A Prospective Study of Sudden Cardiac Death among Children and Young Adults.

BACKGROUND: Sudden cardiac death among children and young adults is a devastating event. We performed a prospective, population-based, clinical and genetic study of sudden cardiac death among children and young adults. METHODS: We prospectively collected clinical, demographic, and autopsy information on all cases of sudden cardiac death among children and young adults 1 to 35 years of age in Australia and New Zealand from 2010 through 2012. In cases that had no cause identified after a comprehensive autopsy that included toxicologic and histologic studies (unexplained sudden cardiac death), at least 59 cardiac genes were analyzed for a clinically relevant cardiac gene mutation. RESULTS: A total of 490 cases of sudden cardiac death were identified. The annual incidence was 1.3 cases per 100,000 persons 1 to 35 years of age; 72% of the cases involved boys or young men. Persons 31 to 35 years of age had the highest incidence of sudden cardiac death (3.2 cases per 100,000 persons per year), and persons 16 to 20 years of age had the highest incidence of unexplained sudden cardiac death (0.8 cases per 100,000 persons per year). The most common explained causes of sudden cardiac death were coronary artery disease (24% of cases) and inherited cardiomyopathies (16% of cases). Unexplained sudden cardiac death (40% of cases) was the predominant finding among persons in all age groups, except for those 31 to 35 years of age, for whom coronary artery disease was the most common finding. Younger age and death at night were independently associated with unexplained sudden cardiac death as compared with explained sudden cardiac death. A clinically relevant cardiac gene mutation was identified in 31 of 113 cases (27%) of unexplained sudden cardiac death in which genetic testing was performed. During follow-up, a clinical diagnosis of an inherited cardiovascular disease was identified in 13% of the families in which an unexplained sudden cardiac death occurred. CONCLUSIONS: The addition of genetic testing to autopsy investigation substantially increased the identification of a possible cause of sudden cardiac death among children and young adults. (Funded by the National Health and Medical Research Council of Australia and others.).

Confronting death from drug self-intoxication (DDSI): prevention through a better definition.

Suicide and other self-directed violence deaths are likely grossly underestimated, reflecting inappropriate classification of many drug intoxication deaths as accidents or unintentional and heterogeneous ascertainment and coding practices across states. As the tide of prescription and illicit drug-poisoning deaths is rising, public health and research needs would be better satisfied by considering most of these deaths a result of self-intoxication. Epidemiologists and prevention scientists could design better intervention strategies by focusing on premorbid behavior. We propose incorporating deaths from drug self-intoxication and investigations of all poisoning deaths into the National Violent Death Reporting System, which contains misclassified homicides and undetermined intent deaths, to facilitate efforts to comprehend and reverse the surging rate of drug intoxication fatalities.

The role of coronial autopsies in a context of decreasing hospital autopsies: an investigation of the issues.

This article scrutinises the argument that decreasing hospital autopsy rates are outside the control of medical personnel, based as they are on families' unwillingness to consent to autopsy procedures, and that, as a consequence, the coronial autopsy is the appropriate alternative to the important medical and educational role of the autopsy It makes three points which are well supported by the research. First, that while hospital autopsy rates are decreasing, they have been doing so for more than 60 years, and issues beyond the simple notion of consent, like funding formulae in hospitals, increased technology and fear of litigation by doctors are all playing their part in this decline. Secondly, the issue of consent has as much to do with families not being approached as with families declining to give consent. This is well supported by recent changes in hospital policy and procedures which include senior medical personnel and detailed consent forms, both of which have been linked to rising consent rates in recent years. Finally, the perception that coronial autopsies are beyond familial consent has been challenged recently by legislative changes in both Australia and the United States of America which allow objections based on religion and culture to be heard by coroners. For these reasons, it is argued that medical personnel need to focus on increasing hospital autopsy rates, while also addressing the complex ethical issues associated with conducting medical research within the context of the coronial autopsy.

Increasing the information available to coroners: the effect on autopsy decision-making.

This paper details research completed in 2007 which investigated autopsy decision-making in a death investigation. The data was gathered during the first year of operation in Queensland, Australia, of a new Coroners Act which changed the process of death investigation in three ways which are important to this paper. First, it required a greater amount of information to be gathered at the scene by police: this included a thorough investigation of the circumstances of the death, including statements from witnesses, friends and family, as well as evidence gathering at the scene. Second, it required coroners, for the first time, to determine the level of invasiveness required in the autopsy to complete the death investigation. Third, it enabled any genuine family concerns to be communicated to the coroner. The outcome of such information was threefold: (i) a greater amount of information offered to the coroner led to a decrease in the number of full internal autopsies ordered, but an increase in the number of partial internal autopsies ordered; (ii) this shift in autopsy decision-making by coroners saw certain factors given greater importance than others in decisions to order full internal, or external only, autopsies; (iii) a raised family concern had a significant impact on autopsy decision-making and tended to decrease the invasiveness of the autopsy ordered by the coroner.

The coronial system in Queensland: the effects of new legislation on decision-making.

The purpose of this article is to detail research completed in 2007 which investigated the way in which coroners made decisions in a death investigation, with a particular focus on their autopsy decision-making. The data were gathered during the first year of operation of a new Coroners Act in Queensland, Australia, which required a greater amount of information to be gathered at the scene by police, and this included a thorough investigation of the circumstances of the death, including statements from witnesses, friends and family, as well as evidence-gathering at the scene. This article addresses the outcomes of that increased information on coronial decision-making in three ways: first, whether or not the greater amount of information offered to coroners enabled them to be less reliant on full internal autopsies to establish cause of death; secondly whether certain factors were more influential in decision-making; and thirdly, whether the information gathered at the scene negates the need for full internal autopsies in many situations, irrespective of the decision-making by coroners.

Issues surrounding a reduction in the use of internal autopsy in the coronial system.

In 2003 it was estimated that 2,700 full internal coronial autopsies were performed in Queensland at a cost of approximately A$5.3 million. This large number of internal coronial autopsies (almost 95% of all matters referred to the coroner) is of concern not only due to the economic cost but also because of the public heath risks, availability of specialist staff and significant religious and cultural sensitivities surrounding internal autopsies. In 2005 the authors began research funded by the Australian Research Council (ARC) to determine if unnecessary internal autopsies are being performed in Queensland and to establish guidelines for when an internal autopsy is required. This article highlights areas of potential concern when the issue of autopsy is reviewed within the coronial system through an examination of international literature on the issue of autopsy diagnosis and error rates more generally, and through preliminary discussion of the data obtained. The article considers the role and purpose of the autopsy generally as well as within the coronial system specifically; compares diagnostic error rates in hospital autopsies with those in the coronial system; the current situation internationally with regard to internal autopsies; and finally the specific circumstances existing in Queensland.

Communicating with the coroner: how religion, culture, and family concerns may influence autopsy decision making.

Based on coronial data gathered in the state of Queensland in 2004, this article reviews how a change in legislation may have impacted autopsy decision making by coroners. More specifically, the authors evaluated whether the requirement that coronial autopsy orders specify the level of invasiveness of an autopsy to be performed by a pathologist was affected by the further requirement that coroners take into consideration a known religion, culture, and/or raised family concern before making such an order. Preliminary data reveal that the cultural status of the deceased did not affect coronial autopsy decision making. However, a known religion with a proscription against autopsy and a raised family concern appeared to be taken into account by coroners when making autopsy decisions and tended to decrease the invasiveness of the autopsy ordered from a full internal examination to either a partial internal examination or an external-only examination of the body. The impact of these findings is briefly discussed.

Declining autopsy rates and suicide misclassification: a cross-national analysis of 35 countries.

CONTEXT: Suicides are prone to misclassification during death ascertainment procedures. This problem has generated frequent criticism of the validity of suicide mortality statistics. OBJECTIVE: To employ an external measure of the validity of cause-of-death statistics (ie, national autopsy rates) and to examine potential misclassification of suicide across countries from Europe to Central and Northern Asia. DESIGN: Cross-national analysis. SETTING: Thirty-five countries. PARTICIPANTS: Aggregated mortality data. MAIN OUTCOME MEASURES: Data from 35 countries during the period from 1979 to 2007 were used to analyze the association of suicide rates with autopsy rates and death rates of undetermined and ill-defined causes, respectively. Analyses were cross-sectional and longitudinal. RESULTS: Cross-sectionally, a 1% difference in autopsy rates among nations was associated with a suicide rate difference of 0.49 per 100,000 population. Longitudinally, a 1% decrease in the autopsy rate aligned with a decrease of 0.42 per 100,000 population in the suicide rate. These cross-sectional and longitudinal associations were robust after adjustment for unemployment, degree of urbanization, and prevalence of undetermined or ill-defined deaths. Associations strengthened when analyses were confined to 19 European Union member countries. CONCLUSION: Autopsy rates may spatially and temporally affect the validity of suicide mortality statistics. Caution should be exercised in comparing international suicide rates and evaluating interventions that target suicide rate reduction.