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Adolescence, between the ages of 10 and 19 years, is a unique period both physically and emotionally. During this time of life, individuals are known to experiment and engage in risky behavior, sometimes with unforeseen morbidity and mortality. We also see suicide emerge as a manner of death in this age group. The most common method is gunshot wound and sometimes in the form of Russian roulette. Few studies have looked at deaths by Russian roulette, the victims, and scenarios. In particular, no study examines the adolescent victim of Russian roulette. To better understand and classify this entity, adolescent Russian roulette autopsy cases over a 20-year period were examined looking at the victims, scenarios, autopsy findings, cause and manner of death, and the weapons. All victims were males, ages 13 to 19 years, with a Black-to-White ratio of 1:1. No victim had a previous psychiatric history. Toxicology was positive for alcohol and/or marijuana in 50% of the victims. Friends were present when the victim shot himself which occurred in the home the majority of the time. In all but 1 case, premeditation of the game was involved as the victim provided the weapon for the roulette. The cause of death was gunshot wound to the head (6 to the right side, 1 to the mouth, 1 to the forehead), and the manner of death was suicide in 6 cases and accident in 2 cases. A review of the literature discusses the adolescent victim, suicide, and Russian roulette.

The pediatric population has received considerable attention in the forensic community; the youth assailant of homicide, however, is understudied. The authors retrospectively reviewed all cases referred to the Forensic Pathology Section of the Medical University of South Carolina between January 1991 and May 2006. Cases included in the study were homicides in which 1 or more assailants were 19 years of age or younger. The cases were examined as to the cause and manner of death, victim age, gender, race, incident location, weapon used, assailant-victim relationship, assailant age, gender, race, motive, and postmortem toxicology results. Assailant information was obtained from forensic records at Medical University of South Carolina, police department records, and online search engines of South Carolina State newspaper archives confirmed by law enforcement reports. The youth assailants were predominantly black men, 15 to 19 years of age (range, 4-19 years). Most victims were black male acquaintances, and the motive was most often an argument. The most common cause of death was cerebral laceration because of a gunshot wound. The incident occurred in the home in 41% of cases, followed by the street in 31%. Victim toxicology was frequently positive for cocaine, marijuana, and alcohol.

Elder neglect, one of the 6 forms of elder maltreatment, is difficult to diagnose and is underreported both in the scientific literature and to law enforcement. Recognizing fatal neglect is even more challenging especially with concurrent organic disease. Many entities can mimic elder neglect, and many age-related changes can result in pathology that may be confused with maltreatment. We retrospectively reviewed all forensic cases of individuals age sixty-five years and older which were referred for autopsy. Cases of fatal neglect were analyzed as to age, sex, race, cause of death, location of incident, perpetrator, victim-to-perpetrator relationship, and autopsy and ancillary findings. The cases studies totaled 8. The age range was 74 to 94 years. Two were white, 6 black, one male, and 7 female. The causes of death were sepsis due to severe decubitus ulcers and severe dehydration. Five cases occurred in the victim's home, and 3 occurred in an institution (nursing home/care facility). In 5 cases, the perpetrators were family members. The pathophysiology of aging with respect to elder maltreatment is reviewed.

Although unexpected natural deaths comprise a large proportion of the cases seen in the forensic setting, the investigation of these cases remains a unique challenge. Some cases are straightforward; however, others require special examination and dissections, as well as the use of special dissections and ancillary studies. For the forensic investigator to accurately assign a cause and manner of death, one must be aware of the differential diagnoses, common scenarios, and typical victim. The authors reviewed all forensic cases referred to the Forensic Section of the Medical University of South Carolina over a 15-year period from January 1989-December 2003. The number of natural deaths occurring in adults (age 18 years and older) was 6932, compared with the overall number of 13,227 cases. The natural deaths were then analyzed as to autopsy findings, cause of death, cardiac versus noncardiac, age, race, and gender. Current techniques, special dissections, and ancillary studies that can assist in the classification of these deaths in the forensic setting are reviewed.

A subcategory of elder maltreatment is the fatal outcome, or elder homicide. Some cases of elder homicide result from chronic abuse and/or neglect, while others appear to be sudden, with no pertinent history. The research and literature of elder homicide are lacking, making the investigation of each case difficult; the typical victim, perpetrator, scenario, and cause of death are not known. Components of homicide such as sexual assault and toxicology also lack study. We analyzed all elder deaths over a 20-year period. Cases included those with victims greater than or equal to 65 years of age. These deaths totaled 2137: natural = 1506, accident = 344, suicide = 139, homicide = 127, and undetermined = 21. Focusing on homicides, variables analyzed were age, race, gender, cause of death, location of death, time of year, motive, perpetrator, toxicology, and sexual assault component. By identifying the typical victim, perpetrator, scenario, and autopsy findings, these cases can be more completely investigated and possibly prevented.

Pregnancy-related death is defined by the International Classification of Diseases, Tenth Revision (ICD-10) as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. In the year 2000, a collaborative effort involving World Health Organization (WHO), UNICEF, and UNFPA estimated 660 maternal deaths in the United States. This averages 11 maternal deaths per 100,000 live births reported. Many pregnancy-associated deaths are not easily identified as such since the presence of a recent or current pregnancy may not be listed on the death certificate. Thus, the WHO estimates that in the United States, the maternal mortality is approximately 17/100,000 pregnancies. This is significantly higher than the goal set by the US Department of Health and Human Services in Healthy People 2010, which sets the target for maternal mortality at less than 3.3/100,000 live births. The most common causes of maternal death vary somewhat from region to region in the United States. They include pulmonary thromboembolism, amniotic fluid embolism, primary postpartum uterine hemorrhage, infection, and complications of hypertension including preeclampsia and eclampsia. Pulmonary disease, complications of anesthesia, and cardiomyopathy also are significant contributors to maternal mortality in some populations. The death of a pregnant or recently pregnant individual poses a wide scope of challenges to the forensic pathologist and investigator. The pathologist must have a broad knowledge of the physiologic and biochemical changes that occur during pregnancy, as well as the clinical and pathological manifestation of these changes. Conditions that may be "benign" in the nonpregnant individual may be lethal in the puerperal period. In addition, it should be kept in mind that deaths during pregnancy may be due to unnatural causes. Accident, homicide, and suicide must be ruled out in each case. The authors reviewed all forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina from January 1989 through December 2003. All decedents listed as pregnant or postpartum were analyzed as to maternal age, race, past medical history, previous pregnancies and outcome, prenatal care, gestational age, fetal or neonatal outcome, location of delivery, placental findings, maternal autopsy findings, toxicology, cause of death, manner of death, and fetal or neonatal autopsy findings. The authors present this retrospective study to better determine the factors leading to maternal demise and discuss the autopsy/ancillary techniques useful in determining the cause of death in this challenging area.

Many burn injuries are mistakenly referred to as "accidents" because they occur suddenly and seem unpredictable and uncontrollable; however, injuries often occur in predictable patterns. We reviewed all pediatric forensic cases referred to the Medical University of South Carolina Forensic Pathology Section over a 28-year period from January 1975 to December 2002. There were 124 cases with 121 fire-related fatalities and three scald fatalities. Ninety of the burn victims were in the 0-5-year age group. The manner of deaths showed 108 accidents and 12 homicides (four undetermined). Eleven of 12 burn-related homicides occurred at the home with all of the victims in the 1-8-year age group. The perpetrator of the home fire homicides was the mother in five cases and the sister in one case (two undetermined). Homicide involved a vehicle fire in one case in which the father caused an explosion with an accelerant. The three scald death perpetrators were the father, mother's boyfriend, and an aunt.This retrospective study and review of the literature may reveal patterns useful for evaluation of manner of death. By recognizing scene characteristics, potential perpetrators, and children at risk, we can better classify pediatric burn-related fatalities.

Adolescents comprise an eclectic mix of people vitally important to society yet long-term comprehensive studies on the circumstances of their deaths are lacking in the pediatric forensic literature. The authors reviewed all forensic cases referred to the Medical University of South Carolina Forensic Pathology section over the fifteen years between January 1989 and December 2003. In accordance with the World Health Organization (WHO) definition of adolescents, only decedents 10-19 years of age were included. The authors examined the cause and manner of death, age, gender, and race of the victims in all cases. The toxicology results, perpetrator, death scenario and location, and victim traits were analyzed when available. For all adolescents, the most common manner of death was accident followed by homicide, suicide, natural, and undetermined. Within the adolescent population two distinct groups, 10-14 years old and 15-19 years old, were identified. Though both groups were similar in that they experienced a high number of accidental deaths, decedents of older age group suffered a higher percentage of violent deaths while decedents of the younger group were more likely to die of natural causes. Many of the accidental deaths in this review were preventable, including deaths due to motor vehicle collisions and drowning. In deaths due to homicide, the perpetrator was often known to the victim, whether as an acquaintance or family member. Toxicology testing was often positive in decedents of the older age group, while only rarely positive in decedents of the younger age group. With a solid understanding of the circumstances, it may be possible to predict, and hopefully prevent, future cases of adolescent death. The authors present their findings in this 15-year retrospective study to better aid forensic pathologists, death investigators, law enforcement, and epidemiologists.

Neglect, defined as the failure of a caregiver to adequately provide safety, food, clothing, shelter, education, protection, medical/dental care, and supervision for a child in his/her care, is a relatively uncommon but important cause of child mortality. A retrospective review of pediatric deaths (age 18 years or less) referred to the Medical University of South Carolina Forensic Pathology Office for autopsy over the past 25 years revealed 16 deaths due to some type of pediatric neglect. Cases were analyzed as to age, sex, race, cause and manner of death, autopsy findings, ancillary studies, past medical history, social/family history, and caregiver. Six cases of malnutrition/starvation and/or dehydration were identified, composing the most common cause of death in the neglect cases identified and the majority of the homicides due to neglect. Other deaths in which neglect contributed significantly included toxic ingestions (2 cases), hyper-/hypothermia (2 cases), unusual drowning/aspiration (4 cases), electrocution (1 case), and delayed/absent medical therapy (2 cases, including one of the previously mentioned ingestions). Of these additional cases, 7 were certified as accidental manner, 2 as natural, and 1 as a homicide. Cases which fell into a "gray zone" in which the appropriateness of invoking neglect was a matter of opinion or societal convention were excluded from the review; examples included conventional accidental drowning, choking on food or aspiration of foreign body, overlying/wedging during sleep, accidental hanging, and motor-vehicle traffic accidents (pedestrians, unrestrained passengers). The findings of this review reinforce the fact that malnutrition/starvation and dehydration compose the most common form of lethal pediatric neglect while highlighting less common forms of neglect and the difficulty of determining manner of death in cases in which neglect plays a more questionable role than in seemingly clear-cut malnutrition/starvation and dehydration cases. We demonstrate the typical victim and scenario that investigators will encounter in cases of fatal pediatric neglect, often a child under the age of 1 year who has been deprived of food and/or drink for some time, or an older, more independently mobile child who has not been adequately supervised. These children may or may not have a demonstrable prior history of maltreatment or (nonfatal) neglect, and review of medical records is an important part of the investigation. We additionally discuss key gross autopsy findings, appropriate specimen collection, helpful ancillary studies, microscopic findings of significance, potential mimickers of neglect, and other special considerations in cases of pediatric neglect.

Fetal death has been defined by the World Health Organization as death before complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy. Certain causes of fetal death, including syphilis, Rh isoimmunization, toxemia, and diabetes, have shown significant declines over the past several decades. However, many fetal losses continue to occur from intrauterine infections, lethal malformations, fetal growth retardation, and abruptio placentae. Fetal death with no identifiable specific cause is another consideration when dealing with these cases. Other risk factors can include maternal, sociodemographic, and medical care factors. The authors reviewed all forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina, Medical Examiners' Office over the 10-year period 1990-1999. All cases listed as fetal death or stillbirth were included. The 42 cases were analyzed as to fetus' gestational age, sex, race, weight, location of delivery, history of prenatal care, maternal drug use, chromosomal abnormalities, cause and manner of death, and autopsy findings. The black:white ratio was approximately 2:1, and the male:female ratio was virtually 1:1. Most fetuses were older than 20 weeks' gestational age, with one third between 20 and 29 weeks. The majority were externally normal aside from maceration. Only 7.5% had congenital anomalies. Twenty-one of 38 placentas were grossly and microscopically normal. Of cases with toxicologic analysis, 21% were positive for drugs, and 17% were positive for cocaine/benzoylecgonine. The manner of death was classified as natural (28), accident (2), and undetermined (12). Few studies have reported the specific causes of fetal death, and the lack of uniformity in data collection and classification of causes of fetal death has made comparisons difficult. The authors present this retrospective study to better determine the factors leading to fetal demise in the hope of assisting death investigators in this challenging arena.

A 10-year retrospective study of pediatric toxicologic deaths was performed at the Medical University of South Carolina (Charleston, SC) from January 1989 to December 1998. During this time, 709 pediatric forensic autopsies were performed on children younger than 18 years of age. Eleven deaths were determined to be secondary to toxic exposures (excluding carbon monoxide poisonings secondary to fires). The remaining deaths were reviewed for the presence of alcohol or illicit drugs. The 11 toxicologic deaths were analyzed for age, sex, race, type of toxic exposure, cause and manner of death, location of incident, witness, and, in the younger age group, the primary caregiver at the time of exposure. The deaths had a bimodal age distribution (6 deaths in victims ages 15 to 17 and 5 deaths in victims ages 4 or younger), involving a wide range of toxins. The teenage group was composed of five males and one female, all white. The preschool group had three females and three males, all black. The manner of death ranged from accidental to suicidal to homicidal. In addition, in eight neonatal and fetal deaths, the victims tested positive for maternal cocaine use, and five of these victims tested positive for cocaine or benzoylecgonine. However, the cause of death was not stated to be cocaine in any of these neonatal and fetal cases.

The suicide rate in the 65-year and older age group has been increasing since 1980. The elderly attempt suicide less often than younger people but are successful more often. The authors retrospectively reviewed all cases referred to the Forensic Pathology Section of the Medical Examiners' Office at the Medical University of South Carolina (Charleston, SC) from January 1988 through December 1997. The cases of suicide in victims 65 years and older totaled 78, accounting for 11.5% of all suicides reviewed. Of these 78 cases, 41% were autopsied and 59% were externally examined. All of the cases were initially analyzed as to age, race, sex, and method of suicide. Files also were reviewed to determine time of year of the suicide, toxicology results, psychiatric history, social history, medical history, and whether a suicide note was left. The ages of these suicide victims ranged from 65 to 94 years; men comprised 85% of the victims, and whites, 94%. The male-to-female and white-to-black ratios were 6:1 and 15: 1, respectively. The average age of the victim was 73 years. Gunshot wound was the most common method of suicide, accounting for 80.7% of the cases. Other methods included overdose (6.4%), hanging (3.8%), fall from height (2.6%), incised wounds (2.6%), drowning (2.6%), and carbon monoxide poisoning (1.3%).

The number of suicides in the pediatric age group is rising, and death investigators need to be aware of the common scenarios, risk factors, and victims as they investigate such cases to properly assign the cause and manner of death. We reviewed all pediatric cases referred to the Medical University of South Carolina, Forensic Section, from January 1988 through January 1998. Thirty-one cases of pediatric suicide were analyzed with regards to age, gender, race, cause of death, surrounding circumstances, and past history. Sixty-eight percent of victims were aged 16 or 17 years, 84% were male, 68% were white, 78% used firearms to commit suicide, 81% were found within close vicinity of their home, and 26% had a documented history of mental illness. Suicide is a manner of death that is often difficult for the public to accept, especially in pediatric cases. We report our findings in this 10-year retrospective study to better understand this entity and work toward the prevention of future cases.