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 x 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.

Occupational electrocutions in Jefferson County, Alabama

Few studies have presented the general epidemiology of electrocution deaths using local medical examiner data. Data were obtained from coroner/medical examiner's files for electrocution deaths occurring between 1981 and 1998. All 27 occupational electrocutions were among men; 92.6% were white and 7.4% were black, with a mean age of 33.1 years. The rates of high- and low-voltage electrocution were similar. Low-voltage deaths showed a seasonal pattern, with the largest numbers in July, August and October. Deaths occurred most frequently among electricians and electrical helpers. The level of detail available from medical examiner records permits more complete evaluation of injury patterns than is possible using death certificate data; however, even more detailed studies, exploring worker activity at the time of injury, education, experience and training, are needed.

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 coroner's 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.

An unusual multiple drug intoxication case involving citalopram

A 47-year-old male with a history of drug abuse and suicide attempts was found dead at home. The death scene investigation showed evidence of cocaine abuse and multiple drug ingestion. Citralopram, a new selective serotonin reuptake inhibitor, cocaine, oxycodone, promethazine, propoxyphene, and norpropoxyphene were identified and quantitated in the postmortem samples by gas chromatography-mass spectrometry. The concentration of citalopram in the femoral blood was 0.88 mg/L. The heart blood concentration was 1.16 mg/L. Femoral blood concentrations of the other drugs were as follows: cocaine, 0.03 mg/L; oxycodone, 0.06 mg/L; promethazine, 0.02 mg/L; propoxyphene, 0.02 mg/L; and norpropoxyphene, 0.07 mg/L. Other tissue samples were also analyzed. The concentrations of cocaine, oxycodone, promethazine, and propoxyphene in the blood, liver, brain, and gastric contents did not suggest an intentional overdose. However, the possibility of multiple drug interactions including citalopram was evident. In this case, the citalopram concentrations were consistent with those reported in fatal cases involving multiple drug use. Citalopram was present in urine at a concentration of 0.9 mg/L.

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 $80 to $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 crane's 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.

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.

Fatal multiple drug intoxication following acute sertraline use

A 53-year-old Caucasian male victim of suicide was suspected of overdose with sertraline and alprazolam after death-scene investigation. The concentration of sertraline, a selective serotonin reuptake inhibitor, was determined by a gas chromatograph with mass selective detection. The concentration of alprazolam, a triazolobenzodiazepine, was determined by high-performance liquid chromatography. The sertraline concentration was reported at 1.0 mg/L in peripheral blood, which is greater than previously reported in other postmortem cases in which death was attributed to a multiple drug overdose. The N-desmethylsertraline concentration was reported at 0.2 mg/L in peripheral blood, which is far less than in other postmortem cases and suggests acute intoxication in this case. The alprazolam concentration was reported at 33 microg/L in heart blood, which is within the therapeutic range. The cause of death was multiple drug intoxication following acute use of sertraline, the manner of death was suicide, and the mechanism of death is an unexplained drug interaction and/or toxicity.

A 15-year review of railway-related deaths in Jefferson County, Alabama

A retrospective computer search of the records of the Jefferson County Coroner/Medical Examiner Office covering the 15-year period from 1981 to 1995 revealed 86 cases in which either a train caused death or in which a body was found dead by the tracks. The average age of the decedents was 39 years (range, 3 weeks-87 years). Men accounted for 88% of the deaths. The manners of death were as follows: three natural, 64 accident, seven suicide, six homicide, and six undetermined. Six decedents were found dead by the tracks, but death was not caused by a train. Six decedents were railroad employees who died on the job. In 47 cases, the decedents were trespassing on railroad property. Five trespassers were riding the rails, and 42 were pedestrians struck by a train. Motor vehicle collisions with trains claimed 27 lives--19 drivers and eight passengers. All together, 45% of the decedents were intoxicated. Intoxication was greatest by far in individuals witnessed to have been lying on the tracks before being hit by a train. The nature of individuals riding the rails has changed in the past few decades. Freight trains today are being used by illegal immigrants as transportation within the United States. The majority of traffic fatalities occurred because the driver intentionally tried to beat the train to the crossing. These drivers were seldom intoxicated, and only two were teenagers. Lives of such impatient drivers might be spared by the installation of a crossing guard-rail that cannot be circumvented.

Aging alters zonation in the adrenal cortex of men

Whereas aging has been shown to be associated with striking reductions in circulating levels of adrenal androgens in humans, the alteration in adrenal function that occurs in aging has not been identified. We sought to determine if there are changes in the zonation of the adrenal in aging men by performing histomorphologic analyses of adrenal specimens that had been obtained at autopsy following sudden death due to trauma. We evaluated adrenals from 21 young men (20-29 yrs) and 12 older men (54-90 yrs); inclusion criteria required the presence of medullary tissue in the specimen and fixation within the first 24 hrs postmortem. Sections stained with H/E were examined microscopically and areas of the cortex that included adjacent medullary tissue were chosen for quantitative evaluation by use of a computerized image analysis system. The average width (arbitrary units, pixels) of the zona reticularis and that of the combined zonae fasciculata/glomerulosa were determined from sections stained for reticulum fibers. The zona reticularis represented 37.1 +/- 1.9% of the total cortical width in the young men, which was significantly greater than that of the older men (27.1 +/- 3.3%, P = 0.0082). The zona fasciculata/glomerulosa to zona reticularis ratio in the young men (1.84 +/- 0.15) was significantly less that that of the older men (3.29 +/- 0.47, P = 0.0011). There was no significant difference in the total width of the cortex in young compared to older men. These data suggest that aging results in alterations within the cortex of the adrenals in men such that there is a reduction in the size of the zona reticularis and a relative increase in the outer cortical zones. A reduced mass of the zona reticularis could be responsible for the diminished production of dehydroepiandrosterone and dehydroepiandrosterone sulfate that occurs during aging.

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.

High-performance liquid chromatography of alprazolam in postmortem blood using solid-phase extraction

Screening and analysis of the numerous benzodiazepines presents a challenge for the forensic toxicologist. The newer benzodiazepines, which are prescribed in daily dose regimens of 0.5-3 mg, are particularly difficult to screen and analyze. Frequently, history or careful investigation by the medical examiner is the only clue that the laboratory has to follow. We describe four cases involving alprazolam and the modification of an existing serum high-performance liquid chromatographic (HPLC) procedure, which allowed us to analyze whole blood. This HPLC procedure for alprazolam uses a protein precipitation step followed by solid-phase extraction. The method is sensitive to 18 ng/mL and linear from 18 to 200 ng/mL. Reproducibility was determined by extracting and analyzing duplicate samples on five separate occasions. The recovery averaged 84% using postmortem blood spiked with 18 and 150 ng/mL alprazolam.

Homicide among black males in Jefferson County, Alabama 1978-1989

This study examined 1505 of 1573 (96%) homicides occurring in Jefferson County, Alabama, between 1978 and 1989, that were investigated by the Coroner/Medical Examiners' Office. During this 12 year period, Jefferson County's average annual homicide rate was 18.9 per 100,000 compared to an 11.3 per 100,000 State of Alabama's rate and a 9.3 per 100,000 US rate. In Jefferson County, the average annual homicide rate among blacks (41.4) was almost six times the rate among whites (7.1). The highest average annual race-specific homicide rate was in black males (75.9), followed by black females (12.4), white males (10.4) and white females (4.1). Black males in the 25-34 year age group had the highest rate (159.7), followed by black males in the 35-44 year age group (151.7) and then by black males in the 15-24 year age group (96.2). These rates ranged from almost eight to over eleven times the rates of similarly aged, black females or white males and were over 33 times higher than the rates for white females of the same age. Our results emphasize the high rates of black male on black male violence, the acquaintance of the black male victim and perpetrator, and the importance of arguments as an inciting event. Moreover, we determined that while the raw numbers and rates for black homicides were and are staggering, the average annual homicide rate for black males was actually declining at a greater rate than for all other race-sex groups. Further, our results suggest that a number of hypothesized determinants commonly believed to be associated with the increase in the homicide rate among black males between 15 and 24 years of age, such as drug use, increased availability of firearms and increased child abuse were not, in fact, major determinants of the change in homicide rates.

Demography of penetrating cardiac trauma

All cases of penetrating cardiac trauma in 1985 and 1986 in Jefferson County, Alabama, where patients dying of penetrating trauma received autopsies, were retrospectively reviewed. All hospitals in the county plus the single coroner's office provided the records of the 72 patients comprising this study. Incidents occurred most often in the home or residence (70%) by a known assailant (83%) due to domestic/social disputes (73%). Frequency was greatest in the evening hours (73% between 6:00 PM and 3:00 AM), on weekends in spring and summer. Victims tended to be male (86%), black (72%), married (46%), blue collar workers (62%). There were 41 (57%) gunshot wounds, 3 (4%) shotgun wounds, and 28 (39%) stab wounds with an associated mortality rate of 97%, 100%, and 68%, respectively. Prehospital mortality rate (dead at the scene) was 54.2% (39/72), and death on arrival was 26.4% (19/72), for a combined pretreatment mortality rate of 80.6%. All patients who arrived with no vital signs died. Mortality appeared to be related to mechanism of injury, age, race, sex, vital signs on arrival, number and specific cardiac chambers injured, associated major vascular injury, hematocrit, and mode of transportation. Mortality was not related to caliber of weapon, ethanol level, transport time, time from arrival to operation, or transfusion requirements. There were only ten survivors (1 gunshot wound and 9 stab wounds), all of whom had ventricular injuries and no associated major vascular injuries. The ten survivors represented a 71.4% (10/14) salvage rate for those victims arriving with vital signs. Complications occurred in three patients. Hospitalization averaged 7.3 days in the survivors. Penetrating cardiac trauma remains a serious, socially linked disease with a high rate of mortality. Rapid transport, aggressive resuscitation and cardiorrhaphy remain the best treatment.

Homicide in Alabama: an analysis of urban, suburban and rural murders in the Deep South

Eleven hundred forty-four (1144) homicides occurring in Alabama, U.S.A. during a 2-year period are presented and analyzed according to the demographic parameters of the victims, location in urban, suburban, or rural community, type of homicide based on a medical examiner's classification, presence of drugs, weapon employed and other factors. Urban dwellers, Blacks and males are found to be at high risk. Alcohol is much more prevalent than other drugs in homicide victims. Although the handgun is the weapon most commonly used throughout the state, in the rural regions the longgun is used almost as often. The difficulty of making valid comparisons with other homicide studies is discussed and the establishment of a uniform classification of homicides urged.

Infanticide by starvation: calculation of caloric deficit to determine degree of deprivation

A review of medical records and autopsy examination of a six-week-old male revealed the cause of death to be severe malnutrition with dehydration. Weight and caloric deficits were calculated to determine the degree of deprivation, which could be expressed as an interval of days for clear courtroom presentation. These calculations may be useful for quantifying the degree of malnutrition in a variety of child abuse cases.

Diabetic glomerulonephropathy: histopathologic, immunofluorescent, and ultrastructural studies of 16 cases

Sixteen cases of diabetic glomerulopathy are reported. Direct immunofluorescent and ultrastructural studies of renal biopsy tissues demonstrated that two patients had linear deposits of IgM and C'3 in the absence of IgG, four diabetic patients had sclerosis-induced entrapment of immunoglobulins and complement, and one patient had granular immune complexes in the subepithelial and intramembranous portion of the glomerular basement membrane. In one patient, who had nodular glomerular lesions, diffuse fibrillar deposits of electron-dense material were observed in the mesangium. In this mesangial infiltrate, light microscopy revealed the absence of amyloid and direct immunofluorescence revealed the absence of all immunoglobulins, complement components, and fibrinogen. Our study suggests that the morphologic alterations observed in diabetic glomerulopathy might be mediated by either immune mechanism or by abnormal biochemical or functional factors, such as impairment of the mesangial IgA clearance mechanism.

Membranous glomerulonephritis in a child asymptomatic for hepatitis B virus. Concomitant seropositivity for HBsAG and anti-HBs

The presence of hepatitis B surface antigen (HBsAg) in association with immunoglobulins and complement components within the glomerular basement membranes of adults having chronic active hepatitis has been well documented. In addition, investigators in Poland have demonstrated HBsAg immune complexes in glomeruli of children who did not have clinical evidence of hepatitis. More recently, a single case of childhood membranous glomerulonephritis in an asymptomatic carrier of hepatitis B virus was cited by observers in Canada. Reported here is the deposition of HBsAg immune complexes in the glomerular basement membranes of a 13-year-old black boy who had membranous glomerulopathy but not clinical evidence of hepatitis. This may be the first reported case in the United States of HbsAg-associated membranous glomerulonephritis in a child asymptomatic for hepatitis B virus, and only the second such case in North America. However, unlike previous studies of childhood glomerulopathy in association with hepatitis B virus, this patient is seropositive for both HBsAg and anti-HBs (antibody for hepatitis B surface antigen). Similar "rare" serologic findings were found for the patient's eldest male sib.

Ultrastructural assessment by colloidal iron of the distribution and localization of anionic sites in human glomerulonephritides

The distribution of anionic sites within glomerular basement membranes from patients with different glomerulonephritides was examined by the dialyzed colloidal iron (DI) staining technique. The correlation of ultrastructural findings with glomerular disease, renal function, and degree of proteinuria revealed three alterations: 1) speckled DI staining in the lamina densa of patients with decreasing renal function and a proteinuria of greater than 1 g/24 hours; 2) an apparent staining disparity and diminution of DI at the lateral borders of swollen and retracted foot processes with inclination of the foot processes in the direction of the more weakly staining lateral border; and 3) heavy DI reaction on the apical of free surfaces of fused foot processes. Human subjects with a proteinuria of more than 1 g/24 hours display optimal labeling of the endothelial fenestrae, endothelial cell coat, lamina rara interna, and lamina rara externa. The staining observed may be explained either on the basis of direct DI interaction with diffusing plasma proteins secondary to a decrease in the transglomerular charge barrier consequential to a loss of intrinsic anionic sites or on the basis of "unmasking" of anionic moieties within the glomerular basement membrane. Regardless of the mechanism involved, the present study indicates that a threshold proteinuria of 1 g/24 hours is needed to effect staining in the lamina densa.

Shotgun wounds: multiple probes and shielding effects as adjuncts to determining position of the decreased at time of injury

Careful and meticulous probing of sites of individual pellet injuries in distant shotgun wounds with repositioning of the body to allow parallel alignment of pellet tracts make possible the determination of the position of a decreased at time of injury. Spared areas, or "gaps," within the pattern may result from shielding either by body parts or by an intermediate object. The present case reports illustrate the method and its importance.

Cytochemical differentiation of nucleic acids with a Schiff-methylene blue sequence

A method is described whereby a Feulgen type of hydrolysis of deoxyribonucleic acid is carried out on paraffin sections of routinely fixed tissues by controlled exposure of the sections to Bouin's fluid. Subsequent staining with Schiff reagent followed by methylene blue distinguishes red-to purple-stained deoxyribonucleic acid from blue-stained ribonucleic acid. This Schiff-methylene blue sequence visualizes ribonucleic acid in nucleoli and the chromidial substance of various normal and neoplastic cells and provides an assessment of their protein synthetic activity. The method has proved valuable in demonstrating normal immunocytes and immunoglobulin-forming tumor cells in pathologic specimens.

Variability of dermal elastin visualized ultrastructurally with iron hematoxylin

The Verhoeff iron hematoxylin-lead citrate (VIH-LC) method demonstrated vertical elastic fibers that were often composed only of microfibrillar component extending into the epidermal basement membrane in human skin. These fibers connected with a network of trabeculae composed of microfibrils and elastin fibrils in varying proportions. The large elastic fibers in the deep two thirds of the dermis consited mainly of compact bundles of small elstin fibrils in infants and of solid elastin cores with a fimbriated periphery in adults; Dermis of a 6-month-old fetus contained very few small elastic fibrils except around blood vessels. Skin of an elderly subject revealed exteme proliferation of unusual reticulated elastic fibers in various areas and disclosed abnormal nodules of elastin or collagen fibrils in finely particulate matter. Small elastin fibrils, abundant microfibrils, and intermixed individual collagen fibrils comprised an adventitial collar between sweat glands and fibroblasts. Elastin fibrils were absent from this collar in the fetus and increased with the subject's age. A permanganate-high iron diamine sequence appeared to impart density to the microfibrillar component of elastic fibers.

The variable fine structure of elastin visualized with Verhoeff's iron hematoxylin

Verhoeff's iron hematoxylin (VIH) followed by lead citrate (LC) applied to epoxy thin sections stained the dense component of elastic fibers heavily and the peripheral microfibrillar component lightly in guinea pig trachea and mouse testis fixed with a glutaraldehyde-osmium tetroxide sequence. This method stained large fimbriated fibers beneath tracheal epithelium, small fibers and stacked aggregates thereof in the deep lamina propria, cartilage and adventitia of the trachea and large stacked fibers in the fibroelastic band of the trachea. Fibers of the fetus differed from those of the adult, especially in the subepithelial elastic lamina of the trachea. Elastic fibers were intimately associated with fibroblasts and particularly slender fibroblast processes in tracheal stroma and with chondrocytes in tracheal cartilage. Fibroblasts associated with elastic fibers in the tracheal subepithelial lamina propria were often closely bordered by eosinophils, mast cells, or monocytes. Occasional mast cells extended slender processes around elastic fibers in the subepithelial lamina propria. In mouse testis and in many regions of the trachea, small elastic fibers were identified which were below the limits of resolution for the light microscope and were not apparent at the ultrastructural level in routinely stained thin sections.

Ultrastructural staining of thin sections with iron hematoxylin

Verhoeff's iron hematoxylin (VIH) applied to epoxy thin sections provides ultrastructural staining of selected sites including elastic fibers, ribosomes, heterochromatin in nuclei of somatic cells, chromatin clumps in germ cells and the nucleolonema and ovoid body of the nucleolus of primary spermatocytes. Granules in rat parotid acinar cells show several staining patterns not otherwise easily recognized. Mucous droplets or granules of goblet or Paneth cells of the ileum stain. Staining of defined polymers in epoxy thin sections indicates that VIH reacts with polycations and polyanions. Ethanolic hematoxylin alone at pH 1.3 imparts electron opacity to heterochromatin, ribosomes, parotid granules and elastica but yields no staining for light microscopy. A hematoxylin-FeCl3, solution stains mucus of goblet and Paneth cells. The latter staining, which requires FeCl3 in the solution, can be eliminated by saturating the solution with NaCl and, accordingly, depends on ionic binding. Staining of elastic fibers and parotid acinar granules depends on hydrogen bonding, since saturation of the VIH or hematoxylin solution with urea blocks the ultrastructural staining. Urea does not, however, alter the staining of nuclear structures or ribosomes.