Position paper on fatal abusive head injuries in infants and young children.

This article represents the work of the National Association of Medical Examiners Ad Hoc Committee on shaken baby syndrome. Abusive head injuries include injuries caused by shaking as well as impact to the head, either by directly striking the head or by causing the head to strike another object or surface. Because of anatomic and developmental differences in the brain and skull of the young child, the mechanisms and types of injuries that affect the head differ from those that affect the older child or adult. The mechanism of injury produced by inflicted head injuries in these children is most often rotational movement of the brain within the cranial cavity. Rotational movement of the brain damages the nervous system by creating shearing forces, which cause diffuse axonal injury with disruption of axons and tearing of bridging veins, which causes subdural and subarachnoid hemorrhages, and is very commonly associated with retinal schisis and hemorrhages. Recognition of this mechanism of injury may be helpful in severe acute rotational brain injuries because it facilitates understanding of such clinical features as the decrease in the level of consciousness and respiratory distress seen in these injured children. The pathologic findings of subdural hemorrhage, subarachnoid hemorrhage, and retinal hemorrhages are offered as "markers" to assist in the recognition of the presence of shearing brain injury in young children.

New fluorescence polarization immunoassays for analysis of barbiturates and benzodiazepines in serum and urine: performance characteristics.

The performance of the new fluorescence polarization immunoassay reagents Cassette COBAS INTEGRA Serum Benzodiazepines assay (SBENZ) and Cassette Serum Barbiturates assay (SBARB) was evaluated as compared to other immunoassays (Abbott TDx Serum Benzodiazepines, Abbott TDx Urine Benzodiazepines, Behring EMIT Serum Benzodiazepines, Abbott ADx Serum Barbiturates, Behring EMIT Serum Barbiturates, and the COBAS INTEGRA Barbiturates (BARB) urine assay) and gas chromatography-mass spectrometry (GC-MS). Recoveries of nordiazepam and secobarbital using the SBENZ and SBARB assays, respectively, were equivalent for serum, plasma, and urine. Cross-reactivities of structurally related benzodiazepines, barbiturates, and their metabolites were very similar in serum and urine for the SBENZ and SBARB assays. Precision was within 5.4% for SBENZ serum and within 11% from 10 to 100 ng/mL for urine. Precision was within 5% for SBARB serum and within 7% from 136 to 277 ng/mL for the urine application. The standard curves for SBENZ and SBARB were stable for at least 16 weeks with the reagents stored open on the COBAS INTEGRA analyzer. Clinical comparison of the SBENZ serum assay indicated an increased pickup rate, as confirmed by GC-MS, compared to TDx and EMIT. The diagnostic sensitivities of the SBENZ serum application, TDx, and EMIT versus GC-MS were 100%, 89%, and 36%, respectively. The diagnostic specificities were 71%, 79%, and 100%, respectively. The diagnostic sensitivities of the SBENZ urine application and TDx versus GC-MS were 100% and the diagnostic specificities were 88%. The increased positive pick-up of the SBENZ assay compared to the other immunoassays is most probably due to the difference in the limit of detection (LOD) and the increased cross-reactivity for the low-dose benzodiazepines. Clinical comparison of the SBARB serum assay indicated an increased positive pick-up rate, as confirmed by GC-MS. The diagnostic sensitivities of the SBARB serum application, ADx, and EMIT versus GC-MS were 96%, 65%, and 35%, respectively. The diagnostic specificities were all 100%. The diagnostic sensitivities for the SBARB urine application and BARB versus GC-MS were all 100%, and the diagnostic specificities were all 91%. The SBENZ and SBARB kits demonstrated increased sensitivity for the detection of benzodiazepines and barbiturates in both serum and urine compared to the other immunoassays.

Wisconsin, July 1999 heat wave: an epidemiologic assessment.

OBJECTIVE: To assess the characteristics of heat-related deaths in Wisconsin during the summer of 1999. METHODS: Review of death certificates indicating heat as an underlying or contributing cause of death. RESULTS: Heat-related illness led to 21 deaths during the summer of 1999 in Wisconsin. The rate of death was highest in the elderly, particularly those aged 65-84 years (2.2/100,000). Heat was the underlying cause for 12 of the 21 deaths. Cardiovascular conditions were the underlying cause in 8 of the deaths, and a contributing cause for another 7. CONCLUSIONS: The elderly, persons taking psychotropic medications, and persons with chronic diseases, particularly cardiovascular conditions, are at increased risk of death from heat during heat waves. Prevention messages and weather advisories during heat emergencies must target these groups. Care givers and medical personnel must be on heightened awareness for the signs and symptoms of heat exhaustion and heat stroke during these periods.

Comparison of the serum barbiturate fluorescence polarization immunoassay by the COBAS INTEGRA to a GC/MS method.

The authors evaluated a new Cassette Serum Barbiturates fluorescence polarization immunoassay (FPIA) on the COBAS INTEGRA. The assay was calibrated with secobarbital standards at 0, 0.5, and 4.0 microg/mL. The assay range was 0.030 to 80 microg/mL using an automatic 1/20 postdilution feature. Precision was established for two COBAS INTEGRA instruments for ten days by assaying secobarbital target concentrations ranging from 0.125 to 2.2 microg/mL. The coefficients of variation (CV) for the above target concentrations for the first instrument ranged from 2.7% to 8.3%, and for a second instrument, 3.8 to 8.3%. Seven clinically elevated bilirubin samples were spiked with 0.46 and 1.77 microg/mL secobarbital. Bilirubin interference was less than 10.9 and less than 7.9%, respectively. The average recovery ranged from 85% to 94%. The mean difference in recovery in serum versus plasma was < or = 3%. Fifty-two clinical samples were analyzed for butalbital, pentobarbital, secobarbital, and phenobarbital by GC/MS, and the results were compared to the new Cassette Serum Barbiturates FPIA. The diagnostic sensitivity and specificity were 95% and 100%, respectively. Both FPIA and GC/MS assays are clinically efficacious for monitoring serum barbiturates.

Acute zolpidem overdose--report of two cases.

This report describes two cases of acute zolpidem overdose. The decedent in the first case was a 36-year-old female found dead in bed in her secured home. She had a history of psychiatric illness, including paranoid disorder, depression with panic episodes, and post-traumatic stress disorder. She was treated with risperidone and sertraline. Nine months prior to her death, the decedent was also prescribed zolpidem (Ambien). The postmortem examination revealed white foam within the larynx and upper trachea, which is indicative of pulmonary edema. Toxicological analyses of the urine showed the presence of caffeine, risperidone, and zolpidem. Subsequent quantitation of postmortem iliac serum revealed 5.6 microg/L of 9-hydroxyrisperidone and the following zolpidem concentrations: blood (subclavian), 4.5 mg/L; blood (iliac), 7.7 mg/L; vitreous humor, 1.6 mg/L; bile, 8.9 mg/L; urine, 1.2 mg/L; liver, 22.6 mg/kg; and gastric contents, 42 mg. The second case involved a 58-year old female, also found dead in bed, with white foam around her mouth. The decedent had a 25-year history of hypertension and mental illness--manic depression and schizophrenia. She was medicated with carbamazepine, naproxen, risperidone, and zolpidem. The postmortem examination revealed cardiomegaly, pulmonary edema, hepatomegaly, mild coronary atherosclerosis, and no signs of trauma. Toxicological analyses of the urine showed the presence of zolpidem and carbamazepine and metabolite. Zolpidem concentrations were as follows: blood (iliac), 1.6 mg/L; vitreous humor, 0.52 mg/L; bile, 2.6 mg/L; liver, 12 mg/kg; and gastric contents, 0.9 mg. The zolpidem blood concentrations of these cases are consistent with those of the previously published fatalities. The blood/vitreous humor ratios of zolpidem were 2.81 (subclavian) and 4.81 (iliac) in the first case and 3.08 (iliac) in the second case. These ratios, along with the sampling times of blood and vitreous humor for both cases, are not conclusive to indicate a definitive presence or absence of postmortem drug redistribution of zolpidem. The cause of death for both cases was determined to be acute zolpidem overdose, and manner of death was suicide.

Self-intoxication with morphine obtained from an infusion pump.

A 36-year-old Caucasian male was found unresponsive by his wife. He had white foam around his mouth and was pronounced dead shortly thereafter. He had a history of back pain and was treated with intrathecal morphine because of his previous addiction to oral opiate medications. Because of crimping of the pump catheter, it was replaced 4 days before his death. Toxicological findings included urine screen positive for amitriptyline, nortriptyline, opiates, hydrocodone metabolites, ibuprofen, acetaminophen, caffeine, nicotine, and metabolite. Drug concentrations were as follows: blood, 0.260 mg/L amitriptyline, 0.160 mg/L nortriptyline, 0.460 mg/L unconjugated morphine, and 0.624 mg/L total morphine; vitreous humor, 0.034 mg/L unconjugated morphine and 0.080 mg/L total morphine; and cerebrospinal fluid, 0.099 mg/L unconjugated morphine and 0.095 mg/L total morphine. Shortly after death, the volume of the residual pump reservoir was only 8 mL instead of the expected 17 mL. Testing by the FDA showed that the pump was functional. The residual content of the pump accounted for only 230 mg instead of the expected 488 mg. The high blood-morphine concentrations did not correlate with the intrathecal infusion dose. The symptoms were consistent with opiate overdose, possibly by injection of morphine withdrawn from the pump reservoir. The cause of death was determined to be fatal morphine self-intoxication, and the manner of death was accidental. This case is intended to alert regulatory agencies, pain management health professionals, pathologists, and toxicologists to the abuse potential of one of the newer analgesic-delivery systems.

Developing medicolegal death investigator systems in forensic pathology.

As a result of recent national events involving high-profile murder cases, medicolegal death investigation has begun to slowly receive the attention it deserves. Despite continued local problems of financial support and political control, the development of regionalized centers of forensic excellence is gradually improving the access of rural and suburban areas to high-quality forensic science services. Recent efforts to improve the quality of lay death investigators through hiring practices, training, and certification promises to eventually provide more professionally qualified and experienced death investigators.

Criteria for the diagnosis of heat-related deaths: National Association of Medical Examiners. Position paper. National Association of Medical Examiners Ad Hoc Committee on the Definition of Heat-Related Fatalities.

The National Association of Medical Examiners Ad Hoc Committee on the Definition of Heat-Related Fatalities recommends the following definition of "heat-related death": a death in which exposure to high ambient temperature either caused the death or significantly contributed to it. The committee also recommends that the diagnosis of heat-related death be based on a history of exposure to high ambient temperature and the reasonable exclusion of other causes of hyperthermia. The diagnosis may be established from the circumstances surrounding the death, investigative reports concerning environmental temperature, and/or measured antemortem body temperature at the time of collapse. In cases where the measured antemortem body temperature at the time of collapse was > or = 105 degrees F (> or = 40.6 degrees C), the cause of death should be certified as heat stroke or hyperthermia. Deaths may also be certified as heat stroke or hyperthermia with lower body temperatures when cooling has been attempted prior to arrival at the hospital and/or when there is a clinical history of mental status changes and elevated liver and muscle enzymes. In cases where the antemortem body temperature cannot be established but the environmental temperature at the time of collapse was high, an appropriate heat-related diagnosis should be listed as the cause of death or as a significant contributing condition.

Asphyxial death caused by a laryngeal schwannoma: a case report.

Neurogenic tumours of the larynx are unusual, with approximately 115 cases reported in the literature to date. Most of these lesions are benign, solitary submucosal nodules which present with hoarseness and are amenable to surgical resection. We present a case of a large pedunculated schwannoma arising in the aryepiglottic fold associated with sudden asphyxial death in an otherwise healthy young female.

Medicolegal death investigator preemployment test development.

The medicolegal death investigator (MDI) represents an essential component in the multidisciplinary investigation of sudden and unexpected deaths. Presently there exists no specific program for the job training evaluation procedure for new (MDI) employees. We discuss the development of a medicolegal death investigator preemployment training tool, which consists of a training and evaluation program containing a list of tasks and task steps. After the investigator demonstrates the ability to perform individual tasks independently, the trainee will be objectively evaluated by the completion of a written test specifically designed to cover the task items. The preemployment test has been developed by those professionals best able to determine the job requirements, the death investigators. The specific outcomes of the process also include further definition of the profession, preemployment testing, policy and procedure development, posttraining evaluation, identification of training needs, curriculum design and further professional development, and identification of the profession of death investigator.

Tandem bullet versus multiple gunshot wounds.

The differentiation of tandem bullets fired simultaneously versus multiple bullets fired separately entering through a single entrance wound may present difficulty in wound interpretation for the forensic pathologist. The authors present a case report of three separate projectiles entering through a single perforation. The differentiation of projectiles fired in tandem and multiple single projectiles is discussed.

Death after discharge from the emergency department.

STUDY OBJECTIVE: To determine the rate and cause of death of patients who were evaluated in the emergency department and discharged and how the cause of death related to the ED visit. DESIGN: Retrospective chart review of medical examiner cases from July 1, 1990, to June 30, 1991. SETTING: Urban county served by 13 hospital EDs with 383,416 visits in 1991. Eighty-five percent of these patients were discharged. PARTICIPANTS: Medical examiner cases of patients who had been evaluated and released from an ED within 8 days prior to death. RESULTS: Forty-two of the 2,665 medical examiner cases met inclusion criteria. Death was classified as expected or unexpected based on the patient's clinical status at the time of discharge, and directly related or not directly related to the ED visit, based on review of all records and the cause of death as listed on the death certificate. Six deaths (14%) were considered expected and directly related. Three deaths (7%) were considered expected and not directly related. Twenty-four deaths (57%) were considered unexpected and not directly related. Nine deaths (21%) were considered unexpected and directly related; the most common cause was ruptured aortic aneurysm, occurring in three of these nine cases. The death rate was 13 per 100,000 discharged patients. CONCLUSION: Death after discharge from the ED is uncommon. The most common cause of unexpected, directly related death is ruptured aortic aneurysm.

Destructive hostility: the Jeffrey Dahmer case. A psychiatric and forensic study of a serial killer.

We were involved as forensic experts in the case of the serial killer Jeffrey Dahmer. We discuss the scene and victim autopsy findings, with a brief consideration of the basic emotion of hostility. These findings support the thesis that at the basis of this serial killer's behavior were primary unconscious feelings of hate that he had channeled into a sadistic programmed destruction of 17 young men. The interview of the serial killer, the photographic scene documentation, and the autopsy findings stress the ambivalent homosexuality of the killer, his sexual sadism, his obsessive fetishism, and his possible cannibalism and necrophilia.

The medical examiner and deaths in the hospital setting.

There has been a perceived increase in the number of medical negligence claims in recent years. The modern metropolitan medical examiner is increasingly called upon to deal with numerous medical, legal, social, and ethical issues. Nowhere is the role of the medical examiner more important than in the investigation of deaths related to surgical, diagnostic, anesthetic, or therapeutic procedures. Medical examiners have an important role in the investigative process. Through utilization of the offices and services of the medical examiner, questions raised by families, physicians, and other hospital employees may be satisfactorily answered a priori, and litigation may therefore be averted.

Forensic toxicology. An overview and an algorithmic approach.

Forensic toxicology has benefited from advances in immunoassay and thin layer chromatography (Toxi-Lab) chemistry and widespread availability of sophisticated instrumentation, such as gas chromatography with mass spectroscopy. Coupled with the increasingly widespread proliferation of illicit drugs of abuse, these have added new challenges to old adversaries in the medicolegal investigation of death. This article presents a comprehensive approach to forensic toxicology from a metropolitan medical examiner's office with emphasis on common questions and problems encountered in this discipline.

Myocardial necrosis due to intraperitoneal administration of phenylpropanolamine in rats.

Overdose with the sympathomimetic agent phenylpropanolamine (PPA) may cause arrhythmias and myocardial injury in humans. To study the mechanism of these toxic effects, unanesthetized rats (6 animals per group) were given single intraperitoneal doses of 1, 2, 4, 8, 16, or 32 mg/kg PPA. Increases in blood pressure, measured by tail cuff, were dose related and comparable to increases reported in patients with PPA toxicity. Animals were killed at 24 hr and light microscopic examination showed diffuse, dose-related myocardial necrosis. Histology scores (a measure of severity of necrosis) in groups receiving 8, 16, and 32 mg/kg PPA were 1.4 +/- 0.5, 1.8 +/- 1.0, and 2.3 +/- 0.4, respectively, and were all significantly greater than the histology score of control animals (0.2 +/- 0.3, p less than 0.01). The observed lesion was similar in appearance to the myocardial necrosis produced by large doses of catecholamines or sympathomimetic agents in rats. In summary, single doses of PPA caused myocardial necrosis in rats at doses comparable to those causing toxicity in humans. Myocardial necrosis may contribute to the cardiac toxicity of PPA overdose.