Recurrent familial case of early childhood sudden death: Complex post mortem genetic investigations.

INTRODUCTION: Sudden Unexplained Death in Childhood (SUDC) needs to be fully assessed considering its impact on the family, parents and siblings. Inborn Errors of Metabolism (IEM) such as Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCADD) should be taken into consideration when SUDC occurres. Our aim is to present a family with two successive SUDC and to discuss the post-mortem genetics investigations revealing an IEM implication. CASES REPORT: A complete autopsy with genetic testing was performed when the proband, a 4-year-old girl, died. A few years previously, her older brother had died at the same age and off the same condition. Years later, his exhumation was necessary in order to perform a post-mortem diagnosis.The two siblings were revealed to have had the same pathogenic genotype of the ACADM gene, heterozygous substitutions in ACADM (NM_000016.5): c.985 A>G p.(Lys329Glu) and c.347 G>A p.(Cys116Tyr). In addition, they also both carried a VUS in TECRL, a gene implicated in Catecholaminergic Polymorphic Tachycardia Ventricular (CPVT) and SUDC. CONCLUSION: We illustrate the importance of exome analyses for investigating unexplained sudden death, especially in children, with the possible impact for genetic counselling in the family. The finding of the implication of ACADM gene in this case, raises likely responsibility of the public health system in countries such as France, who delayed implementation of new born screening for these conditions. Exome analyses in this case detected unexpected complexity in interpretation linked to the identification of a second candidate gene for SUDC.

Is it really possible to kill with insulin without leaving traces? From lifesaver to killer, the issues surrounding the analytical characterization of postmortem insulin illustrated by an exemplary case.

Evidence of an insulin overdose is very complicated in the medico-legal field. The analysis and subsequent interpretation of results is complex, especially when treating postmortem blood samples. The instability of insulin, the special pre-analytical conditions and the absence of specific analytical methods has led most laboratories not to analyze insulin in their routine with a consequent underestimation of cases. This paper aims to assess the difficulties associated with the analytical characterization of insulin by describing a case that typically represents most of the inconveniences encountered following a suspected insulin overdose. The case concerns a man found dead at home by his brother. After an external examination, which did not reveal a specific cause of death, toxicological analysis was requested which did not reveal any substance of toxicological interest. Only 9 months later, it was reported to the toxicologist that the subject was diabetic, on insulin lispro treatment and that three empty syringes were found next to his body. Following analysis by LC-high-resolution mass spectrometry, the presence of insulin lispro at a concentration of 1.1 ng/mL, a therapeutic concentration, was evidenced. Despite the low concentration found, overdose cannot be excluded and this paper will describe the criteria evaluated to reach this conclusion. This case highlights that the interpretation of a postmortem insulin concentration is very complex and requires the evaluation of various elements including the circumstances of death, the subject's medical history, the interval between death and sampling and the sample storage.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action.

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Fatal penetrating iliac wound: A case report with determination of physical activity and time to collapse.

A case of fatal left iliac penetrating wound in a thirty-year-old man, during a fight, was presented. The medical file described a transfixing five-centimeter large wound on the left iliac vein and a puncture wound on the left iliac artery. After performing an autopsy, we concluded that the death was secondary to multivisceral failure, secondary to hemorrhagic shock. The judge investigating the case requested a detailed forensic medical reconstructive opinion focusing on the sequence of events leading to the fatal blow. Our having access to the videorecording and the photographs of the crime scene, added to the testimonies of witnesses proved to be a great help to the investigation. The data from the crime scene video recordings allowed us to estimate the victim's physical activity after the fatal stabbing (running between 20 and 140 meters) and the time when he collapsed (between 32s and 1 min) after the stabbing which is rarely described with methods using Closed-Circuit Television material, especially in cases of fatal vascular injuries. Those data are usually estimated from eyewitnesses' accounts, which remain an unreliable method.

A picture with a caption: Using photovoice as cultural self-reflection in communication sciences and disorders.

PURPOSE: Self-reflection is an essential component of developing cultural competence. However, there is a paucity of research on how to best accomplish cultural self-reflection in CSD courses. Therefore, the purpose of this research study is to examine the teaching and learning practice of using Photovoice as a means of cultural self-reflection in a foundational, multicultural course in CSD. METHOD: This qualitative investigation employed a phenomenological approach with emphasis on the scholarship of teaching and learning. Data gathering involved completion of a Photovoice assignment and a prompted reflection of the assignment. The Photovoice assignment entailed the students reflecting and examining their culture. Then, the students submitted two photographs, one that represents a strength of a culture they identify with and one that represents a challenge of a culture they identify with. The students presented their cultural strength and challenges in small and large group discussions. The prompted reflection required the students to address questions in a written or video-recorded response. When the course was completed, the researcher commenced line-by-line focused coding to cluster frequently used terms and common experiences into specific themes. RESULTS: The student participants shared photos of cultural strengths and challenges, discussed these photos in small and large groups, and completed a prompted reflection of the Photovoice assignment. While each student's project and reflection were unique, common themes prevailed. The themes of safety, privilege, and mental health emerged from the Photovoice projects and the themes of learning and formating arose from the reflections on use of the project toward cultural competence. CONCLUSIONS: The results of this study suggests that Photovoice is a valuable tool for cultural self-reflection and learning in all courses in CSD programs. In this way cultural self-reflection and the progression toward cultural competence is an on-going process where students are better prepared to provide client-centered, culturally competent care for all people.

Thermal bone injuries: postmortem computed tomography findings in 25 cases.

INTRODUCTION: Fire death investigations attempt to determine whether a subject was alive or dead before the fire started. Therefore, it is essential to assess if the bone damage is traumatic or the result of exposure to heat. This observational study aims to expose the specific CT semiology of thermal bone lesions to allow the forensic radiologist to identify and distinguish them from traumatic lesions that would have preceded death. MATERIALS AND METHODS: We retrospectively reviewed the CT findings of 25 bodies with thermal bone lesions for which a postmortem computed tomography (PMCT) was performed prior to an autopsy. Imaging findings were correlated to the autopsy data to identify the specific features of thermal bone lesions. RESULTS: Specific signs of thermal injuries to bone were identified on PMCT on all deceased cases. Thermal damages predominated in areas directly exposed to flames (rib cage, distal extremities) with less soft tissue coverage ("soft tissue shielding"). The mottled appearance of bone marrow was a constant sign of burned bones. Heat fractures such as trans-diploic fractures of flat bones and beveled ("flute-mouthpiece") fractures of extremities seemed specifically related to thermal mechanism. In addition, we provided a better description of superficial cortical fissures of flat bones ("ancient Chinese porcelain") and observed a "stair step" fracture of a long bone until now undescribed in radiological literature. CONCLUSION: Thermal bone lesions have specific CT findings, different on several points from traumatic injuries. Their knowledge is essential for radiologists and forensic physicians to provide an accurate report of injury and conclusions.

H1153Y-KCNH2 Mutation Identified in a Sudden Arrhythmic Death Syndrome Case Alters Channel Gating.

Long QT syndrome is one of the most common hereditary channelopathies inducing fatal arrhythmias and sudden cardiac death. We identified in a sudden arrhythmic death syndrome case a C-term KCNH2 mutation (c.3457C > T; p.His1153Tyr) classified as variant of unknown significance and functional impact. Heterologous expression in HEK293 cells combined with western-blot, flow-cytometry, immunocytochemical and microscope analyses shows no modification of channel trafficking to the cell membrane. Electrophysiological studies reveal that the mutation causes a loss of HERG channel function through an alteration of channel biophysical properties that reduces the current density leading to LQT2. These results provide the first functional evidence for H1153Y-KCNH2 mutation-induced abnormal channel properties. They concur with previous biophysical and clinical presentations of a survived patient with another variant that is G1036D. Therefore, the present report importantly highlights the potential severity of variants that may have useful implications for treatment, surveillance, and follow-up of LQT2 patients.

Be careful with lentils! About a forensic observation.

The discovery of exogenous particles in the broncho-pulmonary tree is frequently described in forensic literature, especially in lung samples, in the context of aspirated gastric content during the death agony period or during resuscitation. We report an original observation of a multi-visceral dispersion of exogenous particles detected, in an 8-year-old boy, who allegedly fell from a 2-m high brick-wall. The autopsy found major liver fracture and diaphragm rupture with massive internal hemorrhage without gastric wall rupture. The histological analyses have identified round to oval bodies in the lung bronchi, alveoli, and, rarely, in vascular sections, and also on the surface of several samples. These particles stained strongly pink by the periodic acid Schiff method, evoking dried vegetables. Two hypotheses were invoked: aspirated vegetable particles into the bronchial tree or parasitic infection, like pinworm larva. In order to characterize the nature of these particles, different legumes were cooked, embedded in paraffin wax, and examined under light microscope. Simultaneously, morphological comparison between the gastric content and pinworm larva and lentils was made and a PCR analysis was performed on gastric fluid sample. The DNA sequencing showed a Fabaceae plant family, Lens culinaris. The possibility of a hematogenous dissemination of the starch grains during a perimortem aspiration of gastric content seems unlikely, and a contamination from the gastric content of the organs samples during the autopsy or the pathologic macroscopic and microscopic processes seems to be the principal hypothesis. The formal identification of such particles is important to avoid the misdiagnosis of a potential parasitic infection. The risk of confusion can be detrimental in some circumstances.

Specific interpretation of hair concentrations in 2 fatal metformin intoxication cases.

Hair analysis is very useful for toxicological investigations since, by providing a wider detection window, it gives the possibility to perform a retrospective study on the historical consumption of a substance. Unfortunately, there are no data available for hair concentrations in metformin-related deaths. In this study, the authors present 2 cases of fatal metformin intoxication in which, for the first time, hair analysis was performed using a specific GC-MS/MS method. Metformin was tested positive in femoral blood (112.3 mg/L and 64.7 mg/L respectively) and cardiac blood (226.9 and 203.2 mg/L) of the two subjects. For case 1, other samples were also tested positive, including vitreous humor (31.1 mg/L) and gastric contents (773.5 mg/L). In case 2, metformin was measured at 844.9 mg/L in urine. Metformin hair concentrations were 28.3-44.8 and 22.5 ng/mg for both cases, respectively. The concentrations found in the 2 fatal cases are clearly higher than those obtained in a previous study with subjects under treatment (0.3-3.8 ng/mg) or those found in 3 post-mortem cases where metformin death was excluded (0.6-1.4 ng/mg). Excessive sweating during the agonal phase due to fatal hypoglycemia could explain these elevated concentrations as sweat can have contaminated the hair.

Murdered while under the influence of 3-MeO-PCP.

The abuse of new psychoactive substances (NPS) has been dramatically increasing all around the world since the late 2000s. The availability of hundreds of NPS in the past decade is challenging for both public health and global drug policies. A 39-year-old woman, known as a multidrug addict, was murdered by her partner by ligature strangulation. A comprehensive toxicological screening by gas chromatography and ultra-high performance liquid chromatography with tandem mass spectrometry revealed the simultaneous presence of ethanol (1.37 g/L), diazepam (157 ng/mL) and nordiazepam (204 ng/mL), cocaine (25 ng/mL) and benzoylecgonine (544 ng/mL), and (3-methoxy-(1-(1-phenylcyclohexyl)piperidine) or 3-MeO-PCP, a dissociative hallucinogen anesthetic drug. Concentrations of 3-MeO-PCP were 63, 64, and 94 ng/mL in femoral blood, bile, and urine, respectively. Hair tested also positive for 3-MeO-PCP on 3 × 2-cm segments at 731, 893, and 846 pg/mg, indicating long-term abuse of the drug. This seems to be the first ever reported hair concentrations. Major impairment of the victim, including visual hallucinations and alteration of behavior, was attributed to the mixture of all the drugs, with a major contribution of 3-MeO-PCP. The toxicological findings were compared to the few reports available in the medical literature.

The benefits and pitfalls of post-mortem computed tomography in forensic external examination: A retrospective study of 145 cases.

OBJECTIVE: Nowadays, post-mortem computed tomography (PMCT) has become an integral part of Forensic practice. The purpose of the study was to determine PMCT impact on diagnosis of the cause of death within the context of the external examination of the body, when autopsy has, at first, not been requested. MATERIAL AND METHODS: We reviewed the records of 145 cases for which unenhanced PMCT was performed in addition to the external examination of the body from January 2014 to July 2015 at the Institute of Forensic medicine in Strasbourg (France). We confronted final reports from forensic pathologist to the corresponding PMCT reports. Data were collected in a contingency table and the impact of PMCT on the final conclusions of the forensic pathologist was evaluated via a Chi2 test. RESULTS: PMCT results significantly impact the final conclusions of forensic pathologist (p<0,001). In some cases, PMCT permits etiological diagnosis by revealing a cause of death hidden from external examination (mainly natural death) or by supporting the clinical findings of the forensic pathologist. In other cases (traumatic death), PMCT enables fast and exhaustive lesion assessment. Lastly, there are situations where PMCT may be ineffective (intoxication, hanging or some natural deaths). CONCLUSION: Performing PMCT within the context of the external examination of the body when autopsy has, at first, not been requested could bring significant benefits in diagnosing the cause of death. The impact of PMCT varies depending on the circumstances of death.

Interpretation of Cannabis Findings in the Hair of Very Young Children: Mission Impossible.

BACKGROUND: Hair has been suggested since the middle of the 90's to be a suitable matrix to document repetitive exposure to cannabis. Because it is possible to detect Δ9-tetrahydrocannabinol (THC), cannabinol (CBN) and cannabidiol (CBD) in cannabis smoke, the identification of the metabolite, 11-nor-Δ9-tetrahydrocannabinol carboxylic acid (THC-COOH) has been considered to allow the discrimination of active use. OBJECTIVE: Although the identification of an active compound in a child's hair shows contamination of the local environment, it is a challenge to discriminate between hair incorporation after ingestion or inhalation and environmental external deposition from dust, smoke, or even contaminated surfaces by hand contact. However, it is particularly important in case of children to correctly interpret the data, particularly for a realistic assessment of the health risk. We present here a series of hair tests for cannabis where the interpretation was almost impossible to establish. METHOD: Hair specimens were collected during the autopsy of the 12 children, aged 2 to 24 months, either deceased from shaken baby syndrome (SBS, n=4), mechanic asphyxia (MA, n=1) or sudden infant death (SID, n=7) during January 2015 to April 2017. After decontamination, the hair specimens were tested for THC, CBN and CBD and THC-COOH. The whole length of hair was submitted to analysis. RESULTS: The amount of hair from children can be as low as 8 mg. This may affect the limit of quantitation of all drugs, but particularly THC-COOH. Eight from twelve hair tests were positive for cannabis markers, i.e. THC (39 to 1890 pg/mg, n=8), CBN (< 5 to 1300 pg/mg n=8), CBD (10 to 2300 pg/mg, n=8) and THC-COOH (not detected to < 0.5 pg/mg, n=5). In 4 cases from 8 positive findings, it was not possible to test for THC-COOH (not enough material). CONCLUSION: Establishing a window of detection when testing for drugs in young children is a very complicated task. Hair from children is finer and more porous in comparison with adult (the risk of contamination from sweat and environmental smoke is higher than in adults). The final interpretation of cannabinoid findings in the children's hair is very complicated as this can result from in utero exposure (although none of the mother admitted cannabis use during pregnancy), oral cannabis administration by the parents to achieve sedation, close contact to cannabis consumers (hands, bedding, dishes) and inhalation of side-stream smoke. Over-interpreting cannabis findings in hair can have very serious legal implication in child protection cases. Practicing scientists have the responsibility to inform the child protection authorities, courts, etc. about these limitations.

Retrospective Demonstration of 25I-NBOMe Acute Poisoning Using Hair Analysis.

BACKGROUND: The abuse of new psychoactive substances or NPS has been dramatically increasing all around the world since the last half of the year 2000 and has become a serious public health problem. NPS are a challenge for the worldwide forensic community due to the difficulties to accurately document the cases. The N-benzylmethoxy (NBOMe) group is a new class of hallucinogenic designer drugs and has gained importance in recent years. 25I-NBOMe (2-(4-iodo-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)- methyl]ethanamine) is an analog of the 2C series of psychedelic phenethylamine drugs that contain an N-methoxybenzyl substituent, which significantly affects their pharmacological activities. It is a potent agonist of 5-HTA receptors and a severe hallucinogenic drug, with numerous irreversible psychedelic effects which can last from 5 to 10 hours. It is consumed most often in the form of drops or blotters by the transmucosal, sublingual or intranasal routes. The active dosage is very low, supposed to be less than 100 µg. The literature is poor in reporting cases where 25I-NBOMe was identified. Only very few clinical cases of over dosages were published, suggesting a low prevalence of this compound. METHODS: We present a retrospective demonstration of 25I-NBOMe acute poisoning with dramatic outcome, using hair analysis. Two hair strands, measuring 9.5 cm, were collected 6.5 months after drug consumption during a forensic clinical evaluation of brain dysfunctions after cardiorespiratory arrest and were analyzed by ultra-high performance liquid chromatography system coupled to a tandem mass spectrometry (UPLC-MS/MS) and using two specific transitions: m/z 428.1 > 121.2 (quantification) and 428.1 > 90.6 (confirmation). Hair strands were segmented to determine the historic pattern of drug use and differentiate a single exposure from a chronic exposure. The hair test result for 25I-NBOMe was the following: not detected (0-2 cm), not detected (2-4 cm), 1.0 pg/mg (4-6 cm), 4.9 pg/mg (6-8 cm) and not detected (8-9.5 cm). RESULT: The result of the segment 6-8 cm coincides with the date of consumption (calculated with a hair growth rate at 1 cm/month) and the low concentration detected in the segment 4-6 cm probably corresponds to the contribution of dormant hair. The toxicological significance of the measured concentrations is difficult to determine because this is the first case dealing with hair analysis for 25I-NBOMe. CONCLUSION: The use of hair analysis for NPS is still at the initial stages. In particular, little is known about the incorporation into the keratin matrix after intake and the correlation between dosage frequency of use, and hair concentrations. Under these circumstances, NPS hair analysis should be cautiously interpreted by experienced forensic toxicologist.

High risk of misinterpreting hair analysis results for children tested for methadone.

The major problem after testing the hair of a child for drugs is the interpretation of the findings. In 2016, the laboratory received several hair specimens with the request to verify if there was any evidence of previous methadone exposure by the donor of the sample. Case 1 was a child admitted to the Emergency Unit for intense sedation and breathing difficulties. Cases 2-4 involved children found dead at home. In all cases, methadone and EDDP, its metabolite, were found in blood. After decontamination, the hair was analysed with LC-MS/MS for methadone and EDDP. The LOQ for both drugs was 10pg/mg. Concentrations were in the range 60-1590 and <10-220pg/mg for methadone and EDDP, respectively. In all of the cases, segmental analysis revealed approximately the same amount of drug along the hair lock. As a consequence, contamination was considered as an issue and interpretation of the results was a challenge that deserves particular attention. It must be considered that the amount of hair from children, available for analysis, can be low, particularly when several drugs have to be tested. This has consequences on the limit of quantitation and the identification of the metabolite(s). It must be also noted that hair from children is finer and more porous in comparison with adult (risk of higher contamination by sweat versus adults). It is very difficult to put any window of detection when testing for drugs in young children as hair growing is asynchronous. It is even more complicated as it has been demonstrated that drugs can be incorporated during pregnancy in the hair of the foetus, which will contribute to the positive findings after delivery. Several weeks or months after delivery, identification of a drug in hair can indicate: 1, in-utero exposure, or 2, exposure after delivery, or 3, a mix of both situations. Whereas the detection of drugs in a child's hair unambiguously shows drug handling in the environment of the child, it is difficult to distinguish between systemic incorporation into hair after ingestion or inhalation and external deposition into hair from smoke, dust, or contaminated surfaces. However, the interpretation of hair results with respect to systemic or only external exposure is particularly important in case of children for a realistic assessment of the toxic health risk. Practising scientists have the responsibility to inform the child protection authorities, courts, etc about these limitations.

Detection of genetic variation in KCNQ1 gene by high-resolution melting analysis in a prospective-based series of postmortem negative sudden death: comparison of results obtained in fresh frozen and formalin-fixed paraffin-embedded tissues.

High-resolution melting (HRM) analysis is a recently developed molecular technique proved to be applicable for detection of genetic variation, notably in sudden cardiac death. In certain circumstances, especially in postmortem genetic investigations, the formalin-fixed and paraffin-embedded (FFPE) tissues are the only DNA source available. The present study aimed to develop HRM assays, optimized for the analysis of FFPE tissues, to detect sequence variations in KCNQ1 exons in a prospective population-based series of postmortem negative sudden death and to compare the results between the paired freshly frozen and FFPE tissue samples simultaneously obtained from the same case. The analyses were conducted in each case of sudden death involving cases younger than 35 years with no significant morphological anomalies particularly with no cardiac structural disease and with negatives toxicological investigations. HRM analysis was successfully optimized for 13 of the 16 exons of the KCNQ1 gene. All mutated samples were correctly identified by HRM whatever the type of tissue tested. However, for FFPE samples, HRM indicated more positive samples than classical sequencing, used in parallel, due to the degradation of DNA by formalin fixation. This is the first postmortem study of KCNQ1 mutation detection with HRM on DNA extracted from FFPE samples with adapted protocol. Despite the false-positive detection, we concluded that the use of HRM as a screening method with FFPE samples to analyze KCNQ1 mutations can reduce the number of sequencing reactions and, thus, results in substantial time and cost savings.

Detection of age-related duplications in mtDNA from human muscles and bones.

Several studies have demonstrated the age-related accumulation of duplications in the D-loop of mitochondrial DNA (mtDNA) extracted from skeletal muscle. This kind of mutation had not yet been studied in bone. The detection of age-related mutations in bone tissue could help to estimate age at death within the context of legal medicine or/and anthropological identification procedures, when traditional osteological markers studied are absent or inefficient. As we detected an accumulation of a point mutation in mtDNA from an older individual's bones in a previous study, we tried here to identify if three reported duplications (150, 190, 260 bp) accumulate in this type of tissue. We developed a sensitive method which consists in the use of back-to-back primers during amplification followed by an electrophoresis capillary analysis. The aim of this study was to confirm that at least one duplication appears systematically in muscle tissue after the age of 20 and to evaluate the duplication age appearance in bones extracted from the same individuals. We found that the number of duplications increase from 38 years and that at least one duplicated fragment is present in 50% of cases after 70 years in this tissue. These results confirm that several age-related mutations can be detected in the D-loop of mtDNA and open the way for the use of molecular markers for age estimation in forensic and/or anthropological identification.

Ricochet of a bullet in the spinal canal: a case report and review of the literature on bullet migration.

Ricochet of a bullet in the spinal canal is well known by neurosurgeons but relatively not a common event in usual medico-legal autopsy practice. This article presents a homicide case of a penetrating gunshot injury of the lumbar spine through the T12-L1 intervertebral foramen with active movement of the projectile within the spinal canal to the L5-S1 level. This case illustrates a bullet intradural and intramedullary active movement because of a ricochet of the body of T12 with active redirection of the path. In the current literature, different types of migration in caudal or cranial direction, intradural, or intramedullary are reported. If spontaneous migration of T10 to S1 seems to be more frequent, some authors reported a C1 to S2 migration. Such migration could be asymptomatic or induce neurological impairment. The medico-legal consequences of these migrations within the spinal canal are described.