Suicide: a ten-year retrospective study

Suicide is a complex phenomenon associated with psychological, biological, and social factors, claiming approximately 30,000 lives each year in the United States. We retrospectively reviewed all cases referred to the Medical Examiners' Office/Forensic Pathology Section at the Medical University of South Carolina from January 1988 to December 1997. The cases of suicide totaled 678. All of the cases were analyzed as to age/race/sex, method of suicide, time of year, and toxicological results. Files were also reviewed to determine if the victim left behind a suicide note. The ages ranged from 12 to 94 years; males comprised 79.5% of the victims, and whites 78.3%. The male to female and white to black ratios were both 3.9:1. The most common methods were gunshot wounds, accounting for 64.6% of the cases. No correlation existed with time of year, and the number of cases was not increased around major holidays. The group of victims 65 years and older and the pediatric group under the age of 18 were also examined separately.     

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.     

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.     

Autoerotic deaths: a 25-year retrospective epidemiological study

It is written in almost all articles on autoerotic deaths that these fatalities account for about 500 to 1000 deaths per year in the United States and Canada. However, contrary to the general belief, this incidence rate was not obtained through a study, but it is an estimation based on 30-year unpublished data from Canada and England. In the present retrospective study from 1985 to 2009, 38 cases of autoerotic deaths were identified in the province of Alberta (Canada). This number corresponds to an incidence of 0.56 autoerotic deaths per million inhabitants per year. The vast majority of these deaths are related to typical, predominantly asphyxial methods, such as hanging. The bodies were most commonly found in basements, bedrooms, and bathrooms. There is no clear evidence of a preferential time of day for these deaths, but there appear to be slightly more autoerotic deaths during summer. The incidence of autoerotic deaths is higher in big cities compared with rural areas. The previously published estimate of 500 to 1000 'autoerotic deaths per year should not be used for Canada. An incidence of 0.2 to 0.5 cases per million inhabitants per year is a better estimate of the incidence of autoerotic deaths. The incidence in United States should be reassessed using epidemiological studies.     

Pediatric toxicologic deaths: a 10-year retrospective study

A 10-year retrospective study of pediatric toxicologic deaths was performed at the Medical University of South Carolina (Charleston, SC) from January 1989 to December 1998. During this time, 709 pediatric forensic autopsies were performed on children younger than 18 years of age. Eleven deaths were determined to be secondary to toxic exposures (excluding carbon monoxide poisonings secondary to fires). The remaining deaths were reviewed for the presence of alcohol or illicit drugs. The 11 toxicologic deaths were analyzed for age, sex, race, type of toxic exposure, cause and manner of death, location of incident, witness, and, in the younger age group, the primary caregiver at the time of exposure. The deaths had a bimodal age distribution (6 deaths in victims ages 15 to 17 and 5 deaths in victims ages 4 or younger), involving a wide range of toxins. The teenage group was composed of five males and one female, all white. The preschool group had three females and three males, all black. The manner of death ranged from accidental to suicidal to homicidal. In addition, in eight neonatal and fetal deaths, the victims tested positive for maternal cocaine use, and five of these victims tested positive for cocaine or benzoylecgonine. However, the cause of death was not stated to be cocaine in any of these neonatal and fetal cases.     

Inhalant deaths in South Australia: a 20-year retrospective autopsy study

A 20-year retrospective study of inhalant deaths in South Australia, autopsied at Forensic Science SA, was undertaken from January 1983 to December 2002. Thirty-nine cases were identified from an autopsy pool of 18,880 cases, with a male to female ratio of 12:1. Sixty-four percent of the victims (N = 25) died during voluntary inhalation of volatile substances and 28% (N = 11) committed suicide utilizing a volatile substance or gas. The remaining 3 cases involved a workplace accident (N = 1) and 2 cases of autoerotic death where inhalants were being used to augment solitary sexual activity. The mean age of the 28 victims of accidental inhalant death of 21 years (range, 13-45 years) was considerably less than that of the 11 suicide victims of 31.5 years (range, 17-48 years). No homicides were found. Approximately one quarter of the victims were Aboriginal (N = 11), 10 of whom had died as a result of gasoline inhalation ("petrol sniffing"). Other common substances of abuse were aliphatic hydrocarbons such as butane. The study has shown that those most at risk for accidental or suicidal inhalant deaths were young males, with 92% of victims overall being male, and with 77% of victims being under 31 years of age. Gasoline inhalation remains a significant problem in Aboriginal communities in South Australia.     

Asphyxial deaths: a retrospective study and review of the literature

An increasing death rate as a result of violence constitutes a large group in medicolegal autopsies. Specially, deaths due to asphyxia are one of the most important causes in violence deaths.During the 21-year period from January 1984 to October 2004, there were 134 asphyxial deaths autopsied by the Department of Forensic Medicine, Trakya University, Edirne, Turkey. Asphyxial deaths comprise 15.7% of all forensic autopsies; 20.8% of the cases are aged between 30 and 39 years, and the average age was 41.9 years. Males constitute 79.8% of all the cases.The most frequent method of asphyxiation death is hanging (56 cases, 41.8%), followed by drowning (30.5%) and carbon monoxide poisoning (8.2%). More violent methods, such as ligature or manual strangulations, constitute 2.9% and 2.3% of all asphyxial deaths, respectively. Although it was varying according to the methods of asphyxiation, suicide was found to be the manner of death in the majority of the cases.     

Drugs and alcohol in hypothermia and hyperthermia related deaths: a retrospective study

Hypothermia and hyperthermia related cases recorded for the period 1973 to 1984 were collected from the files of the Department of Forensic Medicine, University of Oulu, and the necropsy protocols including toxicological results were analyzed. The fact that similar alcohol concentrations were found in both types of fatalities points to the poikilothermic effect of alcohol in humans, as found in animal studies. Both types of deaths seem to be associated with the alcohol elimination phase. Antidepressants and neuroleptics were most often found in the hypothermia cases, but benzodiazepines were also quite frequently present. In spite of the diminished use of barbiturates, these still appear in hypothermia fatalities. Certain other drugs that affect thermoregulation were also noted in solitary cases. Extended toxicological analysis was seldom made in the cases of hyperthermia deaths, and no firm conclusions on the poikilothermic effect of psychotropic drugs could be reached, for example. Therapeutic drug concentrations did not alone predispose the subjects to hypothermia, but appeared in connection with alcohol consumption or chronic diseases.     

Hemolytic staining of the intima of the aortic root in freshwater drowning: a retrospective study

A retrospective study was conducted of files at the Institute of Legal Medicine in Hamburg, Germany from 1998 to 2003 of all cases of drowning where there was no putrefaction, to document the rate of recording of hemolytic staining of the intima of the great vessels. All cases had full police investigations with reviews of previous histories, circumstantial evidence, and autopsy findings. A series of control subjects who had died of various natural and nonnatural, nondrowning deaths, matched for age, sex, and postmortem interval, was also reviewed. One hundred twenty cases of freshwater drowning were identified. Drowning occurred in a garden pool in 1 case, in a bath in 2, and in the river Elbe in 117. The age range was from 2 to 91 years (mean = 55 years; M:F = 1:1.8). Hemolytic intimal staining of the aortic root was documented in 6 cases (6 of 120; 5%). This consisted of reddened discoloration of the proximal portion of the aortic root, without any significant staining of the proximal pulmonary artery. No significant hemolytic staining of the intima of the great vessels was recorded in any of the 120 control cases. Although under-reporting of findings may occur in retrospective analyses, this study has shown that at least 5% of freshwater drowning cases showed differential staining of the pulmonary trunk and aorta, with hemolytic discoloration of the aortic intima. When present, hemolytic staining of the aortic root intima may be a useful and possibly under-recognized corroborative sign of freshwater drowning.     

Death caused by myocarditis in Wayne County, Michigan: a 9-year retrospective study

This paper reviews 72 cases of death caused by myocarditis between the years 1996 and 2004, autopsied at the Office of the Wayne County Medical Examiner in Michigan. Myocarditis as a cause of sudden and unexpected death represented 1.3% of all natural deaths in Wayne County during said period. The year 1999 contained the highest number of deaths of this cause (18), where the average number of myocarditis deaths was 8 per year for this 9-year span. In this study, each case was reviewed based on information gathered from investigative, autopsy, and toxicology reports. Significantly, 58% of these cases were male, and 63.4% were African American. Myocarditis caused death in every age group between 7 months and 67 years, but adults between the ages of 19 and 67 were most significantly affected (75%). Flu and/or cold were the most common symptoms experienced in the days directly proceeding death (28%), followed by shortness of breath (17%) and sudden collapse (15%). Sixty-nine percent of these 72 cases were pronounced dead after ACLS (advanced cardiac life support) protocol by emergency medical services or hospital attendants. Cardiomegaly was observed in 24 cases of adults aged 19 or older (54%), and flabby/soft myocardial tissue was observed grossly in 16% of all 72 cases.     

Pregnancy-associated deaths: a 15-year retrospective study and overall review of maternal pathophysiology

Pregnancy-related death is defined by the International Classification of Diseases, Tenth Revision (ICD-10) as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. In the year 2000, a collaborative effort involving World Health Organization (WHO), UNICEF, and UNFPA estimated 660 maternal deaths in the United States. This averages 11 maternal deaths per 100,000 live births reported. Many pregnancy-associated deaths are not easily identified as such since the presence of a recent or current pregnancy may not be listed on the death certificate. Thus, the WHO estimates that in the United States, the maternal mortality is approximately 17/100,000 pregnancies. This is significantly higher than the goal set by the US Department of Health and Human Services in Healthy People 2010, which sets the target for maternal mortality at less than 3.3/100,000 live births. The most common causes of maternal death vary somewhat from region to region in the United States. They include pulmonary thromboembolism, amniotic fluid embolism, primary postpartum uterine hemorrhage, infection, and complications of hypertension including preeclampsia and eclampsia. Pulmonary disease, complications of anesthesia, and cardiomyopathy also are significant contributors to maternal mortality in some populations. The death of a pregnant or recently pregnant individual poses a wide scope of challenges to the forensic pathologist and investigator. The pathologist must have a broad knowledge of the physiologic and biochemical changes that occur during pregnancy, as well as the clinical and pathological manifestation of these changes. Conditions that may be "benign" in the nonpregnant individual may be lethal in the puerperal period. In addition, it should be kept in mind that deaths during pregnancy may be due to unnatural causes. Accident, homicide, and suicide must be ruled out in each case. The authors reviewed all forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina from January 1989 through December 2003. All decedents listed as pregnant or postpartum were analyzed as to maternal age, race, past medical history, previous pregnancies and outcome, prenatal care, gestational age, fetal or neonatal outcome, location of delivery, placental findings, maternal autopsy findings, toxicology, cause of death, manner of death, and fetal or neonatal autopsy findings. The authors present this retrospective study to better determine the factors leading to maternal demise and discuss the autopsy/ancillary techniques useful in determining the cause of death in this challenging area.     

Suicide: a ten-year retrospective review of Kentucky medical examiner cases

Suicide, a manner of death, ranked as the eleventh leading cause of death in the United States and accounted for approximately 30,000 deaths in 2001. A host of biological and psychosocial components interplay in a suicide investigation. Precipitating factors may include domestic quarrels, loss of employment, financial difficulties, substance abuse, chronic disease, or mental illness. The authors conducted a ten-year (1993--2002) retrospective review of suicide from all Medical Examiners' Offices in Kentucky. There were 2,864 suicides ranging between 11 and 96 years (average age 42.0 years). The majority of victims were males (81.7%) and Caucasian (94.8%). African-American females comprised the smallest group, consisting of only 0.59%. The preferred mode of death was by firearm (67.5%), followed by hanging (13.7%), overdose (9.9%), and carbon monoxide poisoning (4.4%). This comprehensive study discusses the trends of suicide in the United States during the twentieth century and underscores the importance of a multidisciplinary approach to the investigation and prevention of suicide.     

Fatal cocaine interactions: a review of cocaine-related deaths in Bexar County, Texas

Although cocaine is a widely abused illicit substance that is known to cause death, deaths due to its use appear to occur in a minority of those who use it. This report was designed to review drug-related deaths due to cocaine, and the concomitant use of other drugs/medications. A retrospective review of drug deaths at the Bexar County Medical Examiner's Office in San Antonio, Texas, was undertaken for cases where cocaine was one of the drugs implicated in causing death. Analysis was performed comparing the concentrations of cocaine and benzoylecgonine present and the absence or presence of other drugs. The data obtained showed that cocaine was toxic over a large range with deaths occurring at concentrations ranging from 0.01 to 78 mg/L. Analyses also indicated an increased lethality when cocaine is used in combination with ethanol, heroin, opiates, and antidepressant/antipsychotic medications, which is consistent with previous reports and research. Antihistamine data showed that there may be relationship between increased toxicity and co-ingestion, although more research is necessary.     

Methadone-related deaths in Hennepin County,Minnesota: 1992-2002

Methadone maintenance therapy (MMT) is the only currently established medical therapy for heroin addiction. However, MMT still remains controversial. In Hennepin County, Minnesota, methadone is one of the top ten drugs reported in medical examiner investigated deaths and one of the most commonly diverted pharmaceuticals. This report reviews the role of methadone in medical examiner deaths over a 10-year period, 1992-2002. We compare cause and manner of death (accidental, natural, suicide) and methadone blood concentrations for decedents who were members of MMT programs with illicit users and those prescribed methadone for chronic pain. Findings reveal that 65% of decedents with measurable blood methadone concentrations were not participating in MMT programs. A total of 96 cases were identified, with the majority white (90.5%) and male (76.8%). MMTP program members were the minority (34.7%) of the methadone positive deaths and 39% were illicit users. Fifteen percent were chronic pain patients with almost half of this group dying from overdose. Methadone concentrations of drug caused/related deaths (0.18-3.99 mg/L) overlapped with those of deaths not attributable to methadone (0.18-3.03 mg/L) with no definable lethal level. Interpretation of methadone blood concentrations must be done in the context of the clinical history for determining cause of death, and may be confounded by postmortem redistribution.     

Cardiovascular abnormalities in children: a ten-year forensic pathologic study

In order to obtain information on types, incidence, and significance of cardiovascular abnormalities in children, a total of 104 consecutive medicolegal autopsies of children aged 8 days to 16 years during a 10-year period from May 1974 to April 1984 were studied. Extensive histological examination of the hearts was performed in 92 out of 104 cases and complemented with chemical and microbiological analyses. In the natural death group consisting of 53 children, 26 (49%) showed abnormalities: 7 (13%) malformations, 11 (21%) cardiomyopathies, 5 (9%) idiopathic subaortic hypertrophy, and 3 (7%) a heart weight only 50% of the expected weight. In the violent death ("control") group, abnormalities were found in 8 of 39 cases (21%), all of which were cardiomyopathy. Only 5 of 34 cardiovascular abnormalities (every 7th case), all complex malformations, were clinically recognized. In 14 (15%) of the total 92 examined cases the cardiovascular abnormality was the only apparent cause of death, and in 12 (13%) a contributing cause of sudden unexpected natural death, while in 3 (3%) it was related to a fatal accidental injury. In 5 (13%) of the 39 cases of violent death, cardiomyopathy was an incidental finding without any connection to the circumstances or cause of death. The causes of cardiovascular abnormalities were associated with bacterial and viral infections, respiratory disorders, phenytoin sensitivity, or were unknown. Because of the differences in diagnostic criteria employed by previous investigators, it cannot be determined whether the incidence of the cardiovascular abnormalities and sudden cardiac death in children found in this material was higher than in other studies.     

A retrospective analysis of cardiovascular deaths: A 5-year autopsy study of 1045 cases in Antalya,Turkey

This study aims to identify the macroscopic and microscopic changes that occur in the heart in different causes of cardiovascular death and sudden cardiac death in autopsy cases and evaluate the difficulties that a forensic practitioner may encounter during autopsies. All forensic autopsy cases in the Morgue Department of the Council of Forensic Medicine, Antalya Group Administration between January 1, 2015, and December 31, 2019, were examined, retrospectively. The cases were chosen according to inclusion and exclusion criteria, and their autopsy reports were examined in detail. It was determined that 1045 cases met the study criteria, 735 of which were also met the sudden cardiac death criteria. The top three common causes of death were ischemic heart disease (n = 719, 68.8%), left ventricular hypertrophy (n = 105, 10%), and aortic dissection (n = 58, 5.5%). The frequency of myocardial interstitial fibrosis was significantly higher in deaths due to left ventricular hypertrophy than in deaths due to ischemic heart disease and other causes (χ²(2) = 33.365, p < 0.001). Despite detailed autopsy and histopathological examinations, some heart diseases that cause sudden death may still not be detected.     

Cocaine-related deaths in Pima County, Arizona, 1982-1984

A three-year review of toxicology data from medical examiner autopsies in Pima County, Arizona, has demonstrated that cocaine has rapidly become a leading substance of abuse, second only to alcohol in the frequency of drugs detected by toxicologic analysis of all suspicious deaths, motor vehicle accident fatalities, homicides, and suicides. Gastric contents and urine were analyzed by thin-layer chromatography, and nasal swabs, blood, and urine were tested for the combination of cocaine and its metabolite benzoylecgonine by quantitative radioimmunoassay. A total of seventy-two deaths in Pima County from 1982 to 1984 have involved cocaine. Seventy percent of these have occurred in the last fifteen months. Marked variation in the individual response to cocaine compared to the blood concentration of cocaine/metabolite was noted.     

A review of crane deaths in Jefferson County, Alabama

Cranes are machines used to move heavy objects. Cranes are operated by crane operators, usually working in conjunction with an assistant guiding the movements of the crane from his vantage point outside the crane. Few jurisdictions require that crane operators be either licensed or certified. We conducted a retrospective study of those dying of crane-related injuries in our jurisdiction during the 16 years from 1981 to 1996. All ten decedents were male, and the manner of each death was accidental. Neither ethanol nor drugs of abuse were detected in any case. Eight of the ten decedents died due to blunt force injuries, one due to mechanical asphyxia, and one due to thermal burns. Investigation by the Occupational Safety and Health Administration (OSHA) led to fines ranging from $80 to $2700 in six of the ten cases. Nationwide, electrocution is the most common cause of crane-related death, but no crane-related death in Jefferson County was caused by electrocution in our study. The absence of electrocutions was due to the planned, routine suspension of power to electrical lines in the vicinity of a crane during the crane's operation, a practice saving an estimated seven lives. Nevertheless, human error or lack of planning was still responsible for most of the deaths in our study. In addition to careful planning and adherence to safety standards established by planning, we recommend the mandatory licensure and certification of professional crane operators and the assessment of larger fines by OSHA for safety standard violations.     

A review of methadone deaths in Jefferson County,Alabama

Interpretation of the concentration of a drug is more difficult when a combination of drugs is present in a decedent's blood. An increase in deaths resulting from co-intoxication with methadone and a benzodiazepine led the authors to perform a retrospective study of cases examined at the Jefferson County Coroner/Medical Examiner Office. They found 101 deaths wherein methadone was detected in the blood. Based on the drugs detected in the blood, these 101 cases were grouped into four categories: (1) pure methadone intoxication, (2) intoxication with methadone and benzodiazepine, (3) intoxication with methadone and other drugs excluding benzodiazepine, and (4) intoxication with methadone, benzodiazepines, and other drugs. Methadone was the sole intoxicant in 15 cases, with a mean concentration of 0.27 mg/L. Benzodiazepines were the most frequently detected co-intoxicant (60 of 101 cases). Benzodiazepine was the only co-intoxicant in 30 cases, and the mean methadone concentration in those 30 cases was 0.599 mg/L. Higher levels of methadone may occur in acute intoxication with methadone and benzodiazepine because benzodiazepines compete with methadone for methadone receptors. Higher levels of methadone may occur with chronic abuse of methadone and benzodiazepines because over time, benzodiazepines inhibit the hepatic enzymes that metabolize methadone.