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PubMed2003

Mortality in rheumatoid arthritis patients treated with or without methotrexate.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic disease associated with excess mortality. In 1974 a registry of RA patients was established at the Wichita Arthritis Center. It has been directed by its founder, Dr. Frederick Wolfe, ever since. The database for RA patients provided results for the present study and 1 of the 4 series reported previously. RESULTS: These are based on a consecutive series (after specific exclusions) of RA patients, 18 years of age and older, treated at the Wichita Arthritis Center, 1981 through 1999. During this period, 588 of the total 1240 RA patients were treated with methotrexate, and 652 patients did not receive any methotrexate. Total exposure amounted to 7584 patient-years, and total deaths numbered 191. An elaborate statistical method was developed by Wolfe and a team of Harvard epidemiologists to adjust for prognostic risk factors, which were higher in the methotrexate than in the non-methotrexate group. Detailed descriptive data were included in the database. Overall excess mortality in comparison with population rates was higher in the methotrexate than in the non-methotrexate group, but the unadjusted difference was not significant. Results for the 1981-1999 total Wichita cohort were compared with those of the 1974-1990 cohort and the 1983 Impairment Study (both before and after adjustment to the older age distribution of the Wichita patients). CONCLUSION: Mortality improved somewhat in the RA patients at the Wichita Center from 1974-1990 to 1980-1999. In the later period, mortality was lower in patients treated with methotrexate than in those not so treated. After the authors of the source article made adjustments for the increased RA severity in the patients treated with methotrexate, mortality was significantly lower in the methotrexate-treated group, with a mortality hazard ratio of 0.4 (95% confidence interval 0.2-0.8).

Actuarial Analysis↗
PubMed2003

Outcome of early surgery compared to surveillance in the management of small aortic aneurysms--a comparative mortality analysis.

When underwriting individuals with aortic aneurysms, the following factors are used in risk selection: location, initial size, stability or velocity of change in size and co-morbid impairments. Treatment options based on clinical and ultrasonic findings are either surveillance or surgical resection. A recent study examined the 8-year outcome of early-surgery vs surveillance in small (4.6 cm) aortic aneurysms. Over the duration, the early-surgery group had a mortality ratio of 170% and excess death rate of 28; the surveillance group had a mortality ratio of 215% and excess death rate of 45. First-year mortality was expectedly high in the early-surgery group. Excluding first-year experience, the early-surgery group had an improved mortality ratio of 160% and excess death rate of 22. After 6 months, the death rate in the early-surgery group was about three fourths that of the surveillance group. However, due to high initial mortality cumulative survival curves did not cross in favor of early-surgery until about 3 years.

Aged↗
PubMed2003

Excess mortality in remote symptomatic epilepsy.

BACKGROUND: Published estimates of excess mortality associated with epilepsy vary greatly. How much, if any, of the excess is attributable to the seizures themselves as opposed to an underlying condition causing the epilepsy is not clear from the literature. This article offers evidence that epilepsy per se is associated with excess mortality. The excess varies according to severity and frequency of seizures. MATERIALS AND METHODS: The authors studied mortality rates of developmentally disabled persons in California with and without epilepsy. In order to focus on the effect on mortality risk of epilepsy per se, they included only persons with good motor function (able to walk and climb stairs) and at worst moderate mental retardation (MR). The data were 506,204 person-years and 1523 deaths among 80,682 California subjects of age 5 to 65 years during the 1988-1999 study period. Mortality rates for persons with epilepsy were compared to rates for persons with no history of epilepsy. RESULTS: Mortality rates were higher for persons with epilepsy than for those without. Excess death rates (EDRs) varied according to type and frequency of seizures. Combined EDRs were 6 (deaths per 1000 person-years) for persons with recent (< 12 months) history of status epilepticus, 5 for recent history of generalized tonic-clonic (GTC) seizures, 3 for recent history of seizures but no recent GTC seizures, and less than 1 for a history of seizures but no recent events. CONCLUSIONS: The data presented here are evidence that epilepsy per se is associated with increased mortality. The EDRs reported here may be better measures of excess mortality due to epilepsy than previously published estimates.

Adolescent↗
PubMed2003

Insurance and epidemics: SARS, West Nile virus and Nipah virus.

Severe acute respiratory syndrome (SARS) reminds us that sudden disease emergence is a permanent part of our world--and should be anticipated in our planning. Historically the emergence of new diseases has had little or no impact beyond a small, localized cluster of infections. However, given just the right conditions, a highly virulent pathogen can suddenly spread across time and space with massive consequences, as has occurred on several occasions in human history. In the wake of the SARS outbreak, we are now forced to confront the unpleasant fact that human activities are increasing the frequency and severity of these kinds of emergences. The idea of more frequent biological "invasions" with economic and societal impacts comparable to SARS, presents stakeholders in and the global economy with unprecedented new risks, challenges and even opportunities. As a major contributor to economic stability, the insurance industry must follow these trends very closely and develop scenarios to anticipate these events.

China↗
PubMed2003

Matters of the athletic heart.

Frequently an underwriter or medical director will question whether an increase in left ventricular mass represents pathologic left ventricular hypertrophy (LVH) or physiologic changes related to exercise. The LVH condition reflects end-organ damage related to abnormal hemodynamic stresses and confers an increased morbidity and mortality risk. When left ventricular mass is increased because of exercise, measured changes represent a normal, healthy cardiovascular system responding to the demands of that exercise. This article summarizes medical findings that distinguish pathologic LVH from an "athletic heart."

Diagnosis, Differential↗
PubMed2003

Cocaine revisited.

Insurance companies often test applicants for the presence of cocaine. Because a positive test may automatically preclude further consideration, such cases often never reach the medical director. The negative impact of cocaine use on insurability is reviewed.

Cardiovascular Diseases↗
PubMed2003

Assessment for congenital long QT syndrome.

A 29-year-old male presented for an evaluation of his risk for having congenital long QT syndrome. Despite being asymptomatic and having a normal QTc interval on the resting ECG, a suggestive family history was an indication for a thorough cardiac evaluation. A geneticist reviewed this workup and recommended against genetic testing. While up to 10% of affected carriers of a congenital long QT syndrome gene mutation can be asymptomatic with a normal QTc, consideration of all of the clinical factors allowed for further risk stratification. The evaluation of an ECG for the long QT syndrome includes calculating a corrected QT interval for the heart rate and assessing the T-waves for morphology associated with this syndrome.

Adult↗
PubMed1992

[Emotional-psychiatric disorder and the illness concept].

Who is abnormal--who is sick? Illness is an abnormal state. Abnormal psychological states are manyfold and rich in variations. Therefore it is necessary to define what is insanity and what is personal problem, personal disorder, personal decompensation or only any form of suffering. The problem is important with regard to therapeutical and legal decisions.

Affective Symptoms↗
PubMed2004

Mortality outcomes of various causes of syncope.

Syncope, especially in older-age applicants, presents a risk selection quandary. When the etiology is established, risk classification is based on the causative impairment. However, often no diagnosis is ascertained. The lack of diagnosis presents a dilemma for the medical director. Underwriting decisions must be based on sound actuarial principles or related to actual and reasonable anticipated experience. The mortality outcome of various causes of syncope from participants of the Framingham Heart Study is presented in this abstract. The primary value to the medical director is the mortality outcome of those applicants without a specific etiologic diagnosis; those belonging to the unknown, the vasovagal or other causes groups. Over a 24-year observation period, patients whose syncope was attributed to vasovagal or other causes had a mortality ratio of 14% and an excess death rate of 20. Neurogenic syncope had a mortality ratio of 168% and an excess death rate of 34. No excess mortality was observed when those with seizures were excluded from analysis. Those whose cause of syncope was unknown had a mortality ratio of 192% and an excess death rate of 46. Individuals whose syncope was deemed to be cardiac exhibited a mortality ratio of 270% and an excess death rate of 82.

Age Distribution↗
PubMed2004

Nonalcoholic fatty liver disease (NAFLD): a comprehensive review.

Nonalcoholic fatty liver disease (NAFLD) is defined as fatty infiltration of the liver exceeding 5% to 10% by weight. It is a spectrum of disorders ranging from simple fatty liver (steatosis without liver injury), nonalcoholic steatohepatitis (steatosis with inflammation), and fibrosis/cirrhosis that resembles alcohol-induced liver disease but which develops in individuals who are not heavy drinkers. NAFLD is likely the most common cause of chronic liver disease in many countries. NAFLD may also potentiate liver damage induced by other agents, such as alcohol, industrial toxins and hepatatrophic viruses. The lack of specific and sensitive noninvasive tests for NAFLD limits reliable detection of the disease. It is often diagnosed on a presumptive basis when liver enzyme elevations are noted in overweight or obese individuals without identifiable etiology for liver disease, or when imaging studies suggest hepatic steatosis. NAFLD is now considered to be a component of the insulin resistance syndrome (metabolic syndrome X). Controversy exists relative to optimal recognition, diagnosis and management of these conditions, and treatment recommendations are evolving.

Biopsy, Needle↗
PubMed2004

Lone atrial fibrillation: more than meets the eye.

Doxorubicin has been used as a chemotherapeutic agent for over 30 years. Its cardiac toxicity has been known for over 20 years. In recent years, delayed-onset cardiac toxicity has been described as yet another cardiac complication of doxorubicin and other anthracyclines. The following case is felt to represent such an example.

Acute Disease↗