Injury‐Related Healthcare Use and Risk of Filicide Victimization: A Population‐Based Case–Control Study

Research on child‐related risk factors for filicide is scant. We investigated whether prior healthcare use for injury (including poisoning) influences filicide risk. Victims (0–14 years; n = 71) were identified in a national autopsy database for the years 1994–2012 and compared to matched, general population controls (n = 355). Healthcare use data were retrieved from a national patient registry. Risks were estimated using odds ratios (ORs) and 95% confidence intervals (CIs). For females, prior inpatient care for injury conferred a statistically significant sevenfold risk (OR = 6.67 [95% CI: 1.49–29.79]), and any prior injury‐related healthcare use conferred a statistically significant fourfold risk (OR = 3.57 [95% CI: 1.13–11.25]), of filicide victimization. No statistically significant risks were found for males. Healthcare personnel should be aware that children treated for injuries, especially females, may be at an elevated risk of filicide victimization. Nevertheless, the filicide base rate remains low, and parents may be stigmatized by unfounded alerts; thus, prudent reflection should precede reports to the authorities.     

The Drowning Index: Implementation in Drowning,Mechanical Asphyxia,and Acute Myocardial Infarct Cases

Drowning is a diagnosis of exclusion based on circumstantial and autopsy correlation. Sugimura proposed a threshold value of 14.1 for the Drowning Index (DI), the ratio of lung and pleural fluid to spleen weight, as a surrogate marker to diagnose drowning. We questioned the use of DI in diagnosing drowning. We compared DI between three groups—drowning, mechanical asphyxia, and myocardial infarct—seen at Broward MEO from 2008 to 2009. Only 9.4% of 53 drownings exceeded the DI threshold of 14.1, while 30% of 10 mechanical asphyxias and 40% of 10 myocardial infarcts had DI >14.1. Sensitivity for the DI test was <10% and specificity 60–70%. Median DI values for all groups were <10. Mann–Whitney U‐test was not statistically significant between groups. The DI is neither sensitive nor specific and lacks any utility in the diagnosis of drowning.     

Pathologic Findings of Coronary Stents: A Comparison of Sudden Coronary Death Versus Non‐cardiac Death

There are few histologic studies of intracoronary stents found at autopsy. We studied histologic findings of 87 intracoronary stents from 45 autopsy hearts. There were 40 patients with chronically implanted stents and five shorter than 30 days. Of five patients with recent stent placement, the cause of death was related to the stent (in‐stent thrombosis) in one case. Of the 40 patients with chronic stents, there were 16 sudden coronary deaths and 24 noncoronary deaths (controls). There were no late stent thromboses in the coronary deaths. In the coronary deaths, 26% of stents showed restenosis versus 11% in controls (p = 0.1). The rate of healed infarcts and cardiomegaly was similar in the coronary and noncoronary groups, and acute thrombi in native arteries were seen only in three hearts in the coronary group. We conclude that the cause of death is rarely impacted by in‐stent findings at autopsy, especially in chronically implanted stents.     

A Case of Sudden Infant Death Due to Incomplete Kawasaki Disease

Although Kawasaki disease (KD) is a self‐limiting disease, it may cause sudden cardiac death. Diagnosis of KD is principally based on clinical signs; however, some infant cases do not meet the criteria. Such cases are identified as incomplete KD. The sudden death risk in incomplete KD cases is similar to conventional KD. In our 5‐month‐old case, he had been admitted to a hospital for a fever and suppuration at the site of Bacille de Calmette et Guerin (BCG) vaccination. However, after discharge from the hospital, his C‐reactive protein (CRP) levels declined, he got indisposed and died suddenly. A medico‐legal autopsy revealed myocarditis, coronaritis, platelet‐aggregated emboli in coronary arteries, and myocardial degeneration, suggesting that the fatal myocardial infarction was due to thrombus emboli in the coronary arteries. Forensic pathologists therefore should pay attention to the cardiac pathology originated from incomplete KD as a potential cause in cases of sudden infant death.     

Stressful events as a trigger of sudden death: a study of 43 medico-legal autopsy cases

The reports relating emotional stress to sudden death are largely anecdotal. In addition to experimental and electrophysiological studies, an opportunity for a better understanding of possible stress-related sudden death (SSD) may be provided by medico-legal autopsies. The goal of our autopsy study was to analyze cardiovascular pathologic findings in cases of SSD and if possible identify mechanisms by which the stressful event (SE) could be the cause. Forty three cases were studied (29 males and 14 females). In all cases, the SE and the death were witnessed. The age range was 22 to 90 years in males (mean, 52) and 30 to 92 years in females (mean, 64). Death occurred in all cases without premonitory symptoms. In 20 cases, death occurred during the SE and in the other 23 cases occurred within 2 h of the event. SE included fear, 15 cases; altercation, 21 cases; sexual activity, 3 cases; police questioning or arrest, 4 cases. According to police reports, in 40 cases (90%), the victims had no previous clinical history of cardiovascular disease. At autopsy, the heart weight in males ranged from 255 to 1000 g with a mean of 517 g and in females the range was 250–700 g with a mean of 417 g. In only 3 cases, gross and microscopic examination of the heart was normal. In 2 of the remaining 40 cases the subjects died of subarachnoid hemorrhage. In 38 cases, a cardiac cause of death was found as follows: coronary heart disease, 27 cases; cardiomyopathy, 6 cases; aortic valvular stenosis, 2 cases and right ventricular dysplasia, 3 cases. A coronary artery thrombosis was found in 8 cases of sudden coronary death. Post myocardial infarction fibrosis was present in 25 cases (92%) of sudden coronary death. In conclusion, it appears from our autopsy study that SSD occurs primarily in those individuals with severe heart disease, especially coronary heart disease.     

The Role of Postmortem Cardiac Markers in the Diagnosis of Acute Myocardial Infarction*

Abstract: Sudden cardiac deaths because of acute myocardial infarction (MI) constitute a significant percentage of the caseload for death investigators, coroners, and forensic pathologists. Clinicians use cardiac markers, highly sensitive and specific for myocardial damage, to screen living patients for acute MI; however, to this point, the utility of these markers in the autopsy setting has not been fully established. The current study included 10 decedents, five who died of acute MI, and five subjects who died of noncardiac disease. Samples of pericardial fluid and blood from multiple sites were tested for creatine kinase, creatinine kinase MB, and troponin‐I. Three main conclusions were drawn: the levels of cardiac markers from all patients are significantly higher than the reference range for living patients, there are significant differences in cardiac marker levels between samples from different anatomic locations, and only three cardiac marker/anatomic site combinations were significantly different between the control and study groups.     

Forensic Autopsies can Determine Latent Prostate Cancer Prevalence

To evaluate the usefulness of forensic autopsies in determining latent prostate cancer (PC) prevalence, we examined latent PC prevalence from autopsies and compared our findings between decedents with and without cancer. Data from forensic autopsies performed in Japan from 2004 to 2014 were obtained. For each prostate, histopathological examinations were performed in both the base and the apex sections. Three hundred and seventeen Japanese decedents were selected for analysis. The mean age of decedents was 56.4 ± 17.8 years (range, 14–94 years). Among this population, 39.4% died suddenly of disease and 60.6% died of external causes. Latent PC was identified in 45 (14.2%) decedents, who ranged from 27 to 93 years old (mean, 71.1 ± 12.9 years). The prevalence of clinically significant PC with a Gleason score of 7 or more was 8.8%, and the rate increased with age. Fifteen males had cancers other than PC. The prevalence of overall latent PC was significantly higher for those with cancer compared with those without (40.0% vs. 12.9%; P = 0.003). In this study, the use of forensic autopsy materials provided the opportunity to obtain a more accurate natural history of PC, as the decedents in this situation would have been more likely to have died suddenly while behaving as normal prior to death, and less likely to have been impacted by long-term medical interventions.     

Variation in Methods of Cardiac Dissection—A Potential Confounder in Measuring Cardiac Weight at Autopsy

To evaluate whether the weight of the heart measured at autopsy may be affected by the type of dissection, a prospective study was undertaken of the weights of sequential cases of nonpediatric hearts. Four hundred fifty‐eight hearts were examined (age range 17–96 years; mean 55.9 years; M:F = 3:1). The hearts were each weighed fresh, once the apex had been sliced, the auricles of the atria opened and blood drained, and again once the cardiac chambers had been opened completely. The difference in the partially and fully opened heart weights (range 146–1028 g; mean 434.8 g; range 134–1011 g; mean 420.8 g, respectively) (p < 0.05) ranged from 0 to 100 g (mean 14 g). In the most extreme example, the weight of the partially opened heart was 30.3% higher than that of the fully opened specimen. Failure to fully open the heart prior to weighing may result in significant error.     

Sudden Cardiac Death in a Young Man with Migraine-associated Arrhythmia

A 31-year-old man with migraine-induced syncope and bradycardia with subsequent pacemaker implantation died unexpectedly. Clinically unsuspected cardiac anomalies were found at autopsy including myocardial bridging of the left anterior descending artery and shelf-like coronary artery ostia. Nortriptyline was identified by toxicologic analysis. A review of the autopsy findings, the historical information, and the effects of the possible arrhythmogenic circumstances is undertaken and the potential contributions to the death are discussed. Cardiac arrhythmias have been documented during migraines. Coronary artery bridging has been known to lead to ischemia and infarction, ventricular tachycardia, and sudden death; however, these are very rare sequelae. Congenital coronary artery anomalies have been linked to sudden cardiac death, but only rarely cause death in people younger than 31 years. Migraines and the autopsy findings described have been associated with cardiac arrhythmia and sudden death. Altogether, they led to the unexpected death of this young man.     

The Application of the Central Limit Theorem and the Law of Large Numbers to Facial Soft Tissue Depths: T‐Table Robustness and Trends since 2008,

By pooling independent study means (), the T‐Tables use the central limit theorem and law of large numbers to average out study‐specific sampling bias and instrument errors and, in turn, triangulate upon human population means (μ). Since their first publication in 2008, new data from >2660 adults have been collected (c.30% of the original sample) making a review of the T‐Table's robustness timely. Updated grand means show that the new data have negligible impact on the previously published statistics: maximum change = 1.7 mm at gonion; and ≤1 mm at 93% of all landmarks measured. This confirms the utility of the 2008 T‐Table as a proxy to soft tissue depth population means and, together with updated sample sizes (8851 individuals at pogonion), earmarks the 2013 T‐Table as the premier mean facial soft tissue depth standard for craniofacial identification casework. The utility of the T‐Table, in comparison with shorths and 75‐shormaxes, is also discussed.     

Child Fatalities in Dammam: A Call for Child Fatality Reviews in Arab Countries

Identifying children's risk exposure is the first step toward mortality prevention. This retrospective study determined the causes of child fatalities in Dammam, Saudi Arabia. Death reports of children and adolescents from 1999 to 2015 (N = 157) were analyzed. Boys represented most cases (69%) and there were two age peaks (1–5 years and 16–18 years). Accidents (typically immersion) defined the main death circumstance (51%) followed by homicide (25%). Only 33% of cases underwent autopsy, and the most common cause of death was head injury (27%) followed by firearm injury. Only one immersion death underwent autopsy. This study revealed important data about the risk exposure of children in Dammam and emphasizes deficient investigative procedures. Child fatality reviews comprise systematic data collection by multidisciplinary teams to determine the true risks toward children in a community. Such teams do not exist in Arab countries; therefore, strategies should be implemented to initiate them.     

Characterization of Algerian-Seized Hashish Over Eight Years (2011–2018). Part II: Chemical Categorization

In Algeria, large quantities of hashish are seized every year. This study aimed to investigate the total content of major cannabinoids in the illicit seized hashish in Algeria over an 8-year period (2011–2018) in order to establish the chemical profile of North African hashish. A total of 3265 hashish samples were analyzed using a validated high-performance liquid chromatography–diode array detection (HPLC-DAD) method, allowing the simultaneous quantification of both the acidic and the neutral forms of Δ9-tetrahydrocannabinol (THC), cannabidiol (CBD), and cannabinol (CBN). The results revealed a slight upward trend in the mean THC content, from 7.0% in 2011 to 9.4% in 2018, with an overall mean value of 8.4%. The overall means of CBD and CBN content were 3.5% and 0.8%, respectively. The number of high-potency hashish samples gradually increased to reach 6% in 2018. Two distinct hashish chemotypes were identified: the highly populated chemotype II, corresponding to the traditional medium-potency hashish ([THC + CBN]/CBD ~ 2.16), and chemotype I, containing hashish samples of relatively high THC levels and low levels of CBD (ratio ~ 4.90). Both chemotypes I and II were characterized in the ternary plot, and the proportions (THC:CBD:CBN) were about 85%:13%:2% and 60%:35%:5%, respectively.     

Cardiovascular Conditions and the Evaluation of the Heart in Pregnancy‐Associated Autopsies

Abstract: Pregnancy‐associated death is defined as the death of a woman from any cause during pregnancy or in the year after delivery. This review concentrates on cardiac conditions that may result in pregnancy‐associated death including, but not limited to, acute myocardial infarction, endocarditis, peripartum cardiomyopathy, and prolonged QT syndrome. Lethal vascular conditions may also occur involving arterial dissection and thromboembolism, on occasion exacerbated by hypercoagulability, and altered hormonal and physiologic states. The autopsy evaluation of these patients includes a careful assessment of the medical history particularly for prior pregnancy‐related conditions, fetal loss, and episodes of unexplained collapse. A family history of sudden death at an early age may be significant. At autopsy, evaluation for underlying syndromes such as Marfan, or evidence of intravenous narcotism should be undertaken. Autopsy examination involves careful dissection of the heart and vessels with consideration of conduction tract studies and possible genetic evaluation for prolonged QT syndrome.     

钝力性心脏外伤38例尸检病理学研究

本文研究表明钝力作为原始致伤因素作用于胸部通过压、拉、剪切、旋转等可引起钝力性心脏外伤包括心脏震荡、心脏挫裂伤、心脏玻裂、心脏断离等原发性心脏外伤和继发性乃至迟发性心脏外伤，诸如外伤性心脏炎、冠脉血管炎、血栓形成、外伤性心肌梗塞、外伤性冠状动脉瘤、外伤性室壁瘤、迟发性外伤性心脏破裂等。致命性的心脏震荡，除急性冠循环障碍和心失常外，还可有心脏传导系统和神经组织损伤，尤其心肌肌膜爆裂（ｓａｒｃｏｌｅｍｍａｂｕｒｓｔ）及相应的原纤维膨出畸形变可以作为心脏震荡性外伤的形态学指证。外伤性心肌梗塞和迟发性外伤性心脏破裂以突然发生在外伤后的一定间隔期为特征，应予特殊注意．     

Sudden Death Caused by Anomalous Origin of the Coronary Artery During Exercise

Anomalous origin of the coronary artery (AOCA) is a rare, but important cause of sudden cardiac death among young athletes. Nine autopsy cases (8 male, 1 female; mean age, 17.9 years; age range, 11–31 years) of sudden death during or just after exercise caused by AOCA were reviewed. The exercises performed at the time of death were running (4 cases), soccer (2 cases), and baseball, swimming and kendo (Japanese swordsmanship) (1 case each). In 6 cases, the left coronary artery arose from the right sinus of Valsalva, and in 3, the right coronary artery from the left sinus. The coronary arteries passed between the pulmonary artery and the aorta with an acute angle takeoff from the orifice. Three cases had cardiovascular manifestations prior to death. In cases with cardiovascular manifestations, novel imaging methods should be considered to prevent sudden death.     

Basal Vacuolization in Renal Tubular Epithelial Cells at Autopsy and Their Relation to Ketoacidosis

Basal vacuolization of renal tubular epithelial cells is a useful postmortem marker for ketoacidosis. To investigate its incidence and relationship to the severity of ketoacidosis, 158 autopsy cases with elevated β‐hydroxybutyrate (>1 mmol/L) over a 7‐year‐period were retrospectively reviewed. Sixty‐eight cases (43%) exhibited basal vacuolizations (vitreous β‐hydroxybutyrate: 1.16–29.35 mmol/L, mean 10.28 mmol/L), and 90 cases (57%) did not (vitreous β‐hydroxybutyrate: 1.03–13.7 mmol/L, mean 2.84 mmol/L). Quantitative analysis revealed on average a fourfold elevation in β‐hydroxybutyrate in cases with basal vacuolizations compared to those without; 10.3% of cases with β‐hydroxybutyrate concentrations between 1.01 and 2.00 mmol/L had basal vacuolizations, and this incidence increased to 33.3% with concentrations between 4.01 and 6.00 mmol/L. A marked increase in incidence to >70% was observed with concentrations >6.00 mmol/L, and basal vacuoles were invariably present (100%) with concentrations >14.01 mmol/L. This study demonstrates that basal vacuolizations are a sensitive marker for significant ketoacidosis and reaffirms its use as an indicator for likely cases of fatal ketoacidosis at autopsy.     

Olanzapine‐Induced Fatal Ketoacidosis with Pneumomediastinum and Subcutaneous Emphysema

We report a case of fatal olanzapine‐induced ketoacidosis in which pneumomediastinum (PM) and subcutaneous emphysema (SE) were detected on postmortem computed tomographic (CT) images. A man in his forties was found in a state of cardiopulmonary arrest with profuse perspiration, and 50 empty capsules of olanzapine (10 mg) and flunitrazepam (1 mg) were found in his room. The major findings of postmortem CT prior to autopsy were PM and SE from the lower half of the face to the height of the first rib. The results of autopsy, biochemical tests, and toxicological analyses indicated the cause of death to be fatal ketoacidosis induced by olanzapine intoxication. No injuries, medical interventions, or particular diseases were evident, suggesting that PM and SE were caused by ketoacidosis. Our findings indicated that toxicological analyses should be performed when PM and SE are detected on CT images.     

Repeat Coronary Artery Dissection in Pregnancy: A Case Report and Review of the Literature

Non‐atherosclerotic spontaneous coronary artery dissection (NA‐SCAD) is a rare cause of morbidity and mortality with a propensity for young, healthy, and often peripartum women. NA‐SCAD etiology is poorly understood, with possible hormonal and hereditary mechanisms. Current treatment strategies range from conservative management (often showing resolution on angiographic follow‐up) to invasive angiographic procedures. Rarely, NA‐SCAD has recurred in another coronary artery, ranging hours to years later. We report NA‐SCAD of the right coronary artery (RCA) in a 30‐year old, 3‐month postpartum female with an additional autopsy finding of remote myocardial infarction (MI) in the left anterior descending (LAD) coronary artery territory. The remote MI is consistent with prior NA‐SCAD of the LAD and, given the medical history, may have occurred in the peripartum period of the decedent first pregnancy 3 years earlier. As such, to the best of our knowledge, this may represent the first reported case of NA‐SCAD recurrence in a subsequent pregnancy.     

A Preliminary Investigation into the Accuracy of 3D Modeling and 3D Printing in Forensic Anthropology Evidence Reconstruction,

There is currently no published empirical evidence‐base demonstrating 3D printing to be an accurate and reliable tool in forensic anthropology, despite 3D printed replicas being exhibited as demonstrative evidence in court. In this study, human bones (n = 3) scanned using computed tomography were reconstructed as virtual 3D models (n = 6), and 3D printed using six commercially available printers, with osteometric data recorded at each stage. Virtual models and 3D prints were on average accurate to the source bones, with mean differences from ?0.4 to 1.2 mm (?0.4% to 12.0%). Interobserver differences ranged from ?5.1 to 0.7 mm (?5.3% to 0.7%). Reconstruction and modeling parameters influenced accuracy, and prints produced using selective laser sintering (SLS) were most consistently accurate. This preliminary investigation into virtual modeling and 3D printer capability provides a novel insight into the accuracy of 3D printing osteological samples and begins to establish an evidence‐base for validating 3D printed bones as demonstrative evidence.     

Sudden Unexplained Nocturnal Death Syndrome: Epidemiological and Morphological Characteristics in Thai Autopsy Cases

With limited knowledge on epidemiological and morphological characteristics of sudden unexplained nocturnal death syndrome (SUNDS), this study was aimed to identify such data in Thai SUNDS autopsy cases. All the cases were men and nondrug abusers aged 20–49 years old. Most cases were originated in the Northeastern region of Thailand. Half of them were found dead from midnight to 6 a.m., with a peak time at 2 a.m. The death rate was relatively higher in May and June. Most SUNDS cases were blue‐collar workers (93.2%) and nonsmokers (60%), with a normal BMI (72.1%). Approximately one‐fifth of the cases had detectable blood alcohol concentrations. Symptoms before death were respiratory difficulty, seizures, and urinary incontinence. Their mean heart weight was 329.8 ± 35.1 g. Their lungs (88.6%) had some degree of congestion. Acute pancreatitis was not found in these SUNDS cases, and approximately half (40.9%) of the cases had their gastric content <100 mL.