Death Certificates

To describe trends in pregnancy-related mortality and risk factors for pregnancy-related deaths in the United States for the years 1991 through 1997. METHODS: In collaboration with the American College of Obstetricians and Gynecologists and state health departments, the Pregnancy Mortality Surveillance System, part of the Division of Reproductive Health at the Centers for Disease Control and Prevention, has collected information on all reported pregnancy-related deaths occurring since 1979. Data include those present on death certificates and, when available, matching birth or fetal death certificates. Data are reviewed and coded by clinically experienced epidemiologists. The pregnancy-related mortality ratio was defined as pregnancy-related deaths per 100,000 live births. RESULTS: The reported pregnancy-related mortality ratio increased from 10.3 in 1991 to 12.9 in 1997. An increased risk of pregnancy-related death was found for black women, older women, and women with no prenatal care. The leading causes of death were embolism, hemorrhage, and other medical conditions, although the percent of all pregnancy-related deaths caused by hemorrhage declined from 28% in the early 1980s to 18% in the current study period. CONCLUSION: The reported pregnancy-related mortality ratio has increased, probably because of improved identification of pregnancy-related deaths. Black women continue to have an almost four-fold increased risk of pregnancy-related death, the greatest disparity among the maternal and child health indicators. Although review of pregnancyrelated deaths by states remains an important public health function, such work must be expanded to identify factors that influence the survival of women with serious pregnancy complications.

Background: Systematic and reliable epidemiological information at population level, preferably cross-national, is needed for an adequate planning of (end-of-life) health care policies, e.g. concerning place of death, but is currently lacking. This study illustrates opportunities and weaknesses of death certificate data to provide such information on place of death and associated factors in nine European countries (seven entire countries and five regions). Methods: We investigated the possibility and modality of all partners in this international comparative study (BE, DK, IT, NL, NO, SE, UK) to negotiate a dataset containing all deaths of one year with their national/regional administration of mortality statistics, and analysed the availability of information about place of death as well as a number of clinical, socio-demographic, residential and healthcare system factors. Results: All countries negotiated a dataset, but rules, procedures, and cost price to get the data varied strongly between countries. In total, about 1.1 million deaths were included. For four of the nine countries not all desired categories for place of death were available. Most desired clinical and socio-demographic information was available, be it sometimes via linkages with other population databases. Healthcare system factors could be made available by linking existing healthcare statistics to the residence of the deceased. Conclusion: Death certificate data provide information on place of death and on possibly associated factors and confounders in all studied countries. Hence, death certificate data provide a unique opportunity for cross-national studying and monitoring of place of death. However, modifications of certain aspects of death certificate registration and rules of data-protection are perhaps required to make international monitoring of place of death more feasible and accurate.

To determine the role of homicide and other injuries in maternal deaths in North Carolina over the three-year period from 1992 through 1994. Methods: Maternal deaths were identified from death certificates that indicated a maternal death and through an enhanced surveillance system that matches death certificates with live-birth and fetal-death certificates. Deaths were classified as direct, indirect, medically unrelated, or injuryrelated. Patterns of prenatal care were ascertained from the matching live-birth or fetal-death certificates. Maternal death rates for whites and nonwhites were calculated. Results: The most common cause of maternal death was injury, accounting for 62 of the 167 deaths (37%). Homicide was the most common cause of injury-related death (35.5%). The relative risk of maternal death for nonwhites compared with whites was 1.8 (95% confidence interval [CI] 1.6, 2.1). Similarly, their relative risk for injury-related maternal death was 1.7 (95% CI 1.4, 2.2). Conclusion: It is essential to include an analysis of injuryrelated deaths in maternal mortality reporting. As the most common cause of maternal deaths, injury is not limited to densely populated, metropolitan areas. Counseling regarding injury prevention, domestic violence, and depression should be a part of both prenatal and postpartum care.

The study area includes the Municipalities of Gela, Niscemi and Butera located in the South of Sicily, Italy. In 1990 it was declared Area at High Risk of Environmental Crisis. In 2000 part of it was designated as Gela Reclamation Site of National Interest, RSNI. The site includes a private industrial area, public and marine areas, for a total of 51 km(2). Gela populationin 2008 was 77,145 (54,774 in 1961). Sea level:46 m. Total area: 276 km(2). Grid reference: 37 degrees 4' 0" N, 14 degrees 15' 0" E. Niscemi and Butera are located border to Gela. Populations are respectively 26,541 and 5,063. Sea level respectively: 332 m and 402 m. Close to the city of Gela, the industrial area, operating since 1962, includes chemical production plants, a power station and an oil refinery plant, one of the larger in Europe, refining 5 millions tons of crude per year. From the beginning the workforces decreased from 7,000 to the current 3,000 units. Over the years, these industria...

To evaluate the completeness ofregistration ofinfant and child deaths in Egypt, reinterviews were conducted with families who had reported a death of a child under age 5 in the five years before the survey for two national surveys recently conducted in Egypt: the United Nations PAPCHILD survey of 1990-1991 and the Egyptian Demographic and Health Survey (EDHS) of 1992. The survey instrument included questions regarding notification of the death at the local health bureau. Ifthe family said the death had been notified, separate employees searched the health bureau records for the registration. Overall 57% ofinfant deaths were reported as notified and 68% of those death reports were found; the correspondingfiguresfor child deaths were 89% and 74%. Using the percentage reported as notified as an estimate for completeness of registration, we adjusted upward the national infant and child mortality rates from registration data, giving values of 73 per 1,000 for infant mortality and 99 for sqofor the period 1987-1990. These values are approximately 20% above the corresponding direct estimates from the PAPCHILD and EDHS surveys.

Infant mortality in Israel is twofold higher among non-Jews than Jews. To determine the impact of congenital malformations and Mendelian diseases on infant mortality. We compared the causes of infant mortality in a 4 year period among Jewish and non-Jewish Israeli citizens. Classification was done by analyzing all the death reports according to whether or not the child had any known major malformation, Mendelian disease and/or a syndrome, irrespective of the immediate cause of death. The infant mortality among non-Jews was double that among Jews (9 versus 4.4 per 1,000 live births). The rate of children with malformations/genetic syndromes was 3.1 times higher among non-Jews than among Jews (2.94 vs. 1.25 per 1,000 live births). The most significant difference was in the rate of Mendelian diseases, which were 8.3 times more frequent in non-Jewish children (0.16 vs. 1.33 per 1,000 live births respectively). A Mendelian disease was diagnosed in almost 15% of the non-Jewish infants and...

Accurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping. The study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a...

Deaths involving prescription and illicit opioids are on the rise, which is an issue of increasing concern to health care professionals, policymakers, and the public. However, because medical examiners, coroners, and other practitioners do not use uniform standards and case definitions in classifying such drug-related deaths, the incidence and prevalence data are challenging to analyze and difficult to interpret, and thus form a poor basis for crafting effective responses. To address this situation, the Substance Abuse and Mental Health Services Administration convened a Consensus Panel and charged it with devising uniform standards and case definitions that can assist medical examiners, coroners, public health officials, and others in consistently distinguishing between deaths that were caused by a certain opioids and deaths in which such a drug was detected but was not a major cause of or contributor to the death. The consensus statement presented here incorporates the panel's recommendations in four key areas.

Medical examiner and coroner reports are a rich source of data for epidemiologic research. To maximize the utility of this information, medicolegal death investigation data need to be electronically coded. In order to determine the best option for coding, we evaluated four different options (Current Procedural Terminology [CPT], International Classification of Disease [ICD] coding, Systematized Nomenclature of Medicine Clinical Terms [SNOMED CT], and an in-house system), then conducted internal and external needs assessments to determine which system best met the needs of a centralized, statewide medical examiner's office. Although all four systems offer distinct advantages and disadvantages, SNOMED CT is the most accurate for coding pathologic diagnoses, with ICD-10 the best option for classifying the cause of death. For New Mexico's Office of the Medical Investigator, the most feasible coding option is an upgrade of an in-house coding system, followed by linkage to ICD codes for cause of death from the New Mexico Bureau of Vital Records and Health Statistics, and ideally, SNOMED classification of pathologic diagnoses.

The objective of this study was a) to compare patterns of drug use in fatal and nonfatal overdoses and b) to find out if toxic drugs are overrepresented in overdoses with fatal outcome. A total of 179 cases of fatal overdoses in Switzerland (population 6.6 million) were compared with 269 medically treated self-poisoners from the agglomeration of Berne (population 30 1,630). Because of frequent multiple drug use, all the different compounds taken singly or in combination with other drugs were recorded and grouped according to drug types. The patterns of the frequencies of drugs used were remarkably similar in both groups. The majority of the drugs were psychotropics (8 1 % in fatal and 68 % in nonfatal overdose). Twenty-nine completed suicides were the result of drug combinations specifically recommended by EXIT. In the remaining cases benzodiazepines were used most frequently in both attempted and completed suicide, often in combination with other drugs or alcohol. Barbiturates were the only drugs recorded significantly more often in fatal overdoses (9% V,F 3%). No significant difference was found for tricyclic antidepressants (13 % vs lo%), or other types of drugs. The results are consistent with our assumption that drugs with higher toxicity would be overrepresented in overdoses with fatal outcome. Barbiturates, which are well known to be dangerous in overdose, were clearly associated with fatal overdoses, but not tricyclic antidepressants. This, in our view, suggests that the risk of prescribing tricyclic antidepressants should not be overestimated. The frequent use of benzodiazepines in completed suicide, however, indicates that there are no truly safe drugs in overdose.

This qualitative study explores socio-cultural and health systems factors that may impact on death reporting by lay people to registry systems at the commune level. Information on local perceptions of death and factors influencing death reporting were gathered through nine focus group discussions with people of different religions and ethnic affiliations in a rural district of northern Vietnam. Participants classified deaths as "elderly deaths," "young deaths," and "child deaths." Child deaths, including newborn deaths, used to be considered punishment for sins committed by ancestors, but this is no longer the case. Concepts of the human soul and afterlife differ between the Catholic and Buddhist groups, influencing funeral rituals and reporting, especially of infant deaths. Participants regarded elderly deaths as "natural" and "deserved," while young deaths were seen as either "good deaths" or "bad deaths." "Bad deaths" were defined as deaths of "dishonourable" persons who had led a "bad life" involving activities such as gambling, drinking or stealing. The causes of "bad deaths" and deaths due to stigmatized diseases (e.g., HIV/AIDS, tuberculosis and leprosy) were often concealed by the family. The study suggests that the risk of under-reporting deaths seems to be largest for deaths

Accurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping. The study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a...

In Africa, mortality statistics are not reliable due to the low performance of the death registering systems. Our aim is to implement an efficient system. In this article we make a comparison between the existing system model and the new system that will be set up. UML has been used as the modeling language based on the 2TUP analysis methods. the new system for registering deaths and their causes was conceived and represented through activities, utilization cases and data model diagrams. We have developed a tool for death registration taking into account African hospitals characteristics. The progressive deployment of this system at the CHUSS of Bobo-Dioulasso enables users and actors to appropriate it.

Interpretation Death among neonates and infants is commonly preceded by medical end-of-life decisions. Most Dutch paediatricians seem to find prospects for survival and prognostic factors relevant in such decisions. Public control by a committee of physicians, paediatricians, ethicists, and legal experts is widely endorsed by paediatricians.

Although nurses play an important role in end-of-life care for patients, they are not systematically involved in end-of-life decisions with a possible or certain life-shortening effect (ELDs). Until now we know little about factors relating to the involvement of nurses in these decisions. To explore which patient- and decision-characteristics are related to the consultation of nurses and to the administering of life-ending drugs by nurses in actual ELDs in institutions and home care, as reported by physicians. We sampled at random 5005 of all registered deaths in the second half of 2001--before euthanasia was legalized--in Flanders, Belgium. We mailed anonymous questionnaires to physicians who signed the death certificates and asked them to report on ELDs, including nurses' involvement. Response rate was 59% (n=2950). Physicians reported nurses involved in decision making more often in institutions than at home, and more often in care homes for the elderly than in hospitals (OR ...

Background Systematic and reliable epidemiological information at population level, preferably cross-national, is needed for an adequate planning of (end-of-life) health care policies, e.g. concerning place of death, but is currently lacking. This study illustrates opportunities and weaknesses of death certificate data to provide such information on place of death and associated factors in nine European countries (seven entire countries and five regions). Methods We investigated the possibility and modality of all partners in this international comparative study (BE, DK, IT, NL, NO, SE, UK) to negotiate a dataset containing all deaths of one year with their national/regional administration of mortality statistics, and analysed the availability of information about place of death as well as a number of clinical, socio-demographic, residential and healthcare system factors. Results All countries negotiated a dataset, but rules, procedures, and cost price to get the data varied strongl...

The right to be treated humanely when detained is universally recognized. Deficiencies in detention conditions and violence, however, subvert this right. When this occurs, proper medico-legal investigations are critical irrespective of the nature of death. Unfortunately, the very context of custody raises serious concerns over the effectiveness and fairness of medico-legal examinations. The aim of this manuscript is to identify and discuss the practical and ethical difficulties encountered in the medico-legal investigation following deaths in custody. Data for this manuscript come from a larger project on Death in Custody that examined the causes of deaths in custody and the conditions under which these deaths should be investigated and prevented. A total of 33 stakeholders from forensic medicine, law, prison administration or national human rights administration were interviewed. Data obtained were analyzed qualitatively. Forensic experts are an essential part of the criminal justice process as they offer evidence for subsequent indictment and eventual punishment of perpetrators. Their independence when investigating a death in custody was deemed critical and lack thereof, problematic. When experts were not independent, concerns arose in relation to conflicts of interest, biased perspectives, and low-quality forensic reports. The solutions to ensure independent forensic investigations of deaths in custody must be structural and simple: setting binding standards of practice rather than detailed procedures and relying on preexisting national practices as opposed to encouraging new practices that are unattainable for countries with limited resources.

Background: Since the 1990s, West Virginia has led the U.S. in the per-capita death rate from all-terrain vehicle (ATV) crashes, with rates eight times the national average and continually increasing. A comprehensive assessment was conducted of ATV fatalities to provide critical guidance for community interventions and public health policy to prevent further deaths. Methods: In 2007, death certificates for 2004 to 2006 with ICD-10 codes correlating to ATV crashes were used to identify decedents involved in crashes occurring in West Virginia. Data were abstracted from medical examiner records regarding crash circumstances, sustained injuries, and toxicology. Results: During 2004-2006, a total of 112 fatal ATV crashes were identified. Nearly all (92%) decedents were the ATV operator, and only 15% were known to have worn helmets. Among 54 traffic crashes, collisions (56%) and head injuries (65%) predominated, whereas the majority of 58 nontraffic crashes were rollovers (55%) and were most commonly associated with compression injuries of the thorax and abdomen (36%). Regardless of crash class (i.e., traffic versus nontraffic), alcohol was detected in the blood of 50% of decedents; of those, 88% had blood alcohol concentrations Ն0.08% (meanϭ0.17%), West Virginia's legal limit. Drugs of abuse were identified in 21% of decedents, including marijuana (11%); opioid analgesics (7%); diazepam (6%); cocaine (2%); and methamphetamine (1%). Conclusions: Fatal crash and injury types differ significantly depending on the location of ATV use, although alcohol and drug abuse are frequent risk factors in all types of ATV crashes. In addition to promoting helmet use, interventions are needed to address alcohol use among ATV users.

Background Empirical data about end-of-life decision-making practices are scarce. We aimed to investigate frequency and characteristics of end-of-life decision-making practices in six European countries: Belgium, Denmark, Italy, the Netherlands, Sweden, and Switzerland. Methods In all participating countries, deaths reported to death registries were stratified for cause (apart from in Switzerland), and samples were drawn from every stratum. Reporting doctors received a mailed questionnaire about the medical decisionmaking that had preceded the death of the patient. The datacollection procedure precluded identification of any of the doctors or patients. All deaths arose between June, 2001, and February, 2002. We weighted data to correct for stratification and to make results representative for all deaths: results were presented as weighted percentages. Findings The questionnaire response rate was 75% for the Netherlands, 67% for Switzerland, 62% for Denmark, 61% for Sweden, 59% for Belgium, and 44% for Italy. Total number of deaths studied was 20 480. Death happened suddenly and unexpectedly in about a third of cases in all countries. The proportion of deaths that were preceded by any end-of-life decision ranged between 23% (Italy) and 51% (Switzerland). Administration of drugs with the explicit intention of hastening death varied between countries: about 1% or less in Denmark, Italy, Sweden, and Switzerland, 1•82% in Belgium, and 3•40% in the Netherlands. Large variations were recorded in the extent to which decisions were discussed with patients, relatives, and other caregivers. Interpretation Medical end-of-life decisions frequently precede dying in all participating countries. Patients and relatives are generally involved in decision-making in countries in which the frequency of making these decisions is high.

, a case of inhalational anthrax was identified in a 94-year-old Connecticut woman, who later died. We conducted intensive surveillance for additional anthrax cases, which included collecting data from hospitals, emergency departments, private practitioners, death certificates, postal facilities, veterinarians, and the state medical examiner. No additional cases of anthrax were identified. The absence of additional anthrax cases argued against an intentional environmental release of Bacillus anthracis in Connecticut and suggested that, if the source of anthrax had been cross-contaminated mail, the risk for anthrax in this setting was very low. This surveillance system provides a model that can be adapted for use in similar emergency settings.

To assess whether resident physicians (MDs) could complete a death certificate for elderly patients with injury-related fatalities and whether their abilities were related to training or other factors. SETTING: A large tertiary teaching hospital in Boston, Massachusetts. PARTICIPANTS: Three hundred thirty-six MDs. DESIGN: Through an anonymous Web-based test, MDs were questioned regarding prior training and experience in completion of death certificates. The MDs read a case of an elderly patient who died from intracranial bleeding after a fall and then completed a test death certificate. Whether proper completion was associated with MD characteristics such as year of residency, self-assessment, or previous death certificate experience was examined. RESULTS: Almost two-thirds (63.6%) of MDs completed the test. Of participants, 52% (95% confidence interval (CI) 5 46-59%) filled out the death certificate with the correct primary cause of death and 10% (95% CI 5 6-14%) listed the three major contributing causes of death. Only 35% (95% CI 5 28-41%) correctly reported injury as a contributing cause of death, but 51% of the participants reported a high level of confidence in their ability to complete a death certificate accurately. CONCLUSION: Accurate completion of the sample death certificate and identification of injury was low, and MDs overrated their abilities. Death certificates completed by MDs may not be accurate and may underestimate the contribution of injury to elderly mortality.

enfermedad pulmonar obstructiva crónica (EPOC). Métodos/diseño: Se llevó a cabo un estudio de seguimiento en 3 de los 5 centros (Montevideo, Santiago y São Paulo) después de un periodo de 5, 6 y 9 años, respectivamente, con el objetivo de verificar la estabilidad del diagnóstico de EPOC a lo largo del tiempo, la evolución de la enfermedad en cuanto a supervivencia, morbilidad y función respiratoria, y análisis de los biomarcadores genéticos e inflamatorios en sangre. Se añadieron algunas preguntas adicionales al cuestionario original y se obtuvieron los certificados de defunción a partir de los registros oficiales nacionales. Resultados: El trabajo de campo se ha completado en los 3 centros. De las muestras originales de la fase i del PLATINO pudimos localizar y entrevistar al 85,6% en Montevideo, al 84,7% en Santiago y al 77,7% en São Paulo. Los individuos no localizados se caracterizaban por un mayor nivel de estudios en Brasil y era más probable que fueran fumadores actuales en Santiago y São Paulo que en Montevideo. La calidad global de las espirometrías fue ≥ 80% según los criterios de la American Thoracic Society. El número de muertes fue de 71 (Montevideo), 95 (Santiago) y 135 (São Paulo), y se obtuvieron los certificados de defunción a partir de los registros de mortalidad nacionales del 76,1, del 88,3 y del 91,8% de los casos en Montevideo, Santiago y São Paulo, respectivamente. Conclusiones: Este estudio muestra que es posible realizar estudios longitudinales de base poblacional en Latinoamérica, con tasas de seguimiento elevadas y una alta calidad de los datos de espirometría. La idoneidad de los registros de mortalidad nacionales varía en los distintos centros de Latinoamérica.

The United Automobile Workers International Union has established a system of epidemiologic triage to evaluate patterns of mortality among groups of union members. In response to worker concerns, the Union examined mortality at a metal stamping plant, using a method which linked pension records with the State of Michigan computerized death registry. The observed proportion of malignant neoplasms was nearly twice that expected (95% Confidence Limits 1.36, 2.62). Twoto five-fold excess proportional mortality from cancer of the digestive organs, lung cancer, and leukemia accounted for most of the overall excess. Strong associations were found between lung and digestive organ cancer and

Sweden has a long tradition of recording cause of death data. The Swedish cause of death register is a high quality virtually complete register of all deaths in Sweden since 1952. Although originally created for official statistics, it is a highly important data source for medical research since it can be linked to many other national registers, which contain data on social and health factors in the Swedish population. For the appropriate use of this register, it is fundamental to understand its origins and composition. In this paper we describe the origins and composition of the Swedish cause of death register, set out the key strengths and weaknesses of the register, and present the main causes of death across age groups and over time in Sweden. This paper provides a guide and reference to individuals and organisations interested in data from the Swedish cause of death register.

Every physician is duty bound to issue a "Cause of Death" certificate in the unfortunate event death of his/her patient. Incomplete and inaccurate entry in these certificates poses difficulty in obtaining reliable information pertaining to causes of mortality, leads to faulty public health surveillance, and causes hindrance in research. This study intends to evaluate the completeness and accuracy of Medical Certification of Cause of Death in our Institute and to formulate strategy to improve the quality of reporting of cause of death. During the period from January 2012 to December 2012, a total of 151 certificates of cause of death were issued by the faculty members of various departments. Maximum number of death certificates were issued for patients in the extremes of the age <10 years (n ¼ 42, 27.82%) and in >60 years (n ¼ 46, 30.46%). The various inadequacies observed by us are as follows: 40 (26.49%) cases had inaccurate cause of death, interval between onset and terminal event was missing in 94 (62.25%) cases, in 68 (45.03%)cases the seal with registration number of the physician was not available on the certificate, incomplete antecedent & underlying cause of death was found in 35 (23.18%) & 84 (55.63%) cases, in 66 (43.71%) cases there was use of abbreviations and the handwriting was illegible in 79(52.32%) cases.

Objective To examine the incidence and patterns of intimate femicide-suicide in South Africa and to describe the factors associated with an increase in the risk of suicide after intimate femicide (i.e. the killing of an intimate female partner). Methods A cross-sectional retrospective national mortuary-based study was conducted at a proportionate random sample of 25 legal laboratories to identify all homicides committed in 1999 of women aged over 13 years. Data were collected from the mortuary file, autopsy report and a police interview. Findings Among 1349 perpetrators of intimate femicide,19.4% committed suicide within a week of the murder. Suicide after intimate femicide was more likely if the perpetrator was from a white rather than an African racial background (odds ratio, OR: 5.8; 95% confidence interval, CI: 1.21-27.84); was employed as a professional or white-collar worker rather than a blue-collar worker (OR: 37.28; 95% CI: 5.82-238.93); and owned a legal gun rather than not owning a legal gun (OR: 45.26; 95% CI: 8.33-245.8). The attributable fraction shows that 91.5% of the deaths of legal gun-owning perpetrators and their victims may have been averted if this group of perpetrators did not own a legal gun. Conclusion South Africa has a rate of intimate femicide-suicide that exceeds reported rates for other countries. This study highlights the public health impact of legal gun ownership in cases of intimate femicide-suicide.

Suspicious circumstances surrounding the death of wealthy socialite Mary Lily ''Lil''' Kenan Flagler Bingham in 1917 prompted a secret autopsy conducted by renowned physicians at the request of her relatives. Mrs Bingham, who was formerly married to railroad magnate, Henry Flagler, was among America's richest people at the time of her death. Mary Lil's untimely death occurred approximately six months after her marriage to Judge Robert ''Bob'' Worth Bingham, a college boyfriend whom she married three years after Flagler's death. In order to establish Mary Lil's medical condition prior to her death, a book about Mary Lil's life written by Pulitzer Prize author, David Chandler and articles from the New York Times; The Louisville Courier Journal, a Kentucky newspaper; and Mary Lil's hometown newspaper, The Morning Star, in Wilmington, North Carolina were examined. Although a team of medical experts performed a secret autopsy following her death and released their findings to her family, the examination and tests results remain undisclosed to the public.

Gastrointestinal malignancies are among the most common cancers suffered by Cubans. The purpose of our study is to analyse the evolution of digestive cancer mortality in Cuba. Mortality data for this study were obtained from the National Medical Records and Health Statistic Bureau. Trends (1987-2008) in age-standardized cancer mortality were described using joinpoint regression. In the data set of digestive cancer mortality, in the period 1987-2008, colorectal/anal cancer was the most frequent cause of cancer mortality in males and females. In men, a rise in mortality was observed for cancer of the oesophagus between 2001 and 2008, and pancreatic cancer showed a slight mortality rise for the period 1987-2008. In women, colorectal/anal cancer increased from 1989 to 2001. A mortality increase was observed for oesophageal cancer in the period 2005-08. The result of the joinpoint analysis for the age group of 35-64 years was consistent with those for overall mortality. The trend in mort...

Introduction: Black male youth are at high risk of homicide and criminal justice involvement. This study aimed to determine how early mortality among youth offenders varies based on race; gender; and the continuum of justice system involvement: arrest, detention, incarceration, and transfer to adult courts.

Mortality statistics form a crucial component of national Health Management Information Systems (HMIS). However, there are limitations in the availability and quality of mortality data at national level in Viet Nam. This study assessed the completeness of recorded deaths and the reliability of recorded causes of death (COD) in the A6 death registers in the national routine HMIS in Viet Nam. 1477 identified deaths in 2014 were reviewed in two provinces. A capture-recapture method was applied to assess the completeness of the A6 death registers. 1365 household verbal autopsy (VA) interviews were successfully conducted, and these were reviewed by physicians who assigned multiple and underlying cause of death (UCOD). These UCODs from VA were then compared with the CODs recorded in the A6 death registers, using kappa scores to assess the reliability of the A6 death register diagnoses. The overall completeness of the A6 death registers in the two provinces was 89.3% (95%CI: 87.8-90.8). No...

In this paper, we examine geographic and racial/ethnic differences in heart disease and stroke mortality in the Appalachian region. Initial comparisons are made between national rates for heart disease and stroke mortality and those for the Appalachian region. County-level analyses were performed to examine the relative mortality experience of populations in Appalachian counties compared to other counties in the United States and to assess the degree of geographic disparity in mortality from heart disease and stroke among these race/ethnic and gender groups within Appalachia. The Appalachian region exhibits higher rates of both heart disease and stroke mortality for all race/ethnic, gender, and age groups examined. We found that many counties in the Appalachian region endure a considerable burden of the national excess in both heart disease and stroke mortality, and these counties tend to be aggregated in particular areas as opposed to being dispersed regionwide. Finally, we compare...

Background: People who die from heart disease at home before any attempt at transport has been made may represent missed opportunities for life-saving medical intervention. In this study, we undertook a point-pattern spatial analysis of heart disease deaths occurring before transport in a large metropolitan area to determine whether there was spatial clustering of non-transported decedents and whether there were significant differences between the clusters of non-transported cardiac decedents and the clusters of transported cardiac decedents in terms of average travel distances to nearest hospital and area socioeconomic characteristics. These analyses were adjusted for individual predictors of transport status. Methods: We obtained transport status from the place of death variable on the death certificate. We geocoded heart disease decedents to residential street addresses using a rigorous, multistep process with 97% success. Our final study population consisted of 11,485 adults aged 25-74 years who resided in a large metropolitan area in west-central Florida and died from heart disease during 1998-2002. We conducted a kernel density analysis to identify clusters of the residential locations of cardiac decedents where there was a statistically significant excess probability of being either transported or not transported prior to death; we controlled for individual-level covariates using logistic regression-derived probability estimates. Results: The majority of heart disease decedents were married (53.4%), male (66.4%), white (85.6%), and aged 65-74 years at the time of death (54.7%), and a slight majority were transported prior to death (57.7%). After adjustment for individual predictors, 21 geographic clusters of non-transported heart disease decedents were observed. Contrary to our hypothesis, clusters of non-transported decedents were slightly closer to hospitals than clusters of transported decedents. The social environmental characteristics of clusters varied in the expected direction, with lower socioeconomic and household resources in the clusters of non-transported heart disease deaths. Conclusions: These results suggest that in this large metropolitan area unfavorable household and neighborhood resources played a larger role than distance to hospital with regard to transport status of cardiac patients; more research is needed in different geographic areas of the United States and in other industrialized nations.

This article explores trends and correlates of Chicago_s opiate-related overdose (OD) deaths. We manually examined data from every death certificate filed between 1999 and 2003 to identify all Chicago residents_ accidental deaths involving acute intoxication with illicit opiates, OD, or opiate poisoning. The analysis includes an examination of contextual characteristics in 77 Chicago neighborhoods. Negative binomial regression analysis permits the calculation of incidence rate ratios (IRR) associated with time trends. OD incidence peaked in 2000 and then declined markedly by 2003 [year 2000-2003 IRR = 0.65, 95% confidence interval (CI) (0.54, 0.78)]. Over the 2000-2003 period, overall incidence of fatal OD declined by 34%. Over this period, the sharpest observed declines occurred among African-Americans [IRR = 0.64, 95% CI (0.51, 0.81)] and Hispanics/Latinos [IRR = 0.53, 95% CI (0.32, 0.88)]. The opiate-related fatality incidence also declined among non-Hispanic whites [IRR = 0.743, 95% CI (0.52, 1.06)]. Even at the end of the study period, illicit opiate-related OD accounted for 35% of all accidental deaths to Chicago adults aged 18-64, with 45% of OD deaths occurring among African-American men. In summary, illicit opiate OD in Chicago peaked in 2000 and markedly declined by 2003. Opiate OD continues to pose a major threat of mortality to Chicago adults.

Background: We assessed the linkage and correct linkage rate using deterministic record linkage among three commonly used Canadian databases, namely, the population registry, hospital discharge data and Vital Statistics registry. Methods: Three combinations of four personal identifiers (surname, first name, sex and date of birth) were used to determine the optimal combination. The correct linkage rate was assessed using a unique personal health number available in all three databases. Results: Among the three combinations, the combination of surname, sex, and date of birth had the highest linkage rate of 88.0% and 93.1%, and the second highest correct linkage rate of 96.9% and 98.9% between the population registry and Vital Statistics registry, and between the hospital discharge data and Vital Statistics registry in 2001, respectively. Adding the first name to the combination of the three identifiers above increased correct linkage by less than 1%, but at the cost of lowering the linkage rate almost by 10%. Conclusion: Our findings suggest that the combination of surname, sex and date of birth appears to be optimal using deterministic linkage. The linkage and correct linkage rates appear to vary by age and the type of database, but not by sex.

Ill-defined causes of death are common among the elderly owing to the high frequency of comorbidities and, consequently, to the difficulty in defining the underlying cause of death. To analyze the validity and reliability of the &quot;primary diagnosis&quot; in hospitalization to recover the information on the underlying cause of death in natural deaths among the elderly whose deaths were originally assigned to &quot;ill-defined cause&quot; in their Death Certificate. The hospitalizations occurred in the state of Rio de Janeiro, in 2006. The databases obtained in the Information Systems on Mortality and Hospitalization were probabilistically linked. The following data were calculated for hospitalizations of the elderly that evolved into deaths with a natural cause: concordance percentages, Kappa coefficient, sensitivity, specificity, and the positive predictive value of the primary diagnosis. Deaths related to &quot;ill-defined causes&quot; were assigned to a new cause, which was de...

Sexual orientation and gender identity (SO/GI) are not systematically recorded at time of death, limiting identification of mortality disparities in lesbian, gay, bisexual, and transgender (LGBT) people. LGBT populations are thought to have elevated risk of suicide based on high rates of reported lifetime suicide attempts. Lack of data on suicide deaths, however, hinders understanding of the prevalence and patterns of suicide among LGBT populations and development of targeted interventions and prevention programs. This report describes recent efforts to address this knowledge gap by systematically collecting SO/GI information in the investigation of suicide and other violent deaths.

Electronic health records in the United States currently isolate digital information in proprietary, institutional databases. Experts have identified inadequate data exchange as a leading challenge to advancements in care quality and efficiency. Recent federal health information technology incentives adopt an extensible standard, called the Continuity of Care Document (CCD), as a new basis for digital interoperability. Although this instrument was designed for individual provider communications, the CCD can be effectively reused for population-based research and public health. Three examples in this commentary demonstrate the potential of CCD aggregation and highlight required changes to existing public health and research practices. Transitioning to the use of this new interoperability standard should be a priority for public health investment, research, and development. (Am J Public He a l t h . 2 0 1 2 ; 102:e1-e4.

Palliative medicine services have invested in the community to support people dying at home. To develop end-of-life care for older people, we need to know where they die. To examine trends in age and location of death over the last 20 years. Retrospective death certificate review. All Wales death certificates from 1981 to 2001 were examined. Place of death and age were noted. Total deaths decreased from 35,015 in 1981 to 32,966 in 2001, and mortality decreased from 12.45 per 1000 population in 1981 to 11.33 in 2001. Deaths in the community decreased from 37.6% (n = 13,155) to 22.1% (n = 7293) (p &lt; 0.001); deaths increased in hospital from 56.7% (n = 19,871) to 61.7% (n = 20,334) (p &lt; 0.001) and in care homes from 5.7% (n = 1989) to 16.2% (n = 5339) (p &lt; 0.001). Between 1981 and 2001, deaths in those aged 65-74 years dropped from 9752 to 6361, but increased in the over-85s from 5661 to 9779. Deaths amongst 75-84-year-olds remained stable at around 11,000. The biggest rise in...

The authors conducted a nested case-control study to determine whether the fourfold increased risk of pregnancy-related mortality for US Black women compared with White women can be explained by racial differences in sociodemographic and reproductive factors. Cases were derived from a national surveillance database of pregnancy-related deaths and were restricted to White women (n = 840) and Black women (n = 448) whose pregnancies resulted in a livebirth and who died of a pregnancy-related cause between 1979 and 1986. Controls were derived from national natality data and were randomly selected White women and Black women who delivered live infants and did not die from a pregnancy-related cause (n = 5,437). Simultaneous adjustment for risk factors by using logistic regression did not explain the racial gap in pregnancy-related mortality. The largest racial disparity occurred among women with the lowest risk of pregnancy-related death: those of low to moderate parity who delivered normal-birth-weight babies (adjusted odds ratio = 3.53, 95% confidence interval: 2.9, 4.4). In contrast, no racial disparity was found among women with the highest risk of pregnancy-related death: high-parity women who delivered low-birth-weight babies. These findings indicate that reproductive health care professionals need to develop strategies to reduce pregnancy-related deaths among both high-and low-risk Black women.

Purpose Incidence studies reported more end-of-life decisions with possible/certain life-shortening effect (ELDs) among cancer patients than among noncancer patients. These studies did not correct for the different proportions of sudden/unexpected deaths of cancer versus noncancer patients, which could have biased the results. We investigated incidences and characteristics of ELDs among nonsudden cancer and noncancer deaths. Methods We sampled 5,005 certificates of all deaths in 2001 (Flanders, Belgium) stratified for ELD likelihood. Questionnaires were mailed to the certifying physicians. Data were corrected for stratification and nonresponse. Results The response rate was 59%. Among 2,128 nonsudden deaths included, ELDs occurred in 74% of cancer versus 50% of noncancer patients (P &lt; .001). Symptom alleviation with possible life-shortening effect occurred more frequently among cancer patients (P &lt; .001); nontreatment decisions occurred less frequently (P &lt; .001). The highe...

The 21st-century epidemic of pharmaceutical and other drug-intoxication deaths in the United States (US) has likely precipitated an increase in misclassified, undercounted suicides. Drug-intoxication suicides are highly prone to be misclassified as accident or undetermined. Misclassification adversely impacts suicide and other injury mortality surveillance, etiologic understanding, prevention, and hence clinical and public health policy formation and practice. To evaluate whether observed variation in the relative magnitude of drug-intoxication suicides across US states is a partial artifact of the scope and quality of toxicological testing and type of medicolegal death investigation system. This was a national, state-based, ecological study of 111,583 drug-intoxication fatalities, whose manner of death was suicide, accident, or undetermined. The proportion of (nonhomicide) drug-intoxication deaths classified by medical examiners and coroners as suicide was analyzed relative to the ...

Sweden has a long tradition of recording cause of death data. The Swedish cause of death register is a high quality virtually complete register of all deaths in Sweden since 1952. Although originally created for official statistics, it is a highly important data source for medical research since it can be linked to many other national registers, which contain data on social and health factors in the Swedish population. For the appropriate use of this register, it is fundamental to understand its origins and composition. In this paper we describe the origins and composition of the Swedish cause of death register, set out the key strengths and weaknesses of the register, and present the main causes of death across age groups and over time in Sweden. This paper provides a guide and reference to individuals and organisations interested in data from the Swedish cause of death register.