Search

Many previous studies have investigated the use of post-mortem biochemistry to estimate the post-mortem interval (PMI). Vitreous humour (VH) potassium and sodium/chloride levels are well recognized to increase and decrease, respectively, in the post-mortem period but have limited ability in estimating PMI. Cerebrospinal fluid (CSF) is described to have different post-mortem biochemical properties than VH, but is not well studied in relation to estimating PMI. This exploratory study examined 20 paired cases of VH and CSF to investigate their use in estimating PMI. Linear univariate analysis showed Na+, Cl− and K+ in VH and CSF share similar trends, but only K+ in VH and CSF collected via lumbar puncture (LP) showed a significant regression coefficient (p < 0.01). In subsequent linear multivariate analysis, the coefficient for K+ in VH remained positive and significant but not for K+ in CSF. Only minor improvement was observed in the multivariate analysis. Our study showed changes in analytes in VH and CSF follow similar trends. K+ in VH is most accurate in estimating the PMI, with no significant improvement in accuracy when K+ in CSF is combined. Thus, the role of CSF electrolytes in estimating PMI may be very limited. [ABSTRACT FROM AUTHOR]

Cerebrospinal fluid (CSF) and vitreous humour (VH) can be biochemically analysed post-mortem. CSF can be aspirated from the ventricular system (VA) and from lumbar puncture (LP), whereas, VH is aspirated from the orbits. This study compared the biochemical constituents between CSF and VH in 20 post-mortem subjects as well as the effect post-mortem interval and subject age have on these variables. VH samples had significantly higher sodium (Na) and chloride (Cl) and lower magnesium (Mg), potassium (K), urea (Ur) and creatinine (Cr) compared with CSF samples. No statistically significant difference was demonstrated with beta-hydroxybutyrate (BHB) and glucose levels in both VH and both CSF samples. Interestingly, some of the differences in the biochemical analysis correlated with age, but none with post-mortem interval. In addition to sampling and pre-analytical sample processing differences, there may also be ante- and post-mortem factors explaining these observations. This study suggests that post-mortem CSF and VH are biochemically different and reference ranges for VH are not recommended for use in CSF samples. [ABSTRACT FROM AUTHOR]

As a part of a study of suicide in children aged 17 years and under in three centers-Hennepin County in the United States (US), Auckland in New Zealand (NZ), and South Australia in Australia (AUS) from 2008 to 2017 it was decided to characterize potential risk factors and to determine whether these differed by jurisdiction. Reviewed data included a history of psychiatric illness, symptoms prior to suicide, events preceding suicide, previous suicidal ideation or suicide attempts, and communication of suicidal intent. The most common events preceding suicide were arguments with family/friends and relationship issues; in addition depression with or without expressed suicidal ideation, self-harming behavior, sadness, distress, drug/substance abuse, and anorexia were documented. Suicidal intent was on occasion communicated via technological means. In 79.5% of cases in South Australia decedents had a previously diagnosed psychiatric illness, with 62% in Hennepin County. This compared to a much lower proportion of cases in Auckland (23.8%). Whether this reflects more limited access to psychiatric services or a reluctance to seek support and therapy in Auckland is unclear. It does, however, demonstrate that risk factors for child suicide are not uniform among communities and so extrapolation of data from one area to another may not be appropriate. Disturbingly parents/carers were not aware of the decedent's suicidal intent in 84-87.2% of cases., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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., (© 2022. The Author(s).)

Globally, autosomal recessive IFNAR1 deficiency is a rare inborn error of immunity underlying susceptibility to live attenuated vaccine and wild-type viruses. We report seven children from five unrelated kindreds of western Polynesian ancestry who suffered from severe viral diseases. All the patients are homozygous for the same nonsense IFNAR1 variant (p.Glu386*). This allele encodes a truncated protein that is absent from the cell surface and is loss-of-function. The fibroblasts of the patients do not respond to type I IFNs (IFN-α2, IFN-ω, or IFN-β). Remarkably, this IFNAR1 variant has a minor allele frequency >1% in Samoa and is also observed in the Cook, Society, Marquesas, and Austral islands, as well as Fiji, whereas it is extremely rare or absent in the other populations tested, including those of the Pacific region. Inherited IFNAR1 deficiency should be considered in individuals of Polynesian ancestry with severe viral illnesses., (© 2022 Bastard et al.)

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., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Abstract: An enlarged heart can cause electrical instability and impaired contractility, leading to fatal arrhythmia and acute heart failure, and is associated with sudden cardiac death. However, there is limited postmortem evidence on whether heart weight is an independent factor associated with sudden cardiac death. This 18-month retrospective study examined 108 adult heart weights in which all the hearts were weighed after dissection, blood and blood clots removed, rinsed in water, and pat dried. The multivariate logistic regression analysis showed heart weight was an independent factor associated with sudden cardiac death. However, after normalization, the heart weight was a poor predictor of sudden cardiac death with an area under the curve less than 0.7 in the plotted receiver operating characteristic curve., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Blood and blood clots should be removed from the heart chambers before being weighed. The actual method in removing blood and blood clots may vary and can include manual removal with subsequent rinsing the heart in water. It is unclear whether drying the rinsed heart affects the heart weight. The objective of this article was to investigate the effects drying the rinsed dissected heart (residual rinsing water) on postmortem heart weight. The prospective study compared 44 dissected heart weights after being rinsed and after being pat dried. An average 18-20 g of residual rinsing water (4% of heart weight) was present in the dissected heart. The amount of residual rinsing water correlates positively with heart weight. The effects of drying the rinsed dissected heart were considered clinically insignificant. Although being clinically insignificant, this study highlights the lack of standardized approach in weighing the heart and the potential implications in interpreting heart weights., (© 2021 American Academy of Forensic Sciences.)

Abstract: Intestinal perforation is an uncommon complication and presentation of verocytotoxigenic Escherichia coli (VTEC) infection in individuals with Prader-Willi syndrome (PWS). The common site of perforation from VTEC infection is in the colon (and almost exclusively in the pediatric population), whereas PWS is in the stomach. Terminal ileum perforation is uncommon and is not reported in either these 2 conditions. We report a death from terminal ileum perforations in an adult who had PWS and was infected with VTEC. Potential reasons why the perforation occurred at this rare location, rather than in other more common location, in an adult are discussed., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Being found dead in cot or bed is the most common presentation encountered with infant deaths. These deaths are often associated with unsafe sleep environment. The postmortem examination in such cases is often negative, and along with family objections, cultural, and other factors, may lead to a coroner considering not authorizing a postmortem examination. However, not identifying a homicide is a potential risk if a postmortem examination is not performed. This 5-year retrospective study investigated the proportion of infant homicide death initially presenting as cot death. Of a total of 103 cases of infants initially presenting as being found dead in cot or bed, 3 (approximately 3%) were classified as homicides after postmortem examination. During the study period, a total of 9 infant homicides were reported, translating to 33% (3 of 9) of infant homicides presented as cot deaths. Postmortem radiology was a valuable adjunct, but was unable to recognize 2 of the homicide cases with traumatic head injuries (with subdural hemorrhage and brain injury only). We strongly advocate that all infant deaths presenting as cot death require a full postmortem examination., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Haemolysis is reported to be an artefact that may alter post-mortem tryptase levels. However, previous studies did not sample peripheral blood using newly standardised methods. Recent studies have shown that some previously recognised peri- and post-mortem confounders can be muted by careful sample collection with first clamping and then sampling the femoral vein. This prospective study investigated the relationship between the degree of haemolysis of the blood samples and femoral vein post-mortem tryptase levels when sampled using this recommended method. Seventy consecutive post-mortem tryptase levels in non-anaphylactic deaths were compared to the degree of haemolysis of these samples, and results showed no significant correlation between them. The mean post-mortem tryptase level was 9.5 μg/L. This study demonstrated that the effects of haemolysis on femoral vein post-mortem tryptase was negligible when the blood was sampled using the recommended sampling method. Future studies on post-mortem tryptase as well as other typically used blood markers in forensics are recommended to adopt this method of blood sampling in routine practice.

Abstract: Convolutional neural network (CNN) has advanced in recent years and translated from research into medical practice, most notably in clinical radiology and histopathology. Research on CNNs in forensic/postmortem pathology is almost exclusive to postmortem computed tomography despite the wealth of research into CNNs in surgical/anatomical histopathology. This study was carried out to investigate whether CNNs are able to identify and age myocardial infarction (a common example of forensic/postmortem histopathology) from histology slides. As a proof of concept, this study compared 4 CNNs commonly used in surgical/anatomical histopathology to identify normal myocardium from myocardial infarction. A total of 150 images of the myocardium (50 images each for normal myocardium, acute myocardial infarction, and old myocardial infarction) were used to train and test each CNN. One of the CNNs used (InceptionResNet v2) was able to show a greater than 95% accuracy in classifying normal myocardium from acute and old myocardial infarction. The result of this study is promising and demonstrates that CNN technology has potential applications as a screening and computer-assisted diagnostics tool in forensic/postmortem histopathology., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Sudden cardiac death (SCD) is the most common natural cause of death. The hypothesized mechanism of death is an arrhythmia precipitated by increased sympathetic outflow. The left stellate ganglion provides sympathetic innervation to the heart and plays a role in arrhythmogensis. We present a SCD with stellate ganglionitis in which the inflammatory cells were characterized. The case was 37-year-old man who died from ischemic and hypertensive heart disease. The left stellate ganglion showed lymphocytic inflammation with features of humoral immune response. This case report provides evidence that stellate ganglionitis can be seen in SCD and raises the possible association between the two., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Abstract: Postmortem tryptase is a commonly used biochemical test to aid in the diagnosis of fatal anaphylaxis, which is currently recommended to be sampled from peripheral (femoral) veins because of a research showing comparatively elevated levels from central blood sources. Previous studies have used nonstandardized or nondocumented sampling methods; however, more recent research demonstrates that tryptase levels may vary depending on the sampling method. This study used the recommended sampling method of aspirating the femoral vein after clamping and compared in a pairwise comparison with aspiration of central venous and arterial blood sources (inferior vena cava and aorta) in 2 groups of 25 nonanaphylactic deaths. We found no statistically significant differences in postmortem tryptase between central and femoral vein blood; however, sporadic outliers in central blood (particularly aortic blood reaching levels above documented cutoffs for fatal anaphylaxis) were observed. Our findings provide evidence for the existing recommendations that femoral vein blood remains the preferred sample for postmortem tryptase over central blood., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Mass lesions in the brain encompass a wide range neoplastic and nonneoplastic entities. These can present as a diagnostic pitfall, with nonspecific, overlapping symptoms and similar appearances on radiology. They may cause death through varied mechanisms, either specific to the underlying pathophysiology or due to the space-occupying effect of the lesion. We report a case of fatal hemorrhagic cerebral pseudocyst, a rare mass lesion, associated with a cerebral varix, causing death in a morbidly obese individual. To the best of our knowledge, there is no previous documentation in the postmortem literature of this entity as a cause of death. This case aims to document this rare entity in the differential diagnosis of a tumor-like lesion in the brain, highlight the clinical difficulty in its assessment, and demonstrate an uncommon mechanism of death, of a mass lesion acting as a focus causing seizures, with resulting hypoxia due to effects of morbid obesity and heart failure., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Identifying organs/tissue and pathology on radiological and microscopic images can be performed using convolutional neural networks (CNN). However, there are scant studies on applying CNN to post-mortem gross images of visceral organs. This proof-of-concept study used 537 gross post-mortem images of dissected brain, heart, lung, liver, spleen, and kidney, which were randomly divided into a training and teaching datasets for the pre-trained CNN Xception. The CNN was trained using the training dataset and subsequently tested on the testing dataset. The overall accuracies were >95% percent for both training and testing datasets and have an F1 score of >0.95 for all dissected organs. This study showed that small datasets of post-mortem images can be classified with a very high accuracy using a pre-trained CNN. This novel area has the potential for future application in data mining, education and teaching, case review, research, quality assurance, auditing purposes, and identifying pathology., (© 2020 American Academy of Forensic Sciences.)

Diagnosing drowning as a cause of death can pose many challenges for the forensic pathologist and a number of ancillary tests have been proposed to assist in the diagnosis, whether the body was in salt water or fresh water. Although elevated vitreous humor sodium and chloride is a reliable marker, its limitation to prolonged immersion has resulted in the recent investigation of cerebrospinal fluid (CSF) sodium and chloride as alternative matrix in cases of longer or unknown immersion times. This study investigated postmortem CSF from lumbar puncture (CSF&#95;L&#95;Na&#95;Cl) and ventricular aspiration (CSF&#95;Vent&#95;Na&#95;Cl), as well as lung/body (LB) ratio in the diagnosis of salt water drowning and performed comparison and combination testing of methods to improve diagnostic accuracy of the drowning diagnosis. This study found that CSF&#95;L&#95;Na&#95;Cl was the most accurate method (89%) in the given cohort, but that CSF&#95;Vent&#95;Na&#95;Cl and LB combined was the second most accurate method (83%), exceeding CSF&#95;Vent&#95;Na&#95;Cl (77%) and LB (81%) used alone. These findings are useful for stratifying and prioritizing postmortem samples in the investigation of salt water drowning and also have significance for future studies using this methodology to combine and compare the accuracy of different investigations.

Heart weight is routinely measured at postmortem examination and is critical to determine whether the heart is enlarged (ie, cardiomegaly). Cardiomegaly has the potential to cause sudden death by being electrically unstable, resulting in fatal arrhythmias. The majority of fatal cardiac arrhythmias is ventricular in origin and is assumed that ventricular size is disproportionately larger in cardiomegaly. This prospective study compared ventricular weight (VW) and total heart weight (THW) in 40 consecutive cases. The results, unexpectedly, showed that VW increases proportionally and linearly with THW in normal and enlarged hearts (THW, >500 g) and did not increase disproportionally with increased THW. The ratio of VW/THW did not have any significant correlation or difference with sex, height, weight, and cardiac causes of death but did have a negative correlation with age. Further studies are indicated to document the morphological changes when the heart enlarges, which may aid in understanding the pathophysiology of sudden death from cardiomegaly.

Postmortem computed tomography (PMCT) is a relatively recent advancement in forensic pathology practice that has been increasingly used as an ancillary investigation and screening tool. One area of clinical CT imaging that has garnered a lot of research interest recently is the area of "artificial intelligence" (AI), such as in screening and computer-assisted diagnostics. This feasibility study investigated the application of convolutional neural network, a form of deep learning AI, to PMCT head imaging in differentiating fatal head injury from controls. PMCT images of a transverse section of the head at the level of the frontal sinus from 25 cases of fatal head injury were combined with 25 nonhead-injury controls and divided into training and testing datasets. A convolutional neural network was constructed using Keras and was trained against the training data before being assessed against the testing dataset. The results of this study demonstrated an accuracy of between 70% and 92.5%, with difficulties in recognizing subarachnoid hemorrhage and in distinguishing congested vessels and prominent falx from head injury. These results are promising for potential applications as a screening tool or in computer-assisted diagnostics in the future., (© 2020 American Academy of Forensic Sciences.)

Correctly assessing heart weight can be critical at postmortem examination. The current international guidelines advocate using the short-axis method in dissecting the heart and the heart weighed when the blood is emptied. However, it did not specify at what point the heart should be weighed or how the blood should be emptied. This study compared heart weights at three different time points during the heart examination (immediately after dissecting out of the pericardial sac with blood still in chambers, blood washed/removed from heart chambers without the heart opened, and the heart completely opened, blood emptied, and pad dried). This was to illustrate the variation in measurement and potential errors when the heart is weighed at different time of dissection. The results show that there were statistical and clinical significant differences between the heart weights at each weighing points. We recommend the heart to be completely dissected with any blood and residual washing/rinsing water emptied before being weighed. Although performed in this study, the effect of pad drying the heart on heart weight was not explored and was a limitation in this study., (© 2020 American Academy of Forensic Sciences.)

Background: AMB-FUBINACA is a synthetic cannabinoid that has been associated with periodic outbreaks of acute poisonings, but few fatalities. In late May, June and July 2017 Auckland, New Zealand, experienced an outbreak of deaths associated with AMB-FUBINACA that continued at a rate of about 2-3 per month through February 2019. The aim of this study was to define the demographic, circumstantial, pathological and toxicological characteristics of this outbreak., Methods: All records of the Northern Forensic Pathology Service, Auckland Hospital, were reviewed in which the word "AMB-FUBINACA" was referenced, including initial police reports, autopsy reports and toxicology reports. Recorded data included age, sex, race/ethnicity, times and locations, cause of death, autopsy and toxicology findings, and a brief summary of the circumstances of death. Descriptive statistics were performed using IBM® SPSS® Statistics Version 24 and Microsoft® Excel® Version 14.7.2., Findings: Sixty-four cases were identified. One sudden infant death and five cases where cause of death was due to trauma were excluded. Of the remaining 58 cases, 88% were male. Mean age was 42 years. In 95% of the deaths, AMB-FUBINACA alone or in combination with alcohol or another drug was listed as the primary or contributory cause of death. In 41 cases postmortem blood concentrations of AMB-FUBINACA acid were available, ranging from <45 ng/mL to >1000 ng/mL, mean 229 ng/mL, median 140 ng/mL. Comorbidities identified included mixed intoxications (29%), heart disease (47%) and obesity (16%). A mental health diagnosis was reported in 50%, and 40% were on antipsychotic medications., Interpretation: This study presents characteristics, comorbidities and toxicological findings in a unique outbreak of deaths associated with the synthetic cannabinoid AMB-FUBINACA in Auckland, NZ., Funding: All work was funded as part of the usual employment of the authors in their respective institutions. No special funding sources are reported., Competing Interests: All authors report no conflicts of interest., (© 2020 The Author(s).)

Ruptured esophageal varices can present as sudden death from gastrointestinal hemorrhage. The most common underlying pathology causing esophageal varices is cirrhosis leading to portal hypertension. However, not all esophageal varices arise from portal hypertension, and not all portal hypertensions are caused by cirrhosis. We present a rare case of ruptured esophageal varices casing death in an individual with metastatic tumor (high-grade) neuroendocrine tumor in the liver causing portal hypertension. This is, to the best of our knowledge, the first case report in the literature reporting a neuroendocrine tumor causing esophageal varices. This case report aims to document this rather rare entity, highlight another mechanism on how metastatic disease can result in sudden death, and give a brief review of literature on metastatic tumor in the liver causing esophageal varices.

Postmortem tryptase is a useful biochemical test to aid the diagnosis of anaphylaxis. Multiple perimortem and postmortem factors have been documented to cause an elevation in postmortem tryptase level. One factor that was recently recognized to have an impact on postmortem tryptase level is correct sampling technique. A recent study recommended aspirating blood samples from a clamped femoral/external iliac vein to be used for reliable postmortem tryptase analysis. This study sampled 120 consecutive nonanaphylactic deaths in which all the peripheral bloods were sampled as recommended. Postmortem interval, resuscitation, different nonanaphylactic causes of death, sex, and age did not show any statistical significant relation to postmortem tryptase level in Student t test, Pearson correlation, and univariate and multivariate analyses. The mean (SD) postmortem tryptase level was 8.4 (5.2) μg/L (minimum, 1.0 μg/L; maximum, 36.1 μg/L; median, 7.3 μg/L). Using nonparametric methods, the postmortem tryptase reference range in nonanaphylactic death was established as <23 μg/L (97.5th percentile).