A retrospective study of unexpected deaths with alcohol use disorder from Japanese forensic autopsy cases.

BACKGROUND: Alcohol use disorder (AUD) is an important target for prevention of alcohol-related problems. In this study, we analyzed forensic autopsy cases to reveal the characteristics of the living conditions and death situations of individuals with AUD. METHODS: We retrospectively investigated 486 cases with a history of alcohol consumption for which a forensic autopsy was performed from 2012 to 2021 in Yamaguchi prefecture. Judgement of AUD was made using DSM-5. Various factors were compared statistically between AUD and non-AUD cases. RESULTS: Of the 486 cases, 225 (46.2%) were judged to be AUD, including 89 (18.3%) with advanced AUD, 33 (6.8%) were judged not to be AUD, and a judgement could not be made in the remaining cases. AUD was associated with alcohol consumption prior to death. Only 14.3% of the advanced-AUD cases was in treatment for alcohol dependence. The rates of interpersonal, health, financial and legal problems, receipt of public assistance and an extremely cluttered or hoarding house status were higher in all AUD and advanced AUD cases. Living alone, smoking and BMI were also associated with AUD. CONCLUSIONS: Many cases of alcohol-related deaths may have AUD, and persons with AUD who undergo a forensic autopsy commonly have multiple socioeconomic factors that may be associated with isolation that is involved in exacerbation of AUD. Further studies of these associations are needed because early diagnosis and treatment of AUD and support for the patient may lead to reduction of alcohol-related deaths.

[Forensic medical characteristics of the prevalence of sudden death from cardiovascular diseases in the constituent entities of the Russian Federation]. / Sudebno-meditsinskaya kharakteristika rasprostranennosti vnezapnoi smerti ot serdechno-sosudistykh zabolevanii v sub"ektakh Rossiiskoi Federatsii.

The purpose of the study is to study the prevalence and frequency of sudden death (SD) from cardiovascular diseases (CVD) in the structure of non-violent death, taking into account the socio-economic development of the constituent entities of the Russian Federation. We analyzed the frequency of this indicator, compared it with the data of the Federal State Statistics Service, and determined the overall dynamics. We conducted a non-parametric analysis of the initial data, carried out clustering and visualization based on the following parameters of the initial sample: «CVD mortality in the structure of non-violent death¼, «morbidity¼ and «per capita income level¼. Correlation dependences of the level of mortality from CVD according to the form 42 on the indicated indicators of the socio-economic condition of the subject were determined. Identified subjects of the Russian Federation with an increase in mortality from CVD; established the dependence of the level of VS on CVD and a number of medical and economic indicators.

Quality of investigations into unexpected deaths of infants and young children in England after implementation of national child death review procedures in 2008: a retrospective assessment.

OBJECTIVES: In 2008, new statutory national procedures for responding to unexpected child deaths were introduced throughout England. There has, to date, been no national audit of these procedures. STUDY DESIGN: Families bereaved by the unexpected death of a child under 4 years of age since 2008 were invited to participate. Factors contributing to the death and investigations after the death were explored. Telephone interviews were conducted, and coroners' documents were obtained. The nature and quality of investigations was compared with the required procedures; information on each case was reviewed by a multiagency panel; and the death was categorised using the Avon clinicopathological classification. RESULTS: Data were obtained from 91 bereaved families (64 infant deaths and 27 children aged 1-3 years); 85 remained unexplained after postmortem examination. Documentation of multiagency assessments was poorly recorded. Most (88%) families received a home visit from the police, but few (37%) received joint visits by police and healthcare professionals. Postmortem examinations closely followed national guidance; 94% involved paediatric pathologists; 61% of families had a final meeting with a paediatrician to explain the investigation outcome. There was no improvement in frequency of home visits by health professionals or final meetings with paediatricians between 2008-2013 and 2014-2017 and no improvement in parental satisfaction with the process. CONCLUSIONS: Statutory procedures need to be followed more closely. The implementation of a national child mortality database from 2019 will allow continuing audit of the quality of investigations after unexpected child deaths. An important area amenable to improvement is increased involvement by paediatricians.

Sudden natural death behind the wheel: Review of driver deaths and fitness to drive assessment history in Victoria, Australia 2012-2013.

This study reviews the circumstances and medical causes of death of motor vehicle drivers who died in circumstances of sudden illness whilst behind the wheel in Victoria, Australia 2012-13. The driver's fitness to drive assessment history was also examined to identify prevention opportunities. Deaths included in the study were those referred to a panel responsible for determining whether the driver fatality should be included in the official road toll, where prior doubt exists. A research team comprising of forensic physicians examined the case file of each death involving sudden illness. Forty-five driver deaths during the two-year period were reviewed. Ischaemic heart disease was the most common cause of death. Over 80% of drivers were male with a median age of 64 years. While limited medical history was available, significantly impacting study analysis, findings identified minimal opportunity to improve the fitness to drive review process.

Unexpected death in ill old age: An analysis of disadvantaged dying in the English old population.

The literature on death expectation in ill old age is mostly medical. A social science standpoint (especially quantitative) is practically absent. However, whether families, social and healthcare services can anticipate, support and prepare for the deaths of ill old adults is not reducible to the biomedical paradigm. Yet it is critical for end of life care (EOLC) policy. This study's aim is to investigate relatives' perception of death as unexpected in relation to both disease-related and care-related factors. Using the English Longitudinal Study of Ageing End-of-life Interviews Wave 6 this paper draws on probit regression analysis of unexpected (vs. expected) death in ill adults aged 50+. Findings are interpreted considering the containment of sudden death and the trajectories of dying in ill old age. The latter display overall visible decline preceding death. On this basis, EOLC literature and policy evidence death's uncertain timing as much as death's certain emergence in the horizon of expectation. Therefore, unexpected death in ill old age was interpreted as a failure to acknowledge dying, rather than the impossibility of discerning its approach. Very old age, dementia diagnoses and supported care environments were found to shape unexpected death.

Identifying and mitigating Sudden Unexpected Death in Epilepsy (SUDEP) risk factors.

INTRODUCTION: Sudden Unexpected Death in Epilepsy (SUDEP) is a significant cause of death for people with chronic epilepsy. Good practice guidance in the UK and the USA expect SUDEP to be discussed with the individual. The event rarity, methodological variance and lack of robust research into the pathological mechanisms, associated risk factors, and management strategies have created a challenge on how and what to discuss. There are some significant associations which allows for risk assessment and mitigation. Areas covered: The current understanding of static and modifiable risk factors for SUDEP and how to manage these more effectively are reviewed. Longitudinal risk may be assessed using standardised risk assessment tools which help in communicating risk. Technological advancement allows measurement of physiological parameters associated with seizures and risk of SUDEP using small wearable devices. Further evidence is needed to demonstrate such technologies are efficacious and safe. Expert commentary: Risk reduction should be an important part of epilepsy management and we suggest a Gold Standard of Care which healthcare professionals and services should aim for when approaching SUDEP risk management. A Minimum Standard of Care is also proposed that is practical to implement, that all people with epilepsy should expect to receive.

Functional impairment due to bereavement after the death of adolescent or young adult offspring in a national population study of 1,051,515 parents.

PURPOSE: This study addresses the burden of grief after the death of an adolescent or young adult offspring. Parental bereavement following the death of an adolescent or young adult offspring is associated with considerable psychiatric and somatic impairment. Our aim is to fill a research gap by examining offspring death due to suicide, accidents, or natural causes in relation to risk of parental sickness absence with psychiatric or somatic disorders. METHODS: This whole population-based prospective study included mothers and fathers of all offspring aged 16-24 years in Sweden on December 31, 2004 (n = 1,051,515). This study had no loss to follow-up and exposure, confounders, and the outcome were recorded independently of each other. Cox survival analysis was used to model time to sickness absence exceeding 30 days, adjusting for parental demographic characteristics, previous parental sickness absence and disability pension, and inpatient and outpatient psychiatric and somatic healthcare prior to offspring death in 2001-2004. This large study population provided satisfactory statistical power for stratification by parents' sex and adolescent and young adults' cause of death. RESULTS: Mothers and fathers of offspring suicide and accident decedents both had over tenfold higher risk for psychiatric sickness absence exceeding 30 days as compared to parents of live offspring. Fathers of suicide decedents were at 40 % higher risk for somatic sickness absence. CONCLUSIONS: This is the largest study to date of parents who survived their offspring's death and the first study of work-related outcomes in bereaved parents. This study uses a broad metric of work-related functional impairment, sickness absence, for capturing the burden of sudden offspring death.

[Social and health impact of Institutes of Legal Medicine in Spain: beyond justice]. / La proyección social y sanitaria de los Institutos de Medicina Legal en España: más allá de la justicia.

The main mission of Spanish Institutes of Legal Medicine (ILMs) is to serve the justice system. We review the potential broader role of the work done by ILMs, with an emphasis on forensic pathology. The relevance of forensic information to increase the quality of mortality statistics is highlighted, taking into account the persistence of the low validity of the external causes of death in the Mortality Register that was already detected more than a decade ago. The new statistical form and reporting system for the deaths under ILMs jurisdiction, as introduced by the Spanish Instituto Nacional de Estadística in 2009, are also described. The IMLs role in the investigation of the following mortality causes and of their determinants is reviewed in detail: traffic accidents, suicide, drugs of abuse, child deaths and sudden deaths. We conclude that an important public role of IMLs is emerging beyond their valuable service to the justice system, mainly through the gathering of data critical to assess and prevent several medical and public health and safety issues of great social impact and through their participation in epidemiologic research and surveillance.

Sudden unexpected death in epilepsy: assessing the public health burden.

OBJECTIVE: There is not yet a clear consensus on the incidence of sudden unexpected death in epilepsy (SUDEP) or the extent of its burden on public health. In this systematic review, we seek to summarize the incidence of SUDEP and its age distribution, as well as the years of potential life lost and cumulative risks of SUDEP for persons with epilepsy. METHODS: We conducted a systematic search for epidemiologic studies of sudden death in epilepsy and rated their quality of evidence. We pooled data from comparable higher quality population-based studies of SUDEP incidence across all age groups, calculating the overall incidence of SUDEP per 100,000 population, and per 1,000 people with epilepsy. Using standard formulas, we also calculated the years of potential life lost and cumulative risks associated with SUDEP. RESULTS: SUDEP has an estimated overall crude annual incidence rate of 0.81 cases per 100,000 population, or 1.16 cases per 1,000 patients with epilepsy. Comparing years of potential life lost from SUDEP with selected other neurologic diseases, SUDEP ranks second only to stroke. SIGNIFICANCE: Despite limitations to the data on which our analysis is based, we conclude that the public health burden of SUDEP, which has previously been underappreciated, is substantial and deserves much more attention from clinicians, researchers, and the public health community.

Overwork, stroke, and karoshi-death from overwork.

Karoshi, death from over-work, is usually the extreme result of acute cardiovascular events including stroke. Among 203 karoshi cases received worker compensation in Japan, sixty percent died of stroke. Karoshi is a term for social medicine originated form Japan. Literature reviews on karoshi found that long overtime at work, on duty in holidays, attending a new job with no family members around, and working at night shift are risk factors. Work stress increases secretion of catecholamines (epinephrine and norepinephrine) and cortisol which is associated with progression of atherosclerosis and increased risk of cardiovascular diseases and stroke. To avoid long working hours, stress management and treatment of hypertension, diabetes, and hyperlipidemia are key issues in preventing karoshi caused by stroke.

The epidemiology of 'bewitchment' as a lay-reported cause of death in rural South Africa.

BACKGROUND: Cases of premature death in Africa may be attributed to witchcraft. In such settings, medical registration of causes of death is rare. To fill this gap, verbal autopsy (VA) methods record signs and symptoms of the deceased before death as well as lay opinion regarding the cause of death; this information is then interpreted to derive a medical cause of death. In the Agincourt Health and Demographic Surveillance Site, South Africa, around 6% of deaths are believed to be due to 'bewitchment' by VA respondents. METHODS: Using 6874 deaths from the Agincourt Health and Socio-Demographic Surveillance System, the epidemiology of deaths reported as bewitchment was explored, and using medical causes of death derived from VA, the association between perceptions of witchcraft and biomedical causes of death was investigated. RESULTS: The odds of having one's death reported as being due to bewitchment is significantly higher in children and reproductive-aged women (but not in men) than in older adults. Similarly, sudden deaths or those following an acute illness, deaths occurring before 2001 and those where traditional healthcare was sought are more likely to be reported as being due to bewitchment. Compared with all other deaths, deaths due to external causes are significantly less likely to be attributed to bewitchment, while maternal deaths are significantly more likely to be. CONCLUSIONS: Understanding how societies interpret the essential factors that affect their health and how health seeking is influenced by local notions and perceived aetiologies of illness and death could better inform sustainable interventions and health promotion efforts.

[Excess mortality and sudden unexpected death in epilepsy]. / Surmortalité et mort soudaine inattendue dans l'épilepsie.

Patients with epilepsy have a two to three fold increased risk of death as compared to the age-matched general population. This increased risk of death primarily affects young adults with drug resistant epilepsy. Sudden unexpected death in epilepsy (SUDEP) is one of the main cause of mortality in that population, and appears to be the direct consequence of a seizure. The pathophysiology of SUDEP remains unclear, but a post-ictal central or obstructive apnea seems to represent the most likely mechanism. The risk of SUDEP is increased in patients with nocturnal seizures, generalized tonic-clonic seizures, and poor compliance. This risk can be decreased by nocturnal supervision. There is yet no consensus regarding the information about SUDEP that should be delivered to patients with epilepsy, but it seems reasonable to individualize this information according to each patient form of epilepsy.

The thiazolidinediones rosiglitazone and pioglitazone and the risk of coronary heart disease: a retrospective cohort study using a US health insurance database.

BACKGROUND: The thiazolidinediones (TZDs), including rosiglitazone maleate and pioglitazone hydrochloride, are commonly prescribed in patients with type 2 diabetes mellitus. Although recent meta-analyses suggest there is an increased risk of myocardial infarction (MI) among rosiglitazone users, these findings were not supported by data from other studies. OBJECTIVE: The goal of this research was to compare the risk of MI, coronary revascularization (CR), and sudden death in patients who began rosiglitazone therapy versus those who began pioglitazone therapy. METHODS: This was a retrospective cohort study using information from a large health care database (with data available on approximately 14 million individuals). All initiators of rosiglitazone or pioglitazone from July 1, 2000, through March 31, 2007, for whom the first dispensing followed >or=6 months of health plan membership and the member's 18th birthday were identified. The propensity score method was used to create matched cohorts of patients in 3 treatment groups: TZD monotherapy, dual therapy (a TZD plus another antidiabetic agent), and TZD therapy with concomitant insulin. Follow-up continued to a change in treatment regimen, defined as regimen switch (ie, the addition of any antidiabetic agent to an existing regimen) or regimen stop (ie, the discontinuation of any component of the therapeutic regimen). Three outcomes that represent coronary heart disease were assessed for this analysis: MI, CR, and sudden death. The proportional hazards model, stratified by therapeutic regimen, was used to estimate hazard ratios (HRs) and 95% CIs of coronary heart disease risk associated with use of rosiglitazone relative to pioglitazone. RESULTS: Among 47,501 matched pairs of rosiglitazone and pioglitazone users, 72,104 (75.9%) were receiving TZD monotherapy, 17,822 (18.8%) were receiving dual therapy, and 5076 (5.3%) were receiving TZD therapy with insulin. Mean follow-up was 9.6 months with regimen switch as the censoring event and 8.4 months with regimen stop as the censoring event. For MI, the HR was 1.35 (95% CI, 1.12-1.62) through regimen switch and 1.41 (95% CI, 1.13-1.75) through regimen stop. For the composite outcome of MI, CR, and/or sudden death, the HR was 1.09 (95% CI, 0.97-1.22) through regimen switch and 1.12 (95% CI, 0.98-1.27) through regimen stop. CONCLUSIONS: In this retrospective cohort analysis, MI was more common in users of rosiglitazone than in users of pioglitazone. The incidence of a combined end point of MI, CR, and/or sudden death in patients receiving rosiglitazone was not significantly different from that in patients receiving pioglitazone.

[Prophylactic use of cardiac implantable defibrillators in patients with severe left ventricular dysfunction: how to deal with decision making among guidelines, clinical practice, ethical problems, and limited economic resources]. / Uso profilattico del cardioverter-defibrillatore impiantabile nei pazienti con grave disfunzione ventricolare sinistra: come districarsi tra linee guida, pratica clinica, problemi etici e limitazione delle risorse.

Sudden cardiac death (SCD) is usually due to ventricular tachycardia/fibrillation and represents one of the most important medical and socio-economical problems in western countries. It accounts for approximately 1 life/1000 subjects/year. New and effective treatments are necessary to reduce such dramatic event. During the last decade implantable cardioverter-defibrillators (ICDs) showed to be an effective tool to reduce both total and SCD mortality either when used for secondary or primary SCD prevention. At present, ICD implantation guidelines suggest to implant an ICD in all the patients on the basis of a left ventricular ejection fraction < or =30-35% only. This scarcely sensitive and specific criterion implies the necessity to implant very costly devices in a wide number of patients to save only few lives. A more accurate patient selection is desirable either from a clinical or ethical or economic point of view. Fortunately, this appears to be possible using well known and proven epidemiological, clinical and risk stratification data. On the basis of such data, more selective ICD implantation criteria might be used in older patients or in patients with significant comorbidity or in those patients identified at very low risk of SCD.

The lived experience of working in a mortuary.

A four year action research study was undertaken in an attempt to foster change in the current management of sudden deaths in the Accident and Emergency Departments in South Africa. During the phase of interviewing bereaved families and health professionals it became apparent that there was a need to involve mortuary staff as victims of sudden deaths have to undergo an autopsy. The researcher chose an interpretive hermeneutic phenomenological research approach to explore the lived experience of working in a mortuary. The mortuary is a place of mystery, sadness, grief or repulsion and we all hope, while we are alive, we will never need to visit. For families who have lost a loved one to a sudden death, this becomes a reality. Working in a mortuary is an extremely stressful experience which is made worse in South Africa due to the large number of people dying sudden violent deaths due to trauma. The themes which emerged from the interviews with mortuary staff were; secondary trauma for families, delays by health professionals and dehumanised mortuary staff. There is a need for a change in the way bereaved families are being managed as well as revision of the environment for the staff working in mortuaries.

Alcohol tax cuts and increase in alcohol-positive sudden deaths: a time-series intervention analysis.

AIMS: The impact of alcohol regulation changes in Finland during 2004 on alcohol-positive sudden deaths was analysed, focusing on: (1) removal of traveller's allowance quotas on alcohol imports from other European Union (EU) countries, (2) lowering of Finnish alcohol excise duty rates and (3) Estonia joining the EU. DESIGN: The impact of these changes was estimated using an autoregressive integrated moving average (ARIMA) analytical technique. Post-mortem forensic toxicology data were analysed over a 15-year period to account for seasonal and long-term variation. In all, the data comprised a weekly series of 33,782 alcohol-positive cases (at least 0.20 mg/g alcohol in blood) and a control series of 37,617 alcohol-negative cases. SETTING: Finland in 1990-2004. FINDINGS: The liberation of traveller's allowances had no material impact on alcohol-positive sudden deaths, but the impact of alcohol tax cuts in March 2004 was significant, resulting in an estimated eight additional alcohol-positive deaths per week, which is a 17% increase compared with the weekly average of 2003. The impact associated with Estonia joining the EU was not statistically significant. In the models applied to the control series of alcohol-negative deaths, none of the impact coefficients was statistically significant. CONCLUSIONS: Alcohol tax cuts were associated with an increase in the number of sudden deaths involving alcohol. This parallels the reported increases in alcohol consumption and alcohol-related causes of death in 2004 in Finland.

Optimal medical therapy is superior to transplantation for the treatment of class I, II, and III heart failure: a decision analytic approach.

BACKGROUND: The survival benefit of heart transplantation (HT) compared with optimal medical therapy (OMT) has never been tested. METHODS AND RESULTS: We created a decision analytic model that simulates a randomized clinical trial of OMT versus HT for each New York Heart Association (NYHA) class. The simulation calculates average life expectancy. The following assumptions were made for OMT annual mortality: class I no excess mortality from HF; class II and III based on MERIT-HF are 5.3% and 8.1%. Class IV is 12.8%, based on COPERNICUS. HT mortality rates were based on survival curves for HT 1982 to 2001. For classes I, II, and III, OMT demonstrated a life expectancy gain of 113 months (232+/-2.2 versus 119+/-2.1), 38 months (152+/-2.1 versus 114+/-2.1), and 6 months (117+/-1.8 versus 111+/-2.2), respectively, over HT. Class IV favored HT with a life expectancy gain of 26 months (107+/-2.1 versus 81+/-1.4) over OMT. Sensitivity analysis revealed if improvement in OMT decreased mortality by 38% for class IV patients, OMT and HT would have equivalent life expectancies. If improvement in HT resulted in a 7% increase in post-HT survival, OMT and HT would be equivalent for class III patients. If improvement in HT resulted in a 30% increase in post-HT survival, OMT and HT would be equivalent for class II patients. CONCLUSIONS: Our model predicts that currently, OMT is superior to HT for classes I, II, and III, but HT is superior for class IV. However, future advances in OMT or HT may change the relative benefits of these treatment modalities.

Baseline recruitment and analyses of nonresponse of the Heinz Nixdorf Recall Study: identifiability of phone numbers as the major determinant of response.

The Heinz Nixdorf Recall Study is an ongoing population-based prospective cardiovascular cohort study of the Ruhr area in Germany. This paper focuses on the recruitment strategy and its response results including a comparison of participants of the baseline examination with nonparticipants. Random samples of the general population were drawn from residents' registration offices including men and women aged 45-74 years. We used a multimode contact approach including an invitational letter, a maximum of two reminder letters and phone calls for the recruitment of study subjects. Nonparticipants were asked to fill in a short questionnaire. We calculated proportions of response, contact, cooperation and recruitment efficacy to characterize the participation. Overall, 4487 eligible subjects participated in our study. Although the elderly (65-75 years) had the highest contact proportion, the cooperation proportion was the lowest among both men and women. The recruitment efficacy proportion was highest among subjects aged 55-64 years. The identifiability of the phone number of study subjects was an important determinant of response. The recruitment efficacy proportion among subjects without an identified phone number was 11.4% as compared to 65.3% among subjects with an identified phone number. The majority of subjects agreed to participate after one invitational letter only (52.6%). A second reminding letter contributed only very few participants to the study. Nonparticipants were more often current smokers than participants and less often belonged to the highest social class. Living in a regular relationship with a partner was more often reported among participants than nonparticipants.