Inclusion Of Deaths Research Articles

Qur’an course teachers’ views on death education for children aged 4–6

The aim of this study is to examine the views of teachers who teach Qur’an courses to 4–6 year-olds on the inclusion of death in the curriculum, their observations about children’s perceptions of and reactions to death, and the difficulties they experience while informing children about death. A qualitative research approach was adopted in the study. The data obtained from 41 teachers the interview form with were evaluated using descriptive analysis. According to the teachers, the inclusion of the phenomenon of death in the course curriculum for 4–6 year-olds is essential for satisfying the curiosity of children from a correct source. However, due to the multidimensional, deep and unexperienced nature of the death phenomenon, a clear answer has not yet been given to the question of the framework and limit of the explanations, and what and how much should be explained for whom.

Deaths averted: An unbiased alternative to rate ratios for measuring the performance of cancer screening programs.

Screening trials and meta-analyses emphasize the ratio of cancer death rates in screening and control arms. However, this measure is diluted by the inclusion of deaths from cancers that only became detectable after the end of active screening. We review traditional analysis of cancer screening trials and show that ratio estimates are inevitably biased to the null, because follow-up (FU) must continue beyond the end of the screening period and thus includes cases only becoming detectable after screening ends. But because such cases are expected to occur in equal numbers in the two arms, calculation of the difference between the number of cancer deaths in the screening and control arms avoids this dilutional bias. This difference can be set against the number of invitations to screening; we illustrate by reanalyzing data from all trials of tomography screening of lung cancer (LC) using this measure. In nine trials of LC screening from 2000 to 2013, a total of 94,441 high-risk patients were invited to be in screening or control groups, with high participation rates (average 95%). In the older trials comparing computed tomography to chest X-ray, 88,285 invitations averted 83 deaths (1068 per death averted (DA)). In the six more recent trials with no screening in the control group, 69,976 invitations averted 121 deaths (577 invitations per DA). Screens per DA is an undiluted measure of screening's effect and it is unperturbed by the arbitrary duration of FU. This estimate can be useful for program planning and informed consent.

Pitfalls with analyses of real-world data: A look at ASCO’s CancerLinQ Discovery Multiple Myeloma dataset.

e20033 Background: Real world data (RWD) are increasingly used in oncology research. Yet, a big limitation of RWD is missing data, potentially generating misleading conclusions. Methods for handling missing data include excluding patients with missing variables, using machine-based or statistically-imputed values, or using proxies (surrogates). Another limitation deals with excluding deaths at time zero, which may lead to misleading conclusions when analyzing survival of patients with aggressive cancers. This work highlights the impacts data exclusion, variable surrogacy, and death at time zero have on survival analysis results. Methods: ASCO’s CancerLinQ Discovery Multiple Myeloma (MM) dataset was used to assess overall survival (OS) in patients with MM diagnosed from 2009-2021. Of the 34,234 patients included in the actual analyses, 3,582 (10%) were missing a recorded date of MM diagnosis. In these cases, dates of first anti-myeloma therapy were used as surrogates since most MMs are treated at diagnosis. OS was compared between MM patients with “known” vs. surrogate or “presumed” diagnosis dates. To assess how the inclusion of deaths at time zero may or may not affect OS, the data were first analyzed by excluding patients who died within 1 month of second primary malignancy (SPM) diagnosis, including secondary AML (sAML). A second analysis of the same sample added a constant (0.5) to all survival times, allowing for inclusion of patients who died within one month of diagnosis. Analyses were conducted with STATA Version 17.0 (College Station, TX). Results: Despite the strong, positive correlation between recorded MM diagnosis date and date of first anti-myeloma therapy, there was a statistically significant difference in survival of MM patients with a known vs. presumed date of diagnosis (median OS 115 vs. 45 months, HR 2.54, 95% CI 2.41-2.69, p < 0.001). Dropping vs. including deaths within one month of diagnosis resulted in a marked difference (i.e., nearly 1 year) in median OS from the date of diagnosis of any SPM (113 vs. 103.5 months) as well as sAML (41 vs. 30.5 months). Conclusions: Although RWD hold promise, oncologists must be aware of common pitfalls in survival analyses: missing data, variable surrogates, and deaths at time zero being dropped. Patients with a recorded date of MM diagnosis appear to be fundamentally different from those who don’t have a date of diagnosis but do have a date of anti-myeloma therapy recorded. For aggressive malignancies, excluding patients who died at time zero can lead to over-estimation of survival. Adding a small constant (0.5) to the time variable can enable the inclusion of patients who die quickly after their cancer diagnosis. In conclusion, when utilizing RWD to guide clinical decision making, it is important to be aware of common threats to data validity, which can produce misleading results.

Well-being and well-becoming through the life-course in public health economics research and policy: A new infographic.

The term "well-becoming" is not new, but is not routinely used in our everyday language or in research in public health economics. It has been applied in early years research. Well-becoming can be thought of as our multitude of life-journeys toward meaning and purposefulness. To develop a new infographic in the spirit of the Dahlgren and Whitehead rainbow infographic of social determinants of health. The purpose being to redefine well-being as a process of growth through life, articulated as well-becoming. A rapid review of life-course stage appropriate models of well-being was undertaken with stages of the life-course as defined as: preconception and birth; early years; adolescence; working, parenting and caring; older age, and death. Infographics in this area were identified and the information above was used to design a new infographic with the concept of well-being and well-becoming at its center. A new infographic reflecting an underlying concept of "the wheel of life" is presented. It shows movement through the life-course at its center, with concentric rings summarizing personal, local, and national and global factors that have an impact on well-being and well-becoming of individuals through the life-course. Of note, is the inclusion of death, which is a topic often avoided. Prepared during 2021-22, the infographic reflects the role of pandemic and war within the national and global ring of influential factors. I reflect on three ways in which health economists are currently using a life-course approach and the concept of well-becoming in the economic evaluation of individual programs and at a population level of government policy. Moving from solely focusing on a concept of well-being to a concept of well-being and well-becoming acknowledges the influence that socioeconomic and other conditions in a particular life-course stage have on subsequent life-course stages, and the cost-effectiveness of intervening across the life-course.

Impact of a teacher-training MOOC on the Pedagogy of Death during the pandemic

The objective of this study was to determine the impact of a MOOC on the attitudes of pre-service and in-service teachers toward education on death. The study adopted a pre- and post-test design. Participants (N = 139) answered the Death Education Attitudes Scale-Teachers (DEAS-T) questionnaire at the beginning and end of the course. The results confirmed significant differences between the pre- and post-course applications in the three scale factors—need for training in the Pedagogy of Death, inclusion of death in education, and educational awareness of death. Open-access, free, mass training through a MOOC could have a positive impact on attitudes toward death education among both pre- and in-service teachers.

How Do School Principals Perceive Education that Includes Death? A Phenomenological Study

ABSTRACT An education that includes death is lacking in schools, even during this period of the pandemic caused by the Covid-19 virus. The objective of this study was to attain an exploratory understanding of the school principals’ views on death education. The study, undertaken in Spain, adopted a phenomenological design, carrying out interviews with 7 school principals. The main findings were that death was not present, with a clear educational purpose, in their schools’ curricula. Hence the inclusion of death in education requires a change of perspective in death education, based on the knowledge developed by the Pedagogy of Death.

Classifying maternal deaths in Suriname using WHO ICD-MM: different interpretation by Physicians, National and International Maternal Death Review Committees

Plain English summaryThe World Health Organization (WHO) provides a framework (ICD-MM) to classify pregnancy-related deaths systematically, which enables global comparison among countries. We compared the classification of pregnancy-related deaths in Suriname by the attending physician and by the national maternal death review (MDR) committee and among the MDR committees of Suriname, Jamaica and the Netherlands. There were 89 possible pregnancy-related deaths in Suriname between 2010 and 2014. Nearly half (47%) were classified differently by the Surinamese MDR committee as compared to the classification of the attending physicians. All three MDR committees agreed that 18% (n = 16/89) of the cases were no maternal deaths. Out of the remaining 73 cases, there was disagreement regarding whether 15% (n = 11) were maternal deaths. The Surinamese and Jamaican MDR committees achieved greater consensus in classification than the Surinamese and the Netherlands MDR committees. The Netherlands MDR committee classified more deaths as unspecified than Surinamese and the Jamaican MDR committees. Underlying causes that achieved a high level of agreement among the three committees were abortive outcomes and obstetric hemorrhage, while little agreement was reported for unspecified and other direct causes.The issues encountered during maternal death classification using the ICD-MM guidelines included classification of suicide during early pregnancy; when to assume pregnancy without objective evidence; how to count maternal deaths occurring outside the country of residence; the relevance of direct or indirect cause attribution; and how to select the underlying cause when direct and indirect conditions or multiple comorbidities co-occur. Addressing these classification barriers in future revisions of the ICD-MM guidelines could enhance the feasibility of maternal death classification and facilitate global comparison.BackgroundInsight into the underlying causes of pregnancy-related deaths is essential to develop policies to avert preventable deaths. The WHO International Classification of Diseases-Maternal Mortality (ICD-MM) guidelines provide a framework to standardize maternal death classifications and enable comparison in and among countries over time. However, despite the implementation of these guidelines, differences in classification remain. We evaluated consensus on maternal death classification using the ICD-MM guidelines.MethodsThe classification of pregnancy-related deaths in Suriname during 2010–2014 was compared in the country (between the attending physician and the national maternal death review (MDR) committee), and among the MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied the ICD-MM guidelines. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement.ResultsOut of the 89 cases certified by attending physicians, 47% (n = 42) were classified differently by the Surinamese MDR committee. The three MDR committees agreed that 18% (n = 16/89) of these cases were no maternal deaths, and, therefore, excluded from further analyses. However, opinions differed whether 15% (n = 11) of the remaining 73 cases were maternal deaths. The MDR committees achieved moderate agreement classifying the deaths into type (direct, indirect and unspecified) (κ = 0.53) and underlying cause group (κ = 0.52). The Netherlands MDR committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese (4%) committees did. The mutual agreement between the Surinamese and Jamaican MDR committees (κ = 0.69 vs κ = 0.63) was better than between the Surinamese and the Netherlands MDR committees (κ = 0.48 vs κ = 0.49) for classification into type and underlying cause group, respectively. Agreement on the underlying cause category was excellent for abortive outcomes (κ = 0.85) and obstetric hemorrhage (κ = 0.74) and fair for unspecified (κ = 0.29) and other direct causes (κ = 0.32).ConclusionsMaternal death classification differs in Suriname and among MDR committees from different countries, despite using the ICD-MM guidelines on similar cases. Specific challenges in applying these guidelines included attribution of underlying cause when comorbidities occurred, the inclusion of deaths from suicides, and maternal deaths that occurred outside the country of residence.

All-cause mortality supports the COVID-19 mortality in Belgium and comparison with major fatal events of the last century

BackgroundThe COVID-19 mortality rate in Belgium has been ranked among the highest in the world. To assess the appropriateness of the country’s COVID-19 mortality surveillance, that includes long-term care facilities deaths and deaths in possible cases, the number of COVID-19 deaths was compared with the number of deaths from all-cause mortality. Mortality during the COVID-19 pandemic was also compared with historical mortality rates from the last century including those of the Spanish influenza pandemic.MethodsExcess mortality predictions and COVID-19 mortality data were analysed for the period March 10th to June 21st 2020. The number of COVID-19 deaths and the COVID-19 mortality rate per million were calculated for hospitals, nursing homes and other places of death, according to diagnostic status (confirmed/possible infection). To evaluate historical mortality, monthly mortality rates were calculated from January 1900 to June 2020.ResultsNine thousand five hundred ninety-one COVID-19 deaths and 39,076 deaths from all-causes were recorded, with a correlation of 94% (Spearman’s rho, p < 0,01). During the period with statistically significant excess mortality (March 20th to April 28th; total excess mortality 64.7%), 7917 excess deaths were observed among the 20,159 deaths from all-causes. In the same period, 7576 COVID-19 deaths were notified, indicating that 96% of the excess mortality were likely attributable to COVID-19. The inclusion of deaths in nursing homes doubled the COVID-19 mortality rate, while adding deaths in possible cases increased it by 27%. Deaths in laboratory-confirmed cases accounted for 69% of total COVID-19-related deaths and 43% of in-hospital deaths. Although the number of deaths was historically high, the monthly mortality rate was lower in April 2020 compared to the major fatal events of the last century.ConclusionsTrends in all-cause mortality during the first wave of the epidemic was a key indicator to validate the Belgium’s high COVID-19 mortality figures. A COVID-19 mortality surveillance limited to deaths from hospitalised and selected laboratory-confirmed cases would have underestimated the magnitude of the epidemic. Excess mortality, daily and monthly number of deaths in Belgium were historically high classifying undeniably the first wave of the COVID-19 epidemic as a fatal event.

Finitude, choice and the right to die: age and the completed life

AbstractThis paper explores the concept of the completed life outlined in recent writing in the Netherlands on euthanasia and assisted suicide and its implications for ageing studies. Central to this theme is the basic right of people to self-determine the length of their later life, linked with the subsidiary right to assistance in achieving such self-determination. Although the notion of weariness with life has a long history, the recent advocacy of a self-limited life seems shaped by the new social movements presaged upon individual rights together with what might be called a distinctly third-age habitus, giving centre stage to autonomy over the nature and extent of a desired later life, including choice over the manner and timing of a person's ending. In exploring this concept, consideration is given to the notion of a ‘right to die’, ‘rational suicide’ and the inclusion of death as a lifestyle choice. While reservations are noted over the unequivocal good attached to such self-determination, including the limits to freedom imposed by the duty to avoid hurt to society, the article concludes by seeing the notion of a completed life as a challenge to traditional ideas about later life.

The inclusion of death in the curriculum of the Spanish Regions

ABSTRACT This study aims to determine the extent and manner in which the notion of death is provided for in laws regulating school curricula in Spain and the Spanish Autonomous Regions, and to identify any differences and similarities among the Regions. To this end a documentary survey of current legislation, curricular regulations and educational provision for learner diversity was conducted from a quantitative and qualitative, analytical and comparative perspective. 19 expert-selected terms relevant to death education were subjected to study. The main findings were: (a) death is present at all stages of education, but not in a planned and deliberate pattern; (b) comparison of results from the various Autonomous Regions of Spain reveals a range of different sensitivities regarding the issue. The study investigates an aspect of the curriculum that is of interest to an international audience.

Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

ObjectivesMortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates’ place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU). MethodsRetrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week 0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU. ResultsA total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03). ConclusionsThis study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

High Mortality Among Human Immunodeficiency Virus (HIV)-Infected Individuals Before Accessing or Linking to HIV Care: A Missing Outcome in the Cascade of Care?

Background. The “cascade of care” displays the proportion of individuals who are infected with human immunodeficiency virus (HIV), diagnosed, linked, retained, on antiretroviral treatment, and HIV suppressed. We examined the implications of including death in the use of this cascade for program and public health performance metrics.Methods. Individuals newly diagnosed with HIV and living in Calgary between 2006 and 2013 were included. Through linkage with Public Health and death registries, the deaths (ie, all-cause mortality) and their distribution within the cascade were determined. Mortality rates are reported per 100 person-years.Results. Estimated new HIV infections were 680 (543 confirmed and 137 unknown cases). Forty-three individuals, after diagnosis, were never referred for HIV care. Despite referral(s), 88 individuals (18%) never attended the clinic for HIV care. Of individuals retained in care, 87% received antiretroviral therapy and 76% achieved viral suppression. Thirty-six deaths were reported (mortality rate, 1.50/100 person-years). One diagnosis was made posthumously. Deaths (20 of 35; 57%) occurred for individuals linked but not retained in care (6.93/100 person-years), and 70% were HIV-related. Mortality rate for patients in care was 0.79/100 person-years. Retained patients with detectable viremia had a death rate of 2.49/100, which contrasted with 0.28/100 person-years in those with suppressed viremia. Eight of these 15 deaths (53%) were HIV-related.Conclusions. Over half of deaths occurred in those referred but not effectively linked or retained in HIV care, and these cases may be easily overlooked in standard HIV mortality studies. Inclusion of deaths into the cascade may further enhance its value as a public health metric.

Death in Simulation: Comparing the Stress to the Educational Value

Simulation is a modality to teach, practice and master many skills. However, the inclusion of death in simulated patient scenarios has been debated. Experts question whether the experience outweighs potential psychological harms to the learner. Given that unexpected death is a reality in emergency medicine (EM), death notification is a skill that must be learned by EM providers. Excluding this during their training may delay and amplify the psychological harms when facing this in practice. We examined whether EM residents find the learning opportunity of the unexpected death of a simulated patient, and subsequent “family” notification, outweighs the stress of this situation.

The Modified Glasgow Outcome Score for the prediction of outcome in patients after cardiac arrest: a prospective clinical proof of concept study

The Glasgow-Pittsburgh cerebral performance categories (GP-CPC) and the Glasgow Outcome Score (GOS) have been used to categorize patients according to their neurological outcome for prognostic predictors in patients after cardiac arrest (CA). We postulated that inclusion of deaths without knowing the cerebral status into the group of patients with poor outcome after CA using the GP-CPC and GOS will lead to dilution of the prognostic power of the investigated biochemical marker. The present study was conducted to verify this issue by employing a modified outcome score, which we termed as Modified Glasgow Outcome Score (MGOS). In the present study, 97 patients were enrolled in a prospective manner. Serum NSE and S100B levels were measured daily for 7 days after admission to the intensive care unit. Neurological outcome was assessed by employing the GOS and MGOS after 6 months. By employing the GOS, 46 patients were categorized into the group of patients with poor outcome and 51 patients survived with good neurological outcome. Patients who died without certified brain damage or with unknown cerebral status after CA (n = 20) were separated from patients with poor outcome in the MGOS. The magnitude of NSE (S100B) elevation in patients with poor outcome categorized by the MGOS was approximately 1.7-fold (1.5) higher as compared with patients divided by the GOS. The mean calculated sensitivities and area under the curve values of NSE and S100B predicting poor outcome classified by the MGOS were significantly higher as compared with the GOS. Conclusively, inclusion of deaths without certified brain damage or with unknown cerebral status into the group of patients with poor outcome will lead to underestimation of the prognostic power of investigated biochemical markers such as NSE and S100B. The MGOS will help to avoid this bias.

Biochemical markers and somatosensory evoked potentials in patients after cardiac arrest: The role of neurological outcome scores

Biochemical markers, e.g. NSE or S100B, and somatosensory evoked potentials (SSEP) are considered promising candidates for neurological prognostic predictors in patients after cardiac arrest (CA). The Utstein Templates recommend the use of the Glasgow-Pittsburgh Cerebral Performance Categories (GP-CPC) to divide patients according to their neurological outcome. However, several studies investigating biochemical markers and SSEP are based on the Glasgow Outcome Score (GOS). We noticed that many studies failed to exclude patients who died without certified brain damage from patients classified as poor outcome, instead including all patients who died into this category. Therefore, we summarized the published NSE cut-off values and the derived sensitivity and specificity to predict poor outcome of those studies which only included patients with certified brain death in GOS-1 or GP-CPC-5 (group A) vs. those studies which did not differentiate between death from any cause or death due to primary brain damage (group B). On average, mean NSE cut-off values and sensitivity were higher (56 ± 35 ng/ml, 56 ± 18%) in group A than in group B (41 ± 17 ng/ml, 44 ± 25%), respectively. The specificity remained equally high in both groups. In analogy, the average sensitivity of SSEP to predict poor outcome was higher in group A (76 ± 11%) than in group B (50 ± 15%), while the specificity was similar in both groups. Conclusively, inclusion of deaths without certified brain damage after CA in neurological outcome studies will lead to underestimation of the prognostic power of biochemical or electrophysiological markers for brain damage. A modified GOS and GP-CPC score might help to avoid this bias.

A Sustained Mortality Benefit from Screening for Abdominal Aortic Aneurysm

Longer-term mortality benefit and cost-effectiveness for abdominal aortic aneurysm (AAA) screening are uncertain. To estimate the benefits, in terms of AAA-related and all-cause mortality, and cost-effectiveness of ultrasonography screening for AAA in a group that was invited to screening compared with a group that was not invited at a mean 7-year follow-up. Randomized trial. 4 centers in the United Kingdom. Population-based sample of 67,770 men age 65 to 74 years. Patients with an AAA detected at screening had surveillance and were offered surgery after predefined criteria were met. Mortality data were obtained after flagging on the national database. Unit costs obtained from large samples were applied to individual event data for the cost analysis. The hazard ratio was 0.53 (95% CI, 0.42 to 0.68) for AAA-related mortality in the group invited for screening. The rupture rate in men with normal results on initial ultrasonography has remained low: 0.54 rupture (CI, 0.25 to 1.02 ruptures) per 10 000 person-years. In terms of all-cause mortality, the observed hazard ratio was 0.96 (CI, 0.93 to 1.00). At the 7-year follow-up, cost-effectiveness was estimated at $19 500 (CI, $12,400 to $39,800) per life-year gained based on AAA-related mortality and $7600 (CI, $3300 to infinity) per life-year gained based on all-cause death. (All values are reported in U.S. dollars [U.K. 1 pound sterling = U.S. $1.58]). Inclusion of deaths from aortic aneurysm at an unspecified site, which may include some thoracic aortic aneurysms, may have underestimated the treatment effect. These results from a large, pragmatic randomized trial show that the early mortality benefit of screening ultrasonography for AAA is maintained in the longer term and that the cost-effectiveness of screening improves over time. International Standard Randomized Controlled Trial registration number: ISRCTN37381646.

Analysis of Mortality Data From Cancer Screening Studies

Appropriate statistical analysis is required to measure the impact of early detection and treatment of cancer. The current practice of using cumulative mortality ignores both (1) the delay between early treatment and the time that any averted deaths would have otherwise occurred, and (2) cessation of these delayed benefits some time after screening is discontinued. We use time-specific mortality density ratios to estimate the mortality ratio in the "window of influence." We then use time-specific incidence density ratios to assess the extent to which the removal of polyps and other possibly precancerous lesions detected by fecal occult blood screening reduces the incidence of colorectal cancer. Applied to a theoretical example, the current practice of using cumulative mortality substantially underestimates the reduction in mortality achievable by early treatment. If there is sufficient time for the full impact to emerge, time-specific mortality patterns provide a more accurate measure. In a previous analysis of the screening study, the reduction in cumulative incidence in the screened groups was just under 20%. In our reanalysis, yearly incidence density ratios indicate that had screening not been interrupted, there might have been a 40% reduction in incidence. Time-specific mortality ratios provide a more sensitive measure of the effects of early detection and treatment. Measures based on cumulative mortality are diluted by inclusion of deaths that occur soon after the initiation of screening as well as deaths that occur too long after the cessation of screening.

Etiological factors in broncho-pneumonia amongst infants in London

1. In the period 1923–39, more than one-fifth of all deaths in the age group 0-2 years in the Administrative County of London are recorded as having been caused by bronchitis or broncho-pneumonia. It is very unlikely that the returns have been exaggerated by more than 10–15% through the inclusion of deaths from secondary broncho-pneumonia following measles, whooping cough or influenza. In the 8 years in which measles epidemics occurred, the peak of the measles mortality was from 2 to 17 weeks after, and never before, that of the mortality from broncho-pneumonia.2. The winter rise in mortality from broncho-pneumonia is not associated with any comparable increase in the carrier rates for pneumococci and haemolytic streptococci.3. The broncho-pneumonia mortality of infants in the Metropolitan Boroughs is strongly correlated with sub-standard housing incidence, social index and percentage below the poverty line. The relatively small value found for the coefficient of regression between broncho-pneumonia mortality and sub-standard housing may be due to the less rigorous winter temperatures occurring in the more overcrowded central areas.4. Low external temperature appears to be the most important predisposing cause of fatal broncho-pneumonia in infants; their weekly death-rate from this disease in mid-winter is about seven times that in the late summer. This great seasonal fluctuation in mortality is also found for persons over 55 years in the Administrative County, and for persons of all ages in both the urban and rural districts of the Home Counties.5. The weekly mortalities of infants from broncho-pneumonia in the Administrative County are most strongly correlated with low temperatures 2 weeks earlier. The two variables are so associated that the mortality rises sharply when the mean temperature of the coldest day of the week falls below 40° F. There is no indication that low temperatures in the spring are associated with higher death-rates from broncho-pneumonia than the same temperatures in the autumn, so that the data provide no support for the supposition that susceptibility increases during the winter in consequence of the progressive depletion in the body of protective nutrient substances.6. Possible measures to reduce the mortality of infants from broncho-pneumonia are discussed.