Cause-Specific Mortality in Epilepsy: A Cohort Study of More Than 9,000 Patients Once Hospitalized for Epilepsy

Summary: Purpose: We studied overall and cause-specific mortality rates in a large cohort of patients with epilepsy compared with mortality rates of the general population in the same geographic area.
Methods: The cohort consisted of all patients (N = 9,061) aged >15 years admitted with a diagnosis of epilepsy for inpatient care in Stockholm during the years 1980–1989. All patients were followed in the National Cause-of-Death Register, from which the causes of death were obtained, until December 31, 1992. Thus, 53,520 person-years were observed. Mortality rates were compared with those of the general population of Stockholm.
Results: We observed 4,001 deaths in the cohort, compared with an expected number of 1,109 deaths in the general population. This yielded a standardized mortality ratio (SMR) of 3.6 [95% confidence interval (CI) 3.5–3.71] Although highest in the younger patients, the SMR was significantly increased in all age groups. The excess mortality rate in the cohort was due to a wide range of causes of death, including malignant neoplasms [SMR 2.6 (2.4–2.8)], diseases of the circulatory system, [SMR 3.1 (3.0–3.3)], diseases of the respiratory system [SMR 4.0 (3.64.5)], diseases of the digestive system [SMR 5.1 (4.4–5.8)], and injuries and poisoning [SMR 5.6 (5.0–6.3)].
Conclusions: Our results demonstrate that this large subgroup of patients with a diagnosis of epilepsy, once hospitalized and discharged, is a population at risk, with an excess mortality rate due to several different causes.     

Mortality risk in adults with newly diagnosed and chronic epilepsy: a population‐based study

Background: We analyzed mortality in adult patients with newly diagnosed and chronic epilepsy over a 13‐year period. Methods: Eighty‐one patients aged ≥20 years with newly diagnosed epilepsy and 309 adult patients with chronic epilepsy were originally identified from population‐based incidence and prevalence studies conducted in Tartu between 1994 and 1996. Patients with epilepsy were followed until the date of death or until the end of 2007. The standardized mortality ratio (SMR) was analyzed for both cohorts. The influences of age at diagnosis, sex, epilepsy syndrome, seizure type, risk factors and treatment compliance on the SMR were also investigated. Results: The SMR was significantly increased in both cohorts, but was higher in patients with chronic epilepsy (SMR 3.1; 95% confidence interval [CI] 2.5–3.8) relative to patients with newly diagnosed epilepsy (SMR 2.6; 95% CI 1.8–3.5). In the newly diagnosed epilepsy cohort, the increased mortality risk was more pronounced in patients with complex partial seizures (SMR 5.6; 95% CI 2.4–11.0). In the chronic epilepsy cohort, the mortality risk was higher in patients with secondary generalized tonic‐clonic seizures (SMR 3.4; 95% CI 2.5–4.5). Non‐compliant patients had twice the mortality risk (SMR 4.2; CI 95% 2.7–6.2) compared to those who were on anticonvulsant treatment. Conclusions: Mortality rates are higher in people with newly diagnosed and chronic epilepsy. Mortality risks should be discussed with patients with epilepsy, especially if anticonvulsant treatment is refused despite recurrent seizures.     

Mortality after temporal lobe epilepsy surgery

Purpose: To report mortality, after a longer interval, in a cohort of patients with drug‐resistant epilepsy treated by temporal lobe surgery between 1975 and 1995. A previous audit of these patients ending December 1, 1997 observed a standardized mortality ratio (SMR) of 4.5. Methods: We analyzed mortality in a cohort of 306 patients with temporal lobe epilepsy (TLE) who underwent temporal lobe resections between December 1, 1975 and December 1, 1995. Deaths occurring after December 1,1997 and until December 1, 2009 were evaluated. Medical records, death certificates, postmortem examination reports, coroner officer’s reports, and coroner’s inquest reports were sought, and causes of death were ascertained. Sudden unexpected death in epilepsy (SUDEP) cases were identified. Key Findings: In 3,569 person‐years of follow‐up 19 deaths occurred, [SMR 2.00, 95% confidence interval (CI) 1.27–3.13], 14 men (SMR 2.01, 95% CI 1.19–3.39) and 5 women (SMR 1.68, 95% CI 0.70–4.03). On analysis of subgroups, SMRs were significantly elevated in patients with mesial temporal sclerosis (MTS) (SMR 2.50, 95% CI 1.38–4.51), men with MTS (SMR 3.12, 95% CI 1.56–6.25), men with nonspecific lesions (SMR 2.68, 95% CI 1.00–7.09), and right‐sided resections in MTS (SMR 3.33, 95% CI 1.39–8.00). During follow‐up, six SUDEP cases were observed with a rate of 1/595 person‐years. Significance: In this cohort, the risk for premature death in patients undergoing TLE surgery decreased over time but remained above the standard population. Men had a slightly higher risk than women, as did right‐sided resections in MTS, confirming this observation in the original cohort. Although lower, the risk of SUDEP remained. Without up‐to‐date information on seizure outcome, we were unable to directly relate this to mortality.     

Mortality in epilepsy in the first 11 to 14 years after diagnosis: multivariate analysis of a long-term, prospective, population-based cohort

The United Kingdom National General Practice Study of Epilepsy is a prospective, population-based study of newly diagnosed epilepsy. A cohort of 792 patients has now been followed for up to 14 years (median follow-up [25th, 75th percentiles] 11.8 years, range 10.6-11.7 years), a total of 11,400 person-years. These data are sufficient for a detailed analysis of mortality in this early phase of epilepsy. Over 70% of patients in this cohort have developed lasting remission from seizures, although the mortality rate in the long term was still twice that of the general population. The standardized mortality ratio (SMR), the number of observed deaths per number of expected deaths, was 2.1 (95% confidence interval [CI] = 1.8, 2.4). Patients with acute symptomatic epilepsy (SMR 3.0; 95% CI = 2.0, 4.3), remote symptomatic epilepsy (SMR 3.7; 95% CI = 2.9, 4.6), and epilepsy due to congenital neurological deficits (SMR 25; 95% CI = 5.1, 73.1) had significantly increased long-term mortality rates, whereas patients with idiopathic epilepsy did not (SMR 1.3; 95% CI = 0.9, 1.9). This increase in mortality rate was noted particularly in the first few years after diagnosis. Multivariate Cox regression and time-dependent co-variate analyses were utilized for the first time in a prospective study of mortality in epilepsy. The former showed that patients with generalized tonic-clonic seizures had an increased risk of mortality. The hazard ratio (HR), or risk of mortality in a particular group with a particular risk factor compared to another group without that particular risk factor, was 6.2 (95% CI = 1.4, 27.7; p = 0.049). Cerebrovascular disease (HR 2.4; 95% CI = 1.7, 3.4; p < 0.0001), central nervous system tumor (HR 12.0; 95% CI = 7.9, 18.2; p < 0.0001), alcohol (HR 2.9; 95% CI = 1.5, 5.7; p = 0.004), and congenital neurological deficits (HR 10.9; 95% CI = 3.2, 36.1; p = 0.003) as causes for epilepsy and older age at index seizure (HR 1.9; 95% CI = 1.7,2.0; p < 0.0001) were also associated with significantly increased mortality rates. These hazard ratios suggest that epilepsy due to congenital neurological deficits may carry almost the same risk of mortality as epilepsy due to central nervous system tumors and that epileptic seizures subsequent to alcohol abuse may carry almost the same risk of mortality as epilepsy due to cerebrovascular disease. The occurrence of one or more seizures before the index seizure (the seizure that led to the diagnosis of epilepsy and enrolment in the study) was associated with a significantly reduced mortality rate (HR 0.57; 95% CI = 0.42, 0.76; p = 0.00001). Time-dependent co-variate analysis was used to examine the influence of ongoing factors, such as seizure recurrence, remission, and antiepileptic drug use, on mortality rates in the cohort. Seizure recurrence (HR 1.30; 95% CI = 0.84, 2.01) and antiepileptic drug treatment (HR 0.97; 95% CI = 0.67, 1.38) did not influence mortality rate. There were only 5 epilepsy-related deaths (1 each of sudden unexpected death in epilepsy, status epilepticus, burns, drowning, and cervical fracture), suggesting that death directly due to epileptic seizures is uncommon in a population-based cohort with epilepsy.     

Short-Term Mortality After a First Epileptic Seizure: A Population-Based Study

PURPOSE: To determine the short-term mortality in a prospective incidence cohort of patients included after any kind of first afebrile epileptic seizure (i.e., provoked and unprovoked). METHODS: Information on death occurring within the first year of follow-up was collected in a cohort of 804 patients with a first seizure between March 1, 1984, and February 28, 1985, in southwest France. The variables analyzed were the etiology of seizure, cause of death, interval between seizure and death, and age of patients. RESULTS: By the end of the 1-year follow-up, there were 149 deaths among these patients as compared with 16 expected deaths [standardized mortality ratio (SMR), 9.3; 95% confidence interval (CI), 7.9-10.9]. There were no deaths in patients with idiopathic seizures. Patients with cryptogenic seizures had slightly increased mortality (SMR, 1.6; 95% CI, 0.4-4.1). Mortality was increased for patients with remote symptomatic seizures (SMR, 6.5; 95% CI, 3.8-10.5), provoked seizures (SMR, 10.1; 95% CI, 8.1-12.4), and seizures due to a progressive neurologic condition (SMR, 19.8; 95% CI, 14.0-27.3). Causes of death were underlying pathology (64%), unrelated condition (20%), unknown cause (9%), seizure-related death (6%), and one suicide. CONCLUSIONS: Early mortality clearly differed according to the etiology of the first seizure. The highest mortality was associated with provoked seizures and with seizures caused by progressive central nervous system disorders. Patients died far more often from underlying or unrelated conditions than from seizures.     

Excessive mortality and causes of death among patients with personality disorder with comorbid psychiatric disorders

Purpose

Excessive mortality has been seen in patients with personality disorder (PD), but it has not been well-studied when patients also have other psychiatric comorbidities. This study investigated the mortality rates and causes of death in an Asian cohort with PD.

Method

We enrolled patients ≥ 18 years of age with PD as defined by DSM-IV criteria (N = 1172), who had been admitted to a psychiatric service center in northern Taiwan between 1985 and 2008. By linking with the national mortality database (1985–2008), cases of mortality (n = 156, 13.3%) were obtained. We calculated the standardized mortality ratios (SMRs) to estimate the mortality gap between patients with PD and the general population. Stratified analyses of mortality rates by Axis I psychiatric comorbidity and sex were performed.

Results

Borderline PD (n = 391, 33.4%) was the dominant disorder among the subjects. The SMRs for all-cause mortality of PD alone, PD comorbid with non-substance use disorder(non-SUD), and PD comorbid with SUD were 4.46 (95% CI 1.94–6.98), 7.42 (5.99–8.85), and 15.96 (11.07–20.85), respectively. Among the causes of death, the SMR for suicide was the highest (46.92, 95% CI 34.29–59.56). The SMR for suicide in PD patients with comorbid SUD was unusually high (74.23, 95% CI 33.88-114.58). Women had a significant increase in suicide with an SMR of 59.00 (95% CI 37.89–80.11). Men had significant increase in SMRs for cardiovascular disease and gastrointestinal disease.

Conclusions

We found significant synergistic effects of PD and SUD on mortality risk. A personality assessment should be mandatory in all clinical settings to prevent premature death and detect SUD early.

     

Cause-specific mortality in adults with unprovoked seizures. A population-based incidence cohort study.

PURPOSE: To determine the cause-specific mortality relative to that expected in a population-based incidence cohort of people with unprovoked seizures. METHODS: The cohort comprises 224 inhabitants of Iceland first diagnosed as suffering from unprovoked seizures during a 5-year period from 1960 to 1964. The expected number of deaths was calculated by multiplying person-years of observation within 5-year age categories for each year from diagnosis through 1995 by cause-specific and sex-specific national death rates for those aged 20 years and above. The standardized mortality ratio (SMR) and 95% confidence intervals (95% CI) were calculated. RESULTS: All-cause mortality was increased among men (SMR 2.25, 95% CI 1.56-3.14) but not women (SMR 0.79, 95% CI 0.38-1.46). Among men, there were 8 deaths from accidents, poisoning and violence observed versus 2.82 expected (SMR 2.84, 95% CI 1.22-5.59) and 4 deaths from suicide versus 0.69 expected (SMR 5.80, 95% CI 1.56-14.84). All-cause mortality for men was still elevated after restriction of analysis to those with seizures of unknown etiology (SMR 1.73, 95% CI 1.05-2.67) with the excess deaths attributable to suicide (SMR 5.26, 95% CI 1.06-15.38). Both males and females with remote symptomatic unprovoked seizures had an increase in all-cause mortality due to excess mortality from all cancers, cerebrovascular disease and accidents. CONCLUSION: When compared with the age-, time-period- and gender-specific mortality in the general population, there is excess mortality in men but not women. The increased mortality for men is partly attributable to excess mortality from accidents and suicides.     

Mortality risk in an adult cohort with a newly diagnosed unprovoked epileptic seizure: a population-based study

PURPOSE: We sought to investigate mortality risk in an adult cohort with newly diagnosed unprovoked epileptic seizures. METHODS: One hundred seven patients who were at least 17 years old and had newly diagnosed unprovoked epileptic seizures were prospectively identified during a period of 20 months between 1985 and 1987. Patients were followed until the date of death or the end of 1996. The standard mortality ratio (SMR) was analyzed in the whole cohort and in the portion of the cohort with recurrent seizures at inclusion. The influences on the SMR of time since diagnosis, sex, age at diagnosis, seizure cause, seizure type, and cause of death were also investigated. RESULTS: The SMR was significantly increased (SMR, 2.5; 95% confidence interval [CI], 1. 2-3.2). This significantly increased risk was found during the first 2 years after diagnosis (year 1: SMR, 7.3; 95% CI, 4.4-12.1; year 2: SMR, 3.6; 95% CI, 1.6-8.1) and at years 9-11 (SMR, 5.4; 95% CI, 2. 7-11.2). The increased mortality risk was most pronounced when the seizures occurred before the age of 60 years. Mortality risk was elevated among patients with remote symptomatic epilepsy (SMR, 3.3; 95% CI, 2.4-4.5) but not idiopathic epilepsy. CONCLUSIONS: There is increased mortality risk in an adult cohort with newly diagnosed unprovoked epileptic seizures. This increase is found in symptomatic patients, young patients, and during the first 2 years after the diagnosis.     

Mortality in patients with epilepsy: a study of patients in long term residential care.

The causes of death in a group of patients with severe epilepsy in long term residential care over a period of 11 years were assessed and the standardised mortality rate (SMR) determined. A total of 3392 patient-years were surveyed. One hundred and thirteen deaths were recorded in the period and this represents an overall mortality rate which is almost twice the expected rate for this population (SMR = 1.9; 95% CI 1.6-2.3; p < 0.01). Most deaths were due to cancer (26%), bronchopneumonia (25%), circulatory diseases (24%), were seizure-related (12%) or due to sudden unexpected death (6%). The highest SMRs in the neoplasm sub-group were due to cancers of the pancreas (SMR = 6.2) and hepatobiliary tumours (SMR = 17.6). Twenty per cent of patients died of epilepsy or epilepsy related causes (that is accidents, during seizures, status or sudden unexpected death). One in every 480 patients died due to a sudden unexpected death. This study in a highly selected population seems to confirm suggestions that mortality rates are higher in patients with epilepsy than in the general population, but prospective studies are warranted to ascertain underlying mechanisms.     

Long-Term Survival of People with Unprovoked Seizures: A Population-Based Study

Summary: Purpose : Few population-based studies of longterm survival in people with seizures or epilepsy have been made.
Methods: Between January 1, 1960 and December 31, 1964, we identified 224 incidence cases of unprovoked seizures in Iceland and determined survivorship status and date of death for the cases as of January 1, 1996. We compared survivorship with that expected based on data from age-/sex-specific life tables from the country for 1961–1990 and calculated the standardized mortality ratio (SMR).
Results: By 30 years after diagnosis, there were 45 deaths among patients with unprovoked seizures as compared with an expected 28 deaths [standardized mortality ratio (SMR) 1.6; 95% confidence interval (CI) 1.2–2.21. Patients with unprovoked seizures of unknown etiology did not have a significant increase in mortality overall (SMR 1.3, 95% CI 0.8–1.9) or in any time interval. For patients with remote symptomatic un provoked seizures, mortality was increased (SMR 2.3, 95% CI 1.4–3.5). This increase was attributable to excess mortality for the first 15 years after diagnosis (SMR 4.1, 95% CI 2.4–6.6), and SMR was not different after that time.
Conclusions: Survivorship was decreased for the population of patients with unprovoked seizures. The increased mortality was primarily due to excess mortality in patients with remote symptomatic seizures, occurring in the first 15 years after diagnosis. Overall mortality for idiopathic unprovoked seizures was not significantly increased.     

Risk of mortality among patients with epilepsy in southern Taiwan

ObjectivePrevious studies suggested a higher risk of all-cause mortality in patients with epilepsy than in the general population. However, information on the age- and sex-specific risk of mortality, as well as on the cause-specific risk of mortality has been sparse. This study aims to determine sex-, age-, and cause-specific risk of mortality among patients with epilepsy from southern Taiwan.MethodsA total of 2180 patients treated in a tertiary hospital in southern Taiwan between 1989 and 2008 were compared to the general population of Taiwan for age-, sex- and cause-specific mortalities. The age-, sex-, and calendar year-standardized mortality ratios (SMRs) were calculated to estimate the relative risks of mortality associated with the epilepsy.ResultsThere are 266 (12.2%) deaths noted in the study period. The patients with epilepsy experienced a significantly increased SMR of all-cause mortality (SMR, 2.5; 95% confidence interval (CI), 2.2–2.8). The most significantly elevated age-specific SMR was 51.8 (95% CI, 6.2–187.2) and 8.6 (95% CI, 4.4–14.9) for male patients aged 0–9 years and female patients aged 20–29 years, respectively. Additionally, the most increased cause-specific SMR was noted for brain tumor (SMR, 21.4; 95% CI, 9.23–23.1), followed by accidental drowning (SMR, 8.8; 95% CI, 3.5–9.6) and falls (SMR, 5.7; 95% CI, 2.2–6.1).ConclusionYounger epilepsy should be the object of aggressive treatments. Advancement in treating brain tumors and prevention of accidental injuries may help improve the survival of patients with epilepsy.     

Mortality among discharged psychiatric patients in Florence, Italy

OBJECTIVE: Psychiatric disorders involve an increased risk of mortality. In Italy psychiatric services are community based, and hospitalization is mostly reserved for patients with acute illness. This study examined mortality risk in a cohort of psychiatric inpatients for 16 years after hospital discharge to assess the association of excess mortality from natural or unnatural causes with clinical and sociodemographic variables and time from first admission. METHODS: At the end of 2002 mortality and cause of death were determined for all patients (N=845) who were admitted during 1987 to the eight psychiatric units active in Florence. The mortality risk of psychiatric patients was compared with that of the general population of the region of Tuscany by calculating standardized mortality ratios (SMRs). Poisson multivariate analyses of the observed-to-expected ratio for natural and unnatural deaths were conducted. RESULTS: The SMR for the sample of psychiatric patients was threefold higher than that for the general population (SMR=3.0; 95 percent confidence interval [CI]=2.7-3.4). Individuals younger than 45 years were at higher risk (SMR=11.0; 95 percent CI 8.0-14.9). The SMR for deaths from natural causes was 2.6 (95 percent CI=2.3-2.9), and for deaths from unnatural causes it was 13.0 (95 percent CI=10.1-13.6). For deaths from unnatural causes, the mortality excess was primarily limited to the first years after the first admission. For deaths from natural causes, excess mortality was more stable during the follow-up period. CONCLUSIONS: Prevention of deaths from unnatural causes among psychiatric patients may require promotion of earlier follow-up after discharge. Improving prevention and treatment of somatic diseases of psychiatric patients is important to reduce excess mortality from natural causes.     

Cause‐specific mortality among patients with epilepsy: Results from a 30‐year cohort study

Purpose: Death rates of patients with epilepsy are two to three times higher than expected. The aim of our study was to further delineate the causes and the patterns of premature death in patients with epilepsy. Methods: We included all patients who were prospectively enrolled between 1970 and 1999 in our epilepsy outpatient clinical database. Patients were followed until death or December 31, 2003. Standardized mortality ratios (SMRs) were calculated using reference rates from the same region. Key Findings: After 48,595 person years of follow‐up, 648 of 3,334 patients had died, resulting in an overall SMR of 2.2 (95% confidence interval [CI] 2.0–2.4). The highest SMRs were for patients aged 26–45 years (6.8, 95% CI 3.8–11.2) and with symptomatic epilepsies (3.1, 95% CI 2.3–4.9); those for cryptogenic causes (2.2, 95% CI 1.6–3.1) were also elevated, whereas those for idiopathic causes were not increased (2.7, 95% CI 0.7–7.0) after 2 years of follow‐up. SMRs for patients with persistent seizures (3.3, 95% CI 2.6–4.4) were higher than those for seizure‐free patients (1.4, 95% CI 0.8–2.3). The highest cause‐specific SMRs were for epilepsy (91.6, 95% CI 66.3–123.4), brain tumors (22.7, 95% CI 15.7–31.8), and external causes (2.4, 95% CI 1.8–3.3) at end of study period. Significance: Epilepsy patients have a higher‐than‐expected risk of death throughout life and especially during the first 2 years following diagnosis. Standardized mortality rates were especially high in younger patients and in patients with symptomatic epilepsies. Persistent seizures are strongly related to excess mortality.     

Mortality in Parkinson's disease: A 20‐year follow‐up study

We determined mortality rates and predictors of survival in 238 consecutive patients with Parkinson's disease (PD) with symptom onset between 1974 and 1984. All patients were regularly followed at the Movement Disorder Clinic (Department of Neurology at the Innsbruck Medical University) until December 31, 2004, or death. As of December 31, 2004, 189 patients had died. Standardized mortality ratios (SMRs) increased over time. SMRs were 0.6 (95% CI 0.4–1.0) by 5 years, 0.9 (95% CI 0.7–1.2) by 10 years, 1.2 (95% CI 1.0–1.4) by 15 years, and 1.3 (95% CI 1.1–1.5) by 20 to 30 years. SMR for male patients was significantly increased to 1.3 (95% CI 1.1–1.6), whereas SMR increase of 1.2 (0.9–1.4) observed in female patients was not significant. Significantly increased SMRs were detected in patients with younger and older age of onset. Male gender, gait disorder, lack of tremor, and lack of asymmetry as presenting clinical features predicted poor survival in a Cox's proportional hazard analysis. This study demonstrates similar survival of patients with PD to the normal control population up to a disease duration of 10 years, followed by a modest rise of mortality with disease duration beyond 10 years compared with the general population. Under regular specialist care using all currently available therapies life expectancy in PD does not appear seriously compromised, but male gender, gait disorder, and absent rest tremor at presentation are associated with poorer long‐term survival. © 2009 Movement Disorder Society     

Long-term outcome after aneurysmal subarachnoid hemorrhage—risks of vascular events,death from cancer and all-cause death

Smoking and hypertension are risk factors for aneurysmal subarachnoid hemorrhage (aSAH), but also for other cardiovascular diseases and cancer. Few prospective data are available on the very long term risks of vascular diseases and vascular, cancer-related and overall death after aSAH. We determined vascular events and survival status in 1,765 patients with aSAH admitted to our center from 1985 to 2010. Cumulative risks were estimated with survival analysis. We compared risks of vascular, cancer-related and all-cause death with the general population with standardized mortality ratios (SMRs). Incidences of vascular events and death were compared with those after TIA/minor stroke. Conditional on surviving 3 months after aSAH, the risk of death was 8.7 % (95 % CI 7.3–10.1) within 5 years, 17.9 % (16.1–19.9) within 10 years, 29.5 % (27.3–31.8) within 15 years, and 43.6 % (41.2–46.1) within 20 years after SAH. The SMR for all-cause death was 1.8 (1.6–2.1), for vascular death 2.0 (95 % CI 1.6–2.5) and for cancer-related death 1.2 (0.9–1.5; sensitivity analysis 1.4; 95 % CI 1.1–1.8). The increased SMR for all-cause death persevered up to 20 years after aSAH. Compared with TIA/minor stroke patients, the age- and sex-adjusted cumulative incidence on vascular events was lower for aSAH patients [hazard ratio (HR) 0.48; 95 % CI 0.40–0.57); the HR for all-cause death was 0.96 (95 % CI 0.84–1.10). After aSAH, risks of vascular events and death, and probably also that of cancer-related death, are higher than in the general population. Although the long-term risk of vascular events was lower in aSAH patients than in TIA/minor stroke patients, the risk of death was similar.     

Causes of death in patients with multiple sclerosis and matched referent subjects: a population‐based cohort study

Background and purpose: Multiple sclerosis (MS) has been associated with increased mortality rates. However, influence of lifestyle parameters remains unknown, and inconsistencies exist regarding findings for causes of death. Methods: We conducted a population‐based cohort study using the General Practice Research Database, Hospital Episode Statistics, and national death certificates (January 2001 through March 2008). To each patient with MS (n = 1270), up to six referent subjects without MS were matched by age, gender, and practice. Cox proportional hazards models were used to estimate mortality rate ratios (HRs). Results: Patients with MS had a 3.5‐fold increased mortality rate for all‐cause mortality, compared with referent subjects (HR 3.51, 95% CI 2.63–4.69). The rate further increased amongst current smokers (HR 6.72, 95% CI 4.16–10.87) (but not in ex‐smokers) and subjects with a body mass index of <20 kg/m² (HR 6.67, 95% CI 3.50–12.73). The HR was highest for infectious/respiratory‐related deaths (HR 7.69, 95% CI 4.92–12.02) and was significantly increased for deaths related to cardiovascular diseases (2.4‐fold) and cancer (1.9‐fold), but not for accidents and suicide related deaths. Conclusion: British patients with MS have a 3.5‐fold increased mortality rate compared with the general population. Smoking and respiratory diseases are major (potentially preventable) factors related to increased mortality rate amongst patients with MS.     

Incidence and method of suicide mortality in patients with schizophrenia: a Nationwide Cohort Study

Purpose

Suicide is a leading cause of death in patients with schizophrenia. This nationwide cohort study investigated the incidence of each suicide method in patients with schizophrenia compared with the general population.

Methods

In total, records of 174,039 patients with schizophrenia were obtained from the National Health Insurance Research Database in Taiwan from 2001 to 2016. This schizophrenia cohort was linked with the national mortality database, and 26,926 patients died during this follow-up period. Of the deceased, 3033 had died by suicide. Univariate Cox regression was used to estimate the demographic variables associated with suicide. We estimated the difference in the proportion of each suicide method used in patients with schizophrenia compared with the general population. The incidence and standardized mortality ratio (SMR) of each suicide method were calculated and stratified based on sex.

Results

Patients aged 25–34 years exhibited the highest suicide risk. Compared with the general population, patients with schizophrenia were more likely to commit suicide by jumping and drowning and less likely to use charcoal-burning and hanging. Women showed a higher incidence of suicide by drowning and jumping than did men. Comorbidity with substance use disorders (SUDs) was associated with a high suicide SMR (26.9, 95% confidence interval [CI] = 23.4–28.9), particularly for suicide by jumping (61.2, 95% CI = 48.3–76.3).

Conclusions

Patients with schizophrenia had higher suicide rates for all methods than did the general population. Suicide method differed based on sex. Patients with SUDs exhibit a high SMR for each suicide method and warrant intensive clinical attention.

     

Long term risks of stroke,myocardial infarction,and vascular death in "low risk" patients with a non-recent transient ischaemic attack

BACKGROUND: Previous studies of prognosis after a transient ischaemic attack (TIA) have recruited patients soon after the event, when the risk of stroke is very high. However, the majority of patients survive for many years after a TIA, and the need for continued preventive treatment to lower vascular risk will need to be reassessed at a later date. OBJECTIVE: To determine the long term risks of stroke and other vascular events in patients with TIA who survive the initial high risk period. METHODS: 290 patients were studied who had initially been followed up after a TIA in the Oxford community stroke project and in a contemporaneous hospital based cohort study, and who were alive and stroke-free at the end of planned follow up in 1988. All patients were followed for a further 10 years, and the risks of major vascular events (stroke, myocardial infarction, vascular death) were determined. Standardised mortality ratios (SMR) were calculated from the observed numbers of fatal events and the number expected on the basis of age and sex in the general population. RESULTS: Median time since last TIA was 3.8 years (interquartile range, 2.2 to 5.8 years). The risk of major vascular events was constant through time. The 10 year risk of first stroke was 18.8% (95% confidence interval (CI), 13.6 to 23.7; 45 events). The 10 year risk of myocardial infarction or death from coronary heart disease was 27.8% (95% CI, 21.8 to 33.3; 67 events) and there was a significant excess of fatal coronary events compared with that expected in the general population (SMR = 1.47; 95% CI, 1.10 to 1.93; p = 0.009). A total of 114 patients had at least one major vascular event, with a 10 year risk of any first stroke, myocardial infarction, or vascular death of 42.8% (95% CI, 36.4 to 48.5). CONCLUSIONS: The overall risk of major vascular events remains high for 10 to 15 years after a TIA. It is important therefore that preventive treatments are continued in the long term, even in apparently "low risk" patients who have already survived free of stroke for several years.     

Influence of Epilepsy on Mortality in Mental Retardation: An Epidemiologic Study

Summary: Purpose : A cohort consisting of all persons with known mental retardation (MR) and living in a Swedish province on December 31, 1985, was followed for 7 years (1987–1992) to study the mortality pattern.
Methods : A file of the cohort was linked to the cause-of-death pattern of the general population in the study area.
Results : One hundred twenty-four deaths (8.4%) occurred among the 1,478 persons with MR. Thirty deaths (10.1%) occurred among the 296 persons with epilepsy and MR. The standardized mortality ratio (SMR) in those with only MR was significantly increased as compared with that of the general population: 1.6 [95% confidence interval (CI) 1.3–2.01; MR and epilepsy, 5.0 (CI 3.3–7.5); and MR, epilepsy, and cerebral palsy (CP), 5.8 (CI 3.4–9.7). Mortality was increased both in patients with partial seizures without seizures secondarily generalized (SMR 3.7, CI 1.0–13.6) and in patients with seizures secondarily generalized (5.0, CI 2.3–11.0). The highest mortality occurred in patients who had seizures that were always generalized from the onset: 8.1 (CI 5.7–11.5). Mortality increased with increasing seizure frequency during the year preceding the prevalence date. In patients with epilepsy and MR, pneumonia was the most common cause of death and a seizure was the probable cause of death in 6.7%.
Conclusions : Epilepsy is associated with a significantly increased mortality in persons with MR. The increase is related to seizure type and seizure frequency. Death in persons with epilepsy and MR is seldom directly due to seizures. Other impairments associated with epilepsy and MR are important causes of death.     

One-Year Mortality in Bordeaux Cohort: The Value of Syndrome Classification

Summary:  Purpose: To evaluate the usefulness of the International Classification of Epilepsy Syndromes for 1-year mortality in a prospective incidence study of first epileptic seizures.
Methods: Date and cause of death from the treating physician in an incidence study of first afebrile seizures collected 15 years ago in Southwest France. Cases were classified by epilepsy syndrome. A total of 804 patients were included: acute symptomatic (n = 277), unprovoked (n = 439), or unclassifiable (n = 88).
Results: One hundred and fifty-one patients died within the first year: none with idiopathic partial or generalized epilepsy, 16/104 with symptomatic (standardized mortality ratio (SMR) 6.4, 95% CI 3.6–10.3), 1/59 with cryptogenic (SMR 1.7, 95% CI 0.1–9.7 CI) partial epilepsy, 1/14 (SMR 28.1, 95% CI 0.4–156.6) with symptomatic/cryptogenic generalized epilepsy, 2/23 with undetermined epilepsy, 1/135 with isolated seizure (SMR 0.6, 95% CI 0.1–3.1), and 90/277 (SMR 10.3, 95% CI 8.3–12.7) with acute symptomatic seizures. Unclassifiable seizures could not be classified as acute symptomatic or unprovoked: associated with alcohol abuse (death: 3/32, SMR 7.7, 95% CI 1.6–22.6), brain tumors (death: 31/39, SMR 41.5, 95% CI 28.2–58.9), and dementia (death: 6/17, SMR 5.4, 95% CI 2.0–11.7). Most deaths were due to progression of underlying disease, only 5.9% were seizure-related.
Conclusions: Although a syndromic diagnosis is important for treatment decisions and some prognostic aspects of seizure disorders, its value in mortality studies is limited. Mortality can be calculated only at the first (partial, generalized, and undetermined epilepsies, and special syndromes) and the second (idiopathic vs. symptomatic or cryptogenic) levels of the International Classification of Epilepsies.