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To identify factors contributing to asthma mortality and improve our understanding of airway pathology in fatal asthma, we studied 44 cases of fatal asthma using records of one pathologist in the Office of the Medical Examiner. Records included death certificates, autopsies, toxicology, accounts by family and friends of the terminal episode, medical history of the deceased, police and paramedic reports, and hospital charts. Additionally, we interviewed by telephone surviving family and friends. Six (17%) of 35 patients were using inhaled corticosteroids at time of death. Of the nine patients who had seen a physician within 2 weeks of death, two were using corticosteroids. Toxicology was positive in 16 (38%) of 42 cases. Of the 20 patients with sudden-onset asthma (prodrome of increasing symptoms < 1 hour before death), 9 (45%) had positive toxicology. Patients with both sudden-onset and slow-onset asthma (prodrome > 3 hours before death) had airway mucosal or submucosal eosinophilic or neutrophilic infiltrates or both, as well as airways with and without mucus plugging. These findings indicate that asthma deaths are confounded by substance abuse and lack of anti-inflammatory therapy, and there is a heterogeneity in histological findings in sudden-onset and slow-onset asthma.

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The human body must maintain a relatively constant temperature to function. The thermoregulatory system plus human behavior control the balance of heat loss and heat gain. Heat is produced at a relatively constant rate by the body's basal metabolism. Heat production can be increased by increasing skeletal muscular activity. Heat is lost from the body to the environment by conduction, convection, radiation, and evaporation. Illness due to heat stress develops when the body gains more heat than it loses. Illness due to cold stress develops when the body loses more heat than it can produce or gain from external sources. During periods of extreme heat, mortality may rise sharply, sometimes to epidemic proportions. Because nearly all heat-related deaths are preventable, early detection of these deaths will allow appropriate preventive measures to be implemented. The autopsy findings in both heat-related and cold-related deaths are nonspecific. Information about environmental conditions, scene investigation, and the available medical history are very important in formulating the diagnosis.

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The National Association of Medical Examiners Ad Hoc Committee on the Definition of Heat-Related Fatalities recommends the following definition of "heat-related death": a death in which exposure to high ambient temperature either caused the death or significantly contributed to it. The committee also recommends that the diagnosis of heat-related death be based on a history of exposure to high ambient temperature and the reasonable exclusion of other causes of hyperthermia. The diagnosis may be established from the circumstances surrounding the death, investigative reports concerning environmental temperature, and/or measured antemortem body temperature at the time of collapse. In cases where the measured antemortem body temperature at the time of collapse was > or = 105 degrees F (> or = 40.6 degrees C), the cause of death should be certified as heat stroke or hyperthermia. Deaths may also be certified as heat stroke or hyperthermia with lower body temperatures when cooling has been attempted prior to arrival at the hospital and/or when there is a clinical history of mental status changes and elevated liver and muscle enzymes. In cases where the antemortem body temperature cannot be established but the environmental temperature at the time of collapse was high, an appropriate heat-related diagnosis should be listed as the cause of death or as a significant contributing condition.

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BACKGROUND: The Chicago region has been identified as having a very high death rate from asthma in patients aged 5 to 34 years. We investigated circumstances surrounding the fatal attack to determine whether the death was from asthma, of indeterminate cause, or coincidental to asthma. METHODS: Cases of asthma deaths from the Office of the Medical Examiner, where the deceased were younger than 46 years of age, were used to determine clinical, toxicologic, and pathologic findings relevant to asthma. Toxicologic results were compared with homicide victims. RESULTS: From 102 cases of fatal asthma, 46 cases were classified as deaths from asthma and 17 cases were considered probably from asthma as toxicologic tests were negative. Twenty-three cases were of indeterminate cause in that the acute respiratory symptoms were accompanied by substance use or alcohol consumption. Fourteen cases were not caused by asthma but were substance related, primarily cocaine. Overall, 29 of 92 (31.5%) cases were confounded by substance abuse or alcohol ingestion, which is almost as high as in homicide victims (38/82 [46.3%]). Mucus plugging of bronchi and or hyperinflation in fatal asthma occurred in 65 of 93 (69.9%) cases. Anti-inflammatory medications were being utilized by just two patients. Sufficient information was available to identify potentially fatal asthma in 6 of 20 cases (30%). CONCLUSION: Some of the reported rise in asthma deaths is a reflection of substance use or alcohol consumption similar to that seen in victims of homicide. In that patients with asthma are hypersensitive to alpha-adrenergic agonists, the use of cocaine may be especially dangerous and induce fatal ventricular dysrhythmias.

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Asphyxia due to aspiration of a foreign body is a common cause of accidental death in children. Foreign body aspiration is the most likely cause of accidental fatalities in children under 1-year-of-age. Children may die due to airway obstruction by food objects such as hot dogs, nuts, candies, grapes, seeds, and egg shells. Non-food objects such as balloons, coins, pop tops of beverage cans, pills, safety pins, ball bearings, marbles, and baby powder also may be fatally aspirated. To better understand and help prevent this well recognized health risk to children, we reviewed 10 years of cases at the Cook County Medical Examiner's Office in which deaths in children 14-years-of-age and younger were due to aspiration of foreign objects. The most common item that caused fatal aspiration in our series was a toy balloon.

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Deaths during dental and oral surgical procedures may lead to litigation alleging malpractice. For this reason, and because of their sudden and unexpected nature, they often come to the attention of forensic pathologists. We review the clinical and anatomic findings of a 3-year-old boy who expired following an oral surgical procedure in the temporomandibular region. During the operation, perforation of the base of the skull occurred causing laceration of a branch of the middle meningeal artery and fatal subdural and epidural bleeding.

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There has been a marked increase in firearms-related deaths in this country over the past several decades. Especially in urban areas this increase has been correlated with a greater availability of handguns. Children have become more common victims of gunfire. Both accidental and homicidal shooting deaths have increased in the lower age groups. We examined deaths due to gunfire in children ten years and younger in Cook County, Illinois, which contains the large city of Chicago. Homicidal shootings predominated in this age group with the most common circumstances being a child struck by a stray bullet. Accidental shooting deaths always occurred when one or more children were playing with a gun they found in the home.

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The longbow and crossbow are infrequently encountered by the forensic pathologist. As these weapons become more popular for sport and hunting, more fatalities may be anticipated. Three crossbow deaths (two homicides and one suicide) are presented. Included is the first report of a multiple shot death. The design and physics of the crossbow are described. The proper preservation of evidence, as well as wound analysis and interpretation, in such deaths are detailed.

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Forklift truck accidents are a common cause of occupational injury and death. The authors review deaths resulting from forklift accidents cases in the years 1984-1992 in Cook County, Illinois (which contains the large city of Chicago). The fatal injuries, the characteristics of the victims, and the circumstances of the deaths are examined. A forklift striking a pedestrian or crushing the operator when tipping over or falling off a dock or truck were the most common causes of death in this study. The authors compare their findings with those found in the literature on the characteristics and prevention of forklift accidents. Also, they comment on the role of the medical examiner's or coroner's office in the investigation of these work-related deaths.

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Though a rare cause of death, lightning is reported to be responsible for more fatalities each year in this country than any other type of natural disaster. Lightning injuries differ significantly from other high voltage electrical injuries because of the high current flow, but extremely short duration, of the lightning stroke. We present a series of cases over the period of 1985 to 1991 in Cook County, Illinois in which lightning was the direct cause of death. Our discussion reviews the nature of lightning, the effects it may have on humans, and the ways in which deaths due to lightning might be prevented.

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When a fetus dies after its mother has suffered trauma, questions often arise about whether the fetal death was linked to the maternal injury. Many state statutes make it a criminal act to cause the death of a fetus by injuring the mother. The authors present two cases in which fetal death resulted from maternal trauma. In addition, we review the pertinent literature on this subject and offer guidelines that may help forensic pathologists evaluate these difficult and often emotionally charged cases.

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This paper describes a case of a neonate with disseminated herpes simplex born to a 14-year-old asymptomatic mother. The infant's physical examination was normal at birth, and subsequent abnormalities were so subtle that infection was not recognized during life. Postmortem cultures of liver and spleen grew herpes simplex virus, and immunofluorescent direct antibody typing revealed Type 2. A cervical culture of the mother obtained after the infant's death was negative.

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A variety of complications involving heart valve implants have been documented. Embolism originating from thrombosis of the valve has been a recurrent problem in mechanical and to a lesser extent porcine implants. We report two accidental deaths as a result of embolization of cotton pledgets from porcine valves. Hospital personnel failed to remove this cotton material from the valves before surgical placement. In the first case, when portions of the pledgets embolized to both carotid arteries, fatal cerebral infarction occurred. In the second case, portions of the pledgets embolized to a coronary artery producing severe left ventricular failure.

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Strut fracture can be a life-threatening adverse effect of mechanical prosthetic heart valves. This complication has occurred in the DeBakey, the Beall, the Cooley-Cutter and, most recently, the Bjork-Shiley valves. We report the case of a 35-year-old man who died suddenly 16 months after a 60 degree Bjork-Shiley Convexo-Concave heart valve prosthesis was inserted in the aortic position. At autopsy, the two welded attachments of the valve's outlet strut had fractured. The valve's tilting disc was found in his abdominal aorta.

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A nine-month-old girl who had successfully undergone surgery for esophageal atresia sustained a rupture of the stomach when an infusion pump was inadvertently connected to the balloon port of a Foley catheter being used as a gastrostomy tube. A strong similarity in appearance and feel of the balloon port and the drainage port of the catheter was created when a clear plastic adapter was inserted in the drainage port for connection of the pump tubing. Other factors contributing to the accident were poor lighting at the time of the connection, failure of the infusion pump occlusion alarm to activate at pressures low enough to prevent injury, and the reduced size of the child's stomach following surgery.

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Air embolism may rarely cause sudden death during or shortly after pregnancy. Certain obstetric techniques, douching procedures, and blowing air into the vagina have been associated with this phenomenon. A case of venous air embolism in a pregnant woman occurring during sexual intercourse in a rear entry position is presented.

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