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Sudden Unexpected Infant Death Certification in New York City: Intra-Agency Guideline Compliance and Variables that May Influence Death Certification

Pasquale-Styles, Melissa A; Regensburg, Margaret; Bao, Ruijun
Introduction/UNASSIGNED:Differences in certification of similar sudden infant deaths exists among forensic pathologists. This study sought to measure adherence to intra-agency guidelines for infant death certification in one jurisdiction and describe variables that may be associated with the differentiation of sudden infant death syndrome (SIDS), asphyxia, and undetermined death certifications. Methods/UNASSIGNED:A retrospective study of deaths at the New York City Office of Chief Medical Examiner identified 427 sudden infant deaths with investigation and autopsy whose cause of death was ruled SIDS, asphyxia, or undetermined. Cases were reviewed for number and types of risk factors for asphyxia, demonstrable evidence of asphyxia, potential competing causes of death, and a doll reenactment. Descriptive and statistical analysis was performed. Results/UNASSIGNED:Of 427 deaths, the causes of 100 deaths (23.4%) were ruled asphyxia; 43 (10.0%) SIDS; and 284 (66.5%) undetermined. Forensic pathologists conformed to agency guidelines in 406 deaths (95.1%). Three or more risk factors for asphyxia were found in 328 deaths (76.8%). Demonstrable evidence of asphyxia (40.7%) was most associated with a certification of asphyxia. A potential competing cause of death (20%) was most associated with undetermined. A doll reenactment had little association with certification type. Discussion/UNASSIGNED:Guidelines in one agency were effective at limiting incorrect SIDS diagnoses. The interpretation of risk factors can be subjective. Diagnostic overlap occurred in deaths certified differently as SIDS, asphyxia, and undetermined, despite similar findings. Elimination of SIDS as a certification option and better guidelines that help differentiate asphyxia and undetermined deaths are recommended for improved infant death certification.
PMID: 31240005
ISSN: 1925-3621
CID: 3954042

Letter from the Guest Editor [Letter]

Pasquale-Styles, Melissa A
PMID: 31239983
ISSN: 1925-3621
CID: 3954022

Morphometric data on severely and morbidly obese deceased, established on forensic and non-forensic autopsies

Brodsky, Sergey V; Gruszecki, Amy C; Fallon, Kim; Pasquale-Styles, Melissa A; Shaddy, Sophia; Yildiz, Vedat; Long, Sarah K; MacDonell, Michelle; Brideau, Renee L; Keane, Joanne; Allenby, Patricia; Ivanov, Iouri; Moore, Stephen; Smith, Stephen M; Sachak, Taha; Ball, Matthew; Yao, Keluo; James, Iyore; Muni, Navin; Barth, Rolf F
With the widespread increase in the incidence of obesity, autopsies on severely and morbidly obese deceased have become common in the USA. Standard reference tables for organ weights provide little or no information on individuals with a body mass index greater than 35 kg/m(2). Although several recent reports have provided organ weights for small numbers of morbidly obese persons who died naturally from a variety of causes, these data may have been affected by comorbidities. Furthermore, they did not provide information relative to differences in organ weight based on gender, age, and race. The aim of the present study was to fill this void by developing reference tables for organ weights of severely and morbidly obese individuals. Our study was based on data from 802 forensic and medical autopsies, including 435 cases of death of natural and 367 of non-natural causes. Organ weights were compared between these groups, and reference ranges were generated. Significant variability was found in organ weights especially among deceased older than 40 years who died naturally, suggesting that comorbidities affect organ weight. Reference tables were compiled for organ weights and morphometric data based on gender, age, and race. Since obesity is a pathological condition affecting organ weight, these reference tables do not reflect normal organ weights but only weight as seen in severely and morbidly obese individuals. They should be useful to pathologists who perform forensic and non-forensic autopsies.
PMID: 27480641
ISSN: 1432-2307
CID: 3099552

Bilateral first rib anomalous articulations with pseudarthroses mimicking healing fractures in an infant with abusive head injury

Pasquale-Styles, Melissa A; Crowder, Christian M; Fridie, Jeannette; Milla, Sarah S
Bilateral symmetric bone nodules were observed in the anterolateral first ribs of an infant with shaking injuries at autopsy. The location prompted diagnostic considerations of healing fractures versus anomalous articulations with pseudarthroses. The forensic pathologist worked with forensic anthropologists and pediatric radiologists to evaluate autopsy findings and compare premortem and postmortem X-rays. Gross examination of the bones by the pathologist and anthropologists confirmed bilateral, callus-like bone nodules in first-rib locations associated with pseudarthroses. Histologic examination of one of the bones further showed features most consistent with pseudarthrosis, not a healing fracture. Radiologists then compared multiple premortem and postmortem radiographs that showed no remodeling of the bone over a 2-week interval between the time of injury and death, which would be unexpected for a healing fracture in an infant. This multidisciplinary approach resulted in the appropriate diagnosis of pseudarthroses due to anomalous articulations, an uncommon finding in forensic pathology.
PMID: 25382601
ISSN: 0022-1198
CID: 1348672

Postmortem diagnosis of invasive meningococcal disease

Ridpath, Alison D; Halse, Tanya A; Musser, Kimberlee A; Wroblewski, Danielle; Paddock, Christopher D; Shieh, Wun-Ju; Pasquale-Styles, Melissa; Scordi-Bello, Irini; Del Rosso, Paula E; Weiss, Don
We diagnosed invasive meningococcal disease by using immunohistochemical staining of embalmed tissue and PCR of vitreous humor from 2 men in New York City. Because vitreous humor is less subject than other body fluids to putrefaction, it is a good material for postmortem analysis.
PMID: 24565379
ISSN: 1080-6040
CID: 826442

Firearm deaths by law enforcement

Gill, James R; Pasquale-Styles, Melissa
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
PMID: 19040676
ISSN: 1556-4029
CID: 96461

Infant death scene investigation and the assessment of potential risk factors for asphyxia: a review of 209 sudden unexpected infant deaths

Pasquale-Styles, Melissa A; Tackitt, Patricia L; Schmidt, Carl J
At the Wayne County Medical Examiner Office (WCMEO) in Detroit, Michigan, from 2001 to 2004, thorough scene investigations were performed on 209 sudden and unexpected infant deaths, ages 3 days to 12 months. The 209 cases were reviewed to assess the position of the infant at the time of discovery and identify potential risk factors for asphyxia including bed sharing, witnessed overlay, wedging, strangulation, prone position, obstruction of the nose and mouth, coverage of the head by bedding and sleeping on a couch. Overall, one or more potential risk factors were identified in 178 of 209 cases (85.2%). The increasing awareness of infant positions at death has led to a dramatic reduction in the diagnosis of sudden infant death syndrome at the WCMEO. This study suggests that asphyxia plays a greater role in many sudden infant deaths than has been historically attributed to it
PMID: 17553088
ISSN: 0022-1198
CID: 96977

The cellular inflammatory response in human spinal cords after injury

Fleming, Jennifer C; Norenberg, Michael D; Ramsay, David A; Dekaban, Gregory A; Marcillo, Alexander E; Saenz, Alvaro D; Pasquale-Styles, Melissa; Dietrich, W Dalton; Weaver, Lynne C
Spinal cord injury (SCI) provokes an inflammatory response that generates substantial secondary damage within the cord but also may contribute to its repair. Anti-inflammatory treatment of human SCI and its timing must be based on knowledge of the types of cells participating in the inflammatory response, the time after injury when they appear and then decrease in number, and the nature of their actions. Using post-mortem spinal cords, we evaluated the time course and distribution of pathological change, infiltrating neutrophils, monocytes/macrophages and lymphocytes, and microglial activation in injured spinal cords from patients who were 'dead at the scene' or who survived for intervals up to 1 year after SCI. SCI caused zones of pathological change, including areas of inflammation and necrosis in the acute cases, and cystic cavities with longer survival (Zone 1), mantles of less severe change, including axonal swellings, inflammation and Wallerian degeneration (Zone 2) and histologically intact areas (Zone 3). Zone 1 areas increased in size with time after injury whereas the overall injury (size of the Zones 1 and 2 combined) remained relatively constant from the time (1-3 days) when damage was first visible. The distribution of inflammatory cells correlated well with the location of Zone 1, and sometimes of Zone 2. Neutrophils, visualized by their expression of human neutrophil alpha-defensins (defensin), entered the spinal cord by haemorrhage or extravasation, were most numerous 1-3 days after SCI, and were detectable for up to 10 days after SCI. Significant numbers of activated CD68-immunoreactive ramified microglia and a few monocytes/macrophages were in injured tissue within 1-3 days of SCI. Activated microglia, a few monocytes/macrophages and numerous phagocytic macrophages were present for weeks to months after SCI. A few CD8(+) lymphocytes were in the injured cords throughout the sampling intervals. Expression by the inflammatory cells of the oxidative enzymes myeloperoxidase (MPO) and nicotinamide adenine dinucleotide phosphate oxidase (gp91(phox)), and of the pro-inflammatory matrix metalloproteinase (MMP)-9, was analysed to determine their potential to cause oxidative and proteolytic damage. Oxidative activity, inferred from MPO and gp91(phox) immunoreactivity, was primarily associated with neutrophils and activated microglia. Phagocytic macrophages had weak or no expression of MPO or gp91(phox). Only neutrophils expressed MMP-9. These data indicate that potentially destructive neutrophils and activated microglia, replete with oxidative and proteolytic enzymes, appear within the first few days of SCI, suggesting that anti-inflammatory 'neuroprotective' strategies should be directed at preventing early neutrophil influx and modifying microglial activation.
PMID: 17071951
ISSN: 0006-8950
CID: 826562

Fatal bromethalin poisoning [Case Report]

Pasquale-Styles, Melissa A; Sochaski, Mark A; Dorman, David C; Krell, Willane S; Shah, Aashit K; Schmidt, Carl J
Bromethalin is a neurotoxin found in some rodenticides. A delusional 21-year-old male presented to a hospital with altered mental status the day after ingesting a bromethalin-based rodenticide. He died 7 days after his self-reported exposure to c. 17 mg bromethalin (equivalent to 0.33 mg bromethalin/kg). His clinicopathologic course was characterized by altered mental status, obtundation, increased cerebrospinal fluid pressure, cerebral edema, death, and diffuse histologic vacuolization of the white matter in the central nervous system seen on microscopic examination at autopsy. The presence of a demethylated form of bromethalin in the patient's liver and brain was confirmed by gas chromatography with mass spectrometry. Clinical signs and lesions observed in this patient are similar to those seen in animals poisoned with bromethalin. This case illustrates the potential for bromethalin ingestion to result in fatal human poisoning
PMID: 17018099
ISSN: 0022-1198
CID: 96978

Apparent suicidal carbon monoxide poisonings with concomitant prescription drug overdoses [Case Report]

Gupta, Avneesh; Pasquale-Styles, Melissa A; Hepler, Bradford R; Isenschmid, Daniel S; Schmidt, Carl J
We report four separate suicides by apparent motor vehicle-related carbon monoxide (CO) poisoning in which complete toxicological analysis showed the absence of, or lower than expected, percent carboxyhemoglobin saturation and high concentrations of concomitant prescription drugs. These cases, within a population of 71 apparent CO suicides from the Wayne County Medical Examiner's Office over 1998-2004, represent cases where additional factors are in play. Multiple modalities (CO poisoning and drug overdose) and/or undetectable carbon dioxide poisoning from the vehicle exhaust of cars manufactured after laws regulating vehicle emissions were enacted are examples of additional factors that require consideration in these selected cases. All four cases demonstrated some degree of decomposition, so the possible loss of CO could not be ruled out. The need for full toxicological analysis in apparent suicidal CO poisoning is emphasized
PMID: 16419412
ISSN: 0146-4760
CID: 65890