Accidental Gunshot Wound Fatalities Related to Dropped Firearms.

ABSTRACT: A death resulting from the accidental discharge of a firearm represents a rare but oftentimes preventable tragedy. Such deaths may occur in a variety of settings. One such setting involves the discharge of a loaded firearm, which occurs when it is accidentally dropped, thrown, or falls to the ground. We report on 3 cases in which a loaded firearm discharged when it was dropped, resulting in the deaths of 3 individuals. In 2 cases, the person carrying the dropped firearm was killed, whereas in the third case, a child standing near the person who dropped the weapon was killed. We discuss the risk factors involved in these tragic incidents and present preventive strategies.

Sudden Death Due to Necrotizing Fasciitis After Routine Cervical Radiofrequency Ablation Treatment.

ABSTRACT: Cervical facet joint neurotomy, also known as cervical radiofrequency ablation (RFA) or cervical facet rhizotomy, is a medical procedure aimed at alleviating chronic neck pain caused by issues related to the cervical facet joints through ablation of neurons (J Pain Res 2021;14:2807-2831). Although generally safe, adverse events can occur. Infection is a rare consequence of this procedure. Most injection-site infections related to cervical RFA occur spontaneously and resolve with oral antibiotics without sequelae (World Neurosurg 2018;111:e644-e648). We report a case in which a cervical RFA injection resulted in the development of necrotizing fasciitis and ultimately death. To our knowledge, this has not been previously reported and is the first documented fatality due to infectious sequelae of a cervical RFA procedure.

Fatal Iron Tablet Aspiration: Importance of Early Diagnosis and Forensic Pathologist Awareness.

ABSTRACT: Pill aspiration is a significant source of foreign body aspiration in the United States and can occur without swallowing dysfunction or illness. Consequences depend on various factors, such as the pill's chemical composition, size, and diagnostic delay. Aspiration of iron tablets poses a higher risk because of hydroxyl radical formation and subsequent caustic burns, inflammation, obstruction, and/or necrosis. We present a case of a middle-aged obese woman who died 3 weeks after aspirating an iron tablet. Autopsy revealed morbid obesity, a necrotic focus in the right middle lobe of the lung, bronchiolar granulation tissue with iron staining foreign matter, extending into an adjacent arteriole, and mural perforation of the hilar right middle lobe. Despite seeking medical attention twice, the patient was only accurately diagnosed postmortem. This case highlights the importance of accurate and timely diagnosis in preventing fatal outcomes. To enhance diagnostic accuracy and reduce morbidity and mortality associated with pill aspiration, clinicians should maintain a high level of suspicion for foreign body aspiration in patients with persistent or worsening respiratory symptoms. Furthermore, it is crucial for forensic pathologists to have a high index of suspicion about the potential for lethal pill aspiration and complications days after the acute event.

West Michigan Suicide Trends During the COVID-19 Pandemic.

ABSTRACT: The COVID-19 pandemic has resulted in increased concern regarding the mental health of individuals navigating this public health crisis. Various risk factors for suicide have increased during the pandemic, including isolation, depression, access to firearms, substance use, and loss of employment. However, the relationship between the COVID-19 pandemic and suicide rates in the United States remains unclear. In this retrospective study, we examined the relationship between suicide rates and COVID-19 cases in 11 West Michigan counties. Suicide rates in the prepandemic (January 2018 to February 2020) and pandemic (March 2020 to February 2022) months were compared after adjusting for seasonal and population size effects. A mixed effects model was used to assess the impacts of local COVID-19 rates and county on the ratio of pandemic to prepandemic monthly suicide rates. The model did not find a significant effect of COVID-19 case rates on suicide rates. Although this study does not find sufficient evidence for a statistical relationship between COVID-19 cases and suicide rates in West Michigan, close surveillance should continue and public health measures should be used because of the increased risk factors for suicide associated with the pandemic.

Fatal Complication of Mouthguard Used to Treat Awake Bruxism in Patient with Frontotemporal Dementia.

Awake bruxism is an understudied manifestation of frontotemporal dementia, yet awake bruxism can have fatal consequences in the aging population. This report presents a patient suffering from awake bruxism associated with frontotemporal dementia being treated with a mouthguard, which ultimately becomes lodged in her posterior oropharynx leading to asphyxiation. The case highlights the need for investigation into the occurrence and treatment of awake bruxism among patients with dementia, and the unique risk-benefit analysis that must be performed to develop proper treatment plans for patients with dementia.

Cutaneous skin defects overlying tangential gunshot wounds: A case series.

In examining deaths resulting from gunshot wounds, it is important to describe the wound pathway created by the projectile. Forensic pathologists must identify all entrance and exit wounds and account for all projectiles. Occasionally, confusion arises as to whether a skin defect represents an entrance wound or not, an exit wound, or some other type of wound. Herein, we propose the descriptor "bullet track skin defect" as a formal description for a superficial skin defect created along the pathway of a projectile within the body. Specifically, we define the "bullet track skin defect" as a partial- or full-thickness skin defect produced by a projectile traveling beneath the skin in a relatively tangential fashion as part of a wound pathway within the body. It is somewhat analogous to a traditional graze or superficial tangential wound, wherein the projectile traveling outside the body strikes the skin tangentially from above, without entering the body. However, the projectile is already traveling within the body with the bullet track skin defect, disrupting the skin tangentially from below rather than from above, without exiting the body. Although these defects are not a common presentation of gunshot wounds, they are certainly not rare. With this case series, we suggest that such defects may be referred to as "bullet track skin defects." Alternative language that can substitute for "bullet track skin defects" includes "bullet track skin wounds" or "bullet track cutaneous defects."

Lethal Complications of Meningiomas: A Case Series.

Background: Meningiomas are the most prevalent type of primary intracranial tumor in adults, comprising nearly one-third of all intracranial tumors. They are typically benign, slow-growing, and asymptomatic but may cause neurological symptoms as they expand due to mass effect. Classification is determined by World Health Organization (WHO) grades 1 to 3 following pathological examination corresponding to benign, atypical, and anaplastic (malignant), respectively, reflecting their rate of growth and risk of recurrence. The vast majority are WHO grade 1 and their slow growth permits timely presentation for elective resection; however, meningiomas in vulnerable locations and coexisting morbidities can result in sudden death. Objectives: We present a series of four adult patients with meningiomas which resulted in death, including a case of fatal seizure, midline hemorrhagic meningioma, postresection meningitis, and compression of the cerebellum. Research design: Retrospective review of the authors' cases was conducted. Available pathology, medical, and autopsy records including gross images were reviewed in each case. The inclusion criteria were adult patients (>18 years old) and that the cause of death had to include meningioma. Subjects: The four patients included a 61-year-old male, an 84-year-old female, a 62-year-old male, and a 37-year-old female. Measures: Qualitative; autopsy reports describing cause of death and pathology report findings including gross and microscopic analysis. Conclusions: Meningiomas are often benign in nature but can rarely result in death. Size and location of the tumor and risk factors are contributory. Autopsy examination can be instrumental in identifying the cause and mechanism of deaths associated with meningiomas.

SARS-CoV-2 (COVID-19) Experience at an Academic Medical Examiner's Office.

Introduction: The coronavirus disease of 2019 (COVID-19) pandemic has resulted in a great deal of morbidity and mortality worldwide. Since most deaths related to COVID-19 are currently considered natural, and they tend to occur following a clinically recognized illness, many medical examiner/coroner offices within the United States do not take jurisdiction over the majority of COVID-19 deaths. Methods: In this review, we present the experience of a medium-sized medical examiner's office affiliated with an academic medical school institution, over the first 15 months of the COVID-19 pandemic. Results: Compared to a 15-month period that immediately preceded the pandemic, our office experienced a significant increase in the total number of reported deaths, scene investigations, full autopsies, natural deaths, accidents, homicides, and drug-related deaths, but a decrease in the number of suicides. Overall, our office performed 5 autopsies during the study period where COVID-19 was considered the primary cause of death, 4 cases where COVID-19 was considered a contributory cause of death, and 28 cases where COVID-19 testing was positive, but COVID-19 was not contributory to death. Discussion: The COVID-19 pandemic was accompanied by a sizeable increase in work volume within our academic medical examiner's office. Although this increased workload was not related to a large number of COVID-19-related deaths investigated by the office, there were numerous areas of increased workload that were likely secondarily related to the conditions associated with the pandemic.

Inhibition of the Sur1-Trpm4 channel reduces neuroinflammation and cognitive impairment in subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Subarachnoid hemorrhage (SAH) can leave patients with memory impairments that may not recover fully. Molecular mechanisms are poorly understood, and no treatment is available. The sulfonylurea receptor 1-transient receptor potential melastatin 4 (Sur1-Trpm4) channel plays an important role in acute central nervous system injury. We evaluated upregulation of Sur1-Trpm4 in humans with SAH and, in rat models of SAH, we examined Sur1-Trpm4 upregulation, its role in barrier dysfunction and neuroinflammation, and its consequences on spatial learning. METHODS: We used Förster resonance energy transfer to detect coassociated Sur1 and Trpm4 in human autopsy brains with SAH. We studied rat models of SAH involving filament puncture of the internal carotid artery or injection of blood into the subarachnoid space of the entorhinal cortex. In rats, we used Förster resonance energy transfer and coimmunoprecipitation to detect coassociated Sur1 and Trpm4, we measured immunoglobulin G extravasation and tumor necrosis α overexpression as measures of barrier dysfunction and neuroinflammation, and we assessed spatial learning and memory on days 7 to 19. RESULTS: Sur1-Trpm4 channels were upregulated in humans and rats with SAH. In rats, inhibiting Sur1 using antisense or the selective Sur1 inhibitor glibenclamide reduced SAH-induced immunoglobulin G extravasation and tumor necrosis α overexpression. In models with entorhinal SAH, rats treated with glibenclamide for 7 days after SAH exhibited better platform search strategies and better performance on incremental and rapid spatial learning than vehicle-treated controls. CONCLUSIONS: Sur1-Trpm4 channels are upregulated in humans and rats with SAH. Channel inhibition with glibenclamide may reduce neuroinflammation and the severity of cognitive deficits after SAH.

Chronic traumatic encephalopathy neuropathologic change is uncommon in men who played amateur American football.

Introduction: We examined postmortem brain tissue from men, over the age of 50, for chronic traumatic encephalopathy neuropathologic change (CTE-NC). We hypothesized that (i) a small percentage would have CTE-NC, (ii) those who played American football during their youth would be more likely to have CTE-NC than those who did not play contact or collision sports, and (iii) there would be no association between CTE-NC and suicide as a manner of death. Methods: Brain tissue from 186 men and accompanying clinical information were obtained from the Lieber Institute for Brain Development. Manner of death was determined by a board-certified forensic pathologist. Information was obtained from next of kin telephone interviews, including medical, social, demographic, family, and psychiatric history. The 2016 and 2021 consensus definitions were used for CTE-NC. Two authors screened all cases, using liberal criteria for identifying "possible" CTE-NC, and five authors examined the 15 selected cases. Results: The median age at the time of death was 65 years (interquartile range = 57-75; range = 50-96). There were 25.8% with a history of playing American football and 36.0% who had suicide as their manner of death. No case was rated as definitively having "features" of CTE-NC by all five authors. Ten cases were rated as having features of CTE-NC by three or more authors (5.4% of the sample), including 8.3% of those with a personal history of playing American football and 3.9% of those who did not play contact or collision sports. Of those with mood disorders during life, 5.5% had features of CTE-NC compared to 6.0% of those who did not have a reported mood disorder. Of those with suicide as a manner of death, 6.0% had features of CTE-NC compared to 5.0% of those who did not have suicide as a manner of death. Discussion: We did not identify a single definitive case of CTE-NC, from the perspective of all raters, and only 5.4% of cases were identified as having possible features of CTE-NC by some raters. CTE-NC was very uncommon in men who played amateur American football, those with mood disorders during life, and those with suicide as a manner of death.

A comparison of three decalcification agents for assessments of cranial fracture histomorphology.

The extraction of mineral calcium from bone by decalcification is a critical step in the preparation of histological samples for light microscopy. This study assessed the time required for complete decalcification and the resultant histomorphological preservation of bone histomorphology by three decalcification agents: 7% hydrochloric acid (HCl), 5% nitric acid, and 10% ethylenediaminetetraacetic acid (EDTA). The goal of this study was to identify which decalcification agent provides the optimal combination of expedient processing and quality histological outcomes of cranial fracture samples. HCl provided the most rapid decalcification ( X ¯  = 3.57 days), nitric acid followed closely ( X ¯  = 10.35 days), while EDTA took significantly longer on average ( X ¯  = 78.97 days) but encompassed a broader range of times. Decalcification agent, sample thickness, sample width, and decedent age are significant predictors of decalcification time. Sample visualization quality, measured for tissues, cells, and nuclei on a five-point Likert scale, was highest for samples decalcified in 10% EDTA, second highest using 5% nitric acid, and lowest for 7% HCl. The quality difference between EDTA and nitric acid was not highly significant for any of the three features. For basic assessments of bone histomorphology, the study results indicate 5% nitric acid is suitable for the decalcification of adult specimens and samples thicker than 3 mm. EDTA is a suitable agent for thin samples of the cranial vault (<3 mm) from infants and young children less than three years old, decalcifying samples in a timeframe comparable to nitric acid while providing the best quality and clarity of samples.

Suicide in Older Adult Men Is Not Related to a Personal History of Participation in Football.

Introduction: It is reasonable to estimate that tens of millions of men in the United States played high school football. There is societal concern that participation in football confers risk for later-in-life mental health problems. The purpose of this study is to examine whether there is an association between a personal history of playing high school football and death by suicide. Methods: The subjects were obtained from the Lieber Institute for Brain Development (LIBD) brain donation program in collaboration with the Office of the Medical Examiner at Western Michigan University Homer Stryker MD School of Medicine. Donor history was documented via medical records, mental health records, and telephone interviews with the next-of-kin. Results: The sample included 198 men aged 50 or older (median = 65.0 years, interquartile range = 57-75). There were 34.8% who participated in contact sports during high school (including football), and 29.8% participated in high school football. Approximately one-third of the sample had suicide as their manner of death (34.8%). There was no statistically significant difference in the proportions of suicide as a manner of death among those men with a personal history of playing football compared to men who did not play football or who did not play sports (p = 0.070, Odds Ratio, OR = 0.537). Those who played football were significantly less likely to have a lifetime history of a suicide attempt (p = 0.012, OR = 0.352). Men with mood disorders (p < 0.001, OR = 10.712), substance use disorders (p < 0.020, OR = 2.075), and those with a history of suicide ideation (p < 0.001, OR = 8.038) or attempts (p < 0.001, OR = 40.634) were more likely to have suicide as a manner of death. Moreover, those men with a family history of suicide were more likely to have prior suicide attempts (p = 0.031, OR = 2.153) and to have completed suicide (p = 0.001, OR = 2.927). Discussion: Suicide was related to well-established risk factors such as a personal history of a mood disorder, substance abuse disorder, prior suicide ideation, suicide attempts, and a family history of suicide attempts. This study adds to a steadily growing body of evidence suggesting that playing high school football is not associated with increased risk for suicidality or suicide during adulthood.

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.

The Medical Examiner/Coroner's Guide for Contaminated Deceased Body Management.

In the past few years, a number of publications and other resources have appeared concerning the management of mass fatality incidents. Some are geared toward the general management of incidents while others cover more specific topics such as decontamination procedures. Still others cover selected agents, including chemical, biologic, or radiologic ones. Few publications have been written specifically for medical examiners and coroners. The Medical Examiner and Coroner's Guide for Contaminated Deceased Body Management is written specifically for the medical examiner or coroner who will be in charge of investigations of fatalities that result from terrorism or other events that result in contaminated remains. In some such cases, agents may be used that will require mitigation of environmental hazards and decontamination of human bodies. To that end, this Guide provides information and suggestions that may be useful in understanding the principles involved in decontamination procedures, recognizing that it may not be the medical examiner or coroner staff who actually conducts decontamination procedures. The suggestions in this guide may differ slightly from those in other publications. However, those who have contributed to this guide believe that the recommendations are practical, workable, have a scientific basis, and do not differ much in substance when compared with other relevant publications. The contents of this Guide may be reproduced for practical use but the Guide may not be sold and it may not be cited for advertisement purposes. Reference to specific commercial products is for informational purposes only and does not constitute endorsement of the product or company which produces the product. The recommendations contained in this Guide are not mandated nor are they required by federal, state, or local law. Rather, the recommendations are intended to assist medical examiners and coroners for the purposes of planning and providing a set of reasonable practice guidelines for incident response.

Sudden unexpected death in lymphocytic hypophysitis.

Lymphocytic hypophysitis is an unusual inflammatory condition of the pituitary gland, classically seen in females during the peripartum periods. The clinical presentation is varied and depends on hormonal deficiencies and pathophysiological effects on the target organs. Although involvement of the neurohypophysis and secondary diabetes insipidus are rare, progression to multiple organ endocrinopathies is common. Pathologically, the condition is characterized by lymphocytic infiltration of the hypophysis with occasional involvement of the thyroid and adrenal glands. Here, we present the case of a 23-year-old woman diagnosed at autopsy with lymphocytic hypophysitis, with concomitant infiltrates in the thyroid gland and adrenal medulla, who died suddenly and unexpectedly with no other apparent cause of death. This case stresses the importance of greater awareness of the entity, and prompt treatment. Moreover, although the precise mechanism of death is unclear, this case raises the possibility of endocrine dysfunction as a contributing factor to sudden death and emphasizes the need to routinely sample the pituitary gland in young women with sudden unexpected death and no apparent cause.

Can Neck Contusions in Unexplained Pediatric Deaths be Explained by Cardiopulmonary Resuscitation?

The distribution of cutaneous contusions in infants may raise the possibility of maltreatment. Neck contusions are particularly problematic since they seldom occur outside the setting of abuse, while cardiopulmonary resuscitation (CPR)-related maneuvers may involve the neck. To address the role of CPR in neck findings, we examined 260 consecutive pediatric autopsies in which CPR was attempted. No neck contusions were identified in manners of death classified as natural, undetermined, or suicide. Contusions were present in two of 80 deaths classified as accident and had obvious accidental causes. About 26% of deaths classified as homicide had neck contusions with no explanation provided by the caregiver (p < 0.0001). In conclusion, neck contusions in deceased children with no apparent explanation should be regarded as suspicious for abuse and investigated accordingly. CPR is not a plausible explanation for neck contusions in children.

Neuropathology in Consecutive Forensic Consultation Cases with a History of Remote Traumatic Brain Injury.

Traumatic brain injury (TBI) is widely assumed to be causal in neurodegenerative disease, based on epidemiological surveys demonstrating an increased risk of Alzheimer disease (AD) following TBI, and on recent theories surrounding repetitive head movement. We tested this assumption by evaluating 30 consecutive forensic examinations in which neuropathology consultation was sought, and in which a history of remote TBI was uncovered during the course of the investigation. In this series, there was a high frequency of psychiatric co-morbidities (100%), remote contusion (90%), and seizures (63%). Extent of proteinopathy showed no differences with age-matched controls. A subset of the cases showed focal geographic tauopathy that correlated with older age at autopsy, but had no correlation with clinical signs, and was minimal in comparison with the encephalomalacia secondary to trauma. The results suggest that cerebral contusion and post-traumatic epilepsy may be over-represented in civilian TBI, while structural brain damage from trauma is the predominant cause of morbidity following TBI. We found no evidence that TBI initiates a progressive proteinopathy.

Two Novel Methods for Enhancing Postmortem Fingerprint Recovery from Mummified Remains.

Postmortem fingerprint collection is a routine part of many forensic death investigations. Although the production of postmortem prints is usually straight forward, several obstacles and scenarios can make the collection difficult. A common challenge occurs when finger pads are mummified. Several current techniques allow for softening and rehydration of mummified finger pads; however, despite the employment of such techniques, the production of adequate postmortem fingerprints can remain elusive. The authors present two techniques that can improve the chances of obtaining suitable fingerprints from mummified remains. The "baby powder method" involves applying a cornstarch-based powder, such as baby powder, onto the darkened and mummified finger pads, to allow better visualization of the fingerprint detail. The "transillumination method" involves carefully dissecting away the tissues underlying the finger pad, followed by placement of a bright light source underneath the finger pad, such that the finger ridge pattern is illuminated.

A Unique Type of Birth Trauma Mistaken for Abuse.

Pediatric abusive head trauma is a challenging subject across many disciplines. Of particular importance is the identification of mimics of abuse, so cause and manner of death can be properly assigned. We present the case of suspected child abuse involving an infant who presented unresponsive to the hospital with hypoglycemia, hypothermia, and bilateral parietal fractures. An autopsy revealed fractures associated with organizing scalp hemorrhage and gross leptomeningeal congestion and hemorrhage. The fractures were circular with external displacement, rounded margins, and subperiosteal new bone formation indicative of healing. Birth records revealed vacuum assist and cesarean section delivery. Although vacuum extraction-related injuries are typically cephalohematomas and/or linear fractures, the outbending and circular morphology of the fractures are consistent with vacuum extraction. Moreover, microscopic neuropathological examination revealed hemorrhagic purulent leptomeningitis. This unique case demonstrates the importance of considering birth trauma in the determination of cause and manner of death of an infant.