Medical Examiner System Research Articles

AQME: A forensic mitochondrial DNA analysis tool for next-generation sequencing data

The feasibility of generating mitochondrial DNA (mtDNA) data has expanded considerably with the advent of next-generation sequencing (NGS), specifically in the generation of entire mtDNA genome (mitogenome) sequences. However, the analysis of these data has emerged as the greatest challenge to implementation in forensics. To address this need, a custom toolkit for use in the CLC Genomics Workbench (QIAGEN, Hilden, Germany) was developed through a collaborative effort between the Armed Forces Medical Examiner System − Armed Forces DNA Identification Laboratory (AFMES-AFDIL) and QIAGEN Bioinformatics. The AFDIL-QIAGEN mtDNA Expert, or AQME, generates an editable mtDNA profile that employs forensic conventions and includes the interpretation range required for mtDNA data reporting. AQME also integrates an mtDNA haplogroup estimate into the analysis workflow, which provides the analyst with phylogenetic nomenclature guidance and a profile quality check without the use of an external tool. Supplemental AQME outputs such as nucleotide-per-position metrics, configurable export files, and an audit trail are produced to assist the analyst during review. AQME is applied to standard CLC outputs and thus can be incorporated into any mtDNA bioinformatics pipeline within CLC regardless of sample type, library preparation or NGS platform.An evaluation of AQME was performed to demonstrate its functionality and reliability for the analysis of mitogenome NGS data. The study analyzed Illumina mitogenome data from 21 samples (including associated controls) of varying quality and sample preparations with the AQME toolkit. A total of 211 tool edits were automatically applied to 130 of the 698 total variants reported in an effort to adhere to forensic nomenclature. Although additional manual edits were required for three samples, supplemental tools such as mtDNA haplogroup estimation assisted in identifying and guiding these necessary modifications to the AQME-generated profile. Along with profile generation, AQME reported accurate haplogroups for 18 of the 19 samples analyzed. The single errant haplogroup assignment, although phylogenetically close, identified a bug that only affects partial mitogenome data. Future adjustments to AQME’s haplogrouping tool will address this bug as well as enhance the overall scoring strategy to better refine and automate haplogroup assignments. As NGS enables broader use of the mtDNA locus in forensics, the availability of AQME and other forensic-focused mtDNA analysis tools will ease the transition and further support mitogenome analysis within routine casework. Toward this end, the AFMES-AFDIL has utilized the AQME toolbox in conjunction with the CLC Genomics Workbench to successfully validate and implement two NGS mitogenome methods.

Performance evaluation of a mitogenome capture and Illumina sequencing protocol using non-probative, case-type skeletal samples: Implications for the use of a positive control in a next-generation sequencing procedure

Next-generation ancient DNA technologies have the potential to assist in the analysis of degraded DNA extracted from forensic specimens. Mitochondrial genome (mitogenome) sequencing, specifically, may be of benefit to samples that fail to yield forensically relevant genetic information using conventional PCR-based techniques. This report summarizes the Armed Forces Medical Examiner System’s Armed Forces DNA Identification Laboratory’s (AFMES-AFDIL) performance evaluation of a Next-Generation Sequencing protocol for degraded and chemically treated past accounting samples. The procedure involves hybridization capture for targeted enrichment of mitochondrial DNA, massively parallel sequencing using Illumina chemistry, and an automated bioinformatic pipeline for forensic mtDNA profile generation. A total of 22 non-probative samples and associated controls were processed in the present study, spanning a range of DNA quantity and quality. Data were generated from over 100 DNA libraries by ten DNA analysts over the course of five months.The results show that the mitogenome sequencing procedure is reliable and robust, sensitive to low template (one ng control DNA) as well as degraded DNA, and specific to the analysis of the human mitogenome. Haplotypes were overall concordant between NGS replicates and with previously generated Sanger control region data. Due to the inherent risk for contamination when working with low-template, degraded DNA, a contamination assessment was performed. The consumables were shown to be void of human DNA contaminants and suitable for forensic use. Reagent blanks and negative controls were analyzed to determine the background signal of the procedure. This background signal was then used to set analytical and reporting thresholds, which were designated at 4.0X (limit of detection) and 10.0X (limit of quantiation) average coverage across the mitogenome, respectively. Nearly all human samples exceeded the reporting threshold, although coverage was reduced in chemically treated samples resulting in a ∼58% passing rate for these poor-quality samples. A concordance assessment demonstrated the reliability of the NGS data when compared to known Sanger profiles. One case sample was shown to be mixed with a co-processed sample and two reagent blanks indicated the presence of DNA above the analytical threshold. This contamination was attributed to sequencing crosstalk from simultaneously sequenced high-quality samples to include the positive control. Overall this study demonstrated that hybridization capture and Illumina sequencing provide a viable method for mitogenome sequencing of degraded and chemically treated skeletal DNA samples, yet may require alternative measures of quality control.

Presenting hypertension, burn injury, and mortality in combat casualties

IntroductionThe effect of presenting hypertension is poorly studied in combat casualties. We hypothesized that elevated mean arterial pressure (MAP) on presentation to combat hospitals would be associated with poor outcomes. MethodsData was obtained from the Department of Defense Trauma Registry and the Armed Forces Medical Examiner System. Variables analyzed included presenting vital signs to Role II–III military theater hospital, demographic variables, injury severity score (ISS), location and mechanism of injury, presence of traumatic brain injury (TBI), acute kidney injury (AKI), and mortality. Patients were stratified by decile of MAP and logistic regression analysis was employed to adjust for confounders. ResultsA total of 4072 subjects injured from February 2002 to February 2011 were identified. Compared to patients in the middle deciles of presenting MAP, patients in the highest and lowest MAP deciles were the only groups that demonstrated a higher mortality on univariate analysis (OR 2.06, 95% CI 1.16–2.31 and OR 2.86, 95% CI 1.76–4.67, respectively), and this relationship persisted after adjustment for ISS, HR, temperature, presence of burn injury, TBI, and AKI. Burn injury was associated with mortality in the full multivariate analysis. However, further analysis limited to patients without burn injury did not demonstrate an association between high MAP and mortality (OR 0.84, 95% CI 0.36–1.99; p=0.70). Conversely, when limited to patients with burn injury, high MAP was associated with mortality (OR 3.78, 95% CI 1.74–8.20; p=0.001). ConclusionThe relationship between mortality and presenting MAP appears to be U-shaped, demonstrating increased mortality in the lowest and highest deciles. However, mortality in the highest MAP decile appears to be limited to casualties with associated burn injury, even after adjustment for TBI, AKI, and ISS, which takes into account the severity of the burn injury. Physicians should recognize that burn patients presenting with an elevated MAP are at an increased risk for poor outcomes. Level of evidenceIII.

Youth Suicide Deaths: Investigation of Clinical Predictors in a Statewide Sample.

Death by suicide is a significant cause of mortality among youth. However, there is limited information on the demographic and clinical factors associated with youth suicide deaths. The objective of this study was to link large statewide databases to describe demographic, clinical, and cause of death characteristics among youth who died by suicide. We examined 1,218 decedents under age 26 who died by suicie between 2000 and 2014. Eighteen died before age 12, 53 died between ages 12 and 14, 292 died between ages 15 and 18, and 855 died between ages 19 and 25. Most were male (83%), and firearm was most common cause of death; 28% previously attempted suicide, 31% had a mental health diagnosis, and 17% were prescribed psychotropic medication. Younger children died by hanging/smothering (89% of all 7- to 11-year olds), and overdose/poisoning increased progressively with age. Adolescents had a higher proportion of females than young adults (23% vs. 14%, p=.002). Combining data from the medical examiner and large hospital systems allows examination of youth suicide from a developmental perspective. Differences between age groups included gender, method, diagnosed mental illness, and diagnosis of attention deficit hyperactivity disorder. These data point to missed opportunities for effective interventions for specific developmental stages.

Department of Health consultation on medical examiners and death certification reforms: A commentary on the criteria for notification to be laid down in regulation.

The Department of Health has completed its consultation on the nature of the new medical examiner system and supporting regulations. This article considers whether the regulations for death notification to coroners are fit for purpose in the light of the medical literature on unnatural deaths and the experience of a coroner in a jurisdiction with a heavy workload from specialist hospital referrals. It concludes that they are to be welcomed, but that they should not rely on natural/unnatural death as a criterion for notification of deaths during the course of medical treatment, or refer to 'neglect'. Furthermore, they should ensure that sudden-death syndromes, which may be considered by doctors as natural, are still notified. Relying on these changes to reduce coronial investigations would be unwise. If that is the intention, other reforms may be necessary.

Tuberous sclerosis complex: Recent advances in manifestations and therapy

Tuberous sclerosis complex is an autosomal dominant inherited disorder characterized by generalized involvement and variable manifestations with a birth incidence of 1:6000. In a quarter of a century, significant progress in tuberous sclerosis complex has been made. Two responsible genes, TSC1 and TSC2, which encode hamartin and tuberin, respectively, were discovered in the 1990s, and their functions were elucidated in the 2000s. Hamartin-Tuberin complex is involved in the phosphoinositide 3-kinase-protein kinaseB-mammalian target of rapamycin signal transduction pathway, and suppresses mammalian target of rapamycin complex1 activity, which is a center for various functions. Constitutive activation of mammalian target of rapamycin complex1 causes variable manifestations in tuberous sclerosis complex. Recently, genetic tests were launched to diagnose tuberous sclerosis complex, and mammalian target of rapamycin complex1 inhibitors are being used to treat tuberous sclerosis complex patients. As a result of these advances, new diagnostic criteria have been established and an indispensable new treatment method; that is, "a cross-sectional medical examination system," a system to involve many experts for tuberous sclerosis complex diagnosis and treatments, was also created. Simultaneously, the frequency of genetic tests and advances in diagnostic technology have resulted in new views on symptoms. The numbers of tuberous sclerosis complex patients without neural symptoms are increasing, and for these patients, renal manifestations and pulmonary lymphangioleiomyomatosis have become important manifestations. New concepts of tuberous sclerosis complex-associated neuropsychiatric disorders or perivascular epithelioid cell tumors are being created. The present review contains a summary of recent advances, significant manifestations and therapy in tuberous sclerosis complex.

THE Temporal parameters of short and long-LATENT auditory evoked potentials in Operators of Automated bottling OF NON-ALCOHOLIC AND LOW-ALCOHOLIC DRINKS

Objective: to study the state of the auditory analyser central regions in operators of automated bottling of non-alcoholic and low-alcoholic drinks working in the conditions of exposure to high-level industrial noise. Material and methods. The work gives the hygienic assessment of working conditions and related factors, and in-depth clinical examination of the auditory analyser condition in operators of automated bottling of non-alcoholic and low-alcoholic drinks. Results. It has been found that the leading harmful factor in the working environment of the bottling operators is industrial noise. The signs of the specific impact of the noise on the central regions of the auditory analyser manifested in the function infringement of its brainstem and cortical structures. Conclusion. The causal relationship between the conditions, nature of work and the changes in the central regions of auditory analyser in the bottling operators has been established, which makes it possible to improve the system of preventive medical examinations, labour examination and preventive measures.

Evaluation of a methodology to validate National Death Index retrieval results among a cohort of U.S. service members

PurposeAccurate knowledge of the vital status of individuals is critical to the validity of mortality research. National Death Index (NDI) and NDI-Plus are comprehensive epidemiological resources for mortality ascertainment and cause of death data that require additional user validation. Currently, there is a gap in methods to guide validation of NDI search results rendered for active duty service members. The purpose of this research was to adapt and evaluate the CDC National Program of Cancer Registries (NPCR) algorithm for mortality ascertainment in a large military cohort. MethodsWe adapted and applied the NPCR algorithm to a cohort of 7088 service members on active duty at the time of death at some point between 2001 and 2009. We evaluated NDI validity and NDI-Plus diagnostic agreement against the Department of Defense's Armed Forces Medical Examiner System (AFMES). ResultsThe overall sensitivity of the NDI to AFMES records after the application of the NPCR algorithm was 97.1%. Diagnostic estimates of measurement agreement between the NDI-Plus and the AFMES cause of death groups were high. ConclusionsThe NDI and NDI-Plus can be successfully used with the NPCR algorithm to identify mortality and cause of death among active duty military cohort members who die in the United States.

County Coroners and Their Role in the Heart of the Opioid Epidemic.

As drug- and opiate/opioid-related deaths continue to rise in the Midwest, we must look at how the type of death investigation in these areas is affected and taxed by the increase. Many states with a large rural component rely on a local coroner system, where death investigation lacks uniformity and requirements for coroner investigative personnel are extremely variable. This has mixed implications for communities and potentially affects law enforcement and prosecution, data collection, and public policy. Both coroner and medical examiner systems benefit from strong leadership, properly trained personnel, and fiscal support. However, operational differences amongst jurisdictions should be addressed so that all stakeholders ultimately receive optimal data. This paper discusses the coroner system of death investigation in one Midwest state (Ohio) in the context of the region's burgeoning opiate/opioid epidemic and suggests opportunities for improvement.

Mortality Surveillance for Infectious Diseases in the U.S. Department of Defense (1998-2013).

The Mortality Surveillance Division (MSD) of the U.S. Armed Forces Medical Examiner System was established in 1998 to improve surveillance for all military deaths although emphasizing deaths from infectious diseases. Establishment of the MSD was part of the 1997 Department of Defense initiative to improve surveillance and response for emerging infectious diseases. Before 1998, mortality surveillance was limited to compiling information from death certificates, a system that provided limited useful information and lacked the timeliness needed to take meaningful action to address emerging infectious disease threats. The MSD was tasked to quickly identify all infectious disease deaths and the infecting agents. The system developed by the MSD staff identified deaths in near real-time and immediately notified military Public Health authorities of situations that warranted an investigation. Autopsy, medical, and investigative reports were collected. Testing specimens for agent identification was encouraged. The data and information collected were archived in the MSD-developed Medical Mortality Registry (MMR), a database that included all active duty Service Member deaths and contained manner and cause of death with medical, demographic, circumstantial, and diagnostic information. The MMR was the only comprehensive, autopsy-based source for mortality information on active duty military deaths. During 1998-2013, 217 (1.3%) infectious disease deaths were identified among 16,192 noncombat deaths. Of the 217 deaths, 29.5% were classified as respiratory, 18.0% cardiac, 15.2% blood borne, 12.9% nervous system, and 12.4% sepsis. A pathogen was identified for 64.5%. Agents of military interest identified included Neisseria meningitidis, influenza viruses, adenoviruses, and malaria. Neisseria meningitidis was identified in 10 fatal cases; grouping of the agent was done for eight cases. Four were group B, two were C, and two were Y. All eight had been immunized with a quadrivalent meningococcal vaccine. The most commonly detected respiratory agent was influenza virus (nine deaths), three of which were the 2009 pandemic H1N1 influenza virus. Adenoviruses were identified as the infectious agents in a total of nine deaths. Two deaths resulted from Plasmodium falciparum malaria infections acquired in Africa during military deployments. An important but unexplained finding was that Black Service Members made up only16.3% of all military personnel but accounted for 28.6% of all infectious disease deaths. The time lag between death and notification of the MSD at the start of this surveillance program was 24 to 48 hours. The lag at the end of the reported surveillance period was 8 to 24 hours. The MSD surveillance system identified an agent in 140 of 217 (64.5%) uniformed deaths. In a similar program by the Centers for Disease Control and Prevention, in 122 cases with specimens, an agent could be identified in 34 (28%). MMR data and information provided strong support for re-establishing the military recruit adenovirus vaccination program, which ceased in 1999 and was finally re-established in 2011. MMR data and information also assisted in monitoring the military meningococcal vaccine program, helped to describe the virulence of circulating influenza viruses, and identified areas where deadly malaria infections were not being prevented.

Confronting an Upsurge in Opiate Deaths with Limited Resources.

The dramatic increase in drug-related deaths in the last decade has presented fiduciary and logistical difficulties to medicolegal jurisdictions of all types and sizes. New Hampshire, with a centralized state medical examiner system of death investigation, has been confronted with the task of investigating these drug-related deaths against the backdrop of statutory hurdles inhibiting a nimble response to the situation. This has led to a collaborative approach with law enforcement and the state Department of Justice in terms of triaging drug deaths to full autopsy versus external examination with toxicology testing. Preliminary data suggest that between 11 and 13% of suspected drug deaths have an alternative cause of death revealed by autopsy. Positive toxicological findings were documented in 97.5% of cases in which only an external examination was performed; however, some of these cases may have had undetected, significant internal findings that could have accounted for an alternative cause of death if an autopsy had been performed. While the case triage system described has temporarily addressed the acute problem, the issue of the medical examiner's appropriate role in the adequate evaluation of public health and safety remains extant. Furthermore, noncompliance with the National Association of Medical Examiners inspection and accreditation standards puts this agency, and others facing the same issues, at risk of losing full accreditation status until such resource issues are addressed by legislators and other stakeholders in the quality of medicolegal death investigation in the United States.

Drug Intoxication and the Need to Autopsy: A Diagnosis of Exclusion?

The recent surge in drug deaths has focused attention on the diagnosis of drug intoxication as a cause of death. In Maryland, the Department of Vital Records has shown an increase from 649 intoxication deaths in 2012 to 1259 in 2015. Preliminary data for 2016 document 1892 of these deaths. Many of the medicolegal death investigation offices in the United States are facing potential loss of accreditation. There is limited capacity to add more staff due to a lack of appropriately trained pathologists and budget constraints. The diagnosis of this intoxication and the need to autopsy all of these cases is a matter of debate, as many death investigation offices look for alternative means to maintain accreditation. The alternative to adding more staff is to reduce the autopsy caseload. Can this be done without compromising the intent of the medical examiner system and the law? Balancing this with being fiscally responsible may be a very real challenge and one that will test many death investigation systems due to this pandemic of drug deaths. If there is a need to reduce the autopsy caseload, it should be in cases other than where the diagnosis is one of exclusion.

A LARGE WEEKLY INCREASE IN HANDBALL PARTICIPATION INCREASES THE SHOULDER INJURY RATE IN DANISH YOUTH HANDBALL

BackgroundKnowledge of injury patterns, an integral step towards injury prevention, is lacking in youth handball.ObjectiveTo investigate if an increase in weekly handball participation is associated with increased shoulder injury rates...

Handball load and shoulder injury rate: a 31-week cohort study of 679 elite youth handball players

BackgroundKnowledge of injury patterns, an essential step towards injury prevention, is lacking in youth handball.AimTo investigate if an increase in handball load is associated with increased shoulder injury rates compared...

The coroner's autopsies in the Great Britain: the problems related to the quality of the studies, standardization, auditing, financial support and the approaches to their solution

The objective of the present study was to analyze the experience of the coroners and pathologists in the Great Britain based on the results of the coroner's autopsies and recommendations of the experts involved in the activities carried out in the framework of the National Confidential Enquiry into Patient Outcome and Death program (NCEPOD). The recommendations are designed to reform the country's medical examiner system, improve the equipment of the mortuary facilities, and optimize funding for the autopsy studies. The authors consider in the chronological order the following issues of the coroners and pathologists' activities: organization of their work and its procedural aspects, ordering coroner's autopsies, preparation for their performance, analysis of the relevant documentation (autopsy reports) and medical case histories (discharge summaries). Also discussed are the recommendations of the NCEPOD experts for the improvement of the said studies with the detailed analysis of the causes underlying the aforementioned problems and concise comments of the authors.

Additive Effects of Cointoxicants in Single-Opioid Induced Deaths.

A forensic drug database (FDD) was used to capture comprehensive data from all drug-related deaths in West Virginia, with deaths also included from the northern New England states of Maine, Vermont, and New Hampshire. All four states serve predominantly rural populations under two million and all have similar state medical examiner systems that employ statewide uniform death certification policies and practices. This study focused on 1482 single opioid deaths (fentanyl, hydrocodone, methadone, and oxycodone) in the FDD from 2007-2011. We modeled relationships between the opioid concentrations and the presence or absence of the following commonly occurring non-opioid cointoxicants: benzodiazepines (alprazolam and diazepam), alcohol, tricyclic antidepressants, selective serotonin reuptake inhibitors, and diphenhydramine. Additional covariates of state, age, body mass index, and sex were included. Results showed that the presence of alcohol, benzodiazepines, and antidepressants were each associated with statistically significant lower concentrations of some but not all of the opioids studied, which may obscure the interpretation of postmortem toxicology results alone. Fentanyl concentrations appeared to be the least associated with the presence or absence of the variables studied, and cointoxicant alcohol appeared to be associated with lower concentrations in opioid concentrations than were most of the other factors in the model studied. These findings underscore the importance of documenting all potential cointoxicants in opioid-related deaths.

Vascular Injuries in Combat-Specific Soldiers during Operation Iraqi Freedom and Operation Enduring Freedom

This study sought to identify vascular injury patterns among combat-specific cavalry scout personnel within the Iraq and Afghanistan Wars. The Armed Forces Medical Examiner System and Joint Theater Trauma Registry were queried for all injuries with the cavalry scout designation from 2003 to 2011, including those both wounded in action (WIA) and killed in action (KIA). A description of vascular injury, combat causality care statistics, mechanism of injury, and demographic data were recorded. Sixteen percent (n=111) of the 701 cavalry scouts with a combat wound sustained a vascular injury. Among cavalry scouts sustaining vascular injuries, 69% were caused by an explosive mechanism of injury, 63% were KIA, and 29% had a major extremity amputation. Cavalry scout soldiers with a vascular injury were significantly more likely to result from explosion (P<0.0001), be KIA (P<0.0001), and occur in Iraq (P<0.0001). The rate of noncompressible arterial injury was 65%. WIA cavalry scout soldiers with a compressible vascular injury with clear documentation of prehospital tourniquet utilization arrived at a Medical Treatment Facility in 67% of cases with a tourniquet in place. Of these transported with a prehospital tourniquet 83% survived. The high rates of KIA and extremity amputation among cavalry scout soldiers with a vascular injury denotes the lethality of these combat injuries. Uniformly equipping soldiers with battlefield tourniquets and educating them on their prehospital use might improve the survivorship of those servicemembers sustaining a compressible vascular injury.

Characteristics of genitourinary injuries associated with pelvic fractures during operation Iraqi Freedom and operation Enduring Freedom.

Pelvic fractures are markers of severe injury and are often associated with lower genitourinary injuries. The purpose of this study was to investigate the incidence of lower genitourinary injuries and complaints associated with pelvic fractures sustained in combat among nonsurvivors and survivors. The Armed Forces Medical Examiner System and The Joint Theater Trauma Registry databases were searched to identify survivors and nonsurvivors who sustained a pelvic fracture in combat in 2008. Survivor and autopsy data consisted of injury mode and mechanism and associated organ and extremity injuries. Pelvic fractures were classified using the Tile system. The database search yielded 91 nonsurvivors and 10 survivors with pelvic fractures. Forty-one patients (40%) sustained 61 genitourinary injuries. The majority of genitourinary injuries in nonsurvivors were associated with Tile C pelvic fractures (70%). Twenty percent of survivors had genitourinary injuries, all of which were associated with Tile A fractures. A higher incidence of genitourinary injuries in patients with combat-related pelvic fractures (60%) was found than that of their civilian counterparts. Of the survivors, 100% of those with genitourinary injuries were being treated for erectile dysfunction at their last follow-up. Continued collaboration between orthopaedic surgeons and urologist is needed to address these concurrent injuries.

Coroner versus Medical Examiner Systems: Can We End the Debate?

This article is a discussion and comparison of coroner systems and medical examiner systems. Each type of system has potential merits and drawbacks, and virtually all systems face certain problems and challenges and could be improved. The arguments about coroner versus medical examiner systems have gone on for nearly a century, coroner and medical systems remain, and we need to shift our focus from our differences to those goals that we share. We believe the best approach is for each state and its various death investigation jurisdictions to thoroughly study its death investigation system to determine whether it is meeting the needs of the criminal and civil justice system, the courts, prosecution (plaintiff) and defense attorneys, public health and safety agencies, the medical community, and other interested users such as researchers and those interested in prevention strategies. It is also critical that jurisdictions ensure their medicolegal death investigation systems become accredited, their personnel become certified, and that they are following nationally accepted guidelines, standards, and best practices. If there are deficiencies, then the state, in conjunction with local jurisdictions, can decide what changes may be needed and which options are available to implement those changes. Again, the issue is not necessarily one of system type, but rather, the adequacy of support and manpower to function professionally and to meet the needs of users.

A Synopsis of the 1928 National Research Council's Bulletin on “The Coroner and the Medical Examiner”

The 1928 National Research Council (NRC) Bulletin on “ The Coroner and the Medical Examiner” is an often-referenced report because it compares the two system types and recommends that coroner systems be abolished and replaced with medical examiner systems. Copies of the Bulletin are difficult to find, so this article provides a synopsis of the Bulletin's content. The NRC Bulletin 64 was prepared under the auspices of the seven-member “Committee on Medicolegal Problems.” The report itself begins with a historical summary of the coroner system and discussion of the medical and judicial duties of coroners, along with the inadequacy of existing autopsy facilities. Next is a review of previous surveys of coroner systems in New York City, Cleveland, and Missouri. The Committee conducted its own surveys of the coroner systems in New Orleans, San Francisco, and Chicago. The Committee also studied the medical examiner systems in Boston, other parts of Massachusetts, and in New York City. Other sections deal with the comparative costs of the two systems, teaching of forensic medicine, medicolegal institutes, scientific publications, a summary of defects of coroner systems and advantages of medical examiner systems, and eight summary recommendations. We must remember that the historical Bulletin was written nearly a century ago, and there has been much improvement in medicolegal death investigation since that time, many improvements having their roots in the NRC Bulletin recommendations. The Bulletin's recommendations have been fulfilled to various extents in many parts of the United States.