Average thickness of the bones of the human neurocranium: development of reference measurements to assist with blunt force trauma interpretations.

The accurate interpretation of a blunt force head injury relies on an understanding of the case circumstances (extrinsic variables) and anatomical details of the individual (intrinsic variables). Whilst it is often possible to account for many of these variables, the intrinsic variable of neurocranial thickness is difficult to account for as data for what constitutes 'normal' thickness is limited. The aim of this study was to investigate the effects of age, sex and ancestry on neurocranial thickness, and develop reference ranges for average neurocranial thickness in the context of those biological variables. Thickness (mm) was measured at 20 points across the frontal, left and right parietals, left and right temporals and occipital bones. Measurements were taken from post-mortem computed tomography scans of 604 individuals. Inferential statistics assessed how age, sex and ancestry affected thickness and descriptive statistics established thickness means. Mean thickness ranged from 2.11 mm (temporal squama) to 19.19 mm (petrous portion). Significant differences were noted in thickness of the frontal and temporal bones when age was considered, all bones when sex was considered and the, right parietal, left and right temporal and occipital bones when ancestry was considered. Furthermore, significant interactions in thickness were seen between age and sex in the frontal bone, ancestry and age in the temporal bone, ancestry and sex in the temporal bone, and age, sex and ancestry in the occipital bone. Given the assorted influence of the biological variables, reference measurement ranges for average thickness incorporated these variables. Such reference measurements allow forensic practitioners to identify when a neurocranial bone is of normal, or abnormal, thickness.

Whole-genome characterization of chemoresistant ovarian cancer.

Patients with high-grade serous ovarian cancer (HGSC) have experienced little improvement in overall survival, and standard treatment has not advanced beyond platinum-based combination chemotherapy, during the past 30 years. To understand the drivers of clinical phenotypes better, here we use whole-genome sequencing of tumour and germline DNA samples from 92 patients with primary refractory, resistant, sensitive and matched acquired resistant disease. We show that gene breakage commonly inactivates the tumour suppressors RB1, NF1, RAD51B and PTEN in HGSC, and contributes to acquired chemotherapy resistance. CCNE1 amplification was common in primary resistant and refractory disease. We observed several molecular events associated with acquired resistance, including multiple independent reversions of germline BRCA1 or BRCA2 mutations in individual patients, loss of BRCA1 promoter methylation, an alteration in molecular subtype, and recurrent promoter fusion associated with overexpression of the drug efflux pump MDR1.

Suicidal ligature strangulation: a systematic review of the published literature.

To summarize the published forensic pathology evidence base in deaths concluded to be the result of suicidal ligature strangulation, an uncommon entity. Four electronic bibliographic databases Medline Ovid, Embase, Scopus, HEINonline were screened for relevant literature. No date restrictions were applied. All English language case reports or case series were included. Articles were evaluated and key data extracted according to predefined criteria. A total of 1554 references eventually yielded 24 papers with 31 eligible case reports. The location of the deaths and background circumstances and history mirror broadly those of suicide generally. The range of ligature types was diverse. 19/31 cases reported one or more knots present. In the remaining 12 cases, the ligatures did not lend themselves to knots. In only one case were laryngeal fractures reported, but the available material does not justify confidence in that report given the significance of the finding. This systematic review has identified and synthesized the evidence from 31 case reports of suicidal ligature strangulation. A forensic pathologist faced with a possible case can locate it within the spectrum of reported cases and therefore identify its common and distinguishing features. Inherent difficulties for research in forensic pathology mean that case reports are an important source of learning and evidence for the discipline. Opportunities for improvement exist especially in harmonizing terminology and standardizing techniques generally, and in reports of suicidal ligature strangulation in particular.

Autopsy histopathology where the prosector is not a histopathologist: a proposal.

Forensic pathology is a specialty that involves death investigation while clinical forensic medicine is the application of the practice of medicine to the requests of the law in relation to the living. Around the world, there is diverse practice for these two disciplines. The forensic physician or forensic doctor (sometimes, called a forensic pathologist but not a forensic histopathologist) in parts of the world such as continental Europe, the Middle East and India, practice both clinical forensic medicine and forensic pathology. This is the specialty, for the purposes of this paper, we will call forensic medicine. The forensic doctor will usually receive training in autopsy dissection, perhaps with a short training of a few months in anatomical pathology or surgical histopathology. When undertaking autopsies (involving internal as well as external examination), if it is thought histological assessment is required, the forensic doctor will sample the organs and tissues required and refer the specimens to the hospital histopathologist for microscopic examination. This division of responsibility could compromise the quality of the autopsy unless handled correctly.Where the histological assessment of the autopsy specimen is undertaken by a pathologist other than the one who dissected the body and collected the samples, standard operating procedures need to be developed to minimize the risk to the overall quality of the autopsy. We are not aware that any such procedures have been published, hence we offer an outline of what a set of such procedures might contain.

Mortuary operations following mass fatality natural disasters: a review.

This is a critical review to discuss the best practice approaches to mortuary operations in preparation for and the response to natural, mass fatality, disaster events, as identified by a review of published articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) Statement guided the identification of potential articles to use in this critical review. Subsequent searches were also conducted to identify articles relating to heat wave, and flood mortality. All identified peer-reviewed studies published in English which discussed the preparation and response of mortuaries to mass fatality natural disasters occurring in developed countries were included. Using the PRISMA-P method of identifying articles, 18 articles were selected for inclusion in this review. Although there are numerous articles which describe the mortuary response to mass fatality incidents, few articles analyzed the response, or discussed the roles which supported and enabled the organization to undertake the task of identifying disaster victims. It is thus difficult to determine objectively if the actions and activities outlined in the articles represent best-practice.

The Foundations of the Comparison Forensic Sciences: Report of the President's Council of Advisors on Science and Technology.

In September 2016, the President's Council of Advisors on Science and Technology (PCAST) in the United States published its report to the President entitled Forensic Science in Criminal Courts: Ensuring Scientific Validity of Feature-Comparison Methods. The need for this report arose out of the highly critical 2009 National Research Council report on the state of forensic sciences in the United States. The report had noted that there were particular problems in feature-comparison disciplines where the science underpinning the validity of the discipline was poor. The PCAST report has developed the National Research Council's thinking further. It looked at the foundational validity of a number of forensic disciplines, including, for example, bite mark interpretation in forensic odontology. PCAST concluded that bite mark analysis does not meet the scientific standards for foundational validity. In addition, it felt that the prospects of developing bite mark analysis into a scientifically valid method were poor, and they advised against government investment in research to try to establish such validity. The principles discussed in this report, focused as they are on forensic science, will need to be digested by forensic medicine. Forensic medicine will be increasingly called upon to justify the validity of the various areas in which its practitioners provide expert evidence.

The development of a protocol for post-mortem management of Ebola virus disease in the setting of developed countries.

The management of the recent Ebola virus disease (EVD) epidemic continues to pose currently insuperable challenges to health care providers in the resource-deprived countries of West Africa. In an age where air travel facilitates rapid movement of people between countries and continents, there is an urgent requirement for health systems around the globe to develop management strategies and protocols in the event that EVD cases are suspected or confirmed. Departments of forensic pathology play an important, and underestimated, role in public health service delivery, particularly at times of novel infectious disease emergence. This role can include disease identification, characterization, and notification, as well as close engagement with agencies responsible for disease surveillance and treatment provision. A mass outbreak of EVD in the Western world is considered highly unlikely; however, there is clear responsibility on departments of forensic pathology to develop protocols for rapid assessment of sporadic or suspected cases while ensuring the health and safety of mortuary and pathology personnel. The Ontario Forensic Pathology Service and the Victorian Institute of Forensic Medicine have collaborated on the development of a protocol for management of EVD cases presenting at a scene or in the mortuary. It is hoped that this trans-national, inter-departmental exercise will serve as a model for future co-operative endeavors. The protocol has been distributed to forensic pathology departments around Australia and may be modified to accommodate local resource capabilities.

Evolution of late-stage metastatic melanoma is dominated by aneuploidy and whole genome doubling.

Although melanoma is initiated by acquisition of point mutations and limited focal copy number alterations in melanocytes-of-origin, the nature of genetic changes that characterise lethal metastatic disease is poorly understood. Here, we analyze the evolution of human melanoma progressing from early to late disease in 13 patients by sampling their tumours at multiple sites and times. Whole exome and genome sequencing data from 88 tumour samples reveals only limited gain of point mutations generally, with net mutational loss in some metastases. In contrast, melanoma evolution is dominated by whole genome doubling and large-scale aneuploidy, in which widespread loss of heterozygosity sculpts the burden of point mutations, neoantigens and structural variants even in treatment-naïve and primary cutaneous melanomas in some patients. These results imply that dysregulation of genomic integrity is a key driver of selective clonal advantage during melanoma progression.

The role of epidemiology in determining if a simple short fall can cause fatal head injury in an infant: a subject review and reflection.

This article is a subject review summarizing and interpreting the existing knowledge on the question "Can a simple short fall cause fatal head injury in an infant?" It also reflects on the challenges of undertaking a review in the contentious area of pediatric forensic pathology. The authors identified and considered 1055 publications for inclusion. Using explicit selection criteria 27 publications were included in the subject review. The literature suggests that it is rare, but possible, for fatal head injury to occur from a simple short fall. Large population studies of childhood injuries indicate that severe head injury from a short fall is extremely rare. This is counter pointed by a single documented case report that demonstrates it can happen. The question of whether it is a credible claim in a particular case is inextricable from the circumstances of that case.To strengthen the evidence based on fatal potential of simple short falls in infants, future studies addressing this question would ideally be prospective in design and include the key elements of: (1) a large sample size, (2) clearly defined comparison groups, (3) clear and verifiable criteria for causation, (4) specified fall height, (5) specified fall type: vertical free fall or the presence of additional forces, (6) composition of contact surface, and (7) nature of contact point: concentrated to one point or onto a flat surface.We believe subject reviews for forensic pathology require a specific approach because the application of information differs between clinical and courtroom settings.

Management deficiencies and death preventability of road traffic fatalities before and after a new trauma care system in Victoria, Australia.

BACKGROUND: The Consultative Committee's findings that preventable or potentially preventable (P/PP) death rates (survival prospects > or =25%) of road crash fatalities who received treatment were unaltered between 1992 and 1998 led to a Ministerial Taskforce on Trauma and the gradual introduction of a new Victorian trauma care system. The present study compares outcomes before (1997-1998) and after (2002-2004) the new system. METHODS: The emergency and clinical management and death preventability of 245 consecutive fatalities in the 'before' period and 193 in the 'after' period was assessed by the committee's multidisciplinary panels using the complete hospital, ambulance, and autopsy findings. RESULTS: Emergency department admissions to expanded Major Trauma Services (MTS) increased from 34% to 62% (p < 0.05). More patients were attended by Advanced Trauma Life Support paramedics (p < 0.05) and scene times increased (p < 0.05). Patients admitted within 1 hour decreased from 70% to 45% (p < 0.05). The mean number of deficiencies per patient including those contributing to death was decreased (p < 0.05). The combined P/PP death rates decreased from 36% to 28% (22% relative risk reduction). The P/PP death rates for MTS, Metropolitan Trauma Services, Rural Trauma Services, and Urgent Care Centers for 2002 to 2004 were 25%, 33%, 50%, and 83%, respectively, and did not differ significantly from those of 1997 to 1998 (23%, 49%, 36%, 75%, respectively). The P/PP death rates in MTS were less than those of the other hospital groups. CONCLUSIONS: The new Victorian trauma care system has resulted in a significant decrease in deficiencies including those contributing to death and a decrease in P/PP deaths rates. The improvement has been largely consequent to a marked increase in admissions to MTS.

Humanitarian forensic action - Its origins and future.

Humanitarian forensic action is the application of the knowledge and skills of forensic medicine and science to humanitarian action, especially following conflicts or disasters. It has its early roots in the experience of the Argentine Forensic Anthropology Team and that of the Grandmothers of Plaza de Mayo in Argentina, is moulded by International Humanitarian and Human Rights Law and was developed by the International Committee of the Red Cross. Having demonstrated its worth, this new field of application of forensic medicine and science needs further development, integration and research.

The Ebola epidemic in Liberia and managing the dead-A future role for Humanitarian Forensic Action?

With some of their economies, communities and health systems weakened by decades of war and poor governance, it was no accident that an epidemic of Ebola virus disease broke out in west Africa. Being spread in part by contact with body fluids of those who had died from the disease, funerary rites and the way dead bodies were managed were important modes of transmission. The Liberian Red Cross, supported by the International Federation of Red Cross and Red Crescent Societies and the International Committee of the Red Cross, undertook the challenging task of managing the dead bodies in Monrovia during the epidemic. The work was undertaken by volunteers, not health care workers, who were trained and equipped for this task. The authors observed their work and were impressed. Valuable lessons were learned for mortuaries generally, and for Humanitarian Forensic Action involving the management of highly infectious human remains.

The West Kingston/Tivoli Gardens Incursion in Kingston, Jamaica.

On May 24, 2010, 800 soldiers and 370 police officers stormed into Tivoli Gardens, an impoverished district in the capital of Jamaica. Their aim was to restore state authority in this part of Kingston and to arrest Christopher "Dudus" Coke, who was wanted for extradition to the United States on drug and arms trafficking charges. The incursion was the culmination of nine months of national political turmoil. The first aim was achieved, but the second was not, and only at great cost. Around 70 civilians and three members of the security forces were killed. The authors constituted a small group of international forensic pathologists who, at the request of the Public Defender and over a four-week period from mid-June, observed the autopsies of the civilians. This paper describes some of the outcomes of this work, set within the evaluation of the incursion by the Commission of Enquiry. The Enquiry concluded there was evidence of at least 15 extrajudicial killings and was highly critical of many other aspects of the operation and its aftermath.

Post-mortem CT evaluation of atlanto-occipital dissociation.

Atlanto-occipital dissociation injury is an important injury in forensic pathology practice. Radiological diagnosis of atlanto-occipital dissociation clinically is assessed by direct measurement of occipito-vertebral skeletal relationships. Different measurements may be used to diagnose atlanto-occipital dissociation, including the basion-dens interval (BDI) and basion-axial interval (BAI). It is not known whether the normal ante-mortem measurements of BDI and BAI described in the literature are applicable to post-mortem CT images of the occipito-cervical junction (OCJ) or whether these measurements could be affected by early post-mortem changes. This study aims to compare post-mortem BDI and BAI measurements with ante-mortem values. Post-mortem CT scans of the cervical spines of 100 deceased adults were reviewed, and the BDI and BAI were measured. Different parameters were recorded in each case. The results from this study suggest that there are no effects of post-mortem changes on the measurement of BAI as relied upon clinically. There appear to be some effects of fully established rigor mortis on BDI measurement, shortening it. This may have consequences for the post mortem diagnosis of atlanto-occipital dissociation.