Sudden death related to sexual activity: A multicenter study based on forensic autopsies (2010-2021)

INTRODUCTION AND OBJECTIVES

To investigate the epidemiological characteristics, clinic-pathological findings and recent use of substances of abuse and prescribed drugs in sexual activity-related sudden death (SArSD).

METHODS

Multicenter population-based study on forensic autopsies conducted in 27 provinces of Spain over 12 years (2010-2021).

RESULTS

Out of 18046 autopsied natural deaths, 64 cases (0.35 %) of SArSD were investigated (87 % males). Women were younger than males (50.5 ± 13.4 years vs 37.2 ± 14.2; p = 0.017). Sudden cardiac deaths (SCD) accounted for 87 % of cases. Ischemic heart disease was the predominant pathology (58 %), mainly affecting men ≥ 36 years of age. Cerebral haemorrhage (8 %) and asthma (5 %) were the leading non-cardiac causes. In young adults, SADS (36 %) and asthma (27 %) were the main causes The disease responsible of SCD was diagnosed in life in 7 subjects. In 64 % there were cardiovascular risk factors, mainly obesity. Toxicological analysis detected illicit drugs (23 %), mainly cocaine, medications for erectile dysfunction (9 %), and ethanol ≥ 0.5 g/L (8 %). Deaths occurred usually in the context of heterosexual intercourse and during or immediately after sexual activity. The most common location was at home (63 %). In 12 men the sexual partner was a sex worker.

CONCLUSIONS

SArSD has a low incidence in the general population affecting middle-aged males during intercourse with a heterosexual partner. It is of cardiovascular origin, mainly due to ischemic heart disease that frequently remained silent during life. There is a frequent association with obesity, use of cocaine (and, to a lesser extent, medications for erectile dysfunction) and performing unconventional sexual practices. Forensic investigation is useful for developing prevention strategies.

A positive toxicology screen is a rare finding in sports-related sudden cardiac deaths

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): University of Copenhagen

Introduction

Sports-related sudden cardiac deaths (SrSCD) are rare events often occurring in healthy individuals. An underlying cardiac disease may, in combination with strenuous exercise, trigger lethal arrhythmias. Intake of drugs (legal and illicit) increases the risk of sudden cardiac death (SCD), but knowledge on toxicological findings in SrSCD remains sparse.

Purpose

This study aimed to characterize the SrSCD population in an international consortium by investigating the epidemiology and autopsy findings in SrSCD.

Methods

Participating centers of the consortium (Denmark, Australia, England, Spain) provided data on all forensically autopsied SCDs aged 12—49 years in their respective cohorts, spanning from 2000—2019. Demographics, autopsy findings, and toxicology screen were assessed. A toxicology screen was considered positive if any drug was detected, except drugs related to resuscitation.

Results

Of all 5,029 SCDs, we identified 435 (9%) SrSCD. The majority (88%) died during sports while the remaining 12% died within one hour from exercise. SrSCD occurred more often in males (91% vs 71%, p<0.001) who were younger (32 vs 36 years). In SrSCD, the autopsy more frequently revealed an underlying structural cardiac cause of death (64% vs 54%, p<0.001); the most frequent causes of death among SrSCDs were sudden unexpected death (SUD), ischemic heart disease (IHD), and arrhythmogenic cardiomyopathy (ACM). Toxicological screens were performed in approx. 90% of cases, regardless of relation to sport. Among SrSCD cases, the rate of a positive toxicology was less than half compared to other SCDs (18% vs 44%, p<0.001). The most frequent toxicological findings among SrSCDs were ethanol, central stimulants, cannabinoids, and non-opioid analgesics.

Conclusions

Sports-related SCD accounted for 9% of all SCDs in our population aged 12—49 years. The majority of sports-related deaths (88%) occurred during exercise activity. SrSCDs more often had an underlying structural cardiac disease, mainly IHD and ACM. Positive toxicology screens were half as frequent in SrSCDs compared with non-SrSCDs.

Genetic regulation of myocardial fibrosis in hypertrophic cardiomyopathy

Background

Myocardial fibrosis is a common feature of hypertrophic cardiomyopathy (HCM) but its pathophysiology has yet to be elucidated.

Purpose

In this study, we used a multiplex approach to examine the genetic regulation of pathways associated with fibrosis in patients undergoing septal myectomy.

Methods

Myocardial tissue was collected at time of surgical intervention. Control biopsy samples were obtained from the left ventricular free wall from structurally normal hearts during autopsy following non-cardiac related death. Tissue was either snap frozen in liquid nitrogen and subsequently stored at −80 degrees or collected in RNA laterTM and frozen 24 hours later at −80 degrees. Total RNA was extracted from HCM tissue samples using the Qiagen RNeasy fibrous tissues mini kit and from control samples using mirVana isolation kit (Ambion), according to the manufacturer's protocol. Quantitative PCR (qPCR) was performed on the extracted RNA using a RT. Profiler™ Human finrosis PCR Array.

Results

The study cohort comprised 22 HCM samples and 5 controls. The relative regulation of genes involved in myocardial fibrosis in patients with HCM compared to controls is shown in figure 1.

In patients with HCM, there was increased expression of genes involved in collagen synthesis. A significant two-fold upregulation in type III procollagen mRNA was observed relative to controls (p=0.013) with a similar trend identified for type I procollagen (1.5 fold up-regulation, p=0.081). The gene expression of MMP3 (−1.5 fold, p=0.029) and MMP8 (−1.8, p=0.002) which are involved in collaged degradation were downregulated in the HCM group.

The gene expression of pro-fibrotic mediators TGF-β2 (4.8 fold, p=0.008) and CCN2 (2.9 fold, p=0.021) was also significantly elevated. Within the HCM group, there was a correlation between the fold regulation of TGF-β1 (r=0.570, p=0.006; r=0.528, p=0.012), TGF-β2 (r=0.569, p=0.006; r=0.514, p=0.014) and TGF-β3 (r=0.738, p<0.001; r=0.496, p=0.019) to gene regulation of type I and III procollagens respectively.

The expression of BMP-7 which has been shown to reduce myocardial fibrosis by antagonising TGF- β mediated endothelial – mesothelial transformation of fibroblasts was also down-regulated in HCM (−3.8, p=0.015).

Conclusions

Genetic expression of procollagen is significantly upregulated in patients with HCM relative to controls. TGF-β and CCN2 mediated signalling appear to be key mediators in promoting collagen expression.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Heart Hospital Charitable Grant, UK Figure 1. Gene expression in HCM

How to optimise the yield of forensic and clinical post-mortem microbiology with an adequate sampling: a proposal for standardisation

Post-mortem microbiology (PMM) is an important tool in forensic pathology, helping to determine the cause and manner of death, especially in difficult scenarios such as sudden unexpected death (SD). Currently, there is a lack of standardization of PMM sampling throughout Europe. We present recommendations elaborated by a panel of European experts aimed to standardize microbiological sampling in the most frequent forensic and clinical post-mortem situations. A network of forensic microbiologists, pathologists and physicians from Spain, England, Belgium, Italy and Turkey shaped a flexible protocol providing minimal requirements for PMM sampling at four practical scenarios: SD, bioterrorism, tissue and cell transplantation (TCT) and paleomicrobiology. Biosafety recommendations were also included. SD was categorized into four subgroups according to the age of the deceased and circumstances at autopsy: (1) included SD in infancy and childhood (0-16 years); (2) corresponded to SD in the young (17-35 years); (3) comprised SD at any age with clinical symptoms; and (4) included traumatic/iatrogenic SD. For each subgroup, a minimum set of samples and general recommendations for microbiological analyses were established. Sampling recommendations for main bioterrorism scenarios were provided. In the TCT setting, the Belgian sampling protocol was presented as an example. Finally, regarding paleomicrobiology, the sampling selection for different types of human remains was reviewed. This proposal for standardization in the sampling constitutes the first step towards a consensus in PMM procedures. In addition, the protocol flexibility to adapt the sampling to the clinical scenario and specific forensic findings adds a cost-benefit value.

Ocular involvement in Takayasu's arteritis: response to cyclophosphamide therapy

PURPOSE

To report a Takayasu's arteritis (TA) case with an intense ocular involvement and the response to monthly bolus of Cyclophosphamide.

METHODS

Case report and literature review.

RESULTS

Cyclophosphamide was useful to improve the TA symptoms without any additional treatment and any secondary effects. When this therapy was discontinued the ocular symptoms progressed.

CONCLUSION

Although no definitive therapy has been established, Cyclophosphamide intravenous bolus may be useful to improve ocular symptoms of Takayasu's Arteritis, specially in early stages. There are not adequate descriptions in the literature concerning the effect of this treatment on the ocular manifestations of TA.

Technical note: a device for obtaining time-integrated samples of ruminal fluid

A device was adapted to allow for time-integrated sampling of fluid from the rumen via a cannula. The sampler consisted of a cup-shaped ceramic filter positioned in the ventral rumen of a cannulated cow and attached to a tube through which fluid entering the filter was removed continuously using a peristaltic pump. Rate of ruminal fluid removal using the device was monitored over two 36-h periods (at 6-h intervals) and was not affected (P > .05) by time, indicating that the system was not susceptible to clogging during this period. Two cows having ad libitum access to a totally mixed ration were used in a split-block design to evaluate the utility of the system for obtaining time-integrated samples of ruminal fluid. Ruminal fluid VFA concentration and pattern in samples collected in two replicated 8-h periods by the time-integrated sampler (at 1-h intervals) were compared with composite samples collected using a conventional suction-strainer device (at 30-min intervals). Each 8-h collection period started 2 h before or 6 h after feeding. Results indicated that total VFA concentration was not affected (P > .05) by the sampling method. Volatile fatty acid patterns were likewise unaffected (P > .05) except that acetate was 2.5% higher (P < .05) in samples collected 2 h before feeding and valerate was 5% higher (P < .05) in samples collected 6 h after feeding by the suction-strainer device. Although significant, these differences were not considered physiologically important. We concluded that use of the ceramic filter improved the sampling of ruminal fluid by simplifying the technique and allowing time-integrated samples to be obtained.

Cerebellar cortex delayed maturation in sudden infant death syndrome

The cerebellum shows afferent and efferent connections with intrinsic bulbar nuclei and plays an important role in respiration and cardiovascular control. Pathological and neurochemical abnormalities of bulbar nuclei including the arcuate nucleus have been postulated in sudden infant death syndrome (SIDS). Most of these abnormalities have been related to impairment in brain development. The cerebellar cortex has a well-documented evolution from fetal life until infancy; thus, it may be a very good model to assess brain maturation in SIDS. The present study was conducted to investigate changes in the cerebellar cortex in 19 SIDS cases compared with 12 age-related controls using morphological, quantitative, and statistical approaches. Five-microns paraffin sections from the midsagittal cerebellar vermis were stained with hematoxylin and eosin (H&E). Immunohistochemical staining was carried out using a polyclonal antiserum to glial fibrillary acidic protein (GFAP). Each case consisted of a 25-microns parallel paraffin section stained with H&E, where the cerebellar external granular layer (EGL) cell density was obtained in one field magnification (x1,000) using an optical dissector procedure on the basis of a stereological method. A statistically significant high EGL cell density, mostly related to the presence of immature bipolar, elongated neuronal cells of the premigratory zone with hyperchromatic, oval or poor differentiated nuclei, was observed in SIDS. In these cases, EGL expressed immunoreactivity for GFAP mainly in the subpial and the postmitotic zone. These findings demonstrate a delayed or slower decline in the number of EGL neurons in SIDS, suggesting either a prolongation of the growth phase related to postnatal cerebellar foliation or a delay in inward migration. These results suggest that in SIDS there is delayed maturation of the cerebellar cortex/EGL, which may support the hypothesized cardiopulmonary control dysfunction, leading to death in a vulnerable period of postnatal development.

Dietary nucleotides might influence the humoral immune response against cow's milk proteins in preterm neonates

The objective of this study was to evaluate the influence of dietary nucleotide supplementation in preterm infants during the first month of life on the intestinal permeability to lactulose, mannitol and to beta-lactoglobulin and on the development of circulating antibodies to beta-lactoglobulin and alpha-casein. Twenty-seven preterm infants were enrolled in the study; 11 of them were fed a standard low-birth weight milk formula and 16 infants were fed the same formula supplemented with nucleotides at similar levels to those found in human milk. Blood and urine samples were obtained at 1, 7 and 30 days of age. Serum beta-lactoglobulin, serum IgG antibody to alpha-casein and serum IgG antibody to beta-lactoglobulin were measured by ELISA. The lactulose/mannitol urinary excretion rate was measured by gas liquid chromatography. Neither the intestinal permeability to saccharides nor the intestinal absorption of beta-lactoglobulin were affected by the nucleotide supplementation. However, serum concentrations of IgG antibody to beta-lactoglobulin were higher in preterm neonates fed the supplemented formula than in those fed the standard formula. According to these results, dietary nucleotides might influence the maturation of the humoral immune response in preterm newborn infants.

Ependymal changes in sudden infant death syndrome

The ependyma may befall a variety of pathogenic noxae during fetal life, resulting in histological changes which may persist after birth but are without clinical manifestations. Eight of a series of 19 children who died suddenly and unexpectedly, where no explanation as to the cause of death was found at autopsy, were shown to have diverse histological features involving the ependyma. Five micrometer paraffin-embedded brain tissue sections including frontal, temporal, occipital, and ventricular horns as well as the fourth ventricle were stained with hematoxylin-eosin (H&E) and luxol fast blue (LFB). Immunohistochemical stains using antibodies to glial fibrillary acidic protein (GFAP), vimentin and S-100 were also performed. Findings included areas of denuded and/or desquamated ependyma, rosettes in different stages of formation, vacuoles and/or pseudocysts, inflammatory changes consisting in macro- and microglial nodules in the subependymal layer, and gliosis. Chronic brain edema was seen in 4 cases. Our findings indicate that ependymal changes in sudden infant death syndrome (SIDS) cases belong to the prenatal or early postnatal period, thus providing, indirectly, a morphological substrate for the previous existence of a noxa that may also affect other CNS areas, and thus being in the position to produce cardiorespiratory control dysfunction.

Pharmacokinetics of erythropoietin following single-dose subcutaneous administration in preterm infants

The pharmacokinetics of recombinant human erythropoietin was studied in 12 very low birth weight preterm infants < 32 weeks of gestation after subcutaneous administration of 300 IU/kg at a postconceptional age of 34 (32-37) weeks and a weight of 1,505 (1330-1,740)g (median and range). The administration of recombinant human erythropoietin produced a rapid increase in serum erythropoietin levels with a peak level of 362.8 mIU/ml at 8.9 h. The area under the curve was 8,177.5 (4,597.1-15,453.0) mIU/ml/h, the absorption half-life was 5.5 (1.6-6.6) h, the elimination half-life was 7.9 (5.6-19.4) h, and the residence time was 19.6 (5.1-32.6) h (all values reflect median and range). There was no significant correlation between absorption and elimination half-life of erythropoietin and birth weight, gestational age, sex, and age and weight of the infants at the time of administration of erythropoietin. Based on absorption and elimination kinetics, the dosing interval for subcutaneous administration must not be < 48 h.

Vascular lesions in intestinal ischemia induced by cocaine-alcohol abuse: report of a fatal case due to overdose

Intestinal ischemia induced by cocaine abuse is a rare condition. To this date, only three cases have been described. The diagnosis of bowel ischemia should be suspected whenever a cocaine addict has severe abdominal pain. A pathological examination of the resected bowel segment was performed in one case, and the diagnosis was confirmed microscopically. However, the existence of pathologic alterations of the intestinal vessels was not confirmed. Why the intestinal injury is segmental and whether it is related to the dose ingested, the administration route, or the combination of cocaine with alcohol, caffeine, or marijuana remain unclear. The authors report one fatal case associated with cocaine-alcohol overdose. The postmortem examination demonstrated the existence of segmental intestinal ischemia. Microscopic study failed to demonstrate thrombosis in the mesenteric vessels; however, we found an unusual lesion affecting the arterioles located in the intestinal submucosa of the hemorrhagic areas.