Assuming that bodies returned for cremation represented 57.4%,14 then this suggests a low death rate in the order of 12 deaths per 100,000 visits. A large proportion of deaths (20%) were caused by trauma, of which the majority was accidental. Accidental deaths among travelers have been observed to be increasing http://www.selleckchem.com/products/ipilimumab.html in US citizens and it has been argued that pretravel advice tends to focus on infectious disease risk as opposed to risks that cause injury.22 Personal preparedness and planning is important in increasing safety and decreasing the risk of accidents among travelers who due to unfamiliarity with local conditions

or changed personal behavior are at increased risk of death due to drowning21,25 and car accidents22,26,27; children may be particularly vulnerable.25 In terms of Scottish travelers, it is interesting to note the high proportion of deaths due to selleck screening library circulatory causes (52%), although the proportion is less in this study than that observed by Paixao and colleagues24 at 69%. In that study it was proposed that, among the elderly, deaths abroad may have occurred in their home country had they not traveled. However, our observation that for death due to failure of the circulatory system among those aged 25 to 64, the age at death among those whose bodies were returned for cremation was younger

compared to that of the reference Scottish population, raises the possibility that this difference is linked to travel abroad. A number of factors related to travel abroad may detrimentally affect those with preexisting circulatory conditions including warm climate,28 the journey,29 and lifestyle changes,30 such as increased exertion or changes in diet and/or environmental factors.31 The relationship between age at death Interleukin-3 receptor from cardiovascular disease has been observed among US citizens abroad,32 where 49% of deaths were due to this cause, with the highest proportion of deaths occurring in Western Europe. Cardiovascular death rates among US citizens abroad were found to be higher than among those at home aged 35 to 44. Considering

that many of the travelers died in Southern Europe where the incidence of cardiovascular mortality is much lower than that of Scotland,33 it would be interesting to study at which stage of the journey deaths due to failure in the circulatory system occur. Couch29 noted in an analysis of sudden death due to coronary arteriosclerosis that incidence among visitors was four times that of the local population and suggested that stress due to changing time zones or travel may have contributed. In another study of ischemic heart disease among residents of New York City,34 it was observed that increased deaths due to ischemic heart disease were observed among visitors to that city, while residents away from the city were observed to have lower numbers than expected. This effect was again tentatively linked to stress associated with living in New York for both residents and visitors alike.