Unknown Cause Of Death Research Articles

P4150Causes of death in a heart failure clinic in Spain along 17 years

Abstract Background Advances in heart failure (HF) treatment have achieved a reduction of death in HF patients in the last two decades. Indeed, not only mortality has been reduced but also the mode of death might have been modified through these years. Purpose To assess the causes of death in outpatients attended in a HF Unit since the year 2002 up to the year 2018. Methods Causes of death were classified as follows: progression of HF (worsening HF or treatment-resistant HF, in the absence of another cause); sudden death (any unexpected death, witnessed or not, of a previously stable patient with no evidence of worsening HF or any other known cause of death); acute myocardial infarction; stroke; procedural (post-diagnostic or post-therapeutic); other cardiovascular causes (e.g., rupture of an aneurysm, peripheral ischemia, or aortic dissection), and non-cardiovascular. Patients who died of unknown cause were excluded from the analysis. Fatal events were identified from the clinical records of patients with HF, hospital wards, the emergency room, general practitioners, or by contacting the patient's relatives. Furthermore, data were verified from the databases of the Catalan and Spanish Health Systems. Trends on every cause of death were assessed by linear regression. Results Since August 2001 to May 2018, 2295 HF patients were admitted to the HF clinic (age 66.4±12.8 years, 71% men, 49% from ischemic aetiology, mean LVEF 35.2% ± 14). During the 17 years of the study, 1201 deaths were recorded. Seventy-eight patients (6.5% of deaths) were excluded due to unknown cause of death. The evolution in the mode of death by years is shown in the figure. Two trends were observed: a decrease in sudden death (p=0.05) and a very significant linear increase in non-cardiovascular causes of death (p<0.001). The decrease of sudden death was mainly driven from changes observed in the first 10 years (p=0.014); thereafter the incidence of sudden death remained stable (p=0.18). Remarkably we did not observe significant changes in HF progression as mode of death (p=0.17). Conclusions During the 17 years of the study, a very significant trend towards higher percentage of non-cardiovascular deaths was progressively observed. On the other hand, percentage of sudden death showed a gradual decrease, mainly driven from the changes observed in the first 10 years.

Incidence and Causes of Perinatal Mortality in Georgia

Georgia has one of the highest perinatal mortality rates (i.e., stillbirths and early neonatal deaths combined) in Europe. The Georgian Birth Registry was started in 2016 to provide data for preventive measures of maternal and child health. In this study, we aim to determine the incidence of perinatal mortality, assess the distribution of stillbirths and early neonatal deaths, and to determine the major causes of perinatal mortality in Georgia. Data sources were the Georgian Birth Registry and the vital registration system for the year 2017. Causes of early neonatal deaths were assigned into five categories, using the Wigglesworth classification with the Neonatal and Intrauterine deaths Classification according to Etiology modification. The study used descriptive statistics only, specifically counts, means, proportions, and rates, using the statistical software STATA version 15.0 (StataCorp, College Station, TX, USA). In 2017, 489 stillbirths and 238 early neonatal deaths were recorded, resulting in a perinatal mortality rate of 13.6 per 1000 births. About 80% of stillbirths had an unknown cause of death. The majority of stillbirths occurred before the start of labor (85%), and almost one-third were delivered by caesarean section (28%). Prematurity (58%) and congenital malformations (23%) were the main causes of early neonatal deaths, and 70% of early neonatal deaths occurred after the first day of life. The perinatal mortality rate in Georgia remained high in 2017. The major causes of early neonatal deaths were comparable to those of many high-income countries. Contrary to global data, most early neonatal deaths occurred after the first day of life.

Potentially traumatic experiences of seafarers

BackgroundThe aim of the present study is to assess the extent to which seafarers had been affected by severe mental stress situations and what possible psychological effects they may have.MethodsDuring the voyages of 22 German ships, a psychologically trained investigator interviewed 323 seafarers about severe mental stress or potentially traumatic events on board (participation rate 88.5%). Furthermore, a psychologist conducted semi-standardized interviews in 12 shipping companies and in 8 stations of the German Seafarers’ Mission on seafarers’ traumatic experiences.ResultsOf the seafarers surveyed on board, 116 (35.9%) experienced ship wrecks/severe accidents and 55 (17.0%) piracy on board. Experiences with stowaways were indicated by 126 seafarers (39.0%). Repeatedly having to unintentionally think about these events, being reminded of them by certain noises, smells, etc., or often dreaming of them were after-effects in 97 (83.6%) of the affected seafarers after ship wrecks/serious personal accidents on board and in 42 crew members (76.4%) after threats of piracy. Experiences of threat from stowaways had particularly affected non-European seafarers or ratings.According to the interviews with the shipping companies, a total of 14 deaths occurred in the last 3 years in the 12 interviewed shipping companies (due to heart attacks (3), severe cancer (3), very serious accidents (3), suicides (2) and 3 with unknown causes of death). In relation to the container ships of the investigated shipping companies, these frequencies correspond to a mortality rate of 78.4 per 100,000 seafarer years.According to the interviews in 8 Seafarers’ Missions, these organizations are in charge of emergency counselling in the form of crisis intervention when a seafarer has experienced serious psychological stress.DiscussionA serious injury or even the death of a member is a serious psychological stress experience for the other crew members in the closed social system on board. These events are particularly distressing for Filipino seafarers with their strong sociocentric bonds and religious values. Priestly support is often required in order to stabilize the Filipino crew members.ConclusionAs a preventive measure, psychoeducation for seafarers should be established for coping with extreme mental stress situations.

Disease characteristics of diffuse large B-cell lymphoma predicting relapse after autologous stem cell transplantation.

e19030 Background: High-dose chemotherapy followed by autologous stem cell transplantation (HDC/ASCT) is standard of care for patients with diffuse large B-cell lymphoma (DLBCL) whose diseases relapse after, or are refractory to, first-line therapy. However, there are still high rates of relapse following ASCT, and non-relapse mortality also affects survival rates. Prognostic indicators are therefore needed to identify the best candidates for HDC/ASCT. Methods: We retrospectively analyzed medical records of 111 DLBCL patients (78 relapsed, 33 refractory) who underwent HDC/ASCT at the University of California Los Angeles from 2010-2015. Results: The median age at the time of ASCT was 61 years (IQR 51.5-68.0). 80 patients (72%) had DLBCL in a complete response at the time of ASCT, and the majority (98 patients, 88%) had ECOG performance status of 0-1. After a median follow-up of 4.6 years (IQR 2.2-8.1), the 1-year progression-free survival (PFS) rate was 77.3% (95% CI 69.7%-85.7%) and the 1-year overall survival (OS) rate was 84.7% (95% CI 78.2%-91.7%). 41 patients (37%) relapsed after ASCT with a median PFS of 11 months (IQR 5.0-20.0). 37 patients (33%) died, 23 (21%) from relapse mortality, 11 (10%) from non-relapse mortality, and 3 (3%) from unknown cause of death. In univariate analysis, 2 variables were significantly associated with curtailed PFS and OS: higher number (≥ 3 vs < 3) of chemotherapy regimens prior to ASCT (HR 2.20, 95% CI 1.19-4.06, p = 0.013 for PFS; HR 2.01, 95% CI 1.06-3.84, p = 0.036 for OS) and higher International Prognostic Index (IPI) score at time of ASCT (trend HR 1.61, 95% CI 1.10-2.35, p = 0.018 for PFS; trend HR 2.02, 95% CI 1.37-2.98, p = 0.001 for OS). Higher National Comprehensive Cancer Network (NCCN) IPI score at time of ASCT (trend HR 2.29, 95% CI 1.34-3.90, p = 0.002) and refractory versus relapsed disease (HR 1.99, 95% CI 1.04-3.82, p = 0.038) were also significantly associated with curtailed OS. Conclusions: Our study suggests that IPI, while a validated prognostic tool at diagnosis, is also a prognostic indicator at time of ASCT for PFS and OS. NCCN IPI at time of ASCT was also found to be predictive of OS. Age-adjusted IPI was not associated with outcome following ASCT.

Epidemiologic profile of deaths due to drug and chemical poisoning in patients referred to Baharloo Hospital of Tehran, 2011 to 2014

BackgroundIn developing countries with high mortality rates, poisoning is one of the most common causes of admission to emergency rooms. To minimize future deaths related to poisoning, the epidemiological profile of deceased individuals is essential. MethodsThe medical records of all dead patients due to poisoning during 2011–2014 in Baharloo Hospital, Tehran, were evaluated. Exclusion criteria include: incomplete records, unknown causes of death, and persons less than 6 years of age. Data analysis was done by means of SPSS at the significance level of P < 0.05. ResultsThe study included 184 males and 65 females. The mean age range was 37.65 ± 16.78 years. The highest mortality rate was seen in the age range of 21–30 years (30.5%). The most common cause of poisoning was aluminum phosphide (101 cases). The average time of hospitalization was 3.61 days. Most deaths occurred during the first 10 days of admission with intentional poisoning being the most common type (81.5%). ConclusionThe outcome of this study indicates that the main cause of death among young people is intentional poisoning with AIP. This study proves that a greater focus when diagnosing mental health patients, as well as an increase in restrictions when accessing lethal drugs and toxins, is crucial.

Outcome of pediatric non-Hodgkin lymphoma in Central America: A report of the Association of Pediatric Hematology Oncology of Central America (AHOPCA).

Treating B-non-Hodgkin lymphoma (B-NHL) in lower-income countries is challenging because of imprecise diagnosis, the increased risk of fatal toxicity associated with advanced disease at presentation, and limited supportive care. Central American patients with newly diagnosed stage I or II B-NHL received a modified Berlin-Frankfurt-Münster (BFM) regimen including a prephase (prednisone, cyclophosphamide) followed by A/B/A courses (A: cytarabine, dexamethasone, etoposide, ifosfamide, methotrexate, and intrathecal therapy; B: cyclophosphamide, dexamethasone, doxorubicin, methotrexate, and intrathecal therapy). Those with stage III or IV NHL received additional courses (B/A/B), intensified for stage IV disease by additional vincristine and methotrexate doses. Patients in poor condition received a second prephase treatment before their chemotherapy courses. Between March 2004 and June 2016, of 405 patients with B-NHL, 386 (109 females) were eligible for treatment. Immunohistochemistry was performed in 177 cases (47.4%) and characterized the disease as mature B-cell lymphoma. Stage distribution was as follows: I/II, 31 (8.1%); III, 252 (65.3%); IV, 93 (24.1%); 10 (2.6%) not available. The 3-year overall survival was 70% for the whole group (86% for stages I/II, 75% for stage III, 58% for stage IV). Events included death during induction (34 patients, 8.8%), relapse/progression (46, 11.9%), death in remission (9, 2.3%), second malignancy (1, 0.26%), and death of unknown cause (1, 0.26%). Twenty-three (6%) patients abandoned or refused therapy. Approximately 70% of children with B-NHL from Central America experienced long-term, disease-free survival with a modified BFM schedule. Toxic death and relapse/resistant disease were the main reasons for treatment failure.

Racial differences within subsets of Sudden Unexpected Infant Death (SUID) with an emphasis on asphyxia

ObjectiveSudden Unexpected Infant Deaths (SUID) is defined as a combination of Sudden Infant Death Syndrome (SIDS), Unknown Cause of Death (UCD) and Accidental Suffocation and Strangulation in Bed (ASSB). Overall rates from 2000 to 2015 have been trending down. Racial differences in occurrence are seen. Study design and settingUsing the CDC Wonder Database, the total rates of SUID and its subsets were examined. ResultsNon-Caucasian infant death rates for the total SUID group, and the SIDS component, are trending downward significantly faster than for Caucasians. UCD trends in rates show an apparent small, non-significant, decline for non-Caucasians, and are unchanged for Caucasians. ASSB rates are trending upward slightly more rapidly (not significantly) for non-Caucasians than Caucasians. ConclusionThe trend showing ASSB trending upward more in non-Caucasians than Caucasians may suggest: 1) A racial difference that certifiers are more willing to certify SIDS than ASSB in Caucasians, and/or 2) Certifiers are biased towards certifying more ASSB than SIDS in non-Caucasians, and/or 3) Asphyxia risks may be increasing more in non-Caucasian SUIDs. Option #1 would require educational efforts to recognize the asphyxia risks in Caucasians. Option #2 would require documentation of racial bias in infant death certification followed by efforts to reduce the bias. Option #3 would require focused targeting of non-Caucasian populations to reduce asphyxia risks. Potentially all three scenarios could co-exist.

Effects of Cigarette Smoking and Clozapine Treatment on 20-Year All-Cause & Cardiovascular Mortality in Schizophrenia.

To estimate 20-year mortality risk in people with schizophrenia treated with second-generation antipsychotics (SGA) and examine the effects of cigarette smoking on mortality. Of the 1199 individuals with schizophrenia in the study, estimated 20-year all-cause mortality risk by Kaplan Meier Curve was 30% and leading causes of death included 27% cardiovascular disease, 13% cancer, 12% non-HIV infection, 5% respiratory causes, 20% other causes and 18% had unknown cause of death. For all-cause mortality, we found that white race and male sex were significant risk factors (HR = 1.5, p = 0.002 and HR = 1.33, p = 0.033, respectively). For cardiovascular mortality risk, we showed that cigarette smokers and white race were at higher risk (HR = 1.86, p = 0.017 and HR = 1.71, p = 0.045, respectively). Cardiovascular mortality risk at 20-years is 11%. Kaplan-Meier Survival Curve showed a statistical difference for smokers and non-smokers in cardiovascular mortality over the 20-year follow-up (Log rank chi-square = 5.35, df = 1, p = 0.02). 20-year all-cause mortality risk for individuals with schizophrenia was found to be 30% with cardiovascular disease as a leading cause. Cigarette smokers and white race were associated with an increased risk of death. Regarding cardiovascular mortality specifically, cigarette smoking increased risk by 86% over a 20-year period. Clozapine was neither a risk factor for all-neither cause nor cardiovascular mortality. This data suggests that long-term cardiovascular mortality continues to be increased in schizophrenia for those who are or have been cigarette smokers.

Cardiovascular disease-related mortality and factors associated with cardiovascular events in the TREAT Asia HIV Observational Database (TAHOD).

With aging of the HIV-positive population, cardiovascular disease (CVD) increasingly contributes to morbidity and mortality. We investigated CVD-related and other causes of death (CODs) and factors associated with CVD in a multi-country Asian HIV-positive cohort. Patient data from 2003-2017 were obtained from the Therapeutics, Research, Education and AIDS Training in Asia (TREAT Asia) HIV Observational Database (TAHOD). We included patients on antiretroviral therapy (ART) with > 1 day of follow-up. Cumulative incidences were plotted for CVD-related, AIDS-related, non-AIDS-related, and unknown CODs, and any CVD (i.e. fatal and nonfatal). Competing risk regression was used to assess risk factors of any CVD. Of 8069 patients with a median follow-up of 7.3 years [interquartile range (IQR) 4.4-10.7 years], 378 patients died [incidence rate (IR) 6.2 per 1000 person-years (PY)], and this total included 22 CVD-related deaths (IR 0.36 per 1000 PY). Factors significantly associated with any CVD event (IR 2.2 per 1000 PY) were older age [sub-hazard ratio (sHR) 2.21; 95% confidence interval (CI) 1.36-3.58 for age 41-50 years; sHR 5.52; 95% CI 3.43-8.91 for ≥ 51 years, compared with < 40 years], high blood pressure (sHR 1.62; 95% CI 1.04-2.52), high total cholesterol (sHR 1.89; 95% CI 1.27-2.82), high triglycerides (sHR 1.55; 95% CI 1.02-2.37) and high body mass index (BMI) (sHR 1.66; 95% CI 1.12-2.46). CVD crude IRs were lower in the later ART initiation period and in lower middle- and upper middle-income countries. The development of fatal and nonfatal CVD events in our cohort was associated with older age, and treatable risk factors such as high blood pressure, triglycerides, total cholesterol and BMI. Lower CVD event rates in middle-income countries may indicate under-diagnosis of CVD in Asian-Pacific resource-limited settings.

Evaluation of coding ill-defined and unknown causes of death in the Republic of Serbia

One of the most frequently used indicators for the quality of mortality statistics is the use of R-codes as the cause of death (COD) in death certificates. The aim of this study was to analyse the coding of ill-defined and unknown causes of death in the Republic of Serbia (RS). The data for this descriptive study, covering a ten-year period (2006–2015), were obtained from the National Mortality Register. Since population and economic features differ widely between regions in RS, we compared the Belgrade region (BR) with other regions (Or). We estimated the frequency of certain types of death investigation methods regarding R00-99-coded deaths. The frequency of R-codes, by subcategories, and code-specific mortality rates were calculated by region for each year. The use of R-codes was significantly lower in BR than in Or (OR 0.85; 95% CI, 0.84-0.66; p < 0.001). The most frequent method of determining COD was external examination of the body, both in BR and Or (60.7% and 85.5%, respectively). The rate of forensic autopsies in BR was 38.1% while in Or it was only 3.6%. Clinical autopsies were performed in 1% of deaths in BR, compared to 0.5% in Or. Our results suggest that in BR the use of R-codes compared to other CODs has decreased over the past years while there has been an increasing trend in autopsy proportions; in Or the frequency of R-codes, as well as of autopsy proportions, has remained unchanged.

Sodium Iodide: an Alternative Treatment Option for Feline Sporotrichosis?

Background: Sporotrichosis is caused by pathogenic fungi of the genus Sporothrix. The clinically relevant species are S. schenckii, S. globosa and S. brasiliensis. In Brazil, S. brasiliensis is the most prevalent etiological agent among humans and cats. In cats with sporotrichosis, skin lesions are mainly characterized by nodules and ulcers, usually located in the head, nasal region and limbs. The presence of respiratory signs concomitantly with cutaneous lesions is frequent, especially sneezing, and may be associated with lesions located in the nasal mucosa. Ketoconazole (KTZ), itraconazole (ITZ), potassium iodide (KI), sodium iodide (NaI), terbinafine (TRB), fluconazole (FLZ) and amphotericin B (AMB) are the drugs currently available for treating feline sporotrichosis. ITZ remains the drug of choice. ITZ combined with KI has been successfully used in the treatment of naïve cats (especially cases with lesions in the nasal region), cases of recurrence and refractory to ITZ. Clinical cure with NaI has been described in some cases, but its use has been limited by adverse reactions. The conventional formulation is the saturated solution and the recommended dose in the treatment of feline sporotrichosis is 10 mg/kg every 12 h. Cats are sensitive to iodide preparations and should be carefully monitored for clinical evidence of iodism, such as apathy, anorexia, vomiting, diarrhea, hypothermia, hyperthermia, cardiomyopathy, hyperexcitability, muscular spasms and ptyalism. The purpose of this study was to evaluate the therapeutic response of NaI capsules in feline sporotrichosis.Materials, Methods &amp; Results: An observational cohort study was conducted in cats with sporotrichosis at the Laboratory of Clinical Research in Dermatozoonoses in Domestic Animals (Lapclin-Dermzoo), Evandro Chagas National Institute of Infectious Diseases (INI)/Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil. Twenty-eight cats with sporotrichosis confirmed by isolation of Sporothrix spp. in culture, no previous systemic antifungal therapy, and weight above 3.0 kg, were included in the study. The treatment consisted of NaI oral capsules (5 mg/kg/once daily). In cats without clinical improvement after one month of treatment, the dose was increased (10 mg/kg/once daily). The cats were followed up monthly by clinical examination, complete blood count and biochemical analysis (urea, creatinine, alanine aminotransferase - ALT, aspartate aminotransferase - AST, alkaline phosphatase - FA). All procedures were approved by the Animal Ethics Committee (CEUA/Fiocruz), number LW 56/13, and the informed consent term was obtained from all tutors. Clinical cure was achieved in six (21.4%) cases and treatment failure was observed in 13 (46.4%) animals. Seven (25%) cats were lost during follow up, and unknown causes of death occurred in two cases (7.1%). Ten animals (35.7%) presented clinical adverse reactions at some point during treatment. Hyporexia and weight loss were the most frequent ones. Three cats presented alteration in renal function.Discussion: Treatment of feline sporotrichosis in epizootic areas has been a challenge for veterinarians and tutors. Additionally, there are few studies evaluating treatment regimens for this mycosis in animals. In this study, NaI was compounded in capsules, because it is easier to administer when compared to the solution, as previously described for KI. Despite the low cost and the convenient administration of the capsule, NaI presented a low cure rate with the dose used. The study of new pharmaceutical forms and lower doses of low-cost drugs is necessary in a scenario of epizootic sporotrichosis, where investments for the development of new antifungal agents are scarce.

Use of different combination diphtheria-tetanus-acellular pertussis vaccines does not increase risk of 30-day infant mortality. A population-based linkage cohort study using administrative data from the Australian Childhood Immunisation Register and the National Death Index.

ObjectiveTo determine whether differences in combination DTaP vaccine types at 2, 4 and 6 months of age were associated with mortality (all-cause or non-specific), within 30 days of vaccination. DesignObservational nationwide cohort study. SettingLinked population data from the Australian Childhood Immunisation Register and National Death Index. ParticipantsAustralian infants administered a combination trivalent, quadrivalent or hexavalent DTaP vaccine (DTaP types) between January 1999 and December 2010 at 2, 4 and 6 months as part of the primary vaccination series. The study population included 2.9, 2.6, & 2.3 million children in the 2, 4 and 6 month vaccine cohorts, respectively. Main outcome measuresInfants were evaluated for the primary outcome of all-cause mortality within 30 days. A secondary outcome was non-specific mortality (unknown cause of death) within 30 days of vaccination. Non-specific mortality was defined as underlying or other cause of death codes, R95 ‘Sudden infant death syndrome’, R96 ‘Other sudden death, cause unknown’, R98 ‘Unattended death’, R99 ‘Other ill-defined and unspecified cause of mortality’ or where no cause of death was recorded. ResultsThe rate of 30 day all-cause mortality was low and declined from 127.4 to 59.3 deaths per 100,000 person-years between 2 and 6 month cohorts. When compared with trivalent DTaP vaccines, no elevated risk in all-cause or non-specific mortality was seen with any quadrivalent or hexavalent DTaP vaccines, for any cohort. ConclusionUse of routine DTaP combination vaccines with differing disease antigens administered during the first six months of life is not associated with infant mortality.

Time Trend of Liver Cancer Among Subpopulation of Ages Less Than 40 During 2005-2014 in Nghe An, Viet Nam

Background: Liver cancer has been leading cancer mortality nationwide in Viet Nam. Aim: The aim was to examine time trends of liver cancer mortality by performing population-based mortality registration in Nghe An province, 2005-2014. Methods: We yearly collected data from all 480 Commune Health Stations from 2005 to 2014 using the designed form of “Mortality Registration” with a guideline of underlying-, immediate, - and contribute cause of death. Five variables were included name, age, sex, date of death and cause of death. Average residents of each commune were also yearly reported. All cases were coded ICD-10, then liver cancer (C22) was derived. Age-standardized rate (ASR) was estimated. Trend of liver cancer was observed by estimated mortality rates ratio and 95% confident interval (MRR) for 5-period of 2005-2006 (reference), 2007-2008, 2009-2010, 2011-2012, 2013-2014, adjusted for total mortality rate and proportion of cases with unknown causes of death, for total, subgroup of ages 40 or older, and ages less than 40. Results: Among registered 7,667 cases of liver cancer, there were 855 cases aged less than 40. Mortality rates per 100,000 (ASR) were increased from 37.4 to 52.8 in men and 9.2 to 12.6 in women, from 2005 to 2014, respectively. The increased trends were significantly seen for the subpopulation ages 40 or older only, MRR=1.56, 95% CI: 1.38-1.76 in men and MRR=1.67, 95% CI: 1.36-2.04 in women, all P trend &lt; 0.05. In contrast, the decreased trends were significantly observed for the subpopulation ages less than 40, MRR=0.72, 95% CI: 0.54-0.97 in men and MRR=0.47, 95% CI: 0.22-0.99 in women, all P trend &lt; 0.05. Conclusion: The significant decline risks of death from liver cancer for the subpopulation ages less than 40 during 2005-2014 might be explained by HBV vaccine nationwide from 1998 to date and reduction of environmental factors induced this cancer sites in improving healthy environments after the war ended in 1975. Key-words: Liver-cancer, population-based mortality registration, Viet Nam, HBV-vaccine.

Postmortem interrogation of cardiac implantable electrical devices may clarify time and cause of death.

Postmortem interrogation of cardiac implantable electrical devices (CIED) in autopsy is not routinely performed. Thus, it remains unclear whether an interrogation might clarify time and cause of death. Seventy of 4401 patients (1.6%) undergoing autopsy in 2014 and 2015 presented with a CIED. The explanted CIED were interrogated with respect to time and possible cause of death. Battery and lead parameters, clinical and technical alerts, and arrhythmia episodes were reviewed and afterwards correlated with the results of autopsy and clinical data. Twenty-five implantable cardioverter defibrillators (ICD) and 45 pacemaker (PM) devices were analyzed. Death was classified as cardiac by autopsy in 17 of 70 patients. Accordingly, presumably lethal ventricular arrhythmias were documented in six patients (8.6%; 5 ICD, 1 PM). In two of 30 patients with unknown cause of death after autopsy (6.7%), interrogation revealed ventricular tachycardia as potential reason for decease (1 ICD, 1 PM). Postmortem CIED interrogation additionally allowed to make a statement regarding the day of death in 36 patients (51%; 13 ICD, 23 PM). This was in accordance with clinical data or the results of autopsy in nine patients (25%; 3 ICD, 6 PM) or could even clarify the time of death in six patients (16.7%; 4 ICD, 2 PM). Interrogation of CIED revealed potentially lethal ventricular arrhythmias in 9 of 70 patients investigated and enabled valid estimation of the day of death in 15 patients. We therefore conclude that routinely performed postmortem CIED interrogation may clarify time and cause of death.

Prospective registry on cerebral oximetry-guided transcarotid TAVI in patients with moderate-high risk aortic stenosis.

The aim of the study was to assess safety TAVI procedure through the common carotid artery in high-vascular-risk patients. The approach was selected by a multidisciplinary (cardiologists and cardiac surgeons) heart team after analyzing preoperative coronary angiography, transthoracic echocardiography and multislice contrast computed tomography of the peripheral arteries. Patients with the following conditions were qualified to the transcarotid access: severe peripheral artery disease (stenotic, heavily calcified), tortuous or small diameter <6 mm iliofemoral arteries, descending and abdominal aortic disease. Ten transcarotid transcatheter aortic valve implantation procedures were performed in our hospital from September 2017 to May 2018. There were no in-hospital deaths or strokes. The procedural success rate defined as the implantation of the valve with no coronary obstruction and less than moderate paravalvular leak was 100%. Parameters of regional cerebral oximetry were symmetrical on the left and right side in all cases and only during rapid ventricular pacing transiently decreased below the value of 50%. Postoperative cerebrovascular complications and myocardial infarctions were not observed. Statistically significant reduction of the echocardiographic parameters (PGmax and PGmean, Vmax) were observed. Mild paravalvular leaks occurred in 4 patients. Additionally, the heart failure symptoms diminished after the procedure from a median class III to class II. In the 3-month follow-up, mortality is 10% (unknown cause of death of one patient). The mean NYHA class of the other patients is II. Echocardiographic parameters are comparable to postoperative day 4. The pilot registry showed the safety of transcarotid approach in patients with the anatomy precluding the transfemoral approach.

INVESTIGATIONS INTO CAUSES OF NEUROLOGIC SIGNS AND MORTALITY AND THE FIRST IDENTIFICATION OF SARCOCYSTIS CALCHASI IN FREE-RANGING WOODPECKERS IN GERMANY.

Between June and November 2015, 25 woodpeckers (Picidae) with neurologic signs or unknown cause of death were admitted to a veterinary clinic. Alive birds were clinically examined. Birds that were found dead or died despite intensive care treatment were forwarded to a pathologic examination. Necropsy and subsequent tests included screening for several infectious agents and toxins. Three birds tested positive for Sarcocystis calchasi. Toxoplasma gondii was detected in one bird demonstrating intracerebral cysts. Mycoplasma gypis was detected in one woodpecker in the absence of respiratory signs. Several microbial pathogens (eg, Aspergillus fumigatus, Clostridium perfringens, and Escherichia coli) were isolated from single individuals. However, there was no consistent finding in all birds that could explain nervous signs and mortality of the woodpeckers examined. To the authors' knowledge, M. gypis and S. calchasi were detected in a woodpecker for the first time in this study.

Transmission des certificats de décès au CépiDc-Inserm en cas de mort suspecte en France, depuis 2000

BackgroundThe purpose of this study is to assess variability in death certificates’ transmission related to suspicious deaths. MethodsThe medical part of death certificates of suspicious deaths (violent or sudden deaths, unknown or ill-defined causes of death) were examined. We studied the frequency of suspicious deaths, in France, for deaths aged under 65, from 2000 to 2013, searching for temporal (2000–2013) and spatial correlations between unknown causes of death and other suspicious causes, and report of an autopsy. These results were compared with external data. ResultsStandardized proportion of deaths by unknown cause more than doubled during the study period (from 3.4 to 7.5%). The spatial correlation was strongly negative between standardized proportions of unknown causes of death and violent deaths (ICC=−0.80). Report of autopsy varied with cause of suspicious death and estimated zone of the forensic institute. The distribution was consistently distributed with external data, except for homicides. ConclusionInformation transmission to CépiDc-Inserm needs to be improved in case of suspicious death, in particularly from forensic institutes. This study emphasizes the urgent need for a complementary form to the death certificate.

Clinical significance of QT-prolonging drug use in patients with MDR-TB or NTM disease.

Many drugs with potential QT prolongation effects (QT drugs) have already been used for decades in patients with multidrug-resistant TB (MDR-TB) or non-tuberculous mycobacterial (NTM) disease, but without a common consensus. To investigate the effects of QT drugs on cardiac events in patients with MDR-TB or NTM disease. We retrospectively reviewed 373 patients (mean age: 56.4 years) with MDR-TB or NTM disease treated for >1 month with clofazimine (CFZ), moxifloxacin (MFX), bedaquiline (BDQ), delamanid (DLM) or macrolides (clarithromycin or azithromycin). Adverse cardiac events, death and QTcF changes were evaluated. Forty-four per cent had MDR-TB; 165 (44%), 315 (85%), 10 (3%), 229 (61%) and 1 patient received CFZ, MFX, BDQ, macrolides and DLM, respectively. Except for three patients (0.8%) lost to follow-up with unknown cause of death, 3 (0.8%, 95%CI 0.2-2.4) adverse cardiac events were documented: atrial fibrillation, cardiac tamponade due to TB pericarditis and cardiac arrest, which was determined to not have been caused by QT drugs. Clinically significant QTcF changes (QTcF > 500 msec or an increase > 60 msec) were observed in 10/60 patients (17%, 95%CI 8.0-30.7) without clinical events. The use of QT drugs, alone or in combination, in the treatment of MDR-TB or NTM disease is relatively safe.

Enhanced Prophylaxis plus Antiretroviral Therapy for Advanced HIV Infection in Africa

BackgroundIn sub-Saharan Africa, among patients with advanced human immunodeficiency virus (HIV) infection, the rate of death from infection (including tuberculosis and cryptococcus) shortly after the initiation of antiretroviral therapy (ART) is approximately 10%.MethodsIn this factorial open-label trial conducted in Uganda, Zimbabwe, Malawi, and Kenya, we enrolled HIV-infected adults and children 5 years of age or older who had not received previous ART and were starting ART with a CD4+ count of fewer than 100 cells per cubic millimeter. They underwent simultaneous randomization to receive enhanced antimicrobial prophylaxis or standard prophylaxis, adjunctive raltegravir or no raltegravir, and supplementary food or no supplementary food. Here, we report on the effects of enhanced antimicrobial prophylaxis, which consisted of continuous trimethoprim–sulfamethoxazole plus at least 12 weeks of isoniazid–pyridoxine (coformulated with trimethoprim–sulfamethoxazole in a single fixed-dose combination tablet), 12 weeks of fluconazole, 5 days of azithromycin, and a single dose of albendazole, as compared with standard prophylaxis (trimethoprim–sulfamethoxazole alone). The primary end point was 24-week mortality.ResultsA total of 1805 patients (1733 adults and 72 children or adolescents) underwent randomization to receive either enhanced prophylaxis (906 patients) or standard prophylaxis (899 patients) and were followed for 48 weeks (loss to follow-up, 3.1%). The median baseline CD4+ count was 37 cells per cubic millimeter, but 854 patients (47.3%) were asymptomatic or mildly symptomatic. In the Kaplan–Meier analysis at 24 weeks, the rate of death with enhanced prophylaxis was lower than that with standard prophylaxis (80 patients [8.9% vs. 108 [12.2%]; hazard ratio, 0.73; 95% confidence interval [CI], 0.55 to 0.98; P=0.03); 98 patients (11.0%) and 127 (14.4%), respectively, had died by 48 weeks (hazard ratio, 0.76; 95% CI, 0.58 to 0.99; P=0.04). Patients in the enhanced-prophylaxis group had significantly lower rates of tuberculosis (P=0.02), cryptococcal infection (P=0.01), oral or esophageal candidiasis (P=0.02), death of unknown cause (P=0.03), and new hospitalization (P=0.03). However, there was no significant between-group difference in the rate of severe bacterial infection (P=0.32). There were nonsignificantly lower rates of serious adverse events and grade 4 adverse events in the enhanced-prophylaxis group (P=0.08 and P=0.09, respectively). Rates of HIV viral suppression and adherence to ART were similar in the two groups.ConclusionsAmong HIV-infected patients with advanced immunosuppression, enhanced antimicrobial prophylaxis combined with ART resulted in reduced rates of death at both 24 weeks and 48 weeks without compromising viral suppression or increasing toxic effects. (Funded by the Medical Research Council and others; REALITY Current Controlled Trials number, ISRCTN43622374.)

A retrospective study of anti-inflammatory use in dogs with pulmonary blastomycosis: 139 cases (2002-2012).

To determine the effect of anti-inflammatory medications on 30-day survival of dogs treated for pulmonary blastomycosis. Retrospective study. University teaching hospital. One hundred thirty nine client-owned dogs with confirmed pulmonary blastomycosis. The medical records of dogs diagnosed with pulmonary blastomycosis between May 2002 and October 2012 were identified. Of 139 dogs, 85 (61%) survived to 30 days, 38 (27%) were euthanized due to progressive clinical disease, 13 (10%) died secondary to respiratory or cardiac arrest, and 3 (2%) did not survive to 30 days but had an unknown cause of death. Cases were classified based on the anti-inflammatory therapy that was used: nonsteroidal anti-inflammatory drugs (NSAID), corticosteroids, both, or none. Controlling for the effects of itraconazole dose, sex, age, and pretreatment with anti-inflammatory medication, the odds for survival to 30 days was not statistically different between dogs who received no anti-inflammatory medication and the dogs who received NSAIDs (P = 0.86), corticosteroids (P = 0.65), or both (P = 0.27). The need for supplemental oxygen was associated with decreased survival (P < 0.0001). In this population of dogs with pulmonary blastomycosis, the use of anti-inflammatory medications during therapy did not impact 30-day survival; however, the need for oxygen supplementation was associated with significantly lower survival.