Female Homicide Victims in Cook County, Illinois: A Retrospective Review.

ABSTRACT: Female homicide is a broad term that includes any homicide in which the victim is a female, representing the most extreme form of violence against women. This study investigated the characteristics of female homicides to determine the types and characteristics of injury, circumstances of the events, and other aspects in this specific population. The Cook County Medical Examiner's Office files were searched for homicides in female subjects between January 2017 and January 2022, with no limits for age, race, or cause of death. A total of 527 cases met the criteria. Most homicides occurred in Chicago during the summer. The most common cause of death was firearm(s) wounds, followed by sharp force traumas, asphyxia, and blunt force injuries. The remaining deaths were due to combined and "other" mechanisms. Different patterns of injuries were observed at the autopsy. Alleged offenders were mostly male subjects and were frequently in a romantic relationship with the victim, and the reasons for homicide were related to jealousy and personal conflicts. This study offers an overview of homicidal deaths in female subjects in a large metropolitan area.

Report of 5146 Cases of Coronavirus Disease 2019-Related Mortality From Cook County, Illinois Causes of Death, Demographics, and Comorbidities.

ABSTRACT: A cross-sectional study used 5216 laboratory-confirmed coronavirus disease 2019 (severe acute respiratory syndrome coronavirus 2)-related mortality cases in Cook County of Illinois. The data set included each case's demographic data, manner of death, and comorbidities. The age ranged from 0 to 108 years, with a median of 73.5 years. There were few mortality cases in the age group younger than 30 years, and the incidence of fatal infection increased with age. We demonstrated an increased incidence of mortality in males compared with females (P < 0.01). The urban population had a higher incidence of fatal infection than the suburban population (P < 0.01). We found a significant increase (P < 0.01) in the incidence of fatal coronavirus disease 2019 (severe acute respiratory syndrome coronavirus 2) infection in African American males compared with background frequencies. Latino population demonstrated younger ages at death compared with the non-Latino population. Obesity and hypertension significantly predict fatal outcomes in the younger age group. In comparison, dementia and hypertensive and arteriosclerotic cardiovascular disease are significant predictive factors in the older age group. In a large data set, we demonstrated that the demographical distribution of the population and comorbidities is associated with the risk of fatal complications and death.

National Association of Medical Examiners Position Paper: Recommendations for the Documentation and Certification of Disaster-Related Deaths.

ABSTRACT: Collecting and reporting accurate disaster mortality data are critical to informing disaster response and recovery efforts. The National Association of Medical Examiners convened an ad hoc committee to provide recommendations for the documentation and certification of disaster-related deaths. This article provides definitions for disasters and direct, indirect, and partially attributable disaster-related deaths; discusses jurisdiction for disaster-related deaths; offers recommendations for medical examiners/coroners (ME/Cs) for indicating the involvement of the disaster on the death certificate; discusses the role of the ME/C and non-ME/C in documenting and certifying disaster-related deaths; identifies existing systems for helping to identify the role of disaster on the death certificate; and describes disaster-related deaths that may require amendments of death certificates. The recommendations provided in this article seek to increase ME/C's understanding of disaster-related deaths and promote uniformity in how to document these deaths on the death certificate.

Five-year review (2014-2019) of paediatric accidental deaths in Cook County, Illinois (USA).

In the USA, intentional and accidental injuries are the most frequent causes of death in children. Many of these deaths could be avoided through preventive measures, and aetiological studies are needed to reduce fatalities. The leading causes of accidental death vary by age. We analysed all paediatric accidental deaths recorded by a busy urban Medical Examiner"s Office in Chicago, Illinois (USA). We searched the electronic database for accidental deaths in children aged under 10 between 1 August 2014 and 31 July 2019. 131 deaths were identified with a preponderance of males and African Americans. This is consistent with ratios of other deaths recorded for this age group (during the same period and area). The leading causes of death were asphyxia due to an unsafe sleeping environment (in subjects <1-year-old), and road traffic accidents/drowning (in subjects >1-year-old). Behaviours, risk factors and environments most likely to contribute to fatal injuries are discussed. Our study highlights the role of forensic pathologists and medico-legal death investigators who identify the causes and circumstances surrounding these deaths. The research results may help from an epidemiological perspective to implement age-specific preventive strategies.

When public health crises collide: 5 years of pediatric firearm injury prevention opportunities.

Objectives: Prior publications on pediatric firearm-related injuries have emphasized significant social disparities. The pandemic has heightened a variety of these societal stresses. We sought to evaluate how we must now adapt our injury prevention strategies. Patients and methods: Firearm-related injuries in children 15 years old and under at five urban level 1 trauma centers between January 2016 and December 2020 were retrospectively reviewed. Age, gender, race/ethnicity, Injury Severity Score, situation, timing of injury around school/curfew, and mortality were evaluated. Medical examiner data identified additional deaths. Results: There were 615 injuries identified including 67 from the medical examiner. Overall, 80.2% were male with median age of 14 years (range 0-15; IQR 12-15). Black children comprised 77.2% of injured children while only representing 36% of local schools. Community violence (intentional interpersonal or bystander) injuries were 67.2% of the cohort; 7.8% were negligent discharges; and 2.6% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 14-15) compared with 12 years (IQR 6-14, p<0.001) for negligent discharges. Far more injuries were seen in the summer after the stay-at-home order (p<0.001). Community violence and negligent discharges increased in 2020 (p=0.004 and p=0.04, respectively). Annual suicides also increased linearly (p=0.006). 5.5% of injuries were during school; 56.7% after school or during non-school days; and 34.3% were after legal curfew. Mortality rate was 21.3%. Conclusions: Pediatric firearm-related injuries have increased during the past 5 years. Prevention strategies have not been effective during this time interval. Prevention opportunities were identified specifically in the preteenage years to address interpersonal de-escalation training, safe handling/storage, and suicide mitigation. Efforts directed at those most vulnerable need to be reconsidered and examined for their utility and effectiveness. Level of evidence: Level III; epidemiological study type.

Evaluating the Reliability of Dipstick Drug Screens on Vitreous and Postmortem Blood as a Triage Modality in Forensic Pathology.

Dipstick drug screens are cheap, easy to use, and quick presumptive tests to detect common drugs of abuse. Dipsticks are designed for drug detection in urine. There is no literature regarding their potential use on fluids different from urine. The study aimed to determine the performance of dipstick screening tests on postmortem vitreous and blood specimens compared to urine dipsticks and final confirmatory toxicology analyses on blood. The study population included cases in which a complete toxicology analysis was performed. Each subject was screened for three substances: cocaine, fentanyl, and opiates. Dipstick results were checked by visual inspection. Results were compared with urine screening tests and quantitative, confirmatory toxicological analyses by gas chromatography/mass spectrometry on postmortem blood samples as the gold standards for screening and confirmatory analysis, respectively. There was a high number of false-negative results for opiates. Cocaine dipsticks in blood showed the highest reliability. Fentanyl dipsticks in vitreous showed a high number of false-negative results. Both vitreous and blood dipstick screening tests for all substances performed well on negative cases. When both blood and vitreous screening tests are negative, the chance that the confirmatory toxicology analysis will be positive is very low.

Opioid-related overdose deaths by race and neighborhood economic hardship in Chicago.

Compared to national findings, Chicago has both a higher rate of opioid-related overdose death and a markedly different distribution by demographics. The Chicago Department of Public Health analyzed fatal overdoses by level of neighborhood economic hardship. The highest rate of opioid-related deaths occurred in neighborhoods with high economic hardship (36.9 per 100,000 population) compared to medium- (20.5) and low- (12.3) hardship neighborhoods. However, these patterns were not consistent across racial/Hispanic ethnicity subgroups. These data support the need to consider the role of racism and other structural, social, and economic factors when designing interventions to reduce opioid-related overdose deaths.

Genomic Autopsy of Sudden Deaths in Young Individuals.

Importance: Postmortem genetic testing of young individuals with sudden death has previously identified pathogenic gene variants. However, prior studies primarily considered highly penetrant monogenic variants, often without detailed decedent and family clinical information. Objective: To assess genotype and phenotype risk in a diverse cohort of young decedents with sudden death and their families. Design, Setting, and Participants: Pathological and whole-genome sequence analysis was conducted in a cohort referred from a national network of medical examiners. Cases were accrued prospectively from May 2015 to March 2019 across 24 US states. Analysis began September 2016 and ended November 2020. Exposures: Evaluation of autopsy and clinical data integrated with whole-genome sequence data and family member evaluation. Results: A total of 103 decedents (mean [SD] age at death, 23.7 [11.9] years; age range, 1-44 years), their surviving family members, and 140 sex- and genetic ancestry-matched controls were analyzed. Among 103 decedents, autopsy and clinical data review categorized 36 decedents with postmortem diagnoses, 23 decedents with findings of uncertain significance, and 44 with sudden unexplained death. Pathogenic/likely pathogenic (P/LP) genetic variants in arrhythmia or cardiomyopathy genes were identified in 13 decedents (12.6%). A multivariable analysis including decedent phenotype, ancestry, and sex demonstrated that younger decedents had a higher burden of P/LP variants and select variants of uncertain significance (effect size, -1.64; P = .001). These select, curated variants of uncertain significance in cardiac genes were more common in decedents than controls (83 of 103 decedents [86%] vs 100 of 140 controls [71%]; P = .005), and decedents harbored more rare cardiac variants than controls (2.3 variants per individual vs 1.8 in controls; P = .006). Genetic testing of 31 parent-decedent trios and 14 parent-decedent dyads revealed 8 transmitted P/LP variants and 1 de novo P/LP variant. Incomplete penetrance was present in 6 of 8 parents who transmitted a P/LP variant. Conclusions and Relevance: Whole-genome sequencing effectively identified P/LP variants in cases of sudden death in young individuals, implicating both arrhythmia and cardiomyopathy genes. Genomic analyses and familial phenotype association suggest potentially additive, oligogenic risk mechanisms for sudden death in this cohort.

Anatomical distribution and autopsy features of gunshot injuries to support the manner of death.

The autopsy features of gunshot wounds can be useful in understanding the manner of death. This research aims to provide concrete data to help to discriminate between homicide and suicide based on specific autopsy findings. A search of the database of the Cook County Medical Examiner's Office from August 2014 through April 2019 identified 3491 deaths due to gunshot wounds. Deaths due to complication from delayed fatal gunshot wounds, subjects who received hospital care prior to death, and decomposed bodies were identified and excluded. The following data were recorded: manner of death, demographic data, firearm and bullet type, number and location of gunshot wounds, range of fire, toxicology, and additional injuries. The study primary focused on the analysis of the bullet trajectory. A course leftward-upward-backward was the most frequent observed trajectory in suicides; a course rightward-upward-frontward was the most frequent observed trajectory in homicides. When the internal trajectory of a bullet is interpreted in the light of all available evidence it can impeach or corroborate witness statements and highlight consistencies as well inconsistencies in investigative reports and scene examinations.

Prevalence of Abnormal Heart Weight After Sudden Death in People Younger than 40 Years of Age.

Background After sudden cardiac death in people aged <40 years, heart weight is a surrogate for cardiomegaly and a marker for cardiomyopathy. However, thresholds for cardiomegaly based on heart weight have not been validated in a cohort of cases of sudden cardiac death in young people. Methods and Results We surveyed medical examiner offices to determine which tools were used to assess heart weight norms. The survey determined that there was no gold standard for cardiomegaly (52 centers reported 22 different methods). We used a collection of heart weight data from sudden deaths in the Northwestern Sudden Death Collaboration (NSDC) to test the 22 methods. We found that the methods reported in our survey had little consistency: they classified between 18% and 81% of NSDC hearts with cardiomegaly. Therefore, we obtained biometric and postmortem data from a reference population of 3398 decedents aged <40 years. The reference population was ethnically diverse and had no known cardiac pathology on autopsy or histology. We derived and validated a multivariable regression model to predict normal heart weights and a threshold for cardiomegaly (upper 95% CI limit) in the young reference population (the Chicago model). Using the new model, the prevalence of cardiomegaly in hearts from the NSDC was 19%. Conclusions Medical examiner offices use a variety of tools to classify cardiomegaly. These approaches produce inconsistent results, and many overinterpret cardiomegaly. We recommend the model proposed to classify postmortem cardiomegaly in cases of sudden cardiac death in young people.

Relationship between opiates and asthma in the determination of death.

Several studies have shown an association between asthma and opiate abuse. This retrospective study aims to analyse the demographic, toxicological, and seasonal differences in asthmatic and non-asthmatic subjects who died of opiates. In addition, the relationship between toxicological levels of opiates and histologic grade of lung inflammation is examined. Deaths from 2013 to 2018 involving opiates as the primary cause of death in Cook County, Illinois (USA) were reviewed. Twenty-six cases of opiate deaths of individuals with a history of asthma and lung histology slides available were identified. In comparison, 40 cases of deaths due to opiates only were analysed. A check-list system for the evaluation of the grade of microscopic inflammation in asthma was developed. We found statistically significant differences between the asthmatics and the non-asthmatics regarding demography (age and race) and toxicology (6-MAM presence). In particular, the "opiate and asthma group" was mainly composed of African-American subjects, in contrast with the "opiate group", consisting mostly of Caucasian. The mean age was significantly higher in the "opiate and asthma group" compared with the "opiate group". A greater presence of 6-MAM was detected in the "opiate group" compared with the "opiate and asthma group". While we expected to find that low opiate levels would lead to deaths in asthmatics and, in particular, that lower opiate concentrations would cause deaths in subjects with higher grades of histologic inflammation, our study suggests that the quantity of drug and the level of inflammation are not statistically significant in the determination of death. We, therefore, recommend histologic examination of the lungs to evaluate for asthma, particularly in suspected low-level opiate-related deaths, to help further clarify any relationship between asthma and opiate use.

Sudden Cardiac Deaths in Adults with Congenital Heart Disease with Structural Abnormalities: A Retrospective Review of Cases in the Cook County Medical Examiner's Office.

Sudden cardiac death is a significant cause of mortality in adults with congenital heart disease (CHD). The Cook County Medical Examiner's Office database was queried for cases of CHD as a cause of death in the period between July 2008 and April 2019. Twenty-two cases were identified, including 11 decedents with simple defects and 10 decedents with complex defects. All of the subjects were in apparent good health at the time of death. In the absence of other obvious causes of death, simple defects were considered cases of sudden cardiac death. Significant cardiac morphological changes were common in complex defects. While 16 cases had known, diagnosed/treated CHD, 5 cases had no diagnosis prior to autopsy. In these cases, the ability to recognize CHD (sometimes subtle) helped in determining the causes of death. Therefore, forensic pathologists must be able to properly recognize various forms of CHD and request consultations, when needed.

The Outbreak of Fentanyl-Related Deaths in Cook County, Illinois, Between October 2015 and December 2017: A Retrospective Study and a Comparison with Previous Data.

The National Institute on Drug Abuse has observed an increase in fentanyl deaths in the United States. One epidemic related to the abuse of fentanyl happened in Cook County in 2005-2007 (350 deaths). Another outbreak of fentanyl deaths occurred in 2015-2017 in the same area. The database of the Cook County Medical Examiner's Office was searched for cases of fentanyl deaths between 2015 and 2017: 1244 deaths were found. A comparison was performed with the previous data: an increase in the number of females was observed in 2015-2017. Also, in 2005-2007, the majority of deaths occurred among African American, while in 2015-2017, Caucasians were more involved. Within our population, some drug combinations were more common in specific demographic subgroups (male/females; Caucasian/African American; and certain age groups). The epidemiology and the most significant drug associations found at the toxicology are discussed, highlighting the usefulness of the knowledge about this outbreak for public health.

Social Media and Medicolegal Death Investigation: Logged in To the Morgue.

Social media (SM) represent a global consumer phenomenon with an exponential rise in usage within the last few years. The various applications and websites are relatively easy and fast to access, and the number of users increases continuously. SM are an incredible source of freely available, public information about their users. The purpose of this study is to provide information about the usefulness of SM in forensic practice. The electronic database of the Cook County of Medical Examiner's Office ("CCMEO") in Illinois was searched for investigative narratives that included specific SM keywords, in the period from August 2014 to January 2018. A total of 48 cases met the study's criteria. Among these, "Facebook" has been found to be the most helpful SM for medicolegal investigation purposes. Information obtained by SM can play an important role in forensic practice since it can be used to clarify certain aspects of the medicolegal death investigation, with particular regard to time and manner of death.

Health Care Utilization of Opioid Overdose Decedents with No Opioid Analgesic Prescription History.

Opioid overprescribing is a major driver of the current opioid overdose epidemic. However, annual opioid prescribing in the USA dropped from 782 to 640 morphine milligram equivalents per capita between 2010 and 2015, while opioid overdose deaths increased by 63%. To better understand the role of prescription opioids and health care utilization prior to opioid-related overdose, we analyzed the death records of decedents who died of an opioid overdose in Illinois in 2016 and linked to any existing controlled substance monitoring program (CSMP) and emergency department (ED) or hospital discharge records. We found that of the 1893 opioid-related overdoses, 573 (30.2%) decedents had not filled an opioid analgesic prescription within the 6 years prior to death. Decedents without an opioid prescription were more likely to be black (33.3% vs 20.2%, p < .001), Hispanic (16.3% vs 8.8%, p < .001), and Chicago residents (46.8% vs 25.6%, p < .001) than decedents with at least one filled opioid prescription. Decedents who did not fill an opioid prescription were less likely to die of an overdose involving prescribed opioids (7.3% vs 19.5%, p < .001) and more likely to fatally overdose on heroin (63% vs 50.4%, p < .001) or fentanyl/fentanyl analogues (50.3% vs 41.8%, p = .001). Between 2012 and the time of death, decedents without an opioid prescription had fewer emergency department admissions (2.5 ± 4.2 vs 10.6 ± 15.8, p < .001), were less likely to receive an opioid use disorder diagnosis (41.3% vs 47.5%, p = .052), and were less likely to be prescribed buprenorphine for opioid use disorder treatment (3.3% vs 8.6%, p < .001). Public health interventions have often focused on opioid prescribing and the use of CSMPs as the core preventive measures to address the opioid crisis. We identified a subset of individuals in Illinois who may not be impacted by such interventions. Additional research is needed to understand what strategies may be successful among high-risk populations that have limited opioid analgesic prescription history and low health care utilization.

Undiagnosed Congenital Heart Defects as a Cause of Sudden, Unexpected Death in Children.

Despite advances in the diagnosis and treatment of congenital heart defects (CHDs), these defects are still an important cause of sudden, unexpected death in young children. This retrospective study identified 64 cases of CHDs presenting as a cause of sudden, unexpected death in a busy, urban Medical Examiner's Office pediatric population between 2006 and 2016. The majority of cases (52 of 64, 81%) were infants. Interestingly, 52% of cases were undiagnosed prior to autopsy. Ventricular septal defects and atrioventricular septal defects were the most common simple (14%) and complex (17%) malformations observed, respectively. In many cases, there were coexistent simple and/or complex defects. Most of the cases diagnosed with CHD prior to autopsy (48%) had undergone some type of surgical repair. This study highlights the importance of considering undiagnosed CHDs as a cause of sudden, unexpected death, particularly in young children.

Deaths Due to Child Abuse: A 6-Year Review of Cases in The Cook County Medical Examiner's Office.

Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.

Determined to Die! Ability to Act Following Multiple Self-inflicted Gunshot Wounds to the Head. The Cook County Office of Medical Examiner Experience (2005-2012) and Review of Literature.

Cases of multiple (considered 2+) self-inflicted gunshot wounds are a rarity and require careful examination of the scene of occurrence; thorough consideration of the decedent's psychiatric, medical, and social histories; and accurate postmortem documentation of the gunshot wounds. We present a series of four cases of multiple self-inflicted gunshot wounds to the head from the Cook County Medical Examiner's Office between 2005 and 2012 including the first case report of suicide involving eight gunshot wounds to the head. In addition, a review of the literature concerning multiple self-inflicted gunshot wounds to the head is performed. The majority of reported cases document two gunshot entrance wound defects. Temporal regions are the most common affected regions (especially the right and left temples). Determining the capability to act following a gunshot wound to the head is necessary in crime scene reconstruction and in differentiation between homicide and suicide.