Randy Hanzlick

Leading Causes of Unintentional and Intentional Injury Mortality: United States, 2000–2009

OBJECTIVES We have described national trends for the 5 leading external causes of injury mortality. METHODS We used negative binomial regression and annual underlying cause-of-death data for US residents for 2000 through 2009. RESULTS Mortality rates for unintentional poisoning, unintentional falls, and suicide increased by 128%, 71%, and 15%, respectively. The unintentional motor vehicle traffic crash mortality rate declined 25%. Suicide ranked first as a cause of injury mortality, followed by motor vehicle traffic crashes, poisoning, falls, and homicide. Females had a lower injury mortality rate than did males. The adjusted fall mortality rate displayed a positive age gradient. Blacks and Hispanics had lower adjusted motor vehicle traffic crash and suicide mortality rates and higher adjusted homicide rates than did Whites, and a lower unadjusted total injury mortality rate. CONCLUSIONS Mortality rates for suicide, poisoning, and falls rose substantially over the past decade. Suicide has surpassed motor vehicle traffic crashes as the leading cause of injury mortality. Comprehensive traffic safety measures have successfully reduced the national motor vehicle traffic crash mortality rate. Similar efforts will be required to diminish the burden of other injury.

Murder-suicide in Fulton County, Georgia, 1988-1991. comparison with a recent report and proposed typology

Our study of the characteristics of murder-suicide in Fulton County, Georgia is compared with published data, and the usefulness of a proposed typology for classifying murder-suicides is evaluated. Twelve murder-suicides involving 26 decedents occurred in Fulton County (Atlanta), Georgia, during 1988–1991. Similar to national statistics, most offenders were male (100%), there was usually one victim (83%) who was most often female (71%), a spousal or love relationship often existed between the victim and offender (64%), and a firearm was the lethal weapon in almost all incidents (92%). Important differences from published data included a higher incidence of murder-suicide (0.46/100,000), which accounted for a lower proportion of all homicides (1.4%) and a higher proportion of all suicides (3.6%) than is reported nationally, and a lower proportion of white offenders (17%) and higher proportion of male victims (29%). A total of 83% of incidents were intraracial. Murder-suicide in Fulton County was different from national data in ways that might be due to local demographics, the local homicide rate, and the local suicide rate. The proposed typology for classification of murder-suicides is in need of more precise definitions of terminology; further, it does not permit inclusion of some major details that might be useful for study. An alternative classification scheme is offered that enables documentation of more comprehensive information.

Genetic Differences in Pneumocystis Isolates Recovered from Immunocompetent Infants and from Adults with AIDS: Epidemiological Implications

Polymerase chain reaction analysis, direct DNA sequencing, and histological staining were used to determine whether Pneumocystis jirovecii was present in lung tissue specimens obtained, at autopsy, from 58 infants without identifiable immunodeficiency. The results of genotyping of these specimens were compared with the results of genotyping of specimens obtained from 384 human immunodeficiency virus (HIV)-infected adults with Pneumocystis pneumonia. P. jirovecii DNA was detected at the mitochondrial large subunit rRNA and dihydropteroate synthase loci in 100% and 53%, respectively, of the specimens obtained from infants. All specimens obtained from adults tested positive for P. jirovecii at both loci. Genotype distributions at both loci were significantly different in the 2 populations (P < .0001). The observation of different strains circulating in immunocompetent infants and HIV-infected adults suggests independent transmission cycles that warrant further study.

Mind Your Manners: Part Ii: General Results From the National Association of Medical Examiners Manner of Death Questionnaire, 1995

More than 700 physician medical examiner/coroners (ME/Cs) were surveyed to assess differences in manner of death classifications for typical but often controversial death scenarios: 198 physicians participated by choosing the manner of death (homicide, suicide, accident, natural, undetermined) for 23 such scenarios. Sixteen questions related to death certificate training, work location, and manner of death issues were also asked. The classification of manner of death by ME/Cs was highly variable. For some challenging death scenarios, majority agreement was lacking. Agreement was > or = 80% for only 11 of the 23 scenarios and was 100% for only 1. Manner of death classification method was not influenced by forensic pathology board certification status, by whether or not the physician actually completed death certificates, or by previous threats of lawsuits over manner of death classification. However, there were some differences by state. No textbook or individual was widely recognized as authoritative on manner of death issues. Few ME/Cs had formal death certification training in medical school or residency. The data lend credence to the practice of the National Center for Health Statistics (NCHS) of classifying manner of death for statistical purposes by using coding and classification rules and selection criteria rather than solely on the basis of the classification of manner chosen by ME/Cs. The data also indicate that caution is in order when one compares manner of death statistics of one ME/C with those of another Published guidelines and more uniform training are needed so that ME/Cs may become more consistent in their manner of death classifications. Further information is presented in Part I (history of manner of death classification) and in Part III (individual death scenarios and their analysis) companion articles in this issue of the Journal.

Mind your manners. Part III: Individual scenario results and discussion of the National Association of Medical Examiners Manner of Death Questionnaire, 1995.

In 1995, a questionnaire was distributed to the > 700 physician medical examiner/coroners (ME/Cs) who are members of the National Association of Medical Examiners (NAME, St. Louis, MO, U.S.A.). The questionnaire consisted of 23 death scenarios for which individual responders were asked to assign a manner of death (homicide, suicide, accident, natural, or undetermined); 198 questionnaires were completed and analyzed. The distribution of manner of death responses was tabulated. In addition, a nosologist from the National Center for Health Statistics was provided with a cause-of-death statement based on each scenario and was asked to assign an International Classification of Diseases (ICD) code for the underlying cause of death, from which a manner of death was inferred from the ICD codes literal text description. Overall, agreement on a given manner of death in a single scenario was > 90% in only 4 of 23 scenarios and > 70% in only 12 of 23 scenarios. However, in 21 scenarios, the most common response comprised a majority. The manner of death inferred from the ICD code that was assigned by the National Center for Health Statistics (NCHS) matched the most common response of participants in 18 of the 23 scenarios. The questionnaire results show that there is substantial disagreement among experienced MEs concerning the manner of death classification that is preferred for selected types of death. Encouraging, however, is the fact that the manner of death coded for statistical purposes generally agreed with the most common classification of manner made by ME/Cs. Highlights from the discussion of each scenario that occurred during the NAME interim meeting (Nashville, Tennessee, February 1996) are also included. Other portions of the program including history of manner of death concepts and results of questions regarding responder training and characteristics are published separately in this issue of the Journal. Information derived from the questionnaire should be useful to those planning strategies to improve the consistency of manner of death classifications by ME/Cs.

Practice guidelines for autopsy pathology: autopsy reporting

: The Autopsy Committee of the College of American Pathologists has prepared this revised guideline to reflect changes that have occurred in the reporting of autopsies since the original guideline was published in February 1995. It is intended to be an instrument to assist pathologists in the reporting of autopsies. The guideline is to be regarded as being primarily an educational tool. Application of these recommendations on autopsy reporting is to be made on the basis of the judgment of the pathologist engaged in a specific case.

The Abdominal Diameter Index and Sudden Coronary Death in Men

Alternative anthropometric indexes were compared for their ability to discriminate between 35 Atlanta men with sudden coronary death and 81 male controls. With or without adjustments for age, race, and body mass index, the abdominal diameter index (supine sagittal abdominal diameter divided by midthigh circumference) was associated with sudden coronary death more strongly than the waist/hip ratio or waist/thigh ratio of circumferences.

Deaths in Custody: Atlanta City Jail and Fulton County Jail, 1974-1985

A total of 53 in-custody deaths that occurred in Atlanta- Fulton County, Georgia, between 1974 and 1985 are reviewed. Custody deaths showed characteristics similar to those described in other geographical areas. The majority of deaths were due to natural causes, about one-fourth were suicides, and homicides were rare. For jails that housed a daily population of about 1,000 prisoners, an average of 4.4 deaths were observed annually. Men predominated, and racial makeup paralleled the general prison population. Seizures, alcohol-related illness, and cardiovascular disease caused over half of the natural deaths. All suicides were accomplished by hanging. Over two-thirds of the incidents that led to death occurred in the prisoners cell, and about one-half of the victims were found dead in their cells. Two-thirds of those who died in custody had been arrested for crimes in which persons were not harmed, while nearly two-thirds of those committing suicide had been arrested for crimes against persons. Deaths in custody are expected events, and familiarity with the circumstances under which they occur should be helpful in enabling prison managers to establish policies and procedures to minimize their occurrence

Medical Examiners, Coroners, and Public Health: A Review and Update

CONTEXT Traditionally, the emphasis of work done by medical examiners, coroners, and the death investigation community has been viewed as serving the criminal justice system. During the last several decades, however, an important role for these 3 groups has emerged within public health. OBJECTIVE To provide important background information on death investigation systems, the evolution and framework of public health entities that rely on information gathered by medical examiners and coroners, and the role of medical examiners and coroners in epidemiologic research, surveillance, and existing public health programs and activities. DATA SOURCES Previous articles on epidemiologic aspects of forensic pathology and the role of medical examiners and coroners in epidemiologic research and surveillance; a review of the Web sites of public health and safety agencies, organizations, and programs that rely on medical examiner and coroner data collected during medicolegal investigations; and a review of recent public health reports and other publications of relevance to medical examiner and coroner activities. CONCLUSIONS The role of medical examiners and coroners has evolved from a criminal justice service focus to a broader involvement that now significantly benefits the public safety, medical, and public health communities. It is foreseeable that the public health role of medical examiners and coroners may continue to grow and that, perhaps in the not-too-distant future, public health impact will surpass criminal justice as the major focus of medicolegal death investigation in the United States.

Confronting Death From Drug Self-Intoxication (DDSI): Prevention Through a Better Definition

Suicide and other self-directed violence deaths are likely grossly underestimated, reflecting inappropriate classification of many drug intoxication deaths as accidents or unintentional and heterogeneous ascertainment and coding practices across states. As the tide of prescription and illicit drug-poisoning deaths is rising, public health and research needs would be better satisfied by considering most of these deaths a result of self-intoxication. Epidemiologists and prevention scientists could design better intervention strategies by focusing on premorbid behavior. We propose incorporating deaths from drug self-intoxication and investigations of all poisoning deaths into the National Violent Death Reporting System, which contains misclassified homicides and undetermined intent deaths, to facilitate efforts to comprehend and reverse the surging rate of drug intoxication fatalities.