"It's Overwhelming With the Grief" A Qualitative Study of Families' Experiences When a Young Relative Dies of Sudden Cardiac Death.

BACKGROUND: Sudden cardiac death (SCD) in younger individuals is frequently caused by heritable cardiac conditions. The unexpected nature of SCD leaves families with many unanswered questions and an insufficient understanding of the cause of death and their own risk for heritable disease. We explored the experiences of families of young SCD victims upon learning about their relative's cause of death and how they perceive their own risk for heritable cardiac conditions. METHODS: We conducted a qualitative descriptive study, by interviewing families of young (ages 12-45) SCD victims, who died between 2014 and 2018 from a heritable cardiac condition and were investigated by the Office of the Chief Coroner of Ontario, Canada. We used thematic analysis to analyze the transcripts. RESULTS: Between 2018 and 2020, we interviewed 19 family members, of which 10 were males and 9 were females, ages ranging from 21 to 65 (average 46.2±13.1). Four main themes were revealed, each representing a distinct time period that families experience along a trajectory: (1) interactions between bereaved family and others, in particular coroners, shaped their search for answers about their relative's cause of death, with the types, formats, and timing of communication varying by case; (2) searching for answers and processing the cause of death; (3) incidental implications of the SCD event, such as financial strain and lifestyle changes contributed to cumulative stress; (4) receiving answers (or not) and moving forward. CONCLUSIONS: Families rely on communication with others, yet the type, formats, and timing of information received varies, which can influence families' experiences of processing the death (and its cause), their perceived risk and their decision to pursue cascade screening. These results may provide key insights for the interprofessional health care team responsible for the delivery and communication of the cause of death to families of SCD victims.

Exploring the contextual risk factors and characteristics of individuals who died from the acute toxic effects of opioids and other illegal substances: listening to the coroner and medical examiner voice. / Exploration des facteurs de risque contextuels et des caractéristiques des personnes décédées des effets toxiques aigus d'opioïdes et d'autres substances illégales : prise en compte de l'avis des coroners et des médecins légistes.

INTRODUCTION: Substance-related acute toxicity deaths continue to be a serious public health concern in Canada. This study explored coroner and medical examiner (C/ME)perspectives of contextual risk factors and characteristics associated with deaths from acute toxic effects of opioids and other illegal substances in Canada. METHODS: In-depth interviews were conducted with 36 C/MEs in eight provinces and territories between December 2017 and February 2018. Interview audio recordings were transcribed and coded for key themes using thematic analysis. RESULTS: Four themes described the perspectives of C/MEs: (1) Who is experiencing a substance-related acute toxicity death?; (2) Who is present at the time of death?; (3) Why are people experiencing an acute toxicity death?; (4) What are the social contextual factors contributing to deaths? Deaths crossed demographic and socioeconomic groups and included people who used substances on occasion, chronically, or for the first time. Using alone presents risk, while using in the presence of others can also contribute to risk if others are unable or unprepared to respond. People who died from a substance-related acute toxicity often had one or more contextual risk factors: contaminated substances, history of substance use, history of chronic pain and decreased tolerance. Social contextual factors contributing to deaths included diagnosed or undiagnosed mental illness, stigma, lack of support and lack of follow-up from health care. CONCLUSION: Findings revealed contextual factors and characteristics associated with substance-related acute toxicity deaths that contribute to a better understanding of the circumstances surrounding these deaths across Canada and that can inform targeted prevention and intervention efforts.

Investigations After Death in Children.

OBJECTIVES: To discuss the role of investigations after death in children as part of a supplement on "Death and Dying in the PICU." DATA SOURCES: Literature review, personal experience, and expert opinion. DATA SELECTION: Not applicable. DATA EXTRACTION: Moderated by three experts on investigations after death in children. DATA SYNTHESIS: Not relevant. CONCLUSIONS: A multidisciplinary cliniciopathologic conference is important after the death of a child in order to help bring closure to the family and to attempt to address any concerns they may have about the care. It is also an important part of the quality of care process for a tertiary care institution and provides an unique opportunity for ongoing medical education. The model of a multidisciplinary cliniciopathologic conference used by the Ontario Coroner's Office to investigate sudden and unexpected deaths in children under 5 years old, which has been functioning for over 30 years, is described. Reports from this Pediatric Death Review Committee have been influential in improving the care of children in the province of Ontario.

Benford's Law for Quality Assurance of Manner of Death Counts in Small and Large Databases.

To assess if Benford's law, a mathematical law used for quality assurance in accounting, can be applied as a quality assurance measure for the manner of death determination. We examined a regional forensic pathology service's monthly manner of death counts (N = 2352) from 2011 to 2013, and provincial monthly and weekly death counts from 2009 to 2013 (N = 81,831). We tested whether each dataset's leading digit followed Benford's law via the chi-square test. For each database, we assessed whether number 1 was the most common leading digit. The manner of death counts first digit followed Benford's law in all the three datasets. Two of the three datasets had 1 as the most frequent leading digit. The manner of death data in this study showed qualities consistent with Benford's law. The law has potential as a quality assurance metric in the manner of death determination for both small and large databases.

Analysis of the Medical Assistance in Dying Cases in Ontario: Understanding the Patient Demographics of Case Uptake in Ontario since the Royal Assent and Amendments of Bill C-14 in Canada.

On June 17, 2016, the Canadian government legalized medical assistance in dying (MAID) across the country by giving Royal Assent to Bill C-14. This Act made amendments to the Criminal Code and other Acts relating to MAID, allowing physicians and nurse practitioners to offer clinician-administered and self-administered MAID in conjunction with pharmacists being able to dispense the necessary medications. The eligibility criteria for MAID indicates that the individual 1) must be a recipient of publicly funded health services in Canada, 2) be at least 18 years of age, 3) be capable of health-related decision-making, and 4) has a grievous and irremediable medical condition. Because this is a new practice in Canadian health care, there are no published Canadian statistics on MAID cases to date, and this paper constitutes the first analysis of MAID cases in both the province of Ontario and Canada. Internationally, there are only a few jurisdictions with similar legislation already in place (US, the Netherlands, Belgium, Luxembourg, Switzerland, Columbia, Japan, and the United Kingdom). The published statistics on MAID cases from these jurisdictions were reviewed and used to establish the current global practices and demographics of MAID and will provide useful comparisons for Canada. This analysis will 1) outline the Canadian legislative approach to MAID, 2) provide an understanding of which patient populations in Ontario are using MAID and under what circumstances, and 3) determine if patterns exist between the internationally published MAID patient demographics and the Canadian MAID data. Selected patient demographics of the first 100 MAID cases in Ontario were reviewed and analyzed using anonymized data obtained from the Office of the Chief Coroner for Ontario so that an insight into the provision of MAID in Ontario could be obtained. Demographic factors such as age, sex, the primary medical diagnosis that prompted the request for MAID, the patient rationale for making a MAID request, the place where MAID was administered, the nature of MAID drug regimen used, and the status/specialty of medical personnel who administered the MAID drug regimen were analyzed. The analysis revealed that the majority of the first 100 MAID recipients were older adults (only 5.2% of patients were aged 35-54 years, with no younger adults between ages 18-34 years) who were afflicted with cancer (64%) and had opted for clinician-administered MAID (99%) that had been delivered in either a hospital (38.8%) or private residence (44.9%). Although the cohort was small, these Ontario MAID demographics reflect similar observations as those published internationally, but further analysis of both larger and annual case uptake in both Ontario and Canada will be conducted as the number of cases increases.

Drug Toxicity Deaths after Release from Incarceration in Ontario, 2006-2013: Review of Coroner's Cases.

BACKGROUND: There is an increased risk of death due to drug toxicity after release from incarceration. The purpose of this study was to describe the timing, rate and circumstances of drug toxicity deaths following release from incarceration. This information can be used to help design potential preventive interventions. METHODS AND FINDINGS: We reviewed coroner's files to identify deaths in adults in Ontario between 2006 and 2013 caused by drug toxicity (n = 6,978) and these records were matched with provincial correctional records to identify individuals who died within one year of being released from incarceration (n = 702). Twenty percent (n = 137) of the 702 deaths occurred within one week of release. The majority (77%, n = 538) of deaths after release involved one or more opioids. Of the deaths involving opioids, intervention by another person may have been possible in 318 cases. CONCLUSIONS: Between 2006 and 2013 in Ontario, one in ten drug toxicity deaths in adults occurred within one year of release from provincial incarceration. These findings may help to inform the implemention and assessment of interventions aimed at reducing drug toxicity deaths following release from incarceration.

Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome.

Nonophthalmologists did not attempt to (36%) or were "unable to" (19%) examine the fundus in 72 children with shaken baby syndrome. When the retina was examined, nonophthalmologists were accurate in recognizing the absence or presence of retinal hemorrhage in 87%. However, false-negative examinations occurred in 13%. Ophthalmology consultation should be an integral part of the evaluation of children with suspected abuse.

Sternal fractures as a manifestation of abusive injury in children.

BACKGROUND: Sternal fractures are rare injuries in children. The rarity of this injury is likely due to both the relative plasticity of the pediatric thorax and to the difficulty in establishing a radiographic diagnosis without dedicated views. Current literature suggests that this injury in young children is highly specific for abusive injury. HYPOTHESIS: Sternal fractures are not highly specific for abusive injury. MATERIALS AND METHODS: This was a retrospective radiographic and clinical chart review of all documented sternal fractures over an 11-year period at a large pediatric hospital. RESULTS: Of 12 children with sternal fractures identified, four were < or = 2 years of age and eight were > or = 3 years of age. The mechanism of injury was suspicious for child abuse in two children. Both of these children were < or = 2 years of age. In one toddler, an unwitnessed injury resulted in extensive initial familial anxiety until abusive injury was excluded. CONCLUSION: Sternal fractures are unusual injuries, yet they, in themselves, are not highly specific for abusive injury.

Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome.

PURPOSE: To report correlation between retinal and intracranial abnormalities and to evaluate pathogenesis of retinal hemorrhages in the shaken baby syndrome (SBS). DESIGN: Observational case series. METHODS: Seventy-five children with apparent nonaccidental head trauma consistent with SBS had complete physical examination, complete ophthalmologic examination, neuroimaging by CT or MRI, or both, and skeletal radiographic survey. In this retrospective review, ophthalmoscopic and intracranial abnormalities were correlated. RESULTS: The age of patients ranged from 2 to 48 months (mean - SD, 10.6 +/- 10.4 months). Neuroimaging was abnormal in all 75 cases. Findings included subdural hematoma (70 children, 93%), cerebral edema (33 children, 44%), subarachnoid hemorrhage (12 children, 16%), vascular infarction (nine children, 12%), intraparenchymal blood (six children, 8%), parenchymal contusion (six children, 8%), and epidural hemorrhage (one child, 1%). Sixty-four (64/75, 85%) children had retinal abnormalities, mostly (53/64, 82%) confluent multiple hemorrhages that were subretinal, intraretinal, and preretinal in 47/64 (74%) and bilateral in 52/64 (81%). No association was found between anatomic site (left, right, or bilateral) of intracranial and retinal findings (McNemar test kappa = -0.026-0.106) or between any of the intracranial findings mentioned above and the following retinal findings: normal or abnormal retinal examination, multiple (>10) or few retinal hemorrhages (< or =10), symmetric or asymmetric retinal findings, or retinoschisis (kappa = -0.127-0.104). Signs of possible increased intracranial pressure were not correlated with any retinal abnormality (kappa = -0.03-0.073). There was no correlation between evidence of impact trauma to the head and retinal hemorrhages (kappa = 0.058). Total Cranial Trauma Score and Total Retinal Hemorrhage Score, both indicating the severity of injury, were correlated (P =.032). CONCLUSIONS: Our study supports previous observations that the severity of retinal and intracranial injury is correlated in SBS. We cannot support the suggestions that in most children with SBS retinal bleeding is caused by sustained elevated intracranial, elevated intrathoracic pressure, direct tracking of blood from the intracranial space, or direct impact trauma. The correlation in severity of both eye and head findings may suggest, however, that retinal abnormalities are the result of mechanical shaking forces.