“The Scalpel is Passed,” a Conversation With Dr Vincent J.M. DiMaio Editor's Note This is the first article in a new series of interviews with mentors in forensic pathology. These interviews will also be recorded, and the audio files will be available online through the journal's Web site, http://links.lww.com/FMP/A31.

Understanding Gunshot Residue Evidence and Its Role in Forensic Science Gunshot residue, or GSR, can be a valuable tool in forensic science, but its importance depends greatly on how it is utilized during an investigation and applied in criminal courts. This comprehensive review defines what constitutes GSR resulting from a discharged firearm. Sampling methods and analytical testing instrumentation will be discussed along with data interpretation and limitations of analysis.

A 25-Year Review of Pediatric Suicides: Distinguishing Features and Risk Factors Childhood and adolescent suicides have been increasing worldwide in recent years, and the investigation of such deaths is often complex. Forensic pathologists frequently find themselves having to opine as to the manner of death in these difficult cases. The present study was undertaken to identify distinguishing features in childhood and adolescent suicides to assist in the investigation and prevention of these deaths. A 25-year review of pediatric suicides in a metropolitan area was performed, which showed a steady increase in pediatric suicides over time. Male pediatric suicides were more common than female, with both having an average age of 15 years. Gunshots wounds and hanging were the most common methodologies seen, with drug toxicity being more common in females and gunshot wounds more common in males. Approximately 20% of decedents had a psychiatric history, 25% had a previous history of a suicide attempt or ideation, and 24% had a history of drug use. Only a minority of decedents made their intentions known prior to the suicidal act (16%) or left a note of intent (16%). In 62% of cases, a temporal, precipitating event could be identified, of which conflict with a significant other (boyfriend or girlfriend) was the most common. No specific trends over time were identified. While these features may assist forensic pathologists in assessing a possible suicidal death in the pediatric age group, medicolegal death investigators must approach these deaths as they would any violent death in an attempt to accurately determine the manner of death regardless of the societal and familial implications of such a determination.

Evaluation of a Novel Medicolegal Death Investigator–Based Suicide Surveillance System to the National Violent Death Reporting System The abundance of actionable information available in a medicolegal suicide investigation is often inaccessible and underutilized in public health to the detriment of prevention efforts. Epidemiologists obtained the Washington County subset of the Oregon Violent Death Reporting System (OR-VDRS). To determine if additional information beyond the OR-VDRS was available through a standard death investigation, an epidemiologist shadowed medicolegal death investigators (MDIs) for nearly 2 years. The MDIs and epidemiologist developed a novel, real-time, MDI-entered surveillance system, the Suicide Risk Factor Surveillance System (SRFSS), to capture suicide risk factor data with greater timeliness and accuracy than available through the OR-VDRS. To evaluate the performance of each surveillance system, differences in the prevalence of suicide risk factor data from SRFSS were compared with the county OR-VDRS subset for the same 133 suicides occurring in 2014–2015. Across 27 suicide risk factors and circumstances, the median difference in prevalence was 10.5 percentage points between the OR-VDRS and the SRFSS, with the higher prevalence in SRFSS. The prevalence was significantly different between the 2 surveillance systems for 21 (78%) of 27 variables. This study demonstrates the truly exceptional data quality and timeliness of MDI information over traditional sources.

Sudden Infant Death After Vaccination: Survey of Forensic Autopsy Files Sudden infant deaths might be attributable to adverse reaction to vaccination, but separating them from coincidental occurrences is difficult. This study retrospectively investigated vaccination-related details and postmortem findings for 57 cases of sudden death in children 2 years or younger. Data were extracted from autopsy files at the Department of Forensic Medicine, Tokai University School of Medicine. Vaccination histories were available in 50 cases based on the maternity passbook. Of the 32 cases in which any vaccines were administered, 7 infants (21.9%) had received immunization within 7 days of death. The most frequent vaccine cited as the last immunization before death was Haemophilus influenzae B. Although a temporal association of vaccines with sudden death was present for two 3-month-old and one 14-month-old infants in whom death occurred within 3 days of receiving the H. influenzae type b and other vaccinations, a definitive relationship between the vaccine and death could not be identified. Histopathological examinations revealed pneumonia and upper respiratory infection as contributing to death in their cases. Moreover, all 3 cases showed hemophagocytosis in the spleen and lymph nodes, which are similar features to hemophagocytic lymphohistiocytosis. Judgment of the disorders as truly related to vaccination is difficult, but suspicious cases do exist. Forensic pathologists must devote more attention to vaccination in sudden infant death cases.

Medicolegal Investigation for Cremation Clearance: How and Why? This study on cremation clearance examines whether physical inspections detect more unnatural unreported deaths than medicolegal investigations without inspections. We reviewed all deaths reported to the medical examiner for cremation clearance during 2 distinct years and compared subsequent amendments of death certificates after 2 different investigative methodologies (1 with and 1 without physical inspection). Of 10,367 deaths in 2012, there were 86 deaths (0.83%) in which the investigation with physical inspection resulted in amendments to the death certificate. Of 11,906 deaths in 2016 without physical inspection, there were 153 that resulted in amendments (1.3%) including 2 homicides. For the detection of accidents, there was no statistically significant difference (χ2 = 0.8119, P = 0.367552). For cremation investigations, the work effort and costs of performing physical inspections do not appear justified given the similar detection rates (approximately 1%) for unnatural deaths among the 2 groups. Both methods, however, do detect unreported unnatural deaths.

Biomarkers of Cerebral Damage in Fatal Hypothermia: Preliminary Results The identification of hypothermia as the cause of death remains challenging in forensic pathology because of unspecific radiological, morphological, and biochemical results. Hyperemia, edema, and petechial hemorrhages within the cerebral parenchyma were described in cases of death by hypothermia. On the other hand, the effect of low temperatures in the brain has been speculated to cause local injuries on a cellular level with potential occurrences of necrosis and inflammation. In the study herein described, endocan, alkaline phosphatase, neuron-specific enolase, S100 protein subunit B, glial fibrillary acidic protein, and C-reactive protein were measured in postmortem serum from femoral blood and cerebrospinal fluid in a series of hypothermia fatalities and control cases. The combination of data collected failed to identify a specific biochemical profile for death by hypothermia in postmortem serum and/or the cerebrospinal fluid, thus suggesting that an alternative panel of brain damage biomarkers indicative of diffuse hypoxic brain injury needs to be defined in hypothermia fatalities.

Patterns in Forensic Decapitations: A Review of the Literature and Case Report Separation of the head from the body can occur for a variety of reasons and in various locations across the neck. This study presents a review of the literature to identify the patterns of decapitations in forensic cases in relation to manner of death, age, and anatomical location (n = 88). The most common manner of death was suicide, followed by homicide and then accident. Ages ranged from 32 weeks prenatal to 85 years. Decapitation is reported at higher rates for individuals between 19 and 65. The majority of decapitations occurred at the midneck (second to fifth cervical vertebrae), followed by the upper neck and then the lower neck. This pattern holds true for all manners of death; however, in homicides, the percentage occurring at the midneck decreases. The findings of this study indicate some patterns in terms of manner of death, age, and location of decapitation, which could aid the medicolegal community in interpreting neck trauma. A case study is also briefly presented to illustrate findings.

Elevation of Postmortem Cerebrospinal Fluid Sodium and Chloride Levels Is a Potential Adjunct Test in the Diagnosis of Salt Water Drowning Postmortem vitreous humor biochemistry is a useful test in the diagnosis of salt water drowning (SWD). A significant limitation of vitreous humor is the potential effect of prolonged immersion. A recent animal study and case report suggested that cerebrospinal fluid biochemistry may be an alternative to vitreous because it is more resistant to the effects of immersion, given its protected anatomical location. This study compared postmortem cerebrospinal fluid sodium and chloride (PMCSC) levels collected via ventricular aspiration (PMCSC_V) and via lumbar puncture (PMCSC_L) in 13 SWD and 31 nonimmersion deaths. It showed a significant elevation in PMCSC levels in SWD deaths for both PMCSC_V and PMCSC_L (P < 0.05). The areas under the curve on the receiver operating characteristic curves for PMCSC_V and PMCSC_L were 0.73 and 0.83, respectively. The optimal cutoff for PMCSC_V was 216 mmol/L (sensitivity, 0.60; specificity, 0.72; likelihood ratio, 1.80; positive predictive value, 0.45) and for PMCSC_L was 241 mmol/L (sensitivity, 0.78; specificity, 0.73; likelihood ratio, 2.89; positive predictive value, 0.46). This study supports PMCSC levels as another biochemical test that can potentially aid in the diagnosis of SWD, particularly in cases where vitreous humor samples are unavailable or uninterpretable.

Elevated Cerebrospinal Fluid Sodium and Chloride Levels in a Saltwater Drowning Death To ascribe a cause of death from drowning in a body immersed in water can be difficult because of the absence of specific postmortem findings and unreliable ancillary tests. Postmortem vitreous biochemical analysis is documented to be a useful adjunct ancillary test to aid the diagnosis of saltwater drowning. A major confounding factor in using postmortem vitreous is the effect of electrolyte diffusion and water osmosis during immersion. A recent animal study suggested that cerebrospinal fluid (CSF) biochemical analysis, which is unaffected by immersion, may be an alternative. However, to date, there are no human data to support this. We report a saltwater drowning death from presumed suicide in which the postmortem CSF sodium and chloride level was elevated compared with nonimmersion deaths. This case gives evidence to support the potential use of postmortem CSF sodium and chloride level as an adjunct to the diagnosis of saltwater drowning.