Forensic Pathology Practice Research Articles

Postmortem cytology: Alive and well in the practice of autopsy and forensic pathology.

Postmortem cytology: Alive and well in the practice of autopsy and forensic pathology.

Application of Next Generation Sequencing for personalized medicine for sudden cardiac death.

Sudden cardiac death (SCD) is a serious public health problem. In the United States, more than 300,000 people are affected by SCD every year. Significantly, sudden deaths represent 20% of the total mortality and 50% of cardiovascular mortality in Western countries. In addition, SCD constitutes one of the most important unsolved challenges in the practice of forensic pathology because of the failure to determine the exact cause of sudden death. In young individuals, SCD is frequently caused by cardiomyopathies and channelopathies, that have generally an autosomal dominant pattern of inheritance. The impact of genetics and genetic testing on the clinical management of these diseases is unquestioned. In particular, genetic tests are an important tool for identifying pre-symptomatic individuals carrying genetic variant that predisposes them to SCD. High-throughput sequencing technologies offer novel opportunities to deeper investigate the genetic background underlying these fatal diseases and to early identify individuals at risk for SCD. In this review, we provide an overview of the development of Next-Generation Sequencing (NGS) technologies and of guidelines useful to design an efficient sequencing protocol and to perform an accurate data analysis. We suggest a flow chart to follow for the set up of a genetic screening protocol for the prevention of cardiac pathologies, in particular SCD events, in young athletes.

Forensic autopsy practice in the Middle East: Comparisons with the west

Autopsies are performed in the majority of Arab, Muslim countries. Several of these countries face social challenges and others do not have well established academic programs to teach the science. In this article we intend to review the history and practice of the forensic part of autopsies in a few Arab, Muslim countries (Egypt, Kingdom of Saudi Arabia (KSA) and Kuwait) and compare it with the United States of America (USA) and the United Kingdom (UK), 2 countries where the practice of forensic science and Forensic pathology is well established. This was achieved by pub med literature search and the distribution of a questionnaire to colleagues in Arab countries. We recommend that Arab countries explore the field of virtual autopsy to overcome some of the social challenges related to dissection of the cadaver. Kuwait can benefit from the introduction of Forensic training given the high workload in the country.

Assessment and Diagnosis of Trauma in the High Cervical Spine Using Dissection, Radiography, Computed Tomography and Magnetic Resonance Imaging

Cervical spine trauma, particularly that occurring at the craniocervical junction (CCJ), is the cause of a significant number of deaths each year. Although some forms of injury within the high cervical spine will be obvious during routine external and internal examination procedures, others cannot be diagnosed without advanced methods. The anatomy of the CCJ is complex and notoriously difficult to evaluate at autopsy. While specialized autopsy techniques allow thorough evaluation of this region, they are inconsistently understood and performed. Furthermore, although radiography has long been a mainstay of forensic pathology practice, it is not routinely utilized to assess for cervical spine trauma. As advanced radiology techniques become more regularly available in a postmortem setting (computed tomography [CT] and magnetic resonance [MR] imaging), forensic pathologists are offered additional tools that facilitate accurate diagnoses in the high cervical spine. Fundamental to the appropriate use and interpretation of autopsy and radiologic techniques is an understanding of the involved anatomy. The structures within the CCJ, advanced dissection methods, and fundamentals of cervical spine radiology are reviewed in this manuscript. Where available, autopsy evaluation of the CCJ will be complemented by radiography, CT, and MR imaging. In some circumstances, dissection and/or autopsy could be supplanted by the use of postmortem CT and MR scanning.

Allergy in Extremis

Allergy-associated diseases have a multitude of confirmed or suspected etiologies and associations affecting organs and organ systems. The hyper-reactivity of the immune system in which the eosinophils are prominent plays a central role in organ-specific and systemic effects in these diseases. Patients may be plagued with nonspecific, episodic, or progressive signs and symptoms. Patients may also exhibit signs and symptoms that mimic more common conditions. Recognition of certain patterns of clinical signs and symptoms may lead to definitive clinical diagnosis and effective treatment, particularly of less common but potentially lethal disease entities. The lack of clinical recognition of these patterns, whether due to "red herring" historical information, lack of sign/symptom specificity, clinical presentation at early stage, or unfamiliarity with the constellation of disease presentation, may delay or preclude diagnosis and treatment. The forensic pathologist must also have an awareness of varied clinical presentations of diseases because these can provide us with direction toward the ultimate determination of cause and manner of death.The importance and contribution of the practice of forensic pathology are highlighted in the instance of sudden and unexpected death, whereby the previously unrecognized or unconfirmed disease entity that leads to the death is revealed via analysis of scene information, autopsy performance, and review of medical history and history of the most recent illness. Through this comprehensive approach, a greater understanding of the extent and potential lethality of disease with reiteration of the importance of early clinical diagnosis and treatment is reinforced. This benefits the medical community involved in diagnosis and treatment, clinicians and pathologists alike, with the ultimate goal of reduction of morbidity and mortality.Reported is a case of sudden unexpected death with historical, gross, and microscopic findings consistent with a multisystem, inflammatory, allergic disease entity.

Investigation of Sudden Death in Athletes: The Fittest Bodies in the Morgue

Sporting events are generally viewed as regulated activities with fit and healthy participants; therefore, when deaths occur, they draw considerable public interest. Athletic participants can be considered a vulnerable population based on inherent risks within certain sports and the associated physiologic stresses, which may complicate underlying medical conditions. Sudden deaths in young athletes participating in high school and collegiate organized sports occur at an average of four to six deaths per year; however, sudden deaths related to exercise outside of an organized sport setting remain unaccounted for in the overall prevalence of these deaths. A typical forensic pathology practice will see not only these higher-profile deaths occurring during an organized sporting event, but also lower-profile occurrences of individuals dying during more recreational or unstructured exercise. Sport-related deaths can essentially be categorized as those that occur due to dangers inherent in the sport itself, such as forms of heat-related illnesses, blunt force trauma, and water-related deaths, and those that occur due to susceptibilities of a given predisposed participant, including sickle cell trait, hypertrophic cardiomyopathy, and other cardiovascular diseases. This article will address both types of vulnerabilities and provide guidance for appropriate and specific medicolegal death investigation and autopsy procedures in these deaths.

Alcohol and Heart Disease in the Forensic Setting

The impacts of chronic high levels of ethanol consumption on cardiovascular structure and function are reviewed as they pertain to forensic pathology practice. Both hypertrophy and remodeling of the myocardium as well as physiological revision of electrical conduction through the heart can occur in a progressive fashion. A discussion about the likely underappreciated spectrum of structural heart disease that may be seen in individuals with chronic alcohol dependence is presented. Finally, brief reference to the collision between alcohol, cardiovascular disease, and forensically relevant scenarios is provided.

Consideration of Occupational Lung Disease and Pneumoconiosis in Forensic Pathology

Reports of workers stricken with lung disease sustained during the course of their employment date to antiquity. Despite stringent regulations to mitigate all manners of work place hazards, and the emergence of agencies and physicians engaged in the advancement of occupational health, occupational lung disease remains a significant problem within modern society. Inhalation of dusts and fumes sustained in the course of one's occupation may lead to significant morbidity and mortality, and lead to a huge cost to society in terms of lost productivity, medical care for the worker, and litigation. In certain circumstances, the identification of an underlying occupational lung disease may constitute a significant finding in medicolegal death investigation. This article will present an overview of common occupational diseases likely to be encountered in the practice of forensic pathology, based on the particular etiologic agent and occupational means of exposure.

Opioid Overdose Mortality in Kansas, 2001-2011: Toxicologic Evaluation of Intent

Drug concentration is a factor in the determination of the manner of death, but considerable overlap exists between therapeutic and toxic concentrations. This study aims to quantify opioid mortality in Kansas from use of fentanyl, methadone and oxycodone and to evaluate utility of drug concentrations for the determination of the manner of death. Cases referred to a forensic pathology practice in Kansas for autopsy from 1 January 2001 to 31 December 2011 were considered. The criterion for inclusion was detection of fentanyl, methadone and/or oxycodone in postmortem toxicology. Of 9,789 cases, 3,315 had positive toxicology: 180 of fentanyl, 299 of methadone and 310 of oxycodone. There were 207 single opioid fatalities, 264 polydrug overdoses and 318 deaths where an opioid was present but not contributory to the mechanism of death. In line with published studies, incidence of opioid overdose deaths increased over the time of the study. Drug concentrations within each cause and manner of death covered broad ranges. Non-natural and natural manners had less overlap than existed within non-natural manners in limited comparisons. This study shows that drug concentration is independent of manner for non-natural deaths and although insufficient to identify intent, can provide a guideline in differentiating non-natural from natural deaths.

The value of 100% retrospective peer review in a forensic pathology practice

Peer review in forensic pathology practice has become an important cornerstone of continuous quality improvement. Although there are several components to an effective and transparent peer review process, one of the most essential is the review of completed reports.The autopsy report may be reviewed prospectively (report reviewed before sign out) or retrospectively (report reviewed after sign out). Prospective reviews are more likely to be performed on criminal or criminally suspicious cases, pediatric and SIDS deaths and high profile cases.Retrospective reviews on the other hand are performed on a proportion of all other signed-out routine medico-legal cases. The actual percentage varies by jurisdiction since there are no agreed minimum standards. Manpower and workload factors appear to be critical to determining what percentage of cases are reviewed retrospectively.The objective of this report is to present a mechanism by which a 100% retrospective review policy has been implemented, how it integrates with quality management protocols, the outcomes of the reviews and what challenges remain to improve compliance with key quality indicators especially turn around time (TAT) statistics.

Ethics Education in Forensic Pathology Fellowship Training: Is there a Need?

Relatively little has been written about ethics in the practice of forensic pathology, considering its critical importance to the individual practitioner and the specialty's long-term survival. While the general foundation of highly ethical behavior has hopefully been established prior to entering the fellowship year, the practice of forensic pathology is unique and has its own special ethical issues, requiring active intentional education. The fellowship training year is the best setting in which to formally discuss the ethical behaviors required in the daily practice of forensic pathology. The American Counsel for Graduate Medical Education (ACGME) also requires the demonstration of professionalism and ethical behavior during the fellowship, which includes ethics education. Almost all forensic pathology program directors report that ethics training is conducted on an opportunistic case-based basis as ethical issues arise during training. The majority of forensic pathology program directors would welcome a focused “Ethical Issues in Forensic Pathology” educational module following the Core Curriculum lecture platform and based upon the ACGME Core Competencies and developed by the National Association of Medical Examiners (NAME).

Forensic Pathology of Companion Animal Abuse and Neglect

Submission of cases of suspected animal abuse and neglect (AAN) to veterinary pathologists is increasingly frequent. These cases require modification of postmortem procedures and written reports, as the questions asked by courts typically differ from those asked in routine diagnostic cases. Here we review the practice of veterinary forensic pathology as it applies to cases of companion AAN, as well as the fundamental principles of forensic pathology, the components of a forensic necropsy, and the goals of the necropsy in cases of blunt-force trauma, projectile wounds, and starvation. Future directions and endeavors in veterinary forensic pathology are broached.

Obesity Overview: Causes, Epidemiology, Mortality, and Autopsy

Obesity is now recognized as a major health epidemic in the United States and around the world, both in adults and children, and has coincided with the increase in the availability of high calorie/low nutrient foods and changes in lifestyle, particularly the decrease in physical activity. Obese individuals have shorter life spans, increased risk for sudden cardiac death and a number of comorbidities such as diabetes mellitus, venous thromboembolism and respiratory dysfunction, which can negatively affect their quality of life. The increased prevalence of obesity has affected every field of medicine and the costs of treating obesity and its complications are staggering. Forensic pathology has been impacted as well, with obese and morbidly obese decedents posing major technical and practical challenges in transport, handling and autopsy procedures. This article will review the epidemiology and causes of obesity and address the impact of obesity on mortality and the everyday practice of forensic pathology.

The approaches of physicians working in the field of pathology regarding forensic pathology practice and the training process

Forensic autopsies are performed by the forensic medicine department and the microscopic examination processes by pathology specialists within the forensic medicine practice in Turkey. This disconnection in the process raises problems in the training of both branches. The aim of this study was to determine the awareness of pathology staff on forensic medicine practices and responsibilities and their opinion on the pathology training model in the forensic medicine specialty and to discuss the matter within the framework of the present situation and global applications. A 15-item questionnaire form distributed to the participant physicians during registration at the 21st National Pathology Congress held in 2011 was evaluated. 94 participants responded. A negative opinion was expressed by 72% about the interest in the general post-mortem process. The view that pathology specialists should undergo a separate training to perform autopsies was predominant and there was a general lack of interest in all kinds of autopsy processes. The percentage who said they knew the legal responsibility of a pathology specialist regarding forensic autopsies correctly was 37%. The questions "what are the necessary factors to contribute to the pathology training in forensic medicine" and "if anything is required, which of them would take priority" were respectively answered as "for me to be interested (46%)" and "a system guaranteeing that training will always be given by pathology specialists (67%)". Despite the possibility of becoming a forensic medicine specialist in two years, the mean answer score of the participants to the phrase "I do not consider becoming a forensic medicine specialist" was 4.1 (out of 5). A reluctance among the pathologists in our country was seen regarding forensic medicine specialists being able to perform post-mortem microscopic examination. However, despite their legal responsibilities, their interest in forensic pathology practice was low. There seems to be rational factor that would increase this interest in the near future. Cooperation is necessary to enable forensic medicine specialists to perform post-mortem pathology procedures. This cooperation should be based on improving the training of pathology research assistants.

Coronary artery disease, sudden death and implications for forensic pathology practice

Coronary atherosclerosis is the leading cause of sudden death in developed nations. Triggers for sudden death include physical and emotional stress. At autopsy coronary artery atheroma is a common finding and may or may not be related to the cause of death. The forensic pathologist must consider the relative significant of disease, trauma and toxicological findings when determining the cause of death. This requires a consideration of evidence beyond the autopsy including the history, scene and ancillary investigations. Certain drugs including cocaine and methamphetamine are known to be atherogenic and acute and chronic use may be a factor in sudden death with underlying coronary artery atherosclerosis. Sudden death may also be associated with criminal conduct, when the scenario of “homicide by heart attack” needs to be considered. This paper analyses forensic aspects of coronary artery disease.

Assessing Post‐traumatic Time Interval in Human Dry Bone

AbstractThe post‐traumatic status of antemortem fractures in human dry bone remains is currently defined as being either ‘healing’ or ‘healed’. However, detailed ‘dating’ of the related post‐traumatic time interval would be desirable, since it would aid in assessing individual medical status and care at the time of death. Within forensic pathology practice, fresh tissue healing phases are routinely used as an intrinsic parameter for the length of the post‐traumatic time interval. Unfortunately, the direct application of such a method is hampered when applied to dry bone skeletal material.This study explores the possibility of applying a fracture dating system, drawn forth from the traditional forensic pathology method, on dry bone remains. More specifically, the aim is to establish the extent to which various histomorphological features indicative of specific time intervals of healing are consistently detectable. Human dry bones with fractures and amputations in various phases of healing were studied.Results show that the complementary use of radiological and histological investigation techniques improves the differentiation between various healing phases and thus allow for a more detailed dating of lesions. For future use, healing features that have proven to be consistently detectable and their related post traumatic time intervals are listed. The system aids in demarcating a considerably more ‘narrow’ post‐traumatic time interval than usual. Copyright © 2012 John Wiley & Sons, Ltd.

Practice of clinical forensic medicine in Sri Lanka: Does it need a new era?

Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a country. Practice of clinical forensic medicine is evolving, but deviates from one jurisdiction to another. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology. Unlike the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice or training in this discipline. Besides, this is rarely a topic of discussion. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers practice both clinical forensic medicine and forensic pathology. Practice of clinical forensic medicine, and its teaching and training in Sri Lanka depicts unique features. However, this system has not undergone a significant revision for many decades. In this communication, the existing legal framework, current procedure of practice, examination for drunkenness, investigations, structure of referrals, reports, subsequent legal procedures, undergraduate, in-service, and postgraduate training are discussed with suggestions for reforms.

Potential Applications of Digital Pathology and Image Analysis for Forensic Pathology

The analysis of digital images using computer algorithms to mine digital data directly is an important and increasingly utilized tool in many different fields of medicine. However, despite the clear value of image analysis to forensics, there is little research and no current practical applications of this technology to forensic pathology. This paper demonstrates the technique of Spatially Invariant Vector Quantization (SIVQ) in the analysis of gross forensic images. SIVQ is a pattern recognition algorithm that can run on a laptop and be utilized by a forensic pathologist with no programming experience. The user merely points and clicks to the feature of interest and SIVQ searches the entire image for the desired feature. The results can be displayed in a variety of formats, both qualitative and quantitative. Gross forensic images from gunshot wounds, burns and patterned contusions were analyzed by a forensic pathologist using SIVQ. Based on features selected by the user, the algorithm was able to detect both the gunshot wound and its marginal abrasion, calculate the surface area of a gunshot wound defect, distinguish between a thermal burn and the surrounding areas of healing, analyze a patterned contusion, and both identify and calculate the density of gunpowder stippling. Even though the work is preliminary, it is obvious from these few examples that SIVQ is easily able to identify features of interest in gross forensic images. Additional work needs to be done to fully explore the potential for this application of technology to the practice of forensic pathology.

Neurotrauma: basic principles of adult neurotrauma and areas that cause diagnostic problems

Traumatic brain injury remains a major cause of morbidity and mortality, and a common problem in forensic pathology practice. A majority of cases are relatively straight forward, with only a small number of cases presenting diagnostic challenges. This talk will provide an overview of the major pathologies seen in blunt force head injury and, in particular, some time will be spent on diffuse traumatic axonal injury and its diagnosis. I will touch on some aspects of penetrating and blast head injuries, updating on recent research around blast injury in particular. I will focus on specific issues of forensic interest such as ‘talk and die’, delayed traumatic intracerebral haemorrhage, and the settings in which diffuse traumatic axonal injury may be seen. The talk will finish with some discussion around the association (or otherwise) between neurodegeneration and long-term survivors of head injury.

Inference in Forensic Pathology

Forensic pathologists make inferences about cause and manner of death. Those inferences have come under increasing scrutiny by the courts, by social critics of our findings, and by society at large. Much of this criticism is due to our inability to explain our inferential process. Forensic pathologists should be able to cogently explain the reasoning behind their findings, and express it in terms useful to stakeholders. This requires that we have a basic understanding of different kinds of inference and the scientific method, how they are used and their limitations. Medical diagnosis is not a simple matter of application of cookbook-style inferential laws, but involves a combination of deduction, induction, abduction, dialectic, and informal inference. There are significant differences between the way physicians make inferences compared to how they justify them. A discussion of different kinds of inference, inferential fallacies, evaluation of evidence, causation, and the scientific method is provided, with illustrations from the practice of forensic pathology.