Soccer Related Sudden Deaths in Turkey

Regular physical exercise is recommended by the medical community, because it offers the potential to reduce the incidence of coronary events. On the other hand, vigorous exertion may act as a trigger of acute myocardial infarction and sudden cardiac death in susceptible individuals. Death during sports activities differs among sports disciplines and countries. In Turkey, soccer attracts more spectators than any other sports activity and the attention of the press and media, and is preferred over other sports by many young and middle-aged individuals. As autopsy-based studies are infrequent in literature and there is a lack of data detailing sudden death during physical activity in Turkey, we present a Turkish series of sudden deaths that occurred during soccer games based on data provided by the Morgue Specialization Department of the Council of Forensic Medicine. We identified 15 male cases of soccer-related sudden death aged from 10 to 48 years. Coronary artery disease was identified as the cause of sudden death in 11 cases.

Key points

• This study is one of the largest series of soccer related SD with reported 15 cases.
• In our series, CAD is the most common cause of SCD also in very young athletes in contrast with international literature.
• In autopsy, detailed cardio-vascular system evaluation and toxicological analysis including doping agents are essential to determine precise cause of exercise induced SD.
• Medical screening is important for all people interested in sport, not only for athletes, as a powerful means of prevention.

Key words: Recreational, soccer, sudden death, autopsy.     

The risk of sudden infant death from gastroesophageal reflux

Gastroesophageal reflux (GER) has been a suspected cause of infant deaths and sudden infant death syndrome (SIDS). We examined our 10-year experience with 499 consecutive infants 6 months of age or less who had extended (18 to 24 hours) esophageal pH monitoring performed to evaluate for GER. The data extracted from the esophageal pH records included the pH score, the pattern of GER (type I, II, or III), and the mean duration of reflux during sleep (ZMD). All infants were followed to determine the occurrence and cause of death during the first year of life. Of the 19 deaths found in the series, three were classified as SIDS and two were in-hospital deaths caused by reflux-induced aspiration. All five of these infants who died had a prolonged ZMD (greater than 3.8 minutes) and received either basic medical (n = 4) or no (n = 1) antireflux therapy. Four infants also had the type I pattern of GER. There was a 9.1% (4/44; 95% confidence limits, 2.5% to 21.7%) incidence of reflux-related or SIDS deaths in infants with type I GER and a prolonged ZMD who were treated nonoperatively, compared with none (0/83, P = .03) in the same group of infants treated with antireflux surgery. The incidence of SIDS was higher in infants with type I GER and a prolonged ZMD who were treated nonoperatively (3/44, 6.8%) compared with all other infants treated nonoperatively (0/265, 0%; P = .003).(ABSTRACT TRUNCATED AT 250 WORDS)     

Patients with postoperative atrial fibrillation have a doubled cardiovascular mortality

Objectives. To investigate the impact of postoperative AF on late mortality and cause of death in CABG patients. Design. All CABG patients without preoperative AF surgically treated between January 1, 1997 and June 30, 2000 were included (N = 1419). Altogether, 419 patients (29.5%) developed postoperative AF. After a median follow-up of 8.0 years, survival data were obtained, causes of death were compared and Cox proportional hazard analysis was used to determine predictors of late mortality. Results. The total mortality was 140 deaths/419 patients (33.4%) in postoperative AF patients and 191 deaths/1 000 patients (19.1%) in patients without AF. Death due to cerebral ischemia (2.6% vs. 0.5%), myocardial infarction (7.4% vs. 3.0%), sudden death (2.6% vs. 0.9%), and heart failure (6.7% vs. 2.7%) was more common among postoperative AF patients. Postoperative AF was an age-independent risk indicator for late mortality with a hazard ratio (HR) of 1.56 (95% confidence interval 1.23–1.98). Conclusions. Postoperative AF is an age-independent risk factor for late mortality in CABG patients, explained by an increased risk of cardiovascular death.     

Sudden death in chronic dialysis patients

Methods. Causes of sudden death were investigated in 113 chronic dialysis patients who died during the 10-year period from July 1979 to January 1989; post-mortem examination was performed on 93 of the cases (autopsy rate; 82.3%). Sudden death was regarded as death 24 h after the onset of acute illness in patients without any restriction in their daily activities. There were 35 sudden death cases out of the 93 autopsied chronic dialysis patients. We analysed the causes of sudden death for all chronic dialysis patients and for those who died suddenly. Results. The mean age of the 93 cases was 61.4 ± 10.5 years (±SD). Stroke was the most frequent cause of death (24 cases, 25.8%) in the 93 autopsied cases. This was followed by cardiac disease in 18 (19.4%), infectious disease in 16 (17.2%), malignancy in 14 (15.1%), and dissecting aortic aneurysm in 5 (5.4%). The mean age of the 35 sudden death cases was 60.9 ± 10.9 years. Of the 35 sudden death cases in chronic dialysis patients, dissecting aortic aneurysm was the most common cause of sudden death (5 cases, 14.3%), followed by cerebral haemorrhage in three (8.6%), acute subdural haematoma in three (8.6%), acute myocardial infarction in two (5.7%), cerebral infarction in two (5.7%), and subarachnoidal haemorrhage in one (2.9%). Conclusions. Dissecting aortic aneurysm, leading frequently to stroke as a cause of sudden death in chronic dialysis patients, at least in Japan, should be carefully differentiated from other cardiac disease in chronic dialysis patients, such as severe atherosclerosis.     

Is there a familial association between obstructive sleep apnoea/hypopnoea and the sudden infant death syndrome?

BACKGROUND: One postulated cause of the sudden infant death syndrome (SIDS) is upper airway obstruction during sleep. Several studies have suggested that SIDS may be more common in families with obstructive sleep apnoea/hypopnoea syndrome (OSAHS), but were limited by uncertainty as to whether the deaths were due to SIDS. We have tested the hypothesis that parents of true SIDS cases have an increased frequency of apnoeas and hypopnoeas during sleep. METHODS: The parents of 269 rigorously determined SIDS cases were invited for single night polysomnography and daytime ventilatory control measurement. RESULTS: Parents of 198 cases were identified but 152 did not respond or declined. Fifty five parents of 34 cases were studied and matched for age, height, and weight to 55 subjects from general practice registers. There was no difference in breathing during sleep between the parents of SIDS cases (median (IQR) 5.9 (3.2, 10.7) apnoeas+hypopnoeas/h) and controls (6.7 (4.0, 12.2) apnoeas+hypopnoeas/h; p = 0.47), but the SIDS parents had lower minimum nocturnal oxygen saturation (median (IQR) 92 (89, 93)%) than controls (92 (90, 94)%; p = 0.048). There were no major differences in control of breathing when awake between SIDS parents and controls. CONCLUSIONS: These results provide no evidence to support an association between SIDS and OSAHS. However, the minor impairment of oxygenation during sleep in SIDS parents requires further study.     

Injury to the Thoracic Aorta Following Fatal Blunt Trauma: An Autopsy Study

Abstract Background:   Transection of the thoracic aorta (TTA) remains a leading cause of death after blunt trauma. In this autopsy study, the natural history of this injury is reviewed. Patients and Methods:   All blunt trauma deaths that occurred in the Milano urban area over a period of one year were collected. Autopsies were available in all cases. Incidence, mechanisms, anatomical locations of TTA, deaths due to TTA or coexisting injuries, and times of death were reviewed. Cause of death was established. Death was attributed to TTA if its abbreviated injury score was six (hemorrhage not confined to the mediastinum). Results:   199 cases of fatal blunt trauma were included, 72% of which were males; mean age 53 ± 21. A TTA was observed in 53 subjects (27%), with a significantly higher incidence between the ages of 45 and 64 years and after falls from height. The aorta was transected at the isthmus in 36% of cases. Victims with TTA had a higher pre-hospital mortality and more injuries to chest organs, the chest wall and pelvis. In victims with TTA, injury to the aorta was the cause of death in 58%. Only five patients with TTA survived more than 1 h, reaching the hospital alive; four of these died due to the rupture of a mediastinal hematoma during the first hours of in-hospital care. Conclusions:   This study demonstrates that TTA is a frequent cause of immediate deaths among blunt trauma victims. Patients with risk factors for TTA who reach the hospital alive need to be promptly investigated with a contrast CT scan. Evidence of mediastinal hematoma is suggestive for possible rapid evolution.     

Surgical management of parapharyngeal cystic hygroma causing sudden airway obstruction

Parapharyngeal cystic hygroma is a rare tumor of the neck. This report describes two cases in which surgical resection was necessary to overcome sudden airway obstruction and details the surgical technique. These cases were considered "near misses" for sudden infant death syndrome (SIDS) and were revealed by computed tomography (CT) and echography to be parapharyngeal cystic hygroma. The location of this malformation could have produced sudden airway collapse and be erroneously diagnosed as SIDS. The postoperative follow-up was satisfactory and no recurrence was detected. We believe CT and echography should be included in the evaluation of such cases.     

Hemorrhage is More Prevalent than Brain Injury in Early Trauma Deaths: The Golden Six Hours

Abstract Introduction:   Under the trimodal distribution, most trauma deaths occur within the first hour. Determination of cause of death without autopsy review is inaccurate. The goal of this study is to determine cause of death, in hourly intervals, in trauma patients who died in the first 24 h, as determined by autopsy. Materials and Methods:   Trauma deaths that occurred within 24 h at a Level I trauma center were reviewed over a six-year period ending December 2005. Timing of death was separated into 0–1, 1–3, 3–6, 6–12 and 12–24 h intervals. Cause of death was determined by clinical course and AIS scores, and was confirmed by autopsy results. Results:   Overall, 9,388 trauma patients were admitted, of which 185 deaths occurred within 24 h, with 167 available autopsies. Blunt and penetrating were the injury mechanisms in 122 (73%) and 45 (27%) patients, respectively. Of 167 deaths, 73 (43.7%) occurred within the first hour. Brain injury, when compared to other body areas, was the most likely cause of death in all hourly intervals, but hemorrhage was as or more important than brain injury as the cause of death during the first 3 h and up to 6 h. No deaths were attributable to hemorrhage after 12 h. Conclusions:   The temporal distribution of the cause of death varies in the first 24 h after admission. Hemorrhage should not be overlooked as the cause of death, even after survival beyond 1 h. Understanding the temporal relationship of causes of early death can aid in the targeting of management and surgical training to optimize patient outcome.     

Ultrastructural aspects of the alveolar wall in SIDS

The aim of this study is to make a comparative analyse between light and ultrastructural lesions of the alveolar wall in SIDS. The study was made on lung specimens collected from autopsy of infants with sudden unexplained death. There were studied histopathologically 10 cases of sudden death. Only in 3 cases were made electron microscopically studies. At light microscope, there were put in evidence interstitial and intra-alveolar oedema and the presence of many parietal and intra-alveolar macrophages. There is a good correlation between light and ultrastructural aspects.     

Autopsies in trauma do not add to peer review or quality assurance

OBJECTIVES: The literature supports the concept that autopsies are useful in uncovering missed injuries or undiagnosed conditions that contribute to death after injury, especially late deaths that take place in the intensive care unit. Review of autopsies are also used as part of the trauma quality assurance (QA) process, and autopsy rates are queried by the American College of Surgeons Committee on Trauma in their reviews. Our hypothesis was that autopsies add little useful clinical or diagnostic information compared with QA peer review analysis in a mature trauma program. METHODS: Autopsies for all mortalities at a Level I trauma center between January 1998 and October 1999 were reviewed. The autopsies were reviewed in a "blinded" fashion such that each review occurred before examination of the chart, the trauma registry, and the findings of the trauma QA peer review. Findings from all sources were compared and examined for Goldman type errors (I-IV). RESULTS: Two hundred sixty-three mortalities were identified, with 216 autopsies reviewed. One hundred two (39%) mortalities were considered dead on arrival to the trauma center by QA review, with no management errors identified (group 1) (Immediate Death group). Sixty-one patients survived more than 48 hours after injury (group 2). One hundred sixty-one (61%) patients were admitted to the hospital. Ninety-nine patients died within 48 hours (Early Death group) and 62 died between 2 and 143 days (Late Death group). There were no Goldman type I errors (major diagnostic discrepancies that might have influenced mortality) identified in either group. Autopsy data did uncover one potentially technical error in a death that was considered nonpreventable on peer review analysis. CONCLUSION: We conclude that autopsy information for either group appeared to add little useful information to the QA peer review of deaths in a mature trauma program. This was true even in cases where the final QA determination was held pending the results of the autopsy. Autopsy rates may not be a useful parameter in evaluating a trauma QA program.     

Congenital heart defects – occurrence,surgery and prognosis in a Danish County

Objectives—To present population‐based data on prevalence, surgery and mortality for infants and children up to 5 years of age with congenital heart disease (CHD).

Design—Data from the EUROCAT Registry of Congenital Malformations for Funen County, Denmark, 1986–1998.

Results—Five hundred and seventy‐three infants and children were diagnosed with a CHD and livebirth prevalence was 7.9 per 1000 births. Thirty‐two per cent of all infants and children had an intervention (surgery or catheter treatment) performed. Eighteen per cent died within the first 5 years with the majority of deaths within the first year of life. For 74% of all deaths, surgery had not been performed. There was a decline in mortality for 1994–1998 compared to 1986–1993 both as a percentage of all cases (p?<?0.05) and as deaths per 1000 births (p?=?0.13), and deaths within the first 28?d after surgery almost disappeared during the study period.

Conclusion—Mortality and morbidity for infants and children with CHD is rather high although surgical mortality has improved considerably. Survival may be improved further for the small group of severely ill newborns dying before surgery. In newborns with multiple malformations, however, survival might not be possible or desirable.     

Thriving in academic medicine

Apparent life-threatening event (ALTE) is a term used to characterize an event of unknown cause after an infant is found limp, cyanotic, bradycardic, and/or requiring resuscitation. Like sudden infant death syndrome (SIDS), ALTE is a general term used until a precise diagnosis can be established. The relationship between ALTE and SIDS has not been clearly defined, although 7 to 15 percent of children with ALTE die of SIDS. If children with ALTE are at greater risk for SIDS, morbidity and mortality may be prevented if the underlying pathology can be identified and corrected or closely monitored. The otolaryngologist is being consulted more frequently to evaluate children who have been through an ALTE to help elucidate any underlying pathology that may have caused the near-death experience. This retrospective chart review reports the evaluation of 30 infants with ALTE requiring consultation by the Division of Pediatric Otolaryngology at the Children’s Memorial Hospital in Chicago during a 3-year period. We reviewed the literature and here compare our findings with current animal models. Of the 30 children evaluated, 53% had gastroesophageal reflux, 40% had laryngeal abnormalities, 13% had tracheal abnormalities, and 10% had pharyngeal abnormalities. Thirteen percent of the children had nonotolaryngic anomalies identified during evaluation. Surgical intervention was required in 10 patients and medical treatment was used in 18. When evaluating a child with ALTE, a complete history and physical examination, evaluation for gastroesophageal reflux, assessment for upper airway obstruction by radiographs and endoscopy, and a multidisciplinary approach are recommended. (Otolaryngol Head Neck Surg 1997;116:575-9.)     

Do Circumstances of the Death Matter? Identifying Socioenvironmental Risks for Grief‐Related Psychopathology in Bereaved Youth

We examined bereaved children's and surviving caregivers’ psychological responses following the death of the other caregiver as a function of the stated cause of death. Participants included 63 parentally bereaved children and 38 surviving caregivers who were assessed using self‐report instruments and in‐person interviews. Surviving caregivers reported the causes of death as resulting from sudden natural death (34.9%), illness (33.3%), accident (17.5%), and suicide (14.3%). Results revealed differences between caregiver‐reported versus child‐reported cause of death, particularly in cases of suicide. Children who lost a caregiver due to a prolonged illness exhibited higher levels of both maladaptive grief (d = 3.13) and posttraumatic stress symptoms (PTSS; d = 3.33) when compared to children who lost a caregiver due to sudden natural death (e.g., heart attack). In contrast, surviving caregivers did not differ in their levels of maladaptive grief and PTSS as a function of the cause of death; however, caregivers bereaved by sudden natural death reported higher levels of depression than those bereaved by prolonged illness (d = 1.36). Limited sample size prevented analysis of outcomes among those bereaved by suicide or accident. These findings suggest that anticipated deaths may contain etiologic risk factors for maladaptive grief and PTSS in children.     

Pre- and postoperative atrial fibrillation in CABG patients have similar prognostic impact

Objectives. To study pre- and postoperative atrial fibrillation and its long-term effects in a cohort of aortocoronary bypass surgery patients. Design. Altogether 615 patients undergoing aortocoronary bypass graft surgery in 1999–2000 were studied. Forty-four (7%) had preoperative atrial fibrillation. Postoperative atrial fibrillation occurred in 165/615 patients (27%) while 406/615 patients (66%) had no atrial fibrillation. After a median follow-up of 15 years, symptoms and medication in survivors were recorded, and cause of death in the deceased was obtained. Results. Death due to cerebral ischaemia was most common in the pre- and postoperative atrial fibrillation groups (7% and 5%, respectively, v. 2% among those without atrial fibrillation, p?=?.038), as were death due to heart failure (18% and 14%, v. 7%, p?=?.007) and sudden death (9% and 5%, v. 2%, p?=?.029). The presence of pre- or postoperative atrial fibrillation was an independent risk factor for late mortality (hazard ratios 1.47 (1.02–2.12) and 1.28 (1.01–1.63), respectively). Conclusions. Patients with pre- or postoperative atrial fibrillation undergoing aortocoronary bypass surgery have increased long-term mortality and risk of cerebral ischemic and cardiovascular death compared with patients in sinus rhythm.     

Bronchus-associated lymphoid tissue (BALT) in the lungs of children who had died from sudden infant death syndrome and other causes.

BACKGROUND--Bronchus-associated lymphoid tissue (BALT) is well characterised in rabbits and rats. In humans, however, it does not seem to be present in the healthy adult lung, although it can develop after certain microbial stimulation. METHODS--In the present study a consecutive series of lungs from 88 children who had died of sudden infant death syndrome (SIDS) and 34 control cases of comparable age were examined for the presence of BALT. RESULTS--BALT was present in 36.4% of the patients who had died of SIDS and in 44.1% of the control cases. The probability of finding BALT increased with age, with similar kinetics in both groups. CONCLUSIONS--Future studies need to define when and at what rate BALT disappears as children get older. In young children BALT may act as an entry site for antigens to initiate an immune response, as is well documented for the gut-associated lymphoid system.     

Evidence for retarded kidney growth in sudden infant death syndrome

The aim of the study was to compare the growth rate of the kidneys of infants who died of sudden infant death syndrome (SIDS) and control babies under 1 year; 227 infants who died in St. Petersburg from 1983 to 1990 and who met the criteria for SIDS were included in the study; 138 infants who died suddenly of respiratory infections within the same period constituted a control group. The infants did not have signs of dehydration, malformations, tumours or intrauterine infections. Morphologically the kidneys were intact. Factors which might influence the weight of the kidneys at the time of death were: the cause of death (whether SIDS or not), gender, gestational age, weight, length and ponderal index at birth, age, weight and length at death. Stepwise (forward) linear regression analysis identified three variables which in combination most accurately and independently influenced the predicted weight of the kidneys. These were the cause of death, gender and weight at the time of death. The weight of the kidneys increased by 6.0 g for each increase in total body weight of 1,000 g [95% confidence interval (CI) 5.0 – 7.0 g], in boys the kidney weight was 3.3 g (95% CI 1.6 – 5.0 g) higher than in girls and in the SIDS babies kidney weight was 2.5 g (95% CI 0.8 – 4.2 g) less than controls. Delayed kidney growth may be an indicator of increased risk of SIDS in infants under 1 year and may contribute in some cases. Received May 24, 1995; received in revised form and accepted January 31, 1996     

Der plötzliche Kindstod

Despite a dramatic decline in incidence, the sudden infant death syndrome (SIDS) remains the most common cause of death in the post-neonatal period. This review summarizes current knowledge on SIDS. When called to the scene, resuscitation should be avoided if there are already certain signs of death such as rigor mortis. Parents should be given time to part from their infant and should be informed that a post-mortem is crucial to establish a diagnosis and thus in their own interest. They should be provided with information about SIDS organizations to facilitate the grieving process. Knowledge about SIDS prevention is decisive in avoiding these tragedies: All infants should be put to sleep on their backs in their own bed, and should sleep in a sleeping back in the same room with their parents and in a smoke-free environment.     

Circadian variation in unexpected postoperative death.

Unexpected deaths still occur following major surgical procedures. The cause is often unknown but may be cardiac or thromboembolic in nature. Postoperative ischaemia, infarction and sudden cardiac death may be triggered by episodic or constant arterial hypoxaemia, which increases during the night. This study examined the circadian variation of sudden unexpected death following abdominal surgery between 1985 and 1989 inclusive. Deaths were divided into those occurring during the day (08.00-16.00 hours), evening (16.00-24.00 hours) and night (24.00-08.00 hours). Twenty-three deaths were considered to have been totally unexpected. Of 16 such patients undergoing autopsy, pulmonary embolism was the cause of death in five. In the remaining 11 patients, death occurred at night in eight (P < 0.005). Five of the seven patients without an autopsy died at night (P < 0.04); overall, 13 of 18 unexpected deaths occurred at night-time. These results suggest a need for further studies of sleep- and respiration-related effects on postoperative nocturnal cardiac function. The efficacy of monitoring during this apparent high-risk period should be evaluated.     

MALIGNANT HYPERPYREXIA AND SUDDEN INFANT DEATH SYNDROME

This paper reports three investigations of the suggested relationshipbetween sudden infant death syndrome (SIDS) and malignant hyperpyrexia(MH). In the first study 151 MH-susceptible families completeda questionnaire designed to identify the incidence of SIDS withintheir own pedigree. In the second study 106 SIDS families completeda questionnaire designed to identify the incidence of anaestheticrelated problems. In the third study, 14 SIDS parents were subjectedto muscle biopsy and in vitro halothane contracture and caffeinecontracture screening for susceptibility to MH. From the resultsof the three studies it can be concluded that there is no associationbetween SIDS and MH.     

Sleeping positions of infants in the Cape Peninsula.

The prone position is thought to be an important factor in the sudden infant death syndrome (SIDS). The sleep positions of unselected infants aged 6 months and younger attending clinics in the Cape Peninsula were studied; 62.4% slept prone with the face to the side. This position differs between the ethnic groups (whites 50.0%; blacks 58.7%; coloureds 69.8%) and the respondents' social class (higher classes 54.1%; lower classes 69.2%). The sex of the baby, the sleeping place and the educational level of the mother did not influence the position used. Ninety-four per cent of black infants slept with their mothers compared with 71% of coloured and 4% of white babies. The study confirmed that there are cultural differences in sleeping positions adopted by infants. The role this plays in SIDS among different ethnic groupings still needs to be clarified.