Sudden infant death syndrome: risk factors, cause of death, and the death certificate.
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Cause of Death↗
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Underreporting of maternal deaths on death certificates and the magnitude of the problem of maternal mortality.
OBJECTIVES: I studied the extent to which maternal deaths are underreported on death certificates. METHODS: We collected data on maternal deaths from death certificates, linkage of death certificates with birth and fetal death records, and review of medical examiner records. RESULTS: Thirty-eight percent of maternal deaths were unreported on death certificates. Half or more deaths were unreported for women who were undelivered at the time of death, experienced a fetal death or therapeutic abortion, died more than a week after delivery, or died as a result of a cardiovascular disorder. CONCLUSIONS: The number of maternal deaths is substantially underestimated when death certificates alone are used to identify deaths, and it is unlikely that the Healthy People 2010 objective of reducing the maternal mortality rate to no more than 3.3 deaths per 100000 live births by 2010 can be achieved. Increasing numbers of births to older women and multiple-gestation pregnancies are likely to complicate efforts to reduce maternal mortality.
Adolescent↗
Deaths from injury in children and employment status in family: analysis of trends in class specific death rates.
OBJECTIVE: To examine socioeconomic inequalities in rates of death from injury in children in England and Wales. DESIGN: Analysis of rates of death from injury in children by the eight class version of the National Statistics Socio-Economic Classification (NS-SEC) and by the registrar general's social classification. SETTING: England and Wales during periods of four years around the 1981, 1991, and 2001 censuses. SUBJECTS: Children aged 0-15 years. MAIN OUTCOME MEASURES: Death rates from injury and poisoning. RESULTS: Rates of death from injury in children fell from 11.1 deaths (95% confidence interval 10.8 to 11.5 deaths) per 100,000 children per year around the 1981 census to 4.0 deaths (3.8 to 4.2 deaths) per 100,000 children per year around the 2001 census. Socioeconomic inequalities remain: the death rate from all external causes for children of parents classified as never having worked or as long term unemployed (NS-SEC 8) was 13.1 (10.3 to 16.5) times that for children in NS-SEC 1(higher managerial/professional occupations). For deaths as pedestrians the rate in NS-SEC 8 was 20.6 (10.6 to 39.9) times higher than in NS-SEC 1; for deaths as cyclists it was 27.5 (6.4 to 118.2) times higher; for deaths due to fires it was 37.7 (11.6 to 121.9) times higher; and for deaths of undetermined intent it was 32.6 (15.8 to 67.2) times higher. CONCLUSIONS: Overall rates of death from injury and poisoning in children have fallen in England and Wales over the past 20 years, except for rates in children in families in which no adult is in paid employment. Serious inequalities in injury death rates remain, particularly for pedestrians, cyclists, house fires, and deaths of undetermined intent.
Adolescent↗
Are "accidental" gun deaths as rare as they seem? A comparison of medical examiner manner of death coding with an intent-based classification approach.
OBJECTIVES: Unintentional firearm death is often considered a nearly negligible proportion of overall gun death. These rates are based on medical examiner (ME) and coroner death classifications, which affect derived epidemiologic data and subsequent prevention measures. The aim of this study was to compare the proportion of pediatric unintentional gun deaths in Miami-Dade County based on manner of death coding by the ME with an intent-based classification of child gun deaths. METHODS: ME and police records for all pediatric firearm fatalities in Miami-Dade County from 1994 to 1998 were reviewed. The ME's assignment of manner of death as homicide, suicide, or accident was compared with an intent-based classification of intentional homicide, intentional suicide, and unintentional firearm death based on expressed or implied evidence of intent to harm. RESULTS: There were 123 pediatric firearm deaths in Miami-Dade County from 1994 to 1998. A significant difference between ME coding and the intent-based classification was found for homicide (94 vs 78) but not for suicide. A significant difference was also found between the ME's coding for "accident" and the investigator's classification of "unintentional" firearm death (4 vs 26). CONCLUSIONS: The incidence of unintentional pediatric firearm deaths is significantly underreported by the Miami-Dade County ME when the classification of "accidental" firearm death is used. Reviewing the manner of death classification criteria or establishing an intent code on official death documentation is recommended. Furthermore, clinicians should be aware that the true incidence of unintentional gun death may be higher than that reported as accidental.
Accidents↗
[Usefulness of the statistical bulletin of deaths to identify extrahospital deaths in the context of a myocardial infarction population registry].
INTRODUCTION AND AIMS: This paper aimed to study the usefulness of the Statistical Bulletin of Deaths (SBD) for identifying extrahospital deaths due to acute coronary ischaemia, and to determine the most efficient strategy in the selection of death causes that appear in the SBD, which are the most efficient for the identification. METHODS: Those extrahospital deaths, which, among the causes of death, recorded a diagnostic code indicating that they might have been caused by coronary ischaemia, were included. To study the usefulness of the death certificate we calculated the sensitivity and the positive predictive value of cardiac ischaemia. To determine the most efficient strategy for selecting causes of death we compared two selection strategies: the first, using only the basic cause of death; and the second using all the causes appearing in the SBD. RESULTS: Of the 395 SBD selected, 161 were classed as acute heart attacks. In those SBD in which cardiac ischaemic disease was given as the basic cause of death, we obtained a sensitivity of 82.6% (CI 95%: 75.9-88.1) and a positive predictive value of 72.7% (CI 95%: 65.6-79). The most efficient strategy in SBD selection proved to be the investigation of death certificates in which cardiac ischaemia appeared as one of all the causes of death, and death certificates in which the basic cause of death was coded as diabetes mellitus, essential arterial hypertension, hypertensive heart disease, cardiac dysrhythmia, and cardiac insufficiency. CONCLUSIONS: The information provided by death certificates for extrahospital deaths due to coronary ischaemia is reliable. A sensitive and efficient SBD selection strategy is proposed for the detection of cases.
Adult↗
Sudden death in the general population in Okinawa: incidence and causes of death.
Sudden unexpected death is generally considered to be caused by acute myocardial infarction and/or arrhythmia. To document the incidence and causes of sudden death in Japan, where the incidence of myocardial infarction is low, the present study examined death certificates, hospital records, the forensic medical records, and the police records of residents of the southern part of Okinawa island who died at the age of 20-74 years during a 3-year period from January 1, 1992 to December 31, 1994. Sudden death was defined as death within 24 h from the onset of unexpected symptoms. The study documented 126 (87 men and 39 women) sudden deaths. The crude incidence rate was 0.37/1,000 person per year (0.51 in men and 0.23 in women). According to the death certificates, 78 cases died of heart diseases. However, the cause of death could be determined by examination of all available records in only 64 cases: myocardial infarction in 10, non-ischemic heart diseases in 13, and stroke in 23 cases. Even when the analysis was limited to the cases who died within 1 h from the onset of symptoms, heart disease was the cause of death in only 22% of the cases while the cause of death could not be determined in 53% of the cases. Only 13% of those diagnosed as heart diseases on the death certificate were verified. The agreement rate between the diagnosis reached by the re-evaluation of the records and that on the death certificate was 82% for stroke and 33% for other diseases. In Okinawa, Japan, the frequencies of heart disease and stroke as the cause of sudden death may be similar. Except for stroke, the diagnosis appearing on the death certificate has substantial inaccuracy.
Adult↗
Pitfalls in the use of death certificates for assessing cause of death: a study of tonsil carcinoma patients.
A study was undertaken to determine the accuracy of underlying cause of death as stated on the death certificate for patients treated at Mallinckrodt Institute of Radiology (MIR) for carcinoma of the tonsil. The sample consisted of 110 patients who were treated between 1953 and 1976 and who subsequently died; all patients were seen by a physician within 3 months of their death. Death certificate cause of death was compared with the cause of death as stated in the MIR patient record. Death certificates detected 42.5% of the deaths due to tonsil carcinoma recorded in the hospital record, and detection was found to correlate with time between treatment and death. Of the deaths reported on the death certificate as due to tonsil carcinoma, 91% were confirmed by the hospital record to be correctly reported. Overall agreement in assignment of cause of death between the hospital record and the death certificate was 59%, and was significantly affected by stage of disease at diagnosis. This review underscores the low reliability of death certificates and raises a serious question concerning the use of this information for patients who are registered in clinical trials without additional documentation of tumor extent and cause of death.
Aged↗
A comparison of two cause-of-death classification systems for deaths among women of reproductive age in Menoufia, Egypt.
Mortality data ascertained from sources other than a death registration system can validate the accuracy of the system, but this information is rarely obtained. Data on 1979 deaths among reproductive age women were collected in the 1981-1983 Reproductive Age Mortality Survey (RAMOS) in the governorate of Menoufia, Egypt, and compared with data on these deaths as recorded by the Egyptian death registration system. Although the distribution of the causes of death were similar, there were substantial differences between classification systems for deaths due to particular causes. Over half of the deaths classified differently by the systems were those assigned to circulatory disease on the death certificate. In contrast, there was a high rate of agreement between systems in the classification of trauma deaths. About half (52.4%) of cancer deaths had the same site-specific cancer diagnosis assigned by RAMOS. The percentage of deaths assigned to maternal causes was three times higher in RAMOS (19.2%) than on death certificates (6.1%). Reported mortality rates for this often-preventable cause of death have been substantially underestimated in national death registration systems. Such underreporting masks the need for additional prenatal care and maternal health programmes.
Adolescent↗
Small-area variation in multiple causes of death in Sweden--a comparison with underlying causes of death.
BACKGROUND: The effect of using multiple causes of death, i.e. all causes of death mentioned on the death certificates, compared to using the underlying cause of death only for analyses of regional variation among small areas in mortality for asthma, diabetes, hypertensive disease and cerebrovascular disease was studied. METHODS: Standardized mortality ratios (SMR) were analysed for the different health administrative areas in Sweden using data from the Swedish cause of death register for the period 1987-1991. The SMR were calculated for each of the selected underlying causes of death as well as for multiple causes of death. The correlations between SMR for underlying and multiple causes were analysed. RESULTS: The highest level of correlation of the SMR between multiple and underlying causes of death was found for cerebrovascular disease (0.96) and the lowest for hypertensive disease in the age group 0-64 years (0.51). For hypertensive disease, diabetes and asthma, when using multiple causes of death some further areas were found to have high SMR and the level of significance was higher. Significantly high SMR using underlying causes of death were, however, not shown to be false when multiple causes of death were used. In the case of cerebrovascular disease little additional information was gained. CONCLUSION: By including multiple causes of death in small-area analysis more statistical outliers can be detected and the risk of false warning signals due to random effect can be limited. Analyses of underlying causes of death and multiple causes of death should preferably be combined.
Adolescent↗
A comparison of sisterhood information on causes of maternal death with the registration causes of maternal death in Matlab, Bangladesh.
BACKGROUND: To explore whether causes of maternal death can be investigated using the sisterhood method, an indirect method for providing a community-based estimate of the level of maternal mortality, this study compares the sisterhood causes of maternal death with the Matlab Demographic Surveillance System's (DSS) causes of maternal death. METHODS: Data for this study came from the Matlab DSS, which has been in operation since 1966 as a field site of the International Centre for Diarrhoeal Disease Research, Bangladesh. The maternal deaths that occurred during the 15-year period from 1976 to 1990 in the Matlab DSS area are the basis of this study. A sisterhood survey was conducted in Matlab in November and December 1991 to collect information on conditions, events and symptoms that preceded death. The collected information was evaluated to assign a most likely cause of maternal death. The sisterhood survey cause of maternal death was then compared with the DSS cause of maternal death. RESULTS: Cause of death could not be assigned with reasonable confidence for 34 (11%) of the 305 maternal deaths for which information was collected. For the remaining deaths, the agreement between the two classification systems was generally high for most cause-of-death categories considered. CONCLUSIONS: Though cause-of-death information obtained by the sisterhood method will always be subject to some error, it can provide an indication of an overall distribution of causes of maternal deaths. This data can be used for the planning of programmes aimed at reducing maternal mortality and for the evaluation of such programmes over time.
Abortion, Induced↗
Adverse mortality experience of a southwestern American Indian community: overall death rates and underlying causes of death in Pima Indians.
As part of an ongoing epidemiologic study, the death rate and causes of death during 1975 through 1984 were determined in Pima Indians who resided in the Gila River Indian Community (GRIC) in 1965 and later. Death certificates were available for 677 of the 681 deaths. In 78% of the deaths, the underlying cause recorded on the death certificate agreed with the cause determined after review of all available relevant records. The age- and sex-adjusted average annual death rate for the GRIC population (1639/100,000) was 1.9 times (95% CI 1.7-2.0) the 1980 rate for the U.S. all races (878/100,000). In Pima males, whose death rate was substantially higher than that of Pima females, the age-adjusted death rate was 2.3 times that in U.S. males, all races. Moreover among males 25-34 years of age, the Pima death rate was 6.6 times that for the U.S. all races. Diseases of the heart and malignant neoplasms caused 59% of U.S. deaths in 1980, but only 19% of GRIC deaths. By contrast, the age- and sex-adjusted mortality rate in the GRIC Pima was 5.9 times the rate of the U.S. all races for accidents, 6.5 times for cirrhosis, 7.4 times for homicide, 4.3 times for suicide, and 11.9 times for diabetes. Tuberculosis and coccidioidomycosis were important causes of death in the Pima, for whom infectious diseases was the tenth leading cause of death. The findings indicate that programs to improve the adverse mortality experience of the GRIC population should emphasize factors related to fatal accidents, alcoholic cirrhosis, homicide, suicide, diabetes mellitus, and infectious diseases. Young Pimas, especially the males, should be the primary focus of such preventive efforts. These findings and recommendations probably apply to many Native American populations.
Accidents↗
Validity of death certificates for injury-related causes of death.
Exploration of the validity of death certificate information for classifying underlying causes of death has historically focused on "natural" or disease-related causes of death. Current interest in injury-related deaths has emphasized the need for proper certification and coding of these deaths. In this study, the authors compared agreement of the underlying cause of death as determined from death certificate information with that determined from an independent review of all relevant medical and legal documents of death by a panel of physicians. The study sample included all deaths (n = 446) occurring over an approximately 18-year follow-up period (1965-1983) in a randomly selected cohort of 18,313 US Army Veterans of the Vietnam era. Using the physician panel as the "gold standard," sensitivity and specificity were 90% or greater for broad groupings of motor vehicle crash deaths (International Classification of Diseases, Ninth Revision (ICD-9), codes E810-E825), suicides (codes E950-E959), and homicides (codes E960-E969). Agreement for deaths from unintentional poisonings (codes E850-E869), mostly drug- and alcohol-related, was poor (sensitivity, 50 percent); in general, the ICD-9 drug- and alcohol-specific nomenclature is difficult to apply. The specificity and sensitivity for the individual three-digit suicide and homicide codes were all greater than 90%, and although the specificity for three-digit motor vehicle crash deaths was also above 90%, the sensitivity was lower, from 29% to 83%. Agreement on the fourth digit of ICD-9--for example, the role of the decedent in a motor vehicle crash death--was generally poor. The lack of descriptive information on death certificates to allow detailed coding was chiefly responsible for the poor agreement.
Adolescent↗
Mind your manners. Part I: History of death certification and manner of death classification.
Every death is unique, but deaths also share similar features that allow them to be grouped into categories. Since its initial description over 800 years ago, the position of coroner has been charged with the determination of manner of death. This determination has been made by examination into the circumstances surrounding death and of wounds on the surface of the body. Over the years, physicians have gained sufficient understanding of the body such that the autopsy became an important part of a death investigation. With additional time, laws were changed so that individuals charged with the determination of manner of death were required to have appropriate training. Death certification is the means by which deaths are grouped together according to similar characteristics. The practice of death certification has led to effective public health programs and the advancement of medical science. The addition of manner of death to the death certificate is an American contribution to vital statistics registration. The purpose of the autopsy report differs from that of the death certificate; the report fully addresses the unique aspects of a death, while the certificate captures the essence of the circumstances surrounding death in a few words.
Autopsy↗
Role of alcohol in unnatural deaths: a study of all deaths in Sweden.
BACKGROUND: Most previous research has concentrated on the role of alcohol in one type of unnatural death in a selected population, but the present objective was to investigate the role of alcohol in all unnatural deaths (autopsied and not autopsied). METHODS: All cases of unnatural death from 1992 through 1996 in Sweden were analyzed (n = 23,132). Death was attributed at least in part to alcohol if the deceased was a "known alcoholic"; if the underlying or contributing cause of death was alcohol-related; if the deceased had an alcohol-related inpatient diagnosis during the 3-year period prior to death; or if the deceased tested positive for blood alcohol. RESULTS: Just over 28% of the unnatural deaths could be associated with alcohol; the association with alcohol was more than twice as common in deaths of males (35%) as in females (16%). When only autopsied cases or only blood-tested cases were taken as the denominators, 38% and 44%, respectively, of the deaths were associated with alcohol. Alcohol involvement also was twice as common in intentional deaths (36%) as in unintentional deaths (18%). The intoxication group (78%) had the highest fraction of deaths that could be associated with alcohol, followed by the undetermined group (62%), homicide (49%), fire (41%), suicide (35%), asphyxia (29%), traffic (18%) and fall (9%) groups. In the 20- to 59-year age group, alcohol involvement was found in 51% of the males and 35% of the females (47% for males and females combined). CONCLUSIONS: The present estimates are conservative; alcohol involvement in unnatural deaths probably is even higher, up to 44% of the total. The present estimation is an important step in policy-making to lower the number of alcohol-related deaths in Sweden.
Accidents↗
[The quality of registration of causes of death in perinatal and neonatal deaths].
The quality of registration of the causes of death in 273 perinatal and neonatal deaths was assessed. The present authors classified the causes of death according to WHO classification of disease. The authors classification was compared with the Danish Health Department's original classification of deaths and a classification undertaken by one of the staff of the Danish Health Department, the coding of which was based exclusively on information from the original death certificates (death certificate classification). Agreement between the respective forms of classification was assessed by the observed agreement for positive diagnosis and the kappa coefficients calculated by the three-figure level in the ICD diagnosis for categories and between categories of causes of perinatal and neonatal death, respectively. The investigation revealed that the deaths were classified with great accuracy by coding by the staff member when the death certificates were correctly completed. Comparison between the "authors classification" and the "Danish Health Department's original classification" and the "death certificate classification", respectively revealed that the observed agreement for positive diagnoses were 52% and 50% and that the kappa coefficients were between 0.80-0.07 and 0.81-0.04, respectively, on comparison with the three-figure levels in the ICD diagnoses and 0.93-0.32 and 0.85 and 0.32 on comparing the categories in between. It is concluded that considerable improvement in registration of perinatal and neonatal deaths may be obtained if the Danish Health Departments states precisely what information is required on the death certificate in connection with perinatal and neonatal deaths. Correspondingly, local efforts should be made to complete death certificates more correctly.
Cause of Death↗
An increase in the number of deaths in the United States in the first week of the month--an association with substance abuse and other causes of death.
BACKGROUND AND METHODS: There are regular changes in mortality rates, such as increased rates of death from influenza in the winter and from motor vehicle accidents on long holiday weekends. Previous research has shown that among persons with schizophrenia, the rates of cocaine use and hospital admissions increase at the beginning of the month, after the receipt of disability payments. Using computerized data from all death certificates in the United States between 1973 and 1988, we compared the number of deaths in the first week of the month with the number of deaths in the last week of the preceding month. RESULTS: The average number of deaths was about 5500 per day, or about 165,000 in a 30-day month. There were 100.9 deaths (95 percent confidence interval, 100.8 to 101.0) in the first week of the month for every 100 deaths in the last week of the preceding month. This was equivalent to about 4320 more deaths in the first week of each month than in the last week of the preceding month in an average year. Between 1983 and 1988, for deaths involving substance abuse and an external cause (such as suicides, accidents, and homicides), there were 114.2 deaths (95 percent confidence interval, 110.5 to 117.9) in the first week of the month for every 100 in the last week of the preceding month. There were significant increases in the number of deaths in the first week of the month for many causes of death, including substance abuse, natural causes, homicides, suicides, and motor vehicle accidents. CONCLUSIONS: In the United States, the number of deaths is higher in the first week of the month than in the last week of the preceding month. The increase at the beginning of the month is associated with substance abuse and other causes of death.
Aged↗
A review of maternal deaths in South Africa during 1998. National Committee on Confidential Enquiries into Maternal Deaths.
OBJECTIVE: To document the prevalence and causes of maternal mortality and to identify avoidable factors, missed opportunities and substandard care related to these deaths. METHOD: Maternal deaths are notifiable; when a maternal death occurs a maternal death notification form is filled in and sent to the provincial Maternal, Child and Women's Health (MCWH) units. Provincial assessors assess the death and submit a report. This report is forwarded to the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD), where the data are collated and the prevalence, pattern of disease, avoidable factors, missed opportunities and substandard care pertaining to maternal deaths are described. RESULTS: Data were collected on the maternal deaths occurring during 1998 in South Africa. Collection of data on maternal deaths was incomplete and a maternal mortality ratio could not be calculated. However, a clear pattern of disease and problems in patient care emerged. The 'big five' causes of death were complications of hypertensive conditions in pregnancy, AIDS, obstetric haemorrhage, pregnancy-related sepsis and pre-existing medical conditions. Women aged 30 years and older were at greater risk of dying than younger women. Women in their first pregnancy or who had had 5 or more pregnancies were also at greater risk. Obstetric haemorrhage was the most common cause of death at level 1 hospitals, AIDS at level 2 hospitals and hypertensive diseases at level 3 hospitals. The vast majority of anaesthetic-related deaths occurred at level 1 hospitals. Non-attendance and delayed attendance at the health institutions were the most common patient-orientated problems. Poor transport facilities and lack of intensive care facilities were the major administrative problems. Problems in the care of women occurred in more than half the cases of maternal death, the majority at the primary level of care. Poor initial assessment and diagnosis of cases, especially at secondary level of care, failure to follow standard protocols at primary and secondary levels, and poor monitoring of patients at all levels of care were the common health worker-related problems. CONCLUSION: Ten key recommendations based on this information have been made by the NCCEMD; if implemented these will result in a reduction of maternal deaths.
Acquired Immunodeficiency Syndrome↗
Anti-IgM antibody-induced cell death in a human B lymphoma cell line, B104, represents a novel programmed cell death.
We investigated the mechanisms of anti-IgM antibody-induced cell death in a recently established human surface IgM+ IgD+ B lymphoma cell line, B104, the growth of which is irreversibly inhibited by anti-IgM antibody but not by anti-IgD antibody, and compared it with the cell death of T cells via TCR/CD3 complex and with the cell death of a murine anti-IgM antibody-sensitive B lymphoma cell line, WEHI-231. The rapid time course of B104 cell death and its requirements for de novo macromolecular synthesis and Ca2+ influx suggest that anti-IgM antibody-induced B104 cell death is an active Ca(2+)-dependent programmed cell death. Moreover, cyclosporin A rescued B104 cells from this lethal signal, via surface IgM, suggesting that the intracellular mechanisms involved are quite similar to those of T cell death. DNA fragmentation, which has been reported in TCR/CD3 complex-mediated T cell death, apoptosis, was not involved in the B104 cell death process, but the possible involvement of DNA single-strand breaks was suggested. Observations under light microscopy and transmission electron microscopy indicated that the morphologic features of dying B104 cells resembled necrosis rather than apoptosis. B104 cell death was shown to be quite distinct from that of WEHI-231 in cell death kinetics, the mode of cell death, and the response to cyclosporin A. These data collectively indicate that the death of B104 cells resulting from surface IgM cross-linking represents a hitherto undefined mode of programmed cell death.
Antibodies, Anti-Idiotypic↗