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The National Association of Medical Examiners convened an expert panel to update the association's evidence-based recommendations for investigating and certifying deaths associated with opioids and other misused substances to improve death certificate and mortality data for public health surveillance. The recommendations are as follows:1. Autopsy provides the best information on a decedent's medical condition for optimal interpretation of toxicology results, circumstances surrounding death, medical history, and scene findings. The panel considers autopsy an essential component of investigating apparent overdose deaths.2. Scene investigation includes reconciling prescription information and medication counts. Investigators should note drug paraphernalia or other evidence of using intoxicating substances.3. Retain blood, urine, and vitreous humor whenever available. Blood from the iliofemoral vein is preferable to blood from more central sites.4. A toxicological panel should be comprehensive, including potent depressant, stimulant, and antidepressant medications. Detecting novel substances present in the community may require special testing.5. When death is attributed to a drug or combination of drugs (as cause or contributing factor), the certifier should list the drugs by generic name in the autopsy report and death certificate.6. The best classification for manner of death in an overdose without any apparent intent of self-harm is "accident."

In 2005, the National Association of Medical Examiners approved the Forensic Autopsy Performance Standards. Standard B3.7 indicates that a forensic pathologist shall perform a forensic autopsy when the death is by apparent intoxication by alcohol, drugs, or poison.The Jefferson County Coroner/Medical Examiner Office has observed an increase in our caseload by 10% per year since 2012. We designed a study to determine if a pathologist could correctly classify the cause of death (COD) and manner of death (MOD) of suspected drug-related deaths without information from the internal examination. The determination of the COD and MOD was then compared with the case file, which includes information from the internal examination and microscopy, to determine agreement between the case file and the reclassification. The percent correct for COD and MOD was calculated, and kappa values were calculated for MOD.The pathologists were able to correctly classify the COD in 73% of cases. For MOD, 2 pathologists achieved substantial agreement between the test cases and the actual case file. The third pathologist had moderate agreement. These findings indicate that a full postmortem examination is necessary to correctly classify the COD/MOD in cases of suspected drug toxicity.Our null hypothesis is that a full autopsy is not necessary to correctly classify the COD and MOD in cases of drug toxicity.

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.

Obesity can involve any organ system and compromise the overall health of an individual, including premature death. Despite the increased risk of death associated with being obese, obesity itself is infrequently indicated on the death certificate. We performed an audit of our records to identify how often "obesity" was listed on the death certificate to determine how our practices affected national mortality data collection regarding obesity-related mortality. During the span of nearly 25 years, 0.2% of deaths were attributed to or contributed by obesity. Over the course of 5 years, 96% of selected natural deaths were likely underreported as being associated with obesity. We present an algorithm for certifiers to use to determine whether obesity should be listed on the death certificate and guidelines for certifying cases in which this is appropriate. Use of this algorithm will improve vital statistics concerning the role of obesity in causing or contributing to death.

This paper presents the outcome of the first international forensic radiology and imaging research summit, organized by the International Society of Forensic Radiology and Imaging, the International Association of Forensic Radiographers, the National Institute of Justice of the United States of America, and the Netherlands Forensic Institute. During this meeting, an international and multidisciplinary panel of forensic scientists discussed the current state of science in forensic radiology, and drafted a research agenda to further advance the field. Four groups for further research focus were identified: big data and statistics, identification and biological profiling, multimodal imaging, and visualization and presentation. This paper describes each of these research topics and thereby hopes to contribute to the development of this exciting new field of forensic medical science.

Research has reported that a strong risk factor for traumatic injury is having a previous injury (i.e., recidivism). To date, the only study examining the relationship between recidivism and homicide reported strong associations, but was limited by possible selection bias. The current matched case-control study utilized coroner's data from 2004 to 2008. Subjects were linked to trauma registry data to determine whether the person had a previous traumatic injury. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for the association between homicide and recidivism. Homicide risk was increased for those having a previous traumatic injury (OR 1.81, 95% CI 1.09-2.99) or a previous intentional injury (OR 2.53, 95% CI 1.24-5.17). These results suggest an association between homicide and injury recidivism, and that trauma centers may be an effective setting for screening individuals for secondary prevention efforts of homicide through violence prevention programs. Language: en

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.

Medical examiner offices vary in the extent to which they pursue postmortem toxicology. Our office routinely tests decedents for ethanol and drugs of abuse, and we decided to evaluate the usefulness of our practice. We reviewed 1180 medical examiner cases examined in 2002–2003. History and scene investigation indicated that alcohol or drugs of abuse were likely to be detected in 369 cases, yet toxicology testing revealed an intoxicating substance in 589 cases, a prevalence of 50%. Screening for toxicology testing based on investigative findings had a sensitivity of 0.47, a specificity of 0.84, and a positive predictive value of 0.74. Moreover, even in the 811 cases where initial investigation did not suggest substance abuse, toxicology testing revealed at least 1 substance that was pertinent to the subsequent investigation in one third of the cases (260), and the intoxicating substance was sufficiently important to merit inclusion as a cause of death or contributing factor in nearly half of those cases (113). We conclude that investigation alone is ineffective at predicting the presence of intoxicating substances within decedents.

Context.—In our society it is well for a physician to know something of the workings of court and how to interact with attorneys. One need not go to law school to successfully navigate a legal proceeding as a physician witness. Objective.—To show that a physician skilled at interacting with colleagues and patients can successfully apply those skills to interacting with attorneys and testifying in court. Data Sources.—This work is based primarily on the author's experience in interacting with attorneys and testifying in court, with supplemental contributions from textbooks. Conclusions.—Skillful testifying is simply the transmission of medical information in court in a professional, polite, and compelling manner, an ability within the grasp of any physician who has mastered the art of working with colleagues and patients. Careful, honest assessment of the medical matters in a legal case places a physician in a strong position, which the physician can maintain by remaining polite, even in the face of attempts by an attorney to denigrate the physician's professional abilities. The best witnesses tell the truth in a manner that compels people in the courtroom to listen.

The common history of drug abuse in adults with an undetermined cause of death has led us to hypothesize that chronic drug abuse increases the risk of sudden death. To begin evaluating this hypothesis, we conducted a retrospective case-control study of 61 decedents whose cause of death remained undetermined following autopsy matched one to one to a control group of pedestrians or passengers killed in motor vehicle collisions. In 21 pairs, the case subject had evidence of drug abuse but the control did not, and in 5 cases the reverse was true. Analysis showed that individuals with an undetermined cause of death are 4.2 times more likely to have evidence of drug abuse than are victims of a motor vehicle collision.

Despite death being one of the most common reasons for discharge from a nursing home, fewer than 1% of nursing home resident deaths are autopsied. To evaluate our role as medical examiner in nursing home deaths, we conducted a retrospective review of all decedents in Jefferson County, Alabama, for the year 2001. Death certificate data indicate that 995 deaths occurred in nursing homes in Jefferson County in 2001. Of those 995 deaths, 119 (12%) were reported to the Jefferson County Coroner/Medical Examiner Office. Jurisdiction was accepted in 5 cases in which the circumstances already made clear that the death was a nonnatural event. In the remaining 96% of nursing home deaths reported to the medical examiner, the statements of the reporting person were taken to be true concerning the expected nature of the death. An independent scene evaluation was provided by a police officer or paramedic in 82% of the cases reported to the medical examiner's office. Elderly individuals, as a group, are expected to die, but the death of a particular elder may or may not be expected. In our jurisdiction, only 12% of all nursing home deaths are reported to our office, and only 4% of reported deaths are actively investigated. Actively investigating each nursing home death would overwhelm the resources currently available to our office. We advocate the study and development of criteria to aid in determining whether the death of an individual elder is sudden and unexpected.

The National Center for Health Statistics (NCHS) is responsible for publishing Standard Certificates of Birth and Death for the United States of America. The standard certificates are revised roughly every 10 years. The revision process is designed to ensure that the standard certificates meet, as nearly as possible, the use for which they are intended at all levels: individual, local, state, and federal. The authors report on the most recent revision of the U.S. Standard Certificate of Death, recording the process and the role of the National Association of Medical Examiners in the process. Changes recommended during revision include requesting known aliases of a decedent and rearrangement of the certificate to provide more room for those items requesting dates and for describing how the injury occurred. New items have been added asking for information regarding traffic fatalities, the role of tobacco use in causing death, and whether female decedents were pregnant. Once approved by the Department of Health and Human Services, the new standard certificate will be made available to the states. Each state will have 2 years to adapt the U.S. Standard Certificate of Death to its use and to implement new state death certificates on January 1, 2003.

Hair samples are useful as a matrix for drug testing because drugs can be detected in hair for longer periods than in blood or urine. The authors report a prospective comparison of the detection of cocaine and cocaethylene in routine postmortem biologic specimens to the detection of cocaine and cocaethylene in hair. The authors collected hair samples from various areas of the head in 53 autopsy cases, prepared them, and analyzed them by gas chromatography/mass spectrometry (GC/MS) for cocaine and cocaethylene. The authors compared the results of hair analysis with the results of toxicologic analysis performed on routine postmortem samples by enzyme multiplied immunoassay technique and GC/MS. Cocaine was found in either biologic fluids or in hair in 16 of 53 samples tested. Nine samples were positive for cocaine in both biologic fluids and hair. Five samples contained cocaine only in biologic fluids, and two contained cocaine only in hair. Cocaethylene was present in two cases. Drug screening of hair provides additional information in some autopsy cases, but the authors have not made hair analysis a routine practice. It may prove useful to save hair samples in all cases for later analysis if warranted by additional history or autopsy findings.

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. Language: en

An estimated 25% of the US population aged 18 to 50 years has a tattoo, which have been associated with markers of high-risk behaviors including alcohol and drug use, violence, carrying weapons, sexual activity, eating disorders, and suicide. This study compares tattoo prevalence and type in a homicide population to those of an age-, race-, and sex-matched control group of nonhomicide deaths. The data for this study were abstracted from autopsy records maintained by the Jefferson County Alabama Coroner/Medical Examiner's Office for the years 2007 and 2008. Odds ratios and 95% confidence intervals for the association between homicide and tattoo presence and characteristics were calculated using conditional logistic regression. There was no association between tattoo presence and death by homicide; however, among blacks, memorial tattoos were significantly more common among homicides compared with other types of deaths (odds ratio, 2.50; 95% confidence interval, 1.10-5.68). The results of the current study suggest that specific types of tattoos, but not all tattoos, may be risk factors for homicide. Other factors, such as race and lifestyle, along with tattoos may need to be considered.

Motor vehicle-related child hyperthermia fatalities (MVRCHF) have risen slightly in the past decade, but little research has been done investigating the circumstances surrounding MVRCHF. In order to address gaps in our understanding, the current study describes MVRCHF circumstances among children1-14 years of age in the United States from 1999 to 2007. Three sources were used to identify child hyperthermia death cases in the United States from 1999 to 2007: the Centers for Disease Control and Prevention's Compressed Mortality File (1999-2004), the Golden Gate Weather Service's public MVRCHF database (2003-Present), and an independent internet search. Data about the victim's characteristics and the circumstances surrounding the death were extracted. From 1999 to 2007, 231 MVRCHF were identified. Children were left unattended in80% of cases, 25% of victims were playing at the time of death, and 60% were male. On average, the core body temperature was 107.2 degrees F after being left inside the vehicle for an average of 4.6 h. The largest number of deaths occurred in the South, followed by the West, Midwest, and Northeast. Parents were found to be accountable for 2/3 of the hyperthermia deaths. The geographic distribution of incidence may be attributable to two major influences: (1) regional climate differences; and (2) population characteristics. The accountability of parents for MVRCHF is likely due to the exposure-risk concept, in which the situation/circumstances increase the injury probability.

Parafollicular (or monocytoid) B-cell lymphoma (PBCL) is a recently described low grade lymphoma. The relationship of parafollicular B cells to other B lymphocytes is not known, but the authors observed plasmacytic differentiation in the initial case of PBCL. In this report 12 cases of PBCL were studied by light microscopy and immunophenotypic analysis, and plasmacytic differentiation was found in four cases. This plasmacytic differentiation and the anatomic relationship of the neoplastic cells to reactive follicular centers suggest a functional relationship between these cell types.

Context.—Forensic pathologists regularly investigate the deaths of individuals with a history of drug abuse. Autopsy, including toxicology testing, reveals no cause for death in a subset of this cohort. Objective.—To determine whether deaths with an undetermined cause and manner of death are associated with a history of drug abuse. Design.—Retrospective matched case-control study of 52 decedents whose cause of death remained undetermined following autopsy, matched 1:2 to a control group of living patients admitted for cholecystectomy according to age and date of death or procedure. Results.—Individuals whose cause of death was undetermined were 5.3 times (95% confidence interval, 1.9– 14.5) more likely to have a history of drug abuse than were patients with cholecystitis. Conclusions.—Decedents with a history of chronic drug abuse appear to be at an increased risk of dying by their chronic drug abuse, even in the absence of any anatomical or toxicologic finding at autopsy to account for death.

A malpractice suit arises when a patient brings legal charges against a physician for suffering that the patient claims to have endured because the physician failed to provide appropriate care. Suffering usually encompasses a measure of misdiagnosis and of rude treatment of the patient by medical staff. Polite treatment of all patients by all laboratory staff will prevent some disputes from ever forming, thus preventing some charges of malpractice. Even if a patient is treated rudely, that rudeness alone is insufficient to justify a charge of malpractice. Attorneys must follow legal guidelines to determine whether the physician's actions caused actual damage. As soon as a physician is served notice of a lawsuit, the physician must notify the office that insures him or her against claims of malpractice (eg, the office of risk management or the physician's malpractice insurance carrier). Being sued creates an overwhelming urge to talk about the case, but a physician who has been sued must not talk to anyone about the lawsuit or the case involved. Conversations about the lawsuit may only safely be had with the attorney who will defend the physician against the charge of malpractice. Despite any frustrations with the legal system, the physician must work with and even trust the attorney handling the defense. It is possible to overcome a charge of malpractice, but not if the physician creates an indefensible situation by committing fraud. Examples of fraud are changing the medical record or destroying the pertinent microscope slide.

Proposed mechanisms by which sudden unexplained death syndrome in epilepsy (SUDEP) occurs include cardiac dysrhythmias. We hypothesized that individuals dying of SUDEP would have enlarged hearts compared with normal, increasing the risk of sudden cardiac death should the autonomic nervous system initiate a dysrhythmia. We performed a retrospective case-control study in a medical examiner population, comparing the mean heart mass in a group of individuals who died of SUDEP to a group of individuals with epilepsy who died suddenly due to some unrelated cause (non-SUDEP). We found no significant difference in the mean heart mass between the 2 groups when analyzing the unadjusted data. Upon stratifying the cases by age, however, we found a significant reduction in the frequency of SUDEP in individuals 40 or more years of age with an increased heart mass compared with those younger. This reduced frequency disappeared when cases where the cause of death was indeterminate between SUDEP and heart disease were reclassified from non-SUDEP to SUDEP. With increasing age, the likelihood of finding a cause of death that competes with the possibility of SUDEP increases, making SUDEP appear to be a phenomenon of the young. The inclusion of seizure deaths evaluated in a medical examiner office in studies of SUDEP would provide the benefit of a more certain diagnosis in each given case. Moreover, the inclusion of cases from the medical examiner population would stem attrition in a clinical study due to loss to follow-up.

Utilities that supply power are subject to theft of service and theft of hardware used to provide service. Individuals who try to steal from a power utility risk electrocution. We conducted a retrospective study of all individuals examined by the Jefferson County Coroner Medical Examiner Office from January 1981 through December 2001 and found that 8 individuals died trying to steal from a power utility. All decedents were men, with an average age of 33 years. Seven decedents were stealing copper, and 1 was stealing electricity. Only 1 decedent survived long enough to be admitted to a hospital. Five decedents were intoxicated, 3 with ethanol, 1 with cocaine, and 1 with both cocaine and ethanol. Seven decedents sustained electrical burns in keeping with the high voltage to which they were subjected. The unburned decedent died of laceration of the aorta at its origin from the heart, an injury sustained when the decedent fell from the power pole. All 8 decedents attempted their theft during daylight. Items found in the decedent's pockets, the presence of a ladder nearby, or the presence of electrical tools around the body may help to establish the attempted act of theft.

Sudden unexplained death in epilepsy occurs when epilepsy patients die suddenly and unexpectedly in the absence of recent tonic-clonic seizure activity. There is currently no known reliable indicator of acutely lethal seizure activity. Clinical studies record a relationship between recent (within 10-40 minutes) seizure activity and elevated serum prolactin levels, and postictal elevation of prolactin within peripheral vessels has proved clinically useful in determining recent seizure activity. The authors hypothesized that elevated prolactin could be detected in cerebral vessels by immunohistochemical stains, serving as a marker for sudden unexplained death in epilepsy. They conducted a retrospective study of individuals who died in their jurisdiction during the 14 years from 1986 through 1999. The study contained one group of individuals who died of sudden unexplained death in epilepsy, a group with epilepsy who died of some other cause, and a control group whose members died rapidly of a gunshot wound of the torso. Sections of hippocampus and neocortex were obtained and stained with a polyclonal prolactin antibody. No significant difference in the level of immunostaining for prolactin in cerebral vessels was found between the experimental and control groups. A review of the protocols used indicates that revision of certain aspects may provide better immunostaining and more conclusive results.

Interpretation of the concentration of a drug is more difficult when a combination of drugs is present in a decedent's blood. An increase in deaths resulting from co-intoxication with methadone and a benzodiazepine led the authors to perform a retrospective study of cases examined at the Jefferson County Coroner/Medical Examiner Office. They found 101 deaths wherein methadone was detected in the blood. Based on the drugs detected in the blood, these 101 cases were grouped into four categories: (1) pure methadone intoxication, (2) intoxication with methadone and benzodiazepine, (3) intoxication with methadone and other drugs excluding benzodiazepine, and (4) intoxication with methadone, benzodiazepines, and other drugs. Methadone was the sole intoxicant in 15 cases, with a mean concentration of 0.27 mg/L. Benzodiazepines were the most frequently detected co-intoxicant (60 of 101 cases). Benzodiazepine was the only co-intoxicant in 30 cases, and the mean methadone concentration in those 30 cases was 0.599 mg/L. Higher levels of methadone may occur in acute intoxication with methadone and benzodiazepine because benzodiazepines compete with methadone for methadone receptors. Higher levels of methadone may occur with chronic abuse of methadone and benzodiazepines because over time, benzodiazepines inhibit the hepatic enzymes that metabolize methadone.

Pelvic fractures are frequent complications of motor vehicle accidents, and motor vehicle accidents are the most common cause of pelvic fracture. Although pelvic fractures are associated with considerable morbidity and mortality, there has traditionally been no attempt to grade or classify pelvic fractures during postmortem examination. The authors performed a retrospective study of cases examined at the Jefferson County Coroner/Medical Examiner Office from 1994 to 1996, reviewing investigative reports and autopsy findings. Radiographs were examined for the presence and Tile type of pelvic fracture. Pelvic fractures were identified in 88 of 392 cases (23%). In most (89%), the pelvic fracture was readily classified according to Tile type on the basis of radiographs and the inferred mechanism of injury. This study indicates that current estimates of the mortality of pelvic fractures are low because of the exclusion of individuals who do not survive to hospitalization. Furthermore, pelvic fractures in rapidly fatal motor vehicle accidents tend to be more severe than fractures in individuals who have a significant interval of survival. The presence and classification of pelvic fractures may be readily determined by radiographs in most cases. The Tile classification scheme is easy to apply and has important implications in the comparison of study groups.

A 13-year-old girl experienced a fall during gym class that caused immediate unresponsiveness and death. The lone witness reported that the decedent lost her balance as she approached a hurdle and fell, striking her head on a crossbar of the hurdle near the ground. Autopsy revealed no external injury. Internal injury that could be demonstrated anatomically was confined to a contusion within the right semicapitis muscle at the base of the skull. In the absence of an anatomic cause of death, possible explanations of the death include a cardiac dysrhythmia, a vasovagal stimulus, and diffuse axonal injury caused by a concussive force to the junction of the medulla and spinal cord. Animal studies have shown that severe concussion can cause death via profound autonomic dysfunction without leaving anatomic evidence of injury, and that the essential component of concussion is an element of rotational injury to the brain. The authors believe that the blow to the neck caused this death by the transmission of a concussive force through the reticular activating system. The prompt work of police in distinguishing the lone witness from several people in the area who thought they knew what had happened was essential for diagnosis. On reaching our conclusions, the authors notified first the family, then the superintendent of the school system, and finally the news media. The authors told each party in turn that they would be contacting the others.

Understanding the pathogenesis of viral myocarditis is linked to the availability of sensitive assays to detect viruses in clinical material. Recent advances in molecular techniques permit direct detection of viral-specific nucleic acid in tissue samples. This report describes a protocol for DNA extraction and amplification of adenovirus genome from formalin-fixed, paraffin-embedded human tissues that detects as little as 10 copies of viral genome in a background of 0.5 μg of human DNA. This sensitive assay permitted the examination of archived tissues to establish a retrospective diagnosis of adenoviral myocarditis in two pediatric patients.

Dr. Wagner wrote his Color Atlas of the Autopsy for crime scene investigators, law enforcement officials, and other professionals who interact with forensic pathologists during the course of an autopsy. Individuals who lack formal medical training have many questions upon seeing their first autopsy, and Color Atlas of the Autopsy attempts to answer these questions by capturing the process of autopsy examination as it unfolds.

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.

Acute aortic dissections are catastrophic vascular events that have a high rate of mortality. Aortic dissections have been associated with a variety of factors, particularly hypertension. We reviewed 84 medical examiner autopsies on individuals dying from acute aortic dissections with particular emphasis on the role of drugs. Previous case reports have associated aortic dissections with both cocaine and methamphetamine intoxication. We found that seven of the 35 cases tested for drugs of abuse were positive for methamphetamine. Our study had no cases of solely cocaine-related dissection, although one of the cases was positive for both methamphetamine and the cocaine metabolite benzoylecgonine. No significant association was found with any other drugs. As with other studies, we found the most common risk factor to be hypertension. Surprisingly, methamphetamine use was the second most common risk factor. The association between methamphetamine use and aortic dissection is most likely due to its hypertensive effect. Although methamphetamine appears to pose a greater risk than cocaine, both drugs should be considered as possible factors in all aortic dissections.