Histopathological changes in lungs of the mountain snow avalanche victims and its potential usefulness in determination of cause and mechanism of death

On 28 January 2003 snow avalanche in the Polish Tatras happened, in which 8 people died and 5 were injured. We tried to determine cause and manner of death in 6 fatal victims instead of advanced late post mortem changes in internal organs. Taking into consideration the circumstances of death, we paid special attention to histopathological examination of lungs, extended by Gomori's and AZAN staining. Pattern of the changes was similar to those observed in forensic medicine in cases of asphyxia due to airway obstruction and/or immobilization of chest and abdomen (Perthes' syndrome). Histopathological study with the use of more specific staining methods has a significant diagnostic value during establishing the cause and mechanism of death of the deceased snow avalanche victims with advanced post mortem changes.

Traumatic basal subarachnoid haemorrhage or ruptured brain aneurysm in 16-year-old boy? - case report

Traumatic basal subarachnoid haemorrhage (TBSAH) represents only 1.8% of all subarachnoid haemorrhage cases diagnosed during autopsy. This report presents such a case from the current practice of the authors. Sixteen-year-old boy was beaten by the aggressors. Suddenly he lost his consciousness and fall after he received a single blow in the neck. He was resuscitated immediately, but died at the scene. During the external examination we did not find any significant external injuries. Autopsy revealed large contusion of right sternocleidomastoid muscle. In the cranial cavity we found extensive subarachnoid haemorrhage, located mainly on brain basis, in the posterior cranial fossa and covering the subtentorial structures. During the preparation of blood vessels we noticed a slight change of morphology suggesting damaged vessel or aneurysm, or vascular malformation located in the basilar artery bifurcation, which was taken to detailed microscopic evaluation using the special stainings. Histological examination showed vital interruption of the basilar artery wall with massive haemorrhage, without the presence of general microscopic pathology. From the medico-legal viewpoint, to determine traumatic background of haemorrhage it is necessary to find the coexistence of the following circumstances: a sustained trauma, post-mortem findings consistent with a time of injury, the presence of temporal relationship between injury and death, and morphological vital injury of the brain vessel, as well as the absence of prior vascular malformations. For this purpose Verhoeff-van Gieson's, Masson's, Turnbull's and Gomori' histological stainings may be successfully used.

Employment of auditory brainstem responses in verification and objectification of impairment of hearing in criminal legal proceedings / Wykorzystanie badan sluchowych potencjalów wywolanych pnia mózgu w weryfikacji i obiektywizacji uszkodzen sluchu dla potrzeb postepowania karnego.

There are numerous subjective and objective diagnostic methods which allow for assessing the degree of the hearing loss and its anatomical location. Despite widespread availability of those methods, especially the subjective ones, such as pure tone audiometry or speech audiometry, diagnostic errors still frequently occur. They may lead to drawing false conclusions and issuing a fallacious medicolegal expert opinion, which obviously aggravates the situation of the defendant. Medicolegal experience has shown that these errors may result from employment of classic, subjective only methods of hearing examination and failure to perform objective tests, in particular auditory brainstem responses (ABR), autoacustic emissions (OAEs) and audiometry impendance (AI).

A unique case of malignant neoplasm--choriocarcinoma in a 24-year-old man--difficulties in differential diagnostics of intracranial injuries in the aspect of medicolegal opinion / Niezwykle rzadki przypadek nowotworu zlosliwego--kosmówczaka u 24-letniego mezczyzny--trudnosci w diagnostyce róznicowej uszkodzen sródczaszkowych w aspekcie opiniowania sadowo-lekarskiego.

Differential diagnostics of pathologic and traumatic lesions based on image techniques may in some cases cause serious difficulties or even be the cause of a medical error resulting in incorrect medicolegal opinion. The authors present a unique case of primary malignant neoplasm of the testicle (choriocarcinoma) in a 24-year-old man. Several days after the event, he was admitted to Department of Neurology with CT-confirmed traumatic intracerebral hematoma communicating with the ventricular system. Discharged in a good general condition, the patient died several days later. A postmortem examination combined with histopathology demonstrated numerous metastases of the primary carcinoma, which also involved the brain, arousing suspicions of head injury in consequence of a crime.

Filter mask as a new candidate of personal belonging used in cadaver identification - a case report.

The case report presents an identification process based on DNA isolated from personal belongings, including a filter mask. In May 2021, an unidentified 65-year-old male corpse was revealed by the city's outskirts road. Since it was impossible to use material from living relatives for comparative analysis, the samples of personal belongings of the alleged victim were used instead: clippings of the filtering face piece type 2 (FFP2) face mask (parts adhering to the nose and the earlobes, the central part of the mask), swabs from the razor (blade and shaft), toothbrush shaft, and toothbrush filaments clippings. The presented case indicates the need for collecting a wide range of samples for genetic analyses, including filter masks as an alternative item of personal belonging.

[Neurosis as a mental disease--controversies surrounding insurance certification]. / Czy neurastenia to choroba psychiczna--sztuczny, czy rzeczywisty problem opiniodawczy?.

In the years 2008-2009, experts from the Department of Forensic Medicine in Katowice issued a dozen of expert opinions on the nature of the neurosis, addressing the question whether neurosis is a mental disease as understood under the general insurance conditions or whether neurosis is a mental disease as such. All the submitted cases involved policemen who had been diagnosed as neurotic and were refused insurance payments since the insurance company claimed payments could not have been effected due to the diagnosis of mental disease, meaning neurosis in the discussed cases. The plaintiffs invoked the fact that medical terminology describes such states as "mental disorders". In the article, the authors present the adopted model of opinionating, make an attempt at explaining the controversy and discuss the subtleties of medical terminology and the core differences between the terms "mental disorder" and "mental disease" as employed in medico-legal opinionating in such cases.

[An unusual case of gunshot wounds caused with an air gun]. / Niezwykly przypadek postrzalu z broni pneumatycznej.

A 28-year-old woman was shot in the face with an air gun while driving a car. The patient was examined in the Department of Forensic Medicine in Katowice. An inconspicuous scar was found near the medial angle of the right eye. Further ophthalmological and radiological examinations revealed the presence of small foreign bodies in the vitreous body of the right eye, the sphenoid sinus and the ethmoid cells. The authors issued an expert opinion, in which they stated that the sustained injuries had not caused any significant organ dysfunction.

[The evaluation of the mechanism and cause of death of mine rescuers during the group accident in the Niwka-Modrzejów Coal Mine in Sosnowiec in 1998]. / Ocena mechanizmu i przyczyny smierci ratowników górniczych podczas wypadku zbiorowego w Kopalni Wegla Kamiennego "Niwka-Modrzejów" w Sosnowcu w 1998 roku.

On February 24, 1998, in the Niwka-Modrzej6w Coal Mine in Sosnowiec, a group accident occurred and, as a result, six miners died and four others were injured. Mine rescuers, proceeding to work in out of action mining excavation, separated by an isolative dam, were using oxygen escape breathing apparatuses AU-9 type and oxygen breathing apparatuses for work WU-70 type. A comprehensive evaluation of the accident circumstances, medical papers, autopsy, histopatological and chemico-toxicological reports, technical surveys of the Central Station of Mine Rescue and the Military Institution of Chemistry and Radiometry (WIChiR), taking into consideration the microclimatic conditions in the sidewalk and testimonies of the survivors allowed for determining the cause of death in the victims. The authors emphasized special difficulties in compiling the comprehensive opinion in the reviewed case and the significant evidential value of the technical survey prepared by WIChiR that showed numerous and serious abnormalities in the performance of oxygen breathing apparatuses, which in a short time led in their users to acute respiratory insufficiency due to anoxia with its further consequences.

[Medico-legal assessment of the injuries of fatal victims of building collapse at Katowice International Fair in Katowice/Chorzów on January 28, 2006]. / Sadowo-lekarska ocena obrazen u smiertelnych ofiar katastrofy budowlanej na terenie Miedzynarodowych Targów Katowickich w Katowicach/Chorzowie w dniu 28.01.2006 roku.

On January 28, 2006, during an exhibition of carrier pigeons, the roof of one of the buildings at Katowice International Fair collapsed. At the time of accident, there were 700 people in the building--65 died and 171 were injured. It was the biggest building disaster in the history of modern Poland. The aim of this study was to present the type (character) of the observed injuries, the cause of death of 48 fatal victims and the range of activities and medico-legal examinations performed in the Department of Forensic Medicine, Medical University of Silesia in Katowice. In the period of January 29-February 1, 2006, on February 14, 2006, and February 17, 2006, post-mortem examinations of the 48 deceased were carried out, and in some cases additional dissecting techniques were employed. During autopsies, numerous specimens for various additional examinations (histopathological, toxicological) were collected. For identification purposes, photographic material and specimens, necessary for genetic identification, were secured. Additionally, the bodies were identified by families. The post-mortem procedures eventually allowed for establishing the cause of death of all the victims. The authors emphasize the range of necessary medico-legal procedures and examinations that should be carried out in a Department of Forensic Medicine in case of a building collapse with a large number of fatalities in order to determine the type of injuries, cause and mechanism of death and to identify the deceased.

[Medico-legal assessment of medical management in "chest pain" cases based on the review of cases analyzed in the Chair and Department of Forensic Medicine, Medical University of Silesia, Katowice, in the years 2000-2006]. / Sadowo-lekarska ocena postepowania lekarskiego w przypadkach ostrych dolegliwosci bólowych w klatce piersiowej na podstawie analizy materialu aktowego Katedry Medycyny Sadowej w Katowicach w latach 2000-2006.

Among all investigations aiming at assessing medical management carried out in our department between 2000 and 2006, the cases of "chest pain" constituted the largest percentage. In 70% of such cases, the employed medical procedures were found to be incorrect; what might be qualified as medical decisive errors, committed in rescue ambulances, outpatient clinics or in admission rooms. The authors present some examples of causes of such incorrect management strategies, such as neglecting proper and profound clinical examination (with medical history taking); lack or incomplete differential diagnosis; failure to observe appropriate critical attitude and prudence; focusing only on one, most common disease.

[Thromboembolic complications in orthopedic surgery--medico-legal assessment in evaluation of correctness of medical treatment in selected cases]. / Powiklania zakrzepowo-zatorowe w ortopedii-sadowo-lekarska ocena prawidlowosci postepowania lekarskiego w wybranych przypadkach.

Thromboembolic events continue to account for a high percentage of complications after orthopedic surgery. Of significance in prevention of these diseases is appropriate pharmacotherapeutic prophylaxis, both pre and postoperative, as well as orthopedic and trauma surgeons being aware of the risk of such complications and of possibilities of avoiding or minimizing thromboembolic events. The authors present some cases that were certified in Chair of Forensic Medicine, Silesian Medical University in Katowice, in which thromboembolic complications did develop after conservative or surgical orthopedic treatment, emphasizing possible difficulties in unequivocal assessment of the cause-effect relationship between the employed treatment and the thromboembolic event in the aspect of medico-legal certification.

[A serious group accident in Zabrze-Bielszowice Coal Mine--medico-legal evaluation of health consequences for the purpose of criminal proceedings]. / Ciezki wypadek zbiorowy w KWK Zabrze-Bielszowice--sadowo-lekarska ocena nastepstw zdrowotnych dla potrzeb postepowania karnego.

On February 23/24, 2003, in Zabrze-Bielszowice coal mine, 840 m below the surface, a methane blast occurred twice. In group accidents, a total number of 35 miners were injured; the majority of them experienced extensive thermal injuries. The authors compiled a list of body injuries, including their character, severity, initial clinical assessment and types of employed medical procedures, taking into consideration also medical certification of the Social Insurance and results of medico-legal examinations of the miners. Department of Forensic Medicine in Katowice prepared comprehensive medico-legal opinions during preparatory prosecuting proceedings followed by precise, individualized opinions for the court, concerning legal qualification of the injuries, their underlying mechanisms, but also mental and physical suffering, treatment-associated hardships and prognosis for the future.

[A remarkable case of diagnostic difficulties in chronic hepatic pathology caused by a metabolic disorder (Wilson's disease)--evaluation of medical management]. / Szczególny przypadek trudnosci diagnostycznych przewleklej patologii watroby uwarunkowanej zaburzeniami metabolicznymi w aspekcie--oceny prawidlowosci postepowania lekarskiego.

Wilson's disease is a rare genetic disorder. It is characterized by excessive copper deposits--mainly in parenchymal organs--leading to their damage and serious dysfunction. Because of its uncommonness, slow and insidious course and diversified clinical manifestation, diagnosing the condition is not easy, even for experienced physicians. As it is indicated by medical practice, such a situation may occur even in tertiary care centers, which have at their disposal extensive and highly specialist diagnostic tools and vast clinical experience in diagnosing such diseases. As an example, the authors present a case of a 38-year-old man, suffering from Wilson's disease, who was misdiagnosed and treated for another metabolic disease. Although the presented case was difficult and diagnostically complex, it should be emphasized that a diagnostic error led to inappropriate therapeutic decisions and in consequence delayed proper treatment.

Time-related morphometric studies on CD34 protein expression in the cerebral blood vessels after fatal brain contusions.

In our previous work, we have discussed the importance of neurofilaments in determination of the age of brain contusions. The purpose of this paper is to examine a possibility of angiogenesis-related assessment of the age of brain contusions by means of morphometric analysis of the CD34 expression in the contused sites. The researched material comprised 90 cases divided into nine groups according to the time of death: immediately on the spot, 12 hours, 24 hours, 2 days, 3 days, 4 days, 5 days, 6 days, and 7 days after the head trauma. Immunohistochemically stained CD34 antigen was evaluated quantitatively with the Met-Ilo application. The results were then tested statistically for any regularities. Generally, there was a tendency to increase both the number of blood vessels and blood vessels area fraction in time. The results of Kruskal-Wallis analysis showed that numbers of blood vessels were significantly different in the first seven days after the head trauma, but significance levels of specific sample pairs, as calculated by Dunn's test, were not statistically significant. Thus, the conclusion is that the proposed method is of no considerable value in determination of the age of brain contusions.

[Iatrogenic biliary ducts lesions after laparoscopic cholecystectomy: a medical technical error or a therapeutic failure in a routinely performed procedure. A medico-legal evaluation of selected cases]. / Jatrogenne uszkodzenie dróg zólciowych z nastepowa szkoda zólciowa w przypadkach cholecystektomii metoda laparoskopowa: blad medyczny techniczny czy niepowodzenie lecznicze. Ocena sadowo-lekarska wybranych przypadków.

Laparoscopic cholecystectomy due to cholelithiasis is associated with a higher risk of intraoperative lesions of biliary duct in comparison to classic surgery. Technical difficulties, a limited access to operating area, the presence of cholecystic adhesions and inflammatory lesions, as well as possible anomalies or anatomical variations of the extrahepatic biliary ducts pose the risk of damaging the biliary tract. At times, laparoscopic procedures are performed by surgeons with insufficient operator skills and qualifications. The medico-legal evaluation of intraoperative damage to the biliary tract with resulting complications--the so-called "biliary damage"--is very difficult. The presented analysis included six cases of intraoperative biliary ducts lesions evaluated by the Forensic Medicine Department, Medical University, Katowice. Three instances were associated with investigations carried out by public prosecutors in medical error cases, and in three others, civil cases were brought in the court, with the plaintiffs advancing a claim. While defining the scope of the management--both diagnostic, therapeutic and decision-making--in the pre-, intra- and postoperative period, attention was drawn to the prescriptive character of patient management in such cases, including indications for laparoscopic surgery, an increased potential therapeutic risk that also included a possibility of the patient developing "normal, typical" complications, referring the above factors to the scope and limits of the physician's professional and criminal liability and analyzing them to assess whether a medical error had been committed, or else the events had represented a therapeutic failure within the limits of the accepted therapeutic risk. A separate problem emphasized by the authors focused on difficulties in objective evaluation of health-associated consequences that might be defined in a tabular manner as long-term or permanent detriment to health.

[Sudden cardiac death--difficulties in passing a medico-legal opinion for a civil or insurance claim]. / Nagly zgon sercowy--problemy w opiniowaniu sadowo-lekarskim dla potrzeb cywilnych i odszkodowawczych.

Cases of sudden death without prior noticeable clinical symptoms and morphological indicators found at autopsy pose serious problems in medico-legal opinionating. Developing an expert opinion is practically impossible if the body has not been autopsied, as well as in cases, when no histopathological and chemical-toxicological tests have been performed. In the course of proceedings aiming at establishing a given event as a work accident and address the issue of compensation claim, courts of labor and insurance claims, as well as civil courts often demand determination of the cause of death by answering whether the demise resulted from a myocardial infarction or whether the death may be regarded as an accident at work. The authors present problems associated with opinion formulation that are faced by the expert and propose their own model of establishing an opinion in the above mentioned cases

[Exposure to the risk of loss of life or detriment to health as a consequence of an organizational error--a case report]. / Narazenie na niebezpieczenstwo utraty 2ycia lub ciezkiego uszczerbku na zdrowiu, jako konsekwencja bledu organizacyjnego - analiza przypadku.

Frequent changes in organization of the Polish health care sector observed over the past few years may lead to disruption of work in health care institutions, particularly in tertiary, highly specialist centers. Such a situation may result in decreasing the quality of services, what may potentially cause exposing the patient to the risk of death or severe detriment to health. To illustrate the problem, the authors present a case of a 45-year old man, where some organizational errors led to a delay in rendering medical care and in consequence to a poorer therapeutic outcome and poorer prognosis.

[Problems in medical certification of posttraumatic neuropsychiatric disorders for the purpose of criminal and civil law proceedings]. / Trudno'sci opiniodawcze w ocenie pourazowych zaburzen neuropsychiatrycznych dla potrzeb postepowania karnego i cywilno-odszkodowawczego.

In the past several years, in the material of Forensic Medicine Department, Medical University of Silesia in Katowice, a significant increase has been noted in the number of cases associated with CNS dysfunctions, either as isolated conditions or in association with posttraumatic disorders. In the majority of cases, such dysfunctions were causally related to a head trauma. The Faculty of the Department are also requested with an increasing frequency to estimate the association between the observed neuro-psychiatric abnormalities and complaints and the undue exposure to a stress factor. In the present publication, the authors have emphasized difficulties in assessing the complaints reported by the claimants and the possibilities of objectivization of such complaints by neuro-psychiatric examinations. They also stress problems in application of obligatory ICD 10 terms denoting dysfunctions of the central nervous system in medico-legal opinions.

[On the causes of medical errors in life-threatening conditions--a medico-legal assessment based on the material of the chair and Department of Forensic Medicine, Medical University of Silesia, Katowice, collected between 2000 and the end of June, 2006]. / O przyczynach bledu medycznego w stanach zagrozenia zycia-- ocena sadowo-lekarska na podstawie analizy materialu aktowego Katedry i Zakladu Medycyny Sadowej w Katowicach od 2000 roku do konca czerwca 2006 roku.

The authors analyzed the medico-legal opinions on medical management issued by the Chair and Department of Forensic Medicine Katowice between 2000 and the end of June 2006. Among 101 cases, in which medical errors were recognized, in 82 instances inappropriate medical management was associated with direct life-threatening conditions, such as acute cardiac syndrome, cerebrocranial injuries, cerebral an aortic aneurysms, pulmonary embolisms, acute abdominal diseases, such as perforated gastric and duodenal ulcers, appendicitis, post-traumatic rupture of the spleen, and acute metabolic disorders. The majority of errors was diagnostic in character and involved the staff of emergency services, admission rooms and detoxification centers. The investigators also drew attention to factors affecting the degree of risk of medical error commission and the most common causes of inappropriate medical in life-threatening conditions.

[Differentiation possibilities in posttraumatic neuropsychiatric disorders in medico-legal certification]. / Mozliwosci róznicowania pourazowych schorzen neuropsychiatrycznych dla opiniowania sadowo-lekarskiego.

This paper is a continuation of the previous work entitled "Difficulties in estimation of posttraumatic neuropsychiatric disorders for the purpose of criminal and civil law proceedings" presented during the 5th National Symposium "Days of Medical Certification", Poznan 2005. Referring to the then mentioned problem, the authors present in a greater detail the possibilities of objectivization of claims using simple psychiatric and psychological diagnostic tools