Recent trends in an uncommon method of carbon monoxide suicide.

PURPOSE: The most prevalent method of carbon monoxide (CO) suicide is inhalation of vehicle exhaust (VE). However, a new method of CO suicide has recently emerged involving charcoal burning (CB) in a confined space to produce fatal CO levels. This method has been reported from countries in Asia, associated with economic instability and media reporting of high-profile celebrity cases. The current study was undertaken to analyze rates and characteristics of CB suicides in South Australia (SA) for comparison with respect to their characteristics and scene, autopsy and toxicology findings. METHODS: A search was undertaken for all intentional fatal carbon monoxide poisonings in SA between 2000 and 2019. Collected variables included age, sex, cause of death, location of death, decedent histories, scene, autopsy and toxicology findings and manner of death. Statistical analyses were performed using R (version 4.2.3). RESULTS: There was a significant decrease in VE suicides (p < 0.05) and a significant increase in CB suicides (p < 0.001) over the 20-year period. Those who used CB were found to be, on average, between 1.5 and 15.8 years younger than those who used VE (p = 0.017). The risk factors for CB suicide included psychological/psychiatric conditions and financial problems, while VE suicides were associated with a history of physical problems and contact with the legal system. External and internal autopsy findings were consistent with the literature. CONCLUSION: CB suicide is perceived to be widely accessible and painless and is therefore becoming a popular suicide method. Monitoring future trends will be important to determine whether intervention is required.

Prescribed and Diverted Methadone Toxicity in South Australia: An Update.

ABSTRACT: Methadone is one of the most common medications currently prescribed for the treatment of opioid use disorders (OUDs). While methadone maintenance programs (MMPs) have been highly successful in the management and treatment of OUDs resulting in a reduced number of fatalities, the risk of overdose/toxicity remains. The current study was undertaken to analyze trends in overdoses attributed to prescribed and diverted methadone in South Australia (SA) between 2000 and 2019. Over the 20-year period, 344 methadone-related deaths occurred in SA with a significant increase in deaths over the study period ( P = 0.03). The mean age of decedents was 42.5 years with a male to female ratio of 1.8:1, with approximately 20% of decedents enrolled in a MMP at the time of death. Overall, only 5.2% of cases demonstrated methadone diversion, which was associated with methadone prescribed for chronic pain and was most likely to be diverted from a friend/housemate or a partner. However, the source of methadone in more than half of cases was unknown, so this is likely a significant underestimate of actual MMP methadone diversion and total methadone diversion.

Socioeconomic and psychosocial determinants of substance misuse - a national perspective.

Accurate estimates of population drug use and an understanding of the factors that influence substance choice are essential for the development of appropriate and targeted prevention strategies and campaigns. This review aims to provide an overview of the socioeconomic and psychosocial factors that influence substance use patterns within the Australian population through exploration of current and historical examples of substance misuse. Australia's comparatively large online drug market is reflective of the country's relative geographic isolation and high local drug prices. Legislation, particularly relating to cannabis cultivation and personal use, has evolved significantly in response to increased scientific and commercial applications and changing attitudes towards medical and personal use. Methylamphetamine use is disproportionately high, attributed to Australia's geographic location, high rates of local manufacture, steady cost, and increased purity. Despite the increased cost of cocaine over time, the profile of users appears to dictate rates of use. The prevalence of injecting drug use is driven by a lack of education, perceived risk, stigma, and other social factors. Additionally, psychosocial factors also contribute to substance misuse among specific population subgroups such as petrol sniffing among Indigenous Australians. Understanding the reasons for geographical variability in illicit drug use assists in the interpretation of substance-associated behavior in specific groups/populations and in guiding future intervention efforts and predictions of emerging trends. In addition, an understanding of factors influencing local drug usage may assist forensic practitioners in evaluating the occurrence and effects of particular substances that may emerge as significant factors in drug-related deaths.

Fatal blunt chest trauma: an evaluation of rib fracture patterns and age.

The following study was undertaken to determine if any specific occupant characteristics, crash factors, or associated injuries identified at autopsy could predict the occurrence or number of fractured ribs in adults. Data were accrued from the Traffic Accident Reporting System (TARS) and coronial autopsy reports from Forensic Science SA, Adelaide, South Australia, from January 2000 to December 2020. A total of 1475 motor vehicle fatalities were recorded in TARS between January 2000 and December 2020, and 1082 coronial autopsy reports were identified that corresponded to TARS fatal crash data. After applying exclusion criteria involving missing data, 874 cases were included in the analysis. Of the 874 cases, 685 cases had one or more rib fractures. The leading cause of death for those with rib fractures was multiple trauma (54%), followed by head injury (17%) and chest injuries (10%). The strongest predictor of one or more rib fractures was increasing age (p < 0.001). Other factors found in the regression to be predictive of the number of rib fractures were the presence of a variety of other injuries including thoracic spinal fracture, lower right extremity fracture, splenic injury, liver injury, pelvic fracture, aortic injury, lung laceration, and hemothorax. Age is most likely associated with increasing rib fractures due to reduced tolerance to chest deflection with greater injuries occurring at lower magnitudes of impact. The association of other injuries with rib fractures may be a marker of higher impact severity crashes.

Success of Low Aromatic Fuel in Preventing Gasoline Sniffing Deaths.

ABSTRACT: Gasoline (petrol) sniffing is a form of volatile substance misuse that is particularly prevalent within Australian indigenous communities. Although epidemiological studies have shown that gasoline sniffing has decreased over recent years, rates of gasoline sniffing deaths have not been widely reported. Therefore, a study was undertaken to assess the association between the implementation of low aromatic fuel (LAF) and gasoline sniffing deaths. All cases of fatal gasoline sniffing in South Australia between 2000 and 2019 were identified from the Toxicology Database and autopsy reports at Forensic Science South Australia. Furthermore, previous studies of gasoline sniffing deaths were assessed to provide historical context and approximate rates of gasoline sniffing deaths before the current study. The rate of gasoline sniffing deaths decreased significantly ( P = 0.039) over the study period concomitant to an increase in the number of LAF sites nationally. Although not supported by findings of statistical significance because of the small number of cases, this study provides further supportive evidence for the effectiveness of LAF by showing a significant associated decrease in local rates of gasoline sniffing deaths.

Investigating the Source of Fatal Pulmonary Thromboembolism in a Coronial Postmortem Population.

ABSTRACT: The incidence of how often a deep vein thrombosis is found in the calves of the legs at coronial postmortem examination is unclear. This study retrospectively examined postmortem examination reports from Australian Coronial investigations of sudden death resulting from pulmonary thromboembolism to determine the likelihood of dissection of the deep veins of calves of the legs revealing the source of a pulmonary thromboembolism. From 450 cases taken from the National Coronial Information System (NCIS) for 2016, the postmortem reports of 327 cases were reviewed to provide demographic details of victims of sudden death from pulmonary thromboembolism. In 235 cases, it was possible to determine in 76.6% a thrombus had been found in the deep veins of the calves of the legs after dissection. In 141 cases, it was documented that both sides had been examined. From these, it was determined there was no statistically significant difference in the prevalence of thrombus in either side. However, it was shown that the presence of an abnormality of a lower limb (such as leg or hip infection, burns, surgery and nonoperated fractures, or a larger circumference) increased the likelihood that a deep vein thrombus would be found on that side.

Characteristics of fatal insulin overdoses.

This study was undertaken to review fatal cases of insulin overdose in South Australia (SA) over a 20-year period to assess rates and characteristics of insulin-related deaths among insulin-dependent diabetics and non-diabetics for all manners of death. Records from the National Coronial Information System (NCIS) and Forensic Science SA (FSSA) were searched for all cases of fatal insulin overdose in South Australia (SA) between 2000 and 2019. Collected variables included age, sex, cause of death, scene findings, manner of death, decedent medical and personal histories, biochemistry, toxicology, histopathology, and autopsy findings. Statistical analyses were performed using R (version 4.1.2). Forty cases of insulin overdose were identified in SA between 2000 and 2019. Twenty-nine cases (72.5%) were suicides, with the remaining cases classified as accidental or undetermined intent. Thirteen of the 22 insulin-dependent diabetics (59%) had a history of depression, 10 of whom had previously demonstrated suicidal ideation. The current study has shown that suicides using insulin among insulin-dependent diabetics are equally as prevalent, if not more so than fatal accidental insulin overdoses. This can largely be attributed to insulin-dependent diabetic access to a potentially lethal substance. Suicide prevention strategies should focus on insulin-dependent diabetics with a history of depression, particularly for those with access to rapid-acting insulin.

Causes of fatalities in motor vehicle occupants: an overview.

Injuries from motor vehicle collisions are frequently encountered in routine forensic practice. While the most common lethal events involve blunt force trauma with injuries to the head and neck, chest, abdomen, pelvis and limbs, review of the literature and case files shows that a wide variety of other fatal situations can occur that may involve sharp force and penetrating trauma, incineration, drowning, asphyxia, organic diseases and combinations of these. The following overview details potential factors that may contribute to death following vehicle crashes.

Increasing use of sodium nitrite in suicides-an emerging trend.

Sodium nitrite (NaNO2) is a compound with broad practical applications in food preservation, automotive maintenance, and animal control. Sodium nitrite is also potentially fatal when ingested, as it interferes with the ability of red blood cells to transport oxygen. While incidents of accidental consumption have been reported in the literature, case reports of sodium nitrite being used as a pharmacological suicide agent are becoming more frequent. Therefore, a study was undertaken to evaluate trends in sodium nitrite deaths in South Australia between 2000 and 2019. All cases of fatal sodium nitrite ingestion were identified in the Toxicology database and autopsy reports at Forensic Science SA (FSSA). Ten cases of fatal sodium nitrite ingestion were identified, with the rate of cases increasing significantly over the study period (p > .001). Of the ten deaths attributed to sodium nitrite toxicity, eight were male, and two were female. The age range of decedents was 22-74 years (mean 51.9, SD 21.1), 22-74 years for males (mean 58.4, SD 18.2) and 23-29 years for females (mean 26.0, SD 4.2). Males (80%) and those with a history of depression and/or suicidal ideation (70%) were over-represented within the study population. While autopsy findings were generally consistent with the literature, scene findings emphasized the accessibility of sodium nitrite to the general public. This study highlights both a significant increasing trend in the use of sodium nitrite in suicides and important analytical limitations in the evaluation of suspected cases.

Cardiac disease and driver fatality.

To determine the role of cardiac disease in driver fatalities, a retrospective review of autopsy files at Forensic Science SA in Adelaide, Australia, was undertaken over a 13-year-period January 2005-December 2017 for individuals aged ≥ 40 years who had died while driving a motor vehicle. The incidence of significant coronary artery atherosclerosis (CAA) and cardiomegaly was evaluated with comparisons between drivers and a control group of passengers. Autopsy examinations were performed on 303 drivers and 72 passengers who died of trauma and on 63 drivers who died of a cardiac event while driving. The average age for drivers dying of trauma was 58.5 years (range 40-93 years) with 48 (15.8%) having CAA and 31 (10.2%) having cardiomegaly. This was not statistically different to passengers (aged 63.3 years; range 40-93 years; 20.8% having CAA; 11 (15.2%) cardiomegaly; (p > 0.2). Drivers with significant cardiac disease did not, therefore, have increased rates of death in crashes, although a distinct subgroup of drivers consisted of those who had died from cardiac events and not trauma, while driving. The latter may be increasing in number given the aging population.

Evolution and significance of the triple risk model in sudden infant death syndrome.

Sudden infant death syndrome (SIDS) is a leading cause of death in infants, although the mechanisms leading to death remain unclear. Multiple theories have emerged over time, with one of the most influential hypotheses being the triple risk model. This model, first devised in 1972 and later revised in 1994 by Filiano and Kinney, is still widely used in assisting with conceptualising and understanding sudden death in infancy. This model has evolved over time, with each version stressing that SIDS is likely to occur when certain risk factors coincide, suggesting that the lethal mechanisms in SIDS are likely to be multifactorial. All versions of the triple risk model from 1972 to the present have emphasised the complexity of SIDS and serve as useful guides for current and future research into the enigma of sudden and unexpected death in infancy.

Differences in local and national database recordings of deaths from suicide.

A search was undertaken at Forensic Science South Australia (FSSA) for all cases of suicide registered in South Australia, Australia, over a 10-year period from January 2003 to December 2012. More recent data was not accessioned as not all contemporary cases may have been completed or formally registered. The data were compared to corresponding numbers on two national registers: the National Coronial Information System (NCIS) and the Australian Bureau of Statistics (ABS). A total of 2105 cases of suicide were registered at FSSA, with a death rate of 13.3/100,000 population. NCIS data were available from 2003 to 2010, with 1542 suicides recorded (12.3/100,000 population). ABS data were available from 2003 to 2011, with 1366 deaths coded as suicides (12.4/100,000 population). Significant differences were found between local data on suicides and related data accrued nationally from the same population, with only 67.8% of local drug overdoses recorded on the NCIS. Although this represents an Australian-based study the conclusions have global applications. Thus, given the likely accuracy of local data, reliance on smaller, community-specific datasets in any country/jurisdiction may be of far greater use in analyzing and monitoring such complex cases.

The neuroprotective activity of the amyloid precursor protein against traumatic brain injury is mediated via the heparin binding site in residues 96-110.

We have previously shown that following traumatic brain injury (TBI) the presence of the amyloid precursor protein (APP) may be neuroprotective. APP knockout mice have increased neuronal death and worse cognitive and motor outcomes following TBI, which is rescued by treatment with exogenous sAPPα (the secreted ectodomain of APP generated by α-secretase cleavage). Two neuroprotective regions were identified in sAPPα, the N and C-terminal domains D1 and D6a/E2 respectively. As both D1 and D6a/E2 contain heparin binding activity it was hypothesized that this is responsible for the neuroprotective activity. In this study, we focused on the heparin binding site, encompassed by residues 96-110 in D1, which has previously been shown to have neurotrophic properties. We found that treatment with APP96-110 rescued motor and cognitive deficits in APP-/- mice following focal TBI. APP96-110 also provided neuroprotection in Sprague-Dawley rats following diffuse TBI. Treatment with APP96-110 significantly improved functional outcome as well as preserve histological cellular morphology in APP-/- mice following focal controlled cortical impact injury. Furthermore, following administration of APP96-110 in rats after diffuse impact acceleration TBI, motor and cognitive outcomes were significantly improved and axonal injury reduced. These data define the heparin binding site in the D1 domain of sAPPα, represented by the sequence APP96-110, as the neuroprotective site to confer neuroprotection following TBI. The product of α-secretase cleavage of the amyloid precursor protein, sAPPα is neuroprotective following traumatic brain injury (TBI). Of interest was whether this neuroprotective activity could be further delineated to a heparin binding region within sAPPα, corresponding to the region APP96-110 (see diagram demonstrating the domain structure of sAPPα). Indeed treatment with APP96-110 improved functional outcome following TBI, an effect that was not seen with a mutated version of the peptide that had reduced heparin binding affinity.

Body mass index and suicide.

It has been suggested that there is a connection between depression and an increased body mass index (BMI). As depression is related to suicide, a South Australian cohort study was performed to test whether a high BMI may also characterize victims of suicide. Body mass indexes from 100 consecutive cases of suicide (male-to-female ratio, 1:1) taken from the files of Forensic Science South Australia in Adelaide, Australia, were compared with BMIs from 100 sex- and age-matched control cases, where deaths were due to accidents, homicides, or natural diseases. No significant differences in BMIs and BMI categories were found between the 2 groups. However, when cases were subclassified according to the method used, BMIs were noted to be considerably lower in hangings than in both the control group as well as in victims who died of alternative means of suicide (P < 0.001). An association between an increased BMI and suicide could not be substantiated in this local study. However, the reasons for the decreased BMIs in hangings require further consideration that may assist in understanding more about particular victim subgroups.

Difficulties associated with the interpretation of postmortem toxicology.

While postmortem (PM) toxicology results provide valuable information towards ascertaining both the cause and manner of death in coronial cases, there are also significant difficulties associated with the interpretation of PM drug levels. Such difficulties are influenced by several pharmacokinetic and pharmacodynamic factors including PM redistribution, diffusion, site-to-site variability in drug levels, different drug properties and metabolism, bacterial activity, genetic polymorphisms, tolerance, resuscitation efforts, underlying conditions, and the toxicity profile of cases (i.e. single- or mixed-drug toxicity). A large body of research has been dedicated for better understanding and even quantifying the influence of these factors on PM drug levels. For example, several investigative matrices have been developed as potential indicators of PM redistribution, but they have limited practical value. Reference tables of clinically relevant therapeutic, toxic, and potentially fatal drug concentrations have also been compiled, but these unfortunately do not provide reliable reference values for PM toxicology. More recent research has focused on developing databases of peripheral PM drug levels for a variety of case-types to increase transferability to real-life cases and improve interpretations. Changes to drug levels after death are inevitable and unavoidable. As such, guidelines and practices will continue to evolve as we further our understanding of such phenomena.

The spectrum of presentations of unintentional carbon monoxide poisoning.

Carbon monoxide (CO) is an odourless and tasteless gas which can be produced by the incomplete combustion of carbon-containing fuels. Compared to vehicular CO suicides, unintentional cases (excluding those related to fires) are much less common. Increased education surrounding the risks associated with the accumulation of CO in enclosed spaces has contributed to a reduced incidence of unintentional CO poisonings. However, such cases may remain undetected, particularly in domestic and recreational settings where scene findings are often non-specific. The current study of unintentional CO poisonings in South Australia and the Northern Territory, each with a unique climate (Mediterranean and tropical respectively), demonstrated differences in the circumstances of death. Several cases where individuals used carbon-producing fuel sources for heat, both in domestic and vehicular settings and without adequate ventilation, resulted in fatal outcomes. Less common scenarios involved faults in equipment (e.g. a hot water heater), vehicle faults resulting in the accumulation of fatal levels of CO in enclosed spaces, and inadvertent introduction of CO into a diving oxygen supply in a recreational aquatic setting. In ascertaining the cause of death, other considerations include the potential role of underlying chronic cardiovascular and respiratory disease and age which may increase an individual's susceptibility to CO toxicity. Understanding the wide variety of presentations and contributing factors in cases of fatal CO poisoning including consideration of climate-specific differences in domestic and extra-domestic settings may enable improved detection at autopsy.

Increased incidence of mixed drug toxicity deaths involving tapentadol - A forensic study.

Tapentadol is a relatively new synthetic opioid analgesic prescribed for the management of moderate to severe pain. While tapentadol has been shown to be more effective than traditional opioid analgesics, it still carries the risk of addiction, abuse, and misuse. In Australia, tapentadol has become one of the top five most commonly prescribed opioid drugs, with prescriptions increasing by approximately 150,000 each year since it first became available. The rapid increase in tapentadol prescriptions has occurred in parallel to an increasing number of post-mortem tapentadol detections in South Australia (SA). While the number of deaths in SA related to tapentadol use was low in the current study, findings suggest that an increasing trend of deaths involving tapentadol will continue in parallel to a rapidly increasing number of prescriptions, mirroring trends associated with traditional opioids in SA. As a comparatively new opioid analgesic, monitoring future trends will be important to determine if additional prescribing education, intervention, or restrictions are required.

Increasing age and lethal opiate use.

Opioid abuse is a leading cause of drug-related morbidity and mortality worldwide. It has been suggested that the age of opiate users in Australia is rising. To evaluate this further in a local population, toxicology and pathology case files from Forensic Science SA, Adelaide, South Australia, were examined for all cases with lethal opioid levels from 2000 to 2019 (n = 499; M:F 2.3:1; age range 18-91 years, median age 42 years). The median age of opiate deaths increased significantly by approximately 16 years (p = 0.007, R2 = 0.34) with a significant increase in total deaths in the 45-54 years and 55-64 years age groups (p = 0.009, R2 = 0.32) (p = < 0.001, R2 = 0.54). Deaths due to heroin overdose showed the lowest median age (39 years, n = 184), with deaths from tramadol toxicity having the highest (50.5 years, n = 32). Recent changes in the demographic profile of opioid users in cases of lethal overdose involve an aging population. Forensic and clinical practitioners should be aware of significant opioid abuse in certain individuals at older ages as this raises the possibility that this may exacerbate the effects of age-related chronic diseases in this group and/or contribute to fatalities.

Red/near-infrared irradiation therapy for treatment of central nervous system injuries and disorders.

Irradiation in the red/near-infrared spectrum (R/NIR, 630-1000 nm) has been used to treat a wide range of clinical conditions, including disorders of the central nervous system (CNS), with several clinical trials currently underway for stroke and macular degeneration. However, R/NIR irradiation therapy (R/NIR-IT) has not been widely adopted in clinical practice for CNS injury or disease for a number of reasons, which include the following. The mechanism/s of action and implications of penetration have not been thoroughly addressed. The large range of treatment intensities, wavelengths and devices that have been assessed make comparisons difficult, and a consensus paradigm for treatment has not yet emerged. Furthermore, the lack of consistent positive outcomes in randomised controlled trials, perhaps due to sub-optimal treatment regimens, has contributed to scepticism. This review provides a balanced précis of outcomes described in the literature regarding treatment modalities and efficacy of R/NIR-IT for injury and disease in the CNS. We have addressed the important issues of specification of treatment parameters, penetration of R/NIR irradiation to CNS tissues and mechanism/s, and provided the necessary detail to demonstrate the potential of R/NIR-IT for the treatment of retinal degeneration, damage to white matter tracts of the CNS, stroke and Parkinson's disease.

An overview of suicides related to motor vehicles.

Although vehicles may be used in a wide variety of suicides, this has not been a focus in the forensic literature. Thus, an analysis of coronial autopsy reports at Forensic Science SA, Adelaide, South Australia over a 16-year period from January 2005 to December 2020 was undertaken to provide an overview of cases in which it was considered that a vehicle had been integral to the successful completion of a suicide. De-identified details were collected from all cases in which a vehicle had facilitated or been used as a method of suicide. A number of different types of vehicle-related suicide methods were identified, including cases where vehicles had been used as secure places for suicide or where the vehicle had been used to cause significant blunt force trauma or to enter a lethal environment such as water. Specific examples were taken from the following categories: (1) inhalation of gas, (2) drug toxicity, (3) hanging or ligature strangulation, (4) self-immolation, (5) drowning, (6) vehicle collision, (7) driving off a cliff, (8) jumping or lying in front of a vehicle and (9) the use of more than one method (i.e. complex). This report is not intended to provide an epidemiological analysis of car-related suicides. Instead, the details of selected cases have been used to illustrate the spectrum of methods that may be used in vehicle-assisted suicides.