Sudden unexpected death from cardiac concussion (commotio cordis) with unusual legal complications

Sudden and unexpected death may result from cardiac concussion following blunt force trauma to the thorax. Undiagnosed pathologic disease must be carefully evaluated as a possible contributory element. Legal complications may arise from any autopsy. It is recommended that a photograph be taken upon completion of the autopsy. This photograph and adequate records can be used to refute any charges against the pathologist or assistants for the poor condition of a body after its release.     

Use of Craniofacial Superimposition in Historic Investigation

A skeleton discovered in Grand Forks, North Dakota was purported to belong to Clelland “Clell” Miller, a James‐Younger gang member, who was killed during the Northfield Bank robbery on September 7, 1876. A 3‐D image from a computer tomography (CT) scan of the skull was obtained, and a craniofacial superimposition was conducted to determine if the skull could belong to Miller. The superimposition method used in this case was to overlay the CT image of the skull onto Miller's postmortem photograph. In addition to the craniofacial superimposition, the images were juxtaposed to compare similarities or differences in facial morphology between the skull and photograph. Superimposition methods can be used to exclude identifications; however, they should not be used as a conclusive method for identification. In this case, there were sufficient similarities between the skull and Miller's photograph; therefore, the skull could not be eliminated as possibly being that of Miller.     

Identification procedures as a part of death investigation in Turkey

Forensic identification techniques include the examination of ID cards, the decedent's private belongings, fingerprints, footprints, lip marks, dental findings, red blood cell enzymes, performing photograph matching, facial reconstruction, visual identification, and DNA "fingerprinting." As part of forensic examinations, the identification of corpses that are fresh, decomposed, fragmented, or skeletonized as well as individual body parts and human remains can be requested. Identification becomes a challenging task for forensic terms particularly in mass-disaster situations. Each identification case should be considered to its own merit and the way to do that should be based on the effectiveness and cost of each method used. In Turkey, one of the major duties of the medicolegal system on the investigation of deaths is to identify the deceased if unknown.This study is undertaken to investigate the procedures, as well as their validities, used to deal with individualization of dismembered bodies directly sent to the Council of Forensic Medicine, Ministry of Justice, for autopsy and/or visual identification, as well as those received from peripheral districts for forensic identification. According to the Turkish Penal Procedural Law, a positive identification of the deceased is mandatory before performing an autopsy. According to the law, the ID cards are not taken to be sufficient for recognition of the deceased, and the major way of identification in daily practice is visual identification by a relative or any recognizant person to approve the identification to the prosecutor. If visual identification fails, fingerprints, dental x-rays or body x-rays, and DNA "fingerprinting" can be used to establish identity when compared with known records of the individual obtained by law enforcement.This retrospective study was carried out into 421 dismembered bodies, among 3063 autopsies performed in year 2002 by the Department of Morgue at the Council of Forensic Medicine, with particular insight into the identification procedures undertaken and their results. The overall negative identification rate was 30.4%, and in 1% of the cases, the visual identification by relatives were not confirmed by DNA identification and taken as misidentified.     

医疗纠纷法医学鉴定质量评价模型的建立

目的建立医疗纠纷法医学鉴定质量评价模型。方法收集同济医学院法医学系近10年410例涉及医疗纠纷的法医学鉴定的案例,对影响医疗纠纷法医学鉴定质量的10个关键指标,运用SAS软件进行了主成分分析。结果通过统计学分析,筛选出6个能反映所有原指标变量主要信息的主成分,并依此结果推算出评价法医学系医疗纠纷的鉴定质量评价模型。结论在建立“医疗纠纷鉴定质量管理体系”时,应按影响鉴定质量的主成分设计相应的对策。     

Sickle Cell Trait as a Contributory Cause of Death in Natural Disease

Sickle cell trait (SCT) affects 300 million people globally, and awareness is growing that SCT is not an entirely benign condition; however, most reported cases have been non‐natural deaths. Autopsy records from the Baylor University Medical Center (BUMC) in Dallas, Texas, contained seven natural deaths from January 2007 to October 2013 in which micro‐occlusive sickling was identified at autopsy and SCT confirmed by postmortem hemoglobin fractionation. Sickle crisis was never diagnosed clinically. These cases illustrate the importance of red cell morphology in autopsy material. When sickling is suspected, hemoglobin fractionation should be performed. If confirmed, SCT should be listed as an autopsy finding and the severity and distribution of sickling documented. Extensive micro‐occlusive sickling should be considered contributory to death; however, its relative importance depends on all facts of the case. Accurate reporting should facilitate further research and the development of evidence‐based preventative and supportive strategies for these patients.     

A methodology for near-optimal computational superimposition of two-dimensional digital facial photographs and three-dimensional cranial surface meshes

The authors present a methodology for human identification based on digital superimposition techniques. This methodology computes a fast, near optimal fit between a three-dimensional skull surface mesh and a two-dimensional digitized facial photograph. Since this is done digitally, (1) the photograph can be enhanced to reduce or eliminate motion blur, overexposure or underexposure, and out-of-focus distortions; (2) previous problems with skull/photograph scaling and alignment are minimized or eliminated; and (3) the photograph and skull can be numerically correlated. Two of several test cases produced from an implementation of this methodology are also presented.     

Sudden death due to malignant hyperthermia

A case of sudden death in a young athlete, most likely the result of malignant hyperthermia, is reported. This diagnosis was entertained at autopsy and later confirmed by muscle biopsy on the father of the deceased, who was proven to be susceptible to malignant hyperthermia. The condition should be strongly suspected at autopsy in unexplained sudden deaths of young adults occurring during exercise or under stress.     

Bodies found in the water. An investigative approach

The determination of the cause of death of a person whose body is found in the water requires careful investigative work on the part of both police and pathologists. Opinions as to cause and manner of death should not be derived from the autopsy alone but must result from a logical correlation of data regarding victim identity, circumstances, autopsy, and laboratory findings.     

Primary intimal sarcoma of the pulmonary artery misdiagnosed as pulmonary thromboembolism: A case confirmed at medicolegal autopsy

Misdiagnosed PAS confirmed at medicolegal autopsy Pulmonary artery sarcoma (PAS) is a rare disease and usually indistinguishable from acute or chronic thromboembolic disease of the pulmonary arteries. We present a case of pulmonary artery sarcoma in a 54‐year‐old male, who was clinically misdiagnosed as pulmonary thromboembolism. The patient died of disease; however, the actual diagnosis of PAS was made after a medicolegal autopsy. PAS can be a diagnostic challenge for both clinicians and pathologists. In an autopsy case with a clinical suspicion of pulmonary thromboembolism, if there is an abnormal gross appearance in the pulmonary artery, the forensic pathologist should have a high index of suspicion of PAS, which should be ruled out by a histopathologic examination.     

Discrimination between functions of an expert bureau and a burial firm (topic for discussion)

The authors suggest measures aimed at discrimination of the functions performed by forensic medical experts and the services rendered by burial firms. The responsibilities of pathology departments of hospitals and bureaus of forensic medical expert evaluations, which should be reflected in official documents, should be confined to manipulations needed to solve the professional problems and removal of sections. Cases when utilization of certain chemicals or manipulations aimed at restoration of the body are prohibited should be listed in detail. The order of transfer of the body from pathology department or forensic medical bureau to the burial firm and to relatives should be regulated with consideration for the results of autopsy. The moment of the end of autopsy studies is to be determined.     

Sudden death caused by hydatid embolism

An 18-year-old man died on the spot during a foot race. Previously, he had been in a healthy condition. Since the cause of his sudden death was unknown, a forensic autopsy was carried out. The autopsy revealed hydatid cysts in the right ventricle of the heart some of which had embolized the pulmonary arteries. In case of sudden death in endemic areas the possibility of a hydatid disease should be taken into consideration.     

Myocardial Bridging: A Meta‐Analysis of Prevalence

The main objective of this article was to analyze prevalence data about myocardial bridging (MB) in published studies. To this purpose, we performed a meta‐analysis of studies published in English literature that contained data about the prevalence of MB and its anatomical characteristics. The overall prevalence was 19% (CI: 17–21%); autopsy studies revealed an overall prevalence of 42% (CI: 30–55%), CT studies 22% (CI: 18–25%), and coronary angiography 6% (CI: 5–8%). Most bridges were located on the left anterior descending artery (82% overall, 63% on autopsy studies), had a mean thickness of 2.47 mm and a mean length of 19.3 mm. In conclusion, autopsy studies should be the gold standard in evaluating the actual prevalence of myocardial bridges, while in vivo high‐resolution CT scanning should be preferred to coronary angiography studies.     

Marfan syndrome presenting as aortic rupture in a young athlete: sudden unexpected death?

A 20-year-old man had a spontaneous rupture of the ascending aorta while exercising. The diagnosis of Marfan syndrome, established by the gross and microscopic autopsy findings, was further supported by review of the autopsy report of the father, who had died at age 26 of a nearly identical aortic rupture. To avoid occurrences such as the above, the responsibility of the forensic pathologist should extend beyond the autopsy to appropriate counseling of families in instances where medically treatable hereditary conditions may be present in the survivors.     

Post-mortem radiological examination in infants:: Evidence of child abuse?

We examined the value of post-mortem radiological examination of infants who were brought in for medico–legal autopsy. Twenty children between the age of 1 month and 15 months died under the picture of SIDS. No radiological or other signs of previous child abuse were seen in our autopsy material. A fatal case of child abuse with several metaphyseal fractures is reported. Some fractures were not visible on gross examination, but could be demonstrated by radiography and histology. In our material no association between SIDS and child abuse was found. In suspected cases of child abuse, particularly rib fractures and metaphyseal fractures should be sought. We recommend that post-mortem radiography is performed in such cases. If fractures are demonstrated, they should be verified by histologic examination.     

Neuropathology of human immunodeficiency virus infection: a forensic autopsy study in Dar Es Salaam, Tanzania

The objective of this study was to examine the neuropathological changes in the brain of patients infected with human immunodeficiency virus (HIV) in the Tanzanian capital Dar Es Salaam, and investigate whether the prevalence of different forms of HIV-related neuropathology varies from other countries. The subjects were patients with risk factors for HIV infection in whom forensic autopsies were performed between 1997 and 1999. In Dar Es Salaam, forensic autopsy constitutes more than 90% of all autopsies, because hospital autopsy is limited due to socio-cultural and religious reasons. HIV infection was identified in 52 of 143 patients selected from forensic autopsies. Neuropathological findings were observed in 31 of 52 HIV-infected patients; these include lymphocytic meningitis 19, bacterial meningitis 3, tuberculous brain abscess 3, cryptococcal meningitis 3, basal ganglia calcification 3, and toxoplasma encephalitis 1. HIV encephalitis, lymphoma, and cytomegalovirus encephalitis could not be found in this study. Whereas the findings should be interpreted cautiously because of possible autopsy bias and a low percentage of cases examined compared to the total number of HIV-infected patients in Tanzania, our observations provide information on the likely diagnostic possibilities to be considered in the evaluation and management of HIV-infected patients with neurological symptoms in Tanzania. In the face of decreased hospital autopsy, most studies have focused mainly on the end-stage HIV disease; forensic autopsy is a potential source of materials for studies on HIV disease spectrum at different stages.     

Osler-Weber-Rendu syndrome--pathological manifestations and autopsy considerations

An 18-year-old university student with Osler-Weber-Rendu disease collapsed in the bathroom. Attempted resuscitation was unsuccessful. Her past history included recurrent epistaxes, mucosal telangiectasias, intracranial arteriovenous malformations with previous hemorrhage, a single pulmonary arteriovenous malformation, recent onset of grand mal seizures, and depression. There was a positive paternal family history. At autopsy the pulmonary arteriovenous malformation was confirmed. In addition, within the brain there were widespread areas of gliosis with hemosiderin deposition and small vascular malformations. No other significant abnormalities were detected and toxicological screening revealed only moderately elevated levels of carbemazepine. Death was attributed to epilepsy associated with glial scarring from previous microhemorrhages. The detection of vascular malformations in the lung or brain at autopsy should prompt careful examination of all tissues for similar lesions. Given the possibility of Osler-Weber-Rendu disease in such cases, fibroblast cultures should be undertaken to enable molecular studies to proceed. The heritable nature of this disorder necessitates accuracy of diagnosis at autopsy; once the diagnosis is confirmed family screening should be recommended.     

论我国法医尸体检验制度的改革

我国法医尸体检验存在体制设置不合理、侦查机关可裁量启动、尸体检验过程中权利保护不足和专家见证使用混乱等主要问题。我国应从犯罪控制、程序公正和摒弃部门利益原则出发,以法治国家成熟经验为参考,改革我国法医尸检体制、设置强制尸检制度和强化尸检过程的权利保护。     

Findings in newborns of cocaine-abusing mothers

Cocaine has recently been shown to affect the outcome of pregnancy when taken by pregnant women. The authors measured fetal concentrations of cocaine and benzoylecgonine and reviewed autopsy and historical data for 62 successive infants who died at less than two days of age and were seen at the Los Angeles County Office of the Chief Medical Examiner-Coroner. Of 43 infants without an obvious cause of death at autopsy, cocaine or benzoylecgonine or both were present in 40%. None of the parameters studied predicted which infants would show cocaine or benzoylecgonine. We conclude that cocaine and benzoylecgonine concentrations should be measured on all infants who die at less than two days of age when the cause of death is not evident at gross autopsy.     

Computer analysis of face and skull size by "quantitative verbal portrait" method

The aim of this study was to develop a "quantitative verbal portrait" method on the basis of universal measured signs of the face and skull. The database includes 90 cases with expert evaluation of photocompatibility with proven identity. Four groups of signs were investigated: DX and DY--the width and height between accurately fixed concrete craniometrical (facial) points and the so-called RX and RY indices--the ratio between distances within the framework of the same direction. The proposed scheme of evaluation helps compare the photograph of a live human and the skull. For evaluating the degree of identity, one should have a summary characterization of all selected signs for the skull and compare it with the sum on the photograph; sometimes it is possible to rule out the identity of the photograph and the skull by the absolute size, e.g., a very large skull cannot belong to a human with a very little face. The score for each group of signs is used for analysis of the information for detecting the similarities. Accumulation and comparative analysis of two information flows are possible: database on portraits of lost subjects and database on graphic images of the skulls of unidentified corpses.     

Lessons Learned from Autopsying an Unidentified Body with Iodine‐125 Seeds Implanted for Prostate Brachytherapy

We report here lessons learned from an autopsy case involving radioactive materials. We performed an autopsy of an unidentified mummified man with no available medical history whom from imaging findings we suspected had received radioactive seed implants for prostate brachytherapy. We returned the excised prostate and seeds to the body. A few days later, the body was identified by DNA matching and cremated. According to the man's medical record, he had undergone iodine‐125 seeds implantation for prostate cancer 11 months earlier. We should have removed the radioactive seeds from the body to prevent radiation exposure to the bereaved family and/or environmental pollution due to cremation. Surprisingly, one seed was found in the stored prostate specimen. Forensic experts should be cognizant of the risk of both radiation exposure in the autopsy room and environmental pollution. We must remain abreast of the latest advances in medicine.