Molecular Pathology of Pulmonary Edema in Forensic Autopsy Cases with Special Regard to Fatal Methamphetamine Intoxication

Pulmonary edema is a common finding in fatal methamphetamine intoxication. However, the underlying mechanism remains poorly understood. This study investigated the molecular pathology of alveolar damage involving pulmonary edema in forensic autopsy cases. Seven candidate reference genes (RPL13A, YWHAZ, GUSB, SDHA, GAPDH, B2M, and ACTB) were evaluated in the lung by the geNorm module in qBase^plus software. RPL13A, YWHAZ, and GUSB were identified as the most stable reference genes. Using these validated reference genes, intrapulmonary mRNA expressions of matrix metalloproteinases (MMPs), intercellular adhesion molecule‐1 (ICAM‐1), claudin‐5 (CLDN‐5), and aquaporins (AQPs) were examined. Relative mRNA quantification using TaqMan real‐time PCR assay demonstrated higher expressions of all markers except for AQP‐5 in fatal METH intoxication cases. These findings suggested alveolar damage and compensatory response in fatal METH intoxication cases. Systematic analysis of gene expressions using real‐time qPCR is a useful tool in forensic death investigation.     

Further observations on the speed of death in hanging

Given that most fatal hangings are suicidal and occur in locations that have been selected to conceal this activity (thus maximizing the chances of a lethal outcome), there has been very little corroboration of the speed with which unconsciousness and death may occur. A 35-year-old male is reported who committed suicide by hanging immediately after talking to his spouse. Police investigations confirmed her reliability as a witness indicating that lethal anoxia in this case had occurred within a very short time (most likely in less than 1 min) of suspension. The speed with which death may result from hanging not only gives an insight into fatal pathophysiological mechanisms, but also provides useful information for situations where a lethal outcome is to be avoided, or is not intended. For example, individuals at risk of suicide who are being monitored in institutional facilities need to be constantly under direct visual surveillance as significant hypoxia can be rapidly induced, parents and caregivers with infants and children in potentially unsafe sleeping environments need to realize how swiftly death or irreversible anoxic brain damage may occur from neck compression, and those who engage in recreational asphyxia should be informed just how quickly a fatal outcome may ensue.     

An unusual autoerotic accident: sexual pleasure from peritoneal pain

The paper describes a fatal autoerotic accident of a 23-year-old man who derived sexual pleasure from painful irritation of the peritoneum by sharp force. For this purpose he clamped two knife blades into a vice suspended from a rope-pulley construction so that he could lower it to pierce the abdominal skin with the tips of the knives. When one of the ropes broke, the vice with the knives fell onto the man's belly piercing the inferior vena cava and leading to death by exsanguination. This, to the authors' knowledge, has been the first ever report of a fatal autoerotic accident in which sexual pleasure was to be obtained from painful irritation of the peritoneum.     

An analysis of a prehistoric homicide from northern California

An analysis was performed on a prehistoric human vertebral column recovered during an archaeological excavation in the Sierra of northern California. Fifteen burials believed to represent the Maidu culture of 400 to 700 years ago were recovered. The vertebral column from one of the individuals is particularly significant because of three embedded projectile points. The analysis attempts to recreate the trajectory of each point; to determine the possible extent of damage done by each with emphasis upon which could have been fatal; and by employing available ethnographic and archaeological data, to suggest the possible circumstances surrounding the violent event. The conclusion suggests that death may have resulted from any of the three wounds and was probably the result of an intratribal dispute.     

The shaking trauma in infants - kinetic chains

The findings in three children who died as a consequence of shaking and those in another child who survived are presented. In the three fatal cases, a combination of anatomical lesions were identified at autopsy which appear to indicate the sites where kinetic energy related to the shaking episodes had been applied thus enabling the sequence of events resulting in the fatal head injury to be elucidated. Such patterns of injuries involved the upper limb, the shoulder, the brachial nerve plexus and the muscles close to the scapula; hemorrhages were present at the insertions of the sternocleidomastoid muscles due to hyperextension trauma (the so-called periosteal sign) and in the transition zone between the cervical and thoracic spine and extradural hematomas. Characteristic lesions due to traction were also found in the legs. All three children with lethal shaking trauma died from a subdural hematoma only a few hours after the event. The surviving child had persistant hypoxic damage of the brain following on massive cerebral edema. All the children showed a discrepancy between the lack of identifiable external lesions and severe internal ones.     

Death due to neurogenic shock following gastric rupture in an anorexia nervosa patient

We report a case of fatal gastric rupture discovered after death, which developed due to a bulimic attack of a 19-year-old woman suffering from anorexia nervosa. An autopsy revealed an acute gastric dilatation and rupture without commonly observed ischemic damage of gastric wall structures. However, it may be difficult to determine the cause of death despite the marked findings. The death as a consequence of neurogenic shock accounts for all the results of gross examination and histologic analysis. This case is the first reported case of fatal gastric rupture of an anorectic patient discovered after death.     

Fatal accidents and blood ethanol levels in adolescents and adults. The Wayne County experience, 1978-1988

The files of 874 fatal traumatic accident victims, aged 12-25 years, examined at the Wayne County Medical Examiner's Office during the period 1978-1988 were reviewed. Postmortem blood alcohol results of individuals who died after less than 15 min of hospitalization were utilized to approximate alcohol levels at the time of the fatal injury. Relationships between types of accidents, sex, age, race, and time of accident were examined. White victims were far more likely to have been drinking than blacks, and the data indicated that underaged drinkers were involved in fatal accidents at lower levels of blood alcohol than their counterparts of legal drinking age. Consistent racial differences in average alcohol levels were not observed, however. Unlike female and black victims, who much less frequently tested positive for alcohol when underage, white male victims 16-21 years of age were just as likely to have been drinking as those aged 21-25. The results of the study show that postmortem blood alcohol level can be used to identify differences in alcohol consumption among groups of accident victims in a major metropolitan area.     

Case report. Delayed death after pressure on the neck: possible causal mechanisms and implications for mode of death in manual strangulation discussed

Death from hypoxic cerebral damage 1 week after manual strangulation is described, with a discussion of the competing pathophysiological mechanisms responsible for the fatal outcome in this case, and in manual strangulation in general.     

Poisoning with sodium hypochlorite solution. Report of a fatal case, supplemented with an experimental and clinico-epidemiological study.

A case of fatal poisoning in a 1-year-old girl after ingestion of a household cleanser containing 4.5% sodium hypochlorite (Klorin) in an alkaline solution (pH 12.0) is reported. The forensic medical and toxicological investigations were supplemented by animal studies. These studies indicate that 5, 10, and 15 ml of Klorin/kg body wt given to rats is highly toxic, and that local tissue damage and secondary systemic involvement develops with a severity corresponding to the amount administered. The rats, all of which died, showed various degrees of degeneration and necrosis of the esophagoventricular mucosus membranes, changes analogous to those found at the autopsy of the child. A follow-up investigation of similar cases reported to the Swedish Poison Information Centre, during a limited time, was made to complete the picture.     

Reforming Public Safety: An Evaluation of the 1983 British Seat Belt Law

The purpose of this paper is to analyze the impact of the 1983 British seat belt law in England and Wales. The methodology employed is interrupted time series analysis.
In terms of a lasting impact, the seat belt legislation for automobiles compares favorably with other interventions designed to decrease deaths and injuries on the road, such as legislation to control drinking and driving. Typically, such legislation is effective only in the short term. In contrast, the seat belt law thus far shows a stronger and more lasting shift in the reduction of serious and fatal car casualties. The post intervention decline in this variable is stronger than a control series that consists of the number of fatal and serious non-car casualties. A more marginal reduction is found for non-serious car casualties even though this drop in injuries is slightly stronger than a control category of nonserious non-car casualties. The paper suggests also that the seat belt legislation may have had a short term effect on the number of fatal and serious accidents on weekend nights, the period of time during which alcohol-related crashes are most likely to occur.
The policy implications of this study suggest that with comparable compliance, such an intervention may similarly be effective in the United States and other Western countries which up to now have used primarily deterrence-based approaches to reduce highway casualties.     

Blood levels of 3-methylfentanyl in 3 fatal poisoning cases

Three fatal poisoning cases due to 3-methylfentanyl are described. In each case, the death was accidental and occurred after injection of the opioid combined with amphetamine, heroin, or other drugs. The victims' ages, ranging from 30 to 41 years, were higher than those typically found in heroin poisonings in Finland. The blood concentrations of cis-3-methylfentanyl, measured here for the first time by a specific tandem mass spectrometric method, ranged from 0.3 to 0.9 microg/L (mean 0.5 microg/L). These values are significantly lower than the levels reported for alpha-methylfentanyl and fentanyl in fatal poisonings. Repeated seizures of fentanyl and its analogs have been reported in Europe close to the Russian border.     

Grading rigor mortis with myotonometry--a new possibility to estimate time of death.

Myotonometry has been applied to grade rigor mortis. The myotonometer is a hand-held instrument which gives a mechanical impact against the muscle. The muscle responds with a damped vibration which is registered and treated mathematically. The period and the logarithmic decrement of decay of the vibrations were found to change with the development of rigor mortis. The method gives quantitative information on the muscular stiffness and it can be used when estimating the time of death.     

Evaluation of human brain damage in fatalities due to extreme environmental temperature by quantification of basic fibroblast growth factor (bFGF), glial fibrillary acidic protein (GFAP), S100β and single-stranded DNA (ssDNA) immunoreactivities

Fatalities due to extreme environmental temperatures involving hypothermia (cold exposure) and hyperthermia (heat stroke) might present with poor or nonspecific morphological pathologies, which are insufficient to establish the cause of death in forensic practice. The present study immunohistochemically investigated basic fibroblast growth factor (bFGF), glial fibrillary acidic protein (GFAP), S100β and single-stranded DNA (ssDNA) in the parietal lobe and hippocampus of the brain in fatalities from hypothermia (n=15) and hyperthermia (n=18), and compared them to those of controls (n=39), including acute death due to ischemic heart disease, mechanical asphyxiation and drowning. In addition, S100β concentration in cerebrospinal fluid (CSF) was measured. Characteristic findings in hypothermia cases were higher glial bFGF immunopositivity in the cerebral cortex and white matter, and higher S100β immunopositivity in the cerebral cortex with a lower CSF S100β concentration. Hyperthermia showed lower glial GFAP and S100β immunopositivities in the white matter, and higher neuronal ssDNA immunopositivity in the cerebral cortex and hippocampus, accompanied by high glial bFGF and S100β immunopositivities in the cerebral cortex. These findings suggest neuroprotective glial responses without marked neuronal or glial damage in fatal hypothermia, and diffuse neuronal apoptosis despite initiation of neuroprotective cortical astrocyte responses, accompanied by glial damage in the white matter, in fatal hyperthermia. These markers may be useful for evaluating brain damage and responses in fatalities due to extreme environmental temperatures.     

A fatal case of hypovolemic shock after cesarean section

We report a fatal case of hypovolemic shock caused by uncontrollable hemorrhaging after emergency cesarean section. In this patient, the incision in the uterus was located only 1 cm from the cervical os. We suspect that this close incision was the cause of the damage to the uterine venous plexus and the bleeding. We discuss the cause of death and offer advice on performing autopsies in patients who have died of bleeding after cesarean section.     

An unusual missile-type head injury caused by a stone: case report and medicolegal perspectives

Missile head injury is predominantly caused by firearms; however, small blunt objects such as a stone can be propelled into the air and cause a low-velocity-type missile injury, as described in this case report. Since the cerebral damage in low-velocity missile injuries is usually focal, there might not be disturbance of consciousness until secondary brain damage occurs; therefore, adequate medical supervision is necessary to prevent and treat potentially fatal complications in a timely manner. This is a rare case of a penetrating missile wound of the head, most likely caused by the use of a stone propelled by a slingshot that penetrated the skull and lacerated the brain with the stone embedded within the substance of the brain. The deceased died at home 2 days later from focal suppurative meningitis with cerebral abscess formation and a subdural hemorrhage.     

Death caused by "attack dog" bites. A contribution to current discussion

Two cases of fatal dog-bite incidents caused by males of the "American Staffordshire terrier" breed currently known as "fighting dogs" are reported. Both happened in elderly women, one of them handicapped. Reconstruction of the accidents revealed some peculiar characteristics of these dogs, namely the ability to attack undesirably and forcefully as well as the enormous grip of their jaws. Considerable public attention has been drawn to some breeds which seem to predominate in dog-bite statistics and are summarized as "pit bulls". For the animal behaviourist it is not justifiable to condemn only the dog and blame it solely for damage inflicted. Scientific casework has to encompass the situational background of any case and the animal's holder because there is often a close association between the character of the dog and its human counterpart. Implications of such incidents for public safety policy and forensic science are to be discussed.     

Pathologic features of fatal shark attacks

To examine the pattern of injuries in cases of fatal shark attack in South Australian waters, the authors examined the files of their institution for all cases of shark attack in which full autopsies had been performed over the past 25 years, from 1974 to 1998. Of the seven deaths attributed to shark attack during this period, full autopsies were performed in only two cases. In the remaining five cases, bodies either had not been found or were incomplete. Case 1 was a 27-year-old male surfer who had been attacked by a shark. At autopsy, the main areas of injury involved the right thigh, which displayed characteristic teeth marks, extensive soft tissue damage, and incision of the femoral artery. There were also incised wounds of the right wrist. Bony injury was minimal, and no shark teeth were recovered. Case 2 was a 26-year-old male diver who had been attacked by a shark. At autopsy, the main areas of injury involved the left thigh and lower leg, which displayed characteristic teeth marks, extensive soft tissue damage, and incised wounds of the femoral artery and vein. There was also soft tissue trauma to the left wrist, with transection of the radial artery and vein. Bony injury was minimal, and no shark teeth were recovered. In both cases, death resulted from exsanguination following a similar pattern of soft tissue and vascular damage to a leg and arm. This type of injury is in keeping with predator attack from underneath or behind, with the most severe injuries involving one leg. Less severe injuries to the arms may have occurred during the ensuing struggle. Reconstruction of the damaged limb in case 2 by sewing together skin, soft tissue, and muscle bundles not only revealed that no soft tissue was missing but also gave a clearer picture of the pattern of teeth marks, direction of the attack, and species of predator.     

Diffuse vascular injury in fatal road traffic accident victims: its relationship to diffuse axonal injury

The authors have reported a macro- and microscopic study of brain lesions in 120 victims of fatal road traffic accidents, independent of the survival time. Diffuse vascular injury (DVI) was found in 14 patients (11.7%). All patients with DVI died within 24 h after the accident. The 14 patients with DVI also showed severe (Grade 2 or 3) diffuse axonal injury (DAI). Since DVI is restricted to road traffic accidents and incompatible with life, the high frequency observed in our series could be explained by the fact that all 120 patients were victims of road traffic accidents, and 69.2% had died within 24 h after the accident. The association between DVI and severe DAI (Grades 2 and 3) suggests that both lesions depend on the same mechanism, with the degree of axonal and vascular damage being determined by the intensity of the head acceleration. Our results show a relationship between DVI and DAI that suggest there may be a spectrum or at least a continuum between these entities as distinct from DVI being a separate entity.     

Single-stranded DNA as an immunohistochemical marker of neuronal damage in human brain: an analysis of autopsy material with regard to the cause of death

Single-stranded DNA (ssDNA) is a marker of apoptosis and programmed cell death, which appears prior to DNA fragmentation during delayed neuronal death. The present study investigated the immunohistochemical distribution of ssDNA in the brain to investigate apoptotic neuronal damage with regard to the cause of death in medicolegal autopsy cases (n=305). Neuronal immunopositivity for ssDNA was globally detected in the brain, independent of the age, gender of subjects and postmortem interval, and depended on the cause of death. Higher positivity was typically found in the pallidum for delayed brain injury death and fatal carbon monoxide intoxication, and in the cerebral cortex, pallidum and substantia nigra for drug intoxication. For mechanical asphyxiation, a high positivity was detected in the cerebral cortex and pallidum, while the positivity was low in the substantia nigra. The neuronal ssDNA increased during the survival period within about 24h at each site, depending on the type of brain injury, and in the substantia nigra for other blunt injuries. The neuronal positivity was usually lower for drowning and acute ischemic disease. Topographical analysis of ssDNA-positive neurons may contribute to investigating the cause of brain damage and survival period after a fatal insult.     

假设因果关系与损害赔偿

假设因果关系涉及的并非因果关系问题,而是通过假设的原因进程对损害的范围予以限缩。它与损害计算的时点、假设原因的性质及损害的直接性与间接性相关。损害计算的时点决定了可以修正损害的假设原因的时间范围。假设原因的性质排除了可归责于第三人的侵权行为这类假设原因对损害的修正。直接损害与间接损害的区分决定了假设因果关系对损害修正的范围及程度。