Wayne County Medical Examiner Research Articles

Severe Acute Respiratory Syndrome Coronavirus 2 Surveillance in Decedents in a Large, Urban Medical Examiner’s Office

BackgroundSARS-CoV-2 has become a global pandemic. Given the challenges in implementing widespread SARS-CoV-2 testing, there is increasing interest in alternative surveillance strategies.MethodsWe tested nasopharyngeal swabs from 1094 decedents in the Wayne County Medical Examiner’s office for SARS-CoV-2. All decedents were assessed by a COVID-19 checklist, and decedents flagged by the checklist (298) were preferentially tested. A random sample of decedents not flagged by the checklist were also tested (796). We statistically analyzed the characteristics of decedents (age, sex, race, and manner of death), differentiating between those flagged by the checklist and not and between those SARS-CoV-2 positive and not.ResultsA larger percentage of decedents overall were male (70% vs 48%) and Black (55% vs 36%) compared to the catchment population. Seven-day average percent positivity among flagged decedents closely matched the trajectory of percent positivity in the catchment population, particularly during the peak of the outbreak (March and April). After a lull in May to mid-June, new positive tests in late June coincided with increased case detection in the catchment. We found large racial disparities in test results: despite no statistical difference in the racial distribution between those flagged and not, SARS-CoV-2 positive decedents were substantially more likely to be Black (82% vs 51%). SARS-CoV-2 positive decedents were also more likely to be older and to have died of natural causes, including of COVID-19 disease.ConclusionsDisease surveillance through medical examiners and coroners could supplement other forms of surveillance and may serve as a possible early outbreak warning sign.

Associations detected between measures of neighborhood environmental conditions and human microbiome diversity

While emerging research suggests urban green space revegetation increases soil microbiota diversity and native plant species affect skin microbiome diversity, there is still a paucity of knowledge on relationships between neighborhood environmental conditions and the human microbiome. This study leveraged data on human microbiome samples (nose, mouth, rectum) taken at autopsy at the Wayne County Medical Examiner's Office (2014–2015). We evaluated relationships between the microbiome and five measures of environmental conditions (NDVI standard deviation, NDVI mean, percent trees, percent grassland and soil type) near the home of 126 decedents. For the rectum microbiome, NDVI sd had negative, significant associations with diversity (ASVs β = −0.20, p = 0.045; Faith PD β = −0.22, p = 0.026). In contrast, while insignificant, there were consistent, positive associations between diversity and NDVI sd for the mouth microbiome (ASVs β = 0.09, p = 0.337, Faith PD β = 0.14, p = 0.149, Shannon diversity β = 0.14, p = 0.159, Heip's evenness β = 0.11, p = 0.259) and a significant association for the nose microbiome (eigenvalues 3 β = 0.18, p = 0.057). We found consistent, significant, negative associations between percent grassland and diversity of the nose microbiome (ASVs β = −0.25, p = 0.008, Faith PD β = −0.25, p = 0.009, Shannon diversity β = −0.17, p = 0.062). For the mouth microbiome, we found a small effect of percent trees on diversity (eigenvalues 1 β = −0.08, p = 0.053). Clay loam soil was negatively (eigenvalues 2 β = −0.47, p = 0.053) and positively associated (eigenvalues 3 β = 0.65, p = 0.008) with rectum microbiome diversity, compared to loam soil. There was no potential indicator taxon among NDVI quartiles. These findings may be relevant for urban planning and management of urban outdoor spaces in ways that may support healthy human microbiomes. Still, future research is needed to link variation in NDVI, vegetation, plant and/or soil microbe diversity and to confirm or negate our findings that environmental conditions may have contrasting influence on the microbiome of the rectum versus the nose and mouth and that grasslands affect the nose microbiome.

Medical Examiner Review of the Characteristics of Fire-Related Homicides.

While fire-related deaths are regularly encountered by medical examiners, fire-related homicides are relatively uncommon. Although some large retrospective studies of fire-related deaths have been performed, few large studies have specifically reviewed fire-related homicides. Autopsy, scene investigation, and ancillary studies were reviewed for 38 fire-related homicides evaluated at the Wayne County Medical Examiner's Office in Detroit, Michigan. The largest proportion of cases were inhalation-related deaths in dwelling fires (n = 21, 55%), followed by deaths from thermal injury after immolation (n = 8, 21%) and traumatic death with contemporaneous or subsequent immolation (n = 8, 21%). There was one case of postmortem immolation. Although carboxyhemoglobin (COHb) levels played a significant role in evaluation of these cases, no single factor was diagnostic of a particular cause or manner of death. Fire-related homicides present unique diagnostic challenges because multiple insults frequently contribute to the cause death. Death at the scene and COHb level above 10% are the most useful factors in establishing smoke and soot inhalation as the cause of death. Some autopsy findings are helpful in establishing or ruling out smoke and soot inhalation as contributing to or sole cause of death, but an evaluation of the entire circumstances and autopsy findings is necessary.

Carfentanil-Associated Mortality in Wayne County, Michigan, 2015-2017.

To identify opioids associated with a spike in opioid-related mortality in Wayne County, Michigan, from July 2016 through February 2017. We reviewed records from the Wayne County Medical Examiner's Office of 645 people who died because of accidental nonmedically prescribed opioid overdoses from July 2015 through July 2017. We analyzed basic demographics, locations of death, and all opioid toxicology results. Decedents who died in hospitals were excluded. Of the 645 people who died because of nonmedically prescribed opioid overdoses, 65% were male and 63% were White, with an average age of 43 years. Carfentanil was detected in 129 (20%) cases. During the 8-month mortality spike, carfentanil was detected in 114 of 419 cases (average = 27.2%; range = 6.4%-45.2%). Substances most frequently detected with carfentanil included morphine (57%), 6-monoacetylmorphine (38%), fentanyl (43%), norfentanyl (33%), tetrahydrocannabinol (34%), and cocaine (29%). The Wayne County spike in mortality temporally corresponded with the detection of carfentanil and a proportional increase in opioid overdose deaths with detectable carfentanil. Public Health Implications. The abrupt decrease in carfentanil-detected mortality coincided with an announcement indicating an impending ban on fentanyl analogs from China, which suggests that source control is an effective countermeasure.

Opioid Deaths: Trends, Biomarkers, and Potential Drug Interactions Revealed by Decision Tree Analyses.

Opioid abuse is now the primary cause of accidental deaths in the United States. Studies over several decades established the cyclical nature of abused drugs of choice, with a current resurgence of heroin abuse and, more recently, fentanyl’s emergence as a major precipitant of drug-related deaths. To better understand abuse trends and to explore the potential lethality of specific drug–drug interactions, we conducted statistical analyses of forensic toxicological data from the Wayne County Medical Examiner’s Office from 2012–2016. We observed clear changes in opioid abuse over this period, including the rapid emergence of fentanyl and its analogs as highly significant causes of lethality starting in 2014. We then used Chi-square Automatic Interaction Detector (CHAID)-based decision tree analyses to obtain insights regarding specific drugs, drug combinations, and biomarkers in blood most predictive of cause of death or circumstances surrounding death. The presence of the non-opioid drug acetaminophen was highly predictive of drug-related deaths, likely reflecting the abuse of various combined acetaminophen-opioid formulations. The short-lived cocaine adulterant levamisole was highly predictive of a short post-cocaine survival time preceding sudden non-drug-related death. The combination of the opioid methadone and the antidepressant citalopram was uniformly linked to drug death, suggesting a potential drug–drug interaction at the level of a pathophysiological effect on the heart and/or drug metabolism. The presence of fentanyl plus the benzodiazepine midazolam was diagnostic for in-hospital deaths following serious medical illness and interventions that included these drugs. These data highlight the power of decision tree analyses not only in the determination of cause of death, but also as a key surveillance tool to inform drug abuse treatment and public health policies for combating the opioid crisis.

Strangulation and Its Role in Multiple Causes of Death.

Forensic pathologists have a duty to determine the cause and manner of death and are bound by international guidelines in the completion of the death certificate. Sometimes, there are complex circumstances surrounding a death that cannot be captured in the structure of the death certificate and its requirement of listing only 1 cause of death per line. Cases may have multiple causes of death with comorbid medical conditions or inflicted injuries that equally contribute to the ultimate demise. Compared with other forms of homicide, autopsy evidence of strangulation will often be found with other life-threatening traumatic injuries. The Wayne County Medical Examiner's Office conducted a retrospective study of strangulation cases that came into the office from mid-2007 to the end of 2016. The purpose of the study was to examine patterns of injuries in strangulation cases and identify those with additional traumatic injuries of commensurate extent that required incorporation into the cause of death. A total of 43 strangulation cases were found, of which there were equal numbers of ligature and manual strangulations (19 each) and 5 cases in which the method was not specified, and decedents were divided: 63% female and 37% male. Fourteen of these cases were recognized to have multiple causes of death, where blunt force trauma was the most common additional cause, and the sex distribution weighed heavily toward the female (approximately 79%).

Current Analysis of Hangings That Deviates From Recently Published Studies.

The constellation of injuries observed in hangings is a subject receiving frequent review in forensic pathology literature. Whereas recent studies have reported high concordance between hangings and internal findings such as strap muscle hemorrhages and hyoid bone and thyroid cartilage fractures, a 2-part study examining autopsied suicidal hangings over a 9-year period at the Wayne County Medical Examiner's Office produced markedly differing results. Retrospectively and prospectively, external and internal autopsy observations were correlated with factors such as age, sex, body height, body mass index, ligature, and height of suspension. In keeping with well-established forensic textbooks, nearly all cases displayed ligature marks and there was strong association between body position and the presence of petechiae. Diverging from contemporary articles, there was a distinctive paucity of internal injuries in both retrospective and prospective portions. Addressing concerns of confirmation bias, assessments confirmed the consistency in identifying and documenting injuries by the pathologists both retrospectively and prospectively.

Commode Cardia-Death by Valsalva Maneuver: A Case Series.

The Valsalva maneuver is used in clinical medicine for the diagnosis and/or treatment of various cardiovascular conditions. It can also be used in activities of daily living, such as defecation. Due to the cardiovascular effects produced during the Valsalva maneuver, it may be contraindicated in certain medical conditions and could be a trigger of sudden cardiac death. The incidence and prevalence of death following Valsalva maneuver in the presence of underlying cardiovascular disease, or "commode cardia," has not been examined. In 2012, the Wayne County Medical Examiner's Office (Detroit, MI) investigated 21 deaths that occurred on the toilet, fourteen of which were due to cardiovascular disease. In another 31 deaths in the bathroom due to cardiovascular disease, the possibility that the decedent defecated immediately prior to death could not be excluded. Hence, the incidence of commode cardia in this population ranges from 2.3 to 7.4% of all cardiovascular-related deaths.

Applying the Principles of Homicide by Heart Attack.

Homicide by heart attack is a well-established model in forensic pathology that describes death elicited during or immediately after a criminal act where a threat or fear of physical injury is present. After its introduction nearly 4 decades ago, the principle has undergone a handful of modifications but still maintains its core concepts. All cases of this nature during a 20-year period at the Wayne County Medical Examiner's Office were compared and contrasted for demographics, circumstances and scene investigation, and autopsy and toxicology findings. Of the cases fulfilling the previously established criteria for homicide by heart attack, more than 80% displayed significant changes because of hypertension. This finding coincides with the high prevalence of hypertension in our urban population and highlights the significance of this disease. Also present were minor external and internal injuries in select cases, which reinforce the understanding that physical contact between the decedent and assailant does not preclude this diagnosis.

Fibromyalgia: Comorbidity or a psychosomatic symptom of depression leading to the abuse of opioids?

Introduction: We conducted a retrospective study at the Wayne County Medical Examiner Office, which examined decedents diagnosed with Fibromyalgia, a disorder of unknown etiology characterized by widespread chronic musculoskeletal pain, concomitant with fatigue, sleep disturbances, and psychological distress. Material & Methods: Over a seventeen year period a total of 54 cases from our database met this criterion. Other criteria in the study included cause and manner of death, post-mortem toxicology results, major autopsy findings, and medical history. Results: Our study revealed that the cause of death in approximately two-thirds of the cases was due to drug intoxication. The most frequent post-mortem toxicology finding was Opioids, such as Morphine, Hydrocodone, Oxycodone, Fentanyl, and Codeine. The most common manner of death was accident. Almost 90% of the decedents were Caucasian females, which contrasted with the demographic diversity of Wayne County, Michigan. Additional findings revealed that the average age was 47 years, and the average Body Mass Index (BMI) could be categorized as obese. Nearly 67% of the cases had a medical history of depression. Conclusion: Our findings suggest that Fibromyalgia might be a psychosomatic symptom of depression rather than comorbidity. Therefore, physicians should further inquire about, and consider treating, depression in patients with chronic musculoskeletal pain while completely avoiding the use of opioids, for opioids have a greater risk of being abused and resulting in death in such patients, as found in our study.

Companion Cases in a Large Urban Medical Examiner's Office.

Companion death cases, as defined in this study, include 2 or more deaths that occur at the same location or 1 death at a specific location combined with 1 or more individuals transported from that same location to a hospital where death was pronounced within 1 hour of arrival. These types of cases can have multiple causes and manners of death. The Wayne County Medical Examiner's Office conducted a retrospective study of companion death cases that came into the office from mid 2007 to the end of 2014. The purpose of the study was to identify and examine patterns of companion death cases in a large urban area that would assist future companion death case investigations. Three hundred fifty deaths were found to be companion cases, including 135 pairs (2 connected deaths in the same location), 20 trios, and 5 quartets. Approximately 49% of companion case deaths were homicides. Approximately 30% of companion case deaths were traumatic accidental deaths. Around 14% of companion case deaths that were from the same scene location had different manners of death, including suicide, homicide, natural, and indeterminate. The remainder of companion death cases were either drug related or natural. Through this study, we have identified a pattern to these companion death cases and have concluded that it is important to conduct a thorough medicolegal death investigation of such cases to establish and elucidate the true circumstances surrounding these deaths.

Contribution of opiates in sudden asthma deaths.

Asthma is a common disease in the United States and is frequently encountered during medicolegal autopsies. Patients are often young and have a witnessed collapse or are found dead. Opiate abuse is also pervasive and is repeatedly seen in death investigations. All cases over a 7-year period involving asthma investigated at the Wayne County Medical Examiner's Office were reviewed for demographics, circumstances, autopsy toxicology findings, and cause and manner of death. Ninety-four cases met these criteria. Ten cases (10.5%) were positive for opiates, 8 listed drugs as the cause of death, and 2 listed asthma. Of cases with established asthma opiate positivity, 8 (80%) were found dead, and only one had a witnessed collapse. Compared with those without opiate abuse, asthmatic patients abusing opiates had a higher mean age, no reported respiratory symptoms immediately preceding death, and higher frequency of being found dead. A discernable difference exists between deaths in asthmatic patients in the presence of opiates and those without. These findings indicate that it may be possible to predict the presence of opiates given history investigation information, thereby focusing toxicology panels to promote cost-effective practices when ordering supportive tests.

Review of: Forensic Neuropathology: A Practical Review of the Fundamentals

Journal of Forensic SciencesVolume 54, Issue 4 p. 966-966 Review of: Forensic Neuropathology: A Practical Review of the Fundamentals Carl J. Schmidt M.D., M.P.H., Carl J. Schmidt M.D., M.P.H. Wayne County Medical Examiner’s Office, 1300 Warren, Detroit, MI 48207.Search for more papers by this author Carl J. Schmidt M.D., M.P.H., Carl J. Schmidt M.D., M.P.H. Wayne County Medical Examiner’s Office, 1300 Warren, Detroit, MI 48207.Search for more papers by this author First published: 23 June 2009 https://doi.org/10.1111/j.1556-4029.2009.01092.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume54, Issue4July 2009Pages 966-966 RelatedInformation

Gender and Suicide Risk: The Role of Wound Site

That males have higher suicide rates than females is one of the most empirically documented social facts in suicidology, but the reasons for this continue to be debated. For the present paper, we tested a neglected contributing factor to the gender suicide ratio: wound site or the area of the body that is wounded in firearm suicides. Males may have a higher suicide rate, in part, due to their greater likelihood than women for shooting themselves in the head as opposed to the body. This has been related to gender differences in fear of facial disfigurement and suicide intent. Data from the Wayne County Medical examiner's office regarding 807 suicides committed with firearms was analyzed. The dependent variable was dichotomous and referred to the location of the site of the wound: gunshot to the head vs. gunshot to the body. Controls for demographic covariates of suicide included age and race of the suicide victim. The results of the multivariate logistic regression analysis determined that women were 47% less apt than men to shoot themselves in the head. Further analysis determined that women were less apt than men to use shotguns and rifles in their suicides (weapons that make head shooting more awkward). The findings are consistent with the notion that women are more concerned than men with facial disfigurement, and that women have a lower desire to die than men.

Infant Death Scene Investigation and the Assessment of Potential Risk Factors for Asphyxia: A Review of 209 Sudden Unexpected Infant Deaths

At the Wayne County Medical Examiner Office (WCMEO) in Detroit, Michigan, from 2001 to 2004, thorough scene investigations were performed on 209 sudden and unexpected infant deaths, ages 3 days to 12 months. The 209 cases were reviewed to assess the position of the infant at the time of discovery and identify potential risk factors for asphyxia including bed sharing, witnessed overlay, wedging, strangulation, prone position, obstruction of the nose and mouth, coverage of the head by bedding and sleeping on a couch. Overall, one or more potential risk factors were identified in 178 of 209 cases (85.2%). The increasing awareness of infant positions at death has led to a dramatic reduction in the diagnosis of sudden infant death syndrome at the WCMEO. This study suggests that asphyxia plays a greater role in many sudden infant deaths than has been historically attributed to it.

Death Caused by Myocarditis in Wayne County, Michigan

This paper reviews 72 cases of death caused by myocarditis between the years 1996 and 2004, autopsied at the Office of the Wayne County Medical Examiner in Michigan. Myocarditis as a cause of sudden and unexpected death represented 1.3% of all natural deaths in Wayne County during said period. The year 1999 contained the highest number of deaths of this cause (18), where the average number of myocarditis deaths was 8 per year for this 9-year span. In this study, each case was reviewed based on information gathered from investigative, autopsy, and toxicology reports. Significantly, 58% of these cases were male, and 63.4% were African American. Myocarditis caused death in every age group between 7 months and 67 years, but adults between the ages of 19 and 67 were most significantly affected (75%). Flu and/or cold were the most common symptoms experienced in the days directly proceeding death (28%), followed by shortness of breath (17%) and sudden collapse (15%). Sixty-nine percent of these 72 cases were pronounced dead after ACLS (advanced cardiac life support) protocol by emergency medical services or hospital attendants. Cardiomegaly was observed in 24 cases of adults aged 19 or older (54%), and flabby/soft myocardial tissue was observed grossly in 16% of all 72 cases.

Apparent Suicidal Carbon Monoxide Poisonings with Concomitant Prescription Drug Overdoses

We report four separate suicides by apparent motor vehicle-related carbon monoxide (CO) poisoning in which complete toxicological analysis showed the absence of, or lower than expected, percent carboxyhemoglobin saturation and high concentrations of concomitant prescription drugs. These cases, within a population of 71 apparent CO suicides from the Wayne County Medical Examiner's Office over 1998-2004, represent cases where additional factors are in play. Multiple modalities (CO poisoning and drug overdose) and/or undetectable carbon dioxide poisoning from the vehicle exhaust of cars manufactured after laws regulating vehicle emissions were enacted are examples of additional factors that require consideration in these selected cases. All four cases demonstrated some degree of decomposition, so the possible loss of CO could not be ruled out. The need for full toxicological analysis in apparent suicidal CO poisoning is emphasized.

Self-inflicted accidental gunshot wounds

This presentation will demonstrate the dangers of using a loaded gun as a blunt force object and designing toy guns to mimic realistic weapons. The ultimate goals of this presentation are to increase public education by promoting strict adherence to standard guidelines for safe gun usage, and to re-evaluate the future of toy gun designs that realistically mirror designs of current weapons. In a review of firearm deaths in the Wayne County Medical Examiner's Office (Detroit, Michigan, USA) over 10-year period from 1990 to 2000, there was an average of 500 cases of firearm deaths per year. This figure includes homicides, suicides and accidents. Among the 500 cases, seven of the most unusual self-inflicted accidental gunshot deaths are selected for this presentation.

Cocaine in Wayne County Medical Examiner's Cases

We determined the incidence of detection of cocaine or its metabolites in Wayne County (Michigan) Medical Examiner's cases from 1984 to 1987. Over this four-year period there was a significant (P less than 0.01) increase each year in evidence of recent cocaine use in this population, reaching 38.3% of all tested cases in 1987. Much of this increase was accounted for by homicide victims, especially those in their third or fourth decade of life, of whom 58.6 and 56.3%, respectively, tested positive in 1987. There was a large increase in recent cocaine use in teenage homicide victims in 1987, having previously changed little from 1984 to 1986. In victims of drug abuse, recent cocaine use also increased significantly (p less than 0.01) each year, reaching 47.6% in 1987, generally in combination with heroin. Although deaths attributed solely to cocaine were not as common, they also increased significantly each year from 4 in 1984 to 25 in 1987. Compared with the general population, those who use cocaine in Wayne County are more likely than those who do not to die prematurely, often as a result of violence.

Death as a Result of Asthma in Wayne County Medical Examiner Cases, 1975–1987

All deaths ascribed to asthma in the 5-to-40-year age group at the Wayne County Medical Examiners' Office were reviewed from 1975 to 1987 inclusive. Fifty-eight deaths were attributed solely to asthma, and the annual number increased fivefold in the 1980s to a rate of approximately 0.5 per 100,000 per year when extrapolated to the Wayne County population. Blacks were overrepresented to double their proportion in the general population. Almost all cases were known asthmatics, and many had received previous emergency care. Most fatalities occurred at night and did not demonstrate any seasonal variation. The onset of the fatal attack was apparently very rapid in most cases, with many engaged in routine activities and few surviving any length of time in hospital or having sought treatment earlier. Our data reveal a significant increase in sudden death in previously well asthmatics in Wayne County in the 1980s. Similar increases in deaths as a result of asthma have been noted previously in other countries for reasons that remain unclear.