Fluidity of cadaveric blood after sudden death: Part III. Acid-base balance and fibrinolysis

In rats, fibrinolytic activity and acidosis increased rapidly after death. Postmortem fibrinolysis and the pH, base excess (BE), and [HCO3-] levels were affected by the method of sacrifice: the lower the pH, BE, and [HCO3-] levels, the higher the fibrinolytic activity. Conversely, in experiments using the vascular perfusion technique, low pH, BE, and [HCO3-] levels of the perfusate induced abundant release of plasminogen activator from the vascular wall.     

Fluidity of cadaveric blood after sudden death: Part II. Mechanism of release of plasminogen activator from blood vessels

Experiments by the vascular perfusion technique in isolated hind leg of the dog showed that after addition of various vasoactive drugs to the perfusate, fibrinolytic activity (plasminogen activator level) of the effluent was elevated. The effects of the drugs were completely inhibited only by the specific blocker of their receptor on the vascular wall. High K+ level of the perfusate also induced abundant release of plasminogen activator from the vascular wall.     

Heart fatty acid binding protein as a marker for postmortem detection of early myocardial damage

Depletion of heart fatty acid binding protein (H-FABP) from cardiomyocytes with varying post-ischemia intervals was studied in acute myocardial infarction (AMI) model of rat, and 22 human autopsy cases were studied with streptavidin-peroxidase conjugated method (S-P). It was observed that as early as 15 min after ischemia, the depletion of H-FABP could be detected in model rats. With the ischemic time prolonged, the depletion of H-FABP was more and more evident. In all human cases with myocardial infarction, absent H-FABP staining could be found in infarcted area. And in some suspected early myocardial infarction cases, depletion of H-FABP staining could be demonstrated in areas that showed normal hematoxylin-eosin (HE) staining. The blood samples from model rats before ligation, at varying post-ischemia intervals and various postmortem time were measured for plasma concentration of H-FABP with enzyme-linked immuno-sorbent assay (ELISA) method. At 15 min after myocardial ischemia, the concentration of H-FABP was 4 times higher (546.0+/-85.3 microg/l) than that of the baseline level (103.7+/-94.1 microg/l). With the continuation of ischemic time, the concentration of H-FABP increased and peaked at 4 h (1953.5+/-405.3 microg/l), then decreased. The plasma concentration of H-FABP decreased slightly with postmortem time, but was still significant higher at any postmortem intervals than that of baseline level within 48 h after death. The results suggest that H-FABP staining can detect very early ischemic damages in human myocardium and the elevated plasma concentration of H-FABP in rat was an indicator of AMI, which was not affected by autolysis.     

Sympatho-adrenal activity in acute cold stress. The mechanism of sudden death following water immersion]

In addition to currently known mechanisms of sudden death following water immersion, predominantly vagal cardio-depressive reflexes are discussed. The pronounced circulatory centralization in diving animals as well as following exposure to cold water indicates additional sympathetic activity. In cold water baths of 15 degrees C, our own measurements indicate an increase in plasma catecholamine levels by more than 300%. This may lead to cardiac arrhythmias by the following mechanism: Cold water essentially induces sinus bradycardia. Brady- and tachyarrhythmias may supervene as secondary complications. Sinusbradycardia may be enhanced by sympathetic hypertonus. Furthermore, ectopic dysrhythmias are liable to be induced by the strictly sympathetic innervation of the ventricle. Myocardial ischemia following a rise in peripheral blood pressure constitutes another arrhythmogenic factor. Some of these reactions are enhanced by alcohol intoxication.     

Effect of post-mortem changes on peripheral and central whole blood and tissue clozapine and norclozapine concentrations in the domestic pig (Sus scrofa)

Interpretation of the results of psychoactive or other drug measurements in post-mortem blood specimens may not be straightforward, in part because analyte concentrations in blood may change after death. There is also the issue of comparability of plasma (or serum) results to those obtained in whole blood. To investigate these problems with respect to clozapine, this drug (10mg/kg daily) was given orally to two pigs. Blood was collected 3h post-dose on day 7, the animals were sacrificed, and blood taken from central and peripheral veins for up to 48 h after death. Tissue samples were also collected immediately after death and at 48 h. Ante-mortem whole blood clozapine/N-desmethylclozapine (norclozapine) concentrations were 0.86/1.07 and 1.11/1.15 mg/l in pigs 1 and 2, respectively. Blood clozapine and norclozapine concentrations generally increased after death (central vein: clozapine up to 300%, norclozapine up to 460%; peripheral vein: clozapine up to 155%, norclozapine up to 185%). Initial blood and kidney clozapine and norclozapine concentrations were comparable in both animals, but were some two-fold higher in heart, liver and striated muscle in pig 2. In both animals, the heart and striated muscle clozapine and norclozapine concentrations had increased some two- to three-fold at 48 h, whilst the liver and kidney concentrations were essentially unchanged. The reason for the increase in heart and striated muscle concentrations at 48 h is unclear, but could be simple variation in sample site. The plasma:whole blood distribution of clozapine and norclozapine was studied in vitro. In human blood (one volunteer donor, haematocrit 0.50) the plots of plasma versus whole blood concentration were linear for both analytes across the range 0.1-1.5mg/l, although clozapine favoured plasma (plasma:whole blood ratio=1.12), whereas norclozapine favoured whole blood (ratio 0.68). In pig blood, the plots of plasma versus whole blood were non-linear in both cases, although clozapine favoured plasma to a greater extent than norclozapine. This may be due to lower plasma clozapine and norclozapine protein binding capacity in the pig as compared to man.     

Creatine phosphokinase in serum and cerebrospinal fluid, and microscopic findings in brain and heart in hypothermic rabbits

Signs of hypothermia injury were studied in rabbits cooled to a core temperature of 30 degrees C by immersion in ice water and thereafter rewarmed to 35 degrees C. Anaesthetized control rabbits were kept normothermic (37 degrees C) for a corresponding time (4 h). Creatine phosphokinase (CPK) activity increased 24 h after hypothermia to 20-fold in serum. In cerebrospinal fluid the activity was already significantly (5-fold) increased after hypothermia and was still as high at 24 h. Smaller increase was also found in the control normothermic rabbits both in serum (10-fold) and cerebrospinal fluid (2-fold). The values had returned to the initial level after 1 week. Small haemorrhages were observed in the brain at 24 h and slight scarring was seen in the myocardium of some rabbits which had lived 4 weeks following hypothermia. The results indicate that CPK can be a useful marker in the diagnostics of hypothermia death, especially in cerebrospinal fluid, which is less affected than blood by autolysis.     

Cardiac arrest after traffic accident induced through vagal reflex in a case with bilateral stenosis of vertebral arteries

An 84-year-old driver suffered cardiac arrest after a traffic accident. He was quickly resuscitated and transferred to a hospital where he was treated in a state of unconsciousness and respiratory failure for 20 days until his death. The brain stem was rendered anoxic during cardiac arrest, which caused the respiratory failure. Artificial ventilation and catecholamine infusion were carried out, resulting in myocardial degeneration. Bilateral stenosis of the vertebral arteries was disclosed, but no injuries or hemorrhage of the brain and spinal cord were detected. On days 3 and 4 after admission, immediately after the head of the victim was flexed forward for examinations, cardiac arrest was induced twice, but was controlled either by administering atropine or by restoring the original posture. Positional change is known to induce vagal reflex that results in bradycardia, hypotension or cardiac arrest in sensitive persons. The victim might have undergone the reflex-mediated cardiac arrest after the accident, to which the stenosis of the vertebral arteries may have contributed.     

Anaphylactic death: the effect of aminoguanidine and heparin on histamine and stress hormones in guinea pigs

The modifying effect of aminoguanidine (a histaminase inhibitor) and heparin (a histaminase liberator) on anaphylactic shock in guinea pigs was studied using ovalbumin as an antigen and trigger. The animals died of the shock, the time to death remaining unaltered by the drugs. Serum histamine and cortisol values were high after shock, but were reduced by heparin. Both noradrenaline and adrenaline in plasma were also elevated after shock, the final concentration of the latter being lowered by heparin. The lungs were dilated, indicating bronchoconstriction. The results confirm the role of histamine in anaphylactic shock and its potential value for the diagnosis in this kind of rapid death, in which morphological signs are scarce or lacking. Its diagnostic value still requires confirmation, however, which only autopsy studies can supply. It also appears that pretreatment of the animals with heparin affected the blood cortisol and catecholamines, which are involved in the shock mechanism as countermeasures, although aminoguanidine did not have any effect.     

Detection of Gunshot Residue in Blowfly Larvae and Decomposing Porcine Tissue Using Inductively Coupled Plasma Mass Spectrometry (ICP‐MS)*

Abstract: Blowfly larvae and porcine tissue contaminated with gunshot residue (GSR) were collected during summer and winter months, over a 37‐day and a 60‐day sampling period, respectively. Wound samples were microwave‐digested and analyzed by inductively coupled plasma mass spectrometry (ICP‐MS) for the detection of antimony, barium, and lead. During summer, the 37‐day sampling period encompassed all stages of decomposition, except skeletonization. The three elements were detected in larvae only on days 3 and 4 after death but were detected at significant levels in tissue samples throughout the entire sampling period. In winter, no significant decomposition was observed throughout the 60‐day sampling. Although temperatures were too low for blowfly activity, the three elements were detected in the tissue samples at relatively constant, significant levels. Hence, GSR determination in tissue was more dependent on decomposition stage rather than time since death.     

The eye as a chemical indicator of environmental temperature at the time of death

Vitreous humor chemistry profiles were reviewed on 133 autopsied cases in which death occurred outdoors during a six-year period, to determine whether environmental temperature at the time of death influenced chemistry values obtained at autopsy. The glucose concentration and total carbon dioxide content varied inversely with temperature. Values were significantly higher in the winter than the summer months. The mean glucose level was higher in deaths caused by cold exposure than in other deaths occurring in the cold, but individual cases could not be distinguished on the basis of chemistry values. Potassium levels tended to be slightly lower in winter. It was noted that chemistry studies could be used to help determine whether a body found outdoors in winter actually died in a different, warmer environment.     

Uncertainty of determining cause of death in a medicolegal material without autopsy. An autopsy study

In constrast to other studies, this investigation was made on cases of medicolegal deaths that would not normally be autopsied. 223 females and 322 males, whose deaths were found to be natural before as well as after autopsy, were studied. The cause of death was estimated by external medicolegal examination, and after autopsy.In 79 females and 109 males, i.e. 35% and 34% respectively, estimated cause of death was found to be different after the autopsy. This was mostly because ischaemic heart disease as a cause of death was overestimated at the external medicolegal examination. No constant relationship between differing causes of death and age group could be demonstrated. Underdiagnoses and overdiagnoses tended to outweigh each other. Pneumonia, pulmonary embolism, cor pulmonale and aortic stenosis were clearly underestimated before autopsy. In addition, a variety of diseases that were not even mentioned at the medicolegal examination was found (subarachnoid haemorrhage, uraemia, perforated and bleeding gastric ulcers, tuberculosis).The same unreliability in the estimated cause of death therefore exists among cases not normally autopsied as found in retrospective studies of cases where autopsy is performed under all circumstances at the request of the police.False information will thus be given to the mortality statistics among the approximately 5000 cases of medicolegal deaths not autopsied in Denmark per year, most of these being natural deaths. Besides, contagious and inherited diseases could be overlooked, relatives given false information and the value of scientific studies in causes of death diminished.The conclusion is that autopsy is still essential to ensure continuous control and correction of causes of death.     

固定双上肢悬挂致死的SOD,MDA含量变化

固定双上肢将身体悬空致死，是一种罕见的、特殊的窒息死。实验结果表明：实验后与实验前相比，ＳＯＤ活性明显下降，有显著性差异（Ｐ＜０．０１），ＭＤＡ含量明显升高，有显著性差异（Ｐ＜０．０１）。这为进一步阐明这类固定双上肢将身体悬空所致的死亡为窒息死，为法医学鉴定提供科学的依据。     

Stability of plasma total cholesterol, triglycerides, and apolipoproteins B and A-I during the early postmortem period

The stability of plasma lipids and apolipoproteins during the early postmortem period was studied by taking four duplicate blood samples from eight cadavers 2, 6, 12, and 24 h after death. The bodies were kept at +4 degrees C. The plasma samples were analyzed for total cholesterol (TC), triglycerides (TG), apolipoprotein B (apo B), and apolipoprotein A-I (apo A-I). In TC, values rose by 6 and 11% in two cases, and in six cases diminished 3 to 15% during the first 6 h compared to values obtained 2 h postmortem. The greatest changes were a continuing rise in one case by 33% and a fall by 21% in another case during 24 h. In TG values marked changes took place including one case with a rise of 67% within 24 h. The concentrations of apo B rose by 9 to 11% in three cases and fell by 3 and 4% in two cases during 6 h, but during the whole study period a rise up to 78% occurred. In the concentrations of apo A-I, cases fell by as much as 42% in 6 h, and in one case rose by 20% during 6 h. The results indicate that unpredictable fluctuations occur in plasma lipid and apolipoprotein values within 24 h after death, and they should be interpreted cautiously if the samples have been taken after a prolonged postmortem period.     

Post-mortem changes in skeletal muscle protease and creatine phosphokinase activity — A possible marker for determination of time of death

The pattern of change in activity of two enzymes in rat skeletal muscle during body storage after death has been determined. Myofibrillar protease activity was found to increase linearly with time of storage post mortem at room temperature but not at 4 °C. In contrast, creatine phosphokinase activity declines linearly with time, and again storage at 4 °C prevented the change in enzyme activity. Starvation of animals for 5 days or forced exercise prior to death did not markedly alter the rate of change in activity of the two enzymes, although creatine phosphokinase specific activity at time of death was higher in the starved and exercised rats as compared to control animals. A plot of the logarithm of protease/creatine phosphokinase specific activities ratio versus time post mortem yields a linear curve at room temperature. These observations offer a potential method for estimating time of death.     

Comparative evaluation of postmortem serum concentrations of neopterin and C-reactive protein

The cellular immune response is accompanied by the release of neopterin. The level of neopterin in serum is increased in patients suffering from viral infections, autoimmune diseases, systemic inflammation, allograft rejection and malignant diseases, while that of C-reactive protein (CRP) is known to rise during inflammatory diseases and traumas. To investigate postmortem neopterin and CRP concentrations with regard to the cause of death, we examined cardiac and peripheral blood samples in 474 autopsy cases without advanced decomposition (0-96 years of age, 343 males and 131 females), 2.8 h to 3 days (median, 18.0 h) after death. Survival time was 0.1 h to 5 months (median, 3.0 h) for traumatic death, and 0.1-1, 440 h (median, 2.5 h) for natural death. In autopsied subjects, neopterin concentrations were higher than the clinical reference, independent of the time after death, and depended on the survival time. In cases of acute and subacute death due to trauma, the neopterin level in right heart blood was mildly to moderately elevated (about 50-200 nmol/l) except for sharp instrument injury, whereas the CRP concentration usually remained low (<1 mg/dl). However, a moderate rise in the CRP level (around 1-10 mg/dl) was observed in fatal cases of hypothermia (cold exposure). Markedly elevated serum CRP and neopterin levels (>10 mg/dl and >500 nmol/l, respectively) were detected in cases of delayed death due to trauma involving systemic inflammatory response syndrome (SIRS) and of fatal bacterial infections. For sepsis, the serum CRP level was markedly elevated but the neopterin level was low in some cases. Fatal viral infections usually resulted in a marked elevation in the serum neopterin level (>500 nmol/l) with a mild to moderate rise in the CRP level. Combined analyses of neopterin and CRP may be useful to investigate viral infections and delayed traumatic death involving SIRS to support pathological findings.     

重伤家兔体内Cu及代谢酶变化与MOF及死亡关系

目的探讨兔重伤后机体内铜（Cu）含量及其代谢酶铜锌超氧化物歧化酶（Cu/Zn-SOD）、细胞色素c氧化酶（CCO）活性变化与继发性多器官衰竭（MOF）及死亡的关系。方法参照国际通用的创伤程度量化评分标准（ISS）,建立致MOF的家兔重伤模型,检测伤后不同时段血清及组织Cu含量与Cu/Zn-SOD和CCO的活性,分析其变化规律与继发MOF及死亡的关系。结果①重伤组家兔（包括死亡组家兔）血清Cu含量在伤后12h显著下降,36h后逐步回复;脑、心、肺组织中Cu含量伤后下降,肝脏组织Cu含量于伤后12h显著升高,36h后回落。伤后死亡组家兔脑、心、肺、肝Cu含量均较对照组降低,其中脑、肝组织Cu含量下降显著。②重伤组家兔血清Cu/Zn-SOD活性伤后12h下降3,6h之后呈升高的趋势,肝脏组织中的Cu/Zn-SOD活性伤后持续显著升高。③重伤后家兔（包括死亡组家兔）大脑皮质、心、肝CCO活性变化不明显,但脑干组织CCO活性显著升高。伤后死亡组家兔脑、心、肺、肝等器官的大体及组织学呈MOF改变。结论严重创伤可引发兔血清和组织Cu水平及Cu/Zn-SOD、CCO活性变化,这些变化可能与继发多器官衰竭和死亡相关。     

一例药物过敏性休克死亡的医疗问题鉴定分析

目的探讨药物（低分子右旋糖酐）过敏性休克医疗纠纷案件的法医学鉴定思路及关键点，从而为审判提供划分侵权责任及医疗赔偿的科学依据。方法详细报道一例低分子右旋糖酐药物过敏性休克死亡的两级医疗事故鉴定，法医学鉴定及二次不同的法院判决结果的医疗纠纷案例。结果两级医疗事故鉴定均认为该例属医疗意外，不属医疗事故，一审判决驳回起诉。法医学鉴定认为在对该例的抢救过程中确存在不当之处；患者确因药物（低右）过敏性休克死亡，未发现院方有违反医疗常规的行为，对该例的治疗方案属非必要治疗措施。在抢救过程中，肾上腺素没有作为首选用药，肾上腺素应用不及时，药量不充足。因抢救地点的限制致使抢救质量不好。据此，二审判决被告院方对患者方予以赔偿。结论药物过敏性休克的法医学鉴定应注重：①全面审查所提供的详细医疗材料，分析整个医疗过程的临床变化特点；②全面尸检；③进行药品检验、毒物分析；④排除疾病及其它死因；⑤进行确证死因的检验。在此基础上分析确定死因及医疗过程是否存在问题，如存在医疗不当之处，分析此种医疗不当在患者的死亡中的关系比例，并适当表述鉴定意见。     

Distribution profile of 2,5-dimethoxy-4-bromoamphetamine (DOB) in rats after oral and subcutaneous doses

2,5-Dimethoxy-4-bromoamphetamine (DOB) is one of the potent hallucinogenic phenylalkylamines, whose ingestion has already caused several deaths reported all over the world. However, there is unsufficient information on DOB properties based on controlled pharmacokinetic studies available. The aim of this study was to clarify the distribution profile of DOB and its phenolic metabolite 2-methoxy-5-hydroxy-4-bromoamphetamine (2M5H4BA) in blood and biological tissues of experimental rats. The rats were administered a 20 mg/kg dose of DOB·HCl by oral ingestion or subcutaneous injection. Plasma and brain, liver and lung tissues were collected at 0.5, 1, 2, 4, 8, 16, and 32 h after dosing (three animals per time point). The samples were prepared by a liquid–liquid extraction procedure and the extracts were assayed by GC–MS. After per oral application, DOB peak plasma level of 320 ng/mL was reached after one-hour post dosing as well as 2M5H4BA peak concentration of 203 ng/mL. A rapid phase of DOB absorption, 2M5H4BA formation and their tissue distribution during the first two hours after application were followed by a slow decrease rate of the elimination process until 32 h. After subcutaneous application, high plasma levels of the unchanged parent drug and relatively reduced formation of its metabolite 2M5H4BA were observed. DOB maximum plasma concentration of 1143 ng/mL was reached after one-hour post application, whereas its metabolite peak level after 8 h was 213 ng/mL. The concentration profiles of both compounds in plasma after per oral and subcutaneous administration revealed the existence of significant first pass effect after per oral administration that significantly affected DOB bioavailability. DOB tissue concentrations exceeded plasma and the highest values were found in the lungs, where drug accumulation occurred with prolonged retention till 32 h after subcutaneous dose. Although the plasma/tissue transfer was more effective for the lipophilic parent drug than for its hydroxylated metabolite 2M5H4BA, the metabolite tissue levels were significant. The hallucinogenic potential of 2M5H4BA appearing in brain remains unclear as nothing is known about its pharmacological activity at present.     

Sudden death due to a paraganglioma of the organs of Zuckerkandl

A 20-year-old woman died suddenly in a hospital emergency room after presenting with nausea, vomiting, back pain, and hypertension. At autopsy, an extra-adrenal pheochromocytoma (paraganglioma) of the organs of Zuckerkandl was found, with microscopic focal myocardial necrosis similar to that described in death from adrenal pheochromocytomas. Tumors of the organs of Zuckerkandl are extremely rare; less than 100 such cases have been reported in the world's literature, and only six, including the present case, have presented as a sudden, unexpected death. The symptoms of catecholamine storm may mimic those of acute drug intoxications, leading to misdiagnosis by both clinical physicians and pathologists.     

Peroxidase activity in traumatic skin lesions

Peroxidase activity was determined in experimental compression-excoriation lesions and incision wounds of rat skin after different periods of vital time. The peroxidase enzyme was extracted from the tissues by homogenization in 0.5% cetyltrimethylammoniumbromide, and the enzyme activity was measured from the supernatant by o-dianisidine-H2O2 assay. In the blood of the rats a mean activity of approx. 5.26 +/- 1.11 U/g dry weight was observed. In the control specimens of the skin the activity was very low and generally below the detection limit of the methods used. In 30-min-old compression-excoriation lesions the mean peroxidase activity was 0.38 +/- 0.21 U/g dry weight. In lesions older than 30 min the activity started to increase rapidly. In 4-h-old compression-excoriation lesions it was 10 times higher than the 30-min level and was 40 times higher in 12-h-old lesions and 70-100 times higher in 1-3-day-old compression-excoriation lesions, respectively. In 30-min-old incision wounds the mean peroxidase activity was 0.65 +/- 0.37 U/g dry weight. The increase of the activity compared with the 30-min level was even faster in the incision wounds: in 4-h-old wounds the mean activity was 50 times higher, in 12-h-old wounds 200 times higher and in those of 1-5 days it was several hundreds of times higher. Compression-excoriation lesions made after death showed activity similar to the control specimens. Postmortem autolysis at +22 degrees C resulted in a loss of the enzyme activity in 1-day-old compression-excoriation lesions so that after 3 days approx. 80% remained, and after 5 and 7 days approx. 40% was present. After 3 days of autolysis at +4 degrees C, nearly 100% of the activity remained and approx. 90% was present after 5 and 7 days of autolysis. Increased peroxidase activity was also detectable in human vital excoriations in the specimens which were taken in autopsies several days postmortem.