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Social media (SM) represent a global consumer phenomenon with an exponential rise in usage within the last few years. The various applications and websites are relatively easy and fast to access, and the number of users increases continuously. SM are an incredible source of freely available, public information about their users. The purpose of this study is to provide information about the usefulness of SM in forensic practice. The electronic database of the Cook County of Medical Examiner's Office ("CCMEO") in Illinois was searched for investigative narratives that included specific SM keywords, in the period from August 2014 to January 2018. A total of 48 cases met the study's criteria. Among these, "Facebook" has been found to be the most helpful SM for medicolegal investigation purposes. Information obtained by SM can play an important role in forensic practice since it can be used to clarify certain aspects of the medicolegal death investigation, with particular regard to time and manner of death.

Deaths due to meningiomas are routinely diagnosed in clinical practice because this neoplasm tends to present with the typical progression of neurological deficits. On the other hand, sudden unexpected deaths due to meningiomas are rarely described in the literature. The study presents six fatal cases of previously undiagnosed intracranial meningiomas from the Cook County Medical Examiner's Office from 1998 to 2014. The most common explanation of the mechanism of sudden death due to intracranial neoplasms is a rapid increase in intracranial pressure produced by the mass effect of the neoplasm. Other mechanisms of death include acute intracranial and intratumoral hemorrhage, and benign neoplasms that grow in the vicinity of vital centers altering neural discharge in autonomic pathways leading to cardiac suppression or lethal arrhythmia. Forensic pathologists must keep in mind that sudden unexpected death caused by intracranial meningiomas, although extremely rare, may be encountered in the forensic setting.

Urine dipsticks are an inexpensive, rapid tool for detecting common drugs of abuse (e.g., cocaine, oxycodone, methamphetamine, opiates, and benzodiazepines) in postmortem urine samples. For urine dipsticks to be useful as a triage modality, it is important that dipsticks have high diagnostic accuracy. We tested the performance of urine dipsticks as compared with toxicological analysis of postmortem blood as the gold standard for 198 cases for at least one of five common drugs of abuse during a six-month period at the Office of the Medical Examiner of Cook County, Illinois. Toxicological screening with enzyme-linked immunosorbent assay (ELISA) and confirmation with gas chromatography/mass spectrometry (GC/MS) were then performed on postmortem blood samples. The results were compared to calculate the sensitivity, specificity, positive predictive value, and negative predictive value of the urine dipstick screens. For cocaine (n=178), opiates (n=186), oxycodone (n=47), benzodiazepines (n=45), and methamphetamine (n=44), the sensitivity, specificity, positive predictive value, and negative predictive value of the urine dipsticks all exceeded 97%. Urine dipsticks are an accurate and reliable screening tool for drugs of abuse. This inexpensive screen may be used to triage cases to autopsy or external examination in cases where the differential includes natural disease versus drug-related death.

Banked blood exhibits impairments in nitric oxide (NO)‐based oxygen delivery capability, reflected in rapid depletion of S‐nitrosohemoglobin (SNO‐Hb). We hypothesized that transfusion of even freshly‐stored blood used in pediatric heart surgery would reduce SNO‐Hb levels and worsen outcome. In a retrospective review (n = 29), the percent of estimated blood volume (% eBV) replaced by transfusion directly correlated with ventilator time and inversely correlated with kidney function; similar results were obtained in a prospective arm (n = 20). In addition, an inverse association was identified between SNO‐Hb and postoperative increase in Hb (∆Hb), reflecting the amount of blood retained by the patient. Both SNO‐Hb and ∆Hb correlated with the probability of kidney dysfunction and oxygenation‐related complications. Further, regression analysis identified SNO‐Hb as an inverse predictor of outcome. The findings suggest that SNO‐Hb and ∆Hb are prognostic biomarkers following pediatric cardiopulmonary bypass, and that maintenance of red blood cell‐derived NO bioactivity might confer therapeutic benefit.

There is a growing movement in the forensic sciences to base our opinions on a foundation of evidence based science rather than anecdotes, the idiosyncrasies of our mentors, and fervent pontification. The time is rapidly approaching when an expert in forensic pathology will no longer be able to render opinions prefaced by “Most forensic pathologists think…” or “It is widely accepted in the field that …” without producing corroborative data. This internet based study was designed to determine what board certified forensic pathologists really hold to be true on a select list of controversial topics. Chi-square analysis was then conducted to assess the validity of the responses and their applicability to the forensic pathologist population in general. The results suggest that a majority of forensic pathologists opine that death can be caused by deployment of an electronic control device (ECD) even in the absence of drug toxicity (p=0.001); that pressure on the back of a person restrained in a prone position can be lethal (p=0.0); and that it is possible to inflict lethal head injuries on a child by shaking alone (p=0.0035). Elaborating upon the basis for these beliefs was not the goal of this study. These data suggest that expert witnesses should rely on the scientific evidence available when testifying rather than attributing erroneous opinions to their peers based solely on their individual biases.

Drugs, whether illicit, prescription, or over-the-counter, cause or contribute to death in many cases falling under medical examiner or coroner jurisdiction. Thus, toxicological analysis often plays a critical role in the determination of the cause and manner of death. There is significant variability, however, between medicolegal death investigation systems with respect to standards of practice for the performance of “routine” toxicological analysis. Depending on a multitude of variables, including the size of the office, caseload, population base, budget, laboratory testing panel, pathologist philosophy, and personnel availability, routine toxicological analysis may range from no testing at all, to minimalistic urine screening, to complete quantification of all potential toxins identified on screening assays. As physicians, forensic pathologists are trained to search for the correct diagnosis in every case, every time. When establishing protocols and defining routine toxicological analyses, however, the pathologist is often forced to consider the pros of thoroughness and accuracy, versus the cons of cost and diminished timeliness of results. A rational approach to forensic toxicology is offered in an attempt to combine efficiency and frugality with acquisition of essential medicolegal data.

Death certificates provide epidemiologists and other researchers with statistical data regarding causes of death within the community. When the certificates are filled out erroneously they provide misleading and inaccurate information. The aim of our investigation was to determine whether these certificates are being completed correctly by clinicians, how frequently errors are occurring, and what types of errors are being committed by the physicians in our county.A total of 371 consecutive death certificates issued by community physicians from Broward County between February 2007 and March 2007 were reviewed. Errors were grouped into major categories as follows: unacceptable cause of death (UC), nonspecific cause of death, irrelevant information, incorrect order, and incorrectly completed.About 48% of death certificates were found to have at least 1 of the 5 types of errors in the cause of death section. These were unacceptable cause errors 30.2%, non-specific errors 14.8%, incorrectly completed errors 6.5%, irrelevant information errors 4.0%, and incorrect order errors 3.5%.Nearly half of all death certificates reviewed in this study were found to be inaccurate. Using the results of this study, the Broward County Medical Examiner's Office has been able to tailor new physician education programs for the community.

Determination of the time of death is one goal of medicolegal death investigations. Algor mortis has been used as a measure of the postmortem interval (PMI). We prospectively recorded the core temperatures of 19 adult bodies entering our morgue cooler and at 3, 6, and 9 h of refrigeration. We then compared the cooling rate with the calculated body mass index (BMI). For each individual body, the rate of cooling was fairly linear with no evidence of a plateau. There was fair to moderate correlation between the BMI and the cooling rate: cooling rate = -0.052 (BMI) + 3.52. The probability of linearity in any given case was 36%. Variables affecting this correlation included the presence and the layers of clothing and if the clothing was wet. Our data confirm that algor mortis is of very limited utility in determining the PMI in bodies that have been refrigerated.

Context.—Acute splenitis, also known as acute splenic tumor or septic spleen, is loosely defined as a neutrophilic infiltrate and congestion within the red pulp accompanied by splenomegaly. Standard pathology texts state that the histologic finding of acute splenitis is reflective of septic states. However, this association has seldom been tested in the medical literature. Objective.—The purpose of this study was to determine if sepsis can be predicted by the presence of quantitative characteristics used to identify acute splenitis. Methods.—The postmortem splenic tissue of 20 clinically diagnosed cases of sepsis and 20 noninfectious control cases were retrospectively examined in a blinded fashion for amount of neutrophilic infiltration, weight (obtained from autopsy report), and presence of congestion. Results.—No significant correlation could be found between the parameters of neutrophilic infiltrate or splenic weight and clinically diagnosed septicemia. The presence of splenic congestion was unexpectedly found to be more likely with noninfectious causes of death. Conclusion.—Acute splenitis is presently ill defined, and no available evidence convincingly shows that its presence suggests a septic state.

Objective.—The present study examines p53 and Ki-67 staining patterns of the diagnostic entities included within the new World Health Organization/International Society of Urological Pathology (WHO/ISUP) classification of urothelial neoplasms. Design.—We retrospectively studied 151 bladder biopsies from 81 patients with the following neoplasms: normal urothelium (n = 34 biopsies); low-grade intraurothelial neoplasia (LGIUN; n = 19); high-grade intraurothelial neoplasia (HGIUN; n = 20); papillary hyperplasia (n = 4); papilloma (n = 3); papillary neoplasm of low malignant potential (LMP; n = 12); low-grade papillary carcinoma (n = 28); and high-grade papillary carcinoma (n = 31). Sections were labeled immunohistochemically with antibodies to p53 and Ki-67 (MIB-1). Two hundred cells from each lesion were visually counted, and the percentage of positive cells was tabulated without knowledge of the WHO/ISUP diagnosis. Results.—In flat lesions, p53 positivity was of limited diagnostic utility; the marker was present in 6 of 34 benign biopsies, 6 of 19 LGIUNs, and 10 of 20 HGIUNs. In one case in which HGIUN was present elsewhere in the bladder, 29% of the benign urothelial cells were p53 positive. In papillary lesions, p53 positivity was not seen in 4 of 4 cases of papillary hyperplasia, 3 of 3 papillomas, and 8 of 12 LMP tumors. In contrast, p53 was detected in 18 of 28 low-grade and 26 of 31 high-grade papillary urothelial carcinomas. A p53 labeling index (LI) greater than 30% was only seen in HGIUNs and high-grade papillary carcinomas. In flat lesions, an increased Ki-67 LI separated out benign urothelium (mean LI, 0.62%) from dysplasia (mean LI, 3.3%) and HGIUN (mean LI, 11.6%). In papillary lesions, Ki-67 positivity was as follows: papillary hyperplasia (mean LI, 1.1%); papilloma (mean LI, 4.3%); LMP tumors (mean LI, 2.5%), low-grade papillary carcinoma (mean LI, 7.3%); and high-grade carcinoma (mean LI, 15.7%). A Ki-67 LI greater than 10% was seen only in low- and high-grade papillary carcinomas, HGIUN, and single cases of LGIUN and papillary neoplasm of LMP. Conclusions.—An increased proliferative index as demonstrated by immunohistochemical staining for Ki-67 (MIB-1) is most often seen in papillary carcinoma and HGIUN. Marked p53 positivity is also characteristic of carcinoma but may be seen in benign-appearing urothelium, suggesting a “field effect” with occult molecular aberration.

Little is known about pathology residents' ability to Gleason grade or their ability to learn surgical pathology using Internet-based technology. A free Web-based program (available at www.pathology. jhu.edu/prostate) was developed that consisted of 20 pretutorial images for grading, 24 tutorial images, and the same 20 posttutorial images for Gleason grading. The grading images were selected from cases that had a consensus Gleason grade from 10 uropathology experts. In 2.5 months, 255 residents visited the website, and 151 (59%) completed it. Of those who completed the website, their year in training was known in 85 (56%): 1st year, 25.8%; 2nd year, 20%; 3rd year, 22.3%; 4th year, 14.1%; 5th year, 15.3%; and 6th year, 2.4%. Eighty percent learned Gleason grading in residency versus being self-taught, and 66% were male. In a multivariate analysis, higher pretutorial scores were associated with both their year in training (P = .001) and their hospital size (P = .003). Improvements in grading posttutorial were not related to the residents' year in training. Overall, the website significantly improved grading in 11 of 20 images and had no effect in 9 of 20 images. Improvements were noted in 1 of 1 Gleason score 4; 2 of 7 Gleason score 5 to 6; 2 of 6 Gleason score 7; and 6 of 6 Gleason score above 7 tumors. In summary, a Web-based tutorial improved Gleason grading accuracy by pathology residents to an equal extent regardless of their year in training. It is more difficult to teach residents to grade Gleason scores 5 to 7 tumors, and additional training should be concentrated in this area.

After sexual assault, cells originating from the assailant may be recovered from the victim. Through polymerase chain reaction (PCR)-based technology, positive scientific identification of the assailant may be made from these cells. Described is a prospective study describing a method for positively identifying cells from a female sex partner obtained from postcoital swabs of the penis of the male sex partner. Swabs were taken from the penis of a man at 1- to 24-hour intervals after coitus. DNA was isolated from each swab through standard organic extraction methods. The presence of female DNA was detected using the gender-specific amelogenin marker. Extracted DNA was amplified for eight different genetic loci using the Promega PowerPlex kit (Promega) and Amplitaq Gold (Perkin Elmer). Amplified samples were electrophoresed on precast sequencing gels (Hitachi) and were analyzed fluorescently using Hitachi's FMBIO 2 fluorescent scanner and software. Each sample obtained from a penile swab or condom was compared to male and female buccal controls. Female DNA was isolated from all postcoital penile swabs as determined by exclusive amplification of the X-chromosome specific 212 base pair amelogenin marker. In all cases, scientific identification of the female DNA from the swabs was determined by coamplification of eight STR loci (Power-Plex) and was compared to female and male control profiles. Cells shed from a female victim during sexual intercourse can be retrieved from the penis of a male offender after sexual intercourse during a 1- to 24-hour postcoital interval. DNA can be extracted from these cells and can be used to scientifically identify the female sexual participant through PCR-based technology. It is suggested that penile swabs be taken from alleged perpetrators of sexual assaults to associate them with a female victim.

Objective: Patients scheduled for prostatectomy often receive androgen deprivation therapy to make malignant tumors more amenable to resection and improve the postoperative course. These hormonal therapies may significantly alter the histomorphology of carcinoma of the prostate detected on subsequent needle biopsies. Methods: Needle specimens were obtained from resected prostates harboring biopsy-proven carcinoma previously treated with leuprolide. The tissue was examined by light microscopy to note architectural and cytologic characteristics. Results: A high proportion of treated carcinomas had an atrophic, infiltrative appearance. Nuclear and nucleolar enlargement were consistently observed. Macronucleoli, blue-tinged mucin, and intraluminal pink amorphous material was frequently identified. Conclusions: The markedly atrophic nature of the cells and glands may result in eil her overgrading of prostate carcinoma or failure to recognize the more subtle patterns of this malignant neoplasm. It is imperative that clinicians convey a history of hormone treatment to pathologists when core biopsies of the prostate are submitted for histologic evalu ation.

Context.—Clostridium septicum infections are rare but often associated with serious if not fatal outcomes. Clostridium septicum infection does not appear to be associated with a single specific defect in cellular or humoral immunity. It has been associated with multiple medical problems, including but not limited to leukemia, malignancy of the bowel, other solid tumors, cyclic neutropenia with enterocolitis, diabetes mellitus, and severe arteriosclerosis. Most cases of C septicum are associated with malignancy, and mortality approaches 100% if care is not rendered within 12 to 24 hours. Objectives.—To evaluate outcomes of patients with C septicum bacteremia, whether treated medically or surgically or both, and to note associated conditions. Design.—Retrospective evaluation of patients found to have C septicum bacteremia in the past 6 years. Setting.—Two teaching hospitals, Brooke Army Medical Center (250 beds) and Wilford Hall Medical Center (292 beds), were the source of our patients. Patients.—All patients found to have C septicum bacteremia during hospitalization or postmortem examination were included in the study. There were no exclusion criteria. Main Outcome Measure.—Mortality associated with C septicum infection. Results.—In our case series, mortality was 33%, which is slightly lower than reported in prior studies (43%–70%). Conclusion.—Presumptive identification based on Gram stain, awareness of C septicum infection as a paraneoplastic syndrome, and prompt, clear communication between laboratory personnel and clinicians are necessary for early diagnosis of C septicum infection. Early institution of antibiotic therapy improves prognosis.

Pathologists frequently examine victims of sudden cardiac death. In some cases, a firm diagnosis of cardiac-related death can be made based on conclusive gross and histologic findings. In many other cases, we find evidence supportive of, but not diagnostic of, cardiac death (e.g., atherosclerotic coronary artery disease, cardiomegaly, myocardial scarring). A final cohort consists of cases of sudden death with minimal to mild cardiac disease, no other significant pathology, and negative toxicologic studies. This prospective study compared 38 cardiac-related deaths with 52 control cases with respect to concentrations of pericardial cardiac troponin I (cTnI), heart weight, evidence of old and/or recent myocardial injury, and presence of significant coronary artery disease. The influence of documented chest trauma and/or perimortem cardiopulmonary resuscitation (CPR) on levels of cTnI was also analyzed. Even though median cTnI levels were significantly higher in cardiac deaths than in controls (p = .003), cTnI was not found to be a significant predictor of cardiac deaths, as determined by discriminant analysis (p = .52). Heart weight500 g, evidence of old and recent myocardial injury, and significant coronary artery disease were seen statistically more often in cardiac deaths than in controls (por = .005 in each case), and median age was significantly higher in cardiac deaths than in controls (p = .001). Based on a stepwise logistic regression model, significant coronary artery disease, old and recent myocardial injury, and heart weight500 g were found to contribute significantly to the prediction of cardiac death. Finally, neither chest injury nor CPR significantly affected concentrations of cTnI in pericardial fluid. These data confirm that the presence of acute and remote myocardial injury, significant coronary artery disease, and cardiomegaly (heart weight500 g) strongly supports the diagnosis of a cardiac-related death. In contrast to a recently published report, we do not find that elevated concentrations of cTnI in pericardial fluid are strong indicators of cardiac-related deaths using our methodology.

Unexpected deaths related to significant hepatopathology are encountered daily by forensic pathologists. After investigation, a decision will be made regarding whether or not to perform an autopsy. In considering the options available to assess the degree of hepatopathology, a study was undertaken to evaluate the potential role of percutaneous core biopsy of the liver at the time of postmortem examination. Postmortem percutaneous hepatic core biopsy was attempted at the time of external examination in 28 nonconsecutive cases examined at the Office of the Chief Medical Examiner, State of Maryland; hepatic tissue was obtained in 26 cases. In 21 of these cases, hepatic tissue was obtained during subsequent partial or complete autopsy and submitted for histologic correlation. There was complete histologic correlation of tissue obtained via percutaneous biopsy with hepatic tissue obtained by open biopsy in 18 of 20 cases (86%). Significant hepatopathology was identified by core biopsy in 5 of 9 cases (56%) with a history of ethanol abuse and in 8 of 19 cases (42%) with a negative ethanol history. The sensitivity of this technique was 82% and the specificity was 100%. This study has shown that core biopsy of the liver can provide information related to the cause of death in cases with and without a history of alcohol consumption. In cases in which a complete autopsy is deferred because of familial religious objections, infectious disease, or time/budgetary constraints, this modality can be used to obtain diagnostic tissue.

Purpose: Holmium:YAG lithotripsy fragments stones through a photothermal mechanism. Uric acid when heated is known to be converted into cyanide. We test the hypothesis that holmium:YAG lithotripsy of uric acid calculi produces cyanide.Materials and Methods: Human calculi of known uric acid composition were irradiated with holmium:YAG energy in water. Stones received a total holmium:YAG energy of 0 (control), 0.1, 0.25, 0.5, 0.75, 1.0 or 1.25 kJ. The water in which lithotripsy was performed was analyzed for cyanide concentration. A graph was constructed to relate holmium:YAG energy to cyanide production.Results: Holmium:YAG lithotripsy of uric acid calculi in vitro produced cyanide consistently. Cyanide production correlated with total holmium:YAG energy (p

Cytologic evaluation of nongynecologic tissues is a widely accepted diagnostic modality commonly used in the clinical evaluation of living patients. Fine needle aspiration (FNA) of superficial masses and touch preparations of surgical specimens often yield diagnostic results. The adjunctive role of these two techniques during postmortem examination has not been adequately addressed. A prospective study was carried out on a series of 13 patients undergoing postmortem examination. FNA was performed in a standard manner to obtain tissue fragments from superficial masses in three cases. Visceral lesions grossly suspicious for cancer were scraped and smeared onto glass slides to create a "touch prep" in 10 cases. Cytologic evaluation of alcohol-fixed, hematoxylin and eosin (H&E)-stained slides was performed in each case. Cytologic diagnoses were subsequently correlated with histologic sections. In the majority of cases, cytologic material was diagnostic. Touch prep slides, in combination with gross findings, were diagnostic of primary and metastatic carcinoma in visceral lesions. FNA of superficial masses accurately assessed local recurrences of carcinoma and nodal metastases. Both methods yielded diagnoses within minutes, in contrast to the time required to process routine histologic sections. Cytologic evaluation of tissues obtained at autopsy provides accurate, inexpensive, and rapid diagnostic information. The touch prep is an inexpensive adjunct to histologic sections in documenting the presence of carcinoma or the extent of metastatic disease found at autopsy, and its further application can strengthen the standard applied in clinicopathologic diagnosis.

Adenocarcinomas of the prostate with attenuated cytoplasm (i.e., atrophic features) have not been studied formally and represent a diagnostic dilemma to the surgical pathologist. Forty-four cases of adenocarcinoma with atrophic features seen at the Johns Hopkins Medical Institutions were reviewed. Forty-two cases were seen on needle biopsy, and two were from transurethral resection specimens. Neoplastic atrophic glands were characterized by cells with a paucity of cytoplasm, such that the nuclei occupied almost the entire cell height. Atrophic cancers were defined as cancers with atrophic glands constitutingor = 50% of the tumor. Ony two of 44 patients whose prostatic adenocarcinoma showed atrophic features were on hormone therapy at the time of biopsy. Forty-one cases had an infiltrative pattern of growth. Thirty-nine cases were Gleason grade 3 + 3 = 6. Nuclear size was increased in 39 cases, and macronucleoli were noted in 21 cases. The most useful criteria to establish a diagnosis of adenocarcinoma were (1) an infiltrative pattern of growth, (2) the presence of macronucleoli, (3) increased nuclear size, and (4) the presence of adjacent, nonatrophic cancer.

From the perspectives of disease transmission and sterility maintenance, the world’s blood supplies are generally safe. However, in multiple clinical settings, red blood cell (RBC) transfusions are associated with adverse cardiovascular events and multiorgan injury. Because ∼85 million units of blood are administered worldwide each year, transfusion-related morbidity and mortality is a major public health concern. Blood undergoes multiple biochemical changes during storage, but the relevance of these changes to unfavorable outcomes is unclear. Banked blood shows reduced levels of S-nitrosohemoglobin (SNO-Hb), which in turn impairs the ability of stored RBCs to effect hypoxic vasodilation. We therefore reasoned that transfusion of SNO-Hb–deficient blood may exacerbate, rather than correct, impairments in tissue oxygenation, and that restoration of SNO-Hb levels would improve transfusion efficacy. Notably in mice, administration of banked RBCs decreased skeletal muscle pO 2 , but infusion of renitrosylated cells maintained tissue oxygenation. In rats, hemorrhage-induced reductions in muscle pO 2 were corrected by SNO-Hb–repleted RBCs, but not by control, stored RBCs. In anemic awake sheep, stored renitrosylated, but not control RBCs, produced sustained improvements in O 2 delivery; in anesthetized sheep, decrements in hemodynamic status, renal blood flow, and kidney function incurred following transfusion of banked blood were also prevented by renitrosylation. Collectively, our findings lend support to the idea that transfusions may be causally linked to ischemic events and suggest a simple approach to prevention (i.e., SNO-Hb repletion). If these data are replicated in clinical trials, renitrosylation therapy could have significant therapeutic impact on the care of millions of patients.

Metronidazole (Flagyl), a commonly prescribed antimicrobial agent, can produce a reaction similar to that of disulfiram (Antabuse) when administered to patients drinking ethanol. This drug/chemical interaction results in accumulation of acetaldehyde in the blood. Acetaldehyde is hepatotoxic, cardiotoxic, and arrythmogenic; no lethal serum acetaldehyde level has been established. Sudden death has been reported in patients taking disulfiram while using ethanol; no fatalities have been reported due to ethanol/ metronidazole interactions. Described is a case of a 31-year-old woman who died moments after an assault by a male companion, during which he inflicted minor physical trauma to her upper arm. Toxicologic analysis yielded elevated concentrations of serum ethanol (162 mg/d), acetaldehyde (4.6 mg/d), and metronidazole (0.42 mg/L). The cause of death was reported to be cardiac dysrhythmia due to acetaldehyde toxicity due to an ethanol/ metronidazole interaction. Autonomic stress associated with the assault is likely to have contributed to this woman's death. The mechanism of death is examined.

Sudden unexpected death accounts for 200,000-400,000 deaths each year in the United States. Although the vast majority of these fatalities are related to atherosclerotic heart disease, a small percentage (approximately 0.0025%) stem from primary cardiac neoplasms. There have been 120 cases of sudden death attributed to primary cardiac tumors in the (published) literature. Although 103 of these lesions were histologically benign (86%), their intracardiac locations precipitated conductive and hemodynamic abnormalities that resulted in sudden death. These tumors are usually easily recognized at necropsy. The most common intracardiac lesion causing sudden death, endodermal heterotopia of the atrioventricular (AV) node, however, may not be discovered unless the AV node is microscopically examined. Owing to the rarity of these neoplasms, a brief review of their salient gross and microscopic features is in order.

The level of degradation of DNA as a means for determining the time of death has been proposed as a valid adjunct to the classic thanatochronologic methods. The twofold aim of this work was to determine which organ might reveal both a correlation between the percentage of degradation of the DNA and the time lapse since death, and would be easiest to sample and yield the most reproducible results even in technically unfavorable situations such as on-the-spot investigations at the scene of death. A comparison of the spleen, blood, and liver showed that hepatic tissue best meets these specific needs because it shows a virtually linear correlation between the time elapsed since death and the level of degradation of the DNA, and it can easily be sampled at the scene of death by use of a common biopsy needle.

A variety of emboli may be encountered at autopsy. While pulmonary thromboemboli are a relatively common cause of sudden "natural" death, the medical examiner may discover more exotic emboli during the postmortem examination. Other endogenous sources of emboli include the atheromatous debris, bone marrow, fat, liver, brain, trophoblast, and amniotic fluid. Exogenous ("foreign body") emboli may be introduced during medical/surgical procedures or following penetrating trauma. Fatal intravenous air and gas emboli are also well documented. This report details the first case of a fatal suture embolism to the left anterior descending coronary artery following mitral valve replacement. The role of the medical examiner in the investigation of iatrogenic fatalities is discussed.

Peptic ulcer perforation is well recognized as a cause of peritonitis and can result in death. Although amenable to surgery, delay in making the correct diagnosis results in increased mortality. Accurate diagnosis has been hindered by demographic changes in the affected population. In recent years, the population at risk has increased. Specifically, a rising incidence has been observed in women, in the elderly, and in patients with previously undiagnosed peptic ulcer disease. Described are four patients with perforated peptic ulcers, three of which were not detected prior to autopsy. In three of the four instances the patient had been observed in and discharged from a hospital emergency room during the 30 h prior to death. In the fourth case, the decedent had been seen in and discharged from the emergency room four times during the month prior to death. In all patients, the presenting historical, physical, and/or radiographic findings were indicative of perforation. The death of a patient within days of a visit to an emergency room should prompt a forensic autopsy. The role of medical examiners in providing quality assurance feedback to emergency rooms located within their jurisdiction is emphasized.

Hydrogen peroxide is a readily available clear, odorless liquid that is commonly used as an irrigant for superficial wounds. It is not widely thought of as a poison; however, it may rarely be the cause of accidental death. A case of fatal oxygen embolism in a child after ingestion of hydrogen peroxide is reported. A total of five similar cases have been previously described. Morbidity and mortality have also been reported with the use of hydrogen peroxide in hospitals. Gastric catabolism of hydrogen peroxide produces oxygen and water. When the amount of oxygen evolved exceeds its maximal blood solubility, venous embolization occurs. Hydrogen peroxide should not be considered to be innocuous; it should neither be ingested nor used in situations where the evolved oxygen gas cannot dissipate freely. The ubiquitous nature of household peroxide and its erroneous benign reputation suggest that child-resistant containers are in order. A protocol delineating the medicolegal investigation and postmortem examination of fatalities caused by the ingestion of this substance is offered.

Determination of the time of death is one goal of medicolegal death investigations. Algor mortis has been used as a measure of the postmortem interval (PMI). We prospectively recorded the core temperatures of 19 adult bodies entering our morgue cooler and at 3, 6, and 9 h of refrigeration. We then compared the cooling rate with the calculated body mass index (BMI). For each individual body, the rate of cooling was fairly linear with no evidence of a plateau. There was fair to moderate correlation between the BMI and the cooling rate: cooling rate = -0.052 (BMI) + 3.52. The probability of linearity in any given case was 36%. Variables affecting this correlation included the presence and the layers of clothing and if the clothing was wet. Our data confirm that algor mortis is of very limited utility in determining the PMI in bodies that have been refrigerated.

The medical examiner's office in Broward County is responsible for determining the cause and manner of death in cases falling under its jurisdiction and issuing death certificates on these decedents. Amendments are occasionally required to correct misinformation on death certificates or within the autopsy reports. The purpose of this study was to investigate the major causes for the amendments and to develop strategies to avoid future errors. We found 128 cases from 2006 to 2007 that required amendments; 103 contained sufficient data in the file for further analysis. Over this time period, 3790 death certificates were issued over that same period, resulting in a 3.37% amendment rate. In this study, the cohort included both males and females with a ratio of 2:1. Their ages ranged from newborn to 103 years, with a mean age of 49 years. Of the 103 amended cases, amendments were made to the cause (n = 30) and often the manner (n = 21) of death listed on the death certificate; the remaining changes were limited to the autopsy report. The most common reasons for amendments included reception of delayed laboratory findings (35%), acquisition of additional medical history (22.5%), and typographic errors (15.5%). Typographic errors mainly occurred because of inaccuracies in the names originally provided to our office, the use of aliases by decedents, incorrect personal/demographic history, or various misspellings by funeral homes or medical examiner staff. The most significant reclassifications involved changing certified natural deaths to accidental overdoses and vice versa, based on toxicological analysis. Because of delays in specimen turnaround, these amendments often were made months after the original death certificate was issued. STAT urine drug screening has been helpful in reducing the number of amendments made, but certain drugs of significance are missed by rapid screens. Given that our office performed complete toxicological analysis on all cases over this period, it seems likely that we detected several overdoses that would have been missed if natural deaths were not routinely screened for potential toxins.

Medical experimentation on humans began many centuries ago. The first “volunteers” were slaves, considered at that time to be property rather than human beings. One of the first experimenters was the famous Greek physician Herophilos (335–280 BC), co-founder of the great medical school of Alexandria and widely regarded as the “father of anatomy” (though Vesalius may argue this point). He was the first researcher to base his anatomic studies on dissection of the human body. Though this was scientifically valid and led to a greater understanding of the human body, he carried out the procedures on living slaves which raises questions about his ethics. Tertullian, a prolific Christian writer (AD 197–220) claimed that Herophilos had performed vivisections on more than 600 slaves.

Both before and after the Second World War a significant number of American physicians have conducted unethical experiments on vulnerable humans resulting in serious injuries and deaths. Both the American public and the government in later years unequivocally condemned these experiments. While these studies never reached the level or magnitude of depravity manifested by the Nazis and Japanese during World War II, they nevertheless deeply marred the image of American medicine. Unethical medical experiments continued in civilian and military research establishments unabated for 35 years after World War II and more sporadically into the early 2000s. This was in spite of the 1945 Nuremberg Code and American legislation that forbid unethical and involuntary medical experimentation. The subjects of the unethical experimentations were mostly minorities, the poor and the disadvantaged as well as veterans and “captive populations” including members of the military, prison inmates and institutionalized patients, both adults and children.

The history of Americans (and colonists) that have been convicted of serial murder is about 350 years old, a mere trifle when compared with that of some other nations. The Vain Prodigal Life and Tragical Penitent Death of Thomas Hellier, a book published in London in 1680, reported the crimes of Hellier, a bonded servant in the Virginia colony, who was hanged for the murder of “his master, mistress, and a maid.” He was apparently the first American “domestic killer.” Until the late 1800s, murders by American physicians were practically unknown, either because the perpetrators were too good at concealing their crimes, the index of suspicion was too low, or the expectation to die under medical treatment too high. However, the 1900s and early 2000s showed a significant increase in their number. American serial killer physicians are very similar to medical deviants throughout the world and share similar motivations. Not to seem un-American, but our serial murderers aren’t bigger, stronger, smarter or faster than killers from anywhere else. This is not to say our physicians have been slouches when it comes to homicide—far from it. Consider the following examples.

Doctors are supposed to heal people, not kill them. Murders by physicians always arouse a great deal of public interest and invariably instigate a media frenzy. Physicians enjoy a high level of trust and respect as essential providers of life-saving medical care. The doctor is, or at least has been, viewed as a father figure by society – a source of security, safety, and comfort. When a member of the medical profession violates this important public trust, society at large experiences a psychological shock similar to that occurring when a high-ranking military officer or a respected political leader commits treason.

There are a number of healing practices that belong to the general group of alternative or complementary medicine. A 1990 survey published in the New England Journal of Medicine indicated that that there were 425 million visits to alternative or complementary medical practitioners compared to 388 million visits to traditional primary care doctors. Americans spent about $13.7 billion in 1 year alone on alternative medicine, only $3.4 billion of which was covered by insurance. Clearly, non-traditional medicine is big business and patients are willing to pay for these services out of their own pockets. Although some practitioners of unconventional medicine are trained physicians, many are not. Nonetheless, their patients treat them as doctors and, as we have seen, doctors are capable of killing.

It is a trite fact of life that the old Latin maxim “Human erare est” (It is human to err) has lost none of its truth. For centuries, however, healers have sworn to err as little as possible in the performance of their art. As medical practice became more organized and education more uniform, most societies developed ethical and professional codes to provide their physicians rules to live and work by. It seems reasonable to assume that most young doctors would gladly swear to uphold a set of guidelines in lieu of having their fingers lopped off for a mistake.

Seneca, a first century Roman philosopher, coined the popular adage, “To err is human (Errare humanum est).” Much lesser known is his follow-up sentence “to persist is diabolical (perseverare diabolicum).” Most if not all doctors make mistakes some of which result in frank malpractice and litigation. After a physician has gone through the time, money, guilt, and remorse associated with a malpractice suit, he is unlikely to make the same mistake again. Of course, some doctors never learn.

Power, particularly political power giving control of the few over the many, may be a very intoxicating draught. There is much truth in the adage coined by Lord Acton more than a century ago that “power corrupts and absolute power corrupts absolutely.” Less known but just as true is his adjacent pronouncement that “great men are almost always bad men.”

Before and during the Second World War, from 1935 to 1945, Japanese physicians engaged in criminal medical experimentation on thousands of human beings. These doctors dedicated themselves to the development of biological weapons at the direction of and with the full support of the Japanese Government. Their activities were little different from the medical atrocities committed by the Nazi physicians. The involuntary subjects of experiments were mainly Chinese soldiers and civilians but also included members of other nationalities including Koreans, Burmese, Russians, Mongolians, and Americans.

While the vast majority of physicians attempt to optimally perform their duty to care for the sick, a very small minority of physicians are involved in nefarious activities including homicide. In most of Western society, a police investigation culminates in an arrest followed by a trial by jury. In dictatorial countries, the situation is quite different. First of all, medical murders may be more difficult to commit because of the tight social controls and governmental intervention in the practice of medicine. Those physicians who succeed in carrying them out, however, may benefit from such regimes’ tendencies to cover up any social or public ills or perceived flaws in the system and to protect members of the ruling, elite class from disgrace. Alternatively, the murderer may be summarily executed and placed on public display as a deterrent to future crimes. No locale is free of physician killers except perhaps the Arctics and very sparsely populated areas with too few physicians and too few potential victims.

Suicide, the killing of oneself, wastes countless lives and robs society of many gifted individuals. In addition to the average person beset with depression over a broken relationship, financial troubles, or the loss of a job, extremely creative people have also taken their own lives while in the throes of depression. Both Vincent van Gogh, the post-impressionist painter, and author Ernest Hemingway died by gunshot wounds; British novelist Virginia Woolf filled her pockets with stones and walked into a river near her home; and Kurt Cobain, lead singer of Nirvana, killed himself with a shotgun. There about one million suicides occur every year in addition to 20 million suicide attempts throughout the world. The National Institutes of Health (NIH) sees suicide as a major preventable health problem in America and for good reason. More than 32,000 successful suicides are registered every year in the United States with many of the victims being healthy, young adults. Teen suicide has also become an escalating tragedy and occasional pre-teen suicides are reported. There has been religious, ethical, and social opposition to suicide for millennia. It has been characterized as an affront to a life-giving God and a usurpation of the divine power over life and death. It has been widely perceived as the ultimate selfish act. In some locales, suicide has been considered a crime; botched attempts have led to the confiscation of the property of survivors in some cases and imprisonment or fines in others. It does not carry the death penalty.

Just because you kill 10, 50, or 1,000 people doesn’t make you a serial killer. There is a big difference on several levels between serial killers and individuals who kill a lot of people.

There are actually hundreds of definitions of terrorism and cynics have claimed that “one man’s terrorist is another man’s hero.” Terrorists seem particularly fond of this definition. However, it seems more reasonable to rely on the 2004 definition of terrorism adopted by the United Nations Security Council: “Criminal acts, including against civilians, committed with the intent to cause death or serious bodily injury, or taking of hostages, with the purpose to provoke a state of terror in the general public or in a group of persons or particular persons, intimidate a population or compel a government or an international organization to do or to abstain from doing any act.” Similarly, on March 17, 2005 a UN panel defined terrorism as any act: “Intended to cause death or serious bodily harm to civilians or non-combatants with the purpose of intimidating a population or compelling a government or an international organization to do or abstain from doing any act.” These definitions make it fairly clear that terrorists are not heroes.

Humans are self-experimenters from birth. In fact, we cannot prevent ourselves from being so. Our entire life is a string of self-experiments, whether pleasurable or painful, beneficial or disastrous. As children we are fearless and simply don’t appreciate danger. It is the duty of our parents to train us to recognize and avoid the hazardous situations that we invariably seek out. As adults, if we have learned our lessons, we avoid treacherous experiments that may cost us life or limb based on the experience (often tragic) of others and our own reasonable but not infallible judgment. “Not infallible” would be the key words in that sentence.

Most of the world is aware of the awful crimes committed by the Nazis during the Second World War. In addition to the horror of the Holocaust resulting in the death of six million Jews and the murder of countless Russians, Poles, and other Europeans, many disabled, “undesirable,” or otherwise flawed Germans were also categorically eliminated. The active participation of German physicians in the serial murder of thousands of innocent men, women, and children has not been adequately exposed.

People have always been fascinated with celebrities – and doctors have always been willing to line up to treat them. Going back to antiquity, kings and pharaohs had their personal physicians and today’s political elites are no different. The twentieth and twenty-first centuries have also seen the rise of a new generation of gods walking among us, the “superstars.” These darlings of the paparazzi include professional athletes, musicians, artists, actors and actresses, religious icons, as well as some celebrities of dubious talent.