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Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in individuals with chronic, uncontrolled epilepsy. Epidemiologists use information on death certificates to study SUDEP. Certification of seizure-related deaths varies. Multiple classification schemes have been proposed to categorize SUDEP type deaths. Nashef et al. recently proposed categorizing death into Definite SUDEP, Definite SUDEP Plus, Probable SUDEP, Possible SUDEP, Near-SUDEP, and Not SUDEP. This study analyzes certification of seizure-related deaths by our office and considers how it relates to Nashef's classifications. Investigative reports from 2011-2015 from the archives of the Jefferson County Coroner/Medical Examiner's Office were searched for the terms “seizure(s)” and “epilepsy.” Cases (N=61) were categorized as Definite SUDEP (n=13), Definite SUDEP Plus (n=12), Probable SUDEP (n=1), Possible SUDEP (n=2), and Not SUDEP (n=33). The term SUDEP was only used in one case of Definite SUDEP. The other 12 cases were certified with variations of terms “seizure” and “epilepsy.” Cases categorized as Definite SUDEP Plus were overwhelmingly certified as deaths due to heart disease. Categories Probable SUDEP or Possible SUDEP comprised three cases, and in one of those a seizure-related term was used on the death certificate. Thirty-three cases were classified as Not SUDEP. The finding that the majority of cases of Definite SUDEP were certified as some variation of “seizure” or “epilepsy” but not “SUDEP” has important implications for SUDEP research. Our study also suggests that cases of Definite SUDEP Plus would be difficult for epidemiologists to identify because cardiovascular diseases are more frequently implicated.

Objective To evaluate the association between death due to drug overdose and a history of laminectomy. Design A retrospective matched case-control study of 234 drug overdose decedents from the Jefferson County Coroner/Medical Examiner's Office in Birmingham, Alabama were matched 1:2 on age to a control group consisting of decedents with any manner of death (accident, natural, suicide, homicide, or undetermined). Laminectomy cases were identified by the presence of a linear surgical scar near the spine in an orientation and place typical for a laminectomy. Results Decedents whose cause of death was a drug overdose were 2.43 times (95% confidence interval [CI] 1.37-4.31) more likely to have a laminectomy scar compared to decedents in a control group consisting of all manners of death. This association held for males (odds ratio [OR] 2.34; 95% CI: 1.09-5.04) and whites (OR 2.35; 95% CI 1.06-5.18) after stratification. Conclusion In the absence of an obvious cause for death, the presence of a laminectomy scar suggests the possibility of a fatal overdose and is a factor to consider in favor of performing an autopsy and toxicological analysis for drugs of abuse.

Autopsy has been a foundation of pathology training for many years, but hospital autopsy rates are notoriously low. At the 2014 meeting of the Association of Pathology Chairs, some pathologists suggested removing autopsy from the training curriculum of pathology residents to provide additional months for training in newer disciplines, such as molecular genetics and informatics. At the same time, the American Board of Pathology received complaints that newly hired pathologists recently certified in anatomic pathology are unable to perform an autopsy when called upon to do so. In response to a call to abolish autopsy from pathology training on the one hand and for more rigorous autopsy training on the other, the Association of Pathology Chairs formed the Autopsy Working Group to examine the role of autopsy in pathology residency training. After 2 years of research and deliberation, the Autopsy Working Group recommends the following: Autopsy should remain a component of anatomic pathology training. A training program must have an autopsy service director with defined responsibilities, including accountability to the program director to record every autopsy performed by every resident. Specific entrustable activities should be defined that a resident must master in order to be deemed competent in autopsy practice, as well as criteria for gaining the trust to perform the tasks without direct supervision. Technical standardization of autopsy performance and reporting must be improved. The current minimum number of 50 autopsies should not be reduced until the changes recommended above have been implemented.

Purpose Forensic autopsies contain a wealth of information ranging from toxicology results to organ masses. Extracting data by hand from years of reports is tedious. We report a computer program that extracts information from reports in Word, WordPerfect, or Portable Document Format (PDF). Methods The program consists of three Excel macros, written in Visual Basic for Applications, which extract information from autopsy and toxicology reports. The user selects a macro, chooses a folder of documents, and inputs key words to guide the search. The macros open each document in the folder sequentially, extract the desired values automatically, and enter the data into the respective case number's row in a spreadsheet. Another macro combines data from the separate autopsy and toxicology reports by matching the unique case number. Extraction of PDF files is a two-step process involving batch conversion from PDF format to Word with subsequent extraction. Results We have developed a set of macros that extract data from autopsy and toxicology reports, such as age, race, height, manner and cause of death, and drug concentrations. Key words included autopsy headings, such as “Cardiovascular System” and units of measure such as “inches” or “pound.” We analyzed roughly 7000 cases and kept 3455 cases. Conclusions Our system rapidly procures data and places the information in a standardized format. This program will be hosted on our toxicology webpage for others to use. Future goals include combining data from other institutions and uploading the data to an online, queryable database.

Different mechanisms can cause bone fractures. This retrospective study considers whether the distribution of cranial fractures can help distinguish the mechanism by which fractures formed. Data are from two sources: cases of motor vehicle collision (MVC) and fire-related deaths obtained from the Jefferson County Coroner/Medical Examiner (JCC/MEO) archives and information on fatal MVCs from the National Automotive Sampling System Crashworthiness Data System (NASS/CDS). In review of the JCC/MEO archives, cranial fractures were documented in 30% of MVC deaths. Fractures were restricted to the base of the skull in 45% of those cases, involved both base and cranial vault in 53%, and was confined to the cranial vault in 2.6%. Cranial fractures were documented in only 4% of deaths involving fire. The NASS/CDS data (n=31 911) are similar, with fracture involving only the base of the skull in 40.9% of cases, both base and vault in 42.3% of cases, and vault only in 16.8% of cases. Cranial fractures in fire-related MVCs vs. non-fire MVCs were more likely to involve the vault only (31.5% vs. 16.9%) and less likely to involve the base and vault (36.4% vs. 45.0%) or base only (32.1% vs. 38.1%). In conclusion, most (>90%) cranial fractures related to MVCs involved the base of the skull. Few deaths only associated with fire were associated with cranial fracture (4%). In circumstances where alternate mechanisms for fracture exist, such as a vehicle catching fire after a collision, fracture of the base of the skull supports the collision as the likely mechanism of fracture.

Scientific writing is the communication of a new idea that will alter or enlarge the reader's understanding of the subject of the article. Scientific writing follows a standard template defined by the journal that published the article. Authors greatly increase the chance that their manuscript will be published by reading and following the journal's instructions to authors. Every word, image, and diagram in an article should serve the purpose of communicating the author's new idea effectively and forcefully. The title, introduction, method, results, discussion, and reference list serve different purposes within the article and therefore are constructed differently. The abstract is a distillation of the essential points of the article and should always contain the central idea that the article was written to convey. Anyone listed as an author must have made a meaningful contribution to the work; that is, without each author's contribution, the article simply would not exist. Authors must avoid plagiarism by neither copying the writings of others nor copying their own writings or images used in previous publications. Plagiarism is easily avoided by taking notes, not quotes, from articles that serve as references and then writing the new manuscript from these notes; this system changes the original wording of the references twice and transforms the concepts into the author's voice.

The National Institute of Standards and Technologies (NIST) has transformed the majority of the Scientific Working Groups (SWGs) into the Organization of Scientific Area Committees (OSAC). The OSAC has been created to foster the development of standards and guidelines for the practice of documenting evidence by methods that are technically sound and accepted by the consensus of forensic practitioners. The OSAC is composed of 33 committees arranged in a hierarchy. Potential standards begin in a Subcommittee and must work their way through approval by the Subcommittee, the Subcommittee's parent Scientific Area Committee (SAC), and finally the Forensic Science Standards Board (FSSB) before being adopted into the FSSB Registry of Approved Standards. NIST hopes to find existing standards with technical merit that were developed through a standards development process for adoption as national standards of practice. The OSAC provides forensic scientists the unprecedented opportunity of validating their own scientific practices within the framework of sound scientific practice.

The distribution of time from acute traumatic injury to death has three peaks: immediate (less than or equal to one hour), early (6 to 24 hours), and late (days to weeks). It has been suggested that coordinated trauma care dampens the late peak; however, this research may be more reflective of unintentional than intentional deaths. This study examines whether a coordinated trauma system (TS) alters the temporal distribution for assault-related deaths. Data were obtained from homicides examined by the Jefferson County Coroner's/Medical Examiner's Office from 1987 to 2008. Homicides were categorized—based on year of death—as occurring in the presence of no TS, during TS implementation, in the early years of the TS, or in a mature TS. The temporal distribution of homicide mortality was compared among TS categories using a χ2 test. A Cox Markov multistate model was used to estimate proportional changes in the temporal distribution of death adjusted for assault mechanism. With a TS, after adjusting for assault mechanism, a lower proportion of homicide victims survived through the first hour (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.54 to 1.03) and from one to six hours (HR, 0.68; 95% CI, 0.49 to 0.96). Additionally, the presence of a TS was associated with a proportional decrease in deaths after 24 hours ( P = 0.0005). These results suggest that a trauma system is effective in preventing late homicide deaths; however, other means of preventing death (such as violence prevention programs) are needed to decrease the burden of immediate homicide-related deaths.

National statistics on drug intoxication deaths are based solely on data derived from death certificates. This study examines the variation in the manner of death classification by state, and the specificity of drugs involved in drug intoxication deaths by state and by type of death investigation system. The National Vital Statistics System Multiple Cause of Death mortality files (2008–2010) were analyzed. Drug intoxication deaths were those with ICD-10 Underlying Cause of Death of X40-X44 (unintentional), X60-X64 (suicide), X85 (homicide), or Y10-Y14 (undetermined intent). Among drug intoxication deaths, deaths involving non-specified drug(s) were those with Multiple Cause of Death (MCOD) of T50.9, and no MCOD in the range T36-T50.8. State death investigation systems were categorized as follows: centralized state medical examiner offices, county/district medical examiners, hybrid, and decentralized county coroners. In 2008–2010, there was an average of over 37,250 drug intoxication deaths per year in the U.S. The manner was undetermined for 8% for the U.S., ranging from 1% to 85% among the states. During 2008–2010, 75% of the drug intoxication deaths had at least one specific drug reported on the death certificate. States with centralized state medical examiner systems had a higher percent (92%) of drugs specified than did those with other systems. Across the U.S., there is variation in the percent of drug intoxication deaths classified as having undetermined manner of death and with specific drugs identified on death certificates. This variation has significant implications for public health surveillance and for prevention efforts.

The American College of Medical Toxicology and the National Association of Medical Examiners convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of the toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance. The panel finds the following: 1. A complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings. 2. A complete scene investigation extends to reconciliation of prescription information and pill counts. 3. Blood, urine, and vitreous humor, when available, should be retained in all cases. Blood from the femoral vein is preferable to blood from other sites. 4. A toxicological panel should be comprehensive and include opioid and benzodiazepine analytes, as well as other potent depressant, stimulant, and antidepressant medications. 5. Interpretation of postmortem opioid concentrations requires correlation with medical history, scene investigation, and autopsy findings. 6. If death is attributed to any drug or combination of drugs (whether as cause or contributing factor), the certifier should list all the responsible substances by generic name in the autopsy report and on the death certificate. 7. The best classification for manner in deaths due to the misuse or abuse of opioids without any apparent intent of self-harm is “accident.” Reserve “undetermined” as the manner for the rare cases in which evidence exists to support more than one possible determination.

The American College of Medical Toxicology and the National Association of Medical Examiners convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance. The panel finds the following: 1. A complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings. 2. A complete scene investigation extends to reconciliation of prescription information and pill counts. 3. Blood, urine, and vitreous humor, when available, should be retained in all cases. Blood from the femoral vein is preferable to blood from other sites. 4. A toxicological panel should be comprehensive and include opioid and benzodiazepine analytes, as well as other potent depressant, stimulant, and anti-depressant medications. 5. Interpretation of postmortem opioid concentrations requires correlation with medical history, scene investigation, and autopsy findings. 6. If death is attributed to any drug or combination of drugs (whether as cause or contributing factor), the certifier should list all the responsible substances by generic name in the autopsy report and on the death certificate. 7. The best classification for manner of death in deaths due to the misuse or abuse of opioids without any apparent intent of self-harm is “accident.” Reserve “undetermined” as the manner for the rare cases in which evidence exists to support more than one possible determination.

For decades, forensic scientists have sought a means of estimating the postmortem interval using laboratory analyses. The best known of these attempts uses a linear regression formula based on the increasing concentration of potassium ions in vitreous humor following death. Like all laboratory analyses, the determination of a potassium concentration is subject to pre-analytical, analytical, and post-analytical errors. Any error is magnified when entered into a regression formula that itself is subject to statistical variation, typically with a 95% confidence interval. Estimating the postmortem interval based solely on the concentration of potassium in vitreous humor proved too simplistic for accurate modeling of the myriad factors that influence postmortem changes. Research continues, using more complicated algorithms involving multivariate ion and chemical analyses and genomic sequencing of the postmortem biome. However refined estimates of the postmortem interval based on laboratory analysis become, sound medical practice will still require the integration of scene findings and information concerning the last time that a given decedent was known to be alive with the results of postmortem examination and laboratory analyses into a medical opinion concerning the postmortem interval.

Scientists seek to understand how the world works by the creative act of generating a possible explanation for some phenomenon and then by testing that possible explanation to determine whether it is valid. Transforming a creative insight into a hypothesis suitable for rigorous testing is an essential skill that any scientist must develop. Hypotheses are tested in a scientific study by measuring the natural world in some way and then comparing those measurements to determine whether they support or refute the hypothesis. A well designed study reduces the possibility that chance or scientific bias accounts for the results of the study. Chance can be reduced by having at least 30 test subjects and 30 controls in a study. Bias is reduced by diligent and honest effort to make the members of the study group so similar to the members of the control group that nothing distinguishes one from the other except the factor being studied. Prospective cohort studies are powerful but expensive tools for studying common diseases or injuries. Retrospective case-control studies are ideal for studying rare entities. Retrospective studies tend to be inexpensive but often lack desirable details that were not recorded at the time of the initial case investigation. For forensic practitioners to honestly call themselves scientists they should perform original scientific research to substantiate hypotheses and advance knowledge in forensic disciplines. Useful research in forensic pathology can be performed with no more investment than time and effort, but financial support is available from several sources.