Brixia Chest X-ray Score, Laboratory Parameters and Vaccination Status for Prediction of Mortality in COVID-19 Hospitalized Patients.

Chest X-ray has verified its role as a crucial tool in COVID-19 assessment due to its practicability, especially in emergency units, and Brixia score has proven as a useful tool for COVID-19 pneumonia grading. The aim of our study was to investigate correlations between main laboratory parameters, vaccination status, and Brixia score, as well as to confirm if Brixia score is a significant independent predictor of unfavorable outcome (death) in COVID-19 patients. The study was designed as a cross-sectional multicentric study. It included patients with a diagnosed COVID-19 infection who were hospitalized. This study included a total of 279 patients with a median age of 62 years. The only significant predictor of unfavorable outcome (death) was Brixia score (adjusted odds ratio 1.148, p = 0.022). In addition, the results of the multiple linear regression analysis (R2 = 0.334, F = 19.424, p < 0.001) have shown that male gender (B = 0.903, p = 0.046), severe COVID-19 (B = 1.970, p < 0.001), and lactate dehydrogenase (B = 0.002, p < 0.001) were significant positive predictors, while albumin level (B = -0.211, p < 0.001) was a significant negative predictor of Brixia score. Our results provide important information about factors influencing Brixia score and its usefulness in predicting the unfavorable outcome (death) of COVID-19 patients. These findings have clinical relevance, especially in epidemic circumstances.

Double suicidal gunshot wounds to the heart.

A case of double gunshot wounds to the heart is reported, where police investigations determined the manner of death to be suicide. In addition, the autopsy findings supported this conclusion. The localization, appearance, and mutual relations of the inflicted wounds, as well as the direction of the bullet trajectories, helped to determine the most probable sequence of events. The victim had been able to act after the first shot and inflict the second shot as the conduction system of the heart was at least partially preserved. Even when the circumstances indicate the most probable manner of death, multiple gunshot wounds represent a challenge for forensic pathologists; a victim's ability to act after the first shot must be determined with respect to the degree of initial incapacitation.

[Bullet embolism in a case of homicide: case report].

INTRODUCTION: Bullet embolism is a special form of embolism, where embolus is either a bullet or its fragment. Bullet penetrates through the injured part of the body into circulation and then travels to a distant part of the body, until it gets blocked in a vessel of the same diameter as the bullet. CASE OUTLINE: We are presenting a case of gunshot injury in a 26-year-old male, found unconscious on the passenger seat, with the gunshot injury of the right hand and hemithorax, who died two hours after admission to hospital. Post-mortem X-ray revealed the presence of a metallic foreign body - a bullet, in the level of the left femoral neck. The autopsy revealed entrance and exit gunshot wounds of the upper third of the right upper arm.There was a second entrance gunshot wound, and the bullet passed through the right hemithorax and the right lung, and then through the intervertebral disc between the eighth and ninth thoracic vertebrae, and also making a complete laceration of the wall of the thoracic aorta, in the right posterior semicircumference. The slightly deformed bullet, caliber 7.65 mm, was found embedded in the lumen of the vessel at the bifurcation of the deep femoral artery from the left femoral artery. CONCLUSION: Bullet embolism is a rare complication of gunshot wounds. It should be suspected in any gunshot wound victim without an exit wound, or the lack of a missile in the bullet pathway, or if there are premortem signs or symptoms unexpected for the presumed pathway of the bullet, such as distant ischemia or infection. In these cases, some of postmortem imaging techniques should be used to save time in diagnosis, treatment and at autopsy.

Cervical soft tissue emphysema in hanging--a prospective autopsy study.

The underlying mechanism of cervical soft tissue emphysema (CSTE) in hanging remains unclear. The aim of this study was to determine the frequency of CSTE in cases of hanging. The sample included 83 deceased persons, average age 55.3 ± 17.9 years. CSTE was established in 44 cases. CSTE is presented as frothy air, soap bubble-like formations in superficial and/or deep connective tissue between the neck muscles up to the ligature mark, visible during gross neck examination, using special neck autopsy technique-preparation of the neck organs in layers. The interpretation of positive CSTE must be taken with caution: it could be an antemortem phenomenon possibly because of either Macklin Effect or direct or indirect trauma to the cervical airways, as well as an ante- or postmortem artifact.

Suicidal single gunshot injury to the head: differences in site of entrance wound and direction of the bullet path between right- and left-handed--an autopsy study.

The aim of this study was to determine the differences in the anatomical site of a gunshot entrance wound and the direction of the bullet path between right- and left-handed subjects who committed a suicide by a single gunshot injury to the head. The retrospective autopsy study was performed for a 10-year period, and it included selected cases of single suicidal gunshot head injury, committed by handguns. We considered only contact or near-contact wounds. The sample included 479 deceased, with average age 47.1 ± 19.1 years (range, 12-89 years): 432 males and 47 females, with 317 right-handed, 25 left-handed, and 137 subjects with unknown dominant hand. In our observed sample, most cases involved the right temple as the site of entrance gunshot wound (about 67%), followed by the mouth (16%), forehead (7%), left temple (6%), submental (2%), and parietal region (1%). The left temple, right temple, and forehead were the sites of the gunshot entrance wounds, which were the best predictors of the handedness of the deceased (Spearman ρ = 0.149, P = 0.006). Our study showed that the direction of the bullet intracranial path in cases of suicide was even a more potent predictor of the handedness of the deceased (Spearman ρ = 0.263, P = 0.000; Wald = 149.503, P = 0.000).

Hyoid-laryngeal fractures in hanging: where was the knot in the noose?

The aims of this study were to determine the frequency of hyoid-laryngeal fractures in hanging in relation to the position of the ligature knot, to reconstruct the location of the ligature knot in cases of hanging when the furrow is not detectable on the skin, and to identify the possible mechanism of neck structure injuries. We report a retrospective autopsy study which included 557 cases of suicidal hanging: 413 men and 144 women, with an average age of 52.4 +/- 17.8 years. In 57.3% of them, hyoid-laryngeal fractures were found (average age was 54.3 +/- 16.5 years): 15.1% had only hyoid bone fracture, 26% had only thyroid cartilage fracture and 16.2% had both types of injury at the same time. Hyoid-laryngeal fractures were found more often in persons aged over 30 years. Hyoid bone fracture was a weak predictor of ligature knot position in our sample. Fracture frequencies of the thyroid cartilage show a statistically significant difference in relation to the ligature knot position among persons older than 30 years, which indicated the ipsilateral and posterior position of the knot. Absence or presence of any form of hyoid-laryngeal fracture indicated that knot position was anterior or posterior, respectively. The derived data would be useful for cases where the ligature has been removed from the body of the deceased shortly after hanging, where the noose is unavailable, and in cases where the ligature mark has faded such as with soft ligatures removed promptly or in decomposed bodies.

Planned complex occupation-related suicide by captive-bolt gunshot and hanging.

Planned complex suicides are committed by using two or more previously planned methods simultaneously to make sure that death will occur even if one method fails. Herein, we presented a case of occupation-related planned complex suicide, committed by captive-bolt gunshot and hanging. A 29-year-old man, who worked as a butcher, was found dead in the stable, hanging by the neck with a captive-bolt gun embedded in the forehead region of his head. The hanging was complete. Along the bolt canal were bone fragments, and at the end of the path was the punched-out fragment of the skin and soft tissue. There were no fractures of the hyoid bone and laryngeal cartilages, and a superficial hemorrhage was present in the right sternocleidomastoid muscle. Our case underlines the utility of forensic autopsy and death scene investigation in reconstructing the mechanism of death, as well as the dynamics of the event.

Laryngeal choking on food and acute ethanol intoxication in adults--An autopsy study.

The retrospective autopsy study included 98 adults who died because of laryngeal choking on a bolus of food: 67 men and 31 women (χ(2)=6.843, p<0.01), average age 58.61±15.87 years (range 26-92 years). Most of the subjects had poor dentition (χ(2) =34.327, p<0.01). Twenty individuals died in medical institutions, and 78 were nonhospitalized individuals. More than a third of the nonhospitalized individuals were under the influence of ethanol at the moment of death: average blood concentration 8.3g/dL (SD=11.0), ranged from 5.0 to 36.0. Nonhospitalized persons were at the moment of event more often under influence of ethanol than the subjects in control group (χ(2)= 38.874, p<0.01), and at the same time significantly more intoxicated (z=-7.126, p<0.01). Our study pointed out that poor dentition and impairment of the swallowing reflex, as a consequence of ethanol intoxication in individuals without mental disorders, were the most important risk factors for bolus death.

Brain-stem laceration and blunt rupture of thoracic aorta: is the intrapleural bleeding postmortem in origin?: an autopsy study.

Some of the fatally injured car occupants could have had both blunt rupture of thoracic aorta with great amount of intrapleural blood, and pontomedullar laceration of brain-stem as well, with both injuries being fatal. The aim of this study was to answer if all intrapleural bleeding in these cases was antemortem, or the bleeding could also be partially postmortem. We observed the group of 66 cases of blunt aortic rupture: 21 case with brain-stem laceration, and 45 cases without it. The average amount of intrapleural bleeding in cases without brain-stem laceration (1993 ± 831 mL) was significantly higher than in those with this injury (1100 ± 708 mL) (t = 4.252, df = 64, P = 0.000). According to our results, in cases of the thoracic aorta rupture with concomitant brain-stem laceration, the amount of intrapleural bleeding less than 1500 mL, should be considered mostly as postmortem in origin, and in such cases, only the brain-stem injury should be considered as cause of death.

[Sudden cardiac death and acute drunken state--autopsy study].

INTRODUCTION: Sudden natural death occurs unexpectedly in apparently healthy subjects, or in persons during an apparent benign phase in the course of disease. The most common cause is sudden cardiac death, which is sometimes the first and last manifestation of coronary heart disease. Alcohol directly influences excitation of myocytes, and therefore provokes arrhythmias and possibly, sudden cardiac death. OBJECTIVE: To establish the frequency of sudden cardiac death in cases of acute alcohol intoxication, to determine blood alcohol concentration at the moment of death, and to determine frequency and level of ethanol intoxication in chronic alcohol abusers, as well as causes of sudden death in those cases. METHOD: Retrospective autopsy study was performed for a three-year-period. We analyzed cases of sudden natural death, in relation to age and gender, cause of death, and blood alcohol concentration (at least 0.5 g/L). We considered the person to be a chronic alcoholic abuser if gross examination of organs during autopsy showed changes typical for excessive and habitual alcohol consumption. RESULTS: Our sample consisted of 997 cases: 720 men and 277 women, average age 62.0 +/- 15.2 years (min = 11; max = 98). Total of 753 of them died of sudden cardiac death: much more men (chi2 = 167.364; p = 0.000), significantly younger than women (t = 6.203; p = 0.000). We determined acute alcohol intoxication in 73 persons--average blood alcohol concentration 1.85 +/- 1.01 g/L (min = 0.55; max = 3.85), and 61 of them died of cardiovascular diseases (chi2 = 236.781; df = 5; p = 0.000). CONCLUSION: In our observed sample, not many persons were under acute alcohol intoxication (around 7%). Most commonly, they were chronic alcohol abusers who died due to exacerbation of chronic heart disease, mildly or moderately intoxicated--the younger, the drunker.

[Hypothermia as the cause of death in forensic pathology: autopsy study].

INTRODUCTION: The body cooling process goes through few clinical phases. These are followed by some morphological thanatological changes such as frost erythema and Wischnewsky's spots, which are used in diagnosis of death due to hypothermia. In such cases there is no any specific autopsy finding. OBJECTIVE: To establish the frequency of hypothermia as the cause of death for a ten-year-period, and to analyze the sample according to gender and age, risk factors and autopsy findings of subjects. METHODS: A retrospective autopsy study was performed for a ten-year-period (total of 12,765 forensic autopsies). The relevant data were collected from autopsy records, police reports and heteroanamnestic interviews. The sample was analyzed according to gender, age, scene of death, blood alcohol concentration, risk factors, and autopsy findings of all observed subjects. RESULTS: The sample included 67 subjects, 42 males and 25 females (chi2 = 4.31; p < 0.05), of average age 63.9 +/- 14.7 years (min=27, max=92; med=65, mod=55). Nineteen of subjects were found at in-door places. In 13 subjects blood alcohol concentration ranged from 0.50 to 3.32 promille (average 1.81 +/- 0.93). The younger the observed subject was, the higher the blood alcohol concentration (p = -0.251; p = 0.04). One third of the observed subjects were chronic alcohol abusers. Thirteen persons had psychiatric diseases. In 43 observed subjects the concomitant appearance of frost erythema and Wischniewsky's spots were established (chi2 = 49.59; df = 3; p < 0.001). CONCLUSION: In the analyzed ten-year period hypothermia was not often the cause of death; it was disclosed only in 0.5% of the total number of the studied autopsies. The most of the deceased were older males with cardiovascular problems found in unprotected open-air places. The most frequent thanatological findings in the analyzed subjects were frost erythema and Wischnewsky's spots.

[Suicidal asphyxiation by propane-butane mixture inside a plastic bag: case report].

INTRODUCTION: Volatiles are easily accessible and widely used in a form of liquid petroleum gas. Death as a consequence of inhalation of volatiles can be either accidental or suicidal. CASE OUTLINE: We present a 62-year-old men who committed suicide by placing a plastic bag over the head and inhaling propane-butane mixture from a domestic gas tank. A rubber hose was attached to the tank valve and connected with the plastic bag. The body of the deceased showed signs of advanced postmortal changes. A suicidal note was found at the scene. CONCLUSION: Propane-butane mixture, i.e. liquified petroleum gas leads to the depletion of oxygen in the air consequently causing hypoxia and anoxia, and therefore, unconsciousness and eventual death. The mechanisms of death in cases of volatile inhalation include cardiac arrhythmias, reflex cardiac vagal inhibition, and/or central nervous system depression. Similar mechanisms occur in cases of asphyxiation with a plastic bag. The reconstruction of the event in this case was based, not so much on autopsy findings (because of significant putrefaction changes), but on the police investigation and traces found at the scene.

[Unplanned complex suicide--two case reports].

INTRODUCTION: The term complex suicide refers to suicides in which multiple suicidal methods are utilized, as opposed to simple suicide successfully done after one attempt. In planned complex suicides two or more methods are employed simultaneously in order to make sure that death will occur after failure of previous attempt. In unplanned complex suicides, several other methods of suicide tried after the first chosen method either failed or was too painful. OUTLINE OF CASES: We report two cases of unplanned complex suicides. The first case was a female who first tried to commit suicide by cutting the wrists, and then hanged herself. In the other case, a male first tried to commit suicide by stubbing his chest with a knife, and then jumped into a well and drowned himself. In both reported cases the second, successful suicidal method was of higher lethality score. CONCLUSION: From the forensic point of view, the presence of several injuries of different origin strongly suggests infliction by other person. The event could be reconstructed, based on autopsy findings and traces found at the scene.

The significance of pontomedullar laceration in car occupants following frontal collisions: A retrospective autopsy study.

The aim of this study was to determine the frequency of brainstem pontomedullar lacerations among fatally injured car occupants in head-on collisions, as well as the concomitant cranial injuries, and to establish a possible underlying mechanism for brainstem laceration. Brainstem pontomedullar lacerations (PML) are often associated with fractures of the skull base (hinge, ring or pyramidal fractures) or with cervical spine fractures. Out of 705 cases of deceased car occupants involved in head-on car collisions, some form of head injury was present in 447 cases (63.4%). These cases included 353 men and 94 women with an average age of 38.2±15.8 years (range 16-89 years). The collected cases included 229 drivers, 164 front-seat and 54 rear-seat passengers. PML were present in 67 of these cases (15%), 50 men and 17 women with an average age of 42.9±15.6 years (range 15-77 years), including 32 drivers, 26 front-seat and 9 rear-seat passengers. In all of these cases the brainstem laceration was partial and the depth varied approximately from 4mm to 8mm. To understand the mechanisms by which PML occurs, we classified the head impact areas into frontal, lateral, posterior and chin area, depending on the injuries to the soft tissue of the head and scalp, as well as facial and cranial fractures. Injury impact area of the head was a good predictor of PML occurrence (χ(2)=131.112, df=3, p=0.000). Chin impact was most often associated with PML-38 cases (Wald. coeff.=5.805, df=1, p=0.016). Presence or absence of mandibular fracture was significant for PML occurrence (χ(2)=11.413, df=1, p=0.001): persons without mandibular fracture have 2.3 times greater risk for PML than those with fracture (odd ratio=7.196). Among the observed skull base fractures, the best predictor of PML was ring fracture (Wald. coeff.=30.729, df=2, p=0.000). Our study showed that PML was present in a significant number of car occupants sustaining head injuries in head-on collisions (15%). Impact to the chin with or without a ring fracture to the skull base most often led to this fatal injury, probably after collision with the dashboard.

Rate of occurrence, gross appearance, and age relation of hyperostosis frontalis interna in females: a prospective autopsy study.

The aim of our study was to determine rate of occurrence and appearance of hyperostosis frontalis interna (HFI) in females and correlation of this phenomenon with ageing. The sample included 248 deceased females: 45 of them with different types of HFI, and 203 without HFI, average age 68.3 +/- 15.4 years (range, 19-93), and 58.2 +/- 20.2 years (range, 10-101), respectively. According to our results, the rate of HFI was 18.14%. The older the woman was, the higher the possibility of HFI occurring (Pearson correlation 0.211, N=248, P=0.001), but the type of HFI did not correlate with age (Pearson correlation 0.229, N=45, P=0.131). Frontal and temporal bone were significantly thicker in women with than in women without HFI (t= -10.490, DF=246, P=0.000, and t= -5.658, DF=246, P=0.000, respectively). These bones became thicker with ageing (Pearson correlation 0.178, N=248, P=0.005, and 0.303, N=248, P=0.000, respectively). The best predictors of HFI occurrence were respectively, frontal bone thickness, temporal bone thickness, and age(Wald. coeff.=35.487, P=0.000; Wald. coeff.=3.288, P=0.070, and Wald.coeff. =2.727, P =0.099). Diagnosis of HFI depends not only on frontal bone thickness, but also on waviness of internal plate of the frontal bone, as well as-the involvement of the inner bone surface.

[Interparietal bone in forensic practice: case report].

INTRODUCTION: In forensic autopsy, pathologists pay attention to skull fracture lines. They are not much interested in the anatomical morphological variations of the skull bones, as long as the variations are not present. The interparietal bone is one of the anatomical variations that could be of interest for forensic pathologists. CASE OUTLINE: We present a case of a 54-year-old man who, after a fall overlived a head injury for six weeks. By chance, autopsy revealed an undivided interparietal bone. Its lateral sutures were fused with parietal bones and unrecognizable from the anterior skull bones, while the sutura mendosa was clearly visible. CONCLUSION: The forensic pathologist should be able to recognize anatomic morphological variations, including those of skull bones. The interparietal bone could be interpreted wrongly as belonging to the fractured occipital bone, i.e. as a broken fragment. This is of particular significance in the cases, for example, of murder or child abuse. Its inferior suture can be seen by X-ray and possibly wrongly interpreted as a fracture line. The presence of this variation may be occasionally useful in the identification of an unknown or lost person.

Simon's bleedings: a possible mechanism of appearance and forensic importance--a prospective autopsy study.

Simon's bleedings are stripe-like hemorrhages on the ventral surface of the intervertebral disks of the lumbar part of the spinal column. The aims of this study were to determine the appearance frequency of Simon's bleedings in cases of hanging and in other cases of asphyxiations and to determine if the age of the deceased was in correlation with the occurrence of Simon's bleedings. A prospective autopsic study included 147 cases of hanging, 39 other asphyxiation deaths, and 461 deaths other than asphyxiation (blunt trauma, natural deaths, etc.). Simon's bleedings were present in 62.8% cases of hanging and in 61.5% cases of other types of asphyxiations. Simon's bleedings are not specific for hanging (chi (2) = 0.022, p > 0.05). Simon's bleedings were less frequent in other cases. It was established that the older the person was, the possibility of Simon's bleedings to occur would be less (Spearman's correlation coefficient = -0.225, p < 0.001; Wald coefficient = 29.798, p < 0.001). In the cases of hanging, there is statistically significant difference in average age between the groups with and without Simon's bleedings (t = 2.875, p = 0.017). The older the person was, the lower the likelihood of Simon's bleedings to occur: if the person was more than 60 years old, there was 70% probability of not having Simon's bleedings, and if older than 70, this probability would rise to 88% (Wald coefficient = 7.609, p = 0.021). In older persons who died due to hanging, throat skeleton fractures accompanied by local hemorrhage could be considered as a vital sign. In younger persons, where throat skeleton fractures are less frequent, Simon's bleedings could be the vital sign of premortem hanging. Simon's bleedings, in cases of asphyxiation, most likely occur due to agonal convulsions and forced movements in lumbosacral part of spinal column. Additional factor for the appearance of Simon's bleedings in hanging is traction of body and especially this part of spinal column due to gravity.