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

Venous thromboembolism incidence and association with overall survival in pancreatic cancer: A Finnish nationwide cohort study

INTRODUCTION

Pancreatic cancer (PC) is associated with a high risk of venous thromboembolic events (VTEs). We investigated the incidence of VTE before and after the diagnosis of PC and its association with overall survival.

METHODS

We identified PC patients diagnosed in 2013-2016 from the Finnish Cancer Registry. Data on healthcare visits and death were collected, along with follow-up data through the end of 2020. We compared patients who underwent radical-intent surgery (RIS) to those who underwent palliative treatment (PT) alone.

RESULTS

We identified 4086 PC patients, of whom 343 (8.4%) underwent RIS and 3743 (91.6%) received PT. VTE incidence within 1 year before a PC diagnosis was higher in the PT (4.2%, n = 156) than in the RIS group (0.6%, n = 2; p < 0.001). The cumulative incidence of VTE at 12 and 24 months after a PC diagnosis was 6% (n = 21) and 9% (n = 31), respectively, within the RIS group, and 8% (n = 286) and 8% (n = 304) within the PT group. In the PT group, a VTE within 1 year before a PC diagnosis was independently associated with a worse survival {hazard ratio, HR 1.9 [95% confidence interval (CI) 1.6-2.2]}. In both groups, VTE after a PC diagnosis was associated with a worse survival [RIS group: HR 2.6 (95%CI 1.8-3.7) vs. PT group: HR 2.2 (95%CI 1.9-2.4)].

CONCLUSIONS

A VTE within 1 year before a PC diagnosis more often occurred among PT PC patients than among patients who underwent RIS. VTE might serve as a diagnostic clue to detect PC at an earlier stage.

Common hepatic artery lymph node metastasis in pancreatic ductal adenocarcinoma: an analysis of actual survival

BACKGROUND

The common hepatic artery lymph node (CHALN) represents a second-echelon node for tumors in the head of the pancreas. Although early studies suggested survival was comparable between the CHALN and remote metastasis in pancreatic ductal adenocarcinoma (PDAC), whether the lymph node is associated with adverse survival remains equivocal. Here, we examined a prospective cohort of patients calculating actual survival to better understand implications of this specific lymph node metastasis.

METHODS

We studied 215 patients with pancreatic head PDAC, who underwent pancreaticoduodenectomies at a single institution between 2010 and 2017, wherein the CHALNs were excised. We performed actual and actuarial overall survival and disease-free survival (DFS) analyses, with subsequent univariate and multivariate analyses in node-positive patients.

RESULTS

Of this cohort, 7.3% of patients had involvement of the CHALN, and all of them had metastatic spread to first-echelon nodes. Actual median survival of patients with no lymph node involvement was 49 months. In patients with any nodal involvement, the survival was no different when comparing the lymph node positive and negative (13 and 20 months, respectively). Univariate and multivariate analyses likewise attached no significance to the lymph node metastasis, while demonstrating worse survival with positive margin status and poorly differentiated histology. Our DFS analyses yielded similar results.

CONCLUSION

We found no difference in actual survival in node-positive patients regardless of the CHALN involvement and recommended against its assessment in prognosticating survival or guiding surgical treatment.

Establishment and validation of a nomogram model for predicting the specific mortality risk of melanoma in upper limbs based on the SEER database

For patients with upper limb melanoma, the significance of specific death is more important than that of all-cause death, and traditional survival analysis may overestimate the mortality rate of patients. Therefore, the nomogram model for predicting the specific mortality risk of melanoma in the upper limbs was developed. A population with melanoma in the upper limbs, diagnosed from 2010 to 2015, were selected from the National Cancer Institute database of Surveillance, Epidemiology, and End Results (SEER). The independent predictive factors of specific death were confirmed by the competing risk model of one-factor analysis and multi-factor analysis, and the nomogram was constructed according to the independent predictive factors. 17,200 patients with upper limb melanoma were enrolled in the study (training cohort: n = 12,040; validation cohort: n = 5160). Multi-factor analysis of the competing risk model showed that age, marital status, gender, tumor stage, T stage, M stage, regional lymph node surgery information, radiotherapy, chemotherapy, mitotic cell count, ulcer and whether there were multiple primary cancers, were independent factors affecting the specific death of upper limb melanoma patients (P < 0.05). The nomogram has good predictive ability regarding the specific mortality risk of melanoma in the upper limbs, and could be of great help to formulate prognostic treatment strategies and follow-up strategies that are conducive to survival.

Improved 30-Day Survival Estimation in ICU Patients: A Comparative Analysis of Different Approaches With Real-World Data

OBJECTIVES

The objective of this study was to compare three different approaches for estimating 30-day survival in ICU studies, considering the issue of informative censoring that occurs when patients are lost to follow-up after discharge.

DESIGN

A comparative analysis was conducted to evaluate the effect of different approaches on the estimation of 30-day survival. Three methods were compared: the classical approach using the Kaplan-Meier (KM) estimator and Cox regression modeling, the competing risk approach using the Fine and gray model, considering censoring as a competing event, and the logistic regression approach.

SETTING

The study was conducted in a university ICU and data from patients admitted between 2010 and 2020 were included. Patient characteristics were collected from electronic records.

PATIENTS

A total of 10,581 patients were included in the study. The true date of death for each patient, obtained from a national registry, allowed for an absence of censoring.

INTERVENTIONS

All patients were censored at the time of discharge from the ICU, and the three different approaches were applied to estimate the mortality rate and the effects of covariates on mortality. Regression analyses were performed using five variables known to be associated with ICU mortality.

MEASUREMENTS AND MAIN RESULTS

The 30-day survival rate for the included patients was found to be 80.5% (95% CI, 79.7-81.2%). The KM estimator severely underestimated the 30-day survival (50.6%; 95% CI, 48.0-53.4%), while the competing risk and logistic regression approaches provided similar results, only slightly overestimating the survival rate (84.5%; 95% CI, 83.8-85.2%). Regression analyses showed that the estimates were not systematically biased, with the Cox and logistic regression models exhibiting greater bias compared with the competing risk regression method.

CONCLUSIONS

The competing risk approach provides more accurate estimates of 30-day survival and is less biased compared with the other methods evaluated.

Development and evaluation of nomograms and risk stratification systems to predict the overall survival and cancer-specific survival of patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer, and patients with HCC have a poor prognosis and low survival rates. Establishing a prognostic nomogram is important for predicting the survival of patients with HCC, as it helps to improve the patient's prognosis. This study aimed to develop and evaluate nomograms and risk stratification to predict overall survival (OS) and cancer-specific survival (CSS) in HCC patients. Data from 10,302 patients with initially diagnosed HCC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2017. Patients were randomly divided into the training and validation set. Kaplan-Meier survival, LASSO regression, and Cox regression analysis were conducted to select the predictors of OS. Competing risk analysis, LASSO regression, and Cox regression analysis were conducted to select the predictors of CSS. The validation of the nomograms was performed using the concordance index (C-index), the Akaike information criterion (AIC), the Bayesian information criterion (BIC), Net Reclassification Index (NRI), Discrimination Improvement (IDI), the receiver operating characteristic (ROC) curve, calibration curves, and decision curve analyses (DCAs). The results indicated that factors including age, grade, T stage, N stage, M stage, surgery, surgery to lymph node (LN), Alpha-Fetal Protein (AFP), and tumor size were independent predictors of OS, whereas grade, T stage, surgery, AFP, tumor size, and distant lymph node metastasis were independent predictors of CSS. Based on these factors, predictive models were built and virtualized by nomograms. The C-index for predicting 1-, 3-, and 5-year OS were 0.788, 0.792, and 0.790. The C-index for predicting 1-, 3-, and 5-year CSS were 0.803, 0.808, and 0.806. AIC, BIC, NRI, and IDI suggested that nomograms had an excellent predictive performance with no significant overfitting. The calibration curves showed good consistency of OS and CSS between the actual observation and nomograms prediction, and the DCA showed great clinical usefulness of the nomograms. The risk stratification of OS and CSS was built that could perfectly classify HCC patients into three risk groups. Our study developed nomograms and a corresponding risk stratification system predicting the OS and CSS of HCC patients. These tools can assist in patient counseling and guiding treatment decision making.

Incidence of adhesive small bowel obstruction after surgery for colorectal cancer in Sweden 2007-2016

AIM

Population-based data on incidence and risk factors of adhesive small bowel obstruction (SBO) are limited. The aims of this study were to assess the risk of SBO and SBO surgery after bowel resection for colorectal cancer (CRC) and to assess whether this risk is modified by minimally invasive surgery (MIS) and radiotherapy in a retrospective national study.

METHODS

CRCBaSe, a nationwide register linkage originating from the Swedish Colorectal Cancer Register, was used to identify Stage I-III CRC patients who underwent resection in 2007-2016, with follow-up throughout 2017. Matched CRC-free comparators (1:6) were included as a reference of SBO and SBO surgery incidence. The association between MIS and preoperative radiotherapy and the incidence rate of SBO was evaluated in adjusted multivariable Cox regression models.

RESULTS

Among 33 632 CRC patients and 198 649 comparators, the 5-year cumulative incidence of SBO and SBO surgery was 7.6% and 2.2% among patients and 0.6% and 0.2% among comparators, with death as a competing risk. In all patients, MIS was associated with a reduced incidence of SBO (hazard ratio [HR] 0.7, 95% CI 0.6-0.8) and SBO surgery (HR 0.5, 95% CI 0.3-0.7). In rectal cancer patients, radiotherapy was associated with an increased incidence of SBO (HR 1.6, 95% CI 1.4-1.8) and SBO surgery (HR 1.7, 95% CI 1.3-2.3).

DISCUSSION

Colorectal cancer surgery is associated with a marked increase in risk of SBO, compared with the general population. The incidence is further increased if open surgery or radiotherapy is performed.

GPER governs the immune infiltration of gastric cancer and activates the NF-κB/ROS/Apoptosis pathway in gastric mucosal epithelium

BACKGROUND

Gastric cancer (GC) is with high mortality and morbidity. The GC morbidity of males is twice as high as that of females. G-protein estrogen receptor (GPER) bears on this phenomenon.

METHODS

Networks and experiments assessed the GPER expression in different validity and content. The evidence-based practice involved accessing the clinical relevance of GPER by UALCAN and Kaplan-Meier plotter. Enrichment analyses contributed to guide further experimental validations. Activation of the NF-κB/ROS/Apoptosis pathway was analyzed by WB, immunofluorescence (IF), microplate reader and flow cytometry. TISIDB and TIMER identified the immune infiltration investigations, with credibility boosted by the Kaplan-Meier plotter.

RESULTS

The appraisers revealed that GPER significantly decreased in GC at both gene and protein levels with highly approved prognosis value (P < 0.05). GPER was a significant fate determinant governing the inner part of gastric glands. NF-κB pathway and the following ROS in gastric cells were activated after MNU stimulation (20 μM, 24 h), and the GPER antagonist G15 strengthened the effect of MNU. Furthermore, GPER expression positively correlated with immune cells and various immune markers in GC patients, with highly approved clinical relevance. For example, type-2 helper cells enriched GC patients had a lower survival rate in the GPER-high expression group (P < 0.05).

CONCLUSION

We demonstrated that GPER governs the GC progression by activating the NF-κB/ROS/Apoptosis pathway in gastric cells and regulating the immune environment around them.

Small RNA sequencing identified miR-3180 as a potential prognostic biomarker for Chinese hepatocellular carcinoma patients

MicroRNAs (miRNAs) and their target genes are aberrantly expressed in many cancers and are linked to carcinogenesis and metastasis, especially among hepatocellular carcinoma (HCC) patients. This study sought to identify new biomarkers related to HCC prognosis using small RNA sequencing from the tumor and matched normal adjacent tissue of 32 patients with HCC. Eight miRNAs were downregulated and 61 were upregulated more than twofold. Of these, five miRNAs, hsa-miR-3180, hsa-miR-5589-5p, hsa-miR-490-5p, hsa-miR-137, and hsa-miR-378i, were significantly associated with 5-year overall survival (OS) rates. Differential upregulation of hsa-miR-3180 and downregulation of hsa-miR-378i in tumor samples supported the finding that low and high concentrations of hsa-miR-3180 (p = 0.029) and hsa-miR-378i (p = 0.047), respectively, were associated with higher 5-year OS. Cox regression analyses indicated that hsa-miR-3180 (HR = 0.08; p = 0.013) and hsa-miR-378i (HR = 18.34; p = 0.045) were independent prognostic factors of poor survival. However, high hsa-miR-3180 expression obtained larger AUCs for OS and progression-free survival (PFS) and had better nomogram prediction than hsa-miR-378i. These findings indicate that hsa-miR-3180 may be associated with HCC progression and could serve as a potential biomarker for this disease.

Competing risk nomogram for predicting prognosis of patients with spinal and pelvic chordoma: A SEER-based retrospective study

PURPOSE

Recently, competing risk nomograms were widely applied to predict prognosis in numerous tumors other than chordoma. Here, we aimed to construct and validate a competing-risk-based prognostic nomogram to predict 3- and 5-year cancer-specific death (CSD) in patients with spinal and pelvic chordoma.

METHODS

All chordoma patient data were abstracted from the Surveillance, Epidemiology, and End Results (SEER) resource, and a total of 485 chordoma patients were eventually included in this study. Multivariate competing risk model and multivariate Cox model were used to determine independent prognostic factors, respectively, and the results of the two models were compared. Nomogram was employed to visualize the competing risk model. The discrimination, calibration, and clinical utility of this model were evaluated by Harrell concordance index (C-index), time-dependent receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). Ten-fold cross-validation was further utilized to validate the prognostic nomogram.

RESULTS

Significant prognostic factors affecting CSD were age (P = 0.016), localized involvement (P < 0.0001), and radical resection (P < 0.001) in the multivariate competing risk model. C-indexes were 0.799 and 0.76, and AUC were 0.812 and 0.778 for 3- and 5-year CSD. Calibration plots demonstrated the nomogram was well-fitted, and DCA indicated good clinical utility. The nomogram showed good performance in the 10-fold cross-validation.

CONCLUSION

We successfully built the first competing-risk-based nomogram to predict clinical outcomes in patients with spinal and pelvic chordoma. This well-established nomogram hopes to help clinicians with precise prognostic assessment and thus improve clinical outcomes.

Risk of Colorectal Cancer and Colorectal Cancer Mortality Beginning Ten Years after a Negative Colonoscopy, among Screen-Eligible Adults 76 to 85 Years Old

BACKGROUND

Few empirical data are available to inform older adults' decisions about whether to screen or continue screening for colorectal cancer based on their prior history of screening, particularly among individuals with a prior negative exam.

METHODS

Using a retrospective cohort of older adults receiving healthcare at three Kaiser Permanente integrated healthcare systems in Northern California (KPNC), Southern California (KPSC), and Washington (KPWA), we estimated the cumulative risk of colorectal cancer incidence and mortality among older adults who had a negative colonoscopy 10 years earlier, accounting for death from other causes.

RESULTS

Screen-eligible adults ages 76 to 85 years who had a negative colonoscopy 10 years earlier were found to be at a low risk of colorectal cancer diagnosis, with a cumulative incidence of 0.39% [95% CI, 0.31%-0.48%) at 2 years that increased to 1.29% (95% CI, 1.02%-1.61%) at 8 years. Cumulative mortality from colorectal cancer was 0.04% (95% CI, 0.02%-0.08%) at 2 years and 0.46% (95% CI, 0.30%-0.70%) at 8 years.

CONCLUSIONS

These low estimates of cumulative colorectal cancer incidence and mortality occurred in the context of much higher risk of death from other causes.

IMPACT

Knowledge of these results could bear on older adults' decision to undergo or not undergo further colorectal cancer screening, including choice of modality, should they decide to continue screening. See related commentary by Lieberman, p. 6.

Superior survival for breast-conserving therapy over mastectomy in patients with breast cancer: A population-based SEER database analysis across 30 years

Introduction

It has been believed that breast-conserving therapy (lumpectomy plus adjuvant radiation, Lum + RT) and mastectomy without radiation (Mast + NoRT) have equivalent survival outcomes. However, there is a need to re-evaluate the role of lumpectomy plus adjuvant radiation due to changed breast cancer management over time. This study aimed to conduct a population-based study that compare long-term oncologic survival outcomes after Lum + RT vs Mast + NoRT.

Methods

The Surveillance, Epidemiology and End Results database was used to identify female breast cancer patients with a primary localized breast cancer diagnosis from 1988 to 2018. The standardized incidence/mortality ratio (SIR/SMR) for breast cancer recurrence (BCR) and breast cancer-specific death (BSD) was estimated by the SEER*Stat program. Cumulative incidences of BCR and BSD were assessed using Gray's method. We evaluated the effects of Lum + RT vs. Mast + NoRT on breast cancer recurrence-free survival (BRFS) and breast cancer-specific survival (BCSS). Fine-Gray competing risk model analyses, propensity score-adjusted Kaplan-Meier analyses and Cox proportional hazards model analyses were applied.

Results

A total of 205,788 women were included in the study. Patients who underwent Lum + RT had higher SIR of BCR (4.14 [95% confidence interval, CI: 3.94-4.34] vs. 1.11 [95% CI: 1.07-1.14]) and lower SMR (9.89 [95% CI: 9.71-10.08] vs. 17.07 [95% CI: 16.82-17.33]) than patients who underwent Mast + NoRT. Lum + RT was associated with higher competing risk of BCR (adjusted hazard ratio [HR]: 1.996, 95% CI: 1.925-2.069, p < 0.001) and lower competing risk of BSD when compared to Mast + RT (adjusted HR: 0.584, 95% CI: 0.572-0.597, p < 0.001). Multivariate Cox regression analysis revealed similar results (adjusted HR after PSW for BRFS: 1.792, 95% CI 1.716-1.871, p < 0.001; adjusted HR after PSW for BCSS: 0.706, 95% CI 0.688-0.725, p < 0.001). These findings persisted in the sensitivity and subgroup analyses.

Discussion

The present study further confirmed superior long-term survival with lumpectomy plus adjuvant radiation over mastectomy independent of patient characteristics including age, race, time period, historic subtype, tumor size, historic grade and stage, indicating that this benefit may result from the treatment itself.

Identification and validation of a new pyroptosis-associated lncRNA signature to predict survival outcomes, immunological responses and drug sensitivity in patients with gastric cancer

BACKGROUND

Gastric cancer (GC) ranks fifth in prevalence among carcinomas worldwide. Both pyroptosis and long noncoding RNAs (lncRNAs) play crucial roles in the occurrence and development of gastric cancer. Therefore, we aimed to construct a pyroptosis-associated lncRNA model to predict the outcomes of patients with gastric cancer.

METHODS

Pyroptosis-associated lncRNAs were identified through co-expression analysis. Univariate and multivariate Cox regression analyses were performed using the least absolute shrinkage and selection operator (LASSO). Prognostic values were tested through principal component analysis, a predictive nomogram, functional analysis and Kaplan‒Meier analysis. Finally, immunotherapy and drug susceptibility predictions and hub lncRNA validation were performed.

RESULTS

Using the risk model, GC individuals were classified into two groups: low-risk and high-risk groups. The prognostic signature could distinguish the different risk groups based on principal component analysis. The area under the curve and the conformance index suggested that this risk model was capable of correctly predicting GC patient outcomes. The predicted incidences of the one-, three-, and five-year overall survivals exhibited perfect conformance. Distinct changes in immunological markers were noted between the two risk groups. Finally, greater levels of appropriate chemotherapies were required in the high-risk group. AC005332.1, AC009812.4 and AP000695.1 levels were significantly increased in gastric tumor tissue compared with normal tissue.

CONCLUSIONS

We created a predictive model based on 10 pyroptosis-associated lncRNAs that could accurately predict the outcomes of GC patients and provide a promising treatment option in the future.

Risk of incident heart failure after COVID-19 recovery: a systematic review and meta-analysis

Patients recovered from COVID-19 have an increased incidence of cardiovascular disease and heart structural changes. The aim of the present manuscript is to assess the risk of incident heart failure (HF) after COVID-19 infection. Data were obtained searching MEDLINE and Scopus for all studies published at any time up to September 1, 2022 reporting the risk of incident HF in COVID-19 recovered patients. The cumulative post-COVID-19 incidence and risk of incident HF were pooled using a random effects model and presented with the corresponding 95% confidence interval (CI). Statistical heterogeneity was measured using the Higgins I² statistic. Overall, 21,463,173 patients (mean age 54.5 years, 58.7% males) were analyzed. Among them, 1,628,424 had confirmed COVID-19 infection while the remaining 19,834,749 represented the controls. The mean length of follow-up was 9.2 months. A random effect model revealed a pooled incidence of post COVID-19 HF in 1.1% of cases (95% CI: 0.7-1.6, I²: 99.8%). Moreover, recovered COVID-19 patients showed an increased risk of incident HF (HR: 1.90, 95% CI: 1.54-3.24, p < 0.0001, I² = 96.5%) in the same follow-up period. Meta-regression showed a direct relationship for the risk of incident HF using age (p = 0.001) and hypertension (HT) (p = 0.02) as moderators, while an inverse association was observed when the follow-up length was adopted as moderating variable (p = 0.01). COVID-19 survivors had an additional 90% risk of developing HF after COVID-19 infection in the long-term period. This risk was directly related with age and previous history of HT especially in the early post-acute phase of the infection.

Association of Remdesivir Treatment With Mortality Among Hospitalized Adults With COVID-19 in the United States

IMPORTANCE

SARS-CoV-2, which causes COVID-19, poses considerable morbidity and mortality risks. Studies using data collected during routine clinical practice can supplement randomized clinical trials to provide needed evidence, especially during a global pandemic, and can yield markedly larger sample sizes to assess outcomes for important patient subgroups.

OBJECTIVE

To evaluate the association of remdesivir treatment with inpatient mortality among patients with COVID-19 outside of the clinical trial setting.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study in US hospitals using health insurance claims data linked to hospital chargemaster data from December 1, 2018, to May 3, 2021, was conducted among 24 856 adults hospitalized between May 1, 2020, and May 3, 2021, with newly diagnosed COVID-19 who received remdesivir and 24 856 propensity score-matched control patients.

EXPOSURE

Remdesivir treatment.

MAIN OUTCOMES AND MEASURES

All-cause inpatient mortality within 28 days of the start of remdesivir treatment for the remdesivir-exposed group or the matched index date for the control group.

RESULTS

A total of 24 856 remdesivir-exposed patients (12 596 men [50.7%]; mean [SD] age, 66.8 [15.4] years) and 24 856 propensity score-matched control patients (12 621 men [50.8%]; mean [SD] age, 66.8 [15.4] years) were included in the study. Median follow-up was 6 days (IQR, 4-11 days) in the remdesivir group and 5 days (IQR, 2-10 days) in the control group. There were 3557 mortality events (14.3%) in the remdesivir group and 3775 mortality events (15.2%) in the control group. The 28-day mortality rate was 0.5 per person-month in the remdesivir group and 0.6 per person-month in the control group. Remdesivir treatment was associated with a statistically significant 17% reduction in inpatient mortality among patients hospitalized with COVID-19 compared with propensity score-matched control patients (hazard ratio, 0.83 [95% CI, 0.79-0.87]).

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study using health insurance claims and hospital chargemaster data, remdesivir treatment was associated with a significantly reduced inpatient mortality overall among patients hospitalized with COVID-19. Results of this analysis using data collected during routine clinical practice and state-of-the-art methods complement results from randomized clinical trials. Future areas of research include assessing the association of remdesivir treatment with inpatient mortality during the circulation of different variants and relative to time from symptom onset.

MiR-181a reduces radiosensitivity of non-small-cell lung cancer via inhibiting PTEN

BACKGROUND

The aim of this study is to explore the effect of micro ribonucleic acid (miR)-181a on the radiosensitivity of non-small cell lung cancer (NSCLC) and its potential mechanism of action.

METHODS

The differentially expressed miRNAs were screened in lung cancer tissues of radiotherapy-resistant and non-radiotherapy-resistant NSCLC patients, and verified via reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Next, the effects of different miRNA expressions on patients' survival time were discussed, and target genes of miR-181a were predicted. The effect of miR-181a expression on radiosensitivity was determined using cell counting kit-8 (CCK-8) assay and flow cytometry. The direct target of miR-181a was verified via luciferase reporter assay. Phosphatase and tensin homolog deleted on chromosome ten (PTEN) was overexpressed using lentiviruses, and then whether miR-181a reduces radiosensitivity via targeting PTEN was detected via CCK-8 assay and flow cytometry. Finally, Western blotting was performed to detect the protein expression of PTEN.

RESULTS

The screening results of microarray expression profile assay revealed that 15 miRNAs had significant differences in lung cancer tissues of radiotherapy-resistant NSCLC patients compared with those in non-radiotherapy-resistant NSCLC patients. The results of RT-qPCR showed that hsa-miR-181a, hsa-miR-199b, hsa-miR-489 and hsa-miR-589 were significantly up-regulated in the lung cancer tissues of radiotherapy-resistant NSCLC patients compared with those in non-radiotherapy-resistant NSCLC patients. In addition, it was found that the survival time of NSCLC patients was obviously prolonged in hsa-miR-181a low-expression group and hsa-miR-589 high-expression group, but hsa-miR-489 and hsa-miR-199b had no significant influence on the survival time of NSCLC patients. According to KEGG enrichment analysis, the target genes of miR-181a were evidently enriched in the phosphatidylinositol 3-hydroxy kinase (PI3K)/protein kinase B (AKT) signaling pathway, NSCLC signaling pathway and other cancer signaling pathways. Under the radiation dose of 2, 4, 6 and 8 Gy, the survival rate of A549 cells rose in miR-181a mimic group, but declined in miR-181a inhibitor group. Moreover, compared with that in model group, the radiotherapy-induced apoptosis was markedly inhibited in miR-181a mimic group, but markedly promoted in miR-181a inhibitor group. It was also observed that the response of cells to radiotherapy-induced apoptosis was remarkably weakened in miR-181a mimic + PTEN overexpression group compared with that in miR-181a mimic group. Finally, miR-181a mimic group had a significantly lower protein expression of PTEN and significantly higher protein expressions of CXC chemokine receptor 4 (CXCR4), phosphorylated signal transducer and activator of transcription 3 (p-STAT3), p-AKT1 and p-mammalian target of rapamycin (mTOR) than model group, while miR-181a inhibitor group had the opposite protein expressions. The protein expressions of CXCR4, p-STAT3, p-AKT1 and p-mTOR were obviously lower in miR-181a mimic + PTEN overexpression group than those in miR-181a mimic group.

CONCLUSIONS

MiR-181a reduces the radiosensitivity of NSCLC via inhibiting PTEN expression.

Eight hub genes as potential biomarkers for breast cancer diagnosis and prognosis: A TCGA-based study

BACKGROUND

Breast cancer (BC) is the most common malignant tumor in women.

AIM

To investigate BC-associated hub genes to obtain a better understanding of BC tumorigenesis.

METHODS

In total, 1203 BC samples were downloaded from The Cancer Genome Atlas database, which included 113 normal samples and 1090 tumor samples. The limma package of R software was used to analyze the differentially expressed genes (DEGs) in tumor tissues compared with normal tissues. The cluster Profiler package was used to perform Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis of upregulated and downregulated genes. Univariate Cox regression was conducted to explore the DEGs with statistical significance. Protein-protein interaction (PPI) network analysis was employed to investigate the hub genes using the CytoHubba plug-in of Cytoscape software. Survival analyses of the hub genes were carried out using the Kaplan-Meier method. The expression level of these hub genes was validated in the Gene Expression Profiling Interactive Analysis database and Human Protein Atlas database.

RESULTS

A total of 1317 DEGs (fold change > 2; P < 0.01) were confirmed through bioinformatics analysis, which included 744 upregulated and 573 downregulated genes in BC samples. KEGG enrichment analysis indicated that the upregulated genes were mainly enriched in the cytokine-cytokine receptor interaction, cell cycle, and the p53 signaling pathway (P < 0.01); and the downregulated genes were mainly enriched in the cytokine-cytokine receptor interaction, peroxisome proliferator-activated receptor signaling pathway, and AMP-activated protein kinase signaling pathway (P < 0.01).

CONCLUSION

In view of the results of PPI analysis, which were verified by survival and expression analyses, we conclude that MAD2L1, PLK1, SAA1, CCNB1, SHCBP1, KIF4A, ANLN, and ERCC6L may act as biomarkers for the diagnosis and prognosis in BC patients.

Survival in autoimmune hemolytic anemia remains poor, results from a nationwide cohort with 37 years of follow-up

Introduction

Autoimmune hemolytic anemia (AIHA) is considered a chronic disease, with an overall good prognosis. However, recent reports indicate pre‐mature mortality. Causes of death have not been evaluated previously.

Methods

In a nationwide setting, we identified all patients with warm type AIHA or cold agglutinin disease (CAD), and age–sex‐matched comparators from Denmark, 1980–2016. We estimated overall survival and cause‐specific mortality from anemia, infection, cardiovascular causes, hematological or solid cancer, bleeding, or other causes, using cumulative incidence proportions.

Results

We identified 1460 patients with primary AIHA, 1078 with secondary AIHA, 112 with CAD, and 130 801 comparators. One‐year survival and median survival were, 82.7% and 9.8 years for primary AIHA, 69.1% and 3.3 years for secondary AIHA, and 85.5% and 8.8 years for CAD. Prognosis was comparable to the general population only in patients with primary AIHA below 30 years. In all other age and subgroups, the difference was considerable. Cumulated cause‐specific mortality at 1 year was increased among patients versus comparators.

Discussion

All groups of autoimmune hemolytic anemia are associated with increased overall and cause‐specific mortality compared to the general population. This probably reflects unmet needs in both treatment and follow‐up programs.

An advanced network pharmacology study to explore the novel molecular mechanism of Compound Kushen Injection for treating hepatocellular carcinoma by bioinformatics and experimental verification

Background

Compound Kushen Injection (CKI) is a Chinese patent drug that exerts curative effects in the clinical treatment of hepatocellular carcinoma (HCC). This study aimed to explore the targets and potential pharmacological mechanisms of CKI in the treatment of HCC.

Methods

In this study, network pharmacology was used in combination with molecular biology experiments to predict and verify the molecular mechanism of CKI in the treatment of HCC. The constituents of CKI were identified by UHPLC-MS/MS and literature search. The targets corresponding to these compounds and the targets related to HCC were collected based on public databases. To screen out the potential hub targets of CKI in the treatment of HCC, a compound-HCC target network was constructed. The underlying pharmacological mechanism was explored through the subsequent enrichment analysis. Interactive Gene Expression Profiling Analysis and Kaplan-Meier plotter were used to examine the expression and prognostic value of hub genes. Furthermore, the effects of CKI on HCC were verified through molecular docking simulations and cell experiments in vitro.

Results

Network analysis revealed that BCHE, SRD5A2, EPHX2, ADH1C, ADH1A and CDK1 were the key targets of CKI in the treatment of HCC. Among them, only CDK1 was highly expressed in HCC tissues, while the other 5 targets were lowly expressed. Furthermore, the six hub genes were all closely related to the prognosis of HCC patients in survival analysis. Molecular docking revealed that there was an efficient binding potential between the constituents of CKI and BCHE. Experiments in vitro proved that CKI inhibited the proliferation of HepG2 cells and up-regulated SRD5A2 and ADH1A, while down-regulated CDK1 and EPHX2.

Conclusions

This study revealed and verified the targets of CKI on HCC based on network pharmacology and experiments and provided a scientific reference for further mechanism research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03530-3.

The outcome of subsequent revisions after primary total hip arthroplasty in 1,049 patients aged under 50 years : a single-centre cohort study with a follow-up of more than 30 years

AIMS

The aim of this study was to determine the outcome of all primary total hip arthroplasties (THAs) and their subsequent revision procedures in patients aged under 50 years performed at our institution.

METHODS

All 1,049 primary THAs which were undertaken in 860 patients aged under 50 years between 1988 and 2018 in our tertiary care institution were included. We used cemented implants in both primary and revision surgery. Impaction bone grafting was used in patients with acetabular or femoral bone defects. Kaplan-Meier analyses were used to determine the survival of primary and revision THA with the endpoint of revision for any reason, and of revision for aseptic loosening.

RESULTS

The mean age of the patients at the time of the initial THA was 38.6 years (SD 9.3). The mean follow-up of the THA was 8.7 years (2.0 to 31.5). The rate of survival for all primary THAs, acetabular components only, and femoral components only at 20 years' follow-up with the endpoint of revision for any reason, was 66.7% (95% confidence interval (CI) 60.5 to 72.2), 69.1% (95% CI 63.0 to 74.4), and 83.2% (95% CI 78.1 to 87.3), respectively. A total of 138 revisions were performed. The mean age at the time of revision was 48.2 years (23 to 72). Survival of all subsequent revision procedures, revised acetabular, and revised femoral components at 15 years' follow-up with the endpoint of revision for any reason was 70.3% (95% CI 56.1 to 80.7), 69.7% (95% CI 54.3 to 80.7), and 76.2% (95% CI 57.8 to 87.4), respectively. A Girdlestone excision arthroplasty was required in six of 860 patients (0.7%).

CONCLUSION

The long-term outcome of cemented primary and subsequent revision THA is promising in these young patients. We showed that our philosophy of using impaction bone grafting in patients with acetabular and femoral defects is a very suitable option when treating young patients. Surgeons should realize that knowledge of the outcome of subsequent revision surgery, which is inevitable in young patients, must be communicated to this group of patients prior to their initial THA. Cite this article: Bone Joint J 2022;104-B(3):368-375.

Establishment of a Competing Risk Nomogram in Patients with Pulmonary Sarcomatoid Carcinoma

Background and aim: Pulmonary sarcomatoid carcinoma (PSC) is a rare subtype of nonsmall cell lung cancer with a poor prognosis. This study aimed to analyze the clinicopathological characteristics and survival outcomes among patients with PSC, lung squamous cell cancer (SCC), and lung adenocarcinoma (LAC), and to construct a competing risk nomogram for patients with PSC. Method: Data of 3 groups of patients diagnosed with PSC, SCC, or LAC from the surveillance, epidemiology, and end results (SEER) database between 1988 and 2015 were retrospectively reviewed. A 1:1 propensity score matching (PSM) analysis was used to balance the baseline data of patients. Independent risk factors associated with survival outcomes were screened by the least absolute shrinkage and selection operator and further determined by univariate and multivariate Cox proportional risk regression analyses. The overall survival (OS) of patients was evaluated by Kaplan–Meier analysis and compared with a log-rank test. The cumulative incidence function was used to estimate the 5-year probabilities of the cancer-specific mortality of PSC. A nomogram was constructed to illustrate the competing risk model to predict the 3- and 5-year OS, and corresponding concordance indexes (C-indexes) and calibration curves were used to assess and validate the competing risk nomogram. Results: A total of 2285 patients with PSC were included in this study. Compared with SCC and LAC patients, the Kaplan–Meier analysis showed that patients with PSC had a worse prognosis, with a median survival of 5 months (95% confidence interval [CI]: 5-6 months) and a 5-year OS rate of 15.3% (95% CI: 13.9%-16.9%). Similar outcomes were demonstrated after 1:1 PSM. Moreover, the competing risk model showed that age, T stage, M stage, tumor size, lymph node ratio (LNR), surgery, and chemotherapy were associated with PSC-specific mortality. The 5-year C-index of the nomogram was 0.718. Calibration curves illustrated that the nomogram was well-validated and had great accuracy. Conclusions: Patients with PSC had a worse survival outcome compared with SCC or LAC patients. Age, T stage, M stage, tumor size, LNR, surgery, and chemotherapy were associated with PSC-specific mortality. The competing risk nomogram displayed excellent discrimination in predicting PSC-specific mortality.

Nomogram to predict cause-specific mortality of patients with rectal adenocarcinoma undergoing surgery: a competing risk analysis

BACKGROUND

Rectal adenocarcinoma is one of major public health problems, severely threatening people's health and life. Cox proportional hazard models have been applied in previous studies widely to analyze survival data. However, such models ignore competing risks and treat them as censored, resulting in excessive statistical errors. Therefore, a competing-risk model was applied with the aim of decreasing risk of bias and thereby obtaining more-accurate results and establishing a competing-risk nomogram for better guiding clinical practice.

METHODS

A total of 22,879 rectal adenocarcinoma cases who underwent primary-site surgical resection were collected from the SEER (Surveillance, Epidemiology, and End Results) database. Death due to rectal adenocarcinoma (DRA) and death due to other causes (DOC) were two competing endpoint events in the competing-risk regression analysis. The cumulative incidence function for DRA and DOC at each time point was calculated. Gray's test was applied in the univariate analysis and Gray's proportional subdistribution hazard model was adopted in the multivariable analysis to recognize significant differences among groups and obtain significant factors that could affect patients' prognosis. Next, A competing-risk nomogram was established predicting the cause-specific outcome of rectal adenocarcinoma cases. Finally, we plotted calibration curve and calculated concordance indexes (c-index) to evaluate the model performance.

RESULTS

22,879 patients were included finally. The results showed that age, race, marital status, chemotherapy, AJCC stage, tumor size, and number of metastasis lymph nodes were significant prognostic factors for postoperative rectal adenocarcinoma patients. We further successfully constructed a competing-risk nomogram to predict the 1-year, 3-year, and 5-year cause-specific mortality of rectal adenocarcinoma patients. The calibration curve and C-index indicated that the competing-risk nomogram model had satisfactory prognostic ability.

CONCLUSION

Competing-risk analysis could help us obtain more-accurate results for rectal adenocarcinoma patients who had undergone surgery, which could definitely help clinicians obtain accurate prediction of the prognosis of patients and make better clinical decisions.

In-silico analysis unravels the structural and functional consequences of non-synonymous SNPs in the human IL-10 gene

Background

Interleukin-10 (IL-10) is an anti-inflammatory cytokine that affects different immune cells. It is also associated with the stimulation of the T and B cells for the production of antibodies. Several genetic polymorphisms in the IL-10 gene have been reported to cause or aggravate certain diseases like inflammatory bowel disease, rheumatoid arthritis, systemic sclerosis, asthma, etc. However, the disease susceptibility and abnormal function of the mutated IL-10 variants remain obscure.

Results

In this study, we used seven bioinformatics tools (SIFT, PROVEAN, PMut, PANTHER, PolyPhen-2, PHD-SNP, and SNPs&GO) to predict the disease susceptible non-synonymous SNPs (nsSNPs) of IL-10. Nine nsSNPs of IL-10 were predicted to be potentially deleterious: R42G, R45Q, F48L, E72G, M95T, A98D, R125S, Y155C, and I168T. Except two, all of the putative deleterious mutations are found in the highly conserved region of IL-10 protein structure, thus affecting the protein's stability. The 3-D structure of mutant proteins was modeled by project HOPE, and the protein–protein interactions were assessed with STRING. The predicted nsSNPs: R42Q, R45Q, F48L, E72G, and I168T are situated in the binding site region of the IL-10R1 receptor. Disruption of binding affinity with its receptor leads to deregulation of the JAK-STAT pathway and results in enhanced inflammation that imbalance in cellular signaling. Finally, Kaplan–Meier Plotter analysis displayed that deregulation of IL-10 expression affects gastric and ovarian cancer patients' survival rate. Thus, IL-10 could be useful as a potential prognostic marker gene for some cancers.

Conclusion

This study has determined the deleterious nsSNPs of IL-10 that might contribute to the malfunction of IL-10 protein and ultimately lead to the IL-10 associated diseases.

The Effect of Age on Performance of the Kidney Failure Risk Equation in Advanced CKD

Introduction

The Kidney Failure Risk Equation (KFRE) is a clinical tool widely used to predict progression from chronic kidney disease (CKD) to kidney failure. This study aimed to evaluate the effect of age on KFRE performance in advanced CKD.

Methods

We conducted a retrospective cohort study among 1701 consecutive patients referred to an advanced CKD clinic in Ottawa, Canada, between 2010 and 2018. Patients were categorized by age as follows: <60, 60 to 69, 70 to 79, and ≥80 years. Calibration plots compared the predicted (through the KFRE) and observed incidence of kidney failure. Concordance statistic (C-statistic) evaluated discrimination. Cumulative incidence of kidney failure was compared between models that accounted for the competing risk of death and those that did not.

Results

We found that the KFRE overestimated the risk of kidney failure among the oldest subset of patients (≥80 years) with absolute and relative differences of 7.6% and 22.8%, respectively, over 2 years (P = 0.047), and 24.7% and 40.4%, respectively, over 5 years (P < 0.001). The degree of overestimation in the elderly was most pronounced among those with the highest predicted risks for kidney failure. KFRE discrimination was acceptable (C-statistic 0.70–0.79) across all age categories. The cumulative incidence of kidney failure was overestimated in models that did not account for the competing risk of death, and this overestimation was more pronounced with older age.

Conclusion

The KFRE overestimates kidney failure risk among elderly patients with advanced CKD. This overestimation relates to the increasing competing risk of death with older age, particularly over longer time horizons.

HOXD9‑induced SCNN1A upregulation promotes pancreatic cancer cell proliferation, migration and predicts prognosis by regulating epithelial‑mesenchymal transformation

Pancreatic cancer (PC) is a malignant tumor disease, whose molecular mechanism is not fully understood. Sodium channel epithelial 1α subunit (SCNN1A) serves an important role in tumor progression. The current study explored the role of homeobox D9 (HOXD9) and SCNN1A in the progression of PC. The expression of SCNN1A and HOXD9 in PC samples was predicted on online databases and detected in PC cell lines. The association between SCNN1A expression and PC prognosis was examined by the Gene Expression Profiling Interactive Analysis, The Cancer Genome Atlas and Genotype‑Tissue Expression databases and by a Kaplan‑Meier plotter. Subsequently, the biological effects of SCNN1A on PC cell growth, colony formation, migration and invasion were investigated through RNA interference and cell transfection. Next, the expression of E‑cadherin, N‑cadherin, Vimentin and Snail was detected by western blotting to discover whether HOXD9 dysregulation mediated PC metastasis. Binding sites of HOXD9 and SCNN1A promoters were predicted on JASPAR. Reverse transcription‑quantitative PCR and western blotting were used to detect the expression level of SCNN1A following interference and overexpression of HOXD9. Luciferase assay detected luciferase activity following interference with HOXD9 and the transcriptional activity of SCNN1A following binding site deletion. High expression of SCNN1A and HOXD9 in PC was predicted by online databases, signifying poor prognosis. The present study confirmed the above predictions in PC cell lines. Knockdown of SCNN1A and HOXD9 could effectively inhibit the proliferation, migration, invasion and epithelial‑mesenchymal transition of PC cells. Furthermore, HOXD9 activated SCNN1A transcription, forming a feedback regulatory loop. HOXD9 was demonstrated to activate SCNN1A and promote the malignant biological process of PC.

Stratification of Potency Outcomes Following Robot-Assisted Laparoscopic Radical Prostatectomy Based on Age, Preoperative Potency, and Nerve Sparing

Introduction: To identify factors affecting potency and to predict ideal patient subgroups who will have the highest chance of being potent after robot-assisted laparoscopic prostatectomy (RALP) based on nerve sparing (NS). Materials and Methods: Analysis of 7268 patients who underwent RALP between 2008 and 2018 with a minimum of 12 months of follow-up was performed. The patients were then categorized into four separate neurovascular bundle-sparing groups (NVB 1-4). A Cox regression analysis was used to determine the independent factors predicting potency outcomes. Cumulative incidence functions were used to depict the probability and time to potency between the NS groups stratified by age and preoperative sexual health inventory in men (SHIM). Results: Cox regression analysis of age, preoperative SHIM score, and grades of NS significantly predicted potency outcomes post-RALP. Patients with SHIM score ≥22 had a better chance of potency vs patients with SHIM <17 (odds ratio [OR]: 1.69, confidence interval [CI]: 1.47-1.79). NVB1 had better potency vs NVB4 (OR: 3.1, CI: 2.51-3.83). Patients <55 years with NVB1 and no preoperative erectile dysfunction had the best potency rates of 92.5%. However, we did not see any statistical difference between NVB2 and NVB3 in this group, implying that in patient groups with SHIM ≥22 and age <55, NVB1 provided the best chance of potency recovery. As age increased and preoperative SHIM worsened, the curves corresponding to NVB 2 and 3 showed significant differences, suggesting that NVB 2 and 3 may be predictive in unfavorable age and preoperative SHIM groups, especially NVB 2 > NVB 3. Conclusions: Preoperative SHIM, age, and NS are the most influential factors for potency recovery following RALP. Patients with good baseline sexual function had similar postoperative potency, irrespective of their grades of partial NS. In patients with decreased baseline SHIM and older age, a higher grade of partial NS resulted in a significantly better potency compared with a lower grade of partial nerve spare.

Supervivencia de pacientes con cáncer de próstata en un hospital de Bogotá, Colombia 2008-2014

El cáncer de próstata es actualmente una de las principales patologías que afectan a los hombres. El objetivo del presente artículo fue estimar la supervivencia de los pacientes con cáncer de próstata de riesgo intermedio y alto pertenecientes al régimen especial de salud (militares). Se realizó un estudio de cohorte que estima la función de supervivencia con el método de Kaplan-Meier y el Hazard ratio (HR) en función de variables explicativas mediante un modelo de regresión de Cox. Los pacientes incluidos fueron diagnosticados por urología y/o confirmados con apoyos diagnósticos. No se incluyeron pacientes tratados para cáncer de próstata en otra institución o por tumores primarios diferentes a próstata y quienes consultaron para tomar una segunda opinión médica. Los pacientes de riesgo intermedio sobreviven en un 90% tanto a cinco como a siete años, y los de riesgo alto sobrevivieron en 35% y 30% a cinco y siete años, respectivamente, con una mediana de 28 meses. Este estudio permitió concluir que la supervivencia de los pacientes clasificados como riesgo intermedio es similar a la nacional e internacional; sin embargo, en los pacientes de alto riesgo la supervivencia es inferior respecto a otros países.

Development of a gene signature associated with iron metabolism in lung adenocarcinoma

There are few studies on the role of iron metabolism genes in predicting the prognosis of lung adenocarcinoma (LUAD). Therefore, our research aims to screen key genes and to establish a prognostic signature that can predict the overall survival rate of lung adenocarcinoma patients. RNA-Seq data and corresponding clinical materials of 594 adenocarcinoma patients from The Cancer Genome Atlas(TCGA) were downloaded. GSE42127 of Gene Expression Omnibus (GEO) database was further verified. The multi-gene prognostic signature was constructed by the Cox regression model of the Least Absolute Shrinkage and Selection Operator (LASSO). We constructed a prediction signature with 12 genes (HAVCR1, SPN, GAPDH, ANGPTL4, PRSS3, KRT8, LDHA, HMMR, SLC2A1, CYP24A1, LOXL2, TIMP1), and patients were split into high and low-risk groups. The survival graph results revealed that the survival prognosis between the high and low-risk groups was significantly different (TCGA: P < 0.001, GEO: P = 0.001). Univariate and multivariate Cox regression analysis confirmed that the risk value is a predictor of patient OS (P < 0.001). The area under the time-dependent ROC curve (AUC) indicated that our signature had a relatively high true positive rate when predicting the 1-year, 3-year, and 5-year OS of the TCGA cohort, which was 0.735, 0.711, and 0.601, respectively. In addition, immune-related pathways were highlighted in the functional enrichment analysis. In conclusion, we developed and verified a 12-gene prognostic signature, which may be help predict the prognosis of lung adenocarcinoma and offer a variety of targeted options for the precise treatment of lung cancer.

Integrative analysis of multi-omics data highlighted TP53 as a potential diagnostic and prognostic biomarker of survival in breast invasive carcinoma patients

The global incidence of breast invasive carcinoma (BRIC) has risen significantly in recent years, so it is important to identify the novel biomarkers for the early detection and treatment of BRIC. The role of the TP53 gene is well studied in the pathogenesis of BRIC but still, observations are conflicting. Therefore, this study was initiated to have a consolidated overview of TP53 contributions in the BRIC initiation and progression by analyzing its mutatome, expression variations, promoter methylation level, clinical outcome, and drug sensitivity analysis in BRIC using cBioPortal, UALCAN, KM plotter, and CCLE GDSC toolkit database. Mutatome analysis revealed that TP53 was mutated in 30 % BRIC cases and among all the noted mutations, missense and truncation mutation were noticed as the most frequent mutations and thought to be involved in the up-regulation of TP53 expression. TP53 transcription, translation, and promoter methylation levels in BRIC patients of various clinicopathological features were high relative to the normal controls. Kaplan Meier overall survival (OS) analysis revealed a good prognostic value of TP53 overexpression for the survival in BRIC patients. Moreover, TP53 overexpression was found to alter the effectiveness of various drugs used in the chemotherapy of BRIC. Collectively, our findings suggested that TP53 might be a potential diagnostic and prognostic marker for the survival in BRIC patients of various clinicopathological features.

Estimating and comparing adverse event probabilities in the presence of varying follow-up times and competing events

Safety analyses of adverse events (AEs) are important in assessing benefit-risk of therapies but are often rather simplistic compared to efficacy analyses. AE probabilities are typically estimated by incidence proportions, sometimes incidence densities or Kaplan-Meier estimation are proposed. These analyses either do not account for censoring, rely on a too restrictive parametric model, or ignore competing events. With the non-parametric Aalen-Johansen estimator as the "gold standard", that is, reference estimator, potential sources of bias are investigated in an example from oncology and in simulations, for both one-sample and two-sample scenarios. The Aalen-Johansen estimator serves as a reference, because it is the proper non-parametric generalization of the Kaplan-Meier estimator to multiple outcomes. Because of potential large variances at the end of follow-up, comparisons also consider further quantiles of the observed times. To date, consequences for safety comparisons have hardly been investigated, the impact of using different estimators for group comparisons being unclear. For example, the ratio of two both underestimating or overestimating estimators may not be comparable to the ratio of the reference, and our investigation also considers the ratio of AE probabilities. We find that ignoring competing events is more of a problem than falsely assuming constant hazards by the use of the incidence density and that the choice of the AE probability estimator is crucial for group comparisons.

Identification of potential hub genes associated with the pathogenesis and prognosis of hepatocellular carcinoma via integrated bioinformatics analysis

Objective

The objective was to identify potential hub genes associated with the pathogenesis and prognosis of hepatocellular carcinoma (HCC).

Methods

Gene expression profile datasets were downloaded from the Gene Expression Omnibus database. Differentially expressed genes (DEGs) between HCC and normal samples were identified via an integrated analysis. A protein–protein interaction network was constructed and analyzed using the STRING database and Cytoscape software, and enrichment analyses were carried out through DAVID. Gene Expression Profiling Interactive Analysis and Kaplan–Meier plotter were used to determine expression and prognostic values of hub genes.

Results

We identified 11 hub genes (CDK1, CCNB2, CDC20, CCNB1, TOP2A, CCNA2, MELK, PBK, TPX2, KIF20A, and AURKA) that might be closely related to the pathogenesis and prognosis of HCC. Enrichment analyses indicated that the DEGs were significantly enriched in metabolism-associated pathways, and hub genes and module 1 were highly associated with cell cycle pathway.

Conclusions

In this study, we identified key genes of HCC, which indicated directions for further research into diagnostic and prognostic biomarkers that could facilitate targeted molecular therapy for HCC.

Computational Analysis of Drug Resistance Network in Lung Adenocarcinoma

BACKGROUND

Lung cancer is a significant health problem and accounts for one-third of the deaths worldwide. A great majority of these deaths are caused by non-small cell lung cancer (NSCLC). Chemotherapy is the leading treatment method for NSCLC, but resistance to chemotherapeutics is an important limiting factor that reduces the treatment success of patients with NSCLC.

OBJECTIVE

In this study, the relationship between differentially expressed genes affecting the survival of the patients, according to the bioinformatics analyses, and the mechanism of drug resistance is investigated for non-small cell lung adenocarcinoma patients.

METHODS

Five hundred thirteen patient samples were compared with fifty-nine control samples. The employed dataset was downloaded from The Cancer Genome Atlas (TCGA) database. The information on how the drug activity altered against the expressional diversification of the genes was extracted from the NCI-60 database. Four hundred thirty-three drugs with known mechanism of action (MoA) were analyzed. Diversifications of the activity of these drugs related to genes were considered based on nine lung cancer cell lines virtually. The analyses were performed using R programming language, GDCRNATools, rcellminer, and Cytoscape.

RESULTS

This work analyzed the common signaling pathways and expressional alterations of the proteins in these pathways associated with survival and drug resistance in lung adenocarcinoma. Deduced computational data demonstrated that proteins of EGFR, JNK/MAPK, NF-κB, PI3K /AKT/mTOR, JAK/STAT, and Wnt signaling pathways were associated with molecular mechanism of resistance to anticancer drugs in NSCLC cells.

CONCLUSION

To understand the relationships between resistance to anticancer drugs and EGFR, JNK/MAPK, NF-κB, PI3K /AKT/mTOR, JAK/STAT, and Wnt signaling pathways is an important approach to design effective therapeutics for individuals with NSCLC adenocarcinoma.

Presence and duration of feeding tube in a 5-year cohort of patients with head and neck cancer treated with curative intensity-modulated radiation therapy

BACKGROUND

Our study assessed post-radiation therapy (RT) G-tube presence, duration, and clinical predictors in patients with head and neck cancer (HNC).

METHODS

We identified those 1-5-years post-RT with stage III/IV nasopharyngeal, oropharyngeal, hypopharyngeal, laryngeal, or unknown primaries. Logistic regression identified predictors of post-RT G-tube presence, Kaplan-Meier analysis estimated G-tube days, and log-rank test compared by tumor site.

RESULTS

The 977 patients had mean age 60.6 ± 11.6 years, 804 (82.3%) male, 764 (78.2%) stage IV, and 618 (63.3%) oropharyngeal primaries. All patients received intensity-modulated RT (IMRT), 571 (58.4%) received chemotherapy, and 698 (71.4%) prophylactic G-tube. G-tube prevalence 1- and 5-years post-IMRT was 7.1% and 4.8%, respectively. Median post-IMRT G-tube days were overall 63 (95%CI: 56-70), nasopharynx 119 (95%CI: 109-131), oropharynx 57 (95%CI: 51-68), hypopharynx 126 (95%CI: 77-256), larynx 53 (95%CI: 21-63), unknown 30 (95%CI: 17-55), of which hypopharynx was highest p < 0.001.

CONCLUSIONS

At an institution offering prophylactic G-tube for patients with advanced HNC, no differences were found in yearly G-tube use 1-5 years post-IMRT. Across all patients, median post-IMRT days with G-tube was 63 day but those with hypopharyngeal tumors registered the most days.

Identification of an 11-lncRNA signature with high performance for predicting the prognosis of hepatocellular carcinoma using bioinformatics analysis

Hepatocellular carcinoma (HCC) is a common primary liver cancer with a high incidence and mortality. This study was conducted to identify a long non-coding RNA (lncRNA) signature that may serve as a predictor for HCC prognosis.RNA-seq data were extracted from The Cancer Genome Atlas database. Differentially expressed genes, lncRNAs, and miRNAs were identified in HCC (n = 374) and control samples (n = 50) and used to screen prognosis-associated lncRNA signatures. The association of the lncRNA signature with HCC prognosis was analyzed and a competitive endogenous RNA regulatory network involving the lncRNA signature was constructed.A total of 199 mRNAs, 1092 lncRNAs, and 251 miRNAs were differentially expressed between HCC and control samples. Among these lncRNAs, 11 prognosis-associated lncRNAs were used to construct a lncRNA signature. Cox regression analysis showed that patients with higher risk scores of the lncRNA signature were at risk of poor prognosis. Four lncRNAs (including LINC01517, DDX11-AS1, LINC01136, and RP11-20J15.2) and 7 miRNAs (including miR-195, miR-199b, miR-326, miR-424, and let-7c) in the ceRNA network interacted with the upregulated gene E2F2, which was associated with the overall prognosis of patients with HCC.The 11-lncRNA signature might be useful for predicting the prognosis of patients with HCC.

Subjective cognitive complaints and permanent work disability: a prospective cohort study

PURPOSE

Work disability (WD) is a medico-legal concept that refers to disability benefits (DB) granted due to diseases. We assessed whether subjective cognitive complaints (SCC)-presenting as self-rated difficulties of concentration, memory, clear thinking, and decision making-predict permanent WD in knowledge-intensive occupations.

METHODS

In this prospective cohort study with up to 7-year follow-up, we combined the SCC questionnaire results with reliable registry data on the DBs of 7161 professional/managerial employees (46% females). We excluded employees who were on long-term sickness absence (SA) or had received a DB at baseline. The exposure variable was the presence of SCC. Age and SA before the questionnaire as a proxy measure of general health were treated as confounders and the analyses were conducted by gender. The outcome variable was a granted DB. The cumulative incidence function illustrates the difference between SCC categories, and the Fine-Gray model estimates the predictors of WD during the 8-year follow-up.

RESULTS

The annual incidence of DB was 0.15% in the entire cohort: 0.18% among the females, and 0.12% among the males (p = 0.795). The most common primary reasons for permanent WD were mental (36%) and musculoskeletal (20%) disorders. SCC predicted DB in both genders when controlling for age and prior SA. Hazard ratios were 2.9 with a 95% confidence interval 1.4-6.0 for the females and 3.7 (1.8-7.9) for the males.

CONCLUSION

Subjective cognitive complaints predict permanent WD in knowledge-intensive occupations. This finding has implications for supporting work ability and preventing work disability among employees with cognitively demanding tasks.

Survival analysis for AdVerse events with VarYing follow-up times (SAVVY): Rationale and statistical concept of a meta-analytic study

The assessment of safety is an important aspect of the evaluation of new therapies in clinical trials, with analyses of adverse events being an essential part of this. Standard methods for the analysis of adverse events such as the incidence proportion, that is the number of patients with a specific adverse event out of all patients in the treatment groups, do not account for both varying follow-up times and competing risks. Alternative approaches such as the Aalen-Johansen estimator of the cumulative incidence function have been suggested. Theoretical arguments and numerical evaluations support the application of these more advanced methodology, but as yet there is to our knowledge only insufficient empirical evidence whether these methods would lead to different conclusions in safety evaluations. The Survival analysis for AdVerse events with VarYing follow-up times (SAVVY) project strives to close this gap in evidence by conducting a meta-analytical study to assess the impact of the methodology on the conclusion of the safety assessment empirically. Here we present the rationale and statistical concept of the empirical study conducted as part of the SAVVY project. The statistical methods are presented in unified notation, and examples of their implementation in R and SAS are provided.

A comparison of the Cox model to the Fine-Gray model for survival analyses of re-fracture rates

We compared the Cox model with the Fine-Gray model when assessing the risk of low-trauma re-fractures. The risk of re-fracture was consistently higher when using the Cox model compared with the Fine-Gray model. The Fine-Gray model more accurately assesses the risk of re-fracture when a competing risk is present.

PURPOSE

Compared with the Kaplan-Meier and Cox model, the Fine-Gray competing risk model was developed to take competing risks into account, which provides a better estimation for the risk of the main outcome of interest when one or more competing risks are presented. To date, it remains underused. This study aims to use a case study to illustrate why and how the Fine-Gray model should be used and interpreted, especially when a competing risk is present.

METHODS

Using a cohort of patients who presented to a NSW hospital with a non-trauma-related fracture between 2013/2014 and 2017/2018, the cumulative incidence and rate of re-fracture were estimated by the Kaplan-Meier and the Cox model, and by the Fine-Gray model when deaths present as competing events.

RESULTS

The cumulative incidence of re-fracture at day 1825 (5 years) was 20.7% when using the Kaplan-Meier model and was 17.7% when using the Fine-Gray model. The estimations of cumulative incidence or rate of re-fracture were consistently higher by traditional survival analyses (Kaplan-Meier or Cox) compared with the Fine-Gray model. For patients aged 90 years and older, the re-fracture incidence at year 5 was estimated to be 66% vs. 28% whereas patients with a history of osteoporosis were 44% vs. 31%. Similarly, compared with patients without osteoporosis history, the estimated re-fracture rate for those with osteoporosis was 9.2 times higher by the Cox model but only 2.6 times higher by the Fine-Gray model.

CONCLUSION

The Fine-Gray model more accurately estimates the cumulative incidence of re-fracture and the effect of covariates on the hazard rate than the Kaplan-Meier and Cox models in the presence of a competing risk. This accuracy improves the larger the rate of a competing event.

Serum IgG Levels and Risk of COPD Hospitalization: A Pooled Meta-analysis

BACKGROUND

Hypogammaglobulinemia (serum IgG levels < 7.0 g/L) has been associated with increased risk of COPD exacerbations but has not yet been shown to predict hospitalizations.

RESEARCH QUESTION

To determine the relationship between hypogammaglobulinemia and the risk of hospitalization in patients with COPD.

STUDY DESIGN AND METHODS

Serum IgG levels were measured on baseline samples from four COPD cohorts (n = 2,259): Azithromycin for Prevention of AECOPD (MACRO, n = 976); Simvastatin in the Prevention of AECOPD (STATCOPE, n = 653), Long-Term Oxygen Treatment Trial (LOTT, n = 354), and COPD Activity: Serotonin Transporter, Cytokines and Depression (CASCADE, n = 276). IgG levels were determined by immunonephelometry (MACRO; STATCOPE) or mass spectrometry (LOTT; CASCADE). The effect of hypogammaglobulinemia on COPD hospitalization risk was evaluated using cumulative incidence functions for this outcome and deaths (competing risk). Fine-Gray models were performed to obtain adjusted subdistribution hazard ratios (SHR) related to IgG levels for each study and then combined using a meta-analysis. Rates of COPD hospitalizations per person-year were compared according to IgG status.

RESULTS

The overall frequency of hypogammaglobulinemia was 28.4%. Higher incidence estimates of COPD hospitalizations were observed among participants with low IgG levels compared with those with normal levels (Gray's test, P < .001); pooled SHR (meta-analysis) was 1.29 (95% CI, 1.06-1.56, P = .01). Among patients with prior COPD admissions (n = 757), the pooled SHR increased to 1.58 (95% CI, 1.20-2.07, P < .01). The risk of COPD admissions, however, was similar between IgG groups in patients with no prior hospitalizations: pooled SHR = 1.15 (95% CI, 0.86-1.52, P =.34). The hypogammaglobulinemia group also showed significantly higher rates of COPD hospitalizations per person-year: 0.48 ± 2.01 vs 0.29 ± 0.83, P < .001.

INTERPRETATION

Hypogammaglobulinemia is associated with a higher risk of COPD hospital admissions.

Identification of crucial genes correlated with esophageal cancer by integrated high-throughput data analysis

BACKGROUND

Esophageal cancer (ESCA) is one of the most deadly malignancies in the world. Although the management and treatment of patients with ESCA have improved, the overall 5-year survival rate is still very poor.

METHODS

The study aimed to identify potential key genes associated with the pathogenesis and prognosis of ESCA. In the study, integrated bioinformatics methods were used to screen differentially expressed genes (DEGs) between ESCA and normal tissue in the data set of gene expression profiles. The hub gene in DEGs was further analyzed by protein-protein interaction (PPI) network and survival analysis to explore its relationship with the pathogenesis and poor prognosis of ESCA.

RESULTS

134 up-regulated genes and 183 down-regulated genes were obtained in ESCA compared with normal tissues. Moreover, the PPI network was established with 176 nodes and 800 interactions. Ten hub genes (AURKA, CDC20, BUB1, TOP2A, ASPM, DLGAP5, TPX2, CENPF, UBE2C, and NEK2) were filtered out based on the degree value. Functional enrichment analysis indicated that a variety of extracellular related items and ECM-receptor interaction pathway were all correlated with the ESCA.

CONCLUSIONS

The results of this study would provide some guidance for further study of diagnostic and prognostic biomarkers to promote ESCA treatment.

Programmed Death 1 and Programmed Death Ligand 1 Inhibitors in Advanced and Recurrent Urothelial Carcinoma: Meta-analysis of Single-Agent Studies

We performed a systematic review and meta-analysis on the response rates of patients with treatment-refractory urothelial carcinoma treated with programmed cell death 1 (PD-1) and programmed death ligand 1 (PD-L1) inhibitors. We reviewed the literature for prospective studies evaluating PD-1/PD-L1 inhibitors in refractory urothelial carcinoma patients, which formed the basis for US Food and Drug Administration approval of 5 different antagonistic antibodies targeting PD-1 or PD-L1 (atezolizumab, durvalumab, avelumab, nivolumab, and pembrolizumab). We considered studies examining PD-1/PD-L1-treated patients, which we identified using the following key terms in the Pubmed, Scopus, Web of Science, ClinicalTrial.gov, and Cochrane Library databases. Eligible studies had ≥ 20 patients each and reported response rates, duration of response, and overall survival (OS). We performed fixed and random-effects meta-analyses to model the point estimates for objective response rate and complete response. The median progression-free survival (PFS) and OS for studies reporting these statistics were evaluated. We found 10 eligible studies that met our inclusion criteria, providing extractable numerators and denominators for response rates, PFS, and OS for 1934 patients with metastatic urothelial carcinoma. The objective response rate was 18% (95% confidence interval, 15-22) for second-line or later therapies. The random-effects estimate for complete response was 4% (95% confidence interval, 3-5), including all disease locations and all PD-1 and PD-L1 inhibitors. Median OS and PFS were < 13 months and 3 months, respectively, across all studies, irrespective of PD-L1 expression. We found that the estimated response rates of agents included in this meta-analysis seem to be more favorable than other salvage therapies.

Self-reported health problems in a health risk appraisal predict permanent work disability: a prospective cohort study of 22,023 employees from different sectors in Finland with up to 6-year follow-up

Purpose

Work disability (WD) as a medico-legal concept refers to disability benefits (DB) that are granted due to diseases that permanently reduce work ability. We studied whether an occupational healthcare instrument for the prediction of sickness absence (SA) risk—a health risk appraisal (HRA)—also predicts permanent WD.

Methods

HRA results were combined with registry data on DB of 22,023 employees from different industry sectors. We analysed how the HRA risk categories predict DB and considered occupational group, gender, age, and prior SA as confounding variables. Cumulative incidence function illustrates the difference between the HRA risk categories, and the Fine–Gray model estimates the predictors of WD during 6-year follow-up.

Results

The most common primary reasons for permanent WD were musculoskeletal (39%) and mental disorders (21%). Self-reported health problems in the HRA, labelled as “WD risk factors”, predicted DB when controlling for age and prior SA. Hazard ratios were 10.9 or over with the lower limit of the 95% confidence interval 3.3 or over among those with two simultaneous WD risk factors. 14% of the females and 17% of the males with three or more simultaneous WD risk factors had received a DB, whereas the respective figures among those without findings were 1.9% and 0.3%.

Conclusions

Self-reported health problems in the HRA, especially multiple simultaneous WD risk factors, predict permanent WD among both genders across occupational groups. Screening WD risk with a self-administered questionnaire is a potential means for identifying high-risk employees for targeting occupational healthcare actions.

GRADE guidelines 27: how to calculate absolute effects for time-to-event outcomes in summary of findings tables and Evidence Profiles

OBJECTIVES

To provide GRADE guidance on how to prepare Summary of Findings tables and Evidence Profiles for time-to-event outcomes with a focus on the calculation of the corresponding absolute effect estimates.

STUDY DESIGN AND SETTING

This guidance was justified by a research project identifying frequent errors and limitations in the presentation of time-to-event outcomes in the Summary of Findings tables. We developed this guidance through an iterative process that included membership consultation, feedback, presentation, and discussion at meetings of the GRADE Working Group.

RESULTS

Review authors need to carefully consider the definition of the outcome of interest; although often the event is used as label for the outcome of interest (e.g., death or mortality), the event-free survival (e.g., overall survival) is reported throughout individual studies. Review authors should calculate the absolute effect correctly, either for the event or absence of the event. We also provide examples on how to calculate the absolute effects for events and the absence of events for various baseline or control group risks and time points.

CONCLUSIONS

This article aids in the development of Summary of Findings tables and Evidence Profiles, including time-to-event outcomes, and addresses the most common scenarios when calculating absolute effects in order to provide an accurate interpretation.

Comparing the Efficiency of Two Treatment Methods of Hydrocephalus: Shunt Implantation and Endoscopic Third Ventriculostomy

Introduction:

Hydrocephalus is one of the most common diseases in children, and its treatment requires brain operation. However, the pathophysiology of the disease is very complicated and still unknown.

Methods:

Endoscopic Third Ventriculostomy (ETV) and Ventriculoperitoneal Shunt (VPS) implantation are among the common treatments of hydrocephalus. In this study, Cerebrospinal Fluid (CSF) hydrodynamic parameters and efficiency of the treatment methods were compared with numerical simulation and clinical follow-up of the treated patients.

Results:

Studies have shown that in patients under 19 years of age suffering from hydrocephalus related to a Posterior Fossa Brain Tumor (PFBT), the cumulative failure rate was 21% and 29% in ETV and VPS operation, respectively. At first, the ETV survival curve shows a sharp decrease and after two months it gets fixed while VPS curve makes a gradual decrease and reaches to a level lower than ETV curve after 5.7 months. Post-operative complications in ETV and VPS methods are 17% and 31%, respectively. In infants younger than 12 months with hydrocephalus due to congenital Aqueduct Stenosis (AS), and also in the elderly patients suffering from Normal Pressure Hydrocephalus (NPH), ETV is a better treatment option. Computer simulations show that the maximum CSF pressure is the most reliable hydrodynamic index for the evaluation of the treatment efficacy in these patients. After treatment by ETV and shunt methods, CSF pressure decreases about 9 and 5.3 times, respectively and 2.5 years after shunt implantation, this number returns to normal range.

Conclusion:

In infants with hydrocephalus, initial treatment by ETV was more reasonable than implanting the shunt. In adult with hydrocephalus, the initial failure in ETV occurred sooner compared to shunt therapy; however, ETV was more efficient.

Home-based monitoring of falls using wearable sensors in Parkinson's disease

INTRODUCTION

Falling is among the most serious clinical problems in Parkinson's disease (PD). We used body-worn sensors (falls detector worn as a necklace) to quantify the hazard ratio of falls in PD patients in real life.

METHODS

We matched all 2063 elderly individuals with self-reported PD to 2063 elderly individuals without PD based on age, gender, comorbidity, and living conditions. We analyzed fall events collected at home via a wearable sensor. Fall events were collected either automatically using the wearable falls detector or were registered by a button push on the same device. We extracted fall events from a 2.5-year window, with an average follow-up of 1.1 years. All falls included were confirmed immediately by a subsequent telephone call. The outcomes evaluated were (1) incidence rate of any fall, (2) incidence rate of a new fall after enrollment (ie, hazard ratio), and (3) 1-year cumulative incidence of falling.

RESULTS

The incidence rate of any fall was higher among self-reported PD patients than controls (2.1 vs. 0.7 falls/person, respectively; P < .0001). The incidence rate of a new fall after enrollment (ie, hazard ratio) was 1.8 times higher for self-reported PD patients than controls (95% confidence interval, 1.6-2.0).

CONCLUSION

Having PD nearly doubles the incidence of falling in real life. These findings highlight PD as a prime "falling disease." The results also point to the feasibility of using body-worn sensors to monitor falls in daily life. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Identification of Potential Crucial Genes and Key Pathways in Breast Cancer Using Bioinformatic Analysis

Background: The molecular mechanism of tumorigenesis remains to be fully understood in breast cancer. It is urgently required to identify genes that are associated with breast cancer development and prognosis and to elucidate the underlying molecular mechanisms. In the present study, we aimed to identify potential pathogenic and prognostic differentially expressed genes (DEGs) in breast adenocarcinoma through bioinformatic analysis of public datasets.

Methods: Four datasets (GSE21422, GSE29431, GSE42568, and GSE61304) from Gene Expression Omnibus (GEO) and the Cancer Genome Atlas (TCGA) dataset were used for the bioinformatic analysis. DEGs were identified using LIMMA Package of R. The GO (Gene Ontology) and KEGG (Kyoto Encyclopedia of Genes and Genomes) analyses were conducted through FunRich. The protein-protein interaction (PPI) network of the DEGs was established through STRING (Search Tool for the Retrieval of Interacting Genes database) website, visualized by Cytoscape and further analyzed by Molecular Complex Detection (MCODE). UALCAN and Kaplan–Meier (KM) plotter were employed to analyze the expression levels and prognostic values of hub genes. The expression levels of the hub genes were also validated in clinical samples from breast cancer patients. In addition, the gene-drug interaction network was constructed using Comparative Toxicogenomics Database (CTD).

Results: In total, 203 up-regulated and 118 down-regulated DEGs were identified. Mitotic cell cycle and epithelial-to-mesenchymal transition pathway were the major enriched pathways for the up-regulated and down-regulated genes, respectively. The PPI network was constructed with 314 nodes and 1,810 interactions, and two significant modules are selected. The most significant enriched pathway in module 1 was the mitotic cell cycle. Moreover, six hub genes were selected and validated in clinical sample for further analysis owing to the high degree of connectivity, including CDK1, CCNA2, TOP2A, CCNB1, KIF11, and MELK, and they were all correlated to worse overall survival (OS) in breast cancer.

Conclusion: These results revealed that mitotic cell cycle and epithelial-to-mesenchymal transition pathway could be potential pathways accounting for the progression in breast cancer, and CDK1, CCNA2, TOP2A, CCNB1, KIF11, and MELK may be potential crucial genes. Further, it could be utilized as new biomarkers for prognosis and potential new targets for drug synthesis of breast cancer.

Contrapositive logic suggests space radiation not having a strong impact on mortality of US astronauts and Soviet and Russian cosmonauts

Space travelers are exposed to unique forms of ionizing radiation that pose potentially serious health hazards. Prior analyses have attempted to quantify excess mortality risk for astronauts exposed to space radiation, but low statistical power has frustrated inferences. If exposure to deep space radiation were causally linked to deaths due to two particular causes, e.g., cancer and cardiovascular disease, then those cause-specific deaths would not be statistically independent. In this case, a Kaplan-Meier survival curve for a specific cause that treats deaths due to competing causes as uninformative censored events would result in biased estimates of survival probabilities. Here we look for evidence of a deleterious effect of historical exposure to space radiation by assessing whether or not there is evidence for such bias in Kaplan-Meier estimates of survival probabilities for cardiovascular disease and cancer. Evidence of such bias may implicate space radiation as a common causal link to these two disease processes. An absence of such evidence would be evidence that no such common causal link to radiation exposure during space travel exists. We found that survival estimates from the Kaplan-Meier curves were largely congruent with those of competing risk methods, suggesting that if ionizing radiation is impacting the risk of death due to cancer and cardiovascular disease, the effect is not dramatic.

Competing risks and cause-specific mortality in patients with pancreatic neuroendocrine tumors

BACKGROUND AND OBJECTIVE

Currently, there are no competing risk analyses of cause-specific mortality in patients with pancreatic neuroendocrine tumors.

MATERIALS AND METHODS

We estimated a cumulative incidence function for cause-specific mortality. The first nomogram for predicting cause-specific mortality was constructed using a proportional subdistribution hazard model, validated using bootstrap cross-validation, and evaluated with decision curve analysis.

RESULTS

Sex, age, positive lymph node status, metastasis, surveillance, epidemiology, and end results historic stage, grade, and surgery strongly predicted cause-specific mortality. The discrimination performance of Fine-Gray models was evaluated using the c-index, which was 0.864. In addition, the calibration plot of the developed nomogram demonstrated good concordance between the predicted and actual outcomes. Decision curve analysis yielded a range of threshold probabilities (0.014-0.779) at which the clinical net benefit of the risk model was greater than that in hypothetical all-screening or no-screening scenarios.

CONCLUSION

Our nomogram allows selection of a patient population at high risk for cancer-specific mortality and thus facilitates the design of prevention trials for the affected population.