Forensic Science Medicine and Pathology

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Online ISSN: 1556-2891
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Correctly assessing sex from skeletal remains is one of the main elements of creating a biological profile. Many traits allow for this, the obturator foramen being one. However, research on its accuracy has provided mixed results. This study examines the obturator foramen using a 5-point grading scale to assess the degree of sexual dimorphism in four known age and sex skeletal collections from the UK and South Africa. Overall, sexual dimorphism was found in the obturator foramen when using the new scoring system; however, accuracies for correct sex classification ranged from ~ 46 to ~ 75%. Considering its wide range in accuracy rates across the four samples and difficulty in identifying the subtle changes in morphology, the obturator foramen should only be used as part of a multifactorial assessment of sex.
Number of insulin overdoses in South Australia between 2000 and 2019, divided into 5-year bins
This study was undertaken to review fatal cases of insulin overdose in South Australia (SA) over a 20-year period to assess rates and characteristics of insulin-related deaths among insulin-dependent diabetics and non-diabetics for all manners of death. Records from the National Coronial Information System (NCIS) and Forensic Science SA (FSSA) were searched for all cases of fatal insulin overdose in South Australia (SA) between 2000 and 2019. Collected variables included age, sex, cause of death, scene findings, manner of death, decedent medical and personal histories, biochemistry, toxicology, histopathology, and autopsy findings. Statistical analyses were performed using R (version 4.1.2). Forty cases of insulin overdose were identified in SA between 2000 and 2019. Twenty-nine cases (72.5%) were suicides, with the remaining cases classified as accidental or undetermined intent. Thirteen of the 22 insulin-dependent diabetics (59%) had a history of depression, 10 of whom had previously demonstrated suicidal ideation. The current study has shown that suicides using insulin among insulin-dependent diabetics are equally as prevalent, if not more so than fatal accidental insulin overdoses. This can largely be attributed to insulin-dependent diabetic access to a potentially lethal substance. Suicide prevention strategies should focus on insulin-dependent diabetics with a history of depression, particularly for those with access to rapid-acting insulin.
Bodies of deceased persons and human remains and their specimens (i.e., organs, bones, tissues, or biological samples) are essential in forensic research but ad hoc worldwide-recognized ethical standards for their use are still lacking. Such standards are needed both to avoid possible unethical practices and to sustain research in the forensic field. Pending consensus within the forensic science community regarding this topic, with this article we aim to stimulate a debate as to the applicability and usefulness of the Declaration of Helsinki in the field of forensic research involving human cadavers and remains. Considering the fundamental differences compared to clinical research involving human beings and the different moral obligations involved, we focus on the risks, burdens, and benefits of research, ethics committee approval, and informed consent requirements. The Declaration of Helsinki framework allows forensic researchers to focus on substantial ethical principles promoting the consistency, integrity, and quality of research. Consensus regarding ethical standards and the adoption of national and supranational laws that clearly regulate the use of human cadavers and remains, including those from autopsies, continues to be of primary importance for the forensic science community.
a Tearing of clothes that fit under the belt, b tearing of underwear, and singeing of inner leg hair
a Lichtenberg figures in the chest area extending to the left shoulder, b and c burn areas on the skin caused by metallic objects in clothing, d exit wound in the scrotum
a Subarachnoidal fresh hemorrhage in the brain, b diffuse intraleveolar fresh hemorrhage in the lung, c fresh bleeding in the soft tissue of the leg (due to a fall after lightning strike), d burn findings in lightning strike entry wound (dermoepidermal separation and dermal homogenization)
In this study, deaths from lightning strikes in Eastern Turkey revealed distinct patterns in lifestyle and physical injury. Farmers, sailors, and those engaged in outdoor sports are all at risk of being struck by lightning. Death from a lightning strike is associated with cardiovascular and central nervous system damage. This study examines cases of autopsies that were performed on bodies that had suffered a lightning strike, including sociodemographic data, burns on the body, injured regions, histopathological findings, and causes of death. This retrospective evaluation included 17 cases. The cases comprised 88.2% males and 11.8% females, with a mean age of 41.5 years. The person’s occupation was farmer in 29.4% of the cases and shepherd in 70.6%. Their deaths occurred most frequently in the summer months. Deaths associated with lightning strikes are more frequent in east of Turkey than in other regions, as agriculture and livestock are common sources of income. The majority of the victims among the cases were males working outside because of their occupations. Histopathologically, subarachnoid fresh bleeding was seen in five cases, subpleural fresh bleeding in the lungs in five cases, and interlobular rupture in the lungs in three cases. Deaths associated with lightning strikes have been correlated with a low level of education in this subject. This study is the largest case study of deaths associated with lightning strikes in Turkey.
helicopter after the accident. The red arrow indicates the direction of impact with the other helicopter’s propeller
Injuries to the chest and right arm (amputated), knee, and foot
Reconstruction of the impact between the propellers and the cockpit with the pilot in a seated position
CT-scan of the body with 3D reconstruction: Blue arrow, ring fracture of the base of the skull; yellow arrow, multiple fractures with dislocation of the thoracic vertebral column
3D reconstruction of the skull: ring fracture (blue arrow) in posterior a, right lateral b, and left lateral view c. Comminuted fracture (red arrow) of the mandible and left cheekbone
During a helicopter exercise, due to the scarce visibility caused by the presence of snow, a collision between a landing helicopter and one already on the ground occurred. The 40-year-old pilot of the already landed aircraft was killed as a result of a direct propeller impact in the right side of the pilot’s cockpit, while the co-pilot remained uninjured. At autopsy, the macroscopic characteristic findings in the form of cut injuries and amputations along the axis of the rotor blade impact as well as a 3D reconstruction through CT-Scan were analyzed and discussed for a thorough reconstruction of the injuries and the dynamics.
Abdominal computed tomography (CT) findings. CT showed swelling of the left rectus abdominis muscle (red arrow)
Findings on the surface of the abdomen. An injection scar was observed on the epidermis of the upper left portion of the umbilicus (red circle), consistent with the puncture wound suggested by computed tomography
Trends in pentobarbital sodium concentration. Toxicology analysis showed a trend of decreasing pentobarbital sodium concentration after the start of continuous veno-venous hemofiltration (CHF)
Suicide attempts in humans due to injections of the veterinary drug pentobarbital sodium have been rarely reported. Herein, we present a case of a suicide attempt by intramuscular injection of pentobarbital sodium into the rectus abdominis muscle, which was suggested by computed tomography (CT). A 73-year-old man was brought to the emergency department with GCS 3 (E1V1M1) and an incised wound on the right side of the neck. A bottle of Somnopentyl® (pentobarbital sodium, 64.8 mg/ml), a 20-ml empty syringe with an 18-mm needle, and no. 10 scalpel were present at the scene. At the emergency department, the patient was intubated and was admitted to the intensive care unit. A urine drug screen test by SIGNIFY® ER was positive for benzodiazepines and barbiturates, and continuous veno-venous hemofiltration (CHF) was initiated. The route of drug administration was initially unknown; however, a CT scan revealed swelling of the left rectus abdominis muscle with a wound suggestive of a needle puncture, and the CT analysis suggested 38.16 ml as the maximum dose of pentobarbital sodium. On day 3, the patient’s consciousness improved, and he was weaned off CHF and mechanical ventilation. There have been several reports of postmortem CT yielding information on the site of administration of intoxicants, but there have been none for surviving intoxicated patients. This is the first report of the usefulness of CT to identify the site of administration of the causative agent of intoxication while the patient is still alive.
Spontaneous iliac vein rupture is a rare cause of retroperitoneal hemorrhage that may present to the forensic pathologist. It has been reported in association with venous thrombosis, anatomical variants such as May-Thurner syndrome, and as a complication of a long-term indwelling IVC filter. It has a female predominance and most often occurs due to rupture of the left iliac vein. This is the first report of the use of post-mortem computed tomography (PMCT) and post-mortem computed tomography angiography (PMCTA) as an adjunct to a conventional autopsy to diagnose rupture of the left iliac vein causing retroperitoneal hemorrhage arising as a complication of an inferior vena cava (IVC) thrombus. We discuss the use of PMCTA as a useful tool in the diagnosis of vascular injury and how it can be used to assist the forensic pathologist. The use of PMCT with PMCTA is an invaluable adjunct to conventional autopsy to diagnose the site of vascular rupture.
Different stages of sternal synostosis. A Absence, B partial synostosis, C total synostosis
Results from box plot analyses for manubrio-sternal fusion and age
Results from box plot analyses for sterno-xyphoidal fusion and age
Age estimation is essential for the identification of skeletal remains in Forensic Anthropology. Numerous studies have been performed on diverse regions of the skeleton, including the synostosis of the sternal segments. In this sense, the fusion of the different sternal segments was assessed to analyze whether it had a correlation with age-at-death in a Mediterranean population. A total of 189 sternums which belonged to individuals between the ages of 20 and 98 from both sexes (56.6% males; 43.4% females), from the San José’s Cemetery of Granada Contemporary Collection (Spain), were selected. Scores ranging from 1 to 3 were assigned in accordance with the degree of manubrio-sternal fusion and sterno-xyphoidal fusion. Cohen’s kappa coefficient for intra- and inter-observer error was performed and then chi-square test was run to analyze any correlation between the stage of synostosis and the skeletal age. Only the sterno-xyphoidal fusion, which starts between 30 and 39 years old, provided a predictable result, as the manubrium and the sternal body usually remain without fusion. This study demonstrates a direct correlation between fusion of the xyphoid process and chronological age.
Injuries from motor vehicle collisions are frequently encountered in routine forensic practice. While the most common lethal events involve blunt force trauma with injuries to the head and neck, chest, abdomen, pelvis and limbs, review of the literature and case files shows that a wide variety of other fatal situations can occur that may involve sharp force and penetrating trauma, incineration, drowning, asphyxia, organic diseases and combinations of these. The following overview details potential factors that may contribute to death following vehicle crashes.
Cases of child suicide in Hennepin County, South Australia, and Auckland from 2008 to 2017
Cases of child suicide per month in the jurisdictions of Hennepin County, South Australia, and Auckland from 2008 to 2017
Age of child suicide cases in South Australia, Hennepin County, and the Auckland region across a 10-year period (2008 to 2017)
Frequency of child suicide methods in the jurisdictions of Hennepin County, South Australia, and Auckland between 2008 and 2017
The suicide rate per 100,000 young persons (19 years and under) per year in South Australia, Hennepin County, and Auckland from 2008 to 2017 (solid colored lines for each center). The trend is downward for Auckland and upward for South Australia and Hennepin County. The dashed colored lines represent the national suicide rate (per 100,000 young persons 19 years and under for the USA and New Zealand, and 17 years and under for Australia, due to differences in Australia’s presentation of child suicide data). The suicide rate in each center appears to follow the same trend as its respective nation, just at a different level
Although the overall suicide rate worldwide has changed minimally over the past 100 years, different trends have been observed over time in the USA, Australia, and New Zealand (NZ). However, few studies have focused on suicides in children (< 18 years), making evaluation of possible trends difficult. The last 20 years has also seen an increase in childhood obesity, eating disorders, and body image issues for children in many developed nations; however, few studies have shown whether a significant proportion of child suicides have an abnormal BMI. The current study evaluates child suicides (from 2008 to 2017) in South Australia (Australia), compared with the jurisdictions of Auckland (NZ) and Hennepin County (USA). Demographic data (age, sex, ethnicity), body mass index (BMI), the number of cases of youth suicide, and the method of suicide from these three regions were collected and analyzed. Across the 10-year period, the jurisdiction of Auckland had a downward trend, while Hennepin County and South Australia had increasing numbers of cases. The most common method of child suicide in all centers was hanging, occurring in > 80% of cases in South Australia and Auckland and 56% in Hennepin County. Hennepin County had a greater proportion of suicides using firearms (28%), compared to 1.9% in Auckland and 5.1% in South Australia. Unusual means of suicide were used less frequently by youth than previously.
Foetus lying outside the uterine cavity in the peritoneum with haemorrhage at placental attachment (yellow arrow) to the uterine rudimentary horn (green arrow)
A A sagittal view of the uterus (short arrow) showing a non-communicating rudimentary horn (long arrow). The placenta (arrowhead) was attached to the distal end of the horn. B Schematic view showing anatomical relationship of rudimentary horn and uterus
Haematoxylin- and eosin-stained section of rudimentary horn/placental junction shows chorionic villi infiltrated by acute inflammatory cells and haemorrhage with adjacent fibromuscular tissue
Haematoxylin- and eosin-stained section of placenta shows acute neutrophilic infiltration of the chorionic villi
Pregnancy on a rudimentary uterine horn is a rare condition that can lead to a catastrophic outcome when it ruptures. The majority of cases are diagnosed late, after the rupture has occurred. We present the case of a 29-year-old female G2 P1 who complained of abdominal pain. She consulted a medical practitioner who prescribed her analgesics. In the next day, she was found dead in her bedroom. The pregnancy was undiagnosed as she was not aware that she was in a gravid state. At autopsy, there was massive haemoperitoneum and a 24-week gestation foetus lying outside the uterus. The uterus revealed an anomaly in keeping with a non- communicating rudimentary horn. Forensic pathologists do encounter undiagnosed ectopic pregnancies in practice. However, abdominal ectopic pregnancy with a uterine anomaly remains uncommon. These cases are often associated with a high maternal and foetal mortality.
In the town of Calera y Chozas (Spain), five mass graves containing the remains of 28 individuals were discovered during a 2012 excavation. The witnesses and historical evidence indicated that the body of the last Republican mayor of the town, Felipe Fernández Varela, who had died in September 1939, was located in the mass grave designated as no. 1. Within this particular grave, only two bodies were found. Anthropological analysis showed that the first individual was significantly younger than 50 years, being the mayor’s age at the time of death, while the age of the second individual was closer to 50. This second individual had a fractured skull, with a depression on the left parietal bone, and there were unmistakable signs of autopsy, which consisted of cut marks on the frontal bone and the sternal extremity of the right clavicle. Further historical research revealed documents concerning the autopsy performed on this individual. Although, according to the report, the cause of death was a stroke — the consequence of atherosclerosis and alcoholism — no reference was made to the forceful impact to the skull or intracranial bleeding. Considering the size of the fracture on the skull and the fact that there were no signs of bone healing, we believe that this impact, and not the stroke, was the direct cause of the death of the last Republican mayor. The mayor’s case is a clear example of the role forensic medicine performed at the beginning of Franco’s dictatorship. The task was not only to conceal the crime but also to tarnish the victim’s name.
Autopsy evaluation of case 1. a Subtle erythema, the wound suggestive of recent abscess incision (black arrow) and the scar from chronic heroin injection below it in the left groin (white arrow). b Fibrinopurulent exudate within the lower part of the abdominal cavity. c Extensive foul-smelling suppurative inflammation of the deep soft tissue and muscle sheets on the lateral side of the left thigh and left gluteal region
Autopsy evaluation of case 2. a Examination of the left inguinal region revealed extensive soft tissue and muscle necrosis. b Pronounced para-aortic lymphadenopathy (arrows) and exudate in the abdominal cavity were observed, and a longitudinal section of the left iliopsoas muscle revealed pus
Autopsy evaluation of case 3. a The necrotic skin defect with evident loss of the underlying soft tissue in the right groin after removal of spontaneously drained pus. b The foul-smelling dark green-yellow pus in the gap formed between the skin, soft tissue, and underlying muscles of the thigh
We present fatal extensive soft tissue infections, a consequence of groin heroin injection, in three subjects, who were 27, 34, and 39 years old and had a history of over 10-, 15-, and 5-years of heroin injection (cases 1, 2, and 3, respectively). In all cases, the first symptoms of the infection appeared at least a week prior, with rapid deterioration on the last day. The hallmark was a disproportion between external and internal findings in the affected thighs. The latter presented as extensively spread suppurative inflammation with soft tissue necrosis. In case 1, subtle skin erythema was present in the left groin, with a wound suggestive of a recent abscess incision and injection-related scarring. However, dissection revealed that inguinal regions and deep soft tissue (including the muscle sheets) of the left thigh, gluteal region, and lower third of the anterior abdominal wall were inflamed with pus, alongside fibrinopurulent peritonitis. Case 2 had pronounced erythema and swelling of the thigh and knee. Diffuse suppuration was observed upon dissection in the inguinal regions, which extended into the iliopsoas muscles, with soft tissue and muscle necrosis. In the abdominal cavity, we detected 150 mL of serofibrinous exudate. Only case 3 had a prominent, 4 × 3.5-cm necrotic skin defect through which pus spontaneously drained. In contrast to the other two, although extensive pus collection within predominantly necrotic thigh's soft tissue was present, the inflammation did not expand above the inguinal ligament, and peritonitis was not observed. Toxicology analysis excluded acute heroin intoxications.
Scheme showing an appraisal of the articles based on the methodology and eligibility criteria
Many articles on COVID19 deaths have been published since the pandemic has occurred. On reviewing the articles published until June 2021, the findings were very heterogeneous. Adding to the existing knowledge, there were also some unique observations made in the pathogenesis of COVID19. This review was done to determine the findings obtained and inferences drawn from various studies published globally among patients who died due to COVID19. PRISMA guidelines were used to conduct this systematic review. A search of databases like PubMed, ScienceDirect and Epistemonikos was done. The articles focusing on postmortem sample studies involving full autopsies, minimally invasive autopsies and tissue biopsy studies were screened and searched. The studies included were all the case reports, case series, narrative reviews and systematic reviews obtained in full text and in the English language containing study information, and samples obtained postmortem. The information obtained was tabulated using Microsoft excel sheets. The duplicates were removed at the beginning of the tabulation. Zotero referencing software was used for article sorting and citation and bibliography. Two authors independently reviewed the articles throughout the process to prevent bias. Adding to the heterogeneity of COVID19, the concept of lethality in preexisting disease conditions, the occurrence of secondary bacterial and fungal infections, and other pathogenetic mechanisms uniquely encountered are to be considered in treating the patients. Also, the presence of SARS-CoV-2 postmortem is established and should be considered a hazard.
Flow of selection process for eligible studies for inclusion
Topic of FO addressed by the studies: distribution of articles according to the FO areas following the NAS report
Subcategories of FO area of focus: “Dental Identification.” The bottom bar shows the subcategories of the reconstructive dental ID
Dental age estimation (DAE) is one of the most reliable and useful scientific methods employed by forensic odontology (FO) for human identification. In 2009, the US National Academy of Sciences (NAS) report highlighted the need to deepen research in many disciplines, among which FO received strong criticism for specific expertise. The aim of this review is to provide a comprehensive overview in order to systematically map the latest original research done in FO, as well as identify DAE within this field. A systematic search was performed from 2014 to 2019. In total, 644 studies were identified for qualitative analysis: DAE was the most studied topic (41.30%). Asia was the most productive continent with 58.27% of the global production on DAE; India was the most productive Asian country, with 32.33% and 55.48% of global and Asian production, respectively. The University of Macerata (Italy), KU Leuven (Belgium), University of Split (Croatia), and University of São Paulo (Brazil) led DAE research. Authors from leading countries on DAE research demonstrated great individual productivity, which is evidence of their scientific efforts, but also possible risks if the continuity of this line of research depends on them. Although FO has significantly focused its research on DAE, the absence of publications on controversial topics but necessary for research according to the NAS report shows the possible lack of interest of authors or journals to address them.
Falls are the second cause of accidental deaths worldwide. Falls from height are also a common method of suicide. The aim of this study is to compare the characteristics of the victims, the circumstances of the fall and the severity and distribution of the injuries reported in an autopsy case series of falls from height. This study is a retrospective analysis of consecutive autopsy cases of suicidal and accidental falls from height which were investigated in the Department of Forensic Medicine and Toxicology of the National and Kapodistrian University of Athens during the period 2011–2019. The recorded variables included demographic data of the victim, height of fall, length of hospital stay, toxicological results, the existence and location of injuries and Injury Severity Score (ISS). Victims of suicidal falls were younger (55.53 vs. 62.98, p = 0.001), they fell from higher heights (12.35 vs. 5.18 m, p < 0.001), and they sustained more severe injuries compared with victims of accidental falls (ISS 51.01 vs. 40.88, p < 0.001). Injuries in the thorax, abdomen, pelvis, upper and lower extremities were more frequently observed after a suicidal fall (93.6% vs. 67.3%, 72.1% vs. 21.4%, 72.1% vs. 27.6%, 42.9% vs. 15.3%, 45.7% vs. 13.3%, respectively-p < 0.001), probably due to the higher height of fall. Our study outlines the differences in the profile of the victims and in the severity of injuries caused by falls from height depending on the intention of the victim to fall. However, a distinctive injury pattern in victims of suicidal falls was not demonstrated.
Human cadaveric lingual striated muscle tissue. A 6 h PM group. B 12 h PM group. C 24 h PM group. D 48 h PM group. E 72 h PM group. F 92 h PM group. Mf: Myofibers, Ms: Muscle striations, N: Nuclei, U: Undulations, > : Frayed edges, Is: Intercellular space, Pn: Pyknotic nucleus, Rn: Round core, Cv: Cytoplasmic vacuole; Nv: Nuclear vacuole, K: Karyorrhexis, asterisk absence of muscle striations, «: Myofiber rupture
Human cadaveric lingual tissue. 120 h PM group. A Striated muscle tissue. B Mucosa and submucosa. Mf: Myofibers, asterisk absence of muscle striations
Although there are physiological methods to determine the postmortem interval (PMI), interval forensic histopathology can be applied to obtain accuracy. The aim was to describe the histological changes in human lingual striated musculature at different PMI. Seven groups were formed according to increasing PMI of 6, 12, 24, 48, 72, 96 and 120 h postmortem (PM). Each group was made up of 16 samples of tongues from each cadaver. The samples were fixed in buffered formaldehyde at 10% and processed for embedding in paraplast. Section 5 μm thick were cut and dyed with H&E for analysis. The study was approved by the Bioethics Committee of the Universidad San Francisco de Quito, Ecuador. The histological changes in the striated muscle cells of the tongue were associated with the different PMI. From 6 to 24 h PM, there were initial changes in the cellular and nuclear morphology. At 48 h PM, at least 50% of the samples presented poorly conserved and reduced muscle striations. At 72 h PM, 100% of the cases presented myofibers with altered morphology, cytoplasmic vacuoles (93.75%), edema (68.55%) and pyknosis (93.75%). At 96 and 120 h PM, the myofibers presented pyknotic nuclei, and they were absent in the rest. The changes in the histology of the human lingual striated muscle make it possible to estimate the PMI, either in the early phase (0—72 h) or the late phase (92–120 h). However, further research is needed to verify, refine and expand on these results.
The effect of four different bak kut teh formulations on HepG2 cells after 48 h of exposure. A Formulation #1 showed significant toxicity before dilution (p = 0.023), but demonstrated no significant toxicity once diluted (p > 0.05). B Formulation #2 demonstrated significant toxicity with no dilution factor (p = 0.009), but none once diluted (p > 0.05). C Bak kut teh Formulation #3 showed similar toxicity when undiluted (p < 0.0001) but was not found to be toxic with dilution (p > 0.05). D Formulation #4 was shown to be significantly toxic undiluted (p < 0.0001) and in dilutions with a factor of 1:10 (p = 0.023) and 1:1000 (p = 0.024). Values mean ± SEM (n = 3). *p < 0.05, **p < 0.01, ****p < 0.0001. One-way ANOVA with Dunnett’s. Where error bars are not shown, they are smaller than the symbol
Unexpected hepatic failure with liver necrosis is sometimes encountered during a forensic autopsy. Determining the etiology may sometimes be difficult, although increasingly herbal medicines are being implicated. To determine whether such effects might also be caused by foodstuffs, the following in vitro study was undertaken. Four formulations of traditional herbal soup advertised as bak kut teh were prepared and added to cultures of liver carcinoma cells (HepG2). Cell viability was assessed using an MTT colorimetric assay at 48 h demonstrating that all formulations had significant toxicity prior to dilution (p < 0.05). Formulation #1 showed 21% cell death (p = 0.023), Formulation #2 30% (p = 0.009), and Formulation #3 41% (p < 0.0001). Formulations #1–3 showed no significant toxicity once diluted (p > 0.05). Formulation 4 showed approximately 83% cell death before dilution (p < 0.0001) and persistent toxicity even with dilutions at 1:10 (15% ± 3.7, p = 0.023) and 1:1000 (14% ± 3.8, p = 0.024). This study has shown that herbal foodstuffs such as bak kut teh may be responsible for variable degrees of in vitro hepatotoxicity, thus extending the range of herbal products that may be potentially injurious to the liver. If unexpected liver damage is encountered at autopsy, information on possible recent ingestion of herbal food preparations should be sought, as routine toxicology screening will not identify the active components. Liver damage may therefore be caused not only by herbal medicines but possibly by herbal products contained in food.
Study design
Studies on the occurrence of injuries following consensual sexual intercourse (CSI) among patients treated by office-based gynecologists are lacking. This survey aimed to assess the presence and medical relevance of vaginal injuries after CSI in gynecological office-based practice, associated risk factors, and their significance for forensic medical assessment practice. All office-based gynecologists in Hamburg, Germany ( n = 316), were asked to fill in a one-page questionnaire via a fax survey. The questionnaire covered various aspects such as having observed CSI-related injuries, injury severity, risk factors, and concomitant factors (bleeding, need for surgical care, hospitalization). Response rate was 43.2% ( n = 115). Overall, 83.5% of office-based gynecologists reported having observed vaginal injuries after CSI at least once and 59.1% repeatedly. Regarding maximum injury severity, 52.1% observed mucosal erosions, 32.3% mucosa penetrating injuries, and 14.6% injuries penetrating the vagina. Having observed bleeding was reported by 56.3%, 28.1% had to perform surgical suture care, and hospital admission was initiated by 20.8%. Menopause (37.5%), use of objects (19.8%), alcohol, and/or drug use (16.7%) were reported as the most frequently observed associated risk factors. Vaginal injuries after CSI have been observed by the majority of office-based gynecologists in Hamburg involving a wide spectrum of severity, including the necessity of surgical care and hospital admission. Complementing published work in clinical and emergency medicine, these findings are highly relevant to the forensic evaluation of injuries in an allegation of sexual assault, as the severity of a vaginal injury in this setting does not necessarily support a conclusion on the issue of consent.
A 40-year-old man was stabbed multiple times with a cross-tipped, Phillips head screwdriver with many of the puncture wounds characterized by a cruciate pattern consistently measuring approximately 5 × 5 mm corresponding to the shape of the weapon. Death was due to a single penetrating wound to the chest that had transfixed the aorta. This report characterizes the features of injuries that may be inflicted by Phillips head screwdrivers, contrasting this with injuries that may occur if the weapon is a flat or slotted head screwdriver. Given their ready availability, ease of handling, and sharpness, screwdrivers are surprisingly rarely used in fatal assaults.
Metabolites of 5F-MDMB-PICA detected in the analysed fatal case
Metabolites of 4F-MDMB-BINACA detected in the analysed fatal case
Extracted-ion chromatograms (EIC) of 5F-MDMB-PICA and its detected metabolites
Extracted-ion chromatograms (EIC) of 4F-MDMB-BINACA and its detected metabolites
Extracted-ion chromatograms (EIC) of 5F-MDMB-PICA and its metabolite fragment ions enhancing identification
Synthetic cannabinoids (SCs) remain one of the largest groups of new psychoactive substances. Recently, new synthetic cannabinoids 5F-MDMB-PICA and 4F-MDMB-BINACA are increasing in popularity. A 33-year-old man lost consciousness after smoking an unknown substance. A glass pipe and two lumps of substance that turned out to contain 5F-MDMB-PICA and 4F-MDMB-BINACA were found at the scene. Blood, urine and cerebrospinal fluid were collected during the examination of the body. The synthetic cannabinoids were isolated from autopsy materials by precipitation with acetonitrile and extraction with ethyl acetate. The screening and quantitative analyses were performed by liquid chromatography with tandem mass spectrometry (LC–MS/MS). The liquid chromatography-quadrupole/time of flight mass spectrometry (LC–Q/TOF) technique was used for metabolite identification. 5F-MDMB-PICA was detected and quantified in all analysed materials, whereas 4F-MDMB-BINACA was found only in cerebrospinal fluid. The determined concentrations of 5F-MDMB-PICA were 0.9 (blood), 0.1 (urine) and 3.2 ng/mL (cerebrospinal fluid). The concentration of 4F-MDMB-BINACA in cerebrospinal fluid was 0.1 ng/mL. The main metabolites of both compounds (hydrolysis and oxidative defluorination) were found in all analysed body fluids. Cerebrospinal fluid may be important alternative material in autopsy cases. Rapid elimination of 5F-MDMB-PICA and 4F-MDMB-BINACA compounds also means that the metabolite analysis can be crucial for the investigation. Laboratories must be made aware of their presence and incorporate these SCs and their metabolites into workflows for detection and confirmation. Ester hydrolysis and oxidative defluorination products can be found in blood, urine and cerebrospinal fluid making them useful biomarkers of intake.
Dressing in the right lateral cervical region with a double-lumen peripherally inserted central catheter (PICC) by the right jugular
Bulky cardiac tamponade distending the pericardial sac (A), and lumpy white area of fibrin with bluish punctate structure of the catheter in the center (B and C). A milky content is evident (B and D)
The path taken by the catheter in the heart wall and perforation site between the trabeculae carneae of the right ventricle
Fatal adverse events caused by any health professional as consequence of malpractice are uncommon. In this work, the authors report a fatal cardiac tamponade associated with a peripherally inserted central catheter (PICC) by the right jugular vein that perforated the right atrium of the heart. The diagnosis of cardiac tamponade was not detected in hospital during the intrapericardial infusion of total parenteral nutrition and was only registered during the autopsy. The postmortem examination showed a milky liquid inside the pericardial cavity compatible with the total parenteral nutrition administered. The catheter in its migration in the cardiac chambers, mechanically perforated the inner wall of the endocardium between the trabeculae carneae, continued its course between the myocardial fibers until it was externalized. In conclusion, cardiac tamponade, although it is an extremely rare medical complication, has a high risk of fatality specially if peripheral rather than central veins were cannulated.
Bloodstained wall (a) and blood-soaked mattress (b) inside the flat
Outside the flat (a), a few bloodstains around the bay window of the flat where the later victim escaped (b)
Location of the infliction of the fatal wound with marked increase in dripped bloodstains (a) and heavy bloodstaining where the victim was found dead a few metres away (b, c)
Schematic drawing of the fatal wound
Two men were wrongfully convicted of murder in 2017 and sentenced to life imprisonment. After a physical altercation inside a flat, the victim (A) was found dead approximately 60 m away outside a residential address. He had sustained a number of injuries including a stab wound to the left side of his neck which was found to have divided the right carotid artery. The location where A was found was not regarded as a crime scene and not subjected to a specialist forensic examination by scientists as it was assumed that the fatal injury was sustained in the flat. The pathologist, who subsequently carried out the autopsy on A, was not asked to attend the scene. A review of the blood distribution at the scene in conjunction with the pathology findings indicated however that the fatal neck wound had been inflicted outside the flat, near to where the victim was found. An appeal against the convictions for murder was upheld in 2021 and a re-trial ordered. Following this second trial, both accused were acquitted of murder and released from custody. The new pathology and blood pattern evidence introduced at the second trial was a major part of the defense strategy which led to the acquittal of the accused. The case illustrates that a more inclusive and detailed crime scene strategy had been undertaken, including an assessment of the bloodstains present, in conjunction with discussion with the pathologist, then the likelihood is that the two men subsequently charged with murder would have been eliminated as suspects and a miscarriage of justice would have been avoided.
Typical square floor tiles with intervening gaps (A). A faint cruciate pattern of linear lividity with surrounding pallor on the left thigh corresponding to such gaps between ceramic kitchen floor tiles that the body was lying on (B)
Underwear being worn by a decedent at autopsy (A) with the manufacturer’s’ name clearly marked out by dependent lividity (B). Pallor around the letters had been caused by compression of the skin by the elastic waist band of the underwear
A similar situation to Fig. 2 where skin blanching from compression by underwear contrasted with the livid manufacturer’s name in the skin that had not been compressed due to elevation of the stitched letters from the surrounding material
Lividity or livor mortis occurs when blood settles in dependent areas after death due to gravitational effects. Patterned lividity may result from a body lying against a variety of surfaces. Two case are presented where lividity was prevented by tight fitting elastic underwear except in areas where letters from the manufacturers’ names had elevated the material, thus permitting capillaries in the underlying skin to fill. This type of patterned lividity may act as a useful record of the type of clothing being worn at the time of death and in the hours following.
Metabolic pathway of lysine and tryptophan
A Abdominal CT image and B macroscopic and C microscopic images of liver
Alpha-ketoadipic acid is one of the metabolic intermediates of lysine and tryptophan, and it is known as the biochemical hallmark of alpha-ketoadipic aciduria (α-KA). α-KA is a rare autosomal recessive disorder. Its pathophysiology is reduced alpha-ketoadipic acid dehydrogenase activity, and that makes it difficult to metabolize lysine and tryptophan. The symptoms of this disease are multiple, e.g., psychomotor retardation, epilepsy, and ataxia, and it can even be asymptomatic. We present a case of sudden death in a 2-year-old boy with alpha-ketoadipic aciduria. Postmortem computed tomography (CT) and autopsy were performed to elucidate the cause of death. No obvious lesions could be identified except for a marked fatty liver. Urinalysis showed elevated excretion of α-ketoadipic acid.
Postmortem CT (left axial slice, right coronial slice) showing visceral aneurysmal lesion (white arrows) and evidence of blood in abdominal cavity
Macroscopic photograph of fixed specimen showing arterial feeding vessel (white arrows)
Macroscopic photograph of fixed specimen. Left - showing outer wall within omental fat and rupture site (black arrow). Right - section through fixed specimen at level of rupture site (black arrow) showing aneurysm contains laminated thrombus with apparently fibrous wall with patchy outer omental fat
Photomicrograph of Elastic van Gieson stained section through wall from inner (bottom of image) to outer (top of image) of aneurysmal lesion. Left - wall comprises collagenous tissue with layer resembling internal elastic lamina (small arrows) apparently separating collagen from layer resembling reduplicated internal elastic lamina including layer of elastic tissue (marked with *); Right - apparent arterial vessel within wall (indicated by large arrow)
We report unexpected death of a 72-year-old man due to a hemoperitoneum (1.9 L of blood in the abdominal cavity). Postmortem examination revealed that the cause of the hemorrhage was an arterial aneurysmal lesion in the greater omentum. The lesion measured 4 × 4 × 6 cm with a generally smooth wall, but with a focal area of rupture within a hemorrhagic region measuring 1 × 2 cm. There was a substantial feeding artery. Histological examination revealed features in keeping with a pseudoaneurysm, but also with some features of a true aneurysm. There was no history of trauma and the rupture of the aneurysmal lesion that had caused the hematoperitoneum was considered to be spontaneous. Prior to his death the deceased had attended hospital for epigastric pain, which was attributed to dyspepsia, but otherwise he had not had symptoms prior to his death.
a and b. Dense retropharyngeal haematoma with diffuse haemorrhagic swelling and critical reduction in the diameter of the laryngeal outlet
Soft tissue haemorrhage dissection through the anterior neck planes
Acute retropharyngeal haemorrhage (H&E)
Mild chronic tracheitis (H&E)
Diffuse hepatic steatosis and necrosis (H&E)
Extensive retropharyngeal haemorrhage is a rare event, which is occasionally encountered in clinical practice, but very seldom at autopsy. A 43-year-old woman who presented with difficulty breathing after a week's history of sore throat and coughing is reported. She collapsed at a medical centre and was not able to be resuscitated. Staff noted that she had 'swelling' of her throat. At autopsy, the major findings were in the anterior neck where there was extensive and diffuse retropharyngeal haemorrhage extending throughout the soft tissue planes resulting in marked stenosis of the laryngeal inlet. There was no evidence of external or internal trauma, and although no specific source of the retropharyngeal haemorrhage was identified, the haemorrhage clearly originated from the retropharyngeal space with diffuse extension Her past medical history included anticoagulation for atrial fibrillation and heart valve replacements, hepatic steatosis and sleep apnoea. This case demonstrates a significant complication of oral anticoagulation therapy with underlying comorbidities which may result in significant neck haemorrhage with critical upper airway narrowing and rapid clinical deterioration.
Illustration of location and dissection of left stellate ganglion. Gross image of the posterior aspect of the thoracic cavity at the base of the neck after the visceral organs have been removed. The stellate ganglion (*) is located by following along the sympathetic chain superiorly to the neck of the first rib paravertebral sympathetic chain
An illustration of the left stellate ganglion inflammation seen in this study, ranging from focal (a, × 20 hematoxylin and eosin) to multifocal lymphocytic aggregates (arrows) (b, × 2 hematoxylin and eosin) around postsynaptic neurons (*)
One of the hypothesized mechanisms of sudden cardiac death in humans is an arrhythmia precipitated by increased sympathetic outflow to a compromised heart. The stellate ganglia provide the main sympathetic innervation to the heart, where the left stellate ganglion appears to play a role in arrhythmogenesis. Case reports of sudden cardiac death have described left stellate ganglion inflammation but no larger studies have been performed. Thus, we have specifically assessed whether the left stellate ganglion was inflamed in those dying from sudden cardiac death versus other causes of death. Thirty-one left stellate ganglia were resected from cadavers diagnosed with sudden cardiac deaths and compared with 18 ganglia from cadavers diagnosed with non-sudden cardiac deaths. Ganglia were stained with hematoxylin and eosin and lymphocytic aggregates compared. The proportion of left stellate ganglion inflammation (77%) was significantly higher in deaths from sudden cardiac deaths than non-sudden cardiac deaths (33%). This study provides information on a previously recognized, but understudied, structure that may help understand sudden cardiac death. We found high prevalence of stellate ganglion inflammation and propose that this may trigger sympathetic storms.
At DSI, the body, which had been removed from its original location by the rescue team, was lying supine on the floor near the bed (A). The mattress was cluttered with clothes and blankets (B–C); at inspection, traces of blood were found on the lateral edge of the container (B–C, black arrow)
At autopsy, the distribution of postmortem lividities was comparable to that found at the time of death (A). An oval-shaped abrasion, with a size of 4.5 × 2.5 cm, was noticed under the chin on the right side (B). On the posterior cervical region, an oval-shaped abrasion with a length of 5 cm and a width of 3 cm was present (C). Upon anterior and posterior dissection of the neck, the soft tissues corresponding to the above-described abrasions were infiltrated with blood, while the cervical vertebrae were not fractured. Both jugular veins were dilated (D). Micro-CT scans showed no dislocations or fractures of the larynx and the hyoid bone (E)
Sketch depicting the most likely mechanism of compression of the neck between the left bed frame and the partially lifted bed base and mattress (A–B)
Herein, we present an uncommon forensic case of death by asphyxia. The victim was a woman whose body at death scene investigation (DSI) was discovered beside an ottoman storage bed. According to the rescue team, who had moved the body before our arrival, the body was originally found in the prone position and stuck with the neck, thorax and arms within the bed. Examination of the body showed hypostasis that was mainly distributed to the face and the lower chest while sparing the neck and the upper chest. The face was markedly swollen, and the eyes were congested with blood. Dissection and histology revealed pulmonary oedema and emphysema of both lungs. Integrating circumstantial, radiology and autopsy data, it was established that the victim, while trapped between the mattress and the edge of the ottoman storage bed, died by mechanical asphyxia due to cervical-thoracic compression and postural asphyxia acting simultaneously.
The photographs were taken during the autopsy. a Gross aspect of deceased and injuries. b Avulsion of the heart from its base. c Closer aspect of subendocardial hemorrhages of the left ventricle
The photographs were taken during autopsy. a Gross aspect of the pale kidneys. b The histological section of the kidney (H&E)
The histological section of the heart. a Low-power photomicrograph of the streaky hemorrhage under endocardium and between superficial layers of the myocardium. Note the vascular congestion under the endocardium (H&E). b Low-power photomicrograph of the micro bleeding within muscle fibers surrounding small vessel (H&E). c High-power photomicrograph of the erythrocytes within superficial muscle fibers, reaching endocardium (H&E)
A 25-year-old male, suicidal head gun-shot injury, survived for an additional 1 h, the autopsy performed 36 h after death. a Gross aspect of the heart specimen after fixation in formalin for 24 h. b Low-power photomicrograph of the streaky hemorrhage under endocardium and within superficial muscle fibers (H&E). c and d High-power photomicrograph of the bleeding within superficial muscle fibers, surrounding blood vessels, reaching endocardium (H&E)
We present a case of a 66-year-old man who died on the scene in a traffic accident. He was a car driver involved in a head-on collision with a bus. Autopsy performed 4 days after death showed multiple head, torso, and limb injuries, including complete avulsion of the heart from the great vessels and avulsion of both lungs from the tracheobronchial tree due to rapid deceleration. Gross examination of the heart was remarkable for patchy hemorrhages beneath the endocardium involving the left side of the interventricular septum and papillary muscles. Histological examination identified streaky subendocardial hemorrhages and perivascular hemorrhages in the subendocardial myocardium. Since the death, in this case, was instantaneous, the most likely mechanism of subendocardial hemorrhages involved a precipitous decrease in left ventricle pressure, as it is improbable that the timeline of events allowed for a catecholamine surge to occur and take effect. Findings in this case also suggest that subendocardial hemorrhages are an indicator of intravital trauma and that the time required for them to develop is very short.
The photographs were taken during the police investigation. a The body of the deceased lying on the couch in a pool of blood. b The wound in the right groin. c A screwdriver found on the spot during the police investigation (suspected weapon)
The photographs were taken during the autopsy. a Gross appearance of the body. b An infundibular funnel-shaped scar of the left groin
The photographs were taken during the autopsy. a The oblique wound in the right groin after removing the blood. b The thickened superficial femoral arterial wall. c The tract communication between the artery lumen and the skin surface. d The empty cavities with a smooth internal surface constitute a pseudoaneurysm
The histological section of the femoral pseudoaneurysm. a Low-power photomicrograph of the tract communication between the arterial lumen and the skin surface (H&E). b High-power photomicrograph of the recent bleeding around the arterial wall haemorrhage and infiltration of acute and chronic inflammatory cells into fibro-fatty and fibro-skeletal tissue. c Low-power photomicrograph of scar tissue, granulation tissue (neoangiogenesis), with chronic inflammatory infiltrate and numerous hemosiderophages. d Low power photomicrograph and e high-power photomicrograph showing perivascular fibrosis and neoangiogenesis, with chronic inflammatory infiltrate. f High-power photomicrograph of the recent bleeding around the arterial wall haemorrhage, with infiltration of acute and chronic inflammatory cells and surrounding fibrosis and granulation tissue (neoangiogenesis)
A 47-year-old woman with a long-term history of intravenous heroin use was found dead lying on the couch in a pool of blood with the wound in her right groin, 15 × 4 mm in diameter. The autopsy revealed the thickened superficial right femoral artery wall and the tract communication between the artery lumen and the skin surface, with pseudoaneurysm formation, confirmed by microscopic examination. Toxicological findings were negative for heroin and its metabolites. The cause of death was fatal blood loss from ruptured chronic femoral pseudoaneurysm. Persons with a long-term history of intravenous drug use experience injection-related problems: prominent vein scarring, lumps, and swelling. The risk of injecting the groin is substantially greater than in typical areas such as the cubital fossa. The proximity of the femoral vein to the femoral artery and nerve poses the risk of accidental trauma to these sites. Accidental groin arterial injections can cause a tear in the arterial wall, on which a pseudoaneurysm can develop. A false or pseudoaneurysm is a breach in the vascular wall leading to an extravascular hematoma that freely communicates with the intravascular space. In the presented case, the autopsy findings pointed out that the fatal blood loss from femoral pseudoaneurysm rupture occurred probably after trivial trauma (shortly after sexual intercourse) or even spontaneously, and not immediately or shortly after arterial drug injection.
a Post-mortem CT-scan showing dilation of the cecum (red star). b Autopsy in situ view of the anterior part of the cecum presenting diffuse green-brownish discoloration with a red–purple well delineated edge (red arrow)
Cecal wall necrosis with diffuse polymorphonuclear neutrophil (PMN) infiltration (inset) (hematoxylin and eosin, 40 ×). Inset: Close-up view of PMN infiltration highlighted in the black box (hematoxylin and eosin, 400 ×)
Cecal wall necrosis with diffuse polymorphonuclear neutrophil infiltration (black star) and acute peritonitis (black arrowhead) (hematoxylin and eosin, 100 ×)
Ogilvie’s syndrome refers to a massive dilation of the colon without mechanical obstruction. Although this syndrome is well-known in the clinical literature and may sometimes be encountered as a complication of abdominal, pelvic, or hip surgery, it has only been reported sporadically in the forensic literature. We present the case of a forensic autopsy carried out on a patient whose death was related to cecal necrosis with acute peritonitis due to Ogilvie’s syndrome following hip surgery. This diagnosis was based on clinical data, post-mortem imagery, autopsy findings, histological analysis, post-mortem chemistry, and microbiological analysis. A review of the literature and possible physiopathology of this disease are performed, while focusing on medico-legal perspectives.
Genitalia of a 62-year-old morbidly obese man showing marked shortening of the penis with two testes in the scrotum
Genitalia of a 49-year-old morbidly obese man showing marked shortening of the penis with two testes in the scrotum beneath a prominent fatty apron
Genitalia of a 45-year-old morbidly obese man showing marked shortening of the penis with two testes in the scrotum. Fecal soiling and patchy postmortem parchmenting are also present
Peau d’orange changes in striae of the skin of the lower abdomen in a morbidly obese individual
Lymphedema of the lower legs in a morbidly obese individual
Three morbidly obese men aged 69, 49 and 45 years with respective BMIs of 46.3, 49.1 and 59.3 died suddenly from underlying cardiovascular disease. At autopsy all were found to have marked penile shortening typical of an entity known as “buried penis.” This condition arises in adulthood most commonly from morbid obesity as the penile shaft becomes enveloped by encroaching suprapubic adipose tissue. It is associated with infective, obstructive and malignant complications. Histology will be required to identify less-common causative conditions or any inflammatory or premalignant/malignant changes.
DELC grading
Frank’s sign (named after American pulmonologist Sanders T. Frank) refers to a diagonal skin fold between the tragus and outer edge of the earlobe. Gradation is based on the bilateral presence and/or degree of the earlobe fold. The presence of this sign, referred to as the diagonal earlobe crease (DELC), has been associated with coronary artery disease (CAD), independent of other cardiovascular risk factors. Corresponding studies are predominantly based on clinical or angiographic assessments, and few autopsy studies exist. The association of DELC with CAD, cardiovascular risk factors, and causes of death was investigated via retrospective and prospective evaluations. It was also investigated whether the degree of DELC correlated with the macroscopic severity of coronary heart disease. Furthermore, the influence of age on the appearance of DELC was analyzed and compared using two age groups. Additionally, binomial logistic regression analysis was performed to investigate the influence of age on the presence of higher-grade DELC and CAD. In cases related to a lethal cardiac event, the majority (78%) showed high-grade DELC. The DELC grade correlated significantly with CAD severity ( r s = 0.474, p < 0.001) and with the severity of general atherosclerosis ( r s = 0.606, p < 0.001) with medium and large effects sizes, respectively. Age was predominantly more suitable than DELC concerning the sensitivity, specificity, and positive prognostic value for preexisting cardiac disease and cardiac-related causes of death. In both DELC and CAD, age has a significant influence on the presence of higher-grade manifestation, but the influence of age in CAD appears to be even more significant than in DELC. The main results of previous autopsy studies and the prognostic value could have been confirmed, but these findings appear to be limited to younger patients.
Detailed steps of the proposed protocol
The detection of body fluids (e.g., blood, saliva or semen) provides information that is important both for the investigation and for the choice of the analytical protocols. Because of their sensitivity, specificity, as well as their simplicity of use, immunochromatographic tests are widely applied. These tests target different body fluids and generally require specific buffer solutions. If one needs to investigate whether the material is of a specific nature (e.g., blood), this is fine. However, if the material can also contain other material (e.g., saliva or semen) then the use of different tests can be problematic. Indeed, if the different tests require different buffers, it will not be possible to perform all tests on the exact same specimen. In this study, we assess the use of the RSID™-universal buffer to perform three immunochromatographic tests (HEXAGON OBTI, RSID-saliva, and PSA Semiquant) as well as spermatozoa detection. We use the same eluate for the detection of all three body fluids. The proposed protocol provides similar results to those obtained when each test is conducted independently. Furthermore, it does not affect the quality of the DNA profiles. The main advantage of this protocol is that the results of the presumptive test(s) and of the DNA analyses are representative of the exact same specimen.
Intersection of non-fatal strangulation and COVID-19 by body region for patient
Emerging evidence suggests that an onset or escalation of interpersonal violence has been occurring during the COVID-19 pandemic, particularly among persons in intimate or familial relationships. Strangulation (or neck compression) is a common form of interpersonal violence and can result in serious adverse health outcomes, including death. The identification and attribution of injuries from non-fatal strangulation are complex, as there may be an absence of external signs of injury and their appearance may be delayed by many days. There is a heavy reliance on clinician identification of ‘red flag’ symptoms and signs, the presence of which necessitates urgent further assessment. Additional challenges arise when acute non-fatal strangulation symptoms and signs are shared with other clinical conditions. In such cases, differentiating between the conditions based on the symptoms and signs alone is problematic. We present the diagnostic challenges faced when conducting forensic assessments of COVID-19-positive and suspected COVID-19 (S/COVID) patients following allegations of non-fatal strangulation in the setting of physical and sexual assaults. The implications of shared symptoms and signs, for forensic clinicians, primary healthcare, and emergency practitioners, as well as other frontline service providers, are discussed.
Leading causes of death as per literature reviewed
Sudden unexpected death in the young (SUDY) is a tragic event resulting in the fatality of seemingly healthy individuals between the ages of one and 40 years. Whilst studies have been performed on sudden unexpected death in infants, children, and adults respectively, little is known about trends in risk factors and causes of death of SUDY cases. Understanding the factors surrounding these deaths could lead to targeted interventions for at-risk individuals. Hence, a systematic approach to investigate the reported possible causes of SUDY was employed using three major databases and Primo, wherein 67 relevant articles were identified and 2 additional guidelines were read. Sudden unexpected death in epilepsy and sudden cardiac events were well-established causes of death with risk factors such as male predominance, substance use and a familial history identified. It was acknowledged that while the cause of death is established following post-mortem examination in many cases, some remain non-specific or undetermined. Considering the genetic etiology, these cases would be ideal candidates for molecular autopsies in the future. Thus, this review emphasized the significance of acquiring the relevant information to aid in resolving cause of death of these SUDY cases and subsequently highlighted the potential for further studies on risk factors and the value of molecular autopsies.
Multiple-to-Single Ratio by drug families for arrests reported to the Maine Diversion Alert Program. *p < 0.005 versus all other families
Multiple-to-Single Ratio for specific drugs grouped by drug families as reported by the Maine Diversion Alert Program. Each drug’s multiple and single drug arrests are in parentheses, respectively. *p < 0.05, **p < 0.005
Purpose Much of the responsibility for the increasing drug overdoses in the US has been attributed to opioids but most opioid overdoses also involve another drug. The objective of this study was to identify the drugs involved in polysubstance arrests. The substances that were more likely to be found in conjunction with other substances, using the drug arrests reported to Maine’s Diversion Alert Program (DAP) were examined. Methods Single and multiple drug arrests were quantified (N = 9,216). Multiple drug arrest percentages were compared to single drug arrest percentages to create a Multiple-to-Single Ratio (MSR) specific to each drug family and each drug to identify over (MSR > 1) and under-representation (MSR < 1). Results Over three-fifths (63.8%) of all arrests involved a single drug. Opioids accounted for over-half (53.5%) of single arrests, followed by stimulants (27.7%) and hallucinogens (7.7%). Similarly, nearly two-fifths (39.6%) of multiple arrests were for opioids, followed by stimulants (30.8%) and miscellaneous (13.0%). Miscellaneous psychoactive prescription substances (e.g. clonidine, gabapentin, cyclobenzaprine, hydroxyzine) had the highest (1.51) MSR of any drug family. Conversely, stimulants (0.63), opioids (0.42), and hallucinogens (0.35) were significantly underrepresented in polysubstance arrests. Carisoprodol (8.80), amitriptyline (6.34), and quetiapine (4.69) had the highest MSR. Bath-salts (0.34), methamphetamine (0.44), and oxycodone (0.54) had the lowest MSR. Conclusion The misuse of opioids, both alone and in conjunction with another drug, deserves continued surveillance. In addition, common prescription drugs with less appreciated misuse potential, especially carisoprodol, amitriptyline, and quetiapine, require greater attention for their ability to enhance the effects of other drugs.
Examinations per month. n = 130; 67 examinations in 2019, 63 examinations in 2020
Complete amnesia for the assault. n = 130; 67 examinations in 2019, 63 examinations in 2020
To explore if the shutdown of Danish nightlife during the Covid-19 pandemic caused a decrease in the number of clinical forensic examinations of victims of sexual assault in Eastern Denmark. Secondarily, to investigate, if there was a change in criminological characteristics, e.g. scene and time of crime, relation to the perpetrator and the proportion of possible drug-facilitated sexual assaults. 130 case files from clinical forensic examinations of individuals of alleged sexual assault in the period 1st of April to 30th of June in both 2019 and 2020 were included. 67 and 63 examinations were performed in 2019 and 2020, respectively. 125 cases were female and five were male. Approximately 70% were 15–25 years of age. Pre- and post-lockdown victim profiles were similar regarding assailant relation, location of crime and time of assault. Voluntary intake of alcohol prior to the assault was registered with 46.3% in 2019 and 62% in 2020. The ratio of possible drug-facilitated sexual assault (DFSA) was approximately 50% each year. The lockdown did not seem to change the overall number of examinations or the demographic and criminological characteristics of the sexual assault victims. No decrease in cases of possible DFSA was found despite the lockdown of nightlife venues.
The steps that the decedent in case 1 was found lying on, having fallen while intoxicated. The position where her head had been pressing against the vehicle bumper bar with neck hyperflexion is shown by the arrow
Positional asphyxia occurs when the mechanics of normal respiratory processes are impaired by the position of the body, not by external crushing forces. It is a well-known complication of drug and alcohol intoxication. However, less well appreciated is the potential role of neck hyperflexion as a specific cause of death in individuals with acute alcohol intoxication. Two cases are reported to demonstrate the usefulness of meticulous scene descriptions and documentation in cases of alcohol toxicity. Case 1: An intoxicated 51-year-old woman was found deceased with neck hyperflexion due to pressure on her head from a vehicle bumper bar (blood alcohol 0.24%). Case 2: An intoxicated 46-year-old man was found lying on his back with his neck acutely flexed and his chin pressed firmly into his shoulder (blood alcohol 0.4%). In both cases the deaths were attributed to positional asphyxia due to hyperflexion of the neck associated with alcohol intoxication, with potential exacerbation from concussion and alcohol/drug effects. Careful review of the scene findings and statements from those who are first to find a body in cases of acute alcohol intoxication may be necessary to determine the incidence of marked neck hyperflexion and its possible role in these deaths.
Road traffic crashes are responsible for the deaths of 1.35 million people annually around the globe, and pedestrian fatalities account for 23% of these cases. Issues that arise in assessing these deaths involve evaluation of the type of impact, the type and speed of the vehicle, the behavior of the pedestrian and the extent of the injuries. The types of injuries encountered at autopsy vary with age and body habitus. The forensic pathologist’s role is to document injuries and to determine if and how they may have been caused by a particular vehicle(s). Patterned injuries may have been caused by impact with components of the vehicle chassis or from being run over by tires. Determining the manner of death may sometimes be problematic and suicides and homicides may be confused with accidents. The following commentary explores and discusses issues that arise in the assessment of these cases.
Overview of the deceased at autopsy. The abdomen was markedly distended, and the legs were in flexion contracture
The computed tomography topogram showed scoliosis, elevated diaphragm, massive gas in the digestive tract and fecal impaction a, b
Axial a, sagittal b, and coronal c views of abdominal CT showed fecal loading in the sigmoid colon and rectum
a Rib cage and abdominal cavity. The digestive tract, especially the colon was distended with gas. b The rectosigmoid colon contained 2.5 kg of fecaloma with two rectal fecaliths. c Severe scoliosis
A 59-year-old man with a history of cerebral palsy and dextroscoliosis died in a group home. He required supplemental oxygen and had no bowel movement for weeks prior to death. At autopsy, the abdomen was markedly distended and there were flexion contractures of the legs. Postmortem computed tomography revealed a dilated digestive tract and fecal loading in the sigmoid and rectum, marked upwardly displaced diaphragm and scoliosis. On internal examination, the diaphragm was displaced rostrally and the rectosigmoid colon contained 2.5 kg of fecaloma with two rectal fecaliths. Severe scoliosis with marked reduction in volume of thoracic cavity was present. Microscopic examination revealed chronic aspiration pneumonia and chronic pulmonary hypertension. Overall, four factors led to respiratory failure: fecaloma; cerebral palsy; scoliosis; and chronic aspiration pneumonia. Based on clinicopathological correlation, the cause of death was determined to be a combination of these factors, and the key acute factor was the fecaloma.
a and b The body of the deceased in front of the entrance door. c and d Blood traces in the bathroom. e A double-edged razor blade on the bathroom floor. f and g Bloodstains, irregular pools of blood and bloody footprints
a Gross appearance of the body. b Torso. c and d Lower extremity injuries. e and f Upper extremity injuries
a and b Superficial incised wounds and excoriations on the fingertips of both hands
A 32-year-old chronic drug abuser was found dead at the entrance to his home, covered in blood. Pools of blood, bloody footprints and bloodstains were found across the apartment. A double-edged razor was recovered from the scene. Autopsy revealed multiple incised wounds: two on the palmar aspect of both forearms (37 cm and 33 cm long, oriented longitudinally). The cuts extended into the subcutaneous adipose tissue, muscles and blood vessels. There was an additional 30 cm cut extending across the middle of the torso anteriorly and two more cuts on the anteromedial aspect of the lower legs, set symmetrically (about 23 and 25 cm long). These three cuts were more shallow than the upper extremity wounds. No hesitation wounds were identified. Toxicological analysis identified MDMA (ecstasy). The cause of death was exsanguination. The deceased has been using ecstasy for the previous five years and had a history of inpatient psychiatric treatment due to psychosis with delusions and hallucinations. These self-inflicted incised wounds had many atypical features: location (torso, legs and arms), longitudinal orientation and symmetrical distribution, absence of hesitation injuries, use of both dominant and non-dominant hand. The absence of previous suicide attempts and suicide note suggest that these self-inflicted injuries were not planned beforehand, but were abrupt. We hypothesize that this injury pattern is associated with both acute and chronic effects of MDMA.
External examination. a Two abrasions in the frontal region. b 1-cm lacerated wound in right front-parietal region. c Blood-serum material from the nostrils. d Right lower limb extra-rotation
Head internal examination. a Diffuse hematic infiltration of galea capitis and periosteum more marked in the bi-parietal region, as well as infiltration of the bundles of the temporal muscle. b Fracture with a coronal course from right parietal region to left temporal region. c Blood painting of dura mater. d Sub-dural hemorrhage especially in cerebral hemisphere. e Continuation of the fracture into cranial base
Nowadays, one of the most important health and social policy issues concerning all countries is the problem of road accident rates. Traffic is one of the most important risk factors. For this reason, ridesharing companies have been launching electric scooters in Rome since June 2019 with the aim of reducing car traffic. In the absence of relevant legislations, the risk is that of facing an increase in deaths due to electric scooter crashes. We report the case of an electric scooter accident victim with cranio-encephalic trauma associated with limb injuries that caused immediate death. This case report emphasizes how the obligation of using helmets must be extended to all ages, in order to reduce the risk of increasing the number of deaths. Compulsory helmet use can reduce fatalities in all cases where high-speed crashes are not involved.
The identification of ante- and post-mortem burns is challenging in forensic pathology. In this study, microarray analysis was used to detect the mRNA expression profiles in the skin of an experimental burn mouse model; the results were validated using RT-qPCR. Differentially expressed mRNAs (DE-mRNAs) were assessed using the Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) databases. Our results revealed that mRNA expression of 501 genes was significantly different, of which 273 were upregulated and 228 were downregulated in ante-mortem burned mice skin. The expression levels of eight random mRNAs were consistent when measured using the microarray assay-based method and RT-qPCR. Genes from different functional categories and signalling pathways were enriched, including interleukin-20 binding, type IV hypersensitivity, negative regulation of acute inflammatory response, sensory organ development, endocytosis, neuroactive ligand-receptor interaction, and Jak-STAT signalling pathway. Only five of the eight mRNAs exhibited consistent changes in expression between burned skin samples of mice and human autopsy specimens. Our findings showed that DE-mRNAs revealed using microarray are potential biomarkers of ante-mortem burns. However, DE-mRNAs identified from experimental animal models cannot be directly extended to autopsy specimens without careful validation.
Top-cited authors
Roger Byard
  • University of Adelaide
Michael Thali
  • University of Zurich
Olaf H Drummer
  • Victorian Institute of Forensic Medicine
Jens Amendt
  • Goethe-Universität Frankfurt am Main
Carlo P Campobasso
  • University "L. Vanvitelli" of Campania, Naples, Italy