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For most people with chronic diseases such as epilepsy, thorough knowledge of the disease is important in order to reduce feelings of insecurity and to enable better management of everyday life. Whether and when to inform patients and their families about all the risks associated with epilepsy is a matter of controversy. Using a web-based survey, patients with epilepsy (PWE) (n=1183) and carers, family members, or guardians of PWE, who could either answer on behalf of the patients (CBP) (n=676) or on their own behalf (CAR) (n=231) were asked whether they wanted information about the risk of epilepsy-related injuries and premature death and also whether they had received such information. Ninety percent or more of PWE, CBP, and CAR reported that they wanted such information, and 50% of CAR, 81% of CBP, and 70% of PWE had received some information about seizure-related injuries. Regarding risk of unexpected death, 31% of PWE, 35% of CBP, and 28% of CAR had received information on this issue. Those with tonic-clonic seizures were most eager to obtain information on these matters, and those best informed about epilepsy-related risks were males and the youngest part of the cohort. The wish for more information or the likelihood of having already received information was independent of the individual's seizure situation. This study demonstrates that there is a considerable gap between what the patients want regarding information and what they are actually given by healthcare providers.

Sudden unexpected death in epilepsy (SUDEP) in children, although rare, needs critical attention given the tragic nature and devastating consequences for families and caregivers. True incidence is unknown and risk factors are not completely understood, more so in children compared with adults. A focused narrative review of available studies on paediatric SUDEP was undertaken to comprehend its risk factors and to develop strategies to recognise and where possible modify SUDEP risk and ultimately reduce incidence. We reviewed 16 population-based studies from various settings. We found overlapping risk factors from different studies. The prime risk factor is uncontrolled seizures. This review supports the view that children entering adolescence with optimal seizure control could be a key aspect in reducing adult mortality related to SUDEP. Ideally, clinicians would want to be able to predict prospective, individualised SUDEP risk, which is challenging due to a myriad of risk factors and an inherent non-homogeneous paediatric epilepsy population. Nevertheless, an adequate evidence base exists as evidenced by this review to support information giving and communication to support young people with epilepsy and their families in being active partners in recognising and reducing their SUDEP risk. More work particularly in the form of prospective studies and registries are needed to further clarify true incidence which may have been previously underestimated and to update risk factors.

Objective We report on patient-specific durations of postictal periods in long-term intracranial electroencephalography (iEEG) recordings. The objective was to investigate the relationship between seizure duration and postictal suppression duration. Methods Long-term recording iEEG from 9 patients (>50 seizures recorded) were analyzed. In total, 2310 seizures were recorded during a total of 13.8 years of recording. Postictal suppression duration was calculated as the duration after seizure termination until total signal energy returned to background levels. The relationship between seizure duration and postictal suppression duration was quantified using the correlation coefficient (r). The effects of populations of seizures within patients, on correlations, were also considered. Populations of seizures within patients were distinguished by seizure duration thresholds and k-means clustering along the dimensions of seizure duration and postictal suppression duration. The effects of bursts of seizures were also considered by defining populations based on interseizure interval (ISI). Results Seizure duration accounted for 40% of postictal suppression duration variance, aggregated across all patients and seizures. Seizure duration accounted for more than 25% of the variance in postictal suppression duration in 2 patients and accounted for less than 25% in the remaining 7. In 3 patients, heat maps showed multiple distinct postictal patterns indicating multiple populations of seizures. When accounting for these populations, seizure duration accounted for less than 25% of the variance in postictal duration in all populations. Variance in postictal suppression duration accounted for less than 10% of ISI variance in all patients. Significance We have previously demonstrated that some patients have multiple seizure populations distinguishable by seizure duration. This article shows that different seizure populations have distinct and consistent postictal behaviors. The existence of multiple populations in some patients has implications for seizure management and forecasting, whereas the distinct postictal behaviors may have implications for sudden unexpected death in epilepsy (SUDEP) prediction and prevention.

Greenspace has been increasingly recognized as having numerous health benefits. However, its effects are unknown concerning sudden unexpected death (SUD), commonly referred to as sudden cardiac death, which constitutes a large proportion of mortality in the United States. Because greenspace can promote physical activity, reduce stress and buffer air pollutants, it may have beneficial effects for people at risk of SUD, such as those with heart disease, hypertension, and diabetes mellitus. Using several spatial techniques, this study explored the relationship between SUD and greenspace. We adjudicated 396 SUD cases that occurred from March 2013 to February 2015 among reports from emergency medical services (EMS) that attended out-of-hospital deaths in Wake County (central North Carolina, USA). We measured multiple greenspace metrics in each census tract, including the percentages of forest, grassland, average tree canopy, tree canopy diversity, near-road tree canopy and greenway density. The associations between SUD incidence and these greenspace metrics were examined using Poisson regression (non-spatial) and Bayesian spatial models. The results from both models indicated that SUD incidence was inversely associated with both greenway density (adjusted risk ratio [RR] = 0.82, 95% credible/ confidence interval [CI]: 0.69–0.97) and the percentage of forest (adjusted RR = 0.90, 95% CI: 0.81–0.99). These results suggest that increases in greenway density by 1 km/km2 and in forest by 10% were associated with a decrease in SUD risk of 18% and 10%, respectively. The inverse relationship was not observed between SUD incidence and other metrics, including grassland, average tree canopy, near-road tree canopy and tree canopy diversity. This study implies that greenspace, specifically greenways and forest, may have beneficial effects for people at risk of SUD. Further studies are needed to investigate potential causal relationships between greenspace and SUD, and potential mechanisms such as promoting physical activity and reducing stress. Keywords: Green space, Eco-health, Ecosystem services, GIS, Bayesian spatial model

Despite advances in the diagnosis and treatment of congenital heart defects (CHDs), these defects are still an important cause of sudden, unexpected death in young children. This retrospective study identified 64 cases of CHDs presenting as a cause of sudden, unexpected death in a busy, urban Medical Examiner's Office pediatric population between 2006 and 2016. The majority of cases (52 of 64, 81%) were infants. Interestingly, 52% of cases were undiagnosed prior to autopsy. Ventricular septal defects and atrioventricular septal defects were the most common simple (14%) and complex (17%) malformations observed, respectively. In many cases, there were coexistent simple and/or complex defects. Most of the cases diagnosed with CHD prior to autopsy (48%) had undergone some type of surgical repair. This study highlights the importance of considering undiagnosed CHDs as a cause of sudden, unexpected death, particularly in young children.

Background Rapid response systems have been implemented with the aim of preventing patient deterioration, in-hospital cardiac arrests (IHCA) and related deaths. Not all 'unexpected deaths' are preventable, thus compromising the use of unexpected deaths as an outcome measure. Aims To assess temporal trends in potentially preventable deaths as a subset of total unexpected death rates over a 4-year period. Methods A single centre, cohort study of all unexpected deaths between 1 January 2010 and 31 December 2013. Unexpected deaths were identified from the rapid response systems database and patients' case histories were reviewed to reclassify the deaths into one of three categories: potentially preventable: if earlier MET activation may have prevented death; missed not for resuscitation opportunity; and not preventable. Total bed days were obtained from the hospital's patient administration system. Results The rate of potentially preventable deaths decreased from 5.3 to 0.7 per 100 000 bed days (incident rate ratio (IRR) 0.53 (95% CI 0.31-0.90), P = 0.02). The rate of total unexpected deaths was unchanged (IRR 0.96 (0.80-1.16), P = 0.70), as were the rates of non-preventable deaths (IRR 1.06 (0.78-1.42), P = 0.72) and missed NFR deaths (IRR 1.1 (0.83-1.42), P = 0.56). Conclusion The rate of potentially preventable deaths has decreased by 47% per year over a 4-year period without any change in the overall rate of unexpected deaths. Distinguishing between potentially preventable deaths in contrast to total unexpected deaths enables more targeted evaluation of rapid response systems.

Sudden Unexpected Death in Epilepsy (SUDEP) is a significant cause of death for people with chronic epilepsy. Good practice guidance in the UK and the USA expect SUDEP to be discussed with the individual. The event rarity, methodological variance and lack of robust research into the pathological mechanisms, associated risk factors, and management strategies have created a challenge on how and what to discuss. There are some significant associations which allows for risk assessment and mitigation. Areas covered: The current understanding of static and modifiable risk factors for SUDEP and how to manage these more effectively are reviewed. Longitudinal risk may be assessed using standardised risk assessment tools which help in communicating risk. Technological advancement allows measurement of physiological parameters associated with seizures and risk of SUDEP using small wearable devices. Further evidence is needed to demonstrate such technologies are efficacious and safe. Expert commentary: Risk reduction should be an important part of epilepsy management and we suggest a Gold Standard of Care which healthcare professionals and services should aim for when approaching SUDEP risk management. A Minimum Standard of Care is also proposed that is practical to implement, that all people with epilepsy should expect to receive.

Although overweight and obesity are established risk factors for some types of heart disease including ischemic heart disease, heart failure and atrial fibrillation, less is known about the association between adiposity and sudden cardiac death. We conducted a systematic review and meta-analysis of prospective studies to clarify the association between adiposity and risk of sudden cardiac death. PubMed and Embase databases were searched up to July 20th 2017. Summary relative risks (RRs) and 95% confidence intervals (CIs) were calculated using random effects models. The summary RR was 1.16 (95% CI 1.05–1.28, I2 = 68%, n = 14) per 5 unit increment in BMI, and 1.82 (95% CI 1.61–2.07, I2 = 0%, n = 3) per 0.1 unit increase in waist-to-hip ratio, and 1.03 (95% CI 0.93–1.15, I2 = 0%, n = 2) per 10 cm increase in waist circumference. The heterogeneity in the analysis of BMI and sudden cardiac death persisted across most subgroup analyses. The association was stronger among studies with longer follow-up compared to short follow-up and was observed in the European and American studies, but not in the Asian studies. There was a J-shaped association between BMI and sudden cardiac death and the lowest risk was observed in the normal weight range, however, the increased risk with a low BMI was attenuated among studies with a longer duration of follow-up. This meta-analysis suggest an increased risk of sudden cardiac death with increasing BMI and waist-to-hip ratio, however, further studies with stratification for smoking status are needed of waist circumference, weight changes and adiposity at younger ages. Electronic supplementary material The online version of this article (10.1007/s10654-017-0353-9) contains supplementary material, which is available to authorized users.

Objective: to understand the coping strategies nurses use to cope with unexpected death in pediatrics. Methods: qualitative research involving six nursing professionals working in pediatric emergency and intensive care services. Content analysis was performed. Results: two groups of categories emerged from the data describing coping processes: strategies focused on assessing the situation in which the professionals try, through rational processes, to understand and accept the unexpected death; strategies focused on emotional management, in which the suffering resulting from the confrontation coping with the unexpected death is acknowledged, seeking strategies to better manage the event. Conclusion: the professionals suffer and seek coping mechanisms to manage the process of mourning over the unexpected death of a child/adolescent. Objetivo: compreender as estratégias de confronto utilizadas pelos enfermeiros para lidar com a morte inesperada em pediatria. Métodos: pesquisa qualitativa com seis profissionais de enfermagem que trabalham em serviços de urgência e cuidados intensivos pediátricos. Procedeu-se a analise de conteúdo. Resultados: dos dados emergiram dois grupos: Estratégias centradas na avaliação da situação em que os profissionais tentam, através de processos racionais, compreender e aceitar a morte inesperada; estratégias centradas na gestão emocional, em que é reconhecido o sofrimento resultante do confronto com a morte inesperada, procurando estratégias de melhor gestão desse confronto. Conclusão: os profissionais sofrem e procuram mecanismos de confronto para gerir o processo de luto com a morte inesperada de criança/adolescente. info:eu-repo/semantics/publishedVersion

Objective: A traumatic event has a negative impact on the psychological well-being of adolescents, the purpose of our study is to assess the post-traumatic stress disorder PTSD in adolescents in public schools of the prefecture of Sale in Morocco, to evaluate comorbid disorders and thus to study the effect of PTSD on their social and academic life. Method and measures: 871 school adolescents who completed the objectives of the study, their age varied between 12 and 17 years and they completed by themselves the questionnaires concerning socio-demographic data, a list of life events, the CPTS-RI (Children’s Post Traumatic Stress Reaction Index) for assessing the symptoms of PTSD, STAIY (State Trait Inventory Anxiety) and CDI (Children Depression Inventory). Results: A large proportion of post-traumatic stress disorder was found in students with 63.9% but with different levels (19.5% PTSD low, 25.1% PTSD moderate, 18.1% PTSD severe and only 1.2% PTSD very severe). 84.4% of students are anxious and 55.2% of students have depression. Adolescents who have been exposed to at least one traumatic event in their lifetime have 88.69%. In the event, the main traumatic condition that caused the post-traumatic stress disorder was the sudden and unexpected death of a loved one with 27.7%. PTSD, anxiety and depression have a negative effect on students’ school life; therefore, 72.5% of students have poor grades. Conclusion: A traumatic event can develop at a PTSD. There is a high rate of post-traumatic stress disorder and students are in school deficit. There are practical implications for the support and care provided to these adolescents.

A few days ago, the unexpected death of Carlos Echarri moved communities of scholars in both the Mexican and the international population. Carlos Echarri was a research fellow at the Center for Demographic, Urban and Environmental Studies of El Colegio de Mexico, an institution where he held the position of coordinator of the Master’s Degree Program in Demography and the Doctoral Program in Population Studies. He also coordinated the Reproductive Health and Society Program. In his many roles at El Colegio de Mexico. In December 2018, he was appointed director of the National Population Council. Despite his short time at the Council, Carlos Echarri left an unquestionable mark, and was portrayed as an “exemplary official who promoted several initiatives for the benefit of citizens, and the agenda of Human Rights and freedoms in population policies”.

Venous thromboembolism is a condition that includes both deep vein thrombosis and pulmonary thromboembolism. Pulmonary thromboembolism is a condition that is familiar to forensic pathologists for its common cause of sudden unexpected death. Fatal pulmonary thromboembolism following deep vein thrombosis has been previously reported as a consequence of major ankle injury but not following minor ankle injury. Here, I report the case of sudden unexpected death in a 54-year-old female without known underlying risk factors for venous thromboembolism, except for a history of minor injury at her left ankle, which possibly caused local vascular wall damage with subsequent deep vein thrombosis and eventual massive pulmonary thromboembolism.

To characterize peri-ictal apnea and postictal asystole in generalized convulsive seizures (GCS) of intractable epilepsy.This was a prospective, multicenter epilepsy monitoring study of autonomic and breathing biomarkers of sudden unexpected death in epilepsy (SUDEP) in patients ≥18 years old with intractable epilepsy and monitored GCS. Video electroencephalography, thoracoabdominal excursions, nasal airflow, capillary oxygen saturation, and electrocardiogram were analyzed.We studied 148 GCS in 87 patients. Nineteen patients had generalized epilepsy, 65 had focal epilepsy, 1 had both, and the epileptogenic zone was unknown in 2. Ictal central apnea (ICA) preceded GCS in 49 (40.4%) of 121 seizures in 23 patients, all with focal epilepsy. Postconvulsive central apnea (PCCA) occurred in 31 (22.1%) of 140 seizures in 22 patients, with generalized, focal, or unknown epileptogenic zones. In 2 patients, PCCA occurred concurrently with asystole (near-SUDEP), with an incidence rate of 10.2 per 1000 patient-years. One patient with PCCA died of probable SUDEP during follow-up, suggesting a SUDEP incidence rate 5.1 per 1000 patient-years. No cases of laryngospasm were detected. Rhythmic muscle artifact synchronous with breathing was present in 75 of 147 seizures and related to stertorous breathing (odds ratio: 3.856, 95% confidence interval: 1.395-10.663,Postconvulsive central apnea occurred in both focal and generalized epilepsies, suggesting a different pathophysiology from ICA, which occurred only in focal epilepsy. Postconvulsive central apnea was seen in 2 near-SUDEP cases and 1 probable SUDEP case, suggesting that this phenomenon may serve as a clinical biomarker of SUDEP. Larger studies are needed to validate this observation. Rhythmic postictal muscle artifact is suggestive of post-GCS breathing effort rather than a specific biomarker of laryngospasm.To analyze the factors that determine the occurrence or severity of postictal hypoxemia in the immediate aftermath of a generalized convulsive seizure (GCS).We reviewed the video electroencephalography (EEG) recordings of 1006 patients with drug-resistant focal epilepsy included in the REPO2MSE study to identify those with ≥1 GCS and pulse oximetry (SpOA total of 107 GCS in 73 patients were analyzed. A transient hypoxemia was observed in 92 (86%) GCS. Rate of GCS with SpOPostictal hypoxemia was observed in the immediate aftermath of nearly all GCS, but administration of oxygen had a strong preventive effect. Severity of postictal hypoxemia was greater in temporal lobe epilepsy and when hypoxemia was already observed before the onset of secondary GCS.

Nausea and vomiting are common sequelae of a multitude of disorders that can range from mild to severe conditions. Intracranial mass lesions can occasionally present with vomiting followed by acute neurological deterioration and sudden death, although they are usually accompanied by ongoing neurological symptoms. We aimed to report an unusual presentation of an intracranial mass resulting in death to increase awareness among pediatric emergency physicians. A previously healthy 15-month-old boy presented to the pediatric emergency department (PED) with nausea, vomiting and diarrhea. He did not have any symptom of a neurological disorder. He acutely deteriorated, developed cardiopulmonary arrest and was intubated. His cranial computed tomography showed dilatation of the third and the lateral ventricles caused by a 3x4x2 cm tumor in the posterior fossa with an evidence of hemorrhage in the tumor with minimal tonsillar herniation. An emergent extra-ventricular drainage was performed to relieve elevated intracranial pressure. He did not show any improvement and died 9 hours after admission. Common symptoms in PED like nausea and vomiting are mostly due to benign etiologies such as gastroenteritis. One should always keep in mind that there may be an underlying intracranial pathology and further investigation should not be delayed.

Propósito: dar a conocer un caso de muerte inesperada por rickettsiosis, sus implicaciones médico-legales y epidemiológicas. Temas: infecciones agudas, muerte inesperada, demanda de mala praxis médica y consecuencias epidemiológicas del diagnóstico de enfermedad infecciosa. Desarrollo: este artículo hace referencia al caso de un adolescente, domiciliado en Ciudad de Panamá, que presentó un cuadro clínico infeccioso agudo y letal. Al momento de la necropsia, no se contaba con un diagnóstico que confirmara que se trataba de un caso de rickettsiosis. Conclusiones: los casos de rickettsiosis no son frecuentes; existe la posibilidad de que no sean diagnosticados oportunamente, y por lo tanto, ponen en riesgo epidemiológico a la población. La complejidad y rapidez de las manifestaciones clínicas pueden ocasionar errores diagnósticos y de tratamiento, por lo cual los resultados de la necropsia son indispensables para certificar la causa de muerte y aclarar demandas por mala praxis médica.

During medical school, students receive little teaching or experience around unexpected death.1 Formal education and training in caring for dying patients and dealing with death at an undergraduate level is very variable and is under-represented in the medical school curricula. Much of the focus around the subject of death and dying is centred on prevention and care for the palliative patient.1 It is therefore often during clinical placements or even the first year of practice where student doctors will experience emergency resuscitation followed by unexpected death for the first time. This can lead to anxiety and reduced confidence among students in dealing with death in clinical encounters.2 Bringing death into clinical teaching such that students can discuss and reflect on some of the thoughts and emotions this generates would therefore be beneficial. Creating this type of experience, however, is not necessarily easy and has ethical considerations such as potential trauma of a real-life event or the use of deception in any planned simulation of death.3 Healthcare simulation and death has often been a controversial subject with some arguing that …

Patients with uncontrolled epilepsy have a high risk of sudden unexpected death in epilepsy (SUDEP). Seizure-induced respiratory arrest (S-IRA) is thought to be the determining cause of death in many cases of SUDEP. The goal of the present study was to use Scn1aR1407X/+ (Dravet Syndrome, DS) and DBA/1 mice to determine: (1) the effect of a ketogenic diet (KD) on S-IRA and (2) the relationship between serum ketones and the protective effect of a KD. Ketogenic diet treatment significantly decreased spontaneous seizure-induced mortality in DS mice compared to control (8% vs 39%, p = 0.0021). This protective effect was not abolished when ketosis was prevented by supplementing the KD with glucose (10% mortality, p = 0.0007). In DBA/1 mice, the latency to onset of S-IRA due to audiogenic seizures was delayed from 7.6 to 20.8 seconds by a KD on treatment day (TD) 7 compared to control (p

We report an autopsy case of a 25-year-old man with no medical history who died suddenly in an Internet cafe. He was found in cardiorespiratory arrest and did not respond to cardiopulmonary resuscitation. Traumatic lesions were not observed on his body. An autopsy was performed to investigate the cause of death. Upon examination, we discovered a heart tumor that infiltrated from the outside wall to the outflow tract of the left ventricle. Left ventricular outflow tract obstruction due to a cardiac tumor was considered the mechanism of death. Histological examination identified an inflammatory myofibroblastic tumor (IMT). The final diagnosis was death secondary to circulatory failure due to a cardiac IMT. Additionally, a cardiac tumor was diagnosed using post-mortem computed tomography. Only few cases of sudden unexpected death due to cardiac IMT have been reported; we report this case along with a review of the literature.

This study aimed to determine whether severity of newly diagnosed obstructive sleep apnea (OSA) in people with epilepsy is associated with elevated sudden unexpected death in epilepsy (SUDEP) risk as calculated by the revised SUDEP-7 Inventory (rSUDEP-7). To this aim, a retrospective cross-sectional study was conducted at a single academic center. Adults ≥18 years of age with epilepsy and newly diagnosed OSA were retrospectively identified via electronic health records. Analysis was performed for subjects with confirmed epilepsy, OSA, and complete diagnostic PSG and rSUDEP-7 data. OSA severity was categorized as mild, moderate or severe. Logistic regression analysis was used to determine the association between OSA severity and rSUDEP-7 scores, adjusting for significantly different baseline characteristics. Of 86 subjects, OSA severity was classified as mild 38(44.2 %), moderate 25(29.1 %), and severe 23(26.7 %). Multivariate logistic regression demonstrated that severe OSA was significantly associated with rSUDEP-7 ≥ 5 after adjusting for congestive heart failure and diabetes (OR:4.08,p = 0.046,CI:1.04–16.28), but was attenuated when male gender was added to the model (OR:3.91,p = 0.067,CI:0.91–16.77). In conclusion, severe OSA is associated with elevated SUDEP risk. As a treatable disorder, OSA may thus represent a modifiable SUDEP risk factor. However, future confirmatory studies involving the prospective, longitudinal evaluation of SUDEP from broader populations are required.

Importance Epilepsy can be associated with significant morbidity and mortality. Seizure detection devices could be invaluable tools for both people with epilepsy, their caregivers, and clinicians as they could alert caretakers about seizures, reduce the risk of sudden unexpected death in epilepsy, and provide objective and more reliable seizure tracking to guide treatment decisions or monitor outcomes in clinical trials. Objective To synthesize the characteristics of commercial seizure detection tools/devices currently available. Methods We performed a systematic search utilizing a diverse set of resources to identify commercially available seizure detection products for consumer use. Performance data was obtained through a systematic review on commercially available products. Observations We identified 23 products marketed for seizure detection/alerting. Devices utilize a variety of mechanisms to detect seizures, including movement detectors, autonomic change detectors, electroencephalogram (EEG) based detectors, and other mechanisms (audio). The optimal device for a person with epilepsy depends on a variety of factors including the main purpose of the device, their age, seizure type and personal preferences. Only 8 devices have published peer-reviewed performance data and the majority for tonic-clonic seizures. An informed conversation between the clinician and the patient can help guide if a seizure detection device is appropriate. Conclusions and relevance Seizure detection devices have a potential to reduce morbidity and mortality for certain people with epilepsy. Clinicians should be familiar with the characteristics of commercially available devices to best counsel their patients on whether a seizure detection device may be beneficial and what the optimal devices may be.

La muerte súbita e inesperada en la infancia (MSII) definida como la muerte de un menor de 1 año durante el sueño sin motivo evidente de manera inicial, sigue siendo una de las causas más frecuentes de mortalidad infantil tardía. Aproximadamente 3.500 lactantes mueren anualmente en Estados Unidos por muertes relacionadas con el sueño. Se postula un origen complejo y multifactorial en un lactante vulnerable, sin embargo, su fisiopatología no se ha logrado comprender por completo. Los profesionales de la salud juegan un rol clave en la promoción de las medidas preventivas descritas en la literatura que incluyen dormir en posición supina sobre una superficie firme, evitar el tabaquismo y el colecho, promover la lactancia materna, entre otros. El objetivo de esta revisión es resumir las principales características epidemiológicas y fisiopatológicas de la MSII y factores relacionados con el sueño seguro.

Importance Sudden unexpected death in epilepsy (SUDEP) may account for up to 17% of all deaths in epilepsy. However, it is unknown if neurologists discuss this risk with patients. Objective This study aimed to examine the understanding and practices of SUDEP by neurologists in Saudi Arabia. Methods An electronic web-based survey was sent to 125 neurologists using the mailing list of the Saudi Neurology Society. The survey questions included respondents’ demographics, frequency of SUDEP discussion, reasons for discussing/not discussing SUDEP, and perceived patient reactions. Respondents’ knowledge of the SUDEP risk factors was examined using 12 items from the currently available literature. Logistic regression analyses were applied to examine the factors that influence the frequency of SUDEP discussions and perceived patient reactions. Participants The participants were neurologists who had completed postgraduate training, devoted >5% of their time to clinical care, and had at least one patient with epilepsy in their independent neurology clinic. Results A total of 60 respondents met the eligibility criteria and completed the surveys. Of them, 25% discussed SUDEP most of the time, 65% sometimes or rarely, and 10% never discussed it. Of those who discussed SUDEP with their patients, 63.3% did it if the patient was at high risk. Poor compliance with antiepileptic drugs (AEDs) was the most common patient factor highlighted (81.7%). The perceived patients’ reactions were variable, with positive reactions (motivation to comply and appreciation) being the most frequent. The majority of respondents (78.3%) had incomplete understanding of the published SUDEP risk factors, with SUDEP knowledge scores ≤2.5 (≤50% of the possible total score). The most identified risk factors were frequent generalized tonic-clonic seizures (83.3%), long duration of epilepsy (53.3%), lack of use or sub-therapeutic levels of AEDs (50%), and AED polytherapy (50%). No association was found between how often SUDEP was discussed and other factors, including training in epilepsy, ≥10 years in practice, seeing ≥100 patients, and having SUDEP cases in the past two years. It was found that patients positively reacted to discussion on SUDEP if neurologists had a good understanding of the SUDEP risk factors (χ2 = 5.773, p = 0.016). Conclusions Neurologists in Saudi Arabia do not often discuss SUDEP with patients that have epilepsy. Moreover, when they do, they stress a more individualized approach despite having only a limited understanding of the SUDEP risk factors. Our findings suggest that more guidance should be provided to practitioners on how best to counsel their patients about SUDEP.

The origin of post-ictal malfunctions is debatable. We want to propose a novel idea of a cause of these adverse results occurring following epileptic seizures and anesthesia. Previously we have put forward the idea that epileptic seizures termination is caused by the function of the glymphatic system in the brain. A new measurement shows that this system can be much faster than what was estimated before. Moreover, the method enabling this speeding was actually measured in brains of epilepsy subjects. So, the main objection to our model is relegated. As a possible consequence of the glymphatic process, there can be an excess cleaning of the brain's interstitial fluid. We discuss possible adverse results of this process. This over-cleaning (that can, to a lower extent, occur also during anesthesia) which results post-ictally from the previous overexpression of fluid materials by the neurons during their seizure operation, can reduce ingredients essential for regular neuronal functioning, thereby leading to function reduction and EEG suppression which last until those materials are replenished. We argue that this ingredients' scarcity is the cause of post-ictal generalized EEG suppression (PGES), of post-ictal immobility (PI) and possibly of Sudden Unexpected Death in Epilepsy Patients (SUDEP). Similarly, such cleaning can lead to morbidity and even mortality problems following anesthesia. If our assumption is correct, this understanding of the process of the problems' origin can lead to a method to remedy them by judicial supplement of the lost materials.

OBJECTIVE Chronic sleep deficiency is associated with early mortality. In the epileptic population, there is a higher prevalence of sleep disorders, and individuals with severe refractory epilepsy are at greater risk of premature mortality than the general population. Sudden unexpected death in epilepsy affects 1:1000 cases of epilepsy each year. Ketogenic diet (KD) treatment is one of the few effective options for refractory seizures. Despite KD reducing seizures and increasing longevity in Kv1.1 knockout (KO) mice, they still succumb to sudden death. This study aims to determine whether (1) the rest profiles of KO and KD-treated KO (KOKD) mice resemble each other as a function of either age or proximity to death and (2) the timing of death correlates with acute or chronic changes in rest. METHODS Noninvasive actimetry was used to monitor rest throughout the lives of KO and wild-type (WT) littermates administered standard diet or KD. RESULTS As KO mice age, rest is reduced (P

Gastrointestinal conditions are a less common cause of sudden unexpected death when compared to other conditions such as cardiovascular conditions, but they are equally important. Various congenital and acquired gastrointestinal conditions that have resulted in sudden unexpected death are discussed. The possible lethal mechanisms behind each condition, along with any associated risk factors or secondary diseases, have been described. Through this article, we aim to highlight the need for physicians to prevent death in such conditions by ensuring that subclinical cases are diagnosed correctly before it is too late and by providing timely and efficacious treatment to the patient concerned. In addition, this review would certainly benefit the forensic pathologist while dealing with cases of sudden unexpected death due to gastrointestinal causes. This article is a review of the major gastrointestinal causes of sudden unexpected death. In addition, related fatal cases encountered occasionally in forensic autopsy practice are also included. There are several unusual and rare causes of life-threatening gastrointestinal bleeding that may lead to sudden unexpected death to cover all the entities in detail. Nevertheless, this article is a general guide to the topic of gastrointestinal causes of sudden unexpected death.

Aim Sudden unexpected death in infancy (SUDI) rates for Māori and Pacific infants remain higher than for other ethnic groups in New Zealand and bed-sharing is a major risk factor when there is smoking exposure in pregnancy. Sleep space programmes of education and Pēpi-Pod baby beds require evaluation. Methods Two hundred and forty Māori and Pacific women and infants were randomised 1:1, to the Pēpi-Pod sleep space programme, or to a control group with 'usual care'. When infants were under 2 weeks of age, baseline interviews occurred, followed up by interviews at 2 and 4 months of age to assess safe sleep knowledge, infant care practices and Pēpi-Pod use and acceptability. All participants were offered a New Zealand Standard approved portable cot. Results At baseline, 25% of babies did not have a baby bed. Knowledge of smoking and bed-sharing as SUDI risks improved at follow-up in both groups. One quarter regularly bed-shared at follow-up in both groups. Intention to bed-share was a strong predictor of subsequent behaviour. Pēpi-Pods were regularly used by 46% at 2 months and 16% at 4 months follow-up. Conclusions Bed-sharing and knowledge improvement were similar irrespective of group. It is likely that the impact of the intervention was reduced because the control group received better support than 'usual care' and all participants had a baby bed. New Zealand SUDI rates have declined since sleep space programmes have been available. Sleep space programmes should be prioritised for those with modifiable SUDI risk.

The objective of this study was to determine the association of sleep with sudden unexpected death in epilepsy (SUDEP).We conducted a systematic review and meta-analysis based on literature search from databases PubMed, Web of Science, and Scopus using keywords "SUDEP", or "sudden unexpected death in epilepsy", or "sudden unexplained death in epilepsy". Sudden unexpected death in epilepsy was considered to occur during sleep if the patient was found in bed, if the SUDEP cases were documented as in sleep, or if the patient was found at bedside on the bedroom floor.Circadian pattern was documented in 880 of the 1025 SUDEP cases in 67 studies meeting the inclusion and exclusion criteria. Of the 880 SUDEP cases, 69.3% occurred during sleep and 30.7% occurred during wakefulness. Sudden unexpected death in epilepsy was significantly associated with sleep as compared to wakefulness (P0.001). In the subgroup of 272 cases in which circadian pattern and age were documented, patients 40years old or younger were more likely to die in sleep than those older than 40years (OR: 2.0; 95% CI=1.0, 3.8; P=0.05). In the subgroup of 114 cases in which both circadian pattern and body position at the time of death were documented, 87.6% (95% CI=81.1%, 94.2%) of patients who died during sleep were in the prone position, whereas 52.9% (95% CI=24.7%, 81.1%) of patients who died during wakefulness were in the prone position. Patients with nocturnal seizures were 6.3 times more likely to die in a prone position than those with diurnal seizures (OR: 6.3; 95% CI=2.0, 19.5; P=0.002).There is a strong association of SUDEP with sleep, suggesting that sleep is a significant risk factor for SUDEP. Although the risks of SUDEP associated with sleep are unknown and likely multifactorial, the prone position might be an important contributory factor.

Although inpatient epilepsy monitoring units (EMUs) are generally safe, seizures in this setting can still produce significant morbidity. The MORTEMUS (MORTality in Epilepsy Monitoring Unit Study) study revealed that the most feared consequence of an unattended seizure-sudden unexpected death in epilepsy (SUDEP)-does occur rarely in the EMU. Nearly all cases identified in that study occurred in the evening. The hypothesis for this study is that unwitnessed seizures would be more likely to occur during the night shift, and that response times to seizures would be slower at night, due to multiple variables. A retrospective video-EEG review of all seizures captured in our EMU during a 4-week period in 15 patients admitted was conducted. The time between seizure onset and the arrival of an attendant at the bedside was measured. There were 16 diurnal and 14 nocturnal seizures identified. The median response time during the day shift was approximately 22 ± 28 (0-80) seconds during the day shift, and 49 ± 93 (0-360) during the night shift (Mann-Whitney U test, P = 0.03). There were six seizures that were subclinical or showed subtle clinical signs (head turning or eyes opening), including one prolonged seizure lasting nearly 18 minutes, which all occurred in the evening, went unattended, and were excluded from the statistical analysis. These preliminary findings indicate a statistically significant delay in nursing response times to seizures in the EMU during the night shift. All unattended seizures occurred in the evening. More research is needed to study human factors, systems issues, or patient-related/physiological factors that slow response times.

Sudden unexpected death in epilepsy (SUDEP) is an important cause of mortality in epilepsy. To date, there is only one published UK study evaluating information provision of SUDEP among parents of children with epilepsy (CWE), and there are no studies published from Asia. Although SUDEP information provision is recommended among parents of CWE, it is uncertain if these recommendations are applicable to Asian countries due to the different cultural attitude towards epilepsy. Our prospective cohort study consisted of multiethnic parents of children with epilepsy (CWE) seen in a tertiary hospital in Malaysia. Information on SUDEP was delivered to parents using an epilepsy educational software program. Participants completed a set of standardized questionnaire and Depression Anxiety Stress Scales-Short Form (DASS-21) immediately after and retested 3-6months after the SUDEP information provision. A total of 127 parents (84 mothers) participated in the study. The CWE consisted of 3 ethnic groups (38% Malay, 30% Chinese, 32% Indian) with a mean age of 9.6years. Majority (70.9%) felt positive after SUDEP information provision, 90.6% wanted SUDEP discussion for themselves with 70.1% wanted SUDEP discussion with their child, and a lower proportion (58.3%) would discuss SUDEP with their child. None of the participants reported increased symptoms of depression, stress or anxiety attributed to SUDEP information provision. Most parents took steps to reduce SUDEP risk, and most parents did not report an impact on their own functioning. However, there was an increase in parental report over time of impact on their child's functioning following SUDEP information (P

Sudden cardiac death is defined as a natural and unexpected death, in a previous apparently healthy individual. It represents a major public health issue, with up to 50% of the cardiovascular mortality. Using data from the Paris Sudden Death Expertise Centre registry, this article summarises the main cardiovascular abnormalities associated with sudden cardiac death, the different preventives approaches, and provides a systematic diagnostic approach.

Deaths due to meningiomas are routinely diagnosed in clinical practice because this neoplasm tends to present with the typical progression of neurological deficits. On the other hand, sudden unexpected deaths due to meningiomas are rarely described in the literature. The study presents six fatal cases of previously undiagnosed intracranial meningiomas from the Cook County Medical Examiner's Office from 1998 to 2014. The most common explanation of the mechanism of sudden death due to intracranial neoplasms is a rapid increase in intracranial pressure produced by the mass effect of the neoplasm. Other mechanisms of death include acute intracranial and intratumoral hemorrhage, and benign neoplasms that grow in the vicinity of vital centers altering neural discharge in autonomic pathways leading to cardiac suppression or lethal arrhythmia. Forensic pathologists must keep in mind that sudden unexpected death caused by intracranial meningiomas, although extremely rare, may be encountered in the forensic setting.

A 36-year-old woman with a clinical history of Friedreich ataxia and hypertrophic cardiomyopathy was found unexpectedly dead at her home. The heart showed asymmetric left ventricular hypertrophy, with an interventricular septal thickness of 20–25 mm (the remainder of the left ventricular wall measured 15 mm). Histologically, both ventricles had irregular areas of marked myocyte hypertrophy with associated interstitial fibrosis and focal myofibre disarray. There was neuronal loss within the dentate nucleus of the cerebellum, with vacuolation and axonal loss in the dorsal columns and spinocerebellar tracts of the upper cervical spinal cord. Death was due to hypertrophic cardiomyopathy complicating Friedreich ataxia. Other causes of death in this condition include embolic stroke, cerebral haemorrhage, aspiration pneumonia, renal failure, diabetic ketoacidosis, myocardial infarction, generalised inanition and trauma. Sudden death due to cardiac disease, resulting in presentation for medicolegal autopsy, may be the presenting feature at all ages, including childhood.

Bereavement is a state of grieving after the loss of a loved one. Past research has suggested that bereavement is particularly challenging, both physically and emotionally, in the aftermath of unexpected death. Here, we examine bereavement in which death occurred suddenly, compared to a chronic condition where death was expected, in terms of perceived social support and relational maintenance with the deceased in the form of imagined interactions and social media interactions. Results indicated that individuals experiencing sudden death bereavement were more likely to engage in both postmortem relational maintenance techniques and perceived less social support than individuals in the expected death bereavement group. Results are discussed in terms of previous findings.

People with epilepsy have increased mortality rates, which is partially attributed to sudden unexpected death in epilepsy syndrome (SUDEP). Poor seizure control appears to be the strongest SUDEP risk factor. Management of epilepsy and adherence to therapy is critical to seizure control. The belief by caregivers of negative influence caused by being informed about the syndrome is the main reason SUDEP is not disclosed. There are no clear recommendations when to disclose the risk of SUDEP and how much information should be provided. We addressed the preferences of Latvian epilepsy patients for discussing SUDEP as well as awareness of the syndrome. Our study involved 55 epilepsy patients. We found that, as in other studies, our patients were relatively well informed about SUDEP. We found that a considerable proportion of patients preferred to receive information about SUDEP from a general practitioner. We note the belief of patients that the disclosure of SUDEP would either improve or have no effect on the quality of life. We were able to identify groups of patients with a self-reported belief of more frequent expected anxiety and poor adherence to medical treatment. Our data improves the understanding of preferences of patient for discussing the negative aspects of epilepsy.

Eberhard ‘Paddy’ Bort served as Reviews Editor of Scottish Affairs from 2000 to his unexpected death in early 2017. This essay draws together several of his colleagues and friends to outline Paddy's contributions to the study of Borders and his wider activities in and around Scottish academic life.

Status thymico-lymphaticus had ever been explained as a cause of sudden death usually in children, but few cases were reported in adults. We sought to determine the relationship between thymic hypertrophy and sudden unexpected death in adult (SUDA), and associated macroscopic and microscopic findings. Adult post mortems from 1984 to 2014 were reviewed and 23 thymic hypertrophy patients without SUDA, 33 thymic hypertrophy patients with SUDA and 172 SUDAs without thymic hypertrophy entered. The data of thymus, lymph nodes, spleen, heart, aorta, and adrenal glands were collected for macroscopic and histological analysis. Ten antibodies were used and applied to 3 children and 46 adult thymus specimens. We found, as an independent factor, thymic hypertrophy increased significantly the risk of SUDA (6.9 folds) in both male and female. What’s more, SUDAs associated with thymic hypertrophy were quite younger (22.5 years) than those without it. A majority of patients with hypertrophic thymus had a variable number of accompanied anomalies described as the typical characteristics of status thymico-lymphaticus, but no macroscopic and microscopic findings related to SUDA in patients with thymic hypertrophy. Cytokeratins (CKs) showed distinctly different immunohistochemical expression patterns in individuals who had different death causes and disease background. Instead of a disease entity “status thymico-lymphaticus” is a systematic abnormality with thymic hypertrophy as a feature involving mainly immune and/or cardiovascular system, probably caused by gene mutations.

Objective Local anesthesia (LA) is widely used in dental treatment. Although the administration of LA agents is generally very safe, adverse reactions caused by LA are relatively common. The present study was performed to elucidate the possible causes and clinical problems occurring in cases of dental treatment-associated death under LA in Japan. Methods We reviewed possible cases of unexpected dental treatment-associated death under LA in Japan between 1951 and 2014. Cases of outpatients with unexpected death occurring during or after dental treatment under LA were included in the study. Results A total of 38 possible cases of dental treatment-associated death under LA in Japan were selected. Twenty-five of the patients (66%) had no definite relevant medical history or had an inadequate description of medical history. Thirty-six cases (95%) developed adverse events within 30 min of LA application. Emergency first-aid treatment was performed by the dentist in 50% of the cases. The possible causes of death were divided into three major categories: heart failure, cerebrovascular disorders, and anaphylaxis. Conclusions Unexpected dental treatment-associated deaths under LA were reported. It may be difficult to predict these adverse events before treatment from patient records. This study warns that severe adverse events or mortality are possible even during outpatient dental treatment with use of LA alone. A dentist is required to manage these situations. Also, mortality cases must be avoided with maximal reliability on the dentist.

Intraluminal middle cerebral artery occlusion (MCAO) is the most widely used model of stroke. We aimed to predict the outcome of MCAO using a combination of fine behavioural tests for the prediction of unsuccessful surgery in mice leading to no infarction, haemorrhage and unexpected death. MCAO was performed on adult mice under the guidance of laser-Doppler flowmetry (LDF) to warrant a decrease in regional cerebral blood flow (rCBF) in the MCA territory. Four outcomes of MCAO were defined according to histological analysis: infarction, no infarction, haemorrhage and unexpected death (death within 24h post-surgery). Fine behavioural tests including the rotarod, modified neurological severity score (mNSS), Clark general and Clark focal tests were performed separately at 6h, 12h and 24h post-stroke. A total of 94 mice were included in the analysis. The infarction rate associated with MCAO was 58.5% (55/94). After optimization of the timing and behavioural tests, we found that higher Clark focal (>17.5) or higher mNSS scores (>10) were markedly related to early death, whereas a lower mNSS score (

Inherited heart rhythm disorders (IHRDs) are complex and uncommon arrhythmogenic conditions that can lead to sudden unexpected death in seemingly healthy individuals. Multidisciplinary programs can assist in the diagnostic testing of potentially affected individuals and their family members.Patients evaluated in a specialized adult and pediatric IHRD clinic between April 2013 and February 2015 were characterized. The total costs per evaluation and diagnosis were calculated. Patients were divided according to referral indication (primary referral or family member).A total of 618 patients were evaluated (age 36 ± 21 years; 52% male), of which 274 (44%) were primary referrals and 344 (56%) were family members referred for cascade screening. Overall, 47% had at least 1 follow-up visit. Patients had a median of 3 tests; primary referrals required more tests (4 vs 2; P0.01). The median cost per patient was $1340 CAD. Evaluation of the primary referrals was costlier than family members ($3096 vs $983; P0.01). A definite or probable diagnosis was determined in 464 patients (77%), with no difference according to patient type (P = 0.18). The total cost per diagnosis was $4021 in primary referrals compared with $1277 in family members (P0.01).Clinical evaluation of patients with suspected IHRD results in a high diagnostic yield and costs aligned with other complex disorders involving multidisciplinary clinics. Evaluation costs are expectedly higher in primary referrals compared with targeted family screening.

This review aims to empower general neurologists to provide better informed person-centred advice on sudden unexpected death in epilepsy (SUDEP) to people with epilepsy in order to help keep them safe. Past and present evidence is consolidated in order to inform readers about SUDEP, and up-to-date insights into the epidemiology, diagnostic classification, pathophysiology, risk factors, influence of co-morbidity, and importance of sensitive person-centred communication are outlined. This review provides "fingertip" information to the practicing neurologist with regards to identifying and communicating risks for SUDEP and suggests practical measures for managing these risks in partnership with the patient.