected to survive their injuries may be attributable to complications

Estimating the personal cure rate of cancer patients using population-based grouped cancer survival data.

PubMed

Binbing Yu; Tiwari, Ram C; Feuer, Eric J

2011-06-01

Cancer patients are subject to multiple competing risks of death and may die from causes other than the cancer diagnosed. The probability of not dying from the cancer diagnosed, which is one of the patients' main concerns, is sometimes called the 'personal cure' rate. Two approaches of modelling competing-risk survival data, namely the cause-specific hazards approach and the mixture model approach, have been used to model competing-risk survival data. In this article, we first show the connection and differences between crude cause-specific survival in the presence of other causes and net survival in the absence of other causes. The mixture survival model is extended to population-based grouped survival data to estimate the personal cure rate. Using the colorectal cancer survival data from the Surveillance, Epidemiology and End Results Programme, we estimate the probabilities of dying from colorectal cancer, heart disease, and other causes by age at diagnosis, race and American Joint Committee on Cancer stage.

Impact of Competing Risk of Mortality on Association of Weight Loss With Risk of Central Body Fractures in Older Men: A Prospective Cohort Study.

PubMed

Ensrud, Kristine E; Harrison, Stephanie L; Cauley, Jane A; Langsetmo, Lisa; Schousboe, John T; Kado, Deborah M; Gourlay, Margaret L; Lyons, Jennifer G; Fredman, Lisa; Napoli, Nicolas; Crandall, Carolyn J; Lewis, Cora E; Orwoll, Eric S; Stefanick, Marcia L; Cawthon, Peggy M

2017-03-01

To determine the association of weight loss with risk of clinical fractures at the hip, spine, and pelvis (central body fractures [CBFs]) in older men with and without accounting for the competing risk of mortality, we used data from 4523 men (mean age 77.5 years). Weight change between baseline and follow-up (mean 4.5 years between examinations) was categorized as moderate loss (loss ≥10%), mild loss (loss 5% to <10%), stable (<5% change) or gain (gain ≥5%). Participants were contacted every 4 months after the follow-up examination to ascertain vital status (deaths verified by death certificates) and ask about fractures (confirmed by radiographic reports). Absolute probability of CBF by weight change category was estimated using traditional Kaplan-Meier method and cumulative incidence function accounting for competing mortality risk. Risk of CBF by weight change category was determined using conventional Cox proportional hazards regression and subdistribution hazards models with death as a competing risk. During an average of 8 years, 337 men (7.5%) experienced CBF and 1569 (34.7%) died before experiencing this outcome. Among men with moderate weight loss, CBF probability was 6.8% at 5 years and 16.9% at 10 years using Kaplan-Meier versus 5.7% at 5 years and 10.2% at 10 years using a competing risk approach. Men with moderate weight loss compared with those with stable weight had a 1.6-fold higher adjusted risk of CBF (HR 1.59; 95% CI, 1.06 to 2.38) using Cox models that was substantially attenuated in models accounting for competing mortality risk and no longer significant (subdistribution HR 1.16; 95% CI, 0.77 to 1.75). Results were similar in analyses substituting hip fracture for CBF. Older men with weight loss who survive are at increased risk of CBF, including hip fracture. However, ignoring the competing mortality risk among men with weight loss substantially overestimates their long-term fracture probability and relative fracture risk. © 2016 American

Managing Competing Influences: Risk Acceptance in Operation Rolling Thunder

DTIC Science & Technology

2017-03-12

Managing Competing Influences: Risk Acceptance in Operation Rolling Thunder A Monograph by Major Benjamin C. Williams US Air Force School of...REPORT TYPE Master’s Thesis 3. DATES COVERED (From - To) JUN 2016 – MAY 2017 4. TITLE AND SUBTITLE Managing Competing Influences: Risk Acceptance in...ANSI Std. Z39.18 ii Monograph Approval Page Name of Candidate: Major Benjamin C. Williams, USAF Monograph Title: Managing Competing Influences

Epidemiology of competence: a scoping review to understand the risks and supports to competence of four health professions

PubMed Central

Glover Takahashi, Susan; Nayer, Marla

2017-01-01

Objectives This study examined the risks and supports to competence discussed in the literature related to occupational therapists, pharmacists, physical therapists and physicians, using epidemiology as a conceptual model. Design Articles from a scoping literature review, published from 1975 to 2014 inclusive, were included if they were about a risk or support to the professional or clinical competence of one of four health professions. Descriptive and regression analyses identified potential associations between risks and supports to competence and the location of study, type of health profession, competence life-cycle and the domain(s) of competence (organised around the CanMEDS framework). Results A total of 3572 abstracts were reviewed and 943 articles analysed. Most focused on physicians (n=810, 86.0%) and ‘practice’ (n=642, 68.0%). Fewer articles discussed risks to competence (n=418, 44.3%) than supports (n=750, 79.5%). The top four risks, each discussed in over 15% of articles, were: transitions in practice, being an international graduate, lack of clinical exposure/experience (ie, insufficient volume of procedures or patients) and age. The top two supports (over 35%) were continuing education participation and educational information/programme features. About 60% of all the articles discussed medical expert and about 25% applied to all roles. Articles focusing on residents had a greater probability of reporting on risks. Conclusions Articles about physicians were dominant. The majority of articles were written in the last decade and more discussed supports than risks to competence. An epidemiology-based conceptual model offers a helpful organising framework for exploring and explaining the competence of health professions. PMID:28864686

Socioeconomic disadvantage but not remoteness affects short-term survival in prostate cancer: A population-based study using competing risks.

PubMed

Thomas, Audrey A; Pearce, Alison; Sharp, Linda; Gardiner, Robert Alexander; Chambers, Suzanne; Aitken, Joanne; Molcho, Michal; Baade, Peter

2017-04-01

We examined how sociodemographic, clinical and area-level factors are related to short-term prostate cancer mortality versus mortality from other causes, a crucial distinction for this disease that disproportionately affects men older than 60 years. We applied competing risk survival models to administrative data from the Queensland Cancer Registry (Australia) for men diagnosed with prostate cancer between January 2005 and July 2007, including stratification by Gleason score. The men (n = 7393) in the study cohort had a median follow-up of 5 years 3 months. After adjustment, remoteness and area-level disadvantage were not significantly associated with prostate cancer mortality. However, area-level disadvantage had a significant negative relationship with hazard of death from a cause other than prostate cancer within 7 years; compared with those living in the most advantaged areas, the likelihood of mortality was higher for those in the most disadvantaged (subhazard ratio [SHR] = 1.39; 95% CI, 1.01-1.90; P = 0.041), disadvantaged (SHR = 1.51; 95% CI, 1.14-2.00; P = 0.004), middle (SHR = 1.34; 95% CI, 1.02-1.75; P = 0.034) and advantaged areas (SHR = 1.44; 95% CI, 1.09-1.89; P = 0.009). Those with Gleason score of 7 and higher had a lower hazard of prostate cancer mortality if they were living with a partner, whereas those with lower Gleason scores and living a partner had lower hazards of other-cause mortality. Understanding why men living in more disadvantaged areas have higher risk of non-prostate cancer mortality should be a priority. © 2016 John Wiley & Sons Australia, Ltd.

Attitudes of older adults with serious competing health risks toward their implantable cardioverter-defibrillators: a pilot study.

PubMed

Green, Ariel R; Boyd, Cynthia M; Rickard, John; Gomon, Robert; Leff, Bruce

2015-12-23

In elderly heart failure patients, the survival benefit of implantable cardioverter-defibrillators (ICDs) may be attenuated due to competing health risks, and the risk of adverse outcomes magnified. Our objective was to examine older adults' attitudes towards ICD implantation in the context of competing health risks, exploring the determinants of ICD decision-making among a group of patients who had faced the decision in the past. Telephone survey with a qualitative component. Patients were age ≥70 with single- or dual-chamber ICDs from a single academic cardiac device clinic. Health status was assessed with the Vulnerable Elders Survey (VES-13). Responses to open-ended questions were transcribed verbatim; an "editing analysis" approach was used to extract themes. Forty-four ICD recipients participated (mean age 77.5 years). Nineteen participants (43%) had VES-13 scores ≥3, indicating a 50% likelihood of death or functional decline within 2 years. Twenty-one participants (48%) had received prior ICD shocks. Forty participants (91%) said they would "definitely" choose to get an ICD again in their current health. By and large, patients revealed a strong desire to extend life, expressed complete confidence in the lifesaving capabilities of their ICDs, and did not describe consideration of competing health risks. In this pilot telephone survey with a qualitative component, nearly all older adults with ICDs would still choose to get an ICD despite high short-term risk of death or health deterioration. These findings suggest the need to partner more effectively with patients and families to decide how best to use medical technologies, particularly for older adults with competing risks.

Identifying Factors Associated with Risk Assessment Competencies of Public Health Emergency Responders.

PubMed

Hao, Jiejing; Ren, Jiaojiao; Wu, Qunhong; Hao, Yanhua; Sun, Hong; Ning, Ning; Ding, Ding

2017-06-04

This study aimed to better understand the current situation of risk assessment and identify the factors associated with competence of emergency responders in public health risk assessment. The participants were selected by a multi-stage, stratified cluster sampling method in Heilongjiang Centers for Disease Control and Prevention (CDC). The questionnaires that measured their perceptions on risk assessment competences were administered through the face-to-face survey. A final sample of 1889 staff was obtained. Of this sample, 78.6% of respondents rated their own risk assessment competences as "relatively low", contrasting with 21.4% rated as "relatively high". Most of the respondents (62.7%) did not participate in any risk assessment work. Only 13.7% and 42.7% of respondents reported participating in risk assessment training and were familiar with risk assessment tools. There existed statistical significance between risk assessment-related characteristics of respondents and their self-rated competences scores. Financial support from the government and administrative attention were regarded as the important factors contributing to risk assessment competences of CDC responders. Higher attention should be given to risk assessment training and enhancing the availability of surveillance data. Continuous efforts should be made to remove the financial and technical obstacles to improve the competences of risk assessment for public health emergency responders.

Re-entry survivability and risk

NASA Astrophysics Data System (ADS)

Fudge, Michael L.

1998-11-01

This paper is the culmination of the research effort which was reported on last year while still in-progress. As previously reported, statistical methods for expressing the impact risk posed to space systems in general [and the International Space Station (ISS) in particular] by other resident space objects have been examined. One of the findings of this investigation is that there are legitimate physical modeling reasons for the common statistical expression of the collision risk. A combination of statistical methods and physical modeling is also used to express the impact risk posed by reentering space systems to objects of interest (e.g., people and property) on Earth. One of the largest uncertainties in the expressing of this risk is the estimation of survivable material which survives reentry to impact Earth's surface. This point was demonstrated in dramatic fashion in January 1997 by the impact of an intact expendable launch vehicle (ELV) upper stage near a private residence in the continental United States. Since approximately half of the missions supporting ISS will utilize ELVs, it is appropriate to examine the methods used to estimate the amount and physical characteristics of ELV debris surviving reentry to impact Earth's surface. This report details reentry survivability estimation methodology, including the specific methodology used by ITT Systems' (formerly Kaman Sciences) 'SURVIVE' model. The major change to the model in the last twelve months has been the increase in the fidelity with which upper- atmospheric aerodynamics has been modeled. This has resulted in an adjustment in the factor relating the amount of kinetic energy loss to the amount of heating entering and reentering body, and also validated and removed the necessity for certain empirically-based adjustments made to the theoretical heating expressions. Comparisons between empirical results (observations of objects which have been recovered on Earth after surviving reentry) and SURVIVE

Identifying Factors Associated with Risk Assessment Competencies of Public Health Emergency Responders

PubMed Central

Hao, Jiejing; Ren, Jiaojiao; Wu, Qunhong; Hao, Yanhua; Sun, Hong; Ning, Ning; Ding, Ding

2017-01-01

This study aimed to better understand the current situation of risk assessment and identify the factors associated with competence of emergency responders in public health risk assessment. The participants were selected by a multi-stage, stratified cluster sampling method in Heilongjiang Centers for Disease Control and Prevention (CDC). The questionnaires that measured their perceptions on risk assessment competences were administered through the face-to-face survey. A final sample of 1889 staff was obtained. Of this sample, 78.6% of respondents rated their own risk assessment competences as “relatively low”, contrasting with 21.4% rated as “relatively high”. Most of the respondents (62.7%) did not participate in any risk assessment work. Only 13.7% and 42.7% of respondents reported participating in risk assessment training and were familiar with risk assessment tools. There existed statistical significance between risk assessment-related characteristics of respondents and their self-rated competences scores. Financial support from the government and administrative attention were regarded as the important factors contributing to risk assessment competences of CDC responders. Higher attention should be given to risk assessment training and enhancing the availability of surveillance data. Continuous efforts should be made to remove the financial and technical obstacles to improve the competences of risk assessment for public health emergency responders. PMID:28587226

Competing Risk Analysis for Evaluation of Dalteparin Versus Unfractionated Heparin for Venous Thromboembolism in Medical-Surgical Critically Ill Patients.

PubMed

Li, Guowei; Cook, Deborah J; Levine, Mitchell A H; Guyatt, Gordon; Crowther, Mark; Heels-Ansdell, Diane; Holbrook, Anne; Lamontagne, Francois; Walter, Stephen D; Ferguson, Niall D; Finfer, Simon; Arabi, Yaseen M; Bellomo, Rinaldo; Cooper, D Jamie; Thabane, Lehana

2015-09-01

Failure to recognize the presence of competing risk or to account for it may result in misleading conclusions. We aimed to perform a competing risk analysis to assess the efficacy of the low molecular weight heparin dalteparin versus unfractionated heparin (UFH) in venous thromboembolism (VTE) in medical-surgical critically ill patients, taking death as a competing risk.This was a secondary analysis of a prospective randomized study of the Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT) database. A total of 3746 medical-surgical critically ill patients from 67 intensive care units (ICUs) in 6 countries receiving either subcutaneous UFH 5000 IU twice daily (n = 1873) or dalteparin 5000 IU once daily plus once-daily placebo (n = 1873) were included for analysis.A total of 205 incident proximal leg deep vein thromboses (PLDVT) were reported during follow-up, among which 96 were in the dalteparin group and 109 were in the UFH group. No significant treatment effect of dalteparin on PLDVT compared with UFH was observed in either the competing risk analysis or standard survival analysis (also known as cause-specific analysis) using multivariable models adjusted for APACHE II score, history of VTE, need for vasopressors, and end-stage renal disease: sub-hazard ratio (SHR) = 0.92, 95% confidence interval (CI): 0.70-1.21, P-value = 0.56 for the competing risk analysis; hazard ratio (HR) = 0.92, 95% CI: 0.68-1.23, P-value = 0.57 for cause-specific analysis. Dalteparin was associated with a significant reduction in risk of pulmonary embolism (PE): SHR = 0.54, 95% CI: 0.31-0.94, P-value = 0.02 for the competing risk analysis; HR = 0.51, 95% CI: 0.30-0.88, P-value = 0.01 for the cause-specific analysis. Two additional sensitivity analyses using the treatment variable as a time-dependent covariate and using as-treated and per-protocol approaches demonstrated similar findings.This competing risk analysis yields no

Competing Risk Analysis for Evaluation of Dalteparin Versus Unfractionated Heparin for Venous Thromboembolism in Medical-Surgical Critically Ill Patients

PubMed Central

Li, Guowei; Cook, Deborah J.; Levine, Mitchell A.H.; Guyatt, Gordon; Crowther, Mark; Heels-Ansdell, Diane; Holbrook, Anne; Lamontagne, Francois; Walter, Stephen D.; Ferguson, Niall D.; Finfer, Simon; Arabi, Yaseen M.; Bellomo, Rinaldo; Cooper, D. Jamie; Thabane, Lehana

2015-01-01

Abstract Failure to recognize the presence of competing risk or to account for it may result in misleading conclusions. We aimed to perform a competing risk analysis to assess the efficacy of the low molecular weight heparin dalteparin versus unfractionated heparin (UFH) in venous thromboembolism (VTE) in medical-surgical critically ill patients, taking death as a competing risk. This was a secondary analysis of a prospective randomized study of the Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT) database. A total of 3746 medical-surgical critically ill patients from 67 intensive care units (ICUs) in 6 countries receiving either subcutaneous UFH 5000 IU twice daily (n = 1873) or dalteparin 5000 IU once daily plus once-daily placebo (n = 1873) were included for analysis. A total of 205 incident proximal leg deep vein thromboses (PLDVT) were reported during follow-up, among which 96 were in the dalteparin group and 109 were in the UFH group. No significant treatment effect of dalteparin on PLDVT compared with UFH was observed in either the competing risk analysis or standard survival analysis (also known as cause-specific analysis) using multivariable models adjusted for APACHE II score, history of VTE, need for vasopressors, and end-stage renal disease: sub-hazard ratio (SHR) = 0.92, 95% confidence interval (CI): 0.70–1.21, P-value = 0.56 for the competing risk analysis; hazard ratio (HR) = 0.92, 95% CI: 0.68–1.23, P-value = 0.57 for cause-specific analysis. Dalteparin was associated with a significant reduction in risk of pulmonary embolism (PE): SHR = 0.54, 95% CI: 0.31–0.94, P-value = 0.02 for the competing risk analysis; HR = 0.51, 95% CI: 0.30–0.88, P-value = 0.01 for the cause-specific analysis. Two additional sensitivity analyses using the treatment variable as a time-dependent covariate and using as-treated and per-protocol approaches demonstrated similar findings. This competing risk analysis

Risk factors for unplanned readmissions in older adult trauma patients in Washington State: a competing risk analysis.

PubMed

Fawcett, Vanessa J; Flynn-O'Brien, Katherine T; Shorter, Zeynep; Davidson, Giana H; Bulger, Eileen; Rivara, Frederick P; Arbabi, Saman

2015-03-01

Hospital readmission is a significant contributor to increasing health care use related to caring for older trauma patients. This study was undertaken with the following aims: determine the proportion of older adult trauma patients who experience unplanned readmission, as well as risk factors for these readmissions and identify the most common readmission diagnoses among these patients. We conducted a retrospective cohort study of trauma patients age 55 years and older who survived their hospitalization at a statewide trauma center between 2009 and 2010. Linking 3 statewide databases, nonelective readmission rates were calculated for 30 days, 6 months, and 1 year after index discharge. Competing risk regression was used to determine risk factors for readmission and account for the competing risk of dying without first being readmitted. Subhazard ratios (SHR) are reported, indicating the relative risk of readmission by 30 days, 6 months, and 1 year. The cumulative readmission rates for the 14,536 participants were 7.9%, 18.9%, and 25.2% at 30 days, 6 months, and 1 year, respectively. In multivariable models, the strongest risk factors for readmission at 1 year (based on magnitude of SHR) were severe head injury (adjusted SHR = 1.47; 95% CI, 1.24-1.73) and disposition to a skilled nursing facility (SHR = 1.54; 95% CI, 1.39-1.71). The diagnoses most commonly associated with readmission were atrial fibrillation, anemia, and congestive heart failure. In this statewide study, unplanned readmissions after older adult trauma occurred frequently up to 1 year after discharge, particularly for patients who sustained severe head trauma and who could not be discharged home independently. Examining common readmission diagnoses might inform the development of interventions to prevent unplanned readmissions. Copyright © 2015 American College of Surgeons. All rights reserved.

Media influence on risk competence in self-medication and self-treatment.

PubMed

Schweim, Harald; Ullmann, Marcela

2015-01-01

Media play an important role in the reception of health risks; thus, media competence is important for enhancing the risk competence of patients and consumers. In addition to life-long health education, risk competence particularly requires careful handling of health information because, at present, the key problem is not the lack of sufficient information on health topics but the quality of such information. Patients and consumers of health procedures and health products also require information which relates to their daily life and matches their life style.

After accounting for competing causes of death and more advanced stage, do Aboriginal and Torres Strait Islander peoples with cancer still have worse survival? A population-based cohort study in New South Wales.

PubMed

Tervonen, Hanna E; Walton, Richard; You, Hui; Baker, Deborah; Roder, David; Currow, David; Aranda, Sanchia

2017-06-02

Aboriginal and Torres Strait Islander peoples in Australia have been found to have poorer cancer survival than non-Aboriginal people. However, use of conventional relative survival analyses is limited due to a lack of life tables. This cohort study examined whether poorer survival persist after accounting for competing risks of death from other causes and disparities in cancer stage at diagnosis, for all cancers collectively and by cancer site. People diagnosed in 2000-2008 were extracted from the population-based New South Wales Cancer Registry. Aboriginal status was multiply imputed for people with missing information (12.9%). Logistic regression models were used to compute odds ratios (ORs) with 95% confidence intervals (CIs) for 'advanced stage' at diagnosis (separately for distant and distant/regional stage). Survival was examined using competing risk regression to compute subhazard ratios (SHRs) with 95%CIs. Of the 301,356 cases, 2517 (0.84%) identified as Aboriginal (0.94% after imputation). After adjusting for age, sex, year of diagnosis, socio-economic status, remoteness, and cancer site Aboriginal peoples were more likely to be diagnosed with distant (OR 1.30, 95%CI 1.17-1.44) or distant/regional stage (OR 1.29, 95%CI 1.18-1.40) for all cancers collectively. This applied to cancers of the female breast, uterus, prostate, kidney, others (those not included in other categories) and cervix (when analyses were restricted to cases with known stages/known Aboriginal status). Aboriginal peoples had a higher hazard of death than non-Aboriginal people after accounting for competing risks from other causes of death, socio-demographic factors, stage and cancer site (SHR 1.40, 95%CI 1.31-1.50 for all cancers collectively). Consistent results applied to colorectal, lung, breast, prostate and other cancers. Aboriginal peoples with cancer have an elevated hazard of cancer death compared with non-Aboriginal people, after accounting for more advanced stage and competing

Family cumulative risk and at-risk kindergarteners' social competence: the mediating role of parent representations of the attachment relationship.

PubMed

Sparks, Lauren A; Trentacosta, Christopher J; Owusu, Erika; McLear, Caitlin; Smith-Darden, Joanne

2018-08-01

Secure attachment relationships have been linked to social competence in at-risk children. In the current study, we examined the role of parent secure base scripts in predicting at-risk kindergarteners' social competence. Parent representations of secure attachment were hypothesized to mediate the relationship between lower family cumulative risk and children's social competence. Participants included 106 kindergarteners and their primary caregivers recruited from three urban charter schools serving low-income families as a part of a longitudinal study. Lower levels of cumulative risk predicted greater secure attachment representations in parents, and scores on the secure base script assessment predicted children's social competence. An indirect relationship between lower cumulative risk and kindergarteners' social competence via parent secure base script scores was also supported. Parent script-based representations of the attachment relationship appear to be an important link between lower levels of cumulative risk and low-income kindergarteners' social competence. Implications of these findings for future interventions are discussed.

Media influence on risk competence in self-medication and self-treatment

PubMed Central

Schweim, Harald; Ullmann, Marcela

2015-01-01

Media play an important role in the reception of health risks; thus, media competence is important for enhancing the risk competence of patients and consumers. In addition to life-long health education, risk competence particularly requires careful handling of health information because, at present, the key problem is not the lack of sufficient information on health topics but the quality of such information. Patients and consumers of health procedures and health products also require information which relates to their daily life and matches their life style. PMID:26195923

A review and critique of some models used in competing risk analysis.

PubMed

Gail, M

1975-03-01

We have introduced a notation which allows one to define competing risk models easily and to examine underlying assumptions. We have treated the actuarial model for competing risk in detail, comparing it with other models and giving useful variance formulae both for the case when times of death are available and for the case when they are not. The generality of these methods is illustrated by an example treating two dependent competing risks.

Cardiovascular risk factors predictive for survival and morbidity-free survival in the oldest-old Framingham Heart Study participants.

PubMed

Terry, Dellara F; Pencina, Michael J; Vasan, Ramachandran S; Murabito, Joanne M; Wolf, Philip A; Hayes, Margaret Kelly; Levy, Daniel; D'Agostino, Ralph B; Benjamin, Emelia J

2005-11-01

To examine whether midlife cardiovascular risk factors predict survival and survival free of major comorbidities to the age of 85. Prospective community-based cohort study. Framingham Heart Study, Massachusetts. Two thousand five hundred thirty-one individuals (1,422 women) who attended at least two examinations between the ages of 40 and 50. Risk factors were classified at routine examinations performed between the ages of 40 and 50. Stepwise sex-adjusted logistic regression models predicting the outcomes of survival and survival free of morbidity to age 85 were selected from the following risk factors: systolic and diastolic blood pressure, total serum cholesterol, glucose intolerance, cigarette smoking, education, body mass index, physical activity index, pulse pressure, antihypertensive medication, and electrocardiographic left ventricular hypertrophy. More than one-third of the study sample survived to age 85, and 22% of the original study sample survived free of morbidity. Lower midlife blood pressure and total cholesterol levels, absence of glucose intolerance, nonsmoking status, higher educational attainment, and female sex predicted overall and morbidity-free survival. The predicted probability of survival to age 85 fell in the presence of accumulating risk factors: 37% for men with no risk factors to 2% with all five risk factors and 65% for women with no risk factors to 14% with all five risk factors. Lower levels of key cardiovascular risk factors in middle age predicted overall survival and major morbidity-free survival to age 85. Recognizing and modifying these factors may delay, if not prevent, age-related morbidity and mortality.

Front-line intraperitoneal versus intravenous chemotherapy in stage III-IV epithelial ovarian, tubal, and peritoneal cancer with minimal residual disease: a competing risk analysis.

PubMed

Chang, Yen-Hou; Li, Wai-Hou; Chang, Yi; Peng, Chia-Wen; Cheng, Ching-Hsuan; Chang, Wei-Pin; Chuang, Chi-Mu

2016-03-17

In the analysis of survival data for cancer patients, the problem of competing risks is often ignored. Competing risks have been recognized as a special case of time-to-event analysis. The conventional techniques for time-to-event analysis applied in the presence of competing risks often give biased or uninterpretable results. Using a prospectively collected administrative health care database in a single institution, we identified patients diagnosed with stage III or IV primary epithelial ovarian, tubal, and peritoneal cancers with minimal residual disease after primary cytoreductive surgery between 1995 and 2012. Here, we sought to evaluate whether intraperitoneal chemotherapy outperforms intravenous chemotherapy in the presence of competing risks. Unadjusted and multivariable subdistribution hazards models were applied to this database with two types of competing risks (cancer-specific mortality and other-cause mortality) coded to measure the relative effects of intraperitoneal chemotherapy. A total of 1263 patients were recruited as the initial cohort. After propensity score matching, 381 patients in each arm entered into final competing risk analysis. Cumulative incidence estimates for cancer-specific mortality were statistically significantly lower (p = 0.017, Gray test) in patients receiving intraperitoneal chemotherapy (5-year estimates, 34.5%; 95% confidence interval [CI], 29.5-39.6%, and 10-year estimates, 60.7%; 95% CI, 52.2-68.0%) versus intravenous chemotherapy (5-year estimates, 41.3%; 95% CI, 36.2-46.3%, and 10-year estimates, 67.5%, 95% CI, 61.6-72.7%). In subdistribution hazards analysis, for cancer-specific mortality, intraperitoneal chemotherapy outperforms intravenous chemotherapy (Subdistribution hazard ratio, 0.82; 95% CI, 0.70-0.96) after correcting other covariates. In conclusion, results from this comparative effectiveness study provide supportive evidence for previous published randomized trials that intraperitoneal chemotherapy

Years of life lost due to influenza-attributable mortality in older adults in the Netherlands: a competing risks approach.

PubMed

McDonald, Scott A; van Wijhe, Maarten; van Asten, Liselotte; van der Hoek, Wim; Wallinga, Jacco

2018-02-06

We estimated the influenza mortality burden in adults 60 years of age and older in the Netherlands in terms of years of life lost, taking into account competing mortality risks. Weekly laboratory surveillance data for influenza and other respiratory pathogens and weekly extreme temperature served as covariates in Poisson regression models fitted to weekly age-group specific mortality data for the period 1999/2000 through 2012/13. Burden for age-groups 60-64 through 85-89 years was computed as years of life lost before age 90 (YLL90) using restricted mean lifetimes survival analysis and accounting for competing risks. Influenza-attributable mortality burden was greatest for persons aged 80-84 years, at 914 YLL90 per 100,000 persons (95% uncertainty interval:867, 963), followed by 85-89 years (787 YLL90/100,000; 95% uncertainty interval:741, 834). Ignoring competing mortality risks in the computation of influenza-attributable YLL90 would lead to substantial over-estimation of burden, from 3.5% for 60-64 years to 82% for persons aged 80-89 years at death. Failure to account for competing mortality risks has implications for accuracy of disease burden estimates, especially among persons aged 80 years and older. As the mortality burden borne by the elderly is notably high, prevention initiatives may benefit from being redesigned to more effectively prevent infection in the oldest age-groups. © The Author(s) 2018. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Risky-Play at School. Facilitating Risk Perception and Competence in Young Children

ERIC Educational Resources Information Center

Lavrysen, Ann; Bertrands, Els; Leyssen, Leene; Smets, Lieve; Vanderspikken, Anja; De Graef, Peter

2017-01-01

Recent research indicates that risk competence and perception can be improved through the learning environment. The project "Riscki" examined how risk perception and risk competence in young children between three and eight years of age can be observed and measured within the classroom and school context. An intensive package of…

Accounting for individualized competing mortality risks in estimating postmenopausal breast cancer risk.

PubMed

Schonberg, Mara A; Li, Vicky W; Eliassen, A Heather; Davis, Roger B; LaCroix, Andrea Z; McCarthy, Ellen P; Rosner, Bernard A; Chlebowski, Rowan T; Hankinson, Susan E; Marcantonio, Edward R; Ngo, Long H

2016-12-01

Accurate risk assessment is necessary for decision-making around breast cancer prevention. We aimed to develop a breast cancer prediction model for postmenopausal women that would take into account their individualized competing risk of non-breast cancer death. We included 73,066 women who completed the 2004 Nurses' Health Study (NHS) questionnaire (all ≥57 years) and followed participants until May 2014. We considered 17 breast cancer risk factors (health behaviors, demographics, family history, reproductive factors) and 7 risk factors for non-breast cancer death (comorbidities, functional dependency) and mammography use. We used competing risk regression to identify factors independently associated with breast cancer. We validated the final model by examining calibration (expected-to-observed ratio of breast cancer incidence, E/O) and discrimination (c-statistic) using 74,887 subjects from the Women's Health Initiative Extension Study (WHI-ES; all were ≥55 years and followed for 5 years). Within 5 years, 1.8 % of NHS participants were diagnosed with breast cancer (vs. 2.0 % in WHI-ES, p = 0.02), and 6.6 % experienced non-breast cancer death (vs. 5.2 % in WHI-ES, p < 0.001). Using a model selection procedure which incorporated the Akaike Information Criterion, c-statistic, statistical significance, and clinical judgement, our final model included 9 breast cancer risk factors, 5 comorbidities, functional dependency, and mammography use. The model's c-statistic was 0.61 (95 % CI [0.60-0.63]) in NHS and 0.57 (0.55-0.58) in WHI-ES. On average, our model under predicted breast cancer in WHI-ES (E/O 0.92 [0.88-0.97]). We developed a novel prediction model that factors in postmenopausal women's individualized competing risks of non-breast cancer death when estimating breast cancer risk.

Accounting for individualized competing mortality risks in estimating postmenopausal breast cancer risk

PubMed Central

Schonberg, Mara A.; Li, Vicky W.; Eliassen, A. Heather; Davis, Roger B.; LaCroix, Andrea Z.; McCarthy, Ellen P.; Rosner, Bernard A.; Chlebowski, Rowan T.; Hankinson, Susan E.; Marcantonio, Edward R.; Ngo, Long H.

2016-01-01

Purpose Accurate risk assessment is necessary for decision-making around breast cancer prevention. We aimed to develop a breast cancer prediction model for postmenopausal women that would take into account their individualized competing risk of non-breast cancer death. Methods We included 73,066 women who completed the 2004 Nurses’ Health Study (NHS) questionnaire (all ≥57 years) and followed participants until May 2014. We considered 17 breast cancer risk factors (health behaviors, demographics, family history, reproductive factors), 7 risk factors for non-breast cancer death (comorbidities, functional dependency), and mammography use. We used competing risk regression to identify factors independently associated with breast cancer. We validated the final model by examining calibration (expected-to-observed ratio of breast cancer incidence, E/O) and discrimination (c-statistic) using 74,887 subjects from the Women’s Health Initiative Extension Study (WHI-ES; all were ≥55 years and followed for 5 years). Results Within 5 years, 1.8% of NHS participants were diagnosed with breast cancer (vs. 2.0% in WHI-ES, p=0.02) and 6.6% experienced non-breast cancer death (vs. 5.2% in WHI-ES, p<0.001). Using a model selection procedure which incorporated the Akaike Information Criterion, c-statistic, statistical significance, and clinical judgement, our final model included 9 breast cancer risk factors, 5 comorbidities, functional dependency, and mammography use. The model’s c-statistic was 0.61 (95% CI [0.60–0.63]) in NHS and 0.57 (0.55–0.58) in WHI-ES. On average our model under predicted breast cancer in WHI-ES (E/O 0.92 [0.88–0.97]). Conclusions We developed a novel prediction model that factors in postmenopausal women’s individualized competing risks of non-breast cancer death when estimating breast cancer risk. PMID:27770283

Calibration plots for risk prediction models in the presence of competing risks.

PubMed

Gerds, Thomas A; Andersen, Per K; Kattan, Michael W

2014-08-15

A predicted risk of 17% can be called reliable if it can be expected that the event will occur to about 17 of 100 patients who all received a predicted risk of 17%. Statistical models can predict the absolute risk of an event such as cardiovascular death in the presence of competing risks such as death due to other causes. For personalized medicine and patient counseling, it is necessary to check that the model is calibrated in the sense that it provides reliable predictions for all subjects. There are three often encountered practical problems when the aim is to display or test if a risk prediction model is well calibrated. The first is lack of independent validation data, the second is right censoring, and the third is that when the risk scale is continuous, the estimation problem is as difficult as density estimation. To deal with these problems, we propose to estimate calibration curves for competing risks models based on jackknife pseudo-values that are combined with a nearest neighborhood smoother and a cross-validation approach to deal with all three problems. Copyright © 2014 John Wiley & Sons, Ltd.

Developing points-based risk-scoring systems in the presence of competing risks.

PubMed

Austin, Peter C; Lee, Douglas S; D'Agostino, Ralph B; Fine, Jason P

2016-09-30

Predicting the occurrence of an adverse event over time is an important issue in clinical medicine. Clinical prediction models and associated points-based risk-scoring systems are popular statistical methods for summarizing the relationship between a multivariable set of patient risk factors and the risk of the occurrence of an adverse event. Points-based risk-scoring systems are popular amongst physicians as they permit a rapid assessment of patient risk without the use of computers or other electronic devices. The use of such points-based risk-scoring systems facilitates evidence-based clinical decision making. There is a growing interest in cause-specific mortality and in non-fatal outcomes. However, when considering these types of outcomes, one must account for competing risks whose occurrence precludes the occurrence of the event of interest. We describe how points-based risk-scoring systems can be developed in the presence of competing events. We illustrate the application of these methods by developing risk-scoring systems for predicting cardiovascular mortality in patients hospitalized with acute myocardial infarction. Code in the R statistical programming language is provided for the implementation of the described methods. © 2016 The Authors. Statistics in Medicine published by John Wiley & Sons Ltd. © 2016 The Authors. Statistics in Medicine published by John Wiley & Sons Ltd.

Risks, risk assessment and risk competence in toxicology.

PubMed

Stahlmann, Ralf; Horvath, Aniko

2015-01-01

Understanding the toxic effects of xenobiotics requires sound knowledge of physiology and biochemistry. The often described lack of understanding pharmacology/toxicology is therefore primarily caused by the general absence of the necessary fundamental knowledge. Since toxic effects depend on exposure (or dosage) assessing the risks arising from toxic substances also requires quantitative reasoning. Typically public discussions nearly always neglect quantitative aspects and laypersons tend to disregard dose-effect-relationships. One of the main reasons for such disregard is the fact that exposures often occur at extremely low concentrations that can only be perceived intellectually but not by the human senses. However, thresholds in the low exposure range are often scientifically disputed. At the same time, ignorance towards known dangers is wide-spread. Thus, enhancing the risk competence of laypersons will have to be initially restricted to increasing the awareness of existing problems.

Risk factors affecting survival in heart transplant patients.

PubMed

Almenar, L; Cardo, M L; Martínez-Dolz, L; García-Palomar, C; Rueda, J; Zorio, E; Arnau, M A; Osa, A; Palencia, M

2005-11-01

Certain cardiovascular risk factors have been linked to morbidity and mortality in heart transplant (HT) patients. The sum of various risk factors may have a large cumulative negative effect, leading to a substantially worse prognosis and the need to consider whether HT is contraindicated. The objective of this study was to determine whether the risk factors usually available prior to HT result in an excess mortality in our setting that contraindicates transplantation. Consecutive patients who underwent heart transplantation from November 1987 to January 2004 were included. Heart-lung transplants, retransplants, and pediatric transplants were excluded. Of the 384 patients, 89% were men. Mean age was 52 years (range, 12 to 67). Underlying disease included ischemic heart disease (52%), idiopathic dilated cardiomyopathy (36%), valvular disease (8%), and other (4%). Variables considered risk factors were obesity (BMI >25), dyslipidemia, hypertension, prior thoracic surgery, diabetes, and history of ischemic heart disease. Survival curves by number of risk factors using Kaplan-Meier and log-rank for comparison of curves. Overall patient survival at 1, 5, 10, and 13 years was 76%, 68%, 54%, and 47%, respectively. Survival at 10 years, if fewer than two risk factors were present, was 69%; 59% if two or three factors were present; and 37% if more than three associated risk factors were present (P = .04). The presence of certain risk factors in patients undergoing HT resulted in lower survival rates. The combination of various risk factors clearly worsened outcomes. However, we do not believe this should be an absolute contraindication for transplantation.

Hypertension, Obesity, Diabetes, and Heart Failure-Free Survival: The Cardiovascular Disease Lifetime Risk Pooling Project.

PubMed

Ahmad, Faraz S; Ning, Hongyan; Rich, Jonathan D; Yancy, Clyde W; Lloyd-Jones, Donald M; Wilkins, John T

2016-12-01

This study was designed to quantify the relationship between the absence of heart failure risk factors in middle age and incident heart failure, heart failure-free survival, and overall survival. Quantification of years lived free from heart failure in the context of risk factor burden in mid-life may improve risk communication and prevention efforts. We conducted a pooled, individual-level analysis sampling from communities across the United States as part of 4 cohort studies: the Framingham Heart, Framingham Offspring, Chicago Heart Association Detection Project in Industry, and ARIC (Atherosclerosis Risk In Communities) studies. Participants with and without hypertension (blood pressure ≥140/90 mm Hg or treatment), obesity (body mass index ≥30 kg/m 2 ), or diabetes (fasting glucose ≥126 mg/dl or treatment), and combinations of these factors, at index ages of 45 years and 55 years through 95 years. Competing risk-adjusted Cox models, a modified Kaplan-Meier estimator, and Irwin's restricted mean were used to estimate the association between the absence of risk factors at mid-life and incident heart failure, heart failure-free survival, and overall survival. For participants at age 45 years, over 516,537 person-years of follow-up, 1,677 incident heart failure events occurred. Men and women with no risk factors, compared to those with all 3, had 73% to 85% lower risks of incident heart failure. Men and women without hypertension, obesity, or diabetes at age 45 years lived on average 34.7 years and 38.0 years without incident heart failure, and they lived on average an additional 3 years to 15 years longer free of heart failure than those with 1, 2, or 3 risk factors. Similar trends were seen when stratified by race and at index age 55 years. Prevention of hypertension, obesity, and diabetes by ages 45 years and 55 years may substantially prolong heart failure-free survival, decrease heart failure-related morbidity, and reduce the public health impact of

Embryonic background risk promotes the survival of tadpoles facing surface predators

PubMed Central

Chivers, Douglas P.; Ferrari, Maud C. O.

2018-01-01

Exposure to intense predation risk can induce morphological and behavioural phenotypes that prepare prey, often at young ages, for surviving attacks from unknown predators. However, previous studies revealed that this survival advantage depended on the predator species. Here, we used alarm cues from injured conspecifics to simulate a period of high predation risk for embryonic wood frogs, Lithobates sylvaticus. Two weeks post-hatching, we tested whether the embryonic risk exposure influenced survival in encounters with two novel predators: (1) a spider (Dolomedes sp.) that ambushes prey exclusively on the surface of the water, and (2) the adult predacious diving beetle (Dytiscus sp.) which displays underwater sit-and-wait posture and pursuit tactics. Tadpoles exposed to embryonic high-risk survived longer when encountering spiders, whereas background risk had no influence on survival with adult beetles. These findings, coupled with survival studies involving other predator types, indicate that a high-risk environment promotes tadpole survival in future encounters with unknown sit-and-wait predators, but at the cost of increased vulnerability to novel predators capable of active pursuit. PMID:29561913

Metroticket 2.0 Model for Analysis of Competing Risks of Death After Liver Transplantation for Hepatocellular Carcinoma.

PubMed

Mazzaferro, Vincenzo; Sposito, Carlo; Zhou, Jian; Pinna, Antonio D; De Carlis, Luciano; Fan, Jia; Cescon, Matteo; Di Sandro, Stefano; Yi-Feng, He; Lauterio, Andrea; Bongini, Marco; Cucchetti, Alessandro

2018-01-01

Outcomes of liver transplantation for hepatocellular carcinoma (HCC) are determined by cancer-related and non-related events. Treatments for hepatitis C virus infection have reduced non-cancer events among patients receiving liver transplants, so reducing HCC-related death might be an actionable end point. We performed a competing-risk analysis to evaluate factors associated with survival of patients with HCC and developed a prognostic model based on features of HCC patients before liver transplantation. We performed multivariable competing-risk regression analysis to identify factors associated with HCC-specific death of patients who underwent liver transplantation. The training set comprised 1018 patients who underwent liver transplantation for HCC from January 2000 through December 2013 at 3 tertiary centers in Italy. The validation set comprised 341 consecutive patients who underwent liver transplantation for HCC during the same period at the Liver Cancer Institute in Shanghai, China. We collected pretransplantation data on etiology of liver disease, number and size of tumors, patient level of α-fetoprotein (AFP), model for end-stage liver disease score, tumor stage, numbers and types of treatment, response to treatments, tumor grade, microvascular invasion, dates, and causes of death. Death was defined as HCC-specific when related to HCC recurrence after transplantation, disseminated extra- and/or intrahepatic tumor relapse and worsened liver function in presence of tumor spread. The cumulative incidence of death was segregated for hepatitis C virus status. In the competing-risk regression, the sum of tumor number and size and of log 10 level of AFP were significantly associated with HCC-specific death (P < .001), returning an average c-statistic of 0.780 (95% confidence interval, 0.763-0.798). Five-year cumulative incidence of non-HCC-related death was 8.6% in HCV-negative patients and 18.1% in HCV-positive patients. For patients with HCC to have a 70

Crude incidence in two-phase designs in the presence of competing risks.

PubMed

Rebora, Paola; Antolini, Laura; Glidden, David V; Valsecchi, Maria Grazia

2016-01-11

In many studies, some information might not be available for the whole cohort, some covariates, or even the outcome, might be ascertained in selected subsamples. These studies are part of a broad category termed two-phase studies. Common examples include the nested case-control and the case-cohort designs. For two-phase studies, appropriate weighted survival estimates have been derived; however, no estimator of cumulative incidence accounting for competing events has been proposed. This is relevant in the presence of multiple types of events, where estimation of event type specific quantities are needed for evaluating outcome. We develop a non parametric estimator of the cumulative incidence function of events accounting for possible competing events. It handles a general sampling design by weights derived from the sampling probabilities. The variance is derived from the influence function of the subdistribution hazard. The proposed method shows good performance in simulations. It is applied to estimate the crude incidence of relapse in childhood acute lymphoblastic leukemia in groups defined by a genotype not available for everyone in a cohort of nearly 2000 patients, where death due to toxicity acted as a competing event. In a second example the aim was to estimate engagement in care of a cohort of HIV patients in resource limited setting, where for some patients the outcome itself was missing due to lost to follow-up. A sampling based approach was used to identify outcome in a subsample of lost patients and to obtain a valid estimate of connection to care. A valid estimator for cumulative incidence of events accounting for competing risks under a general sampling design from an infinite target population is derived.

Risks, risk assessment and risk competence in toxicology

PubMed Central

Stahlmann, Ralf; Horvath, Aniko

2015-01-01

Understanding the toxic effects of xenobiotics requires sound knowledge of physiology and biochemistry. The often described lack of understanding pharmacology/toxicology is therefore primarily caused by the general absence of the necessary fundamental knowledge. Since toxic effects depend on exposure (or dosage) assessing the risks arising from toxic substances also requires quantitative reasoning. Typically public discussions nearly always neglect quantitative aspects and laypersons tend to disregard dose-effect-relationships. One of the main reasons for such disregard is the fact that exposures often occur at extremely low concentrations that can only be perceived intellectually but not by the human senses. However, thresholds in the low exposure range are often scientifically disputed. At the same time, ignorance towards known dangers is wide-spread. Thus, enhancing the risk competence of laypersons will have to be initially restricted to increasing the awareness of existing problems. PMID:26195922

Survival of high-risk pediatric neuroblastoma patients in a developing country.

PubMed

Easton, Joseph C; Gomez, Sergio; Asdahl, Peter H; Conner, J Michael; Fynn, Alcira B; Ruiz, Claudia; Ojha, Rohit P

2016-09-01

Little information is available about survival of high-risk pediatric neuroblastoma patients in developing countries. We aimed to assess survival among high-risk pediatric neuroblastoma patients in La Plata, Argentina. Individuals eligible for our cohort were aged <20 yr when diagnosed with high-risk neuroblastoma and received cancer-directed therapy including stem cell transplantation at Hospital de Niños Sor Maria Ludovica between February 1999 and February 2015. We estimated overall survival probabilities using an extended Kaplan-Meier approach. Our study population comprised 39 high-risk neuroblastoma patients, of whom 39% were aged >4 yr at diagnosis, 54% were male, and 62% had adrenal neuroblastoma. We observed 18 deaths, and the median survival time of our study population was 1.7 yr. The five-yr overall survival probability was 24% (95% CL: 10%, 41%). In contrast, five-yr survival of high-risk neuroblastoma patients ranges between 23% and 76% in developed countries. Survival among high-risk neuroblastoma patients is generally poor regardless of geographic location, but our results illustrate dramatically worse survival for patients in a developing country. We speculate that the observed survival differences could be attenuated or eliminated with improvements in treatment and supportive care, but addressing these issues will require creative solutions because of resource limitations. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

High- and Low-Risk Characteristics of Youth: The Five Cs of Competency.

ERIC Educational Resources Information Center

McWhirter, J. Jeffries; And Others

1994-01-01

Identifies and discusses five basic skill strengths or skill deficits that mark critical difference between low-risk and high-risk youth. The "Five Cs of Competency" described include critical school competencies, concept of self and self-esteem, communication skills, coping ability, and control. Contends that these characteristics discriminate…

Project Work English Competency-Based Curriculum: Survival-Level One.

ERIC Educational Resources Information Center

Northwest Educational Cooperative, Des Plaines, IL.

This guide outlines a curriculum designed to provide English-as-a-Second-Language (ESL) life-skills instruction for refugees in the Chicago metropolitan area, concentrating on the Level One survival skills. Non-Southeast Asians account for more than half of those served, all of whom receive, or are at risk of receiving, public assistance. Most are…

Linear and nonlinear variable selection in competing risks data.

PubMed

Ren, Xiaowei; Li, Shanshan; Shen, Changyu; Yu, Zhangsheng

2018-06-15

Subdistribution hazard model for competing risks data has been applied extensively in clinical researches. Variable selection methods of linear effects for competing risks data have been studied in the past decade. There is no existing work on selection of potential nonlinear effects for subdistribution hazard model. We propose a two-stage procedure to select the linear and nonlinear covariate(s) simultaneously and estimate the selected covariate effect(s). We use spectral decomposition approach to distinguish the linear and nonlinear parts of each covariate and adaptive LASSO to select each of the 2 components. Extensive numerical studies are conducted to demonstrate that the proposed procedure can achieve good selection accuracy in the first stage and small estimation biases in the second stage. The proposed method is applied to analyze a cardiovascular disease data set with competing death causes. Copyright © 2018 John Wiley & Sons, Ltd.

A Method for Evaluating Competency in Assessment and Management of Suicide Risk

ERIC Educational Resources Information Center

Hung, Erick K.; Binder, Renee L.; Fordwood, Samantha R.; Hall, Stephen E.; Cramer, Robert J.; McNiel, Dale E.

2012-01-01

Objective: Although health professionals increasingly are expected to be able to assess and manage patients' risk for suicide, few methods are available to evaluate this competency. This report describes development of a competency-assessment instrument for suicide risk-assessment (CAI-S), and evaluates its use in an objective structured clinical…

Score tests for independence in semiparametric competing risks models.

PubMed

Saïd, Mériem; Ghazzali, Nadia; Rivest, Louis-Paul

2009-12-01

A popular model for competing risks postulates the existence of a latent unobserved failure time for each risk. Assuming that these underlying failure times are independent is attractive since it allows standard statistical tools for right-censored lifetime data to be used in the analysis. This paper proposes simple independence score tests for the validity of this assumption when the individual risks are modeled using semiparametric proportional hazards regressions. It assumes that covariates are available, making the model identifiable. The score tests are derived for alternatives that specify that copulas are responsible for a possible dependency between the competing risks. The test statistics are constructed by adding to the partial likelihoods for the individual risks an explanatory variable for the dependency between the risks. A variance estimator is derived by writing the score function and the Fisher information matrix for the marginal models as stochastic integrals. Pitman efficiencies are used to compare test statistics. A simulation study and a numerical example illustrate the methodology proposed in this paper.

Risk factors for deep vein thrombosis and pulmonary embolism after traumatic injury: A competing risks analysis.

PubMed

Van Gent, Jan-Michael; Calvo, Richard Yee; Zander, Ashley L; Olson, Erik J; Sise, C Beth; Sise, Michael J; Shackford, Steven R

2017-12-01

Venous thromboembolism, including deep vein thrombosis (DVT) and pulmonary embolism (PE), is typically reported as a composite measure of the quality of trauma center care. Given that recent data suggesting postinjury DVT and PE are distinct clinical processes, a better understanding may result from analyzing them as independent, competing events. Using competing risks analysis, we evaluated our hypothesis that the risk factors and timing of postinjury DVT and PE are different. We examined all adult trauma patients admitted to our Level I trauma center from July 2006 to December 2011 who received at least one surveillance duplex ultrasound of the lower extremities and who were at high risk or greater for DVT. Outcomes included DVT and PE events, and time-to-event from admission. We used competing risks analysis to evaluate risk factors for DVT while accounting for PE as a competing event, and vice versa. Of 2,370 patients, 265 (11.2%) had at least one venous thromboembolism event, 235 DVT only, 19 PE only, 11 DVT and PE. Within 2 days of admission, 38% of DVT cases had occurred compared with 26% of PE. Competing risks modeling of DVT as primary event identified older age, severe injury (Injury Severity Score, ≥ 15), mechanical ventilation longer than 4 days, active cancer, history of DVT or PE, major venous repair, male sex, and prophylactic enoxaparin and prophylactic heparin as associated risk factors. Modeling of PE as the primary event showed younger age, nonsevere injury (Injury Severity Score, < 15), central line placement, and prophylactic heparin as relevant factors. The risk factors for PE and DVT after injury were different, suggesting that they are clinically distinct events that merit independent consideration. Many DVT events occurred early despite prophylaxis, bringing into question the preventability of postinjury DVT. We recommend trauma center quality reporting program measures be revised to account for DVT and PE as unique events. Epidemiologic

Competing risks of death in younger and older postmenopausal breast cancer patients

PubMed Central

Chapman, Judy-Anne W; Pritchard, Kathleen I; Goss, Paul E; Ingle, James N; Muss, Hyman B; Dent, Susan F; Vandenberg, Ted A; Findlay, Brian; Gelmon, Karen A; Wilson, Carolyn F; Shepherd, Lois E; Pollak, Michael N

2014-01-01

AIM: To show a new paradigm of simultaneously testing whether breast cancer therapies impact other causes of death. METHODS: MA.14 allocated 667 postmenopausal women to 5 years of tamoxifen 20 mg/daily ± 2 years of octreotide 90 mg, given by depot intramuscular injections monthly. Event-free survival was the primary endpoint of MA.14; at median 7.9 years, the tamoxifen+octreotide and tamoxifen arms had similar event-free survival (P = 0.62). Overall survival was a secondary endpoint, and the two trial arms also had similar overall survival (P = 0.86). We used the median 9.8 years follow-up to examine by intention-to-treat, the multivariate time-to-breast cancer-specific (BrCa) and other cause (OC) mortality with log-normal survival analysis adjusted by treatment and stratification factors. We tested whether baseline factors including Insulin-like growth factor 1 (IGF1), IGF binding protein-3, C-peptide, body mass index, and 25-hydroxy vitamin D were associated with (1) all cause mortality, and if so and (2) cause-specific mortality. We also fit step-wise forward cause-specific adjusted models. RESULTS: The analyses were performed on 329 patients allocated tamoxifen and 329 allocated tamoxifen+octreotide. The median age of MA.14 patients was 60.1 years: 447 (82%) < 70 years and 120 (18%) ≥ 70 years. There were 170 deaths: 106 (62.3%) BrCa; 55 (32.4%) OC, of which 24 were other malignancies, 31 other causes of death; 9 (5.3%) patients with unknown cause of death were excluded from competing risk assessments. BrCa and OC deaths were not significantly different by treatment arm (P = 0.40): tamoxifen patients experienced 50 BrCa and 32 OC deaths, while tamoxifen + octreotide patients experienced 56 BrCa and 23 OC deaths. Proportionately more deaths (P = 0.004) were from BrCa for patients < 70 years, where 70% of deaths were due to BrCa, compared to 54% for those ≥ 70 years of age. The proportion of deaths from OC increased with increasing body mass index (BMI) (P

Risk Competence in Dealing With Alcohol and Other Drugs in Adolescence.

PubMed

Nagy, Ede; Verres, Rolf; Grevenstein, Dennis

2017-12-06

Adolescence is a critical phase for the development substance use patterns. We propose that individual competence in dealing with psychoactive substances is crucial for the development of healthy substance use behavior and prevention of substance misuse or addiction. We present a new concept of health related skills in dealing with alcohol and other drugs in adolescence, its operationalization and validation. Our conception of risk competence (RICO) consists of the four major factors being Reflective, Informed, Self-Controlled and Life-Oriented, and their sub-facets. Based on a sample of N = 753 adolescents we used classical test theory as well as item response theory to create a new measure of RICO. Validity was investigated in a new sample of N = 229 with regard to substance use, risk perception, and measures of personality (Big Five, sense of coherence, general self-efficacy). RICO contains 7 scales with 28 items that measure independent aspects of risk competence. Cross-sectional criterion validity for most of the scales could be shown. Conclusions/Importance: The new RICO scales are a valid measure of different aspects of risk competence in dealing with psychoactive substances. The questionnaire can be used in general research settings, but may also be applied to assess the effects of interventions.

Inverse probability of treatment-weighted competing risks analysis: an application on long-term risk of urinary adverse events after prostate cancer treatments.

PubMed

Bolch, Charlotte A; Chu, Haitao; Jarosek, Stephanie; Cole, Stephen R; Elliott, Sean; Virnig, Beth

2017-07-10

To illustrate the 10-year risks of urinary adverse events (UAEs) among men diagnosed with prostate cancer and treated with different types of therapy, accounting for the competing risk of death. Prostate cancer is the second most common malignancy among adult males in the United States. Few studies have reported the long-term post-treatment risk of UAEs and those that have, have not appropriately accounted for competing deaths. This paper conducts an inverse probability of treatment (IPT) weighted competing risks analysis to estimate the effects of different prostate cancer treatments on the risk of UAE, using a matched-cohort of prostate cancer/non-cancer control patients from the Surveillance, Epidemiology and End Results (SEER) Medicare database. Study dataset included men age 66 years or older that are 83% white and had a median follow-up time of 4.14 years. Patients that underwent combination radical prostatectomy and external beam radiotherapy experienced the highest risk of UAE (IPT-weighted competing risks: HR 3.65 with 95% CI (3.28, 4.07); 10-yr. cumulative incidence = 36.5%). Findings suggest that IPT-weighted competing risks analysis provides an accurate estimator of the cumulative incidence of UAE taking into account the competing deaths as well as measured confounding bias.

Suicide Risk Assessment Training for Psychology Doctoral Programs: Core Competencies and a Framework for Training

PubMed Central

Cramer, Robert J.; Johnson, Shara M.; McLaughlin, Jennifer; Rausch, Emilie M.; Conroy, Mary Alice

2014-01-01

Clinical and counseling psychology programs currently lack adequate evidence-based competency goals and training in suicide risk assessment. To begin to address this problem, this article proposes core competencies and an integrated training framework that can form the basis for training and research in this area. First, we evaluate the extent to which current training is effective in preparing trainees for suicide risk assessment. Within this discussion, sample and methodological issues are reviewed. Second, as an extension of these methodological training issues, we integrate empirically- and expert-derived suicide risk assessment competencies from several sources with the goal of streamlining core competencies for training purposes. Finally, a framework for suicide risk assessment training is outlined. The approach employs Objective Structured Clinical Examination (OSCE) methodology, an approach commonly utilized in medical competency training. The training modality also proposes the Suicide Competency Assessment Form (SCAF), a training tool evaluating self- and observer-ratings of trainee core competencies. The training framework and SCAF are ripe for empirical evaluation and potential training implementation. PMID:24672588

Suicide Risk Assessment Training for Psychology Doctoral Programs: Core Competencies and a Framework for Training.

PubMed

Cramer, Robert J; Johnson, Shara M; McLaughlin, Jennifer; Rausch, Emilie M; Conroy, Mary Alice

2013-02-01

Clinical and counseling psychology programs currently lack adequate evidence-based competency goals and training in suicide risk assessment. To begin to address this problem, this article proposes core competencies and an integrated training framework that can form the basis for training and research in this area. First, we evaluate the extent to which current training is effective in preparing trainees for suicide risk assessment. Within this discussion, sample and methodological issues are reviewed. Second, as an extension of these methodological training issues, we integrate empirically- and expert-derived suicide risk assessment competencies from several sources with the goal of streamlining core competencies for training purposes. Finally, a framework for suicide risk assessment training is outlined. The approach employs Objective Structured Clinical Examination (OSCE) methodology, an approach commonly utilized in medical competency training. The training modality also proposes the Suicide Competency Assessment Form (SCAF), a training tool evaluating self- and observer-ratings of trainee core competencies. The training framework and SCAF are ripe for empirical evaluation and potential training implementation.

Criteria for use of composite end points for competing risks-a systematic survey of the literature with recommendations.

PubMed

Manja, Veena; AlBashir, Siwar; Guyatt, Gordon

2017-02-01

Composite end points are frequently used in reports of clinical trials. One rationale for the use of composite end points is to account for competing risks. In the presence of competing risks, the event rate of a specific event depends on the rates of other competing events. One proposed solution is to include all important competing events in one composite end point. Clinical trialists require guidance regarding when this approach is appropriate. To identify publications describing criteria for use of composite end points for competing risk and to offer guidance regarding when a composite end point is appropriate on the basis of competing risks. We searched MEDLINE, CINAHL, EMBASE, The Cochrane's Central & Systematic Review databases including the Health Technology Assessment database, and the Cochrane's Methodology register from inception to April 2015, and candidate textbooks, to identify all articles providing guidance on this issue. Eligible publications explicitly addressed the issue of a composite outcome to address competing risks. Two reviewers independently screened the titles and abstracts for full-text review; independently reviewed full-text publications; and abstracted specific criteria authors offered for use of composite end points to address competing risks. Of 63,645 titles and abstracts, 166 proved potentially relevant of which 43 publications were included in the final review. Most publications note competing risks as a reason for using composite end points without further elaboration. None of the articles or textbook chapters provide specific criteria for use of composite end points for competing risk. Some advocate using composite end points to avoid bias due to competing risks and others suggest that composite end points seldom or never be used for this purpose. We recommend using composite end points for competing risks only if the competing risk is plausible and if it occurs with sufficiently high frequency to influence the interpretation

Competing risks to breast cancer mortality in Catalonia

PubMed Central

Vilaprinyo, Ester; Gispert, Rosa; Martínez-Alonso, Montserrat; Carles, Misericòrdia; Pla, Roger; Espinàs, Josep-Alfons; Rué, Montserrat

2008-01-01

Background Breast cancer mortality has experienced important changes over the last century. Breast cancer occurs in the presence of other competing risks which can influence breast cancer incidence and mortality trends. The aim of the present work is: 1) to assess the impact of breast cancer deaths among mortality from all causes in Catalonia (Spain), by age and birth cohort and 2) to estimate the risk of death from other causes than breast cancer, one of the inputs needed to model breast cancer mortality reduction due to screening or therapeutic interventions. Methods The multi-decrement life table methodology was used. First, all-cause mortality probabilities were obtained by age and cohort. Then mortality probability for breast cancer was subtracted from the all-cause mortality probabilities to obtain cohort life tables for causes other than breast cancer. These life tables, on one hand, provide an estimate of the risk of dying from competing risks, and on the other hand, permit to assess the impact of breast cancer deaths on all-cause mortality using the ratio of the probability of death for causes other than breast cancer by the all-cause probability of death. Results There was an increasing impact of breast cancer on mortality in the first part of the 20th century, with a peak for cohorts born in 1945–54 in the 40–49 age groups (for which approximately 24% of mortality was due to breast cancer). Even though for cohorts born after 1955 there was only information for women under 50, it is also important to note that the impact of breast cancer on all-cause mortality decreased for those cohorts. Conclusion We have quantified the effect of removing breast cancer mortality in different age groups and birth cohorts. Our results are consistent with US findings. We also have obtained an estimate of the risk of dying from competing-causes mortality, which will be used in the assessment of the effect of mammography screening on breast cancer mortality in Catalonia

A Joint Model for Longitudinal Measurements and Survival Data in the Presence of Multiple Failure Types

PubMed Central

Elashoff, Robert M.; Li, Gang; Li, Ning

2009-01-01

Summary In this article we study a joint model for longitudinal measurements and competing risks survival data. Our joint model provides a flexible approach to handle possible nonignorable missing data in the longitudinal measurements due to dropout. It is also an extension of previous joint models with a single failure type, offering a possible way to model informatively censored events as a competing risk. Our model consists of a linear mixed effects submodel for the longitudinal outcome and a proportional cause-specific hazards frailty submodel (Prentice et al., 1978, Biometrics 34, 541-554) for the competing risks survival data, linked together by some latent random effects. We propose to obtain the maximum likelihood estimates of the parameters by an expectation maximization (EM) algorithm and estimate their standard errors using a profile likelihood method. The developed method works well in our simulation studies and is applied to a clinical trial for the scleroderma lung disease. PMID:18162112

Competing risk analysis of mortality in prostate cancer treated with radical prostatectomy.

PubMed

Ruiz-Cerdá, J L; Soto-Poveda, A; Luján-Marco, S; Loras-Monfort, A; Trassierra-Villa, M; Rogel-Bertó, R; Boronat-Tormo, F

To determine the risk of cancer-specific mortality (CSM) versus the competing risk of mortality by other causes (MOC) in patients with localised prostate cancer (LPC) treated with radical prostatectomy (RP). An observational cohort study of 982 patients with LPC treated with RP selected from our department's PC registry database. A competing risk analysis was performed, calculating the probability of CSM in the presence of the competing risk of MOC. Cumulative incidence curves were constructed, and point estimates were performed at 5, 10 and 15 years. The analysis was stratified by age (≤65 vs. >65 years) and risk group: low (Gleason score ≤6 and pT2abc); intermediate (Gleason score of 7 and pT2abc) and high (Gleason score of 8-10 or pT3ab). With a median follow-up of 60 months, the overall probability of dying from PC was 3.5%, and the probability of dying from other causes was 9%. A competing effect for MOC was observed. The risk of MOC was almost 3 times greater than that of CSM. This effect remained for all risk groups, although its magnitude decreased progressively according to the risk group level. At 10 years, CSM was only 0%, 1% and 2% for the low, intermediate and high-risk groups, respectively, while the likelihood of MOC was 4%, 4% and 10%, respectively. The mortality risk was shown after 10years of follow-up and was higher for other causes not attributable to PC and for patients older than 65years. The benefit of RP might be overestimated, given that the risk of MOC is greater than that of CSM, regardless of the age group and risk group, especially after 10years of follow-up. The only parameter that varied was the magnitude of the CSM/MOC ratio. This information could help in choosing the active treatment for patients with LPC and short life expectancies. Copyright © 2016 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.

Core Competencies and the Prevention of High-Risk Sexual Behavior

ERIC Educational Resources Information Center

Charles, Vignetta Eugenia; Blum, Robert Wm.

2008-01-01

Adolescent sexual risk-taking behavior has numerous individual, family, community, and societal consequences. In an effort to contribute to the research and propose new directions, this chapter applies the core competencies framework to the prevention of high-risk sexual behavior. It describes the magnitude of the problem, summarizes explanatory…

Variable selection in subdistribution hazard frailty models with competing risks data

PubMed Central

Do Ha, Il; Lee, Minjung; Oh, Seungyoung; Jeong, Jong-Hyeon; Sylvester, Richard; Lee, Youngjo

2014-01-01

The proportional subdistribution hazards model (i.e. Fine-Gray model) has been widely used for analyzing univariate competing risks data. Recently, this model has been extended to clustered competing risks data via frailty. To the best of our knowledge, however, there has been no literature on variable selection method for such competing risks frailty models. In this paper, we propose a simple but unified procedure via a penalized h-likelihood (HL) for variable selection of fixed effects in a general class of subdistribution hazard frailty models, in which random effects may be shared or correlated. We consider three penalty functions (LASSO, SCAD and HL) in our variable selection procedure. We show that the proposed method can be easily implemented using a slight modification to existing h-likelihood estimation approaches. Numerical studies demonstrate that the proposed procedure using the HL penalty performs well, providing a higher probability of choosing the true model than LASSO and SCAD methods without losing prediction accuracy. The usefulness of the new method is illustrated using two actual data sets from multi-center clinical trials. PMID:25042872

Anthropometric characteristics and ovarian cancer risk and survival.

PubMed

Minlikeeva, Albina N; Moysich, Kirsten B; Mayor, Paul C; Etter, John L; Cannioto, Rikki A; Ness, Roberta B; Starbuck, Kristen; Edwards, Robert P; Segal, Brahm H; Lele, Sashikant; Odunsi, Kunle; Diergaarde, Brenda; Modugno, Francesmary

2018-02-01

Multiple studies have examined the role of anthropometric characteristics in ovarian cancer risk and survival; however, their results have been conflicting. We investigated the associations between weight change, height and height change and risk and outcome of ovarian cancer using data from a large population-based case-control study. Data from 699 ovarian cancer cases and 1,802 controls who participated in the HOPE study were included. We used unconditional logistic regression adjusted for age, race, number of pregnancies, use of oral contraceptives, and family history of breast or ovarian cancer to examine the associations between self-reported height and weight and height change with ovarian cancer risk. Cox proportional hazards regression models adjusted for age and stage were used to examine the association between the exposure variables and overall and progression-free survival among ovarian cancer cases. We observed an increased risk of ovarian cancer mortality and progression for gaining more than 20 pounds between ages 18-30, HR 1.36; 95% CI 1.05-1.76, and HR 1.31; 95% CI 1.04-1.66, respectively. Losing weight and gaining it back multiple times was inversely associated with both ovarian cancer risk, OR 0.78; 95% CI 0.63-0.97 for 1-4 times and OR 0.73; 95% CI 0.54-0.99 for 5-9 times, and mortality, HR 0.63; 95% CI 0.40-0.99 for 10-14 times. Finally, being taller during adolescence and adulthood was associated with increased risk of mortality. Taller stature and weight gain over lifetime were not related to ovarian cancer risk. Our results suggest that height and weight and their change over time may influence ovarian cancer risk and survival. These findings suggest that biological mechanisms underlying these associations may be hormone driven and may play an important role in relation to ovarian carcinogenesis and tumor progression.

On the importance of accounting for competing risks in pediatric cancer trials designed to delay or avoid radiotherapy: I. Basic concepts and first analyses.

PubMed

Tai, Bee-Choo; Grundy, Richard G; Machin, David

2010-04-01

In trials designed to delay or avoid irradiation among children with malignant brain tumor, although irradiation after disease progression is an important event, patients who have disease progression may decline radiotherapy (RT), or those without disease progression may opt for elective RT. To accurately describe the cumulative need for RT in such instances, it is crucial to account for these distinct events and to evaluate how each contributes to the delay or advancement of irradiation via a competing risks analysis. We describe the summary of competing events in such trials using competing risks methods based on cumulative incidence functions and Gray's test. The results obtained are contrasted with standard survival methods based on Kaplan-Meier curves, cause-specific hazard functions and log-rank test. The Kaplan-Meier method overestimates all event-specific rates. The cause-specific hazard analysis showed reduction in hazards for all events (A: RT after progression; B: no RT after progression; C: elective RT) among children with ependymoma. For event A, a higher cumulative incidence was reported for ependymoma. Although Gray's test failed to detect any difference (p = 0.331) between histologic subtypes, the log-rank test suggested marginal evidence (p = 0.057). Similarly, for event C, the log-rank test found stronger evidence of reduction in hazard among those with ependymoma (p = 0.005) as compared with Gray's test (p = 0.086). To evaluate treatment differences, failing to account for competing risks using appropriate methodology may lead to incorrect interpretations.

Individual survival curves comparing subjective and observed mortality risks.

PubMed

Bissonnette, Luc; Hurd, Michael D; Michaud, Pierre-Carl

2017-12-01

We compare individual survival curves constructed from objective (actual mortality) and elicited subjective information (probability of survival to a given target age). We develop a methodology to estimate jointly subjective and objective individual survival curves accounting for rounding on subjective reports of perceived survival. We make use of the long follow-up period in the Health and Retirement Study and the high quality of mortality data to estimate individual survival curves that feature both observed and unobserved heterogeneity. This allows us to compare objective and subjective estimates of remaining life expectancy for various groups and compare welfare effects of objective and subjective mortality risk using the life cycle model of consumption. We find that subjective and objective hazards are not the same. The median welfare loss from misperceptions of mortality risk when annuities are not available is 7% of current wealth at age 65 whereas more than 25% of respondents have losses larger than 60% of wealth. When annuities are available and exogenously given, the welfare loss is substantially lower. Copyright © 2017 John Wiley & Sons, Ltd.

Optimising import risk mitigation: anticipating the unintended consequences and competing risks of informal trade.

PubMed

Hueston, W; Travis, D; van Klink, E

2011-04-01

The effectiveness of risk mitigation may be compromised by informal trade, including illegal activities, parallel markets and extra-legal activities. While no regulatory system is 100% effective in eliminating the risk of disease transmission through animal and animal product trade, extreme risk aversion in formal import health regulations may increase informal trade, with the unintended consequence of creating additional risks outside regulatory purview. Optimal risk mitigation on a national scale requires scientifically sound yet flexible mitigation strategies that can address the competing risks of formal and informal trade. More robust risk analysis and creative engagement of nontraditional partners provide avenues for addressing informal trade.

Risk-Stratified Imputation in Survival Analysis

PubMed Central

Kennedy, Richard E.; Adragni, Kofi P.; Tiwari, Hemant K.; Voeks, Jenifer H.; Brott, Thomas G.; Howard, George

2013-01-01

Background Censoring that is dependent on covariates associated with survival can arise in randomized trials due to changes in recruitment and eligibility criteria to minimize withdrawals, potentially leading to biased treatment effect estimates. Imputation approaches have been proposed to address censoring in survival analysis; and while these approaches may provide unbiased estimates of treatment effects, imputation of a large number of outcomes may over- or underestimate the associated variance based on the imputation pool selected. Purpose We propose an improved method, risk-stratified imputation, as an alternative to address withdrawal related to the risk of events in the context of time-to-event analyses. Methods Our algorithm performs imputation from a pool of replacement subjects with similar values of both treatment and covariate(s) of interest, that is, from a risk-stratified sample. This stratification prior to imputation addresses the requirement of time-to-event analysis that censored observations are representative of all other observations in the risk group with similar exposure variables. We compared our risk-stratified imputation to case deletion and bootstrap imputation in a simulated dataset in which the covariate of interest (study withdrawal) was related to treatment. A motivating example from a recent clinical trial is also presented to demonstrate the utility of our method. Results In our simulations, risk-stratified imputation gives estimates of treatment effect comparable to bootstrap and auxiliary variable imputation while avoiding inaccuracies of the latter two in estimating the associated variance. Similar results were obtained in analysis of clinical trial data. Limitations Risk-stratified imputation has little advantage over other imputation methods when covariates of interest are not related to treatment, although its performance is superior when covariates are related to treatment. Risk-stratified imputation is intended for

Mixed-effects varying-coefficient model with skewed distribution coupled with cause-specific varying-coefficient hazard model with random-effects for longitudinal-competing risks data analysis.

PubMed

Lu, Tao; Wang, Min; Liu, Guangying; Dong, Guang-Hui; Qian, Feng

2016-01-01

It is well known that there is strong relationship between HIV viral load and CD4 cell counts in AIDS studies. However, the relationship between them changes during the course of treatment and may vary among individuals. During treatments, some individuals may experience terminal events such as death. Because the terminal event may be related to the individual's viral load measurements, the terminal mechanism is non-ignorable. Furthermore, there exists competing risks from multiple types of events, such as AIDS-related death and other death. Most joint models for the analysis of longitudinal-survival data developed in literatures have focused on constant coefficients and assume symmetric distribution for the endpoints, which does not meet the needs for investigating the nature of varying relationship between HIV viral load and CD4 cell counts in practice. We develop a mixed-effects varying-coefficient model with skewed distribution coupled with cause-specific varying-coefficient hazard model with random-effects to deal with varying relationship between the two endpoints for longitudinal-competing risks survival data. A fully Bayesian inference procedure is established to estimate parameters in the joint model. The proposed method is applied to a multicenter AIDS cohort study. Various scenarios-based potential models that account for partial data features are compared. Some interesting findings are presented.

Avoidance of sun exposure as a risk factor for major causes of death: a competing risk analysis of the Melanoma in Southern Sweden cohort.

PubMed

Lindqvist, P G; Epstein, E; Nielsen, K; Landin-Olsson, M; Ingvar, C; Olsson, H

2016-10-01

Women with active sunlight exposure habits experience a lower mortality rate than women who avoid sun exposure; however, they are at an increased risk of skin cancer. We aimed to explore the differences in main causes of death according to sun exposure. We assessed the differences in sun exposure as a risk factor for all-cause mortality in a competing risk scenario for 29 518 Swedish women in a prospective 20-year follow-up of the Melanoma in Southern Sweden (MISS) cohort. Women were recruited from 1990 to 1992 (aged 25-64 years at the start of the study). We obtained detailed information at baseline on sun exposure habits and potential confounders. The data were analysed using modern survival statistics. Women with active sun exposure habits were mainly at a lower risk of cardiovascular disease (CVD) and noncancer/non-CVD death as compared to those who avoided sun exposure. As a result of their increased survival, the relative contribution of cancer death increased in these women. Nonsmokers who avoided sun exposure had a life expectancy similar to smokers in the highest sun exposure group, indicating that avoidance of sun exposure is a risk factor for death of a similar magnitude as smoking. Compared to the highest sun exposure group, life expectancy of avoiders of sun exposure was reduced by 0.6-2.1 years. The longer life expectancy amongst women with active sun exposure habits was related to a decrease in CVD and noncancer/non-CVD mortality, causing the relative contribution of death due to cancer to increase. © 2016 The Association for the Publication of the Journal of Internal Medicine.

A proportional hazards regression model for the subdistribution with right-censored and left-truncated competing risks data

PubMed Central

Zhang, Xu; Zhang, Mei-Jie; Fine, Jason

2012-01-01

With competing risks failure time data, one often needs to assess the covariate effects on the cumulative incidence probabilities. Fine and Gray proposed a proportional hazards regression model to directly model the subdistribution of a competing risk. They developed the estimating procedure for right-censored competing risks data, based on the inverse probability of censoring weighting. Right-censored and left-truncated competing risks data sometimes occur in biomedical researches. In this paper, we study the proportional hazards regression model for the subdistribution of a competing risk with right-censored and left-truncated data. We adopt a new weighting technique to estimate the parameters in this model. We have derived the large sample properties of the proposed estimators. To illustrate the application of the new method, we analyze the failure time data for children with acute leukemia. In this example, the failure times for children who had bone marrow transplants were left truncated. PMID:21557288

Student Competencies Guide: Survival Skills for a Changing World.

ERIC Educational Resources Information Center

Northwest Regional Educational Lab., Portland, OR.

This guide is designed to help junior and senior high school students acquire basic competencies in daily living. In addition to identifying 13 competencies, the guide explains how students can obtain certification in those skills by members of the community whose jobs require them to be proficient in them. The competencies include transacting…

Conduct problems and level of social competence in Head Start children: prevalence, pervasiveness, and associated risk factors.

PubMed

Webster-Stratton, C; Hammond, M

1998-06-01

The purpose of the current project was to determine the prevalence of conduct problems, low social competence, and associated risk factors in a sample of 4-year-old low-income children (N = 426) from 64 Head Start classrooms in the Seattle area. Conduct problems and social competence were assessed based on a combination of teacher reports, parent reports, and independent observations of children interacting with peers in the classroom and with parents at home. We examined the relative contribution of a variety of risk factors, including maternal history and socioeconomic background, current levels of stress and social support, mothers' emotional state, and parenting competence in relation to "pervasive" (i.e., at home and school) and "nonpervasive" conduct problems and low social competence. Findings indicated similar risk factors for conduct problems and for low social competence, with an ordered increase in the number of risk factors from normal to "nonpervasive" to "pervasive" groups. Harshness of parenting style (i.e., slapping, hitting, yelling) significantly distinguished between the three groups for low social competence and conduct problems. Positive affect, praise, and physical warmth from mothers were positively related to social competence but unrelated to conduct problems.

Analysis and design of randomised clinical trials involving competing risks endpoints.

PubMed

Tai, Bee-Choo; Wee, Joseph; Machin, David

2011-05-19

In randomised clinical trials involving time-to-event outcomes, the failures concerned may be events of an entirely different nature and as such define a classical competing risks framework. In designing and analysing clinical trials involving such endpoints, it is important to account for the competing events, and evaluate how each contributes to the overall failure. An appropriate choice of statistical model is important for adequate determination of sample size. We describe how competing events may be summarised in such trials using cumulative incidence functions and Gray's test. The statistical modelling of competing events using proportional cause-specific and subdistribution hazard functions, and the corresponding procedures for sample size estimation are outlined. These are illustrated using data from a randomised clinical trial (SQNP01) of patients with advanced (non-metastatic) nasopharyngeal cancer. In this trial, treatment has no effect on the competing event of loco-regional recurrence. Thus the effects of treatment on the hazard of distant metastasis were similar via both the cause-specific (unadjusted csHR = 0.43, 95% CI 0.25 - 0.72) and subdistribution (unadjusted subHR 0.43; 95% CI 0.25 - 0.76) hazard analyses, in favour of concurrent chemo-radiotherapy followed by adjuvant chemotherapy. Adjusting for nodal status and tumour size did not alter the results. The results of the logrank test (p = 0.002) comparing the cause-specific hazards and the Gray's test (p = 0.003) comparing the cumulative incidences also led to the same conclusion. However, the subdistribution hazard analysis requires many more subjects than the cause-specific hazard analysis to detect the same magnitude of effect. The cause-specific hazard analysis is appropriate for analysing competing risks outcomes when treatment has no effect on the cause-specific hazard of the competing event. It requires fewer subjects than the subdistribution hazard analysis for a similar effect size

Development and evaluation of the "BRISK Scale," a brief observational measure of risk communication competence.

PubMed

Han, Paul K J; Joekes, Katherine; Mills, Greg; Gutheil, Caitlin; Smith, Kahsi; Cochran, Nancy E; Elwyn, Glyn

2016-12-01

To develop and evaluate a brief observational measure of clinical risk communication competence. A 4-item checklist-type measure, the BRISK (Brief Risk Information Skill) Scale, was developed by selecting and refining items from a more comprehensive measure of clinical risk communication competence. Six volunteer raters received brief training on the measure and then used the BRISK Scale to evaluate 52 video-recorded encounters between 2nd-year medical students and standardized patients conducted as part of an Observed Structured Clinical Examination (OSCE) involving a risk communication task. Internal consistency reliability, inter-rater reliability, and criterion validity were assessed. Raters reported no difficulties using the BRISK Scale; scores across all raters and subjects ranged from 0 to 16 with a mean score of 6.49 (SD=3.17). The BRISK Scale showed good internal consistency reliability (α=0.64), and inter-rater reliability at the scale level (Intraclass Correlation Coefficient (ICC)=0.79 for consistency, and 0.75 for absolute agreement) and individual-item level (ICC range: 0.62-.91). Novice raters' BRISK Scale scores were highly correlated (r=0.84, p<0.01) with expert raters' scores on the Risk Communication Content measure, a more comprehensive measure of risk communication competence. The BRISK Scale is a promising new brief observational measure of clinical risk communication competence. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Risk-adjusted monitoring of survival times

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sego, Landon H.; Reynolds, Marion R.; Woodall, William H.

2009-02-26

We consider the monitoring of clinical outcomes, where each patient has a di®erent risk of death prior to undergoing a health care procedure.We propose a risk-adjusted survival time CUSUM chart (RAST CUSUM) for monitoring clinical outcomes where the primary endpoint is a continuous, time-to-event variable that may be right censored. Risk adjustment is accomplished using accelerated failure time regression models. We compare the average run length performance of the RAST CUSUM chart to the risk-adjusted Bernoulli CUSUM chart, using data from cardiac surgeries to motivate the details of the comparison. The comparisons show that the RAST CUSUM chart is moremore » efficient at detecting a sudden decrease in the odds of death than the risk-adjusted Bernoulli CUSUM chart, especially when the fraction of censored observations is not too high. We also discuss the implementation of a prospective monitoring scheme using the RAST CUSUM chart.« less

Tula hantavirus isolate with the full-length ORF for nonstructural protein NSs survives for more consequent passages in interferon-competent cells than the isolate having truncated NSs ORF.

PubMed

Jääskeläinen, Kirsi M; Plyusnina, Angelina; Lundkvist, Ake; Vaheri, Antti; Plyusnin, Alexander

2008-01-11

The competitiveness of two Tula hantavirus (TULV) isolates, TULV/Lodz and TULV/Moravia, was evaluated in interferon (IFN) -competent and IFN-deficient cells. The two isolates differ in the length of the open reading frame (ORF) encoding the nonstructural protein NSs, which has previously been shown to inhibit IFN response in infected cells. In IFN-deficient Vero E6 cells both TULV isolates survived equally well. In contrast, in IFN-competent MRC5 cells TULV/Lodz isolate, that possesses the NSs ORF for the full-length protein of 90 aa, survived for more consequent passages than TULV/Moravia isolate, which contains the ORF for truncated NSs protein (66-67 aa). Our data show that expression of a full-length NSs protein is beneficial for the virus survival and competitiveness in IFN-competent cells and not essential in IFN-deficient cells. These results suggest that the N-terminal aa residues are important for the full activity of the NSs protein.

Causes of death and competing risk analysis of the associated factors for non-small cell lung cancer using the Surveillance, Epidemiology, and End Results database.

PubMed

Wei, Shenhai; Tian, Jintao; Song, Xiaoping; Wu, Bingqun; Liu, Limin

2018-01-01

To investigate the probability of death (POD) from any causes by time after diagnosis of non-small cell lung cancer (NSCLC) and the factors associated with survival for NSCLC patients. A total of 202,914 patients with NSCLC from 2004 to 2013 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The overall survival (OS) and lung cancer-specific survival (LCSS) were calculated and POD from any causes at different time periods after diagnosis was explored. The predictive factors for OS, LCSS and survival from non-lung cancer deaths were investigated using multivariate analysis with Cox proportional hazards regression and competing risk regression analysis. The 5- and 10-year OS were 20.4% and 11.5%, accordingly that for LCSS were 25.5% and 18.4%, respectively. Lung cancer contributed 88.3% (n = 128,402) of the deaths. The POD from lung cancer decreased with time after diagnosis. In multivariate analysis, advanced age and advanced stage of NSCLC were associated with decreased OS and LCSS. Comparing to no surgery, any kind of resection conferred lower risk of death from lung cancer and higher risk of dying from non-lung cancer conditions except lobectomy or bilobectomy, which was associated with lower risk of death from both lung cancer and non-lung cancer conditions. Most of the patients with NSCLC died from lung cancer. Rational surveillance and treatment policies should be made for them. Early stage and lobectomy or bilobectomy were associated with improved OS and LCSS. It is reasonable to focus on early detection and optimal surgical treatment for NSCLC.

A method for evaluating competency in assessment and management of suicide risk.

PubMed

Hung, Erick K; Binder, Renée L; Fordwood, Samantha R; Hall, Stephen E; Cramer, Robert J; McNiel, Dale E

2012-01-01

Although health professionals increasingly are expected to be able to assess and manage patients' risk for suicide, few methods are available to evaluate this competency. This report describes development of a competency-assessment instrument for suicide risk-assessment (CAI-S), and evaluates its use in an objective structured clinical examination (OSCE). The authors developed the CAI-S on the basis of the literature on suicide risk-assessment and management, and consultation with faculty focus groups from three sites in a large academic psychiatry department. The CAI-S structures faculty ratings regarding interviewing and data collection, case formulation and presentation, treatment-planning, and documentation. To evaluate the CAI-S, 31 faculty members used it to rate the performance of 31 learners (26 psychiatric residents and 5 clinical psychology interns) who participated in an OSCE. After interviewing a standardized patient, learners presented their risk-assessment findings and treatment plans. Faculty used the CAI-S to structure feedback to the learners. In a subsidiary study of interrater reliability, six faculty members rated video-recorded suicide risk-assessments. The CAI-S showed good internal consistency, reliability, and interrater reliability. Concurrent validity was supported by the finding that CAI-S ratings were higher for senior learners than junior learners, and were higher for learners with more clinical experience with suicidal patients than learners with less clinical experience. Faculty and learners rated the method as helpful for structuring feedback and supervision. The findings support the usefulness of the CAI-S for evaluating competency in suicide risk-assessment and management.

Survival Bias When Assessing Risk Factors for Age-Related Macular Degeneration: A Tutorial with Application to the Exposure of Smoking.

PubMed

McGuinness, Myra B; Karahalios, Amalia; Kasza, Jessica; Guymer, Robyn H; Finger, Robert P; Simpson, Julie A

2017-08-01

We illustrate the effect of survival bias when investigating risk factors for eye disease in elderly populations for whom death is a competing risk. Our investigation focuses on the relationship between smoking and late age-related macular degeneration (AMD) in an observational study impacted by censoring due to death. Statistical methodology to calculate the survivor average causal effect (SACE) as a sensitivity analysis is described, including example statistical computing code for Stata and R. To demonstrate this method, we examine the causal effect of smoking history at baseline (1990-1994) on the presence of late AMD at the third study wave (2003-2007) using data from the Melbourne Collaborative Cohort Study. Of the 40,506 participants eligible for inclusion, 38,092 (94%) survived until the start of the third study wave, 20,752 (51%) were graded for AMD (60% female, aged 47-85 years, mean 65 ± 8.7 years). Late AMD was detected in 122 participants. Logistic regression showed strong evidence of an increased risk of late AMD for current smokers compared to non-smokers (adjusted naïve odds ratio 2.99, 95% confidence interval, CI, 1.74-5.13). Among participants expected to be alive at the start of follow-up regardless of their smoking status, the estimated SACE odds ratio comparing current smokers to non-smokers was at least 3.42 (95% CI 1.57-5.15). Survival bias can attenuate associations between harmful exposures and diseases of aging. Estimation of the SACE using a sensitivity analysis approach should be considered when conducting epidemiological research within elderly populations.

Do Health Professionals Need Additional Competencies for Stratified Cancer Prevention Based on Genetic Risk Profiling?

PubMed Central

Chowdhury, Susmita; Henneman, Lidewij; Dent, Tom; Hall, Alison; Burton, Alice; Pharoah, Paul; Pashayan, Nora; Burton, Hilary

2015-01-01

There is growing evidence that inclusion of genetic information about known common susceptibility variants may enable population risk-stratification and personalized prevention for common diseases including cancer. This would require the inclusion of genetic testing as an integral part of individual risk assessment of an asymptomatic individual. Front line health professionals would be expected to interact with and assist asymptomatic individuals through the risk stratification process. In that case, additional knowledge and skills may be needed. Current guidelines and frameworks for genetic competencies of non-specialist health professionals place an emphasis on rare inherited genetic diseases. For common diseases, health professionals do use risk assessment tools but such tools currently do not assess genetic susceptibility of individuals. In this article, we compare the skills and knowledge needed by non-genetic health professionals, if risk-stratified prevention is implemented, with existing competence recommendations from the UK, USA and Europe, in order to assess the gaps in current competences. We found that health professionals would benefit from understanding the contribution of common genetic variations in disease risk, the rationale for a risk-stratified prevention pathway, and the implications of using genomic information in risk-assessment and risk management of asymptomatic individuals for common disease prevention. PMID:26068647

Decision-making competence predicts domain-specific risk attitudes

PubMed Central

Weller, Joshua A.; Ceschi, Andrea; Randolph, Caleb

2015-01-01

Decision-making competence (DMC) reflects individual differences in rational responding across several classic behavioral decision-making tasks. Although it has been associated with real-world risk behavior, less is known about the degree to which DMC contributes to specific components of risk attitudes. Utilizing a psychological risk-return framework, we examined the associations between risk attitudes and DMC. Italian community residents (n = 804) completed an online DMC measure, using a subset of the original Adult-DMC battery. Participants also completed a self-reported risk attitude measure for three components of risk attitudes (risk-taking, risk perceptions, and expected benefits) across six risk domains. Overall, greater performance on the DMC component scales were inversely, albeit modestly, associated with risk-taking tendencies. Structural equation modeling results revealed that DMC was associated with lower perceived expected benefits for all domains. In contrast, its association with perceived risks was more domain-specific. These analyses also revealed stronger indirect effects for the DMC → expected benefits → risk-taking path than the DMC → perceived risk → risk-taking path, especially for behaviors that may be considered more maladaptive in nature. These results suggest that DMC performance differentially impacts specific components of risk attitudes, and may be more strongly related to the evaluation of expected value of a specific behavior. PMID:26029128

A Model-Free Machine Learning Method for Risk Classification and Survival Probability Prediction.

PubMed

Geng, Yuan; Lu, Wenbin; Zhang, Hao Helen

2014-01-01

Risk classification and survival probability prediction are two major goals in survival data analysis since they play an important role in patients' risk stratification, long-term diagnosis, and treatment selection. In this article, we propose a new model-free machine learning framework for risk classification and survival probability prediction based on weighted support vector machines. The new procedure does not require any specific parametric or semiparametric model assumption on data, and is therefore capable of capturing nonlinear covariate effects. We use numerous simulation examples to demonstrate finite sample performance of the proposed method under various settings. Applications to a glioma tumor data and a breast cancer gene expression survival data are shown to illustrate the new methodology in real data analysis.

Androgen Deprivation Therapy Use in the Setting of High-dose Radiation Therapy and the Risk of Prostate Cancer–Specific Mortality Stratified by the Extent of Competing Mortality

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rose, Brent S., E-mail: brose44@gmail.com; Chen, Ming-Hui; Wu, Jing

Purpose: The addition of androgen deprivation therapy (ADT) to radiation therapy (RT) is the standard of care for men with intermediate- and high-risk prostate cancer (PC). However, whether competing mortality (CM) affects the ability of ADT to improve, survival remains unanswered. Methods and Materials: We calculated a CM risk score using a Fine-Gray semiparametric model that included age and cardiometabolic comorbidities from a cohort of 17,669 men treated with high-dose RT with or without supplemental ADT for nonmetastatic PC. Fine and Gray competing risk regression analysis was used to assess whether ADT reduced the risk of PC-specific mortality for menmore » with a low versus a high risk of CM among the 4550 patients within the intermediate- and high-risk cohort after adjustment for established PC prognostic factors, year of treatment, site, and ADT propensity score. Results: After a median follow-up of 8.4 years, 1065 men had died, 89 (8.36%) of PC. Among the men with a low CM score, ADT use was associated with a significant reduction in the risk of PC-specific mortality (adjusted hazard ratio 0.35, 95% confidence interval 0.14-0.87, P=.02) but was not for men with high CM (adjusted hazard ratio 1.33, 95% confidence interval 0.77-2.30, P=.30). Conclusions: Adding ADT to high-dose RT appears to be associated with decreased PC-specific mortality risk in men with a low but not a high CM score. These data should serve to heighten awareness about the importance of considering competing risks when determining whether to add ADT to RT for older men with intermediate- or high-risk PC.« less

Neyman, Markov processes and survival analysis.

PubMed

Yang, Grace

2013-07-01

J. Neyman used stochastic processes extensively in his applied work. One example is the Fix and Neyman (F-N) competing risks model (1951) that uses finite homogeneous Markov processes to analyse clinical trials with breast cancer patients. We revisit the F-N model, and compare it with the Kaplan-Meier (K-M) formulation for right censored data. The comparison offers a way to generalize the K-M formulation to include risks of recovery and relapses in the calculation of a patient's survival probability. The generalization is to extend the F-N model to a nonhomogeneous Markov process. Closed-form solutions of the survival probability are available in special cases of the nonhomogeneous processes, like the popular multiple decrement model (including the K-M model) and Chiang's staging model, but these models do not consider recovery and relapses while the F-N model does. An analysis of sero-epidemiology current status data with recurrent events is illustrated. Fix and Neyman used Neyman's RBAN (regular best asymptotic normal) estimates for the risks, and provided a numerical example showing the importance of considering both the survival probability and the length of time of a patient living a normal life in the evaluation of clinical trials. The said extension would result in a complicated model and it is unlikely to find analytical closed-form solutions for survival analysis. With ever increasing computing power, numerical methods offer a viable way of investigating the problem.

Genetic parameters for lamb birth weight, survival and death risk traits.

PubMed

Everett-Hincks, J M; Mathias-Davis, H C; Greer, G J; Auvray, B A; Dodds, K G

2014-07-01

This paper reports genetic parameters for lamb survival and mortality traits on sheep farms in New Zealand. Lamb survival and mortality records were obtained from 38 flocks (103,357 lambs) from 5 yr of lambing data (2007 to 2011) and include many breeds and their crosses (predominantly Romney, Perendale, Coopworth, and Texel). A number of models were tested, all including environmental weather effects and investigating the random environmental effect of dam and litter (dam/year) as well as logit transformation for binary traits. Total heritability (direct + maternal) estimates were low for lamb viability at birth (0.01), lamb death risk to dystocia (0.01), and lamb death risk to starvation exposure (0.01) from birth to 3 d of age in an analysis accounting for direct and maternal genetic effects and the maternal environmental effects. Lamb survival heritabilities reported are very low (total heritabilities range from 0.02 to 0.06). The total heritabilities for the lamb death risk traits are lower than reported estimates of survival to 3 d of age or to weaning suggesting selection for the postmortem traits are not warranted at this time within these flocks. The total heritability for lamb birth weight was moderate (0.38) and the genetic correlations with the lamb death risk traits suggested that directional selection on lamb birth weight would have an effect on survival, although it is likely to have a nonlinear effect and therefore an optimum birth weight at which survival is maximized. This study has also shown that the total heritabilities may be overestimated when not accounting for maternal genetic and environment effects and in particular not accounting for the random environmental effect of litter (dam/year).

Partially linear mixed-effects joint models for skewed and missing longitudinal competing risks outcomes.

PubMed

Lu, Tao; Lu, Minggen; Wang, Min; Zhang, Jun; Dong, Guang-Hui; Xu, Yong

2017-12-18

Longitudinal competing risks data frequently arise in clinical studies. Skewness and missingness are commonly observed for these data in practice. However, most joint models do not account for these data features. In this article, we propose partially linear mixed-effects joint models to analyze skew longitudinal competing risks data with missingness. In particular, to account for skewness, we replace the commonly assumed symmetric distributions by asymmetric distribution for model errors. To deal with missingness, we employ an informative missing data model. The joint models that couple the partially linear mixed-effects model for the longitudinal process, the cause-specific proportional hazard model for competing risks process and missing data process are developed. To estimate the parameters in the joint models, we propose a fully Bayesian approach based on the joint likelihood. To illustrate the proposed model and method, we implement them to an AIDS clinical study. Some interesting findings are reported. We also conduct simulation studies to validate the proposed method.

Prior health expenditures and risk sharing with insurers competing on quality.

PubMed

Marchand, Maurice; Sato, Motohiro; Schokkaert, Erik

2003-01-01

Insurers can exploit the heterogeneity within risk-adjustment classes to select the good risks because they have more information than the regulator on the expected expenditures of individual insurees. To counteract this cream skimming, mixed systems combining capitation and cost-based payments have been adopted that do not, however, generally use the past expenditures of insurees as a risk adjuster. In this article, two symmetric insurers compete for clients by differentiating the quality of service offered to them according to some private information about their risk. In our setting it is always welfare improving to use prior expenditures as a risk adjuster.

CASAS: Cancer Survival Analysis Suite, a web based application.

PubMed

Rupji, Manali; Zhang, Xinyan; Kowalski, Jeanne

2017-01-01

We present CASAS, a shiny R based tool for interactive survival analysis and visualization of results. The tool provides a web-based one stop shop to perform the following types of survival analysis:  quantile, landmark and competing risks, in addition to standard survival analysis.  The interface makes it easy to perform such survival analyses and obtain results using the interactive Kaplan-Meier and cumulative incidence plots.  Univariate analysis can be performed on one or several user specified variable(s) simultaneously, the results of which are displayed in a single table that includes log rank p-values and hazard ratios along with their significance. For several quantile survival analyses from multiple cancer types, a single summary grid is constructed. The CASAS package has been implemented in R and is available via http://shinygispa.winship.emory.edu/CASAS/. The developmental repository is available at https://github.com/manalirupji/CASAS/.

Semiparametric regression analysis of interval-censored competing risks data.

PubMed

Mao, Lu; Lin, Dan-Yu; Zeng, Donglin

2017-09-01

Interval-censored competing risks data arise when each study subject may experience an event or failure from one of several causes and the failure time is not observed directly but rather is known to lie in an interval between two examinations. We formulate the effects of possibly time-varying (external) covariates on the cumulative incidence or sub-distribution function of competing risks (i.e., the marginal probability of failure from a specific cause) through a broad class of semiparametric regression models that captures both proportional and non-proportional hazards structures for the sub-distribution. We allow each subject to have an arbitrary number of examinations and accommodate missing information on the cause of failure. We consider nonparametric maximum likelihood estimation and devise a fast and stable EM-type algorithm for its computation. We then establish the consistency, asymptotic normality, and semiparametric efficiency of the resulting estimators for the regression parameters by appealing to modern empirical process theory. In addition, we show through extensive simulation studies that the proposed methods perform well in realistic situations. Finally, we provide an application to a study on HIV-1 infection with different viral subtypes. © 2017, The International Biometric Society.

Ohio Financial Services and Risk Management. Technical Competency Profile (TCP).

ERIC Educational Resources Information Center

Ray, Gayl M.; Wilson, Nick; Mangini, Rick

This document describes the essential competencies from secondary through post-secondary associate degree programs for a career in financial services and risk management. Ohio College Tech Prep Program standards are described, and a key to profile codes is provided. Sample occupations in this career area, such as financial accountant, loan…

Prevalence, Risk Factors, and Survival of Patients with Intrahepatic Cholangiocarcinoma.

PubMed

Chinchilla-López, Paulina; Aguilar-Olivos, Nancy; García-Gómez, Jaime; Hernández-Alejandro, Karen; Chablé-Montero, Fredy; Motola-Kuba, Daniel; Patel, Tushar; Méndez-Sánchez, Nahum

2017-01-01

To investigate the prevalence, related risk factors, and survival of intrahepatic cholangiocarcinoma in a Mexican population. We conducted a cross-sectional study at Medica Sur Hospital in Mexico City with approval of the local research ethics committee. We found cases by reviewing all clinical records of in-patients between October 2005 and January 2016 who had been diagnosed with malignant liver tumors. Clinical characteristics and comorbidities were obtained to evaluate the probable risk factors and the Charlson index. The cases were staged based on the TNM staging system for bile duct tumors used by the American Joint Committee on Cancer and median patient survival rates were calculated using the Kaplan-Meier method. We reviewed 233 cases of hepatic cancer. Amongst these, hepatocellular carcinomas represented 19.3% (n = 45), followed by intrahepatic cholangiocarcinomas, which accounted for 7.7% (n = 18). The median age of patients with intrahepatic cholangiocarcinoma was 63 years, and most of them presented with cholestasis and intrahepatic biliary ductal dilation. Unfortunately, 89% (n = 16) of them were in an advanced stage and 80% had multicentric tumors. Median survival was 286 days among patients with advanced stage tumors (25th-75th interquartile range, 174-645 days). No correlation was found between the presence of comorbidities defined by the Charlson index, and survival. We evaluated the presence of definite and probable risk factors for the development of intrahepatic cholangiocarcinoma, that is, smoking, alcohol consumption, and primary sclerosing cholangitis. We found an overall prevalence of intrahepatic cholangiocarcinoma of 7.7%; unfortunately, these patients were diagnosed at advanced stages. Smoking and primary sclerosing cholangitis were the positive risk factors for its development in this population.

Chronic kidney disease in dogs in UK veterinary practices: prevalence, risk factors, and survival.

PubMed

O'Neill, D G; Elliott, J; Church, D B; McGreevy, P D; Thomson, P C; Brodbelt, D C

2013-01-01

The prevalence for chronic kidney disease (CKD) in dogs varies widely (0.05-3.74%). Identified risk factors include advancing age, specific breeds, small body size, and periodontal disease. To estimate the prevalence and identify risk factors associated with CKD diagnosis and survival in dogs. Purebred dogs were hypothesized to have higher CKD risk and poorer survival characteristics than crossbred dogs. A merged clinical database of 107,214 dogs attending 89 UK veterinary practices over a 2-year period (January 2010-December 2011). A longitudinal study design estimated the apparent prevalence (AP) whereas the true prevalence (TP) was estimated using Bayesian analysis. A nested case-control study design evaluated risk factors. Survival analysis used the Kaplan-Meier survival curve method and multivariable Cox proportional hazards regression modeling. The CKD AP was 0.21% (95% CI: 0.19-0.24%) and TP was 0.37% (95% posterior credibility interval 0.02-1.44%). Significant risk factors included increasing age, being insured, and certain breeds (Cocker Spaniel, Cavalier King Charles Spaniel). Cardiac disease was a significant comorbid disorder. Significant clinical signs included halitosis, weight loss, polyuria/polydipsia, urinary incontinence, vomiting, decreased appetite, lethargy, and diarrhea. The median survival time from diagnosis was 226 days (95% CI 112-326 days). International Renal Interest Society stage and blood urea nitrogen concentration at diagnosis were significantly associated with hazard of death due to CKD. Chronic kidney disease compromises dog welfare. Increased awareness of CKD risk factors and association of blood biochemistry results with survival time should facilitate diagnosis and optimize case management to improve animal survival and welfare. Copyright © 2013 by the American College of Veterinary Internal Medicine.

Usefulness of cancer-free survival in estimating the lifetime attributable risk of cancer incidence from radiation exposure.

PubMed

Seo, Songwon; Lee, Dal Nim; Jin, Young Woo; Lee, Won Jin; Park, Sunhoo

2018-05-11

Risk projection models estimating the lifetime cancer risk from radiation exposure are generally based on exposure dose, age at exposure, attained age, gender and study-population-specific factors such as baseline cancer risks and survival rates. Because such models have mostly been based on the Life Span Study cohort of Japanese atomic bomb survivors, the baseline risks and survival rates in the target population should be considered when applying the cancer risk. The survival function used in the risk projection models that are commonly used in the radiological protection field to estimate the cancer risk from medical or occupational exposure is based on all-cause mortality. Thus, it may not be accurate for estimating the lifetime risk of high-incidence but not life-threatening cancer with a long-term survival rate. Herein, we present the lifetime attributable risk (LAR) estimates of all solid cancers except thyroid cancer, thyroid cancer, and leukemia except chronic lymphocytic leukemia in South Korea for lifetime exposure to 1 mGy per year using the cancer-free survival function, as recently applied in the Fukushima health risk assessment by the World Health Organization. Compared with the estimates of LARs using an overall survival function solely based on all-cause mortality, the LARs of all solid cancers except thyroid cancer, and thyroid cancer evaluated using the cancer-free survival function, decreased by approximately 13% and 1% for men and 9% and 5% for women, respectively. The LAR of leukemia except chronic lymphocytic leukemia barely changed for either gender owing to the small absolute difference between its incidence and mortality. Given that many cancers have a high curative rate and low mortality rate, using a survival function solely based on all-cause mortality may cause an overestimation of the lifetime risk of cancer incidence. The lifetime fractional risk was robust against the choice of survival function.

Quantifying the predictive accuracy of time-to-event models in the presence of competing risks.

PubMed

Schoop, Rotraut; Beyersmann, Jan; Schumacher, Martin; Binder, Harald

2011-02-01

Prognostic models for time-to-event data play a prominent role in therapy assignment, risk stratification and inter-hospital quality assurance. The assessment of their prognostic value is vital not only for responsible resource allocation, but also for their widespread acceptance. The additional presence of competing risks to the event of interest requires proper handling not only on the model building side, but also during assessment. Research into methods for the evaluation of the prognostic potential of models accounting for competing risks is still needed, as most proposed methods measure either their discrimination or calibration, but do not examine both simultaneously. We adapt the prediction error proposal of Graf et al. (Statistics in Medicine 1999, 18, 2529–2545) and Gerds and Schumacher (Biometrical Journal 2006, 48, 1029–1040) to handle models with competing risks, i.e. more than one possible event type, and introduce a consistent estimator. A simulation study investigating the behaviour of the estimator in small sample size situations and for different levels of censoring together with a real data application follows.

'Putting it into words': developing the RCGP competency descriptors to include 'at-risk behaviours'.

PubMed

Jones, Tim; Tracey, Sue

2012-11-01

As part of the Royal College of General Practitioners' (RCGP) arrangements to satisfy the GMC's requirement for Work Place Based Assessment (WPBAs) a range of 12 WPBA competencies was drawn up. Further to this the RCGP produced descriptors of the behaviours that would demonstrate a trainee had gained competence in that area. Recently the RCGP have expanded the rating scale available to educational supervisors at the time of a review to allow for a finding of 'Needs Further Development (NFD) - below expectations'. In the North of Scotland Deanery it has been recognised that a number of trainees are struggling to demonstrate competency in WPBA and to complete training. Reviewing how we could help these trainees and their educational supervisors there was recognition that early identification of these trainees would assist remedial action. Additionally, having reliable indicators of behaviours associated with a trainee in difficulty would aid the assessment of a trainee as 'NFD - below expectations'. Although many reliable descriptors of 'at-risk' behaviour exist, within frameworks and systems for doctors felt to be in difficulty these systems lie outwith the WPBA competency framework. This paper describes the work undertaken in the North of Scotland Deanery to modify the original table of descriptors for the 12 WPBA competencies to include an 'NFD - below expectations'/'at-risk' behaviours column. The descriptors of behaviours associated with trainees in difficulty have been aligned to the 12 WPBA competencies and used to populate the additional column in the descriptor table. The expectation is that the expanded table of descriptors will assist both in early identification of trainees' at-risk behaviours so that formative work can be engaged in at an early stage in an attachment, and also in the objective assessment of a trainee at an educational supervisor's review if they're in difficulties.

Quantifying and estimating the predictive accuracy for censored time-to-event data with competing risks.

PubMed

Wu, Cai; Li, Liang

2018-05-15

This paper focuses on quantifying and estimating the predictive accuracy of prognostic models for time-to-event outcomes with competing events. We consider the time-dependent discrimination and calibration metrics, including the receiver operating characteristics curve and the Brier score, in the context of competing risks. To address censoring, we propose a unified nonparametric estimation framework for both discrimination and calibration measures, by weighting the censored subjects with the conditional probability of the event of interest given the observed data. The proposed method can be extended to time-dependent predictive accuracy metrics constructed from a general class of loss functions. We apply the methodology to a data set from the African American Study of Kidney Disease and Hypertension to evaluate the predictive accuracy of a prognostic risk score in predicting end-stage renal disease, accounting for the competing risk of pre-end-stage renal disease death, and evaluate its numerical performance in extensive simulation studies. Copyright © 2018 John Wiley & Sons, Ltd.

CASAS: Cancer Survival Analysis Suite, a web based application

PubMed Central

Rupji, Manali; Zhang, Xinyan; Kowalski, Jeanne

2017-01-01

We present CASAS, a shiny R based tool for interactive survival analysis and visualization of results. The tool provides a web-based one stop shop to perform the following types of survival analysis:  quantile, landmark and competing risks, in addition to standard survival analysis.  The interface makes it easy to perform such survival analyses and obtain results using the interactive Kaplan-Meier and cumulative incidence plots.  Univariate analysis can be performed on one or several user specified variable(s) simultaneously, the results of which are displayed in a single table that includes log rank p-values and hazard ratios along with their significance. For several quantile survival analyses from multiple cancer types, a single summary grid is constructed. The CASAS package has been implemented in R and is available via http://shinygispa.winship.emory.edu/CASAS/. The developmental repository is available at https://github.com/manalirupji/CASAS/. PMID:28928946

Varying coefficient subdistribution regression for left-truncated semi-competing risks data.

PubMed

Li, Ruosha; Peng, Limin

2014-10-01

Semi-competing risks data frequently arise in biomedical studies when time to a disease landmark event is subject to dependent censoring by death, the observation of which however is not precluded by the occurrence of the landmark event. In observational studies, the analysis of such data can be further complicated by left truncation. In this work, we study a varying co-efficient subdistribution regression model for left-truncated semi-competing risks data. Our method appropriately accounts for the specifical truncation and censoring features of the data, and moreover has the flexibility to accommodate potentially varying covariate effects. The proposed method can be easily implemented and the resulting estimators are shown to have nice asymptotic properties. We also present inference, such as Kolmogorov-Smirnov type and Cramér Von-Mises type hypothesis testing procedures for the covariate effects. Simulation studies and an application to the Denmark diabetes registry demonstrate good finite-sample performance and practical utility of the proposed method.

Competing risks regression for clustered data

PubMed Central

Zhou, Bingqing; Fine, Jason; Latouche, Aurelien; Labopin, Myriam

2012-01-01

A population average regression model is proposed to assess the marginal effects of covariates on the cumulative incidence function when there is dependence across individuals within a cluster in the competing risks setting. This method extends the Fine–Gray proportional hazards model for the subdistribution to situations, where individuals within a cluster may be correlated due to unobserved shared factors. Estimators of the regression parameters in the marginal model are developed under an independence working assumption where the correlation across individuals within a cluster is completely unspecified. The estimators are consistent and asymptotically normal, and variance estimation may be achieved without specifying the form of the dependence across individuals. A simulation study evidences that the inferential procedures perform well with realistic sample sizes. The practical utility of the methods is illustrated with data from the European Bone Marrow Transplant Registry. PMID:22045910

Risk Factors of Mortality from All Asbestos-Related Diseases: A Competing Risk Analysis.

PubMed

Abós-Herràndiz, Rafael; Rodriguez-Blanco, Teresa; Garcia-Allas, Isabel; Rosell-Murphy, Isabel-Magdalena; Albertí-Casas, Constança; Tarrés, Josep; Krier-Günther, Illona; Martinez-Artés, Xavier; Orriols, Ramon; Grimau-Malet, Isidre; Canela-Soler, Jaume

2017-01-01

The mortality from all malignant and nonmalignant asbestos-related diseases remains unknown. The authors assessed the incidence and risk factors for all asbestos-related deaths. The sample included 544 patients from an asbestos-exposed community in the area of Barcelona (Spain), between Jan 1, 1970, and Dec 31, 2006. Competing risk regression through a subdistribution hazard analysis was used to estimate risk factors for the outcomes. Asbestos-related deaths were observed in 167 (30.7%) patients and 57.5% of these deaths were caused by some type of mesothelioma. The incidence rate after diagnosis was 3,600 per 100,000 person-years. In 7.5% of patients death was non-asbestos-related, while pleural and peritoneal mesothelioma were identified in 87 (16.0%) and 18 (3.3%) patients, respectively. Age, sex, household exposure, cumulative nonmalignant asbestos-related disease, and single malignant pathology were identified as risk factors for asbestos-related death. These findings suggest the need to develop a preventive approach to the community and to improve the clinical follow-up process of these patients.

The prognostic role of body mass index on mortality amongst the middle-aged and elderly: a competing risk analysis.

PubMed

Ghaem Maralani, Haleh; Tai, Bee Choo; Wong, Tien Y; Tai, E Shyong; Li, Jialiang; Wang, Jie Jin; Mitchell, Paul

2014-01-01

To determine the relationship between body mass index (BMI) including its 5-year changes and mortality, and compare the results obtained using Cox and competing risks models. Our study subjects included 2216 persons aged ≥49 years who participated in the Blue Mountains Eye Study, Australia between 1992 and 1994, and returned for further follow-up examinations between 1997 and 1999. We examined the relationship between BMI and mortality using cubic spline. The Cox and competing risks models were used to assess the associations between baseline BMI and its 5-year changes with all-cause and cause-specific mortality. Amongst subjects aged ≤70 years, the relationship between BMI and all-cause mortality was U-shaped. For those aged >70 years, an L-shaped relationship was seen with no elevation in risk amongst the overweight/obese. Based on the competing risks model, obesity at baseline was associated with increased risk of cardiovascular death and reduction in BMI at 5-year was linked to an increase risk of cancer death amongst those aged ≤70 years. The cause-specific Cox model showed that reduction in BMI at 5-year was associated with cancer-death regardless of age, and with cardiovascular deaths among subjects aged ≤70 years. Cox regression model showed larger magnitude of effect with wider confidence interval as compared with competing risks model. Conditions associated with obesity are more likely to affect mortality among subjects aged ≤70 years, but not among those aged over 70 years. Cox model shows larger magnitude of effect in comparison with competing risks model. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

When perception reflects reality: Non-native grass invasion alters small mammal risk landscapes and survival

USGS Publications Warehouse

Ceradnini, Joseph P.; Chalfoun, Anna D.

2017-01-01

Modification of habitat structure due to invasive plants can alter the risk landscape for wildlife by, for example, changing the quality or availability of refuge habitat. Whether perceived risk corresponds with actual fitness outcomes, however, remains an important open question. We simultaneously measured how habitat changes due to a common invasive grass (cheatgrass, Bromus tectorum) affected the perceived risk, habitat selection, and apparent survival of a small mammal, enabling us to assess how well perceived risk influenced important behaviors and reflected actual risk. We measured perceived risk by nocturnal rodents using a giving-up density foraging experiment with paired shrub (safe) and open (risky) foraging trays in cheatgrass and native habitats. We also evaluated microhabitat selection across a cheatgrass gradient as an additional assay of perceived risk and behavioral responses for deer mice (Peromyscus maniculatus) at two spatial scales of habitat availability. Finally, we used mark-recapture analysis to quantify deer mouse apparent survival across a cheatgrass gradient while accounting for detection probability and other habitat features. In the foraging experiment, shrubs were more important as protective cover in cheatgrass-dominated habitats, suggesting that cheatgrass increased perceived predation risk. Additionally, deer mice avoided cheatgrass and selected shrubs, and marginally avoided native grass, at two spatial scales. Deer mouse apparent survival varied with a cheatgrass–shrub interaction, corresponding with our foraging experiment results, and providing a rare example of a native plant mediating the effects of an invasive plant on wildlife. By synthesizing the results of three individual lines of evidence (foraging behavior, habitat selection, and apparent survival), we provide a rare example of linkage between behavioral responses of animals indicative of perceived predation risk and actual fitness outcomes. Moreover, our results

Polymorphisms in chemokine and receptor genes and gastric cancer risk and survival in a high risk Polish population

PubMed Central

Gawron, Andrew J.; Fought, Angela J.; Lissowska, Jolanta; Ye, Weimin; Zhang, Xiao; Chow, Wong-Ho; Freeman, Laura E. Beane; Hou, Lifang

2010-01-01

Objective To examine if genetic variations in chemokine receptor and ligand genes are associated with gastric cancer risk and survival. Methods The study included 298 cases and 417 controls from a population-based study of gastric cancer conducted in Warsaw, Poland in 1994–1996. We investigated seven single nucleotide polymorphisms in a chemokine ligand (CXCL12) and chemokine receptor (CCR2, CCR5, CX3CR1) genes and one frameshift deletion (CCR5) in blood leukocyte DNA in relation to gastric cancer risk and survival. Genotyping was conducted at the NCI Core Genotyping Facility. Odds ratios and 95% confidence intervals were computed using univariate and multivariate logistic regression models. Survival analysis was performed using Cox proportional hazards models. Results Gastric cancer risk was not associated with single chemokine polymorphisms. A CCR5 haplotype that contained the common alleles of IVS1+151 G>T (rs2734648), IVS2+80 C>T (rs1800024) and minor allele of IVS1+246 A>G (rs1799987) was associated with a borderline significantly increased risk (OR = 1.5, 95% CI: 1.0–2.2). For gastric cancer cases, there was a greater risk of death for carriers of the minor alleles of CCR2 Ex2+241 G>A (rs1799864) (HR = 1.5, 95% CI: 1.1–2.1) and CCR5 IVS2+80 C>T (rs1800024) (HR = 1.5, 95% CI: 1.1–2.1). Carriers of the CCR5 minor allele of IVS1+151 G>T (rs2734648) had a decreased risk of death compared to homozygote carriers of the common allele (HR = 0.8, 95% CI: 0.6–1.0). Conclusions Our findings do not support an association between gastric cancer risk and single chemokine genetic variation. The observed associations between cancer risk and a CCR5 haplotype and between survival and polymorphisms in CCR2 and CCR5 need replication in future studies. PMID:21091093

Polymorphisms in chemokine and receptor genes and gastric cancer risk and survival in a high risk Polish population.

PubMed

Gawron, Andrew J; Fought, Angela J; Lissowska, Jolanta; Ye, Weimin; Zhang, Xiao; Chow, Wong-Ho; Beane Freeman, Laura E; Hou, Lifang

2011-03-01

To examine if genetic variations in chemokine receptor and ligand genes are associated with gastric cancer risk and survival. The study included 298 cases and 417 controls from a population-based study of gastric cancer conducted in Warsaw, Poland in 1994-1996. We investigated seven single nucleotide polymorphisms in a chemokine ligand (CXCL12) and chemokine receptor (CCR2, CCR5, CX3CR1) genes and one frameshift deletion (CCR5) in blood leukocyte DNA in relation to gastric cancer risk and survival. Genotyping was conducted at the NCI Core Genotyping Facility. Odds ratios and 95% confidence intervals were computed using univariate and multivariate logistic regression models. Survival analysis was performed using Cox proportional hazards models. Gastric cancer risk was not associated with single chemokine polymorphisms. A CCR5 haplotype that contained the common alleles of IVS1+151 G>T (rs2734648), IVS2+80 C>T (rs1800024) and minor allele of IVS1+246 A>G (rs1799987) was associated with a borderline significantly increased risk (OR = 1.5, 95% CI: 1.0?2.2). For gastric cancer cases, there was a greater risk of death for carriers of the minor alleles of CCR2 Ex2+241 G>A (rs1799864) (HR = 1.5, 95% CI: 1.1-2.1) and CCR5 IVS2+80 C>T (rs1800024) (HR = 1.5, 95% CI: 1.1-2.1). Carriers of the CCR5 minor allele of IVS1+151 G>T (rs2734648) had a decreased risk of death compared to homozygote carriers of the common allele (HR = 0.8, 95% CI: 0.6-1.0). Our findings do not support an association between gastric cancer risk and single chemokine genetic variation. The observed associations between cancer risk and a CCR5 haplotype and between survival and polymorphisms in CCR2 and CCR5 need replication in future studies.

Human disease mortality kinetics are explored through a chain model embodying principles of extreme value theory and competing risks.

PubMed

Juckett, D A; Rosenberg, B

1992-04-21

The distributions for human disease-specific mortality exhibit two striking characteristics: survivorship curves that intersect near the longevity limit; and, the clustering of best-fitting Weibull shape parameter values into groups centered on integers. Correspondingly, we have hypothesized that the distribution intersections result from either competitive processes or population partitioning and the integral clustering in the shape parameter results from the occurrence of a small number of rare, rate-limiting events in disease progression. In this report we initiate a theoretical examination of these questions by exploring serial chain model dynamics and parameteric competing risks theory. The links in our chain models are composed of more than one bond, where the number of bonds in a link are denoted the link size and are the number of events necessary to break the link and, hence, the chain. We explored chains with all links of the same size or with segments of the chain composed of different size links (competition). Simulations showed that chain breakage dynamics depended on the weakest-link principle and followed kinetics of extreme-values which were very similar to human mortality kinetics. In particular, failure distributions for simple chains were Weibull-type extreme-value distributions with shape parameter values that were identifiable with the integral link size in the limit of infinite chain length. Furthermore, for chains composed of several segments of differing link size, the survival distributions for the various segments converged at a point in the S(t) tails indistinguishable from human data. This was also predicted by parameteric competing risks theory using Weibull underlying distributions. In both the competitive chain simulations and the parametric competing risks theory, however, the shape values for the intersecting distributions deviated from the integer values typical of human data. We conclude that rare events can be the source of

Accelerated failure time models for semi-competing risks data in the presence of complex censoring.

PubMed

Lee, Kyu Ha; Rondeau, Virginie; Haneuse, Sebastien

2017-12-01

Statistical analyses that investigate risk factors for Alzheimer's disease (AD) are often subject to a number of challenges. Some of these challenges arise due to practical considerations regarding data collection such that the observation of AD events is subject to complex censoring including left-truncation and either interval or right-censoring. Additional challenges arise due to the fact that study participants under investigation are often subject to competing forces, most notably death, that may not be independent of AD. Towards resolving the latter, researchers may choose to embed the study of AD within the "semi-competing risks" framework for which the recent statistical literature has seen a number of advances including for the so-called illness-death model. To the best of our knowledge, however, the semi-competing risks literature has not fully considered analyses in contexts with complex censoring, as in studies of AD. This is particularly the case when interest lies with the accelerated failure time (AFT) model, an alternative to the traditional multiplicative Cox model that places emphasis away from the hazard function. In this article, we outline a new Bayesian framework for estimation/inference of an AFT illness-death model for semi-competing risks data subject to complex censoring. An efficient computational algorithm that gives researchers the flexibility to adopt either a fully parametric or a semi-parametric model specification is developed and implemented. The proposed methods are motivated by and illustrated with an analysis of data from the Adult Changes in Thought study, an on-going community-based prospective study of incident AD in western Washington State. © 2017, The International Biometric Society.

Incidence and survival of stomach cancer in a high-risk population of Chile

PubMed Central

Heise, Katy; Bertran, Enriqueta; Andia, Marcelo E; Ferreccio, Catterina

2009-01-01

AIM: To study the incidence and survival rate of stomach cancer (SC) and its associated factors in a high risk population in Chile. METHODS: The population-based cancer registry of Valdivia, included in the International Agency for Research on Cancer system, covers 356 396 residents of Valdivia Province, Southern Chile. We studied all SC cases entered in this Registry during 1998-2002 (529 cases). Population data came from the Chilean census (2002). Standardized incidence rates per 100 000 inhabitants (SIR) using the world population, cumulative risk of developing cancer before age 75, and rate ratios by sex, age, ethnicity and social factors were estimated. Relative survival (Ederer II method) and age-standardized estimates (Brenner method) were calculated. Specific survival rates (Kaplan-Meier) were measured at 3 and 5 years and survival curves were analyzed with the Logrank and Breslow tests. Survival was studied in relation to demographics, clinical presentation, laboratory results and medical management of the cases. Those variables significantly associated with survival were later included in a Cox multivariate model. RESULTS: Between 1998 and 2002, 529 primary gastric cancers occurred in Valdivia (crude incidence rate 29.2 per 100 000 inhabitants). Most cases were male (69.0%), residents of urban areas (57.5%) and Hispanic (83.2%), with a low education level (84.5% < 8 school years). SC SIR was higher in men than women (40.8 and 14.8 respectively, P < 0.001), risk factors were low education RR 4.4 (95% CI: 2.9-6.8) and 1.6, (95% CI: 1.1-2.1) for women and men respectively and Mapuche ethnicity only significant for women (RR 2.2, 95% CI: 1.2-3.7). Of all cases, 76.4% were histologically confirmed, 11.5% had a death certificate only (DCO), 56.1% were TNM stage IV; 445 cases (84.1%) were eligible for survival analysis, all completed five years follow-up; 42 remained alive, 392 died of SC and 11 died from other causes. Specific 5-year survival, excluding cases

Causal inference in survival analysis using pseudo-observations.

PubMed

Andersen, Per K; Syriopoulou, Elisavet; Parner, Erik T

2017-07-30

Causal inference for non-censored response variables, such as binary or quantitative outcomes, is often based on either (1) direct standardization ('G-formula') or (2) inverse probability of treatment assignment weights ('propensity score'). To do causal inference in survival analysis, one needs to address right-censoring, and often, special techniques are required for that purpose. We will show how censoring can be dealt with 'once and for all' by means of so-called pseudo-observations when doing causal inference in survival analysis. The pseudo-observations can be used as a replacement of the outcomes without censoring when applying 'standard' causal inference methods, such as (1) or (2) earlier. We study this idea for estimating the average causal effect of a binary treatment on the survival probability, the restricted mean lifetime, and the cumulative incidence in a competing risks situation. The methods will be illustrated in a small simulation study and via a study of patients with acute myeloid leukemia who received either myeloablative or non-myeloablative conditioning before allogeneic hematopoetic cell transplantation. We will estimate the average causal effect of the conditioning regime on outcomes such as the 3-year overall survival probability and the 3-year risk of chronic graft-versus-host disease. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.

REVEAL risk scores applied to riociguat-treated patients in PATENT-2: Impact of changes in risk score on survival.

PubMed

Benza, Raymond L; Farber, Harrison W; Frost, Adaani; Ghofrani, Hossein-Ardeschir; Gómez-Sánchez, Miguel A; Langleben, David; Rosenkranz, Stephan; Busse, Dennis; Meier, Christian; Nikkho, Sylvia; Hoeper, Marius M

2018-04-01

The Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL) risk score (RRS) calculator was developed using data derived from the REVEAL registry, and predicts survival in patients with pulmonary arterial hypertension (PAH) based on multiple patient characteristics. Herein we applied the RRS to a pivotal PAH trial database, the 12-week PATENT-1 and open-label PATENT-2 extension studies of riociguat. We examined the effect of riociguat vs placebo on RRS in PATENT-1, and investigated the prognostic implications of change in RRS during PATENT-1 on long-term outcomes in PATENT-2. RRS was calculated post hoc for baseline and Week 12 of PATENT-1, and Week 12 of PATENT-2. Patients were grouped into risk strata by RRS. Kaplan-Meier estimates were made for survival and clinical worsening-free survival in PATENT-2 to evaluate the relationship between RRS in PATENT-1 and long-term outcomes in PATENT-2. A total of 396 patients completed PATENT-1 and participated in PATENT-2. In PATENT-1, riociguat significantly improved RRS (p = 0.031) and risk stratum (p = 0.018) between baseline and Week 12 compared with placebo. RRS at baseline, and at PATENT-1 Week 12, and change in RRS during PATENT-1 were significantly associated with survival (hazard ratios for a 1-point reduction in RRS: 0.675, 0.705 and 0.804, respectively) and clinical worsening-free survival (hazard ratios of 0.736, 0.716 and 0.753, respectively) over 2 years in PATENT-2. RRS at baseline and Week 12, and change in RRS, were significant predictors of both survival and clinical worsening-free survival. These data support the long-term predictive value of the RRS in a controlled study population. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Risks of Death and Stroke in Patients Undergoing Hemodialysis With New-Onset Atrial Fibrillation: A Competing-Risk Analysis of a Nationwide Cohort.

PubMed

Shih, Chia-Jen; Ou, Shuo-Ming; Chao, Pei-Wen; Kuo, Shu-Chen; Lee, Yi-Jung; Yang, Chih-Yu; Tarng, Der-Cherng; Lin, Chih-Ching; Huang, Po-Hsun; Li, Szu-Yuan; Chen, Yung-Tai

2016-01-19

Whether oral anticoagulant use should be considered in patients undergoing hemodialysis with atrial fibrillation (AF) remains controversial because of the uncertainty regarding risk-benefit assessments. The purpose of this study was to investigate the risk of ischemic stroke in patients undergoing hemodialysis with new-onset AF, in comparison with those without arrhythmia. This nationwide, population-based, propensity score-matched cohort study used data from Taiwan's National Health Insurance Research Database during 1998 to 2011 for patients on hemodialysis with new-onset nonvalvular AF and matched subjects without arrhythmia. The clinical end points were ischemic stroke (fatal or nonfatal), all-cause death, and other serious adverse cardiovascular events. In comparison with the matched cohort, patients with AF (n=6772) had higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.13-1.43), all-cause death (aHR, 1.59; 95% CI, 1.52-1.67), in-hospital cardiovascular death (aHR, 1.83; 95% CI, 1.71-1.94), myocardial infarction (aHR, 1.33; 95% CI, 1.17-1.51), and hospitalization for heart failure (aHR, 1.90; 95% CI, 1.76-2.05). After considering in-hospital death as a competing risk, AF significantly increased the risk of heart failure (HR, 1.56; 95% CI, 1.45-1.68), but not those of ischemic stroke and myocardial infarction. Additionally, the predictive value of the CHA2DS2-VASc score for ischemic stroke was diminished in the competing-risk model. The risk of stroke was only modestly higher in patients undergoing hemodialysis with new-onset AF than in those without AF, and it became insignificant when accounting for the competing risk of in-hospital death. © 2015 American Heart Association, Inc.

[Assessment of risk of burden in construction: improvement interventions and contribution of the competent physician].

PubMed

Martinelli, R; Tarquini, M

2012-01-01

Three construction companies in three years have changed the operating modes, making use of innovative carpentry, with little amount of equipment, improved usability of the site, reduced cleaning time, less manual handling and reduced risk of accidents. The Competent Doctor has participated in the review of the risk assessment of manual handling: data has been acquired on musculoskeletal disorders to compare, in terms of this innovation, the average trend and changes, with encouraging results in terms of incidence of musculoskeletal disorders, absenteeism due to illness by these causes, new cases of lumbar diseases. It remains difficult in building to assess manual handling risk, but the collaboration between the Employer, Prevention and Protection Service and Competent Doctor, thanks to the greater attention that the design subject to these issues, suggests improvements and further steps to extend to all phases of operation of building.

A PROSPECTIVE STUDY OF PHOBIC ANXIETY, RISK OF OVARIAN CANCER, AND SURVIVAL AMONG PATIENTS

PubMed Central

Poole, Elizabeth M.; Kubzansky, Laura D.; Sood, Anil K.; Okereke, Olivia I.; Tworoger, Shelley S.

2016-01-01

Purpose In ovarian cancer patients and mouse models, psychosocial stress is associated with higher circulating markers of angiogenesis and cell migration, impaired immune response, and increasing tumor burden and aggressiveness. In the Nurses’ Health Studies (NHS/NHSII), we assessed whether phobic anxiety, a marker of chronic distress, was associated with risk of incident ovarian cancer as well as survival among ovarian cancer patients. Methods We used Cox proportional hazards regression to model the relative risks (RR) and 95% confidence intervals (CI) of ovarian cancer incidence and survival by categories of the Crown-Crisp phobic anxiety index (CCI). Results We identified 779 cases of ovarian cancer during 2,497,892 person-years of follow-up. For baseline CCI (NHS: 1988; NHSII: 1993), we observed a statistically non-significant increased risk of epithelial ovarian cancer (RR for CCI ≥4 vs. 0 or 1: 1.14; 95% CI: 0.96–1.36). However, when we updated CCI (NHS: 2004; NHSII: 2005), the associations were attenuated. Pre-diagnosis CCI was not associated with ovarian cancer survival (RR: for ≥4 vs. 0 or 1: 1.00; 95% CI: 0.77–1.31); results were similar for post-diagnosis CCI. Conclusions Distress, as measured by phobic anxiety symptoms, was not associated with ovarian cancer risk, although we cannot rule out a modest association. Future research should explore the role of phobic anxiety and other forms of psychological distress and ovarian cancer risk and survival. PMID:27023470

A prospective study of phobic anxiety, risk of ovarian cancer, and survival among patients.

PubMed

Poole, Elizabeth M; Kubzansky, Laura D; Sood, Anil K; Okereke, Olivia I; Tworoger, Shelley S

2016-05-01

In ovarian cancer patients and mouse models, psychosocial stress is associated with higher circulating markers of angiogenesis and cell migration, impaired immune response, and increasing tumor burden and aggressiveness. In the Nurses' Health Studies (NHS/NHSII), we assessed whether phobic anxiety, a marker of chronic distress, was associated with risk of incident ovarian cancer as well as survival among ovarian cancer patients. We used Cox proportional hazards regression to model the relative risks (RRs) and 95 % confidence intervals (CI) of ovarian cancer incidence and survival by categories of the Crown-Crisp phobic anxiety index (CCI). We identified 779 cases of ovarian cancer during 2,497,892 person-years of follow-up. For baseline CCI (NHS: 1988; NHSII: 1993), we observed a statistically nonsignificant increased risk of epithelial ovarian cancer (RR for CCI ≥ 4 vs. 0 or 1: 1.14; 95 % CI 0.96-1.36). However, when we updated CCI (NHS: 2004; NHSII: 2005), the associations were attenuated. Pre-diagnosis CCI was not associated with ovarian cancer survival (RR for ≥4 vs. 0 or 1: 1.00; 95 % CI 0.77-1.31); results were similar for post-diagnosis CCI. Distress, as measured by phobic anxiety symptoms, was not associated with ovarian cancer risk, although we cannot rule out a modest association. Future research should explore the role of phobic anxiety and other forms of psychological distress and ovarian cancer risk and survival.

A Competence-Based Science Learning Framework Illustrated through the Study of Natural Hazards and Disaster Risk Reduction

ERIC Educational Resources Information Center

Oyao, Sheila G.; Holbrook, Jack; Rannikmäe, Miia; Pagunsan, Marmon M.

2015-01-01

This article proposes a competence-based learning framework for science teaching, applied to the study of "big ideas", in this case to the study of natural hazards and disaster risk reduction (NH&DRR). The framework focuses on new visions of competence, placing emphasis on nurturing connectedness and behavioral actions toward…

Survival analysis of cancer risk reduction strategies for BRCA1/2 mutation carriers.

PubMed

Kurian, Allison W; Sigal, Bronislava M; Plevritis, Sylvia K

2010-01-10

Women with BRCA1/2 mutations inherit high risks of breast and ovarian cancer; options to reduce cancer mortality include prophylactic surgery or breast screening, but their efficacy has never been empirically compared. We used decision analysis to simulate risk-reducing strategies in BRCA1/2 mutation carriers and to compare resulting survival probability and causes of death. We developed a Monte Carlo model of breast screening with annual mammography plus magnetic resonance imaging (MRI) from ages 25 to 69 years, prophylactic mastectomy (PM) at various ages, and/or prophylactic oophorectomy (PO) at ages 40 or 50 years in 25-year-old BRCA1/2 mutation carriers. With no intervention, survival probability by age 70 is 53% for BRCA1 and 71% for BRCA2 mutation carriers. The most effective single intervention for BRCA1 mutation carriers is PO at age 40, yielding a 15% absolute survival gain; for BRCA2 mutation carriers, the most effective single intervention is PM, yielding a 7% survival gain if performed at age 40 years. The combination of PM and PO at age 40 improves survival more than any single intervention, yielding 24% survival gain for BRCA1 and 11% for BRCA2 mutation carriers. PM at age 25 instead of age 40 offers minimal incremental benefit (1% to 2%); substituting screening for PM yields a similarly minimal decrement in survival (2% to 3%). Although PM at age 25 plus PO at age 40 years maximizes survival probability, substituting mammography plus MRI screening for PM seems to offer comparable survival. These results may guide women with BRCA1/2 mutations in their choices between prophylactic surgery and breast screening.

Survival of ovarian cancer patients in Denmark: excess mortality risk analysis of five-year relative survival in the period 1978-2002.

PubMed

Hannibal, Charlotte Gerd; Cortes, Rikke; Engholm, Gerda; Kjaer, Susanne Krüger

2008-01-01

To explore the variation in ovarian cancer survival in Denmark in the period 1978-2002 in relation to time since diagnosis, age at diagnosis, period of diagnosis, stage and histology. Register-based cohort study. Denmark in the period 1978-2002. Using the nationwide Danish Cancer Registry, we included a total of 13,035 women diagnosed with invasive ovarian cancer in Denmark in the period 1978-2002. Excess mortality risk analyses of five-year relative survival of ovarian cancer patients diagnosed in the period 1978-2002 with follow-up through 2006 were made based on data from the NORDCAN database. Five-year relative survival, excess mortality rate (ER) and relative excess mortality risk (RER) after an ovarian cancer diagnosis. The relative survival of Danish ovarian cancer patients slightly increased in the period 1978-2002. The ERs were highest in the first year following diagnosis, in particular in the first three months, and among older patients, even for localized and regional tumors. The pattern remained the same when stratified by histological subgroup. Older age at diagnosis, earlier period of diagnosis, more advanced stage at diagnosis and being diagnosed with undifferentiated carcinoma predicted poorer survival among Danish ovarian cancer patients diagnosed in the period 1978-2002. The survival of Danish ovarian cancer patients has slightly increased from 1978 through 2002. Despite this, the mortality rate of ovarian cancer in Denmark is still higher than in the other Nordic countries. Explanations for these differences are still to be identified.

Survival and Risk Comparison of Campylobacter jejuni on Various Processed Meat Products

PubMed Central

Hong, Soo Hyeon; Kim, Han Sol; Yoon, Ki Sun

2016-01-01

The objective of this study was to investigate survival kinetics of Campylobacter jejuni on various processed meat products (dry-cured ham, round ham with/without sodium nitrite, garlic seasoned ham with/without sodium nitrite, and sausage without sodium nitrite). Additionally, a semi-quantitative risk assessment of C. jejuni on various processed meat products was conducted using FDA-iRISK 1.0. Inoculated processed meat products with 6.0 ± 0.5 log CFU/g of C. jejuni were vacuum packed and stored at 4, 10, 17, 24, 30, and 36 °C. Survival curves were fitted to the Weibull model to obtain the delta values of C. jejuni on various processed meat products. The most rapid death of C. jejuni was observed on dry-cured ham, followed by sausage without sodium nitrite. The results of semi-quantitative risk assessment indicate that dry-cured ham represented the lowest risk among all samples. C. jejuni on processed meats presented a greater risk at 4 °C than at 10 °C. The risk of ham was greater than the risk of sausage, regardless of type. Among all samples, the highest risk of C. jejuni was observed in round ham without sodium nitrite. Overall, our data indicates that risk of processed meat products due to C. jejuni is relatively low. PMID:27294947

Competing-risks mortality after radiotherapy vs. observation for localized prostate cancer: a population-based study.

PubMed

Abdollah, Firas; Sun, Maxine; Schmitges, Jan; Thuret, Rodolphe; Tian, Zhe; Shariat, Shahrokh F; Briganti, Alberto; Jeldres, Claudio; Perrotte, Paul; Montorsi, Francesco; Karakiewicz, Pierre I

2012-09-01

Contemporary patients with localized prostate cancer (PCa) are more frequently treated with radiotherapy. However, there are limited data on the effect of this treatment on cancer-specific mortality (CSM). Our objective was to test the relationship between radiotherapy and survival in men with localized PCa and compare it with those treated with observation. A population-based cohort identified 68,797 men with cT1-T2 PCa treated with radiotherapy or observation between the years 1992 and 2005. Propensity-score matching was used to minimize potential bias related to treatment assignment. Competing-risks analyses tested the effect of treatment type (radiotherapy vs. observation) on CSM, after accounting to other-cause mortality. All analyses were carried out within PCa risk, baseline comorbidity status, and age groups. Radiotherapy was associated with more favorable 10-year CSM rates than observation in patients with high-risk PCa (8.8 vs. 14.4%, hazard ratio [HR]: 0.59, 95% confidence interval [CI]: 0.50-0.68). Conversely, the beneficial effect of radiotherapy on CSM was not evident in patients with low-intermediate risk PCa (3.7 vs. 4.1%, HR: 0.91, 95% CI: 0.80-1.04). Radiotherapy was beneficial in elderly patients (5.6 vs. 7.3%, HR: 0.70, 95% CI: 0.59-0.80). Moreover, it was associated with improved CSM rates among patients with no comorbidities (5.7 vs. 6.5%, HR: 0.81, 95% CI: 0.67-0.98), one comorbidity (4.6 vs. 6.0%, HR: 0.87, 95% CI: 0.75-0.99), and more than two comorbidities (4.2 vs. 5.0%, HR: 0.79, 95% CI: 0.65-0.96). Radiotherapy substantially improves CSM in patients with high-risk PCa, with little or no benefit in patients with low-/intermediate-risk PCa relative to observation. These findings must be interpreted within the context of the limitations of observational data. Copyright © 2012 Elsevier Inc. All rights reserved.

Risk Factors of Anastomotic Leakage and Long-Term Survival After Colorectal Surgery

PubMed Central

Park, Jong Seob; Huh, Jung Wook; Park, Yoon Ah; Cho, Yong Beom; Yun, Seong Hyeon; Kim, Hee Cheol; Lee, Woo Yong

2016-01-01

Abstract Anastomotic leakage (AL) is one of the most serious complications of colorectal surgery. It can affect long-term oncologic outcomes, but the impact on long-term survival remains uncertain. The aim of this study is to evaluate the operative characteristics of leakage and no leakage groups and to analyze long-term oncologic outcomes. We prospectively enrolled 10,477 patients from 2000 to 2011 and retrospectively reviewed the data. Male sex (odds ratio [OR], 3.90; P < 0.001), intraoperative transfusion (OR, 2.31; P = 0.042), and operative time (OR, 1.73; P = 0.032) were independent risk factors of AL in the colon. In the rectum, male sex (OR, 2.37; P < 0.001), neoadjuvant chemoradiotherapy (OR, 2.26; P < 0.001), and regional lymph node metastasis (OR, 1.43; P = 0.012) were independent risk factors of AL, and diverting stoma (OR, 0.24; P < 0.001) was associated with a deceased risk of AL. AL in the rectum without a diverting stoma was associated with disease-free survival (DFS, OR, 1.47; P = 0.037). Colonic leakage was not associated with 5-year DFS (leakage group vs nonleakage group, 72.4% vs 80.9%, P = 0.084); however, in patients undergoing rectal resection, there was a significant difference in 5-year DFS (67.0% vs 76.6%, P = 0.005, respectively). AL in the rectum is associated with worse long-term DFS and overall survival. A diverting stoma was shown to protect against this effect and was associated with long-term survival in rectal surgery. Therefore, creating a diverting stoma should be considered in high-risk patients undergoing rectal surgery. PMID:26937928

Personalized Prognostic Risk Score for Long-Term Survival for Children with Acute Leukemia after Allogeneic Transplantation.

PubMed

Bitan, Menachem; Ahn, Kwang Woo; Millard, Heather R; Pulsipher, Michael A; Abdel-Azim, Hisham; Auletta, Jeffery J; Brown, Valerie; Chan, Ka Wah; Diaz, Miguel Angel; Dietz, Andrew; Vincent, Marta González; Guilcher, Gregory; Hale, Gregory A; Hayashi, Robert J; Keating, Amy; Mehta, Parinda; Myers, Kasiani; Page, Kristin; Prestidge, Tim; Shah, Nirali N; Smith, Angela R; Woolfrey, Ann; Thiel, Elizabeth; Davies, Stella M; Eapen, Mary

2017-09-01

We studied leukemia-free (LFS) and overall survival (OS) in children with acute myeloid (AML, n = 790) and acute lymphoblastic leukemia (ALL, n = 1096) who underwent transplantation between 2000 and 2010 and who survived for at least 1 year in remission after related or unrelated donor transplantation. Analysis of patient-, disease-, and transplantation characteristics and acute and chronic graft-versus-host disease (GVHD) was performed to identify factors with adverse effects on LFS and OS. These data were used to develop risk scores for survival. We did not identify any prognostic factors beyond 4 years after transplantation for AML and beyond 3 years for ALL. Risk score for survival for AML includes age, disease status at transplantation, cytogenetic risk group, and chronic GVHD. For ALL, the risk score includes age at transplantation and chronic GVHD. The 10-year probabilities of OS for AML with good (score 0, 1, or 2), intermediate (score 3), and poor risk (score 4, 5, 6, or 7) were 94%, 87%, and 68%, respectively. The 10-year probabilities of OS for ALL were 89% and 80% for good (score 0 or 1) and poor risk (score 2), respectively. Identifying children at risk for late mortality with early intervention may mitigate some excess late mortality. Copyright © 2017 The American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.

A balanced hazard ratio for risk group evaluation from survival data.

PubMed

Branders, Samuel; Dupont, Pierre

2015-07-30

Common clinical studies assess the quality of prognostic factors, such as gene expression signatures, clinical variables or environmental factors, and cluster patients into various risk groups. Typical examples include cancer clinical trials where patients are clustered into high or low risk groups. Whenever applied to survival data analysis, such groups are intended to represent patients with similar survival odds and to select the most appropriate therapy accordingly. The relevance of such risk groups, and of the related prognostic factors, is typically assessed through the computation of a hazard ratio. We first stress three limitations of assessing risk groups through the hazard ratio: (1) it may promote the definition of arbitrarily unbalanced risk groups; (2) an apparently optimal group hazard ratio can be largely inconsistent with the p-value commonly associated to it; and (3) some marginal changes between risk group proportions may lead to highly different hazard ratio values. Those issues could lead to inappropriate comparisons between various prognostic factors. Next, we propose the balanced hazard ratio to solve those issues. This new performance metric keeps an intuitive interpretation and is as simple to compute. We also show how the balanced hazard ratio leads to a natural cut-off choice to define risk groups from continuous risk scores. The proposed methodology is validated through controlled experiments for which a prescribed cut-off value is defined by design. Further results are also reported on several cancer prognosis studies, and the proposed methodology could be applied more generally to assess the quality of any prognostic markers. Copyright © 2015 John Wiley & Sons, Ltd.

Cerebral metastases in metastatic breast cancer: disease-specific risk factors and survival.

PubMed

Heitz, F; Rochon, J; Harter, P; Lueck, H-J; Fisseler-Eckhoff, A; Barinoff, J; Traut, A; Lorenz-Salehi, F; du Bois, A

2011-07-01

Survival of patients suffering from cerebral metastases (CM) is limited. Identification of patients with a high risk for CM is warranted to adjust follow-up care and to evaluate preventive strategies. Exploratory analysis of disease-specific parameter in patients with metastatic breast cancer (MBC) treated between 1998 and 2008 using cumulative incidences and Fine and Grays' multivariable regression analyses. After a median follow-up of 4.0 years, 66 patients (10.5%) developed CM. The estimated probability for CM was 5%, 12% and 15% at 1, 5 and 10 years; in contrast, the probability of death without CM was 21%, 61% and 76%, respectively. A small tumor size, ER status, ductal histology, lung and lymph node metastases, human epidermal growth factor receptor 2 positive (HER2+) tumors, younger age and M0 were associated with CM in univariate analyses, the latter three being risk factors in the multivariable model. Survival was shortened in patient developing CM (24.0 months) compared with patients with no CM (33.6 months) in the course of MBC. Young patients, primary with non-metastatic disease and HER2+ tumors, have a high risk to develop CM in MBC. Survival of patients developing CM in the course of MBC is impaired compared with patients without CM.

Influence of Competing Risks on Estimating the Expected Benefit of Warfarin Among Atrial Fibrillation Patients not Currently Taking Anticoagulants: the ATRIA Study

PubMed Central

Ashburner, Jeffrey M.; Go, Alan S.; Chang, Yuchiao; Fang, Margaret C.; Fredman, Lisa; Applebaum, Katie M.; Singer, Daniel E.

2016-01-01

Background/Objectives To date, studies examining the association between warfarin therapy and incidence of ischemic stroke among patients with atrial fibrillation (AF) have not accounted for the competing risk of death. Competing risk analysis may provide greater understanding of the “real world” impact of anticoagulation on stroke risk over a multiyear time span. Design Cohort study Setting ATRIA Study community-based cohort Participants 13,559 adults with nonvalvular AF between 1996 and 2003. Measurements All events were clinician-adjudicated. We used extended Cox regression with longitudinal warfarin exposure to estimate cause-specific hazard ratios (HR) for thromboembolism (TE) and the competing risk event (all cause death). The Fine and Gray subdistribution regression approach was used to estimate this association while accounting for competing death events. As a secondary analysis, follow-up was limited to 1, 3, and 5-years. Results The rate of death was much higher in the non-warfarin group (8.1 deaths/100 person-years) compared to the warfarin group (5.5 deaths/100 person-years). The cause-specific HR indicated a large reduction in TE with warfarin use (adjusted HR: 0.57, 95% CI: 0.50–0.65). However, after accounting for competing death events, this association was substantially attenuated (adjusted HR: 0.87, 95% CI: 0.77–0.99). In analyses limited to 1-year of follow-up with fewer competing death events, the results for models that did and did not account for competing risks were similar. Conclusion Analyses accounting for competing death events may provide a more realistic estimate of the longer-term stroke prevention benefits of anticoagulants for patients with AF, particularly those who are not currently treated with anticoagulants. PMID:27861698

MRI breast screening in high-risk women: cancer detection and survival analysis.

PubMed

Evans, D Gareth; Gareth, Evans D; Kesavan, Nisha; Nisha, Kesavan; Lim, Yit; Yit, Lim; Gadde, Soujanye; Soujanye, Gadde; Hurley, Emma; Emma, Hurley; Massat, Nathalie J; Maxwell, Anthony J; Ingham, Sarah; Sarah, Ingham; Eeles, Rosalind; Rosalind, Eeles; Leach, Martin O; Howell, Anthony; Anthony, Howell; Duffy, Stephen W; Stephen, Duffy

2014-06-01

Women with a genetic predisposition to breast cancer tend to develop the disease at a younger age with denser breasts making mammography screening less effective. The introduction of magnetic resonance imaging (MRI) for familial breast cancer screening programs in recent years was intended to improve outcomes in these women. We aimed to assess whether introduction of MRI surveillance improves 5- and 10-year survival of high-risk women and determine the accuracy of MRI breast cancer detection compared with mammography-only or no enhanced surveillance and compare size and pathology of cancers detected in women screened with MRI + mammography and mammography only. We used data from two prospective studies where asymptomatic women with a very high breast cancer risk were screened by either mammography alone or with MRI also compared with BRCA1/2 carriers with no intensive surveillance. 63 cancers were detected in women receiving MRI + mammography and 76 in women receiving mammography only. Sensitivity of MRI + mammography was 93 % with 63 % specificity. Fewer cancers detected on MRI were lymph node positive compared to mammography/no additional screening. There were no differences in 10-year survival between the MRI + mammography and mammography-only groups, but survival was significantly higher in the MRI-screened group (95.3 %) compared to no intensive screening (73.7 %; p = 0.002). There were no deaths among the 21 BRCA2 carriers receiving MRI. There appears to be benefit from screening with MRI, particularly in BRCA2 carriers. Extended follow-up of larger numbers of high-risk women is required to assess long-term survival.

Intelligence quotient discrepancy indicates levels of motor competence in preschool children at risk for developmental delays.

PubMed

Yu, Tzu-Ying; Chen, Kuan-Lin; Chou, Willy; Yang, Shu-Han; Kung, Sheng-Chun; Lee, Ya-Chen; Tung, Li-Chen

2016-01-01

This study aimed to establish 1) whether a group difference exists in the motor competence of preschool children at risk for developmental delays with intelligence quotient discrepancy (IQD; refers to difference between verbal intelligence quotient [VIQ] and performance intelligence quotient [PIQ]) and 2) whether an association exists between IQD and motor competence. Children's motor competence and IQD were determined with the motor subtests of the Comprehensive Developmental Inventory for Infants and Toddlers and Wechsler Preschool and Primary Scale of Intelligence™ - Fourth Edition. A total of 291 children were included in three groups: NON-IQD (n=213; IQD within 1 standard deviation [SD]), VIQ>PIQ (n=39; VIQ>PIQ greater than 1 SD), and PIQ>VIQ (n=39; PIQ>VIQ greater than 1 SD). The results of one-way analysis of variance indicated significant differences among the subgroups for the "Gross and fine motor" subdomains of the Comprehensive Developmental Inventory for Infants and Toddlers, especially on the subtests of "body-movement coordination" (F=3.87, P<0.05) and "visual-motor coordination" (F=6.90, P<0.05). Motor competence was significantly worse in the VIQ>PIQ group than in the NON and PIQ>VIQ groups. Significant negative correlations between IQD and most of the motor subtests (r=0.31-0.46, P<0.01) were found only in the VIQ>PIQ group. This study demonstrates that 1) IQD indicates the level of motor competence in preschoolers at risk for developmental delays and 2) IQD is negatively associated with motor competence in preschoolers with significant VIQ>PIQ discrepancy. The first finding was that preschoolers with VIQ>PIQ discrepancy greater than 1 SD performed significantly worse on motor competence than did preschoolers without significant IQD and preschoolers with PIQ>VIQ discrepancy greater than 1 SD. However, preschoolers with significant PIQ>VIQ discrepancy performed better on motor competence than did preschoolers without significant IQD, though the

Contextual Risk and Parenting as Predictors of Effortful Control and Social Competence in Preschool Children

ERIC Educational Resources Information Center

Lengua, Liliana J.; Honorado, Elizabeth; Bush, Nicole R.

2007-01-01

Using a short-term longitudinal design (6 months), this study examined cumulative contextual risk as a predictor of effortful control (EC) and social competence in a community sample of children (N = 80, ages 33-40 months at time 1). Maternal parenting was examined as a mediator of contextual risk. EC was assessed using laboratory tasks, and…

[Mortality in early-stage, surgically resected non-small cell lung cancer less than 3 cm of size: Competing risk analysis].

PubMed

Jordá Aragón, Carlos; Peñalver Cuesta, Juan Carlos; Mancheño Franch, Nuria; de Aguiar Quevedo, Karol; Vera Sempere, Francisco; Padilla Alarcón, José

2015-09-07

Survival studies of non-small cell lung cancer (NSCLC) are usually based on the Kaplan-Meier method. However, other factors not covered by this method may modify the observation of the event of interest. There are models of cumulative incidence (CI), that take into account these competing risks, enabling more accurate survival estimates and evaluation of the risk of death from other causes. We aimed to evaluate these models in resected early-stage NSCLC patients. This study included 263 patients with resected NSCLC whose diameter was ≤ 3 cm without node involvement (N0). Demographic, clinical, morphopathological and surgical variables, TNM classification and long-term evolution were analysed. To analyse CI, death by another cause was considered to be competitive event. For the univariate analysis, Gray's method was used, while Fine and Gray's method was employed for the multivariate analysis. Mortality by NSCLC was 19.4% at 5 years and 14.3% by another cause. Both curves crossed at 6.3 years, and probability of death by another cause became greater from this point. In multivariate analysis, cancer mortality was conditioned by visceral pleural invasion (VPI) (P=.001) and vascular invasion (P=.020), with age>50 years (P=.034), smoking (P=.009) and the Charlson index ≥ 2 (P=.000) being by no cancer. By the method of CI, VPI and vascular invasion conditioned cancer death in NSCLC >3 cm, while non-tumor causes of long-term death were determined. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.

Model for End-Stage Liver Disease, Model for Liver Transplantation Survival and Donor Risk Index as predictive models of survival after liver transplantation in 1,006 patients.

PubMed

Aranzana, Elisa Maria de Camargo; Coppini, Adriana Zuolo; Ribeiro, Maurício Alves; Massarollo, Paulo Celso Bosco; Szutan, Luiz Arnaldo; Ferreira, Fabio Gonçalves

2015-06-01

Liver transplantation has not increased with the number of patients requiring this treatment, increasing deaths among those on the waiting list. Models predicting post-transplantation survival, including the Model for Liver Transplantation Survival and the Donor Risk Index, have been created. Our aim was to compare the performance of the Model for End-Stage Liver Disease, the Model for Liver Transplantation Survival and the Donor Risk Index as prognostic models for survival after liver transplantation. We retrospectively analyzed the data from 1,270 patients who received a liver transplant from a deceased donor in the state of São Paulo, Brazil, between July 2006 and July 2009. All data obtained from the Health Department of the State of São Paulo at the 15 registered transplant centers were analyzed. Patients younger than 13 years of age or with acute liver failure were excluded. The majority of the recipients had Child-Pugh class B or C cirrhosis (63.5%). Among the 1,006 patients included, 274 (27%) died. Univariate survival analysis using a Cox proportional hazards model showed hazard ratios of 1.02 and 1.43 for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival, respectively (p<0.001). The areas under the ROC curve for the Donor Risk Index were always less than 0.5, whereas those for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival were significantly greater than 0.5 (p<0.001). The cutoff values for the Model for End-Stage Liver Disease (≥29.5; sensitivity: 39.1%; specificity: 75.4%) and the Model for Liver Transplantation Survival (≥1.9; sensitivity 63.9%, specificity 54.5%), which were calculated using data available before liver transplantation, were good predictors of survival after liver transplantation (p<0.001). The Model for Liver Transplantation Survival displayed similar death prediction performance to that of the Model for End-Stage Liver Disease. A simpler model

Eating Competence: Definition and Evidence for the Satter Eating Competence Model

ERIC Educational Resources Information Center

Satter, Ellyn

2007-01-01

The evidence- and practice-based Satter Eating Competence Model (ecSatter) outlines an inclusive definition of the interrelated spectrum of eating attitudes and behaviors. The model is predicated on the utility and effectiveness of biopsychosocial processes: hunger and the drive to survive, appetite and the need for subjective reward and the…

Self-Reported Risk and Delinquent Behavior and Problem Behavioral Intention in Hong Kong Adolescents: The Role of Moral Competence and Spirituality.

PubMed

Shek, Daniel T L; Zhu, Xiaoqin

2018-01-01

Based on the six-wave data collected from Grade 7 to Grade 12 students ( N = 3,328 at Wave 1), this pioneer study examined the development of problem behaviors (risk and delinquent behavior and problem behavioral intention) and the predictors (moral competence and spirituality) among adolescents in Hong Kong. Individual growth curve models revealed that while risk and delinquent behavior accelerated and then slowed down in the high school years, adolescent problem behavioral intention slightly accelerated over time. After controlling the background socio-demographic factors, moral competence and spirituality were negatively associated with risk and delinquent behavior as well as problem behavioral intention across all waves as predicted. Regarding the rate of change in the outcome measures, while the initial level of spirituality was positively linked to the growth rate of risk and delinquent behavior, the initial level of moral competence was negatively associated with the growth rate of problem behavioral intention. The theoretical and practical implications of the present findings are discussed with reference to the role of moral competence and spirituality in the development of adolescent problem behavior.

Self-Reported Risk and Delinquent Behavior and Problem Behavioral Intention in Hong Kong Adolescents: The Role of Moral Competence and Spirituality

PubMed Central

Shek, Daniel T. L.; Zhu, Xiaoqin

2018-01-01

Based on the six-wave data collected from Grade 7 to Grade 12 students (N = 3,328 at Wave 1), this pioneer study examined the development of problem behaviors (risk and delinquent behavior and problem behavioral intention) and the predictors (moral competence and spirituality) among adolescents in Hong Kong. Individual growth curve models revealed that while risk and delinquent behavior accelerated and then slowed down in the high school years, adolescent problem behavioral intention slightly accelerated over time. After controlling the background socio-demographic factors, moral competence and spirituality were negatively associated with risk and delinquent behavior as well as problem behavioral intention across all waves as predicted. Regarding the rate of change in the outcome measures, while the initial level of spirituality was positively linked to the growth rate of risk and delinquent behavior, the initial level of moral competence was negatively associated with the growth rate of problem behavioral intention. The theoretical and practical implications of the present findings are discussed with reference to the role of moral competence and spirituality in the development of adolescent problem behavior. PMID:29651269

Survival Analysis of Papillary Thyroid Carcinoma in Relation to Stage and Recurrence Risk: A 20-Year Experience in Pakistan.

PubMed

Hassan, Aamna; Razi, Mairah; Riaz, Saima; Khalid, Madeeha; Nawaz, M Khalid; Syed, Aamir Ali; Bashir, Humayun

2016-08-01

The aim of this study was to evaluate the overall and progression-free survival of papillary thyroid carcinoma (PTC), comparing the American Thyroid Association (ATA) guideline for risk of recurrence with the TNM staging system with dynamic assessment at 2 years. This study is a retrospective analysis of 689 PTC patients over a 20-year period at a single center. Disease-free survival based on the TNM staging and ATA recurrence risk was calculated using Kaplan-Meier curves. Dynamic response assessment during the first 2 years was compared for both systems. Survival was calculated based on age, baseline resectability, and postthyroidectomy serum tumor marker levels. Six hundred eighty-nine (72.2%) of the total thyroid cancer patients had PTC. Four hundred sixty-nine patients were females, and 220 patients were males. The age range was 6 to 87 years. Five hundred thirty-five patients were resectable, and 56 patients were unresectable. One hundred fifty-one patients were excluded due to insufficient information on recurrence risk. By ATA categorization, 39% had low risk, no disease-related mortality; 44% had intermediate risk, 3 died; and 17% had high risk, 32 died. The 5-year disease-free survival was 54%, 26%, and 5% in low-, intermediate-, and high-risk groups, respectively. The log-rank test showed a significant difference in the percent survival (P < 0.01). TNM stage wise, in terms of survival, 1.3% in stage I, 2.2% in stage II, 0% in stage III, and 37.5% in stage IV died. The 20-year disease-free survival showed the following: stage I, 43%; stage II, 28%; stage III, 18%; and stage IV, 2%. There is significant difference in survival rate (P < 0.01). Both ATA risk classification and TNM staging were significant predictors of disease-free survival. On bivariate analysis, ATA classification (hazards ratio, 2.1; 95% confidence interval, 1.64-2.67; P = 0.001) was better predictive of overall survival versus TNM classification (hazards ratio, 1.3; 95% confidence

Finding Risk Groups by Optimizing Artificial Neural Networks on the Area under the Survival Curve Using Genetic Algorithms.

PubMed

Kalderstam, Jonas; Edén, Patrik; Ohlsson, Mattias

2015-01-01

We investigate a new method to place patients into risk groups in censored survival data. Properties such as median survival time, and end survival rate, are implicitly improved by optimizing the area under the survival curve. Artificial neural networks (ANN) are trained to either maximize or minimize this area using a genetic algorithm, and combined into an ensemble to predict one of low, intermediate, or high risk groups. Estimated patient risk can influence treatment choices, and is important for study stratification. A common approach is to sort the patients according to a prognostic index and then group them along the quartile limits. The Cox proportional hazards model (Cox) is one example of this approach. Another method of doing risk grouping is recursive partitioning (Rpart), which constructs a decision tree where each branch point maximizes the statistical separation between the groups. ANN, Cox, and Rpart are compared on five publicly available data sets with varying properties. Cross-validation, as well as separate test sets, are used to validate the models. Results on the test sets show comparable performance, except for the smallest data set where Rpart's predicted risk groups turn out to be inverted, an example of crossing survival curves. Cross-validation shows that all three models exhibit crossing of some survival curves on this small data set but that the ANN model manages the best separation of groups in terms of median survival time before such crossings. The conclusion is that optimizing the area under the survival curve is a viable approach to identify risk groups. Training ANNs to optimize this area combines two key strengths from both prognostic indices and Rpart. First, a desired minimum group size can be specified, as for a prognostic index. Second, the ability to utilize non-linear effects among the covariates, which Rpart is also able to do.

Comparing multiple competing interventions in the absence of randomized trials using clinical risk-benefit analysis

PubMed Central

2012-01-01

Background To demonstrate the use of risk-benefit analysis for comparing multiple competing interventions in the absence of randomized trials, we applied this approach to the evaluation of five anticoagulants to prevent thrombosis in patients undergoing orthopedic surgery. Methods Using a cost-effectiveness approach from a clinical perspective (i.e. risk benefit analysis) we compared thromboprophylaxis with warfarin, low molecular weight heparin, unfractionated heparin, fondaparinux or ximelagatran in patients undergoing major orthopedic surgery, with sub-analyses according to surgery type. Proportions and variances of events defining risk (major bleeding) and benefit (thrombosis averted) were obtained through a meta-analysis and used to define beta distributions. Monte Carlo simulations were conducted and used to calculate incremental risks, benefits, and risk-benefit ratios. Finally, net clinical benefit was calculated for all replications across a range of risk-benefit acceptability thresholds, with a reference range obtained by estimating the case fatality rate - ratio of thrombosis to bleeding. Results The analysis showed that compared to placebo ximelagatran was superior to other options but final results were influenced by type of surgery, since ximelagatran was superior in total knee replacement but not in total hip replacement. Conclusions Using simulation and economic techniques we demonstrate a method that allows comparing multiple competing interventions in the absence of randomized trials with multiple arms by determining the option with the best risk-benefit profile. It can be helpful in clinical decision making since it incorporates risk, benefit, and personal risk acceptance. PMID:22233221

Landmark Estimation of Survival and Treatment Effect in a Randomized Clinical Trial

PubMed Central

Parast, Layla; Tian, Lu; Cai, Tianxi

2013-01-01

Summary In many studies with a survival outcome, it is often not feasible to fully observe the primary event of interest. This often leads to heavy censoring and thus, difficulty in efficiently estimating survival or comparing survival rates between two groups. In certain diseases, baseline covariates and the event time of non-fatal intermediate events may be associated with overall survival. In these settings, incorporating such additional information may lead to gains in efficiency in estimation of survival and testing for a difference in survival between two treatment groups. If gains in efficiency can be achieved, it may then be possible to decrease the sample size of patients required for a study to achieve a particular power level or decrease the duration of the study. Most existing methods for incorporating intermediate events and covariates to predict survival focus on estimation of relative risk parameters and/or the joint distribution of events under semiparametric models. However, in practice, these model assumptions may not hold and hence may lead to biased estimates of the marginal survival. In this paper, we propose a semi-nonparametric two-stage procedure to estimate and compare t-year survival rates by incorporating intermediate event information observed before some landmark time, which serves as a useful approach to overcome semi-competing risks issues. In a randomized clinical trial setting, we further improve efficiency through an additional calibration step. Simulation studies demonstrate substantial potential gains in efficiency in terms of estimation and power. We illustrate our proposed procedures using an AIDS Clinical Trial Protocol 175 dataset by estimating survival and examining the difference in survival between two treatment groups: zidovudine and zidovudine plus zalcitabine. PMID:24659838

Type 2 diabetes, adiposity and cancer morbidity and mortality risk taking into account competing risk of noncancer deaths in a prospective cohort setting

PubMed Central

Gullberg, Bo; Sonestedt, Emily; Stocks, Tanja; Bjartell, Anders; Wirfält, Elisabet; Wallström, Peter; Orho‐Melander, Marju

2017-01-01

Type 2 diabetes (T2D) and adiposity associate with increased risk of several cancers, but the impact of competing risk of noncancer deaths on these associations is not known. We prospectively examined participants in the Malmö Diet and Cancer Study aged 44–73 years with no history of cancer at baseline (n = 26,953, 43% men). T2D was ascertained at baseline and during follow‐up, and body mass index (BMI) and waist circumference (WC) at baseline. Multivariable cause‐specific hazard ratios (HR) and subdistribution hazard ratios (sHR), taking into account noncancer deaths, were estimated using Cox‐ and competing risk regression. During follow‐up (mean 17 years), 7,061 incident cancers (3,220 obesity‐related cancer types) and 2,848 cancer deaths occurred. BMI and WC were associated with increased risk of obesity‐related cancer incidence and cancer mortality. In T2D subjects, risk of obesity‐related cancer was elevated among men (HR = 1.31, 95% CI: 1.12–1.54; sHR = 1.29, 95% CI: 1.10–1.52), and cancer mortality among both men and women (HR = 1.34, 95% CI: 1.20–1.49; sHR = 1.30, 95% CI: 1.16–1.45). There was no elevated actual risk of cancer death in T2D patients with long disease duration (sHR = 1.00, 95% CI: 0.83–1.20). There was a significant additive effect of T2D and adiposity on risk of obesity‐related cancer and cancer mortality. In conclusion, detection bias may partially explain the increased risk of cancer morbidity among T2D patients. Both excess risk of competing events among patients with T2D and depletion of susceptibles due to earlier cancer detection will lower the actual risk of cancer, particularly with longer diabetes duration and at older ages. PMID:28593629

Ethnic specific differences in survival of patients with type 2 diabetes: analysis of data collected from an Australian multi-ethnic cohort over a 25 year period.

PubMed

Alharbi, Turki J; Constantino, Maria I; Molyneaux, Lynda; Wu, Ted; Twigg, Stephen M; Yue, Dennis K; Wong, Jencia

2015-01-01

To examine the survival of patients with type 2 diabetes from 7 ethnic groups, living in the shared environment of an Australian city. Hazard ratio of death (HR) after diagnosis of diabetes was compared between Anglo-Celtic (n=5433), Indigenous Australian (n=439), Pacific Islander (n=354), Mediterranean (n=3138), Arabic (n=768), Indian (n=702) and Chinese (n=1632) patients who live in metropolitan Sydney. Mortality was ascertained by data-linkage with the Australian National Death Index. The modulating effects of glycaemic control, diabetes/vascular complications and risk factors, year of diabetes diagnosis and duration of diabetes on ethnic differences were analysed by Cox regression. Socio-economic status and competence in English were also examined. There were significant differences in survival between the ethnic groups; the Indigenous Australians had the highest HR for death (2.3, 95% CI 1.7-3.0) and the Chinese the lowest (0.4, 95% CI 0.4-0.5). The survival of the Anglo-Celtics (HR 1) was surprisingly poorer than for Indian (0.6, 95% CI 0.5-0.8), Arab (0.7, 95% CI 0.6-0.8) and Mediterranean groups (0.8, 95% CI 0.7-0.9). Prevalence of smoking and albuminuria were strongly associated with HR. The better survival of Chinese and Arab and the worse survival of Indigenous Australians remained after adjustment of risk factors. Need for an interpreter was a favourable risk factor for survival. Ethnicity is a significant determinant of survival in type 2 diabetes and this is substantially but not completely mediated by smoking and vascular risk factors. The favourable impact associated with less competence in English may represent a Healthy-migrant effect. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

On comparison of net survival curves.

PubMed

Pavlič, Klemen; Perme, Maja Pohar

2017-05-02

Relative survival analysis is a subfield of survival analysis where competing risks data are observed, but the causes of death are unknown. A first step in the analysis of such data is usually the estimation of a net survival curve, possibly followed by regression modelling. Recently, a log-rank type test for comparison of net survival curves has been introduced and the goal of this paper is to explore its properties and put this methodological advance into the context of the field. We build on the association between the log-rank test and the univariate or stratified Cox model and show the analogy in the relative survival setting. We study the properties of the methods using both the theoretical arguments as well as simulations. We provide an R function to enable practical usage of the log-rank type test. Both the log-rank type test and its model alternatives perform satisfactory under the null, even if the correlation between their p-values is rather low, implying that both approaches cannot be used simultaneously. The stratified version has a higher power in case of non-homogeneous hazards, but also carries a different interpretation. The log-rank type test and its stratified version can be interpreted in the same way as the results of an analogous semi-parametric additive regression model despite the fact that no direct theoretical link can be established between the test statistics.

[Essential thrombocythemia: baseline characteristics and risk factors for survival and thrombosis in a series of 214 patients].

PubMed

Angona, Anna; Alvarez-Larrán, Alberto; Bellosillo, Beatriz; Martínez-Avilés, Luz; Garcia-Pallarols, Francesc; Longarón, Raquel; Ancochea, Àgueda; Besses, Carles

2015-03-15

Two prognostic models to predict overall survival and thrombosis-free survival have been proposed: International Prognostic Score for Essential Thrombocythemia (IPSET) and IPSET-Thrombosis, respectively, based on age, leukocytes count, history of previous thrombosis, the presence of cardiovascular risk factors and the JAK2 mutational status. The aim of the present study was to assess the clinical and biological characteristics at diagnosis and during evolution in essential thrombocythemia (ET) patients as well as the factors associated with survival and thrombosis and the usefulness of these new prognostic models. We have evaluated the clinical data and the mutation status of JAK2, MPL and calreticulin of 214 ET patients diagnosed in a single center between 1985 and 2012, classified according to classical risk stratification, IPSET and IPSET-Thrombosis. With a median follow-up of 6.9 years, overall survival was not associated with any variable by multivariate analysis. Thrombotic history and leukocytes>10×10(9)/l were associated with thrombosis-free survival (TFS). In our series, IPSET prognostic systems of survival and thrombosis did not provide more clinically relevant information regarding the classic risk of thrombosis stratification. Thrombotic history and leukocytosis>10×10(9)/l were significantly associated with lower TFS, while the prognostic IPSET-Thrombosis system did not provide more information than classical thrombotic risk assessment. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.

Therapeutic risk management of clinical-legal dilemmas: should it be a core competency?

PubMed

Simon, Robert I; Shuman, Daniel W

2009-01-01

Therapeutic risk management of clinical-legal dilemmas achieves an optimal alignment between clinical competence and an understanding of legal concerns applicable to psychiatric practice. Understanding how psychiatry and law interact in frequently occurring clinical situations is essential for effective patient care. Successful management of clinical-legal dilemmas also avoids unnecessary, counterproductive defensive practices.

The Role of Child Temperament on Head Start Preschoolers' Social Competence in the Context of Cumulative Risk

ERIC Educational Resources Information Center

Corapci, Feyza

2008-01-01

This study examined the main and interactive effects of cumulative risk and child temperament on teacher ratings of social competence and observer ratings of peer play in a sample of Head Start preschoolers. A cumulative risk index (CRI) was computed by summing the total number of risk factors for each family. There was a difference in the…

Intelligence quotient discrepancy indicates levels of motor competence in preschool children at risk for developmental delays

PubMed Central

Yu, Tzu-Ying; Chen, Kuan-Lin; Chou, Willy; Yang, Shu-Han; Kung, Sheng-Chun; Lee, Ya-Chen; Tung, Li-Chen

2016-01-01

Purpose This study aimed to establish 1) whether a group difference exists in the motor competence of preschool children at risk for developmental delays with intelligence quotient discrepancy (IQD; refers to difference between verbal intelligence quotient [VIQ] and performance intelligence quotient [PIQ]) and 2) whether an association exists between IQD and motor competence. Methods Children’s motor competence and IQD were determined with the motor subtests of the Comprehensive Developmental Inventory for Infants and Toddlers and Wechsler Preschool and Primary Scale of Intelligence™ – Fourth Edition. A total of 291 children were included in three groups: NON-IQD (n=213; IQD within 1 standard deviation [SD]), VIQ>PIQ (n=39; VIQ>PIQ greater than 1 SD), and PIQ>VIQ (n=39; PIQ>VIQ greater than 1 SD). Results The results of one-way analysis of variance indicated significant differences among the subgroups for the “Gross and fine motor” subdomains of the Comprehensive Developmental Inventory for Infants and Toddlers, especially on the subtests of “body-movement coordination” (F=3.87, P<0.05) and “visual-motor coordination” (F=6.90, P<0.05). Motor competence was significantly worse in the VIQ>PIQ group than in the NON and PIQ>VIQ groups. Significant negative correlations between IQD and most of the motor subtests (r=0.31–0.46, P<0.01) were found only in the VIQ>PIQ group. Conclusion This study demonstrates that 1) IQD indicates the level of motor competence in preschoolers at risk for developmental delays and 2) IQD is negatively associated with motor competence in preschoolers with significant VIQ>PIQ discrepancy. The first finding was that preschoolers with VIQ>PIQ discrepancy greater than 1 SD performed significantly worse on motor competence than did preschoolers without significant IQD and preschoolers with PIQ>VIQ discrepancy greater than 1 SD. However, preschoolers with significant PIQ>VIQ discrepancy performed better on motor competence than

Estimating the concordance probability in a survival analysis with a discrete number of risk groups.

PubMed

Heller, Glenn; Mo, Qianxing

2016-04-01

A clinical risk classification system is an important component of a treatment decision algorithm. A measure used to assess the strength of a risk classification system is discrimination, and when the outcome is survival time, the most commonly applied global measure of discrimination is the concordance probability. The concordance probability represents the pairwise probability of lower patient risk given longer survival time. The c-index and the concordance probability estimate have been used to estimate the concordance probability when patient-specific risk scores are continuous. In the current paper, the concordance probability estimate and an inverse probability censoring weighted c-index are modified to account for discrete risk scores. Simulations are generated to assess the finite sample properties of the concordance probability estimate and the weighted c-index. An application of these measures of discriminatory power to a metastatic prostate cancer risk classification system is examined.

What should the African health workforce know about disasters? Proposed competencies for strengthening public health disaster risk management education in Africa.

PubMed

Olu, Olushayo; Usman, Abdulmumini; Kalambay, Kalula; Anyangwe, Stella; Voyi, Kuku; Orach, Christopher Garimoi; Azazh, Aklilu; Mapatano, Mala Ali; Nsenga, Ngoy; Manga, Lucien; Woldetsadik, Solomon; Nguessan, Francois; Benson, Angela

2018-04-02

As part of efforts to implement the human resources capacity building component of the African Regional Strategy on Disaster Risk Management (DRM) for the health sector, the African Regional Office of the World Health Organization, in collaboration with selected African public health training institutions, followed a multistage process to develop core competencies and curricula for training the African health workforce in public health DRM. In this article, we describe the methods used to develop the competencies, present the identified competencies and training curricula, and propose recommendations for their integration into the public health education curricula of African member states. We conducted a pilot research using mixed methods approaches to develop and test the applicability and feasibility of a public health disaster risk management curriculum for training the African health workforce. We identified 14 core competencies and 45 sub-competencies/training units grouped into six thematic areas: 1) introduction to DRM; 2) operational effectiveness; 3) effective leadership; 4) preparedness and risk reduction; 5) emergency response and 6) post-disaster health system recovery. These were defined as the skills and knowledge that African health care workers should possess to effectively participate in health DRM activities. To suit the needs of various categories of African health care workers, three levels of training courses are proposed: basic, intermediate, and advanced. The pilot test of the basic course among a cohort of public health practitioners in South Africa demonstrated their relevance. These competencies compare favourably to the findings of other studies that have assessed public health DRM competencies. They could provide a framework for scaling up the capacity development of African healthcare workers in the area of public health DRM; however further validation of the competencies is required through additional pilot courses and follow up of

Predicting survival using clinical risk scores and non-HLA immunogenetics.

PubMed

Balavarca, Y; Pearce, K; Norden, J; Collin, M; Jackson, G; Holler, E; Dressel, R; Kolb, H-J; Greinix, H; Socie, G; Toubert, A; Rocha, V; Gluckman, E; Hromadnikova, I; Sedlacek, P; Wolff, D; Holtick, U; Dickinson, A; Bickeböller, H

2015-11-01

Previous studies of non-histocompatibility leukocyte antigen (HLA) gene single-nucleotide polymorphisms (SNPs) on subgroups of patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT) revealed an association with transplant outcome. This study further evaluated the association of non-HLA polymorphisms with overall survival in a cohort of 762 HSCT patients using data on 26 polymorphisms in 16 non-HLA genes. When viewed in addition to an already established clinical risk score (EBMT-score), three polymorphisms: rs8177374 in the gene for MyD88-adapter-like (MAL; P=0.026), rs9340799 in the oestrogen receptor gene (ESR; P=0.003) and rs1800795 in interleukin-6 (IL-6; P=0.007) were found to be associated with reduced overall survival, whereas the haplo-genotype (ACC/ACC) in IL-10 was protective (P=0.02). The addition of these non-HLA polymorphisms in a Cox regression model alongside the EBMT-score improved discrimination between risk groups and increased the level of prediction compared with the EBMT-score alone (gain in prediction capability for EBMT-genetic-score 10.8%). Results also demonstrated how changes in clinical practice through time have altered the effects of non-HLA analysis. The study illustrates the significance of non-HLA genotyping prior to HSCT and the importance of further investigation into non-HLA gene polymorphisms in risk prediction.

Modeling the survival kinetics of Salmonella in tree nuts for use in risk assessment.

PubMed

Santillana Farakos, Sofia M; Pouillot, Régis; Anderson, Nathan; Johnson, Rhoma; Son, Insook; Van Doren, Jane

2016-06-16

Salmonella has been shown to survive in tree nuts over long periods of time. This survival capacity and its variability are key elements for risk assessment of Salmonella in tree nuts. The aim of this study was to develop a mathematical model to predict survival of Salmonella in tree nuts at ambient storage temperatures that considers variability and uncertainty separately and can easily be incorporated into a risk assessment model. Data on Salmonella survival on raw almonds, pecans, pistachios and walnuts were collected from the peer reviewed literature. The Weibull model was chosen as the baseline model and various fixed effect and mixed effect models were fit to the data. The best model identified through statistical analysis testing was then used to develop a hierarchical Bayesian model. Salmonella in tree nuts showed slow declines at temperatures ranging from 21°C to 24°C. A high degree of variability in survival was observed across tree nut studies reported in the literature. Statistical analysis results indicated that the best applicable model was a mixed effect model that included a fixed and random variation of δ per tree nut (which is the time it takes for the first log10 reduction) and a fixed variation of ρ per tree nut (parameter which defines the shape of the curve). Higher estimated survival rates (δ) were obtained for Salmonella on pistachios, followed in decreasing order by pecans, almonds and walnuts. The posterior distributions obtained from Bayesian inference were used to estimate the variability in the log10 decrease levels in survival for each tree nut, and the uncertainty of these estimates. These modeled uncertainty and variability distributions of the estimates can be used to obtain a complete exposure assessment of Salmonella in tree nuts when including time-temperature parameters for storage and consumption data. The statistical approach presented in this study may be applied to any studies that aim to develop predictive models to be

Quantifying discrimination of Framingham risk functions with different survival C statistics.

PubMed

Pencina, Michael J; D'Agostino, Ralph B; Song, Linye

2012-07-10

Cardiovascular risk prediction functions offer an important diagnostic tool for clinicians and patients themselves. They are usually constructed with the use of parametric or semi-parametric survival regression models. It is essential to be able to evaluate the performance of these models, preferably with summaries that offer natural and intuitive interpretations. The concept of discrimination, popular in the logistic regression context, has been extended to survival analysis. However, the extension is not unique. In this paper, we define discrimination in survival analysis as the model's ability to separate those with longer event-free survival from those with shorter event-free survival within some time horizon of interest. This definition remains consistent with that used in logistic regression, in the sense that it assesses how well the model-based predictions match the observed data. Practical and conceptual examples and numerical simulations are employed to examine four C statistics proposed in the literature to evaluate the performance of survival models. We observe that they differ in the numerical values and aspects of discrimination that they capture. We conclude that the index proposed by Harrell is the most appropriate to capture discrimination described by the above definition. We suggest researchers report which C statistic they are using, provide a rationale for their selection, and be aware that comparing different indices across studies may not be meaningful. Copyright © 2012 John Wiley & Sons, Ltd.

Evaluation of Death among the Patients Undergoing Permanent Pacemaker Implantation: A Competing Risks Analysis.

PubMed

Ghaem, Haleh; Ghorbani, Mohammad; Zare Dorniani, Samira

2017-06-01

Permanent artificial pacemaker is one of the important therapies for treatment of cardiac conduction system problems. The present study aimed to determine the association between some predictive variables and all-cause and cause-specific mortality in the patients who had undergone pacemaker implantation. This study was conducted on 1207 patients who had undergone permanent pacemaker implantation in the hospitals affiliated with Shiraz University of Medical Sciences, Iran, from Mar 2002 to Mar 2012. The variables that existed in the patients' medical records included sex, diabetes mellitus, obesity, cerebrovascular accident, cardiomegaly, smoking, hypertension, ischemic heart disease, congenital heart disease, sick sinus syndrome, and atrial fibrillation. Competing risks model was used to assess the association between the predictive variables and cause-specific (i.e., cardiac and vascular) mortality. The patients' mean age was 66.32±17.92 yr (70.62±14.45 yr in the patients with single-chamber pacemakers vs. 61.91±17.69 yr in those with two-chamber pacemakers) ( P <0.001). Sick sinus syndrome and age increased the risk of all-cause mortality, while two-chamber pacemaker decreased this risk. Obesity increased the risk of cardiac death, and diabetes mellitus and heart valve disease increased the risk of vascular death. The variables predicting mortality in all-cause model were completely different from those in cause-specific model. Moreover, death in such patients may occur due to reasons other than pacemaker. Therefore, future studies, particularly prospective ones, are recommended to use competing risks models.

Evaluation of Death among the Patients Undergoing Permanent Pacemaker Implantation: A Competing Risks Analysis

PubMed Central

GHAEM, Haleh; GHORBANI, Mohammad; ZARE DORNIANI, Samira

2017-01-01

Background: Permanent artificial pacemaker is one of the important therapies for treatment of cardiac conduction system problems. The present study aimed to determine the association between some predictive variables and all-cause and cause-specific mortality in the patients who had undergone pacemaker implantation. Methods: This study was conducted on 1207 patients who had undergone permanent pacemaker implantation in the hospitals affiliated with Shiraz University of Medical Sciences, Iran, from Mar 2002 to Mar 2012. The variables that existed in the patients’ medical records included sex, diabetes mellitus, obesity, cerebrovascular accident, cardiomegaly, smoking, hypertension, ischemic heart disease, congenital heart disease, sick sinus syndrome, and atrial fibrillation. Competing risks model was used to assess the association between the predictive variables and cause-specific (i.e., cardiac and vascular) mortality. Results: The patients’ mean age was 66.32±17.92 yr (70.62±14.45 yr in the patients with single-chamber pacemakers vs. 61.91±17.69 yr in those with two-chamber pacemakers) (P<0.001). Sick sinus syndrome and age increased the risk of all-cause mortality, while two-chamber pacemaker decreased this risk. Obesity increased the risk of cardiac death, and diabetes mellitus and heart valve disease increased the risk of vascular death. Conclusion: The variables predicting mortality in all-cause model were completely different from those in cause-specific model. Moreover, death in such patients may occur due to reasons other than pacemaker. Therefore, future studies, particularly prospective ones, are recommended to use competing risks models. PMID:28828325

Competency Index. [Health Technology Cluster.

ERIC Educational Resources Information Center

Ohio State Univ., Columbus. Center on Education and Training for Employment.

This competency index lists the competencies included in the 62 units of the Tech Prep Competency Profiles within the Health Technologies Cluster. The unit topics are as follows: employability skills; professionalism; teamwork; computer literacy; documentation; infection control and risk management; medical terminology; anatomy, physiology, and…

Epidemiology of systemic sclerosis: incidence, prevalence, survival, risk factors, malignancy, and environmental triggers.

PubMed

Barnes, Jammie; Mayes, Maureen D

2012-03-01

To identify the recent data regarding prevalence, incidence, survival, and risk factors for systemic sclerosis (SSc) and to compare these data to previously published findings. SSc disease occurrence data are now available for Argentina, Taiwan, and India and continue to show wide variation across geographic regions. The survival rate is negatively impacted by older age of onset, male sex, scleroderma renal crisis, pulmonary fibrosis, pulmonary arterial hypertension, cancer, and antitopoisomerase and anti-U1 antibodies. It appears that silica exposure confers an increased risk for developing scleroderma, but this exposure accounts for a very small proportion of male patients. Smoking is not associated with increased SSc susceptibility. Malignancies are reported in scleroderma at an increased rate, but the magnitude of this risk and the type of cancer vary among reports. Prevalence and incidence of SSc appears to be greater in populations of European ancestry and lower in Asian groups. Exposure to silica dust appears to be an environmental trigger, but this only accounts for a small proportion of male cases. Evidence for increased risk of neoplasia is suggestive, but the magnitude of the risk and the types of malignancies vary among reports.

Learning at work: competence development or competence-stress.

PubMed

Paulsson, Katarina; Ivergård, Toni; Hunt, Brian

2005-03-01

Changes in work and the ways in which it is carried out bring a need for upgrading workplace knowledge, skills and competencies. In today's workplaces, and for a number of reasons, workloads are higher than ever and stress is a growing concern (Health Risk Soc. 2(2) (2000) 173; Educat. Psychol. Meas. 61(5) (2001) 866). Increased demand for learning brings a risk that this will be an additional stress factor and thus a risk to health. Our research study is based on the control-demand-support model of Karasek and Theorell (Health Work: Stress, Productivity and the Reconstruction of Working Life, Basic Books/Harper, New York, 1990). We have used this model for our own empirical research with the aim to evaluate the model in the modern workplace. Our research enables us to expand the model in the light of current workplace conditions-especially those relating to learning. We report empirical data from a questionnaire survey of working conditions in two different branches of industry. We are able to define differences between companies in terms of working conditions and competence development. We describe and discuss the effects these conditions have on workplace competence development. Our research results show that increased workers' control of the learning process makes competence development more stimulating, is likely to simplify the work and reduces (learning-related) stress. It is therefore important that learning at work allows employees to control their learning and also allows time for the process of learning and reflection.

Limitation of Inverse Probability-of-Censoring Weights in Estimating Survival in the Presence of Strong Selection Bias

PubMed Central

Howe, Chanelle J.; Cole, Stephen R.; Chmiel, Joan S.; Muñoz, Alvaro

2011-01-01

In time-to-event analyses, artificial censoring with correction for induced selection bias using inverse probability-of-censoring weights can be used to 1) examine the natural history of a disease after effective interventions are widely available, 2) correct bias due to noncompliance with fixed or dynamic treatment regimens, and 3) estimate survival in the presence of competing risks. Artificial censoring entails censoring participants when they meet a predefined study criterion, such as exposure to an intervention, failure to comply, or the occurrence of a competing outcome. Inverse probability-of-censoring weights use measured common predictors of the artificial censoring mechanism and the outcome of interest to determine what the survival experience of the artificially censored participants would be had they never been exposed to the intervention, complied with their treatment regimen, or not developed the competing outcome. Even if all common predictors are appropriately measured and taken into account, in the context of small sample size and strong selection bias, inverse probability-of-censoring weights could fail because of violations in assumptions necessary to correct selection bias. The authors used an example from the Multicenter AIDS Cohort Study, 1984–2008, regarding estimation of long-term acquired immunodeficiency syndrome-free survival to demonstrate the impact of violations in necessary assumptions. Approaches to improve correction methods are discussed. PMID:21289029

Autonomy, Competence and Non-interference.

PubMed

Roberts, Joseph T F

2017-12-30

In light of the variety of uses of the term autonomy in recent bioethics literature, in this paper, I suggest that competence, not being as contested, is better placed to play the anti-paternalistic role currently assigned to autonomy. The demonstration of competence, I will argue, can provide individuals with robust spheres of non-interference in which they can pursue their lives in accordance with their own values. This protection from paternalism is achieved by granting individuals rights to non-interference upon demonstration of competence. In this paper, I present a risk-sensitive account of competence as a means of grounding rights to non-interference. On a risk-sensitive account of competence individuals demonstrate their competence by exercising three capacities to the extent necessary to meet a threshold determined by the riskiness of the decision. These three capacities are the capacity to (i) acquire knowledge, (ii) use instrumental rationality, and (iii) form and revise a life plan.

Cumulative incidence rate of medical consultation for fecundity problems--analysis of a prevalent cohort using competing risks.

PubMed

Duron, S; Slama, R; Ducot, B; Bohet, A; Sørensen, D N; Keiding, N; Moreau, C; Bouyer, J

2013-10-01

contraceptive use were considered as informative censoring events, using a competing risk model. Using the competing risk survival model, the cumulative incidence rate of first consultation was 9.0% [95% CI: 6.5%; 11.9%] 12 months after the start of the PUI and 12.2% [95% CI: 9.6%; 15.3%] after 24 months. The Kaplan-Meier method, which does not take competing risks into account, yielded substantially higher estimates: 26.0% [95% CI: 18.8%; 32.5%] at 12 months and 56.8% [95% CI: 44.2%; 66.6%] at 24 months. Among the 219 women who had attempted to become pregnant for at least 12 months, cumulative incidences of first medical consultations were 28.2% [18.7-38.9%] 24 months after the start of the PUI, and 31.2% [21.3- 42.4%] after 36 months. The rates were higher among nulliparous but non-nulligravid women, followed by nulligravid women, as compared with parous women. Age was not strongly related to the occurrence of medical consultation. The main limitation of this study is the number of women lost to follow-up (29.7%). In addition, results regarding the absence of an age effect should be taken with caution as few women in our study were aged over 35 years. Although such an attrition rate is commonly observed in prospective studies in the general population, it could have induced a selection bias that may have led to an underestimation of the rates of medical consultation. Sensitivity analyses, using the inverse probability weighting method suggest that our results are unlikely to be biased. This study reveals frequencies of medical consultation for fertility problems, which, after considering competing events such as pregnancy in a relevant statistical model, are lower than generally reported in the literature. The results also indicate the existence of a difference between the potential need and the actual use of medical care for fecundity problems. This suggests a need for studies to look for factors other than medical recommendations that may play a role in the patterns of

Choline intake and risk of lethal prostate cancer: incidence and survival123

PubMed Central

Richman, Erin L; Kenfield, Stacey A; Stampfer, Meir J; Giovannucci, Edward L; Zeisel, Steven H; Willett, Walter C; Chan, June M

2012-01-01

Background: Meat, milk, and eggs have been inconsistently associated with the risk of advanced prostate cancer. These foods are sources of choline—a nutrient that may affect prostate cancer progression through cell membrane function and one-carbon metabolism. No study has examined dietary choline and the risk of lethal prostate cancer. Objective: Our objective was to examine whether dietary choline, choline-containing compounds, and betaine (a choline metabolite) increase the risk of lethal prostate cancer. Design: We prospectively examined the intake of these nutrients and the risk of lethal prostate cancer among 47,896 men in the Health Professionals Follow-Up Study. In a case-only survival analysis, we examined the postdiagnostic intake of these nutrients and the risk of lethal prostate cancer among 4282 men with an initial diagnosis of nonmetastatic disease during follow-up. Diet was assessed with a validated questionnaire 6 times during 22 y of follow-up. Results: In the incidence analysis, we observed 695 lethal prostate cancers during 879,627 person-years. Men in the highest quintile of choline intake had a 70% increased risk of lethal prostate cancer (HR: 1.70; 95% CI: 1.18, 2.45; P-trend = 0.005). In the case-only survival analysis, we observed 271 lethal cases during 33,679 person-years. Postdiagnostic choline intake was not statistically significantly associated with the risk of lethal prostate cancer (HR for quintile 5 compared with quintile 1: 1.69; 95% CI: 0.93, 3.09; P-trend = 0.20). Conclusion: Of the 47,896 men in our study population, choline intake was associated with an increased risk of lethal prostate cancer. PMID:22952174

The Learning and Competency Development of Master Teachers in Alternative High Schools for At-Risk Youth: A Case Study

ERIC Educational Resources Information Center

Williams, Nida W.

2012-01-01

This qualitative case study was designed to explore how master teachers in transfer high schools learn the competencies they perceive are required to engage at-risk students so that they persist and graduate. The study is based on the following assumptions: (1) The requisite teacher competencies can be defined and identified and, in fact,…

Russian Language Competencies for Peace Corps Volunteers in Russia.

ERIC Educational Resources Information Center

Strobykina, Irina; Fomenko, Nataliya

This Peace Corps volunteer language training manual is based on the experience of two pre-service trainings and was guided by the Peace Corps language training curriculum. The learning approach is competency-based or topic-oriented to provide survival competencies. Three main sections review phonetics, topics for discussion, and practical grammar…

Cumulative Risk, the Mother-Child Relationship, and Social-Emotional Competence in Latino Head Start Children

ERIC Educational Resources Information Center

Martí, Maria; Bonillo, Albert; Jané, Maria Claustre; Fisher, Elisa M.; Duch, Helena

2016-01-01

Research Findings: Supportive mother-child interactions promote the development of social-emotional competence. Poverty and other associated psychosocial risk factors have a negative impact on mother-child interaction. In spite of Latino children being disproportionately represented among children living in poverty, research on mother-child…

Coding variants in NOD-like receptors: An association study on risk and survival of colorectal cancer.

PubMed

Huhn, Stefanie; da Silva Filho, Miguel I; Sanmuganantham, Tharmila; Pichulik, Tica; Catalano, Calogerina; Pardini, Barbara; Naccarati, Alessio; Polakova-Vymetálkova, Veronika; Jiraskova, Katerina; Vodickova, Ludmila; Vodicka, Pavel; Löffler, Markus W; Courth, Lioba; Wehkamp, Jan; Din, Farhat V N; Timofeeva, Maria; Farrington, Susan M; Jansen, Lina; Hemminki, Kari; Chang-Claude, Jenny; Brenner, Hermann; Hoffmeister, Michael; Dunlop, Malcolm G; Weber, Alexander N R; Försti, Asta

2018-01-01

Nod-like receptors (NLRs) are important innate pattern recognition receptors and regulators of inflammation or play a role during development. We systematically analysed 41 non-synonymous single nucleotide polymorphisms (SNPs) in 21 NLR genes in a Czech discovery cohort of sporadic colorectal cancer (CRC) (1237 cases, 787 controls) for their association with CRC risk and survival. Five SNPs were found to be associated with CRC risk and eight with survival at 5% significance level. In a replication analysis using data of two large genome-wide association studies (GWASs) from Germany (DACHS: 1798 cases and 1810 controls) and Scotland (2210 cases and 9350 controls) the associations found in the Czech discovery set were not confirmed. However, expression analysis in human gut-related tissues and immune cells revealed that the NLRs associated with CRC risk or survival in the discovery set were expressed in primary human colon or rectum cells, CRC tissue and/or cell lines, providing preliminary evidence for a potential involvement of NLRs in general in CRC development and/or progression. Most interesting was the finding that the enigmatic development-related NLRP5 (also known as MATER) was not expressed in normal colon tissue but in colon cancer tissue and cell lines. Future studies may show whether regulatory variants instead of coding variants might affect the expression of NLRs and contribute to CRC risk and survival.

The Relation Between Adolescent Social Competence and Young Adult Delinquency and Educational Attainment Among At-Risk Youth: The Mediating Role of Peer Delinquency

PubMed Central

Stepp, Stephanie D; Pardini, Dustin A; Loeber, Rolf; Morris, Nancy A

2015-01-01

Objective We examined trajectories of adolescent social competence as a resilience factor among at-risk youth. To examine potential mechanisms of this resilience process, we investigated the putative mediating effect of peer delinquency on the relation between adolescent social competence and young adult delinquency seriousness and educational attainment. Method Participants (n = 257) were screened to be at risk for antisocial behaviour at age 13 years. Data were derived from an ongoing longitudinal study of the development of antisocial and delinquent behaviour among inner-city boys, the Pittsburgh Youth Study. We used data collected from participants when aged 13 years until they were aged 25.5 years for our study. Results Results indicated that boys with high levels of social competence decreased their involvement with deviant peers throughout adolescence, which, in turn, predicted less serious forms of delinquency in early adulthood. Social competence had a direct effect on educational attainment in early adulthood, as boys who developed social competencies in adolescence went further in school irrespective of their involvement with delinquent peers. Conclusions Results suggest that promoting the development of social competencies and reducing involvement with delinquent peers will protect at-risk youth from engaging in serious delinquency in early adulthood while increasing their educational success. PMID:21878156

Melanoma risk and survival among organ transplant recipients

PubMed Central

Robbins, Hilary A.; Clarke, Christina A.; Arron, Sarah T.; Tatalovich, Zaria; Kahn, Amy R.; Hernandez, Brenda Y.; Paddock, Lisa; Yanik, Elizabeth L.; Lynch, Charles F.; Kasiske, Bertram L.; Snyder, Jon; Engels, Eric A.

2015-01-01

Solid organ transplant recipients, who are medically immunosuppressed to prevent graft rejection, have increased melanoma risk, but risk factors and outcomes are incompletely documented. We evaluated melanoma incidence among 139,991 non-Hispanic white transplants using linked U.S. transplant-cancer registry data (1987–2010). We used standardized incidence ratios (SIRs) to compare incidence to the general population, and incidence rate ratios (IRRs) from multivariable Poisson models to assess risk factors. Separately, we compared post-melanoma survival among transplant recipients (N=182) and non-recipients (N=131,358) using multivariable Cox models. Among transplant recipients, risk of invasive melanoma (N=519) was elevated (SIR=2.20, 95%CI 2.01-2.39), especially for regional stage tumors (SIR=4.11, 95%CI 3.27–5.09). Risk of localized tumors was stable over time after transplantation, but higher with azathioprine maintenance therapy (IRR=1.35, 95%CI 1.03–1.77). Risk of regional/distant stage tumors peaked within 4 years following transplantation and increased with polyclonal antibody induction therapy (IRR=1.65, 95%CI 1.02–2.67). Melanoma-specific mortality was higher among transplant recipients than non-recipients (HR 2.98, 95%CI 2.26–3.93). Melanoma exhibits increased incidence and aggressive behavior under transplant-related immunosuppression. Some localized melanomas may result from azathioprine, which acts synergistically with ultraviolet radiation, while T-cell depleting induction therapies may promote late stage tumors. Our findings support sun safety practices and skin screening for transplant recipients. PMID:26270022

Turkmen Language Competencies for Peace Corps Volunteers in Turkmenistan.

ERIC Educational Resources Information Center

Tyson, David; Clark, Larry

This textbook is designed for use by Peace Corps volunteers learning Turkmen in preparation for serving in Turkmenistan. It takes a competency-based approach to language learning, focusing on specific tasks the learner will need to accomplish through language. Some competencies are related to work tasks and others to survival needs or social…

Survival outcome of intermediate risk neuroblastoma at Children Cancer Hospital Egypt.

PubMed

Elzomor, Hossam; Ahmed, Gehad; Elmenawi, Salma; Elkinaai, Naglaa; Refaat, Amal; Soliman, Sonya; Abdelwahab, Mai Amr; Zaghloul, Mohamed Saad; Fawzy, Mohamed

2018-03-01

The study aims to evaluate survival outcome in newly diagnosed pediatric intermediate risk neuroblastoma patients treated at the Children Cancer Hospital - Egypt and their relation to various clinical and pathological factors. The study included stage 3 patients <1.5 years, children 1.5 years or older with stage 3 disease and favorable histopathological features, infants (<1 year) with International Neuroblastoma Staging System (INSS) stage 4 disease, stage 4 children 1-1.5 years with favorable biology, and infants stage 4 s (with unfavorable biologic features). Patients received systemic chemotherapy, in the form of etoposide and carboplatin alternating with cyclophosphamide, doxorubicin and vincristine, administered at 3-week intervals, with a total of 6 or 8 cycles guided by reaching objective overall response (complete/very good partial/partial response). The study included 136 patients, 67 males and 69 females. 101 patients had abdominal primary tumors, 28 had mediastinal masss and 7 with masses in the neck; 68% were stage 3 and the remaining (n = 44) had metastatic disease. The three-year overall survival (OS) and event-free survival (EFS) estimates were 94% ± 2% and 90.9% ± 2.5%, respectively. OS and EFS by gender, age, pathology and INPC were all statistically not significantly different. Moreover, OS for patients having surgery versus no surgery (inoperable residual only) was statistically significant (98.4% ± 1.6% & 88.7% ± 5.3%, respectively, p = .034). A very high rate of survival is currently achievable in patients with intermediate risk neuroblastoma by chemotherapy or chemotherapy and surgery. In addition to response, our plan is to adopt biologically-based treatment to reduce treatment-induced complications among survivors. Copyright © 2018 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. All rights reserved.

Survival and Associated Risk Factors for Mortality Among Infants with Critical Congenital Heart Disease in a Developing Country.

PubMed

Mat Bah, Mohd Nizam; Sapian, Mohd Hanafi; Jamil, Mohammad Tamim; Alias, Amelia; Zahari, Norazah

2018-05-14

Critical congenital heart disease (CCHD) is associated with significant morbidity and mortality. However, data on survival of CCHD and the risk factors associated with its mortality are limited. This study examined CCHD survival and the risk factors for CCHD mortality. Using a retrospective cohort study of infants born with CCHD from 2006 to 2015, survival over 10 years was estimated using Kaplan-Meier analysis, and the risk factors for mortality were analyzed using multivariate Cox proportional hazards regression. A total of 491 CCHD cases were included in the study, with an overall mortality rate of 34.8% (95% confidence interval [CI] 30.6-39.2). The intervention/surgical mortality rate was 9.8% ≤ 30 days and 11.5% > 30 days after surgery, and 17% died before surgery or intervention. The median age at death was 2.7 months [first quartile: 1 month, third quartile: 7.3 months]. The CCHD survival rate was 90.4% (95% CI 89-91.8%) at 1 month, 69.3% (95% CI 67.2-71.4%) at 1 year, 63.4% (95% CI 61.1-65.7%) at 5 years, and 61.4% (95% CI 58.9-63.9%) at 10 years. Weight of < 2 kg at diagnosis, associated syndromes, poor pre-operative condition, and non-duct-dependent CCHD were independent risk factors for poor survival, with hazard ratios of 2.61, 2.10, 2.22, and 1.70, respectively. CCHD is associated with a high mortality rate. Low weight, poor pre-operative condition, associated syndromes, and non-duct-dependent CCHD are significant risk factors affecting the survival of infants with CCHD.

Interleukin genes and associations with colon and rectal cancer risk and overall survival

PubMed Central

Bondurant, Kristina L.; Lundgreen, Abbie; Herrick, Jennifer S.; Kadlubar, Susan; Wolff, Roger K.; Slattery, Martha L.

2012-01-01

Interleukins are a group of cytokines that contribute to growth and differentiation, cell migration, and inflammatory and anti-inflammatory responses by the immune system. In this study we examined genetic variation in genes from various anti-inflammatory and pro-inflammatory interleukins to determine association with colon and rectal cancer risk and overall survival. Data from two population-based incident studies of colon cancer (1555 cases and 1956 controls) and rectal cancer (754 cases and 954 controls) were utilized. After controlling for multiple comparisons, single nucleotide polymorphisms (SNPs) from four genes, IL3, IL6R, IL8, IL15, were associated with increased colon cancer risk and CXCR1, and CXCR2 were significantly associated with increased rectal cancer risk. Only SNPs from genes within the IL-8 pathway (IL8, CXCR1, and CXCR2) showed a significant association with both colon and rectal cancer risk. Several SNPs interacted significantly with IL8 and IFNG SNPs and with aspirin/NSAID, cigarette smoking, estrogen use and BMI. For both colon and rectal cancer, increasing numbers of risk alleles were associated with increased hazard of death from cancer; the estimated hazard of death for colon cancer for the highest category of risk alleles was 1.74 (95% CI 1.18–2.56) and 1.96 (95% CI 1.28–2.99) for rectal cancer. These data suggest interleukin genes play a role in risk and overall survival for colon and rectal cancer. PMID:22674296

Reentry survivability modeling

NASA Astrophysics Data System (ADS)

Fudge, Michael L.; Maher, Robert L.

1997-10-01

Statistical methods for expressing the impact risk posed to space systems in general [and the International Space Station (ISS) in particular] by other resident space objects have been examined. One of the findings of this investigation is that there are legitimate physical modeling reasons for the common statistical expression of the collision risk. A combination of statistical methods and physical modeling is also used to express the impact risk posed by re-entering space systems to objects of interest (e.g., people and property) on Earth. One of the largest uncertainties in the expressing of this risk is the estimation of survivable material which survives reentry to impact Earth's surface. This point was recently demonstrated in dramatic fashion by the impact of an intact expendable launch vehicle (ELV) upper stage near a private residence in the continental United States. Since approximately half of the missions supporting ISS will utilize ELVs, it is appropriate to examine the methods used to estimate the amount and physical characteristics of ELV debris surviving reentry to impact Earth's surface. This paper examines reentry survivability estimation methodology, including the specific methodology used by Caiman Sciences' 'Survive' model. Comparison between empirical results (observations of objects which have been recovered on Earth after surviving reentry) and Survive estimates are presented for selected upper stage or spacecraft components and a Delta launch vehicle second stage.

Background level of risk and the survival of predator-naive prey: can neophobia compensate for predator naivety in juvenile coral reef fishes?

PubMed

Ferrari, Maud C O; McCormick, Mark I; Meekan, Mark G; Chivers, Douglas P

2015-01-22

Neophobia--the generalized fear response to novel stimuli--provides the first potential strategy that predator-naive prey may use to survive initial predator encounters. This phenotype appears to be highly plastic and present in individuals experiencing high-risk environments, but rarer in those experiencing low-risk environments. Despite the appeal of this strategy as a 'solution' for prey naivety, we lack evidence that this strategy provides any fitness benefit to prey. Here, we compare the relative effect of environmental risk (high versus low) and predator-recognition training (predator-naive versus predator-experienced individuals) on the survival of juvenile fish in the wild. We found that juveniles raised in high-risk conditions survived better than those raised in low-risk conditions, providing the first empirical evidence that environmental risk, in the absence of any predator-specific information, affects the way naive prey survive in a novel environment. Both risk level and experience affected survival; however, the two factors did not interact, indicating that the information provided by both factors did not interfere or enhance each other. From a mechanistic viewpoint, this indicates that the combination of the two factors may increase the intensity, and hence efficacy, of prey evasion strategies, or that both factors provide qualitatively separate benefits that would result in an additive survival success.

Conceptualization and Pilot Testing of a Core Competency-Based Training Workshop in Suicide Risk Assessment and Management: Notes From the Field.

PubMed

Cramer, Robert J; Bryson, Claire N; Eichorst, Morgam K; Keyes, Lee N; Ridge, Brittany E

2017-03-01

As professional psychology training programs and continuing education have moved toward competency based approaches, it has become equally important to develop uniform, evidence-based approaches for suicide risk assessment and management. The present article presents a workshop curriculum based on established core competencies in suicide risk assessment and management. Drawing on theories suicide risk formation, the workshop features an integration of didactic, process, and experiential components. We present pilot data from 2 small group workshops (n = 17): 1 from a clinical psychology doctoral program and 1 from a university counseling center. Workshop participation yielded increases in (a) the ability to recognize appropriate clinician responses to suicidal client statements, (b) self-perceptions of general capacity to interface with suicidal patients and mastery of the 10 core competencies, (c) factual knowledge concerning suicide risk assessment and management, and (d) the self-rated ability to assess and manage a suicidal patient. We discuss statistical and generalizability limitations as well as implications for future modification, implementation, and provision of this training method. © 2016 Wiley Periodicals, Inc.

Intern Boot Camp: Feasibility and impact of a 1-hour session to ensure graduating medical student competency in falls risk assessment.

PubMed

Omlor, Rebecca L; Watkins, Franklin S; Lawlor, Janice S; Lovato, James F; Fino, Nora F; Atkinson, Hal H

2017-01-01

The authors evaluated the feasibility of a 1-hour session to ensure competency in gait and falls risk assessment for medical students at their institution. The session included a history and exam with faculty and staff as standardized patients, gait recognition videos, and case evaluation for falls risk assessment and prevention. Student perceptions were evaluated using a retrospective pre-post survey, scored on a 5-point Likert-type scale. Wilcoxon signed-rank tests were used to assess change and Kruskal-Wallis tests were used to analyze differences by residency choice. A range of five to 11 faculty and staff certified 238 medical students during eight 1-hour sessions. Overall self-perception of competence in falls risk assessment and prevention improved (p ≤ .001), and did not differ by residency choice, both before and after the training program (p = .73 and p = .25). Feedback was positive. This session is a feasible way to teach and assess the competency for falls risk assessment with modest time commitment.

Effects of Maternal Nutrition, Resource Use and Multi-Predator Risk on Neonatal White-Tailed Deer Survival

PubMed Central

Duquette, Jared F.; Belant, Jerrold L.; Svoboda, Nathan J.; Beyer, Dean E.; Lederle, Patrick E.

2014-01-01

Growth of ungulate populations is typically most sensitive to survival of neonates, which in turn is influenced by maternal nutritional condition and trade-offs in resource selection and avoidance of predators. We assessed whether resource use, multi-predator risk, maternal nutritional effects, hiding cover, or interactions among these variables best explained variation in daily survival of free-ranging neonatal white-tailed deer (Odocoileus virginianus) during their post-partum period (14 May–31 Aug) in Michigan, USA. We used Cox proportional hazards mixed-effects models to assess survival related to covariates of resource use, composite predation risk of 4 mammalian predators, fawn body mass at birth, winter weather, and vegetation growth phenology. Predation, particularly from coyotes (Canis latrans), was the leading cause of mortality; however, an additive model of non-ideal resource use and maternal nutritional effects explained 71% of the variation in survival. This relationship suggested that dams selected areas where fawns had poor resources, while greater predation in these areas led to additive mortalities beyond those related to resource use alone. Also, maternal nutritional effects suggested that severe winters resulted in dams producing smaller fawns, which decreased their likelihood of survival. Fawn resource use appeared to reflect dam avoidance of lowland forests with poor forage and greater use by wolves (C. lupus), their primary predator. While this strategy led to greater fawn mortality, particularly by coyotes, it likely promoted the life-long reproductive success of dams because many reached late-age (>10 years old) and could have produced multiple generations of fawns. Studies often link resource selection and survival of ungulates, but our results suggested that multiple factors can mediate that relationship, including multi-predator risk. We emphasize the importance of identifying interactions among biological and environmental factors

Real-world impact of non-breast cancer-specific death on overall survival in resectable breast cancer.

PubMed

Fu, Jianfei; Wu, Lunpo; Jiang, Mengjie; Li, Dan; Jiang, Ting; Fu, Wei; Wang, Liangjing; Du, Jinlin

2017-07-01

The real-world occurrence rate of non-breast cancer-specific death (non-BCSD) and its impact on patients with breast cancer are poorly recognized. Women with resectable breast cancer from 1990 to 2007 in the Surveillance, Epidemiology, and End Results database (n = 199,963) were analyzed. The outcome events of breast cancer were classified as breast cancer-specific death (BCSD), non-BCSD, or survival. Binary logistics was used to estimate the occurrence rates of non-BCSD and BCSD with different clinicopathological factors. The Gray method was used to measure the cumulative incidence of non-BCSD and BCSD. The ratio of non-BCSDs to all causes of death and stacked cumulative incidence function plots were used to present the impact of non-BCSD on overall survival (OS). Models of Cox proportional hazards regression and competing risk regression were compared to highlight the suitable model. There were 12,879 non-BCSDs (6.44%) and 28,784 BCSDs (14.39%). The oldest age group (>62 years), black race, and a single or divorced marital status were associated with more non-BCSDs. With adjustments for age, a hormone receptor-positive (HoR+) status was no longer related to increased non-BCSDs. In patients with grade 1, stage I disease and an HoR+ status as well as the oldest subgroup, a great dilution of non-BCSD on all causes of death could be observed, and this led to incorrect interpretations. The inaccuracy, caused by the commonly used Cox proportional hazards model, could be corrected by a competing risk model. OS was largely impaired by non-BCSD during early breast cancer. For some future clinical trial planning, especially for the oldest patients and those with HoR+ breast cancer, non-BCSD should be considered a competing risk event. Cancer 2017;123:2432-43. © 2017 American Cancer Society. © 2017 American Cancer Society.

Impact of genomic risk factors on survival after haematopoietic stem cell transplantation for patients with acute leukaemia.

PubMed

Pearce, K F; Balavarca, Y; Norden, J; Jackson, G; Holler, E; Dressel, R; Greinix, H; Toubert, A; Gluckman, E; Hromadnikova, I; Sedlacek, P; Wolff, D; Holtick, U; Bickeböller, H; Dickinson, A M

2016-12-01

The EBMT risk score is an established tool successfully used in the prognosis of survival post-HSCT and is applicable for a range of haematological disorders. One of its main advantages is that score generation involves summation of clinical parameters that are available pretransplant. However, the EBMT risk score is recognized as not being optimal. Previous analyses, involving patients with various diagnoses, have shown that non-HLA gene polymorphisms influence outcome after allogeneic HSCT. This study is novel as it focuses only on patients having acute leukaemia (N = 458) and attempts to demonstrate how non-HLA gene polymorphisms can be added to the EBMT risk score in a Cox regression model to improve prognostic ability for overall survival. The results of the study found that three genetic factors improved EBMT risk score. The presence of MAL (rs8177374) allele T in the patient, absence of glucocorticoid receptor haplotype (consisting of rs6198, rs33389 and rs33388) ACT in the patient and absence of heat-shock protein 70-hom (+2437) (rs2227956) allele C in the patient were associated with decreased survival time. When compared to the EBMT risk score, the scores combining EBMT risk score with the genetic factors had an improved correlation with clinical outcome and better separation of risk groups. A bootstrapping technique, involving repeated testing of a model using multiple validation sets, also revealed that the newly proposed model had improved predictive value when compared to the EBMT risk score alone. Results support the view that non-HLA polymorphisms could be useful for pretransplant clinical assessment and provide evidence that polymorphisms in the recipient genotype may influence incoming donor cells, suppressing the initiation of the graft versus leukaemia effect and reducing survival. © 2016 John Wiley & Sons Ltd.

The Strategies for Significant Survival of Postsecondary Centers for Continuing Education.

ERIC Educational Resources Information Center

Caldwell, Phyllis A.

While the financial survival of postsecondary institutions is being stressed, continuing education operarions are facing increasing difficulties in surviving and competing. Strategies are needed for the significant survival of continuing education operations at the small college. The Lifelong Learning Center and others like it need to be concerned…

Does colour polymorphism enhance survival of prey populations?

PubMed Central

Wennersten, Lena; Forsman, Anders

2009-01-01

That colour polymorphism may protect prey populations from predation is an old but rarely tested hypothesis. We examine whether colour polymorphic populations of prey exposed to avian predators in an ecologically valid visual context were exposed to increased extinction risk compared with monomorphic populations. We made 2976 artificial pastry prey, resembling Lepidoptera larvae, in four different colours and presented them in 124 monomorphic and 124 tetramorphic populations on tree trunks and branches such that they would be exposed to predation by free-living birds, and monitored their ‘survival’. Among monomorphic populations, there was a significant effect of prey coloration on survival, confirming that coloration influenced susceptibility to visually oriented predators. Survival of polymorphic populations was inferior to that of monomorphic green populations, but did not differ significantly from monomorphic brown, yellow or red populations. Differences in survival within polymorphic populations paralleled those seen among monomorphic populations; the red morph most frequently went extinct first and the green morph most frequently survived the longest. Our findings do not support the traditional protective polymorphism hypothesis and are in conflict with those of earlier studies. As a possible explanation to our findings, we offer a competing ‘giveaway cue’ hypothesis: that polymorphic populations may include one morph that attracts the attention of predators and that polymorphic populations therefore may suffer increased predation compared with some monomorphic populations. PMID:19324729

Genetic polymorphisms in the vitamin D pathway in relation to lung cancer risk and survival

PubMed Central

Kong, Jinyu; Xu, Fangxiu; Qu, Jinli; Wang, Yu; Gao, Ming; Yu, Herbert; Qian, Biyun

2015-01-01

Studies have suggested that vitamin D may have protective effects against cancer development or tumor progression. To search for additional evidence, we investigated the role of genetic polymorphisms involved in the vitamin D pathway in non-small cell lung cancer (NSCLC). We evaluated common genetic polymorphisms associated with the vitamin D pathway in relation to NSCLC in a case-control study of 603 newly diagnosed NSCLC patients and 661 matched healthy controls. Seven single nucleotide polymorphisms (SNPs) were genotyped, the expression of CYP27B1 and CYP24A1 were measured in 153 tumor samples and their associations with genotypes and patient survival were also analyzed. In the case-control comparison, we found SNP rs3782130 (CYP27B1), rs7041 (GC), rs6068816 and rs4809957 (CYP24A1) associated with NSCLC risk. The risk of NSCLC was increased with the number of risk alleles. CYP27B1 and CYP24A1 expression were significantly different between tumor and normal tissues in NSCLC. High CYP27B1 expression was associated with better overall survival, and the expression was different by the rs3782130 genotype. The study suggests that some genetic polymorphisms involved in the vitamin D pathway may associate with NSCLC risk, and one of the polymorphisms (rs3782130) may affect gene expression and patient survival. PMID:25544771

Associations between eating competence and cardiovascular disease biomarkers.

PubMed

Psota, Tricia L; Lohse, Barbara; West, Sheila G

2007-01-01

Explore the relationship between eating competence (EC) and biomarkers of risk for cardiovascular disease (CVD). Secondary analysis of data collected for a larger, 2-way crossover clinical trial. Outpatient clinical research center. Forty-eight hypercholesterolemic (LDL cholesterol > or = 110 mg/dL) men (n = 19) and women (n = 29) 21 to 70 years of age. Participant descriptives, cardiovascular disease biomarker levels, and eating competence (EC) determined by the ecSatter Inventory (ecSI). T tests for differences in eating competence between males and females, analysis of variance for differences in risk between those categorized as EC or not. Associations between EC and baseline biochemical measures, as well as participant characteristics and dietary intake, were assessed by Pearson correlation analyses. Logistic regression estimated relative risk of CVD risk factors from ecSI scores. Several significant associations were found between EC total and CVD risk factors. Eating competence was positively correlated with HDL-cholesterol, and inversely associated with systolic and diastolic blood pressure. High EC participants had significantly lower ratios of total cholesterol: HDL-cholesterol and triglycerides: HDL-cholesterol. Participants who were not eating competent were 5 times more likely to have LDL-cholesterol levels > or =130 mg/dL and 7 times more likely to have triglyceride levels > or =150 mg/dL. Eating competence appears to be a cognitive, affective construct with physiological manifestations, making nutrition education to increase eating competence a medical nutrition therapy.

Patient survival and risk of death after prostate cancer treatment in the Brazilian Unified Health System.

PubMed

Braga, Sonia Faria Mendes; Souza, Mirian Carvalho de; Oliveira, Raphael Romie de; Andrade, Eli Iola Gurgel; Acurcio, Francisco de Assis; Cherchiglia, Mariangela Leal

2017-05-15

Analyze the probability of specific survival and factors associated with the risk of death of patients with prostate cancer who received outpatient cancer treatment in the Brazilian Unified Health System, Brazil. Retrospective cohort study using the National Database of Oncology, developed through the deterministic-probabilistic pairing of health information systems: outpatient (SIA), hospital (SIH) and mortality (SIM). The probability of overall and specific survival was estimated by the time elapsed between the date of the first ambulatory treatment, from 2002 to 2003, until the patient's death or the end of the study. Fine and Gray's model of competing-risks regression was adjusted according to the variables: age of diagnostic, region of residence, tumor clinical staging, type of outpatient cancer treatment and hospitalization in the assessment of factors associated with risk of patient death. Of 16,280 patients studied, the average age was 70 years, approximately 25% died due to prostate cancer and 20% for other causes. The probability of overall survival was 0.50 (95%CI 0.49-0.52) and the specific was 0.70 (95%CI 0.69-0.71). The factors associated with the risk of patient death were: stage III (HR = 1.66; 95%CI 1.39-1.99) and stage IV (HR = 3.49; 95%CI 2.91-4.18), chemotherapy (HR = 2.34; 95%CI 1.76-3.11) and hospitalization (HR = 1.6; 95%CI 1.55-1.79). The late diagnosis of the tumor, palliative treatments, and worse medical condition were factors related to the worst survival and increased risk of death from prostate cancer patients in Brazil. Analisar a probabilidade de sobrevida específica e os fatores associados ao risco de óbito dos pacientes com câncer de próstata, que receberam tratamento oncológico ambulatorial no SUS, Brasil. Estudo de coorte retrospectivo utilizando a Base Nacional em Oncologia, desenvolvida por meio de pareamento determinístico-probabilístico dos sistemas de informação de saúde: ambulatorial (SIA), hospitalar (SIH) e de

Relevance of both individual risk factors and occupational exposure in cancer survival studies: the example of intestinal type sinonasal adenocarcinoma.

PubMed

Tripodi, Dominique; Ferron, Christophe; Malard, Olivier; de Montreuil, Claude Beauvillain; Planche, Lucie; Sebille-Rivain, Veronique; Roedlich, Claude; Quéméner, Sylvia; Renaudin, Karine; Longuenesse, Claire; Verger, Christian; Meflah, Khaled; Gratas, Catherine; Géraut, Christian

2011-09-01

Wood dust is a well-established risk factor for intestinal type sinonasal adenocarcinoma. The 5-year overall survival has varied from 20% to 80% according T1-T4 stages; 5-year survival according to histologic subtype has varied from 20% to 50%. To date, no study has evaluated whether environmental, occupational, and personal risk factors have any impact on both overall and cancer-specific survival. We aimed to determine whether exposure to carcinogenic risk factors besides wood exposure can influence the survival of patients with sinonasal ethmoid carcinoma. Retrospective cohort study of the association of survival data and occupational and personal carcinogenic risk factors. All patients hospitalized for ethmoid adenocarcinoma at the Nantes University Hospital between 1988 and 2004 were included . Data concerning TNM classification, histology, type and quality of tumor resection at the macro- and microscopic level, and occupational and personal exposure to carcinogens were collected. Statistical analysis was conducted using univariate and multivariate linear regression. A total of 98 patients were included with a response rate of 98%. Data showed 86% of patients had been exposed to wood dust. The 5-year survival was 62%. We first identified four factors that independently influenced overall survival: diplopia (P = .0159), spread to the orbit (P = .0113), bilateral involvement (P = .0134), TNM stage (P < .001). When the analysis included all occupational environmental factors (wood dust, solvent, and metals exposure) as well as personal risk factors, the length of exposure to metals (P = .0307) and tobacco exposure (P = .0031) also were found to influence 5-year overall survival. We identified high prevalence of colon cancer (4%) and double cancer (18%). We showed exposure to both environmental (tobacco) and occupational (metal dust) factors could influence survival in the diagnosis of a cancer. Our study suggests that screening for colon cancer should be offered

Maximal exercise testing variables and 10-year survival: fitness risk score derivation from the FIT Project.

PubMed

Ahmed, Haitham M; Al-Mallah, Mouaz H; McEvoy, John W; Nasir, Khurram; Blumenthal, Roger S; Jones, Steven R; Brawner, Clinton A; Keteyian, Steven J; Blaha, Michael J

2015-03-01

To determine which routinely collected exercise test variables most strongly correlate with survival and to derive a fitness risk score that can be used to predict 10-year survival. This was a retrospective cohort study of 58,020 adults aged 18 to 96 years who were free of established heart disease and were referred for an exercise stress test from January 1, 1991, through May 31, 2009. Demographic, clinical, exercise, and mortality data were collected on all patients as part of the Henry Ford ExercIse Testing (FIT) Project. Cox proportional hazards models were used to identify exercise test variables most predictive of survival. A "FIT Treadmill Score" was then derived from the β coefficients of the model with the highest survival discrimination. The median age of the 58,020 participants was 53 years (interquartile range, 45-62 years), and 28,201 (49%) were female. Over a median of 10 years (interquartile range, 8-14 years), 6456 patients (11%) died. After age and sex, peak metabolic equivalents of task and percentage of maximum predicted heart rate achieved were most highly predictive of survival (P<.001). Subsequent addition of baseline blood pressure and heart rate, change in vital signs, double product, and risk factor data did not further improve survival discrimination. The FIT Treadmill Score, calculated as [percentage of maximum predicted heart rate + 12(metabolic equivalents of task) - 4(age) + 43 if female], ranged from -200 to 200 across the cohort, was near normally distributed, and was found to be highly predictive of 10-year survival (Harrell C statistic, 0.811). The FIT Treadmill Score is easily attainable from any standard exercise test and translates basic treadmill performance measures into a fitness-related mortality risk score. The FIT Treadmill Score should be validated in external populations. Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Estimation of the Standardized Risk Difference and Ratio in a Competing Risks Framework: Application to Injection Drug Use and Progression to AIDS After Initiation of Antiretroviral Therapy

PubMed Central

Cole, Stephen R.; Lau, Bryan; Eron, Joseph J.; Brookhart, M. Alan; Kitahata, Mari M.; Martin, Jeffrey N.; Mathews, William C.; Mugavero, Michael J.; Cole, Stephen R.; Brookhart, M. Alan; Lau, Bryan; Eron, Joseph J.; Kitahata, Mari M.; Martin, Jeffrey N.; Mathews, William C.; Mugavero, Michael J.

2015-01-01

There are few published examples of absolute risk estimated from epidemiologic data subject to censoring and competing risks with adjustment for multiple confounders. We present an example estimating the effect of injection drug use on 6-year risk of acquired immunodeficiency syndrome (AIDS) after initiation of combination antiretroviral therapy between 1998 and 2012 in an 8-site US cohort study with death before AIDS as a competing risk. We estimate the risk standardized to the total study sample by combining inverse probability weights with the cumulative incidence function; estimates of precision are obtained by bootstrap. In 7,182 patients (83% male, 33% African American, median age of 38 years), we observed 6-year standardized AIDS risks of 16.75% among 1,143 injection drug users and 12.08% among 6,039 nonusers, yielding a standardized risk difference of 4.68 (95% confidence interval: 1.27, 8.08) and a standardized risk ratio of 1.39 (95% confidence interval: 1.12, 1.72). Results may be sensitive to the assumptions of exposure-version irrelevance, no measurement bias, and no unmeasured confounding. These limitations suggest that results be replicated with refined measurements of injection drug use. Nevertheless, estimating the standardized risk difference and ratio is straightforward, and injection drug use appears to increase the risk of AIDS. PMID:24966220

Radical cystectomy in octogenarians--does morbidity outweigh the potential survival benefits?

PubMed

Donat, S Machele; Siegrist, Timothy; Cronin, Angel; Savage, Caroline; Milowsky, Matthew I; Herr, Harry W

2010-06-01

Surveillance, Epidemiology, and End Results data indicate only 19.7% of patients 80 years old or older with muscle invasive bladder cancer undergo radical cystectomy vs 49.4% of those with similar stage disease age 65 to 79 years, reflecting concern for perioperative morbidity. We evaluated the morbidity and survival outcomes of octogenarians treated with radical cystectomy at a tertiary cancer center. We conducted a retrospective review of 1,142 patients entered prospectively into a hospital based complication database between 1995 and 2005 using a modified Clavien system. Complications were classified as minor or major based on the complexity of intervention required. Disease specific and competing risk survival curves for patients younger than 80 years vs 80 years old or older were created. Octogenarians had a nonsignificantly higher rate of minor (55% vs 50%) and major complications (17% vs 13%) than younger patients, respectively (global p = 0.15). After adjusting for baseline characteristics the risk of any complication was roughly flat across all ages (p = 0.9). For major complications risk appeared to increase slightly up to age 65 years and then plateau (p = 0.16). After adjusting for deaths from other causes the cumulative incidence of death from bladder cancer in octogenarians was comparable to that in younger patients (5-year cumulative incidence of death from bladder cancer 26% vs 25%). In our experience radical cystectomy in older patients with bladder cancer provides similar disease control and survival outcomes with risks of high grade perioperative morbidity comparable to those in younger patients, and remains an important treatment option. Copyright 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

A survey of risk factors for digit injuries among dogs training and competing in agility events.

PubMed

Sellon, Debra C; Martucci, Katherine; Wenz, John R; Marcellin-Little, Denis J; Powers, Michelle; Cullen, Kimberley L

2018-01-01

OBJECTIVE To identify potential risk factors for digit injuries in dogs training and competing in agility events. DESIGN Internet-based, retrospective, cross-sectional survey. ANIMALS 1,081 dogs training or competing in agility events. PROCEDURES Data were collected for eligible animals via retrospective surveys distributed electronically to handlers of dogs participating in agility-related activities. Variables evaluated included demographic (handlers) and signalment (dogs) information, physical characteristics of dogs, and injury characteristics. A separate survey of dogs competing in similar agility-related activities but without digit injuries was also administered. Multivariable logistic regression was used to develop a model for assessment of risk factors. RESULTS Data were collected from 207 agility dogs with digit injuries and 874 agility dogs without digit injuries. Factors associated with significantly increased odds of injury included Border Collie breed (OR, 2.3; 95% confidence interval [CI], 1.5 to 3.3), long nails (OR, 2.4; 95% CI, 1.3 to 4.5), absence of front dewclaws (OR, 1.9; 95% CI, 1.3 to 2.6), and greater weight-to-height ratio (OR, 1.5; 95% CI, 1.1 to 2.0). Odds of injury decreased with increasing age of the dog (OR, 0.8; 95% CI, 0.76 to 0.86). CONCLUSIONS AND CLINICAL RELEVANCE Results should be cautiously interpreted because of potential respondent and recall bias and lack of review of medical records. Nevertheless, results suggested that retaining healthy dewclaws, maintaining lean body mass, and trimming nails short for training and competition may decrease the likelihood of digit injuries. Research to investigate training practices, obstacle construction specifcations, and surface considerations for dogs competing in agility activities is indicated.

Gallbladder cancer: incidence and survival in a high-risk area of Chile.

PubMed

Bertran, Enriqueta; Heise, Katy; Andia, Marcelo E; Ferreccio, Catterina

2010-11-15

We assessed population incidence rates 1998-2002 and 5-year survival rates of 317 primary gallbladder cancer (GBC) entered in the population-based cancer registry in Valdivia. We analyzed GBC incidence (Poisson regression) and GBC survival (Cox regression). Cases were identified by histology (69.4%), clinical work-up (21.8%), or death certificate only (8.8%). Main symptoms were abdominal pain (82.8%), jaundice (53.6%) nausea (42.6%), and weight loss (38.2%); at diagnosis, 64% had Stage TNM IV. In the period, 4% of histopathological studies from presumptively benign cholecystectomies presented GBC. GBC cases were mainly females (76.0%), urban residents (70.3%), Hispanic (83.7%) of low schooling <4 years (64.0%). GBC standardized incidence rate per 100,000 (SIR) were all 17.5 (95%CI: 15.5-19.4), women 24.3, and men 8.6 (p < 0.00001); Mapuche 25.0, Hispanic 16.2 (p = 0.09). The highest SIRs were in Mapuche (269.2) and Hispanic women (199.6) with <4 years of schooling. Lowest SIRs were among Hispanic men (19.8) and women (21.9) with >8 years of schooling. Low schooling, female and urban residence were independent risk factors. By December 31, 2007, 6 (1.9%) cases were living, 280 (88.3%) died from GBC, 32 (10.1%) were lost of follow-up. Kaplan Meier Global 5-year survival was: 10.3%, 85% at stage I and 1.9% at stage IV; median survival: 3.4 months. Independent poor prognostic factors were TNM IV, jaundice and nonincidental diagnoses. Our results suggest that women of Mapuche ancestry with low schooling (>50 years) are at the highest risk of presenting and dying from GBC and should be the target for early detection programs.

Evaluation of non-genomic, clinical risk and survival results in endocrine-sensitive, HER-2 negative, node negative breast cancer.

PubMed

Baena Cañada, José M; Gámez Casado, Salvador; Rodríguez Pérez, Lourdes; Quílez Cutillas, Alicia; Cortés Carmona, Cristina; Rosado Varela, Petra; Estalella Mendoza, Sara; Ramírez Daffós, Patricia; Benítez Rodríguez, Encarnación

2018-02-28

In endocrine-sensitive, HER-2 negative, node negative breast cancer, the presence of a low genomic risk allows treatment with adjuvant endocrine therapy alone, obtaining excellent survival rates. The justification for this study is to show that excellent survival rates are also obtained by treating with adjuvant hormone therapy alone, based on clinical risk assessment. A descriptive, observational and retrospective study was performed between 2006 and 2016 with endocrine-sensitive, HER-2 negative, node negative breast cancer, greater than 1cm or between 0.6 and 1cm with unfavourable features. Retrospective review of health records. Mortality data of the National Registry of Deaths. A total of 203 patients were evaluable for survival. One hundred and twenty-three (60.50%) were treated with adjuvant endocrine therapy alone, 77 (37.90%) with chemotherapy and endocrine therapy, one (0.50%) with chemotherapy alone and 2 (1%) were not treated. The overall survival rate at 5 years was 97% (95% confidence interval [CI] 94-100). Distant recurrence-free interval was 94% (95% CI 90-98). In the subgroup of patients treated with endocrine therapy alone, overall survival and distant recurrence-free interval rates at 5 years were 98% (95% CI 95-100) and 97% (95% CI 93-100), respectively. Patients with endocrine-sensitive, HER-2-negative, node negative breast cancer treated with endocrine therapy alone according to their clinical risk have similar survival outcomes as those treated with endocrine therapy according to their genomic risk. Copyright © 2018 Elsevier España, S.L.U. All rights reserved.

Carfilzomib significantly improves the progression-free survival of high-risk patients in multiple myeloma.

PubMed

Avet-Loiseau, Hervé; Fonseca, Rafael; Siegel, David; Dimopoulos, Meletios A; Špička, Ivan; Masszi, Tamás; Hájek, Roman; Rosiñol, Laura; Goranova-Marinova, Vesselina; Mihaylov, Georgi; Maisnar, Vladimír; Mateos, Maria-Victoria; Wang, Michael; Niesvizky, Ruben; Oriol, Albert; Jakubowiak, Andrzej; Minarik, Jiri; Palumbo, Antonio; Bensinger, William; Kukreti, Vishal; Ben-Yehuda, Dina; Stewart, A Keith; Obreja, Mihaela; Moreau, Philippe

2016-09-01

The presence of certain high-risk cytogenetic abnormalities, such as translocations (4;14) and (14;16) and deletion (17p), are known to have a negative impact on survival in multiple myeloma (MM). The phase 3 study ASPIRE (N = 792) demonstrated that progression-free survival (PFS) was significantly improved with carfilzomib, lenalidomide, and dexamethasone (KRd), compared with lenalidomide and dexamethasone (Rd) in relapsed MM. This preplanned subgroup analysis of ASPIRE was conducted to evaluate KRd vs Rd by baseline cytogenetics according to fluorescence in situ hybridization. Of 417 patients with known cytogenetic risk status, 100 patients (24%) were categorized with high-risk cytogenetics (KRd, n = 48; Rd, n = 52) and 317 (76%) were categorized with standard-risk cytogenetics (KRd, n = 147; Rd, n = 170). For patients with high-risk cytogenetics, treatment with KRd resulted in a median PFS of 23.1 months, a 9-month improvement relative to treatment with Rd. For patients with standard-risk cytogenetics, treatment with KRd led to a 10-month improvement in median PFS vs Rd. The overall response rates for KRd vs Rd were 79.2% vs 59.6% (high-risk cytogenetics) and 91.2% vs 73.5% (standard-risk cytogenetics); approximately fivefold as many patients with high- or standard-risk cytogenetics achieved a complete response or better with KRd vs Rd (29.2% vs 5.8% and 38.1% vs 6.5%, respectively). KRd improved but did not abrogate the poor prognosis associated with high-risk cytogenetics. This regimen had a favorable benefit-risk profile in patients with relapsed MM, irrespective of cytogenetic risk status, and should be considered a standard of care in these patients. This trial was registered at www.clinicaltrials.gov as #NCT01080391. © 2016 by The American Society of Hematology.

Carfilzomib significantly improves the progression-free survival of high-risk patients in multiple myeloma

PubMed Central

Fonseca, Rafael; Siegel, David; Dimopoulos, Meletios A.; Špička, Ivan; Masszi, Tamás; Hájek, Roman; Rosiñol, Laura; Goranova-Marinova, Vesselina; Mihaylov, Georgi; Maisnar, Vladimír; Mateos, Maria-Victoria; Wang, Michael; Niesvizky, Ruben; Oriol, Albert; Jakubowiak, Andrzej; Minarik, Jiri; Palumbo, Antonio; Bensinger, William; Kukreti, Vishal; Ben-Yehuda, Dina; Stewart, A. Keith; Obreja, Mihaela; Moreau, Philippe

2016-01-01

The presence of certain high-risk cytogenetic abnormalities, such as translocations (4;14) and (14;16) and deletion (17p), are known to have a negative impact on survival in multiple myeloma (MM). The phase 3 study ASPIRE (N = 792) demonstrated that progression-free survival (PFS) was significantly improved with carfilzomib, lenalidomide, and dexamethasone (KRd), compared with lenalidomide and dexamethasone (Rd) in relapsed MM. This preplanned subgroup analysis of ASPIRE was conducted to evaluate KRd vs Rd by baseline cytogenetics according to fluorescence in situ hybridization. Of 417 patients with known cytogenetic risk status, 100 patients (24%) were categorized with high-risk cytogenetics (KRd, n = 48; Rd, n = 52) and 317 (76%) were categorized with standard-risk cytogenetics (KRd, n = 147; Rd, n = 170). For patients with high-risk cytogenetics, treatment with KRd resulted in a median PFS of 23.1 months, a 9-month improvement relative to treatment with Rd. For patients with standard-risk cytogenetics, treatment with KRd led to a 10-month improvement in median PFS vs Rd. The overall response rates for KRd vs Rd were 79.2% vs 59.6% (high-risk cytogenetics) and 91.2% vs 73.5% (standard-risk cytogenetics); approximately fivefold as many patients with high- or standard-risk cytogenetics achieved a complete response or better with KRd vs Rd (29.2% vs 5.8% and 38.1% vs 6.5%, respectively). KRd improved but did not abrogate the poor prognosis associated with high-risk cytogenetics. This regimen had a favorable benefit-risk profile in patients with relapsed MM, irrespective of cytogenetic risk status, and should be considered a standard of care in these patients. This trial was registered at www.clinicaltrials.gov as #NCT01080391. PMID:27439911

Core competencies of the entrepreneurial leader in health care organizations.

PubMed

Guo, Kristina L

2009-01-01

The purpose of this article is to discuss core competencies that entrepreneurial health care leaders should acquire to ensure the survival and growth of US health care organizations. Three overlapping areas of core competencies are described: (1) health care system and environment competencies, (2) organization competencies, and (3) interpersonal competencies. This study offers insight into the relationship between leaders and entrepreneurship in health care organizations and establishes the foundation for more in-depth studies on leadership competencies in health care settings. The approach for identifying core competencies and designing a competency model is useful for practitioners in leadership positions in complex health care organizations, so that through the understanding and practice of these 3 areas of core competencies, they can enhance their entrepreneurial leadership skills to become more effective health care entrepreneurial leaders. This study can also be used as a tool by health care organizations to better understand leadership performance, and competencies can be used to further the organization's strategic vision and for individual improvement purposes.

Marriage is a dependent risk factor for mortality of colon adenocarcinoma without a time-varying effect

PubMed Central

Yu, Wei; Chen, Jie; Xiong, Weibin; Chen, Shuang; Yu, Li

2017-01-01

Background It has been well recognized that the effects of many prognostic factors could change during long-term follow-up. Although marriage has been proven to be a significant prognostic factor for the survival of colon cancer, whether the effect of marriage is constant with time remain unknown. This study analyzed the impact of marital status on the mortality of colon cancer patients with an extended Cox model that allowed for time-varying effects. Methods We identified 71,955 patients who underwent colectomy between 2004 and 2009 to treat colon adenocarcinoma from the Surveilance, Epidemiology and End Results Database. The multivariate extended Cox model was used to evaluate the effect of marital status on all-cause mortality, while the Fine-Gray competing risks model was used for colon cancer-specific mortality, with death from other causes as the competing risk. Results The unmarried patients carried a 1.37-fold increased risk of all-cause mortality compared with the married patients (95%CI: 1.33-1.40; p<0.001), and the hazard ratio remained constant over time. Being unmarried was at a higher risk of death from colon adenocarcinoma as well as death from other causes. Four variables including tumor site, tumor grade, sex and TNM stage were proved to have time-varying effects on survival. Conclusions Marriage is a dependent prognosis factor for survival of surgically treated colon adenocarcinoma patients. Psychological interventions are suggested to improve receipt of treatment among unmarried patients, as their poor survival may be due to the inefficient treatment. PMID:28423614

Marriage is a dependent risk factor for mortality of colon adenocarcinoma without a time-varying effect.

PubMed

Liu, Minling; Li, Lixian; Yu, Wei; Chen, Jie; Xiong, Weibin; Chen, Shuang; Yu, Li

2017-03-21

It has been well recognized that the effects of many prognostic factors could change during long-term follow-up. Although marriage has been proven to be a significant prognostic factor for the survival of colon cancer, whether the effect of marriage is constant with time remain unknown. This study analyzed the impact of marital status on the mortality of colon cancer patients with an extended Cox model that allowed for time-varying effects. We identified 71,955 patients who underwent colectomy between 2004 and 2009 to treat colon adenocarcinoma from the Surveilance, Epidemiology and End Results Database. The multivariate extended Cox model was used to evaluate the effect of marital status on all-cause mortality, while the Fine-Gray competing risks model was used for colon cancer-specific mortality, with death from other causes as the competing risk. The unmarried patients carried a 1.37-fold increased risk of all-cause mortality compared with the married patients (95%CI: 1.33-1.40; p<0.001), and the hazard ratio remained constant over time. Being unmarried was at a higher risk of death from colon adenocarcinoma as well as death from other causes. Four variables including tumor site, tumor grade, sex and TNM stage were proved to have time-varying effects on survival. Marriage is a dependent prognosis factor for survival of surgically treated colon adenocarcinoma patients. Psychological interventions are suggested to improve receipt of treatment among unmarried patients, as their poor survival may be due to the inefficient treatment.

Beyond utilitarianism: a method for analyzing competing ethical principles in a decision analysis of liver transplantation.

PubMed

Volk, Michael L; Lok, Anna S F; Ubel, Peter A; Vijan, Sandeep

2008-01-01

The utilitarian foundation of decision analysis limits its usefulness for many social policy decisions. In this study, the authors examine a method to incorporate competing ethical principles in a decision analysis of liver transplantation for a patient with acute liver failure (ALF). A Markov model was constructed to compare the benefit of transplantation for a patient with ALF versus the harm caused to other patients on the waiting list and to determine the lowest acceptable 5-y posttransplant survival for the ALF patient. The weighting of the ALF patient and other patients was then adjusted using a multiattribute variable incorporating utilitarianism, urgency, and other principles such as fair chances. In the base-case analysis, the strategy of transplanting the ALF patient resulted in a 0.8% increase in the risk of death and a utility loss of 7.8 quality-adjusted days of life for each of the other patients on the waiting list. These harms cumulatively outweighed the benefit of transplantation for an ALF patient having a posttransplant survival of less than 48% at 5 y. However, the threshold for an acceptable posttransplant survival for the ALF patient ranged from 25% to 56% at 5 y, depending on the ethical principles involved. The results of the decision analysis vary depending on the ethical perspective. This study demonstrates how competing ethical principles can be numerically incorporated in a decision analysis.

Statin use and breast cancer survival and risk: a systematic review and meta-analysis.

PubMed

Wu, Qi-Jun; Tu, Chao; Li, Yuan-Yuan; Zhu, Jingjing; Qian, Ke-Qing; Li, Wen-Jing; Wu, Lang

2015-12-15

The purpose of this study is to determine the associations between statin use and breast cancer survival and risk by performing a systematic review and meta-analysis. We searched PubMed, Embase and Web of Science up to August 2015 for identifying relevant prospective or case-control studies, or randomized clinical trials. Five prospective studies involving 60,911 patients reported the association between statin use and breast cancer mortality. Eleven prospective studies, 12 case-control studies and 9 randomized clinical trials involving 83,919 patients reported the association between statin use and breast cancer risk. After pooling estimates from all available studies, there was a significantly negative association between pre-diagnosis statin use and breast cancer mortality (for overall survival (OS): hazard ratio (HR) = 0.68, 95% confidence interval (CI) 0.54-0.84; for disease specific survival (DSS): HR = 0.72, 95% CI 0.53-0.99). There was also a significant inverse association between post-diagnosis statin use and breast cancer DSS (HR = 0.65, 95% CI 0.43-0.98), although the association with breast cancer OS did not reach statistical significance (HR = 0.71, 95% CI 0.48-1.07). Additionally, there was a non-linear relationship for the duration of post-diagnosis statin use with breast cancer specific mortality. On the other hand, with regards to the relationship between statin use and breast cancer risk, no significant association was detected. Our analyses suggest that although statin use may not influence breast cancer risk, the use of statin may be associated with decrease mortality of breast cancer patients. Further large-scale studies are warranted to validate our findings.

SEMIPARAMETRIC ADDITIVE RISKS REGRESSION FOR TWO-STAGE DESIGN SURVIVAL STUDIES

PubMed Central

Li, Gang; Wu, Tong Tong

2011-01-01

In this article we study a semiparametric additive risks model (McKeague and Sasieni (1994)) for two-stage design survival data where accurate information is available only on second stage subjects, a subset of the first stage study. We derive two-stage estimators by combining data from both stages. Large sample inferences are developed. As a by-product, we also obtain asymptotic properties of the single stage estimators of McKeague and Sasieni (1994) when the semiparametric additive risks model is misspecified. The proposed two-stage estimators are shown to be asymptotically more efficient than the second stage estimators. They also demonstrate smaller bias and variance for finite samples. The developed methods are illustrated using small intestine cancer data from the SEER (Surveillance, Epidemiology, and End Results) Program. PMID:21931467

Incidence of bone metastases and survival after a diagnosis of bone metastases in breast cancer patients.

PubMed

Harries, M; Taylor, A; Holmberg, L; Agbaje, O; Garmo, H; Kabilan, S; Purushotham, A

2014-08-01

Bone is the most common metastatic site associated with breast cancer. Using a database of women with breast cancer treated at Guy's Hospital, London 1976-2006 and followed until end 2010, we determined incidence of and survival after bone metastases. We calculated cumulative incidence of bone metastases considering death without prior bone metastases as a competing risk. Risk of bone metastases was modelled through Cox-regression. Survival after bone metastases diagnosis was calculated using Kaplan-Meier methodology. Of the 7064 women, 589 (22%) developed bone metastases during 8.4 years (mean). Incidence of bone metastases was significantly higher in younger women, tumour size >5 cm, higher tumour grade, lobular carcinoma and ≥ four positive nodes, but was not affected by hormone receptor status. Median survival after bone metastases diagnosis was 2.3 years in women with bone-only metastases compared with <1 year in women with visceral and bone metastases. There was a trend for decreased survival for patients who developed visceral metastases early, and proportionately fewer patients in this group. Incidence of bone metastases has decreased but bone metastases remain a highly relevant clinical problem due to the large number of patients being diagnosed with breast cancer. Copyright © 2014 Elsevier Ltd. All rights reserved.

5-year survival and rehospitalization due to stroke recurrence among patients with hemorrhagic or ischemic strokes in Singapore.

PubMed

Sun, Yan; Lee, Sze Haur; Heng, Bee Hoon; Chin, Vivien S

2013-10-03

Stroke is the 4th leading cause of death and 1st leading cause of disability in Singapore. However the information on long-term post stroke outcomes for Singaporean patients was limited. This study aimed to investigate the post stroke outcomes of 5-year survival and rehospitalization due to stroke recurrence for hemorrhagic and ischemic stroke patients in Singapore. The outcomes were stratified by age, ethnic group, gender and stroke types. The causes of death and stroke recurrence were also explored in the study. A multi-site retrospective cohort study. Patients admitted for stroke at any of the three hospitals in the National Healthcare Group of Singapore were included in the study. All study patients were followed up to 5 years. Kaplan-Meier was applied to study the time to first event, death or rehospitalization due to stroke recurrence. Cox proportional hazard model was applied to study the time to death with adjustment for stroke type, age, sex, ethnic group, and admission year. Cumulative incidence model with competing risk was applied for comparing the risks of rehospitalization due to stroke recurrence with death as the competing risk. Totally 12,559 stroke patients were included in the study. Among them, 59.3% survived for 5 years; 18.4% were rehospitalized due to stroke recurrence in 5 years. The risk of stroke recurrence and mortality increased with age in all stroke types. Gender, ethnic group and admitting year were not significantly associated with the risk of mortality or stroke recurrence in hemorrhagic stroke. Male or Malay patient had higher risk of stroke recurrence and mortality in ischemic stroke. Hemorrhagic stroke had higher early mortality while ischemic stroke had higher recurrence and late mortality. The top cause of death among died stroke patients was cerebrovascular diseases, followed by pneumonia and ischemic heart diseases. The recurrent stroke was most likely to be the same type as the initial stroke among rehospitalized stroke

Competing risk of atherosclerotic risk factors for arterial and venous thrombosis in a general population: the Tromso study.

PubMed

Brækkan, Sigrid K; Hald, Erin M; Mathiesen, Ellisiv B; Njølstad, Inger; Wilsgaard, Tom; Rosendaal, Frits R; Hansen, John-Bjarne

2012-02-01

To investigate and compare the impact of traditional atherosclerotic risk factors for the risk of arterial and venous thrombosis, taking into account competing risks. In 1994-1995, 26,185 subjects were screened in the Tromsø study. Information on traditional atherosclerotic risk factors was obtained by physical examination, blood samples, and questionnaires. Subjects were followed to the first incident event of myocardial infarction (MI) or venous thromboembolism (VTE), or December 31, 2005. During a median of 10.8 years of follow-up, there were 1279 cases of incident MI and 341 VTE events. Advancing age and high body mass index were both associated with MI and VTE. Hazard ratio per decade of age was 2.34 (95% CI: 2.25-2.43) for MI and 1.87 (1.74-2.01) for VTE, and 3 kg/m(2) increase in body mass index was associated with 1.16 (1.11-1.21) and 1.20 (1.12-1.29) increased risk of MI and VTE, respectively. Blood pressure, high levels of triglycerides and total cholesterol, low HDL cholesterol, self-reported diabetes, and smoking were all associated with increased risk of MI but not associated with VTE. Our findings imply that traditional atherosclerotic risk factors, such as smoking, hypertension, dyslipidemia, and diabetes mellitus are not shared by arterial and venous thrombosis.

Association study of genetic variants in estrogen metabolic pathway genes and colorectal cancer risk and survival.

PubMed

Li, Shuwei; Xie, Lisheng; Du, Mulong; Xu, Kaili; Zhu, Lingjun; Chu, Haiyan; Chen, Jinfei; Wang, Meilin; Zhang, Zhengdong; Gu, Dongying

2018-05-16

Although studies have investigated the association of genetic variants and the abnormal expression of estrogen-related genes with colorectal cancer risk, the evidence remains inconsistent. We clarified the relationship of genetic variants in estrogen metabolic pathway genes with colorectal cancer risk and survival. A case-control study was performed to assess the association of single-nucleotide polymorphisms (SNPs) in ten candidate genes with colorectal cancer risk in a Chinese population. A logistic regression model and Cox regression model were used to calculate SNP effects on colorectal cancer susceptibility and survival, respectively. Expression quantitative trait loci (eQTL) analysis was conducted using the Genotype-Tissue Expression (GTEx) project dataset. The sequence kernel association test (SKAT) was used to perform gene-set analysis. Colorectal cancer risk and rs3760806 in SULT2B1 were significantly associated in both genders [male: OR = 1.38 (1.15-1.66); female: OR = 1.38 (1.13-1.68)]. Two SNPs in SULT1E1 were related to progression-free survival (PFS) [rs1238574: HR = 1.24 (1.02-1.50), P = 2.79 × 10 -2 ; rs3822172: HR = 1.30 (1.07-1.57), P = 8.44 × 10 -3 ] and overall survival (OS) [rs1238574: HR = 1.51 (1.16-1.97), P = 2.30 × 10 -3 ; rs3822172: HR = 1.53 (1.67-2.00), P = 2.03 × 10 -3 ]. Moreover, rs3760806 was an eQTL for SULT2B1 in colon samples (transverse: P = 3.6 × 10 -3 ; sigmoid: P = 1.0 × 10 -3 ). SULT2B1 expression was significantly higher in colorectal tumor tissues than in normal tissues in the Cancer Genome Atlas (TCGA) database (P < 1.0 × 10 -4 ). Our results indicated that SNPs in estrogen metabolic pathway genes confer colorectal cancer susceptibility and survival.

Improved Survival Endpoints With Adjuvant Radiation Treatment in Patients With High-Risk Early-Stage Endometrial Carcinoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Elshaikh, Mohamed A., E-mail: melshai1@hfhs.org; Vance, Sean; Suri, Jaipreet S.

2014-02-01

Purpose/Objective(s): To determine the impact of adjuvant radiation treatment (RT) on recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) in patients with high-risk 2009 International Federation of Gynecology and Obstetrics stage I-II endometrial carcinoma. Methods and Materials: We identified 382 patients with high-risk EC who underwent hysterectomy. RFS, DSS, and OS were calculated from the date of hysterectomy by use of the Kaplan-Meier method. Cox regression modeling was used to explore the risks associated with various factors on survival endpoints. Results: The median follow-up time for the study cohort was 5.4 years. The median age was 71 years.more » All patients underwent hysterectomy and salpingo-oophorectomy, 93% had peritoneal cytology, and 85% underwent lymphadenectomy. Patients with endometrioid histology constituted 72% of the study cohort, serous in 16%, clear cell in 7%, and mixed histology in 4%. Twenty-three percent of patients had stage II disease. Adjuvant management included RT alone in 220 patients (57%), chemotherapy alone in 25 patients (7%), and chemoradiation therapy in 27 patients (7%); 110 patients (29%) were treated with close surveillance. The 5-year RFS, DSS, and OS were 76%, 88%, and 73%, respectively. On multivariate analysis, adjuvant RT was a significant predictor of RFS (P<.001) DSS (P<.001), and OS (P=.017). Lymphovascular space involvement was a significant predictor of RFS and DSS (P<.001). High tumor grade was a significant predictor for RFS (P=.038) and DSS (P=.025). Involvement of the lower uterine segment was also a predictor of RFS (P=.049). Age at diagnosis and lymphovascular space involvement were significant predictors of OS: P<.001 and P=.002, respectively. Conclusion: In the treatment of patients with high-risk features, our study suggests that adjuvant RT significantly improves recurrence-free, disease-specific, and overall survival in patients with early-stage endometrial

Estimation of the standardized risk difference and ratio in a competing risks framework: application to injection drug use and progression to AIDS after initiation of antiretroviral therapy.

PubMed

Cole, Stephen R; Lau, Bryan; Eron, Joseph J; Brookhart, M Alan; Kitahata, Mari M; Martin, Jeffrey N; Mathews, William C; Mugavero, Michael J

2015-02-15

There are few published examples of absolute risk estimated from epidemiologic data subject to censoring and competing risks with adjustment for multiple confounders. We present an example estimating the effect of injection drug use on 6-year risk of acquired immunodeficiency syndrome (AIDS) after initiation of combination antiretroviral therapy between 1998 and 2012 in an 8-site US cohort study with death before AIDS as a competing risk. We estimate the risk standardized to the total study sample by combining inverse probability weights with the cumulative incidence function; estimates of precision are obtained by bootstrap. In 7,182 patients (83% male, 33% African American, median age of 38 years), we observed 6-year standardized AIDS risks of 16.75% among 1,143 injection drug users and 12.08% among 6,039 nonusers, yielding a standardized risk difference of 4.68 (95% confidence interval: 1.27, 8.08) and a standardized risk ratio of 1.39 (95% confidence interval: 1.12, 1.72). Results may be sensitive to the assumptions of exposure-version irrelevance, no measurement bias, and no unmeasured confounding. These limitations suggest that results be replicated with refined measurements of injection drug use. Nevertheless, estimating the standardized risk difference and ratio is straightforward, and injection drug use appears to increase the risk of AIDS. © The Author 2014. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Observing and Planning for Play and Competence.

ERIC Educational Resources Information Center

Neumann, Eva A.

This paper presents a framework useful for preschool and elementary teachers in developing a basic understanding of competency and play and their interrelationship. Specific guidelines are given for observing and planning toward increasing opportunities for competency and play. Competency is viewed as consisting of growth, risk-taking, and a…

Survival or Mortality: Does Risk Attribute Framing Influence Decision-Making Behavior in a Discrete Choice Experiment?

PubMed

Veldwijk, Jorien; Essers, Brigitte A B; Lambooij, Mattijs S; Dirksen, Carmen D; Smit, Henriette A; de Wit, G Ardine

2016-01-01

To test how attribute framing in a discrete choice experiment (DCE) affects respondents' decision-making behavior and their preferences. Two versions of a DCE questionnaire containing nine choice tasks were distributed among a representative sample of the Dutch population aged 55 to 65 years. The DCE consisted of four attributes related to the decision regarding participation in genetic screening for colorectal cancer (CRC). The risk attribute included was framed positively as the probability of surviving CRC and negatively as the probability of dying from CRC. Panel mixed-logit models were used to estimate the relative importance of the attributes. The data of the positively and negatively framed DCE were compared on the basis of direct attribute ranking, dominant decision-making behavior, preferences, and importance scores. The majority (56%) of the respondents ranked survival as the most important attribute in the positively framed DCE, whereas only a minority (8%) of the respondents ranked mortality as the most important attribute in the negatively framed DCE. Respondents made dominant choices based on survival significantly more often than based on mortality. The framing of the risk attribute significantly influenced all attribute-level estimates and resulted in different preference structures among respondents in the positively and negatively framed data set. Risk framing affects how respondents value the presented risk. Positive risk framing led to increased dominant decision-making behavior, whereas negative risk framing led to risk-seeking behavior. Attribute framing should have a prominent part in the expert and focus group interviews, and different types of framing should be used in the pilot version of DCEs as well as in actual DCEs to estimate the magnitude of the effect of choosing different types of framing. Copyright © 2016 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Perspective: Toward a competency framework for faculty.

PubMed

Milner, Robert J; Gusic, Maryellen E; Thorndyke, Luanne E

2011-10-01

Today, faculty in academic medicine face challenges in all three mission areas--research, education, and patient care--and require a broad set of competencies to survive in this changing environment. To support faculty and to design assessments that match new expectations, the authors argue that it is essential to capture the full scope of skills, knowledge, and behaviors necessary for a successful faculty member. Thus, it is timely to explore and define competencies for faculty in academic medicine. The authors describe three approaches to identifying faculty competencies. Each reveals diverse but overlapping sets of competency domains, reflecting the breadth of activities expected of today's faculty. To organize these competencies into a coherent framework, the authors propose a model based on a typology of competency. A key feature of the model is the division between occupational competencies, which are largely role-specific, and personal competencies, which are necessary for all faculty. A competency framework also must be developmental, to reflect the growth in skills, knowledge, and behaviors from trainee to expert and to allow for an individual's changing roles over a career. Such a competency framework will inform professional development activities and require assessment of competence. The generation of competencies also will reveal areas of faculty practice that are poorly measured, requiring new tools to be incorporated into existing processes of faculty evaluation. The authors provide general principles to guide the identification of a competency framework for faculty and invite the academic medicine community to engage in further discussion.

Connection between competence, usability, environment and risk of falls in elderly adults.

PubMed

Leiva-Caro, José Alex; Salazar-González, Bertha Cecilia; Gallegos-Cabriales, Esther Carlota; Gómez-Meza, Marco Vinicio; Hunter, Kathleen F

2015-01-01

To determine connections between competence, usability, environment and risk of falls in elderly adults. Correlational descriptive study, 123 elderly adults, both male and female, aged 70 years and older were included. Data was collected via the Tinetti Scale, CESD-7 Scale, Montreal Cognitive Assessment, Usability Questionnaire on Housing and Housing Enabler; and sociodemographic and health background certificate data. For data analysis, descriptive and inferential statistics were used, multivariate linear and logistic regression models were adjusted. 42.0% of the elderly adults had presented with falls, with a higher prevalence in women, and in the group of 70-75 years. The physical environment of the house, gait, and usability were set as risk factors for falls. A negative relationship between usability and depressive symptoms, cognitive health, balance, gait, the social and physical environment was found, p <0.05; and a strong positive correlation between walking and balance, p <0.05. This study helps to better understand the phenomenon of falling, to find a connection between usability with the risk of falls, and other variables.

Connection between competence, usability, environment and risk of falls in elderly adults

PubMed Central

Leiva-Caro, José Alex; Salazar-González, Bertha Cecilia; Gallegos-Cabriales, Esther Carlota; Gómez-Meza, Marco Vinicio; Hunter, Kathleen F.

2015-01-01

Objective: to determine connections between competence, usability, environment and risk of falls in elderly adults. Method: correlational descriptive study, 123 elderly adults, both male and female, aged 70 years and older were included. Data was collected via the Tinetti Scale, CESD-7 Scale, Montreal Cognitive Assessment, Usability Questionnaire on Housing and Housing Enabler; and sociodemographic and health background certificate data. For data analysis, descriptive and inferential statistics were used, multivariate linear and logistic regression models were adjusted. Results: 42.0% of the elderly adults had presented with falls, with a higher prevalence in women, and in the group of 70-75 years. The physical environment of the house, gait, and usability were set as risk factors for falls. A negative relationship between usability and depressive symptoms, cognitive health, balance, gait, the social and physical environment was found, p <0.05; and a strong positive correlation between walking and balance, p <0.05. Conclusion: this study helps to better understand the phenomenon of falling, to find a connection between usability with the risk of falls, and other variables. PMID:26626006

Fine and Gray competing risk regression model to study the cause-specific under-five child mortality in Bangladesh.

PubMed

Mohammad, Khandoker Akib; Fatima-Tuz-Zahura, Most; Bari, Wasimul

2017-01-28

The cause-specific under-five mortality of Bangladesh has been studied by fitting cumulative incidence function (CIF) based Fine and Gray competing risk regression model (1999). For the purpose of analysis, Bangladesh Demographic and Health Survey (BDHS), 2011 data set was used. Three types of mode of mortality for the under-five children are considered. These are disease, non-disease and other causes. Product-Limit survival probabilities for the under-five child mortality with log-rank test were used to select a set of covariates for the regression model. The covariates found to have significant association in bivariate analysis were only considered in the regression analysis. Potential determinants of under-five child mortality due to disease is size of child at birth, while gender of child, NGO (non-government organization) membership of mother, mother's education level, and size of child at birth are due to non-disease and age of mother at birth, NGO membership of mother, and mother's education level are for the mortality due to other causes. Female participation in the education programs needs to be increased because of the improvement of child health and government should arrange family and social awareness programs as well as health related programs for women so that they are aware of their child health.

Thrombotic Thrombocytopenic Purpura in Black People: Impact of Ethnicity on Survival and Genetic Risk Factors.

PubMed

Martino, Suella; Jamme, Mathieu; Deligny, Christophe; Busson, Marc; Loiseau, Pascale; Azoulay, Elie; Galicier, Lionel; Pène, Frédéric; Provôt, François; Dossier, Antoine; Saheb, Samir; Veyradier, Agnès; Coppo, Paul

2016-01-01

Black people are at increased risk of thrombotic thrombocytopenic purpura (TTP). Whether clinical presentation of TTP in Black patients has specific features is unknown. We assessed here differences in TTP presentation and outcome between Black and White patients. Clinical presentation was comparable between both ethnic groups. However, prognosis differed with a lower death rate in Black patients than in White patients (2.7% versus 11.6%, respectively, P = .04). Ethnicity, increasing age and neurologic involvement were retained as risk factors for death in a multivariable model (P < .05 all). Sixty-day overall survival estimated by the Kaplan-Meier curves and compared with the Log-Rank test confirmed that Black patients had a better survival than White patients (P = .03). Salvage therapies were similarly performed between both groups, suggesting that disease severity was comparable. The comparison of HLA-DRB1*11, -DRB1*04 and -DQB1*03 allele frequencies between Black patients and healthy Black individuals revealed no significant difference. However, the protective allele against TTP, HLA-DRB1*04, was dramatically decreased in Black individuals in comparison with White individuals. Black people with TTP may have a better survival than White patients despite a comparable disease severity. A low natural frequency of HLA-DRB1*04 in Black ethnicity may account for the greater risk of TTP in this population.

Thrombotic Thrombocytopenic Purpura in Black People: Impact of Ethnicity on Survival and Genetic Risk Factors

PubMed Central

Martino, Suella; Jamme, Mathieu; Deligny, Christophe; Busson, Marc; Loiseau, Pascale; Azoulay, Elie; Galicier, Lionel; Pène, Frédéric; Provôt, François; Dossier, Antoine; Saheb, Samir; Veyradier, Agnès; Coppo, Paul

2016-01-01

Black people are at increased risk of thrombotic thrombocytopenic purpura (TTP). Whether clinical presentation of TTP in Black patients has specific features is unknown. We assessed here differences in TTP presentation and outcome between Black and White patients. Clinical presentation was comparable between both ethnic groups. However, prognosis differed with a lower death rate in Black patients than in White patients (2.7% versus 11.6%, respectively, P = .04). Ethnicity, increasing age and neurologic involvement were retained as risk factors for death in a multivariable model (P < .05 all). Sixty-day overall survival estimated by the Kaplan-Meier curves and compared with the Log-Rank test confirmed that Black patients had a better survival than White patients (P = .03). Salvage therapies were similarly performed between both groups, suggesting that disease severity was comparable. The comparison of HLA-DRB1*11, -DRB1*04 and -DQB1*03 allele frequencies between Black patients and healthy Black individuals revealed no significant difference. However, the protective allele against TTP, HLA-DRB1*04, was dramatically decreased in Black individuals in comparison with White individuals. Black people with TTP may have a better survival than White patients despite a comparable disease severity. A low natural frequency of HLA-DRB1*04 in Black ethnicity may account for the greater risk of TTP in this population. PMID:27383202

Effects of delayed metamorphosis on larval survival, metamorphosis, and juvenile performance of four closely related species of tropical sea urchins (genus Echinometra).

PubMed

Rahman, M Aminur; Yusoff, Fatimah Md; Arshad, A; Uehara, Tsuyoshi

2014-01-01

We report here, the effects of extended competency on larval survival, metamorphosis, and postlarval juvenile growth of four closely related species of tropical sea urchins, Echinometra sp. A (Ea), E. mathaei (Em), Echinometra sp. C (Ec), and E. oblonga (Eo). Planktotrophic larvae of all four species fed on cultured phytoplankton (Chaetoceros gracilis) attained metamorphic competence within 22-24 days after fertilization. Competent larvae were forced to delay metamorphosis for up to 5 months by preventing them from settling in culture bottles with continuous stirring on a set of 10 rpm rotating rollers and larval survival per monthly intervals was recorded. Larval survival was highest at 24 days, when competence was attained (0 delayed period), and there were no significant differences among the four species. Larvae that had experienced a prolonged delay had reduced survival rate, metamorphosis success, and juvenile survival, but among older larvae, Em had the highest success followed by Ea, Eo, and Ec. Juveniles from larvae of all four species that metamorphosed soon after becoming competent tended to have higher growth rates (test diameter and length of spines) than juveniles from larvae that metamorphosed after a prolonged period of competence with progressively slower growth the longer the prolonged period. Despite the adverse effects of delaying metamorphosis on growth parameters, competent larvae of all four species were able to survive up to 5 months and after metamorphosis grew into 1-month-old juveniles in lab condition. Overall, delayed larvae of Em showed significantly higher larval survival, metamorphosis, and juvenile survival than Ea and Eo, while Ec showed the lowest values in these performances. Em has the most widespread distribution of these species ranging from Africa to Hawaii, while Ec probably has the most restricted distribution. Consequently, differences in distribution may be related to differences in the ability to delay metamorphosis.

Effects of Delayed Metamorphosis on Larval Survival, Metamorphosis, and Juvenile Performance of Four Closely Related Species of Tropical Sea Urchins (Genus Echinometra)

PubMed Central

Rahman, M. Aminur; Yusoff, Fatimah Md.; Arshad, A.; Uehara, Tsuyoshi

2014-01-01

We report here, the effects of extended competency on larval survival, metamorphosis, and postlarval juvenile growth of four closely related species of tropical sea urchins, Echinometra sp. A (Ea), E. mathaei (Em), Echinometra sp. C (Ec), and E. oblonga (Eo). Planktotrophic larvae of all four species fed on cultured phytoplankton (Chaetoceros gracilis) attained metamorphic competence within 22–24 days after fertilization. Competent larvae were forced to delay metamorphosis for up to 5 months by preventing them from settling in culture bottles with continuous stirring on a set of 10 rpm rotating rollers and larval survival per monthly intervals was recorded. Larval survival was highest at 24 days, when competence was attained (0 delayed period), and there were no significant differences among the four species. Larvae that had experienced a prolonged delay had reduced survival rate, metamorphosis success, and juvenile survival, but among older larvae, Em had the highest success followed by Ea, Eo, and Ec. Juveniles from larvae of all four species that metamorphosed soon after becoming competent tended to have higher growth rates (test diameter and length of spines) than juveniles from larvae that metamorphosed after a prolonged period of competence with progressively slower growth the longer the prolonged period. Despite the adverse effects of delaying metamorphosis on growth parameters, competent larvae of all four species were able to survive up to 5 months and after metamorphosis grew into 1-month-old juveniles in lab condition. Overall, delayed larvae of Em showed significantly higher larval survival, metamorphosis, and juvenile survival than Ea and Eo, while Ec showed the lowest values in these performances. Em has the most widespread distribution of these species ranging from Africa to Hawaii, while Ec probably has the most restricted distribution. Consequently, differences in distribution may be related to differences in the ability to delay metamorphosis

Quantifying intrinsic and extrinsic control of single-cell fates in cancer and stem/progenitor cell pedigrees with competing risks analysis

PubMed Central

Cornwell, J. A.; Hallett, R. M.; der Mauer, S. Auf; Motazedian, A.; Schroeder, T.; Draper, J. S.; Harvey, R. P.; Nordon, R. E.

2016-01-01

The molecular control of cell fate and behaviour is a central theme in biology. Inherent heterogeneity within cell populations requires that control of cell fate is studied at the single-cell level. Time-lapse imaging and single-cell tracking are powerful technologies for acquiring cell lifetime data, allowing quantification of how cell-intrinsic and extrinsic factors control single-cell fates over time. However, cell lifetime data contain complex features. Competing cell fates, censoring, and the possible inter-dependence of competing fates, currently present challenges to modelling cell lifetime data. Thus far such features are largely ignored, resulting in loss of data and introducing a source of bias. Here we show that competing risks and concordance statistics, previously applied to clinical data and the study of genetic influences on life events in twins, respectively, can be used to quantify intrinsic and extrinsic control of single-cell fates. Using these statistics we demonstrate that 1) breast cancer cell fate after chemotherapy is dependent on p53 genotype; 2) granulocyte macrophage progenitors and their differentiated progeny have concordant fates; and 3) cytokines promote self-renewal of cardiac mesenchymal stem cells by symmetric divisions. Therefore, competing risks and concordance statistics provide a robust and unbiased approach for evaluating hypotheses at the single-cell level. PMID:27250534

Bayesian regression analyses of radiation modality effects on pericardial and pleural effusion and survival in esophageal cancer.

PubMed

He, Liru; Chapple, Andrew; Liao, Zhongxing; Komaki, Ritsuko; Thall, Peter F; Lin, Steven H

2016-10-01

To evaluate radiation modality effects on pericardial effusion (PCE), pleural effusion (PE) and survival in esophageal cancer (EC) patients. We analyzed data from 470 EC patients treated with definitive concurrent chemoradiotherapy (CRT). Bayesian semi-competing risks (SCR) regression models were fit to assess effects of radiation modality and prognostic covariates on the risks of PCE and PE, and death either with or without these preceding events. Bayesian piecewise exponential regression models were fit for overall survival, the time to PCE or death, and the time to PE or death. All models included propensity score as a covariate to correct for potential selection bias. Median times to onset of PCE and PE after RT were 7.1 and 6.1months for IMRT, and 6.5 and 5.4months for 3DCRT, respectively. Compared to 3DCRT, the IMRT group had significantly lower risks of PE, PCE, and death. The respective probabilities of a patient being alive without either PCE or PE at 3-years and 5-years were 0.29 and 0.21 for IMRT compared to 0.13 and 0.08 for 3DCRT. In the SCR regression analyses, IMRT was associated with significantly lower risks of PCE (HR=0.26) and PE (HR=0.49), and greater overall survival (probability of beneficial effect (pbe)>0.99), after controlling for known clinical prognostic factors. IMRT reduces the incidence and postpones the onset of PCE and PE, and increases survival probability, compared to 3DCRT. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Emotional competence and online game use in adolescents.

PubMed

Seo, Mia; Kang, Hee Sun; Chae, Sun-Mi

2012-12-01

The purpose of this study was to explore the relations between emotional competence and online game use in adolescents. This study is a cross-sectional descriptive survey using a convenience sample. The participants were 2199 adolescents in South Korea. Online game use and emotional competence including positive emotion, emotional expression, and emotional intelligence were measured. The study results indicated that emotional competence was negatively correlated with excessive online game use. All variables of emotional competence were significantly lower in high-risk users compared with general users. In addition, female adolescents were rated significantly higher in emotional competence among general users, but there were no significant gender differences among high-risk users. The results of our study imply that high-risk game users have lower levels of emotional intelligence than general users do. The results of this study suggest that emotion is an important factor to which practitioners in psychomedical fields and nursing should pay attention. Therefore, nurses in schools and communities should regularly screen the emotions of adolescents who habitually play online games and develop a program to enhance emotional competence associated with online games.

Important risk factors of allograft survival in cadaveric renal transplantation. A study of 426 patients.

PubMed Central

Diethelm, A G; Blackstone, E H; Naftel, D C; Hudson, S L; Barber, W H; Deierhoi, M H; Barger, B O; Curtis, J J; Luke, R G

1988-01-01

Multiple risk factors contribute to the allograft survival of patients who have cadaveric renal transplantation. A retrospective review of 19 such factors in 426 patients identified race, DR match, B + DR match, number of transplants, and preservation time to have a significant influence. The parametric analysis confirmed the effect to be primarily in the early phase, i.e., first 6 months. All patients received cyclosporine with other methods of immunosuppression resulting in an overall 1-year graft survival rate of 66%. The overall 1-year graft survival rate in the white race was 73% and in the black race was 57% (p = 0.002). Allograft survival and DR match showed white recipients with a 1 DR match to have 75% survival at 1 year compared with 57% in the black patient (p = 0.009). If HLA B + DR match was considered, the white recipient allograft survival increased to 76%, 84%, and 88% for 1, 2, and 3 match kidneys by parametric analysis. Patients receiving first grafts had better graft survival (68%) than those undergoing retransplantation (58%) (p = 0.05). Organ preservation less than 12 hours influenced allograft survival with a 78% 1-year survival rate compared with 63% for kidneys with 12-18 hours of preservation. Despite the benefits of B + DR typing, short preservation time, and first transplants to the white recipient, the allograft survival in the black recipient remained uninfluenced by these parameters. PMID:3288138

Risk Management. Unit 20. Level 1. Instructor Guide. PACE: Program for Acquiring Competence in Entrepreneurship. Third Edition. Research & Development Series No. 301-20.

ERIC Educational Resources Information Center

Ohio State Univ., Columbus. Center on Education and Training for Employment.

This instructor guide for a unit on risk management in the PACE (Program for Acquiring Competence in Entrepreneurship) curriculum includes the full text of the student module and lesson plans, instructional suggestions, and other teacher resources. The competencies that are incorporated into this module are at Level 1 of learning--understanding…

Eating competence: definition and evidence for the Satter Eating Competence model.

PubMed

Satter, Ellyn

2007-01-01

The evidence- and practice-based Satter Eating Competence Model (ecSatter) outlines an inclusive definition of the interrelated spectrum of eating attitudes and behaviors. The model is predicated on the utility and effectiveness of biopsychosocial processes: hunger and the drive to survive, appetite and the need for subjective reward and the biological propensity to maintain preferred and stable body weight. According to ecSatter, competent eaters have 1) positive attitudes about eating and about food, 2) food acceptance skills that support eating an ever-increasing variety of the available food, 3) internal regulation skills that allow intuitively consuming enough food to give energy and stamina and to support stable body weight, and 4) skills and resources for managing the food context and orchestrating family meals. Identifying these four constructs allows nutrition professionals to target interventions as well as trust and support the individual's own capabilities and tendency to learn and grow.

Sociodemographic disparities in survival from colorectal cancer in South Australia: a population-wide data linkage study.

PubMed

Beckmann, Kerri R; Bennett, Alice; Young, Graeme P; Cole, Stephen R; Joshi, Rohit; Adams, Jacqui; Singhal, Nimit; Karapetis, Christos; Wattchow, David; Roder, David

2016-01-20

Inequalities in survival from colorectal cancer (CRC) across socioeconomic groups and by area of residence have been described in various health care settings. Few population-wide datasets which include clinical and treatment information are available in Australia to investigate disparities. This study examines socio-demographic differences in survival for CRC patients in South Australia (SA), using a population-wide database derived via linkage of administrative and surveillance datasets. The study population comprised all cases of CRC diagnosed in 2003-2008 among SA residents aged 50-79 yrs in the SA Central Cancer Registry. Measures of socioeconomic status (area level), geographical remoteness, clinical characteristics, comorbid conditions, treatments and outcomes were derived through record linkage of central cancer registry, hospital-based clinical registries, hospital separations, and radiotherapy services data sources. Socio-demographic disparities in CRC survival were examined using competing risk regression analysis. Four thousand six hundred and forty one eligible cases were followed for an average of 4.7 yrs, during which time 1525 died from CRC and 416 died from other causes. Results of competing risk regression indicated higher risk of CRC death with higher grade (HR high v low =2.25, 95% CI 1.32-3.84), later stage (HR C v A = 7.74, 95% CI 5.75-10.4), severe comorbidity (HR severe v none =1.21, 95% CI 1.02-1.44) and receiving radiotherapy (HR = 1.41, 95% CI 1.18-1.68). Patients from the most socioeconomically advantaged areas had significantly better outcomes than those from the least advantaged areas (HR =0.75, 95% 0.62-0.91). Patients residing in remote locations had significantly worse outcomes than metropolitan residents, though this was only evident for stages A-C (HR = 1.35, 95 % CI 1.01-1.80). These disparities were not explained by differences in stage at diagnosis between socioeconomic groups or area of residence. Nor were they

The risk of allograft failure and the survival benefit of kidney transplantation are complicated by delayed graft function.

PubMed

Gill, Jagbir; Dong, Jianghu; Rose, Caren; Gill, John S

2016-06-01

Concern about the long-term impact of delayed graft function (DGF) may limit the use of high-risk organs for kidney transplantation. To understand this better, we analyzed 29,598 mate kidney transplants from the same deceased donor where only 1 transplant developed DGF. The DGF associated risk of graft failure was greatest in the first posttransplant year, and in patients with concomitant acute rejection (hazard ratio: 8.22, 95% confidence interval: 4.76-14.21). In contrast, the DGF-associated risk of graft failure after the first posttransplant year in patients without acute rejection was far lower (hazard ratio: 1.15, 95% confidence interval: 1.02-1.29). In subsequent analysis, recipients of transplants complicated by DGF still derived a survival benefit when compared with patients who received treatment with dialysis irrespective of donor quality as measured by the Kidney Donor Profile Index (KDPI). The difference in the time required to derive a survival benefit was longer in transplants with DGF than in transplants without DGF, and this difference was greatest in recipients of lower quality kidneys (difference: 250-279 days for KDPI 20%-60% vs. 809 days for the KDPI over 80%). Thus, the association of DGF with graft failure is primarily limited to the first posttransplant year. Transplants complicated by DGF provide a survival benefit compared to treatment with dialysis, but the survival benefit is lower in kidney transplants with lower KDPI. This information may increase acceptance of kidneys at high risk for DGF and inform strategies to minimize the risk of death in the setting of DGF. Copyright © 2016 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.

Risk of second primary malignancies and survival of adult patients with polycythemia vera: A United States population-based retrospective study.

PubMed

Khanal, Nabin; Giri, Smith; Upadhyay, Smrity; Shostrom, Valerie K; Pathak, Ranjan; Bhatt, Vijaya Raj

2016-01-01

Although the median survival in polycythemia vera (PV) is 14 years, mortality is higher than in an age- and sex-matched population. This study included 3941 PV patients diagnosed between 2000-2012 from Surveillance, Epidemiology and End Results (SEER) 13 registry to determine 5-year survival and the incidence of second primary malignancies (SPM). The actuarial 5 year survival in the overall cohort was 79.5%. The cumulative incidence of SPM was 13.1% at 10 years. SPMs occurred at a standardized incidence ratio (SIR) of 1.29 (95% CI = 1.16-1.43; p < 0.001) with an absolute excess risk (AER) of 42.49 per 10 000 population. A significantly higher risk was noted for acute myeloid leukemia (SIR = 12.24; 95% CI = 8.17-17.8; p-value < 0.001) and chronic myeloid leukemia (SIR = 10.66; 95% CI = 3.75-19.6; p-value < 0.001). Patients with PV are at a high risk of SPM and leukemic transformation, which may compromise long-term survival.

Racial differences in the effects of comorbidity on breast cancer-specific survival.

PubMed

Santorelli, Melissa L; Hirshfield, Kim M; Steinberg, Michael B; Lin, Yong; Rhoads, George G; Bandera, Elisa V; Demissie, Kitaw

2017-08-01

In an effort to explain racial disparities in breast cancer survival, this study aimed to investigate how comorbidity affects breast cancer-specific mortality by race. A retrospective cohort study was conducted using the Surveillance, Epidemiology and End Results-Medicare linked data including 68,090 women 66+ years, who were diagnosed with stage I-III breast cancer in the United States from 1994 to 2004. Hospital and outpatient claims from the year prior to breast cancer diagnosis were used to identify comorbid conditions and patients were followed for survival through 2010. Competing risk survival analysis failed to demonstrate any negative comorbidity effects on breast cancer-specific survival for black women. An increased breast cancer-specific mortality hazard was observed for white women who had diabetes without complication relative to white women without this condition after adjusting for age and year of diagnosis (hazard ratio: 1.22, 95% confidence interval 1.13, 1.30). The Cochran-Armitage Test showed diabetes was associated with a later stage of diagnosis (p < 0.01) and a more aggressive tumor grade (p < 0.01) among white women in the study population. Race specific comorbidity effects do not explain breast cancer-specific survival disparities. However, the relationship between diabetes and breast cancer, including the role of aggressive tumor characteristics, warrants special attention.

A Competence-Based Science Learning Framework Illustrated Through the Study of Natural Hazards and Disaster Risk Reduction

NASA Astrophysics Data System (ADS)

Oyao, Sheila G.; Holbrook, Jack; Rannikmäe, Miia; Pagunsan, Marmon M.

2015-09-01

This article proposes a competence-based learning framework for science teaching, applied to the study of 'big ideas', in this case to the study of natural hazards and disaster risk reduction (NH&DRR). The framework focuses on new visions of competence, placing emphasis on nurturing connectedness and behavioral actions toward resilience and sustainability. The framework draws together competences familiarly expressed as cognitive knowledge and skills, plus dispositions and adds connectedness and action-related behaviors, and applies this by means of a progression shift associated with NH&DRR from abilities to capabilities. The target is enhanced scientific literacy approached through an education through science focus, amplified through the study of a big idea, promotion of sustained resilience in the face of disaster and the taking of responsibilities for behavioral actions. The framework is applied to a learning progression for each interrelated education dimension, thus serving as a guide for both the development of abilities and as a platform for stimulating student capabilities within instruction and assessment.

Lifetime competing risks between coronary heart disease mortality and other causes of death during 50years of follow-up.

PubMed

Puddu, Paolo Emilio; Piras, Paolo; Menotti, Alessandro

2017-02-01

To study coronary heart disease (CHD) death versus 11 other causes of death using the cumulative incidence function (CIF) and the competing risks procedures to disentangle the differential role of risk factors for different end-points. Standard Cox and Fine-Gray models among 1712 middle-aged men were compared during 50years of follow-up. CHD death was the primary event, while deaths from 11 selected causes, mutually exclusive from the primary end-point, were considered as secondary events. Reverse solutions were also performed. We considered 10 selected risk factors. CHD death risk was the second highest among 12 mostly specific causes of death. Some risk factors were specific: serum cholesterol for CHD death whereas, systolic blood pressure, cigarette smoking and age may have a differential role in other causes of death. Application of the Fine-Gray model based on CIF enabled to dissect, at least in part, the respective role that baseline covariates may have to segregate the probabilities of two types of death in contrast from each other. They also point to the absence of contributing significance for some of the selected risk factors and this calls for a parsimonious approach in predictions. The relative rarity of competing risk challenges when defining the risk factors role at long-term needs now be corrected since we have clearly shown, with Fine-Gray model, at direct or reverse use, that comparing different end-points heavily influences the risk factor predictive capacity. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Slow Gait Speed and Risk of Long-Term Nursing Home Residence in Older Women, Adjusting for Competing Risk of Mortality: Results from the Study of Osteoporotic Fractures.

PubMed

Lyons, Jennifer G; Ensrud, Kristine E; Schousboe, John T; McCulloch, Charles E; Taylor, Brent C; Heeren, Timothy C; Stuver, Sherri O; Fredman, Lisa

2016-12-01

To determine whether slow gait speed increases the risk of costly long-term nursing home residence when accounting for death as a competing risk remains unknown. Longitudinal cohort study using proportional hazards models to predict long-term nursing home residence and subdistribution models with death as a competing risk. Community-based prospective cohort study. Older women (mean age 76.3) participating in the Study of Osteoporotic Fractures who were also enrolled in Medicare fee-for-service plans (N = 3,755). Gait speed was measured on a straight 6-m course and averaged over two trials. Long-term nursing home residence was defined using a validated algorithm based on Medicare Part B claims for nursing home-related care. Participants were followed until long-term nursing home residence, disenrollment from Medicare plan, death, or December 31, 2010. Over the follow-up period (median 11 years), 881 participants (23%) experienced long-term nursing home residence, and 1,013 (27%) died before experiencing this outcome. Slow walkers (55% of participants with gait speed <1 m/s) were significantly more likely than fast walkers to reside in a nursing home long-term (adjusted hazards ratio (aHR) = 1.79, 95% confidence interval (CI) = 1.54-2.09). Associations were attenuated in subdistribution models (aHR = 1.52, 95% CI = 1.30-1.77) but remained statistically significant. Older community-dwelling women with slow gait speed are more likely to experience long-term nursing home residence, as well as mortality without long-term residence. Ignoring the competing mortality risk may overestimate long-term care needs and costs. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

Influence of an elevated nutrition risk score (NRS) on survival in patients following gastrectomy for gastric cancer.

PubMed

Bachmann, J; Müller, T; Schröder, A; Riediger, C; Feith, M; Reim, D; Friess, H; Martignoni, M E

2015-07-01

In the last years, the impact of weight loss in patients with malignant tumors has come more and more into the focus of clinical research, as the occurrence of weight loss is often associated with a reduced survival. Weight loss can be a hint for metastases in patients suffering from malignant tumors; furthermore, these patients are usually not able to be treated with chemotherapy. The aim of the study was to show the influence of weight loss and an elevated nutrition risk score on survival following tumor resection in patients suffering from gastric cancer. In 99 patients in whom a gastrectomy due to gastric cancer was performed, the nutrition risk score was calculated and its influence on mortality, morbidity and survival was analyzed. Of the included patients, 45 % of the patients gave a history of weight loss; they had significantly more often a NRS ≥ 3. In UICC stage 1a/b, a NRS ≥ 3 was associated with a significantly reduced survival compared to patients with a NRS < 3. In early tumor stages (UICC 1a/b), a NRS ≥ 3 was associated with a significantly reduced survival, while in progressed tumor stage, the influence of a poor NRS was not significant. This seems to show that in progressed stages in patients with gastric cancer, the influence of a reduced NRS is negligible.

Long-Term Survival Prediction for Coronary Artery Bypass Grafting: Validation of the ASCERT Model Compared With The Society of Thoracic Surgeons Predicted Risk of Mortality.

PubMed

Lancaster, Timothy S; Schill, Matthew R; Greenberg, Jason W; Ruaengsri, Chawannuch; Schuessler, Richard B; Lawton, Jennifer S; Maniar, Hersh S; Pasque, Michael K; Moon, Marc R; Damiano, Ralph J; Melby, Spencer J

2018-05-01

The recently developed American College of Cardiology Foundation-Society of Thoracic Surgeons (STS) Collaboration on the Comparative Effectiveness of Revascularization Strategy (ASCERT) Long-Term Survival Probability Calculator is a valuable addition to existing short-term risk-prediction tools for cardiac surgical procedures but has yet to be externally validated. Institutional data of 654 patients aged 65 years or older undergoing isolated coronary artery bypass grafting between 2005 and 2010 were reviewed. Predicted survival probabilities were calculated using the ASCERT model. Survival data were collected using the Social Security Death Index and institutional medical records. Model calibration and discrimination were assessed for the overall sample and for risk-stratified subgroups based on (1) ASCERT 7-year survival probability and (2) the predicted risk of mortality (PROM) from the STS Short-Term Risk Calculator. Logistic regression analysis was performed to evaluate additional perioperative variables contributing to death. Overall survival was 92.1% (569 of 597) at 1 year and 50.5% (164 of 325) at 7 years. Calibration assessment found no significant differences between predicted and actual survival curves for the overall sample or for the risk-stratified subgroups, whether stratified by predicted 7-year survival or by PROM. Discriminative performance was comparable between the ASCERT and PROM models for 7-year survival prediction (p < 0.001 for both; C-statistic = 0.815 for ASCERT and 0.781 for PROM). Prolonged ventilation, stroke, and hospital length of stay were also predictive of long-term death. The ASCERT survival probability calculator was externally validated for prediction of long-term survival after coronary artery bypass grafting in all risk groups. The widely used STS PROM performed comparably as a predictor of long-term survival. Both tools provide important information for preoperative decision making and patient counseling about potential

Competing approaches to analysis of failure times with competing risks.

PubMed

Farley, T M; Ali, M M; Slaymaker, E

2001-12-15

For the analysis of time to event data in contraceptive studies when individuals are subject to competing causes for discontinuation, some authors have recently advocated the use of the cumulative incidence rate as a more appropriate measure to summarize data than the complement of the Kaplan-Meier estimate of discontinuation. The former method estimates the rate of discontinuation in the presence of competing causes, while the latter is a hypothetical rate that would be observed if discontinuations for the other reasons could not occur. The difference between the two methods of analysis is the continuous time equivalent of a debate that took place in the contraceptive literature in the 1960s, when several authors advocated the use of net (adjusted or single decrement life table rates) rates in preference to crude rates (multiple decrement life table rates). A small simulation study illustrates the interpretation of the two types of estimate - the complement of the Kaplan-Meier estimate corresponds to a hypothetical rate where discontinuations for other reasons did not occur, while the cumulative incidence gives systematically lower estimates. The Kaplan-Meier estimates are more appropriate when estimating the effectiveness of a contraceptive method, but the cumulative incidence estimates are more appropriate when making programmatic decisions regarding contraceptive methods. Other areas of application, such as cancer studies, may prefer to use the cumulative incidence estimates, but their use should be determined according to the application. Copyright 2001 John Wiley & Sons, Ltd.

Risk of Fatal Cerebrovascular Accidents after External Beam Radiation Therapy for Early Stage Glottic Larynx Cancer

PubMed Central

Swisher-McClure, Samuel; Mitra, Nandita; Lin, Alexander; Ahn, Peter; Wan, Fei; O’Malley, Bert; Weinstein, Gregory S.; Bekelman, Justin E.

2013-01-01

Background This study compared the risk of fatal cerebrovascular accidents (CVA) in patients with early stage glottic larynx cancer receiving surgery or external beam radiation therapy (EBRT). Methods and Materials Using a competing risks survival analysis, we compared the risk of death due to CVA among patients with early stage glottic larynx cancer receiving surgery or EBRT in the SEER database. Results The cumulative incidence of fatal CVA at 15 years was higher in patients receiving EBRT (2.8 %; 95% CI 2.3%–3.4%) compared to surgery (1.5 %; 95% CI 0.8 %–2.3%, p= 0.024). In multivariable competing risks regression models, EBRT remained associated with an increased risk of fatal CVA compared to surgery (adjusted HR 1.75; 95% CI 1.04–2.96, p= 0.037). Conclusion Treatment of early stage glottic larynx cancer with EBRT was associated with a small increase in the risk of late fatal CVA events relative to surgery. PMID:23595858

Repeated testing improves achievement in a blended learning approach for risk competence training of medical students: results of a randomized controlled trial.

PubMed

Spreckelsen, C; Juenger, J

2017-09-26

Adequate estimation and communication of risks is a critical competence of physicians. Due to an evident lack of these competences, effective training addressing risk competence during medical education is needed. Test-enhanced learning has been shown to produce marked effects on achievements. This study aimed to investigate the effect of repeated tests implemented on top of a blended learning program for risk competence. We introduced a blended-learning curriculum for risk estimation and risk communication based on a set of operationalized learning objectives, which was integrated into a mandatory course "Evidence-based Medicine" for third-year students. A randomized controlled trial addressed the effect of repeated testing on achievement as measured by the students' pre- and post-training score (nine multiple-choice items). Basic numeracy and statistical literacy were assessed at baseline. Analysis relied on descriptive statistics (histograms, box plots, scatter plots, and summary of descriptive measures), bootstrapped confidence intervals, analysis of covariance (ANCOVA), and effect sizes (Cohen's d, r) based on adjusted means and standard deviations. All of the 114 students enrolled in the course consented to take part in the study and were assigned to either the intervention or control group (both: n = 57) by balanced randomization. Five participants dropped out due to non-compliance (control: 4, intervention: 1). Both groups profited considerably from the program in general (Cohen's d for overall pre vs. post scores: 2.61). Repeated testing yielded an additional positive effect: while the covariate (baseline score) exhibits no relation to the post-intervention score, F(1, 106) = 2.88, p > .05, there was a significant effect of the intervention (repeated tests scenario) on learning achievement, F(1106) = 12.72, p < .05, d = .94, r = .42 (95% CI: [.26, .57]). However, in the subgroup of participants with a high initial numeracy score no similar

Personalized Risk Prediction in Clinical Oncology Research: Applications and Practical Issues Using Survival Trees and Random Forests.

PubMed

Hu, Chen; Steingrimsson, Jon Arni

2018-01-01

A crucial component of making individualized treatment decisions is to accurately predict each patient's disease risk. In clinical oncology, disease risks are often measured through time-to-event data, such as overall survival and progression/recurrence-free survival, and are often subject to censoring. Risk prediction models based on recursive partitioning methods are becoming increasingly popular largely due to their ability to handle nonlinear relationships, higher-order interactions, and/or high-dimensional covariates. The most popular recursive partitioning methods are versions of the Classification and Regression Tree (CART) algorithm, which builds a simple interpretable tree structured model. With the aim of increasing prediction accuracy, the random forest algorithm averages multiple CART trees, creating a flexible risk prediction model. Risk prediction models used in clinical oncology commonly use both traditional demographic and tumor pathological factors as well as high-dimensional genetic markers and treatment parameters from multimodality treatments. In this article, we describe the most commonly used extensions of the CART and random forest algorithms to right-censored outcomes. We focus on how they differ from the methods for noncensored outcomes, and how the different splitting rules and methods for cost-complexity pruning impact these algorithms. We demonstrate these algorithms by analyzing a randomized Phase III clinical trial of breast cancer. We also conduct Monte Carlo simulations to compare the prediction accuracy of survival forests with more commonly used regression models under various scenarios. These simulation studies aim to evaluate how sensitive the prediction accuracy is to the underlying model specifications, the choice of tuning parameters, and the degrees of missing covariates.

Albumin-Bilirubin and Platelet-Albumin-Bilirubin Grades Accurately Predict Overall Survival in High-Risk Patients Undergoing Conventional Transarterial Chemoembolization for Hepatocellular Carcinoma.

PubMed

Hansmann, Jan; Evers, Maximilian J; Bui, James T; Lokken, R Peter; Lipnik, Andrew J; Gaba, Ron C; Ray, Charles E

2017-09-01

To evaluate albumin-bilirubin (ALBI) and platelet-albumin-bilirubin (PALBI) grades in predicting overall survival in high-risk patients undergoing conventional transarterial chemoembolization for hepatocellular carcinoma (HCC). This single-center retrospective study included 180 high-risk patients (142 men, 59 y ± 9) between April 2007 and January 2015. Patients were considered high-risk based on laboratory abnormalities before the procedure (bilirubin > 2.0 mg/dL, albumin < 3.5 mg/dL, platelet count < 60,000/mL, creatinine > 1.2 mg/dL); presence of ascites, encephalopathy, portal vein thrombus, or transjugular intrahepatic portosystemic shunt; or Model for End-Stage Liver Disease score > 15. Serum albumin, bilirubin, and platelet values were used to determine ALBI and PALBI grades. Overall survival was stratified by ALBI and PALBI grades with substratification by Child-Pugh class (CPC) and Barcelona Liver Clinic Cancer (BCLC) stage using Kaplan-Meier analysis. C-index was used to determine discriminatory ability and survival prediction accuracy. Median survival for 79 ALBI grade 2 patients and 101 ALBI grade 3 patients was 20.3 and 10.7 months, respectively (P < .0001). Median survival for 30 PALBI grade 2 and 144 PALBI grade 3 patients was 20.3 and 12.9 months, respectively (P = .0667). Substratification yielded distinct ALBI grade survival curves for CPC B (P = .0022, C-index 0.892), BCLC A (P = .0308, C-index 0.887), and BCLC C (P = .0287, C-index 0.839). PALBI grade demonstrated distinct survival curves for BCLC A (P = 0.0229, C-index 0.869). CPC yielded distinct survival curves for the entire cohort (P = .0019) but not when substratified by BCLC stage (all P > .05). ALBI and PALBI grades are accurate survival metrics in high-risk patients undergoing conventional transarterial chemoembolization for HCC. Use of these scores allows for more refined survival stratification within CPC and BCLC stage. Copyright © 2017 SIR. Published by Elsevier Inc. All

Percutaneous radiofrequency ablation for early hepatocellular carcinoma: Risk factors for survival

PubMed Central

Kikuchi, Luciana; Menezes, Marcos; Chagas, Aline L; Tani, Claudia M; Alencar, Regiane SSM; Diniz, Marcio A; Alves, Venâncio AF; D’Albuquerque, Luiz Augusto Carneiro; Carrilho, Flair José

2014-01-01

AIM: To evaluate outcomes of radiofrequency ablation (RFA) therapy for early hepatocellular carcinoma (HCC) and identify survival- and recurrence-related factors. METHODS: Consecutive patients diagnosed with early HCC by computed tomography (CT) or magnetic resonance imaging (MRI) (single nodule of ≤ 5 cm, or multi- (up to 3) nodules of ≤ 3 cm each) and who underwent RFA treatment with curative intent between January 2010 and August 2011 at the Instituto do Câncer do Estado de São Paulo, Brazil were enrolled in the study. RFA of the liver tumors (with 1.0 cm ablative margin) was carried out under CT-fluoro scan and ultrasonic image guidance of the percutaneous ablation probes. Procedure-related complications were recorded. At 1-mo post-RFA and 3-mo intervals thereafter, CT and MRI were performed to assess outcomes of complete response (absence of enhancing tissue at the tumor site) or incomplete response (enhancing tissue remaining at the tumor site). Overall survival and disease-free survival rates were estimated by the Kaplan-Meier method and compared by the log rank test or simple Cox regression. The effect of risk factors on survival was assessed by the Cox proportional hazard model. RESULTS: A total of 38 RFA sessions were performed during the study period on 34 patients (age in years: mean, 63 and range, 49-84). The mean follow-up time was 22 mo (range, 1-33). The study population showed predominance of male sex (76%), less severe liver disease (Child-Pugh A, n = 26; Child-Pugh B, n = 8), and single tumor (65%). The maximum tumor diameters ranged from 10 to 50 mm (median, 26 mm). The initial (immediately post-procedure) rate of RFA-induced complete tumor necrosis was 90%. The probability of achieving complete response was significantly greater in patients with a single nodule (vs patients with multi-nodules, P = 0.04). Two patients experienced major complications, including acute pulmonary edema (resolved with intervention) and intestinal perforation

Hyperimmunoglobulin prophylaxis, monitoring and preemptive ganciclovir treatment eliminate the risk of CMV infection to improve patient and renal allograft survival.

PubMed

Schneeberger, H; Aydemir, S; Müller, R; Illner, W D; Pfeiffer, M; Theodorakis, J; Zanker, B; Land, W

2000-01-01

This study was designed to investigate whether the introduction of ganciclovir to clinical use for anti-CMV treatment changes the risk of CMV infection in renal transplant patients. A total of 1545 cases who had received cadaveric renal transplants were divided into two groups: group 1 (n = 721) was made up of patients who received their transplants within 6 years before the introduction (1991) of ganciclovir and group 2 (n = 824), of individuals transplanted thereafter. Patient and graft survival of CMV D+/R- patients was uni- and multivariately compared with non-CMV D+/R- patients. In CMV D+/R- patients in group 1, survival was significantly lower, and their relative risk for graft loss was 1.32-fold (P = 0.0483) that of non-CMV D+/R- patients. In group 2 patient and graft survival was identical regardless of whether the patients were at risk for CMV infection or not. The risk of CMV infection can be eliminated by hyperimmunoglobulin prophylaxis, CMV monitoring and preemptive ganciclovir treatment in renal transplant patients.

Differential adult survival at close seabird colonies: The importance of spatial foraging segregation and bycatch risk during the breeding season.

PubMed

Genovart, Meritxell; Bécares, Juan; Igual, José-Manuel; Martínez-Abraín, Alejandro; Escandell, Raul; Sánchez, Antonio; Rodríguez, Beneharo; Arcos, José M; Oro, Daniel

2018-03-01

Marine megafauna, including seabirds, are critically affected by fisheries bycatch. However, bycatch risk may differ on temporal and spatial scales due to the uneven distribution and effort of fleets operating different fishing gear, and to focal species distribution and foraging behavior. Scopoli's shearwater Calonectris diomedea is a long-lived seabird that experiences high bycatch rates in longline fisheries and strong population-level impacts due to this type of anthropogenic mortality. Analyzing a long-term dataset on individual monitoring, we compared adult survival (by means of multi-event capture-recapture models) among three close predator-free Mediterranean colonies of the species. Unexpectedly for a long-lived organism, adult survival varied among colonies. We explored potential causes of this differential survival by (1) measuring egg volume as a proxy of food availability and parental condition; (2) building a specific longline bycatch risk map for the species; and (3) assessing the distribution patterns of breeding birds from the three study colonies via GPS tracking. Egg volume was very similar between colonies over time, suggesting that environmental variability related to habitat foraging suitability was not the main cause of differential survival. On the other hand, differences in foraging movements among individuals from the three colonies expose them to differential mortality risk, which likely influenced the observed differences in adult survival. The overlap of information obtained by the generation of specific bycatch risk maps, the quantification of population demographic parameters, and the foraging spatial analysis should inform managers about differential sensitivity to the anthropogenic impact at mesoscale level and guide decisions depending on the spatial configuration of local populations. The approach would apply and should be considered in any species where foraging distribution is colony-specific and mortality risk varies spatially

Competing risk models in reliability systems, an exponential distribution model with Bayesian analysis approach

NASA Astrophysics Data System (ADS)

Iskandar, I.

2018-03-01

The exponential distribution is the most widely used reliability analysis. This distribution is very suitable for representing the lengths of life of many cases and is available in a simple statistical form. The characteristic of this distribution is a constant hazard rate. The exponential distribution is the lower rank of the Weibull distributions. In this paper our effort is to introduce the basic notions that constitute an exponential competing risks model in reliability analysis using Bayesian analysis approach and presenting their analytic methods. The cases are limited to the models with independent causes of failure. A non-informative prior distribution is used in our analysis. This model describes the likelihood function and follows with the description of the posterior function and the estimations of the point, interval, hazard function, and reliability. The net probability of failure if only one specific risk is present, crude probability of failure due to a specific risk in the presence of other causes, and partial crude probabilities are also included.

Acute myeloid leukaemia: expression of MYC protein and its association with cytogenetic risk profile and overall survival.

PubMed

Mughal, Muhammad Kashif; Akhter, Ariz; Street, Lesley; Pournazari, Payam; Shabani-Rad, Meer-Taher; Mansoor, Adnan

2017-09-01

Acute myeloid leukaemia (AML) is a clinically aggressive disease with marked genetic heterogeneity. Cytogenetic abnormalities provide the basis for risk stratification into clinically favourable, intermediate, and unfavourable groups. There are additional genetic mutations, which further influence the prognosis of patients with AML. Most of these result in molecular aberrations whose downstream target is MYC. It is therefore logical to study the relationship between MYC protein expression and cytogenetic risk groups. We studied MYC expression by immunohistochemistry in a large cohort (n = 199) of AML patients and correlated these results with cytogenetic risk profile and overall survival (OS). We illustrated differential expression of MYC protein across various cytogenetic risk groups (p = 0.03). Highest expression of MYC was noted in AML patients with favourable cytogenetic risk group. In univariate analysis, MYC expression showed significant negative influence of OS in favourable and intermediate cytogenetic risk group (p = 0.001). Interestingly, MYC expression had a protective effect in the unfavourable cytogenetic risk group. In multivariate analysis, while age and cytogenetic risk group were significant factors influencing survival, MYC expression by immunohistochemistry methods also showed some marginal impact (p = 0.069). In conclusion, we have identified differential expression of MYC protein in relation to cytogenetic risk groups in AML patients and documented its possible impact on OS in favourable and intermediate cytogenetic risk groups. These preliminary observations mandate additional studies to further investigate the routine clinical use of MYC protein expression in AML risk stratification. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Nutrition support can bring survival benefit to high nutrition risk gastric cancer patients who received chemotherapy.

PubMed

Qiu, Miaozhen; Zhou, Yi-xin; Jin, Yin; Wang, Zi-xian; Wei, Xiao-li; Han, Hong-yu; Ye, Wen-feng; Zhou, Zhi-wei; Zhang, Dong-sheng; Wang, Feng-hua; Li, Yu-hong; Yang, Da-jun; Xu, Rui-hua

2015-07-01

The aim of our study is firstly to evaluate the prevalence and prognostic value of nutrition risk in gastric cancer patients and secondly to explore whether the nutrition support can prolong the survival of advanced gastric cancer patients. It contained two study periods. In the first period, we prospectively evaluated the nutritional risk of gastric adenocarcinoma patients from 2009 to 2011 using the method of European Nutritional Risk Screening (NRS) 2002. The Kaplan-Meier method and log-rank test were used to evaluate the prognostic value of high nutrition risk. The second period was between 2012 and 2013. We prospectively gave the nutrition support to stage IV gastric cancer patients whose NRS is ≥3. There were 830 patients in the first period, 50.7% patients with a NRS ≥ 3. Patients with NRS ≥ 3 presented a significantly higher percentage of stage IV diseases, elevated values of C-reactive protein, and hypoproteinemia. The median survival was significantly higher in NRS < 3 patients (31.9 vs. 25.7 months, P < 0.001). Multivariate analysis confirmed that NRS status was an independent prognostic factor. There were 347 patients in the second period. Young, male, and good response to chemotherapy were more likely to have the NRS shift to <3 after nutrition support. The median survival was 14.3 and 9.6 months for patients with and without NRS shift, respectively, P = 0.001. NRS ≥ 3 was an independent adverse prognostic factor in gastric cancer patients. For stage IV patients whose NRS ≥ 3, the nutrition support might be helpful to improve the prognosis.

Validated Competing Event Model for the Stage I-II Endometrial Cancer Population

DOE Office of Scientific and Technical Information (OSTI.GOV)

Carmona, Ruben; Gulaya, Sachin; Murphy, James D.

2014-07-15

Purpose/Objectives(s): Early-stage endometrial cancer patients are at higher risk of noncancer mortality than of cancer mortality. Competing event models incorporating comorbidity could help identify women most likely to benefit from treatment intensification. Methods and Materials: 67,397 women with stage I-II endometrioid adenocarcinoma after total hysterectomy diagnosed from 1988 to 2009 were identified in Surveillance, Epidemiology, and End Results (SEER) and linked SEER-Medicare databases. Using demographic and clinical information, including comorbidity, we sought to develop and validate a risk score to predict the incidence of competing mortality. Results: In the validation cohort, increasing competing mortality risk score was associated with increasedmore » risk of noncancer mortality (subdistribution hazard ratio [SDHR], 1.92; 95% confidence interval [CI], 1.60-2.30) and decreased risk of endometrial cancer mortality (SDHR, 0.61; 95% CI, 0.55-0.78). Controlling for other variables, Charlson Comorbidity Index (CCI) = 1 (SDHR, 1.62; 95% CI, 1.45-1.82) and CCI >1 (SDHR, 3.31; 95% CI, 2.74-4.01) were associated with increased risk of noncancer mortality. The 10-year cumulative incidences of competing mortality within low-, medium-, and high-risk strata were 27.3% (95% CI, 25.2%-29.4%), 34.6% (95% CI, 32.5%-36.7%), and 50.3% (95% CI, 48.2%-52.6%), respectively. With increasing competing mortality risk score, we observed a significant decline in omega (ω), indicating a diminishing likelihood of benefit from treatment intensification. Conclusion: Comorbidity and other factors influence the risk of competing mortality among patients with early-stage endometrial cancer. Competing event models could improve our ability to identify patients likely to benefit from treatment intensification.« less

Effects of larvicidal and larval nutritional stresses on Anopheles gambiae development, survival and competence for Plasmodium falciparum.

PubMed

Vantaux, Amélie; Ouattarra, Issiaka; Lefèvre, Thierry; Dabiré, Kounbobr Roch

2016-04-23

Many studies have shown that the environment in which larvae develop can influence adult characteristics with consequences for the transmission of pathogens. We investigated how two environmental stresses (larviciding and nutritional stress) interact to affect Anopheles gambiae (previously An. gambiae S molecular form) life history traits and its susceptibility for field isolates of its natural malaria agent Plasmodium falciparum. Larvae were reared in the presence or not of a sub-lethal concentration of larvicide and under a high and low food regimen. Development time, individual size, adult survival and competence for P. falciparum were assessed. Individuals under low food regimen took more time to develop, had a lower development success and were smaller while there was no main effect of larvicide exposure on these traits. However, larvicide exposure impacted individual size in interaction with nutritional stress. Female survival was affected by the interaction between gametocytemia, parasite exposure and larval diet, as well as the interaction between gametocytemia, parasite exposure and larvicidal stress, and the interaction between gametocytemia, larvicidal exposure and larval diet. Among the 951 females dissected 7 days post-infection, 559 (58.78%) harboured parasites. Parasite prevalence was significantly affected by the interaction between larvicidal stress and larval diet. Indeed, females under low food regimen had a higher prevalence than females under high food regimen and this difference was greater under larvicidal stress. The two stresses did not impact parasite intensity. We found that larval nutritional and larvicidal stresses affect mosquito life history traits in complex ways, which could greatly affect P. falciparum transmission. Further studies combining field-based trials on larvicide use and mosquito experimental infections would give a more accurate understanding of the effects of this vector control tool on malaria transmission.

Risk

PubMed Central

Cole, Stephen R.; Hudgens, Michael G.; Brookhart, M. Alan; Westreich, Daniel

2015-01-01

The epidemiologist primarily studies transitions between states of health and disease. The purpose of the present article is to define a foundational parameter for such studies, namely risk. We begin simply and build to the setting in which there is more than 1 event type (i.e., competing risks or competing events), as well as more than 1 treatment or exposure level of interest. In the presence of competing events, the risks are a set of counterfactual cumulative incidence functions for each treatment. These risks can be depicted visually and summarized numerically. We use an example from the study of human immunodeficiency virus to illustrate concepts. PMID:25660080

Detectable end of radiation prostate specific antigen assists in identifying men with unfavorable intermediate-risk prostate cancer at high risk of distant recurrence and cancer-specific mortality.

PubMed

Hayman, Jonathan; Phillips, Ryan; Chen, Di; Perin, Jamie; Narang, Amol K; Trieu, Janson; Radwan, Noura; Greco, Stephen; Deville, Curtiland; McNutt, Todd; Song, Daniel Y; DeWeese, Theodore L; Tran, Phuoc T

2018-06-01

Undetectable End of Radiation PSA (EOR-PSA) has been shown to predict improved survival in prostate cancer (PCa). While validating the unfavorable intermediate-risk (UIR) and favorable intermediate-risk (FIR) stratifications among Johns Hopkins PCa patients treated with radiotherapy, we examined whether EOR-PSA could further risk stratify UIR men for survival. A total of 302 IR patients were identified in the Johns Hopkins PCa database (178 UIR, 124 FIR). Kaplan-Meier curves and multivariable analysis was performed via Cox regression for biochemical recurrence free survival (bRFS), distant metastasis free survival (DMFS), and overall survival (OS), while a competing risks model was used for PCa specific survival (PCSS). Among the 235 patients with known EOR-PSA values, we then stratified by EOR-PSA and performed the aforementioned analysis. The median follow-up time was 11.5 years (138 months). UIR was predictive of worse DMFS and PCSS (P = 0.008 and P = 0.023) on multivariable analysis (MVA). Increased radiation dose was significant for improved DMFS (P = 0.016) on MVA. EOR-PSA was excluded from the models because it did not trend towards significance as a continuous or binary variable due to interaction with UIR, and we were unable to converge a multivariable model with a variable to control for this interaction. However, when stratifying by detectable versus undetectable EOR-PSA, UIR had worse DMFS and PCSS among detectable EOR-PSA patients, but not undetectable patients. UIR was significant on MVA among detectable EOR-PSA patients for DMFS (P = 0.021) and PCSS (P = 0.033), while RT dose also predicted PCSS (P = 0.013). EOR-PSA can assist in predicting DMFS and PCSS among UIR patients, suggesting a clinically meaningful time point for considering intensification of treatment in clinical trials of intermediate-risk men. © 2018 Wiley Periodicals, Inc.

Ventilator Dependence Risk Score for the Prediction of Prolonged Mechanical Ventilation in Patients Who Survive Sepsis/Septic Shock with Respiratory Failure.

PubMed

Chang, Ya-Chun; Huang, Kuo-Tung; Chen, Yu-Mu; Wang, Chin-Chou; Wang, Yi-Hsi; Tseng, Chia-Cheng; Lin, Meng-Chih; Fang, Wen-Feng

2018-04-04

We intended to develop a scoring system to predict mechanical ventilator dependence in patients who survive sepsis/septic shock with respiratory failure. This study evaluated 251 adult patients in medical intensive care units (ICUs) between August 2013 to October 2015, who had survived for over 21 days and received aggressive treatment. The risk factors for ventilator dependence were determined. We then constructed a ventilator dependence (VD) risk score using the identified risk factors. The ventilator dependence risk score was calculated as the sum of the following four variables after being adjusted by proportion to the beta coefficient. We assigned a history of previous stroke, a score of one point, platelet count less than 150,000/μL a score of one point, pH value less than 7.35 a score of two points, and the fraction of inspired oxygen on admission day 7 over 39% as two points. The area under the curve in the derivation group was 0.725 (p < 0.001). We then applied the VD risk score for validation on 175 patients. The area under the curve in the validation group was 0.658 (p = 0.001). VD risk score could be applied to predict prolonged mechanical ventilation in patients who survive sepsis/septic shock.

Comparisons of survival predictions using survival risk ratios based on International Classification of Diseases, Ninth Revision and Abbreviated Injury Scale trauma diagnosis codes.

PubMed

Clarke, John R; Ragone, Andrew V; Greenwald, Lloyd

2005-09-01

We conducted a comparison of methods for predicting survival using survival risk ratios (SRRs), including new comparisons based on International Classification of Diseases, Ninth Revision (ICD-9) versus Abbreviated Injury Scale (AIS) six-digit codes. From the Pennsylvania trauma center's registry, all direct trauma admissions were collected through June 22, 1999. Patients with no comorbid medical diagnoses and both ICD-9 and AIS injury codes were used for comparisons based on a single set of data. SRRs for ICD-9 and then for AIS diagnostic codes were each calculated two ways: from the survival rate of patients with each diagnosis and when each diagnosis was an isolated diagnosis. Probabilities of survival for the cohort were calculated using each set of SRRs by the multiplicative ICISS method and, where appropriate, the minimum SRR method. These prediction sets were then internally validated against actual survival by the Hosmer-Lemeshow goodness-of-fit statistic. The 41,364 patients had 1,224 different ICD-9 injury diagnoses in 32,261 combinations and 1,263 corresponding AIS injury diagnoses in 31,755 combinations, ranging from 1 to 27 injuries per patient. All conventional ICD-9-based combinations of SRRs and methods had better Hosmer-Lemeshow goodness-of-fit statistic fits than their AIS-based counterparts. The minimum SRR method produced better calibration than the multiplicative methods, presumably because it did not magnify inaccuracies in the SRRs that might occur with multiplication. Predictions of survival based on anatomic injury alone can be performed using ICD-9 codes, with no advantage from extra coding of AIS diagnoses. Predictions based on the single worst SRR were closer to actual outcomes than those based on multiplying SRRs.

A FORTRAN program for multivariate survival analysis on the personal computer.

PubMed

Mulder, P G

1988-01-01

In this paper a FORTRAN program is presented for multivariate survival or life table regression analysis in a competing risks' situation. The relevant failure rate (for example, a particular disease or mortality rate) is modelled as a log-linear function of a vector of (possibly time-dependent) explanatory variables. The explanatory variables may also include the variable time itself, which is useful for parameterizing piecewise exponential time-to-failure distributions in a Gompertz-like or Weibull-like way as a more efficient alternative to Cox's proportional hazards model. Maximum likelihood estimates of the coefficients of the log-linear relationship are obtained from the iterative Newton-Raphson method. The program runs on a personal computer under DOS; running time is quite acceptable, even for large samples.

APOL1 renal-risk genotypes associate with longer hemodialysis survival in prevalent nondiabetic African American patients with end-stage renal disease.

PubMed

Ma, Lijun; Langefeld, Carl D; Comeau, Mary E; Bonomo, Jason A; Rocco, Michael V; Burkart, John M; Divers, Jasmin; Palmer, Nicholette D; Hicks, Pamela J; Bowden, Donald W; Lea, Janice P; Krisher, Jenna O; Clay, Margo J; Freedman, Barry I

2016-08-01

Relative to European Americans, evidence supports that African Americans with end-stage renal disease (ESRD) survive longer on dialysis. Renal-risk variants in the apolipoprotein L1 gene (APOL1), associated with nondiabetic nephropathy and less subclinical atherosclerosis, may contribute to dialysis outcomes. Here, APOL1 renal-risk variants were assessed for association with dialytic survival in 450 diabetic and 275 nondiabetic African American hemodialysis patients from Wake Forest and Emory School of Medicine outpatient facilities. Outcomes were provided by the ESRD Network 6-Southeastern Kidney Council Standardized Information Management System. Dates of death, receipt of a kidney transplant, and loss to follow-up were recorded. Outcomes were censored at the date of transplantation or through 1 July 2015. Multivariable Cox proportional hazards models were computed separately in patients with nondiabetic and diabetic ESRD, adjusting for the covariates age, gender, comorbidities, ancestry, and presence of an arteriovenous fistula or graft at dialysis initiation. In nondiabetic ESRD, patients with 2 (vs. 0/1) APOL1 renal-risk variants had significantly longer dialysis survival (hazard ratio 0.57), a pattern not observed in patients with diabetes-associated ESRD (hazard ratio 1.29). Thus, 2 APOL1 renal-risk variants are associated with longer dialysis survival in African Americans without diabetes, potentially relating to presence of renal-limited disease or less atherosclerosis. Copyright © 2016 International Society of Nephrology. All rights reserved.

APOL1 renal-risk genotypes associate with longer hemodialysis survival in prevalent nondiabetic African American patients with end-stage renal disease

PubMed Central

Ma, Lijun; Langefeld, Carl D.; Comeau, Mary E.; Bonomo, Jason A.; Rocco, Michael V.; Burkart, John M.; Divers, Jasmin; Palmer, Nicholette D.; Hicks, Pamela J.; Bowden, Donald W.; Lea, Janice P.; Krisher, Jenna O.; Clay, Margo J.; Freedman, Barry I.

2016-01-01

Relative to European Americans, evidence supports that African Americans with end-stage renal disease (ESRD) survive longer on dialysis. Renal-risk variants in the apolipoprotein L1 gene (APOL1), associated with non-diabetic nephropathy and less subclinical atherosclerosis, may contribute to dialysis outcomes. Here, APOL1 renal-risk variants were assessed for association with dialytic survival in 450 diabetic and 275 non-diabetic African American hemodialysis patients from Wake Forest and Emory School of Medicine outpatient facilities. Outcomes were provided by the ESRD Network 6-Southeastern Kidney Council Standardized Information Management System. Dates of death, receipt of a kidney transplant, and loss to follow-up were recorded. Outcomes were censored at the date of transplantation or through July 1, 2015. Multivariable Cox proportional hazards models were computed separately in patients with non-diabetic and diabetic ESRD, adjusting for the covariates age, gender, comorbidities, ancestry, and presence of an arteriovenous fistula or graft at dialysis initiation. In non-diabetic ESRD, patients with two (vs. zero/one) APOL1 renal-risk variants had significantly longer dialysis survival (hazard ratio 0.57); a pattern not observed in patients with diabetes-associated ESRD (hazard ratio 1.29). Thus, two APOL1 renal-risk variants are associated with longer dialysis survival in African Americans without diabetes, potentially relating to presence of renal-limited disease or less atherosclerosis. PMID:27157696

Prostate-Specific Antigen (PSA) Bounce After Dose-Escalated External Beam Radiation Therapy Is an Independent Predictor of PSA Recurrence, Metastasis, and Survival in Prostate Adenocarcinoma Patients.

PubMed

Romesser, Paul B; Pei, Xin; Shi, Weiji; Zhang, Zhigang; Kollmeier, Marisa; McBride, Sean M; Zelefsky, Michael J

2018-01-01

To evaluate the difference in prostate-specific antigen (PSA) recurrence-free, distant metastasis-free, overall, and cancer-specific survival between PSA bounce (PSA-B) and non-bounce patients treated with dose-escalated external beam radiation therapy (DE-EBRT). During 1990-2010, 1898 prostate adenocarcinoma patients were treated with DE-EBRT to ≥75 Gy with ≥5 years follow-up. Patients receiving neoadjuvant/concurrent androgen-deprivation therapy (n=1035) or with fewer than 4 PSA values obtained 6 months or more after post-EBRT completion (n=87) were excluded. The evaluable 776 patients were treated (median, 81.0 Gy). Prostate-specific antigen bounce was defined as a ≥0.2-ng/mL increase above the interval PSA nadir, followed by a decrease to nadir or below. Prostate-specific antigen relapse was defined as post-radiation therapy PSA nadir + 2 ng/mL. Median follow-up was 9.2 years (interquartile range, 6.9-11.3 years). One hundred twenty-three patients (15.9%) experienced PSA-B after DE-EBRT at a median of 24.6 months (interquartile range, 16.1-38.5 months). On multivariate analysis, younger age (P=.001), lower Gleason score (P=.0003), and higher radiation therapy dose (P=.0002) independently predicted PSA-B. Prostate-specific antigen bounce was independently associated with decreased risk for PSA relapse (hazard ratio [HR] 0.53; 95% confidence interval [CI] 0.33-0.85; P=.008), distant metastatic disease (HR 0.34; 95% CI 0.12-0.94; P=.04), and all-cause mortality (HR 0.53; 95% CI 0.29-0.96; P=.04) on multivariate Cox analysis. Because all 50 prostate cancer-specific deaths in patients without PSA-B were in the non-bounce cohort, competing-risks analysis was not applicable. A nonparametric competing-risks test demonstrated that patients with PSA-B had superior cancer-specific survival compared with patients without PSA-B (P=.004). Patients treated with dose-escalated radiation therapy for prostate adenocarcinoma who experience posttreatment PSA-B have

Competency assessment tools: An exploration of the pedagogical issues facing competency assessment for nurses in the clinical environment.

PubMed

Franklin, Natasha; Melville, Paula

2015-01-01

Competency assessment is a paradigm that is common in the healthcare environment and this being particularly true within the nursing profession. Demonstration of competence is necessary to meet the requirements of healthcare organisations and is a mandated requirement of nurses by the Nursing and Midwifery Board of Australia. Within the nursing education sector, one approach to determine competence, is through the use of competency assessment tools. Despite widespread use of competency assessment tools there remains ongoing concerns relating to the efficacy of competency assessment tools as a mean to demonstrate 'competency' amongst enrolled and registered nurses in the clinical environment. The authors of this paper ascertain that competency assessment tools run a serious risk of being nothing more than a 'quick-fix' means of assessment to demonstrate 'nursing competence' required for key performance indicators and clinical governance and that will provide evidence for accreditation standards. Based on this premise, the authors, provide an alternative approach to the use of competency assessment tools that moves away from a 'tick-box' approach to a 'patient-centred' competency model. This approach increases the reliability and validity of competency assessments, allows for the recognition of the knowledge, skills and experience of individual nurses, offers a more satisfying and rewarding approach to demonstrating 'competency' for nurses and finally, demonstrates 'real-life' competency.

Future Directions for Research on Core Competencies

ERIC Educational Resources Information Center

Bradshaw, Catherine P.; Guerra, Nancy G.

2008-01-01

This concluding commentary highlights common themes that emerged across the chapters in this volume. We identify strengths and limitations of the core competencies framework and discuss the importance of context, culture, and development for understanding the role of the core competencies in preventing risk behavior in adolescence. We also outline…

Risk of fatal cerebrovascular accidents after external beam radiation therapy for early-stage glottic laryngeal cancer.

PubMed

Swisher-McClure, Samuel; Mitra, Nandita; Lin, Alexander; Ahn, Peter; Wan, Fei; O'Malley, Bert; Weinstein, Gregory S; Bekelman, Justin E

2014-05-01

This study compared the risk of fatal cerebrovascular accidents (CVAs) in patients with early-stage glottic laryngeal cancer receiving surgery or external beam radiation therapy (EBRT). Using a competing risks survival analysis, we compared the risk of death because of CVA among patients with early-stage glottic laryngeal cancer receiving surgery or EBRT in the Surveillance, Epidemiology, and End Results (SEER) database. The cumulative incidence of fatal CVA at 15 years was higher in patients receiving EBRT (2.8%; 95% confidence interval [CI], 2.3% to 3.4%) compared to surgery (1.5%; 95% CI, 0.8% to 2.3%; p = .024). In multivariable competing risks regression models, EBRT remained associated with an increased risk of fatal CVA compared to surgery (adjusted hazard ratio [HR], 1.75; 95% CI, 1.04-2.96; p = .037). Treatment for early-stage glottic laryngeal cancer with EBRT was associated with a small increase in the risk of late fatal CVA events relative to surgery. Copyright © 2013 Wiley Periodicals, Inc.

Competent Children at Risk: Their Parents and Families. 2. Markers of Competent Children.

ERIC Educational Resources Information Center

Kokes, Ronald F.; And Others

Hypotheses presented in an initial report of this study were tested and, in general, all were supported. Maternal diagnosis, chronicity, and age of onset with regard to the child and to parent/child interaction were significantly associated with child competence. However, effects of these factors were not consistent across age of child or child…

Phase-dependent climate-predator interactions explain three decades of variation in neonatal caribou survival.

PubMed

Bastille-Rousseau, Guillaume; Schaefer, James A; Lewis, Keith P; Mumma, Matthew A; Ellington, E Hance; Rayl, Nathaniel D; Mahoney, Shane P; Pouliot, Darren; Murray, Dennis L

2016-03-01

Climate can have direct and indirect effects on population dynamics via changes in resource competition or predation risk, but this influence may be modulated by density- or phase-dependent processes. We hypothesized that for ungulates, climatic conditions close to parturition have a greater influence on the predation risk of neonates during population declines, when females are already under nutritional stress triggered by food limitation. We examined the presence of phase-dependent climate-predator (PDCP) interactions on neonatal ungulate survival by comparing spatial and temporal fluctuations in climatic conditions, cause-specific mortality and per capita resource limitation. We determined cause-specific fates of 1384 caribou (Rangifer tarandus) from 10 herds in Newfoundland, spanning more than 30 years during periods of numerical increase and decline, while exposed to predation from black bears (Ursus americanus) and coyotes (Canis latrans). We conducted Cox proportional hazards analysis for competing risks, fit as a function of weather metrics, to assess pre- and post-partum climatic influences on survival on herds in population increase and decline phases. We used cumulative incidence functions to compare temporal changes in risk from predators. Our results support our main hypothesis; when caribou populations increased, weather conditions preceding calving were the main determinants of cause-specific mortality, but when populations declined, weather conditions during calving also influenced predator-driven mortality. Cause-specific analysis showed that weather conditions can differentially affect predation risk between black bears and coyotes with specific variables increasing the risk from one species and decreasing the risk from the other. For caribou, nutritional stress appears to increase predation risk on neonates, an interaction which is exacerbated by susceptibility to climatic events. These findings support the PDCP interactions framework, where

A survival strategy for an academic psychiatry department in a managed care environment.

PubMed

Harris, E S; Neufeld, J; Hales, R E; Hilty, D

2001-12-01

The changing economics of medical practice have had a profound effect on the educational, research, and service missions of academic departments of psychiatry across the country. The authors describe the development of a managed behavioral health care organization in their parent academic health system as a survival strategy for allowing their department to function in a managed care environment. They present a series of lessons learned in this effort to adapt to a highly volatile managed behavioral health care market: know how you fit into your market as well as your institution, form cooperative alliances within and outside of your institution, provide incentives to manage risk, focus on core competencies, innovate in your areas of strength, and collect data.

Vitamin D receptor polymorphisms and survival in patients with cutaneous melanoma: a population-based study

PubMed Central

Orlow, Irene; Reiner, Anne S.; Thomas, Nancy E.; Roy, Pampa; Kanetsky, Peter A.; Luo, Li; Paine, Susan; Armstrong, Bruce K.; Kricker, Anne; Marrett, Loraine D.; Rosso, Stefano; Zanetti, Roberto; Gruber, Stephen B.; Anton-Culver, Hoda; Gallagher, Richard P.; Dwyer, Terence; Busam, Klaus; Begg, Colin B.; Berwick, Marianne

2016-01-01

Factors known to affect melanoma survival include age at presentation, sex and tumor characteristics. Polymorphisms also appear to modulate survival following diagnosis. Result from other studies suggest that vitamin D receptor (VDR) polymorphisms (SNPs) impact survival in patients with glioma, renal cell carcinoma, lung, breast, prostate and other cancers; however, a comprehensive study of VDR polymorphisms and melanoma-specific survival is lacking. We aimed to investigate whether VDR genetic variation influences survival in patients with cutaneous melanoma. The analysis involved 3566 incident single and multiple primary melanoma cases enrolled in the international population-based Genes, Environment, and Melanoma Study. Melanoma-specific survival outcomes were calculated for each of 38 VDR SNPs using a competing risk analysis after adjustment for covariates. There were 254 (7.1%) deaths due to melanoma during the median 7.6 years follow-up period. VDR SNPs rs7299460, rs3782905, rs2239182, rs12370156, rs2238140, rs7305032, rs1544410 (BsmI) and rs731236 (TaqI) each had a statistically significant (trend P values < 0.05) association with melanoma-specific survival in multivariate analysis. One functional SNP (rs2239182) remained significant after adjustment for multiple testing using the Monte Carlo method. None of the SNPs associated with survival were significantly associated with Breslow thickness, ulceration or mitosis. These results suggest that the VDR gene may influence survival from melanoma, although the mechanism by which VDR exerts its effect does not seem driven by tumor aggressiveness. Further investigations are needed to confirm our results and to understand the relationship between VDR and survival in the combined context of tumor and host characteristics. PMID:26521212

Brachytherapy Boost Utilization and Survival in Unfavorable-risk Prostate Cancer.

PubMed

Johnson, Skyler B; Lester-Coll, Nataniel H; Kelly, Jacqueline R; Kann, Benjamin H; Yu, James B; Nath, Sameer K

2017-11-01

There are limited comparative survival data for prostate cancer (PCa) patients managed with a low-dose rate brachytherapy (LDR-B) boost and dose-escalated external-beam radiotherapy (DE-EBRT) alone. To compare overall survival (OS) for men with unfavorable PCa between LDR-B and DE-EBRT groups. Using the National Cancer Data Base, we identified men with unfavorable PCa treated between 2004 and 2012 with androgen suppression (AS) and either EBRT followed by LDR-B or DE-EBRT (75.6-86.4Gy). Treatment selection was evaluated using logistic regression and annual percentage proportions. OS was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards, and propensity score matching. We identified 25038 men between 2004 and 2012, during which LDR-B boost utilization decreased from 29% to 14%. LDR-B was associated with better OS on univariate (7-yr OS: 82% vs 73%; p<0.001) and multivariate analyses (hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.64-0.77). Propensity score matching verified an OS benefit associated with LDR-B boost (HR 0.74, 95% CI 0.66-0.89). The OS benefit of LDR-B boost persisted when limited to men aged <60 yr with no comorbidities. On subset analysis, there was no interaction between treatment and age, risk group, or radiation dose. Limitations include the retrospective design, nonrandomized selection bias, and the absence of treatment toxicity, hormone duration, and cancer-specific outcomes. Between 2004 and 2012, LDR-B boost utilization declined and was associated with better OS compared to DE-EBRT alone. LDR-B boost is probably the ideal treatment option for men with unfavorable PCa, pending long-term results of randomized trials. We compared radiotherapy utilization and survival for prostate cancer (PCa) patients using a national database. We found that low-dose rate brachytherapy (LDR-B) boost, a method being used less frequently, was associated with better overall survival when compared to dose-escalated external

Proposed Core Competencies and Empirical Validation Procedure in Competency Modeling: Confirmation and Classification.

PubMed

Baczyńska, Anna K; Rowiński, Tomasz; Cybis, Natalia

2016-01-01

Competency models provide insight into key skills which are common to many positions in an organization. Moreover, there is a range of competencies that is used by many companies. Researchers have developed core competency terminology to underline their cross-organizational value. The article presents a theoretical model of core competencies consisting of two main higher-order competencies called performance and entrepreneurship. Each of them consists of three elements: the performance competency includes cooperation, organization of work and goal orientation, while entrepreneurship includes innovativeness, calculated risk-taking and pro-activeness. However, there is lack of empirical validation of competency concepts in organizations and this would seem crucial for obtaining reliable results from organizational research. We propose a two-step empirical validation procedure: (1) confirmation factor analysis, and (2) classification of employees. The sample consisted of 636 respondents (M = 44.5; SD = 15.1). Participants were administered a questionnaire developed for the study purpose. The reliability, measured by Cronbach's alpha, ranged from 0.60 to 0.83 for six scales. Next, we tested the model using a confirmatory factor analysis. The two separate, single models of performance and entrepreneurial orientations fit quite well to the data, while a complex model based on the two single concepts needs further research. In the classification of employees based on the two higher order competencies we obtained four main groups of employees. Their profiles relate to those found in the literature, including so-called niche finders and top performers. Some proposal for organizations is discussed.

Proposed Core Competencies and Empirical Validation Procedure in Competency Modeling: Confirmation and Classification

PubMed Central

Baczyńska, Anna K.; Rowiński, Tomasz; Cybis, Natalia

2016-01-01

Competency models provide insight into key skills which are common to many positions in an organization. Moreover, there is a range of competencies that is used by many companies. Researchers have developed core competency terminology to underline their cross-organizational value. The article presents a theoretical model of core competencies consisting of two main higher-order competencies called performance and entrepreneurship. Each of them consists of three elements: the performance competency includes cooperation, organization of work and goal orientation, while entrepreneurship includes innovativeness, calculated risk-taking and pro-activeness. However, there is lack of empirical validation of competency concepts in organizations and this would seem crucial for obtaining reliable results from organizational research. We propose a two-step empirical validation procedure: (1) confirmation factor analysis, and (2) classification of employees. The sample consisted of 636 respondents (M = 44.5; SD = 15.1). Participants were administered a questionnaire developed for the study purpose. The reliability, measured by Cronbach’s alpha, ranged from 0.60 to 0.83 for six scales. Next, we tested the model using a confirmatory factor analysis. The two separate, single models of performance and entrepreneurial orientations fit quite well to the data, while a complex model based on the two single concepts needs further research. In the classification of employees based on the two higher order competencies we obtained four main groups of employees. Their profiles relate to those found in the literature, including so-called niche finders and top performers. Some proposal for organizations is discussed. PMID:27014111

Does chemotherapy improve survival in high-risk stage I and II Merkel cell carcinoma of the skin?

DOE Office of Scientific and Technical Information (OSTI.GOV)

Poulsen, Michael G.; Rischin, Danny; Porter, Ian

2006-01-01

Purpose: The effectiveness of synchronous carboplatin, etoposide, and radiation therapy in improving survival was evaluated by comparison of a matched set of historic control subjects with patients treated in a prospective Phase II study that used synchronous chemotherapy and radiation and adjuvant chemotherapy. Patients and Methods: Patients were included in the analysis if they had disease localized to the primary site and nodes, and they were required to have at least one of the following high-risk features: recurrence after initial therapy, involved nodes, primary size greater than 1 cm, or gross residual disease after surgery. All patients who received chemotherapymore » were treated in a standardized fashion as part of a Phase II study (Trans-Tasman Radiation Oncology Group TROG 96:07) from 1997 to 2001. Radiation was delivered to the primary site and nodes to a dose of 50 Gy in 25 fractions over 5 weeks, and synchronous carboplatin (AUC 4.5) and etoposide, 80 mg/m{sup 2} i.v. on Days 1 to 3, were given in Weeks 1, 4, 7, and 10. The historic group represents a single institution's experience from 1988 to 1996 and was treated with surgery and radiation alone, and patients were included if they fulfilled the eligibility criteria of TROG 96:07. Patients with occult cutaneous disease were not included for the purpose of this analysis. Because of imbalances in the prognostic variables between the two treatment groups, comparisons were made by application of Cox's proportional hazard modeling. Overall survival, disease-specific survival, locoregional control, and distant control were used as endpoints for the study. Results: Of the 102 patients who had high-risk Stage I and II disease, 40 were treated with chemotherapy (TROG 96:07) and 62 were treated without chemotherapy (historic control subjects). When Cox's proportional hazards modeling was applied, the only significant factors for overall survival were recurrent disease, age, and the presence of residual

Genetic polymorphisms in the microRNA binding-sites of the thymidylate synthase gene predict risk and survival in gastric cancer.

PubMed

Shen, Rong; Liu, Hongliang; Wen, Juyi; Liu, Zhensheng; Wang, Li-E; Wang, Qiming; Tan, Dongfeng; Ajani, Jaffer A; Wei, Qingyi

2015-09-01

Thymidylate synthase (TYMS) plays a crucial role in folate metabolism as well as DNA synthesis and repair. We hypothesized that functional polymorphisms in the 3' UTR of TYMS are associated with gastric cancer risk and survival. In the present study, we tested our hypothesis by genotyping three potentially functional (at miRNA binding sites) TYMS SNPs (rs16430 6bp del/ins, rs2790 A>G and rs1059394 C>T) in 379 gastric cancer patients and 431 cancer-free controls. Compared with the rs16430 6bp/6bp + 6bp/0bp genotypes, the 0bp/0bp genotype was associated with significantly increased gastric cancer risk (adjusted OR = 1.72, 95% CI = 1.15-2.58). Similarly, rs2790 GG and rs1059394 TT genotypes were also associated with significantly increased risk (adjusted OR = 2.52, 95% CI = 1.25-5.10 and adjusted OR = 1.57, 95% CI = 1.04-2.35, respectively), compared with AA + AG and CC + CT genotypes, respectively. In the haplotype analysis, the T-G-0bp haplotype was associated with significantly increased gastric cancer risk, compared with the C-A-6bp haplotype (adjusted OR = 1.34, 95% CI = 1.05-1.72). Survival analysis revealed that rs16430 0bp/0bp and rs1059394 TT genotypes were also associated with poor survival in gastric cancer patients who received chemotherapy treatment (adjusted HR = 1.61, 95% CI = 1.05-2.48 and adjusted HR = 1.59, 95% CI = 1.02-2.48, respectively). These results suggest that these three variants in the miRNA binding sites of TYMS may be associated with cancer risk and survival of gastric cancer patients. Larger population studies are warranted to verify these findings. © 2014 Wiley Periodicals, Inc.

Pulmonic stenosis in dogs: survival and risk factors in a retrospective cohort of patients.

PubMed

Locatelli, C; Spalla, I; Domenech, O; Sala, E; Brambilla, P G; Bussadori, C

2013-09-01

To assess survival and risk factors in dogs with pulmonic stenosis. A retrospective review of medical case records of all cases of pulmonic stenosis >50 mmHg, undergoing pulmonary balloon valvuloplasty or not. Survival curves and multivariate analysis were calculated in the overall population and in subgroups. One hundred and seventy-two cases were included. Factors negatively affecting survival were clinical signs [hazard ratio (HR) 3 · 44, P < 0 · 001], younger age at diagnosis (HR 3 · 96, P = 0 · 001) and valve morphology type B (HR 3 · 33, P = 0 · 001) in the overall population. In those that had pulmonary balloon valvuloplasty group only clinical signs was significant (HR 3 · 44, P < 0 · 001). In cases that did not undergo pulmonary balloon valvuloplasty group Doppler gradient (HR 1 · 02, P < 0 · 001), clinical signs (HR 5 · 41, P = 0 · 002), valve morphology type B (HR 10 · 20, P = 0 · 001) and younger age at diagnosis (HR 12 · 82, P < 0 · 001) negatively affected survival. Dogs with severe pulmonic stenosis undergoing pulmonary balloon valvuloplasty (HR 0 · 47, P = 0 · 047) and asymptomatic dogs with moderate pulmonic stenosis (HR 0 · 10, P = 0 · 042) had a better outcome. Younger age at diagnosis was correlated with poorer outcome in right-sided congestive heart failure dogs (HR 14 · 02, P = 0 · 01). Clinical signs, valve morphology type B and age at diagnosis are risk factors in pulmonic stenosis patients. Pulmonary balloon valvuloplasty is a reasonable treatment choice in dogs with severe pulmonic stenosis. © 2013 British Small Animal Veterinary Association.

Association of Ovarian Tumor β2-Adrenergic Receptor Status with Ovarian Cancer Risk Factors and Survival.

PubMed

Huang, Tianyi; Tworoger, Shelley S; Hecht, Jonathan L; Rice, Megan S; Sood, Anil K; Kubzansky, Laura D; Poole, Elizabeth M

2016-12-01

The β 2 -adrenergic signaling pathway mediates the effects of chronic stress on ovarian cancer progression in mouse models. The relevance of this pathway to human ovarian cancer remains unknown. We assessed tumor expression of β 2 -adrenergic receptor (ADRB2) using tissue microarrays in 237 ovarian cancer cases from the Nurses' Health Studies (NHS/NHSII). Competing risks Cox regression was used to evaluate whether associations of reproductive, hormonal, and psychosocial factors with ovarian cancer risk differed by ADRB2. We also examined the association between tumor ADRB2 expression and ovarian cancer survival. Forty-five (19%) cases were positive for ADRB2 staining. High levels of anxiety symptoms were positively associated with ADRB2-positive tumors (HR, 2.59; 95% confidence interval [CI], 1.15-5.84) but not with ADRB2-negative tumors (HR, 1.16; 95% CI, 0.81-1.66; P heterogeneity = 0.07). We observed similar results for depression. No associations were observed for job strain, caregiving stress, or widowhood for either positive or negative ADRB2 status. Lifetime ovulatory years were more strongly associated with ADRB2-positive tumors (HR per 5 years, 1.60; 95% CI, 1.15-2.21) compared with ADRB2-negative tumors (HR, 1.11; 95% CI, 0.96-1.27; P heterogeneity = 0.04). Significant heterogeneity by ADRB2 was also observed for parity (P heterogeneity = 0.01), oral contraceptive use (P heterogeneity = 0.03), and age at menopause (P heterogeneity = 0.04). Tumor expression of ADRB2 was not associated with ovarian cancer mortality (HR, 1.05; 95% CI, 0.69-1.59). Several stress- and ovulation-related factors were differentially associated with ovarian tumors responsive to β 2 -adrenergic signaling. Replication in larger studies is warranted to confirm the role of β 2 -adrenergic signaling in ovarian cancer etiology. Cancer Epidemiol Biomarkers Prev; 25(12); 1587-94. ©2016 AACR. ©2016 American Association for Cancer Research.

Societal perspectives on risk awareness and risk competence

PubMed Central

Koller, Michael; Hoffrage, Ulrich

2015-01-01

Medical risks can be assessed by objectifiable therapeutic features; however, these risks are also characterised to a considerable degree by individual and social values. People tend to strive towards both freedom as well as safety; in a medical context, these two aims are taken into account by shared decision-making models and by stricter regulations in the pharmaceutical sector. Media reports on medical risks are caught between providing information and economic interests, and this conflict particularly complicates rational discussions about unexpected risks (for instance, in the field of natural medicine). Thus, it is necessary to create the type of information culture which allows differentiating between real and less pronounced risks. PMID:26195921

Survival outcomes of radical prostatectomy and external beam radiotherapy in clinically localized high-risk prostate cancer: a population-based, propensity score matched study

PubMed Central

Gu, Xiaobin; Gao, Xianshu; Cui, Ming; Xie, Mu; Ma, Mingwei; Qin, Shangbin; Li, Xiaoying; Qi, Xin; Bai, Yun; Wang, Dian

2018-01-01

Objective This study was aimed to compare survival outcomes in high-risk prostate cancer (PCa) patients receiving external beam radiotherapy (EBRT) or radical prostatectomy (RP). Materials and methods The Surveillance, Epidemiology, and End Results (SEER) database was used to identify PCa patients with high-risk features who received RP alone or EBRT alone from 2004 to 2008. Propensity-score matching (PSM) was performed. Kaplan–Meier survival analysis was used to compare cancer-specific survival (CSS) and overall survival (OS). Multivariate Cox regression analysis was used to identify independent prognostic factors. Results A total of 24,293 patients were identified, 14,460 patients receiving RP and 9833 patients receiving EBRT. Through PSM, 3828 patients were identified in each group. The mean CSS was 128.6 and 126.7 months for RP and EBRT groups, respectively (P<0.001). The subgroup analyses showed that CSS of the RP group was better than that of the EBRT group for patients aged <65 years (P<0.001), White race (P<0.001), and married status (P<0.001). However, there was no significant difference in CSS for patients aged ≥65 years, Black race, other race, and unmarried status. Similar trends were observed for OS. Multivariate analysis showed that EBRT treatment modality, T3–T4 stage, Gleason score 8–10, and prostate-specific antigen >20 ng/mL were significant risk factors for both CSS and OS. Conclusion This study suggested that survival outcomes might be better with RP than EBRT in high-risk PCa patients aged <65 years; however, RP and EBRT provided equivalent survival outcomes in older patients, which argues for primary radiotherapy in this older cohort.

Molecular markers to complement sentinel node status in predicting survival in patients with high-risk locally invasive melanoma.

PubMed

Rowe, Casey J; Tang, Fiona; Hughes, Maria Celia B; Rodero, Mathieu P; Malt, Maryrose; Lambie, Duncan; Barbour, Andrew; Hayward, Nicholas K; Smithers, B Mark; Green, Adele C; Khosrotehrani, Kiarash

2016-08-01

Sentinel lymph node status is a major prognostic marker in locally invasive cutaneous melanoma. However, this procedure is not always feasible, requires advanced logistics and carries rare but significant morbidity. Previous studies have linked markers of tumour biology to patient survival. In this study, we aimed to combine the predictive value of established biomarkers in addition to clinical parameters as indicators of survival in addition to or instead of sentinel node biopsy in a cohort of high-risk melanoma patients. Patients with locally invasive melanomas undergoing sentinel lymph node biopsy were ascertained and prospectively followed. Information on mortality was validated through the National Death Index. Immunohistochemistry was used to analyse proteins previously reported to be associated with melanoma survival, namely Ki67, p16 and CD163. Evaluation and multivariate analyses according to REMARK criteria were used to generate models to predict disease-free and melanoma-specific survival. A total of 189 patients with available archival material of their primary tumour were analysed. Our study sample was representative of the entire cohort (N = 559). Average Breslow thickness was 2.5 mm. Thirty-two (17%) patients in the study sample died from melanoma during the follow-up period. A prognostic score was developed and was strongly predictive of survival, independent of sentinel node status. The score allowed classification of risk of melanoma death in sentinel node-negative patients. Combining clinicopathological factors and established biomarkers allows prediction of outcome in locally invasive melanoma and might be implemented in addition to or in cases when sentinel node biopsy cannot be performed. © 2016 UICC.

Familial Risk and Child Competence.

ERIC Educational Resources Information Center

Sameroff, Arnold J.; Seifer, Ronald

1983-01-01

Examines components of familial risk in the context of a four-year longitudinal study of children with mentally ill mothers. Risk factors examined were parental mental health, social status, parental perspectives, and family stress. Interactions among risk factors were found to be complex and different for cognitive and social-emotional…

Surviving global risks through the preservation of humanity's data on the Moon

NASA Astrophysics Data System (ADS)

Turchin, Alexey; Denkenberger, David

2018-05-01

Many global catastrophic risks are threatening human civilization, and a number of ideas have been suggested for preventing or surviving them. However, if these interventions fail, society could preserve information about the human race and human DNA samples in the hopes that the next civilization on Earth will be able to reconstruct Homo sapiens and our culture. This requires information preservation of an order of magnitude of 100 million years, a little-explored topic thus far. It is important that a potential future civilization discovers this information as early as possible, thus a beacon should accompany the message in order to increase visibility. The message should ideally contain information about how humanity was destroyed, perhaps including a continuous recording until the end. This could help the potential future civilization to survive. The best place for long-term data storage is under the surface of the Moon, with the beacon constructed as a complex geometric figure drawn by small craters or trenches around a central point. There are several cost-effective options for sending the message as opportunistic payloads on different planned landers.

Risk of revision surgery for adult idiopathic scoliosis: a survival analysis of 517 cases over 25 years.

PubMed

Riouallon, Guillaume; Bouyer, Benjamin; Wolff, Stéphane

2016-08-01

Little is known about the long-term status of patients operated for spine deformities. The aim of this study was to determine the survival of primary fusion in adult idiopathic scoliosis and identify the risk factors of revision surgery. Adult patients who underwent primary fusion for idiopathic scoliosis between 1983 and 2011 were included in a continuous monocentric retrospective series. Any additional surgery was registered for survival analysis. Survival and follow-up were estimated by the Kaplan-Meier method and an analysis was performed to identify the risk factors of revision surgery. This series included 447 women (86.5 %) and 70 men (13.5 %) reviewed after a mean follow-up of 7 years (range 0-26.4). Mean age was 44.4 years. Fusion was performed on a median 11 levels (range 3-15); revision rate was 13 % (CI 10-17), 18 % (CI 14-23) and 20 % (CI 16-26) at 5, 10 and 15 years, respectively. Revision surgery was associated with age, anterior release, length of fusion, the inferior limit of fusion, post-operative sagittal balance and junctional kyphosis. The length of fusion (HR 1.13 per vertebrae fused, p = 0.007) and the lower limit of fusion (HR 5.9, p < 0.001) remained independent predictors of revision surgery on multivariate analysis. This series evaluated the risk of revision surgery following spinal fusion for idiopathic scoliosis. Our results show that the risk seemed to increase linearly with a rate of nearly 20 % after 10 years. The length and lower limit of fusion are the main risk factors for revision surgery. Level IV (e.g. case series).

Geographic disparities in colorectal cancer survival

PubMed Central

Henry, Kevin A; Niu, Xiaoling; Boscoe, Francis P

2009-01-01

Background Examining geographic variation in cancer patient survival can help identify important prognostic factors that are linked by geography and generate hypotheses about the underlying causes of survival disparities. In this study, we apply a recently developed spatial scan statistic method, designed for time-to-event data, to determine whether colorectal cancer (CRC) patient survival varies by place of residence after adjusting survival times for several prognostic factors. Methods Using data from a population-based, statewide cancer registry, we examined a cohort of 25,040 men and women from New Jersey who were newly diagnosed with local or regional stage colorectal cancer from 1996 through 2003 and followed to the end of 2006. Survival times were adjusted for significant prognostic factors (sex, age, stage at diagnosis, race/ethnicity and census tract socioeconomic deprivation) and evaluated using a spatial scan statistic to identify places where CRC survival was significantly longer or shorter than the statewide experience. Results Age, sex and stage adjusted survival times revealed several areas in the northern part of the state where CRC survival was significantly different than expected. The shortest and longest survival areas had an adjusted 5-year survival rate of 73.1% (95% CI 71.5, 74.9) and 88.3% (95% CI 85.4, 91.3) respectively, compared with the state average of 80.0% (95% CI 79.4, 80.5). Analysis of survival times adjusted for age, sex and stage as well as race/ethnicity and area socioeconomic deprivation attenuated the risk of death from CRC in several areas, but survival disparities persisted. Conclusion The results suggest that in areas where additional adjustments for race/ethnicity and area socioeconomic deprivation changed the geographic survival patterns and reduced the risk of death from CRC, the adjustment factors may be contributing causes of the disparities. Further studies should focus on specific and modifiable individual and

Mortality Risk and Survival in the Aftermath of the Medieval Black Death

PubMed Central

DeWitte, Sharon N.

2014-01-01

The medieval Black Death (c. 1347-1351) was one of the most devastating epidemics in human history. It killed tens of millions of Europeans, and recent analyses have shown that the disease targeted elderly adults and individuals who had been previously exposed to physiological stressors. Following the epidemic, there were improvements in standards of living, particularly in dietary quality for all socioeconomic strata. This study investigates whether the combination of the selective mortality of the Black Death and post-epidemic improvements in standards of living had detectable effects on survival and mortality in London. Samples are drawn from several pre- and post-Black Death London cemeteries. The pre-Black Death sample comes from the Guildhall Yard (n = 75) and St. Nicholas Shambles (n = 246) cemeteries, which date to the 11th–12th centuries, and from two phases within the St. Mary Spital cemetery, which date to between 1120-1300 (n = 143). The St. Mary Graces cemetery (n = 133) was in use from 1350–1538 and thus represents post-epidemic demographic conditions. By applying Kaplan-Meier analysis and the Gompertz hazard model to transition analysis age estimates, and controlling for changes in birth rates, this study examines differences in survivorship and mortality risk between the pre- and post-Black Death populations of London. The results indicate that there are significant differences in survival and mortality risk, but not birth rates, between the two time periods, which suggest improvements in health following the Black Death, despite repeated outbreaks of plague in the centuries after the Black Death. PMID:24806459

Mortality risk and survival in the aftermath of the medieval Black Death.

PubMed

DeWitte, Sharon N

2014-01-01

The medieval Black Death (c. 1347-1351) was one of the most devastating epidemics in human history. It killed tens of millions of Europeans, and recent analyses have shown that the disease targeted elderly adults and individuals who had been previously exposed to physiological stressors. Following the epidemic, there were improvements in standards of living, particularly in dietary quality for all socioeconomic strata. This study investigates whether the combination of the selective mortality of the Black Death and post-epidemic improvements in standards of living had detectable effects on survival and mortality in London. Samples are drawn from several pre- and post-Black Death London cemeteries. The pre-Black Death sample comes from the Guildhall Yard (n = 75) and St. Nicholas Shambles (n = 246) cemeteries, which date to the 11th-12th centuries, and from two phases within the St. Mary Spital cemetery, which date to between 1120-1300 (n = 143). The St. Mary Graces cemetery (n = 133) was in use from 1350-1538 and thus represents post-epidemic demographic conditions. By applying Kaplan-Meier analysis and the Gompertz hazard model to transition analysis age estimates, and controlling for changes in birth rates, this study examines differences in survivorship and mortality risk between the pre- and post-Black Death populations of London. The results indicate that there are significant differences in survival and mortality risk, but not birth rates, between the two time periods, which suggest improvements in health following the Black Death, despite repeated outbreaks of plague in the centuries after the Black Death.

Vitamin D receptor polymorphisms and survival in patients with cutaneous melanoma: a population-based study.

PubMed

Orlow, Irene; Reiner, Anne S; Thomas, Nancy E; Roy, Pampa; Kanetsky, Peter A; Luo, Li; Paine, Susan; Armstrong, Bruce K; Kricker, Anne; Marrett, Loraine D; Rosso, Stefano; Zanetti, Roberto; Gruber, Stephen B; Anton-Culver, Hoda; Gallagher, Richard P; Dwyer, Terence; Busam, Klaus; Begg, Colin B; Berwick, Marianne

2016-01-01

Factors known to affect melanoma survival include age at presentation, sex and tumor characteristics. Polymorphisms also appear to modulate survival following diagnosis. Result from other studies suggest that vitamin D receptor (VDR) polymorphisms (SNPs) impact survival in patients with glioma, renal cell carcinoma, lung, breast, prostate and other cancers; however, a comprehensive study of VDR polymorphisms and melanoma-specific survival is lacking. We aimed to investigate whether VDR genetic variation influences survival in patients with cutaneous melanoma. The analysis involved 3566 incident single and multiple primary melanoma cases enrolled in the international population-based Genes, Environment, and Melanoma Study. Melanoma-specific survival outcomes were calculated for each of 38 VDR SNPs using a competing risk analysis after adjustment for covariates. There were 254 (7.1%) deaths due to melanoma during the median 7.6 years follow-up period. VDR SNPs rs7299460, rs3782905, rs2239182, rs12370156, rs2238140, rs7305032, rs1544410 (BsmI) and rs731236 (TaqI) each had a statistically significant (trend P values < 0.05) association with melanoma-specific survival in multivariate analysis. One functional SNP (rs2239182) remained significant after adjustment for multiple testing using the Monte Carlo method. None of the SNPs associated with survival were significantly associated with Breslow thickness, ulceration or mitosis. These results suggest that the VDR gene may influence survival from melanoma, although the mechanism by which VDR exerts its effect does not seem driven by tumor aggressiveness. Further investigations are needed to confirm our results and to understand the relationship between VDR and survival in the combined context of tumor and host characteristics. © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Risk in Science Instruction. The Realist and Constructivist Paradigms of Risk

NASA Astrophysics Data System (ADS)

Hansen, Julia; Hammann, Marcus

2017-11-01

Risk is always present in people's lives: diseases, new technologies, socio-scientific issues (SSIs) such as climate change, and advances in medicine—to name just a few examples—all carry risks. To be able to navigate risks in everyday life, as well as to participate in social debate on risk-related issues, students need to develop risk competence. Science education can be a powerful tool in supporting students' risk competence, which is an important component of scientific literacy. As there are different definitions of risk within the scientific community, the aims of this article are (1) to review the literature on two major theoretical frameworks for conceptualising risk, the realist, and the constructivist paradigms of risk and (2) to connect both in order to suggest a working definition of what can be understood as risk competence in science instruction.

Association Between NRAS and BRAF Mutational Status and Melanoma-Specific Survival Among Patients With Higher Risk Primary Melanoma

PubMed Central

Thomas, Nancy E.; Edmiston, Sharon N.; Alexander, Audrey; Groben, Pamela A.; Parrish, Eloise; Kricker, Anne; Armstrong, Bruce K.; Anton-Culver, Hoda; Gruber, Stephen B.; From, Lynn; Busam, Klaus J.; Hao, Honglin; Orlow, Irene; Kanetsky, Peter A.; Luo, Li; Reiner, Anne S.; Paine, Susan; Frank, Jill S.; Bramson, Jennifer I.; Marrett, Lorraine D.; Gallagher, Richard P.; Zanetti, Roberto; Rosso, Stefano; Dwyer, Terence; Cust, Anne E.; Ollila, David W.; Begg, Colin B.; Berwick, Marianne; Conway, Kathleen

2015-01-01

Importance NRAS and BRAF mutations in melanoma inform current treatment paradigms but their role in survival from primary melanoma has not been established. Identification of patients at high risk of melanoma-related death based on their primary melanoma characteristics before evidence of recurrence could inform recommendations for patient follow-up and eligibility for adjuvant trials. Objective To determine tumor characteristics and survival from primary melanoma by somatic NRAS and BRAF status. Design, Setting, and Participants A population-based study with median follow-up of 7.6 years for 912 patients with first primary cutaneous melanoma analyzed for NRAS and BRAF mutations diagnosed in the year 2000 from the United States and Australia in the Genes, Environment and Melanoma Study and followed through 2007. Main Outcomes and Measures Tumor characteristics and melanoma-specific survival of primary melanoma by NRAS and BRAF mutational status. Results The melanomas were 13% NRAS+, 30% BRAF+, and 57% with neither NRAS nor BRAF mutation (wildtype). In a multivariable model including clinicopathologic characteristics, NRAS+ melanoma was associated (P<.05) with mitoses, lower tumor infiltrating lymphocyte (TIL) grade, and anatomic site other than scalp/neck and BRAF+ melanoma was associated with younger age, superficial spreading subtype, and mitoses, relative to wildtype melanoma. There was no significant difference in melanoma-specific survival for melanoma harboring mutations in NRAS (HR 1.7, 95% CI, 0.8–3.4) or BRAF (HR, 1.5, 95% CI, 0.8–2.9) compared to wildtype melanoma adjusted for age, sex, site, AJCC tumor stage, TIL grade, and study center. However, melanoma-specific survival was significantly poorer for higher risk (T2b or higher stage) tumors with NRAS (HR 2.9; 95% CI 1.1–7.7) or BRAF (HR 3.1; 95% CI 1.2–8.5) mutations but not for lower risk (T2a or lower) tumors (P=.65) adjusted for age, sex, site, AJCC tumor stage, TIL grade, and study center

Association of Matrix Metalloproteinase-1 Polymorphisms with Risk of COPD and Lung Cancer and Survival in Lung Cancer

PubMed Central

ENEWOLD, LINDSEY; MECHANIC, LEAH E.; BOWMAN, ELISE D.; PLATZ, ELIZABETH A.; ALBERG, ANTHONY J.

2013-01-01

Background The primary risk factor for chronic obstructive pulmonary disease (COPD) and non-small cell lung cancer (NSCLC) is cigarette smoking but shared susceptibility factors, such as variations in the matrix metalloproteinase-1 (MMP1) gene, may also underlie both diseases. Materials and Methods Cases with prevalent COPD (n=167), incident NSCLC (n=242), or prevalent COPD plus incident NSCLC (n=128) were compared to disease-free controls (n=338) to assess six MMP1 polymorphisms. The association between these polymorphisms and survival in NSCLC was also evaluated. Results Rs11292517 among African-Americans [odds ratio (OR)=5.48, 95% confidence interval (CI)=1.17–25.72] and rs2071230 among Caucasians (OR=2.51, 95% CI=1.09–5.77) appeared to be associated with NSCLC risk in the presence of COPD. Rs470558 appeared to be associated with survival in NSCLC among African-Americans (hazard ratio=3.94; 95%CI=1.14–13.63). No associations remained after adjusting for multiple comparisons. Conclusion Polymorphisms in MMP1 were not consistently associated with prevalent COPD or incident NSCLC nor with survival in NSCLC. PMID:22993337

Cancer risk management decision making for BRCA+ women.

PubMed

Leonarczyk, Terri Jabaley; Mawn, Barbara E

2015-01-01

Women with pathogenic BRCA genetic mutations face high risks for cancer development. Estimates vary among mutation carriers, with lifetime risks ranging from 41% to 90% for breast cancer and 8% to 62% for ovarian cancer. Cancer risk management options for BRCA mutation positive (BRCA+) women have life-altering implications. This qualitative, phenomenological study explored the experience of cancer risk management decision making for women who are unaffected carriers of a BRCA mutation (previvors). Fifteen previvors recruited from Facing Our Risk of Cancer Empowered (FORCE), an online informational and support group, were interviewed. Findings consisted of four major themes: the early previvor experience, intense emotional upheaval; the decisional journey, navigating a personal plan for survival; lack of knowledge and experience among health care providers; and support is essential. Findings highlight the different decisional perspectives of previvors based on age and individual factors and the need for increased competence among health care providers. © The Author(s) 2014.

Survival of HIV-1 vertically infected children

PubMed Central

Davies, Mary-Ann; Gibb, Diana; Turkova, Anna

2017-01-01

Purpose of review It is 20 years since the start of the combination antiretroviral therapy (cART) era and >10 years since cART scale-up began in resource-limited settings. We examined survival of vertically HIV-infected infants and children in the cART era. Recent findings Good survival has been achieved on cART in all settings with up to ten-fold mortality reductions compared to before cART availability. Although mortality risk remains high in the first few months after cART initiation in young children with severe disease, it drops rapidly thereafter even for those who started with advanced disease, and longer term mortality risk is low. However, suboptimal retention on cART in routine programs threatens good survival outcomes and even on treatment children continue to experience high comorbidity risk; infections remain the major cause of death. Interventions to address infection risk include co-trimoxazole prophylaxis, isoniazid preventive therapy, routine childhood and influenza immunization and improving maternal survival. Summary Pediatric survival has improved substantially with cART and HIV-infected children are aging into adulthood. It is important to ensure access to diagnosis and early cART, good program retention and optimal co-morbidity prophylaxis and treatment to achieve the best possible long-term survival and health outcomes for vertically infected children. PMID:27716730

The Importance of Military Cultural Competence.

PubMed

Meyer, Eric G; Writer, Brian W; Brim, William

2016-03-01

Military cultural competence has recently gained national attention. Experts have posited that limited outcomes in the treatment of posttraumatic stress disorder and depression in the military may be related to limited familiarity with the military. National surveys have indicated low military cultural competence among providers and limited educational efforts on military culture or pertinent military pathology in medical schools and residency training programs. Military families, with their own unique military cultural identity, have been identified as a population with increased risks associated with deployment. In response to these findings, several curricula regarding military culture have been established and widely distributed. Assessments of military cultural competence have also been developed. The clinical impact of enhanced cultural competence in general has thus far been limited. The military, however, with its highly prescribed cultural identity, may be a model culture for further study.

Competing Risks or Different Pathways? An Event History Analysis of the Relationship between Financial Aid and Educational Outcomes for Latinos

ERIC Educational Resources Information Center

Gross, Jacob P. K.; Torres, Vasti

2010-01-01

Using a competing risks event history model this study explores the effects of differentiated forms of financial aid on the postsecondary enrollment patterns of Latino college students in Indiana. Much of the prior research on financial aid has employed cross-sectional methods, which assume that the effects of aid do not vary across time. This…

Cumulative Risk, Negative Emotionality, and Emotion Regulation as Predictors of Social Competence in Transition to School: A Mediated Moderation Model

ERIC Educational Resources Information Center

Chang, Hyein; Shelleby, Elizabeth C.; Cheong, JeeWon; Shaw, Daniel S.

2012-01-01

The goals of this study were to examine the additive and interactive effects of cumulative risk and child negative emotionality on children's social competence in the transition from preschool to school and to test whether these associations were mediated by child emotion regulation within a sample of 310 low-income, ethnically diverse boys.…

Access to Heart Transplantation: A Proper Analysis of the Competing Risks of Death and Transplantation Is Required to Optimize Graft Allocation.

PubMed

Cantrelle, Christelle; Legeai, Camille; Latouche, Aurélien; Tuppin, Philippe; Jasseron, Carine; Sebbag, Laurent; Bastien, Olivier; Dorent, Richard

2017-08-01

Heart allocation systems are usually urgency-based, offering grafts to candidates at high risk of waitlist mortality. In the context of a revision of the heart allocation rules, we determined observed predictors of 1-year waitlist mortality in France, considering the competing risk of transplantation, to determine which candidate subgroups are favored or disadvantaged by the current allocation system. Patients registered on the French heart waitlist between 2010 and 2013 were included. Cox cause-specific hazards and Fine and Gray subdistribution hazards were used to determine candidate characteristics associated with waitlist mortality and access to transplantation. Of the 2053 candidates, 7 variables were associated with 1-year waitlist mortality by the Fine and Gray method including 4 candidate characteristics related to heart failure severity (hospitalization at listing, serum natriuretic peptide level, systolic pulmonary artery pressure, and glomerular filtration rate) and 3 characteristics not associated with heart failure severity but with lower access to transplantation (blood type, age, and body mass index). Observed waitlist mortality for candidates on mechanical circulatory support was like that of others. The heart allocation system strongly modifies the risk of pretransplant mortality related to heart failure severity. An in-depth competing risk analysis is therefore a more appropriate method to evaluate graft allocation systems. This knowledge should help to prioritize candidates in the context of a limited donor pool.

Competing risks and the development of adaptive management plans for water resources: Field reconnaissance investigation of risks to fishes and other aquatic biota exposed to endocrine disrupting chemicals (edcs) in lake mead, Nevada USA

USGS Publications Warehouse

Linder, G.; Little, E.E.

2009-01-01

The analysis and characterization of competing risks for water resources rely on a wide spectrum of tools to evaluate hazards and risks associated with their management. For example, waters of the lower Colorado River stored in reservoirs such as Lake Mead present a wide range of competing risks related to water quantity and water quality. These risks are often interdependent and complicated by competing uses of source waters for sustaining biological resources and for supporting a range of agricultural, municipal, recreational, and industrial uses. USGS is currently conducting a series of interdisciplinary case-studies on water quality of Lake Mead and its source waters. In this case-study we examine selected constituents potentially entering the Lake Mead system, particularly endocrine disrupting chemicals (EDCs). Worldwide, a number of environmental EDCs have been identified that affect reproduction, development, and adaptive behaviors in a wide range of organisms. Many EDCs are minimally affected by current treatment technologies and occur in treated sewage effluents. Several EDCs have been detected in Lake Mead, and several substances have been identified that are of concern because of potential impacts to the aquatic biota, including the sport fishery of Lake Mead and endangered razorback suckers (Xyrauchen texanus) that occur in the Colorado River system. For example, altered biomarkers relevant to reproduction and thyroid function in fishes have been observed and may be predictive of impaired metabolism and development. Few studies, however, have addressed whether such EDC-induced responses observed in the field have an ecologically significant effect on the reproductive success of fishes. To identify potential linkages between EDCs and species of management concern, the risk analysis and characterization in this reconnaissance study focused on effects (and attendant uncertainties) that might be expressed by exposed populations. In addition, risk reduction

Jaundice: an important, poorly recognized risk factor for diminished survival in patients with adenocarcinoma of the head of the pancreas

PubMed Central

Strasberg, Steven M; Gao, Feng; Sanford, Dominic; Linehan, David C; Hawkins, William G; Fields, Ryan; Carpenter, Danielle H; Brunt, Elizabeth M; Phillips, Carolyn

2014-01-01

Objectives: Jaundice impairs cellular immunity, an important defence against the dissemination of cancer. Jaundice is a common mode of presentation in pancreatic head adenocarcinoma. The purpose of this study was to determine whether there is an association between preoperative jaundice and survival in patients who have undergone resection of such tumours. Methods: Thirty possible survival risk factors were evaluated in a database of over 400 resected patients. Univariate analysis was used to determine odds ratio for death. All factors for which a P-value of <0.30 was obtained were entered into a multivariate analysis using the Cox model with backward selection. Results: Preoperative jaundice, age, positive node status, poor differentiation and lymphatic invasion were significant indicators of poor outcome in multivariate analysis. Absence of jaundice was a highly favourable prognostic factor. Interaction emerged between jaundice and nodal status. The benefit conferred by the absence of jaundice was restricted to patients in whom negative node status was present. Five-year overall survival in this group was 66%. Jaundiced patients who underwent preoperative stenting had a survival advantage. Conclusions: Preoperative jaundice is a negative risk factor in adenocarcinoma of the pancreas. Additional studies are required to determine the exact mechanism for this effect. PMID:23600768

Sensitivity Analysis of Median Lifetime on Radiation Risks Estimates for Cancer and Circulatory Disease amongst Never-Smokers

NASA Technical Reports Server (NTRS)

Chappell, Lori J.; Cucinotta, Francis A.

2011-01-01

Radiation risks are estimated in a competing risk formalism where age or time after exposure estimates of increased risks for cancer and circulatory diseases are folded with a probability to survive to a given age. The survival function, also called the life-table, changes with calendar year, gender, smoking status and other demographic variables. An outstanding problem in risk estimation is the method of risk transfer between exposed populations and a second population where risks are to be estimated. Approaches used to transfer risks are based on: 1) Multiplicative risk transfer models -proportional to background disease rates. 2) Additive risk transfer model -risks independent of background rates. In addition, a Mixture model is often considered where the multiplicative and additive transfer assumptions are given weighted contributions. We studied the influence of the survival probability on the risk of exposure induced cancer and circulatory disease morbidity and mortality in the Multiplicative transfer model and the Mixture model. Risks for never-smokers (NS) compared to the average U.S. population are estimated to be reduced between 30% and 60% dependent on model assumptions. Lung cancer is the major contributor to the reduction for NS, with additional contributions from circulatory diseases and cancers of the stomach, liver, bladder, oral cavity, esophagus, colon, a portion of the solid cancer remainder, and leukemia. Greater improvements in risk estimates for NS s are possible, and would be dependent on improved understanding of risk transfer models, and elucidating the role of space radiation on the various stages of disease formation (e.g. initiation, promotion, and progression).

Bot fly parasitism of the red-backed vole: host survival, infection risk, and population growth.

PubMed

Lemaître, Jérôme; Fortin, Daniel; Montiglio, Pierre-Olivier; Darveau, Marcel

2009-03-01

Parasites can play an important role in the dynamics of host populations, but empirical evidence remains sparse. We investigated the role of bot fly (Cuterebra spp.) parasitism in red-backed voles (Myodes gapperi) by first assessing the impacts of the parasite on the probability of vole survival under stressful conditions as well as on the reproductive activity of females. We then identified the main factors driving both the individual risk of infection and the abundance of bot flies inside red-backed voles. Finally, we evaluated the impacts of bot fly prevalence on the growth rate of vole populations between mid-July and mid-August. Thirty-six populations of red-backed voles were sampled in the boreal forest of Québec, Canada. The presence and the abundance of parasites in voles, two host life history traits (sex and body condition), three indices of habitat complexity (tree basal area, sapling basal area, coarse woody debris volume), and vole abundance were considered in models evaluating the effects of bot flies on host populations. We found that the probability of survival of red-backed voles in live traps decreased with bot fly infection. Both the individual risk of infection and the abundance of bot flies in red-backed voles were driven mainly by vole abundance rather than by the two host life history traits or the three variables of habitat complexity. Parasitism had population consequences: bot fly prevalence was linked to a decrease in short-term growth rate of vole populations over the summer. We found that bot flies have the potential to reduce survival of red-backed voles, an effect that may apply to large portions of populations.

Risk of Cause-Specific Death in Individuals With Diabetes: A Competing Risks Analysis.

PubMed

Baena-Díez, Jose Miguel; Peñafiel, Judit; Subirana, Isaac; Ramos, Rafel; Elosua, Roberto; Marín-Ibañez, Alejandro; Guembe, María Jesús; Rigo, Fernando; Tormo-Díaz, María José; Moreno-Iribas, Conchi; Cabré, Joan Josep; Segura, Antonio; García-Lareo, Manel; Gómez de la Cámara, Agustín; Lapetra, José; Quesada, Miquel; Marrugat, Jaume; Medrano, Maria José; Berjón, Jesús; Frontera, Guiem; Gavrila, Diana; Barricarte, Aurelio; Basora, Josep; García, Jose María; Pavone, Natalia C; Lora-Pablos, David; Mayoral, Eduardo; Franch, Josep; Mata, Manel; Castell, Conxa; Frances, Albert; Grau, María

2016-11-01

Diabetes is a common cause of shortened life expectancy. We aimed to assess the association between diabetes and cause-specific death. We used the pooled analysis of individual data from 12 Spanish population cohorts with 10-year follow-up. Participants had no previous history of cardiovascular diseases and were 35-79 years old. Diabetes status was self-reported or defined as glycemia >125 mg/dL at baseline. Vital status and causes of death were ascertained by medical records review and linkage with the official death registry. The hazard ratios and cumulative mortality function were assessed with two approaches, with and without competing risks: proportional subdistribution hazard (PSH) and cause-specific hazard (CSH), respectively. Multivariate analyses were fitted for cardiovascular, cancer, and noncardiovascular noncancer deaths. We included 55,292 individuals (15.6% with diabetes and overall mortality of 9.1%). The adjusted hazard ratios showed that diabetes increased mortality risk: 1) cardiovascular death, CSH = 2.03 (95% CI 1.63-2.52) and PSH = 1.99 (1.60-2.49) in men; and CSH = 2.28 (1.75-2.97) and PSH = 2.23 (1.70-2.91) in women; 2) cancer death, CSH = 1.37 (1.13-1.67) and PSH = 1.35 (1.10-1.65) in men; and CSH = 1.68 (1.29-2.20) and PSH = 1.66 (1.25-2.19) in women; and 3) noncardiovascular noncancer death, CSH = 1.53 (1.23-1.91) and PSH = 1.50 (1.20-1.89) in men; and CSH = 1.89 (1.43-2.48) and PSH = 1.84 (1.39-2.45) in women. In all instances, the cumulative mortality function was significantly higher in individuals with diabetes. Diabetes is associated with premature death from cardiovascular disease, cancer, and noncardiovascular noncancer causes. The use of CSH and PSH provides a comprehensive view of mortality dynamics in a population with diabetes. © 2016 by the American Diabetes Association.

Identifying context-specific competencies required by community Australian Football sports trainers.

PubMed

Donaldson, Alex; Finch, Caroline F

2012-08-01

First-aid is a recommended injury prevention and risk management strategy in community sport; however, little is known about the sport-specific competencies required by first-aid providers. To achieve expert consensus on the competencies required by community Australian Football (community-AF) sports trainers. A three-round online Delphi process. Community-AF. 16 Australian sports first-aid and community-AF experts. Rating of competencies as either 'essential', 'expected', 'ideal' or 'not required'. Results After Round 3, 47 of the 77 (61%) competencies were endorsed as 'essential' or 'expected' for a sports trainer to effectively perform the activities required to the standards expected at a community-AF club by ≥75% of experts. These competencies covered: the role of the sports trainer; the responsibilities of the sports trainer; emergency management; injury and illness assessment and immediate management; taping; and injury prevention and risk management. Four competencies (5%) were endorsed as 'ideal' or 'not required' by ≥85% of experts and were excluded from further consideration. The 26 competencies where consensus was not reached were retained as second-tier, optional competencies. Sports trainers are important members of on-field first-aid teams, providing support to both injured players and other sports medicine professionals. The competencies identified in this study provide the basis of a proposed two-tiered community-AF-specific sports trainer education structure that can be implemented by the peak sports body. This includes six mandatory modules, relating to the 'required' competencies, and a further six optional modules covering competencies on which consensus was not reached.

Examining mortality risk and rate of ageing among Polish Olympic athletes: a survival follow-up from 1924 to 2012

PubMed Central

Lin, Yuhui; Gajewski, Antoni; Poznańska, Anna

2016-01-01

Objectives Population-based studies have shown that an active lifestyle reduces mortality risk. Therefore, it has been a longstanding belief that individuals who engage in frequent exercise will experience a slower rate of ageing. It is uncertain whether this widely-accepted assumption holds for intense wear-and-tear. Here, using the 88 years survival follow-up data of Polish Olympic athletes, we report for the first time on whether frequent exercise alters the rate of ageing. Design Longitudinal survival data of male elite Polish athletes who participated in the Olympic Games from year 1924 to 2010 were used. Deaths occurring before the end of World War II were excluded for reliable estimates. Setting and participants Recruited male elite athletes N=1273 were preassigned to two categorical birth cohorts—Cohort I 1890–1919; Cohort II 1920–1959—and a parametric frailty survival analysis was conducted. An event-history analysis was also conducted to adjust for medical improvements from year 1920 onwards: Cohort II. Results Our findings suggest (1) in Cohort I, for every threefold reduction in mortality risk, the rate of ageing decelerates by 1%; (2) socioeconomic transitions and interventions contribute to a reduction in mortality risk of 29% for the general population and 50% for Olympic athletes; (3) an optimum benefit gained for reducing the rate of ageing from competitive sports (Cohort I 0.086 (95% CI 0.047 to 0.157) and Cohort II 0.085 (95% CI 0.050 to 0.144)). Conclusions This study further suggests that intensive physical training during youth should be considered as a factor to improve ageing and mortality risk parameters. PMID:27091824

Aspirin use and endometrial cancer risk and survival.

PubMed

Takiuchi, Tsuyoshi; Blake, Erin A; Matsuo, Koji; Sood, Anil K; Brasky, Theodore M

2018-01-01

The role of acetylsalicylic acid (aspirin) as a chemo-preventive and adjuvant therapeutic agent for cancers is generating attention. Mounting evidence indicates that aspirin reduces the incidence and mortality of certain obesity-related cancers, particularly colorectal cancer. In endometrial cancer, previous studies examining the effect of aspirin remain inconsistent as to the reduction in the risk of endometrial cancer. While some evidence indicates protective effects in obese women, other studies have showed a potential deleterious effect of these medications on endometrial cancer outcomes. However, exposure measurement across studies has been inconsistent in recording dose, duration, and frequency of use; thus making comparisons difficult. In this article, we review the evidence for the association between endometrial cancer and obesity, the pharmacological differences between regular- and low-dose aspirin, as well as the potential anti-tumor mechanism of aspirin, supporting a possible therapeutic effect on endometrial cancer. A proposed mechanism behind decreased cancer mortality in endometrial cancer may be a result of inhibition of metastasis via platelet inactivation and possible prostaglandin E 2 suppression by aspirin. Additionally, aspirin use in particular may have a secondary benefit for obesity-related comorbidities including cardiovascular disease in women with endometrial cancer. Although aspirin-related bleeding needs to be considered as a possible adverse effect, the benefits of aspirin therapy may exceed the potential risk in women with endometrial cancer. The current evidence reviewed herein has resulted in conflicting findings regarding the potential effect on endometrial cancer outcomes, thus indicating that future studies in this area are needed to resolve the effects of aspirin on endometrial cancer survival, particularly to identify specific populations that might benefit from aspirin use. Copyright © 2017 Elsevier Inc. All rights reserved.

The impact of rectal cancer tumor height on recurrence rates and metastatic location: A competing risk analysis of a national database.

PubMed

Augestad, Knut M; Keller, Deborah S; Bakaki, Paul M; Rose, Johnie; Koroukian, Siran M; Øresland, Tom; Delaney, Conor P

2018-04-01

The impact of rectal cancer tumor height on local recurrence and metastatic spread is unknown. The objective was to evaluate the impact of rectal cancer tumor height from the anal verge on metastatic spread and local recurrence patterns. The Norwegian nationwide surgical quality registry was reviewed for curative rectal cancer resections from 1/1/1996-12/15/2006. Cancers were stratified into five height groups: 0-3 cm, >3-5 cm, >5-9 cm, >9-12 cm, 12 cm-HI. Competing risk and proportional hazards models assessed the relationship between tumor height and patterns of metastasis and survival. 6859 patients were analyzed. After median follow-up of 52 months (IQR 20-96), 26.7% (n = 1835) experienced recurrence. With tumors >12 cm, the risk of liver metastases increased (crude HR 1.49, p = 0.03), while lung metastases decreased (crude HR 0.66, p = 0.03), and risk of death decreased (crude HR 0.81, p = 0.001) The cumulative incidence of pelvic recurrence were highest for the low tumors (p = 0.01). Median time to liver metastases was 14months (IQR 7-24), lung metastases 25months (IQR 13-39), pelvic recurrence 19months (IQR10-32), (p < 0.0001). Time to metastases in liver and lungs were significantly associated with tumor height (p < 0.001) CONCLUSION: There are distinct differences in metastatic recurrence patterns and time to recurrence from different anatomic areas of the rectum. In crude analyses, tumor height impacted metastatic spread to the liver and lungs. However, when adjusting for treatment variables, the hazard of metastatic spread to the liver and lungs are limited. Nevertheless, time to metastases in liver and lungs is significantly impacted by tumor height. Venous drainage of the rectal cancer may be a significant contributor of rectal cancer metastatic spread, but further research is warranted. Copyright © 2018 Elsevier Ltd. All rights reserved.

The HOVON68 CLL trial revisited: performance status and comorbidity affect survival in elderly patients with chronic lymphocytic leukemia.

PubMed

Vojdeman, Fie Juhl; Van't Veer, Mars B; Tjønnfjord, Geir E; Itälä-Remes, Maija; Kimby, Eva; Polliack, Aaron; Wu, Ka L; Doorduijn, Jeanette K; Alemayehu, Wendimagegn G; Wittebol, Shulamiet; Kozak, Tomas; Walewski, Jan; Abrahamse-Testroote, Martine C J; van Oers, Marinus H J; Geisler, Christian Hartmann

2017-03-01

In the HOVON68 CLL trial, patients 65 to 75 years of age had no survival benefit from the addition of low-dose alemtuzumab to fludarabine and cyclophosphamide (FC) in contrast to younger patients. The reasons are explored in this 5-year trial update using both survival analysis and competing risk analysis on non-CLL-related mortality. Elderly FCA patients died more frequently from causes not related to CLL, and more often related to comorbidity (mostly cardiovascular) than to infection. In a Cox multivariate analysis, del(17p), performance status >0, and comorbidity were associated with a higher non-CLL-related mortality in the elderly independent of the treatment modality. Thus, while the 'fit' elderly with no comorbidity or performance status of 0 might potentially benefit from chemo-immunotherapy with FC, caution is warranted, when considering alemtuzumab treatment in elderly patients with cardiovascular comorbidity.

Children, Gillick competency and consent for involvement in research

PubMed Central

Hunter, David; Pierscionek, Barbara K

2007-01-01

This paper looks at the issue of consent from children and whether the test of Gillick competency, applied in medical and healthcare practice, ought to extend to participation in research. It is argued that the relatively broad usage of the test of Gillick competency in the medical context should not be considered applicable for use in research. The question of who would and could determine Gillick competency in research raises further concerns relating to the training of the researcher to make such a decision as well as to the obvious issue of the researcher's personal interest in the project and possibility of benefiting from the outcome. These could affect the judgment of Gillick competency if the researcher is charged with making this decision. The above notwithstanding, there are two exceptional research situations in which Gillick competency might be legitimately applied: (1) when the research is likely to generate significant advantages for the participants while exposing them to relatively minor risks, and (2) when it is likely to generate great societal benefit, pose minimal risks for the participants and yet raise parental objection. In both cases, to ensure that autonomy is genuinely respected and to protect against personal interest, Gillick competency should be assessed by an individual who has no interest or involvement in the research. PMID:17971470

Breast cancer survival in New Zealand women.

PubMed

Campbell, Ian D; Scott, Nina; Seneviratne, Sanjeewa; Kollias, James; Walters, David; Taylor, Corey; Webster, Fleur; Zorbas, Helen; Roder, David M

2015-01-01

The Quality Audit (BQA) of Breast Surgeons of Australia and New Zealand includes a broad range of data and is the largest New Zealand (NZ) breast cancer (BC) database outside the NZ Cancer Registry. We used BQA data to compare BC survival by ethnicity, deprivation, remoteness, clinical characteristic and case load. BQA and death data were linked using the National Health Index. Disease-specific survival for invasive cases was benchmarked against Australian BQA data and NZ population-based survivals. Validity was explored by comparison with expected survival by risk factor. Compared with 93% for Australian audit cases, 5-year survival was 90% for NZ audit cases overall, 87% for Maori, 84% for Pacific and 91% for other. BC survival in NZ appears lower than in Australia, with inequities by ethnicity. Differences may be due to access, timeliness and quality of health services, patient risk profiles, BQA coverage and death-record methodology. © 2014 Royal Australasian College of Surgeons.

Outcome of heart transplants 15 to 20 years ago: graft survival, post-transplant morbidity, and risk factors for mortality.

PubMed

Roussel, Jean C; Baron, Olivier; Périgaud, Christian; Bizouarn, Philippe; Pattier, Sabine; Habash, Oussama; Mugniot, Antoine; Petit, Thierry; Michaud, Jean L; Heymann, Marie Françoise; Treilhaud, Michèle; Trochu, Jean N; Gueffet, Jean P; Lamirault, Guillaume; Duveau, Daniel; Despins, Philippe

2008-05-01

The study was conducted to determine the long-term outcome of patients who underwent heart transplantation 15 to 20 years ago, in the cyclosporine era, and identify risk factors for death. A retrospective analysis was done of 148 patients who had undergone heart transplantation between 1985 and 1991 at a single center. Operative technique and immunosuppressive treatment were comparable in all patients. Actuarial survival rates were 75% (n = 111), 58% (n = 86), and 42% (n = 62) at 5, 10, and 15 years, respectively. The mean follow-up period was 12.1 +/- 5.6 years for patients who survived more than 3 months after transplantation (n = 131). The major causes of death were malignancy (35.8%) and cardiac allograft vasculopathy (24.7%). No death related to acute rejection was reported after the first month of transplantation. Graft coronary artery disease was detected on angiography in 66 (50.3%), and 7 (5.3%) had retransplantation. Malignancies developed in 131 patients (48.1%), including skin cancers in 31 (23.6%), solid tumors in 26 (19.8%), and hematologic malignancies in 14 (10.6%). Severe renal function requiring dialysis or renal transplantation developed in 27 patients (20.6%). By multivariable analysis, the only pre-transplant risk factor found to affect long-term survival was a history of cigarette use (p < 0.0004). Long-term survival at 15 years after cardiac transplantation remains excellent in the cyclosporine era. Controlling acute allograft rejection can be achieved but seems to carry a high rate of cancers and renal dysfunction. History of cigarette use affects significantly long-term survival in our study.

p63 and Ki-67 immunostainings in laryngeal squamous cell carcinoma are related to survival.

PubMed

Re, M; Zizzi, A; Ferrante, L; Stramazzotti, D; Goteri, G; Gioacchini, F M; Olivieri, F; Magliulo, G; Rubini, C

2014-06-01

To examine the prognostic significance of the immunohistochemical expression of p63 and Ki-67 oncoproteins in patients with laryngeal squamous cell carcinoma, a retrospective evaluation was carried out on a cohort of 108 patients with primary laryngeal squamous cell carcinoma (LSCC) treated by primary surgery. For the immunohistochemical evaluation, tissue section obtained by formalin-fixed and paraffin-embedded tissue blocks from resection of each patient was used. Clinicopathologic data were associated with the immunostaining results. The association among the considered variables was assessed by Fisher's exact test, Mann-Whitney test, non-parametric χ(2) test, and Spearman's rho rank test was used to assess the relations among them. Differences in p63 and Ki-67 immunoreactivity among the different groups were compared via Kruskal-Wallis test and post hoc tests were performed using Mann-Whitney test with Bonferroni correction. The overall survival rate was estimated via Kaplan-Meier method, and the cumulative incidence functions for different groups were compared using log-rank statistics. Cox proportional hazard model was employed in a multivariate analysis to assess the effect of prognostic factors in the overall survival rate. Furthermore, taking into account death due to other causes, we estimated LSCC-related survival and disease-free survival rates using competing risk analysis. The results of immunohistochemical examination showed a statistically significant relationship between the up-regulation of P63 and Ki-67, an increase in histological grading, and primary tumours associated with lymph node metastases. p63 and Ki-67 up-regulation was related to a shorter disease-free survival and a significant association was found between p63 and Ki-67 percentage of positive cells and patient survival. Finally, we noticed a significant relation between p63 and Ki-67 (ρ = 0.87). On the other hand, no statistically significant associations were found between p63 and

Geometry of the q-exponential distribution with dependent competing risks and accelerated life testing

NASA Astrophysics Data System (ADS)

Zhang, Fode; Shi, Yimin; Wang, Ruibing

2017-02-01

In the information geometry suggested by Amari (1985) and Amari et al. (1987), a parametric statistical model can be regarded as a differentiable manifold with the parameter space as a coordinate system. Note that the q-exponential distribution plays an important role in Tsallis statistics (see Tsallis, 2009), this paper investigates the geometry of the q-exponential distribution with dependent competing risks and accelerated life testing (ALT). A copula function based on the q-exponential function, which can be considered as the generalized Gumbel copula, is discussed to illustrate the structure of the dependent random variable. Employing two iterative algorithms, simulation results are given to compare the performance of estimations and levels of association under different hybrid progressively censoring schemes (HPCSs).

Teaching Problem-Solving Competency in Business Studies at Secondary School Level

ERIC Educational Resources Information Center

Meintjes, Aloe; Henrico, Alfred; Kroon, Japie

2015-01-01

The high unemployment rate in South Africa compels potential entrepreneurs to start their own businesses in order to survive. Often this is with little or no formal training or education in entrepreneurship. Since problem recognition and problem-solving are amongst the most crucial competencies required for a successful entrepreneurial career,…

Factors associated with survival after relapse in patients with low-risk endometrial cancer treated with surgery alone

PubMed Central

2017-01-01

Objective To determine factors influencing overall survival following recurrence (OSFR) in women with low-risk endometrial cancer (EC) treated with surgery alone. Methods A multicenter, retrospective department database review was performed to identify patients with recurrent “low-risk EC” (patients having less than 50% myometrial invasion [MMI] with grade 1 or 2 endometrioid EC) at 10 gynecologic oncology centers in Turkey. Demographic, clinicopathological, and survival data were collected. Results We identified 67 patients who developed recurrence of their EC after initially being diagnosed and treated for low-risk EC. For the entire study cohort, the median time to recurrence (TTR) was 23 months (95% confidence interval [CI]=11.5–34.5; standard error [SE]=5.8) and the median OSFR was 59 months (95% CI=12.7–105.2; SE=23.5). We observed 32 (47.8%) isolated vaginal recurrences, 6 (9%) nodal failures, 19 (28.4%) peritoneal failures, and 10 (14.9%) hematogenous disseminations. Overall, 45 relapses (67.2%) were loco-regional whereas 22 (32.8%) were extrapelvic. According to the Gynecologic Oncology Group (GOG) Trial-99, 7 (10.4%) out of 67 women with recurrent low-risk EC were qualified as high-intermediate risk (HIR). The 5-year OSFR rate was significantly higher for patients with TTR ≥36 months compared to those with TTR <36 months (74.3% compared to 33%, p=0.001). On multivariate analysis for OSFR, TTR <36 months (hazard ratio [HR]=8.46; 95% CI=1.65–43.36; p=0.010) and presence of HIR criteria (HR=4.62; 95% CI=1.69–12.58; p=0.003) were significant predictors. Conclusion Low-risk EC patients recurring earlier than 36 months and those carrying HIR criteria seem more likely to succumb to their tumors after recurrence. PMID:28657226

Hair Follicle Dermal Sheath Derived Cells Improve Islet Allograft Survival without Systemic Immunosuppression

PubMed Central

Wang, Xiaojie; Hao, Jianqiang; Leung, Gigi; Breitkopf, Trisia; Wang, Eddy; Kwong, Nicole; Akhoundsadegh, Noushin; Warnock, Garth L.; Shapiro, Jerry; McElwee, Kevin J.

2015-01-01

Immunosuppressive drugs successfully prevent rejection of islet allografts in the treatment of type I diabetes. However, the drugs also suppress systemic immunity increasing the risk of opportunistic infection and cancer development in allograft recipients. In this study, we investigated a new treatment for autoimmune diabetes using naturally immune privileged, hair follicle derived, autologous cells to provide localized immune protection of islet allotransplants. Islets from Balb/c mouse donors were cotransplanted with syngeneic hair follicle dermal sheath cup cells (DSCC, group 1) or fibroblasts (FB, group 2) under the kidney capsule of immune-competent, streptozotocin induced, diabetic C57BL/6 recipients. Group 1 allografts survived significantly longer than group 2 (32.2 ± 12.2 versus 14.1 ± 3.3 days, P < 0.001) without administration of any systemic immunosuppressive agents. DSCC reduced T cell activation in the renal lymph node, prevented graft infiltrates, modulated inflammatory chemokine and cytokine profiles, and preserved better beta cell function in the islet allografts, but no systemic immunosuppression was observed. In summary, DSCC prolong islet allograft survival without systemic immunosuppression by local modulation of alloimmune responses, enhancing of beta cell survival, and promoting of graft revascularization. This novel finding demonstrates the capacity of easily accessible hair follicle cells to be used as local immunosuppression agents in islet transplantation. PMID:26000314

ESHOL study reanalysis: All-cause mortality considered by competing risks and time-dependent covariates for renal transplantation.

PubMed

Maduell, Francisco; Moreso, Francesc; Mora-Macià, Josep; Pons, Mercedes; Ramos, Rosa; Carreras, Jordi; Soler, Jordi; Torres, Ferrán

2016-01-01

The ESHOL study showed that post-dilution online haemodiafiltration (OL-HDF) reduces all-cause mortality versus haemodialysis. However, during the observation period, 355 patients prematurely completed the study and, according to the study design, these patients were censored at the time of premature termination. The aim of this study was to investigate the outcome of patients who discontinued the study. During follow-up, 207 patients died while under treatment and 47 patients died after discontinuation of the study. Compared with patients maintained on haemodialysis, those randomised to OL-HDF had lower all-cause mortality (12.4 versus 9.46 per 100 patient-years, hazard ratio and 95%CI: 0.76; [0.59-0.98], P= 0.031). For all-cause mortality by time-dependent covariates and competing risks for transplantation, the time-dependent Cox analysis showed very similar results to the main analysis with a hazard ratio of 0.77 (0.60-0.99, P= 0.043). The results of this analysis of the ESHOL trial confirm that post-dilution OL-HDF reduces all-cause mortality versus haemodialysis in prevalent patients. The original results of the ESHOL study, which censored patients discontinuing the study for any reason, were confirmed in the present ITT population without censures and when all-cause mortality was considered by time-dependent and competing risks for transplantation. Copyright © 2015 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.

γ-amino butyric acid (GABA) level as an overall survival risk factor in breast cancer.

PubMed

Brzozowska, Anna; Burdan, Franciszek; Duma, Dariusz; Solski, Janusz; Mazurkiewicz, Maria

2017-09-21

The γ-amino butyric acid (GABA) plays important role in the proliferation and migration of cancer cells. The aim of the study was to evaluate the level of GABA in breast cancer, in relation to clinical and epidemiological data. The study was conducted on 89 patients with breast cancer in stage I-II. GABA level was assessed using spectrofluorometric method in tumour homogenates. Immunoexpression of E-cadherin was evaluated histologically on paraffin fixed specimens. Overall and disease-free survival was assessed for a 15-year interval period. Median overall survival was significantly longer (127.2 months) in patients with a high level of GABA (>89.3 μg/1), compared with a group with a low level of the amino acid (106.4 months). Disease-free survival was insignificantly different - 99 and 109 months, respectively. A significantly longer overall survival (131.2 months) was seen among patients with a high level of GABA and positive E-cadherin immunoexpression, compared with a group characterized by a low level of GABA and lack of E-cadherin immunorectivity (98.1 months). The co-existence of negative immunoexpression of E-cadherin and low GABA concentration resulted in a six-fold increase in the risk of death (HR=6.03). GABA has a significant prognostic value in breast cancer. Co-existence of a low level of GABA and loss of E-cadherin immune-expression seems to be a new, independent, and negative prognostic marker of the neoplasm.

Childhood Predictors of Adolescent Competence and Self-Worth in Rural Youth

PubMed Central

Rew, Lynn; Grady, Matthew W.; Spoden, Micajah

2012-01-01

Problem Urban children who become competent adults despite circumstances that place their development and mental health at risk are considered to be resilient. Less is known about the risk and protective factors that characterize resilience among Hispanic/Latinos living in rural areas. Methods Data for regression analyses were collected when children (N = 603; 54% Hispanic/Latino) enrolled in the study in fifth grade, (M=10.4 years of age) and again five years later when they were in high school (M=15 years of age). Findings Statistically significant predictors of competence and self-worth in high schoolers included gender, ethnicity, and mother’s education, as well as stress, temperament (task persistence), and competences measured in grade school. Conclusions Parents’ perceptions of child’s temperament is a significant predictor of future competence and self-worth among rural adolescents. PMID:23121139

Childhood predictors of adolescent competence and self-worth in rural youth.

PubMed

Rew, Lynn; Grady, Matthew W; Spoden, Micajah

2012-11-01

Urban children who become competent adults despite circumstances that place their development and mental health at risk are considered to be resilient. Less is known about the risk and protective factors that characterize resilience among Hispanic/Latinos living in rural areas. Data for regression analyses were collected when children (n = 603; 54% Hispanic/Latino) enrolled in the study in fifth grade (M = 10.4 years of age), and again 5 years later when they were in high school (M = 15 years of age). Statistically significant predictors of competence and self-worth in high schoolers included gender, ethnicity, and mother's education, as well as stress, temperament (task persistence), and competences measured in grade school. Parents' perception of child's temperament is a significant predictor of future competence and self-worth among rural adolescents. © 2012 Wiley Periodicals, Inc.

A simple prognostic model for overall survival in metastatic renal cell carcinoma.

PubMed

Assi, Hazem I; Patenaude, Francois; Toumishey, Ethan; Ross, Laura; Abdelsalam, Mahmoud; Reiman, Tony

2016-01-01

The primary purpose of this study was to develop a simpler prognostic model to predict overall survival for patients treated for metastatic renal cell carcinoma (mRCC) by examining variables shown in the literature to be associated with survival. We conducted a retrospective analysis of patients treated for mRCC at two Canadian centres. All patients who started first-line treatment were included in the analysis. A multivariate Cox proportional hazards regression model was constructed using a stepwise procedure. Patients were assigned to risk groups depending on how many of the three risk factors from the final multivariate model they had. There were three risk factors in the final multivariate model: hemoglobin, prior nephrectomy, and time from diagnosis to treatment. Patients in the high-risk group (two or three risk factors) had a median survival of 5.9 months, while those in the intermediate-risk group (one risk factor) had a median survival of 16.2 months, and those in the low-risk group (no risk factors) had a median survival of 50.6 months. In multivariate analysis, shorter survival times were associated with hemoglobin below the lower limit of normal, absence of prior nephrectomy, and initiation of treatment within one year of diagnosis.

A simple prognostic model for overall survival in metastatic renal cell carcinoma

PubMed Central

Assi, Hazem I.; Patenaude, Francois; Toumishey, Ethan; Ross, Laura; Abdelsalam, Mahmoud; Reiman, Tony

2016-01-01

Introduction: The primary purpose of this study was to develop a simpler prognostic model to predict overall survival for patients treated for metastatic renal cell carcinoma (mRCC) by examining variables shown in the literature to be associated with survival. Methods: We conducted a retrospective analysis of patients treated for mRCC at two Canadian centres. All patients who started first-line treatment were included in the analysis. A multivariate Cox proportional hazards regression model was constructed using a stepwise procedure. Patients were assigned to risk groups depending on how many of the three risk factors from the final multivariate model they had. Results: There were three risk factors in the final multivariate model: hemoglobin, prior nephrectomy, and time from diagnosis to treatment. Patients in the high-risk group (two or three risk factors) had a median survival of 5.9 months, while those in the intermediate-risk group (one risk factor) had a median survival of 16.2 months, and those in the low-risk group (no risk factors) had a median survival of 50.6 months. Conclusions: In multivariate analysis, shorter survival times were associated with hemoglobin below the lower limit of normal, absence of prior nephrectomy, and initiation of treatment within one year of diagnosis. PMID:27217858

Survival impact of rituximab combined with ACVBP and upfront consolidation autotransplantation in high-risk diffuse large B-cell lymphoma for GELA

PubMed Central

Fitoussi, Olivier; Belhadj, Karim; Mounier, Nicolas; Parrens, Marie; Tilly, Hervé; Salles, Gilles; Feugier, Pierre; Ferme, Christophe; Ysebaert, Loic; Gabarre, Jean; Herbrecht, Raoul; Janvier, Maud; Van Den Neste, Eric; Morschhauser, Franck; Casasnovas, Olivier; Ghesquieres, Hervé; Anglaret, Bruno; Brechignac, Sabine; Haioun, Corinne; Gisselbrecht, Christian

2011-01-01

Background As rituximab combined with CHOP improves complete remission and overall survival in diffuse large B-cell lymphoma, intensified chemotherapy followed by autologous stem-cell transplantation has also been advocated for high-risk patients. The aim of this study was to establish whether or not combining rituximab with high-dose chemotherapy and auto-transplantation also benefits patient survival. Design and Methods The LNH2003-3 study was a phase II trial including diffuse large B-cell lymphoma patients with 2 or 3 International Prognostic Index factors. They received four cycles of intensive biweekly chemotherapy with rituximab, doxorubicine, cyclophosphamide, vindesine, bleomycine, prednisolone (R-ACVBP) followed by auto-transplantation in responding patients. Two hundred and nine patients under 60 years of age were included in the study and 155 responding patients underwent auto-transplantation. In addition, a case-control study was performed by matching (1:1) 181 patients treated with R-ACVBP with ACVBP patients not given rituximab but submitted to auto-transplantation from the previous LNH1998-3 trial. Results With a median follow up of 45 months, 4-year progression-free survival and overall survival were estimated at 76% (CI: 69–81) and 78% (CI: 72–83), respectively. There was no difference between patients with 2 or 3 International Prognostic Index factors. Four year progression-free survival was significantly higher in R-ACVBP than ACVBP patients (74% vs. 58%; P=0.0005). There was also a significant increase in 4-year overall survival (76% vs. 68%; P=0.0494). Conclusions In high-risk diffuse large B-cell lymphoma patients, treatment with R-ACVBP followed by auto-transplantation results in a 78% 4-year overall survival which should be compared to other approaches. (Clinicaltrials.gov identifier: NCT00144807) PMID:21546499

Risk factors for reporting poor cultural competency among patients with diabetes in safety net clinics.

PubMed

Seligman, Hilary K; Fernandez, Alicia; Stern, Rachel J; Weech-Maldonado, Robert; Quan, Judy; Jacobs, Elizabeth A

2012-09-01

The Consumer Assessment of Healthcare Providers and Systems Cultural Competency Item Set assesses patient perceptions of aspects of the cultural competence of their health care. To determine characteristics of patients who identify the care they receive as less culturally competent. Cross-sectional survey consisting of face-to-face interviews. Safety-net population of patients with type 2 diabetes (n=600) receiving ongoing primary care. Participants completed the Consumer Assessment of Healthcare Providers and Systems Cultural Competency and answered questions about their race/ethnicity, sex, age, education, health status, depressive symptoms, insurance coverage, English proficiency, duration of relationship with primary care provider, and comorbidities. In adjusted models, depressive symptoms were significantly associated with poor cultural competency in the Doctor Communication--Positive Behaviors domain [odds ratio (OR) 1.73, 95% confidence interval, 1.11-2.69]. African Americans were less likely than whites to report poor cultural competence in the Doctor Communication--Positive Behaviors domain (OR 0.52, 95% CI, 0.28-0.97). Participants who reported a longer relationship (≥ 3 y) with their primary care provider were less likely to report poor cultural competence in the Doctor Communication--Health Promotion (OR 0.35, 95% CI, 0.21-0.60) and Trust domains (OR 0.4, 95% CI, 0.24-0.67), whereas participants with lower educational attainment were less likely to report poor cultural competence in the Trust domain (OR 0.51, 95% CI, 0.30-0.86). Overall, however, sociodemographic and clinical differences in reports of poor cultural competence were insignificant or inconsistent across the various domains of cultural competence examined. Cultural competence interventions in safety-net settings should be implemented across populations, rather than being narrowly focused on specific sociodemographic or clinical groups.

Addressing missing covariates for the regression analysis of competing risks: Prognostic modelling for triaging patients diagnosed with prostate cancer.

PubMed

Escarela, Gabriel; Ruiz-de-Chavez, Juan; Castillo-Morales, Alberto

2016-08-01

Competing risks arise in medical research when subjects are exposed to various types or causes of death. Data from large cohort studies usually exhibit subsets of regressors that are missing for some study subjects. Furthermore, such studies often give rise to censored data. In this article, a carefully formulated likelihood-based technique for the regression analysis of right-censored competing risks data when two of the covariates are discrete and partially missing is developed. The approach envisaged here comprises two models: one describes the covariate effects on both long-term incidence and conditional latencies for each cause of death, whilst the other deals with the observation process by which the covariates are missing. The former is formulated with a well-established mixture model and the latter is characterised by copula-based bivariate probability functions for both the missing covariates and the missing data mechanism. The resulting formulation lends itself to the empirical assessment of non-ignorability by performing sensitivity analyses using models with and without a non-ignorable component. The methods are illustrated on a 20-year follow-up involving a prostate cancer cohort from the National Cancer Institutes Surveillance, Epidemiology, and End Results program. © The Author(s) 2013.

Immune competence assessment in marine medaka (Orzyias melastigma)-a holistic approach for immunotoxicology.

PubMed

Ye, Roy R; Peterson, Drew R; Seemann, Frauke; Kitamura, Shin-Ichi; Lee, J S; Lau, Terrance C K; Tsui, Stephen K W; Au, Doris W T

2017-12-01

Many anthropogenic pollutants in coastal marine environments can induce immune impairments in wild fish and reduce their survival fitness. There is a pressing need to establish sensitive and high throughput in vivo tools to systematically evaluate the immunosuppressive effects of contaminants in marine teleosts. This study reviewed a battery of in vivo immune function detection technologies established for different biological hierarchies at molecular (immune function pathways and genes by next generation sequencing (NGS)), cellular (leukocytes profiles by flow cytometry), tissues/organ system (whole adult histo-array), and organism (host resistance assays (HRAs)) levels, to assess the immune competence of marine medaka Oryzias melastigma. This approach enables a holistic assessment of fish immune competence under different chemical exposure or environmental scenarios. The data obtained will also be useful to unravel the underlying immunotoxic mechanisms. Intriguingly, NGS analysis of hepatic immune gene expression profiles (male > female) are in support of the bacterial HRA findings, in which infection-induced mortality was consistently higher in females than in males. As such, reproductive stages and gender-specific responses must be taken into consideration when assessing the risk of immunotoxicants in the aquatic environment. The distinct phenotypic sexual dimorphism and short generation time (3 months) of marine medaka offer additional advantages for sex-related immunotoxicological investigation.

Acetabular revision with impaction bone grafting and a cemented polyethylene acetabular component: comparison of the Kaplan-Meier analysis to the competing risk analysis in 62 revisions with 25 to 30 years follow-up.

PubMed

Te Stroet, M A J; Keurentjes, J C; Rijnen, W H C; Gardeniers, J W M; Verdonschot, N; Slooff, T J J H; Schreurs, B W

2015-10-01

We present the results of 62 consecutive acetabular revisions using impaction bone grafting and a cemented polyethylene acetabular component in 58 patients (13 men and 45 women) after a mean follow-up of 27 years (25 to 30). All patients were prospectively followed. The mean age at revision was 59.2 years (23 to 82). We performed Kaplan-Meier (KM) analysis and also a Competing Risk (CR) analysis because with long-term follow-up, the presence of a competing event (i.e. death) prevents the occurrence of the endpoint of re-revision. A total of 48 patients (52 hips) had died or had been re-revised at final review in March 2011. None of the deaths were related to the surgery. The mean Harris hip score of the ten surviving hips in ten patients was 76 points (45 to 99). The KM survivorship at 25 years for the endpoint 're-revision for any reason' was 58.0% (95% confidence interval (CI) 38 to 73) and for 're-revision for aseptic loosening' 72.1% (95% CI 51 to 85). With the CR analysis we calculated the KM analysis overestimates the failure rate with respectively 74% and 93% for these endpoints. The current study shows that acetabular impaction bone grafting revisions provide good clinical results at over 25 years. ©2015 The British Editorial Society of Bone & Joint Surgery.

Risk of Hematologic Malignancies After Radioiodine Treatment of Well-Differentiated Thyroid Cancer.

PubMed

Molenaar, Remco J; Sidana, Surbhi; Radivoyevitch, Tomas; Advani, Anjali S; Gerds, Aaron T; Carraway, Hetty E; Angelini, Dana; Kalaycio, Matt; Nazha, Aziz; Adelstein, David J; Nasr, Christian; Maciejewski, Jaroslaw P; Majhail, Navneet S; Sekeres, Mikkael A; Mukherjee, Sudipto

2017-12-18

Purpose To investigate the risk and outcomes of second hematologic malignancies (SHMs) in a population-based cohort of patients with well-differentiated thyroid cancer (WDTC) treated or not with radioactive iodine (RAI). Methods Patients with WDTC were identified from SEER registries. Competing risk regression analysis was performed to calculate the risks of SHMs that occurred after WDTC treatment and outcomes after SHM development were assessed. Results Of 148,215 patients with WDTC, 53% received surgery alone and 47% received RAI. In total, 783 patients developed an SHM after a median interval of 6.5 years (interquartile range, 3.3 to 11.2 years) from WDTC diagnosis. In multivariable analysis, compared with those undergoing thyroidectomy alone, RAI treatment was associated with an increased early risk of developing acute myeloid leukemia (AML; hazard ratio, 1.79; 95% CI, 1.13 to 2.82; P = .01) and chronic myeloid leukemia (CML; hazard ratio, 3.44; 95% CI, 1.87 to 6.36; P < .001). This increased risk of AML and CML after RAI treatment was seen even in low-risk and intermediate-risk WDTC tumors. Occurrence of AML but not CML in patients with WDTC was associated with shorter median overall survival compared with matched controls (8.0 years v 31.0 years; P = .001). In addition, AML developing after RAI trended toward inferior survival compared with matched controls with de novo AML (median overall survival, 1.2 years v 2.9 years; P = .06). Conclusion Patients with WDTC treated with RAI had an increased early risk of developing AML and CML but no other hematologic malignancies. AML that arises after RAI treatment has a poor prognosis. RAI use in patients with WDTC should be limited to patients with high-risk disease features, and patients with WDTC treated with adjuvant RAI should be monitored for myeloid malignancies as part of cancer surveillance.

Commercial kidney transplantation is an important risk factor in long-term kidney allograft survival.

PubMed

Prasad, G V Ramesh; Ananth, Sailesh; Palepu, Sneha; Huang, Michael; Nash, Michelle M; Zaltzman, Jeffrey S

2016-05-01

Transplant tourism, a form of transplant commercialization, has resulted in serious short-term adverse outcomes that explain reduced short-term kidney allograft survival. However, the nature of longer-term outcomes in commercial kidney transplant recipients is less clear. To study this further, we identified 69 Canadian commercial transplant recipients of 72 kidney allografts transplanted during 1998 to 2013 who reported to our transplant center for follow-up care. Their outcomes to 8 years post-transplant were compared with 702 domestic living donor and 827 deceased donor transplant recipients during this period using Kaplan-Meier survival plots and multivariate Cox regression analysis. Among many complications, notable specific events included hepatitis B or C seroconversion (7 patients), active hepatitis and/or fulminant hepatic failure (4 patients), pulmonary tuberculosis (2 patients), and a type A dissecting aortic aneurysm. Commercial transplantation was independently associated with significantly reduced death-censored kidney allograft survival (hazard ratio 3.69, 95% confidence interval 1.88-7.25) along with significantly delayed graft function and eGFR 30 ml/min/1.73 m(2) or less at 3 months post-transplant. Thus, commercial transplantation represents an important risk factor for long-term kidney allograft loss. Concerted arguments and efforts using adverse recipient outcomes among the main premises are still required in order to eradicate transplant commercialization. Copyright © 2016 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.

Examining mortality risk and rate of ageing among Polish Olympic athletes: a survival follow-up from 1924 to 2012.

PubMed

Lin, Yuhui; Gajewski, Antoni; Poznańska, Anna

2016-04-18

Population-based studies have shown that an active lifestyle reduces mortality risk. Therefore, it has been a longstanding belief that individuals who engage in frequent exercise will experience a slower rate of ageing. It is uncertain whether this widely-accepted assumption holds for intense wear-and-tear. Here, using the 88 years survival follow-up data of Polish Olympic athletes, we report for the first time on whether frequent exercise alters the rate of ageing. Longitudinal survival data of male elite Polish athletes who participated in the Olympic Games from year 1924 to 2010 were used. Deaths occurring before the end of World War II were excluded for reliable estimates. Recruited male elite athletes N=1273 were preassigned to two categorical birth cohorts--Cohort I 1890-1919; Cohort II 1920-1959--and a parametric frailty survival analysis was conducted. An event-history analysis was also conducted to adjust for medical improvements from year 1920 onwards: Cohort II. Our findings suggest (1) in Cohort I, for every threefold reduction in mortality risk, the rate of ageing decelerates by 1%; (2) socioeconomic transitions and interventions contribute to a reduction in mortality risk of 29% for the general population and 50% for Olympic athletes; (3) an optimum benefit gained for reducing the rate of ageing from competitive sports (Cohort I 0.086 (95% CI 0.047 to 0.157) and Cohort II 0.085 (95% CI 0.050 to 0.144)). This study further suggests that intensive physical training during youth should be considered as a factor to improve ageing and mortality risk parameters. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Modification effects of genetic polymorphisms in FTO, IL-6, and HSPD1 on the associations of diabetes with breast cancer risk and survival.

PubMed

Zhu, Rui-Mei; Lin, Wei; Zhang, Wei; Ren, Jun-Ting; Su, Yi; He, Jian-Rong; Lin, Ying; Su, Feng-Xi; Xie, Xiao-Ming; Tang, Lu-Ying; Ren, Ze-Fang

2017-01-01

The contribution of diabetes to breast cancer remains uncertain among Chinese females, which may result from different genetic factors. We evaluated the associations of diabetes, combined with the polymorphisms in the genes of fat mass and obesity-associated gene (FTO), interleukin 6 (IL-6), and heat shock protein 60 (HSPD1), with breast cancer risk and survival in a Chinese Han population. The information on the history of diabetes was collected from 1551 incident breast cancer cases and 1605 age-frequency matched controls in Guangzhou, China. In total, 1168 cases were followed up. Diabetes was associated with both an increased risk of breast cancer [OR (95%CI): 1.67 (1.11, 2.52)] and a poor overall survival and progression free survival for breast cancer patients [HRs (95%CIs): 2.66 (1.10, 6.44) and 2.46 (1.29, 4.70), respectively]. IL-6 rs1800796 and HSPD1 rs2605039 had interactions with diabetes on breast cancer risk. Among women with CC genotype of IL-6 rs1800796 or GG genotype of HSPD1 rs2605039, diabetic individuals had a remarkably increased risk of breast cancer compared to non-diabetic women with ORs and 95%CIs of 2.53 (1.45, 4.41) and 6.40 (2.29, 17.87), respectively. GT/TT genotypes of HSPD1 rs2605039 was also associated with a better progression free survival for breast cancer patients [HR (95%CI): 0.70 (0.49, 0.99)]. Our results suggest that the contribution of diabetes to breast cancer risk might be modified by IL-6 rs1800796 and HSPD1 rs2605039. Diabetes and HSPD1 rs2605039 might also influence breast cancer prognosis.

Competing Uses of Underground Systems Related to Energy Supply: Applying Single- and Multiphase Simulations for Site Characterization and Risk-Analysis

NASA Astrophysics Data System (ADS)

Kissinger, A.; Walter, L.; Darcis, M.; Flemisch, B.; Class, H.

2012-04-01

Global climate change, shortage of resources and the resulting turn towards renewable sources of energy lead to a growing demand for the utilization of subsurface systems. Among these competing uses are Carbon Capture and Storage (CCS), geothermal energy, nuclear waste disposal, "renewable" methane or hydrogen storage as well as the ongoing production of fossil resources like oil, gas, and coal. Besides competing among themselves, these technologies may also create conflicts with essential public interests like water supply. For example, the injection of CO2 into the underground causes an increase in pressure reaching far beyond the actual radius of influence of the CO2 plume, potentially leading to large amounts of displaced salt water. Finding suitable sites is a demanding task for several reasons. Natural systems as opposed to technical systems are always characterized by heterogeneity. Therefore, parameter uncertainty impedes reliable predictions towards capacity and safety of a site. State of the art numerical simulations combined with stochastic approaches need to be used to obtain a more reliable assessment of the involved risks and the radii of influence of the different processes. These simulations may include the modeling of single- and multiphase non-isothermal flow, geo-chemical and geo-mechanical processes in order to describe all relevant physical processes adequately. Stochastic approaches have the aim to estimate a bandwidth of the key output parameters based on uncertain input parameters. Risks for these different underground uses can then be made comparable with each other. Along with the importance and the urgency of the competing processes this may lead to a more profound basis for a decision. Communicating risks to stake holders and a concerned public is crucial for the success of finding a suitable site for CCS (or other subsurface utilization). We present and discuss first steps towards an approach for addressing the issue of competitive

Comparison of cardiovascular risk factors and survival in patients with ischemic or hemorrhagic stroke.

PubMed

Henriksson, Karin M; Farahmand, Bahman; Åsberg, Signild; Edvardsson, Nils; Terént, Andreas

2012-06-01

Differences in risk factor profiles between patients with ischemic and hemorrhagic stroke may have an impact on subsequent mortality. To explore cardiovascular disease risk factors, including the CHADS(2) score, with survival after ischemic or hemorrhagic stroke. Between 2001 and 2005, 87 111 (83%) ischemic stroke, 12 497 (12%) hemorrhagic stroke, and 5435 (5%) patients with unspecified stroke were identified in the Swedish Stroke Register. Data on gender, age, and cardiovascular disease risk factors were linked to the Swedish Hospital Discharge and Cause of Death Registers. Adjusted odds and hazard ratios and 95% confidence interval were calculated using logistic and Cox proportional hazard regression models. Hemorrhagic stroke patients were younger than ischemic stroke patients. All cardiovascular disease risk factors studied, alone or combined in the CHADS(2) score, were associated with higher odds ratios for ischemic stroke vs. hemorrhagic stroke. Higher CHADS(2) scores and all studied risk factors except hypertension were associated with higher odds ratio for death by ischemic stroke than hemorrhagic stroke. Ischemic stroke was associated with lower early mortality (within 30 days) vs. hemorrhagic stroke (hazard ratio = 0·28, confidence interval 0·27 to 0·29). Patients with hemorrhagic stroke had a higher risk of dying within the first 30 days after stroke, but the risk of death was similar in the two groups after one-month. Hypertension was the only cardiovascular disease risk factor associated with an increased mortality rate for hemorrhagic stroke as compared to ischemic stroke. © 2011 The Authors. International Journal of Stroke © 2011 World Stroke Organization.

Enhanced secondary analysis of survival data: reconstructing the data from published Kaplan-Meier survival curves.

PubMed

Guyot, Patricia; Ades, A E; Ouwens, Mario J N M; Welton, Nicky J

2012-02-01

The results of Randomized Controlled Trials (RCTs) on time-to-event outcomes that are usually reported are median time to events and Cox Hazard Ratio. These do not constitute the sufficient statistics required for meta-analysis or cost-effectiveness analysis, and their use in secondary analyses requires strong assumptions that may not have been adequately tested. In order to enhance the quality of secondary data analyses, we propose a method which derives from the published Kaplan Meier survival curves a close approximation to the original individual patient time-to-event data from which they were generated. We develop an algorithm that maps from digitised curves back to KM data by finding numerical solutions to the inverted KM equations, using where available information on number of events and numbers at risk. The reproducibility and accuracy of survival probabilities, median survival times and hazard ratios based on reconstructed KM data was assessed by comparing published statistics (survival probabilities, medians and hazard ratios) with statistics based on repeated reconstructions by multiple observers. The validation exercise established there was no material systematic error and that there was a high degree of reproducibility for all statistics. Accuracy was excellent for survival probabilities and medians, for hazard ratios reasonable accuracy can only be obtained if at least numbers at risk or total number of events are reported. The algorithm is a reliable tool for meta-analysis and cost-effectiveness analyses of RCTs reporting time-to-event data. It is recommended that all RCTs should report information on numbers at risk and total number of events alongside KM curves.

Survival and risk factors related to death in outpatients with cirrhosis treated in a clinic in Southern Brazil.

PubMed

John, Jorge Alberto; de Mattos, Angelo Alves; da Silva Miozzo, Suelen Aparecida; Comerlato, Pedro Henrique; Porto, Mariana; Contiero, Priscila; da Silva, Renata Rodrigues

2015-12-01

Cirrhosis represents a public health issue that generally evolves and presents serious complications. To assess the outcomes of outpatients with cirrhosis. We used a retrospective outpatient-based cohort, assessing 527 patients with cirrhosis. Demographic, clinical, and laboratory variables were analyzed, as well as the risk factors related to death, using the Cox proportional-hazard regression model. The Kaplan-Meier method was used to analyze survival rates. Patients had a mean age of 52.9±9.7 years and were more frequently men (59%), presenting Child-Turcotte-Pugh B or C in 43% of the cases in addition to a mean Model for End-Stage Liver Disease score of 12.0±4.1. The predominant etiology of liver disease was the hepatitis C virus. The most frequent complications during follow-up were ascites (34%), hepatic encephalopathy (17%), and hepatocellular carcinoma (17%). The survival rate at years 5 and 10 was 73 and 57%, respectively. The main risk factors that were related to death were, in a multivariate analysis, hepatitis C virus etiology, presence of hepatocellular carcinoma, and serum levels of albumin. Patients with cirrhosis monitored on an outpatient basis, despite showing a reasonable survival rate, have a worse prognosis when the etiology of liver disease is related to hepatitis C virus and when they have hepatocellular carcinoma or hypoalbuminemia.

Deriving injury risk curves using survival analysis from biomechanical experiments.

PubMed

Yoganandan, Narayan; Banerjee, Anjishnu; Hsu, Fang-Chi; Bass, Cameron R; Voo, Liming; Pintar, Frank A; Gayzik, F Scott

2016-10-03

Injury risk curves from biomechanical experimental data analysis are used in automotive studies to improve crashworthiness and advance occupant safety. Metrics such as acceleration and deflection coupled with outcomes such as fractures and anatomical disruptions from impact tests are used in simple binary regression models. As an improvement, the International Standards Organization suggested a different approach. It was based on survival analysis. While probability curves for side-impact-induced thorax and abdominal injuries and frontal impact-induced foot-ankle-leg injuries are developed using this approach, deficiencies are apparent. The objective of this study is to present an improved, robust and generalizable methodology in an attempt to resolve these issues. It includes: (a) statistical identification of the most appropriate independent variable (metric) from a pool of candidate metrics, measured and or derived during experimentation and analysis processes, based on the highest area under the receiver operator curve, (b) quantitative determination of the most optimal probability distribution based on the lowest Akaike information criterion, (c) supplementing the qualitative/visual inspection method for comparing the selected distribution with a non-parametric distribution with objective measures, (d) identification of overly influential observations using different methods, and (e) estimation of confidence intervals using techniques more appropriate to the underlying survival statistical model. These clear and quantified details can be easily implemented with commercial/open source packages. They can be used in retrospective analysis and prospective design of experiments, and in applications to different loading scenarios such as underbody blast events. The feasibility of the methodology is demonstrated using post mortem human subject experiments and 24 metrics associated with thoracic/abdominal injuries in side-impacts. Published by Elsevier Ltd.

Greater decision-making competence is associated with greater expected-value sensitivity, but not overall risk taking: an examination of concurrent validity.

PubMed

Parker, Andrew M; Weller, Joshua A

2015-01-01

Decision-making competence reflects individual differences in the susceptibility to committing decision-making errors, measured using tasks common from behavioral decision research (e.g., framing effects, under/overconfidence, following decision rules). Prior research demonstrates that those with higher decision-making competence report lower incidence of health-risking and antisocial behaviors, but there has been less focus on intermediate processes that may impact real-world decisions, and, in particular, those implicated by normative models. Here we test the associations between measures of youth decision-making competence (Y-DMC) and one such process, the degree to which individuals make choices consistent with maximizing expected value (EV). Using a task involving hypothetical gambles, we find that greater EV sensitivity is associated with greater Y-DMC. Higher Y-DMC scores are associated with (a) choosing risky options when EV favors those options and (b) avoiding risky options when EV favors a certain option. This relationship is stronger for gambles that involved potential losses. The results suggest that Y-DMC captures decision processes consistent with standard normative evaluations of risky decisions.

Gastric dilation-volvulus in dogs attending UK emergency-care veterinary practices: prevalence, risk factors and survival.

PubMed

O'Neill, D G; Case, J; Boag, A K; Church, D B; McGreevy, P D; Thomson, P C; Brodbelt, D C

2017-11-01

To report prevalence, risk factors and clinical outcomes for presumptive gastric dilation-volvulus diagnosed among an emergency-care population of UK dogs. The study used a cross-sectional design using emergency-care veterinary clinical records from the VetCompass Programme spanning September 1, 2012 to February 28, 2014 and risk factor analysis using multivariable logistic regression modelling. The study population comprised 77,088 dogs attending 50 Vets Now clinics. Overall, 492 dogs had presumptive gastric dilation-volvulus diagnoses, giving a prevalence of 0·64% (95% Confidence interval: 0·58 to 0·70%). Compared with cross-bred dogs, breeds with the highest odds ratios for the diagnosis of presumptive gastric dilation-volvulus were the great Dane (odds ratio: 114·3, 95% Confidence interval 55·1 to 237·1, P<0·001), akita (odds ratio: 84·4, 95% Confidence interval 33·6 to 211·9, P<0·001) and dogue de Bordeaux (odds ratio: 82·9, 95% Confidence interval 39·0 to 176·3, P<0·001). Odds increased as dogs aged up to 12 years and neutered male dogs had 1·3 (95% Confidence interval 1·0 to 1·8, P=0·041) times the odds compared with entire females. Of the cases that were presented alive, 49·7% survived to discharge overall, but 79·3% of surgical cases survived to discharge. Approximately 80% of surgically managed cases survived to discharge. Certain large breeds were highly predisposed. © 2017 British Small Animal Veterinary Association.

Risk Factors for Reporting Poor Cultural Competency Among Patients with Diabetes in Safety-Net Clinics

PubMed Central

Seligman, Hilary K.; Fernandez, Alicia; Stern, Rachel J.; Weech-Maldonado, Robert; Quan, Judy; Jacobs, Elizabeth A.

2012-01-01

Background The Consumer Assessment of Healthcare Providers and Systems Cultural Competency (CAHPS-CC) Item Set assesses patient perceptions of aspects of the cultural competence of their health care. Objective To determine characteristics of patients who identify the care they receive as less culturally competent Research Design Cross-sectional survey consisting of face-to-face interviews Subjects Safety-net population of patients with type 2 diabetes (n=600) receiving ongoing primary care Measures Participants completed the CAHPS-CC and answered questions about their race/ethnicity, gender, age, education, health status, depressive symptoms, insurance coverage, English proficiency, duration of relationship with primary care provider, and co-morbidities. Results In adjusted models, depressive symptoms were significantly associated with poor cultural competency in the Doctor Communication – Positive Behaviors domain (OR 1.73, 95%CI 1.11, 2.69). African-Americans were less likely than Whites to report poor cultural competence in the Doctor Communication – Positive Behaviors domain (OR 0.52, 0.28–0.97). Participants who reported a longer relationship (≥3 years) with their primary care provider were less likely to report poor cultural competence in the Doctor Communication – Health Promotion (OR 0.35, 0.21–0.60) and Trust domains (OR 0.4, 0.24–0.67), while participants with lower educational attainment were less likely to report poor cultural competence in the Trust domain (OR 0.51, 0.30–0.86). Overall, however, sociodemographic and clinical differences in reports of poor cultural competence were insignificant or inconsistent across the various domains of cultural competence examined. Conclusions Cultural competence interventions in safety-net settings should be implemented across populations, rather than being narrowly focused on specific sociodemographic or clinical groups. PMID:22895232

Demisability and survivability sensitivity to design-for-demise techniques

NASA Astrophysics Data System (ADS)

Trisolini, Mirko; Lewis, Hugh G.; Colombo, Camilla

2018-04-01

The paper is concerned with examining the effects that design-for-demise solutions can have not only on the demisability of components, but also on their survivability that is their capability to withstand impacts from space debris. First two models are introduced. A demisability model to predict the behaviour of spacecraft components during the atmospheric re-entry and a survivability model to assess the vulnerability of spacecraft structures against space debris impacts. Two indices that evaluate the level of demisability and survivability are also proposed. The two models are then used to study the sensitivity of the demisability and of the survivability indices as a function of typical design-for-demise options. The demisability and the survivability can in fact be influenced by the same design parameters in a competing fashion that is while the demisability is improved, the survivability is worsened and vice versa. The analysis shows how the design-for-demise solutions influence the demisability and the survivability independently. In addition, the effect that a solution has simultaneously on the two criteria is assessed. Results shows which, among the design-for-demise parameters mostly influence the demisability and the survivability. For such design parameters maps are presented, describing their influence on the demisability and survivability indices. These maps represent a useful tool to quickly assess the level of demisability and survivability that can be expected from a component, when specific design parameters are changed.

The social competence of Latino kindergartners and growth in mathematical understanding.

PubMed

Galindo, Claudia; Fuller, Bruce

2010-05-01

We know that social competence contributes to young children's adaptation to, and cognitive learning within, classroom settings. Yet initial evidence is mixed on the social competencies that Latino children bring to kindergarten and the extent to which these skills advance cognitive growth. Building from ecocultural and developmental-risk theory, this paper shows children's social competence to be adaptive to the normative expectations and cognitive requirements of culturally bounded settings in both the home and classroom. Latino socialization in the home may yield social competencies that teachers value rather than reflect "risk factors" that constrain children's school readiness. We draw on the Early Childhood Longitudinal Study, kindergarten cohort (N = 19,590) to detail 5 social competencies at entry to school--self-control, interpersonal skills, approaches to learning, internalizing and externalizing problem behaviors--and to examine variability among Latino subgroups. We then test the extent to which baseline variation in social competence accounts for children's cognitive growth during the kindergarten year. We find that Latino children from poor, but not middle-class, families display weaker social competencies vis-à-vis White children (all relationships p < or = .05). Social competence levels contribute to Latino children's cognitive growth, which is shaped most strongly by positive approaches to learning. The disparities in competencies observed for Latino children from poor families, relative to White children, are significant yet much smaller than gaps in baseline levels of mathematical understanding. We discuss how the consonance or mismatch between competencies acquired at home and those valued by teachers must consider cultural differences, social-class position, and variation among diverse Latino subgroups. 2010 APA, all rights reserved

Brachytherapy Improves Biochemical Failure–Free Survival in Low- and Intermediate-Risk Prostate Cancer Compared With Conventionally Fractionated External Beam Radiation Therapy: A Propensity Score Matched Analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Smith, Graham D.; Pickles, Tom; Crook, Juanita

2015-03-01

Purpose: To compare, in a retrospective study, biochemical failure-free survival (bFFS) and overall survival (OS) in low-risk and intermediate-risk prostate cancer patients who received brachytherapy (BT) (either low-dose-rate brachytherapy [LDR-BT] or high-dose-rate brachytherapy with external beam radiation therapy [HDR-BT+EBRT]) versus external beam radiation therapy (EBRT) alone. Methods and Materials: Patient data were obtained from the ProCaRS database, which contains 7974 prostate cancer patients treated with primary radiation therapy at four Canadian cancer institutions from 1994 to 2010. Propensity score matching was used to obtain the following 3 matched cohorts with balanced baseline prognostic factors: (1) low-risk LDR-BT versus EBRT; (2)more » intermediate-risk LDR-BT versus EBRT; and (3) intermediate-risk HDR-BT+EBRT versus EBRT. Kaplan-Meier survival analysis was performed to compare differences in bFFS (primary endpoint) and OS in the 3 matched groups. Results: Propensity score matching created acceptable balance in the baseline prognostic factors in all matches. Final matches included 2 1:1 matches in the intermediate-risk cohorts, LDR-BT versus EBRT (total n=254) and HDR-BT+EBRT versus EBRT (total n=388), and one 4:1 match in the low-risk cohort (LDR-BT:EBRT, total n=400). Median follow-up ranged from 2.7 to 7.3 years for the 3 matched cohorts. Kaplan-Meier survival analysis showed that all BT treatment options were associated with statistically significant improvements in bFFS when compared with EBRT in all cohorts (intermediate-risk EBRT vs LDR-BT hazard ratio [HR] 4.58, P=.001; intermediate-risk EBRT vs HDR-BT+EBRT HR 2.08, P=.007; low-risk EBRT vs LDR-BT HR 2.90, P=.004). No significant difference in OS was found in all comparisons (intermediate-risk EBRT vs LDR-BT HR 1.27, P=.687; intermediate-risk EBRT vs HDR-BT+EBRT HR 1.55, P=.470; low-risk LDR-BT vs EBRT HR 1.41, P=.500). Conclusions: Propensity score matched analysis showed that BT

Brachytherapy improves biochemical failure-free survival in low- and intermediate-risk prostate cancer compared with conventionally fractionated external beam radiation therapy: a propensity score matched analysis.

PubMed

Smith, Graham D; Pickles, Tom; Crook, Juanita; Martin, Andre-Guy; Vigneault, Eric; Cury, Fabio L; Morris, Jim; Catton, Charles; Lukka, Himu; Warner, Andrew; Yang, Ying; Rodrigues, George

2015-03-01

To compare, in a retrospective study, biochemical failure-free survival (bFFS) and overall survival (OS) in low-risk and intermediate-risk prostate cancer patients who received brachytherapy (BT) (either low-dose-rate brachytherapy [LDR-BT] or high-dose-rate brachytherapy with external beam radiation therapy [HDR-BT+EBRT]) versus external beam radiation therapy (EBRT) alone. Patient data were obtained from the ProCaRS database, which contains 7974 prostate cancer patients treated with primary radiation therapy at four Canadian cancer institutions from 1994 to 2010. Propensity score matching was used to obtain the following 3 matched cohorts with balanced baseline prognostic factors: (1) low-risk LDR-BT versus EBRT; (2) intermediate-risk LDR-BT versus EBRT; and (3) intermediate-risk HDR-BT+EBRT versus EBRT. Kaplan-Meier survival analysis was performed to compare differences in bFFS (primary endpoint) and OS in the 3 matched groups. Propensity score matching created acceptable balance in the baseline prognostic factors in all matches. Final matches included 2 1:1 matches in the intermediate-risk cohorts, LDR-BT versus EBRT (total n=254) and HDR-BT+EBRT versus EBRT (total n=388), and one 4:1 match in the low-risk cohort (LDR-BT:EBRT, total n=400). Median follow-up ranged from 2.7 to 7.3 years for the 3 matched cohorts. Kaplan-Meier survival analysis showed that all BT treatment options were associated with statistically significant improvements in bFFS when compared with EBRT in all cohorts (intermediate-risk EBRT vs LDR-BT hazard ratio [HR] 4.58, P=.001; intermediate-risk EBRT vs HDR-BT+EBRT HR 2.08, P=.007; low-risk EBRT vs LDR-BT HR 2.90, P=.004). No significant difference in OS was found in all comparisons (intermediate-risk EBRT vs LDR-BT HR 1.27, P=.687; intermediate-risk EBRT vs HDR-BT+EBRT HR 1.55, P=.470; low-risk LDR-BT vs EBRT HR 1.41, P=.500). Propensity score matched analysis showed that BT options led to statistically significant improvements in bFFS in

Rifaximin treatment is associated with reduced risk of cirrhotic complications and prolonged overall survival in patients experiencing hepatic encephalopathy.

PubMed

Kang, S H; Lee, Y B; Lee, J-H; Nam, J Y; Chang, Y; Cho, H; Yoo, J-J; Cho, Y Y; Cho, E J; Yu, S J; Kim, M Y; Kim, Y J; Baik, S K; Yoon, J-H

2017-11-01

Rifaximin might decrease the risk of portal hypertension-related complications by controlling small intestinal bacterial overgrowth. To evaluate whether rifaximin was associated with the risk of death and cirrhotic complications. We conducted a retrospective study that included 1042 patients experiencing hepatic encephalopathy (HE): 421 patients without hepatocellular carcinoma (HCC; the non-HCC cohort) and 621 patients with HCC (the HCC cohort). The primary endpoint was overall survival and secondary endpoints were recurrence of HE and the development of spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS) and variceal bleeding. In the non-HCC cohort, 145 patients received rifaximin plus lactulose (the rifaximin group) and 276 patients received lactulose alone (the control group). The multivariate analysis revealed that rifaximin was significantly associated with lower risk of death (adjusted hazard ratio [aHR], 0.697; P = .024) and reduced the risk of recurrent HE (aHR, 0.452; P < .001), SBP (aHR, 0.210; P < .001) and variceal bleeding (aHR, 0.425; P = .011) but not HRS (aHR, 0.598; P = .08). In the HCC cohort, 173 patients received rifaximin plus lactulose and 448 patients received lactulose. Rifaximin was not associated with the risk of death (aHR, 1.177; P = .121). Rifaximin was associated with lower risk of SBP (aHR, 0.323; P < .001) but not with variceal bleeding (aHR, 0.660; P = .104) or recurrent HE (aHR, 0.689; P = .057). The risk of Clostridium difficile-associated diarrhoea was not different between the groups (aHR, 0.028; P = .338). In patients without HCC, rifaximin treatment was significantly associated with prolonged overall survival and reduced risks of spontaneous bacterial peritonitis, variceal bleeding and recurrent hepatic encephalopathy. © 2017 John Wiley & Sons Ltd.

Melanoma-specific mortality and competing mortality in patients with non-metastatic malignant melanoma: a population-based analysis.

PubMed

Shen, Weidong; Sakamoto, Naoko; Yang, Limin

2016-07-07

The objectives of this study were to evaluate and model the probability of melanoma-specific death and competing causes of death for patients with melanoma by competing risk analysis, and to build competing risk nomograms to provide individualized and accurate predictive tools. Melanoma data were obtained from the Surveillance Epidemiology and End Results program. All patients diagnosed with primary non-metastatic melanoma during the years 2004-2007 were potentially eligible for inclusion. The cumulative incidence function (CIF) was used to describe the probability of melanoma mortality and competing risk mortality. We used Gray's test to compare differences in CIF between groups. The proportional subdistribution hazard approach by Fine and Gray was used to model CIF. We built competing risk nomograms based on the models that we developed. The 5-year cumulative incidence of melanoma death was 7.1 %, and the cumulative incidence of other causes of death was 7.4 %. We identified that variables associated with an elevated probability of melanoma-specific mortality included older age, male sex, thick melanoma, ulcerated cancer, and positive lymph nodes. The nomograms were well calibrated. C-indexes were 0.85 and 0.83 for nomograms predicting the probability of melanoma mortality and competing risk mortality, which suggests good discriminative ability. This large study cohort enabled us to build a reliable competing risk model and nomogram for predicting melanoma prognosis. Model performance proved to be good. This individualized predictive tool can be used in clinical practice to help treatment-related decision making.

Understanding aquatic animal virus survival and trafficking and its role in risk assessment

USGS Publications Warehouse

LaPatra, S.; Troyer, R.; Shewmaker, W.; Jones, G.; Kurath, Gael; Rogers, C.J.

2001-01-01

evaluating virus survival and trafficing and using this sort of information in risk assessment.

Winter survival of Eurasian woodcock Scolopax rusticola in central Italy

USGS Publications Warehouse

Aradis, A.; Miller, M.W.; Landucci, G.; Ruda, P.; Taddei, S.; Spina, F.

2008-01-01

The Eurasian woodcock Scolopax rusticola is a popular game bird in much of Europe. However, little is known about its population dynamics. We estimated winter survival of woodcock in a protected area with no hunting in central Italy. We radio-tagged 68 woodcocks with battery-powered radio-transmitters during 2001-2005. Woodcocks were captured in fields at night from November through February and fitted with radios. Birds were classified on capture as juveniles or adults using plumage characteristics. Woodcocks were relocated daily through March of each year or until they died, disappeared from the study area, or until their radio failed. We constructed a set of eight competing models of daily survival for the period 1 December - 28 February. Estimates of survival were obtained using the program SURVIV and Akaike's Information Criteria. The best model suggested daily survival was a constant 0.9985 (95% CI = 0.9972-0.9998), corresponding to a survival rate of 0.88 (SE = 0.05) for the 90-day winter study period. Our estimate of juvenile survival is higher than previously reported, and may reflect the protected status of the study area. Our estimates of winter survival may be helpful in managing harvested woodcock populations as well as in conserving populations in an increasingly urbanised environment. ?? Wildlife Biology (2008).

Conditional survival is greater than overall survival at diagnosis in patients with osteosarcoma and Ewing's sarcoma.

PubMed

Miller, Benjamin J; Lynch, Charles F; Buckwalter, Joseph A

2013-11-01

Conditional survival is a measure of the risk of mortality given that a patient has survived a defined period of time. These estimates are clinically helpful, but have not been reported previously for osteosarcoma or Ewing's sarcoma. We determined the conditional survival of patients with osteosarcoma and Ewing's sarcoma given survival of 1 or more years. We used the Surveillance, Epidemiology, and End Results (SEER) Program database to investigate cases of osteosarcoma and Ewing's sarcoma in patients younger than 40 years from 1973 to 2009. The SEER Program is managed by the National Cancer Institute and provides survival data gathered from population-based cancer registries. We used an actuarial life table analysis to determine any cancer cause-specific 5-year survival estimates conditional on 1 to 5 years of survival after diagnosis. We performed a similar analysis to determine 20-year survival from the time of diagnosis. The estimated 5-year survival improved each year after diagnosis. For local/regional osteosarcoma, the 5-year survival improved from 74.8% at baseline to 91.4% at 5 years-meaning that if a patient with localized osteosarcoma lives for 5 years, the chance of living for another 5 years is 91.4%. Similarly, the 5-year survivals for local/regional Ewing's sarcoma improved from 72.9% at baseline to 92.5% at 5 years, for metastatic osteosarcoma 35.5% at baseline to 85.4% at 5 years, and for metastatic Ewing's sarcoma 31.7% at baseline to 83.6% at 5 years. The likelihood of 20-year cause-specific survival from the time of diagnosis in osteosarcoma and Ewing's sarcoma was almost 90% or greater after 10 years of survival, suggesting that while most patients will remain disease-free indefinitely, some experience cancer-related complications years after presumed eradication. The 5-year survival estimates of osteosarcoma and Ewing's sarcoma improve with each additional year of patient survival. Knowledge of a changing risk profile is useful in counseling

Association Between NRAS and BRAF Mutational Status and Melanoma-Specific Survival Among Patients With Higher-Risk Primary Melanoma.

PubMed

Thomas, Nancy E; Edmiston, Sharon N; Alexander, Audrey; Groben, Pamela A; Parrish, Eloise; Kricker, Anne; Armstrong, Bruce K; Anton-Culver, Hoda; Gruber, Stephen B; From, Lynn; Busam, Klaus J; Hao, Honglin; Orlow, Irene; Kanetsky, Peter A; Luo, Li; Reiner, Anne S; Paine, Susan; Frank, Jill S; Bramson, Jennifer I; Marrett, Lorraine D; Gallagher, Richard P; Zanetti, Roberto; Rosso, Stefano; Dwyer, Terence; Cust, Anne E; Ollila, David W; Begg, Colin B; Berwick, Marianne; Conway, Kathleen

2015-06-01

NRAS and BRAF mutations in melanoma inform current treatment paradigms, but their role in survival from primary melanoma has not been established. Identification of patients at high risk of melanoma-related death based on their primary melanoma characteristics before evidence of recurrence could inform recommendations for patient follow-up and eligibility for adjuvant trials. To determine tumor characteristics and survival from primary melanoma by somatic NRAS and BRAF status. A population-based study with a median follow-up of 7.6 years (through 2007), including 912 patients from the United States and Australia in the Genes, Environment, and Melanoma (GEM) Study, with first primary cutaneous melanoma diagnosed in the year 2000 and analyzed for NRAS and BRAF mutations. Tumor characteristics and melanoma-specific survival of primary melanoma by NRAS and BRAF mutational status. The melanomas were 13% NRAS+, 30% BRAF+, and 57% with neither NRAS nor BRAF mutation (wildtype [WT]). In a multivariable model including clinicopathologic characteristics, relative to WT melanoma (with results reported as odds ratios [95% CIs]), NRAS+ melanoma was associated with presence of mitoses (1.8 [1.0-3.3]), lower tumor-infiltrating lymphocyte (TIL) grade (nonbrisk, 0.5 [0.3-0.8]; and brisk, 0.3 [0.5-0.7] [vs absent TILs]), and anatomic site other than scalp/neck (0.1 [0.01-0.6] for scalp/neck vs trunk/pelvis), and BRAF+ melanoma was associated with younger age (ages 50-69 years, 0.7 [0.5-1.0]; and ages >70 years, 0.5 [0.3-0.8] [vs <50 years]), superficial spreading subtype (nodular, 0.5 [0.2-1.0]; lentigo maligna, 0.4 [0.2-0.7]; and unclassified/other, 0.2 [0.1-0.5] [vs superficial spreading]), and presence of mitoses (1.7 [1.1-2.6]) (P < .05 for all). There was no significant difference in melanoma-specific survival (reported as hazard ratios [95% CIs]) for melanoma harboring mutations in NRAS (1.7 [0.8-3.4]) or BRAF (1.5 [0.8-2.9]) compared with WT melanoma, as adjusted for age

Fortune favours the brave: Movement responses shape demographic dynamics in strongly competing populations.

PubMed

Potts, Jonathan R; Petrovskii, Sergei V

2017-05-07

Animal movement is a key mechanism for shaping population dynamics. The effect of interactions between competing animals on a population's survival has been studied for many decades. However, interactions also affect an animal's subsequent movement decisions. Despite this, the indirect effect of these decisions on animal survival is much less well-understood. Here, we incorporate movement responses to foreign animals into a model of two competing populations, where inter-specific competition is greater than intra-specific competition. When movement is diffusive, the travelling wave moves from the stronger population to the weaker. However, by incorporating behaviourally induced directed movement towards the stronger population, the weaker one can slow the travelling wave down, even reversing its direction. Hence movement responses can switch the predictions of traditional mechanistic models. Furthermore, when environmental heterogeneity is combined with aggressive movement strategies, it is possible for spatially segregated co-existence to emerge. In this situation, the spatial patterns of the competing populations have the unusual feature that they are slightly out-of-phase with the environmental patterns. Finally, incorporating dynamic movement responses can also enable stable co-existence in a homogeneous environment, giving a new mechanism for spatially segregated co-existence. Copyright © 2017 Elsevier Ltd. All rights reserved.

Providing Clinicians and Patients With Actual Prognosis: Cancer in the Context of Competing Causes of Death

PubMed Central

Mariotto, Angela B.; Woloshin, Steven; Schwartz, Lisa M.

2014-01-01

Background To isolate progress against cancer from changes in competing causes of death, population cancer registries have traditionally reported cancer prognosis (net measures). But clinicians and cancer patients generally want to understand actual prognosis (crude measures): the chance of surviving, dying from the specific cancer and from competing causes of death in a given time period. Objective To compare cancer and actual prognosis in the United States for four leading cancers—lung, breast, prostate, and colon—by age, comorbidity, and cancer stage and to provide templates to help patients, clinicians, and researchers understand actual prognosis. Method Using population-based registry data from the Surveillance, Epidemiology, and End Results (SEER) Program, we calculated cancer prognosis (relative survival) and actual prognosis (five-year overall survival and the “crude” probability of dying from cancer and competing causes) for three important prognostic determinants (age, comorbidity [Charlson-score from 2012 SEER-Medicare linkage dataset] and cancer stage at diagnosis). Result For younger, healthier, and earlier stage cancer patients, cancer and actual prognosis estimates were quite similar. For older and sicker patients, these prognosis estimates differed substantially. For example, the five-year overall survival for an 85-year-old patient with colorectal cancer is 54% (cancer prognosis) versus 22% (actual prognosis)—the difference reflecting the patient’s substantial chance of dying from competing causes. The corresponding five-year chances of dying from the patient’s cancer are 46% versus 37%. Although age and comorbidity lowered actual prognosis, stage at diagnosis was the most powerful factor: The five-year chance of colon cancer death was 10% for localized stage and 83% for distant stage. Conclusion Both cancer and actual prognosis measures are important. Cancer registries should routinely report both cancer and actual prognosis to help

Providing clinicians and patients with actual prognosis: cancer in the context of competing causes of death.

PubMed

Howlader, Nadia; Mariotto, Angela B; Woloshin, Steven; Schwartz, Lisa M

2014-11-01

To isolate progress against cancer from changes in competing causes of death, population cancer registries have traditionally reported cancer prognosis (net measures). But clinicians and cancer patients generally want to understand actual prognosis (crude measures): the chance of surviving, dying from the specific cancer and from competing causes of death in a given time period. To compare cancer and actual prognosis in the United States for four leading cancers-lung, breast, prostate, and colon-by age, comorbidity, and cancer stage and to provide templates to help patients, clinicians, and researchers understand actual prognosis. Using population-based registry data from the Surveillance, Epidemiology, and End Results (SEER) Program, we calculated cancer prognosis (relative survival) and actual prognosis (five-year overall survival and the "crude" probability of dying from cancer and competing causes) for three important prognostic determinants (age, comorbidity [Charlson-score from 2012 SEER-Medicare linkage dataset] and cancer stage at diagnosis). For younger, healthier, and earlier stage cancer patients, cancer and actual prognosis estimates were quite similar. For older and sicker patients, these prognosis estimates differed substantially. For example, the five-year overall survival for an 85-year-old patient with colorectal cancer is 54% (cancer prognosis) versus 22% (actual prognosis)-the difference reflecting the patient's substantial chance of dying from competing causes. The corresponding five-year chances of dying from the patient's cancer are 46% versus 37%. Although age and comorbidity lowered actual prognosis, stage at diagnosis was the most powerful factor: The five-year chance of colon cancer death was 10% for localized stage and 83% for distant stage. Both cancer and actual prognosis measures are important. Cancer registries should routinely report both cancer and actual prognosis to help clinicians and researchers understand the difference between

Association Between Treatment at a High-Volume Facility and Improved Survival for Radiation-Treated Men With High-Risk Prostate Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chen, Yu-Wei; Mahal, Brandon A.; Harvard Medical School, Boston, Massachusetts

Purpose: Although the association between higher hospital volume and improved outcomes has been well-documented in surgery, there is little data about whether this effect exists for radiation-treated patients. We investigated whether treatment at a radiation facility that treats a high volume of prostate cancer patients is associated with improved survival for men with high-risk prostate cancer. Methods and Materials: We used the National Cancer Database (NCDB) to identity patients diagnosed with prostate cancer from 2004 to 2006. The radiation case volume (RCV) of each hospital was based on its number of radiation-treated prostate cancer patients. We used propensity-score based analysismore » to compare the overall survival (OS) of high-risk prostate cancer patients in high versus low RCV hospitals. Primary endpoint is overall survival. Covariates adjusted for were tumor characteristics, sociodemographic factors, radiation type, and use of androgen deprivation therapy (ADT). Results: A total of 19,565 radiation-treated high-risk patients were identified. Median follow-up was 81.0 months (range: 1-108 months). When RCV was coded as a continuous variable, each increment of 100 radiation-managed patients was associated with improved OS (adjusted hazard ratio [AHR]: 0.97; 95% confidence interval [CI]: 0.95-0.98; P<.0001) after adjusting for known confounders. For illustrative purposes, when RCV was dichotomized at the 80th percentile (43 patients/year), high RCV was associated with improved OS (7-year overall survival 76% vs 74%, log-rank test P=.0005; AHR: 0.91, 95% CI: 0.86-0.96, P=.0005). This association remained significant when RCV was dichotomized at 75th (37 patients/year), 90th (60 patients/year), and 95th (84 patients/year) percentiles but not the 50th (19 patients/year). Conclusions: Our results suggest that treatment at centers with higher prostate cancer radiation case volume is associated with improved OS for radiation-treated men with high-risk

[The role of "competent physician" for prevention of accidents at work].

PubMed

Ramistella, E; Bergamaschi, A; Mosconi, G; Rossi, O; Sallese, D

2008-01-01

Using at best the professional and legal tools at his/her disposal, the "competent physician" can have a relevant role in reducing accidents in the workplace. In assessing the worker's suitability to specific tasks, the competent physician checks the presence of pathologies or functional impairments of organs or apparatuses that can be an additional risk for the occurrence of accidents at work. The activity aimed to preventing accidents at work translates also in taking part in the planning and implementation of information activities and workers' training within the company. The various risk factors inherent in the workplace and so-called "human factors" can interact in a negative way to the point of becoming a cause of accidents. The human variables of accident risk at the industrial, occupational and even individual level, may be numerous. In this paper we shall review these important aspects and attempt to clarify the role that can be played by the competent physician in the prevention of accidents at work.

An Incident Cohort Study Comparing Survival on Home Hemodialysis and Peritoneal Dialysis (Australia and New Zealand Dialysis and Transplantation Registry)

PubMed Central

Nadeau-Fredette, Annie-Claire; Hawley, Carmel M.; Pascoe, Elaine M.; Chan, Christopher T.; Clayton, Philip A.; Polkinghorne, Kevan R.; Boudville, Neil; Leblanc, Martine

2015-01-01

Background and objectives Home dialysis is often recognized as a first-choice therapy for patients initiating dialysis. However, studies comparing clinical outcomes between peritoneal dialysis and home hemodialysis have been very limited. Design, setting, participants, & measurements This Australia and New Zealand Dialysis and Transplantation Registry study assessed all Australian and New Zealand adult patients receiving home dialysis on day 90 after initiation of RRT between 2000 and 2012. The primary outcome was overall survival. The secondary outcomes were on-treatment survival, patient and technique survival, and death-censored technique survival. All results were adjusted with three prespecified models: multivariable Cox proportional hazards model (main model), propensity score quintile–stratified model, and propensity score–matched model. Results The study included 10,710 patients on incident peritoneal dialysis and 706 patients on incident home hemodialysis. Treatment with home hemodialysis was associated with better patient survival than treatment with peritoneal dialysis (5-year survival: 85% versus 44%, respectively; log-rank P<0.001). Using multivariable Cox proportional hazards analysis, home hemodialysis was associated with superior patient survival (hazard ratio for overall death, 0.47; 95% confidence interval, 0.38 to 0.59) as well as better on-treatment survival (hazard ratio for on-treatment death, 0.34; 95% confidence interval, 0.26 to 0.45), composite patient and technique survival (hazard ratio for death or technique failure, 0.34; 95% confidence interval, 0.29 to 0.40), and death-censored technique survival (hazard ratio for technique failure, 0.34; 95% confidence interval, 0.28 to 0.41). Similar results were obtained with the propensity score models as well as sensitivity analyses using competing risks models and different definitions for technique failure and lag period after modality switch, during which events were attributed to the

External validation of a published nomogram for prediction of brain metastasis in patients with extra-cerebral metastatic breast cancer and risk regression analysis.

PubMed

Genre, Ludivine; Roché, Henri; Varela, Léonel; Kanoun, Dorra; Ouali, Monia; Filleron, Thomas; Dalenc, Florence

2017-02-01

Survival of patients with metastatic breast cancer (MBC) suffering from brain metastasis (BM) is limited and this event is usually fatal. In 2010, the Graesslin's nomogram was published in order to predict subsequent BM in patients with breast cancer (BC) with extra-cerebral metastatic disease. This model aims to select a patient population at high risk for BM and thus will facilitate the design of prevention strategies and/or the impact of early treatment of BM in prospective clinical studies. Nomogram external validation was retrospectively applied to patients with BC and later BM between January 2005 and December 2012, treated in our institution. Moreover, risk factors of BM appearance were studied by Fine and Gray's competing risk analysis. Among 492 patients with MBC, 116 developed subsequent BM. Seventy of them were included for the nomogram validation. The discrimination is good (area under curve = 0.695 [95% confidence interval, 0.61-0.77]). Risk factors of BM appearance are: human epidermal growth factor receptor 2 (HER2) overexpression/amplification, triple-negative BC and number of extra-cerebral metastatic sites (>1). With a competing risk model, we highlight the nomogram interest for HER2+ tumour subgroup exclusively. Graesslin's nomogram external validation demonstrates exportability and reproducibility. Importantly, the competing risk model analysis provides additional information for the design of prospective trials concerning the early diagnosis of BM and/or preventive treatment on high risk patients with extra-cerebral metastatic BC. Copyright © 2016 Elsevier Ltd. All rights reserved.

Self-competence Among Early and Middle Adolescents Affected by Maternal HIV/AIDS

PubMed Central

Marelich, William D.; Murphy, Debra A.; Payne, Diana L.; Herbeck, Diane M.; Schuster, Mark A.

2012-01-01

Adolescent children of mothers with HIV face a host of stressors that place them at increased risk for poor outcomes. Using covariance structure analysis, this study examines adolescent risk outcomes and their relationships to maternal health, as well as the potentially protective factors of family environment and self-competence. The final model indicated that poor maternal health was negatively related to a protective family environment, which in turn was negatively related to adolescent risk outcomes. A protective family environment was also positively related to adolescent self-competence, which was negatively related to adolescent risk outcomes. Implications of the study are discussed, including how these findings can influence interventions aimed at reducing the risk for poor outcomes among adolescent youth with HIV-infected mothers. PMID:22485061

Risk factors for competing noncancer mortality after definitive treatment for advanced-stage head and neck cancer.

PubMed

Kim, Yong Han; Roh, Jong-Lyel; Kim, Sung-Bae; Choi, Seung-Ho; Nam, Soon Yuhl; Kim, Sang Yoon

2018-05-27

Patients with head and neck cancer (HNC) can die of index tumor progression and second tumor or noncancer causes. Here, we investigated the risk factors for competing noncancer mortality (NCM) in a prospective cohort of patients with advanced-stage HNC. A prospective observational study was conducted with 604 patients who underwent definitive treatment for advanced-stage HNC between 2010 and 2015. Main outcomes were NCM and cancer mortality (CM) defined as death from noncancer causes and HNC or second cancers, respectively. Cumulative incidence and cause-specific hazard functions were used to analyze the risk factors of NCM and CM. Age, smoking, Charlson comorbidity index (CCI), performance status, body mass index, rural residence, education and hemoglobin level at diagnosis, and chemotherapy were significantly associated with NCM (all P<0.05). Multivariate analyses showed that age, CCI, and hemoglobin were independent factors of NCM. Age (≥65 years), CCI (≥2), and hemoglobin (<11 g/dL) were related to 4.5-, 3.2-, and 2.7-fold increased adjusted risk of NCM, respectively. Old age, comorbidity, and hemoglobin at diagnosis were independent predictors of NCM. The risk factors could be used to predict noncancer death after definitive treatment for advanced-stage HNC. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Physician leadership is essential to the survival of teaching hospitals.

PubMed

Schwartz, R W; Pogge, C

2000-06-01

Academic medical centers (AMCs) face severe financial constraints because they must now compete directly with private providers that focus exclusively on cost-effective healthcare delivery. Educational and research capacities developed at AMCs have been supported by government and third party payers, but government support is diminishing. Physicians are ill-equipped to respond to market pressures. Analyses of cultural change and restructuring in corporate giants such as Greyhound, IBM and FedEx are relevant to teaching hospitals. To succeed, organizations must flatten hierarchy, empower staff, train leaders, and mobilize intellectual capital. Effective leadership is essential. Physicians must educate themselves on forces impacting the AMC, understand changes needed in the structure and processes of AMC governance and acquire competencies for leadership and management if AMCs are to survive and thrive. Surgeons should acquire competencies that will enable them to become leaders in the process of AMC transformation.

Lymphocyte Nadir and Esophageal Cancer Survival Outcomes After Chemoradiation Therapy.

PubMed

Davuluri, Rajayogesh; Jiang, Wen; Fang, Penny; Xu, Cai; Komaki, Ritsuko; Gomez, Daniel R; Welsh, James; Cox, James D; Crane, Christopher H; Hsu, Charles C; Lin, Steven H

2017-09-01

Host immunity may affect the outcome in patients with esophageal cancer. We sought to identify factors that influenced absolute lymphocyte count (ALC) nadir during chemoradiation therapy (CRT) for esophageal cancer (EC) and looked for clinically relevant associations with survival. 504 patients with stage I-III EC (2007-2013) treated with neoadjuvant or definitive CRT with weekly ALC determinations made during treatment were analyzed. Grade of lymphopenia from ALC nadir during CRT was based on Common Terminology Criteria for Adverse Events version 4.0. Associations of ALC nadir with survival were examined using multivariate Cox proportional hazards analysis (MVA) and competing risks regression analysis. The median follow-up time was 36 months. The incidences of grade 1, 2, 3, and 4 ALC nadir during CRT were 2%, 12%, 59%, and 27%, respectively. The impact was lymphocyte-specific because this was not seen for monocyte or neutrophil count. On MVA, grade 4 ALC nadir (G4 nadir) was significantly associated with worse overall and disease-specific survival outcomes. Predictors of G4 nadir included distal tumor location, definitive CRT, taxane/5-fluorouracil chemotherapy, and photon-based radiation type (vs proton-based). Radiation type strongly influenced the mean body dose exposure, which was a strong predictor for G4 nadir (odds ratio 1.22 per Gray, P<.001). G4 nadir during CRT for EC was associated with poor outcomes, suggesting a role of host immunity in disease control. This observation provides a rationale to prospectively test chemotherapeutic and radiation treatment strategies that may have a lower impact on host immunity. Copyright © 2017 Elsevier Inc. All rights reserved.

Trends in Survival After In-Hospital Cardiac Arrest

PubMed Central

Girotra, Saket; Nallamothu, Brahmajee K.; Spertus, John A.; Li, Yan; Krumholz, Harlan M.; Chan, Paul S.

2012-01-01

BACKGROUND Despite numerous advances in resuscitation care in recent years, it remains unknown whether survival and neurological function after in-hospital cardiac arrest has improved over time. METHODS We identified all adults with an index in-hospital cardiac arrest at 374 hospitals in the Get With The Guidelines-Resuscitation registry between 2000 and 2009. Using multivariable regression, we examined temporal trends in risk-adjusted rates of survival to discharge. Additional analyses explored whether trends: (1) were due to improved survival during the acute resuscitation or post-resuscitation care and (2) occurred at the expense of greater neurological disability among survivors. RESULTS Among 84,625 hospitalized patients with cardiac arrest, 67,135 (79.3%) had an initial rhythm of asystole or pulseless electrical activity while 17,490 (20.7%) had ventricular fibrillation or pulseless ventricular tachycardia. The proportion of cardiac arrests due to asystole or pulseless electrical activity increased over time (P for trend <0.001). Risk-adjusted rates of survival to discharge in the overall cohort increased from 13.7% in 2000 to 22.4% in 2009 (adjusted rate-ratio per 1-year: 1.04, 95% CI [1.02–1.05]; P for trend <0.001). Survival improvement was similar in both rhythm groups and largely due to improved survival from the acute resuscitation (risk-adjusted rates: 42.7% in 2000, 54.1% in 2009; adjusted rate-ratio per 1-year: 1.03, 95% CI [1.02–1.04]; P for trend <0.001). Importantly, rates of neurological disability among survivors decreased over time (risk-adjusted rates: 32.9% in 2000, 28.1% in 2009; P for trend=0.02). CONCLUSIONS Both survival and neurological outcomes after in-hospital cardiac arrest have improved over the past decade. PMID:23150959

Feature selection through validation and un-censoring of endovascular repair survival data for predicting the risk of re-intervention.

PubMed

Attallah, Omneya; Karthikesalingam, Alan; Holt, Peter J E; Thompson, Matthew M; Sayers, Rob; Bown, Matthew J; Choke, Eddie C; Ma, Xianghong

2017-08-03

Feature selection (FS) process is essential in the medical area as it reduces the effort and time needed for physicians to measure unnecessary features. Choosing useful variables is a difficult task with the presence of censoring which is the unique characteristic in survival analysis. Most survival FS methods depend on Cox's proportional hazard model; however, machine learning techniques (MLT) are preferred but not commonly used due to censoring. Techniques that have been proposed to adopt MLT to perform FS with survival data cannot be used with the high level of censoring. The researcher's previous publications proposed a technique to deal with the high level of censoring. It also used existing FS techniques to reduce dataset dimension. However, in this paper a new FS technique was proposed and combined with feature transformation and the proposed uncensoring approaches to select a reduced set of features and produce a stable predictive model. In this paper, a FS technique based on artificial neural network (ANN) MLT is proposed to deal with highly censored Endovascular Aortic Repair (EVAR). Survival data EVAR datasets were collected during 2004 to 2010 from two vascular centers in order to produce a final stable model. They contain almost 91% of censored patients. The proposed approach used a wrapper FS method with ANN to select a reduced subset of features that predict the risk of EVAR re-intervention after 5 years to patients from two different centers located in the United Kingdom, to allow it to be potentially applied to cross-centers predictions. The proposed model is compared with the two popular FS techniques; Akaike and Bayesian information criteria (AIC, BIC) that are used with Cox's model. The final model outperforms other methods in distinguishing the high and low risk groups; as they both have concordance index and estimated AUC better than the Cox's model based on AIC, BIC, Lasso, and SCAD approaches. These models have p-values lower than 0

A hybrid approach of gene sets and single genes for the prediction of survival risks with gene expression data.

PubMed

Seok, Junhee; Davis, Ronald W; Xiao, Wenzhong

2015-01-01

Accumulated biological knowledge is often encoded as gene sets, collections of genes associated with similar biological functions or pathways. The use of gene sets in the analyses of high-throughput gene expression data has been intensively studied and applied in clinical research. However, the main interest remains in finding modules of biological knowledge, or corresponding gene sets, significantly associated with disease conditions. Risk prediction from censored survival times using gene sets hasn't been well studied. In this work, we propose a hybrid method that uses both single gene and gene set information together to predict patient survival risks from gene expression profiles. In the proposed method, gene sets provide context-level information that is poorly reflected by single genes. Complementarily, single genes help to supplement incomplete information of gene sets due to our imperfect biomedical knowledge. Through the tests over multiple data sets of cancer and trauma injury, the proposed method showed robust and improved performance compared with the conventional approaches with only single genes or gene sets solely. Additionally, we examined the prediction result in the trauma injury data, and showed that the modules of biological knowledge used in the prediction by the proposed method were highly interpretable in biology. A wide range of survival prediction problems in clinical genomics is expected to benefit from the use of biological knowledge.

A Hybrid Approach of Gene Sets and Single Genes for the Prediction of Survival Risks with Gene Expression Data

PubMed Central

Seok, Junhee; Davis, Ronald W.; Xiao, Wenzhong

2015-01-01

Accumulated biological knowledge is often encoded as gene sets, collections of genes associated with similar biological functions or pathways. The use of gene sets in the analyses of high-throughput gene expression data has been intensively studied and applied in clinical research. However, the main interest remains in finding modules of biological knowledge, or corresponding gene sets, significantly associated with disease conditions. Risk prediction from censored survival times using gene sets hasn’t been well studied. In this work, we propose a hybrid method that uses both single gene and gene set information together to predict patient survival risks from gene expression profiles. In the proposed method, gene sets provide context-level information that is poorly reflected by single genes. Complementarily, single genes help to supplement incomplete information of gene sets due to our imperfect biomedical knowledge. Through the tests over multiple data sets of cancer and trauma injury, the proposed method showed robust and improved performance compared with the conventional approaches with only single genes or gene sets solely. Additionally, we examined the prediction result in the trauma injury data, and showed that the modules of biological knowledge used in the prediction by the proposed method were highly interpretable in biology. A wide range of survival prediction problems in clinical genomics is expected to benefit from the use of biological knowledge. PMID:25933378

The Analysis of Rush Orders Risk in Supply Chain: A Simulation Approach

NASA Technical Reports Server (NTRS)

Mahfouz, Amr; Arisha, Amr

2011-01-01

Satisfying customers by delivering demands at agreed time, with competitive prices, and in satisfactory quality level are crucial requirements for supply chain survival. Incidence of risks in supply chain often causes sudden disruptions in the processes and consequently leads to customers losing their trust in a company's competence. Rush orders are considered to be one of the main types of supply chain risks due to their negative impact on the overall performance, Using integrated definition modeling approaches (i.e. IDEF0 & IDEF3) and simulation modeling technique, a comprehensive integrated model has been developed to assess rush order risks and examine two risk mitigation strategies. Detailed functions sequence and objects flow were conceptually modeled to reflect on macro and micro levels of the studied supply chain. Discrete event simulation models were then developed to assess and investigate the mitigation strategies of rush order risks, the objective of this is to minimize order cycle time and cost.

None of Us Will Get Out of Here Alive: The Intersection of Perceived Risk for HIV, Risk Behaviors and Survival Expectations among African American Emerging Adults.

PubMed

Edwards, Lorece V; Lindong, Ian; Brown, Lawrence; Hawkins, Anita S; Dennis, Sabriya; Fajobi, Olaoluwa; Rowel, Randolph; Braithwaite, Ronald; Sydnor, Kim D

2017-01-01

The Human Immunodeficiency Virus (HIV) significantly affects minority emerging adults, among whom the rate of new diagnoses is high and health disparities are more pronounced. Importantly, emerging adults today have limited knowledge of the earlier toll of the virus when it was identified as a killer. Among this population, perceptions of risk for HIV are low and sexual risk taking behaviors are high. The Get SMART Project is a behavioral intervention aimed to provide re-purposed HIV, alcohol, and substance abuse prevention education and HIV testing to African American emerging adults ages 18-24. The project was guided by the Health Belief Model, Community Promise, and Training for Institutional Procedures. Findings revealed that HIV testing is low. Marijuana and alcohol are drugs of choice. Emerging adults do not see themselves at risk for HIV, although they engaged in high-risk behaviors. Additionally, survival expectations influence behavior risk.

HEMORRHAGIC CYSTITIS AFTER ALLOGENEIC HEMATOPOIETIC CELL TRANSPLANTATION: RISK FACTORS, GRAFT SOURCE, AND SURVIVAL

PubMed Central

Lunde, Laura E.; Dasaraju, Sandhyarani; Cao, Qing; Cohn, Claudia S.; Reding, Mark; Bejanyan, Nelli; Trottier, Bryan; Rogosheske, John; Brunstein, Claudio; Warlick, Erica; Young, Jo Anne H.; Weisdorf, Daniel J.; Ustun, Celalettin

2017-01-01

Although hemorrhagic cystitis (HC) is a common complication of allogeneic hematopoietic cell transplantation (alloHCT), its risk factors and effects on survival are not well-known. We evaluated HC in a large cohort (n=1321, 2003 – 2012) receiving alloHCT from all graft sources, including umbilical cord blood (UCB). We compared HC patients with non-HC (control) patients and examined clinical variables at HC onset and resolution. Of these 1321 patients, 219 (16.6%) developed HC at a median of 22 days after alloHCT. BK viruria was detected in 90% of 109 tested HC patients. Median duration of HC was 27 days. At the time of HC diagnosis, acute graft-versus-host disease (GVHD), fever, severe thrombocytopenia, and steroid use were more frequent than at the time of HC resolution. In univariate analysis, male sex, age <20 years, myeloablative conditioning with cyclophosphamide and acute GVHD were associated with HC. In multivariate analysis, HC was significantly more common in males and HLA-mismatched UCB graft recipients. Severe grade HC (grade III–IV) was associated with increased treatment-related mortality (TRM) but not with overall survival at 1 year. HC remains hazardous and therefore better prophylaxis and early interventions to limit its severity are still needed. PMID:26168069

The robust corrective action priority-an improved approach for selecting competing corrective actions in FMEA based on principle of robust design

NASA Astrophysics Data System (ADS)

Sutrisno, Agung; Gunawan, Indra; Vanany, Iwan

2017-11-01

In spite of being integral part in risk - based quality improvement effort, studies improving quality of selection of corrective action priority using FMEA technique are still limited in literature. If any, none is considering robustness and risk in selecting competing improvement initiatives. This study proposed a theoretical model to select risk - based competing corrective action by considering robustness and risk of competing corrective actions. We incorporated the principle of robust design in counting the preference score among corrective action candidates. Along with considering cost and benefit of competing corrective actions, we also incorporate the risk and robustness of corrective actions. An example is provided to represent the applicability of the proposed model.

Venous thromboembolism in patients with acute leukemia: incidence, risk factors, and effect on survival

PubMed Central

Ku, Grace H.; White, Richard H.; Chew, Helen K.; Harvey, Danielle J.; Zhou, Hong

2009-01-01

A population-based cohort was used to determine the incidence and risk factors associated with development of venous thromboembolism (VTE) among Californians diagnosed with acute leukemia between 1993 to 1999. Principal outcomes were deep vein thrombosis in both the lower and upper extremities, pulmonary embolism, and mortality. Among 5394 cases with acute myelogenous leukemia (AML), the 2-year cumulative incidence of VTE was 281 (5.2%). Sixty-four percent of the VTE events occurred within 3 months of AML diagnosis. In AML patients, female sex, older age, number of chronic comorbidities, and presence of a catheter were significant predictors of development of VTE within 1 year. A diagnosis of VTE was not associated with reduced survival in AML patients. Among 2482 cases with acute lymphoblastic leukemia (ALL), the 2-year incidence of VTE in ALL was 4.5%. Risk factors for VTE were presence of a central venous catheter, older age, and number of chronic comorbidities. In the patients with ALL, development of VTE was associated with a 40% increase in the risk of dying within 1 year. The incidence of VTE in acute leukemia is appreciable, and is comparable with the incidence in many solid tumors. PMID:19088376

Survival Outcomes of Whole-Pelvic Versus Prostate-Only Radiation Therapy for High-Risk Prostate Cancer Patients With Use of the National Cancer Data Base

DOE Office of Scientific and Technical Information (OSTI.GOV)

Amini, Arya; Jones, Bernard L.; Yeh, Norman

Purpose/Objectives: The addition of whole pelvic (WP) compared with prostate-only (PO) radiation therapy (RT) for clinically node-negative prostate cancer remains controversial. The purpose of our study was to evaluate the survival benefit of adding WPRT versus PO-RT for high-risk, node-negative prostate cancer, using the National Cancer Data Base (NCDB). Methods and Materials: Patients with high-risk prostate cancer treated from 2004 to 2006, with available data for RT volume, coded as prostate and pelvis (WPRT) or prostate alone (PO-RT) were included. Multivariate analysis (MVA) and propensity-score matched analysis (PSM) were performed. Recursive partitioning analysis (RPA) based on overall survival (OS) usingmore » Gleason score (GS), T stage, and pretreatment prostate-specific antigen (PSA) was also conducted. Results: A total of 14,817 patients were included: 7606 (51.3%) received WPRT, and 7211 (48.7%) received PO-RT. The median follow-up time was 81 months (range, 2-122 months). Under MVA, the addition of WPRT for high-risk patients had no OS benefit compared with PO-RT (HR 1.05; P=.100). On subset analysis, patients receiving dose-escalated RT also did not benefit from WPRT (HR 1.01; P=.908). PSM confirmed no survival benefit with the addition of WPRT for high-risk patients (HR 1.05; P=.141). In addition, RPA was unable to demonstrate a survival benefit of WPRT for any subset. Other prognostic factors for inferior OS under MVA included older age (HR 1.25; P<.001), increasing comorbidity scores (HR 1.46; P<.001), higher T stage (HR 1.17; P<.001), PSA (HR 1.81; P<.001), and GS (HR 1.29; P<.001), and decreasing median county household income (HR 1.15; P=.011). Factors improving OS included the addition of androgen deprivation therapy (HR 0.92; P=.033), combination external beam RT plus brachytherapy boost (HR 0.71; P<.001), and treatment at an academic/research institution (HR 0.84; P=.002). Conclusion: In the largest reported analysis of WPRT for

Autonomy and Firefighting: Perceived Competence and Stress.

PubMed

Chiang, Evelyn S; Baley, John; Ponder, Joy; Padilla, Miguel A

2016-12-01

In workplace settings, autonomy is implicated in employee motivation as well as supervisor autonomy support. As a profession of risk, firefighters may experience greater levels of stress. A self-determination paradigm was applied to the firefighter workplace. Of particular interest were perceived competence (to perform job duties) and the experience of stress. Firefighters' levels of autonomous and controlled regulation were surveyed, along with their perceptions of the autonomy support of their immediate supervisor. Autonomous regulation was positively related to perceived competence, whereas controlled regulation was negatively related. Higher levels of controlled regulation were also connected with greater stress. In contrast, greater perceived autonomy support was associated with decreased stress. Both perceived competence and stress are related to firefighter motivation and autonomy support. Recommendations are offered to increase autonomy support by chief officers.

Discrete improvement in racial disparity in survival among patients with stage IV colorectal cancer: a 21-year population-based analysis.

PubMed

Castleberry, A W; Güller, U; Tarantino, I; Berry, M F; Brügger, L; Warschkow, R; Cerny, T; Mantyh, C R; Candinas, D; Worni, M

2014-06-01

Recently, multiple clinical trials have demonstrated improved outcomes in patients with metastatic colorectal cancer. This study investigated if the improved survival is race dependent. Overall and cancer-specific survival of 77,490 White and Black patients with metastatic colorectal cancer from the 1988-2008 Surveillance Epidemiology and End Results registry were compared using unadjusted and multivariable adjusted Cox proportional hazard regression as well as competing risk analyses. Median age was 69 years, 47.4 % were female and 86.0 % White. Median survival was 11 months overall, with an overall increase from 8 to 14 months between 1988 and 2008. Overall survival increased from 8 to 14 months for White, and from 6 to 13 months for Black patients. After multivariable adjustment, the following parameters were associated with better survival: White, female, younger, better educated and married patients, patients with higher income and living in urban areas, patients with rectosigmoid junction and rectal cancer, undergoing cancer-directed surgery, having well/moderately differentiated, and N0 tumors (p < 0.05 for all covariates). Discrepancies in overall survival based on race did not change significantly over time; however, there was a significant decrease of cancer-specific survival discrepancies over time between White and Black patients with a hazard ratio of 0.995 (95 % confidence interval 0.991-1.000) per year (p = 0.03). A clinically relevant overall survival increase was found from 1988 to 2008 in this population-based analysis for both White and Black patients with metastatic colorectal cancer. Although both White and Black patients benefitted from this improvement, a slight discrepancy between the two groups remained.

Arthritis and the Risk of Falling Into Poverty: A Survival Analysis Using Australian Data.

PubMed

Callander, Emily J; Schofield, Deborah J

2016-01-01

Low income is known to be associated with having arthritis. However, no longitudinal studies have documented the relationship between developing arthritis and falling into poverty. The purpose of this study was to evaluate Australians who developed arthritis to determine if they had an elevated risk of falling into poverty. Survival analysis using Cox regression models was applied to nationally representative, longitudinal survey data obtained between January 1, 2007 and December 31, 2012 from Australian adults who were ages 21 years and older in 2007. The hazard ratio for falling into income poverty was 1.08 (95% confidence interval [95% CI] 1.06-1.09) in women who were diagnosed as having arthritis and 1.15 (95% CI 1.13-1.16) in men who were diagnosed as having arthritis, as compared to those who were never diagnosed as having arthritis. The hazard ratio for falling into multidimensional poverty was 1.15 (95% CI 1.14-1.17) in women who were diagnosed as having arthritis and 1.88 (95% CI 1.85-1.91) in men who were diagnosed as having arthritis. Developing arthritis increases the risk of falling into income poverty and multidimensional poverty. The risk of multidimensional poverty is greater than the risk of income poverty. Given the high prevalence of arthritis, the condition is likely an overlooked driver of poverty. © 2016, American College of Rheumatology.

Competent Psychopharmacology

PubMed Central

Gardner, David M

2014-01-01