Investigating the Source of Fatal Pulmonary Thromboembolism in a Coronial Postmortem Population.

ABSTRACT: The incidence of how often a deep vein thrombosis is found in the calves of the legs at coronial postmortem examination is unclear. This study retrospectively examined postmortem examination reports from Australian Coronial investigations of sudden death resulting from pulmonary thromboembolism to determine the likelihood of dissection of the deep veins of calves of the legs revealing the source of a pulmonary thromboembolism. From 450 cases taken from the National Coronial Information System (NCIS) for 2016, the postmortem reports of 327 cases were reviewed to provide demographic details of victims of sudden death from pulmonary thromboembolism. In 235 cases, it was possible to determine in 76.6% a thrombus had been found in the deep veins of the calves of the legs after dissection. In 141 cases, it was documented that both sides had been examined. From these, it was determined there was no statistically significant difference in the prevalence of thrombus in either side. However, it was shown that the presence of an abnormality of a lower limb (such as leg or hip infection, burns, surgery and nonoperated fractures, or a larger circumference) increased the likelihood that a deep vein thrombus would be found on that side.

Visceral artery aneurysmal lesion of the omentum - a rare cause of spontaneous fatal intra-abdominal hemorrhage.

We report unexpected death of a 72-year-old man due to a hemoperitoneum (1.9 L of blood in the abdominal cavity). Postmortem examination revealed that the cause of the hemorrhage was an arterial aneurysmal lesion in the greater omentum. The lesion measured 4 × 4 × 6 cm with a generally smooth wall, but with a focal area of rupture within a hemorrhagic region measuring 1 × 2 cm. There was a substantial feeding artery. Histological examination revealed features in keeping with a pseudoaneurysm, but also with some features of a true aneurysm. There was no history of trauma and the rupture of the aneurysmal lesion that had caused the hematoperitoneum was considered to be spontaneous. Prior to his death the deceased had attended hospital for epigastric pain, which was attributed to dyspepsia, but otherwise he had not had symptoms prior to his death.

An analysis of child suicide from three centers (2008-2017).

Although the overall suicide rate worldwide has changed minimally over the past 100 years, different trends have been observed over time in the USA, Australia, and New Zealand (NZ). However, few studies have focused on suicides in children (< 18 years), making evaluation of possible trends difficult. The last 20 years has also seen an increase in childhood obesity, eating disorders, and body image issues for children in many developed nations; however, few studies have shown whether a significant proportion of child suicides have an abnormal BMI. The current study evaluates child suicides (from 2008 to 2017) in South Australia (Australia), compared with the jurisdictions of Auckland (NZ) and Hennepin County (USA). Demographic data (age, sex, ethnicity), body mass index (BMI), the number of cases of youth suicide, and the method of suicide from these three regions were collected and analyzed. Across the 10-year period, the jurisdiction of Auckland had a downward trend, while Hennepin County and South Australia had increasing numbers of cases. The most common method of child suicide in all centers was hanging, occurring in > 80% of cases in South Australia and Auckland and 56% in Hennepin County. Hennepin County had a greater proportion of suicides using firearms (28%), compared to 1.9% in Auckland and 5.1% in South Australia. Unusual means of suicide were used less frequently by youth than previously.

Signet-ring cell appearance of atrophic fat cells.

Cells with 'signet-ring' appearance were found at post-mortem examination of a man with a history of chronic illness, weight loss and multiple regions of 'bowel thickening' during life. Due to the decedent's history, the finding raised the possibility of disseminated signet-ring adenocarcinoma. However, the vacuoles did not stain for mucin and the cells did not stain for keratin. The cells did stain for calretinin and so a diagnosis of signet ring mesothelioma was considered. However, it was suggested that the cells with a cytoplasmic vacuole displacing the nucleus to one side producing the signet-ring appearance were instead atrophic fat cells. This was subsequently proven by Oil Red O staining.

Comparison of conventional autopsy with post-mortem magnetic resonance, computed tomography in determining the cause of unexplained death.

Conventional autopsy is the gold standard for identifying unexplained death but due to declines in referrals, there is an emerging role for post-mortem imaging. We evaluated whether post-mortem magnetic resonance (PMMR) and computed tomography (PMCT) are inferior to conventional autopsy. Deceased individuals ≥ 2 years old with unexplained death referred for coronial investigation between October 2014 to December 2016 underwent PMCT and PMMR prior to conventional autopsy. Images were reported separately and then compared to the autopsy findings by independent and blinded investigators. Outcomes included the accuracy of imaging modalities to identify an organ system cause of death and other significant abnormalities. Sixty-nine individuals underwent post-mortem scanning and autopsy (50 males; 73%) with a median age of 61 years (IQR 50-73) and median time from death to imaging of 2 days (IQR 2-3). With autopsy, 48 (70%) had an organ system cause of death and were included in assessing primary outcome while the remaining 21 (30%) were only included in assessing secondary outcome; 12 (17%) had a non-structural cause and 9 (13%) had no identifiable cause. PMMR and PMCT identified the cause of death in 58% (28/48) of cases; 50% (24/48) for PMMR and 35% (17/48) for PMCT. The sensitivity and specificity were 57% and 57% for PMMR and 38% and 73% for PMCT. Both PMMR and PMCT identified 61% (57/94) of other significant abnormalities. Post-mortem imaging is inferior to autopsy but when reported by experienced clinicians, PMMR provides important information for cardiac and neurological deaths while PMCT is beneficial for neurological, traumatic and gastrointestinal deaths.

Variable Mechanisms of Dog-Related Deaths.

As the literature has tended to focus on injuries and deaths due to active dog attacks, the following review was undertaken to examine the range of circumstances and mechanisms that may be associated with all types of fatal encounters with dogs. A search was undertaken of the literature and the Forensic Science SA, Australia, autopsy database for cases where deaths had been caused by dog-related activity. Only 2 cases were found in the autopsy database over a 15-year period from 2005 to 2019. The first was a 55-year-old man who bled to death from a large degloving dog bite to his forehead exacerbating underlying cardiovascular disease. The second was a 40-year-old previously splenectomized man who died of Capnocytophaga canimorsus sepsis shortly after being bitten by his dog. Dogs may be involved in vehicle crashes if drivers swerve to avoid them or if pedestrians attempt to rescue dogs that have strayed onto roads. In the literature, trauma has also occurred from "non-bite dog-related injuries" where individuals have been pulled over by, or tripped on, dogs. Dogs may also be responsible for specific types of infections such as echinococcosis and C. canimorsus, which may have potentially lethal consequences. Thus, the types of cases of injuries, illnesses, and deaths associated with dogs encountered by pathologists in a forensic context may be extremely diverse and not always straightforward.

Determining a sampling regime for PCR detection of respiratory tract viral infection at coronial post-mortem examinations.

Death due to respiratory infection is commonly encountered at autopsy. With only one opportunity to obtain samples for identification of a causative agent, it is important to ensure that sampling regimes are optimized to provide the greatest detection, without the expense and redundancy that can arise from over-sampling. This study was performed retrospectively using data from Coronial autopsies over the period 2012-2019 from which swabs from the nasopharyngeal region, trachea and lung parenchyma, in addition to samples of lung tissue, had been submitted for multiplex PCR detection of respiratory pathogens. From 97 cases with all four samples, there were 24 with at least one positive result for viral infection. Some cases had multiple positive results and a total of 27 respiratory tract viruses were identified, of which rhinovirus, influenza A virus and respiratory syncytial virus were the most common. Seventeen of the 27 viral infections (63%) were identified in all four samples. However, in nearly all cases (96%) the nasopharyngeal swab detected the infective agent when the multiplex PCR panel had detected infection in any of the four sample types. A nasopharyngeal swab is considered to be an optimal sample for detection of respiratory tract viral infection. As the samples analyzed were acquired before the appearance of the COVID-19 virus, the applicability of this finding for COVID-19 screening is not established.

A Prospective Study of Sudden Cardiac Death among Children and Young Adults.

BACKGROUND: Sudden cardiac death among children and young adults is a devastating event. We performed a prospective, population-based, clinical and genetic study of sudden cardiac death among children and young adults. METHODS: We prospectively collected clinical, demographic, and autopsy information on all cases of sudden cardiac death among children and young adults 1 to 35 years of age in Australia and New Zealand from 2010 through 2012. In cases that had no cause identified after a comprehensive autopsy that included toxicologic and histologic studies (unexplained sudden cardiac death), at least 59 cardiac genes were analyzed for a clinically relevant cardiac gene mutation. RESULTS: A total of 490 cases of sudden cardiac death were identified. The annual incidence was 1.3 cases per 100,000 persons 1 to 35 years of age; 72% of the cases involved boys or young men. Persons 31 to 35 years of age had the highest incidence of sudden cardiac death (3.2 cases per 100,000 persons per year), and persons 16 to 20 years of age had the highest incidence of unexplained sudden cardiac death (0.8 cases per 100,000 persons per year). The most common explained causes of sudden cardiac death were coronary artery disease (24% of cases) and inherited cardiomyopathies (16% of cases). Unexplained sudden cardiac death (40% of cases) was the predominant finding among persons in all age groups, except for those 31 to 35 years of age, for whom coronary artery disease was the most common finding. Younger age and death at night were independently associated with unexplained sudden cardiac death as compared with explained sudden cardiac death. A clinically relevant cardiac gene mutation was identified in 31 of 113 cases (27%) of unexplained sudden cardiac death in which genetic testing was performed. During follow-up, a clinical diagnosis of an inherited cardiovascular disease was identified in 13% of the families in which an unexplained sudden cardiac death occurred. CONCLUSIONS: The addition of genetic testing to autopsy investigation substantially increased the identification of a possible cause of sudden cardiac death among children and young adults. (Funded by the National Health and Medical Research Council of Australia and others.).

Post-Mortem Imaging Adjudicated Sudden Death: Causes and Controversies.

Sudden cardiac death (SCD) is a catastrophic complication of many cardiac conditions often occurring without warning. In these cases, a post-mortem examination is required to elucidate the cause of death and is regarded as the 'gold standard'. However, in circumstances of certain religious/cultural beliefs and advanced body decomposition an alternative non-invasive approach would be preferred. Although a developing field, post-mortem imaging using computed tomography (pmCT) or magnetic resonance imaging (pmMR) provides a non-invasive and accurate alternative to traditional post-mortem in specific circumstances. In particular, pmMR has an important role in younger decedents while pmCT is more suited to examination of adults with SCD. Despite encouraging results from several preliminary studies, more research is needed to determine the most appropriate role for post-mortem imaging in the clinical algorhythm for investigation of SCD.

Turnaround time data for Coronial autopsies - time to complete forensic post-mortem examination reports and influencing factors for Australia and New Zealand in 2015 and 2010.

This study aimed to provide information regarding key performance indicators (KPIs) for forensic pathology in Australia and New Zealand, focusing on the time to complete a Coronial post-mortem examination report. Data was obtained from the National Coronial Information System (NCIS). The mean and median time to complete a post-mortem examination report in 2015 was determined from a sample of 100 cases from each of the nine Coronial jurisdictions. Results of univariate and multivariable analysis of factors potentially influencing the completion time are presented. The multivariable analysis indicated the time to complete a post-mortem examination report was significantly dependent on if any internal examination had been performed, the Coronial jurisdiction and requesting toxicological analysis. The number of days for Coroners to close cases is also presented as well as the number of days for a post-mortem examination to be performed. A comparison between 2015 and 2010 was instigated. However, this data had to be constrained to eight of the Coronial jurisdictions. Within this dataset, the time to complete a post-mortem examination report when an internal examination had been performed was statistically significant greater in 2015. However, the time to complete reports for all Coronial post-mortem examinations in 2015 was not statistically significantly different to 2010. This could be attributed to a higher proportion of post-mortem examinations without internal examination ('external only') in 2015. The time to perform a post-mortem examination following the death being reported to a Coroner increased, but the time for Coroners to close a case decreased.

Evaluation of a model of bruising in pigmented skin for investigating the potential for alternate light source illumination to enhance the appearance of bruises by photography of visible and infrared light.

The purpose of this study was to evaluate the ability of alternate light source illumination to enhance bruises in pigmented skin. Previous work was limited to simulating bruises in non-pigmented (Caucasoid type) skin by injecting blood into pigskin. In this study, it was investigated if adding a layer of melanin to the surface of the skin would simulate pigmented skin. The study included evaluating the use of a filter that transmitted infrared light (wavelength greater than 720 nm) in place of the recommended visible light filters for the alternate light sources. The results obtained using pigskin with a layer of melanin were almost the same as results using the naturally pigmented goat ear. This indicated adding a layer of melanin could be used as a model for pigmented skin in this simulation of fresh bruising. Comparing the pigskin without melanin with pigskin with melanin revealed that the optimal light source to enhance the appearance of bruising, simulated by injection of blood, changed from violet to blue-green. Using the infrared transmitting filter resulted in greater enhancement than using the alternate light sources with their recommended visible light filter. The advantage of using the infrared transmitting filter was greater with the pigskin coated with melanin and the naturally pigmented goat ears than in the non-pigmented pigskin, however, the results remain to be validated using real bruises in naturally pigmented human skin.

Investigation into the potential for post-mortem formation of carboxyhemoglobin in bodies retrieved from fires.

The forensic investigation of a deceased person retrieved following a fire includes measuring carboxyhemoglobin. A carboxyhemoglobin saturation above 10% is considered indicative of respiration during a fire, implying the person had been alive. This relies on the assumption that carbon monoxide will not diffuse into blood used for toxicological analysis. This project investigated the potential for carbon monoxide to passively diffuse into a body and if carboxyhemoglobin levels could become elevated post-mortem. Stillborn piglets with intact skin were exposed to carbon monoxide. Carboxyhemoglobin formed in the hypostasis of the skin, but carboxyhemoglobin levels in blood from the heart and chest cavities were not significantly elevated. However, defects in the skin over body cavities (producing breaches to replicate cases with stab wounds or heat damage) resulted in cavity blood carboxyhemoglobin levels above 10%. A review of fire death cases in South Australia 2000-2015 was performed to determine the origin of the blood samples used for toxicological analysis and the incidence of cases with breaches of body cavities. This revealed a small number of cases in which blood from the cavities had been analyzed when cavity breaches were present. Thus, there is a potential for significant elevation of carboxyhemoglobin saturation post-mortem in forensic casework involving bodies retrieved from fires.

Review of autopsy reports of deaths relating to fire in South Australia 2000-2015.

It has been noted there are gaps and inconsistencies in data pertaining to fire related deaths in Australia, which poses difficulties for analysis of national statistics. A search of post-mortem examination reports at Forensic Science SA from 2000 to 2015 revealed 275 cases regarded as fire related in which the body had been involved in a fire. The autopsy reports were evaluated to determine parameters including the location of the fire event, age and sex of victim, as well as the presence of soot in the airways and cherry-red coloration to the blood and/or organs, in addtion to toxicological levels of carboxyhemoglobin and alcohol. Fire events were clasified as structural, transportation or open air in type. Males were more commonly victims than females, especially in transportation fires, where males aged below 50 years were most at risk of death. Carboxyhemoglobin levels tended to be lower in victims of transportation fires. This study has confirmed that presence of soot in the respiratory tract and cherry-red coloration of a body retrieved from a fire are both linked to an increased level of blood carboxyhemoglobin. These findings significantly contribute to the documentation of fire deaths in Australia.

"Defense" type wounds in suicide.

"Defense" type wounds are sustained when a victim is attempting to ward off an attacker, or a weapon. A 39-year-old woman is reported who was found deceased with incised wounds to the dorsa of both hands that resembled defense wounds. Examination of the flexor surfaces of both wrists, however, revealed horizontal incised wounds typical of self-infliction. Perfusion of the subclavian arteries produced leakage of water from peripheral veins within wounds on both hands and the right wrist. Death was due to exsanguination from incised wounds of the hands and right wrist; manner suicide. This case demonstrates the difficulties that may arise in differentiating self-inflicted from assaultive wounds. On occasion suicidal sharp force injuries may be multiple and in atypical locations. In these circumstances a high index of suspicion for homicide must be maintained.

Validation of alternate light sources for detection of bruises in non-embalmed and embalmed cadavers.

Bruising is frequently documented in cases of violence for use as forensic evidence. However, bruises can be overlooked if they are not visible to the naked eye. Alternate light sources such as ultraviolet, narrow band, and infrared have been used in an attempt to reveal the presence of bruising that is not otherwise apparent. However, there is a significant gap in knowledge surrounding this technique as it has not been validated against histology to confirm that bruising is genuinely being enhanced. A recent study evaluated the ability of alternate light sources to enhance visibility of bruises using a pigskin model. However, histological confirmation of bruising in humans using these light sources has not yet been performed. In this study, embalmed and non-embalmed human cadavers were used. Bodies were surveyed with alternate light sources, and enhanced regions that were unapparent under white light were photographed with the alternate light sources and sampled for histological assessment. Immunohistochemical staining for the red blood cell surface protein glycophorin was used determine if the enhanced area was a bruise (defined by the presence of extravasated erythrocytes). Photographs of areas confirmed to be bruises were analyzed using the program Fiji to measure enhancement, which was defined as an increase in the measured transverse diameter. In the non-embalmed and the embalmed cadavers violet alternate light produced the greatest enhancement of histologically confirmed bruises, followed by blue (both p < 0.0001). Regions that were not confirmed as bruises also enhanced, indicating that light sources may not be specific. This suggests that the use of light sources to enhance the visibility of bruising should be undertaken with caution and further studies are required.

Validation of ultraviolet, infrared, and narrow band light alternate light sources for detection of bruises in a pigskin model.

Alternate light sources such as ultraviolet, narrow band, and infrared have been used in an attempt to reveal the presence of bruising that is not otherwise apparent (inapparent). The following study evaluates the ability of alternate light sources to enhance visibility of bruises by employing an objective assessment of digital photography images in conjunction with histology. A pigskin model was employed with bruises created by injection of blood to be not visible or barely visible (inapparent) under white light. The pigskin was photographed using alternate light source illumination. Images were assessed using the program Fiji® to measure enhancement in terms of bruise length (cm). Photography results were compared with histology to confirm the presence of bruising. Violet and blue light sources produced the greatest enhancement, both with a p < 0.0001. Regions that were not bruises were also enhanced with light sources in this study, indicating that light sources are not specific, and that their use to enhance the visibility of bruising should be undertaken with caution.

Use of a non-volatile agent to stabilize severely incinerated dental remains.

PURPOSE: The aim of this study was to identify volatile-free products that would be suitable for stabilizing incinerated dental remains at the scene of an incident, and that would not compromise any postmortem examination. METHODS: The anterior mandibles of sheep were incinerated, sprayed unilaterally with stabilizing agents, vibrated for 30 s, and assessed. The effect of the stabilizing solutions on radiographic examination was also recorded. Tests for volatility and the effect on human mandibles were also conducted. RESULTS: A flour/water mixture of one part flour to two parts water, and a paste mixture of one part Clag™ glue to one part water both produced significant stabilization results. The flour mixture left an opaque layer on the samples that it was applied to, which still allowed dental examination, but the glue paste mixture resulted in a clearer layer. Both solutions allowed radiographic examination and were free of volatiles. CONCLUSION: Diluted Clag™ paste, when sprayed on to incinerated remains, assists in their stabilization for transportation. When Clag™ paste is unavailable a mixture of two parts water to one part plain flour could be utilized for stabilization.

Heme oxygenase-1 and heme oxygenase-2 expression in bruises.

The first step in catabolism of hemoglobin in a bruise is performed by the enzyme heme oxygenase, which produces biliverdin that is then reduced to bilirubin. The development of yellow coloration in bruises can be attributed to local accumulation of degradation products of hemoglobin, including bilirubin, but it is not clear why there is a delay before this color change is apparent. One explanation may be that time is required for the establishment of heme oxygenase activity at the bruise site. This study used immunohistochemistry to examine the time course of expression of heme oxygenase-1 and heme oxygenase-2 in a rat bruise model. Heme oxygenase-1 levels rose above background from 6 h to peak from days 1 to 3. There was strong expression by macrophages, but only occasional neutrophils expression of heme oxygenase-1. Heme oxygenase-2 did not change significantly from background levels. The results suggest that the delay in the development of yellow coloration of bruises may in part be attributed to the requirement for macrophages to be recruited to the site of injury.

Is sudden death random or is it in the weather?

It has been suggested that the weather may promote some types of death; this study sought to determine if types of death in the region around Adelaide, South Australia, occur in non-random clusters and in relationship to the weather. A Poisson model was used to determine if the occurrence of types of death were random. An exploratory analysis was performed for each death type to see if there was a relationship to weather variables using data supplied by the Bureau of Meteorology. Cases examined at Forensic Science South Australia from 1 January 2008 to 31 December 2009 were reviewed. It was ascertained that cardiovascular deaths were distributed non-randomly; there was statistical evidence to suggest that deaths from ischemic heart disease, pulmonary embolus and drug toxicity had non-random occurrence. Maximum temperatures and increases in temperatures correlated with deaths from natural causes, cardiovascular disease, ischemic heart disease and pulmonary thromboembolus; lower hours of sunlight were statistically significant for deaths due to pulmonary thromboembolus. The distribution pattern of deaths resulting from motor vehicle collision did not fit the Poisson (random) model with variation through the week also being present. Non-random clusters of deaths do occur and weather events, such as increase in temperature, are associated with some types of death. However, analysis indicates that the weather is not responsible for all clustering. With regards to motor vehicle collision deaths temporal variation may be related to social factors, such as holiday periods. Further investigation may assist with health resource planning.