Characteristic Features of Pediatric Firearm Fatalities—Comparisons Between Australia and the United States

Abstract:  Gunshot deaths in children less than 17 years of age from Adelaide, SA, Australia (1969–2005) and from San Diego County, CA, United States (1988–2005) were compared. Forty-two pediatric gunshot fatalities occurred in South Australia (1.1 cases/year; M:F = 30:12). There were 6 accidents (14%), 14 suicides (33%), and 22 homicides (52%). In San Diego there were 185 cases ( c. 10 cases/year; M:F = 148:37). There were 6 accidents (3%), 42 suicides (23%), 130 homicides (70%), and 7 undetermined cases (4%). The incidence of homicide was significantly higher in San Diego County compared to Adelaide ( p  < 0.001), with a higher proportion of murder–suicides occurring in Adelaide. There were markedly more accidents and suicides involving males in Adelaide and a far higher number of male homicide victims in San Diego County compared to females. Rifles of 0.22-caliber were preferred weapons in South Australia, compared to handguns in San Diego County.     

Toxicology and characteristics of deaths involving zolpidem in new South wales, australia 2001-2010*

Abstract: All cases presenting to the New South Wales Department of Forensic Medicine between January 1, 2001 and September 31, 2010 in which zolpidem was detected, were retrieved. A total of 91 cases were identified. The mean age was 49.4 years, 65.9% were male, and 61.5% were suicides. Zolpidem was a factor contributing to death in 35 (37.3%) cases, of which 31 (34.1%) involved zolpidem toxicity. The median blood zolpidem concentration was 0.20 mg/L (range 0.05–3.50 mg/L), with no significant gender difference. Drug toxicity cases involving zolpidem had significantly higher median blood zolpidem concentrations than other cases (0.50 vs. 0.10 mg/L). In 83.5% of cases, psychoactive substances other than zolpidem were detected, most commonly antidepressants (46.2%), benzodiazepines (35.2%), opioids (26.4%), and alcohol (39.6%). In summary, zolpidem was a factor contributing to death in a large proportion of cases, predominately involving drug toxicity and suicide.     

Toxicology and characteristics of fatal oxycodone toxicity cases in New South Wales, Australia 1999-2008

All cases of fatal oxycodone toxicity presenting to the New South Wales Department of Forensic Medicine over the period January 1, 1999, to December 31, 2008, were retrieved. A total of 70 cases were identified. The mean age was 48.9 years, 58.6% were men, 21.4% were suicides, and in 30% oxycodone had not been prescribed to the decedent. Injecting drug users constituted 27.1% of cases, and oxycodone tablets were injected immediately prior to death by 21.4%. The mean blood oxycodone concentration was 0.40 mg/L (range 0.06-53.00 mg/L). In all cases, psychoactive substances other than oxycodone were also detected, most frequently hypnosedatives (68.6%), other opioids (54.3%), antidepressants (41.4%), and alcohol (32.9%). Preexisting systemic disease was common: cardiovascular (64.2%), pulmonary (49.3%), hepatic (66.7%), and renal (43.9%).     

Antidepressants at Autopsy in Hispanic Suicidal Youth in Miami‐Dade County,Florida*

Abstract: Controversy has surrounded the use of antidepressants and suicidal behaviors in youth. This study reviewed the Medical Examiner’s Office records of 253 persons aged 24 years or younger classified as suicides in Miami‐Dade County, Florida, from 1990 to 2007. Information was collected regarding demographic information, suicidal characteristics, psychiatric and psychosocial factors, and toxicology results. Eighty‐five percent of the sample was men, and 53.4% of the subjects were Hispanic. Consistent with previous literature, the existence of antidepressants at autopsy was rare; present in only 6% (n = 15) of the victims. The occurrence of antidepressants was not significantly different between Hispanics (n = 7) and non‐Hispanics (n = 8). The incidence of antidepressants was weakly correlated with a tendency to be men and no history of psychiatric illness. The presence of antidepressants in Hispanic youth suicide victims was similar to non‐Hispanics.     

The prevalence of drugs in carbon monoxide-related deaths: a retrospective study, 2000-2003

The objective of this study was to review demographic characteristics and drugs detected in carbon monoxide (CO)-related deaths from cases received by the Office of the Cuyahoga County Coroner in Cleveland, Ohio, from 2000-2003. Postmortem reports were reviewed, and decedents for which CO was listed as the cause of death were included. The data were compiled into 3 groups according to the official coroner's verdict as to the manner of death: accident, suicide, and homicide. Included in this study were 122 cases: 84 (69%) accidental, 31 (25%) suicide, and 7 (6%) homicide. Accident decedents were typically white males, aged 40-59 years, residing in Cleveland. Suicide decedents were also middle-aged, white males but residing in the suburbs. Homicide decedents under the age of 6 were characteristically black (N=2), while decedents over the age of 39 were predominately white (N=3). Carboxyhemoglobin (COHb) levels in suicide cases were higher than concentrations measured in accidental deaths. The highest percentage of suicide decedents (36%) had a COHb level>70% saturation, accident decedents (36%) between 50% and 69% saturation, and homicide decedents (71%) below 50% saturation. Ethanol (N=34) was detected in 28% of deaths, and therapeutic and/or abused drugs (N=50) were detected in 41% of deaths. Illicit drugs were detected in 11% of cases (cocaine/metabolites; THC/metabolites), other drug positives were therapeutic medications. The most common drugs detected were antidepressants and antihistamines in suicides and pain medications and antihistamines in accidents.     

Contributory and Incidental Blood Concentrations in Deaths Involving Citalopram

All cases presenting to the New South Wales Department of Forensic Medicine between January 1, 2001 and December 31, 2010 in which citalopram was detected were retrieved. A total of 348 cases were identified. Citalopram contributed to death in 21.0%, and was incidental in 79.0%. Cases in which citalopram was contributory to death had significantly higher blood citalopram concentrations than incidental cases (0.50 mg/L vs. 0.30 mg/L). Citalopram concentrations varied significantly by contributory status: sole citalopram toxicity (median = 1.30 mg/L), citalopram/other drug toxicity (0.50 mg/L), and incidental cases (0.30 mg/L). Citalopram concentrations also varied by suicide status, with the highest concentration found in suicides where citalopram contributed to death (0.70 mg/L) compared with 0.50 mg/L for nonsuicide cases where citalopram contributed to death. In almost all contributory cases (69/73), other psychoactive substances were also detected, most commonly benzodiazepines (47.9%), alcohol (45.2%), and opioids (40.1%).     

Fatal intoxications in a Swedish forensic autopsy material during 1992-2002

Compilations of substances detected in fatal intoxications are important in order to observe changes in intoxication patterns, to monitor effects of preventive work and to discover new trends in drug usage. The aim of the present study was to describe the current pattern of substances detected in fatal intoxications in Sweden. Fatal intoxications investigated at the Department of Forensic Chemistry, Link?ping, Sweden, during 1992-2002, were analysed. All suicides, uncertain cases and accidents where the cause of death were fatal intoxications (ICD-9: E950, E980 and E859) were included and substances detected in more than 50 fatal intoxications (in femoral blood) were listed. For each substance, a cut off value was set, above which concentrations were considered toxic. Fatal intoxications were detected by forensic-chemical analyses in 12% (6998/60,314) of the forensic autopsies during the study period. Among the suicides, an average of 3.8 substances were detected per case, the corresponding figure for uncertain cases and accidents were 3.5 and 4.1 substances, respectively. Ethanol was by far the most frequently detected substance, detected in 43% (3039) of the fatal intoxications, of which 32% (960) had toxic concentrations, followed by propoxyphene, detected in 27% (1863) of the fatal intoxications of which 74% (1370) had toxic concentrations. The number of cases where ethanol and propoxyphene were detected decreased during the study period. Moreover, other CNS-active drugs such as antidepressants, analgesics and anxiolytics were also frequently detected. The drugs with high proportions of cases with toxic concentrations detected were propoxyphene, amitriptyline, zolpidem, carisoprodol, alprazolam, thioridazine, methadone and ketobemidone. Selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepressants (TCA) were detected in 12% (833) and 10% (665), respectively. A significantly (P <0.001) higher proportion of cases where TCA were detected had toxic concentrations when compared with cases where SSRI were detected (64% versus 31%).     

Trends in suicide by carbon monoxide inhalation in King County, Washington: 1996-2009

Carbon monoxide (CO) inhalation is one of the leading methods of suicide in the United States. A sharp increase in suicide by inhaling the CO produced from burning charcoal has been reported in parts of Asia; however, the incidence of this method has not been determined in a U.S. population. Thus, we determined trends of CO suicide in the ethnically diverse population of King County, Washington, U.S.A. During the period 1996-2009, we identified 158 cases of suicide by CO poisoning, with 125 because of automotive exhaust, 26 because of charcoal burning, and seven from other CO sources. While historical U.S. data indicate >99% of CO suicides in the United States occurring by automobile exhaust inhalation, in the most recent years analyzed, c. 40% of CO-related suicides in King County, Washington, were because of charcoal burning, indicating a possible shift in suicide trends that warrants further scrutiny in additional populations.     

The Richard Cory phenomenon: suicide and wealth in Kansas City, Missouri

This case-control study investigates the relationship between suicide and wealth in Kansas City, Missouri. House and personal property appraisal data on all victims of suicide from 1998 and 2002 and victims from a control population of deaths reported to the Jackson County Medical Examiner during the same time interval were obtained from the Jackson County Government website. The controls were matched to suicide cases by race, gender, year of death, and age at death (+/- 1 year). Data from the 426 members of each group of suicides and controls indicate that suicide victims were: 1) 77% more likely than controls to have lived in houses rather than in apartments or trailers, 2) more likely than controls to have lived in more expensive houses (mean values dollar 70,143 versus dolllar 61,513 respectively, p = 0.04) and 3) more likely to have killed themselves because of factors other than financial strain (8.0% of suicides showed financial strain).     

Drugs and chronic alcohol abuse in drivers

Blood specimens from 210 drivers (179 male and 31 female) apprehended in Luxembourg from autumn 2001 to spring 2002 and requested for the determination of their blood alcohol concentration (BAC) were tested for medicinal drugs, illicit drugs, and chronic alcohol abuse (by quantification of the carbohydrate-deficient transferrin: CDT). These additional analyses were performed anonymously and with permission of state prosecutor. The 22.8% had consumed medicinal drugs, with benzodiazepines and antidepressants (10.9 and 7.6%, respectively) as main psychoactive classes. Cannabis was the most detected illicit drug (9.5%) but only one in three had THC detectable in their blood. Association of two or more psychoactive substances (poly-drug use) was observed in 27.6% of drivers (90.6% of drug consumers). On the basis of CDT values, 29.5% of drivers investigated were assumed to be chronic alcohol abusers. Statistical analysis revealed that chronic alcohol abuse and medicinal psychoactive drugs were associated with significantly higher BAC. Medicinal psychoactive drugs were clearly associated with poly-drug use, and were furthermore detected at supra-therapeutic levels in 34.9%.     

Suicidal drowning in south Florida.

Autopsy protocols at the office of the Chief Medical Examiner were reviewed with respect to suicidal drowning. Between July 1, 1994 and June 30, 1998, there were 267 drownings and 873 people committed suicide in Broward County, Florida. Of those, 25 were suicidal drownings, representing 2.86% of all suicides, and overall the 8th leading cause of suicidal death. When considering suicide in the age group of 65 years and older, (n = 239), which accounts for 19.8% of the population and 27.4%, of all suicides, drowning represents 6.7% of all suicidal deaths, and within females in this group represents the third most common form of suicidal death (13.8%). The presence of alcohol or other drugs is less usual in elderly suicide victims than younger victims. Of the 25 drowning suicides, there was a preference for swimming pools, canals, and lakes as the locations of choice. Additional drowning and suicide related criteria were evaluated including marital status, mental health, clothing worn, previous attempts or threats, suicide notes, and personal effects at the scene; with the intention of establishing a profile for drowning by suicide. Given the relative abundance of water, the suicidal drowning rate appears to be lower than what might otherwise be anticipated.     

Homicide–Suicide in Cuyahoga County,Ohio, 1991–2016

Research on homicides followed by suicides has relied heavily on small samples and relatively short time spans of data. This study helps to fill this gap by examining 26 years of homicide–suicide data from Cuyahoga County, Ohio, between 1991 and 2016. The main data source for the study is medical examiner files. Analyses of the data indicate the rate of homicide–suicide in Cuyahoga County is consistent with other studies but fluctuates considerably across years studied. The majority of victims are female while perpetrators are overwhelmingly male. Black people are overrepresented as victims and offenders. Use of drugs and/or alcohol leading up to the incident is common among perpetrators. Both the homicides and suicides were overwhelming committed with firearms. When comparing our results to the typology of murder–suicides developed by Marzuk, Tardiff, and Hirsch (JAMA 1992;267:3179), we find amorous jealousy is a significant motivating factor in a many cases, including those involving nonintimate partners. Our findings underscore the importance of widespread use of lethality assessment instruments.     

Suffocation using plastic bags: a retrospective study of suicides in Ontario, Canada

One hundred and ten cases of suicidal suffocation using a plastic bag were identified in the files of the Office of the Chief Coroner of Ontario, Canada, between 1993 and 1997. The records were reviewed to determine the demographic characteristics of this group compared with all cases of suicide in Ontario, the scene information, autopsy findings and toxicology results. Most suicides occurred in people over 60 years of age, with older women making up a considerable proportion of cases as compared with other methods of suicide. In 40% of cases the deceased was suffering from a serious illness. Autopsy findings were usually minimal, with facial, conjunctival and visceral petechiae present in a minority of cases. One or more drugs were detected in the blood in 92.6% of cases where toxicologic testing was performed. Benzodiazepines, diphenhydramine and antidepressants were the most common drugs found, with diphenhydramine the most common drug present at an elevated concentration. Information at the scene from "right to die" societies was uncommon. One quarter of decedents took additional measures, besides the use of drugs or alcohol, to ensure the rapidity, certainty or comfort of their death. This study further elucidates the characteristics of this uncommon method of suicide. It emphasizes additional scene findings, such as the presence of dust masks, physical restraints and modification of the plastic bag that may be of use to death investigators in determining the correct manner of death.     

Toxicology and Circumstances of Completed Suicide by Means Other than Overdose*

Abstract: To determine the prevalence and circumstances of psychoactive substances amongst nonoverdose completed suicide, 1436 consecutive cases autopsied at the NSW Department of Forensic Medicine over the period 1/1/1997–12/31/2006 were analyzed. Substances were detected in 67.2% of cases, and illicit drugs in 20.1%. Alcohol was present in 40.6% of cases. Males were more likely to be positive for alcohol, cannabis, and psychostimulants, and females for pharmaceuticals. Illicits were associated with younger age. Alcohol was most prominent amongst toxicity cases, as were opioids, psychostimulants amongst gunshot cases, and pharmaceuticals amongst drownings. Cases in which drug and alcohol histories were noted were more likely to have a substance detected. Alcohol was more common where a suicide note was left and where relationship problems were involved. Pharmaceuticals were more common where a previous attempt was noted. Licit and illicit substances are strongly associated with suicide, even when the method does not involve drug overdose.     

Global functioning and suicide among Chinese rural population aged 15-34 years: a psychological autopsy case-control study

As the relationship between global functioning and young suicide remains unclear in rural China, this study was aimed to explore the relationship between them. Data of 391 rural suicides and 416 controls, all aged 15-34 years in three provinces in China were used for this study. The Global Assessment of Functioning (GAF) scale was adopted to assess global functioning of suicides and controls. The results showed that GAF score was stronger than mental illness in predicting suicide in China. Different correlates of GAF score were found between suicides and controls. Unsurprisingly, GAF score was significantly correlated with mental illness in both suicides and controls. Different characteristics were also found among three types of suicide which were classified using GAF score. Assessing global functioning is useful and GAF scale should be regularly used in suicide prevention practice.     

Female suicides in Diyarbakir, Turkey

The aim of this study was to investigate the methods used and demographic data of women suicides by examining postmortem investigation and autopsy reports from the Branch of the Council of Forensic Medicine in Diyarbakir Province, Turkey, between 1996 and 2001. Fifty-eight percent (174/302) of suicides were females and 42% (128/302) were males. The suicide rates were similarly higher for females than for males (2.6 and 1.8 per 10,000 population, respectively). Over half of female suicides (56.3%) occurred in those under 20 years of age. The most common suicide method for women was hanging (32.2%), and for men was firearms (51.7%), but for women younger than 20 years the most frequent method was firearms. Among the female suicides, five (2.8%) were known to have attempted suicide at least once in the past. Twenty-nine women (16.7%) were documented to have any psychiatric illness. None of the women had a history of drug or alcohol abuse. A suicide note was found in only six cases (3.4%). The predominant suicide motive was family problems (in 32% or 56/174). The higher rate of suicide in females than in males, and the absolute female predominance in suicides in Diyarbakir, Turkey, are in contrast to most of the medical literature and statistical information about suicide rates by country, in which suicide rates are usually higher among males.     

"Legal highs"-Toxicity in the clinical and medico-legal aspect as exemplified by suicide with bk-MBDB administration

The easily available "legal highs", which are products containing psychoactive substances, such as cathinones, piperazines and synthetic cannabinoids, are abused by adolescents in Poland and in the world as alternatives to classic drugs, such as amphetamines or marijuana. The majority of these potentially dangerous substances are still legal and they are associated with a risk of severe poisoning or even death, and provide new challenges in clinical and forensic toxicological practice. Investigations in the field of "designer drugs" may be well illustrated by the case of a suicide of a 21-year old male who ingested a specified dose of a preparation called "Amphi-bi-a" that contains bk-MBDB, chemically 2-methylamino-1-(3,4-methylenedioxyphenyl) butan-1-one, which belongs to the cathinone group, as a synthetic euphoric empathogen and psychoactive stimulant that is chemically similar to MDMA. It is one of more common components of "legal highs" examined in Poland and other countries. The documentation of the case includes a clinical assessment of the patient's health status performed during his almost 4-h hospitalization before death, autopsy and histological examinations supported by toxicological findings revealing bk-MBDB at extremely high concentrations (at 20mg/l in the blood and 33mg/kg in the liver); hence, this body of evidence contributes to knowledge in the field of "designer drugs". Inventions of designers of new psychoactive xenobiotics, which are much in demand, especially in view of the dynamic Internet marketing, which drums up narcobusiness, must be balanced by a national strategy developed by medical, legal and educational circles in the modern civilized world in order to prevent the spreading of the phenomenon.     

Child and adolescent suicide in a large, urban area: psychological, demographic, and situational factors.

We examined all completed suicides by children and adolescents in Los Angeles County who died during 1996 and 1997. There were 46 subjects, aged 11 through 16. The majority of the decedents were males and over age 14. The predominant racial group was Hispanic. There was an almost even split between firearms and hanging as the means of death. Females had a statistically significantly higher rate of prior suicide attempts than males. Over one-third left a suicide note, almost one-half were noted to be depressed, and 22% tested positive for alcohol or illicit drugs. Less than one-quarter were in mental health treatment. Eighty-seven percent had difficulty transitioning to or during adolescence; e.g., problems at home, legal and school difficulties, and relationship losses. These findings are discussed in terms of Eriksonian developmental theory. We offer recommendations for intervention and prevention of suicide.