Survey on postmortem screening and management of COVID-19 related deaths.

The COVID-19 pandemic is associated with a high case fatality rate in some countries even thought the majority of cases are asymptomatic. Scientific studies on this novel virus is limited and there is uncertainty regarding the best practices for death investigations both in terms of detection of the disease as well as autopsy safety. An online survey was conducted to identify how different institutions responded to the screening and management of dead bodies during the early phase of the pandemic from January to May. A questionnaire was developed using Google Forms and data was collected from 14 different forensic and pathological institutions in 9 countries. None of the institutions had performed any screening prior to March. Four institutions stated that screening was done routinely. In total, 322 cases had been screened using RT-PCR, out of which 40 positive cases were detected among four institutions. The commonest types of samples obtained were nasopharyngeal and oropharyngeal swabs which also had the highest rates of positivity followed by tracheal swab. Blood, swabs from cut surfaces of lung and lung tissue also gave positive results in some cases. Majority of the positive cases were > 65 years with a history suggestive of respiratory infection and were clinically suspected to have COVID-19 before death. Except for one institution which performed limited dissections, standard autopsies were conducted on all positive cases. Disposal of bodies involved the use of sealed body bags and labelling as COVID positive. Funeral rites were restricted and none of the institutions advocated cremation. There were no reports of disease transmission to those who handled COVID positive bodies.

Challenges in implementing best practice DVI guidelines in low resource settings: lessons learnt from the Meethotamulla garbage dump mass disaster.

The management of mass fatalities following disasters is a complex process which requires the involvement of multiple stakeholders and resources. A garbage dump at Meethotamulla in Sri Lanka suddenly collapsed, resulting in the death of 32 individuals. Efforts to implement best practice guidelines in Disaster Victim Identification (DVI) during this disaster revealed several important aspects that need to be considered by the forensic community. Delays in initiating the legal processes to investigate and manage the incident resulted in public dissatisfaction towards the post-disaster management process. Body recovery by Police and military personnel without the involvement of medical teams had numerous shortcomings including the lack of proper tagging and photography, commingling of body parts, and non-preservation of personal items. Public expectation and demand for early release of the bodies conflicted with the necessity to undergo a stringent DVI process according to best practice guidelines. Many adaptations and alternate strategies were necessary to ensure that DVI could be done scientifically. The use of primary identification markers including odontology and DNA had many limitations including non-availability of antemortem data, resource availability and cost. Identification was established using a combination of secondary identification markers including clothing, jewelry, scars, tattoos, morphological descriptions and circumstantial evidence. In two cases, odontological features further supported positive identification. Samples for DNA were obtained and preserved but were not utilized in establishing the identities. This paper highlights the need for better public awareness and multidisciplinary commitment in managing mass fatalities and also reflects on the challenges of implementing best practice DVI guidelines in low-resource settings with different legal and socio-cultural expectations.

Artefactual incised wounds due to postmortem predation by the Sri Lankan water monitor (kabaragoya).

Monitor lizards are large reptilian animals mostly seen around water based habitats. Sri Lanka has an endemic water monitor lizard called the kabaragoya (Varanus salvator salvator) which is perhaps the most common large animal scavenger in the country. Scavenging by the kabaragoya can result in postmortem incised injuries which are caused by their sharp pointed claws as they grip or crawl over a dead body. The author presents four cases where these claw marks raised significant medicolegal issues. In one case of a young female they mimicked defense injuries that might be seen in a person that was killed with heavy sharp weapon trauma to the head. In another case, claw marks on the face raised homicidal allegations in an immersion death following intoxication. In a case of suicidal drowning these injuries simulated self-inflicted cuts. The fourth case shows how claw marks complicated the investigation of a dismembered upper limb. Kabaragoya claw marks are mostly seen in decomposed and macerated bodies recovered from water. Injuries are mostly superficial and limited to skin and soft tissues. Bony injuries are not seen. Awareness of the creature's scavenging habits and careful analysis of the appearance and distribution of the injuries is essential to differentiate claw marks from sharp weapon trauma.

The effect of the COVID-19 pandemic on the trends and characteristics of natural and unnatural deaths in an urban Sri Lankan cohort viewed through retrospective analysis of forensic death investigations from 2019 to 2022.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had a severe impact on global health. Apart from the disease itself, the strict restrictions and lockdowns enforced to minimize its spread have also substantially disrupted personal and public health. METHODS: An analysis of forensic autopsy investigations was conducted between 2019 and 2022 on a selected urban population in Colombo, Sri Lanka, assessing the effects of the COVID-19 pandemic on mortality within these communities. RESULTS: During the COVID-19 restrictions, there was a 2.5-fold increase in the total number of deaths, with a significantly higher percentage of female deaths than before. The majority of these deaths were due to cardiovascular causes, while COVID-19-related deaths ranked third overall. The highest proportion of COVID-19 deaths occurred among unvaccinated females. The monthly frequency of deaths from traffic accidents, poisoning, and asphyxiation decreased, while deaths from blunt trauma, sharp trauma, burns, and immersion increased. There was also a rise in blunt homicides and a greater number of femicides during the COVID-19 restrictions than in the pre-pandemic period. A significantly higher percentage of males who received the COVID-19 vaccine died from cardiovascular causes compared to those in the unvaccinated group. CONCLUSION: The significant changes in mortality demographics and causes of death within this community during the COVID-19 restrictions underscore the disruption in healthcare, healthseeking behavior, and social interactions during this period. The vulnerability of individuals residing in highly urbanized areas with lower socioeconomic status, particularly women, is brought into sharp focus.

Retrospective analysis of factors affecting rate of skeletonization within a tropical climate.

Estimating the post mortem interval (PMI) in skeletonized cases is an extremely challenging exercise. Sri Lanka lacks adequate taphonomic research which is a serious limitation when assessing PMI in forensic death investigations. Methods that have been proposed to estimate PMI using the total body score (TBS) and accumulated degree days (ADD) are mainly based on data from continental and temperate climates and have shown less reliability in tropical climates. With the intention of developing a region-specific, evidence-based guide which would be applicable to tropical climates like Sri Lanka, we selected thirteen skeletonized remains with known PMIs from forensic case records and analysed their taphonomy in relation to selected weather data. We also compared the ADD values within our dataset with reference ranges calculated using published formula. All except one were found from outdoor locations. The TBS ranged from 24 to 32 and had a weak positive correlation with the PMI. The earliest appearance of skeletonization was 15 days in a body found indoors. The highest rate of skeletonization was seen in a body with a TBS of 32 and a PMI of 23 days. The average daily temperature and relative humidity were similar across all the cases however, the amount of rainfall varied. Bodies exposed to monsoon rains (n = 6) had a lower mean rate of skeletonization compared to those that were not exposed (n = 4) suggesting lower rates of decomposition during periods of heavy rainfall. No correlation was found between ADD and TBS. In 9 (69.2%) cases, the actual ADD was much lower than reference ADD ranges for TBS values, indicating poor applicability of TBS and ADD based formulae in estimating PMI within the Sri Lankan climate. Our study shows a strong need for taphonomic and entomological research in tropical climates to further explore the impact of monsoons on biotic and abiotic factors affecting skeletonization.

Corrigendum to A Systematic Review of Renal Pathology in Chronic Kidney Disease of Uncertain Etiology Kidney International Reports Volume 6, Issue 6, June 2021, Pages 1711-1728.

[This corrects the article DOI: 10.1016/j.ekir.2021.03.898.].

A Systematic Review of Renal Pathology in Chronic Kidney Disease of Uncertain Etiology.

INTRODUCTION: Despite much research on chronic kidney disease of uncertain etiology (CKDu) in Sri Lanka and the Mesoamerican nephropathy, the etiology and pathogenesis of this disease remains elusive. The pathology has broadly been described as chronic tubulointerstitial nephritis and no specific signature lesions have been identified. METHODS: A scoping review was conducted through MEDLINE and Google Scholar databases for peer-reviewed publications on biopsy studies related to CKDu - Sri Lanka and Mesoamerican nephropathy to develop a comparative and critical analysis of the renal pathology found in these patients. RESULTS: Thirteen studies met the selection criteria. Interstitial fibrosis was the predominant lesion in all the studies. Tubulointerstitial and glomerular abnormalities showed a more variable distribution. No characteristic histopathological feature was reported other than a proximal tubular lysosomal inclusion body which was claimed to indicate a toxic etiology. Three main pathogenetic mechanisms were postulated: repeated acute insults leading to scarring, low-grade chronic insults leading to non-inflammatory fibrosis, and tubulointerstitial damage in combination with glomerular injury. The main limitations in the interpretation and comparative analysis of these studies were the heterogeneity in case selection and biopsy reporting. CONCLUSIONS: Although no characteristic histopathological feature could be found in CKDu-Sri Lanka or Mesoamerican nephropathy, there are noticeable differences between these two groups in the frequency and severity of the glomerular and tubulointerstitial changes which warrant more explorative studies preferably on kidneys in early stages of the disease. Future strategies should ensure that more uniform selection criteria and reporting methods are used.

Renal bioaccumulation of trace elements in urban and rural Sri Lankan populations: A preliminary study based on post mortem tissue analysis.

INTRODUCTION: Environmental pollution, especially by toxic trace elements, is a global health concern. Heavy metals such as Cadmium (Cd), Arsenic (As) and Lead (Pb) are associated with numerous disorders and are considered by some as an aetiological factor for the Chronic Kidney Disease (CKDu1) epidemic in Sri Lanka. This study explores patterns of bioaccumulation of six trace elements in kidneys obtained during forensic autopsies from urban and rural regions in Sri Lanka. METHODS: Kidney samples obtained from one urban district (n = 13) and three rural districts (n = 18) were lyophilized, microwave digested and profiled by ICP-MS techniques. RESULTS AND DISCUSSION: The mean age of the sampled population was 47.9 ±â€¯11.3 yrs. Median (IQR) for Cd, As, Pb, Cr, Zn and Se were, 14.67(8.04-22.47) µg/g, 0.44(0.29-0.56) µg/g, 0.11(0.07-0.30) µg/g, 0.15(0.1096-0.3274), 25.55(17.24-39.35) µg/g and 0.52(0.37-0.84) µg/g, respectively. Cd, Zn and Se levels were significantly higher (p < 0.05) among the urban samples compared to that of the rural group. Zn and Se levels were higher among younger age groups. As, Pb and Cr did not show any significant differences between the two cohorts nor any correlations with age. CONCLUSION: This population-specific baseline study provides an insight into the differences in exposure to toxic trace elements and essential elements between urban and rural populations. Residents in CKDu affected rural districts did not appear to be at risk of toxic heavy metal exposure, however their renal bioaccumulation of nephroprotective essential elements was lower than urban residents.