Rapid death from thrombotic thrombocytopaenic purpura following caesarean section.

We report a case of rapid death from thrombotic thrombocytopaenic purpura (TTP) in a young pregnant lady who developed full blown symptoms soon after caesarean section. Extensive intramyocardial confluent haemorrhages and widespread microthrombi in heart, brain, adrenals and kidney were found at autopsy. Thrombotic thrombocytopaenic purpura is an uncommon condition, which carries a high fatality rate if untreated. Awareness of this syndrome together with its high risk of sudden death underlines the importance of rapid diagnosis and treatment.     

Klebsiella meningitis mimicking clinical deterioration from hemorrhage of a complex posterior fossa arteriovenous malformation

We report a case of a 33-year-old male with a history of complex posterior fossa arteriovenous malformation (AVM) with partial resection done in China; at follow-up in our unit, he presented with a 1-day history of acute deterioration of consciousness level after minor head injury. The clinical and radiologic features were compatible with spontaneous hemorrhage from the AVM, and the patient died 1 day after admission. However, postmortem examination revealed the direct cause of death was due to Klebsiella meningitis. The clinical catch is highlighted, and the importance of early and prompt detection of this condition is emphasized.     

Fatal intoxication because of trihexyphenidyl

Trihexyphenidyl (THP) is an anticholinergic agent with forensic toxicological interest. We present a case of a 59-year-old woman with a history of paranoid disorder, who was found dead in the house where she lived alone. The autopsy findings revealed no marked pathological changes. Toxicological analysis based on gas chromatography-mass spectrometry (GC-MS) analysis revealed THP and its major metabolite (hydroxy-THP) in blood and urine, with THP concentrations of 0.053 and 0.560 mg/L, respectively. The blood and urine ethanol concentrations were low 0.096 and 0.100 g/L, respectively. Based on these results, we determined the cause of death to be THP poisoning. It is suggested that rare case of death associated with THP overdosage should be taken in conjunction with central nervous system depressants (benzodiazepines, ethanol) and/or with other pathological disorders. Thus, our case could not be supportive for this allegation.     

Sudden Death Due to Undiagnosed Rheumatic Heart Disease in a Child

We report the case of a 5‐year‐old boy who died from complications of rheumatic heart disease with atypical presentation. He was hospitalized for recent inflammatory and neurological symptoms. He was diagnosed with viral encephalitis. He died the day after he was discharged. The macroscopic autopsy findings were unremarkable. Histology revealed typical rheumatic heart disease. Neuropathology showed cerebral infarction due to an embolic event linked with the rheumatic valvulitis. The cause of death was determined as heart failure due to rheumatic heart disease secondary to an undiagnosed acute rheumatic fever. It is related to an autoimmune response to infection with group A streptococcus. It mainly affects children in developing countries. In our case, viral encephalitis was consistent with the medical history and the proper diagnosis was made on histological analysis. Forensic pathologists should consider this diagnosis facing a sudden unexpected death in childhood, even in industrialized countries.     

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.     

Sudden Death as a Complication of Choriocarcinoma

We report the case of a young man with a history of sudden death. On autopsy, a large retroperitoneal mass was found along with secondaries in the liver and lungs. No testicular abnormality was detected on palpation. Based on histopathological examination, it was diagnosed to be a case of choriocarcinoma. Unfortunately, it was not definitively determined whether the retroperitoneal mass represents the primary tumor or secondary involvement with testes being the primary source. It is important that forensic pathologists are aware of this disease as a potential cause of sudden death. The main focus of the paper is the approach of a forensic pathologist to a case of a sudden death when an unexpected and undiagnosed tumor is found in the retroperitoneum and not much information is available about the clinical history of the deceased.     

Fatal intoxication due to tramadol alone: case report and review of the literature

Poisoning may also lead to both coma and multiple organ failure, also in youngsters without a known major medical history. As not all toxic agents are routinely screened when a poisoning is suspected, it is useful to consider less frequently encountered poisons in certain cases. We describe the occurrence of asystole and multiple organ failure which occurred in a young man after a suspected tramadol overdose. The tramadol concentration on admission in the ICU was indeed 8 microg/ml (mg/l), far above the therapeutic range. Subsequently, the patient developed severe acute liver failure, finally leading to death. Post-mortem toxicology did not reveal any other poison responsible for this unfavourable course as only very high serum and tissue tramadol and desmethyltramadol concentrations were found. Only a few fatal poisonings attributable to tramadol alone, as observed in our case, have been reported. An overview of these cases is presented.     

Correlations Among the HLA-DQB1 Alleles and Suicidal Behavior

Suicide is a worldwide health problem with multiple causes, including genetic factors. The major histocompatibility complex (MHC) is represented by an assembly of gene encoding the human leukocyte antigen (HLA). The purpose of our study was to determine associations between the HLA profiles and predisposition for suicidal behavior. We harvested blood samples from persons with history of suicidal attempts (case group) and persons never exhibiting such behavior (control group). The DNA was extracted and amplified via polymerase chain reaction (PCR) to determine the HLA-DQB1 profiles. Statistical data processing was performed with the Epi Info program. We found that the presence of the HLA-DQB1*02 allele increases the risk of suicidal behavior, while HLA-DQB1*05 alleviates such risk. The genotype that presented the most increased risk for suicidal behavior was found to be HLA-DQB1*02/HLA-DQB1*03. Our study has demonstrated the presence of several associations between HLA profiles and suicidal behavior.     

Sudden death during prolonged religious fasting

Sickle cell trait (SCT) is estimated to occur in 6% to 10% of Africans, and the United Kingdom (UK) prevalence rate has been estimated at 3.2%. Although sudden death in sickle cell disease is well known, its occurrence in SCT is rare and requires extremes of physiological stress. We present a case of a 29-year-old black woman who died suddenly during a period of religious fasting. Her medical history was unremarkable, and there was no family history of sickle cell disease. At postmortem, she was found to be dehydrated, and macroscopically, the main abnormal findings were congested lungs and a small spleen. Histological examination revealed extensive vascular congestion with red blood cell sickling in both lungs, the liver, and the spleen. Electrophoresis on a postmortem blood sample confirmed the clinical suspicion that the patient was a carrier of SCT. The case highlights a novel scenario of SCT associated sudden death. We discuss the potential pathophysiological mechanisms that may have led to the patient's demise. We also remind pathologists to consider this diagnosis as potentially contributing to the cause of death in apparently fit young people of ethnic origin during episodes of physiological stress.     

Gunshot suicide with nasal entry

A man with a long history of depression had recently borrowed a rifle. His body was found on its back in bed in his caravan. A rifle lay over the body with the muzzle pointing towards the head. A suicide note was found at the scene. Autopsy revealed entry via the nose with the track passing through the base of the skull to the right parietal region where the main bullet fragments were located beneath the scalp. The history, scene and autopsy findings were consistent with the gunshot wound being suicidal. We can find only one mention of a suicidal gunshot wound with nasal entry in the English-language literature, although a personal communication informed us of a similar case in the Republic of Ireland within the past two years. We report this case because of its unusual nature.     

Narcolepsy mimicking suicidal carbon monoxide poisoning

We present a case of narcolepsy mimicking suicidal carbon monoxide poisoning. The signs and symptoms of narcolepsy in this previously undiagnosed man were initially missed, which emphasizes the importance of extracting a detailed history of a decedent's behavior prior to his or her death. Narcoleptics are often involved in motor vehicle accidents. This report again demonstrates that narcolepsy and driving don't mix, even when the vehicle is stationary. We also briefly review the various sleep disorders.     

Thinking Critically about Race and Genetics

We must critically rethink race and genetics in the context of the new genetic breakthroughs and haplotype mapping. We must avoid the slippery slope of turning socially constructed racial categories into genetic realities. It is a potentially dangerous arena given the history of racialized science in the United States and globally. Indeed, the new advances must be viewed in the context of a long history of racial inequality, continuing into the current period. This is more than a question of how carefully we use categories of analysis such as race. Justice and equity must be core to our considerations. There is a community stake in this work that must be seriously considered and included in decision making. A progressive and critical analysis is in order.     

The chain saw: an uncommon means of committing suicide

A suicide committed with a power saw is an uncommonly reported incident: and the use of a chain saw in particular has been extremely rare. We report two cases of suicide that were committed by using chain saws. In each case the victim had a history of depression or of a prior suicide attempt, and applied the chain saw to his neck to kill himself. We summarize the findings of the two death investigations and the world literature pertaining to suicide committed with power saws.     

美国“法院之友”制度研究

“法院之友”制度是美国法院制度的重要组成部分,美国法院所审理的案件中,有“法院之友”介入的占很大比例,而且很多判决中都援引了“法院之友”书状的意见。本文首先考察了“法院之友”制度的历史轨迹,系统地介绍了政府“法院之友”、中立的“法院之友”和与案件有利益关系的“法院之友”的运作概况,评判了“法院之友”制度的利弊得失,提出了借鉴“法院之友”完善我国现行法院制度的初步设想。     

Two consecutive fatal cases of acute myocardial infarction caused by free floating thrombus in the ascending aorta and review of literature

Free floating thrombus in the ascending aorta is an uncommon source of acute myocardial infarction. We report on two cases of young women who died of acute myocardial infarction caused by a free floating thrombus in the sinus of Valsalva obstructing the coronary arteries' ostia. The first case reports on a 30-year-old pregnant woman who anamnestically had episodes with short loss of consciousness and weakness. The second case presents a 37-year-old woman suffering from multiple sclerosis with no previous history of thrombotic events. The review of literature revealed a predominance of women (eight females and three males). Interestingly, the coronary arteries bear no preference concerning the right (RCA) or left coronary artery (LCA) being more often occluded by a free floating thrombus. Especially, younger women (mean age 45.5 years, range 30-59 years) with no history of cardiac symptoms and without atherosclerotic changes seem to be predispositioned. The hypothesis that thrombus formation in cases without plaque disruption may depend on an endothelial erosion which seems to be more common in younger women and promoted by a hyperthrombogenic state is supported by our two cases. A comprehensive literature search revealed, that these are the first two reports on a free floating thrombus being the cause of fatal acute myocardial infarction in a pregnant woman, respectively, a woman suffering from multiple sclerosis.     

Predicting Outcomes with Juvenile Court Case Histories

This report supplements a prior article in this journal (Rogers and Williams, 1994). Utilizing Ted Palmer's 1991 formulation, we identified a set of indicators relevant to juvenile court decision-making and to policy formulation. Here, through a more stringent statistical technique, we provide additional evidence of the potential that juvenile court histories possess for both theory and practice. We explore case materials gained and maintained by juvenile probation officers as a way of generating outcome predictors for whether youth receive probation or institutionalization. Using discriminant function analysis, we obtain relatively good prediction. Delinquency history and social psychological variables are found to enhance prediction of case outcomes. Contrary to some scholars, we believe the juvenile court is here to stay. Thus, the fundamental issue becomes one of making it a more efficient, effective instrument for reintegrating youths it must serve. As this institution approaches its centennial in 1999, we believe the court must become a focal point of research. This article is intended to further that task. After identifying the three strongest predictive variables (offense after first hearing, alienation, and denial of blame), we employ our seven key indicators as a guide for illustrating their everyday application for juvenile probation officers working with their youthful clientele.     

Amendments to the quick disability determination process. Final rule

We are amending our regulations to extend the quick disability determination process (QDD), which is operating now in the Boston region, to all of the State disability determination services (DDSs). We also are removing from the QDD process the existing requirements that each State DDS maintain a separate QDD unit and that each case referred under QDD be adjudicated within 20 days. These actions stem from our continuing effort to improve our disability adjudication process.     

“人性恶”与法治——一个形而上学的视角

本文以形而上学的视角 ,探讨了对人性的不同判断可能与政治实践之间的关系 ,尤其是“人性恶”的理论前置与近代西方法治文明之间的关系 ,并且指出 ,我国的法治前景能否可瞻可欲 ,关键在于能否以历史为鉴 ,以先进为师 ,充分认识人性之恶 ,在制度安排 ,首先是政治架构的安排上以防恶为首要。     

The Biological Effects of Kambo: Is There a Relationship Between its Administration and Sudden Death?

Kambo is a substance obtained from the skin secretions of a frog, Phyllomedusa bicolor, popular in the Amazon region, which is administered via the transdermal route. We report a case of 42‐year‐old man found dead in his house. Near the corpse, a plastic box labeled as “Kambo sticks” was found. The man was a chronic consumer of Kambo and no previous pathology or genetic disease emerged in clinical history from the declaration of his general practitioner. Autopsy investigations and toxicological analysis were performed. The histopathological examination showed left ventricular hypertrophy. Toxicological screening was negative for ethanol and other drugs. Phyllocaerulein, phyllokinin, and deltorphin A were isolated from the Kambo sticks but, only deltorphin A was detected in blood sample. We describe the first forensic case of death associated with Kambo administration. We attempt to explain how its use could be related to the cause of sudden death in this case.