Office Of The Chief Medical Examiner Research Articles

Discovery Context of Skeletal Remains Received at the Federal Bureau of Investigation Laboratory

Cases received for anthropological examination by the Federal Bureau of Investigation (FBI) Laboratory for a 4-year period (2013–2017) were reviewed for the context of the discovery of remains. The assessment was compared with a previous similar review of cases received by the Massachusetts Office of the Chief Medical Examiner (OCME), with particular attention to whether remains were initially discovered through deliberate law enforcement searches or inadvertently discovered by others. Results show that 52.9% of FBI Laboratory anthropology cases were initially discovered by law enforcement, compared to only 3.6% of Massachusetts OCME cases. Reasons for this difference are discussed, as well as other similarities and differences in discovery mode and context for anthropology cases between these two laboratories.

Determining Youth Intentional Fatal Drug Intoxication: The Case for a Psychological Autopsy to Complement the Medical Examiner’s Report

Background Opioids and cocaine are the leading drugs for fatal drug intoxication (FDI). Manner of death may be accidental (i.e., unintentional); suicide (i.e., intentional), or undetermined. Difficulties of the medical examiner (ME) in confirming the manner of death by a standard investigation may result in underreporting of intentional FDI thus limiting efforts to identify, reduce, and prevent it. Objective Examine the rate of youth intentional and undetermined FDI and address the need for closing the gap in the determination of intentional FDI among youths by the addition of a psychological autopsy. Method Two hundred ninety-three (293) consecutive FDI case files from the State of Connecticut Office of the Chief Medical Examiner were reviewed. The case files were those of youths, 10 to 25 years of age, who died between January 1, 2016, and December 31, 2018. Results The annual intentional FDI rates among this group were between 3% and 5%. Undetermined manner of death rates were between 0% and 5% percent, while the remaining cases was reported as accidental. A majority of the FDI cases involved youths 20 to 25.11 years old, while a small percentage were among those ages 15 to 19.11 and none for 10 to 14.11. Male-to-female ratio was approximately 2:1 in all categories of FDI. Conclusion These low rates of intentional FDI among youths support the arguments regarding limitations in the procedures employed by a ME to determine intent. There is a need for an individual-level study of a multipronged approach to identify modifiable acute high-risk circumstances for intentional FDI, including a psychological autopsy.

Trends in opioid use disorder and overdose among opioid‐naive individuals receiving an opioid prescription in Massachusetts from 2011 to 2014

To examine how the risks of incident opioid use disorder (OUD), non-fatal and fatal overdose have changed over time among opioid-naive individuals receiving an initial opioid prescription. Retrospective, longitudinal study using the Massachusetts Chapter 55 data set, which linked multiple administrative data sets to study the opioid epidemic. We identified the cumulative incidence of OUD, non-fatal and fatal overdose among the opioid-naive initiating opioid treatment in Massachusetts from 2011 to 2014 and estimated rates of these outcomes at 6months and at 1, 2, 3 and 4years to 2015. We used Cox regression to examine the association between characteristics of the initial prescription and risk of these outcomes. Massachusetts, USA. Massachusetts residents aged ≥11years in 2011-15 who were opioid-naive (no opioid prescriptions or evidence of OUD in the 6months prior to the index prescription) (n=2 154 426). The mean age was 49.1years, 55.3% were female and 47.3% had commercial insurance. Opioid prescriptions were identified in the Prescription Monitoring Program (PMP) database, as were the characteristics of the initial prescription database. The outcomes of OUD and non-fatal overdose were identified from claims in the All Payer Claims Database (APCD) and hospital encounters in the acute hospital case mix files. Fatal overdoses were identified using Registry of Vital Records and Statistics (RVRS) death certificates and the Office of the Chief Medical Examiner (OCME) circumstances of death and toxicology reports. Among opioid-naive individuals receiving an initial opioid prescription, the risk of incident OUD appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. For example, the 1-year OUD rate was 1.18% in 2011, 1.11% in 2012, 1.26% in 2013 and 0.94% in 2014. Longer therapy duration was associated with higher risk of OUD [hazard ratio (HR)=2.24, 95% confidence interval (CI)=2.19-2.29 for duration of 3 or more months], non-fatal (HR=1.67, 95% CI=1.53-1.82) and fatal opioid overdose (HR=2.24, 95% CI=1.91-2.61). Concurrent benzodiazepine treatment was also associated with higher risk of OUD (HR=1.14, 95% CI =1.12-1.17), non-fatal (HR=1.20, 95% CI=1.10-1.30) and fatal overdose (HR=1.86, 95% CI =1.61-2.16). Among opioid-naive individuals in Massachusetts receiving an initial opioid prescription, the risk of incident opioid use disorder appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. Longer therapy duration and concurrent benzodiazepines were associated with higher rates of opioid use disorder and opioid overdose.

Predicting Opioid Overdose Deaths Using Prescription Drug Monitoring Program Data

Prescription Drug Monitoring Program data can provide insights into a patient's likelihood of an opioid overdose, yet clinicians and public health officials lack indicators to identify individuals at highest risk accurately. A predictive model was developed and validated using Prescription Drug Monitoring Program prescription histories to identify those at risk for fatal overdose because of any opioid or illicit opioids. From December 2018 to July 2019, a retrospective cohort analysis was performed on Maryland residents aged 18-80 years with a filled opioid prescription (n=565,175) from January to June 2016. Fatal opioid overdoses were identified from the Office of the Chief Medical Examiner and were linked at the person-level with Prescription Drug Monitoring Program data. Split-half technique was used to develop and validate a multivariate logistic regression with a 6-month lookback period and assessed model calibration and discrimination. Predictors of any opioid-related fatal overdose included male sex, age 65-80 years, Medicaid, Medicare, 1 or more long-acting opioid fills, 1 or more buprenorphine fills, 2 to 3 and 4 or more short-acting schedule II opioid fills, opioid days' supply ≥91 days, average morphine milligram equivalent daily dose, 2 or more benzodiazepine fills, and 1 or more muscle relaxant fills. Model discrimination for the validation cohort was good (area under the curve: any, 0.81; illicit, 0.77). A model for predicting fatal opioid overdoses was developed using Prescription Drug Monitoring Program data. Given the recent national epidemic of deaths involving heroin and fentanyl, it is noteworthy that the model performed equally well in identifying those at risk for overdose deaths from both illicit and prescription opioids.

Causes of Sudden Unexpected Death in Schizophrenia Patients: A Forensic Autopsy Population Study.

Schizophrenia is a detrimental psychiatric disorder, with an increased mortality from natural and nonnatural causes. This study was a retrospective review of autopsy cases of all the individuals with history of schizophrenia investigated by the Office of the Chief Medical Examiner, State of Maryland, for a 5-year period from 2008 to 2012. A total of 391 schizophrenia patients were autopsied at the Office of the Chief Medical Examiner because they died suddenly and unexpectedly. Their age ranged from 15 to 100 years with the mean age of 49.5 years. Of the 391 deaths, 191 (48.8%) were white, 185 (47.3%) were African American, and 15 (3.9%) were either Hispanic or Asian. The male and female ratio was 1.5:1. The majority of deaths (64.2%) were caused by natural diseases, 12.0% deaths were accidents, 11.5% deaths were suicides, and 9.7% deaths were homicides. The manner of death remained undetermined in 38 cases (9.7%). Of the 251 natural deaths, 198 cases (78.9%) were owing to cardiovascular diseases. Cause of death was listed as cardiac arrhythmia in 11 cases. This diagnosis of cardiac arrhythmia was made by exclusion based on death scene investigation, review of medical history, complete autopsy, and toxicological tests. Drug intoxication was the second most common cause of death. The study shows high fatality caused by cardiovascular diseases and drug intoxication among schizophrenia patients, which calls attention of the medical community to closely monitor the high risk factors of sudden death among schizophrenia patients.

Accidental drug overdose deaths in Connecticut, 2012–2018: The rise of polysubstance detection?

ObjectivesTo examine trends in polysubstance detection associated with drug-related overdose deaths in Connecticut. MethodsWe used 2012–2018 data provided by Connecticut’s Office of the Chief Medical Examiner (OCME) on accidental overdose deaths. We estimated annual trends, standardizing the number of deaths per 100,000 Connecticut residents each year. We then conducted stratified analyses by polysubstance use status. We also examined the numbers of deaths involving fentanyl in a separate analysis. We obtained data in April 2019, and statistical analyses were performed from April to September 2019. ResultsThe rate of overdose deaths in Connecticut increased from 9.9 per 100,000 residents in 2012 to 28.5 per 100,000 residents in 2018—a 221 % increase—with the majority occurring among persons aged 35–64 (65.3 %), men (73.9 %), and non-Hispanic whites (78.5 %). Among deaths involving fentanyl, the overall deaths escalated from 5.2 deaths per 100,000 residents in 2015 to 21.3 deaths per 100,000 residents in 2018, and more than 50% of these fentanyl-related deaths involved polysubstance use. ConclusionsConnecticut experienced a more-than doubling of opioid-involved overdose deaths, largely driven by fentanyl and polysubstance use. The role of polysubstance use should be considered in efforts toward reducing opioid-related overdose incidents.

Distribution of synthetic opioids in postmortem blood, vitreous humor and brain

In the US, the use of synthetic opioids (e.g. fentanyl and derivatives) has become an increasing health issue with thousands of overdose deaths being observed since 2013. With the high mortality rate associated with these substances, postmortem analyses and interpretation of synthetic opioids has become extremely important. However, due to the novelty of these compounds, the available data are limited and provides challenges to toxicologists. The objectives of this study were (1) to develop and validate analytical methods for the determination of synthetic opioids in vitreous humor and brain, and (2) to investigate the postmortem distribution of new synthetic opioids in blood, vitreous humor, and brain tissue. Vitreous humor (0.5mL) and brain tissue (5g) homogenized in water (diluted 1:3, w/w) were extracted by mixed mode cation exchange-reversed phase solid phase extraction. Extracts were analyzed by liquid chromatography tandem mass spectrometry (LC–MSMS). The chromatographic separation was performed by reversed-phase with 0.1% formic acid in water and in acetonitrile as mobile phases in gradient mode, with a total run time of 21min. Data were acquired with ESI+ in dynamic multiple reaction mode (dMRM), monitoring 2 transitions per compound. The methods were succesfully validated following SWGTOX guidelines, with limits of quantification of 0.1ng/mL in vitreous humor and 0.1ng/g in brain. Fifty-eight authentic case samples from the New York City Office of the Chief Medical Examiner (NYC-OCME) were analyzed to assess the distribution and detectability of synthetic opioids in these postmortem samples. Of the fifteen synthetic opioids included in the method, six synthetic opioids and metabolites (4-ANPP, acetylfentanyl, fentanyl, furanylfentanyl, norfentanyl, U-47700) were detected in the authentic cases. Concentrations for most analytes were within the 0.1 to 100ng/mL or ng/g calibration range across all three matrices, with only concentrations from acetylfentanyl and U-47700 exceeding 100ng/mL or ng/g. The highest concentrations were observed in brain (except norfentanyl), followed by blood and vitreous humor. Most analytes were detected in all three matrices in a given case. This was followed by detection of an analyte in combinations of brain and another matrix or brain only. Through the case analyses, vitreous humor and brain demonstrated to be viable alternatives to blood when performing postmortem analyses of synthetic opioids. Brain exhibited a higher detectability for most analytes when compared to blood and vitreous humor.

Effects of Bariatric Surgery Observed in Postmortem Toxicology Casework.

Bariatric surgery has been on the rise and patients often have multiple indications for pre- and post-operative pharmacotherapy. Procedures target the stomach and/or small intestine and affect weight loss through restriction, malabsorption, or a combination of the two. The absorption and/or metabolism of drugs via the gastrointestinal tract could be altered by different mechanisms. Several cases at the North Carolina Office of the Chief Medical Examiner's Toxicology Laboratory (NCOCME) have raised questions about the potential impact of these procedures on the disposition of drugs in the body and how that altered disposition may affect cause and manner of death. Overmedication and postmortem redistribution are not enough to explain the phenomena seen in some NCOCME bariatric surgery-related casework. Case examples include a 46-year-old female with a history of Roux-en-Y gastric bypass (RYGB) who suffered a witnessed collapse. Toxicological findings included elevated concentrations of oxymorphone at 0.49mg/L in vena cava blood. A 67-year-old female, who died from vomiting and bacterial gastritis one day after placement of two intragastric weight-loss balloons, had elevated concentrations of duloxetine at 1.4mg/L in the iliac vein blood and 9.3mg/kg in the liver. Her medication was strictly controlled by her sister and gastric contents were without intact tablets or residue at autopsy.

Unintentional drug overdose deaths involving cocaine among middle-aged and older adults in New York City

BackgroundCocaine is commonly involved in unintentional drug poisoning (overdose) deaths, accounting for 46% of overdose deaths in New York City (NYC) in 2016. However, little research exists regarding cocaine use by middle-aged and older adults, who are more likely than younger individuals to have underlying cardiovascular disease (CVD) and therefore, may be at increased risk for the adverse health consequences of cocaine. MethodsWe conducted a retrospective analysis of unintentional drug overdose deaths of middle-aged and older NYC residents age 45–84 from 2000 to 2016 using two linked sources, NYC death certificates and toxicology results from the Office of the Chief Medical Examiner. ResultsFrom 2000 to 2016, there were 6061 unintentional drug overdose deaths among New Yorkers age 45–84. Of those, cocaine was involved in 53% (n = 3183). Co-occurring opioid involvement (fentanyl, heroin, methadone, or opioid analgesics) among deaths involving cocaine was common (58%). Compared to decedents of non-cocaine involved overdose, decedents of cocaine-involved overdose were more likely to be male and non-Latino Black. Multivariable analysis showed that adults age 45–54 (adjusted odds ratio [AOR] = 1.34, 95% 1.05, 1.70), males (AOR = 1.30, 95% CI 1.15, 1.46), Bronx residence (AOR = 1.29, 95% CI 1.08, 1.54), and non-Latino black race/ethnicity (AOR = 2.37, 95% CI 2.07, 2.72) were independently associated with cocaine-involved overdose. ConclusionCharacteristics of decedents of cocaine-involved overdose overlap with populations with high CVD burden in NYC. Studies are needed to better understand the risks of cocaine among adults with underlying CVD.

Cold Case Homicides: DNA Testing of Retained Autopsy Sexual Assault Smears.

Archival medical examiner specimens may contain perpetrator DNA evidence useful in unsolved ("cold case") homicides. The Office of the Chief Medical Examiner (OCME) histology slide archives were searched for sexual assault smears for all 376 female homicides from 1990 to 1999. Of these, the OCME had sexual assault smears on 84 of which 13 slides had sperm. Of these 13, six were still unsolved. DNA profiles were obtained on all six (5 from smears and one from swabs). Combined DNA Index System ( submission resulted in two matches ("hits") for new suspects. In addition, three suspects were eliminated in two cases. Our review of archival sexual assault smears resulted in DNA profiles that were able to assist in the investigation of four cold case homicide investigations. It may be worthwhile for medical examiner offices to search their archival histology slides for sexual assault smears on previously unsolved cases particularly those prior to the mid-1990s when DNA testing was less widely available.

Geographic variation and trends in opioid-involved crash deaths in Maryland: 2006–2017

The objective of this study was to describe trends in the prevalence of opioids in driver fatalities and examine geographic variation in opioid-involved crashes at a county level. Using comprehensive toxicological data from the Office of the Chief Medical Examiner in Maryland, we examined the prevalence of opioids in all motor vehicle crash fatalities in Maryland between 2006–2017 and tested for trends to assess the statistical significance of changes in the prevalence of prescription opioids detected in these drivers over time. Opioid-involved crash deaths accounted for 10.0% of all driver deaths during the study period. The prevalence of opioids detected in fatally injured drivers increased from 8.3% in 2006 to 14.1% in 2017, (Z = −1.9, p < .05). The trends in opioid deaths do not follow broader trends in motor vehicle crash deaths; opioid-involved crashes appear to be increasing while overall motor vehicle crashes appear to be decreasing over the same period. To determine if the increase in opioid-involved crash deaths was the result of changes in pain management related to injuries sustained from the crash, we analyzed a subgroup of cases where death occurred at the scene of the crash. Within this group, there was no statistically significant increase in opioid-involved crashes during the study period. Opioid prevalence was higher in middle aged, and white drivers, and in crashes occurring in rural counties. Geographic distribution of opioid-involved crash deaths reflect broader patterns of opioid deaths overdose across the state. Irrespective of the timing of the deaths, of the drivers testing positive for opioids, 28% had elevated blood alcohol concentrations (‡ 0.01 g/dL), and 45% tested positive for other drugs.

Overdose Deaths Involving Fentanyl and Fentanyl Analogs — New York City, 2000–2017

Unintentional drug overdose deaths have climbed to record high levels, claiming approximately 70,000 lives in the United States in 2017 alone (1). The emergence of illicitly manufactured fentanyl* (a synthetic, short-acting opioid with 50-100 times the potency of morphine) mixed into heroin, cocaine, and counterfeit pills, with or without the users' knowledge, has increased the risk for fatal overdose (2,3). The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) conducts routine overdose mortality surveillance by linking death certificates with toxicology findings from the NYC Office of the Chief Medical Examiner (OCME). A 55% increase in the rate of fatal drug overdose in NYC was observed from 2015 to 2017, resulting in the highest number of overdose deaths recorded since systematic reporting began in 2000. Toxicology data indicate that this unprecedented increase in overdose deaths is attributable to fentanyl. Early identification of increased fentanyl involvement enabled DOHMH to respond rapidly to the opioid overdose epidemic by increasing awareness of the risks associated with fentanyl and developing effective risk reduction messaging. These results strongly suggest that, wherever possible, jurisdictions should consider integrating toxicology findings into routine overdose surveillance and work with local medical examiners or coroners to include fentanyl in the literal text on death certificates.

Degradation of Bupropion: Implications for Interpretation of Postmortem Case Data.

The interpretation of postmortem bupropion is often a challenge to the forensic toxicology community because of the instability of the parent compound. At the North Carolina Office of the Chief Medical Examiner (NC OCME) toxicology laboratory, one of the active metabolites, threobupropion, is used as a complementary indicator for the extent of exposure to the parent compound. Metabolite data will address postmortem normal concentrations as well as when bupropion was attributed to the cause of death. For 55 natural cases where bupropion was unattributed to the cause of death, the blood and liver mean threobupropion concentrations were 1.8 mg/L and 12.1 mg/kg, respectively, with median concentrations of 1.5 mg/L and 10 mg/kg, respectively. For the 51 suicidal ingestion cases when bupropion was attributed to the cause of death, the blood and liver mean threobupropion concentrations were 15.8 mg/L and 131.5 mg/kg, respectively, with median concentrations of 13.5 mg/L and 110 mg/kg, respectively. The laboratory completed a stability study over the course of 50 days to evaluate how bupropion and threobupropion degrade in postmortem blood, liver and liver homogenate. The samples were subjected to forensically relevant conditions by storing them at room temperature (RT, 20°C), refrigerated (4°C) and frozen (-20°C). While the concentration of bupropion decreased in all specimens, the rate of degradation of the RT samples was the most dramatic. The threobupropion metabolite appeared to be relatively stable. The postmortem case data along with the evaluation of potential degradation products should provide an overall picture to assist the toxicological community with the interpretation of bupropion found in routine casework.

ALCOHOL CONTRIBUTION TO MORTALITY FROM EXTERNAL REASONS

The aim of the study is to compare the visibility and, possibly, the objectivity of various mathematical techniques to identify the connection between mortality and certain external causes with the previous alcohol consumption. Methods. A frequency analysis was carried out on the basis of 4,768 acts of forensic, forensic histologic and forensic and chemical examination of dead bodies, residents of Cheboksary and Novocheboksarsk cities copied out in the Republican Office of the Chief Medical Examiner (Ministry of Health of Chuvashia) for the period 1997-2002 with confirmed posthumous presence or absence of alcohol in the blood. The dead bodies were classified by sex, age, ethanol concentration in the blood, forensic medical diagnoses (ciphers ICD10: T58, T68, T15-T19, T66-T78, S00-S09, I250, I200-I209, I241-I249, I252-I259, T00-T07, S00-S39). The data obtained were investigated by the methods of correlation analysis (Spirman), Kolmogorov-Smirnov with Lillieforce correction, xi-square (х2). Results. The alcohol intake immediately before the event increased the risk of death from hypothermia (the proportion of people died with alcohol in the blood 2.10 % - 74.07 %), by drowning (2.69 % - 73.08 %) and asphyxia of upper airway (2.57 % - 73.68 %), but did not affect death frequency from head trauma, sudden cardiac death, pedestrian accidents and murders. Of all the investigated death causes the maximum was in the range of posthumous alcohol content in the blood 1-3.9 %. The most effective method of connection detection between alcohol consumption and the risk of death from any causes was calculation of rank correlation between birth cohorts divided into two subgroups based on the principle of presence or absence of alcohol in the blood of postmortem. In addition, to determine the alcohol effect on mortality increase from any causes, it is necessary to compare the sex-disaggregated samples of individuals whose blood was found posthumously and those without alcohol in the blood. Conclusion. Standardization of methods of statistical analysis of alcohol consumption with any death cause is necessary.

Child Maltreatment Surveillance Improvement Opportunities: A Wake County, North Carolina Pilot Project.

BACKGROUND As child maltreatment often occurs in private, child welfare numbers underestimate its true prevalence. Child maltreatment surveillance systems have been used to ascertain more accurate counts of children who experience maltreatment. This manuscript describes the results from a pilot child maltreatment surveillance system in Wake County, North Carolina.METHODS We linked 2010 and 2011 data from 3 sources (Child Protective Services, Raleigh Police Department, and Office of the Chief Medical Examiner) to obtain rates of definite and possible child maltreatment. We separately analyzed emergency department visits from 2010 and 2011 to obtain counts of definite and possible child maltreatment. We then compared the results from the surveillance systems to those obtained from Child Protective Services (CPS) data alone.RESULTS In 2010 and 2011, rates of definite child maltreatment were 11.7 and 11.3 per 1,000 children, respectively, when using the linked data, compared to 10.0 and 9.5 per 1,000 children using CPS data alone. The rates of possible maltreatment were 25.3 and 23.8 per 1,000, respectively. In the 2010 and 2011 emergency department data, there were 68 visits and 84 visits, respectively, that met the case definition for maltreatment.LIMITATIONS While 4 data sources were analyzed, only 3 were linked in the current surveillance system. It is likely that we would have identified more cases of maltreatment had more sources been included.CONCLUSION While the surveillance system identified more children who met the case definition of maltreatment than CPS data alone, the rates of definite child maltreatment were not considerably higher than official reports. Rates of possible child maltreatment were much higher than both the definite case definition and child welfare records. Tracking both definite and possible case definitions and using a variety of data sources provides a more complete picture of child maltreatment in North Carolina.

Using medical examiner case narratives to improve opioid overdose surveillance

BackgroundCurrent opioid overdose mortality surveillance methods do not capture the complexity of the overdose epidemic. Most rely on death certificates, which may underestimate both opioid analgesic and heroin deaths. Categorizing deaths using other characteristics from the death record including route of drug administration may provide useful information to design and evaluate overdose prevention interventions. MethodsWe reviewed California Electronic Death Reporting System records and San Francisco Office of the Chief Medical Examiner (OCME) toxicology reports and investigative case narratives for all unintentional opioid overdose deaths in San Francisco County from 2006 to 2012. We chose this time period because it encompassed a period of evolution in local opioid use patterns and expansion of overdose prevention efforts. We created a classification system for heroin-related and injection-related opioid overdose deaths and compared demographic, death scene, and toxicology characteristics among these groups. ResultsWe identified 816 unintentional opioid overdose deaths. One hundred fifty-two (19%) were standard heroin deaths, as designated by the OCME or by the presence of 6–monoacetylmorphine. An “expanded” classification for heroin deaths incorporating information from toxicology reports and case narratives added 20 additional heroin deaths (13% increase), accounting for 21% of all opioid deaths. Two hundred five deaths (25%) were injection-related, 60% of which were attributed to heroin. A combined classification of expanded heroin and injection-related deaths accounted for 31% of opioid overdose deaths during this period. ConclusionsUsing additional sources of information to classify opioid overdose cases resulted in a modest increase in the count of heroin overdose deaths but identified a substantial number of non-heroin injection-related opioid analgesic deaths. Including the route of administration in the characterization of opioid overdose deaths can identify meaningful subgroups of opioid users to enhance surveillance efforts and inform targeted public health programming including overdose prevention programs.

Prescription drug fatalities among women in rural Virginia: A study of medical examiner cases

To evaluate female drug overdose deaths from the Office of the Chief Medical Examiner, Western Virginia (1997-2003) for demographics, medical history, toxicology results, and prescribed medications. Autopsy reports, death investigations, and hospital/physician notes were reviewed for 330 fatal drug poisonings among women. Data were evaluated with both qualitative and quantitative methods. Most decedents were Caucasian (95 percent), their average age was 42.8 years, and the predominant manner and cause of death was accidental and polydrug toxicity, respectively. Drugs were identified on toxicology or assigned as a cause of death in all 330 cases. The three most common drug classes detected on toxicology were opioids (n = 239; 72.4 percent), antidepressants (n = 201; 60.9 percent), and sedative/anxiolytic/muscle relaxant (SAMR) (n = 161; 48.8 percent) with all three drug classes detected in 89 (27 percent) cases. Illicit drugs identified included cocaine (n = 33; 10 percent) and heroin (n = 3; 0.9 percent). Prescriptions for opioids, SAMR, and antidepressants were found in decedent name in 48 percent, 67.1 percent, and 58 percent of cases, respectively, and 46.1 percent of cases were prescribed at least one medication from each of those three drug classes. Although many decedents held prescriptions, and often for multiple drugs, toxicological findings indicate the frequent presence of other therapeutic drugs in the absence of a prescription. Moreover, many of these cases held simultaneous prescriptions for which there are known drug interactions. It is likely that misuse, fatal medication errors, abuse, and addiction were factors in the increased numbers of these deaths. Interventions to prevent prescription overdose deaths must involve education of both physicians and patients.

Biological sex variation in bone mineral density in the cranium and femur

ObjectivesSex and age trends in bone mineral density (BMD) play an important role in the estimation of age-at-death (AAD) of unidentified human remains. Current methodologies lack the ability to precisely estimate age in older individuals. In this study, BMD of the cranium and femur measured by DXA were examined to establish their applicability for age estimation in older adults. BMD as measured by DXA, is most commonly used clinically for prediction of osteoporotic fracture risk. We hypothesized that weight-bearing and non-weight-bearing bones, the femur and cranium, respectively, would provide valuable insights for aging. MethodsThe sample consists of 32 sets of excised cranial fragments from the Regional Forensic Center, Johnson City, Tennessee and 41 associated crania and femora from the North Carolina Office of the Chief Medical Examiner. All crania and femora were scanned using a Hologic (R) DXA scanner and data were analyzed using Student t-tests, Loess regression, and ANOVA. ResultsStudent t-tests indicate a significant relationship between the sexes and cranial BMD and a significant relationship between age cohorts and femoral neck BMD. The Loess regression showed different aging patterns in the cranium for females and males older than 55. And the ANOVA showed changes in femoral neck after age 55. ConclusionsThese results indicate age and sex dependent changes in BMD especially for individuals over the age of 55, which offers improvement from current aging methods for older individuals. Further research using a larger sample size could improve the predictive capabilities of the model.

Deaths due to electrocution: An evaluation of death scene investigations and autopsy findings

The purpose of the study was to delineate the epidemiological characteristics of electrocution deaths in Maryland, identify any potential risks, and address preventive measures. A retrospective review of all the deaths due to electrocution was conducted at the Office of the Chief Medical Examiner in the State of Maryland from 2005 to 2015. During the 11-year period, a total of 55 electrocution deaths were identified from the autopsy cases at the statewide medical examiner system. More males died of electrocution than females with its ratio of (M: F) = 9:1. Of the 55 cases, 67.3% were White, 18.2% were African-American, 12.7% were Hispanic, and 1.8% were other races. The age of the victims ranged from 4 to 83 years with mean age of 40 years. >96% deaths due to accidents and 3.4% were suicide. The majority of deaths (70.9%) were caused by high-voltage circuits. Approximately 64% of fatalities were work-related accidents. The study indicated that electrocution deaths frequently affected young male workers who were in contact with a high-voltage currents while on the job. The detailed death scene investigation and autopsy findings are presented. The potential hazards of electricity must continue to be addressed in public safety campaigns to prevent such deaths. Strategies should ensure safe work environments for any contact with electric currents.

The distribution and redistribution of fentanyl & norfentanyl in post mortem samples

This article compares 249 post mortem case reports that were positive for fentanyl/norfentanyl. All the cases were submitted to, and analyzed by, the toxicology department of the Office of the Chief Medical Examiner, Edmonton, Alberta, Canada. This study highlights the varied distribution of fentanyl in the body after death as a result of misadventure, i.e., these are accidental drug overdose cases as opposed to a study of analytical data resulting from fentanyl use/administration in a clinical environment and/or death as a result of suicide.Post mortem samples were collected from more than one anatomical site and analyzed for fentanyl and norfentanyl using liquid chromatography–tandem mass spectrometry. Ante-mortem samples were available in 4 of these cases and were also analyzed.Post mortem mean blood fentanyl concentrations were found to be 13.2ng/mL (femoral), 19.1ng/mL (iliac) and 42.0ng/mL (subclavian). For norfentanyl the mean concentrations were 4.6ng/mL (femoral), 4.6ng/mL (iliac) and 7.4ng/mL (subclavian). Mean vitreous fentanyl and norfentanyl concentrations were 10.8ng/mL and 3.5ng/mL respectively. Mean liver fentanyl and norfentanyl concentrations were found to be 185.5ng/g and 18.8ng/g respectively.This study demonstrates the importance of multi-site sample collection and subsequent analysis for a thorough post mortem toxicological investigation. The study also highlights the risks and limitations associated with the interpretation of post mortem analytical results concerning fentanyl.