Investigation Of Sudden Death Research Articles

Investigative practice into sudden death in epilepsy: A global survey.

Sudden death is a recognized consequence of epilepsy. Little is known about the practice of confirming the cause of sudden death from most nations. We sought to determine how often autopsy is undertaken, clinician confidence in cause of death and identify the factors which may influence autopsy utilization. An online questionnaire survey was sent to all International League Against Epilepsy (ILAE) chapters chairpersons, asking them to complete the survey based on their perceptions in their country. Questions included: confidence in cause of death in people with epilepsy, frequency of autopsy uptake, and perceived barriers to an accurate diagnosis and ongoing research work. Data were analyzed by chi-squared, Kruskal-Wallis and Spearman rank analysis. Responses were obtained from 77 of 114 individual chapter leaders (68%). Legal, coronial, family attitudes, including cultural and religious factors, to autopsy were considered the major barriers to obtaining an accurate diagnosis. Only 13% had a high level of confidence in the accuracy of the cause of death. There was greater confidence in the diagnosis of the causes of sudden death in epilepsy in the countries with higher autopsy rates. Sixty-six percent of responders were not aware of published or unpublished research or audits on sudden death in epilepsy in their country in the last decade. Significant disparities exist in the investigation of sudden death in epilepsy across countries and identified factors in this study provide an opportunity to formulate a global public health strategy to help overcome this gap.

An investigation of sudden death in farmed infantSiamesecrocodiles during winter and spring in Hainan, China

Sudden deaths without any specific clinical sign occurred among one year old young ones on Siamese crocodile (Crocodylus siamensis) farms in Hainan province, China, during winter and spring in 2012 - 2013. The autopsy showed that the internal organs seemed normal except full of clear ascites in abdominal cavity. There were total six bacterial species isolated, Edwardsiella tarda, Proteus penneri, Proteus vulgaris, Enterobacter asburiae, Citrobacter freundii and Micrococcus luteus from either the heart bloods or the spleens and livers. The virulence of isolated strains was tested by intraperitoneal inoculation in female Chinese edible frogs (Rana rugulosa or Hoplobatrachus rugulosus). The six-day mortality revealed that E. tarda was the most pathogenic, whereas P. penneri and E. asburiae exhibited no infection at all, and the rest demonstrated similar inconspicuous toxicity. All these findings suggest that E. tarda would be the principal suspect causing death of Siamese crocodile. The sensitivities of the E. tarda isolates were tested against 20 kinds of antimicrobial drugs. The results showed that ceftazidime, norfloxacin and amikacin were highly sensitive to the isolates of E.tarda.

Investigation of Sudden Death in Athletes: The Fittest Bodies in the Morgue

Sporting events are generally viewed as regulated activities with fit and healthy participants; therefore, when deaths occur, they draw considerable public interest. Athletic participants can be considered a vulnerable population based on inherent risks within certain sports and the associated physiologic stresses, which may complicate underlying medical conditions. Sudden deaths in young athletes participating in high school and collegiate organized sports occur at an average of four to six deaths per year; however, sudden deaths related to exercise outside of an organized sport setting remain unaccounted for in the overall prevalence of these deaths. A typical forensic pathology practice will see not only these higher-profile deaths occurring during an organized sporting event, but also lower-profile occurrences of individuals dying during more recreational or unstructured exercise. Sport-related deaths can essentially be categorized as those that occur due to dangers inherent in the sport itself, such as forms of heat-related illnesses, blunt force trauma, and water-related deaths, and those that occur due to susceptibilities of a given predisposed participant, including sickle cell trait, hypertrophic cardiomyopathy, and other cardiovascular diseases. This article will address both types of vulnerabilities and provide guidance for appropriate and specific medicolegal death investigation and autopsy procedures in these deaths.

Cocaine-associated increase of atrial natriuretic peptides: an early predictor of cardiac complications in cocaine users?

ObjectiveCocaine is known to produce life-threatening cardiovascular complications, and the investigation of the causes of death may be challenging in forensic medicine. The increasing knowledge of the cardiac function biomarkers...

Adult post-mortem imaging in traumatic and cardiorespiratory death and its relation to clinical radiological imaging

The use of post-mortem imaging is expanding throughout the world with increasing use of advanced imaging techniques, such as contrast-enhanced CT and MRI. The questions asked of post-mortem imaging are complex and can be very different, for example for natural sudden death investigation will focus on the cause, whereas for trauma the cause of death is often clear, but injury patterns may be very revealing in investigating the background to the incident. Post-mortem imaging is different to clinical imaging regarding both the appearance of pathology and the information required, but there is much to learn from many years of clinical research in the use of these techniques. Furthermore, it is possible that post-mortem imaging research could be used not only for investigating the cause of death but also as a model to conduct clinically relevant research. This article reviews challenges to the development of post-mortem imaging for trauma, identification and cardiorespiratory death, and how they may be influenced by current clinical thinking and practice.

Two Fatalities Associated with Sibutramine

Sibutramine is an amphetamine derivative that has been prescribed as an antidepressant and appetite suppressant. It was voluntarily removed from the U.S. market in 2010 following a clinical trial that showed an increased risk of stroke and myocardial infarction. It has been detected as a clandestine additive in some over-the-counter weight loss and herbal remedies available on the Internet and in retail stores. We describe two fatalities involving the non-prescribed use of sibutramine by women using over-the-counter, herbal, weight loss supplements. Physicians need to be aware of inadvertent ingestion of sibutramine by patients who take herbal remedies for weight loss. Medical examiners and coroners may consider further investigation of sudden deaths in people who are taking herbal remedies for weight loss even with a history of heart disease. Since routine toxicology screens may not detect sibutramine, the toxicology laboratory should be informed when sibutramine is suspected.

Sudden adult death

In the investigation of sudden death in adults, channelopathies, such as long QT syndrome, have risen to the fore in the minds of forensic pathologists in recent years. Examples of these disorders are touched upon in this review as an absence of abnormal findings at postmortem examination is characteristic and the importance of considering the diagnosis lies in the heritable nature of these conditions. Typically, a diagnosis of a possible channelopathy is evoked as an explanation for a 'negative autopsy' in a case of apparent sudden natural death. However, the one potential adverse effect of this approach is that subtle causes of sudden death may be overlooked. The intention of this article is to review and discuss potential causes of sudden adult death (mostly natural) that should be considered before resorting to a diagnosis of possible channelopathy. Nonetheless, it becomes apparent that many of the potential causes of sudden death can have a genetic basis. Thus, it becomes an important consideration that there may be a genetic basis to sudden death that extends beyond the negative autopsy.

Genetic aspects and investigation of sudden death in young people

Sudden unexpected or arrhythmic death syndrome (SADS) is frequently cased by inherited cardiac disease The families of SADS victims should be offered screening in dedicated clinics with expertise in inherited cardiovascular disease Systematic screening of family members identifies a probable cause in 20-40% of families

Comparison of extraction efficiencies and LC–MS–MS matrix effects using LLE and SPE methods for 19 antipsychotics in human blood

Antipsychotic drugs are frequently associated with sudden death investigations. Detection of these drugs is necessary to establish their use and possible contribution to the death. LC-MS(MS) methods are common; however accurate and precise quantification is assured by using validated methods. This study compared extraction efficiency and matrix effects using common liquid-liquid and solid-phase extraction procedures in both ante-mortem and post-mortem specimen using LC-MS-MS. Extraction efficiencies and matrix effects were determined in five different blank blood specimens of each blood type. The samples were extracted using a number of different liquid-liquid extraction methods and compared with a standard mixed-mode solid-phase extraction method. Matrix effects were determined using a post-extraction addition approach-the blank blood specimens were extracted as described above and the extracts were reconstituted in mobile phase containing a known amount of analytes. The extraction comparison of ante-mortem and post-mortem blood showed considerable differences, in particular the extraction efficiency was quite different between ante-mortem and post-mortem blood. Quantitative methods used for determination of antipsychotic drugs in post-mortem blood should establish that there are no differences in extraction efficiency and matrix effects, particularly if using ante-mortem blood as calibrator.

SH11 THE MEDIEVAL ENGLISH CORONER

The office of Coroner is a uniquely English institution. Scotland never had coroners. England exported her Coroner to almost everywhere coloured red in the Victorian atlas. The first mention of the Coroner dates from the reign of Alfred the Great. We have no records of that period.The Coroner, as we know him today, dates from September 1194, during the reign of Richard the Lionheart whose interest in England was as a source of money to help finance his obsession with warfare.Much of today’s English legal structure was born in the last decade of the 12th century. The edict that formally established the Coroners was Article 20 of the “Articles of Eyre” in September 1194. In 1195, Justices of the Peace were established. Ironically, they became the major reason for the decline of the Coroner in later centuries.Coroners originally had to be Knights and men of substance. They were unpaid. Their prime function was to service the Royal Courts of Law, the General Eyre, which circulated slowly around the kingdom. This took so long to return to each county that, unless careful records were kept by the coroners, many cases never came to trial and potential revenue was lost to the Crown.Other activities of the Coroner includes jurisdiction over “treasure troves”, shipwrecks and catches of royal fish: the whale and the sturgeon. Historically, his most important role, the only one to survive until today, was his role in the investigation of sudden death.

Is there progress in the autopsy diagnosis of sudden unexpected death in adults?

Sudden death is now currently described as natural unexpected death occurring within 1 h of new symptoms. Most studies on the subject focused on cardiac causes of death because most of the cases are related to cardiovascular disease, especially coronary artery disease. The incidence of sudden death varies largely as a function of coronary heart disease prevalence and is underestimated. Although cardiac causes are the leading cause of sudden death, the exact incidence of the other causes is not well established because in some countries, many sudden deaths are not autopsied. Many risk factors of sudden cardiac death are identified: age, gender, heredity factors such as malignant mutations, left ventricular hypertrophy and left ventricle function impairment. The role of the police surgeon in the investigation of sudden death is very important. This investigation requires the interrogation of witnesses and of the family members of the deceased. The interrogation of physicians of the rescue team who attempted resuscitation is also useful. Recent symptoms before death and past medical history must be searched. Other sudden deaths in the family must be noted. The distinction between sudden death at rest and during effort is very important because some lethal arrhythmia are triggered by catecholamines during stressful activity. The type of drugs taken by the deceased may indicate a particular disease linked with sudden death. Sudden death in the young always requires systematic forensic autopsy performed by at least one forensic pathologist. According to recent autopsy studies, coronary artery disease is still the major cause of death in people aged more than 35 years. Cardiomyopathies are more frequently encountered in people aged less than 35 years. The most frequent cardiomyopathy revealed by sudden death is now arrhythmogenic right ventricular cardiomyopathy also known simply as right ventricular cardiomyopathy (RVC). The postmortem diagnosis of cardiomyopathies is very important because the family of the deceased will need counseling and the first-degree relatives may undergo a possible screening to prevent other sudden deaths. In each case of sudden death, one important duty of the forensic pathologist is to inform the family of all autopsy results within 1 month after the autopsy. Most of the recent progress in autopsy diagnosis of sudden unexpected death in the adults comes from molecular biology, especially in case of sudden death without significant morphological anomalies. Searching mutations linked with functional cardiac pathology such as long-QT syndrome, Brugada syndrome or idiopathic ventricular fibrillation is now the best way in order to explain such sudden death. Moreover, new syndromes have been described by cardiologists, such as short-QT syndrome and revealed in some cases by a sudden death. Molecular biology is now needed when limits of morphological diagnosis have been reached.

Investigation of sudden death from Mycobacterium tuberculosis in a foreign-born worker at a resort hotel

A 60 year-old man born in Central America died suddenly in the hallway of his residence on the grounds of a resort hotel where he worked as a dishwasher. The dishwashing station was in a large, poorly ventilated area where a substantial number of food service workers (cooks, wait staff, bus persons, dishwashers, supervisors, etc.) shared air space with the index patient. Several social contacts of the patient reported that he had been coughing for many months before his death. The County Department Of Health conducted a contact investigation, which identified 171 individuals in need of follow-up. Thirty-six percent of those tested in the first round were tuberculin skin test-positive; a second round of testing yielded a 15% (8 of 52) conversion rate.

Death on the needle syndrome

A toxicological analysis is mandatory in the investigation of sudden deaths, which in drug abusers may be due to many factors. In some instances the toxicology may be essentially negative and requires an explanation for the cause of death. The case report illustrates a challenge for forensic practitioners when 'death on the needle' may be the mode of death with an anaphylactoid reaction.

Microbiology in sudden infant death syndrome (SIDS) and other childhood deaths

The usefulness of post-mortem microbiology in the assessment of sudden unexpected deaths in infants and children has been debated by many pathologists. In our centre, microbiological investigations have been part of the post-mortem protocol for investigation of sudden deaths in infants and children for the past 12 years. The objective of this study was to review the microbiological findings for infants and children examined by our unit during the past 4 years in relation to gross and histological findings of the autopsy and the medical and social histories of the children. We reviewed 57 consecutive sudden deaths in infants and children examined by our Referral Centre between November 1994 and 0ctober 1998. These 57 sudden deaths were aged from 1 day to 4 years and 9 months including 40 cases of sudden infant death syndrome (SIDS) and 17 non-SIDS deaths. Results of the microbiological investigations of tissues and body fluids were assessed during the case review with reference to histological shock signs, severe gastric aspiration, and signs of acute thymic involution. Bacteria alone or in association with viruses were identified in 45/57 (79%) cases including 34/40 (85%) SIDS. The most frequent bacterial isolate was Escherichia coli (27), and the virus identified most frequently was enterovirus (8). C-reactive protein was increased in 10 out of the 42 cases tested including 8/32 (25%) SIDS. Significant gastric content aspiration was found in 17/57 (29.8%) including 13/40 (32.5%) SIDS. Histological signs of shock were present in 33/55 (60%) cases including 22/39 SIDS (56.4%). The microbiological findings were positive for 27/33 (81.8%). We conclude that post-mortem microbiology is essential in sudden death investigation. The conclusion that a death is unexplained if no microbiology was done is not valid, even if in some cases it may be difficult to know precisely in what way the pathogen contributed to the death.

Human Herpesvirus-6 and Sudden Death in Infancy: Report of a Case and Review of the Literature

Investigation of sudden death in infancy is a vital function of the medical examiner's office. Surveillance of these cases may lead to recognition of new diseases or new manifestations of previously described diseases. Human herpesvirus-6 (HHV-6) is a relatively newly described virus that has been recognized as a cause of acute febrile illness in early childhood. While most cases are apparently self-limited, seven fatal cases have been reported. We present a case of a seven-month-old Latin American male with recent otitis media and vomiting who was found dead in bed. Autopsy revealed interstitial pneumonitis with an atypical polymorphous lymphocytic infiltrate in the liver, kidney, heart, spleen, lymph nodes, and bone marrow, associated with erythrophagocytosis. Polymerase chain reaction (PCR) analysis of formalin-fixed paraffin-embedded tissue was positive for HHV-6 and negative for Epstein-Barr virus (EBV) and cytomegalovirus (CMV). HHV-6 was also detected in the atypical lymphoid infiltrate by in-situ hybridization.

A survey of sudden death among school children in Osaka Prefecture.

For 2 years, from January 1985 to December 1986, we carried out a thorough investigation of sudden death or apparent sudden death in a population between 5 and 19 years of age in Osaka Prefecture. Sudden death (unexpected death caused by intrinsic factors within 24 h after the onset of symptoms) occurred in 62 boys and 30 girls, with an annual sudden death rate of 3.0 per 100,000 for boys and 1.5 per 100,000 for girls. Of these 92 deaths, 64 occurred among school children (elementary or high school students), and it was these that were subjected to further analyses. Of the school children deaths, 29.7% seemed to be apparent sudden cardiac death (based on circumstances immediately before death, although there was no definite evidence for sudden cardiac death), and 29.7% were sudden death clearly attributable to underlying heart diseases (hence, sudden cardiac death in the usual meaning of this term accounted for about 60% of the 64 sudden deaths). In addition, 17.2% of the 64 cases were sudden death from bronchial asthma. Analysis of seasonal variation in the incidence of sudden death showed that apparent sudden cardiac death frequently occurred in summer, while sudden death clearly attributable to underlying cardiac diseases often took place in winter, sudden death from bronchial asthma occurred chiefly in summer and fall. Of the total number of sudden deaths, death occurred during exercise in 29.7%, and during sleep in 18.8% of individuals. The percentage of sudden deaths occurring during school hours was as low as 23.4% (15/64). Analysis of the physical condition of the 64 sudden death cases immediately before death disclosed the presence of respiratory infection in 10.9%, fatigue in 21.9%, lack of sleep in 4.7% and other conditions in 4.7%. Thus, the percentage of sudden deaths which occurred under ordinary physical conditions was 57.8% (37/64), of which 14 deaths (21.9% of the total) were associated with exercise.

Sudden Death due to Diabetic Ketoacidosis

Two obese women not known to be diabetic died suddenly of diabetic ketoacidosis (DKA). To our knowledge, sudden unexpected death due to DKA has not been reported as the only manifestation of diabetes mellitus. The investigation of sudden death in patients with risk factors for diabetes, especially in the absence of significant disease of the internal organs, should include determination of vitreous glucose and ketones.

An epidemiological study of sudden death in hard and soft water areas

Death certificates were obtained for men and women aged 30–59 yr in 6 towns with soft water and high CVD death rates and 6 towns with hard water and low CVD death rates. Further information was obtained from the certifying doctor in all deaths attributed to or associated with cardiovascular disease. The classification system used provided for three main groups of sudden death; definite, probable and possible and final coding was carried out “blind” by three independent observers. As anticipated, CVD death rates were higher in the soft water areas and differences in IHD death rates between soft and hard water towns were present in all age groups. Sudden death made up a greater proportion of male IHD deaths in the soft than in the hard water towns, but at a low level of statistical significance. With one exception, there was a fairly clear separation between hard and soft water towns in the proportion of IHD deaths which were sudden. Sudden death as a proportion of IHD death was consistently higher in the soft water towns when subjects were classified by age or social class and also during both winter and summer. The overall findings do not constitute firm evidence that the proportion of IHD deaths which are sudden is higher in soft water towns but they are sufficiently consistent to justify further investigation of sudden death in relation to the hardness of drinking water.

Investigation of sudden deaths from myocardial ischaemia

Investigation of sudden deaths from myocardial ischaemia