Effect of History and Context on Forensic Pathologist Interpretation of Photographs of Patterned Injury of the Skin

In a previous study, a survey‐based analysis of pathologist diagnoses of patterned injury was performed. Subjects were provided with photographs of “classic” injuries and asked to diagnose the lesion in the absence of history or context. There was a relatively low diagnostic consensus among respondents. A second survey suggested that the disparate answers were not due to a strong belief in different diagnoses, but instead reflected how the respondents dealt with ambiguity. A third survey was created that asked participants to evaluate patterned injuries of the skin, but provided history and contextual information. The addition of history and contextual information increased consensus from a median of 80% to 98% on a per‐question basis. Confidence increased from a median of 56%–92%. These results demonstrate the importance of history and context in medical diagnosis of patterned injuries of the skin.     

Forensic Pathologist Consensus in the Interpretation of Photographs of Patterned Injuries of the Skin

Forensic pathologists are commonly asked to evaluate injuries on the basis of photographs. Members of the National Association of Medical Examiners were asked to participate in an online survey in which they were presented with 68 patterned injuries of the skin and asked to make a diagnosis ranging from very general (e.g., “blunt” vs. “sharp”) to specific (e.g., “baton blow”). This was not the case. Consensus for general diagnosis averaged 0.77 and 0.72 for specific diagnosis. While there was a strong correlation between consensus and confidence in aggregate, individual correlations were poor. Consensus diagnosis was inversely correlated with age, and positively correlated with jurisdictional size, medical degree, and whether or not the respondent was actively performing autopsies as a job function. A subsequent survey is exploring possible reasons for lack of consensus in low‐consensus questions. The high correlation between confidence and consensus at the aggregate level and low correlation at the individual level may have implications for quality assurance protocols.     

Self‐Embedding Behavior in Adults: A Report of Two Cases and a Systematic Review

Self‐embedding behavior (SEB) is the repeated insertion of sharp objects, such as needles or pins, into the soft tissues of abdomen, limbs, and other body parts. In this study, two cases of SEB were reported and the scientific worldwide literature reviewed. Thirty‐two cases of SEB were identified through systematic searches in the main bibliographic databases. Mean age was 35 years (SD = 8.97). Just over two‐thirds of the patients were female. Although the number of embedded objects could be as high as 200, major clinical and surgical complications were uncommon and mortality was null. Patients with SEB presented three major diagnoses: psychotic (25%), personality (21.9%), and factitious (28.1%) disorders. The practice of SEB largely went undetected as the patients themselves did not bring it to the attention of family members or physicians and usually denied they have engaged in SEB. A high level of suspicion is required to avoid a missed diagnosis.     

90例医疗纠纷尸检分析

目的分析、讨论医疗纠纷中法医病理学尸体解剖的重要性。方法收集温州医学院法医学系2001—2008年涉及医疗纠纷尸体解剖案例90例,按照死者年龄、性别、死亡原因及临床诊断和法医病理诊断等要素进行分类整理和分析。结果死者年龄从新生儿至72岁,男女比例为1∶1,医院级别以县级医院较多（30例,33.33%）,临床诊断与法医病理死因诊断符合率为33.33%。结论尸体解剖对涉及死亡的医疗纠纷的正确处理和防范有重要作用。     

The Difficult Task of Diagnosing Prostate Cancer Metastases on Dry Bone

The interpretation of pathology on skeletal remains is mandatory for implementing the biological profile and for disease recognition. Prostate cancer is one of the most common tumors, with a high preference for the skeleton as a primary site of metastasis. Its diagnosis on bone is however still ambiguous, due to its “osteoblastic” and resorptive manifestation. This study investigates distribution and appearance of prostate cancer metastases on dry bone on six known cases (selected from the Milano Cemetery Skeletal Collection) and one healthy individual. A macroscopic inspection was performed highlighting the abnormalities observed, describing location, shape, dimension, and aspect. A great amount of proliferative and mixed lesions was noticed, but also cases of pure lytic lesions were displayed. The multiple appearances of the manifestations observed display the difficulty in correctly identifying such a pathology, but also the potential and advantages provided by investigating a study sample with known antemortem history.     

Computer‐aided Dental Identification: An Objective Method for Assessment of Radiographic Image Similarity*

Abstract: A pilot study evaluated a computer‐based method for comparing digital dental images, utilizing a registration algorithm to correct for variations in projection geometry between images prior to a subtraction analysis. A numerical assessment of similarity was generated for pairs of images. Using well‐controlled laboratory settings, the method was evaluated as to its ability to identify the correct specimen with positive results. A subsequent clinical study examined longitudinal radiographic examinations of selected anatomical areas on 47 patients, analyzing the computer‐based method in making the correct identification based upon a threshold level of similarity. The results showed that at a threshold of 0.855, there were two false negative and two false positive identifications out of 957 analyses. Based on these initial findings, 25 dental records having two sets of full mouth series of radiographs were selected. The radiographs were digitized and grouped into six anatomical regions. The more recent set of films served as postmortem images. Each postmortem image was analyzed against all other images within the region. Images were registered to correct for differences in projection geometry prior to analysis. An area of interest was selected to assess image similarity. Analysis of variance was used to determine that there was a significant difference between images from the same individual and those from different individuals. Results showed that the threshold level of concordance will vary with the anatomical region of the mouth examined. This method may provide the most objective and reliable method for postmortem dental identification using intra‐oral images.     

Context Effects in Forensic Entomology and Use of Sequential Unmasking in Casework

Context effects are pervasive in forensic science, and are being recognized by a growing number of disciplines as a threat to objectivity. Cognitive processes can be affected by extraneous context information, and many proactive scientists are therefore introducing context‐minimizing systems into their laboratories. Forensic entomologists are also subject to context effects, both in the processes they undertake (e.g., evidence collection) and decisions they make (e.g., whether an invertebrate taxon is found in a certain geographic area). We stratify the risk of bias into low, medium, and high for the decisions and processes undertaken by forensic entomologists, and propose that knowledge of the time the deceased was last seen alive is the most potentially biasing piece of information for forensic entomologists. Sequential unmasking is identified as the best system for minimizing context information, illustrated with the results of a casework trial (n = 19) using this approach in Victoria, Australia.     

Influenza A/H1N1 (2009) Infection as a Cause of Unexpected Out‐of‐Hospital Death in the Young*

Abstract: In March 2009, a new strain of influenza A/H1N1 virus was identified in Mexico, responsible for a pandemic. Worldwide, more than 13,500 patients died, most often from acute respiratory distress syndrome. Because sudden death cases were rare, involving mostly young apparently healthy persons, influenza A/H1N1 (2009)‐related deaths may be misdiagnosed, which can raise medico‐legal issues. Case history: we report on an unexpected out‐of‐hospital death involving a young male with no past medical history and no vaccination. Fever was his only symptom. Laboratory tests: histology showed patchy necrotic foci with mononuclear inflammation in the lungs. The heart was histologically normal, but virological analyses using molecular biology on frozen myocardial samples showed high virus load. In conclusion, this case report shows that influenza A/H1N1 (2009) virus can be a cause of sudden cardiac death in the young and demonstrates the importance of quantitative virological analyses for the diagnosis of myocarditis.     

Profile of Hospital Admissions due to Self‐Inflicted Harm in Los Angeles County from 2001 to 2010

We aimed to describe the demographic profile of self‐inflicted harm (SIH) in Los Angeles County between 2001 and 2010 and to investigate trends over this 10‐year period. We used the California Hospital Discharge Data to investigate all cases of hospital admission due to SIH, including suicide attempts and if they had a concurrent psychiatric diagnosis based on ICD‐9 codes. African‐Americans (AA) had the highest 10‐year SIH admission rates. SIH admission rates remained steady throughout the 10‐year study period. Median age of SIH was significantly lower in Latinos. Episodic mood disorders were the most common psychiatric comorbidity. The use of solid/liquid poisoning was the most common SIH method among all racial/ethnic groups. We found major disparities in SIH admissions across racial/ethnic subgroups. The importance of programs to identify, prevent, and treat SIH in these groups is discussed.     

The Forensic Confirmation Bias: A Comparison Between Experts and Novices

A large body of research has described the influence of context information on forensic decision‐making. In this study, we examined the effect of context information on the search for and selection of traces by students (N = 36) and crime scene investigators (N = 58). Participants investigated an ambiguous mock crime scene and received prior information indicating suicide, a violent death or no information. Participants described their impression of the scene and wrote down which traces they wanted to secure. Results showed that context information impacted first impression of the scene and crime scene behavior, namely number of traces secured. Participants in the murder condition secured most traces. Furthermore, the students secured more crime‐related traces. Students were more confident in their first impression. This study does not indicate that experts outperform novices. We therefore argue for proper training on cognitive processes as an integral part of all forensic education.     

Coincidence of Nicolau Syndrome and Rhabdomyolysis: Report of a Forensic Autopsy Case and Review of the Literature

Nicolau syndrome (NS) is a dermatological adverse reaction of intramuscular injections and is caused by several mechanisms. The etiopathogenesis remains unclear, and several hypotheses have suggested a vascular origin. Rhabdomyolysis (RM) is the destruction of striated muscle, with the subsequent release of muscle cell contents into circulation. NS and RM diagnoses may overlap. Herein, we present the autopsy findings of a 40‐year‐old female with NS complicated with RM. On clinical follow‐up, creatine kinase (CK) was 7146 IU/L, and urea and creatinine levels were elevated on the third day after intramuscular diclofenac injection. Possible ischemic process triggered the RM and subsequent acute renal failure. The opportunity for an early diagnosis was missed because the patient delayed seeking medical aid. The prognosis worsened, and the patient died due to secondary sepsis. Early diagnosis of NS before the occurrence of complications is the most important issue in patient education and can be life‐saving.     

Spontaneous Coronary Artery Dissection: Case Report and Literature Review

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction and sudden cardiac death. It occurs most commonly in otherwise healthy women during pregnancy or the postpartum period. The true incidence of SCAD is underestimated, as most cases are diagnosed at autopsy. The pathophysiology of SCAD is still not fully understood, and its management can be challenging. This report describes a 35‐year‐old pregnant female who presented with an acute antero‐lateral ST elevation secondary to spontaneous dissection of the left anterior descending artery and the circumflex artery. The diagnosis was established by coronary artery angiography. However, the patient died following cardiac tamponade. The examination of this case represented a starting point for the reviewing of the diagnosis, clinical course, and management of SCAD, and for the placing of this in context with the existing literature. This study highlights the importance of prompt diagnosis and subsequent lifesaving treatment.     

Bestiality in Forensically Committed Sexual Offenders: A Case Series

Although bestiality has occurred since prehistoric times, it remains a poorly understood aspect of human sexuality. Prevalence studies in the mid‐20th century suggested that bestiality was a relatively common phenomenon. Since that time, researchers have studied bestiality among specific populations, including self‐identified “zoophiles” and inmates who report a history of bestiality. Findings from inmate research suggest that bestiality may represent a risk factor for future interpersonal violence. This study presents a case series of bestiality among sexual offenders committed under forensic commitment schemes. The case series demonstrates the range of animal partners, sexual acts, and comorbid paraphilic and nonparaphilic diagnoses in individuals who report a history of bestiality. In addition, it helps clarify potential motivations for sex with animals and how such motivations may influence the forensic psychiatric assessment of offenders who have sex with animals.     

Homicide by a Forensic Female Sample in Brazil: A Preliminary Study

The objective of the study was to evaluate the mental status of all women (n = 14) who were acquitted by reason of insanity of charges of murder or attempted murder and committed to a forensic psychiatric hospital in the state of Rio de Janeiro, Brazil. All cases were retrospectively examined, including medical files, technical records, and forensic experts' official reports. A conclusive psychiatric diagnosis was established using the Structured Clinical Interview for DSM‐IV Axis I and II Disorders and clinical and forensic records. The most common diagnosis was schizophrenia/schizoaffective disorders (n = 8; 57.3%). Most victims (n = 12; 75%) were close relatives of the patients. We found that 43% (n = 6) of the patients had a previous history of violent behavior. According to the initial psychiatric forensic evaluation, 5 patients (35.7%) had psychotic symptoms. It is expected that a growing understanding of motivational factors underlying homicidal behavior in mentally disturbed female offenders may further the implementation of effective preventive and therapeutic interventions.     

Morphologic patterns of lip prints in a portuguese population: a preliminary analysis

Lip prints are thought to have the ability to distinguish individuals and, hence, have a potential use in human identification purposes. However, questions remain regarding their utility for sex determination. This study aimed to classify lip prints for different individuals in a Portuguese population and to determine whether sex differences exist. Lip prints of 25 females and 25 males were obtained using dark-colored lipstick and cellophane tape. Lip prints were analyzed using a magnifying lens and classified according to the Suzuki and Tsuchihashi classification. A Type II pattern was found to be most common. A comparison of lip-print patterns between males and females showed results with a statistically significant difference: Type III pattern was most common in males, and a Type II pattern in females. This study corroborates the hypothesis that lip prints are able to distinguish individuals and may be useful in sex determination.     

Increased risk of fatal intoxication and polypharmacy among psychiatric patients at death

Patients suffering from psychiatric disorders have an excess mortality and a shorter life span expectancy compared to the general population. Furthermore, they are treated with multiple drugs and are known to have an increased risk of drug abuse. In this study, we aimed at investigating the pharmaceutical drug and drug of abuse profiles of the deceased included in the Danish prospective autopsy‐based forensic study on psychiatric patients, SURVIVE. Using the postmortem systematic toxicological analysis results, we identified 129 different consumed compounds in our population (n = 443). Polypharmacy (≥5 compounds) was detected in 39.5% of the deceased. Deceased with a psychiatric diagnosis or who died from a fatal intoxication had significantly more compounds at the time of their death compared to having either no psychiatric diagnosis or another cause of death, respectively. Evidence of drug abuse was present, as 29.8% of our total population had consumed either methadone or illicit drugs of abuse, excluding tetrahydrocannabinol. Of those deceased with a psychiatric diagnosis, 33.6% had either consumed methadone or illicit drugs of abuse, a greater number than those without a psychiatric diagnosis. Fatal intoxication was the most frequent cause of death (40.6%) with methadone as the major intoxicant. Here, we found that those without a psychiatric diagnosis had fewer fatal pharmaceutical drug intoxications compared to the psychiatric diagnosis groups. Our findings add further context to understanding the excess mortality of psychiatric patents, since there is an increased occurrence of fatal intoxication, polypharmacy, and drug abuse in this population.     

Skeletal Indicators of Shark Feeding on Human Remains: Evidence from Florida Forensic Anthropology Cases

This research examines a series of six Florida forensic anthropology cases that exhibit taphonomic evidence of marine deposition and shark‐feeding activities. In each case, we analyzed patterns of trauma/damage on the skeletal remains (e.g., sharp‐force bone gouges and punctures) and possible mechanisms by which they were inflicted during shark predation/scavenging. In some cases, shark teeth were embedded in the remains; in the absence of this evidence, we measured interdental distance from defects in the bone to estimate shark body length, as well as to draw inferences about the potential species responsible. We discuss similarities and differences among the cases and make comparisons to literature documenting diagnostic shark‐inflicted damage to human remains from nearby regions. We find that the majority of cases potentially involve bull or tiger sharks scavenging the remains of previously deceased, adult male individuals. This scavenging results in a distinctive taphonomic signature including incised gouges in cortical bone.     

Carbon Monoxide Poisoning and Death in a Large Enclosed Ventilated Area

A 55‐year‐old man with a medical history of tobacco use suddenly collapsed while power washing an empty indoor pool in a hotel. The decedent was transported to the local hospital where he was pronounced. A postmortem examination revealed atherosclerotic heart disease and bilateral pulmonary edema and congestion. A postmortem blood carbon monoxide (CO) level was 27% saturation, and a CO performed on hospital admission blood was 49% saturation. CO poisoning is a common cause of toxicological morbidity and mortality in the United States. The circumstances most often occur in an enclosed environment and may be intentional or unintentional. CO poisoning has been reported in open, well‐ventilated spaces, but rarely results in death. A warning label was present on the engine clearly stating the dangers of CO emission. However, there was a false sense of security due to the large size of the pool room and the presence of industrial blowers that were being used for ventilation.