Day-of-the-week variation of sudden unexpected cardiac death.

Background: There has been some controversy about the day-of-the-week (septadian) variation of unexpected sudden cardiac death (SCD). Methods: We evaluated the incidence of unexpected SCD on different days of the week in a consecutive series of 5869 SCD victims from Northern Finland [the FINGESTURE study (Finnish Genetic Study of Arrhythmic Events)]. As it is mandatory in Finland, a medico-legal autopsy was performed on all unexpected sudden death victims. The autopsies were performed between the years 1998-2017. Results: The mean incidence of unexpected SCD was higher at weekends (during the days from Friday to Sunday, peaking on Saturday) than during the days from Monday to Thursday (8.54 ± 0.72 vs. 7.22 ± 0.19 SCDs per day of the week per 100,000 inhabitants per year, p < 0.001). Regardless of sex or ischemic versus non-ischemic etiology of SCD, the distribution of the occurrence of SCD among the days of the week was similar compared with the whole SCD cohort. Conclusion: The incidence of unexpected SCD was highest at weekends (during the days from Friday to Sunday, peaking on Saturday).

Pattern of suspicious deaths of married females brought for medico-legal autopsy at teaching institute of India.

Background: Death is unnatural and suspicious when it is caused by external causation like injury or poisoning or other than natural course. In such deaths of married females, the inquest is carried out, and a medico-legal autopsy is conducted to ascertain the cause of death and manner of death. Materials and Methods: This record-based, retrospective study was carried out at RVRS Medical College, Rajasthan in the year 2021 (1st January, 2021 to 31st December, 2021) to know the pattern of the suspicious death of married females brought for medico-legal autopsy. The inquest report, medico-legal autopsy report, histopathological examination report, and chemical analysis report findings were tabulated and analyzed. Results: The maximum number (31.62%) of female deaths belonged to the age group of 18-22 years of age. A total of 33.82% of females died during a marriage duration of less than 5 years of married life. A total of 22.79% of female deaths were related to dowry and 60.2% of females belonged to rural areas. A total of 59.56% of females were died due to poisoning and 75% of female deaths considered suicidal. Conclusion: Suspicious deaths of married women brought for medico-legal autopsy must be dealt with due to precaution to determine the cause and manner of death. One must be vigilant that the suspicious death of a married female may be associated with dowry in the Indian scenario.

External challenges for specialists dealing with forensic autopsies.

BACKGROUND: In addition to poor infrastructure, and human resource constraints, forensic medicine specialists in developing countries face many external challenges. OBJECTIVES: We aimed to investigate the prevalence, type, and source of external challenges confronting them including sex, age, religion, deceased's place of residence and the number of accompanying relatives. MATERIALS AND METHODS: This cross-sectional, observational study was conducted between August 2020 and July 2022 at the Mortuary of AIIMS, Bhubaneswar with the approval of the ethical committee. RESULTS: Of note, forensic medicine specialists faced external challenges in about one in five cases (20.5%). Most demands were to either minimise the autopsy procedure (n = 65) or to conduct the autopsy at inappropriate times (n = 58). The demands to minimise the autopsy procedure were significantly associated with the deceased's age (p = 0.046), religion (p = 0.010), socioeconomic class (p = 0.020) and manner of death (p = 0.019). CONCLUSIONS: Our study found that forensic medicine specialists in India face significant external challenges. Avoiding unnecessary complete autopsies, implementing night autopsies, and embracing minimally invasive autopsies are recommended to mitigate these challenges.

The utility of histology in assessing the cause of death in medico-legal autopsies in selected trauma deaths: Suspension-, immersion-, fire-, and traffic-related.

The goal of a medico-legal autopsy is primarily to determine the cause and manner of death. To this end, the pathologist often uses auxiliary analyses, including histology. However, the utility of routine histology in all medico-legal autopsies is unknown. Earlier studies on the utility of routine histology have shown inconsistent effects, with some studies recommending it and others rejecting it. To study the degree to which histology informs on the underlying cause of death, we sent autopsy reports from suspension-, immersion-, fire-, and traffic-related deaths to senior board-certified forensic pathologists and had them assess the cause of death, first without knowledge of the histological findings and then with knowledge thereof. Fifty cases were identified in each of four subgroups: fire-, immersion-, suspension-, and traffic-related deaths. The autopsy reports were anonymized, and the histological findings and conclusions were removed. Two board-certified forensic pathologists independently reviewed the reports in each subgroup and assessed the manner and underlying cause of death (including their certainty of this assessment on a five-level scale) with and without access to histological findings. The probability of changing the underlying cause of death posthistology was low in all study groups. There was a slight increase in the degree of certainty posthistology in cases where the underlying cause of death was not changed, but only when the antehistology certainty was low. Our results suggest that histology does not meaningfully inform on the underlying cause of death in suspension-, immersion-, fire-, and traffic-related deaths except when antehistology certainty is low.

Seasonal variation in medico-legal autopsies in Finland-a nationwide analysis of the period 2016-2021.

Both natural and unnatural mortality have seasonal variation. In spite of the established link between season and mortality, it is unclear whether medico-legal autopsies are subject to similar variation. Building on a nationwide dataset from the years 2016-2021, this short report aimed to analyse whether medico-legal autopsies are subject to seasonal variation in Finland. An electronic information system was queried for the monthly numbers of performed autopsies. Monthly and yearly trends were estimated with Kruskal-Wallis test and linear regression. A total of 50,457 medico-legal autopsies were performed during the 6-year study period. There were on average 29 to 47 autopsies per day, with an estimated annual decline of 1.8% (95% confidence interval 0.7-2.9%) over the study period. Monthly and yearly variation in autopsies was mostly minor and irregular; statistically significant differences were only observed between January and September as well as January and November (p < 0.05). As such, there appears to be little seasonal variation in medico-legal autopsies in Finland. A mild declining trend in the number of autopsies was observed. Future studies are invited to explore patterns of seasonality in other medico-legal systems, for example in those with generally lower autopsy rates than in Finland.

Postmortem Bacteriology in Forensic Autopsies-A Single Center Retrospective Study in Romania.

Postmortem bacteriology examinations have been a controversial topic over the years, though the value of postmortem bacteriology cultures remains promising. The aim of this study was to review the postmortem bacteriological sampling procedures and results in a single centre in Bucharest over a period of 10 years. Material and methods: The present study was a retrospective, single-center study, performed at the Mina Minovici National Institute of Legal Medicine in Bucharest, Romania, from 2011-2020. Results: Postmortem bacteriology was requested 630 forensic autopsies, 245 female (38.9%) and 385 male (61.1%), age range 0 and 94 years, median age of 52 years. Deaths occurred in hospital for 594 cases (94.3%) and out-of-hospital for 36 cases (5.7%-field case). Blood cultures were requested in the majority of cases, followed by tracheal swabs and lung tissue. In-hospital and out of hospital deaths did not differ significantly regarding the number of microorganisms identified in a positive blood culture. Postmortem bacteriology cultures of the respiratory tract showed a statistically significant association to microscopically confirmed lung infections. Conclusions Postmortem sampling for bacteriology testing in our center in Bucharest is heterogeneous with a high variation of patterns. A positive blood culture result for Staphylococcus species without the identification of a specific microorganism is more likely due to postmortem contamination.

Utility of inquest and medico-legal autopsy in community deaths at tertiary care hospital of India.

Background: In India, inquest is carried out by police or magistrate depending upon the type of death and medico-legal autopsy is carried out by doctor. In some cases, inquest is sufficient to make out necessary information related to death and medico-legal autopsy can be avoided in such death, but medico-legal autopsy has its own value. Materials and Methods: A retrospective record-based study was carried out at RVRS Medical College, Bhilwara, Rajasthan, regarding the correlation of inquest and medico-legal autopsy findings in community deaths which were brought dead to hospital in the year 2020. Results: A total of 467 cases of community deaths were brought dead for medico-legal autopsy in the year 2020. As per inquest, 7.28% died due to hanging, 3.85% died due to burns, 3.43% died due to electrocution, 16.27% died due to poisoning, and the same was established via medico-legal autopsy without any difference from inquest report. After inquest, in 3% of cases, the cause of death remained undetermined, while after the medico-legal autopsy, it was only 0.86%. The manner of death was undetermined in 3% of cases after inquest, while after the medico-legal autopsy, only in 0.86% of cases. Conclusion: We recommend proper training of the investigating officers who conduct inquest to overcome the discrepancies observed between the investigating officer and the doctor in ascertaining the cause of death and manner of death in all unnatural deaths in India. If well-trained person will conduct in depth inquest, then medico-legal autopsies can be avoided in certain types of death.

Prevalence of blood-borne infections in forensic samples: Epidemiology in areas of Chiba, Japan.

OBJECTIVES: To statistically clarify the prevalence and risk factors of infections in forensic autopsy cases in Chiba Prefecture, Japan. The aim was to improve preventive measures against infection in forensic autopsies. METHODS: We retrospectively investigated the positive detection rates of five infections (hepatitis B, HBV; hepatitis C, HCV; human immunodeficiency virus, HIV; human T-lymphotropic virus, HTLV; Treponema pallidum, TP) using 1491 samples obtained in forensic autopsy at our facility from 2014 to 2018. In addition, risk factors related to infection such as methamphetamine and tattoos were analyzed. Pearson's chi-square test was used for statistical analysis, and the difference was judged to be significant at p < 0.05. RESULTS: Among our samples, 9.0% of cadavers tested positive for infection, and the prevalence rates for HBV, HCV, HIV, HTLV, and TP were 1.0%, 6.7%, 0.3%, 0.7%, and 1.1% respectively. Statistically, cadavers linked to information about methamphetamine use had a 7.2 times higher rate of infection, and those with tattoos had a 5.6 times higher rate of infection, with HCV being the predominant cause. CONCLUSIONS: To limit the risk of infection among autopsy workers, cadavers and samples should be handled on the presupposition that the bodies are at risk of infections. It is also important to obtain as much information as possible about the medical history and potential illegal drug use to help assess the risk of infection in a patient during forensic autopsy. We propose that all autopsy cases should be screened for infections whenever possible.

Trends and Characteristics in Health Care-related Deaths Investigated through Medico-legal Autopsies after System Changes in Japan.

In Japan, a new cause-of-death investigation system and related new laws were enacted in the mid-2010s. These laws provided for an autopsy system for non-criminal unnatural deaths and a medical accident investigation system outside the criminal justice process for health care-related deaths. We retrospectively explored changes in the number and characteristics of medico-legal autopsy cases of health care-related deaths in Chiba Prefecture, Japan, and examined trends over time during these reforms. We found that the percentage of forensic autopsies based on the Code of Criminal Procedure for health care-related deaths had decreased significantly. The number of autopsies of accidental and unintentional deaths in nursing homes, which are not covered by the newly established medical accident investigation system, has been increasing, reflecting the ageing of society. The trend toward decriminalisation of health care-related deaths was expected to contribute more to medical safety if the scope was expanded and a system for disclosure of autopsy information was established.

Death in custody in Spain: Excited delirium syndrome. Importance of a multidisciplinary approach.

This article aims to analyse the excited delirium syndrome, especially, when Law Enforcement Officers have to make use of force and deaths in custody occur. Through a bibliographic review, inferences have been obtained to identify, in first place, what a death in custody is and the differences between positional asphyxia and excited delirium syndrome. Subsequently, we have summarized the major findings that the medical examiner should look for in order to diagnose the excited delirium syndrome from the scene examination, the autopsy and the complementary analysis. Finally, we propose some directives that may help to avoid the death of these subjects and to study them in case they occur.

The incidence of iatrogenic deaths in the Finnish cause-of-death statistics; a retrospective study.

PURPOSE: An adverse event in health care leading to death is a significant event when assessing patient safety. This study was designed in order to assess, how many iatrogenic deaths are registered in Finland annually, and what type of treatment they are mostly related to. METHODS: Material was collected using cause of death-statistics that includes "manner of death"-classification in Finland in 2014-2015. RESULTS: There were 350 cases that met the criteria of the study. In a majority of the cases (264, 75%), a medico-legal autopsy was performed. This represents only 1.4% of all medicolegal autopsies during the study period in Finland. The cases were most often related to medication (30%) or known high-risk procedures such as gastrointestinal surgery (23%) and cardiothoracic surgery (11%). Only 12% of the cases had no prior significant medical history. Patient characteristics were somewhat different among the surgical disciplines, probably reflecting treatment practices. CONCLUSION: Deaths that are classified as iatrogenic are mostly related to known high-risk surgery or medication. Further studies are needed to assess the true incidence of malpractice among this material.

Forensic medicine in Nepal: Past, present, and future.

The practice of autopsy for medico-legal purposes in Nepal was started during the 1960s when jail doctors used to perform the autopsy. However, the medico-legal service in clinical forensic settings is less than three decades old. In Nepal, a police inquest is done for all the unnatural deaths who then subjects the body for medico-legal autopsy at the nearest government hospital. Except for a few hospitals where forensic medicine experts are available, the medico-legal work in Nepal is done by medical officers most of who have no forensic qualification. For a country with a population of nearly 30 million, there are less than 50 forensic medicine experts who are currently practicing. There are 21 medical colleges in Nepal each having a forensic medicine department engaged in teaching forensic medicine as a separate subject in the undergraduate medical curriculum. Currently, postgraduate courses are also offered in the country. However, there is a lack of uniformity in the curriculum set by different universities for both postgraduate and undergraduate education. Due to the lack of forensic medicine faculty members in some medical colleges, the undergraduate students of medicine have to undertake the exam being taught by some guest lectures and without witnessing a single medico-legal autopsy. To standardize the medico-legal services and forensic medicine education, the Medico-Legal Society of Nepal was established with an aim to conduct regular seminars, conferences, and CMEs and also various training programs for the non-forensic medicine experts who deal with medico-legal cases. This paper aims to provide a brief history of medico-legal practice in Nepal, the current situation, and future plans to improve the medico-legal service of the country.

Suicidio con cloruro de potasio: Reporte de un caso / Suicide with potassium chloride: Case report

Resumen El suicidio es el uso deliberado de violencia externa con la intención de quitarse la vida, y el uso de medicamentos es una forma en la que esta se puede consumar, el cloruro de potasio es uno de los medicamentos que en concentraciones elevadas tienen efectos letales, por lo que el objetivo de este artículo científico es detallar características farmacológicas del cloruro de potasio, y los elementos a considerar en el estudio postmorten de cadáveres cuando se sospecha de una intoxicación por cloruro de potasio con manera de muerte suicida; con la metodología de estudio de artículos científicos, exposición de un caso clínico y discusión de la importancia del análisis de los elementos aportados y solicitados durante la investigación médico legal, también la especial y delicada importancia de una correcta recolección de muestras biológicas y continentes de medicamentos para el estudio toxicológico y químicoanalítico; de esta manera se concluye que el Cloruro de potasio es un fármaco con efectos colaterales dañinos en la función eléctrica cardiaca, la determinación de la manera de muerte es un trabajo complejo para el médico forense en este tipo de casos, y los resultados de la pericias complementarias a la autopsia tienen mucha importancia para el análisis de este tipo de casos.

Abstract Suicide is the deliberate use of external violence with the intention of taking one's life, and the use of medications is one way in which this can be consumed, potassium chloride is one of the medications that in high concentrations have lethal effects, Therefore, the objective of this scientific article is to detail the pharmacological characteristics of potassium chloride, and the elements to be considered in the postmortem study of corpses when potassium chloride poisoning is suspected as a suicidal death; with the methodology of study of scientific articles, presentation of a clinical case and discussion of the importance of the analysis of the elements provided and requested during the medical-legal research, also the special and delicate importance of a correct collection of biological samples and drug containers for toxicological and chemical analysis; In this way, it is concluded that potassium chloride is a drug with harmful collateral effects on cardiac electrical function, determining the manner of death is a complex job for the forensic doctor in this type of case, and the results of the expertise complementary to the autopsy are very important for the analysis of this type of case.

Causes of Death and Survival in Alcoholic Cirrhosis Patients Undergoing Liver Transplantation: Influence of the Patient's Clinical Variables and Transplant Outcome Complications.

BACKGROUND: Clinical and molecular mechanisms involved in the cause and time of death of alcoholic cirrhosis (AC) patients undergoing liver transplantation (LT) are not entirely understood. In sudden death cases, judicial autopsy practice is mandatory for determining the cause and circumstances of death. The medico-legal autopsy data are essential for helping health authorities to guide future public health activities, assess the effectiveness of health systems, and adopt the necessary preventive measures to improve and adapt the treatments in order to increase these patients' survival. OBJECTIVE: Our study aimed to determine the different clinical and sociodemographic causes that influence the different causes of death and the short- and long-term survival of AC patients undergoing liver transplantation. METHODS: A total of 122 deceased AC patients undergoing LT were analyzed at different times post-transplantation. The main pre- and post-transplant complications were analyzed in relation to the cause of death and the patient's survival, as well as the causes and time at which the patient's death occurred. RESULTS: A total of 53.3% of non-sudden death was observed. A large number of the deaths of AC patients undergoing transplantation were due to non-sudden death, sepsis, and graft failure (GF), the main causes of death in the sample being similar in both sexes. In non-sudden deaths, there were no significant differences between the death rates either related or not related to the liver transplant. Sepsis was the main cause, with the highest percentage (21.3%) of mortality, followed by GF (18.9%) and multiorgan failure (15.6%) at ten years. Furthermore, our results showed how pre-transplant clinical complications, such as viral infections and encephalopathy, influence the age at which multiorgan failure occurs in the transplanted patient. CONCLUSION: Multiorgan failure is the leading cause of sudden death, with higher mortality during the first year after transplantation, followed by sepsis and GF. Our results show the vulnerability of AC patients, both in the hospital period after the transplant and outside.

PCR Array Technology in Biopsy Samples Identifies Up-Regulated mTOR Pathway Genes as Potential Rejection Biomarkers After Kidney Transplantation.

Background: Antibody-mediated rejection (AMR) is the major cause of kidney transplant rejection. The donor-specific human leukocyte antigen (HLA) antibody (DSA) response to a renal allograft is not fully understood yet. mTOR complex has been described in the accommodation or rejection of transplants and integrates responses from a wide variety of signals. The aim of this study was to analyze the expression of the mTOR pathway genes in a large cohort of kidney transplant patients to determine its possible influence on the transplant outcome. Methods: A total of 269 kidney transplant patients monitored for DSA were studied. The patients were divided into two groups, one with recipients that had transplant rejection (+DSA/+AMR) and a second group of recipients without rejection (+DSA/-AMR and -DSA/-AMR, controls). Total RNA was extracted from kidney biopsies and reverse transcribed to cDNA. Human mTOR-PCR array technology was used to determine the expression of 84 mTOR pathway genes. STRING and REVIGO software were used to simulate gene to gene interaction and to assign a molecular function. Results: The studied groups showed a different expression of the mTOR pathway related genes. Recipients that had transplant rejection showed an over-expressed transcript (≥5-fold) of AKT1S1, DDIT4, EIF4E, HRAS, IGF1, INS, IRS1, PIK3CD, PIK3CG, PRKAG3, PRKCB (>12-fold), PRKCG, RPS6KA2, TELO2, ULK1, and VEGFC, compared with patients that did not have rejection. AKT1S1 transcripts were more expressed in +DSA/-AMR biopsies compared with +DSA/+AMR. The main molecular functions of up-regulated gene products were phosphotransferase activity, insulin-like grown factor receptor and ribonucleoside phosphate binding. The group of patients with transplant rejection also showed an under-expressed transcript (≥5-fold) of VEGFA (>15-fold), RPS6, and RHOA compared with the group without rejection. The molecular function of down-regulated gene products such as protein kinase activity and carbohydrate derivative binding proteins was also analyzed. Conclusions: We have found a higher number of over-expressed mTOR pathway genes than under-expressed ones in biopsies from rejected kidney transplants (+DSA/+AMR) with respect to controls. In addition to this, the molecular function of both types of transcripts (over/under expressed) is different. Therefore, further studies are needed to determine if variations in gene expression profiles can act as predictors of graft loss, and a better understanding of the mechanisms of action of the involved proteins would be necessary.

Blood alcohol levels in Finnish victims of non-ischaemic sudden cardiac death.

INTRODUCTION: Non-ischaemic heart disease (NIHD) is the underlying pathology in∼20% of all sudden cardiac deaths (SCDs). Heavy drinking is known to be associated with SCD due to ischaemic heart disease, but studies on association of recent alcohol consumption and SCD in patients with NIHD are scarce. We evaluated the blood alcohol levels of autopsy verified non-ischaemic SCD victims. METHODS: Study population was derived from the Finnish Genetic Study of Arrhythmic Events (Fingesture) (n = 5869, mean age 65 ± 12, 79% males). All deaths occurred in Northern Finland during 1998-2017. All victims underwent a medico-legal autopsy. Subjects of SCD due to ischaemic heart disease were excluded. RESULTS: A total of 1301 (mean age 57 ± 12, 78% males) victims of SCD due to NIHD were included in the study. The blood ethanol level was elevated in 543 (42%) subjects, out of which the blood alcohol level was ≥0.10%in 339 (62%) subjects and ≥0.15%in 252 (46%) subjects. Male SCD victims had alcohol in blood more frequently compared to females (45% versus 31%, p < .001). CONCLUSION: Elevated blood alcohol level is common in SCD victims due to NIHD, especially in males. Recent alcohol consumption might contribute to the subsequent SCD in many non-ischaemic SCD victims.KEY MESSAGESElevated blood alcohol level is common in victims of sudden cardiac death due to non-ischaemic heart disease, especially in males.Recent alcohol consumption may contribute to the subsequent death in many nonischemic sudden cardiac death victims.

Association of non-shockable initial rhythm and psychotropic medication in sudden cardiac arrest.

BACKGROUND: Asystole (ASY) and pulseless electrical activity (PEA) have a poor outcome during sudden cardiac arrest (SCA). Psychotropic medication has been associated with a risk for sudden cardiac death (SCD). Our aim was to study the association of psychotropic medication with ASY/PEA during SCA. METHODS AND RESULTS: A total of 659 SCA subjects were derived from the emergency data of Oulu University Hospital (2007-2012). Subjects with non-cardiac origin of SCA and over 30-minute delay to rhythm recording were excluded. Population included 222 subjects after exclusions (mean age 64 ± 14 years, 78% males). Initial rhythm was ventricular fibrillation (VF) or ventricular tachycardia (VT) in 123 (55%), ASY in 67 (30%) and PEA in 32 (14%) subjects. The delay (collapse to rhythm recording) was similar in VF/VT and ASY/PEA subjects (median 8 min [1st-3rd quartile 3-12 min] versus 10 [0-14] minutes, p = 0.780). Among VF/VT subjects underlying cardiac disease was more often ischemic compared to ASY/PEA subjects (85% versus 68%, p = 0.003). Psychotropic medication was associated with ASY/PEA rhythm (OR 3.18, 95%CI 1.40-7.23, p = 0.006) after adjustment for gender, age and underlying cardiac disease. Subsequently, antipsychotics (OR 4.27, 95%CI 1.28-14.25, p = 0.018) were more common in the ASY/PEA group. Benzodiazepines and antidepressants were not associated with ASY/PEA. CONCLUSION: Psychotropic medication and especially antipsychotics are associated with non-shockable rhythm during SCA and may lower the possibility of survival from the event. This might partly explain the risk of SCD related to psychotropic medication.

Influence of Preformed Antibodies in Liver Transplantation.

The significance of human leukocyte antigen (HLA) matching and preformed donor-specific antibodies (DSAs) in liver transplantation remains unclear. The aim of this study was to analyze the presence of DSAs in a large cohort of 810 liver recipients undergoing liver transplant to determine the influence on acute (AR) or chronic liver rejection (CR), graft loss and allograft survival. DSAs were identified using complement dependent cytotoxicity crossmatch (CDC-CM) and multiplexed solid-phase-based flow cytometry assay (Luminex). CDC-CM showed that a 3.2% of liver transplants were positive (+CDC-CM) with an AR frequency of 19.2% which was not different from that observed in negative patients (-CDC-CM, 22.3%). Only two patients transplanted with +CDC-CM (7.6%) developed CR and suffered re-transplant. +CDC-CM patients showed a significantly lower survival rate compared to -CDC-CM patients (23.1% vs. 59.1%, p = 0.0003), developing allograft failure within the first three months (p < 0.00001). In conclusion, we have demonstrated a relationship between the presence of preformed DSAs and the low graft liver survival, indicating the important role and the potential interest of performing this analysis before liver transplantation. Our results could help to detect patients with an increased risk of graft loss, a better choice of liver receptors as well as the establishment of individualized immunosuppressive regimens.

Cocaine in Hospital Admissions for Diseases of the Circulatory System and as the Underlying Cause of Death: Analysis and Discussion.

Cocaine is a cardiotoxic drug which has been associated with morbi-mortality due to cardiovascular diseases (CVD). This study aims to: (1) analyze the hospitalizations due to cardiovascular processes and the presence of cocaine among the toxic habits of patients; and (2) discuss the forensic difficulties in sudden cardiac death (SCD) in the presence of cocaine. Hospital discharges due to CVD reporting cocaine consumption as a secondary diagnosis between 2003 and 2013 in Spain were analyzed. Subsequently, a review of judicial autopsies (SCD in cocaine users) was carried out to illustrate the forensic difficulties in the determination of the manner and underlying cause of death when cocaine use is involved. The average CVD morbidity rate was 1104.4 per 100,000 population. The most common main diagnoses of which cocaine use was recorded as a secondary diagnosis were rheumatic fever, ischemic heart disease and cerebrovascular disease in male patients between 15 and 44 years. The cardiovascular findings in the autopsies of cocaine users vary, and determining the mechanism that triggered the death in forensic practice is a challenge. The presence of cocaine among the toxic habits of young patients admitted for CVD in Spain is increasing. In our opinion, criteria must be unified to establish the manner and underlying cause of death in SCD and toxicological analysis can be a key part in the process.

Significant decrease in the rate of fatal alcohol poisonings in Finland validated by blood alcohol concentration statistics.

BACKGROUND: Alcohol may cause death directly by acute poisoning, as well as induce illnesses or accidents that lead to death. Our research question was whether the current decreasing trend in acute fatal alcohol poisonings in Finland is a real phenomenon or an artefact caused by possible changes in the process of determining the cause of death. METHODS: All cases in the national post-mortem toxicology database in which the underlying cause of death was acute alcohol poisoning in 1987-2018 were investigated in terms of blood alcohol concentration (BAC), age and gender. The number of acute alcohol poisonings was compared to the number of deaths from alcohol induced illness in the post-mortem toxicology database. RESULTS: A total of 12 126 acute alcohol poisoning cases were retrieved. Between 2004 and 2017 the number of acute alcohol poisonings decreased 60.1 %. At the same time the number of alcohol induced illnesses in the study material remained stable or decreased marginally. The median BAC in all acute alcohol poisonings was 3.2 g/kg. The annual median BAC values showed a small but significant decrease over the study period. The proportion of women in acute alcohol poisonings increased significantly over the study period, from 17.1%-22.3%. Women were on average 2.5 years older than men. CONCLUSIONS: On grounds of the BAC statistics and supporting evidence, we conclude that the significant decrease in the number of fatal alcohol poisonings is true and likely reflects changes in the overall consumption of alcohol.