Social Media and Medicolegal Death Investigation: Logged in To the Morgue.

Social media (SM) represent a global consumer phenomenon with an exponential rise in usage within the last few years. The various applications and websites are relatively easy and fast to access, and the number of users increases continuously. SM are an incredible source of freely available, public information about their users. The purpose of this study is to provide information about the usefulness of SM in forensic practice. The electronic database of the Cook County of Medical Examiner's Office ("CCMEO") in Illinois was searched for investigative narratives that included specific SM keywords, in the period from August 2014 to January 2018. A total of 48 cases met the study's criteria. Among these, "Facebook" has been found to be the most helpful SM for medicolegal investigation purposes. Information obtained by SM can play an important role in forensic practice since it can be used to clarify certain aspects of the medicolegal death investigation, with particular regard to time and manner of death.

Sudden Unexpected Deaths Due to Intracranial Meningioma: Presentation of Six Fatal Cases, Review of the Literature, and A Discussion of the Mechanisms of Death.

Deaths due to meningiomas are routinely diagnosed in clinical practice because this neoplasm tends to present with the typical progression of neurological deficits. On the other hand, sudden unexpected deaths due to meningiomas are rarely described in the literature. The study presents six fatal cases of previously undiagnosed intracranial meningiomas from the Cook County Medical Examiner's Office from 1998 to 2014. The most common explanation of the mechanism of sudden death due to intracranial neoplasms is a rapid increase in intracranial pressure produced by the mass effect of the neoplasm. Other mechanisms of death include acute intracranial and intratumoral hemorrhage, and benign neoplasms that grow in the vicinity of vital centers altering neural discharge in autonomic pathways leading to cardiac suppression or lethal arrhythmia. Forensic pathologists must keep in mind that sudden unexpected death caused by intracranial meningiomas, although extremely rare, may be encountered in the forensic setting.

Algor mortis: an erroneous measurement following postmortem refrigeration.

Determination of the time of death is one goal of medicolegal death investigations. Algor mortis has been used as a measure of the postmortem interval (PMI). We prospectively recorded the core temperatures of 19 adult bodies entering our morgue cooler and at 3, 6, and 9 h of refrigeration. We then compared the cooling rate with the calculated body mass index (BMI). For each individual body, the rate of cooling was fairly linear with no evidence of a plateau. There was fair to moderate correlation between the BMI and the cooling rate: cooling rate = -0.052 (BMI) + 3.52. The probability of linearity in any given case was 36%. Variables affecting this correlation included the presence and the layers of clothing and if the clothing was wet. Our data confirm that algor mortis is of very limited utility in determining the PMI in bodies that have been refrigerated.

Errors on death certificates requiring amendments: the Broward County experience.

The medical examiner's office in Broward County is responsible for determining the cause and manner of death in cases falling under its jurisdiction and issuing death certificates on these decedents. Amendments are occasionally required to correct misinformation on death certificates or within the autopsy reports. The purpose of this study was to investigate the major causes for the amendments and to develop strategies to avoid future errors. We found 128 cases from 2006 to 2007 that required amendments; 103 contained sufficient data in the file for further analysis. Over this time period, 3790 death certificates were issued over that same period, resulting in a 3.37% amendment rate. In this study, the cohort included both males and females with a ratio of 2:1. Their ages ranged from newborn to 103 years, with a mean age of 49 years. Of the 103 amended cases, amendments were made to the cause (n = 30) and often the manner (n = 21) of death listed on the death certificate; the remaining changes were limited to the autopsy report. The most common reasons for amendments included reception of delayed laboratory findings (35%), acquisition of additional medical history (22.5%), and typographic errors (15.5%). Typographic errors mainly occurred because of inaccuracies in the names originally provided to our office, the use of aliases by decedents, incorrect personal/demographic history, or various misspellings by funeral homes or medical examiner staff. The most significant reclassifications involved changing certified natural deaths to accidental overdoses and vice versa, based on toxicological analysis. Because of delays in specimen turnaround, these amendments often were made months after the original death certificate was issued. STAT urine drug screening has been helpful in reducing the number of amendments made, but certain drugs of significance are missed by rapid screens. Given that our office performed complete toxicological analysis on all cases over this period, it seems likely that we detected several overdoses that would have been missed if natural deaths were not routinely screened for potential toxins.

The accuracy of death certificate completion in a suburban community.

BACKGROUND: Death certificates provide epidemiologists and other researchers with statistical data regarding causes of death within the community. When the certificates are filled out erroneously they provide misleading and inaccurate information. The aim of our investigation was to determine whether these certificates are being completed correctly by clinicians, how frequently errors are occurring, and what types of errors are being committed by the physicians in our county. METHODS: A total of 371 consecutive death certificates issued by community physicians from Broward County between February 2007 and March 2007 were reviewed. Errors were grouped into major categories as follows: unacceptable cause of death (UC), nonspecific cause of death, irrelevant information, incorrect order, and incorrectly completed. RESULTS: About 48% of death certificates were found to have at least 1 of the 5 types of errors in the cause of death section. These were unacceptable cause errors 30.2%, non-specific errors 14.8%, incorrectly completed errors 6.5%, irrelevant information errors 4.0%, and incorrect order errors 3.5%. DISCUSSION/CONCLUSIONS: Nearly half of all death certificates reviewed in this study were found to be inaccurate. Using the results of this study, the Broward County Medical Examiner's Office has been able to tailor new physician education programs for the community.

Is lymphocytic (hashimoto) thyroiditis associated with suicide?

The histologic diagnosis of lymphocytic (Hashimoto) thyroiditis requires lymphocytic inflammation of the thyroid gland in combination with Hourthle cell metaplasia of follicular epithelial cells. Clinically, this autoimmune process has been associated with hypothyroidism and psychiatric conditions including depression. This retrospective study was designed to quantify the incidence and severity of lymphocytic thyroiditis in a series of nonconsecutive suicides compared with a cohort of motor vehicle accident victim controls. Eighty-one suicide victims (61 male, 20 female; age range 13-79 years, average 43) were compared with 88 age and gender matched controls (64 males, 24 females; age range 19-85 years, average 36). The degree of lymphocytic inflammation of the thyroid gland was graded on a scale of 0 to 3 (0 = no inflammation, 1 = mild inflammation, 2-3 moderate-to-marked inflammation with Hourthle cell metaplasia). Slides from each case were reviewed while blinded to the cause and manner of death in each case. Of these 169 total cases, 8 (4.7%) received a score of 3, whereas additional 7 (4.1%) received a grade of 2. Eighty-six percent of all of the cases showed no significant inflammation and recorded a score of 0. Of the 81 suicides, 3 had a score of 3, and 3 had a score of 2 (combined incidence of 7.4%). Within the control group, 5 of 88 cases scored 3 and another 4 scored 2 (combined incidence = 10.2%). Three males and 5 females scored 3 with an age range of 23 to 63 years, average 42. Incidental data tabulated showed that 19% of suicide victims were on psychoactive medications compared with 6% in the motor vehicle accident control group. No one on this study was on thyroid hormone replacement therapy. Depression is strongly linked to suicide and lymphocytic thyroiditis may be a cause of depression. Based on this study, however, the presence of lymphocytic thyroiditis cannot be used as a histologic adjunct to discriminate between suicide and accident in problematic cases (ie, overdose deaths). This diagnosis is rendered with essentially equal frequency in suicide victims versus controls.

Suggested guidelines for the management of high-profile fatality cases.

CONTEXT: The investigation of high-profile fatalities poses special challenges to medical examiners and coroners. Most high-profile cases can be readily recognized early in the course of the investigation. Commonly encountered examples include police-related fatalities or deaths in custody, deaths of celebrities, and mass fatalities or clustered deaths (eg, serial killers). Medical examiner and coroner offices should have policies and procedures in place for adequately handling such cases. A rational approach to these high-profile cases includes activating medical examiner or coroner investigative teams, preplanning before the autopsy, using special autopsy techniques and toxicology procedures, skillful questioning of key witnesses, preparing detailed and comprehensive reports, and planning effective communication with the media. OBJECTIVE: The investigation of the sudden and unexpected death of Anna Nicole Smith, an entertainment personality, is presented as an example of how to address the challenging issues inherent in high-profile fatalities and how to adequately prepare for the forensic investigation of high-profile cases. DESIGN: This article presents a methodical approach to the investigation of high-profile deaths. RESULTS: A comprehensive, preplanned forensic investigation and autopsy (including use of adjunctive studies) following the death of Anna Nicole Smith resulted in the accurate determination of the cause and manner of her death while adequately convincing the public of the objectivity and reliability of the Medical Examiners Office with respect to its conclusions. CONCLUSION: The forensic investigation of death in high-profile cases can be much more tedious and demanding than the investigation of routine cases. It requires more stringent safekeeping of the body and its evidence, more extensive and sophisticated dissection techniques on occasion, and exhaustive toxicologic analysis to exclude low-probability allegations. Procedures for honest, unbiased, and judicious communication with outside agencies and the media must be followed. Failure to follow such procedures might have serious consequences for the medical examiner, the family of the deceased, and the community at large. Adherence to these suggested guidelines may resolve most of the intricate problems involved in the investigation of these types of cases.

Comamonas testosteroni meningitis in a homeless man.

We report a case of meningitis caused by Comamonas testosteroni in a 54-year-old, alcoholic, homeless man. He, as a pedestrian, was struck by a car and suffered multiple fractures of the facial bones including the left frontal sinus. Over the course of 2-week hospitalization, he was clinically diagnosed with multiple cerebral and cerebellar infarcts resulting in altered mental status. He was pronounced dead 15 days after the injury. At the time of autopsy, diffuse purulent meningitis was found on gross examination. A swab culture of the brain surface was positive for C. Testosteroni, a saprophytic organism commonly found in soil and water. This is the first reported case of fatal meningitis caused by this micro-organism.

Tibial insertion of the posterior cruciate ligament: a sagittal plane analysis using gross, histologic, and radiographic methods.

PURPOSE: The literature is imprecise regarding the ideal tibial site for the posterior cruciate ligament (PCL) placement. We detail anatomic and radiographic landmarks for consistent placement of graft fixation in PCL reconstruction. METHODS: Fourteen fresh-frozen cadaver knees were sectioned in the sagittal plane. The distance from the posterior cortex of the tibia to the anterior edge of the PCL was measured. Three specimens were fixed in 10% formalin and stained using hematoxylin-eosin and trichrome to determine ligament fiber distribution and insertion. Two knees were used for radiographic analysis of pin placement. RESULTS: The mean distance across the PCL facet from the posterior cortex to the anterior edge of the PCL was 15.6 mm (+/-1.1 mm). Histologic analysis in three knees showed that the PCL fibers inserting along the PCL facet comprise the bulk of the ligament, while the fibers that insert along the posterior cortex are less than 0.5 mm thick. CONCLUSIONS: The bulk of the PCL inserts in the posterior half of the PCL facet. We show that, in the sagittal plane, the center of the working fibers of the PCL lies 7 mm anterior to the posterior cortex of the tibia, measured along the PCL facet. Tunnel placement at the center of the original ligament can be measured along the PCL facet as seen in a true lateral radiographic view. CLINICAL RELEVANCE: This study provides anatomic and radiographic criteria helpful for guide-pin placement in arthroscopic PCL reconstruction.

What is the best sample for determining the early postmortem period by on-the-spot flow cytometry analysis?

The level of degradation of DNA as a means for determining the time of death has been proposed as a valid adjunct to the classic thanatochronologic methods. The twofold aim of this work was to determine which organ might reveal both a correlation between the percentage of degradation of the DNA and the time lapse since death, and would be easiest to sample and yield the most reproducible results even in technically unfavorable situations such as on-the-spot investigations at the scene of death. A comparison of the spleen, blood, and liver showed that hepatic tissue best meets these specific needs because it shows a virtually linear correlation between the time elapsed since death and the level of degradation of the DNA, and it can easily be sampled at the scene of death by use of a common biopsy needle.