Autopsy Suite Research Articles

Utility of a Handheld Blood Ketone Meter as a Postmortem Indicator of Diabetic Ketoacidosis.

When investigating a death potentially due to diabetic ketoacidosis (DKA), it is challenging to assess the glucose level in the blood, but β-hydroxybutyrate, the most prevalent ketone body in the blood, is relatively stable after death. The aim of this project is to prove that a commercially available ketone meter can be used on postmortem blood samples to aid the diagnosis of DKA in a novel setting (during coroner/medical examiner examination). Samples with acetone detected via gas chromatography were chosen retrospectively to determine whether the meter could detect ketones in postmortem blood (proof-of-concept). In all of the thawed samples, the meter detected an elevated ketone level. Samples were then obtained in a prospective manner to include those with a possible cause of death from DKA along with controls. We correctly identified 16 cases in which death was due to DKA with use of the ketone manner. The ketone levels ranged from 2.6 to 5.4 mmol/L in those cases. The diagnosis was confirmed with a greatly elevated vitreous glucose concentration or glycated hemoglobin concentration. Detecting the presence of ketones while in the autopsy suite allowed for more accurate preliminary diagnoses and utilization of resources.

The International Society for Biological and Environmental Repositories Presents Abstracts from Its 2021 Annual Meeting Connect and Collaborate through Biobanking: Powering Innovation and Discovery May 10–14, 2021

The International Society for Biological and Environmental Repositories Presents Abstracts from Its 2021 Annual Meeting Connect and Collaborate through Biobanking: Powering Innovation and Discovery May 10–14, 2021

Modeling Temperature Variations Using Monte Carlo Simulation: Implications for Estimation of the Postmortem Interval Based on Insect Development Times*, †.

The association between insect development and temperature is well established. Thermal summation using accumulated degree-day measures is commonly used. However, the time at which evidence is collected is important in these estimates. The aim of this study was to provide a simulated model of the effect of temperatures on six dipteran species commonly associated with cadavers, from the death scene to the refrigerator, and finally at the time of autopsy. Temperatures measurements were sampled over a 16-month period from the external environment (external to the mortuary), within the mortuary refrigerator, and within the mortuary autopsy suite. Monte Carlo simulation using accumulated degree-days (ADD) was used to estimate the variations based on the mean and standard deviation of the temperature measurements. It was found that there was a negative correlation between the base temperature of the fly species (lowest temperature at which the flies will survive) and developmental likelihood. Species with high base temperatures (Chrysomya albiceps, Chrysomya chloropyga, and Musca domestica) were less likely to continue development in refrigerators than species with lower base temperatures (Lucilia sericata and Piophila casei). The findings of this study highlight the importance of recording temperature measurements and the period of refrigeration on PMI estimation especially when continued development occurs in spite of a period of cooling of the insect evidence.

Rethinking COVID-19 'pneumonia' - is this primarily a vaso-occlusive disease, and can early anticoagulation save the ventilator famine?

Rethinking COVID-19 'pneumonia' - is this primarily a vaso-occlusive disease, and can early anticoagulation save the ventilator famine?

The craniotomy box: an innovative method of containing hazardous aerosols generated during skull saw use in autopsy on a COVID-19 body.

During a disease pandemic, there is still a requirement to perform postmortem examinations within the context of legal considerations. The management of the dead from COVID-19 should not impede the medicolegal investigation of the death where required by the authorities and legislation but additional health and safety precautions should be adopted for the necessary postmortem procedures. The authors have therefore used the craniotomy box in an innovative way to enable a safe alternative for skull and brain removal procedures on suspected or confirmed COVID-19 bodies. The craniotomy box technique was tested on a confirmed COVID-19 positive body where a full postmortem examination was performed by a team of highly trained personnel in a negative pressure Biosafety Level 3 (BSL-3) autopsy suite in the National Institute of Forensic Medicine (IPFN) Malaysia. This craniotomy box is a custom-made transparent plastic box with five walls but without a floor. Two circular holes were made in one wall for the placement of arms in order to perform the skull opening procedure. A swab to detect the presence of the SARS-CoV-2 virus was taken from the interior surface of the craniotomy box after the procedure. The result from the test using real-time reverse transcriptase polymerase chain reaction (rRT-PCR) proved that an additional barrier provided respiratory protection by containing the aerosols generated from the skull opening procedure. This innovation ensures procedures performed inside this craniotomy box are safe for postmortem personnel performing high risk autopsies during pandemics.

Exposure reduction in COVID-19 autopsies.

DEAR EDITOR: With personal protective equipment (PPE) in high demand during the COVID-19 pandemic, members of the clinical and laboratory communities, including those in autopsy pathology, have had to conserve PPE and revise protocols to expand safety measures. Many institutions are not performing autopsies on COVID-19 patients due to lack of PPE and appropriate environmental controls. Others are performing limited autopsy examinations to decrease risk to staff. Until the infectiousness of SARS-CoV-2 in postmortem tissues and fluids can be quantified, the U.S. Centers for Disease Control and Prevention and The College of American Pathologists (CAP) recommends standard, contact, and airborne precautions to be practiced during autopsies on COVID-19 positive patients, as well as limiting aerosol-generating procedures.1,2 While these precautions are important and effective, splash risk and surface contamination of tissues during handling are still prevalent during these procedures. To help mitigate splash risk, potential aerosolization, and surface contamination, two specialty devices were built to decrease exposure to contaminated fluids and materials (Figure 1). Figure 1R.A.G.E. cage full set up with ironing board support (A) and close up of suspension with door hooks (B).: The first device, named the R.A.G.E. (Reduction in Autopsy Grossing Exposure) cage, was developed to supplement protection to the autopsy staff in addition to PPE and environmental controls. Engineering and fabrication means were limited, so design and construction were kept to feasible methods with standard hand and power tools. The cage consists of readily available 3/4 inch PVC pipe, acrylic glass panes, standard metal screws, and hardware (approximate cost $300). The PVC pipe and acrylic panes were cut to size at local hardware stores and the pieces assembled by the autopsy staff. “Hand slots” for access were cut into the acrylic using a standard rotary tool. Once aligned, pilot holes were drilled into the acrylic and PVC and were screwed together. The cage is slightly larger than the dimensions of the autopsy table to allow full coverage. Suspension was achieved using over-the-door hooks wedged into the perimeter of the table. For extra support at the head of the table, an adjustable ironing board was placed underneath (Figure 1). In addition to the cage, a two-person autopsy performance protocol was developed to decrease splash leading to potential aerosolization. This procedure utilizes an assembly line workflow with personnel alternating between “cutting” and “measurement/handling” roles. Our experience with the R.A.G.E. cage has proven to decrease excessive splash during fluid suctioning and organ removal. While all staff wears powered, air-purifying respirators (PAPR) with full face coverage, the R.A.G.E. cage has prevented incidents that otherwise would have led to staff and autopsy suite contamination. This protection does come at a small cost of mobility during autopsy performance, but with the two-person protocol mentioned above, this is minimal. R.A.G.E. cage materials can be easily wiped, disinfected, and stored after the conclusion of the case. The second device that was developed is called the “viral Deactivation Under Nesting-compression Kinetics” (D.U.N.K.) tank. The D.U.N.K. tank is a simple device composed of two nesting plastic buckets. One is filled approximately halfway with 10% formalin, and the second is perforated with several coin-sized holes on the bottom (Figure 2). Figure 2D.U.N.K. tank schematic.: Organs of interest that pose higher a risk of viral contamination are placed into the formalin bucket and are then compressed with the perforated bucket. Compression increases the likelihood that the entirety of the organ(s) external surface is decontaminated. In cases of patients diagnosed with COVID-19, the heart and lungs are placed in the D.U.N.K. tank and decontaminated for 10 minutes.3,4 Further insufflation of the lungs and stuffing of the heart chambers with formalin-soaked gauze may be accomplished safely. It is worth considering that while the COVID-19 pandemic is expected to subside in the upcoming months, the current challenges have increased personal and institutional awareness on resource limitations. The responsibility lies on the healthcare industry to work together to conserve resources and innovate new solutions that can reinforce the abilities to provide optimal patient care while maintaining safe working conditions.

VirtoScan-on-Rails - an automated 3D imaging system for fast post-mortem whole-body surface documentation at autopsy tables.

Two-dimensional photographic documentation is a substantial part of post-mortem examinations for legal investigations. Additional three-dimensional surface documentation has been shown to assist in the visualization of findings and contribute to the reconstruction of the sequence of events. However, 2D photo documentation and, especially, 3D surface documentation, are time-consuming procedures that require specially trained personnel. In this study a 3D imaging system, called VirtoScan-on-Rails, was developed to automate and facilitate 3D surface documentation for photo documentation in autopsy suites. The imaging system was built to quickly acquire photogrammetric image sets of whole bodies during different stages of external and internal examinations. VirtoScan-on-Rails was set up in the autopsy suite of the Zurich Institute of Forensic Medicine at the University of Zurich (Zurich, Switzerland). The imaging system is based on a movable frame that carries a multi-camera array. Data quality and the applicability of the system were analyzed and evaluated within two test series. Up to 200 overlapping photographic images were acquired at consecutive image-capturing positions over a distance of approximately 2000mm. The image-capturing process took 1min and 23s to acquire a set of 200 images for one side of the body. During test series one and two, 53 photogrammetric image sets taken from 31 forensic cases were successfully reconstructed. VirtoScan-on-Rails is an automated, fast and easy-to-use 3D imaging setup for autopsy suits. It facilitates documenting bodies during different stages of forensic examinations and allows standardizing the procedure of photo documentation.

Implementation of modern tools in autopsy practice-the way towards contemporary postmortal diagnostics.

Medical, legal, and socioeconomic issues have contributed to the decline of autopsy rates. Pathology-related factors, however, with changing clinical duties on the one hand and decreasing interest and lack of substantial technical developments in this field on the other, may have contributed to this condition as well. We present our experience of a restructuring project that culminated in the introduction of a modernized postmortal diagnostic (PMD) unit: Workflows of PMD procedures and space organization were restructured according to LEAN management principles method. Classical autopsy suites were transformed into postmortal operating rooms. A PMD pathologist staff was designated to perform postmortal operative diagnostics (i.e., using laparotomy and thoracotomy approaches) with the intention of gradually replacing classical autopsy procedures. Postmortal minimal invasive diagnostics (PMID) using laparoscopy and thoracoscopy were successfully implemented with the expertise of clinical colleagues. Reorganization of workflow reduced turn-around times for PMD reports from a median of 33days to 15days. Short-term analysis revealed that this combined effort leads to a slight increase in the number of adult postmortal examinations 1year after the introduction of this project. A change of culture in postmortal diagnostics may contribute to a better reputation of postmortal examinations from the perspective of clinicians, the general public, and affected relatives of the deceased. It may also serve to demonstrate that the pathology community is keen not only to preserve but also to further develop this valuable tool for medical quality control and education.

VirtoScan - a mobile, low-cost photogrammetry setup for fast post-mortem 3D full-body documentations in x-ray computed tomography and autopsy suites.

Injuries such as bite marks or boot prints can leave distinct patterns on the body's surface and can be used for 3D reconstructions. Although various systems for 3D surface imaging have been introduced in the forensic field, most techniques are both cost-intensive and time-consuming. In this article, we present the VirtoScan, a mobile, multi-camera rig based on close-range photogrammetry. The system can be integrated into automated PMCT scanning procedures or used manually together with lifting carts, autopsy tables and examination couch. The VirtoScan is based on a moveable frame that carries 7 digital single-lens reflex cameras. A remote control is attached to each camera and allows the simultaneous triggering of the shutter release of all cameras. Data acquisition in combination with the PMCT scanning procedures took 3:34min for the 3D surface documentation of one side of the body compared to 20:20min of acquisition time when using our in-house standard. A surface model comparison between the high resolution output from our in-house standard and a high resolution model from the multi-camera rig showed a mean surface deviation of 0.36mm for the whole body scan and 0.13mm for a second comparison of a detailed section of the scan. The use of the multi-camera rig reduces the acquisition time for whole-body surface documentations in medico-legal examinations and provides a low-cost 3D surface scanning alternative for forensic investigations.

Utilitarian Aspects of Postmortem Computed Tomography

Computed tomography has been used in clinical medicine for decades, but only recently introduced into the forensic pathology setting. The reasons for the slow adoption of this technology into the autopsy suite are various, including concerns about funding, infrastructural maintenance, training, competency, and scope of utilization. Practical experience in a busy statewide medical examiner department confirmed the utility of this technology as a part of daily practice. The impact of postmortem computed tomography (PMCT) on casework can be stratified into three broad groups: where PMCT 1) supplants invasive autopsy, 2) supplements invasive autopsy, or 3) has limited or no potential for impact on practice. A detailed understanding of the practical uses of this science is important for the practicing forensic pathologist so as to guide decisions about the ways in which PMCT can be implemented within their own institutions and utilized on a daily basis. Dramatic changes in personal and institutional practice trends can be observed once forensic pathologists are comfortable with the evaluation, documentation, and interpretation of PMCT data. Examples of potential paradigm shifts include the performance of only external examination and PMCT instead of invasive autopsy in many cases of motor vehicle fatalities, suicide with violence, and broad categories of death due to natural disease. Over time, the authors believe that the PMCT will become one of the fundamental tools in the forensic pathologist's toolkit.

Epidemiological Study of Acute Toxicity in Children Admitted to Poison Control Center, Ain Shams University Hospitals during the Year 2012 -A Retrospective Study

The autopsy room is regarded as a special place for gathering scientific knowledge by conducting autopsy. The dead body for autopsy is a big sized good culture media, contaminated with microorganisms, explosives or evidence material, and so on. So, it needs lot of watchfulness, chain of custody & a bio-containment area -Autopsy suit. Water, air, people, bodies, samples, scientific equipment, gurneys, information, and disposables, all must be decontaminated before safely removed from the containment area. There must be awareness about biosafety application in dissection/autopsy room. To start with, including the same in the UG curriculum/syllabus and awareness programs for doctors who already engaged in the autopsy work. A pilot survey results authenticate the deficiency in autopsy facilities and the open space autopsy in nearly 50% of PHCs level. It is time for the department of inquest- Ministry of home affairs, to implement mobile autopsy unit/suite to avoid the heinous open space autopsy. However, Construction of autopsy suite and implementation of mobile autopsy suite with the consideration of biosafety, is must and is to be proceeded in consultation with experts in the subject.

Systemic sclerosis (scleroderma): An insight into a rare condition and cause of death

Systemic sclerosis is a debilitating and rare autoimmune disease with only approximately 200 cases in Singapore (from 2008-2012). Cardiovascular and pulmonary involvement remain the leading causes of mortality in these patients. We present a 46-year-old Chinese male who was found dead in his home. He had presented to the emergency department with generalised weakness, dysphagia and skin thickening prior to his demise, prompting a presumptive diagnosis of scleroderma. He also had anaemia and mild transaminitis. Significant autopsy findings included thickened skin and extensive adhesions in the pleural cavity. Histological sections showed extensive subendocardial fibrosis with vasculopathy affecting the intramural myocardial vessels as well as pulmonary arterial hypertension. Fibrosis involving the wall of the oesophagus and the dermis was also present. An interesting finding was that of extensive hyalinisation of the lymph nodes in the deceased. Our findings concur with those described previously in literature and the likely cause of mortality in our case was due to extensive cardiac and pulmonary involvement. Most of the mortalities occurring from this condition are not subjected to the coroner's jurisdiction. However, the rare case that presents at the autopsy suite does provide an educational insight to the pathology behind the condition.

Infectious Disease Surveillance by Medical Examiners and Coroners

To the Editor: Medical examiners and coroners (ME/C) investigate ≈20% of all deaths in the United States (1); these include persons who die outside the health care system or die precipitously without a confirmed diagnosis. Surveillance through ME/C offices for unexplained deaths that might have infectious causes can serve as a sentinel system to identify new agents, identify notifiable diseases missed by traditional surveillance systems, recognize unique signs and symptoms of known pathogens, and detect bioterrorism (1). This surveillance model, called Med-X, is based on standards for autopsy performance, diagnostic testing, and public health reporting and is currently being performed locally in a small number of offices. To assess more widely the capacity of ME/C offices to conduct infectious disease surveillance, the National Association of Medical Examiners distributed an Internet-based questionnaire to 155 ME/C offices in the United States that serve populations >300,000; the questionnaires were completed during August–September 2009. Survey questions addressed interest in and physical, personnel, and logistical capacities for conducting surveillance for deaths that could have resulted from infectious diseases. Because many infections can be transmitted during autopsy, specific biosafety features for the autopsy suite were also assessed. The ME/C offices that responded (68/155) are responsible for 59% of the population served by the target ME/C offices and, on average, perform autopsies on 33% (range 12%–80%) of their cases. Most of the responding offices were the principal office for the area, which was primarily at the county or parish level. Of the responding offices, 97% indicated an interest in a medical examiner–based surveillance system for infectious diseases; 13% currently identify and report cases through the Med-X system. Almost half of the respondents noted some Biosafety Level 3 features in their facilities, including negative pressure ventilation, double-door entry into autopsy suites, or appropriate air exchange and ventilation systems. With respect to current capabilities and practices of surveillance of infectious diseases, most respondents had optimal databases that contained complete and searchable data that included circumstances of death narrative, autopsy findings, and laboratory results. Most offices also had established practices of identifying infectious diseases and of reporting to local or state health departments notifiable and nonnotifiable diseases. The most often cited barriers to participation in ME/C infectious disease surveillance were funding and resources (85%), lack of supplies (76%), insufficient laboratory testing capability (69%), and personnel requirements (63%). These factors all relate primarily to the subsequent autopsies resulting from the surveillance. With respect to current autopsy practices, survey results suggest that inadequate usage of personal protective equipment (6%), lack of autopsy suites with negative pressure (21%), and inadequate required vaccinations (e.g., hepatitis B) for pathologists (40%) are areas where improvement is needed. During the past few decades, several diseases of public health importance, including new or emerging infectious diseases, have been recognized and identified through the collaborative efforts of public health partners and medical examiners, performance of autopsies, and subsequent postmortem diagnostic testing (2–4). The findings from this survey suggest that interest and potential exist for the establishment of an enhanced national ME/C-based surveillance system for novel or emerging infectious diseases and bioterrorism. A surveillance protocol is already available for distribution (5). Although survey respondents showed high interest in such a system, this result may be an overestimation because of the offices targeted and the low overall response rate. Addressing existing barriers, including funding and infrastructure deficiencies, may increase participation in such a national surveillance system. Development of a national surveillance system of this type would require fulfilling recently identified steps needed to strengthen the competency of national death investigation systems (6), establishment of uniform statewide and interstate standards of operation such as those outlined in the National Association of Medical Examiners accreditation checklist (7), consolidation of smaller offices, regionalization of services, and standardization of staff training.

Digital UV/IR Photography for Tattoo Evaluation in Mummified Remains*

The presence and location of tattoos can be an important component in the identification of remains in the extended postmortem period if remnants of skin persist. However, when there is significant mummification, visualization of tattoos can be problematic. Multiple methods have been proposed to make tattoos more visible, but all have limitation. In this case report, a mummified body was discovered. The presumptive victim was reported to have a small tattoo on her hand but it was not visible to the naked eye. The hand was photographed using ultraviolet (UV) and infrared (IR) light. A tattoo matching the description was noted in the photographs. In contrast to film-based IR and UV photography, digital UV and IR photography allows rapid visual evaluation of results and optimization of image utility. The ability to quickly modify photographic parameters quickly greatly increases the utility of IR and UV photography in the autopsy suite.

You Can’t Touch This

Keyboards, mice, and touch screens are a potential source of infection or contamination in operating rooms, intensive care units, and autopsy suites. The authors present a low-cost prototype of a system, which allows for touch-free control of a medical image viewer. This touch-free navigation system consists of a computer system (IMac, OS X 10.6 Apple, USA) with a medical image viewer (OsiriX, OsiriX foundation, Switzerland) and a depth camera (Kinect, Microsoft, USA). They implemented software that translates the data delivered by the camera and a voice recognition software into keyboard and mouse commands, which are then passed to OsiriX. In this feasibility study, the authors introduced 10 medical professionals to the system and asked them to re-create 12 images from a CT data set. They evaluated response times and usability of the system compared with standard mouse/keyboard control. Users felt comfortable with the system after approximately 10 minutes. Response time was 120 ms. Users required 1.4 times more time to re-create an image with gesture control. Users with OsiriX experience were significantly faster using the mouse/keyboard and faster than users without prior experience. They rated the system 3.4 out of 5 for ease of use in comparison to the mouse/keyboard. The touch-free, gesture-controlled system performs favorably and removes a potential vector for infection, protecting both patients and staff. Because the camera can be quickly and easily integrated into existing systems, requires no calibration, and is low cost, the barriers to using this technology are low.

The Intervened Heart: Cardiac Hardware in the Forensic Suite

Cardiovascular interventions—in the form of bypass grafts, stents, prosthetic valves, and ventricular assist devices—are increasingly common for the typical citizen of the industrialized world. While these certainly contribute to longevity and improved quality of life, they can also be a source of morbidity and mortality. In most cases, a handful of predictable pathogenic pathways underlie the eventual degeneration or failure of the various interventions, and may be implicated as a cause of death. Much less frequently, an untoward and unexpected complication can be the culprit. The objectives of this manuscript are to describe the more common cardiac interventions (both mechanical and surgical), highlight the typical failure modes, and present approaches to evaluate devices and grafts when encountered in the forensic autopsy suite.

An introduction to the work of a medical examiner: from death scene to autopsy suite

An introduction to the work of a medical examiner: from death scene to autopsy suite

Cytodiagnosis in the Autopsy Suite: A Tool for Improving Autopsy Quality and Resident Education

Despite several publications attesting to its accuracy and value, cytology is rarely used for preliminary autopsy diagnosis in the United States. Postmortem cytodiagnosis has the potential to increase the accuracy and specificity of the provisional and final autopsy diagnoses, increase resident interest in cytodiagnostic techniques, and direct pathologists to request pertinent special studies, such as microbial cultures and special stains. To assess and illustrate the value of cytodiagnostic techniques for improving autopsy quality assurance and resident education. Eighty-five samples were evaluated from 49 nonconsecutive autopsies. Sixty-five focal lesions were sampled by direct scraping. Diffuse lung consolidation was sampled by fine-needle aspiration (20 samples). Smears and cytocentrifuge preparations of fine-needle aspirations were routinely stained by both Papanicolaou and Romanowski methods. Cytologic diagnoses were compared with final autopsy diagnoses, and both cytology and pertinent histology were reviewed. Clinical or radiographic antemortem site-specific diagnoses had been made in 28 (33%) of the 85 samples. A definite diagnosis was made by postmortem cytology in 68 (80%) of 85 samples, and these diagnoses could contribute to provisional autopsy diagnosis in 46 instances (68%). Resident and faculty enthusiasm for the use of cytology in the autopsy suite has increased during the 7 years following the study. Case examples illustrating the benefits of postmortem cytology are provided. Postmortem cytology benefits both autopsy quality and resident education.

Cytodiagnosis in the Autopsy Suite: A Tool for Improving Autopsy Quality and Resident Education

Abstract Context.—Despite several publications attesting to its accuracy and value, cytology is rarely used for preliminary autopsy diagnosis in the United States. Postmortem cytodiagnosis has the potential to increase the accuracy and specificity of the provisional and final autopsy diagnoses, increase resident interest in cytodiagnostic techniques, and direct pathologists to request pertinent special studies, such as microbial cultures and special stains. Objective.—To assess and illustrate the value of cytodiagnostic techniques for improving autopsy quality assurance and resident education. Design.—Eighty-five samples were evaluated from 49 nonconsecutive autopsies. Sixty-five focal lesions were sampled by direct scraping. Diffuse lung consolidation was sampled by fine-needle aspiration (20 samples). Smears and cytocentrifuge preparations of fine-needle aspirations were routinely stained by both Papanicolaou and Romanowski methods. Cytologic diagnoses were compared with final autopsy diagnoses, and bot...

Forensic Medicine in the 21st Century: A Realistic View of Our Changing Science

Forensic medicine and pathology have undergone a sea change in the last 20 years, because what was traditionally an anecdotal profession has matured into a true laboratory science replete with accuracy and reproducibility in determinations of cause, manner, and mechanisms of death. “War stories” have given way to bench science translating into the application of the scientific method at the death/crime scene and in the autopsy suite. New technologies, not the least of which is evolving DNA methodologies, have even transformed the way we all view medicolegal death investigation.Contemporaneous with developing technologies are the dual phenomena of popular television shows featuring real and fictional medical examiners and the explosion of information available to lay persons on the Internet. Such electronic accessibility is a double-edged sword: although the public may know a little about what we do, a little learning, as we know, can be a dangerous thing,1 as evidenced by juries' demands to “see the DNA evidence” even in cases in which DNA could play no role.2Several authors in this issue of the Archives of Pathology & Laboratory Medicine offer a realistic view of our quotidian tasks, as opposed to the fantasy versions in popular media. We are delighted to present the work of myriad experts renowned and revered in the subspecialty of forensic pathology for their professional, technical, and scholarly skill. Hunsaker et al write eloquently about deaths resulting from extremes of temperature, a challenge encountered throughout the world. Denton and colleagues review gunshot wounds, a universal concern confronting all in forensic science. Dr Kim Collins tackles the increasingly apparent entity of elder maltreatment, a routinely underdiagnosed tragedy. Dr Greg Davis (no relation) offers the physician reader instruction and peace of mind in how to interact with the legal profession, and Dr Randy Hanzlick reviews medical examiner and coroner systems, underscoring the reality that we are all public health physicians.This writer is privileged to know these individuals and their work.