Death rates and causes of death after bariatric surgery for Pennsylvania residents, 1995 to 2004.

BACKGROUND: Bariatric surgery has emerged as the most effective treatment for class III obesity (body mass index, >or=40). The number of operations continues to increase. We measured case fatality and death rates by time since operation, sex, age, specific causes of death, and mortality rates. DESIGN AND SETTING: Data on all bariatric operations performed on Pennsylvania residents between January 1, 1995, and December 31, 2004, were obtained from the Pennsylvania Health Care Cost and Containment Council. Matching mortality data were obtained from the Division of Vital Records, Pennsylvania State Department of Health. OUTCOME MEASURES: Age- and sex-specific death rates after bariatric surgery. RESULTS: There were 440 deaths after 16 683 operations (2.6%). Age-specific death rates were much higher in men than in women and increased with age. Age- and sex-specific death rates after bariatric surgery were substantially higher than comparable rates for the age- and sex-matched Pennsylvania population. The 1-year case fatality rate was approximately 1% and nearly 6% at 5 years. Less than 1% of deaths occurred within the first 30 days. Fatality increased substantially with age (especially among those > 65 years), with little evidence of change over time. Coronary heart disease was the leading cause of death overall, being cited as the cause of death in 76 patients (19.2%). Therapeutic complications accounted for 38 of 150 natural deaths within the first 30 days, including pulmonary embolism in 31 (20.7%), coronary heart disease in 26 (17.3%), and sepsis in 17 (11.3%). CONCLUSIONS: There was a substantial excess of deaths owing to suicide and coronary heart disease. Careful monitoring of bariatric surgical procedures and more intense follow-up could likely reduce the long-term case fatality rate in this patient population.

Nursing home deaths which fall under the jurisdiction of the coroner: an 11-year retrospective study.

Twenty percent of deaths in the United States occur in nursing homes, yet less than 1% come to autopsy. The current study analyzed causes and manners of death in all nursing homes between 1993 and 2003, investigated by the coroner of Allegheny County, PA, which has the second highest elderly population in the United States. Two hundred eight decedents were identified, aged 19 to 91 years, 58% women and 42% men, 88% Caucasian and 22% African-American. Fifty-eight percent were accidental and 38.5% were natural manners of death, with 2 homicides, 2 suicides, and 3 undetermined cases. The manner of death was significantly different between Caucasians and African-Americans, with 92.6% of accidental deaths occurring in Caucasians and 6.6% in African-Americans (P < 0.1). Most common natural deaths were arteriosclerotic cardiovascular disease, nonarteriosclerotic cardiovascular disease, pneumonia, pulmonary thromboembolism, chronic obstructive pulmonary disease (COPD), seizure disorder, and atraumatic intracranial hemorrhage. Blunt force trauma was the single most commonly identified traumatic accidental death. Accidental deaths were more common in Caucasians than African-Americans. Homicides and suicides were rare events (<2%). Blunt force trauma is a major autopsy finding in accidental nursing home deaths, and a root-cause analysis may be helpful in developing policies and procedures to decrease the incidence of blunt force trauma.

The role of environmental factors in the causation of sudden death in infants: two cases of sudden unexpected death in two unrelated infants who were cared for by the same babysitter.

We report two cases of sudden unexpected death in two unrelated African American female infants, 2 months and 4 months old. Both infants were attended to by the same babysitter in the same apartment and died 39 days apart in the same bed and in the same bedroom. The autopsy of the first infant revealed sudden unexplained death in an infant. Toxicologic analysis for carbon monoxide (CO) was not performed because it was not suspected. When the second infant died, investigation into the ambient air quality within the apartment revealed high levels of CO emanating from a poorly ventilated and defective hot water heater, which was located across a hallway from the bedroom where the two babies died. CO saturation levels in the postmortem blood samples of the two babies were elevated and were similar (13% and 14%). Nicotine and cotinine were not detected in the blood sample of the two infants. Cherry-red livor mortis was absent. Acute CO intoxication was determined to be the underlying cause of these two unexpected deaths. These two cases underscore the need to integrate ambient air analysis and postmortem CO analysis as routine components of the comprehensive death investigation of infants who die suddenly and unexpectedly.

Decoding of emotion through facial expression, prosody and verbal content in children and adolescents with Asperger's syndrome.

This study examined differences in the ability to decode emotion through facial expression, prosody, and verbal content between 14 children with Asperger's Syndrome (AS) and 16 typically developing peers. The ability to decode emotion was measured by the Perception of Emotion Test (POET), which portrayed the emotions of happy, angry, sad, and neutral among the modalities of static and dynamic facial expression, prosody, verbal content, and all modalities combined. Results revealed that children with AS had more difficulty identifying emotions through static facial expression, dynamic facial expression, and prosody than typically developing children. Results are discussed in relationship to an over-reliance on verbal content as a compensatory strategy in social interactions. Treatment implications for individuals with AS are also discussed.

The diagnostic utility of D2-40 for malignant mesothelioma versus pulmonary carcinoma with pleural involvement.

Differentiating malignant mesothelioma (MM) from pulmonary carcinoma in pleural fluid cytology can be challenging. Recent studies have suggested that D2-40, a novel lymphatic marker, may be a useful marker for mesothelial differentiation in surgical specimens. However, there are no available data regarding its utility in effusion cytology specimens. We investigated the utility of D2-40 in pleural fluid cytology in differentiating MM from pulmonary carcinomas. Twenty cases of pleural effusion smears of surgically confirmed MM with their corresponding cell blocks were retrieved from the database of the hospital computer system. We also included 10 cases of metastatic pulmonary adenocarcinoma (PA) and 10 cases metastatic pulmonary squamous cell carcinoma (PSCC) involving the pleural fluid. Cell blocks were formalin-fixed, paraffin embedded, and immunostained for TTF1, p63, calretinin, CK5/6, WT-1, and D2-40. Cases were scored as negative (<5% positivity) or positive (>5% moderate/strong positivity). The positive rates for TTF1, p63, calretinin, CK5/6, WT-1, and D2-40 were as follows: MM (0/20), (0/20), (17/20), (18/20), (19/20), (17/20), for PA (8/10), (0/10), (3/10), (0/10), (0/10), (0/10), and for PSCC (1/10), (10/10), (6/10), (10/10), (0/15), (0/10). The staining pattern for D2-40 was characterized by thick membranous staining. Diffuse cytoplasmic staining by D2-40 was seen in 2 cases of pulmonary carcinoma, counted as negative. Our study showed that in differentiating MM from PA, CK5/6, WT-1, and D2-40 have high specificity and sensitivity for MM. Although calretinin is a sensitive IHC marker for MM, it is not specific since it stained 30% of PA. Conversely, to differentiate between MM and PSCC, p63 and WT-1 are the best available markers. We recommend a panel of CK5/6, p63, D2-40, and WT-1 to differentiate MM from pulmonary carcinomas in effusion cytology specimens.

Lymphatic vessel density as prognostic marker in esophageal adenocarcinoma.

We studied tumor lymphatic vascular density (LVD) as a predictive marker for the risk of lymph node (LN) metastasis and its relationship to other prognostic parameters and survival in 75 patients with esophageal adenocarcinoma. Samples were immunostained for D2-40, CD31, and vascular endothelial growth factor (VEGF). Microvessels were counted in densely vascular/lymphatic foci (hot spots) at x400 field (0.17 mm2). Intensity of staining for VEGF was scored on a 2-tiered scale. CD31 microvessel counts showed significant correlation with tumor stage and patient survival (P < .01). D2-40 LVD demonstrated a significant correlation with LN metastases, lymphovascular invasion, and tumor stage (r = 0.45, r = 0.47, and r = 0.37, respectively) and with shorter disease-free survival. D2-40 detected lymphovascular invasion in 29 of 75 cases, more than with CD31 (23/75) and H&E (18/75). VEGF was expressed in 48 (64%) of 75 cases and was significantly correlated with lymphovascular invasion, LN metastases, and overall survival. Our study showed that angiogenesis and lymphangiogenesis have important roles in the progression of esophageal adenocarcinoma.

Intestinal type and endocervical-like ovarian mucinous neoplasms are immunophenotypically distinct entities.

Ovarian mucinous neoplasm (OMN) is traditionally classified as either intestinal type or endocervical-like subtypes. The 2 subtypes represent different clinicopathologic characteristics. The immunophenotype of the 2 subtypes has not been adequately investigated. In this study, we investigated 14 intestinal type OMNs (borderline and adenocarcinoma) and 12 endocervical-like OMNs (borderline and adenocarcinoma) for their expression of PDX-1, CDX-2, CA-125, CK7, CK20, WT-1, D2-40, and TTF-1. We also included 15 colorectal adenocarcinomas metastatic in the ovary, as they may occasionally mimic OMN. The intestinal type OMNs were positive for PDX-1 (100%), CK7 (100%), CK20 (100%), CDX-2 (29%), whereas were negative for CA-125. The endocervical-like OMNs were positive for CA-125 (100%) and CK7 (100%), whereas were negative for CK20, PDX-1, and CDX-2. Metastatic colorectal adenocarcinomas were positive for CK20 (100%), CDX-2 (100%), and PDX-1 (33%), whereas were negative for CA-125 and CK7. All of the intestinal type and endocervical-like OMNs as well as metastatic colorectal adenocarcinomas were negative for WT-1, D2-40, and TTF-1. Our results demonstrated that the intestinal type and endocervical-like OMNs are immunophenotypically distinct entities. The 2 subtypes can be separated from metastatic colorectal adenocarcinoma by the different immunohistochemical profile of PDX-1, CA-125, CK7, CK20, and CDX-2. In the work-up of mucinous adenocarcinoma in the ovary or abdominal cavity, caution should be exercised in interpreting the possible primary site on the basis of the immunohistochemical profiles.