Excess Risk Of Death Research Articles

Factors That Contribute to Differences in Survival of Black vs White Patients With Colorectal Cancer

Previous studies reported that black vs white disparities in survival among elderly patients with colorectal cancer (CRC) were because of differences in tumorcharacteristics (tumor stage, grade, nodal status, and comorbidity) rather than differences in treatment. We sought todetermine the contribution of differences in insurance, comorbidities, tumor characteristics, and treatment receipt to disparities in black vs white patients with CRC 18-64 years old. We used data from the National Cancer Database, a hospital-based cancer registry database sponsored by the American College of Surgeons and the American CancerSociety, on non-Hispanic black (black) and non-Hispanic white (white) patients, 18-64 years old, diagnosed from 2004 through 2012 with single or first primary invasive stage I-IV CRC. Each black patient was matched, based on demographic, insurance, comorbidity, tumor, and treatment features, with 5 white patients, from partially overlapping subgroups, using propensity score and greedy matching algorithms. We used theKaplan-Meier method to estimate 5-year survival and Coxproportional hazards models to generate hazard ratios. The absolute 5-year survival difference between black and white unmatched patients with CRC was 9.2% (57.3% for black patients vs 66.5% forwhite patients; P<.0001). The absolute difference in survival did not change after patient groups were matched for demographics, but decreased to 4.9% (47% relative decrease [4.3% of 9.2%]) when they were matched for insurance and to2.3% when they were matched for tumor characteristics (26% relative decrease [2.4% of 9.2%]). Further matching by treatment did not reducethe difference in 5-year survival between black and white patients. In proportional hazards model, insurance andtumor characteristics matching accounted for the 54% and 27% excess risk of death in black patients, respectively. In an analysis of datafrom the National Cancer Database, we found that insurance coverage differences accounted for approximately one half of the disparity in survival rate of black vs white patients with CRC, 18-64 years old; tumor characteristics accounted for a quarter of the disparity. Affordable health insurance coverage for all populations could substantially reduce differences in survival times of black vs white patients with CRC.

Factors That Contributed to Black-White Disparities in Survival Among Nonelderly Women With Breast Cancer Between 2004 and 2013.

Purpose To estimate the contribution of differences in demographics, comorbidity, insurance, tumor characteristics, and treatment to the overall mortality disparity between nonelderly black and white women diagnosed with early-stage breast cancer. Patients and Methods Excess relative risk of all-cause death in black versus white women diagnosed with stage I to III breast cancer, expressed as a percentage and stratified by hormone receptor status for each variable (demographics, comorbidity, insurance, tumor characteristics, and treatment) in sequentially, propensity-scored, optimally matched patients by using multivariable hazard ratios (HRs). Results We identified 563,497 white and black women 18 to 64 years of age diagnosed with stage I to III breast cancer from 2004 to 2013 in the National Cancer Data Base. Among women with hormone receptor-positive disease, who represented 78.5% of all patients, the HR for death in black versus white women in the demographics-matched model was 2.05 (95% CI, 1.94 to 2.17). The HR decreased to 1.93 (95% CI, 1.83 to 2.04), 1.54 (95% CI, 1.47 to 1.62), 1.30 (95% CI, 1.24 to 1.36), and 1.25 (95% CI, 1.19 to 1.31) when sequentially matched for comorbidity, insurance, tumor characteristics, and treatment, respectively. These factors combined accounted for 76.3% of the total excess risk of death in black patients; insurance accounted for 37.0% of the total excess, followed by tumor characteristics (23.2%), comorbidities (11.3%), and treatment (4.8%). Results generally were similar among women with hormone receptor-negative disease, although the HRs were substantially smaller. Conclusion Matching by insurance explained one third of the excess risk of death among nonelderly black versus white women diagnosed with early-stage breast cancer; matching by tumor characteristics explained approximately one fifth of the excess risk. Efforts to focus on equalization of access to care could substantially reduce ethnic/racial disparities in overall survival among nonelderly women diagnosed with breast cancer.

Biological Behavior and Long-Term Outcomes of Carcinoma In Situ in Upper Urinary Tract Managed by Radical Nephroureterectomy

In patients with urothelial carcinoma CIS (carcinoma in situ) generally has a poor prognosis. However, to our knowledge the outcomes of pure/primary CIS and the behavior of CIS concomitant with pTa-pT4 upper tract urothelial carcinoma managed by nephroureterectomy have not been previously specified. We explored the biological and prognostic features of concomitant CIS compared with those of pure/primary CIS. We queried a multicenter upper tract urothelial carcinoma database. Data from NUOG (Nishinihon Uro-Oncology Group) were analyzed, including patient gender, age, presence of bladder cancer and pT stage. Clinicopathological features were compared between the different subtypes. Cancer specific and overall survival, and the relative excess risk of death were estimated by CIS subtype. We identified 163 patients with CIS in the upper urinary tract, of whom pure/primary CIS was noted in 24.5%. In the concomitant CIS cohort the pathological diagnosis of the nonCIS region was pTa, pT1, pT2, pT3 and pT4 in 4.9%, 22.8%, 25.2%, 44.7% and 1.6% of patients, respectively. The sensitivity of a selective urine cytology test was higher in the pure/primary CIS group than in the concomitant CIS group (60.0% vs 37.4%). At a median followup of 32 months 10-year estimated mean cancer specific survival was 92.4 months (range 83.7 to 101.0) in the overall CIS cohort. Ten-year estimated mean cancer specific survival in patients with pure/primary CIS was significantly longer than in patients with concomitant carcinoma in situ (111.8 months, range 101.0 to 122.6 vs 85.89, range 75.3 to 96.5, log rank p = 0.007). Patients presenting with concomitant CIS have a worse outcome than those who present with pure/primary CIS, suggesting a need to differentiate these 2 entities in the treatment decision process.

Impact of Diabetes Duration on the Extent and Severity of Coronary Atheroma Burden in Type 2 Diabetic Patients : Evaluation by Coronary CT Angiography

Aim of the work: this study aimedto explore the association between diabetes duration on both the extent and severity of coronary atheroma burden using coronary computed tomography angiography (CCTA) in type 2 diabetic patients. Patients and methods: we analyzed 105 symptomatic type 2 diabetic patients without known CAD who underwent CCTA from August 2016 to June 2017. Patients were categorized into two groups according to the duration of diabetes: < 10 years, and ≥ 10 years. Stenosis by CCTA was scored as none (0%), non-obstructive (1–49%), or obstructive (≥50%) for each coronary artery segment. For these patients, we compared the prevalence, extent, and severity of CAD, including coronary artery calcium score (CACS), atheroma burden obstructive score (ABOS), segment involvement score (SIS), segment stenosis score (SSS) and syntax score. Results: patients with longer duration of type 2 diabetes possessed higher rates of obstructive CAD. Patients with longer duration of diabetes also manifested greater degree of CACS, ABOS, SIS, SSS and syntax score (P < 0.001 for all). Conclusion: in symptomatic type 2 diabetic patients, longer diabetes duration was associated with a higher prevalence, extent, and severity of CAD so, increased risk of developing atherosclerotic cardiovascular disease including major events as myocardial infarction or even sudden cardiac death. INTRODUCTION Reducing atherosclerotic cardiovascular disease (ASCVD) burden in diabetes mellitus (DM) is a major clinical imperative that should be prioritized to reduce premature death, improve quality of life and lessen individual and economic burdens of associated morbidities, decreased work productivity, and high cost of medical care [1]. Atherosclerotic cardiovascular disease remains the principal cause of death and disability among patients with diabetes mellitus, especially in those with type 2 diabetes mellitus in whom it typically occurs 14.6 years earlier [2], with greater severity, and with more diffuse distribution than in individuals without diabetes mellitus [3]. Furthermore, about two-thirds of deaths in people with diabetes mellitus are attributable to cardiovascular disease: of these, ≈ 40% are from ischemic heart disease, 15% from other forms of heart disease, principally congestive heart failure, and ≈10% from stroke. Among those with diabetes mellitus, excess risks of death from any cause and of ASCVD mortality are particularly prominent in those with younger age, higher burden of glycaemia, and greater renal complications, in comparison with those without [4]. Although the incidences of diabetes mellitus–related complications including cardiovascular disease have decreased over the past 2 decades, patients with diabetes mellitus continue to have significantly increased risk for vascular complications in comparison with individuals without diabetes mellitus [5]. An estimated 382 million people worldwide have diabetes mellitus and this number is expected to reach 592 million by the year 2035 [6]. Key manifestations of ASCVD in diabetes mellitus included advanced atherosclerosis manifest as coronary artery disease (CAD), ischemic stroke, peripheral vascular disease, and heart failure. Understanding the mechanisms, strategies for and challenges with managing ASCVD and heart failure risk in diabetes mellitus, as well as the potential cardiovascular risks and benefits of glucose-lowering drugs, is important for managing cardiovascular disease in diabetes mellitus [1]. Coronary computed tomography angiography (CCTA) has emerged as a non-invasive imaging modality for the detection or exclusion of CAD, with prior studies observing a high prevalence of CAD in asymptomatic type 2 diabetic patients using CCTA that is associated with worsened outcomes [7]. A

The impact of comorbidities on hip fracture mortality: a retrospective population-based cohort study.

This work aimed to estimate the impact of pre-fracture comorbidities on the 10-year excess risk of all-cause death after hip fracture among Estonian men and women ≥50years of age. Retrospective, population-based 10-year study of people aged ≥50 in two cohorts: those with a hip fracture and an age- and sex-matched random sample from the national health insurance fund for comparison. We found that hip fracture was a strong independent risk factor for death. Upon adjustment for Charlson Comorbidities Index (CCI) score, the impact of life-threatening comorbidities on average hip fracture-related excess mortality was modest: only 8% of excess deaths over 10years were related to comorbidities. Upon stratification by CCI groups, the excess risk of patients in CCI groups ≥3 and 1-2 exceeded that in the CCI 0 group over 5-7years, indicating that in patients with life-threatening comorbidities, a hip fracture accelerates the chain of lethal events and brings deaths from other conditions forward. The impact of comorbidities was age- and time-dependent: in younger hip fracture patients, the comorbidities almost doubled the excess risk from a fracture in 10years; in older patients, the effect was shorter and modest. The presence of pre-fracture comorbidities increases the risk of excess death in hip fracture patients, but the comorbidity impact on aggregated excess mortality is modest.

Radiation dose and cardiac risk in breast cancer treatment: An analysis of modern radiation therapy including community settings

PurposeAdjuvant radiation therapy (RT) for breast cancer improves outcomes, but prior studies have documented substantive cardiac dose and cardiac risk. We assessed the mean heart dose (MHD) of RT and estimated the risk of RT-associated cardiac toxicity in women undergoing adjuvant RT for breast cancer in contemporary (predominantly) community practice. Methods and materialsWe identified women with left-sided breast cancer receiving adjuvant RT between 2012 and 2014 from 94 centers across 16 states. We used bivariate analyses and multivariable linear regression to assess associations between RT techniques and MHD. Excess RT-related cardiac risk by age 80 was estimated for women diagnosed at age 60 using the previously reported relationship between MHD and cardiac risk. ResultsAmong 1161 women, 77.3% were treated in community practice and with breast conservation (77.8%). The most common techniques were free-breathing (92.2%), supine (94.8%), and fixed gantry intensity modulated RT (FG-IMRT; 46.9%). The median MHD was 2.76 Gy (interquartile range, 1.47-5.03). In multivariable analyses, the predicted median MHD with deep inspiration breath hold was 2.41 Gy compared with 3.86 Gy with free-breathing (P < .001). Three-dimensional conformal RT (3D-CRT) was associated with a lower predicted median MHD (2.78 Gy) than FG-IMRT (4.02 Gy) or rotational IMRT, 6.60 Gy, P < .001). For 60-year-old women with the median MHD of the study population (2.76 Gy) and no cardiovascular risk factors, the 20-year predicted excess risk of death from ischemic heart disease attributable to radiation was 3.5 excess events/1000 patients, in contrast to estimates of 8 events/1000 from prior analyses. The predicted risk of cardiac events varied based on radiation technique, with 4 excess events/1000 with 3D-CRT, 5 excess events/1000 with FG-IMRT, and 8 excess events/1000 with rotational IMRT. ConclusionsMHD varies substantially across patients and is influenced by technique in predominantly community settings. Overall risk of cardiac toxicity is modest.

The impact of hip fracture on mortality in Estonia: a retrospective population-based cohort study

BackgroundEstimates of hip fracture mortality in Eastern Europe are scarce. We aimed to estimate the magnitude and duration of excess mortality after hip fracture in Estonia.MethodsRetrospective, population-based 10-year study of persons aged ≥50 in two cohorts: with hip fracture and an age- and sex-matched (in a 1:4 ratio) random sample from the national health insurance fund database for comparison. Cumulative risks, excess risks and relative risks of death were estimated using Poisson regression with 95% bootstrap confidence intervals (CI). Risks were adjusted for age and Charlson comorbidity index.ResultsWe identified 8298 (2383 men, 5915 women) incident hip fracture patients from 2005 to 2013 and 33,191 (9531 men, 23,660 women) individuals for the reference group. 5552 (1564 men, 3988 women) cases and 14,037 (3514 men, 10,523 women) reference individuals died during the 10-year follow-up period. Among hip fracture patients we observed a pronounced and durable excess risk of death that was highest within 3–6 months after fracture and persisted for the full 10-year follow-up period. After adjustment for age and Charlson index, hip fracture was associated with a 21.1% (95% CI 20.0–22.5%) 10-year cumulative excess risk of death (RR 1.37, 95% CI 1.35–1.40). We found a high immediate excess risk of death in older age groups (≥80 years) and gradually accumulating excess risk in younger age groups (50–79 years). The excess risk was more pronounced among men than women.ConclusionsBy the end of the 10-year follow-up, 1 in 4 deaths in the hip fracture group was attributable to the hip fracture. The results indicate a high attributable impact of hip fracture as an independent risk factor for death.

Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans

ObjectiveProton pump inhibitors (PPIs) are widely used, and their use is associated with increased risk of adverse events. However, whether PPI use is associated with excess risk of death is...

Infantile spasms: Long-term mortality of the patients

Objective: To study the long-term survival and mortality among patients with infantile spasms. Methods: The study population included all children born in 1960–1976 and treated for infantile spasms in three tertiary care hospitals in Helsinki, Finland. The participants were prospectively followed for five decades for survival. Death data were derived from the National Causes of Death Register of the Population Register Center of Statistics Finland. Results: During follow-up, 102 (49%) of 207 patients had died at the mean age of 19 years. The mean overall annual mortality rate was 15.3 per 1,000 patient-years years. The rates ranged from 18.2 per 1,000 after 10 years to 17.2 per 1,000 after 20 years and 15.4 per 1,000 patient-years after 40 years of follow-up. One fourth (25%) had died by 17.2 (95% CI 11.8–22.7) years and 50% by 48.6 (95% CI 38.5–NA) years of follow-up. Etiology at onset was symptomatic in 87% patients and cryptogenic in 13%. The mean annual mortality rate was 3.7 per 1,000 for patients with cryptogenic etiology and 17.6 per 1,000 for those with symptomatic etiology. The hazard of death was fivefold in patients with symptomatic etiology versus cryptogenic etiology. The overall autopsy rate was 73%. Pneumonia was the most frequent cause of death (46%). All patients who died of pneumonia had symptomatic etiology. SUDEP occurred in 10 patients and was the most common epilepsy-related cause of death (10%). Conclusion: Risk of excess death of participants with infantile spams is not limited to early age but continues into adulthood, particularly in those with symptomatic etiology, and leads to death in half the cases at around 50 years of age. Measures should be directed to prevent pneumonia, the most common overall cause, and SUDEP, the most frequent seizure-related cause, of death.

Mortality and Cardiovascular Disease in Type 1 and Type 2 Diabetes

BackgroundLong-term trends in excess risk of death and cardiovascular outcomes have not been extensively studied in persons with type 1 diabetes or type 2 diabetes.MethodsWe included patients registered in the Swedish National Diabetes Register from 1998 through 2012 and followed them through 2014. Trends in deaths and cardiovascular events were estimated with Cox regression and standardized incidence rates. For each patient, controls who were matched for age, sex, and county were randomly selected from the general population.ResultsAmong patients with type 1 diabetes, absolute changes during the study period in the incidence rates of sentinel outcomes per 10,000 person-years were as follows: death from any cause, −31.4 (95% confidence interval [CI], −56.1 to −6.7); death from cardiovascular disease, −26.0 (95% CI, −42.6 to −9.4); death from coronary heart disease, −21.7 (95% CI, −37.1 to −6.4); and hospitalization for cardiovascular disease, −45.7 (95% CI, −71.4 to −20.1). Absolute changes per 10,000 person-years among patients with type 2 diabetes were as follows: death from any cause, −69.6 (95% CI, −95.9 to −43.2); death from cardiovascular disease, −110.0 (95% CI, −128.9 to −91.1); death from coronary heart disease, −91.9 (95% CI, −108.9 to −75.0); and hospitalization for cardiovascular disease, −203.6 (95% CI, −230.9 to −176.3). Patients with type 1 diabetes had roughly 40% greater reduction in cardiovascular outcomes than controls, and patients with type 2 diabetes had roughly 20% greater reduction than controls. Reductions in fatal outcomes were similar in patients with type 1 diabetes and controls, whereas patients with type 2 diabetes had smaller reductions in fatal outcomes than controls.ConclusionsIn Sweden from 1998 through 2014, mortality and the incidence of cardiovascular outcomes declined substantially among persons with diabetes, although fatal outcomes declined less among those with type 2 diabetes than among controls. (Funded by the Swedish Association of Local Authorities and Regions and others.)

Hepatitis C Virus in Peripheral Mononuclear Cells in Patients on Regular Hemodialysis

Background: Occult hepatitis C virus infection (OCI) was identified as Hepatitis C virus (HCV), characterized by undetectable HCV antibodies and HCV RNA in serum, while HCV RNA is detectable in liver and peripheral blood mononuclear cells (PBMCs) only. Nosocomial transmission in dialysis units maintains a higher prevalence of hepatitis C virus (HCV) infection in patients on maintenance dialysis than in the general population. HCV infection has a detrimental effect on survival in patients on maintenance dialysis and after renal transplantation. The excess risk for death in HCV-positive patients was partially attributed to chronic liver disease with its attendant complications, particularly hepatocellular carcinoma and liver cirrhosis(1). The aim of this study: was to evaluate the hidden infection of hepatitis C virus among regular hemodialysis patients in Bab Al Sharia University Hospital with negative ELISA and PCR by using PCR in mononuclear cells as a marker in the serum of these patients Patients and methods:in this prospective study, 60 patients with end-stage renal disease on regular hemodialysis(for at least 6 months duration)were included. For all patients thorough medical history, clinical examination, kidney function tests, liver function tests, complete blood count, pelvi-abdominal ultrasound, HCVantibodies, hepatitis C viral RNA, quantitative, HbsAg,. HCV PCR done for all patients in serum and mononuclear cells.. Patients with acute or chronic HCV infection as marked by positive hepatitis C antibody,acute or chronic HBV infections marked by hepatitis B surface antigen,other causes of liver dysfunction ( e.g., primary biliary cirrhosis, autoimmune hepatitis, HIV infection) and patient on anti HCV treatment.were excluded. Results: showed detection of HCV-PCR in PBMCs in the absence of HCV-PCR in plasma; was found in three of the 60 patients (3.3%). All patients had negative HIV, HBsAg, HCV Ab and serum HCV PCR. Conclusion: it could be concluded that testing for HCV-RNA in PBMCs is more reliable than hepatitis serological markers in identifying patients with an OCI when a liver biopsy is not available.

Prognostic Value of Soluble ST2 After Myocardial Infarction: A Community Perspective

BackgroundSoluble ST2 (sST2) is a marker of cardiac mechanical strain hypothesized to adversely impact short-term prognosis after myocardial infarction. We examined the association of sST2 with longer-term outcomes after myocardial infarction in a geographically defined community. MethodsOlmsted County, Minnesota residents who experienced an incident (first-ever) myocardial infarction between November 1, 2002 and December 31, 2012 were prospectively enrolled; sST2 levels were measured. Patients were followed for heart failure and death. ResultsWe studied 1401 patients with incident myocardial infarction (mean age 67 years; 61% men; 79% non-ST-elevation myocardial infarction). Median sST2 (ng/mL) was 48.7 (25th-75th percentile 32.5-103.3). Soluble ST2 was elevated in 51% of patients. Higher values of sST2 were associated with increased age, female sex, and comorbidities. During 5 years of follow-up, 388 persons died and 360 developed heart failure. After adjustment for age, sex, comorbidities, Killip class, and troponin T, the hazard ratios for death were 1.73 (95% confidence interval [CI], 1.22-2.45) and 3.57 (95% CI, 2.57-4.96) for sST2 tertiles 2 and 3, respectively (Ptrend <.001). For heart failure, the hazard ratios were 1.67 (95% CI, 1.18-2.37) and 2.88 (95% CI, 2.05-4.05), respectively (Ptrend <.001). Results were similar among 30-day survivors. ConclusionsIn the community, sST2 elevation is present in half of myocardial infarctions. Higher values of sST2 are associated with a large excess risk of death and heart failure independently of other prognostic indicators. Measurement of sST2 should be considered for risk stratification after myocardial infarction.

All-Cause and Cause-Specific Mortality in Patients with Psoriasis in Taiwan: A Nationwide Population-Based Study

Asian population-based data evaluating all-cause mortality and cause-specific mortality in patients with psoriasis are limited. This study aimed to evaluate the risk of all-cause mortality (stratified according to onset status, disease severity, and concomitant psoriatic arthritis) and cause-specific mortality in patients with psoriasis. Our study cohort consisted of 80,167 patients with newly diagnosed psoriasis between 2001 and 2012 in the National Health Insurance Database. Vital status and cause of death were ascertained from the National Death Registry of Taiwan. All-cause and cause-specific crude mortality rates and standardized mortality ratios were estimated. A total of 7,198 deaths were identified during the follow-up period (508,505 person-years). The standardized mortality ratios were 1.53 for severe psoriasis (95% confidence interval= 1.45-1.60), 1.47 for early-onset psoriasis (95% confidence interval= 1.34-1.61), and 1.47 for patients with psoriatic arthritis (95% confidence interval= 1.36-1.58). In the cause-specific mortality analysis, the absolute and excess risks of death were highest for malignancies (3.6 and 1.57 deaths per 1,000 patient-years, respectively) and circulatory system diseases (3.0 and 1.44 deaths per 1,000 patient-years, respectively). Patients with severe psoriasis, early-onset psoriasis, and psoriatic arthritis had higher all-cause mortality risks. In particular, patients with psoriasis had higher excess risks of mortality from malignancies and circulatory system diseases.

Antipsychotic Drug Interactions and Mortality Among Nursing Home Residents With Cognitive Impairment.

Among elderly individuals with dementia, the use of antipsychotics has been associated with serious adverse events including ischemic stroke and death. Multiple medications can interact with antipsychotics and increase the risk of such adverse events. The purpose of this retrospective, longitudinal cohort study was to estimate the prevalence of potential antipsychotic drug interactions and their effect on increasing the risk of death among cognitively impaired elderly individuals treated with antipsychotics. We conducted a retrospective longitudinal cohort study in 59 nursing homes of 7 European Union countries and Israel. The study was conducted during the years 2009 to 2011. Participants were cognitively impaired individuals aged 65 years or older residing in the participating nursing homes and being treated with antipsychotics (N = 604). Risk of death associated with potential antipsychotic drug interactions was the main outcome. The inter-Resident Assessment Instrument for Long Term Care Facilities (interRAI LTCF) was used to assess participants. Follow-up time was 12 months. The prevalence of potential antipsychotic drug interactions was 46.0%. Antipsychotic drug interactions were associated with higher mortality (incidence rate of 0.26 per person-year in the antipsychotic drug-interaction group versus 0.17 per person year in the no antipsychotic drug-interaction group). After adjusting for potential confounders, risk of death was higher in the group of residents with potential antipsychotic drug interactions relative to those unexposed to such interactions (hazard ratio = 1.71; 95% CI, 1.15-2.54). Part of the observed excess risk of death associated with the use of antipsychotic medications in elderly individuals with cognitive impairment may be attributable to antipsychotic drug interactions. Antipsychotics should be used with extreme caution especially among those individuals receiving concomitant cardiovascular or psychotropic medications.

Heart Failure in Late Pregnancy and Postpartum: Incidence and Long-Term Mortality in Sweden From 1997 to 2010

BackgroundHeart failure (HF) in late pregnancy and postpartum (HFPP), of which peripartum cardiomyopathy (PPCM) constitutes the larger part, is still a rare occurrence in Sweden. Population-based data are scarce. Our aim was to characterize HFPP and determine the incidence and mortality in a Swedish cohort. Methods and ResultsThrough merging data from the National Inpatient, Cause of Death, and Medical Birth Registries, we identified ICD-10 codes for HF and cardiomyopathy within 3 months before delivery to 6 months postpartum. Each case was assigned 5 age-matched control subjects from the Medical Birth Registry. From 1997 to 2010, 241 unique HFPP case subjects and 1063 matched control subjects were identified. Mean incidence was 1 in 5719 deliveries. HFPP was strongly associated with preeclampsia (odds ratio [OR] 11.91, 95% confidence interval [CI] 7.86–18.06), obesity (OR 2.5, 95% CI 1.7–3.7), low- and middle-income country (LMIC) of origin (OR 1.73, 95% CI 1.14–2.63), and twin deliveries (OR 4.39 CI 95% 2.24–8.58). By the end of the study period deaths among cases were >35-fold those of controls: 9 cases (3.7 %) and 1 control (0.1 %; P < .0001). Among control subjects, 17.9% of mortalities occurred within 3 years, of diagnosis compared with 100% among cases. ConclusionsThe mean incidence and mortality among women with HFPP in Sweden from 1997 to 2010 was low but carried a marked excess risk of death compared with control subjects and was strongly linked to preeclampsia, obesity, multifetal births, and LMIC origin of the mother.

Does exposure to opioid substitution treatment at prison release reduce the risk of death? A prospective, observational study in England

BackgroundOpioid use disorders are common in the prison population. Prisoners face an acute risk of death in the first 4 weeks after release. We tested whether prison-based opioid substitution treatment (OST) reduces post-release mortality. MethodsThis was a national prospective cohort study of adult prisoners with opioid use disorders recruited from 39 prisons (and transferred to and released from 123 prisons) in England during 2010–16 linked to Prison Health, Justice Statistics Analytical Services, Office for National Statistics, and National Drug Treatment Monitoring System. We assessed the association between OST exposure at prison release and all-cause mortality using Cox proportional hazards models adjusted for demographic and behavioural confounders and community treatment. FindingsWe created a risk set of 15 141 incarcerations (12 260 individuals) with opioid use disorders (8645 exposed to OST on release, 6496 unexposed). 401 individuals died during the observation period (160 in the first year, 24 in the first month). The mortality risk in the OST-exposed group was lower than in the unexposed group in the first 4 weeks (0·93 per 100 person-years [95% CI 0·4–2·1] vs 3·67 [2·3–5·8]; unadjusted hazard ratio [HR] 0·25, 95% CI 0·10–0·64). Mortality risk did not differ from 4 weeks to 4 months (HR 1·07, 95% CI 0·57–2·00) or from 4 months to 1 year (0·97, 0·65–1·45). OST-exposed prisoners were more likely than the non-exposed group to enter community treatment (odds ratio 2·47, 95% CI 2·3–2·65). The protective effect of OST exposure was not attenuated after adjustment for demographic or behavioural confounders or for community drug treatment (adjusted HR 0·27, 95% CI 0·11–0·71). There was no evidence of an interaction between OST exposure on prison release and community treatment (ratio of HRs 0·99, 95% CI 0·12–8·11; p for likelihood ratio test=0·99). InterpretationOST at prison release lowered risk of mortality in the first month by 75% (removing the excess risk of death in people with an opioid use disorder leaving prison compared with risk of death in the community after 4 weeks) and increased the likelihood of entering drug treatment in the community. FundingDepartment of Health, NHS England, Public Health England.

Cause-Specific Mortality Trends Following Total Hip and Knee Arthroplasty

BackgroundWhile studies have demonstrated that mortality after total hip (THA) and total knee (TKA) arthroplasty is better than the general population, the causes of death are not well established. We evaluated cause-specific mortality after THA and TKA. MethodsThe study included population-based cohorts of patients who underwent THA (N = 2019) and TKA (N = 2259) between 1969 and 2008. Causes of death were classified using the International Classification of Diseases 9th and 10th editions. Cause-specific standardized mortality ratios (SMR) and 95% confidence intervals (CI) were calculated by comparing observed and expected mortality. Expected mortality was derived from mortality rates in the United States white population of similar calendar year, age, and sex characteristics. ResultsAll-cause mortality was lower than expected following both THA and TKA. However, there was excess mortality due to mental diseases such as dementia following both THA (SMR 1.40, 95% CI 1.08, 1.80) and TKA (SMR 1.49, 95% CI 1.19, 1.85). There was also excess mortality from inflammatory musculoskeletal diseases in THA (SMR 3.50, 95% CI 2.11, 5.46) and TKA (SMR 4.85, 95% CI 3.29, 6.88). When the cohorts were restricted to patients with osteoarthritis as the surgical indication, the excess risk of death from mental diseases still persisted in THA (SMR 1.36, 95% CI 1.02, 1.78) and TKA (SMR 1.52, 95% CI 1.20, 1.91). ConclusionTHA and TKA patients experience a higher risk of death from mental and inflammatory musculoskeletal diseases. These findings warrant further research to identify drivers of mortality and prevention strategies in arthroplasty patients.

The risk of late or advanced presentation of HIV infected patients is still high, associated factors evolve but impact on overall mortality is vanishing over calendar years: results from the Italian MASTER Cohort.

BackgroundWe aimed at evaluating frequency and factors associated with late presentation and advanced HIV disease and excess risk of death due to these conditions from 1985 to 2013 among naïve HIV infected patients enrolled in the Italian MASTER Cohort.MethodsAll antiretroviral naive adults with available CD4+ T cell count after diagnosis of HIV infection were included. Multivariable logistic regression analysis investigated factors associated either with late presentation or advanced HIV disease. Probabilities of survival were estimated both at year-1 and at year-5 according to the Kaplan-Meier method. Flexible parametric models were used to evaluate changes in risk of death overtime according to late presentation and advanced HIV disease. The analyses were stratified for calendar periods.Results19,391 patients were included (54 % were late presenters and 37.6 % were advanced presenters). At multivariable analysis, the following factors were positively associated with late presentation: male gender (OR = 1.29), older age (≥55 years vs. <25 years; OR = 7.45), migration (OR = 1.54), and heterosexual risk factor for HIV acquisition (OR = 1.52) or IDU (OR = 1.27) compared to homosexual risk. Survival rates at year-5 increased steadily and reached 92.1 % for late presenters vs. 97.4 % for non-late presenters enrolled in the period 2004–2009. Using flexible parametric models we found a sustained reduction of hazard ratios over time for any cause deaths between late and non-late presenters over time. Similar results were found for advanced HIV disease.ConclusionScreening polices need to be urgently implemented, particularly in most-at-risk categories for late presentation, such as migrants, older patients and those with heterosexual intercourse or IDU as risk factors for HIV acquisition. Although in recent years the impact of late presentation on survival decreased, about 10 % of patients diagnosed in more recent years remains at increased risk of death over a long-term follow-up.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3477-z) contains supplementary material, which is available to authorized users.

Long-term mortality of patients with West syndrome.

SummaryObjectiveTo study long‐term survival and mortality among patients with West syndrome.MethodsThe study population included all children born in 1960–1976 and treated for West syndrome in three tertiary care hospitals in Helsinki, Finland. The participants were prospectively followed for five decades for survival. Death data were derived from the National Causes of Death Register of the Population Register Center of Statistics Finland.ResultsDuring follow‐up, 102 (49%) of 207 patients had died at the mean age of 19 years. The mean overall annual mortality rate was 15.3 per 1,000 patient‐years. The rates ranged from 18.2 per 1,000 after 10 years to 17.2 per 1,000 after 20 years and 15.4 per 1,000 patient‐years after 40 years of follow‐up. One fourth (25%) had died by 17.2 (95% CI 11.8–22.7) years and 50% by 48.6 (95% CI 38.5–NA) years of follow‐up. Etiology at onset was symptomatic in 87% patients and cryptogenic in 13%; 6 of the latter 26 patients later turned out to be symptomatic. The mean annual mortality rate was 3.7 per 1,000 for 4 patients with cryptogenic etiology and 17.6 per 1,000 for those with symptomatic etiology. The hazard of death was fivefold in patients with symptomatic etiology versus cryptogenic etiology. The overall autopsy rate was 73%. Pneumonia was the most frequent cause of death (46%). All patients who died of pneumonia had symptomatic etiology. SUDEP occurred in 10 patients and was the most common epilepsy‐related cause of death (10%).SignificanceRisk of excess death of participants with West syndrome is not limited to early age but continues into adulthood, particularly in those with symptomatic etiology, and leads to death in half the cases at around 50 years of age. Measures should be directed to prevent pneumonia, the most common overall cause, and SUDEP, the most frequent seizure‐related cause, of death.

Chronic kidney disease and the risk of cancer: an individual patient data meta-analysis of 32,057 participants from six prospective studies.

BackgroundChronic kidney disease (CKD) is an established risk factor for cardiovascular disease but the relevance of reduced kidney function to cancer risk is uncertain.MethodsIndividual patient data were collected from six studies (32,057 participants); including one population-based cohort and five randomized controlled trials. Participants were grouped into one of five CKD categories (estimated glomerular filtration rate [eGFR] ≥75 mL/min/1.73 m2; eGFR ≥60 to <75 mL/min/1.73 m2; eGFR ≥45 to <60 mL/min/1.73 m2; eGFR <45 mL/min/1.73 m2; on dialysis). Stratified Cox regression was used to assess the impact of CKD category on cancer incidence and cancer death.ResultsOver a follow-up period of 170,000 person-years (mean follow-up among survivors 5.6 years), 2626 participants developed cancer and 1095 participants died from cancer. Overall, there was no significant association between CKD category and cancer incidence or death. As compared with the reference group with eGFR ≥75 mL/min/1.73 m2, adjusted hazard ratio (HR) estimates for each category of renal function, in descending order, were: 0.98 (95 % CI 0.87–1.10), 0.99 (0.88–1.13), 1.01 (0.84–1.22) and 1.24 (0.97–1.58) for cancer incidence, and 1.03 (95 % CI 0.86–1.24), 0.95 (0.78–1.16), 1.00 (0.76–1.33), and 1.58 (1.09–2.30) for cancer mortality. Among dialysis patients, there was an excess risk of cancers of the urinary tract (adjusted HR: 2.34; 95 % CI 1.10–4.98) and endocrine cancers (11.65; 95 % CI: 1.30–104.12), and an excess risk of death from digestive tract cancers (2.11; 95 % CI: 1.13–3.99), but a reduced risk of prostate cancers (0.38; 95 % CI: 0.18–0.83).ConclusionsWhilst no association between reduced renal function and the overall risk of cancer was observed, there was evidence among dialysis patients that the risk of cancer was increased (urinary tract, endocrine and digestive tract) or decreased (prostate) at specific sites. Larger studies are needed to characterise these site-specific associations and to identify their pathogenesis.Electronic supplementary materialThe online version of this article (doi:10.1186/s12885-016-2532-6) contains supplementary material, which is available to authorized users.