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Michael Nair-Collins and Franklin G. Miller argue in an extended essay that the dominant view in medical ethics of patients who are brain dead but sustained on mechanical ventilation is false. According to this view, these unfortunate patients are biologically dead, yet appear to be alive as a result of the fact that mechanical ventilation ensures that their heart continues to beat, that their skin remains warm, that their wounds continue to heal, that their body does not decay, and (of course) that they continue to breathe. This view was defended by the U.S. President’s Commission in 1981, and again by the President’s Council in 2008. That brain-dead, mechanically ventilated patients are biologically dead—rather than dead merely in a social or legal sense—is seen by defenders of this view as important. The President’s Council explicitly rejected the idea that death is anything other than a fact of biology. The significance of this move is explained by Nair-Collins and Miller as follows: > Getting this biological conception right is critically important: responsible moral and policy deliberation begins with an unbiased assessment of relevant factual questions. One cannot address the difficult normative questions surrounding organ retrieval, just use of resources, withdrawal of mechanical support and so on, without first addressing the biological question: what is the vital status of this organism? ( see page 746 ) Essentially, working with a biological conception of death makes certain decisions much less ethically murky than they would be in the absence of such a conception. The ‘dead donor rule’, for example, prohibits causing death to a patient by removing their organs. If it is a fact of biology that brain-dead, mechanically ventilated patients are dead, then removing their organs for donation clearly does not fall foul of the dead donor rule. If, on the other hand, the …

Objective To explore the effect of research ethics, governance and consent requirements and recent reforms on UK-wide follow-up of children with congenital heart defects (CHD). Design Prospective cohort study. Setting UK National Health Service. Patients 3897 children with CHD requiring intervention, or resulting in death, before they were 1-year-old (1993–1995). Main outcomes Impact on study protocol, timeliness and findings of a multicentre study of survival and quality of life. Results The peer-reviewed study protocol was altered to accommodate ethics committee stipulations that researchers should not approach families directly with a request to participate and that the general practitioner9s (GP) permission be sought before the local clinician could do so. Individual consent was required to confirm the vital status of participants and for future tracing of public death registrations. Local study registration took a median of 40 weeks (IQR 25–57). 180 (24%) of 739 surviving children (five centres) could not be contacted because their GP was untraceable (32), had changed (128) or considered contact inappropriate (20). Invitations could not be sent to 31% from the most deprived compared with 17% from the least deprived areas. Conclusions Decision making concerning childhood interventions should be influenced by evidence on long-term outcomes. However, current UK research regulations hinder follow-up in multicentre studies. Stipulations preventing researchers contacting families directly with research invitations appear disproportionate to the risks, impede equitable access to research opportunities and introduce bias. The requirement for an individual9s consent to confirm whether they are alive and monitor survival precludes effective long-term follow-up.

STUDY OBJECTIVE—This study examined both individual and neighbourhood correlates of injury mortality to better understand the contribution of socioeconomic status to cause specific injury mortality. Of particular interest was whether neighbourhood effects remained after adjusting for individual demographic characteristics and socioeconomic status. DESIGN—Census tract data (measuring small area socioeconomic status, racial concentration, residential stability, urbanisation, and family structure) was merged with the National Health Interview Survey (NHIS) and a file that links the respondents to subsequent follow up of vital status and cause of death data. Cox proportional hazards models were specified to determine individual and neighbourhood effects on homicide, suicide, motor vehicle deaths, and other external causes. Variances are adjusted for the clustered sample design of the NHIS. SETTING—United States, 1987-1994, with follow up to the end of 1995. PARTICIPANTS—From a sample of 472 364 persons ages 18-64, there were 1195 injury related deaths over the follow up period. MAIN RESULTS—Individual level effects were generally robust to the inclusion of neighbourhood level variables in the models. Neighbourhood characteristics had independent effects on the outcome even after adjustment for individual variability. For example, there was approximately a twofold increased risk of homicide associated with living in a neighborhood characterised by low socioeconomic status, after adjusting for individual demographic and socioeconomic characteristics. CONCLUSIONS—Social inequalities in injury mortality exist for both persons and places. Policies or interventions aimed at preventing or controlling injuries should take into account not only the socioeconomic characteristics of people but also of the places in which they live. Keywords: socioeconomic status; injury; neighborhood

OBJECTIVES: To describe the methodology and feasibility of follow up for vital status in retrospective cohort studies in Estonia. METHODS: A cohort of 7412 workers who had been employed at two factories in Tallinn between 1946 and 1988 was followed up for vital status from the date of first employment until death, emigration, or the end of the study, 31 December 1995, whichever occurred first. The cohort was electronically linked with the National Population Registry of Estonia that was created in 1992 and includes personal identification numbers of Estonian citizens and residents, and the Mortality Database that contains information from death certificates issued in 1983-95. A manual search was carried out on several non-computerised population data sources and archives. RESULTS: By 31 December 1995, the vital status of 6780 (91.5%) subjects could be traced (4495 (60.6%) subjects were alive, 1993 (26.9%) had died, and 292 (3.9%) had emigrated). Analysis by calendar period of leaving work showed that the proportion of subjects traced was lowest in the group of workers who had left work between 1946 and 1955 (58.4%), especially those whose age at leaving work was < 30 (53.2%) or > 60 years (42.3%). Among subjects who left work in 1956-65, 1966-75, and 1976-88, the follow up rate was 84.7%, 94.6%, and 98.2%, respectively. CONCLUSIONS: The findings, which are especially important for occupational epidemiology, confirm the feasibility of conducting retrospective cohort studies in Estonia. Most of the issues discussed in the paper apply to other former Soviet countries.

Introduction Epidemiological studies performed in the last decades confirmed the significant role of sleep as an independent predictor of survival in older age. Objective The aim of the study was to assess the role of the social position, self-reported functional status, self-rated health, and a feeling of life-weariness as risk factors of sleep duration, and to evaluate how the relationship between sleep duration and these psychosocial factors influences the risk of death. Methods Baseline study using a structured questionnaire was performed in 1986/1987 on a random sample (n=2605) of older people aged 65 years and over, community-dwelling citizens of Krakow. Vital status was monitored over 22 years. The analysis was performed using logistic regression and Cox hazard models. Results The mean observation period of the cohort was 11.5 years, for a total of 29 951 person-years. 1341 deaths in women and 771 in men were recorded. Strong feeling of life-weariness was found as predictor of short sleep in both genders. Poor self-rated health in women and both low functional activity and low level of education in men was associated with a long sleep. Analysis showed increased risk of death in men who slept Conclusions Results suggest that sleeping patterns in elders depending on several psychosocial conditions influence the mortality patterns in older age.

Working in the rubber industry is associated with increased cancer risks, particularly for cancers of the lung, larynx, urinary bladder and leukaemia.1 Most epidemiological studies, however, still reflect working conditions back to the 1940s. As occupational exposures were lowered considerably since the late 1970s, prospective health surveillance is warranted to assess the effectiveness of exposure control. The cohort included all blue-collar workers of 13 participating rubber manufacturing companies in western Germany who were hired after 1 January 1981 and worked for at least 1 year until the end of follow-up. Follow-up started on 1 January 1982 and ended on 31 December 2000, but was censored at the age of 85 years. The vital status was ascertained via population registries. Death certificates were requested from community health departments and underlying causes of death were coded by professional nosologists according to the ninth revision of the International Classification of Diseases (ICD-9). The mortality experience of the cohort was compared with the mortality of the corresponding population of western Germany. Standardised mortality ratios (SMRs) and exact 95% confidence …

Objectives Linkages of cancer and occupation provide an important resource to aid in our understanding of the role of occupational exposures in the aetiology of cancer. The majority of existing surveys have, however, been based on census data including occupational information from only one certain date, thus lacking the general situation with several changed between different jobs during a work career. We report on a series of 60 Danish nested case-control studies based on nationwide data linkages, including information on all employments since 1964. Methods All cancer cases (N = 1,031,504; 50.4% women and 49.6% men) diagnosed between 1970 and 2010, aged 18 and 84 years old, was retrieved from the Danish Cancer Registry. Each subject was individually linked with employment information from the Nationwide Pension Scheme with compulsory membership, including information on start and end of each employment, and a 5-digit hierarchically trade code. Information on job title, civil and vital status was obtained from the Central Population Register (CPR). Controls free of cancer and matched on birth year and sex have been selected from the CPR and linked in the same way as cases. Finally, individual information on SES, residential history, reproduction, prescribed medicine, and comorbidity has been added to each case and control. Finally, a JEM on potential carcinogens can be applied. Results Results confirm increased risk for e.g. lung and bladder cancer among painters and for nasal cancer in wood dust exposed workers. On the other hand, farmers, gardeners and forestry workers had deficits for many cancers. Results on new significant associations will also be presented. Conclusions These data confirms many well established associations between work and cancer, and demonstrates that many associations are not fully explained. The large number of cancers available for analysis provides the opportunity to evaluate possible occupational associations even with rare cancers.

Objectives To determine the relationship between exposure to hard-metal dusts and lung cancer mortality. This international cohort study is coordinated by the Universityof Pittsburghand funded by the International Tungsten Industry Association (Marsh et al 2013, EPICOH abstract). The German component comprises three Kennametal manufacturing sites in North Rhine-Westphalia and Bavaria. Methods We enrolled all current and former workers at two Bavarian sites (start of production 1960 and 1971 respectively). At the largest plant in North Rhine-Westphalia (start of production 1926) we will enrol all blue-collar workers who were employed for at least 6 months. We will collect and analyse measurement data, work history, and medical information like smoking and urine data. We will apply an electronic data collection system to protect personal data. To investigate total and cause-specific mortality for the period 1980–2011, we aim to determine each subject’s vital status and, if applicable, cause of death. External comparisons (SMRs) to the German population and state populations will be performed. Cox models will be used for internal analyses. Results Our preliminary estimates of the numbers of participants at the two Bavarian plants are 2,711 and 1,577. At the North Rhine-Westphalian plant we have enrolled 3,700 workers (less than half of the overall workforce). Some current workers refused to be enrolled in the study. 3.7% of 676 and 0.2% of 417 at Bavarian plants and 0.9% of 637 at North Rhine-Westphalian plant. Basic data of these workers will be documented. Conclusions The data collection process in North Rhine-Westphalia was restricted due to the large number of paper files. Otherwise it would not be feasible to meet the budget and time schedule of the international pooling project. Vital status and cause of death tracing are challenging in Germany. We will try to optimise procedures in cooperation with the responsible institutions.

Editor,—We read with interest the article by Loughlin, Rothman, and Dreyer,1 and we write to provide the factual background for the study and additional information that may be of interest to your readers. The study was commissioned by 17 chemical companies to defend against lawsuits we filed on them on behalf of 14 former students, who attended for two or three years (from 1943 to 1989) Port Neches-Groves High School and who contracted lymphohaematopoietic cancers (Hodgkin's disease, leukaemia, and non-Hodgkin's lymphoma). Because of the study design, only four of the 14 cases we represent were counted in the study. Seven of the remaining 10 either still are alive or died after the cut off date for determining vital status. Two attended high school before 1963. And the remaining case died of “small cell carcinoma, unknown primary” (probably secondary to … Dr Loughlin.