Statewide Medical Examiner Research Articles

Rapid Identification of Suspected Drug Overdose Deaths by Death Investigators, New Jersey, 2020.

While the number of overdoses in the United States continues to increase, lags in data availability have undermined efforts to monitor, respond to, and prevent drug overdose deaths. We examined the performance of a single-item mandatory radio button implemented into a statewide medical examiner database to identify suspected drug overdose deaths in near-real time. The New Jersey Office of the Chief State Medical Examiner operates a statewide mandated case management data system to document deaths that fall under the jurisdiction of a medical examiner office. In 2018, the New Jersey Office of the Chief State Medical Examiner implemented a radio button into the case management data system that requires investigators to report whether a death is a suspected drug overdose death. We examined the performance of this tool by comparing confirmed drug overdose deaths in New Jersey during 2020 with suspected drug overdose deaths identified by investigators using the radio button. To measure performance, we calculated sensitivity, specificity, positive predictive value, negative predictive value, and false-positive and false-negative error rates. During 2020, New Jersey medical examiners investigated 26 527 deaths: 2952 were confirmed by the state medical examiner as a drug overdose death and 3050 were identified by investigators using the radio button as a suspected drug overdose death. Sensitivity was calculated as 96.1% (2837/2952), specificity as 99.1% (23 362/23 575), positive predictive value as 93.0% (2837/3050), negative predictive value as 99.5% (23 362/23 477), false-positive error rate as 7.0% (213/3050), and false-negative error rate as 3.9% (115/2952). Implementation of a radio button into death investigation databases provides a simple and accurate method for identifying and tracking drug overdose deaths in near-real time.

The Impact of COVID-19 on Adolescent Suicide Deaths in the State of Maryland

Abstract On March 11, 2020, the World Health Organization officially declared the SARS-CoV-2 virus (COVID-19) a worldwide pandemic. As of December 2021, there have been over 278 million cases and 5.4 million deaths reported. One area of concern regarding the pandemic was its potential impact on mental health, and it was feared that the onset of such a devastating pandemic would lead to increased suicide risks among the general population. With suicide being a leading cause of death in adolescents, it is important to assess the potential mental health consequences that the COVID-19 pandemic may impose. Aim The aim of the study was to analyze the impact of COVID-19 on suicide deaths among adolescents in the state of Maryland from 2019 to 2021. Subjects and Methods This was a retrospective study of adolescent suicide victims, aged 10–19 years, from January 2019 to December 2021 in the state of Maryland. De-identified data were collected from the statewide medical examiner’s office which is responsible for the medicolegal death investigation in Maryland. Results A total of 102 adolescent suicide deaths were investigated statewide by the Maryland Office of the Chief Medical Examiner during these 3 years. The number of adolescent suicide cases stayed relatively stable during the COVID-19 pandemic, with slightly more cases during the pre-COVID-19 pandemic period (2019: n = 37; 2020: n = 31; and 2022: n = 34). Looking at months of incidence, less cases were reported in March–May 2020 (n = 5), which marks the beginning of the pandemic when compared to the same period in 2019 (n = 13). The number was higher for August–November 2020 (n = 15) than for that of 2019 (n = 8) and 2021 (n = 8). The male-to-female suicide ratio was 3.7:1 (n = 80/22). However, the data exhibited a significant increase in the number of female adolescent suicides, from 8.11% in 2019 (n = 3) to 25.81% in 2020 (n = 8) and 32.35% in 2021 (n = 11). Of the cases examined, more than 50% were white and approximately 27% were African-Americans. The two leading causes of death were hanging (47%) and firearm injuries (29%). Maryland consists of 23 countries and Baltimore City. The majority of adolescent suicides occurred in county residents with only 8.8% of cases in Baltimore City.

Identifying bright spot communities: Socioecological, workforce, and healthcare delivery factors influencing opioid mortality.

There were 50,000 U.S. opioid overdose deaths in 2019. Millions suffer from opioid addiction. Identifying protective factors for low community opioid mortality may have important implications for addressing the opioid epidemic. This study was funded through the Virginia (VA) Department of Medical Assistance Services (DMAS) through a SUPPORT Act Grant. To identify "Bright Spot" communities in Virginia with protective factors associated with reduced opioid mortality and morbidity. Ecologic study. Virginia All Payer Claims Database (APCD), Virginia Department of Health (VDH) statewide medical examiner registry, and American Community Survey (ACS). 2016-2019; 2019 data cited here. APCD includes VA residents with medical claims through commercial, Medicaid, and Medicare coverage. VDH data includes fatal drug overdoses. ACS surveys all VA residents. Primary outcome: fatal opioid overdoses. Secondary outcomes: emergency room visits for overdoses and opioid-related diagnoses, outpatient diagnoses for opioid-related disorder, prescription rate for opioids, and prescription rate for buprenorphine. Opioid mortality was associated with higher rates of community poverty (r=.38, p<.0001) and disability (r=.52, r<.0001). Opioid mortality was associated with inequality, with higher Gini index associated with higher opioid mortality (r=.23, p<.0001). A higher percentage of black residents was associated with increased fatal opioid overdoses (r=.37, p<.0001) and ED visits for overdoses (r=.30, p<.0001). A higher percentage of white residents correlated with increased outpatient visits for opioid use disorder (r=.24, p<.0001) and higher rates of buprenorphine (r=.34, p<.0001) and opioid prescriptions (r=.31, p <.0001). These findings suggest significant racial disparities in opioid outcomes. Communities with a higher percentage of black residents are more likely to have higher opioid mortality and a lower rate of outpatient treatment. This association may be affected by the time period used in the analysis (2015-2019), as nationally there has been an increasing rate of synthetic opioid deaths in Black communities. These measures have been incorporated into a multivariate analysis to identify Bright Spot communities, which will be discussed during the presentation.

Evaluation of pedestrian–train fatalities in the State of Maryland: A 5-year retrospective study

Few studies have been done on the incidences of train-related pedestrian fatalities throughout the United States, with no previous studies reported in the State of Maryland. A retrospective study was conducted at the statewide medical examiner's office in Maryland to evaluate the characteristics of train-related pedestrian fatalities from 2014 to 2018. The aim of the study was to analyze circumstances of deaths through the medicolegal death investigation and postmortem examination findings, including toxicological study, to help identify epidemiological characteristics of pedestrian–train-related fatalities. A total of 48 pedestrian-train deaths were identified. Of the 48 cases identified, 21 deaths (43.75%) were determined to be accident, 20 deaths (41.67%) were suicide, and 7 deaths (14.58%) whose manner of death could not be determined. Of the 21 accidental victims, 17 were male and 4 were female (M:F ratio = 4.3:1), 11 (52.38%) were white, 6 (28.57%) African American, and 4 Hispanic (19.05%), with age ranging from 16 to 58 years (mean age = 35). Of the 20 suicide victims, 17 were males and 3 females (M:F ratio = 5.7:1), 16 (80%) were white, 2 (10%) African American, and 2 (10%) Hispanic, with age ranging from 22 to 60 years (mean age = 40). The majority of accidents occurred during weekday evening rush hours between 4:00 pm and 7:00 pm, while the suicides showed no specific time frames. No specific peak for seasons of year was found in suicides or accidents. Postmortem toxicological studies showed that 52.38% (11/21 cases) of accidental victims were positive for alcohol and 30% (6/20 cases) of suicide victims were positive for alcohol. Manner of death could not be determined in 7 cases because of unclear circumstances of death. Thorough death scene investigation and complete postmortem examination, including comprehensive toxicological testing, is very important in all train-related pedestrian fatalities. Determining the manner of death can directly affect the outcome of civil ligation and dispersal of insurance benefits. The characteristic profiles of train-related pedestrian fatalities can also assist effective preventive measures on railway suicides and accidents.

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.

Morphologic features of culprit lesions in sudden coronary death with family history of premature coronary artery disease

The morphologic features of familial coronary artery disease (CAD) resulting in sudden coronary death (SCD) are poorly studied. The presence and type of culprit lesions may have important implications in the genetic basis for familial heart disease. Autopsies of SCD victims over a 5-year period from a statewide medical examiner's office were studied. Premature familial disease was defined as sudden death at ≤50 years in women and ≤45 years in men, with premature SCD or acute coronary syndrome in a first-degree relative. Culprit lesion was defined as acute plaque rupture, plaque erosion, and severe narrowing without thrombus (stable plaque). There were 174 acute plaque ruptures (age 49±10 years, 9% women), 49 plaque erosions (age 45±8 years, 37% women), and 213 stable plaques (age 53±11 years, 22% women). There were 8 plaque rupture with family history. There were 9 plaque erosions with family history. There were 7 stable plaques with family history. The rate of familial history in premature coronary disease was 18.4% in erosions, 4.6% in ruptures (p=.02 vs. erosion), and 3.3% in stable plaque (p=.002 vs. erosion). We concluded that the frequency of family history of premature sudden death due to CAD may be higher in plaque erosion as compared to patients dying with acute plaque rupture or stable plaque.

Utilitarian Aspects of Postmortem Computed Tomography

Computed tomography has been used in clinical medicine for decades, but only recently introduced into the forensic pathology setting. The reasons for the slow adoption of this technology into the autopsy suite are various, including concerns about funding, infrastructural maintenance, training, competency, and scope of utilization. Practical experience in a busy statewide medical examiner department confirmed the utility of this technology as a part of daily practice. The impact of postmortem computed tomography (PMCT) on casework can be stratified into three broad groups: where PMCT 1) supplants invasive autopsy, 2) supplements invasive autopsy, or 3) has limited or no potential for impact on practice. A detailed understanding of the practical uses of this science is important for the practicing forensic pathologist so as to guide decisions about the ways in which PMCT can be implemented within their own institutions and utilized on a daily basis. Dramatic changes in personal and institutional practice trends can be observed once forensic pathologists are comfortable with the evaluation, documentation, and interpretation of PMCT data. Examples of potential paradigm shifts include the performance of only external examination and PMCT instead of invasive autopsy in many cases of motor vehicle fatalities, suicide with violence, and broad categories of death due to natural disease. Over time, the authors believe that the PMCT will become one of the fundamental tools in the forensic pathologist's toolkit.

Childhood Fatalities in New Mexico: Medical Examiner‐Investigated Cases, 2000–2010

To better understand risk factors and populations at risk of childhood fatalities, a review of all records of childhood deaths (≤19years) between 2000 and 2010 from New Mexico's statewide medical examiner was conducted. Annually, 313-383 childhood deaths were investigated (3820 total). Males and American Indians were overrepresented (62% and 20.4% of deaths, respectively). The most common manner of death was natural (44.8%), followed by accidental (31.4%), homicide (8.8%), suicide (8.8%), and undetermined (4.1%). Infants under 1year of age accounted for 41.4% of deaths. Motor vehicle crashes were responsible for the majority of accidental deaths (69%), followed by unintentional overdoses (6.9%), and drowning (5.3%). Gunshot wounds, either intentional or unintentional, caused 10.7% of childhood deaths. Complete medico-legal investigation of childhood fatalities is needed to provide public health agencies with adequate data to evaluate and prevent childhood deaths.

Correlation between coronary plaque burden and heart weight

It is unclear if the extent of coronary atherosclerosis is associated with increase in heart muscle mass. We retrospectively reviewed autopsy reports of sudden coronary deaths occurring in a statewide medical examiner system over a one-year period. Cardiomegaly was assessed by height, and given a score of 0–4 based on amount above the upper limit of normal range. Coronary disease was quantitated as number of epicardial arteries with ≥75% cross sectional luminal narrowing. There were 100 hearts with one-vessel disease, 77 with two-vessel disease, and 59 with three- or four-vessel diseases. The extent of disease was less in women than men (P=0.002). Healed infarcts were present in 21% of women and 36% of men. Cardiomegaly was present in 50% of women and 69% of men. By univariate analysis, in patients without hypertension, cardiomegaly score in the three- or four-vessel disease group was significantly greater than in the one-vessel disease group (P=0.005), as well as the frequency of cardiomegaly (P=0.001). Hearts with myocardial scar had a more frequent cardiomegaly (P=0.0004) and higher cardiomegaly score (P=0.004) than without myocardial scar. Moreover, by multivariate analysis, body mass index (P<0.0001), extent of coronary disease (P=0.02) and healed infarct (P=0.04) were positively associated with cardiomegaly. We conclude that there is a significant correlation between the extent of coronary atherosclerosis and cardiac hypertrophy independent of age and body mass index in sudden coronary deaths as well as healed infarct. These data support a causative association between chronic ischemia and cardiomegaly

Cause and Manner of Death in Traumatic Spinal Cord Injuries: A 20 year Retrospective Review at a Statewide Medical Examiner Office

In the United States approximately 250,000 persons have a traumatic spinal cord injury (TSCI) and most will die from complications related to their injury. Interpretation of TSCI deaths by medical examiners is evolving as understanding of SCI pathophysiology increases. We queried our electronic database for deaths meeting inclusion criteria from 1989 to 2008 and identified 305 cases, of which 81% were males and 19% were females. A full autopsy was performed in 38.7% of cases and an external exam was performed in the remaining cases (61.3%). The manner of death distribution was accident (80%), homicide (7%), natural (7%), suicide (4%) or undetermined (2%). The most common mechanisms of spinal cord injury were motor vehicle accidents (42.6%), fall from a standing height (12.8%), fall from above a standing height (9.2%) and gunshot wounds (8.8%). The mechanism of spinal cord injury significantly impacted survival (p=0.0001) with decedents injured from motor vehicle accidents having a mean survival time of 14.4 years compared to 0.7 year from falling from a standing height. Analyzing patterns of deaths due to TSCI in a medical examiner office provides excellent epidemiological data for injury tracking and prevention as well as a context for medical examiners evaluating TSCI.

Sudden coronary death in children

Coronary disease is an uncommon cause of severe morbidity and death in the young. The great majority of lesions are congenital, and anomalous origins and courses of the coronary arteries are the most common groups of diseases in the age group. Intimal proliferation and coronary arteritis are even less common causes of death in this age population. For this review, we retrospectively studied cases of coronary cardiac death in children and adolescents, from 2004 to 2007, from a statewide medical examiner's office. There were 197 natural deaths in children ages ≤16 years and 58 deaths from sudden infant death syndrome. Of these, the largest group of deaths showed no morphologic abnormalities and was attributed to arrhythmias. The next largest group of deaths comprised complex congenital heart disease (n=13; 20%), followed by myocarditis (n=11; 17%), coronary disease (n=9; 14%), cardiomyopathy (n=8; 12%), valve disease (n=4; 6%), and cardiac fibroma (n=1). Nine coronary deaths occurred in seven boys and two girls, ranging from 14 days to 16 years of age (mean, 8 years). An anomalous course of the coronaries was seen in seven of the nine coronary deaths, and the other two casualties were examples of intimal proliferations involving the coronaries. The rare examples of coronary lesions in the young are discussed in this article.

Child Abuse‐Related Homicides in New Mexico: A 6‐year Retrospective Review

We retrospectively reviewed autopsy records at a statewide medical examiner's office in order to identify and characterize deaths due to child abuse. In a 6-year period in New Mexico, the medical examiner investigated 45 deaths determined to be child abuse-related. Decedents were predominantly male (68.9%), Hispanic White (53.3%), and all were 5 years of age or younger, with a median age of 1 year. Head injuries were the most common cause of death (44.4%), followed by battered baby syndrome (15.6%). Relatives were involved as alleged perpetrators in 80% of the cases, with the father most often implicated (36.1% of cases), and 88.9% of child abuse injuries resulting in death occurred in the family's residence. Toxicology was positive in 26.7% of cases, but only two cases had substances of abuse present. Information on risk factors such as prematurity, parental age, and history of abuse was also collected.

Comparison of Necropsy Findings in Patients With Sarcoidosis Dying Suddenly from Cardiac Sarcoidosis Versus Dying Suddenly from Other Causes

The clinical diagnosis of cardiac sarcoidosis can be difficult and is largely dependent on newer imaging modalities. A retrospective search of sudden cardiac deaths was performed from a reference laboratory and statewide medical examiner system for a 12-year period. Planimetry was performed on gross photographs of transverse short-axis sections, and the phase of the lesion and the portion of myocardium extent was estimated histologically. Lesions were classified histologically as early (primarily lymphocytic), intermediate (primarily granulomatous), and late (primarily scar). A total of 41 cases were found, including 25 in which the death was ascribed to sarcoidosis of the heart (group 1) and 16 in which sudden death was due to other findings (group 2). No significant differences were found in age or activity at death, although gross scars and epicardial nodules were more frequent in group 1 (p <0.0001). In the hearts with gross scars, the ventricular septum had the largest percentage of involvement (32%) followed by the posterior wall (25%). Histologically, the intermediate phase predominated in group 1, and the late phase predominated in group 2. Approximately 50% of the cases in group 1 had involvement in the right ventricular apex and septum, suggesting a positive yield by biopsy. In conclusion, cardiac sarcoidosis causing sudden death is characterized by extensive active granulomas with a predilection for the subepicardium and ventricular septum.

Medical Terminology Coding Systems and Medicolegal Death Investigation Data: Searching for a Standardized Method of Electronic Coding at a Statewide Medical Examiner’s Office*

Medical examiner and coroner reports are a rich source of data for epidemiologic research. To maximize the utility of this information, medicolegal death investigation data need to be electronically coded. In order to determine the best option for coding, we evaluated four different options (Current Procedural Terminology [CPT], International Classification of Disease [ICD] coding, Systematized Nomenclature of Medicine Clinical Terms [SNOMED CT], and an in-house system), then conducted internal and external needs assessments to determine which system best met the needs of a centralized, statewide medical examiner's office. Although all four systems offer distinct advantages and disadvantages, SNOMED CT is the most accurate for coding pathologic diagnoses, with ICD-10 the best option for classifying the cause of death. For New Mexico's Office of the Medical Investigator, the most feasible coding option is an upgrade of an in-house coding system, followed by linkage to ICD codes for cause of death from the New Mexico Bureau of Vital Records and Health Statistics, and ideally, SNOMED classification of pathologic diagnoses.

Utility of Infectious Disease Coding Sheets for Surveillance in a State Medical Examiner’s Office*

Medical examiners are often first to recognize unusual occurrences of fatal infectious diseases. Recognition of these deaths allows public health officials to institute appropriate public health measures. Therefore, we developed a simple method of identifying and tracking infectious disease deaths in a statewide medical examiner's office. One-page infectious disease forms were completed for 1566/1949 autopsies (80%) performed at the New Mexico Office of the Medical Investigator in 2004. In 241 cases one infectious disease was identified at autopsy and 58 cases had two infectious diseases. Fourteen of the infectious-diseases caused deaths involved diseases that are notifiable conditions in New Mexico. Pneumonia was the most commonly reported infectious process (47 deaths) followed by sepsis (25 deaths). Tracking infectious disease deaths highlighted the importance of recognizing these deaths, although hand-written entries were unstandardized. Preferably, a tracking system would be built into electronic databases at medical examiner and coroner's offices, expediting the identification of these diseases and contact of public health agencies.

Animal-Caused Fatalities in New Mexico, 1993–2004

To evaluate animal-caused fatalities in New Mexico using data collected during medicolegal death investigations, including toxicology, survival interval, and circumstances. A retrospective review of the computerized database and hard copies of files from a centralized, statewide medical examiner's office, excluding deaths due to zoonotic diseases and motor vehicle collisions involving animals. Between 1993 and 2004, 63 deaths caused by animals were reported in New Mexico. The majority of decedents were male (46/63, 73%) and non-Hispanic white (33/63, 52%). Horses were the most commonly implicated animals, with 43 (68%) deaths due to a person being thrown from, crushed, dragged, or kicked by a horse. Cattle caused 9 deaths (14%), dogs caused 3 (5%), and venomous animals caused 3, whereas a bear was responsible for 1 death. Ten decedents (16%) had alcohol present at the time of death, and 8 would have been over the legal blood alcohol concentration for driving (0.08%). Ten deaths (16%) were work-related and included deaths of jockeys and ranch workers. The majority of deaths (42/63, 67%) occurred in remote locations, potentially delaying access to treatment. Survival intervals ranged from 1 day to 33 years. Whereas both human and animal behavior can be difficult to predict, a review of animal-caused fatalities investigated by a medical examiner revealed that in many cases, deaths could have been prevented by either the use of protective gear or alterations in human behavior.

Effectiveness of safety measures recommended for prevention of workplace homicide.

Homicide is the second leading cause of death on the job for US workers. Government agencies recommend that employers prevent violence against workers by adopting interventions originally designed to prevent robbery, but the effectiveness of these interventions is unknown. To investigate the effectiveness of existing administrative and environmental interventions recommended for preventing workplace homicide. Population-based case-control study of North Carolina workplaces where a worker had been killed between January 1, 1994, and March 31, 1998, identified through a statewide medical examiner system (cases; n = 105) and an industry-matched random sample of workplaces at risk during the same period, selected from business telephone listings (controls; n = 210). Risk of death of a worker due to homicide. Among environmental interventions, strong and consistent reductions in the risk of a worker being killed on the job were associated with bright exterior lighting (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.3-1.0). Among administrative interventions, the largest beneficial effect was for staffing practices that prevented workers from being alone at night (OR, 0.4; 95% CI, 0.2-0.9). Keeping doors closed during working hours was also associated consistently with substantially reduced risk (OR, 0.4; 95% CI, 0.1-1.1) but was not statistically significant. Combinations of 5 or more administrative measures were associated with significantly lower levels of risk (OR, 0.1; 95% CI, 0.0-0.5). We found evidence suggesting that eliminating solo work at night could reduce the risk of homicide for workers. Keeping doors closed and using bright exterior lighting or combinations of administrative interventions also appear to be beneficial, but there was no evidence of effectiveness for a number of other recommended measures.