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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. If a death investigation office lacks adequate resources to investigate all deaths under its jurisdiction while meeting expected standards, then that office may be forced to consider altering its protocols for investigation by changing the types of deaths investigated or the extent of its investigations. Drug death investigations take longer to complete because novel illicit drugs and mixtures of drugs complicate toxicological analyses, prolonging a family's wait for completion of a death certificate and autopsy report. Public health agencies must also wait for results, but some agencies have developed mechanisms for rapid notification of preliminary results to allow timely deployment of public health resources. The increased deaths have strained the resources of medicolegal death investigation systems throughout the United States. Given the significant workforce shortage of forensic pathologists, newly trained forensic pathologists are too few to meet the demand. Nevertheless, forensic pathologists (and all pathologists) must make time to present their work and themselves to medical students and pathology trainees to encourage an understanding of the importance of quality medicolegal death investigation and autopsy pathology and to provide a model that can encourage interest in a career in forensic pathology. [ABSTRACT FROM AUTHOR]

In this commentary, the authors discuss a paper by Prof Alan Wayne Jones that identifies the highly cited forensic practitioners in the United States. The paper uses a composite citation score to evaluate the performance of each individual. The authors highlight the variability in the number of authors in research papers and the need to consider collaboration norms within the specific field. They also discuss the limitations of the composite score and suggest the addition of other citation-based indicators to provide a more comprehensive evaluation. The authors conclude by suggesting the publication of papers analyzing top forensic scientists globally using various bibliometric indicators. [Extracted from the article]

In the United States, medicolegal death investigation practices and policies pertaining to sudden unexpected deaths are mandated by state government. Practices vary across states, which contributes to inconsistency in job prerequisites and training. In preparation for a study focused on occupational safety and health of medicolegal death investigators in their on‐scene and follow‐up activities, a scoping review was conducted to document known occupational safety risks and health‐related conditions associated with death investigation. Searches used Boolean and subject heading operators both broad and narrow in scope, and search terms included scene responder, hazard, investigator, forensic pathology, injury, and safety. Twenty‐five articles met inclusion criteria, which included seventeen survey‐mixed method designs, two systematic reviews, five quasi‐experimental designs, and one case study. Twelve articles addressed mental health and eleven focused on risks associated with infectious disease. One article addressed the risk of chemical exposure from cyanide among autopsy personnel (including forensic pathologists) and nine included a wide range of employees within the setting of medical examiner or coroner offices. One article, addressing burnout, included employees in a forensic science laboratory setting as well as medicolegal death investigators and two articles included forensic pathologists and medicolegal death investigators. Only one article addressed medicolegal death investigators specifically. Articles addressing occupational and environmental hazards of medicolegal death investigators associated with musculoskeletal, respiratory, cardiovascular, radiological, nuclear, electrical, or explosive threats were not identified. There is little published about safety risks inherent in conducting death investigations. Research is needed to adequately inform health promotion and injury prevention strategies. [ABSTRACT FROM AUTHOR]

Table saws are dangerous tools able to create severe injuries. In accidental injuries, the most commonly injured body parts are fingers (85.9%) while amputations occur in 10% of cases. Accidental neck or head injuries account for only 3.1% of all injuries. Table saws cause nearly half of all saw‐related amputations. There are approximately 30,000 cases of table saw‐related injuries in the United States annually, but only a few table saw‐related suicides have been reported in the scientific literature. In regard to suicides, usually the head or the neck is targeted. Usually, only the soft tissues of the neck are injured because the blade height limits the cutting depth and the victim falls down from the table saw before complete transection. A rare case of suicide committed by a modified table saw that resulted in near decapitation is presented. Previously reported cases of suicides by table saw are also reviewed. [ABSTRACT FROM AUTHOR]

Since late 2014, fentanyl has become the major driver of opioid mortality in the United States. However, a descriptive analysis of fentanyl victims is limited. We studied the 2016 fentanyl and heroin overdose deaths and compared them to previously studied heroin‐associated fatalities from 2012 over a wide range of demographic and investigative variables, including overdose scene findings, toxicology results, and prescription drug history. We observed a significant increase in fentanyl‐related deaths (n = 421, 2016) versus heroin deaths (n = 160, 2012) but the baseline demographics between both cohorts remained similar. Victims were predominantly of ages 35–64 years (60%–64%), White (83%–85%), and male (73%–76%). 2016 fentanyl decedents were more likely to have naloxone administered upon overdose, and the majority still had a positive prescription history for a controlled substance. Toxicology data showed a decrease in mean morphine and 6‐monoacetylmorphine concentrations when cointoxication with fentanyl occurred. Our study emphasizes the medical examiner's role as a public health data source and bridge between different stakeholders combating the opioid epidemic. [ABSTRACT FROM AUTHOR]

Recent increases in deaths in the United States from synthetic opioids such as fentanyl and fentanyl analogues (fentanyls) have raised concerns about possible occupational exposures to these potent agents. Medicolegal death investigators and autopsy suite staff might perform job tasks involving exposure to fentanyls. The potential for exposure to fentanyls among medicolegal death investigators and autopsy technicians at a state medical examiner's office was evaluated through review of caseload characteristics, injury and illness logs, and procedures and policies and discussions with management and employee representatives. The evaluation showed that this medical examiner's office had low potential for work‐related exposure to fentanyls; its standard operating procedures and personal protective equipment requirements should reduce the potential for occupational exposure. Medicolegal death investigation agencies can develop and implement guidance to control exposures and provide workforce education and training to reduce the potential for work‐related exposure to fentanyls. [ABSTRACT FROM AUTHOR]

Residential fires are a significant cause for morbidity and mortality in the United States. Death is often the result of soot and smoke inhalation causing carbon monoxide (CO) toxicity. The approximate lethal level of carboxyhemoglobin (COHb) in healthy adults has been well described. However, a significant number of medical examiner cases involve infirmed decedents, often elderly, with complex cardiovascular disease burdens. It is well known that death in these cases will occur at sublethal levels of COHb; however, increased lethality has been largely documented via anecdotal experience and lacks quantification. Fifty‐five cases were identified where death resulted from smoke and soot inhalation suffered in a residential fire. The control group, with no cardiovascular disease, had an age‐adjusted mean COHb level of 61.6% at the time of death. Presence of hypertensive cardiovascular disease showed a 30% reduction in COHb (age‐adjusted mean 43.2%), atherosclerotic disease showed a 33% reduction (age‐adjusted mean 41.5%), and combined disease presentation accounted for 41% reduction (age‐adjusted mean 36.3%). When controlling for age, atherosclerotic and hypertensive cardiovascular diseases were each associated with statistically significant decreases in COHb (p < 0.01). Increasing age was associated with decreased COHb levels at 2.8% per 10 years of life (p < 0.01), even when modeled with hypertensive and atherosclerotic disease. These findings carry important public health significance, as well as practical significance for the medical examiner when interpreting COHb levels in cases of suspected deaths due to smoke and soot inhalation. [ABSTRACT FROM AUTHOR]

Elevators are mechanical transportation devices used to move vertically between different levels of a building. When first developed, elevators lacked the safety features. When safety mechanisms were developed, elevators became a common feature of multistory buildings. Despite their well‐regarded safety record, elevators are not without the potential for danger of injury or death. Persons at‐risk for elevator‐related death include maintenance and construction workers, other employees, and those who are prone to risky behavior. Deaths may be related to asphyxia, blunt force, avulsion injuries, and various forms of environmental trauma. In this review, we report on 48 elevator‐related deaths that occurred in nine different medicolegal death investigation jurisdictions within the United States over an approximately 30‐year period. The data represents a cross‐section of the different types of elevator‐related deaths that may be encountered. The review also presents an overview of preventive strategies for the purpose of avoiding future elevator‐related fatalities. [ABSTRACT FROM AUTHOR]

Since the landmark Supreme Court decisions that comprise the Daubert trilogy and the release of the 2009 National Academy of Science report, Strengthening Forensic Sciences in the United States: A Path Forward, forensic anthropology has improved technical competencies and promoted certification of practitioners. However, the field would benefit from developing and employing education and continuing professional development curricula that address areas beyond technical competencies, such as laboratory management, court testimony, and vicarious trauma. Laboratory management and accreditation following international standards is the gold standard, but the language and requirements of international standards are not intuitive; students and trainees would benefit from training in this arena. Furthermore, several Supreme Court decisions have stipulated that forensic analysts must be available to testify when analytical results are admitted into evidence. Therefore, students must be versed in relevant Supreme Court rulings and understand courtroom proceedings and etiquette before taking the stand as an expert witness. Finally, forensic anthropologists are playing a larger role in medicolegal death investigations with increased exposure to victim suffering and vicarious trauma. Trainees, professionals, and organizations must be trauma-informed, self-aware, and knowledgeable about appropriate coping mechanisms. Developing these competencies requires dedicated education and training to ensure that students are prepared to enter the workforce and professionals receive continuing education to meet the demands of the dynamic medicolegal environment. This article reviews these non-technical competencies and their relevance to forensic anthropology practice. [ABSTRACT FROM AUTHOR]

Forensic pathologists are commonly tasked with identifying human remains. Although DNA analysis remains the gold standard in identification, time and cost make it particularly prohibitive. Radiological examination, more specifically analog imaging, is more cost‐effective and has been widely used in the medical examiner setting as a means of identification. In the United States, CT imaging is a fairly new imaging modality in the forensic setting, but in more recent years, offices are acquiring CT scans or collaborating with local hospitals to utilize the technology. To broaden the spectrum of potential identifying characteristics, we collected 20 cases with antemortem and postmortem CT images. The results were qualitatively assessed by a forensic pathologist and a nonmedically trained intern, and all cases were correctly identified. This study demonstrates that identification of human remains using visual comparison could be performed with ease by a forensic pathologist with limited CT experience. [ABSTRACT FROM AUTHOR]

2,4‐dinitrophenol (2,4‐DNP) is a compound used in the early 1900s as a weight‐loss drug but later prohibited due to its severe adverse effects, including death. It has however been attracting interest, due to its weight‐loss properties, and appears to be re‐emerging in forensic casework. As 2,4‐DNP is available for use in industry and as a pesticide and easily accessible online, the dissemination of this drug can be fast. The compound exerts its effects through inhibition of ATP synthesis, and corresponding thermogenic energy loss which can be fatal. A method for qualitative and quantitative analysis of 2,4‐DNP in blood and urine specimens using GC‐MS with hydrogen as carrier gas is described. The method was validated and displayed acceptable performance parameters with linearity (R2 higher than 0.998), inter‐assay imprecision (lower than 10.6%), intra‐assay imprecision (lower than 10.7%), and extraction efficiency (92.1%). Stability of 2,4‐DNP in blood and urine was studied, and the drug was stable up to 30 days refrigeration or frozen. Six cases in United States suspected to be related to 2,4‐DNP were analyzed. Three cases were found to be positive for 2,4‐DNP. Concentrations of 2,4‐DNP were in the range of 61.6–220 mg/L in urine and <3–114 mg/L in blood. Based on our findings, we suggest that medical examiners and forensic toxicologists be aware of the reappearance of 2,4‐DNP, including this compound as a target in death investigations related to weight‐loss drugs. [ABSTRACT FROM AUTHOR]

Originally motivated by the need for research reproducibility and data reuse, large-scale, open access information repositories have become key resources for training and testing of advanced machine learning applications in biomedical and clinical research. To be of value, such repositories must provide large, high-quality data sets, where quality is defined as minimising variance due to data collection protocols and data misrepresentations. Curation is the key to quality. We have constructed a large public access image repository, The Cancer Imaging Archive, dedicated to the promotion of open science to advance the global effort to diagnose and treat cancer. Drawing on this experience and our experience in applying machine learning techniques to the analysis of radiology and pathology image data, we will review the requirements placed on such information repositories by state-of-the-art machine learning applications and how these requirements can be met. [ABSTRACT FROM AUTHOR]

This study seeks to establish whether medico-legal practitioners differ in their autopsy conclusions within and across medico-legal institutions. Data include 459 violent deaths (homicides, suicides, and accidents) autopsy reports written by more than 20 death certifiers from four medico-legal institutions in two countries (France and the United States). Multinomial models show that compared with accidental deaths, weapon use and decedents' characteristics both influence a homicide verdict, but not a suicide one. In addition, French practitioners are more likely than Americans to reach a conclusion of homicide or suicide compared with accident, and homicides are more likely to be certified by male practitioners. [ABSTRACT FROM AUTHOR]

• Sudden cardiac death in the young is often due to a genetically transmitted disease process. • No consistent forensic pathology guidelines for cardiac examination in these cases. • Collaboration of SCVP members and CV-trained, practicing forensic pathologists. • These guidelines may result in life-saving medical intervention for family members. Sudden cardiac death is, by definition, an unexpected, untimely death caused by a cardiac condition in a person with known or unknown heart disease. This major international public health problem accounts for approximately 15-20% of all deaths. Typically more common in older adults with acquired heart disease, SCD also can occur in the young where the cause is more likely to be a genetically transmitted process. As these inherited disease processes can affect multiple family members, it is critical that these deaths are appropriately and thoroughly investigated. Across the United States, SCD cases in those less than 40 years of age will often fall under medical examiner/coroner jurisdiction resulting in scene investigation, review of available medical records and a complete autopsy including toxicological and histological studies. To date, there have not been consistent or uniform guidelines for cardiac examination in these cases. In addition, many medical examiner/coroner offices are understaffed and/or underfunded, both of which may hamper specialized examinations or studies (e.g., molecular testing). Use of such guidelines by pathologists in cases of SCD in decedents aged 1-39 years of age could result in life-saving medical intervention for other family members. These recommendations also may provide support for underfunded offices to argue for the significance of this specialized testing. As cardiac examinations in the setting of SCD in the young fall under ME/C jurisdiction, this consensus paper has been developed with members of the Society of Cardiovascular Pathology working with cardiovascular pathology-trained, practicing forensic pathologists. [ABSTRACT FROM AUTHOR]

The article presents a forensic analysis on strangulation injuries of homicide victims in the U.S. It sites several clinical features of potentially lethal strangulation including the presence of facial petechiae, loss of consciousness, and fecal or urinary incontinence. Moreover, it indicates that the outcome from strangulation is worse if the patient has cerebral edema on computed tomography scan or is comatose on emergency department arrival.

This paper provides a critical assessment of the National Research Council's (NRC) 2009 report in light of comparative experience in Australia, Canada, and the United Kingdom. It suggests that the NRC's proposals for federal regulation of the forensic sciences are more appropriate for a unitary state than a federal system. The NRC report could have been strengthened by examining the British experience with a forensic regulator and a 2008 report on forensic pathology in the Canadian province of Ontario. The Ontario pathology report has already produced tangible reforms to the practice of forensic pathology within coroners' systems while the NRC unrealistically calls for the abolition of all coroner systems. The dangers of superficial reforms are examined, including a Canadian example of published research being misapplied in a manner that contributed to a wrongful conviction. Finally, the NRC's pessimistic conclusions about judicial exclusion of unreliable forensic science are contrasted with recent and more optimistic reform proposals in Canada and the United Kingdom. [ABSTRACT FROM AUTHOR]

The determination of the cause of death from exposure to extreme temperatures is a diagnosis of exclusion. Because both clinical and autopsy findings are nonspecific, a thorough investigation of the background and scene, evaluation of temporally relevant environmental conditions, and assessment of the victim's underlying state of health with appropriate laboratory studies, which frequently include autopsy, are essential to establish the cause of injury and/or death with reasonable medical probability. Individuals may encounter environmental extremes in many settings during any season. Both constitutional and external factors exacerbate the stress brought about by extreme temperature. Objective.—This article reviews guidelines for forensic investigation into environmental temperature extremes that contribute to an important seasonal grouping of morbidity and mortality in the United States. Data Sources.—Articles on clinical and pathologic aspects of hyperthermia and hypothermia were collected and reviewed. Conclusions.—Recognition of multiple risk factors predisposing humans to both cold-related and heat-related morbidity and mortality enhances prevention. Awareness of the susceptibility of these exposed at-risk individuals is crucial to investigations by both clinicians and medicolegal death investigators. [ABSTRACT FROM AUTHOR]

Context.—Traditionally, the emphasis of work done by medical examiners, coroners, and the death investigation community has been viewed as serving the criminal justice system. During the last several decades, however, an important role for these 3 groups has emerged within public health. Objective.—To provide important background information on death investigation systems, the evolution and framework of public health entities that rely on information gathered by medical examiners and coroners, and the role of medical examiners and coroners in epidemiologic research, surveillance, and existing public health programs and activities. Data Sources.—Previous articles on epidemiologic aspects of forensic pathology and the role of medical examiners and coroners in epidemiologic research and surveillance; a review of the Web sites of public health and safety agencies, organizations, and programs that rely on medical examiner and coroner data collected during medicolegal investigations; and a review of recent public health reports and other publications of relevance to medical examiner and coroner activities. Conclusions.—The role of medical examiners and coroners has evolved from a criminal justice service focus to a broader involvement that now significantly benefits the public safety, medical, and public health communities. It is foreseeable that the public health role of medical examiners and coroners may continue to grow and that, perhaps in the not-too-distant future, public health impact will surpass criminal justice as the major focus of medicolegal death investigation in the United States. [ABSTRACT FROM AUTHOR]

Presents the studies on the circumstances of adolescent death in the U.S. Evaluation on all forensic cases referred to the Medical University of South Carolina Forensic Pathology section; Presentation of the most common manner of death for all adolescents; Significance of the 15-year retrospective study on prediction and prevention of future cases of adolescent death.

Focuses on the reliability of forensic psychological examinations in personal injury cases in the U.S. Claim for compensation from the perpetrators of harm; Severity of distress; Cause of impairments in the plaintiff's psychological functioning.

Suicide by burning is an extreme act that is uncommon in the United States and throughout the Western world. The characteristics of people who complete such acts are not well understood. To address this issue, we examined the death records of the King County Medical Examiner's Office in Washington State over the 13 years from 1996 to 2009. Twenty-five cases of suicide by burning were identified and used to characterize decedent demographics, circumstances of death, and motivating factors. Compared to other methods of suicide, burning demonstrated a significant overrepresentation of decedents who were women, 40-59 years of age, and Asian/Pacific Islander. They also tended to have previous psychiatric illness and/or substance abuse issues. Self-burning predominantly occurred at the decedent's residence with the intent of suicide given. There was no unifying theme in motivating factors. Together, these data represent the characteristics of people whose death is because of suicide by burning in King County, Washington. [ABSTRACT FROM AUTHOR]

Focuses on the review of intentional ingestions of cyanide in suicides which occurred in New York City over a ten-year interval. Evaluation of the toxicologic and postmortem findings; Predominance of occupations and nationalities of the decedents; Use of a color test for screening for cyanide.

Whole slide imaging (WSI) scanners and automatic image analysis algorithms, in order to be used for clinical applications, including primary diagnosis in pathology, are subject to specific regulatory frameworks in each country. Until May 25, 2018, in the European Union (EU), in vitro diagnostic (IVD) medical devices were regulated by directive 98/79/EC (in vitro diagnostic medical device directive [IVDD]). Main scanner vendors have obtained a Conformité Européenne mark of their products that in Europe were classified as General Class IVDD, so that conformity is only based on a self-declaration of the manufacturer. This contrasts with the initial classification of the US Food and Drug Administration (FDA) of WSI system as Class III medical devices, although the first digital pathology WSI system to be cleared by FDA was classified as Class II, with special controls. Other digital pathology solutions (automated cervical cytology slide reader) are considered of higher risk by US and European regulations. There is also some disparity in the classification of image analysis solutions between Europe and the United States. All IVD-MDs must be approved under the new European regulation (in vitro diagnostic medical device regulation) 2017/746 after May 26, 2024. This means the need of a performance evaluation, including a scientific validity report, an analytical performance report, and a clinical performance report. According to its clinical use (e.g., screening, diagnosis, or staging of cancer), a WSI slide scanner can be now classified as Class C device. A special regulation is applied to companion diagnostics. The new EU regulation 2017/746 contemplates the use of standard unique identifiers for medical devices and the creation of a European database on medical devices (Eudamed). Existing validation studies and clinical guidelines already available in the literature are a sound basis to avoid that this new regulation becomes a barrier for digital pathology development in Europe. [ABSTRACT FROM AUTHOR]

Discusses the portrayal of forensic pathology in U.S. crime television programs. Examples of several crime shows, which feature crime scene investigation and forensic pathology, and generally replace the detective's use of live witnesses with investigation of dead bodies; Identification of the underlying attitudes of the programs, such as the assumption that forensic scientists and evidence are always correct; Impact of such shows on public perception of police evidence and the status of forensic pathologists.

Discusses the evolution of modern day medical examiners in the United States. Origin of the official office of the coroner; Judicial and administrative functions of coroners; Background on Philadelphia physician William Scott Wadsworth, one of the pioneers in the area of forensic pathology.

Presents a paper that appeared in the "Journal of the American Medical Association" on April 23, 1904. Report that the Elsberg bill abolishing the office of coroner in Greater New York has been passed; Power of investigation that remains to the coroners still in office; Assertion that miscarriages of justice have occurred due to the inadequacy of coroners; Way that deaths will be assessed by medical examiners.

In recent years, behavioural analysis in unsolved homicide cases is playing a more and more important role in the field of police work in Germany. The method of behavioural analysis was developed in the USA and first carried out in Germany at the end of the 80s by the Federal Criminal Police Office (BKA). Since 1998 each Federal State has set up behavioural analysis units. In Germany, behavioural analysis is defined as complex information processing system for the purpose of enabling an overall view of a case and of supporting the case work in ongoing investigations. The procedure of behavioural analysis is based on empirically and scientifically proven knowledge, on case information (e.g. crime scene characteristics, medico-legal findings) and on methods of combining the existing knowledge on statements relevant to the case. To assess the role of legal medicine in the process of behavioural analysis, a retrospective examination of more than 40 case analyses in unsolved homicide cases was performed. It turned out that medico-legal findings played a major role in the process of case analysis because the results were of central importance for the case reconstruction and further deductions (e.g. offender aims, organized/disorganized components, escalation). In a vast majority of cases though, the autopsy reports did not provide sufficiently detailed information, explanations and/or interpretations of injuries, wound patterns and sequence of events. Various examples are presented to elucidate the significance of medico-legal findings for the process of behavioural analysis. As a basic principle, the role of the forensic scientist as independent, unbiased, unprejudiced expert for the court should not be influenced by speculative interpretations within the process of behavioural analysis. This can be established by a very precise and comprehensive autopsy protocol on the one hand and – separately – an interpretation by another experienced specialist who works for the behavioural analysis unit but not for the court. [Copyright &y& Elsevier]

Presents updates on medicine in the U.S. as of October 1991. Background on occupational medicine; Features of forensic pathology; Activities included in training on radiation oncology.