Safety in bullet recovery procedures: a study of the Black Talon bullet.

Bullets or bullet fragments that are recovered during forensic autopsy and examined later as evidence may present hazards to both pathologists and forensic scientists due to sharp edges or jagged projections created by the deformation or fragmentation of a bullet upon impact with its target. The recent introduction of the Black Talon bullet has increased this hazard by its design, which produces a controlled expansion upon target impact that raises six harp edges from its copper jacket. We describe the appearance of the bullet along with methods for detection and recovery that can be applied as universal precautions of safe bullet handling.

Detection of drugs-of-abuse in meconium of a stillborn baby and in stool of a deceased 41-day-old infant.

When blood or urine is unavailable, postmortem meconium or stool from infants or stillbirths can be used to detect drugs-of-abuse, thus providing datum in assessing drug-abuse exposure. Two case reports illustrate how drugs-of-abuse findings in post-mortem specimens were used to substantiate exposure prior to death or a history of maternal drug abuse. The first, a congenital hydrocephalus, born to a non-drug abusing mother, expired at the age of 41 days, had opiates in the stool by screening method, enzyme multiplied immunoassay technique, confirmed by gas chromatographic/mass spectrometric (GC/MS) analysis. Investigation revealed that morphine had been administered for three days prior to death. The second was a stillbirth infant born to a drug abuser. Almost equal amounts of benzoylecgonine were found in different bowel segments, a finding consistent with admitted cocaine use throughout pregnancy.

Evolving trends revealed by autopsies of patients with the acquired immunodeficiency syndrome. 565 autopsies in adults with the acquired immunodeficiency syndrome, Los Angeles, Calif, 1982-1993 [corrected].

OBJECTIVE: To determine changes in causes of death, survival, and organ system distribution of major opportunistic infections and neoplasms in adults dying with the acquired immunodeficiency syndrome (AIDS) following the widespread use of antiretroviral therapy and prophylaxis for opportunistic infections since 1988. DESIGN: A retrospective review of autopsy records with gross and microscopic pathologic findings, laboratory data, and clinical histories in cases of AIDS, comparing findings from 1982 through 1988 with those from 1989 through May 1993. SETTING: All autopsies were performed on persons dying in the metropolitan Los Angeles, Calif, area from January 1982 through May 1993. RESULTS: In 565 adult cases of AIDS at autopsy, Pneumocystis carinii pneumonia (PCP) remained the most common cause of death, but both the frequency of and number of deaths of PCP declined over time. Deaths from bacterial sepsis, cytomegalovirus infection, Mycobacterium avium complex infection, and toxoplasmosis also declined during this period, but mortality from fungal infections, tuberculosis, encephalopathy, and causes unrelated to AIDS increased. The death rate from malignant lymphoma remained high. Kaposi's sarcoma (KS) continued to occur more frequently in patients whose risk factor for human immunodeficiency virus infection (HIV) was homosexuality or bisexuality, but the death rate from KS was greatest for patients with a risk factor of blood exposure to HIV. Survival was shorter and deaths from tuberculosis more common in patients with a history of intravenous drug use. Overall survival of patients in other AIDS risk groups increased over time, particularly in those treated with antiretroviral therapy. The organ system distribution of major opportunistic infections and neoplasms was similar throughout the years of the study. The lung was the most frequent organ involved by AIDS-associated diseases leading to death, followed by the gastrointestinal tract and the central nervous system. CONCLUSIONS: The causes of death in AIDS have evolved since 1988 following the widespread use of prophylactic and antiretroviral therapies in patients with HIV infection. This has occurred primarily from changes in overall frequency and death rates from infections. Organ system involvement by AIDS-associated diseases has not changed significantly over time.

Testing for drugs of abuse in meconium of newborn infants.

A reliable and sensitive screening procedure has been developed for drugs of abuse (amphetamines, cocaine metabolites, opiates, and phencyclidine [PCP]) in meconium from infants. The substances in meconium were extracted with chloroform-isopropanol (3:1) and screened by enzyme multiplied immunoassay technique (EMIT). The lower detection limits of the EMIT for benzoylecgonine, d-methamphetamine, morphine, and PCP were 250 ng/g, 730 ng/g, 110 ng/g, and 100 ng/g, respectively. This method was applied to meconium from 50 infants born to mothers suspected of using the drugs of abuse during pregnancy. Of the 50, 12 were positive for benzoylecgonine, seven for opiates, and one for PCP. The presence of benzoylecgonine and PCP in meconium was confirmed by gas chromatography/mass spectrometry and that of opiates by thin-layer chromatography. The routine analysis of meconium for drugs of abuse is recommended in cases where (A) urine can not be obtained or (B) urinalysis is negative for the substances despite a strong suspicion of maternal use of the substances during pregnancy.

[AIDS epidemic and infection control in the United States].

AIDS is the second leading cause of death among persons 25-44 years of age. The risk to patients from physicians and other health care workers with HIV infection has also become a great public concern. There are no specific procedures for infection control in AIDS. Universal precautions are applied to AIDS as well as to any other infectious diseases. Recommended universal infection control in autopsy room is as follows: 1. Wear protective masks and eyewear (or face shields), laboratory coats, gloves, and waterproof aprons; 2. Develop and consistently practice the skills necessary to avoid penetrating injuries; 3. Decontaminate instruments and work areas contaminated during postmortem procedures with a 1:10 dilution of common household bleach, whose active ingredient is sodium hypochlorite; 4. Dispose of waste contaminated with body fluids into a red trash can indicated "BIOHAZARD". In case of accident such as needlestick or cut during autopsy of HIV infected corpe, the person should have the HIV antibody test and start taking azidothymidine (AZT) within 24 hours.

Fatal hydrothorax associated with subclavian vein catheterization for hemodialysis.

A rare iatrogenic complication of subclavian vein catheterization for hemodialysis is massive hydrothorax. A case is presented that illustrates the need for adherence to a standard procedure of prompt roentgenologic examination in conjunction with catheterization, and emphasizes the importance of the autopsy as a means of quality assurance.

[Death investigation system in the United States].

In light of recent developments and public interest on the issue of organ transplant and the definition of death by neurological function ("brain death"). A more expansive role of medicolegal investigation of deaths may be needed. This article was presented for the purpose of understanding the medicolegal investigative system in the United States. The traditional coroner system in the United States was taken from the English system and was established as an elected coroner system during a colonial period. The coroner system became more politically involved and the coroner was elected by popular votes. The political aspect was the main driving force and the medicolegal aspect was ignored, thus, the Commonwealth of Massachusetts was the first state to adopt the medical examiner system. In 1991, 41 out of 50 states have adopted the medical examiner system, either state-wide or on a local option. One of the principal differences between coroner and medical examiner systems is the qualification of the head of the agency. The coroner is an elected individual who acts as an administrator and conducts quasi-judicial function of the department. The medical function is delegated to a physician who performs his duty often on a part-time basis. The medical examiner's office is headed by a Board certified Forensic Pathologist who acts as an administrator and directs all functions including medical and scientific investigation. He is a public employee and is protected under the civil service rules, thus, his decision would be less likely influenced by political pressure. The jurisdiction of the coroner and medical examiner is generally the same by law, however a medical examiner's approach and decision-making is more medically oriented and tends to be more expansive and ready to adopt to the needs in medicolegal issues arising from scientific progress.(ABSTRACT TRUNCATED AT 250 WORDS)

Fixed human tissues: a resource for the identification of individuals.

Polymorphic genetic loci of the deoxyribonucleic acid (DNA) present in formalin-fixed, paraffin-embedded tissues were successfully analyzed by utilizing the polymerase chain reaction. Using this analysis, with three different polymorphic loci [human leucocyte antigen (HLA) DQ alpha, low-density lipoprotein receptor, and parathyroid hormone], fixed tissues representing 14 different individuals were genotyped and could be distinguished from each other. The techniques were further applied to the fixed autopsy tissues of a man in which a question of paternity arose postmortem. Since many individuals have surgical procedures or autopsy, these readily available fixed tissues represent an additional resource for the identification of individuals.

A simple histochemical technique for the identification of gunshot residue.

Alizarin red S (ARS) is a commonly used organic dye useful in the histologic identification of calcium deposits. ARS also forms colored reaction products with other metal ions, including barium and lead, which are present in primer residue. In histochemical studies, ARS is shown to identify primer residues from several manufacturers as well as primer residue deposited in tissue, either experimentally or in close-range gunshot wounds. This can be easily accomplished with routine histologic techniques. ARS does not stain gunpowder residue, tattoo pigment, melanin, graphite, india ink, or anthracotic pigment.

Causes of death in hospitalized intravenous drug abusers.

The authors reviewed at autopsy the causes of death of 274 patients with evidence of intravenous drug abuse who had been admitted to a large public hospital. There were 127 who died from diseases unrelated to intravenous drug abuse, and in 41% of these, chronic alcoholism was implicated. Deaths from overdose syndromes and drug-related organ pathology comprised only 11% of all cases. The mean age at death was 39 years. There was a male/female ratio of 3.6:1. Half of all patients died from infection--72 from acquired immunodeficiency syndrome (AIDS) alone. These findings indicate that persons hospitalized with a history of intravenous drug abuse usually die from causes other than overdose and that AIDS and chronic alcoholism are significant problems. Emphasis should be placed upon detecting "hidden" intravenous drug deaths to provide more accurate statistical information.

AIDS and infection control in forensic investigation.

Infection control in the workplace is becoming an increasingly important issue, not only for health care workers, but also for any workers who could potentially be exposed to infectious material. We discuss the nature, modes of transmission, and infectivity of important infectious agents likely to be encountered in the course of forensic investigations. We provide principles and guidelines for appropriate procedures and practices to be followed in a program of infection control.

Death certification. Purposes, procedures, and pitfalls.

Completing a death certificate properly and promptly is an important duty for physicians, who must understand how the death certificate is used and be able to recognize and employ the concepts of immediate, underlying, and contributing causes of death. Accurate, concise terminology should be used to give in a logical order a sequence of events leading to death. Avoiding mistakes in death certification helps reduce potential medicolegal problems and provides more meaningful statistics for health care personnel.

The epidemiology of fatal burn injuries.

The paper retrospectively reviews 80 burn fatalities from accidents or attempted suicides with patients admitted to the LAC-USC Medical Center from 1983 to 1987 to determine demographic factors, etiology of the burn injury, and existence of predisposing risk factors. The average age of fatal burn victims was 44 years; 74% were males, 39% were Caucasian, 35% were black, 21% were Hispanic, and 5% were of Asian descent. Blacks and Caucasians were overrepresented and Hispanics underrepresented in relation to all autopsy cases. Major etiologic factors included suicide, falling asleep while smoking, accidents while working with volatile solvents, housefires, scalds, cooking accidents, and accidents involving motor vehicles. Gasoline was the commonest solvent involved with burn fatalities. Significant risk factors for burn fatality were substance abuse (25% of cases) and impaired mental function (19% of cases).

Significance of cyanide in medicolegal investigations involving fires.

This article presents the significance of cyanide in medicolegal investigation of fires. It discusses the various aspects of fire investigation and the pathophysiology of cyanide toxicity and evidence interpretation in fire investigations.

Evaluation of death from hypoglycemia.

Hypoglycemia involving a serum glucose of 40 mg/dl or less may lead to death from hypoglycemic coma. Hypoglycemia may be a factor in sudden or unexpected deaths investigated by a medical examiner. We reviewed the data from 54,850 autopsies in a large acute-care medical center to investigate the range of underlying conditions leading to hypoglycemic coma and found 123 cases, which included complications of alcoholism in 41 (33%), drugs in 26 (21%), neoplasia in 26 (21%), conditions producing chronic passive congestion of liver in eight (7%), debilitating neurologic disease in eight (7%), endocrine disorders in four (3%), and a variety of miscellaneous conditions in ten (8%) cases. The commonest mechanisms producing hypoglycemia included liver disease with impaired carbohydrate metabolism, endogenous or exogenous drug or hormonal effect, and inanition from decreased intake of food.

The medical examiner and AIDS. Death certification, safety procedures, and future medicolegal issues.

The current worldwide epidemic of AIDS will have profound consequences not only for the delivery of health care, but also for forensic pathologists and investigators. AIDS continues to spread in definable risk groups, and deaths within some of these groups may fall under the jurisdiction of the medical examiner. We outline an approach to handling AIDS deaths based upon case definition, diagnosis by available information and procedures, and proper infection control. We also discuss medicolegal issues surrounding deaths due to AIDS.

Suicide in a patient with undiagnosed periarteritis nodosa.

Surveys of medical examiners' records have shown that as many as one-third of suicide victims have serious physical illnesses. We report the case of a 56-year-old woman who committed suicide by drug overdose. At autopsy, she had severe widespread periarteritis nodosa, which had been unsuspected during life. The identification of treatable physical illness in suicide victims is important in suicide prevention, yet such illness may be overlooked after death unless a forensic autopsy is performed.