Search

The objective of this study was to determine which causes of death are more frequent in persons with autism, and by how much, compared with the general population. Subjects were 13,111 ambulatory Californians with autism, followed between 1983 and 1997. The units of study were person-years, each linked to the subject's age, sex, and cause of death (if any) for the specific year. Observed numbers of cause-specific deaths were compared with numbers expected according to general population mortality rates. Standardized mortality rates (SMRs) were computed for each mental retardation level. Elevated death rates were observed for several causes, including seizures and accidents such as suffocation and drowning; elevated mortality due to respiratory disease was observed among persons with severe mental retardation. Overall, excess mortality was especially marked for persons with severe mental retardation, but life expectancy is reduced even for persons who are fully ambulatory and who have only mild mental retardation. [ABSTRACT FROM AUTHOR]

Introduction: Non-Alcoholic Steatohepatitis is an increasing reason for liver transplantation in the western world. Knowledge of recipient life expectancy may assist in prudent allocation of a relatively scarce supply of donor livers. Research Questions: We calculated life expectancies for Non-alcoholic steatohepatitis (NASH) patients both at time of transplant and one year later, stratified by key risk factors, and examined whether survival has improved in recent years. Design: Data on 6635 NASH patients who underwent liver transplantation in the MELD era (2002-2018) from the United States OPTN database were analyzed using the Cox proportional hazards regression model and life table methods. Results: Factors related to survival were age, presence of diabetes or hepatic encephalopathy (HE), and whether the patient required dialysis in the week prior to transplant. Other important factors were whether the patient was working, hospitalization prior to transplant, ventilator support, and length of hospital stay (LOS). Survival improved over the study period at roughly 4.5% per calendar year during the first year posttransplant, though no improvement was observed in those who had survived one year. Conclusion: Life expectancy in NASH transplant patients was much reduced from normal, and varied according to age, medical factors, status at transplant, and post transplant course. Over the 17-year study period, patient survival improved markedly during the first year posttransplant, though not thereafter. The results given here may prove helpful in medical decision-making regarding treatment for both liver disease and other medical conditions, as they provide both clinicians and their patients with evidence-based information on prognosis.

Objective: To update the life expectancy estimates according to age, sex, mobility, and feeding skills reported in the 2015 study of Brooks et al. To examine trends in survival over the past decade., Design: Observational cohort study., Setting: Poisson regression and life table analysis applied to long-term follow-up data on United States (US) Traumatic Brain Injury (TBI) Model Systems patients recorded in the national database. Functional mobility and feeding skills were assessed with FIM., Participants: A total of 14,803 persons with TBI during the years 1988-2019 who underwent inpatient rehabilitation and provided at least 1 long-term assessment of functional skills 1 year or more postinjury (N=14,803)., Interventions: Not applicable., Main Outcome Measures: Survival, mortality rates, and life expectancy., Results: Life expectancy was lower than that of the age- and sex-matched general population. Older age and severity of functional impairments were risk factors for mortality (both P<.0001 in regression models). Among ambulatory individuals, mortality was 51% (95% confidence interval, 35%-69%) higher in men than women. Life expectancy of 20-year-old women who walked well (FIM ambulation score 7) was 55 (SE=0.8) additional years to age 75, representing a reduction of 6.9 years from the normal general population figure. For 20-year-old men who walked well, the life expectancy was 49 (SE=0.5) additional years, representing a reduction of 8.1 years from normal. Life expectancies for men and women who did not walk and were fed by others were much lower. There was no significant change in mortality rates during the study period (hazard ratio, 1.008; P=.07)., Conclusions: There has been no significant change in the long-term survival of persons with TBI in the US since the late 1980s. The life expectancies reported here are similar to those reported in the 2015 study of Brooks et al, although they are more precise because of the larger sample size and longer follow-up., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Alcohol-associated liver disease is the leading cause of liver transplantation in the western world. For these patients we calculated life expectancies both at time of transplant and several years later, stratified by key risk factors, and determined if survival has improved in recent years., Methods: Data on 14 962 patients with alcohol-associated liver disease who underwent liver transplantation in the MELD era (2002-2018) from the United States Organ Procurement and Transplantation Network database were analyzed using the Cox proportional hazards regression model and life table methods., Results: Demographic and past medical history factors related to survival were patient age, presence of diabetes or severe hepatic encephalopathy, and length of hospital stay. Survival improved over the study period, at roughly 3% per calendar year during the first 5 years posttransplant and 1% per year thereafter., Conclusions: Life expectancy in transplanted patients with alcohol-associated liver disease was much reduced from normal, and varied according to age, medical risk factors, and functional status. Survival improved modestly over the study period. Information on patient longevity can be helpful in making treatment decisions.

Background: Hepatocelluar carcinoma typically occurs with underlying cirrhosis. However roughly 20% of cases arise in a non-cirrhotic liver. There is limited literature that addresses the long-term survival of the narrow subgroup who received transplantation. For such patients we sought to calculate life expectancies both at time of transplant and several years later, stratified by key risk factors, and to determine if survival has improved in recent years. Such information can be helpful in making treatment decisions., Methods: Data on 4,373 non-cirrhotic HCC patients who underwent liver transplantation in the MELD era (2002-2018) from the United States OPTN database were analyzed using the Cox proportional hazards regression model and life table methods., Results: Demographic and past medical history factors related to survival were patient age, donor age over 20, and the presence of ascites or severe hepatic encephalopathy. Survival did not vary by race or sex. HCC-specific factors significantly related to survival were the total number of tumors, extrahepatic spread, lymph node involvement, satellite lesions, micro- or macrovascular invasion, tumor differentiation (grade), and pre-transplant treatment. Survival improved over the study period, at 4% per calendar year during the first 5 years post transplant and 1% per year thereafter., Conclusions: Life expectancy in non-cirrhotic HCC transplant patients is much reduced from normal, and varies according to age and tumor-related factors. Survival improved modestly over the study period.

Background: Stroke is a leading cause of death and disability in the developed world. The major factor affecting long term survival (other than age) is known to be the severity of disability. Yet to our knowledge there are no studies reporting life expectancies stratified by both age and severity. Remaining life expectancy is a key measure of health., Methods: We identified 11 long-term follow-up studies of stroke patients that reported the multivariate effects of age, sex, the modified Rankin Scale (mRS) grade of disability, and other factors. From these we computed the composite effects of these factors on survival, then used these to calculate age-, sex-, and mRS-specific mortality rates. Finally we used the rates to construct life tables, and hence obtain life expectancies., Results: Life expectancy varies by age, sex, and mRS. The life expectancies of males age 70, for example, were 13, 13, 11, 8, 6, and 5 years for Rankin Grades 0-5, respectively, representing reductions of 1, 1, 3, 6, 8, and 9 years from the corresponding general population figure., Conclusions: These figures demonstrate the importance of rehabilitation following stroke, and can be used in discussion of public policy and benchmarking of future results., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The prognoses widely reported for pancreatic cancer reflect the very poor survival associated with the most common histological type, exocrine adenocarcinoma. We calculated life expectancies for patients with less common pancreatic neuroendocrine tumors (PNETs), and also for the subsets of these patients who survive 1 and 5 years post-diagnosis, all of which carry a significantly better prognosis. Results for 1- and 5-year PNET survivors appear not to have been previously reported, nor have life expectancies (average long-term survival times) been given., Methods: We identified 5287 cases of PNET in the SEER US national database, 1973-2013. The Kaplan-Meier estimator was used to compute empirical survival probabilities and median survival times for functioning (n = 279) and non-functioning PNET (n = 5008) cases. The Cox proportional hazards regression model was used to examine univariate associations of survival with covariates including patient age, sex, race, cancer stage, tumor grade, surgical treatment, and calendar year. A multivariate multiplicative hazard Poisson regression model estimated mortality rates for all combinations of the covariates. The rates were used to construct actuarial life tables, which gave life expectancies for male and female patients according to age, cancer stage, tumor grade, histology (functioning versus non-functioning), surgical treatment status, and time since diagnosis. These life expectancies were compared with age- and sex-specific figures from the US general population., Results: Life expectancy in PNET is lower than that of the US general population and varies significantly according to patient age, cancer stage, tumor grade, mode of treatment, and time since diagnosis. For example, it is near normal for persons aged 70 and older who undergo surgical resection of localized well-differentiated (i.e., grade I) tumors. By contrast, persons with metastatic high-grade tumors not amenable to surgery have life expectancies of only 1 to 4 years depending on patient age. Functioning PNETs were associated with somewhat lower mortality than non-functioning within the first few years after diagnosis, though no major differences were observed long-term. Positive factors for survival were younger age, localized stage, low tumor grade, and surgical treatment. Survival improved over the 1973-2013 study period: on average mortality rates fell by 1.2% per year after controlling for changes in the patient population. Life expectancy increased markedly with time since diagnosis: those surviving 1 and 5 years post-diagnosis had longer additional life expectancies., Conclusions: Life expectancies of patients with PNETs may be markedly reduced from normal, but even in the worst cases their prognoses remain significantly better than that of patients with the more common pancreatic adenocarcinomas. In some very favorable cases, the life expectancy is near-normal, especially amongst 1- and 5-year survivors. This information can be used to counsel patients., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objectives: To compute the life expectancy of persons with traumatic brain injury (TBI) based on validated prognostic models from 2 cohorts, to compare mortality and life expectancy of persons with TBI with those of the U.S. general population, and to investigate trends toward improved survival over the last 2 decades., Design: Survival analysis., Setting: Postdischarge from rehabilitation units and long-term follow-up at regional centers., Participants: Two cohorts of long-term survivors of TBI (N=12,481): the Traumatic Brain Injury Model Systems (TBIMS) cohort comprised 7365 persons who were admitted to a TBIMS facility with moderate to severe TBI and were assessed at ≥1 years postinjury, and the California Department of Developmental Services (CDDS) cohort comprised 5116 persons who sustained a TBI and received long-term services from the CDDS., Interventions: Not applicable., Main Outcome Measures: Life expectancy., Results: The estimates of age-, sex-, and disability-specific life expectancy of persons with TBI derived from the CDDS and TBIMS were similar. The estimates of age- and sex-specific life expectancy were lower than those of the U.S. general population. Mortality rates of persons with TBI were higher than those of the U.S. general population. Mortality rates did not improve and the standardized mortality ratio increased over the study period from 1988 to 2010., Conclusions: Life expectancy of persons with TBI is lower than that of the general population and depends on age, sex, and severity of disability. When compared, the survival outcomes in the TBIMS and CDDS cohorts are remarkably similar. Because there have been no marked trends in the last 20 years, the life expectancies presented in this article may remain valid in the future., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To develop prognostic models for long-term survival in adults with traumatic brain injury (TBI) and to assess their external validity in 2 independent populations., Design: Survival analysis., Setting: Post-discharge from rehabilitation units and long-term follow-up at regional centers., Participants: Two cohorts of long-term survivors of TBI (N=12,481): the Traumatic Brain Injury Model Systems (TBIMS) cohort comprised 7365 persons who were admitted to a TBIMS facility and were assessed at ≥1 years postinjury, and the California Department of Developmental Services (CDDS) cohort comprised 5116 persons who sustained a TBI and received long-term services from the CDDS., Interventions: Not applicable., Main Outcome Measures: Survival/mortality., Results: Older age, male sex, and severity of disability in walking and feeding were significant predictors of increased long-term mortality rates (all P<.05, both databases). The CDDS model predicted 623 deaths for persons in the TBIMS cohort, with an observed-to-expected ratio of .94 (95% confidence interval [CI], 0.87-1.02). The TBIMS model predicted a total of 525 deaths for persons in the CDDS cohort, with an observed-to-expected ratio of 1.08 (95% CI, 0.99-1.17). Regression calibration statistics were satisfactory, and both models ranked survival times well from shortest to longest (TBIMS: C index, .78; 95% CI, .76-.80; CDDS: C index, .80; 95% CI, .78-.82)., Conclusions: Long-term survival prognosis in TBI is related to age, sex, and severity of disability. When compared on the basis of these factors, the survival estimates derived from the TBIMS and CDDS cohorts are found to be similar. The close agreement between model predictions and actual mortality rates confirm the external validity of the prognostic models presented herein., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate whether there have been improvements in long-term survival after spinal cord injury in recent decades., Design: Survival analysis using time-varying covariates. The outcome variable was survival or mortality, and the explanatory variables were age, sex, level and grade of injury, and calendar year. The data were analyzed using the logistic regression model, Poisson regression model with comparison to the general population, and the computation of standardized mortality ratios for various groups., Setting: National Spinal Cord Injury Model Systems facilities., Participants: Persons (N=31,531) who survived 2 years postinjury, were older than 10 years, and who did not require ventilator support. These persons contributed 484,979 person-years of data, with 8536 deaths over the 1973 to 2012 study period., Interventions: Not applicable., Main Outcome Measures: Survival; survival relative to the general population; life expectancy., Results: After adjustment for age, sex, race, etiology of injury, time since injury, and level and grade of injury, mortality in persons with spinal cord injury was higher in the 2005 to 2012 period than in 1990 to 2004 or 1980 to 1989, the odds ratios for these 3 periods were .857, .826, and .802 as compared with the 1970 to 1979 reference period., Conclusions: There was no evidence of improvement. Long-term survival has not changed over the past 30 years., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Previous research on the life expectancy of persons with American Spinal Injury Association (ASIA) Impairment Scale Grade D spinal cord injury has considered them as a large homogenous group, making no functional or medical distinctions. This study sought to (1) determine how survival in this group depends on ambulatory function and the extent of bowel or bladder dysfunction, (2) compute life expectancies for various subgroups, and (3) examine whether survival has improved over time., Design: Data were from 8,206 adults with ASIA Impairment Scale Grade D spinal cord injury in the Spinal Cord Injury Model Systems database who were not ventilator dependent and who survived more than 1 yr after injury. There were a total of 114,739 person-years of follow-up and 1,730 deaths during the 1970-2011 study period. Empirical age- and sex-specific mortality rates were computed. Regression analysis of survival data with time-dependent covariates was used to determine the effect of risk factors, to test for a time trend, and to estimate mortality rates for subgroups. Life expectancies were obtained from life tables constructed for each subgroup., Results: The ability to walk, whether independently or with an assistive device, was associated with longer survival than wheelchair dependence. The need for an indwelling catheter, and to a lesser extent intermittent catheterization, was associated with increased mortality risk. Persons who walked unaided and who did not require catheterization had life expectancies roughly 90% of normal. Those who required a wheelchair for locomotion had life expectancies comparable with that in paraplegia, less than 75% of normal. No time trend in survival was found., Conclusions: Life expectancy of persons with ASIA Impairment Scale D spinal cord injury depends strongly on the ability to walk and the need for catheterization.

Background: Much is known about survival after traumatic brain injury (TBI), yet relatively little about survival after anoxic brain injury (ABI)., Objective: To determine whether long-term survival after ABI is comparable to that after TBI., Methods: We identified 237 patients with ABI and 1,620 with TBI in California who were aged 15 to 35, survived at least 1 year post injury, and were injured in 1986 or later. We analyzed the long-term follow-up data using the Cox Proportional Hazards Regression Model, controlling for age, sex, and severity of disability., Results: After adjustment for risk factors, no significant differences in long-term survival between ABI and TBI were found (hazard ratio = 0.97; 95% c.i. 0.57-1.65)., Conclusions: In adolescents and young adults, long-term survival after ABI appears to be similar to that after TBI.

Aim: The aim of the study was to determine survival probabilities and life expectancies for individuals with cerebral palsy based on data collected over a 28-year period in California., Method: We identified all individuals with cerebral palsy, aged 4 years or older, who were clients of the California Department of Developmental Services between 1983 and 2010. Kaplan-Meier survival curves were constructed for 4-year-old children, and the estimated survival probabilities were adjusted to reflect trends in mortality by calendar year. For persons aged 15, 30, 45, and 60 years, separate Poisson regression models were used to estimate age-, sex-, and disability-specific mortality rates. These mortality rates were adjusted to reflect trends of improved survival, and life expectancies were obtained using life table methods., Results: The sample comprised 16,440, 14,609, 11,735, 7023, and 2375 persons at ages 4, 15, 30, 45, and 60 years, respectively. In 1983, 50% of 4-year-old children who did not lift their heads in the prone position and were tube fed lived to age 10.9 years. By 2010, the median age at death had increased to 17.1 years. In ambulatory children the probability of survival to adulthood did not change by more than 1%. Life expectancies for adolescents and adults were lower for those with more severe limitations in motor function and feeding skills, and decreased with advancing age. Life expectancies for tube-fed adolescents and adults increased by 1 to 3 years, depending on age and pattern of disability, over the course of the study period., Interpretation: Over the past three decades in California there have been significant improvements in the survival of children with very severe disabilities. There have also been improvements to the life expectancy of tube-fed adults, though to a lesser extent than in children., (© 2014 Mac Keith Press.)

Aim: To determine whether the trend of improved survival among individuals with cerebral palsy (CP) in California during the 1980s and 1990s has continued during the most recent decade., Method: In an observational cohort study we evaluated individuals with CP, aged 4 years and older, who were clients of the California Department of Developmental Services. Medical diagnoses, functional disabilities, and special health care requirements were assessed with Client Development Evaluation Reports made between 1983 and 2010. Trends in birth cohort survival were analyzed with Kaplan-Meier curves and Cox regression. Calendar year period effects were analyzed with Poisson regression., Results: A total of 51,923 persons with CP (28,789 males [55%], 23,134 females [45%]; mean age 14y 11mo, SD 14y 1mo, range 4y 0mo to 96y 10mo) collectively contributed 662,268 years of follow-up. There were 7690 deaths for an overall mortality rate of 11.6 per 1000 persons per year. No significant birth cohort effects on survival were observed in 4-year-olds who had no severe disabilities. By contrast, children who did not lift their heads in prone position who were born in more recent years had significantly lower mortality rates (Cox hazard ratio 0.971, p<0.001) than those with comparable disabilities born earlier. With regard to calendar year period effects, we found that age-, sex-, and disability-specific mortality rates declined by 1.5% (95% CI 0.9-2.1) year-over-year from 1983 to 2010. The estimate increased to 2.5% (95% CI 1.9-3.1) per year when we additionally controlled for tube-feeding status. Mortality rates in tube fed adolescents and adults, ages 15 to 59 years, declined by 0.9% (95% CI, 0.4-1.4) per year. No improvement was observed for adolescents or adults who fed orally or for those over age 60. In fact, the ratio of age-specific mortality rates for these latter groups to those in the general population, increased by 1.7% (95% CI 1.3-2.0) per year during the study period., Interpretation: The trend toward improved survival has continued throughout the most recent decade. Declines in CP childhood mortality are comparable to the improvements observed in the United States general population (i.e. the mortality ratio in childhood has remained roughly constant over the last three decades). In contrast, the mortality ratio for most adolescents and adults with CP, relative to the general population, has increased., (© 2014 Mac Keith Press.)

This paper updates our 2003 study on the effect of intellectual disability (ID) on mortality in persons with no significant physical disability. As previously, we used the California Department of Developmental Services database to compute mortality rates by age, sex, and severity of ID. There were 64,207 subjects age 5 and older, who contributed 386,000 person-years of follow-up and 1514 deaths during the 2000 to 2010 study period. The excess death rates increased with age, ranging from 0.1 to 6.8 per 1000 in mild/moderate ID, and 3.4 to 6.7 in severe/profound.

Objectives: To document long-term survival in 1-year survivors of traumatic brain injury (TBI); to compare the use of the Disability Rating Scale (DRS) and FIM as factors in the estimation of survival probabilities; and to investigate the effect of time since injury and secular trends in mortality., Design: Cohort study of 1-year survivors of TBI followed up to 20 years postinjury. Statistical methods include standardized mortality ratio, Kaplan-Meier survival curve, proportional hazards regression, and person-year logistic regression., Setting: Postdischarge from rehabilitation units., Participants: Population-based sample of persons (N=7228) who were admitted to a TBI Model Systems facility and survived at least 1 year postinjury. These persons contributed 32,505 person-years, with 537 deaths, over the 1989 to 2011 study period., Interventions: Not applicable., Main Outcome Measure: Survival., Results: Survival was poorer than that of the general population (standardized mortality ratio=2.1; 95% confidence interval, 1.9-2.3). Age, sex, and functional disability were significant risk factors for mortality (P<.001). FIM- and DRS-based proportional hazards survival models had comparable predictive performance (C index: .80 vs .80; Akaike information criterion: 11,005 vs 11,015). Time since injury and current calendar year were not significant predictors of long-term survival (both P>.05)., Conclusions: Long-term survival prognosis in TBI depends on age, sex, and disability. FIM and DRS are useful prognostic measures with comparable statistical performance. Age- and disability-specific mortality rates in TBI have not declined over the last 20 years. A survival prognosis calculator is available online (http://www.LifeExpectancy.org/tbims.shtml)., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Anemia is a common condition among community-dwelling older adults. The present study investigates the effect of type of anemia on subsequent mortality. We analyzed data from participants of the Third National Health and Nutrition Survey who were aged ≥50 and had valid hemoglobin levels determined by laboratory measurement. Anemia was defined by World Health Organization criteria. 7,171 subjects met our inclusion criterion. Of those with anemia (n = 862, deaths = 491), 24% had nutritional anemia, 11% had anemia of chronic renal disease, 26% had anemia of chronic inflammation, and 39% had unexplained anemia. We found an overall relative risk (RR) for mortality of 1.8 (p < 0.001) comparing those with anemia to those without, after adjusting for age, sex, and race. After we controlled for a number of chronic medical conditions, the overall RR was 1.6. Compared to persons without anemia, we found the following RRs for the type of anemia: nutritional (2.34, p < 0.0001), chronic renal disease (1.70, p < 0.0001), chronic inflammation (1.48, p < 0.0001), and unexplained (1.26, p < 0.01). Anemia is common although not severe in older non-institutionalized adults. When compared with non-anemic older adults, those with nutritional anemia or anemia due to chronic renal disease have the highest mortality risk.

Rationale: Previous studies have demonstrated that chronic obstructive pulmonary disease (COPD) causes increased mortality in the general population. But life expectancy and the years of life lost have not been reported., Objectives: To quantify mortality, examine how it varies with age, sex, and other risk factors, and determine how life expectancy is affected., Methods: We constructed mortality models using the Third National Health and Nutrition Examination Survey, adjusting for age, sex, race, and major medical conditions. We used these to compute life expectancy and the years of life lost., Measurements and Main Results: Pulmonary function testing classified patients as having Global Initiative on Obstructive Lung Disease (GOLD) stage 0, 1, 2, 3 or 4 COPD or restriction. COPD is associated with only a modest reduction in life expectancy for never smokers, but with a very large reduction for current and former smokers. At age 65, the reductions in male life expectancy for stage 1, stage 2, and stages 3 or 4 disease in current smokers are 0.3 years, 2.2 years, and 5.8 years. These are in addition to the 3.5 years lost due to smoking. In former smokers the reductions are 1.4 years and 5.6 years for stage 2 and stages 3 or 4 disease, and in never smokers they are 0.7 and 1.3 years., Conclusions: Persons with COPD have an increased risk of mortality compared to those who do not, with consequent reduction in life expectancy. The effect is most marked in current smokers, and this is further reason for smokers to quit.

Cognitive impairment is associated with increased mortality, depending on the severity of impairment. We analyzed data from the Cardiovascular Health Study (CHS), using Cox proportional hazards regression models to quantify the effect of the impairment. After adjustment for age, sex, and medical risk factors, we found the resulting relative risks to range from 1.19 for mild impairment to 1.98 for severe.

The United States has had 43 presidents. We examined whether they survive significantly longer or shorter than their contemporaries. We found that survival was better for presidents elected in the 1789-1841 and 1933-2001 periods (SMRs of 0.7 and 0.6, respectively), but worse for those elected in 1845-1929 (SMR = 2.9). We also found increased mortality during the years lived in office (SMR = 1.4), but no increase in mortality after leaving office (SMR = 1.0).

Cigarette smoking leads to excess mortality risk. Although it is well known that the risk increases with the number of pack-years of smoking--that is, how much a person smokes, or "habit"--there is apparently no published studies that organize and synthesize the evidence on this topic. This paper provides a meta-analysis of the latest published findings relating to cigarette smoking habit and excess mortality. A combined estimate of the relative risk (RR) of death for smokers, stratified by habit (light, medium, or heavy smoking), compared with non-smokers is provided.

This study aimed to determine the probability that a child with cerebral palsy (CP) will lose or gain ambulatory ability through adolescence and young adulthood. We analyzed retrospectively data from 1987 to 2002 on Californians with CP initially aged 10 years (SD 0.9y; n=7550 [4304 males, 3246 females]) and 25 years (SD 0.8y; n=5721 [3261 males, 2460 females]) who had varying levels of ambulatory ability (initial Gross Motor Function Classification System Levels I-IV). We used the Aalen-Johansen estimator to estimate probabilities of transition to other levels of ambulatory ability in the future. Those who walked and climbed stairs without difficulty at age 10 had only a 23% chance of decline (to requiring a handrail to manage stairs, or worse) 15 years later. Those who ambulated with some difficulty but did not use a wheelchair had a significant chance (33%) of improvement (to being able to walk unsteadily alone at least 3m or better) and only a small chance (11%) of becoming non-ambulatory. Those who used a wheelchair were more likely to lose ambulatory ability (34%) or die (6%). Those who walked and climbed stairs well at age 25 were likely to maintain that ability 15 years later (76%), while those needing support to climb stairs were more likely to lose ability. Improvement in ambulation after age 25 was unlikely. Children and young adults with CP are likely to maintain their ambulatory ability during their next 15 years. Some who ambulate with difficulty at age 10 may improve through adolescence, but those who use a wheelchair are more likely to decline. By age 25 improvement in ambulation is unlikely and decline more likely. Most, however, will not change over the next 15 years.

This study examined growth of children and adolescents with cerebral palsy (CP) who received services from the California Department of Developmental Services from 1987 to 2002. In all, 141 961 measurements of height and weight were taken from 24920 patients with CP (14103 males, 10817 females). Centiles of weight and height were determined by age, sex, and five levels of functional ability ranging from fully ambulatory to unable to walk, crawl, or feed self, and fed via gastrostomy tube. Resulting charts of height and weight centiles were compared with Centers for Disease Control and Prevention weight and height charts for the general population of the US. Centiles of height and weight of patients with CP were close to those of the general population for the highest functioning groups with CP, but lagged substantially for other groups. Presence of a feeding tube was associated with greater height and weight in the lowest functioning groups, with centiles for weight being 2 to 5 kg higher for those with gastrostomy tubes. The charts may assist in early identification of nutritional or metabolic difficulties beyond what might be expected for patients with similar functional disabilities.

Objective: To determine whether persons who incur a spinal cord injury as children are at increased risk of mortality compared with persons injured as adults given comparable current age, sex, and injury severity., Methods: A total of 25,340 persons admitted to the National Spinal Cord Injury Statistical Center database or the National Shriners Spinal Cord Injury database who were not ventilator dependent and who survived more than 2 years after injury were included in this study. These persons contributed 274,020 person-years of data, with 3844 deaths, over the 1973-2004 study period. Data were analyzed using pooled repeated observations analysis of person-years. For each person-year the outcome variable was survival/mortality, and the explanatory variables included current age, sex, race, cause of injury, severity of injury, and age at injury (the focus of the current analysis)., Results: Other factors being equal, persons who were less than 16 years of age at time of injury had a 31% (95% CI = 3%-65%) increase in the annual odds of dying compared with persons injured at older ages (P= 0.013). This increased risk did not vary significantly by current age, sex, race, injury severity, or era of injury (P > 0.05)., Conclusion: Life expectancy for persons injured as children appears to be slightly lower than that of otherwise comparably injured persons who suffered their injuries as adults. Nonetheless, persons who are injured young can enjoy relatively long life expectancies, ranging from approximately 83% of normal life expectancy for persons with minimal deficit incomplete injuries to approximately 50% of normal in high-cervical-level injuries without ventilator dependence.

Objective: To investigate whether there have been improvements in survival after spinal cord injury (SCI) over time, both in the critical first 2 years after injury and in the longer term., Design: Pooled repeated observations analysis of person-years. For each person-year, the outcome variable is survival and mortality, and the explanatory variables include age, level and grade of injury, and calendar year (the main focus of the analyses). The method can be viewed as a generalization of proportional hazards regression., Setting: Model spinal cord injury systems and hospital SCI units across the United States., Participants: Persons (N=30,822) admitted to a Spinal Cord Injury Model Systems facility a minimum of 1 day after injury. Only persons over 10 years of age and known not to be ventilator dependent were included. These persons contributed 323,618 person-years of data, with 4980 deaths, over the 1973 to 2004 study period., Interventions: Not applicable., Main Outcome Measure: Survival., Results: Other factors being equal, over the last 3 decades there has been a 40% decline in mortality during the critical first 2 years after injury. However, the decline in mortality over time in the post-2-year period is small and not statistically significant., Conclusions: The absence of a substantial decline in mortality after the first 2 years postinjury is contrary to widely held impressions. Nevertheless, the finding is based on a large database and sensitive analytic methods and is consistent with previous research. Improvements in critical care medicine after spinal cord injury may explain the marked decline in short-term mortality. In contrast, although there have no doubt been improvements in long-term rehabilitative care, their effect in enhancing the life span of persons with SCI appears to have been overstated.

We wish to estimate the associated excess death rate (EDR) or mortality ratio (MR) from a published study of persons with a given medical condition. This requires computation of the expected mortality in the study population. If age- and sex-specific person years of data are available, this task is straightforward. Most often, however, we have only descriptive statistics--percentage male, average and standard deviation of age--at the beginning of follow up. We show here how this limited information can be used to compute an exact EDR or other quantities of interest.

Objective: To develop predictive models to estimate worklife expectancy after spinal cord injury (SCI)., Design: Inception cohort study., Setting: Model SCI Care Systems throughout the United States., Participants: 20,143 persons enrolled in the National Spinal Cord Injury Statistical Center database since 1973., Intervention: Not applicable., Main Outcome Measure: Postinjury employment rates and worklife expectancy., Results: Using logistic regression, we found a greater likelihood of being employed in any given year to be significantly associated with younger age, white race, higher education level, being married, having a nonviolent cause of injury, paraplegia, ASIA D injury, longer time postinjury, being employed at injury and during the previous postinjury year, higher general population employment rate, lower level of Social Security Disability Insurance benefits, and calendar years after the passage of the Americans with Disabilities Act., Conclusions: The likelihood of postinjury employment varies substantially among persons with SCI. Given favorable patient characteristics, worklife should be considerably higher than previous estimates.

Background/objective: Identify factors related to long-term survival, and quantify their effect on mortality and life expectancy., Setting: Model spinal cord injury systems of care across the United States., Study Design: Survival analysis of persons with traumatic spinal cord injury who are ventilator dependent at discharge from inpatient rehabilitation and who survive at least 1 year after injury., Methods: Logistic regression analysis on a data set of 1,986 person-years occurring among 319 individuals injured from 1973 through 2003., Results: The key factors related to long-term survival were age, time since injury, neurologic level, and degree of completeness of injury. The life expectancies were modestly lower than previous estimates. Pneumonia and other respiratory conditions remain the leading cause of death but account for only 31% of deaths of known causes., Conclusions: Whereas previous research has suggested a dramatic improvement in survival over the last few decades in this population, this is only the case during the critical first few years after injury. There was no evidence for such a trend in the subsequent period.

The objective of this study was to characterize the reproducibility and variability in the measurement to the activated clotting time (ACT) when performed on two different types of instruments, the HemoTec ACT (Medtronic) and the Hemochron 801 (International Technidyne). The ACT has evolved into the most common point-of-care test used in the cardiac catheterization lab to manage patient heparinization. Since the test has not been standardized, different systems frequently produce different results under the same clinical conditions. Duplicate paired ACT tests (n = 885) from 359 patients were performed on both instruments. Prothrombin times (PT) and activated partial thromboplastin times (aPTT) were also determined on subsets of these same samples (PT = 533; aPTT = 487). The performance and relationships between the two tests were determined using a variety of statistical analytical techniques. The average difference between the ACT devices was only 8 sec, yet more than 60% of the measurements varied by more than 10%. Over one-fourth of measurements varied by more than 20%. The reproducibility to the HemoTec instrument was superior to the Hemochron instrument across the entire range of ACTs measured (mean coefficient of variation 2.4% +/- 3.1% vs. 7.2% +/- 6.1% for HemoTec and Hemochron, respectively; P < 0.00001; range = 65-555 sec). The relationship between the two ACTs was nonlinear. In therapeutic ranges used for interventional procedures (200-350 sec), HemoTec and Hemochron ACTs are not comparable to one another. Statistical comparative analysis indicated that the HemoTec ACT has better overall performance.

This study investigated mortality and causes of death between 1988 and 1999 in 14781 persons (6702 female) with Down syndrome in California, comparing age, sex, ethnicity, and other factors. Mean age at the start of follow-up was 14 years 8 months (SD 14y 10mo). During the study period 600 persons died. The standardized mortality ratio (SMR) for the population was 5.5. Blacks were at greater risk than whites, Hispanics, or Asians (relative risk = 1.5). Mortality declined during the period, especially for children with congenital heart defects. Leukemia (SMR = 17), respiratory illnesses (SMR = 27), congenital anomalies (SMR = 72), and circulatory diseases (SMR = 5.3) accounted for most of the excess mortality. With the exception of leukemia, cancer mortality was not different from that of the general population.

Estimates of old-age mortality are necessary for the construction of life tables and computation of life expectancy, and are essential in the growing area of life insurance for the elderly. Two common assumptions are that either the excess death rate (EDR) or the relative risk (RR) stays constant with increasing age. It is known, however, that for most medical conditions the former underestimates the risk and the latter overestimates it. A third popular method is that of rating up: a subject is said to be "rated up k years" if his future mortality rates are assumed to be those of a person in the general population who is k years older. It is shown here that this method generally leads to gross overestimates of old-age mortality. We consider two less-commonly used models, log-linear declining relative risk (LDR) and constant proportional life expectancy (PLE), and compare them to the methods of constant EDR, constant RR and rating up. Although slightly more complicated to employ than the other methods, both LDR and PLE generally give better estimates of mortality and life expectancy. When mortality rates for chronic conditions are known within a certain age range, and estimates outside of the range are required, the LDR and PLE methods may be preferable to the more familiar methods of constant EDR, constant RR, or rating up.

Objectives: To determine independent predictors of ambulation among children with cerebral palsy and to develop a simple tool that estimates the probability that a child will walk., Methods: In a retrospective study of all children with cerebral palsy who were not yet walking at 2 to 3(1/2) years of age, while receiving services from the California Department of Developmental Services during the years 1987-1999, we analyzed medical and functional data obtained annually by Department of Developmental Services physicians and social workers. Using logistic regression analyses, we determined independent predictors of a child's ability to walk well alone at least 20 feet, without assistive devices, by age 6. We then estimated the probabilities of walking at various levels of ability over time, using multistate survival analysis., Results: Of 5366 study subjects, 2295 (43%) were evaluated at age 6; 12.8% could walk independently and 18.4% walked with support. Independent predictors of successful ambulation included early motor milestones such as sitting (odds ratio: 12.5; 95% confidence interval: 5.8-27.2) and pulling to a stand (odds ratio: 28.5; 95% confidence interval: 13.4-60.4) when compared with lack of rolling at age 2, cerebral palsy type other than spastic quadriparesis (odds ratio: 2.2; 95% confidence interval: 1.5-3.1), and preserved visual function (odds ratio: 2.4; 95% confidence interval: 1.1-5.4). Our ambulation charts depict the probability of remaining nonambulatory, transitioning to 1 of 3 possible ambulatory states, or expiring at all subsequent ages through age 14., Conclusion: The ambulation charts provide a simple straightforward way to estimate the probability that a child with cerebral palsy who is nonambulatory at 2 to 3 12 years of age will eventually walk with or without support.

Background: We sought to study a large cohort of symptomatic women to determine the clinical use of electron beam tomography (EBT), with evaluation of the sensitivity and specificity of obstructive coronary disease and the differences between premenopausal and postmenopausal cohorts., Methods: Patients who underwent angiography for evaluation of coronary artery disease (CAD) and EBT within 3 months were enrolled. Receiver operating characteristic curves were used to establish relationships between EBT calcium scores and angiographic disease., Results: We studied 1120 symptomatic patients, 387 women and 733 men. We found no significant differences with respect to sensitivity for obstructive disease (96% in men and women). However, women had a significantly higher specificity (46% in men versus 57% in women; P =.01). The area under the curves for coronary calcium score predicting angiographic disease was 0.85 for all patients and 0.84 in women. Evaluation of scores on the basis of age revealed a 14.4-year lag between men and women. One hundred thirty-five women had negative EBT study results (score, zero; no calcium present), with 6 with single-vessel disease and 129 with normal coronaries or nonobstructive disease only (negative predictive value, 96%)., Conclusion: EBT may have a great value in evaluation of women with possible CAD. The high sensitivity and high negative predictive value may serve as the basis for a new diagnostic approach to filter symptomatic women with suspected CAD before coronary angiography.

Objectives: The study was done to evaluate whether ethnic differences exist in the prevalence of coronary artery calcification (CAC), and to determine whether differences in calcification correlate with the degree of coronary obstruction., Background: Electron beam tomography (EBT) can be used to quantitate the amount of CAC and assist in prognostication of future cardiac events. It is unclear whether ethnic differences in coronary mortality are related to differences in the prevalence of coronary obstruction and CAC., Methods: A total of 782 symptomatic subjects underwent both EBT and angiography. A 50% luminal narrowing defined an angiographic obstruction., Results: We observed substantial ethnic differences in prevalence of both CAC and angiographic stenosis. In whites (n = 453), prevalence of CAC (score >0) was 84%, and significant obstruction on angiogram was 71%. Compared with whites, blacks (n = 108) had a significantly lower prevalence of CAC (62%, p < 0.001) and angiographic disease (49%, p < 0.01). Hispanics (n = 177) also had a lower prevalence of CAC (71%, p < 0.001) and angiographic obstruction (58%, p < 0.01). Asians (n = 44) were not significantly different in regard to CAC (73%, p = 0.06) or angiographic stenosis (64%, p = 0.30). These ethnic differences remained after simultaneously controlling (by use of multiple logistic regression) for age, gender and cardiac risk factors., Conclusions: As compared with whites, blacks and Hispanics had significantly lower prevalence of CAC and obstructive coronary disease. Ethnic differences in risk-factor profiles do not explain these differences. This study demonstrated that whites have a higher atherosclerotic burden than blacks and Hispanics, independent of risk-factor differences among symptomatic patients referred for angiography.

We determined estimates of survival in children, 3-15 years of age, in the vegetative state (VS) (n = 564), immobile minimally conscious state (MCS) (n = 705), and mobile MCS (n = 3,806). Data were extracted from the annual Client Development Evaluation Reports of the California Department of Developmental Services between 1988 and 1997 using the operational definitions for these three states on the basis of 15 descriptive behavioral categories. Patients were also categorized according to the following four etiologies: acquired (traumatic and nontraumatic) brain injury; perinatal/genetic; degenerative; and unknown/undetermined. The percentage of patients surviving 8 years was 63%, 65%, and 81%, for the VS, immobile MCS, and mobile MCS, respectively. Children in the VS and MCSs with acquired brain injury had lower mortality rates and those with degenerative diseases the highest mortality rates. We observed little difference in survival between patients in the VS and immobile MCS, suggesting that the presence of consciousness is not a critical variable in determining life expectancy. Furthermore, survival was much greater for patients in the mobile MCS than for those in the immobile MCS, suggesting that mobility is more important in predicting survival than the level of consciousness.