Report summary - injury in review, 2012 edition: spotlight on road and transport safety

Injury in Review, 2012 Edition: Spotlight on Road and Transport Safety, the first national public health report of its kind, synthesizes road- and transport-related injury statistics from a variety of sources. It profiles injury patterns among Canadians aged up to 24 years, explains risks and protective factors, and makes recommendations for action. The findings inform the development of targeted injury prevention efforts.

Gender differences in suicide methods

INTRODUCTION

Gender differences in suicide completion rates have been attributed to the differences in lethality of suicide methods chosen by men and women, but few empirical studies have investigated factors other than demographic characteristics that might explain this differential.

METHODS

Data from the 621 suicides in Summit County, Ohio during 1997-2006 were disaggregated by gender to compare known correlates of suicide risk on three methods of suicide-firearm, hanging and drug poisoning.

RESULTS

Compared to women, men who completed suicide with firearms were more likely to be married and committed the act at home. Unmarried men were likelier to hang themselves than married men, but unmarried women were less likely to hang themselves than married women. Men with a history of depression were more likely to suicide by hanging, but women with depression were half as likely to hang themselves compared to the women without a history of depression. Men with a history of substance abuse were more likely to suicide by poisoning than men without such history, but substance abuse history had no influence on women's use of poisoning to suicide. For both sexes, the odds of suicide by poisoning were significantly higher for those on psychiatric medications.

Somatostatin modulates generation of inspiratory rhythms and determines asphyxia survival

Breathing and the activity of its generator (the pre-Bötzinger complex; pre-BötC) are highly regulated functions. Among neuromodulators of breathing, somatostatin (SST) is unique: it is synthesized by a subset of glutamatergic pre-BötC neurons, but acts as an inhibitory neuromodulator. Moreover, SST regulates breathing both in normoxic and in hypoxic conditions. Although it has been implicated in the neuromodulation of breathing, neither the locus of SST modulation, nor the receptor subtypes involved have been identified. In this study, we aimed to fill in these blanks by characterizing the SST-induced regulation of inspiratory rhythm generation in vitro and in vivo. We found that both endogenous and exogenous SST depress all preBötC-generated rhythms. While SST abolishes sighs, it also decreases the frequency and increases the regularity of eupnea and gasping. Pharmacological experiments showed that SST modulates inspiratory rhythm generation by activating SST receptor type-2, whose mRNA is abundantly expressed in the pre-Bötzinger complex. In vivo, blockade of SST receptor type-2 reduces gasping amplitude and consequently, it precludes auto-resuscitation after asphyxia. Based on our findings, we suggest that SST functions as an inhibitory neuromodulator released by excitatory respiratory neurons when they become overactivated in order to stabilize breathing rhythmicity in normoxic and hypoxic conditions.

Individual and area socioeconomic inequalities in cause-specific unintentional injury mortality: 11-year follow-up study of 2.7 million Canadians

This study investigated the association between individual and area socioeconomic status (SES) and leading causes of unintentional injury mortality in Canadian adults. Using the 1991-2001 Canadian Census Mortality Follow-up Study cohort (N=2,735,152), Cox proportional hazard regression was used to calculate hazard ratios and 95% confidence intervals for all-cause unintentional injury, motor vehicle collision (MVC), fall, poisoning, suffocation, fire/burn, and drowning deaths. Results indicated that associations with SES differed by cause of injury, and were generally more pronounced for males. Low education was associated with an elevated risk of mortality from all-cause unintentional injury and MVC (males only) and poisoning and drowning (both sexes). Low income was strongly associated with most causes of injury mortality, particularly fire/burn and poisoning. Having no occupation or low occupational status was associated with higher risks of all-cause injury, fall, poisoning and suffocation (both sexes) and MVC deaths among men. Associations with area deprivation were weak, and only areas with high deprivation had elevated risk of all-cause injury, MVC (males only), poisoning and drowning (both sexes). This study reveals the importance of examining SES differentials by cause of death from a multilevel perspective. Future research is needed to clarify the mechanisms underlying these differences to implement equity-oriented approaches for reducing differential exposures, vulnerability or consequences of injury mortality.

[The analysis of the causes of deaths involving fetuses, neonates and infants in the autopsy material from the Chair and Department of Forensic Medicine, Medical University of Łódź, in the years 2000-2010]

The aim of this study was the comparison of causes of deaths of fetuses, neonates and infants based on the autopsy reports taken from the Chair and Department of Forensic Medicine, Medical University of Łódź, in the years 2000-2010, and especially establishing what the most common causes of death occurred in this age group. We evaluated 94 autopsy reports of such children from this period. It turned out that the most frequent causes of death were pneumonia in neonates delivered at term and sepsis (usually due to hospital infection) in premature neonates. Other common causes of death were trauma and violent asphyxia (smothering, or choking or positional asphyxia).

[Autoerotic fatalities in Greater Dusseldorf]

Autoerotic fatalities in the Greater Dusseldorf area correspond to the relevant medicolegal literature. Our results included exclusively young to middle-aged, usually single men who were found dead in their city apartments. Clothing and devices used showed a great variety. Women's or fetish clothing and complex shackling or hanging devices were disproportionately frequent. In most cases, death occurred due to hanging or ligature strangulation. There was no increased incidence of underlying psychiatric disorders. In most of the deceased no or at least no remarkable alcohol intoxication was found. Occasionally, it may be difficult to reliably differentiate autoerotic accidents, accidents occurring in connection with practices of bondage & discipline, dominance & submission (BDSM) from natural death, suicide or homicide.

Accidental deaths occurring in bed: review of cases and proposal of preventive strategies

The bed is thought to be a safe place, but posses a number of risks that can cause deaths. To identify the causes of accidental death in bed and propose strategies for the prevention of further accidents, we surveyed and analyzed the literature on accidental deaths in bed from Japan and abroad, as well as legal cases related to accidental death in bed in Japan. A search of the medical literature in Japan (1983-2007), abroad (1976-2007), and Japan's legal cases (1989-2007) located 39 cases. The vast majority of accidental deaths in bed occur among infants and elderly individuals with neurologic disorders. The main causes of death within these two groups are head injuries caused by falls from a bed and asphyxia caused by pressure to the neck when wedged against a bed rail. It is necessary to focus on prevention of falls from bed and prevention of asphyxia caused by bed rails in the case of infants and elderly individuals with neurologic disorders. Infants should be placed to sleep in beds designed for their ages and placed on their back. Elderly individuals need to sleep in beds with properly fitting bed rails to reduce wedging.

Abandonment of newborn infants: a Danish forensic medical survey 1997-2008

Concealment of pregnancy and newborn infant abandonment are closely associated with neonaticide, the killing of an infant within the first 24 h of life or less than 28-30 days depending on the jurisdiction. Abandonment of newborn infants occurs throughout the world and often the outcome for the infant is death. Together with neonaticide it is felt to be one of the least preventable crimes. In this retrospective study we present all forensically known Danish cases of abandoned newborn infant corpses, covering the period from 1997 to 2008. Eleven newborn infant corpses were found; we registered characteristics of the newborn infants and the circumstances of the cases based on autopsy reports. One further newborn infant was included, dating back to 1992, as it was found to be connected with one of the later cases. The mean age of the women who abandoned their newborn infants was 22 years, and five of the autopsied newborn infants were probably alive when abandoned. In two cases the newborn infants were half siblings and abandoned by the same mother. The time span from abandonment to when the newborn infant was found ranged from hours to 7 years. Two-thirds of the newborn infants were girls (66.6%). The most common means of disposal was in a plastic bag (~60%); only one newborn infant was wearing clothes when found. Causes of death were usually given as asphyxia, brain injury or simply undetermined. Two-thirds of the newborn infants showed signs of violence. None of the newborn infants had congenital malformations.

[Lethal sex]

Asphyxiophilic sex is a form of autoerotic activity, in which the user creates mechanical means (such as hanging or bondage) in order to achieve cerebral hypoxia, which, in turn, enhances sexual, as well as orgasmic, stimulus. Failure of safety mechanisms, created by the user, may lead to instant death as a result of asphyxiation or strangulation. This kind of sexual practice is more prevalent among men than in women. In cases of death, it is difficult to relate it to the sexual practice itself. Suicide and homicide are the main differential diagnoses. Closely related derivatives of asphyxiophilic sex are anesthesiophilia (inhalation of variable volatile substances) and electrophilia (use of electric current during sexual activity)--both also intended to enhance the sexual stimulation. These forms of sexual practice are less prevalent than asphyxiophilia.

[Analysis on the long-term trend of injury related deaths in Macheng of Hubei province, 1974-2008]

OBJECTIVE

To study the long-term trend of injury related deaths, the distribution of causes of injuries as well as disease burden in Macheng city, Hubei province, in 1974 - 2008.

METHODS

Data was gathered from vital statistics and registration system of Macheng city which was established in 1974. Data related to Cause Eliminated Life Expectancy (CELE), years of potential life lost (YPLL) and proportion of YPLL on total deaths were calculated.

RESULTS

The injury death rates varied between 62.64/100 000 and 154.97/100 000 during that 35 years. In males and females, injury death rates varied between 69.16/100 000 - 163.86/100 000 and 55.34/100 000 - 157.35/100 000, respectively. Death rates on injury in males exceeded those of females. The average infant injury mortality was 770.13/100 000, stayed the highest in all of the age groups. In terms of geographic region, death rate showed the highest in the hilly area (37.03/100 000), followed by mountainous area (33.66/100 000) and the rate was lowest in the plain area (31.43/100 000). In terms of causes of deaths, suicide, drowning, suffocation, traffic accident and fall were the five top causes of injury, accounting for 84.26% of all the injury mortality. The mortality of suicide showed highest in the injury mortality accounting for 48.14% of all the injury mortality. Injury was the main causes of death among children and youths. The mortality of injury was the highest in people aged from 15 to 29 years, with 59.38% in males and 62.26% in females. Injury eliminated life expectancy increased while the YPLL due to injury decreased, annually.

CONCLUSION

Although the trends of mortality rates on injuries were declining over the past 10 years, it remained high in figures. The main causes of injury shifted around, but suicide had always been the main cause over the years, in different age groups, sex or terrains. The death rate of traffic accident was increasing. Effective control strategies should be formulated based on the caused of death related to injuries and among the high-risk populations.

The 2008 annual report of the Regional Infant and Child Mortality Review Committee

The 2008 annual report of the Regional Infant and Child Mortality Review Committee (RICMRC) is presented. This committee has as its mission the review of infant and child deaths so that information can be transformed into action to protect young lives. The 2008 review area includes South Dakota's Minnehaha, Turner, Lincoln, Moody, Lake, McCook, Union, Hansen, Miner and Brookings counties. Within our region in 2008, there were six infant deaths labeled as Sudden Unexpected Infant Deaths (SUID), of which two met the criteria for the Sudden Infant Death Syndrome (SIDS). The four non-SIDS SUID deaths all represented deaths where asphyxia from unsafe sleeping environments could not be excluded. In addition, there were two accidental deaths from asphyxia in unsafe sleeping enviroments. We need to continue to promote the "Back to Sleep" campaign message of not only placing infants to sleep on their backs, but also making sure infants are put down to sleep on safe, firm, sleeping surfaces and are appropriately dressed for the ambient temperature. Parents need to be aware of the potential hazards of bed-sharing with their infants. In both 2007 and 2008, four children died in motor vehicle crashes, none of which were alcohol-related. Three fire-related childhood deaths were associated with one house fire involving a nonfunctional smoke alarm and a sleeping arrangement without an easy egress from a fire. Since 1997, the RICMRC has sought to achieve its mission to "review infant and child deaths so that information can be transformed into action to protect young lives". For 2008, the committee reviewed 21 deaths from Minnehaha, Turner, Lincoln, Moody, Lake, McCook, Union, Hansen, Miner and Brookings counties that met the following criteria: Children under the age of 18 dying subsequent to hospital discharge following delivery. Children who either died in these counties from causes sustained in them, or residents who died elsewhere from causes sustained in the ten-county region.

True and simulated homicidal hangings: a six-year retrospective study

The manner of death in hangings is virtually always suicide. Uncommonly, accidental hangings do also occur. Homicidal hangings, however, are generally thought to be highly unusual. Despite some case reports of homicidal hangings, retrospective studies have demonstrated that homicidal hangings are virtually non-existent. The present study was undertaken retrospectively to evaluate the incidence of true and simulated homicidal hangings in the forensic population of Quebec (Canada) during a six-year study period. In a total of 251 cases of hanging, suicide was the leading manner of death (239 cases); the remaining cases were accidents (eight cases) and homicides (four cases). This unusually high homicidal hanging rate in Quebec (1.6%) is hard to explain. It could be attributed to an intrinsic particularity of the population and culture. It could also be that our forensic team shares a strong interest in asphyxial deaths as a research topic and, therefore, is particularly alert in detecting such homicides. Nevertheless, this relatively higher homicidal rate may be a reminder that homicidal hangings do sometimes occur. This study emphasises the importance of not disregarding this manner of death in hangings.

Pattern of injury mortality by age-group in children aged 0-14 years in Scotland, 2002-2006, and its implications for prevention

BACKGROUND

Knowledge of the epidemiology of injuries in children is essential for the planning, implementation and evaluation of preventive measures but recent epidemiological information on injuries in children both in general and by age-group in Scotland is scarce. This study examines the recent pattern of childhood mortality from injury by age-group in Scotland and considers its implications for prevention.

METHODS

Routine mortality data for the period 2002-2006 were obtained from the General Register Office for Scotland and were analysed in terms of number of deaths, mean annual mortality rates per 100,000 population, leading causes of death, and causes of injury death. Mid-year population estimates were used as the denominator. Chi-square tests were used to determine statistical significance.

RESULTS

186 children aged 0-14 died from an injury in Scotland during 2002-06 (MR 4.3 per 100,000). Injuries were the leading cause of death in 1-14, 5-9 and 10-14 year-olds (causing 25%, 29% and 32% of all deaths respectively). The leading individual causes of injury death (0-14 years) were pedestrian and non-pedestrian road-traffic injuries and assault/homicide but there was variation by age-group. Assault/homicide, fire and suffocation caused most injury deaths in young children; road-traffic injuries in older ones. Collectively, intentional injuries were a bigger threat to the lives of under-15s than any single cause of unintentional injury. The mortality rate from assault/homicide was highest in infants (<1 year) and decreased with increasing age. Children aged 5-9 were significantly less likely to die from an injury than 0-4 or 10-14 year-olds (p < 0.05). Suicide was an important cause of injury mortality in 10-14 year-olds.

CONCLUSION

Injuries continue to be a leading cause of death in childhood in Scotland. Variation in causes of injury death by age-group is important when targeting preventive efforts. In particular, the threats of assault/homicide in infants, fire in 1-4 year-olds, pedestrian injury in 5-14 year-olds, and suicide in 10-14 year-olds need urgent consideration for preventive action.

Patterns of death among avalanche fatalities: a 21-year review

BACKGROUND

Avalanches are a significant cause of winter recreational fatalities in mountain regions. The purpose of this study was to determine the relative contributions of trauma and asphyxia to avalanche deaths.

METHODS

We reviewed all avalanche fatalities between 1984 and 2005 that had been investigated by the offices of the British Columbia Coroners Service and the Chief Medical Examiner of Alberta. In addition, we searched the database of the Canadian Avalanche Centre for fatal avalanche details. We calculated injury severity scores for all victims who underwent autopsy.

RESULTS

There were 204 avalanche fatalities with mortality information over the 21-year study period. Of these, 117 victims underwent autopsy, and 87 underwent forensic external examination. Asphyxia caused 154 (75%) deaths. Trauma caused 48 (24%) deaths, with the rate of death from trauma ranging from 9% (4/44) for snowmobilers to 42% (5/12) for ice climbers. In addition, 13% (12/92) of the asphyxia victims who underwent autopsy had major trauma, defined as an injury severity score of greater than 15. Only 48% (23/48) of victims for whom trauma was the primary cause of death had been completely buried.

INTERPRETATION

Asphyxia and severe trauma caused most avalanche fatalities in western Canada. The relative rates differed between snowmobilers and those engaged in other mountain activities. Our findings should guide recommendations for safety devices, safety measures and resuscitation.

A demographic study of homicide-suicide in the Pretoria region over a 5 year period

A study was undertaken to research the occurrence of homicide-suicide events in the Pretoria region from January 1997 until October 2001. It is important to attempt understanding this tragic phenomenon from psychiatric and forensic perspectives. This uncommon phenomenon has attracted widespread and sensational media coverage, but little is known about the causal factors and demographic profile of perpetrators and victims, and possible sites of intervention. Case files of the Pretoria Medico-Legal Laboratory (where all cases of unnatural death in Pretoria are investigated) were reviewed and information collected from relevant investigating officers of the South African Police Services. The average annual incidence of homicide-suicide in Pretoria over the period studied was found to be 1 per 100,000 of the population. Two profiles of typical perpetrators seem to emerge: a younger, single, black male shooting his girlfriend and himself at home; and an older, married, Caucasian male shooting his wife and himself at home. Employment in peace forces and unemployment are shown to play significant roles, suggesting need for the availability of psychological support systems to members of peace forces and for intervention regarding unemployment.

[Hereditary angioedema. Family history and clinical manifestations in 58 patients]

Hereditary angioedema (HAE) is a rare autosomal dominant disease, characterized by episodes of edema typically involving the skin, gastrointestinal tract and larynx. We here describe the epidemiologic and clinical characteristic of a series of 58 patients with diagnosis of HAE, 53 (91%) type I and 5 (9%) type II. The mean age at first symptom was 10.8 +/- 9.5 years and the mean age at diagnosis was 25.8 +/- 16.2 years old, with a diagnosis delay of 15.3 +/- 14.3 years. The mean number of attacks in the previous 6 months was 7.4 +/- 7.6 range 0 to 40. Fifty four (93%) had cutaneous attacks, 50 (86%) abdominal attacks, 24 (41%) laryngeal attacks and 24 (41%) combined cutaneous and abdominal attacks. Twenty seven (46.5%) patients never received preventive treatments and 17 (29%) received danazol in different doses for different periods of time. During the attacks, 15 (26%) patients were treated with C1 inhibitor at least once, 7 (12%) with fresh frozen plasma and 40 (69%) received only supportive treatment. Stress and trauma were identified as attacks triggers. Six (10%) patients were first mutation and 52 (90%) had HAE ancestors. We reconstructed 20 kindred, identifying 205 individuals at risk of inheriting the disease, 109 (53 %) of them had signs or laboratory diagnosis of HAE. The total number of identified HAE individuals was 145, 19 (13%) died with asphyxia. So, shortening of diagnosis delay and appropriate treatment of HAE are a challenge to be fulfilled.

Common causes of open-circuit recreational diving fatalities

Diving fatalities causes were investigated in 947 recreational open-circuit scuba diving deaths from 1992-2003. Where possible, cases were classified at each step of a four step sequence: trigger, disabling agent, disabling injury, cause of death (COD). The most frequent adverse events within each step were: (a) triggers 41% insufficient gas, 20% entrapment, 15% equipment problems; (b) disabling agents--55% emergency ascent, 27% insufficient gas, 13% buoyancy trouble; (c) disabling injuries--33% asphyxia, 29% arterial gas embolism (AGE), 26% cardiac incidents; and (d) COD--70% drowning, 14% AGE, 13% cardiac incidents. We concluded that disabling injuries were more relevant than COD as drowning was often secondary to a disabling injury. Frequencies and/ or associations with risk factors were investigated for each disabling injury by logistic regression. (The reference group for each injury was all other injuries.) Frequencies and/or associations included: (a) asphyxia--40% entrapment (Odds Ratio, OR > or = 30), 32% insufficient gas (OR = 15.9), 17% buoyancy trouble, 15% equipment trouble (OR = 4.5), 11% rough water, drysuit (OR = 4.1), female gender (OR = 2.1); (b) AGE--96% emergency ascent (OR > or = 30), 63% insufficient gas, 17% equipment trouble, 9% entrapment; (c) cardiac incidents--cardiovascular disease (OR = 10.5), age > 40 (OR = 5.9). Minimizing the frequent adverse events would have the greatest impact on reducing diving deaths.

[Determination of antidepressants in biological materials originating from victims of suicide by hanging]

The report presents the results of determinations of medication levels in biological materials collected from victims of suicide by hanging. The analysis included cases autopsied at Forensic Medicine Department in Bydgoszcz in the years 2005-2006. The authors observed that of 928 postmortem examinations, suicide by hanging accounted for 7.8% of cases; in this group, 11.1% victims were female and 88.9% were male. The most numerous group included individuals aged 20-29 years (20.7%), while the smallest group consisted of suicide victims below 20 years of age (8.3%). A total of 23.6% of individuals were under the influence of antidepressant drugs at the moment of death. The detected antidepressants included phenotiazine derivatives and such tricyclic antidepressants as amitryptyline, chloropromazine, clomipramine, levomepromazine, mianserin, promazine and thioridazine. Based on the above investigations, 11.1% of suicide victims may be said to have taken antidepressants in the past, but to be under no influence of such medications at the time of death.

Suicide risk among recently released prisoners in New South Wales, Australia

OBJECTIVE

To determine the risk of suicide and drug overdose death among recently released prisoners.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study of 85 203 adult offenders who had spent some time in full-time custody in prisons in New South Wales between 1 January 1988 and 31 December 2002.

MAIN OUTCOME MEASURES

Association between time after release and risk of suicide and overdose death.

RESULTS

Of 844 suicides (795 men, 49 women), 724 (86%) occurred after release. Men had a higher rate of suicide than women both in prison (129 v 56 per 100,000 person-years) and after release (135 v 82 per 100,000 person-years). The suicide rate in men in the 2 weeks after release was 3.87 (95% CI, 2.26-6.65) times higher than the rate after 6 months. Male prisoners admitted to the prison psychiatric hospital had a threefold higher risk than non-admitted men both in prison and after release. No suicides among women were observed in the 2 weeks after release. No increased risk of suicide was observed among Aboriginal Australians in the first 2 weeks after release. Of 1674 deaths due to overdose, 1627 (97%) occurred after release. Drug-related mortality in men was 9.30 (95% CI, 7.80-11.10) times higher, and in women was 6.42 (95% CI, 3.88-10.62) times higher, in the 2 weeks after release than after 6 months.

CONCLUSIONS

Prisoners are at a heightened risk of suicide and overdose death in the immediate post-release period. After 6 months post-release, the suicide rate approaches the rate observed in custody.

The impact of avalanche rescue devices on survival

BACKGROUND

Within Europe and North America, the median annual mortality from snow avalanches between 1994 and 2003 was 141. There are two commonly used rescue devices: the avalanche transceiver, which is intended to speed up locating a completely buried person, and the avalanche airbag, which aims to prevent the person from being completely buried.

OBJECTIVE

This retrospective study aimed to evaluate whether these avalanche rescue devices had an effect on mortality.

METHODS

The study population was 1504 persons who were involved in 752 avalanches either in Switzerland from 1990 to 2000 and from 2002 to 2003 (1296 persons, 86.2%) or in Austria from 1998 to 2004 (208 persons, 13.8%).

RESULTS

Persons equipped with an avalanche airbag had a lower chance of dying (2.9% versus 18.9%; P=0.026, OR 0.09, n=1504). In persons who were completely buried, without visible or audible signs at the surface and who did not rescue themselves (n=317), we found a lower median duration of burial (25min versus 125min; P<0.001) and mortality (55.2% versus 70.6%; P<0.001, OR 0.26) in those using an avalanche transceiver than in those not using the device.

CONCLUSIONS

Our data showed that both the avalanche airbag and the avalanche transceiver reduce mortality. However, to improve the evaluation of rescue devices in the future, the data collection procedures should be reviewed and prospective trials should be considered, as the reliability of retrospective studies is limited.