Can the size of the contact area body-ground influence the presence of acute pulmonary emphysema in cases of incomplete hanging?

In a recently published study, we showed that acute pulmonary emphysema (APE) was present in cases of death by incomplete hanging and absent in cases of complete hanging. This result suggested a possible role of the hanging position on the respiratory distress of these victims. To further investigate this hypothesis, in the present study, we compared cases of incomplete hanging with a small contact area between body and ground (group A) to cases of incomplete hanging with a large contact area (group B). As positive and negative control group, we investigated cases of freshwater drowning (group C) and acute external bleeding (group D) respectively. Pulmonary samples were histologically examined, and the mean alveolar area (MAA) for each group was measured by digital morphometric analysis. MAA was 23,485 µm2 for group A and 31,426 µm2 for group B (p < 0.05). MAA of group B was similar to MAA of positive control group (33,135 µm2) and MAA of group A was similar to MAA of negative control group (21,991 µm2). These results seem to confirm our hypothesis and suggest that the size of the contact area between body and ground influences the presence of APE. Furthermore, the present study showed that APE can be proposed as a vitality sign in incomplete hanging, but only in cases with a large contact area between body and ground.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating.

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Immunohistochemical renal expression of aquaporin 2, arginine-vasopressin, vasopressin receptor 2, and renin in saltwater drowning and freshwater drowning.

The diagnosis of drowning is considered one of the most difficult in forensic medicine. Due to the paucity of signs, it is a classical diagnosis by exclusion. For this reason, specific immunohistochemical markers would be useful. Far too little has been done to analyze in-depth the differences between SWD and FWD. We focused on the renal immunohistochemical expression of aquaporin 2, AVP, V2R, and renin in cases of drowning. This study has two purposes: (1) to better understand the differences between saltwater drowning (SWD) and freshwater drowning (FWD), which may indicate different pathophysiology and (2) to eventually identify markers useful for the diagnosis of drowning. We retrospectively investigated 10 cases of SWD gathered from the Institute of Legal Medicine in Genoa (Italy), and 10 cases of FWD from the University Center of Legal Medicine in Geneva (Switzerland). As a control group, we investigated 10 cases of death by gunshot to the head. A strong expression of AQP2 and AVP was significantly (p < 0.05) more evident in cases of SWD than in FWD and control cases. Regarding the V2R, no statistically significant differences were found between the studied groups. The renin tubular expression was particularly intense (p < 0.05) both in SWD and in FWD compared controls. According to our results, AQP2 and AVP represent potential useful markers for the differential diagnosis between SWD and other causes of death, including FWD. Renin may be a useful marker in the diagnosis of drowning but it does not allow for differentiation between FWD and SWD.

Immunohistochemical expression of P-selectin, SP-A, HSP70, aquaporin 5, and fibronectin in saltwater drowning and freshwater drowning.

The diagnosis of drowning is one of the most difficult in forensic medicine. The aim of this study was to analyze pulmonary tissue reactions in death by drowning. In particular, we focused on the immunohistochemical expression of P-selectin, SP-A, HSP70, AQP-5, and fibronectin to investigate our expression in drowning and to understand whether there are differences between saltwater drowning (SWD) and freshwater drowning (FWD), which may indicate a different pathophysiology. We retrospectively investigated 10 cases of SWD (Mediterranean Sea) from the Institute of Legal Medicine of Genoa (Italy), and 10 cases of FWD (Lake of Geneva) from the University Center of Legal Medicine of Geneva (Switzerland). As control group, we examined 10 cases of death by acute external bleeding, characterized by minimal respiratory distress. As compared with controls, in SWD cases, the results showed a decrease of SP-A expression with membrane patterns. Furthermore, we observed a greater SP-A expression with granular pattern in drowning cases without statistically significant difference between SWD and FWD. For the markers AQP-5, HSP70, fibronectin, and P-selectin, no statistically significant differences were found between SWD, FWD, and controls.

HIF1α protein and mRNA expression as a new marker for post mortem interval estimation in human gingival tissue.

Estimating the post mortem interval (PMI) is still a crucial step in Forensic Pathology. Although several methods are available for assessing the PMI, a precise estimation is still quite unreliable and can be inaccurate. The present study aimed to investigate the immunohistochemical distribution and mRNA expression of hypoxia inducible factor (HIF-1α) in post mortem gingival tissues to establish a correlation between the presence of HIF-1α and the time since death, with the final goal of achieving a more accurate PMI estimation. Samples of gingival tissues were obtained from 10 cadavers at different PMIs (1-3 days, 4-5 days and 8-9 days), and were processed for immunohistochemistry and quantitative reverse transcription-polymerase chain reaction. The results showed a time-dependent correlation of HIF-1α protein and its mRNA with different times since death, which suggests that HIF-1α is a potential marker for PMI estimation. The results showed a high HIF-1α protein signal that was mainly localized in the stratum basale of the oral mucosa in samples collected at a short PMI (1-3 days). It gradually decreased in samples collected at a medium PMI (4-5 days), but it was not detected in samples collected at a long PMI (8-9 days). These results are in agreement with the mRNA data. These data indicate an interesting potential utility of Forensic Anatomy-based techniques, such as immunohistochemistry, as important complementary tools to be used in forensic investigations.

Back to the Future - Part 1. The medico-legal autopsy from ancient civilization to the post-genomic era.

Part 1 of the review "Back to the Future" examines the historical evolution of the medico-legal autopsy and microscopy techniques, from Ancient Civilization to the Post-Genomic Era. In the section focusing on "The Past", the study of historical sources concerning the origins and development of the medico-legal autopsy, from the Bronze Age until the Middle Ages, shows how, as early as 2000 BC, the performance of autopsies for medico-legal purposes was a known and widespread practice in some ancient civilizations in Egypt, the Far East and later in Europe. In the section focusing on "The Present", the improvement of autopsy techniques by Friedrich Albert Zenker and Rudolf Virchow and the contemporary development of optical microscopy techniques for forensic purposes during the 19th and 20th centuries are reported, emphasizing, the regulation of medico-legal autopsies in diverse nations around the world and the publication of international guidelines or best practices elaborated by International Scientific Societies. Finally, in "The Future" section, innovative robotized and advanced microscopy systems and techniques, including their possible use in the bio-medicolegal field, are reported, which should lead to the improvement and standardization of the autopsy methodology, thereby achieving a more precise identification of natural and traumatic pathologies.

Autopsy histopathology where the prosector is not a histopathologist: a proposal.

Forensic pathology is a specialty that involves death investigation while clinical forensic medicine is the application of the practice of medicine to the requests of the law in relation to the living. Around the world, there is diverse practice for these two disciplines. The forensic physician or forensic doctor (sometimes, called a forensic pathologist but not a forensic histopathologist) in parts of the world such as continental Europe, the Middle East and India, practice both clinical forensic medicine and forensic pathology. This is the specialty, for the purposes of this paper, we will call forensic medicine. The forensic doctor will usually receive training in autopsy dissection, perhaps with a short training of a few months in anatomical pathology or surgical histopathology. When undertaking autopsies (involving internal as well as external examination), if it is thought histological assessment is required, the forensic doctor will sample the organs and tissues required and refer the specimens to the hospital histopathologist for microscopic examination. This division of responsibility could compromise the quality of the autopsy unless handled correctly.Where the histological assessment of the autopsy specimen is undertaken by a pathologist other than the one who dissected the body and collected the samples, standard operating procedures need to be developed to minimize the risk to the overall quality of the autopsy. We are not aware that any such procedures have been published, hence we offer an outline of what a set of such procedures might contain.

Lethal nitrous oxide (N2O) intoxication during surgery: the contribution of immunohistochemistry in identifying the cause of death: a case report.

BACKGROUND: Nitrous oxide (N2O) is a gas used in medicine for its analgesic, anxiolytic and amnesic properties. It is a drug considered safe if adequately administered. In the literature, accidental N2O-related deaths are rare. They are mostly related to inhalation of this substance for recreational and autoerotic purposes; rarely are reported deaths due to incorrect administration of medical gas in anesthesia. The diagnosis of death from acute N2O intoxication is complex and is generally an exclusion diagnosis: the macroscopic and microscopic post-mortem signs are entirely nonspecific. Furthermore, the circumstantial data are not always supportive and can even be confusing, mainly if the death occurred inside a hospital. CASE PRESENTATION: We describe a particular case of death from acute nitrous oxide poisoning in a hospital environment, of a Caucasian male of 72-years-old. The intoxication occurred during a minimally invasive vascular surgery due to an incorrect assembly of the supply lines of medical gases (O2 and N2O). The identification of the cause of death resulted from the analysis of circumstantial data, macroscopic and microscopic autoptic findings, and immunohistochemical investigations based on the search for antibodies anti E-selectin, P-selectin, and HIF 1-α. CONCLUSION: Although not pathognomonic of asphyxiation by N2O, the latter molecules are a valid and early marker of hypoxic insult. Therefore, in concert with all other findings, it may constitute valid support for the forensic pathologist to ascertain the cause of death in case of suspected intoxication by N2O.

Diagnostic significance of the histopathology of bone marrow macrophages in forensic autopsies.

Forensic pathologists often encounter autopsies that require an assessment of antemortem general conditions (e.g., infection, metabolic disorders). To establish evaluation clues for such cases, we quantitatively examined macrophages and the general pathology of bone marrow in samples from 180 forensic autopsy cases of decedents with various conditions. Hematoxylin-eosin staining, Berlin blue staining, and immunostainings for CD163, CD138, and CD61 were performed. We determined the numbers per field (density) of total macrophages, swollen macrophages, macrophages with hemophagocytosis, and hemosiderin-laden macrophages. Each density was standardized by identifying its ratio to the total number of macrophages. The decedents' background data (cause of death, other pathological findings, postmortem interval, antemortem symptoms, and presence of resuscitation) were extracted. No correlations were found between the postmortem interval and the other decedent data, indicating that these data are not affected by postmortem changes. In the group in which inflammatory disease was the cause of death, there were significant elevations in the ratio of the swollen macrophage density to total macrophages. Significantly higher ratios of the density of swollen and hemophagocytic macrophages were observed in the group in which conditions with a prolonged agonal period were the cause of death. The group with a return of spontaneous circulation to resuscitation showed a significantly higher ratio of macrophage density with hemophagocytosis. This study provides the first statistical analysis focused on bone marrow histopathology in forensic autopsies. The results will be useful for elucidating causes of death and agonal-period conditions.

Immunohistochemical detection of insulin at the injection site in a case of suspected murder with the suicide of the perpetrator.

In medicolegal practice, rare cases involving suicidal, criminal, or accidental insulin overdose are both analytically and forensically challenging. The aim of this study is to present a model procedure in such cases, developed at the Department of Forensic Medicine and Toxicology of the Medical University of Silesia in Katowice, with particular emphasis on the possibility of additional confirmation of insulin intake by its immunohistochemical detection at the injection site. In the example case presented here, an immunohistochemical examination using FLEX Polyclonal Guinea Pig Anti-Insulin antibody (code IR002, Dako) confirmed the presence of insulin in the subcutaneous tissue of the victims. In our opinion, the method of immunohistochemical detection of insulin at the injection site can and should be used routinely in such cases.

Cirsoid aneurysm rupture of the splenic artery as a rare cause of fatal hemoperitoneum.

Cirsoid aneurysms are rare arteriovenous malformations without any capillaries interposed and almost always observed in the scalp region. These types of aneurysms are so-called "cirsoid" because of their serpiginous appearance. In this report, the authors present the first case of a lethal spontaneous rupture of a cirsoid aneurysm of the splenic artery, which could be diagnosed only by post-mortem histologic examination. The victim was a 70-year-old man who was suddenly found dead in bed while he was hospitalized and waiting for a scheduled cardiac surgery. A forensic autopsy was ordered due to the suspicion that the man's death could have been related to medical malpractice. An accurate autopsy and a complete forensic histologic examination could clarify the cause of death, which was identified in the spontaneous rupture of a cirsoid aneurysm of the splenic artery. The case is intended to be used as source data for similar forensic cases, where the cause of a massive hemoperitoneum is difficult to be identified.

An Unusual Encounter of Skin Condition Mimicking Acrokeratosis Paraneoplastica (Bazex Syndrome).

Acrokeratosis paraneoplastica is a rare paraneoplastic skin disease in which there are erythematous violaceous, scaly plaques on the hands, feet, and acral locations. There is a relationship between various carcinomas of the aerodigestive tract and skin eruptions. These were the pioneering work done pertaining to a clinical entity that was showing some inter-relationship between a skin condition and carcinoma anywhere inside the body. Bazex syndrome is mostly associated with carcinomas of the upper aero-digestive tract, but other malignancies were also being reported. In this case, the patient was in advancing age with cachexic features along with liver and lung lesions which prompted us to investigate histologically for evidence of malignancy which came out to be negative. In our case, lungs showed features of pulmonary edema with normal histology. When we examined the liver, gross lesions were present but no evidence of malignancy was noted and the liver showed normal parenchyma histologically. Specimens taken from hand and foot showed hyperkeratosis along with bacterial colonies in the overlying epidermis. The spleen showed red pulp with congestion and hemorrhage. Similarly, sections from the kidneys were showing interstitial inflammation and congestion of blood vessels. Specimens from the brain and heart showed unremarkable histology.

Pediatric medicolegal autopsy in France: A forensic histopathological approach.

The aim of postmortem medicolegal examination in pediatric death is primarily to establish the circumstances and causes of death and to exclude child abuse. In France, pediatric death is systematically documented by medicolegal or medical autopsy. In case of medicolegal autopsy, the complementary examinations, requested and financed by justice, are rarely limited to a histopathological examination. However in medical autopsies other tools are available to the pathologist as toxicology, biochemistry and molecular biology. The purpose of this article is to evaluate the efficacy of forensic histopathology in pediatric forensic autopsies. We analyze the main causes of pediatric death in a forensic context. Between 2004 and 2015, 157 infant deaths were identified in Marseille university hospital. The forensic histopathology and autopsy reports of all 157 cases were available for systematic review. Medical or surgical causes represented 41,3% of deaths in our center, accidental causes 8.1% and child abuse 28,8%. The definitive diagnosis was made at autopsy in 30% of cases and at histopathological examination in 70% highlighting that forensic histopathology is an indispensable tool in pediatric medicolegal autopsies. Significant histological abnormalities may be detected in selected organs such as the brain, lungs, heart, liver, adrenal glands and kidneys in spite of macroscopically normal appearances. This justifies systematic sampling of all organs. Despite the implementation of the French sudden infant death protocol which recommends medical autopsies, too many pediatric autopsies are carried out in a medicolegal context. 30% of the cases remain without diagnosis at the end of the autopsy and histological examination. This number could be reduced by the contribution of others laboratory investigation.

A case report of lethal post-viral lymphocytic myocarditis with exclusive location in the right ventricle.

The inflammatory involvement of vital organs may represent a dangerous and life-threatening situation: in particular, the inflammation of the myocardial tissue of the heart may lead to severe consequences since the clinical history of the disease may be completely asymptomatic, any clinical sign may be lacking, thus preventing correct diagnosis and treatment. This may occur even in the case of myocarditis and may lead to unexpected death whose cause can be assessable only by means of a thorough histopathological examination. The article reports the case of 61-year old female who developed a flu-like syndrome with very few symptoms, followed by sudden death in three weeks. The autopsy and following histopathological investigations identified the cause of death in a post-viral lymphocytic myocarditis, probably related to the previous infectious disease, and alternative causes (as arrhythmic ventricular dysplasia, vasculitis, sarcoidosis and giant cell myocarditis) were excluded. The exclusive location in the right ventricle was a peculiar finding. The case highlights the importance of the myocardium of the right ventricle, a tissue which is often less considered even in histopathological surveys. The exclusive location of myocarditis in the right ventricle is a rare event but in this case fully responsible for death.