Competing Risk Survival Analysis Research Articles

Women's beliefs about methods and contraceptive discontinuation: Results from a prospective study from Nairobi and Homa Bay counties in Kenya.

Rates of contraceptive discontinuation are high in many low and middle countries contributing to unmet need for contraception and other adverse reproductive health outcomes. Few studies have investigated how women's beliefs about methods and strength of fertility preferences affect discontinuation rates. This study examines this question using primary data collected in Nairobi and Homa Bay counties in Kenya. We used data from two rounds of a longitudinal study of married women ages 15-39 years (2,812 and 2,424 women from Nairobi and Homa Bay respectively at round 1). Information on fertility preferences, past and current contraceptive behavior, and method-related beliefs about six modern contraceptive methods were collected, along with a monthly calendar of contraceptive use between the two interviews. The analysis focused on discontinuation of the two most commonly used methods in both sites, injectables and implants. We carry out competing risk survival analysis to identify which method related beliefs predict discontinuation among women using at the first round. The percentages of episodes discontinued in the 12 months between the two rounds was 36%, with a higher rate of discontinuation in Homa Bay (43%) than in the Nairobi slums (32%) and higher for injectables than implants. Method related concerns and side effects were the major self-reported reasons for discontinuation in both sites. The competing risk survival analysis showed that the probability of method related discontinuation of implants and injectables was significantly lower among respondents who believed that the methods do not cause serious health problems (SHR = 0.78, 95% CI: 0.62-0.98), do not interfere with regular menses (SHR = 0.76, 95% CI: 0.61-0.95) and do not cause unpleasant side effects (SHR = 0.72, 95% CI 0.56-0.89). By contrast, there were no net effects of three method related beliefs that are commonly cited as obstacles to contraceptive use in African societies: safety for long-term use, ability to have children after stopping the method, and the approval of the husband. This study is unique in its examination of the effect of method-specific beliefs on subsequent discontinuation for a method-related reason, using a longitudinal design. The single most important result is that concerns about serious health problems, which are largely unjustified and only moderately associated with beliefs about side effects, are a significant influence on discontinuation. The negative results for other beliefs show that the determinants of discontinuation differ from the determinants of method adoption and method choice.

Oxidized Zirconium Versus Cobalt Chromium for Primary TKA: No Difference in Midterm Revision Rates From the American Joint Replacement Registry.

Cobalt chromium (CoCr) is the most commonly used material in TKA; however, the use of oxidized zirconium (OxZr) implants has increased. The advantages to this material demonstrated in basic science studies have not been borne out in clinical studies to date. In the setting of the American Joint Replacement Registry (AJRR), how do revision rates differ between CoCr and OxZr after primary TKA? The AJRR was accessed for all primary TKAs performed between 2012 and 2020 for osteoarthritis, resulting in 441,605 procedures (68,506 with OxZr and 373,099 with CoCr). The AJRR is the largest joint replacement registry worldwide and collects procedure-specific details, making it ideal for large-scale comparisons of implant materials in the United States. Competing risk survival analyses were used to evaluate the all-cause revision rates of primary TKAs, comparing CoCr and OxZr implants. Data from the Centers for Medicare and Medicaid Services claims from 2012 to 2017 were also cross-referenced to capture additional revisions from other institutions. Revision rates were tabulated and subclassified by indication. Multivariate Cox regression was used to account for confounding variables such as age, gender, region, and hospital size. After controlling for confounding variables, there were no differences between the OxZr and CoCr groups in terms of the rate of all-cause revision at a mean follow-up of 46 ± 23 months and 44 ± 24 months for CoCr and OxZr implants, respectively (hazard ratio 1.055 [95% confidence interval 0.979 to 1.137]; p = 0.16) The univariate analysis demonstrated increased rates of revisions for pain and instability in the OxZr group (p = 0.003 and p < 0.001, respectively). These findings suggest there is no difference in all-cause revision between OxZr and CoCr implants in the short-term to mid-term. However, further long-term in vivo studies are needed to monitor the safety and all-cause revision rate of OxZr implants compared with those of CoCr implants. OxZr implants may be favorable in patients who have sensitivity to metal. Despite similar short-term to mid-term all-cause revision rates to CoCr implants, because of the limitations of this study, definitive recommendations for or against the use of OxZr cannot be made. Level III, therapeutic study.

Long-Term Suicidal Ideation Profiles in Late-Life Depression and Their Association With Suicide Attempt or Death by Suicide.

Objective: In young and middle-aged adults, suicidal ideation is an important predictor of prospective suicide attempts, but its predictive power in late life remains unclear. In this study, we used Latent Profile Analysis (LPA) in a cohort of depressed older adults to identify distinct ideation profiles and their clinical correlates and test their association with risk of suicidal behavior longitudinally. Methods: A total of 337 depressed older adults (aged 50–93 years) were assessed for suicidal ideation and behavior for up to 14 years (median = 3 years), at least once per year (study period: 2002–2020). LPA was used, which derived 4 profiles of ideation scores based on subject-level aggregates. Groups were compared using analysis of variance (ANOVA) and χ2 tests at baseline and competing risk survival analysis during follow-up. Results: Ideation showed significant decline over time, on average (P < .001). LPA identified 4 suicidal ideation profiles. Risk of suicide attempt/death was higher for chronic severe ideators (age-adjusted hazard ratio = 5.75; 95% CI, 2.25–14.7; P < .001) and highly variable ideators (HR = 3.21; 95% CI, 1.03–10.1; P = .045) compared to fast-remitting ideators, despite comparable current ideation severity at baseline. Fast-remitting ideators had higher risk than low/non-ideators with no attempts or suicides (P < .001). Chronic severe ideators displayed the most severe dysfunction across personality, social characteristics, and impulsivity measures, whereas highly variable and fast-remitting ideators displayed specific deficits. Conclusions: Assessing suicidal ideation over months/years has clinical relevance, as it enabled the identification of distinct ideation patterns associated with substantive differences in clinical presentation and risk of future suicidal behavior despite similar ideation levels at baseline.

Intracranial hemorrhage after recombinant tissue plasminogen Activator: The competing risks survival analysis

Intravenous recombination of tissue plasminogen activator is a recommended treatment for patients with ischemic stroke. However, its side effects are associated with an increased risk of intracerebral hemorrhage. This study aimed to verify the factors associated with hemorrhagic transformation, classified by the clinical system, with time from onset to treatment. The medical records of patients with ischemic stroke who underwent recombination tissue plasminogen activator therapy at Siriraj Hospital, Thailand from October 2005 to June 2017 were included in this study. A sub-distribution hazard function by Fine-Gray model was applied to the data. Of the 241 records, 12.9 % presented with intracerebral hemorrhage, 4.6 % were symptomatic, and 8.3% were asymptomatic. The factors associated with increased risks of symptomatic intracerebral hemorrhage were older age (6.38–7.62 times higher than that compared with patients of younger age), high initial blood glucose (14.5 times higher), and systolic blood pressure (7.84 times higher). The factors associated with the asymptomatic type, in comparison with the risk of the symptomatic type, were older age (1.67–9.46 times higher than that compared with patients of younger stroke), higher stroke severity (1.39 times higher), and history of aspirin use (1.79 times higher). Modern technology and medical innovations cannot change the factors affecting intracranial hemorrhage. Screening methods for identifying hemorrhagic transformation after recombinant tissue plasminogen activator are important for patients with ischemic stroke.

Individual factors predict substance use treatment course patterns among patients in community-based substance use disorder treatment.

Substance use disorders (SUDs) usually involve a complex natural trajectory of recovery alternating with symptom reoccurrence. This study examined treatment course patterns over time in a community SUD clinic. We examined depressive symptoms level, primary SUD assigned at each admission, and lifetime misuse of multiple substances as potential risk factors for premature treatment termination and subsequent treatment readmission. De-identified longitudinal data were extracted from charts of 542 patients from an SUD treatment center. Survival analysis methods were applied to predict two time-to-event outcomes: premature treatment termination and treatment readmission. Primary opioid (vs alcohol) use disorder diagnosis at admission was associated with higher hazard of premature termination (HR = 1.91, p<0.001). The interaction between depressive symptoms level and substance use status (multiple vs single use) on treatment readmission was significant (p = 0.024), such that higher depressive symptoms level was predictive of readmission only among those with a history of single substance use (marginally significant effect). Lifetime use of multiple (vs single) substances (HR = 1.55, p = 0.002) and age (HR = 1.01, p = 0.019) predicted increased hazard of readmission. Findings did not support a universal role for depressive symptoms level in treatment course patterns. Primary SUD diagnosis, age, and history of substance misuse can be easily assessed and incorporated into treatment planning to support SUD patients and families. This study is the first to our knowledge that afforded a stringent test of these relationships and their interactions in a time-dependent, recurrent event, competing risks survival analysis examining both termination and readmission patterns utilizing a real-world clinic-based sample.

Radiation after radical prostatectomy in elderly patients - a SEER database-derived competing-risk survival analysis of propensity score-matched age groups.

This study aimed to evaluate cancer-specific (CSM) and other-cause mortality (OCM) in elderly patients with prostate cancer treated with radical prostatectomy (RP) and postoperative radiotherapy (RT). The Surveillance, Epidemiology, and End Results (SEER) database was searched for clinically non-metastatic prostate cancer (PCa) treated with RT after RP between 2010 and 2015. Patients were stratified according to age groups and underwent propensity score (PS) matching. The Kaplan-Meier method and competing-risk Cox regression (CRR) were used for survival analysis. In total, 5385 patients were analysed, including 738 (13.7%) elderly patients (≥70 years old) and 4647 (86.29%) younger individuals. A total of 54 (7.32%) and 69 (9.35%) patients aged ≥70 years died due to PCa and competing reasons, respectively. Among younger patients these included 275 (5.92%) and 208 (4.48%) deaths, respectively. At a median follow-up of 80 months, patients ≥70 years old had significantly shorter OCM (p <0.0001) than PS-matched younger controls without significant impairment of cancer-specific survival when compared to controls (p = 0.19). In CRR analysis older patients were at significantly higher risk of OCM (HR = 2.24, p = 0.0002 and HR = 3.3, p = 0.011 for patients aged ≥70 and ≥75 years, respectively). Simultaneously, the CRR revealed no increased risk of CSM for patients older than 70 and 75 years (HR = 1.2, p = 0.33 and HR = 1.53, p = 0.29, respectively). Elderly patients with PCa are at high risk of dying due to competing reasons, which might prevent the survival benefit of RT after RP. Selection for salvage and adjuvant RT in these individuals should be cautious.

Bidirectional Associations Between Asthma and Types of Mental Disorders

Asthma and mental disorders frequently co-occur. Studies of their comorbidity have generally focused on associations related to a subset of mental disorders. To estimate bidirectional associations between asthma and 10 broad types of mental disorders. In a population-based cohort study, including all individuals born in Denmark between 1955 and 2011 (N= 5,053,471), we considered diagnoses of comorbid mental disorders among those with asthma, and vice versa, between 2000 and 2016. We used Cox regression models to calculate overall and time-dependent hazard ratios for mental disorder-asthma pairs and competing-risks survival analyses to estimate absolute risks. Altogether, 376,756 individuals were identified as having an incident mental disorder and 364,063 incident asthma during follow-up. An increased risk was seen for all bidirectional mental disorder-asthma pairs. Following an asthma diagnosis, adjusted hazard ratios for different subsequent mental disorders ranged from 1.75 (95% CI, 1.64-1.87) for organic disorders to 2.75 (95% CI, 2.69-2.81) for personality disorders. Following a prior mental disorder diagnosis, hazard ratios for asthma ranged from 1.06 (95% CI, 1.00-1.12) for developmental disorders to 2.33 (95% CI, 2.28-2.39) for substance use disorders. Risks varied with time since prior disorder diagnosis but remained elevated. Cumulative incidence of (1) asthma after a mental disorder and (2) a mental disorder after asthma was higher in those with prior disorders than in matched reference groups. Our findings provide evidence of bidirectional associations between asthma and each of the mental disorder types, suggesting possible shared etiological factors or pathophysiologic processes.

Prognostic implications of inactive status in highest urgency categories among heart transplantation recipients in the new donor heart allocation system.

Patients on the waiting list for heart transplantation (HT) can become inactive or made status seven because of medical reasons, such adverse events, complications, or psychosocial circumstances. If the condition that caused the inactivation is resolved, patients are re- activated. Information about the prognostic implications of Status 7 in the new donor heart allocation system has not been described. To bridge this knowledge gap, we performed an analysis of the United Network of Organ Sharing (UNOS) registry. Data on adult patients who underwent HT between October 18th, 2018 and October 2021, were queried from the UNOS registry. The main outcomes were post- transplant all-cause mortality, 1-year all-cause mortality and treated acute rejection. Since re-transplantation is a competing event for all-cause mortality, we performed competing risk survival analysis and reported sub distribution hazard ratios (SHR) from the Fine and Gray model to examine the relationship between inactive status and all-cause mortality. A total of 5267 adult patients underwent HT and were previously listed as Status 1 or Status 2 in the new allocation system. We identified 946 HT recipients temporarily inactivated while on HT list (18%). The number of temporarily inactive patients remained stable since the implementation of the new donor allocation system (p=.37). Approximately, two-thirds of temporarily inactive patients (65.9%) were inactivated for being too sick, whereas other frequent justifications for inactivity included left ventricular assist device implantation (7.8%) and insurance related issues (4.8%). Temporarily inactive HT recipients were more likely to be African Americans, males, have a higher body mass index (BMI) and significantly longer waiting time (391.6±600vs. 72.3±223 days, p<.001) compared with never inactivated patients. In the unadjusted analyses 30-day mortality did not differ between groups, but both 1-year and overall all-cause mortality was significantly higher in temporarily inactive patients (1-year: SHR: 1.3; 95% confidence intervals [CI]: 1.03, 1.64; p=.028, overall mortality SHR: 1.31; 95% CI: 1.06, 1.64; p=.014). After adjustment for donor and recipient characteristics, a trend towards higher 1-year and overall mortality remained (1-year: SHR 1.32; 95% CI .99, 1.76, p=.006, overall mortality SHR: 1.29; 95% CI: .98-1.68, p=.065). No differences in treated acute allograft rejection at 1 year were found between groups. Temporary inactive status while waiting for HT occurs in approximately one in five HT recipients listed in higher urgency categories after the implementation of the new allocation system. A signal of adverse long-term outcomes was found, and this could be explained by differences in recipient characteristics. Further research is required to elucidate pathways involved and possible implications for clinical practice.

External Validation of the Skin and UV Neoplasia Transplant Risk Assessment Calculator (SUNTRAC) in a Large European Solid Organ Transplant Recipient Cohort

The Skin and UV Neoplasia Transplant Risk Assessment Calculator (SUNTRAC) tool has been developed in the US to facilitate the identification of solid organ transplant recipients (SOTRs) at a higher risk of developing skin cancer. However, it has not yet been validated in populations other than the one used for its creation. To provide an external validation of the SUNTRAC tool in different SOTR populations. This retrospective external validation prognostic study used data from a prospectively collected cohort of European SOTRs from transplant centers at teaching hospitals in the Netherlands (1995-2016) and Spain (2011-2021). Participants were screened and followed up at dermatology departments. Data were analyzed from September to October 2021. The discrimination ability of the SUNTRAC tool was assessed via a competing risk survival analysis, cumulative incidence plots, and Wolbers concordance index. Calibration of the SUNTRAC tool was assessed through comparison of projected skin cancer incidences. Skin cancer diagnoses included squamous cell carcinoma, basal cell carcinoma, melanoma, and Merkel cell carcinoma. A total of 3421 SOTRs (median age at transplant, 53 [quartile 1: 42; quartile 3: 62] years; 2132 [62.3%] men) were assessed, including 72 Asian patients (2.1%), 137 Black patients (4.0%), 275 Latinx patients (8.0%), 109 Middle Eastern and North African patients (3.2%), and 2828 White patients (82.7%). With a total of 23 213 years of follow-up time, 603 patients developed skin cancer. The SUNTRAC tool classified patients into 4 groups with significantly different risks of developing skin cancer during follow-up. Overall, the relative rate for developing skin cancer estimated using subdistribution hazard ratios (SHRs) and using the low-risk group as the reference group, increased according to the proposed risk group (medium-risk group: SHR, 6.8 [95% CI, 3.8-12.1]; P < .001; high-risk group: SHR, 15.9 [95% CI, 8.9-28.4]; P < .001; very-high-risk group: SHR, 54.8 [95% CI, 29.1-102.9]; P < .001), with a concordance index of 0.72. Actual skin cancer incidences were similar to those predicted by the SUNTRAC tool (5-year skin cancer cumulative incidence for medium-risk group: predicted, 6.2%; observed, 7.0%). The findings of this external validation prognostic study support the use of the SUNTRAC tool in European populations for stratifying SOTRs based on their skin cancer risk and also detecting patients at a high risk of developing skin cancer. This can be helpful in prioritizing and providing better screening and surveillance for these patients.

Actual over 3-year survival after stereotactic body radiation therapy in patients with unresectable intrahepatic cholangiocarcinoma.

As a non-invasive treatment, stereotactic body radiation therapy (SBRT) has been an emerging and effective option for patients with unresectable intrahepatic cholangiocarcinoma (ICC). The Cyber Knife has an SBRT system, which can realize real-time tracking of tumors during treatment. It can protect the surrounding normal liver tissue while the tumor gets the therapeutic dose. The purpose of this study was to evaluate the factors affecting the local control rate for patients after SBRT treatment, and to predict the factors affecting survival rates, then to report the 3-year actual survival rates after treatment and identify the influencing factors of 3-year survival rate. We conducted a long-term follow-up of 43 patients with unresectable intrahepatic cholangiocarcinoma who underwent Cyber Knife in our hospital from January 2016 to December 2018. Regular medical check-ups were performed every 2-3 months after SBRT to evaluated the effect of treatment. The median follow-up time was 15 months (4-78 months), and the median progression-free survival (PFS) was 6 months (95% CI, 2.788-9.212) and the median overall survival (OS) was 12 months (95% CI, 3.434-20.566), respectively. Based on modified Response Evaluation and Criteria in Solid Tumor (mRECIST), response rate (RR) and disease control rate (DCR) of SBRT in unresectable ICC were 55.2% and 86%. The 1-, 2- and 3-years OS rate were 51.2%, 32.6% and 23.3%. Multivariate analysis based on competing risk survival analysis identified that patients with multiple nodules, large diameter, high level of CA199 and CEA, poor ECOG performance status had worse overall survival (p<0.05). Patients who survived ≥3 years had significantly lower levels of CEA, CA199, smaller tumor diameters and lower number of lesions (p<0.05). The SBRT might be a candidate option for patients who unable to perform surgery. The rate of 3-year survival after SBRT for unresectable ICC can be expected with 23.3%.

PSOR3 Presentation Time: 11:40 AM: The Role of CAPRA Score as a Predictor of Outcomes in High-Risk Prostate Cancer Patients Treated with EBRT Plus HDR Brachytherapy Boost: A 20-year Single-Institution Experience

<h3>Purpose</h3> The study aimed to report clinical outcomes of high-risk prostate cancer (PCa) patients treated with external beam radiation therapy (EBRT) and high dose-rate boost (HDRB) according to CAPRA score. <h3>Material and Methods</h3> The study sample consisted of 361 high-risk PCa patients stratified according to D'Amico classification and treated with EBRT and HDRB and antiandrogen therapy (ADT) between 1999 and 2016. We conducted retrospective competing-risk survival analyses to compare individuals with a CAPRA score lesser than or equal to five and greater than five on biochemical recurrence (BCR) and metastasis incidence. Kaplan-Meier analysis was performed to assess overall survival (OS). Subsequently, we used ROC curves to compare the performance of the CAPRA model to the MSKCC stratification tool on BCR and metastasis incidence. <h3>Results</h3> The mean age of the patients at treatment time was 69.6±7.3 years. The median follow-up was 55.5 months. Of the 361 individuals, 52,4 % (n=189) had a CAPRA score above five. In comparison to individuals with a CAPRA score lesser than or equal to five, individuals with a CAPRA score above five were deemed at higher risk of BCR (sHR = 2.74, 95% CI: 1.12-6.66, p=0.027) and demonstrated a tendency towards significance in their metastasis incidence trend (sHR 2.33 95% CI: 0.89-6.12, p = 0.085). For 10-year OS, there was a HR for mortality of 1.89 (95% CI: 1.04-3.43, p=0.036) for individuals with a CAPRA score above five. There was no significant difference between either risk stratification strategy in ROC curves analysis. <h3>Conclusions</h3> The data suggest that patients' tumours classified as high-risk using the CAPRA score correlated with a higher risk of BCR, metastasis, and mortality when compared to lower-risk tumours. Further studies are needed to validate the use of the CAPRA score to predict cancer-specific mortality (CSM) as an initial risk stratification tool.

Recidivism among People Convicted of Gun Offenses: A Call to Better Leverage Reentry Resources to Decrease Gun Violence

This study provides a primary step towards exploring whether rehabilitation efforts informed by the risk, needs, responsivity approach should be leveraged to decrease gun violence. Through the use of competing risks survival analyses, we assess the gun offense recidivism patterns of people released from prison that do (n = 1,158) and do not (n = 9,868) have gun crime conviction histories. We then explore whether gun offense recidivism increases along with actuarially based risk, how gun offense histories impact the odds of receiving community-based programming during the transition from prison to the community, and, in turn, whether programming impacts gun offending recidivism. Findings indicate that people with a history of gun offense convictions are at more than twice the hazard of committing gun offenses than similarly situated people without such histories. Predicted subhazards of recidivism and magnitudes of differences between offense history groups increase substantially as actuarially assessed risk for recidivism increases. However, predicted probabilities of receipt of community-based programming do not significantly differ between the groups with and without gun offense histories, and recidivism hazards did not meaningfully differ between those that do and do not receive community-based programs despite their gun offending histories. The results illuminate a need to expand reentry-based services towards addressing the criminogenic needs of people previously convicted of gun offenses.

Etoposide treatment in secondary hemophagocytic syndrome: impact on healthcare-associated infections and survival

BackgroundEtoposide remains the cornerstone of symptomatic management of critically ill patients with secondary hemophagocytic syndrome (sHS). Risk of healthcare-associated infections (HAIs) in this setting with etoposide has never been assessed. We sought to evaluate the association between etoposide administration, HAIs occurrence and survival in critically ill adult patients with sHS. In this retrospective single-center study conducted in a university hospital ICU between January 2007 and March 2020, all consecutive patients with sHS were included. HAIs were defined as any microbiologically documented infection throughout ICU stay. Competing risk survival analysis was performed to determine factors associated with HAIs. Propensity score-based overlap weighting was performed to adjust for factors associated with etoposide use.Results168 patients with a median age of 49 [38, 59] were included. Forty-three (25.6%) patients presented with at least 1 microbiologically documented HAI throughout ICU stay. After adjustment, cumulative incidence of HAI was higher in patients receiving etoposide (p = 0.007), while survival was unaffected by etoposide status (p = 0.824). By multivariable analysis, etoposide treatment was associated with a higher incidence of HAIs (sHR 3.75 [1.05, 6.67]), whereas no association with survival (sHR 0.53 [0.20, 1.98]) was found. Other factors associated with increased mortality after adjustment included age, immunodepression, male sex, SOFA score > 13, and occurrence of HAI.ConclusionsIn patients with sHS, etoposide treatment is independently associated with increased occurrence of HAIs, whereas no association with survival was found. Intensivists should be aware of increased infectious risk, to promptly detect and treat infections in this specific setting. Studies to assess benefits from prophylactic anti-infectious agents in this setting are warranted and the lack of benefit of etoposide on survival needs to be interpreted cautiously.

Risk of arterial thromboembolism in patients with concomitant atrial fibrillation and cancer: a systematic review and meta-analysis

Abstract Background/Introduction Atrial fibrillation (AF) and cancer often co-exist and have been independently associated with increased risk of arterial thromboembolism (TE), all cause death and bleeding; however, no cumulative data exist regarding the clinical course of AF patients with comorbid cancer. Purpose The aim of this systematic review and meta-analysis is to synthesize the available data regarding the incidence of major adverse cardiovascular events in AF patients in association with concurrent cancer. Methods The composite outcome of any TE (ischemic stroke, transient ischemic attack, or arterial thrombosis) was defined as the primary study outcome, while all-cause mortality and major or clinically relevant non-major bleeding occurrence as the secondary ones. Literature search was conducted in PubMed (MEDLINE), WebOfScience, Scopus, CENTRAL, OpenGrey, and EThOS databases. A random-effects model meta-analysis was performed. Subgroup analyses were conducted assessing the effect of active cancer history and various cancer subtypes on the outcomes of interest. Meta-regression analyses were also performed to examine the relative impact of CHA2DS2VASC and HASBLED prognostic scores on the risk of TE and bleeding, respectively. Results Overall 17 studies were included in our analysis, encompassing a total of 3,151,861 AF patients. Comorbid cancer was non-significantly associated with lower odds of TE than AF alone (pooled odds ratio (pOR) = 0.85, 95% confidence interval (CI): 0.69–1.03, I2=87%). The likelihood for all-cause death and bleeding occurrence was significantly higher in AF patients with cancer (pOR = 2.27, 95% CI: 1.69–3.06, I2=99%); pOR = 1.58, 95% CI: 1.26–1.97, I2=97% respectively) compared to those without cancer. Subgroup analysis on active cancer status did not yield any substantial difference, marginally improving the heterogeneity of our analysis. The highest all-cause mortality likelihood was observed in Liver-Pancreas-Gallbladder category (pOR = 10.58, 95% CI: 4.69–23.88, I2=98%) while the highest bleeding likelihood was encountered in Genitourinary cancer (pOR = 1.90, 95% CI: 1.42–2.55, I2=71.9%). The performed meta-regression analyses did not yield any significant results. Conclusions Our meta-analysis of 17 eligible studies demonstrated that cancer does not seem to be associated with increased risk of TE, while with increased all-cause death and bleeding occurrence in AF patients. This correlation might be explained by higher cancer-driven mortality rates (competing risk), many cases of TE being left undiagnosed within the scope of palliative cancer care, misdiagnosed episodes of TE due to the presence of brain metastases, optimal cardio-oncology monitoring, and more frequent usage of prophylactic anticoagulation treatment for cancer-associated venous thromboembolism. Nonetheless, further competing-risk survival analyses are warranted before reaching definite conclusions. Funding Acknowledgement Type of funding sources: None.

Clinical Prognosis of Lung Cancer in Patients with Moderate Chronic Kidney Disease.

Simple SummaryLung cancer has a high incidence and mortality rate worldwide. In addition, lung cancer develops commonly in the elderly, and it is necessary to consider comorbidities when planning treatment. Chronic kidney disease (CKD) is a common comorbidity in patients with lung cancer. However, there are conflicting results regarding its effect on the clinical prognosis of lung cancer, and only insufficient evidence for treatment of lung cancer according to renal function. In this retrospective multicenter study, we evaluate clinical course and prognostic factors of lung cancer according to the renal function of moderate CKD patients.The clinical outcomes of patients with lung cancer coexisting with chronic kidney disease (CKD) are reported to have been conflicting. There is insufficient evidence for treatment and prognosis of lung cancer according to renal function in patients with CKD. We evaluate clinical course and prognostic factors of lung cancer according to the renal function of moderate CKD patients. A retrospective, multicenter study of lung cancer patients with moderate CKD was performed. Moderate CKD was defined as having an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2. CKD was classified as stage 3, stage 4, and stage 5 according to eGFR. The cumulative mortality of lung cancer was calculated by competing risks survival analysis, and the risk factors were evaluated by the Cox-proportional hazards model. Among the lung cancer patients with moderate CKD (n = 181), median overall survival (OS) was 11.1 (4.2–31.3) months for stage 3 CKD patients, 6.0 (1.8–16.3) months for stage 4 CKD patients, and 4.7 (2.1–40.1) months for stage 5 CKD patients (p = 0.060), respectively. In a subgroup analysis, CKD stage was associated with an increased mortality in early-stage non-small cell lung cancer (NSCLC). Cox regression analysis revealed that age ≥ 75 years (adjusted hazard ratio (aHR), 1.581; 95% confidence interval (CI), 1.082–2.310), Charlson comorbidity index (aHR, 1.669; 95% CI, 10.69–2.605), and stage IV NSCLC (aHR, 2.395; 95% CI, 1.512–3.796) were associated with increased mortality risk, whereas adenocarcinoma (aHR, 0.580; 95% CI, 0.352–0.956) and stage 3 CKD (aHR, 0.598; 95% CI, 0.399–0.895) were associated with decreased mortality risk. In conclusion, the mortality risk of patients with lung cancer was lower in stage 3 CKD compared with stage 4 or 5 CKD. In addition, in the early stages of NSCLC, the CKD stage affected the prognosis, but not in the advanced stage NSCLC.

Long-term Outcome Reporting in Older Kidney Transplant Recipients and the Limitations of Conventional Survival Metrics

The kidney transplant recipient population in the United States is aging rapidly, which may exacerbate some of the limitations of conventional outcome metrics. Using data from the Scientific Registry of Transplant Recipients (SRTR), age-stratified unadjusted Kaplan-Meier and competing risk survival analyses were performed on a cohort of 238,123 adult recipients of a first-time single kidney transplant between 2000 and 2017. These were compared with a multistate model incorporating 5 post-transplant states (alive with functioning graft, death with functioning graft, graft failed (alive), retransplanted, and death after graft failure). Kaplan-Meier resulted in an age-dependent overestimation of the risks of graft failure and death with functioning graft, compared with competing risk or multistate models. In elderly (≥75 years old) recipients, the absolute overestimation of the risk of death with functioning graft was 4-fold higher than in those younger than 55 years. The multistate model demonstrated that for patients transplanted at age 55 years and older, the probability of being back on dialysis was never more than 4% at any point post-transplant. The underlying reasons were low graft failure rates and high mortality after resuming dialysis as follows: 2-year mortality after graft failure was 38%, 54%, and 67% in recipients aged from 55 to 64 years, from 65 to 74 years, and those aged 75 years and older, versus 20% in those younger than 55 years. Multistate models provide an accurate and comprehensive assessment of the life course of kidney transplant recipients. This may be particularly relevant in older recipients, who are more prone to event rate overestimation and for whom outcomes after graft failure are substantially worse than for younger recipients.

Marriage survival in new married couples: A competing risks survival analysis.

Background and aimMarriage is one of the most important phenomena in human life. The survival of the marriage and the impact of various competing factors on the survival is of high importance. This study aimed at utilizing competing risks survival analysis to investigate the marriage survival of new couples in Tabriz.MethodsIn this longitudinal study, a number of 386 individuals who were married and divorced from 1991 to 2017, were selected by random sampling. The registered information was attained from the general registry office of Tabriz. Data analysis was carried out using the Lunn-McNeil procedure and the results were presented using an adjusted hazard ratio (AHR).ResultsThe average age of marriage was about 23.9 (SD 6.6) years. The results of multivariate Lunn-McNeil models indicated that for the competing cause of having a relationship with another person (AHRs range: 1.12 to 2.03), the traditional mode of being familiar (AHRs range: 1.55 to 3.39), family weak role in choosing a wife/spouse (AHRs range: 0.25 to 3.25) and the role of moral-religious commitment (AHRs range: 0.37 to 0.47), along with other causes severed the risk of marriage survival reduction.ConclusionAccording to the results of this study in assessing competing risks, we conclude that the decline in marriage survival is a multifactorial phenomenon. Examining the survival of marriage in order to better understand all the dimensions and factors affecting this phenomenon and providing information to counselors and officials can play an important role in increasing marriage survival.

The profitability of online loans: A competing risks analysis on default and prepayment

Traditional credit scoring models help lenders to make informed decisions in identifying those borrowers most likely to default. We analyse over one million online loans and find that the rates for both default and prepayment are relatively high compared to traditional bank loans. A preliminary nonparametric life-table estimate shows that loans with different terms exhibit varying patterns of hazards. We use a proportional hazard model with competing risks to predict the time to default and prepayment, and parameterise those covariates affecting the time to both events. Two dimensions of predictive performance, the discriminant power and the probability calibration, are then examined. To further support the primacy of profit-driven decisions, we propose a framework based on competing risks survival analysis to estimate the profitability of loans and the return of loan portfolios. Profitability forecasts incorporating both the time to default and prepayment are compared to the profitability of real assets, and finally a penalty is suggested to compensate for those losses incurred by prepayment.

Indirect effect of the COVID-19 pandemic on hospital mortality in patients with hip fracture: a competing risk survival analysis using linked administrative data

BackgroundHip fracture is a leading cause of disability and mortality among older people. During the COVID-19 pandemic, orthopaedic care pathways in the National Health Service in England were restructured to...

Switches between biologics in patients with moderate-to-severe psoriasis: results from the French cohort PSOBIOTEQ.

Biologics are the cornerstone of treatment of patients with moderate-to-severe plaque psoriasis and switches between biologics are frequently needed to maintain clinical improvement over time. The main purpose of this study was to describe precisely switches between biologics and how their pattern changed over time with the recent availability of new biologic agents. We included patients receiving a first biologic agent in the Psobioteq multicenter cohort of adults with moderate-to-severe psoriasis receiving systemic treatment. We described switches between biologics with chronograms, Sankey and Sunburst diagrams, assessed cumulative incidence of first switch by competing risks survival analysis and reasons for switching. We assessed the factors associated with the type of switch (intra-class - i.e. within the same therapeutic class - vs. inter-class) in patients switching from a TNF-alpha inhibitor using multivariate logistic regression. A total of 2153 patients was included. The cumulative incidence of switches from first biologic was 34% at 3 years. Adalimumab and ustekinumab were the most prescribed biologic agents as first and second lines of treatment. The main reason for switching was loss of efficacy (72%), followed by adverse events (11%). Patients receiving a TNF-alpha inhibitor before 2016 mostly switched to ustekinumab, whereas those switching in 2016 or after mostly switched to an IL-17 inhibitor. Patients switching from a first-line TNF-alpha inhibitor before 2016 were more likely to switch to another TNF-alpha inhibitor compared with patients switching since 2018. Patients switching from etanercept were more likely to receive another TNF-alpha inhibitor rather than another therapeutic class of bDMARD compared with patients switching from adalimumab. This study described the switching patterns of biologic treatments and showed how they changed over time, due to the availability of the new biologic agents primarily IL-17 inhibitors.