Post-mortem formation of ethanol: Is 1-propanol a reliable marker? A proof-of-concept study using an in vitro putrefactive environment setup.

Ethanol is the psychoactive substance identified most frequently in post-mortem specimens. Unfortunately, interpreting post-mortem ethanol concentrations can be difficult because of post-mortem alcohol redistribution and the possibility of post-mortem alcohol neogenesis. Indeed, in the time interval between death and sample collection, the decedent may be exposed to non-controlled environments for an extended period, promoting microbial colonization.

The effects of the (fentanyl-fueled) drug overdose epidemic on medicolegal death investigation in the United States.

The evolving opioid epidemic in the United States, fueled by illicit fentanyl, has greatly increased deaths from illicit drug use. These nonnatural deaths require formal death investigation. The National Association of Medical Examiners states in its Forensic Autopsy Performance Standards that autopsy remains a necessary component for proper investigation of suspected acute overdose deaths.

Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid and Other Drugs.

The National Association of Medical Examiners convened an expert panel to update the association's evidence-based recommendations for investigating and certifying deaths associated with opioids and other misused substances to improve death certificate and mortality data for public health surveillance. The recommendations are as follows:1. Autopsy provides the best information on a decedent's medical condition for optimal interpretation of toxicology results, circumstances surrounding death, medical history, and scene findings.

Correctly Identifying Deaths Due to Drug Toxicity Without a Forensic Autopsy.

In 2005, the National Association of Medical Examiners approved the Forensic Autopsy Performance Standards. Standard B3.7 indicates that a forensic pathologist shall perform a forensic autopsy when the death is by apparent intoxication by alcohol, drugs, or poison.

Report and Recommendations of the Association of Pathology Chairs' Autopsy Working Group.

Autopsy has been a foundation of pathology training for many years, but hospital autopsy rates are notoriously low. At the 2014 meeting of the Association of Pathology Chairs, some pathologists suggested removing autopsy from the training curriculum of pathology residents to provide additional months for training in newer disciplines, such as molecular genetics and informatics. At the same time, the American Board of Pathology received complaints that newly hired pathologists recently certified in anatomic pathology are unable to perform an autopsy when called upon to do so.

Correcting the Count: Improving Vital Statistics Data Regarding Deaths Related to Obesity.

Obesity can involve any organ system and compromise the overall health of an individual, including premature death. Despite the increased risk of death associated with being obese, obesity itself is infrequently indicated on the death certificate. We performed an audit of our records to identify how often "obesity" was listed on the death certificate to determine how our practices affected national mortality data collection regarding obesity-related mortality.

A survey of medical examiner death certification of vignettes on death in epilepsy: Gaps in identifying SUDEP.

Objective: Lack of standardized terminology on death certificates (DCs) of SUDEP type cases may obscure the presence of epilepsy in these deaths. Most DCs for individuals dying unexpectedly with epilepsy are certified by medical examiners (MEs). The purpose of this study was to gauge death certification practices of MEs when interpreting SUDEP cases and assess implications for valid surveillance of SUDEP.

Identifying cases of heroin toxicity where 6-acetylmorphine (6-AM) is not detected by toxicological analyses.

Purpose: Heroin has a half-life of 2-6 min and is metabolized too quickly to be detected in autopsy samples. The presence of 6-acetylmophine (6-AM) in urine, blood, or other samples is convincing evidence of heroin use by a decedent, but 6-AM itself has a half-life of 6-25 min before it is hydrolyzed to morphine, so 6-AM may not be present in sufficient concentration to detect in postmortem samples. Codeine is often present in heroin preparations as an impurity and is not a metabolite of heroin.

Implications of Death Certification on Sudden Unexpected Death in Epilepsy (SUDEP) Research.

Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in individuals with chronic, uncontrolled epilepsy. Epidemiologists use information on death certificates to study SUDEP. Certification of seizure-related deaths varies.

Review of Postmortem Interval Estimation Using Vitreous Humor: Past, Present, and Future.

For decades, forensic scientists have sought a means of estimating the postmortem interval using laboratory analyses. The best known of these attempts uses a linear regression formula based on the increasing concentration of potassium ions in vitreous humor following death. Like all laboratory analyses, the determination of a potassium concentration is subject to pre-analytical, analytical, and post-analytical errors.

The effect of previous traumatic injury on homicide risk.

Research has reported that a strong risk factor for traumatic injury is having a previous injury (i.e., recidivism).

The effect of trauma care on the temporal distribution of homicide mortality in Jefferson County, Alabama.

The distribution of time from acute traumatic injury to death has three peaks: immediate (less than or equal to one hour), early (6 to 24 hours), and late (days to weeks). It has been suggested that coordinated trauma care dampens the late peak; however, this research may be more reflective of unintentional than intentional deaths. This study examines whether a coordinated trauma system (TS) alters the temporal distribution for assault-related deaths.

Complete republication: National Association of Medical Examiners position paper: Recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs.

The American College of Medical Toxicology and the National Association of Medical Examiners convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance. The panel finds the following: 1. A complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings.

Drug abuse: newly-emerging drugs and trends.

Drug abusers have access to new, more potent compounds that evade existing laws by virtue of their novel chemical structures. These drugs are available for purchase at stores and over the internet. The drugs are not illegal because they are so new that laws have not yet been passed to ban them.

Forensic toxicology.

Toxicologic analysis is an integral part of death investigation, and the use or abuse of an unsuspected substance belongs in the differential diagnosis of patients who have a sudden, unexpected change in their condition. History and physical findings may alter suspicion that intoxication played a role in a patient's decline or death, but suspicions cannot be confirmed and is performed, analysis unless toxicologic no toxicologic analysis is possible unless someone collects the proper specimens necessary for analysis. In a hospital autopsy the only specimens that can rightfully be collected are those within the restrictions stated in the autopsy permit.

Study of vitreous potassium correlation with time since death in the postmortem range from 2 to 110 hours using capillary ion analysis.

The time-dependent postmortem increase of potassium concentration in the eye fluids has been studied since the 1960s. However, important discrepancies on the reproducibility of the phenomenon have hampered the use of this parameter in real cases. In recent years, a new analytical approach based on capillary ion analysis (CIA) has been reported.

Hyperthermia deaths among children in parked vehicles: an analysis of 231 fatalities in the United States, 1999-2007.

Motor vehicle-related child hyperthermia fatalities (MVRCHF) have risen slightly in the past decade, but little research has been done investigating the circumstances surrounding MVRCHF. In order to address gaps in our understanding, the current study describes MVRCHF circumstances among children <1-14 years of age in the United States from 1999 to 2007. Three sources were used to identify child hyperthermia death cases in the United States from 1999 to 2007: the Centers for Disease Control and Prevention's Compressed Mortality File (1999-2004), the Golden Gate Weather Service's public MVRCHF database (2003-Present), and an independent internet search.

Reassessment of the tri-modal mortality distribution in the presence of a regional trauma system.

Background: The temporal distribution of trauma-related deaths has been described as tri-modal with immediate, early, and late peaks. With the development of trauma centers and systems, it has been suggested that this distribution might be altered.

Methods: Information regarding all trauma-related deaths occurring from 1990 through 2003 in Jefferson County, AL, was obtained and the elapsed time from injury to death was calculated and categorized as <1 hour, 1 to 6 hours, 7 to 24 hours, 1 to 3 days, 4 to 7 days, and >1 week.

The relationship of drug abuse to unexplained sudden death.

Context: Forensic pathologists regularly investigate the deaths of individuals with a history of drug abuse. Autopsy, including toxicology testing, reveals no cause for death in a subset of this cohort.

Objective: To determine whether deaths with an undetermined cause and manner of death are associated with a history of drug abuse.

The predictive value of history and scene investigation for toxicology results in a medical examiner population.

Medical examiner offices vary in the extent to which they pursue postmortem toxicology. Our office routinely tests decedents for ethanol and drugs of abuse, and we decided to evaluate the usefulness of our practice. We reviewed 1180 medical examiner cases examined in 2002-2003.

The art of attorney interaction and courtroom testimony.

Context: In our society it is well for a physician to know something of the workings of court and how to interact with attorneys. One need not go to law school to successfully navigate a legal proceeding as a physician witness.

Objective: To show that a physician skilled at interacting with colleagues and patients can successfully apply those skills to interacting with attorneys and testifying in court.