Epidemic Fentanyl Deaths in Maryland: A Public Health Intervention Involving Geographic Information Systems and Collaboration with the Drug Enforcement Administration.

An ongoing epidemic of illicit fentanyl overdose deaths started in Maryland in July 2013. The records of the Office of the Chief Medical Examiner for the state of Maryland were searched to identify these deaths from July 2013 to February 2015. A geographic information system was used to map and analyze the spatial and temporal distribution of the deaths in Maryland. A total of 266 fentanyl-related deaths were identified. The number of deaths per month generally increased from July 2013 to June 2014, decreased precipitously in August 2014, and rose steadily until the end of the study in February 2015. Deaths began in Baltimore City and then spread throughout the state. A statistically significant cluster ("hot spot") of deaths was centered in Baltimore City. Greater death densities were also centered on other cities. A high-density band of deaths extended from Baltimore City towards Annapolis. Deaths extended past cities and into the surrounding suburbs; this effect was most pronounced around Baltimore City. Deaths in Baltimore City appeared concentrated in certain neighborhoods. However, the activity moved between various neighborhoods over the course of the study. Review of the above data with the United States Drug Enforcement Administration's Baltimore Office (DEA) allowed some of the above trends to be explained in terms of illicit drug production, transportation and distribution. The DEA is implementing a new strategy to combat illicit narcotic distribution and use in Maryland.

Modeling the Distribution of Scald Type Burns in a Child.

Splash or spill scald burns may be seen by medical examiners in the setting of intentional trauma or accidental injury. In order to model various scald burn scenarios, an 8-year-old subject dressed in white had colored water spilled or dropped onto her. The results were recorded by video and still photography. Five trials were performed and included: liquid in a cup thrown towards the anterior body surfaces; liquid in a cup thrown towards the posterior body surfaces; a cup of liquid spilled across a table into the lap of a seated subject; a saucepan pulled down onto the anterior torso; and a cup of liquid spilled onto the top of the head. In each of the spill and splash models described above, a large often confluent zone of staining at the site of initial liquid contact with the body was often accompanied by elongate runoff patterns following gravity; droplet staining was often noted on adjacent areas. When seated, an inverted U-shaped staining pattern was on the buttocks. Anticipation of the splash event in one trial resulted in the subject instinctively turning the anterior body away from the oncoming liquid. When presented with a scalded victim, modeling of the reported history may provide a pattern of staining that supports or refutes the explanation offered for the burn. A mobile and neurologically intact subject who can anticipate an incipient scald injury may move prior to and during contact with the liquid resulting in unique staining patterns on multiple surfaces of the body.

Neck and scleral hemorrhage in drowning.

The determination of the cause and manner of death for a body recovered from the water can be difficult because of a lack of autopsy findings specific for drowning. This case report describes a 30-year-old man found submerged at the bottom of a hotel pool. An autopsy revealed scleral hemorrhages and fascial hemorrhages of multiple muscles of the anterior and posterior neck bilaterally. No evidence of traumatic injury was on the surface of the body. An investigation by law enforcement found no evidence of foul play. The occurrence of petechial and neck hemorrhage in a body recovered from the water is controversial, and a review of this literature will be given. We suggest that fascial hemorrhages of the muscles of the neck, as well as cephalic hemorrhages, can be explained by drowning-related elevated central venous pressure that is communicated to the head through the valveless veins of the neck.

Graft vascular disease after cardiac transplantation and its relationship to mean acute rejection score.

CONTEXT: Graft vascular disease remains a significant source of morbidity and mortality in heart transplant patients. The influence of acute cellular rejection on the development of graft vascular disease is controversial. OBJECTIVE: To determine the relationship between mean acute cellular rejection score and the presence of atherosclerosis or fibrointimal hyperplasia in cardiac allografts at autopsy. DESIGN: This retrospective, autopsy-based study examined 27 heart transplant patients to evaluate for graft vascular disease. A rejection score for each patient was calculated as the average of all the rejection scores determined by endomyocardial biopsy. Gross and histologic examination of the heart was used to divide patients into 3 groups: no coronary artery disease, atherosclerosis, and fibrointimal hyperplasia. Mean rejection scores were calculated for each of these groups for all patients and patients who survived longer than 3 months. Mean rejection scores were compared by an analysis of variance and pairwise t tests. RESULTS: Mean rejection scores demonstrated a trend of increasing value from no coronary disease (0.323) to atherosclerosis (0.569) to fibrointimal hyperplasia (0.835). Only fibrointimal hyperplasia had a significantly higher mean rejection score compared with patients with no coronary disease when examined in all patients (P = .01) and in patients who survived longer than 3 months (P = .049). CONCLUSION: This study showed that the development of coronary artery fibrointimal hyperplasia, but not atherosclerosis, was significantly related to mean acute rejection score.

Sudden infant death syndrome risk factors with regards to sleep position, sleep surface, and co-sleeping.

We present a study of 102 Sudden Infant Death Syndrome (SIDS) deaths using a retrospective review of medical examiner autopsy reports. The prevalence of sleep related risk factors with regards to sleep surface, sleep position, and co-sleeping were determined in a population of infants less than 1-year-old. Of the 102 SIDS deaths, 67 (65.7%) were not in a crib, 63 (61.8%) were prone, and 48 (47.1%) were co-sleeping. However, 94 (92.2%) of these deaths had at least one risk factor present. Only 8 (7.8%) infants had slept alone, in a crib or bassinet, and on their back or side. Infants less than 4-months-old had a higher rate of co-sleeping (54.7%) than the older infants (25.9%), and a higher frequency of heart malformations at post-mortem examination. The older infants were more likely to exhibit pulmonary and tracheal inflammation, and neuropathology.

Cause of death and sudden cardiac death after heart transplantation. An autopsy study.

Postmortem findings in 39 patients following cardiac transplantation are presented. Causes of death were right-sided heart failure after transplantation (6 [15%]), infection (5 [13%]), multisystem organ failure (4[10%]), complications of noncardiac surgery (3 [8%]), acute rejection (3 [8%]), malignant neoplasm (3 [8%]), graft vascular disease (3 [8%]), preservation procurement injury (3 [8%]), cardiac arrhythmia (2 [5%]), other (4 [10%]), and unclear (3 [8%]). Seven patients in medically stable condition died after a sudden cardiac arrest, and these constituted 27% (7/26) of deaths more than 1 month after transplant. The 7 sudden cardiac arrests were due to graft vascular disease (2 [29%]), acute rejection (2 [29%]), cardiac arrhythmias (2 [29%]), and hyperkalemia during an exacerbation of acute renal failure (1 [14%]). In 3 of the 5 patients who died of sudden cardiac arrest not due to acute rejection, hemodialysis and plasmapheresis were triggers of the event. Pulmonary hypertensive arteriopathy was associated with early death and right-sided heart failure, and 6 of 8 patients with these changes died perioperatively or postoperatively.