John D. Butts

Risk factors for fatal residential fires

BACKGROUND Residential fires are the most important cause of fire-related mortality in the United States. Previous research has concentrated on fatal fires in urban areas; considerably less is known about fatal fires in rural areas. METHODS We studied fatal and nonfatal residential fires in predominantly rural areas. Using a case-control design, we compared all 151 fatal fires (cases) in single-family dwellings in North Carolina during a 13-month period with a sample of nonfatal fires (controls). Case fires were identified through the medical-examiner system, and control fires that occurred within a few weeks of the case fires were chosen from the records of randomly selected fire departments statewide. For each fire, fire officials were interviewed about the dwelling, the fire, the people involved, and the fire-response system. RESULTS Although heating incidents were the leading cause of fires, fatal fires were more likely to have been caused by smoking (31 percent of fatal fires vs. 6 percent of nonfatal fires). Mobile homes posed a higher risk of death if a fire occurred (odds ratio, 1.7; 95 percent confidence interval, 1.1 to 2.6), as did the absence of a smoke detector (odds ratio, 3.4; 95 percent confidence interval, 2.1 to 5.6). Smoke detectors were more protective against death in fires involving young children and when no one present was impaired by alcohol or drugs or had a physical or mental disability. The presence of an alcohol-impaired person was the strongest independent risk factor for death in the case of a fire (odds ratio, 7.5; 95 percent confidence interval, 4.4 to 12.7). CONCLUSIONS Residential fires are most likely to be caused by heating equipment or smoking materials. The risk of death is greatest in fires in mobile homes, in those involving alcohol-impaired persons, and in those in houses without smoke detectors.

Femicide in North Carolina, 1991-1993: A Statewide Study of Patterns and Precursors

This population-based study describes all 586 North Carolina femicide victims age 15 and older between 1991 and 1993. We combined reviews of medical examiner records with interviews of law enforcement officers to obtain information about the events and the contexts in which the Femicides occurred. Victimization rates were highest for African American and young women. Fifty-four percent of the femicides were committed with firearms and 67% occurred at a residence. More than half the women were killed by current or former intimate partners; at least 67% of these cases were preceded by domestic violence. Nonpartner femicides often involved multiple overlapping circumstances such as criminal activity, drug-related activity, and arguments. The findings demonstrate the complexity of femicide and the need to disentangle the many contributing factors. Medical examiner data and law enforcement interviews proved complementary, but information gaps still exist, signaling possibilities for changes in data collection, as well as needs for further research.

ELEVATED POSTMORTEM TRYPTASE IN THE ABSENCE OF ANAPHYLAXIS

Elevations in tryptase, a recently discovered mast cell enzyme, have been proposed as a postmortem indicator of fatal anaphylaxis. The previous studies had limited numbers of controls and thus the specificity of the test with postmortem samples was not known. Therefore, tryptase was evaluated in postmortem blood samples from 49 autopsy cases where there was no evidence of fatal anaphylaxis. The tryptase was above the normal serum threshold of 1 nanogram/mL (ng/mL) in 31 of these cases. Twenty-four cases had values in the 1 to 5 ng/mL range, two cases were between 5 and 10 ng/mL, and five were greater than 10 ng/mL. One autopsy specimen had a tryptase value of 106 ng/mL. The postmortem interval and the specimen storage condition did not appear to correlate with these elevations in tryptase. Although elevations in the postmortem tryptase remain an important supporting finding in the diagnosis of fatal anaphylaxis, it should not be used alone as the sole criterion for the postmortem diagnosis of anaphylaxis.

Partner homicide-suicide involving female homicide victims: a population-based study in North Carolina, 1988-1992.

Homicide-suicide is a form of fatal violence in which an individual commits homicide and subsequently kills him- or herself. One hundred and sixteen homicide-suicide events involving 119 female homicide victims in North Carolina from 1988-1992 were identified through state medical examiner files. Case files were reviewed retrospectively to identify event characteristics, precursors, and typologies. In 86% of cases the perpetrator was the current or former partner of the victim. During the study period, 24% of men who killed their female partners in North Carolina subsequently committed suicide and another 3% attempted suicide but survived. Victim separation from the perpetrator was the most prevalent precursor (41%), followed by a history of domestic violence (29%). In nearly half of the cases with a history of domestic violence, the victim had previously sought protection from the perpetrator in the form of an arrest warrant, restraining order, or intervention by a law enforcement officer. Children of the victim (and/or perpetrator) witnessed the homicide-suicide, were in the immediate vicinity, found their parents’ bodies, or were killed, in 43% of cases. The prevalence of separation and domestic violence suggests several potential points of intervention, including stronger domestic violence legislation. Future research should place priority on assessing the impact of partner homicidesuicides on the families in which they occur. Such studies are essential for the informed development of preventive and therapeutic interventions for the families of both the victims and perpetrators of these fatal events. In addition, research focused on assisting men in coping with issues of control and separation is needed.

Serotonin transporter binding sites and mRNA levels in depressed persons committing suicide

The serotonin transporter (5-HTT) has been found altered in postmortem brain samples from persons committing suicide, but the results of radioligand binding studies have been inconsistent. In the present series of experiments, autoradiographic radioligand binding and in situ hybridization techniques were utilized to examine 5-HTT function in the brains of 8 depressed subjects who had committed suicide, and matched controls. It was hypothesized that depressed subjects would demonstrate decreased numbers of 5-HTT binding sites and mRNA; however, [125I]RTI-55 binding to the 5-HTT was not different in the midbrain, hippocampus, or frontal cortex of depressed subjects. Also, 5-HTT mRNA levels in dorsal and median raphe nuclei were not different between controls and depressed subjects. The current results, although limited in scope because of the small number of subjects included, offer no evidence that alterations in the 5-HTT occur in pertinent brain regions of depressed individuals.

Partner homicide in context: a population-based perspective.

The authors used a combination of medical examiner data and police interviews to develop profiles of all partner homicides that occurred in North Carolina in a single year. This methodology allowed us to investigate gender differences that might shape the context for male and female homicide perpetration and victimization. Five themes emerged: (a) The context for partner homicides is often chronic women battering, (b) leaving an abusive partner and remaining are both dangerous options, (c) protective measures for battered women are inadequate, (d) domestic violence is not necessarily private violence, and (e) alcohol and firearms often accompany homicide. These themes suggested: Partner homicides emanated almost uniformly from a history of male-perpetrated aggression; analysis of partner homicide should not be detached from the daily life created and sustained by battering; and a gender analysis of partner homicide focuses on the context of gender-based power imbalances rather than on frequency or severity of injury.

Fentanyl Patches Left on Dead Bodies—Potential Source of Drug for Abusers

We report a fatal case of fentanyl poisoning in which the decedent apparently obtained the drug from a used transdermal patch removed from a deceased nursing home patient. Fentanyl drug patches, even those previously used, contain a potentially lethal amount of this potent narcotic analgesic and provide a source of fentanyl for drug abusers. This case demonstrates the importance of proper disposal of these drug patches and the need for strict policies and guidelines in patient care settings regarding their disposal. Since fentanyl derivatives may not be detected on routine toxicologic analysis, specific assays should be utilized for the detection of fentanyl in cases of suspected drug overdose.

Intracellular Concentrations of Antibacterial Agents and Related Clinical Implications

SummaryIntracellular penetration, accumulation and disposition of antibacterial agents is crucial for effective treatment of infections caused by intracellular bacteria. Intracellular concentrations and locations of both antibacterials and bacteria remain poorly understood and further research is needed to establish the importance of these concepts. For example, concepts that have been shown to be important outcome predictors when applied to concentrations of antibacterial agents in the serum include: (i) the effect of the peak antibacterial serum concentration to minimum concentration inhibitory to 90% of organisms (MIC90) for bacteria; (ii) the effect of length of time the serum antibacterial concentration remains above the MIC90 curve; or (iii) the area under the MIC90 curve, but above the serum antibacterial concentration curve.Further research should determine whether or not these concepts have important applications in an intracellular environment. Intracellular pathogens have been increasingly contributing to respiratory infections in the community. Therefore, on the basis of intracellular activity against bacteria causing respiratory infections, macrolides are favoured as the most broad spectrum class of oral antibacterial agents available for the treatment of patients with community-acquired respiratory infections.

Multivariate population-based analysis of the association of county trauma centers with per capita county trauma death rates

UNLABELLED The purpose of this study was to utilize a large population-based data base to determine the association of trauma centers with per capita county trauma death rates. METHODS Per capita county trauma death rate, the dependent variable in the model, was obtained from a well-validated state Medical Examiners data base. Over 200 county demographic, prehospital, and hospital trauma care resource variables were obtained from a variety of sources for multivariate modeling. Bivariate analysis identified candidate variables for multivariate modeling, excluding highly correlated independent variables to avoid problems of collinearity. Multivariate linear regression, logistic regression, and stepwise discriminant analysis were used to determine the relative association of the candidate variables with per capita county trauma death rates. RESULTS Bivariate analysis identified multiple factors associated with per capita county trauma death rates. These included, among others: county rurality, percentage of unemployment, percentage nonwhite, 911 access, and ALS certified EMS. Per capita trauma death rates were significantly lower in counties with trauma centers compared with counties without trauma centers (4.0 +/- 0.5 and 5.0 +/- 1.1 deaths per 10,000 population, p = 0.0001, respectively). Multivariate analysis demonstrated that the presence of a trauma center in the county and ALS were the best medical system factors predicting decreased per capita county trauma death rates. CONCLUSIONS This study is unique in utilizing a regional population-based data base of all trauma deaths in a large state to analyze the association of trauma centers and trauma death rates. Multivariate modeling controlling for other county variables demonstrated that the presence of a trauma center and Advanced Life Support training were the best predictors of per capita county trauma death rates. These findings are consistent with the hypothesis that trauma centers decrease trauma death rates.

Killed on the clock : A population-based study of Workplace homicide, 1977-1991

BACKGROUND This paper describes the epidemiology of workplace homicides in North Carolina, with emphasis on the circumstances. METHODS Workplace homicide victims were identified by and data were abstracted from the North Carolina medical examiner system. RESULTS Workplace homicide rates are highest for men, older and self-employed workers, minorities and specific occupations, especially taxi drivers. Robberies, mostly in retail settings, accounted for half of the cases, while 20% were known to involve disputes, the contexts of which differed by sex. Women were most likely to be killed by estranged partners. CONCLUSIONS Preventive strategies need to address the specific contexts in which workplace homicide occurs, such as retail and taxi robberies, and law enforcement officers interacting with suspects. A workplace response to domestic violence is also needed. Other areas for future research and intervention include environmental modifications, employee screening and training, and identifying more inclusive occupational data sources.