Pulmonary function and atherosclerosis in the general population: causal associations and clinical implications

Reduced lung function is associated with cardiovascular mortality, but the relationships with atherosclerosis are unclear. The population-based Swedish CArdioPulmonary BioImage study measured lung function, emphysema, coronary CT angiography, coronary calcium, carotid plaques and ankle-brachial index in 29,593 men and women aged 50-64 years. The results were confirmed using 2-sample Mendelian randomization. Lower lung function and emphysema were associated with more atherosclerosis, but these relationships were attenuated after adjustment for cardiovascular risk factors. Lung function was not associated with coronary atherosclerosis in 14,524 never-smokers. No potentially causal effect of lung function on atherosclerosis, or vice versa, was found in the 2-sample Mendelian randomization analysis. Here we show that reduced lung function and atherosclerosis are correlated in the population, but probably not causally related. Assessing lung function in addition to conventional cardiovascular risk factors to gauge risk of subclinical atherosclerosis is probably not meaningful, but low lung function found by chance should alert for atherosclerosis.

Suicidal drowning deaths in northern Sweden 1992-2009 - The role of mental disorder and intoxication

Suicides by drowning have received limited attention by researchers. A recent finding that almost one-third of all drowning deaths in Sweden were classified as suicide instigated this study. We identified 129 cases of suicide by drowning in Northern Sweden and analyzed the circumstances and the psychiatric history prior to the suicide. Information was obtained from autopsy, police and medical records, as well as from the National Inpatient Register. One-third of the suicide victims had previously attempted suicide and half of the victims had been hospitalized due to mental health problems. One-third of these had left the hospital less than one week before the suicide. Alcohol and psychoactive drugs were present in 16% and 62% of the cases, respectively. A history of mental disorder and previous suicide attempt (s), especially by drowning, is an ominous combination necessitating efficient clinical identification, treatment and follow-up if a complete suicide is to be prevented.

Accuracy of death certificates of cardiovascular disease in a community intervention in Sweden

AIM

The aim was to investigate the possibility to evaluate the mortality pattern in a community intervention programme against cardiovascular disease by official death certificates.

METHODS

For all deceased in the intervention area (Norsjö), the accuracy of the official death certificates were compared with matched controls in the rest of Västerbotten. The official causes of death were compared with new certificates, based on the last clinical record, issued by three of the authors, and coded by one of the authors, all four accordingly blinded.

RESULTS

The degree of agreement between the official underlying causes of death in "cardiovascular disease" (CVD) and the re-evaluated certificates was not found to differ between Norsjö and the rest of Västerbotten. The agreement was 87% and 88% at chapter level, respectively, but only 55% and 55% at 4-digit level, respectively. The reclassification resulted in a 1% decrease of "cardiovascular deaths" in both Norsjö and the rest of Västerbotten.

CONCLUSIONS

The disagreements in the reclassification of cause of death were equal but large in both directions. The official death certificates should be used with caution to evaluate CVD in small community intervention programmes, and restricted to the chapter level and total populations.

Puumala virus infections associated with cardiovascular causes of death

We studied the causes of death of patients in Sweden with diagnoses of hemorrhagic fever with renal syndrome (HFRS) during 1997–2009. Cardiovascular disorders were a common cause of death during acute-phase HFRS and were the cause of death for >50% of those who died during the first year after HFRS.

Pelvic fractures at a new level 1 trauma centre: who dies from pelvic trauma? The Inkosi Albert Luthuli Central Hospital experience

OBJECTIVE

To identify the incidence of pelvic trauma, causes of death and factors predicting death with pelvic fractures.

METHODS

All pelvic fractures were retrospectively identified from a registry spanning from March 2007 to August 2009. Data was captured on a proforma. Data for survivors, non-survivors and a subgroup with pelvic injury as the underlying cause of death were compared.

RESULTS

Pelvic fracture incidence was 16% of major trauma cases. Patient with pelvic fractures had 31% mortality and 9% pelvic fracture-induced mortality. Motor vehicle collisions were the commonest external cause of pelvic fractures (59%); however, the highest mortality was from falls >6 m. The Injury Severity Score (ISS) was 29 in survivors, 36 in non-survivors, and 54 in the pelvic death subgroup. Type C fracture was a predictor of mortality (P = 0.135). 53% of the cases required transfusion in the first 24 hours. The pelvic death subgroup received a mean of 10.7 units of blood, versus 4 units for survivors and 3.7 units for non-survivors (P = 0.259).

CONCLUSION

The overall incidence of pelvic fracture and associated mortality were higher than previously reported. Fracture severity and falls from heights are associated with additional injuries (higher ISS) and mortality. More severe fractures cause deaths directly attributable to the pelvic injury. The requirement for major blood transfusions for pelvic fracture hemorrhage was related to mortality. Female patients appeared to fare worse than males.

Drowning deaths in Sweden with emphasis on the presence of alcohol and drugs - a retrospective study, 1992-2009

BACKGROUND

Drowning deaths constitute a significant proportion of unnatural deaths globally. In Sweden and other high-income countries, drowning deaths have decreased. This study investigates the epidemiology and current trends of unintentional, intentional, and undetermined drowning deaths with emphasis on the presence of alcohol and other drugs.

METHODS

During an 18-years period, 5,125 drowning deaths were autopsied in Sweden. Data on cases including toxicological analysis on alcohol, pharmaceutical drugs, and illicit drugs were obtained from the National Board of Forensic Medicine.

RESULTS

During the study period, the annual incidence of drowning deaths in Sweden was 3.1/100,000 inhabitants and decreased on average by about 2% each year (p<0.001). The highest incidence was found among males and in middle/older age groups. The incidence increased 3% for each year of age. Children/adolescents (≤18 years) constituted 5% of all drowning deaths. Of all drowned females in the study, 55% (847/1,547) committed suicide, which was a significantly higher proportion compared with males (21%, 763/3,578) (p<0.001). In total, 38% (1,656/4,377) of tested drowned persons had alcohol in their blood and the mean concentration was 1.8 g/l. In the unintentional drowning group, intentional drowning group, and the undetermined group, the proportion of alcohol positive was 44%, 24%, and 45%, respectively. One or several psychoactive drugs were present in the blood in 40% (1,688 /4,181) of all tested persons and in 69% (965/1,394) of tested persons who died from suicidal drowning. The most common drug was benzodiazepines (21%, 891/4,181). Illicit drugs were detected in 10% (82/854) of tested persons.

CONCLUSION

Presence of alcohol and drugs were frequent and may have contributed to the drowning deaths. The incidence of drowning deaths significantly decreased during the study period. Males and the middle/older age groups had a higher incidence compared to females and children. Suicidal drowning was common especially among women. Alcohol and drugs are significant contributors in drowning deaths in Sweden and should be considered as part of a comprehensive prevention program.

Unnatural deaths in reindeer-herding Sami families in Sweden, 1961-2001

OBJECTIVES

Unnatural deaths among Indigenous populations, including the Swedish Sami, occur more often than among the general population. To find prevention strategies, we explored the circumstances of the unnatural deaths of members of reindeer-herding Sami families.

STUDY DESIGN

The number of deaths from among a cohort of 7,482 members of reindeer-herding Sami families were retrieved from the National Board of Health and Welfare for the years 1961- 2001.

METHODS

An evaluation of the information from autopsy records at the National Board of Forensic Medicine, police reports, and available medical records identified 158 unnatural deaths. These were then analysed in detail.

RESULTS

Transport-related deaths and suicides were the most common unnatural deaths among Swedish reindeer-herding Sami family members. Suicides contributed to 23% of all deaths, road traffic accidents to 16%, and snowmobile fatalities to 11%. The accidents generally reflected an "outdoor lifestyle" and the working conditions were characterized by the use of off-road vehicles such as snowmobiles. Half of the number of victims tested positive for alcohol and alcohol abuse was documented in 15% of all victims.

CONCLUSIONS

The results indicate that alcohol is an important factor in preventing unnatural deaths among reindeer-herding Sami, together with increased safety of both on-road and off-road transportation.

Alcohol and drugs in fatally and non-fatally injured motor vehicle drivers in northern Sweden

Alcohol and drugs are important risk factors for traffic injuries, a major health problem worldwide. This prospective study investigated the epidemiology and the presence of alcohol and drugs in fatally and hospitalized non-fatally injured drivers of motor vehicles in northern Sweden. During a 2-year study period, blood from fatally and hospitalized non-fatally injured drivers was tested for alcohol and drugs. The study subjects were recruited from well-defined geographical areas with known demographics. Autopsy reports, medical journals, police reports, and toxicological analyses were evaluated. Of the fatally injured, 38% tested positive for alcohol and of the non-fatally 21% tested positive; 7% and 13%, respectively, tested positive for pharmaceuticals with a warning for impaired driving; 9% and 4%, respectively, tested positive for illicit drugs. The most frequently detected pharmaceuticals were benzodiazepines, opiates, and antidepressants. Tetrahydrocannabinol was the most frequently detected illicit substance. No fatally injured women had illegal blood alcohol concentration. The relative proportion of positively tested drivers has increased and was higher than in a similar study 14 years earlier. This finding indicates that alcohol and drugs merit more attention in future traffic safety work.

Driver's alcohol and passenger's death in motor vehicle crashes

OBJECTIVE

Previous studies on alcohol involvement associated with fatal injury in traffic crashes have focused on the drivers, but the passenger's view is not well known. This study (1) analyzes the relationship between passenger's death and alcohol inebriation of the driver and (2) estimates the role of alcohol as the cause of a crash by examining who was at fault, sober, or inebriated.

METHOD

The study includes all motor vehicle passengers (n = 420) who died in crashes in Sweden 1993 through 1996 and were medicolegally autopsied. Autopsy reports from the Departments of Forensic Medicine, including toxicological analyses, and police reports were studied. Presence of alcohol among drivers was based on blood and breath tests.

RESULTS

One-fifth of the fatally injured passengers and one-fifth of the tested drivers were under the influence of alcohol. The youngest drivers had the highest prevalence of drunken driving. Drivers at fault were alcohol positive in 21% of these crashes and drivers were not at fault in 2% of these crashes. In 53% of the crashes where both the passenger and driver were alcohol positive, the passenger had a lower alcohol concentration than the driver. Children (<16 years) comprised 15% of the killed passengers. Notably, the children were riding with a driver who was under influence of alcohol in 13% of these crashes. Alcohol involvement was not tested in half of the surviving drivers.

CONCLUSIONS

The data show that 20% of both passengers and drivers were under the influence of alcohol. Increased testing of surviving drivers regarding alcohol and other drugs is recommended.

Violent deaths in small children in northern Sweden

OBJECTIVES

To identify causes and trends of violent deaths among children younger than 4 years in a northern region.

STUDY DESIGN

Retrospective analysis of medico-legal autopsy and police data.

METHODS

Data from all 72 deaths from "external causes" 1977-2004, in children < 4 years from the northern half of Sweden were analysed.

RESULTS

The death rate was 7.1 per 100,000 children and year during the first half of the study period, and 5.2 during the second half. Vehicle- and drowning-related deaths were halved. Fifteen were struck by motor vehicles (in 8 cases by heavy vehicles), 14 car occupants were killed in car crashes, 12 were killed by intentional violence inflicted by an adult, and 9 each were killed by (i) carbon monoxide/smoke inhalation, (ii) asphyxiation, or (iii) drowning. The boy:girl ratio was 1:1 in all groups, except in the groups "drowning" and "run over by motor vehicle", where boys dominated.

CONCLUSIONS

Medical professionals have a difficult but important task in identifying and taking action against child abuse and in promoting child safety especially in the traffic and home environments.

[All traffic related deaths are not "fatalities"--analysis of the official Swedish statistics of traffic accident fatalities in 1999]

In 1997 the Swedish Parliament decided, in accordance with the so-called Vision Zero, that one official goal for the national traffic safety effort is that the number of traffic fatalities in the year 2007 must not exceed 270. In order to monitor efforts toward this hard-won goal, it is of course of utmost importance that official statistics on traffic deaths are reliable. In a meticulous analysis of all 580 officially registered traffic deaths in Sweden in 1999, we found that 490 were true accidental deaths, while 18 were suicides, 12 were deaths due to indeterminate causes, 59 were natural deaths and 1 case was not possible to evaluate due to missing data. Thus, only 84% of the officially registered "accidental traffic deaths" were bona fide accidents. In order to enhance the reliability of the official statistics, we suggest that regulations concerning police investigation and medicolegal autopsy of all unnatural deaths be adhered to all deaths reported to the Swedish National Road Administration should be checked in the database of autopsied cases in the National Board of Forensic Medicine in order to exclude natural deaths the time delay (1.5 years) to complete the official Cause-of-Death Register be shortened criteria for the classification of manner of death in "borderline" cases be suggested for international acceptance.

[Inadequate management of unnatural deaths]

A death certificate was issued without a medicolegal autopsy in one third of all Swedish cases of unnatural death during 1991 through 1996. Out of 415 unnatural deaths in the northern part of Sweden, not subjected to a medicolegal autopsy but analyzed in this study, only 14% were reported to police authorities. Elderly, women and patients dying after a longer period of hospital care were more often not reported to the police. It is recommended that forensic pathologists be consulted in order to achieve better management of unnatural deaths.

Quantification of alcohol-related mortality in Sweden

The main aim of the present study was to estimate total alcohol-related mortality in Sweden. For natural deaths, a meta-analysis carried out in Australia was updated to the end of March 1998, and pooled estimates of the relative risks were calculated for different diseases based on data from scientific studies that have been published in the international literature. The proportion of current alcohol drinkers from recent Swedish surveys, and the pooled relative risk estimates were used to estimate disease-specific alcohol-attributable fractions. Natural deaths 'caused' or 'prevented' by alcohol were estimated for the period 1992-1996. For unnatural deaths, all cases from 1992 through 1996 in Sweden were analysed (n = 23 132). Alcohol was regarded to attribute to the death: if the deceased was a 'known alcoholic'; if the underlying or contributing cause of death was alcohol-related; if the deceased had an alcohol-related in-patient diagnosis during a 3-year period prior to death; if the case tested positive for blood alcohol. Person years of life lost/gained (<70 years) due to alcohol were also assessed. The assumptions underlying the attributable risk methods used to analyse alcohol-related mortality due to natural causes need to be borne in mind when interpreting the results on natural deaths. Moreover, the preventive effect of alcohol on coronary heart disease and stroke is still controversial. The findings of alcohol-related mortality due to unnatural causes were much more reliable. About 3.5% of deaths were attributed to alcohol; alcohol involvement was more than twice as common in deaths of males (4.8%) than in those of females (2.0%). About one-quarter of the deaths in those aged below 50 years were attributed to alcohol. In those (</=69 years, alcohol had a net harmful effect in that it 'caused' more deaths than it 'prevented'; 7% of deaths were in net 'caused'. More person years of life were in net lost than were saved by alcohol, suggesting that alcohol has a negative effect on premature mortality. We conclude that alcohol accounted for about 3. 5% of deaths in all ages, and 25% of deaths in those aged below 50 years, and about 10% of person years of life lost in Sweden. The balance of harm and benefit does not weigh in favour of making a recommendation to the public to drink in order to prevent death.

Role of alcohol in unnatural deaths: a study of all deaths in Sweden

BACKGROUND

Most previous research has concentrated on the role of alcohol in one type of unnatural death in a selected population, but the present objective was to investigate the role of alcohol in all unnatural deaths (autopsied and not autopsied).

METHODS

All cases of unnatural death from 1992 through 1996 in Sweden were analyzed (n = 23,132). Death was attributed at least in part to alcohol if the deceased was a "known alcoholic"; if the underlying or contributing cause of death was alcohol-related; if the deceased had an alcohol-related inpatient diagnosis during the 3-year period prior to death; or if the deceased tested positive for blood alcohol.

RESULTS

Just over 28% of the unnatural deaths could be associated with alcohol; the association with alcohol was more than twice as common in deaths of males (35%) as in females (16%). When only autopsied cases or only blood-tested cases were taken as the denominators, 38% and 44%, respectively, of the deaths were associated with alcohol. Alcohol involvement also was twice as common in intentional deaths (36%) as in unintentional deaths (18%). The intoxication group (78%) had the highest fraction of deaths that could be associated with alcohol, followed by the undetermined group (62%), homicide (49%), fire (41%), suicide (35%), asphyxia (29%), traffic (18%) and fall (9%) groups. In the 20- to 59-year age group, alcohol involvement was found in 51% of the males and 35% of the females (47% for males and females combined).

CONCLUSIONS

The present estimates are conservative; alcohol involvement in unnatural deaths probably is even higher, up to 44% of the total. The present estimation is an important step in policy-making to lower the number of alcohol-related deaths in Sweden.

Alcohol and unnatural deaths in Sweden: a medico-legal autopsy study

OBJECTIVE

To investigate alcohol involvement in all types of unnatural deaths in Sweden.

METHOD

All cases of unnatural death that underwent medico-legal autopsies (1992-1996) in Sweden were analyzed (N = 15,630; i.e., 68% of all unnatural deaths). Alcohol was regarded as contributing to the death if: (1) there was any indication that the deceased was a "known alcoholic"; (2) the underlying or contributing causes of death were alcohol-related; (3) the deceased had alcohol-related inpatient diagnosis during a period of 3 years prior to death; or (4) the case tested positive for blood alcohol.

RESULTS

Thirty-nine percent of the blood-tested cases (n = 13,099) were positive for alcohol. Almost 40% of the unnatural deaths were associated with alcohol. Alcohol involvement was most common in the intoxication group (84%), followed by the "undetermined" (65%), homicide (55%), fall (48%), fire (44%), asphyxia (41%), suicide (35%) and traffic (22%) groups. More than half (52%) of the deaths in the age group 30-60 years, 35% of those aged 0-29 years and 25% of those aged 60 and over were associated with alcohol.

CONCLUSIONS

In Sweden, two of five unnatural deaths are associated with alcohol; this is a conservative estimate. Alcohol-associated mortality varies considerably between different groups of external causes of death, between men and women, and with age.

[Shortcomings in the coverage of death occurring outside hospitals]

The article consists in a report of physicians' observance of legislative requirements concerning the documentation and investigation of deaths outside hospital, as studied in a series of 973 cases of death occurring in four medium-sized Swedish communities during 1993. The results showed manifest shortcomings in the performance of post-mortem investigations: long delays in submitting the death certificate, negligence in reporting unnatural and unexpected deaths to the police, and inadequate notes in the patients' journals concerning death certification, which relatives had been informed, the circumstances of death, and whether post-mortem examination had been performed. A special checklist would be of value in the documentation adn investigation of deaths occurring outside hospital.