Definite SUDEP population in Bexar County, Texas: A 36-year data registry.

OBJECTIVE: Sudden unexplained death in epilepsy (SUDEP) is one of the leading causes of mortality in epilepsy. In this study, cases of definite SUDEP are reported for Bexar County from a 36-year period. METHODS: Death reports by Bexar County Medical Examiner (BCME) from 1983 to 2018 were reviewed to identify cases with definite SUDEP. The findings were based upon investigators' reports, which included medical history, medication list, sleep position, time of death, and pathology reports. In addition to these potential risk factors, body mass indices (BMI), as well as heart, lung, and brain weights were compared between SUDEP victims with therapeutic vs subtherapeutic anti-seizure medication (ASM) levels. RESULTS: Definite SUDEP was identified in 286 cases. The incidence of definite SUDEP was 0.51 ±â€¯0.26/1000 person-years among PWE and 0.56 ±â€¯0.29 per 100,000 person-years among the general population in Bexar County. The median age was 37 years old (interquartile range 27-48), and the majority were male (65%). While 171 (60%) people were prescribed at least one ASM, ASM levels were subtherapeutic in 239 cases (83.6%). Risk factors for SUDEP did not differ between SUDEP victims with therapeutic vs subtherapeutic ASM levels. While BMIs were only slightly increased in adherent vs nonadherent SUDEP victims, they were significantly associated with subtherapeutic ASM levels. Abnormal lung, heart, and brain weights were reported in 48 (16.8%), 67 (23.4%), and 43 (15.0%) SUDEP cases, respectively. SIGNIFICANCE: This study is one of the largest autopsy-based registries of definite SUDEP. Subtherapeutic ASM levels measured in post-mortem blood samples suggest that nonadherence to ASM therapy was a leading risk factor for SUDEP. As BMI was elevated in this cohort, and obesity was significantly associated with subtherapeutic ASM levels, it may also be a risk factor for SUDEP. Case-controlled studies are needed to validate the specific role of obesity and related comorbidities in this population.

The Prevalence of Paraphernalia Found at the Scene of Drug-Related Deaths.

Many illicit drugs involve the use of paraphernalia, and the presence of paraphernalia found at the scene of death may suggest that the death is drug-related. Few sources of objective data are available regarding the prevalence of drug paraphernalia found at the scene of drug-related deaths or the likelihood of a death with drug paraphernalia found at the scene to be drug-related. This study reviews the deaths which were investigated by the Bexar County Medical Examiner's Office in an attempt to provide objective data. Over 4000 deaths with scene investigations were reviewed, and the presence of paraphernalia was found to be strongly associated with the death being drug-related, heroin-related, or cocaine-related with the relative risk for each being 5.0, 15.4, and 6.6, respectively. This confirms that the presence of drug paraphernalia at the scene of death strongly suggests the death to be drug-related and in particular heroin-related.

The Frequency of Truly Unknown/Undetermined Deaths: A Review of 452 Cases Over a 5-Year Period.

The forensic autopsy is often regarded as the final medical diagnosis and expert scientific opinion in matters of death investigation, usually in the legal setting, and sometimes in the clinical setting as well. There are however limitations to what the autopsy can answer, and sometimes the circumstances surrounding a death, despite our best efforts, are simply unable to be determined. Approximately 5% of cases reportedly remain unknown after a complete autopsy. With this in mind, we sought to examine the frequency of deaths in which both the cause and manner are unknown after complete forensic examination and autopsy. Data from 452 undetermined deaths over a 5-year period were analyzed; sudden unexpected infant deaths and decomposed or skeletonized remains were excluded, as well as those with a known cause but undetermined manner of death. After exclusion of these deaths, our analysis revealed that only 0.015% of cases during this period were truly undetermined in both cause and manner of death.