National Association of Medical Examiners Position Paper: Recommendations for the Documentation and Certification of Disaster-Related Deaths.

ABSTRACT: Collecting and reporting accurate disaster mortality data are critical to informing disaster response and recovery efforts. The National Association of Medical Examiners convened an ad hoc committee to provide recommendations for the documentation and certification of disaster-related deaths. This article provides definitions for disasters and direct, indirect, and partially attributable disaster-related deaths; discusses jurisdiction for disaster-related deaths; offers recommendations for medical examiners/coroners (ME/Cs) for indicating the involvement of the disaster on the death certificate; discusses the role of the ME/C and non-ME/C in documenting and certifying disaster-related deaths; identifies existing systems for helping to identify the role of disaster on the death certificate; and describes disaster-related deaths that may require amendments of death certificates. The recommendations provided in this article seek to increase ME/C's understanding of disaster-related deaths and promote uniformity in how to document these deaths on the death certificate.

Recommendations for the Autopsy of an Infant who has Died Suddenly and Unexpectedly.

As the result of improved death scene investigations and the performance of more thorough and thoughtful pediatric forensic autopsies, there has been a widespread increase in the recognition of asphyxial mechanisms of death as well as lethal natural diseases that might have otherwise been erroneously labeled as sudden infant death syndrome (SIDS) or sudden unexpected infant death (SUID). Although it is fair to state that "more thorough autopsies provide more thorough medical evidence" from which to draw upon when determining cause and manner of death, there is no standard, accepted baseline from which forensic pathologists operate. Although anatomic pathologists are quite accustomed to practicing within well-defined boundaries for specimen (and thus diagnostic) adequacy, forensic pathologists are frequently hesitant to embrace or adopt such concepts. This has made it difficult to evaluate standards of practice in forensic pathology. Recommendations have been developed and published by the National Association of Medical Examiners for the postmortem assessment of suspected infant head trauma. However, significant variation exists in the way autopsies are performed on infants without trauma, such as the common scenario of an infant who has died suddenly and unexpectedly of asphyxial or apparent natural means. A wide variety of autopsy techniques and ancillary studies are available to forensic pathologists, but as survey data indicates, are not consistently used throughout the United States. This paper will discuss the different components of the pediatric autopsy and make recommendations for the best use of available tests and consultation services.

An Overview of the Thyroid Gland and Thyroid-Related Deaths for the Forensic Pathologist.

The thyroid gland is a butterfly-shaped organ situated in the anterior neck whose functions have system-wide effects. Thyroid diseases represent some of the most commonly encountered endocrine disorders and therefore are commonly encountered at the time of autopsy. Knowing how the gland functions and the effects it may have on vital organs is important when determining the cause of death and significant contributory conditions. Endocrine-related deaths may be anatomically subtle, therefore histologic examination, review of medical records, and selected postmortem testing must be performed to correctly identify and document their presence. For this reason, it is recommended that pathologists consider regularly examining the thyroid gland histologically, particularly on decedents where no apparent anatomic cause of death is identified after the autopsy. This article provides an in-depth review of the thyroid gland, thyroid hormones, and thyroid diseases, including potential thyroid-related deaths and incidental autopsy findings.

Rabies death attributed to exposure in Central America with symptom onset in a U.S. detention facility - Texas, 2013.

On June 7, 2013, a man was diagnosed in a Texas hospital with rabies. He had been detained in a U.S. detention facility during his infectious period. To identify persons exposed to rabies who might require rabies postexposure prophylaxis (PEP), CDC and the Texas Department of State Health Services (DSHS) conducted investigations at four detention facilities, one medical clinic, and two hospitals. In all, 25 of 742 persons assessed for rabies exposure were advised to receive PEP. Early diagnosis of rabies is essential for implementation of appropriate hospital infection control measures and for rapid assessment of potential contacts for PEP recommendations.

Manual and automated cardiopulmonary resuscitation (CPR): a comparison of associated injury patterns.

The purpose of this study was to identify and compare patterns of trauma associated with AutoPulse(®) CPR and manual CPR. Finalized autopsy records from 175 decedents brought to the Harris County Institute of Forensic Sciences were reviewed, 87 received manual-only CPR, and 88 received AutoPulse(®) CPR (in combination with manual CPR as per standard protocol). The characteristic pattern observed in manual-only CPR use included a high frequency of anterior rib fractures, sternal fractures, and midline chest abrasions along the sternum. The characteristic pattern observed in AutoPulse(®) CPR use included a high frequency of posterior rib fractures, skin abrasions located along the anterolateral chest and shoulder, vertebral fractures, and a few cases of visceral injuries including liver lacerations, splenic lacerations, and hemoperitoneum. Knowledge of the AutoPulse(®) CPR injury pattern can help forensic pathologists differentiate therapeutic from inflicted injuries and therefore avoid an erroneous assessment of cause and manner of death.

Susceptibility to acute thoracic aortic dissections in patients dying outside the hospital: an autopsy study.

BACKGROUND: The objectives of this study were to identify the incidence and predictors of death from acute thoracic aortic dissections (AoDs) and to describe their associated clinical findings. METHODS: We analyzed the clinical and pathologic data from 141 consecutive autopsies of individuals with sudden death due to AoDs in Harris County, TX, from 2003 to 2010, which represented 20% (107/534) of all deaths attributed to AoDs during this period by the Texas Department of Health. Multivariate Cox regression was used to identify predictors of survival adjusting for differences in demographic and clinical characteristics. RESULTS: During the study period, 141 of 145 fatal victims of acute thoracic dissections underwent a full autopsy and were included in the analysis. In 84% of cases, death was caused by pericardial tamponade from ascending AoD. The frequency of deaths showed seasonal variation with peak incidence in the winter months. Compared with patients presenting to hospitals with AoD, individuals dying outside the hospital were more likely to be female, African American, younger than 50 years and to have had prior aortic disease. One third of subjects with AoD had seen a physician within 1 week of sudden death. The most consistent pathologic abnormality was marked ventricular hypertrophy (257 g/m(2) on average) out of proportion to expected values for age, gender, and body size. Hispanic patients and patients with congenital disorders, such as bicuspid aortic valve and Marfan syndrome, were significantly more likely to die of AoD at a younger age (38% vs 13%, P < .002). CONCLUSIONS: Our findings identify differences between patients hospitalized for AoD versus those who died without being hospitalized. Previously unreported vulnerabilities to sudden death from AoD in minority populations, specifically Hispanics, were also identified that merit follow-up in prospective studies.

Postmortem findings in eight cases of influenza A/H1N1.

In March and early April 2009, cases of a new swine-origin influenza A (H1N1) virus were diagnosed in Mexico and the United States. Influenza virus presents as a respiratory infection with high morbidity and mortality. We describe the postmortem findings of eight confirmed cases of influenza A/H1N1 in a medical examiner setting. The eight cases falling under the jurisdiction of the Harris County Medical Examiner (Houston, TX, USA) with confirmed influenza A/H1N1 infection between June and September 2009 were included in this study. All cases were males between 6 months and 54 years of age. All adult patients had a body mass index from 31 to 49.8 kg/m(2). Five cases had comorbid conditions including one case with sleep apnea and mental retardation, three cases with chronic ethanolism, and one case with thymoma, sarcoidosis, and myasthenia gravis. The remaining three cases had no pre-existing medical conditions. All patients presented with severe flu-like symptoms; yet, only five were febrile. Rapid influenza diagnostic tests were performed in three cases by primary-care physicians, two of which were negative. None of the patients received antiviral medication. The average disease duration time was 8.2 days (3-14 days). A wide range of histopathological findings including tracheitis, necrotizing bronchiolitis, alveolitis, intra-alveolar hemorrhage, and hyaline membranes, both in a focal and in a diffuse distribution, were identified. Influenza A/H1N1 viral infection presents with a wide range of histological findings in a diffuse or focal distribution; most consistently with tracheitis, necrotizing bronchiolitis, and alveolitis with extensive alveolar hemorrhage. These histopathological findings at autopsy along with a clinical history of flu-like symptoms should raise suspicion for influenza A/H1N1 infection, and postmortem analysis by the reverse transcription-polymerase chain reaction (RT-PCR) is recommended for an accurate diagnosis.

Check Sample Abstracts.

The following abstracts are compiled from Check Sample exercises published in 2008. These peer-reviewed case studies assist laboratory professionals with continuing medical education and are developed in the areas of clinical chemistry, cytopathology, forensic pathology, hematology, microbiology, surgical pathology, and transfusion medicine. Abstracts for all exercises published in the program will appear annually in AJCP.