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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.

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.

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.

Objective Lack of standardized terminology on death certificates (DCs) of SUDEP type cases may obscure the presence of epilepsy in these deaths. Most DCs for individuals dying unexpectedly with epilepsy are certified by medical examiners (MEs). The purpose of this study was to gauge death certification practices of MEs when interpreting SUDEP cases and assess implications for valid surveillance of SUDEP. Materials and methods A survey consisting of clinical vignettes describing deaths in individuals with epilepsy was sent to medical examiners. Respondents were asked to indicate how they would certify death on a DC. Similar text responses were aggregated and coded according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) coding system. Results A total of 847 responses on 11 cases were received. Depending upon the vignette, the proportion of responses within each case that did not have an ICD-10 seizure code ranged from 3% to 62%. G40.9 (Epilepsy, unspecified) resulted from 43% of responses, and R56.8 (Other and unspecified convulsion) resulted from 38% of responses. Conclusion The survey indicates that a high proportion of DCs do not have a seizure code and would not be identified utilizing these ICD-10 codes. The complicated nature of deaths in SUDEP, unclear circumstances surrounding a given death, and the lack of familiarity with SUDEP by surviving relatives may all contribute to variable terminology used to certify SUDEP deaths. Our results emphasize the need for collaboration between neurologists and forensic pathologists to develop a more uniform approach to death certification in SUDEP that will facilitate SUDEP research and inform relatives of individuals who die of SUDEP.

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.

Drug abusers have access to new, more potent compounds that evade existing laws by virtue of their novel chemical structures. These drugs are available for purchase at stores and over the internet. The drugs are not illegal because they are so new that laws have not yet been passed to ban them. These drugs are leading to emergency department visits for cardiovascular, neurologic, and psychiatric complications. Standard drug screens are not designed to detect these new substances. The internet provides access to drugs for substance abusers but also provides physicians speed of access to the habits of substance abusers.

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.

This study compared data from death certificates (DC), medical examiner (ME) reports, and Uniform Crime Reporting (UCR) Program for homicides among children age 5 years or younger in Jefferson County, Alabama between 1988 and 1998. Records from each source were matched independently to records from the other two sources. Kappa coefficients measured the chance-corrected agreement between sources. The strongest correlations were for victim's gender and race. Correlations were weakest for victim's relationship to the offender and offender's gender. DC and ME data demonstrated excellent agreement and provided a comprehensive count of homicides in Jefferson County, whereas UCR comparisons had lower correlations. However, the UCR is a valuable source of child homicide data in the United States that is underutilized in public health research.

Few studies have presented the general epidemiology of electrocution deaths using local medical examiner data. Data were obtained from coroner/medical examiner's files for electrocution deaths occurring between 1981 and 1998. All 27 occupational electrocutions were among men; 92.6% were white and 7.4% were black, with a mean age of 33.1 years. The rates of high- and low-voltage electrocution were similar. Low-voltage deaths showed a seasonal pattern, with the largest numbers in July, August and October. Deaths occurred most frequently among electricians and electrical helpers. The level of detail available from medical examiner records permits more complete evaluation of injury patterns than is possible using death certificate data; however, even more detailed studies, exploring worker activity at the time of injury, education, experience and training, are needed.

Introduction—Some reported characteristics associated with hypothermia mortality include older age, alcohol consumption, male sex, and black race. The purpose of this paper is to present the epidemiology of hypothermia deaths in Jefferson County, Alabama. Methods—Autopsy reports maintained by the county coroner's office were abstracted for all cases with primary or underlying causes of death listed as "hypothermia" or "exposure to cold" between January 1983 and July 1999. Results—Sixty three hypothermia deaths occurred in Jefferson County during the study period. The mean age among cases was 68 years, 63.9% were male and 70% were of black race. Rates of hypothermia death were highest among black males, followed by black females, particularly blacks aged 80 years or older. Deaths occurring indoors were more common among older persons and outdoor deaths more common among younger persons. Thirty per cent of decedents tested positive for alcohol, 75% of whom were found outdoors. Nine decedents tested positive for drugs or medications. Approximately 90% of decedents were identified as having one or more chronic medical conditions. Excluding alcoholics, 52% of decedents had one or more chronic medical conditions. Conclusions—Hypothermia in Jefferson County, Alabama is a cause of death primarily affecting two distinct groups of individuals, elderly persons who develop hypothermia inside a dwelling and middle aged males who develop hypothermia out of doors and have consumed alcohol.

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.

Background: On April 8, 1998, an F5 tornado touched down in two counties of Alabama producing a wide path of destruction. The presence of a regional trauma system in this area presents an opportunity to evaluate the effectiveness of the system in responding to the victims of this natural disaster. Methods: Emergency room logs and the regional trauma system database were searched for all patients treated for injuries sustained from the tornado, and medical records were reviewed for demographic information, mode of transportation to hospital, injuries, treatment, and outcome. Fatalities were identified by means of the coroner's office. Results: A total of 224 patients were evaluated at nine area hospitals, of whom 63 (28%) required admission. There were 32 deaths: 30 persons were dead at the scene, and 2 patients subsequently died at Level I trauma centers. Among patients with nonfatal injuries, 39% were managed at Level I facilities, 46% at Level III facilities, and 15% at nontrauma facilities. Forty patients (55%) seen at Level I facilities required admission compared with 15 patients (17%) at Level III facilities and 8 patients (29%) at nontrauma facilities; Level I facilities also had the highest Injury Severity Score. Of patients requiring admission, 83% were transported by emergency medical services; these patients also had the highest Injury Severity Score. Conclusion: The regional trauma system facilitated appropriate and efficient triage to system hospitals, routing the most severely injured patients to the Level I centers without overwhelming them with the more numerous, less severely injured patients.

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

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.

Drug abusers have access to new, more potent compounds that evade existing laws by virtue of their novel chemical structures. These drugs are available for purchase at stores and over the internet. The drugs are not illegal because they are so new that laws have not yet been passed to ban them. These drugs are leading to emergency department visits for cardiovascular, neurologic, and psychiatric complications. Standard drug screens are not designed to detect these new substances. The internet provides access to drugs for substance abusers but also provides physicians speed of access to the habits of substance abusers.

The time-dependent postmortem increase of potassium concentration in the eye fluids has been studied since the 1960s. However, important discrepancies on the reproducibility of the phenomenon have hampered the use of this parameter in real cases. In recent years, a new analytical approach based on capillary ion analysis (CIA) has been reported. In the present work, the correlation between vitreous potassium and postmortem interval (PMI) has been re-evaluated by using CIA in a group of 164 cases with PMIs ranging from 2 to 110 hours. The correlation of the two parameters was described by the following regression equation: y = 0.1733x + 2.3008 (x = PMI; y = K+ concentration); correlation coefficient = 0.962. The re-calculation of PMIs on the basis of this equation provided calculated PMIs with an average error of 5.54 hours (SD = 4.16). However, the percent PMI calculation error decreased with the increase of PMI, becoming acceptable for practical application above 24 hours since death.

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.

The temporal distribution of trauma-related deaths has been described as tri-modal with immediate, early, and late peaks. With the development of trauma centers and systems, it has been suggested that this distribution might be altered.Information regarding all trauma-related deaths occurring from 1990 through 2003 in Jefferson County, AL, was obtained and the elapsed time from injury to death was calculated and categorized as1 hour, 1 to 6 hours, 7 to 24 hours, 1 to 3 days, 4 to 7 days, and1 week. The distribution of the time from injury to death was compared before and after the implementation (November 1, 1996) of a regional trauma system.Of the 5,240 deaths included in the analysis, 2,830 occurred between January 1, 1990 and October 31, 1996, before trauma system implementation, and 2,410 occurred afterward (i.e. November 1, 1996 to December 31, 2003). The temporal distribution of trauma death was significantly different (p0.0001) after trauma system development with a higher percentage of immediate deaths (56.3% compared with 51.4%) and a lower percentage that occurred 1 week after injury (4.8% compared with 8.1%).The development of a regional trauma system had a significant impact on the temporal distribution of trauma deaths. An increase in the proportion of immediate deaths and a decrease in the proportion of deaths that occurred1 week after injury was observed, suggesting a shift toward a bimodal distribution.

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.

A 41-year-old black woman with a history of well-controlled, insulin-dependent diabetes mellitus was in her usual state of relatively good health when she had acute onset of right upper quadrant and epigastric abdominal pain, nausea, and vomiting. Physical examination and laboratory evaluation revealed gastrointestinal hemorrhage, decreased mental status, and acidemia, and emergency exploratory laparotomy elucidated ischemic bowel, of which 90 cm was resected. Postoperatively, the patient had cardiac arrest and could not be resuscitated. Autopsy was remarkable for mesenteric venous thrombosis and pylethrombosis, with ischemic necrosis of bowel and passive hyperemia. The arterial side of the cardiovascular system was relatively unaffected. Although arterial vascular complications of diabetes mellitus are well known, venous complications are less well described.

Background: Among older trauma patients, those with preexisting chronic medical conditions (CMCs) appear to have an elevated risk of death. Whether this association is dependent on the severity of injury or other occult factors remains unanswered. This study evaluated the association between preexisting CMCs and risk of death among older trauma patients according to injury severity. Methods: This was a retrospective cohort study using data from the National Trauma Data Bank, a registry of trauma patients admitted to 131 trauma centers across the United States. The main outcome measure was in-hospital mortality. Results: In patients 50 to 64 years of age who sustain severe (Injury Severity Score [ISS] of 26+) and moderate injuries (ISS of 16-25), the presence of one or more CMCs is not associated with an increased relative risk (RR) of death (RR, 0.80 and 95% confidence interval [CI], 0.71-0.90; RR, 1.09 and 95% CI, 0.95-1.24, respectively). Those with minor injuries (ISS < 16) have increased risk of death (RR, 2.80; 95% CI, 2.33-3.36). For those patients 65 years of age and older who sustain severe, moderate, and minor injuries, the pattern of results is similar (RR, 0.91 and 95% CI, 0.83-1.00; RR, 1.13 and 95% CI, 1.04-1.23; and RR, 1.88 and 95% CI, 1.73-2.05, respectively). Conclusion: Older trauma patients with CMCs who present with minor injuries should be considered to have an increased risk of death when compared with their nonchronically ill counterparts.