Confronting an Upsurge in Opiate Deaths with Limited Resources.

The dramatic increase in drug-related deaths in the last decade has presented fiduciary and logistical difficulties to medicolegal jurisdictions of all types and sizes. New Hampshire, with a centralized state medical examiner system of death investigation, has been confronted with the task of investigating these drug-related deaths against the backdrop of statutory hurdles inhibiting a nimble response to the situation. This has led to a collaborative approach with law enforcement and the state Department of Justice in terms of triaging drug deaths to full autopsy versus external examination with toxicology testing. Preliminary data suggest that between 11 and 13% of suspected drug deaths have an alternative cause of death revealed by autopsy. Positive toxicological findings were documented in 97.5% of cases in which only an external examination was performed; however, some of these cases may have had undetected, significant internal findings that could have accounted for an alternative cause of death if an autopsy had been performed. While the case triage system described has temporarily addressed the acute problem, the issue of the medical examiner's appropriate role in the adequate evaluation of public health and safety remains extant. Furthermore, noncompliance with the National Association of Medical Examiners inspection and accreditation standards puts this agency, and others facing the same issues, at risk of losing full accreditation status until such resource issues are addressed by legislators and other stakeholders in the quality of medicolegal death investigation in the United States.

Common Findings and Predictive Measures of Opioid Overdoses.

PURPOSE: This research examines autopsy findings from fatal opiate/opioid intoxications in New Hampshire for cerebral edema, pulmonary edema, and urinary bladder distension in the interest of finding predictability of such cases. METHODS: Autopsy reports of 150 decedents, between 20 and 40 years old, were reviewed. Subjects were divided into three groups as follows: 50 whose cause of death was opioid intoxication excluding fentanyl, 50 who died from fentanyl, and 50 who, lacking intoxication, died from cardiac issues, seizure disorders, or positional asphyxia as the control group. Autopsy reports were reviewed for cerebral edema, pulmonary edema, and urinary bladder distension. RESULTS: Pulmonary edema was present in 96% of those who died of fentanyl alone and in 94% of those who died of opioids excluding fentanyl. Cerebral edema occurred in 54% of decedents who died of opiates/opioids excluding fentanyl and 8% in those who died solely of fentanyl. Thirty-four percent of the fatal intoxications excluding fentanyl had bladder distension while only 16% of those who died of fentanyl intoxication. The control group found 30% had pulmonary edema, 2% had cerebral edema, and none had bladder distension. The triad occurred in 8% of intoxications and never in the control group. CONCLUSION: The results validated correlation between opioid intoxication and pulmonary edema, cerebral edema, and bladder distension. Cerebral edema and bladder distension suggest opioid intoxication, but arise less frequently in fentanyl intoxication. We hypothesize that fentanyl causes death more rapidly than other opioids leading to these results. Given the variations, we do not recommend reliance on postmortem computed tomography in lieu of autopsy to evaluate potential fatal intoxications.

Cardiac Tropism of Borrelia burgdorferi: An Autopsy Study of Sudden Cardiac Death Associated with Lyme Carditis.

Fatal Lyme carditis caused by the spirochete Borrelia burgdorferi rarely is identified. Here, we describe the pathologic, immunohistochemical, and molecular findings of five case patients. These sudden cardiac deaths associated with Lyme carditis occurred from late summer to fall, ages ranged from young adult to late 40s, and four patients were men. Autopsy tissue samples were evaluated by light microscopy, Warthin-Starry stain, immunohistochemistry, and PCR for B. burgdorferi, and immunohistochemistry for complement components C4d and C9, CD3, CD79a, and decorin. Post-mortem blood was tested by serology. Interstitial lymphocytic pancarditis in a relatively characteristic road map distribution was present in all cases. Cardiomyocyte necrosis was minimal, T cells outnumbered B cells, plasma cells were prominent, and mild fibrosis was present. Spirochetes in the cardiac interstitium associated with collagen fibers and co-localized with decorin. Rare spirochetes were seen in the leptomeninges of two cases by immunohistochemistry. Spirochetes were not seen in other organs examined, and joint tissue was not available for evaluation. Although rare, sudden cardiac death caused by Lyme disease might be an under-recognized entity and is characterized by pancarditis and marked tropism of spirochetes for cardiac tissues.

Additive Effects of Cointoxicants in Single-Opioid Induced Deaths.

A forensic drug database (FDD) was used to capture comprehensive data from all drug-related deaths in West Virginia, with deaths also included from the northern New England states of Maine, Vermont, and New Hampshire. All four states serve predominantly rural populations under two million and all have similar state medical examiner systems that employ statewide uniform death certification policies and practices. This study focused on 1482 single opioid deaths (fentanyl, hydrocodone, methadone, and oxycodone) in the FDD from 2007-2011. We modeled relationships between the opioid concentrations and the presence or absence of the following commonly occurring non-opioid cointoxicants: benzodiazepines (alprazolam and diazepam), alcohol, tricyclic antidepressants, selective serotonin reuptake inhibitors, and diphenhydramine. Additional covariates of state, age, body mass index, and sex were included. Results showed that the presence of alcohol, benzodiazepines, and antidepressants were each associated with statistically significant lower concentrations of some but not all of the opioids studied, which may obscure the interpretation of postmortem toxicology results alone. Fentanyl concentrations appeared to be the least associated with the presence or absence of the variables studied, and cointoxicant alcohol appeared to be associated with lower concentrations in opioid concentrations than were most of the other factors in the model studied. These findings underscore the importance of documenting all potential cointoxicants in opioid-related deaths.

Asphyxial games in children and adolescents.

Asphyxial games, as played by young adolescents, and going by various names, are not new phenomena. What seems to be different at present is an increase in lethality introduced by the increasing use of ligatures and "playing" the game alone. The authors present a properly certified but insufficiently appreciated case followed 2 years later by 2 closely spaced but unrelated deaths in young adolescent males that made known this practice in New Hampshire youth. Other cases presented to the author from other jurisdictions are reviewed in aggregate. Presented are characteristics of victims of this practice that may help distinguish these deaths from suicidal asphyxia. A relative paucity of literature regarding asphyxial games outside the realm of autoerotic asphyxia gives rise to certification difficulties given the high prevalence of youth suicide.

Role of chemical tests and scene investigation in determination of range of fire.

Forensic pathologists have historically found several characteristics of the entrance wound invaluable in determining range of fire in gunshot fatalities. Among these characteristics are the pattern and constituents of any deposited material such as soot and/or gun powder residues. We describe a case in which the application of previously described characteristics, in the absence of laboratory testing and examination of the crime scene, would have led to an erroneous conclusion with potentially grave consequences. We suggest that all attempts be made to use available laboratory tests and to perform detailed examination of crime scenes in determining the circumstances surrounding fatal gunshot injuries.

Prothrombin G20210A mutation and sudden death.

The authors present a case of sudden death in a previously healthy 36-year-old male. At autopsy there were bilateral pulmonary thromboemboli and right ventricular dilatation. Histologic findings in the lungs included recanalized, old thrombi and evidence of pulmonary hypertension. Genetic analysis for hereditary risk factors was heterozygous positive for the prothrombin G20210A mutation. Implications of this finding, its history and the diagnostic technique shall be discussed. The authors recommend that all cases of deep venous thromboses and pulmonary thromboemboli lacking known risk factors be evaluated for newly described genetic variations associated with an increased risk for venous thrombosis.