SUDEP classification: Discordances between forensic investigators and epileptologists.

We compared sudden unexpected death in epilepsy (SUDEP) diagnosis rates between North American SUDEP Registry (NASR) epileptologists and original death investigators, to determine degree and causes of discordance. In 220 SUDEP cases with post-mortem examination, we recorded the epileptologist adjudications and medical examiner- and coroner- (ME/C) listed causes of death (CODs). COD diagnosis concordance decreased with NASR's uncertainty in the SUDEP diagnosis: highest for Definite SUDEP (84%, n = 158), lower in Definite Plus (50%, n = 36), and lowest in Possible (0%, n = 18). Rates of psychiatric comorbidity, substance abuse, and toxicology findings for drugs of abuse were all higher in discordant cases than concordant cases. Possible SUDEP cases, an understudied group, were significantly older, and had higher rates of cardiac, drug, or toxicology findings than more certain SUDEP cases. With a potentially contributing or competing COD, ME/Cs favored non-epilepsy-related diagnoses, suggesting a bias toward listing CODs with structural or toxicological findings; SUDEP has no pathognomonic features. A history of epilepsy should always be listed on death certificates and autopsy reports. Even without an alternate COD, ME/Cs infrequently classified COD as "SUDEP." Improved collaboration and communication between epilepsy and ME/C communities improve diagnostic accuracy, as well as bereavement and research opportunities.

Using medical examiner case narratives to improve opioid overdose surveillance.

BACKGROUND: Current opioid overdose mortality surveillance methods do not capture the complexity of the overdose epidemic. Most rely on death certificates, which may underestimate both opioid analgesic and heroin deaths. Categorizing deaths using other characteristics from the death record including route of drug administration may provide useful information to design and evaluate overdose prevention interventions. METHODS: We reviewed California Electronic Death Reporting System records and San Francisco Office of the Chief Medical Examiner (OCME) toxicology reports and investigative case narratives for all unintentional opioid overdose deaths in San Francisco County from 2006 to 2012. We chose this time period because it encompassed a period of evolution in local opioid use patterns and expansion of overdose prevention efforts. We created a classification system for heroin-related and injection-related opioid overdose deaths and compared demographic, death scene, and toxicology characteristics among these groups. RESULTS: We identified 816 unintentional opioid overdose deaths. One hundred fifty-two (19%) were standard heroin deaths, as designated by the OCME or by the presence of 6-monoacetylmorphine. An "expanded" classification for heroin deaths incorporating information from toxicology reports and case narratives added 20 additional heroin deaths (13% increase), accounting for 21% of all opioid deaths. Two hundred five deaths (25%) were injection-related, 60% of which were attributed to heroin. A combined classification of expanded heroin and injection-related deaths accounted for 31% of opioid overdose deaths during this period. CONCLUSIONS: Using additional sources of information to classify opioid overdose cases resulted in a modest increase in the count of heroin overdose deaths but identified a substantial number of non-heroin injection-related opioid analgesic deaths. Including the route of administration in the characterization of opioid overdose deaths can identify meaningful subgroups of opioid users to enhance surveillance efforts and inform targeted public health programming including overdose prevention programs.

Aportaciones de la medicina forense a la investigación de la conducta suicida / Contributions of forensic medicine to research of suicidal behaviour

El suicidio es la principal causa de muerte violenta en España, por delante de los accidentes de tráfico, y se estima que cada año se suicidan cerca de 3.500 personas. Los factores de riesgo identificados de la conducta suicida se basan, principalmente, en estudios de intentos de suicidio. La centralización de las autopsias en los Institutos de Medicina Legal facilita la homogenización del método de trabajo y la consistencia de los resultados a nivel práctico-judicial y de investigación. La medicina forense debe proyectarse en la investigación en general y de la conducta suicida en particular, en colaboración con otros equipos de investigación. La investigación debe efectuarse según la normativa ética y administrativa vigente y ser aprobada por el Comité Ético de referencia. Con respecto a la investigación de los factores de riesgo del suicidio, el reclutamiento de casos y controles, la obtención de muestras biológicas, la colaboración en la realización de autopsias psicológicas y los estudios epidemiológicos, son aportaciones esenciales de la medicina forense(AU)

In Spain, suicide is the leading cause of violent death, ahead of motor vehicle accidents, with about 3,500 people dying by this mean in Spain. The risk factors identified are primarily based on studies of suicide attempts. The centralization of autopsies in the Institutes of Legal Medicine allows the homogenization of working methods and the consistency of results for both research and legal purposes. Forensics should focus on medical research in general and on suicidal behaviour in particular, in collaboration with other research teams. Research must be conducted according to existing ethical and administrative legislation. All must be approved by the Ethics Committee of reference. With regard to the investigation of risk factors for suicide, forensics are essential in the recruitment of cases and controls-obtaining biological samples, collaborating in conducting psychological autopsies and epidemiological studies(AU)

Criterios cualitativos en toxicología forense / Qualitative criteria in forensic toxicology

La toxicología forense requiere resultados analíticos científicamente indiscutibles y legalmente defendibles. Los criterios cualitativos son proporcionados por prestigiosos organismos de ámbito internacional y local. Este trabajo revisa y evalúa los documentos elaborados por ellos, con el fin de recoger en uno solo las distintas directrices existentes. El objetivo es contribuir a la calidad de la pericia y al avance en la unidad de criterio científico, aspectos cruciales en toxicología forense para obtener resultados toxicológicos científicamente sólidos. Se discuten los criterios necesarios para una correcta detección e identificación, detallándose las estrategias de detección y los requisitos para validar las metodologías. Respecto a la identificación, se reconoce la importancia de la espectrometría de masas, y también se hace referencia a los criterios relativos a las técnicas analíticas y a los tóxicos. Esta revisión y recopilación pretende además, servir a aquellos profesionales que deban evaluar los resultados toxicológicos emitidos por los laboratorios forenses(AU)

Forensic toxicology requires indisputable and legally defensible analytical results. The qualitative criteria are provided by prestigious international and local organizations. This work reviews and evaluates them to gather in one document these different existing guidelines. The aim of this work is to contribute to the quality of the expertise and to implement the common scientific criteria. Both aspects are crucial in forensic toxicology to achieve toxicological results based on solid scientific foundations. The criteria, to be taken into consideration, for a correct detection and identification are discussed. The strategies for detection and the requirements for validation of these methodologies are detailed. The importance of mass spectrometry, as the most reliable technique for identification, is recognized. The criteria for analytical techniques and for toxics are also detailed. Moreover, this review and compendium of criteria try to serve those professionals who need to evaluate the toxicological findings submitted by the forensic laboratories(AU)

Perícia odontolegal / Dentistry expert

A Odontologia Legal tem como finalidade precípua a aplicaçãodos conhecimentos da ciência odontológica a serviço da Justiça. É o perito a pessoa judicialmente habilitada para uma avaliação,exame ou vistoria de determinada área. Segundo Afrânio Peixoto, as qualidades essenciais dos peritos são: honestidade, técnica e imparcialidade.O perito odontolegista em seu dia a dia desenvolve tanto atividades clínicas quanto necroscópicas.

The conversion of coroner systems to medical examiner systems in the United States: a lull in the action.

Coroner and medical examiner systems in the United States conduct death investigations for most deaths that are sudden and unexplained, or which involve external causes such as injury and poisoning. They play a very important role in the criminal justice, public health, public safety, and medical communities, and they also contribute a substantial portion of autopsy-based mortality data to the state and federal mortality statistics systems. Death investigations often involve complex medical issues and necessarily require the involvement of appropriately trained physicians. Over the years, there has been a trend to replace the elected lay coroner systems with systems run by appointed, physician medical examiners. Presently, about 31% of counties in the United States are served by a medical examiners at the county, district, or state level. Between 1960 and 1989, there was considerable conversion to medical examiner systems, but this trend slowed in the 1990s. Since 2000, only 6 counties in the United States have converted to a medical examiner system, no states have converted since 1996, and 1 county has reverted to a sheriff-coroner system. Possible reasons for this decline are discussed, including legislative, political, geographical, financial, population-based, and physician manpower distribution factors. It is important to ensure that all death investigation systems have appropriate access to medically educated and trained physicians such as forensic pathologists.

[Today and tomorrow of forensic thanatology]. / Dzis i jutro tanatologii sadowo-lekarskiej.

The essence of post-mortem examination and its special place among other disciplines of forensic medicine were presented. Attention was drawn to the role of better understanding of phenomena occurring during and directly after death in the development of forensic medicine. Progress in determination of the time of death and in estimation of the intravital character of injuries found on the corpse was discussed. The need for a wider application of results of bio- and thanatochemical analyses in determination of the cause of death and its mechanism was emphasized. Examples of progress in this domain were presented, based on a number of papers published in this field, especially in Poland. Finally, the author pointed to the necessity of upgrading training of medical doctors in the field of thanatology.

Valoración médico forense del esguince cervical / Medico legal evaluation of whyplash injury

El esguince cervical es la patología traumática más frecuente en el ámbito de la valoración médico forense. Se realiza una aproximación a la misma a través de las peritaciones realizadas por 22 médicos forenses de 15 partidos judiciales españoles, sobre un total de 572 lesionados. Se concluye la mayor incidencia en el sexo femenino (57.52%), en el rango de edades entre 21 y 40 años (58%), siendo conductor de un turismo (54.7%) que recibe un golpe posterior (59%). Con un tiempo de sanidad entre los 31 y 90 días (52%), resultando en un mayor porcentaje con secuelas (64,3%), comúnmente SPC o cervicalgia, generalmente (56%) de grado leve

Whiplash is the leading traumatic cause concerning the evaluation in forensic activity. It has been carried out an approximation through the reports done by 22 forensic examiners working in 15 Spanish jurisdictions, over a total amount of 572 injured people. In fact there is a bigger incidence of damage in female gender (57.52%), in the age ranging from 21 to 40 years (58%), driving a car (54.7%), following a rear-end collision (59%). The healing time varies from 31 to 90 days (52%), and mostly with sequels (64.3%), commonly Cervical Post-Traumatic Syndrome or cervical pain, usually (56%) in a low degree

Are maternal deaths on the ascent in Singapore? A review of maternal mortality as reflected by coronial casework from 1990 to 1999.

INTRODUCTION: In Singapore, published maternal mortality rates (MMR) over the last decade (1990 to 1999) have been so low (0.0 to 1.0 per 1000 live births and still births) as to imply that maternal deaths are rare to the point of being non-existent in some years. This inference is counterintuitive, and earlier studies on maternal mortality, amniotic fluid embolism (AFE) and pulmonary thromboembolism (PTE) have also suggested otherwise. Accordingly, local trends in maternal mortality warrant further examination. MATERIALS AND METHODS: A descriptive and comparative study, comprising a clinico-pathological review of maternal deaths, for which autopsies were conducted by the Centre for Forensic Medicine, during a 10-year period from 1990 to 1999. The annual necropsy-based, MMR (estimated MMR), as well as the prevalence of maternal deaths during this time, were estimated with the aid of the relevant, published demographic data on live births and still births. These were compared with the corresponding rates calculated (calculated MMR) from raw demographic data on maternal deaths classified as such in the published data. RESULTS: Coronial autopsies were conducted on a total of 51 cases of maternal death, of which 33, 17 and 1 were direct, indirect and fortuitous deaths, respectively. The annual, estimated MMR ranged from 0.4 to 1.8 per 10,000 live births and still births. The estimated MMR was twice as high as the calculated MMR and a statistically significant upward linear trend was demonstrated for the former (P = 0.046). AFE (16/51) and PTE (10/51) were the two most common causes of maternal death; their corresponding cause-specific, 10-year prevalence being 0.33 and 0.21 per 10,000 live births and still births, respectively. There was apparent clustering of the cases of PTE during the earlier part of the last decade (1990 to 1995), corresponding to a statistically significant, upward trend in its overall necropsy incidence during that time (P = 0.019). Cardiovascular and pulmonary disorders constituted the bulk of indirect deaths (13/17), while antenatal suicides accounted for 3 of these deaths (0.06 per 10,000 live births and still births). CONCLUSIONS: This was an upward trend in MMR, as reflected in coronial casework, over the last decade. It would appear that the local, estimated (direct and indirect) maternal mortality prevalence compares favourably with the MMR reported in developed countries. The apparent rate of AFE was no less than 4 times higher than that reported in the United Kingdom, while the maternal mortality rate from PTE was at least as high. Allowing for the possibility that such deaths were under-reported, the actual annual MMR and 10-year prevalence could be appreciably higher than the estimates presented here. There may well be a case for the establishment of a comprehensive database of maternal deaths, that is updated continually and contemporaneously, in Singapore.

Investigación forense del asalto sexual / Forensic research of sexual rapes

En este artículo se tratan los asuntos primordiales de los cuales depende el éxito de la investigación de los delitos sexuales. Se explica el uso de la evidencia científica como elemento conductor de las tareas de inteligencia orientadas a mejorar la capacidad probatoria y demostrativa de los investigadores, dentro del proceso penal. Involucra terminología moderna y sus definiciones, como un aporte más de la ciencia a la investigación judicial. Se presenta con algún grado de detalle el manejo, la búsqueda y la importancia de la evidencia de contacto y su potencial utilidad en el esclarecimiento de los delitos sexuales. Para ello se clasifica la búsqueda y análisis de la evidencia en la escena, en la víctima y en el sospechoso y se dan algunos instrumentos para reconocer cuando una escena corresponde a homicidio relacionado con sexo. En este escrito se muestra la importancia del conocimiento que deben tener los funcionarios judiciales, investigadores, criminalísticos y médicos forenses, no sólo en el área técnica sobre la evidencia física, sino en aspecto propios de la conducta psicosexual humana, de la cual dependen grandes decisiones en el análisis e interpretación que de estas se hacen en la escena. Para finalizar se plantea de manera breve una explicación sobre las diferentes maneras en que actúa un delincuente sexual, de acuerdo con las diversas psicopatologías descritas en la literatura científica. En conclusión se trata de una exposición orientada hacia el mejoramiento del manejo de las escenas de asalto sexual con víctima viva o muerta

Perioperative deaths: a further comparative review of coroner's autopsies with particular reference to the occurrence of fatal iatrogenic injury.

INTRODUCTION: In previous triennial reviews of Coroner's perioperative autopsies conducted during the periods 1989 to 1991 and 1992 to 1994, it was observed that the necropsy incidence of such deaths rose from 2% to 2.6% (P < 0.05). Concurrently, the rate of iatrogenic deaths had nearly doubled from 15.2% to 28.8% (P < 0.02). These findings spurred a review of the subsequent triennium (1995 to 1997), in order to monitor the apparent rise in these trends and to study the frequency and occurrence of iatrogenic deaths in relation to the number of invasive procedures performed, as well as during emergency and elective procedures. MATERIALS AND METHODS: A retrospective (descriptive and comparative) study, comprising a clinico-pathological review of a series of 270 perioperative deaths (defined as deaths occurring during or after invasive therapeutic or diagnostic procedures, up to a week after discharge, and excluding cases of major trauma from suicides, homicides, as well as road and industrial accidents) reported to the Coroner, for which autopsies were conducted at the Department of Forensic Medicine from 1995 to 1997. RESULTS: The necropsy incidence of 4.4% (270/6074) represented a significant rise over the previous triennia (P < 0.01). As in previous years, there was a predominance of males (M:F = 1.65:1) and middle-aged to elderly patients (range 0 to 92 years, mean 55.8 years, median 63 years), most of whom had died after a variable, but usually brief, postoperative interval [0 to 97, 4.2, 1 day(s)] and a more variable period of hospitalisation (< 1 to 289, 12.6, 7 days). A total of 408 invasive procedures were performed, amounting to an average of 1.5 per patient; 101 patients (37.4%) underwent multiple (> 1) interventions, which were initially classified as elective procedures in 27 cases. There were 66 (24.4%) iatrogenic deaths, of which 2 (0.7%) were due to anaesthetic mishaps; 18/64 iatrogenic deaths, unrelated to anaesthesia, occurred after the first postoperative day. The proportions of such deaths amongst patients subjected to multiple interventions, or initial elective procedures, were more than twice as high as amongst those undergoing single procedures, and those initially classified as emergencies (35.6% versus 16.6% and 33.3% versus 13.2%, respectively; P < 0.01). Only 51/66 (77.3%) iatrogenic deaths received Coroner's verdicts of misadventure; no verdict of criminal negligence was recorded during the period in question. CONCLUSIONS: There appears to have been a steady increase in the number of perioperative deaths reported to the Coroner over the previous triennia (1989 to 1997) for which autopsies were conducted. While this observation may not denote an increase in perioperative morality rates per se, it may be indicative of an increasingly "aggressive" or defensive approach to the clinical management of seriously ill patients, particularly over the past decade. Although the rate of iatrogenic deaths appears to have stabilised, it is too early to say whether this apparent trend will persist in the future. It is perhaps not surprising that the risk of iatrogenic injury appears to increase with the number of interventions performed; however, it is not clear why initial, supposedly elective, interventions should be associated with an apparently greater risk of iatrogenic injury than those classified as emergency procedures. The substantial divergence between the autopsy finding of an iatrogenic death and the corresponding Coroner's verdict of misadventure may be comforting to clinicians, but certainly warrants further examination.

Medical examiner and coroner systems: history and trends.

CONTEXT: Medical legal investigations in the United States (primarily unnatural or suspected unnatural deaths) are carried out by medical examiner or coroner systems. Medical examiners-usually physicians and generally with training in pathology, medicolegal death investigation, and performance of forensic autopsies-generally have greater expertise in unnatural death investigations than do coroners. OBJECTIVE: To document the locations and implementation year for states and counties that have medical examiner systems that have replaced coroner systems or that are defined in statute and assist coroners in their investigations. DESIGN: Review of published information and national survey in 1997. SETTING: United States. PARTICIPANTS: County medical examiners and state medical examiners or their administrators. MAIN OUTCOME MEASURES: The location of states and counties with medical examiner systems, the implementation year for each system, and the proportion of counties and population served by medical examiner systems. RESULTS: A total of 79 of 91 county medical examiners responded. A total of 36 states have at least 1 medical examiner system at the county, district, or state level in which there is no coroner involved in the death investigation process. Only 22 states have medical examiner death investigation systems in place and have no coroners in the state. Among 13 states in which some counties have coroner systems and some have medical examiner systems, medical examiner systems exist in 8% of counties and serve 43% of the population. Medical examiner systems that operate without coroner involvement serve about 48% of the population nationwide. Few state or county medical examiner systems have been implemented since 1990. CONCLUSIONS: In this century, medical examiner systems have gradually replaced coroner systems, but such change has slowed in recent years, with medical examiner systems now serving about 48% of the national population.

Forensic autopsies from 1984 to 1993 in Vienna, Austria.

In Austria every death is subject to an examination by a medical doctor authorized by the local health authority. If death is suspected to be natural and/or perpetrated by another person, this doctor has to report it to the police. Depending on the investigation results, the examining magistrate in charge demands a judicial autopsy at the Institute of Forensic Medicine. In 1989, 41 murders of old patients by nursing assistants in a Viennese public hospital were disclosed. The main aim of this retrospective study was to determine any change in the demand for forensic autopsies by the Viennese health authority, as well as by the criminal court, after 1989. Furthermore, it was of interest to analyze the reporting practices of medical doctors examining corpses, as well as thr reaction of the criminal court during the study period. After 1989, there was a significant increase of non-judicial and judicial autopsies, performed by Viennese forensic pathologists. In addition, there was a significant increase of reports to the police by coroners as well as by forensic pathologists, paralleled by a higher rate of forensic autopsies demanded by the examining magistrate. This increase of forensic autopsies took place even though the overall rate of deaths in Vienna significantly decreased during the 10-year study period. Thus, the disclosure of 41 murders in the Viennese hospital in 1989 can be assumed as a turning point in the reporting practices of Viennese coroners, as well as the autopsy rate handled by Viennese forensic pathologists.

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.

Public relations for the Medical Examiner's Office. Speech delivered September 27, 1994, Charleston, South Carolina, USA, on receiving the Helpern Laureate Award.

Use of the suggestions outlined in these brief remarks are meant to enhance the quality of your service to the community. This is the primary reason for their implementation. However, they also enhance the perception of your office by the people of the community who interact with you. This can frequently provide a base of support when trouble arises. And many, if not most of you, have experienced or will experience unfavorable media coverage sometime during your professional career. How you will fare in such a situation will depend not only on the validity of the criticism directed against you but on the perception of the public, as influenced by the news media. It is at this unexpected and critical time that your past public relations' efforts will bear fruit.

Changes in classification of suicide in England and Wales: time trends and associations with coroners' professional backgrounds.

BACKGROUND: The legal definition of suicide in England and Wales (E & W) gives rise to a high proportion of open verdicts and an underestimated suicide rate. We examined whether the ratio between open and suicide verdicts in E & W has changed between 1974 and 1991 and whether it varies according to coroners' qualifications. METHODS: Temporal changes of the ratio of open and suicide verdicts were examined using logistic regression adjusting for confounders such as changing age and gender distributions of suicide victims and the methods they use. RESULTS: Adjusted for age at death and suicide method, the ratio between open and suicide verdicts had, over successive 3-year time periods, increased with a factor 1.21 (95% CI 1.20-1.23) for male and 1.15 (95% CI 1.14-1.17) for female deaths. Medical coroners were 1.25 (1.08-1.44) times more likely than non-medical coroners to return open rather than suicide verdicts. CONCLUSIONS: As a likely result of factors in the death registration system, the ratio between open and suicide verdicts has increased substantially in E & W since the early 70s. In 1990 it was higher than in any other comparable country. This has important implications for comparisons of time trends in suicide between E & W and other countries.