Robert M. Brissie

Postmortem Diagnosis of Unsuspected Diabetes Mellitus Established by Determination of Decedent's Hemoglobin A1c Level

Although approximately 15.7 million Americans have diabetes mellitus, with the vast majority having type 2 diabetes, it is estimated that as many as 5.4 million are undiagnosed. The present case illustrates that undiagnosed diabetes can be a factor in otherwise unexplained deaths. A 39-year-old white male with no significant past medical history other than alcohol abuse was found deceased at his residence. The manner of death appeared to be natural, but no anatomic cause was found. Toxicological analysis revealed a blood ethanol level of 0.02 g/dL and was negative for drugs of abuse. Analysis of the vitreous fluid revealed a glucose level of 502 mg/dL. The blood glucose level was 499 mg/dL, and the hemoglobin A1c (HbA1c) level was 10.6%. Only trace urine ketones were detected, suggesting that the death was the result of hyperglycemic hyperosmolar non-ketosis (HHNK) from unsuspected diabetes. The postmortem HbA1c value serves as a definitive indicator of prolonged hyperglycemia. In order to aid the interpretation of the clinical data, this case is discussed in conjunction with a similar case of a known diabetic patient.

Hypothermia deaths in Jefferson County, Alabama.

Introduction—Some reported characteristics associated with hypothermia mortality include older age, alcohol consumption, male sex, and black race. The purpose of this paper is to present the epidemiology of hypothermia deaths in Jefferson County, Alabama. Methods—Autopsy reports maintained by the county coroners office were abstracted for all cases with primary or underlying causes of death listed as “hypothermia” or “exposure to cold” between January 1983 and July 1999. Results—Sixty three hypothermia deaths occurred in Jefferson County during the study period. The mean age among cases was 68 years, 63.9% were male and 70% were of black race. Rates of hypothermia death were highest among black males, followed by black females, particularly blacks aged 80 years or older. Deaths occurring indoors were more common among older persons and outdoor deaths more common among younger persons. Thirty per cent of decedents tested positive for alcohol, 75% of whom were found outdoors. Nine decedents tested positive for drugs or medications. Approximately 90% of decedents were identified as having one or more chronic medical conditions. Excluding alcoholics, 52% of decedents had one or more chronic medical conditions. Conclusions—Hypothermia in Jefferson County, Alabama is a cause of death primarily affecting two distinct groups of individuals, elderly persons who develop hypothermia inside a dwelling and middle aged males who develop hypothermia out of doors and have consumed alcohol.

DETECTION OF ALPRAZOLAM IN THREE CASES OF METHADONE/BENZODIAZEPINE OVERDOSE

Benzodiazepine abuse is common among clients at methadone maintenance clinics. Diazepam and lorazepam are readily detected by immunological screening methods and confirmed by GC/MS. Alprazolam has been relatively difficult to confirm. We recently reported a modification of an existing serum HPLC procedure which allows us to analyze whole blood. We report here three cases of fatal drug overdose caused by co-ingestion of methadone and alprazolam. In all three cases, alprazolam was detected by HPLC and could not be identified by alkaline extraction GC/MS. Postmortem blood concentrations of methadone were at the lower range or below the concentrations previously identified in methadone overdose fatalities, suggesting an increased risk from co-ingestion of methadone and alprazolam.

Is Reduced Cell Size the Mechanism for Shrinkage of the Adrenal Zona Reticularis in Aging

In aging humans, corticosteroid production is preserved, or even increased, but there is an unexplained reduction in adrenal androgen secretion that likely has significant health implications. Preliminary analyses on adrenocortical morphology have revealed an age‐associated reduction in the thickness of the zona reticularis (ZR), the cortical zone responsible for the majority of DHEA/DHEA sulfate production in the adult human, but no change in the overall thickness of the adrenal cortex. The ZR width could decrease in aging due to loss of ZR cells and/or to shrinkage of ZR cells. In the current study, we investigated whether there was a relation between thickness of the zona reticularis in young and old humans and the cell density in this zone. Paraffin‐embedded sections of the adrenal cortex of 10 young (21–35 yr old) and 10 old (54–89 yr old) adults who had died suddenly as the result of trauma were stained with hematoxylin and eosin. These specimens were chosen from a larger cohort of samples for having a broad ZR in the young group and a narrower ZR in the older group. After determining the overall cortical thickness and the width of the ZR by use of computerized image analysis software, we counted the number of adrenocortical cells in two random high power fields of the ZR of each specimen. The ZR width of the older group (57 ± 7 arbitrary units, Mean ± SE) was significantly reduced compared to that of the young group (124 ± 21), P < 0.001. On the other hand, the overall cortical width in the old group (232 ± 17) was similar to that of the young adults (249 ± 38). In the old group, the ZR comprised 24.7 ± 3% of the total cortical width, whereas it was 50 ± 2% of the cortical width in the young adrenals, P < 0.001. The cell density (cell number/60 × high power field) of the ZR of old adults (83 ± 9) was similar to that of the young group (87 ± 5). In summary, although the width of the ZR regresses with aging, cell size in this zone is preserved. Therefore, loss of trophic support for ZR cells would not appear to be the explanation for zonal shrinkage in aging. Rather, it is likely that aging effects may be due to increased cell loss in the ZR or else reduced rates of differentiation/migration of cells into this cortical zone.

A case of homicide by lethal injection with lidocaine

This report describes a homicide by overdosage with lidocaine. The decedent, a 32-year-old male hospitalized for a lengthy period with acute intermittent porphyria and chronic pancreatitis, suffered apparent asystole and seizure. Failed resuscitation preceded death. A forensic autopsy was conducted based upon suspicions of alleged patient mistreatment by one of the attending nurses. Toxicological analyses revealed the presence of lidocaine in blood, liver, kidney, brain, and heart at 22.2 mg/L and 43.6, 28.3, 23.1, and 13.1 mg/kg, respectively. Also present were diazepam, phenytoin, and promethazine. Both diazepam and phenytoin had been administered during resuscitation, but lidocaine had not. The cause of death was determined to be ventricular arrhythmia precipitated by lidocaine overdosage. The administered dose was calculated to have been approximately 1500 mg. The manner of death was determined to be homicide. The nurse was arrested and subsequently tried for murder by administering a lethal quantity of lidocaine.

Death during theft from electric utilities.

Utilities that supply power are subject to theft of service and theft of hardware used to provide service. Individuals who try to steal from a power utility risk electrocution. We conducted a retrospective study of all individuals examined by the Jefferson County Coroner Medical Examiner Office from January 1981 through December 2001 and found that 8 individuals died trying to steal from a power utility. All decedents were men, with an average age of 33 years. Seven decedents were stealing copper, and 1 was stealing electricity. Only 1 decedent survived long enough to be admitted to a hospital. Five decedents were intoxicated, 3 with ethanol, 1 with cocaine, and 1 with both cocaine and ethanol. Seven decedents sustained electrical burns in keeping with the high voltage to which they were subjected. The unburned decedent died of laceration of the aorta at its origin from the heart, an injury sustained when the decedent fell from the power pole. All 8 decedents attempted their theft during daylight. Items found in the decedent’s pockets, the presence of a ladder nearby, or the presence of electrical tools around the body may help to establish the attempted act of theft.

Study of vitreous potassium correlation with time since death in the postmortem range from 2 to 110 hours using capillary ion analysis.

The time-dependent postmortem increase of potassium concentration in the eye fluids has been studied since the 1960s. However, important discrepancies on the reproducibility of the phenomenon have hampered the use of this parameter in real cases. In recent years, a new analytical approach based on capillary ion analysis (CIA) has been reported. In the present work, the correlation between vitreous potassium and postmortem interval (PMI) has been re-evaluated by using CIA in a group of 164 cases with PMIs ranging from 2 to 110 hours. The correlation of the two parameters was described by the following regression equation: y = 0.1733x + 2.3008 (x = PMI; y = K+ concentration); correlation coefficient = 0.962. The re-calculation of PMIs on the basis of this equation provided calculated PMIs with an average error of 5.54 hours (SD = 4.16). However, the percent PMI calculation error decreased with the increase of PMI, becoming acceptable for practical application above 24 hours since death.

A review of crane deaths in Jefferson County, Alabama.

Cranes are machines used to move heavy objects. Cranes are operated by crane operators, usually working in conjunction with an assistant guiding the movements of the crane from his vantage point outside the crane. Few jurisdictions require that crane operators be either licensed or certified. We conducted a retrospective study of those dying of crane-related injuries in our jurisdiction during the 16 years from 1981 to 1996. All ten decedents were male, and the manner of each death was accidental. Neither ethanol nor drugs of abuse were detected in any case. Eight of the ten decedents died due to blunt force injuries, one due to mechanical asphyxia, and one due to thermal burns. Investigation by the Occupational Safety and Health Administration (OSHA) led to fines ranging from

Aging Alters Zonation in the Adrenal Cortex of Men

80 to

Epidemiology of child homicide in Jefferson County, Alabama

2700 in six of the ten cases. Nationwide, electrocution is the most common cause of crane-related death, but no crane-related death in Jefferson County was caused by electrocution in our study. The absence of electrocutions was due to the planned, routine suspension of power to electrical lines in the vicinity of a crane during the cranes operation, a practice saving an estimated seven lives. Nevertheless, human error or lack of planning was still responsible for most of the deaths in our study. In addition to careful planning and adherence to safety standards established by planning, we recommend the mandatory licensure and certification of professional crane operators and the assessment of larger fines by OSHA for safety standard violations.