The validity of death certificates: routine validation of death certification and its effects on mortality statistics

Alcohol Policy in Adolescence and Subsequent Alcohol-attributable Hospitalizations and Mortality at Ages 21-54 Years: A Register-based Cohort Study

BACKGROUND

Little is known about how alcohol policies experienced in adolescence are associated with later health. We assess whether the age of exposure to stricter alcohol policies is associated with later alcohol-attributable hospitalizations and mortality. We take advantage of an alcohol advertising ban and alcohol tax increases introduced in 1975-1977 with relatively stable alcohol policies before and after.

METHODS

We used Finnish register data on birth cohorts 1950-1964 (1,175,878 individuals) to assess cohort-wise hazard ratios for the first incidence of alcohol-attributable hospitalization and mortality, and mortality due to external and other causes at ages 21-54 years.

RESULTS

Men who were aged 19-25 at the time of the restrictive reform had similar risks for alcohol-attributable hospitalization and mortality to the reference group of those aged 18-legal drinking age-at the time of reform. For those underage at the time, hospitalization and mortality rates were incrementally smaller cohort by cohort. For example, men who were 17 at the time of the reform had lower hazard ratios of alcohol-attributable hospitalization: 0.91 (95% confidence interval: 0.87, 0.95) as did those who were 13 (0.85; 95% confidence interval: 0.81, 0.89). The findings were similar for external-cause mortality, and similar yet more uncertain for women. In contrast, mortality from other causes declined continuously from cohort to cohort.

CONCLUSIONS

Our findings are consistent with the hypothesis that stricter alcohol policies in adolescence reduce harmful alcohol consumption patterns extending into adulthood and manifesting as lower alcohol-related harm to health.

Genetic Liability to Higher Muscle Strength Associates With a Lower Risk of Cardiovascular Disease Mortality in Men Irrespective of Leisure-Time Physical Activity in Adulthood: A Longitudinal Cohort Study

BACKGROUND

Low muscle strength predicts premature mortality. We determined whether genetic liability to muscle strength is associated with mortality and whether this association is influenced by long-term leisure-time physical activity (LTPA).

METHODS AND RESULTS

We estimated the effects of a polygenic score for handgrip strength (PGS HGS) on all-cause and cardiovascular disease (CVD) mortality risk in the older Finnish Twin Cohort (N=8815, 53% women). LTPA was assessed longitudinally using validated questionnaires. During the 16.9-year median follow-up (143 723 person-years), 2896 deaths occurred, of which 1089 were attributable to CVD. We found a significant interaction between sex and PGS HGS (P=0.016) in relation to all-cause mortality. In men, 1-SD increase in the PGS HGS was associated with a decreased risk of all-cause (hazard ratio [HR], 0.93 [95% CI, 0.89-0.98]) and CVD mortality (HR, 0.88 [95% CI, 0.81-0.96]), but was not statistically significantly associated with mortality in women (HR, 1.01 [95% CI, 0.96-1.07]; and HR, 0.96 [95% CI, 0.87-1.05], respectively). In men, associations remained after adjusting for LTPA and persisted for CVD mortality (HR, 0.85 [95% CI, 0.76-0.96]), even after accounting for other lifestyle covariates. This remained statistically significant even when non-CVD death was accounted for as a competing risk event. No PGS HGS×LTPA interactions were found. The predictive area under the curve estimates for PGS HGS alone were limited (0.53-0.64) but comparable to that of several lifestyle factors.

CONCLUSIONS

Higher PGS HGS was associated with a decreased risk of CVD mortality in men. Long-term LTPA in adulthood did not potentiate this association.

A Finnish nationwide register-based study shows a further 50% decline in already low child mortality

AIM

Child mortality declined significantly in Finland in 1969-2004. We investigated whether the already low mortality rate could still decline from 2005 to 2020.

METHODS

This was a nationwide register-based study. The subjects were children under 16 years of age who had resided in Finland between 2005 and 2020. The study population was identified from Finland's Population Information System of the Digital and Population Data Services Agency. Causes of death were obtained from Statistics Finland. Changes in annual overall and cause-specific mortality rates were evaluated.

RESULTS

3685 children (55% boys) under 16 years of age died in Finland in 2005-2020 from 325 causes. Overall annual child mortality declined by 50% (95% confidence interval 37 to 64%) during the study period, from 0.31/1000 in 2005 to 0.16/1000 in 2020. The mortality rate in children under one year of age declined from 3.1/1000 in 2005 to 1.8/1000 in 2020. The deaths from sudden infant death syndrome fell by 84%, congenital malformations by 62%, infectious diseases by 60%, external causes by 52%, and perinatal disorders by 41%.

CONCLUSION

Finland's low child mortality further declined over the past two decades. Contributing factors likely include achievements in paediatric research, public health, and clinical practice.

External post-mortem examination in virtual reality-scalability of a monocentric application

Conducting external post-mortem examinations is an essential skill required of physicians in various countries, regardless of their specialization. However, the quality of these examinations has been a subject of continuous debates, and notable errors were reviled. In response to these shortcomings, a virtual reality (VR) application was developed at Halle's medical department in Germany, focusing on the scene of discovery and the completion of death certificates. The initial trial of this VR application in 2020 involved 39 students and 15 early-career professionals. Based on the feedback, the application underwent improvements and was subsequently introduced to the medical department in Dresden, Germany, in 2022. Its primary objective was to showcase the VR training's adaptability and scalability across various educational structures and levels of medical expertise. Out of 73 students who participated, 63 completed the evaluation process. 93.1% (n = 58) of the evaluators reported increased confidence in conducting external post-mortem examinations, and 96.8% (n = 61) felt more assured in filling out death certificates, crediting this progress to the VR training. Additionally, 98.4% (n = 62) believed that repeating forensic medical aspects in their coursework was crucial, and 96.8% (n = 61) viewed the VR examination as a valuable addition to their academic program. Despite these positive responses, 91.6% (n = 55) of participants maintained that training with real corpses remains irreplaceable due to the insufficiency of haptic feedback in VR. Nevertheless, the potential for enhancing the VR content and expanding the training to additional locations or related disciplines warrants further exploration.

Association of duration of treatment on post-discharge mortality in forensic psychiatric patients in Finland

Background

Longer treatment time has been shown to be associated with lower crime recidivism among forensic psychiatric patients, but it is not known if this applies also to mortality. In this study, we aim to research whether treatment time is associated with risk of post-discharge mortality in Finnish forensic psychiatric patients.

Materials and methods

The study population consisted of 989 patients committed to compulsory forensic psychiatric hospital treatment in Finland from 1980 to 2009 who were released from care by the end of 2018. Each patient included in the cohort was linked with the Statistics Finland register, which includes all data on dates and causes of deaths in Finland. Crude cumulative rate of mortality were estimated using Kaplan-Meier method and compared using logrank-test. Adjusted cumulative rate analyzed using Cox regression model. A possible nonlinear relationship between the treatment time and the hazard of death was assessed by using 3-knot-restricted cubic spline regression. Adjusted models included age, sex, and SUD (substance use disorder) as covariates.

Results

The mean duration of care was 7.1 (SD 6) years. The duration of treatment variable was divided into tertiles of treatment duration less than 3.5 years, 3.5-7.9 years and equal or more than 8 years. The risk of mortality was highest in the first tertile, and lowest in the last tertile. The risk of mortality was higher for patients suffering from SUD, for patients of male sex and for those released at younger age.

Conclusions

Longer treatment time is associated with reduced post-discharge mortality in forensic psychiatric patients in Finland. Especially males and individuals with SUD are at higher mortality risk after release, but longer treatment duration may mitigate these risks. Longer periods of hospitalization have to be, however, viewed against the backdrop of institutionalization and loss of self-determination.

The association of breast cancer patients survival and prior menopausal hormone therapy in women with type 2 diabetes

We investigated the association of prediagnostic use of menopausal hormone therapy (MHT) with breast cancer survival among women with type 2 diabetes (T2D). The study cohort was identified from a Finnish nationwide diabetes database, and consisted of women with T2D, who were diagnosed with breast cancer between 2000 and 2011 (n = 3189). The patients were classified according to their previous MHT use: systemic MHT, local MHT, and no history of any MHT. The cumulative mortality from breast cancer, cardiovascular diseases, and other causes in three MHT groups was described by the Aalen-Johansen estimator. The cause-specific mortality rates were analyzed by Cox models, and adjusted hazard ratios (HRs) were estimated for the use of MHT. The breast cancer mortality appeared to be lower among systemic MHT users (HR 0.49, 95% Cl 0.36-0.67) compared with non-users of MHT. The mortality from cardiovascular diseases and from other causes of death was found to be lower among systemic MHT users, (HR 0.49, 95% Cl 0.32-0.74), and (HR 0.51, 95% Cl 0.35-0.76), respectively. In conclusion, prediagnostic systemic MHT use is associated with reduced breast cancer, cardiovascular, and other causes of mortality in women with T2D.

Stimulating leisure-time activities and the risk of dementia: a multi-cohort study

BACKGROUND

Stimulating activities are associated with a decreased risk of dementia. However, the extent to which this reflects a protective effect of activity or non-participation resulting from dementia is debated. We investigated the association of stimulating leisure-time activity in late adulthood with the risk of dementia across up to two decades' follow-up.

METHODS

We used data from five prospective cohort studies from Finland and Sweden. Mental, social, outdoor, consumptive and physical leisure-time activities were self-reported. Incident dementia was ascertained from clinical diagnoses or healthcare and death registers. Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Of the 33 263 dementia-free individuals aged ≥50 years at baseline, 1408 had dementia during a mean follow-up of 7.0 years. Active participation in mental (HR: 0.52, 95% CI: 0.41 to 0.65), social (HR: 0.56 95% CI: 0.46 to 0.72), outdoor (HR: 0.70, 95% CI: 0.58 to 0.85), consumptive (HR: 0.67, 95% CI: 0.53 to 0.94) and physical (HR: 0.62, 95% CI: 0.51 to 0.75) activity, as well as variety (HR: 0.54, 95% CI: 0.43 to 0.68) and the overall frequency of activity (HR: 0.41, 95% CI: 0.34 to 0.49) were associated with a reduced risk of dementia in <10 years' follow-up. In ≥10 years' follow-up all associations attenuated toward the null.

CONCLUSION

Stimulating leisure-time activities are associated with a reduced risk of dementia in short-term but not long-term follow-up. These findings may reflect a reduction in leisure-time activity following preclinical dementia or dilution of the association over time.

Cervicocerebral Atherosclerosis Burden Increases Long-Term Mortality in Patients With Ischemic Stroke or Transient Ischemic Attack

BACKGROUND

The influence of burden of atherosclerosis in the brain supplying arteries on mortality in patients with acute ischemic stroke or transient ischemic attack is poorly known. We assessed whether total burden of atherosclerosis within cervicocerebral arteries is associated with long-term mortality.

METHODS AND RESULTS

A total of 406 patients (median age, 71.8 years; 57.9% male) with acute ischemic stroke or transient ischemic attack were included and their cervicocerebral arteries imaged with computed tomography angiography. The presence of atherosclerotic findings was scored for 25 artery segments and points were summed as a Cervicocerebral Atherosclerosis Burden (CAB) score, analyzed as quartiles. Data on all-cause mortality came from Statistics Finland. After a median follow-up of 7.3 years, 147 (33.5%) patients had died. Compared with surviving patients, those who died had a higher median CAB score (5, interquartile range 2-10 versus 11, 7-16; P<0.001). Cumulative mortality increased from 8.9% (95% CI, 7.0-10.8) in the lowest to 61.4% (95% CI, 55.4-67.4) in the highest quartile of CAB score. Adjusted for demographics, cardiovascular risk factors, secondary preventive medication, and admission National Institute of Health Stroke Scale score, every CAB score point increased probability of death by 3%. Analyzed in quartiles, the highest CAB quartile was associated with a 2.5-fold likelihood of all-cause mortality.

CONCLUSIONS

The main findings of our study were the increasing mortality with the total burden of computed tomography angiography-defined atherosclerosis in the brain supplying arteries after ischemic stroke or transient ischemic attack and that the CAB score-integrating this pathology-independently increased all-cause mortality.

Risk stratification-based thromboprophylaxis does not affect mortality after fast-track hip and knee arthroplasty

BACKGROUND AND PURPOSE

Use of thromboprophylaxis effectively prevents pulmonary embolism (PE) and deaths after total hip and knee arthroplasty (THA and TKA). The optimum length of thromboprophylaxis is not known and has traditionally been based on the type of operation. Nowadays, a more individualized approach is preferred. This study analyzed if risk stratification-based planning of thromboprophylaxis has an association with the all-cause mortality after fast-track THA and TKA.

PATIENTS AND METHODS

We compared fast-track THAs and TKAs operated between 2015-2016 and 2020-2021. Between 2015 and 2016, all patients received a routine length of thromboprophylaxis. From 2020 onwards, thromboprophylaxis was planned by risk stratification, and patients at low risk for venous thromboembolism received thromboprophylaxis only during hospitalization. All causes of death within 90 days of surgery were identified and the incidence of mortality was calculated. Mortality rates between the two periods were then compared.

RESULTS

Between 2015 and 2016, 3192 arthroplasties were performed. A total of eight deaths occurred within 90 days of surgery, yielding an incidence of all-cause mortality of 0.3% (95% CI 0.1-0.5). Between 2020 and 2021, a total of 3713 arthroplasties were performed to patients who received risk stratification-based thromboprophylaxis. Thirteen of these patients died within 90 days of surgery, yielding an all-cause mortality incidence of 0.4% (95% CI 0.2-0.6). Cardiovascular diseases were the main cause of death during both study periods. None of the deaths were caused by PEs.

INTERPRETATION

Risk stratification-based thromboprophylaxis was not associated with increased all-cause mortality within 90 days of fast-track THA and TKA.

Surgical and oncological results after rectal resections with or without previous treatment for prostate cancer

Introduction

Previous treatment for prostate cancer (PC) may potentially affect the surgical and oncological outcomes of subsequent rectal cancer surgery, but there are only a few studies regarding this particular group. In this study, we present the 3-year surgical and oncological results of rectal cancer patients who had received previous treatment for PC at a single Finnish tertiary referral centre.

Material and methods

Data regarding all male patients diagnosed with rectal cancer and treated at Tampere University Hospital (TAUH) between 1997 and 2016 were gathered from medical records. In total, this study included 553 rectal cancer patients who underwent curative surgery, and 54 of them (9.8%) had a prior history of treatment for prostate cancer.

Results

Patients in the PC group were older and had more comorbidities compared with those in the non-PC group. The PC patients had a significantly higher risk of permanent stoma compared with the non-PC patients (61.5% vs. 45.2%, respectively, p = 0.025). The PC patients seemed to have lower tumours than the non-PC patients (87% vs. 75%, respectively, p = 0.05). Overall, the 3-year overall survival (OS) for the PC and non-PC patients was 74.1% and 80.6%, respectively. No significant differences were observed between the study groups even in the age-adjusted comparison [hazard ratio (HR): 1.07, confidence interval (CI) 95%: 0.60-1.89]. In the univariable analysis, radically operated patients without a history of PC exhibited an improved overall survival, (HR: 2.46, 95% CI: 1.34-4.53, p = 0.004). However, only a higher age-adjusted Charlson comorbidity index (CCI) and a low tumour location (<10 cm) were found to have an independent prognostic impact on worse OS in the multivariable analysis (HR: 1.57, 95% CI: 1.36-1.82, p < 0.001 and HR: 2.74, 95% CI: 1.32-5.70, p = 0.007, respectively). No significant differences were observed between the groups in terms of disease-free or local recurrence-free survival.

Conclusion

Rectal cancer is more frequently found in the middle or lower part of the rectum in patients who have previously received treatment for prostate cancer. These patients also have a higher likelihood of requiring a permanent stoma. In radically operated rectal cancer, the PC group had a worse OS rate, according to the univariable analysis. However, the only independent prognostic factors for a worse OS that were highlighted in the multivariable analysis included a higher CCI and a low tumour location.

Suicides in degenerative neurocognitive disorders and traumatic brain injuries

BACKGROUND

Neuropsychiatric symptoms in major neurocognitive disorders have been strongly associated with suicidality.

METHODS

The objectives were to explore suicide rates in degenerative neurocognitive disorders (DNDs), alcohol-related neurocognitive disorders (ARNDs), and traumatic brain injuries (TBIs). Patients who received these diagnoses between 1998 and 2015 (N = 231,817) were identified from nationwide registers, and their mortality was followed up until December 31, 2018. We calculated incidences of suicides per 100,000 person-years, types of suicides, and suicide rates compared with the general population (standardized mortality ratio [SMR]).

RESULTS

During the follow-up, 0.3% (95% confidence interval [95% CI]: 0.2-0.5) of patients with DNDs, 1.1% (0.7-1.8) with ARNDs, and 1.0% (0.7-1.3) with TBIs committed suicide. Suicide mortality rate was higher in men (58.9, 51.3, to 67.4 per 100,000) than in women (9.8, 7.5, to 12.5 per 100,000). The highest suicide rate was in ARNDs (98.8, 65.1, to 143.8 per 100,000), followed by TBIs (82.0, 62.4, to 105.8 per 100,000), and DNDs (21.2, 18.3, to 24.5 per 100,000). The SMRs (95% CI) were 3.69 (2.53-5.38), 2.99 (2.31-3.86), and 1.31 (1.13-1.51), respectively, and no sex difference emerged. The most common cause of death was self-inflicted injury by hanging or drowning (12.4, 10.3, to 14.8 per 100,000).

CONCLUSIONS

Suicide rates were higher in all three patient groups than the general population. Suicide risk remained elevated for more than 10 years after diagnosis. The suicide methods were mostly violent.

Trends in suicide mortality in Spain from 1998 to 2021 and its relationship with the COVID-19 pandemic: A joinpoint regression analysis

In the European Union, a rate of 11.9 cases per 100,000 was estimated in 2019.In Spain, suicide is the leading cause of external death. Social crises can have an impact on suicide rates. We analyzed changes in suicide mortality trends in Spain following the COVID-19 pandemic. We used statistical data from the National Institute of Statistics of Spain (1998-2021). We calculated age-specific rates, age and sex-adjusted rates, and analyzed trends and changes using joinpoint-regression models. Rates decrease in both sexes at the ages of 65 and older. In women, they increase in the ages of 1-29 years and 45-59 years. In men, they decrease in the ages of 15-39 years. Among women, age-adjusted rates remained stable between 1998 and 2021, with a non-significant annual decrease of 0.4 %. Among men, there was a significant annual decrease of 0.7 %. The years 2020 and 2021 had 8 % higher mortality compared to the two years prior to the COVID-19 pandemic. Suicide mortality in Spain slightly decreased among men and remained stable among women between 1998 and 2021, but there seems to be an increase following the COVID-19 pandemic.

Non-erosive gastro-oesophageal reflux disease and incidence of oesophageal adenocarcinoma in three Nordic countries: population based cohort study

OBJECTIVE

To assess the incidence rate of oesophageal adenocarcinoma among patients with non-erosive gastro-oesophageal reflux disease compared with the general population.

DESIGN

Population based cohort study.

SETTING

All patients in hospital and specialised outpatient healthcare in Denmark, Finland, and Sweden from 1 January 1987 to 31 December 2019.

PARTICIPANTS

486 556 adults (>18 years) who underwent endoscopy were eligible for inclusion: 285 811 patients were included in the non-erosive gastro-oesophageal reflux disease cohort and 200 745 patients in the validation cohort with erosive gastro-oesophageal reflux disease.

EXPOSURES

Non-erosive gastro-oesophageal reflux disease was defined by an absence of oesophagitis and any other oesophageal diagnosis at endoscopy. Erosive gastro-oesophageal reflux disease was examined for comparison reasons and was defined by the presence of oesophagitis at endoscopy.

MAIN OUTCOME MEASURES

The incidence rate of oesophageal adenocarcinoma was assessed for up to 31 years of follow-up. Standardised incidence ratios with 95% confidence intervals were calculated by dividing the observed number of oesophageal adenocarcinomas in each of the gastro-oesophageal reflux disease cohorts by the expected number, derived from the general populations in Denmark, Finland, and Sweden of the corresponding age, sex, and calendar period.

RESULTS

Among 285 811 patients with non-erosive gastro-oesophageal reflux disease, 228 developed oesophageal adenocarcinomas during 2 081 051 person-years of follow-up. The incidence rate of oesophageal adenocarcinoma in patients with non-erosive gastro-oesophageal reflux disease was 11.0/100 000 person-years. The incidence was similar to that of the general population (standardised incidence ratio 1.04 (95% confidence interval 0.91 to 1.18)), and did not increase with longer follow-up (1.07 (0.65 to 1.65) for 15-31 years of follow-up). For validity reasons, we also analysed people with erosive oesophagitis at endoscopy (200 745 patients, 1 750 249 person-years, and 542 oesophageal adenocarcinomas, corresponding to an incidence rate of 31.0/100 000 person-years) showing an increased overall standardised incidence ratio of oesophageal adenocarcinoma (2.36 (2.17 to 2.57)), which became more pronounced with longer follow-up.

CONCLUSIONS

Patients with non-erosive gastro-oesophageal reflux disease seem to have a similar incidence of oesophageal adenocarcinoma as the general population. This finding suggests that endoscopically confirmed non-erosive gastro-oesophageal reflux disease does not require additional endoscopic monitoring for oesophageal adenocarcinoma.

A 5-Year Suicide Rate of Adolescents Who Enrolled to an Open Dialogue-Based Services: A Nationwide Longitudinal Register-Based Comparison

In the Open Dialogue (OD) based psychiatric services adolescent patients receive less medication and are more often treated within an outpatient setting as compared to standard services. An evaluation of the possible risks of implementing OD are required. The aim of this longitudinal register-based study was to evaluate how treatment under OD is associated with the probability of suicide as compared standard psychiatric care. Study included all 13- to 20-year-old adolescents who enrolled to a psychiatric service in Finland in 2003-2013. The OD-group included adolescents whose treatment commenced in the Western Lapland area (n = 2107), this being the only region where OD covered all psychiatric services. The comparison group (CG) included rest of Finland (n = 121,658). Information was gathered from onset of treatment to the end of the 5-year follow-up or death. In a multivariate Cox regression there were no statistically significant differences in 5-year suicide hazard ratios between OD and CG.

The 10-year treatment outcome of open dialogue-based psychiatric services for adolescents: A nationwide longitudinal register-based study

AIM

To evaluate the 10-year treatment outcomes and cost-effectiveness of adolescents' mental health treatment initiated under the social network-oriented open dialogue (OD) approach.

METHODS

This longitudinal register-based study included all persons who, for the first time, received psychiatric treatment in Finland during the period 1 January 2003-31 December 2008, and who were aged 13-20 at onset (n = 44 868). The OD group included all persons whose treatment commenced in the Western Lapland catchment area (n = 780), this being the only region in Finland where OD covered the entire mental healthcare service at the time of inclusion. The comparison group (CG) included the rest of Finland (n = 44 088). The primary outcome variables were psychiatric treatment and/or disability allowances at the end of the 10-year follow-up, or death. The secondary outcome variables were treatment and disability expenses. Generalized linear models weighted by inverse probability of treatment were used to study the association between OD and the primary outcomes. Population proportions were used to evaluate the cost-effectiveness of the approaches.

RESULTS

Treatment that commenced outside OD was associated with higher odds of continuing to receive treatment (adjusted odds ratio [aOR] 1.4; 95%CI 1.2-1.6) and disability allowances (aOR 1.6; 95%CI 1.2-2.1) at the end of the 10-year follow-up. No significant difference in the mortality ratio emerged. The cumulative 10-year expenses per capita were lower under OD.

CONCLUSIONS

OD associated with favourable long-term outcomes, but due the observational design and possible residual confounding, further studies with a more robust research design are required.

Long-term Survival After Sleeve Gastrectomy Versus Gastric Bypass in a Binational Cohort Study

OBJECTIVE

Bariatric surgery prolongs life expectancy in severely obese individuals, but it is uncertain which of the two dominating bariatric procedures, sleeve gastrectomy or gastric bypass, offers the best long-term survival.

RESEARCH DESIGN AND METHODS

This was a population-based cohort study of primary laparoscopic sleeve gastrectomy compared with gastric bypass for obesity in Sweden and Finland between 1 January 2007 and 31 December 2020. The risk of all-cause mortality was calculated using multivariable Cox regression, providing hazard ratios (HRs) with 95% CIs adjusted for age, sex, hypertension, diabetes, Charlson comorbidity index, country, and calendar year.

RESULTS

Among 61,503 patients (median age 42 years; 75.4% women), who contributed 415,712 person-years at risk (mean 6.8 person-years), 1,571 (2.6%) died during follow-up. Compared with patients who underwent gastric bypass (n = 51,891 [84.4%]), the sleeve gastrectomy group (n = 9,612 [15.6%]) had similar all-cause mortality during the entire study period (HR 0.98, 95% CI 0.81-1.20), but decreased all-cause mortality in more recent years (HR 0.72, 95% CI 0.54-0.97, from 2014 onward). Diabetes interacted statistically significantly with the type of bariatric surgery, with higher all-cause mortality after sleeve gastrectomy than after gastric bypass (HR 1.54, 95% CI 1.06-2.24).

CONCLUSIONS

The overall survival following sleeve gastrectomy seems to compare well with gastric bypass and may even be better during recent years. A tailored surgical approach in relation to patients' diabetes status may optimize survival in patients selected for bariatric surgery (i.e., sleeve gastrectomy for patients without diabetes and gastric bypass for patients with diabetes).

Evaluation of the impact of changes in the autopsy rate on mortality trend of pulmonary embolism, Finland, 1996-2017

Pulmonary embolism is listed as a cause of death in fewer and fewer cases in the twenty-first century. Autopsies reveal undiagnosed pulmonary embolism at a significant rate, but fewer and fewer autopsies are being performed. It could be that deaths from pulmonary embolism are not decreasing, but are increasingly missed because of decreasing autopsy rate. Population-based registry data of all individuals with pulmonary embolism related death from the Finnish death certificate archive from 1996 to 2017 were collected. The pulmonary embolism mortality trend was analysed with linear regression and the association of pulmonary embolism mortality with the number of autopsies was also assessed. Deaths with pulmonary embolism as immediate, underlying and contributory cause of death were not only included, but also analysed separately. In addition, the estimated pulmonary embolism mortality when presumptively missed pulmonary embolisms are taken into account is presented. During 1996-2017, the pulmonary embolism related mortality rate decreased 28% from 25: 100 000 to 18: 100 000, if all pulmonary embolism deaths were analysed, and 51% from 21: 100 000 to 11: 100 000 if contributory pulmonary embolism deaths were excluded. From 1996 to 2009, autopsy rate in the population remained unchanged, but declined thereafter. In 1996, autopsy rate was 31.1% (15 319/49167) and in 2017 20.1% (10830/53 923). Our results suggest that there has been real improvement in the prevention of death from pulmonary embolism in Finland in the twenty-first century. However, due to the decreasing autopsy rate, the pulmonary embolism mortality trend after 2010 should be interpreted more carefully.

Gastric cancer completeness in Finnish Cancer Registry and Finnish Patient Registry: a population-based nationwide retrospective cohort study

BACKGROUND

Gastric cancer is the fourth-leading cause of cancer-related deaths worldwide. The only curative treatment options of gastric cancer are perioperative chemotherapy and surgical resection. Many nationwide registries have high validity and provide vast range of opportunities for registry-based research. Cancer diagnoses in the Finnish Cancer Registry (FCR) are reported by pathology laboratories and clinician forms, while discharge diagnosis codes are reported to the Finnish Patient Registry (HILMO) automatically. Finland is known for complete registries but the completeness of gastric cancer in FCR and HILMO remains unclear.

OBJECTIVES

The aim of this study is to assess the registry coverage for gastric cancer in FCR and HILMO and to explore potential reasons for possible differences between these registries.

DESIGN

Population-based nationwide retrospective cohort study.

PARTICIPANTS

All patients diagnosed with gastric cancer in Finland during 1990 to 2014, with follow-up until 31 December 2019.

RESULTS

Out of 21 468 total gastric cancers reported to either registry, 17 107 (79.7%) had a gastric cancer diagnosis in both registries. A substantial decrease from 88.3% to 83.4% was observed in the proportion of cases reported to FCR over time. The completeness of FCR was estimated at 87%. For HILMO, the completeness was 92.7%. Death due to gastric cancer was most common in those with gastric cancer in both registries (80.8%), and less common in those reported to only FCR (36.3%), followed by those reported to only HILMO (9.3%).

CONCLUSIONS

The study indicates that gastric cancer is well captured by both FCR and HILMO but there is an alarming decrease in the proportion of cases captured by the FCR over time. Some gastric cancer diagnoses in HILMO might, however, be misclassified due to cancer diagnoses being assigned based on clinical suspicion.

Family's socioeconomic profile at birth and offspring mortality until midlife - The Northern Finland Birth Cohort 1966 study

Family's socioeconomic profile collected prenatally is known to predict offspring mortality during early life, but it remains unclear whether it has the potential to predict offspring mortality until later life. In this study, 12,063 individuals belonging to the Northern Finland Birth Cohort 1966 were followed up from mid-pregnancy for 52 years (570,000 person years). Five distinct socioeconomic profiles were identified by latent class analysis based on mother's marital status, education, and occupation; father's occupation; number of family members; location of residence, room count, and utilities; and family's wealth. The classes were highest status families (15.4% of the population), small families (22.1%), larger families (15.4%), average wealth families (23.4%), and rural families (23.3%). Their associations to offspring mortality, via linkage to national offspring death records, were analysed by Cox regression, stratified by sex and age groups (0-19, 20-38 and 40-52 years). In total, mortality was 9.2% among male and 5.0% among female offspring. Risk for midlife mortality was higher among male offspring from larger families (hazard ratio 2.19, 95% confidence interval 1.32-3.63), average wealth families (1.66, 1.02-2.73) and rural families (1.63, 1.00-2.68), relative to offspring from highest status families. It seems that family's socioeconomic profile constructed prenatally has predictive value for midlife mortality among male offspring. Premature mortality of men and women seem to be two distinct phenomena with differing underlying factors as socioeconomic profile was not associated with mortality among female offspring.

Evidence of large systematic differences between countries in assigning ischaemic heart disease deaths to myocardial infarction: the contrasting examples of Russia and Norway

BACKGROUND

There is considerable variation in mortality rates from myocardial infarction (MI) across high-income countries, some of which may be artefactual.

METHODS

Time trends in mortality rates from ischaemic heart disease (IHD) and MI were analysed for a set of high-income countries from the end of the 1970s. Using individual-level mortality data from Russia (2005-2017) and Norway (2005-2016), we investigated factors associated with the proportion of total IHD deaths certified as due to MI.

RESULTS

In most countries, MI mortality rates have dramatically declined from the 1970s. However, the share of MI in total IHD deaths varies substantially across countries. In Russia, only 12% of IHD deaths had MI assigned as the underlying cause vs 63% in Norway. IHD deaths occurring outside of hospital without autopsy were far less likely to be assigned as MI in Russia (2%) than in Norway (59%).

CONCLUSIONS

Although established international criteria for MI require specific clinical or post-mortem evidence, it appears that certifying specialists in different countries may interpret these criteria differently. At one extreme, Russian doctors may only assign MI as a cause of death when there is specific pathophysiological evidence. At the other extreme, their counterparts in Norway may be willing to specify MI as the cause even when this evidence is not available. Internationally established criteria for MI diagnosis are challenging to apply for out-of-hospital deaths. Differences between countries in how certifiers interpret these criteria may account for at least some of the international variation in MI mortality rates.

Association between participation to the Northern Finland Birth Cohort 1986 and mental disorders and suicidal behaviour

OBJECTIVES

In prospective follow-up studies, participants are normally contacted during the follow-up period. Even though the idea is not to intervene, the studies conducted during follow-up may affect the target population. Our hypotheses were that participation in the prospective Northern Finland Birth Cohort 1986 study (NFBC 1986) increased the use of mental health services and reduced suicidal behaviour due to participation in follow-up studies.

METHODS

The NFBC 1986 study covered people with an expected date of birth between July 1985 and June 1986 in northern Finland (n=9,396). The participants of the NFBC 1986 were followed since the antenatal period with follow-ups including clinical examinations. The comparison cohort comprised people born in the same area in 1987 (n=8,959), who were not contacted. Registry data on psychiatric treatment, suicide attempts, and suicides were available. Crude risk ratios (RRs) and adjusted (for marital status and education) Mantel-Haenszel RRs were reported.

RESULTS

No increase in mental disorders were found in NFBC 1986 compared to comparison cohort. In the crude RR analysis of female participants, a lower risk for suicide attempts was found (RR, 0.67; 95% confidence interval, 0.49 to 0.92; p=0.011).

CONCLUSIONS

The results did not support our first hypothesis regarding the increased use of mental health services in the NFBC 1986 cohort. However, our second hypothesis gained some support as female participants of the NFBC 1986 had a lower risk of suicide attempts, although it was not due to a higher number of participants receiving psychiatric treatment.

Gender differences in time to first hospital admission at age 60 in Denmark, 1995-2014

Women have consistently lower mortality rates than men at all ages and with respect to most causes. However, gender differences regarding hospital admission rates are more mixed, varying across ages and causes. A number of intuitive metrics have previously been used to explore changes in hospital admissions over time, but have not explicitly quantified the gender gap or estimated the cumulative contribution from cause-specific admission rates. Using register data for the total Danish population between 1995 and 2014, we estimated the time to first hospital admission for Danish men and women aged 60. This is an intuitive population-level metric with the same interpretive and mathematical properties as period life expectancy. Using a decomposition approach, we were able to quantify the cumulative contributions from eight causes of hospital admission to the gender gap in time to first hospital admission. Between 1995 and 2014, time to first admission increased for both, men (7.6 to 9.4 years) and women (8.3 to 10.3 years). However, the magnitude of gender differences in time to first admission remained relatively stable within this time period (0.7 years in 1995, 0.9 years in 2014). After age 60, Danish men had consistently higher rates of admission for cardiovascular conditions and neoplasms, but lower rates of admission for injuries, musculoskeletal disorders, and sex-specific causes. Although admission rates for both genders have generally declined over the last decades, the same major causes of admission accounted for the gender gap. Persistent gender differences in causes of admission are, therefore, important to consider when planning the delivery of health care in times of population ageing.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10433-021-00614-w.

Sociodemographic Indicators of Child and Adolescent Mortality in Finland-A Nationwide Study of 310 Municipalities Covering Over 5,000,000 Inhabitants

Background: The reduction of child and adolescent deaths (defined as decedents aged 0–19 years) remains a crucial public health priority also in high-income countries such as Finland. There is evidence of a relationship between socioeconomic gradients and child mortality, but the association is considered complex and relatively poorly understood. Exploiting a Finnish dataset with nationwide coverage, the present study aimed to shed light on the sociodemographic predictors of child and adolescent mortality at the municipality level.

Methods: A public database of Statistics Finland was queried for municipality-level data on sociodemographic traits and child and adolescent deaths in Finland during the years 2011–2018. The sociodemographic indicators included total population size, child and adolescent population size, sex distribution, mean age, education, unemployment, median income, population density, rurality, percentage of individuals living in their birth municipality, household size, overcrowded households, foreign language speakers, divorce rate, car ownership rate, and crime rate. The sociodemographic indicators were modeled against child and adolescent mortality by means of generalized estimating equations.

Results: A total of 2,371 child and adolescent deaths occurred during the 8-year study period, yielding an average annual mortality rate of 26.7 per 100,000 individuals. Despite a fluctuating trend, the average annual decline in child and adolescent deaths was estimated to be 3% (95% confidence interval 1–5%). Of the sociodemographic indicators, population density was associated with higher child and adolescent mortality (rate ratio 1.03, 95% confidence interval 1.01–1.06), whereas the percentage of foreign language speakers was associated with lower child and adolescent mortality (0.96, 0.93–0.99).

Conclusion: Densely populated areas should be the primary focus of efforts to reduce child and adolescent mortality. Of note is also the apparently protective effect of foreign language speakers for premature mortality. Future studies are welcomed to scrutinize the mediating pathways and individual-level factors behind the associations detected in this study.

Risk for Premature Mortality and Intentional Self-harm in Autism Spectrum Disorders

To examine the risk for premature mortality and intentional self-harm in autism spectrum disorders (ASD). Based on a national birth cohort. Children born in 1987-2005, diagnosed with ASD by 2007 (n = 4695) were matched with four non-ASD subjects (n = 18,450) and followed until 2015 for mortality and intentional self-harm. The risk among ASD subjects was elevated only for natural cause of death. The risk for intentional self-harm was increased in the unadjusted analyses, but decreased to non-significant after adjusting for comorbid psychiatric disorders. ASD subjects are at increased risk for premature mortality due to natural causes of death. While ASD subjects die of suicide and present with more self-harm, the association is explained by comorbid psychiatric disorders.

Background of fatal pulmonary embolism: an analysis of all diagnosed fatal pulmonary embolism in 2015-2018 from Hospital District of Helsinki and Uusimaa

Pulmonary embolism (PE) mortality has decreased in the last decades but acute PE is still associated with significant fatality. Specific information on fatal PE patients could guide how to efficiently improve PE management but to date this information has been scarce. All the individuals with PE defined as an immediate or underlying cause of death were collected from the death certificate archive of the Hospital District of Helsinki and Uusimaa, Finland, including approximately 1.7 million inhabitants (2015–2018). Crude and age-adjusted mortality rates and proportional mortality were calculated, and the distribution of comorbidities at death and death location (in-hospital, palliative care, or out-of-hospital) was analyzed. In total, 451 individuals with fatal PE were identified (238 females) with a mean age of 72 years (SD 13.5 year). Most of the fatal PEs (n = 264, 54.5%) occurred out-of-hospital and surprisingly, 70 (26.5%) of these individuals s had a history of mental illness or substance abuse. The out-of-hospital resuscitation was attempted in 108 (40.1%) individuals but only 7 (6.5%) received thrombolysis during resuscitation. Fatal PE occurred during hospitalization in 98 individuals and in 54 (55.1%), the diagnosis was only made postmortem. Majority of the fatal PEs occurred out-of-hospital and were diagnosed postmortem whereas only small proportion of deaths occurred to in-hospital PE patients. The earlier diagnosis of PE, which may be accomplished by raising the general awareness of PE, is necessary to prevent these sudden deaths of whom many occurred to individuals with history of mental illnesses or substance abuse.

Surgical and functional outcomes and survival following Colon Cancer surgery in the aged: a study protocol for a prospective, observational multicentre study

Background

The number of colorectal cancer patients increases with age. The decision to go through major surgery can be challenging for the aged patient and the surgeon because of the heterogeneity within the older population. Differences in preoperative physical and cognitive status can affect postoperative outcomes and functional recovery, and impact on patients’ quality of life.

Methods / design

A prospective, observational, multicentre study including nine hospitals to analyse the impact of colon cancer surgery on functional ability, short-term outcomes (complications and mortality), and their predictors in patients aged ≥80 years. The catchment area of the study hospitals is 3.88 million people, representing 70% of the population of Finland. The data will be gathered from patient baseline characteristics, surgical interventional data, and pre- and postoperative patient-questionnaires, to an electronic database (REDCap) especially dedicated to the study.

Discussion

This multicentre study provides information about colon cancer surgery’s operative and functional outcomes on older patients. A further aim is to find prognostic factors which could help to predict adverse outcomes of surgery.

Trial registration

ClinicalTrials.gov (NCT03904121). Registered on 1 April 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08454-8.

Unnatural-cause mortality patterns of Northern Finnish men and women diverge in adolescence - A 52-year follow-up

The Finnish population has a long life expectancy but ranks high in unnatural deaths on the European scale. Mortality has historical regional discrepancy in Finland, as Northern Finns are overrepresented in both natural and unnatural deaths. This study aimed to characterize the age- and sex-related trends in unnatural mortality among Northern Finns. Altogether 12 143 individuals, constituting >95% of births in Northern Finland in 1966, were followed up for a median of 52 years. The mortality patterns of this population were studied using death record data. Crude annual mortality rates were calculated and graphed for 10-year age strata (all-cause, natural-cause, and unnatural-cause mortality, as well as accident, suicide, and homicide mortality). Cox regression was used to analyze the sex discrepancy in mortality. A total of 874 deaths (7.2%) occurred during the follow-up period. Women had 47% and 73% lower risks of any death and unnatural death than men, respectively. From the second decade of life onwards, the unnatural mortality of men was 3-5 times that of women. Accident and suicide mortality rates of men were 2-13 and 2-3 times those of women, respectively. Homicides were rare among either sex. We conclude that Northern Finnish women have a substantially lower risk of all-cause mortality and unnatural mortality than men. To aid the development of preventive strategies, future studies should aim to identify the underlying factors behind unnatural mortality. Primarily, emphasis should be placed on the increased mortality of men from the second decade of life onwards.

Association of antidiabetic medication and statins with survival from ductal and lobular breast carcinoma in women with type 2 diabetes

We investigated the survival of female patients with pre-existing type 2 diabetes (T2D) diagnosed with invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) of breast, in relation to the use of metformin, other antidiabetic medication (ADM) and statins. The study cohort consisted of 3,165 women (2,604 with IDC and 561 with ILC). The cumulative mortality from breast cancer (BC) and from other causes was calculated using the Aalen-Johansen estimator. The cause-specific mortality rates were analysed by Cox models, and adjusted hazard ratios (HRs) were estimated for the use of different medications. No evidence of an association of metformin use with BC mortality was observed in either IDC (HR 0.92, 95% confidence interval [CI] 0.64-1.31) or ILC (HR 0.68, 95% CI 0.32-1.46) patients, when compared to other oral ADMs. The mortality from other causes was found to be lower amongst the IDC patients using metformin (HR 0.64, 95% CI 0.45-0.89), but amongst ILC patients the evidence was inconclusive (HR 1.22, 95% CI 0.64-2.32). Statin use was consistently associated with reduced mortality from BC in IDC patients (HR 0.77, 95% CI 0.62-0.96) and ILC patients (HR 0.59, 95% CI 0.37-0.96), and also mortality from other causes in IDC patients (HR 0.81, 95% CI 0.67-0.96) and in ILC patients (HR 0.66, 95% CI 0.43-1.01). We found no sufficient evidence for the possible effects of metformin and statins on the prognosis of BC being different in the two histological subtypes.

Antipsychotics as a method of suicide: population based follow-up study of suicide in Northern Finland

AIM

This study examined the trend and role of antipsychotics as a method of self-poisoning suicide.

MATERIALS AND METHODS

The basic data covered 483 poisoning suicides, occurring between the years 1988 and 2011, in Northern Finland, of which 178 (115 men, 63 women) were completed using antipsychotics.

RESULTS

During the 23-year follow-up period, second-generation antipsychotics (SGAs) overtook first-generation antipsychotics (FGAs) as a suicide method. Female victims, compared to males, had more commonly used quetiapine (17.5% vs. 6.1%, p = .016), while suicides using promazine were more common in males compared to females (36.5% vs. 22.2%, p = .049). People with unipolar depression had more frequently used SGAs (40.0%) or a combination of SGAs and FGAs (12.5%) than FGAs (19.2%) (p = .019) in their suicides.

CONCLUSION

The use of SGAs in suicides is becoming increasingly common, which calls for further studies.

Breast Cancer Mortality After Implementation of Organized Population-Based Breast Cancer Screening in Norway

BACKGROUND

We estimated breast cancer (BC) mortality reduction associated with invitations to a nationwide population-based screening program and with changes in treatment.

MATERIALS AND METHODS

BreastScreen Norway started in 1996 and became nationwide in 2005. It invites women aged 50-69 years to biennial mammographic screening. We retrieved individual-level data for 1 340 333 women from national registries. During 1996-2014 (screening window), women contributed person-years in noninvited and invited periods. We created comparable periods for 1977-1995 (prescreening window) by dividing the follow-up time for each woman into pseudo-noninvited and pseudo-invited periods. We estimated BC mortality for the four periods, using the so-called evaluation model: counting BC deaths in each period for all women diagnosed within the period and counting BC deaths and person-years after screening-age for those diagnosed within screening age. We used a multivariable flexible parametric survival model to estimate hazard ratio (HR) for the effect of invitation and improved treatment.

RESULTS

Using the regression approach, we found 5818 BC deaths across 16 533 281 person-years. Invitations to screening reduced BC mortality by 20% (HR = 0.80, 95% confidence interval [CI] = 0.70 to 0.91) among women 50 years and older and by 25% (HR = 0.75, 95% CI = 0.65 to 0.86) among screening-aged women. The treatment effect was 23% (HR = 0.77, 95% CI = 0.65 to 0.92) for women 50 years and older and 17% (HR = 0.83, 95% CI = 0.74 to 0.94) for screening-aged women.

CONCLUSION

We observed a similar reduction in BC mortality associated with invitations to screening and improvements in treatment during 1977-2014, among women 50 years and older.

Is birth out-of-hospital associated with mortality and morbidity by seven years of age?

Background and aims

Compared to in-hospital births, the long-term outcome of children born out-of-hospital, planned or unplanned, is poorly studied. This study aimed to examine mortality and morbidity by seven years of age in children born out-of-hospital compared to those born in-hospital.

Methods

This study was registered retrospectively and included 790 136 children born in Finland between 1996 and 2013. The study population was divided into three groups according to birth site: in-hospital (n = 788 622), planned out-of-hospital (n = 176), and unplanned out-of-hospital (n = 1338). Data regarding deaths, hospital visits, reimbursement of medical expenses, and disability allowances was collected up to seven years of age or by the year-end of 2018. The association between birth site and childhood morbidity was determined using multivariable-adjusted Cox hazard regression analysis.

Results

No deaths were reported during the first seven years after birth in the children born out-of-hospital. The percentage of children with hospital visits due to infection by seven years of age was lower in those born planned out-of-hospital and in the combined planned out-of-hospital and unplanned out-of-hospital group compared to those born in-hospital. Furthermore, the percentage of children with hospital visits and who received disability allowances due to neurological or mental disorders was higher among those born unplanned out-of-hospital and out-of-hospital in total when compared to those born in-hospital. In the multivariable-adjusted Cox proportional hazard regression analysis, the hazard ratio for hospital visits due to asthma and/or allergic diseases (HR 0.84; 95% CI 0.72–0.98) was lower in children born out-of-hospital when compared to those born in-hospital. A similar decreased risk was found due to infections (HR 0.76; 95% CI 0.68–0.84). However, the risk for neurological or mental health disorders was similar between the children born in-hospital and out-of-hospital.

Conclusions

Morbidity related to asthma or allergic diseases and infections by seven years of age appeared to be lower in children born out-of-hospital. Birth out-of-hospital seemed to not be associated with increased risk for neurological morbidity nor early childhood mortality. Our study groups were small and heterogeneous and because of this the results need to be interpreted with caution.

Obesity is associated with early hip fracture risk in postmenopausal women: a 25-year follow-up

Association of body mass index and hip fracture has been controversial. In this study, women with lowest and highest body weight had the highest fracture incidence. A 25-year follow-up indicated that obesity associates with early hip fracture risk and suggested increasing trend in normal-weight women at a later stage.

INTRODUCTION

Obesity is a pandemic health issue. Its association with hip fracture risk remains controversial. We studied the long-term relationship of body mass index and hip fracture incidence in postmenopausal women.

METHODS

The cohort of 12,715 Finnish women born in 1932-1941 was followed for 25 years, covering ages from 58 up to 83. Fractures and deaths were obtained from national registries. Women were investigated in deciles of BMI as well as in WHO weight categories (normal, overweight, or obese). The follow-up analysis was carried out in two age strata as "early" (58-70 years) and "late" (> 70 years). Body weight information was updated accordingly. Femoral neck BMD was recorded for a subsample (n = 3163). Altogether, 427 hip fractures were observed.

RESULTS

A higher risk of early hip fracture was observed in obese and normal-weight compared with overweight women with hazard ratios (HRs) of 2.3 ((95% CI) 1.4-3.7) and 2.0 (1.3-3.1) while no difference was observed in late hip fracture risk between the three WHO categories (log rank p = 0.14). All-cause mortality during the follow-up was 19.3%. Compared with normal weight women, the obese women had a higher risk of death with an HR of 1.6 (1.4-1.8) and higher baseline BMD (p < 0.001). Faster bone loss was observed in the obese compared with other women (p < 0.001).

CONCLUSION

Obesity associates with earlier hip fracture and higher postfracture mortality. The obese women with low BMD have clearly the highest risk of hip fracture. This combination increases hip fracture risk more than either of the factors alone. After 75 years of age, risk appears to increase more in normal weight women, but this trend is in need of further confirmation.

Causes of death for intensive care survivors with and without acute kidney injury in 5-year follow-up

BACKGROUND

Data on the causes of death and long-term mortality of intensive care unit-treated hospital survivors with acute kidney injury (AKI) are limited. The goal of this study was to analyze the causes of death among critically ill patients during a 5-year follow-up.

METHODS

In this predetermined sub-study of a prospective, observational, multi-center cohort from the FINNAKI study, we analyzed 2436 patients who were discharged from the hospital. Statistics Finland provided the follow-up data and causes of death.

RESULTS

During the follow-up, 765 (31%) patients died, of whom 295 (39%) had AKI and 73 (9.5%) had received renal replacement therapy. More than half of the deaths in both the non-AKI and AKI groups occurred after the 1 year follow-up (58% vs. 54%, respectively). The three most common causes of death in AKI were cardiovascular diseases (36%), malignancies (21%), and neurological diseases (11%). In early deaths (<90 days) cardiovascular causes were more prevalent in AKI patients compared to non-AKI (38% vs 25%, P = .037.) In six cases (0.8%), the main cause of death was kidney disease, out of which five were in the AKI group. In patients with cardiovascular causes, the median time to death was shorter in AKI patients compared to non-AKI patients (508 vs 816 days, P = .018).

CONCLUSION

Cardiovascular causes and malignancies account for more than half of the causes of death in patients who had suffered AKI, while death from kidney disease after AKI is rare. Early cardiovascular deaths are more prevalent in AKI compared to non-AKI patients.

Survival after antireflux surgery versus medication in patients with reflux oesophagitis or Barrett's oesophagus: multinational cohort study

BACKGROUND

The aim was to examine the hypothesis that antireflux surgery with fundoplication improves long-term survival compared with antireflux medication in patients with reflux oesophagitis or Barrett's oesophagus.

METHOD

Individuals aged between 18 and 70 years with reflux oesophagitis or Barrett's oesophagus (intestinal metaplasia) documented from in-hospital and specialized outpatient care were selected from national patient registries in Denmark, Finland, Iceland, and Sweden from 1980 to 2014. The study investigated all-cause mortality and disease-specific mortality, comparing patients who had undergone open or laparoscopic antireflux surgery with fundoplication versus those using antireflux medication. Multivariable Cox regression analysis was used to estimate hazard ratios (HRs) with 95 per cent confidence intervals for all-cause mortality and disease-specific mortality, adjusted for sex, age, calendar period, country, and co-morbidity.

RESULTS

Some 240 226 patients with reflux oesophagitis or Barrett's oesophagus were included, of whom 33 904 (14.1 per cent) underwent antireflux surgery. The risk of all-cause mortality was lower after antireflux surgery than with use of medication (HR 0.61, 95 per cent c.i. 0.58 to 0.63), and lower after laparoscopic (HR 0.56, 0.52 to 0.60) than open (HR 0.80, 0.70 to 0.91) surgery. After antireflux surgery, mortality was decreased from cardiovascular disease (HR 0.58, 0.55 to 0.61), respiratory disease (HR 0.62, 0.57 to 0.66), laryngeal or pharyngeal cancer (HR 0.35, 0.19 to 0.65), and lung cancer (HR 0.67, 0.58 to 0.80), but not from oesophageal cancer (HR 1.05, 0.87 to 1.28), compared with medication, The decreased mortality rates generally remained over time.

CONCLUSION

In patients with reflux oesophagitis or Barrett's oesophagus, antireflux surgery is associated with lower mortality from all causes, cardiovascular disease, respiratory disease, laryngeal or pharyngeal cancer, and lung cancer, but not from oesophageal cancer, compared with antireflux medication.

Mortality Among Young Adults Born Preterm and Early Term in 4 Nordic Nations

IMPORTANCE

Adverse long-term outcomes in individuals born before full gestation are not confined to individuals born at extreme gestational ages. Little is known regarding mortality patterns among individuals born in the weeks close to ideal gestation, and the exact causes are not well understood; both of these are crucial for public health, with the potential for modification of risk.

OBJECTIVE

To examine the risk of all-cause and noncommunicable diseases (NCD) deaths among young adults born preterm and early term.

DESIGN, SETTING, AND PARTICIPANTS

This multinational population-based cohort study used nationwide birth cohorts from Norway, Sweden, Denmark, and Finland for individuals born between 1967 and 2002. Individuals identified at birth who had not died or emigrated were followed up for mortality from age 15 years to 2017. Analyses were performed from June 2019 to May 2020.

EXPOSURES

Categories of gestational age (ie, moderate preterm birth and earlier [23-33 weeks], late preterm [34-36 weeks], early term [37-38 weeks], full term [39-41 weeks] and post term [42-44 weeks]).

MAIN OUTCOMES AND MEASURES

All-cause mortality and cause-specific mortality from NCD, defined as cancer, diabetes, chronic lung disease, and cardiovascular disease (CVD).

RESULTS

A total of 6 263 286 individuals were followed up for mortality from age 15 years. Overall, 339 403 (5.4%) were born preterm, and 3 049 100 (48.7%) were women. Compared with full-term birth, the adjusted hazard ratios (aHRs) for all-cause mortality were 1.44 (95% CI, 1.34-1.55) for moderate preterm birth and earlier; 1.23 (95% CI, 1.18-1.29) for late preterm birth; and 1.12 (95% CI, 1.09-1.15) for early-term birth. The association between gestational age and all-cause mortality were stronger in women than in men (P for interaction = .03). Preterm birth was associated with 2-fold increased risks of death from CVD (aHR, 1.89; 95% CI, 1.45-2.47), diabetes (aHR, 1.98; 95% CI, 1.44-2.73), and chronic lung disease (aHR, 2.28; 95% CI, 1.36-3.82). The main associations were replicated across countries and could not be explained by familial or individual confounding factors.

CONCLUSIONS AND RELEVANCE

The findings of this study strengthen the evidence of increased risk of death from NCDs in young adults born preterm. Importantly, the increased death risk was found across gestational ages up to the ideal term date and includes the much larger group with early-term birth. Excess mortality associated with shorter gestational age was most pronounced for CVDs, chronic lung disease, and diabetes.

Using simulation mannequins and actors in training for external post-mortem examinations -experiences from use in medical students and police officers

In the daily practice of external post-mortem examinations and dealing with surviving dependents, striking failures can be observed regularly, pointing to an increased demand for training of the various professional groups involved. In this study, the experience gained from using simulation mannequins and actors for post-mortem examination training in medical students and police officers are presented. Since 2017, a training station has been offered at the Medical Faculty of the Technical University of Dresden (Germany) for practicing examinations in death scene and establishing communication with grieving relatives. It is conducted in small groups of up to 5 people, both for medical students and for police officers and police recruits. These courses are evaluated by means of questionnaires including 3 and 11 items respectively for the different groups. The questionnaires have been completed by 679 medical students and 67 police participants. Both groups of participants evaluated their previous experience as average. They assessed the course as having a high degree of practical and professional relevance. The didactic transfer of the teaching contents and its competent support were rated remarkably positive by the participants. Additionally, the police group reported high rates of approval for the use of feedback, the learning effect, and the appropriateness of the group size. The establishment and continuation of the simulation-based external post-mortem examination in the form of small-group teaching is associated with a considerable expenditure of equipment, material and personnel. In addition, its implementation requires sound cooperation structures. On the other hand, introduction and continuation of these types of additional teaching and learning methods, with a large practical component, can increase confidence in daily practice, and thus improve the quality of external post-mortem examination. Ultimately, this can also improve the cooperation between forensic medicine and the investigating authorities.

Feasibility and validity of using death surveillance data and SmartVA for fact and cause of death in clinical trials in rural China: a substudy of the China salt substitute and stroke study (SSaSS)

BACKGROUND

In rural China, mortality surveillance data may be an alternative to primary data collection in clinical trials; SmartVA (verbal autopsy) is also a potential alternative for endpoint adjudication. The feasibility and validity of both need to be assessed.

METHODS

We used mortality data from the first 24 months of the China Salt Substitute and Stroke Study (SSaSS) trial and assessed the agreement between (1) mortality surveillance data and face-to-face visits for fact of death; (2) mortality surveillance data and SSaSS adjudication for causes of death; (3) SmartVA and SSaSS adjudication for causes of death; (4) cause-specific mortality fraction of different methods. Face-to-face visits and SSaSS adjudication were taken as reference methods. The agreement was measured by sensitivity, specificity and positive predictive value (PPV) across different 10th Revision of International Statistical Classification of Diseases chapters.

RESULTS

One thousand three hundred and sixty-five deaths were included. Mortality surveillance data had 82% sensitivity for fact of death and 81% sensitivity for causes of death, with substantial variances across different disease types and reasonable quality for circulatory death (91% sensitivity and 94% PPV). The sensitivity of SmartVA for causes of death was 61%, with reasonable quality for deaths of external causes of morbidity (90% sensitivity). The leading causes of death from different sources were the same with some variances in the fractions.

CONCLUSION

Using mortality surveillance data for fact of death in clinical trials need to account for under-reporting. A face-to-face visit to all participants at the completion of trials may be warranted. Neither mortality surveillance data nor SmartVA provided valid data source for endpoint events.

Long-term survival following elective colon cancer surgery in the aged. A population-based cohort study

AIM

The number of colorectal cancer patients increases with age. Long-term data support personalized management due to heterogeneity within the older population. This registry- and population-based study aimed to analyse long-term survival, and causes of death, after elective colon cancer surgery in the aged, focusing on patients who survived more than 3 months postoperatively.

METHODS

The data included patients ≥ 80 years who had elective surgery for Stage I-III colon cancer in four Finnish centres. The prospectively collected data included comorbidities, functional status, postoperative outcomes and long-term survival. Univariate and multivariate Cox regression analysis were conducted to determine factors associated with long-term survival.

RESULTS

A total of 386 surgical patients were included, of whom 357 survived over 3 months. Survival rates for all patients at 1, 3 and 5 years were 85%, 66% and 55%, compared to 92%, 71% and 59% for patients alive 3 months postoperatively, respectively. Higher age, American Society of Anesthesiologists (ASA) score ≥ 4, Charlson Comorbidity Index ≥ 6, tumour Stage III, open compared to laparoscopic surgery and severe postoperative complications were independently associated with reduced overall survival. Higher age (hazard ratio 1.97, 1.14-3.40), diabetes (1.56, 1.07-2.27), ASA score ≥ 4 (3.27, 1.53-6.99) and tumour Stage III (2.04, 1.48-2.81) were the patient-related variables affecting survival amongst those surviving more than 3 months postoperatively. Median survival time for patients given adjuvant chemotherapy was 5.4 years, compared to 3.3 years for patients not given postoperative treatment.

CONCLUSIONS

Fit aged colon cancer patients can achieve good long-term outcomes and survival with radical, minimally invasive surgical treatment, even with additional chemotherapy.

Survival after breast cancer in women with type 2 diabetes using antidiabetic medication and statins: a retrospective cohort study

Background: We assessed survival of breast cancer in women with type 2 diabetes (T2D) treated with metformin, other types of antidiabetic medication (ADM) and statins.Materials and Methods: The study cohort consisted of women with T2D and diagnosed with breast cancer in Finland in 1998─2011. Mortality rates from breast cancer and other causes were analysed by Cox models, and adjusted hazard ratios (HRs) with 95% confidence intervals (Cls) were estimated in relation to the use of different types of medication.Results: The final cohort consisted of 3,533 women. No clear evidence was found for breast cancer mortality being different in metformin users (HR 0.86, 95% Cl 0.63-1.17), but their other-cause mortality appeared to be lower (HR 0.73, 95% Cl 0.55-0.97) in comparison with women using other types of oral ADM. Other-cause mortality was higher among insulin users (HR 1.45, 95% Cl 1.16-1.80) compared with users of other oral ADMs, other than metformin. Prediagnostic statin use was observed to be associated with decreased mortality from both breast cancer (HR 0.76, 95% Cl 0.63-0.92) and other causes (HR 0.75, 95% Cl 0.64-0.87).Conclusions: We did not find any association between ADM use and disease-specific mortality among women with T2D diagnosed with breast cancer. However, interestingly, prediagnostic statin use was observed to predict reduced mortality from breast cancer and other causes. We hypothesise that treating treatment practices of T2D or hypercholesterolaemia of breast cancer patients might affect overall prognosis of women diagnosed with breast cancer and T2D.

Risk Factors for Suicide After Bariatric Surgery in a Population-based Nationwide Study in Five Nordic Countries

OBJECTIVE

To identify risk factors for suicide after bariatric surgery.

SUMMARY BACKGROUND DATA

Bariatric surgery reduces obesity-related mortality. However, it is for unclear reasons is associated with an increased risk of suicide.

METHODS

This population-based cohort study included patients having undergone bariatric surgery in 1982 to 2012 in any of the 5 Nordic countries, with follow-up through 2012. Eleven potential risk factors of suicide (sex, age, comorbidity, surgery type, surgical approach, calendar year of surgery, history of depression or anxiety, psychosis, schizophrenia, mania, or bipolar disorder, personality disorder, substance use, and number of previously documented psychiatric diagnoses) were analyzed using Cox regression.

RESULTS

Of 49,977 bariatric surgery patients, 98 (0.2%) committed suicide during follow-up. Women had a decreased risk of suicide compared to men (hazard ratio [HR] = 0.48, 95% confidence interval [CI] 0.33-0.77), although age and comorbidity did not influence this risk. Compared to gastric bypass, other types of bariatric surgery had lower risk of suicide (HR = 0.44, 95%CI 0.27-0.99). There was no difference in suicide risk between laparoscopic and open surgical approach. A history of depression or anxiety (HR = 6.87, 95%CI 3.97-11.90); mania, bipolar disorder, psychosis, or schizophrenia (HR = 2.70, 95%CI 1.14-6.37); and substance use (HR = 2.28, 95%CI 1.08-4.80), increased the risk of suicide. More of the above psychiatric diagnoses increased the risk of suicide (HR = 22.59, 95%CI 12.96-39.38 for ≥2 compared to 0 diagnoses).

CONCLUSIONS

Although the risk of suicide is low, psychiatric disorders, male sex, and gastric bypass procedure seem to increase the risk of suicide after bariatric surgery, indicating a role for tailored preoperative psychiatric evaluation and postoperative surveillance.

Trends and predictors in all-cause and cause-specific mortality in diabetic and reference populations during 21 years of follow-up

BACKGROUND

Patients with diabetes mellitus (DM) have a markedly higher overall mortality from coronary heart disease (CHD), as well as many other causes of death like cancer. Since diabetes is a multisystem disease, this fact together with the increased lifespan among individuals with diabetes may also lead to the emergence of other diabetes-related complications and ultimately to diversification of the causes of death.

METHODS

The study population of this observational historic cohort study consisted of subjects with DM, who had purchased for at least one insulin prescription and/or one oral antidiabetic between January 1, 1997 and December 31, 2010 (N=199 354), and a reference population matched by age, sex and hospital district (N=199 354). Follow-up was continued until December 31, 2017. All-cause and cause-specific mortality (cancer, CHD and stroke) was analysed with Poisson and Cox's regression. Associations between baseline medications and mortality were analysed using LASSO (Least Absolute Shrinkage and Selection Operator) models.

RESULTS

The mortality rates were significantly elevated among the patients with DM. However, the relative risk of all-cause mortality between the DM and reference populations tended to converge during the follow-up. The lowering trend was most apparent in CHD mortality. The difference between DM and reference populations in stroke mortality vanished with a later entrance to the follow-up period. There were a few differences between DM and no-DM groups with respect to how baseline medications were associated with mortality.

CONCLUSIONS

The gap between the mortality of patients with diabetes compared to subjects who are non-diabetic diminished markedly during the 21-year period. This was driven primarily by the reduced CHD mortality.

Patients With APECED Have Increased Early Mortality Due to Endocrine Causes, Malignancies and infections

CONTEXT

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is an autoimmune endocrinopathy with severe and unpredictable course. The impact of APECED on mortality has not been determined.

OBJECTIVE

To assess overall and cause-specific mortality of patients with APECED.

DESIGN AND SETTING

A follow-up study of Finnish patients with APECED from 1971 to 2018. Causes and dates of death were collected from Finnish registries.

PATIENTS

Ninety-one patients with APECED.

MAIN OUTCOME MEASURE

Overall and cause-specific standardized mortality ratios (SMRs) determined by comparing the observed numbers of death and those expected on the basis of respective population death rates in Finland.

RESULTS

The overall disease mortality was significantly increased (29 deaths, SMR 11; 95% confidence interval [CI] 7.2-16; P < 0.001). The relative risk (SMR) was highest in the youngest age groups but the absolute excess risk was similar (about 10 per 10 000 person-years) in all age categories. The highest SMRs were seen for endocrine and metabolic diseases (SMR 570; 95% CI, 270-1000; P < 0.001) and for oral and esophageal malignancies (SMR 170; 95% CI, 68-360; P < 0.001). Mortality was also increased for infections, diseases of digestive system, alcohol-related deaths, and for accidents. Due to the small number of cases we were unable to evaluate whether mortality was affected by disease severity.

CONCLUSIONS

Patients with APECED have significantly increased mortality in all age groups. Highest SMRs are found for causes that are directly related to APECED but also for infections. Increased alcohol- and accident-related deaths may be influenced by psychosocial factors.

Antiepileptic drug use and mortality among community-dwelling persons with Alzheimer disease

OBJECTIVE

To evaluate the risk of death in relation to incident antiepileptic drug (AED) use compared with nonuse in people with Alzheimer disease (AD) through the assessment in terms of duration of use, specific drugs, and main causes of death.

METHODS

The MEDALZ (Medication Use and Alzheimer Disease) cohort study includes all Finnish persons who received a clinically verified AD diagnosis (n = 70,718) in 2005-2011. Incident AED users were identified with 1-year washout period. For each incident AED user (n = 5,638), 1 nonuser was matched according to sex, age, and time since AD diagnosis. Analyses were conducted with Cox proportional regression models and inverse probability of treatment weighting (IPTW).

RESULTS

Nearly 50% discontinued AEDs within 6 months. Compared with nonusers, AED users had an increased relative risk of death (IPTW hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.12-1.36). This was mainly due to deaths from dementia (IPTW HR, 1.62; 95% CI, 1.42-1.86). There was no difference in cardiovascular and cerebrovascular deaths (IPTW HR, 0.98; 95% CI, 0.67-1.44). The overall mortality was highest during the first 90 days of AED use (IPTW HR, 2.40; 95% CI, 1.91-3.03). Among users of older AEDs, relative risk of death was greater compared to users of newer AEDs (IPTW HR, 1.79; 95% CI, 1.52-2.16).

CONCLUSION

In older vulnerable patients with a cognitive disorder, careful consideration of AED initiation and close adverse events monitoring are needed.

Rethinking morbidity compression

Studies of morbidity compression routinely report the average number of years spent in an unhealthy state but do not report variation in age at morbidity onset. Variation was highlighted by Fries (1980) as crucial for identifying disease postponement. Using incidence of first hospitalization after age 60, as one working example, we estimate variation in morbidity onset over a 27-year period in Denmark. Annual estimates of first hospitalization and the population at risk for 1987 to 2014 were identified using population-based registers. Sex-specific life tables were constructed, and the average age, the threshold age, and the coefficient of variation in age at first hospitalization were calculated. On average, first admissions lasting two or more days shifted towards older ages between 1987 and 2014. The average age at hospitalization increased from 67.8 years (95% CI 67.7-67.9) to 69.5 years (95% CI 69.4-69.6) in men, and 69.1 (95% CI 69.1-69.2) to 70.5 years (95% CI 70.4-70.6) in women. Variation in age at first admission increased slightly as the coefficient of variation increased from 9.1 (95% CI 9.0-9.1) to 9.9% (95% CI 9.8-10.0) among men, and from 10.3% (95% CI 10.2-10.4) to 10.6% (95% CI 10.5-10.6) among women. Our results suggest populations are ageing with better health today than in the past, but experience increasing diversity in healthy ageing. Pensions, social care, and health services will have to adapt to increasingly heterogeneous ageing populations, a phenomenon that average measures of morbidity do not capture.

Hospital-treated physical illnesses and mortality: An 11-year follow-up study of long-stay psychiatric patients

Under-recognitions of somatic illnesses have frequently been suggested to explain the well-known increased risks of mortality in long-stay psychiatric patients. There are, however, no studies, in which register information on realized somatic hospitalisations and mortality from somatic illnesses in psychiatric patients are actually linked and simultaneously evaluated. In this study, 208 long-stay psychiatric patients, suffering from functional psychoses (mainly schizophrenia) in Northern Finland were followed up for 11 years, and screened for all somatic hospitalisations and subsequent causes of death. 86.5% of the patients had undergone hospital treatment due to some physical illness after their first psychiatric admission. During specialized psychiatric care the majority of the deceased patients had received some somatic treatment for illnesses that ultimately caused their deaths: 81% representing circulatory, 71% digestive, 56% neoplastic, and 36% respiratory ailments. We found no evidence for the frequently expressed view that somatic illnesses in psychiatric patients were under-recognized. Thus, the widely-documented poor physical outcome of long-stay psychiatric patients may be not attributable to neglect of care or abandon, but to difficulties in efficaciously addressing medical conditions in a population characterised by unhealthy life-style habits, psychiatric disability and isolation. The health care systems apparently offer a range of services, but the latter do not always reach the patients. Why this is so requires detailed further investigation.