Mortality and Causes of Death in Celiac Disease in a Mediterranean Area

No data on mortality in celiac disease arecurrently available in southern Europe. Our aim was toevaluate mortality and the cause of death in adultceliac disease in a Mediterranean area. In all, 228adults with celiac disease were histologicallydiagnosed in our department from 1980 to 1997. Fullinformation on their state of health was obtained in 216of 228 patients. A tabulation of patient-years at risk was constructed in terms of age at diagnosisand the interval from diagnosis. Standardized mortalityratio was calculated by dividing the number of observeddeaths by the number of expected deaths. Twelve deaths were observed, whereas 3.12 deaths wereexpected (SMR = 3.8; 95% CI 2-7). The increasedmortality was mainly observed within four years fromdiagnosis (8 observed; 1.4 expected) (SMR = 5.8; 95% CI 2.5-11.5). Twelve tumors were observed (sixlymphomas). In conclusion, mortality from adult celiacdisease in our geographical area is increased comparedwith the general population, and this increased risk seems due to non-Hodgkin'slymphoma.     

Long-term mortality in people with celiac disease diagnosed in childhood compared with adulthood: a population-based cohort study

INTRODUCTION: To explore whether the excess mortality in celiac disease is related directly to the disease and duration of gluten exposure before diagnosis we have examined the long-term mortality experience of people with celiac disease diagnosed as children and as adults. METHODS: Two hundred eighty-five children and 340 adults diagnosed with celiac disease were followed until death, loss to follow-up, or December 31, 2004. We calculated standardized mortality ratios (SMRs). RESULTS: All-cause mortality more than 5 yr after diagnosis was increased threefold in children (SMR 3.32, 95% CI 2.05-5.07) compared with only a 38% increase in adults (SMR 1.38, 95% CI 1.16-1.63). This excess mortality in children was primarily because of an increased risk of death from accidents, suicide, and violence (seven deaths, SMR 3.22, 95% CI 1.29-6.63), cancer (five deaths, SMR 3.72, 95% CI 1.21-8.67), and cerebrovascular disease (two deaths, SMR 10.03, 95% CI 1.21-36.00). CONCLUSIONS: Children diagnosed with celiac disease had a threefold increased risk of long-term mortality. This is in marked contrast to the experience of adult celiac disease where the long-term increase of mortality was modest. The increased mortality in children from external causes may reflect behavioral change associated with coping with a chronic disease and its treatment.     

Mortality in diabetes mellitus: experience of a geographically defined population.

A population-based cohort study identified 915 deaths in 4186 patients with diabetes mellitus over a 5-year period. Ischaemic heart disease, cerebrovascular disease and malignant neoplasms were the major causes of death and accounted for 40%, 16%, and 14% of deaths, respectively, compared with 27%, 14%, and 25% of deaths in the non-diabetic population. Diabetic patients had a standardized mortality ratio (SMR) of 1.15 (95% Cl 1.08-1.22) (p less than 0.001). This excess risk of death was largely due to the excess death from ischaemic heart disease (SMR 1.55 (1.40-1.71); p less than 0.001) and the impact was greatest in middle-aged female patients. Stroke mortality was not significantly increased (SMR 1.09 (0.92-1.29)) while cancer mortality was reduced (SMR 0.75 (0.63-0.89); p less than 0.01). Death rates in diabetic male patients (SMR 1.04 (0.96-1.13)) did not differ significantly from those in non-diabetic male patients because the increased risk of ischaemic heart disease deaths (SMR 1.41 (1.22-1.62); p less than 0.001) was offset by the reduced risk of deaths from malignant neoplasms (SMR 0.65 (0.51-0.82); p less than 0.001). The reduction in cancer mortality did not reach statistical significance in diabetic women (SMR 0.82 (0.64-1.05)). Diabetic nephropathy and metabolic disasters were uncommon as causes of death.     

Immune complexes and complement abnormalities in patients with cystic fibrosis. Increased mortality associated with circulating immune complexes and decreased function of the alternative complement pathway

Serum samples from 139 patients with cystic fibrosis (CF) were tested for complement abnormalities and circulating immune complexes (CIC). We found no consistent changes in whole complement activity. However, we found CIC in 29% of these patients and decreased activity of the alternative complement pathway (ACP) in 36%. During 5 yr of observation, mortality was much higher in patients whose sera contained CIC (p less than 0.001) or decreased ACP activity (p less than 0.01). Of patients with both abnormalities, 31% died; however, no deaths occurred in patients with normal ACP activity and negative tests for CIC (p less than 0.001). During a subsequent 2.5-yr period, 55% of patients greater than or equal to 21 yr old with both findings died. In contrast, no deaths occurred in older patients lacking this combination (p = 0.0062). Circulating immune complexes but not decreased ACP activity were an independent risk factor for death. Our findings support the hypothesis that humoral immune mechanisms may contribute to morbidity and mortality in CF.     

Mortality and causes of death in Crohn's disease: follow-up of a population-based cohort in Copenhagen County,Denmark

BACKGROUND & AIMS: A population-based cohort comprising 374 patients with Crohn's disease diagnosed in Copenhagen County between 1962 and 1987 was observed until 1997 for mortality and causes of death. METHODS: Observed deaths were compared with expected deaths calculated by using individually computed person-years at risk and 1995 rates for Copenhagen County. Cumulative survival curves were calculated. RESULTS: A total of 84 deaths occurred vs. 67 expected (standardized mortality ratio [SMR], 1.3; 95% confidence interval [CI], 1.01-1.56): 45 women vs. 31.8 expected (SMR, 1.4; 95% CI, 1.03-1.89) and 39 men vs. 35.2 expected (SMR, 1.1; 95% CI, 0.79-1.51). An excess mortality was observed among women observed for 21-25 years after diagnosis. Among women aged <50 years at diagnosis, 25 deaths were observed vs. 7.3 expected (SMR, 3.42; 95% CI, 2.21-5.04). Fourteen (31%) of the observed deaths among women and 8 (21%) among men had a certain or possible connection to Crohn's disease. Among causes of death unrelated to Crohn's disease, an overrepresentation of gastrointestinal diseases, infections, and diseases of the urinary organs was observed. CONCLUSIONS: An increased mortality was observed late in the disease course that was most pronounced among women younger than 50 years at diagnosis and was attributed to death associated with severe Crohn's disease.     

Mortality factors associated with chronic pancreatitis. Unidimensional and multidimensional analysis of a medical-surgical series of 240 patients

The purpose of the study was to determine (a) the frequency and cause of mortality in patients with chronic pancreatitis; (b) the cumulative survival rates corrected by comparison of patients with a matched French population; and (c) the factors associated with mortality by a unidimensional and multidimensional analysis. The study population consisted of 240 patients (men = 208, women = 32; alcoholic = 210, nonalcoholic = 30) followed for a mean time of 8.7 yr. The status of the patients (dead or alive) was recorded in February 1987. Mean age at onset of chronic pancreatitis was 41.5 yr. Fifty-seven patients died. Mean age at time of death was 52.3 yr. "Overmortality" after 20 yr of course was 35.8% in comparison with a matched French population (p less than 0.0001). Chronic pancreatitis was the direct cause of death for only 19.3% of patients. The main causes of death have been alcoholic hepatopathy (n = 10), cancer (n = 9), postoperative mortality (n = 8). Unidimensional analysis of mortality rates showed that male sex (p less than 0.03), surgery (p less than 0.007), hepatopathy (p less than 0.01), diabetes mellitus (p less than 0.02), and absence of attack of acute pancreatitis (p less than 0.02) were associated with mortality. Multidimensional analysis showed that the following variables were linked with mortality: in a first model including the totality of the study population: surgery (p less than 0.006), hepatopathy (p less than 0.008), no attack of acute pancreatitis (p less than 0.03), male sex (p less than 0.03); in a second model excluding cirrhosis: surgery (p less than 0.001), male sex (p less than 0.06), diabetes mellitus (p less than 0.09). Nevertheless, surgery did not seem to interfere with long-term mortality. The lower mortality of patients with attacks of acute pancreatitis suggests a favorable influence for alcohol abstinence.     

Pituitary adenomas in Sweden between 1958 and 1991: incidence, survival, and mortality

The objective of the present study was to determine the incidence of pituitary adenomas (PAs) and the associated rates and causes of mortality in a large population. The study population comprised 2279 patients (1010 women and 1269 men) of all individuals (n = 3321) with pituitary tumors included in the Swedish Cancer Registry between 1958 and 1991. The mean age (+/-SD) at diagnosis was 52.3 +/-15.7 yr. The age-standardized incidence of PA increased significantly from approximately 6 cases/million inhabitants in 1958 to 11 cases/ million in 1991. The age-specific incidence peaked between 60-70 yr of age in both sexes. Excess mortality was found in the study population. The total number of deaths was 842. The standardized mortality ratio (SMR) for the study population was 2.0. The SMR for women (2.3) was significantly (P < 0.01) higher than that for men (1.9). Cardiovascular diseases were the most common cause of mortality among patients, accounting for 346 deaths (SMR, 1.6). The difference between the sexes was significant (men, 1.4; women, 1.8; P < 0.05). Cerebrovascular death occurred in 97 patients (SMR, 2.4), with no significant difference between men (SMR, 2.5) and women (SMR, 2.2). Excess mortality was also observed for tumors, endocrine diseases, and gastrointestinal diseases. These findings suggest that the annual incidence of PA is increasing. Possible explanations are improved diagnostic skill and/or increased awareness of pituitary diseases among physicians. However, a real increase in the incidence of PA cannot be ruled out.     

Survival and causes of death in patients with inflammatory bowel disease: a population-based study.

Relative survival up to December 31, 1986 was analyzed for all patients diagnosed with ulcerative colitis (UC) (n = 2,509) and Crohn's disease (CD) (n = 1,469) within the Uppsala Region, Sweden 1965-1983. After 10 years survival was 96% of that expected for UC and CD. Patients with ulcerative proctitis, left-sided colitis, and pancolitis at diagnosis had relative survival rates of 98%, 96%, and 93% respectively. Survival did not differ by extent at diagnosis for patients with CD. After including prevalent cases, 684 deaths occurred compared with 481.1 expected deaths [standardized mortality ratio (SMR) = 1.4; 95% confidence interval (CI) = 1.3-1.5]. Inflammatory bowel disease was the main reason for this excess mortality. Colorectal cancer increased mortality (50 deaths observed vs. 15.2 expected). Death from other cancers were not greater than expected. Obstructive respiratory diseases, especially bronchitis, emphysema, and asthma increased mortality SMR = 1.5 (95% CI = 1.1-2.2) in UC. Cerebrovascular disease mortality occurred less often than expected (SMR = 0.7; 95% CI = 0.5-1.0). Mortality for other diseases and groups of diseases was close to that expected.     

Survival and cause-specific mortality in ulcerative colitis: follow-up of a population-based cohort in Copenhagen County

BACKGROUND & AIMS: A population-based cohort from Copenhagen County comprising 1160 patients diagnosed with ulcerative colitis between 1962 and 1987 was followed-up until 1997 to describe survival and cause-specific mortality. METHODS: Observed vs. expected deaths were presented as standardized mortality ratio (SMR) with exact 95% confidence intervals (CI) calculated by using individually registered person-years at risk and Danish 1995 mortality rates. Cumulative survival curves were calculated. RESULTS: A total of 261 deaths occurred, not significantly different from the expected number of 249 (SMR, 1.05; 95% CI, 0.92-1.19). The median age at death among men was 70 years (range, 6-96 years) and among women 74 years (range, 25-96 years). Twenty-five deaths (9.6%) were caused by complications to ulcerative colitis, mostly infectious and cardiovascular postoperative complications. Patients older than 50 years of age at diagnosis and with extensive colitis showed an increased mortality within the first 2 years because of ulcerative colitis-associated causes. The mortality from colorectal cancer was not increased and that of cancer in general was significantly lower than expected: 50 vs. 71 (SMR, 0.70; 95% CI, 0.52-0.93). A significantly increased mortality from pulmonary embolism and pneumonia was found. Among women only, death from genitourinary tract diseases and suicide was significantly increased. CONCLUSIONS: Despite an overall normal life expectancy for patients with ulcerative colitis, patients >50 years of age and with extensive colitis at diagnosis had increased mortality within the first 2 years after diagnosis, owing to colitis-associated postoperative complications and comorbidity.     

Outcome of patients with newly diagnosed atrial fibrillation at the Mayo Clinic and residing in that area

This study examined the prognostic significance of atrial fibrillation (AF) in a community-based cohort. AF, the most common cardiac dysrhythmia, frequently occurs in the presence of concomitant medical illness. Population-based studies have associated AF with excess mortality, and this risk of death is independent of concomitant cardiovascular disease. The effect of noncardiovascular medical illnesses on mortality in patients who have AF has not been determined. We examined a community-based cohort of 390 residents of Olmsted County, Minnesota, who had newly diagnosed AF; patients were identified retrospectively but followed prospectively. The cohort included all patients who had electrocardiographically proved first-onset AF; patients were not excluded on the basis of medical illness. Mean age of the cohort was 73 +/- 14 years (56% were men). Mean follow-up was 2.7 +/- 1.7 years. Onset of AF frequently occurred during hospitalization (78%). One hundred sixty-six deaths occurred, a death rate significantly higher than expected for the cohort. Most deaths had a noncardiovascular cause. This trend was maintained for patients who had no previous cardiovascular disease and for those who had a cardiovascular diagnosis at the time AF was diagnosed. AF is observed frequently among hospitalized patients who are medically ill. The survival rate of these patients is low, but AF may be only a minor component of the excess mortality.     

Patterns of referral and recovery in women and men undergoing coronary artery bypass grafting.

This study compares women and men undergoing coronary artery bypass grafting. Factors before and after coronary surgery were examined to identify variables related to mortality and morbidity. The study population included 465 women and 465 men matched for age (mean age 64.2 years) who underwent first time isolated coronary artery bypass grafting between 1983 and 1988. There were higher incidences of systemic hypertension, diabetes mellitus, postmyocardial infarction angina, thyroid gland disease, arthritis (p less than 0.001 for all), acute myocardial infarction (p = 0.03), congestive heart failure (p = 0.03), and emergency surgery (p = 0.02) in women, whereas more men had peptic ulcer disease (p less than 0.001). The in-hospital death rate was not significantly different (women 4.3% vs men 3.7%). For all subjects, emergency surgery (p less than 0.001), significant left main narrowing (p less than 0.05) and renal disease (p less than 0.001) were related to death, whereas history of myocardial infarction (p less than 0.05) and diabetes (p less than 0.05) were related to death only in men. Age and body surface area were not related to death. After surgery men had a higher incidence of atrial arrhythmia (p less than 0.001), and women had a higher incidence of congestive heart failure (p less than 0.001). Although women did not have a higher mortality rate, the data suggest that women and men do not share all the same predictors of mortality after surgery.     

Low mortality in ulcerative colitis and Crohn's disease in three regional centers in England

OBJECTIVES: Recent epidemiological studies suggest that mortality rates for inflammatory bowel disease (IBD) are similar to those of the general population. However, most of this work has been done in referred populations or larger urban centers. We intended to estimate mortality rates for ulcerative colitis (UC) and Crohn's disease (CD) in three British district general hospital practices in Wolverhampton, Salisbury, and Swindon. METHODS: Consecutive patients with CD or UC were identified from 1978 to 1986 and followed prospectively. Demographic data, date and cause of death or health status at December 31, 1993 were used to estimate standardized mortality ratios (SMRs) and 95% confidence intervals. RESULTS: Sixty-four deaths occurred in 552 patients (UC 41 of 356; CD 23 of 196). The overall SMRs were 103 [95% confidence interval (CI): 79-140] for UC and 94 (95% CI: 59-140) for CD. The respective SMRs were higher only in the first year after diagnosis at 223 (95% CI: 99-439; p = 0.02) and 229 (74-535; p = 0.056), and even then, most subjects died from non-IBD causes (5 of 13). Nonsurvivors were significantly older than survivors in both UC and CD (p < 0.01). The SMR was also significantly greater during a severe first attack of UC at 310 (95% CI: 84-793; p = 0.04). Patients with perianal or colonic CD had an increased SMR [396 (95% CI: 108-335; p = 0.02) and 164 (95% CI: 82-335; p = 0.02)] respectively, partly related to the older mean age (52 vs 32 yr, p < 0.001). CONCLUSIONS: Mortality rates are not increased in IBD compared with the general population. However, older patients may be at increased risk of dying from other causes early in the disease clinical course.     

A long-term follow-up study of Japanese diabetic patients: Mortality and causes of death

A systematic 20-year follow-up study of 1,221 diabetic patients was carried out in Osaka, Japan. The mean annual mortality rates were 2.55% for men and 1.64% for women. The ratios of observed to expected numbers of deaths were 1.50 for men and 1.39 for women, indicating an excess mortality for diabetic patients of both sexes, and higher mortality in men than in women. Factors that predisposed diabetic patients to premature death were early age of onset, albuminuria, diabetic retinopathy and fasting glucose level greater than 11.1 mmol/l at the initial examination. Insulin dependence was also associated with poor prognosis. Cerebro-cardiovascular and renal diseases were the major causes of death in the diabetic patients; heart disease was the cause of death in 16.9%, cerebrovascular disease in 16.4% and renal disease in 11.9%. The relatively high incidence of renal disease as cause of death in diabetic patients was striking. Malignant neoplasms of liver and of pancreas and cirrhosis were also associated with increased ratio of observed to expected number of deaths in the patients.     

Mortality in rheumatoid arthritis. Increased in the early course of disease, in ischaemic heart disease and in pulmonary fibrosis

OBJECTIVE: To examine the cause of death in a large UK inception cohort of rheumatoid arthritis (RA), and whether this was related to disease duration and severity, treatment effects or extra-articular features and complications of RA. METHODS: Standard clinical, laboratory, radiological and socio-economic measures were recorded at baseline and yearly in an inception cohort started in nine centres in 1986. Date and the cause of death were based on death certificates and the comparisons made with age and sex matched population figures. Risk factors for mortality were identified from baseline measures of disease. RESULTS: There were 459 deaths (32%) in 1429 patients followed for up to 18 yrs. Standard mortality ratio was 1.27. Survival was significantly lower in the first 7 yrs of RA. Excess mortality was seen in cardiovascular disease (31%), pulmonary fibrosis (4%) and lymphoma (2.3%). Baseline predictors for mortality were men, older age, poor function, lower socio-economic status, extra-articular features, comorbidity, rheumatoid factor, X-ray erosions, high-ESR and low-haemoglobin. CONCLUSION: There was a modest increase in mortality in RA, mainly in the first 7 yrs. Deaths from cardiovascular disease and pulmonary fibrosis were higher than expected, but treatment-related deaths were low. Risk factors included less favourable socio-economic status, markers of disease severity and diminished function within the first year.     

Heart failure in a cold climate. Seasonal variation in heart failure-related morbidity and mortality

OBJECTIVES: This study was done to determine whether seasonal variation exists in hospitalizations and deaths due to heart failure (HF) and to examine possible contributors to such variability. BACKGROUND: Although seasonal variation in the incidence of acute myocardial infarction and sudden death is well recognized, it is less well documented in HF. METHODS: We used the linked Scottish Morbidity Record scheme, which provides individualized morbidity and mortality data for the entire Scottish population. RESULTS: Between 1990 and 1996, there were a total of 75,452 male and 81,269 female hospitalizations related to HF in Scotland, with an average rate of admissions per 100,000 population of 8.4 and 8.5 per day, respectively. Significantly more admissions occurred in winter compared to summer (p < 0.0001). In women, the peak rate of admission occurred in December (12% more than average) and the lowest rate in July (7% less than average) (odds ratio [OR] 1.14, p < 0.001). The respective figures for men were 6% more, 8% less (OR 1.16, p < 0.001). In both genders, the greatest variation occurred in those aged >75 years---peak winter rates being 15% to 18% higher than average. There was also a winter peak in concomitantly coded respiratory disease; this seasonal excess accounted for approximately one-fifth of the winter increment in HF hospitalizations. Seasonal variation in mortality was also seen in these patients. The number of male deaths in December was 16% higher, and in July 7% lower, than average (OR 1.25, p < 0.001). In women, the equivalent figures were 21% higher (January) and 14% lower (July) (OR 1.21, p < 0.001). Again, the greatest variation occurred in those aged >75 years---peak rates being 23% to 35% higher than average. CONCLUSIONS: There is substantial seasonal variation in HF hospitalizations and deaths, particularly in the elderly. Approximately one-fifth of the winter excess in admissions is attributable to respiratory disease. Extra vigilance in patients with HF is advisable in winter, as is immunization against pneumococcus and influenza.     

Postmortem findings in sudden and non-sudden deaths among Japanese-American men in Hawaii

Analyses were made of the cause of death and major pathologic findings among 1,085 autopsied Japanese-American men in Hawaii to determine the differences between the 167 men who experienced sudden death within 24 hours of being well and the 918 men with non-sudden death. Sudden deaths were further divided into three subgroups according to the interval from the onset of symptoms to death: (less than one hour; one to six hours; more than six hours). Nearly 90 percent of sudden deaths and 25 percent of non-sudden deaths were attributed to cardiovascular disease. The proportion of deaths due to coronary heart disease was highest in sudden deaths less than one hour (72 percent) and lowest in sudden deaths more than six hours (49 percent), whereas the proportion of stroke deaths was highest in sudden deaths more than six hours (37 percent) and lowest in sudden deaths less than one hour (9 percent). The prevalence of myocardial infarction and the grade of coronary atherosclerosis were also significantly greater for sudden deaths (especially sudden deaths less than one hour) than for non-sudden deaths.     

Is respiratory mucus hypersecretion really an innocent disorder? A 22-year mortality survey of 1,061 working men

The relation of chronic air-flow limitation and respiratory mucus hypersecretion to all causes of mortality was studied in a population of 1,061 men working in the Paris area, surveyed initially in 1960/1961, and followed for 22 yr. During this period, 369 deaths occurred; VC, FEV1, FEV1/H3, and FEV1/VC were significantly associated with mortality, even when age, smoking, occupational dust exposure, and chronic phlegm were taken into account. Besides the obstructive disorder, the hypersecretory disorder (chronic phlegm) was significantly associated with mortality. Controlling, using Cox's model, for age, FEV1/H3, smoking habits, and dust exposure, all factors associated with chronic mucus hypersecretion and mortality, showed that phlegm production remained significantly related to death (relative risk, = 1.35; p less than 0.01). Although relatively weak, this relationship is not negligible in terms of public health because of the high prevalence of chronic phlegm.     

Long-term predictors of sudden and low output death in chronic congestive heart failure secondary to coronary artery disease

Clinical, hemodynamic and neurohumoral variables in 238 patients with chronic congestive heart failure (CHF) secondary to coronary artery disease were analyzed to determine potential predictors of mortality in a large population and to allow analysis according to mode of death (sudden or low output death). All variables were assessed before initiation of treatment with vasodilators (converting enzyme inhibitors, direct acting vasodilators) or with the nonglycoside, noncatecholamine class of inotropic agents. Survival outcome was determined as alive, sudden death or low output death. When all variables except ejection fraction were analyzed by Cox multiple regression analysis, the most important independent predictor of all deaths was the baseline plasma renin activity (p less than 0.001). When subdivided by cause of cardiovascular death, baseline plasma renin activity was retained as the most important determinant of low output death (p less than 0.001), whereas baseline left ventricular stroke work index (p less than 0.001), pulmonary capillary wedge pressure (p less than 0.002) and absence of sinus rhythm (p less than 0.006) were the most powerful independent predictors of sudden death. Plasma norepinephrine was markedly elevated in the group dying of low output, but only modestly elevated in the group of survivors and the group dying suddenly. However, baseline norepinephrine was not found to be an important independent predictor of mortality in any of the subgroups. Plasma renin activity, but not plasma norepinephrine, is a powerful independent prognostic determinant of mortality in this group of patients with CHF.     

Sudden cardiac death after aortic valve surgery: incidence and concomitant factors

A retrospective analysis of 599 consecutive patients after aortic valve surgery aged 7-82 years (mean 56) was performed. During a follow-up of 1-14 years (mean 4.7 years) a 4-week perioperative mortality of 6.9% and a late annual mortality of 3.6% were observed. Sudden cardiac death was the most frequent single cause of death, accounting for 24% of all deaths. Patients dying suddenly were younger than patients dying from other causes (51 +/- 17 vs. 59 +/- 14 years, p less than 0.05) and showed more left ventricular hypertrophy by electrocardiographic criteria when compared with matched survivors (mean Estes score 5.2 +/- 2.4 vs. 2.8 +/- 1.9; p less than 0.01) and with patients dying nonsuddenly (mean Estes score 5.2 +/- 2.4 vs. 1.8 +/- 1.8; p less than 0.01). Ventricular premature beats in the resting electrocardiogram were more prevalent in patients dying suddenly than in matched survivors (55 vs. 20%; p less than 0.025) as well as in patients dying from other causes (55 vs. 25%; p less than 0.05). In addition, there were more intracardiac conduction disturbances and more ungrafted coronary vessels with insignificant stenoses at the time of surgery in sudden death patients. Our findings suggest that after aortic valve replacement patients with left ventricular hypertrophy, bundle-branch block, and ventricular premature beats in the resting electrocardiogram are at increased risk for sudden cardiac death. A possible etiological role of concomitant coronary artery disease must be considered.     

Factors influencing mortality in rheumatoid arthritis

The prognosis in rheumatoid arthritis respecting mortality was studied in a consecutive series of 489 hospital patients over a period of 18 years. The relative risk of mortality was raised in both men (2.6; p less than 0.001) and women (3.4; p less than 0.001). In the women the relative risk was also influenced by prior duration of RA and was characterised by a diminution in risk 5-9 years after first presentation. Relative risks for men were more uniformly distributed over time. Annual excess mortality rates were strongly associated with age at first presentation in women, the rate increasing with increasing age in both the group seen within 5 years of onset of disease (chi 2(1) for trend = 30.4; p less than 0.001) and in the later referral group (chi 2(1) = 34.0; p less than 0.001). A similar but much less marked effect was observed in men in the early referral group (chi 2(1) = 13.7; p less than 0.001) only. These results suggest that initially women may have a milder form of disease and that hormonal status may affect prognosis. Future long-term therapeutic studies in RA should take into account the prognostic factors of age, sex and duration of disease.