Staphylococci in Bronchi of Hospital Patients: An Autopsy Study

Swabs were taken from the main bronchi of hospital patients at routine autopsy, and cultures examined for the presence of coagulase-positive staphylococci. The proportion of patients yielding positive cultures increased steadily with the length of stay in hospital. There was no correlation between positive cultures and age or sex. The results of this study suggest that bronchi of long-stay patients may form a significant source of dissemination of staphylococci producing “hospital” infections.     

Autopsy Study of Adrenals in Unselected Normotensive and Hypertensive Patients

The records of the Hôtel-Dieu Hospital of Montreal, a general teaching hospital, provided 2425 consecutive autopsies done between January 1, 1955 and January 1, 1965. According to the diagnostic criteria used, 44.2% of the patients were hypertensive. Adrenal adenomas, nodules or hyperplasia were found in 7% of the hypertensive patients and in only 1.9% of the normotensive ones. The most frequently encountered lesion was adenoma (4.2% in the hypertensive population and 1.1% in the normotensive one). These results constitute supportive evidence for a low incidence of “normokalemic primary aldosteronism”.     

Suicide in Nepal: Qualitative Findings from a Modified Case-Series Psychological Autopsy Investigation of Suicide Deaths

South Asia accounts for the majority of the world’s suicide deaths, but typical psychiatric or surveillance-based research approaches are limited due to incomplete vital surveillance. Despite rich anthropological scholarship in the region, such work has not been used to address public health gaps in surveillance and nor inform prevention programs designed based on surveillance data. Our goal was to leverage useful strategies from both public health and anthropological approaches to provide rich narrative reconstructions of suicide events, told by family members or loved ones of the deceased, to further contextualize the circumstances of suicide. Specifically, we sought to untangle socio-cultural and structural patterns in suicide cases to better inform systems-level surveillance strategies and salient community-level suicide prevention opportunities. Using a mixed-methods psychological autopsy approach for cross-cultural research (MPAC) in both urban and rural Nepal, 39 suicide deaths were examined. MPAC was used to document antecedent events, characteristics of persons completing suicide, and perceived drivers of each suicide. Patterns across suicide cases include (1) lack of education (72% of cases); (2) life stressors such as poverty (54%), violence (61.1%), migrant labor (33% of men), and family disputes often resulting in isolation or shame (56.4%); (3) family histories of suicidal behavior (62%), with the majority involving an immediate family member; (4) gender differences: female suicides were attributed to hopeless situations, such as spousal abuse, with high degrees of social stigma. In contrast, male suicides were most commonly associated with drinking and resulted from internalized stigma, such as financial failure or an inability to provide for their family; (5) justifications for suicide were attributions to ‘fate’ and personality characteristics such as ‘stubbornness’ and ‘egoism’; (5) power dynamics and available agency precluded some families from disputing the death as a suicide and also had implications for the condemnation or justification of particular suicides. Importantly, only 1 out of 3 men and 1 out of 6 women had any communication to family members about suicidal ideation prior to completion. Findings illustrate the importance of MPAC methods for capturing cultural narratives evoked after completed suicides, recognizing culturally salient warning signs, and identifying potential barriers to disclosure and justice seeking by families. These findings elucidate how suicide narratives are structured by family members and reveal public health opportunities for creating or supplementing mortality surveillance, intervening in higher risk populations such as survivors of suicide, and encouraging disclosure.     

Unnatural Deaths in Shanghai from 2000 to 2009: A Retrospective Study of Forensic Autopsy Cases at the Shanghai Public Security Bureau

Shanghai is the most developed city in China and has a soaring population. This study uses forensic epidemiology to determine the relationship between unnatural deaths and the development in Shanghai, based on recently released forensic autopsy cases from the 2000s at the Shanghai Public Security Bureau (SPSB). There were 5425 accidental deaths, 2696 homicides, 429 suicides, 186 natural deaths, and 1399 deaths of undetermined cause. There was a male-to-female ratio of 2.02:1, and the average age was 40.9±18.7 years. Traffic accidents (84.2%) were the number one cause of accidental deaths, which decreased during the study period. Sharp force injury (50.6%) was the leading cause of homicides, different from Western countries, where firearms are the leading cause. Hanging (24.5%) was the leading cause of suicides, whereas drug and chemical intoxication was the leading cause in the previous decade; pesticide ingestion decreased in the 2000s. In addition to traffic accidents, manual strangulation was the leading cause of death in childhood fatalities. Children under age 2 were vulnerable to homicides. In the 2000s, there were a large number of drug overdoses, and illegal medical practices and subway-related deaths first appeared in Shanghai. A new type of terrorist attack that involved injecting people with syringes in public places was reflected in the SPSB archives. The forensic epidemiology and changes in unnatural deaths in this decade reflected their relationship with the law, policy and changes in Shanghai. Illegal medical practices, subway-related deaths and terrorist attacks were closely related to the development in Shanghai. Identifying the risks of unnatural deaths will improve public health.     

Reduction of Thromboembolic Events in Meningioma Surgery: A Cohort Study of 724 Consecutive Patients

Background

Meningiomas are associated with the highest postoperative rate of venous thromboembolic events (VTE) among all intracranial tumors. The aim of this study is to compare two entirely different VTE prophylaxis regimens in 724 consecutive patients undergoing meningioma surgery.

Methods

Two cohorts at a single institution treated with different regimens to prevent VTE were reviewed retrospectively. Cohort A (n = 482; 314 females, mean age 57 years, range: 11–87 years) received our institutional regimen during the years 1999–2006, consisting of low-molecular-weight heparin (LMWH) and compression stockings. For cohort B (n = 242; 163 females, mean age 56.8 years, range: 16–90 years), during the years 2008–2010, the management included intraoperative 10°–20° leg elevation with intermittent pneumatic compression (IPC), heparin and LMWH administration. We compared the incidence of the endpoints pulmonary embolism (PE), deep venous thrombosis (DVT), hemorrhage and death, taking into account several known associated risk factors.

Results

For all endpoints, we observed a more favorable outcome with the new regimen. The difference in incidence of PEs (cohort A: 38/482, 8%; cohort B: 6/242, 2.5%) reached statistical significance (p = 0.002). In general, patients with skull base meningiomas had a higher risk for PE (OR 2.77). Regarding VTE prophylaxis, an adjusted subgroup analysis suggests that the new regimen is particularly beneficial for patients with skull base meningiomas.

Conclusions

We recommend perioperative prophylaxis using a management composed of intraoperative leg-elevation, IPC, early heparin administration and LMWH to reduce the risk for PE.     

Factors Associated with Physician Agreement on Verbal Autopsy of over 27000 Childhood Deaths in India

Introduction

Each year, more than 10 million children younger than five years of age die. The large majority of these deaths occur in the developing world. The verbal autopsy (VA) is a tool designed to ascertain cause of death in such settings. While VA has been validated against hospital diagnosed cause of death, there has been no research conducted to better understand the factors that may influence individual physicians in determining cause of death from VA.

Methodology/Principal Findings

This study uses data from over 27,000 neonatal and childhood deaths from The Million Death Study in which 6.3 million people in India were monitored for vital status between 1998 and 2003. The main outcome variable was physician agreement or disagreement of category of death and the variables were assessed for association using the kappa statistic, univariate and multivariate logistic regression using a conceptual hierarchical model, and a sensitivity and specificity analysis using the final VA category of mortality as the gold standard. The main variables found to be significantly associated with increased physician agreement included older ages and male gender of the deceased. When taking into account confounding factors in the multivariate analysis, we did not find consistent significant differences in physician agreement based on the death being in a rural or urban area, at home or in a health care facility, registered or not, or the respondent''s gender, religion, relationship to the deceased, or whether or not the respondent lived with the deceased.

Conclusions/Significance

Factors influencing physician agreement/disagreement to the greatest degree are the gender and age of the deceased; specifically, physicians tend to be less likely to agree on a common category of death in female children and in younger ages, particularly neonates. Additional training of physician reviewers and continued adaptation of the VA itself, with a focus on gender and age of the deceased, may be useful in increasing rates of physician agreement in these groups.     

Safety of Immediate Discharge after Parathyroidectomy: A Prospective Study of 3,000 Consecutive Patients

ObjectiveTo evaluate the safety of immediate discharge after parathyroidectomy and to establish a protocol for the amount and duration of supplemental orally administered calcium for patients with varied clinical presentations of primary hyperparathyroidism.MethodsA 40-months, prospective, single institution, cohort study of 3,000 consecutive patients undergoing parathyroidectomy and discharged within 2.5 hours after the operation is reviewed. The amount of oral calcium supplementation prescribed postoperatively varied according to a protocol that considered the degree of serum calcium elevation preoperatively as well as the intraoperative findings (hyperplasia versus adenoma). Symptoms of hypocalcemia were tracked, and all surgical outcomes were monitored.ResultsWith use of the reported protocol, less than 7% of patients had postoperative symptoms of hypocalcemia, most of whom were successfully selftreated with additional orally administered calcium. Only 6 patients (0.2%) required a visit to the emergency department for intravenous calcium infusion, all occurring on postoperative day 3 or later, and none of these patients required rehospitalization. Postoperative calcium requirements varied on the basis of the degree of serum calcium elevation preoperatively, number of parathyroid glands removed or subjected to biopsy, presence of morbid obesity, and presence of severe osteoporosis.ConclusionPatients with primary hyperparathyroidism can be sent home immediately after successful parathyroidectomy, provided specific measures are taken regarding postoperative oral calcium supplementation. Use of a specific calcium dosing protocol that considers several patient variables will prevent the postoperative development of symptomatic hypocalcemia in 93% of patients, identify patients at high risk of hypocalcemia, and allow most patients who develop symptoms of hypocalcemia to self-medicate in a simple and predictable fashion. Routine monitoring of postoperative serum calcium levels in the hospital can be safely eliminated if the details of this protocol are followed. (Endocr Pract. 2007;13:105-113)     

Aspiration-Related Acute Respiratory Distress Syndrome in Acute Stroke Patient

Background

Aspiration of oral or gastric contents into the larynx and lower respiratory tract is a common problem in acute stroke patients, which significantly increases the incidence of acute respiratory distress syndrome (ARDS). However, little is known about the clinical characteristics of aspiration-related ARDS in acute stroke patients.

Methods

Over 17-month period a retrospective cohort study was done on 1495 consecutive patients with acute stroke. The data including demographic characteristics, clinical manifestations, laboratory examinations, chest imaging, and hospital discharge status were collected to analysis.

Results

Aspiration-related ARDS was diagnosed in 54 patients (3.6%). The most common presenting symptom was tachypnea (respiratory rate ≥25 breaths/min) in 50 cases. Computed tomography (CT) images usually demonstrated diffuse ground-glass opacities (GGOs) and inhomogeneous patchy consolidations involving the low lobes. Age, NIHSS score, GCS score, dysphagia, dysarthria, hemoglobin concentration, serum aspertate aminotransferase (AST), serum albumin, serum sodium, and admission glucose level were independently associated with aspiration-related ARDS (odds ratio (OR) 1.05, 95% confidence interval (CI) (1.04–1.07); OR 2.87, (2.68–3.63); OR 4.21, (3.57–5.09); OR 2.18, (1.23–3.86); OR 1.67, (1.31–2.14); OR 2.31, (1.11–4.84); OR 1.68, (1.01–2.80); OR 2.15, (1.19–3.90); OR 1.92, (1.10–3.36) and OR 1.14, (1.06–1.21) respectively).

Conclusions

Aspiration-related ARDS frequently occurs in acute stroke patient with impairment consciousness. It is advisable that performing chest CT timely may identify disease early and prompt treatment to rescue patients.     

Association of Body Mass Index with Cause Specific Deaths in Chinese Elderly Hypertensive Patients: Minhang Community Study

Background

Most studies have suggested that elevated body mass index (BMI) was associated with the risk of death from all cause and from specific causes. However, there was little evidence illustrating the effect of BMI on the mortality in elderly hypertensive patients in Chinese population.

Methods

The information of 10,957 hypertensive patients at baseline not less than 60 years were from Xinzhuang, a town in Minhang district of Shanghai, was extracted from the Electronic Health Record (EHR) system. All study participants were divided into eight categories of baseline BMI (with cut-points at 18, 20, 22, 24, 26, 28 and 30 kg/m²). Relative hazard ratio of death from all cause, cardiovascular and non-cardiovascular cause by baseline BMI groups were calculated, standardized for sex, age, smoking, drinking, physical activity, systolic blood pressure, history of cardiovascular disorders, serum lipid disturbance, diabetes mellitus and antihypertensive drug treatment.

Results

During follow up (median: 3.7 years), 561 deaths occurred. Underweight (BMI<18 kg/m²) was associated with significantly increased mortality from all cause mortality (OR: 2.00; 95% CI: 1.43–2.79) and non cardiovascular mortality (OR: 2.76; 95% CI: 1.87–4.07), but not with cardiovascular mortality. For the cause specific analysis, the underweight was associated significantly with neoplasms (OR: 2.15; 95% CI: 1.16–4.00) and respiratory disorders (OR: 3.41; 95% CI: 1.64–7.06). The results for total mortality and specific cause mortality were not influenced by sex, age and smoking status.

Conclusion

Our study revealed an association between underweight and increased mortality from non-cardiovascular disorders in elderly hypertensive patients in Chinese community. Overweight and obesity were not associated with all cause or cause specific death.     

Mortality Patterns in Patients with Multiple Trauma: A Systematic Review of Autopsy Studies

Purpose

A high percentage (50%-60%) of trauma patients die due to their injuries prior to arrival at the hospital. Studies on preclinical mortality including post-mortem examinations are rare. In this review, we summarized the literature focusing on clinical and preclinical mortality and studies included post-mortem examinations.

Methods

A literature search was conducted using PubMed/Medline database for relevant medical literature in English or German language published within the last four decades (1980–2015). The following MeSH search terms were used in different combinations: “multiple trauma”, “epidemiology”, “mortality “, “cause of death”, and “autopsy”. References from available studies were searched as well.

Results

Marked differences in demographic parameters and injury severity between studies were identified. Moreover, the incidence of penetrating injuries has shown a wide range (between 4% and 38%). Both unimodal and bimodal concepts of trauma mortality have been favored. Studies have shown a wide variation in time intervals used to analyze the distribution of death. Thus, it is difficult to say which distribution is correct.

Conclusions

We have identified variable results indicating bimodal or unimodal death distribution. Further more stundardized studies in this field are needed. We would like to encourage investigators to choose the inclusion criteria more critically and to consider factors affecting the pattern of mortality.     

Moving from Data on Deaths to Public Health Policy in Agincourt,South Africa: Approaches to Analysing and Understanding Verbal Autopsy Findings

Background

Cause of death data are an essential source for public health planning, but their availability and quality are lacking in many parts of the world. Interviewing family and friends after a death has occurred (a procedure known as verbal autopsy) provides a source of data where deaths otherwise go unregistered; but sound methods for interpreting and analysing the ensuing data are essential. Two main approaches are commonly used: either physicians review individual interview material to arrive at probable cause of death, or probabilistic models process the data into likely cause(s). Here we compare and contrast these approaches as applied to a series of 6,153 deaths which occurred in a rural South African population from 1992 to 2005. We do not attempt to validate either approach in absolute terms.

Methods and Findings

The InterVA probabilistic model was applied to a series of 6,153 deaths which had previously been reviewed by physicians. Physicians used a total of 250 cause-of-death codes, many of which occurred very rarely, while the model used 33. Cause-specific mortality fractions, overall and for population subgroups, were derived from the model''s output, and the physician causes coded into comparable categories. The ten highest-ranking causes accounted for 83% and 88% of all deaths by physician interpretation and probabilistic modelling respectively, and eight of the highest ten causes were common to both approaches. Top-ranking causes of death were classified by population subgroup and period, as done previously for the physician-interpreted material. Uncertainty around the cause(s) of individual deaths was recognised as an important concept that should be reflected in overall analyses. One notably discrepant group involved pulmonary tuberculosis as a cause of death in adults aged over 65, and these cases are discussed in more detail, but the group only accounted for 3.5% of overall deaths.

Conclusions

There were no differences between physician interpretation and probabilistic modelling that might have led to substantially different public health policy conclusions at the population level. Physician interpretation was more nuanced than the model, for example in identifying cancers at particular sites, but did not capture the uncertainty associated with individual cases. Probabilistic modelling was substantially cheaper and faster, and completely internally consistent. Both approaches characterised the rise of HIV-related mortality in this population during the period observed, and reached similar findings on other major causes of mortality. For many purposes probabilistic modelling appears to be the best available means of moving from data on deaths to public health actions. Please see later in the article for the Editors'' Summary     

Ethnic Variability in Cholelithiasis—An Autopsy Study

By reviewing 3,506 autopsy records to determine the prevalence of gallbladder disease among San Francisco county coroner cases for 1981 and 1982, we found an overall prevalence rate of 92.7 per 1,000. After confirming age as a significant risk factor (P ≤.0001), the data were age adjusted and then analyzed using a stepwise logistic regression. Women were found to have a twofold to threefold greater prevalence compared with men. Latina women showed a higher prevalence than whites, blacks or Asians. Black women did not have a significantly higher prevalence than the white sample. Actual to ideal weight was also significantly related to the presence of gallbladder disease.     

Autopsy in California

From information complied from death certificates registered in 1952 and 1962 an examination was made of California''s autopsy performance and the characteristics of deaths in which autopsy was done. The data indicated that California had an overall autopsy rate of 37 per cent of total deaths in 1962, probably higher than any other state. In the decade reviewed, there was a 62 per cent absolute increase in autopsies and a 7 per cent increase relative to total deaths.Substantial increases in the proportion of deaths in which autopsy was done were found for physician-certified deaths in both metropolitan and nonmetropolitan counties and for coroner-certified deaths in nonmetropolitan counties. For all but two of forty-five selected natural causes of death there were increases in the proportion of deaths in which autopsy was done.Seventy per cent of deaths occurred in some type of facility. About one-half of all deaths occurred in general hospitals, and autopsy was done in 42 per cent of such cases.The dual factors of a high autopsy rate and overrepresentation of deaths brought to autopsy in white males, ages 35-64, support the validity of a reported decline in California''s death rate for arteriosclerotic heart disease.     

Single Umbilical Artery: A Prospective Study of 2000 Consecutive Deliveries

A prospective study of 2000 obstetrical deliveries was undertaken to establish the incidence of single umbilical artery in the newborn and the frequency of congenital malformations reported to be associated with this disorder. Twenty cases of single umbilical artery were discovered; two proved to have an associated congenital malformation. In neither of these cases was medical management affected by the discovery of a single artery. In addition, the vascular arrangement in the cords of 31 concurrently occurring congenitally malformed babies was examined, and in no instance was a single umbilical artery found.     

Developing a Social Autopsy Tool for Dengue Mortality: A Pilot Study

BackgroundDengue fever is a public health problem in the tropical and sub-tropical world. Dengue cases have grown dramatically in recent years as well as dengue mortality. Colombia has experienced periodic dengue outbreaks with numerous dengue related-deaths, where the Santander department has been particularly affected. Although social determinants of health (SDH) shape health outcomes, including mortality, it is not yet understood how these affect dengue mortality. The aim of this pilot study was to develop and pre-test a social autopsy (SA) tool for dengue mortality.ConclusionsThe SA tool is based on the scientific literature, a validated conceptual framework, researchers’ and health professionals’ expertise, and a pilot study. It is the first time that a SA tool has been created for the dengue mortality context. Our work furthers the study on SDH and how these are applied to neglected tropical diseases, like dengue. This tool could be integrated in surveillance systems to provide complementary information on the modifiable and avoidable death-related factors and therefore, be able to formulate interventions for dengue mortality reduction.