Health Outcomes Among Long-term Opioid Users With Testosterone Prescription in the Veterans Health Administration.

Importance: Androgen deficiency is common among male opioid users, and opioid use has emerged as a common antecedent of testosterone treatment. The long-term health outcomes associated with testosterone therapy remain unknown, however. Objective: To compare health outcomes between long-term opioid users with testosterone deficiency who filled testosterone prescriptions and those with the same condition but who did not receive testosterone treatment. Design, Setting, and Participants: This cohort study focused on men in the care of the Veterans Health Administration (VHA) facilities throughout the United States from October 1, 2008, to September 30, 2014. It included male veterans who were long-term opioid users, had low testosterone levels (<300 ng/dL), and received either a testosterone prescription or any other prescription. It excluded male patients with HIV infection, gender dysphoria, or prostate cancer and those who received testosterone in fiscal year 2008. Data were analyzed from April 1, 2017, to April 30, 2019. Exposure: Prescription for testosterone. Main Outcomes and Measures: All-cause mortality and incidence of major adverse cardiovascular events (MACE), vertebral or femoral fractures, and anemia during the 6-year follow-up through September 30, 2015. Results: After exclusions, 21 272 long-term opioid users (mean [SD] age, 53 [10] years; n = 16 689 [78.5%] white) with low total or free testosterone levels were included for analysis, of whom 14 121 (66.4%) received testosterone and 7151 (33.6%) did not. At baseline, compared with opioid users who did not receive testosterone, long-term opioid users who received testosterone treatment were more likely to have obesity (43.7% vs 49.0%; P < .001), hyperlipidemia (43.0% vs 48.8%; P < .001), and hypertension (53.9% vs 55.2%; P = .07) but had lower prevalence of coronary artery disease (15.9% vs 12.9%; P < .001) and stroke (2.4% vs 1.3%; P < .001). After adjusting for covariates, opioid users who received testosterone had significantly lower all-cause mortality (hazard ratio [HR] = 0.51; 95% CI, 0.42-0.61) and lower incidence of MACE (HR = 0.58; 95% CI, 0.51-0.67), femoral or hip fractures (HR = 0.68; 95% CI, 0.48-0.96), and anemia (HR = 0.73; 95% CI, 0.68-0.79) during the follow-up period of up to 6 years, compared with their counterparts without a testosterone prescription. In covariate-adjusted models, men who received opioids plus testosterone were more likely to have resolved anemia compared with those who received opioids only during the 6-year follow-up (HR = 1.16; 95% CI, 1.02-1.31). Similar results were obtained in propensity score-matched models and when analyses were restricted to opioid users with noncancer pain or those who did not receive glucocorticoids. Conclusions and Relevance: This study found that, in the VHA system, male long-term opioid users with testosterone deficiency who were treated with opioid and testosterone medications had significantly lower all-cause mortality and significantly lower incidence of MACE, femoral or hip fractures, and anemia after a multiyear follow-up. These results warrant confirmation through a randomized clinical trial to ascertain the efficacy of testosterone in improving health outcomes for opioid users with androgen deficiency.

Immune-related adverse events associated with programmed cell death protein-1 and programmed cell death ligand 1 inhibitors for non-small cell lung cancer: a PRISMA systematic review and meta-analysis.

BACKGROUND: Programmed cell death protein-1 (PD-1) and programmed cell death ligand 1 (PD-L1) inhibitors have remarkable clinical efficacy in the treatment of non-small cell lung cancer (NSCLC); however, the breakdown of immune escape causes a variety of immune-related adverse events (irAEs). With the increasing use of PD-1/PD-L1 inhibitors alone or in combination with other therapies, awareness and management of irAEs have become more important. We aimed to assess the incidence and nature of irAEs associated with PD-1 and PD-L1 inhibitors for NSCLC. METHODS: Articles from the MEDLINE, EMBASE, and Cochrane databases were searched through December 2017. The incidence of overall and organ-specific irAEs was investigated in all clinical trials with nivolumab, pembrolizumab, atezolimumab, durvalumab, and avelumab as single agents for treatment of NSCLC. We calculated the pooled incidence using R software with package Meta. RESULTS: Sixteen trials were included in the meta-analysis: 10 trials with PD-1 inhibitors (3734 patients) and 6 trials with PD-L1 inhibitors (2474 patients). The overall incidence of irAEs was 22% (95% confidence interval [CI], 17-28) for all grades and 4% (95% CI, 2-6) for high-grade irAEs. The frequency of irAEs varied based on drug type and organ, and patients treated with PD-1 inhibitors had an increased rate of any grade and high-grade irAEs compared with patients who received PD-L1 inhibitors. Organ-specific irAEs were most frequently observed in, in decreasing order, the endocrine system, skin, pulmonary tract, and gastrointestinal tract. The total number of patients whose death was attributed to irAEs was 14 (0.34%), and most (79%) of these patients died because of pneumonitis. The median time to the onset of irAEs after the initiation of treatment was 10 weeks (interquartile range, 6-19.5 weeks) and varied depending on the organ system involved. CONCLUSIONS: The specificity of irAEs was closely associated with the mechanism of PD-1/PD-L1 antibodies involved in restarting anticancer immune attacks. Comprehensive understanding, timely detection, and effective management could improve the compliance of patients and guide the interruption of treatment.

Systemic Complications of Acromegaly and the Impact of the Current Treatment Landscape: An Update.

Acromegaly is a chronic systemic disease with many complications and is associated with increased mortality when not adequately treated. Substantial advances in acromegaly treatment, as well as in the treatment of many of its complications, mainly diabetes mellitus, heart failure, and arterial hypertension, were achieved in the last decades. These developments allowed change in both prevalence and severity of some acromegaly complications and furthermore resulted in a reduction of mortality. Currently, mortality seems to be similar to the general population in adequately treated patients with acromegaly. In this review, we update the knowledge in complications of acromegaly and detail the effects of different acromegaly treatment options on these complications. Incidence of mortality, its correlation with GH (cumulative exposure vs last value), and IGF-I levels and the shift in the main cause of mortality in patients with acromegaly are also addressed.

Diagnosis and mortality of emergency department patients in the North Denmark region.

BACKGROUND: Emergency departments handle a large proportion of acute patients. In 2007, it was recommended centralizing the Danish healthcare system and establishing emergency departments as the main common entrance for emergency patients. Since this reorganization, few studies describing the emergency patient population in this new setting have been carried out and none describing diagnoses and mortality. Hence, we aimed to investigate diagnoses and 1- and 30-day mortality of patients in the emergency departments in the North Denmark Region during 2014-2016. METHODS: Population-based historic cohort study in the North Denmark Region (580,000 inhabitants) of patients with contact to emergency departments during 2014-2016. The study included patients who were referred by general practitioners (daytime and out-of-hours), by emergency medical services or who were self-referred. Primary diagnoses (ICD-10) were retrieved from the regional Patient Administrative System. For non-specific diagnoses (ICD-10 chapter 'Symptoms and signs' and 'Other factors'), we searched the same hospital stay for a specific diagnosis and used this, if one was given. We performed descriptive analysis reporting distribution and frequency of diagnoses. Moreover, 1- and 30-day mortality rate estimates were performed using the Kaplan-Meier estimator. RESULTS: We included 290,590 patient contacts corresponding to 166 ED visits per 1000 inhabitants per year. The three most frequent ICD-10 chapters used were 'Injuries and poisoning' (38.3% n = 111,274), 'Symptoms and signs' (16.1% n = 46,852) and 'Other factors' (14.52% n = 42,195). Mortality at day 30 (95% confidence intervals) for these chapters were 0.86% (0.81-0.92), 3.95% (3.78-4.13) and 2.84% (2.69-3.00), respectively. The highest 30-day mortality were within chapters 'Neoplasms' (14.22% (12.07-16.72)), 'Endocrine diseases' (8.95% (8.21-9.75)) and 'Respiratory diseases' (8.44% (8.02-8.88)). CONCLUSIONS: Patients in contact with the emergency department receive a wide range of diagnoses within all chapters of ICD-10, and one third of the diagnoses given are non-specific. Within the non-specific chapters, we found a 30-day mortality, surpassing several of the more organ specific ICD-10 chapters. TRIAL REGISTRATION: Observational study - no trial registration was performed.

Adolescents and Young Adults with Chronic or End-Stage Kidney Disease.

BACKGROUND: Adolescents and young adults face unique and complex physical, psychological, and family challenges. Despite improvements in care for chronic kidney disease (CKD) and end-stage kidney disease (ESKD), long-term mortality for children, adolescents, and young adults with CKD remains substantially higher than their healthy counterparts. SUMMARY: In this article, we discuss the complex challenges that adolescent and young adult CKD/ESKD patients face. Adolescents have different CKD etiologies and progress along a course dissimilar to the adult population, but have similar multifarious comorbidities. In the setting of puberty and learning to become self-sufficient, adolescence is a critical time for growth and psychosocial development. Physiological complications of CKD underlie many of the long-term outcomes. CKD-mineral and bone disorder and anemia are particularly challenging given that they are exacerbated by the rapid growth of adolescents. Endocrine imbalances and malnutrition can delay and limit growth. All of these factors, together with family dynamics and socioeconomic status, contribute to the poor long-term outcomes and decreased quality of life (QoL) for these patients and their families. KEY MESSAGES: Care for the adolescent CKD/ESKD population is uniquely challenging, but research has identified ways in which we can continue to improve long-term outcomes and QoL for adolescents with CKD/ESKD.

What's New in Old Horses? Postmortem Diagnoses in Mature and Aged Equids.

Postmortem findings in 241 equids admitted to a teaching hospital that were at least 15 years old at autopsy were reviewed (1) to determine disease prevalence, (2) to compare the cause of death (or euthanasia) in equids 15 to 19 years of age (n = 116) with that in equids ≥20 years of age (n = 125), and (3) to catalog coexisting lesions in equids with pituitary pars intermedia dysfunction (PPID). Breed and sex were evenly distributed between the age groups. Death or euthanasia was attributed to disease of the digestive system (41.5%), pituitary gland (12.9%), locomotor system (10.0%), nervous system (7.9%), cardiovascular system (4.6%), urinary system (4.6%), reproductive system (4.2%), respiratory system (4.2%), integumentary system (4.2%), lymphoid system (2.5%), liver (2.5%), or systemic neoplasia (1.2%). Nervous system disease was more common in the 15- to 19-year group; urinary tract disease was more common in the ≥20-year group. Neoplastic disease, regardless of systemic location, was the basis for death or euthanasia in 18.7% of all equids. Squamous cell carcinoma, lymphoma, and melanoma were the most common malignant neoplasms. PPID was the most common specific diagnosis, based on the postmortem presence of hyperplasia or adenoma, and was the reason for euthanasia in 47.7% of 65 equids with PPID. The most common nonpituitary causes for death or euthanasia in equids with PPID were colic, lameness, cancer, and spinal cord disease. Coexisting conditions in equids with PPID that were not considered the basis for euthanasia included neoplasms, infections, lameness, and recurrent airway obstruction.

Long-term follow-up after allogeneic stem cell transplantation.

BACKGROUND: Over 3000 persons undergo allogeneic hematopoietic stem-cell transplantation (allo-HSCT) in Germany every year. Advances in allo-HSCT have prolonged the survival of treated patients but have concomitantly increased the risk of long-term complications that impair their quality of life. METHODS: This literature review of the long-term sequelae of allo-HSCT is based on pertinent articles that were retrieved by a selective search of PubMed, and on current international guidelines. Case reports were excluded from consideration. RESULTS: Hardly any randomized clinical trials have been performed to investigate the long-term outcome of allo-HSCT, but international consensus-based guidelines have been published. 50% to 70% of patients treated with allo-HSCT develop chronic graft-versus-host disease (cGVHD) within ten years of treatment. Transplant recipients are at higher risk of infection, including the reactivation of dormant herpes viruses; therefore, vaccination is recommended, as described in the current guidelines. Gonadal dysfunction arises in up to 92% of men and up to 99% of women; its frequency depends on the timing of transplantation, on radiotherapy, and on other factors. The medications that transplant recipients need to take can impair liver function, and transfusionassociated hemosiderosis can do so as well. 40% to 50% of patients suffer from lipid metabolic disturbances that increase the risk of myocardial infarction, peripheral arterial occlusive disease, and stroke. Their life expectancy is shorter than that of the overall population. CONCLUSION: Measures should be taken to prevent the potential long-term complications of allo-HSCT. All patients who have been treated with allo-HSCT should receive individualized, risk-adapted, and multidisciplinary follow-up care, so that any complications that arise can be correctly diagnosed and appropriately treated. Long-term follow-up care could be improved by prospective clinical trials investigating the long-term sequelae of allo-HSCT, as well as by consistent, uniform documentation of these sequelae in supraregional data registries.

Late morbidity and mortality in patients with Hodgkin's lymphoma treated during adulthood.

BACKGROUND: Survivors of Hodgkin's lymphoma (HL) treated as adults are at risk for late effects of therapy. However, the burden of late morbidity and mortality among adults treated for HL remains incompletely characterized. METHODS: Vital status and, for deceased, cause of death were determined for 746 adults treated on a first-line trial at a single center from 1975 to 2000. Survivors completed a detailed survey describing their physical and mental health. A severity score (grades 1-4, ranging from mild to life-threatening or disabling) was assigned to self-reported conditions. RESULTS: At a median follow-up of 22 years, 227 of patients (30.4%) had died, 107 (47.1%) from HL, 120 (52.9%) from other causes, including second primary malignancies (SPMs) (n = 52) and cardiovascular disease (n = 27). Across the duration of follow-up, all-cause and SPM-specific risk of death remained higher than predicted by normative data. Among survivors, late morbidity survey data are available for 238 patients (45.9%). Ninety-four-point-one percent of respondents reported at least one morbidity, and 47.5% reported at least one grade 3 or 4 morbidity; 20.2% reported two or more grade 3 morbidities. Commonly reported morbidities included cardiovascular (54.6%), endocrine (68.5%), pulmonary disease (21.4%), and nonfatal second malignancy (23.1%). Anxiety, depression, and fear of recurrence were frequently reported. CONCLUSIONS: Among a large cohort of patients treated for HL with extensive follow-up, risk of late mortality from causes other than HL and prevalence of late medical morbidity are high. Guidelines for prevention, screening, and management of late effects in adult survivors of HL are needed.

High prevalence of early hypothalamic-pituitary damage in childhood brain tumor survivors: need for standardized follow-up programs.

INTRODUCTION: Childhood brain tumor survivors (CBTS) are at increased risk to develop endocrine disorders. Alerted by two cases who experienced delay in diagnosis of endocrine deficiencies within the first 5 years after brain tumor diagnosis, our aim was to investigate the current screening strategy and the prevalence of endocrine disorders in survivors of a childhood brain tumor outside of the hypothalamic-pituitary region, within the first 5 years after diagnosis. PROCEDURES: Firstly, we performed a retrospective study of 47 CBTS treated in our center, diagnosed between 2008 and 2012. Secondly, the literature was reviewed for the prevalence of endocrine disorders in CBTS within the first 5 years after diagnosis. RESULTS: Of 47 CBTS eligible for evaluation, in 34% no endocrine parameters had been documented at all during follow up. In the other 66%, endocrine parameters had been inconsistently checked, with different parameters at different time intervals. In 19% of patients an endocrine disorder was found. At literature review 22 studies were identified. The most common reported endocrine disorder within the first 5 years after diagnosis was growth hormone deficiency (13-100%), followed by primary gonadal dysfunction (0-91%) central hypothyroidism (0-67%) and primary/subclinical hypothyroidism (range 0-64%). CONCLUSION: Endocrine disorders are frequently seen within the first 5 years after diagnosis of a childhood brain tumor outside of the hypothalamic-pituitary region. Inconsistent endocrine follow up leads to unnecessary delay in diagnosis and treatment. Endocrine care for this specific population should be improved and standardized. Therefore, high-quality studies and evidence based guidelines are warranted.

Morbidities and mortality in transfusion-dependent Beta-thalassemia patients (single-center experience).

BACKGROUND: The improvement of quality and duration of life of transfusion-dependent B thalassemia patients over the last years discloses several complications due to the underling disorder, iron overload and the treatment with iron chelators. Our Aim was to assess the morbidity patterns and mortality rate of transfusion-dependent thalassemia patients, and compare the outcomes in relation to age of onset, type, duration, and compliance to iron chelation therapy and frequency of blood transfusion. PROCEDURE: This retrospective study included 447 transfusion-dependent ß-thalassemia patients who attended the Thalassemia Center, Ain Shams University Children's Hospital over the last 10 years in the period between January 2000 and January 2010. Data were collected from the patients or their caregivers, as well as by reviewing follow up sheets for examinations and investigations done to detect morbidities as well as iron chelation therapies given. Determination of mortality rate and the causes of death were also done. RESULTS: Results revealed that the most common morbidities were endocrinologic (44.7%) followed by cardiovascular (41.3%) and hepatic (40.5%), then renal (4%). The different iron chelation therapy groups showed a comparable prevalence of different morbidities. The mortality rate was 1.5% and infection was the most common cause of death. The 5, 10, 20 years' survival rate among the studied patients was 80%, 50%, 20%, respectively. CONCLUSION: In the past 10 years, the survival and morbidity rates in our center have markedly improved as a result of regular blood transfusion, new iron chelators, and better compliance of the patients.

Light deficiency confers breast cancer risk by endocrine disorders.

North-America and northern European countries exhibit the highest incidence rate of breast cancer, whereas women in southern regions are relatively protected. Immigrants from low cancer incidence regions to high-incidence areas might exhibit similarly higher or excessive cancer risk as compared with the inhabitants of their adoptive country. Additional cancer risk may be conferred by incongruence between their biological characteristics and foreign environment. Many studies established the racial/ethnic disparities in the risk and nature of female breast cancer in United States between African-American and Caucasian women. Mammary tumors in black women are diagnosed at earlier age, and are associated with higher rate of mortality as compared with cancers of white cases. Results of studies on these ethnic/racial differences in breast cancer incidence suggest that excessive pigmentation of dark skinned women results in a relative light-deficiency. Poor light exposure may explain the deleterious metabolic and hormonal alterations; such as insulin resistance, deficiencies of estrogen, thyroxin and vitamin-D conferring excessive cancer risk. The more northern the location of an adoptive country the higher the cancer risk for dark skinned immigrants. Recognition of the deleterious systemic effects of darkness and excessive melatonin synthesis enables cancer protection treatment for people living in light-deficient environment. Recent patents provide new methods for the prevention of hormonal and metabolic abnormities.

Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement.

OBJECTIVE: The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement. EVIDENCE: The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society. CONCLUSIONS: Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

Long-term follow-up of children with confirmed newborn screening disorders using record linkage.

BACKGROUND: Long-term follow-up of children identified through newborn screening is a critical process of data collection and analysis for advancing the public health understanding of the health outcomes and service uptake of the affected children. This article describes first steps toward the long-term follow-up of newborn screening children with confirmed disorders through records linkage using population-based administrative data. METHODS: The study cohort consisted of children born in 2006-2007 with confirmed disorders identified through newborn screening. Deterministic data linkage methods were used for record matching. RESULTS: The cohort was followed up to 2 years after birth by matching to data sources including vital records, hospital discharges, the Congenital Malformations Registry, and Early Intervention to monitor service utilization, comorbidities, and mortality of the affected children. Of 1215 children with confirmed conditions identified through newborn screening, 25 deaths (2.1%) were identified, 86.1% used hospital (in- or outpatient) services, 36.1% were enrolled in the Congenital Malformations Registry, and 19.9% used the services of the Early Intervention program during the 2-year follow-up period. CONCLUSIONS: Long-term follow-up of children with disorders identified through newborn screening can be initiated by using existing administrative data. This method is an inexpensive, cost-effective. and efficient approach for periodical assessment of services utilization, the efficiency of service delivery, and health outcomes for affected individuals.

Mortality with Alzheimer's disease and dementia in France, 2006.

BACKGROUND: Alzheimer's and related diseases have become a major public health issue in all developed countries, particularly with the aging of the population. Given the potential burden of these pathologies, the French government launched a third National Alzheimer's Strategic Plan 2008-2012 in 2008. The aim of the study was to provide French data on the mortality statistics of Alzheimer's and related diseases by age, gender, and geographical area. METHODS: Analyses were based on the number of deaths from Alzheimer's disease (AD) and dementia, extracted from the 2000-2006 French National Mortality Registry (Inserm-Centre d'épidémiologie sur les causes médicales de décès [CépiDc]). Underlying and multiple causes of death were taken into account. Gender, age, area of residence, and place of death were noted for all subjects deceased with AD or dementia. Mortality rates were standardized on the truncated 60+ French 2006 population. Mortality rates were also estimated by 5-year age groups. Causes of death in demented and nondemented people were compared by estimating an age-adjusted relative-risk ratio. RESULTS: In France, in 2006, AD or dementia was reported as the underlying cause or a multiple cause of death on 45,597 death certificates. Among these death certificates, 70% were women and the mean age at death was 85.9 years. Age-standardized mortality rates were 341/100,000 person-years for men and 333/100,000 person-years for women. Age-specific mortality rates increased with age and were higher in women than in men over 90 years of age. The analysis of the changes in mortality rates showed an overall increase of 11.3% between 2000 and 2006. The most frequent underlying cause when AD or dementia was mentioned as an associated cause were cardiovascular diseases (40.5%), neoplasms (11.9%), and endocrine diseases (8.5%). CONCLUSION: The analysis of mortality data on AD and dementia provides insight into the burden of these diseases in France. If carried out regularly, these analyses can provide trend analyses of mortality rates.

A cohort study linked increased mortality in patients treated surgically for Dupuytren's contracture.

OBJECTIVE: Dupuytren's contracture (DC) is a fibromatous disease of the palmar fascia of unknown etiology. The objective of this study was to assess whether individuals treated for DC exhibited an altered standardized mortality ratio. STUDY DESIGN AND SETTING: A total of 16,517 patients operated on for DC between 1965 and 1995 were identified by the Swedish Inpatient Register. For the 7,579 patients who had died during that period, cause of death was obtained from the Swedish Death Register. RESULTS: There was an overall increased mortality (standardized mortality ratio [SMR]=1.06), inversely related to age and significant for both sexes, in patients under 70 years of age. The risk estimate was highest for endocrine diseases (highest value in patients 40-49 years of age at surgery; SMR=2.82), gastrointestinal diseases (highest value in those 40-49 years of age at surgery; SMR=2.69), accidents (highest value in those 30-39 years of age at surgery; SMR=2.40), and respiratory diseases (highest value in those 50-59 years of age at surgery; SMR=1.61). There was also an increased SMR for cardiovascular diseases in patients 40-59 years of age more than 10 years after surgery (highest value in those 40-49 years of age at surgery; SMR=1.65). CONCLUSION: The most probable mechanism for the increased mortality is related to smoking and other lifestyle factors.

Time trends in cause-specific mortality in Estonia from 1965 to 1989.

BACKGROUND: During the last 30 years, in most developed countries, life expectancy has increased considerably. In Estonia, over the past half century, health and social policy was dictated by the Soviet socioeconomic system. In order to evaluate the consequences to health and to evaluate trends in health, cause-specific mortality was studied in Estonia. METHODS: The study was based on national death records from 1965 to 1989. Mortality rates were computed for all causes of death combined and for 16 cause groups. Age-standardization (European population) was performed using 5-year age groups. RESULTS: From 1965-1969 to 1985-1989, the age-standardized mortality rate for all causes combined increased by 4.0% for males and decreased by 1.5% for females. The greatest increase was observed for ages 45-54 among males (26.3%) and for ages 55-64 among females (7.0%). Very high death rates from circulatory diseases and high mortality from injuries and poisoning are of specific concern, particularly for males. Mortality from circulatory diseases continues to rise for ages 45-74 among males and for ages 55-64 among females. Mortality rates for neoplasms and endocrine disorders are also increasing; however, the mortality rates from respiratory and infectious diseases have shown a substantial decrease. CONCLUSIONS: Chronic diseases, together with injuries and poisoning, remain a serious public health problem in Estonia. Preventive measures, including earlier detection of diseases as well as changes in social security and individual health behaviour are needed to improve the health of the population.

Causas básicas de morte em mulheres com 40 anos ou mais / Basic causes of death among women over 40 years old

As estatísticas de mortalidade sao freqüentemente utilizadas como estimativas de morbidade. O objetivo deste estudo foi conhecer as causas de morte em mulheres de 40 anos ou mais em hospital terciário de referência. Realizou-se a revisao dos atestados de óbito, ocorridos nos anos de 1991 e 1992, e as causas de morte foram discriminadas como básica, conseqüencial e terminal, segundo normatizaçao do Centro da Organizaçao Mundial da Saúde para classificaçao de doenças em português. Consideramos apenas as causas básicas, distribuídas por faixa etária e de acordo com o código internacional de doenças, nona ediçao. As neoplasias malignas foram as causas mais freqüentes, seguidas por doenças do aparelho circulatório, doenças infecciosas e parasitárias, doenças endócrinas nutricionais e do sistema imunitário e doenças do aparelho respiratório. Todas as outras causas representaram 10,3 por cento do total de óbitos. Dentre as neoplasias ginecológicas, as mamárias foram as mais freqüentes, e entre as doenças do aparelho vascular, os fenômenos cérebro-vasculares. Os autores consideram importante a proposiçao de estratégias para o atendimento das mulheres com mais de 40 anos também em países como o Brasil.

Accuracy of admission and pre-autopsy clinical diagnoses in the light of autopsy findings: a study conducted in Budapest.

Pre- and post-autopsy diagnoses of underlying cause of death were compared in consecutive autopsies on persons aged 30 to 80 years; 1000 from each of two pathology departments in Budapest. Data on admission diagnoses and on contributory causes of death were also analysed. At autopsy, the percentages of deaths by underlying cause were neoplasms (any site) 34.9%, diseases of the circulatory system 40.2%, digestive system 13.8%, endocrine, nutritional, metabolic or immune systems 2.7%, and respiratory system 2.2%. For these five disease groupings, the percentages of cases diagnosed clinically as the underlying cause of death which were confirmed at autopsy were, respectively, 90.9%, 84.0%, 82.9%, 55.2% and 32.5%. Although, out of 697 cases with an autopsy diagnosis of neoplasia as the underlying cause, there were only 61 (8.8%) where neoplasms were not diagnosed clinically as the underlying cause, this conceals the fact that in 130 (18.7%) the two diagnoses differed as to the site of the primary neoplasm (ICD 3 digit code). The fact that 43% of post-mortem diagnoses (ICD major category) of underlying cause are missed on admission, and that 19% are missed clinically, indicates that improved clinical diagnostic procedures have not diminished the need for high autopsy rates. Morbid anatomy needs to be better resourced.

Mortality in patients treated for hyperthyroidism with iodine-131.

Causes of death were studied in 10,552 Swedish hyperthyroid patients treated with 131I diagnosed between 1950 and 1975. The patients were followed for an average of 15 years (range 0-35 years) and were matched with the Swedish Cause of Death Register. A total of 5,400 deaths were observed and the overall standardized mortality ratio was 1.47 (95% confidence interval (CI) 1.43-1.51). The standardized mortality ratio for females was 1.50 (95% CI 1.46-1.55) compared to 1.31 (95% CI 1.23-1.39) in males. The most common cause of death (61%) was from cardiovascular diseases (standardized mortality ratio 1.65; 95% CI 1.59-1.71). Significantly elevated risks were also seen for tumours, diseases of the endocrine system, respiratory system, gastro-intestinal system, and congenital malformations. In all causes of death, except tumours and trauma, decreasing standardized mortality ratios over time were seen. Patients followed for more than 10 years had significantly elevated risks for tumours, diseases of the endocrine, respiratory, and cardiovascular systems. Patients given higher 131I activity and younger patients had higher standardized mortality ratios than those given lower activity and older patients. The hyperthyroidism per se, rather than the 131I treatment, appeared to be the major explanation for the elevated mortality.