Amy C. Gruszecki

Investigation of elderly deaths in nursing homes by the medical examiner over a year.

Despite death being one of the most common reasons for discharge from a nursing home, fewer than 1% of nursing home resident deaths are autopsied. To evaluate our role as medical examiner in nursing home deaths, we conducted a retrospective review of all decedents in Jefferson County, Alabama, for the year 2001. Death certificate data indicate that 995 deaths occurred in nursing homes in Jefferson County in 2001. Of those 995 deaths, 119 (12%) were reported to the Jefferson County Coroner/Medical Examiner Office. Jurisdiction was accepted in 5 cases in which the circumstances already made clear that the death was a nonnatural event. In the remaining 96% of nursing home deaths reported to the medical examiner, the statements of the reporting person were taken to be true concerning the expected nature of the death. An independent scene evaluation was provided by a police officer or paramedic in 82% of the cases reported to the medical examiners office. Elderly individuals, as a group, are expected to die, but the death of a particular elder may or may not be expected. In our jurisdiction, only 12% of all nursing home deaths are reported to our office, and only 4% of reported deaths are actively investigated. Actively investigating each nursing home death would overwhelm the resources currently available to our office. We advocate the study and development of criteria to aid in determining whether the death of an individual elder is sudden and unexpected.

Utilization, Reliability, and Clinical Impact of Point-of-Care Testing during Critical Care Transport: Six Years of Experience

The use of point-of-care testing (POCT) has been reported in the setting of critical care transport (1)(2)(3)(4)(5)(6), although the overall benefits have not been evaluated in depth. In addition, problems with testing reliability may be uncovered only after an extended period of field use. This report describes the use of POCT by our critical care transport program over 6 years. All critical care transports made from January 1996 to December 2001 were reviewed. Transport vehicles were ambulances or twin-engine jets. The transport teams consisted of a physician on transport or with radio contact, a respiratory therapist, and a registered nurse. All transports were equipped with i-STAT® portable analyzers (i-STAT® Corporation) and disposable cartridges for testing. The analyzer and cartridges were stored in an insulated bag for temperature control during the trip. The analytical performance verification protocol (electronic controls) recommended in the i-STAT System Manual was followed before each patient test. Liquid controls were run monthly. Proficiency testing was completed in accordance with the requirements of the College of American Pathologists. The manufacturer’s test cartridges were the G3, 6+, EG7+, and glucose. Tests included pH, P co2, P o2, calculated bicarbonate, total CO2, base excess, oxygen saturation, sodium, potassium, chloride, urea, glucose, hematocrit, and calculated hemoglobin and glucose. Each cartridge requires 65 μL of whole blood for testing. The blood was drawn and analyzed by physician order. From 1997 through 2001, the team filled out an evaluation form for quality review after cases where POCT was performed. Patient test results and charts for each POCT episode were reviewed retrospectively to identify changes in treatment linked to test results. Other data were extracted from transport department and quality-control records. This research was approved by …

The predictive value of history and scene investigation for toxicology results in a medical examiner population.

Medical examiner offices vary in the extent to which they pursue postmortem toxicology. Our office routinely tests decedents for ethanol and drugs of abuse, and we decided to evaluate the usefulness of our practice. We reviewed 1180 medical examiner cases examined in 2002–2003. History and scene investigation indicated that alcohol or drugs of abuse were likely to be detected in 369 cases, yet toxicology testing revealed an intoxicating substance in 589 cases, a prevalence of 50%. Screening for toxicology testing based on investigative findings had a sensitivity of 0.47, a specificity of 0.84, and a positive predictive value of 0.74. Moreover, even in the 811 cases where initial investigation did not suggest substance abuse, toxicology testing revealed at least 1 substance that was pertinent to the subsequent investigation in one third of the cases (260), and the intoxicating substance was sufficiently important to merit inclusion as a cause of death or contributing factor in nearly half of those cases (113). We conclude that investigation alone is ineffective at predicting the presence of intoxicating substances within decedents.

Unexplained Sudden Death and the Likelihood of Drug Abuse

The common history of drug abuse in adults with an undetermined cause of death has led us to hypothesize that chronic drug abuse increases the risk of sudden death. To begin evaluating this hypothesis, we conducted a retrospective case-control study of 61 decedents whose cause of death remained undetermined following autopsy matched one to one to a control group of pedestrians or passengers killed in motor vehicle collisions. In 21 pairs, the case subject had evidence of drug abuse but the control did not, and in 5 cases the reverse was true. Analysis showed that individuals with an undetermined cause of death are 4.2 times more likely to have evidence of drug abuse than are victims of a motor vehicle collision.

Plasma Cell Crystalline Inclusions

A woman presented to her primary care physician with right shoulder pain. There was no history of trauma to the shoulder. Her past medical history was notable for a left nephrectomy 25 years earlier, secondary to complications of sepsis. At time of presentation, the woman had hypertension, osteoarthritis, and mild renal insufficiency with proteinuria. Radiographs of her shoulder revealed a large bony lesion of the proximal humerus with an associated pathologic fracture. Other lytic lesions were identified in the glenoid, the distal right clavicle, and the inferior scapula. Laboratory values included calcium, 9.9 mg/dL (2.48 mmol/L) (reference range, 8.4– 10.2 mg/dL [2.05–2.55 mmol/L]); phosphorus, 3.8 mg/dL (1.23 mmol/L) (2.7–4.5 mg/dL [0.74–1.52 mmol/L]); glucose, 84 mg/dL (4.7 mmol/L) (70–105 mg/dL [2.8–4.4 mmol/L]); sodium, 140 mEq/L (133–145 mEq/L); potassium, 3.6 mEq/L (3.3–5.1 mEq/L); creatinine, 1.4 mg/dL (107 mmol/L) (0.4–1.2 mg/dL [8–31 mmol/L]); serum urea nitrogen, 16 mg/dL (5.7 mmol/L) (6–19 mg/dL [2.9–8.2 mmol/L]); and albumin, 3.9 g/dL (3.9–4.8 g/dL). A urine and serum immunofixation electrophoresis revealed a monoclonal gammopathy of free k light chain. A bone marrow aspirate and biopsy was done to rule out multiple myeloma. The bone marrow aspirate was also sent for flow cytometry. The bone marrow biopsy showed hypercellular marrow (60%–70%) with replacement by plasma cells. Several megakaryocytes were noted, and erythroid and myeloid precursors were decreased. The plasma cells were atypical and had large nuclei. The bone marrow aspirate stained with Wright-Giemsa showed several crystalline structures in the cytoplasm of the plasma cells (50%–60%) (Figure, oil immersion, original magnification 3760). They were unstained, needlelike in shape, and were not birefringent. Cytoplasmic immunoglobulin stains revealed k light chain restriction; however, the crystals remained unstained. The bony trabeculae were unremarkable. Prussian blue stain showed iron present mostly in macrophages. No ringed sideroblasts were noted. Flow cytometry confirmed a clon-

Rhizobium radiobacter bacteremia and its detection in the clinical laboratory

Abstract Rhizobium radiobacter is an aerobic, gram-negative bacterium closely related to several species of plant pathogens that occur in soils worldwide. It has been associated with human systemic diseases, including peritonitis, urinary tract infection, cellulitis, and myositis. Only eight isolates of R. radiobacter have been encountered in the Clinical Microbiology Laboratory at the University of Alabama at Birmingham Medical Center between 1995 and 2000, four of which were detected in blood cultures of immunosuppressed and/or debilitated patients. Both the RapID NF Plus and the BBL Crystal bacterial identification systems readily identified the organisms. Antimicrobial susceptibilities for R. radiobacter varied and should be tested in each case to guide therapy. Drugs such as ciprofloxacin, piperacillin-tazobactam, trimethoprim-sulfamethoxazole, ceftriaxone, imipenem, gentamicin, and amikacin were reasonable therapeutic choices for the organisms we encountered.

An unusual finding of plasma cell iron.

56-year-old woman presented with cryptogenic liver cirrhosis, diabetes, hypertension, hypothyroidism, and myelodysplasia. She reported a history of splenectomy for idiopathic thrombocytopenic purpura 12 years earlier and 2 recent episodes of hepatic encephalopathy. She said she does not drink alcohol. The patient said she was on a number of medications, most notably erythropoietin. She was being evaluated for liver transplantation. As part of the transplant evaluation, a bone marrow study was performed to assess her myelodysplastic changes. The peripheral smear showed macrocytosis of the red blood cells with a mean corpuscular volume of 134 fL (reference range, 83‐99 fL). Occasional target cells and a few Howell-Jolly bodies were noted. The white blood cells and platelets showed normal morphology and differential. The bone marrow aspirate stained with Wright-Giemsa showed dyserythropoietic changes, including binucleated red cells. Erythropoiesis was left-shifted with megaloblastic changes. Slightly increased numbers of plasma cells and mast cells were seen (Figure 1, oil immersion, original magnification 3750). The bone marrow biopsy demonstrated a hypercellular marrow (60%‐70%) with an increase in erythroid precursors adjacent to the trabeculae (topographic alteration). Iron stain of the aspirate with Prussian blue revealed many ringed sideroblasts (20%‐30%) and a large number of plasma cells containing hemosiderin granules (Figures 2 and 3, oil immersion, original magnification 3750). The patient’s iron studies at the time of biopsy included iron, 96 mg/dL (reference range, 30‐ 160 mg/dL) with iron saturation, 79% (reference range, 15%‐55%); ferritin, 884 ng/mL (reference range, 32‐284 ng/mL); and total iron binding capacity, 122 mg/dL (reference range, 250‐450 mg/dL). Of note, 5 months prior to the bone marrow study the patient’s iron level was 173 mg/dL with iron saturation, 88%; ferritin, 608 ng/mL; and total iron binding capacity, 197 mg/dL. The presence of iron (hemosiderin) in plasma cells is an unusual and often incidental finding. Little is known to explain this finding. Plasma cell iron has been noted in patients with iron overload, dysgammaglobulinemia, acute myeloid leukemia, and acute lymphoid leukemia, and in alcoholics with liver disease. 1‐3 In a recent survey,

The relationship of drug abuse to unexplained sudden death.

CONTEXT Forensic pathologists regularly investigate the deaths of individuals with a history of drug abuse. Autopsy, including toxicology testing, reveals no cause for death in a subset of this cohort. OBJECTIVE To determine whether deaths with an undetermined cause and manner of death are associated with a history of drug abuse. DESIGN Retrospective matched case-control study of 52 decedents whose cause of death remained undetermined following autopsy, matched 1:2 to a control group of living patients admitted for cholecystectomy according to age and date of death or procedure. RESULTS Individuals whose cause of death was undetermined were 5.3 times (95% confidence interval, 1.9-14.5) more likely to have a history of drug abuse than were patients with cholecystitis. CONCLUSIONS Decedents with a history of chronic drug abuse appear to be at an increased risk of dying by their chronic drug abuse, even in the absence of any anatomical or toxicologic finding at autopsy to account for death.