Sudden deaths in the mentally handicapped

Trends in the incidence and causes of sudden deaths in a hospital group for the mentally handicapped were identified during a 50-year period, and the two halves of the period were compared. There were significantly more deaths in the second 25-year period than in the first. Longevity was greater during the second period, and a decrease in deaths due to status epilepticus was outweighed by an increase in deaths from arterial degenerative disease in the larger number of older patients. In the second period there was also a significant rise in sudden deaths due to asphyxia, probably attributable to modern medication with side-effects giving rise to feeding difficulties.     

Sudden unexpected death in infancy

Infants die suddenly and unexpectedly and constitute a distinct category of autopsy, almost invariably ordered by the Coroner. Most of these infants will die with no significant demonstrable pathology and are likely to be diagnosed as sudden infant death syndrome. Before this diagnosis can be reached, however, other specific natural and unnatural causes of death have to be excluded. This can only be done with a properly followed autopsy protocol and an understanding of the criteria that permit a diagnosis of sudden infant death syndrome. This review will consider the approach to this type of autopsy, and the considerations that need to be given before arriving at this diagnosis. It will emphasise the need for a full history and features, if encountered, that should discourage a diagnosis of sudden infant death syndrome     

Sleep and mortality: a population-based 22-year follow-up study

STUDY OBJECTIVES: Long and short sleep have been associated with increased mortality. We assessed mortality and 3 aspects of sleep behavior in a large cohort with 22-year follow-up. DESIGN/SETTING: Prospective, population-based cohort study. PARTICIPANTS: 21,268 twins aged > or =18 years responding to questionnaires administered to the Finnish Twin Cohort in 1975 (response rate 89%), and 1981 (84%). INTERVENTIONS: N/A. MEASUREMENTS: Subjects were categorized as short (<7 h), average, or long (>8 h) sleepers; sleeping well, fairly well, or fairly poorly/poorly; no, infrequent, or frequent users of hypnotics and/or tranquilizers. Cox proportional hazard models were used to obtain hazard ratios (HR) for mortality during 1982-2003 by sleep variable categories and their combinations. Adjustments were done for 10 sociodemographic and lifestyle covariates known to affect risk of death. RESULTS: Significantly increased risk of mortality was observed both for short sleep in men (+26%) and in women (+21%), and for long sleep (+24% and +17%), respectively, and also frequent use of hypnotics/tranquilizers (+31% in men and +39% in women). Snoring as a covariate did not change the results. The effect of sleep on mortality varied between age groups, with strongest effects in young men. Between 1975 and 1981, sleep length and sleep quality changed in one-third of subjects. In men there was a significant increase for stable short (1.34) and stable long (1.29) sleep for natural deaths, and for external causes in stable short sleepers (1.62). CONCLUSIONS: Our results show complicated associations between sleep and mortality, with increased risk in short and long sleep.     

Sudden unexpected unexplained death in infants

Summary Gross and histologic findings at autopsy in 32 cases of sudden unexpected unexplained death (SUUD) in infants were compared with autopsy findings in (1) 7 cases in which alarming clinical symptoms had been observed but no cause of death was found pathologically (morphologically unexplained death, MUD) and (2) 74 cases in which the cause of death was clearly established [8 cases of sudden unexpected explained death (SUED) and 66 control cases]. Laryngotracheitis was found most often in SUUD cases but did not differ histologically from the upper respiratory infections in the other categories. Other infections in SUUD which may be considered primary were bronchitis, focal pancreatitis, and mild pyelonephritis. Similar lesions were also found in control cases in which death was due to unrelated causes. The history in some SUUD and MUD cases and the morphologic changes in the spleen, thyroid gland, and adrenal gland indicated that unexpected unexplained death may occur at any time during the course of an upper respiratory or other type of infection. Our findings suggest that 2 factors have to combine to initiate the lethal episode: (1) an infection, usually of the upper respiratory tract, and (2) a predisposing condition or a trigger mechanism such as irritating skin lesions, trauma, or pain. The final common pathway appeared to be independent of the underlying disease. The characteristic findings of the terminal episode — hemorrhagic pulmonary edema and petechial hemorrhages — may also be part of a known fatal disease such as encephalitis or sepsis.

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Plötzlicher, unerwarteter und ungeklärter Tod im SäuglingsalterEine vergleichende klinisch-pathologische Studie

Zusammenfassung Makroskopische und mikroskopische Autopsiebefunde von 32 plötzlichen, unerwarteten und ungeklärten Todesfällen im Säuglingsalter (SUUD, Krippentod). werden verglichen mit 1. 7 Fällen, bei denen sich morphologisch keine Todesursache fand, obwohl alarmierende klinische Symptome beobachtet worden waren (MUD, morphologisch ungeklärter Tod) und 2. 74 Fällen, bei denen die Todesursache autoptisch gesichert war [8 Kinder dieser Gruppe waren plötzlich und unerwartet gestorben (SUED), und 66 Kinder mit schweren klinischen Symptomen dienten als Kontrollen].Laryngotracheitis war am häufigsten bei Krippentod (SUUD). Histologisch fanden sich keine Unterschiede zu den Infektionen der oberen Atemwege in den anderen Gruppen. Bronchitis, herdförmige Pankreatitis und geringgradige Pyelonephritis kamen ebenfalls als Primärinfektionen in Frage. Ähnliche Befunde wurden jedoch auch in Kontrollfällen mit anderer Todesursache erhoben.Der Krippentod (SUUD) kann wahrscheinlich zu jeder beliebigen Zeit im Ablauf einer Infektion, besonders der oberen Atemwege, auftreten. Dafürd srechen die klinischen Vorgeschichten einiger Krippentodesfälle (SUUD) sowie einiger Fälle von morphologisch ungeklärtem Tod (MUD) und außerdem morphologische Veränderungen in der Milz, der Schilddrüse und der Nebennierenrinde.Nach unseren Befunden müssen 2 Faktoren zusammentreffen, um den Krippentod auszulösen: 1. eine Infektion, gewöhnlich der oberen Atemwege, und 2. eine Disposition, z. B. als Folge einer Frühgeburt, oder Auslösemechanismen wie irritierende Hautschäden, Trauma oder Schmerz. Der Todesmechanismus scheint unabhängig von der auslösenden Krankheit zu sein. Die typischen Befunde des Endstadiums, hämorrhagisches Lungenödem und petechiale Schleimhautblutungen, finden sich auch bei tödlichen Krankheiten bekannter Ursache, wie Encephalitis oder Sepsis.

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This investigation was supported in part by Research Grant GM-14231 from the National Institutes of Health, Public Health Service.     

Asthma deaths during sports: report of a 7-year experience

BACKGROUND: Asthma mortality and the mortality of athletes during sports have been described separately in detail in the medical literature. However, asthma has not been reported as a cause of death in competitive athletes. OBJECTIVE: The object of this study was to raise the awareness of physicians, coaches, trainers, and parents that children and adults can have fatal asthma exacerbations during and immediately after participating in sports. METHODS: The Temple Sports Asthma Research Center identified athletes from 1993 until 2000 who died during or after sporting activity by using the nationwide Burrell's Information Service. Once a possible asthma-related sports death was identified, the autopsy report was requested from the coroner or medical examiner, and an attempt was made to contact the family. Contact with the family was limited to information about the death, medical history, sports involvement, and any medication usage by the person who had died. Secondary sources, including news reports, were used to confirm whether the subject died of asthma during or immediately after a sporting activity. RESULTS: Two hundred sixty-three possible cases were identified. Sixty-one deaths met the criteria for study inclusion. White deaths outnumbered black deaths by 2 to 1. Deaths among male subjects predominated. Most subjects were younger than the age of 20 years, with the most prevalent age group being between 10 to 14 years old. Fifty-one percent (18 of 35) of the competitive athletes had their fatal event while participating in organized sport, 14 in a practice situation and 4 deaths during a game or meet setting. Basketball and track were the 2 most frequent activities performed at the time of the fatal event. CONCLUSION: The subjects who had fatal asthma exacerbations were usually white male subjects between the ages of 10 and 20 years. Mild intermittent or persistent asthma by history was commonly identified. Sudden fatal asthma exacerbations occur in both competitive and recreational athletes and can be precipitated by sporting activity.     

A population-based autopsy study of sudden, unexpected deaths from natural causes among persons 5 to 39 years old during a 12-year period

All unexpected deaths in New Mexico from 1977 to 1988 were reviewed. By statute each such death must be reported to the Office of the Medical Examiner (OMI) and according to institutional policy autopsied even when death is presumed to be from natural causes. From this group the 650 index cases that form the basis of this report were obtained. The crude rate of sudden, unexpected death among New Mexico residents 5 to 39 years old during the study period was persons at risk. As documented by autopsy, the underlying cause of death in majority of these cases (53.4%) was related to cardiovascular disease and alcoholism. Male persons in general are at increased risk for sudden, unexpected death, and American Indian and black male persons are at greater risk than their Anglo and Hispanic counterparts. American Indians account for a disproportionate share of the unexpected deaths resulting from alcoholism, and black male persons are at particular risk for unexpected death resulting from cardiovascular diseases. This report emphasizes the importance of life style and diet in the well-being of persons 5 to 39 years old.     

Sudden infant deaths: stress, arousal and SIDS

The prevalence of the sudden infant death syndrome (SIDS) has dropped in most countries following the development of education campaigns on the avoidance of preventable risk factors for SIDS. These include factors in the infant’s microenvironment, such as prenatal passive smoking, administration of sedative drugs, prone sleep, high ambient temperature or sleeping with the face covered. Sleep laboratory studies have shown that these risk conditions contribute to the development of respiratory and autonomic disorders and reduce the child’s arousability. The opposite effects were seen when studying factors protective from SIDS, such as breastfeeding or the use of a pacifier. In victims of SIDS, similar breathing, autonomic and arousal characteristics were recorded days or weeks before their death. It is concluded that in some infants, already immature control mechanisms can be aggravated by environmental factors.     

Sudden unexpected death in epilepsy: an important concern

Epilepsy is one of the most common neurologic problems worldwide. Unfortunately, individuals with epilepsy are at higher risk of death than the general population, and sudden unexpected death in epilepsy is the most important direct epilepsy-related cause of death. In this review article, our research group focused on the risk factors, mechanisms and preventative measures obtained from clinical and experimental studies on sudden unexpected death in epilepsy.     

Sleep during menopausal transition: a 10-year follow-up

Study ObjectivesA 10-year observational follow-up study to evaluate the changes in sleep architecture during the menopausal transition.MethodsFifty-seven premenopausal women (mean age 46 years, SD 0.9) were studied at baseline and after a 10-year follow-up. At both time points, polysomnography (PSG) was performed, and the serum follicle-stimulating hormone (S-FSH) concentration was measured. Linear regression models were used to study the effects of aging and menopause (assessed as change in S-FSH) on sleep.ResultsAfter controlling for body mass index, vasomotor, and depressive symptoms, higher S-FSH level was associated with longer sleep latency (B 0.45, 95% confidence interval [CI]: 0.07 to 0.83). Aging of 10 years was associated with shorter sleep latency (B −46.8, 95% CI: −77.2 to −16.4), shorter latency to stage 2 sleep (B −50.6, 95% CI: −85.3 to −15.9), decreased stage 2 sleep (B −12.4, 95% CI: −21.4 to −3.4), and increased slow-wave sleep (B 12.8, 95% CI: 2.32 to 23.3) after controlling for confounding factors.ConclusionsThis study suggests that PSG measured sleep of middle-aged women does not worsen over a 10-year time span due to the menopausal transition. The observed changes seem to be rather age- than menopause-dependent.     

Ulceration and necrosis of vocal cords in hospital and unexpected child deaths.

Lesions are described in the vocal cords of an unselected group of 91 infants dying as "cot deaths", 11 stillbirths and 107 infants and children dying from conventional diseases. The lesions have been classified into six types. After allowances for the effects of intubation, the same incidence and type of change was present in all but the stillbirths. This argues against them being a specific pathogenic mechanism confined to the cot death situation. The aetiology and pathogenesis are unexplained but indicate the existence of an unsuspected laryngeal disorder that merits further study in mechanism leading to child death.     

Sudden and unexpected infant death due to an hemangioendothelioma located in the medulla oblongata

Herein, we report the case of a 4-month-old male infant dying suddenly and unexpectedly. Post mortem examination was requested with clinical diagnosis of Sudden Infant Death Syndrome (SIDS). Histological examination showed instead the presence of an hemangioendothelioma located in the medulla oblongata. Sudden unexpected death is the commonest form of death among babies between 1 month and 1 year of age. Although the vast majority of these fatalities are related to SIDS, a very small percentage is due to primary neoplasm. Necroscopy studies of sudden infant death should always include an accurate histological examination of the medulla oblongata on serial sections but seldom do.     

Infectious complications and antibiotic use in renal transplant recipients during a 1-year follow-up

Objective   To evaluate infectious complications and antibiotic use in 192 renal transplant recipients.
Methods   Infectious complications and antibiotic use were monitored in all patients receiving renal transplantation at our center from 1992 to 1997. Risk factors for infectious complications were evaluated. Transplants and patient survival were monitored. The follow-up period was 1 year.
Results   One-hundred and ninety-two patients received renal transplants during the study period. The mean duration of urethral catheterisation after transplantation was 10.5 days (SD = 5). Seventy-one per cent ( n  = 137) of patients had at least one infectious episode. In all, 284 infectious episodes were monitored. The most frequent infections were: urinary tract infections 61%, respiratory tract infections 8%, intra-abdominal infections 7%, and cytomegalovirus infection 8%. Escherichia coli and Enterococcus faecalis were the most frequently isolated microorganisms. Seventy-four per cent ( n  = 142) of patients received 314 antimicrobial courses (284 for therapy, and 30 for prophylaxis). Female gender and duration of urethral catheterisation were risk factors for urinary tract infection. Cytomegalovirus reactivation was associated with acute graft rejection and additional immunosuppressive therapy. Overall mortality was 4%. Infection-related mortality was 2.6%. Mortality was associated with Enterobacteriaceae in three patients, with Pseudomonas aeroginosa in one patient and with Enterococcus faecali s in one patient.
Conclusions   The incidence of infectious complications remains high in renal transplant recipients. Most cases of mortality were associated with infections. Early removal of the urethral catheter to reduce the risk of urinary tract infections is recommended.