Female Decedents Research Articles

Factors associated with incomplete toxicology reporting in drug overdose deaths, 2010–2016

PurposeClassification of overdose deaths is often geographically and demographically inconsistent. Incomplete surveillance records may distort estimates of drug overdose rates across time and place. We examined incomplete toxicology reporting among drug overdose decedents by demographic and geographic characteristics, measuring changes in missingness rates and their associations with decedent characteristics over time. MethodsWe estimated the percentage of overdose deaths reported in the National Vital Statistics System with missing toxicology results from 2010 to 2016, overall and by decedents’ demographic and geographic characteristics. Multilevel logistic regression models evaluated prevalence of missingness by decedent characteristics, accounting for geographic clustering. ResultsOverall, 20.3% of death certificates did not indicate a specific drug, declining from 24.4% in 2010 to 14.6% in 2016. Deaths were less likely to have missing information if they occurred in counties with medical examiners versus coroners. Female decedents were more likely to have missing information than males, as were non-Hispanic whites compared with Hispanics and non-Hispanic blacks. ConclusionsThe percentage of deaths with missing toxicology information declined over time, but demographic and geographic differences in missingness persist. This yields detection biases that skew temporal trends and understanding of groups impacted by the opioid epidemic.

Utilization History of Emergency Medical Services Among West Virginia Drug Overdose Decedents

Utilization History of Emergency Medical Services Among West Virginia Drug Overdose Decedents

Date Rape Drugs in Las Vegas: Detection After the Fact [11I

INTRODUCTION: Date rape drugs (DRDs) are drugs which can be used to conduct drug-facilitated sexual assault. The three major drugs classified by the U.S Department of Health & Human Services misused for this purpose are Rohypnol (Flunitrazepam), Gamma hydroxybutyric acid (GHB) and Ketamine. Existing studies in the literature analyze self-reported incidents in women which likely underestimate the prevalence of this problem. Our study aimed to evaluate how frequently there was clinical or criminal suspicion of DRD use prior to autopsy evaluation in a group of deceased DRD positive women. METHODS: This study was a retrospective analysis of all female decedents aged 20-55 who tested positive for Flunitrazepam, GHB and Ketamine referred to the Clark County medical examiner from 2000-2015. Medical records, police report, and autopsy findings were reviewed. All decedents underwent standard toxicology screening from whole blood toxicology analysis. Statistical analysis was performed using student t-test for continuous variables and chi-square for categorical variables. RESULTS: 23 women referred to the Clark County medical examiner tested positive for DRDs. At autopsy 6 women were positive for Rohypnol, 15 for GHB, and 2 for ketamine. After clinical, autopsy and police report review, 74% of 17/23 women had no clinical suspicion of DRD involvement at the time of death. Specifically, 83% (n=5) women had no suspicion of flunitrazepam use prior to toxicology results. CONCLUSION: Only a small minority of cases raised suspicion of DRD use upon police or clinical assessment. DRD use may be more prevalent in society than previously thought posing a significant public health threat.

PP19 Opioid poisoning deaths: a national picture

BackgroundThe factors associated with opioid poisoning death are poorly understood. We performed a retrospective autopsy study of decedents of opioid poisoning in Wales in 2015. Using anonymised linked data, we describe demographic characteristics, patterns of emergency service utilisation, and clinical presentation prior to death.MethodsDecedents of opioid poisoning in Wales in 2015 were identified from Office of National Statistics (ONS) mortality data. Records were linked with the Emergency Department Dataset (EDDS) by the National Welsh Informatics Service (NWIS); and held in the Secure Anonymised Information Linkage (SAIL) databank. Data were accessed and analysed in the SAIL gateway.ResultsAge at death ranged from eighteen to seventy-eight years, with a mean of forty-two years. Average male age was forty-one years and average female age was forty-four and a half years. Seventy-six percent of decedents were men (n=98/112).Eight-seven percent of decedents (n=112/129) attended the emergency department in the three years prior to death; eighty-nine in the previous year, ninety-nine in the previous two years and 112 in the previous three years. Eighty-four percent of male and ninety-three percent of female decedents attended the ED in the three years prior to death.In total 665 attendances were made, half of which involved conveyance by ambulance. Attendances per individual ranged from one to sixty, with over half of decedents attending more than three times.Diagnostic codes were mostly missing or non-specific, with only six and a half percent of attendances representing twenty seven decedents, coded as drug related.ConclusionsMatching previously published data, we found that fatal opioid poisoning is preceded by a period of high emergency health service utilisation. On average decedents were in their fifth decade and more likely to be male than female. Attendances varied widely, with men less likely to attend than women.

The characteristics of all-terrain vehicle (ATV)-related deaths: A forensic autopsy data-based study

Using forensic autopsy-based data from a regional medical examiner office in the midwestern U.S. with a mixed small urban-rural population, we describe the characteristics of all-terrain vehicle (ATV)-related deaths occurring between 2000 and 2018. During this period, there were 25 ATV-related deaths. There was a strong male predominance with 22 male and 3 female decedents. The average age at death was 35years, with a range from 10 to 82years, and a bimodal age distribution with one peak at 10-19years old, and a second peak at 60-69years old. The most common cause of death was blunt trauma (n= 22), with the remainder being torso compression (n= 1), drowning (n = 1) and hypothermia (n = 1). Of the 22 blunt trauma deaths, 15 were due to head trauma. The most common mechanism of accident was roll-over (n= 11), followed by striking a stationary object (n= 6). Of the stationary objects struck, the most common was cable wire fencing accounting for 3 of the 6. A survival period following discovery of the body was present in 11 of the 25 deaths. Postmortem toxicology was positive for ethanol in 7 deaths and tramadol in 1 death.

Older women who died by suicide: suicide means, sociodemographic and psychiatric risk factors, and other precipitating circumstances.

Data are from the 2005 to 2015 US National Violent Death Reporting System (N = 12,401 female decedents aged 50 years and over). We used three logistic regression models, with overdose versus firearms, overdose versus hanging/suffocation, and overdose versus "other" means as the dependent variables, to examine associations between suicide means and sociodemographic and risk/precipitating factors. χ2 tests were used to examine positive toxicology of prescription and illicit drugs by suicide means. Compared to firearm users, overdose users were younger and had higher odds of having had previous suicide attempts/intent disclosures, mental disorders (e.g. depression/dysthymia: AOR = 1.18, 95% CI = 1.05-1.34), and substance abuse other than alcohol, but lower odds of having had relationship problems and any crisis. Compared to hanging/suffocation, overdose declined (AOR = 0.95, 95% CI = 0.93-0.97) during the study period and was less prevalent among Hispanic and Asian women and those with job/finance/housing problems. Toxicology reports showed that 47%, 43%, and 45% of overdose users were antidepressant, opiate, and benzodiazepine positive, respectively. Firearm users had the lowest rates of positive toxicology results for these drugs. Suicide prevention should include limiting access to large quantities of prescription medications and firearms for those at risk of suicide. More effective mental health/substance abuse treatment and chronic illness management support are also needed.

Impact of Sex on Systemic Lupus Erythematosus-Related Causes of Premature Mortality in the United States.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that is a source of significantly decreased life expectancy in the United States. This study investigated causes of deaths among males and females with SLE. This cross-sectional study used the national death certificate database of ∼2.7 million death records in the United States, 2014. SLE was defined using Tenth Revision of the International Classification of Diseases codes: M32.1, M32.9, and M32.8. We compared sex-stratified demographic characteristics and the most commonly listed comorbidities in decedents with and without SLE. Relative risks (RRs) quantified the risk of dying with the most commonly listed comorbidities among decedents with SLE aged ≤50 years compared with non-SLE decedents. There were 2,036 decedents with SLE in the United States (86.2% female). Female SLE decedents were 22 years younger than non-SLE females (median: 59 years vs. 81 years). This difference was 12 years among male decedents (median: 61 years vs. 73 years). The most frequently listed causes of death among female SLE decedents were septicemia (4.32%) and hypertension (3.04%). In contrast, heart disease (3.70%) and diabetes mellitus with complications (3.61%) were the most common among male SLE decedents. Among younger male decedents, SLE had higher co-occurrence of coagulation/hemorrhagic disorders and chronic renal failure compared with non-SLE (RR = 16.69 [95% confidence interval {CI} = 10.50-27.44] and RR = 5.76 [95% CI = 2.76-12.00], respectively). These also contributed to premature mortality among women (RR = 4.98 [95% CI = 3.69-6.70] and 8.55 [95% CI = 6.89-10.61], respectively). Our findings identify clinically relevant comorbidities that may warrant careful consideration in patients' clinical management and the natural history of SLE.

Estimating Age at Death Based on Costal Cartilage Calcification.

Age estimation is a crucial part of forensic investigations. Because different parts of the body are often found at crime scenes, it is important to explore the regions that can be used for age estimation. Previous studies have used simple X-ray to analyze changes in costal cartilage calcification as a measure of age. Here, we tested whether age could be better estimated using measurements of costal cartilage calcification on postmortem CT images. In this study, male and female decedents (n = 10 each) from autopsy cases were grouped into 10-year incremental age groups (20-29 y; 30-39 y; up to 89 y). We found that the mean Hounsfield unit (CT number) and percentage calcification (the ratio of the ossified area to the whole area) increased with age for both sexes. However, there were marked individual differences within many of the groups, and this led to a statistically significant difference (P < 0.05) only between the 20-29 y group and the older age groups. To improve the ability to correctly assign cases to age groups, we introduced and reanalyzed the data using Bayesian statistics. This improved the classifications rates, with 40% of males and 35% of females correctly assigned into their age groups. Broadening the age range could further improve the number of matches. Thus, combining Bayesian statistics with CT imaging can be used to estimate age at death from costal cartilage calcification, and could be used as an adjunct in forensic investigations.

Precipitating Circumstances of Suicide and Alcohol Intoxication Among U.S. Ethnic Groups.

Our goal was to assess the prevalence of 9 different types of precipitating circumstances among suicide decedents, and examine the association between circumstances and postmortem blood alcohol concentration (BAC≥0.08g/dl) across U.S. ethnic groups. Data come from the restricted 2003 to 2011 National Violent Death Reporting System, with postmortem information on 59,384 male and female suicide decedents for 17 U.S. states. Among men, precipitating circumstances statistically associated with a BAC≥0.08g/dl were physical health and job problems for Blacks, and experiencing a crisis, physical health problems, and intimate partner problem for Hispanics. Among women, the only precipitating circumstance associated with a BAC≥0.08g/dl was substance abuse problems other than alcohol for Blacks. The number of precipitating circumstances present before the suicide was negatively associated with a BAC≥0.08g/dl for Whites, Blacks, and Hispanics. Selected precipitating circumstances were associated with a BAC≥0.08g/dl, and the strongest determinant of this level of alcohol intoxication prior to suicide among all ethnic groups was the presence of an alcohol problem.

Characterization of Diphenhydramine-Related Accidental Overdose Deaths

Characteristics of diphenhydramine (DPH)-induced accidental overdose deaths were compared to deaths without DPH present. Data from 4702 drug-induced deaths during 2005 to 2011 in four states were reviewed, with 3884 of these certified as accidental. DPH was involved in 276 cases (5.9%), with the manner of death ruled accidental in 181 (DPH group). The remaining 3703 accidental deaths constituted the control group. Age, body mass index, and the cases with benzodiazepine or opioid co-intoxicants did not differ significantly between groups. In the DPH deaths, methadone was the most frequently identified additional co-intoxicant, particularly when only one or two other co-intoxicants were present. Significantly more females (57.5% vs. 31.5%, respectively) and co-intoxicants were present (55.8% vs. 20.1% with ≥ 3 other co-intoxicants present, respectively) in the DPH compared to the control group. Alcohol was identified significantly less often in DPH decedents. Antidepressants overall and the selective serotonin reuptake inhibitor (SSRI) and tricyclic antidepressant (TCA) classes appeared significantly more often as co-intoxicants in DPH decedents compared to controls. Female DPH decedents were also significantly more likely than control females to have antidepressants (32.7% vs. 16.8%, respectively), TCAs (16.4% vs. 7.1%), or SSRIs present (21.2% vs. 11.6%). DPH concentrations in the accidental deaths were usually lower compared to the suicides although overlap was present. In conclusion, the availability of over-the-counter DPH appears to pose significant potential for drug abuse and should be identified as contributory to death with other detected co-intoxicants such as antidepressants, benzodiazepines, opioids, and other central nervous system depressant drugs.

Changes in overall and firearm veteran suicide rates by gender, 2001-2010.

Introduction To date, the majority of information on veteran suicide rates has been based on the population of veterans utilizing Veterans Health Administration (VHA) services. From 2001 to 2010, both male and female VHA veterans had higher age-adjusted suicide rates than men and women in the U.S. general population. Importantly, however, only 25% of veterans use VHA services, and there is a relative paucity of information on suicide rates overall and by specific mechanisms for the broader population of all veterans. Firearms are a particularly important mechanism for suicide among the veteran population, given their military history and extensive knowledge of and familiarity with firearms. Indeed, firearms have been shown to account for a disproportionate number of veteran suicides when compared to firearm use among suicide decedents in the U.S. general population. Among veterans using VHA services, defined as those who received inpatient or outpatient care during the study period, 69% of suicides among men involved firearms in fiscal years 2007–2008, while 38% of suicides among women involved firearms. By contrast, the proportion of suicides involving firearms in the U.S. general population was lower: 56% among male and 30% among female decedents in 2008. Although information exists on the prevalence of firearms used in veteran suicides, information on mechanism-specific suicide rates and trends in these rates over time is currently lacking. Accordingly, this study aimed to provide novel information on overall and firearm-specific suicide rates among the broad veteran population, which includes both veterans who do and do not utilize VHA services. Suicide rates were computed and compared over time from 2001 to 2010. Furthermore, given documented

Economic contraction, alcohol intoxication and suicide: analysis of the National Violent Death Reporting System

ObjectivesAlthough there is a large and growing body of evidence concerning the impact of contracting economies on suicide mortality risk, far less is known about the role alcohol consumption plays...

A Comparison of Suicides and Undetermined Deaths by Poisoning among Women: An Analysis of the National Violent Death Reporting System

The study compared the prevalence of common suicide risk factors between poisoning deaths classified as injuries of undetermined intent or suicides among women. Data were derived from the 2003–10 National Violent Death Reporting System. Multiple logistic regression assessed the factors associated with 799 undetermined deaths (relative to 3,233 suicides). Female decedents with lower education, a substance use problem, and a health problem were more likely to be classified as undetermined death. Older women, those with an intimate partner problem, financial problem, depressed mood, mental health problem, attempted suicide, and disclosed intent to die were less likely to be classified as undetermined death. The present study raises the possibility that many (perhaps most) undetermined female poisoning deaths are suicides.

Use of alcohol before suicide in the United States

PurposeFew studies have compared acute use of alcohol in suicide decedents with that in a nonsuicide group. This study provides the first national analysis of acute use of alcohol before suicide compared with an estimate of acute use of alcohol in a living sample. MethodsPooled 2003–2011 National Violent Death Reporting System data were used to estimate the prevalence of postmortem blood alcohol content positivity (blood alcohol content >0.0 g/dL) and intoxication (blood alcohol content ≥0.08 g/dL). Population estimates of comparable use of alcohol (within the past 48 hours) were based on the National Epidemiologic Survey on Alcohol and Related Conditions. ResultsCompared with the living sample, male and female suicide decedents showed, respectively, a 1.83-fold (95% confidence interval [CI], 1.73–1.93) and 2.40-fold (95% CI, 2.24–2.57) increased risk of alcohol ingestion before their death after age, race/ethnicity, and chronic alcohol problems were controlled. Furthermore, male and female decedents exhibited, respectively, a 6.18-fold (95% CI, 5.57–6.86) and a 10.04-fold (95% CI, 8.67–11.64) increased risk of being intoxicated before their death after confounders were considered. ConclusionsThe findings underscore the crucial need to include among the essential components of suicide prevention policies programs that minimize the use of alcohol, particularly drinking to intoxication.

A reconsideration of the correlation between veteran status and firearm suicide in the general population

BackgroundThe relationship between veteran status and firearm suicide has been evaluated previously, but multiple sources of bias limit conclusions. This study aimed to clarify the relationship between a history of...

TU‐G‐103‐03: Validation of a Novel CT Breast Dosimetry Method in Post Mortem, Unembalmed Female Subjects

Purpose: Validate breast dose from CT in post mortem subjects, as measured by implanted dosimeters, for later comparison to currently accepted calculation methods. Methods: The study population consisted of 22 female decedents, referred to the New Mexico Office of the Medical Investigator and scheduled for autopsy. Exclusion criteria were: postmortem interval greater than 24hours, significant trauma to the thorax, large pleural or vascular gas collections and significant external or internal decomposition. Under CT guidance, using a Philips large bore 16 slice CT scanner, a microMOSFET detector was implanted in the glandular tissue of the decedent's left breast using plastic flexi‐needles under CT guidance. The implanted dosimeter was placed in the subaereolar breast, at a depth midway between nipple and the posterior margin of glandular tissue. An additional MOSFET and Unfors PSD detector (for cross comparison) were placed on the skin surface, over the nipple of the contralateral breast. Each decedent was scanned using our standard clinical chest and clinical CTA protocol.Breast dose calculations were performed using ImpactCT dose calculator and PCXMCrotation software packages for comparison to measured data. Results: Results demonstrate good agreement between the implanted microMOSFET detector, PSD, and the surface microMOSFET detector. Additionally, there is poor agreement between measured doses and the Impact CT calculations, which are limited by the assumption of a single standard patient size. Calculations using PCXMCrotation, which allows for some patient size specifications, are in progress. Conclusion: The agreement between the implanted surface dosimeters suggests that 1) an accurate surface measurement may be sufficient to determine the breast dose, and 2) as employed, the method of measuring dose using an implanted microMOSFET is accurate. The postmortem microMOSFET model presented here may, in future, produce more meaningful dose estimates and patient specific dose models and be used for measuring dose in other radiosensitive organs.

Acute Alcohol Intoxication and Suicide Among United States Ethnic/Racial Groups: Findings from the National Violent Death Reporting System

To assess the prevalence and sociodemographic correlates of suicide involving acute alcohol intoxication among U.S. ethnic minorities. Data were derived from the restricted 2003 to 2009 National Violent Death Reporting System. The study focused on the sociodemographic and toxicological information of 59,384 male and female suicide decedents for 16 states of the United States. Acute alcohol intoxication was defined as having a blood alcohol content (BAC) ≥0.08g/dl. Overall, 76% of decedents were tested for the presence of alcohol. The proportion of suicide decedents with a positive BAC ranged from 47% among American Indians/Alaska Natives (AIs/ANs) to 23% among Asians/Pacific Islanders (PIs). Average BAC was highest among AIs/ANs. Among those who were tested for BAC, the proportion of decedents legally intoxicated prior to suicide was as follows: Blacks, 15%; AIs/ANs, 36%; Asians/PIs, 13%; and Hispanics, 28%. Bivariate associations showed that most suicide decedents who were legally intoxicated were male, younger than 30years of age, with a high school education, not married, nonveterans, lived in metropolitan areas, and used a firearm to complete suicide. However, with the exception of Whites, most of these associations became not statistically significant in multivariate analysis. Alcohol use and legal intoxication prior to completing suicide are common among U.S. ethnic groups, especially among men and those who are younger than 30years of age. The AI/AN group had the highest mean BAC, the highest rate of legal intoxication and decedents who were particularly young. Suicide prevention strategies should address alcohol use as a risk factor. Alcohol problems prevention strategies should focus on suicide as a consequence of alcohol use, especially among AI/AN youth and young adults.

Sex-based Differences in End-of-Life Decision Making in Flanders, Belgium

Sex-related differences in end-of-life decisions (EOLD) are underresearched and unexplored. To investigate whether there are (1) differences in demographic and/or clinical characteristics between male and female decedents; (2) differences between men and women in the prevalence of EOLD with a possible or certain life-shortening effect; (3) differences in EOL decision making between men and women. In 2007, we performed a postmortem survey in Flanders, Belgium among physicians certifying a large representative sample (n=6927) of death certificates. Response rate was 58.4%. Of patients with nonsudden death, women more often die in a care home than men (31.4% vs. 18.2%) who more often die at home (24.1% vs. 17.9%). Men tend to die more often from cancer than women (45.4% vs. 32.1%). Decisions to withhold or withdraw potentially life-prolonging treatment are more often made in women (28.0% vs. 22.8%, P=0.003); euthanasia and pain and symptoms treatment [alleviation of pain and symptoms (APS)] occur more often in men (3.6% vs. 2.1% euthanasia, P=0.023; 41.8% vs. 36.9% APS, P=0.012). These differences disappear after controlling for confounders. Bivariate associations were found between sex and EOL decision making. Some of them remained after controlling for confounders. It is not the patient's sex in itself that determines the likelihood of an EOLD, but the different clinical profiles of men and women at the end of life. Although sex is not a determining factor in the prevalence of EOLD, it influences the decision-making process, indicating that there may be a difference in the way that male and female patients participate in EOL decision making.

Outpatient Health Care Utilization of Suicide Decedents in Their Last Year of Life

The characteristics of health care utilization during the last year of life by Taiwanese who died by suicide were analyzed. The degree of health services utilization was evaluated by extracting the data of National Health Insurance (NHI) outpatient cohort records in 2006. A total of 4,406 fatal suicide cases were matched with the 17,587,901 subjects in the NHI beneficiary registry file. Rate of visit of the suicide decedents for all NHI outpatient services during their last year before death was 85%, and that for mental disorders service only was 30.2%. Average number of visits per person-year of the suicide decedents was 24.5 visits per year, two times higher than that of the survivors. The average numbers of visits (ANV) of male suicide decedents who used the mental disorders services was increased 6.8 times compared to that for all survivors. The increase in female decedents, in contrast, was 2.7 times. The increase in ANV for 15-24 age group was 14.6 times, significantly higher than that for the other age groups (<4 times). Effective prediction or prevention of potential suicides through increased awareness and surveillance of medical care resource utilization is possible, especially for male and young adult patients under mental disorder health care.

Pandemic (H1N1) 2009, Abu Dhabi, United Arab Emirates, May 2009–March 2010

To ascertain characteristics of pandemic (H1N1) 2009 virus infection, we reviewed medical records for all suspected or confirmed cases reported in Abu Dhabi during May 2009–March 2010. Overall case-fatality rate was 1.4/100,000 population. Most patients who died had ≥1 risk factor, and female decedents were considerably younger than male decedents.