Oral abuse of fentanyl patches (Duragesic): seven case reports

In order to increase the understanding regarding the oral abuse and potential toxicity of fentanyl patches seven cases were identified over a 3-year period where fentanyl, either alone or in combination with other factors, contributed to death following the oral abuse of Duragesic patches. The decedents comprised three females and four males with ages ranging from 20 to 51 years. Postmortem blood fentanyl concentrations were determined in all cases and ranged from 7 to 97 ng/mL. Two deaths were classified as a fentanyl overdose, three deaths were classified as a fentanyl and ethanol overdose, one death was considered a mixed drug intoxication and the remaining death was determined to be a combination of fentanyl and medical causes. These cases represent the largest reported series of deaths following the oral administration of transdermal fentanyl patches and provide detailed information on the potential for the abuse of transdermal Duragesic patches via this route. The postmortem blood fentanyl concentrations detected for each of the decedents demonstrate the potentially fatal blood concentrations that can arise after this relatively rare route of administration.     

Firearm Deaths by Law Enforcement

Abstract:  The use of deadly force during law enforcement is a matter that compels public scrutiny. There were 42 gunshot deaths caused by police over a 4-year period in New York City. The decedents' average age was 31 years and ranged from 17 to 64 years. There were 41 males and one female; and 26 Black, nine Hispanic, and seven White decedents. Ethanol and/or drugs of abuse were detected in 78% (31/40) of the decedents. The vast majority of shootings occurred with the police responding to a crime and 90% of the decedents were armed (26 handguns, six knives, one axe, one metal pipe, and one toy gun). Vehicles were used as weapons in two incidents. A total of 177 bullets struck the 42 decedents. Fourteen decedents sustained single gunshot wounds (GSWs), and the remainder had multiple GSWs ranging from 2 to 21. In the majority of the cases in this study, the number of GSWs of the body was three or fewer. Thirteen decedents had at least one GSW of the back or buttocks, accounting for 25 of the total 177 wounds, and four of the 13 had GSWs of only the back. With the exception of the upper extremities, GSWs of all locations were more likely to penetrate than perforate. Although these deaths may be high profile, the certification is typically straightforward and the cause (i.e., GSW) and manner of death (homicide) are readily apparent. Although police shootings in which the decedent was unarmed and/or sustained numerous GSWs are widely reported by the lay press, these types of shootings were not typical in our study.     

Trends in Officer‐involved Firearm Deaths in Oklahoma from 2000 to 2015

The purpose of this study was to collect data and disseminate trends in officer‐involved firearm deaths in Oklahoma from 2000 to 2015. The Oklahoma Office of the Chief Medical Examiner (OCME) database was searched for civilian decedents with gunshot wounds inflicted by law enforcement officers and officer decedents with gunshot wounds inflicted by civilians. Five decedents were law enforcement officers, while 274 decedents were civilians. The number of civilian decedents throughout the study followed a quadratic trend. Civilian decedents were most commonly males (95%) between the ages of 20 and 39 (64%), had one or two gunshot wounds (46%), and had an increasing number of gunshot wounds over time. Postmortem toxicology testing most commonly detected ethanol, methamphetamine, cocaine, and PCP. Efforts toward increased tracking by various agencies and more scientific studies like this are needed to facilitate future analysis of trends in officer‐involved firearm deaths.     

A “concrete” identification in a dismemberment case

Homicide perpetrators can use concrete as a means to conceal their victims. When concrete encasement is encountered in the forensic field, albeit rarely, it is often coupled with postmortem dismemberment. This method of obscuring the evidence presents unique investigative obstacles, specifically related to identification. Various approaches to obtaining fingerprints from decedents encased in concrete have been suggested and implemented over the years. The presented case is that of an initially unidentified 44-year-old male, who was subject to postmortem dismemberment and concrete encasement. Meticulous excavation techniques facilitated preservation of evidence and an anatomical reconstruction of the body. These techniques enabled inspection of the incision sites of the dismembered remains during the postmortem examination. Identifiable jewelry and tattoos were noted at autopsy. Further, the resulting concrete molds could be utilized to obtain fingerprints. These prints were used to ultimately identify the decedent.     

607例不同年份中毒尸检资料对比分析

目的研究不同年份中毒案例的毒物种类、中毒途径、中毒方式等相关问题,为此类案例的法医学鉴定提供参考。方法对华中科技大学同济医学院法医学系（湖北同济法医学司法鉴定中心）1957—2008年鉴定的607例中毒案例尸检资料进行对比分析。结果 1999—2008年218例中毒案例中死者男性居多,30～49岁占50%,中毒以口服方式为主,意外中毒居首位,毒物种类以杀鼠剂、有毒气体、农药类位居前三位。与1983—1998年及1957—1982年的中毒尸检资料对比,不同年份间毒物种类明显变化,近年农药、氰化物中毒减少,杀鼠药、有毒气体及醇类中毒增加,毒品滥用激增。结论农药中毒是长期威胁公众健康的一类毒物,须对此提高防范意识;对联合中毒日益增多的趋势应引起关注。     

Multiple Symmetric Lipomatosis

A significant number of medicolegal deaths involve ethanol. Deaths may be related to the acute, intoxicating effects of ethanol, either in decedents or within persons responsible for causing the deaths of others. Additionally, deaths may be related to chronic alcoholism. A chronic alcoholic may display characteristic external features which allow an observer, such as a forensic pathologist or other physician, to conclude that he/she is probably an alcoholic. Herein, the authors report two decedents with a rare condition known as “multiple symmetric lipomatosis” (MSL), which has a strong correlation with chronic alcoholism. Identification of the peculiar features associated with MSL should prompt the forensic pathologist to consider chronic alcoholism as a probable diagnosis.     

Psychosocial Complications of Crohn's Disease and Cause of Death

Patients who suffer from Crohn's disease are prone not only to the complications of a relapsing, unpredictable disease, but also to feelings of stigmatization; depression; and increased risk of suicidal ideation, suicide, or drug and alcohol abuse. Cases performed at the Jackson County Medical Examiner's Office from 2008 to 2010 were reviewed. Autopsy findings, investigator reports, toxicology results, medical records, and interviews with survivors were analyzed. Twelve cases of Crohn's disease were recovered. In 10 of these cases, inflammatory bowel disease was not the cause of death. Instead, psychosocial consequences of the disease had significant implications in the deaths. The mean age of decedents was 45 years, with a female predominance. In eight cases, the decedents lived alone. Five patients had issues of acute or chronic drug or alcohol use. Five patients committed suicide. These cases underscore the role of psychosocial factors that can contribute significantly to the cause of death in patients with Crohn's disease.     

A study of drug detection in a postmortem pediatric population

At The Office of the Cuyahoga County Coroner (CCCO), Cleveland, Ohio, it is customary to perform an autopsy and conduct toxicological testing on decedents less than 19 years of age. This study provides a retrospective evaluation of drugs detected in a pediatric postmortem population between the years 1998 and 2002 (n = 730). Demographic information, cause and manner of death, and toxicological results were examined. Blacks comprised 54% of cases, males 59%, and 48% were less than one year of age or stillborn. Forty-two percent of deaths were ruled natural, 27% accident, 13% undetermined, 5% suicide, and 2% homicide. Of the 640 cases subjected to comprehensive testing, 38% of the cases were positive for at least one compound. Resuscitative/treatment drugs were detected most frequently (56% of positive results), followed by illicit drugs (26%), ethanol (11%), carbon monoxide (8%), and antihistamines (6%). Eighty-seven cases contained more than one drug. The deaths of 47 individuals were drug related (6%). In this population, it is recommended that illicit drugs and ethanol are targeted for testing, especially when limited specimens are available for analysis.     

Lightning Deaths: A Retrospective Review of New Mexico's Cases, 1977–2009

To better understand lightning deaths, a retrospective review of electronic records from New Mexico's Office of the Medical Investigator database was performed between 1977 and 2009 to update and assess current risk factors. Information on demographics, circumstances, autopsy, and death certificates were collected and analyzed. Fifty‐four decedents were identified, ages 2–71 years old (mean 34 years old), 42 males and 12 females. Common racial/ethnic groups were non‐Hispanic Whites and American Indians (together comprising 72% of all cases). Physical findings were often related to the heat carried by the electrical current including clothing alterations (29.6%) and burning of skin (53.7%). Most deaths occurred on weekend afternoons in summer months, associated with recreational activities or agricultural work, and rural locations (77.8%). Utilizing the demographic information, clustered events, and associated outdoor activities will assist in creating public awareness and provide a framework to support targeted warnings in an attempt to prevent future deaths.     

Fatal footsteps: murder of undocumented border crossers in Maricopa County, Arizona

In the past 5 years, the mortality rate among undocumented workers in Arizona has increased steadily. In 1998-1999, the number of deaths among border crossers was 28. That number increased dramatically in 1999-2000 to 106 and has exceeded 200 in each of the past 2 years. In the past, many immigrant deaths occurred as a result of dehydration and exposure (1). More recently, a new trend has emerged, that is, death of border crossers at the hands of the persons ("coyotes") hired to lead them across the border to safety. In some cases, the smugglers attempt to extort additional money from the families by holding the victims hostage once they have crossed the border into the United States. If the families fail to pay, the hostage is killed. Rival gangs are also murdering one another over their human cargo. Nine recent cases illustrate this trend in Maricopa County. In each example, the victims were bound, shot (or in one instance stabbed) and dumped in a remote desert area. All of the decedents were linked to murder for extortion by the 'coyotes' or rival gang members.     

Trace Evidence Potential in Postmortem Skin Microbiomes: From Death Scene to Morgue

Microbes can be used effectively as trace evidence, at least in research settings. However, it is unknown whether skin microbiomes change prior to autopsy and, if so, whether these changes interfere with linking objects to decedents. The current study included microbiomes from 16 scenes of death in the City and County of Honolulu and tested whether objects at the scenes can be linked to individual decedents. Postmortem skin microbiomes were stable during repeated sampling up to 60 h postmortem and were similar to microbiomes of an antemortem population. Objects could be traced to decedents approximately 75% of the time, with smoking pipes and medical devices being especially accurate (100% match), house and car keys being poor (0%), and other objects like phones intermediate (~80%). These results show that microbes from objects at death scenes can be matched to individual decedents, opening up a new method of establishing associations and identifications.     

Fatalities associated with fentanyl and co-administered cocaine or opiates

Fatalities associated with fentanyl hydrochloride are increasingly seen in Massachusetts. Between September 2005 and November 2006, 5009 medicolegal investigations associated 107 deaths with licit or illicit fentanyl use, along with a co-detection of an opiate/opioid or cocaine/benzoylecognine, or both. Deaths associated with illicit fentanyl use occur in younger people (39.4 vs. 61.5 years) with higher fentanyl (17.1 ng/mL vs. 4.4 ng/mL) and lower morphine (76.9 ng/mL vs. 284.2 ng/mL) postmortem blood concentrations, and more frequent cocaine co-intoxication (65% vs. 3%), than deaths associated with illicit fentanyl use. A wide range of postmortem blood concentrations of fentanyl was detected (trace-280 ng/mL), with a minimum concentration of 7 ng/mL of fentanyl strongly associated with illicit use of fentanyl in poly-drug cases. The most commonly detected opiates/opioids in illicit fentanyl users were: morphine (29%), oxycodone (14.5%), and methadone (14.5%). Ethanol, cannabinoids, diazepam, citalopram, and diphenhydramine were each detected in greater than 10% of the licit fentanyl cases. Most fentanyl abusers died at their own home and their deaths were most often classified as accidental. Mapping of primary residences of decedents revealed conspicuous clustering of the illicit fentanyl use cases, as opposed to the random pattern in licit use cases. Fentanyl misuse is a public health problem in Massachusetts.     

The prevalence of drugs in carbon monoxide-related deaths: a retrospective study, 2000-2003

The objective of this study was to review demographic characteristics and drugs detected in carbon monoxide (CO)-related deaths from cases received by the Office of the Cuyahoga County Coroner in Cleveland, Ohio, from 2000-2003. Postmortem reports were reviewed, and decedents for which CO was listed as the cause of death were included. The data were compiled into 3 groups according to the official coroner's verdict as to the manner of death: accident, suicide, and homicide. Included in this study were 122 cases: 84 (69%) accidental, 31 (25%) suicide, and 7 (6%) homicide. Accident decedents were typically white males, aged 40-59 years, residing in Cleveland. Suicide decedents were also middle-aged, white males but residing in the suburbs. Homicide decedents under the age of 6 were characteristically black (N=2), while decedents over the age of 39 were predominately white (N=3). Carboxyhemoglobin (COHb) levels in suicide cases were higher than concentrations measured in accidental deaths. The highest percentage of suicide decedents (36%) had a COHb level>70% saturation, accident decedents (36%) between 50% and 69% saturation, and homicide decedents (71%) below 50% saturation. Ethanol (N=34) was detected in 28% of deaths, and therapeutic and/or abused drugs (N=50) were detected in 41% of deaths. Illicit drugs were detected in 11% of cases (cocaine/metabolites; THC/metabolites), other drug positives were therapeutic medications. The most common drugs detected were antidepressants and antihistamines in suicides and pain medications and antihistamines in accidents.     

A Novel Method for Removing a Spinal Cord with Attached Cervical Ganglia from a Pediatric Decedent

A diagnosis of child abuse is dependent on a comprehensive and accurate assessment of injury in the context of a thorough investigation. However, signatures of trauma are often subtle and interpretation can be very difficult. Recently, researchers have refocused their attention from the head to the neck in search of traumatic signatures of abusive head trauma. HCIFS has developed a technique to remove the cervical spinal cord with the ganglia attached that is less destructive and more time and cost efficient than alternative methods previously published. Once removed, the dorsal nerve roots and ganglia are evaluated for the presence of hemorrhage. The authors performed a small pilot study using the novel method to evaluate 20 decedents with a history of blunt force trauma and eight without a traumatic history. Fifteen of the traumatic deaths and two of the nontraumatic deaths were found to have dorsal nerve root and/or ganglia hemorrhage.     

Adolescent death: a 15-year retrospective review

Adolescents comprise an eclectic mix of people vitally important to society yet long-term comprehensive studies on the circumstances of their deaths are lacking in the pediatric forensic literature. The authors reviewed all forensic cases referred to the Medical University of South Carolina Forensic Pathology section over the fifteen years between January 1989 and December 2003. In accordance with the World Health Organization (WHO) definition of adolescents, only decedents 10-19 years of age were included. The authors examined the cause and manner of death, age, gender, and race of the victims in all cases. The toxicology results, perpetrator, death scenario and location, and victim traits were analyzed when available. For all adolescents, the most common manner of death was accident followed by homicide, suicide, natural, and undetermined. Within the adolescent population two distinct groups, 10-14 years old and 15-19 years old, were identified. Though both groups were similar in that they experienced a high number of accidental deaths, decedents of older age group suffered a higher percentage of violent deaths while decedents of the younger group were more likely to die of natural causes. Many of the accidental deaths in this review were preventable, including deaths due to motor vehicle collisions and drowning. In deaths due to homicide, the perpetrator was often known to the victim, whether as an acquaintance or family member. Toxicology testing was often positive in decedents of the older age group, while only rarely positive in decedents of the younger age group. With a solid understanding of the circumstances, it may be possible to predict, and hopefully prevent, future cases of adolescent death. The authors present their findings in this 15-year retrospective study to better aid forensic pathologists, death investigators, law enforcement, and epidemiologists.     

Fatal Intoxication with Toluene Due to Inhalation of Glue

Two cases of fatal intoxications with toluene due to glue sniffing are described. In case 1, the autopsy did not indicate cause of death, while in case 2, the cause of death was determined to possibly be due to mechanical asphyxia by drowning. As the decedents had a history of glue sniffing, toxicological analyses were performed. Using gas chromatography with flame ionization detector and gas chromatography/mass spectrometry (GC/MS) with headspace method, toluene was detected in biological samples. Toluene ranged from 3.81 to 20.97 μg/g, with the highest concentrations observed in liver and brain (13.82–20.97 μg/g) in both cases. Based upon this data, the cause of death in both cases was determined to be toluene poisoning. Toxicological investigations are extremely important and should be considered mandatory in all deaths thought to be due to volatile substance abuse, as well as all deaths that are thought to be due to poisoning in young people.     

Cannabinoid Hyperemesis Syndrome: Reports of Fatal Cases

Cannabinoid hyperemesis syndrome (CHS) is one of the more clinically challenging effects of cannabis consumption. It is characterized by cyclic attacks of nausea and vomiting in chronic cannabinoid users and learned behavior of compulsive hot bathing. The deaths of a 27‐year‐old female, a 27‐year‐old male, and a 31‐year‐old male with a history of CHS are reported. The decedents had a history of cyclical nausea and vomiting, chronic cannabinoid use and negative laboratory, radiological and endoscopic findings. All presented to the emergency department with nausea and vomiting in the days preceding death and were treated symptomatically. Toxicological analysis revealed tetrahydrocannabinol in postmortem blood. The cause of death of two of the three cases was attributed to CHS. CHS was appreciated in the third case but was not the cause of death. These three cases demonstrate the importance of recognizing CHS as a potential cause or contributing factor to death in cannabinoid user.     

Medical examiner response to the drug overdose epidemic in King County Washington: “Real-time” surveillance,data science,and applied forensic epidemiology

As the overdose epidemic overwhelmed medicolegal death investigation offices and toxicology laboratories, the King County Medical Examiner's Office responded with “real-time” fatal overdose surveillance to expedite death certification and information dissemination through assembling a team including a dedicated medicolegal death investigator, an information coordinator, and student interns. In-house testing of blood, urine, and drug evidence from scenes was performed using equipment and supplies purchased for surveillance. Collaboration with state laboratories allowed validation. Applied forensic epidemiology accelerated data dissemination. From 2010 to 2022, the epidemic claimed 5815 lives in King County; the last 4 years accounted for 47% of those deaths. After initiating the surveillance project, in-house testing was performed on blood from 2836 decedents, urine from 2807, and 4238 drug evidence items from 1775 death scenes. Time to complete death certificates decreased from weeks to months to hours to days. Overdose-specific information was distributed weekly to a network of law enforcement and public health agencies. As the surveillance project tracked the epidemic, fentanyl and methamphetamine became dominant and were associated with other indicators of social deterioration. In 2022, fentanyl was involved in 68% of 1021 overdose deaths. Homeless deaths increased sixfold; in 2022, 67% of 311 homeless deaths were due to overdose; fentanyl was involved in 49% and methamphetamine in 44%. Homicides increased 250%; in 2021, methamphetamine was positive in 35% of 149 homicides. The results are relevant to the value of rapid surveillance, its impact on standard operations, selection of cases requiring autopsy, and collaboration with other agencies in overdose prevention.     

John and Jane Doe: the epidemiology of unidentified decedents

Abstract:  The number of people who cannot be identified at the time of death, sometimes referred to as John or Jane Does, is unknown, and little is known about them as a group. The study's objectives were to estimate the number of annual unidentified deaths, to identify demographic characteristics associated with dying unidentified, to determine whether the rates of such deaths vary geographically or over time, and to better characterize the causes of death. This was a population-based surveillance study of data collected from death certificates from 1979 to 2004 in the U.S. Subjects were selected by the absence of name, date of birth, and Social Security Number on their certificates. Main outcome measures were distributions by age, sex, and underlying cause of death and rates by sex, race, year, and state of death. An average of 413 unidentified persons died each year. The peak year was 1987 with 691 deaths, a rate of 28.5 per 10 million people. The rate declined to 9.7 per 10 million in 2004. Most unidentified decedents were male (80.6%). Unidentified death rates were highest among black people and in the Southwest. Among deaths for which the cause was known, 82.7% were due to injuries. Among injury deaths, 31.8% were homicides. Improvement in identification technology may have reduced rates of unidentified death since the 1980s. In addition, variations in rates of unidentified decedents may reflect changes in risk factors such as homelessness and substance abuse.