Fatalities Due to Failure of Continuous Subcutaneous Insulin Infusion Devices: A Report of Six Cases

Diabetes mellitus type 1 and type 2 are diseases characterized by impaired regulation of blood glucose due to decreased insulin production and insulin resistance, respectively. Management of diabetes mellitus often requires injection of exogenous insulin. Continuous subcutaneous insulin infusion (CSII or insulin pump) is a diabetes treatment modality utilizing a device to aid in regulation of glycemic control. Malfunctions in device components can have rare fatal consequences. Described in this report are six fatalities due to one such malfunction, the failure of plastic cannulas of CSII devices to penetrate the skin and deliver insulin, resulting in fatal diabetic ketoacidosis (DKA). The cases derive from four different death investigation systems. For each case, scene and autopsy findings are presented, as well as selected toxicology and histology findings. These cases illustrate the importance of careful examination of CSII devices in death investigations and introduce a discussion on discrepant manner of death classifications.

National Association of Medical Examiners Position Paper: Recommendations for the Investigation and Certification of Deaths in People with Epilepsy

Sudden unexpected death of an individual with epilepsy (SUDEP) can pose a challenge to death investigators, as most deaths are unwitnessed and the individual is commonly found dead in bed. Anatomic findings (e.g., tongue/lip bite) are commonly absent and of varying specificity, limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus, it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden, unexpected death in a person with epilepsy is encountered.

Fatal Rotavirus Infection in a 4-Year-Old with Unsuspected Autoimmune Adrenal Insufficiency

The diagnosis of adrenal insufficiency is often delayed, as the presenting symptoms of fatigue, abdominal pain, and anorexia are vague and nonspecific. However, timely diagnosis and treatment with replacement steroids are needed to prevent fatal adrenal crisis. While the most common cause of primary adrenal insufficiency in childhood is congenital adrenal hyperplasia, a significant minority (13-23%) is caused by autoimmune destruction of the gland. We present a case of a 4-year-old, previously healthy child who had a one-day history of nausea and vomiting, and was found unresponsive by her caretaker. Despite emergency rescue and transport to the hospital, she was pronounced dead. At autopsy, the adrenal glands were atrophied. Histologic examination revealed lymphocytic infiltration of the adrenal glands consistent with autoimmune adrenal insufficiency. Fecal viral antigen testing was positive for rotavirus. The cause of death was determined to be adrenal crisis in the setting of rotavirus gastroenteritis due to adrenal insufficiency (Addison disease).

Death with Dignity Laws and the Medical Examiner

Currently, three states (Oregon, Washington, and Vermont) have “death with dignity,” physician-assisted suicide laws. Twenty-five other states considered death with dignity (DWD) legislation in 2015. Americans and American physicians have mixed opinions about these laws. Oregon, Washington, and Vermont have similar DWD laws that establish criteria and define roles and responsibilities of the physician, patient, and pharmacist. States require record-keeping and statistical reports administered by public health agencies. Yearly summary reports in Oregon and Washington show that physician assisted suicide (PAS) is uncommon. In Oregon in 2014, 105 PAS deaths were documented, of approximately 34 000 total deaths. The majority of PAS deaths involve patients with terminal cancer or neurodegenerative disease. The laws require that the cause of death be attributed to and certified as the underlying natural disease, making the manner of death natural. The attending physician may sign the death certificate. Because the cause and manner of death are legally mandated, the physician assisted suicide laws have little impact on medical examiner offices.

Death Certificate Surveillance: A Component of Death Investigation

Introduction

Medical examiners/coroners serve various functions beyond the medicolegal framework, including making contributions to public safety and health. In order to effectively fulfill this role, it is essential to ensure accurate certification of each death.

Materials and Methods

In Vermont, the Department of Health, Vital Records Division has developed a death certificate surveillance program in which all registered deaths are reviewed by the Office of the Chief Medical Examiner (OCME). A death certificate is fagged by the OCME for further investigation when cause and manner of death statements are incomplete, erroneous, or suggest the possibility of an unnatural death. If necessary, after review, death certificates are amended. Death Certificate Review (DCR) cases between 2008 and 2011 were retrieved from the OCME database. Data were evaluated for amendments of cause and manner of death.

Results

The OCME reviewed all death certificates and further investigated 4.4% and amended 3.3% of all death certificates in Vermont between the years 2008–2011. Eighty-eight percent of the amended DCRs were for cause of death statements and 10% resulted in change of manner. For the latter, change from natural to accident was most frequent.

Conclusions

Death certificates are a major source of epidemiologic data. Ensuring complete and accurate death certification through death certificate surveillance is a small but significant contribution of the OCME to public health.

Embryonic substantia nigra grafts show directional outgrowth to cografted striatal grafts and potential for pathway reconstruction in nonhuman primate

Transplantation of embryonic dopamine (DA) neurons has been tested as a therapy for Parkinson's disease. Most studies placed DA neurons into the striatum instead of the substantia nigra (SN). Reconstruction of this DA pathway could serve to establish a more favorable environment for control of DA release by grafted neurons. To test this we used cografts of striatum to stimulate growth of DA axons from embryonic SN that was implanted adjacent to the host SN in African green monkeys. Embryonic striatum was implanted at one of three progressive distances rostral to the SN. Immunohistochemical analysis revealed DA neuron survival and neuritic outgrowth from the SN grafts at 12-36 weeks after grafting. Each animal showed survival of substantial numbers of DA neurons. Most fibers that exited SN grafts coursed rostrally. Striatal grafts showed evidence of target-directed outgrowth and contained dense patterns of DA axons that could be traced from their origin in the SN grafts. A polarity existed for DA neurites that exited the grafts; that is, those seen caudal to the grafts did not appear to be organized into a directional outflow while those on the rostral side were arranged in linear profiles coursing toward the striatal grafts. Some TH fibers that reached the striatal grafts appeared to arise from the residual DA neurons of the SN. These findings suggest that grafted DA neurons can extend neurites toward a desired target over several millimeters through the brain stem and caudal diencephalon of the monkey brain, which favors the prospect of circuit reconstruction from grafted neurons placed into appropriate locations in their neural circuitry. Further study will assess the degree to which this approach can be used to restore motor balance in the nonhuman primate following neural transplantation.

Immunohistochemical staining for claudin-1 can help distinguish meningiomas from histologic mimics

The histologic distinction between meningiomas and other tumors of the central nervous system occasionally can be difficult. Claudin-1 is a tight junction-associated protein recently shown to be expressed in anaplastic meningiomas. The purpose of this study was to determine whether immunohistochemical staining for claudin-1 could help distinguish meningiomas from histologic mimics, compared with commonly used markers. Tissue sections from 10 meningothelial meningiomas, 20 fibrous meningiomas, 10 atypical meningiomas, 7 solitary fibrous tumors of the meninges, 5 meningeal hemangiopericytomas, and 7 vestibular schwannomas were stained immunohistochemically for claudin-1, epithelial membrane antigen, S-100 protein, CD34, and glial fibrillary acidic protein. In total, 21 (53%) of 40 meningiomas were immunoreactive for claudin-1, whereas none of the other tumors were positive. In contrast, there was considerable overlap in the distribution of the other antibodies evaluated. Claudin-1 seems to be a specific marker for meningiomas in this context. Although its sensitivity is relatively low, claudin-1 may be helpful in a panel of immunostains to distinguish meningiomas from histologic mimics.

Tissue distribution of synthetic heme analogues: studies with tin, chromium, and zinc mesoporphyrins

The uptake in tissue of Sn-mesoporphyrin (SnMP), Cr-mesoporphyrin (CrMP) and Zn-mesoporphyrin (ZnMP) administered at doses ranging from 1 to 10 mu mol/kg BW and the effects of these compounds on heme oxygenase activity were examined in both adult and neonatal rats. SnMP and CrMP, but not ZnMP, were rapidly cleared from blood and taken up by liver, spleen and kidney where marked inhibition of heme oxygenase activity was demonstrated. None of the metalloporphyrins were detectable in brain, and no inhibition of heme oxygenase activity was demonstrable in this tissue after administration of the compounds to both adult and neonatal rats. These results demonstrate that SnMP, CrMP and ZnMP do not cross the blood brain barrier, a fact of interest in relation to the potential use of these compounds clinically.