Review Of Deaths Research Articles

A 3 YEARS REVIEW OF MATERNAL DEATH AND ASSOCIATED FACTORS AT AYDER COMPREHENSIVE SPCIALIZED HOSPITAL, NORTHERN ETHIOPIA

ABSTRACT BACKGROUND: Maternal mortality ratio in Ethiopia is one of the highest in the world. Despite measures to alleviate it and showing a promising declining trend, it still remains one of the highest at 412 maternal deaths per 100,000 live births. To our knowledge there is no accessible published study on maternal mortality at Ayder Comprehensive Specialized Hospital (ACSH). OBJECTIVE The aim of this study is to systematically analyze causes of maternal deaths and contributing factors at (ACSH).METHODS This was a descriptive, retrospective chart review of institutional maternal deaths using a 3-years record from July 1, 2014 – June 30, 2017 at ACSH.RESULTS There were 52 maternal deaths from July 1, 2014 – June 30, 2017 at ACSH. The main causes of these deaths were related to obstetric hemorrhage (n=11, 21.2 %), hypertensive disorders of pregnancy (n=10, 19.2%) and sepsis (n=7, 13.5%). About 86.5% (n=45) of the mothers were referral cases of whom 24 (53.33%) of them travelled more than 100 kilometers to reach ACSH. The furthest referral site was 498 kilometers from ACSH. Most common reasons for referral include for admission to intensive care unit, for further workup and management, for blood transfusion and for high risk admission. Most of the maternal deaths occurred in the postpartum period.CONCLUSIONThere is an urgent need for expansion of intensive care unit (ICU) and availing blood transfusion services in all the general and regional hospitals with close monitoring of mothers in the postpartum period. The referral system needs coordinnation from the lower level to the teritirary care centers. KEY WORDS: Maternal death, cause of maternal death, factors for maternal death, Ayder Comprehensive Specialized Hospital, Mekelle, Tigray, Ethiopia (Ethiopian Journal of Reproductive Health 2018; 10; 3: 38-45)

298: Pregnancy-related death review of ten years - Florida 2007-2016

Objective: The U.S. pregnancy-related mortality ratio (PRMR) increased since 2004. Since 1999, Florida has performed systematic review of pregnancy-related deaths (PRDs). One goal has been to identify opportunities for prevention. We sought to describe the PRMR trend in Florida and record share the risk factors associated with PRDs. Study Design: The Florida Pregnancy Associated Mortality Review Committee (PAMR) identifies pregnancy- associated deaths by linking death certificates of reproductive age women to birth and fetal death certificates as well as Florida prenatal screens. Health records of possible PRDs are abstracted, reviewed and assessed by the multi -disciplinary PAMR team. PRD cases from 2007-2016 were analyzed for PRMR trend as well as risk factors. Results: In 2007-2016, Florida experienced 406 PRDs and 2,217,018 live births. Florida’s PRMR fluctuated from a high of 26.2 deaths per 100,000 live births in 2009, to 12.9 in 2016; 2016 is the lowest PRMR since 1999. Although not significant, there was a trend towards a reduced PRMR from 2009 through 2016. For the period 2007-2016, five causes of death accounted for 68% of PRDs: hemorrhage (21%), infection (15%), hypertensive disorders (14%), cardiomyopathy (9%), and thrombotic embolism (8%). Risk factors associated with PRD were class III obesity (RR 5.7), cesarean delivery (RR 4.2), age 35 or older (RR 3.0), no prenatal care (RR 2.7), non-Hispanic black (RR 2.7), and high school or less education (RR 1.4). PRDs due to ectopic pregnancy and flu-like infections increased between 2009 and 2013. Conclusion: Contrary to an increasing national trend, Florida’s PRMR trend declined between 2009 and 2016. Hemorrhage and infection were leading causes of PRDs. Obesity and cesarean delivery were leading risk factors. This may reflect combined Florida activities including Florida PAMR efforts, grass roots efforts of the Florida Perinatal Quality Collaborative, and efforts from other professional and community organizations. Florida PAMR should continue focusing on developing Urgent Maternal Mortality Messages, other educational efforts and promote needed women’s health policies and actions. The Florida Perinatal Quality Collaborative should continue to promote quality efforts that contribute to understanding leading causes, risk factors and disparities around maternal mortality.

718: Drug-related maternal deaths in Utah, 2013-2016

The Utah Perinatal Mortality Review is a multi-disciplinary committee that reviews all maternal and infant deaths in Utah. We described causes of maternal deaths in Utah from 2013-16, and evaluated the impact of committee classification of drug-related deaths as pregnancy-related (rather than pregnancy-associated) beginning in 2015. Retrospective review of all Utah maternal deaths from 2013-16. Pregnancy-associated (PA) death defined as death of a woman during pregnancy or within one year of the end of pregnancy, regardless of cause. Pregnancy-related (PR) death defined as death of a woman in the same time period, from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. Accidental drug-related deaths included deaths from prescribed and illicit drugs. Contributing factors, defined by Centers for Disease Control and Prevention, were identified for each death. Beginning in 2015, the Committee classified accidental drug-related deaths as PR given mounting evidence that substance use disorder (SUD) and mental health (MH) conditions may be aggravated during pregnancy and in the post-partum period. To assess the impact of reclassifying accidental drug-related death as PR, we compared the PR mortality ratio in Utah in 2013-2016 using test of trend. In 2015-2016, 40 PA deaths and 26 PR deaths occurred: accidental drug toxicity was the leading cause of both PA (n=10, 25%) and PR (n=10, 38%) death (Figure 1). In 2015-2016, all women with accidental drug-related deaths had MH conditions and 80% of these deaths occurred 43-365 days postpartum. For all PA deaths (n=40), contributing factors included SUD (n=18, 45%), mental health conditions (n=16, 40%) and clinical issues, namely inadequate screening and treatment for SUD and MH conditions (n=15, 38%). In 2013-2014, there were 44 PA deaths. Leading causes were motor vehicle accident (n=10, 20%) followed by accidental drug-related death (n=7, 17.5%) (Figure 1). From 2013-2016, there was no significant increase in PR deaths attributable to reclassification of drug-related deaths as PR (p=0.06) (Figure 2). Accidental drug-related death was the most common identifiable cause of PR death in Utah in 2015-6 following reclassification of drug-related deaths as PR. Effective interventions aimed at identifying and treating pregnant and postpartum women with SUD and MH conditions are imperative.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A 36-year review of maternal deaths in a low-resource country

A 36-year review of maternal deaths in a low-resource country

Highlights in this issue

Measles is one of the most contagious infectious diseases. Before the introduction of an efficient vaccine, it is estimated that there were 30 million cases and two million deaths each year, mostly among children in low-income countries. During the 1980s, measles was almost eliminated in many European countries. An editorial by Leif Dotevall 1 discusses the paradoxical and painful resurgence of measles in Europe in the last few years and highlights the need to regain confidence in immunisation. In a double-blind randomised study, Wejryd et al. gave 134 extremely low-birthweight infant oil drops containing the probiotic Lactobacillus reuteri DSM 17938 or a placebo. They did this once a day until the infants reached 36 weeks of gestation 2. The authors found that the probiotic did not reduce the time it took the infants to reach full enteral feeds. However, the infants who received the probiotic supplements had a better head growth rate during the first month of life. Claris 3 comments on the findings. This issue includes three reviews on paediatric hypertension. Wühl 4 shows that hypertension in childhood obesity was associated with significantly increased cardiovascular morbidity and mortality and states that early diagnosis and treatment for blood pressure control and weight reduction are essential. Meanwhile, Krmar 5 reviewed the prevalence of white-coat hypertension from a paediatric perspective and reports that this condition was best diagnosed in children by using ambulatory blood pressure monitoring over a 24-hour period. Carlström 6 studied hydronephrosis, and the risk of later hypertension, and points out that today's nonoperative management of hydronephrosis should be reconsidered to reduce the risk of developing elevated blood pressure or hypertension later in life. In 2014, an outbreak of group B streptococcus caused severe late-onset septicaemia in five very preterm infants and colonisation in 10 more infants in a neonatal intensive care unit (NICU) in Sweden. Åberg et al. 7 analysed the course of the outbreak, to find tools that stopped it from happening again. Meanwhile, Rønning et al. 8 adopted a similar approach to investigate an outbreak caused by antibiotic-susceptible Klebsiella oxytoca in a Norwegian NICU. The authors concluded that appropriate microbiological molecular screening methods and strict infection control measures are important, in order to control an outbreak. Readers may also be interested in the paper by Özenci and Schubert 9, which evaluated the implementation of an earlier, and more targeted, treatment of neonatal sepsis. The number of child deaths fell in Sweden from 2000 to 2014, but as many as 25% were from badly defined external causes or unknown causes, according to a study by Otterman et al. 10. A sizeable number of deaths were registered without death certificates, especially for infants. The authors conclude that systematic death reviews could yield information that could prevent future deaths. Palusci 11 comments on the findings. Readers may also be interested in the paper by Lykke et al. 12 on child mortality rates in Denmark, which we published in 2018, and the accompanying editorial by Kreicbergs 13, who discussed why and where children die. Figures 1–5. Istockphoto.com.

Heart failure nurse specialists and increased winter demand

British Journal of Cardiac NursingVol. 13, No. 12 BANCCHeart failure nurse specialists and increased winter demandMary Kirk, Liz WilliamsMary KirkSearch for more papers by this author, Liz WilliamsSearch for more papers by this authorMary Kirk; Liz WilliamsPublished Online:6 Dec 2018https://doi.org/10.12968/bjca.2018.13.12.616AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References British Heart Foundation. An integrated approach to managing heart failure in the community. 2015. https://tinyurl.com/ybnfl8jq (accessed 28 November 2018) Google ScholarFares A. Winter Cardiovascular Diseases Phenomenon. N Am J Med Sci. 2013; 5(4): 266–279. https://doi.org/10.4103/1947-2714.110430 Crossref, Google ScholarKershaw M. NHS winter crisis: when a plan is not a plan. 2018. https://tinyurl.com/y9b2tmrn (accessed 28 November 2018) Google ScholarMorton, G, Masters J, Cowburn PJ. Multidisciplinary team approach to heart failure management. Heart. 2018; 104: 1376–1382 Crossref, Google ScholarNational Institute for Health and Care Excellence. Evidence review and economic analysis of excess winter deaths. 2013. https://tinyurl.com/y8x84tuc (accessed 28 November 2018) Google ScholarNational Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. 2018. https://tinyurl.com/y8govppa (accessed 28 November 2018) Google ScholarScottish Intercollegiate Guidelines Network. Management of chronic heart failure. 2016. https://tinyurl.com/y8chdkyk (accessed 28 November 2018) Google ScholarVanasse A, Talbot D, Chebana F et al.. Effects of climate and fine particulate matter on hospitalizations and deaths for heart failure in elderly: A population-based cohort study. Environ Int. 2017; 106: 257–266 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 December 2018Volume 13Issue 12ISSN (online): 2052-2207 Metrics History Published online 6 December 2018 Published in print 2 December 2018 Information© MA Healthcare LimitedPDF download

Delivering Hospice Level Care for Palliative Inpatients at a District General Hospital

The Record of End of Life Care (RELC) is an initiative within NHS Lanarkshire to improve the documentation of care of palliative patients in the last days of life. Our aim was to achieve hospice level care in the hospital setting. Three wards were chosen to pilot the Record of End of Life Care – Cardiology, Respiratory and Renal at a 500 bedded District General Hospital in Scotland. A retrospective 3 month review of deaths was undertaken. Each death was allocated a score out of 12 (this was named the 12Score). The highest possible score was 12 indicating there was documented evidence for 12 agreed domains of care. Following this the RELC was introduced to ward staff. A number of interventions were piloted with varying success. Notably, a weekly Mortality Meeting was instituted. This was nurse led to achieve continuity but all members of staff participated. Also, an anticipatory care form was created for chronic conditions. Overall a culture of reflective practice was promoted with relation to end of life care. 38 deaths occurred in the initial review period. The patients with the highest scores all had either a Cancer Diagnosis or Specialist Palliative Care (SPC) Team involvement. All patients with a score of 0 to 6 were either Non-malignant patients or did not have SPC involvement. Since introducing the RELC and subsequent interventions, 12Scores have improved. Of all the patients whose care was guided by the RELC, the lowest score was 7 and 50% were greater than 10. In addition to this, Non-malignant deaths and deaths without SPC involvement are now achieving scores of greater than 7. Death is invariably subjective however, guidance on exemplary practice alongside a shift in culture allows us to assess, document and improve on the quality of care delivered.

Interim Analysis Results from an International, Multi-Centre, Non-Interventional Retrospective Study to Describe Treatment Pathways, Outcomes, and Resource Use in Patients with Classical Hodgkin Lymphoma: B-CD30+ Hodgkin Lymphoma International Multi-Centre Retrospective Study of Treatment Practices and Outcomes (B-HOLISTIC)

Interim Analysis Results from an International, Multi-Centre, Non-Interventional Retrospective Study to Describe Treatment Pathways, Outcomes, and Resource Use in Patients with Classical Hodgkin Lymphoma: B-CD30+ Hodgkin Lymphoma International Multi-Centre Retrospective Study of Treatment Practices and Outcomes (B-HOLISTIC)

Incidence and Risk Factors for Second Malignancies after Transplant in Long Term Survivors of Allogeneic Haematopoietic Stem Cell Transplant: A Single Centre Experience

Second malignancies are well recognised complications of haematopoietic stem cell transplantation (HCT). The incidence increases with time after HCT with no evidence of plateau with follow up times of 15-20 years. In this study we have investigated patients over a 37-year period to include all patients transplanted at The Hammersmith hospital since 1979 who survived a minimum of two years after transplant. We aimed to describe the post-transplant malignancies (PTM) that occurred and calculate the cumulative incidence with time.MethodsData was gathered through internal databases and supplemented with case notes with all patients giving consent for their data to be used in clinical studies. Additional information on patients who had died at the time of analysis included review of death certificates for evidence of a second malignancy. If a patient had not been seen within 5 years evidence of death was sought on the NHS Spine and if apparently still alive, the date of last follow up was taken as follow up time. Second malignancies included second solid neoplasms (SSN), non-melanoma skin cancer (NMSC) and leukemias/lymphomas. These were recorded and categorised in accordance with the international classification of disease for oncology (ICD-O).Results697 patients survived a minimum of two years after HCT between 1979-2018, 60% of whom were male. Follow up was prolonged with 20% of our 2-year survivors followed up for more than 20 years. The majority of patient (80%) were aged between 20-50 at time of HCT. (median age 35.6y, range 4-69) with only 7 patients < 10 y at HCT. The most frequent diagnoses were CML (n=463) or AML (n=103). The majority of patients (n=538, 77%) had received TBI, and the most frequently used conditioning was Cyclo-TBI (479 patients, 69%). At the time of analysis, 222 patients had died and of the remaining 475, 107 were lost to follow up.We identified 97 PTM in 87 patients a median of 14.2 years post HCT (range 0.8-35.9 years). These included 58 cases of SSN, 28 cases of NMSC and 11 cases of leukemia or lymphoma. The most frequent SSN were breast (n=12), tongue (n=7), colorectal (n=6), melanoma (n=5), bladder (n=4), thyroid (n=3) and oesophagus (n=3). Of 28 patients with NMSC, 19 developed one or more BCC and 9 developed SCC.The cumulative incidence of PTMs did not plateau with time. Cumulative incidences were as follows with 95% confidence intervals (CI) in parentheses: 4.9% (3.3-7.3) at 10 years, 12.2% (9.1-16.2) at 15 years, 22.5% (17.6-28.9) at 20 years, 39% (30.3-48.4) at 25 years and 53% (41.6-64.1) at 30 years. These data reflected the substantial increases in the CI of SSN and NMSC between these time points. For SSN the cumulative incidence increased from 3% (1.8-5) at 10 years to 37.9% (27.4-49.6) at 30 years; for NMSC the cumulative incidence increased from 1.3% (0.6-2.7) at 10 years 16.6% (9.2-28.2) at 30 years.In multivariate analyses older age (>50) at time of transplant was associated with significantly increased (p<0.01) risk of PTM with a relative risk (RR) of 4.53 (2.1-9.6). On subgroup analysis this was only relevant to SSN where the RR was 5.17 (2.2-12.1). Patient/donor sex combinations other than male patient/male donor were also at increased risk of PTM, RR 1.797 (1.1-2.9), p=0.033, and again this was only significant for SSN (RR 2.11, 1.13-3.93).Discussion and conclusionsIn this predominantly adult study, the cumulative incidence of SSN and NMSC increased substantially with time after HCT beyond a 10-year follow-up period. The risk was increased in patients who were >50 at time of HCT. Prolonged expert follow-up with a high index of suspicion for second malignancy in these patients is recommended to facilitate early diagnosis. DisclosuresApperley:Novartis: Honoraria, Research Funding, Speakers Bureau; Pfizer: Honoraria, Speakers Bureau; BMS: Honoraria, Speakers Bureau; Incyte: Honoraria, Speakers Bureau. Milojkovic:Incyte: Honoraria, Speakers Bureau; BMS: Honoraria, Speakers Bureau; Pfizer: Honoraria, Speakers Bureau; Novartis: Honoraria, Speakers Bureau.

Comorbid Depression and Substance Abuse in Domestic Homicide: Missed Opportunities in the Assessment and Management of Mental Illness in Perpetrators.

Almost 40% of murdered women are victims of domestic homicide across the world. However, research has yet to examine comorbid depression and substance abuse in domestic homicide perpetrators, despite comorbid mental health conditions being associated with homicide in the general population. A retrospective case analysis approach was performed using domestic homicide cases that had been reviewed by the Domestic Violence Death Review Committee in Ontario, Canada. Group comparisons were made by compiling cases into groups based on perpetrators with depression and/or substance abuse: a no history of depression and/or substance use group, depression only group, substance abuse only group, and comorbid depression and substance abuse group. Statistical analyses compared groups on number and types of risk factors and service provider contacts. A major finding of the current study was the resounding lack of mental health care and batterer intervention program engagement across groups. Results also indicated that perpetrators with comorbid depression and substance abuse have an elevated number of risk factors for domestic homicide and elevated number of service provider contacts. Furthermore, results indicated that perpetrators with comorbid depression and substance abuse had an increased likelihood of having engaged in hostage-taking behavior and increased likelihood of having contact with mental health and health care providers. The study demonstrates the necessity for future research into the barriers associated with help-seeking by perpetrators, family and friends, as well as the barriers to agency referral and to mental health agencies providing service to perpetrators. It also highlights the need for service providers to take multiple mental health conditions into account when working with perpetrators of domestic homicide. Overall, this study underscores the importance of mental health and domestic violence training for service providers in different sectors. Moreover, it emphasizes the necessity of collaboration among service providers to address both violence-specific and mental health-specific concerns in perpetrators of domestic violence.

Alerts for managing postpartum haemorrhage

A review of maternal deaths from postpartum haemorrhage (PPH) in 2014 - 2016 raises concern at the slow rate of reduction of mortality. Folder review showed that 87.8% of deaths were avoidable and identified ‘red flags’: common omissions (poor problem recognition), commissions (incorrect treatment) and areas of substandard care (inadequate monitoring and/or management). The lessons learnt have led to key practice points for managing PPH, which are presented in this article. These include: referral to an appropriate level of care for delivery, medications for prevention of PPH, and how facilities can be prepared for PPH to detect it timeously – before the onset of coagulopathy. Emergency management of severe obstetric haemorrhage includes resuscitation, identifying the cause/s of the bleeding, medical treatment of PPH, non-medical interventions for PPH in the labour ward, early recourse to theatre with ongoing bleeding and a description of effective surgical interventions. The problems associated with referral of patients with PPH are discussed. Updated management algorithms for PPH in South Africa are presented.

No evidence of adverse fertility and pregnancy outcomes in patients with unrecognized and untreated multiple endocrine neoplasia type 1.

Literature concerning the impact of multiple endocrine neoplasia type 1 (MEN 1) on fertility is limited to case reports despite the early onset of endocrinopathies, such as primary hyperparathyroidism and prolactinoma, that may impact fertility. This study describes the impact of unrecognized and untreated MEN 1 on fertility and pregnancy outcomes in a multigenerational cohort of the Tasman 1 MEN 1 kindred. All MEN 1 positive (MEN 1+ , n=63) and MEN 1 negative (MEN 1- , n=75) descendants born between 1825 and 1951 of a common founder. Review of birth, death, marriage and medical records provided data on date of birth and death, gender, MEN 1 status and the number of pregnancies and children per parent. Compared to MEN 1- parents, MEN 1+ parents had more children (RR 1.30, 1.02-1.66) and live births (RR 1.31, 1.02-1.67) with no excess of stillbirths (RR 1.24, 0.24-6.36). Compared to the era-matched Tasmanian fertility rate, MEN 1+ parents had more children (4.87±4.11 vs 3.40±0.61, P=0.048), whereas MEN 1- parents had similar numbers of children (3.67±3.27 vs 3.36±0.62, P=0.55). MEN 1+ parents had a similar number of MEN 1+ and MEN 1- offspring (2.1±1.9 vs 2.5±2.3, P=0.31). Indirectly assessed miscarriage rate was similar between MEN 1+ and MEN 1- mothers (P=0.77). Clinically overt pituitary disease reduced MEN 1+ kindred member likelihood of parenthood (33% vs 97%). There was no adverse impact of MEN 1 on patient fertility overall; however, MEN 1-related pathology may have impaired the reproductive potential of a subset of individuals with pituitary disease.

Working Together to Understand Why Infants Die: A Qualitative Study of Professionals' Experiences of Joint Agency Investigation of Sudden Unexpected Death in Infancy

A comprehensive Child Death Review programme commenced in England in 2008; police, healthcare and social care professionals now work together, using a joint agency approach (JAA) to investigate unexpected child deaths. The aim of this paper is to explore professionals' experiences of the JAA investigation of sudden unexpected death in infancy (SUDI). This was part of a mixed‐methods study evaluating the JAA investigation of SUDI. Professionals participated in qualitative interviews and case notes were scrutinised. Data were analysed using a framework approach. A total of 23 of a possible 113 eligible SUDI cases were recruited. Twenty‐six professionals involved in investigating 12 of the 23 SUDI cases were interviewed giving theoretical saturation of data. The overarching theme was the conflict between the need to investigate deaths while remaining sensitive to families. Other themes were working together, supporting parents, and the benefits and difficulties of joint working practices. All professionals were positive about the JAA, especially joint police and paediatric interviews and home visits. The difficulties included non‐engagement by social care and poor liaison with coroners. The JAA seems to be a thorough investigative process but could be improved by closer joint agency working and information sharing, and more support and training for professionals. © 2018 John Wiley &amp; Sons, Ltd.Key Practitioner Messages Joint agency investigation of unexpected infant deaths enables a detailed understanding of the causes of death and the provision of support to families. Joint home visits by police and paediatricians following unexpected infant deaths provide more detailed information and can be more sensitive to families than police death scene examination alone. Prompt information sharing across all agencies is a key part of effective investigation of unexpected infant deaths. ‘Explore[s] professionals' experiences of the joint agency approach investigation of sudden unexpected death in infancy’

Registration, documentation, and auditing of stillbirths and neonatal deaths in Jordan from healthcare professionals’ perspectives: reality, challenges and suggestions

Objectives: The current study aimed to explore healthcare professionals’ (HCPs) perceptions towards the registration and reporting process of stillbirth and neonatal mortality and their causes. Another aim is to explore HCPs’ perceived importance of registering stillbirths and neonatal deaths as well as the perceived challenges and suggestions of building a new surveillance and auditing system to report stillbirths and neonatal deaths in Jordan.Methods: A descriptive qualitative approach using an in-depth focus group discussion was used. A total of 16 focus groups were conducted in four major representative hospitals that cover different geographical areas in Jordan. An average of five healthcare providers (HCPs) was interviewed in each focus group with a total of 80 HCPs. All recorded focus group interviews were transcribed in a full verbatim, which was checked for accuracy by the project team. The whole content thematic analysis process was conducted in its original Arabic language to conserve credibility of the findings. Healthcare providers’ perceptions were derived from the group discussions using a group-interview guide.Results: Overall, the majority of HCPs across all hospitals agreed that it is important to document neonatal deaths and stillbirths in the hospital records mainly for statistical purposes. HCPs usually document neonatal deaths but not stillbirths. The causes of stillbirths and neonatal deaths are inaccurately recorded and not usually completed by the attending physician. Surprisingly, only neonates who live more than 4 h after delivery are registered as neonatal deaths but any neonate who dies before 4 h after delivery is not registered or registered as stillbirth. The majority of HCPs said that they were not aware of having neonatal death review committee in their hospitals. Importantly, the majority of HCPs in the four hospitals were enthusiastic about the development of a new surveillance system to register neonatal deaths and stillbirths in Jordan. Several suggestions were conveyed by the HCPs to better build, develop, implement, and sustain the proposed surveillance system.Conclusions: Electronic health information system and centralized database for compiling audit, registering births and deaths, and assigning causes of deaths should be developed and implemented. Designing and implementing an electronic registry or surveillance system that adopts ICD-10 codes is expected not only improve the completeness and timeliness of registration but also results in accurate recording of the causes of deaths.

Prevalence and associated factors of pediatric emergency mortality at Tikur Anbessa specialized tertiary hospital: a 5\xa0year retrospective case review study

BackgroundChildhood mortality remains high in resource-limited third world countries. Most childhood deaths in hospital often occur within the first 24 h of admission. Many of these deaths are from preventable causes. This study aims to describe the patterns of mortality in children presenting to the pediatric emergency department.MethodsThis was a five-year chart review of deaths in pediatric patients aged 7 days to 13 years presenting to the Tikur Anbessa Specialized Tertiary Hospital (TASTH) from January 2012 to December 2016. Data were collected using a pretested, structured checklist, and analyzed using the SPSS Version 20. Multivariate analysis by logistic regression was carried out to estimate any measures of association between variables of interest and the primary outcome of death.ResultsThe proportion of pediatric emergency department (PED) deaths was 4.1% (499 patients) out of 12,240 PED presentations. This translates to a mortality rate of 8.2 deaths per 1000 patients per year. The three top causes of deaths were pneumonia, congestive heart failure (CHF) and sepsis. Thirty two percent of the deaths occurred within 24 h of presentation with 6.5% of the deaths being neonates and the most common co-morbid illness was malnutrition (41.1%).Multivariate analysis revealed that shortness of breath [AOR=2.45, 95% CI (1.22-4.91)], late onset of signs and symptoms [AOR=3.22, 95% CI (1.34-7.73)], fever [AOR=3.17, 95% CI (1.28-7.86)], and diarrhea [AOR=3.36, 95% CI (1.69-6.67)] had significant association with early mortality.ConclusionThe incidence of pediatric emergency mortality was high in our study. A delay in presentation of more than 48 hours, diarrheal diseases and shortness of breath were significantly associated with early pediatric mortality. Early identification and intervention are required to reduce pediatric emergency mortality.

326. Confidential review of maternal deaths in the Community Level Interventions for Pre-eclampsia (CLIP) Mozambique Trial

Introduction Computer based algorithms, such as the WHO’s verbal autopsy tool (InterVA), are often used to attribute cause of death (COD) in low-resource settings despite their variable agreement with physician review. After a large scale community-level intervention trial for pre-eclampsia in Mozambique, maternal deaths were assessed in order to identify COD and barriers to care. Objective To compare COD for women who died in the Community Level Interventions in Pre-eclampsia (CLIP) Mozambique Trial (NCT01911494), 2015–2017, by physician review vs. the InterVA output. Methods Two physicians independently reviewed maternal mortality data from the trial (i.e., verbal autopsy [2012 WHO Instrument], baseline data and outcomes, and in the intervention arm, data from a mobile health application that included blood pressure readings), and assigned COD (by International Classification of Disease-Maternal Mortality). Disagreement was resolved by a third reviewer. Assigned COD was compared between physician review and InterVA output (set for high prevalence of malaria and HIV) using Cohen’s Kappa. Results Of the twenty-one (0.14%) maternal deaths reported, most were postpartum (14/21, 66.7%), and due to indirect causes (12, 57.1%). Malaria during or prior to pregnancy (14/21, 66.7%) and HIV/AIDs (11/21 reported, 52.3%) were found to significantly affect pregnancy. The three most common causes of death were 1) non-obstetric complications, 2) obstetric hemorrhage and 3) pregnancy-induced hypertension. Agreement between physicians and InterVA was fair, K = 0.40 [0.10–0.69]). Compared with InterVA, physicians were more likely to assign COD due to non-obstetric complications, specifically infectious diseases (9/21, 42.9%), including malaria and HIV/AIDS. Discussion Addressing infectious diseases, such as malaria and HIV/AIDs, obstetric hemorrhage and pregnancy-induced hypertension as most important causes of death is important to reduce maternal mortality in Mozambique. We found a fair level of agreement between COD assigned by InterVA and physician review at an individual case level, particularly for indirect causes of death.

Reviewing prehospital trauma deaths

Introduction: This study aimed to conduct detailed reviews of prehospital and early in-hospital trauma deaths to identify opportunities to improve the system of care.

Military Preventable Death Conceptual Framework: A Systematic Approach for Reducing Battlefield Mortality.

The National Academies of Sciences, Engineering, and Medicine Report on Zero Preventable Deaths highlighted the need for a military and civilian partnership to take lessons learned from the wars in Iraq and Afghanistan and incorporate them into a national learning trauma care system. One of the specific objectives in the report was to establish military preventable death metrics. Upon further inspection, it became apparent that the Department of Defense did not have an established methodology to reliably estimate and report preventable death metrics and opportunities to improve the military trauma care system. Over the last year, clinical and non-clinical subject matter experts from the Joint Trauma System and Armed Forces Medical Examiners System began the process of establishing a standard military preventable death review process to meet the objective outlined in the report. Based on an assessment to understand methodological best practices for preventable death reviews, this manuscript presents the conceptual framework that is guiding our effort to establish the first ever battle-related mortality surveillance system with preventable death metrics and opportunities to improve the trauma care system.

How does social accountability contribute to better maternal health outcomes? A qualitative study on perceived changes with government and civil society actors in Gujarat, India

BackgroundSocial accountability mechanisms have been highlighted as making a contribution to improving maternal health outcomes and reducing inequities. But there is a lack of evidence on how they contribute to such improvements. This study aims to explore social accountability mechanisms in selected districts of the Indian state of Gujarat in relation to maternal health, the factors they address and how the results of these mechanisms are perceived.MethodsWe conducted qualitative research through in-depth interviews and focus group discussions with actors of civil society and government health system. Data were analyzed using a framework of social determinants of maternal health in terms of structural and intermediary determinants.ResultsThere are social accountability mechanisms in the government and civil society in terms of structure and activities. But those that were perceived to influence maternal health were mainly from civil society, particularly women’s groups, community monitoring and a maternal death review. The social accountability mechanisms influenced structural determinants – governance, policy, health beliefs, women’s status, and intermediary determinants – social capital, maternal healthcare behavior, and availability, accessibility and the quality of the health service delivery system. These further positively influenced the increased use of maternal health services. The social accountability mechanisms, through the process of information, dialogue and negotiation, particularly empowered women to make collective demands of the health system and brought about changed perceptions of women among actors in the system. It ultimately improved relations between women and the health system in terms of trust and collaboration, and generated appropriate responses from the health system to meeting women’s groups’ demands.ConclusionSocial accountability mechanisms in Gujarat were perceived to improve interaction between communities and the health system and contribute to improvements in access to and use of maternal health services. The influence of social accountability appeared to be limited to the local/district level and there was lack of capacity and ownership of the government structures.

‘His home is his castle. And mine is a cage’: a new partial defence for primary victims who kill

This article provides an in-depth analysis of the Crimes Amendment (Abolition of Defensive Homicide) Act 2014 which had the effect of repealing the Australian state of Victoria’s only general ‘partial defence’ of defensive homicide, and replaced the existing statutory self-defence in murder/manslaughter provisions and general common law self-defence rules with a single test. The abolition of defensive homicide means there is now no general ‘partial defence’ to accommodate cases falling short of self-defence. The change is likely to mean that some primary victims will find themselves bereft of a defence. This is the experience in New Zealand where the Family Violence Death Review Committee recently recommended the reintroduction of a partial defence, postabolition of provocation in 2009. Primary victims in New Zealand are being convicted of murder and sentences are double those issued pre-2009. Both jurisdictions require that a new partial defence be introduced, and accordingly, an entirely new defence predicated on a fear of serious violence and several threshold filter mechanisms designed to accommodate the circumstances of primary victims is advanced herein. The proposed framework draws upon earlier recommendations of the Law Commission for England and Wales, and a comprehensive review of the operation of ss 54 and 55 of the Coroners and Justice Act 2009, but the novel framework rejects the paradoxical loss of self-control requirement and sexed normative standard operating within that jurisdiction. The recommendations are complemented by social framework evidence and mandatory jury directions, modelled on the law in Victoria. A novel interlocutory appeal procedure designed to prevent unnecessary appellate court litigation is also outlined. This bespoke model provides an appropriate via media and optimal solution to the problems faced by primary victims in Victoria and New Zealand.