Ethna McFerran, James F O'Mahony, Richard Fallis, Duncan McVicar, Ann G Zauber, Frank Kee
Lifetime risk of developing colorectal cancer is 5%, and 5-year survival at early stage is 92%. Individuals with precancerous lesions removed at primary screening are typically recommended surveillance colonoscopy. Because greater benefits are anticipated for those with higher risk of colorectal cancer, scope for risk-specific surveillance recommendations exists. This review assesses published cost-effectiveness estimates of postpolypectomy surveillance to consider the potential for personalized recommendations by risk group. Meta-analyses of incidence of advanced neoplasia postpolypectomy for low-risk cases were comparable to those without adenoma, with both rates under the lifetime risk of 5%. This group may not benefit from intensive surveillance, which risks unnecessary harm and inefficient use of often scarce colonoscopy capacity. Therefore, greater personalization through deintensified strategies for low-risk individuals could be beneficial. The potential for noninvasive testing, such as fecal immunochemical tests, combined with primary prevention or chemoprevention may reserve colonoscopy for targeted use in personalized risk-stratified surveillance. This review appraised evidence supporting a program of personalized surveillance in patients with colorectal adenoma according to risk group and compared the effectiveness of surveillance colonoscopy with alternative prevention strategies. It assessed trade-offs among costs, benefits, and adverse effects that must be considered in a decision to adopt or reject personalized surveillance.
终生罹患大肠癌的风险为 5%,早期患者的 5 年生存率为 92%。对于在初筛中切除了癌前病变的人,通常建议进行结肠镜监测检查。由于预计患结直肠癌风险较高的人群可获得更大的益处,因此存在针对特定风险提出监测建议的空间。本综述评估了已发表的息肉切除术后监测的成本效益估算,以考虑按风险组别提出个性化建议的可能性。对低风险病例切除息肉术后晚期肿瘤发生率的 Meta 分析结果与无腺瘤的病例相当,两者的发生率均低于 5% 的终生风险。这部分患者可能无法从强化监测中获益,因为强化监测可能会造成不必要的伤害,并使稀缺的结肠镜检查能力得不到有效利用。因此,通过针对低风险人群的非强化策略来提高个性化程度可能是有益的。无创检测(如粪便免疫化学检测)与一级预防或化学预防相结合的潜力可为结肠镜检查在个性化风险分级监控中的有针对性使用预留空间。本综述评估了支持根据风险组别对结直肠腺瘤患者进行个性化监测计划的证据,并比较了结肠镜监测与其他预防策略的有效性。它评估了在决定采用或拒绝个性化监测时必须考虑的成本、效益和不良反应之间的权衡。
{"title":"Evaluation of the Effectiveness and Cost-Effectiveness of Personalized Surveillance After Colorectal Adenomatous Polypectomy.","authors":"Ethna McFerran, James F O'Mahony, Richard Fallis, Duncan McVicar, Ann G Zauber, Frank Kee","doi":"10.1093/epirev/mxx002","DOIUrl":"10.1093/epirev/mxx002","url":null,"abstract":"<p><p>Lifetime risk of developing colorectal cancer is 5%, and 5-year survival at early stage is 92%. Individuals with precancerous lesions removed at primary screening are typically recommended surveillance colonoscopy. Because greater benefits are anticipated for those with higher risk of colorectal cancer, scope for risk-specific surveillance recommendations exists. This review assesses published cost-effectiveness estimates of postpolypectomy surveillance to consider the potential for personalized recommendations by risk group. Meta-analyses of incidence of advanced neoplasia postpolypectomy for low-risk cases were comparable to those without adenoma, with both rates under the lifetime risk of 5%. This group may not benefit from intensive surveillance, which risks unnecessary harm and inefficient use of often scarce colonoscopy capacity. Therefore, greater personalization through deintensified strategies for low-risk individuals could be beneficial. The potential for noninvasive testing, such as fecal immunochemical tests, combined with primary prevention or chemoprevention may reserve colonoscopy for targeted use in personalized risk-stratified surveillance. This review appraised evidence supporting a program of personalized surveillance in patients with colorectal adenoma according to risk group and compared the effectiveness of surveillance colonoscopy with alternative prevention strategies. It assessed trade-offs among costs, benefits, and adverse effects that must be considered in a decision to adopt or reject personalized surveillance.</p>","PeriodicalId":50510,"journal":{"name":"Epidemiologic Reviews","volume":"39 1","pages":"148-160"},"PeriodicalIF":5.5,"publicationDate":"2017-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858033/pdf/mxx002.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34907473","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In the article “Disasters: Introduction and State of the Art” by Noji (1), multiple instances of improper or missing attribution were brought to the Editor’s attention. Upon investigation, the following irregularities, which have been acknowledged by the author, were identified. On page 5, the second full paragraph in the second column, which begins “Major advances have been made during the past decade...” was taken from the article by Salama et al. (2, p. 1801; reference 20 in the original article). Although that article is cited as a reference, it was not made clear that the entire paragraph was a quote. In addition, on pages 5 and 6, several paragraphs were taken verbatim without proper attribution from the article by Noji and Toole (3).
{"title":"RE: \"WHAT DO WE KNOW ABOUT THE ASSOCIATION BETWEEN FIREARM LEGISLATION AND FIREARM-RELATED INJURIES?\"","authors":"","doi":"10.1093/epirev/mxx011","DOIUrl":"https://doi.org/10.1093/epirev/mxx011","url":null,"abstract":"In the article “Disasters: Introduction and State of the Art” by Noji (1), multiple instances of improper or missing attribution were brought to the Editor’s attention. Upon investigation, the following irregularities, which have been acknowledged by the author, were identified. On page 5, the second full paragraph in the second column, which begins “Major advances have been made during the past decade...” was taken from the article by Salama et al. (2, p. 1801; reference 20 in the original article). Although that article is cited as a reference, it was not made clear that the entire paragraph was a quote. In addition, on pages 5 and 6, several paragraphs were taken verbatim without proper attribution from the article by Noji and Toole (3).","PeriodicalId":50510,"journal":{"name":"Epidemiologic Reviews","volume":"39 1","pages":"171-172"},"PeriodicalIF":5.5,"publicationDate":"2017-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/epirev/mxx011","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"35000895","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Charles W LeHew, Darien J Weatherspoon, Caryn E Peterson, Abigail Goben, Karolina Reitmajer, Herve Sroussi, Linda M Kaste
Oral cavity and oropharyngeal cancers are typically grouped under the general term, "oral cancer." Yet, the incidence of oropharyngeal cancers is increasing in the United States, while the incidence of oral cavity cancers has declined. These 2 distinct but conflated groups of oral cancers are attributed to different risk factors. Incidence and survival trends were examined across US population groups and by anatomical subsite. Disparities in incidence and survival by sex, race/ethnicity, and subsite were identified. Risk factors are complex, interactive, and not fully identified. Cancer control research illustrates health disparities in access to care and patient outcomes. Database and supplemental searches yielded 433 articles published between 1995 and 2016 characterizing aspects of oral cancer epidemiology relating to incidence, survival, risk, disparities, and cancer control. Oral cavity cancer survival in black men remains the most intractable burden. Although understanding of oral cancer etiology is improving, application to policy is limited. Cancer control efforts are diverse, sporadic, limited in scope, and generally lacking in success, and they need stratification by oral cavity cancers/oropharyngeal cancers. Further intervention and epidemiologic research, improved workforce capacity, and integrated care delivery are identified as important directions for public health policy. Sustained, multilevel campaigns modeled on tobacco control success are suggested.
{"title":"The Health System and Policy Implications of Changing Epidemiology for Oral Cavity and Oropharyngeal Cancers in the United States From 1995 to 2016.","authors":"Charles W LeHew, Darien J Weatherspoon, Caryn E Peterson, Abigail Goben, Karolina Reitmajer, Herve Sroussi, Linda M Kaste","doi":"10.1093/epirev/mxw001","DOIUrl":"https://doi.org/10.1093/epirev/mxw001","url":null,"abstract":"<p><p>Oral cavity and oropharyngeal cancers are typically grouped under the general term, \"oral cancer.\" Yet, the incidence of oropharyngeal cancers is increasing in the United States, while the incidence of oral cavity cancers has declined. These 2 distinct but conflated groups of oral cancers are attributed to different risk factors. Incidence and survival trends were examined across US population groups and by anatomical subsite. Disparities in incidence and survival by sex, race/ethnicity, and subsite were identified. Risk factors are complex, interactive, and not fully identified. Cancer control research illustrates health disparities in access to care and patient outcomes. Database and supplemental searches yielded 433 articles published between 1995 and 2016 characterizing aspects of oral cancer epidemiology relating to incidence, survival, risk, disparities, and cancer control. Oral cavity cancer survival in black men remains the most intractable burden. Although understanding of oral cancer etiology is improving, application to policy is limited. Cancer control efforts are diverse, sporadic, limited in scope, and generally lacking in success, and they need stratification by oral cavity cancers/oropharyngeal cancers. Further intervention and epidemiologic research, improved workforce capacity, and integrated care delivery are identified as important directions for public health policy. Sustained, multilevel campaigns modeled on tobacco control success are suggested.</p>","PeriodicalId":50510,"journal":{"name":"Epidemiologic Reviews","volume":"39 1","pages":"132-147"},"PeriodicalIF":5.5,"publicationDate":"2017-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/epirev/mxw001","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34907468","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sarina R Isenberg, Rebecca A Aslakson, Thomas J Smith
The American Society of Clinical Oncology (ASCO) recently convened an Ad Hoc Palliative Care Expert Panel to update a 2012 provisional clinical opinion by conducting a systematic review of clinical trials in palliative care in oncology. The key takeaways from the updated ASCO clinical practice guidelines (CPGs) are that more people should be referred to interdisciplinary palliative care teams and that more palliative care specialists and palliative care-trained oncologists are needed to meet this demand. The following summary statement is based on multiple randomized clinical trials: "Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs" (J Clin Oncol. 2017;35(1):96). This paper addresses potential epidemiologic and policy interpretations and implications of the ASCO CPGs. Our review of the CPGs demonstrates that to have clinicians implement these guidelines, there is a need for support from stakeholders across the health-care continuum, health system and institutional change, and changes in health-care financing. Because of rising costs and the need to improve value, the need for coordinated care, and change in end-of-life care patterns, many of these changes are already underway.
{"title":"Implementing Evidence-Based Palliative Care Programs and Policy for Cancer Patients: Epidemiologic and Policy Implications of the 2016 American Society of Clinical Oncology Clinical Practice Guideline Update.","authors":"Sarina R Isenberg, Rebecca A Aslakson, Thomas J Smith","doi":"10.1093/epirev/mxw002","DOIUrl":"10.1093/epirev/mxw002","url":null,"abstract":"<p><p>The American Society of Clinical Oncology (ASCO) recently convened an Ad Hoc Palliative Care Expert Panel to update a 2012 provisional clinical opinion by conducting a systematic review of clinical trials in palliative care in oncology. The key takeaways from the updated ASCO clinical practice guidelines (CPGs) are that more people should be referred to interdisciplinary palliative care teams and that more palliative care specialists and palliative care-trained oncologists are needed to meet this demand. The following summary statement is based on multiple randomized clinical trials: \"Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs\" (J Clin Oncol. 2017;35(1):96). This paper addresses potential epidemiologic and policy interpretations and implications of the ASCO CPGs. Our review of the CPGs demonstrates that to have clinicians implement these guidelines, there is a need for support from stakeholders across the health-care continuum, health system and institutional change, and changes in health-care financing. Because of rising costs and the need to improve value, the need for coordinated care, and change in end-of-life care patterns, many of these changes are already underway.</p>","PeriodicalId":50510,"journal":{"name":"Epidemiologic Reviews","volume":"39 1","pages":"123-131"},"PeriodicalIF":5.5,"publicationDate":"2017-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858032/pdf/mxw002.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34968895","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Alison M Mondul, Stephanie J Weinstein, Tracy M Layne, Demetrius Albanes
There has been substantial enthusiasm recently regarding the potential role of vitamin D in the primary and secondary prevention of cancer. Laboratory studies demonstrate a range of anticarcinogenic effects for vitamin D compounds, but human studies have yielded little consistent evidence supporting a protective association. Higher circulating levels of vitamin D (i.e., 25-hydroxyvitamin D or 25(OH)D) appear to be associated with reduced risk of colorectal and bladder malignancies, but higher risk of prostate and possibly pancreatic cancers, with no clear association for most other organ sites examined. Despite there being no official institutional recommendations regarding the use of vitamin D supplements for cancer prevention, screenings for vitamin D deficiency and vitamin D supplement use have increased substantially over the past decade. These widespread practices demonstrate that population sociobehavioral changes are often adopted before scientifically well-informed policies and recommendations are available. This review critically examines the currently available epidemiologic literature regarding the associations between circulating 25(OH)D, vitamin D supplementation, and vitamin D-related genetic variation and cancer risk and mortality, with a particular emphasis on prospective studies. We identify several important gaps in our scientific knowledge that should be addressed in order to provide sufficient reproducible data to inform evidence-based recommendations related to optimal 25(OH)D concentrations (and any role for vitamin D supplementation) for the primary and secondary prevention of cancer. With few exceptions, such recommendations cannot be made at this time.
{"title":"Vitamin D and Cancer Risk and Mortality: State of the Science, Gaps, and Challenges.","authors":"Alison M Mondul, Stephanie J Weinstein, Tracy M Layne, Demetrius Albanes","doi":"10.1093/epirev/mxx005","DOIUrl":"https://doi.org/10.1093/epirev/mxx005","url":null,"abstract":"<p><p>There has been substantial enthusiasm recently regarding the potential role of vitamin D in the primary and secondary prevention of cancer. Laboratory studies demonstrate a range of anticarcinogenic effects for vitamin D compounds, but human studies have yielded little consistent evidence supporting a protective association. Higher circulating levels of vitamin D (i.e., 25-hydroxyvitamin D or 25(OH)D) appear to be associated with reduced risk of colorectal and bladder malignancies, but higher risk of prostate and possibly pancreatic cancers, with no clear association for most other organ sites examined. Despite there being no official institutional recommendations regarding the use of vitamin D supplements for cancer prevention, screenings for vitamin D deficiency and vitamin D supplement use have increased substantially over the past decade. These widespread practices demonstrate that population sociobehavioral changes are often adopted before scientifically well-informed policies and recommendations are available. This review critically examines the currently available epidemiologic literature regarding the associations between circulating 25(OH)D, vitamin D supplementation, and vitamin D-related genetic variation and cancer risk and mortality, with a particular emphasis on prospective studies. We identify several important gaps in our scientific knowledge that should be addressed in order to provide sufficient reproducible data to inform evidence-based recommendations related to optimal 25(OH)D concentrations (and any role for vitamin D supplementation) for the primary and secondary prevention of cancer. With few exceptions, such recommendations cannot be made at this time.</p>","PeriodicalId":50510,"journal":{"name":"Epidemiologic Reviews","volume":"39 1","pages":"28-48"},"PeriodicalIF":5.5,"publicationDate":"2017-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/epirev/mxx005","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34980184","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"RE: \"DISASTERS: INTRODUCTION AND STATE OF THE ART\".","authors":"","doi":"10.1093/epirev/mxx010","DOIUrl":"https://doi.org/10.1093/epirev/mxx010","url":null,"abstract":"","PeriodicalId":50510,"journal":{"name":"Epidemiologic Reviews","volume":"39 1","pages":"170"},"PeriodicalIF":5.5,"publicationDate":"2017-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/epirev/mxx010","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"35000894","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2016-01-01Epub Date: 2016-01-24DOI: 10.1093/epirev/mxv010
Charles C Branas, SeungHoon Han, Douglas J Wiebe
Although the misuse of firearms is necessary to the occurrence of firearm violence, there are other contributing factors beyond simply firearms themselves that might also be modified to prevent firearm violence. Alcohol is one such key modifiable factor. To explore this, we undertook a 40-year (1975-2014) systematic literature review with meta-analysis. One large group of studies showed that over one third of firearm violence decedents had acutely consumed alcohol and over one fourth had heavily consumed alcohol prior to their deaths. Another large group of studies showed that alcohol was significantly associated with firearm use as a suicide means. Two controlled studies showed that gun injury after drinking, especially heavy drinking, was statistically significant among self-inflicted firearm injury victims. A small group of studies investigated the intersection of alcohol and firearms laws and alcohol outlets and firearm violence. One of these controlled studies found that off-premise outlets selling takeout alcohol were significantly associated with firearm assault. Additional controlled, population-level risk factor and intervention studies, including randomized trials of which only 1 was identified, are needed. Policies that rezone off-premise alcohol outlets, proscribe blood alcohol levels and enhance penalties for carrying or using firearms while intoxicated, and consider prior drunk driving convictions as a more precise criterion for disqualifying persons from the purchase or possession of firearms deserve further study.
{"title":"Alcohol Use and Firearm Violence.","authors":"Charles C Branas, SeungHoon Han, Douglas J Wiebe","doi":"10.1093/epirev/mxv010","DOIUrl":"10.1093/epirev/mxv010","url":null,"abstract":"<p><p>Although the misuse of firearms is necessary to the occurrence of firearm violence, there are other contributing factors beyond simply firearms themselves that might also be modified to prevent firearm violence. Alcohol is one such key modifiable factor. To explore this, we undertook a 40-year (1975-2014) systematic literature review with meta-analysis. One large group of studies showed that over one third of firearm violence decedents had acutely consumed alcohol and over one fourth had heavily consumed alcohol prior to their deaths. Another large group of studies showed that alcohol was significantly associated with firearm use as a suicide means. Two controlled studies showed that gun injury after drinking, especially heavy drinking, was statistically significant among self-inflicted firearm injury victims. A small group of studies investigated the intersection of alcohol and firearms laws and alcohol outlets and firearm violence. One of these controlled studies found that off-premise outlets selling takeout alcohol were significantly associated with firearm assault. Additional controlled, population-level risk factor and intervention studies, including randomized trials of which only 1 was identified, are needed. Policies that rezone off-premise alcohol outlets, proscribe blood alcohol levels and enhance penalties for carrying or using firearms while intoxicated, and consider prior drunk driving convictions as a more precise criterion for disqualifying persons from the purchase or possession of firearms deserve further study. </p>","PeriodicalId":50510,"journal":{"name":"Epidemiologic Reviews","volume":"38 1 1","pages":"32-45"},"PeriodicalIF":5.2,"publicationDate":"2016-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4762248/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"60827318","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Despite the magnitude and consistency of risk estimates in the peer-reviewed literature linking firearm availability and suicide, inferring causality has been questioned on the theoretical basis that existing studies may have failed to account for the possibility that members of households with firearms differ from members of households without firearms in important ways related to suicide risk. The current bias analysis directly addresses this concern by describing the salient characteristics that such an unmeasured confounder would need to possess in order to yield the associations between firearm availability and suicide observed in the literature when, in fact, the causal effect is null. Four US studies, published between 1992 and 2003, met our eligibility criteria. We find that any such unmeasured confounder would need to possess an untenable combination of characteristics, such as being not only 1) as potent a suicide risk factor as the psychiatric disorders most tightly linked to suicide (e.g., major depressive and substance use disorders) but also 2) an order of magnitude more imbalanced across households with versus without firearms than is any known risk factor. No such confounder has been found or even suggested. The current study strongly suggests that unmeasured confounding alone is unlikely to explain the association between firearms and suicide.
{"title":"Are We Missing Something Pertinent? A Bias Analysis of Unmeasured Confounding in the Firearm-Suicide Literature.","authors":"M. Miller, S. Swanson, D. Azrael","doi":"10.1093/epirev/mxv011","DOIUrl":"https://doi.org/10.1093/epirev/mxv011","url":null,"abstract":"Despite the magnitude and consistency of risk estimates in the peer-reviewed literature linking firearm availability and suicide, inferring causality has been questioned on the theoretical basis that existing studies may have failed to account for the possibility that members of households with firearms differ from members of households without firearms in important ways related to suicide risk. The current bias analysis directly addresses this concern by describing the salient characteristics that such an unmeasured confounder would need to possess in order to yield the associations between firearm availability and suicide observed in the literature when, in fact, the causal effect is null. Four US studies, published between 1992 and 2003, met our eligibility criteria. We find that any such unmeasured confounder would need to possess an untenable combination of characteristics, such as being not only 1) as potent a suicide risk factor as the psychiatric disorders most tightly linked to suicide (e.g., major depressive and substance use disorders) but also 2) an order of magnitude more imbalanced across households with versus without firearms than is any known risk factor. No such confounder has been found or even suggested. The current study strongly suggests that unmeasured confounding alone is unlikely to explain the association between firearms and suicide.","PeriodicalId":50510,"journal":{"name":"Epidemiologic Reviews","volume":"16 1","pages":"62-9"},"PeriodicalIF":5.5,"publicationDate":"2016-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1093/epirev/mxv011","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"60827332","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}