Is the role of forensic medicine in the covid-19 pandemic underestimated?

We believe that forensic medicine should play a significant role in the COVID-19 pandemic. Forensic pathologists should ask and answer various questions through autopsy cases during the COVID-19 period, thus providing a significant contribution to science. Some of the potential roles of forensic medicine in this issue include: determining the exact cause of death among the deceased who were SARS-CoV-2 positive, contribution to the accuracy of mortality statistics, understanding pathological mechanisms of COVID-19, tracking the presence of the virus over time, survival of the virus after death as well as dealing with medicolegal issues. A detailed multidisciplinary analysis of autopsy samples would undoubtedly help understand this new illness and its clinical management. Therefore, autopsies during the COVID-19 pandemic should not be an exception, but certainly a rule.

Late Occurrence of Raccoon Eyes: The Role of the Ligature.

This case represents a planned complex suicide in which the victim combined gunshot to the head and hanging. The most interesting finding in the presented case was pale face, but without any visible injury to it at the time the body was found (more than 24 hours after death), whereas at autopsy (20 hours later), black eyes were prominent. The removal of the ligature led to the decompression of the neck and its blood vessels with consequential blood redistribution, which, alongside the liquid state of blood, resulted in the aforementioned finding. Considering the described postponed appearance of periorbital ecchymosis, this kind of finding suggests that great caution is necessary when interpreting hematomas in terms of their vitality.

Gunshot Suicide: Cherry-Red Discoloration of the Temporal Muscle Beneath the Exit Wound.

The article describes a case of gunshot suicide to the head in a 51-year-old man. The entrance wound was located in the left temple and exit wound in the right temple. The entrance wound had the characteristics of a hard-contact gunshot wound. The most interesting finding in this case was cherry-red discoloration of the right temporal muscle surrounding the exit wound. This finding could make the determination of the entrance versus exit gunshot wound challenging, especially if the wounds are of atypical appearance. In addition, the finding described in the presented case could be the proof that carbon monoxide may follow the missile through the body and may be prominent in the soft tissue at the exit.

Copper-Beaten Skull Appearance as a Response of Chronically Increased Intracranial Pressure.

We present a case of 19-year-old female patient, who was injured in childhood and subsequently developed hydrocephalus, chronic elevation of intracranial pressure (ICP), and a copper-beaten skull appearance. Chronic hydrocephalus leads to an increase in intraventricular pressure, causing ventricular expansion and dislocation of adjacent cerebral structures. According to literature data, it has been hypothesized that chronically elevated ICP in persons with craniosynostosis, and other developmental structural abnormalities of the skull, may induce bone remodeling. In cases with copper-beaten skull appearance, increased ICP should be considered as a cause of death (after exclusion of all other obvious causes), and for that reason, careful examination of the skull appearance is suggested. This finding could be useful in cases with advanced postmortem changes, where it might indicate some medical conditions of the deceased or could even be considered unique feature for body identification, although this rationale should be used with great caution.

The use of gasoline in a complex suicide.

This case represents a planned complex suicide in which the victim shot himself in the head after dousing his living quarters with gasoline. The spark induced ignition of gasoline vapors and led to an explosion. Liquid gasoline is not flammable, but the vapor/mixture of gases above the surface of the liquid is. In this case the victim might have counted on the resulting fire and/or explosion, but we are not able to tell that with certainty. We have assumed that the plan was for the gunshot to the head to lead to instantaneous death, and for the flame and/or explosion to lead to the destruction of the body. The explosion launched the body out of the apartment, meaning it did not get charred. It is also our assumption that the victim did not expect that the explosion would eject his body from the flames and lead to less severe burns than he had calculated, making this complex suicide "less successful" than he had planned.

The association between pro-arrhythmic agents and aortic stenosis in young adults: is it sufficient to clarify the sudden unexpected deaths?

Most young patients with mild-to-moderate aortic stenosis show no symptoms, and sudden death appears only occasionally. We hypothesised that malignant ventricular arrhythmias could be responsible for the high incidence of sudden death in such patients. If multiple factors such as asymptomatic aortic stenosis in association with arrhythmia-provoking agents are involved, could it be sufficient to account for sudden unexpected death? In this study, eight cases of sudden death in young adults, with ages ranging from 22 to 36 years, who had never reported any symptoms that could be related to aortic stenosis, were investigated. Full autopsies were performed, and congenital aortic stenosis in all eight cases was confirmed. DNA testing for channelopathies was negative. Comprehensive toxicological analyses found an electrolyte imbalance, or non-toxic concentrations of amitriptyline, terfenadine, caffeine, and ethanol. Collectively, these results suggest that congenital asymptomatic aortic stenosis without cardiac hypertrophy in young adults is not sufficient to cause sudden death merely on its own; rather, an additional provoking factor is necessary. According to our findings, the provoking factor may be a state of physical or emotional stress, a state of electrolyte imbalance, or even taking a therapeutic dose of a particular drug.

Analysis of Closed Soft Tissue Subcutaneous Injuries-"Impact Décollement" in Fatal Free Falls From Height-Forensic Aspect.

The aim of this study was to assess the frequency of "décollement," traumatic lesions of subcutaneous soft tissue, among victims fatally injured because of falls from different heights. Three hundred seventy-five cases of fatalities due to injuries acquired when falling from various heights onto a solid, flat surface, in which the complete forensic autopsy was performed, were analyzed. Décollement was noted in 125 (33%) of the cases. Comparative analysis of groups with and without décollement and observed factors has shown that the height of fall and the manner of death have statistically significant influence on décollement appearance. With regard to suicidal, accidental, or undefined origin of death décollement is statistically more common in accidental deaths. Décollement provides important clues for forensic reconstruction and could be a significant indicator of the body's position at primary impact and the height from which the victim has either jumped or fallen.

Proper death certification in the time of the COVID-19 pandemic: Forensic perspective.

It is well known that the quality of death certificates determines the accuracy of public health mortality data. In the light of a pandemic, forensic pathologists must understand the true definition of a COVID-19 death and the requirements for filling out the death certificate, as these are critical for maintaining accurate and trustworthy mortality data. To determine the scope and evolution of the COVID-19 epidemic, accurate death certification is critical. We believe that COVID-19 should be enlisted under part II or section "note" (if it exists in DC form in a particular country) of the DC in all suicide instances and putrefied bodies with positive autopsy swabs for SARS-CoV-2. In addition to our suggestions for the completion of the DC in some COVID-19 instances, we feel that forensic pathologists should follow the WHO criteria for proper DC completion in COVID-19 cases. Better physician education at this stage of the pandemic would increase adherence to existing (WHO and CDC) standards. As a result, forensic pathologists with competence in death certification could help by teaching treating physicians in this area.

Case Report: Post-mortem Histopathological and Molecular Analyses of the Very First Documented COVID-19-Related Death in Europe.

In Europe, the first case of coronavirus disease (COVID-19) and the first COVID-19-related death were reported in France on January 24th and February 15th, 2020, respectively. Officially, the first case of COVID-19 infection in the Republic of Serbia was registered on March 6th. Herein, we presented the first case of retrospective detection of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in the post-mortem-obtained vitreous humor (VH), which took place on February 5th, 2020. This is the first death in Europe proven to be caused by COVID-19 by means of post-mortem histopathological and molecular analyses. Based on this finding, it appears that SARS-CoV-2 has been spreading faster and started spreading much earlier than it had been considered and that COVID-19 was probably the cause of the much-reported pneumonia of unknown origin in January and February 2020.

The significance of post-mortem vitreous calcium concentration in forensic practice.

Calcium, as one of the main extracellular ions, maintains a key role in numerous biologic functions. For forensic purposes, it was analyzed mostly for estimation of postmortem interval (PMI). We have designed our experiment with the concept that the repetitive withdrawal of vitreous humor (VH) might clarify the postmortem metabolism of calcium in greater detail to estimate the PMI. Accordingly, 248 samples of VH from 31 autopsy cases were evaluated over three years; samples (0,1 mL of VH) were taken and analyzed at equal time intervals after death-every three hours until 24 h after death. Each sample was centrifuged and analyzed using the ARCHITECT C SYSTEM 8000. Moreover, functional relationship between PMI and calcium concentration was established: PMI (hours) = [Ca2+] × 13.696-7.843. Although the concentration of calcium in VH in the analyzed group increases with time, the coefficient of variation for the regression (CVreg = 46.8%) indicates that this correlation is not so strong, meaning that the level of predictiveness of calcium for estimation of time since death is poor when is not used in combination with other relevant substances.

Two cases of firearm-related murder-suicide: Forensic implications of the ability to act.

One of the most important tasks in forensic medicine is differentiating between a homicide and a suicide, especially in cases where more than one self-inflicted gunshot wound is present. The significance is even greater when the victim's ability to act after the first gunshot is questionable. In these cases, the only way to determine the sequence of the shots is to consider the severity of the injuries and their disabling effect. Therefore, the importance of previously mentioned facts is even greater, not only in everyday forensic practice but also in court. The questions dealing with the crime scene and interpretation of the wounds' trajectories are of the utmost importance.

Mathematical model in post-mortem estimation of brain edema using morphometric parameters.

Current autopsy principles for evaluating the existence of brain edema are based on a macroscopic subjective assessment performed by pathologists. The gold standard is a time-consuming histological verification of the presence of the edema. By measuring the diameters of the cranial cavity, as individually determined morphometric parameters, a mathematical model for rapid evaluation of brain edema was created, based on the brain weight measured during the autopsy. A cohort study was performed on 110 subjects, divided into two groups according to the histological presence or absence of (the - deleted from the text) brain edema. In all subjects, the following measures were determined: the volume and the diameters of the cranial cavity (longitudinal and transverse distance and height), the brain volume, and the brain weight. The complex mathematical algorithm revealed a formula for the coefficient ε, which is useful to conclude whether a brain edema is present or not. The average density of non-edematous brain is 0.967 g/ml, while the average density of edematous brain is 1.148 g/ml. The resulting formula for the coefficient ε is (5.79 x longitudinal distance x transverse distance)/brain weight. Coefficient ε can be calculated using measurements of the diameters of the cranial cavity and the brain weight, performed during the autopsy. If the resulting ε is less than 0.9484, it could be stated that there is cerebral edema with a reliability of 98.5%. The method discussed in this paper aims to eliminate the burden of relying on subjective assessments when determining the presence of a brain edema.

Fatal Penetrating Injuries Sustained by High-pressure Water Jet Unit.

The high-pressure water jet unit is a generator of frequent burst of water jets. The water jet reaches very high speeds and is able to cause wounds similar to those of high-velocity projectiles. In the presented case, unusual fatal injuries sustained by water jet are presented. Operating with the unit, an untrained worker accidentally activated a high-pressure water jet unit, and the extremely high pressure of water liberated the jet unit from his hand and whirled it around him. A jet stream of water ran across his body and caused fatal penetrating injuries in the femoral region. The edges of the wound were mainly sharp with contusion rings on the skin beyond the edges. Exploring the inside of the canals during the autopsy, the left femoral artery and vein were found to be completely transected. The resemblance to a firearm entry wound and the severity of the internal injury make it a noteworthy entity.

Multiple stabbing in sex-related homicides.

It is possible that sexually driven homicides are the consequence of sexual deviation, but more often than not the main cause of such homicides stems from a non-paraphilic person's emotional component. It is known that homicides which involve multiple stabbing are very often the result of the assailant's highly expressed affect. This study tries to establish whether such homicides are essentially related to the sexual motives of the murderer. This paper is conducted through a retrospective autopsy study that includes 766 cases of homicides. These were reviewed and analysed according to the motive of the homicide, as well as by method, age, and gender of the victim, and the relationship between the victim and the assailant. The motives of homicides are classified as non-sexual and sexual, including homicides related to rape, jealousy, amorous affairs outside of an established relationship, deviant sexual behaviour of psychiatric patients, paraphilia, and disturbed emotional relationships between the victim and the assailant. Cases include both hetero- and homosexual relationships. Multiple stabbing occurs significantly more frequently in sex-related homicides (≥ 3 stab wounds) than in other homicide types. When the criteria for multiple stabbing are changed (≥ 4, 5, or 25 stab wounds), the percentage of sex-related homicides rises in every group in relation to the increased number of wounds. Sensitivity and specificity are represented by ROC curves for 3, 5 and 7 stab wounds. The correlation coefficients between multiple stabbing and sex-related homicides regarding gender are all near 0.9. For female victims, all homicides committed by 25 and more stab wounds were found to be sex-related. Statistically, jealousy was the most frequent motive for sex-related multiple stabbing homicides. Regardless of age, homicides involving multiple stabbings should be considered sex-related, especially when the victim is female.

Pulmonary thromboembolism after air travel: two case reports, the review of literature and forensic implications.

Air travel as a risk factor for pulmonary thromboembolism (PTE) is rarely described in forensic literature. Two cases of PTE after air travel are presented in this report. Each flight was intercontinental and lasted for more than 10 h, resulting in typical "traveler's thrombosis" within 2 weeks. In both cases, the risk factors were age, duration of flight and also peripheral circulation problems caused by heart (hypertension, arrhythmia), and varicose veins failures. Possible pathophysiological mechanisms of thrombus formation in these cases were blood flow stasis from prolonged recumbence, reduced function of the lower leg muscle pump, dehydration, and hypobaric hypoxia. Legal aspects of death due to PTE after air travel and possible responsibility of air companies are discussed.