Probable Cause Of Death Research Articles

A 90-Day Oral Toxicological Evaluation of the Methylurate Purine Alkaloid Theacrine.

A 90-day repeated-dose oral toxicological evaluation was conducted according to GLP and OECD guidelines on the methylurate purine alkaloid theacrine, which is found naturally in certain plants. Four groups of Hsd.Brl.Han Wistar rats (ten/sex/group) were administered theacrine by gavage doses of 0 (vehicle only), 180, 300, and 375 mg/kg bw/day. Two females and one male in the 300 and 375 mg/kg bw/day groups, respectively, died during the study. Histological examination revealed centrilobular hepatocellular necrosis as the probable cause of death. In 375 mg/kg bw/day males, slight reductions in body weight development, food consumption, and feed efficiency, decreased weight of the testes and epididymides and decreased intensity of spermatogenesis in the testes, lack or decreased amount of mature spermatozoa in the epididymides, and decreased amount of prostatic secretions were detected at the end of the three months. At 300 mg/kg bw/day, slight decreases in the weights of the testes and epididymides, along with decreased intensity of spermatogenesis in the testes, and lack or decreased amount of mature spermatozoa in the epididymides were detected in male animals. The NOAEL was considered to be 180 mg/kg bw/day, as at this dose there were no toxicologically relevant treatment-related findings in male or female animals.

Two Sudden and Unexpected Deaths of Patients with Schizophrenia Associated with Intramuscular Injections of Antipsychotics and Practice Guidelines to Limit the Use of High Doses of Intramuscular Antipsychotics.

Intravenous haloperidol has been associated with torsades de pointes (TdP). These two sudden deaths were probable adverse drug reactions (ADRs) following intramuscular (IM) antipsychotics. The autopsies described lack of heart pathology and were highly compatible with the possibility of TdP in the absence of risk factors other than the accumulation of antipsychotics with a high serum peak after the last injection, leading to death within hours. The first case was a 27-year-old African-American male with schizophrenia but no medical issues. His death was probably caused by repeated IM haloperidol injections of 10 mg (totaling 35 mg in 2 days). The second case involves a 42-year-old African-American female with metabolic syndrome. Her probable cause of death was the last ziprasidone IM injection of 20 mg in addition to (1) three extra haloperidol doses (2 hours before the ziprasidone injection, 5 mg oral haloperidol; approximately 21 hours earlier, 5 mg oral haloperidol; and 2 days prior, one 10 mg IM haloperidol injection), (2) 10 mg/day of scheduled oral haloperidol for 6 days before death, and (3) a long-acting paliperidone injection of 156 mg 18 days before death. The study of haloperidol glucuronidation and its impairment in some African-Americans is urgently recommended.

Eculizumab Treatment of Paroxysmal Nocturnal Hemoglobinuria (PNH). the Argentinian Experience

INTRODUCTIONparoxysmal nocturnal hemoglobinuria (PNH) is a clonal, non malignant disease of hematopoiesis characterized by intravascular hemolysis, a variable depth of bone marrow failure and a marked thrombophilia. Classic therapeutic resources are supportive care and allogeneic hematopoietic stem cell transplantation. Eculizumab arrival to our country -in 2009- revolutionized PNH treatment. We report here our experience with a cohort of 33 patients treated with eculizumab. AIMSto evaluate indications of eculizumab, hematologic response, delays to initiate treatment, interruptions and its consequences, and mortality in our patients. PATIENTS and METHODSdata of 33 patients with PNH who begun treatment with eculizumab between '01/09 and '12/14 were collected with a specific questionnaire. Qualitative data were analyzed as proportions. Quantitative data were evaluated as median (Md), range (R) and percentiles 25% and 75%, or mean (Mn) and 95% confidence interval (95% CI). Quantitative responses to treatment were evaluated with a non parametric test for paired data (Wilcoxon signed Rank test). A probability value <0.05 was used to define statistical significance. RESULTScohort characteristics: Md age at diagnosis: 32 years old. R: 18 a 73. Eighteen were females and 15 males. Interval simptoms-PNH diagnosis Md: 284 days, R: 1 a 4,518. Granulocyte PNH clon size Md: 91%, R: 18 a 99%. Symptoms prevalencefatigue: 90.6%, dyspnea: 71.9%, abdominal pain 56.2%, dysphagia 25%, erectil dysfunction: 20% (of males). Complications frequency: thrombosis 27.3%, impaired renal function 21.2%, pulmonary hypertension 3.1%. Severity criteria of PNH leading to eculizumab prescriptiondisabling symptoms 90.6%, steroid dependence 70%, transfusional requirement 54.5%, thrombosis 24.2%, impaired renal function 21.2%, severe dyspnea/ pulmonary hypertension 21.2%.Delay of eculizumab treatment (from medical prescription to first infusion) in 28 patients: Md: 196 days, R: 37 to 592. Hematologic responses to eculizumabMn LDH decline: 2,081 U/L (95% CI: 1,204 to 2,958) p=0.0003. Mn elevation of hemoglobin 1,5 g/dL (95% CI: 0.82 to 2.18) p=0.0005. Platelet counts increase in thrombocytopenic patients (<150,000 platelets/µL) Mn: 20,720/µL (95% CI: 712 to 40,730) p=0.042. There were no significant changes in neutrophil counts. Eculizumab treatment interruptions were extremely frequent93.7% of patients suffered at least one or more treatment delay(s) ≥ 7 days. Only 2/33 patients did not have any treatment interruption. The mean cause of this treatment irregularities were delays in drug provision by the medical insurance (in 100% of affected patients). In only 10% of cases, lack of patient adherence was responsible for treatment interruptions. Even more, 25.8% of drug supplies were delayed for 7 days or more (99/384 provisions). Results of treatment interruptions weretransfusional requirement in 41.4% of cases, severe anemia in 34.5%, hospital admission in 27.6%, acute renal impairment in 16.7%, Budd-Chiari syndrome progression in one case, and probable cause of death in another one.Three patients died (9.1%). Causes were infection in 1, advanced colon cancer in 1, and multiorgan failure, probably related to visceral thrombosis, in the third case. CONCLUSIONSthis argentinian cohort shows that disabling symptoms, corticosteroids dependence and transfusional requirements are the most frequents causes to start eculizumab treatment in our patients. Eculizumab was effective to block hemolysis, to improve anemia and thrombocytopenia and to prevent new thrombotic events. However, eculizumab achievements were hindered in our experience by the delay to initiate treatment and the frequent interruptions it suffered, as it is usual in Latin America. These treatment delays/interruptions, uncommon in the medical literature, led to multiple and severe complications. DisclosuresBrodsky:Alexion Pharmaceuticals: Consultancy, Speakers Bureau. Touliet:Alexion Pharmaceuticals: Speakers Bureau. Dinardo:Alexion Pharmaceuticals: Speakers Bureau. Blanca:Alexion Pharmaceuticals: Speakers Bureau.

Etiology and pathology of epidemic outbreaks of avian influenza H5N1 infection in Egyptian chicken farms.

Epidemic outbreaks of avian influenza (AI) virus H5N1 have been frequently reported in Egypt during the last nine years. Here we investigate the involvement of AI H5N1 in outbreaks of acute respiratory disease that occurred in several commercial chicken farms in Egypt in 2011, and we describe to the pathology caused by the virus in the course of the outbreak. Twenty-one chicken farms with history of acute respiratory symptoms and high mortalities were screened for AI H5N1. Virus identification was based on hemagglutination inhibition test, and PCR detection and sequencing of the hemagglutinin and neuraminidase genes. Virus distribution was determined by immunohistochemical staining of AI antigens in organs of infected birds. Standard H&E staining was performed for histological examination of affected organs. Eighty-one % of the examined birds, representing 100% of the screened farms, were positive for AI H5N1 virus. Phylogenetic analysis of the hemagglutinin and neuraminidase genes of the isolated virus reveals its affiliation to clade 2.2.1. Viral antigens were localized in the endothelial cells of the heart, liver, lungs and skin, where pathological lesions including congestion, hemorrhages, multifocal inflammation and necrosis were concurrently observed. According to the pattern of the viral antigen and lesion distribution in the visceral organs, we suggest cardiovascular and circulatory failures as the probable cause of death during these outbreaks. In conclusion, the present study further confirms the epidemic status of AI H5N1 virus in Egypt and reveals the highly pathogenic nature of the local isolates.

Stillbirth evaluation: a stepwise assessment of placental pathology and autopsy

The American Congress of Obstetricians and Gynecologists places special emphasis on autopsy as one of the most important tests for evaluation of stillbirth. Despite a recommendation of an autopsy, many families will decline the autopsy based on religious/cultural beliefs, fear of additional suffering for the child, or belief that no additional information will be obtained or of value. Further, many obstetric providers express a myriad of barriers limiting their recommendation for a perinatal autopsy despite their understanding of its value. Consequently, perinatal autopsy rates have been declining. Without the information provided by an autopsy, many women are left with unanswered questions regarding cause of death for their fetus and without clear management strategies to reduce the risk of stillbirth in future pregnancies. To avoid this scenario, it is imperative that clinicians are knowledgeable about the benefit of autopsy so they can provide clear information on its diagnostic utility and decrease potential barriers; in so doing the obstetrician can ensure that each family has the necessary information to make an informed decision. We sought to quantify the contribution of placental pathologic examination and autopsy in identifying a cause of stillbirth and to identify how often clinical management is modified due to each result. This is a cohort study of all cases of stillbirth from 2009 through 2013 at a single tertiary care center. Records were reviewed in a stepwise manner: first the clinical history and laboratory results, then the placental pathologic evaluation, and finally the autopsy. At each step, a cause of death and the certainty of that etiology were coded. Clinical changes that would be recommended by information available at each step were also recorded. Among the 144 cases of stillbirth examined, 104 (72%) underwent autopsy and these cases constitute the cohort of study. The clinical and laboratory information alone identified a cause of death in 35(24%). After placental pathologic examination, 88 (61%) cases had a probable cause of death identified. The addition of autopsy resulted in 78(74%) cases having an identifiable probable cause of death. Placental examination alone changed clinical management in 52 (36%) cases. Autopsy led to additional clinical management changes in 6 (6%) cases. This stepwise assessment of the benefit of both placental pathological examination and autopsy in changing probable cause of death beyond traditional clinical history and laboratory results emphasizes the need to implement more comprehensive evaluation of all stillbirths. With the aim of providing a cause of stillbirth to the parents, and to prevent future stillbirths, it behooves health care professionals to understand the value of this more comprehensive approach and convey that information to the bereaved parents.

Late Diagnosis of Coarctation Despite Prenatal Ultrasound and Postnatal Pulse Oximetry.

To determine what contribution prenatal ultrasound screening and neonatal pulse oximetry screening (POS) make to the timely diagnosis of neonatal coarctation of the aorta (CoA). We identified infants and fetuses diagnosed with isolated CoA in our referral area between 2003 and 2012 who died without surgery, underwent surgical repair before 2 months of age, or were terminated after a prenatal diagnosis. Clinical data were collected from hospital charts. Only 3 of the 90 cases were diagnosed prenatally. Two of the 3 were born alive and in 1 case the couple opted for termination of pregnancy. Nineteen of the remaining 87 cases were born in units that used POS (hand and foot) and 4 of 19 screened positive. Of the remaining 83 cases, 46 were discharged undiagnosed (7 after nondiagnostic echocardiography), including 9 with a murmur and weak femoral pulses and 8 with a murmur and normal pulses. One was diagnosed postmortem after dying at home, and 22 of the remaining 45 discharged infants were in circulatory failure on readmission. Five of the patients who were not discharged died without surgery and undiagnosed CoA was the most probable cause of death in 2 of these patients. The contribution of prenatal ultrasound screening and postnatal POS to the timely diagnosis of CoA was low. Careful physical examination of all newborns therefore continues to play a fundamental role in detecting this life-threatening cardiac defect, and better screening methods need to be developed.

A knot in the gut: A paediatric post-mortem CT diagnosis

We present a case of a previously healthy, five month old boy who, after a short history of mild abdominal complaints died unexpectedly. In this case no parental permission for a conventional autopsy could be obtained on religious grounds, but a and post-mortem CT was consented to and performed. Based on the clinical evaluation combined with PMCT findings a probable cause of death, ileosigmoid knotting, could be established.

Five-year mortality rate in an ophthalmic ward in Zimbabwe

Objective: To determine the mortality rate in the ophthalmic ward at the Sekuru KaguviHospital Eye Unit (SKHEU), Zimbabwe, from January 2009 to December 2013 and to identify the causes of death.Design: A hospital-based clinical audit.Methods: Data from completed hospital death notification forms and medical records of patients who had died in the ward during the review period were collected that included age, gender, diagnoses, date of admission, date of death and cause of death. The data were analysed using Epi Info7 software.Setting: The audit was conducted at SKHEU, the largest tertiary eye unit in Zimbabwe. It comprises an ophthalmic ward with 30 beds and caters for about 900 patients per year. Patients are admitted via the Out-patients Department where about 30 000 patients are seen yearly. SKHEU is part of the Parirenyatwa Group of Hospitals, which is one of the four major referral hospitals in Zimbabwe.Results: Of the 4722 ophthalmic admissions at SKHEU during the 5-year study period, therewere 15 (0.3%) deaths, with a male:female ratio of 3:2 giving a mortality rate of 0.3% and an average of 3 deaths per year. The highest number of deaths was in 2009 when 7 deaths occurred, whilst the lowest number was 1 death in 2010 and 1 in 2013. Of the 15 deaths,4 (26.7%) were children &lt; 12 years old and 11 (73.3%) were adults; of whom 12 (80%) patients had orbital malignancies, 2 (13.3%) had orbital cellulitis and 1 (6.7%) had ocular trauma. Theorbital malignancies included ocular surface squamous neoplasia (OSSN), retinoblastomaand non-Hodgkins lymphoma (NHL). The most common probable cause of death was OSSN which accounted for 9 (60%) of the deaths.Conclusion: The mortality rate at SKHEU was 0.3%, with approximately 3 deaths occurring per year. The most common attributable cause of death was OSSN.

Health & Demographic Surveillance System Profile: The Rufiji Health and Demographic Surveillance System (Rufiji HDSS).

The Rufiji Health and Demographic Surveillance System (HDSS) was established in October 1998 to evaluate the impact on burden of disease of health system reforms based on locally generated data, prioritization, resource allocation and planning for essential health interventions. The Rufiji HDSS collects detailed information on health and survival and provides a framework for population-based health research of relevance to local and national health priorities.In December 2012 the population under surveillance was about 105,503 people, residing in 19,315 households. Monitoring of households and members within households is undertaken in regular 6-month cycles known as 'rounds'. Self reported information is collected on demographic, household, socioeconomic and geographical characteristics. Verbal autopsy is conducted using standardized questionnaires, to determine probable causes of death. In conjunction with core HDSS activities, the ongoing studies in Rufiji HDSS focus on maternal and new-born health, evaluation of safety of artemether-lumefantrine (AL) exposure in early pregnancy and the clinical safety of a fixed dose of dihydroartemisinin-piperaquine (DHA-PQP) in the community. Findings of studies conducted in Rufiji HDSS can be accessed at www.ihi.or.tz/IHI-Digital-Library.

First reported outbreak of severe spirorchiidiasis in Emys orbicularis, probably resulting from a parasite spillover event.

The importance of disease-mediated invasions and the role of parasite spillover as a substantial threat to the conservation of global biodiversity are now well known. Although competition between invasive sliders Trachemys scripta elegans and indigenous European turtles has been extensively studied, the impact of this invasive species on diseases affecting native populations is poorly known. During winter 2012-2013 an unusual event was detected in a population of Emys orbicularis (Linnaeus, 1758) inhabiting a pond system in Galicia (NW Spain). Most turtles were lethargic and some had lost mobility of limbs and tail. Necropsies were performed on 11 turtles that were found dead or dying at this site. Blood flukes belonging to the species Spirorchis elegans were found inhabiting the vascular system of 3 turtles, while numerous fluke eggs were trapped in the vascular system, brain, lung, heart, liver, kidney, spleen, and/or gastrointestinal tissues of all necropsied animals. Characteristic lesions included miliary egg granulomas, which were mostly found on serosal surfaces, particularly of the small intestine, as well as endocarditis, arteritis, and thrombosis. The most probable cause of death in the 3 turtle specimens which were also examined histologically was a necrotic enteritis with secondary bacterial infection associated with a massive egg embolism. The North American origin of S. elegans, the absence of prior recorded epizootics in the outbreak area, and the habitual presence of its type host, the highly invasive red-eared slider, in this area suggest a new case of parasite spillover resulting in a severe emerging disease.

Early detection of maternal deaths in Senegal through household-based death notification integrating verbal and social autopsy: a community-level case study

BackgroundReliable detection of maternal deaths is an essential prerequisite for successful diagnosis of barriers to care and formulation of relevant targeted interventions. In a community-level case study, the use of household-level surveillance in Senegal unveiled an apparent increase in maternal deaths, which triggered a rapid-cycle collaborative response to implement a multipronged set of quick-win and sustained interventions intended to improve quality care.MethodsPart of a multi-country effort, the Millennium Villages Project is implementing a routine community-level information system in Senegal, able to detect maternal deaths in real-time and uncover clinical and social factors contributing to mortality. Within this geographically demarcated area of approximately 32 000 inhabitants, with a well-structured health system with patient referral services, deaths were registered and notified by community health workers, followed by timely verbal and social autopsies. Using the Pathway to Survival conceptual framework, case analysis and mortality reviews were conducted for evaluation and quality improvement purposes.ResultsThe estimated maternal mortality rates rose from 67/100000 births in 2009 (1 death), to 202/100000 births in 2010 (3 deaths) and 392/100000 births (5 deaths) in 2011. Although absolute numbers of maternal deaths remained too small for robust statistical analysis, following verbal autopsy analyses in 2011, it became evident that an unexpectedly high proportion of maternal deaths were occurring at the referral hospital, mostly post-Caesarian section. Inadequate case management of post-partum haemorrhage at the referral hospital was the most frequently identified probable cause of death. A joint task team systematically identified several layers of inefficiencies, with a potential negative impact on a larger catchment area than the study community.ConclusionsIn this study, routine community-based surveillance identified inefficiencies at a tertiary level of care. Community-level surveillance systems that include pregnancy, birth and death tracking through household visits by community health workers , combined with verbal and social autopsy can identify barriers within the continuum of maternal care. Use of mHealth data collection tools sensitive enough to detect small changes in community-level mortality trends in real-time, can facilitate rapid-cycle quality improvement interventions, particularly when associated with social accountability structures of mortality reviews.

A Retrospective Study of Pattern of Neck Injuries in the Cases of Hanging

In case of asphyxial deaths either due to hanging or strangulation, a ligature mark may be the only external evidence available. Therefore a through examination of ligature mark is needed to ascertain hanging as a probable cause of death. A retrospective study was conducted at the Department of Forensic Medicine and Toxicology, North Delhi Municipal Corporation Medical College, Hindu Rao Hospital, New Delhi from January 2014 to December 2014. During that period we found, death due to hanging constituted 26 (12.09%) of total deaths (215),which were subjected to medicolegal autopsy. Young adults of age group 21 to 30 years accounted for maximum cases, 57.69% while male to female ratio was 1:1.16. Ligature mark was obliquely placed in 88.46% cases and was found to be running above thyroid cartilage in 69.23% cases. On dissection of neck, soft tissue injuries were found in 19.23% cases while fracture of hyoid bone was present in 7.69% cases. Language: en

Non-Communicable Disease Mortality and Risk Factors in Formal and Informal Neighborhoods, Ouagadougou, Burkina Faso: Evidence from a Health and Demographic Surveillance System.

The expected growth in NCDs in cities is one of the most important health challenges of the coming decades in Sub-Saharan countries. This paper aims to fill the gap in our understanding of socio-economic differentials in NCD mortality and risk in low and middle income neighborhoods in urban Africa. We use data collected in the Ouagadougou Health and Demographic Surveillance System. 409 deaths were recorded between 2009–2011 among 20,836 individuals aged 35 years and older; verbal autopsies and the InterVA program were used to determine the probable cause of death. A random survey asked in 2011 1,039 adults aged 35 and over about tobacco use, heavy alcohol consumption, lack of physical activity and measured their weight, height, and blood pressure. These data reveal a high level of premature mortality due to NCDs in all neighborhoods: NCD mortality increases substantially by age 50. NCD mortality is greater in formal neighborhoods, while adult communicable disease mortality remains high, especially in informal neighborhoods. There is a high prevalence of risk factors for NCDs in the studied neighborhoods, with over one-fourth of the adults being overweight and over one-fourth having hypertension. Better-off residents are more prone to physical inactivity and excessive weight, while vulnerable populations such as widows/divorced individuals and migrants suffer more from higher blood pressure. Females have a significantly lower risk of being smokers or heavy drinkers, while they are more likely to be physically inactive or overweight, especially when married. Muslim individuals are less likely to be smokers or heavy drinkers, but have a higher blood pressure. Everything else being constant, individuals living in formal neighborhoods are more often overweight. The data presented make clear the pressing need to develop effective programs to reduce NCD risk across all types of neighborhoods in African cities, and suggest several entry points for community-based prevention programs.

Abstract 18984: Discrepancy Between Originally Assigned and Adjudicated Causes of Out-of-Hospital-Cardiac-Arrest of “No Obvious Cause” in Young Patients

Background: Death due to out-of-hospital cardiac arrest (OHCA) is most commonly attributed to “no obvious cause” after review of the prehospital and in-hospital documentation. To establish cause of death in younger patients, autopsy and toxicology data are important, especially in younger patients. We examined the probable cause of death in a large urban cohort of younger OHCA patients. Methods: A prospective population-based registry of all OHCAs attended by Emergency Medical Services (EMS) in the Toronto area was used to identify cases from 2009-2012. Identified OHCAs were cases aged 2-45 who died and assigned ‘no obvious cause’ based on abstracted data from ambulance call reports and in-hospital chart review, including narrative review and contributing factors compliant with the Resuscitation Outcomes Consortium Epistry Manual of Operations. Cases with inadequate information (coroners and/or EMS), or with expected death (e.g. DNR or long term care) or homicide were then excluded. The remaining cases were adjudicated by 3 reviewers using additional data from coroner investigative statements, autopsy, toxicology and police reports, and classified as primary cardiac or another non-cardiac etiology. Results: A total of 2048 OHCA cases with no obvious cause were identified; of these, 547 were excluded. Of the remaining 1501 cases with complete information, 48.2% were treated by EMS. Of the treated cases, 41.3 % (299/724) of those assigned to ‘no obvious cause’ had an adjudicated cardiac etiology. Of the untreated group, 21.2% (165/777) had an adjudicated cardiac etiology. The majority consisted of drug overdoses (214/425; 50.3%) and other non-cardiac causes (49.7%) including trauma (Figure 1). Conclusions: In younger OHCA patients who die, the category "OHCA of no obvious cause”, on detailed review, is most often due to a non-cardiac cause. This observation may contribute to a better understanding of the etiology of sudden cardiac death in younger patients.

Distribution of cause of death in rural Bangladesh during 2003–2010: evidence from two rural areas within Matlab Health and Demographic Surveillance site

Objective This study used the InterVA-4 computerised model to assign probable cause of death (CoD) to verbal autopsies (VAs) generated from two rural areas, with a difference in health service provision, within the Matlab Health and Demographic Surveillance site (HDSS). This study aimed to compare CoD by gender, as well as discussing possible factors which could influence differences in the distribution of CoD between the two areas. Design Data for this study came from the Matlab the HDSS maintained by the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) since 1966. In late 1977, icddr,b divided HDSS and implemented a high-quality maternal, newborn and child health and family planning (MNCH-FP) services project in one half, called the icddr,b service area (SA), in addition to the usual public and private MNCH-FP services that serve the other half, called the government SA. HDSS field workers registered 12,144 deaths during 2003–2010, and trained interviewers obtained VA for 98.9% of them. The probabilistic model InterVA-4 probabilistic model (version 4.02) was used to derive probable CoD from VA symptoms. Cause-specific mortality rates and fractions were compared across gender and areas. Appropriate statistical tests were applied for significance testing. Results Mortality rates due to neonatal causes and communicable diseases (CDs) were lower in the icddr,b SA than in the government SA, where mortality rates due to non-communicable diseases (NCDs) were lower. Cause-specific mortality fractions (CSMFs) due to CDs (23.2% versus 18.8%) and neonatal causes (7.4% versus 6%) were higher in the government SA, whereas CSMFs due to NCDs were higher (58.2% versus 50.7%) in the icddr,b SA. The rank-order of CSMFs by age group showed marked variations, the largest category being acute respiratory infection/pneumonia in infancy, injury in 1–4 and 5–14 years, neoplasms in 15–49 and 50–64 years, and stroke in 65+ years. Conclusions Automated InterVA-4 coding of VA to determine probable CoD revealed the difference in the structure of CoD between areas with prominence of NCDs in both areas. Such information can help local planning of health services for prevention and management of disease burden.

Applying the InterVA-4 model to determine causes of death in rural Ethiopia

Background In Ethiopia, most deaths take place at home and routine certification of cause of death by physicians is lacking. As a result, reliable cause of death (CoD) data are often not available. Recently, a computerized method for interpretation of verbal autopsy (VA) data, called InterVA, has been developed and used. It calculates the probability of a set of CoD given the presence of circumstances, signs, and symptoms reported during VA interviews. We applied the InterVA model to describe CoD in a rural population of Ethiopia. Objective VA data for 436/599 (72.7%) deaths that occurred during 2010–2011 were included. InterVA-4 was used to interpret the VA data into probable cause of death. Cause-specific mortality fraction was used to describe frequency of occurrence of death from specific causes. Results InterVA-4 was able to give likely cause(s) of death for 401/436 of the cases (92.0%). Overall, 35.0% of the total deaths were attributed to communicable diseases, and 30.7% to chronic non-communicable diseases. Tuberculosis (12.5%) and acute respiratory tract infections (10.4%) were the most frequent causes followed by neoplasms (9.6%) and diseases of circulatory system (7.2%). Conclusion InterVA-4 can produce plausible estimates of the major public health problems that can guide public health interventions. We encourage further validation studies, in local settings, so that InterVA can be integrated into national health surveys.

Pathological findings and probable causes of the death of Stejneger's beaked whales (Mesoplodon stejnegeri) stranded in Japan from 1999 and 2011.

One hundred and twenty stranding events of Stejneger’s beaked whales were reported in Japan between 1999 and 2011. The purpose of this study is to introduce pathological data and to discuss probable causes of death for 44 Stejneger’s beaked whales among them. The significant pathological findings were the pulmonary edema, parasitic granulomatous nephritis, emaciation, amyloidosis, suppurative bronchopneumonia and so on. The probable causes of death were categorized as noninfectious in 43 of the cases, which included drowning, starvation and secondary amyloidosis. One individual was diagnosed with septicemia, which was the only example of an infectious disease. Because we could not always perform advanced analyses, such as microbiology tests, biotoxin examinations or contaminant analyses, the finality of our findings may be impaired. However, the present study has broad implications on the causes of death of Stejneger’s beaked whales of the seas around Japan, which are valuable for the future studies and for the detection of emerging diseases.

The possibility of establishing causes of death on the basis of the exhumed remains of prisoners executed during the communist regime in Poland: the exhumations at Powązki Military Cemetery in Warsaw.

This study presents the results of the analysis of forensic examinations of the remains of 194 prisoners exhumed at Powązki Military Cemetery in Warsaw. In all probability, most of those buried there were judicially sentenced to death by firing squad or hanging in connection with activities of the Polish independence underground in its struggles with the postwar communist regime. Forensic medical research focussed on determining causes of death and reconstructing the mechanisms of injury leading to death. Most probable causes of death were found in 108 of 194 cases; of these, 76 were isolated gunshot wounds to the head, mostly directed to the occipital region. In 29 of 194 cases, only extensive skull fractures were observed, making it impossible to determine the mechanism of injury. The condition of these skulls do not permit the exclusion of injuries due to gunshots, which were very likely given the historical context of the studied location. In one case, it is assumed that the cause of death could be blunt force trauma to the head. In 86 of 194 cases, it was not possible to determine the cause of death. Of these cases, 20 skeletons were in such poor condition that erosive changes could have completely obliterated even very extensive head injuries leading to death. No injuries were observed that could be associated with execution by hanging.

Perimortem trauma in King Richard III: a skeletal analysis

Richard III was the last king of England to die in battle, but how he died is unknown. On Sept 4, 2012, a skeleton was excavated in Leicester that was identified as Richard. We investigated the trauma to the skeleton with modern forensic techniques, such as conventional CT and micro-CT scanning, to characterise the injuries and establish the probable cause of death. We assessed age and sex through direct analysis of the skeleton and from CT images. All bones were examined under direct light and multi-spectral illumination. We then scanned the skeleton with whole-body post-mortem CT. We subsequently examined bones with identified injuries with micro-CT. We deemed that trauma was perimortem when we recorded no evidence of healing and when breakage characteristics were typical of fresh bone. We used previous data to identify the weapons responsible for the recorded injuries. The skeleton was that of an adult man with a gracile build and severe scoliosis of the thoracic spine. Standard anthropological age estimation techniques based on dry bone analysis gave an age range between 20s and 30s. Standard post-mortem CT methods were used to assess rib end morphology, auricular surfaces, pubic symphyseal face, and cranial sutures, to produce a multifactorial narrower age range estimation of 30-34 years. We identified nine perimortem injuries to the skull and two to the postcranial skeleton. We identified no healed injuries. The injuries were consistent with those created by weapons from the later medieval period. We could not identify the specific order of the injuries, because they were all distinct, with no overlapping wounds. Three of the injuries-two to the inferior cranium and one to the pelvis-could have been fatal. The wounds to the skull suggest that Richard was not wearing a helmet, although the absence of defensive wounds on his arms and hands suggests he was still otherwise armoured. Therefore, the potentially fatal pelvis injury was probably received post mortem, meaning that the most likely injuries to have caused his death are the two to the inferior cranium. The University of Leicester.

Age-specific malaria mortality rates in the KEMRI/CDC health and demographic surveillance system in western Kenya, 2003-2010.

Recent global malaria burden modeling efforts have produced significantly different estimates, particularly in adult malaria mortality. To measure malaria control progress, accurate malaria burden estimates across age groups are necessary. We determined age-specific malaria mortality rates in western Kenya to compare with recent global estimates. We collected data from 148,000 persons in a health and demographic surveillance system from 2003–2010. Standardized verbal autopsies were conducted for all deaths; probable cause of death was assigned using the InterVA-4 model. Annual malaria mortality rates per 1,000 person-years were generated by age group. Trends were analyzed using Poisson regression. From 2003–2010, in children <5 years the malaria mortality rate decreased from 13.2 to 3.7 per 1,000 person-years; the declines were greatest in the first three years of life. In children 5–14 years, the malaria mortality rate remained stable at 0.5 per 1,000 person-years. In persons ≥15 years, the malaria mortality rate decreased from 1.5 to 0.4 per 1,000 person-years. The malaria mortality rates in young children and persons aged ≥15 years decreased dramatically from 2003–2010 in western Kenya, but rates in older children have not declined. Sharp declines in some age groups likely reflect the national scale up of malaria control interventions and rapid expansion of HIV prevention services. These data highlight the importance of age-specific malaria mortality ascertainment and support current strategies to include all age groups in malaria control interventions.