Cognitive bias in forensic pathology decisions.

Forensic pathologists' decisions are critical in police investigations and court proceedings as they determine whether an unnatural death of a young child was an accident or homicide. Does cognitive bias affect forensic pathologists' decision-making? To address this question, we examined all death certificates issued during a 10-year period in the State of Nevada in the United States for children under the age of six. We also conducted an experiment with 133 forensic pathologists in which we tested whether knowledge of irrelevant non-medical information that should have no bearing on forensic pathologists' decisions influenced their manner of death determinations. The dataset of death certificates indicated that forensic pathologists were more likely to rule "homicide" rather than "accident" for deaths of Black children relative to White children. This may arise because the base-rate expectation creates an a priori cognitive bias to rule that Black children died as a result of homicide, which then perpetuates itself. Corroborating this explanation, the experimental data with the 133 forensic pathologists exhibited biased decisions when given identical medical information but different irrelevant non-medical information about the race of the child and who was the caregiver who brought them to the hospital. These findings together demonstrate how extraneous information can result in cognitive bias in forensic pathology decision-making.

Hybrid oncocytic/chromophobe renal tumors are molecularly distinct from oncocytoma and chromophobe renal cell carcinoma.

Hybrid oncocytic/chromophobe tumor (HOCT) of the kidney represents a poorly understood clinicopathologic entity with pathologic features that overlap between benign renal oncocytoma (RO) and malignant chromophobe renal cell carcinoma (ChRCC). Consequently, characterization of HOCT and its separation from the foregoing entities are clinically important. The aim of this study was to describe the pathologic and molecular features of HOCT and to compare them with those of RO and ChRCC. We retrospectively identified a cohort of 73 cases with renal oncocytic tumors (19 RO, 27 HOCT, and 27 ChRCC) for whom clinical follow-up data were available by 2 tertiary care hospitals. All cases were sporadic except for 2 HOCTs that were associated with Birt-Hogg-Dubé syndrome. Lesional tissues were retrieved for molecular analysis. We performed targeted gene sequencing of all exons of 261 cancer related genes on a subset of HOCT samples (n = 16). Gene expression profiling of a customized codeset was conducted on 19 RO, 24 HOCT, and 27 ChRCC samples. Clinicopathologic characteristics as well as DNA copy number alterations, mutational and transcriptional features of HOCT derived from sequencing and expression profiling data are described and compared to those in RO and ChRCC. HOCTs were more frequently multifocal and did not exhibit mutations in genes that are recurrently mutated in RO or ChRCC but showed copy number alterations primarily involving losses in chromosomes 1 and X/Y. The mRNA transcript data show that HOCT can be separated from RO and ChRCC. Hence, HOCT appears to represent a distinct renal tumor entity with genomic features that are intermediate between those of RO and ChRCC.

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.The Jefferson County Coroner/Medical Examiner Office has observed an increase in our caseload by 10% per year since 2012. We designed a study to determine if a pathologist could correctly classify the cause of death (COD) and manner of death (MOD) of suspected drug-related deaths without information from the internal examination. The determination of the COD and MOD was then compared with the case file, which includes information from the internal examination and microscopy, to determine agreement between the case file and the reclassification. The percent correct for COD and MOD was calculated, and kappa values were calculated for MOD.The pathologists were able to correctly classify the COD in 73% of cases. For MOD, 2 pathologists achieved substantial agreement between the test cases and the actual case file. The third pathologist had moderate agreement. These findings indicate that a full postmortem examination is necessary to correctly classify the COD/MOD in cases of suspected drug toxicity.Our null hypothesis is that a full autopsy is not necessary to correctly classify the COD and MOD in cases of drug toxicity.

n-Ethyl Pentylone-Related Deaths in Alabama.

n-Ethyl pentylone (NEP) is a chemical substance derived from cathinone. Synthetic cathinones are an evolving group of drugs with stimulating, mind-altering effects sometimes referred to as novel or new psychoactive substances (NPS). There is scarce information in the medical literature regarding forensic cases in which NEP is detected in toxicological testing. We present four fatalities involving NEP from Alabama in 2017. Deaths were attributed to NEP toxicity in two cases (peripheral blood concentrations of 0.121 and 0.953 mg/L) and injuries caused by gunshot wounds in two cases (peripheral blood concentrations of 0.045 and 0.031 mg/L). One case involving NEP described an individual who exhibited classic CNS-stimulant induced erratic behavior before being found dead. These cases enhance the forensic literature regarding specific NPS like NEP and provide contextual reference for professionals considering the significance of NEP in toxicological interpretation.

Postradiation Histiocytic Sarcoma in the Setting of Muir-Torre Syndrome.

Hereditary nonpolyposis colorectal carcinoma (HNPCC) is an autosomal dominant genetic disorder characterized by a predisposition towards colorectal carcinoma and other extracolonic neoplasms. Histiocytic sarcoma (HS) is a very rare hematologic neoplasm characterized by a malignant proliferation of cells with histiocytic differentiation. We present the case of a 62-year-old male with previous diagnosis of MTS who presented with metastatic colorectal adenocarcinoma, bilateral papillary renal cell carcinoma, and a new squamous cell carcinoma of the scalp, treated with resection and adjuvant radiation therapy. After reconstructive surgery for his scalp resection, the patient developed a persistent nonhealing skin defect. A punch biopsy of this nonhealing skin defect and subsequent immunohistochemistry revealed neoplastic histiocytic cells restricted to the epidermis and underlying dermis. The diagnosis of cutaneous histiocytic sarcoma was then rendered. Histiocytic sarcoma is an exceptionally rare malignancy. Consequently, there is no universally agreed upon management protocol for this malignancy. The patient was admitted to hospice and treated with palliative radiation. This case demonstrates the need for awareness of the risk of secondary malignancies in cancer patients in order to facilitate early surgical intervention and optimal treatment.

National Association of Medical Examiners position paper: Recommendations for the investigation and certification of deaths in people with epilepsy.

Sudden unexpected death of an individual with epilepsy can pose a challenge to death investigators, as most deaths are unwitnessed, and the individual is commonly found dead in bed. Anatomic findings (eg, tongue/lip bite) are commonly absent and of varying specificity, thereby limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention constituted an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden unexpected death in a person with epilepsy is encountered.

National Association of Medical Examiners Position Paper: Recommendations for the Investigation and Certification of Deaths in People with Epilepsy.

Sudden unexpected death of an individual with epilepsy (SUDEP) can pose a challenge to death investigators, as most deaths are unwitnessed and the individual is commonly found dead in bed. Anatomic findings (e.g., tongue/lip bite) are commonly absent and of varying specificity, limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus, it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden, unexpected death in a person with epilepsy is encountered.

Quantification of Loperamide by Gas Chromatography Mass Spectrometry.

Due to reported pharmacological activity similar to classical opioids at supratherapeutic concentrations, abuse of the anti-diarrheal medication loperamide (Imodium AD™) has become a target in the opioid epidemic. While this phenomenon is not new, published quantitative analytical methods use liquid chromatography tandem mass spectrometry. Described here is an 11 min method for quantification of loperamide in postmortem whole blood by gas chromatography mass spectrometry. Validation studies performed followed SWGTOX guidelines and included: accuracy, specificity, limit of detection (LOD), regression model analysis, stability, and matrix recovery enhancement and/or suppression. The accuracy study consisted of inter-day, intra-day, reproducibility and dilution integrity experiments. Inter-day and intra-day accuracy, precision and coefficient of variation (CV) were measured; normalized results were 1.05 ± 0.09 with 8.87% CV (n = 36) and 1.03 ± 0.09 with 8.53% CV (n = 27), respectively. Reproducibility was evaluated through standard addition with an observed CV of 10.84% (n = 10). Dilution integrity (2× and 4×) resulted in 0.94 ± 0.13 with a CV of 13.9% (n = 5). No interference was observed through analyses of the internal standard (loperamide-d6), endogenous compounds (10 blank matrices) or 60 commonly encountered analytes. The LOD/decision point was 100 ng/mL (CV 8.40%). A linear calibration model was established from 100 to 1,000 ng/mL. Stability was examined; observed analyte-to-internal standard response resulted in 6.59% CV. Recovery was determined for loperamide and loperamide-d6 (31% and 36%, respectively). Neither matrix suppression nor enhancement was observed with loperamide at 750 ng/mL and loperamide-d6 at 300 ng/mL (-6.5% and -4.2%); however, some suppression was exhibited at lower concentrations (-39.8%). The designed method was determined to be sufficient for the analysis of loperamide-related death cases in Alabama (n = 8) and offers postmortem toxicology laboratories an alternative approach that is both highly selective and specific.

The Regional Autopsy Center: The University of Alabama at Birmingham Experience.

Rates of autopsied deaths have decreased significantly for the last several decades. It may not be practical for some institutions to maintain the facilities and staffing required to perform autopsies. In recent years, the University of Alabama at Birmingham (UAB) has established contracts to perform autopsies for several regional institutions including the Alabama Department of Forensic Sciences (ADFS), the United States Veterans Affairs, the local prison system, local community hospitals, and with families for private autopsy services. Contracts and autopsy data from 2004 to 2015 were obtained and reviewed. Since 2004, the number of UAB hospital autopsies trended slightly downward. On average, UAB hospital cases comprised most yearly cases, and the ADFS was the second largest contributor of cases. Income generated from outside autopsies performed from 2006 to 2015 totaled just more than 2 million dollars, and most of the income was generated from referred ADFS cases. This study provides evidence that a centralized institution (regional autopsy center [RAC]) can provide regional autopsy service in a practical, feasible, and economically viable manner, and a RAC can benefit both the referring institutions as well as the RAC itself.