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Should euthanasia be legal? An international survey of neonatal intensive care units staff.

OBJECTIVE: To present the views of a representative sample of neonatal doctors and nurses in 10 European countries on the moral acceptability of active euthanasia and its legal regulation. DESIGN: A total of 142 neonatal intensive care units were recruited by census (in the Netherlands, Sweden, Hungary, and the Baltic countries) or random sampling (in France, Germany, Italy, Spain, and the United Kingdom); 1391 doctors and 3410 nurses completed an anonymous questionnaire (response rates 89% and 86% respectively). MAIN OUTCOME MEASURE: The staff opinion that the law in their country should be changed to allow active euthanasia "more than now". RESULTS: Active euthanasia appeared to be both acceptable and practiced in the Netherlands, France, and to a lesser extent Lithuania, and less acceptable in Sweden, Hungary, Italy, and Spain. More then half (53%) of the doctors in the Netherlands, but only a quarter (24%) in France felt that the law should be changed to allow active euthanasia "more than now". For 40% of French doctors, end of life issues should not be regulated by law. Being male, regular involvement in research, less than six years professional experience, and having ever participated in a decision of active euthanasia were positively associated with an opinion favouring relaxation of legal constraints. Having had children, religiousness, and believing in the absolute value of human life showed a negative association. Nurses were slightly more likely to consider active euthanasia acceptable in selected circumstances, and to feel that the law should be changed to allow it more than now. CONCLUSIONS: Opinions of health professionals vary widely between countries, and, even where neonatal euthanasia is already practiced, do not uniformly support its legalisation.

Adult↗

Association between minihaplotypes and mutations at the PAH locus in Polish hyperphenylalaninemic patients.

Hereditary hyperphenylalaninemia (HPA) is a disorder of amino acid metabolism and results from an insufficiency of hepatic phenylalanine hydroxylase (PAH). HPA phenotypes form a spectrum ranging from classical phenylketonuria (PKU) to mild hyperphenylalaninemia (MHP). The phenotypic diversity reflects heterogeneity at the molecular level, and more than 320 different mutations in the PAH gene are known to date. The association of 3 mutations (R408W, IVS10 and A403V) common in different European populations with a variable number tandem repeat (VNTR) and short tandem repeat sites (minihaplotype) in the PAH gene was examined in a group of Polish PKU and MHP patients. Additionally, minihaplotypes were established for another 16 mutations. The presented data support the hypothesis that the R408W/VNTR3/STR238 allele originated among pre-Indo-Europeans on the territory in present-day Lithuania and Belarus. Mutation IVS10nt-11g-->a (IVS10) is strongly associated with VNTR7/STR250 minihaplotype and is possibly of Mediterranean origin.

Haplotypes↗

Prospective study of the effect of post-brushing rinsing behaviour on dental caries.

Previous studies have indicated that rinsing the mouth with a beaker of water after toothbrushing may compromise the caries reducing effect of fluoride toothpaste. A 3-year clinical trial of daily supervised brushing with fluoride toothpaste at school was used to test the effect of post-brushing rinsing with water on caries increment. A total of 407 children, mean age 11.8 years, attending three schools in Kaunas, Lithuania were enrolled following informed consent of the children and their parents. Caries was recorded at baseline and annually for 3 years. During the study, children in two schools (A and B) performed daily supervised brushing with a 1,500-ppm fluoride toothpaste. Children in school A rinsed their mouths thoroughly with a beaker of water after toothbrushing whereas children in school B were only permitted to spit out once after brushing. Furthermore, the children in these schools were supplied with toothpaste and toothbrushes for use at home and in school. A third school (C), without daily brushing and without supply of toothpaste, served as control. Compliance with the protocol was consistently better in school B. After 3 years 276 children were available for examination. Three-year DMFS increments, including non-cavitated lesions (mean, 95% CI), were: school A, 6.8 (5.3; 8.3); school B, 6.2 (4.6; 7.8), and school C, 12.4 (10.6; 14.1). Mean increments for schools A and B did not differ significantly but were both significantly lower than those of school C (p< 0.001). It is concluded that post-brushing rinsing with water, under the conditions of this study, does not significantly affect the caries reducing effect of a fluoride toothpaste.

Analysis of Variance↗

Endocervical pathogens in women with preterm and term labour.

The purpose of this study was to compare the endocervical microflora of women in preterm and term labour and to determine whether the presence of a specific microflora is significantly associated with preterm labor. A prospective study was performed in Lithuania among 212 women in preterm labour (latent phase, n = 110; active phase, n = 102) and among 62 healthy women in term labour. Microbiological assessment included cultures for aerobic bacteria, yeasts, and Trichomonas vaginalis and direct immunofluorescence reaction for Chlamydia trachomatis, Escherichia coli (odds ratio 8.16; 95% confidence interval 1.27-340.23) and Staphylococcus aureus (odds ratio 7.79; 95% confidence interval 1.21-325.40) were significantly more often isolated from women in preterm than from women in term labour. The prevalence of C. trachomatis was the same in the preterm and in the term labour group. The pregnancy outcome during the latent or active phase of preterm labour with or without C. trachomatis infection did not differ. It is concluded that E. coli and S. aureus are significantly more prevalent in endocervical cultures from Lithuanian women in preterm than from those in term labour.

Adult↗

A Pst+ polymorphism in the HEXA gene with an unusual geographic distribution.

A polymorphic variant in the human HEXA gene is described. This gene encodes the alpha-subunit of hexosaminidase A, the enzyme which is deficient in Tay-Sachs disease (TSD). In individuals carrying the polymorphism there is a T-->C transition at position -6 in intron 13. The substitution creates a site for the restriction endonuclease Pst1. This variant has an unusual ethnogeographic distribution. It occurs on 1.4% of non-TSD carrier chromosomes in Ashkenazi Jews. All individuals ascertained carrying the Pst+ allele have ancestry in Lithuania, Belarus and Ukraine. By contrast, no individuals carrying the Pst+ allele have been detected among non-Jewish Lithuanians, Jews of Sephardic origin or in several other ethnic groups. Two unrelated non-Jewish families have been identified in which the Pst+ variant occurs. In both cases the variant occurs on a chromosome carrying a novel TSD mutation (G772C) association with the B1 phenotype. The Pst+ G772C chromosomes are of Scots-Irish descent.

Alleles↗

Stroke incidence and mortality correlated to stroke risk factors in the WHO MONICA Project. An ecological study of 18 populations.

BACKGROUND: The aim of the present study was to determine the extent to which the variation in conventional risk factors contributed to the variation in stroke incidence among these populations. METHODS: Within the WHO MONICA Project, stroke has been recorded in 18 populations in 11 countries. In population surveys, risk factors for cardiovascular diseases have been examined in the age group 35 to 64 years. Over a 3-year period, 12,224 acute strokes were registered in men and women within the same age range. RESULTS: The highest stroke attack rates were found in Novosibirsk in Siberia, Russia, and Finland, with a more than three-fold higher incidence than in Friuli, Italy. The mean diastolic blood pressure among the populations differed by 15 mm Hg between Novosibirsk (highest) and Denmark (lowest). In multiple regression analyses, the presence of conventional cardiovascular risk factors (smoking and elevated blood pressure) explained 21% of the variation in stroke incidence among the population in men and 42% in women. In Finland, in China, and in men in Lithuania, the stroke incidence rates were higher than expected from the population risk factor levels. CONCLUSION: Prevalence of smoking and elevated blood pressure explain a substantial proportion of the variation of stroke attack rates between populations. However, other risk factors for stroke that were not measured in the present study also contribute considerably to interpopulation differences in stroke rates.

Adult↗

ECVAM'S activities in the EU candidate countries.

ECVAM has been given a special grant for collaborative projects on alternative/advanced testing methods involving eleven Candidate Countries for membership of the European Union (Bulgaria, Cyprus, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Slovakia and Slovenia). The project involves the promotion of the Three Rs (reduction, refinement, replacement) concept of Russell & Burch, in cooperation with appropriate individuals and national and international organisations in the Candidate Countries themselves, and elsewhere. The scope of the programme's activities covers: conferences in some of the Candidate Countries, workshops, training courses, training visits, and technology development/transfer initiatives. A database of contacts in the Candidate Countries and in relevant institutions in other countries, is being compiled.

Animal Testing Alternatives↗

Estimated numbers and prevalence of PI*S and PI*Z alleles of alpha1-antitrypsin deficiency in European countries.

The current study focuses on developing estimates of the numbers of individuals carrying the two most common deficiency alleles, PI*S and PI*Z, for alpha1-antitrypsin deficiency (AT-D) in Europe. Criteria for selection of epidemiological studies were: 1) AT phenotyping performed by isoelectrofocusing or antigen-antibody crossed electrophoresis; 2) rejection of "screening studies"; 3) statistical precision factor score of > or = 5 for Southwest, Western and Northern Europe, > or = 4 for Central Europe, > or = 3 for Eastern Europe; and 4) samples representative of the general population. A total of 75,390 individuals were selected from 21 European countries (one each from Austria, Belgium, Latvia, Hungary, Serbia-Montenegro, Sweden and Switzerland; two each from Denmark, Estonia and Lithuania; three each from Portugal and the UK; four each from Finland, The Netherlands, Norway and Spain; five each from Russia and Germany; six from Poland; eight from Italy; and nine from France). The total AT-D populations of a particular phenotype in the countries selected were: 124,594 ZZ; 560,515 SZ; 16,323,226 MZ; 630,401 SS; and 36,716,819 MS. The largest number of ZZ (5,000-15,000) were in Italy, Spain, Germany, France, the UK, Latvia, Sweden and Denmark, followed by Belgium, Portugal, Serbia-Montenegro, Russia, The Netherlands, Norway and Austria (1,000-2,000), with < 1,000 in each of the remaining countries. A remarkable lack in number of reliable epidemiological studies and marked differences among these European countries and regions within a given country was also found.

Alleles↗

Determinants of cardiovascular disease and other non-communicable diseases in Central and Eastern Europe: rationale and design of the HAPIEE study.

BACKGROUND: Over the last five decades, a wide gap in mortality opened between western and eastern Europe; this gap increased further after the dramatic fluctuations in mortality in the former Soviet Union (FSU) in the 1990s. Recent rapid increases in mortality among lower socioeconomic groups in eastern Europe suggests that socioeconomic factors are powerful determinants of mortality in these populations but the more proximal factors linking the social conditions with health remain unclear. The HAPIEE (Health, Alcohol and Psychosocial factors In Eastern Europe) study is a prospective cohort study designed to investigate the effect of classical and non-conventional risk factors and social and psychosocial factors on cardiovascular and other non-communicable diseases in eastern Europe and the FSU. The main hypotheses of the HAPIEE study relate to the role of alcohol, nutrition and psychosocial factors. METHODS AND DESIGN: The HAPIEE study comprises four cohorts in Russia, Poland, the Czech Republic and Lithuania; each consists of a random sample of men and women aged 45-69 years old at baseline, stratified by gender and 5 year age groups, and selected from population registers. The total planned sample size is 36,500 individuals. Baseline information from the Czech Republic, Russia and Poland was collected in 2002-2005 and includes data on health, lifestyle, diet (food frequency), socioeconomic circumstances and psychosocial factors. A short examination included measurement of anthropometric parameters, blood pressure, lung function and cognitive function, and a fasting venous blood sample. Re-examination of the cohorts in 2006-2008 focuses on healthy ageing and economic well-being using face-to-face computer assisted personal interviews. Recruitment of the Lithuanian cohort is ongoing, with baseline and re-examination data being collected simultaneously. All cohorts are being followed up for mortality and non-fatal cardiovascular events. DISCUSSION: The HAPIEE study will provide important new insights into social, behavioural and biological factors influencing mortality and cardiovascular risk in the region.

Aged↗

Good self-rated health is related to psychosocial resources and a strong cortisol response to acute stress: the LiVicordia study of middle-aged men.

Self-rated health (SRH) is a strong predictor for disease and death. The relations among SRH, psychosocial factors, and cortisol dynamics were tested using pooled data from the LiVicordia study of 50-year-old men in Lithuania (n = 94) and Sweden (n = 89), controlling for effect of residence. SRH was assessed by "How would you assess your own health?" A standardized laboratory stress test included measures of cortisol in serum and saliva. Good SRH related to high scale scores of decision latitude, social support at work, coping, self-esteem, and sense of coherence; to low scores of overcommitment (all p < .01) and vital exhaustion (r = -0.40, p < 0.001); to low concentrations of saliva baseline cortisol (r = -.26, p = .001); and to a strong cortisol response to stress (r = .27, p = .001). Findings that good SRH related to favorable psychosocial characteristics and to a dynamic cortisol stress response indicate a possible explanation for observed lower risk for disease and death in this state.

Cross-Sectional Studies↗

Oral moxifloxacin vs high-dosage amoxicillin in the treatment of mild-to-moderate, community-acquired, suspected pneumococcal pneumonia in adults.

STUDY OBJECTIVES: Comparison of the efficacy and safety of moxifloxacin vs amoxicillin for treatment of mild-to-moderate, suspected pneumococcal community-acquired pneumonia (CAP) in adult patients. DESIGN: Multinational, multicenter, double-blind, randomized study. SETTING: Eighty-two centers in 20 countries (Argentina, Brazil, Chile, Croatia, Czech Republic, Estonia, France, Hong Kong, Hungary, Lithuania, Mexico, Portugal, Russia, Slovenia, South Africa, Spain, Turkey, Ukraine, United Kingdom, and Uruguay). PATIENTS: Four hundred eleven adults (inpatients or outpatients) with suspected pneumococcal CAP. INTERVENTIONS: Randomization 1:1 to moxifloxacin, 400 mg/d, or amoxicillin, 1,000 g tid, for 10 days. RESULTS: Primary efficacy parameter was clinical response, 3 to 5 days after therapy (end of therapy [EOT]) in the per protocol (PP) population (362 patients). The clinical success rate in the PP population was 91.5% (moxifloxacin) and 89.7% (amoxicillin; two-sided 95% confidence interval, -4.2 to 7.8%). The clinical cure rate in patients with proven pneumococcal pneumonia was similar in both treatment groups (87.8%). The bacteriologic success rate in 136 bacteriologically evaluable patients at the EOT was 89.7% (moxifloxacin) and 82.4% (amoxicillin). The bacteriologic success rate against Streptococcus pneumoniae was 89.6% (moxifloxacin) and 84.8% (amoxicillin). The frequency of adverse events was comparable in both treatment groups. Digestive symptoms were the most common drug-related adverse events in both treatment groups. CONCLUSIONS: Moxifloxacin was statistically at least as effective as high-dose amoxicillin for treatment of mild-to-moderate, suspected pneumococcal CAP. Moxifloxacin may be an alternative for empiric CAP treatment, especially in areas where multidrug resistance in S pneumoniae is sufficiently prevalent to preclude routine penicillin.

Administration, Oral↗

Obesity and adolescence. A public health concern.

Obesity in adolescence has increased significantly over the past 30-40 years and a recent international comparison study (13 European countries, Israel and the US) showed that the highest prevalence in adolescents was found in the US (12.6% in 13 year old boys, 10.8% in girls; 13.9% in 15 year old boys and 15.1% in 15 year old girls) and the lowest in Lithuania. This increase in adolescence is a public health concern, because most obese adolescents continue their obesity into adulthood with serious risk for chronic disease. Focus should therefore be on prevention programs that increase healthier patterns of lifestyle and physical activity.

Adolescent↗

Correlation of two levels of space proton flux with monthly distribution of deaths from cardiovascular disease and suicide.

In our previous studies /1-3/ we described some significant links between monthly number of deaths due to cardiovascular disease and suicide and space proton flux > 90 MeV. The aims of the present study were to compare the relationship of some solar and geomagnetic parameters with space proton fluxes of > 60 and > 90 MeV; to examine the monthly correlation of these two proton groups with the monthly death distribution in two countries, Israel and Lithuania. Physical data were obtained from the National Geophysical Data Center and the SESC in Boulder, CO; NSSDC in Goddard Space Flight Center, USA, and the Izmiran Institute of the Academy of Sciences in Russia. Pearson correlation coefficients and probabilities were compared for 56-180 consecutive months. Proton flux of > 60 MeV significantly correlated with three of the four studied monthly geomagnetic activity indices (Ap, Am, Dst), but not with such solar activity markers as sunspot number and solar flux (2800 MGH, 10.6 cm). There was no significant relationship between proton flux of > 60 MeV and monthly number of deaths from cardiovascular diseases and suicide, in contrast to the results for > 90 MeV. From the data available during the 36 months (1986-1988), there was no correlation between monthly levels of > 60 to > 90 MeV. In conclusion, a monthly space proton flux of > 60 MeV is not significantly correlated with the monthly death distribution from cardiovascular disease and suicide and some solar activity indices, such as proton flux of > 90 MeV. It is possible that the 60-90 MeV fraction in the > 60 MeV proton flux "blunts" the cosmobiological relationship between proton flux of > 90 MeV and monthly death number.

Cardiovascular Diseases↗

Alcohol culture, family structure and adolescent alcohol use: multilevel modeling of frequency of heavy drinking among 15-16 year old students in 11 European countries.

OBJECTIVE: Frequency of heavy alcohol use among adolescents is examined by family structure and propensity toward heavy alcohol use on the individual level, and by alcohol availability and drinking patterns among adolescents on the societal level. The analysis includes direct effects and moderating effects of societal-level indicators on individual-level associations between family structure and frequency of heavy alcohol use. METHOD: The study drew upon self-reports from 34,001 students in Cyprus, France, Hungary, Iceland, Ireland, Lithuania, Malta, the Slovak Republic, Slovenia, Sweden and the United Kingdom participating in the 1999 European School Survey Project on Alcohol and Other Drugs study. Distinctions were drawn between adolescents living with both parents, a single mother, a single father, a mother and stepfather, a father and stepmother, and neither biological parent. The multilevel analysis estimated the effects of societal-level factors on the intercepts and slopes of individual-level regression models. RESULTS: Adolescents living with both biological parents engaged less frequently in heavy alcohol use than those living in any other arrangements. Living with a single mother was associated with less heavy drinking than living with a single father or with neither biological parent. National beer sales figures and societal patterns of heavy adolescent alcohol use predicted more frequent heavy drinking and greater effects of living in nonintact families. CONCLUSIONS: Adolescent heavy drinking is more common in all types of nonintact families. The adverse effect of living in nonintact families is greater in societies where alcohol availability is greater and where adolescents drink more heavily.

Adolescent↗

[Multiple drug resistance: a threat for tuberculosis control].

Drug-resistant tuberculosis (TB) was reported soon after the introduction of streptomycin, although it did not receive major attention until recently. It was not considered a major issue in the industrialized world until outbreaks of multidrug-resistant TB (MDR-TB) were reported among HIV infected people. Administration of standard short-course chemotherapy (SSCC) with first-line drugs under directly observed therapy (DOT) is the cornerstone of modern TB control. Unfortunately, data available on the treatment outcome of MDR-TB cases under routine programmatic conditions suggest that patients with MDR-TB respond poorly to SSCC with first-line drugs. Since 1994, the World Health Organization and the International Union Against Tuberculosis and Lung Disease (IU-ATLD) have conducted anti-TB drug resistance surveys through a network of subregional laboratories and researchers. Drug resistance was present in almost all settings surveyed, and prevalence varied widely across regions. High prevalence of MDR-TB is widespread in the Russian Federation and areas of the former Soviet Union (Estonia, Kazakhstan, Latvia, and Lithuania) as well as Israel, Liaoning and Henan Provinces in China, and Ecuador. The Global Project has surveyed areas representing over one third of notified TB cases. However, enormous gaps still exist in the most crucial areas. The most effective strategy to prevent the emergence of drug resistance is through implementation of the directly observed treatment short (DOTS) strategy. Effective implementation of the DOTS strategy saves lives through decreased TB transmission, decreased risk of emergence of drug-resistance, and decreased risk for individual TB patients of treatment failure, TB relapse, and death. The World Bank recognizes the DOTS strategy as one of the most cost-effective health interventions, and recommends that effective TB treatment be a part of the essential clinical services package available in primary health care settings. Governments are responsible for ensuring the provision of effective TB control through the DOTS strategy. WHO and its international partners have formed the DOTS-Plus Working Group, which is attempting to determine the best possible strategy to manage MDR-TB. One of the goals of DOTS-Plus is to increase access to expensive second-line anti-TB drugs for WHO-approved TB control programmes in low- and middle-income countries.

Antitubercular Agents↗

Exploring health, safety and environment in central and Eastern Europe: an introduction to the European Centre for Occupational Health, Safety and the Environment (ECOHSE).

This article traces the development of the European Centre for Occupational Health, Safety and the Environment (ECOHSE) at the University of Glasgow. ECOHSE recently has been designated a Thematic Network by the European Union which is providing administrative support through 2004. The de facto de-regulation that accompanied emergent capitalism in Eastern Europe created opportunities for exploitation of the work force. Voluntary efforts of a loose network of occupational and environmental health academics led to a series of yearly conferences to discuss these problems and the lack of research about them. Then, in 1999, a more formal organization was established at Glasgow to pursue continuity and funding. The first occupational and environmental health conference under ECOHSE was held last year in Lithuania, and selected presentations of that meeting are offered in this journal. A second ECOHSE conference will be held this fall in Romania.

Journal Article↗

A multinational comparison of complications assessment in type 1 diabetes: the DiaMond substudy of complications (DiaComp) level 2.

OBJECTIVE: To describe the global geographic variation of micro- and macrovascular complications in childhood-onset type 1 diabetes assessed by both reported and measured disease and risk factors and relate any such variation to diabetes control and health care activities. RESEARCH DESIGN AND METHODS: The DiaComp study is a multinational (17 countries) cross-sectional study of complications in type 1 diabetes and is comprised of two levels (level 1 includes survey only and level 2 includes survey plus examination). This report concerns level 2, representing 12 countries (n = 892). All participants were diagnosed at <15 years of age and had a diabetes duration of 5-24 years when surveyed. All complications were assessed by self-report and for microalbuminuria by Micral II dipstick, neuropathy by the Michigan Neuropathy Screening Instrument exam, and hypertension using the Hypertension Detection and Follow-up Program (HDFP) protocol. HbA(1c) was determined by using the DCA analyzer. RESULTS: A wide variation in neuropathy, reported renal disease/proteinuria, and hypertension among those of short diabetes duration was noted, with central Europe (Romania and Lithuania) standing out for both self-reported renal disease and measured microalbuminuria and for both self-reported and examined neuropathy. The Caribbean (Puerto Rico) also had high rates of microalbuminuria and examined neuropathy. For those of long duration, variation was more moderate. We found generally good agreement between the reported and clinically determined measures for neuropathy (r = 0.5, P = 0.01) and hypertension (r = 0.61, P = 0.001) as demonstrated by the high overall correlation between examination and self-report for these two complications. However, the agreement between examination and self-report for renal disease/proteinuria was less, with low overall correlation (r = -0.05, P = 0.86) and incongruous centers (Slovakia and Finland). Geographic variation in prevalence was not consistently explained for all complications, even with strong independent prediction by systolic blood pressure, although the variation in microalbuminuria was largely accounted for by self-monitored blood glucose, which was significantly protective. CONCLUSIONS: This report has identified wide variation and geographic patterns in complication prevalence, with a further indication that self-report is generally in agreement with examined prevalence, though less for renal disease/proteinuria. However, this level of DiaComp, with more complete assessment of risk factors and health care practice, was still not able to completely explain the variation in complication prevalence, except for microalbuminuria.

Asia↗

Ancestry, genes, and suicide: a test of the Finno-Ugrian Suicide Hypothesis in the United States.

There is now convergent evidence from classic quantitative genetics (family, twin, and adoption studies) and molecular genetic studies for specific genetic risk factors for suicidal behavior. This emerging research field has recently been supplemented by geographical studies concerned with the Finno-Ugrian Suicide Hypothesis (FUSH), which states that population differences in genetic risk factors may partially account for conspicuous geographical patterns seen in suicide prevalence. In particular, the European high-suicide-rate nations constitute a contiguous, J-shaped belt, spanning from Finland to Austria. This area maps onto the second principal component identified for European gene distribution, most likely reflecting a major migration event of the past (i.e., the ancestral adaptation to cold climates and the Uralic language dispersion) still detectable in modern European populations. The present research tested the hypothesis in the United States. Consistent with the hypothesis, available historical (1913-1924 and 1928-1932) U.S. state suicide rates were uniformly positively associated with available state proportions of reported American ancestries from European high-suicide-rate countries (Hungary, Lithuania, Poland, Russia, Slovakia, and the Ukraine). However, contrary to the hypothesis, available contemporary (1990-1994) suicide rates were uniformly negatively associated with these ancestry proportions. The findings of this first test outside Europe are therefore conflicting. A proposal based on the geographical study approach is offered to further the progress of investigations into the genetics of suicide.

Cause of Death↗