Office Of The Chief Medical Examiner Research Articles

Investigation of sudden infant deaths in the State of Maryland (1990–2000)

The Office of the Chief Medical Examiner (OCME) has recorded a significant decline in the deaths of sudden infant death syndrome (SIDS) in the state of Maryland since 1994. However, infants who died of accidental or non-accidental injuries remained consistent during the same time period. This report focuses on the epidemiological characteristics and scene investigation findings of infant victims who died suddenly and unexpectedly in Maryland between 1990 and 2000. A retrospective study of OCME cases between 1990 and 2000 yielded a total of 1619 infant fatalities. 802 infant deaths were determined to be SIDS, which represented 50% of the total infant deaths in our study population. Five hundred and twenty-three (31.8%) deaths were due to natural diseases, 128 (7.9%) deaths were accidents, and 74 (4.6%) were homicides. The manner of death could not be determined after a thorough scene investigation, review of history and a complete postmortem examination in 92 (5.7%) infants. SIDS deaths most often involved infants who were male and black. The peak incidence of SIDS was between 2 and 4 months of age. The majority of SIDS infants (60%) were found unresponsive on their stomach. Among SIDS infants, 269 (33.4%) were found in bed with another person or persons (bed sharing). Of the bed-sharing SIDS cases, 182 (68%) were African–American. In the past 11 years, 52 infants died of asphyxia due to unsafe sleeping environment, such as defective cribs, ill-fitting mattresses, inappropriate bedding materials. Of the 74 homicide victims, 53 (70%) involved infants less than 6 months of age. Twenty (27%) exhibited the classical abuse syndrome characterized by repeated acts of trauma to the infants.

Oxycodone Intoxication in an Infant: Accidental or Intentional Exposure?

A case is presented of a 10 month old male who went into cardiac arrest at a local store. The infant subsequently expired and was autopsied at the Office of the Chief Medical Examiner, State of Maryland. The only remarkable finding was the detection of oxycodone in the postmortem specimens; the blood and liver oxycodone concentrations were 0.6 mg/L and 1.6 mg/kg, respectively. Oxycodone was identified and quantitated by gas chromatography-nitrogen-phosphorus detection and confirmed by full scan electron ionization gas chromatography-mass spectrometry. The medical examiner ruled that the cause of death was oxycodone intoxication, and the manner of death was homicide. The key toxicologic question in this case was whether or not it was reasonable for the infant to be exposed to oxycodone exclusively through breast milk or through an alternate source. It was concluded that, at best, there were serious concerns about the likelihood of drug exposure through consumption of breast milk.

Hydroxycarbazepine Distribution in Three Postmortem Cases

This paper presents three cases investigated by the Office of the Chief Medical Examiner where hydroxycarbazepine, the active metabolite of the anticonvulsant prodrug oxcarbazepine, was detected in the biological specimens submitted for toxicological analysis. Hydroxycarbazepine was quantitated using a single-step pH 5 extraction and detection on a DB-5 column by gas chromatography-nitrogen-phosphorus detection. In the three cases, the heart blood concentrations were 34.6, 40.5, and 3.7 mg/L, respectively. In cases 2 and 3, the peripheral blood concentrations were 36 and 4.1 mg/L, respectively. In each case, the medical examiner ruled that the hydroxycarbazepine was an incidental finding to the cause of death.

Overdose deaths attributed to methadone and heroin in New York City, 1990-1998.

Methadone treatment has been shown to be an effective intervention that can lower the risk of heroin-induced overdose death. Recent reports have suggested increases in methadone-induced overdose deaths in several locations in the USA and in Europe. This study investigated the role of methadone and opiates in accidental overdose deaths in New York City. We analysed data from the Office of the Chief Medical Examiner to examine all accidental drug overdose deaths in New York City between 1990 and 1998. Of 7451 total overdose deaths during this period, there were 1024 methadone-induced overdose deaths, 4627 heroin-induced overdose deaths and 408 overdose deaths attributed to both methadone and heroin. Fewer than a third as many accidental overdose deaths were attributed to methadone than were attributed to heroin during this period. The proportion of accidental overdose deaths attributed to methadone did not change appreciably (12.6-15.8% of total overdose mortality), while the proportion of overdose deaths attributed to heroin increased significantly (53.5-64.2%) during the period of study. There was no appreciable increase in methadone-induced overdose mortality in New York City during the 1990s. Both heroin-induced overdose mortality and prescriptions of methadone increased during the same interval.

The urban built environment and overdose mortality in New York City neighborhoods

Accidental drug overdose continues to be a substantial cause of mortality for drug users. Characteristics of the neighborhood built environment may be important determinants of the likelihood of drug overdose mortality independent of individual-level factors. Using data from the New York City Office of the Chief Medical Examiner, we conducted a multilevel case control study using data on accidental overdose deaths as cases and non-overdose accidental deaths as controls. We used archival data from the New York City Housing and Vacancy Survey and the Mayor's Office of Operations to assess characteristics of neighborhood external (e.g. dilapidation of buildings) and internal (e.g. quality of utilities in houses) built environment. Multilevel analyses were used to assess the relations between the neighborhood built environment and the likelihood of overdose death. Six out of the eight characteristics of the external environment studied and three out of the six characteristics of the internal environment studied were significantly associated with the likelihood of fatal drug overdose in multilevel models after adjusting for individual-level (age, race, sex) and neighborhood-level (income, drug use) variables. Deterioration of the built environment, particularly the external environment, is associated with an increased likelihood of fatal accidental drug overdose. Disinvestment in social resources, psychosocial stressors, neighborhood differences in response to a witnessed overdose, and differences in vulnerability to the adverse consequences of drug use in different neighborhoods may explain the observed associations.

Unintentional and undetermined firearm related deaths: a preventable death analysis for three safety devices

Objective: To determine the proportion of unintentional and undetermined firearm related deaths preventable by three safety devices: personalization devices, loaded chamber indicators (LCIs), and magazine safeties. A personalized gun will...

Prevalence of tuberculin skin test positivity and conversions among healthcare workers in New York City during 1994 to 2001.

To determine the prevalence of and risk factors for tuberculin skin test positivity and conversion among New York City Department of Health and Mental Hygiene employees. Point-prevalence survey and prospective cohort analysis. Sentinel surveillance was conducted from March 1, 1994, to December 31, 2001. HCWs in high-risk and low-risk settings for occupational TB exposure. Baseline tuberculin positivity was 36.2% (600 of 1,658), 15.5% (143 of 922) among HCWs born in the United States, and 48.5% (182 of 375) among HCWs not born in the United States. There were 36 tuberculin conversions during 2,754 observation-years (rate, 1.3 per 100 person-years). For HCWs born in the United States, the risk for tuberculin conversion was greater in high-risk occupational settings compared with low-risk settings (OR, 5.7; CI95, 1.7-19.2; P < .01). HCWs not born in the United States and those employed at the Office of the Chief Medical Examiner (OCME) were at high risk for baseline tuberculin positivity (OR, 3.2; CI95, 1.7-5.8; P < .001); OCME HCWs (OR, 4.7; CI95, 2.3-9.4; P < .001), those of Asian ethnicity (OR, 4.3; CI95, 1.4-13.5; P < .01), and older HCWs (OR, 1.0; CI95, 1.0-1.1; P < .05) were at a higher risk for conversion. Although the prevalence of tuberculin positivity decreased after the peak of the recent TB epidemic in New York City, the conversion rate among HCWs in high-risk occupational settings for TB exposure was still greater than that among HCWs in low-risk settings. Continued surveillance of occupational TB infection is needed, especially among high-risk HCWs.

Inflicted Traumatic Brain Injury in Young Children

Source: Keenan HT, Runyan DK, Marshall SW, et al. A population-based study of inflicted traumatic brain injury in young children. JAMA. 2003;290:621–626.To ascertain the incidence of serious inflicted traumatic brain injury (TBI), the authors from the University of North Carolina at Chapel Hill, North Carolina, prospectively studied all children ≤2 years of age who were admitted to a pediatric intensive care unit (PICU) in the state of North Carolina between January 2000 and December 2001 with TBI. The authors also monitored the 3 closest out-of-state PICUs during the study for admission of North Carolina residents who met study criteria. Information was obtained from the North Carolina Office of the Chief Medical Examiner to identify children who died without admission to a PICU or prior to hospital admission.A diagnosis of inflicted injury required evidence of TBI accompanied by a confession or a medical and child protective services determination that the injury was inflicted. This assessment was made by the treating providers at each hospital and was reviewed by 2 of the study authors. The incidence of inflicted TBI and non-inflicted TBI was calculated. Children with inflicted TBI were compared to those with non-inflicted TBI and to the general population of children without TBI (North Carolina birth certificate information).A total of 152 cases of TBI were identified, of which 53% were inflicted. The incidence of inflicted TBI for children ≤2 years that resulted in death or admission to a PICU was 17.0/100,000 person years. Children <1 year of age had a higher rate of inflicted TBI than children 1–2 years of age (29.7 versus 3.8/100,000 person years). Boys had higher rates of inflicted TBI than girls (21.0 versus 13.0/100,000 person years). The median age of patients with inflicted TBI was 4.0 months compared to 7.5 months for patients with non-inflicted TBI.Relative to the general population of North Carolina, children with inflicted injury were more likely to have young mothers (≤21 years) (OR 4.7; 95% CI, 1.9–11.4); to be non-white (OR 2.1; 95% CI, 1.1–4.2 for African Americans and OR 6.0; 95% CI, 2.2–16.8 for other minorities); to be male (OR 2.0; 95% CI, 1.1–3.9); or to be the product of multiple births (OR 5.0; 95% CI, 1.2–21.5).Approximately 1,300 children in the United States die each year due to maltreatment.1 Many of these children are infant victims of inflicted TBI. Children who survive often have serious neurological consequences. The medical and societal costs to care for these children acutely and during their rehabilitation are extensive.2 However, the scope of the problem has been difficult to measure, as definitions and reporting of TBI have been inconsistent.This prospective, population-based study is the first to report the incidence of serious inflicted TBI in children under the age of 2 years in a US population. As the authors acknowledge, the study underestimates the incidence of all inflicted TBI, as only children who were monitored in an intensive care unit or who died were included in the study. Milder cases of TBI may not present for medical care, and may be misdiagnosed when they do present.3 Many of these children may also have long-lasting neurological or educational disabilities.2This study demonstrates that inflicted traumatic brain injury is a serious public health concern. Follow-up of this cohort will help assess whether the outcome of inflicted TBI is, in fact, worse than unintentional TBI. Treatment and outcome of brain-injured infants have not been studied and current recommendations for TBI treatment are based on studies of older children and adults.4 Armed with a new estimate of the incidence of serious TBI, as well as estimates of the extensive associated medical and societal costs, more convincing arguments can now be made to find and fund effective prevention efforts. Knowledge of the epidemiology of TBI may help target such efforts.This report constitutes another in a series of heads-up alerts regarding the extent and enormous societal costs of child maltreatment. Prevention is a formidable challenge. We believe it requires transforming our communities into child-friendly environments that can intercept the victims of abuse and block the transfer of that terrible legacy on to the next generation.

Contribution of Selected Metabolic Diseases to Early Childhood Deaths—Virginia, 1996-2001

Sudden infant death syndrome (SIDS), or the death of an infant aged <1 year that remains unexplained after a thorough investigation, is the third most common cause of death among infants in the United States. Sudden, unexplained deaths also occur among children aged >/=1 year; however, the number of these deaths is not well documented. Certain cases of SIDS and sudden unexplained death beyond infancy might be attributable to complications of unrecognized metabolic diseases. Tandem mass spectrometry (tandem MS) can be used to screen for several of these disorders. Despite the low prevalence of these diseases, newborn screening for these disorders has been found to compare favorably with the cost of other screening programs. However, the contribution of these diseases to early childhood deaths is not well understood. To determine the proportion of sudden, unexpected early childhood deaths associated with selected metabolic diseases, CDC, the Office of the Chief Medical Examiner (ME) in Virginia, and a private laboratory conducted a population- based study. This report summarizes the results of the study, which indicate that 1% of children had a positive postmortem metabolic screen using tandem MS. Of the eight children with positive screening tests, seven might have had improved outcomes had they been identified and treated during the newborn period. The use of tandem MS in newborn screening programs could offer an opportunity to prevent early childhood mortality.

Fatal occupational injuries among self‐employed workers in North Carolina

Research suggests that rates of occupational injury and death may be higher among self-employed workers than in the wage and salaried population. This analysis was conducted to describe the demographic and occupational characteristics, as well as injuries, activities, and occupations of self-employed workers who are fatally injured on the job. Characteristics of workers by type of employment were compared using data from the North Carolina Office of the Chief Medical Examiner, 1978-1994. Age-, activity-, and industry-specific fatality rates in self-employed workers (N=395) were contrasted to those privately employed (N=1,654). Highest fatal injury rates among the self-employed occurred in agriculture, retail, and transportation industries. Homicide deaths occurred more frequently among self-employed workers; deaths resulting from unintentional injuries occurred more frequently among non-self-employed workers. Elevated occupational fatality death rates among self-employed workers, especially in retail and transportation industries, provide justification for addressing work-related conditions of self-employed workers in North Carolina.

Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990–98

Accidental drug overdose contributes substantially to mortality among drug users. Multi-drug use has been documented as a key risk factor in overdose and overdose mortality in several studies. This study investigated the contribution of multiple drug combinations to overdose mortality trends. We collected data on all overdose deaths in New York City between 1990 and 1998 using records from the Office of the Chief Medical Examiner (OCME). We standardized yearly overdose death rates by age, sex and race to the 1990 census population for NYC to enable comparability between years relevant to this analysis. Opiates, cocaine and alcohol were the three drugs most commonly attributed as the cause of accidental overdose death by the OCME, accounting for 97.6% of all deaths; 57.8% of those deaths were attributed to two or more of these three drugs in combination. Accidental overdose deaths increased in 1990-93 and subsequently declined slightly in 1993-98. Changes in the rate of multi-drug combination deaths accounted for most of the change in overdose death rates, whereas single drug overdose death rates remained relatively stable. Trends in accidental overdose death rates within gender and racial/ethnic strata varied by drug combination suggesting different patterns of multi-drug use among different subpopulations. These data suggest that interventions to prevent accidental overdose mortality should address the use of drugs such as heroin, cocaine and alcohol in combination.

Adolescent pregnancy and homicide: findings from the Maryland Office of the Chief Medical Examiner, 1994-1998.

Homicide has remained the third leading cause of death among girls aged 10 to 19 for more than a decade. Recent research indicates that pregnant or postpartum teens are three times more likely to be victims of homicide compared to their nonpregnant counterparts. These findings portray a compelling picture that leads the authors to investigate the relationship between homicide and pregnancy among teens in Maryland. The purpose of this study is to compare women whose deaths had been evaluated by the medical examiner and who had evidence of pregnancy to women without evidence of pregnancy, with a particular focus on adolescents; 329 (17.7%) adults and 66 (32.7%) adolescents were victims of homicide. Adolescent homicide victims were 3.7 (1.2 to 11.8) times more likely to be pregnant compared to adult homicide victims. The rate of homicide was nearly double in all women who were pregnant. Further research is necessary to evaluate factors associated with these risks so that the future generation and society are protected.

A Review of Available Data on the Health of the Latino Population in North Carolina

To portray major health problems and conditions in the Latino population of North Carolina. Presentation of descriptive information from North Carolina data sets on Latino health issues, with whites and African Americans as comparison groups. Statewide data on the health of the Latino population are provided from the following data sets: North Carolina Behavioral Risk Factor Surveillance System (BRFSS), death certificates, North Carolina Office of the Chief Medical Examiner records, sexually transmitted disease reports, reported pregnancies, certificates of live birth, North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS), and North Carolina Birth Defects Monitoring Program (BDMP) cases. Review of existing data systems. Latinos in North Carolina have high death rates from motor vehicle injuries and homicide. Latinos who die from unintentional injuries, homicide, and suicide are much more likely than whites or African Americans to have a high blood alcohol level. Latinos are less likely than other groups to have health insurance. Latinos have much higher pregnancy rates, both for teens and older women, and are more likely to begin prenatal care late or have no prenatal care. Rates of sexually transmitted disease are higher than those for whites but lower than those for African Americans. Latinos are more likely to initiate breastfeeding. Latinos have a higher rate of neural tube defects compared to the other groups, while being less likely to take folic acid every day before pregnancy. Despite lower family incomes, later entry into prenatal care, and higher rates of certain birth defects, Latinos had the lowest rates of low birth weight and infant mortality. Lower rates of smoking during pregnancy among Latinos may partially account for the better birth outcomes. Many of the health issues among Latinos in North Carolina are consistent with the fact that they are a very young, mainly recently-arrived, immigrant population with more males than females. These findings may provide a basis for designing more effective health improvement programs for the Latino population of North Carolina.

Suicide among North Carolina women, 1989–93: information from two data sources

Objectives: To characterize the events and examine suicide precursors among women and to examine gaps in surveillance. Setting: A statewide study in North Carolina. Methods: Suicides of women age 15...

Income distribution and risk of fatal drug overdose in New York City neighborhoods

Accidental drug overdose is a substantial cause of mortality for drug users. Neighborhood-level factors, such as income distribution, may be important determinants of overdose death independent of individual-level factors. We used data from the Office of the Chief Medical Examiner to identify all cases of accidental deaths in New York City (NYC) in 1996 and individual-level covariates. We used 1990 US Census data to calculate the neighborhood-level income distribution. This multi-level case–control study included 725 accidental overdose deaths (cases) and 453 accidental deaths due to other causes (controls) in 59 neighborhoods in NYC. Overdose deaths were more likely in neighborhoods with higher levels of drug use and with more unequal income distribution. In multi-level models, income maldistribution was significantly associated with risk of overdose independent of individual-level variables (age, race, and sex) and neighborhood-level variables (income, drug use, and racial composition). The odds of death due to drug overdose were 1.63–1.88 in neighborhoods in the least equitable decile compared with neighborhoods in the most equitable decile. Disinvestment in social and economic resources in unequal neighborhoods may explain this association. Public health interventions related to overdose risk should pay particular attention to highly unequal neighborhoods.

Spontaneous Fractures in the Differential Diagnosis of Fractures in Children

A four-year-old male with cerebral palsy and spasticity, as a result of a non-accidental head injury sustained when he was two years old, died of pneumonia. Postmortem full body X-rays revealed fractures of varying ages of the left humerus and both femora, tibiae, and fibulae. This led to a thorough investigation of the case by the Office of the Chief Medical Examiner. Child abuse, accidents, metabolic bone disorders, other primary or secondary diseases of the bones, and pathological fractures were ruled out. The final diagnosis was spontaneous fractures secondary to osteopenia. The term spontaneous fractures is used to define fractures that occur without any known external cause, especially in cerebral palsy patients with spasticity.

Community Needs Assessment of Lower Manhattan Residents Following the World Trade Center Attacks—Manhattan, New York City, 2001

On September 11, 2001, terrorists attacked and destroyed the World Trade Center (WTC) in New York City (NYC). An estimated 2,819 persons were reported killed in the attacks; many others were injured (Office of the Chief Medical Examiner, New York City Department of Health and Mental Hygiene [NYCDOHMH], unpublished data, 2002). An estimated 25,000 persons living nearby in lower Manhattan were affected both physically and emotionally. Many persons witnessed the attacks; lost family and friends; were exposed to smoke, dust, and debris; and evacuated their homes. To identify the health-related needs and concerns of persons residing near the attack site, NYCDOHMH, in collaboration with CDC, surveyed persons residing in areas immediately surrounding the WTC site. The primary purpose of the survey was to gather information to set priorities and direct public health interventions. This report summarizes findings from the assessment, which indicate that a large proportion of respondents had physical and psychological symptoms potentially associated with the exposure and needed information to address their health and safety concerns. On the basis of the results of the survey, NYCDOHMH responded to resident concerns, helped reduce exposure to dust and debris, and provided information about mental health resources.

Lithium augmentation in venlafaxine non-responders: an open study

In postmortem cases where the cause of death is hanging, toxicological analyses may be considered unnecessary by some medical examiners, toxicologists, and other persons involved in medico-legal investigations because the cause of death seems “obvious.” To ascertain if toxicological analyses are necessary when the cause of death is hanging, all 102 hanging cases (25 females; 77 males) from 2011 to 2013 that came under the jurisdiction of the San Francisco Office of the Chief Medical Examiner were examined from a total of 3912 sudden, unexpected, or violent death cases in the same period. Suicide was the manner of death in 99 of these cases, with two accidental and one undetermined death. The average age of decedents was 43.9 years (median 41), the youngest was an 11-year old male and the oldest was an 86-year old female. Of the 102 cases, 33 had negative toxicology while 69 cases had at least one positive toxicology result. Females were equally likely to have negative or positive results (12 and 13 cases respectively), but males were 37.5% more likely to have positive toxicology (n = 56) rather than negative toxicology (n = 21). For females, alcohol, mirtazapine, venlafaxine, and trazodone were the top psychoactive substances in peripheral blood while THC, cocaine, hydrocodone, bupropion, olanzapine, doxylamine, quetiapine and dextromethorphan were also reported. For males, alcohol, THC, cocaine, amphetamine, methamphetamine, bupropion, and diphenhydramine were the top psychoactive substances in blood, but several other drugs were also found in individual cases. Our study of hanging cases over a 3-year period support the idea that complete postmortem toxicology investigation of hangings should be performed, even when the “obvious” cause of death is asphyxia due to hanging. Many of these cases involved psychoactive substances (most often alcohol and cannabis), and having such knowledge provides a better understanding of the circumstances surrounding the decedent's death, their possible state of impairment, including the possibility of a staged suicide if the decedent was too impaired to perform a self-hanging.

Pseudo-Subarachnoid Hemorrhage of the Head Diagnosed by Computerized Axial Tomography: A Postmortem Study of Ten Medical Examiner Cases

In this report, we describe ten cases of pseudo-subarachnoid hemorrhage on computer axial tomography (CT) scan of the head. A pseudo-subarachnoid hemorrhage is a false positive finding by CT of the head in which the scan is interpreted as being positive for a subarachnoid hemorrhage not substantiated by subsequent neuropathologic findings. This study is a retrospective review of postmortem cases brought into the Office of the Chief Medical Examiner for the State of Maryland over a three-year period (from 1997 to 2000). We compared the clinician's impression of the CT scan with the postmortem neuropathology. The clinical diagnosis of subarachnoid hemorrhage was based on misinterpretation of non-contrast CT scans of the head. In six of the ten cases, the reading was performed by a radiologist and in four cases by nonradiologist physicians (emergency room physician, neurologist, or neurosurgeon). All the patients survived between a few hours to a few days after being admitted to the hospital. For most of the cases (80%), the neuropathology showed hypoxic/ischemic encephalopathy. The most common cause of death (four out of ten cases) was narcotic intoxication. This report is submitted so that clinicians and pathologist become more familiar with this entity.

Assessment of the acuteness of heroin deaths from the analysis of multiple blood specimens.

Data was compiled from 126 morphine-involved cases investigated by the Office of the Chief Medical Examiner, State of Maryland, USA. An investigation was conducted into whether comparison of morphine concentrations from a central and peripheral site could be used to determine whether a morphine death was acute or delayed. Fifty cases were identified as 'acute' because the urine free morphine concentration by radioimmunoassay (RIA) was less than 25 ng/mL; 76 cases were classified as 'random' because they had a urine morphine concentration greater than 25 ng/mL by RIA. The average heart blood to peripheral blood morphine concentration ratio in the acute deaths was 1.40. The average heart blood to peripheral blood morphine concentration ratio in the random deaths was 1.18. Because there was considerable overlap between the two groups of data, the authors conclude that it was not possible to predict 'acute' opiate intoxication deaths versus 'delayed' deaths when the only information available is heart and peripheral blood free morphine concentrations.