Discrete-time Hazard Models Research Articles

Longitudinal Changes in Peak Expiratory Flow Predict Risk for Incident Dementia.

Impaired respiratory function, measured via peak expiratory flow (PEF), has been associated with increased dementia risk. However, much of the current literature uses cross-sectional measures of PEF, whereas longitudinal relationships between changes in respiratory function and dementia risk are underexplored. Using 10 years of data (2011-2021) from 2,439 adults ages 65 and older in the National Health and Aging Trends Study (NHATS), we examined whether 5-year changes in PEF (2011-2016) were associated with risk for incident dementia over the subsequent 5-year period (2017-2021). PEF slopes for each participant were estimated using linear mixed-effects models and then grouped into quartiles: rapid, moderate, mild, and no declines. Discrete-time Cox proportional hazards models were used to estimate the risk for incident dementia by PEF slope category, while controlling for several health and sociodemographic characteristics. After excluding dementia cases during the exposure window (2011-2016), we identified 338 cases of incident dementia (13.9%) between 2017-2021. Rapid PEF declines between 2011-2016 were associated with 85% higher risk for incident dementia between 2017-2021 compared to those with no declines in PEF (HR=1.85; 95% CI [1.24, 2.76]). Results were robust to several sensitivity analyses. These findings demonstrate that declines in PEF may precede declines in cognition, suggesting that respiratory function may be an important dementia risk factor in older adults. Additionally, these findings highlight the utility of measuring PEF via a peak flow meter, which is a simple and inexpensive measure of respiratory function.

Firms’ innovation and export survival in a Crisis

ABSTRACT Firms pay sunk costs to enter the export market. However, some firms fail to continue exporting despite paying the high sunk costs. The existing literature has not broadly explored such export market survival for firms, considering their level of innovation. Thus, this study investigates the effects of innovation on firms’ export market survival, using a panel dataset of South Korean manufacturing firms from 2006 to 2019. Adopting a discrete-time hazard model, this study uses patents for measuring innovation and considers the financial crisis period. The study finds that firms with higher innovation levels have lower hazard rates in the export market, implying a higher survival rate. Furthermore, a nonlinear relationship between innovation and export market survival demonstrates diminishing returns to innovation. Innovation is critical to firms’ export market survival, especially during the global financial crisis. Particularly, innovation during the global financial crisis helps high–medium technology firms survive in the export market. These empirical findings suggest that innovation is likely to increase the competitiveness of firms’ products and support their survival in the export market, even during the crisis period.

Random Survival Forests With Competing Events: ASubdistribution-Based Imputation Approach.

Random survival forests (RSF) can be applied to many time-to-event research questions and are particularly useful in situations where the relationship between the independent variables and the event of interest is rather complex. However, in many clinical settings, the occurrence of the event of interest is affected by competing events, which means that a patient can experience an outcome other than the event of interest. Neglecting the competing event (i.e., regarding competing events as censoring) will typically result in biased estimates of the cumulative incidence function (CIF). A popular approach for competing events is Fineand Gray's subdistribution hazard model, which directly estimates the CIF by fitting a single-event model defined on a subdistribution timescale. Here, we integrate concepts from the subdistribution hazard modeling approach into the RSF. We develop several imputation strategies that use weights as in a discrete-time subdistribution hazard model to impute censoring times in cases where a competing event is observed. Our simulations show that the CIF is well estimated if the imputation already takes place outside the forest on the overall dataset. Especially in settings with a low rate of the event of interest or a high censoring rate, competing events must not be neglected, that is, treated as censoring. When applied to a real-world epidemiological dataset on chronic kidney disease, the imputation approach resulted in highly plausible predictor-response relationships and CIF estimates of renalevents.

Effect of mental health staffing inputs on initiation of care among recently separated Veterans.

To estimate a causal relationship between mental health staffing and time to initiation of mental health care for new patients. As the largest integrated health care delivery system in the United States, the Veterans Health Administration (VHA) provides a unique setting for isolating the effects of staffing on initiation of mental health care where demand is high and out-of-pocket costs are not a relevant confounder. We use data from the Department of Defense and VHA to obtain patient and facility characteristics and health care use. To isolate exogenous variation in mental health staffing, we used an instrumental variables approach-two-stage residual inclusion with a discrete time hazard model. Our outcome is time to initiation of mental health care after separation from active duty (first appointment) and our exposure is mental health staffing (standardized clinic time per 1000 VHA enrollees per pay period). Our cohort consists of all Veterans separating from active duty between July 2014 and September 2017, who were enrolled in the VHA, and had at least one diagnosis of post-traumatic stress disorder, major depressive disorder, and/or substance use disorder in the year prior to separation from active duty (N = 54,209). An increase of 1 standard deviation in mental health staffing results in a higher likelihood of initiating mental health care (adjusted hazard ratio: 3.17, 95% confidence interval: 2.62, 3.84, p < 0.001). Models stratified by tertile of mental health staffing exhibit decreasing returns to scale. Increases in mental health staffing led to faster initiation of care and are especially beneficial in facilities where staffing is lower, although initiation of care appears capacity-limited everywhere.

The asbestos-asbestosis exposure-response relationship: a cohort study of the general working population.

The association between asbestos exposure and asbestosis in high-exposed industrial cohorts is well-known, but there is a lack of knowledge about the exposure-response relationship for asbestosis in a general working population setting. We examined the exposure-response relationship between occupational asbestos exposure and asbestosis in asbestos-exposed workers of the Danish general working population. We followed all asbestos-exposed workers from 1979 to 2015 and identified incident cases of asbestosis using the Danish National Patient Register. Individual asbestos exposure was estimated with a quantitative job exposure matrix (SYN-JEM) from 1976 onwards and back-extrapolated to age 16 for those exposed in 1976. Exposure-response relations for cumulative exposure and other exposure metrics were analyzed using a discrete time hazard model and adjusted for potential confounders. The range of cumulative exposure in the population was 0.001 to 18 fibers per milliliter-year (f/ml-year). We found increasing incidence rate ratios (IRR) of asbestosis with increasing cumulative asbestos exposure with a fully adjusted IRR per 1 f/ml-years of 1.18 [95% confidence interval (CI) 1.15- -1.22]. The IRR was 1.94 (95% CI 1.53-2.47) in the highest compared to the lowest exposure tertile. We similarly observed increasing risk with increasing cumulative exposure in the inception population. This study found exposure-response relations between cumulative asbestos exposure and incident asbestosis in the Danish general working population with mainly low-level exposed occupations, but there is some uncertainty regarding the exposure levels.

Economic Cycles and Entry into Parenthood: Is the Association Changing and Does it Affect Macro-Level Trends? Micro-Level Hazard and Simulation Models of Belgian Fertility Trends, 1960–2010

The association between economic cycles—typically measured in terms of GDP growth or swings in unemployment—and macro-level fertility trends has received ample attention in the literature. Compared to studies that consider macro-level fertility, individual-based models can address the association between economic cycles and specific stages of family formation (e.g. entry into parenthood) more precisely while allowing for structural factors that contribute to fertility postponement. Using population-wide longitudinal microdata from the Belgian censuses we combine discrete-time hazard models of entry into parenthood for the period 1960 to 2010 with microsimulation models to assess whether economic cycles in tandem with educational expansion can account for year-to-year variation in the proportion of women entering parenthood and variation in the pace of fertility postponement at the macro-level. Results indicate that educational expansion has been a structural driver of fertility postponement, whereas the procyclical effect of economic cycles accounts for accelerations and decelerations of fertility postponement throughout the period considered. Microsimulation of macro-level fertility trends indicates that individual-based models predict the annual proportion of women entering parenthood and the mean age at first birth with average errors of prediction below 1 per cent and 3 months, respectively, while also showing strong correlations between first differences of observed and simulated time-series. Because the extended observation window encompasses several severe recessions, we test whether the association between economic cycles and entry into parenthood has changed over time and how this affected macro-level trends, discussing several mechanisms that may account for such temporal variation.

Maternal exposure to metals and time-to-pregnancy: The MIREC cohort study.

To study the association between maternal exposure to arsenic, cadmium, lead, manganese and mercury, time-to-pregnancy (TTP) and infertility. Pregnancy-based retrospective TTP cohort study. Hospitals and clinics from ten cities across Canada. A total of 1784 pregnant women. Concentrations of arsenic, cadmium, lead, manganese and mercury were measured in maternal whole blood during the first trimester of pregnancy as a proxy of preconception exposure. Discrete-time Cox proportional hazards models generated fecundability odds ratios (FOR) for the association between metals and TTP. Logistic regression generated odds ratios (OR) for the association between metals and infertility. Models were adjusted for maternal age, pre-pregnancy body mass index, education, income, recruitment site and plasma lipids. TTP was self-reported as the number of months of unprotected intercourse to become pregnant. Infertility was defined as TTP longer than 12 months. A total of 1784 women were eligible for the analysis. Mean ± SD maternal age and gestational age at interview were 32.2 ± 5.0 years, and 11.6 ± 1.6 weeks, respectively. Exposure to arsenic, cadmium, manganese or mercury was not associated with TTP or infertility. Increments of one standard deviation of lead concentrations resulted in a shorter TTP (adjusted FOR 1.09, 95% CI 1.02-1.16); however, the association was not linear when exposure was modelled in tertiles. Blood concentrations of metals at typical levels of exposure among Canadian pregnant women were not associated with TTP or infertility. Further studies are needed to assess the role of lead, if any, on TTP.

Waived English Learners: The Understudied Intersection of English Learner and Special Education Status

Under federal law, parents have the right to decline, or waive, English language support services when their child is identified as an English learner (EL) in school. In this study, we focus on this important subgroup of ELs—referred to as waived ELs—at the understudied intersection of EL status and special education (SPED) status. Using longitudinal statewide Tennessee data from 2010 to 2021, we used discrete-time hazard modeling to explore ELs’ representation in SPED services by their English language service waiver status (i.e., ever-waived EL vs. never-waived EL). Results revealed that ELs’ likelihood of placement into SPED services, and specifically for specific learning disability and speech-language impairment, varied by their English language service waiver status. We describe similarities and differences in the timing and likelihood of placement trends and discuss implications for practice and policy.

The impacts of rent burden and eviction on mortality in the United States, 2000–2019

Investments in stable, affordable housing may be an important tool for improving population health, especially in the context of rising costs and evictions for American renters. Still, a lack of longitudinal data linking these exposures to health outcomes has limited prior research. In this study, we use linked administrative data to estimate the associations of rent burden and eviction with all-cause mortality. We constructed a novel dataset linking renters in the long-form 2000 Census (N = 6,587,000) to mortality follow-up through 2019 from the Census Numident file. To measure exposure to eviction, we further linked this dataset to 38 million eviction records between 2000 and 2016 using names and addresses. For a subsample of renters, we also measured within-individual changes in rent burden between 2000 and 2008–2012 by linking to the American Community Survey. We estimated the associations of rent burden and eviction with mortality using Cox proportional-hazards models and discrete-time hazard models adjusted for individual, household, neighborhood, and state characteristics, examining varying associations by cohort, race, gender, and eviction risk. Higher baseline rent burden, increases in rent burden during midlife, and evictions were all associated with increased mortality. Compared to a baseline rent burden of 30%, a burden of 70% was associated with 12% (95% confidence interval = 11–13%) higher mortality. A 20-point increase in rent burden between 2000 and 2008–2012 was associated with 16% (12–19%) higher mortality through 2019. An eviction filing without judgment was associated with a 19% (15–23%) increase in mortality and an eviction judgment was associated with a 40% (36–43%) increase. Associations were larger for those at lower predicted risk of eviction. These findings reveal how rising costs and evictions are shaping mortality for American renters. Policies designed to increase the supply of affordable housing and prevent eviction may lead to widespread improvements in population health.

Cataract surgery utilization in Parkinson's disease: the english longitudinal survey on ageing.

Older adults with Alzheimer's disease are less likely to be offered cataract surgery than the general population, but these disparities have not been examined in the context of other neurodegenerative disorders such as Parkinson's disease (PD). Using data from the English Longitudinal Study on Ageing (ELSA), an ongoing, longitudinal population-based survey of older adults in England, we examined the relationship between PD and cataract surgery among adults 50 and older. We used logistic regression to measure the association between PD and history of cataract surgery at baseline. In longitudinal analyses of subjects with no history of cataract surgery at time of enrollment, we used semiparametric, discrete-time proportional hazards models to model the incidence of cataract surgery as a function of PD and other time-dependent covariates. Models were adjusted for demographic variables, self-reported comorbidities, and measures of daily activity limitation. We included data from 19,241 eligible ELSA respondents, of whom 231 (1.2%) reported a diagnosis of PD. PD was positively associated with a history of self-reported cataract surgery at baseline (OR 3.66, 95% CI: 2.55-5.26), but this did not remain significant after adjusting for confounders (OR 1.22, 95% CI: 0.75-1.98). Among subjects with no history of cataract surgery at baseline, PD was also not associated with incident cataract surgery (adjusted HR 1.32, 95% CI: 0.86-2.02). Unlike Alzheimer's disease, people with PD were no less likely to receive cataract surgery compared to those without PD.

Association of Neighborhood Economic Status and Race With Developing Pelvic Inflammatory Disease After Sexually Transmitted Infections.

To explore the association of neighborhood-level socioeconomic status (SES) and race with developing pelvic inflammatory disease (PID) after sexually transmitted infection (STI) among female adolescents and young adults in Maryland. We used Maryland statewide hospital claims data (outpatient and inpatient visits) for this retrospective cohort study. Female adolescents and young adults aged 15-24 years who had at least one STI from July 1, 2013, to March 31, 2015, were included. A participant entered the cohort on the date of the first STI diagnosis and was followed up until PID occurrence or 3 years after the first STI. Median household income of the participant's residential ZIP code tabulation area was used as the neighborhood-level SES. Discrete-time hazard models were used to estimate the hazard of PID. Of the 2,873 participants, 88.5% were of Black race, and 67.2% were aged 20-24 years. The hazard of PID after an STI among Black women was 1.40 times that of White women (95% CI 1.06-1.85). After adjustment for age, insurance type, and number of STI events, the hazard ratio (HR) did not change. However, adding neighborhood-level SES to the model attenuated the disparity in PID after STI between Black and White women (HR 1.25, 95% CI 0.94-1.67). Racial disparities in PID diagnosis are mitigated by neighborhood-level SES.

What Motivates Mergers and Acquisitions in India?

This paper attempts to explore the motives behind merger and acquisition strategy of Indian corporates. Covering the domestic activity over two decades, 1998--2017, the firm-level determinants of acquiring and acquired firms are studied to analyze the merger motives. The results from Logit and discrete-time hazard model show that firms with higher technological and financial productivity are more likely to go for acquisitions. On the other hand, firms that have potential to grow in the future but are struggling at present owing to low profits or losses are more likely to be acquired. The managements of firms that are not actively involved in research activities are also likely to be replaced. The findings of the article, therefore, suggest that Indian firms are using mergers for expansionary and efficiency-enhancing motives.

Impact of beta-blockers on mortality and cardiovascular disease outcomes in patients with obstructive sleep apnoea: a population-based cohort study in target trial emulation framework

There is no real-world evidence regarding the association between beta-blocker use and mortality or cardiovascular outcomes in patients with obstructive sleep apnoea (OSA). We aimed to investigate the impact of beta-blocker use on all-cause mortality and cardiovascular diseases (CVDs) in patients with OSA. We conducted a target trial emulation study of 37,581 patients with newly diagnosed OSA from 1st January 2000 to 30th November 2021 using the IMRD-UK database (formerly known as the THIN database). We compared the treatment strategies of initiating beta-blocker treatment within one year versus non-beta-blocker treatment through the method of clone-censor-weight. Covariates, including patients' demographics, lifestyle, comorbidities, and recent medications, were measured and controlled. Patients were followed up for all-cause mortality or composite CVD outcomes (angina, myocardial infarction, stroke/transient ischaemic attack, heart failure, or atrial fibrillation). We estimated the five-year absolute risks, risk differences and risk ratio with 95% confidence intervals (CIs) with standardised, weighted pooled logistic regression, which is a discrete-time hazard model for survival analysis. Several sensitivity analyses were performed, including multiple imputation addressing the missing data. The median follow-up time was 4.1 (interquartile range, 1.9-7.8) years. The five-year absolute risk of all-cause mortality and CVD outcomes were 4.9% (95% CI, 3.8-6.0) and 13.0% (95% CI, 11.4-15.0) among beta-blocker users, and 4.0% (95% CI, 3.8-4.2) and 9.4% (95% CI, 9.1-9.7) among non-beta-blocker users, respectively. The five-year absolute risk difference and risk ratio between the two groups for all-cause mortality and CVD outcomes were 0.9% (95% CI,-0.2 to 2.1) and 1.22 (95% CI, 0.96-1.54), and 3.5% (95% CI, 2.1-5.5) and 1.37 (95% CI, 1.22-1.62), respectively. Findings were consistent across the sensitivity analyses. Beta-blocker treatment was associated with an increased risk of CVD and a trend for an increased risk of mortality among patients with OSA. Further studies are needed to confirm our findings. Innovation and Technology Commission of the Hong Kong Special Administration Region Government.

Fungi in Early-Life House Dust Samples and the Development of Asthma: A Birth Cohort Study.

Rationale: Fungal exposure has been associated with predisposing and protective effects on the development of childhood asthma. Objectives: To study whether early-life house dust mycobiota composition is associated with the development of asthma. Methods: Mycobiota were determined by amplicon sequencing from 382 dust samples collected from living room floors 2 months after birth in homes of the LUKAS cohort. Asthma status by 10.5 years of age was defined from questionnaires and assigned as ever asthma (n = 68) or current asthma (n = 27). Inhalant atopy was clinically determined at the same age. β-composition was analyzed using PERMANOVA-S, and asthma and atopy analyses were performed using discrete time hazard models and logistic regression, respectively. Results: The house dust mycobiota composition based on Bray-Curtis distance was different in the homes of children who later did or did not develop asthma. The first and the fourth axes scores of principal coordinates analysis based on Bray-Curtis were associated with ever asthma. Of the genera with the strongest correlation with these axes, the relative abundance of Boeremia, Cladosporium, Microdochium, Mycosphaerella, and Pyrenochaetopsis showed protective associations with asthma. None of these associations remained significant after mutual adjustment among the five genera or when mutually adjusted for other microbial cell wall markers and previously identified asthma-protective bacterial indices. Neither fungal α-diversity nor load was associated with asthma in the whole population, but higher fungal richness was a risk factor among children on farms. Higher fungal loads (measured via quantitative polymerase chain reaction) in house dust were associated with the risk of inhalant atopy. Conclusions: The results of our analyses from this well-characterized birth cohort suggest that the early-life house dust mycobiota in Finnish homes, characterized via DNA amplicon sequencing, do not have strong predisposing or protective effects on asthma development.

Longitudinal Examination of Which Married Young Women Use Contraception to Delay a First Pregnancy in Bihar and Uttar Pradesh, India.

Early marriage and childbearing put young women and their babies at risk of poor health and well-being. This study uses two rounds of longitudinal data from young women ages 15-19 in 2015-2016 and followed in 2018-2019 to determine factors associated with contraceptive use before a first pregnancy among young, married women in Bihar and Uttar Pradesh, India. Discrete time hazard models were used to analyze time to first use starting from the month of marriage. Overall, use of contraception prior to a first pregnancy was low in this sample (between 12 to 20% used before a first pregnancy). Young women who reported that someone discussed the importance of delaying a first birth at the time of marriage were significantly more likely to have used a method of family planning (FP) before a first pregnancy than those who did not receive this information. Further, women who discussed FP with their husband before a first pregnancy were more likely to use contraception. Finally, among recently married young women, those who experienced pressure to have a child were less likely to use before a first pregnancy. As young women recognize the advantages of delaying a first birth and adopt FP to meet their needs, social norms around early childbearing will slowly adjust and early use to delay a first pregnancy will become more normative.

Effects on mortality of shielding clinically extremely vulnerable patients in Liverpool, UK, during the COVID-19 pandemic

ObjectiveThis study evaluates the impact of England's COVID-19 shielding programme on mortality in the City of Liverpool in North West England. Study designShielded and non-shielded people are compared using data from linked routine health records on all people registered with a general practitioner in Liverpool from April 2020 to June 2021. MethodsA discrete time hazard model and interactions between the shielding status and the periods of higher risk of transmission are used to explore the effects of shielding across the major phases of the COVID-19 pandemic. ResultsShielding was associated with a 34% reduction in the risk of dying (HR = 0.66, 95% CI: 0.58 to 0.76) compared with a propensity-matched non-shielded group. Shielding appeared to reduce mortality during the first and third waves, but not during the second wave, where shielding was not mandated by the government. The effects were similar for males and females, but more protective for those living in the least deprived areas of Liverpool. ConclusionsIt is likely that the shielding programme in Liverpool saved lives, although this seems to have been a little less effective in more deprived areas. A comprehensive programme for identifying vulnerable groups and providing them with advice and support is likely to be important for future respiratory virus pandemics. Additional support may be necessary for socio-economically disadvantaged groups to avoid increased inequalities.

Alcohol use and internal migration in Nepal: a cross-sectional study

BackgroundAlcohol use is a leading cause of disease. Although low- and middle-income countries (LMICs) have lower per capita alcohol consumption, the alcohol-attributable disease burden is high in these settings with...

Longitudinal Association Between Exclusive and Dual Use of Cigarettes and Electronic Nicotine Delivery Systems and Asthma Among U.S. Adolescents

PurposeElectronic Nicotine Delivery Systems (ENDS) use among adolescents has increased greatly over the past decade, but its impact on chronic respiratory health conditions, like asthma, is not fully understood. MethodsWe examined data from Waves 1–5 (2013–2019) of the Population Assessment of Tobacco and Health Study using discrete time hazard models to analyze the association between time-varying tobacco product use and incident diagnosed asthma among adolescents aged 12–17 years at baseline. We lagged the time-varying exposure variable by one wave and categorized respondents by current use status (1+ days in the past 30 days): never or non-current, exclusive cigarette, exclusive ENDS, and dual cigarette and ENDS use. We also controlled for sociodemographic (age, sex, race/ethnicity, parental education) and other risk factors (urban/rural setting, secondhand smoke exposure, household combustible tobacco use, body mass index). ResultsAt baseline, over half the analytic sample (n = 9,141) was 15–17 years old (50.4%), female (50.2%), and non-Hispanic White (55.3%). Adolescents who exclusively smoked cigarettes had a statistically significant higher risk of incident diagnosed asthma at follow-up (adjusted Hazard Ratio (aHR): 1.68, 95% confidence interval (CI): 1.21–2.32) compared to those not currently using cigarettes or ENDS, but adolescents using ENDS exclusively (aHR: 1.25, 95% CI: 0.77–2.04) or in combination with cigarettes (aHR: 1.54, 95% CI: 0.92–2.57) did not. DiscussionShort-term exclusive cigarette use was associated with a higher risk of incident diagnosed asthma over five years of follow-up among adolescents. We did not find conclusive evidence for an association between exclusive ENDS or dual use and incident diagnosed asthma.

Survival of the fittest: tourism exposure and firm survival

ABSTRACT In this article, a discrete-time hazard model to study firm survival in the Portuguese Tourism sector is estimated. This sector has experienced a remarkable performance over the last decades. Results show that when compared to other sectors, tourism firms are more likely to exit: (i) if they are young (less than 10 years of existence); and (ii) if they belong to the group of worse performers (i.e. belong to the lower tail of the firm distribution). Within tourism related sectors, firms with highest tourism exposure, such as travel agencies and hotels are always among the best performers in terms of survival. Moreover, despite of Tourism being one of the most volatile sectors in periods of high uncertainty, results show a higher survival resilience among established tourism associated firms.

Clinical manifestations of cancer in patients with acute pulmonary embolism.

Neoplasmatic disease increases the risk of acute pulmonary embolism (APE) by different pathophysiological mechanisms that favor thrombosis in patients with cancer. Recently, the role of cancer (active and occult) in the prevalence of venous thromboembolism has been discussed more thoroughly in the subject literature. Medical records of 366 consecutive patients with a diagnosis of APE (aged: mean = 65.0 ± 16.6, median = 68, range = 19-94; men = 41%/women = 59%) were collected with a wide range of demographic data, medical history of coexisting diseases, computer examination, and laboratory tests. The APE patients were analyzed in two groups: negative cancer cases (83%), i.e. without concomitant active malignancy or a history of cancer, and positive ones (17%), i.e. those hospitalized with concomitant active cancer disease or a history of cancer within the past 5 years. Based on the application of the Student's t -test for independent samples and the χ2 test of independence, a statistically significant difference ( P < 0.05) between cancer (-) and cancer(+) groups of patients was calculated for the following selected risk factors: BMI, smoking status, hemoglobin, hematocrit, red blood cell, urea, glomerular filtration rate, high-sensitivity troponin T, C-reactive protein (CRP), D-dimer, and NT-proBNP. Using univariate Cox regression and a discrete-time hazard model, the estimated hazard ratios and odds ratios, respectively, for the risk of an earlier death from cancer as well as for a secondary APE episode in APE patients with malignancy are more than three times higher than in cancer-free patients and they are statistically significant ( P < 0.05). Moreover, the modeled discrete-time hazard curves show a constant excess risk of death and a secondary APE episode in patients diagnosed with malignancy over the period of observation. Cancer and APE seem to go 'hand in hand'. Attention should be paid to many factors, primarily clinical, differentiating patients with cancer from those with an APE incident. The patients with cancer after a primary APE should receive anticoagulants to prevent a secondary APE episode and to reduce the risk of mortality.