Cardiovascular mortality--the hidden peril of heat waves.

OBJECTIVE: Define the mortality associated with extremely hot weather during the 04 July through 14 July, 1993 heat wave that struck the northeastern United States. METHODS: DESIGN--A rapid field assessment was used to compare mortality occurring during the heat wave to mortality occurring during a period in which there was no heat wave using copies of death certificates. The findings of the rapid field assessment were validated, and it was determined whether increases in mortality occurred in other metropolitan east-coast counties also affected by the heat wave, by reviewing computerized mortality files. SETTING--Information was collected on all deaths occurring in Baltimore City, Maryland; Baltimore County, Maryland; Essex County, New Jersey; Newcastle County, Delaware; and Philadelphia County, Pennsylvania; during these specified study periods: 08-18 June (comparison period) and 06-16 July (heat wave study period), 1993. MAIN OUTCOME MEASURES--Ratios for total mortality, cause-specific mortality, and variables such as age, sex, race, residence, and day and place of death, that were available from death certificates were calculated. RESULTS: From the rapid field assessment, the following were observed: a 26% increase in total mortality and a 98% increase in cardiovascular mortality associated with the heat wave in Philadelphia. Data from the computerized mortality files showed an increase in total mortality in four of five counties examined and an increase in cardiovascular mortality in all five counties. The risk for death for those dying from cardiovascular disease increased significantly for people older than 64 years, for both sexes, and all races. CONCLUSION: As initially indicated by the Philadelphia Medical Examiner, there was excess mortality associated with a heat wave in Philadelphia. All other nearby counties examined also experienced excess mortality associated with the heat wave, although this excess was not recognized by the local health officials. The true impact of a heat wave that causes excess preventable mortality must be appropriately and rapidly ascertained. Using a national standard to certify a death as heat-related will provide the needed information rapidly so that public health resources can be more effectively allocated and mobilized to prevent further heat-related illnesses and death.

Assessing disaster-attributed mortality: development and application of a definition and classification matrix.

BACKGROUND: A useful step in developing and implementing sound policies to prevent disaster-attributed mortality is to classify the relationship between disasters and mortality. While there are classification methods for specific health outcomes, there is no standard method that includes all potential outcomes from exposure to a natural disaster. Without standards, our ability to assess health effects from disasters and implement prevention programmes is limited. METHODS: We present a method for ascertaining and classifying disaster-attributed mortality which includes a case definition, flow chart, and matrix. The matrix is used for coding, reporting, and evaluating information about manner, cause, and circumstance of disaster-attributed deaths and geographical location and time of the disaster. To illustrate its use, two readers determine and classify deaths attributed to Hurricane Andrew (1992, USA). RESULTS: Of 322 deaths investigated by the Dade County Medical Examiner's Office, our readers showed 97% (313/322) agreement on case status and 83% (35/42) agreement on case classification. CONCLUSIONS: Our definition allows for a liberal interpretation of what constitutes disaster-related circumstances and the conditions or diseases that might arise from these circumstances. The inclusion of the flow chart and matrix provides a framework for consistent case classification and reporting. It also provides information about relationships between exposures and health effects, thereby identifying prevention policy needs.

Homonymous hemianopsia due to a dural cavernous hemangioma.

The clinical and radiographic features of extra-axial cavernous hemangiomas are described, and a case of homonymous visual field loss due to a dural-based occipital cavernous hemangioma is reported. A patient presented with a homonymous hemianopsia due to an enhancing tentorial mass lesion. The preoperative clinical and magnetic resonance imaging features were suggestive of meningioma. The patient underwent gross total resection of the lesion and the final pathologic examination was consistent with cavernous hemangioma. There was complete resolution of the visual field defect after surgery. Extra-axial cavernous hemangiomas differ from intra-axial cavernous hemangiomas in their clinical and radiographic features. The former lesions may mimic meningioma and should be considered in the differential diagnosis of a dural-based mass. Early recognition of the lesion is important because surgical removal of cavernous hemangiomas may be associated with a higher morbidity and mortality rate than meningiomas.

Hemochromatosis-associated mortality in the United States from 1979 to 1992: an analysis of Multiple-Cause Mortality Data.

BACKGROUND: Hemochromatosis, which can lead to serious chronic diseases resulting from iron overload, has an estimated prevalence of 50 to 80 cases per 10000 persons. However, little population-based information is available on the impact of hemochromatosis on morbidity and mortality. OBJECTIVE: To evaluate trends over 14 years in deaths and medical conditions associated with hemochromatosis in the United States. DESIGN: We searched Multiple-Cause Mortality Files compiled by the National Center for Health Statistics for the years 1979 to 1992 for all records listing hemochromatosis. We used these data to calculate age-adjusted and age-specific mortality rates, identify medical conditions associated with a known diagnosis of hemochromatosis at death, and calculate proportionate mortality ratios for these medical conditions. RESULTS: The listing of hemochromatosis on death certificates increased 60% from 1979 to 1992. Decedents with hemochromatosis were 23, 13, and 5 times more likely to have liver neoplasms, liver disease, and cardiomyopathy, respectively, than were decedents without hemochromatosis. Conversely, decedents with liver neoplasms, liver disease, and cardiomyopathy were 26, 14, and 5 times more likely, respectively, to have hemochromatosis than were decedents without these conditions. Hemochromatosis was 82 times more likely in persons with the combination of liver neoplasms and diabetes and 43 times more likely in those with the combination of liver disease and diabetes than in those without these conditions. CONCLUSIONS: Comparison of the reported prevalence of hemochromatosis among decedents with estimates of prevalence in the general U.S. population suggests that either the penetrance or the recognition of hemochromatosis, or both, is low. Nevertheless, substantial mortality resulting from liver disease, liver neoplasms, cardiomyopathy, and a combination of liver disease and diabetes in patients with hemochromatosis argues for the improved diagnosis and treatment of hemochromatosis in persons with these conditions.

Epidemiologic aspects of forensic pathology.

Forensic pathologists have made great contributions to epidemiologic research and will undoubtedly continue to do so by providing information that can help to describe, explain, predict, and control the occurrence of specific disorders. Greater funding is needed, however, to realize the potential applications of forensic pathology to epidemiologic research. Public health officials have only recently recognized what forensic pathologists have known for a long time and what Hirsch has recently stated: the public health aspects of forensic pathology, which include epidemiologic research, exemplify "forensic pathology at its best."

Deaths from unintentional carbon monoxide poisoning and potential for prevention with carbon monoxide detectors.

CONTEXT: Unintentional carbon monoxide (CO) poisoning causes approximately 2100 deaths in the United States per year, but the use of CO detectors could potentially prevent many of these deaths. OBJECTIVE: To describe the epidemiology of potentially preventable unintentional CO poisoning deaths in New Mexico. DESIGN: Descriptive analysis. POPULATION STUDIED: A total of 136 deaths from CO poisoning investigated by the New Mexico Office of the Medical Investigator, 1980 through 1995. MAIN OUTCOME MEASURES: Characteristics of deaths from CO poisoning; estimates of the number of deaths potentially preventable with CO detectors. RESULTS: Of 136 people whose deaths were classified as "unintentional carbon monoxide poisoning, not fire related," 49 (36%) most likely were asleep when poisoned. Thirty-nine (49%) of 80 people whose deaths were identified as "residential fatalities" most likely were asleep vs 10 (18%) of 56 of those whose deaths were identified as occurring in or around motor vehicles. A blood-alcohol level greater than 0.01% was present in 56 (42%) of the decedents. Among decedents who had a negative blood-alcohol level (52 in residences and 26 in vehicles), an electronic audible CO detector may have prevented CO poisoning; whereas, among those who had a negative blood-alcohol level and most likely were awake at the time of CO exposure (28 in residences and 23 in vehicles), an electronic detector or a nonaudible, chemical reagent type detector may have prevented CO poisoning. CONCLUSION: Differences exist between deaths due to unintentional CO poisoning that occur in residences and those that occur in or around motor vehicles. Carbon monoxide detectors, whether the electronic or chemical reagent types, may have prevented approximately half of these deaths. The high proportion of decedents with alcohol in their blood indicates that effective public health campaigns must address the role of alcohol in CO poisoning deaths.

Deaths related to Hurricane Andrew in Florida and Louisiana, 1992.

BACKGROUND: Information about circumstances leading to disaster-related deaths helps emergency response coordinators and other public health officials respond to the needs of disaster victims and develop policies for reducing the mortality and morbidity of future disasters. In this paper, we describe the decedent population, circumstances of death, and population-based mortality rates related to Hurricane Andrew, and propose recommendations for evaluating and reducing the public health impact of natural disasters. METHODS: To ascertain the number and circumstances of deaths attributed to Hurricane Andrew in Florida and Louisiana, we contacted medical examiners in 11 Florida counties and coroners in 36 Louisiana parishes. RESULTS: In Florida medical examiners attributed 44 deaths to the hurricane. The mortality rate for directly-related deaths was 4.4 per 1 000 000 population and that for indirectly-related deaths was 8.5 per 1 000 000 population. In Louisiana, coroners attributed 11 resident deaths to the hurricane. Mortality rates were 0.6 per 1000 000 population for deaths directly related to the storm and 2.8 for deaths indirectly related to the storm. Six additional deaths occurred among non-residents who drowned in international waters in the Gulf of Mexico. In both Florida and Louisiana, mortality rates generally increased with age and were higher among whites and males. CONCLUSIONS: In addition to encouraging people to follow existing recommendations, we recommend emphasizing safe driving practices during evacuation and clean-up, equipping shelters with basic medical needs for the population served, and modifying zoning and housing legislation. We also recommend developing and using a standard definition for disaster-related deaths, and using population-based statistics to describe the public health effectiveness of policies intended to reduce disaster-related mortality.

Surveillance in environmental public health: issues, systems, and sources.

This article describes environmental public health surveillance and proposes a framework to enhance its practice in the United States. Special issues for surveillance in environmental public health are examined, and examples of existing systems useful for environmental public health practice are provided. Current and projected surveillance needs, as well as potential sources of data, are examined. The proposed framework for conducting environmental public health surveillance involves data from three points in the process by which an agent in the environment produces an adverse outcome in a host: hazards, exposures, and outcomes. Environmental health practitioners should build on efforts in other fields (e.g., infectious diseases and occupational health) to establish priorities in the surveillance of health conditions associated with exposure to environmental toxicants. For specific surveillance programs, existing data systems, as well as data gaps, should be identified. Coordinated surveillance systems can facilitate public health efforts to prevent and control disease, injury, and disability related to the interaction between people and their environment.

An investigation of medical examiner cases in which methadone was detected, Harris County, Texas, 1987-1992.

In 1991, media reports of an increase in the number of deaths attributed to methadone toxicity in Harris County, Texas, raised public concern about the safety of methadone. This concern was heightened by publicity surrounding the closure of three Harris County methadone maintenance treatment programs due to their poor compliance with federal methadone regulations. In response to this concern, the Texas Department of Public Health requested that the Centers for Disease Control and Prevention (CDC) assist in an epidemiologic study to determine the extent of methadone-related mortality in Harris County during 1991 and to determine the role of methadone maintenance treatment in these deaths. We reviewed cases investigated by the Harris County Medical Examiner's Office from 1987 through 1992 in which methadone was detected by postmortem drug testing. The autopsy reports for cases occurring in 1991 were also reviewed by three independent forensic pathologists who were asked to determine the role of methadone in the death. In addition, we attempted to document Harris County methadone maintenance treatment program enrollment for each decedent. We identified 91 decedents in whom methadone was detected at the time of death, with the largest number of cases occurring in 1991 (n = 27). Other substances, including alcohol, were detected in 85% of the cases. The Harris County Medical Examiner attributed 11 of the deaths to methadone toxicity. No more than three cases per year from 1987 through 1992 were attributed to methadone toxicity. In contrast, 34 deaths were attributed to polydrug toxicity, the largest number occurring in 1991 (n = 11). There was good agreement between the results of the independent review and the opinions of the Harris County Medical Examiner. Only 20% of the decedents were found to have been enrolled in a Harris County methadone maintenance treatment program at the time of death. Four people died of drug toxicity shortly after enrolling in a methadone maintenance treatment program. We found an increase in the number deaths occurring in Harris County, Texas, in 1991 in which methadone was detected. We also found that methadone blood levels were higher among decedents identified for 1991 and 1992 than among those identified in the previous years studied. However, we did not find evidence that the cause of these deaths could be attributed solely to methadone toxicity. Instead, for all years studied, the use of multiple drugs was the leading cause of death among people in whom methadone was detected. This finding points out the difficulties involved in determining the role of methadone as a cause of death.

Pulmonary fibrosis deaths in the United States, 1979-1991. An analysis of multiple-cause mortality data.

We sought to describe pulmonary fibrosis mortality in the United States from 1979 through 1991 by analyzing death certificate reports compiled by the National Center for Health Statistics. Of the 26,866,600 people who died during the study period, 107,292 had a diagnosis of pulmonary fibrosis listed on their death certificates. Among men, age-adjusted mortality rates increased from 48.6 per 1,000,000 in 1979 to 50.9 per 1,000,000 in 1991 and, among women, these rates increased from 21.4 per 1,000,000 in 1979 to 27.2 per 1,000,000 in 1991. Among both men and women rates were higher in older age strata than in younger age strata. Age-adjusted mortality rates were consistently higher among whites and people of races than blacks. The frequency with which pulmonary fibrosis was listed as the underlying cause of death increased from 40% in 1979 to 56% in 1991. Age-adjusted mortality rates varied by state, with lowest rates in the Midwest and Northeast, and the highest rates in the West and Southeast. We conclude that the age-adjusted rate of pulmonary fibrosis among decedents in the United States increased, and pulmonary fibrosis was listed as the underlying cause of death with increasing frequency, over the study period. We cannot determine whether the differences we detected between regions, sexes, and races are related to characteristics of the disease or problems in death certification and coding.

The abstractability and consistency of medical examiner/coroner reports: results from the 1993 National Mortality Followback Survey pilot.

UNLABELLED: The 1993 National Mortality Followback Survey (NMFS) is designed to provide national estimates of important characteristics of the 2,218,940 people aged 15 years and older who died in 1993. One topic of special interest in the survey is injury-related deaths. Previous followback surveys have not obtained data from medical examiner and coroner offices (ME/Cs), who investigate most injury-related deaths. In this study, we sought to determine the feasibility of collecting data from various ME/C offices for the NMFS and the usefulness and limitations of data derived from their records. METHODS: We 1) developed a pilot survey instrument, the Medical Examiner/Coroner Abstract (MECA); 2) attempted to collect ME/C records on 159 deaths from 55 ME/C offices in four states with a variety of death investigation systems; and 3) assessed the feasibility of abstracting data from these records using the MECA. RESULTS: We received records on 105 deaths from 39 ME/C offices in three states. We identified items that could be abstracted from the records of most deaths and found that different abstractors could reproducibly and reliably identify information on these core items. Using the results of this study, we revised the MECA for use in the NMFS.

The role of medical examiners and coroners in public health surveillance and epidemiologic research.

The role of medical examiners and coroners (ME/Cs) in public health surveillance and epidemiologic research is reviewed. Definitions are offered, and discussion centers on the advantages of, and obstacles to the use of ME/C data; existing surveillance systems relevant to ME/Cs; studies assessing the usefulness of ME/C data; newly emerging tools for ME/C surveillance and epidemiologic research; and recommendations for the future. ME/C data have been used quite successfully in some settings and are potentially very useful for surveillance and epidemiologic research on a large scale, but the data have limitations that need to be addressed in the future.

Unintentional deaths from carbon monoxide poisoning in New Mexico, 1980 to 1988. A comparison of medical examiner and national mortality data.

Carbon monoxide was the number 1 cause of poisoning deaths in the United States from 1980 through 1988, with the highest rates reported in the western states. We studied unintentional deaths from carbon monoxide poisoning in New Mexico during this period using the multiple-cause mortality files from the National Center for Health Statistics (NCHS) and data from the New Mexico Office of the Medical Investigator (OMI). We compared the nationally available NCHS data with the more detailed OMI data to determine the sensitivity of NCHS data for the surveillance of this preventable cause of death. The NCHS data were 88% sensitive in identifying deaths from unintentional carbon monoxide poisoning and had a positive predictive value of 81% when compared with OMI data. Half of the unintentional carbon monoxide-related deaths were attributable to a home heating mechanism of some sort, 46% involved motor vehicle exhaust, and at least 42% were associated with alcohol use. We conclude that available NCHS data are a sensitive source of surveillance information about unintentional deaths from carbon monoxide poisoning. Additional details about specific deaths can be obtained from medical examiner files when needed.

Profile of mortality from the 1989 Loma Prieta earthquake using coroner and medical examiner reports.

Mortality patterns from earthquakes in the United States may differ from those observed in other parts of the world. We reviewed coroner and medical examiner records for all investigated deaths from seven California counties for 15 days following the Loma Prieta earthquake of October 17, 1989 (N = 327). Data on the circumstances surrounding death were used to classify each case as directly earthquake-related, indirectly earthquake-related, or not earthquake-related. Fifty-seven deaths were judged as directly earthquake-related. Six other deaths were indirectly related. Ten circumstances accounted for all directly earthquake-related deaths, with the collapse of an elevated freeway accounting for 40 of these deaths. Forty-six (80.8 per cent) of the 57 directly earthquake-related deaths occurred in motor vehicles on public roadways. Fifty-three (93.0 per cent) of the directly earthquake-related deaths occurred within seconds or minutes of injury. Future earthquake deaths in the United States may best be prevented by identifying and modifying seismic hazards in earthquake-prone regions, particularly transportation structures.

Death investigation report forms (DIRFs): generic forms for investigators (IDIRFs) and certifiers (CDIRFs).

On the basis of data collection procedures and forms used in various death investigation offices, we developed generic death investigation report forms (DIRFs). One form was designed for documenting information collected by the initial investigator of death, and another form was designed for documenting information collected by the medical examiner, pathologist, or other person who certifies the death or otherwise finalizes the investigation by determining the cause, manner, and circumstances of death. The benefits, problems, and criteria associated with designing the forms are discussed. Both the investigators DIRF (IDIRF) and the certifier's DIRF (CDIRF) are available in printed or electronic form for those who wish to use them or to modify them according to their specific needs. We hope that these DIRFs will be useful and promote uniformity in documenting death investigations.

Standard language in death investigation laws.

Death investigation statutes and practices vary among the 50 states. We reviewed the Model Postmortem Examinations Act, recommendations of the National Association of Medical Examiners, the College of American Pathologists' "criteria for autopsies," and the death investigation statutes and practices in each state. By consolidating the terminology from these various information sources, we developed a list of death categories for which investigation by medical examiners or coroners in the United States is either mandated, commonly performed, or recommended. The list contains specific categories of death, which fall under these three more general areas: 1) unexpected and unexplained deaths, 2) deaths from intentional and unintentional external causes, and 3) deaths that fall under specialized categories related to the decedent's age, environment, or medical conditions, or to the method of bodily disposition. To promote greater uniformity in the death investigation practices among states, we recommend that the Model Postmortem Examinations Act be modified to explicitly recommend certain types of deaths for investigation and that states modify their death investigation statues to conform to such provisions. Presently, in states where death investigation statutes lack specificity in detailing the types of deaths that should be reported for possible medico-legal investigation, our recommendations, if not in conflict with local statutes, might be used as practice guidelines for the reporting and investigation of certain types of deaths.

Features of commercial computer software systems for medical examiners and coroners.

There are many ways of automating medical examiner and coroner offices, one of which is to purchase commercial software products specifically designed for death investigation. We surveyed four companies that offer such products and requested information regarding each company and its hardware, software, operating systems, peripheral devices, applications, networking options, programming language, querying capability, coding systems, prices, customer support, and number and size of offices using the product. Although the four products (CME2, ForenCIS, InQuest, and Medical Examiner's Software System) are similar in many respects and each can be installed on personal computers, there are differences among the products with regard to cost, applications, and the other features. Death investigators interested in office automation should explore these products to determine the usefulness of each in comparison with the others and in comparison with general-purpose, off-the-shelf databases and software adaptable to death investigation needs.