Temporal trends in age- and stage-specific incidence of colorectal adenocarcinomas in Germany.

BACKGROUND: A national colorectal cancer (CRC) screening programme was launched in 2002 in Germany. A comprehensive evaluation of the programme effectiveness using real-world data is still lacking. In addition, there are regional reports on increasing colorectal cancer incidence in younger populations. Therefore, we aimed to describe and compare the overall, age- and stage-specific incidence trends for colorectal, colon and rectal cancer. METHODS: We used data from seven population-based cancer registries in Germany. We report absolute and relative changes in incidence rates between the early screening phase (2003-2005) and the most recent time period available (2015-2017), as well as annual percent changes. We analysed incidences according to tumour site (colorectum, colon, and rectum) and to six age groups (young adults: 15-34, 35-39, 40-49, screening-entitled/older adults: 50-54, 55-69 and 70 + years old). RESULTS: In our sample of 271,011 colorectal adenocarcinomas, about two-thirds were located in the colon and 95% of them occurred in the age group 50+ (50-54: 5%, 55-69: 32.8%, 70+: 57.2%). For the time period 2003-2005 the age-specific incidence rates of individuals in the age group 55-69 were about 76/100,00 for colon and 54/100,000 for rectal cancer (age group 70 + colon: 179/100,000; rectum: 84/100,000). The incidence rates in young adults were less than 13% of that of individuals in the age group 55-69 (< 5% of individuals aged 70+; <33% of individuals aged 50-54). Over time, incidence decreased in individuals at the age of 55+, for all subsites considered as well as for early and late stage cancers (with few exceptions), while incidence of young adult CRC (both early and late stage) increased steepest in the youngest age groups. For late stage rectal cancer, a shift was observed in all age groups from UICC stage IV to stage III being the most frequent stage. CONCLUSIONS: Six years after the introduction of the national colonoscopy screening program, late stage CRC incidence began to decline substantially in the screening-eligible age groups (55-69, 70+). It is likely that this decline and the increase in early stage CRC observed in younger age groups can be attributed to the program. Long lasting public awareness campaigns for CRC screening might have led to opportunistic screening in younger adults. Whether these benefits outweigh the possible harm of screening in younger age groups remains unclear.

Polypharmacy and multiple sclerosis: A population-based study.

BACKGROUND: Little is known about polypharmacy and multiple sclerosis (MS). OBJECTIVES: To estimate polypharmacy prevalence in a population-based MS cohort and compare persons with/without polypharmacy. METHODS: Using administrative and pharmacy data from Canada, we estimated polypharmacy prevalence (⩾5 concurrent medications for >30 consecutive days) in MS individuals in 2017. We compared the characteristics of persons with/without polypharmacy and described the number of polypharmacy days, the most common medication classes contributing to polypharmacy and hyper-polypharmacy prevalence (⩾10 medications). RESULTS: Of 14,227 included individuals (75% women), mean age = 55.4 (standard deviation (SD): 13.2) years; 28% (n = 3995) met criteria for polypharmacy (median polypharmacy days = 273 (interquartile range (IQR): 120-345)). Odds of polypharmacy were higher for women (adjusted odds ratio (aOR) = 1.14; 95% confidence intervals (CI):1.04-1.25), older individuals (aORs 50-64 years = 2.04; 95% CI:1.84-2.26; ⩾65 years = 3.26; 95% CI: 2.92-3.63 vs. <50 years), those with more comorbidities (e.g. ⩾3 vs. none, aOR = 6.03; 95% CI: 5.05-7.22) and lower socioeconomic status (SES) (e.g. most (SES-Q1) vs. least deprived (SES-Q5) aOR = 1.64; 95% CI: 1.44-1.86). Medication classes most commonly contributing to polypharmacy were as follows: antidepressants (66% of polypharmacy days), antiepileptics (47%), and peptic ulcer drugs (41%). Antidepressants were most frequently co-prescribed with antiepileptics (34% of polypharmacy days) and peptic ulcer drugs (27%). Five percent of persons (716/14,227) experienced hyper-polypharmacy. CONCLUSION: More than one in four MS persons met criteria for polypharmacy. The odds of polypharmacy were higher for women, older persons, and those with more comorbidities, but lower SES.

A new cure model that corrects for increased risk of non-cancer death: analysis of reliability and robustness, and application to real-life data.

BACKGROUND: Non-cancer mortality in cancer patients may be higher than overall mortality in the general population due to a combination of factors, such as long-term adverse effects of treatments, and genetic, environmental or lifestyle-related factors. If so, conventional indicators may underestimate net survival and cure fraction. Our aim was to propose and evaluate a mixture cure survival model that takes into account the increased risk of non-cancer death for cancer patients. METHODS: We assessed the performance of a corrected mixture cure survival model derived from a conventional mixture cure model to estimate the cure fraction, the survival of uncured patients, and the increased risk of non-cancer death in two settings of net survival estimation, grouped life-table data and individual patients' data. We measured the model's performance in terms of bias, standard deviation of the estimates and coverage rate, using an extensive simulation study. This study included reliability assessments through violation of some of the model's assumptions. We also applied the models to colon cancer data from the FRANCIM network. RESULTS: When the assumptions were satisfied, the corrected cure model provided unbiased estimates of parameters expressing the increased risk of non-cancer death, the cure fraction, and net survival in uncured patients. No major difference was found when the model was applied to individual or grouped data. The absolute bias was < 1% for all parameters, while coverage ranged from 89 to 97%. When some of the assumptions were violated, parameter estimates appeared more robust when obtained from grouped than from individual data. As expected, the uncorrected cure model performed poorly and underestimated net survival and cure fractions in the simulation study. When applied to colon cancer real-life data, cure fractions estimated using the proposed model were higher than those in the conventional model, e.g. 5% higher in males at age 60 (57% vs. 52%). CONCLUSIONS: The present analysis supports the use of the corrected mixture cure model, with the inclusion of increased risk of non-cancer death for cancer patients to provide better estimates of indicators based on cancer survival. These are important to public health decision-making; they improve patients' awareness and facilitate their return to normal life.

COVID-19 outbreak in Lombardy: Impact on reducing solid cancer diagnoses in 2020.

Our aim was to analyse, on a population level, the year-long decline in cancer diagnoses in the region of Lombardy (Italy), and to characterise the tumours with the greatest reduction in diagnosis by patient age, sex and tumour stage at diagnosis. We used the health care utilisation databases of the Lombardy region to identify cancer patients' characteristics (eg, sex, age) and cancer-related information (eg, cancer site, stage at diagnosis). The frequency of new cancer diagnoses in 2019 and 2020 were compared in terms of percentage differences in undiagnosed cases. We observed two peaks in the decline in cancer diagnoses: March to May 2020 (-37%) and October to December 2020 (-19%). The decline persisted over the course of 2020 and was higher in males and patients aged 74+. Diagnoses of all four common cancers analysed (female breast, lung, colorectal and prostate) remained below pre-pandemic levels. For breast and colorectal cancers, the decline in diagnoses was high in the age groups targeted by population-based screening programmes. We observed a reduction in localised stage cancer diagnoses for all four cancers. Our data confirm that timely monitoring of cancer diagnoses and interventions to prevent disruption of routine diagnostic services are needed to mitigate the impact of emergencies on cancer patients.

Mammographic breast density and survival in women with invasive breast cancer.

PURPOSE: We explored the under-debate association between mammographic breast density (MBD) and survival. METHODS: From the Piedmont Cancer Registry, we identified 693 invasive breast cancer (BC) cases. We analyzed the overall survival in strata of MBD through the Kaplan-Meier method. Using the Cox proportional hazards model, we estimated the hazard ratios (HRs) of death; using the cause-specific hazards regression model, we estimated the HRs of BC-related and other causes of death. Models included term for Breast Imaging-Reporting and Data System (BI-RADS) MBD (categorized as BI-RADS 1 and BI-RADS 2-4) and were adjusted for selected patient and tumour characteristics. RESULTS: There were 102 deaths, of which 49 were from BC. After 5 years, the overall survival was 69% in BI-RADS 1 and 88% in BI-RADS 2-4 (p < 0.01). Compared to BI-RADS 2-4, the HRs of death for BI-RADS 1 were 1.65 (95% CI 1.06-2.58) in the crude model and 1.35 (95% CI 0.84-2.16) in the fully adjusted model. Compared to BI-RADS 2-4, the fully adjusted HRs for BI-RADS 1 were 1.52 (95% CI 0.74-3.13) for BC-related death and 1.83 (95% CI 0.84-4.00) for the other causes of death. CONCLUSION: Higher MBD is one of the strongest independent risk factors for BC, but it seems not to have an unfavorable impact on survival.

Emergency department use by persons with MS: A population-based descriptive study with a focus on infection-related visits.

We described emergency department (ED) visits (all visits and infection-related) by persons with multiple sclerosis (MS) in British Columbia, Canada (1 April 2012 to 31 December 2017). We identified 15,350 MS cases using health administrative data; 73.4% were women, averaging 51.4 years at study entry. Over 4.9 years of follow-up (mean), 56.0% of MS cases visited an ED (mean = 0.6 visits/person/year; total = 37,072 visits). A diagnosis was documented for 25,698 (69.3%) ED visits, and 18.4% (4725/25,698) were infection-related. Inpatient admissions were reported for 20.4% (5238/25,698) of all and 29.2% (1380/4725) of infection-related ED visits. Findings suggest that the ED plays a substantial role in MS healthcare and infection management.

Describing the safety of abortion at the population level using network-based survey approaches.

BACKGROUND: Despite the negative impact of unsafe abortions on women's health and rights, the degree of abortion safety remains strikingly undocumented for a large share of abortions globally. Data on how women induce abortions (method, setting, provider) are central to the measurement of abortion safety. However, health-facility statistics and direct questioning in population surveys do not yield representative data on abortion care seeking pathways in settings where access to abortion services is highly restricted. Recent developments in survey methodologies to study stigmatized / illegal behaviour and hidden populations rely on the fact that such information circulates within social networks; however, such efforts have yet to give convincing results for unsafe abortions. OBJECTIVE: This article presents the protocol of a study whose purpose is to apply and develop further two network-based methods to contribute to the generation of reliable population-level information on the safety of abortions in contexts where access to legal abortion services is highly restricted. METHODS: This study plans to obtain population-level data on abortion care seeking in two Health and Demographic Surveillance Systems in urban Kenya and rural Burkina Faso by applying two methods: Anonymous Third-Party Reporting (ATPR) (also known as confidantes' method) and Respondent Driven Sampling (RDS). We will conduct a mixed methods formative study to determine whether these network-based approaches are pertinent in the study contexts. The ATPR will be refined notably by incorporating elements of the Network Scale-Up Method (NSUM) to correct or account for certain of its biases (transmission, barrier, social desirability, selection). The RDS will provide reliable alternative estimates of abortion safety if large samples and equilibrium can be reached; an RDS multiplex variant (also including social referents) will be tested. DISCUSSION: This study aims at documenting abortion safety in two local sites using ATPR and RDS. If successful, it will provide data on the safety profiles of abortion seekers across sociodemographic categories in two contrasted settings in sub-Saharan Africa. It will advance the formative research needed to determine whether ATPR and RDS are applicable or not in a given context. It will improve the questionnaire and correcting factors for the ATPR, improve the capacity of RDS to produce quasi-representative data on abortion safety, and advance the validation of both methods.

Representative data on how women induce abortions and their consequences are central to measurements of abortion safety. However, due to the stigmatized nature of abortion, measuring the details of the process is challenging when the latter occur out of the realm of the law and do not result in complications registered in hospital statistics. Hence, there is sparse empirical population-level data on how women terminate their pregnancies in countries where access to abortion services is highly restricted, as well as little data on the side effects and complications associated with the methods they chose and health seeking for these complications. Recent developments in indirect survey methodologies to study stigmatized/illegal behaviour and hidden populations are likely to improve the quality of data collected on abortion safety in restrictive contexts: all are based on the sharing of information on stigmatized practices in social networks. We propose to refine and pilot two such network-based methods to validate their use for collecting (quasi) representative data on abortion safety in large population health surveys. These two approaches are: (i) a modified Anonymous Third-Party Reporting method (ATPR) integrating elements of the Network-Scale-up Method (NSUM) and (ii) Respondent-Driven Sampling (RDS). We will conduct this study in two African Health and Demographic Surveillance Systems (HDSS) sites, one urban (Nairobi, Kenya), and one comprising a town and adjacent villages (Kaya, Burkina Faso).

Fatigue, sleep disorders, anaemia and pain in the multiple sclerosis prodrome.

BACKGROUND: There is increasing evidence of prodromal multiple sclerosis (MS). OBJECTIVE: The aim of this study was to determine whether fatigue, sleep disorders, anaemia or pain form part of the MS prodrome. METHODS: This population-based matched cohort study used linked administrative and clinical databases in British Columbia, Canada. The odds of fatigue, sleep disorders, anaemia and pain in the 5 years preceding the MS cases' first demyelinating claim or MS symptom onset were compared with general population controls. The frequencies of physician visits for these conditions were also compared. Modifying effects of age and sex were evaluated. RESULTS: MS cases/controls were assessed before the first demyelinating event (6863/31,865) or MS symptom onset (966/4534). Fatigue (adj.OR: 3.37; 95% CI: 2.76-4.10), sleep disorders (adj.OR: 2.61; 95% CI: 2.34-2.91), anaemia (adj.OR: 1.53; 95% CI: 1.32-1.78) and pain (adj.OR: 2.15; 95% CI: 2.03-2.27) during the 5 years preceding the first demyelinating event were more frequent among cases, and physician visits increased for cases relative to controls. The association between MS and anaemia was greater for men; that between MS and pain increased with age. Pre-MS symptom onset, sleep disorders (adj.OR: 1.72; 95% CI: 1.12-2.56) and pain (adj.OR: 1.53; 95% CI: 1.32-1.76) were more prevalent among cases. CONCLUSION: Fatigue, sleep disorders, anaemia and pain were elevated before the recognition of MS. The relative anaemia burden was higher in men and pain more evident among older adults.

Utilization of occupational therapy services and relation to survival in people taking dementia-specific medication in Austria-A retrospective population-based study with a 13-year observation period.

OBJECTIVES: Evidence-based treatment of dementia includes pharmacological and non-pharmacological methods of which psycho-social interventions are an important component, commonly administered by occupational therapists. The aim of this study was to investigate the utilization of occupational therapy (OT) services and its association with survival in people taking dementia-specific medication in a population-based Austrian dataset compared to a two times as large control group without dementia-specific medication. METHODS/DESIGN: A retrospective study with a 13-year observation period (2003-2016) was conducted on real-world data. Two stratifications were done and we used descriptive statistics, Chi-squared/Fisher's Exact Tests and survival analyses including three Cox models. RESULTS: Data from 286,553 participants were analysed. Only 4.5% (n = 12,950) received OT services. In the dementia-medication group (n = 111,033), participants who received OT services (3.6%; n = 4032) had significantly more comorbidities (4.7%) compared to those without OT (3.5%; p < 0.001) and were also more likely to be male (4 vs. 3.5%; p < 0.001). While persons taking dementia-specific medication showed a slightly reduced survival with OT (p < 0.001) compared to those without, the result in the control group without dementia-specific medication showed a slightly better result of the participants who received OT (p < 0.001). The reduced survival in the dementia-medication group with OT is likely to be related to the higher number of comorbidities in this group. CONCLUSION: People receiving dementia-specific medication were more likely to receive OT if they had additional comorbidities, however our analysis showed that utilization of OT services in Austria was very low indicating an overall insufficient accessibility of OT services for patients who needed it.

Clinical Suspicion Sensitivity of Nodular and Superficial Spreading Melanoma.

In Norway, nodular melanoma is the most fatal melanoma subtype and superficial spreading melanoma the most common, indicating diagnostic challenges. The aim of this study was to assess the clinical suspicion sensitivity of nodular melanoma and superficial spreading melanoma, by diagnosing physician, using randomly selected 100 nodular melanomas and 100 superficial spreading melanomas from the Norwegian Melanoma Registry, diagnosed in 2014 to 2015. Information about suggested diagnoses and diagnosing physician was collected from pathology request forms. Suspicion sensitivity was defined as the proportion (%) of cases with "melanoma" as a suggested diagnosis, estimated with 95% confidence interval (95% CI). Most melanomas (74.5%) were diagnosed by non-dermatologists, with a suspicion sensitivity of 23% (95% CI 15-34) for nodular melanoma and 24% (95% CI 16-35) for superficial spreading melanoma. Corresponding estimates for dermatologists were 50% (95% CI 32-68) and 96% (95% CI 80-99), respectively (pinteraction=0.007). The low suspicion sensitivity for both subtypes among non-dermatologists calls for educational efforts.

Regional and gender differences in population-based oral health insurance data.

OBJECTIVE: Early dental monitoring contributes substantially to good oral health in children. However, little is known on whether children from different geographical regions and gender are equally reached with current preventive and curative oral health strategies. The aim of our study therefore was to explore regional and gender differences in a population-based oral health dataset of Austrian children up to the age of 14. MATERIALS AND METHODS: We extracted the first electronically available health insurance data of children aged up to 14 years on dental services within a 4-year observation period in Austria and performed a separate analysis in up to 6-year-old children. In addition, we used a smaller randomly selected sample dataset of 3000 children as the large numbers would result in significant, but very small effects. RESULTS: In a total of 130,895 children, of whom 77,173 children (59%) were up to the age of six, we detected an east-west gradient: The eastern regions of Austria showed an older age at first contact and a higher number of dental services. A child aged up to 6 years who needed more than four dental services had a likelihood of 40% to be from Vienna, Austria's capital city located in the east. The smaller random sample did not show significant gender differences. CONCLUSIONS: Even in regions with a high density of dentists, such as Vienna, we obviously did not reach young children in the same extent as in other regions. CLINICAL RELEVANCE: Stratified interventions could be developed to overcome regional inequalities.

Association between age, deprivation and specific comorbid conditions and the receipt of major surgery in patients with non-small cell lung cancer in England: A population-based study.

INTRODUCTION: We investigated socioeconomic disparities and the role of the main prognostic factors in receiving major surgical treatment in patients with lung cancer in England. METHODS: Our study comprised 31 351 patients diagnosed with non-small cell lung cancer in England in 2012. Data from the national population-based cancer registry were linked to Hospital Episode Statistics and National Lung Cancer Audit data to obtain information on stage, performance status and comorbidities, and to identify patients receiving major surgical treatment. To describe the association between prognostic factors and surgery, we performed two different analyses: one using multivariable logistic regression and one estimating cause-specific hazards for death and surgery. In both analyses, we used multiple imputation to deal with missing data. RESULTS: We showed strong evidence that the comorbidities 'congestive heart failure', 'cerebrovascular disease' and 'chronic obstructive pulmonary disease' reduced the receipt of surgery in early stage patients. We also observed gender differences and substantial age differences in the receipt of surgery. Despite accounting for sex, age at diagnosis, comorbidities, stage at diagnosis, performance status and indication of having had a PET-CT scan, the socioeconomic differences persisted in both analyses: more deprived people had lower odds and lower rates of receiving surgery in early stage lung cancer. DISCUSSION: Comorbidities play an important role in whether patients undergo surgery, but do not completely explain the socioeconomic difference observed in early stage patients. Future work investigating access to and distance from specialist hospitals, as well as patient perceptions and patient choice in receiving surgery, could help disentangle these persistent socioeconomic inequalities.

Five years before multiple sclerosis onset: Phenotyping the prodrome.

BACKGROUND: The multiple sclerosis (MS) prodrome is poorly characterized. OBJECTIVE: To phenotype the MS prodrome via health care encounters. METHODS: Using data from a population-based cohort study linking administrative and clinical data in four Canadian provinces, we compared physician and hospital encounters and prescriptions filled (via International Classification of Diseases chapters, physician specialty or drug classes) for MS subjects in the 5 years before the first demyelinating claim in an administrative cohort or the clinical symptom onset in an MS clinic-derived cohort, to age-, sex- and geographically matched controls. Rate ratios (RRs), 95% confidence intervals (95% CIs) and proportions were estimated. RESULTS: The administrative and clinical cohorts included 13,951/66,940 and 3202/16,006 people with and without MS (cases/controls). Compared to controls, in the 5 years before the first demyelinating claim or symptom onset, cases had more physician and hospital encounters for the nervous (RR (range) = 2.31; 95% CI: 1.05-5.10 to 4.75; 95% CI: 3.11-7.25), sensory (RR (range) = 1.40; 95% CI: 1.34-1.46 to 2.28; 95% CI: 1.72-3.02), musculoskeletal (RR (range) = 1.19; 95% CI: 1.07-1.33 to 1.70; 95% CI: 1.57-1.85) and genito-urinary systems (RR (range) = 1.17; 95% CI: 1.05-1.30 to 1.59; 95% CI: 1.48-1.70). Cases had more psychiatrist and urologist encounters (RR (range) = 1.48; 95% CI: 1.36-1.62 to 1.80; 95% CI: 1.61-2.01), and higher proportions of musculoskeletal, genito-urinary or hormonal-related prescriptions (1.1-1.5 times higher, all p < 0.02). However, cases had fewer pregnancy-related encounters than controls (RR = 0.78; 95% CI: 0.71-0.86 to 0.88; 95% CI: 0.84-0.92). CONCLUSION: Phenotyping the prodrome 5 years before clinical recognition of MS is feasible.

Prodrome in relapsing-remitting and primary progressive multiple sclerosis.

BACKGROUND AND PURPOSE: The multiple sclerosis prodrome remains poorly understood. We aimed to examine the prodrome in people with relapsing remitting multiple sclerosis at onset (RMS) and primary progressive multiple sclerosis (PPMS). METHODS: We conducted a matched cohort study using clinical and linked health administrative data in two Canadian provinces. We identified people with RMS, PPMS and age- sex- and geographically-matched population controls, and compared the number of physician encounters (total number, per International Classification of Diseases chapter, and per physician speciality) in the five years before symptom onset. Negative binomial regression models were sex, age, socioeconomic status and calendar year adjusted. RESULTS: We identified 1887 RMS, 171 PPMS cases, and 9837 matched population controls. No difference existed in the total number of encounters in the five years before index between RMS and PPMS, or between the phenotypes and their respective controls. Compared to RMS cases, PPMS cases had more nervous system-related encounters (adjusted rate ratio, 3.00; 95% confidence interval, 1.06-8.49) and fewer encounters with dermatologists (adjusted rate ratio 0.53; 95% confidence interval, 0.30-0.96). CONCLUSION: Findings suggest that people with RMS and PPMS may both experience a prodrome, although aspects may differ.

Using ecological socioeconomic position (SEP) measures to deal with sample bias introduced by incomplete individual-level measures: inequalities in breast cancer stage at diagnosis as an example.

BACKGROUND: When studying the influence of socioeconomic position (SEP) on health from data where individual-level SEP measures may be missing, ecological measures of SEP may prove helpful. In this paper, we illustrate the best use of ecological-level measures of SEP to deal with incomplete individual level data. To do this we have taken the example of a study examining the relationship between SEP and breast cancer (BC) stage at diagnosis. METHODS: Using population based-registry data, all women over 18 years newly diagnosed with a primary BC in 2007 were included. We compared the association between advanced stage at diagnosis and individual SEP containing missing data with an ecological level SEP measure without missing data. We used three modelling strategies, 1/ based on patients with complete data for individual-SEP (n = 1218), or 2/ on all patients (n = 1644) using an ecological-level SEP as proxy for individual SEP and 3/ individual-SEP after imputation of missing data using an ecological-level SEP. RESULTS: The results obtained from these models demonstrate that selection bias was introduced in the sample where only patients with complete individual SEP were included. This bias is redressed by using ecological-level SEP to impute missing data for individual SEP on all patients. Such a strategy helps to avoid an ecological bias due to the use of aggregated data to infer to individual level. CONCLUSION: When individual data are incomplete, we demonstrate the usefulness of an ecological index to assess and redress potential selection bias by using it to impute missing individual SEP.

The Effects of Marijuana Use on Transitions through Stages of Alcohol Involvement for Men and Women in the NESARC I and II.

Background: With the changing context of marijuana use, it is critical to identify effects of use. We extend previous work by examining whether marijuana use influences progression and remission through alcohol involvement stages for men and women. Methods: Data come from Waves I and II of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, n = 34,432). We assess the potential influence of marijuana use at Wave 1 on transitions across three latent statuses of alcohol involvement between waves. We apply propensity score weighting to account for shared risk factors. Results: Marijuana use was associated cross-sectionally and longitudinally with alcohol involvement statuses for both sexes. After propensity score adjustment, men with marijuana histories were 3.50 times as likely as men without such histories to transition from no to severe problems across waves relative to staying in the same status (p < .001). Women with marijuana histories were 1.74 times as likely as women without such histories to transition from no problems at Wave 1 to moderate problems at Wave 2 (p = .030) and 0.13 times as likely as women without such histories to transition from severe problems to no problems (p = .006). Conclusions: Results suggest that marijuana use impacts progression to more serious stages of alcohol involvement for both men and women, as well as hinders remission among women. Findings point to the importance of screening those with marijuana histories for alcohol problems, as well as the need to understand the mechanism of why marijuana use may increase the risk of alcohol problems.

Reduced feeding tube duration with intensity-modulated radiation therapy for head and neck cancer: A Surveillance, Epidemiology, and End Results-Medicare Analysis.

BACKGROUND: Intensity-modulated radiation therapy (IMRT) is a technologically advanced and resource-intensive method of delivering radiation therapy (RT) and is used to minimize toxicity for patients with head and neck cancer (HNC). Dependence on feeding tubes is a significant marker of toxicity of RT. The objective of this analysis was to compare the placement and duration of feeding tube use among patients with HNC from 1999 through 2011. METHODS: The cohort, demographics, and cancer-related variables were determined using the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database, and claims data were used to analyze treatment details. RESULTS: In total, 2993 patients were identified. At a median follow-up of 47 months, 54.4% of patients had ever had a feeding tube placed. The median duration from feeding tube placement to removal was 277 days. On zero-inflated negative binomial regression, patients who received IMRT and 3-dimensional RT (3DRT) (non-IMRT) had similar rates of feeding tube placement (odds ratio, 1.10; P = .35); however, patients who received 3DRT had a feeding tube in place 1.18 times longer than those who received IMRT (P = .03). The difference was only observed among patients who received definitive RT; patients who underwent surgery and also received adjuvant RT had no statistically significant difference in feeding tube placement or duration. CONCLUSIONS: Patients with HNC who received definitive IMRT had a significantly shorter duration of feeding tube placement than those who received 3DRT. These data suggest that there may be significant quality-of-life benefits to IMRT with respect to long-term swallowing function in patients with HNC. Cancer 2017;123:283-293. © 2016 American Cancer Society.

Infection-related health care utilization among people with and without multiple sclerosis.

BACKGROUND: Little is known about infection risk in multiple sclerosis (MS). OBJECTIVE: We examined infection-related health care utilization in people with and without MS. METHODS: Using population-based health administrative data from British Columbia, Canada, people with MS were followed from their first demyelinating claim (1996-2013) until death, emigration, or study end (2013). Infection-related hospital, physician, and prescription data of MS cases were compared with sex-, age-, and geographically matched controls using adjusted regression models. Sex and age differences (18-39, 40-49, 50-59, 60+ years) were explored. RESULTS: Relative to 35,837 controls, 7179 MS cases were over twice as likely to be hospitalized for infection (adjusted odds ratio: 2.39; 95% confidence interval (CI): 2.16-2.65), had 41% more physician visits (adjusted rate ratio (aRR): 1.41; 95% CI: 1.36-1.47), and filled 57% more infection-related prescriptions (aRR: 1.57; 95% CI: 1.49-1.65). Utilization was disproportionately higher in MS men than women and was elevated across all ages. MS cases had nearly twice as many physician visits and two to three times more hospitalizations for pneumonia, urinary system infections, and skin infections (aRRs ranged from 1.6 to 3.3) and over twice as many hospitalizations for intestinal infections (aRR = 2.6) and sepsis (aRR = 2.2). CONCLUSION: Infection-related health care utilization was increased in people with MS across all age groups, with a higher burden for men.

How is disease severity associated with quality of life in psoriasis patients? Evidence from a longitudinal population-based study in Sweden.

BACKGROUND: Assessing the impact of disease severity on generic quality of life (QOL) is a critical step in outcomes research and in the development of decision-analytic models structured around health states defined by clinical measures. While data from routine clinical practice found in healthcare registers are increasingly used for research, more attention should be paid to understanding the relationship between clinical measures of disease severity and QOL. The purpose of this work was therefore to investigate this relationship in psoriasis using a population-based dataset. METHODS: Severity was measured by the Psoriasis Area and Severity Index (PASI), which combines severity of erythema, induration, and desquamation into a single value ranging from 0 to 72. The generic EQ-5D-3L utility instrument, under the UK tariff, was used to measure QOL. The association between PASI and EQ-5D-3L was estimated using a population-based dataset of 2674 patients with moderate to severe psoriasis enrolled over ten years in the Swedish psoriasis register (PsoReg). Given the repeated measurement of patients in the register data, a longitudinal fixed-effects model was employed to control for unobserved patient-level heterogeneity. RESULTS: Marginal changes in PASI are associated with a non-linear response in EQ-5D-3L: Moving from PASI 10 to 9 (1 to 0) is associated with an increase of 0.0135 (0.0174) in EQ-5D-3L. Furthermore, unobserved patient-level heterogeneity appears to be an important source of confounding when estimating the relationship between QOL and PASI. CONCLUSIONS: Using register data to estimate the impact of disease severity on QOL while controlling for unobserved patient-level heterogeneity shows that PASI appears to have a larger impact on QOL than previously estimated. Routine collection of generic QOL data in registers should be encouraged to enable similar applications in other disease areas. TRIAL REGISTRATION: Not applicable.

Pregnancy among US women: differences by presence, type, and complexity of disability.

BACKGROUND: Approximately 12% of women of reproductive age have some type of disability. Very little is known about sexual and reproductive health issues among women with disabilities, including what proportion of women with disabilities experience pregnancy. Data on pregnancy are important to inform needs for preconception and pregnancy care for women with disabilities. OBJECTIVE: The purpose of this study was to describe the occurrence of pregnancy among women with various types of disability and with differing levels of disability complexity, compared with women without disabilities, in a nationally representative sample. STUDY DESIGN: We conducted cross-sectional analyses of 2008-2012 Medical Expenditure Panel Survey annualized data to estimate the proportion of women aged 18-44 years with and without disabilities who reported a pregnancy during 1 year of participation on the survey panel. We used a multivariable logistic regression to test the association of pregnancy with presence, type, and complexity of disability, controlling for other factors associated with pregnancy. RESULTS: Similar proportions of women with and without disabilities reported a pregnancy (10.8% vs 12.3%, with 95% confidence intervals overlapping). Women with the most complex disabilities (those that impact activities such as self-care and work) were less likely to have been pregnant (adjusted odds ratio, 0.69, 95% confidence interval, 0.52-0.93), but women whose disabilities affected only basic actions (seeing, hearing, movement, cognition) did not differ significantly from women with no disabilities. CONCLUSION: Women with a variety of types of disabilities experience pregnancy. Greater attention is needed to the reproductive health care needs of this population to ensure appropriate contraceptive, preconception, and perinatal care.