Relative Risk Of All-cause Mortality Research Articles

Clustering of risk factors for non-communicable disease and healthcare expenditure in employees with private health insurance presenting for health risk appraisal: a cross-sectional study

BackgroundThe global increase in the prevalence of NCD’s is accompanied by an increase in risk factors for these diseases such as insufficient physical activity and poor nutritional habits. The main aims of this research study were to determine the extent to which insufficient physical activity (PA) clustered with other risk factors for non-communicable disease (NCD) in employed persons undergoing health risk assessment, and whether these risk factors were associated with higher healthcare costs.MethodsEmployees from 68 companies voluntarily participated in worksite wellness days, that included an assessment of self-reported health behaviors and clinical measures, such as: blood pressure (BP), Body Mass Index (BMI), as well as total cholesterol concentrations from capillary blood samples. A risk-related age, ‘Vitality Risk Age’ was calculated for each participant using an algorithm that incorporated multiplicative pooled relative risks for all cause mortality associated with smoking, PA, fruit and vegetable intake, BMI, BP and cholesterol concentration. Healthcare cost data were obtained for employees (n = 2 789).ResultsParticipants were 36 ± 10 years old and the most prevalent risk factors were insufficient PA (67%) and BMI ≥ 25 (62%). Employees who were insufficiently active also had a greater number of other NCD risk factors, compared to those meeting PA recommendations (chi2 = 43.55; p < 0.0001). Moreover, employees meeting PA guidelines had significantly fewer visits to their family doctor (GP) (2.5 versus 3.11; p < 0.001) than those who were insufficiently PA, which was associated with an average cost saving of ZAR100 per year (p < 0.01). Furthermore, for every additional year that the ‘Vitality Risk Age’ was greater than chronological age, there was a 3% increased likelihood of at least one additional visit to the doctor (OR = 1.03; 95% CI = 1.01 – 1.05).ConclusionPhysical inactivity was associated with clustering of risk factors for NCD in SA employees. Employees with lower BMI, better self-reported health status and readiness to change were more likely to meet the PA guidelines. These employees might therefore benefit from physical activity intervention programs that could result in improved risk profile and reduced healthcare expenditure.

Indirect Comparison Of Dabigatran, Rivaroxaban and Apixaban For Venous Thromboembolic Disease

BackgroundThree target-specific oral anticoagulants (TSOA's) have been recently compared to standard therapy with a vitamin K antagonist (VKA) for the treatment of acute venous thromboembolism (VTE). Dabigatran (D) is a direct thrombin inhibitor, while rivaroxaban (R) and apixaban (A) block activated coagulation factor X. Those agents have not been compared head-to-head and minimal data exist to guide the choice of drug for any given patient. Materials and MethodsWe performed an indirect comparison between TSOA's using all phase III trials comparing D, R or A to a VKA for the acute treatment of VTE. Studies including patients with deep vein thrombosis (DVT), pulmonary embolism (PE) or both were considered. The method used to compute the measure of effect has been described elsewhere (Altman DG et al); briefly, the relative risk (RR) of an event for patients receiving treatment X versus Y (RRXY) is estimated by dividing the RR for treatment X versus Z by the RR for treatment Y versus Z. The standard error (SE) on the logarithmic scale for the indirect comparison XY can be easily computed (SEXY=√[SEXZ2+SEYZ2]). This approach has been previously applied to compare the results of atrial fibrillation trials for D, R and A (Mantha S et al). We employed the SAS 3.0.1 statistical platform, along with the “meta” package. The hazard ratio (HR) of an event during the study period was used for computations when provided in the original journal article since it reflected adjustment for pertinent factors and because for infrequent events the HR and RR have similar values. ResultsFour phase III trials were identified, consisting of RE-COVER (Schulman S et al), EINSTEIN-DVT (EINSTEIN Investigators), EINSTEIN-PE (EINSTEIN-PE Investigators) and AMPLIFY (Agnelli G et al). The distribution of patient characteristics was similar between studies (see Table). VTE outcomes were reported for the intention-to-treat population and results for major bleeding were given for the safety (ie “on-treatment”) groups. The measures of effect for EINSTEIN-DVT and EINSTEIN-PE where combined using inverse variance weights and the fixed effect meta-analysis model.The estimated RR of recurrent VTE was 0.76 (95% CI=0.41-1.42, p=0.39) for A vs D, 0.95 (95% CI=0.61-1.48, p=0.81) for A vs R and 0.81 for R vs D (95% CI=0.44-1.47, p=0.48). For major bleeding, the RR of an event was 0.38 for A vs D (95% CI=0.16-0.87, p=0.02), compared with 0.58 for A vs R (95% CI=0.29-1.17, p=0.13) and 0.65 for R vs D (95% CI=0.32-1.33, p=0.24). Finally, the RR of all-cause mortality was 0.81 for A vs D (95% CI=0.39-1.67, p=0.56), 0.88 for A vs R (95% CI=0.54-1.45, p=0.63) and 0.91 for R vs D (95% CI=0.47-1.78, p=0.79). See Figure for corresponding plots. [Display omitted] ConclusionsExcept for major bleeding, there was no significant difference in evaluated outcomes between dabigatran, rivaroxaban and apixaban. A dedicated randomized trial directly comparing the new agents would be required to confirm those results. Disclosures:Ansell:Bristol-Myers Squibb: Consultancy; Pfizer: Consultancy; Janssen: Consultancy; Boehringer Ingelheim: Consultancy; Daiichi: Consultancy; Alere: Consultancy; Perosphere: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Instrumentation Laboratories: Membership on an entity's Board of Directors or advisory committees.

Red Meat and Processed Meat Consumption and All-Cause Mortality: A Meta-Analysis

High consumption of red meat and processed meat has been associated with increased risk of several chronic diseases. We conducted a meta-analysis to summarize the evidence from prospective studies on red meat and processed meat consumption in relationship to all-cause mortality. Pertinent studies were identified by searching PubMed through May 2013 and by reviewing the reference lists of retrieved articles. Prospective studies that reported relative risks with 95% confidence intervals for the association of red meat or processed meat consumption with all-cause mortality were eligible. Study-specific results were combined by using a random-effects model. Nine prospective studies were included in the meta-analysis. The summary relative risks of all-cause mortality for the highest versus the lowest category of consumption were 1.10 (95% confidence interval (CI): 0.98, 1.22; n = 6 studies) for unprocessed red meat, 1.23 (95% CI: 1.17, 1.28; n = 6 studies) for processed meat, and 1.29 (95% CI: 1.24, 1.35; n = 5 studies) for total red meat. In a dose-response meta-analysis, consumption of processed meat and total red meat, but not unprocessed red meat, was statistically significantly positively associated with all-cause mortality in a nonlinear fashion. These results indicate that high consumption of red meat, especially processed meat, may increase all-cause mortality.

Long-term consistency of diurnal-type preferences among men

Diurnal type (chronotype) differentiates individuals on an axis between the extremes of evening type to morning type. These diurnal-type preferences are thought to be relatively stable, but follow-up studies are sparse. The study aims were (1) to compare cross-sectional studies of diurnal type preferences between two decades and (2) to analyze the consistency of diurnal-type preferences using a longitudinal dataset. We analyzed a total of 18 087 adult males from four datasets with information on diurnal type and age. Of these, 2144 were available for survival analysis and 567 for analysis of longitudinal diurnal consistency. Diurnal type was assessed by asking the individual to what extent they would rate themselves a morning or an evening person, categorized into four groups. Statistical tests for stability of diurnal type were based on transition matrices and p values obtained using likelihood ratios. Cox regression was used to calculate the relative risk of all-cause mortality in each of the four diurnal type groups. After direct age standardization, 9.5% (95% CI: 9.0–10.1%) of participants in the four datasets were evening types. The cross-sectional data yielded that morning types were less common in the 2000s than two decades earlier. The longitudinal dataset revealed a significant shift from evening type to another type from 1985 to 2008 (p = 0.002). The relative risk of all-cause mortality was 1.3-fold (95% CI: 1.0–1.6; p = 0.05) higher for evening types compared to morning types. At the population level, eveningness appears to have become more prevalent over recent decades. However, on the individual level, the more morningness the chronotype, the more persistent it remains with aging.

Most Important Outcomes Research Papers on Device Therapies for Cardiomyopathies

Disorders of the cardiac muscle or cardiomyopathies are a broad, yet collectively common, group of conditions. Despite the heterogeneous etiologies, mode of death from these conditions is remarkably similar - progressive decline in cardiac function leading to intractable heart failure (HF) and sustained ventricular arrhythmias resulting in sudden cardiac death (SCD). Nearly 50% of patients die within 5 years of a HF diagnosis.1 Indeed, in the United States, HF alone is thought to cause 55,000 deaths per year2 and further contribute to 1 in 9 deaths overall.1 However, while advanced HF and the risk of SCD were once thought to be untreatable, technological advances has seen the emergence of device therapies as viable treatment options. Specifically, implantable cardioverter-defibrillator (ICD) therapy for treatment of ventricular arrhythmias, cardiac resynchronization therapy (CRT) for restoring cardiac synchrony and mechanical efficiency, and ventricular assist device (VAD) therapy to temporarily or permanently replace the function of the failing heart, have all emerged as highly efficacious therapies. The expanding use of device therapies, however, poses many challenges. First, while the indications for these devices are well summarized in clinical guidelines,3,4 considerable hurdles remain in ensuring eligible patients receive these therapies.5 By the same token, establishing the safety and effectiveness of these therapies in populations that are found in clinical practice, yet commonly excluded from trials, such as the elderly6 and uncommon forms of cardiomyopathies,7 is a high priority. Second, rapid dissemination of technologies frequently results in disparities in care. Indeed, age, gender, and racial disparities, in both receipt of these devices and outcomes following implantation, have been well documented. Whether these disparities have persisted, and the potential causative mechanisms underlying these disparities, however, are uncertain.8,9 Third, these devices are not without significant untoward effects; understanding …

Relation of poor R-wave progression to risk of cardiovascular mortality

Purpose: Loss of anterior forces (R waves) may signify prior anterior myocardial infarction. We examined the prevalence and prognostic impact of poor R-wave progression (PRWP) in a standard electrocardiogram (ECG) in a general population. Methods: The Health 2000 survey is prospective and nationally representative population cohort (random sample) health examination survey conducted in Finland in 2000–2001. The final study population consisted of 5613 individuals with extensive clinical data, including resting ECG. Results: The prevalence of PRWP (defined as RV3 ≤3 mm and RV2 ≤ RV3) was 7.0% in women and 2.7% in men (P<0.001 for difference). During follow-up of 70±9 months (mean ± SD), 317 patients died (5.6%). Men and women with PRWP were older, had more diabetes, CHD, and previous MIs, than did those without PRWP, while for hypertension there was a difference between the groups that only concerned females. Both all-cause and cardiovascular mortality was higher in the group with PRWP than in those without PRWP in both women and men. In Cox regression analysis after adjustment for age, hypertension, diabetes, previous myocardial infarction, and coronary heart disease, the relative risk for all-cause mortality for PRWP was 1.69 (95% CI 0.89–3.22, P=0.112) for men and 2.00 (95% CI 1.28–3.13, P<0.002) for women. For cardiovascular mortality the relative risk for individuals with PRWP was 1.85 (0.74–4.65, P=0.19) for men and 3.02 (1.54–5.93, P<0.001) for women.When also subjects with inferior and anterior Q-waves were included in the analysis, PRWP independently predicted all-cause and cardiovascular mortality in both women and men. Conclusions: PRWP is a common ECG finding and predicts risk for total and cardiovascular mortality in women in a general population.

Bayesian meta-analysis of percutaneous coronary intervention compared to optimal medical therapy in stable ischemic heart disease patients

Background: While the benefit of PCI in acute coronary syndromes is well established, the role of PCI in stable ischemic heart disease (SIHD) is less well clear. Our purpose is to investigate about the combined risk ratio of death or Myocardial Infarction (MI) and all cause mortality among the trials that compare PCI and optimal medical therapy (OMT). Methods: A literature search on OVID/Medline, from 1946 until now, was used to identify all published paper that compared OMT vs PCI. Two clinician-researchers have independently reviewed, abstracted and recorded into common data base. Data were then scrutinized by a third investigator. Meta-analysis, using the DerSimonian and Laird model, was conducted on the abstracted data. Bayesian analysis was performed. Results: 16 main randomized clinical trials were identified. Meta-analyses showed no difference between PCI and OMT for the combined outcome of MI/death across all trials (RR: 0.975; 95%, CI: 0.754-1.261, W: 100%, I2=89.9%) and when we analyzed the stable angina and post MI trials separately (RR: 1.024 95% CI: 0.905-1.160, W: 100%, I2: 23.5%). Relative risk of all cause mortality was not reduced with PCI (pooled RR: 0.986; CI: 0.841-1.156; W: 100%; I2: 0%). Bayesian analysis results are showed in table 1. View this table: Bayesian analysis results Conclusion: Our study confirms that PCI does not yield any additional benefit above OMT in patients with SIHD for the combined end points of MI/Death or all cause mortality alone.

Adherence to cardiovascular therapy: a meta-analysis of prevalence and clinical consequences

The aim of this study was to determine the extent to which adherence to individual vascular medications, assessed by different methods, influences the absolute and relative risks (RRs) of cardiovascular disease (CVD) and all-cause mortality. We performed a systematic review and meta-analysis of prospective epidemiological studies (cohort, nested case-control, or clinical trial) identified through electronic searches using MEDLINE, Web of Science, EMBASE, and Cochrane databases, involving adult populations (≥ 18 years old) and reporting risk estimates of cardiovascular medication adherence with any CVD (defined as any fatal or non-fatal coronary heart disease, stroke or sudden cardiac death) and/or all-cause mortality (defined as mortality from any cause) outcomes. Relative risks were combined using random-effects models. Forty-four unique prospective studies comprising 1 978 919 non-overlapping participants, with 135 627 CVD events and 94 126 cases of all-cause mortality. Overall, 60% (95% CI: 52-68%) of included participants had good adherence (adherence ≥ 80%) to cardiovascular medications. The RRs (95% CI) of development of CVD in those with good vs. poor (<80%) adherence were 0.85 (0.81-0.89) and 0.81 (0.76-0.86) for statins and antihypertensive medications, respectively. Corresponding RRs of all-cause mortality were 0.55 (0.46-0.67) and 0.71 (0.64-0.78) for good adherence to statins and antihypertensive agents. These associations remained consistent across subgroups representing different study characteristics. Estimated absolute risk differences for any CVD associated with poor medication adherence were 13 cases for any vascular medication, 9 cases for statins and 13 cases for antihypertensive agents, per 100 000 individuals per year. A substantial proportion of people do not adhere adequately to cardiovascular medications, and the prevalence of suboptimal adherence is similar across all individual CVD medications. Absolute and relative risk assessments demonstrate that a considerable proportion of all CVD events (~9% in Europe) could be attributed to poor adherence to vascular medications alone, and that the level of optimal adherence confers a significant inverse association with subsequent adverse outcomes. Measures to enhance adherence to help maximize the potentials of effective cardiac therapies in the clinical setting are urgently required.

Meta‐analysis of observational studies: hepatitis C and survival after renal transplant

Recent evidence has shown that anti-HCV-positive serologic status is significantly linked to lower patient and graft survival after renal transplant, but conflicting results have been given on this point. The aim of this study was to conduct a systematic review of the published medical literature concerning the impact of HCV infection on all-cause mortality and graft loss after RT. The relative risk of all-cause mortality and graft loss was regarded as the most reliable outcome end-point. Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random-effect pooled estimates for mortality and graft loss with HCV across the published studies. We identified eighteen observational studies involving 133530 unique renal transplant recipients. The summary estimate for adjusted relative risk (aRR) of all-cause mortality was 1.85 with a 95% confidence interval (CI) of 1.49; 2.31 (P<0.0001); heterogeneity statistics, Ri=0.87 (P-value by Q-test=0.001). The overall estimate for adjusted RR of all-cause graft loss was 1.76 (95% CI, 1.46; 2.11) (P<0.0001), heterogeneity statistics, Ri=0.65 (P-value by Q-test=0.001). Stratified analysis did not change meaningfully these results. Meta-regression showed that living donor rate had a favourable influence on patient (P=0.031) and graft survival (P=0.01), whilst diabetes mellitus having a detrimental role on patient survival (P=0.001). This meta-analysis of observational studies supports the notion that HCV-positive patients after RT have an increased risk of mortality and graft loss. Further studies are in progress to understand better the mechanisms underlying the relationship between HCV and mortality or graft dysfunction after renal transplant.

A meta-analysis of prospective studies of coffee consumption and mortality for all causes, cancers and cardiovascular diseases

Several prospective studies considered the relation between coffee consumption and mortality. Most studies, however, were underpowered to detect an association, since they included relatively few deaths. To obtain quantitative overall estimates, we combined all published data from prospective studies on the relation of coffee with mortality for all causes, all cancers, cardiovascular disease (CVD), coronary/ischemic heart disease (CHD/IHD) and stroke. A bibliography search, updated to January 2013, was carried out in PubMed and Embase to identify prospective observational studies providing quantitative estimates on mortality from all causes, cancer, CVD, CHD/IHD or stroke in relation to coffee consumption. A systematic review and meta-analysis was conducted to estimate overall relative risks (RR) and 95% confidence intervals (CI) using random-effects models. The pooled RRs of all cause mortality for the study-specific highest versus low (≤1 cup/day) coffee drinking categories were 0.88 (95% CI 0.84-0.93) based on all the 23 studies, and 0.87 (95% CI 0.82-0.93) for the 19 smoking adjusting studies. The combined RRs for CVD mortality were 0.89 (95% CI 0.77-1.02, 17 smoking adjusting studies) for the highest versus low drinking and 0.98 (95% CI 0.95-1.00, 16 studies) for the increment of 1 cup/day. Compared with low drinking, the RRs for the highest consumption of coffee were 0.95 (95% CI 0.78-1.15, 12 smoking adjusting studies) for CHD/IHD, 0.95 (95% CI 0.70-1.29, 6 studies) for stroke, and 1.03 (95% CI 0.97-1.10, 10 studies) for all cancers. This meta-analysis provides quantitative evidence that coffee intake is inversely related to all cause and, probably, CVD mortality.

The impact of ACE inhibition on all-cause and cardiovascular mortality in contemporary hypertension trials: a review

The renin–angiotensin–aldosterone system is a key therapeutic target in hypertension. The latest meta-analysis of mortality reduction with angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in hypertension features 158,998 patients from 20 contemporary hypertension trials. ACE inhibitors and ARBs significantly reduced relative risk for all-cause mortality by 5% (p = 0.032) and cardiovascular mortality by 7% (p = 0.018) in populations with a high prevalence of hypertension (≥66%). ACE inhibitors produced a 10% reduction in relative risk for all-cause mortality (p = 0.004) and a trend toward a 12% reduction in cardiovascular mortality (p = 0.051), whereas ARBs had no effect. On balance, mortality evidence suggests that in hypertension, ACE inhibitors should be considered ahead of ARBs, and ARBs restricted to patients intolerant of ACE inhibitors.

FRI0114 Rheumatoid arthritis related interstitial lung disease – relevance of lung function tests and high resolution computed tomography in a large multi centre series

BackgroundRheumatoid arthritis (RA) is associated with clinically relevant interstitial lung disease (ILD) in approximately 5% of patients. The natural history of the association has been shown to be poor: in...

Gamma-glutamyltransferase is associated with cardiovascular and all-cause mortality: A meta-analysis of prospective cohort studies

ObjectiveThe purpose of the present study was to investigate whether gamma-glutamyltransferase (GGT) is an independent predictor for future cardiovascular (CV) and all-cause mortality with prospective observational studies by meta-analysis. MethodsElectronic literature databases (Cochrane Library, Medline, and Embase) were searched for relevant prospective observational studies on the association between baseline GGT and CV and all-cause mortality published prior to June 2012. Pooled adjust relative risk (RR) and corresponding 95% confidence intervals(CI) were calculated separately for categorical risk estimates(highest vs. lowest GGT quartile) and continuous risk estimates (per unit-log GGT increment). ResultsSeven studies with 273,141 participants were identified and analyzed. The pooled RR of CV mortality for highest vs. lowest GGT quartile was 1.52 (95% CI 1.36–1.70). The pooled RR of CV mortality for per unit-log (GGT) increment was 1.76 (95% CI 1.60–1.94). The pooled RR for all-cause mortality for highest vs. low GGT quartile was 1.56 (95% CI 1.34–1.83). Subgroup analyses based on region, gender, follow-up duration, and sample size showed that the positive association between GGT and risk of CV mortality was consistently observed in each subgroup except for the Asia subgroup (RR=1.59, 95% CI 0.76–3.30). ConclusionsGGT is an independent predictor for future CV mortality and all-cause mortality, and might be independent of alcohol intake.

Coronary artery calcium score prediction of all cause mortality and cardiovascular events in people with type 2 diabetes: systematic review and meta-analysis

Objective To investigate the association of coronary artery calcium score with all cause mortality and cardiovascular events in people with type 2 diabetes. Design Systematic review and meta-analysis of observational...

Efficacy of Carbon Dioxide Insufflation for Cerebral and Cardiac Protection During Open Heart Surgery: A Systematic Review and Meta‐Analysis

In spite of widespread application around the world, there has been controversy on the cerebral and cardiac protection efficacy of carbon dioxide insufflation (CDI) during open heart surgery. To make a comprehensive evaluation, we screened all relevant published randomized controlled trials to perform the first systematic review and meta-analysis for CDI during open heart surgery. We searched PubMed, EMBASE, the Cochrane Controlled Clinical Trial register, WANFAN, CQVIP, and CNKI database for published articles. Randomized controlled trials were included when the research provided data of neurological complications postoperatively, creatinine kinase, MB isoenzyme (CK-MB) on the first postoperative day, or all-cause mortality. We chose a fixed-effects model when the trials showed low heterogeneity, otherwise a random effects model was used. The quality of studies was assessed by modified Jadad scale. Four studies were included in this meta-analysis. The overall pooled relative risk (RR) for neurological complications was 1.59, 95% confidence interval (CI) = [0.57, 4.46], and the z-score for overall effect was 0.89 (P = 0.37). The standardized mean difference of the CK-MB between groups was 1.15, 95% CI = [-1.27, 3.56], and the z-score for overall effect was 0.93 (P = 0.35). The overall pooled RR for all-cause mortality was 0.5, 95% CI = [0.16, 1.64], and the z-score for overall effect was 1.14 (P = 0.25). There was no significant difference between groups. Because of the insufficiency of powerful evidences, the cerebral and cardiac protection efficacy of CDI during open heart surgery needs to be further verified by more high-quality trials.

Metformin and mortality. Reply to Lund SS [letter

To the Editor: We thank Dr Lund for his comments [1] on our analysis of cancer incidence and mortality in randomised trials of metformin [2] and confirm that the Hyperinsulinaemia: the Outcome of its Metabolic Effects (HOME) trial [3] was excluded because it did not meet our sample size inclusion criterion. Dr. Lund also calls attention to our sensitivity analysis of all-cause mortality, which excluded one trial, the UK Prospective Diabetes Study (UKPDS) trial of metformin in patients with sulfonylurea failure (UKPDS-S) [4], from the group of trials in which the comparator was placebo or usual care. This acknowledged post hoc sensitivity analysis was carried out because of the high heterogeneity in this group of studies (I=50.8%), but Dr Lund correctly observes that we could equally conduct a sensitivity analysis to exclude the other large trial in this group of studies, the UKPDS trial of metformin in overweight patients (UKPDS-O). For completeness, we include here a table of relative risks for all-cause mortality, and corresponding confidence intervals and heterogeneity statistics, for all placeboor usual-carecontrolled trials, and excluding each trial in turn (Table 1). Exclusion of either UKPDS trial, but not any other trial in this group, reduces the I statistic for heterogeneity to 0.0%. We believe that the remarks in our paper that the summary estimates ‘are dominated by the two large trials from the UKPDS group, which appear to show for metformin effects in opposite directions’ and that our analyses have limitations to be overcome by future randomised trials, remain justified. We re-emphasise our observation that the average follow-up for mortality in our analysis is just 2.8 years, and that our results for all-cause mortality in particular are unlikely to fully reflect the long-term effects of metformin. R. J. Stevens (*) Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK e-mail: richard.stevens@phc.ox.ac.uk

Abstract 111: Comparison of Long-term Outcomes Associated with Endovascular Treatment Versus Surgical Treatment Among Medicare Beneficiaries with Unruptured Intracranial Aneurysms

Objective: To determine the 5 year risk of new intracranial hemorrhage, second procedure, and all-cause mortality in elderly patients with unruptured intracranial aneurysms who underwent either surgical or endovascular treatment. Methods: The study included a representative sample of fee-for-service Medicare beneficiaries aged 65 years or older who underwent endovascular or surgical treatment for unruptured intracranial aneurysms between 1999 through 2010. The Medicare Provider Analysis and Review files were linked to the Center for Medicaid and Medicare Services denominator files for 2000-2010 to ascertain any new admission or mortality. Cox proportional hazards and Kaplan Meir survival analyses were used to assess the relative risk of all-cause mortality, new intracranial hemorrhage, or second procedure for patients treated with endovascular treatment compared with those treated with surgical treatment after adjusting for potential confounders. Results: A total of 1005 patients with unruptured intracranial aneurysms were treated with either endovascular (n=569) or surgical treatment (n=436) with post-procedure follow-up available for 4.64 (±2.98) years. The rate of immediate post-procedural neurological complications (8.7% vs. 3.2%, p&lt;0.0001) and requirement for intraventricular catheter (2.8% vs. 0.7%, p=0.019) was higher among patients treated with surgery compared with those treated with endovascular treatment. The estimated 5 year survival was 93.6% and 95.8% in patients treated with surgical and endovascular treatments, respectively. After adjusting for age, gender, and race/ethnicity, relative risks of all-cause mortality (RR 0.5, 95% CI 0.3-0.9) and new intracranial hemorrhage (RR 0.4, 95% CI 0.2-0.8) were significantly lower with endovascular treatment. Conclusions: In elderly patients with unruptured intracranial aneurysms, endovascular treatment was associated with lower rates of acute adverse events, long-term all-cause mortality and new intracranial hemorrhages.

Risks of mortality associated with common laboratory tests: a novel, simple and meaningful way to set decision limits from data available in the Electronic Medical Record

Laboratory tests provide objective measurements of physiologic functions, but are usually evaluated by demographic reference-intervals (RI), instead of risk-based decision-limits (DL). We show that hospital electronic medical record (EMR) data can be utilized to associate all-cause mortality risks with analyte test values, thereby providing more information than RIs and defining new DLs. Our cohort was 39,964 patients admitted for any reason and discharged alive, during two 1-year periods, at Sarasota Memorial Hospital, Florida, USA. We studied five routinely-performed in-hospital laboratory tests: serum creatinine, blood urea nitrogen, serum sodium, serum potassium, and serum chloride. By associating a mortality odds ratio with small intervals of values for each analyte, we calculated relative risk of all-cause mortality as a function of test values. We found mortality risks below the population average within these proposed DLs: potassium 3.4-4.3 mmol/L; sodium 136-142 mmol/L; chloride 100-108 mmol/L; creatinine 0.6-1.1 mg/dL; blood urea nitrogen (BUN) 5-20 mg/dL. The DLs correspond roughly to the usually-quoted RIs, with a notable narrowing for electrolytes. Potassium and sodium have reduced upper limits, avoiding a "high-normal" area where the odds ratio rises 2 to 3 times the population average. Any clinical laboratory test can be transformed into a mortality odds ratio function, associating mortality risk with each value of the analyte. This provides a DL determined by mortality risk, instead of RI assumptions about distribution in a "healthy" population. The odds ratio function also provides important risk information for analyte values outside the interval.

Economic Impact of Reduced Mortality Due to Increased Cycling

Increasing regular physical activity is a key public health goal. One strategy is to change the physical environment to encourage walking and cycling, requiring partnerships with the transport and urban planning sectors. Economic evaluation is an important factor in the decision to fund any new transport scheme, but techniques for assessing the economic value of the health benefits of cycling and walking have tended to be less sophisticated than the approaches used for assessing other benefits. This study aimed to produce a practical tool for estimating the economic impact of reduced mortality due to increased cycling. The tool was intended to be transparent, easy to use, reliable, and based on conservative assumptions and default values, which can be used in the absence of local data. It addressed the question: For a given volume of cycling within a defined population, what is the economic value of the health benefits?The authors used published estimates of relative risk of all-cause mortality among regular cyclists and applied these to levels of cycling defined by the user to produce an estimate of the number of deaths potentially averted because of regular cycling. The tool then calculates the economic value of the deaths averted using the “value of a statistical life.” The outputs of the tool support decision making on cycle infrastructure or policies, or can be used as part of an integrated economic appraisal. The tool's unique contribution is that it takes a public health approach to a transport problem, addresses it in epidemiologic terms, and places the results back into the transport context. Examples of its use include its adoption by the English and Swedish departments of transport as the recommended methodologic approach for estimating the health impact of walking and cycling.

Physical activity and survival after cancer diagnosis in men.

The number of cancer survivors is increasing rapidly; however, little is known about whether engaging in physical activity after a cancer diagnosis is associated with lower mortality rates in men. We conducted a prospective cohort study of 1021 men (mean age, 71.3 years) who were diagnosed with cancer (other than nonmelanoma skin cancer). Men reported their physical activities (walking, stair climbing, and participation in sports and recreational activities) on questionnaires in 1988, a median of 6 years after their cancer diagnosis. Physical activity was updated in 1993 and men were followed until 2008, with mortality follow-up > 99% complete, during which 777 men died (337 from cancer, 190 from cardiovascular disease). In multivariate analyses, the relative risks for all-cause mortality associated with expending < 2100, 2100-4199, 4200-8399, 8400-12,599, and ≥ 12,600 kJ/week in physical activity were 1.00 (referent), 0.77, 0.74, 0.76, and 0.52, respectively (P-trend < 0.0001). Higher levels of physical activity also were associated with lower rates of death from cancer and cardiovascular disease (P- trend = 0.01 and 0.002, respectively). Engaging in physical activity after cancer diagnosis is associated with better survival among men.