The effect of access to lethal methods of injury on suicide rates.

The relationship between the availability of lethal methods of injury and suicide rates is an important, but unresolved question. We investigated this relationship by prospectively classifying lethal methods according to their accessibility in the five counties of New York City. These counties have both similarities and differences in the proportion of their populations with access to specific lethal means. We then compared the age- and gender-adjusted method-specific suicide rates of these counties. There were marked differences in overall crude suicide rates among the five counties. The counties had similar suicide rates involving methods that were equally accessible to all persons in each county (eg, hanging, laceration, suffocation, and burns) as well as methods that were accessible to a smaller, but similar proportion of the population in each county (eg, firearms and drowning in waterways). Virtually all of the differences in overall suicide risk among counties were explained by differences in rates involving methods that were differentially available in the counties, principally fall from height, overdose of prescription medications, and carbon monoxide poisoning. We conclude that differences in suicide rates between communities are, in large part, due to differences in accessibility to lethal methods of injury. Therefore, systematic studies should evaluate the effect of reducing accessibility to specific lethal means on suicide rates.

Prevalence of cocaine use among residents of New York City who committed suicide during a one-year period.

OBJECTIVE: In the mid-1980s the form of cocaine called "crack" became widely available in New York City. The authors sought to determine the prevalence of cocaine metabolites detected at autopsy in persons who committed suicide in New York City during this period. METHOD: Individual reviews of the autopsy and toxicological records of all persons under the age of 61 who had committed suicide in the city during a 1-year period were conducted to determine demographic characteristics, suicide methods, and cocaine and alcohol use at the time of death. RESULTS: In one of every five cases studied, the person who committed suicide had used cocaine within days of his or her death. The prevalence of cocaine use among young Hispanic males who committed suicide was 45%. Persons who were young, black, or Hispanic and who had used alcohol immediately before the fatal injury were most likely to have been recent cocaine users. After controlling for demographic variables and ethanol use, the investigators found that individuals who committed suicide with firearms were twice as likely to have used cocaine as those who used other methods. CONCLUSIONS: In contrast to the results of regional and household surveys during this period, which suggested that the current prevalence of cocaine use in New York City was 3%-5%, these results suggest a high prevalence of cocaine use in the days immediately preceding death by young persons who commit suicide. Additional studies are needed to determine how cocaine may act as a risk factor for suicide.

Use of prescription psychotropic drugs among suicide victims in New York City.

OBJECTIVE: The authors examined the rate of prescription psychotropic drug use among suicide victims at the time of their death. METHOD: From a total of 1,970 suicides that occurred in New York City from 1990 to 1992, 1,635 cases that had a complete toxicologic analysis and an injury-death interval of 48 hours or less were assessed at autopsy for the presence of commonly prescribed antidepressants and neuroleptics. RESULTS: Prescription psychotropic medications were detected in only 16.4% (N = 268) of the suicide victims studied. Demographic factors associated with use of these drugs included female gender and white race. Poisoning accounted for 17.9% (N = 293) of all suicides studied, but antidepressants or neuroleptics were detected in less than half of these victims. Among all suicide victims in whom an antidepressant or neuroleptic was detected, almost half had used lethal methods other than poisoning. CONCLUSIONS: In this study, most individuals who committed suicide in New York City were not taking prescription psychotropic medications at the time of their death and either were not receiving pharmacotherapy or were noncompliant.

A profile of homicides on the streets and in the homes of New York City.

Although prior research has found that homes containing firearms and illicit drug and ethanol users are more likely to be the scene of a homicide than homes that do not contain these elements, the authors studied homicides on the streets as well as in homes so as to assess the role of firearms, cocaine, and ethanol in both settings. Using the files of the Chief Medical Examiner, the authors reviewed all 4,468 homicides occurring in New York City in 1990 and 1991. The most frequent places of occurrence were the streets and other outdoor places (49.6 percent) and the victims' homes (19.3 percent). Firearms were the cause of death for 49.6 percent of homicides in the home and 80.3 percent of those on the streets. Use of cocaine and ethanol was found more frequently among victims killed on the streets than those killed at home. In addition, victims killed on the streets were more likely to be male, ages 15-24 years, and African American. Further research in regard to prevention and intervention strategies is needed, keeping in mind the different patterns of homicide on the streets compared with those occurring in other settings.

Cocaine and fetal death.

Toxicologic screening for cocaine and its metabolites was performed on 103 cases of fetal death autopsied in the Office of Chief Medical Examiner, City of New York. In 64 cases cocaine or its metabolites were found in the blood or in the brain. Some malformations were also found. The study indicates that maternal use of cocaine may lead to abruptio placentae, abortion and fetal death. The importance of toxicologic examination in these deaths is emphasized.

Report of a fatal thiamylal intoxication.

A fatality due to the intravenous administration of thiamylal is reported. Quantitation of the drug was accomplished by high-performance liquid chromatography (HPLC) and confirmation was by gas chromatography/mass spectrometry (GC/MS). Postmortem tissue concentrations of thiamylal were as follow: 129 mg/L in blood, 366 mg/kg in liver, and 116 mg/kg in brain. Thiamylal was not detected in the urine, gastric contents, or bile. Analytical caveats involving the quantitation of thiamylal are also discussed.

Fatal metoprolol overdose.

Metoprolol, a beta 1-adrenergic blocking agent, has been found effective in the treatment of hypertension. A death due to deliberate ingestion of metoprolol is described, including the case history, postmortem toxicologic findings, and identification and quantitation of the drug by high pressure liquid chromatography and gas chromatography/mass spectrometry. Metoprolol levels were found to be 4.7 mg/L in blood, 194 mg/L in urine, 3.3 mg/L in vitreous humor, 3.9 mg/L in pleural fluid, 254 mg/L in bile, 7.1 mg/kg in kidney, and 6.3 mg/kg in liver.

Ketamine in non-hospital and hospital deaths in New York City.

We reviewed all ketamine-positive deaths (87) examined at the New York City Office of Chief Medical Examiner over a two-year period (1997 to 1999). There were 15 non-hospital deaths with 12 due to acute multidrug intoxications, one due to sarcoidosis, and two due to physical injury (blunt and thermal). In no instance was a fatal intoxication caused exclusively by ketamine. Opiates (10/15), followed by amphetamines (7/15) and cocaine (6/15), were the most frequent co-intoxicants. Ethanol was found in only one death. The race of all decedents was white and the majority were men (11/15) between the ages of 18 and 30 years. The remaining 72 instances of positive ketamine findings were hospital deaths following surgical procedures or burns.

Detection of drugs using XAD-2 resin. I:Choice of resin, chromatographic conditions, and recovery studies.

Amberlite XAD-2, a nonionic polystyrene divinylbenzene resin, was first used for the analysis of drugs in urine and a number of reports have described the development at optimal conditions for extraction, including type of resin columns, pH conditions, and eluting solvents. XAD-4 and XAD-7 resins were compared to the similarly structured XAD-2 resin and no significant advantage over the XAD-2 resin for drug screening was observed. A quantity of 5 to 6 g of resin was found to have sufficient capacity for the extraction of 200 ml of pentobarbital solution (1 mg/100ml). A column flow rate of approximately 15 ml/min (gravitational flow) was sufficient for analysis and slower rates were not more efficient. A mixture of ethyl acetate and 1,2-dichloroethane (3:2) was found to give best overall recovery (66 to 94%) of drugs, the resulting extracts being reasonably free of interfering substances. A pH value of 8.5 is recommended as optimum for comprehensive analysis of acidic and basic drugs. Recovery studies were conducted on spiked samples to determine drug losses occuring during various steps in the XAD-2 extraction procedure for four acidic (amobarbital, secobarbital, pentobarbital, and phenobarbital) and four basic (morphine, codeine, meperidine, and methadone) drugs. A relatively small amount (0 to 5%) of the drugs was not adsorbed by the resin and amounts varying from 6 to 40% failed to be desorbed by the eluting solvent. Additional losses occurred during the removal and analysis of TLC spots. Recovery of drugs from aqueous solutions analyzed with the XAD-2 resin were compared to recoveries reported in the literature with other XAD-2 resin methods for the extraction of drugs from urine. Recovery of phenobarbital, morphine, and codeine improved by 4 to 23% while recoveries of amobarbital, pentobarbital, secobarbital, methadone, and meperidine were 4 to 28% less efficient when compared to literature data.

Detection of drugs using XAD-2 resin. II:Analysis of liver in medical examiner's cases.

Liver tends to concentrate drugs in quantities generally higher than those found in blood or other body compartments. This fact as well as the general availability of liver in postmortem cases makes it an important specimen for comprehensive toxicologic investigation. A scheme for the analysis of liver for drugs with tissue hydrolysis, XAD-2 resin extraction, and TLC has been developed and the parameters affecting recovery have been studied. The hydrolysis of liver specimens at various pH conditions resulted in an improved recovery for morphine by using pH 2 (2N hydrochloric acid). Recoveries of barbiturates, codeine, and meperidine were essentially the same at pH 2 and pH 3. A considerable loss (22 to 55%) was observed for four drugs (pentobarbital, morphine, codeine, and meperidine) as a result of drug binding to the tissue pellets during the process of centrifuging the liver homogenates. This method is recommended as a comprehensive screening procedure for drugs in liver tissue. For quantitative purposes, however, it is necessary to determine a correction factor for all the losses occurring at the various steps of the procedure. This procedure compared favorably with other procedures for liver analysis reported in literature.

Drug identification through analysis of maggots.

The examination of insect larvae from decomposed bodies not only can serve in the estimation of the postmortem interval but also can be used in qualitative identification of drug substances.

Detection of drugs using XAD-2 resin. III:A routine screening procedure for bile.

The ability of bile to concentrate drugs and metabolites coupled with its general availability make it suitable for analysis and often the fluid of choice in postmorten cases requiring drug screening. Bile (5 to 10 ml) was diluted with water, sulfuric acid was added, and the mixture was autoclaved. The precipitated bile salts were easily removed by filtration and the filtrate (pH adjusted to 8.0 to 8.5) extracted with XAD-2 resin. Drugs were eluted with a mixture of ethyl acetate/1,2-dichloroethane and analyzed with thin-layer chromatography. Varying the dilution of bile improved the recovery of morphine, codeine, methadone, amobarbital, and phenobarbital. Excessive dilution, however, caused a washing phenomenon and reduced recovery of some drugs, as shown with morphine and codeine. The procedure described is useful for the rapid screening of bile specimens for drugs.

Analysis of cocaine-positive fatalities.

A review of all autopsy and toxicology reports for persons dying in New York City in an 11-month period found 935 persons dying with cocaine in their bodies. Cocaine-positive fatalities were more likely in the young black and Hispanic and male population. In addition to cocaine and its metabolites, heroin and other opiates were found in 39% of persons and ethanol in 33% and barbiturates and minor tranquilizers in only 2% of the deceased. Cocaine overdose was responsible for 4% of the deaths and overdose with heroin and cocaine for 12% of the deaths. Violence was often the cause of death. Thirty-eight percent died of homicide, seven percent of suicide, and eight percent from accidents. Of particular interest were 6 persons who died of acute cardiac events directly related to cocaine as well as 4 cases of ruptured dissections of the ascending aorta, and 9 cases of cerebral hemorrhage. Autopsy findings for these individuals are described, and possible mechanisms of death are discussed.

HIV seroprevalence rates among homicide victims in New York City: 1991-1993.

This study assessed HIV seroprevalence in homicide victims killed in New York City in 1991-1993, using data from the Office of Chief Medical Examiner. Among 5852 homicide victims there were 344 (5.9%) victims who were HIV positive. Females were just as likely as males to be HIV positive. For females, the highest rates were in the 25-34 year (11.7%) and 35-44 year (12.6%) age categories. For males the highest rates were in the 35-44 year (13.7%) and 45-54 year (11.5%) age categories. Other than there being no HIV positive Asian victims, there were no differences in HIV rates among racial/ethnic groups. The highest rates of HIV infection for homicide victims were among those using both opiates and cocaine (males: 23.0%; females: 27.3%). Women, not men, using cocaine alone had a high HIV positive rate (18.4%). Victims not using these drugs had rates of HIV around 2%. The authors believe that the high risk of HIV among homicide victims, may be due to the use of cocaine and associated risky use of needles and risky sex practices.

Cocaine, opiates, and ethanol in homicides in New York City: 1990 and 1991.

Studies using medical examiner cases are useful in monitoring drug use in special populations. This study assesses the presence of cocaine and its metabolite, benzoylecgonine (BE), opiates and ethanol in all homicide victims who were injured and who survived two hours or less after injury in 1990 and 1991 in New York City. There were 2824 homicides in the study period and cocaine and/or BE were found in 884 (31.3%) of cases. In over half of the cases positive for cocaine/BE, ethanol or opiates were found. African-Americans and Latinos were much more likely than whites or Asians to be positive for cocaine/BE. There were no differences between men and women in regard to being positive for cocaine/BE. Cocaine/BE was most frequently identified among victims 25 to 44 years of age. Males were more likely to be positive for ethanol. There were no differences among age groups or ethnic groups in regard to ethanol except for a very low ethanol incidence among Asians. Victims positive for cocaine/BE were more likely to be killed with firearms in open places. The percentage of victims positive for cocaine/BE remains approximately that found by other studies in the late 1980s, however, the percentage of opiate-positive homicides seems to be increasing. Opiates usually were found with cocaine/BE. Two-thirds of the cocaine and/or BE positive cases had cocaine present, thus they were under the influence of the drug at the time they were injured. The authors discuss how the use of cocaine, ethanol and opiates may be related to one's becoming a homicide victim.

Diagnostic significance of alpha-fetoproteins in neonatal hyperbilirubinaemias and primary cancer of the liver in adults.

The presence in the serum of alpha-1-fetoprotein (AFP) was studied by the following immunological methods: immunoprecipitation electrophoresis after Pesendorfer et al., modified micro Ouchterlony technique as described by Prince, and for quantitative determination of this fraction commercial Partigen plates with sensitivity above 1 mg/100 ml. were used (Behringwerke A.G.). Anti AFP serum produced by the same company was used. In our experiance these three methods were equally sensitive In the newborn (41) with hyperbilirubinemia (cytomegalic inclusion disease, toxoplasmosis, ABO and Rh incompatibility) despite persisting abnormal laboratory tests indicating liver damage AFP disappeared from circulation by the end of the first month. Fetoprotein has been demonstrated in the serum by the end of the third month in nine babies in whom malformation of the biliary ducts was confirmed intraoperatively (7,14). In adults AFP was observed in the serum of only those patients in whom presence of primary hepatocellular liver cancer was proved pathohistologically Out of 15 verified cases of primary liver cancer AFP was positive in 43.7%.

[Alcohol and the liver. Present knowledge of pathogenic mechanisms]. / Alkohol i jetra. Savremena shvatanja o patogenetskom mehanizmu.

Intensive longtime experimental and clinically-experimental investigations have not yet succeeded unriddling the intimate mechanism of liver alcoholic damage. Earlier knowledge on accumulation of fats in liver under the influence of alcohol (ethanol) is still actual, but it probably represents only epiphenomenon and does not explain the intimate mechanism of events. It still can be stated that, although the aim has not been achieved, gradually, as a consequence of very studious investigations we have signification information which bring more light in regard to identify the mechanism of this frequent disease of modern mankind. We have tried to summarize the latest knowledge on alcoholic liver damages. However, some of the most simple questions still do not have an answer: why do, for example, some longtime alcoholics, whose everyday intake of alcohol is big, develop liver cirrhosis at the end of their lives, while the others, under the same circumstances, develop it very early?

[Physiologic values of coagulation factors in newborn infants]. / Fizioloske vrednosti cinilaca koagulacije u novorodene dece.

Hemorrhagic tendencies are frequently seen in the neonatal period. From the practical point of view, recognition of physiologic deficiencies of coagulation factors and hemostasis is essential, for the differential diagnosis of hemorrhagic syndromes and adequate treatment. Values of coagulation factors in the newborn and comparison of our results and the results of other authors are presented. It seems that there are no essential changes in hemostasis of term infant, but many coagulation factors exhibit deficient clotting activity as like vitamin K-dependent factors (II, VII, IX, X). Values of fibrinogen, F. XI, XII, XIII are decreased. Those factors which physiologically low in the term infant reach normal adult levels in a few weeks, with the exception of factors IX and XI which may require several months to reach normal levels. In the same time authors presented the results of coagulation factors in mothers during delivery and term infants, to explain the nature of the disorders. For the investigation of these physiological defects, screening tests can be used.

[Malignant tumors in patients in our hospital 1985-1989]. / Maligni tumori digestivnog trakta u nasih stacioniranih bolesnika u periodu 1985-1989. godine.

An analysis was conducted concerning the data on malignant digestive-tract tumors which were treated in the period from 1985 to 1989 at the Department for Gastroenterology of the Clinical-Hospital Center in Zemun. The research results showed that malignant digestive-tract tumors are not in an increase, they are rare in persons which are younger than 40 years of age (10%) and are two times more frequent in males. The share of malignant tumors of the large intestine in overall morbidity is somewhat more frequent, they occur two times more in males and with 10.6% in persons younger than 40 years. The malignant tumors of the stomach are the only ones which are in a decrease, they are considerably less frequent in younger persons (3.7%), but are also two times more frequent in males. Malignant tumors of the pancreas are somewhat more represented in overall morbidity, they are very rare in young persons (3.7%) and are more frequent in males. The data on malignant tumors of the liver show that in the last few years they are somewhat more represented in overall morbidity, they are rare in persons younger than 40, and are more frequent in males.

[Substitution therapy in the treatment of acute leukoses]. / Supstituciona therapija u lecenju akutnih leukoza

In the treatment of acute leukoses, from the first onset of the disease till the occurrence of the first remission, as well as in the course of intesive hemiotherapy, the substitution therapy by blood derivatives has the great importance. Anaemia, granulocytopenia, hypoproteinaemia and hemorrhagic syndroms, caused by thrombocytopenia, liver diseases and disseminated intravascular coagulation, are the most frequent disorders requiring the substitution therapy. Authors presented the advantages of the substitution therapy by blood derivatives upon the whole blood.