Population Attributable Risk Estimates Research Articles

Trends and population attributable risk estimates for individual and community-level factors of neonatal mortality in Pakistan (1990–2018)

PurposePakistan ranks third globally in terms of newborn deaths occuring within the first 24 hours of life. With a neonatal mortality rate of 42.0%, it carries the highest burden compared to neighboring countries such as Bangladesh (17%), India (22.7%) and Afghanistan (37%). While there has been a decline in neonatal mortality rates in Pakistan, the pace of this decline is slower than that of other countries in the region. Hence, it is crucial to conduct a comprehensive examination of the risk factors contributing to neonatal mortality in Pakistan over an extended period. This study aims to analyze the trends and determinants of neonatal mortality in Pakistan over three decades, providing valuable insights into this persistent issue.Design/methodology/approachThe study focused on neonatal mortality as the response variable, which is defined as the death of a live-born child within 28 days of birth. Neonates who passed away during this period were categorized as “cases,” while those who survived beyond a specific timeframe were referred to as “noncases.” To conduct a pooled analysis of neonatal mortality, birth records of 39,976 children born in the five years preceding the survey were extracted from four waves (1990–2018) of the Pakistan Demographic and Household Survey. The relationship between risk factors and the response variable was examined using the Cox Proportional Hazard Model. Neonatal mortality rates were calculated through the direct method using the “syncmrates” package in Stata 15.FindingsDuring the extended period in Pakistan, several critical protective factors against neonatal mortality were identified, including a large family size, improved toilet facilities, middle-aged and educated mothers, female children, singleton live births, large size at birth and longer birth intervals. These factors were found to reduce the risk of neonatal mortality significantly.Originality/valueThis study makes the first attempt to analyze the trends and patterns of potential risk factors associated with neonatal mortality in Pakistan. By examining a large dataset spanning several years, the study provides valuable insights into the factors influencing neonatal mortality.Peer reviewThe peer review history for this article is available at: https://publons.com/publon/10.1108/IJSE-09-2022-0604

Sodium Intake and Cause-Specific Mortality Among Predominantly Low-Income Black and White US Residents

Epidemiologic evidence regarding the outcomes of dietary sodium intake on mortality remains limited for low-income individuals, particularly Black people. To investigate the associations of excessive dietary sodium with all-cause and cause-specific mortality among predominantly low-income Black and White Americans. This cohort study included participants aged 40 to 79 years from the Southern Community Cohort Study who were recruited at Community Health Centers in 12 southeastern states from 2002 to 2009. Analyses were conducted between March 2022 and June 2023. Dietary sodium intake was assessed using a validated food frequency questionnaire at baseline. Multivariable-adjusted Cox regression was used to estimate hazard ratios (HRs) and 95% CIs for mortality outcomes (all-cause, cardiovascular disease [CVD], coronary heart disease [CHD], stroke, heart failure, cancer, and other) associated with sodium intake. Nonlinear associations and population-attributable risk (PAR) of the mortality burden associated with excess sodium were further assessed. Among the 64 329 participants, 46 185 (71.8%) were Black, 18 144 (28.2%) were White, and 39 155 (60.9%) were female. The mean (SD) age at study enrollment was 51.3 (8.6) years for Black participants and 53.3 (9.3) years for White counterparts. Mean (SD) dietary sodium intake was 4512 (2632) mg/d in Black individuals and 4041 (2227) mg/d in White individuals; 37 482 Black individuals (81.2%) and 14 431 White individuals (79.5%) exceeded the current dietary recommendations of 2300 mg/d. During a median (IQR) follow-up of 13.8 (11.3-15.8) years, 17 811 deaths were documented, including 5701 from CVD. After adjustment for potential confounders, in Black individuals, HRs per 1000-mg increase in daily sodium intake were 1.07 (95% CI, 1.03-1.10) and 1.08 (95% CI, 1.02-1.14) for deaths from total CVD and CHD, respectively; while in White individuals, the corresponding HRs were 1.08 (95% CI, 1.02-1.14) and 1.13 (95% CI, 1.03-1.23). No significant associations were found for cancer mortality. PAR estimates suggest that sodium intake above the recommended threshold may account for 10% of total CVD, 13% of CHD, and 30% of heart failure deaths in this low-income southern population. In this cohort study of 64 329 low-income Americans, nearly 80% of study participants consumed sodium exceeding the current recommended daily amount, which was associated with 10% to 30% of CVD mortality. Public health programs targeted to reduce sodium intake among this underserved population may be beneficial.

Medical and Psychiatric Risk Factors for Dementia in Veterans with and without Traumatic Brain Injury (TBI): A Nationwide Cohort Study

AbstractBackgroundTraumatic brain injury (TBI) is an important risk factor for dementia and is especially common among Veterans. It is unknown whether TBI exposure moderates the effect of other common medical/psychiatric comorbidities that are also important risk factors for dementia in Veterans. If treatable or preventable comorbidities are either especially common or risky in TBI‐exposed Veterans, then this may have important public health implications for dementia prevention.MethodWe conducted a retrospective cohort study using the Nationwide Veterans Health Administrative inpatient and outpatient data (2001‐2019). We identified all Veterans age 55 years with prior TBI and without baseline dementia (N = 95,139) and age/sex/race‐matched 1:2 with Veterans without prior TBI or baseline dementia (N = 190,278). We compared prevalence of seven common medical/psychiatric comorbidities (hypertension, coronary artery disease (CAD), diabetes, cerebrovascular disease (CVD), epilepsy, depression, and post‐traumatic stress disorder (PTSD)) and associated risk of incident dementia among Veterans with versus without prior TBI. We tested for interaction of each comorbidity with TBI on risk of dementia. We calculated risk of dementia associated with each comorbidity using multivariable hazard ratios (adjusting for demographics and all other comorbidities) and Fine‐Grey competing risk of death. We estimated population attributable risk (PAR) of dementia due to each comorbidity.ResultAll comorbidities were more prevalent among Veterans with TBI compared to those without TBI: hypertension +12.5%, CAD +13.6%, diabetes +7.9%, CVD +10.8%, epilepsy +5.7%, depression +21.5%, PTSD +14.9%). All comorbidities were associated with elevated risk for dementia among Veterans with and without TBI. However, there was a significant interaction with TBI such that point estimates were slightly lower among Veterans with TBI (adjusted HRs 1.02‐1.31) versus Veterans without TBI (adjusted HRs 1.03‐1.82). However, the overall PARs for dementia were higher in Veterans with versus without TBI for several comorbidities (depression 8.7% vs. 7.4%; hypertension 3.8% vs. 1.6%; CVD 3.7% vs. 2.0%; epilepsy 2.1% vs. 1.1%), due to their higher prevalence in Veterans with TBI.ConclusionWhile treating or preventing medical/psychiatric comorbidities among all Veterans remains a high public health priority, targeting depression, hypertension, CVD, and epilepsy may be especially important for dementia risk reduction among Veterans with prior TBI.

Risk factors for development of long-term mood and anxiety disorder after pediatric traumatic brain injury: a population-based, birth cohort analysis

ABSTRACT Objectives The objective of this study was to identify characteristics associated with an increased risk of anxiety and mood disorder prior to 25 years of age, in children who sustained a traumatic brain injury (TBI) prior to age 10. Methods This population-based study identified 562 TBI cases from a 1976–1982 birth cohort in Olmsted County, Minnesota. TBI cases were manually confirmed and classified by injury severity. Separate Cox proportional hazards regression models were fit to estimate the association of TBI and secondary non-TBI related characteristics with the risk of a subsequent clinically determined anxiety or mood disorder. Multivariable-adjusted population attributable risk (PAR) estimates were calculated for TBI characteristics. Results Older age at initial TBI and extracranial injury at time of initial TBI were significantly associated with an increased risk of anxiety (adjusted HR [95% CI]: 1.33 [1.16, 1.52] per 1-year increase and 2.41 [1.26, 4.59]), respectively. Older age at initial TBI was significantly associated with an increased risk of a mood disorder (adjusted HR 1.17 [1.08–1.27]). Conclusion In individuals sustaining a TBI prior to age 10, age at injury greater than 5 years old was the largest contributor to development of a mood or anxiety disorder.

Population attributable risk for colorectal and breast cancer in England, Wales, Scotland, Northern Ireland, and the United Kingdom.

The population attributable risk (PAR) is a statistic commonly used for quantifying preventability of cancer. We report here PAR estimates for the United Kingdom (UK) along with its constituent countries for up-to-date risk factor-attributable colorectal cancer (CRC) and breast cancer (BC), focusing on diet and nutrition related factors and tobacco (CRC) using representative national surveys. The PAR was calculated using established, modifiable risk factors by the World Cancer Research Fund/American Institute of Cancer Research (WCRF/AICR): physical activity, body mass index (BMI), alcoholic drinks, red meat, processed meat, dietary fiber, dietary calcium, as well as cigarette smoking for CRC, and physical activity, BMI, alcoholic drinks, and fruits and vegetable consumption for BC. National prevalence estimates and relative risks (RRs) for CRC and BC were obtained from meta-analyses or large pooled analyses. Based on eight dietary and lifestyle risk factors, the estimates for attributable cases of CRC for males and females, respectively, were as follows: England: 67% and 60%; Scotland: 68% and 59%, Wales: 66% and 61%; Northern Ireland: 67% and 61%; and UK: 67% and 60%. Excluding smoking, the PAR for the UK was 61% for men and 52% for women. Based on four dietary and lifestyle risk factors, the estimates for BC were as follows: England: 26%, Scotland: 27%; Wales: 25%; Northern Ireland: 26%; and UK: 27%. Up to 67% for CRC and 27% of BC were attributable to modifiable dietary and lifestyle factors in the UK. Moderate differences in PAR are observed between countries due to different prevalence of exposure to risk factors.

Baseline periodontal status and modifiable risk factors are associated with tooth loss over a 10-year period: Estimates of population attributable risk in a Japanese community.

BackgroundThis study aimed to examine whether modifiable risk factors can predict tooth loss over 10 years and estimate population attributable risk (PAR) for a combination of modifiable factors.MethodsThis longitudinal study included 1466 participants who underwent dental examinations in 2007 and 2017 and were aged 40 to 79 years at baseline. Periodontal conditions were assessed using the 2018 periodontal classification. Incident tooth loss was defined as ≥4 teeth lost over a 10‐year period. We calculated the partial PAR (pPAR%) for tooth loss to estimate the combined effect of modifiable risk factors.ResultsIncidence of tooth loss was 17.5%. Directed acyclic graphs were used to identify risk factors for tooth loss. A logistic regression model showed that baseline periodontitis, dental caries experience, no regular dental visit, periodontal treatment, smoking, and obesity were associated with tooth loss after adjusting for covariates; pPAR% was 55.5% (95% confidence interval: 31.1% to 73.0%) in periodontitis Stage III to IV and 87.6% (50.4% to 97.4%) in the combination of all factors, respectively. The sex‐stratified analysis showed that smoking and no regular dental visit in men and obesity in women were identified as potential risk factors for tooth loss.ConclusionsModifiable factors accounted for most cases of incident tooth loss. Risk factors for tooth loss might differ by sex, suggesting that the appropriate approach for preventing tooth loss base on sex.

Exome Sequencing Reveals a Putative Role for HLA-C*03:02 in Control of HIV-1 in African Pediatric Populations.

Human leucocyte antigen (HLA) class I molecules present endogenously processed antigens to T-cells and have been linked to differences in HIV-1 disease progression. HLA allelotypes show considerable geographical and inter-individual variation, as does the rate of progression of HIV-1 disease, with long-term non-progression (LTNP) of disease having most evidence of an underlying genetic contribution. However, most genetic analyses of LTNP have occurred in adults of European ancestry, limiting the potential transferability of observed associations to diverse populations who carry the burden of disease. This is particularly true of HIV-1 infected children. Here, using exome sequencing (ES) to infer HLA allelotypes, we determine associations with HIV-1 LTNP in two diverse African pediatric populations. We performed a case-control association study of 394 LTNPs and 420 rapid progressors retrospectively identified from electronic medical records of pediatric HIV-1 populations in Uganda and Botswana. We utilized high-depth ES to perform high-resolution HLA allelotyping and assessed evidence of association between HLA class I alleles and LTNP. Sixteen HLA alleles and haplotypes had significantly different frequencies between Uganda and Botswana, with allelic differences being more prominent in HLA-A compared to HLA-B and C allelotypes. Three HLA allelotypes showed association with LTNP, including a novel association in HLA-C (HLA-B∗57:03, aOR 3.21, Pc = 0.0259; B∗58:01, aOR 1.89, Pc = 0.033; C∗03:02, aOR 4.74, Pc = 0.033). Together, these alleles convey an estimated population attributable risk (PAR) of non-progression of 16.5%. We also observed novel haplotype associations with HLA-B∗57:03-C∗07:01 (aOR 5.40, Pc = 0.025) and HLA-B∗58:01-C∗03:02 (aOR 4.88, Pc = 0.011) with a PAR of 9.8%, as well as a previously unreported independent additive effect and heterozygote advantage of HLA-C∗03:02 with B∗58:01 (aOR 4.15, Pc = 0.005) that appears to limit disease progression, despite weak LD (r2 = 0.18) between these alleles. These associations remained irrespective of gender or country. In one of the largest studies of HIV in Africa, we find evidence of a protective effect of canonical HLA-B alleles and a novel HLA-C association that appears to augment existing HIV-1 control alleles in pediatric populations. Our findings outline the value of using multi-ethnic populations in genetic studies and offer a novel HIV-1 association of relevance to ongoing vaccine studies.

Chlamydia pneumoniae and chronic asthma: Updated systematic review and meta-analysis of population attributable risk.

BackgroundChlamydia pneumoniae (Cp) is an obligate intracellular human respiratory pathogen producing persisting lung infection with a plausible link to asthma pathogenesis. The population attributable risk of potentially treatable Cp infection in asthma has not been reported.MethodsThe author searched from 2000 to 2020 inclusive for previously un-reviewed and new cross sectional and prospective controlled studies of Cp biomarkers and chronic asthma in both children and adults. Qualitative descriptive results and quantitative estimates of population attributable risk for selected biomarkers (specific IgG, IgA and IgE) are presented.FindingsNo large, long-term prospective population-based studies of Cp infection and asthma were identified. About half of case-control studies reported one or more significant associations of Cp biomarkers and chronic asthma. Heterogeneity of results by age group (pediatric v adult asthma), severity category (severe/uncontrolled, moderate/partly controlled, mild/controlled) and antibody isotype (specific IgG, IgA, IgE) were suggested by the qualitative results and confirmed by meta-analyses. The population attributable risks for Cp-specific IgG and IgA were nul in children and were 6% (95% confidence interval 2%-10%, p = 0.002) and 13% (9%-18%, p<0.00001) respectively in adults. In contrast to the nul or small population attributable risks for Cp-specific IgG and IgA, the population attributable risk for C. pneumoniae-specific IgE (children and adults combined) was 47% (39%-55%, p<0.00001). In the subset of studies that reported on asthma severity categories, Cp biomarkers were positively and significantly (P<0.00001) associated with asthma severity.InterpretationC. pneumoniae-specific IgE is strongly associated with asthma and asthma severity, suggesting a possible mechanism linking chronic Cp infection with asthma in a subset of individuals with asthma. Infection biomarkers should be included in future macrolide treatment trials for severe and uncontrolled asthma.

Population attributable risk for colorectal and breast cancer in England, Wales, Scotland, Northern Ireland, and the United Kingdom

Background: The population attributable risk (PAR) is a statistic commonly used for quantifying preventability of cancer. We report here PAR estimates for the United Kingdom (UK) along with its constituent countries for up-to-date risk factor-attributable colorectal cancer (CRC) and breast cancer (BC), focusing on diet and nutrition related factors and tobacco (CRC) using representative national surveys. Methods: The PAR was calculated using established, modifiable risk factors by the World Cancer Research Fund/American Institute of Cancer Research (WCRF/AICR): physical activity, body mass index (BMI), alcoholic drinks, red meat, processed meat, dietary fiber, dietary calcium, as well as cigarette smoking for CRC, and physical activity, BMI, alcoholic drinks, and fruits and vegetable consumption for BC. National prevalence estimates and relative risks (RRs) for CRC and BC were obtained from meta-analyses or large pooled analyses. Results: Based on eight dietary and lifestyle risk factors, the estimates for attributable cases of CRC for males and females, respectively, were as follows: England: 67% and 60%; Scotland: 68% and 59%, Wales: 66% and 61%; Northern Ireland: 67% and 61%; and UK: 67% and 60%. Excluding smoking, the PAR for the UK was 61% for men and 52% for women. Based on four dietary and lifestyle risk factors, the estimates for BC were as follows: England: 26%, Scotland: 27%; Wales: 25%; Northern Ireland: 26%; and UK: 27%. Conclusion: Up to 67% for CRC and 27% of BC were attributable to modifiable dietary and lifestyle factors in the UK. Moderate differences in PAR are observed between countries due to different prevalence of exposure to risk factors.

Short sleep and chronic neck and shoulder discomfort in nurses.

ObjectiveShort sleep duration is common among nurses. Sleep restriction has been associated with musculoskeletal discomfort. However, studies on the effect of short sleep duration on chronic neck and shoulder discomfort in nurses have been lacking. The aim of this study was to determine whether short sleep duration is related to chronic neck and shoulder discomfort.MethodsWe conducted a cross‐sectional survey of female nurses in secondary referral health centers in Taiwan. We applied stratified sampling based on region (north, central, south, and east) to select representative centers for this study. A self‐administered structured questionnaire, including demographic data, the psychological working environment, and musculoskeletal symptoms, was administered to nurses. Multiple logistic regression and population attributable risk analyses were performed to assess the effect of average sleeping hours per working day on chronic neck and shoulder discomfort.ResultsA total of 1602 (78.9%) questionnaires were eligible for final analysis. The prevalence rates of chronic neck and shoulder discomfort were 33.9% and 34.7%, respectively. Population attributable risk estimation revealed that a sleep duration of <7 hours per working day was the most crucial factor for chronic neck and shoulder discomfort in the nurses, accounting for 8.8% of chronic neck discomfort and 8.6% of chronic shoulder discomfort respectively.ConclusionOur study found that sleep duration on working days was associated with chronic neck and shoulder discomfort in female nurses. Further interventions are warranted for maintaining nurses’ sleep hygiene.

Factors associated with non-utilization of postnatal care among newborns in the first 2 days after birth in Pakistan: a nationwide cross-sectional study

ABSTRACT Background Recent data indicated that approximately four in every ten newborns in Pakistan do not receive postnatal care (PNC) services in the first 48 hours after delivery. Objectives This study aimed to identify factors associated with the non-utilization of PNC for newborns in Pakistan using the 2017–18 Pakistan Demographic and Health Survey (PDHS). Methods This was a cross-sectional analytical study utilizing data from 3887 live-born newborns recorded in the 2017–18 PDHS. Non-utilization of PNC was assessed against a set of independent factors using multilevel logistic regression analysis, and the population attributable risk estimates of factors associated with non-utilization of PNC were also calculated. Results There were 1443 newborns (37%) in Pakistan whose mothers did not utilize PNC check-ups in the first 2 days after delivery. The non-utilization of PNC was largely attributable to newborns delivered at non-health facilities 53% (47% to 59%) and those born to uneducated women 27% (13% to 38%). Adjusted analyses indicated that newborns with higher birth order and with a birth interval of more than 2 years, women who perceived their baby to be small at birth, women with no formal education and those living in regional areas of Khyber Pakhtunkhwa and Federally Administered Tribal Areas were significantly associated with non-utilization of PNC services. Conclusions Tailored health messages by community health workers, including door-to-door visits on utilizing health facilities through pregnancy to the postnatal periods, are needed and should target places of low socioeconomic status, including educationally disadvantaged women from regional areas of Pakistan.

Population Attributable Risk of Hyperuricemia in Hypertension Incidence in 20-74-Year-Old Population during a 10-Year Longitudinal Cohort: Yazd Healthy Heart Cohort.

Background:The population attributable risk (PAR) percent has used widely in public health policy. We aimed to calculate the attribute risk of hypertension due to hyperuricemia by Levin’s formulas compare to direct PAR calculation method.Methods:This was a sub-study of Yazd Healthy Heart Cohort (YHHC). Overall, 1256 normotensive individuals were enrolled through multistage randomized cluster sampling and followed up for mean 9.8 years, from 2005–2015. The threshold cutoff point of the hyperuricemia was considered equal and more than 75th percentile that equal to 5.5 mg/dl for men and 4.3mg/dl for women. To calculate the attributable risk of hyperuricemia in developing hypertension, two methods were applied. Levin’s formulas and direct PAR estimation by population risk calculation via exposure prevalence weighted formula. Multiple logistic regression was used for estimate of odds ratio (OR) of hyperuricemia in developing hypertension. We calculated Relative Risk (RR) from OR. The data were analyzed using SPSS software version 16. A significant level of 0.05 was considered.Results:Hypertension developed in 44.7% of individuals with uric acid level ≥ 75th percentile vs. 35.6% of other individuals (P=0.024). Attributable risk (AR) of hyperuricemia in hypertension incidence was 9.1%. PAR of hyperuricemia for hypertension incidence by using two methods mentioned before was 6%, 5.8% respectively.Conclusion:The results of the study confirmed the noticeable contribution of hyperuricemia as an independent other risk factor for the occurrence of hypertension. PAR of hyperuricemia for hypertension incidence by using two methods almost near was 6%, 5.8% respectively.

Prior sleep problems and adverse post-traumatic neuropsychiatric sequelae of motor vehicle collision in the AURORA study.

Many patients in Emergency Departments (EDs) after motor vehicle collisions (MVCs) develop post-traumatic stress disorder (PTSD) or major depressive episode (MDE). This report from the AURORA study focuses on associations of pre-MVC sleep problems with these outcomes 8 weeks after MVC mediated through peritraumatic distress and dissociation and 2-week outcomes. A total of 666 AURORA patients completed self-report assessments in the ED and at 2 and 8 weeks after MVC. Peritraumatic distress, peritraumatic dissociation, and pre-MVC sleep characteristics (insomnia, nightmares, daytime sleepiness, and sleep duration in the 30 days before the MVC, trait sleep stress reactivity) were assessed retrospectively in the ED. The survey assessed acute stress disorder (ASD) and MDE at 2 weeks and at 8 weeks assessed PTSD and MDE (past 30 days). Control variables included demographics, MVC characteristics, and retrospective reports about PTSD and MDE in the 30 days before the MVC. Prevalence estimates were 41.0% for 2-week ASD, 42.0% for 8-week PTSD, 30.5% for 2-week MDE, and 27.2% for 8-week MDE. Pre-MVC nightmares and sleep stress reactivity predicted 8-week PTSD (mediated through 2-week ASD) and MDE (mediated through the transition between 2-week and 8-week MDE). Pre-MVC insomnia predicted 8-week PTSD (mediated through 2-week ASD). Estimates of population attributable risk suggest that blocking effects of sleep disturbance might reduce prevalence of 8-week PTSD and MDE by as much as one-third. Targeting disturbed sleep in the immediate aftermath of MVC might be one effective way of reducing MVC-related PTSD and MDE.

High suicide rates during psychiatric inpatient stay and shortly after discharge

Over recent decades, intense efforts to address suicides in psychiatric admitted people have been initiated. The aim was to calculate suicide rates, rate ratios, population attributable risks (PAR) and trends among people admitted to or recently discharged from psychiatric wards. Using a cohort design, we obtained nationwide register data on 6292932 individuals aged 15+ living in Denmark during 1995-2016. Of these, 178703 (5.73%) males and 201033 females (6.33%) had been admitted to psychiatric hospital. Incidence rate ratios (IRR) were obtained using Poisson regression analyses while adjusting for age and calendar period. Trends were assessed using joinpoint analyses. In total, 15075 persons died by suicide, of which 6174 had been psychiatrically admitted. Among males, the suicide rate during the first week of admission and after discharge was 3409 and 3148 per 100000 person-years, respectively. The corresponding values for females were 1267 and 1631. Generally, estimated suicide rates were highest in those with affective or anxiety stress disorders. During first week of hospitalization, the IRR was 237 for males and of 322 for females when compared with those never hospitalized. In first week after discharge, the IRR was 225 and 425 for males and females, respectively. PAR estimates indicated 6% of male suicides and 13% of female suicides attributes to first week of admission and discharge. The inpatient suicide rate decreased annually 2.5% until 2009 followed by a 7.5% annual percentage increase. The suicide rate after discharge decreased steadily annually over the study period. Despite finding declining post-discharge suicide rates, the period surrounding a psychiatric admission was still associated with extremely high suicide rates.

Population attributable risk estimates of risk factors for contrast-induced acute kidney injury following coronary angiography: a cohort study

BackgroundContrast-induced acute kidney injury (CI-AKI) is a common complication with poor outcomes following coronary angiography (CAG) or percutaneous coronary intervention (PCI). However, no study has explored the population attributable risks (PARs) of the CI-AKI risk factors. Therefore, we aimed to identify the independent risk factors of CI-AKI and estimate their PARs.MethodsWe analyzed 3450 consecutive patients undergoing CAG/PCI from a prospective cohort in Guangdong Provincial People’s Hospital. CI-AKI was defined as a serum creatinine elevation ≥50% or 0.3 mg/dL from baseline within the first 48 to 72 h after the procedure. Independent risk factors for CI-AKI were evaluated through stepwise approach and multivariable logistic regression analysis, and those that are potentially modifiable were of interest. PARs of independent risk factors were calculated with their odds ratios and prevalence among our cohort.ResultsThe overall incidence of CI-AKI was 7.19% (n = 248), which was associated with increased long-term mortality. Independent risk factors for CI-AKI included heart failure (HF) symptoms, hypoalbuminemia, high contrast volume, hypotension, hypertension, chronic kidney disease stages, acute myocardial infarction and age > 75 years. Among the four risk factors of interest, the PAR of HF symptoms was the highest (38.06%), followed by hypoalbuminemia (17.69%), high contrast volume (12.91%) and hypotension (4.21%).ConclusionsThese modifiable risk factors (e.g., HF symptoms, hypoalbuminemia) could be important and cost-effective targets for prevention and treatment strategies to reduce the risk of CI-AKI. Intervention studies targeting these risk factors are needed.

Abstract C070: Racial disparities in body mass index and ovarian cancer risk in the OCWAA Consortium

Abstract Objective: Obesity disproportionately affects African American (AA) women, and there is some suggestion that its association with ovarian cancer risk may be stronger among AA compared to white women, but no study to date has been adequately powered to compare risk between the two populations. The Ovarian Cancer in Women of African Ancestry (OCWAA) Consortium provided a unique opportunity to evaluate the association between body mass index (BMI) and invasive epithelial ovarian cancer (EOC) risk in AA and white women and to estimate the contribution of obesity to ovarian cancer risk in both racial groups. Methods: The OCWAA Consortium is a collaboration of six of the largest epidemiologic studies of ovarian cancer in the United States that include AA women: four case-control and two case-control studies nested within cohort studies. The six studies are the Chicago Case-Control Study, the North Carolina Ovarian Cancer Study, the Los Angeles Ovarian Cancer Case-Control Studies, the African American Cancer Epidemiology Study, the Black Women’s Health Study, and the Multiethnic Cohort. BMI before diagnosis was available in all the studies and data on BMI and relevant confounders were harmonized for analyses. There were 1,144 AA cases, 2,910 AA controls, 3,174 white cases, and 9,160 white controls included. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were computed using random-effects multi-level logistic regression models separately by race and histotype with control for relevant covariates, which included study, age, education, parity, oral contraceptive use, age at menarche and family history of breast/ovarian cancer. Multinomial regression was used for histotype analyses. Population attributable risk (PAR) estimates were computed by race and histotype. Results: The prevalence of obesity (BMI≥30 kg/m2) was higher in AAs compared to white women for both cases (53.2% vs 21.4%) and controls (45.7% vs. 18.4%). For EOC, there was little evidence of an association with obesity for white women. For AAs, risk was elevated for BMI≥30 kg/m2 (ORBMI 30-34=1.37, 95% CI: 1.12, 1.69; ORBMI≥35 = 1.26, 95% CI: 0.74, 2.15) relative to BMI 18.5-&amp;lt;25 kg/m2. There was an elevated risk for non-high-grade serous EOC for both AA and white women (for AA women, ORBMI 30-34=1.67, 95% CI: 1.14, 2.44 and ORBMI≥35 = 1.76; 95% CI: 0.84, 3.69; for white women, ORBMI ≥35 = 1.39; 95% CI: 1.06, 1.82), but not for high-grade serous EOC. The PAR for BMI≥30 was 7.1% (95% CI: 2.4, 15.6) for AAs and 2.6% (95% CI: -0.3, 5.4) for whites for all EOC. For non-high-grade serous EOC, the PAR was 16.5% (95% CI: 3.4, 28.2) for AAs and 6.4% (95% CI: 2.2, 10.3) for whites. Conclusions: Obesity was a contributor to overall EOC risk among AA women but not among white women. Obesity did not contribute to the risk of high-grade serous EOC for AAs or whites, but it was associated with non-high-grade serous cases among both AA and white women. The association with non-high-grade serous EOC was greater among AAs than whites. Citation Format: Elisa V Bandera, Fabian Camacho, Deanna Chyn, Emily K Cloyd, Traci N Bethea, Alicia Beeghly-Fadiel, Charlotte E Joslin, Evan Myers, Patricia G Moorman, Heather M Ochs-Balcom, Holly R Harris, Lauren C Peres, Veronica Wendy Setiawan, Anna H Wu, Lynn Rosenberg, Joellen M Schildkraut. Racial disparities in body mass index and ovarian cancer risk in the OCWAA Consortium [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C070.

Assessing the Relationship Between School Failure and Suicidal Behavior in Adolescents and Young Adults: A Systematic Review and Meta-analysis of Longitudinal Studies

There is an increasing acknowledgment that suicidal behaviors are negatively affected by school failure in adolescents and young adults. However, no systematic reviews with meta-analysis have been performed to evaluate the strength of this association. We assessed the magnitude of association of school failure as risk factor for suicide behavior in adolescents and young adults. Six international databases were searched up until January 2017. Inclusion criteria were: (1) assessment of suicide attempt or suicide; (2) case–control or cohort studies; (3) subjects aged 12–26 years; (4) school failure evaluated, which includes low academic performance, school dropout, school expulsion, and grade repetition. Random effect models were used; population attributable risks (PARs) were estimated. From 26,883 potentially eligible articles, 14 (62,298 individuals) were included. Meta-analyses could only be performed for suicide attempt. A history of school dropout (OR 6.44, 95% CI 3.03–13.65), low academic performance (OR 1.48, 95% CI 1.22–1.81), and school failure (OR 1.98, 95% CI 1.49–2.64) were significant risks of suicide attempts. Highest PAR estimates were 9.9% for school dropout, 5.1% for low academic performance, and 6.7% for any school failure. Only one study has been found for suicide, but results suggest an association with school dropout. Results show that the students who had school failure are at higher risk of suicide attempt and probably for suicide. The development of effective programs to prevent suicidal behaviors in educational settings may be an effective strategy to reduce these behaviors. However, reliable conclusions from this review are limited by the small amount of included studies for analysis. PROSPERO Registration Number CRD42013005775.

A comparison of approaches for estimating combined population attributable risks (PARs) for multiple risk factors

Abstract Objectives The methods to estimate the population attributable risk (PAR) of a single risk factor or the combined PAR of multiple risk factors have been extensively studied and well developed. Ideally, the estimation of combined PAR of multiple risk factors should be based on large cohort studies, which account for both the joint distributions of risk exposures and for their interactions. However, because such individual-level data are often lacking, many studies estimate the combined PAR using a comparative risk assessment framework. It involves estimating PAR of each risk factor based on its prevalence and relative risk, and then combining the individual PARs using an approach that relies on two key assumptions: that the distributions of exposures to the risk factors are independent and that the relative risks are multiplicative. While such assumptions rarely hold true in practice, no studies have investigated the magnitude of bias incurred if the assumptions are violated. Methods Using simulation-based models, we compared the combined PARs obtained with this approach to the more accurate estimates of PARs that are available when the joint distributions of exposures and risks can be established. Results We show that the assumptions of exposure independence and risk multiplicativity are sufficient but not necessary for the combined PAR to be unbiased. In the simplest situation of two risk factors, the bias of this approach is a function of the strength of association and the magnitude of risk interaction, for any values of exposure prevalence and their associated risks. In some cases, the combined PAR can be strongly under- or over-estimated, even if the two assumptions are only slightly violated. Conclusions We encourage researchers to quantify likely biases in their use of the M–S method, and here, we provided level plots and R code to assist.

Association of puberty timing with type 2 diabetes: A systematic review and meta-analysis

BackgroundEmerging studies have investigated the association between puberty timing, particularly age at menarche (AAM), and type 2 diabetes. However, whether this association is independent of adiposity is unclear. We aimed to systematically review published evidence on the association between puberty timing and type 2 diabetes (T2D) or impaired glucose tolerance (IGT), with and without adjustment for adiposity, and to estimate the potential contribution of puberty timing to the burden of T2D in the United Kingdom (UK).Methods and findingsWe searched PubMed, Medline, and Embase databases for publications until February 2019 on the timing of any secondary sexual characteristic in boys or girls in relation to T2D/IGT. Inverse-variance-weighted random-effects meta-analysis was used to pool reported estimates, and meta-regression was used to explore sources of heterogeneity. Twenty-eight observational studies were identified. All assessed AAM in women (combined N = 1,228,306); only 1 study additionally included men. In models without adjustment for adult adiposity, T2D/IGT risk was lower per year later AAM (relative risk [RR] = 0.91, 95% CI 0.89–0.93, p < 0.001, 11 estimates, n = 833,529, I2 = 85.4%) and higher for early versus later menarche (RR = 1.39, 95% CI 1.25–1.55, p < 0.001, 23 estimates, n = 1,185,444, I2 = 87.8%). Associations were weaker but still evident in models adjusted for adiposity (AAM: RR = 0.97 per year, 95% CI 0.95–0.98, p < 0.001, 12 estimates, n = 852,268, I2 = 51.8%; early menarche: RR = 1.19, 95% CI 1.11–1.28, p < 0.001, 21 estimates, n = 890,583, I2 = 68.1%). Associations were stronger among white than Asian women, and in populations with earlier average AAM. The estimated population attributable risk of T2D in white UK women due to early menarche unadjusted and adjusted for adiposity was 12.6% (95% CI 11.0–14.3) and 5.1% (95% CI 3.6–6.7), respectively. Findings in this study are limited by residual and unmeasured confounding, and self-reported AAM.ConclusionsEarlier AAM is consistently associated with higher T2D/IGT risk, independent of adiposity. More importantly, this research has identified that a substantial proportion of T2D in women is related to early menarche, which would be expected to increase in light of global secular trends towards earlier puberty timing. These findings highlight the need to identify the underlying mechanisms linking early menarche to T2D/IGT risk.

Association between Plasma N-6 Polyunsaturated Fatty Acids Levels and the Risk of Cardiovascular Disease in a Community-based Cohort Study

Most studies support that saturated fatty acid replacement with polyunsaturated fatty acids (PUFAs) may reduce the risk of cardiovascular diseases (CVDs) and put emphasis on the effects of N-3 PUFAs. The reported relationships between N-6 PUFAs and CVD risks vary. We aimed to examine the associations between N-6 PUFA concentrations and CVD risks. In this community-based prospective cohort study on CVD-free patients at baseline (N = 1835, age: 60.6 ± 10.5 years, women: 44.5%), we measured the fatty acid concentrations in the blood using gas chromatography. Four hundred twenty-four participants developed CVDs during follow up. The total N-6 PUFA concentration was inversely associated with the CVD risk, with a 48% lower risk in the highest N-6 PUFA concentration quartile (hazard ratio = 0.52; P for trend <0.001). The estimated population attributable risk of N-6 PUFAs indicated that approximately 20.7% of CVD events would have been prevented if the plasma N-6 PUFA concentration had been higher than the median value. The total N-6 PUFA concentration presented the highest net reclassification improvement (NRI = 7.2%, P = 0.03) for predicting incident CVD. Further studies on N-6 PUFAs, diet habits, and their relationships with healthcare are warranted.