bluuebunny/crossref_metadata_2025 huggingface dataset:
Myocarditis at Post-Mortem Examination: A Forensic Perspective
Authors: Edgecombe Allison , Veinot John
Published: April 2017

Myocarditis is an uncommon cause of death but its myriad clinical presentations, young target population, diverse etiologies and potential to cause sudden unexpected death warrant its review. Myocarditis has been defined as myocardial necrosis and/or degeneration in the presence of an inflammatory infiltrate adjacent to the damaged myocytes. The type of predominant inflammatory cell present may assist with elucidating its pathoetiology. Ancillary testing as an adjunct to routine histopathological examination, such as immunohistochemical or immunofluorescence staining or detection of viral nucleic acid are of debatable diagnostic use in either the biopsy or autopsy setting. Myocarditis may clinically and/or histologically mimic other disease entities such as acute or organizing myocardial infarction, or hematological malignancy. There are no macroscopic pathognomonic features suggestive of myocarditis, thus in cases of unexplained sudden death it is vital to sample the heart extensively to rule out myocarditis. It is important to recognize that myocarditis may be an incidental finding in an autopsy. To attribute the cause of death to myocarditis, all relevant case findings including scene investigation, autopsy and ancillary testing including toxicology should be assessed.
Scientific Inquiry — Conceiving and Testing Hypotheses
Authors: Davis Gregory G.
Published: April 2017

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.
Inference in Forensic Pathology
Authors: Oliver William R.
Published: April 2017

Forensic pathologists make inferences about cause and manner of death. Those inferences have come under increasing scrutiny by the courts, by social critics of our findings, and by society at large. Much of this criticism is due to our inability to explain our inferential process. Forensic pathologists should be able to cogently explain the reasoning behind their findings, and express it in terms useful to stakeholders. This requires that we have a basic understanding of different kinds of inference and the scientific method, how they are used and their limitations. Medical diagnosis is not a simple matter of application of cookbook-style inferential laws, but involves a combination of deduction, induction, abduction, dialectic, and informal inference. There are significant differences between the way physicians make inferences compared to how they justify them. A discussion of different kinds of inference, inferential fallacies, evaluation of evidence, causation, and the scientific method is provided, with illustrations from the practice of forensic pathology.
Forensic Pathology and Epidemiology, Public Health and Population-Based Research
Authors: Lathrop Sarah L.
Published: April 2017

Forensic pathology can play a pivotal role in safeguarding public health. While medicolegal death investigation focuses on certifying cause and manner of individual deaths, taken in aggregate this information provides a powerful tool for epidemiologic research. The published literature provides numerous examples of the utility of forensic pathology in public health research, from describing trends in substance abuse deaths to reducing occupational fatalities and identifying unusual infectious disease deaths. Medical examiner and coroner (ME/C) offices contribute to public health research by participating in surveillance systems, including those for sudden unexplained infant deaths and violent deaths, and by alerting public health agencies to emerging threats. Accessing and utilizing ME/C data for epidemiologic research can be challenging, given the wide variation in types of jurisdictions and the availability of electronic data, but the rewards for researchers justify the endeavor. Mutually beneficial relationships can develop between epidemiologists and ME/Cs, improving both public health and medicolegal death investigation.
Critical Appraisal of Scientific Literature
Authors: Keith Pinckard J.
Published: April 2017

Despite the relatively small size of our profession, there is abundant scientific literature within the field of forensic pathology. The written word does not imply truth, however, and it is vitally important that the forensic pathologist approach the literature with a critical eye and understand how to evaluate a paper for oneself and come to a conclusion regarding its validity and the level of evidence it provides. The purpose of this paper is to provide a basic outline of the concepts important to critically reviewing a scientific paper; not so much as a peer reviewer, but rather as a practicing medical consumer of information. It will outline the key steps in approaching and reading a scientific study: identifying the type of study the paper represents, describing the process of critically reading the paper, assessing its scientific quality, describing various types of errors and where to look for them within the paper, and assessing the level of evidence provided in the study.
GoodFellow: An Electronic Portfolio System for Forensic Pathology Fellows
Authors: Hanzlick Randy
Published: April 2017

The Accreditation Council on Graduate Medical Education (ACGME) requires documentation of the progress of residents and fellows in training, and the keeping of a portfolio is one method to comply with ACGME requirements. This article briefly describes Good-Fellow, an electronic portfolio database written in Microsoft Access ®. GoodFellow provides the fellow with electronic forms to track work hours, scene visits, court visits, court testimony, consults with families, police, and attorneys, and it also includes a place to document competence in required procedures (technical skills). Also included are forms to document experiences relevant to systems-based-practice, practice-based learning, required and optional reading, and evaluation of external rotations. If an office does not have an electronic database for tracking the fellow's case log and status of autopsy reports, GoodFellow offers those functions as well. In our office setting, a copy of GoodFellow is placed on an office network computer drive which is accessible by the fellow and the training program director and associate director. This allows the programs directors to continuously monitor the fellows progress, and data from GoodFellow are quite useful in preparing periodic status reports for, and required formal evaluations of the fellow. At year's end, a copy of GoodFellow can be placed in the fellows training file and a copy can be provided to the fellow as a keepsake and documentation of training.
Forensic Pathology Fellowship Training Issues and Suggestions
Authors: Hanzlick Randy , Stauffenberg Michele
Published: April 2017

This article is a summary of tasks required of forensic pathology fellowship program directors and puts forth the idea that the amount of effort and time required to comply with Accreditation Council for Graduate Medical Education (ACGME) requirements is excessive for the nature of the discipline and the small number and size of existing programs. Suggestions are made for how to simplify the fellowship director process yet not adversely impact on training.
Extramedullary Cardiac Plasmacytoma
Authors: Quinton Reade A.
Published: April 2017

An 86 year old female presented to the emergency department with a one week history of leg swelling and recent weight gain. An echocardiogram revealed an 8.7 x 5 cm mass of the right atrium that appeared to be adherent to the atrial wall and filled over 90% of the volume of the right atrial chamber. The patient expired approximately one month later, and an autopsy limited to the heart and pericardial sac was requested. The autopsy confirmed the presence of a 9 cm mass involving the right atrium and completely encasing the right coronary artery. Microscopically the tumor was composed of sheets of plasma cells. Immunohisto-chemical studies showed that the cells were kappa light chain restricted, strongly positive for LCA and CD79a, and negative for CD138 and CD20. Given the gross and microscopic findings, the lesion was diagnosed as an extramedullary plasmacytoma of the heart.
Best Practices: Infant Death Scene Recreation and Investigation
Authors: Hargrave Kathleen L. Diebold
Published: April 2017

This manuscript will discuss Best Practices for Death Investigation when conducting Infant Death Scene Investigations. The autopsy starts at the scene, a thorough investigation cannot be done without completing a scene recreation. During the infant death scene investigation, the Death Investigator will gather information concerning all potential causes of the sudden unexpected infant death. The Pathologist will use this information to interpret autopsy findings, and determine cause and manner of death. One goal of the death scene recreation is to be able to accurately depict the sleep environment and sleep position in which the infant was last placed down to sleep, how the infant was last known to be alive and the position the infant was found unresponsive. Another goal of the scene recreation is to be able to provide the family with an explanation of what happened to their infant. Best Practice for the Death Investigator is to follow the Centers for Disease Control and Prevention's (CDC) Sudden Unexplained Infant Death Investigation (SUIDI) Training guidelines. This includes the use of the Sudden Unexpected Infant Death reporting form. The SUIDI reporting form is an essential tool designed to standardize and improve the data collected at infant death scenes. Inaccurate classification of cause and manner of death hampers prevention efforts and researchers are unable to adequately monitor national trends, identify risk factors, or evaluate prevention programs. Valid and consistent data is needed to support research and prevention efforts if we want to reduce infant deaths.
AFOSI's Specialist Approach to Death Investigations
Authors: Gerns John E. , Lecea Julie A.
Published: April 2017

The Air Force Office of Special Investigations (AFOSI) has repeatedly shown that all of its specialists can play a role in the investigation of death. The key to its successes has been its ability to “think outside the box” and use its specialists’ expertise in non-traditional manners.
Capecitabine-Induced Hand and Foot Syndrome and the Reproducibility of Friction Skin
Authors: Swofford Henry J. , Schenck Rodney A.
Published: April 2017

In 2008 a sixty-two year old male was detained by United States Customs and Immigration officials when attempting to enter the United States because his fingerprints were not detectable thus preventing his identify from being verified. It was later reported by his physician in Singapore that the individual suffered from Hand and Foot Syndrome (palmar-plantar erythrodysaesthesia) as a result of his cancer treatment of capecitabine (N4-pentyloxycarbonyl-5-deoxy-5-fluorocytidine) which causes interruptions to the normal growth of keratinocytes in the friction skin. Capecitabine is a recently developed, orally administered fluoropyrimidine prodrug designed to generate 5-fluorouracil through a three step enzymatic process giving it antineoplastic properties to combat cancerous tumor growth in a number of different cancers, including adjuvant colon cancer, metastatic colorectal cancer, and metastatic breast cancer. This study consisted of a 253 day evaluation of the physiological effects to the friction ridge skin from an individual undergoing capecitabine chemotherapy treatment. The results indicate the quality of the friction ridge skin impressions decreased by 32% and to a degree which may impair the ability to positively identify individuals using friction skin impressions alone while undergoing this type of treatment and experiencing hand and foot syndrome. Following cessation of capecitabine treatment, normal growth of keratinocytes resumed returning the skin to a normal state with no indication of damage thus demonstrating the persistency of the friction ridge skin despite the temporary toxicity of capecitabine.
Sudden Death in 14 Month Old Due to Fibromuscular Dysplasia of Atrioventricular Nodal Artery
Authors: Slemp Stephanie N. , Hoover Rick L. , Prahlow Joseph A.
Published: April 2017

Fibromuscular dysplasia is a non-atherosclerotic, non-inflammatory vascular disease that is most commonly found in the renal arteries of pre-menopausal women. However, this disease entity has rarely been described in the coronary arteries and small cardiac conduction arteries. To our knowledge, there is no recorded case of fibromuscular dysplasia in small cardiac conduction arteries in infants/children. In this report, we present a case of unexplained death of a 14 month old wherein routine histologic examination failed to reveal a cause of death, but subsequent submission of the cardiac conduction system (atrioventricular [AV] and sinoatrial [SA] node regions) demonstrated the presence of isolated AV nodal artery fibromuscular dysplasia, which was considered the cause of death. The case serves to emphasize the potential importance of evaluating the cardiac conduction system in cases where routine gross and microscopic autopsy fails to reveal an adequate explanation for death.
Forensic Sciences under Scrutiny: Forensic Pathology
Authors: Davis Joseph H.
Published: April 2017

Forensic pathology, as a scientific discipline, must depend upon generally accepted procedural standards in order to be useful in court. Procedural standards should assist investigations and determination of proper decisions necessary for the administration of justice.
A Pragmatic Approach to the Postmortem Neuropathological Diagnosis of Dementia
Authors: Reichard R. Ross , Parisi Joseph E.
Published: April 2017

Increased age is a significant risk factor for the development of dementia, predominately Alzheimer disease (AD). Since the fastest growing population sector in the United States is individuals over the age of 85 years, a surge in cases of dementia is expected. The inherent features of dementia mean those affected will eventually be incapacitated and require a high level of medical care. The majority of individuals dying from the complications of dementia will be under the care of a physician. However, dementia is a significant morbidity and demented patients are at risk from dying of non-natural causes (e.g., neglect/abuse or accidental injury) that necessitates the medical examiner/coroner (ME/C) to determine if the individual was incapacitated by a neurodegenerative process. The definitive diagnosis of a specific type of dementia requires a postmortem neuropathological examination. This paper provides a concise description of and a practical neuropathological algorithmic approach to the diagnosis of the most common neurodegenerative diseases.
Neuropathology of Seizure Disorders
Authors: Moreno Vanessa , Bhattacharjee Meenakshi B. , Powell Suzanne Z.
Published: April 2017

Epilepsy is a common neurological disorder characterized by an enduring predisposition to generate recurrent seizures. Pathologists may be called upon to evaluate brain tissue from patients with a history of seizures, and it is important to keep in mind the diversity of histopathologic findings associated with this disorder and the limitations imposed by both, limited sampling and neuroanatomy. Review of the literature has shown that the three most common clinicopathological entities in surgically resected medically refractory epilepsy are mesial temporal sclerosis (MTS), long-term epilepsy-associated tumors (LEAT), and malformations of cortical development (MCD) which includes focal cortical dysplasia (FCD). Here, we will review the most common clinicopathological entities seen in surgically resected cases of refractory epilepsy, such as MTS, MCD, LEAT, as well as vascular and encephalitic lesions. We will also touch upon traumatic brain injuries and SUDEP, and the role of the forensic pathologist. A better understanding of the etiopathology, recent classifications, and underlying molecular mechanisms involved in each entity will be helpful in order to identify the cause of death in patients with seizure disorders, candidates who will benefit from tailored surgical resection strategies, as well as to develop new and targeted drug treatment.
Intracranial Hemorrhage: Traumatic Fall versus Terminal Collapse
Authors: Quinton Reade A. , Pinckard J. Keith
Published: April 2017

When approaching a case in which a decedent's body is on the ground, death investigators collect circumstantial, historical, and clinical (radiographic) information to infer whether the person fell to the ground and sustained a head injury or simply experienced a terminal collapse due to a natural event. We have observed that cases presenting as presumed accidental head trauma, some of which have diagnosed subdural hematomas, are sometimes proven to be of natural causes following autopsy. Autopsies sometimes demonstrate that either 1) the intracranial hemorrhage is intracerebral rather than subdural, 2) the subdural hemorrhage is an extension from an intracerebral hemorrhage, or 3) there is no intracranial hemorrhage at all. In each of these examples, the autopsy established that the manner of death is natural rather than accidental, as originally presumed at the outset of the investigation.

We performed a 5 year retrospective study on cases indicating intracranial hemorrhage in the cause of death statement in order to assess how often the cause and manner of death would have been incorrectly certified without an autopsy. We found that 6% of cases presumed at the time of initial investigation to represent falls with accidental head trauma (specifically, subdural hemorrhage) were proven by autopsy to represent intracranial hemorrhage of natural manner. Conversely, 7% of cases with intracranial hemorrhage that were presumed to be due to natural disease were proven by autopsy to represent accidental trauma.

Proper certification of manner of death has important legal implications which may be of critical importance to family members.
Forensic Evaluation of Subarachnoid Hemorrhage
Authors: Ross Jennifer L. , Sandberg Glenn D. , Powell Suzanne Z.
Published: April 2017

Subarachnoid hemorrhage (SAH) may occur with natural, accidental, homicidal, suicidal, and/or undetermined events. The forensic autopsy and death scene investigation are useful in reconstructing the mechanism of death, as well as the dynamics of the event. Therefore, an accurate forensic evaluation of SAH is crucial. The annual incidence of subarachnoid hemorrhage in the United States is estimated at 1 per 10,000 persons with a median age of 50 years, and a high mortality rate. SAH is the most common indicator of traumatic brain injury (TBI). The majority (80%) of nontraumatic SAH is due to a ruptured saccular aneurysm. Other causes of nontraumatic SAH include arteriovenous malformations, cavernous angiomas, mycotic aneurysms, neoplasms, blood dyscrasias, perimesencephalic hemorrhage and central venous thrombosis. Risk factors for nontraumatic SAH include cigarette smoking, hypertension, cocaine use, heavy alcohol use, and a first-degree relative with subarachnoid hemorrhage. The rate and amount of hemorrhage determine the morbidity and mortality of the lesion. Computed tomography (CT) is considered the study of choice for ante-mortem identification of SAH. In rare circumstances, however, a similar CT appearance may occur in the absence of blood in the subarachnoid space. Such “pseudo-subarachnoid hemorrhage” is confirmed when autopsy shows no subarachnoid hemorrhage in those carrying the premortem CT diagnosis. However, when true SAH is present, dating of the hemorrhage, by both gross and microscopic examination, may aid in the forensic evaluation.
The Neuropathological Features of Fatal Pediatric Brain Trauma
Authors: Smith Colin , Lo Milly
Published: April 2017

Aims

This study aims to describe the neuropathological features of fatal pediatric brain trauma within a cohort with different survival durations and mode of primary injury mechanisms, and to review the exiting literature.

Methods

A cohort of 49 cases of fatal pediatric brain trauma were identified from the archive of the Academic Department of Neuropathology, University of Edinburgh. The pathological features were documented in a standardized proforma, and comparisons were made of the pathological features between cases of different survival durations and mode of injury.

Results

Brain swelling was the most common feature identified and was found in 94% of cases. Sixty-six percent of cases had evidence of ischemic brain damage. Survival beyond 24 hours did not increase the prevalence of ischemic brain damage. Traumatic axonal injury was identified in 24% of the cohort.

Conclusion

Brain swelling, ischemic brain damage, and traumatic axonal injury remain prominent features of fatal childhood brain trauma.
The Utility of Routine Brain Histology in Forensic Cases
Authors: Hutchins Kenneth D. , Menke Joshua , Reichard R. Ross
Published: April 2017

The medicolegal autopsy is part of a death investigation that determines the cause and manner of death and the extent of the testing performed is variable and is directed by the specifics of a particular case. Published studies disagree on the value of routine examination of microscopic sections of internal organs in forensic cases and no studies have specifically reviewed the utility of routine neuropathology microscopic sections. We reviewed the Miami-Dade County Medical Examiner Department and Mayo Clinic computer databases to determine whether routine brain histology is of value in medicolegal autopsies and the impact on the cause and manner of death. Consecutive cases from each institution were analyzed to determine whether the microscopic neuropathological findings revealed a previously unrecognized disease, changed the cause or manner of death, or significantly impacted the death investigation. In the cases in which the immediate cause of death was attributable to central nervous system (CNS) pathology, the cause of death was readily apparent from the gross brain examination. If CNS pathology was the proximate cause of death, contributed significantly to the death, or was a significant part of the death investigation, full appreciation of the neuropathology required microscopic examination and often additional special/immunostains. We conclude that microscopic brain examination is needed in selected medicolegal autopsies to exclude and/or diagnose underlying disease processes, particularly if the gross examination doesn't reveal an obvious explanation of the CNS pathology or the clinical history suggests underlying neuropathology.
Low Force Fracture of the Odontoid, with Discussion of High Force Cervical Fracture
Authors: Dolinak David
Published: April 2017

Cervical fracture may occur with a high force mechanism of injury such as a motor vehicle crash, or with a low force mechanism of injury such as a ground level fall. To better characterize and understand low force cervical fractures and their significance, case files from the Travis County Medical Examiner's office covering a 5-year time period were retrospectively reviewed for fatal cervical fracture occurring with an accidental ground level fall. Thirty such fatal cervical fractures were identified, all occurring in elderly individuals (>65 years of age), with odontoid type 2 fracture of the C2 vertebra identified as the most frequent type of fracture. Odontoid fracture should be included in the list of craniocervical injury that may result from not only motor vehicle crashes and other high force mechanisms of injury, but also low force mechanisms of injury such as a ground level fall with head impact in an elderly individual.
Chasing the Dragon: A Review of Toxic Leukoencephalopathy
Authors: Krinsky Clarissa S. , Reichard R. Ross
Published: April 2017

The report begins with the case of an 18-year-old male who presented to a community hospital with difficulty walking and speaking. His illicit drug use history included smoking heroin. After admission to the hospital, a thorough workup was consistent with toxic heroin related leukoencephalopathy. The young man continued to decline and died approximately 2 months after his initial presentation and diagnosis. An autopsy and a thorough neuropathology examination were completed. Sections through the cerebral hemispheres and the cerebellum revealed diffuse and profound softening and discoloration of the white matter, most prominently in the occipital lobes. Microscopically, there was vacuolization and spongiosis of the white matter. The pathologic findings were consistent with the diagnosis of toxic or heroin related leukoencephalopathy. Toxic leukoencephalopathy is a rare disorder of unknown etiology linked to the smoking of heroin, known as “chasing the dragon.” The exact mechanism of the disorder is unknown, but it is thought that impurities cut into the heroin may become toxic substances upon sublimation, as the disorder is not seen with injected heroin. Currently, therapy is supportive with no effective cures available. The natural history of the disorder is variable, with an approximately 25% mortality rate. The popularity of smoking heroin is growing in the United States, and it is particularly seen with increasing frequency in new heroin users. Thus, this is an important, and likely increasingly common, effect of illicit drug use that should be recognized by forensic pathologists.
Potential Applications of Digital Pathology and Image Analysis for Forensic Pathology
Authors: Levy Bruce P. , Hipp Jason D. , Balis Ulysses J. , Yagi Yukako
Published: April 2017

The analysis of digital images using computer algorithms to mine digital data directly is an important and increasingly utilized tool in many different fields of medicine. However, despite the clear value of image analysis to forensics, there is little research and no current practical applications of this technology to forensic pathology.

This paper demonstrates the technique of Spatially Invariant Vector Quantization (SIVQ) in the analysis of gross forensic images. SIVQ is a pattern recognition algorithm that can run on a laptop and be utilized by a forensic pathologist with no programming experience. The user merely points and clicks to the feature of interest and SIVQ searches the entire image for the desired feature. The results can be displayed in a variety of formats, both qualitative and quantitative.

Gross forensic images from gunshot wounds, burns and patterned contusions were analyzed by a forensic pathologist using SIVQ. Based on features selected by the user, the algorithm was able to detect both the gunshot wound and its marginal abrasion, calculate the surface area of a gunshot wound defect, distinguish between a thermal burn and the surrounding areas of healing, analyze a patterned contusion, and both identify and calculate the density of gunpowder stippling.

Even though the work is preliminary, it is obvious from these few examples that SIVQ is easily able to identify features of interest in gross forensic images. Additional work needs to be done to fully explore the potential for this application of technology to the practice of forensic pathology.
Work-Related Predictors of Psychological Distress among Medical Examiner and Coroner Personnel
Authors: Brondolo Elizabeth , Wellington Robin , Brondolo Elena , Brondolo Thomas J. , Delahanty Douglas
Published: April 2017

Personnel employed in medical examiner and coroner offices are involved in the identification of the deceased, the determination of causes of death, and the communication of this information to relevant parties, including the families of the victims, public health authorities and the criminal justice system. Although the mental health needs of other types of emergency workers (i.e., fire, police, emergency medical services) have been well identified and acknowledged in the literature and in planning efforts, the mental health needs of medical examiner and coroner personnel have not received the same attention. The aim of this study was to identify predictors of mental and physical health symptoms among employees of medical examiner and coroner offices. Data was collected from a convenience sample composed of employees of eight medical examiner sites nationwide, attendees of a coroners' conference, and through the web. A total of 395 employees completed a survey evaluating symptoms of depression, posttraumatic stress, anxiety, self-reported health and sleep quality. Results indicated variations among job titles in the intensity of mental and physical health symptoms, with investigators, clerical and administrative staff, and coroners reporting the highest levels of symptoms. Work-related stressors associated with increased levels of psychological symptoms included: exposure to cases involving the accidental death of infants, as well as stress associated with interacting with the families of the deceased and concerns about bringing home infection or illness. The results have implications for the development of intervention strategies designed to prevent work-related illness in medical examiner personnel.
Sudden Death in a 61-Year-Old Woman with Subcortical Band Heterotopia
Authors: Patterson Nathaniel B.
Published: April 2017

Subcortical band heterotopia (SBH), also known as double cortex syndrome, is a rare congenital abnormality seen almost exclusively in women. Affected individuals present with seizures, decreased cognitive ability, and behavioral problems, all of which may be expressed with variable severity. The diagnosis is considered with the characteristic MRI findings coupled with the neurologic features and appropriate family history.

The rarity of this disorder combined with the typically early presentation with seizures and the characteristic imaging findings make initial diagnosis in a forensic setting unlikely. Therefore, to our knowledge, SBH has not been described in the forensic literature. This case demonstrates a case of sudden death in a woman with known epilepsy, without further clinical history available at the time of autopsy.
Reflections upon Forensic Pathophysiology: Mechanism of Death Does Matter
Authors: Pinckard J. Keith
Published: April 2017

The primary responsibility of the forensic pathologist is to determine the cause of death. Inclusion of the mechanism of death is not required on death certificates, and therefore, forensic pathologists often (appropriately) do not include mechanisms in cause of death statements. When determining the cause of death; however, it is nonetheless important to consider the responsible physiologic mechanism. If the mechanism of death is not taken into account, an erroneous cause of death may be attributed. This review article will highlight examples of the types of cases in which this may occur.
Is Race Determination in the Medicolegal Setting Important?
Authors: Haden-Pinneri Kathryn , Love Jennifer C. , Spradley M. Kate
Published: April 2017

Racial designations have evolved over the years to accommodate the changes in our population demographics. The Federal Office of Management and Budget (OMB) has developed Federal Standards to assist with the uniform documentation and reporting of race and ethnicity. A minimum of five defined categories currently exist for race (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander and White). Ethnicity is separated into either Hispanic origin or Non-Hispanic origin. Current death certificates allow for the selection of one or more races; however, only one ethnicity may be chosen. Race of unknown decedents is either based subjectively on the observer's opinion or, in severely decomposed or skeletal remains, by anthropological analysis utilizing sound statistical methodology. If the data and statistical analysis suggest a good classification, the race determination will be correct more often than not. Information obtained from the National Missing and Unidentified Persons System (NamUs) indicates that absence of race determination does not hinder the identification potential. Mortality rates, life expectancy, disease risk and causes of death are often disaggregated by race and/or ethnicity. Differences in the presentation, etiology and outcomes of many diseases have been based on race and ethnicity data. Uniform collection of this data is the key to its importance. Medical examiners, coroners and others tasked with examination of decedents should utilize the defined categories set forth in the OMB Revised Standards for race and ethnicity documentation.
Controversies in Forensic Pathology: Results of a 2010 Survey of Name Fellows
Authors: Cina Stephen J.
Published: April 2017

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.
The Armanni-Ebstein Lesion and the Postmortem Diagnosis of Ketoacidosis
Authors: Milroy Chris , Parai Jacqueline L.
Published: April 2017

The diagnoses of ketoacidosis and disturbances of glucose metabolism are difficult at autopsy because of changes in glucose concentrations postmortem. The Armanni-Ebstein lesion is a histological change in the kidney that has been reported as a marker of diabetic ketoacidosis. This paper examines the specificity of the Armanni-Ebstein lesion and the diagnosis of alterations in glucose metabolism and ketoacidosis at autopsy. The Armanni-Ebstein lesion consists of subnuclear vacuolation of the proximal tubules. The vacuoles contain fat and can be demonstrated on fresh and formalin fixed tissue using standard fat stains. Recently it has been reported in other conditions associated with non-diabetic ketoacidosis. The lesion has the same appearance whatever the cause of the ketoacidosis. This review, with illustrative cases shows the Armanni-Ebstein lesion is a marker of ketoacidosis and not specific for diabetic ketoacidosis. It may be seen in cases of diabetic and alcoholic ketoacidosis and in starvation and hypothermia, in which ketoacidosis occurs. It has also been reported in isopropanol poisoning.
Analysis of 101 Vehicle Fire Fatalities
Authors: Harruff Richard C. , Lubin Micheline
Published: April 2017

Vehicle fire fatalities encompass both fire and traffic investigations important for the forensic pathologist. Previous studies have demonstrated the challenges in victim identification, determining cause and manner of death, evaluating the role of collision dynamics, and estimating the excess burden of deaths due to post-collision fire. To address these challenges, the present study analyzed 101 vehicle fire fatalities representing 85 accidents, six suicides, four homicides, two natural deaths and four deaths of undetermined manner. Deliberately set fires in homicides, suicides, and suspicious deaths caused nine deaths. Non-accidental deaths were twice as common in parked vehicles. Of 78 collision fatalities, 46 were occupants of cars, 47 were drivers, and 48 died in collisions involving fixed objects or non-impact rollovers. Occupants of heavy trucks and collisions with light trucks and SUVs had the highest per-collision fatality rates. Frontal and rollover collisions claimed most lives, and rear collisions had the highest fatality rate. Carboxyhemoglobin (COHb) levels were highest in parked cars wherein toxic inhalation occurred prior to fire. In post-collision fires, COHb ranged no higher than 31% saturation and were much lower than in house fires. Potentially survivable blunt force injuries (BFI) and no BFI were present in more than half of charred bodies of post-collision fires. Evidence of inhalation of combustion products correlated imperfectly with severity of BFI, and airway soot deposition was a more sensitive indicator of post-collision viability than COHb. Between 13% and 59% of collision fatalities were due to post-collision fire and not BFI.
The Consistency and Advantage of Therapeutic Complication as a Manner of Death
Authors: Gill James R. , Maloney Katherine F. , Hirsch Charles S.
Published: April 2017

The standard manners of death of the Vital Statistics Bureau of the United States include: natural, accident, suicide, homicide, and undetermined. The therapeutic complication (TC) manner of death is used in some jurisdictions for fatalities caused by predictable complications of appropriate medical therapy; it is not a synonym for medical malpractice. The usefulness of the TC manner, and whether it can be applied consistently, has never been formally assessed. A survey was conducted that asked for the manner of death in 16 case vignettes of a variety of fatal medical complications. This survey was completed by forensic pathologists from a jurisdiction that routinely uses the TC manner of death and by forensic pathologists from other jurisdictions that do not have the TC option. The forensic pathologists from the TC jurisdiction had the option of selecting TC as the manner of death in the survey while the other group did not. There was excellent consistency for the TC fatalities among the TC-jurisdiction respondents. Among the non-TC group there was less agreement, particularly with allergic reactions and some procedural complications. In that one instance there was a 57% to 43% disagreement between a natural and accidental manner. The therapeutic complication manner of death may be more easily applied in a consistent fashion and may improve agreement of certification in certain types of deaths. Without the TC option, some forensic pathologists will certify deaths due to medical complications as natural and others will certify them as accidents.
A Comparison of Florida Medical Examiners’ Reports and Death Certificates for Specific Drug Related Overdose Deaths
Authors: Paulozzi Leonard J. , Ibrahimova Aybaniz , Rudd Rose A. , Goldberger Bruce A. , Thogmartin Jon R. , Shelton Kyla
Published: April 2017

Death certificates are a source of information on deaths caused by specific drugs. However, the completeness of such information has been questioned. This study compared counts in the Florida Medical Examiner Commission's drug related death reporting system (ME) with those from death certificates (DC) for overdose deaths involving selected drugs during 2005-2008 to assess the completeness of death certificate information. DC data indicated 2,401 deaths with benzodiazepines as a cause, 2,182 for cocaine, 2,055 for methadone, and 416 for heroin. The ratios of ME deaths to DC deaths were 1.19 (95% CI 1.13-1.26) for benzodiazepines, 1.38 (95% CI 1.31-1.46) for cocaine, 1.37 (95% CI 1.29-1.44) for methadone, and 0.96 (95% CI 0.83-1.09) for heroin. For each drug, ratios were similar for unintentional (accidental), suicide, and undetermined intent deaths. Ratios varied across the 24 ME districts, but few districts reported significantly fewer deaths in the ME system than in the DC system. Results suggest that surveillance based on death certificate data underestimates specific drug caused deaths as counted by medical examiners in a state with multiple, independent medical examiners. Death certificate data might therefore underestimate drug overdose mortality nationwide.
Synthetic Cannabinoid Use and Sudden Death
Authors: Stoppacher Robert
Published: April 2017

Synthetic cannabinoids are chemical compounds that act on the cannabinoid receptors to produce psychoactive effects. Originally created to better understand the cannabinoid receptors, these drugs are readily accessible over the internet or in “head shops” and are sold as herbal incense under various names such as K2, Spice, K9, or Legal Phunk. While neurologic and cardiac toxicity from the use of these compounds has been described, and deaths of individuals that have used synthetic cannabinoids have been publicized in the media, no fatalities directly related to synthetic cannabinoid toxicity have been reported in the scientific literature. This report describes a fatality directly related to the toxic effects of synthetic cannabinoid use. It will also review the development of synthetic cannabinoids, current literature with respect to their toxicity, and the regulatory issues surrounding these substances.
Neuropathological Alterations in Illicit Drug Abuse
Authors: Büttner Andreas
Published: April 2017

A variety of neuropathological findings has been described in illicit drug abusers. The majority of these alterations result from the consequences of hypoxia-ischemia and from cerebrovascular diseases. Within the last few years, widespread morphological alterations of the cellular elements of the brain have been detected. These changes consist of neuronal loss, a numerical reduction of astrocytes, widespread axonal damage with concomitant microglial activation and reactive and degenerative changes of the cerebral microvessels. Based on various studies there is also concern that drug abusers develop neurodegeneration or Parkinsonism as they age. However, whether or to what extent neurodegeneration occurs in human drug abusers remains to be established. In the present paper a brief overview on the neuropathological changes in drug abuse is presented for the forensic pathologist/toxi-cologist with reference to the most pertinent literature.
Deaths at Sea: Los Angeles, 2000-2011
Authors: Marinovich Adrian M. , Rogers Christopher B. , Sathyavagiswaran Lakshmanan
Published: April 2017

With the expansion of the shipping and cruise ship industries, there is a need for a more complete understanding of the mortality risks at sea. We conducted a retrospective review of shipboard deaths coming under the jurisdiction of the County of Los Angeles Department of Coroner during the years 2000-2011. Sixty-one shipboard deaths were identified, of which 24 (39%) were among crew, and 37 (61%) were among passengers. Among both crew and passengers, there was a prominence of deaths due to cardiovascular disease. Also prevalent were accidents due to blunt trauma, accidents involving ethanol or medications, and suicides. The identification of multiple potentially preventable deaths after onset of symptoms at sea underscores the need for further improvements in maritime telemedicine, crew medical capability and long-distance evacuation.
Skull Base Fractures are Markers of Severe Forces in the First Two Years of Life
Authors: Matshes Evan W. , Selanders Lori , Lew Emma O.
Published: April 2017

While experience indicates that basilar skull fractures are an uncommon injury in the first two years of life, an evidential basis for this observation is lacking in the forensic pathology literature. The aim of this study was to determine the incidence and forensic significance of basilar skull fractures in the first two years of life. This retrospective analysis reviewed pediatric deaths over a 17-year period in a large metropolitan medical examiner jurisdiction and included the deaths of infants and children under 24 months of age. All cases had a cause of death statement of “blunt head trauma”, “blunt head and neck trauma” or “blunt trauma”. Sixty-three cases were found, 23 of which had basilar skull fractures. The most common circumstance with basilar skull fracture was pedestrian versus motor vehicle accidents (57%), followed by inflicted injury (30%), and vehicle accidents in which the child was an occupant (13%). As such, basilar skull fractures are uncommon injuries that are the end result of the application of significant forces to the head. The discovery of a basilar skull fracture without an appropriate history of the accidental application of severe forces should cause those tasked with the investigation of child injuries and death to carefully consider inflicted head trauma.
Injuries of the Upper Cervical Spinal Column are Markers of Severe Forces in the First Two Years of Life
Authors: Matshes Evan W. , Selanders Lori , Hatch Gary , Lew Emma O.
Published: April 2017

Cervical spinal column injuries occur uncommonly in infants and young toddlers, and rarely in the upper cervical spine. Any injury, when discovered at forensic autopsy, must be interpreted within the context of a complete case investigation, and available science. When severe upper cervical spinal column injury is detected, such as atlanto-occipital dislocation (AOD), atlanto-axial dislocation (AAD) or spinal cord transection, forensic pathologists commonly regard such trauma as a marker of significant forces. This retrospective study evaluated 60 cases of accidental and homicidal deaths occurring in the first 24 months of life and investigated by a large metropolitan medical examiner jurisdiction. All cases with AOD, AAD or spinal cord transection occurred under documented accidental circumstances, and all of those cases involved severe forces, including being struck by or run over by a car. While such high cervical spinal column pathology is not unusual when an infant or young toddler is struck by or run over by a motor vehicle, or other accidental circumstance involving severe forces, this discovery in a case of apparent natural death or death following alleged short fall or other commonplace activity of daily living should be considered highly suspect.