Category: Statistics

JAMA Netw Open. 2025 Apr 1;8(4):e253469. doi: 10.1001/jamanetworkopen.2025.3469.

ABSTRACT

IMPORTANCE: Comorbidities in midlife are common but how these conditions are associated with cancer outcomes is poorly understood.

OBJECTIVE: To investigate the association between different comorbidities and risk of incident cancer and cancer mortality.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study is a secondary analysis of the prospective Prostate, Lung, Colorectal, and Ovarian (PLCO) screening trial conducted at 10 PLCO screening centers across the US. Participants included adults aged 55 to 74 years without a history of cancer enrolled between 1993 and 2001. Statistical analysis was performed from June 2023 to December 2024.

EXPOSURES: Self-reported history of 12 comorbid conditions classified into 5 distinct classifications guided by World Health Organization categorization.

MAIN OUTCOME AND MEASURES: Outcomes included risk of all cancers combined, risk of 19 individual cancer types, and cancer mortality. Multivariable Cox proportional hazards models were used to estimate the association between comorbidity classifications and cancer outcomes.

RESULTS: Among 128 999 participants included in the analysis, 330 (0.3%) were American Indian, 5414 (4.2%) were Asian or Pacific Islander, 6704 (5.2%) were non-Hispanic Black, and 114 073 (88.4%) were non-Hispanic White; 64 171 (49.7%) were male; and the median (IQR) age was 62 (58-66) years. After a median (IQR) follow-up of 20 (19-22) years, the risk of any incident cancer was significantly higher for individuals with a history of respiratory (hazard ratio [HR], 1.07 [95% CI, 1.02-1.12]) and cardiovascular conditions (HR, 1.02 [95% CI, 1.00-1.05]). History of each comorbid condition evaluated was significantly associated with incidence of at least 1 cancer type. The strongest association was between history of liver conditions and risk of liver cancer (HR, 5.57 [95% CI, 4.03-7.71]), whereas metabolic conditions (obesity or type 2 diabetes) were significantly associated with higher risk of 9 cancer types and lower risk of 4 cancer types. Respiratory (HR, 1.19 [95% CI, 1.11-1.28]), cardiovascular (HR, 1.08 [95% CI, 1.04-1.13]), and metabolic (HR, 1.09 [95% CI, 1.05-1.14]) conditions were positively associated with a higher hazard of cancer death.

CONCLUSIONS AND RELEVANCE: In this cohort study of 128 999 adults without a history of cancer, comorbidities in midlife were associated with the overall risk of cancer and more strongly associated with risk of multiple individual cancer types, with the direction of association differing across cancer types. These results may inform clinical management of patients at risk for cancer.

PMID:40193077 | DOI:10.1001/jamanetworkopen.2025.3469

JAMA Netw Open. 2025 Apr 1;8(4):e253721. doi: 10.1001/jamanetworkopen.2025.3721.

ABSTRACT

IMPORTANCE: Suicide is a major public health concern, and as most individuals have contact with health care practitioners before suicide, health systems are essential for suicide prevention. The Zero Suicide (ZS) model is the recommended approach for suicide prevention in health systems, but more evidence is needed to support its widespread adoption.

OBJECTIVE: To examine suicide attempt rates associated with implementation of the ZS model in outpatient mental health care within 6 US health systems.

DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study with an interrupted time series design used data collected from January 2012 through December 2019, from patients aged 13 years or older who received mental health care at outpatient mental health specialty settings within 6 US health systems located in 5 states: California, Oregon, Washington, Colorado, and Michigan. Analyses were conducted from January through December 2024.

EXPOSURE: The ZS model was implemented in 4 health systems at different points during the observation period (2012-2019) and compared with health systems that implemented the model before the observation period (postimplementation). Implementation included suicide risk screening, assessment, brief intervention (safety plan, means safety protocol), and behavioral health treatment.

MAIN OUTCOMES AND MEASURES: The primary outcome was a measure of standardized monthly suicide attempt rates captured using health system records and government mortality records. Suicide death rates were also measured as a secondary outcome.

RESULTS: There was a median of 309 107 (range, 55 354-451 837) unique patients per month. In 2017, there were 317 939 eligible individuals (63.2% female). Baseline suicide attempt rates were at least 30 to 40 per 100 000 individuals at each implementation site and decreased to less than 30 per 100 000 individuals at 3 sites by 2019. Decreases in suicide attempt rates were observed at 3 intervention health systems after site-specific implementation: health systems A and B had decreases of 0.7 per 100 000 individuals per month and C, 0.1 per 100 000 individuals per month. System D evidenced a similar suicide attempt rate after implementation (before implementation: median rate: 35.0 [range, 11.0-50.3] per 100 000 patients per month; after implementation: median rate: 34.3 [range, 18.5-42.0] per 100 000 patients per month). The 2 postimplementation health systems maintained low or declining suicide attempt rates throughout the observation period. The rate at system Y decreased by 0.3 per 100 000 individuals per month across the observation period. The rate at system Z began at 11 per 100 000 individuals per month and declined by 0.03 per 100 000 individuals per month during the observation period. Two systems evidenced reductions in the suicide death rate after implementation: system B declined by 0.2 per 100 000 individuals per month and system C by 0.1 per 100 000 individuals per month.

CONCLUSIONS AND RELEVANCE: In this quality improvement study, ZS model implementation was associated with a reduction in suicide attempt rates among patients accessing outpatient mental health care at most study sites, which supports widespread efforts to implement the ZS model in these settings within US health systems.

PMID:40193074 | DOI:10.1001/jamanetworkopen.2025.3721

JAMA Netw Open. 2025 Apr 1;8(4):e253807. doi: 10.1001/jamanetworkopen.2025.3807.

ABSTRACT

IMPORTANCE: Due to the legacy of structural racism in the United States, Black US residents are more likely to live in disadvantaged neighborhoods regardless of individual socioeconomic status. Black women are also more likely to die from their breast cancer.

OBJECTIVE: To investigate whether neighborhood disadvantage and individual experiences of racism are associated with breast cancer mortality among Black US women.

DESIGN, SETTING, AND PARTICIPANTS: Prospective follow-up study conducted within the Black Women’s Health Study (BWHS), a nationwide cohort study of 59 000 self-identified Black females enrolled in 1995 and followed up by biennial questionnaires. BWHS participants diagnosed with breast cancer at stages I to III and who survived 12 months after initial diagnosis were included (n = 2290). Deaths and cause of death were identified through linkage with the National Death Index.

EXPOSURES: Geocoded participant addresses were linked with US Census Bureau and American Community Survey data to create neighborhood-level indices reflecting relative disadvantage. Data on experiences of racism were obtained from questionnaires.

MAIN OUTCOMES AND MEASURES: Breast cancer-specific and all-cause mortality. Hazard ratios (HRs) and 95% CIs were estimated from multivariable Cox proportional hazards regression models.

RESULTS: There were 305 breast cancer-specific deaths among 2290 women with invasive breast cancer (mean [SD] age at diagnosis, 56.7 [10.9] years) who were followed up for a median (IQR) of 10.5 (5.6-16.1) years. The mortality rate was 14.26 (95% CI, 11.01-17.51) per 1000 person-years for those living in the most disadvantaged neighborhoods and 8.82 (95% CI, 6.55-11.09) per 1000 person-years for those living in the least disadvantaged neighborhoods (HR, 1.47; 95% CI, 1.02-2.12). HRs for women living in areas of extreme economic deprivation (vs privilege) and for women who reported experiences of racism in at least 2 institutional spheres (vs none) were also greater than 1, but not statistically significant (extreme economic deprivation vs privilege: HR, 1.19; 95% CI, 0.88-1.61; racism in 2 spheres vs none: HR, 1.28; 95% CI, 0.96-1.73).

CONCLUSIONS AND RELEVANCE: In this cohort of Black women, living in disadvantaged neighborhoods was associated with a higher mortality from breast cancer, even after accounting for stage at diagnosis, treatments, and individual-level lifestyle factors. Community-level interventions to reduce environmental stressors and improve conditions in disadvantaged neighborhoods, including access to high-quality cancer care, may be critical to reducing racial disparities in breast cancer survival.

PMID:40193073 | DOI:10.1001/jamanetworkopen.2025.3807

JAMA Netw Open. 2025 Apr 1;8(4):e254457. doi: 10.1001/jamanetworkopen.2025.4457.

ABSTRACT

IMPORTANCE: To safely age at home, millions of older adults rely on the services of home care workers (HCWs), a workforce marked by poor working conditions, high turnover, and critical worker shortages. Home care cooperatives-businesses co-owned and controlled by HCWs-have demonstrated significantly lower turnover and higher job quality than traditional home care businesses, but the factors associated with these outcomes have not been investigated.

OBJECTIVE: To identify potential factors associated with higher job quality and lower turnover at home care cooperatives.

DESIGN, SETTING, AND PARTICIPANTS: In this qualitative study, semistructured interviews were conducted in English from November 2023 to June 2024. To be eligible for the study, participants had to be 18 years old or older, speak English, and currently be employed by a home care cooperative. Interviews were conducted remotely over Zoom with individual HCWs and staff from home care cooperatives from across the US. Data were analyzed from May to July 2024.

EXPOSURE: Employment at a home care cooperative.

MAIN OUTCOMES AND MEASURES: Interviews were audio recorded and transcribed. A thematic analysis approach was used to code interviews and identify major themes and subthemes, informed by a conceptual model of direct care worker job outcomes.

RESULTS: A total of 23 HCWs and 9 staff members (14 participants aged 20-39 years [44%]; 8 [25%] African American, 4 [13%] Latinx, and 17 [53%] non-Latinx White) from 5 home care cooperatives participated in the study. Participants identified 4 key aspects of the cooperative work environment they perceived to be contributing to higher job quality and lower turnover compared with traditional agencies: (1) greater workplace control regarding patient care, case assignments, and organizational policies; (2) stronger community support and camaraderie; (3) a deeper culture of respect in which HCWs felt more valued; and (4) higher overall compensation in the form of wages, benefits, or profit sharing.

CONCLUSIONS AND RELEVANCE: In this qualitative study of HCWs and staff at home care cooperatives, participants perceived cooperatives’ relatively high levels of HCW control, community, respect, and compensation to be important contributors to HCWs’ retention in the field. The participatory structure and practices of home care cooperatives in these areas may represent novel approaches for home care agencies to reduce HCW turnover and improve job quality to address critical workforce shortages.

PMID:40193072 | DOI:10.1001/jamanetworkopen.2025.4457

Updates Surg. 2025 Apr 7. doi: 10.1007/s13304-025-02191-4. Online ahead of print.

ABSTRACT

We aimed to analyze the effect of surgical approach on patients with malignant phyllode tumor of the breast (MPTB) and to develop a prognostic prediction model for patients with MPTB. We extracted MPTB patients aged 18-80 years between 2000 and 2020 from the SEER database. Covariable imbalance was reduced using the propensity-score matching (PSM) method. An analysis of Cox proportional hazard regression was performed to compare breast cancer-specific survival (BCSS) with overall survival (OS). The survival curves were generated using the Kaplan-Meier method. The 5-year BCSS and 5-year OS of patients with MPTB were predicted by ten models based on machine learning. According to multivariate Cox analysis, surgical treatment of MPTB does not affect long-term survival outcomes (p > 0.05). Among our study, the survival outcomes of mastectomy and BCS would not be statistically significant even for patients with poor pathologic type of MPTB (p > 0.05). In terms of AUC, CatBoost performed better than other algorithms with a 5-year BCSS of 0.8488 and a 5-year OS of 0.8512. BCS and mastectomy do not make a significant difference in the long-term survival outcomes of patients with MPTB. Therefore, we suggest that BCS is feasible and preferred provided that surgical margin requirements can be met. As a trusted model, CatBoost provides better guidance and support for the systemic treatment of patients with MPTB.

PMID:40193050 | DOI:10.1007/s13304-025-02191-4

Res Rep Health Eff Inst. 2025 Feb;(223):1-88.

ABSTRACT

INTRODUCTION: In the United States, billions of dollars have been spent implementing interventions to reduce traffic-related air pollution (TRAP). These interventions are usually regulatory actions focused on reducing tailpipe emissions. However, they also include local programs to reduce traffic congestion and excess vehicle emissions, such as electronic tolls and roadway capacity improvements. Few health studies have empirically evaluated the direct impact of air pollution exposure reductions from these emission regulations and congestion reduction programs; no studies have examined infant health, an important population health outcome linked to air pollution exposures.

OBJECTIVE: Assess changes in birth outcomes for all recorded births in Texas from 1996 to 2016 associated with (1) long-term cumulative regulatory improvements of motor vehicle emissions and resulting TRAP change and (2) local congestion reduction programs that may yield localized TRAP changes over shorter time periods.

METHODS: We used Vital Statistics data in Texas from 1996 to 2016 (n = 8.1 million recorded births; n = 6,158,518 births analyzed after exclusions). We calculated diverse traffic-related exposure measures using residential addresses at the time of delivery. We implemented research triangulation methods using different study design and analysis approaches to test our primary hypotheses on the effects of long-term cumulative regulatory improvements and local congestion reduction programs on birth outcomes.

RESULTS: Traffic-related exposure measures (nitrogen dioxide [NO₂] air pollution, traffic volume, congestion) were consistently associated with adverse birth outcomes over the 20-year study period. This finding is supported by an analysis of pregnant individuals living upwind versus downwind of the same major road, where living downwind within 500 m was associated with an 11.6-g decrease (95% CI: -18.01, -5.21) in term birth weight. For all pregnant individuals, NO₂ exposures decreased 59% from 1996 to 2016, while the total vehicle miles traveled (VMT) within 500 m of residential addresses (VMT_500m) remained relatively stable. We observed marked differences in TRAP exposure for pregnant individuals by sociodemographic characteristics. While levels of air pollution disparities reduced in absolute terms over the 20 years, relative disparities persisted, and large differences in traffic levels remained. The magnitude of associations between VMT_500m and adverse birth outcomes decreased for term low birth weight (-60%, OR in 1996: 1.08, OR in 2016: 1.03 for the highest vs. lowest quintile) and preterm (-65%) and very preterm (-61%) births, but not for term birth weight. A direct analysis of congestion exposure for 2015-2016 births, measured for all roadways in Texas using connected device data, showed that congestion was associated with decreased term birth weight, background traffic, and TRAP levels. When we examined local projects designed to reduce congestion as a natural experiment and applied a difference-in-differences (DiD) study design, we found little evidence that the implementation of tolling projects was associated with improved birth outcomes. For roadway construction projects, we observed increased congestion during construction and decreased congestion post-construction. This dynamic translated into increased odds of term low birth weight (OR 1.19; 95% CI: 1.05, 1.36) for pregnant individuals living within 300 m during construction but no consistent improvements in birth outcomes post-construction.

CONCLUSIONS: TRAP is an important environmental health and justice issue that affects pregnancy. Our results provide some evidence supporting that cleaning up the vehicle fleet was more impactful at decreasing adverse pregnancy outcomes than local programs aimed at reducing congestion.

PMID:40191931

Int J Surg. 2025 Apr 4. doi: 10.1097/JS9.0000000000002374. Online ahead of print.

ABSTRACT

BACKGROUND: The relationship between the Advanced Lung Cancer Inflammation Index (ALI) and all-cause mortality in patients with Metabolic Dysfunction-Associated Steatohepatitis and Metabolic-Associated Alcoholic Liver Disease and other combination etiology of steatosis (MASLD/MetALD & Mixed Etiology Steatosis) is not well-understood. Current evidence is insufficient to establish this association, yet it holds critical importance for healthcare and public health. Research into the link between ALI and all-cause mortality in MASLD/MetALD & Mixed Etiology Steatosis remains a topic of interest.

OBJECTIVE: This study investigated the association between ALI and all-cause mortality in MASLD/MetALD & Mixed Etiology Steatosis patients, and explored the clinical significance of this association.

METHODS: We conducted a cohort study using data from the National Health and Nutrition Examination Survey between 2007 and 2018, involving 4502 adult participants with MASLD/MetALD & Mixed Etiology Steatosis in the United States. Data collected included age, sex, race, education, marital status, poverty-to-income ratio, alanine aminotransferase levels, aspartate aminotransferase levels, high-density lipoprotein cholesterol, total cholesterol, diabetes mellitus, coronary heart disease, and stroke. Cox proportional hazards regression models were used to assess the relationship between ALI and all-cause mortality, with follow-up through 31 December 2019, from the National Center for Health Statistics.

RESULTS: The study found that ALI in patients was significantly negatively associated with the risk of all-cause mortality in U.S. adults with MASLD/MetALD & Mixed Etiology Steatosis. Participants with higher ALI levels had a significantly lower risk of all-cause mortality compared to those with lower ALI levels. After full adjustment, moderate ALI levels were associated with a 42% reduced risk (hazard ratio [HR]: 0.58, 95% confidence interval [CI]: 0.41-0.81), and high ALI levels were associated with a 49% reduced risk (HR: 0.51, 95% CI: 0.35-0.73) of all-cause mortality. No significant interactions were observed in subgroup analyses (P > 0.05).

CONCLUSION: This study suggested that high ALI levels are associated with a reduced risk of all-cause mortality in MASLD/MetALD & Mixed Etiology Steatosis patients. These findings may have important clinical implications for healthcare providers managing MASLD/MetALD & Mixed Etiology Steatosis patients, emphasizing the potential role of ALI as a prognostic marker for all-cause mortality.

PMID:40191909 | DOI:10.1097/JS9.0000000000002374

Neurologist. 2025 Apr 7. doi: 10.1097/NRL.0000000000000625. Online ahead of print.

ABSTRACT

OBJECTIVES: Cerebral venous sinus thrombosis (CVST) often leads to seizures, potentially worsening prognosis. This study aimed to assess the relationship between specific occlusion sites and seizure occurrence.

METHODS: We retrospectively analyzed 154 patients diagnosed with CVST in 3 major hospitals in Tehran. Medical records detailing sinus involvement, seizure occurrence, and baseline characteristics were reviewed. Statistical analyses included the χ2 or the Fisher exact tests, followed by binomial logistic regression to identify independent predictors. Model performance was evaluated using receiver operating characteristic (ROC) curves.

RESULTS: The study included 102 women (66.2%) and 52 men (33.8%), with a mean age of 36.4±10.8 years. A total of 35 patients (22.7%) experienced seizures, predominantly generalized tonic-clonic (85.7%). Superior sagittal sinus (SSS) involvement was strongly associated with seizures (odds ratio=3.056, P=0.006), while left transverse sinus involvement showed a marginally significant inverse relationship in univariate analysis (P=0.027), which became nonsignificant in the multivariate model (P=0.056). Trolard vein thrombosis was rare but associated with a high seizure rate (3/4 cases). The ROC for the final model showed moderate predictive ability (AUC=0.676).

CONCLUSION: SSS thrombosis significantly predicted seizures in Iranian CVST patients. Although rare, trolard vein involvement may carry a substantial seizure risk. These findings underscore the importance of precise imaging and individualized treatment plans for high-risk CVST patients. By illuminating the role of SSS and trolard vein, this study highlights the need for prospective trials to refine clinical decision-making.

PMID:40191892 | DOI:10.1097/NRL.0000000000000625

Arch Esp Urol. 2025 Mar;78(2):170-175. doi: 10.56434/j.arch.esp.urol.20257802.24.

ABSTRACT

OBJECTIVE: Approximately one-third of individuals diagnosed with prostate cancer (PCa) experience biochemical recurrence (BCR) following their initial curative therapy. BCR significantly increases the risk of distant metastases and is associated with higher mortality rates, particularly in patients with poor prognostic indicators. This study aims to investigate the strong correlation between positive surgical margins (PSMs) and BCR after radical prostatectomy, offering foundational insights and guidance for predicting patient survival and optimising postoperative intervention strategies.

METHODS: A retrospective analysis was conducted on the clinical data of 498 patients who underwent laparoscopic radical prostatectomy between January 2015 and January 2021 at Ningbo Yinzhou No.2 Hospital. Pathological specimens and medical records were reviewed. Of these, 127 patients with PSMs and 279 patients with negative surgical margins (NSMs) were included in the statistical analysis. The analysis incorporated clinical and pathological parameters, including primary tumour characteristics, PSMs, pathological tumour staging, surgical margin status, Gleason grade group, and other relevant factors, with BCR-free survival as the primary endpoint.

RESULTS: During the follow-up period of this study, 129 cases of BCR were identified among the 406 patients. Of these, 34 cases occurred in patients with PSMs, accounting for approximately 26.8% (34/127), and 95 cases occurred in patients with NSMs, accounting for approximately 34.1% (95/279). The difference in recurrence between the two groups was statistically significant (p < 0.001). The median time to BCR was 19.2 months for patients with PSMs, compared to 28.2 months for patients with NSMs, with this difference also reaching statistical significance (p < 0.001). The Gleason grading group in patients with PSMs was a stronger predictor of recurrence than the primary tumour characteristics.

CONCLUSIONS: The presence of PSMs is a significant independent predictor of BCR in patients undergoing radical prostatectomy for PCa. Early detection and timely intervention for patients with PSMs are crucial for improving postoperative outcomes.

PMID:40191860 | DOI:10.56434/j.arch.esp.urol.20257802.24

Arch Esp Urol. 2025 Mar;78(2):164-169. doi: 10.56434/j.arch.esp.urol.20257802.23.

ABSTRACT

OBJECTIVE: This study aimed to investigate the effectiveness, safety and outcomes of the combination therapy of low-intensity extracorporeal shockwave therapy (Li-ESWT) and platelet-rich plasma (PRP) for the treatment of chronic-phase Peyronie’s disease.

METHODS: The clinical outcomes of patients diagnosed with Peyronie’s disease and treated with Li-ESWT combined with PRP at our clinic between January 2018 and January 2024 were retrospectively reviewed and analysed. Twenty-three patients were excluded based on inclusion criteria, leaving 26 patients for the retrospective analysis. Each patient received three sessions of PRP and six sessions of Li-ESWT. The treatment regimen involved sessions administered twice weekly over a period of 3 weeks, followed by 1-week post-treatment follow-up. The patients were then monitored for 24 weeks.

RESULT: After treatment, no significant reduction in average plaque size was observed. However, a statistically significant average improvement of 10° was noted for penile curvature. Among the patients, 14 (53.8%) reported satisfaction with the treatment outcome, and 12 (46.2%) expressed dissatisfaction. No significant adverse effects were observed at the injection sites or in the areas subjected to Li-ESWT post-procedure.

CONCLUSIONS: The combination of Li-ESWT and PRP is effective and safe for the treatment of chronic-phase Peyronie’s disease.

PMID:40191859 | DOI:10.56434/j.arch.esp.urol.20257802.23