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Introduction: Hypotension is known to be associated with increased mortality in severe traumatic brain injury (TBI) patients. Systolic blood pressure (SBP) of <90 mmHg is the threshold for hypotension in consensus TBI treatment guidelines; however, evidence suggests hypotension should be defined at higher levels for these patients. Our objective was to determine the influence of hypotension on mortality in TBI patients requiring ICU admission using different thresholds of SBP on arrival at the emergency department (ED). Methods: Retrospective cohort study of patients with severe TBI (Abbreviated Injury Scale Head score ≥3) admitted to ICU at the QEII Health Sciences Centre (Halifax, Canada) between 2002 and 2013. Patients were grouped by SBP on ED arrival ( <90 mmHg, <100 mmHg, <110 mmHg). We performed multiple logistic regression analysis with mortality as the dependent variable. Models were adjusted for confounders including age, gender, Injury Severity Score (ISS), injury mechanism, and trauma team activation (TTA). Results: A total of 1233 patients sustained a severe TBI and were admitted to the ICU during the study period. The mean age was 43.4 ± 23.9 years and most patients were male (919/1233; 74.5%). The most common mechanism of injury was motor vehicle collision (491/1233; 41.2%) followed by falls (427/1233; 35.8%). Mean length of stay in the ICU was 6.1 ± 6.4 days, and the overall mortality rate was 22.7%. SBP on arrival was available for 1182 patients. The <90 mmHg group had 4.6% (54/1182) of these patients; mean ISS was 20.6 ± 7.8 and mortality was 40.7% (22/54). The <100 mmHg had 9.3% (110/1182) of patients; mean ISS was 19.3 ± 7.9 and mortality was 34.5% (38/110). The <110 mmHg group had 16.8% (198/1182) of patients; mean ISS was 17.9 ± 8.0 and mortality was 28.8% (57/198). After adjusting for confounders, the association between hypotension and mortality was 2.22 (95% CI 1.19-4.16) using a <90 mmHg cutoff, 1.79 (95% CI 1.12-2.86) using a <100 mmHg cutoff, and 1.50 (95% CI 1.02-2.21) using a <110 mmHg cutoff. Conclusion: While we found that TBI patients with a SBP <90 mmHg were over 2 times more likely to die, patients with an SBP <110 mmHg on ED arrival were still 1.5 times more likely to die from their injuries compared to patients without hypotension. These results suggest that establishing a higher threshold for clinically meaningful hypotension in TBI patients is warranted.
Background: Secondary hormonal deficiency (SHD) in patients with sellar masses (SM) is associated with significant morbidity. Purpose: to compare long-term risk of new-onset SHD in SM found incidentally (ISM) versus those clinically manifesting (CMSM). Methods: From the Halifax Neuropituitary Program’s database, we identified all patients having non-functioning and non-pituitary SM from January 1, 2006, with ≥ 12 months follow-up. Results: There were 214 CMSM (108 with baseline SHD) and 148 ISM (37 with baseline SHD) patients (mean follow-up: 5.7 and 5.0 years, respectively). In patients who underwent early surgery (<90 days from diagnosis), 3-month post-op hormonal function was considered baseline. Despite unchanged tumour size in over 95%, 129 (35.6%) developed new-onset SHD at up to 120 months. The risk of developing new-onset SHD was similar in CMSM and ISM groups (HR = 1.10; CI= 0.69-1.75; p= 0.7), and in surgical and nonsurgical patients (HR=1.24; CI= 0.59-2.61; p = 0.58). Conclusions: More than one third of patients with non-functioning or non-pituitary SM, presenting either with clinical manifestations or as incidental lesions, will develop new-onset SHD. Furthermore, SHD may develop several years later and despite stability of tumors, highlighting the need for ongoing, long-term hormonal assessment.
Introduction: Our emergency department (ED) sees a low volume of high acuity pediatric cases. A needs assessment revealed that 68% of our Emergency Physicians (EP) manage pediatric patients in less than 25% of their shifts. The same percentage of EPs as well as ED nurses indicated they were uncomfortable managing a critically unwell neonate. Thus, an interprofessional curriculum focused on pediatric emergencies for ED staff was developed. In-situ simulation education was chosen as the most appropriate method to consolidate each didactic block of curriculum, and uncover important system gaps. Methods: Needs assessment conducted, and emerging themes informed IPE curriculum objectives. A committee of experts in simulation, pediatric emergencies and nursing education designed a full-day, RCPSC accredited, interprofessional in-situ simulation program. Results: Progressive segmental strategy maximized learning outcomes. The initial phase (2 hrs) comprised an” early recognition of sepsis” seminar and 4 rotating skills stations (equipment familiarity, sedating the child, IV starts, and mixing IV medication). This deliberate, adaptive, customized practice was enhanced by expert facilitation at each station, directly engaging participants and providing real-time feedback. The second phase allowed interprofessional teams of MDs, RNs and Physician Assistants to apply knowledge gained from the didactic and skills stations to in-situ simulated emergencies. Each group participated in two pediatric emergency scenarios. Scenarios ran 20 minutes, followed by a 40 minute debrief. Each scenario had a trained debriefer and content expert. The day concluded with a final debrief, attended by all participants. Formalized checklists assessed participants knowledge translation during simulation exercises. Participants assessed facilitators and evaluated the simulation day and curriculum via anonymous feedback forms. Debriefing sessions were scribed and knowledge gaps and system errors were recorded. Results were distributed to ED leaders and responsibilities assigned to key stakeholders to ensure accountability and improvement in system errors. Results All participants reported the experience to be relevant and helpful in their learning. All participants requested more frequent simulation days. System gaps identified included: use of metric vs imperial measurements, non-compatible laryngoscope equipment, inadequate identification of team personnel. As a result, the above-mentioned equipment has been replaced, and we are developing resuscitation room ID stickers for all team roles. Conclusion: Simulation as a culmination to a didactic curriculum provides a safe environment to translate acquired knowledge, increasing ED staff comfort and familiarity with rare pediatric cases. Additionally, is an excellent tool to reveal system gaps and allow us to fill these gaps to improve departmental functioning and safety.
Introduction: Tertiary care emergency departments (EDs) in large urban environments may have a low volume of high acuity pediatric presentations due to their proximity to dedicated childrens hospitals or large community centres. This may lead to discomfort among emergency physicians (EPs) and registered nurses (RNs) in managing these patients and a waning of knowledge and skills for this unique population. Among the EP group at our institution, 68% indicated they managed pediatric patients in less than 25% of their shifts, 68% also indicated they were uncomfortable managing an undifferentiated critically unwell neonate and only 32% indicated they would be comfortable teaching pediatric topics to emergency medicine residents. At our institution, our innovation was to create a useful curriculum for certified EPs and RNs to improve the interdisciplinary teams comfort level, knowledge and skill set when managing pediatric emergencies. Methods: A needs assessment was undertaken of the EPs and RNs working in our centre. This information was used to develop intended learning outcomes in a collaborative manner with the clinical nursing educator and physician curriculum leads. The team further collaborated with the local simulation centre and a pediatric emergency physician from the local childrens hospital. Results: A one-year, three-module curriculum was developed to cover the areas felt to be highest yield by the EP group: febrile illness, respiratory disease and critically ill neonates and infants. Each module contains three components: an in person interactive lecture delivered by an EP who routinely manages pediatric patients, either at a childrens hospital or large community centre; an online component with e-mail blasts of high yield pediatric content; and, culminating in an interdisciplinary interdepartmental simulation held in situ. This latter is particularly important so that all members of the interdisciplinary team can practice finding and using equipment based on its actual location within the ED. Each component of each module is then evaluated by the participants to ensure improvement for subsequent delivery. Conclusion: Well delivered continuing professional development (CPD) will become increasingly important as competence by design becomes the model for maintenance of certification. Maintaining skills for pediatric patients is an important component of CPD for physicians working in general emergency departments that see a low volume of high acuity pediatric presentations. Our curriculum seeks to address this identified need in an innovative manner using a modular and interdisciplinary approach with a diversity of teaching methods to appeal to the learning styles among our health care team.
J. E. Colwell, University of Central Florida Orlando, Florida, USA,
J. Blum, Technische Universität Braunschweig Braunschweig, GERMANY,
R. N. Clark, Planetary Science Institute Tucson, Arizona, USA,
S. Kempf, University of Colorado Boulder, Colorado, USA,
R. M. Nelson, Planetary Science Institute Tucson, Arizona, USA
The surface area of Saturn's rings is greater than that of any of the planets in the solar system, yet, aside from dust, we have never observed or sampled an individual ring particle. Rings are unique in the solar system in that they are a complex dynamical system whose individual constituents interact not only with the light that we use to sense them remotely, but also with each other through gravitational and contact forces. These dynamical interactions play as large a role in determining the appearance of the ring system as do the optical properties of the individual ring particles. In this chapter we review the experimental work that has been done to help us understand both aspects of planetary rings: their collective dynamical behavior and their optical properties.
We have a wealth of data on the behavior of ensembles of particles, both dynamically and their optical properties. Laboratory measurements of the behavior of various likely ring particle analogs are a critical link in connecting these bulk observations with the nature of individual ring particles, and understanding the properties of individual ring particles should provide clues to the outstanding unanswered questions about the age and origin of rings.
Images of Saturn's rings and optical depth profiles from occultations show features at a variety of spatial scales, from the resolution limit of tens of meters for occultations up to thousands of kilometers, and including most scales in between (Colwell et al., 2009; Chapter 3). A frustratingly small fraction of these structures is well understood. Many that remain puzzling, such as the large optical depth fluctuations in Saturn's central B ring, the complex structure in the B ring and the inner A ring, the long-wavelength low-amplitude undulations in optical depth in the C ring, and the plateaus in the C ring, are likely linked to either the collective behavior of the ring particles governed in part by their collisional properties (see e.g. Schmidt et al., 2009, for a review) or by ballistic transport of material due to extrinsic micrometeoroid bombardment (Chapter 9). The mechanical properties of individual ring particles are critical in both types of process.
It is well established that the equid olfactory system is highly sensitive. It has been suggested that there is an intimate link between the sense of smell in the horse (Williams, 1995) and the fight and flight response, which is mediated by the autonomic nervous system (Marlin and Nankervis, 2002), thus affecting the heart. In humans, it has been demonstrated that lavender can have a pronounced impact on heart rate variability (Saeki, 2000) but it is not yet know whether the autonomic nervous system of the horse can be influenced by odour. It is the aim of the study to determine the effect of odour on the autonomic status of the horses.
Eight geldings were used in the study and the electrical activity of their heart was assessed using the “Polar S810” telemetric system before and during the presentation of either pig faeces or lavender to the horses’ nostrils. The experiment was conducted over a two–day period so that their response to both odours could be determined.
The relationship between depression and sexual behaviour among men who have sex with men (MSM) is poorly understood.
To investigate prevalence and correlates of depressive symptoms (Patient Health Questionnaire-9 score ≥10) and the relationship between depressive symptoms and sexual behaviour among MSM reporting recent sex.
The Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) is a cross-sectional study of UK genitourinary medicine clinic attendees without diagnosed HIV (2013–2014).
Among 1340 MSM, depressive symptoms (12.4%) were strongly associated with socioeconomic disadvantage and lower supportive network. Adjusted for key sociodemographic factors, depressive symptoms were associated with measures of condomless sex partners in the past 3 months (≥2 (prevalence ratio (PR) 1.42, 95% CI 1.17–1.74; P=0.001), unknown or HIV-positive status (PR 1.43, 95% CI 1.20–1.71; P<0.001)), sexually transmitted infection (STI) diagnosis (PR 1.46, 95% CI 1.19–1.79; P<0.001) and post-exposure prophylaxis use in the past year (PR 1.83, 95% CI 1.33–2.50; P<0.001).
Management of mental health may play a role in HIV and STI prevention.
We present an indentation-scope that interfaces with confocal microscopy, enabling direct observation of the three-dimensional (3D) microstructural response of coatings on substrates. Using this method, we compared microns-thick polymer coatings on glass with and without silica nanoparticle filler. Bulk force data confirmed the >30% modulus difference, while microstructural data further revealed slip at the glass-coating interface. Filled coatings slipped more and about two times faster, as reflected in 3D displacement and von Mises strain fields. Overall, these data indicate that silica-doping of coatings can dramatically alter adhesion. Moreover, this method compliments existing theoretical and modeling approaches for studying indentation in layered systems.
There is convincing evidence that lower socioeconomic position is associated with increased risk of mental disorders. However, the mechanisms involved are not well understood. This study aims to elucidate the causal pathways between socioeconomic position and depression symptoms in South African adults. Two possible causal theories are examined: social causation, which suggests that poor socioeconomic conditions cause mental ill health; and social drift, which suggests that those with poor mental health are more likely to drift into poor socioeconomic circumstances.
The study used longitudinal and cross-sectional observational data on 3904 adults, from a randomised trial carried out in 38 primary health care clinics between 2011 and 2012. Structural equation models and counterfactual mediation analyses were used to examine causal pathways in two directions. First, we examined social causation pathways, with language (a proxy for racial or ethnic category) being treated as an exposure, while education, unemployment, income and depression were treated as sequential mediators and outcomes. Second, social drift was explored with depression treated as a potential influence on health-related quality of life, job loss and, finally, income.
The results suggest that the effects of language on depression at baseline, and on changes in depression during follow-up, were mediated through education and income but not through unemployment. Adverse effects of unemployment and job loss on depression appeared to be mostly mediated through income. The effect of depression on decreasing income appeared to be mediated by job loss.
These results suggest that both social causation and social selection processes operate concurrently. This raises the possibility that people could get trapped in a vicious cycle in which poor socioeconomic conditions lead to depression, which, in turn, can cause further damage to their economic prospects. This study also suggests that modifiable factors such as income, employment and treatable depression are suitable targets for intervention in the short to medium term, while in the longer term reducing inequalities in education will be necessary to address the deeply entrenched inequalities in South Africa.
In studies of extragalactic radio sources with multiple compact components the determination of which components, if any, are stationary and which moving is of importance. In order to learn about the radio properties of the individual components it is also relevant to be able to register maps made at several wavelengths. Both tasks are usually not possible with VLBI because of the irrecoverable corruption of the fringe phase introduced by the propagation medium and the instrumentation. However, when two or more compact radio sources are separated by only a small angle from each other difference techniques can be used to help tackle both questions.
A series of VLBI observations of the gravitational lens system 0957+561 at λ13 cm has yielded the positions of the A and B images, the relative magnification of their largest discernible radio structures, and the time variability of their smallest discernible radio structures. These observations have also allowed upper limits to be placed on the flux density of an expected third image. The positions and relative magnification of the A and B images provide new information with which to constrain models of the lens that forms the images. The detection of variations in the flux densities of the cores of A and B suggests that observations at shorter wavelengths may reveal superluminal motion, which may in turn provide a means to measure the relative time delay.
VLBI observations at 2.3 GHz of SN1987A on 28 February 1987 yielded no fringes, implying, for an optically thin shell, a lower bound on the (outer) diameter of 1.9 mas. From the comparison of the VLBI and optical results, we infer that the radiosphere of SN1987A was either about equal to, or larger than, the photosphere of the supernova five days after the explosion.
Objectives: The purpose of this study was to investigate the longitudinal trajectory of self- and informant-subjective cognitive complaints (SCC), and to determine if SCC predict longitudinal changes in objective measures (OM) of cognitive function. Methods: The study included healthy and cognitively normal late middle-aged adults enriched with a family history of AD who were evaluated at up to three visits over a 4-year period. At each visit (Visit 1–3), self- and informant-SCC and OM were evaluated. Linear mixed models were used to determine if the longitudinal rate of change of self- and informant-SCC were associated with demographic variables, depressive symptoms, family history (FH), and apolipoprotein epsilon 4 (APOE4) status. The same modeling approach was used to examine the effect of Visit 1 SCC on longitudinal cognitive change after controlling for the same variables. Results: At Visit 1, more self-SCC were associated with fewer years of education and more depressive symptoms. SCC were also associated with poorer performance on cognitive measures, such that more self-SCC at Visit 1 were associated with poorer performance on memory and executive functioning measures at Visit 1, while more informant-SCC were associated with faster rate of longitudinal decline on a measure of episodic learning and memory. FH and APOE4 status were not associated with SCC. Discussion: Self- and informant-SCC showed an association with OM, albeit over different time frames in our late middle-aged sample. Additional longitudinal follow-up will likely assist in further clarifying these relationships as our sample ages and more pronounced cognitive changes eventually emerge. (JINS, 2017, 23, 617–626)
Contact precautions are a traditional strategy to prevent transmission of methicillin-resistant Staphylococcus aureus (MRSA). Chlorhexidine bathing is increasingly used to decrease MRSA burden and transmission in intensive care units (ICUs). We sought to evaluate a hospital policy change from routine contact precautions for MRSA compared with universal chlorhexidine bathing, without contact precautions. We measured new MRSA acquisition in ICU patients and surveyed for MRSA environmental contamination in common areas and non-MRSA patient rooms before and after the policy change. During the baseline and chlorhexidine bathing periods, the number of patients (453 vs. 417), ICU days (1999 vs. 1703) and MRSA days/1000 ICU days (109 vs. 102) were similar. MRSA acquisition (2/453 vs. 2/457, P = 0·93) and environmental MRSA contamination (9/474 vs. 7/500, P = 0·53) were not significantly different between time periods. There were 58% fewer contact precaution days in the ICU during the chlorhexidine period (241/1993 vs. 102/1730, P < 0·01). We found no evidence that discontinuation of contact precautions for patients with MRSA in conjunction with adoption of daily chlorhexidine bathing in ICUs is associated with increased MRSA acquisition among ICU patients or increased MRSA contamination of ICU fomites. Although underpowered, our findings suggest this strategy, which has the potential to reduce costs and improve patient safety, should be assessed in similar but larger studies.
Worldwide 350 million people suffer from major depression, with the majority of cases occurring in low- and middle-income countries. We examined the patterns, correlates and care-seeking behaviour of adults suffering from major depressive episode (MDE) in China.
A nationwide study recruited 512 891 adults aged 30–79 years from 10 provinces across China during 2004–2008. The 12-month prevalence of MDE was assessed by the Modified Composite International Diagnostic Interview-short form. Logistic regression yielded adjusted odds ratios (ORs) of MDE associated with socio-economic, lifestyle and health-related factors and major stressful life events.
Overall, 0.7% of participants had MDE and a further 2.4% had major depressive symptoms. Stressful life events were strongly associated with MDE [adjusted OR 14.7, 95% confidence interval (CI) 13.7–15.7], with a dose–response relationship with the number of such events experienced. Family conflict had the highest OR for MDE (18.9, 95% CI 16.8–21.2) among the 10 stressful life events. The risk of MDE was also positively associated with rural residency (OR 1.5, 95% CI 1.4–1.7), low income (OR 2.3, 95% CI 2.1–2.4), living alone (OR 2.6, 95% CI 2.3–3.0), smoking (OR 1.4, 95% CI 1.3–1.6) and certain other mental disorders (e.g. anxiety, phobia). Similar, albeit weaker, associations were observed with depressive symptoms. Among those with MDE, about 15% sought medical help or took psychiatric medication, 15% reported having suicidal ideation and 6% reported attempting suicide.
Among Chinese adults, the patterns and correlates of MDE were generally consistent with those observed in the West. The low rates of seeking professional help and treatment highlight the great gap in mental health services in China.
Extended emission line regions aligned with the radio axis are a common feature of powerful radio galaxies and there is much interest in the origin of the extended gas and excitation mechanism. One model that can produce this alignment is photoionization by anisotropic nuclear continuum radiation. However, strong evidence exists, especially in high redshift radio galaxies, for powerful interactions between the relativistic radio jets and the ISM/IGM. Here we present the results of our study of the southern radio galaxy PKS 2250–41 (z = 0.308). This object is the most spectacular found in a sample of southern radio sources studied by Tadhunter et al. (1993) and it displays particularly clear evidence for such an interaction (Tadhunter et al. 1994; Dickson et al. 1995).
Introduction: Traumatic brain injury (TBI) is a leading cause of death and disability in Nova Scotia. TBI occurs in approximately 50% of major trauma seen annually in the province. The purpose of this study was to describe the characteristics and patterns of major TBI seen in Nova Scotia over a 12-year period. Methods: This was a retrospective case series. Data were obtained from the Nova Scotia Trauma Registry for all patients presenting with major TBI (abbreviated injury score [AIS] head ≥3) between 2002 and 2013. Injury rates were calculated on the basis of 100,000 population (all ages) using population estimates from Statistics Canada. Results: Overall, 4152 major TBI patients were seen in Nova Scotia hospitals during the study period. Mean age of TBI patients was 51±25 years; 73% were male. The majority of injuries were the result of blunt trauma (93%), with relatively few major TBIs resulting from penetrating trauma (7%). The most common mechanisms of injury were falls (44%) and motor vehicle crashes (27%). Analysis of census-based subpopulations of the province showed that injury rates varied significantly among counties (from 25 to 63 per 100,000 population). We observed an increase in the number of major TBI patients over twelve years. Conclusion: Our findings suggest significant regional variation in major TBI rates in Nova Scotia. There are ongoing needs for prevention and intervention efforts that focus on unintentional falls and motor vehicle crashes, especially in older adults. These results also suggest that geographically targeted efforts may be warranted.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. In the absence of high-level evidence base for follow-up practices, the duration and frequency are often at the discretion of local centres. By reviewing the existing literature and collating experience from varying practices across the UK, this paper provides recommendations on the work up and management of lateral skull base cancer based on the existing evidence base for this rare condition.
• Patients should be followed up to a minimum of five years with a prolonged follow-up for selected patients. (G)
• Patients should be followed up at least two monthly in the first two years and three to six monthly in the subsequent years. (G)
• Patients should be seen in dedicated multidisciplinary head and neck oncology clinics. (G)
• Patients should be followed up by dedicated multidisciplinary clinical teams. (G)
• The multidisciplinary follow-up team should include clinical nurse specialists, speech and language therapists, dietitians and other allied health professionals in the role of key workers. (G)
• Clinical assessment should include adequate clinical examination including fibre-optic rigid or flexible nasopharyngolaryngoscopy. (R)
• Magnetic resonance imaging and positron emission tomography combined with computed tomography imaging should be used when recurrence is suspected. (R)
• Narrow band imaging can be used in the follow-up in selected sites. (R)
• Second primary tumours should be part of rationale of follow-up and therefore adequate screening strategies should be used to detect them. (G)
• Patients should be educated with regard to the appearance and detection of recurrences. (G)
• Patients with persistent pain should be investigated to exclude recurrent disease. (R)
• Patients should be offered support with tobacco and alcohol cessation services. (R)
Introduction: Although alcohol use increases the risk of experiencing a traumatic brain injury (TBI), it remains unclear whether outcomes in alcohol-impaired patients are different from those of unimpaired patients. The objective of this study was to evaluate the effect of alcohol on length of stay (LOS) and mortality in patients with major TBI. Methods: Using data collected from the Nova Scotia Trauma Registry, we performed a retrospective analysis of all patients with major TBI (defined as having an abbreviated injury score (AIS) head ≥3) seen in Nova Scotia hospitals between 2002 and 2013. Patients were compared by blood alcohol concentration (BAC) at time of injury: negative (0-1.9 mmol/L), low (2-21 mmol/L), and moderate/high (≥22 mmol/L). A logistic regression model was constructed to test for outcomes and adjusted for the effects of age, gender, location, injury severity score (ISS), and BAC level. Results: In a twelve-year period, there were 4152 major TBI patients in Nova Scotia. Alcohol testing was performed in 43% of cases (80% male, mean age 44±20 years), with 48% having a positive BAC. Mean acute LOS was similar for all three BAC groups. Increasing age (odds ratio [OR]=1.01; p<0.001), high ISS (OR=4.92; p<0.001), injuries occurring outside of Halifax Regional Municipality (OR=1.72; p<0.001), and having a lower BAC level (OR = 0.99; p<0.001) independently predicted mortality. Conclusion: Our findings suggest that low BAC levels are associated with increased mortality in major TBI patients. Further study is warranted to elucidate alcohol’s mechanism in TBI outcomes.
Little is known about cause-specific long-term mortality beyond 30 days in pneumonia. We aimed to compare the mortality of patients with hospitalized pneumonia compared to age- and sex-matched controls beyond 30 days. Participants were drawn from the European Prospective Investigation into Cancer (EPIC)-Norfolk prospective population study. Hospitalized pneumonia cases were identified from record linkage (ICD-10: J12-J18). For this study we excluded people with hospitalized pneumonia who died within 30 days. Each case identified was matched to four controls and followed up until the end June 2012 (total 15 074 person-years, mean 6·1 years, range 0·08–15·2 years). Cox regression models were constructed to examine the all-cause, respiratory and cardiovascular mortality using date of pneumonia onset as baseline with binary pneumonia status as exposure. A total of 2465 men and women (503 cases, 1962 controls) [mean age (s.d.) 64·5 (8·3) years] were included in the study. Between a 30-day to 1-year period, hazard ratios (HRs) of all-cause and cardiovascular mortality were 7·3 [95% confidence interval (CI) 5·4–9·9] and 5·9 (95% CI 3·5–9·7), respectively (with very few respiratory deaths within the same period) in cases compared to controls after adjusting for age, sex, asthma, smoking status, pack years, systolic and diastolic blood pressure, diabetes, physical activity, waist-to-hip ratio, prevalent cardiovascular and respiratory diseases. All outcomes assessed also showed increased risk of death in cases compared to controls after 1 year; respiratory cause of death being the most significant during that period (HR 16·4, 95% CI 8·9–30·1). Hospitalized pneumonia was associated with increased all-cause and specific-cause mortality beyond 30 days.