Protocol for writing cause-of-death statements for deaths due to natural causes.

The purpose of this article is to describe a protocol that provides suggestions and guides the clinical practice of writing cause-of-death statements for death certificates, autopsy reports, and other medical documents. The 16 members of the Autopsy Committee of the College of American Pathologists (CAP), Northfield, Ill, were appointed by the CAP officers based on demonstrated interest and expertise in autopsy performance and reporting. The committee perceived a need for specific instructions aimed at promoting consistency, accuracy, and completeness when writing cause-of-death statements. Development of a protocol was supported by CAP after approval by the CAP board of governors. The framework for the protocol was based on recommendations of the National Center for Health Statistics, Hyattsville, Md, with additional concepts added by the autopsy committee. The protocol for writing cause-of-death statements for natural causes is expected to foster consistency, accuracy, and completeness in the writing of cause-of-death statements. The quality of individual death certificates, autopsy reports, and national mortality data may improve through protocol usage. Application of the protocol principles should impose no ongoing costs at any user level because no new products or personnel are required for its application.

The abdominal diameter index and sudden coronary death in men.

Alternative anthropometric indexes were compared for their ability to discriminate between 35 Atlanta men with sudden coronary death and 81 male controls. With or without adjustments for age, race, and body mass index, the abdominal diameter index (supine sagittal abdominal diameter divided by midthigh circumference) was associated with sudden coronary death more strongly than the waist/hip ratio or waist/thigh ratio of circumferences.

Subclinical hemolytic disease of the newborn due to anti-e.

A case of subclinical hemolytic disease of the newborn resulting in reticulocytosis and positive direct and indirect antiglobulin tests in an infant both ABO- and Rh(D)-compatible with its mother is reported. The antibody was an IgG, non-complement-binding molecule present in low titer with a low avidity for the antigen, acted optimally in enzyme systems, did not manifest dosage effect, and caused slight extravascular destruction of fetal erythrocytes. Routine antibody screening of all pregnant women should be performed and neonatal cord blood specimens analyzed to avoid unexpected infant morbidity and mortality, and to characterize hemolytic disease of the newborn due to rare atypical antibodies more fully.

National Association of Medical Examiner's Pediatric Toxicology (PedTox) Registry.

In 1985, the National Association of Medical Examiners (St. Louis, MO) established a Pediatric Toxicology (PedTox) Registry to collect case reports of drugs and substances detected in children. For many drugs and substances detected in children, to date, the medical and toxicology literature contain little useful information regarding toxic and lethal concentrations, and the PedTox Registry was established to provide additional information to those who must interpret observed concentrations of drugs and substances in children. This article includes a description of the development of the PedTox Registry, its management, and a brief summary of data that have been published, including information for acetaminophen, benzene, carboxyhemoglobin, codeine, desipramine, dextromethorphan, ethanol, phenobarbital, phenylpropanolamine, and pseudoephedrine.

Epidemiologic aspects of forensic pathology.

Forensic pathologists have made great contributions to epidemiologic research and will undoubtedly continue to do so by providing information that can help to describe, explain, predict, and control the occurrence of specific disorders. Greater funding is needed, however, to realize the potential applications of forensic pathology to epidemiologic research. Public health officials have only recently recognized what forensic pathologists have known for a long time and what Hirsch has recently stated: the public health aspects of forensic pathology, which include epidemiologic research, exemplify "forensic pathology at its best."

Deaths among the homeless in Fulton County, GA, 1988-90.

The circumstances surrounding the deaths of 128 homeless persons investigated by the Fulton County, GA, Medical Examiner's Office during the period 1988-90 and the demographic characteristics of the deceased were studied and analyzed. Emphasis was placed on cause and manner of death, unintentional injuries, and alcohol-related mortality. Ninety-eight percent of those who died were men, 55 percent occurred outdoors, 55 percent were due to natural causes, and 42 percent resulted from injuries, most of which were unintentional. The average age at death was 46 years, and 80 percent of those who died were found dead. Nearly half of the deaths (47 percent) were related to the acute or chronic effects of alcohol; the blood of 45 percent tested positive for ethanol; of that 45 percent, 75 percent had a blood ethanol concentration that exceeded 0.1 grams per deciliter. Mortality patterns among the homeless persons in the study were similar to those previously reported in Fulton County and in San Francisco, CA. Available data indicate that mortality prevention strategies for the homeless in Fulton County should target alcohol abuse and unintentional injuries. Further studies are needed to document regional mortality patterns of the homeless.

Principles for including or excluding 'mechanisms' of death when writing cause-of-death statements.

OBJECTIVE: To develop principles and refined definitions designed to improve the content of cause-of-death statements regarding inclusion or exclusion of so-called mechanisms of death. DATA SOURCES: Survey of readily available instruction manuals and other literature regarding mechanisms of death and instructions for death certificate completion. DATA SYNTHESIS: Definitions and principles contained in the information sources were reviewed, and a set of specific principles, criteria, and definitions were written. These principles are consistent with, but are more extensive and practically applicable than, those found in each of the information sources surveyed and may be used to decide which conditions to report in cause-of-death statements. CONCLUSIONS: Mechanisms of death include a defined list of terminal events (such as asystole) and a larger group of nonspecific physiologic derangements (such as portal hypertension) and are differentiated by definition from nonspecific anatomic processes (such as cirrhosis). Three principles may be applied in individual cases. Principle 1 states that terminal events are not reported in cause-of-death statements. Principle 2 states that a nonspecific physiologic derangement or a nonspecific anatomic process should be reported if (1) it is a recognized, potentially fatal complication of the underlying cause of death; (2) it constitutes part of the sequence of conditions that led to the death of the patient in question; (3) it is not a symptom or sign; (4) its existence in the patient would not be apparent unless included and explicitly stated in the cause-of-death statement; (5) its inclusion does not constitute an oversimplification of the facts; and (6) an etiologically specific underlying cause of death is also reported. Principle 3 states that if the existence of the complication is obvious based on the underlying cause of death or another reported complication, it need not be reported.

The autopsy lexicon: suggested headings for the autopsy report.

CONTEXT: Although standard autopsy texts and other publications discuss the general content of autopsy reports, and some provide examples of autopsy report formats, no publication to date has recommended specific headings for autopsy report organization. The College of American Pathologists Autopsy Committee decided it would be helpful to provide suggestions for autopsy report headings to foster more standardized autopsy reporting, to facilitate review of reports by third parties, and to facilitate searches of electronically stored autopsy reports. OBJECTIVES: To create a model document (named the Autopsy Lexicon), which defines standard categories of information that are useful to include in autopsy reports; to offer specific wording for the headings of various sections of the report; and to explain the rationale for including the various items of information and headings. PARTICIPANTS AND METHODS: The members of the Autopsy Committee of the College of American Pathologists prepared the document by reviewing various examples of autopsy report formats, identifying specific categories of information usually contained in such reports, and developing wording for various sections of the autopsy report that would contain specific information. A draft was submitted to 45 members (including 12 forensic pathologists) of the College of American Pathologists for review, comment, and reality testing. Reviewers included pathologists from both community and academic settings. Comments of reviewers were incorporated to the extent possible. RESULTS: The Autopsy Lexicon was prepared and is a model document for autopsy pathologists who wish to define an autopsy template of headings for consistent organization of autopsy reports. CONCLUSIONS: The Autopsy Lexicon is available to foster more uniform reporting of autopsy information, which may facilitate review of autopsy reports and retrieval of information from electronically stored autopsy reports.

Practice guidelines for autopsy pathology: autopsy reporting. Autopsy Committee of the College of American Pathologists.

The Autopsy Committee of the College of American Pathologists has prepared this revised guideline to reflect changes that have occurred in the reporting of autopsies since the original guideline was published in February 1995. It is intended to be an instrument to assist pathologists in the reporting of autopsies. The guideline is to be regarded as being primarily an educational tool. Application of these recommendations on autopsy reporting is to be made on the basis of the judgment of the pathologist engaged in a specific case.

A prototype Internet autopsy database. 1625 consecutive fetal and neonatal autopsy facesheets spanning 20 years.

OBJECTIVE: To demonstrate that cause-of-death statements can be generated by a computer algorithm from an autopsy database composed of diagnostic terms. DATA SOURCES: Over 49 000 autopsy facesheets contributed by over a dozen institutions were collected from a publicly accessible Internet autopsy database. This database is available at the following web site: http:@www.med.jhu.edu/pathology/iad.html STUDY SELECTION: To test the feasibility of creating and using a publicly available autopsy database, and to identify the technical and medicolegal problems that may arise with such a novel resource, a prototype study was designed by selecting autopsy facesheets from fetal and neonatal deaths. An algorithm was developed to determine the cause of death from the listing of anatomic diagnoses. DATA EXTRACTION: One thousand six hundred twenty-five fetal and neonatal autopsy facesheets were selected encompassing fetal and neonatal deaths occurring up to 28 days after birth. DATA SYNTHESIS: The algorithm determined causes of death from autopsy facesheet data in all cases. On review by an experienced pediatric pathologist, these automatically generated cause-of-death statements required no modification or only slight modification in over 90% of cases. CONCLUSIONS: A large multi-institutional autopsy database composed of demographic and diagnostic information has been deposited on the Internet. This information can be freely downloaded and used by any researcher without violating patient confidentiality. As a demonstration of one possible application of the database, fetal and neonatal autopsies generated cause-of-death statements using a computer algorithm. One can anticipate that the wealth of information contained in autopsy facesheets can be assembled into a database that will serve the public interest.

Radioimmunoassay screening of dried blood spot materials for benzoylecgonine.

Residual samples of blood spots, which are routinely collected on almost all newborns in the United States, can be used to determine seroprevalence information on newborns and maternal exposures to various substances, including drugs of abuse. By modifying a commercial radioimmunoassay (RIA) kit for urinary samples, one can use blood spotted on filter paper as a matrix to quantitate the cocaine metabolite benzoylecgonine (BE). BE is stable for long periods of time in blood spots and we were able to quantitatively extract it with aqueous buffer. There were no matrix effects of the blood spot eluate on the RIA, and excess lipid in the blood did not alter measurement of BE. By using standards made up of BE in negative blood spot eluate and calibrators of blood that were spiked with BE and then spotted on filter paper to determine extraction efficiency, low levels of BE in blood could be measured. The limit of detection was 5 ng/mL, and the limit of quantitation was 10 ng/mL. Levels of BE in blood collected at autopsy in eluates of blood spots were measured, and they established excellent correlation (r2 = 0.93) with gas chromatography/mass spectrometry measurements. To test this technology, residual blood spots on 545 infants from three states were analyzed for BE.

The Centers for Disease Control and Prevention's Medical Examiner/Coroner Information Sharing Program (MecISP)

In 1986, the Centers for Disease and Prevention established the Medical Examiner and Coroner Information Sharing Program (MecISP) with four primary goals: 1) To improve the quality of death investigations in the United States and to promote more standardized practices concerning when and how to conduct these investigations; 2) to facilitate communication among death investigators, the public health community, federal agencies, and other interested groups. 3) to improve the quality, completeness, management, and dissemination of information regarding investigated deaths; and 4) to promote the sharing and use of medical examiner/coroner death investigation data. Major MecISP projects have included periodic production of a directory of death investigators in the United States and Canada, creation of standard and generic death investigation report forms, development of death investigation data sets, and collection of death investigation data from medical examiner/coroner offices. MecISP also conducts site visits to assist in office computerization, supports educational meetings and the development of training materials for death investigators, facilitates ongoing projects of relevant professional organizations, contributes publications to the death investigation literature, conducts surveillance of selected types of deaths, and responds to specific inquiries from medical examiners and coroners about administrative and practical death investigation issues.

The impact of homicide trials on the forensic pathologist's time--the Fulton County experience.

Subpoenas received for criminal trials related to homicides in Fulton County (Atlanta) Georgia were tracked in a computer database for an 18 month period in order to determine the proportion of forensic pathologist worktime required for testimony in homicide cases. The number of subpoenas received annually amounted to 64% of the average number of homicides occurring annually. Testimony was required in about 33% of cases in which a subpoena was received, and, therefore, the number of testimony appearances per year was about 21% of the average annual number of homicides. Assuming a 40 hour work week for 52 weeks per year and an average of 3 hours of time preparing for, traveling to, and testifying in court, the time required of the forensic pathologist to testify in homicide trials amounted to about 2% of a full-time-equivalent. Although the time required for testimony in homicide cases may vary among jurisdictions because of the nature of its homicides, distance and travel time to court, and other factors, the data presented here may be used to estimate the impact of homicide trial court time on forensic pathology practice.

Death registration: history, methods, and legal issues.

This article includes a brief discussion of the evolution death registration as it changed from records of church burial ceremonies to the recording of vital events by government in defined registration areas; today's death registration system in the United States; classification and coding procedures; limitations of data derived from death registration; educational materials; legal issues involving death certificates; and the re-engineering of the death registration process.

Lingual thyroglossal duct cyst causing death in a four-week-old infant.

A 12-mm spherical thyroglossal duct cyst at the base of the tongue caused the death of a four-week-old infant by obstructing the glottis. Previous case reports of this rare entity indicate that the supine position aggravates airway obstruction. Proof of a cause and effect relationship between such a cyst and death is difficult in the sudden infant death syndrome (SIDS) age group because of nonspecific findings associated with asphyxia and SIDS. Autopsy should include a thorough examination of the oral cavity to detect such lesions.

Death investigation report forms (DIRFs): generic forms for investigators (IDIRFs) and certifiers (CDIRFs).

On the basis of data collection procedures and forms used in various death investigation offices, we developed generic death investigation report forms (DIRFs). One form was designed for documenting information collected by the initial investigator of death, and another form was designed for documenting information collected by the medical examiner, pathologist, or other person who certifies the death or otherwise finalizes the investigation by determining the cause, manner, and circumstances of death. The benefits, problems, and criteria associated with designing the forms are discussed. Both the investigators DIRF (IDIRF) and the certifier's DIRF (CDIRF) are available in printed or electronic form for those who wish to use them or to modify them according to their specific needs. We hope that these DIRFs will be useful and promote uniformity in documenting death investigations.

Suicide far from home: the concept of transjurisdictional suicide.

A review of a series of eleven persons who committed suicide in a city long distances from home is presented, and the concept of transjurisdictional suicide is introduced. Those eleven cases suggest a high likelihood that the victim will be found in a hotel or motel bed by a hotel/motel employee within a day of check-in; the victim will be a white male who drove to the city and who lived in a hometown closely associated with an urban center which is within a day's drive and on an interstate route connecting the hometown to the city selected; the victim will be older than twenty-one years, married or never married but not divorced or widowed, and will not have been born in the state where death occurred; a suicide message will be found, and a specific reason for selecting a given city will not be apparent.

The cutaneous ink sign: a tipoff to suicide or suicide notes.

The presence of smeared or unsmeared ink on the skin resulting from the writing process has been observed in a number of suicide victims who have left suicide notes. The authors report a case of a palmar "cutaneous ink sign" and discuss its forensic science import.

Suicide in Fulton County, Georgia (1975-1984).

Demographic and trend analysis of 881 consecutive suicides in blacks and whites is presented. For the years 1975 through 1984, the suicide rate was 15.1/100 000 and did not significantly change. White males were overrepresented in all age groups, had an overall suicide rate of 34.9, and showed a small but statistically significant increase in rate which was not accounted for by any specific age group. White females, in general, were represented in proportion to their prevalence in the population, and those ages 20 to 24 demonstrated an increasing suicide rate which was small. Black males were at highest risk in their twenties, showed no significant trends, and were also represented near their prevalence in the population. Black females of all ages were underrepresented, and had low suicide rates which decreased with time. No significant rate changes were noted for teenagers or the elderly. Firearms was the method of choice in all groups, although methods varied with age, race, and sex, and male children preferred hanging. Small but significant increases were noted for the prevalence of nondrug methods in females and carbon monoxide deaths in white males. Similarities and differences to larger scale studies are discussed. Suicide may have characteristics unique to given geographical areas and pervasive to all areas. The authors advocate study and publication of local data to clarify further the nature of suicide.

Gunshot wound with asphalt related pseudo-soot, pseudo-tattooing, and pseudo-scorching.

Artifacts which mimic the tattooing and soot deposition of close range gunshot wounds have been described as "pseudo-soot" and "pseudo-tattooing." The origin of such findings includes glass, intermediate targets, insect bites, medical manipulation, graphite, and sutures. The authors present a case of pseudo-soot and pseudo-tattooing as a result of asphalt pavement, and describe the associated entity of pseudo-scorching.