Contribution of alcohol use in HIV/hepatitis C virus co-infection to all-cause and cause-specific mortality: A collaboration of cohort studies

Among persons with HIV (PWH), higher alcohol use and having hepatitis C virus (HCV) are separately associated with increased morbidity and mortality. We investigated whether the association between alcohol use and mortality among PWH is modified by HCV. Data were combined from European and North American cohorts of adult PWH who started antiretroviral therapy (ART). Self-reported alcohol use data, collected in diverse ways between cohorts, were converted to grams/day. Eligible PWH started ART during 2001-2017 and were followed from ART initiation for mortality. Interactions between the associations of baseline alcohol use (0, 0.1-20.0, >20.0 g/day) and HCV status were assessed using multivariable Cox models. Of 58,769 PWH, 29,711 (51%), 23,974 (41%) and 5084 (9%) self-reported alcohol use of 0 g/day, 0.1-20.0 g/day, and > 20.0 g/day, respectively, and 4799 (8%) had HCV at baseline. There were 844 deaths in 37,729 person-years and 2755 deaths in 443,121 person-years among those with and without HCV, respectively. Among PWH without HCV, adjusted hazard ratios (aHRs) for mortality were 1.18 (95% CI: 1.08-1.29) for 0.0 g/day and 1.84 (1.62-2.09) for >20.0 g/day compared with 0.1-20.0 g/day. This J-shaped pattern was absent among those with HCV: aHRs were 1.00 (0.86-1.17) for 0.0 g/day and 1.64 (1.33-2.02) for >20.0 g/day compared with 0.1-20.0 g/day (interaction p < .001). Among PWH without HCV, mortality was higher in both non-drinkers and heavy drinkers compared with moderate alcohol drinkers. Among those with HCV, mortality was higher in heavy drinkers but not non-drinkers, potentially due to differing reasons for not drinking (e.g. illness) between those with and without HCV.

Cause-Specific Mortality in Patients With Gout in the US Veterans Health Administration: A Matched Cohort Study

OBJECTIVE

To compare all-cause and cause-specific mortality risk between patients with gout and patients without gout in the Veteran's Health Administration (VHA).

METHODS

We performed a matched cohort study, identifying patients with gout in the VHA from January 1999 to September 2015 based on the presence of ≥2 International Classification of Diseases, Ninth Revision codes for gout (274.X). Gout patients were matched up to 1:10 on birth year, sex, and year of VHA enrollment with patients without gout and followed until death or end of study (December 2017). Cause of death was obtained from the National Death Index. Associations of gout with all-cause and cause-specific mortality were examined using multivariable Cox regression.

RESULTS

Gout (n = 559,243) and matched non-gout controls (n = 5,428,760) had a mean age of 67 years and were 99% male. There were 246,291 deaths over 4,250,371 patient-years in gout patients and 2,000,000 deaths over 40,441,353 patient-years of follow-up in controls. After matching, gout patients had an increased risk of death (hazard ratio [HR] 1.09 [95% confidence interval (95% CI) 1.08-1.09]), which was no longer present after adjusting for comorbidities (HR 0.98 [95% CI 0.97-0.98]). The strongest association of gout with cause-specific mortality was observed with genitourinary conditions (HR 1.50 [95% CI 1.47-1.54]). Gout patients were at lower risk of death related to neurologic (e.g., Alzheimer's disease and Parkinson's disease) (HR 0.63 [95% CI 0.62-0.65]) and mental health (HR 0.66 [95% CI 0.65-0.68]) conditions.

CONCLUSION

A higher risk of death among gout patients in the VHA was related to comorbidity burden. While deaths attributable to neurologic and mental health conditions were less frequent among gout patients, genitourinary conditions were the most overrepresented causes of death.

Premature mortality 16 years after emergency department presentation among homeless and at risk of homelessness adults: a retrospective longitudinal cohort study

BACKGROUND

People experiencing homelessness have an increased risk of mortality. The association between being at risk of homelessness and premature mortality is unclear. We aimed to determine all-cause and cause-specific mortality in patients who were homeless, at risk of homelessness (marginally housed), or housed.

METHODS

This retrospective longitudinal cohort study compared mortality patterns in adult patients identified in 2003/04 by linking data from an Australian metropolitan emergency department to national mortality data. We used Cox proportional hazards models to estimate associations between housing status and mortality. To address competing risks, cause-specific hazards were modelled and transformed into stacked cumulative incidence functions.

FINDINGS

Data from 6290 patients (homeless deceased = 382/1050, marginally housed deceased = 259/518, housed deceased = 1204/4722) found increased risk of mortality in homeless [hazard ratio (HR) = 4.0, 95% confidence interval (CI) = 2.0-3.3) and marginally housed (HR = 2.6, 95% CI = 3.4-4.8) patients. Homeless patients had an excess risk from external causes (HR = 6.1, 95% CI = 4.47-8.35), cardiovascular disease (HR = 4.9, 95% CI = 2.78-8.70) and cancer (HR = 1.5, 95% CI = 1.15-2.09). Marginally housed patients had increased risk from external causes (HR = 3.6, 95% CI = 2.36-5.40) and respiratory diseases (HR = 4.7, 95% CI = 1.82-12.05). Taking account of competing risk, marked inequality was observed, with homeless, marginally housed and housed patients having probabilities of death by 55 years of 0.2, 0.1 and 0.02, respectively.

CONCLUSIONS

Mortality rates were elevated in patients who were homeless or at risk of homelessness. Increasing numbers of people are at risk of homelessness, and the effect of this on mortality is relatively unrecognized. Marginal housing may assuage some risk of premature mortality associated with homelessness; however, it is not equivalent to stable housing.

Prognostic factors for squamous cervical carcinoma identified by competing-risks analysis: A study based on the SEER database

Cervical cancer has a high incidence of malignant tumors and a high mortality rate, with squamous cervical carcinoma (SCC) accounting for 80% of cases. A competing-risks model is recommended as being more feasible for evaluating the prognosis and guiding clinical practice in the future compared to Cox regression. Data originating from the Surveillance, epidemiology, and end results (SEER) database during 2004 to 2013 were analyzed. Univariate analysis with the cumulative incidence function was performed to assess the potential risk of each covariate. Significant covariates (P < .05) were extracted for inclusion in a Cox regression analysis and a competing-risks model that included a cause-specific (CS) hazard function model and a sub-distribution (SD) hazard function model. A total of 5591 SCC patients met the inclusion criteria. The three methods (Cox regression analysis, CS analysis, and SD analysis) showed that age, metastasis, American Joint Committee on Cancer stage, surgery, chemotherapy, radiation sequence with surgery, lymph node dissection, tumor size, and tumor grade were prognostic factors affecting survival in patients with SCC. In contrast, race and radiation status were prognostic factors affecting survival in the Cox regression and CS analysis, but the results were different in the SD analysis. Being separated, divorced, or widowed was an independent prognostic factor in the Cox regression analysis, but the results were different in the CS and SD analyses. A competing-risks model was used as a new statistical method to more accurately identify prognostic factors than conventional Cox regression analysis leading to bias in the results. This study found that the SD model may be better suited to estimate the clinical prognosis of a patient, and that the results of an SD model analysis were close to those of a CS analysis.

Survival for endometrial cancer as a second primary malignancy

BACKGROUND

Endometrial cancer (EC) often occurs subsequently to a primary cancer arising from a different site. However, little is known regarding the survival experience of EC as a second primary (ECSP) malignancy, specifically in relation to the original primary site and prior treatment.

METHODS

Using Florida's cancer registry, all EC cases (first, second, or higher-order) diagnosed from 2005-2016 were analyzed. Kaplan-Meier methods and Cox Regression were used in a cause-specific survival analysis.

RESULTS

A total of 2879 clinically independent ECSPs and 42,714 first primary ECs were analyzed. The most common first primary sites for ECSPs were breast cancer (BC) (n = 1422) and colorectal cancer (CRC) (n = 359). Five-year cause-specific survival was 84.0% (95% CI: 83.6-84.3) for first primary ECs and 81.8% (95% CI: 80.0-83.4) for ECSPs. After adjusting for age, race/ethnicity, histology, and stage at diagnosis, ECSPs had a lower risk of EC mortality than first primary ECs (hazard ratios [HR] 0.88, 95% CI: 0.79-0.97). ECSPs with a first primary CRC had a higher risk of EC-specific death (HR 1.47, 95% CI: 1.04-2.06) compared to ECSPs that followed BC in multivariable analysis. Finally, women who had chemotherapy for ECSP and preceding BC did not have a higher risk of death (HR 0.80, 95% CI: 0.49-1.31) compared to those who only received chemotherapy for first primary EC.

CONCLUSIONS

ECSPs present a complex clinical profile. ECSP survival is superior to that of first primary EC. However, ECSPs following CRC may constitute a population of interest for their worse prognosis. Chemotherapy for a previous BC does not seem to impact the effectiveness of chemotherapy for ECs.

Trends, patterns and cause-specific neonatal mortality in Tanzania: a hospital-based retrospective survey

Background

Globally, large numbers of children die shortly after birth and many of them within the first 4 wk of life. This study aimed to determine the trends, patterns and causes of neonatal mortality in hospitals in Tanzania during 2006–2015.

Methods

This retrospective study involved 35 hospitals. Mortality data were extracted from inpatient registers, death registers and International Classification of Diseases-10 report forms. Annual specific hospital-based neonatal mortality rates were calculated and discussed. Two periods of 2006–2010 and 2011–2015 were assessed separately to account for data availability and interventions.

Results

A total of 235 689 deaths were recorded and neonatal deaths accounted for 11.3% (n=26 630) of the deaths. The majority of neonatal deaths (87.5%) occurred in the first week of life. Overall hospital-based neonatal mortality rates increased from 2.6 in 2006 to 10.4 deaths per 1000 live births in 2015, with the early neonates contributing 90% to this rate constantly over time. The neonatal mortality rate was 3.7/1000 during 2006–2010 and 10.4/1000 during 2011–2015, both periods indicating a stagnant trend in the years between. The leading causes of early neonatal death were birth asphyxia (22.3%) and respiratory distress (20.8%), while those of late neonatal death were sepsis (29.1%) and respiratory distress (20.0%).

Conclusion

The majority of neonatal deaths in Tanzania occur among the early newborns and the trend over time indicates a slow improvement. Most neonatal deaths are preventable, hence there are opportunities to reduce mortality rates with improvements in service delivery during the first 7 d and maternal care.

FGF23 and Cause-Specific Mortality in Community-Living Individuals-The Health, Aging, and Body Composition Study

OBJECTIVES

Fibroblast growth factor (FGF)-23 is a key regulator of mineral metabolism and has been linked with left ventricular hypertrophy in animal models. Most existing epidemiologic studies evaluated a C-terminal FGF23 assay which measures both the intact (active) hormone and inactive fragments. The relationship of intact FGF23 with cause-specific mortality is unknown.

DESIGN

Prospective analyses of data from Health, Aging, & Body Composition (HABC) study.

SETTING

Community-living adults aged 70 to 79 years with longitudinal follow up.

Mortality in adult-onset and elderly-onset IBD: a nationwide register-based cohort study 1964-2014

OBJECTIVES

To examine all-cause and cause-specific mortality in adult-onset and elderly-onset IBD and to describe time trends in mortality over the past 50 years.

DESIGN

Swedish nationwide register-based cohort study 1964-2014, comparing mortality in 82 718 incident IBD cases (inpatient and non-primary outpatient care) with 10 times as many matched general population reference individuals (n=801 180) using multivariable Cox regression to estimate HRs. Among patients with IBD, the number of participants with elderly-onset (≥60 years) IBD was 17 873.

RESULTS

During 984 330 person-years of follow-up, 15 698/82 718 (19%) of all patients with IBD died (15.9/1000 person-years) compared with 121 095/801 180 (15.1%) of reference individuals, corresponding to an HR of 1.5 for IBD (95% CI=1.5 to 1.5 (HR=1.5; 95% CI=1.5 to 1.5 in elderly-onset IBD)) or one extra death each year per 263 patients. Mortality was increased specifically for UC (HR=1.4; 95% CI=1.4 to 1.5), Crohn's disease (HR=1.6; 95% CI=1.6 to 1.7) and IBD-unclasssified (HR=1.6; 95% CI=1.5 to 1.8). IBD was linked to increased rates of multiple causes of death, including cardiovascular disease (HR=1.3; 1.3 to 1.3), malignancy (HR=1.4; 1.4 to 1.5) and digestive disease (HR=5.2; 95% CI=4.9 to 5.5). Relative mortality during the first 5 years of follow-up decreased significantly over time. Incident cases of 2002-2014 had 2.3 years shorter mean estimated life span than matched comparators.

CONCLUSIONS

Adult-onset and elderly-onset patients with UC, Crohn's disease and IBD-unclassified were all at increased risk of death. The increased mortality remained also after the introduction of biological therapies but has decreased over time.

Association between PM2.5 Exposure and All-Cause, Non-Accidental, Accidental, Different Respiratory Diseases, Sex and Age Mortality in Shenzhen, China

Background: China is at its most important stage of air pollution control. Research on the association between air pollutants and human health is very important and necessary. The purpose of this study was to evaluate the association between PM_2.5 concentrations and residents’ mortality and to compare the effect of PM_2.5 on the different diseases, accidental deaths, sex or age of residents from high polluted areas with less polluted areas. Methods: The semi-parametric generalized additive model (GAM) with Poisson distribution of time series analysis was used. The excess risk (ER) of mortality with the incremental increase of 10 µg/m³ in PM_2.5 concentration was calculated. Concentration-response relationship curves and autocorrelation between different lags of PM_2.5 were also evaluated. Results: PM_2.5 exposure was significantly associated with the mortality of residents. The strongest ERs per 10 µg/m³ increase in PM_2.5 were 0.74% (95% CI: 0.11–1.38%) for all-cause, 0.67% (95% CI: 0.01–1.33%) for non-accidental, 1.81% (95% CI: 0.22–3.42%) for accidental, 3.04% (95% CI: 0.60–5.55%) for total respiratory disease, 6.38% (95% CI: 2.78–10.11%) for chronic lower respiratory disease (CLRD), 8.24% (95% CI: 3.53–13.17%) for chronic obstructive pulmonary disease (COPD), 1.04% (95% CI: 0.25–1.84%) for male and 1.32% (95% CI: 0.46–2.19%) for elderly. Furthermore, important information on the concentration-response relationship curves was provided. Conclusions: PM_2.5 can increase the risk of residents’ mortality, even in places with less air pollution and developed economy in China.

Analysis of quality-of-life adjusted failure time data in the presence of competing, possibly informative, censoring mechanisms

We derive estimators of the mean of a function of a quality-of-life adjusted failure time, in the presence of competing right censoring mechanisms. Our approach allows for the possibility that some or all of the competing censoring mechanisms are associated with the endpoint, even after adjustment for recorded prognostic factors, with the degree of residual association possibly different for distinct censoring processes. Our methods generalize from a single to many censoring processes and from ignorable to non-ignorable censoring processes.

Non-parametric estimation of bivariate failure time associations in the presence of a competing risk

Most research on the study of associations among paired failure times has either assumed time invariance or been based on complex measures or estimators. Little has accommodated competing risks. This paper targets the conditional cause-specific hazard ratio, henceforth called the cause-specific cross ratio, a recent modification of the conditional hazard ratio designed to accommodate competing risks data. Estimation is accomplished by an intuitive, non-parametric method that localizes Kendall's tau. Time variance is accommodated through a partitioning of space into 'bins' between which the strength of association may differ. Inferential procedures are developed, small-sample performance is evaluated and the methods are applied to the investigation of familial association in dementia onset.