Small Bowel Cancer: Epidemiological and Clinical Characteristics from a Population-based Registry

Objectives: Data on small bowel cancers are scarce, and are derived primarily from hospital series. Our aim was to examine the epidemiological and clinical characteristics of these rare cancers. The database is population-based registry with complete ascertainment. It is thus free of the selection bias innate to hospital series. Methods: Review of the Utah Cancer Registry for all small bowel cancers from 1966 through 1990. For comparison, other cancers were reviewed for incidence and relative survival rates. Results: There were 328 small howel cancers, including 136 (41%) carcinoids, 80 (24%) adenocarcinomas, 72 (22%) lymphomas, 36 (11%) sarcomas, and four (1%) unclassified. The overall age-adjusted incidence per 100,000 was 1.4 for small howel cancers compared to 35.7 for colorectum and 92.9 for breast. Small bowel cancers occurred most frequently in the sixth and seventh decades of life, and were more common in men. Carcinoids, lymphomas, and sarcomas occurred in order of decreasing frequently in the ileum, jejunum, and duodenum; the reverse was true for adenocarcinomas. Distant metastases occurred in 35 (27%) carcinoids, 14 (28%) adenocarcinomas, 17 (26%) lymphomas, and 10 (33%) sarcomas. Surgery was the primary form of therapy in 108 (79%) carcinoid patients, 80 (49%) adenocarcinoma patients, 52 (72%) lymphoma patients, and 26 (72%) sarcoma patients. The overall 5-year relative survival rate for small bowel cancers was 54%; 83% for carcinoids, 25% for adenocarcinomas, 62% for lymphomas, and 45% for sarcomas. Overall survival, compared to other cancer sites, was surpassed only by cancers of the prostate, breast, and colorectum. Conctusions: Small bowel cancers consist of several types of rare tumors, each with unique characteristics. The overall prognosis is better than for most common cancers.     

Echocardiographic and Clinical Predictors of Mortality in Chronic Chagas' Disease

Background: In a prospective epidemiological study of chronic Chagas' disease, several clinical and echocardiographic variables were analyzed as predictors of mortality. Methods: Among 960 subjects seropositive for Chagas' disease who were examined between June 1981 and June 1992, 283 had echocardiograms. Results: During a mean follow-up period of 48.3 ± 36.4 months (range, 1–156 months), 108 subjects died. Echocardiographic end-diastolic and -systolic left ventricular internal dimensions, fractional shortening, radius-to-thickness ratio, left ventricular mass, mitral E-point septal separation, and 17 other nonechocardiographic variables were predictors of death on univariate analysis (P < 0.001 for each). On stepwise multiple regression analysis of 215 subjects, significant risk covariates in a Cox model analysis were clinical group (P < 0.0001), M-mode echocardiographic E-point septal separation of 22 mm (P = 0.003), presence of first- or second-degree heart block (P = 0.003), chest radiologic cardiothoracic ratio ≤ 0.55 (P = 0.012), presence of electrocar-diographic ST segment elevation on precordial leads (P = 0.014), age ≤ 56 years (P = 0.028), and presence of right bundle-branch block (P = 0.045). Patients with an apical aneurysm on two-dimensional echocardiography had an increased mortality (Chi-square = 11.5, P < 0.001). Conclusions: Echocardiography is a valuable tool to assess the risk of death in prospective studies on chronic Chagas' heart disease.     

Lymphangioleiomyomatosis: A review

Lymphangioleiomyomatosis (LAM) is a rare disease, of unknown etiology, affecting women almost exclusively. Microscopically, LAM consists of a diffuse proliferation of smooth muscle cells. LAM can occur without evidence of other disease (sporadic LAM) or in conjunction with tuberous sclerosis complex (TSC). TSC is an autosomal dominant tumor suppressor gene syndrome characterized by seizures, mental retardation, and tumors in the brain, heart, skin, and kidney. LAM commonly presents with progressive breathlessness or with recurrent pneumothorax, chylothorax, or sudden abdominal hemorrhage. Computed tomography (CT) scans show numerous thin-walled cysts throughout the lungs, abdominal angiomyolipomas, and lymphangioleiomyomas. No effective treatment currently exists for this progressive disorder. The prevalence of lymphangioleiomyomatosis is probably underestimated based on its clinical latency and the absence of specific laboratory tests. With the utilization of international LAM data registries the "classical" picture of the disorder appears to be evolving as a larger number of patients are evaluated. An increased awareness of LAM and its common clinical presentation may advance the development of new therapeutic strategies and reduce the number of mistakenly diagnosed patients.     

Disparities in Sarcoidosis Mortality by Region,Urbanization, and Race in the United States: A Multiple Cause of Death Analysis

PurposeSex, race/ethnicity, and geographic disparities in sarcoidosis-associated mortality were assessed for the most recent period.MethodsUS data for multiple causes of death for 1999-2016 were used to determine numbers of deaths and age-adjusted rates for sarcoidosis as an underlying or a contributing cause of death using International Classification of Diseases, 10th Revision code D86 for Hispanics, non-Hispanic blacks, and non-Hispanic whites.ResultsFor persons of all ages in the United States in 1999-2016, there were a total of 28,923 sarcoidosis-associated deaths. In 2008-2016, 9112 deaths had sarcoidosis as the underlying cause (56%) compared with 16,129 with sarcoidosis listed as any cause. Age-adjusted annual death rates per 100,000 were 5.7 (95% confidence interval [CI], 5.6-5.8) for females and 4.1 (95% CI, 4.0-4.2) for males. Age-adjusted annual death rates were 1.5 (95% CI, 1.4-1.6) for Hispanics and 5.4 (95% CI, 5.3-5.4) for non-Hispanics. Rates in non-Hispanic blacks were 8 times those in non-Hispanic whites. Among females, the highest rate was in non-Hispanic blacks in the East-Central division. Between 1999-2007 and 2008-2016, rates increased most in non-Hispanic white males (52.5%) and least in non-Hispanic black females (5.8%).ConclusionsSarcoidosis-related multiple cause of death mortality rates were highest in females and in non-Hispanic blacks, and they varied geographically.     

Predictors of Mortality in Alcoholic Women: A Prospective Follow-up Study

An 11-year follow-up of 100 alcoholic women who were systematically interviewed and diagnosed during hospitalization found 31% dead, the majority as a result of alcohol-related causes. There were over 4 times as many deaths in alcoholic women as expected in the general population. The life span of alcoholic women was shortened by over 15 years. Only those women who had abstained during the interval followlng hospitalization had fewer than expected deaths. Five variables correctly predicted survival status for 79% of the subjects (80% of survivors and 77% of those who died): older age at index, onset of alcoholism before age 30, history of frequent benders, primary diagnosis of antisocial personality, and short-term drinking status.     

Clinical Predictors of Late Death in Survivors of Acute Myocardial Infarction

Survivors of acute myocardial infarction have higher mortality rates than do the general population. This study examined the value of multiple clinical characteristics in predicting late death among patients who present with acute myocardial infarction.We reviewed the electronic medical records of patients who had been treated for acute myocardial infarction at our institution from 1992 through 2000. We abstracted the clinical, laboratory, electrocardiographic, echocardiographic, and treatment characteristics.Of 144 patients (79.2% men; 97.2% white; mean age, 63 ± 14.2 yr) included in this analysis, 63 (43.8%) patients died during a follow-up period of 5.6 ± 2.8 years (5 d–12.7 yr). Higher age (hazard ratio, 1.83 ± 0.31 for every 10-year increase), elevated serum creatinine (hazard ratio, 2.87 ± 0.76), and lower baseline left ventricular ejection fraction (hazard ratio, 0.74 ± 0.21 for every 5% increase) were found to be predictors of late death after adjusting for the white blood cell count, the QRS duration, the presence of coronary revascularization or defibrillator implantation, and the history of coronary artery disease. Elevated white blood cell count predicted early but not late death. Patients with none of the above risk factors had 100% survival at 5 years, in comparison with 22.7% survival for those with 3 or more of the 4 risk factors identified above.In this study, we have identified clinical predictors of long-term survival after acute myocardial infarction that might help in prognostication, patient education, and risk modification.Key words: Acute disease, European continental ancestry group, mortality, late, myocardial infarction/mortality, predictive value of tests, prognosis, retrospective studies, risk assessment, survival analysisAcute myocardial infarction (AMI) is experienced by more than 800,000 people in the United States annually. Although approximately 75% of AMI victims survive beyond the 1st year, they have significantly higher mortality rates than does the general population.¹Several studies have contributed to our understanding of characteristics at presentation that predict death. Most of them, however, have focused on predictors of death at 30 days or less,^2–5 or during the 1st year,^6–11 and very few have examined long-term mortality rates.¹² Furthermore, most of the above studies have examined only a few clinical factors simultaneously. Some of the predictors of death were higher age, larger infarct size, elevated cardiac tissue-injury markers, impaired renal function, elevated blood-sugar levels, elevated white blood cell (WBC) counts, decreased left ventricular ejection fraction (LVEF), and increased QRS duration.This current study examined retrospectively the prognostic value of various clinical characteristics on late, all-cause mortality rates in patients presenting with AMI at a single, large, tertiary center.     

Clinical Predictors for Death in HIV-positive and HIV-negative Tuberculosis Patients in Guinea-Bissau

Abstract Object: To assess easily monitored predictors for tuberculosis mortality. Design: Risk factors for tuberculosis mortality were assessed during the 8-month treatment in 440 men and 269 women diagnosed with confirmed or presumed intrathoracic tuberculosis included prospectively in Guinea-Bissau from May 1996 to April 2001. A civil war occurred in the study area from June 1998 to May 1999. Results: 12% were HIV-1 positive, 16% HIV-2 positive and 7% were HIV dually infected. Case fatality rates for HIV positive were higher during (35% [22/63]) and after the war (29% [27/92]) compared to before the war (17% [15/88]). The war did not have an effect on the case fatality rate in HIV negative (10% [13/135] before the war). HIV-1-infected patients had higher mortality than HIV-2 infected, mortality rate ratio (MRR) = 2.28 (95% confidence interval 1.17–4.46). Men had higher mortality than women but only among the HIV negative (MRR = 2.09 [0.95–4.59]). Hence, the negative impact of HIV infection on mortality was stronger in women (MRR = 6.51 [2.98–14.2]) than in men (MRR = 2.64 [1.67–4.17]) (test of homogeneity, p = 0.051). Anergy to tuberculin was associated with death in HIV positive (MRR = 2.77 [1.38–5.54]) but not in HIV negative (MRR = 1.14 [0.52–2.53]). Signs of immune deficiency, such as oral candida infection or leukoplakia (MRR = 4.25 [1.92–9.44]) and diarrhea (MRR = 2.15 [1.29–3.58] was associated with mortality in HIV positive. Tendencies were similar among HIV negative. HIV-positive relapse cases were at increased risk of dying (MRR = 2.42 [1.10–5.34]). Malnutrition, measured through mid-upper arm circumference (MUAC), increased the risk of death. Conclusion: Easily monitored predictors for mortality in tuberculosis patients include clinical signs of immune deficiency and low MUAC.     

Cause of Death Analysis in the NHLBI PTCA Registry: Results and Considerations for Evaluating Long-Term Survival After Coronary Interventions

Objectives. We examined cause of death in relation to age, length of follow-up and other baseline characteristics in patients in the 1985–1986 National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty (NHLBI PTCA) Registry.Background. The manner in which cardiac versus noncardiac mortality of patients with coronary revascularization varies in relation to patient and study characteristics has not been well documented.Methods. Cause of death determined from a review of 5 years of annual follow-up forms and death certificates was analyzed in 2,127 patients who had coronary angioplasty (mean age 57.6 years) without acute myocardial infarction.Results. Within 5 years of the initial procedure, there were 205 deaths (9.6%), with 52.7% attributed to cardiac causes. Patients with a low baseline ejection fraction, history of hypertension, previous bypass surgery, previous myocardial infarction, inoperable or high surgical risk or multivessel disease had significantly higher 5-year cardiac mortality. Patients with a history of diabetes, congestive heart failure or severe concomitant noncardiac disease had higher rates of both cardiac and noncardiac mortality. As length of follow-up increased, older patients died of noncardiac causes more often than cardiac causes. Age ≥65 years was a strong independent predictor of 5-year noncardiac mortality (p < 0.001), but not cardiac mortality (p = 0.08).Conclusions. All-cause mortality rates may be high in elderly revascularized patients, yet cardiac mortality may be less than that expected because of a high risk of noncardiac death. Although all-cause mortality is a more reliable end point than cause-specific mortality, both cardiac and all-cause mortality should be considered in coronary intervention studies involving older patients and long-term follow-up.     

Predictors of Mortality in Alcoholic Women: A 20-Year Follow-Up Study

Very little is known about the factors that predict mortality in female alcoholics. This study investigates these predictors in 103 female alcoholics who were psychiatrically hospitalized between 1967 and 1968 and followed for over 20 years. The findings showed that age, benders, and/or delirium tremens, comorbidity, and 3-year posttreatment drinking status were associated with time to death. That older alcoholics and those with pathological drinking within 3 years after treatment had a significantly shorter time to death was not surprising. However, the association of benders with mortality indicated that women may be very sensitive to short periods of high concentrations of alcohol. Comorbidity also had an intriguing effect in that women with a history of depression were more likely to survive. The predictors of mortality in these female alcoholics differed from those of the male alcoholics in this sample. These differences will be discussed in future publications.     

Predictors of Mortality in Alcoholic Men: A 20-Year Follow-Up Study

This study investigates the predictors of mortality in 158 male alcoholics who were psychiatrically hospitalized between 1907 and 1968 and followed for >20 years. The findings showed that an older age, liver cimhosis, and separation or divorce at intake were all associated with a shorter time to death. These results corroborate those of other follow-up studies that have identified age, health, and social support as independent correlates of mortality in alcoholics. From a therapeutic standpoint, the most alterable predictor is social support. Thus, the establishment of a salutary social network and social support system should be an integral part of the alcoholic's treatment plan.     

Clinical Predictors of Mortality in Patients with Moderate to Severe Mitral Regurgitation

BackgroundMitral regurgitation is the most common form of valvular heart disease worldwide, however, there is an incomplete understanding of predictors of mortality in this population. This study sought to identify risk factors of mortality in a real-world population with mitral regurgitation.MethodsAll patients with moderate or severe mitral regurgitation were identified at a single center from January 1, 2016 to August 31, 2017. Multivariate regression was performed to evaluate variables independently associated with all-cause mortality.ResultsA total of 490 patients with moderate (76.3%) or severe (23.7%) mitral regurgitation due to primary (20.8%) or secondary (79.2%) etiology were identified. The mean age was 66.7 years; 50% were male. At a median follow-up of 3.1 years, the incidence of all-cause mortality was 30.1%, heart failure hospitalization 23.1%, and mitral valve intervention 11.6%. Of 117 variables, multivariate analysis demonstrated 5 that were independently predictive of mortality: baseline creatinine (hazard ratio [HR] 1.2; 95% CI, 1.0-1.3; P = .02), right atrial pressure by echocardiogram (HR 1.3; 95% CI, 1.07-1.55; P = .008), hemoglobin (HR 0.65; 95% CI, 0.52-0.83; P = .001), hospitalization for heart failure (HR 1.6; 95% CI, 1.1-2.4; P = .015), and mitral valve intervention (HR 0.40; 95% CI, 0.16-0.83; P = .049).ConclusionIn this retrospective, pragmatic analysis of patients with moderate or severe mitral regurgitation, admission for heart failure exacerbation, elevated right atrial pressure, renal dysfunction, anemia, and lack of mitral valve intervention were independently associated with increased risk of all-cause mortality. Whether these risk factors may better identify select patients who may benefit from more intensive monitoring or earlier intervention should be considered in future studies.