Piecemeal stewardship activities miss numerous social and environmental benefits associated with culturally appropriate ways of caring for country.

Prior research has identified both the contribution that people make to nature and the contribution that nature makes to people (by enhancing wellbeing) - with clear conceptual models to describe the interactions. Prior research has also made a clear case for incorporating insights from multiple perspectives and knowledge systems when seeking to better understand this interactive system. What is lacking, is guidance on how to operationalise some of these ideas to provide bespoke advice to environmental managers. Arguably, we have an adequate, albeit imperfect, understanding of how to operationalise (measure, value and/or otherwise account for) some parts of the conceptual model. There is, for example, abundant literature that describes different ways of valuing Ecosystem services, and a growing body of literature that describes and quantifies the ecological benefits of various stewardship activities, which will subsequently also generate an indirect benefit to people (since improved ecological conditions will improve Ecosystem services). In comparison, we know relatively little about the way in which stewardship activities directly benefit people - and it is on this gap that our paper focuses. We partially fill that knowledge gap by first reaching out to and learning from some of Australia's First Nations People. Key learnings underscore the inter-connectedness of the system, and the need for resource managers to not only monitor the extent and condition of natural system but also the extent and condition of an inextricably connected human system, in addition to the human-nature interactions. We clearly identify ways in which those insights can be used to improve and extend accounting frameworks, such as SEEA Ecosystem Accounts developed by the United Nations that are often used by natural resource managers. In so doing, we generate new insights about Indigenous stewardship (Caring for Country) and methods of accounting for and monitoring stewardship activities. As such, our work provides a practical illustration of one way to populate conceptual models with 'real world' data that also incorporates different world views, to support decision makers for improved social and environmental outcomes.

Psychometric properties of the DSM-5 social anxiety disorder dimensional scale in an Australian community sample.

OBJECTIVE: The Social Anxiety Disorder Dimensional Scale (SAD-D) is a 10-item scale developed by the Diagnostic and Statistical Manual (Fifth Edition) Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorder work group to supplement current dichotomous approaches to assessment of Social Anxiety Disorder (SAD). The aim of the present study was to evaluate the psychometric properties of the SAD-D in an Australian community sample. METHODS: Two-hundred and ninety-one participants (72.9% female) aged 18-76 years (M =28.46; SD = 12.30) completed the study. RESULTS: Confirmatory factor analysis indicated support for the unidimensional structure of the SAD-D (root mean square error of approximation [RMSE] = 0.08; comparative fit index [CFI] = 0.97). The measure demonstrated strong internal consistency (α = 0.94), as well as good divergent validity. The SAD-D showed excellent test-retest reliability (intraclass correlation coefficient [ICC] = 0.93). CONCLUSIONS: Overall, the SAD-D appears to be a brief and reliable measure of SAD symptomatology. Limitations, including the use of a predominantly female convenience sample, and failure to include the mental health and background of the sample, are discussed.

The economic burden of cancer, coronary heart disease, dementia, and stroke in England in 2018, with projection to 2050: an evaluation of two cohort studies.

BACKGROUND: Cancer, coronary heart disease, dementia, and stroke are major contributors to morbidity and mortality in England. We aimed to assess the economic burden (including health-care, social care, and informal care costs, as well as productivity losses) of these four conditions in England in 2018, and forecast this cost to 2050 using population projections. METHODS: We used individual patient-level data from the Clinical Practice Research Datalink (CPRD) Aurum, which contains primary care electronic health records of patients from 738 general practices in England, to calculate health-care and residential and nursing home resource use, and data from the English Longitudinal Study on Ageing (ELSA) to calculate informal and formal care costs. From CPRD Aurum, we included patients registered on Jan 1, 2018, in a CPRD general practice with Hospital Episode Statistics (HES)-linked records, omitting all children younger than 1 year. From ELSA, we included data collected from wave 9 (2018-19). Aggregate English resource use data on morbidity, mortality, and health-care, social care, and informal care were obtained and apportioned, using multivariable regression analyses, to cancer, coronary heart disease, dementia, and stroke. FINDINGS: We included 4 161 558 patients from CPRD Aurum with HES-linked data (mean age 41 years [SD 23], with 2 079 679 [50·0%] men and 2 081 879 [50·0%] women) and 8736 patients in ELSA (68 years [11], with 4882 [55·9 %] men and 3854 [44·1%] women). In 2018, the total cost was £18·9 billion (95% CI 18·4-19·4) for cancer, £12·7 billion (12·3-13·0) for coronary heart disease, £11·7 billion (9·6-12·7) for dementia, and £8·6 billion (8·2-9·0) for stroke. Using 2050 English population projections, we estimated that costs would rise by 40% (39-41) for cancer, 54% (53-55) for coronary heart disease, 100% (97-102) for dementia, and 85% (84-86) for stroke, for a total of £26·5 billion (25·7-27·3), £19·6 billion (18·9-20·2), £23·5 billion (19·3-25·3), and £16·0 billion (15·3-16·6), respectively. INTERPRETATION: This study provides contemporary estimates of the wide-ranging impact of the most important chronic conditions on all aspects of the economy in England. The data will help to inform evidence-based polices to reduce the impact of chronic disease, promoting care access, better health outcomes, and economic sustainability. FUNDING: Alzheimer's Research UK.

Psychometric properties of the Generalised Anxiety Disorder Dimensional Scale in an Australian sample.

The Generalised Anxiety Disorder Dimensional Scale is a new measure of generalised anxiety disorder developed to assist clinicians in the dimensional assessment of generalised anxiety disorder by the Diagnostic and Statistical Manual (Fifth Edition) Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorder Work Group. This study aims to evaluate the psychometric properties of the scale in an Australian community sample. A sample of 293 Australians (72.7% female) aged between 18 and 73 (M = 28.31 years; SD = 12.11 years) was recruited. Participants completed the Generalised Anxiety Disorder Dimensional Scale, as well as related measures used to assess convergent and discriminant validity. A small proportion of the sample (n = 21) completed the scale a second time to assess test-retest reliability. The scale demonstrated a unidimensional factor structure, good internal consistency (Cronbach's α = .94), good test-retest reliability (ICC = .85), good convergent validity with the Generalised Anxiety Disorder- 7 item (rs = .77), and discriminant validity with the Panic Disorder Severity Scale-Self Report (rs = .63). The scale appears to be a reliable and valid measure of generalised anxiety disorder symptomology for use in the Australian population.

Lithosphere architecture characterized by crust-mantle decoupling controls the formation of orogenic gold deposits.

This study, via combined analysis of geophysical and geochemical data, reveals a lithospheric architecture characterized by crust-mantle decoupling and vertical heat-flow conduits that control orogenic gold mineralization in the Ailaoshan gold belt on the southeastern margin of Tibet. The mantle seismic tomography indicates that the crust-mantle decoupled deformation, defined from previous seismic anisotropy analysis, was formed by upwelling and lateral flow of the asthenosphere, driven by deep subduction of the Indian continent. Our magnetotelluric and seismic images show both a vertical conductor across the Moho and high Vp/Vs anomalies both in the uppermost mantle and lowest crust, suggesting that crust-mantle decoupling promotes ponding of mantle-derived basic melts at the base of the crust via a heat-flow conduit. Noble gas isotope and halogen ratios of gold-related ore minerals indicate a mantle source of ore fluid. A rapid decrease in Cl/F ratios of lamprophyres under conditions of 1.2 GPa and 1050°C suggests that the ore fluid was derived from degassing of the basic melts. Similar lithospheric architecture is recognized in other orogenic gold provinces, implying analogous formational controls.

Learning and Expertise in Mineral Exploration Decision-Making: An Ecological Dynamics Perspective.

The declining discovery rate of world-class ore deposits represents a significant obstacle to future global metal supply. To counter this trend, there is a requirement for mineral exploration to be conducted in increasingly challenging, uncertain, and remote environments. Faced with such increases in task and environmental complexity, an important concern in exploratory activities are the behavioural challenges of information perception, interpretation and decision-making by geoscientists tasked with discovering the next generation of deposits. Here, we outline the Dynamics model, as a diagnostic tool for situational analysis and a guiding framework for designing working and training environments to maximise exploration performance. The Dynamics model is based on an Ecological Dynamics framework, combining Newell's Constraints model, Self Determination Theory, and including feedback loops to define an autopoietic system. By implication of the Dynamics model, several areas are highlighted as being important for improving the quality of exploration. These include: (a) provision of needs-supportive working environments that promote appropriate degrees of effort, autonomy, creativity and technical risk-taking; (b) an understanding of the wider motivational context, particularly the influence of tradition, culture and other 'forms of life' that constrain behaviour; (c) relevant goal-setting in the design of corporate strategies to direct exploration activities; and (d) development of practical, representative scenario-based training interventions, providing effective learning environments, with digital media and technologies presenting decision-outcome feedback, to assist in the development of expertise in mineral exploration targeting.

Predicting Future Health Risk in COPD: Differential Impact of Disease-Specific and Multi-Morbidity-Based Risk Stratification.

Objective: Multi-morbidity contributes to mortality and hospitalisation in COPD, but it is uncertain how this interacts with disease severity in risk prediction. We compared contributions of multi-morbidity and disease severity factors in modelling future health risk using UK primary care healthcare data. Methods: Health records from 103,955 patients with COPD identified from the Clinical Practice Research Datalink were analysed. We compared area under the curve (AUC) statistics for logistic regression (LR) models incorporating disease indices with models incorporating categorised comorbidities. We also compared these models with performance of The John Hopkins Adjusted Clinical Groups® System (ACG) risk prediction algorithm. Results: LR models predicting all-cause mortality outperformed models predicting hospitalisation. Mortality was best predicted by disease severity (AUC & 95% CI: 0.816 (0.805-0.827)) and prediction was enhanced only marginally by the addition of multi-morbidity indices (AUC & 95% CI: 0.829 (0.818-0.839)). The model combining disease severity and multi-morbidity indices was a better predictor of hospitalisation (AUC & 95% CI: 0.679 (0.672-0.686)). ACG-derived LR models outperformed conventional regression models for hospitalisation (AUC & 95% CI: 0.697 (0.690-0.704)) but not for mortality (AUC & 95% CI: 0.816 (0.805-0.827)). Conclusion: Stratification of future health risk in COPD can be undertaken using clinical and demographic data recorded in primary care, but the impact of disease severity and multi-morbidity varies depending on the choice of health outcome. A more comprehensive risk modelling algorithm such as ACG offers enhanced prediction for hospitalisation by incorporating a wider range of coded diagnoses.

Resilience of the Eastern African electricity sector to climate driven changes in hydropower generation.

Notwithstanding current heavy dependence on gas-fired electricity generation in the Eastern African Power Pool (EAPP), hydropower is expected to play an essential role in improving electricity access in the region. Expansion planning of electricity infrastructure is critical to support investment and maintaining balanced consumer electricity prices. Variations in water availability due to a changing climate could leave hydro infrastructure stranded or result in underutilization of available resources. In this study, we develop a framework consisting of long-term models for electricity supply and water systems management, to assess the vulnerability of potential expansion plans to the effects of climate change. We find that the most resilient EAPP rollout strategy corresponds to a plan optimised for a slightly wetter climate compared to historical trends. This study demonstrates that failing to climate-proof infrastructure investments can result in significant electricity price fluctuations in selected countries (Uganda & Tanzania) while others, such as Egypt, are less vulnerable.

Clinical implications of QRS duration and QT peak prolongation in patients with suspected coronary disease referred for elective cardiac catheterization.

BACKGROUND: The electrocardiogram (ECG) remains a simple, universally available, and prognostically powerful investigation in heart failure, and acute coronary syndromes. We sought to assess the prognostic utility of clinical, angiographic, and simple ECG parameters in a large cohort of patients undergoing elective cardiac catheterization (CC) for known or suspected coronary artery disease. METHODS: Consecutive consenting patients undergoing CC for coronary disease were enrolled at a single tertiary center. Patient data, drug therapy, catheter reports, and ECG recordings were prospectively recorded in a validated electronic archive. The primary outcome measure was death or nonfatal myocardial infarction (MI) over 1 year or until percutaneous or cardiac surgical intervention. Independent prognostic markers were identified using the Cox proportional hazard model. RESULTS: A total of 682 individuals were recruited of whom 17(2.5%) died or suffered a nonfatal MI in 1 year. In multivariate analysis QRS duration (ms) (HR 1.03 95% CI 1.01-1.05, P = 0.003), extent of coronary disease (HR 2.01 95% CI 1.24-3.58, P = 0.006), and prolonged corrected QT peak interval in lead I (HR 1.02 95% CI 1.00-1.03, P = 0.044) were independently associated with death or nonfatal MI. Receiver-operator characteristic (ROC) analysis for the multivariate model against the primary end point yielded an area under the curve of 0.759 (95% CI 0.660-0.858), P < 0.001. CONCLUSIONS: QRS duration and QT peak are independently associated with increased risk of death or nonfatal MI in stable patients attending for coronary angiography.

A brief cognitive-behavioral intervention reduces hospital admissions in refractory angina patients.

Chronic refractory angina is an increasingly prevalent, complex chronic pain condition, which results in frequent hospitalization for chest pain. We have previously shown that a novel outpatient cognitive-behavioral chronic disease management program (CB-CDMP) improves angina status and quality of life in such patients. In the present study of 271 chronic refractory angina patients enrolled in our CB-CDMP, total hospital admissions were reduced from 2.40 admissions per patient per year to 1.78 admissions per patient per year (P<0.001). The rising trend of total hospital bed day occupancy prior to enrollment fell from 15.48 days per patient per year to a stable 10.34 days per patient per year (P<0.001). There were 32 recorded myocardial infarctions prior to enrollment compared to eight in the year following enrollment (14% vs. 2.3%, P<0.001) and overall mortality was lower that comparable groups treated with surgery. This study shows that educating patients and demystifying angina using a brief outpatient CB-CDMP produces an immediate and sustained reduction in hospital admission costs that represents a major potential health care saving. This benefit accrues in addition to the known effects of CB-CDMP on symptoms and quality of life. These data suggest that a CB-CDMP approach to symptom palliation represents a low cost alternative to palliative revascularization.

Heart rate turbulence and death due to cardiac decompensation in patients with chronic heart failure.

BACKGROUND: As treatment strategies for patients with chronic heart failure (HF) become more sophisticated, identifying patients at high risk of death and predicting mode of death is important. The aim of this study was to explore the potential utility of heart rate turbulence (HRT) to identify patients with HF at high risk of death. METHODS AND RESULTS: In a prospective study, 553 ambulant outpatients age 63+/-10 with symptoms of HF and evidence of cardiac dysfunction were recruited. All patients underwent 24-h Holter ECG recordings, which were analysed for arrhythmias, heart rate variability and HRT a measurement that is thought to quantify cardiac autonomic regulatory mechanisms. Baseline chest radiograph, biochemistry and 12-lead electrocardiograms were also obtained. In patients with HRT measurements at 5 years follow up, 146 patients had died, 59 due to decompensated HF. Independent predictors of death from decompensated HF at 5-year follow up (Cox proportional hazard model) were HRT slope (HR for 10% increment 0.84, 95% CI 0.77-0.91), serum sodium (HR for 10% increment 0.75, 95% CI 0.62-0.91) and serum creatinine (for 10% increment HR 1.14, 95% CI 1.08-1.19) all P<0.01. These 3 variables combined had excellent discrimination between patients dying of decompensated HF and other patients, C-statistic=0.82. CONCLUSIONS: In patients with mild-to-moderate HF, HRT slope is an independent predictor of death due to decompensated HF. HRT may have the potential to help tailor therapy in this patient group.

Diabetes mellitus is associated with adverse structural and functional cardiac remodelling in chronic heart failure with reduced ejection fraction.

BACKGROUND: Diabetes mellitus is associated with an increased risk of death and hospitalisation in patients with chronic heart failure. Better understanding of potential underlying mechanisms may aid the development of diabetes mellitus-specific chronic heart failure therapeutic strategies. METHODS: Prospective observational cohort study of 628 patients with chronic heart failure associated with left ventricular systolic dysfunction receiving contemporary evidence-based therapy. Indices of cardiac structure and function, along with symptoms and biochemical parameters, were compared in patients with and without diabetes mellitus at study recruitment and 1 year later. RESULTS: Patients with diabetes mellitus (24.2%) experienced higher rates of all-cause [hazard ratio, 2.3 (95% confidence interval, 1.8-3.0)] and chronic heart failure-specific mortality and hospitalisation despite comparable pharmacological and device-based therapies. At study recruitment, patients with diabetes mellitus were more symptomatic, required greater diuretic doses and more frequently had radiologic evidence of pulmonary oedema, despite higher left ventricular ejection fraction. They also exhibited echocardiographic evidence of increased left ventricular wall thickness and pulmonary arterial pressure. Diabetes mellitus was associated with reduced indices of heart rate variability and increased heart rate turbulence. During follow-up, patients with diabetes mellitus experienced less beneficial left ventricular remodelling and greater deterioration in renal function. CONCLUSION: Diabetes mellitus is associated with features of adverse structural and functional cardiac remodelling in patients with chronic heart failure.

Ambulatory heart rate range predicts mode-specific mortality and hospitalisation in chronic heart failure.

OBJECTIVE: We aimed to define the prognostic value of the heart rate range during a 24 h period in patients with chronic heart failure (CHF). METHODS: Prospective observational cohort study of 791 patients with CHF associated with left ventricular systolic dysfunction. Mode-specific mortality and hospitalisation were linked with ambulatory heart rate range (AHRR; calculated as maximum minus minimum heart rate using 24 h Holter monitor data, including paced and non-sinus complexes) in univariate and multivariate analyses. Findings were then corroborated in a validation cohort of 408 patients with CHF with preserved or reduced left ventricular ejection fraction. RESULTS: After a mean 4.1 years of follow-up, increasing AHRR was associated with reduced risk of all-cause, sudden, non-cardiovascular and progressive heart failure death in univariate analyses. After accounting for characteristics that differed between groups above and below median AHRR using multivariate analysis, AHRR remained strongly associated with all-cause mortality (HR 0.991/bpm increase in AHRR (95% CI 0.999 to 0.982); p=0.046). AHRR was not associated with the risk of any non-elective hospitalisation, but was associated with heart-failure-related hospitalisation. AHRR was modestly associated with the SD of normal-to-normal beats (R(2)=0.2; p<0.001) and with peak exercise-test heart rate (R(2)=0.33; p<0.001). Analysis of the validation cohort revealed AHRR to be associated with all-cause and mode-specific death as described in the derivation cohort. CONCLUSIONS: AHRR is a novel and readily available prognosticator in patients with CHF, which may reflect autonomic tone and exercise capacity.

Temporary sympathectomy in the treatment of chronic refractory angina.

The aim of this study was to investigate the safety and efficacy of the two most commonly practiced temporary sympathectomy techniques in the treatment of chronic refractory angina. Fifty-nine consecutive refractory angina patients commencing outpatient temporary sympathectomy from November 1, 2000 to November 1, 2002, were prospectively audited for duration of pain relief and procedural complications over a two-year period. A total of 227 stellate ganglion blockades (SGB) and 100 paravertebral blockades (PVB) were performed on 59 chronic refractory angina (CRA) patients naïve to sympathectomy. The mean period of pain relief obtained following SGB was 3.48 weeks (SD 3.38) and the mean relief following PVB was 2.80 weeks (SD 2.00). Mild, fully reversible complications occurred in 3% of SGB and 3% of PVB procedures, with one patient requiring overnight hospitalization. This study demonstrates that temporary sympathectomy may provide a safe and effective outpatient procedure in refractory angina patients when applied as part of holistic care.

Impairment in work productivity and health-related quality of life in patients with IBS.

Irritable bowel syndrome (IBS) is a long-term and episodic medical disorder shown to have an impact on work productivity and health-related quality of life (QOL). The objective of this study was to assess the impact of IBS on work productivity and on health-related QOL in an employed population in the United States and to quantify the cost of these factors to the employer. A 2-phase survey was sent to the workforce of a large US bank to assess the presence of IBS among employees and to measure their work productivity (absenteeism [time lost from work] and presenteeism [reduced productivity at work]) and health-related QOL. Forty-one percent of the 1776 employees responding to both phases of the survey met the Rome II criteria for IBS. Employees with IBS reported a 15% greater loss in work productivity because of gastrointestinal symptoms than employees without IBS and had significantly lower Medical Outcomes Study Short Form 36 (SF-36) scores than those without IBS. IBS was associated with a 21% reduction in work productivity, equivalent to working less than 4 days in a 5-day workweek. Employees with IBS also had significantly lower scores on all domains of the SF-36, indicating poorer functional outcomes. Reduced work productivity and diminished QOL of these magnitudes may have substantial financial impact on employers.

In vivo force during arterial interventional radiology needle puncture procedures.

To adequately simulate the forces generated during interventional radiological (IR) procedures, non intrusive in-vivo methods must be used. Using finger tip mounted, non intrusive capacitance force sensor pads (PPS, Los Angeles, California) we have been able to measure the forces involved in interventional radiology without a change in procedure technique. Data acquired during the process of calibration of the capacitance pads in conjunction with extensive in-vitro needle puncture force measurement using a commercially available tensile tester (Nene Industries, UK) are presented here.

Temporary sympathectomy in chronic refractory angina: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Temporary sympathectomy by injection of bupivacaine at the site of the left stellate ganglion is used in the management of refractory angina at several UK centres. Although patients frequently report significant reduction in symptoms, efficacy has not been established by double-blind, randomised placebo-controlled trial (RCT). OBJECTIVE: To investigate the efficacy of the procedure for the first time by a double-blind RCT. METHODS: Consecutive patients referred to the authors' National Health Service (NHS) angina centre who were candidates for temporary sympathectomy were invited to participate in a trial. A total of 65 patients were randomised to receive either bupivacaine or saline injections. Identical syringes were prepared remotely, blinding patients and staff from randomisation. Cardiac autonomic function was measured 3 hours pre- and post-injection using new heart rate variability (HRV) analyses. Angina episodes were recorded contemporaneously by patients in study diaries in the 7-day periods pre- and post-injection. RESULTS: In 51 patients suitable for analysis, no significant differences between the active and placebo groups were found in patient-recorded frequency or intensity of angina episodes pre- and post-injection. However, across both groups combined, a significant difference was found in the frequency of angina episodes pre- and post-injection. CONCLUSION: The reduction in frequency of angina episodes produced by this procedure may not be due to drug pharmacology. It may be a placebo response or due to the mechanical effects of the injection of fluid. There is a need for further work using a larger patient cohort considering both mechanical and psychological factors.

Training costs and investment payback of implementing molecular diagnostics for identification of vancomycin resistant enterococci in a clinical microbiology laboratory.

Molecular diagnostics may be a more efficient method to manage resources; but most Microbiology laboratories have not introduced them into routine use due to the specialized training required. Using vancomycin resistant enterococci (VRE) screening during a comparison of a multiplex PCR (MPCR) and conventional biochemical testing (CBT) we studied 3 objectives: 1) to develop a molecular diagnostics in-house training program, 2) to assess the training program outcomes for competency and confidence, and 3) to determine laboratory payback. A training program for 14 technologists using multiple adult learning methods was implemented. Methods to minimize technical errors were introduced and included: use of a calibrated loop to deliver sample; prealiquotting reagents; increasing volume of specimen; addition of gel loading dye directly into reaction tubes; and establishment of an equivocal zone. In our laboratory MPCR costs $7.06 less than CBT, therefore the payback period for training and implementation would be approximately 3 years.

Functional assessment of heart rate variability: physiological basis and practical applications.

The autonomic nervous system dynamically controls the response of the body to a range of external and internal stimuli, providing physiological stability in the individual. With the progress of information technology, it is now possible to explore the functioning of this system reliably and non-invasively using comprehensive and functional analysis of heart rate variability. This method is already an established tool in cardiology research, and is increasingly being used for a range of clinical applications. This review describes the theoretical basis and practical applications for this emerging technique.

Changing characteristics and mode of death associated with chronic heart failure caused by left ventricular systolic dysfunction: a study across therapeutic eras.

BACKGROUND: Therapies for patients with chronic heart failure caused by left ventricular systolic dysfunction have advanced substantially over recent decades. The cumulative effect of these therapies on mortality, mode of death, symptoms, and clinical characteristics has yet to be defined. METHODS AND RESULTS: This study was a comparison of 2 prospective cohort studies of outpatients with chronic heart failure caused by left ventricular systolic dysfunction performed between 1993 and 1995 (historic cohort: n=281) and 2006 and 2009 (contemporary cohort: n=357). In the historic cohort, 83% were prescribed angiotensin-converting enzyme inhibitors and 8.5% were prescribed ß-adrenoceptor antagonists, compared with 89% and 80%, respectively, in the contemporary cohort. Mortality rates over the first year of follow-up declined from 12.5% to 7.8% between eras (P=0.04), and sudden death contributed less to contemporary mortality (33.6% versus 12.7%; P<0.001). New York Heart Association class declined between eras (P<0.001). QTc dispersion across the chest leads declined from 85 ms (SD, 2) to 34 ms (SD, 1) and left ventricular end-diastolic dimensions declined from 65 mm (SD, 0.6) to 59 mm (SD, 0.5) (both P<0.001). CONCLUSIONS: Survival has significantly improved in patients with chronic heart failure caused by left ventricular systolic dysfunction over the past 15 years; furthermore, sudden death makes a much smaller contribution to mortality, and noncardiac mortality is a correspondingly greater contribution. This has been accompanied by an improvement in symptoms and some markers of adverse electric and structural left ventricular remodeling.