Fournier Gangrene and Unexpected Death

Abstract: Fournier gangrene represents a rare but progressive perineal infection that may result in rapid death. A 70‐year‐old man with poorly controlled diabetes mellitus and alcohol abuse is reported who was found unexpectedly dead. He had last been contacted the night before his death. At autopsy, the most striking finding was deep necrotic ulceration of the scrotum with exposure of underlying deep muscles and testicles, with blood cultures positive for Escherichia coli. Death was, therefore, attributed to necrotic ulceration/gangrene of the perineum (Fournier gangrene) that was due to E. coli sepsis with underlying contributing factors of diabetes mellitus and alcoholism. In addition there was morbid obesity (body mass index 46.9), cirrhosis of the liver, and marked focal coronary artery atherosclerosis with significant cardiomegaly. Fournier gangrene may be an extremely aggressive condition that can result in rapid death, as was demonstrated by the rapid progression in the reported case.     

Lethal manifestations of systemic lupus erythematosus in a forensic context

Systemic lupus erythematosus is an autoimmune connective tissue disorder that affects multiple organs. While the clinical manifestations may vary in intensity over time and be associated with chronic disease, occasional cases occur where sudden and unexpected death has occurred. Cardiovascular disease is common, with accelerated atherosclerosis, intravascular thrombosis associated with antiphospholipid syndrome, and hypertensive cardiomegaly. Vasculitis with superimposed thrombosis may result in critical reduction in blood to vital organs, such as the heart and brain with infarction. Mesenteric ischemia may be caused by vasculitis, thrombosis, and accelerated atherosclerosis and may result in lethal intestinal infarction. Other diverse causes of sudden death include myocarditis, epilepsy, pulmonary hypertension, pulmonary thromboembolism, and sepsis. The autopsy evaluation of such cases requires careful examination of all organs with extensive histological sampling to include blood vessels, and microbiological sampling for bacteria, viruses, and fungi.     

Leave it at the gate: job stress and satisfaction in correctional staff

Though academic literature firmly establishes an inverse relationship between job stress and job satisfaction, global correctional studies fail to examine the extent of that affiliation on overall correctional job satisfaction. As such, this study uses a faceted approach to explore underlying relationships between organizational, job, and personal characteristics of correctional staff and causes of job stress and satisfaction. Using the Job Satisfaction Survey, nine aspects of job satisfaction are considered. The Work Stress Scale for Correctional Officers’ analyses of five areas of stress directly related to correctional environments. This study examines both uniform and nonuniform staff assigned to a minimum security prison. On average, staff scored well below the average American worker on the Job Satisfaction Survey. Job satisfaction was predicted exclusively by job characteristics or stressors, including the job itself, role conflict, and ambiguity, and the physical condition of the prison, while employee demographic variables and variables that measure healthy lifestyles (such as sleep and exercise) were not significant predictors. While job stress does predict a substantively significant portion of job satisfaction (21%), there is still room to improve prediction.     

Non-traumatic forensic neuropathology

The practicing Forensic Pathologist is likely to encounter case material in which either the cause of death or a major contribution to the cause of death is underlying damage to or disease of the central nervous system. While it is good practice in many instances to have a working relationship with a Department of Neuropathology, from which advice and practical help can be sought, there may be instances when the Forensic Pathologist needs to proceed on a basis of a working knowledge of Forensic Neuropathology up to and including how to examine the specimen and take tissue blocks for processing and subsequent histological examination. Some of the more common conditions of the central nervous system such as damage consequent to hypoxia-ischaemia, hypoglycemia and epilepsy, the encephalopathies associated with altered sodium concentration, deficiency due to Vitamin B(1) and various neurodegenerative diseases that manifest as dementia and include Alzheimer's disease, cortical Lewy body disease and the prion disorders, are outlined in this article.     

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.     

Jurors’ reactions to recanted confessions: Do the defendant's personal and dispositional characteristics play a role?

Abstract

Confession evidence presented at trial is extremely damaging to the defense. This study examines the impact of a recanted confession on jurors’ perceptions of a murder case in which the defendant claimed to have falsely confessed due either to an underlying medical condition, a psychological disorder, or the general stress of the interrogation. Also included were an inadmissible confession condition and a no-confession control condition. Results showed that the impact of the confession was mediated in part by the circumstances surrounding it. Although probability-of-commission estimates were as high in all of the conditions involving a confession, conviction rates were marginally higher when the disputed confession involved mental illness or interrogation-induced stress than when there was no confession, yet did not differ when the disputed confession involved a medical disorder or there was no confession. These findings show that not all recanted confessions are treated equally and that people selectively discount confessions depending on biases and beliefs they hold.     

Shareholder Coordination Costs, Shark Repellents, and Takeout Mergers: The Case Against Fiduciary Duties

When a bidding corporation succeeds in obtaining voting control of a target corporation through a hostile tender offer, many commentators argue that it is unfair to allow the bidder to exercise its voting power to set the price terms of a second-step takeout merger in which the bidder purchases the shares of the remaining target shareholders. This concern is inappropriate because it treats a unitary acquisition between adversaries as if it were two separate transactions–the second of which involves abuse of power by fiduciaries–and also because it assumes that shareholders of the target corporation are incapable of protecting themselves from the power of a successful bidder. Moreover, imposition of fiduciary rules may impose either prohibitive costs or absolute barriers to some takeovers, even if such transactions would be wealth producing. While there is a risk that some takeovers may exploit the “prisoner's dilemma” facing target shareholders threatened with an unattractive takeout threat, target shareholders are capable of responding to that threat with devices to coordinate their response. So-called “shark repellent” amendments that raise the proportion of votes required to approve second-step mergers or that limit the terms of such mergers can function as coordination devices to alleviate the prisoner's dilemma. Commentators' fears that such devices may unduly burden the market for corporate control appear to depend to a large extent on unfounded assumptions that all takeovers are wealth producing and that takeovers are never motivated by potential gains flowing from exploitation of the lack of coordination among target shareholders. However, empirical studies indicate that adoption of such coordination rules can benefit target shareholders and that it is unlikely that shareholders will approve voting rules so restrictive that they would preclude wealth-creating acquisitions. The usual notions of shareholder apathy are simply inapplicable to takeout mergers.     

Travel, time zones, and sudden cardiac death. Emporiatric pathology

In an 11-year retrospective study of coroner's autopsies on the Hawaiian island of Kauai, it was found that an unusual and apparently unique subset of travelers died suddenly. Death was caused by coronary arteriosclerosis, was characterized by acute coronary changes, and occurred in a group younger than the usual age for sudden cardiac death. Visitors with two-vessel disease had an incidence of sudden death nearly four times that of Kauaians (p less than 0.02), with a ninefold increase of coronary thrombosis (p less than 0.001), a sixfold prevalence of old myocardial infarcts (p less than 0.001), and three times the prevalence of cardiomegaly (p less than 0.001). The circadian pattern of these deaths was different from that previously described in acute myocardial infarction or sudden death, with the number of incidents rising steadily through the day in contrast to the morning peak described in previously published series. The syndrome was expressed in decedents with two-vessel coronary disease either with acute coronary artery lesions--thrombosis, hemorrhage in a plaque, or ruptured coronary artery--or no lesions, presumably spasm. Underlying chronic processes included enlarged heart or old myocardial infarct, which both occurred with a significantly greater incidence in travelers than in local residents, and in a totally different pattern from that occurring in subjects with three-vessel disease. It is postulated that the syndrome is caused by stress related to travel and time zone changes.     

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.     

Larval-mass effect: Characterisation of heat emission by necrophageous blowflies (Diptera: Calliphoridae) larval aggregates

Numerous Calliphoridae species larvae are necrophageous and develop on animal cadavers. During the feeding stages, a strong gregarious behaviour leads to the formation of large larval masses, allowing larvae to share digestive fluids. Furthermore, a mass of larvae emits heat, resulting in a local increase of temperature. Differences greater than 20°C between ambient and larval mass temperatures have already been observed, and the temperature of the mass can reach 50°C. Thus, larvae could benefit from this increased local temperature to speed up their development. This study focuses on the dynamic and characterisation of heat emission by Lucilia sericata (Diptera: Calliphoridae) (Meigen, 1826) larval masses. Experiments were performed under controlled conditions using several ambient temperatures and different numbers of larvae. Results indicate that heat emission depends on the instar and is strongly affected by available amount of food. Furthermore, according to the experimental data, the heat emission is also relative to the weight of the larval mass, the larvae number and the local temperature. These results also demonstrate that optimum ambient-temperature values ranging between 22°C and 25°C produce maximal heat-emission per larva. Furthermore, a feedback loop, involving heat exchanges and physiological and behavioural thermoregulation processes, appears inside aggregates. In the context of forensic cases and post-mortem interval (PMI) estimation, these results indicate that heat emission can occur even with "small" masses if they are composed of high number of second stage larvae. Furthermore, particular attention should be paid on cases involving L. sericata larvae at ambient temperature ranging from 22°C to 25°C, which appears to maximise the heat-emission process.     

Occupational stress,supervisor support,job satisfaction,and work-related burnout: perceptions of Turkish National Police (TNP) members

The present study examines whether, and to what degree, occupational stress in law enforcement is associated with job satisfaction, work-related burnout, and supervisor support. A total of 538 Turkish National Police (TNP) members form seven cities in Turkey completed the study survey. The results of the study indicate that the more TNP members experience their organization as stress inducing, the lower their job satisfaction levels, and the higher their burnout levels. Perceived operational stress was found to be significantly associated with their work-related burnout, but not with their job satisfaction. This study also suggests that there is an indirect causal effect of both organizational and operational stress on job satisfaction via supervisor support as mediator. Overall, the findings of this study illustrate a need for internal policy reform and managerial change in how the executives of TNP organize their agency and policies since organizational stressors are the most prevalent factors determining the work-related wellbeing of TNP members.     

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.     

The Delayed and Cumulative Consequences of Traumatic Stress: Challenges and Issues in Compensation Settings

Delayed onset posttraumatic stress disorder has been a challenging issue in medico-legal settings. Prospective studies have done much to characterise the validity of this construct and the prevalence in various populations. The delayed impact of these events places significant challenges on a plaintiff in establishing a causal link to some distal exposure. Furthermore, the literature highlights that depression is a frequent independent outcome from posttraumatic events, independent of the frequent comorbidity for posttraumatic stress disorder. To date, there has been little examination of the commonality of the underlying mechanisms of aetiology between depression and posttraumatic stress disorder. The concepts of sensitisation and kindling have been extensively discussed as underlying mechanisms relevant to a range of psychiatric disorders. This idea of increasing sensitisation of individuals who have multiple traumatic stress exposures is of critical importance to understanding the shared aetiology of major depressive disorder and posttraumatic stress disorder. Furthermore, the neural circuitry involved in these conditions particularly involves the amygdala, medial prefrontal cortex and anterior cingulate. Given the shared aetiological mechanisms, it is probable that the delays in treatment which have been demonstrated to be important factors for decreasing the probability of a full treatment response in depression are equally relevant to posttraumatic stress disorder. This raises important issues about the liability of employers particularly in the emergency services for vetting individuals where there is a foreseeable risk. A further challenge in litigation settings is the increasing body of evidence linking posttraumatic stress disorder and depression to cardiovascular disease and hypertension.     

Left Ventricular Aneurysm: Sudden Unexpected Deaths in a 29‐Year‐Old Man

Left ventricular aneurysm (LVA) is an abnormal dilated heart structure, either congenital or acquired. LVA is a rare cardiac condition with no symptoms in most cases, thus occasionally diagnosed during investigations of other diseases. Its association with certain cardiac complications and sudden cardiac deaths has been reported. However, its role as a cause of sudden unexpected death is rare. The author reported a sudden cardiac death in a 29‐year‐old man with LVA. Without a significant coronary artery disease and known etiologies of LVA, such an abnormal heart structure in the present case was considered congenital LVA. As no other possible mechanisms of death could be identified other than LVA with its associated pathologic lesions, mural thrombi, and dilated cardiomegaly, his death was attributable to fatal cardiac arrhythmia (most commonly ventricular tachycardia) secondary to LVA.     

Entrapment in small, enclosed spaces: a case report and points to consider regarding the mechanism of death

The mechanism of death due to confinement in an enclosed space is usually ascribed to asphyxia from oxygen deprivation. We report the case of the decomposed remains of a 23-year-old man discovered in an unused industrial size refrigerator in which the mechanism of death is heatstroke. The investigation of the death indicates the subject most likely voluntarily entered the refrigerator and for unknown reasons, closed the door. Injuries identified at autopsy and damage to the inside of the structure indicate he struggled to exit the cabinet. The autopsy shows no significant natural disease processes and toxicology studies were negative. The diagnosis of heat stroke typically rests on the evaluation of multiple features, including the age and size of the decedent, the ambient temperature, the medical history of the decedent, whole body hydration, body fat content, alcohol and drug use, medication history, general physical condition, and many other factors. The diagnosis of heatstroke due to confinement in an enclosed container requires evaluation of the heat stress of the container, the heat strain experienced by the individual, autopsy findings suggesting signs of a struggle to exit the container, and other factors. In all such cases, a careful death investigation with correlation of autopsy findings is required to accurately determine the mechanism and cause of death. We suggest that for all such deaths, physiological and environmental factors promoting hyperthermia and heatstroke be considered as a possible mechanism of death, along with those associated with the more obvious danger of asphyxiation.     

"Homicide by heart attack" revisited

The sudden death of a person caused by an arrhythmia that is induced by physical and/or emotional stress provoked by the criminal activity of another person is sometimes referred to as "homicide by heart attack." Published criteria for such an event relate to situations where no physical contact occurs between the perpetrator and the victim. Situations involving physical contact, but with absence of lethal injuries, are frequently treated is a similar fashion by forensic pathologists. Herein, we propose a set of modified criteria, which include cases where physical contact has occurred. Five examples of so-called "homicide by heart attack" are presented, including a 40-year-old man who was struck in the head with a wooden statue, a 74-year-old man who was punched in the jaw by a robber, a 66-year-old woman who was started awake by a home-intruder, a 67-year-old woman who struggled with a would-be purse-snatcher in a parking lot, and a 52-year-old man who was in a physical altercation with a younger man. In each instance, autopsy revealed the presence of severe, underlying heart disease, as well as absence of lethal injuries. In each case, investigative information was such that the emotional and/or physical stress associated with the criminal activity of another individual was deemed contributory to the death. The presumed mechanism of death in each case was a cardiac dysrhythmia related to underlying heart disease, but initiated by the emotional and/or physical stress.     

Insight into stress-induced cardiomyopathy and sudden cardiac death due to stress. A forensic cardio-pathologist point of view

Emotional, physiological and physical stress is associated with increased rates of cerebrovascular events and sudden deaths. The pathophysiology of stress-induced cardiomyopathy is not well understood. Proposed mechanisms for catecholamine-mediated stunning in stress cardiomyopathy include epicardial vasospasm, microvascular dysfunction, hyperdynamic contractility with midventricular or outflow tract obstruction, and direct effects of catecholamines on cardiomyocytes. Studies show evidence of significant heritable influences on individual responses to adrenergic stimulation. Data from such studies may be of help for a more accurate comprehension of clinical and morphological alterations of the heart. Irrespective of the cause, patients with the classic stress-induced cardiomyopathy morphology deserve special attention because this extensive distribution of wall motion abnormalities has implications for potential associated complications. Cardiac response may be significantly coupled to genetic differences at candidate loci that encode components of catecholamine biosynthesis, storage, and metabolic pathway. Given the role of the sympathetic nervous system in responses to acute stress, it is reasonable to explore whether genetically determined alterations in catecholamine system functions contribute to acute and chronic cardiovascular disorders such as stress-induced cardiomyopathy.     

Police stress as a professional self-image

This article examines what appears to be an original and recent strategy of police professionalization in the United States—an emphasis on police stress as a means of gaining professional legitimacy and prestige as well as a means of bringing coherence to a number of conceptions surrounding the tasks of, and role expectations for, the police. A focus on police stress provides a vehicle for organizing the disparate crime control and peacekeeping elements of law enforcement into a single whole. Because the notions of stress, danger, and service are concepts with which the public are readily able to sympathize and because the public recognizes the stress-related aspects of traditional professions such as medicine, law, and the ministry, especially the responsibility of those in these professions for the lives and welfare of others, the idea of police stress would seem to enhance the public's acceptance of the police claim to professional status. Unfortunately, the social and political conditions underlying police work inhibit such acceptance.     

D-dimer assays for the identification of menstrual blood

A method to reliably distinguish menstrual blood from blood in the normal circulation (peripheral blood) would be of considerable use in the forensic analysis and interpretation of evidence in sexual offence investigations. Previous attempts to address this issue have explored microscopy, lactate dehydrogenase isozyme identification, mRNA and miRNA profiling, and identification of the products of fibrinolysis. Here, four assays for D-dimer, a terminal degradation product of fibrinolysis, are evaluated for their specificity and sensitivity in detection of menstrual blood. In addition the effect of exercise, and sample storage upon D-dimer detection was investigated. Comparison of different assays revealed significant differences in results given. Nevertheless, no positive results for D-dimer were obtained using peripheral blood, mixtures of peripheral blood with semen, or peripheral blood taken from donors after moderate exercise. D-dimer was found to be detectable in 100% of menstrual blood samples after 1 week at room temperature and also in samples stored long-term (>3 years) at -20 °C. D-dimer may be an effective, simple to use tool for the presumptive identification of menstrual blood identification.     

Congestive hemorrhage caused by burns?

Phenomena occurring under exposure to heat such as epidural burn hematoma, hyperemia of the internal organs and extravasation of blood into the serous mucosae have been known for a long time. There has so far been less attention to an alteration which was recently observed in two burn corpses. These were punctiform hemorrhages in the conjunctivae as well as hemorrhages in the throat musculature which initially suggested application of force to the neck. After it could be established by usual investigations that the cases were suicides, an attempt was made to clarify the origin of these hemorrhages and the question of their vitality in animal experiments. To the extent that unequivocal results could be obtained, these indicated that the blood extravasations are vital phenomena which are associated with the still-intact circulation. However, differentiation between the action of third parties and extravasation of blood due to heat it difficult and can only be possible with the consideration of the overall circumstances in the individual case.