Hidden Coronary Artery Ostium and Sudden Death.

A 1-week-old girl died suddenly and unexpectedly. At autopsy the major finding was of a right dominant coronary artery circulation with an inapparent left coronary artery ostium. After careful examination, an anomalous origin of the left coronary artery was found with the ostium located in the non-coronary cusp immediately adjacent to the commissure of the non- and left coronary cusps. The ostium was of small caliber with an obliquely oriented artery (<45°) with no ostial ridges. The artery coursed anteriorly past the left coronary cusp between the aorta and the left atrial appendage to then follow its usual course inferiorly along the anterior aspect of the left ventricle. The reminder of the autopsy was unremarkable. Death was, therefore, attributed to an anomalous and hypoplastic left coronary artery (and ostium) with an acute angle of take-off. Tracing coronary arteries in the very young may be technically difficult due to their small size, thus identifying the location of ostia is important. This may be difficult when the ostium was located close to a commissure.

Understanding the immune profile of sudden infant death syndrome - proteomic perspectives.

AIM: The aim of this study was to investigate a panel of immune proteins in cases of sudden infant death syndrome (SIDS). It was hypothesised that, in at least a subset of SIDS, a dysregulated immune response may be a contributing factor leading to death. METHODS: The subjects included 46 SIDS cases and 41 controls autopsied at the Department of Forensic Sciences, Norway. The causes of death in the controls were accidents/trauma. Samples of cerebrospinal fluid (CSF) were analysed quantitatively by Proximity Extension Assay (PEA). RESULTS: Initial results revealed that normalised protein expression differed in 35 proteins. For the purposes of this report five proteins that are involved in immune system were selected for analysis: IFNLR1 (p = 0.003), IL10 (p = 0.007), IRAK4 (p < 0.001) and IL6 (p = 0.035); all had lower protein concentrations in SIDS cases compared to controls except for CD28 (p = 0.024) which had higher protein concentrations in SIDS cases. CONCLUSION: The results confirm previous studies indicating that a dysregulation of the immune system may be a predisposing factor for SIDS. The results may indicate that these aberrant protein concentrations could lead to an inadequate response to immune triggers and uncontrolled defence mechanisms towards the common cold or other non-fatal infections.

Concealed Homicides-A Postmortem Study and Review.

ABSTRACT: A study was undertaken at Forensic Science SA, Adelaide, South Australia, of all cases of homicide (January 2003-December 2022) where the victims' bodies had been concealed. Three hundred twenty-six homicides were identified, which included 27 cases where bodies had been deliberately hidden (8%) (age range, 2-82 years; ave, 34.9 years; M:F = 1.5:1). Deaths were due to blunt force trauma (n = 11), sharp force trauma (n = 4), asphyxia (n = 4), gunshot wound (n = 2), and a combination of drowning and asphyxia (n = 1). In 5 cases, the cause of death was not determinable. The methods of concealment (which were sometimes overlapping) included the following: dumping at a hidden/isolated location (n = 8), burial (n = 7), dismembering (n = 3), incinerating (n = 3), hiding in a wheeled garbage bin (n = 2), disposing in garbage resulting in the remains being located at waste disposal facilities (n = 2), hiding in a shed (n = 1), under a concrete floor (n = 1), in a suitcase (n = 1), in a river (n = 1), in a mine shaft (n = 1), and in a septic tank (n = 1). Although it has been asserted that concealed homicides are rarely encountered in forensic practice, the current study has demonstrated that the bodies in at least 8% of victims of homicide in South Australia have undergone some form of concealment.

Death and injuries caused by cattle: A forensic overview.

Lethal episodes arising from interactions with cattle may be the result of a response of the animals to simple handling and herding, or from reactions to deliberate provocation or goading intended to incite aggressive behavior for public entertainment purposes. Deaths may be considered to be unprovoked and unanticipated, or provoked and predictable. Cattle cause significant numbers of deaths globally and are considered the most dangerous large animal in Britain. Behavior may be unpredictable even in apparently docile domesticated animals, and attacks may be by a single animal or a herd and result in injuries from kicking, head/butting/charging, stomping, goring, and crushing. Craniofacial injuries may involve fractures of the spine or skull with cerebral contusions and lacerations associated with subarachnoid, subdural, and extradural hemorrhages. Chest injuries are also characterized by fractures which may be multiple with flail chest, hemo- and pneumothoraces, and organ disruption. Injuries to the abdomen and perineum include intestinal perforations, splenic rupture, perineal and vaginal tears, urethral lacerations and avulsions, and bladder and rectal perforations. Significant vascular injuries include complete and partial transections and lacerations. Males living in rural areas are most at risk of a fatal encounter.

The death of Rasputin-A forensic evaluation.

Grigori Yefimovich Rasputin, a confidant of Tsar Nicholas and his wife, was murdered by Prince Yussupov and his co-conspirators in the cellar of the prince's Moika Palace in St Petersburg, Russia, on the evening of December 30th, 1916 (December 17th in the Russian calendar). The narrative of his death is largely based on Prince Yussupov's published memoirs and has Rasputin being poisoned with cyanide, shot, bludgeoned, and finally drowned. A review of the available forensic material, however, shows a photograph with a contact gunshot wound to Rasputin's forehead. This would indicate that he was dead prior to being dropped into the Little Nevka River. His distaste for sweet foods and the absence of poison at autopsy would also suggest that the story of cyanide toxicity was fabricated. Yussupov's description of Purishkevich firing at Rasputin from a distance as he ran across the courtyard in an attempt to escape would also not be consistent with the post mortem photograph. The simplest version of the events would be that Rasputin was executed by a contact gunshot wound to the forehead when he visited the Yussupov Palace. While it appears that the events of that fateful evening have been embellished, it is certainly not uncommon for perpetrators of homicides to provide histories that are later shown to be at odds with the truth. Re-evaluation of historic cases may provide compelling evidence for alternative interpretations to the popular historic record.

The role of alcohol in infant cosleeping deaths.

The well-established epidemiological and neuropathological differences between infants who die alone compared to those in shared sleeping environments indicate that these cohorts have differences. Risk factors in both situations depend on both exogenous and endogenous factors. Although parental consumption of alcohol continues to be cited as a risk factor for sudden infant death syndrome (SIDS) it is difficult to understand how a substance which impairs parental consciousness rather than infant arousal could contribute to SIDS. Surely a more logical mechanism to explain these deaths would be suffocation by a sedated adult rather than evoking predisposing factors for SIDS.

Acanthosis nigricans - a potentially useful clue to the presence of significant occult disease at autopsy.

A 19-year-old male was found dead in his apartment. At autopsy he was morbidly obese (Body mass index; BMI - 40.5) with multiple areas of velvety pigmented thickening of the skin in folds around the neck, in the axillae, in the inframammary regions, over the anterior waistline and groin regions and over the dorsal aspects of the feet. These had the typical appearance of acanthosis nigricans. Internal examination revealed aspiration of gastric contents into the airways. Vitreous humour biochemistry showed markedly elevated levels of both glucose (62.9 mmol/L) and ß-hydroxybutyrate (13.54 mmol/L). Death was, therefore, due to aspiration pneumonia complicating diabetic ketoacidosis on a background of morbid obesity. The initial indicator of underlying diabetes, in conjunction with obesity had been acanthosis nigricans.

Identifying and documenting osseous trauma from shark attacks by post mortem CT examination and autopsy.

A 15-year-old male was attacked by a large white shark while surfing. CT examination revealed an above-knee amputation of the right lower extremity with stripping of soft tissues from the groin distally. 3-dimensional volume rendering did not show any fragments of shark teeth but did reveal linear gouges, areas of shaving of cortical bone and an inverted 'V'-shaped defect at the distal margin of the femoral shaft. At autopsy these injuries were confirmed in addition to areas with fine parallel cross-striations matching the marginal serrations of the teeth of a white shark. Thus, while post mortem CT with 3-dimensional reconstruction at high resolution can show the nature and number of the bony injuries following shark attack, it is complimented by pathological examination which may find fine parallel grooves from teeth serrations. Post mortem 3-dimensional volume rendering may also help to find or exclude fragments of teeth, and silicone casting may provide a permanent record of bone lesions.

Domestic violence and chronic traumatic encephalopathy (CTE) - a forensic perspective.

Chronic Traumatic Encephalopathy, or CTE, is an entity characterized by neurological deficits that are thought to arise from repetitive episodes of blunt head trauma. It has gained considerable attention recently in those who have engaged in contact sports. However, given that it is caused by mechanical cerebral strain from nonspecific blunt impact, it seems reasonable to assume that it could arise from a multitude of causes, such as craniocentric domestic violence. While the literature is somewhat contradictory, the possibilities are that CTE may be caused by either the incremental additive effects of less severe trauma, or from more forceful impacts, or from a combination of both of these mechanisms. Another issue to consider is the degree of acceleration/rotation trauma associated with particular events. Careful study of the chronology, nature and dose-relationships of previous head impacts in victims of inflicted lethal head trauma will, therefore, be required. This will help to clarify its significance in cases of domestic violence and also specifically whether it can be additive from more minor impacts, or whether there is a threshold of force required before it occurs.

Does citing early SIDS research skew contemporary conclusions?

Research on infants who have allegedly succumbed to sudden infant death syndrome (SIDS) has been of variable quality over the years. Even now peer-reviewed papers are being published on cases termed 'SIDS' without autopsies having been performed, despite this being a requirement of the three major definitions for over five decades. Clearly cases used in earlier research studies could not have complied with the requirements of as-yet unpublished definitions/guidelines. For this reason care must be taken in citing initial papers as their results may have been skewed by the presence of non-SIDS cases. This may have particular relevance for meta analyses. Reviewing the literature on substance P and its relationship to SIDS provides an excellent example of how diametrically opposed conclusions were reached at different time points. Early studies on SIDS, and studies that use cases that were classified before the standard NICHD and San Diego definitions, should, therefore, be approached with a degree of scepticism and not cited in contemporary papers or at meetings as they have the potential to confuse rather than clarify.

Cardiac tamponade - a rare cause of sudden death in autoimmune polyglandular syndrome.

A 27-year-old male died suddenly due to cardiac tamponade arising from pericarditis complicating autoimmune polyglandular syndrome (APS) type 2. He had a history of primary Addison disease and autoimmune hypothyroidism which were corroborated at autopsy. In addition a florid fibrinous pericarditis was associated with 287 g of turbid fluid in the pericardial sac. Although pericarditis with tamponade is a potential complication of APS, it has rarely if ever, been reported as a cause of sudden death. Lethal mechanisms may involve both compressive and restrictive effects.

Recent trends in an uncommon method of carbon monoxide suicide.

PURPOSE: The most prevalent method of carbon monoxide (CO) suicide is inhalation of vehicle exhaust (VE). However, a new method of CO suicide has recently emerged involving charcoal burning (CB) in a confined space to produce fatal CO levels. This method has been reported from countries in Asia, associated with economic instability and media reporting of high-profile celebrity cases. The current study was undertaken to analyze rates and characteristics of CB suicides in South Australia (SA) for comparison with respect to their characteristics and scene, autopsy and toxicology findings. METHODS: A search was undertaken for all intentional fatal carbon monoxide poisonings in SA between 2000 and 2019. Collected variables included age, sex, cause of death, location of death, decedent histories, scene, autopsy and toxicology findings and manner of death. Statistical analyses were performed using R (version 4.2.3). RESULTS: There was a significant decrease in VE suicides (p < 0.05) and a significant increase in CB suicides (p < 0.001) over the 20-year period. Those who used CB were found to be, on average, between 1.5 and 15.8 years younger than those who used VE (p = 0.017). The risk factors for CB suicide included psychological/psychiatric conditions and financial problems, while VE suicides were associated with a history of physical problems and contact with the legal system. External and internal autopsy findings were consistent with the literature. CONCLUSION: CB suicide is perceived to be widely accessible and painless and is therefore becoming a popular suicide method. Monitoring future trends will be important to determine whether intervention is required.

Changing diagnostic patterns in cases of sudden and unexpected natural death in infants and young children: 1994-2018.

AIM: To determine whether there has been a change in the incidence and type of conditions causing sudden and unexpected natural death in infants and young children in recent years. METHODS: A search was undertaken of pathology records at Forensic Science SA in Adelaide, Australia for all cases of sudden and unexpected natural death in children aged less than 10 years at the time of death over two time periods: 1994-1998 and 2014-2018. RESULTS: Overall, 136 cases were identified consisting of 81 boys and 55 girls (M:F = 16:11; age range 0-9 years). No difference was shown in the numbers of sudden unexplained deaths in infants and young children between the two time periods (80 vs. 56; p = 0.18). A trend was shown for a prominent decrease in SIDS cases (55 vs. 12) with an increase in undetermined cases, <1 year (5 vs. 18). However, when the two categories were combined there was no statistical difference between the two periods (60/80 vs. 30/56) (p = 0.26), although a decrease in numbers had occurred. CONCLUSION: Analysis of numbers of fatalities reported from medicolegal institutes should be undertaken with an awareness of the potential effect of diagnostic shift.

The San Diego SIDS definition-20 Years on.

AIM: As it is now 20 years since the San Diego definition of sudden infant death syndrome (SIDS) was proposed, it is timely to examine the impact of this consensus statement. RESULTS: Concerns at the time were expressed that 'death scene' had been replaced by circumstances of death and so it may have been more useful to have a more inclusive statement of 'death scene, including circumstances of death'. The category of unclassified sudden infant deaths (USID) that was proposed has not been widely adopted. More disturbing, however, is the increasing failure to use either the San Diego or earlier definitions in published research, with recent studies showing that almost two-thirds of peer-reviewed SIDS publications (2019-2021) did not quote or reference internationally accepted definitions. This is a decrease of 33% from the 68% of papers that correctly used SIDS definitions in 2011. The definition is therefore not being uniformly applied and in addition, diagnostic shift is occurring, with more pathologists favouring 'undetermined' over a designation of SIDS. CONCLUSIONS: Given these developments, how can we correctly interpret conclusions relating to SIDS research, and can we accurately monitor trends in SIDS mortality? The authors would suggest that unfortunately, at present we cannot with any precision.

Investigating genetic variants in microRNA regulators of Neurokinin-1 receptor in sudden infant death syndrome.

Sudden infant death syndrome (SIDS) occurs more often in male than in female infants, suggesting involvement of the X-chromosome. Histopathological studies have suggested that altered expression of the Neurokinin-1 receptor may also play a role in the pathogenesis of SIDS. It was hypothesised that genetic variants in three X-chromosome-encoded microRNA (miRNA/miR), known to down-regulate expression of the Neurokinin-1 receptor, may contribute to SIDS. AIM: To identify sequence variants in the miRNAs within a study cohort (27 cases of SIDS and 28 controls) and determine if there was a difference in the frequencies in male and female SIDS infants. METHODS: Genomic DNA prepared from stored blood spots was amplified and sequenced to identify genetic variants in miR500A, miR500B and miR320D2. RESULTS: No novel variants in the miRNAs were identified in our study cohort. We identified one known single-nucleotide polymorphism (SNP) in miR320D2: rs5907732 G/T, in both cases and controls. No significant difference in the SNP frequency was observed between male and female SIDS cases. CONCLUSION: This pilot study suggests that sequence variants in three miRNAs do not contribute to the reported higher prevalence of SIDS in male infants and do not contribute to the pathogenesis of SIDS in our cohort.

Intestinal epithelial damage due to herbal compounds - an in vitro study.

Intestinal epithelial injury from herbal products has rarely been reported, despite the gut being the first point of contact for oral preparations. These products often consist of multiple herbs, thereby potentially exposing consumers to higher levels of reactive phytochemicals than predicted due to pharmacokinetic interactions. The phytochemical coumarin, found in many herbal products, may be taken in combination with herbal medicines containing astragalosides and atractylenolides, purported cytochrome P450 (CYP) modulators. As herbal use increases, the need to predict interactions in multiple at-risk organ systems is becoming critical. Hence, to determine whether certain herbal preparations containing coumarin may cause damage to the intestinal epithelium, Caco2 cells were exposed to common phytochemicals. Coumarin, astragaloside IV (AST-IV) or atractylenolide I (ATR-I) solutions were exposed to Caco2 cultures in increasing concentrations, individually or combined. Coumarin produced a significant concentration-dependant fall in cell viability that was potentiated when CYP enzymes were induced with rifampicin and incubated with CYP3A4 inhibitor econazole, suggesting a role for other CYP enzymes generating toxic metabolites. ATR-I alone produced no toxicity in uninduced cells but showed significant toxicity in rifampicin-induced cells. ATR-I had no effect on coumarin-induced toxicity. AST-IV was nontoxic alone but produced significant toxicity when combined with nontoxic concentrations of coumarin. The combination of coumarin, ATR-I and AST-IV was significantly toxic, but no synergistic interaction was seen. This investigation was conducted to determine the likelihood for intestinal-based interactions, with the results demonstrating coumarin is potentially toxic to intestinal epithelium, and combinations with other phytochemicals can potentiate this toxicity.

A 20-Year Review of Recumbent Pedestrian Fatalities (2001-2020).

ABSTRACT: A retrospective study was performed in the Northern Territory of Australia of all cases of pedestrian fatalities where the decedents had been sitting, crouching, sleeping, or lying on or next to a road, over a 20-year period (January 1, 2001 to December 31, 2020). Of the 865 road traffic fatalities, 161 (19%) were pedestrians, and 42 of these were recumbent at the time of the incident (26% of all pedestrians). The most common age range was 30 to 39 years with a male to female ratio of 25:17. No individuals younger than 15 years were involved. Acute alcohol intoxication played a role in death in all of the cases with medium to high range blood alcohol concentrations. In addition, cannabis or its metabolites were detected in 6 cases, and methylamphetamine in 1 case. A history of chronic alcohol use or dependence was known in 6 (14%) of cases. In no case was an underlying medical condition contributory to death. The majority of incidents occurred at night. This study has shown a very high incidence of recumbent pedestrian deaths in an Australian subpopulation related to acute alcohol intoxication, decreased visibility, and vulnerability because of their position on or proximate to a road.

Prescribed and Diverted Methadone Toxicity in South Australia: An Update.

ABSTRACT: Methadone is one of the most common medications currently prescribed for the treatment of opioid use disorders (OUDs). While methadone maintenance programs (MMPs) have been highly successful in the management and treatment of OUDs resulting in a reduced number of fatalities, the risk of overdose/toxicity remains. The current study was undertaken to analyze trends in overdoses attributed to prescribed and diverted methadone in South Australia (SA) between 2000 and 2019. Over the 20-year period, 344 methadone-related deaths occurred in SA with a significant increase in deaths over the study period ( P = 0.03). The mean age of decedents was 42.5 years with a male to female ratio of 1.8:1, with approximately 20% of decedents enrolled in a MMP at the time of death. Overall, only 5.2% of cases demonstrated methadone diversion, which was associated with methadone prescribed for chronic pain and was most likely to be diverted from a friend/housemate or a partner. However, the source of methadone in more than half of cases was unknown, so this is likely a significant underestimate of actual MMP methadone diversion and total methadone diversion.

Electrocution - post-mortem presentations, problems and pitfalls.

Deaths due to electrocution occur when there has been passage of an electric current through the body. Lethal mechanisms may involve the heart with ventricular fibrillation, or the respiratory muscles or brainstem respiratory centres with respiratory paralysis/cessation. The size of the current that flows through the body is directly dependent on the potential difference of the circuit and the resistance of the tissues. The majority of deaths are accidental, with suicides being less common and homicides being very rare. Problems arising in the evaluation of cases include situations where electrocution has clearly occurred from the scene findings, but no injuries are detectable at autopsy, or when electrical burns are found at autopsy with no defective equipment/circuitry identified at the death scene.

Clinicopathologic discordance-a not unexpected occurrence.

Disagreements between clinical and forensic interpretations of post-mortem findings are sometimes influenced by prior experiences with particular patient cohorts. While patients who present clinically have characteristic indicators of disease (thus enabling diagnosis), symptoms and signs may not have been manifested by those who die suddenly and unexpectedly and present for medicolegal assessment. Thus, the determination of likely or possible lethal mechanisms requires an understanding of occult disease processes and idiosyncratic responses that may be very different from case to case. Summaries of cases should be undertaken with an awareness of the limitations of individual knowledge and may be augmented by collaboration and pooling of expertise.