Understanding the role of environmental and socioeconomic factors in the geographic variation of breast cancer risk in the US-wide Sister Study

OBJECTIVE

To describe the geographic pattern of breast cancer incidence in a nationwide prospective cohort and investigate whether environmental exposures and/or neighborhood socioeconomic status explain observed geographic disparities.

METHODS

Using accelerated failure time models with a spatial random effect term, we mapped the health region-level association between residential location and breast cancer incidence for 44,707 participants in the Sister Study after controlling for established individual-level breast cancer risk factors. We performed a variable selection process to select environmental exposures [i.e., ambient nitrogen dioxide (NO2) and fine particulate matter (PM2.5), PM2.5 chemical composition, outdoor light at night (LAN), ambient noise, ultraviolet radiation, and greenspace] and neighborhood-level factors [i.e., population density and area deprivation index (ADI)] that predicted breast cancer incidence and quantified the spatial variation explained by the selected factors. We also considered whether the geographic pattern and predictors were similar when restricting to estrogen receptor-positive (ER+) tumors.

RESULTS

We observed a spatial patterning in the incidence of overall breast cancer (Moran's I = 16.7, p < 0.05) and ER+ breast cancer (Moran's I = 13.2, p < 0.05), with a lower risk observed in the South and Southeast and a greater risk in the Northwest and certain areas of the Midwest and Northeast. NO2, LAN, and ADI explained 21.4% of the spatial variation in overall breast cancer incidence whereas NO2, PM2.5 chemical composition, LAN, greenspace, and ADI together explained 63.3% of the spatial variation in ER+ breast cancer incidence.

CONCLUSIONS

Our findings provide additional evidence for a role of environmental exposures in breast cancer incidence and suggest that geographic-based risk factors may vary according to breast cancer subtype. Our findings support the need for additional research to quantify the relative contributions of geographic-based risk factors for breast cancer.

Supply and quality of colonoscopy according to the characteristics of gastroenterologists in the French population-based colorectal-cancer screening program

BACKGROUND

Since its complete roll-out in 2009, the French colorectal cancer screening program (CRCSP) experienced 3 major constraints [use of a less efficient Guaiac-test (gFOBT), stopping the supply of Fecal-Immunochemical-Test kits (FIT), and suspension of the program due to the coronavirus disease 2019 (COVID-19)] affecting its effectiveness.

AIM

To describe the impact of the constraints in terms of changes in the quality of screening-colonoscopy (Quali-Colo).

METHODS

This retrospective cohort study included screening-colonoscopies performed by gastroenterologists between Jan-2010 and Dec-2020 in people aged 50-74 living in Ile-de-France (France). The changes in Quali-colo (Proportion of colonoscopies performed beyond 7 mo (Colo_7 mo), Frequency of serious adverse events (SAE) and Colonoscopy detection rate) were described in a cohort of Gastroenterologists who performed at least one colonoscopy over each of the four periods defined according to the chronology of the constraints [gFOBT: Normal progress of the CRCSP using gFOBT (2010-2014); FIT: Normal progress of the CRCSP using FIT (2015-2018); STOP-FIT: Year (2019) during which the CRCSP experienced the cessation of the supply of test kits; COVID: Program suspension due to the COVID-19 health crisis (2020)]. The link between each dependent variable (Colo_7 mo; SAE occurrence, neoplasm detection rate) and the predictive factors was analyzed in a two-level multivariate hierarchical model.

RESULTS

The 533 gastroenterologists (cohort) achieved 21509 screening colonoscopies over gFOBT period, 38352 over FIT, 7342 over STOP-FIT and 7995 over COVID period. The frequency of SAE did not change between periods (gFOBT: 0.3%; FIT: 0.3%; STOP-FIT: 0.3%; and COVID: 0.2%; P = 0.10). The risk of Colo_7 mo doubled between FIT [adjusted odds ratio (aOR): 1.2 (1.1; 1.2)] and STOP-FIT [aOR: 2.4 (2.1; 2.6)]; then, decreased by 40% between STOP-FIT and COVID [aOR: 2.0 (1.8; 2.2)]. Regardless of the period, this Colo_7 mo’s risk was twice as high for screening colonoscopy performed in a public hospital [aOR: 2.1 (1.3; 3.6)] compared to screening-colonoscopy performed in a private clinic. The neoplasm detection, which increased by 60% between gFOBT and FIT [aOR: 1.6 (1.5; 1.7)], decreased by 40% between FIT and COVID [aOR: 1.1 (1.0; 1.3)].

CONCLUSION

The constraints likely affected the time-to-colonoscopy as well as the colonoscopy detection rate without impacting the SAE’s occurrence, highlighting the need for a respectable reference time-to-colonoscopy in CRCSP.

Examining Mental Health Disorders in Overweight and Obese Pediatric Patients

INTRODUCTION

We investigated the frequency and variation in three mental health diagnoses among obese or overweight children and adolescents.

METHOD

Logistic regression was used to examine the association between the outcome variables-anxiety, depression, and adjustment disorders-with the following covariates: overweight/obesity status, sex, age, and race.

RESULTS

Findings show anxiety, depressive, and adjustment disorder diagnoses were significantly higher for overweight or obese youth in our sample. In addition, diagnosis rates for one or more of these disorders increase as children grow into adolescence. Furthermore, we found significantly higher rates of depression and significantly lower rates of anxiety among youth who live in places with higher rates of poverty.

DISCUSSION

Findings indicate a target age for providers to focus on mental health screening among overweight/obese patients: (1) early adolescence (aged 11-14 years) for depressive and adjustment disorders and (2) early childhood (aged 2-4 years) for anxiety disorder.

Population estimates of obstructive and non-obstructive hypertrophic cardiomyopathy in the UK and Germany

Background

While numerous publications have estimated the prevalence of diagnosed hypertrophic cardiomyopathy (HCM), none have quantified the real-world proportion of obstructive and non-obstructive HCM using nationally representative data sources in any European countries.

Purpose

To estimate the prevalence of diagnosed HCM and its subtypes in the UK and Germany.

Methods

Patients with HCM were identified in the UK from 01 Apr 2009 to 30 Oct 2020 and Germany from 2011 to 2019. UK patients with HCM were identified using electronic health records from the Clinical Practice Research Datalink (CPRD) primary care data linked with Hospital Episode Statistics (HES) secondary care data using ICD-10 (I42.1, I42.2), Read, Medcode, SNOMED, and OPCS codes. German patients with HCM were identified using a nationally representative administrative claims data pool (WIG2 Benchmark database) from several German Statutory Health Insurance (SHI)-insurances using ICD-10 and OPS codes. Obstructive HCM was identified as any obstructive HCM diagnosis, any HCM diagnosis with septal reduction therapy, and any HCM diagnosis and left ventricular outflow tract obstruction (LVOTO; not in German claims data). Non-obstructive HCM was any non-obstructive or unspecified HCM diagnosis without evidence of any obstructive HCM. Annual prevalence was calculated for each year in the respective study periods and average annual prevalence across the study period.

Results

The average annual prevalence rate of HCM was 4.15/10,000 in the UK and 8.61/10,000 in Germany, while the average annual prevalence rate of obstructive HCM was 2.84/10,000 in the UK and 4.18/10,000 in Germany (Table). The proportion of HCM that was obstructive HCM was 68% in the UK and 49% in Germany. The prevalence rates of diagnosed HCM and obstructive HCM tended to increase over time (Figure).

Conclusion

The prevalence of HCM, obstructive HCM and the proportion of HCM that is obstructive varied between the UK and Germany. The prevalence of HCM was generally consistent with previously published estimates. Although there are limitations with coding in administrative data, it is important to differentiate obstructive HCM from non-obstructive HCM given their unique treatments and disease progression and management, especially since at least 49–68% of HCM is obstructive.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol Myers-Squibb

Evaluation of initiatives including an EHR prompt (EP) and APP involvement to increase germline genetic testing compliance in a pancreatic cancer population

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Background: Germline genetic testing is now recommended for all pancreas cancer patients (pts); identification of a BRCA1/2, ATM or PALB2 mutation can impact upfront and/or second line therapy. These mutations have been found in approximately 4-11% of prior reports of pancreatic cancer populations. Previous reports have found that genetic testing is done in a minority of patients, especially in private practice. This project assesses how two interventions on physician behavior can impact the frequency of germline genetic testing in pancreas cancer patients in a multi-office private practice setting. Methods: Retrospectively, we used algorithms in Flatiron’s OncoEMR to identify baseline germline genetic testing frequency in all pancreas cancer patients. In phase 1, we used an EP to communicate with doctors immediately before upcoming appts for their pancreas cancer pts. In phase 2, advanced practice providers (APPs) educated pancreas cancer patients about germline genetic testing and ordered the test ahead of the patients’ visits. Our primary endpoint was to determine the percentage of pancreas cancer patients who had germline genetic testing; our secondary endpoint was to determine frequency of BRCA/PALB2/ATM mutations. Results: Retrospectively, 82 pancreas cancer pts were identified from 6/1/2020 - 1/1/2021. 32 pts (39%) had germline genetic testing. Prospectively, in phase 1, 35 pts with pancreas cancer and upcoming appointments were identified between 6/28/2021 - 8/6/2021. 21 (60%) had previously had germline testing. Of 14 patients who had not had testing, the EP prompted additional testing of 7 (50%) pts. Of the total 35 pts in phase 1, 2 (5.7%) were found to have mutations. In phase II, 47 of 74 pts (63%) had previously had germline testing, and APP intervention resulted in 19 of 27 patients (70%) receiving germline testing, with 5 (6.7%) found to have BRCA1/2, PALB2 or ATM mutations of the 74 patients. Conclusions: Our results reveal that while APP education and ordering of germline genetic testing is slightly more effective than involving the doctors in the process, further improvement is needed. Utilizing the EMR when a diagnosis code is entered and then automating genetic counseling and ordering for these patients will be needed. Lastly, a team based approach with navigators involved in rounding will also improve testing frequency even with more automated testing. While our % of patients with an actionable mutation is low, given the options it opens for these patients, universal testing is still warranted.

Real-world treatment sequencing and survival in previously treated advanced renal cell carcinoma patients receiving nivolumab monotherapy: a UK retrospective cohort study

Background

The CheckMate 025 trial established nivolumab monotherapy as one of the standards of care in previously treated advanced or metastatic renal cell carcinoma (aRCC). However, supporting real-world data is lacking. This study investigated characteristics, treatment sequences and clinical outcomes of patients who received nivolumab monotherapy for previously treated aRCC in the UK.

Methods

This was a retrospective cohort study of aRCC patients treated with nivolumab at second line or later (2L +) at 4 UK oncology centres. Eligible patients commenced nivolumab (index date) between 01 March 2016 and 30 June 2018 (index period). Study data were extracted from medical records using an electronic case report form. Data cut-off (end of follow-up) was 31 May 2019.

Results

In total, 151 patients were included with median follow-up of 15.2 months. Mean age was 66.9 years, male preponderance (72.2%), and mostly Eastern Cooperative Oncology Group performance status grade 0–1 (71.5%). Amongst 112 patients with a known International Metastatic RCC Database Consortium score, distribution between favourable, intermediate, and poor risk categories was 20.5%, 53.6%, and 25.9% respectively.

The majority of patients (n = 109; 72.2%) received nivolumab at 2L, and these patients had a median overall survival (OS) of 23.0 months [95% confidence interval: 17.2, not reached]. All patients who received nivolumab at 2L had received TKIs at 1L. Amongst the 42 patients (27.8%) who received nivolumab in third line or later (3L +) the median OS was 12.4 months [95% CI: 8.8, 23.2]. The most common reasons for nivolumab discontinuation were disease progression (2L: 61.2%; 3L: 68.8%) and adverse events (2L: 34.7%; 3L: 28.1%).

Conclusion

This study provides real-world evidence on the characteristics, treatment sequences, and outcomes of aRCC patients who received 2L + nivolumab monotherapy in the UK. Nivolumab-specific survival outcomes were similar to those achieved in the CheckMate 025 trial.

Is ECOG-PS ≥3 appropriate to guide rehabilitation referral decisions? Using patient-reported outcome measures to examine the prevalence of functional disability in patients with ECOG-PS 0-2

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Background: Outpatient physical or occupational therapy (PT/OT) can optimize cancer patients’ performance status and ability to complete instrumental activities of daily living (IADL). The American College of Sports Medicine recommends referral to PT/OT for those with Eastern Cooperative Oncology Group performance status (ECOG-PS) ≥3/5. However, ECOG-PS alone may not accurately indicate needs for PT/OT. We used functional patient reported outcome measures (F-PROM) to quantify the prevalence of functional disability for cancer patients with favorable ECOG-PS (0-2) starting a new line of systemic therapy. Methods: Patients with cancer at a multi-office community-based oncology private practice who were enrolled in a clinical trial (NCT04852575) completed a validated online geriatric assessment (the Cancer Aging Resiliency Evaluation) including F-PROM before starting a new line of systemic treatment. F-PROM included: Patient Reported Outcome Measurement System (PROMIS) - Cognitive Function (4 item, T-score = 41-80); impact of physical/emotional problems on social activities (social impact, 1-item); ability to walk one block (1-item); pain (0-10); and ability to perform nine IADL (3-point Likert scale). We extracted clinical characteristics from medical records, then used descriptive statistics and established F-PROM disability cut off to quantify the prevalence of functional disability. Results: Most patients (N = 86) were female (58%) and diagnosed with stage 3 or 4 (68%) breast (33%) or gastrointestinal cancer (24%). The mean±SD age was 64.3±10.7 years. ECOG was 0 (66%) or 1 (34%); none had ECOG-PS of >2. Across F-PROM, prevalence of disability ranged 24% (cognitive function) to 42% (social impact), see Table. IADL disability was reported by 31% of patients; median number of unique IADL disabilities was 3 (IQR = 1-4). Most common IADL disabilities were housework (29%), shopping (19%), ability to get to places out of walking distance (16%), and meal preparation (14%). Conclusions: Despite favorable ECOG-PS (0-1), 24 to 41% of patients starting a new line of systemic therapy in this study had one or more needs amendable to PT/OT. Future work should identify strategies to integrate F-PROM into routine oncology practice to identify rehabilitation needs and evaluate if subsequent PT/OT improves patient outcomes. Clinical trial information: NCT04852575. [Table: see text]

Prevalence of frailty for middle-aged and older adults starting a new line of systemic cancer treatment: Is age just a number?

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Background: Frailty is associated with adverse outcomes and increased risk of mortality for older adults (>60 years) with cancer. Geriatric assessment (GA) has gained popularity in routine cancer care as a clinical tool to screen for frailty in older adults starting a new line of cancer treatment, and to guide clinical decision making during systemic therapy. Emerging research indicates GA may also be useful to identify frailty in middle-aged adults (40-60 years) with cancer, but more research is needed. In this study, we used GA data to compare the prevalence of frailty between middle-aged and older adults starting a new line of systemic cancer treatment. Methods: Participants included adult patients with cancer due to begin a new line of systemic therapy at a multi-office community-based oncology private practice and enrolled in a clinical trial (NCT04852575). At baseline, participants completed an online version of the Cancer and Aging Resilience Evaluation (CARE) — a patient-reported GA adapted from the Cancer and Aging Research Group. Frailty score was constructed using a 44-item deficit accumulation method and categorized as frail (>0.35), pre-frail (0.2-0.35) or robust (0-0.2) using published cutoffs. We grouped participants by age, middle-aged (40-60 years) or older-aged (>60 years), then used independent t-test and chi-squared statistic to compare frailty scores (continuous) prevalence of frailty (categorical) between groups. Hypothesis testing was two sided and the level of significance was 0.05. Results: Participants ( n=96) were predominantly female (62%), Caucasian (68%) and beginning first line systemic therapy (69%) for either newly diagnosed cancer or new recurrence of disease; median time since diagnosis was 1 month. Common cancer types included: breast (34%), gastrointestinal (23%), hematologic (15%) and lung (12%). Disease stage was predominantly stage 3 (28%) or stage 4 (38%). When comparing middle-aged ( n=31, Mage = 54.74 ± 4.79, range = 41.23 – 59.98 years) vs. older adult -groups ( n=65, Mage = 70.27 ± 5.91, range = 60.64 – 84.29 years), there was no significant difference in mean frailty score ( p = 0.22) or the proportion categorized as frail vs. pre-frail vs. robust ( p = 0.32); see Table. Stage of disease and prevalence of common cancer types was similar between age groups (p>.05). Conclusions: In our cohort, middle and older aged patients who completed patient-report GA had similar prevalence of frailty before starting systemic therapy. Using the GA as a functional-age assessment to detect frailty for adults of varied ages could allow for earlier intervention aimed at impacting tolerance to therapy. Clinical trial information: NCT04852575. [Table: see text]

Implications for health system resilience: Quantifying the impact of the COVID-19-related stay at home orders on cancer screenings and diagnoses in southeastern North Carolina, USA

COVID-19 impacted hospital systems across the globe. Focus shifted to responding to increased healthcare demand while mitigating COVID-19 spread on their campuses. Mitigation efforts limited medical professional-patient interactions, including patient access to preventive cancer screenings. Data were gleaned from a health information exchange containing records on over 2 million patients in southeastern North Carolina, USA. This study tested five hypotheses: H₁: Weekly cancer screenings significantly decreased during North Carolina's (NC) Stay-At-Home (SAH) orders; H₂: Weekly cancer diagnoses significantly decreased during NC's SAH orders; H₃: Weekly cancer screenings significantly increased after the end of NC's SAH orders; H₄: Weekly cancer diagnoses significantly increased after the end of NC's SAH orders; and H₅: Weekly advanced cancer diagnoses significantly increased after the end of NC's SAH orders. Time series regression analysis was employed to quantify trends. Results suggested strong support of H₁ and H₃, moderate support of H₄, mixed support of H₅, and no support of H₂. For example, compared to before the SAH orders, we estimated 662.3 fewer weekly breast cancer screenings during the SAH orders (H₁). After the SAH orders (H₃), we estimated 232.5 more breast cancer screenings and 10.6 more breast cancer diagnoses. This work quantifies the impact of COVID-19 associated SAH orders on cancer screenings and diagnoses and suggests the potential for delayed or missed cancer diagnoses. This evident disruption in providing routine medical care also highlights the importance of strengthening health systems (or organizations) and improving resilience to natural disasters and infectious disease outbreaks.

Community vulnerability and mobility: What matters most in spatio-temporal modeling of the COVID-19 pandemic?

Community vulnerability is widely viewed as an important aspect to consider when modeling disease. Although COVID-19 does disproportionately impact vulnerable populations, human behavior as measured by community mobility is equally influential in understanding disease spread. In this research, we seek to understand which of four composite measures perform best in explaining disease spread and mortality, and we explore the extent to which mobility account for variance in the outcomes of interest. We compare two community mobility measures, three composite measures of community vulnerability, and one composite measure that combines vulnerability and human behavior to assess their relative feasibility in modeling the US COVID-19 pandemic. Extensions – via temporally dependent fixed effect coefficients – of the commonly used Bayesian spatio-temporal Poisson disease mapping models are implemented and compared in terms of goodness of fit as well as estimate precision and viability. A comparison of goodness of fit measures nearly unanimously suggests the human behavior-based models are superior. The duration at residence mobility measure indicates two unique and seemingly inverse relationships between mobility and the COVID-19 pandemic: the findings indicate decreased COVID-19 presence with decreased mobility early in the pandemic and increased COVID-19 presence with decreased mobility later in the pandemic. The early indication is likely influenced by a large presence of state-issued stay at home orders and self-quarantine, while the later indication likely emerges as a consequence of holiday gatherings in a country under limited restrictions. This study implements innovative statistical methods and furnishes results that challenge the generally accepted notion that vulnerability and deprivation are key to understanding disparities in health outcomes. We show that human behavior is equally, if not more important to understanding disease spread. We encourage researchers to build upon the work we start here and continue to explore how other behaviors influence the spread of COVID-19.

A systematic review of spatial habitat associations and modeling of marine fish distribution: A guide to predictors, methods, and knowledge gaps

As species distribution models, and similar techniques, have emerged in marine ecology, a vast array of predictor variables have been created and diverse methodologies have been applied. Marine fish are vital food resources worldwide, yet identifying the most suitable methodology and predictors to characterize spatial habitat associations, and the subsequent distributions, often remains ambiguous. Our objectives were to identify knowledge gaps in fish guilds, identify research themes, and to determine how data sources, statistics, and predictor variables differ among fish guilds. Data were obtained from an international literature search of peer-reviewed articles (2007-2018; n = 225) and research themes were determined based on abstracts. We tested for differences in data sources and modeling techniques using multinomial regressions and used a linear discriminant analysis to distinguish differences in predictors among fish guilds. Our results show predictive studies increased over time, but studies of forage fish, sharks, coral reef fish, and other fish guilds remain sparse. Research themes emphasized habitat suitability and distribution shifts, but also addressed abundance, occurrence, stock assessment, and biomass. Methodologies differed by fish guilds based on data limitations and research theme. The most frequent predictors overall were depth and temperature, but most fish guilds were distinguished by their own set of predictors that focused on their specific life history and ecology. A one-size-fits-all approach is not suitable for predicting marine fish distributions. However, given the paucity of studies for some fish guilds, researchers would benefit from utilizing predictors and methods derived from more commonly studied fish when similar habitat requirements are expected. Overall, the findings provide a guide for determining predictor variables to test and identifies novel opportunities to apply non-spatial knowledge and mechanisms to models.

Successful Perioperative Management of Orthotopic Cardiac Transplantation in a Pediatric Patient With Concurrent Congenital von Willebrand Disease and Acquired von Willebrand Syndrome Using Recombinant von Willebrand Factor

Von Willebrand disease (VWD) is the most common bleeding disorder and reportedly affects 1:1,000 of the world's population. There are three subtypes of VWD characterized by a quantitative defect (types 1 and 3 VWD) or a qualitative defect (type 2 VWD). Type 1 VWD results in a partial deficiency of von Willebrand factor (VWF) and affects approximately 75% of individuals with VWD, whereas type 3 VWD results in a severe or complete deficiency of VWF. Individuals with type 2 VWD subtypes (types 2A, 2B, 2M, and 2N VWD) express a dysfunctional VWF protein that has impaired interactions with platelets or factor VIII. The majority of individuals with VWD have mild type 1 VWD and occasionally require bolus infusions of VWF for severe bleeding or major surgery. A subset of patients, especially those with type 2A or 3 VWD, may require more frequent VWF replacement or prophylaxis for refractory bleeding or bleeding prevention, respectively. Acquired von Willebrand syndrome (AVWS) is a rare bleeding disorder that primarily occurs as a result of an underlying disease or other pathologic mechanism. Cases of AVWS associated with heart valve defects, left ventricular assist devices, or congenital cardiac disease result from high shear stress in the circulation that induces VWF unfolding and subsequent proteolysis of high-molecular-weight multimers by ADAMTS-13. In rare instances, plasma-derived factor VIII-containing VWF concentrates have been administered to individuals with AVWS for persistent or challenging bleeding events. In this case report, the hemostatic challenges and the perioperative management of cardiac transplantation surgery using a novel recombinant VWF product in a pediatric patient diagnosed with AVWS concomitant with congenital type 1 VWD are described. Written informed consent was obtained from the patient's mother for this case report. The diagnosis of congenital VWD remains a challenge because of multiple potential modifiers that can alter VWF laboratory results. Concurrent conditions, such as congenital heart disease and the rare secondary condition of AVWS, in addition to congenital VWD, can further affect interpretation of coagulation studies. This can result in delays in diagnosis, increase severity of the bleeding phenotype, and complicate hemostatic management in individuals at risk for bleeding and thrombosis. A multidisciplinary approach, including anesthesiologists, cardiologists, cardiovascular surgeons, hematologists, and pharmacists, is critical to achieving optimal patient outcomes, as highlighted in this case report. As diagnostic capabilities and understanding of VWD broaden, future studies evaluating alternative treatment approaches for individuals with various types of VWD would be of great benefit to the medical community.

C-reactive protein trajectory to predict colorectal anastomotic leak: PREDICT Study

BACKGROUND

Anastomotic leak is a common complication after colorectal surgery, associated with increased morbidity and mortality, and poorer long-term survival after oncological resections. Early diagnosis improves short-term outcomes, and may translate into reduced cancer recurrence. Multiple studies have attempted to identify biomarkers to enable earlier diagnosis of anastomotic leak. One study demonstrated that the trajectory of C-reactive protein (CRP) levels was highly predictive of anastomotic leak requiring intervention, with an area under the curve of 0·961. The aim of the present study was to validate this finding externally.

METHODS

This was a prospective international multicentre observational study of adults undergoing elective colorectal resection with an anastomosis. CRP levels were measured before operation and for 5 days afterwards, or until day of discharge if earlier than this. The primary outcome was anastomotic leak requiring operative or radiological intervention.

RESULTS

Between March 2017 and July 2018, 933 patients were recruited from 20 hospitals across Australia, New Zealand, England and Scotland. Some 833 patients had complete CRP data and were included in the primary analysis, of whom 41 (4·9 per cent) developed an anastomotic leak. A change in CRP level exceeding 50 mg/l between any two postoperative days had a sensitivity of 0·85 for detecting a leak, and a high negative predictive value of 0·99 for ruling it out. A change in CRP concentration of more than 50 mg/l between either days 3 and 4 or days 4 and 5 after surgery had a high specificity of 0·96-0·97, with positive likelihood ratios of 4·99-6·44 for a leak requiring intervention.

CONCLUSION

This study confirmed the value of CRP trajectory in accurately ruling out an anastomotic leak after colorectal resection.

Personality Factors Associated with the Decision to Accept Or Reject Mobility Training

The purpose of this ex post facto study was to determine what personality factors and demographic characteristics are related to acceptance or rejection of mobility training for adventitiously blind adults. The sample consisted of 79 subjects who had accepted mobility training and 60 subjects who had rejected training. The results indicated that the groups varied significantly on 7 of the 13 personality scales of the MMPI. No significant differences were found for any of the demographic variables. Different approaches to service for resistant clients are suggested.

Sequential Nature of (p,3p) Two-Proton Knockout from Neutron-Rich Nuclei

Twenty-one two-proton knockout (p,3p) cross sections were measured from neutron-rich nuclei at ∼250  MeV/nucleon in inverse kinematics. The angular distribution of the three emitted protons was determined for the first time, demonstrating that the (p,3p) kinematics are consistent with two sequential proton-proton collisions within the projectile nucleus. Ratios of (p,3p) over (p,2p) inclusive cross sections follow the trend of other many-nucleon removal reactions, further reinforcing the sequential nature of (p,3p) in neutron-rich nuclei.

An analysis of hurricane impact across multiple cancers: Accessing spatio-temporal variation in cancer-specific survival with Hurricane Katrina and Louisiana SEER data

Considering the impact of events such as natural disasters on disease risk is important. For this study, we examined temporal trends in multiple cancers available via Louisiana SEER data to understand how event impacts differ in timing and strength by cancer type. The specific event of interest for these Louisiana residents diagnosed with lung and bronchus, prostate, breast, colorectal, leukemia, or ovarian cancer in during the years 2000-2013 was Hurricane Katrina (August 2005). The results across multiple cancers showed similarities among trends, both spatial and temporal. With these results in mind, direct action could be made with the aim of improving survival after detrimental events or in detected Louisiana parishes with worse than average survival.

Biopsychosocial factors associated with depression and anxiety in older adults with intellectual disability: results of the wave 3 Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing

BACKGROUND

Depression and anxiety are amongst the most prevalent mental health disorders in the older population with intellectual disability (ID). There is a paucity of research that pertains to associative biopsychosocial factors for depression and anxiety in this population. The aim of this study is to determine the biopsychosocial factors associated with depression and anxiety in a population of older adults with ID in Ireland.

METHODS

The study was part of 'The Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing'. Depressive symptoms were assessed using the Glasgow Depression Scale for people with a Learning Disability. Anxiety symptoms were measured using the Glasgow Anxiety Scale for people with a Learning Disability. The cross-sectional associations of depression and anxiety with biopsychosocial parameters were measured using a variety of self-report and proxy-completed questionnaires.

RESULTS

For the study population, 9.97% met the criteria for depression, and 15.12% met the criteria for an anxiety disorder. Participants meeting criteria for depression were more likely to be taking regular mood stabiliser medications and to exhibit aggressive challenging behaviour. Participants meeting criteria for anxiety were more likely to have sleep difficulties and report loneliness. Participants meeting criteria for either/both depression and anxiety were more likely to report loneliness.

CONCLUSIONS

This study identified both treatable and modifiable, as well as unmodifiable, biopsychosocial factors associated with depression and/or anxiety in older adults with ID. A longitudinal study follow-up will further develop our knowledge on the causality and direction of associated biopsychosocial factors with depression and anxiety in older adults with ID and better inform management strategies, prevention policies and funding of services.

Latent classes for chemical mixtures analyses in epidemiology: an example using phthalate and phenol exposure biomarkers in pregnant women

Latent class analysis (LCA), although minimally applied to the statistical analysis of mixtures, may serve as a useful tool for identifying individuals with shared real-life profiles of chemical exposures. Knowledge of these groupings and their risk of adverse outcomes has the potential to inform targeted public health prevention strategies. This example applies LCA to identify clusters of pregnant women from a case-control study within the LIFECODES birth cohort with shared exposure patterns across a panel of urinary phthalate metabolites and parabens, and to evaluate the association between cluster membership and urinary oxidative stress biomarkers. LCA identified individuals with: "low exposure," "low phthalates, high parabens," "high phthalates, low parabens," and "high exposure." Class membership was associated with several demographic characteristics. Compared with "low exposure," women classified as having "high exposure" had elevated urinary concentrations of the oxidative stress biomarkers 8-hydroxydeoxyguanosine (19% higher, 95% confidence interval [CI] = 7, 32%) and 8-isoprostane (31% higher, 95% CI = -5, 64%). However, contrast examinations indicated that associations between oxidative stress biomarkers and "high exposure" were not statistically different from those with "high phthalates, low parabens" suggesting a minimal effect of higher paraben exposure in the presence of high phthalates. The presented example offers verification of latent class assignments through application to an additional data set as well as a comparison to another unsupervised clustering approach, k-means clustering. LCA may be more easily implemented, more consistent, and more able to provide interpretable output.

Temporally dependent accelerated failure time model for capturing the impact of events that alter survival in disease mapping

The introduction of spatial and temporal frailty parameters in survival models furnishes a way to represent unmeasured confounding in the outcome of interest. Using a Bayesian accelerated failure time model, we are able to flexibly explore a wide range of spatial and temporal options for structuring frailties as well as examine the benefits of using these different structures in certain settings. A setting of particular interest for this work involved using temporal frailties to capture the impact of events of interest on breast cancer survival. Our results suggest that it is important to include these temporal frailties when there is a true temporal structure to the outcome and including them when a true temporal structure is absent does not sacrifice model fit. Additionally, the frailties are able to correctly recover the truth imposed on simulated data without affecting the fixed effect estimates. In the case study involving Louisiana breast cancer-specific mortality, the temporal frailty played an important role in representing the unmeasured confounding related to improvements in knowledge, education, and disease screenings as well as the impacts of Hurricane Katrina and the passing of the Affordable Care Act. In conclusion, the incorporation of temporal, in addition to spatial, frailties in survival analysis can lead to better fitting models and improved inference by representing both spatially and temporally varying unmeasured risk factors and confounding that could impact survival. Specifically, we successfully estimated changes in survival around the time of events of interest.

Air Pollution, Clustering of Particulate Matter Components, and Breast Cancer in the Sister Study: A U.S.-Wide Cohort

BACKGROUND

Particulate matter (PM) is a complex mixture. Geographic variations in PM may explain the lack of consistent associations with breast cancer.

OBJECTIVE

We aimed to evaluate the relationship between air pollution, PM components, and breast cancer risk in a United States-wide prospective cohort.

METHODS

We estimated annual average ambient residential levels of particulate matter <2.5 μm and <10 μm in aerodynamic diameter (PM2.5 and PM10, respectively) and nitrogen dioxide (NO2) using land-use regression for 47,433 Sister Study participants (breast cancer-free women with a sister with breast cancer) living in the contiguous United States. Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk associated with an interquartile range (IQR) increase in pollutants. Predictive k-means were used to assign participants to clusters derived from PM2.5 component profiles to evaluate the impact of heterogeneity in the PM2.5 mixture. For PM2.5, we investigated effect measure modification by component cluster membership and by geographic region without regard to air pollution mixture.

RESULTS

During follow-up (mean=8.4 y), 2,225 invasive and 623 ductal carcinoma in situ (DCIS) cases were identified. PM2.5 and NO2 were associated with breast cancer overall [HR=1.05 (95% CI:0.99, 1.11) and 1.06 (95% CI:1.02, 1.11), respectively] and with DCIS but not with invasive cancer. Invasive breast cancer was associated with PM2.5 only in the Western United States [HR=1.14 (95% CI:1.02, 1.27)] and NO2 only in the Southern United States [HR=1.16 (95% CI:1.01, 1.33)]. PM2.5 was associated with a higher risk of invasive breast cancer among two of seven identified composition-based clusters. A higher risk was observed [HR=1.25 (95% CI: 0.97, 1.60)] in a California-based cluster characterized by low S and high Na and nitrate (NO3-) fractions and for another Western United States cluster [HR=1.60 (95% CI: 0.90, 2.85)], characterized by high fractions of Si, Ca, K, and Al.

CONCLUSION

Air pollution measures were related to both invasive breast cancer and DCIS within certain geographic regions and PM component clusters. https://doi.org/10.1289/EHP5131.

The LAPLAP study: a randomized placebo-controlled clinical trial assessing postoperative functional recovery using intraperitoneal local anaesthetic in laparoscopic colorectal surgery

AIM

Postoperative pain remains a major factor in recovery from colorectal resection. There is increasing interest in opioid-sparing analgesia, and intraperitoneal local anaesthetic (IPLA) has recently been shown to be useful in minor laparoscopic and open colorectal procedures. The aim of this study was to evaluate the impact of IPLA on functional recovery following major laparoscopic surgery. In this controlled trial, mobility, as measured by the De Morton Mobility Index (DEMMI), was used as a surrogate for postoperative functional recovery.

METHOD

Patients undergoing laparoscopic colorectal resection were randomized either to continuous ropivacaine (0.2% at 4-6 ml/h) or to saline (0.9%) which were administered via intraperitoneal catheter for 3 days postoperatively. Results were analysed in a double-blind manner. DEMMIs were assessed on postoperative days 1, 2, 3, 7 and 30, and data on pain, opioid consumption, gut and respiratory function, length of stay (LOS) and complications were recorded.

RESULTS

Ninety-six patients were recruited. There was no difference in primary outcome (i.e., functional recovery) between IPLA and placebo groups. Opioid consumption and LOS were similar between groups, and no differences were found for any secondary outcome measure. There were no adverse events related to ropivacaine.

CONCLUSION

Infusional intraperitoneal local anaesthetic appears to be safe but does not improve functional recovery or analgesic consumption following elective laparoscopic colorectal surgery, in the setting of an established enhanced recovery programme.

Increasing compliance of an oral oncolytic program in a multi-location practice

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Background: Over the past two decades the rise in number of oral oncolytics has significantly changed the landscape of cancer treatment. Although these medications offer patients the convenience of home administration, they pose different challenges. Two examples are adherence and education of associated toxicities. In an ongoing effort to provide quality cancer care, the Central Jersey Division of Regional Cancer Care Associates (CJD RCCA) has reconstructed its oral oncolytic program. Methods: In 2016 the CJD of RCCA developed an oral oncolytic program to educate patients on how to safely manage their medications. After the provider sent the prescription, a flowsheet is entered into the EMR, triggering the chemotherapy teaching session and appropriate follow up visits. During this visit patients are provided drug specific educational sheets which include lab monitoring, common adverse effects, and calendars to document adherence. Due to failure of entering flowsheets into the EMR, patients lost to scheduling while waiting for medication delivery, or patient refusal of teaching, compliance remained low. The program was modified to include running a daily report to identify all new oral oncolytic prescriptions. Schedulers are immediately calling patients to schedule a teaching session. A field in the EMR was created to document “patient refusal”. By making these improvements, CJD RCCA has increased compliance along with upholding quality care for patients receiving oral oncolytics. Results: Since re-structuring the program the RCCA CJD APNs have performed teaching on 124 of 172 (72%) patients from January to May of 2019. This is compared to only 79 of 144 (54%) in all of 2018. Of the patients identified in 2019 30 refused, 13 were completed by the physician, and 5 expired. This dramatic rise of 18% is largely due to running the daily oral oncolytic reports and entering the flowsheet into the EMR. Conclusions: Patient compliance has increased by identifying new patients and prompt enrollment into the program. It provides them the tools to safely navigate through treatment. At CJD RCCA, the oral oncolytic program is vital to ensuring positive clinical outcomes for these patients.

Trends in Colorectal Cancer Incidence and Survival in Iowa SEER Data: The Timing of It All

BACKGROUND

Colorectal cancer (CRC) is common worldwide, with 140,250 diagnoses and 50,630 deaths estimated for the United States in 2018. Guidelines current to the most recent individuals in our analysis suggested regular screenings beginning at age 50 have reduced the incidence of CRC. However, the incidence continues to rise among those under 50. Less is known about survival following CRC diagnosis, but research has suggested that younger cases may also have worse survival. However, we hypothesize that younger individuals are generally healthier with fewer comorbidities, leading to the potential for better survival following diagnosis.

MATERIALS AND METHODS

We utilized the Surveillance, Epidemiology, and End Results data to estimate and assess both spatial and temporal variation in age-specific colorectal cancer incidence and survival in Iowa.

RESULTS

Both overall and older-onset colorectal cancer incidence began to decline in the early 2000s, whereas younger-onset incidences decreased until the late 1980s but then increased steeply through the 2000s. The risk for those younger than 50 years of age first exceeded the risk for those 50 years or older in 2007. Survival times did increase for overall CRC, older-onset CRC, and young-onset CRC throughout the study period, with young-onset CRC increasing at a higher rate. The spatial variation assessment indicated that the survival was positively associated with several variables of interest, most notably disparities including better access to healthcare and higher sociodemographic status.

CONCLUSION

In conclusion, results suggest that regular colorectal screenings could reduce incidence and mortality in people under 50.

A data-driven approach for estimating the change-points and impact of major events on disease risk

Considering the impact of events on disease risk is important. Here, a Bayesian spatio-temporal accelerated failure time model furnished an ideal situation for modeling events that could impact survival experience via spatial and temporal frailty estimates. Through a hierarchical structure, this model allowed the data to detect the change-point(s) in addition to generating the event-related estimates. Both a real data case study and a simulation study were employed for testing these methods. The results suggested that meaningful and accurate change-points could be detected. Further, accurate event-related estimates for individuals in relation to those change-points could be obtained. By allowing the data to drive the change-point choices, the models were better fitting and the inference was more accurate.

The association of life events and mental ill health in older adults with intellectual disability: results of the wave 3 Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing

BACKGROUND

Exposures to life events are associated with emotional, psychological and behavioural problems in those with intellectual disability (ID). Older adults with ID may experience different life events given differences in living circumstances, cognitive decline, greater dependency on others and less autonomy. This study examines the relationship of life events and mental ill health in an older ID population in Ireland.

METHODS

The study was part of 'The Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing'. The frequency of life events was assessed using a 20-item checklist, and the level of stress experienced was assessed using a three-point Likert scale measuring the burden of the life event. The associations of life events with factors associated with mental ill health were measured using a variety of self-report and proxy completed questionnaires.

RESULTS

For the study population, 88.1% had been exposed to at least one life event in the preceding 12 months and 64.5% to two or more life events. Frequency and burden of life events were significantly higher in individuals living in institutional settings and in individuals with any current psychiatric condition, increased depressive and anxiety symptoms, challenging behaviour and reported poorer self-rated mental and physical health. More life events were significantly associated with new psychiatric diagnoses as well as initiation and increased dosage of mood stabilising, hypnotic and sedative medications.

CONCLUSIONS

Life events are significantly associated with mental ill health in the older ID population. Service providers must focus on limiting the exposure to these events and, in situations where they cannot be avoided, should support and manage individuals compassionately and effectively, prioritising their mental and physical well-being.

Prominence of Pairing in Inclusive (p,2p) and (p,pn) Cross Sections from Neutron-Rich Nuclei

Fifty-five inclusive single nucleon-removal cross sections from medium mass neutron-rich nuclei impinging on a hydrogen target at ∼250  MeV/nucleon are measured at the RIKEN Radioactive Isotope Beam Factory. Systematically higher cross sections are found for proton removal from nuclei with an even number of protons as compared to odd-proton number projectiles for a given neutron separation energy. Neutron removal cross sections display no even-odd splitting, contrary to nuclear cascade model predictions. Both effects are understood through simple considerations of neutron separation energies and bound state level densities originating in pairing correlations in the daughter nuclei. These conclusions are supported by comparison with semimicroscopic model predictions, highlighting the enhanced role of low-lying level densities in nucleon-removal cross sections from loosely bound nuclei.

Metallic Air Pollutants and Breast Cancer Risk in a Nationwide Cohort Study

BACKGROUND

Toxic metals show evidence of carcinogenic and estrogenic properties. However, little is known about the relationship between airborne metals and breast cancer. We evaluated the risk of breast cancer in relation to exposure to toxic metallic substances in air, individually and combined, in a US-wide cohort.

METHODS

Sister Study participants (n = 50,884), breast cancer-free women who had a sister with breast cancer were recruited, from 2003 to 2009. The 2005 Environmental Protection Agency National Air Toxic Assessment's census-tract estimates of metal concentrations in air (antimony, arsenic, cadmium, chromium, cobalt, lead, manganese, mercury, nickel, and selenium) were matched to participants' enrollment residence. We used Cox regression to estimate the association between quintiles of individual metals and breast cancer incidence and weighted quantile sum regression to model the association between the metal mixture and breast cancer.

RESULTS

A total of 2,587 breast cancer cases were diagnosed during follow-up (mean = 7.4 years). In individual chemical analyses comparing the highest to lowest quintiles, postmenopausal breast cancer risk was elevated for mercury (hazard ratio [HR] = 1.3, 95% confidence interval [CI], 1.1, 1.5), cadmium (HR = 1.1, 95% CI, 0.96, 1.3), and lead (HR = 1.1, 95% CI, 0.98, 1.3). The weighted quantile sum index was associated with postmenopausal breast cancer (odds ratio [OR] = 1.1, 95% CI, 1.0, 1.1). Consistent with the individual chemical analysis, the most highly weighted chemicals for predicting postmenopausal breast cancer risk were lead, cadmium, and mercury. Results were attenuated for overall breast cancer.

CONCLUSIONS

Higher levels of some airborne metals, specifically mercury, cadmium, and lead, were associated with a higher risk of postmenopausal breast cancer.

Urinary trace metals individually and in mixtures in association with preterm birth

One in ten infants born in the United States is born preterm, or prior to 37 weeks gestation. Exposure to elevated levels of metals, such as lead and arsenic, has been linked to higher risk of preterm birth (PTB), but consequences of lower levels of exposure and less studied metals are unclear. We examined the associations between 17 urinary trace metals individually and in mixtures in relation to PTB. The LIFECODES birth cohort enrolled pregnant women at <15 weeks gestation at Brigham and Women's Hospital in Boston. We selected cases of PTB (n = 99) and unmatched controls (n = 291) and analyzed urine samples for a panel of trace metals (median: 26 weeks gestation). We used logistic regression models to calculate the odds ratio (OR) for PTB and subtypes of PTB based on presentation at delivery. Subtypes included spontaneous and placental PTB. We used elastic net (ENET) regularization to identify individual metals or pairwise interactions that had the strongest associations with PTB, and principal components analysis (PCA) to identify classes of exposures associated with the outcome. We observed increased odds of PTB (OR: 1.41, 95% Confidence Interval [CI]: 1.12, 1.78) in association with an interquartile range difference in urinary copper (Cu). We also observed an increased OR for selenium (OR: 1.33, 95% CI: 0.98, 1.81). ENET selected Cu as the most important trace metal associated with PTB. PCA identified 3 principal components (PCs) that roughly reflected exposure to toxic metals, essential metals, and metals with seafood as a common source of exposure. PCs reflecting essential metals were associated with increased odds of overall and spontaneous PTB. Maternal urinary copper in the third trimester was associated with increased risk of PTB, and statistical analyses for mixtures indicated that after accounting for correlation this metal was the most important statistical predictor of the outcome.

Mobile Momentary Assessment and Biobehavioral Feedback for Adolescents with Type 1 Diabetes: Feasibility and Engagement Patterns

BACKGROUND

Integration of momentary contextual and psychosocial factors within self-management feedback may provide more specific, engaging, and personalized targets for problem solving.

METHODS

Forty-four youth ages 13-19 with type 1 diabetes (T1D) were provided a Bluetooth meter and completed the 30-day protocol. Participants were randomized to "app + meter" or "meter-only" groups. App + meter participants completed mealtime and bedtime assessment each day. Assessments focused on psychosocial and contextual information relevant for self-management. Graphical feedback integrated self-monitored blood glucose (SMBG), insulin, and Bluetooth-transmitted blood glucose data with the psychosocial and contextual data. App + meter participants completed an interview to identify data patterns.

RESULTS

The median number of momentary assessments per participant was 80.0 (range 32-120) with 2.60 per day. By 2 weeks participants had an average of 40.77 (SD 12.23) assessments. Dose-response analyses indicated that the number of app assessments submitted were significantly related to higher mean daily SMBG (r = -0.44, P < 0.05) and to lower% missed mealtime SMBG (r = -0.47, P < 0.01). Number of feedback viewing sessions was also significantly related to a lower% missed mealtime SMBG (r = -0.44, P < 0.05). Controlling for baseline variables, mixed-effects analyses did not indicate group × time differences in mean daily SMBG. Engagement analyses resulted in three trajectory groups distinguished by assessment frequencies and rates of decline. Engagement group membership was significantly related to gender, mean daily SMBG, and HbA1c values.

CONCLUSIONS

Momentary assessment combined with device data provided a feasible means to provide novel personalized biobehavioral feedback for adolescents with T1D. A 2-week protocol provided sufficient data for self-management problem identification. In addition to feedback, more intensive intervention may need to be integrated for those patients with the lowest self-management at baseline.

Gaining relevance from the random: Interpreting observed spatial heterogeneity

In Bayesian disease mapping, spatial random effects are used to account for confounding in the data so that reasonable estimates for the fixed effects can be obtained. Typically, the spatial random effects are mapped and qualitative comments are made related to an increase or decrease in risk for certain areas. The approach outlined here illustrates how a quantitative secondary assessment can be applied to make more useful and applicable inference related to these spatial random effects. We are able to recover important but unmeasured or unincluded risk factors via a secondary model fit. Results from the secondary model fit can determine association between spatial region-level risk factors and the estimated spatial random effects. We believe this work presents a useful, quantitative technique highlighting the importance and applicability of spatial random effects as well as illustrates how these methods lead to more interpretable conclusions.

Multiscale measurement error models for aggregated small area health data

Spatial data are often aggregated from a finer (smaller) to a coarser (larger) geographical level. The process of data aggregation induces a scaling effect which smoothes the variation in the data. To address the scaling problem, multiscale models that link the convolution models at different scale levels via the shared random effect have been proposed. One of the main goals in aggregated health data is to investigate the relationship between predictors and an outcome at different geographical levels. In this paper, we extend multiscale models to examine whether a predictor effect at a finer level hold true at a coarser level. To adjust for predictor uncertainty due to aggregation, we applied measurement error models in the framework of multiscale approach. To assess the benefit of using multiscale measurement error models, we compare the performance of multiscale models with and without measurement error in both real and simulated data. We found that ignoring the measurement error in multiscale models underestimates the regression coefficient, while it overestimates the variance of the spatially structured random effect. On the other hand, accounting for the measurement error in multiscale models provides a better model fit and unbiased parameter estimates.

Zero-inflated multiscale models for aggregated small area health data

It is our primary focus to study the spatial distribution of disease incidence at different geographical levels. Often, spatial data are available in the form of aggregation at multiple scale levels such as census tract, county, state, and so on. When data are aggregated from a fine (e.g. county) to a coarse (e.g. state) geographical level, there will be loss of information. The problem is more challenging when excessive zeros are available at the fine level. After data aggregation, the excessive zeros at the fine level will be reduced at the coarse level. If we ignore the zero inflation and the aggregation effect, we could get inconsistent risk estimates at the fine and coarse levels. Hence, in this paper, we address those problems using zero inflated multiscale models that jointly describe the risk variations at different geographical levels. For the excessive zeros at the fine level, we use a zero inflated convolution model, whereas we consider a regular convolution model for the smoothed data at the coarse level. These methods provide a consistent risk estimate at the fine and coarse levels when high percentages of structural zeros are present in the data.

Lifetime measurement in neutron-rich A~100 nuclei

Lifetimes of excited states of the 98;100;102Zr nuclei were measured by using the Generalized Centroid Difference Method. The nuclei of interest were populated via neutron-induced fission of 241Pu and 235U during the EXILL-FATIMA campaign. The obtained lifetimes were used to calculate the B(E2) transition strengths and β deformation parameters which were then compared with the recent theoretical predictions obtained with Monte Carlo Shell Model.

Studies of fission fragment yields via high-resolution γ-ray spectroscopy

Precise spectroscopic information on the fast neutron induced fission of the 238U(n,f) reaction was recently gained using a new technique which involved coupling of the Miniball high resolution y-ray spectrometer and the LICORNE directional neutron source. The experiment allowed measurement of the isotopic fission yields for around 40 even-even nuclei at an incident neutron energy of around 2 MeV where yield data are very sparse. In addition spectroscopic information on very neutron-rich fission products was obtained. Results were compared to models, both the JEFF-3.1.1 data base and the GEF code, and large discrepancies for the S1 fission mode in the Sn/Mo isotope pair were discovered. This suggests that current models are overestimating the role played by spherical shell effects in fast neutron induced fission. In late 2017 and 2018 the nu-ball hybrid spectrometer will be constructed at the IPN Orsay to perform further experimental investigations with directional neutrons coupled to a powerful hybrid Ge/LaBr3 detector array. This will open up new possibilities for measurements of fission yields for fast-neutron-induced fission using the spectroscopic technique and will be complimentary to other methods being developed.

Spatiotemporal multivariate mixture models for Bayesian model selection in disease mapping

It is often the case that researchers wish to simultaneously explore the behavior of and estimate overall risk for multiple, related diseases with varying rarity while accounting for potential spatial and/or temporal correlation. In this paper, we propose a flexible class of multivariate spatio-temporal mixture models to fill this role. Further, these models offer flexibility with the potential for model selection as well as the ability to accommodate lifestyle, socio-economic, and physical environmental variables with spatial, temporal, or both structures. Here, we explore the capability of this approach via a large scale simulation study and examine a motivating data example involving three cancers in South Carolina. The results which are focused on four model variants suggest that all models possess the ability to recover simulation ground truth and display improved model fit over two baseline Knorr-Held spatio-temporal interaction model variants in a real data application.

Assessment of spatial variation in breast cancer-specific mortality using Louisiana SEER data

BACKGROUND

Previous studies suggest spatial differences in mortality for many types of cancer, including breast cancer. Identifying explanations for these spatial differences results in a better understanding of what leads to longer survival time.

METHODS

We used a Bayesian accelerated failure time model with spatial frailty terms to investigate potential spatial differences in breast cancer mortality following breast cancer diagnosis using 2000-2013 Louisiana SEER data.

RESULTS

There are meaningful spatial differences in breast cancer mortality across the parishes of Louisiana, even after adjusting for known demographic and clinical risk factors. For example, the average survival time of a woman diagnosed in Orleans parish was 1.51 times longer than that of a woman diagnosed in Terrebonne parish. Additionally, there is evidence to suggest shorter survival times in lower income parishes along the Red and Mississippi Rivers, as well as parishes with lower socioeconomic status, less access to care and fresh food, worse quality of care, and more workers in certain industries.

CONCLUSION

The addition of spatial frailties to account for an individual's geographic location is useful when analyzing breast cancer mortality data. Our findings suggest that survival following breast cancer diagnosis could potentially be improved if socioeconomic status differences were addressed, healthcare improved in quality and became more accessible, and certain industrial situations were improved for individuals diagnosed in parishes identified as having shorter average survival times.

A prospective 20-year longitudinal follow-up of dementia in persons with Down syndrome

GOAL

To examine dementia characteristics, age at onset and associated co-morbidities in persons with Down syndrome.

METHOD

A total of 77 people with Down syndrome aged 35 years and older were followed up from 1996 to 2015. The diagnosis of dementia was established using the modified ICD 10 Criteria and a combination of objective and informant-based tests. Cognitive tests included the Test for Severe Impairment and the Down Syndrome Mental Status Examination; adaptive behaviour was measured using the Daily Living Skills Questionnaire, and data from the Dementia Questionnaire for People with Intellectual Disabilities have been available since 2005.

RESULTS

Over the 20-year period, 97.4% (75 of 77) persons developed dementia with a mean age of dementia diagnosis of 55 years (SD = 7.1, median = 56 years). Clinical dementia was associated with cognitive and function decline and seizure activity. Risk for dementia increased from 23% in those aged 50 years to 80% in those aged 65 years and above. There were no differences by level of ID.

CONCLUSION

The previously reported high risk levels for dementia among people with Down syndrome were confirmed in this data as was the relationship with late onset epilepsy. The value of the instruments utilised in tracking decline and helping to confirm diagnosis is further highlighted.

Comparing multilevel and multiscale convolution models for small area aggregated health data

In spatial epidemiology, data are often arrayed hierarchically. The classification of individuals into smaller units, which in turn are grouped into larger units, can induce contextual effects. On the other hand, a scaling effect can occur due to the aggregation of data from smaller units into larger units. In this paper, we propose a shared multilevel model to address the contextual effects. In addition, we consider a shared multiscale model to adjust for both scale and contextual effects simultaneously. We also study convolution and independent multiscale models, which are special cases of shared multilevel and shared multiscale models, respectively. We compare the performance of the models by applying them to real and simulated data sets. We found that the shared multiscale model was the best model across a range of simulated and real scenarios as measured by the deviance information criterion (DIC) and the Watanabe Akaike information criterion (WAIC).

Double versus single thrombophilias during pregnancy

OBJECTIVE

The primary objective of this study was to evaluate whether women with double thrombophilias have a greater risk for obstetric complications as compared with women who have single thrombophilias.

STUDY DESIGN

This is a retrospective cohort study of all patients in a single practice with a clinically significant inherited thrombophilia and treated with anticoagulation between 2005 and 2013. Thrombophilias evaluated include: factor V Leiden, prothrombin G20210A gene mutation, protein S deficiency, protein C deficiency, and antithrombin III deficiency. Double thrombophilia was defined as the presence of two thrombophilias or homozygosity for factor V Leiden or prothrombin Gene Mutation. Demographic and obstetrical outcome data were collected. Data on all patients with double thrombophilias who met inclusion criteria was reported. Data was then compared between the patients with double thrombophilias and single thrombophilias with singleton gestations. The data was analyzed with Pearson's chi-squared or Student's t-test as appropriate with p value <.05 used for significance.

RESULTS

Eighteen patients with clinically significant double thrombophilias who met inclusion criteria were identified. Most patients delivered full term (88.9%) and appropriate for gestational age (77.8%) infants. One hundred thirty-two patients with single thrombophilias and 14 patients with double thrombophilias with singleton gestations were then compared. Demographic characteristics were not significantly different between the two groups. There were no significant differences in obstetrical outcomes between patients.

CONCLUSIONS

There were no significant differences in obstetrical outcomes for patients with clinically significant double thrombophilias versus single thrombophilias when treated with anticoagulation.

Spatial small area smoothing models for handling survey data with nonresponse

Spatial smoothing models play an important role in the field of small area estimation. In the context of complex survey designs, the use of design weights is indispensable in the estimation process. Recently, efforts have been made in these spatial smoothing models, in order to obtain reliable estimates of the spatial trend. However, the concept of missing data remains a prevalent problem in the context of spatial trend estimation as estimates are potentially subject to bias. In this paper, we focus on spatial health surveys where the available information consists of a binary response and its associated design weight. Furthermore, we investigate the impact of nonresponse as missing data on a range of spatial models for different missingness mechanisms and different degrees of missingness by means of an extensive simulation study. The computations were performed in R, using INLA and other existing packages. The results show that weight adjustment to correct for missingness has a beneficial effect on the bias in the missing at random setting for all models. Furthermore, we estimate the geographical distribution of perceived health at the district level based on the Belgian Health Interview Survey (2001). Copyright © 2017 John Wiley & Sons, Ltd.