Undetermined Deaths Research Articles

Cannabis Policies, Cannabis, and Opioids in Suicide and Undetermined Intent Death

Introduction: Suicides and deaths of undetermined intent frequently involve cannabis or opioids, yet the relationships between cannabis and opioids, and cannabis policies and cannabis or opioid involvement in these deaths are not well-characterized. Additionally, although there have been substantial changes to cannabis policies, there have been conflicting findings on relationships between changing cannabis policies and cannabis-involved or opioid-involved deaths. MethodsThis was a repeated, cross-sectional study of decedents using restricted access data from the National Violent Death Reporting System (NVDRS) from 2003-2018, and the Cannabis Policy Scale (CPS). The following associations were assessed among decedents from suicide and deaths of undetermined intent using mixed effects logistic regression: 1) relationships between cannabis involvement and opioid involvement; 2) relationships between cannabis policies and cannabis involvement; and 3) relationships between cannabis policies and opioid involvement. Analyses were conducted from 2021-2022. ResultsStates contributing to NVDRS increased in number from 7 to 41 throughout the study period, and the final sample included 68,924 decedents of suicide and undetermined intent. Cannabis involvement was associated with increased odds of opioid involvement (AOR 1.29, 95% CI: 1.22-1.37). A 10% increase in CPS, representing a more restrictive cannabis policy environment, was associated with reduced odds of cannabis involvement (AOR 0.87, 95% CI: 0.84-0.90) and opioid involvement (AOR 0.88, 95% CI: 0.85-0.91). ConclusionsThese findings do not support the idea that cannabis policy liberalization and/or cannabis use are likely to be useful strategies to reduce cannabis or opioid involvement in deaths of suicide and undetermined intent.

Galectin-3 and cancer mortality in patients with suspected or known coronary artery disease: the ANOX study

Abstract Background Galectin-3 is a multifunctional carbohydrate-binding lectin that is involved in inflammation, tissue remodeling, and fibrosis. High circulating levels of galectin-3 are associated with all-cause mortality, cardiovascular (CV) mortality, and/or major adverse CV events in patients with CV diseases such as heart failure and coronary artery disease (CAD). However, the associations of galectin-3 with non-CV mortality and cancer mortality in patients with suspected or known CAD are unknown. Methods Serum galectin-3 levels were measured in 2,418 patients with suspected or known CAD undergoing elective coronary angiography. The outcomes were all-cause death, CV death, non-CV death, cancer death, and other non-CV death. Patients were followed up over a 6-year period. Results During the follow-up, 536 (22.2%) deaths occurred, including 166 (6.9%) CV deaths, 326 (13.5%) non-CV deaths, 128 (5.3%) cancer deaths, 198 (8.2%) other non-CV deaths, and 44 (1.8%) undetermined deaths. After adjustment for potential clinical confounders (i.e., age, sex, body mass index, hypertension, dyslipidemia, diabetes, current smoker, estimated glomerular filtration rate, the Gensini score, previous myocardial infarction, previous stroke, previous heart failure hospitalization, atrial fibrillation, valvular heart disease, malignancies, anemia, antihypertensive drug use, statin use, and aspirin use) and established CV biomarkers (i.e., N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin I, and high-sensitivity C-reactive protein), galectin-3 levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.22; 95% confidence interval [CI], 1.13–1.31), CV death (HR, 1.16; 95% CI, 1.02–1.33), non-CV death (HR, 1.27; 95% CI, 1.15–1.40), cancer death (HR, 1.31; 95% CI, 1.07–1.61), and other non-CV death (HR, 1.30; 95% CI, 1.15–1.46). The addition of galectin-3 levels to the model with potential clinical confounders and established CV biomarkers significantly improved the prediction of all-cause death (P<0.001 for continuous net reclassification improvement [NRI], P<0.001 for integrated discrimination improvement [IDI]) and cancer death (P=0.001 for NRI, P=0.005 for IDI), but not that of CV death (P=0.601 for NRI, P= 0.708 for IDI), non-CV death (P=0.060 for NRI, P=0159 for IDI), or other non-CV death (P=0.266 for NRI, P=0.699 for IDI). Conclusions The galectin-3 level independently predicted all-cause mortality and cancer mortality in patients with suspected or known CAD.

Serum amyloid A-low-density-lipoprotein complex and cause-specific mortality in patients with suspected or known coronary artery disease: The ANOX Study

Abstract Background Serum amyloid A-low-density-lipoprotein (SAA-LDL) is a complex formed from the oxidative interaction between SAA and LDLs. A relatively small-scale study has shown that circulating SAA-LDL levels may serve as a prognostic marker in patients with stable coronary artery disease (CAD). However, the association between SAA-LDL and cause-specific mortality in patients with suspected or known CAD is unknown. Methods Serum SAA-LDL levels were measured in 2416 patients with suspected or known CAD undergoing elective coronary angiography. The outcomes were all-cause death, cardiovascular (CV) death, non-CV death, cancer death, and other non-CV death. Patients were followed up over a 3-year period. Results During the follow-up, 254 (10.5%) deaths occurred, including 88 (3.6%) CV deaths, 151 (6.3%) non-CV deaths, 66 (2.7%) cancer deaths, 85 (3.5%) other non-CV deaths, and 15 (0.6%) undetermined deaths. Stepwise regression analysis including baseline data on potential clinical confounders and established CV biomarkers (i.e., N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin I, and high-sensitivity C-reactive protein [hs-CRP]) revealed that the strongest independent determinant of SAA-LDL levels was hs-CRP (partial regression coefficient, 0.248; standard error, 0.010; p<0.001). After adjusting for potential clinical confounders and established CV biomarkers, the highest quartile of SAA-LDL levels (vs. the lowest quartile) was significantly associated with all-cause death (adjusted hazard ratio [aHR], 1.56; 95% confidence interval [CI], 1.05–2.34) and non-CV death (aHR, 1.76; 95% CI, 1.02–3.11), but not with CV death (aHR, 1.16; 95% CI, 0.62–2.20), cancer death (aHR, 1.68; 95% CI, 0.71–4.34), or other non-CV death (aHR, 1.65; 95% CI, 0.82–3.45) in the entire cohort. In patients with low hs-CRP levels (≤1.0 mg/L, n=1253), the highest quartile of SAA-LDL levels was significantly associated with all-cause death (aHR, 2.19; 95% CI, 1.11–4.57), non-CV death (aHR, 2.78; 95% CI, 1.05–8.79), and cancer death (aHR, 4.65; 95% CI, 1.12–31.9), but not with CV death (aHR, 1.22; 95% CI, 0.39–3.92) or other non-CV death (aHR, 1.68; 95% CI, 0.42–8.35). In contrast, the highest quartile of SAA-LDL levels was not significantly associated with all-cause death (aHR, 1.18; 95% CI, 0.72–1.96), CV death (aHR, 1.02; 95% CI, 0.45–2.31), non-CV death (aHR, 1.46; 95% CI, 0.75–2.91), cancer death (aHR, 1.35; 95% CI, 0.43–4.58), or other non-CV death (aHR, 1.38; 95% CI, 0.60–3.25) in patients with high hs-CRP levels (>1.0 mg/L, n=1163). Conclusions Elevated SAA-LDL levels were independently associated with all-cause and non-CV mortality, but unexpectedly not with CV mortality, in patients with suspected or known CAD. These associations were pronounced in patients with low hs-CRP levels (≤1.0 mg/L). The association between the SAA-LDL level and cancer mortality suggests its predictive utility in patients with low hs-CRP levels (≤1.0 mg/L).

Characterising fire or burn-related fatalities in the USA using the National Violent Death Reporting System, 2003–2020

ObjectivesIntentional fire or burn-related deaths are rare in the USA compared with some countries, but do occur, and our knowledge of their epidemiology is limited. The objective of this study...

Psychosocial and pandemic-related circumstances of suicide deaths in 2020: Evidence from the National Violent Death Reporting System.

To describe and explore variation in 'pandemic-related circumstances' among suicide decedents during the first year of the COVID-19 pandemic. We identified pandemic-related circumstances using decedents' text narratives in the 2020 National Violent Death Reporting System. We use time-series analysis to compare other psychosocial characteristics (e.g., mental health history, interpersonal difficulties, financial strain) of decedents pre-pandemic (2017/2018: n = 56,968 suicide and n = 7,551 undetermined deaths) to those in 2020 (n = 31,887 suicide and n = 4,100 undetermined). We characterize common themes in the narratives with pandemic-related circumstances using topic modeling, and explore variation in topics by age and other psychosocial circumstances. In 2020, n = 2,502 (6.98%) narratives described pandemic-related circumstances. Compared to other deaths in 2020 and to the pre-pandemic period, decedents with pandemic-related circumstances were older and more highly educated. Common themes of pandemic-related circumstances narratives included: concerns about shutdown restrictions, financial losses, and infection risk. Relative to decedents of the same age that did not have pandemic-related circumstances in 2020, those with pandemic-related circumstances were more likely to also have financial (e.g., for 25-44 years, 43% vs. 12%) and mental health (76% vs. 66%) psychosocial circumstances, but had similar or lower prevalence of substance abuse (47% vs. 49%) and interpersonal (40% vs. 42%) circumstances. While descriptive, these findings help contextualize suicide mortality during the acute phase of the COVID-19 pandemic and can inform mental health promotion efforts during similar public health emergencies.

Maryland opioid overdose deaths from 2018 to 2022: occupational patterns and their sociodemographic variations

IntroductionWe aimed to describe the occupational pattern of opioid overdose deaths in Maryland between 2018 and 2022 and determine the occupations at higher risk of opioid overdose death.MethodsThe sample included...

The Effect of Semaglutide on Mortality and COVID-19–Related Deaths: An Analysis From the SELECT Trial

BackgroundPatients with overweight and obesity are at increased risk of death from multiple causes, including cardiovascular (CV) death, with few therapies proven to reduce the risk. ObjectivesThis study sought to assess the effect of semaglutide 2.4 mg on all-cause death, CV death, and non-CV death, including subcategories of death and death from coronavirus disease-2019 (COVID-19). MethodsThe SELECT (Semaglutide Effects on Cardiovascular Outcomes in Patients With Overweight or Obesity) trial randomized 17,604 participants ≥45 years of age with a body mass index ≥27 kg/m2 with established CV disease but without diabetes to once-weekly subcutaneous semaglutide 2.4 mg or placebo; the mean trial duration was 3.3 years. Adjudicated causes of all deaths, COVID-19 cases, and associated deaths were captured prospectively. ResultsOf 833 deaths, 485 (58%) were CV deaths, and 348 (42%) were non-CV deaths. Participants assigned to semaglutide vs placebo had lower rates of all-cause death (HR: 0.81; 95% CI: 0.71-0.93), CV death (HR: 0.85; 95% CI: 0.71-1.01), and non-CV death (HR: 0.77; 95% CI: 0.62-0.95). The most common causes of CV death with semaglutide vs placebo were sudden cardiac death (98 vs 109; HR: 0.89; 95% CI: 0.68-1.17) and undetermined death (77 vs 90; HR: 0.85; 95% CI: 0.63-1.15). Infection was the most common cause of non-CV death and occurred at a lower rate in the semaglutide vs the placebo group (62 vs 87; HR: 0.71; 95% CI: 0.51-0.98). Semaglutide did not reduce incident COVID-19; however, among participants who developed COVID-19, fewer participants treated with semaglutide had COVID-19–related serious adverse events (232 vs 277; P = 0.04) or died of COVID-19 (43 vs 65; HR: 0.66; 95% CI: 0.44-0.96). High rates of infectious deaths occurred during the COVID-19 pandemic, with less infectious death in the semaglutide arm, and resulted in fewer participants in the placebo group being at risk for CV death. ConclusionsCompared to placebo, patients treated with semaglutide 2.4 mg had lower rates of all-cause death, driven similarly by CV and non-CV death. The lower rate of non-CV death with semaglutide was predominantly because of fewer infectious deaths. These findings highlight the effect of semaglutide on mortality across a broad population of patients with CV disease and obesity. (Semaglutide Effects on Cardiovascular Outcomes in Patients With Overweight or Obesity [SELECT]; NCT03574597)

Impact of the COVID-19 Pandemic on Conduct and Results of CLEAR Outcomes Trial.

The COVID-19 pandemic disrupted clinical research. CLEAROutcomes investigated the effect of bempedoic acid (BA) versus placebo in 13 970 patients with statin intolerance and high cardiovascular (CV) risk. BA reduced the risk of the primary endpoint (composite of CV death, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularization) by 13%. CLEAROutcomes began beforeand continued for 2.7 years afterthe start of the pandemic. The impact of the COVID-19 pandemic on patient disposition, adverse events, and major adverse CV events (MACE) in CLEAROutcomes was assessed. Rates of severe infection, hospitalization, or first MACE associated with a positive COVID-19 test were low and balanced between treatment groups. Rates of all-cause death, non-CV death, and undetermined death increased in the pandemic period compared with the pre-pandemic period, while rates of CV death with a known etiology remained stable. A sensitivity analysis excluding undetermined deaths occurring after the onset of the pandemic from the CV death designation yielded hazard ratios of 0.84 (95% CI, 0.76-0.93) for the primary endpoint and 0.94 (95% CI, 0.76-1.16) for the secondary endpoint of CV death, compared with 0.87 (95% CI, 0.79-0.96) and 1.04 (95% CI, 0.88-1.24), respectively, in the original analysis. The CLEAR Outcomes trial continued uninterrupted throughout the COVID-19 pandemic. Certain trial endpoints may have been impacted by the pandemic. Specifically, the classification of undetermined deaths as CV deaths may have attenuated the effect of BA on key efficacy endpoints.

Autopsy rates and the misclassification of suicide and accident deaths

Mortality statistics are critical to determine the burden of disease. Certain causes of death are prone to being misclassified on cause of death certificates. This poses a serious risk for public health and safety, as accurate death certificates form the basis for mortality statistics, which in turn are crucial for research, funding allocation and health interventions. This study uses generalised estimating equations and regression modelling to investigate for which cause of death categories suicide and accident deaths are misclassified as. National mortality statistics and autopsy rates from North America and Europe covering the past forty years were analysed to determine the associations between the different causes of death in cross-sectional and longitudinal models. We find that suicides and deaths by accidents are frequently mutually misclassified. We also find that suicides are frequently misclassified as drug use disorder deaths, in contrast to accident deaths, which are not misclassified as drug use disorder deaths. Furthermore, suicides do not seem to be misclassified as undetermined deaths or ill-defined deaths. The frequency of misclassification shows that the quality of death certificates should be improved, and autopsies may be used systematically to control the quality of death certificates.

Suicide Mortality During the Perinatal Period

The US has the highest maternal mortality rate among developed countries. The Centers for Disease Control and Prevention deems nearly all of these deaths preventable, especially those attributable to mental health conditions. Coordination between US health care and social service systems could help further characterize circumstances and risks associated with perinatal suicide mortality. To examine contextual and individual precipitating circumstances and risks associated with perinatal suicide. This cross-sectional observational study used a convergent mixed methods design to explore factors contributing to maternal suicides and deaths of undetermined intent (hereinafter, undetermined deaths) identified in National Violent Death Reporting System (NVDRS) data for January 1, 2003, to December 31, 2021. Analyses included decedents who were aged 10 to 50 years and pregnant or post partum at death (collectively, the perinatal group) and demographically matched female decedents who were not pregnant or recently pregnant (nonperinatal group) at death. Analyses were performed between December 2022 and December 2023. Pregnancy status at death (perinatal or nonperinatal). The main outcomes included contributing circumstances associated with suicides and undetermined deaths cited in coroner, medical examiner, or law enforcement case narratives. The study examined quantitative differences between groups using a matched analysis and characterized key themes of salient suicide circumstances using qualitative content analysis. This study included 1150 perinatal decedents identified in the NVDRS: 456 (39.6%) were pregnant at death, 203 (17.7%) were pregnant within 42 days of death, and 491 (42.7%) were pregnant within 43 to 365 days before death, yielding 694 postpartum decedents. The nonperinatal comparison group included 17 655 female decedents aged 10 to 50 years. The mean (SD) age was 29.1 (7.4) years for perinatal decedents and 35.8 (10.8) years for nonperinatal decedents. Compared with matched nonperinatal decedents, perinatal decedents had higher odds of the following identified contributing circumstances: intimate partner problems (IPPs) (odds ratio [OR], 1.45 [95% CI, 1.23-1.72]), recent argument (OR, 1.33 [95% CI, 1.09-1.61]), depressed mood (OR, 1.39 [95% CI, 1.19-1.63]), substance abuse or other abuse (OR, 1.21 [95% CI, 1.03-1.42]), physical health problems (OR, 1.37 [95% CI, 1.09-1.72]), and death of a family member or friend (OR, 1.47 [95% CI, 1.06-2.02]). The findings of the qualitative analysis emphasized the importance of mental health and identified 128 decedents (12.4%) with postpartum depression. This study provides insights into complex factors surrounding maternal suicide, and it highlights opportunities for further research to understand long-term consequences of perinatal mental health. These findings also underscore the need for targeted evidence-based interventions and effective policies targeting mental health, substance use, and IPPs to prevent maternal suicide and enhance maternal health outcomes.

Inequities in naloxone administration among fatal overdose decedents by race and ethnicity in Pennsylvania, 2019-21.

The aim of this study was to characterize the circumstances of drug overdose deaths and determine whether naloxone administration differed by overdose decedent race and ethnicity. Analysis of data on unintentional and undetermined intent drug overdose deaths in Pennsylvania (2019-21) was collected from death certificates and the State Unintentional Drug Overdose Reporting System. Multivariable logistic regression models were adjusted for overdose death circumstances and the odds of naloxone administration were estimated by race/ethnicity and year. The analytical sample included 3386 fatal overdose decedents in 2019, 3864 in 2020 and 3816 in 2021. Evidence of naloxone administration (yes/no) was defined using scene evidence and toxicology reports from coroner and medical examiner records, while race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White) was based on the death certificate. In the analytic sample, overdose death rates were the highest among Black people and increased over time (rate per 10 000 population, 2019: 4.3; 2020: 6.1; 2021: 6.5); rates were lowest among White people and remained constant over time (rate per 10 000 population, 2019: 2.6; 2020: 2.7; 2021: 2.6). Throughout all years, Black decedents had approximately 40-50% lower odds of naloxone administration compared with White decedents as referent [2019: odds ratio (OR) = 0.7, 95% confidence interval (CI) = 0.5-0.9; 2020: OR = 0.5, 95% CI = 0.4-0.7; 2021: OR = 0.6, 95% CI = 0.5-0.8], while Hispanic decedents had similar odds of naloxone administration to that of White decedents. After controlling for overdose circumstances in drug overdose deaths in Pennsylvania, USA, from 2019 to 2021, Black people had lower odds of naloxone administration compared with White people, while there were no differences between Hispanic and White people.

Recognising inaccuracies in Australian suicide and 'hidden suicide' data.

To examine the effects of revision of Australian mortality statistics every year since 2007 on numbers and rates of suicide and 'hidden suicide'. Nine months after the end of each year, the Australian Bureau of Statistics releases preliminary statistics concerning deaths registered in that year, together with revised and finalised data regarding previous years. Numbers and rates of suicide and of deaths coded to selected categories of accidental, undetermined and unknown cause deaths were tabled. Upward revision of suicide and accidental drug poisoning death numbers, three years after first release, show that true rates are substantially higher than initially released data suggested. Concomitant downward revision of rates of undetermined and unknown cause deaths supports evidence that at first release some suicides are coded to these categories. Australia's finalised suicide data are likely to be more accurate than equivalent data from nations that do not revise mortality data. More comprehensive investigation (including verbal or psychological autopsy) in doubtful cases in Australia and elsewhere would probably lead to reported suicide rates being higher.

Autopsy findings in fire deaths in relation to manner of death: Analysis of autopsy records in Friuli, Italy (1993–2020)

The determination of the cause and manner of death can be particularly difficult in burned and charred bodies and autopsy remains a key element in the investigation. In this study, 39 autopsy records of fire deaths were reviewed in relation to the manner of death (25 accidents, 8 suicides, 3 homicides and 3 instances in which the manner of death remained undetermined). The analysis focused on the study of the burns, the degree to which the bodies were consumed by fire and the evidence of signs of vital exposure to fire and of non-fire-related injuries. Total surface body area (TBSA) was found to be significantly higher (p = 0.02) in suicides than in accidents. Moreover, the degree of destruction according to the Crow-Glassman Scale and the presence of a pugilistic posture tended to be higher in suicides compared to accidental deaths, whereas such parameters were found to be variable in homicides.With regard to the anatomical distribution of burns, in contrast with the literature, the feet were affected by burning in all suicides, with a significantly higher prevalence than in accidents (p < 0.01).Traumatic non-fire related injuries were noted in all homicides (with no signs of vital exposure to fire), 1 complicated suicide, 1 undetermined death and 13 accidents.We found that very few studies have focused on the analysis of burn distribution and extension according to manner of death and that there is currently no standardised anatomical model with which to study these variables for forensic purposes.

Statistical Analysis of Medicolegal Autopsy of Migrant Workers in Korea

The number of migrant workers is increasing worldwide every year, and their number and role in Korean society is also increasing. However, the poor conditions faced by migrant workers often become a social issue, and it is not uncommon for them to be the subject of forensic autopsies. This study aimed to investigate the current status of medicolegal autopsy on migrant workers in Korea. We collected data of medicolegal autopsies on migrant workers conducted in Korea from 2016 to 2020 by requesting data from the institutions performing medicolegal autopsy. We calculated the autopsy rate and analyzed manner of death and cause of death. The medicolegal autopsy rate for foreign deaths was 16.4%, which was more than five times higher than the autopsy rate for Korean deaths. By manner of death, 43.7% were natural death, 6.4% were homicides, 8.5% were suicides, 23.6% were accidental deaths, 2.7% were undetermined unnatural deaths and 15.0% were unknown. These results showed a high rate of homicide, accidental death, and unknown death compared to Korean. And the proportion of industrial accident deaths and sudden manhood death syndrome were high. Through this study, it was confirmed that medicolegal autopsies are performed at a relatively high frequency when migrant workers die, and the characteristics related to the deaths of migrant workers were identified.

Receipt of opioid use disorder treatments prior to fatal overdoses and comparison to no treatment in Connecticut, 2016–17

ObjectiveTo determine the relative risk of death following exposure to treatments for OUD compared to no treatment. MethodsIn this retrospective cohort study we compiled and merged state agency data on accidental and undetermined opioid overdose deaths in 2017 and exposures to OUD treatment in the prior six months to determine incidence rates following exposure to different treatment modalities. These rates were compared to the estimated incidence among those exposed to no treatment to determine relative risk of death for each treatment exposure. ResultsIncidence rates for opioid poisoning deaths for those exposed to treatment ranged from 6.06±1.40 per 1000 persons exposed to methadone to 17.36±3.22 per 1000 persons exposed to any non-medication treatment. The estimated incidence rate for those not exposed to treatment was 9.80±0.72 per 1000 persons. With no exposure to treatment as referent, exposure to methadone or buprenorphine reduced the relative risk by 38% or 34%, respectively; the relative risk of non-medication treatments was equal to or worse than no exposure to treatment (RR = 1.27–1.77). Principal conclusionsExposure to non-MOUD treatments provided no protection against fatal opioid poisoning whereas the relative risk was reduced following exposures to MOUD treatment, even if treatment was not continued. Population level efforts to reduce opioid overdose deaths need to focus on expanding access to agonist-based MOUD treatments and are unlikely to succeed if access to non-MOUD treatments is made more available.

Naturalizing unnatural death in Los Angeles County jails.

In this paper we use quantitative and qualitative methods to examine how death investigations in Los Angeles County jails disproportionately naturalize death among Black and Latino incarcerated people. Our study is based on an assessment of 58 autopsies, coroner investigator narratives, and toxicology reports produced between 2009 and 2018. We found that the Medical Examiner frequently arrived at natural or undetermined death determinations that minimized the culpability of carceral staff for loss of life that occurred within county jail. In our dataset, Black people were disproportionately classified as natural. Undetermined deaths were almost exclusively Latino. More than 75% of the cases in our study were deaths that occurred before standing trial. Our findings reveal how biomedical knowledge about incarcerated Black and Latino people is used to erase the life-diminishing effects of punishment, neglect, and maltreatment that are central to the project of mass incarceration.

17th International Conference on Malignant Lymphoma, Palazzo dei Congressi, Lugano, Switzerland, 13 - 17 June, 2023.

Introduction: Adult T-cell leukemia/lymphoma (ATL) is a peripheral T-cell malignancy caused by human T-cell leukemia virus type I (HTLV-1), endemic in some areas of the world, such as Brazil. Between 3% and 5% of HTLV-1-infected individuals develop ATL after a long latency. The clinical features are heterogeneous and classified into acute, lymphoma, chronic and smoldering types. Acute and lymphoma types are defined as aggressive whereas the others as indolent ATL. On April 2017, the T-cell Brazil project was launched. Methods: Ambispective observational study design collected 90 ATL patients from 606 registered cases in the T-Cell Brazil Project. Its main goal is to describe demographic and clinical features, analyze the overall and progression-free survival (OS and PFS), and try to identify factors that could influence them. REDcap Platform has been used to collect and store data, and the IBM-SPSS version 24 for statistical analysis. Results: The median age was 50 years (23–88), 59% female; 50% was lymphoma subtype, followed by 33% acute (both aggressive), 12% chronic and 5% smoldering (indolent); 87% had advanced stage disease (III-IV, Ann Arbor), 57% had B symptoms and 11% had Central Nervous System involved. Both indolent and aggressive had elevated serum LDH levels. 25% received chemotherapy plus immunotherapy, whilst 46% took chemotherapy alone with anthracycline-based regimens (46% CHOEP; 33% CHOP; 21% others). The best response (complete plus partial) after 1st line of treatment reached 50%; 31% had no response or progression; 13% was undetermined due early death; 5% were on treatment, and 1% had stable disease (without treatment). Median follow-up was ten months (0–78) and 18 months for 35% of alive cases. OS for 24 months was 34% (95% CI: 24%–44%), whereas 24-month PFS was 20% (95% CI: 12%–28%). Indolent presented better OS and PFS when compared with Aggressive; 86% versus 33%, P = 0.001 for OS and 45% versus 12%, P = 0.002 for PFS. Public medical care had worst OS and PFS than private (P = 0.14 and P = 0.05). The multivariate Cox Regression for OS resulted hypoalbuminemia - albumin <3.5 g/dL (HR 2.13 CI95% 1.10–4.12, P = 0.024) plus LDH twice the normal value (HR 2.49 CI95% 1.17–5.32, P = 0.018) as predictors. And for PFS were male (HR 1.83 CI95% 1.03–3.24, P = 0.037), ECOG > 1 (HR 2.01 CI95% 1.10–3.70, P = 0.023) and hypoalbuminemia (HR 3.35 CI95% 1.82–6.17, P < 0.0001). The research was funded by: Educational Support by Takeda Keyword: aggressive T-cell non-Hodgkin lymphoma No conflicts of interests pertinent to the abstract.

Prevalence of hepatitis C virus among fatal drug overdoses in Tennessee: an analysis using 2019-2020 Tennessee State Unintentional Drug Overdose Reporting System Data.

Given the nature of the co-occurring epidemics of hepatitis C virus (HCV) and fatal stimulant overdose, we sought to assess the prevalence of HCV among opioid and stimulant-positive overdoses. We conducted a cross-sectional study to examine theprevalence of HCV among fatal drug overdoses in Tennessee using 2019-2020 data from the State Unintentional Drug Overdose Reporting System. We defined history of HCV using surveillance data and autopsy reports. Descriptive statistics were calculated for circumstances of overdose deaths for different categories of opioid and stimulant positivity on toxicology. Between 2019 and 2020, 3570 unintentional or undetermined drug overdose deaths occurred in Tennessee with an available autopsy. History of HCV was found in 24.6% of deaths. When assessing different involvement between stimulants and opioids, the highest prevalence of HCV was found for deaths where methamphetamine and opioids were present in toxicology (35.4%). Scene evidence of injection drug use occurred more frequently among decedents with a history of HCV (P<.0001). This analysis while descriptive highlights the importance of linking datasets to enhance infectious disease and drug overdose surveillance. Partnership between communicable disease and drug overdose surveillance teams should continue toidentify relationships between disease and drug overdose and strengthen the evidence to tailor crucial treatment and prevention activities.

Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study

BackgroundEstimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as ‘accidents,’ and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia.MethodsCost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention’s (CDC’s) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019.Results40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%—from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and − 1%, respectively.ConclusionThe scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs—fiscal, social, and personal—incurred by deaths due to self-injurious behaviors.

Cause-Specific Mortality in Patients With Advanced Chronic Kidney Disease in the ISCHEMIA-CKD Trial

BackgroundIn ISCHEMIA-CKD, 777 patients with advanced chronic kidney disease and chronic coronary disease had similar all-cause mortality with either an initial invasive or conservative strategy (27.2% vs 27.8%, respectively). ObjectivesThis prespecified secondary analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches–Chronic Kidney Disease) was conducted to determine whether an initial invasive strategy compared with a conservative strategy decreased the incidence of cardiovascular (CV) vs non-CV causes of death. MethodsThree-year cumulative incidences were calculated for the adjudicated cause of death. Overall and cause-specific death by treatment strategy were analyzed using Cox models adjusted for baseline covariates. The association between cause of death, risk factors, and treatment strategy were identified. ResultsA total of 192 of the 777 participants died during follow-up, including 94 (12.1%) of a CV cause, 59 (7.6%) of a non-CV cause, and 39 (5.0%) of an undetermined cause. The 3-year cumulative rates of CV death were similar between the invasive and conservative strategies (14.6% vs 12.6%, respectively; HR: 1.13, 95% CI: 0.75-1.70). Non-CV death rates were also similar between the invasive and conservative arms (8.4% and 8.2%, respectively; HR: 1.25; 95% CI: 0.75-2.09). Sudden cardiac death (46.8% of CV deaths) and infection (54.2% of non-CV deaths) were the most common cause-specific deaths and did not vary by treatment strategy. ConclusionsIn ISCHEMIA-CKD, CV death was more common than non-CV or undetermined death during the 3-year follow-up. The randomized treatment assignment did not affect the cause-specific incidences of death in participants with advanced CKD and moderate or severe myocardial ischemia. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches–Chronic Kidney Disease [ISCHEMIA-CKD]; NCT01985360)