Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid and Other Drugs.

The National Association of Medical Examiners convened an expert panel to update the association's evidence-based recommendations for investigating and certifying deaths associated with opioids and other misused substances to improve death certificate and mortality data for public health surveillance. The recommendations are as follows:1. Autopsy provides the best information on a decedent's medical condition for optimal interpretation of toxicology results, circumstances surrounding death, medical history, and scene findings. The panel considers autopsy an essential component of investigating apparent overdose deaths.2. Scene investigation includes reconciling prescription information and medication counts. Investigators should note drug paraphernalia or other evidence of using intoxicating substances.3. Retain blood, urine, and vitreous humor whenever available. Blood from the iliofemoral vein is preferable to blood from more central sites.4. A toxicological panel should be comprehensive, including potent depressant, stimulant, and antidepressant medications. Detecting novel substances present in the community may require special testing.5. When death is attributed to a drug or combination of drugs (as cause or contributing factor), the certifier should list the drugs by generic name in the autopsy report and death certificate.6. The best classification for manner of death in an overdose without any apparent intent of self-harm is "accident."

Hyperoxalosis Secondary to Intravenous Vitamin C Administration as a Non-Allopathic Treatment for Cancer.

Vitamin C (ascorbic acid) has long been known to have antioxidant properties, with associated claims that it can boost the immune system, fight off infection, and help in the treatment of cancer. Similar to many other over-the-counter and herbal medicines, vitamin C can cause potential side effects with significant morbidity and rarely mortality. We discuss a case of an elderly woman with metastatic adenocarcinoma of the lung that was treated with several rounds of allopathic chemotherapy; however, treatment was stopped because of worsening quality of life and disease progression. She was treated with 10 courses of intravenous high-dose vitamin C at a local homeopathic medical center as an alternative treatment method. Five days after the last vitamin C administration, she was admitted to an allopathic hospital due to acute renal failure and oliguria culminating in a myocardial infarct due to underlying atherosclerotic disease. Workup revealed dehydration secondary to poor oral intake and acute renal failure which was clinically concerning for calcium oxalate- induced kidney injury. At the time of autopsy, in addition to her widely metastatic adenocarcinoma and myocardial damage, hyperoxalosis of the kidney with acute kidney injury was present. Hyperoxalosis of the kidney is a documented phenomenon related to administration of intravenous and oral vitamin C at superphysiologic doses as recommended by some natural and homeopathic practitioners and is, therefore, a significant complication of treatment. This case highlights the renal complications of supertherapeutic vitamin C administration and the associated morbidity which can contribute to death.

"Med-X": a medical examiner surveillance model for bioterrorism and infectious disease mortality.

We created a model surveillance system (Med-X) designed to enable medical examiners and coroners to recognize fatal infections of public health importance and deaths due to bioterrorism. All individuals who died in New Mexico and fell under medical examiner jurisdiction between November 23, 2000, and November 22, 2002, were prospectively evaluated using sets of surveillance symptoms and autopsy-based pathologic syndromes. All infectious disease deaths were evaluated to identify the specific causative agent. Of 6104 jurisdictional cases, 250 (4.1%) met Med-X criteria, of which 141 (56.4%) had a target pathologic syndrome. Ultimately, 127 (51%) of the 250 cases were due to infections. The causative organism was identified for 103 (81%) of the infectious disease deaths, of which 60 (58.3%) were notifiable conditions in New Mexico. Flu-like symptoms, fever and respiratory symptoms, and encephalopathy or new-onset seizures had predictive values positive for fatal infections of 65%, 72%, and 50%, respectively, and are useful as autopsy performance criteria. Before the development of surveillance criteria, 37 (14.8%) of the cases ordinarily would not have been autopsied resulting in a 1% increase in autopsy workload. Med-X is an effective method of detecting infectious disease deaths among medical examiner cases. Uniform criteria for performing medical examiner autopsies and reporting cases to public health authorities enhance surveillance for notifiable infectious diseases and increase the likelihood of recognizing deaths related to bioterrorism.