Contributing Cause Of Death Research Articles

SARS-CoV-2 (COVID-19) Experience at an Academic Medical Examiner's Office.

The coronavirus disease of 2019 (COVID-19) pandemic has resulted in a great deal of morbidity and mortality worldwide. Since most deaths related to COVID-19 are currently considered natural, and they tend to occur following a clinically recognized illness, many medical examiner/coroner offices within the United States do not take jurisdiction over the majority of COVID-19 deaths. In this review, we present the experience of a medium-sized medical examiner's office affiliated with an academic medical school institution, over the first 15 months of the COVID-19 pandemic. Compared to a 15-month period that immediately preceded the pandemic, our office experienced a significant increase in the total number of reported deaths, scene investigations, full autopsies, natural deaths, accidents, homicides, and drug-related deaths, but a decrease in the number of suicides. Overall, our office performed 5 autopsies during the study period where COVID-19 was considered the primary cause of death, 4 cases where COVID-19 was considered a contributory cause of death, and 28 cases where COVID-19 testing was positive, but COVID-19 was not contributory to death. The COVID-19 pandemic was accompanied by a sizeable increase in work volume within our academic medical examiner's office. Although this increased workload was not related to a large number of COVID-19-related deaths investigated by the office, there were numerous areas of increased workload that were likely secondarily related to the conditions associated with the pandemic.

Verminous bronchitis and pneumonia by nasal trematodes in Greater Caribbean manatees from Puerto Rico.

Five adult Greater Caribbean manatees Trichechus manatus manatus were found stranded on various coasts of Puerto Rico; 2 stranded alive and 3 stranded dead. Clinical signs observed in live-stranded manatees included emaciation, weakness, bradypnea, arrhythmia, and nasal mucus discharge. Postmortem examinations revealed serosanguinous, mucohemorrhagic, or suppurative exudate in bronchi associated with luminal adult Pulmonicola cochleotrema (range: 18-182 trematodes), accompanied by pulmonary abscesses in 2 cases. Histologically, we observed eosinophilic bronchopneumonia of varying severity (n = 4) and chronic erosive to eosinophilic tracheobronchitis (n = 4) with squamous metaplasia (n = 3) and intralesional trematodes and eggs. The trematode identity was confirmed and compared through molecular analysis for the amplified 18S rDNA fragment. Comorbidities included enteric chiorchosis (n = 5), gastric heterocheilosis (n = 4), malnutrition (n = 4), trauma related to watercraft collision (n = 3), systemic toxoplasmosis (n = 1), acute bacterial peritonitis (n = 1), and interstitial nephritis (n = 1), suggesting that immunosuppression was a predisposing factor for lower respiratory tract pulmonicolosis. Based on lesion severity, clinical signs, and the presence and absence of other findings to explain death, this condition was considered the primary cause of death in 1 manatee, a contributory cause of death in 3 manatees, and an incidental finding in 1 individual. These clinicopathological descriptions will facilitate the diagnosis and clinical management of pulmonicolosis in T. manatus, a species endangered with extinction.

A case study for local data surveillance in opioid overdose fatalities in Cuyahoga County, OH 2016-2020

IntroductionFentanyl and fentanyl analogs have increased the overdose mortality rates in the United States, significantly impacting states like Ohio. We examined carfentanil overdose deaths, other contributing Cause of Death (COD) drugs, and drug seizure trends from 2016 to 2020 in Northeast Ohio. Materials and methodsWe studied death investigation data from the Cuyahoga County, Ohio Medical Examiner's Office (CCMEO) of all fatal accidental opioid overdoses as well as drug seizure data from Cuyahoga County Regional Forensic Science Laboratory (CCRFSL). We also compared decedents’ race, gender, age, residential locality, drugs contributing to the COD in opioid cases, and for carfentanil, fentanyl, and cocaine seizures in Cuyahoga County from 2016 to 2020 (N = 2948). ResultsDecedents’ had an average of three different drugs contributing to their COD. A bimodal carfentanil spike was observed in fatal accidental overdoses in Cuyahoga County for the years 2017 and 2019. Decedents in urban residency, who were Non-Hispanic, White and younger, significantly predicted the presence of carfentanil contributing to the COD. In 2020, decedents who were Black and older were significantly associated with cocaine contributing to the COD. Carfentanil and carfentanil-related overdoses were significantly correlated. DiscussionThe pervasiveness of illicitly manufactured fentanyl and fentanyl analog (e.g., carfentanil) mixtures with other drugs are changing the demographics of persons who fatally overdose in Cuyahoga County, OH. Significant trending shifts can also be observed for the presence of carfentanil in decedent and seizure county data. ConclusionsLocal data of drug-related overdose deaths and drug seizures from a medical examiner's office and affiliated forensic laboratory lab can be used for timely public health surveillance, and informing prevention, and intervention at the county level.

Estimating Drug Involvement in Fatal Overdoses With Incomplete Information

Death certificates provide incomplete information on the specific drug categories involved in fatal overdoses. The accuracy of previously developed corrections for this and modifications to them was examined. Uncorrected mortality rates were compared with rates from the preferred correction models. Data were obtained for the universe of 932,364 drug overdoses in the U.S. between 1999 and 2020, including 769,982 (82.6%) with a drug classification and 162,382 (17.4%) without, from the National Center for Health Statistics Multiple Cause of Death files. Opioid and cocaine involvement for unclassified overdoses were estimated using multiple approaches. Prediction accuracy was assessed as the mean absolute deviation between actual and estimated involvement for a test sample with known drug involvement. Corrected death rates from preferred models were compared with uncorrected rates. Analyses were conducted in 2022-2023. Previous regression-based corrections that controlled for decedent characteristics can be improved upon by adding state-fixed effects as covariates. Once this is done, supplementary controls for county characteristics or contributory causes of death do not materially improve prediction accuracy. Properly designed naïve models, which distribute unspecified drug deaths proportionately to specified deaths, often provide similar results and, for county-level analyses, supply the most accurate predictions. Uncorrected results substantially understate the levels of opioid and cocaine involvement and can either understate or overstate changes over time. Failing to correct for incomplete information on death certificates leads to inaccurate counts of deaths from specific categories of drugs, such as opioids. However, relatively simple corrections are available that substantially improve accuracy.

Immediate and contributory causes of death in patients hospitalized with COVID-19

ObjectivesAccurate determination of the immediate causes of death in patients with COVID-19 is important for optimal care and mitigation strategies. MethodsAll deaths in Qatar between March 01, 2020, and August 31, 2022, flagged for likely relationship to COVID-19 were reviewed by two independent, trained reviewers using a standardized methodology to determine the immediate and contributory causes of death. ResultsAmong 749 flagged deaths, the most common admitting diagnoses were respiratory tract infection (91%) and major adverse cardiac event (MACE, 2.3%). The most common immediate causes of death were COVID-19 pneumonia (66.2%), MACE (7.1%), hospital-associated pneumonia (HAP, 6.8%), bacteremia (6.3%), disseminated fungal infection (DFI, 5.2%), and thromboembolism (4.5%). After COVID-19 pneumonia, MACE was the predominant cause of death in the first 2 weeks but declined thereafter. No death occurred due to bacteremia, HAP, or DFI in the first week after hospitalization, but became increasingly common with increased length of stay in the hospital accounting for 9%, 12%, and 10% of all deaths after 4 weeks in the hospital, respectively. ConclusionNearly one-third of patients with COVID-19 infection die of non-COVID-19 causes, some of which are preventable. Mitigation strategies should be instituted to reduce the risk of such deaths.

Prediction of cardiovascular death and non-fatal cardiovascular events by the Kidney age–Chronological age Difference (KCD) score in men and women of different ages in a community-based cohort

ObjectiveWe examined the utility of the Kidney age–Chronological age Difference (KCD) score, an age-adapted measure of kidney function, to identify increased cardiovascular (CV) death or non-fatal CV event risk in...

Physician’s Knowledge and Skill to Complete the Certificate of Cause of Death According to who Guidelines A Survey Among the Doctors of A Tertiary Care Hospital at Lahore\

Background: The medical document certifying the cause of death provides vital data to develop health policies. In spite of very comprehensive guidelines issued by the WHO for thecompletion of death certificates; very few certificate arefound errorfree which might be due to lack of knowledge and practice on the part of physicians issuing that certificate.Purpose of this study is to assess the knowledge and competencies of a doctor in completing a death certificate. Methods: This study was cross-sectional. The population of this study was physicians of a tertiary care hospital of Lahore. A structured questionnaire along with a case scenario was given to 137 physicians having variable working experiences, performing in different clinical departments of a tertiary care hospital of Lahore.The participants were asked to complete the component of cause of death of the certificateonly. The percentage of omissions done by the doctors during the completion of said section was analyzed using the chi square test to establish the association between participant’s characteristics and their relevant responses. Results: Among 137participants working in different clinical departments of a Tertiary Care Hospital at Lahore, 89% were having less than 5 years’ experience and 11% having more than 5 years’ experience. 53% were qualified from public sector, 24% from private sector and 23% from foreign institutes. 77% doctors identified immediate cause of death incorrectly, 83 % did not identify and interpret underlying cause of death correctly; 90 % did notidentify contributory cause of death correctly. In46 % cases mechanism/mode of death was confused with the cause of death. Practical Implication: The correct completion of death certificates would provide an accurate and genuine mortality index essential for framing a national health policy. Conclusion: Physician’s knowledge and skill of completing the death certificates is very deficient and alarming which necessitate periodical and regular training of the physicians on completing the death certificates as per guidelines of the WHO to get an appropriate and valid health statistics effective for future public national health policies and strategies. Keywords (MeSH): Death certificate completion, Medical certification of cause of death, Physician’s knowledge, skill to complete death certificate, Mortality index

94 Adolescents’ Suicide Rates by Ethnicity - Data from the National Vital Statistics System 2015-2020

94 Adolescents’ Suicide Rates by Ethnicity - Data from the National Vital Statistics System 2015-2020

The contribution of alcohol-related deaths to the life-expectancy gap between people with and without depression – a cross-country comparison

BackgroundAlcohol-related deaths may be among the most important reasons for the shorter life expectancy of people with depression, yet no study has quantified their contribution. We quantify the contribution of alcohol-related deaths to the life-expectancy gap in depression in four European countries with differing levels of alcohol-related mortality. MethodsWe used cohort data linking population registers with health-care and death records from Denmark, Finland, Sweden and Turin, Italy, in 1993–2007 (210,412,097 person years, 3046,754 deaths). We identified psychiatric inpatients with depression from hospital discharge registers in Denmark, Finland, and Sweden and outpatients with antidepressant prescriptions from prescription registers in Finland and Turin. We assessed alcohol-related and non-alcohol-related deaths using both underlying and contributory causes of death, stratified by sex, age and depression status. We quantified the contribution of alcohol-related deaths by cause-of-death decomposition of the life-expectancy gap at age 25 between people with and without depression. ResultsThe gap in life expectancy was 13.1–18.6 years between people with and without inpatient treatment for depression and 6.7–9.1 years between those with and without antidepressant treatment. The contribution of alcohol-related deaths to the life-expectancy gap was larger in Denmark (33.6%) and Finland (18.1–30.5%) – i.e., countries with high overall alcohol-related mortality – than in Sweden (11.9%) and Turin (3.2%), and larger among men in all countries. The life-expectancy gap due to other than alcohol-related deaths varied little across countries. ConclusionsAlcohol contributes heavily to the lower life expectancy in depression particularly among men and in countries with high overall alcohol-related mortality.

Risk of serious infections in multiple sclerosis patients by disease course and disability status: Results from a Swedish register-based study

Background and objectivesSerious infections are an emerging concern with increasing use of potent immunomodulation in multiple sclerosis (MS), but the extent to which MS disease features influence infectious susceptibility is poorly characterized. The objective of this study was to assess the associations of MS disease course and disability status with risk of serious infections. MethodsA cohort of 8660 MS patients was individually matched on age, sex and region of residence with 86,600 people without MS from the general population using national registers in Sweden. The study period was from 1996 to 2012, with follow-up until December 31, 2014. The main outcomes were infection as the underlying or contributory cause of death or infection-related hospital admission identified in the Cause of Death and Patient registers. MS disease course (relapsing-remitting or progressive disease) and Expanded Disability Status Scale (EDSS) score (six and over or below six) were extracted from the MS Register Hazard ratios (HRs) for any serious infection were estimated using flexible parametric models. ResultsDuring a median follow-up of 9.6 years (interquartile range = 5.5–13.5 years), 1337 MS patients experienced a serious infection. Compared with individually matched people without MS, risk of serious infection was greater for progressive disease (HR = 3.80; 95% CI 3.52: 4.09) than relapsing-remitting disease (HR = 1.77; 95% CI: 1.62:1.93). A similar pattern of risk was seen for dichotomised EDSS score (HR = 4.26; 95% CI 3.87: 4.70 for EDSS 6.0–9.5 and HR = 1.30; 95% CI 1.1853: 1.43 for EDSS 0.0–5.5). Overall, associations with greater disability did not notably differ by immunomodulatory therapy use, but associations with lower disability were more pronounced in patients receiving these therapies. ConclusionsDisease course or EDSS score (which may be more readily available than MS course in some patients) should be considered in individual management and monitoring of MS patients, including assessing benefit-risk of therapies that influence general immune function.

Urban scaling of opioid overdose deaths in the USA: a cross-sectional study in three periods between 2005 and 2017

ObjectivesTo describe the association between population size, population growth and opioid overdose deaths—overall and by type of opioid—in US commuting zones (CZs) in three periods between 2005 and 2017.Settings741 CZs...

Evaluation of the impact of changes in the autopsy rate on mortality trend of pulmonary embolism, Finland, 1996-2017.

Pulmonary embolism is listed as a cause of death in fewer and fewer cases in the twenty-first century. Autopsies reveal undiagnosed pulmonary embolism at a significant rate, but fewer and fewer autopsies are being performed. It could be that deaths from pulmonary embolism are not decreasing, but are increasingly missed because of decreasing autopsy rate. Population-based registry data of all individuals with pulmonary embolism related death from the Finnish death certificate archive from 1996 to 2017 were collected. The pulmonary embolism mortality trend was analysed with linear regression and the association of pulmonary embolism mortality with the number of autopsies was also assessed. Deaths with pulmonary embolism as immediate, underlying and contributory cause of death were not only included, but also analysed separately. In addition, the estimated pulmonary embolism mortality when presumptively missed pulmonary embolisms are taken into account is presented. During 1996-2017, the pulmonary embolism related mortality rate decreased 28% from 25: 100 000 to 18: 100 000, if all pulmonary embolism deaths were analysed, and 51% from 21: 100 000 to 11: 100 000 if contributory pulmonary embolism deaths were excluded. From 1996 to 2009, autopsy rate in the population remained unchanged, but declined thereafter. In 1996, autopsy rate was 31.1% (15 319/49167) and in 2017 20.1% (10830/53 923). Our results suggest that there has been real improvement in the prevention of death from pulmonary embolism in Finland in the twenty-first century. However, due to the decreasing autopsy rate, the pulmonary embolism mortality trend after 2010 should be interpreted more carefully.

Increasing epilepsy-related mortality: A multiple causes of death study in Northern Italy

Purposeto assess the burden of epilepsy as the underlying or contributory cause of death, to investigate time trends in mortality with epilepsy, and to examine the main associated comorbidities. MethodsAll deaths from January 1, 2008 to December 31, 2019 with any mention of epilepsy were retrieved from the mortality register of the Veneto Region (Italy). The average annual percent change (AAPC) in age-standardized mortality rates was estimated by log-linear models. The association between mention of epilepsy and of selected disease categories in death certificates was assessed by conditional logistic regression. ResultsAny mention of epilepsy was reported in 5,907 death certificates; of these, epilepsy was selected as the underlying cause in 1,020 decedents. Deaths with epilepsy represented 0.8% of total mortality in 2008–2011, increasing to 1.3% in 2016–2019. The AAPC was 4.7% for males (95% CI 3.0–6.4, p<0.001) and 6.2% for females (95% CI 4.5–7.9, p<0.001). A strong association was found between mention of epilepsy and meningitis/encephalitis, congenital anomalies/cerebral palsy and other paralytic syndromes, central nervous system tumours, cerebrovascular diseases, and dementia/Alzheimer. ConclusionsThe present analysis from Southern Europe confirms recent reports limited to the UK and the US on increasing epilepsy-related mortality rates. aging of the population and the growing prevalence of neurological disorders are among long-term causes of this unfavorable trend; further studies on mortality data and other health archives are warranted.

Multiple hospitalisations towards the end of life among patients with serious mental illness: A retrospective cohort study in England, UK

IntroductionMultiple hospitalisations towards the end of life is an indicator of poor-quality care. Understanding the characteristics of patients who experience hospitalisations at the end-of-life and how they vary is important for improved care planning.ObjectivesTo describe socio-demographic and clinical characteristics of patients diagnosed with serious mental illness who experienced multiple hospitalisations in the last 90 days of life.MethodsData for all adult patients with a diagnosis of serious mental illness who died in 2018-2019 in England, UK were extracted from the National Mental Health Services Data Set linked with Hospital Episode Statistics and death registry data. Variables of interest included age, gender, marital status, underlying and contributory cause of death, ethnicity, place of death, deprivation status, urban-rural indicator, and patient’s region of residence. The number of hospitalisations and patient’s sociodemographic &amp; clinical were described using descriptive statistics and percentages, respectively.ResultsOf the 45924 patients, 38.1% (n=17505, Male=42.9%, Female=57.1%, Mean age:78.4) had at least one hospitalisation in the last 90 days of life. The median number of hospitalisations was 2(StdDev:1.64, Minimum=1,Maximum=23). Most of those hospitalised (n=11808, 67.5%), died in a health care establishment (e.g. Hospital or hospice). There were marked geographic differences in the proportions of hospitalisations.The North West region of England recorded the most hospitalisations (n= 2906,16.6%), compared to other regions.ConclusionsFurther analysis is needed to understand factors independently associated with hospitalisations in people with serious mental illness. Funding: This project is supported by the National Institute for Health Research (NIHR) Applied Research Collaborations (ARC) South London.

Predators, Disease, and Environmental Change in the Nearshore Ecosystem: Mortality in Southern Sea Otters (Enhydra lutris nereis) From 1998–2012

We compiled findings from 15 years (1998–2012) of southern sea otter (Enhydra lutris nereis) necropsies, incorporating data from 560 animals. Sensitive diagnostic tests were used to detect biotoxins, bacteria, parasites and fungi. Methods to classify primary and contributing causes of death (COD) and sequelae utilized an updated understanding of health risks affecting this population. Several interesting patterns emerged, including identification of coastal regions of high mortality risk for sea otter mortality due to shark bite, cardiomyopathy, toxoplasmosis, sarcocystosis, acanthocephalan peritonitis and coccidioidomycosis. We identified demographic attributes that enhanced the risk of disease in relation to age, sex, and reproductive stage. Death due to white shark (Carcharodon carcharias) bite increased dramatically during the study period and was the most common primary COD. However, when primary and contributing COD were combined, the most prevalent COD was infectious disease (affecting 63% of otters), especially fatal infections by acanthocephalans (Profilicollisspp.) and protozoa (e.g.,Sarcocystis neuronaandToxoplasma gondii). Fatal bacterial infections were also extremely common as a primary process or a sequela, affecting 68% of examined otters. Substantial advances were made in identifying sea otters that died following exposure to the pervasive marine neurotoxin domoic acid (DA), and DA intoxication was conservatively estimated as a primary or contributing COD for 20% of otters. Cardiomyopathy was also highly prevalent as a primary or contributing COD (41%) and exhibited significant associations with DA intoxication and protozoal infection. For adult and aged adult females in late pup care through post-weaning at the time of death, 83% had end lactation syndrome (ELS) as a primary or contributing COD. This comprehensive longitudinal dataset is unique in its depth and scope. The large sample size and extensive time period provided an opportunity to investigate mortality patterns in a changing environment and identify spatial and temporal disease “hot spots” and emerging threats. Our findings will help improve estimates of population-level impacts of specific threats and optimize conservation and environmental mitigation efforts for this threatened species.

Linking death registration and survey data: Procedures and cohort profile for The Irish Longitudinal Study on Ageing (TILDA).

Background: Research on mortality at the population level has been severely restricted by an absence of linked death registration and survey data in Ireland. We describe the steps taken to link death registration information with survey data from a nationally representative prospective study of community-dwelling older adults. We also provide a profile of decedents among this cohort and compare mortality rates to population-level mortality data. Finally, we compare the utility of analysing underlying versus contributory causes of death. Methods: Death records were obtained for 779 and linked to individual level survey data from The Irish Longitudinal Study on Ageing (TILDA). Results: Overall, 9.1% of participants died during the nine-year follow-up period and the average age at death was 75.3 years. Neoplasms were identified as the underlying cause of death for 37.0%; 32.9% of deaths were attributable to diseases of the circulatory system; 14.4% due to diseases of the respiratory system; while the remaining 15.8% of deaths occurred due to all other causes. Mortality rates among younger TILDA participants closely aligned with those observed in the population but TILDA mortality rates were slightly lower in the older age groups. Contributory cause of death provides similar estimates as underlying cause when we examined the association between smoking and all-cause and cause-specific mortality. Conclusions: This new data infrastructure provides many opportunities to contribute to our understanding of the social, behavioural, economic, and health antecedents to mortality and to inform public policies aimed at addressing inequalities in mortality and end-of-life care.

The Role of Dementia as Cause of Death: Certifiers’ Opinions versus Automated Coding

Background: Dementia is a major cause of death in many countries today. The way in which countries code causes of death determines the occurrence of dementia in statistics. The change over from manual to automated coding is accompanied by a 7–19% increase in the occurrence of dementia as the underlying cause of death. Because of this sudden change, researchers, physicians, policy makers, and press question the validity of the outcome of automated coding. Therefore, the role of dementia as a cause of death was investigated. Methods: A questionnaire was sent to a random sample of 700 certifiers who mentioned “dementia” on a death certificate in the second half of 2017. They were asked questions about the role of dementia as a cause of death. For each certificate, the opinion of the certifier was compared with the outcome of automated coding. Results: A response of 65% (n = 446) was obtained. The automated coding system selected dementia as the underlying cause of death 9.5% points (95% CI: 5.8–14.4%) more often than the certifier would do. This finding in the sample corresponded to an overestimation of dementia in the cause-of-death statistics with 22.7% (95% CI: 18–28%). Main reason for this overestimation was the selection of dementia as the underlying cause of death by the automated coding system, while it was noted as the contributory cause of death on part 2 of the death certificate by the certifier. Conclusion: For international comparisons of data on dementia as a cause of death, the outcome of automated coding can be used as the system adheres to international (ICD-10) guidelines and reduces coding variations in and between countries. However, for interpreting the local (national) impact of dementia as a cause of death, the opinion of the certifier should be taken into account.

Reporting of alcohol as a contributor to death in Australian national suicide statistics and its relationship to post-mortem alcohol concentrations.

To describe the assignment of International Classification of Disease (ICD)-10 alcohol codes as underlying or contributory causes of death by the Australian Bureau of Statistics during mortality coding for suicides according to the blood alcohol concentration (BAC) detected at autopsy. Population-based case-series descriptive analysis. Data for all alcohol-related (Alc+) suicide deaths (aged 15+) in Australia from 2010-2015 (n=3132) from the National Coronial Information System. Alc+suicides were categorised as those with a post-mortem BAC≥0.05g/100mL. The outcome variable was whether the case was assigned an ICD-10 alcohol code (F10.0-F10.9, R78.0, T51, X45 and/or X65). We estimated OR for the assignment of codes in Alc+suicides using BAC as the key predictor. We also examined several covariates that have been implicated in the risk of Alc+suicides. An ICD-10 alcohol code was assigned during the mortality coding process in 47.6% (n=1491) of Alc+suicides. Higher BAC was associated with higher odds of having a code assigned; cases with a BAC over 0.20g/100mL over were twice as likely to have an alcohol code assigned (adjusted OR [AOR]=2.06, 95% CI = 1.59, 2.67) compared with cases with a BAC of 0.050-0.075g/100mL. Compared with New South Wales, higher likelihood of code assignment was found in Northern Territory (AOR=3.85, 95% CI = 2.32, 6.63) and Western Australia (AOR=2.89, 95% CI = 2.27, 3.68). Compared with 15-24year olds, 25-44 (AOR=0.79, 95% CI = 0.63, 0.99) and 65-84year olds (AOR=0.63, 95% CI = 0.43, 0.93) were less likely to have a code assigned. An ICD-10 alcohol code was not assigned as an underlying or contributory cause of death in over half of suicides in Australia (2010-2015) with a BAC≥0.05g/100mL. The higher the BAC detected at autopsy, the more likely cases were to be assigned an alcohol code during the mortality coding process.

An outbreak of deaths associated with AMB-FUBINACA in Auckland NZ.

BackgroundAMB-FUBINACA is a synthetic cannabinoid that has been associated with periodic outbreaks of acute poisonings, but few fatalities. In late May, June and July 2017 Auckland, New Zealand, experienced an outbreak of deaths associated with AMB-FUBINACA that continued at a rate of about 2–3 per month through February 2019. The aim of this study was to define the demographic, circumstantial, pathological and toxicological characteristics of this outbreak.MethodsAll records of the Northern Forensic Pathology Service, Auckland Hospital, were reviewed in which the word “AMB-FUBINACA” was referenced, including initial police reports, autopsy reports and toxicology reports. Recorded data included age, sex, race/ethnicity, times and locations, cause of death, autopsy and toxicology findings, and a brief summary of the circumstances of death. Descriptive statistics were performed using IBM® SPSS® Statistics Version 24 and Microsoft® Excel® Version 14.7.2.FindingsSixty-four cases were identified. One sudden infant death and five cases where cause of death was due to trauma were excluded. Of the remaining 58 cases, 88% were male. Mean age was 42 years. In 95% of the deaths, AMB-FUBINACA alone or in combination with alcohol or another drug was listed as the primary or contributory cause of death. In 41 cases postmortem blood concentrations of AMB-FUBINACA acid were available, ranging from <45 ng/mL to >1000 ng/mL, mean 229 ng/mL, median 140 ng/mL. Comorbidities identified included mixed intoxications (29%), heart disease (47%) and obesity (16%). A mental health diagnosis was reported in 50%, and 40% were on antipsychotic medications.InterpretationThis study presents characteristics, comorbidities and toxicological findings in a unique outbreak of deaths associated with the synthetic cannabinoid AMB-FUBINACA in Auckland, NZ.FundingAll work was funded as part of the usual employment of the authors in their respective institutions. No special funding sources are reported.

Linking death registration and survey data: Procedures and cohort profile for The Irish Longitudinal Study on Ageing

Background: Research on mortality at the population level has been severely restricted by an absence of linked death registration and survey data in Ireland. We describe the steps taken to link death registration information with survey data from a nationally representative prospective study of community-dwelling older adults. We also provide a profile of decedents among this cohort and compare mortality rates to population-level mortality data. Finally, we compare the utility of analysing underlying versus contributory causes of death. Methods: Death records were obtained for 779 (90.3% of all confirmed deaths at that time) and linked to individual level survey data from The Irish Longitudinal Study on Ageing (TILDA). Results: Overall, 9.1% of participants died during the nine-year follow-up period and the average age at death was 75.3 years. Neoplasms were identified as the underlying cause of death for 37.0%; 32.9% of deaths were attributable to diseases of the circulatory system; 14.4% due to diseases of the respiratory system; while the remaining 15.8% of deaths occurred due to all other causes. Mortality rates among younger TILDA participants closely aligned with those observed in the population but TILDA mortality rates were slightly lower in the older age groups. Contributory cause of death provides similar estimates as underlying cause when we examined the association between smoking and all-cause and cause-specific mortality. Conclusions: This new data infrastructure provides many opportunities to contribute to our understanding of the social, behavioural, economic, and health antecedents to mortality and to inform public policies aimed at addressing inequalities in mortality and end-of-life care.