Trends in dermatomyositis- and polymyositis-related mortality in the state of São Paulo, Brazil, 1985-2007: multiple cause-of-death analysis.

BACKGROUND: Dermatomyositis (DM) and polymyositis (PM) are rare systemic autoimmune rheumatic diseases with high fatality rates. There have been few population-based mortality studies of dermatomyositis and polymyositis in the world, and none have been conducted in Brazil. The objective of the present study was to employ multiple-cause-of-death methodology in the analysis of trends in mortality related to dermatomyositis and polymyositis in the state of São Paulo, Brazil, between 1985 and 2007. METHODS: We analyzed mortality data from the São Paulo State Data Analysis System, selecting all death certificates on which DM or PM was listed as a cause of death. The variables sex, age and underlying, associated or total mentions of causes of death were studied using mortality rates, proportions and historical trends. Statistical analysis were performed by chi-square and H Kruskal-Wallis tests, variance analysis and linear regression. A p value less than 0.05 was regarded as significant. RESULTS: Over a 23-year period, there were 318 DM-related deaths and 316 PM-related deaths. Overall, DM/PM was designated as an underlying cause in 55.2% and as an associated cause in 44.8%; among 634 total deaths females accounted for 71.5%. During the study period, age- and gender-adjusted DM mortality rates did not change significantly, although PM as an underlying cause and total mentions of PM trended lower (p < 0.05). The mean ages at death were 47.76 ± 20.81 years for DM and 54.24 ± 17.94 years for PM (p = 0.0003). For DM/PM, respectively, as underlying causes, the principal associated causes of death were as follows: pneumonia (in 43.8%/33.5%); respiratory failure (in 34.4%/32.3%); interstitial pulmonary diseases and other pulmonary conditions (in 28.9%/17.6%); and septicemia (in 22.8%/15.9%). For DM/PM, respectively, as associated causes, the following were the principal underlying causes of death: respiratory disorders (in 28.3%/26.0%); circulatory disorders (in 17.4%/20.5%); neoplasms (in 16.7%/13.7%); infectious and parasitic diseases (in 11.6%/9.6%); and gastrointestinal disorders (in 8.0%/4.8%). Of the 318 DM-related deaths, 36 involved neoplasms, compared with 20 of the 316 PM-related deaths (p = 0.03). CONCLUSIONS: Our study using multiple cause of deaths found that DM/PM were identified as the underlying cause of death in only 55.2% of the deaths, indicating that both diseases were underestimated in the primary mortality statistics. We observed a predominance of deaths in women and in older individuals, as well as a trend toward stability in the mortality rates. We have confirmed that the risk of death is greater when either disease is accompanied by neoplasm, albeit to lesser degree in individuals with PM. The investigation of the underlying and associated causes of death related to DM/PM broaden the knowledge of the natural history of both diseases and could help integrate mortality data for use in the evaluation of control measures for DM/PM.

[Nosocomial infection and multiple causes of death]. / Infecção hospitalar e causas múltiplas de morte.

OBJECTIVE: The purpose of this study was to evaluate the possibility for collecting data on nosocomial infections by means of death certificates. METHODS: The medical charts of children who died after 48 hours of their admission to a pediatric hospital were revised to get information about the causes of death. Death certificates were also revised to verify whether they were properly filled out. The death certificates were redrafted according to the data obtained from patients' medical charts. Nosocomial infections and procedures related to them were codified using the Supplementary External Causes of Injury and Poisoning codes of the International Disease Classification-9th Revision. RESULTS: The causes mentioned on medical death certificates compared with revised causes obtained after revision of patients' charts showed an agreement of 69.9%, with a Kappa coefficient of 0.65. Only one case of nosocomial infection was found on original death certificates, whereas the redrafted certificates revealed 88.9% of nosocomial infections in the study population up to fifteen days before death. CONCLUSION: Death certificates are not a good source of information on nosocomial infection because they are often filled out inadequately. The solution to this is to qualify physicians so that they can identify and record nosocomial infections on the patient's medical chart and complete death certificates accordingly.

Mortality profile related to systemic lupus erythematosus: a multiple cause-of-death analysis.

OBJECTIVE: To analyze the mortality profile related to systemic lupus erythematosus (SLE) in the state of São Paulo, Brazil. METHODS: For the 1985-2007 period, we analyzed all death certificates (n = 4815) on which SLE was listed as an underlying (n = 3133) or non-underlying (n = 1682) cause of death. We evaluated sex, age, and the causes of death, comparing the first and last 5 years of the period, as well as determining the observed/expected death ratio (O/E ratio). RESULTS: For SLE as an underlying cause, the mean age at death was 35.77 years (SD 15.12) and the main non-underlying causes of death were renal failure, circulatory system diseases, pneumonia, and septicemia. Over the period, the proportional mention of infectious causes and circulatory system diseases increased, whereas renal diseases decreased. For SLE as a non-underlying cause of death, the most common underlying causes of death were circulatory, respiratory, genitourinary, and digestive system diseases, and certain infections. The overall death O/E ratio was > 1 for renal failure, tuberculosis, septicemia, pneumonia, and digestive system diseases, as well as for circulatory system diseases at < 50 years of age, particularly acute myocardial infarct. CONCLUSION: Unlike in developed countries, renal failure and infectious diseases are still the most frequent causes of death. The increase in SLE deaths associated with infection, especially pneumonia and septicemia, is worrisome. The judicious use of immunosuppressive therapy together with vigorous treatment of cardiovascular comorbidities is crucial to the successful management of SLE and to improving survival of patients with SLE.

Tabulador de causas mútiplas de morte / Multiple causes-of-death tabulator

O uso de causas mútiplas de morte vem sendo preconizado para descrever e analisar os determinantes patológicos da mortalidade em populações, como complemento ao uso tradicional da causa básica de morte. O estudo das causas múltiplas pode realizar-se por meio da apresentação de todas as menções das causas básicas e associadas de morte e por meio de associações de causas. Um programa para microcomputador foi desenvolvido para processar bancos de dados contendo as causas de morte informadas no Modelo Internacional de Atestado Médico de Causa de Morte, denominado Tabulador de Causas Mútiplas, que gera uma tabela matriz a partir da qual podem ser derivadas as demais formas de apresentação e análise, além de poder ser usado como instrumento de crítica dos dados de mortalidade

Infecção hospitalar e causas múltiplas de morte / Nosocomial infection and multiple causes of death

Objetivo: este estudo se propôs a avaliar a possibilidade de se obter informações de infecção hospitalar por meio da declaração de óbito. Material e métodos: foi feita revisão de prontuários de crianças que faleceram com mais de 48 horas de internação num hospital pediátrico, para coleta de dados sobre as causas múltiplas de morte. Também foram revistas as declarações de óbito, para verificar sua qualidade de preenchimento. Os atestados de óbito foram refeitos segundo as informações do prontuário, utilizando-se a classificação suplementar de causas externas de lesões e envenenamentos da Classificação Internacional de Doenças -9ºrevisão, para codificar as infecções hospitalares e procedimentos associados. Resultados: após refazer os atestados, observou-se concordância da causa básica de morte entre atestados originais e refeitos de 69,9por cento, com índice de Kappa de 0,65. No atestado médico original, identificou-se somente uma infecção hospitalar, enquanto pelo atestado refeito recuperaram-se 88,9 por cento de todas as infecções hospitalares, ocorridas nas crianças, até 15 dias antes do óbito. Conclusão: a qualidade de preenchimento dos atestados de óbito não permite utilizar as declarações de óbito como fonte de dados de infecção hospitalar, a não ser que haja capacitação dos profissionais médicos para identificar e registrar as infecções hospitalares no prontuário, bem como preencher os atestados adequadamente