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Purpose of review It is recognized that death is inevitable but rarely are we prepared for the death of significant persons in our lives. Sudden death is by its nature unexpected and thus shocking for family members and friends of the decedent. Sudden deaths have customarily been divided into four categories based on the cause of death, including natural, accidental, suicidal, or homicidal (NASH) deaths. Supporting the suddenly bereaved can be stressful, for both novice and experienced professionals; this review provides information important to healthcare professionals (HCP) who are often in a position to support family members after a sudden death. Recent findings Evidence suggests that supportive actions for those suddenly bereaved include HCPs conveying empathy, answering questions about the cause of death, allowing family members an opportunity to say goodbye, and providing follow-up over time. Bereaved individuals appreciate ongoing connections with healthcare professionals after the death, and HCPs need to recognize that the bereaved are at increased risk of illness in the months after a sudden death. Summary Supporting those bereaved after a sudden unexpected death is not easy, even for experienced professionals. This review identifies supportive strategies to use with individuals and family members who are suddenly bereaved. The suggestions in this review can be used in emergency departments and other settings involved with death notifications. Also provided is information that HCPs can use to support bereaved family members.

Eleanor Roosevelt experienced demanding challenges following the unexpected death of her husband, Franklin D. Roosevelt (FDR), the president of the United States, on April 12, 1945. That she was no longer first lady led to a series of secondary losses: the loss of status, the loss of staff, the loss of financial security, and, within a week, the loss of her primary residence, The White House. Her transition into “Widow Roosevelt” was complicated by her discovery that FDR had died in the presence of Lucy Mercer Rutherfurd, with whom he had had an affair during World War I. As a condition for staying married and having a political career, he agreed never to see Lucy again. The circumstances of FDR’s betrayal and death were kept secret for nearly two decades. A week after FDR’s death, Eleanor answered a question about her future by a New York Times reporter, with a tense, “The story is over.” However, Harry Truman, FDR’s successor, had other ideas and appointed her as a delegate to the United Nations. Over the next 17 years, Eleanor evolved into “First Lady of the World” and had a significant role in world affairs and American politics.

Although there has recently been significant debate regarding the importance of disclosing the risk of SUDEP, professional societies and clinical practice guidelines currently recommend that the risk of SUDEP be disclosed as part of a comprehensive epilepsy education program. Therefore, the primary aim of the present study was to examine whether healthcare providers treating pediatric patients with epilepsy in Italy would disclose the risk of SUDEP to the parents of children with epilepsy.The present study assessed data from a questionnaire that collected sociodemographic information and clinicians' attitudes towards SUDEP. The survey was available online from September to December 2015. Chi-squared (χA total of 114 medical doctors (71 females and 43 males) completed the questionnaire. Of the respondents, 18 (16.2%) stated that all patients should be counseled about SUDEP, 22 (19.8%) thought that the majority should be, 58 (52.3%) said that only a minority should be, and 13 (11.7%) believed none should be. With respect to physicians' experience in counseling about SUDEP, only 2 (1.8%) counseled all their patients. A univariate logistic regression analysis showed that the factors associated with "not counseling about SUDEP at all" were the low number of patients with epilepsy they took care of (p0.01), fewer years of experience (p=0.03), and the belief that it was safe from a legal point of view (p0.001), The main reasons for counseling about SUDEP were refractory course of epilepsy (79%) and if the parent/patient requested information (65%). Additionally, the findings of the qualitative analysis highlighted the emotional difficulties that neuropediatricians encounter when dealing with the disclosure of SUDEP.The present findings showed that a minority of neuropediatricians in Italy counseled all parents of their patients about SUDEP. Educational training may help physicians better communicate with the patient/parents regarding this difficult issue.

Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality in young patients with epilepsy (PWE). Although its mechanisms are still poorly understood, they may include cardiorespiratory dysfunction. Standard 12-lead electrocardiograms (ECGs) were obtained from 62 consecutive patients (aged 18-66y) with a definite diagnosis of epilepsy, without seizures at the day of ECG, and 57 healthy controls matched for sex, age and body mass index (BMI). All ECGs were evaluated by a blinded board-certified cardiologist. Patients with symptomatic focal epilepsy represented 90.3% (N=56), of whom 56.4% (N=35) had temporal lobe epilepsy, with a mean duration of 22.02±14.96years of epilepsy. We observed more prolonged P-wave (p0.0001) and PR interval (p=0.01) in patients than in controls. Additionally, longer QT intervals (p0.01), pathologic QT dispersion (p0.01) and left atrial overload (p0.01) were more common in PWE. Multiple linear regression analysis evidenced age, gender and polytherapy as factors associated with altered ECG. Therefore, routine ECG should be requested in PWE, especially for males, increasing age and in polytherapy. Findings such as longer PR and QT interval, and pathologic QT dispersion, may reflect cardiac structural changes and/or autonomic nervous system dysfunction and indicate a risk for SUDEP.

People with epilepsy have increased risk of premature death, and their life expectancy may reduce by 2-10 yr. Population- and hospital-based studies have shown that the excess mortality in epilepsy is not entirely explained by deaths directly attributable to epilepsy such as accidents and drowning during a seizure. It is also significantly contributed by deaths from other causes such as cardiac deaths, deaths due to malignancies and other causes. It had recently been recognized that sudden unexpected deaths in epilepsy (SUDEP) contributed to a small yet important proportion of mortality in epilepsy. SUDEPs are deaths (witnessed or unwitnessed) unrelated to trauma, drowning or status epilepticus and not attributable to any specific medical conditions. Several factors related to epilepsy and drug therapy have been found to be associated with higher risk of SUDEP.

Perinatal autopsy practice is undergoing a state of change with the introduction of evidence-based cross-sectional imaging, driven primarily by parental choice. In particular, the introduction of post mortem magnetic resonance imaging (PMMR) has helped to advance less-invasive perinatal autopsy in the United Kingdom (UK) and Europe. However, there are limitations to PMMR and other imaging techniques which need to be overcome, particularly with regard to imaging very small fetuses. Imaging is also now increasingly used to investigate particular deaths in childhood, such as suspected non-accidental injury (NAI) and sudden unexpected death in infancy (SUDI). Here we focus on current topical developments the field, with particular emphasis on the application of imaging to perinatal autopsy, and pediatric forensic deaths. Different imaging modalities and their relative advantages and disadvantages are discussed, together with other benefits of more advanced cross-sectional imaging which currently lie in the research domain. Whilst variations in local imaging service provision and need may determine different practice patterns, and access to machines and professionals with appropriate expertise and experience to correctly interpret the findings may limit current practices, we propose that gold standard perinatal and pediatric autopsy services would include complete PMMR imaging prior to autopsy, with PMCT in suspicious childhood deaths. This approach would provide maximal diagnostic yield to the pathologist, forensic investigator and most importantly, the parents.

It was not that long ago that some believed there was little point in discussing sudden unexpected death in epilepsy (SUDEP) with patients. Why cause anxiety, it was argued, if the risk could not be influenced? The results of the landmark study by Sveinsson et al.1–3 reporting on a nationwide population-based case–control study of 255 SUDEP cases from Sweden, the largest so far, which combines data from linked records with detailed review of medical charts, suggest otherwise.

Neurogenic pulmonary edema (NPE) is a non‐cardiogenic pulmonary edema that is caused by an acute central nervous system injury and usually develops rapidly after an injury. Although several episodes of NPE resolve spontaneously, the condition may cause unexpected death among patients with epilepsy.

We present a case report of a 25 year-old man with MELAS (Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes) syndrome, who died suddenly and unexpectedly from diabetic ketoacidosis. This case report illustrates why it is important for medical examiners to be familiar with the clinical and autopsy features of MELAS syndrome and to be aware of the common complications, which may lead to sudden unexpected death.

Objective To assess relative rates and clinical features of patients with genetic generalized epilepsy (GGE), focal epilepsy (FE), and developmental encephalopathic epilepsy (DEE) in the North American SUDEP Registry (NASR). Methods We identified all adjudicated definite, definite plus, and probable sudden unexpected death in epilepsy (SUDEP) cases (n = 262) and determined epilepsy type (GGE, FE, or DEE) from medical record review including history, imaging and EEG results, genetics, and next-of-kin interviews. Results Of the 262 SUDEP cases, 41 occurred in GGE, 95 in FE, 24 in DEE, and 102 were unclassifiable. GGE cases comprised 26% of NASR cases with an epilepsy syndrome diagnosis. The relative frequency of FE:GGE was slightly lower (2.3:1) than in population cohorts (2.1–6:1). Compared to patients with FE, patients with GGE had similar (1) ages at death and epilepsy onset and rates of (2) terminal and historical antiseizure medication adherence; (3) abnormal cardiac pathology; (4) illicit drug/alcohol use histories; and (5) sleep state when SUDEP occurred. Conclusions GGE cases were relatively overrepresented in NASR. Because GGEs are less often treatment-resistant than FE or DEE, seizure type rather than frequency may be critical. Many people with GGE predominantly have generalized tonic-clonic seizures (GTCS) when they have uncontrolled or breakthrough seizures, whereas patients with FE more commonly experience milder seizures. Future mechanistic SUDEP studies should assess primary and focal-to-bilateral GTCS to identify potential differences in postictal autonomic and arousal disorders and to determine the differential role that lifestyle factors have on breakthrough seizures and seizure types in GGE vs FE to effectively target SUDEP mechanisms and prevention.

Sudden infant death syndrome (SIDS) is a leading cause of death in infants, although the mechanisms leading to death remain unclear. Multiple theories have emerged over time, with one of the most influential hypotheses being the triple risk model. This model, first devised in 1972 and later revised in 1994 by Filiano and Kinney, is still widely used in assisting with conceptualising and understanding sudden death in infancy. This model has evolved over time, with each version stressing that SIDS is likely to occur when certain risk factors coincide, suggesting that the lethal mechanisms in SIDS are likely to be multifactorial. All versions of the triple risk model from 1972 to the present have emphasised the complexity of SIDS and serve as useful guides for current and future research into the enigma of sudden and unexpected death in infancy.

Altered Brain Connectivity in Sudden Unexpected Death in Epilepsy (SUDEP) Revealed Using Resting-State fMRIAllen LA, Harper RM, Guye M, et al. Neuroimage Clin. 2019;24:102060.The circumstances surrounding sudden unexpected death in epilepsy (SUDEP) suggest autonomic or respiratory collapse, implying central failure of regulation or recovery. Characterization of the communication among brain areas mediating such processes may shed light on mechanisms and noninvasively indicate risk. We used rs-fMRI to examine network properties among brain structures in people with epilepsy who suffered SUDEP (n = 8) over an 8-year follow-up period, compared with matched high- and low-risk subjects (n = 16/group) who did not suffer SUDEP during that period and a group of healthy controls (n = 16). Network analysis was employed to explore connectivity within a “regulatory subnetwork” of brain regions involved in autonomic and respiratory regulation and over the whole brain. Modularity, the extent of network organization into separate modules, was significantly reduced in the regulatory subnetwork, and the whole-brain, in SUDEP and high-risk groups. Increased participation, a local measure of intermodular belonging, was evident in SUDEP and high-risk groups, particularly among thalamic structures. The medial prefrontal thalamus was increased in SUDEP compared with all other control groups, including high-risk group. Patterns of hub topology were similar in SUDEP and high-risk groups but were more extensive in low-risk patients who displayed greater hub prevalence and a radical reorganization of hubs in the subnetwork. Sudden unexpected death in epilepsy is associated with reduced functional organization among cortical and subcortical brain regions mediating autonomic and respiratory regulation. Living high-risk subjects demonstrated similar patterns, suggesting such network measures may provide prospective risk-indicating value, though a crucial difference between SUDEP and high-risk groups was altered connectivity of the medial thalamus in SUDEP, which was also elevated compared with all subgroups. Disturbed thalamic connectivity may reflect a potential noninvasive marker of elevated SUDEP risk.

Primary cardiac lymphomas represent approximately 1% to 2% of primary cardiac neoplasms and 5% of malignant cardiac neoplasms. Here we present a case of sudden unexpected death of a middle-aged male resulting from an unusually large cardiac B-cell lymphoma. The neoplasm infiltrated the myocardium of the right atrium and ventricle and, to a lesser extent, the wall of the left atrium and pulmonary trunk. Extensive infiltration of the heart by the primary cardiac lymphoma, combined with the complete lack of symptoms, makes this case unusual.

Sudden cardiac death (SCD) is the leading cause of sudden death in young athletes. It has been estimated that SCD occurs three times more often in athletes than in nonathletes and is defined as a sudden unexpected death due to a previously undiagnosed cardiac structural abnormality. The precise incidence of SCD is unclear, but various studies have estimated that 2–3% of the general population have some cardiovascular anomaly and that the SCD rate in athletes ranges from 1:50,000 to 1:200,000 athletes per year. According to the National Athletic Trainers’ Association (NATA) position statement on preventing sudden death, a report from the National Collegiate Athletic Association stated that the SCD rate in student-athletes is slightly higher, at 1:43,000 per year.

Sudden unexpected death in epilepsy (SUDEP) occurs in 1 in 4,500 children, and this incidence is more than 20 times that of sudden death in the general population. We report two cases of SUDEP and a review of the literature. There are various hypotheses regarding the cause of this event, but investigation and research are difficult due to the small number of autopsy cases. The risk of SUDEP may be reduced by the accumulation of cases in the future.

Shortly following the unexpected death of Booker T. Washington in 1915, many began appraising his life and legacy. From 1915 through the modern civil rights movement, numerous biographies, articles...

Introduction: The association between sudden unexpected death in infancy (SUDI) and low socio-economic status has been well described in the literature. While the rate of SUDI had declined dramatically following successful campaigns that promoted safe sleeping habits, it has remained stable over the past decade and increasingly been confined to the most socially disadvantaged and vulnerable families. Racial and ethnic disparities persist. Despite extensive research associating the multitude of societal level factors associated with social and economic disadvantage and the increased risk of SUDI, their mechanisms on SUDI remain poorly understood. Hypothesis: A novel composite multi-dimensional marker of neighborhood-level disadvantage may be used to evaluate the association between SUDI and neighborhood-level disadvantages in the City of Chicago. Methods: Sudden unexpected death in infancy cases were identified from the Cardiac Arrest Registry to Enhance Survival database. The composite neighborhood-level disadvantage index was derived using an explanatory factor analysis of the social economic factors recorded in the 2015 American Community Survey of the 77 community areas of the City of Chicago. We defined 3 levels of disadvantage: high, medium, and low. A geographic information system, was used to map the community areas’ disadvantage level and individual SUDI cases. Results: Ninety-one SUDI cases were identified. Non-Hispanic Black (64/91(70%)) and Hispanic (16/91 (18%)) comprised the majority of SUDI cases. Sudden unexpected death in infancy cases were highly concentrated in disadvantaged areas. Eighty-six cases (94.5%) occurred in high and medium disadvantaged areas while 5 cases (5.5%) occurred in the low and no disadvantaged areas (P < 0.0001). Finally, SUDI cases from high and medium disadvantaged areas had a lower hospital admission rate when compared to those from the low and no disadvantaged areas (OR 0.04). Conclusions: The study confirms the persistent racial and socio-economic disparities in SUDI in the City of Chicago. The study’s use of a multi-dimensional composite index of neighborhood-level disadvantage and domestic violence would serve as the basis for further analyses and potential social intervention programs.

Schizophrenia is a detrimental psychiatric disorder, with an increased mortality from natural and nonnatural causes.This study was a retrospective review of autopsy cases of all the individuals with history of schizophrenia investigated by the Office of the Chief Medical Examiner, State of Maryland, for a 5-year period from 2008 to 2012.A total of 391 schizophrenia patients were autopsied at the Office of the Chief Medical Examiner because they died suddenly and unexpectedly. Their age ranged from 15 to 100 years with the mean age of 49.5 years. Of the 391 deaths, 191 (48.8%) were white, 185 (47.3%) were African American, and 15 (3.9%) were either Hispanic or Asian. The male and female ratio was 1.5:1. The majority of deaths (64.2%) were caused by natural diseases, 12.0% deaths were accidents, 11.5% deaths were suicides, and 9.7% deaths were homicides. The manner of death remained undetermined in 38 cases (9.7%). Of the 251 natural deaths, 198 cases (78.9%) were owing to cardiovascular diseases. Cause of death was listed as cardiac arrhythmia in 11 cases. This diagnosis of cardiac arrhythmia was made by exclusion based on death scene investigation, review of medical history, complete autopsy, and toxicological tests. Drug intoxication was the second most common cause of death.The study shows high fatality caused by cardiovascular diseases and drug intoxication among schizophrenia patients, which calls attention of the medical community to closely monitor the high risk factors of sudden death among schizophrenia patients.

Introduction Sudden Unexpected Infant Death (SUID) is a term that englobes the sudden and unexpected death of an infant less than 12 months, which can be explained by organic or traumatic causes, or that can't be explained such as cases of Sudden Infant Death Syndrome (SIDS). Although many risk factors have been associated with this syndrome, one of the most widely associated and studied are incorrect sleeping techniques and practices. In 2016, the American Academy of Pediatrics (AAP) updated their safe-sleeping guidelines and sleeping environment recommendations and strategies to prevent SIDS. Methods We conducted a cross-sectional study to analyze the sleeping environments in infants that attended both the inpatient and outpatient services at a public pediatric hospital in Mexico City. A 6-item questionnaire was applied to the parent or guardian to assess the sleeping habits of infants in their homes. Results A total of 184 infants were included in the study, with a mean age of 5.87 months. Overall, the number of parents that follow safe sleeping practices was very low, with no parents following all the AAP recommendations, and over 10% not following any. Although there is uncertainty about the pathogenesis of this syndrome, the focus has shifted to prevention, especially regarding the modifiable risk factors. Conclusions It was demonstrated that our population did not know about the proper and safe sleeping techniques. In the nearby future, our goal is for health authorities in our country to implement a strategy to make the AAP recommendations part of government health campaigns.

Sudden unexpected death in epilepsy (SUDEP) is the second leading neurological cause of potential years of lifelost after stroke. Despite growing numbers of studies on social aspects of epilepsy, there is a paucity of research on the awareness of SUDEP among the parents of children with epilepsy (CWE), especially in Turkey. In this study, we aimed to evaluate the knowledge of parents of the CWE regarding SUDEP in the tertiary setting.A total of 146 parents (108 female) aged 19 to 55 years (median age:34) of CWE were included at Marmara University, School of Medicine, Department of Pediatric Neurology outpatient clinic between May 2018 and September 2018. A total of 30 multiple-choice questions and a written survey were administered, which consisted of three sections. In the first section, the sociodemographics of parents and CWE were questioned. In the second section, the severity of epilepsy was evaluated. In the third section, the knowledge level and awareness of parents of CWE were assessed.Of 146 parents, only 16.6% previously heard about SUDEP, while 45% of them heard from their relatives. The presence of prior knowledge of SUDEP was associated with the presence of prolonged postictal confusion and longer duration of epilepsy (p 0.05). Ninety-seven (66%) parents desired to be informed about SUDEP, while 76 (54.7%) of them agreed that this information should be given at the time of diagnosis. The degree of anxiety in parents regarding death of epilepsy-related causes was significantly related with prolonged postictal confusion (p 0.001) and using three or more antiepileptic drugs (p = 0.005).Our data suggest that knowledge about SUDEP among parents with CWE found inadequate in Turkey. There should be much effort to inform parents and caregivers in epilepsy clinics on SUDEP, which may help to reduce the associated risk factors.

ObjectivesIn 2008, new statutory national procedures for responding to unexpected child deaths were introduced throughout England. There has, to date, been no national audit of these procedures.Study designFamilies bereaved by the unexpected death of a child under 4 years of age since 2008 were invited to participate. Factors contributing to the death and investigations after the death were explored. Telephone interviews were conducted, and coroners’ documents were obtained. The nature and quality of investigations was compared with the required procedures; information on each case was reviewed by a multiagency panel; and the death was categorised using the Avon clinicopathological classification.ResultsData were obtained from 91 bereaved families (64 infant deaths and 27 children aged 1–3 years); 85 remained unexplained after postmortem examination. Documentation of multiagency assessments was poorly recorded. Most (88%) families received a home visit from the police, but few (37%) received joint visits by police and healthcare professionals. Postmortem examinations closely followed national guidance; 94% involved paediatric pathologists; 61% of families had a final meeting with a paediatrician to explain the investigation outcome. There was no improvement in frequency of home visits by health professionals or final meetings with paediatricians between 2008–2013 and 2014–2017 and no improvement in parental satisfaction with the process.ConclusionsStatutory procedures need to be followed more closely. The implementation of a national child mortality database from 2019 will allow continuing audit of the quality of investigations after unexpected child deaths. An important area amenable to improvement is increased involvement by paediatricians.

This chapter’s aim is to analyze how the unexpected death of a goalkeeperoriginally from Croatia became relevant for supporters of AllmannaIdrottsklubben (AIK), a Swedish football club. I argue that this particularevent drew the attention of club supporters and influenced them, due to thelarger context in which AIK was rooted.

Veterinarians and producers often underestimate the amount of useful information that can be gained thorough necropsy of small ruminants that die or are euthanized following puzzling clinical signs. Necropsy is a valuable tool for identifying underlying health problems in the herd as well as discovering the cause of an acute or unexpected death. Thorough examination of the body as soon as possible after death allows for collection of multiple samples for diagnostic purposes, while information gathered about body condition, nutritional status, and subclinical diseases may alter management and treatment choices for cohorts on the same premise., American Association of Bovine Practitioners Proceedings of the Annual Conference, 2019

Dijkstra and collaborators provide interesting and important issue in clinical research addressing REM sleep without atonia as a possible prodromal marker for Lewy body disease, an early finding in Parkinson's disease. Though prodromal studies are relevant, it is also mandatory to consider the causes of mortality of Parkinson's disease once it is stablished, such as Sudden Unexpected Death in Parkinson's Disease.

ObjectivesTo investigate whether decreased otoacoustic emission (OAE) signal recordings in the right ear are associated with an increased risk of sudden infant death syndrome (SIDS) and to monitor any temporal changes in risk factors.DesignRetrospective case–control study.SettingTelephone interviews with families recruited in England between July 2016 and October 2017 who experienced the unexpected death of a child ParticipantsWe recruited 91 (89%) of the 102 bereaved families who made initial contact, 64 deaths were under 1 year (sudden unexpected death in infancy) of which 60 remained unexplained (SIDS). Of the 220 control families, 194 (88%) follow-up interviews were conducted. We had analysable hearing data for 24 SIDS infants (40%) and 98 controls (51%).ResultsOAE signals were marginally increased rather than decreased among SIDS infants for the right ear, especially at lower frequencies, but not significantly so. The strongest predictors of SIDS were bed-sharing in hazardous (infant sleeping next to a carer who smoked, drank alcohol or slept on a sofa) circumstances (35% vs 3% controls, pConclusionsHearing data were difficult to obtain; larger numbers would be needed to determine if asymmetrical differences between the right and left ear were a marker for SIDS. A national prospective registry for monitoring and a renewed campaign to a new generation of parents needs to be considered underlining the initial message to place infants on their backs for sleep and the more recent message to avoid bed-sharing in hazardous circumstances.

Sudden cardiac death (SCD) is an unexpected death condition and occurs with unknown causes or cardiac condition. The SCD incidence at young age is a rare condition but when this condition happens it become traumatic event for both family and community. Incidence rate of death on 1-35 years old is around 0.8-2.8/100.000 each year. This number also varies according to age and sex. Death incidence on 1-4 years old is more common than on 5-10 years old group. This number is increasing after 15 years old, where age of 31-35 years has 10 fold risk of SCD compared to 1-10 years old group. Ratio of SCD in men and woman are 2: 1. Early detection of underlying heart disease is the most important action of preventio. If young people are known to have a risk of SCD, the lifestyle changing and appropriate medical therapy, including implantation of implantable cardioverter defibrillator, according to risk stratification must be done.

Several definitions of “sudden and unexpected death” exist. The World Health Organization definition is of natural death within 24 h from the onset of symptoms, but this is much too long for many clinicians and pathologists; some will only accept death within 1 h from the onset of illness. If the event was not witnessed, sudden death is defined as the interval between the time the subject was last seen and the time the body was found within 6 h.

The potential for an epileptic seizure to end life has been known throughout history, although the cause of many such deaths is still not understood. Over the last 25 years there has been increasing interest in the phenomenon of Sudden Unexpected Death in Epilepsy (SUDEP) leading to an upswing in the investigation of epilepsy-related mortality. Families bereaved by epilepsy have played an important role in promoting awareness and research, with the UK leading the way on community and political action to tackle epilepsy-related mortality; SUDEP has now become a global conversation with clinicians, scientists, and the community working together to identify strategies that can reduce deaths. The evolution in the approach to epilepsy-related deaths and the impact on epilepsy care are discussed. This paper is for the Special Issue “Prevent 21: SUDEP Summit - Time to Listen”.

Objective To obtain medical records, family interviews, and death-related reports of sudden unexpected death in epilepsy (SUDEP) cases to better understand SUDEP. Methods All cases referred to the North American SUDEP Registry (NASR) between October 2011 and June 2018 were reviewed; cause of death was determined by consensus review. Available medical records, death scene investigation reports, autopsy reports, and next-of-kin interviews were reviewed for all cases of SUDEP. Seizure type, EEG, MRI, and SUDEP classification were adjudicated by 2 epileptologists. Results There were 237 definite and probable cases of SUDEP among 530 NASR participants. SUDEP decedents had a median age of 26 (range 1–70) years at death, and 38% were female. In 143 with sufficient information, 40% had generalized and 60% had focal epilepsy. SUDEP affected the full spectrum of epilepsies, from benign epilepsy with centrotemporal spikes (n = 3, 1%) to intractable epileptic encephalopathies (n = 27, 11%). Most (93%) SUDEPs were unwitnessed; 70% occurred during apparent sleep; and 69% of patients were prone. Only 37% of cases of SUDEP took their last dose of antiseizure medications (ASMs). Reported lifetime generalized tonic-clonic seizures (GTCS) were

Background: Deaths occuring without a known disease and/or a known cause, deaths with non-lethal diseases are interpretated as sudden-unexpected-suspected deaths. Autopsy should always required to evaluate the cause of death. Some of the cases can be termed as negative autopsy since the cause of death can not be determined. This is one of the main interests of the future forensics. Molecular autopsies are one of the main practices of to reduce the negative autopsy ratios. Thus, post-mortem KCNQ1 genetic variation tests are done in sudden unexpected death cases. Material and methods: In this study 0 – 50 years old sudden-unexpected deaths autopsy cases were handled. Samples taken from cases were evaluated and “KCNQ1” genetic variation tests were done in our Department. Results: This study included 47 cases of 42 sudden unexpected death cases (0 – 50 age group) and 5 control group. 15 cases were between 40 – 50 age group and number of cases were increasing with age. 29 of cases (% 69) were male. Evaluation of body-mass index of cases were done and normal weighted cases were the most common with 21 cases (% 50). According to death locations; 17 cases had died (% 45,9) at home. Death location records of 5 cases couldn’t be found. Pathological examinations of all cases were done. We had identified fibrosis and fatty change appearances in SA node of 9 cases (% 21,4) and AV node of 13 cases (% 30,9) especially in conduction tissue examinations. As the result of KCNQ1 genetic analysis of cases, we identified sequence variations in 1638th nucleotid of exon 13 and 1986th nucleotid of exon 16. Conclusion: Cases with conduction system pathology and sequence variations of KCNQ1 genetic analysis shows that we are in need of these tests among routine practice to reduce negative autopsy ratios. Key words: KCNQ1, molecular autopsy, sudden unexpected death, conduction system, negative autopsy.

The article presents modern views on the essence of the term “medical care safety”, and describes the relevance of the topic, systemic approaches to adverse event risk management in medicine. The authors consider the term “medical care safety” as the ratio of the benefit for the patients and the risk of harm to the patient and medical staff, as well as the risk of unfavorable changes in the internal and external environment. Additional harm related to medical care (adverse events) is observed in 10.6% of hospitalized patients. Medical errors, as a cause of preventable harm, account for 45.5% of cases, other adverse events are classified as unpreventable. The cumulative probability of severe harm among patients with medical care-related complications is 11.8%, of unexpected death – 5.3%. Deaths due to adverse events account for 24.9% of hospital mortality and 9.7% of population deaths. High percentage of deaths unrelated to the progression of the underlying disease and comorbidities allows the authors to define medical care as a high-risk type of services. Systemic causes of medical care-related additional harm are latent threats that are constantly present and subsequently transformed into incidents and adverse events at the level of medical staff, patients and the environment in which medical care is provided. Identification of all latent threats and subsequent management of their transformation is the basis of the modern strategy of medical care safety management. It is impossible to ensure high level of safety in medical facilities without formation of a new culture not only at the level of an individual medical facility but also at the level of the government, the entire medical care system and the society.

Infant mortality comprises deaths among infants younger than one year old. The proportion of sudden unexpected death in infancy (SUDI) varies by country and based on the cause of death.To describe the spatial and temporal variation of SUDI in Argentina between 1991 and 2014 according to the International Classification of Diseases, tenth revision.Based on infant death data (provided by the Health Statistics and Information Department), we estimated the percentage of SUDI over the total number of infant deaths and the frequency of causes of death at a provincial, regional, and national level. The risk for death and the secular trend were estimated using a Poisson regression. The SaTScan software, v9.1.1, was used to detect clusters of districts where the percentage of SUDI was significantly different from the national percentage.In Argentina, between 1991 and 2014, 267 552 infants younger than 1 year died; 7 % corresponded to SUDI; the secular trend of causes was negative and statistically significant; the risk for SUDI was 0.86, and a great spatial heterogeneity was observed. At a national level, the most common cause was sudden infant death syndrome, with inter-regional differences. In nine district clusters, the risk for SUDI ranged between 4.36 and 1.24, which is significantly different from the rest of the country.The proportion of SUDI and its causes show inter-regional heterogeneity; codes related to inaccurate diagnoses predominated in more unfavorable regions, while sudden infant death syndrome was prevalent in the more developed regions.Introducción. La mortalidad infantil incluye defunciones de menores de un año. La proporción de muerte súbita inesperada infantil (MSII) varía entre países y según las causas de muerte consideradas. Objetivo. Describir la variación espacial y temporal de MSII en Argentina entre 1991 y 2014 utilizando la Clasificación Internacional de Enfermedades, décima revisión. Materiales y métodos. A partir de la información de defunciones infantiles (Dirección de Estadísticas e Información de Salud), se calculó el porcentaje de MSII sobre el total de muertes infantiles y la frecuencia de las causas que la componían a nivel nacional, regional y provincial. El riesgo de muerte y la tendencia secular se calcularon con regresión de Poisson. Para detectar agrupamientos departamentales con porcentajes de MSII significativamente diferentes a los nacionales, se utilizó el programa SaTScan v9.1.1. Resultados. En Argentina, entre 1991 y 2014, fallecieron 267 552 menores de un año; el 7 % fueron MSII; la tendencia secular de estas causas fue negativa y estadísticamente significativa; el riesgo de MSII fue de 0,86, y se observó una gran heterogeneidad espacial. A nivel nacional, la causa más frecuente fue síndrome de la muerte súbita del lactante, con diferencias interregionales. Nueve agrupamientos departamentales tuvieron riesgo de MSII entre 4,36 y 1,24, significativamente diferentes al resto del país. Conclusiones. La proporción de MSII y de las causas que la componen presenta heterogeneidad interregional con predominio de códigos relacionados con diagnósticos imprecisos en las regiones más desfavorecidas y de síndrome de muerte súbita del lactante en las más desarrolladas.

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Wild-type ATTR amyloidosis (ATTR-wt) is characterized by the accumulation of amyloid in the heart, leading to fatal heart failure and arrhythmia. In this study, we investigated the amyloid deposits in the heart from 556 forensic autopsy cases over 60 years of age. The prevalence of ATTR-wt was 5.8% (32 of the 556), with the prevalence increasing as a function of age. We identified an ATTR-wt-specific morbidity rate of 12.3% for patients over 80 years of age, while the prevalence among individuals over 90 years of age was 34.9%. In none of these 32 cases had a clinical diagnosis of ATTR-wt been made. In 29 of the 32 cases found to be ATTR-wt positive, an obvious extraneous cause of death was identified and included burning, drowning, hypothermia, suicide, and traffic accident. On the other hand, heart failure due to ATTR-wt was confirmed as the cause of death in 3 of the 32 cases. It is suggested that ATTR-wt may be associated with unexpected death among the elderly.

A leadless pacemaker is a recently approved pacing technology that helps mitigate lead-related complications, but it has several limitations. Careful candidate selection is needed. Here, we demonstrate leadless pacing as the solution for prolonged postictal bradycardia/asystole; there is no consensus regarding pacemaker implantation for seizure patients with such a risk of sudden cardiac death.

Sudden unexpected death in epilepsy (SUDEP) is a leading cause of abrupt death in patient with epilepsy. It represents 5-30% of all rapid deaths in individuals with epilepsy. Ketogenic diet (KD) has been used in clinic for treatment of epilepsy for many decades. However, the cellular and molecular mechanisms underlying the SUDEP and the relationship between KD and SUDEP remain uncertain. Kcna1-null (Kcna1-/-) mouse, an animal model of SUDEP, is frequently used to study mechanisms underlying SUDEP. The current mini-review focus on risk factors for SUDEP and their relationship with KD treatment in Kcna1-/- mice. Emerging data suggest that factors including seizure frequency, longevity, rest, age, and gender both in Kcna1-/- mice and KD treated Kcna1-/-mice are involved in SUDEP. This provides valuable prediction for clinical application of KD for treatment of SUDEP.

The elusive nature of sudden unexpected death in epilepsy (SUDEP) has led to investigations of mechanisms and identification of biomarkers of this fatal scenario that constitutes the leading cause of premature death in epilepsy. In this short review, we compile evidence from structural and functional neuroimaging that demonstrates alterations to brain structures and networks involved in central autonomic and respiratory control in SUDEP and those at elevated risk. These findings suggest that compromised central control of vital regulatory processes may contribute to SUDEP. Both structural changes and dysfunctional interactions indicate potential mechanisms underlying the fatal event; contributions to individual risk prediction will require further study. The nature and sites of functional disruptions suggest potential non-invasive interventions to overcome failing processes.