Causes of death in Japanese patients with diabetes based on the results of a survey of 68,555 cases during 2011-2020: Committee report on causes of death in diabetes mellitus, Japan Diabetes Society (English version).

The principal causes of death among 68,555 patients with diabetes and 164,621 patients without diabetes who died in 208 hospitals throughout Japan between 2011 and 2020 were determined based on a survey of hospital records. The most frequent cause of death in patients with diabetes was malignant neoplasms (38.9%) (lung 7.8%, pancreas 6.5%, liver 4.1%), followed, in order of descending frequency, by infectious diseases (17.0%) and then vascular diseases (10.9%) (cerebrovascular diseases 5.2%, ischemic heart diseases 3.5%, renal failure 2.3%). The proportion of deaths from malignant neoplasms and vascular diseases has trended upward and downward, respectively. Almost all deaths from ischemic heart diseases were due to myocardial infarction, and the proportion of deaths from heart diseases other than ischemic heart diseases was relatively high (9.0%), with most cases due to heart failure. Diabetic coma associated with hyperglycemia accounted for only 0.3% of deaths. The proportion of deaths from malignant neoplasms, infectious diseases, renal failure, ischemic heart diseases, and heart failure was significantly higher in patients with diabetes than in those without diabetes, and the proportion of deaths from cerebrovascular diseases was significantly lower in patients with diabetes. With regard to the relationship between the age and cause of death in patients with diabetes, malignant neoplasms were the most frequent cause of death in all age groups, and the incidence was around 50% for those in their 50s and 60s. The incidence of death due to infectious diseases was highest in patients older than their 70s. The incidence of death due to vascular diseases for patients in their 40s and 50s was higher than that due to infectious diseases. The highest incidence of death due to ischemic heart diseases was observed for patients in their 40s, and that due to renal failure and heart failure in patients older than their 70s. Compared with patients without diabetes, patients with diabetes demonstrated a higher incidence of death due to pancreatic cancer, infectious diseases, renal failure, ischemic heart diseases, and heart failure, and a lower incidence of death due to cerebrovascular diseases in all age groups. The average age at death of patients with diabetes was 74.4 years old in men and 77.4 years old in women, which were lower than the average lifespan of the Japanese general population in 2020 by 7.2 and 10.3 years, respectively. However, these differences were smaller than in previous surveys. The average age at death due to all causes, especially due to ischemic heart diseases, cerebrovascular diseases, heart failure, infectious diseases, and diabetic coma, was lower in patients with 'poorer' glycemic control than in those with 'better' glycemic control. In the total survey population, the average age at death of patients with diabetes was significantly higher than that of patients without diabetes. The average age at death due to malignant neoplasms and cerebrovascular diseases was higher in patients with diabetes than in those without diabetes and that due to renal failure, ischemic heart diseases, and infectious diseases was lower in patients with diabetes than in those without diabetes.

The interpretation of COVID-19 in cause-of-death statistics: a matter of causality.

Background: Mortality is an important indicator for estimating the impact of the COVID-19 pandemic. However, different registrations provide different figures and the question is how to interpret the number of COVID-19 deaths reported. Objective: To study the role of COVID-19 in dying in order to explain the representation of COVID-19 in cause-of-death statistics. Methods: Analysis of all death certificates mentioning COVID-19 in the Dutch cause-of-death registry during the pandemic (n=51,181). The role of COVID-19 as cause of death was studied by the way it was reported on death certificates. A calculation of odds ratios was performed for studying associations between COVID-19 and other reported causes of death. Results: In 24% of the cases COVID-19 was the only cause of death mentioned on a death certificate. In 76% of the cases, one or more other diseases played a role in dying. Three patterns emerged: COVID-19 associated with 1. neurodegenerative disorders, 2. chronic respiratory disorders, and 3. metabolic disorders. Of all death certificates mentioning the diseases, COVID-19 was the start of the causal chain leading to death in 45.2% of the cases, while COVID-19 was selected for cause-of-death statistics by special World Health Organization WHO instructions in 93.9% of the cases. Conclusions: Cause-of-death statistics overestimate the role of COVID-19 as underlying cause of death. In a majority of the deceased cases, there is an association of COVID-19 with other diseases not captured by cause-of-death statistics reporting (only) one cause of death per deceased. A multi-causal approach is needed to evaluate the pandemic and inform health policy.

Mortality Following Childbirth in Ontario - A Twenty-Year Analysis of Temporal Trends and Causes.

OBJECTIVE: Maternal death during or after pregnancy is often preventable and accurate surveillance is key to prevention. We examined the number and causes of maternal death in Ontario over 20 years. METHODS: Retrospective cohort study including all hospital livebirths and stillbirths from 2002-2022 in the Canadian Institute for Health Information (CIHI) Discharge Abstracts (for hospitalizations) and National Ambulatory Care System (for emergency department encounters) linked to the Better Outcomes and Registry (BORN) births. Death was ascertained from childbirth to 365 days thereafter; all deaths were reviewed by at least 3 clinicians. RESULTS: There were 485 deaths among 2 764 214 live and stillbirths over 20 years-a maternal mortality ratio (MMR) of 17.5 per 100 000 (95% CI 16.0-19.2). There were 222 (45.8%) early deaths within 42 days of birth (MMR of 8.0 per 100 000; 95% CI 7.0-9.2), and 263 (54.2%) late deaths from 43 to 365 days after birth (MMR 9.5 per 100 000; 95% CI 8.4-10.7). Death was pregnancy-related in 169/485 cases (34.8%). Early death causes were predominantly hemorrhage, infection, preeclampsia, and pulmonary embolism. Top causes of 263 late deaths were cancer, injury, and cardiac arrest, or unknown. CONCLUSION: Most deaths within one-year of childbirth are not related to obstetrical factors; however, pregnancy complications factor in early deaths. Causes of early and late deaths differ, but examining late deaths is equally important to identify factors not regularly examined in maternal mortality. As death in early pregnancy or outside hospitals is not reported, mortality is likely higher.

Comparison of Clinical Diagnosis and Autopsy Findings of Early Neonatal Deaths: Diagnostic Challenges and the Value of Autopsy in Identifying Rare Pathologies.

BACKGROUND: In a non-forensic hospital setting, neonatal death within the first week of life is often related to premature birth and/or lung diseases. Without post-mortem examination, the identification of the cause of death may be challenging. Autopsy can confirm the clinical diagnosis, uncover additional information or change the diagnosis. Our study aimed to assess the correlation between the clinical diagnosis and post-mortem findings in early neonatal deaths. METHODS: The retrospective study included autopsy cases with neonatal deaths within the first 7 days of life (arbitrary time interval 2006-2021). Discrepancies between clinical and histopathological findings were classified into 3 groups: (i) full agreement, (ii) additional findings discovered by autopsy, or (iii) autopsy changed the diagnosis. RESULTS: A cohort of 27 cases could be identified and lung pathologies were the most common finding (56%). Additional findings could be discovered in 48% of cases. Major discrepancies which changed the clinical diagnosis could be found in 11% (n = 3/27) of cases. CONCLUSION: Frequently, post-mortem examinations validate the clinical diagnosis while revealing crucial information in a few cases. In these discrepant cases, autopsy findings can provide information for genetic counselling and quality control of clinical management.

Are multiple coders needed for cause of death assignment: results from telephonic verbal autopsy interviews conducted in 2021 in South Africa.

Introduction: Verbal autopsy (VA) methods have emerged to estimate causes of death in populations lacking robust civil registration and vital statistics (CRVS) systems. Despite World Health Organization endorsement of routine VA use, cost and efficiency concerns persist. Telephonic verbal autopsies (teleVAs) can reduce cost. Physician coding offers a valuable approach, but the expertise required makes it resource-intensive, often involving multiple coders for consensus. Objective: To assess inter-coder agreement for cause of death (CoD) in South African teleVAs using Kappa statistics, evaluating if agreement surpasses a 0.8 cut-off (very high) potentially allowing single coders. Methods: A cross-sectional study employed telephonic VA interviews on non-facility deaths in Cape Town (December 2020-September 2021). Trained fieldworkers administered a standard VA questionnaire. Each case's VA responses were reviewed independently by two physicians, medically certifying the CoD. A panel was used to solve disagreements. Cohen's kappa-statistic (k-statistic) tested agreement levels. Results: Decedents were aged between 18 and 98 years. In total, 228 teleVAs (16.6% response rate) were conducted. Physician coding agreement was good overall (k-statistic: 0.63). Diabetes mellitus (47%) and other non-communicable disease (42%) had initial agreement between physician coders in less than 50% of cases in comparison to consensus totals. COVID-19 (89%) and acute cardiac disease (83%) showed initial agreement in more than 80% of cases compared to consensus totals. A chi-square test revealed a significant difference in the number of causes listed on death notification forms for cases with and without agreement in Part 1 (χ2 = 14.71, p < 0.01), but not in Part 2 (χ2 = 4.97, p = 0.17). Conclusion: CoD agreement might not be high enough to infer that single coders can be used instead of multiple coders. Challenges with co-morbidities and specific CoDs with multiple sequelae highlight the need for further research and refinement of VA methodologies for reliable CoD determination in routine practice.

A novel approach to the cause of death identification-multi-strategy integration of multi-organ FTIR spectroscopy information using machine learning.

Identifying the cause of death has always been a major focus and challenge in forensic practice and research. Traditional techniques for determining the causes of death are time-consuming, labor-intensive, have high professional barriers, and are vulnerable to significant subjective bias. Additionally, most current studies on causes of death are limited to specific organs and single causes. To overcome these challenges, this study utilized simple and rapid fourier transform infrared spectroscopy (FTIR) detection technology, integrating data from six organs-heart, liver, spleen, lung, kidney, and brain. The optimum model for identifying seven different causes of death was determined by evaluating the performance of models developed using the model efficiencies of single-organ (SO), single-organ model fusion (SOMF), multi-organ data fusion (MODF), and multi-organ data model fusion (MODMF) modeling methods. Considering factors such as operational costs, model performance, and model complexity, the MODF artificial neural network (ANN) model was found to be the most suitable choice for constructing a cause of death identification model, with a cross-validation mean accuracy of 0.960 and a test set accuracy of 0.952. The heart and kidney contributed more spectral features to the construction of the cause of death identification model compared to other organs. This study not only demonstrated that data fusion and model fusion are effective strategies for improving model performance but also provided a comprehensive data analysis framework and process for modeling with small sample multi-modal data (multiple organ data). In conclusion, by exploring various approaches, this study offers new solutions for identifying the cause of death.

The Value of Medical Chart Reviews: A Methodological Approach to Supplement Mortality Data During Pandemic Outbreaks.

Administrative data may provide incomplete understanding of pandemic disease impact. Medical record review-based assessments of COVID-19-related causes of death were conducted among people with diagnosed HIV in New York State, which identified more COVID-19-related causes of death than Vital Statistics, thereby offering a deeper understanding of the pandemic's impact on this population.

The under-recognition and significance of frailty syndrome - a geriatric and forensic conundrum.

Frailty syndrome occurs in elderly individuals with declining muscle mass (sarcopenia), unintentional weight loss, decreasing physical strength and activity, exhaustion, and slow ambulation. It significantly increases morbidity and mortality with cardiovascular, renal disease and neurological disorders, osteoporosis and fractures, endocrine and immunological dysfunction and a variety of malignancies. It is increasing in incidence as the population ages. However, unfortunately as identification relies on clinical and not pathological evaluations, its contribution to a wide range of comorbidities and its role in terminal episodes may not be recognized in a forensic context.

How Vulnerable Are the Elderly in Road Traffic-Autopsy Study?

Background: The aim of this study was to analyze characteristic and pattern of road traffic injuries in this special aging group, as well to examine the relevance of certain injuries or risk factors to outliving the injuries. Methods: This epidemiological, analytical, retrospective, autopsy study investigated the road traffic deaths for period between 2001 and 2022. The subjects were divided into two age groups, elderly (65 years and older) and middle aged (16-64 years old). Results: We included 213 (32%) elderly participants out of all 665 RTA subjects who died from sustained injuries or complications of the injuries. The majority of elderly subjects (61%) were pedestrians, and elderly participants in RTA were more likely to survive the injuries. The most common injuries among the elderly in all group of participants were chest injuries 81% (and among them, rib fractures were present in 76%). Cranio-cerebral injury is the most common cause of death in RTA subjects, singular (45%) or in combination with other causes. In the group of elderly RTA subjects complication of injury is represented in 36 subjects (17%), while as cause of death is represented in 22 subjects (10%). Elderly are less likely to have positive BAC, and even in cases when BAC was increased, the levels were on the lower scale. Conclusion: More effort should be made to enhance road safety for elderly pedestrians, especially considering the expected rapid growth in the elderly population.

A scoping review on the errors in medical certification of the cause of death in India.

Medical certification of the cause of death provides epidemiological information for developing cause-specific mortality and disease trends, guiding the monitoring of health programmes and allocating health resources. Therefore, providing correct information on the cause of death is essential. This study describes the errors in medical certification of the cause of death in India. We conducted a scoping review through a systematic inquiry in four databases, PubMed, ProQuest, Google Scholar and EBSCO, for all published articles reporting errors in medical certification of cause of death in India between December 31, 1998 and December 31, 2020. The review outcomes were the proportion of major and minor certification errors reported. Out of 135 screened studies, 20 were included based on the eligibility criteria. We observed a high proportion of certification errors and a large proportion of variation. Major certification errors were in the form of incorrect underlying cause of death (8.5-99.2%) and incorrect chain of events leading to death (12-64.7%). Minor certification errors in the form of missing clerical details, abbreviations and illegible handwriting were 0.3-100 per cent. The proportion of incomplete death certificates ranged between 12-100 per cent. Absence of time intervals was the most common type of certification error (62.3-99.5%). Training of doctors to accurately certify the medical cause of death and its addition to medical education is urgently needed to ensure accurate information for mortality-related statistics. A uniform methodology for auditing and reporting errors in medical certification of cause of death should be adopted.

2,4-dinitrophenol intoxication and its morphological findings as an indication of substance intake.

Lethal intoxications can only very rarely be recognized during an external examination of corpses, as poisoning does not leave any characteristic findings on the deceased. The present study is a retrospective review on 2,4-dinitrophenol (2,4-DNP) intoxications in human subjects from the beginning of the 20th century until today, as well as a case report on a fatal intoxication of a 50-year old obese man in Rostock (Germany) and an introduction for toxicological analysis in post-mortem specimens of the substance ingested in these rare cases. Via selective literature search, the information on occurrence and localization of abnormal pathomorphological external and/or internal findings in cases of 2,4-DNP ingestion/ intoxication was gathered. By 2021, a total of 13 case reports with information on morphological findings due to 2,4-DNP ingestion/intoxication were found. The external findings were dominated by yellowing of the skin, followed by exanthemas/rashes and yellowing of the sclera. The internal findings included yellowing of the internal organs, yellow color of the stomach contents, yellowing of the mucous membranes and an intense yellow color of the urine. Yellowish discoloration of the skin, sclera, mucous membranes, internal organs, sweat and/or an intensive yellow discoloration of the urine are not observed in every 2,4-DNP intoxication. However, when they do occur, they are a characteristic indication of 2,4-DNP ingestion and, if localized to the skin, indicate prolonged consumption. A fatal case from Rostock in 2016 due to prolonged intake of 2,4-DNP for weight loss is exemplified. A simple, fast and cost-effective workup combined with HPLC-DAD for post-mortem toxicology ultimately delivers reliable analysis results.

Evolving Characteristics of Decedents With Hepatitis A Listed as a Cause of Death, United States, 2011-2021.

Hepatitis A is a vaccine-preventable disease that typically causes mild illness. Hepatitis A outbreaks associated with person-to-person transmission have been widespread in the United States since 2016. We used public-use US Multiple Cause of Death data to compare characteristics and listed comorbidities among decedents with hepatitis A-listed deaths during non-outbreak (2011-2015) and outbreak (2017-2021) periods and assessed the median age at death among decedents with and without hepatitis A-listed deaths during the outbreak period. From the non-outbreak period to the outbreak period, hepatitis A-listed deaths more than doubled (from 369 to 801), while the hepatitis A-listed age-adjusted mortality rate increased 150% (p < 0.001). When compared with the non-outbreak period, hepatitis A-listed decedents during the outbreak period were more frequently male, aged 18-49 years, non-Hispanic White, died in an inpatient setting, and had hepatitis A listed as their underlying cause of death. The median age at death for hepatitis A-listed decedents was significantly younger during the outbreak period overall and among females (62 and 66 years, respectively) compared with the non-outbreak period (64 and 72 years, respectively, p < 0.001). During the outbreak period, median age at death for hepatitis A-listed decedents was 14 years younger than decedents without hepatitis A listed. Compared with the general US population, decedents with hepatitis A listed on the death certificate died at younger ages during 2017-2021. Efforts are needed to improve hepatitis A vaccination coverage among adults recommended for hepatitis A vaccination to prevent additional premature hepatitis A deaths.

Postdischarge Mortality in a Cohort Hospitalized With Anorexia Nervosa.

OBJECTIVE: To characterize mortality after hospital discharge in cohorts with and without anorexia nervosa (AN). METHODS: We obtained data for all hospitalizations for psychiatric reasons in Canada (except Quebec) between April 1, 2006, and March 31, 2021 (n = 1.3 million admissions). Cases of AN were identified using ICD-10 (F50.0 and F50.1) codes. First admissions during this interval for AN and other psychiatric conditions were linked to vital statistics data. Mortality was characterized through cross-tabulation, Cox proportional hazards models, and competing cause regression. RESULTS: After adjustment for age and sex, there was no significant difference in mortality between AN and those with other psychiatric conditions (HR = 1.04; p = 0.644). Among AN admissions, 25% (95% CI 18.6-31.4) of deaths were attributed to psychiatric conditions (ICD-F codes), with 88% of these (comprising 22% of all deaths in the AN group) having AN itself identified as the underlying cause of death. In contrast, only 8% of deaths among non-AN admissions were attributed to a mental disorder. DISCUSSION: Prevention of premature mortality in the general psychiatric population emphasizes modification of metabolic (e.g., hyperlipidemia) and lifestyle-related (e.g., sedentary behavior) risk factors. However, as AN itself makes a major contribution to mortality, specialized preventive strategies may be required.

Diagnostic Performance of GPT-4o and Claude 3 Opus in Determining Causes of Death From Medical Histories and Postmortem CT Findings.

INTRODUCTION: This study evaluates the diagnostic performance of the latest large language models (LLMs), GPT-4o (OpenAI, San Francisco, CA, USA) and Claude 3 Opus (Anthropic, San Francisco, CA, USA), in determining causes of death from medical histories and postmortem CT findings. METHODS: We included 100 adult cases whose postmortem CT scans were diagnosable for the causes of death using the gold standard of autopsy results. Their medical histories and postmortem CT findings were compiled, and clinical and imaging diagnoses of both the underlying and immediate causes of death, as well as their personal information, were carefully separated from the database to be shown to the LLMs. Both GPT-4o and Claude 3 Opus generated the top three differential diagnoses for each of the underlying or immediate causes of death based on the following three prompts: 1) medical history only; 2) postmortem CT findings only; and 3) both medical history and postmortem CT findings. The diagnostic performance of the LLMs was compared using McNemar's test. RESULTS: For the underlying cause of death, GPT-4o achieved primary diagnostic accuracy rates of 78%, 72%, and 78%, while Claude 3 Opus achieved 72%, 56%, and 75% for prompts 1, 2, and 3, respectively. Including any of the top three differential diagnoses, GPT-4o's accuracy rates were 92%, 90%, and 92%, while Claude 3 Opus's rates were 93%, 69%, and 93% for prompts 1, 2, and 3, respectively. For the immediate cause of death, GPT-4o's primary diagnostic accuracy rates were 55%, 58%, and 62%, while Claude 3 Opus's rates were 60%, 62%, and 63% for prompts 1,2, and 3, respectively. For any of the top three differential diagnoses, GPT-4o's accuracy rates were 88% for prompt 1 and 91% for prompts 2 and 3, whereas Claude 3 Opus's rates were 92% for all three prompts. Significant differences between the models were observed for prompt two in diagnosing the underlying cause of death (p = 0.03 and <0.01 for the primary and top three differential diagnoses, respectively). CONCLUSION: Both GPT-4o and Claude 3 Opus demonstrated relatively high performance in diagnosing both the underlying and immediate causes of death using medical histories and postmortem CT findings.

Disability during the last ten years of life: evidence from a register-based study in Austria.

Analyses of late-life disability based on survey data of the oldest old often suffer from non-representative samples due to selective participation and attrition. Here, we use register data on the Austrian long-term care allowance (ALTCA) as a proxy for late-life disability. In this retrospective mortality follow-back study, we analyze receipt of ALTCA, a universal cash benefit based on physician-assessed disability in activities of daily living during the last 10 years of life, among all decedents aged 65 years and over from 2020 in Austria (n = 76,781) and its association with sex, age at death, and underlying cause of death. We find that on average, ALTCA was received for 3.5 and 5.3 years in men and women. At 10 years before death, 10% of men and 25% of women received ALTCA, which increased to 56% and 77% at one year before death. Both the probability and duration of ALTCA increased with age at death and varied by cause of death: Those who died from cancer, myocardial infarction, and external causes of death were less likely to receive ALTCA and for shorter durations, while those who died from dementia, Parkinson's disease, chronic heart disease, or chronic lung disease were more likely to receive it and longer so. Overall, our register-based estimates of the prevalence of late-life disability were higher than previous survey-based estimates. Policy-makers should be aware that costs of long-term care will rise as life expectancy rises and deaths from dementia and chronic heart disease will likely increase in the rapidly aging European societies.

[Inspection of deceased : Issuing a death certificate]. / Prähospitale Leichenschau : Durchführung und das Ausstellen der Todesbescheinigung.

The obligatory post-mortem examination and the issuing of a death certificate are among the more unpopular medical tasks. Nevertheless, the legislature has entrusted the medical profession with a socially important task that should be carried out carefully. The examining physician decides whether the death remains a private matter or whether an official death investigation should first shed light on the circumstances of the death. The post-mortem examination system is the only instrument for the systematic detection of homicide offences. The prerequisite for issuing a death certificate is a carefully conducted external post-mortem examination, which must be carried out in full at least when certifying a natural or unexplained cause of death. In addition, the medical information on the death certificate serves epidemiological and health policy purposes and contains important information on infection control.

Using machine learning methods to investigate the impact of age on the causes of death in patients with early intrahepatic cholangiocarcinoma who underwent surgery.

BACKGROUND: The impact of age on the causes of death (CODs) in patients with early-stage intrahepatic cholangiocarcinoma (ICC) who had undergone surgery was analyzed in this study. METHODS: A total of 1555 patients (885 in the older group and 670 in the younger group) were included in this study. Before and after applying inverse probability of treatment weighting (IPTW), the different CODs in the 2 groups were further investigated. Additionally, 7 different machine learning models were used as predictive tools to identify key variables, aiming to evaluate the therapeutic outcome in early ICC patients undergoing surgery. RESULTS: Before (5.92 vs. 4.08 years, P < 0.001) and after (6.00 vs. 4.08 years, P < 0.001) IPTW, the younger group consistently showed longer overall survival (OS) compared with the older group. Before IPTW, there were no significant differences in cholangiocarcinoma-related deaths (CRDs, P = 0.7) and secondary malignant neoplasms (SMNs, P = 0.78) between the 2 groups. However, the younger group had a lower cumulative incidence of cardiovascular disease (CVD, P = 0.006) and other causes (P < 0.001) compared with the older group. After IPTW, there were no differences between the 2 groups in CRDs (P = 0.2), SMNs (P = 0.7), and CVD (P = 0.1). However, the younger group had a lower cumulative incidence of other CODs compared with the older group (P < 0.001). The random forest (RF) model showed the highest C-index of 0.703. Time-dependent variable importance bar plots showed that age was the most important factor affecting the 2-, 4-, and 6-year survival, followed by stage and size. CONCLUSIONS: Our study confirmed that younger patients have longer OS compared with older patients. Further analysis of the CODs indicated that older patients are more likely to die from CVDs. The RF model demonstrated the best predictive performance and identified age as the most important factor affecting OS in early ICC patients undergoing surgery.

Mortality among Swedish seafarers 1985-2013.

AIM: The aim was to investigate mortality among Swedish seafarers compared to the general population, and differences in mortality between occupational categories and differences over time. METHODS: Longitudinal register-based cohort study of 85,169 Swedish seafarers registered in the Swedish Transport Agency's Seafarers' Registry (SR) 1985-2013. The cohort was matched with the Swedish Cause of Death Register. Standardized mortality ratios (SMRs) and 95% confidence intervals (CIs) were calculated stratified by gender, job category, start of sea service, and time registered in the SR. Seafarers were followed until 66 years of age. Mortality by diseases was analyzed for seafarers with at least 5 years of sea service and mortality due to external causes was analyzed for all seafarers. RESULTS: Total mortality was increased among men who started to work before 1985 (SMR: 1.27, 95% CI: 1.21-1.32) and borderline significantly increased among women (SMR: 1.14, 95% CI: 0.99-1.32). Mortality ratios due to lung cancer, accidents, suicides, and mental disorders including substance abuse, were increased among seafarers who started to work before 1985. Mortality risks were particularly increased among the crew. SMRs tended to decrease over time, but mortality due to accidents was still increased among the crew who started to work 1985 or later (SMR: 1.64, 95% CI: 1.02-2.63). CONCLUSION: Swedish seafarers had an increased mortality compared to the general population in 1985-2013, particularly the crew. There is still an increased mortality in accidents among crew who started to work 1985 or later.

Assessing educational disparities in COVID-19 related excess mortality in Spain: a population register-linked mortality study.

Introduction: Data on the increase in mortality during the COVID-19 pandemic based on individuals' socioeconomic positions are limited. This study examines this increase in mortality in Spain during the epidemic waves of 2020 and 2021. Methods: We calculated the overall and cause-specific mortality rates during the 2017-2019 pre-pandemic period and four epidemic periods in 2020 and 2021 (first, second, third-fourth, and fifth-sixth waves). Mortality rates were analyzed based on educational levels (low, medium, and high) and across various age groups (25-64, 65-74, and 75+). The increase in mortality during each epidemic period compared to the pre-pandemic period was estimated using mortality rate ratios (MRR) derived from Poisson regression models. Results: An inverse educational gradient in overall mortality was observed across all periods; however, this pattern was not consistent for COVID-19 mortality in some age groups. Among those aged 75 years and older, highly educated individuals showed higher COVID-19 mortality during the first wave. In the 25-64 age group, individuals with low education experienced the highest overall mortality increase, while those with high education had the lowest increase. The MRRs were 1.21 and 1.06 during the first wave and 1.12 and 0.97 during the last epidemic period. In the 65-74 age group, highly educated individuals showed the highest overall mortality increase during the first wave, whereas medium-educated individuals had the highest increase during the subsequent epidemic periods. Among those aged 75 and older, highly educated individuals exhibited the highest overall mortality increase while the individuals with low education showed the lowest overall mortality increment, except during the last epidemic period. Conclusion: The varying educational patterns of COVID-19 mortality across different age groups contributed to the disparities of findings in increased overall mortality by education levels during the COVID-19 pandemic.