Causes of sudden natural death in Jamaica: a medicolegal (coroner's) autopsy study from the University Hospital of the West Indies

Medicolegal (coroner's) autopsies are an important source of epidemiological data. A large proportion of them comprise sudden natural deaths and an analysis of such cases has never been undertaken at the University Hospital of the West Indies, the only teaching hospital in Jamaica. In a retrospective study, 841 cases of sudden natural deaths comprising 51.3% of the medicolegal autopsies conducted over the 15-year period, January 1983 to December 1997, were analyzed. There were 459 males and 382 females (M:F ratio = 1.2:1); 35 patients (4.1%) were less than 1 year of age, and the mean age of the remainder was 53.7+/-21.8 years. The peak age group was the seventh decade accounting for 21.9% of cases. The most common causes of death were cerebrovascular accidents (13.6%), pneumonia (9.4%), pulmonary embolism (7.4%), ischaemic heart disease (7.0%) and diabetes mellitus (6.1%). These findings contrasted with those from developed countries in which ischaemic heart disease is the commonest cause of sudden death. Hypertension was associated with the majority of cases of cerebrovascular accident and congestive cardiac failure (78.1 and 61.9%, respectively). Sickle cell disease represented one of the 10 most common causes of death accounting for 2.5% of cases. Documentation of autopsy-based data such as these is important in the planning of medical services in a developing country.     

The forensic pathology of nonagenarians and centenarians: do they die of old age? (The Auckland experience)

The aim of this study is to provide awareness of the common causes of death and their associated trends in the very aged. Forensic autopsies on patients aged >90 years were reviewed. The study lasted from January 1, 1988 to December 11, 1998 and was done in Auckland, New Zealand, the population of which is 1.3 million. Cases were divided into natural or unnatural deaths. Of the total of 319 cases, 272 (85%) deaths were natural. Of those, only 13 (5%) were "written off" as being attributed to old age or senile debility. The most common causes of death were ischemic heart disease (IHD), 74 cases (23%); bronchopneumonia, 37 cases (12%); fractures, 28 cases (9%); acute myocardial infarction, 25 cases (8%); cerebrovascular accident, 19 cases (6%); and ruptured aneurysm, 17 cases (5%); 61 (19%) deaths were multifactorial. Fractures, either as the primary cause of death or as a complicating factor, accounted for 29 cases, third only to IHD and bronchopneumonia. Forty-seven deaths (15%) were unnatural; of those, 43 were accidents, 3 were suicides, and 1 was a homicide. From these results it is clear that the very elderly succumb to disease; they do not often die of old age.     

105例精神病人尸体检验的法医学分析

目的 回顾分析精神病人尸体检验案例的死亡原因及死亡方式,为医疗卫生服务和司法鉴定提供参考.方法 收集中国刑事警察学院物证鉴定中心2004—2019年受理并结案的精神病人尸体检验案例105例,分为疾病死亡、自杀死亡、意外死亡及他杀死亡4组,统计各组的常见死亡原因,分析各组之间年龄、病程、体重指数(body mass in...     

Presence of psychoactive substances in oral fluid from randomly selected drivers in Denmark

The aim of this investigation was to identify and characterise pathogenic mutations in a sudden cardiac death (SCD) cohort suspected of cardiomyopathy in persons aged 0-40 years. The study material for the genetic screening of cardiomyopathies consisted of 41 cases and was selected from the case database at the Institute of Forensic Medicine. Mutational screening by DNA sequencing was performed to detect mutations in DNA samples from deceased persons suspected of suffering from hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), and arrhythmogenic right ventricle cardiomyopathy (ARVC). A total of 9 of the examined 41 cases had a rare sequence variant in the MYBPC3, MYH7, LMNA, PKP2 or TMEM43 genes, of which 4 cases (9.8%) were presumed to be pathogenic mutations. The presumed pathogenic mutations were distributed with one case of suspected HCM and DCM (MYH7; p.R442H), one case of suspected DCM (LMNA; p.R471H), and two cases of suspected ARVC (PKP2; p.R79X and LMNA; p.R644C). The presented data adds important information on the genetic elements of SCD in the young, and calls for expert pathological evaluation and molecular autopsy in the post-mortem examination of SCD victims with structural anomalies of the heart.     

Identification of Arrhythmogenic Right Ventricular Cardiomyopathy‐Causing Gene Mutations in Young Sudden Unexpected Death Autopsy Cases

Arrhythmogenic right ventricular cardiomyopathy (ARVC) results in an increased risk of sudden death. We sought mutations of desmoglein‐2 (DSG2), desmoplakin (DSP), and plakophilin‐2 (PKP2) in 15 cases of sudden death whose causes of death could not be determined at autopsy. In three victims, mutations were identified in DSP. Two of these mutations were novel; one had previously been reported in a patient with ARVC that had been diagnosed clinically. Histological findings were not typical of ARVC; however, it was notable that these mutations were present in three of 15 cases, a relatively high proportion. The causal relationship between the mutations and ARVC is unclear, but the mutations might have been associated with faulty desmosomal proteins resulting in fatal arrhythmia. Combining information gathered by the traditional means of gross and histological examination with postmortem genetic analysis of young victims would assist in identifying their cause of death.     

Non-traumatic postmortem computed tomographic (PMCT) findings of the lung

PURPOSE: We attempted to obtain postmortem computed tomographic (PMCT) images of the lung in cases of non-traumatic death and describe the results to distinguish usual postmortem findings from those of specific thoracic causes of death. MATERIALS AND METHODS: Our subjects were a total of 150 consecutive non-traumatic cases with cardiopulmonary arrest on arrival who were examined by CT within 2h after certification of death between January 1993 and December 2001. PMCT images of the lung and the frequency of imaging findings (dependent density, ground glass attenuation (GGA), consolidation, pleural effusion, and endotracheal (or endobronchial) air defect) were retrospectively reviewed. Autopsy had been conducted in 16 of the cases. RESULTS: The causes of death and frequency percentages of dependent density, GGA, consolidation, pleural effusion, and endotracheal (or endobronchial) air defect were: 91 cases of acute heart failure (AHF) (69, 66, 24, 11, 14%), 23 cases of aortic dissection (57, 39, 4, 52, 0%), 11 cases of pneumonia (18, 82, 100, 45, 27%), 23 other specified cases (52, 30, 13, 17, 9%), and two unspecified cases (0, 0, 0, 50, 0%), [total respective frequency percentages were (60, 57, 25, 21, 12%)]. Autopsy confirmed that GGA on PMCT in AHF cases corresponded to pulmonary edema. CONCLUSION: When PMCT of the lung shows no other shadows than dependent density, further analysis is necessary to detect the cause of death.     

Sudden death resulting from lesions of the cardiac conduction system

Sudden unexpected deaths in young persons with noncontributory histories, autopsy results, and drug screen results are a common problem in forensic pathology. As part of the evaluation of such cases, the cardiac conduction system (CCS) should be studied. To determine the type and incidence of lethal CCS lesions, the authors reviewed their files of sudden unexpected cardiac deaths with particular attention to cases with causes of death in the conduction system. Cases of sudden cardiac death in patients aged < or=40 years during a 10-year period (Michigan) and a 4 year-period (Spain) were selected from the files. From this group, cases were identified in which the cause of death was a lethal change in the CCS. The portions of the heart containing the CCS were excised, and at least one hematoxylin and eosin slide and at least one trichrome or elastic trichrome slide per block were studied. In the two centers, 381 cases of sudden cardiac death were identified. The most common causes of sudden cardiac death were arteriosclerotic narrowing of the coronary arteries, cardiomyopathy, and myocarditis. In 82 cases, there was no identifiable cause of death even after complete gross and microscopic autopsy was performed, a medical history was obtained, and a drug screen was performed. In 11 cases, the CCS contained lesions that were considered lethal: narrowing of the atrioventricular node artery by fibromuscular hyperplasia (7 cases) and atrioventricular node tumors (4 cases). The 11 cases accounted for 2.9% of the 381 cases of sudden cardiac death and 11.8% of the indeterminable cases. It was concluded that examination of the CCS in deaths in which the gross and microscopic autopsy, history, and drug screen fail to provide a cause of death can yield a cause of death in a significant percentage of cases. If heart block was not documented during life and no explanatory lesions were found during routine cardiac examination, examination of the CCS can yield valuable information.     

Assessment of the stability of 30 antipsychotic drugs in stored blood specimens

The accuracy of antemortem diagnosis of pulmonary embolism is within the range of just 10-30%, so representing one of the most frequent missed diagnosis in sudden, unexpected death. We describe 43 fatal cases of pulmonary embolism as confirmed by post-mortem examination. The aim of our study was to verify the systematic search for the most common genetic thrombophilias (Factor V Leiden (G1691A) and FII (G20210A) gene variants) and dating the thrombus. As a whole, 41 patients (95.3%) had at least one risk factor. Pre-existing symptoms are described just before fatal embolism in 18 (41.9%) out 43 patients. In 18 out of 43 (41.9%) it was not possible to find the thrombotic site. In 24 out of the remaining 25 cases the involvement of the deep veins of one leg was shown; in 1 case the thrombus was localised in the inferior caval vein. 10 (41.7%) were iliac vein thromboses, 7 (29.1%) femoral, 2 (8.3%) popliteal, 3 (12.6%) posterior-tibial, 1 (4.1%) anterior-tibial and 1 (4.1%) peroneal vein thromboses. In our cohort of patients, 4 (10%) out of 40 cases carried the 20210A prothrombin gene variant in heterozygosis. One (2.5%) out of 40 carried the Factor V Leiden (G1691A) gene variant in heterozygosis. Patients carrying these gene variants in homozygosis or carrying both were not present in our case-series. We strongly underline the relevance of a complete methodological approach, integrating clinical data by means of autopsy findings and histological study. On the contrary, investigating common inherited thrombophilia is not warranted.     

Gc亚型检测的复合MS-PCR法及其应用

目的探讨建立Gc亚型检测的复合MS-PCR法及其应用价值。方法根据Gc基因中的2处点突变,设计2对片段相差5bp的等位基因特异性引物和1条公共引物进行复合MS-PCR,分析Gc多态性,并调查武汉地区218例汉族无关个体Gc多态性和鉴定10例亲子关系。结果复合MS-PCR检测的Gc基因型,与AmpliTypePM试剂盒的分型结果一致;武汉地区汉族人群Gc基因的3个常见等位基因Gc1F、Gc1S、Gc2的基因频率分别为0.4816、0.2592、0.2592,观察杂合度(Hobs)、期望杂合度(Hexp)、多态性信息含量(PIC)、个人识别能力(DP)、非父排除率(PE)分别为0.6193、0.6359、0.6253、0.7974、0.3480,基因型分布符合Hardy-Weinberg平衡;真三联体和非真三联体亲子鉴定各5例,前者不排除父子关系,与常规STR分型一致,后者经Gc-MS-PCR分型排除2例。结论建立复合MS-PCR法检测Gc亚型在法医物证鉴定中有实用价值。     

遗传性心律失常猝死的分子解剖研究现状及展望

遗传性心律失常所致猝死的死因鉴定是法医病理学领域亟待解决的难题之一。近年来心律失常易感基因/突变的发现和高通量组学技术的推广,使得利用分子遗传学方法筛查猝死的遗传学病因（即＂分子解剖＂）成为可能。本文通过汇总心律失常分子遗传研究的进展,综述传统遗传分析和近期全基因组关联性研究（GWAS）筛查的结果,为心源性猝死的＂分子解剖＂研究提供候选基因列表;并进一步比较针对不明原因猝死所开展的回顾性＂分子解剖＂筛查的结果,探讨新技术在该领域的应用前景。这一综述有助于更好的认识心律失常所致猝死的分子机制,并为借助新一代遗传分析技术进行分子解剖提供有益参考。     

Burden of Neurodegenerative Diseases in a Cohort of Medical Examiner Subjects*

Abstract: Here we report studies of the burden of neurodegenerative neuropathologies in a cohort of Medical Examiner (ME) subjects from the County of Santa Clara (California) to determine if this unique population of decedents manifested evidence of neurodegeneration that might underlie causes of death seen in an ME practice. We found that 13% of the brains from ME cases showed significant tau pathology, including 55% of those 65 years old and older and 63% of those 70 years old and older. The histochemical and immunohistochemical findings were consistent with Alzheimer’s disease (AD) in 7 subjects and frontotemporal lobar degeneration (FTLD) tauopathy type in six cases. There were no cases of Parkinson’s disease, dementia with Lewy Bodies or other neurodegenerative conditions. Our study suggests that decedents >65 years of age in an ME practice are afflicted by common causes of dementia such as AD and FTLD which could contribute wholly or in part to their causes of death.     

Morphometric Investigation of Death by Asphyxia

Abstract:  The aim of this study was to investigate the possibility of distinguishing deaths by asphyxia from those due to natural causes by comparing morphometric measurements in lungs. The study population comprised 27 subjects: 14 cases of death by asphyxia (hanging or drowning) and 13 cases of sudden natural death. Eighty parenchyma sections were used for each subject. Data were collected by computerized image analysis. Measurements aimed at quantifying, as percentages, pulmonary parenchyma (mean values of positive-fraction areas [PFA] and their standard deviations). Subjects who died of natural causes and of drowning showed a relative internal homogeneity compared to those who hanged. Results show significant discrimination between drowned subjects and those dying of natural causes (mean of PFA p  = 0.01) and between hanged and drowned subjects (SD of PFA p  = 0.04). Attention must be paid to the possible role played by senile emphysema. The method is proposed as a complementary tool in forensic cases.     

An Analysis of The Morbidity and Mortality of Diabetes Mellitus in a Forensic Context

To investigate the spectrum of diseases seen in diabetes mellitus in a forensic context, all autopsy reports of diabetic individuals who presented to Forensic Science, South Australia (FSSA), over a 5‐year period from 2005 to 2009 were studied. The leading cause of death was cardiovascular disease (55.0%), followed by unnatural deaths (15.4%) and infections (9.4%). In type 1 diabetics, principal causes of death included cardiovascular disease (44.7%), acute metabolic complications (18.7%), unnatural deaths (17.9%), and infections (8.9%). However, frequencies of these diseases differed in type 2 diabetics, with cardiovascular events responsible for 56.6% of cases, followed by unnatural deaths (15.0%) and infections (10.9%). A larger number of male deaths were seen in all disease categories, except respiratory and gastrointestinal where the frequencies were similar to females. Cardiovascular disease was the leading overall cause of death across all ages except in those under the age of 30 where metabolic complications were more common.     

Forensic Pathological Examination on 73 Medical Malpractice Cases of PediatricsCSCD

Objective: To analyse 73 medical malpractice cases of pediatrics for discussing the importance of forensic pathology in solving the issues such as medical malpractice of pediatrics. Methods: From January 2002 to August 2016, 73 medical malpractice cases of pediatrics with age of death between 28 days old and 10 years old were collected from Institute of Judical Expertise of Nanjing Medical University. The relationship between causes of death and related medical institutions was retrospectively analysed. Results: In 73 cases, the male to female ratio was 1.70:1, and ages of 28 days old to 1 year old were common (26 cases, 35.62%), followed by ages between 1 year old and 3 years old (21 cases, 28.77%). In 71 cases which had been determined the cause of death by postmortem examination, the main cause of death was disease, especially respiratory diseases (33 cases, 46.48%), followed by cardiovascular diseases (12 cases, 16.90%). In 75 medical institutes which involved with these medical malpractices, most were tertiary medical institutes (32, 42.67%), followed by the sub-secondary (excluding the secondary)medical institutions (23, 30.67%). The clinical diagnosis of 38 cases (52.05%) completely or mostly corresponded with the pathological findings. There were 35 cases (47.95%) undefined or misdiagnosed cases. Conclusion: Autopsy and forensic pathological examination contribute to determine causes of death, which not only provide scientific evidence for medical malpractice of pediatrics, but also enrich and develop clinical medical knowledge, and thus improve diagnosis and treatment level in a certain extent. © 2018 by the Editorial Department of Journal of Forensic Medicine.     

Sudden Cardiac Deaths in Adults with Congenital Heart Disease with Structural Abnormalities: A Retrospective Review of Cases in the Cook County Medical Examiner's Office

Sudden cardiac death is a significant cause of mortality in adults with congenital heart disease (CHD). The Cook County Medical Examiner's Office database was queried for cases of CHD as a cause of death in the period between July 2008 and April 2019. Twenty-two cases were identified, including 11 decedents with simple defects and 10 decedents with complex defects. All of the subjects were in apparent good health at the time of death. In the absence of other obvious causes of death, simple defects were considered cases of sudden cardiac death. Significant cardiac morphological changes were common in complex defects. While 16 cases had known, diagnosed/treated CHD, 5 cases had no diagnosis prior to autopsy. In these cases, the ability to recognize CHD (sometimes subtle) helped in determining the causes of death. Therefore, forensic pathologists must be able to properly recognize various forms of CHD and request consultations, when needed.     

类胰蛋白酶和IgE测定在过敏性猝死诊断中的应用研究

目的探讨过敏性猝死法医学鉴定的诊断方法和指标。方法采取10例正常人、9例过敏性猝死和19例其他死因（排除过敏反应、冠心病）尸体的静脉血，采用荧光酶联免疫法（Pharmacia UniCAP100过敏原定量分析仪）和酶联免疫吸附试验ELISA法分别测定血清肥大细胞类胰蛋白酶和]gE含量，采用免疫组化方法观察过敏性猝死和其他死因的肺组织中的肥大细胞类胰蛋白酶免疫组化染色。结果过敏性猝死者的血清类胰蛋白酶和IgE含量升高，与其他死因之间的差异具有显著性意义（P〈0．01），其他死因和正常人之间的差异无统计学意义（P〉0．05）；与其它死因相比，过敏性猝死肺组织中的肥大细胞类胰蛋白酶免疫组化阳性染色增强（P〈0．01）。结论过敏性猝死者血清IgE和肥大细胞类胰蛋白酶含量显著升高；过敏性猝死者肺组织中肥大细胞类胰蛋白酶染色增强。     

Postmortem molecular screening for mutations in ryanodine receptor type 1 (RYR1) gene in psychiatric patients suspected of having died of neuroleptic malignant syndrome

Postmortem diagnosis of neuroleptic malignant syndrome (NMS) is difficult to perform, because the clinical symptoms just before death are not usually available. Malignant hyperthermia (MH) is a catastrophic, life-threatening hypermetabolic syndrome triggered by certain anesthetics. Ryanodine receptor type 1 (RYR1) gene mutations are known to be involved in susceptibility to MH. Similarities in clinical features, such as elevated body temperature, between NMS and MH have led to the suggestion that NMS is a neurogenic form of MH. In this study, we analyzed possible mutations of the RYR1 gene in 11 psychiatric patients suspected at autopsy to have died of NMS. All cases were suspected of having elevated body temperature at death, and their causes of death could not be determined by autopsy examinations. Two mutations (R4645Q and A612T) in the RYR1 gene were identified. The R4645Q mutation has previously been reported in MH patients, but five heterozygous mutations were also found in 400 Japanese control alleles. The other mutation was novel, and was not found in the same control alleles. The results of this study provide the first successful identification of RYR1 mutations in psychiatric patients suspected at autopsy of having died of NMS. However, the association between RYR1 gene mutations and cause of death in psychiatric patients suspected of dying of NMS remains unclear.     

A retrospective analysis of cardiovascular deaths: A 5-year autopsy study of 1045 cases in Antalya,Turkey

This study aims to identify the macroscopic and microscopic changes that occur in the heart in different causes of cardiovascular death and sudden cardiac death in autopsy cases and evaluate the difficulties that a forensic practitioner may encounter during autopsies. All forensic autopsy cases in the Morgue Department of the Council of Forensic Medicine, Antalya Group Administration between January 1, 2015, and December 31, 2019, were examined, retrospectively. The cases were chosen according to inclusion and exclusion criteria, and their autopsy reports were examined in detail. It was determined that 1045 cases met the study criteria, 735 of which were also met the sudden cardiac death criteria. The top three common causes of death were ischemic heart disease (n = 719, 68.8%), left ventricular hypertrophy (n = 105, 10%), and aortic dissection (n = 58, 5.5%). The frequency of myocardial interstitial fibrosis was significantly higher in deaths due to left ventricular hypertrophy than in deaths due to ischemic heart disease and other causes (χ²(2) = 33.365, p < 0.001). Despite detailed autopsy and histopathological examinations, some heart diseases that cause sudden death may still not be detected.     

What is the incidence and significance of "dry-lungs" in bodies found in water?

BACKGROUND: Drowning without aspiration of liquid, generally attributed to death from asphyxia while submerged and in laryngospasm, has been reported to occur in approximately 10% to 15% of drowning victims. OBJECTIVES: The occurrence of "dry-drowning" recently has been questioned and the hypothesis developed that "dry-lungs" in bodies found dead in the water could conceal more natural deaths than previously recognized. METHODS: Based on 578 selected adult victims who presumably drowned, we analyzed the correlation between the cases with a low combined lung/pleura liquid weight (< 1000 g and < 750 g) and a wide set of individual, circumstantial, and postmortem (PM) variables, using multivariate logistic regression analysis. Victims with lung weight < 1000 g were screened for long-QT syndrome (LQTS) founder mutations in KCNQ1 and KCNH2 genes. RESULTS: Of the 578 victims, 120 (20.7%) had a lung weight of < 1000 g, and 22 of these (3.8%) of < 750 g. Multivariate analysis showed a significant correlation for women (P < 0.001), for women aged 65 years or older (P < 0.001), and for men with prolonged PM submersion time (P < 0.001). "Normal" lungs were found in only 8 (1.4%) victims. Low-weight (< 1000 g), overdistended lungs with no sign of liquid penetration were seen in 11 (1.9%). No LQTS founder mutations were detected. CONCLUSIONS: The actual incidence of death of persons found in water who have normal lungs or do not have penetration of liquid into their airways, based on our study, is much lower (below 2%) than currently assumed.     

Errors on death certificates requiring amendments: the Broward County experience

The medical examiner's office in Broward County is responsible for determining the cause and manner of death in cases falling under its jurisdiction and issuing death certificates on these decedents. Amendments are occasionally required to correct misinformation on death certificates or within the autopsy reports. The purpose of this study was to investigate the major causes for the amendments and to develop strategies to avoid future errors. We found 128 cases from 2006 to 2007 that required amendments; 103 contained sufficient data in the file for further analysis. Over this time period, 3790 death certificates were issued over that same period, resulting in a 3.37% amendment rate. In this study, the cohort included both males and females with a ratio of 2:1. Their ages ranged from newborn to 103 years, with a mean age of 49 years. Of the 103 amended cases, amendments were made to the cause (n = 30) and often the manner (n = 21) of death listed on the death certificate; the remaining changes were limited to the autopsy report. The most common reasons for amendments included reception of delayed laboratory findings (35%), acquisition of additional medical history (22.5%), and typographic errors (15.5%). Typographic errors mainly occurred because of inaccuracies in the names originally provided to our office, the use of aliases by decedents, incorrect personal/demographic history, or various misspellings by funeral homes or medical examiner staff. The most significant reclassifications involved changing certified natural deaths to accidental overdoses and vice versa, based on toxicological analysis. Because of delays in specimen turnaround, these amendments often were made months after the original death certificate was issued. STAT urine drug screening has been helpful in reducing the number of amendments made, but certain drugs of significance are missed by rapid screens. Given that our office performed complete toxicological analysis on all cases over this period, it seems likely that we detected several overdoses that would have been missed if natural deaths were not routinely screened for potential toxins.