Short-term Mortality in Childhood Onset Insulin-dependent Diabetes Mellitus: a High Frequency of Unexpected Deaths in Bed

Mortality and the causes of death have been studied in a population-based cohort of 4919 childhood onset IDDM cases. Enrolment began in 1977 and at the time of study there had been a maximum duration of disease of 13.5 years, with a total of 33 721 person years at risk. Survival status was ascertained by linkage to the Swedish Cause-of-Death register. Death certificates, autopsy protocols, and hospital records were scrutinized for classification of causes of deaths. Twenty males and 13 females with IDDM died before the age of 28.5 years. This corresponds to a Standardized Mortality Rate for age of 262% (95% confidence limits, 172–400) for the boys and 384% (95% confidence limits, 232–635) for girls. Seven patients died of ketoacidosis, four at onset of diabetes. Nine cases were found ‘dead in bed’, having been seen apparently healthy 1–2 days before death. One of these cases had signs of cerebral haemorrhages at autopsy and another one had signs of bite marks in the mouth, but otherwise all autopsies were normal and no evidence of alcohol or other intoxication was found. In a well-educated population with good access to inexpensive diabetes care, there is still a two- to threefold excess mortality among young onset insulin-dependent diabetic individuals including a high frequency of unexplained deaths in bed.     

Sudden Death and Human Insulin: Is There a Link?

Case reports from the United Kingdom (UK) in 1989 have suggested that the introduction of human insulin in 1985 was associated with an increased risk of sudden death in insulin-treated diabetic patients. If human insulin increases the risk of sudden death, the number of these should have increased during the period where human insulin was introduced. We therefore identified all cases of sudden death in Denmark in younger insulin-treated diabetic patients, age at death below 50 years. During this period the consumption of human insulin went from 0.2% to 70% of the total consumption in Denmark. The total number of cases fulfilling the inclusion criteria was 226, and the annual number of sudden deaths did not change during the study period (p = 0.14). The number of deaths due to hypoglycaemia and cases with unexplained cause of death also remained constant (test for trend: p = 0.44). Chronic alcohol abuse or acute alcohol intoxication was found in 50% of the 135 patients dying from hypoglycaemia, ketoacidosis or unknown cause of death (including found dead in bed), while this was the case in only 16% of the remaining 91 cases dying from other natural causes. We conclude that introduction of human insulin in Denmark was not followed by an increase in sudden deaths among younger insulin-treated diabetic patients.     

Effects of a controlled hypoglycaemia test on QTc in adolescents with Type 1 diabetes

Our objective was to test the ventricular repolarization response to a controlled hypoglycaemia test in Type 1 diabetic adolescents, an age group at risk for ‘dead in bed syndrome’. We measured QTc, blood glucose level, potassium, heart rate, blood pressure and urinary metanephrine levels in 16 Type 1 diabetic adolescents during an insulin clamp mimicking the transition from mild hyperglycaemia to hypoglycaemia. QTc increased in all patients by 146 ± 44 ms (mean ±sd ) ranging from 70 to 230 ms. The longest QTc (630 ms) was recorded in the sibling of a diabetic patient found ‘dead in bed’. Heart rate and urinary metanephrine levels correlated with QTc (r = 0.60 and 0.79, respectively; P = 0.02 and 0.003). QTc in euglycaemia showed no correlation with hypoglycaemia associated QTc prolongation. The prognostic value of the hypoglycaemia test for the risk of recurrent episodes of QTc prolongation should be evaluated in real‐life conditions in large‐scale studies of diabetic adolescents.     

Epidemiology of paediatric immune thrombocytopenia in the General Practice Research Database

This study assessed the incidence of immune thrombocytopenia (ITP) and characteristics associated with ITP in the paediatric population using the General Practice Research Database (GPRD). Two hundred and fifty‐seven paediatric ITP patients were identified out of 1145 incident patients with ITP recorded between 1990 and 2005. The age‐specific incidence for ITP in paediatric patients was 4·2 per 100 000 person‐years (PY) [95% confidence interval (CI): 3·7–4·8 per 100 000 PY], with a statistically significantly higher incidence in boys compared to girls aged 2–5 years [9·7 (95% CI: 7·5–12·2) per 100 000 PY vs. 4·7 (95% CI: 3·2–6·6) per 100 000 PY, respectively]. By contrast, among teenagers aged 13–17 years, the overall incidence was lower [2·4 (95% CI: 1·7–3·3) per 100 000 PY] with a similar incidence in girls and boys. There was a relationship between age and sex with ITP incidence, suggesting that patterns of disease burden differ among children and teenagers. Evidence of an infection or immunization shortly before ITP diagnosis was apparent in 52 (20·2%) and 22 (8·6%) of the 257 paediatric ITP patients, respectively. Two deaths were observed during the study period. ITP is an important although rarely fatal disease in paediatric patients and its aetiology remains unexplained in the majority of cases.     

Influence of age on the presumed cause of syncope in patients with the Wolff-Parkinson-White syndrome

The aim of this study was to assess the causes of syncope in patients with the Wolff-Parkinson-White syndrome (WPW) and to determine whether the age of the patients was a significant factor. Forty-seven patients with a WPW, aged 11 to 72 years, underwent electrophysiological study by the oesophageal approach because of an unexplained syncope. Nineteen patients were under 20 years of age (16 +/- 3 years: group I) and 28 were over 20 years of age (40 +/- 13 years: group II). Junctional tachycardia was induced in 8 patients of group I (42%) and in 13 of group II (46%) (NS); atrial fibrillation was induced in 8 patients of group I (42%) and in 9 of group II (35%) (NS). A potentially malignant form of WPW was identified in 8 patients of group I (42%) and in 11 of group II (39%) (NS); Syncope was directly attributed to the WPW in 14 patients of group I (74%) and in 19 of group II (78%), either after identification of a serious form or induction of junctional tachycardia (6 patients of group I and 8 of group II). The rest of the syncopal episodes had various causes. There were no deaths. The authors conclude that oesophageal electrophysiological investigations enable rapid identification of a high incidence of tachycardias probably responsible for syncope in WPW. The causes of syncope and incidence of potentially severe forms of WPW were not significantly influenced by the age of the patients.     

High incidence of juvenile Graves'disease in Hong Kong

OBJECTIVE Childhood Graves’disease has been reported to be rare and epidemiological data on its incidence are limited. In our Paediatric Endocrine Clinic, Graves’disease was the most common thyroid disorder seen. There is no previous epidemiological study on Graves’disease in Chinese children. This study was performed to determine the incidence of childhood Graves’disease in Hong Kong Chinese. DESIGN AND PATIENTS We established a registry of childhood Graves’disease in 1990 at our centre, which has a catchment population of 1 010 000 with 240 000 under 15 years of age. Graves’disease was diagnosed on clinical features, diffuse thyroid gland enlargement, elevated free thyroxine or trilodothyronine levels with suppressed TSH level. All confirmed cases were recorded prospectively. Population data were obtained from the Statistics Department of the Hong Kong Government. RESULTS Forty-six Chinese children under 15 years of age had a confirmed diagnosis of Graves’disease during the study period from January 1990 to December 1994. The overall incidence was 3.8/100 000/year with a 95% confidence interval of 1.8–7.3/100 000/year. Incidence was low in children under 4 years. The highest incidence was in girls between 10 and 14 years of age at 15.5/100 000/year. The cumulative incidence for boys and girls of developing Graves’disease during the first 15 years was 11 and 104 per 100 000 respectively. CONCLUSIONS Our data demonstrate a very high incidence of Graves’disease in Hong Kong Chinese children, with an overall incidence about 5 times that reported in Danish children. A female predominance was found in all three age groups (0–4, 5–9 and 10–14 years) and was particularly striking in the adolescent girls.     

Impact of measles in Canada

The reported incidence of measles in Canada in 1981 was reduced 97% from the average annual rates during the prevaccine period, 1949-1958. Throughout recent years the age-specific incidence of reported cases of measles has remained highest in the group five to nine years of age, but there has been a definite increase in the proportion of cases of measles in persons greater than 10 years of age. During the extensive measles epidemic in Alberta in 1979, a high proportion of the reported cases occurred in adolescents and young adults previously vaccinated with killed vaccine, and the majority of these developed atypical measles syndrome. In Canada, from five to 36 patients per 100,000 population have required hospitalization annually for complications due to measles over the past 16 years. Measles-related deaths have declined in a pattern similar to that for reported incidence. Despite favorable trends in the control of measles in Canada, the social and economic impacts of this disease remain substantial and warrant a nationwide effort to eliminate indigenous infection.     

Population prevalence and incidence of Parkinson's disease in an Australian community

Background: Parkinson’s disease (PD) is the second most common neurodegenerative disorder affecting older individuals. Few studies have determined the prevalence and incidence of this disease in Australia. The aim of the study was to estimate the prevalence and 10‐year incidence of PD in the Australian community. Methods: In the Blue Mountains Eye Study (BMES), a population‐based health survey of Australian residents aged 49 years or more, we determined the cross‐sectional prevalence (BMES2, 1997–1999, n = 3509) and 10‐year incidence (BMES1, 2 and 3, 1992–1994, 1997–1999 and 2002–2004, respectively, n = 2545) of PD. We screened participants who took PD medications. PD diagnosis was confirmed by contacting the participant’s medical/general practitioners. Results: Nineteen new cases of PD were identified over the 10‐year period, a 10‐year incidence of 0.84% (95% confidence interval (CI) 0.54–1.33%). In the cross‐sectional study, 16/3509 participants were confirmed to have PD (0.46%), with age‐specific prevalence rates of 0.48% in persons aged 60–69 years, 0.82% for ages 70–79 years and 0.56% in persons aged 80 years or older. No PD cases were identified among participants less than 60 years of age. When age standardized to the 2001 Australian population, the prevalence of PD was 362 per 100 000 (95%CI 183–541) among persons aged 50 years or older and 104 per 100 000 for the Australian population at all ages, assuming no prevalent cases in persons aged less than 50 years. Conclusion: This study estimates a 0.46% (95%CI 0.23–0.68) prevalence of PD patients treated with medications aged 50 years or older and a 10‐year incidence of 0.84% (95%CI 0.54–1.33).     

Incidence of and risk factors for bacteraemia in HIV-infected adults in the era of highly active antiretroviral therapy

Background

HIV‐infected patients have an increased risk for bacteraemia compared with HIV‐negative patients. Few data exist on the incidence of and risk factors for bacteraemia across time in the current era of highly active antiretroviral therapy (HAART).

Methods

We assessed the incidence of bacteraemia among patients followed between 2000 and 2008 at 10 HIV Research Network sites. This large multisite, multistate clinical cohort study collected demographic, clinical and therapeutic data longitudinally. International Statistical Classification of Diseases and Related Health Problems (ICD)‐9 codes were examined to identify all cases of in‐patient bacteraemia. Logistic regression analysis was used to assess risk factors for bacteraemia and trends over time in the odds of bacteraemia.

Results

A total of 39 318 patients were followed for 146 289 person‐years (PY). During the study period, there were 2025 episodes of bacteraemia (incidence 13.8 events/1000 PY). The most common bacteraemia diagnosis was ‘bacteraemia, not otherwise specified (NOS)’ (51%) followed by Staphylococcus aureus (16%) and Streptococcus species (6.5%). In multivariate analysis, the likelihood of bacteraemia was found to have increased in 2005–2008, compared with 2000. Other factors associated with higher odds of bacteraemia included a history of injection drug use (IDU), age ≥50 years, Black race and greater immunosuppression.

Conclusions

The likelihood of bacteraemia has risen slightly in recent years. Patients who are Black or have a history of IDU are at higher risk. Further research is needed to identify reasons for this increase and to evaluate programmes designed to reduce the bacteraemia risk.     

Very early mortality in patients starting antiretroviral treatment at primary health centres in rural Malawi

Objectves  To report on the cumulative proportion of deaths occurring within 3 months of starting antiretroviral treatment (ART) and to identify factors associated with such deaths, among adults at primary health centres in a rural district of Malawi.
Methods  Retrospective cohort study: from June 2006 to April 2008, deaths occurring over a 3-month period were determined and risk factors examined.
Results  A total of 2316 adults (706 men and 1610 women; median age 35 years) were included in the analysis and followed up for a total of 1588 person-years (PY); 277 (12%) people died, of whom 206 (74%) people died within 3 months of initiating ART (cumulative incidence: 13.0; 95% confidence interval: 11.3–14.8 per 100 PY of follow-up). Significant risk factors associated with early deaths included male sex, WHO stage 4 disease, oesophageal or persistent oral candidiasis and unexplained presumed or measured weight loss >10%. One in every 3 patients who either died or was lost to follow up had unexplained weight loss >10%, and survival in this group was significantly different from patients without this condition.
Conclusions  Seven in 10 individuals initiating ART at primary health centres die early. Specific groups of patients are at higher risk of such mortality and should receive priority attention, care and support.     

Incidence and clinical features of hyperimmunoglobulinemia D and periodic fever syndrome (HIDS) and spectrum of mevalonate kinase (MVK) mutations in German children

Autoinflammatory diseases (AIDs) are characterized by recurrent, self-limiting systemic inflammation. Disorders include hereditary recurrent fever (HRF) syndromes such as hyperimmunoglobulinemia D and periodic fever syndrome (HIDS). To determine the incidence of HIDS and report clinical and genetic characteristics together with the underlying MVK genotypes in German children, a prospective active surveillance was conducted in Germany during a period of 3?years. Monthly inquiries were sent to 370 children's hospitals by the German Paediatric Surveillance Unit (Clinic-ESPED, n1) and to two laboratories (Laboratory-ESPED, n2) performing genetic analyses. Inclusion criteria were a MVK mutation-positive patient ≤16?years of age with more than three self-limiting episodes of fever >38.5°C associated with increased inflammation markers. Clinical, epidemiological, and genetic data were assessed via questionnaires. Eight out of 16 patients were identified in Clinic-ESPED (n1) and 15 of 16 in Laboratory-ESPED (n2). Clinical and laboratory surveys overlapped in 7 of 16 cases. Incidence of HIDS was estimated to be 0.39 (95% CI: 0.22, 0.64) per 10(6) person-years. HIDS symptoms generally started in infancy with recurrent fever episodes lasting 3-12 (median, 4.5) days and recurring every 1-12?weeks. Fever was accompanied by abdominal pain, vomiting, diarrhea, cervical lymphadenopathy, and sometimes by headache, skin and joint symptoms. The patients carried 11 different MVK mutations mostly in compound heterozygosity (75%, 12 out of 16). The most frequent mutation was p.Val377Ile (81%, 13 out of 16). In Germany, the incidence of HIDS is very low with 0.39 per 10(6) person-years.     

The Incidence and Prognosis of Cerebrovascular Disease in Hospital Patients in Helsinki,Finland, in the Decade 1970–1980

ABSTRACT Over 21000 hospital episodes due to cerbrovascular disease (CVD, ICD-8 nos. 430–438) were registered in the Helsinki hospitals in 1970–1980. Of those 17629 were identified as new cases. The age-adjusted incidence of haemorrhagic and thrombotic stroke (430–433) declined during the period 1970–1975 from 221 to 139 cases/100000 inhabitants, whereafter no further decrease was observed. The decline in incidence was significant in both sexes. Analysis by diagnosis group showed that the decrease was confined to the incidence of haemorrhagic stroke (430–432), whereas the incidence of thromboembolic stroke (433, 434) and transient ischaemic attacks (435) remained virtually unchanged. Survival was mainly determined by patient age and type of CVD. Intracerebral haemorrhage and occlusion of precerebral arteries exhibited the poorest short-term prognosis. About half of the patients hospitalised due to cerebral thrombosis and embolism survived over One year. Long-term prognosis of the major CVD groups was very poor with only 10% of the patients alive after eight years. Transient cerebral ischaemia and subarachnoid haemorrhage had a clearly better prognosis, the survival rates after eight years being 45 and 30%, respectively.     

Mortality, Asthma, Smoking and Acute Chest Syndrome in Young Adults with Sickle Cell Disease

Purpose

Sickle cell disease (SCD) patients with asthma have an increased risk of death. Acute chest syndrome (ACS) is a major cause of mortality in patients with SCD, and ACS may be more common in SCD patients who smoke. The purpose of this study was to test the hypothesis that mortality in young adults with SCD would be greater than that of controls during a 10-year period and to determine whether asthma, reduced lung function, ACS episodes, and/or smoking predicted mortality during the follow-up period.

Methods

The outcomes during a 10-year period were ascertained of SCD patients and race-matched controls who had taken part in a pulmonary function study when they were between age 19 and 27 years. Smoking and asthma status and whether they had had ACS episodes were determined, and lung function was measured at the initial assessment.

Results

Seventy-five subjects with SCD were followed for 683 patient years. There were 11 deaths with a mortality rate of 1.6 deaths per 100 patient years, which was higher than that of the controls; one death in 47 controls was observed for 469 patient years with a mortality rate of 0.2 per 100 patient years (p = 0.03). There were no significant associations of body mass index, recurrent episodes of acute chest, steady state haemoglobin, or gender with mortality. Adjusting for baseline lung function in SCD patients, “current” asthma [hazard ratio (HR) 11.2; 95 % confidence interval (CI) 2.5–50.6; p = 0.002] and smoking [HR 2.7; (95 % CI 1.3–5.5); p = 0.006] were significantly associated with mortality during the 10-year period.

Conclusions

Our results indicate that young adults with SCD should be discouraged from smoking and their asthma aggressively treated.     

Cancer incidence rate and mortality rate in sickle cell disease patients at Howard University Hospital: 1986–1995

The incidence of cancer in patients with sickle cell disease (SCD) is not known. The 10-year follow-up data on 696 patients with SCD was analyzed at our institution in order to determine the cancer incidence and cancer mortality rates. The age range was 18 to 79 years, with a mean age of 28.8 years. There were 377 females and 319 males. The median follow-up was 3 years. Five patients developed cancer during this period. The cancer incidence rate was 5/2,864 or 1.74 per 1,000 patient years. The 95% CI was 0.64 to 4.32 per 1,000 patient years. There were 68 deaths with 3 being due to cancer. The cancer mortality rate was 3/2,873 or 1.04 cases per 1,000 patient years. Our data represent the first published paper that the authors are aware of, where the cancer incidence and mortality rates have been calculated for any group of patients with SCD. Am. J. Hematol. 55:188–192, 1997. © 1997 Wiley-Liss, Inc.     

The Prevalence of Mutations in KCNQ1, KCNH2, and SCN5A in an Unselected National Cohort of Young Sudden Unexplained Death Cases

Introduction: Sudden unexplained death account for one‐third of all sudden natural deaths in the young (1–35 years). Hitherto, the prevalence of genopositive cases has primarily been based on deceased persons referred for postmortem genetic testing. These deaths potentially may represent the worst of cases, thus possibly overestimating the prevalence of potentially disease causing mutations in the 3 major long‐QT syndrome (LQTS) genes in the general population. We therefore wanted to investigate the prevalence of mutations in an unselected population of sudden unexplained deaths in a nationwide setting. Methods: DNA for genetic testing was available for 44 cases of sudden unexplained death in Denmark in the period 2000–2006 (equaling 33% of all cases of sudden unexplained death in the age group). KCNQ1, KCNH2, and SCN5A were sequenced and in vitro electrophysiological studies were performed on novel mutations. Results: In total, 5 of 44 cases (11%) carried a mutation in 1 of the 3 genes corresponding to 11% of all investigated cases (R190W KCNQ1, F29L KCNH2 (2 cases), P297S KCNH2 and P1177L SCN5A). P1177L SCN5A has not been reported before. In vitro electrophysiological studies of P1177L SCN5A revealed an increased sustained current suggesting a LQTS phenotype. Conclusion: In a nationwide setting, the genetic investigation of an unselected population of sudden unexplained death cases aged 1–35 years finds a lower than expected number of mutations compared to referred populations previously reported. We therefore conclude that the prevalence of mutations in the 3 major LQTS associated genes may not be as abundant as previously estimated. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1092‐1098, October 2012)     

Improved survival for adolescents and young adults with Hodgkin lymphoma and continued high survival for children in the Netherlands: a population-based study during 1990–2015

Population-based studies that assess long-term patterns of incidence, major aspects of treatment and survival are virtually lacking for Hodgkin lymphoma (HL) at a younger age. This study assessed the progress made for young patients with HL (<25 years at diagnosis) in the Netherlands during 1990–2015. Patient and tumour characteristics were extracted from the population-based Netherlands Cancer Registry. Time trends in incidence and mortality rates were evaluated with average annual percentage change (AAPC) analyses. Stage at diagnosis, initial treatments and site of treatment were studied in relation to observed overall survival (OS). A total of 2619 patients with HL were diagnosed between 1990 and 2015. Incidence rates increased for 18–24-year-old patients (AAPC + 1%, P = 0·01) only. Treatment regimens changed into less radiotherapy and more ‘chemotherapy only’, different for age group and stage. Patients aged 15–17 years were increasingly treated at a paediatric oncology centre. The 5-year OS for children was already high in the early 1990s (93%). For patients aged 15–17 and 18–24 years the 5-year OS improved from 84% and 90% in 1990–1994 to 96% and 97% in 2010–2015, respectively. Survival for patients aged 15–17 years was not affected by site of treatment. Our present data demonstrate that significant progress in HL treatment has been made in the Netherlands since 1990.     

Causes of death in Japanese patients with diabetes based on the results of a survey of 45,708 cases during 2001–2010: Report of the Committee on Causes of Death in Diabetes Mellitus

The principal causes of death among 45,708 patients with diabetes (29,801 men and 15,907 women) who died in 241 hospitals throughout Japan during 2001–2010 were determined based on a survey of the hospital records. Autopsy had been conducted in 978 of the 45,708 cases. The most frequent cause of death was malignant neoplasia (38.3%), followed by, in order of descending frequency: infections (17.0%); and then vascular diseases (14.9%), including renal failure (3.5%), ischemic heart diseases (4.8%) and cerebrovascular diseases (6.6%). Diabetic coma associated with hyperglycemia with or without ketoacidosis accounted for only 0.6% of the deaths. In regard to the relationship between the age and cause of death in patients with diabetes, the incidence of death due to vascular diseases was higher in patients over the age of 30 or 40 years, and the 97.0% of the total death due to vascular diseases was observed in patients over the age of 50 years. The incidence of death due to infectious diseases, especially pneumonia, increased in an age‐dependent fashion, and the 80.7% of the total death due to pneumonia was observed in patients over the age of 70 years. ’Poorer’ glycemic control was associated with the reduced lifespan of patients with diabetes, especially of those with nephropathy. The average age at death in the survey population was 72.6 years. The lifespan was 1.6 years shorter in patients with ‘poorer’ glycemic control than in those with ‘better’ glycemic control. In patients with diabetes of less than 10 years’ duration, the incidence of death due to macroangiopathy was higher than that due to nephropathy. Of the 45,708 patients with diabetes, 33.9% were on oral medication, 41.9% received insulin therapy and 18.8% were treated by diet alone. Among the patients in whom the cause of death was diabetic nephropathy, a high percentage, 53.7%, was on insulin therapy. The average age at death of the 45,708 patients with diabetes was 71.4 years in men and 75.1 years in women. However, the report of the Ministry of Health and Welfare of Japan in 2010 set the average lifespan of the Japanese at 79.6 years for men and 86.3 years for women. Thus, the average lifespan of patients with diabetes still appears to be shorter than that of the general population in Japan. However, the differences in lifespan between patients with diabetes and the general population were shorter than those in the former surveys.     

Outcome of patients with Eisenmenger syndrome. Apropos of 62 cases followed-up for an average of 16 years]

In an era when heart-lung transplantation offers a therapeutic option for patients with Eisenmenger's syndrome, it is important to assess the natural history of this condition. With this objective the authors studied 62 patients followed-up by the same cardiologist. The average follow-up period was 16 years, but 22 patients were followed up for over 20 years. The average age at death was 29 years. It differed significantly for genetically normal patients (31 years for 21 fatalities) compared with a population of trisomics (21 years for 6 fatalities). Half the patient population lived for over 30 years. Fourteen of the 27 deaths occurred during the third decade and only 4 before the age of 20. The probability of surviving 10 more years for a 20 years old genetically normal patient was 56%. The causes of death in the 19 cases in which it could be established were: 5 sudden deaths, 4 right heart failures, 3 massive haemoptyses, 3 pulmonary emboli, 2 pneumonias and 2 peroperative deaths. The functional disability was nearly always minimal or mild, enabling the patient to work: 24 of the 45 non-trisomic patients had full-time jobs. Pregnancy was a poor prognosis factor and could be lethal (2 deaths due to pulmonary embolism in the post-partum period). A heart-lung transplantation would only seem to be justified in patients with severe symptoms, polycythaemia, irreversible right heart failure and/or haemoptysis.     

Antecedents to hospital deaths

Background: Recent studies have suggested there are a large number of potentially preventable deaths in Australian hospitals. Aim: This study aimed to document antecedent factors in hospital deaths in an attempt to identify potentially preventative factors. Methods: The study was conducted at three separate acute hospitals. Demographics of all deaths were recorded over a 6‐month period as well as antecedent factors present within 0–8 and 8–48 h of all deaths including vital sign abnormalities, cardiorespiratory arrests and admission to intensive care. Separate analysis was performed on ‘not for resuscitation’ deaths. Results: There were a total of 778 deaths, of which 549 (71%) were ‘not for resuscitation’. There were 171 (22%) deaths preceded by arrest and 160 (21%) preceded by admission to intensive care. Of the remaining deaths, 30% had severely abnormal physiological abnormalities documented. This incidence was 50% in the non‐do not resuscitate (DNR) subgroup. Concern about the patient’s condition was expressed in the patient’s notes by attending nursing staff and junior medical staff in approximately one‐third of non‐DNR deaths. Hypotension (30%) and tachypnoea (17%) were the most common antecedents in the non‐DNR deaths. Conclusion: There is a high incidence of serious vital sign abnormalities in the period before potentially preventable hospital deaths. These antecedents may identify patients who would benefit from earlier intervention. (Intern Med J 2001; 31: 343–348)     

Incidence of pneumonia,bacteremia, and invasive pneumococcal disease in Pakistani children

Objective To determine the incidence of pneumonia, bacteremia, and invasive pneumococcal disease (IPD) in Pakistani children <5 years old. Methods Household surveillance from 1st February 2007 to 12th May 2008 was conducted in two low‐income, coastal communities of Karachi. Community health workers referred each sick child <5 years old to the local clinic. Blood culture was obtained whenever possible from children meeting inclusion criteria. Results Overall, 5570 children contributed 3949 observation years. There were 1039 clinical cases of pneumonia, of which 54 were severe pneumonia and four cases of very severe disease according to WHO criteria. The overall pneumonia incidence was 0.26 (95% CI: 0.25–0.28) episodes per child‐year. A pathogen was isolated from the blood of 29 (2.8%) pneumonia cases. Bacteremia incidence was 912 (95% CI: 648–1248) episodes per 100 000 child‐years with a case fatality rate of 8%. The detected IPD incidence was 25 (95% CI: 1–125) episodes per 100 000 child‐years. The under‐five mortality rate was 55 per 1000 live births, with pneumonia causing 12 (22%) deaths among children <5 years old. Conclusion Clinical pneumonia is common in Pakistani children, with one in four deaths attributable to the disease. Bacteremia occurs at a high rate but surveillance for pneumococcus underestimates the burden of IPD.