Kim A. Collins

Elder Maltreatment: A Review

CONTEXT Elder maltreatment is not a new entity but is one that is recently recognized as a widespread and growing social problem. Unfortunately, few physicians are trained to recognize the different forms of elder maltreatment including physical abuse, sexual abuse, and neglect. The elder, age 65 years or older, is also a unique individual with respect to pathophysiology. The natural changes of aging must be considered when assessing any physical or laboratory findings. OBJECTIVE The practicing pathologist and resident/fellow in training must be familiar with the 6 forms of elder abuse, in particular the 3 forms that are seen in general and forensic pathology: physical abuse, sexual abuse, and neglect. Naturally occurring conditions must also be recognized so that these are not erroneously interpreted as trauma or neglect. Furthermore, the victims and perpetrators, scenarios and risk factors, common anatomic and clinical findings, the pathophysiology of aging, and possible imitators of abuse must be understood. DATA SOURCES This review explores the current medical and psychological understanding of elder maltreatment. Current scientific literature including peer-reviewed journal publications and texts is cited. CONCLUSIONS As a prevalent form of domestic violence, we can only expect to see more cases of elder maltreatment as the number and percentage of elders in our population increase. The correct interpretation of physical and laboratory findings is needed to adequately classify these cases, certify the cause and manner of death, and prevent future incidents.

Pregnancy-associated deaths: a 15-year retrospective study and overall review of maternal pathophysiology

Pregnancy-related death is defined by the International Classification of Diseases, Tenth Revision (ICD-10) as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. In the year 2000, a collaborative effort involving World Health Organization (WHO), UNICEF, and UNFPA estimated 660 maternal deaths in the United States. This averages 11 maternal deaths per 100,000 live births reported. Many pregnancy-associated deaths are not easily identified as such since the presence of a recent or current pregnancy may not be listed on the death certificate. Thus, the WHO estimates that in the United States, the maternal mortality is approximately 17/100,000 pregnancies. This is significantly higher than the goal set by the US Department of Health and Human Services in Healthy People 2010, which sets the target for maternal mortality at less than 3.3/100,000 live births. The most common causes of maternal death vary somewhat from region to region in the United States. They include pulmonary thromboembolism, amniotic fluid embolism, primary postpartum uterine hemorrhage, infection, and complications of hypertension including preeclampsia and eclampsia. Pulmonary disease, complications of anesthesia, and cardiomyopathy also are significant contributors to maternal mortality in some populations. The death of a pregnant or recently pregnant individual poses a wide scope of challenges to the forensic pathologist and investigator. The pathologist must have a broad knowledge of the physiologic and biochemical changes that occur during pregnancy, as well as the clinical and pathological manifestation of these changes. Conditions that may be “benign” in the nonpregnant individual may be lethal in the puerperal period. In addition, it should be kept in mind that deaths during pregnancy may be due to unnatural causes. Accident, homicide, and suicide must be ruled out in each case. The authors reviewed all forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina from January 1989 through December 2003. All decedents listed as pregnant or postpartum were analyzed as to maternal age, race, past medical history, previous pregnancies and outcome, prenatal care, gestational age, fetal or neonatal outcome, location of delivery, placental findings, maternal autopsy findings, toxicology, cause of death, manner of death, and fetal or neonatal autopsy findings. The authors present this retrospective study to better determine the factors leading to maternal demise and discuss the autopsy/ancillary techniques useful in determining the cause of death in this challenging area.

Elderly suicide: a 10-year retrospective study

The suicide rate in the 65-year and older age group has been increasing since 1980. The elderly attempt suicide less often than younger people but are successful more often. The authors retrospectively reviewed all cases referred to the Forensic Pathology Section of the Medical Examiners’ Office at the Medical University of South Carolina (Charleston, SC) from January 1988 through December 1997. The cases of suicide in victims 65 years and older totaled 78, accounting for 11.5% of all suicides reviewed. Of these 78 cases, 41% were autopsied and 59% were externally examined. All of the cases were initially analyzed as to age, race, sex, and method of suicide. Files also were reviewed to determine time of year of the suicide, toxicology results, psychiatric history, social history, medical history, and whether a suicide note was left. The ages of these suicide victims ranged from 65 to 94 years; men comprised 85% of the victims, and whites, 94%. The male-to-female and white-to-black ratios were 6:1 and 15:1, respectively. The average age of the victim was 73 years. Gunshot wound was the most common method of suicide, accounting for 80.7% of the cases. Other methods included overdose (6.4%), hanging (3.8%), fall from height (2.6%), incised wounds (2.6%), drowning (2.6%), and carbon monoxide poisoning (1.3%).

A 25-year retrospective review of deaths due to pediatric neglect.

Neglect, defined as the failure of a caregiver to adequately provide safety, food, clothing, shelter, education, protection, medical/dental care, and supervision for a child in his/her care, is a relatively uncommon but important cause of child mortality. A retrospective review of pediatric deaths (age 18 years or less) referred to the Medical University of South Carolina Forensic Pathology Office for autopsy over the past 25 years revealed 16 deaths due to some type of pediatric neglect. Cases were analyzed as to age, sex, race, cause and manner of death, autopsy findings, ancillary studies, past medical history, social/family history, and caregiver. Six cases of malnutrition/starvation and/or dehydration were identified, composing the most common cause of death in the neglect cases identified and the majority of the homicides due to neglect. Other deaths in which neglect contributed significantly included toxic ingestions (2 cases), hyper-/hypothermia (2 cases), unusual drowning/aspiration (4 cases), electrocution (1 case), and delayed/absent medical therapy (2 cases, including one of the previously mentioned ingestions). Of these additional cases, 7 were certified as accidental manner, 2 as natural, and 1 as a homicide. Cases which fell into a “gray zone” in which the appropriateness of invoking neglect was a matter of opinion or societal convention were excluded from the review; examples included conventional accidental drowning, choking on food or aspiration of foreign body, overlying/wedging during sleep, accidental hanging, and motor-vehicle traffic accidents (pedestrians, unrestrained passengers). The findings of this review reinforce the fact that malnutrition/starvation and dehydration compose the most common form of lethal pediatric neglect while highlighting less common forms of neglect and the difficulty of determining manner of death in cases in which neglect plays a more questionable role than in seemingly clear-cut malnutrition/starvation and dehydration cases. We demonstrate the typical victim and scenario that investigators will encounter in cases of fatal pediatric neglect, often a child under the age of 1 year who has been deprived of food and/or drink for some time, or an older, more independently mobile child who has not been adequately supervised. These children may or may not have a demonstrable prior history of maltreatment or (nonfatal) neglect, and review of medical records is an important part of the investigation. We additionally discuss key gross autopsy findings, appropriate specimen collection, helpful ancillary studies, microscopic findings of significance, potential mimickers of neglect, and other special considerations in cases of pediatric neglect.

Interpretation of Fatal, Multiple, and Exiting Gunshot Wounds by Trauma Specialists

Firearm-related injuries are a leading cause of morbidity and mortality in the United States. Trauma care centers and trauma specialists (emergency medicine, trauma surgery, and neurosurgery) provide emergency care for those injured and mortally wounded from firearms. Consequently, trauma specialists may be asked to address forensic questions regarding gunshot wounds. Many firearm-related injuries are nonfatal and ultimately, fatal gunshot wounds can suffer from surgical alteration or, if the time interval between injury and death is prolonged, considerable healing of entrance and exit wounds may occur. Thus, accurate initial evaluation of firearm-related injuries is essential. We reviewed all firearm-related fatalities at our institution over the last five and a half years. Our objective was to determine how accurately trauma specialists can differentiate entrance and exit wounds in fatal perforating (exiting) gunshot wounds and determine the number of penetrating or perforating projectiles in fatal multiple gunshot wounds. A total of 271 fatal gunshot wound deaths were reviewed. Of these, we excluded all fatal penetrating (nonexiting) single gunshot wounds and fatalities not evaluated by trauma specialists. Postmortem findings were compared with the medical records from those individuals seen in the emergency department and/or admitted to North Carolina Baptist Hospital (Level I trauma center). Forty six cases with fatal multiple or exiting gunshot wounds were identified. Twenty four (52.2%) were misinterpreted by trauma specialists. Errors included inaccurate determination of the total number of multiple penetrating and/or perforating gunshot wounds and erroneous identification of entrance and exit wounds. Of the exiting, single gunshot wounds 37% were misclassified and 73.6% of multiple gunshot wounds were interpreted incorrectly.(ABSTRACT TRUNCATED AT 250 WORDS)

Sudden Death Due to Asphyxia by Esophageal Polyp: Two Case Reports and Review of Asphyxial Deaths

Asphyxia, not an uncommon cause of sudden death, may result from numerous etiologies. Foreign-body aspiration and strangulation are 2 extrinsic causes. Airway obstruction may also be caused by laryngeal edema, asthma, infection, or anaphylaxis. Chronic causes of asphyxia include musculoskeletal diseases (eg, muscular dystrophy, amyotrophic lateral sclerosis), neurologic disorders (eg, myasthenia gravis, multiple sclerosis), respiratory disease (eg, emphysema, chronic bronchitis), or tumors. The manner of death in cases of asphyxiation may be natural, accidental, homicide, or suicide. For the death investigator, determining the cause and manner of death can often be quite challenging. We report here 2 cases of an esophageal fibrovascular polyp causing sudden asphyxial death, review of the literature, and discussion of other differential diagnoses in the case of asphyxial death.

Death by overlaying and wedging: a 15-year retrospective study.

Overlaying, the accidental death by smothering caused by a larger individual sleeping on top of an infant, is a cause of death that has been documented for centuries. The hazard of death has been reported to be greater in infants less than 5 months of age but may occur in children up to the age of 2 years. When an adult or older child rolls on top of an infant, mechanical asphyxia results. The face may be pressed into the mattress or into the body of the sleeping adult or older child. The infant’s air may be expressed, and he or she is unable to cry due to pressure on the thorax and the inability to inhale. Some pathologists and investigators believe that the victims of overlaying have no pertinent physical findings at autopsy and that any injury is indicative of inflicted trauma. Others believe that one may see contusions and abrasions from overlaying in and of itself. Wedging is another form of accidental mechanical asphyxia that may have negative autopsy findings. The prevalence of bruising, contusions, or facial and ocular petechiae is not clear.The author reviewed all pediatric forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina/Medical Examiners’ Office over the past 15 years, from 1985 to 1999. Of these, all cases of overlaying, cases listed as undetermined sudden infant death syndrome versus overlaying, and wedging were included. The cases were analyzed as to victims’ age, sex, race, location/bedding, bed-sharer, and whether the bed-sharer was known to have ingested drugs or alcohol before sleep. Postmortem physical findings were also reviewed, particularly for documentation of contusions, abrasions, or facial or ocular petechiae. By clarifying not only the victim, bed-sharer, and scenario but also the presence or absence of physical findings in cases of overlaying, wedging, and other accidental asphyxia, we can better categorize these cases.

A rapid postmortem cardiac troponin T assay: laboratory evidence of sudden cardiac death.

Postmortem examination may be useful in establishing the cause of sudden unexpected death. In many instances, however, limitations of staffing, budget, and time may force the pathologist to triage cases to external examination rather than autopsy. A rapid assay for cardiac troponin T (cTnT) to document suspected cardiac-related deaths may optimize the use of the time and resources of the autopsy pathologist. Peripheral blood was sampled percutaneously before each of 40 autopsies and placed in the well of the Cardiac T Rapid Assay unit in accordance with the included instructions, and the results were read after 15 minutes. The assay result, decedent age, postmortem interval, and evidence of cardiopulmonary resuscitation were tabulated and subsequently correlated with the cause of death. On final sign-out of each of the autopsies, the cause of death was determined to be cardiac-related (n = 20) versus the cause in noncardiac control subjects (n = 20). This determination was made while the investigators were blinded to the cTnT assay result. Of the 20 cardiac deaths, 17 (85%) showed positive results for cTnT compared with 6 (30%) false-positive results among the 20 control cases; this result was statistically significant according to the chi-square test. In the over-50 age group, the sensitivity of this assay in detecting cardiac-related death was 91%, with a specificity of 86%. Perimortem cardiopulmonary resuscitation did not appear to result in false-positive results. In the appropriate setting, this rapid assay for cTnT can provide valuable data supportive of a cardiac-related death. This inexpensive test may best be used in triaging sudden deaths in persons over 50 to external examination versus complete autopsy.

Elder neglect and the pathophysiology of aging.

Elder neglect, one of the 6 forms of elder maltreatment, is difficult to diagnose and is underreported both in the scientific literature and to law enforcement. Recognizing fatal neglect is even more challenging especially with concurrent organic disease. Many entities can mimic elder neglect, and many age-related changes can result in pathology that may be confused with maltreatment. We retrospectively reviewed all forensic cases of individuals age sixty-five years and older which were referred for autopsy. Cases of fatal neglect were analyzed as to age, sex, race, cause of death, location of incident, perpetrator, victim-to-perpetrator relationship, and autopsy and ancillary findings. The cases studies totaled 8. The age range was 74 to 94 years. Two were white, 6 black, one male, and 7 female. The causes of death were sepsis due to severe decubitus ulcers and severe dehydration. Five cases occurred in the victims home, and 3 occurred in an institution (nursing home/care facility). In 5 cases, the perpetrators were family members. The pathophysiology of aging with respect to elder maltreatment is reviewed.

A case of Ludwig angina: a case report and review of the literature.

Ludwig angina is a rapidly progressing submaxillary, submandibular, and sublingual necrotizing cellulitis of the floor of the mouth that can have lethal consequences due to airway obstruction. Various aerobic and anaerobic microorganisms, and less often fungi, have been implicated to cause Ludwig angina, including oral flora such as streptococci and staphylococci. Early recognition and the use of parenteral antibiotics can prevent mortality and morbidity. We report a case of a 25-year-old white man who was admitted to the hospital by his dentist after being diagnosed with Ludwig angina secondary to periodontal abscesses involving teeth #17 and #32. Although antibiotics were administered, while in the hospital, the decedent had difficulty swallowing and was drooling. He suddenly began to have seizure-like activity thought to be anoxic myoclonus. The decedent was aggressively resuscitated and taken to the operating room for neck exploration and a tracheostomy. Neck exploration revealed severe necrotizing acute inflammation of the deep soft tissues and musculature of the neck. He remained on life support for 7 days until he was declared brain dead. Ludwig angina is a progressive cellulitis that often results in death by asphyxia. Ludwig angina can be complicated by subsequent deep neck infection. The underlying etiologies and common scenarios are examined, and significant autopsy findings and dissecting procedures are discussed. The pathophysiology of Ludwig angina is studied with a review of the current literature.