Ascertainment Of Cause Research Articles

The application of vibrational spectroscopy in forensic analysis of biological evidence.

Vibrational spectroscopy is a powerful analytical domain, within which Fourier transform infrared spectroscopy (FTIR) and Raman spectroscopy stand as exemplars, offering high chemical specificity and sensitivity. These methodologies have been instrumental in the characterization of chemical compounds for an extensive period. They are particularly adept at the identification and analysis of minute sample quantities. Both FTIR and Raman spectroscopy are proficient in elucidating small liquid samples and detecting nuanced molecular alterations. The application of chemometrics further augments their analytical prowess. Currently, these techniques are in the research phase within forensic medicine and have yet to be broadly implemented in examination and identification processes. Nonetheless, studies have indicated that a combined classification model utilizing FTIR and Raman spectroscopy yields exceptional results for the identification of biological fluid-related information and the determination of causes of death. The objective of this review is to delineate the current research trajectory and potential applications of these two vibrational spectroscopic techniques in the detection of body fluids and the ascertainment of causes of death within the context of forensic medicine.

Ascertainment of causes of neonatal death using verbal autopsy in Rishikesh, Uttarakhand: A cross-sectional study.

India shares a huge burden of the total number of global neonatal deaths. The neonatal mortality rate in Uttarakhand is higher in comparison to the national rate. Understanding the causes and contextual factors that contribute to neonatal deaths is critical for developing a health programme and policy. Therefore, this study was aimed to ascertain causes of neonatal deaths using verbal autopsy in Rishikesh, Uttarakhand. A community-based cross-sectional study was conducted in Rishikesh, Uttarakhand from July 2018 to June 2019. The study participants were mothers or primary caregivers of deceased neonates. The verbal autopsy tool of the National Health Mission, Government of India was used to collect data. All neonatal deaths from July 2018 to June 2019 were included in this study. The cause of neonatal death was ascertained by two independent doctors. A total of 23 neonatal deaths could be traced during July 2018 through June 2019 in Rishikesh. One death was excluded from the study. Sixty-eight percent (15/22) of neonatal deaths occurred in the first week of life. Major causes of neonatal deaths were perinatal asphyxia (7/22), congenital malformation (6/22), and prematurity (4/22). Most (9/22) of the delays were in making a decision to seek medical care for neonates. The major causes of neonatal deaths were perinatal asphyxia, congenital malformation, and prematurity. Most of the deaths occurred during the early neonatal period.

Medicare Coverage Improves Mortality Outcomes in Regions of Poverty in United States

Objectives: Access to care and poverty have been associated with a higher risk of breast cancer, but their impact on breast cancer death has not been fully evaluated. We hypothesized that analysis of data from a large database would further elucidate the association between socioeconomic status and breast cancer mortality. Methods: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify cases of invasive ductal carcinoma diagnosed between 2006-2011, as well as data reflecting the presence or absence of a breast cancer death within five years. Two age groups, 40-64 year old women, and 65+ year old women, were analyzed. From the American Community Survey were acquired annual county level hospital rates, ambulatory care facility rates, nursing/residential care facility rates, rural business rates, population densities, and counts of women in the age groups of interest. Results: With respect to poverty rates, incidence based mortality rates for 40-64 year old women were 13% (99% CI 3%, 25%) higher for counties in the third quartile and 19% (7%, 35%) higher for counties in the fourth quartile (p < 0.01) than for counties in the first quartile; counties in the second quartile did not show higher incidence mortality rates (p > 0.01). Mortality rates for 65+ year old women did not differ among poverty rate quartiles (p > 0.01 for each assessment). A 50% increase in hospitals per 100,000 persons was associated with 8% (5%, 11%) and 5% (1%, 8%) increases in mortality rates for 40-64 y and 65+ y women, respectively, likely reflecting better ascertainment of causes of death at hospitals. Impacts of differences in other rates and population density were not detected (p > 0.01 for each analysis). Conclusion: Counties with higher poverty rates have increased breast cancer mortality rates for 40-64 y women, but not for 65+ y women. Universal coverage associated with Medicare is associated with the absence of an apparent effect of poverty upon breast cancer mortality.

Fall-related mortality trends in Australia and the United Kingdom: Implications for research and practice

ObjectivesTo characterise changes in nationwide fall-related mortality rates in Australia and the United Kingdom (UK) between 2006 and 2016 by age group and sex. Study designTrend analysis of falls mortality data from World Health Organization (WHO) Mortality Database for the Australian and UK population. Main outcome measuresWe assessed age-specific, sex-specific and age-adjusted mortality rates. Mortality trends were assessed via the annual percentage change (APC) using joinpoint regression. ResultsThe annual average age-adjusted falls mortality rate was 38.63 per 1,000,000 population in Australia, and 34.12 per 1,000,000 population in the UK. From 2006 to 2016, age-adjusted mortality rate due to falls increased in Australia and the UK by an average annual rate of 3.77% (95% CI 2.91% to 4.64%; p<0.01) and 2.11% (95% CI 1.43% to 2.80%; p<0.01) respectively. Death rates from falls increased with age. People aged ≥95 years had the highest mortality rate from falls in Australia and the UK. Men had a higher annual average age-adjusted mortality rate from falls than women (1.6 times higher in Australia and 1.7 times higher in the UK). Women had a larger annual percentage increase in falls mortality rate compared to men over the study period. ConclusionsThere was a major increase in reported fall-related deaths in Australia and the UK between 2006 and 2016, especially in the very elderly. Men had a higher mortality rate from falls than women. Factors contributing to the apparent increases in fall-related mortality may include reduced cancer and cardiovascular mortality and better ascertainment of cause of death.

Ascertaining cause of mortality among middle-aged and older persons using computer-coded and expert review verbal autopsies in the China Health and Retirement Longitudinal Study

ABSTRACT Background Verbal autopsy is designed to ascertain causes of death that are not registered or certified. Verbal autopsy has been validated in multiple settings but has not been as widely evaluated for older populations as for younger age groups. Objective This study aims to provide empirical evidence of the value of verbal autopsy interviews in the context of population-based surveys of older adults by comparing the cause-of-death assignments derived from two methods of interpreting verbal autopsy data. Methods Data used in this study come from the China Health and Retirement Longitudinal Study, a nationally representative longitudinal survey of older Chinese. We compared 407 causes of death determined using InterVA, which is a computer-coded method, and causes of death as assigned by experts; then evaluated factors that affect the results of the two approaches. Results Among the 407 deaths, neoplasms, cardiac disease, and stroke are the leading causes of death according to both approaches. The consistency of the two approaches is about 45% at the individual level. The primary reason for the mismatch is that no cause of death could be assigned for more than 25% of the sample based on expert review. A higher likelihood of mismatch is associated with advanced age and a long period between death and verbal autopsy interview. Conclusion Both approaches identify the same leading causes of death at the aggregate level, but consistency is relatively low at the individual level. InterVA works well when causes of death are characterized by distinctive signs and symptoms. Grouping the various causes of death with shared etiology or common risk factors may help improve the quality of the ascertainment of causes of death. Open-ended narratives are helpful because they provide information about the circumstances surrounding the death that are not available in the structured verbal autopsy interviews.

Determining the Cause of Death Among Children Hospitalized With Respiratory Illness in Kenya: Protocol for Pediatric Respiratory Etiology Surveillance Study (PRESS).

BackgroundIn sub-Saharan Africa, where the burden of respiratory disease–related deaths is the highest, information on the cause of death remains inadequate because of poor access to health care and limited availability of diagnostic tools. Postmortem examination can aid in the ascertainment of causes of death. This manuscript describes the study protocol for the Pediatric Respiratory Etiology Surveillance Study (PRESS).ObjectiveThis study protocol aims to identify causes and etiologies associated with respiratory disease–related deaths among children (age 1-59 months) with respiratory illness admitted to the Kenyatta National Hospital (KNH), the largest public hospital in Kenya, through postmortem examination coupled with innovative approaches to laboratory investigation.MethodsWe prospectively followed children hospitalized with respiratory illness until the end of clinical care or death. In case of death, parents or guardians were offered grief counseling, and postmortem examination was offered. Lung tissue specimens were collected using minimally invasive tissue sampling and conventional autopsy where other tissues were collected. Tissues were tested using histopathology, immunohistochemistry, and multipathogen molecular-based assays to identify pathogens. For each case, clinical and laboratory data were reviewed by a team of pathologists, clinicians, laboratorians, and epidemiologists to assign a cause of and etiology associated with death.ResultsWe have enrolled pediatric cases of respiratory illness hospitalized at the KNH at the time of this submission; of those, 14.8% (140/945) died while in the hospital. Both analysis and interpretation of laboratory results and writing up of findings are expected in 2019-2020.ConclusionsPostmortem studies can help identify major pathogens contributing to respiratory-associated deaths in children. This information is needed to develop evidence-based prevention and treatment policies that target important causes of pediatric respiratory mortality and assist with the prioritization of local resources. Furthermore, PRESS can provide insights into the interpretation of results using multipathogen testing platforms in resource-limited settings.International Registered Report Identifier (IRRID)DERR1-10.2196/10854

Multilocular cystic renal cell carcinoma: pathological t staging makes no difference to favorable outcomes and should be reclassified. Bhatt JR, Jewett MA, Richard PO, Kawaguchi S, Timilshina N, Evans A, Alibhai S, Finelli A.J Urol. November 2016;196(5):1350–1355.

ObjectiveWe evaluated survival outcomes of cystic/multilocular cystic renal cell carcinomas in a long-term population-based study based on size and pathological tumor stage. Materials and methodsWe, retrospectively, reviewed a provincial cancer registry of all histologically proven cases of multilocular cystic renal cancers treated surgically between 1995 and 2008. All cases of cystic necrosis were excluded from study. Primary end points were overall- and cancer-specific survival estimated using Kaplan-Meier curves. Cox proportional hazards models of univariable and multivariable analyses were used to assess for factors associated with survival. ResultsOf 172 cases of cystic renal cancers 168 with complete data were analyzed, of which 98% were multilocular cystic. Median patient age at treatment was 55 years and 58% of the patients were male. More than 40% of cases were pT1b or greater, 15% were pT2 or greater and most cases were low Fuhrman grade (1–2). At a median follow-up of 9.75-years overall- and cancer-specific survival was 82.1% and 100%, respectively. No difference was noted in higher pathological T stage, size, or grade. Limitations inherent in population-based studies include under ascertainment of cause of death, lack of data on histologically benign cysts that are treated surgically and a lack of central pathology review. ConclusionsMultilocular cystic renal cell carcinoma has an excellent prognosis, which remains unchanged regardless of tumor size or pathological T stage. This suggests a strong case for nephron and adrenal sparing surgery when indicated, and nonsurgical management when feasible. As postoperative follow-up protocols are dictated by staging, we propose that for this entity pathological T staging should be abandoned or reassigned as pT1c to guide clinicians.

Rationale and design of the coronary artery calcium consortium: A multicenter cohort study

BackgroundAlthough coronary artery calcium (CAC) has been investigated for over two decades, there is very limited data on the association of CAC with cause of death. The CAC Consortium is a large ongoing multi-center observational cohort of individuals who underwent non-contrast cardiac-gated CAC testing and systematic, prospective, long-term follow-up for mortality with ascertainment of cause of death. MethodsFour participating institutions from three states within the US (California, Minnesota, and Ohio) have contributed individual-level patient data to the CAC Consortium (spanning years 1991–2010). All CAC scans were clinically indicated and physician-referred in patients without a known history of coronary heart disease. Using strict inclusion and exclusion criteria to minimize missing data and to eliminate non-dedicated CAC scans (i.e. concomitant CT angiography), a sharply defined and well-characterized cohort of 66,636 patients was assembled. Mortality status was ascertained using the Social Security Administration Death Master File and a validated algorithm. In addition, death certificates were obtained from the National Death Index and categorized using ICD (International Classification of Diseases) codes into common causes of death. ResultsMean patient age was 54 ± 11 years and the majority were male (67%). Prevalence of CVD risk factors was similar across sites and 55% had a <5% estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Approximately 45% had a Calcium score of 0 and 11% had an Agatston Score ≥400. Over a mean follow-up of 12 ± 4 years, there were 3158 deaths (4.15 per 1000 person-years). The majority of deaths were due to cancer (37%) and CVD (32%). Most CVD deaths were due to CHD (54%) followed by stroke (17%). In general, CAC score distributions were similar across sites, and there were similar cause of death patterns. ConclusionsThe CAC Consortium is large and highly generalizable data set that is uniquely positioned to expand the understanding of CAC as a predictor of mortality risk across the spectrum of disease states, allowing innovative modeling of the competing risks of cardiovascular and non-cardiovascular death.

Evaluation issues in the Swedish Two-County Trial of breast cancer screening: An historical review.

ObjectivesTo summarize debate and research in the Swedish Two-County Trial of mammographic screening on key issues of trial design, endpoint evaluation, and overdiagnosis, and from these to infer promising directions for the future.MethodsA cluster-randomized controlled trial of the offer of breast cancer screening in Sweden, with a single screen of the control group at the end of the screening phase forms the setting for a historical review of investigations and debate on issues of design, analysis, and interpretation of results of the trial.ResultsThere has been considerable commentary on the closure screen of the control group, ascertainment of cause of death, and cluster randomization. The issues raised were researched in detail and the main questions answered in publications between 1989 and 2003. Overdiagnosis issues still remain, but methods of estimation taking full account of lead time and of non-screening influences on incidence (taking place mainly before 2005) suggest that it is a minor phenomenon.ConclusionDespite resolution of issues relating to this trial in peer-reviewed publications dating from years, or even decades ago, issues that already have been addressed continue to be raised. We suggest that it would be more profitable to concentrate efforts on current research issues in breast cancer diagnosis, treatment, and prevention.

Multilocular Cystic Renal Cell Carcinoma: Pathological T Staging Makes No Difference to Favorable Outcomes and Should be Reclassified

We evaluated survival outcomes of cystic/multilocular cystic renal cell carcinomas in a long-term population based study based on size and pathological tumor stage. We retrospectively reviewed a provincial cancer registry of all histologically proven cases of multilocular cystic renal cancers treated surgically between 1995 and 2008. All cases of cystic necrosis were excluded from study. Primary end points were overall and cancer specific survival estimated using Kaplan-Meier curves. Cox proportional hazards models of univariable and multivariable analyses were used to assess for factors associated with survival. Of 172 cases of cystic renal cancers 168 with complete data were analyzed, of which 98% were multilocular cystic. Median patient age at treatment was 55years and 58% of the patients were male. More than 40% of cases were pT1b or greater, 15% were pT2 or greater and most cases were low Fuhrman grade (1-2). At a median followup of 9.75 years overall and cancer specific survival was 82.1% and 100%, respectively. No difference was noted in higher pathological T stage, size or grade. Limitations inherent in population based studies include under ascertainment of cause of death, lack of data on histologically benign cysts that are treated surgically and a lack of central pathology review. Multilocular cystic renal cell carcinoma has an excellent prognosis, which remains unchanged regardless of tumor size or pathological T stage. This suggests a strong case for nephron and adrenal sparing surgery when indicated, and nonsurgical management when feasible. Since postoperative followup protocols are dictated by staging, we propose that for this entity pathological T staging should be abandoned or reassigned as pT1c to guide clinicians.

Agreement between international classification of disease (ICD) and cause of death and associated conditions (CODAC) for the ascertainment of cause of stillbirth (SB) in the rural areas of north India

International Classification of Diseases-10 th version (ICD-10) has been used to ascertain the cause of death but its use for stillbirths (SBs) is limited. Cause of Death and Associated Conditions (CODAC) as a detailed system expected to provide the exact cause of SB, so a community-based study was planned to study the level of agreement between ICD-10 and CODAC for ascertaining the cause of SB. A verbal autopsy (VA) tool was used to collect the information and then the cause of each SB was assigned using ICD-10 and CODAC separately. Each tool was used for 87 SBs and found that prolonged singleton labor, maternal pregnancy induced hypertension (PIH), and central nervous system (CNS) related congenital malformations were considered the top three causes. There was a significant agreement between ICD-10 and CODAC but the latter offers a scope to delineate the causes more precisely due to its hierarchal nature.

Risk of Death among HIV Co-Infected Multidrug Resistant Tuberculosis Patients, Compared To Mortality in the General Population of South Africa.

Even though highly effective drugs are available in South Africa, multidrug resistant tuberculosis (MDR-TB) patients with HIV infection have higher mortality compared to HIV-uninfected MDR-TB patients. This trend has been observed in similar countries with high HIV prevalence. This study sought to determine excess mortality attributable to HIV among MDR-TB patients in South Africa using relative survival methods. Data available were from a cohort of 2079 MDR-TB patients enrolled in a Standardized Programmatic Management of MDR-TB from 2000 to 2004 in South Africa. A Poisson-based model adjusted for age, gender, year of diagnosis, TB history, and resistance to ethambutol, anti-TB injectable drugs and fluoroquinolones antibiotics was constructed to assess the excess mortality among HIV co-infected MDR-TB patients. Excess hazard ratios (EHRs) were used to describe the effect of the predictors on net mortality, controlling for the general mortality in the South African population. Death was recorded on 1619 patients, of whom 367 (22.7%) had died within 2 years. Out of the 1413 patients that tested for HIV infection, 554 (39.2%) tested positive. Excess mortality was higher in HIV infected, compared to HIV uninfected, MDR-TB patients (adjusted excess hazard ratio, 5.6 [95% CI, 3.2-9.7]); in patients whose TB isolates' resistance to ethambutol and kanamycin was unknown (3.7 [2.1-6.2] and 4.87 [1.9-13.3], respectively) vs. known. There were no differences in excess mortality between age and gender of the patient, year of diagnosis and TB history. Adjusting for some important predictors, MDR-TB patients with HIV infection experienced higher excess mortality compared to HIV-uninfected MDR-TB patients, after accounting for the general mortality in South Africa. An appropriate, though complex method has produced predictor effect estimates similar to those obtained from classical methods. Thus, the use of relative survival methods should be encouraged in the analysis of causespecific mortality, when ascertainment of cause of death is inaccurate or unknown.

Strengthening civil registration and vital statistics in the Asia-Pacific region: learning from country experiences

In the present paper, the civil registration and vital statistics (CRVS) system experiences of five countries in the region – Afghanistan, India, Kazakhstan, Pakistan and the Philippines – are highlighted. In the case studies, a brief account is provided of the progress, challenges and lessons learned on key aspects of importance for CRVS systems in each country, and a glimpse is offered of the diversity of CRVS systems across the region. Some of the key strategies implemented by countries to address challenges in CRVS systems include legal and policy changes; improved collaboration across multiple sectors, in particular between the registration and statistical authorities; the growing involvement of the health sector in the notification of vital events and in improving the ascertainment of causes of death; public information campaigns; and capacity development for the analysis, dissemination and use of vital statistics for policy and planning purposes.

Road traffic related mortality in Vietnam: Evidence for policy from a national sample mortality surveillance system

BackgroundRoad traffic injuries (RTIs) are among the leading causes of mortality in Vietnam. However, mortality data collection systems in Vietnam in general and for RTIs in particular, remain inconsistent and incomplete. Underlying distributions of external causes and body injuries are not available from routine data collection systems or from studies till date. This paper presents characteristics, user type pattern, seasonal distribution, and causes of 1,061 deaths attributable to road crashes ascertained from a national sample mortality surveillance system in Vietnam over a two-year period (2008 and 2009).MethodsA sample mortality surveillance system was designed for Vietnam, comprising 192 communes in 16 provinces, accounting for approximately 3% of the Vietnamese population. Deaths were identified from commune level data sources, and followed up by verbal autopsy (VA) based ascertainment of cause of death. Age-standardised mortality rates from RTIs were computed. VA questionnaires were analysed in depth to derive descriptive characteristics of RTI deaths in the sample.ResultsThe age-standardized mortality rates from RTIs were 33.5 and 8.5 per 100,000 for males and females respectively. Majority of deaths were males (79%). Seventy three percent of all deaths were aged from 15 to 49 years and 58% were motorcycle users. As high as 80% of deaths occurred on the day of injury, 42% occurred prior to arrival at hospital, and a further 29% occurred on-site. Direct causes of death were identified for 446 deaths (42%) with head injuries being the most common cause attributable to road traffic injuries overall (79%) and to motorcycle crashes in particular (78%).ConclusionThe VA method can provide a useful data source to analyse RTI mortality. The observed considerable mortality from head injuries among motorcycle users highlights the need to evaluate current practice and effectiveness of motorcycle helmet use in Vietnam. The high number of deaths occurring on-site or prior to hospital admission indicates a need for effective pre-hospital first aid services and timely access to emergency facilities. In the absence of standardised death certification, sustained efforts are needed to strengthen mortality surveillance sites supplemented by VA to support evidence based monitoring and control of RTI mortality.

Reports of Increased Mortality and GH: Will This Affect Current Clinical Practice?

Although randomized controlled studies are considered the “gold standard” to assess efficacy and safety, this approach is not always practical to ascertain long-term safety. To better define emerging safety signals, particularly for products already on the market, we mostly rely on observational studies. However, we are cognizant that all observational studies suffer from a critical deficiency: the design is not an experimental one. Because each patient's treatment is deliberately chosen rather than randomly assigned, the risk of selection bias is unavoidable. As a result, systematic differences in outcomes may not be due to the treatment itself. Although methods to adjust for identifiable differences are available, it is impossible to be certain that such adjustments are sufficient or whether they address all patients' relevant characteristics. Estimates of the magnitude of the treatment effect and on the generalizability of the findings are therefore imprecise. All these caveats apply to any observational study. Observational studies do not definitively answer a question, but rather generate hypotheses that need to be further explored with additional studies. Questions regarding the short- and long-term safety of GH have been gaining attention due to the expansion of GH indications and the use of increased dosages. In this issue of the JCEM, Carel et al. (1) report the results of a longitudinal follow-up study of subjects receiving GH where they ascertained its long-term effects on mortality. By 2009, after a mean follow-up of 17.3 yr, they were able to determine the vital status of about 95% of approximately 7000 subjects who received GH in France. Indications for GH varied, but 75% were labeled as idiopathic GH deficient (IGHD), 11.5% as idiopathic short stature, 8% as having a GH neurosecretory disorder, and 5.5% as small for gestational age. Ninety-three subjects died. Eighty-six deaths occurred after GH discontinuation, but six occurred while on active treatment. All-cause mortality was 33% higher than expected when compared with the general population. This increase was attributed to a higher than expected number of bone tumors, as well as subarachnoid and intracerebral hemorrhages. The increases were not associated with any other types of cancer. Doses in excess of 50 μg/kg·d were strongly associated with the increase in mortality. Significance was seen only after 15 yr of follow-up. Analyses at 5 and 10 yr did not show a significant increase in mortality compared with the general population. Shorter children at baseline and males were at increased risk, as well as those with more robust responses to provocative tests. The strengths of this study (1) include the balanced review and fair presentation of the information; the extent of the data, including diagnoses, dosages, time of exposure, and long-term follow-up; the attempts to ascertain in depth causes of death; and the use of internal and external controls. A major weakness of this study (1) is the lack of efficacy data. We do not know how these subjects responded to the treatment. Other limitations are related to the inability to identify and secure an appropriate short stature comparator, the lack of data on growth velocity before GH was administered, the absence of IGF-I levels before and during GH, the small number of events, and the significant amount of missing data, particularly in the ascertainment of cause of death in 22% of cases. The mean age at the time of censoring was less than 30 yr, and it is unknown whether the encountered trend will continue or disappear with passage of time. The number of females may be too small to detect any effect in this group. Many of these shortcomings were recognized by the authors, and attempts to address them were made. Each of these deficiencies, however, opens the door to alternative explanations. It is important to stress that the difficulties facing these authors are common in the field, and that investigators undertaking this sort of project are likely to encounter similar barriers.

Psychic trauma as cause of death

of study Psychic trauma is described as the action of 'an emotionally overwhelming factor' capable of causing neurovegetative alterations leading to transitory or persisting bodily changes. The medico-legal concept of psychic trauma and its definition as a cause in penal cases is debated. The authors present three cases of death after psychic trauma, and discuss the definition of cause within the penal ambit of identified 'emotionally overwhelming factors'. The methodological approach to ascertainment and criterion-based assessment in each case involved the following phases: (1) examination of circumstantial evidence, clinical records and documentation; (2) autopsy; (3) ascertainment of cause of death; and (4) ascertainment of psychic trauma, and its coexisting relationship with the cause of death. The results and assessment of each of the three cases are discussed from the viewpoint of the causal connotation of psychic trauma. In the cases presented, psychic trauma caused death, as deduced from assessment of the type of externally caused emotional insult, the subjects' personal characteristics and the circumstances of the event causing death. In cases of death due to psychic trauma, careful methodological ascertainment is essential, with the double aim of defining 'emotionally overwhelming factors' as a significant cause of death from the penal point of view, and of identifying the responsibility of third parties involved in the death event and associated dynamics of homicide.

Mortality due to myocardial infarction in the Bavarian population during World Cup Soccer 2006

Previously, we had demonstrated that the World Cup Soccer 2006 provoked levels of emotional stress sufficient to increase the incidence of acute cardiovascular events. We sought to assess whether mortality was also increased as a result. We analyzed daily data on mortality due to myocardial infarction (MI) and total mortality using data from the Bavarian State Office for Statistics. We retrospectively assessed study periods from 2006, 2005 and 2003. Quasi-Poisson regression with a log link to model the number of daily deaths was used. To be able to account for a possible delay, we also fitted a cubic distributed lag quasi-Poisson model for both 1 and 2weeks post-exposure. A total of 6,699 deaths due to MI were investigated. No increase in death was found on days of World Cup matches either with or without German participation compared to the matched control periods. In addition, none of the analyses showed a significant effect of the (lagged) exposure to the risk period. Likewise, total mortality rates remained unchanged over the entire period of our analysis. During World Cup Soccer, the number of deaths due to myocardial infarction was not measurably increased compared to a matched control period. Thus, we could not demonstrate a translation of a stress-induced increase of cardiac morbidity into a noticeable increase in mortality. However, our findings are based on a public mortality registry, which may be flawed in many ways, regarding ascertainment of causes of death, in particular.

COPD-related morbidity and mortality after smoking cessation: status of the evidence

The evidence base for the benefit of quitting smoking as regards morbidity and mortality outcomes in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) is limited. The present article is a review of the existing literature. A systematic literature search in medical databases was performed until March 2006, and subsequently until September 1, 2007. The outcomes examined were COPD-related morbidity and mortality (including all-cause mortality) in COPD patients in connection with smoking cessation. A total of 21 and 27 published articles on morbidity and mortality, respectively, were identified and reviewed. For both outcomes, only a few of the studies included patients with severe COPD. Most of the studies reported a beneficial effect of smoking cessation compared with continued smoking, whereas a few found no improvement. Methodological problems, including small study sizes, poor data quality, possibility of reverse causality and incomplete ascertainment of cause of death, limit interpretation of some of the studies. The evidence as a whole supports the conclusion that, even in severe chronic obstructive pulmonary disease, smoking cessation slows the accelerated rate of lung function decline and improves survival compared with continued smoking.

Verbal Autopsy Methods to Ascertain Birth Asphyxia Deaths in a Community-based Setting in Southern Nepal

The goals of this study were to (1) develop an approach to ascertain birth asphyxia deaths by using verbal autopsy data from a community-based setting in Nepal, and (2) explore variations in birth asphyxia mortality fractions by using different birth asphyxia case definitions and hierarchical classifications. Data were prospectively collected during a cluster-randomized, community-based trial of health interventions on neonatal mortality in Sarlahi, Nepal from 2002 to 2006. To assign cause of death, 4 computer-assigned, symptom-based asphyxia case definitions; Nepali physician classification; and our independent review of verbal autopsy open narratives were used. Various hierarchical classification approaches to assign cause of death were also explored. Birth asphyxia specific mortality ranged from 26% to 54%, depending on the computer case definition used. There was poor agreement between computer and physician classification of birth asphyxia. By comparing computer results, physician results, and our independent ascertainment of cause of death, we identified 246 cases of birth asphyxia (32% of neonatal deaths). Allowing for >1 cause of death, 30% and 42% of asphyxia cases also met criteria for prematurity and serious infection, respectively. When a hierarchy was used to assign a single cause of death, the birth asphyxia proportionate mortality was reduced to 12% when identification of deaths because of congenital anomalies, prematurity, and serious infections preceded birth asphyxia. The use of various verbal autopsy definitions and hierarchical approaches to assign cause of death may substantially affect estimates of birth asphyxia-specific mortality and analyses of risk factors. Verbal autopsy methods need to be standardized and validated to generate accurate global estimates to direct policy and resource allocation in low-middle-income countries.

Measuring maternal mortality

A reduction in the maternal mortality ratio (MMR) is one of six health-related Millennium Development Goals (MDGs). However, there is no consensus about how to measure MMR in the many countries that do not have complete registration of deaths and accurate ascertainment of cause of death. In this study, we compared estimates of pregnancy-related deaths and maternal mortality in a developing country from three different household survey measurement approaches: a module collecting information on deaths of respondents' sisters; collection of information about recent household deaths with a time-of-death definition of maternal deaths; and a verbal autopsy instrument to identify maternal deaths. We used data from a very large nationally-representative household sample survey conducted in Bangladesh in 2001. A total of 104 323 households were selected for participation, and 99 202 households (95.1% of selected households, 98.8% of contacted households) were successfully interviewed. The sisterhood and household death approaches gave very similar estimates of all-cause and pregnancy-related mortality; verbal autopsy gave an estimate of maternal deaths that was about 15% lower than the pregnancy-related deaths. Even with a very large sample size, however, confidence intervals around mortality estimates were similar for all approaches and exceeded +/- 15%. Our findings suggest that with improved training for survey data collectors, both the sisterhood and household deaths methods are viable approaches for measuring pregnancy-related mortality. However, wide confidence intervals around the estimates indicate that routine sample surveys cannot provide the information needed to monitor progress towards the MDG target. Other approaches, such as inclusion of questions about household deaths in population censuses, should be considered.