Prescription opioid related deaths in New York City: a 2 year retrospective analysis prior to the introduction of the New York State I-STOP law.

The United States is in the midst of an unprecedented drug epidemic. Illicit use of prescription medicine, predominantly opioids, has become one of the nation's fastest-growing drug problems. We have conducted a retrospective review of prescription opioid fatalities in New York City (NYC) prior to the introduction of a 2013 law intended to curtail prescription drug abuse. Over the 2 years of our study, there were 1286 chemical intoxication fatalities in NYC. Of these, 547 (42.5%) were associated with prescription opioids (6.5/100,000 population). Methadone was most frequently encountered followed by oxycodone. Only 36.7% of decedents had a valid opioid prescription. Of non-opioid medications associated with the prescription opiate deaths, benzodiazepines were the most frequently encountered (68.4%), and alprazolam (35.1%) was most common. Though prescribers have no control over drug diversion they should be cognizant of the urgent public health concern regarding prescription opioid abuse and associated fatalities and attempt to identify doctor shoppers and limit prescription of these potent drugs to those with a legitimate need for pain control. They also need to be aware of the high incidence of fatalities due to combined opioid and benzodiazepine use/abuse and refrain from prescribing them in tandem.

Upper and lower gastrointestinal endoscopy mortality: the medical examiner's perspective.

Fiberoptic endoscopy is utilized to diagnose and treat a wide variety of gastrointestinal tract diseases and is currently one of the most commonly performed invasive medical procedures. Though generally considered to be safe, the procedure may be associated with serious complications including death. Herein, we correlate the clinical history with the autopsy findings in gastrointestinal endoscopy (GIE) related fatalities that were reported to the New York City Medical Examiner Office over a 5 year period. The complication rate is higher in therapeutic procedures when compared to diagnostic procedures. Though fatalities following iatrogenic complications are four times more common, emphasis is placed on patients who died following a cardiorespiratory event during or immediately following the procedure. Of 41 upper and 36 lower GIE related fatalities, 10 and 9 respectively, fit this category. The comorbidities frequently associated with fatal cardiorespiratory events were: hypertension and obesity with associated cardiac hypertrophy, diabetes mellitus and coronary artery atherosclerosis. For colonoscopies, the approximate incidence of perforation was 0.00625% and the procedure-related fatality rate was 0.014%. The literature on anesthesia for GIE is also discussed.

Suicidal ligature strangulation utilizing cable ties: a report of three cases.

In 2006 the US National Vital Statistics Report recorded 33,300 suicides in the United States, of which hanging, strangulation and suffocation combined to account for 7,491 (22.5%) of the cases. Self strangulation by ligature is uncommon and in the majority of cases, scarves, belts, neckties and rope are used. We report three instances where cable ties were secured around the neck in order to commit suicide. All had a history of depression. One was a 37-year-old man who used a belt to complete the act after an unsuccessful attempt to use cable ties. The second was a 63-year old woman who used multiple cable ties to accomplish her goal. In the third case a tensioning tool was used by a 54-year old man to tighten a cable tie around his neck during self strangulation. Utilization of a tool to tighten the cable ties has not previously been reported.

"Bath Salts" the New York City Medical Examiner Experience: A 3-Year Retrospective Review.

"Bath salts" are synthetic derivatives of cathinones, compounds found in the leaves of Catha edulis, which possesses amphetamine-like properties. At the New York City Office of Chief Medical Examiner, we conducted a 3-year retrospective analysis of deaths in which cathinones were detected. Two categories emerged; those in which cathinones were a contributory cause of death (15 cases) and those in which they were an incidental finding (15 cases). Of the former group, 13 were associated with additional intoxicants; two deaths were attributed solely to cathinone intoxication, both survived 10 h: a man whose postmortem blood methylone concentration was 0.71 mg/L and a woman whose postmortem blood ethylone concentration was 1.7 mg/L. In the latter category, there were several individuals who had higher concentrations of cathinones than the above two, the highest being a blood methylone of 4.8 mg/L. Based upon our data and the literature presented, lethal concentrations of cathinones cannot be established.

Suicidal asphyxiation by inhalation of automobile emission without carbon monoxide poisoning.

Reported herein is the suicidal asphyxiation of a young man due to exhaustion of oxygen in the interior of a sealed automobile into which the exhaust emissions were diverted. His blood carboxyhemaglobin concentration was less than 5% saturation. The car was equipped with a catalytic converter and when tested, the exhaust carbon monoxide concentration was 0.01%.

Pulmonary interstitial emphysema in live birth determination: radiographic and gross pathologic features.

Pulmonary interstitial emphysema (PIE) has previously been reported as a useful finding in the determination of live birth in cases where the birth and death were not attended. Herein, we present the radiographic and gross pathologic features of PIE in such a case. In this instance, in addition to parenchymal interstitial emphysema, there were subpleural air collections and a pneumothorax.

Fatality following right atrial perforation by a screw-in pacemaker electrode.

This paper describes the first reported fatality from right atrial perforation complicating the insertion of a screw-in right atrial pacemaker electrode. The patient was an 84-year-old woman with the sick sinus syndrome who also had hepatic cirrhosis.

Fatalities by ingestion of propylene glycol.

Propylene glycol (PG), a widely used solvent and lubricant, is thought to have low toxicity when ingested. Three cases were identified where PG, either alone or in combination with other chemical agents, contributed to death. The decedent in whom PG was the sole agent was a 32-year-old schizophrenic man with cardiomegaly and renal impairment. The blood PG concentration was 4410 mg/L at least 9.5 h following ingestion.

Subdural Hemorrhage, a Retrospective Review with Emphasis on a Cohort of Alcoholics.

Subdural hemorrhage (SDH) is a common cause of death. As external evidence of injury may be absent, an autopsy is frequently needed to detect it. We conducted a 3-year review of SDH from the New York City Office of Chief Medical Examiner, with emphasis on a cohort of alcoholics. Our study population of 1942 included 1588 alcoholics. Of the alcoholics, c. 8% had SDH (26% of the total number of SDH). Of the alcoholics with SDH, 57% had associated brain injuries. As alcohol intoxication is frequently associated with aggressive and violent behavior, we are concerned that 6% of alcoholics in our review had no autopsy or imaging studies. It is possible that a portion of these may have had a SDH due to an unrecognized inflicted injury. We recommend that autopsies be performed on all alcoholics without a clear cause or mechanism of death.

Isolated fibromuscular dysplasia of the coronary ostium: a rare cause of sudden death. Case report and review of the literature.

We present a unique case of sudden death in a 21-year-old man with history of cocaine use and a solitary fibromuscular dysplastic lesion completely occluding the left coronary artery ostium. We document intimal proliferation of myofibroblasts at the opening of the left coronary ostium without other concomitant lesions. This report discusses the gross and histologic features of the lesion, explores in careful detail the possible etiologies, and gives a comprehensive literature review of isolated coronary ostial fibromuscular dysplasia presenting with sudden death.

Phencyclidine: a 5-year retrospective review from the New York City Medical Examiner's Office.

We report here a 5-year retrospective review of autopsy cases from the New York City Medical Examiner's Office that demonstrated phencyclidine (PCP) in the blood. There were a total of 138 cases. There were 52 deaths because of mixed drug intoxication: the blood PCP concentrations in these cases ranged from <1 to 598 ng/mL. There were 80 violent deaths in which PCP was quantified in the blood but was unrelated to the cause of death. There were five nonviolent deaths in which PCP exclusively was detected. In four of these, there were preexisting medical conditions that could also have contributed to death. In these, the highest PCP concentration was 361.3 ng/mL, a concentration lower than seven of the individuals in our violent death category. This suggests that lower concentrations may be fatal with comorbid conditions.

Motor vehicle occupants, neck injuries, and seat belt utilization: a 5-year study of fatalities in New York City.

Despite the implementation of numerous safety devices in automobiles, vehicular occupant fatalities following collisions remain common. We reviewed all fatalities of vehicular occupants in New York City over a 5-year period on whom autopsies were performed (437) to determine the incidence of neck injuries and correlate them with seat belt utilization; 26.5% had neck injuries (mild to severe) and only 10.3% of these occupants were confirmed to be wearing seatbelts. Of those that had documentation of seat belt utilization there were twice as many neck injuries in the unbelted group. We highlight two cases of submarining with severe neck injuries that were related to automatic 2-point shoulder harness restraints without engagement of the lap belt.