Overall Risk Of Death Research Articles

Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants.

Most premature infants are not sufficiently mature physiologically to take all of their required water and nutrients orally, and so they cannot regulate their own water intake. Thus, the caregiver must determine the amount of water to be given each day to such infants. The objective of this review is to examine the effects of water intake on postnatal weight loss and on the risks of dehydration, patent ductus arteriosus, necrotizing enterocolitis, bronchopulmonary dysplasia, intracranial hemorrhage, and death in premature infants. Randomized clinical trials were sought that compared the outcomes of interest in groups of premature infants who were given different levels of water intake according to experimental protocol. Such trials were sought in a previous review by one of the authors (Bell EF. Fluid therapy. In: Effective Care of the Newborn Infant, eds JC Sinclair, MB Bracken. Oxford: Oxford University Press, 1992: 59-72, approximately approximately Bell 1992 approximately approximately ), in a list of trials provided by the Cochrane Neonatal Review Group, and in the authors' personal files. Only randomized clinical trials of varying water intake in premature infants are included. The review was limited to trials that included infants whose water intake was provided mainly or entirely by parenteral means. Studies were included regardless of outcomes examined. Trials were selected by two reviewers, who also assessed the methodological quality of each trial. Data were independently extracted by the reviewers, and differences were reconciled. The data were then entered into tables using RevMan 3.1 for Windows. The adverse event rates were calculated for the restricted and liberal water intake groups for each dichotomous outcome, and the relative risk was computed. In addition, the maximal weight loss results were recorded, and the weighted mean difference was computed. The analyses (including calculation of relative risk, risk difference, and weighted mean difference) and tests of heterogeneity were accomplished with MetaView 3.1 software and a fixed effects model. No subgroup analyses were conducted. The analysis of the four studies taken together indicates that restricted water intake significantly increases postnatal weight loss and significantly reduces the risks of patent ductus arteriosus, necrotizing enterocolitis, and death. With restricted water intake, there are trends toward increased risk of dehydration and reduced risk of bronchopulmonary dysplasia, but these trends are not statistically significant. Based on this analysis, the most prudent prescription for water intake to premature infants would seem to be careful restriction of water intake so that physiological needs are met without allowing significant dehydration. This practice could be expected to decrease the risks of patent ductus arteriosus and necrotizing enterocolitis--and perhaps the overall risk of death--without significantly increased risk of adverse consequences.

Cardiovascular fitness as a predictor of mortality in men.

To examine the relations of cardiorespiratory fitness, as measured by maximal oxygen uptake and exercise test duration at the initiation of the study, with overall, cardiovascular disease (CVD)-related, and non-CVD-related mortality. A population-based cohort study of 1294 men with no CVD, pulmonary disease, or cancer at baseline in Kuopio and surrounding communities in eastern Finland. During an average follow-up of 10.7 years, there were 124 overall, 42 CVD-related, and 82 non-CVD-related deaths. The relative risk of overall death in unfit men (maximal oxygen uptake <27.6 mL/kg per minute) was 2.76 (95% confidence interval, 1.43-5.33) (P =.002), and the relative risk of CVD-related death was 3.09 (95% confidence interval, 1.10-9.56) (P =.05), compared with fit men (maximal oxygen uptake >37.1 mL/kg per minute) after adjusting for age, examination years, smoking, and alcohol consumption. The relative risk of non-CVD-related death in unfit men was almost the same magnitude as for overall death. Furthermore, adjustment for serum lipid levels, blood pressure, plasma fibrinogen level, diabetes, and fasting serum insulin level did not weaken these associations significantly. Exercise test duration also had a strong inverse relation to overall, CVD-related, and non-CVD-related mortality. Poor cardiorespiratory fitness was comparable with elevated systolic blood pressure, smoking, obesity, and diabetes in importance as a risk factor for mortality. Cardiorespiratory fitness had a strong, graded, inverse association with overall, CVD-related, and non-CVD-related mortality. Maximal oxygen uptake and exercise test duration represent the strongest predictors of mortality.

Child mortality in Stockholm during 1885-1910: the impact of household size and number of children in the family on the risk of death from measles.

Previous studies have associated overcrowding at the household level with increased mortality, especially from airborne diseases. This association may be confounded by associations with adverse socioeconomic conditions or low age at infection. This study investigated the effect of crowding on the risk of measles death. Individual entries in a population-based register and on death certificates for children aged 0-15 years living in one parish in Stockholm in 1885, 1891, and 1910 (n = 36,718) were used to analyze cause-specific and overall death rates in relation to household size and the number of children in the household, using Cox regression analysis. Bivariate analysis identified significant relations between crowding and the cause-specific risk of death, which were subsequently tested while controlling for other known risk factors for childhood death. Significant negative associations between crowding and the risk of death from pneumonia and bronchitis disappeared when controlling for other risk factors. A negative association between the risk of overall death and large household size became significantly positive when controlling for other risk factors. The increased risk of death from measles associated with proxies for crowding remained after controlling for other risk factors. In conclusion, crowding may have a statistically independent effect on the risk of death from measles.

Use of a historical register in social epidemiology: child mortality in Stockholm at the turn of the 19th century.

This study describes the age- and cause-specific levels and social determinants of high child mortality in Stockholm around the turn of the century. The study is based on computerized individual level sociodemographic information and the death certificates of children aged 0-15 years residing in Maria parish in Stockholm during the years 1885, 1891 and 1910 (n = 36,718) from a historical register (the Roteman archives). The usefulness of such data for further studies in social epidemiology is discussed. Age-specific rates and major causes of death compared well with other studies. Low social class and being born out of wedlock increased the overall risk of death in early childhood. Data appear valid and may be useful in social epidemiology. Further analyses of data from the Roteman archives may contribute to the understanding of causes behind high levels of cause- specific child mortality and trends in mortality in relation to societal change.

Alcohol consumption and mortality among middle-aged and elderly U.S. adults.

Alcohol consumption has both adverse and beneficial effects on survival. We examined the balance of these in a large prospective study of mortality among U.S. adults. Of 490,000 men and women (mean age, 56 years; range, 30 to 104) who reported their alcohol and tobacco use in 1982, 46,000 died during nine years of follow-up. We compared cause-specific and rates of death from all causes across categories of base-line alcohol consumption, adjusting for other risk factors, and related drinking and smoking habits to the cumulative probability of dying between the ages of 35 and 69 years. Causes of death associated with drinking were cirrhosis and alcoholism; cancers of the mouth, esophagus, pharynx, larynx, and liver combined; breast cancer in women; and injuries and other external causes in men. The mortality from breast cancer was 30 percent higher among women reporting at least one drink daily than among nondrinkers (relative risk, 1.3; 95 percent confidence interval, 1.1 to 1.6). The rates of death from all cardiovascular diseases were 30 to 40 percent lower among men (relative risk, 0.7; 95 percent confidence interval, 0.7 to 0.8) and women (relative risk, 0.6; 95 percent confidence interval, 0.6 to 0.7) reporting at least one drink daily than among nondrinkers, with little relation to the level of consumption. The overall death rates were lowest among men and women reporting about one drink daily. Mortality from all causes increased with heavier drinking, particularly among adults under age 60 with lower risk of cardiovascular disease. Alcohol consumption was associated with a small reduction in the overall risk of death in middle age (ages 35 to 69), whereas smoking approximately doubled this risk. In this middle-aged and elderly population, moderate alcohol consumption slightly reduced overall mortality. The benefit depended in part on age and background cardiovascular risk and was far smaller than the large increase in risk produced by tobacco.

Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population.

Intermittent claudication is associated with a poor prognosis, but less is known of the risks associated with asymptomatic peripheral arterial disease. The aims of this study were to determine the incidence and natural history of claudication, and the incidence of cardiovascular events in symptomatic and asymptomatic peripheral arterial disease. In 1988, 1592 subjects aged 55-74 years were selected randomly from the age-sex register of 10 general practices in Edinburgh, Scotland. The presence of peripheral arterial disease was determined by the World Health Organization questionnaire on intermittent claudication, the ankle brachial pressure index and a reactive hyperaemia test. This cohort was followed prospectively over 5 years for subsequent cardiovascular events and death. One hundred and sixteen new cases of claudication were identified (incidence density 15.5 per 1000 person-years). Of those with claudication at baseline, 28.8% and still had pain after 5 years, 8.2% underwent vascular surgery or amputation, and 1.4% developed leg ulceration. Claudicants had a significantly increased risk of developing angina compared with normals (RR: 2.31, 95% CI: 1.04-5.10), and asymptomatic subjects had a slightly increased risk of myocardial infarction and stroke. Deaths from cardiovascular disease were more likely in both claudicants (RR: 2.67, 95% CI: 1.34-5.29) and subjects with major (RR: 2.08, 95% CI: 1.13-3.83) or minor asymptomatic disease (RR: 1.74, 95% CI: 1.09-2.76). Subjects with major asymptomatic disease also had an increased risk of non-cardiovascular death (RR: 2.19, 95% CI: 1.33-3.59), and therefore had the highest overall risk of death (RR: 2.44, 95% CI: 1.59-3.74). Subjects with asymptomatic peripheral arterial disease appear to have the same increased risk of cardiovascular events and death found in claudicants.

Prevalence of Parkinsonian Signs and Associated Mortality in a Community Population of Older People

Older people frequently have signs of parkinsonism, but information about the prevalence of parkinsonism and mortality among those with the condition in the community is limited. A stratified random sample of 467 residents of East Boston, Massachusetts, 65 years of age or older, were given structured neurologic examinations. Using uniform, specified combinations of parkinsonian signs, we estimated the prevalence of four categories of signs--bradykinesia, gait disturbance, rigidity, and tremor--and of parkinsonism, defined as the presence of two or more categories. We did not study Parkinson's disease because it could not be distinguished from other conditions that can cause parkinsonism. Proportional-hazards models were used to compare the risk of death among people with and those without parkinsonism. One hundred fifty-nine persons had parkinsonism, 301 did not, and 7 could not be classified. The overall prevalence estimates were 14.9 percent for people 65 to 74 years of age, 29.5 percent for those 75 to 84, and 52.4 percent for those 85 and older. With a mean follow-up period of 9.2 years, 124 persons with parkinsonism (78 percent) and 146 persons without (49 percent) died. Adjusted for age and sex, the overall risk of death among people with parkinsonism was 2.0 (95 percent confidence interval, 1.6 to 2.6) times that among people without. Among people with parkinsonism, the presence of gait disturbance was associated with an increased risk of death. Parkinsonism is very common among people over the age of 65, and its prevalence increases markedly with age. Parkinsonism is associated with a twofold increase in the risk of death, which is strongly related to the presence of a gait disturbance.

A meta-analysis of randomized trials comparing coronary artery bypass grafting with percutaneous transluminal coronary angioplasty in multivessel coronary artery disease

We performed a meta-analysis of randomized trials that compared percutaneous transluminal coronary angioplasty (PTCA) with coronary artery bypass graft (CABG) surgery in patients with multivessel coronary artery disease. The outcomes of death, combined death, and nonfatal myocardial infarction (MI), repeat revascularization, and freedom from angina were analyzed. The overall risk of death and nonfatal MI was not different over a follow-up of 1 to 3 years (CABG: PTCA odds ratio [OR] 1.03, 95% confidence interval 0.81 to 1.32, p = 0.81). Patients randomized to CABG tended to have a higher risk of death or MI in the early, periprocedural period (OR 1.33, p = 0.091), but a lower risk in subsequent follow-up (OR 0.74, p = 0.093). CABG patients were much less likely to undergo another revascularization procedure (p < 0.00001), and were more likely to be angina free (OR 1.57, p < 0.00001). Thus, CABG and PTCA patients have similar overall risks of death and nonfatal MI at 1 to 3 years of follow-up, but relative risk differences in mortality of up to 25% cannot be excluded. CABG patients have significantly less angina and less repeat revascularization than PTCA patients.

982-68 Outcome Following Stress Testing: Are There Any Gender Related Differences? A Population Based Study

Gender differences in management after stress tests have been documented, possibly reflecting gender bias. Whether these differences impact on long-term outcome is not known but is critical to assess appropriateness of care. We conducted a retrospective population based cohort study of 604 persons (413 men, 191 women) who had a first stress test in 1987 in Olmsted County MN with complete follow up until 1994 or death. At study entry, women were older(55 ± 17 years oldvs 48 ± 14years old for men) and more likely to have typical angine (38% vs 29% of men), hypertension (37% vs 30% of men), a family history of coronary artery disease (72% vs 59% of men), and a positive stress test (19% vs 12% of men) (p &lt; 0.05). The frequency and relative risks (RR) of cardiac event (myocardial infarction, congestive heart failure cardiac death) with and without inclusion of revascularization (revasc) and overall death were: Women Men RR 95% CI Cardiac event 14(7%) 36(9%) 0.8 0.4 to 1.5 Cardiac event incl revasc 18(9%) 66(16%) 0.5 0.3 to 0.9 Overall death 16(8%) 19(5%) 1.7 0.9 to 3.4 After adjusting for history of myocardial infarction, symptoms, age, stress test results and comorbidity, no gender difference in risk of death was seen. Women with a negative stress test were at a lower risk of cardiac event (RR 0.4, 95% CI 0.16 to 1.0); when revascularization was included as cardiac event, the relative risk was lower in women than in men (RR 0.4, 95% CI 0.2 to 0.6). These population based data suggest that there is no excess risk of overall death, cardiac death or myocardial infarction in women. The risk of cardiac event including revascularization, however, was lower in women: this may represent underutilization of revascularization in women or overutilization in men.

Serum cholesterol in young men and subsequent cardiovascular disease.

The increased risk of cardiovascular disease associated with higher serum cholesterol levels in middle-aged persons has been clearly established, but there have been few opportunities to examine a potential link between serum cholesterol levels measured in young men and clinically evident premature cardiovascular disease later in life. We performed a prospective study of 1017 young men (mean age, 22 years) followed for 27 to 42 years to quantify the risk of cardiovascular disease and total mortality associated with serum cholesterol levels during early adult life. The mean serum cholesterol level at entry was 192 mg per deciliter (5.0 mmol per liter). During a median follow-up of 30.5 years, there were 125 cardiovascular-disease events, 97 of which were due to coronary heart disease. The serum cholesterol level at base line was strongly associated with the incidence of events related to coronary heart disease and cardiovascular disease, as well as to total mortality and mortality due to cardiovascular disease. The risks were similar whether the events occurred before or after the age of 50. In a proportional-hazards analysis adjusted for age, body-mass index (the weight in kilograms divided by the square of the height in meters), the level of physical activity, coffee intake, change in smoking status, and the incidence of diabetes and hypertension during follow-up, a difference in the serum cholesterol level at base line of 36 mg per deciliter (0.9 mmol per liter)--the difference between the 25th and 75th percentiles of cholesterol level in the study population at base line--was associated with an increased risk of cardiovascular disease (relative risk, 1.72; 95 percent confidence interval, 1.39 to 2.14), coronary heart disease (relative risk, 2.01; 95 percent confidence interval, 1.59 to 2.53), and mortality due to cardiovascular disease (relative risk, 2.02; 95 percent confidence interval, 1.23 to 3.32). A difference in the base-line serum cholesterol level of 36 mg per deciliter was significantly associated with an increased risk of death before the age of 50 (relative risk, 1.64; 95 percent confidence interval, 1.03 to 2.61), but not with the overall risk of death (relative risk, 1.21; 95 percent confidence interval, 0.93 to 1.58). These findings indicate a strong association between the serum cholesterol level measured early in adult life in men and cardiovascular disease in midlife.

Debulking and intervention surgery

Summary Background Cytoreductive surgery is generally regarded as integral to the management of patients with advanced ovarian cancer, although definitive conclusions about its role have been plagued by the lack of randomized, prospective studies. With the availability of new information, the current status of cytoreductive surgery for epithelial ovarian cancer is reviewed. Materials and methods Available literature was reviewed, including some data currently published in abstract form only. Results Several non-randomized studies of primary cyto-reduction have shown that optimal cytoreduction (usually defined as residual nodules ≼ 1 cm diameter) can be achieved in the majority of cases, with acceptably low morbidity. Chemoresistant tumours will not benefit from cytoreduction, but these cannot be identified preoperatively. A recent EORTC randomized phase III trial examined the role of intervention cytoreduction after 3 cycles of chemotherapy for patients with >1 cm residual disease following primary laparotomy. Patients with chemoresistant tumours, who progressed on therapy, were excluded from the study, while the remaining patients were randomized between intervention cytoreduction or 3 further cycles of chemotherapy. Seventy-five percent of patients were randomized. With follow-up data available on 278 patients, median progression-free interval and overall survival were prolonged by 5 and 6 months, respectively, in the surgical arm of the study (p = 0.01). The risk of progression and the overall risk of death were decreased by one third in patients in the surgical arm, and in the multivariate analysis, intervention surgery was an independent prognostic factor for progression-free and overall survival. Conclusions The EORTC study of intervention cyto-reduction is the first phase III trial ever completed to evaluate the role of cytoreductive surgery in advanced ovarian cancer. The conclusions clearly demonstrate the importance of adequate surgery in the management of such patients.

Fear of dying and HIV infection vs hepatitis B infection.

Accidental exposure to the blood of hepatitis B patients produced less fear than does accidental exposure today to the human immunodeficiency virus (HIV), even though both have an approximately equal overall risk of death (approximately 1%). Subjects responding to hypothetical insect-exposure and disease-exposure scenarios chose to avoid the HIV-type risk of 1% chance of exposure/100% chance of death. Fear of certain death seems to account for the greater concern about exposure to HIV than to Hepatitis B.

The Adjuvant Advantage

The Adjuvant Advantage

Distal spleno-renal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding: A meta-analysis of 4 randomized clinical trials

Meta-analysis was used to evaluate 4 clinical trials comparing distal spleno-renal shunt (DSRS) with endoscopic sclerotherapy (EVS) in the prevention of variceal rebleeding: the interval between bleeding and therapy ranges from <14 days to >100 days. A questionnaire was sent to each author of the published trials concerning methods, definitions and results of the trials in order to obtain more detailed and up-to-date information. The selected end-points for the meta-analysis were: rebleeding, mortality and chronic encephalopathy. Analysis of the results in the questionnaires was made using the method proposed by Collins. The pooled relative risk (i.e. the combined Odds ratio of each trial as an estimate of overall efficacy) of rebleeding was statistically reduced by DSRS (0.16; 95% confidence interval 0.10–0.27). Despite this, the overall risk of death following DSRS was only marginally decreased (0.78; 95% confidence interval 0.47–1.29); the lack of homogeneity in the results does not permit any significant conclusions on this end-point. However, in non-alcoholic patients, the decrease in risk of death was greater, and this without heterogeneity, following DSRS than EVS (0.59; 95% confidence interval 0.23–1.50). The overall risk of chronic encephalopathy was slightly increased after DSRS (1.86; 95% confidence interval 0.90–3.86). In conclusion, DSRS significantly reduced the risk of rebleeding compared to EVS without increasing the risk of chronic hepatic encephalopathy. However, DSRS did not significantly affect the overall death risk. Only in non-alcoholic disease did it seem to show an advantage over EVS.

Risk management in local communities

This article discusses the current state of risk-management practices in local communities in the United States and offers some alternatives to present policies, which are mainly implicit rather than explicit attempts to limit overall risks of death and injury due to technological and natural causes. The article is divided into three sections. The first discusses the concept of risk-management as presently used in local government. The second section results from a limited survey of local risk-managers. The third section offers some policy alternatives. While generalization is itself risky, all of our observations point toward the conclusion that local government officials have little understanding of, hence little concern for, the quantity of risk posed for citizens by various hazards. If it seems desirable to place risk-management decisions in the hands of local officials, then some capacity for risk quantification, hence comparison, must be developed. The bulk of the policy suggestions at the end of this article concerns possible means through which this capacity might be augmented.

Prospects for using implanted systems of assisted circulation and artificial heart with a radioisotope power source (biomedical, thermal, and radiation aspects).

The capacity of dogs to diffuse heat (up to 50 W) from an artificial heart and to tolerate prolonged intracorporeal ionizing radiation from a radioisotope power source (238Pu) was investigated, using electrical models of vascular blood heat exchangers that permit reproduction of elimination and heat transmission in autonomous systems. It was shown that up to 50 W can be discharged at temperatures of the wall-blood interface that do not exceed 43 degrees C. Clotting indexes, concentration of total protein, hemolysis, and serum enzyme activity during 1-1.5 months of heating remained within physiologically normal limits. A specific power load of up to 1.5 W/kg at ambient temperatures of 18-20 degrees C revealed no evidence of changes in heat production. By measuring the distribution of power of the dose absorbed around a 45-W plutonium source it was possible to estimate dose loads on critical organs and to assess overall risk of death from malignant tumors induced by radiation over a 10-year period: 6-12% for males and 8-14% for females. It is not very probable that use of the artificial heart with a radioisotope power source will be limited by thermal and radiational effects.

PREGNANCY COMPLICATIONS IN TYPE IV EHLERS-DANLOS SYNDROME

Type IV Ehlers-Danlos syndrome (EDS IV), unlike other forms of EDS, appears to be associated with a high incidence of pregnancy complications. In a group of fourteen families 20 women with EDS IV were identified. The diagnosis was confirmed in at least 1 member of each family by in-vitro measurement of type III collagen production by dermal fibroblasts, and all affected subjects produced lower levels of the protein than controls. Of the 20 women identified, 10 had been pregnant, and 5 had died from pregnancy-related complications. The overall risk of death in each pregnancy in this group was 25%. The complications of pregnancy included rupture of bowel, aorta, vena cava, or uterus, vaginal laceration; and post-partum uterine haemorrhage. The severity and frequency of the complications in this type of EDS warrant careful counselling before pregnancy and care of all pregnant patients in a high-risk facility.

7 - Postmenopausal Bleeding

Several non-invasive scoring systems have been developed to determine risk of advanced fibrosis in non-alcoholic fatty liver disease (NAFLD). We examined the association between 4 scoring systems and incident severe liver disease and overall mortality in a large cohort of patients with biopsy-proven NAFLD.We performed a retrospective analysis of data from 646 patients with biopsy-proven NAFLD, recruited from 2 hospitals in Sweden, from 1971 through 2009. The NAFLD fibrosis score (NFS), FIB-4, APRI, and BARD scores were calculated at the time of the liver biopsy. Based on each score, patients were assigned to categories of low, intermediate, or high risk for advanced fibrosis. Overall mortality and severe liver disease (cirrhosis, decompensated liver disease, liver failure, or hepatocellular carcinoma) were ascertained through linkage with national registers until the end of 2014. Cox regression, area under the receiver operating characteristic (AUROC) curve, and C-statistic analyses were used to study the predictive capacity of each scoring system.During a mean follow-up time of 19.9±8.7 years, there were 214 deaths and 76 cases of severe liver disease. For overall mortality, AUROC curve values were: NFS, 0.72 (95% CI, 0.68–0.76); FIB-4, 0.72 (95% CI, 0.68–0.76); BARD, 0.62 (95% CI, 0.58–0.66); and APRI, 0.52 (95% CI, 0.47–0.57). For severe liver disease, AUROC curve values were: NFS, 0.72 (95% CI, 0.66–0.78); FIB-4, 0.72 (95% CI, 0.66–0.79); BARD, 0.62 (95% CI, 0.55–0.69); APRI, 0.69 (95% CI, 0.63–0.76). C-statistics for all scores were of moderate capacity to predict outcomes.In a retrospective analysis of data from 646 patients with biopsy-proven NAFLD, we found the NFS and the FIB-4 scores to most accurately determine risk of overall death or severe liver disease. However, the AUROC values for these scoring systems are not high enough for use in the clinic; new systems are needed to determine prognoses of patients with NAFLD.