Coroner's Office Research Articles

An exploration of integrated data on the social dynamics of suicide among women.

The gender-based nature of suicide-related behaviour is largely accepted. However, studies that report exclusively on female suicides are rare. Here we demonstrate how female suicide has effectively been 'othered' and appears incidental in studies which compare female and male behaviour. We highlight how recent studies of suicide have tended to be dominated by male-only approaches, which increasingly link issues of masculinity with male death by suicide.Drawing on data collected from the general practitioner and coroner's office, we then apply the sociological autopsy approach to a cohort of 78 deaths recorded as suicides in the UK between 2007 and 2009. By focusing on females in isolation from males, we demonstrate that, as in male-only suicide studies, it is similarly possible to draw out issues associated with the feminine identity, which can be linked to death by suicide. We find that bereavement, sexual violence and motherhood could all be linked to the lives and help-seeking of the females who died. In closing, we suggest that a reorientation towards sociological analytic approaches of female suicide may help to produce further reductions in the rate of female death by suicide. A Virtual Abstract of this paper can be found at: https://www.youtube.com/watch?v=a0w9KKMFdIQ.

Injury-related fatalities in selected governorates of Iraq from 2010 to 2013: Prospective surveillance.

After several years of relative stability in Iraq, the emergence of the Islamic State militant group has spurred a resurgence of violence. This study explores the impact of the conflict on the overall injury profile to estimate the proportion of injury fatalities related to conflict and better understand how violence has affected nonconflict-related injuries. Routine prospective injury surveillance operated by the Iraqi Ministry of Health. Surveillance data were collected from coroner offices in eight pilot governorates: Al-Anbar, Baghdad, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. We analyzed all fatalities from external injury causes recorded between January 1, 2010 and December 31, 2013. Analysis included 32,664 fatal injuries. Of all injury fatalities reported, 27.1 percent were conflict-related fatalities, approximately the same proportion as road traffic-related fatalities (24.4 percent) and other unintentional injuries (27.5 percent). The proportion of fatalities from conflict was approximately three times higher among males than females (33.0 percent and 10.3 percent, respectively) and four times higher among adults than children (29.8 percent and 7.3 percent, respectively). The total number of injury fatalities remained stable between 2010 and 2012; an increase in injury fatalities in 2013 was driven primarily by increases in fatalities from both interpersonal violence and conflict. From 2010 to 2013, nearly one in four injury fatalities in Iraq was attributable to conflict, a notably higher proportion than other conflict-affected countries in the region. The overall profile of nonconflict injuries in Iraq is also distinct from other countries of similar socioeconomic level that have not experienced violence.

Fibromyalgia: Comorbidity or a psychosomatic symptom of depression leading to the abuse of opioids?

Introduction: We conducted a retrospective study at the Wayne County Medical Examiner Office, which examined decedents diagnosed with Fibromyalgia, a disorder of unknown etiology characterized by widespread chronic musculoskeletal pain, concomitant with fatigue, sleep disturbances, and psychological distress. Material & Methods: Over a seventeen year period a total of 54 cases from our database met this criterion. Other criteria in the study included cause and manner of death, post-mortem toxicology results, major autopsy findings, and medical history. Results: Our study revealed that the cause of death in approximately two-thirds of the cases was due to drug intoxication. The most frequent post-mortem toxicology finding was Opioids, such as Morphine, Hydrocodone, Oxycodone, Fentanyl, and Codeine. The most common manner of death was accident. Almost 90% of the decedents were Caucasian females, which contrasted with the demographic diversity of Wayne County, Michigan. Additional findings revealed that the average age was 47 years, and the average Body Mass Index (BMI) could be categorized as obese. Nearly 67% of the cases had a medical history of depression. Conclusion: Our findings suggest that Fibromyalgia might be a psychosomatic symptom of depression rather than comorbidity. Therefore, physicians should further inquire about, and consider treating, depression in patients with chronic musculoskeletal pain while completely avoiding the use of opioids, for opioids have a greater risk of being abused and resulting in death in such patients, as found in our study.

Companion Cases in a Large Urban Medical Examiner's Office.

Companion death cases, as defined in this study, include 2 or more deaths that occur at the same location or 1 death at a specific location combined with 1 or more individuals transported from that same location to a hospital where death was pronounced within 1 hour of arrival. These types of cases can have multiple causes and manners of death. The Wayne County Medical Examiner's Office conducted a retrospective study of companion death cases that came into the office from mid 2007 to the end of 2014. The purpose of the study was to identify and examine patterns of companion death cases in a large urban area that would assist future companion death case investigations. Three hundred fifty deaths were found to be companion cases, including 135 pairs (2 connected deaths in the same location), 20 trios, and 5 quartets. Approximately 49% of companion case deaths were homicides. Approximately 30% of companion case deaths were traumatic accidental deaths. Around 14% of companion case deaths that were from the same scene location had different manners of death, including suicide, homicide, natural, and indeterminate. The remainder of companion death cases were either drug related or natural. Through this study, we have identified a pattern to these companion death cases and have concluded that it is important to conduct a thorough medicolegal death investigation of such cases to establish and elucidate the true circumstances surrounding these deaths.

Effectiveness of dental records in human identification

Forensic dentistry, a branch of the forensic sciences, plays an important role within postmortem human identification, especially in cases of corpses that are charred, skeletonized or in an advanced state of decomposition. Identification of human remains via dental knowledge is done using a comparative technique, which is simple, inexpensive and reliable, the aim of which is to compare dental records and information recorded by dentists in clinical appointments made before an individual's death, with postmortem dental records obtained via forensic examination. In this context, the present study aims to demonstrate the importance of dental records and the effectiveness of forensic dentistry in human identification, illustrated by the report of a case that was conducted at the São Luis Coroner's Office in the Brazilian state of Maranhão. It may be concluded that dental records maintained by a dentist, when complete, properly structured and correctly archived, retain important personal information and are fundamental tools in the process of human identification.

Postmortem Diagnosis of Dengue as an Epidemiological Surveillance Tool.

Dengue remains a problem in Brazil, and a substantial number of cases that progress to death are not diagnosed by health services. We evaluated the impact of a protocol adopted by the Coroner's Office Rocha Furtado (CO-RF) for the detection of unreported deaths from dengue in Brazil. We evaluated prospectively cases of deaths referred to the CO-RF with suspicion of dengue and those referred with other diagnosis in which the pathologists suspected dengue as the cause of death. Biological material was collected from all bodies autopsied, for which the suspected cause of death was dengue, between January 2011 and December 2012. Of the 214 bodies autopsied, 134 (62.6%) tested positive for dengue; of these cases, 121 were classified as dengue according to the World Health Organization's case definition (1997 or 2009, as appropriate). Thus, CO-RF detected 90 deaths from dengue, which were not suspected during disease progression. This CO-RF protocol, through a combined effort of the surveillance and laboratory teams, increased the detection of fatal dengue cases by 5-fold. This is the largest series of autopsies performed in cases of death related to dengue in the world to date.

Abstract 17817: The Incidence and Mortality Risk of Acute Thoracic Aortic Dissection: Results From a Nationwide Population-based Study

Introduction: Acute thoracic aortic dissection is a potentially lethal disease associated with high morbidity, however, contemporary data on incidence and mortality risk are lacking. Utilizing a nationwide data comprising the Icelandic population we aimed to determine the incidence, mortality and the time-dependent mortality risk of acute thoracic aortic dissection. Methods: Data was retrospectively collected using hospital discharge registries in Iceland from 1992-2013 as well as autopsy database from Medical Examiner Office. To capture all cases diagnostic codes for dissection (ICD-9: 441.1 and ICD-10: I71.0) were queried as well as for aortic aneurysm and arterial dissection. Total of 1811 charts were reviewed resulting in 153 confirmed diagnoses of acute thoracic aortic dissection. Demographics, medical history, risk factors and clinical symptoms were collected for all patients. Incidence was calculated using age and gender specific information provided by National Statistics Iceland. Results: Age and gender-adjusted incidence of acute thoracic aortic dissection was 2.5/100,000/year and no significant change in incidence was observed. The mean age was 66.9±13.6 years, 61% (94/153) were males and 66% (101/153) were Stanford type A. Of all patients diagnosed with dissection 18% (27/153) died prior to hospital arrival while the risk of death for all patients that arrived alive to a hospital was 21% (27/126) within 24 hours and 45% (57/126) at 30 days. Predictors for short-term mortality included female sex, renal disease and family history of dissection. The overall 10-year survival was 39% of which negative predictors included age, coronary artery disease, renal disease, peripheral vascular disease and family history of dissection. During the course of the study the 30-day mortality rate decreased by 0.96/year, (95% CI: 0.92- 0.99) and the 10-year survival improved significantly (p=0.04). Conclusions: Acute thoracic aortic dissection is uncommon but a lethal condition where two thirds of patients die within 30 days of the index event. The incidence remained constant but a decline in short-term mortality and increased long-term survival was observed indicating improved overall outcome in patients diagnosed with this complex condition.

Correlation between death while bathing and meteorological parameters in the 23 wards of Tokyo

OBjectives: Japanese people bathe every day and every home has a bathtub. The number of deaths while bathing increases during colder months. The present ecological study aimed to determine whether or not low air temperature is associated with death while bathing in Japan. Materials and Methods. The monthly numbers of deaths while bathing in the 23 wards of Tokyo were obtained from the Tokyo Medical Examiner's Office and data on air temperature and humidity were obtained from the Japan Meteorological Agency. Results. The monthly numbers of deaths while bathing significantly and negatively correlated with air temperature and humidity (mean air temperature, r = -0.943; p Conclusions. Lower air temperature is closely associated with higher rates of death while bathing in the 23 wards of Tokyo, Japan. Language: en

The Perfect Murder: How a Suicide Became a Homicide

This case report describes the death of a 51-year-old female, which presented by autopsy, scene circumstances, and social history as a suicidal ligature hanging. However, when her boyfriend walked into a police department in another state, months later, claiming to have killed the woman and staged a hanging, the medical examiner's office was asked to review the admission, as it was thought wholly inconsistent with the timeline provided. Upon reenactment of the admission, the perpetrator perfectly demonstrated the use of a lateral vascular neck restraint (carotid restraint), known to incapacitate and potentially kill an individual within a matter of seconds. The autopsy finding of severe atherosclerotic heart disease was important in understanding the mechanism of death, the timeline of events, and in corroborating the confession. This case demonstrates the value of performing an autopsy even though investigation and history suggested an obvious cause and manner of death.

Suicide by Hypothermia: A Report of Two Cases and 23-Year Retrospective Review

Hypothermia deaths are frequently accidental and associated with impairment by alcohol, injuries, mental illness, or natural disease. Hypothermia as a method of suicide is unusual, with only nine case reports in the scientific literature. In the early months of 2014, during one of the coldest winters on record, the Hennepin County Medical Examiner's office investigated and certified two unrelated cases of suicide by hypothermia; we describe the salient features of these cases. A retrospective review of all cases investigated by our office from January 1991-April 2014 identified 146 cases in which “hypothermia” or “environmental cold exposure” was listed as a cause of death, contributing condition, or mechanism of injury. Death investigation narratives and autopsy reports were reviewed to confirm hypothermia and evaluate for the presence or absence of characteristic hypothermia findings. In these cases the manner of death was certified as follows: 116 accident (79.4%), 15 undetermined (10.3%), 8 suicide (5.5%), 6 natural (4.1%), and 1 homicide (0.7%). Further examination of the eight suicide cases revealed that half were female and half were male, and most were younger individuals with only one decedent above 50 years of age. Four of these deaths were associated with drug toxicities, five were associated with additional self-inflicted injuries (blunt force, sharp force, and/or gunshot wounds), and none of them exhibited paradoxical undressing. It is important for medicolegal death investigation professionals to recognize that, while rare, hypothermia deaths may represent intentional injury, and suicide as a manner of death should be considered in all cases.

Death with Dignity Laws and the Medical Examiner

Currently, three states (Oregon, Washington, and Vermont) have “death with dignity,” physician-assisted suicide laws. Twenty-five other states considered death with dignity (DWD) legislation in 2015. Americans and American physicians have mixed opinions about these laws. Oregon, Washington, and Vermont have similar DWD laws that establish criteria and define roles and responsibilities of the physician, patient, and pharmacist. States require record-keeping and statistical reports administered by public health agencies. Yearly summary reports in Oregon and Washington show that physician assisted suicide (PAS) is uncommon. In Oregon in 2014, 105 PAS deaths were documented, of approximately 34 000 total deaths. The majority of PAS deaths involve patients with terminal cancer or neurodegenerative disease. The laws require that the cause of death be attributed to and certified as the underlying natural disease, making the manner of death natural. The attending physician may sign the death certificate. Because the cause and manner of death are legally mandated, the physician assisted suicide laws have little impact on medical examiner offices.

Understanding and predicting suicidality using a combined genomic and clinical risk assessment approach.

Worldwide, one person dies every 40 seconds by suicide, a potentially preventable tragedy. A limiting step in our ability to intervene is the lack of objective, reliable predictors. We have previously provided proof of principle for the use of blood gene expression biomarkers to predict future hospitalizations due to suicidality, in male bipolar disorder participants. We now generalize the discovery, prioritization, validation, and testing of such markers across major psychiatric disorders (bipolar disorder, major depressive disorder, schizoaffective disorder, and schizophrenia) in male participants, to understand commonalities and differences. We used a powerful within-participant discovery approach to identify genes that change in expression between no suicidal ideation and high suicidal ideation states (n=37 participants out of a cohort of 217 psychiatric participants followed longitudinally). We then used a convergent functional genomics (CFG) approach with existing prior evidence in the field to prioritize the candidate biomarkers identified in the discovery step. Next, we validated the top biomarkers from the prioritization step for relevance to suicidal behavior, in a demographically matched cohort of suicide completers from the coroner's office (n=26). The biomarkers for suicidal ideation only are enriched for genes involved in neuronal connectivity and schizophrenia, the biomarkers also validated for suicidal behavior are enriched for genes involved in neuronal activity and mood. The 76 biomarkers that survived Bonferroni correction after validation for suicidal behavior map to biological pathways involved in immune and inflammatory response, mTOR signaling and growth factor regulation. mTOR signaling is necessary for the effects of the rapid-acting antidepressant agent ketamine, providing a novel biological rationale for its possible use in treating acute suicidality. Similarly, MAOB, a target of antidepressant inhibitors, was one of the increased biomarkers for suicidality. We also identified other potential therapeutic targets or biomarkers for drugs known to mitigate suicidality, such as omega-3 fatty acids, lithium and clozapine. Overall, 14% of the top candidate biomarkers also had evidence for involvement in psychological stress response, and 19% for involvement in programmed cell death/cellular suicide (apoptosis). It may be that in the face of adversity (stress), death mechanisms are turned on at a cellular (apoptosis) and organismal level. Finally, we tested the top increased and decreased biomarkers from the discovery for suicidal ideation (CADM1, CLIP4, DTNA, KIF2C), prioritization with CFG for prior evidence (SAT1, SKA2, SLC4A4), and validation for behavior in suicide completers (IL6, MBP, JUN, KLHDC3) steps in a completely independent test cohort of psychiatric participants for prediction of suicidal ideation (n=108), and in a future follow-up cohort of psychiatric participants (n=157) for prediction of psychiatric hospitalizations due to suicidality. The best individual biomarker across psychiatric diagnoses for predicting suicidal ideation was SLC4A4, with a receiver operating characteristic (ROC) area under the curve (AUC) of 72%. For bipolar disorder in particular, SLC4A4 predicted suicidal ideation with an AUC of 93%, and future hospitalizations with an AUC of 70%. SLC4A4 is involved in brain extracellular space pH regulation. Brain pH has been implicated in the pathophysiology of acute panic attacks. We also describe two new clinical information apps, one for affective state (simplified affective state scale, SASS) and one for suicide risk factors (Convergent Functional Information for Suicide, CFI-S), and how well they predict suicidal ideation across psychiatric diagnoses (AUC of 85% for SASS, AUC of 89% for CFI-S). We hypothesized a priori, based on our previous work, that the integration of the top biomarkers and the clinical information into a universal predictive measure (UP-Suicide) would show broad-spectrum predictive ability across psychiatric diagnoses. Indeed, the UP-Suicide was able to predict suicidal ideation across psychiatric diagnoses with an AUC of 92%. For bipolar disorder, it predicted suicidal ideation with an AUC of 98%, and future hospitalizations with an AUC of 94%. Of note, both types of tests we developed (blood biomarkers and clinical information apps) do not require asking the individual assessed if they have thoughts of suicide, as individuals who are truly suicidal often do not share that information with clinicians. We propose that the widespread use of such risk prediction tests as part of routine or targeted healthcare assessments will lead to early disease interception followed by preventive lifestyle modifications and proactive treatment.

Globus Pallidus Necrosis Unrelated to Carbon Monoxide Poisoning: Retrospective Analysis of 27 Cases of Basal Ganglia Necrosis.

Bilateral globus pallidus necrosis is said to be characteristic of carbon monoxide (CO) poisoning. However, there has been no scientific test of this hypothesis. To examine the assertion that globus pallidus necrosis is typical of CO poisoning, this study examined autopsy cases from the King County Medical Examiner's Office (KCMEO) between 1994 and 2013. Twenty-seven cases with bilateral basal ganglia lesions were identified and examined for associated or causative disease or injury with the following results: 10 cases of drug overdose, seven heart disease, three asphyxia, two chronic ethanolism, two Huntington-like disorder, and one case each of remote trauma, rheumatic heart disease, and cerebral artery gas embolism. Additionally, review of all known cases at KCMEO of CO poisoning found no evidence of globus pallidus or basal ganglia necrosis. Thus, this study provides no support for the assertion that globus pallidus necrosis is characteristic of CO poisoning.

The value and availability of forensic anthropological consultation in medicolegal death investigations.

Forensic anthropological analysis is a valuable component of medicolegal death investigations. Like many other forensic sciences, forensic anthropology has become increasingly sophisticated in recent years, requiring qualified practitioners to complete intensive and long-term postgraduate study. In addition, forensic anthropology has experienced a recent increase in interest (facilitated in part by increased media attention), with the result that many are now much more aware of the nature and value of forensic anthropological services. While the number of qualified and certified forensic anthropologists is increasing, a misconception by a few in the medicolegal community that the numbers of forensic anthropologists cannot properly meet the consultation needs of medical examiner and coroner offices appears to exist, and moreover that anthropological services are often cost-prohibitive. Here we present an overview of the current state of forensic anthropology, including the typically available services, education and training requirements, as well as some information and suggestions for ways in which forensic pathologists and coroners can seek forensic anthropological consultation. Forensic pathology and forensic anthropology are both highly specialized fields with extensive education and training requirements, and a collaborative approach results in the most reliable and scientifically accurate forensic results. This collaboration is eminently achievable. Forensic anthropology is the science of applying anthropological method and theory to matters of medicolegal concern. Many are familiar with the traditional uses of forensic anthropology including estimation of the biological profile (age, sex, ancestry, stature) from unknown skeletal remains and the assessment of skeletal trauma. The science of forensic anthropology, however, has experienced a significant increase in sophistication and breadth in recent years. Depending on the training and interests of the individual anthropologist, as well as the resources of the institution by which they are employed, anthropological examinations may include search and recovery of human remains, the determination of skeletal versus non-skeletal origin, the determination of human versus non-human origin, the assessment of forensic significance of human remains, estimation of various biological parameters (including sex, age, ancestry, stature, as well as skeletal anomalies, pathologies and other conditions), trauma analysis, and personal identification (typically by radiographic comparison). Disclaimer: The views expressed are those of the authors and do not necessarily reflect the official policy or position of the FBI, Department of Defense, or the U.S. Government.

Forensic Entomology in the Medical Examiner's Office

The application of forensic entomology to medicolegal death investigations has clear benefits to the role of the medical examiner's office (MEO) in evaluating insect activity as it relates to not only cause and manner of death but in the investigative role of the medical examiner as a resource to law enforcement. Until recently, applied forensic entomology in the MEO has been conducted by consulting forensic entomologists removed from the context of the investigation. The addition of a forensic entomologist to the staff of a MEO has provided an opportunity to explore the benefits and challenges of having the forensic entomologist involved at every step of the death investigation. In this study, data are provided on the types and variety of cases that the forensic entomologist has reported on for the Harris County Institute of Forensic Sciences in Houston, TX, over the first two years of the program. Case types, trends in colonization and insects involved in forensic entomology casework in this setting are highlighted, as well as the remaining challenges that forensic entomology must overcome on its path to standardization in the United States.

Patient adherence with emergency department referral to a cardiovascular evaluation and risk assessment clinic.

Patient adherence with emergency department (ED) referral has not been well studied in Canada, and there are no Canadian studies assessing patient follow-up for evaluation of cardiovascular disease. Our primary objective was to determine the proportion of patients who adhered with an ED referral to a cardiac evaluation and risk assessment (CERA) clinic in Calgary, Alta. Secondary objectives included determining the final diagnoses and outcomes for patients attending CERA appointments. We also assessed the association between adherence and various system and patient factors. A retrospective review of 385 patients who were referred to CERA from EDs in the study region between June 1, 2004, and Apr. 7, 2005, was performed. Hospital charts and the database at the medical examiner's office were reviewed for patients who did not attend their CERA appointment. The majority of patients (345/385, 89.6%) followed through with their referral to CERA. No deaths were identified from hospital records or from the medical examiner's office for nonadherent patients. Of the 315 patients who completed their follow-up, 225 (71.4%) were diagnosed with noncardiac or low-risk cardiac disease, whereas 90 (28.6%) were diagnosed with cardiovascular disease. The referring hospital was the only variable significantly associated with adherence with the referral (p=0.004). The great majority of patients referred to CERA from Calgary EDs were adherent with the referral. Future studies may identify factors impairing adherence that are amenable to intervention. Implementation of a referral model similar to the one used by CERA may improve adherence with attendance at other outpatient clinics.

Testing for Infectious Diseases in Sudden Unexpected Infant Death: A Survey of Medical Examiner and Coroner Offices in the United States

To determine interoffice variability in routinely performed sudden unexpected infant death (SUID) postmortem studies for infection and to assess availability and perceived utility of various tests of infectious diseases. Online surveys were sent to all 154 offices of US medical examiners and coroners serving populations >300,000 people. Surveys included a set of potential laboratory tests for infectious disease. Respondents were asked to select which tests were available in their offices, and which tests were performed routinely in SUIDs vs which tests should be performed routinely. Of the 45 complete responses, 4.4% did not routinely perform histology, 8.9% did not routinely perform viral studies (ie, culture or molecular diagnostics), 22.2% did not routinely perform blood cultures, 26.7% did not routinely perform lung bacterial cultures, and 44.4% did not routinely perform cerebrospinal fluid cultures. Our findings suggest that there is considerable interoffice variability with testing for infectious diseases in SUIDs. This appeared to be largely the result of a perceived lack of testing utility rather than a lack of test availability. Evidence-based practice guidelines regarding the interpretation of microbial testing results, as well as common testing protocols/algorithms, may lead to more accurate and standardized data, thus improving SUID investigation and surveillance.

Comparative analysis of hospital and forensic laboratory ethanol concentrations: A 15 month investigation of antemortem specimens

Quantitative serum alcohol concentrations from regional hospitals (from specimens collected at time of hospital admission) were compared to results from whole blood (from specimens collected at the time of hospital admission) concentrations measured at the San Diego County Medical Examiner's Office (SDCMEO). Over a 15 month period (January 2012 to March 2013), the postmortem forensic toxicology laboratory analyzed a total of 2,321 cases. Of these, 280 were hospital cases (antemortem) representing 12% of the overall Medical Examiner toxicology casework. 59 of the 280 hospital cases (or 21%) screened positive for alcohol (ethanol). 39 of these 59 cases were included in the study based on available specimens for quantitative analyses. This investigation indicated that serum hospital ethanol concentrations correlated well (R2 = 0.942) with ethanol values determined at SDCMEO (generally measured in whole blood). There was an observed negative bias with an average of −14.1%. A paired t-test was applied to the data and it was shown that this observed bias is statistically significant. These differences in ethanol concentrations could result from differences in specimen, analytical techniques, and/or calibration. The potential for specimen contamination is also discussed.

Determined to Die! Ability to Act Following Multiple Self‐inflicted Gunshot Wounds to the Head. The Cook County Office of Medical Examiner Experience (2005–2012) and Review of Literature

Cases of multiple (considered 2+) self-inflicted gunshot wounds are a rarity and require careful examination of the scene of occurrence; thorough consideration of the decedent's psychiatric, medical, and social histories; and accurate postmortem documentation of the gunshot wounds. We present a series of four cases of multiple self-inflicted gunshot wounds to the head from the Cook County Medical Examiner's Office between 2005 and 2012 including the first case report of suicide involving eight gunshot wounds to the head. In addition, a review of the literature concerning multiple self-inflicted gunshot wounds to the head is performed. The majority of reported cases document two gunshot entrance wound defects. Temporal regions are the most common affected regions (especially the right and left temples). Determining the capability to act following a gunshot wound to the head is necessary in crime scene reconstruction and in differentiation between homicide and suicide.

Individual and area-level factors correlated with death by suicide in older adults

ObjectiveTo determine the influence of individual and area-level characteristics associated with suicide in older adults. MethodThis study used two complementary data sources. The first used administrative data from the Quebec Coroner's office and included information on suicide deaths in older adults aged 65years and over who died by suicide between 2000 and 2005 (n=903 persons). The second data source, which was used to identify the control group, came from a longitudinal study on seniors' health that was conducted in Quebec between 2004 and 2005 (n=2493 persons). Logistic regression analyses were used to test for associations between suicide and individual and area-level level characteristics. ResultsSuicide was associated with male gender, age, the presence of a physical and mental disorder and the use of health services. At the area-level level, suicide was associated with a higher population density, concentration of men, lower rates of education and higher rate of unemployment. Gender specific analyses also showed different patterns of associations on suicide risk. ConclusionsSuicide in older adults is associated with area-level and individual characteristics. This suggests that policies targeting only one level of risk factors are less likely to significantly influence suicide among this population.