Preventing deaths and injuries from house fires: a cost-benefit analysis of a community-based smoke alarm installation programme.

BACKGROUND: Operation Installation (OI), a community-based smoke alarm installation programme in Dallas, Texas, targets houses in high-risk urban census tracts. Residents of houses that received OI installation (or programme houses) had 68% fewer medically treated house fire injuries (non-fatal and fatal) compared with residents of non-programme houses over an average of 5.2 years of follow-up during an effectiveness evaluation conducted from 2001 to 2011. OBJECTIVE: To estimate the cost-benefit of OI. METHODS: A mathematical model incorporated programme cost and effectiveness data as directly observed in OI. The estimated cost per smoke alarm installed was based on a retrospective analysis of OI expenditures from administrative records, 2006-2011. Injury incidence assumptions for a population that had the OI programme compared with the same population without the OI programme was based on the previous OI effectiveness study, 2001-2011. Unit costs for medical care and lost productivity associated with fire injuries were from a national public database. RESULTS: From a combined payers' perspective limited to direct programme and medical costs, the estimated incremental cost per fire injury averted through the OI installation programme was $128,800 (2013 US$). When a conservative estimate of lost productivity among victims was included, the incremental cost per fire injury averted was negative, suggesting long-term cost savings from the programme. The OI programme from 2001 to 2011 resulted in an estimated net savings of $3.8 million, or a $3.21 return on investment for every dollar spent on the programme using a societal cost perspective. CONCLUSIONS: Community smoke alarm installation programmes could be cost-beneficial in high-fire-risk neighbourhoods.

The eyeball killer: serial killings with postmortem globe enucleation.

Although serial killings are relatively rare, they can be the cause of a great deal of anxiety while the killer remains at-large. Despite the fact that the motivations for serial killings are typically quite complex, the psychological analysis of a serial killer can provide valuable insight into how and why certain individuals become serial killers. Such knowledge may be instrumental in preventing future serial killings or in solving ongoing cases. In certain serial killings, the various incidents have a variety of similar features. Identification of similarities between separate homicidal incidents is necessary to recognize that a serial killer may be actively killing. In this report, the authors present a group of serial killings involving three prostitutes who were shot to death over a 3-month period. Scene and autopsy findings, including the unusual finding of postmortem enucleation of the eyes, led investigators to recognize the serial nature of the homicides.

Preventing deaths and injuries from house fires: an outcome evaluation of a community-based smoke alarm installation programme.

BACKGROUND: Few studies have examined the impact of community-based smoke alarm (SA) distribution programmes on the occurrence of house fire-related deaths and injuries (HF-D/I). OBJECTIVE: To determine whether the rate of HF-D/I differed for programme houses that had a SA installed through a community-based programme called Operation Installation, versus non-programme houses in the same census tracts that had not received such a SA. METHODS: Teams of volunteers and firefighters canvassed houses in 36 high-risk target census tracts in Dallas, TX, between April 2001 and April 2011, and installed lithium-powered SAs in houses where residents were present and gave permission. We then followed incidence of HF-D/I among residents of the 8134 programme houses versus the 24 346 non-programme houses. RESULTS: After a mean of 5.2 years of follow-up, the unadjusted HF-D/I rate was 68% lower among residents of programme houses versus non-programme houses (3.1 vs 9.6 per 100 000 population, respectively; rate ratio, 0.32; 95% CI 0.10 to 0.84). Multivariate analysis including several demographic variables showed that the adjusted HF-D/I rate in programme houses was 63% lower than non-programme houses. The programme was most effective in the first 5 years after SA installation, with declining difference in rates after the 6th year, probably due to SAs becoming non-functional during that time. CONCLUSIONS: This collaborative, community-based SA installation programme was effective at preventing deaths and injuries from house fires, but the duration of effectiveness was less than 10 years.

Deaths related to chemical burns.

The authors present a series of 6 deaths due to the uncommon cause of chemical burns. Of the 6 deaths due to chemical burns, 4 deaths were due to ingestion of a chemical, 1 death was caused by chemical burns of the skin, and 1 death resulted from rectal insufflation of a chemical. Seven additional cases where chemical burns may have been a contributing factor to the death or an incidental finding are also presented. Four cases are related to an incident involving chemical exposure during an industrial explosion. Three cases involve motor fuel burns of the skin. Two cases concern a plane crash incident, and 1 case involved a vehicular collision. Cases are derived from the records of the Dallas County Medical Examiner's Office and those of the authors' consultation practices. Each of the cases is presented, followed by a discussion of the various mechanisms of chemical injury.

Fatal disseminated cryptococcus as the initial presentation of HIV infection in the era of highly active antiretroviral therapy.

Despite the availability of highly active antiretroviral treatment, many HIV-positive patients still present for the first time with a low CD4 count or an acquired immune deficiency syndrome (AIDS) defining illness. This may be due to patients' refusal to be tested for HIV, delay in seeking medical treatment, or the misdiagnosis of an AIDS-associated condition. We present a 39-year-old African American male with undiagnosed HIV, who died shortly after arrival to the emergency room. An autopsy was performed at the Dallas County Medical Examiners' Office, and the cause of death was determined to be disseminated cryptococcosis. Further investigation at autopsy revealed HIV 1/2 antibody positivity and HIV western blot positivity. This case demonstrates the importance of considering complications of HIV as a cause of death, even when the patient has no prior history.

The "unintended pedestrian" on expressways.

OBJECTIVE: To explore the epidemiology of pedestrian deaths in Dallas County, Texas, and to compare factors associated with pedestrian deaths on expressways versus those that occurred on other roadways. METHODS: We studied all pedestrian deaths among persons 15 years of age or older in Dallas County, Texas, from 1997 to 2004 by linking data from Medical Examiner's office, the Fatality Analysis Reporting System, and local police records. Univariate and multivariate analysis compared various factors associated with death on an expressway. RESULTS: Among 437 pedestrian deaths who were 15 years of age or older, 197 (45%) occurred on expressways; the proportion that occurred on expressways was highest among 15- to 29-year-olds (65%) and was lower with advancing age group (p < 0.01, chi square for trend). At least 36% of these expressway-related pedestrian deaths were known to have been "unintended pedestrians," who had exited a vehicle after being on the roadway, compared with 11% of pedestrian deaths on surface streets (OR 4.6, 95% CI, 2.7-8.1), and this was also highest among younger age groups. Pedestrian deaths on an expressway, compared with deaths on surface streets, remained strongly associated with having been an "unintended pedestrian" (OR 6.2, 95% CI, 3.1-14.0), after controlling for several other variables, including age, sex, race, nighttime of crash, and alcohol involvement. CONCLUSIONS: Expressways are the predominant site of fatal pedestrian crashes among young adults in this urban area. Since many of these deaths were "unintended pedestrians," procedures for management of occupants of disabled vehicles on expressways could have a large impact on pedestrian deaths in young adults.

Syphilitic coronary artery ostial stenosis resulting in acute myocardial infarction and death.

Cardiovascular abnormalities are well-known manifestations of tertiary syphilis infections. Most notable in this regard is syphilitic aortitis, which tends to result in aortic root dilatation and its associated complications. A less common manifestation of syphilitic aortitis is coronary artery ostial narrowing related to aortic wall thickening. Herein, we present the case of a 32-year-old female who died of a myocardial infarct due to coronary artery ostial stenosis secondary to syphilitic aortitis.

Sudden death due to asphyxia by esophageal polyp: two case reports and review of asphyxial deaths.

Asphyxia, not an uncommon cause of sudden death, may result from numerous etiologies. Foreign-body aspiration and strangulation are 2 extrinsic causes. Airway obstruction may also be caused by laryngeal edema, asthma, infection, or anaphylaxis. Chronic causes of asphyxia include musculoskeletal diseases (eg, muscular dystrophy, amyotrophic lateral sclerosis), neurologic disorders (eg, myasthenia gravis, multiple sclerosis), respiratory disease (eg, emphysema, chronic bronchitis), or tumors. The manner of death in cases of asphyxiation may be natural, accidental, homicide, or suicide. For the death investigator, determining the cause and manner of death can often be quite challenging. We report here 2 cases of an esophageal fibrovascular polyp causing sudden asphyxial death, review of the literature, and discussion of other differential diagnoses in the case of asphyxial death.

Forensic dermatopathology and internal disease.

The gross and microscopic analysis of skin lesions at autopsy can help the pathologist understand diseases and injuries inflicted premortem, perimortem, or postmortem. From January 2003 to January 2004, skin findings at autopsy were closely examined by a dermatologist and sampled for microscopic analysis at the Southwestern Institute of Forensic Sciences. Dermatologic abnormalities in some of these cases led to the discovery of internal disease and allowed for a more complete understanding of the pathologic disease processes affecting the individual. We present four autopsy cases with skin manifestations of internal disease, including pseudoxanthoma elasticum, calciphylaxis, the sign of Leser Trelat, and papular mucinosis, and demonstrate the usefulness of the dermatological assessment at autopsy. In all cases, discovery of these skin lesions and internal disease manifestations allowed contributing factors to the death of the individual to be uncovered.

Lethal basal cell carcinoma secondary to cerebral invasion.

Intracranial invasion by a basal cell carcinoma on the scalp is extremely rare. We present an autopsy case of a 57-year-old woman who developed a large destructive basal cell carcinoma with extension through the calvarium and compression of the dura. We compare 7 similar cases reported in the literature and review the risks for development of these aggressive fatal basal cell carcinomas on the scalp.

Motor-vehicle collision-related death due to delayed-onset subarachnoid hemorrhage associated with anticoagulant therapy.

Delayed deaths following injury are not rare. Various mechanisms may be responsible for such deaths, including pulmonary thromboembolism, fat embolism, infection, systemic inflammatory response syndrome, and delayed hemorrhage. In the present case, we describe a death due to delayed subarachnoid hemorrhage following a motor vehicle collision, wherein the hemorrhage occurred ten days after the incident, while the patient remained hospitalized for skeletal trauma. At no time prior to the hemorrhage did the victim show any symptoms of brain injury. Autopsy revealed basilar subarachnoid hemorrhage arising from a cerebral cortical contusion. There was no evidence of aneurysm or arteriovenous malformation. A significant underlying contributing factor in the delayed hemorrhage was the victim's chronic anticoagulant therapy, which was required because of a mechanical heart valve.

Pregnancy-related maternal deaths.

Pregnancy is a normal biologic process, but because of a variety of physiologic factors, it increases a woman's risk for death. Maternal deaths in pregnancy may be due to conditions unique to pregnancy, conditions associated with pregnancy, or conditions unrelated to but exacerbated by pregnancy. Death may occur during any trimester, during labor/birth, or postpartum. In this report, we present 45 cases of pregnancy-related maternal deaths that were investigated and autopsied at the Dallas County Medical Examiners office between 1977 and 1999, and we review the topic of pregnancy-related maternal death.

"Homicide by heart attack" revisited.

The sudden death of a person caused by an arrhythmia that is induced by physical and/or emotional stress provoked by the criminal activity of another person is sometimes referred to as "homicide by heart attack." Published criteria for such an event relate to situations where no physical contact occurs between the perpetrator and the victim. Situations involving physical contact, but with absence of lethal injuries, are frequently treated is a similar fashion by forensic pathologists. Herein, we propose a set of modified criteria, which include cases where physical contact has occurred. Five examples of so-called "homicide by heart attack" are presented, including a 40-year-old man who was struck in the head with a wooden statue, a 74-year-old man who was punched in the jaw by a robber, a 66-year-old woman who was started awake by a home-intruder, a 67-year-old woman who struggled with a would-be purse-snatcher in a parking lot, and a 52-year-old man who was in a physical altercation with a younger man. In each instance, autopsy revealed the presence of severe, underlying heart disease, as well as absence of lethal injuries. In each case, investigative information was such that the emotional and/or physical stress associated with the criminal activity of another individual was deemed contributory to the death. The presumed mechanism of death in each case was a cardiac dysrhythmia related to underlying heart disease, but initiated by the emotional and/or physical stress.

Suicide by drowning: a 20-year review.

Drowning as a method of suicide is known to occur, but has primarily been described in environments with readily available access to water, such as coastal regions. In this study, we describe and analyze a series of suicidal drownings occurring in a noncoastal area of Texas. Between 1977 and 1996, 52 cases of suicidal drowning were investigated at the Southwestern Institute of Forensic Sciences in Dallas, Texas. Such deaths accounted for only 0.85% of all suicides and 4% of all drowning deaths. In contrast. suicidal drownings reportedly account for 2.8 to 8.9% of all suicides in regions with easy access to water. As with other studies of suicidal drowning, the victims are usually sober white males over the age of 40 years. Our results also confirm that certain individuals who commit suicide by drowning use weights to facilitate the process. A detailed analysis of the cases is provided. as is a synopsis of several questions that may aid in determining the manner of death in suicidal drowning cases.

Death resulting from ruptured cerebral artery aneurysm: 219 cases.

To characterize the demographics of ruptured cerebral artery aneurysm as a cause of death and to examine the effect of improved diagnostic and therapeutic techniques on the incidence of sudden death associated with the condition, the authors reviewed 219 autopsies performed at the Dallas County Medical Examiner's Office between 1977 and 1997 in which the cause of death was ruptured cerebral artery aneurysm. Ruptured cerebral artery aneurysms accounted for 1.5% of 15,033 natural deaths and 0.4% of all deaths (45,492) followed by autopsy during this period. The majority (56%) of cases occurred in females, with Caucasian females composing the largest group (38%). Seventy-seven percent of cases occurred in individuals between the ages of 31 and 70 years, with the highest concentration in the 41- to 50-year decade (29%). The most common location for ruptured aneurysms was the middle cerebral artery distribution (39%). Multiple aneurysms occurred in 22 (9.1%) cases. Other factors, such as medical history, coexisting disease, symptoms, activity at onset of symptoms, survival time, and toxicology results are also presented. Compared with literature reports before 1980, when ruptured cerebral artery aneurysms were reported as the cause of death in approximately 4% to 5% of sudden natural deaths, the results of this study suggest that despite improved diagnostic and therapeutic techniques during the past two decades, morbidity and mortality from ruptured aneurysms remain a significant health problem.

Neurocysticercosis.

Neurocysticercosis results when the ingested eggs of the pork tapeworm, Taenia solium, hatch into larval forms that penetrate the gut wall, disseminate hematogenously, and then encyst in the brain. The subsequent symptoms and associated morbidity are variable. Worldwide, cysticercosis is the most common parasitic disease affecting the central nervous system, but it is not a common autopsy finding in the United States. Neurocysticercosis may be an incidental finding, a contributing cause of death, or the underlying cause of death. It is also important for the forensic pathologist to be aware of the possibility of neurocysticercosis in the autopsy population for purposes of epidemiology studies and infection control. The authors use cases of neurocysticercosis found at autopsy at their institution to give examples of each scenario and to review the clinical and pathologic features of this parasitic disease.