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Understanding Competing Risks

Highlights: • Clinicians and researchers need to be cognizant of competing risks (ie, the occurrence of an event that precludes future development of the outcome of interest). • Censoring is appropriate when a patient being censored at a particular time (eg, owing to loss to follow-up) is deemed to have approximately the same future risk of developing the outcome of interest as patients still being followed, and when the reason for censoring is not related to events of interest. • Censoring is not appropriate in many scenarios; for example, a dead patient can never develop a future cancer recurrence or late effect. • Kaplan-Meier (KM) analysis is commonly used for a time-to-event analysis when the primary outcome (eg, overall survival) has no meaningful competing risk and censoring is appropriate. Cox proportional hazards modeling can be used for multivariable analysis to examine the association between covariates and the primary outcome. • In the presence of competing events, incorrect use of the KM analysis will likely lead to an overestimation of the risk of the outcome of interest and biased estimates from both univariable and multivariable analyses. Therefore, KM usually should not be used to determine local recurrence risk because humanity is always at risk for dying, which is a competing risk. • A competing risk analysis is therefore most appropriate when there are competing events to the primary outcome of interest. The most commonly used multivariable model in these situations is the Fine-Gray model. • Many fundamental questions in radiation oncology—local and regional recurrence, treatment-related toxicity—are best addressed using competing risk methodologies.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Female “Paradox” in Atrial Fibrillation—Role of Left Truncation Due to Competing Risks

Female sex in patients with atrial fibrillation (AF) is a controversial and paradoxical risk factor for stroke—controversial because it increases the risk of stroke only among older women of some ethnicities and paradoxical because it appears to contradict male predominance in cardiovascular diseases. However, the underlying mechanism remains unclear. We conducted simulations to examine the hypothesis that this sex difference is generated non-causally through left truncation due to competing risks (CR) such as coronary artery diseases, which occur more frequently among men than among women and share common unobserved causes with stroke. We modeled the hazards of stroke and CR with correlated heterogeneous risk. We assumed that some people died of CR before AF diagnosis and calculated the hazard ratio of female sex in the left-truncated AF population. In this situation, female sex became a risk factor for stroke in the absence of causal roles. The hazard ratio was attenuated in young populations without left truncation and in populations with low CR and high stroke incidence, which is consistent with real-world observations. This study demonstrated that spurious risk factors can be identified through left truncation due to correlated CR. Female sex in patients with AF may be a paradoxical risk factor for stroke.

59 BASIC BIOLOGICAL SCIENCES↗

Estimation of conditional cumulative incidence functions under generalized semiparametric regression models with missing covariates, with application to analysis of biomarker correlates in vaccine trials

Herein, this article presents generalized semiparametric regression models for conditional cumulative incidence functions with competing risks data when covariates are missing by sampling design or happenstance. A doubly robust augmented inverse probability weighted (AIPW) complete-case approach to estimation and inference is investigated. This approach modifies IPW complete-case estimating equations by exploiting the key features in the relationship between the missing covariates and the phase-one data to improve efficiency. An iterative numerical procedure is derived to solve the nonlinear estimating equations. The asymptotic properties of the proposed estimators are established. A simulation study examining the finite-sample performances of the proposed estimators shows that the AIPW estimators are more efficient than the IPW estimators. The developed method is applied to the RV144 HIV-1 vaccine efficacy trial to investigate vaccine-induced IgG binding antibodies to HIV-1 as correlates of acquisition of HIV-1 infection while taking account of whether the HIV-1 sequences are near or far from the HIV-1 sequences represented in the vaccine construct.

97 MATHEMATICS AND COMPUTING↗

Lung cancer mortality among construction workers: implications for early detection

Objectives This study examined predictors of lung cancer mortality, beyond age and smoking, among construction workers employed at US Department of Energy (DOE) sites to better define eligibility for low-dose CT (LDCT) lung cancer screening. Methods Predictive models were based on 17 069 workers and 352 lung cancer deaths. Risk factors included age, gender, race/ethnicity, cigarette smoking, years of trade or DOE work, body mass index (BMI), chest X-ray results, spirometry results, respiratory symptoms, beryllium sensitisation and personal history of cancer. Competing risk Cox models were used to obtain HRs and to predict 5-year risks. Results Factors beyond age and smoking included in the final predictive model were chest X-ray changes, abnormal lung function, chronic obstructive pulmonary disease (COPD), respiratory symptoms, BMI, personal history of cancer and having worked 5 or more years at a DOE site or in construction. Risk-based LDCT eligibility demonstrated improved sensitivity, specificity and positive predictive value compared with current US Preventive Services Task Force guidelines. The risk of lung cancer death from 5 years of work in the construction industry or at a DOE site was comparable with the risk from a personal cancer history, a family history of cancer or a diagnosis of COPD. LDCT eligibility criteria used for DOE construction workers, which includes factors beyond age and smoking, identified 86% of participants who eventually would die from lung cancer compared with 51% based on age and smoking alone. Conclusions Results support inclusion of risk from occupational exposures and non-malignant respiratory clinical findings in LDCT clinical guidelines.

Public, Environmental & Occupational Health↗

Familial Associations of Prevalence and Cause-Specific Mortality for Thoracic Aortic Disease and Bicuspid Aortic Valve in a Large-Population Database

Thoracic aortic disease and bicuspid aortic valve (BAV) likely have a heritable component, but large population-based studies are lacking. This study characterizes familial associations of thoracic aortic disease and BAV, as well as cardiovascular and aortic-specific mortality, among relatives of these individuals in a large-population database. In this observational case-control study of the Utah Population Database, we identified probands with a diagnosis of BAV, thoracic aortic aneurysm, or thoracic aortic dissection. Age- and sex-matched controls (10:1 ratio) were identified for each proband. First-degree relatives, second-degree relatives, and first cousins of probands and controls were identified through linked genealogical information. Cox proportional hazard models were used to quantify the familial associations for each diagnosis. We used a competing-risk model to determine the risk of cardiovascular-specific and aortic-specific mortality for relatives of probands. The study population included 3,812,588 unique individuals. Familial hazard risk of a concordant diagnosis was elevated in the following populations compared with controls: first-degree relatives of patients with BAV (hazard ratio [HR], 6.88 [95% CI, 5.62–8.43]); first-degree relatives of patients with thoracic aortic aneurysm (HR, 5.09 [95% CI, 3.80–6.82]); and first-degree relatives of patients with thoracic aortic dissection (HR, 4.15 [95% CI, 3.25–5.31]). In addition, the risk of aortic dissection was higher in first-degree relatives of patients with BAV (HR, 3.63 [95% CI, 2.68–4.91]) and in first-degree relatives of patients with thoracic aneurysm (HR, 3.89 [95% CI, 2.93–5.18]) compared with controls. Dissection risk was highest in first-degree relatives of patients who carried a diagnosis of both BAV and aneurysm (HR, 6.13 [95% CI, 2.82–13.33]). First-degree relatives of patients with BAV, thoracic aneurysm, or aortic dissection had a higher risk of aortic-specific mortality (HR, 2.83 [95% CI, 2.44–3.29]) compared with controls. Our results indicate that BAV and thoracic aortic disease carry a significant familial association for concordant disease and aortic dissection. The pattern of familiality is consistent with a genetic cause of disease. Furthermore, we observed higher risk of aortic-specific mortality in relatives of individuals with these diagnoses. In conclusion, this study provides supportive evidence for screening in relatives of patients with BAV, thoracic aneurysm, or dissection.

60 APPLIED LIFE SCIENCES↗

The interaction of the ITER first wall with magnetic perturbations

Mitigation of the multiple risks associated with disruptions and runaway electrons in tokamaks involves competing demands. Success requires that each risk be understood sufficiently that appropriate compromises can be made. Here the focus is on the interaction of short timescale magnetic-perturbations with the structure in ITER that is closest to the plasma, blanket modules covered by separated beryllium tiles. The effect of this tiled surface on the perturbations and on the forces on structures is subtle. Indeterminacy can be introduced by tile-to-tile shorting. A determinate subtlety is introduced because electrically separated tiles can act as a conducting surface for magnetic perturbations that have a normal component to the surface. A practical method for including this determinate subtlety into plasma simulations is developed. The shorter the timescales and the greater the localization, particularly in the toroidal direction, the more important the magnetic effects of the tiles become.

70 PLASMA PHYSICS AND FUSION TECHNOLOGY↗

Habitat use by female desert tortoises suggests tradeoffs between resource use and risk avoidance

Animals may select habitat to maximize the benefits of foraging on growth and reproduction, while balancing competing factors like the risk of predation or mortality from other sources. Variation in the distribution of food resources may lead animals to forage at times or in places that carry greater predation risk, with individuals in poor quality habitats expected to take greater risks while foraging. We studied Mojave desert tortoises ( Gopherus agassizii ) in habitats with variable forage availability to determine if risk aversion in their selection of habitat relative was related to abundance of forage. As a measure of risk, we examined tortoise surface activity and mortality. We also compared tortoise body size and body condition between habitats with ample forage plants and those with less forage plants. Tortoises from low forage habitats selected areas where more annual plants were nutritious herbaceous flowering plants but did not favor areas of greater perennial shrub cover that could shelter them or their burrows. In contrast, tortoises occupying high forage habitats showed no preference for forage characteristics, but used burrows associated with more abundant and larger perennial shrubs. Tortoises in high forage habitats were larger and active above ground more often but did not have better body condition. Mortality was four times higher for females occupying low forage habitat than those in high forage habitat. Our results are consistent with the idea that tortoises may minimize mortality risk where food resources are high, but may accept some tradeoff of greater mortality risk in order to forage optimally when food resources are limiting.

59 BASIC BIOLOGICAL SCIENCES↗

Cascade Dielectrophoretic Separation for Selective Enrichment of Polyhydroxybutyrate (PHB)-Producing Cyanobacterium Synechocystis sp. PCC 6803

Maintaining favorable biological productivities in photosynthetic biomanufacturing systems, especially when the risk of contamination with competing microbes is high, remains a challenge to achieve while maintaining economic feasibility. This study presents a dielectrophoresis (DEP)-based microfluidic approach for isolating a desired strain within a co-culture. The cyanobacterium Synechocystis sp. PCC 6803 (a strain capable of producing the bioplastic precursor polyhydroxybutyrate, or PHB) was enriched from mixed cultures containing the competing cyanobacterium Synechococcus elongatus PCC 7942 (which does not naturally produce PHB). A DEP cascade electrode system was established to increase purification efficiency through sequential enrichment, which leveraged inherent differences in cell morphology and dielectric properties, to achieve the selective separation of these strains under physiological conditions. A substantial increase in the relative abundance of PHB-producing cells was assessed by optical microscopy and flow cytometry characterization, confirming more than five-fold reduction of the Synechococcus fraction in the refined cell mix. The presented electrokinetic platform offers a scalable and effective approach for selectively enhancing desired microbial components within microbial biomanufacturing systems, leading towards improved product yields.

60 APPLIED LIFE SCIENCES↗

Changing temperature profiles and the risk of dengue outbreaks

As temperatures change worldwide, the pattern and competency of disease vectors will change, altering the global distribution of both the burden of infectious disease and the risk of the emergence of those diseases into new regions. To evaluate the risk of potential summer dengue outbreaks triggered by infected travelers under various climate scenarios, we develop an SEIR-type model, run numerical simulations, and conduct sensitivity analyses under a range of temperature profiles. Our model extends existing theoretical frameworks for studying dengue dynamics by introducing temperature dependence of two key parameters: the mosquito extrinsic incubation period and the lifespan of mosquitoes, which empirical data suggests are both highly temperature dependent. We find that changing temperature significantly alters dengue risk in an inverted U-shape, with temperatures in the range 27-31°C producing the highest risk. As temperatures increase beyond 31°C, the determinants of dengue risk begin to shift from mosquito biting rate and carrying capacity to the duration of the human infectious period, suggesting that changing temperatures not only alter dengue risk but also the potential efficacy of control measures. To illustrate the role of spatial and temporal temperature heterogeneity, we select five US cities where the primary dengue vector, the mosquito Aedes aegypti , has been observed, and which have had dengue cases in the past: Los Angeles, Houston, Miami, Brownsville, and Phoenix. Our analysis suggests that an increase of 3°C leads to an approximate doubling of the risk of dengue in Los Angeles and Houston, but a reduction of risk in Miami, Brownsville, and Phoenix due to extreme heat.

54 ENVIRONMENTAL SCIENCES↗

Cyber-CHAMP White Paper

Cyber-CHAMP white paper intern school assignment. Worldwide there is a tremendous shortfall in the cybersecurity workforce. By 2021, researchers have forecasted a deficit of 3.5 million cyber professionals. As workforce capabilities diminished, the world's cybersecurity threats have continued to multiply. Industrial control systems (ICSs) and their operational technology (OT) components became more vulnerable to attack and compromise. When an ICS is compromised, attackers can cause widespread impacts on national security, public health, and safety. This capacity makes ICSs attractive targets, with 90% of surveyed OT organizations reporting a damaging cyberattack in the last two years. To address the risk to ICSs, personnel must be competent in operational best practices and the latest threats. While frameworks for information technology (IT) cybersecurity education have been developed, educational standards for OT cybersecurity are nonexistent.

97 MATHEMATICS AND COMPUTING↗

Gen IV Education and Training Working Group Webinars’ Initiative

Collaboration and support among national laboratories, industry, universities, and research and development organizations are vital to not only maintain a skilled and competent nuclear workforce but also to avert the risk of human resource shortages. As stated in a recent IAEA paper [1], the world nuclear electrical generating capacity is projected to increase to 554 GW(e) by 2030 and up to 874 GW(e) by 2050 (Fig. 1). This represents a 42% increase over current levels by 2030 and a doubling of the current capacity by 2050. To promote Education and Training (E&T) on Gen IV reactor systems and other nuclear related topics of interest, the Gen IV Education and Training Working Group (ETWG) identifies and advertises training courses; engages collaboration with other international education and training organizations; delivers webinars dedicated to Gen IV systems; and maintains a modern social medium platform to exchange information and ideas on Gen IV R&D topics, as well as on related GIF education and training activities. At the end of June 2020, the GIF ETWG has produced, podcasted and posted forty-one webinars covering the six Gen IV systems and various subjects addressing e.g. the economics of the nuclear fuel cycle, sustainability aspects of Gen IV systems, nuclear fuels and materials challenges, the thorium fuel cycle, energy conversion systems, and lessons learned for knowledge management and preservation. This paper describes the development of these webinars from the initial concept to its full realization, with future webinars planned in 2021, addressing topics such as materials and fuels performance for advanced reactors, small modular reactor.

Paviet, Patricia D.↗

Explaining Health Risk Behaviors in the U.S. with Social Deprivation at Local and Regional Levels

Health risk behaviors are precursors to many chronic health outcomes, and hence, they pose a challenge to public health. Social deprivation undoubtedly creates circumstances that limit access to healthy habits. Moreover, broad regional effects (weather patterns, political ideology, social norms), and local characteristics (cultural notions and barriers, urban places) also influence lifestyle choices and must be accounted for to truly understand the impact of social deprivation on risky behaviors. This research fills the knowledge gap in epidemiological modeling of health risk behaviors by leveraging machine learning to find associations between social deprivation and health risk behaviors, when adjusted by regional and local effects. Four health risk behaviors, namely, binge drinking, smoking, lack of sleep, and lack of physical activity from the CDC PLACES project are considered in a single framework to understand and compare the interplay between local/regional characteristics and seven measures of social deprivation. Our results indicate that local and/or regional factors rise to the top for three out of four risk behaviors (binge drinking, smoking and lack of sleep) out-competing social deprivation measures. Un-entangling the geographical effects reveals that poverty, educational attainment and non-employment are the three deprivation measures most significantly associated with all four health risk factors. The research thus indicates that public health policies to promote healthy lifestyle behaviors must seek to remedy social deprivation, but using socially and culturally sensitive interventions.

Gokhale, Swapna↗

Analyzing Insider Risk Threat to the Internet of Things (IoT)

Recent technological advancement has created a growing convergence of innovation. From machine learning to ubiquitous computing to wireless networks and automation, the world is seeing new technology increasingly capable of connecting with each other. Devices and systems use open communications networks to interact, process information, and react. This is called the Internet of Things (IoT) and is comprised of physical devices that exchange data over networks, creating revolutionary possibilities. The most common way most people interact with an IoT is through ‘smart home’ products like Amazon’s Alexa, which use microphones, speakers, and phones to control a variety of devices, from lights and thermostats, to cameras, to appliances and vacuum cleaners. But the open nature of IoT networks—necessary for their ability to communicate and operate—also introduces privacy and security concerns. At a personal level, this might mean a hack into a home to steal private information, but when applied in broader industries like healthcare, transportation, manufacturing, or the military, this vulnerability can have serious consequences. As IoT usage and interconnectivity increases, so too does the susceptibility to malicious actors. And the entire system is only as secure as its least secure member. This creates particular risk and vulnerability to radiological material industries, as a competent insider adversary could utilize the IoT to potentially steal or access classified or sensitive information about employees, sites, or systems; or simply sabotage security or maintenance from a more remote—and less secure—device. The IoT relies on a secure network across the entire system, especially in transport which may lack the security of more permanent locations; if one device fails, it can create a ripple effect and an insider threat may seek to exploit that connectivity. While IoT benefits drive increased innovation and usage, there are also vulnerabilities an insider threat could exploit; this risk of an IoT to radiological material must be addressed in any mitigation effort.

Kinney, Justin↗

Finding middle ground: Flow regimes designed for salmon and energy value

In regulated rivers, shaping seasonal flows to recover species at risk depends on understanding when to expect conflicts with competing water users and when their interests are aligned. Multi-objective optimization can be used to reveal such conflicts and commonalities. When species are involved, multi-objective optimization is challenged by the need to simulate complex species responses to flow regimes. Previously, we addressed that challenge by developing a simplified salmon model (Quantus) that defines cohorts of salmon by the river section and time in which they were spawned. Salmon in these space-time cohorts are tracked from the time redds (nests) are constructed until the cohort exits the tributary en route to the ocean. In this study, we modeled seasonal patterns in energy value and developed a Pareto-optimal frontier of seasonal flow patterns to maximize in-river salmon survival and hydropower value. Candidate flow regimes were characterized by two pulse flows varying in magnitude, timing, and duration and constrained by a total annual flow near the historical median. Our analysis revealed times when economic and salmon objectives were aligned and times when they differed. Pulse flows that favored higher energy value were timed to meet demand during extreme temperatures. Both salmon and hydropower objectives produced optimal flow regimes with pulse flows in early summer, but only solutions favoring hydropower value included high flows in mid-winter. Solutions favoring higher age-0 salmon survival provided an extended pulse flow in late winter/early spring, which suggests that access to productive floodplain habitat allowed faster growth and earlier out-migration and reduced the need for higher temperature-moderating flows later in spring. Minimum flows were also higher among solutions favoring salmon over energy. The tools used to produce these results can help to design simplified seasonal flow regimes by revealing compromise solutions that satisfy both fish and energy producers and highlighting when potential conflicts are likely.

54 ENVIRONMENTAL SCIENCES↗

Contribution of carbon pricing to meeting a mid-century net zero target

A mid-century net zero target creates a challenge for reducing the emissions of emissions-intensive, trade-exposed sectors with high cost mitigation options. These sectors include aluminium, cement, chemicals, iron and steel, lime, pulp and paper and petroleum refining. Available studies agree that decarbonization of these sectors is possible by mid-century if more ambitious policies are implemented soon. Existing carbon pricing policies have had limited impact on the emissions of these sectors because their marginal abatement costs almost always exceed the tax rate or allowance price. But emissions trading systems with free allowance allocations to emissions-intensive, trade-exposed sectors have minimized the adverse economic impacts and associated leakage. Internationally coordinated policies are unlikely, so implementing more ambitious policies creates a risk of leakage. This paper presents policy packages a country can implement to accelerate emission reduction by these sectors with minimal risk of leakage. To comply with international trade law the policy packages differ for producers whose goods compete with imports in the domestic market and producers whose goods are exported. Carbon pricing is a critical component of each package due its ability to minimize the risk of adverse economic impacts on domestic industry, support innovation and generate revenue. The revenue can be used to assist groups adversely impacted by the domestic price and production changes due to carbon pricing and to build public support for the policies.

54 ENVIRONMENTAL SCIENCES↗

Supporting Risk-informed Decision-making During Reactor Accidents

Uncertainty in severe accident evolution and outcome is driven by event bifurcations that represent distinctive challenges to defensive layers and tend to promote the emergence of discrete classes of core damage and accident risk. This discrete set of "attractor" states arise from the complex networks of competing physical phenomena and conditional event cascades occurring as the overall system degrades – a process that yields increasing degrees of freedom and accident progression pathways. Characterization of these event spaces has proven elusive to more traditional data interrogation methods, but proves tractable by application of more advanced data collection and machine learning approaches. Through application of these approaches we demonstrate a conceptual framework that enables real-time/robust, risk-informed decision-making support to improve accident mitigation and encourage “graceful exits” during low probability, extreme events limiting accident consequences. In this analysis, we simulated over 8,000 short-term station blackout (STSBO) accidents with the state-of-the-art integral severe accident code, MELCOR, and demonstrate the potential for ML approaches to predict simulation outcomes. We chose to pair ML tools with interpretable and mechanistic event trees for the considered STSBO accident space to predict the likelihood of future event paths along the tree. In addition to the current state of the system, we use information from recent trajectories of temperature, pressure, and other physical features, combining both the current state and past trajectories to forecast future event paths. Finally, we simulate the random injection of variable amounts of water to quantify the efficacy of available actions at reducing risks along the many branches in the event tree. We identify scenarios and windows of opportunity to mitigate risk as well as scenarios in which such actions are unlikely to alter the accident end-state.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

Digital risk analysis in nuclear engineering projects: Designing for safety, performance, reliability, and security

Cyber-informed engineering and security-by-design frameworks are important in promoting the need to identify cybersecurity concerns early in the systems engineering lifecycle so risks from adversarial cyber-attacks can be eliminated or reduced through engineering design practices. In addition to adversarial risk, risk in operational technology systems also includes non-adversarial and unintentional risk from other factors such as human performance errors, environmental conditions, design flaws, and device degradation or failure. This paper introduces a new concept for characterizing digital risk, both adversarial and non-adversarial, and provides the basis for initial research into a novel digital risk analysis approach focused on incorporating attack difficulty into a multi-attribute analysis technique using robust decision-making. This digital risk characterization is also used to frame a discussion on the challenges of competing objectives and competing stakeholder requirements in an integrated energy system project that incorporates a small modular reactor and industrial facility.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

A Kinetic Model-Driven Techno-Economic Analysis of Plastic Pyrolysis: Linking Process Dynamics to Economic Viability

This study employs a kinetic model integrated into Aspen Plus to predict pyrolysis product distribution under various conditions. A techno-economic assessment calculated the minimum selling price (MSP) of pyrolysis oil under different operating conditions for the baseline capacity of 100 kta, and across eight processing capacities ranging from 30 to 150 kta. The lowest MSP under the baseline capacity is estimated at $\$$420/ton, which is 33% lower than the 2023 average US crude oil price ($\$$74.6/bbl, equivalent to $\$$634/ton based on the density of pyrolysis oil). Under Monte Carlo simulation, accounting for variability in key economic and technical parameters, the mean MSP is estimated at $\$$1137/ton. The economic viability depends on feedstock price remaining below $\$$320/ton, defining the break-even feedstock price threshold. Sensitivity analysis further identifies capital investment and transportation cost as key economic drivers. Capacities beyond 90 kta show limited economies of scale benefits. Reducing product storage time cuts capital costs by 7% but raises operational risk. Uncertainty analysis suggests the economic feasibility of pyrolysis oil is unlikely to compete with crude oil without policy incentives.

petrochemicals↗