908 Am J Clin Pathol 2015;143:908-911 © American Society for Clinical Pathology CorrespondenCe correspondence 908 Am J Clin Pathol 2015;143:908-911 © American Society for Clinical Pathology Tattoos Containing Useful Messages Am J Clin Pathol June 2015;143:908-910 DOI: 10.1309/AJCPL32VLCNTMLDV To the Editor The article by Carson 1 draws attention to the association of tattoos with violent death in an autopsy population. However, as the author correctly points out, age may be a confounding factor, since tattooing is becoming an increasingly popular form of body decoration in young adults. While tattoos may be markers for individuals who have engaged in criminal activities (eg, tattoos may signify gang membership, an illegal drug habit, or time spent in prison), a much wider and more diverse population is now being inked. 2,3 As such, the potential association of tattoos with violent deaths would be more clearly delineated by performing a population-based study of living individuals. Another point to consider is that although negative and antisocial messages are often found in tattoos, they may also contain useful information that may assist during life with clinical management or after death with identification or with clarification of particular acts. Tattoos that help with clinical decision making may document significant medical conditions such as insulin-dependent diabetes mellitus, epilepsy or allergies, or blood groups and may be favored over medic alert bracelets that can be removed or not worn. On occasion, directions not to perform cardiopulmonary resuscitation or to take steps to prolong life may be present. Examples include “DNR” for “do not resuscitate” and “no PEG” for not having a feeding gastrostomy tube inserted. 2,3 Unique tattoos that may assist with the identification of a traumatized, burnt, or decomposed body include fine-line tattoos of family members or names and dates commemorating significant events such as births or marriages. Particular types of tattoos may indicate a country or region of origin. 4 Rarely, tattoos may include dates of deaths that were significant and that may match the date of the decedent’s death. As detailed histories and/or suicide notes are often not available at the time of a forensic autopsy, these commemorative tattoos may provide the only evidence to indicate a possible anniversary suicide. 5 Thus, although tattoos may be associated with negative outcomes in an individual’s life, they may also provide very useful information, both before and after death. Roger W. Byard, MD The University of Adelaide Medical School Adelaide, Australia References What Is Hidden in Tattoos? To the Editor The article by Carson 1 stimulates several questions. The differences between the three groups (persons with no tattoos, those tattooed with nonnegative messages, and persons tattooed with negative messages) are significant in age of death. The author concludes that the comparatively shorter life spans for those with tattoos having negative messages may be explained by more frequent deaths from nonnatural causes in this group. Including illicit drugs and alcohol use contributed. However, the difference between those with tattoos without negative content and those having no tattoos must be understood from other aspects. We propose that the biochemical, toxic, and immunologic 1. Carson HJ. The medium, not the message: how tattoos correlate with early mortality. Am J Clin Pathol. 2014;142:99-103. 2. Byard RW. Tattoos—forensic considerations. Forensic Sci Med Pathol. 2013;9:534-542. 3. Cains G, Byard RW. The forensic and cultural implications of tattooing. In: Tsokos M, ed. Forensic Pathology Reviews. Vol 5. Totowa, NJ: Humana; 2008:197-220. 4. Byard RW. Ned Kelly tattoos—origins and forensic implications. J Forensic Leg Med. 2011;18:276-279. 5. Byard RW, Charlwood C. Commemorative tattoos as markers for anniversary reactions and suicide. J Forensic Leg Med. 2014;24:15-17.