Age-specific excess deaths associated with stroke among racial/ethnic minority populations--United States, 1997

Stroke was the third leading cause of death in the United States in 1997. During 1950-1996, age-standardized stroke death rates declined 70% for the entire U.S. population; however, the decline varied among racial/ethnic populations. The estimated number of stroke deaths by race/ethnicity and age illustrate the differences in stroke mortality that may be used to direct prevention efforts. This report presents an analysis of stroke mortality by age and racial/ethnic group; the findings indicate that for persons aged 35-64 years, excess stroke deaths and higher risk for stroke mortality occurred among members of U.S. racial/ethnic minority populations than among the non-Hispanic white population.     

Estonia 1989-2000: enormous increase in mortality differences by education

BACKGROUND: Having regained its political autonomy in 1991, Estonia experienced major changes in political, economic, and social realities. We aimed to analyse mortality changes by education from 1989 to 2000 in order to assess the impact of recent changes in Estonia, as well as the delayed effects of pre-transitional developments. METHODS: Two census-based analyses were compared. Individual cause-specific death data for those aged 20+ for 1987-1990 (72 003 deaths) and 1999-2000 (35 477 deaths) came from the national mortality database. Population denominators came from the population censuses of 1989 and 2000. Mortality for all causes combined and for selected causes of death were analysed for high, mid, and low educational groups. The absolute differences in mortality were evaluated through life expectancy at age 25 and age-standardized mortality rates. To assess the relative differences between educational levels, mortality rate ratios with 95% CI were calculated using Poisson regression. RESULTS: Educational differences in mortality increased tremendously from 1989 to 2000: over the 10-year period life expectancy improved considerably for graduates, and worsened for those with the lowest education. In 2000, male graduates aged 25 could expect to live 13.1 years longer than corresponding men with the lowest education; among women the difference was 8.6 years. Large differences were observed in all selected causes of death in 1989 and in 2000 and the trends were invariably much more favourable for the higher educated. Educational differences in total mortality increased in all age groups. CONCLUSIONS: Social disruption and increasing inequalities in wealth can be considered main recent determinants; however, causal processes, shaped decades before recent reforms, also contribute to this widening gap.     

Unusually strong association between education and mortality in young adults in a community with a high rate of injection-drug users

BACKGROUND: To examine the association between education and mortality for various causes of death in young adults in a community with a high rate of injection-drug users. METHODS: Linked mortality study based on mortality records for 1996 and 1997 and on 1996 population census data from the Region of Madrid (Spain). The association between educational level and mortality was estimated by the mortality rate ratio. RESULTS: After adjustment for age and other socioeconomic variables the mortality rate in men and women aged 25-44 years with no education was, respectively, 4.7 and 3.7 times higher than in men and women with the highest educational level. The causes of death with the strongest association were chronic liver disease and cirrhosis, AIDS and diseases of the heart in both sexes and suicide in men. For these causes of death the mortality rate ratio between persons with the lowest and highest educational level ranged from 6.8 to 21.8 in men and from 4.1 to 16.9 in women. CONCLUSIONS: These causes of death are the leading specific causes of death in persons aged 25-44 years. Given that probably a substantial part of deaths from diseases of the heart in this age category are drug-related, the common denominator of the excess mortality related poor education seems to be drug injection.     

National trends in educational differentials in mortality

The authors examined national changes in socioeconomic differentials in mortality for middle-aged and older white men and women in the United States with the use of 1960 data from the Matched Records Study and 1971-1984 data from the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study (NHEFS). In 1960, there was little difference in mortality by educational level among middle-aged and older men. Since 1960, death rates among men declined more rapidly for the more educated than the less educated, which resulted in substantial educational differentials in mortality in 1971-1984. In contrast, among women, death rates declined at about the same rate regardless of educational attainment, so that a strong inverse relation between education and mortality in 1960 remained about the same magnitude during 1971-1984. Trends in educational differentials for heart disease mortality are responsible for much of the change for all causes of death. Relative risk estimates based on the NHEFS indicate that after taking into account selected baseline risk factors the least educated are still at substantially elevated risk of death from heart disease, ranging from a relative risk of 1.38 for men aged 65-74 years at baseline to 2.27 for men aged 45-64 years. Reasons for the observed educational differentials and their changes over time are not easily explained and are likely to be multifactorial.     

Trends in rates for mortality from all causes among Indians in Minnesota, 1960-79

Trends in age- and sex-specific mortality rates for all causes of death for Indians in Minnesota during the years 1960-79 were examined using the Mantel-Haenszel chi-square extension test. Indians younger than 15 years of age were not included in the analysis because of the changes in classification for Indian race in census reports for Indian children and adolescents, known decreases in Indian infant mortality, and the small number of deaths among Indian children and adolescents during the years 1960-79. Declines in mortality rates were observed for Indian men and women 75 years of age and older, men 65 through 74 years of age, and women 25 through 54 years of age. Overall, only 8 percent of men and 53 percent of women were in age groups that showed declining mortality rates for all causes of death during the years 1960-79. The greatest decline in mortality rates for men and women occurred among those 75 years of age and older. Mortality rates for Indians in Minnesota declined during the study period for fewer than half of the age groups. Such strategies as risk factor surveillance, public health programs, and medical interventions need to be directed toward these groups that have not experienced the same declines in mortality rates as nearly all age groups of whites, both nationwide and in Minnesota, during the same period.     

Changing social disparities and mortality in France (1968-1996): cause of death analysis by educational level

BACKGROUND: Little information is available on temporal trend in socioeconomic inequalities in cause of death mortality in France. The aim of this paper was to study educational differences in mortality in France by cause of death and their temporal trend. METHODS: We used a representative sample of 1% of the French population and compared four periods (1968-1974, 1975-1981, 1982-1988, 1990-1996). Causes of death were obtained by direct linkage with the French national death registry. Education was measured at the beginning of each period, and educational disparities in mortality were studied among men and women aged 30-64 at the beginning of each period. Analyses were conducted for all deaths and for the following causes of death: all cancers, lung cancer (among men), upper aerodigestive tract cancers (among men), breast cancer (among women), colorectal cancer, other cancers, cardiovascular diseases, ischaemic heart diseases, cerebrovascular diseases, other cardiovascular diseases, external causes, other causes of death. Socioeconomic inequalities were quantified with relative risks and relative indices of inequality. The relative indices of inequality measures socioeconomic inequalities across the population and can be interpreted as the ratio of mortality rates of those with the lowest to those with the highest socioeconomic status. RESULTS: Analyses showed an increase in educational differences in all cause mortality among men (the relative indices of inequality increased from 1.96 to 2.77 from the first to the last period) and among women (the relative indices of inequality increased from 1.87 to 2.53). Socioeconomic inequalities increased for all cause of death studied among women, and for cancer and cardiovascular diseases among men. The contribution of cancer mortality to difference in overall mortality between the lowest and the highest levels of education increased strongly over the whole study period, especially among women. CONCLUSION: This study shows that large socioeconomic inequalities in mortality are observed in France, and that they increase over time among men and women.     

Temporal trends in socioeconomic inequality in mortality in France between 1968 and 1996. Study of educational differences by cause of death

BackgroundLittle information is available on temporal trends in socioeconomic inequalities in mortality by cause of death in France. The aim of this paper was to study educational differences in mortality in France by cause of death and their temporal trend.MethodsWe used a representative sample of 1% of the French population and compared four periods (1968–1974, 1975–1981, 1982–1988, 1990–1996). Causes of death were obtained from the French national death registry. Education was measured at the beginning of each period, and educational disparities in mortality were studied among men and women aged 30–64 at the beginning of each period. Analyses were conducted for all deaths and for the following causes of death: all cancers, lung cancer (in men), head and neck cancers (in men), breast cancer (in women), colorectal cancer, other cancers, cardiovascular diseases, ischemic heart diseases, cerebrovascular diseases, other cardiovascular diseases, external causes, and other causes of death. Socioeconomic inequalities were quantified with relative risk and relative index of inequality (RII). The RII measures socioeconomic inequalities across the population and can be interpreted as the ratio of mortality rates of those with the lowest to those with the highest socioeconomic status.ResultsAnalyses showed an increase in educational differences in all-cause mortality among men (the RII increased from 1.96 to 2.77 from the first to the last period) and among women (the RII increased from 1.87 to 2.53). Socioeconomic inequalities increased for all causes of death studied among women, and for cancer and cardiovascular diseases among men. The contribution of cancer mortality to the difference in overall mortality between the lowest and the highest levels of education sharply increased over the entire study period, especially for women.ConclusionThis study shows that large socioeconomic inequalities in mortality exist in France, and that they have increased over time in both men and women.     

Disparities in deaths from stroke among persons aged <75 years--United States, 2002

Despite declines in deaths from stroke, stroke remained the third leading cause of death in the United States in 2002, and age-adjusted death rates for stroke remained higher among blacks than whites. In 1997, excess deaths from stroke occurred among persons aged <65 years in most racial/ethnic minority groups, compared with whites. A younger age distribution among Hispanics and other racial/ethnic groups compared with whites might partly explain the disproportionate burden in deaths at younger ages. To examine disparities in stroke mortality among persons aged <75 years, CDC assessed several characteristics of mortality at younger ages by using death certificate data for 2002. This report summarizes the results of that assessment. Overall, 11.9% of all stroke deaths in 2002 occurred among persons aged <65 years; the proportion of stroke decedents who were aged <65 years was higher among blacks, American Indians/Alaska Natives, and Asians/Pacific Islanders, compared with whites. In addition, the mean ages of stroke decedents were statistically significantly lower in these racial groups than among whites. Blacks had more than twice the age-specific death rates from stroke than whites aged <75 years. Approximately 3,400 excess stroke deaths would not have occurred among blacks in 2002 if blacks had had the same death rates for stroke as whites aged <65 years. Moreover, age-adjusted estimates of years of potential life lost (YPLL) before age 75 years from stroke were more than twice as high for blacks than for all other racial groups. Reducing premature death from stroke in these groups will require early prevention, detection, treatment, and control of risk factors for stroke in young and middle-aged adults.     

Impact of the human immunodeficiency virus epidemic on mortality trends in young men, United States.

Following a long-term decline, death rates in men 25-44 years of age increased from 212 deaths/100,000 in 1983 to 236 deaths/100,000 in 1987. To assess the impact of human immunodeficiency virus (HIV) infections on this trend and to identify causes that are increasing in association with the HIV epidemic, we analyzed national mortality statistics and compared death rates in states with high and low incidence of acquired immunodeficiency syndrome (AIDS). In 1987, there were 10,248 deaths with HIV infection, AIDS, or conditions in the AIDS surveillance definition assigned as the underlying cause, representing 11 percent of deaths for men in this age group compared to less than 1 percent in 1980. In addition, deaths with other underlying causes, such as other infections, drug abuse, and unknown/unspecified causes, had diverging and higher rates in states with high versus low AIDS incidence. In the absence of deaths due to HIV/AIDS and excess deaths due to these associated conditions, we estimate that death rates for men 25-44 years of age would have been 201-209/100,000 in 1987. For 1987, approximately 70-90 percent of HIV-related deaths were reported through national AIDS surveillance. The HIV epidemic has led to a reversal in mortality trends and to increases in various causes of death for young men.     

Inequalities in mortality according to educational level in two large Southern European cities

BACKGROUND: In Spain, studies on social inequalities in mortality based on individuals are few due to the poor quality of information on occupation in death certificates. This study looks at the differences in mortality according to educational level, using individual information obtained through the linkage between the Death Register and the Municipal Census, in the cities of Madrid and Barcelona, Spain. METHODS: The study populations were residents of Madrid and Barcelona aged >24 years, who died in 1993 and 1994. Indicators obtained for each city and educational level were: age- and sex-specific mortality rates, and life expectancy at 25 years. Poisson regression models were fitted to obtain the relative risk (RR) of death for each educational level with respect to the reference level (higher education completed), adjusted for age. RESULTS: The mortality rate was lower among individuals with higher educational levels, while life expectancy at 25 years was higher. In both cities men and women with no education showed the highest mortality in all age groups, with very high RR in the youngest age group (RR for men aged 25-34 years = 7.08 in Madrid and 6.02 in Barcelona, whereas in women these RR were 6.33 and 5.63 respectively). In Barcelona the greater part of the overall mortality difference for the group aged 25-34 years was due to AIDS (acquired deficiency syndrome, 33.4% in men and 59.3% in women). CONCLUSION: The present study has found higher mortality (mainly from AIDS) among individuals with no academic qualifications thus drawing attention to the need to implement policies aimed at reducing these inequalities.     

Smoking-attributable mortality in Bangladesh: proportional mortality study

Objective

To directly estimate how much smoking contributes to cause-specific mortality in Bangladesh.

Methods

A case–control study was conducted with surveillance data from Matlab, a rural subdistrict. Cases (n = 2213) and controls (n = 261) were men aged 25 to 69 years who had died between 2003 and 2010 from smoking-related and non-smoking-related causes, respectively. Cause-specific odds ratios (ORs) were calculated for “ever-smokers” versus “never-smokers”, with adjustment for education, tobacco chewing status and age. Smoking-attributable deaths among cases, national attributable fractions and cumulative probability of surviving from 25 to 69 years of age among ever-smokers and never-smokers were also calculated.

Findings

The fraction of ever-smokers was about 84% among cases and 73% among controls (OR: 1.7; 99% confidence interval, CI: 1.1–2.5). ORs were highest for cancers and lower for respiratory, vascular and other diseases. A dose–response relationship was noted between age at smoking initiation and daily number of cigarettes or bidis smoked and the risk of death. Among 25-year-old Bangladeshi men, 32% of ever-smokers will die before reaching 70 years of age, compared with 19% of never-smokers. In 2010, about 25% of all deaths observed in Bangladeshi men aged 25 to 69 years (i.e. 42 000 deaths) were attributable to smoking.

Conclusion

Smoking causes about 25% of all deaths in Bangladeshi men aged 25 to 69 years and an average loss of seven years of life per smoker. Without a substantial increase in smoking cessation rates, which are low among Bangladeshi men, smoking-attributable deaths in Bangladesh are likely to increase.     

Increasing mortality among adults in Scotland 1981 to 1999

BACKGROUND: The aim of the study was to describe the change in overall and cause-specific mortality in Scotland between the early 1980s and late 1990s, with particular reference to the mortality experience of young adults. METHOD: The study was based on death records for Scottish residents. Changes in age and cause-specific death rates between 1981-83, 1989-91 and 1997-99 were compared. RESULTS: Between 1981-83 and 1989-91 death rates in Scotland began to rise among young men aged 20-24 while for those aged over 25 rates declined. The greatest fall in rates was experienced at ages 40 to 59. When death rates during 1997-99 were compared to rates in 1989-91 this pattern had changed. During the 1990s death rates among 20 to 34-year-olds increased, with a slight rise at ages 35-44. At older ages overall mortality continued to decline but the greatest fall was at ages 60 and over. Trends among women shared similarities with men. For both men and women falls in mortality from heart disease, stroke, and cancers were being differentially offset by increases in other causes of death across all age groups. The causes of death that contributed to the increased death rate among young adults include to various degrees, suicides, drug deaths, alcohol and violence. CONCLUSION: In Scotland changes in mortality result from a complex combination of different trends in mortality from various causes of death. The rate of decline in mortality among men aged 59 and below is slowing down, and death rates among young men aged 15-44 are increasing. If these trends continue there is a suggestion that future death rates may begin to rise at older ages.     

Suicide and marital status in the United States, 1991-1996: is widowhood a risk factor?

OBJECTIVES: This study examined whether marital status is associated with suicide rates among various age, sex, and racial groups, in particular with widowhood among young adults of both sexes. METHODS: US national suicide mortality data were compiled for the years 1991-1996, and suicide rates were broken down by race, 5-year age groups, sex, and marital status. RESULTS: Data on suicide rates indicated an approximately 17-fold increase among young widowed White men (aged 20-34 years), a 9-fold increase among young widowed African American men, and lesser increases among young widowed White women compared with their married counterparts. CONCLUSIONS: National data suggest that as many as 1 in 400 White and African American widowed men aged 20-35 years will die by suicide in any given year (compared with 1 in 9000 married men in the general population).     

Pedestrian fatalities by race/ethnicity in Arizona, 1990-1996

PURPOSE: To explore rates of pedestrian fatalities in Arizona, and how rates and circumstances of pedestrian deaths differ by race/ethnicity, urban or rural residence, age, and gender. METHODS: Using the Fatality Analysis Reporting System and the National Center for Health Statistics' Multiple Cause of Death file, pedestrian fatalities in Arizona from 1990 through 1996 were classified by gender, race/ethnicity, and urban or rural residence. Age-adjusted rates were calculated and adjusted for the proportion of rural residence. Age analyses compared pedestrian fatality rates in 10-year age groups by race/ethnicity. Conditions associated with pedestrian deaths were examined, including the time and day of occurrence, alcohol involvement, and degree of pedestrian contribution to the crash. RESULTS: American Indians had rates of pedestrian deaths 6 to 13 times those of non-Hispanic whites. Elevated rates for American Indians were found in urban and rural areas, in both genders, in all age groups in men, and in five of nine age groups in women. American-Indian pedestrian death rates and relative risks (RRs) were higher in rural areas than in urban areas. Compared to non-Hispanic whites, urban Hispanic males had an elevated RR of 1.56, rural Hispanic females had an RR of 2.45, and urban African-American (AA) females had an RR of 2.33. However, significantly elevated rates, compared to non-Hispanic whites, were limited to Hispanic males aged <5 years and African-American females aged 65 to 74 years. In all race/ethnic groups, except rural Hispanics, men had higher rates than women, although American-Indian women had higher rates than non-Hispanic whites, African Americans, and Hispanic men.Rural residence accounted for 27% of the excess American-Indian pedestrian mortality. Sixty-one percent of urban, American-Indian pedestrian deaths occurred on weekends, compared to 29% among non-Hispanic whites and 46% among Hispanics. American Indians had six times the rate of alcohol-related pedestrian deaths as non-Hispanic whites in urban areas and 16 times that respective rate in rural areas. Hispanics had an alcohol- involvement RR of 1.82 in urban areas, but the RR was not elevated in rural areas. When blood alcohol was measured, the blood alcohol concentration was >0.20 g/dL in 64.4% of American Indians, 35% of Hispanics, and 29% of non-Hispanic whites. CONCLUSION: A major disparity in pedestrian fatalities exists for both American-Indian men and women in urban and rural areas. Other racial/ethnic groups have elevated pedestrian fatality rates that are gender and residence specific, and are limited to specific age groups. Much of the American-Indian excess mortality is alcohol related and associated with residence in rural areas.     

Trends in mortality from major non-communicable diseases in the middle-aged population of Malta

Trends in life expectancy and mortality from major non-communicable diseases in Malta were analyzed from the national vital statistics available. Most of the increased life expectancy during the 20th century in Malta took place between 1930 and 1960 and since then only a minor increase was observed. The peak in age standardized total mortality in men and women aged 40-69 years was during 1974-76. Total mortality in men was about 40% higher than that of women. The proportion of deaths from major non-communicable diseases (cardiovascular diseases, cancer and diabetes) of all deaths increased during 1968-82. In 1983-84 in the age group 45-64 cardiovascular diseases accounted for 54% of deaths in men and 43% in women, cancer 27% and 34%, and diabetes 3% and 11% in men and women, respectively. The international comparison of mortality data showed that mortality from both cardiovascular diseases, cancer and diabetes was clearly higher than in other European Mediterranean countries ranking among the highest in the whole Europe. Public health intervention programmes have initiated in Malta to reduce these high death rates in the future.     

Years of potential life lost before age 65, by race, Hispanic origin, and sex--United States, 1986-1988.

A substantial proportion of mortality among young persons is preventable. National vital statistics were used to establish a baseline for the surveillance of rates of years of potential life lost before age 65 (YPLL < 65) in the United States. Rates of YPLL < 65 were calculated for 1986 through 1988 for leading causes of preventable death, by race, Hispanic origin, and sex. U.S. racial and ethnic populations differed widely in YPLL < 65. Among males, the rate (per 1,000 population < 65 years) of YPLL < 65 was highest for non-Hispanic blacks (140.0), followed by American Indians/Alaskan Natives (100.9), Hispanics (74.3), non-Hispanic whites (68.3), and Asians/Pacific Islanders (38.2). Among females, the rate was highest for non-Hispanic blacks (73.7), followed by American Indians/Alaskan Natives (52.0), non-Hispanic whites (35.7), Hispanics (32.9), and Asians/Pacific Islanders (23.2). For non-Hispanic blacks, the high rate of YPLL < 65 was due to increased rates for all causes of death considered, particularly homicide. The high rate for American Indians/Alaskan Natives was due principally to deaths from four causes: unintentional injuries, cirrhosis, suicide, and diabetes. Asians/Pacific Islanders had low rates for most causes of death. In setting health-care priorities and prevention strategies to reduce the large racial-ethnic gap in early deaths, it is essential to recognize the differences in causes of premature mortality among sex, racial, and ethnic populations. Periodic reassessment of YPLL < 65 among these groups provides a simple, timely, and representative means of conducting surveillance to measure the impact of intervention strategies on a national basis.     

Systemic Sclerosis Mortality in the United States: 1979–1998

The US national mortality rates from systemic sclerosis (SSc) have not been reported since 1979. We studied age, gender and race specific time trends in US national mortality rates of SSc during the period 1979–1998 using poisson regression models. Over the 4.93 billion person-years of observation during the study period, there were 18,126 deaths from SSc, representing a mortality rate of 3.9 per million. The age adjusted mortality rates for men and women were 1.9 and 5.4 per million respectively. There were relatively few deaths in the extremes of age. SSc mortality rates increased with age in both genders and in all racial groups (p<0.001). In multivariable models adjusted for two-way statistical interactions, being African–American, female and of older age were associated with higher death rates. Over the 20 years of observation, overall (age-adjusted) SSc mortality rates showed a 36% increase (p<0.001) and subgroup analyses revealed that the increases were confined to women of both races. This rise occurred during a period in which post-diagnosis survival of SSc is known to have increased, suggesting an increasing incidence of this disease.     

Estimation of excess mortality associated with influenza-epidemics by age and cause specific death in Japan, 1975-1999

OBJECTIVES: The purpose of this study was to assess the effects of recent influenza epidemics on mortality in Japan. METHODS: We applied a new definition of excess mortality associated with influenza epidemics and a new estimation method (new method) proposed in our previous paper to the national vital statistics for 1975-1999 (ICD8-ICD10 had been adopted) in Japan. This new method has the advantages of removing a source of random variations in excess mortality and of being applicable to shifting trends in mortality rates from different causes of death in response to the revision of ICD. The monthly rates of death from all causes other than accidents (all causes) and some cause-specific deaths such as pneumonia, malignant neoplasm, heart disease, cerebrovascular disease(C.V.D) and diabetes(D.M.) were analyzed by total and by five age groups: 0-4 years, 5-24 years, 25-44 years, 45-64 years, and 65 years old or older. RESULTS: The following findings were noted: 1. For each epidemic in every other year since 1993, large-scale excess mortality of over 10,000 deaths was observed and the effect of those epidemics could be frequently detected in mortality even among young persons, i.e., 0-4 years or 5-25 years. 2. Excess mortality associated with influenza epidemics influenced mortality by some chronic diseases such as pneumonia, heart disease, C.V.D., D.M., etc. For some epidemic years since 1978, excess mortality rates were detected even in mortality by malignant neoplasm. CONCLUSIONS: It has been definitely shown by applying the new method to the national vital statistics for 1975-1999 in Japan that influenza epidemics in recent years exerted an influence on overall mortality, increasing the number of deaths among the elderly and the younger generation. Monitoring of the trends in excess mortality associated with influenza epidemics should be continued.     

Deaths due to injuries among employed adults: the effects of socioeconomic class

BACKGROUND: Few studies have investigated socioeconomic status (SES) and external causes of death (ie, deaths attributable to injuries). These deaths are of particular interest because they are potentially preventable and they represent the second leading cause of years of life lost under age 75. METHODS: We studied 261,723 deaths from external causes in 27 states from 1984 to 1997 among employed persons age 20-64. Numerator data came from occupation on the death certificate. Occupation-specific denominator data came from the U.S. Census. A Nam-Powers SES score was assigned to each occupation based on its relative income and education in the U.S. Census. RESULTS: After adjusting for age, sex, year and race, SES was strongly associated with mortality from all external causes combined for men (rate ratios = 2.9, 2.3, 1.5, and 1.0 by ascending SES quartile), and to a lesser extent for women (rate ratios = 1.6, 1.0, 1.1, and 1.0). A similar pattern was seen for each of the specific external causes (motor vehicle deaths, suicide, homicide, injuries other than by motor vehicle, and medical complications). CONCLUSIONS: We estimate 41% of deaths from external causes are attributable to having a SES below the top quartile (both sexes combined).