Lessons from the national asthma mortality study: deaths in hospital

The circumstances surrounding 38 deaths from asthma in hospital in New Zealanders under 70 years of age between August 1981 and July 1983 have been analysed. Twelve deaths did not appear to be preventable, all but one occurring in chronic severe asthmatics despite apparently optimal therapy. Critical delays by patients or relatives in seeking medical help occurred in six cases, and inadequate assessment of severity and undertreatment by medical practitioners prior to the patient reaching hospital was a major contributing factor in a further six deaths. In four cases, insufficient speed and indecisive treatment in the accident and emergency department appeared to contribute to death. Ten patients died after many hours or days in hospital wards in circumstances where assessment, monitoring and treatment were deficient. There were no deaths in intensive care units. Urgent expert assessment is necessary in A & E departments, and more severe cases should be managed in intensive care units. Patients with acute severe asthma may need continuous oxygen, intravenous therapy and close objective assessment for a week or more after hospitalisation.     

Death from asthma in Auckland: circumstances and validation of causes

New Zealand has experienced an epidemic of asthma deaths since 1977 with mortality rates of over 3.0/100 000 for people aged 5-34 years, more than three times the rate of comparable countries. To examine the reasons for this high mortality rate all deaths from asthma in people under 70 years in the Auckland region in 1981-82 were investigated. A total of 84 possible cases were studied and the validity of death certificates was found to be excellent for people under the age of 50 years. Fifty-three cases had usefully reversible asthma at the time of death and the mortality rate was almost four times higher in Pacific Islanders than in caucasians, with the Maori rate being intermediate. Sixty-seven percent (35) of the deaths in people with usefully reversible asthma occurred at home. In only 40% of cases had the patient reached some form of medical care. No deaths occurred in the patients admitted to hospital with the diagnosis of asthma during this period.     

Asthma mortality in New Zealand: a two year national study

The epidemic of deaths from bronchial asthma in New Zealand was investigated by a two-year national review of all deaths of persons under 70 years where "asthma" appeared in part I of a death certificate or in a coroner's report of cause of death. Information about the patients, the characteristics and management of their asthma and the circumstances of the fatal episode was obtained by interviewing relatives and general practitioners and perusal of hospital records. The reviewing panel of the asthma task force of the Medical Research Council considered 271 of the 342 deaths studied were due to asthma. A high national asthma mortality rate (5.1 per 100 000) was confirmed, with rates for Maoris (18.9) and Pacific Islanders (9.4) considerably higher than that for Europeans (3.4 per 100 000). After standardising for age and ethnic groups, there remained a threefold variation in mortality rates among health districts suggesting regional differences in prevalence, severity or management of asthma. No single cause for these high mortality rates was found. One-quarter of the deaths occurred in patients who had had previous life threatening attacks. Excessive use of bronchodilator drugs did not account for the high mortality rates, but inappropriate prolonged use of a home nebuliser may have delayed institution of other therapy in a few cases.     

Observations on recent increase in mortality from asthma

The mortality attributed to asthma has increased annually in England and Wales from 1960 to 1965. The increase is more pronounced at ages 5 to 34 years than at older ages and is most pronounced at ages 10 to 14 years. In this last age group the mortality increased nearly eight times in seven years, and in 1966 asthma accounted for 7% of all deaths. No comparable increase has been observed in any other country, but smaller increases at ages 10 to 19 years have been observed in Australasia, Japan, western Europe, and the United States. There is no evidence to suggest that there has been any change in diagnostic habits, certification of deaths, or methods of classification which could account for the increase in Great Britain, and it is concluded that the increase is real. General practitioners' records provide no evidence of an increase in prevalence and it seems probable that there has been an increase in case fatality. No environmental hazards are known which could have increased the severity of the disease, and the possibility has to be considered that the increase may be due to new methods of treatment. Corticosteroids have been used increasingly since 1952, and in Great Britain the use of pressurized aerosols containing sympathomimetics has increased rapidly since 1960.     

Investigation into use of drugs preceding death from asthma

Copies of death certificates were provided by the Registrar General for all deaths attributed to asthma in persons aged 5 to 34 years which were registered in England and Wales in the last quarter of 1966 and the first quarter of 1967. Information was obtained from the relevant general practitioners about 177 of the 184 subjects, and necropsy data were obtained for 113 of the 124 cases in which a post-mortem examination was known to have been made. Ninety-eight per cent. of the subjects for whom evidence was obtained were known to have been suffering from asthma, and signs of severe asthma (overdistended lungs and small bronchi plugged with mucus) were found in 91% of necropsies (57% of all deaths). Evidence that death might have been due to any other pathological condition was rare. Death was sudden and unexpected in 81% of the subjects (137 out of 171), and 59% of all deaths were referred to coroners. In 39% of cases (67 out of 171) the practitioner had not regarded the patient as suffering from severe asthma in his terminal episode. Corticosteroids and sympathomimetic preparations were the only drugs to have been used by a large proportion of patients. Two-thirds of the patients had received corticosteroids before the terminal episode, but detailed information about their use provided no suggestion that excess use could have been responsible for any large proportion of the deaths. Eighty-four per cent. of the patients were known to have used pressurized aerosol bronchodilators, and several instances of their use in excess were described. Routine inquiries about their use in the hours immediately preceding death were not made, and further evidence is required before their effect can be assessed adequately.     

A national study of sudden infant death syndrome in New Zealand

Although the sudden infant death syndrome is a major component of New Zealand's high postneonatal mortality rate, little is known about its national epidemiological patterns. In this paper, based on all cases born during 1981-83, the rate of sudden infant death syndrome was 4.2/1000 livebirths. The rate declined with maternal age, birthweight, and length of gestation, but increased with parity and Registrar-General's social class. Exnuptial and male births were also at high risk, as were births to Maori and New Zealand born mothers. There was a significant seasonal pattern and a distinct north-south gradient. The rate of sudden infant death syndrome in the south of the South Island was almost twice that in the north of the North Island. These patterns are, however, similar to those of the other preventable causes of postneonatal mortality. Future research into New Zealand's postneonatal mortality needs to consider all the possible preventable causes of mortality during this period of an infant's life, rather than concentrating on only one group of at-risk infants.     

Developing national best practice recommendations for harm reduction programmes: Lessons learned from a community-based project

Through promotion of consistent, evidence-based policy and practice, best practice recommendations can improve service delivery. Nationally relevant best practice recommendations, including guidance for programmes that provide service to people who use drugs, are often created and disseminated by government departments or other national organisations. However, funding priorities do not always align with stakeholder- and community-identified needs for such recommendations, particularly in the case of harm reduction. We achieved success in developing and widely disseminating best practice documents for Canadian harm reduction programmes by bringing together a multi-stakeholder, cross-regional team of people with relevant and diverse experience and expertise. In this commentary, we summarise key elements of our experience to contribute to the literature more detailed and transparent dialogue about team processes that hold much promise for developing best practice resources. We describe our project’s community-based principles and process of working together (e.g., regularly scheduled teleconferences to overcome geographic distance and facilitate engagement), and integrate post-project insights shared by our team members. Although we missed some opportunities for power-sharing with our community partners, overall team members expressed that the project offered them valuable opportunities to learn from each other. We aim to provide practical considerations for researchers, other stakeholders, and community members who are planning or already engaged in a process of developing best practice recommendations for programmes and interventions that address drug use.     

A private inquiry into the circumstances surrounding the 1972 death of John Gomilla, Jr., who died after allegedly consuming ten hallucinogenic mushrooms while residing in Hawaii

In December 1972, an 18-year-old male apparently took an accidental overdose of heroin. After becoming ill, he attempted to receive treatment for his condition by being admitted to the emergency room of Wahiawa General Hospital. When confronted by attending physicians in the emergency room as to the nature of his illness, the youth stated that he had only eaten 10 hallucinogenic mushrooms (an average dose for Copelandia cyanescens, the mushroom in question) and nothing else. This story was most likely concocted either by the youth himself or by some of his friends, who probably thought that they could or would be prosecuted for the use of an illegal substance. It is not uncommon that when confronted by an overdose of drugs, many young people are afraid to report their illness to the proper medical authorities out of fear of prosecution due to their illegal activities (Young et al. 1982). The doctors who attempted to treat this young man should not be held liable for his death, even though their treatment of the patient was more supportive (i.e., the talk-down method) than pharmacological. They had no way of knowing that the patient had lied to them about his condition. While it is true that several doctors had diagnosed Gomilla as possibly suffering from muscarine poisoning, why was no atropine or scopolamine administered to the patient? And why was his stomach not pumped and specimens collected for a toxicologist to study for the presence of toxins?(ABSTRACT TRUNCATED AT 250 WORDS)     

医改新处方，以欧洲为鉴

医疗体制的优化改革对于每个政府来说都是一项高难度的命题。因为关乎民生,所以引起广泛重视。拥有相对完善医疗体制的国家在这个方面的成功经验能否提供借鉴？