Death due to microvascular occlusion in sickle-cell trait following physical exertion

The heterozygous condition characterized by the presence of hemoglobin AS (sickle-cell trait) occurs in approximately 8% of the American black population. Unlike the homozygous state (sickle-cell disease), sickle-cell trait is not widely recognized as a cause of life-threatening illness or death despite over 30 case reports describing fatal or serious complications of exercise in young black males with this condition. These reports identify heat stress, dehydration, viral illness, and poor physical conditioning as factors which may contribute to exertional rhabdomyolysis and sudden death, suggesting multifactorial etiology. However, since sickling is known to occur postmortem, it remains controversial as to whether the pathogenesis of these exercise related deaths involves microvascular obstruction by sickled erythrocytes. We describe three young black individuals with no significant past medical history who died following physical exertion. In all three cases, postmortem hemoglobin electrophoresis demonstrated hemoglobin AS. In none of the cases was the body temperature found to be elevated. These cases serve to remind the forensic community that, in the proper setting, sickle-cell trait must be viewed as a potentially fatal disorder.     

Sudden unexpected nocturnal death syndrome in the Mariana Islands

Sudden unexpected nocturnal death syndrome (SUNDS) is a distinct clinical entity in previously healthy, young, Southeast Asian males. It is well known in the Philippines and more recently recognized in the U.S. by nonspecific autopsy findings, with no evidence of underlying disease and absence of toxic drug or alcohol levels. In 1973-89, 14 cases of apparent SUNDS came to coroner's autopsy in the Commonwealth of the Northern Marianas (CNMI) and Guam. All 14 cases, with the exception of one Yapese, were previously healthy, male Filipinos, aged 23 to 55, who were either found dead in bed, or described by their colleagues as having nocturnal seizure activity consisting of gurgling, frothing, and tongue biting immediately prior to death. Autopsy findings showed no anatomic findings to account for death. Comprehensive serum and urine drug analyses were negative. All decedents showed absence of significant atherosclerosis or grossly detectable structural cardiac anomaly, while four showed cardiomegaly. Migrants from Southeast Asia carry with them a pre-disposition to this syndrome, which appears to decline with longer residence in the new country. The mechanism of death in SUNDS is believed to be ventricular fibrillation, possibly precipitated by sudden sympathetic discharge. Studies suggest at least some deaths may be associated with an abnormal cardiac conduction system. Acute pancreatitis has been a finding in some series, but not our cases. Why the condition is virtually limited to males and seemingly sleep-triggered, has not been adequately explained. Stress and depression are believed to be predisposing factors.     

The presence of gamma-hydroxybutyric acid (GHB) and gamma-butyrolactone (GBL) in alcoholic and non-alcoholic beverages

Gamma-hydroxybutyric acid (GHB) and its precursor gamma-butyrolactone (GBL) are regularly implicated in instances of surreptitious drug administration, particularly in beverages (so-called "spiked drinks"). In order to assist in the interpretation of cases where analysis of the actual beverage is required, over 50 beverages purchased in the UK were analysed for the presence of GHB and GBL. It was found that naturally occurring GHB and GBL were detected in those beverages involving the fermentation of white and particularly red grapes. No GHB or GBL was detected in other drinks such as beer, juice, spirits or liqueurs. GHB/GBL was detected in red wine vermouth (8.2 mg/L), sherry (9.7 mg/L), port (GBL), red wine (4.1-21.4 mg/L) and white wine (<3-9.6 mg/L). The presence of GHB/GBL did not appear to be influenced by the alcohol content or the pH of the beverage. In addition, the concentration in wines did not appear to be related to the geographical origin of the grape type. This is believed to be the first published data concerning the endogenous presence of GHB and GBL in the beverages described.     

Cocaine and sudden "natural" death

The cardiovascular effects of cocaine may culminate in clinical episodes of angina pectoris, myocardial infarction, arrhythmias, and intracranial hemorrhage. To clarify whether or not cocaine causes fatalities by these mechanisms, we studied 24 cases of sudden, apparently natural deaths as a result of coronary arteriosclerosis (15 cases), hypertensive cardiovascular disease (4 cases), and intracranial hemorrhage (5 cases) associated with cocaine use. In 11 cases, cocaine was found in the blood (average concentration: 0.57 mg/L, range: 0.05 to 1.45 mg/L), whereas in the remainder, cocaine or its major metabolite was found in the urine or other tissues. In the majority of decedents, autopsy disclosed the existence of severe natural disease which could have been exacerbated by the administration of stimulant drugs, including cocaine. These data, and a review of the current medical literature, indicate that cocaine may precipitate the sudden death of an individual with undiagnosed cardiovascular disease. A contributory role of cocaine should be considered in any apparently natural death occurring in a population where cocaine abuse is prevalent.     

An Analysis of Possible Mechanisms of Unexpected Death Occurring in Hydatid Disease (Echinococcosis)

Abstract:  Most cases of hydatid disease in human populations are due to Echinococcus granulosus. The hydatid life cycle involves passage between definitive hosts such as dogs and intermediate hosts such as sheep. Humans become accidental intermediate hosts following ingestion of food or water contaminated with eggs or by contact with infected dogs. Although hydatid disease may remain asymptomatic, occasional cases of sudden and unexpected death present to autopsy. Causes of rapid clinical decline involve a wide range of mechanisms including anaphylaxis (with or without cyst rupture), cardiac outflow obstruction or conduction tract disturbance, pulmonary and cerebral embolism, pericarditis, cardiac tamponade, myocardial ischemia, pulmonary hypertension, peritonitis, hollow organ perforation, intracerebral mass effect, obstructive hydrocephalus, seizures, cerebral ischemia/infarction, and pregnancy complications. The autopsy assessment of cases therefore requires careful examination of all organ systems for characteristic cystic lesions, as multiorgan involvement is common, with integration of findings so that possible mechanisms of death can be determined. Measurement of serum tryptase and specific IgE levels should be undertaken for possible anaphylaxis.     

Decisional Capacity and Personality Disorders: Substantially Unable or Substantially Unwilling?

Capacity assessments are performed when there is suspicion that a person is unable to adequately care for their physical, medical, or financial well-being. The purpose of these assessments is to inform the legal system as to whether or not guardianship may be necessary. It is well established that certain mental illnesses, such as neurocognitive disorders (dementia) or psychotic disorders (like schizophrenia), may diminish capacity and, in some cases, lead to the need for establishment of a legal guardian. However, personality disorders are another common category of mental illness which may impair decision-making. There is very little information in the literature about how or why these disorders could impair capacity, and thus, it can often be difficult to discern whether clients with personality disorders are substantially unable to care for themselves—versus unwilling to act in a way contrary to their ingrained habits. We present a series of three cases in which clients are determined to lack capacity primarily mediated by a personality disorder diagnosis. They are demonstrated to have mild deficits in cognitive functioning, but they show impaired decision-making out of proportion to these deficits. In all three cases, it is apparent that the personality disorder is substantially impairing their ability to care for themselves. Discussion includes consideration for ways to incorporate evaluations of cognitive function, activities of daily living, and personality considerations into capacity assessments, and how to approach recommendations (such as guardianship vs. less restrictive option) based on both level and scope of impairment.     

Anal findings in sexual abuse of children (a descriptive study)

The aim of this study was to assess anal physical findings in children whose abuse was admitted by the perpetrator. Fifty children were studied in whom medical assessment took place remote in time from anal abuse which was admitted by the perpetrator. Medical assessment included examination to detect the presence of anal physical signs. Most frequent signs were anal scars and tags (either single or multiple) present, respectively, in 84 and 32% of cases. In some cases scars extended to the perianal region. Other signs included reflex anal dilatation (RAD) and venous congestion (VC) found, separately or associated with other signs, in over 33% of the cases. In 6% of the cases there were no abnormal anal findings. The results confirm earlier reports that physical signs, including scars, tags, RAD, funneled anus and extensive venous congestion, are often present in abused children, singly or in combination, and that anal examination should be undertaken even months after a known or suspected sexual assault. In the legal setting these physical signs are seen in association with anal abuse and support the child's statement. They do not per se provide proof of abuse.     

The Effect of Gender in the Perception of Elder Physical Abuse in Court

Two experiments investigated mock jurors' perceptions of elder abuse (EA) in a physical assault case. In Experiment 1, participants read a fictional criminal trial summary of a physical assault case in which the alleged victim was 66, 76, or 86 years old. In Experiment 2, the age of the alleged victim was 76 years old, but the gender of the alleged victim and the gender of the defendant were crossed. The results of the experiments showed that women believed the alleged victim more and rendered a guilty verdict more often than men. Overall, the alleged victim was believed more than the defendant regardless of the age of the alleged victim, and most verdicts were guilty. These results are discussed in terms of the factors that affect perceptions of alleged victims of EA in court.     

Predictors of adult attitudes toward corporal punishment of children

This study identifies predictors of favorable attitudes toward spanking. Analyses were performed with survey data collected from a representative sample of 1,000 adults from Quebec, Canada. According to this survey, a majority of respondents endorsed spanking, despite their recognition of potential harm associated with corporal punishment (CP) of children. The prediction model of attitudes toward spanking included demographics, experiencing or witnessing various forms of family violence and abuse in childhood, and perceived frequency of physical injuries resulting from CP. Spanking was the most reported childhood experience (66.4%), and most violence and abuse predictors were significantly and positively correlated. Older respondents who were spanked in childhood and who believed that spanking never or seldom results in physical injuries were the most in favor of spanking. On the other hand, respondents who reported more severe physical violence or psychological abuse in childhood were less in favor of spanking. Findings are discussed in terms of prevention of CP and family coercion cycle.     

Sudden unexplained death among persons 1-35 years old

Sudden unexplained death (SUD) on children and young people is unusual, although the real magnitude is unknown. The clinical and physiopathological characteristics are poorly defined. The aim of this work is to analyse the epidemiological, clinical and pathological characteristics of SUD on children and young people. In this population observational study, all sudden non-violent deaths between 1 and 35 years occurred in Bizkaia (north Spain) from 1991 to 1998 were investigated, analysing those diagnosed as SUD. Pathological records, circumstances of death and autopsy findings were obtained. Out of 107 cases of sudden death (SD), 19 were SUD. The mortality rate of SUD was 0.43/100,000 persons per year. Five had pathological antecedents: syncopal episodes in three cases and tachycardia and ventricular extrasystoles one each. The initial symptom was sudden collapse (N=13). In four cases, a precipitating factor was identified (two physical exercise and two emotional stress). Six cases died during sleep. Minimal pathological findings in coronary arteries, myocardium or conduction system was found in nine cases. Heart weight increased (under interval of confidence of 95%) was present in 12 cases. In conclusion, the SUD is very infrequent in children and young people. However, it has great clinical significance because it affects people in good health and occurs without warning symptoms. Some of these cases can be due to cardiac arrhythmias. In deaths in bed there is a high frequency of SUD. In the future, it may be possible that abnormalities at a molecular level will be detected in some of the cases identified today as SUD.     

Quantitative analysis of methamphetamine in hair of children removed from clandestine laboratories--evidence of passive exposure?

In New Zealand many children have been removed from clandestine laboratories following Police intervention. In the last few years it has become standard procedure that these children have hair samples taken and these samples are submitted to the laboratory for analysis. There are various mechanisms for the incorporation of drugs into hair. The hair follicle has a rich blood supply, so any drug that may be circulating in the blood can be incorporated into the growing hair. Another mechanism is via external contamination, such as spilling a drug on the hair or through exposure to fumes or vapours. Hair samples were analysed for methamphetamine and amphetamine. From the 52 cases analysed 38 (73%) were positive for methamphetamine (>0.1 ng/mg) and amphetamine was detected in 34 of these cases. In no case was amphetamine detected without methamphetamine. The hair washes (prior to extraction) were also analysed (quantified in 30 of the positive cases) and only 3 had a wash to hair ratio of >0.1 (all were <0.5), which may be indicative of a low level of external contamination. This low level of evidence of external contamination suggests that the children are exposed to methamphetamine and are incorporating it into the hair through the blood stream.     

Death from minor head trauma and alcohol

Sudden death in association with minor or otherwise insignificant head injury is increasingly being recognised in the forensic medical literature. While the exact mechanism of the cardiorespiratory arrest that appears to occur in these cases is unclear, a number of mechanisms have been postulated. Animal studies have provided evidence that alcohol can be associated with an increased period of apnoea following minor physical brain injury and cardiac changes have also been identified. The limited information in the community about the risk of alcohol in association with minor head injury causing death may be relevant in homicide cases where this issue is raised.     

Sudden Unexpected Death Due to Graves' Disease During Physical Altercation

We report a case of a 30‐year‐old woman who suddenly collapsed after having a physical altercation with her husband. Despite immediate resuscitation, she died on arrival at the hospital. The victim's parents requested an autopsy because they believed that their daughter was killed by her husband. Postmortem examination revealed that the victim had a diffusely enlarged thyroid gland and cardiomegaly with left ventricular hypertrophy. There was no evidence of significant trauma on the body. Further postmortem thyroid function tests and review of her medical history indicated that her death was due to Graves' disease. To the best of our knowledge, this is the first case reported of sudden death due to cardiac arrhythmia from Graves' disease induced by physical and emotional stress associated with the criminal activity of another person. The autopsy findings are described. In addition, the literature is reviewed and the significance of postmortem evaluation of thyroid hormones in the cases of sudden death is discussed.     

Tissue distribution of tramadol and metabolites in an overdose fatality

Tramadol (Ultram) is a centrally acting, synthetic analgesic agent. Although it has some affinity for the opiate receptors, tramadol is believed to exert its analgesic effect by inhibiting the re-uptake of norepinephrine and serotonin. There are several published cases of tramadol's involvement in drug-related deaths and impairment. Reports of deaths involving tramadol alone with associated tissue concentrations are rare. This report documents a case in which tramadol overdose was identified as the cause of death. The following tramadol concentrations were found in various tissues: blood, 20 mg/L; urine, 110.2 mg/L; liver, 68.9 mg/kg; and kidney, 37.5 mg/kg. Tissue distributions of the two primary metabolites, N-desmethyl and O-desmethyl tramadol, are also reported. In each tissue or fluid except urine, the tramadol concentration was greater than either metabolite, consistent with other reports of drug-impaired drivers and postmortem cases. The O-desmethyl metabolite concentration was greater than the N-desmethyl metabolite concentration in all tissues; this is in contrast to other postmortem reports, in which the majority of cases report concentrations of O-desmethyl as less than those of N-desmethyl. This may be useful as an indicator of time lapse between ingestion and death.     

Utilization of serum tryptase and immunoglobulin e assay in the postmortem diagnosis of anaphylaxis

The postmortem diagnosis of anaphylaxis is difficult. Serum concentrations of tryptase (a mast cell product released during anaphylaxis) have been used after death as an indicator of possible antemortem anaphylaxis. However, studies have indicated that tryptase may be elevated with increasing postmortem interval (PMI), or in nonanaphylactic deaths with significant atherosclerosis or chest trauma. Serum total IgE has been used by some to confirm anaphylaxis when tryptase is elevated. Serum levels of tryptase from 57 decedents with varying PMI, all dying of presumed nonanaphylactic causes, were determined. In cases with elevated levels (>11.4 ng/mL), an assay of total serum IgE was also performed. Both tryptase and IgE demonstrated significant elevations with increasing PMI. Decedents were categorized according to presence of cardiovascular disease, chest trauma, or both; many demonstrated elevation of 1 or both markers, without statistically significant differences between categories. Postulated mechanisms for nonanaphylactic elevations of these markers are reviewed. The possible utility of allergen-specific IgE or allergen panels is discussed.     

Fairness, Efficiency and Effectiveness in Court-based Dispute Resolution Schemes in England

In recent years in England there has been renewed emphasis oncourt-based dispute resolution schemes (in-court conciliation)as a means to avoid the use of contested hearings in litigatedcontact cases. These alternative dispute resolution mechanismsare believed to be less likely to fuel parental conflict, morelikely to result in an outcome tailored to individual circumstancesand to be accepted by the parties as well as reducing delayand costs. Previous research has, however, raised questionsabout whether rapid negotiations in a highly pressurized courtenvironment can produce a fair, safe or sustainable solution.In this paper, we draw upon a recently completed research studyto explore the fairness, efficiency and effectiveness of disputeresolution schemes in litigated contact cases. Like others weraise concerns about some of the limitations of in-court conciliation.We conclude by arguing for the development of a more facilitativeor educational-therapeutic approach to litigated contact cases.     

How pedophilic men think about adult-child sex: effects of child gender and physical maturity

To date, very little research has tackled whether pedophilic men’s attitude towards adult–child sex depends on characteristics of the adult or the child involved in such acts. This study examines the effect of the child’s gender (male vs. female) and physical maturity (pre-pubescent vs. early pubescent) on the moral evaluation of apparently noncoercive adult–child sex in a 2?×?2 factorial online vignette experiment. One hundred eighty-three English-speaking pedophilic men rated their agreement with moral arguments on the Immoral Sex Scale, as well as whether they believed this behavior to be typical for a child. The results revealed considerable inter-individual differences, with about one third showing restrictive moral attitudes. Contrary to our expectations, gender and physical maturity neither affected the perceived morality of the sexual act, nor beliefs about the representativeness of the child’s behavior. However, when controlling for confounds, pedophilic men believed that boys were more likely to willingly engage in adult–child sex. Furthermore, participants with stronger liberal attitudes were found to be more likely to defend the sexual act, as were participants with a preferential interest in pre-pubescents. There was no link between attitudes towards adult–child sex and sexual offending, replicating the non-associations reported in previous community surveys.     

School violence prevention measures: School officials' attitudes about various strategies

Concern about school violence has been escalating in recent years. A variety of strategies are used in efforts to prevent violence in schools. These remedies can be classified as legal, interactionist, and physical remedies. Legal remedies refer to laws, like the reasonable suspicion to search strategy that allows school officials to search and seize contraband. Interactionist remedies refer to practices that encourage students and other school officials to communicate more openly with school officials about possible cases of violence. Physical remedies refer to strategies that involve altering the school environment in an effort to prevent violence. This study considered the way that 138 school officials from the Commonwealth of Virginia defined the usefulness of these strategies. Attention was also given to whether certain factors contribute to the officials' assessments of the efficacy of each prevention strategy. Results of the study showed that the interactionist, and then legal remedies are believed to be the most useful, while physical remedies are perceived as the least useful strategies. The study uncovered differences of opinion based on racial lines. As an example, more Blacks than Whites were more likely to describe metal detectors as a very useful strategy. Implications of the study are provided.     

Early traumatization and psychopathy in female and male juvenile offenders

Childhood traumatization is expected to have a significant impact on the development of antisocial and aggressive behavior in adulthood. Psychopathy as a syndrome that can predict future violent and aggressive behavior in adults is therefore believed to be associated with early traumatization. The association between early childhood victimization and violence might at least be mediated through psychopathy. The present study examined the relationship between early emotional, physical or sexual trauma and neglect and psychopathy in incarcerated delinquent female and male juveniles using the Childhood Trauma Questionnaire (CTQ) and the Psychopathy Checklist—Youth Version (PCL-YV). A sample of detained adolescents (n = 185) was compared to adolescent students (n = 98). Also, gender differences were analyzed with respect to the association of trauma and psychopathy. As expected, our analyses revealed higher scores of traumatization in delinquent juveniles compared to school adolescents. Hypothesized relationships between physical traumatization and the PCL-YV total score could be confirmed among criminal boys, but not among delinquent girls. Results, therefore, indicated that an association exists between early physical, but also emotional traumatic experience and psychopathy in detained boys. In girls, however, other family-related variables, such as non-parental living arrangements, seemed to be more influential in developing the psychopathy syndrome than traumatization.     

Road crash cervical injuries. A radiological study of fatalities

A lateral radiograph of the cervical spine was obtained for 174 of the 207 persons killed in road crashes in Adelaide, South Australia, during the 12-month period of June 1, 1987 to May 31, 1988. Of the total of 57 cases of cervical injury, routine postmortem examination identified 30 cases (52.6%), and the radiographic examinations identified 51 cases (89.5%). In the cases where it was performed, radiography identified 96.2% of injuries. One-half of injuries of level C3 and above were not reported at postmortem examination, compared with 22% of those occurring below this level. This finding correlates with the physical difficulties of examining the upper part of the cervical spine. This study has shown that lateral cervical radiography is a simple and effective method of more accurately identifying significant cervical spinal injuries, thus improving greatly the value of postmortem examinations in determining the patterns and mechanisms of these injuries.