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.

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."

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.

Features of commercial computer software systems for medical examiners and coroners.

There are many ways of automating medical examiner and coroner offices, one of which is to purchase commercial software products specifically designed for death investigation. We surveyed four companies that offer such products and requested information regarding each company and its hardware, software, operating systems, peripheral devices, applications, networking options, programming language, querying capability, coding systems, prices, customer support, and number and size of offices using the product. Although the four products (CME2, ForenCIS, InQuest, and Medical Examiner's Software System) are similar in many respects and each can be installed on personal computers, there are differences among the products with regard to cost, applications, and the other features. Death investigators interested in office automation should explore these products to determine the usefulness of each in comparison with the others and in comparison with general-purpose, off-the-shelf databases and software adaptable to death investigation needs.

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.

Atypical autoerotic deaths.

So-called "typical" autoerotic fatalities are the result of asphyxia due to mechanical compression of the neck, chest, or abdomen, whereas "atypical" autoeroticism involves sexual self-stimulation by other means. We present five atypical autoerotic fatalities that involved the use of dichlorodifluoromethane, nitrous oxide, isobutyl nitrite, cocaine, or compounds containing 1-1-1-trichloroethane. Mechanisms of death are discussed in each case and the pertinent literature is reviewed.

Computer software program to plot locations of death.

A BASIC computer software program that plots the occurrence of various types of death on a grid map is described. The capabilities, requirements, and potential uses of the program are discussed.

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 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.

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.

Postmortem blood concentrations of parent tricyclic antidepressant (TCA) drugs in 11 cases of suicide.

The blood levels of parent tricyclic antidepressant (TCA) drugs in 11 cases of suicide are reviewed. Values ranged from 0.11 mg% to 2.4 mg% with a mean of 0.80 mg%, which is consistant with the recent literature. The data suggest that in autopsy cases where TCA tissue levels or TCA metabolite concentrations could not be, or were not determined, blood levels of parent TCA drugs exceeding 0.1 mg% may be regarded confidently as the cause of death when no other cause is present.

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.

Sudden death due to anomalous right coronary artery in a 26-year-old marathon runner.

Sudden death due to an anomalous right coronary artery is reported. Once considered a normal variant, there is now evidence that origin of the right coronary artery from the left sinus of Valsalva may cause morbidity and mortality. Salient features of the condition are discussed.

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.