European Maxillofacial Trauma (EURMAT) in children: a multicenter and prospective study

OBJECTIVE

The aim of this study is to present and discuss the results of a European multicentre prospective study about pediatric maxillofacial trauma epidemiology during a year.

STUDY DESIGN

The following data were recorded: gender, age, etiology, site of fracture, date of injury. Of the 3396 patients with maxillofacial fractures admitted within the study period, 114 (3.3%) were children aged 15 years and younger, with a male/female ratio of 2.6:1. Mean age was 10.9 years. Most patients (63%) were aged 11-15 years.

RESULTS

The most frequent cause of injury was fall (36 patients). Sport injuries and assaults were almost limited to the oldest group, whereas falls were more uniformly distributed in the 3 groups. The most frequently observed fracture involved the mandible with 47 fractures. In particular, 18 condylar fractures were recorded, followed by 12 body fractures.

CONCLUSIONS

Falls can be acknowledged as the most important cause of facial trauma during the first years of life. The high incidence of sport accidents after 10 years may be a reason to increase the use of mouthguards and other protective equipment. Finally, the mandible (and in particular the condyle) was confirmed as the most frequent fracture site.

[Which cancerous diseases are significant for the risk assessment when underwriting life insurance?]

Cancer is the most important cause of death in life insurance and not cardiovascular disease! Life insurance is bought by persons aged between 15 and 65 years with an average of about 35 years. Therefore mortality statistics for the total population cannot be transferred to life insurance. In that segment cancer ranks before cardiovascular diseases. In females, cancer is even more important than in males because they are less prone to cardiovascular diseases in the age groups under consideration. Tumor mortality rises after age 40 and reaches its peak in males at age 70, in females the curve is moved towards higher ages and peaks at age 80.

[Work disability in public press professions]

In this study more than 1,000 cases of long-term disability among members of the press and media were evaluated. Mental disorders were the main cause of disability in almost every fourth case. In women psychiatric illnesses were even more important. The most common diagnosis was that of a depressive disorder which accounted for more than half of all psychiatric cases. The causes of disability of other insurance systems such as the German social security scheme and the pension and disability plan for the medical profession were compared. Mental illnesses are the leading cause of disability in white collar workers and orthopaedic illnesses, especially disorders of the vertebral column, are the leading cause in blue collar workers, as one might have expected. In females mental disorders are even more common than in men whereas men tend to have more cardiovascular problems than women. In this study also some interesting features regarding disability caused by various illnesses after long-term follow-up were found. This opens unknown perspectives allowing new assessment of diseases and eventually will enable the actuary to price medical diagnoses for disability insurance.

[Cause of death in life insurance]

In this study, mortality cases of a leading insurance company were collected over a period of several years and evaluated for the causes of death. In case of incorrect information given concerning the status of health, German rules and regulations allow an insurance company to resign from a contract only within the first three years. Because of this restriction, the cause of death is usually investigated during this period of time only. In Germany, unlike in many other countries, the official death certificate does not contain the cause of death, therefore the attending physicians have to be contacted for medical information. This rather costly and time-consuming procedure has to be limited to the three-year period. What seems to be at first glance an unfortunate restriction, turns out to be an enormous advantage at second glance. This three-year period can give excellent feedback about specific risks and trends of antiselection. Data of 1,549 persons dying within the first three years were evaluated. It turns out that cancer is the most common cause of death and cardiovascular diseases follow in second place. The underwriter and the consulting physician should keep in mind this surprising fact that tumors and not cardiovascular diseases play the most important role in life assurance. Unfortunately there are no such screening measures for tumors as we have at hand for cardiovascular diseases. Females have a lower mortality than males. Cross-sections show risks typical for certain age groups. In people under age 30, unnatural causes of death such as accidents and suicide cause more than two thirds of deaths. In the higher age groups, natural causes such as cancer and cardiovascular diseases become more and more important. In females cancer is even more important than in males, since they are less prone to die from cardiovascular diseases during the age period that is of interest to life assurance. The most common type of cancer in men was lung cancer and in females breast cancer. Trends of antiselection could be found in contracts with low sums assured, especially in older applicants. Our current practice of risk assessment can easily explain this phenomenon. For economical reasons, less time, money and effort can be spend on minor contracts than on those with high sums assured. On the other hand, it is unquestionable that a mandatory examination before offering life assurance coverage guarantees excellent risk assessment.

[AIDS and life insurance in Germany. 10 years successful risk management]

The introduction of AIDS specific measures by the German life assurance industry in 1988 was an important step towards prevention of adverse selection by the well known risk groups. In retrospect one can state that in the eighties there was a tendency of risk groups for inappropriately high insurance coverage. This could be curtailed with the introduction of a question as to a positive HIV test in each proposal form and a mandatory HIV test for every policy exceeding DM 250,000. These tendencies could very nicely be demonstrated by studies of own AIDS cases. The claims for death and disability benefits because of AIDS are as of now compared to the total claims of minor importance.

[Suicide and life insurance. Evaluation of suicide cases]

A retrospective evaluation of 521 life assurance contracts belonging to 468 persons who had committed suicide within the first 3 years of contract was performed. Contract data such as tarif, sum assured and duration do not differ from those of the other customers. Except for a few there were hardly any persons who acquired life assurance under speculative purposes, such as the intention to gain financial advantages for their relatives at the expense of the community of all insured persons by claiming life insurance benefits after suicide. By means of these results, one can easily state that the 3 years' exemption period according to the German rules and regulations for life assurance is an effective barrier against misuse in case of suicide. The incidence of suicide cases among all mortality cases cannot be established due to peculariarities of the German insurance market. Other evaluations were performed as to age, sex and marital status of the persons involved, the point in time when suicide was performed, the methods chosen and possible motives. Psychiatric problems such as depression and addiction can be found in the past medical history of many persons. The criterium of exclusion of free will was found in 14.4 percent of all cases.

[Cause of death statistics (III). Sources for insurance medicine: cardiovascular diseases and selected causes of death]

Among cardiovascular diseases coronary artery disease ranks first as cause of death in the age group that is of importance for life insurance. It is the main cause of death in males age 30 and up. More females die from cerebral hemorrhage than from coronary artery disease. From age 50 upwards coronary artery disease is also the main cause of cardiovascular death in females. Over two thirds of all deaths due to gastrointestinal diseases are caused by liver disease, mainly cirrhosis of the liver. Chronic obstructive pulmonary disease causes two thirds of all respiratory deaths. Accidental deaths seem to be a male privilege, since only 20 per cent females are involved. Especially young males are at risk to get killed in an accident. The particular situation of accidents in the elderly mainly due to falls is discussed. Neurological, psychiatric illnesses, alcohol and drug addiction are discussed briefly. Males in general are more prone to commit suicide than females who account for only one quarter of all suicide deaths. Hanging was the preferred method. Young males especially are in danger of killing themselves. The importance of this new method of compiling vital statistics for life insurance purposes is discussed. These are the conclusions: 1. Main risk for life insurance is death due to cancer, mainly of the alimentary and respiratory tract. This applies to the population at large. In females breast and genital cancer are of crucial importance. 2. In males cardiovascular diseases cause slightly more deaths than tumors. From age 30 on coronary artery disease is the main cause of cardiovascular death.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cause of death statistics (II). Findings for insurance medicine: malignant tumors]

In the age group that is of importance for life insurance, tumors of the alimentary tract are the main cause of death. Lung cancer takes place number 2 in the male and breast cancer in the female population. In females age 30 to 60 breast cancer is the killer number one of all tumors. Tumors specific to the female sex account for about half of all cancer deaths in that age group. In children and young adults under age 30 leukemia takes first place of all malignancies. Age specific problems are shown in cross-sections and longitudinal sections. In general the overall mortality of tumors rises with age. In the young, death due to tumors is a rare event. The difference between the clinical incidence of tumors and the frequency of tumors as causes of death was elaborated.

[Cause of death statistics (I). Resources for risk evaluation in life insurance?]

Vital statistics as they are generally used are of no help for evaluation of risks in life insurance since they are biased by the high number of the elderly population beyond age 70. Therefore the causes of death were compiled for the age groups from 15 to 70 that are of importance in life insurance. Tumors are the number one cause of death and not cardiovascular diseases which so far have been considered to be the number one. They take second place. Even in the male population cardiovascular diseases are the number one cause of death only from age 60 on upwards. Further cross-sectioning according to decades of age shows the typical causes of death for any particular age group. Below age 30 non-natural causes s. a. accident and suicide take with over 50 per cent first place. Females have a much lower mortality as is generally known; they contribute only one third to the overall mortality of the age group under consideration.

[Performance spectrum in occupational disability. Causes--occupational groups--age--duration of insurance]

The causes of disability were elaborated in an extensive study. Accidents, coronary heart disease, diseases of the spine, and orthopedic diseases are the four most common diagnoses and account together for 52.4% of all cases of disability. The incidence of other even rarer diagnoses was shown. The average ages differ from diagnosis to diagnosis. While the average of all cases is at age 45.5 years for the beginning of disability and 9.8 years for the duration period there are diagnoses that lead to disability at an earlier age and after a shorter duration period such as for instance schizophrenia, inflammatory bowel diseases, allergies and skin affections. Heart and circulatory diseases and depressions on the other side occur at a later age and after a longer duration period. At the evaluation of risks special attention should be paid to those causes of early disability since they can turn into a claim after a short duration period and therefore can cause great subsequent costs. Some general statements can be made about occupational groups and causes of disability. Diseases of heart and circulation are rarer in physically active occupations such as construction, agriculture, and industry than in white collar workers and liberal professions. On the other side orthopedic diseases and accidents occur more frequently in construction, industry and agriculture. White collar workers tend to have more psychiatric problems which can be explained with a higher potential of conflicts at work.