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Defining death: there ought to be a law.
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Defining death in theory and practice.
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How does your state define death?
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Minnesota "brain death" legislation: a step forward...or backward? II. Defining "brain death".
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Enhanced surveillance for pregnancy-associated mortality--Maryland, 1993-1998.
CONTEXT: Deaths occurring among women who are pregnant or who have had a recent pregnancy have a devastating impact on the family and community. It is important to understand the magnitude and causes of pregnancy-associated mortality so that comprehensive strategies can be formulated to prevent such deaths. OBJECTIVE: To ascertain the number and causes of pregnancy-associated deaths using enhanced surveillance techniques. DESIGN, SETTING, AND SUBJECTS: Retrospective, cross-sectional analysis of death certificate data of reproductive-age women, live birth and fetal death records, and medical examiner records in Maryland during 1993-1998. MAIN OUTCOME MEASURE: Number of pregnancy-associated deaths, defined as death from any cause during pregnancy or within 1 year of delivery or pregnancy termination, by source of data and cause of death. RESULTS: A total of 247 pregnancy-associated deaths were ascertained. Twenty-seven percent (n = 67) were identified through cause-of-death information obtained from death certificates, 70% (n = 174) through linkage of death records with birth and fetal death records, and 47% (n = 116) through review of medical examiner records. Homicide was the leading cause of pregnancy-associated death (n = 50; 20%), and cardiovascular disorders were the second-leading cause (n = 48; 19%). CONCLUSIONS: In this Maryland sample, comprehensive identification of pregnancy-associated deaths was accomplished only after collecting information from multiple sources and including all deaths occurring up to 1 year after delivery or pregnancy termination. This enhanced pregnancy mortality surveillance led to the disturbing finding that a pregnant or recently pregnant woman is more likely to be a victim of homicide than to die of any other cause. By broadening pregnancy mortality to include all possible causes, previously neglected factors may assume increased importance in prenatal and postpartum care.
The results of treatment of epithelial ovarian cancer after centralisation of primary surgery. Results from North Jutland, Denmark.
OBJECTIVE: The study was performed to evaluate the results of treatment of ovarian carcinoma after the introduction of centralised primary surgery in the County of North Jutland, Denmark. METHOD: Prospective study of consecutive cases of ovarian cancer undergoing primary surgical treatment at the Gynecologic Oncologic Center after the introduction of centralised primary surgery. Results of treatment recorded up to the date of last examination or death. RESULTS: From 1999 to 2002, 107 patients with primary epithelial ovarian cancer underwent primary surgery at the Gynecologic Oncologic Center, Aalborg. This corresponds to 95.5% of patients with invasive carcinoma in the County of North Jutland. All patients with Stage I to Stage IIIB disease had a complete, macroscopically radical cytoreduction performed. In patients with Stage III and IV invasive tumors, the optimal debulking rate was 79.5%, and, in Stage IIIC and IV, the optimal debulking rate was 78.2%. Intra-operative and post-operative complications were generally few. Post-operative death, defined as death within 30 days after surgery, was observed in 4 cases (3.7%). After primary surgery, platinum-based chemotherapy was given in most cases. For Stage I to IV invasive cancer, the median survival was 46 months. In patients with Stage IIIC and IV disease, the median survival was 32 months. In optimally debulked Stage IIIC and IV disease, the median survival was 41 months. CONCLUSIONS: The results indicate a survival benefit after introduction of centralised primary surgery. Compared to existing national and regional data on survival in ovarian cancer, the results indicate an increase in median survival for all stages of approximately 15 months. Centralisation of primary surgery to centres with the necessary expertise may be the most significant way to increase survival in ovarian cancer in Denmark.
Use of left ventricular ejection fraction or wall-motion score index in predicting arrhythmic death in patients following an acute myocardial infarction. The TRACE Study Group.
All-cause mortality and morbidity following an acute myocardial infarction (AMI) are correlated to LV systolic dysfunction. The correlation is closest with mortality and morbidity associated with congestive heart failure (CHF). Prediction of arrhythmic death in patients with AMI relies on the correlation between arrhythmic death and "sudden unexpected death" defined as death within 1 hour of onset of new symptoms. Assessment of late potentials, heart rate variability (HRV), T wave alternans, arrhythmias seen on Holter monitoring or during exercise testing, electrophysiological testing, and baroreceptor assessment have all proven to be useful in the prediction of sudden death even when LV systolic function is known. In selected populations HRV is superior to LV systolic function assessment in predicting sudden death and/or arrhythmic events, and may even predict all-cause mortality with the same precision. Comparisons of other methods with LV function assessment should be interpreted with care because most methods have been evaluated in subgroups of infarct patients with a low risk of death. Results from a large series of high risk patients with AMI (the TRAndolapril Cardiac Evaluation study) have shown that even in patients with severe depressed LV systolic function around one-third of the patients will die suddenly. The current situation is that LV function appears to be the best method of predicting death whereas other methods appear very promising for detecting arrhythmic death in more selected populations. The optimal method for selecting patients at high risk of arrhythmic death has not yet been developed, but a combination of LV function and another method, i.e., HRV, appears promising. This may ensure that the enrolled patients have an increased risk of death and that this risk will be due to arrhythmic events. Patients with LVEF of 10% or less can be excluded as they will most likely not die suddenly.
Improved survival from fungaemia in patients with haematological malignancies: analysis of risk factors for death and usefulness of early antifungal therapy.
Fourty-three episodes of fungaemia encountered from 1978 to 1991 in 43 patients with haematological malignancies are reviewed here to analyse the risk factors for death and to evaluate the efficacy of early antifungal therapy. Low serum cholinesterase and elevated serum blood urea nitrogen were significantly associated with fungaemic death, defined as death occurring within 2 weeks after documentation of fungaemia. Overall death rate from fungaemia was 62.8%. Before the introduction of early antifungal therapy in 1986, however, fungaemic mortality was 85.7%; it was reduced to 51.7% thereafter (p = 0.01). Determination of plasma (1-->3)-beta-D-glucan was helpful in detecting deep fungal infections and initiating antifungal therapy early.
Sudden and unexpected death due to hemorrhage from occult central nervous system lesions. A pediatric autopsy study.
A retrospective review of the Department of Histopathology files at the Adelaide Children's Hospital was conducted to examine all cases where sudden death (defined as death occurring within 24 h of sudden collapse and unconsciousness in a previously apparently well child) was attributable to hemorrhage from an occult central nervous system lesion. Ten cases were found with significant hemorrhage and associated cerebral edema. The diagnoses were cerebral arteriovenous malformation (1), probable cerebellar vascular malformation (4), berry aneurysm of middle cerebral artery (1), cerebellar medulloblastoma (1), optic chiasm astrocytoma (1), pineal gland teratoma (1), and fourth ventricle ependymoma (1). These cases demonstrate the wide range and variable location of intracranial lesions capable of causing sudden death in children. Careful examination of the brain in all cases of sudden pediatric death is essential so that intracranial lesions causing unexpected death will be adequately characterized.
Perioperative deaths: a further comparative review of coroner's autopsies with particular reference to the occurrence of fatal iatrogenic injury.
INTRODUCTION: In previous triennial reviews of Coroner's perioperative autopsies conducted during the periods 1989 to 1991 and 1992 to 1994, it was observed that the necropsy incidence of such deaths rose from 2% to 2.6% (P < 0.05). Concurrently, the rate of iatrogenic deaths had nearly doubled from 15.2% to 28.8% (P < 0.02). These findings spurred a review of the subsequent triennium (1995 to 1997), in order to monitor the apparent rise in these trends and to study the frequency and occurrence of iatrogenic deaths in relation to the number of invasive procedures performed, as well as during emergency and elective procedures. MATERIALS AND METHODS: A retrospective (descriptive and comparative) study, comprising a clinico-pathological review of a series of 270 perioperative deaths (defined as deaths occurring during or after invasive therapeutic or diagnostic procedures, up to a week after discharge, and excluding cases of major trauma from suicides, homicides, as well as road and industrial accidents) reported to the Coroner, for which autopsies were conducted at the Department of Forensic Medicine from 1995 to 1997. RESULTS: The necropsy incidence of 4.4% (270/6074) represented a significant rise over the previous triennia (P < 0.01). As in previous years, there was a predominance of males (M:F = 1.65:1) and middle-aged to elderly patients (range 0 to 92 years, mean 55.8 years, median 63 years), most of whom had died after a variable, but usually brief, postoperative interval [0 to 97, 4.2, 1 day(s)] and a more variable period of hospitalisation (< 1 to 289, 12.6, 7 days). A total of 408 invasive procedures were performed, amounting to an average of 1.5 per patient; 101 patients (37.4%) underwent multiple (> 1) interventions, which were initially classified as elective procedures in 27 cases. There were 66 (24.4%) iatrogenic deaths, of which 2 (0.7%) were due to anaesthetic mishaps; 18/64 iatrogenic deaths, unrelated to anaesthesia, occurred after the first postoperative day. The proportions of such deaths amongst patients subjected to multiple interventions, or initial elective procedures, were more than twice as high as amongst those undergoing single procedures, and those initially classified as emergencies (35.6% versus 16.6% and 33.3% versus 13.2%, respectively; P < 0.01). Only 51/66 (77.3%) iatrogenic deaths received Coroner's verdicts of misadventure; no verdict of criminal negligence was recorded during the period in question. CONCLUSIONS: There appears to have been a steady increase in the number of perioperative deaths reported to the Coroner over the previous triennia (1989 to 1997) for which autopsies were conducted. While this observation may not denote an increase in perioperative morality rates per se, it may be indicative of an increasingly "aggressive" or defensive approach to the clinical management of seriously ill patients, particularly over the past decade. Although the rate of iatrogenic deaths appears to have stabilised, it is too early to say whether this apparent trend will persist in the future. It is perhaps not surprising that the risk of iatrogenic injury appears to increase with the number of interventions performed; however, it is not clear why initial, supposedly elective, interventions should be associated with an apparently greater risk of iatrogenic injury than those classified as emergency procedures. The substantial divergence between the autopsy finding of an iatrogenic death and the corresponding Coroner's verdict of misadventure may be comforting to clinicians, but certainly warrants further examination.
Differences in operative mortality between high- and low-volume hospitals in Ontario for 5 major surgical procedures: estimating the number of lives potentially saved through regionalization.
BACKGROUND: Previous research has shown that persons undergoing certain high-risk surgical procedures at high-volume hospitals (HVHs) have a lower risk of postoperative death than those undergoing surgery at low-volume hospitals (LVHs). We estimated the absolute number of operative deaths that could potentially be avoided if 5 major surgical procedures in Ontario were restricted to HVHs. METHODS: We collected data on all persons who underwent esophagectomy (613), colon or rectal resection for colorectal cancer (18 898), pancreaticoduodenectomy (686), pulmonary lobectomy or pneumonectomy for lung cancer (5156) or repair of an unruptured abdominal aortic aneurysm (AAA) (6279) in Ontario from Apr. 1, 1994, to Mar. 31, 1999. We calculated the excess number of operative deaths (defined as deaths in the period from the day of the operation to 30 days thereafter), adjusted for age, sex and comorbidity, among the 75% of persons treated in LVHs, as compared with the 25% treated in the highest-volume quartile of hospitals. Bootstrap methods were used to estimate 95% confidence intervals (CIs). RESULTS: Of the 31 632 persons undergoing any of the 5 procedures, 1341 (4.24%) died within 30 days of surgery. If the 75% of persons treated at the LVHs had instead been treated at the HVHs, the annual number of lives potentially saved would have been 4 (95% CI, 0 to 9) for esophagectomy, 6 (95% CI, 1 to 11) for pancreaticoduodenectomy, 1 (95% CI, -10 to 13) for major lung resection and 14 (95% CI, 1 to 25) for repair of unruptured AAA. For resection of colon or rectum, the regionalization strategy would not have saved any lives, and 17 lives (95% CI, 36 to -3) would potentially have been lost. INTERPRETATION: A small number of operative deaths are potentially avoidable by performing 4 of 5 complex surgical procedures only at HVHs in Ontario. In determining health policy, the most compelling argument for regionalizing complex surgical procedures at HVHs may not be the prevention of a large number of such deaths.
'Local recurrence' and 'disease-free survival'. Doubtful parameters when comparing non-randomized studies of prostate cancer.
We reviewed recent literature on studies with external radiation of prostatectomy for localized prostate cancer considering the definitions of 'local recurrence' and 'disease-free survival' and the reporting of patients lost to follow-up. Among studies evaluating external radiation, 5/71 (29%) mention that prostate biopsy is used for some patients in determining local recurrence, versus 6/11 (55%) for prostatectomy. Several studies, 15/28 (54%), present figures for disease-free survival without giving a definition of the parameter. In the majority of the reports no comments are made relative to patients lost to follow-up. Three authors consider patients lost to follow-up as dead with disease. Considerations regarding 'local recurrence' and 'disease-free survival' warrant caution in the interpretation of data based on such parameters. In a comparison of non-randomized studies of localized prostate cancer, cancer-specific survival with prostate cancer death defined as 'death wtih diagnosed distant metastases' may be a robust parameter.
Radiation death from cardiovascular shock following a criticality accident. Report of a second death from a newly defined human radiation death syndrome.
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Defining cause of death in stroke patients: The Brain Attack Surveillance in Corpus Christi Project.
Stroke mortality is an important national health statistic and represents a frequent endpoint for epidemiologic studies. Several methods have been used to determine cause of death after stroke, but their agreement and reliability are unknown. Two hundred consecutive deaths of transient ischemic attack or ischemic stroke patients were identified (January 2000-September 2001) from an ongoing population-based stroke surveillance study in Texas, The Brain Attack Surveillance in Corpus Christi Project. Two neurologists independently recorded the cause of death based on two methods: 1) determining the underlying cause of death as defined by the World Health Organization, and 2) determining whether the death was stroke related. Kappa statistics with 95% confidence intervals were calculated by comparing agreement between methods within reviewers and between reviewers within methods. Agreement between the two cause-of-death-determination methods for each neurologist was 0.41 (95% confidence interval (CI): 0.31, 0.51) and 0.47 (95% CI: 0.38, 0.58), respectively. Agreement between neurologists for the underlying-cause-of-death method was 0.46 (95% CI: 0.32, 0.60); for the stroke-related method, it was 0.63 (95% CI: 0.52, 0.75). Accurate, reliable determinations of cause of death after stroke/transient ischemic attack are not currently feasible. More research is needed to identify a reliable process for coding cause of death from stroke.
Death as defined by Hinduism.
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Comparison of surveillance vs Aortic Endografting for Small Aneurysm Repair (CAESAR) trial: study design and progress.
OBJECTIVE: The CAESAR Trial aims to assess the outcome of endovascular repair (EVAR) vs surveillance of small abdominal aortic aneurysms (AAA) with maximum diameter of 4.1-5.4 cm on computerised tomography (CT) scan. DESIGN: Patients between 50 and 80 years of age, with small AAA, anatomically suitable for EVAR, are randomly allocated to early EVAR or surveillance. The primary outcome measure is survival. Secondary endpoints include: aneurysm-related deaths (defined as any death caused directly or indirectly by rupture or endovascular/open aneurysm repair), AAA rupture, peri-operative or late complications, conversion to open repair, complications associated with delayed treatment including loss of treatment options, AAA growth rates and quality of life. Target recruitment is 740 patients to show that early EVAR is associated with a 15% survival benefit at 54 months. PROGRESS: Randomization started in September 2004. By the end of April 2005, 86 patients had been enrolled by 10 active European centres. Completion of recruitment is expected for September 2006 and publication of the results in mid 2007.
Maternal mortality associated with tuberculosis-HIV-1 co-infection in Durban, South Africa.
OBJECTIVES: To document the impact of tuberculosis and HIV-1 on maternal mortality. DESIGN: Prospective study, 1997 and 1998; retrospective analysis, 1996. PARTICIPANTS: Known maternal deaths, defined as the death of a mother within a year post-delivery, were studied in Durban, KwaZulu Natal. The HIV-1 status, presence of tuberculosis, maternal clinical features and perinatal outcomes were documented. The overall as well as HIV-1 and tuberculosis-specific maternal mortality rates for the hospital were calculated. The attributable fraction of deaths as a result of HIV-1 was calculated in the overall group and in those with tuberculosis co-infection. RESULTS: A total of 50 518 deliveries and 101 maternal deaths were recorded. Of the deaths, 29.7% (30/101) were HIV-1 infected. The overall mortality rate was 200/100 000; for HIV-1-infected women this was 323.3/100 000, HIV-1-negative mothers, 148.6/100 000 live births. The attributable fraction of overall deaths as a result of HIV-1 was 15.9% Fourteen of the 15 mothers with tuberculosis were HIV-1 co-infected. The mortality rate for tuberculosis and HIV-1 co-infection was 121.7/1000; for tuberculosis without HIV-1 co-infection, 38.5/1000. Fifty-four per cent of maternal deaths caused by tuberculosis were attributable to HIV-1 infection. Thirty-five per cent of maternal deaths were associated with stillbirths; perinatal outcomes were no different between groups of mothers with tuberculosis, HIV-1 or neither infection. CONCLUSION: Tuberculosis and HIV-1 are emerging as significant contributors to maternal mortality in KwaZulu Natal. Any attempt to improve maternal health must also include careful screening and investigation for tuberculosis in high-risk pregnant women.