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Several researchers in the 1950's proposed that hypernatremia causes water to leave brain cells, shrinking the brain, thus tearing the bridging veins and resulting in subdural hematomas. Although the old literature suggests mechanisms linking the two in a cause and effect relationship, there is controversy as to whether hypernatremia leads to subdural bleeding or whether the reverse is true. This issue is important for forensic pathologists who must distinguish natural disease from trauma. An etiologic link between hypernatremia and subdural hematomas was suggested recently, and was proposed originally before Kempe's 1962 paper “The Battered Child Syndrome” which widely disseminated the concepts of child physical abuse, and of subdural bleeding resulting from non-accidental injury. Our study is a multifaceted investigation of infants which includes: a literature review, retrospective chart reviews of both living and deceased hypernatremic infants, a retrospective review of infants hospitalized with subdural hematoma, and a prospective collection of head injured, hypernatremic children. We conclude that hypernatremia, if present in association with subdural hemorrhage, is most likely secondary to intracranial pathology, and that hypernatremia often develops in critically ill infants suffering from a variety of medical conditions.

Artifacts which mimic the tattooing and soot deposition of close range gunshot wounds have been described as “pseudo-soot” and “pseudo-tattooing.” The origin of such findings includes glass, intermediate targets, insect bites, medical manipulation, graphite, and sutures. The authors present a case of pseudo-soot and pseudo-tattooing as a result of asphalt pavement, and describe the associated entity of pseudo-scorching.

This article includes a brief discussion of the evolution death registration as it changed from records of church burial ceremonies to the recording of vital events by government in defined registration areas; today's death registration system in the United States; classification and coding procedures; limitations of data derived from death registration; educational materials; legal issues involving death certificates; and the re-engineering of the death registration process.

The 1992 Senate Report #102-104 and House Report #102-121 recommended that the Interagency Panel on Sudden Infant Death Syndrome (SIDS) review and establish an updated standard death scene investigation protocol for scene investigation of unexplained infant deaths. As a result of the recommendation, the Centers for Disease Control and Prevention's (CDC) Division of Reproductive Health (DRH), and the National Institute for Child Health and Human Development (NICHD) organized a workshop entitled “Workshop on Guidelines for Scene Investigation of Sudden Unexplained Infant Deaths,” which was held in Rockville, Maryland, on July 12–13, 1993. This article outlines the proceedings of the workshop. The goal of the workshop was to gather information and ideas that could be used to establish guidelines which could be useful in developing a model death scene investigation protocol. It was not a goal of this workshop to produce a specific protocol during the workshop. The workshop was successful in generating a variety of information and ideas concerning the desirable attributes of a protocol including essential items of data, identification of certain training needs, specification of procedures for data collection, reporting, and quality assurance, and proposed strategies for implementation. This information can now be considered by the HHS Interagency SIDS Panel to develop specific guidelines for developing a standard scene investigation protocol for sudden unexplained infant deaths.

On the basis of data collection procedures and forms used in various death investigation offices, we developed generic death investigation report forms (DIRFs). One form was designed for documenting information collected by the initial investigator of death, and another form was designed for documenting information collected by the medical examiner, pathologist, or other person who certifies the death or otherwise finalizes the investigation by determining the cause, manner, and circumstances of death. The benefits, problems, and criteria associated with designing the forms are discussed. Both the investigators DIRF (IDIRF) and the certifier's DIRF (CDIRF) are available in printed or electronic form for those who wish to use them or to modify them according to their specific needs. We hope that these DIRFs will be useful and promote uniformity in documenting death investigations.

Death investigation statutes and practices vary among the 50 states. We reviewed the Model Postmortem Examinations Act, recommendations of the National Association of Medical Examiners, the College of American Pathologists' “criteria for autopsies,” and the death investigation statutes and practices in each state. By consolidating the terminology from these various information sources, we developed a list of death categories for which investigation by medical examiners or coroners in the United States is either mandated, commonly performed, or recommended. The list contains specific categories of death, which fall under these three more general areas: 1) unexpected and unexplained deaths, 2) deaths from intentional and unintentional external causes, and 3) deaths that fall under specialized categories related to the decedent's age, environment, or medical conditions, or to the method of bodily disposition. To promote greater uniformity in the death investigation practices among states, we recommend that the Model Postmortem Examinations Act be modified to explicitly recommend certain types of deaths for investigation and that states modify their death investigation statutes to conform to such provisions. Presently, in states where death investigation statutes lack specificity in detailing the types of deaths that should be reported for possible medico-legal investigation, our recommendations, if not in conflict with local statutes, might be used as practice guidelines for the reporting and investigation of certain types of deaths.

We conducted a survey to summarize the status of medicolegal death investigation in the United States in terms of system type, language in state statutes, and terms of service and educational requirements for coroners and medical examiners (death investigators). Certain types of deaths are often mentioned in statutes while others are inconsistently investigated in the various states. The majority of the U.S. population is served by death investigation that is organized on a local or district level, but often administered by a nonmedical branch of government. Many more jurisdictions have elected coroners than appointed medical examiners, but the majority of the population is served by a medical examiner. One-fourth of the population is served by death investigators who are not required to have a medical background or training or experience in death investigation. We recommend that all States adopt policies and minimum educational and training requirements for their death investigators that emphasize medical investigation of death, ongoing continuity and experience, and medically oriented administration. We also recommend that each state address in their statutes certain types of deaths that are inconsistently investigated, including fetal deaths, anesthetic and intra-operative deaths, peri-therapeutic or peri-diagnostic deaths, requested cremations, deaths of institutionalized individuals, suspected cases of sudden infant death syndrome, and deaths occurring shortly after arrival or admission to hospitals.

This paper summarizes data obtained from the new AAFS continuing medical education report forms to provide potentially useful information to future presenters and for program planning. The proportion of presentations that were above average to excellent in content, delivery, and visual aid usage along with the proportion of presentations that brought new knowledge, affirmed existing knowledge, or modified current practice and categorization and tabulation of specific comments about presentations and the program are given. The American Academy of Forensic Sciences (AAFS) revised its CME reporting procedures for its annual meeting in February 1996. A CME credit reporting booklet was prepared, and space was provided to rank each presentation from 1 (poor) to 5 (excellent) regarding the quality of visual aids, presentation, and delivery. In addition, responders could indicate with Yes/No answers whether the presentation affirmed current knowledge, brought new knowledge, or would result in a modification of practice. Space was also provided for open ended comments. Data were summarized in aggregate for all presentations within the Pathology/Biology Section. 52% of presentations were rated overall as being above average or excellent. 52% of presentations had rankings of four or five (better than average to excellent) for delivery, 57% had such ratings for audiovisuals, and 56% had such ratings for content. The number of responders who were brought new knowledge ranged from 43% to 92% for a given presentation and showed an overall average of 66%. Affirmation of existing knowledge ranged from 36% to 85% of for the various presentations and averaged 68%. Presented material was reported to result in a change of practice among 10% to 73% of responders for the various presentations and averaged 31%. Generally supportive comments such as “good presentation” were the most common. Somewhat negative comments about information being of limited usefulness, irrelevant to practice, or of suspicious conclusion were second most common. These and other related data, and the feedback of individual evaluations to presenters may be useful for improving the AAFS Path/Bio program in the future.

In 1986, the Centers for Disease and Prevention established the Medical Examiner and Coroner Information Sharing Program (MecISP) with four primary goals: 1) To improve the quality of death investigations in the United States and to promote more standardized practices concerning when and how to conduct these investigations; 2) to facilitate communication among death investigators, the public health community, federal agencies, and other interested groups. 3) to improve the quality, completeness, management, and dissemination of information regarding investigated deaths; and 4) to promote the sharing and use of medical examiner/coroner death investigation data. Major MecISP projects have included periodic production of a directory of death investigators in the United States and Canada, creation of standard and generic death investigation report forms, development of death investigation data sets, and collection of death investigation data from medical examiner/coroner offices. MecISP also conducts site visits to assist in office computerization, supports educational meetings and the development of training materials for death investigators, facilitates ongoing projects of relevant professional organizations, contributes publications to the death investigation literature, conducts surveillance of selected types of deaths, and responds to specific inquiries from medical examiners and coroners about administrative and practical death investigation issues.

Subpoenas received for criminal trials related to homicides in Fulton County (Atlanta) Georgia were tracked in a computer database for an 18 month period in order to determine the proportion of forensic pathologist worktime required for testimony in homicide cases. The number of subpoenas received annually amounted to 64% of the average number of homicides occurring annually. Testimony was required in about 33% of cases in which a subpoena was received, and, therefore, the number of testimony appearances per year was about 21% of the average annual number of homicides. Assuming a 40 hour work week for 52 weeks per year and an average of 3 hours of time preparing for, traveling to, and testifying in court, the time required of the forensic pathologist to testify in homicide trials amounted to about 2% of a full-time-equivalent. Although the time required for testimony in homicide cases may vary among jurisdictions because of the nature of its homicides, distance and travel time to court, and other factors, the data presented here may be used to estimate the impact of homicide trial court time on forensic pathology practice.

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