Evaluation of Concordance Between Original Death Certifications and an Expert Panel Process in the Determination of Sudden Unexplained Death in Childhood.

Importance: The true incidence of sudden unexplained death in childhood (SUDC), already the fifth leading category of death among toddlers by current US Centers for Disease Control and Prevention estimates, is potentially veiled by the varied certification processes by medicolegal investigative offices across the United States. Objective: To evaluate the frequency of SUDC incidence, understand its epidemiology, and assess the consistency of death certification among medical examiner and coroner offices in the US death investigation system. Design, Setting, and Participants: In this case series, 2 of 13 forensic pathologists (FPs) conducted masked reviews of 100 cases enrolled in the SUDC Registry and Research Collaborative (SUDCRRC). Children who died aged 11 months to 18 years from 36 US states, Canada, and the United Kingdom had been posthumously enrolled in the SUDCRRC by family members from 2014 to 2017. Comprehensive data from medicolegal investigative offices, clinical offices, and family members were reviewed. Data analysis was conducted from December 2014 to June 2020. Main Outcomes and Measures: Certified cause of death (COD) characterized as explained (accidental or natural) or unexplained, as determined by SUDCRRC masked review process. Results: In this study of 100 cases of SUDC (mean [SD] age, 32.1 [31.8] months; 58 [58.0%] boys; 82 [82.0%] White children; 92 [92.0%] from the United States), the original pathologist certified 43 cases (43.0%) as explained COD and 57 (57.0%) as unexplained COD. The SUDCRRC review process led to the following certifications: 16 (16.0%) were explained, 7 (7.0%) were undetermined because of insufficient data, and 77 (77.0%) were unexplained. Experts disagreed with the original COD in 40 cases (40.0%). These data suggest that SUDC incidence is higher than the current Centers for Disease Control and Prevention estimate (ie, 392 deaths in 2018). Conclusions and Relevance: To our knowledge, this is the first comprehensive masked forensic pathology review process of sudden unexpected pediatric deaths, and it suggests that SUDC may often go unrecognized in US death investigations. Some unexpected pediatric deaths may be erroneously attributed to a natural or accidental COD, negatively affecting surveillance, research, public health funding, and medical care of surviving family members. To further address the challenges of accurate and consistent death certification in SUDC, future studies are warranted.

A Case of Granulomatosis with Polyangiitis Diagnosed at Autopsy.

Herein is reported a case of granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, diagnosed at forensic autopsy in an 83-year-old woman with a history of Alzheimer disease. Significant findings at autopsy were cardiac hypertrophy, nephroarteriolosclerosis, hemorrhagic lungs, and necrotizing granulomatous inflammation with vasculitis involving the lungs and kidneys. Semiquantitative immunofluorescence testing was positive for cytoplasmic antineutrophil cytoplasm antibodies at a titer of 1:40. An enzyme-linked immunosorbent assay for proteinase 3 was strongly positive at 134 units (reference range: positive greater than 30 units). The cause of death was therefore determined to be granulomatosis with polyangiitis. Presentation of GPA at such an advanced age is rare, especially with the presentation at death.

A rare case of thyrotoxic periodic paralysis presenting to the medical examiner.

Thyrotoxic periodic paralysis is a rare and dramatic complication of hyperthyroidism. Thyrotoxic periodic paralysis classically presents with proximal lower limb weakness in the setting of hypokalemia and thyrotoxicosis. Thyrotoxic periodic paralysis represents an endocrine emergency with a rapidly ascending paralysis that can result in respiratory insufficiency, cardiac arrhythmias, and death if not accurately and rapidly diagnosed. We report a case of undiagnosed fatal thyrotoxic periodic paralysis presenting to the medical examiner. The diagnosis was made primarily by review of the clinical history.

Memorial Eckert paper for 2007 forensic DNA analysis for the medical examiner.

The objective of this manuscript is to provide an overview of the application of forensic DNA analysis as it pertains directly to the medical examiner, namely, in the identification of human remains. For samples yielding a sufficient amount of nondegraded DNA, the analysis of a standardized set of 13 short tandem repeats can provide enough statistical power not only to exclude a potential source but also to essentially attribute or match a source of DNA. Short tandem repeats from the Y chromosome may be analyzed in paternal lineage analysis and to isolate male DNA from a male-female mixture. For samples that are degraded, decomposed, or contain insufficient amounts of nuclear DNA, mitochondrial DNA may provide sufficient exclusionary potential and may also be used in lineage analysis. The Federal Bureau of Investigation maintains databases of both nuclear and mitochondrial DNA profiles against which profiles generated from postmortem examinations may be compared to identify human remains. Medical examiners must have sufficient familiarity with forensic DNA testing to obtain the most appropriate test samples during the postmortem examination and to obtain the most appropriate comparison samples from family members, when available, to maximize the statistical power of DNA analysis for the identification of human remains.

National Association of Medical Examiners position paper on the medical examiner release of organs and tissues for transplantation.

The medical examiner community plays a key role in the organ and tissue procurement process for transplantation. Since many, if not most, potential organ or tissue donors fall under medicolegal jurisdiction, the medical examiner bears responsibility to authorize or deny the procurement of organs or tissues on a case-by-case basis. This responsibility engenders a basic dichotomy for the medical examiner's decision-making process. In cases falling under his/her jurisdiction, the medical examiner must balance the medicolegal responsibility centered on the decedent with the societal responsibility to respect the wishes of the decedent and/or next of kin to help living patients. Much has been written on this complex issue in both the forensic pathology and the transplantation literature. Several studies and surveys of medical examiner practices, as well as suggested protocols for handling certain types of cases, are available for reference when concerns arise that procurement may potentially hinder medicolegal death investigation. It is the position of the National Association of Medical Examiners (NAME) that the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases, without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings. The purpose of this position paper is to review the available data, the arguments for and against medical examiner release, and to encourage the release of organs and tissues in all but the rarest of circumstances.

Heart valve tissue donation does not preclude the diagnosis of clinically significant pediatric cardiac abnormalities.

Medical examiners/coroners often have the responsibility of deciding whether to allow organ and tissue donation to proceed in cases under their jurisdiction. A 10-year retrospective study was conducted of autopsy cases in children younger than 6 years to determine whether the donation of cardiac valve tissue would preclude the diagnosis of clinically significant pediatric cardiac abnormalities. Only 1 case (0.1%) was found in the entire 10-year period in which valve tissue donation might have prevented the correct diagnosis. According to the results of the study, (1) most cardiac findings in forensic pediatric autopsies are not clinically significant; (2) clinically significant findings will be diagnosed in properly examined hearts, even those processed for valve tissue donation, and special studies will remain possible in nearly all hearts except those with suspicion of conduction defects; and (3) as long as there is good communication between forensic pathologists and organ and tissue procurement organizations, the concern of failing to diagnose significant cardiac findings should not inhibit medical examiners/coroners from allowing the donation of pediatric cardiac valve tissue.

A comprehensive analysis of forensic science training in forensic pathology fellowship programs.

The purpose of this study is to assess the current nature and extent of forensic science training in the nation's 43 Accreditation Council for Graduate Medical Education (ACGME)-accredited forensic pathology fellowship programs. This manuscript describes the results of a survey of training program directors performed as a project for the College of American Pathologists (CAP) Forensic Identity Committee. The results show a considerable diversity in the forensic sciences training in forensic pathology programs, ranging from one to ten weeks, with an average of 4.1 weeks. However, almost one half of programs provide no training in at least one of the surveyed disciplines. Only 58.1% of responding programs meet the ACGME requirements for forensic science training, and a similar percentage (56.0%) currently provides the duration of forensic science training recommended by the National Association of Medical Examiners (NAME). The deficit in the NAME training recommendations, surprisingly, was strictly in the field of toxicology.

Pulmonary hyalinizing granuloma associated with Aspergillus infection.

A 38-year-old immunocompetent man with occupational exposure to Aspergillus presented with dyspnea, pleuritic chest pain, and hemoptysis. Chest roentgenograms and computed tomography scans demonstrated multiple pulmonary nodules bilaterally. An initial set of bronchial washing cultures grew Aspergillus fumigatus, serologic testing showed an elevated anti-Aspergillus titer, and immunodiffusion testing was positive for antibody against A. fumigatus and A. niger. There was no microbiologic or serologic evidence of infection by other pathogens, and no clinical or laboratory evidence of autoimmune disease. An open lung biopsy was diagnostic of pulmonary hyalinizing granuloma. This novel association with Aspergillus infection not only expands the spectrum of pathogens linked to pulmonary hyalinizing granuloma but also documents a new pattern of lung disease that can be caused by Aspergillus.

Culturing bronchial washings obtained during bronchoscopy fails to add diagnostic utility to culturing the bronchoalveolar lavage fluid alone.

A retrospective analysis was performed to determine whether cultures of bronchial washings (BW) obtained during bronchoscopy added to the diagnostic efficiency of cultures of bronchoalveolar lavage fluid (BAL) alone. Results of BW and BAL cultures submitted from 268 patients over a 7-month period were compared. The isolation of an organism from the BW but not from the BAL occurred in only 17.4% of cases. Moreover, the vast majority of those organisms consisted of yeasts or molds of questionable clinical significance that did not prompt a change in antimicrobial therapy. Culturing the BAL specimen alone would have resulted in an efficiency of 97.0% (95% confidence interval 94.2-98.7%) for the isolation of clinically relevant pathogens identified from bronchoscopic specimens. These results suggest that the submission of BW obtained during the BAL procedure for culture evaluation not only fails to add diagnostic value, but may also result in unnecessary laboratory evaluations and provide misleading information to clinicians.