Medicolegal Death Investigation of Railroad-Related Fatalities.

ABSTRACT: Railroad-related fatalities in the United States are increasing. A paucity of literature exists regarding the medicolegal death investigation of railroad-related deaths. We report on a subset of deaths in western Michigan, propose protocols for investigating train-related deaths, and propose a stepwise approach for the medicolegal investigation of railroad-related fatalities. Fourteen railroad-related fatalities from 2015 to 2019 were reviewed. Each case was analyzed for demographics, investigative components, train variables, and death certification. The average age was 32 years. Nine decedents involved pedestrians versus trains, and 5 involved motor vehicles versus trains. Male victims were more common, and 50% of the cases were associated with mental illness or recent stressors. Accident was the most common manner of death. With the exception of basic weather conditions, the remaining investigative variables were rarely reported. Image and audio recordings were taken in 3 cases, but railroad companies refused to allow the recordings to be viewed by the medical examiner. We conclude that in addition to a thorough medicolegal death scene investigation and postmortem examination, audio/video recordings are crucial components of death certification in railroad-related fatalities and advocate that medical examiners/coroners be given the legal right to view and retain them.

Positional Asphyxia in Opioid-Related Deaths: Is It Being Overlooked?

The contribution of positional asphyxia in opioid-related deaths is currently unknown. Diagnostic criteria for positional asphyxia include finding the decedent in a position that does not allow for adequate respiration and an inability to extricate themselves from the position due to various conditions. Our primary objective was to assess whether positional asphyxia and the resulting airway compromise were a contributing factor to death due to the toxic effects of opioids. We evaluated 225 deaths where the death scene investigation contained adequate information to evaluate for positional asphyxia and performed a Pearson chi-square test to determine if the proportion of deaths found in an airway compromising position was higher when opioid(s) caused the death. The proportion of decedents found in a potential airway compromising position was greater when the death was related to opioid use (p < 0.0001). Further, narrowing the dataset to decedents who were definitely in an airway compromising position [Yes (24.49%) vs. No (11.02%)] showed a statistically significant association between positional asphyxia and deaths related to opioid use (p = 0.0021). Carefully documenting the position in which the decedent was initially found may be a significant factor in accurate reporting and in harm reduction efforts to decrease the opioid mortality rate.

No Evidence of Increased Chronic Traumatic Encephalopathy Pathology or Neurodegenerative Proteinopathy in Former Military Service Members: A Preliminary Study.

It is presently unknown whether military service members are at risk for chronic traumatic encephalopathy (CTE) or Alzheimer's disease (AD) pathology, due to traumatic brain injury (TBI). Studies with respect to AD have had mixed results with respect to mild TBI, although an increased risk of clinical AD with moderate and severe TBI is more consistently demonstrated. No studies to date have demonstrated a longitudinal progression from TBI to autopsy. We therefore initiated a cross-sectional survey of former military service members. 18 brain specimens have been examined to date, with a mean age of 68.9±16 years (range 32-94). Twelve had a history of psychiatric problems; 10 had a history of PTSD specifically. Five had neurological problems including stroke and seizures. One subject had early-onset AD. Two subjects had a history of TBI and two had a history of blast exposure. Age-related proteinopathy, ranging from AD neuropathologic change A0B1C0 to A3B3C3 by NIA-AA guidelines, was identified. None of the cases showed changes specific for CTE pathology. There was no relationship between p-tau in the amygdala and psychiatric signs. There was no significant difference in phosphorylated tau (p-tau) or amyloid-ß burden compared to age-matched controls. These preliminary data suggest that military service per se is not a risk factor for CTE pathology or neurodegenerative proteinopathy. More research is needed to study the relationship, if any, between TBI and neurodegenerative proteinopathy.

Recreational Sporting Activity Vehicle-Related Deaths.

Deaths occurring in the setting of nonprofessional, vehicle-related, recreational sporting activities occurring on land or in water during warm or winter months represent a diverse group of cases. These deaths tend to involve scenarios where the participants are purposefully attempting to enjoy themselves prior to experiencing sudden, catastrophic accidents resulting in lethal outcomes. Ultimately, many of the deaths are related to the high speed at which these vehicle-related activities normally occur. Three broad categories of factors may play contributory roles in death: human factors, vehicle factors, and environmental factors. A series of selected cases are presented, representing examples of varying activity types, involving motorized and nonmotorized vehicles, land and water activities, and warm weather and cold weather environments. For each case, the various human, vehicle and environmental factors believed to be contributory to the accident are considered, and strategies for prevention of these and similar deaths involving recreational sporting vehicles are presented.

Gabapentin in Mixed Drug Fatalities: Does this Frequent Analyte Deserve More Attention?

From 2000 to 2014, drug overdose deaths increased 137% in the United States, and 61% of these deaths included some form of opiate. The vast majority of opiate-related drug fatalities include multiple drugs, although there is scant data quantitatively describing the exact drugs that contribute to deaths due to multiple drugs. In the present study, we sought to quantitatively identify the drugs that occur with opiates in accidental multidrug-related fatalities. We retrospectively explored fatal drug trends in four Michigan counties, with a focus on profiling drugs present concurrently with opiates. Blood and urine toxicology reports for mixed drug fatalities (N=180) were analyzed using frequent item analysis approaches to identify common analyte trends in opiate-related fatalities. Within our cohort, the most prevalent serum analytes included caffeine (n=147), morphine (n=90), alprazolam (n=69), gabapentin (n=46), and tetrahydrocannabinol (n=44). In 100% of cases where gabapentin was present (n=46), an opiate was also present in the serum or urine. The average gabapentin serum concentration was 13.56 µg/mL (SEM =0.33 µg/mL), with a range of 0.5-88.7 µg/mL. Gabapentin was found at very high frequency in accidental mixed drug fatalities. Gabapentin concentrations were generally within the normal therapeutic range (2-20 µg/mL). It is unknown whether a synergistic effect with opioids may contribute to central respiratory depression. Further research is warranted to determine any contributory role of gabapentin in these deaths. Confirmed interactions could have broad implications for future reporting by forensic pathologists as well as prescribing practices by clinicians.