Cyril H. Wecht

Forensic antiepileptic drug levels in autopsy cases of epilepsy

A 1-year retrospective coroner-based forensic examination of causes of death among persons with a history of epilepsy was conducted at the Allegheny County Coroners Office to evaluate the phenomenon of sudden unexplained/unexpected death in epilepsy (SUDEP), a diagnosis of exclusion. All cases at the Coroners Office from January 1, 2001 through December 31, 2001, were examined. Review of a total of 1200 autopsied deaths revealed 12 cases with a past medical history of seizure disorder on the death certificate, which listed seizure disorder as the immediate cause of death or contributory cause of the death. Of the 7 men with seizure disorders, 5 were categorized as definite SUDEP and 2 as possible SUDEP. Of the 5 women with seizure disorders, 2 were listed as definite SUDEP, 2 as possible, and 1 as non-SUDEP because the convulsive seizures developed from a grade II glial tumor. Postmortem findings were evaluated for 11 cases; 1 body was decomposed. Toxicological screens were carried out on blood, bile, urine, and eye fluid for all 12. Antiepileptic drug (AED) levels detected in postmortem toxicological analysis were examined. AED levels were determined in 7 cases. Four of 7 had subtherapeutic AED levels, 2 had therapeutic levels, and only 1 victim of SUDEP had levels above the therapeutic range. Five cases had no detectable AED levels. AED levels at autopsy were either absent or subtherapeutic in 9 of 10 SUDEP cases, findings consistent with the likelihood of poor AED compliance. Subtherapeutic levels of AEDs may be a risk factor for SUDEP that could contribute to increased interictal and/or ictal epileptiform activity with associated autonomic dysfunction leading to disturbance of heart rate, heart rhythm, and/or blood pressure.

Forensic Pathology and Forensic Epidemiology of Suicides in Allegheny County, Pennsylvania: A 10-Year Retrospective Review (1990–1999)

Suicide has assumed epidemic proportions and constitutes a major public health issue throughout the United States. Suicide remains one of the top eight leading causes of death, accounting for approximately 30,000 deaths annually. The understanding and prevention of suicide requires a multidisciplinary approach that involves psychosocial and medical specialties starting with a forensic analysis of the characteristics of suicide. The aim of this 10-year (1990–1999) retrospective study was threefold: first, to examine the forensic epidemiological characteristics of suicides examined by the Allegheny County Coroner’s Office; second, to describe emerging epidemiological patterns of suicide; and finally, to make recommendations for preventive measures. A total of 1447 suicides were identified, with 1164 males (80%) and 283 females (20%) resulting in a male to female ratio of 4:1. The race distribution comprised 90% whites, 9% blacks, and 1% other races. The age of suicide victims ranged from 13 to 96 years old with a peak within the 31- to 40-year-old age group, which represented 24.5% of all suicides. Overall, 40% of the victims were single and more blacks than whites were single. The greatest number of suicides occurred in July, with the least in December. Suicides most frequently occurred between 9:01 am and 3:00 pm. Suicide notes were present in 29% of all suicides. Firearm injuries, hanging, and drug overdose were the leading methods of suicide. Use of firearms was the leading method of suicide among both sexes. Female drug overdose deaths outnumbered male drug overdose deaths. The 10 most common overdose drugs were all central nervous system depressants, with amitriptyline being the most common prescription overdose drug. Based on reported antecedent trends in suicides, we make two recommendations regarding suicide prevention: (1) physicians should be educated to replace the prescription of older and more toxic antidepressants such as amitriptyline with newer and less toxic antidepressants such as serotonin reuptake inhibitors; and (2) firearms should be made inaccessible to individuals with risk factors for suicide, especially in the home.

Case Studies in Forensic Epidemiology

Traditionally, the science of epidemiology has concentrated on the patterns of distribution of disease in human populations and the risk factors that influence these patterns. Epidemiologists primarily study the occurrence of disease by time, place, and individual. Their discipline provides the means to describe and predict patterns of the spread of a disease from a select group to and through a larger population. Their science seeks to distinguish personal, biological, socioeconomic, and other characteristics that increase the risk of disease and death. Put simply, the basic epidemiological methodology is to identify statistical association(s) among certain characteristics and a particular disease process, and then derive biological, socioeconomic, behavioral, or other inferences from such patterns. Currently, the curricula of graduate programs in epidemiology remain focused on basic course work that prepares students to design and conduct research studies. Most of these studies are carried out in an academic environment and their results are then presented in relatively nonadversarial settings, such as conferences and peer-reviewed publications. Consequently, although graduates emerge from such programs knowing the fundamentals of epidemiology, their educational background does not adequately prepare them to perform in the legal arenas where epidemiological analysis is increasingly put to use. Badly needed is a new form of training that better equips epidemiologists for their evolving role in today’s world.

Postmortem grading of cerebral contusions : A proposed modification of the adams' contusion index with re-definition of anatomic markers.

In the 1970s, J. H. Adams and other researchers at the Institute of Neurological Sciences, Glasgow, Scotland introduced a grading system for the quantification and analysis of contusions of the brain. They derived a brain contusion index based on regional surface distribution and parenchymal depth of contusions of the brain. Following a subsequent modification of this scheme in the 1980s, they recommended evolving modifications that will fit a variety of possible applications. Having tested the applicability of this grading system for the forensic/medico-legal autopsy, we have encountered some applied anatomic limitations and have derived a modification that addresses these limitations in reference to the forensic/medico-legal autopsy.We recommend a two-tier system based on the Adams’ system, which quantifies contusions of the brain by the gyral spread of contusions and by the parenchymal depth of penetration of contusions with a re-definition of the lobar distinctions and classifications of the brain. Gyral spread is assigned a grading scheme of 0–3 and the parenchymal depth of contusions is assigned a grading scheme of 0–4. A lobar contusion score is derived by multiplying the two assigned grades. A total brain contusion index is derived by summating all the lobar contusion scores. This reproducible grading system can be applied to routine bench forensic neuropathology reporting, court room illustrations and in comparative research analysis of brain trauma subjects.

Medicolegal problems in determining cause of death in motor vehicle accidents

The major problems of medical and legal causation in traffic-associated fatalities have been reviewed, and the possible pitfalls in relating causation emphasized. In conclusion, the determination and evaluation of causality in vehicular traffic deaths may be a very complex process, requiring special skills and thorough understanding of medicolegal issues. Proper determination of medicolegal causality is crucial to the financial, legal, and medical interests of many individuals and social groups.