Lower microhardness along with less heterogeneous mineralization in the femoral neck of individuals with type 2 diabetes mellitus indicates higher fracture risk.

There is still limited understanding of the microstructural reasons for the higher susceptibility to fractures in individuals with type 2 diabetes mellitus (T2DM). In this study, we examined bone mineralization, osteocyte lacunar parameters, and microhardness of the femoral neck trabeculae in 18 individuals with T2DM who sustained low-energy fracture (T2DMFx: 78 ± 7 years, 15 women and 3 men) and 20 controls (74 ± 7 years, 16 women and 4 men). Femoral necks of the T2DMFx subjects were obtained at a tertiary orthopedic hospital, while those of the controls were collected at autopsy. T2DMFx individuals had lower trabecular microhardness (P = .023) and mineralization heterogeneity (P = .001), and a tendency to a lower bone area with mineralization above 95th percentile (P = .058) than the controls. There were no significant intergroup differences in the numbers of osteocyte lacunae per bone area, mineralized lacunae per bone area, and total lacunae per bone area (each P > .05). After dividing the T2DMFx group based on the presence of vascular complications (VD) to T2DMFxVD (VD present) and T2DMFxNVD (VD absent), we observed that microhardness was particularly reduced in the T2DMFxVD group (vs. control group, P = .02), while mineralization heterogeneity was significantly reduced in both T2DMFx subgroups (T2DMFxNVD vs. control, P = .002; T2DMFxVD vs. control, P = .038). The observed changes in mineralization and microhardness may contribute to the increased hip fracture susceptibility in individuals with T2DM.

Assessing the knot in a noose position by thyrohyoid and cervical spine fracture patterns in suicidal hangings using machine learning algorithms: A new insight into old dilemmas.

Hanging is one of the most common suicide methods worldwide. Neck injuries that occur upon such neck compression - fractures of the thyrohyoid complex and cervical spine, occupy forensic pathologists for a long time. However, research failed to identify particular patterns of these injuries corresponding to the force distribution a ligature applies to the neck: the issue of reconstructing the knot in a noose position persists. So far, machine learning (ML) models were not utilized to classify knot positions and reconstruct this event. We conducted a single-institutional, retrospective study on 1235 autopsy cases of suicidal hanging, developed several ML models, and assessed their classification performance in a stepwise manner to discriminate between: 1. typical ('posterior) and atypical ('anterior' and 'lateral') hangings, 2. anterior and lateral hangings, and 3. left and right lateral hangings. The variable coding was based on the presence/absence of fractures of greater hyoid bone horns (GHH), superior thyroid cartilage horns (STH), and cervical spine. Subject age was considered. The models' parameters were optimized by the Genetic Algorithm. The accuracy of ML models in the first step was very modest (c. 60%) but increased subsequently: Multilayer Perceptron - Artificial Neural Network and k-Nearest Neighbors performed excellently discriminating between left and right lateral hangings (accuracy 91.8% and 90.6%, respectively). The latter is of great importance for clarifying probable hanging fracture biomechanics. Alongside the conventional inferential statistical analysis we performed, our results further indicate the association of the knot position with ipsilateral GHH and contralateral STH fractures in lateral hangings. Moreover, odds for unilateral GHH fracture, simultaneous GHH and STH fractures, and cervical spine fracture were significantly higher in atypical ('anterior' and 'lateral') hangings, compared to typical ('posterior') hangings.

Penile Pearls and Pearling: Characteristics and Social Identity from the Perspective of Forensic Pathologists.

Penile pearls are artificial implants placed beneath the skin of a penis to provide enhanced sexual experience for the partner or present a stigma of a particular social subgroup (e.g., prisoner, member of a gang). This genital modification is usually encountered in men of low socioeconomic status and prisoners who might (self) implant improvised pearls under poor sanitary conditions. We have only recently started to encounter penile pearls on autopsy, incidentally. The aim of this study was to analyze our autopsy cases with penile pearls to assess the characteristics of these subjects regarding their socioeconomic status, history of imprisonment, substance abuse, as well as the characteristics of implants. Nineteen men were included. Most were born in the 1970s and 1980s, with only elementary/vocational school education (n = 10). Only five men graduated from high school. At least 14 were in prison at some point in life and 13 were unemployed. Ten men were unmarried. In 11 men, regular alcohol consumption was reported. 12 used illicit substances, most with a history of heroin injection. Penile pearls were improvised and made of rigid plastic in 10 men, eight were of soft silicone-like material, and one was of metal. A distinct characteristic was a ribbed contour of some implants. Although this genital modification seems to gain more attention outside of described vulnerable groups, it mostly remains limited to them in our region. It is most likely performed in improvised, non-professional, unsanitary conditions, probably in prisons.

Improved femoral micro-architecture in adult male individuals with overweight: fracture resistance due to regional specificities.

BACKGROUND: It is still unclear whether femoral fracture risk is positively or negatively altered in individuals with overweight. Considering the lack of studies including men with overweight, this study aimed to analyze regional specificities in mechano-structural femoral properties (femoral neck and intertrochanteric region) in adult male cadavers with overweight compared to their normal-weight age-matched counterparts. METHODS: Ex-vivo osteodensitometry, micro-computed tomography, and Vickers micro-indentation testing were performed on femoral samples taken from 30 adult male cadavers, divided into the group with overweight (BMI between 25 and 30 kg/m2; n = 14; age:55 ± 16 years) and control group (BMI between 18.5 and 25 kg/m2; n = 16; age:51 ± 18 years). RESULTS: Better quality of trabecular and cortical microstructure in the inferomedial (higher trabecular bone volume fraction, trabecular thickness, and cortical thickness, coupled with reduced cortical pore diameter, p < 0.05) and superolateral femoral neck (higher trabecular number and tendency to lower cortical porosity, p = 0.043, p = 0.053, respectively) was noted in men with overweight compared to controls. Additionally, the intertrochanteric region of men with overweight had more numerous and denser trabeculae, coupled with a thicker and less porous cortex (p < 0.05). Still, substantial overweight-induced change in femoral osteodensitometry parameters and Vickers micro-hardness was not demonstrated in assessed femoral subregions (p > 0.05). CONCLUSIONS: Despite the absence of significant changes in femoral osteodensitometry, individuals with overweight had better trabecular and cortical femoral micro-architecture implying higher femoral fracture resistance. However, the microhardness was not significantly favorable in the individuals who were overweight, indicating the necessity for further research.

Age-at-death estimation based on micro-CT assessment of pubic symphysis: Potentially new methodological approach.

BACKGROUND: Although various methods for age-at-death estimation of skeletal remains are available, this is still an unsolved issue in forensic anthropology, especially concerning elderly individuals. Moreover, the lack of population-specific methods often made age-at-death estimation unreliable in other populations. AIM: Our study aimed to examine whether micro-computed tomography (micro-CT) analysis of pubic bone samples obtained from the contemporary Serbian population could be used in anthropological and forensic practice for age-at-death estimation. METHODOLOGY: This study encompassed 62 pubic samples obtained from 26 adult male and 36 adult female cadaveric donors (age range: 22-91 years). Initially, staging according to the Suchey-Brooks phases was performed by two experienced investigators, followed by micro-CT assessment of pubic bone trabecular and cortical compartments (spatial resolution of the scans was 10 µm). RESULTS: Our results revealed an age-associated decline in trabecular and cortical micro-architecture of elderly male and female individuals, with the most prominent changes present in trabecular bone volume fraction and total porosity of the anterior and posterior cortical surface of the pubic bone. Those parameters were used to generate age-at-death estimation equations. One sample t-test did not reveal a significant difference between estimated age-at-death and real (known) age-at-death in the overall sample (mean absolute error [MAE] of 4.76 years), female (MAE of 9.66 years) and male cadaveric donors (MAE of 6.10 years, p > 0.05). CONCLUSION: Our data indicated that micro-architectural features of trabecular and cortical compartments of pubic bone could potentially be applied as an additional reliable method for age-at-death estimation in the Serbian population.

Atheroprotective effect of myocardial bridge sustains in aging: Autopsy study on subjects with dual left anterior descending coronary artery type 3.

BACKGROUND: The atheroprotective role of the myocardial bridge (MB) on a tunneled segment is already demonstrated in subjects with dual left anterior descending coronary artery (dual LAD) type 3 anomaly, but the dynamics of changes and whether this protective effect sustains during aging is unknown. METHODS: The retrospective autopsy study included cases of dual LAD type 3 anomaly identified over 18 years. The severity grade of atherosclerosis in branches of dual LAD was estimated by microscopy. The Spearman's correlation test and Receiver operator characteristics (ROC) curve analyses were performed to determine the relation of subjects' age with a degree of the protective role of the myocardial bridge. RESULTS: A total of 32 dual LAD type 3 cases were identified. The systematic heart examination revealed an anomaly prevalence of 2.1%. The age significantly positively correlated with the severity of atherosclerosis in the subepicardial dual LAD branch but not with the severity of atherosclerosis in the intramyocardial dual LAD branch. Subjects aged ≥38 years were likely to have a more severe degree of atherosclerosis in subepicardial than in intramyocardial LAD arteries (AUC 0.81 95% CI 0.59-1; sensitivity 100%, specificity 66.7%). In subjects aged ≥58 years, this difference was likely to be more pronounced (≥2 degree difference; AUC 0.75 95% CI 0.58-0.93; sensitivity 92.9%, specificity 66.7%). CONCLUSION: The atheroprotective effect of the myocardial bridge on tunneled segments usually becomes evident throughout the second half of the fourth decade of life and is most pronounced after about 60 years and ceases only in some.

Subendocardial hemorrhages in a case of crush asphyxia.

This case represents a 27-year-old man, who was found dead in a truckload, trapped between several coils of steel wire, each weighing 500 kg. The autopsy was remarkable for subendocardial hemorrhages in addition to Perthes' syndrome and florid internal findings: congestion/cyanosis of the cervical organs, intrathyroidal and submucosal bleedings. All this implies that compression significantly raised intrathoracic pressure. This might have reached a point that obstructed venous blood return and restricted filling of the right heart during diastole, while simultaneously preserving the function of a left ventricle for some time. A precipitous fall of the blood pressure and consequent decrease in the left ventricle filling, with a pressure gradient between the ventricular lumen and higher-pressured heart vessels could have resulted in myocardial vessel rupture - the same pathophysiologic mechanism that underlies the appearance of subendocardial hemorrhages. If this man was conscious and aware for some time prior and upon initial compression, the fight or flight response could have resulted in a sudden surge of circulating catecholamine levels - which is the second described mechanism of subendocardial hemorrhage development. However, we believe that autopsy findings favor the firstly described scenario. Nevertheless, subendocardial hemorrhages are out of the common finding in crush asphyxia.

Burn index, burn characteristics and carboxyhemoglobin levels in indoor fire-related deaths: Significance and interpretation of the autopsy findings.

INTRODUCTION: The Burn Index (BI) is a significant clinical prognostic parameter for patients with burns. It simultaneously considers major mortality risk factors: age and burns extensivity. Despite the inability to distinguish between ante- and post-mortem burns, their characteristics on autopsy might indicate if a significant thermal injury occurred before the onset of death. We investigated whether autopsy BI, burn extensivity, and severity could tell whether burns were the concurrent cause of fire-related death (FRD), even if the body remained in a fire. MATERIAL AND METHODS: Ten-year retrospective study analyzed FRD that occurred at the scene in a confined space. Soot aspiration was the main inclusion criterion. Autopsy reports were reviewed for demographic data, burn characteristics (degree, Total Body Surface Area burned- TBSA), coronary artery disease, and blood ethanol. We calculated the BI as a sum of the victim's age and percentage of TBSA affected by 2nd, 3rd and 4th-degree burns. Cases were divided into two groups: those with COHb≤ 30% and with COHb> 30%. Subjects with burned TBSA≤ 40% were analyzed separately afterward. RESULTS: The study included 53 males (71.6%) and 21 females (28.4%). No significant difference in age was observed between groups (p > 0.05). COHb≤ 30% had 33, and COHb> 30% had 41 victims. BI and burns extensivity (TBSA) had significant negative correlation with COHb values (ρ = -0.581, p < 0.01 and ρ = -0.439, p < 0.01, respectively). Both were significantly higher in subjects with COHb≤ 30% compared to those with COHb> 30% (140.7 ± 29.57 vs. 95.49 ± 38.49, p < 0.01 and 98 (13-100) vs. 30 (0-100), p < 0.01, BI and TBSA respectively). BI had excellent and TBSA fair performance for detection of subjects with COHb≤ 30% on ROC curve analysis (AUCs 0.821, p < 0.001 and 0.765, p < 0.001), with optimal cut-off values: BI≥ 107 (sensitivity 81.3%, specificity 70.7%) and TBSA≥ 45 (sensitivity 84.8%, specificity 70.7%). On logistic regression analysis BI≥ 107 was independently associated with COHb≤ 30% values (aOR 6; 95%CI 1.55-23.37). The same holds for the presence of 3rd-degree burns (aOR 5.9; 95%CI 1.45-23.99). In the subgroup of subjects with TBSA≤ 40% burned, those with COHb≤ 50% were significantly older than victims with COHb> 50% (p < 0.05). Here BI≥ 85 was a particularly good predictor for detection of subjects with COHb≤ 50% (AUC=0.913, p < 0.001, 95% CI 0.813-1.00; sensitivity 90.9%, specificity 81%). CONCLUSION: The BI≥ 107, TBSA≥ 45% burned, and 3rd-degree burns observed on autopsy point to a significantly higher odds that limited CO intoxication occurred, and burns should be considered a concurrent cause of indoor FRD. When less than 40% of TBSA was affected, BI≥ 85 indicated sub-lethal CO poisoning.

Anomalous papillary muscle insertion into mitral valve leaflet: Autopsy study and implications.

Anomalous papillary muscle (APM) insertion into the anterior mitral valve leaflet is often associated with hypertrophic cardiomyopathy (HCM) but is reported in other cases as a rare finding. Mere presence does not strictly imply hemodynamic disturbance, and several types exist, with various impacts on left ventricular outflow tract (LVOT) obstruction. The interpretation of isolated anomaly is challenging at autopsy because significant LVOT obstruction is dynamic. We analyzed autopsy cases with APM regarding the site of PM insertion and origin, number of PM bellies, anomalous insertions, heart weight, left ventricle (LV) thickness, LV endocardial fibrosis, subjects' age, sex, cause, and manner of death. A total of 20 cases were identified. Fourteen were identified incidentally, while in 670 systematically examined hearts, the APM was identified in six cases, indicating a prevalence of 0.9%. In eight cases, the manner of death was natural (one case with HCM), and in 12 non-natural. Type II anomaly of PM was most frequent (n = 8), followed by Type III (n = 7) and Type I (n = 5). Subjects who died of natural causes were significantly older and had heavier hearts (median 455 g vs. 330 g; p < 0.05) without difference in LV thickness (median 16 mm vs. 15 mm; p > 0.05). Histology performed in four cases showed a pattern of direct insertion of cardiomyocytes into the leaflet's thick fibrous tissue with a narrow overlapping zone. The APM is rare, can be easily overlooked, and does not imply significant pathology per se. We discussed proper assessment of the significance of this anomaly at autopsy.

Extensive direct spreading of "groin hit"-related soft tissue infections: a report of three cases.

We present fatal extensive soft tissue infections, a consequence of groin heroin injection, in three subjects, who were 27, 34, and 39 years old and had a history of over 10-, 15-, and 5-years of heroin injection (cases 1, 2, and 3, respectively). In all cases, the first symptoms of the infection appeared at least a week prior, with rapid deterioration on the last day. The hallmark was a disproportion between external and internal findings in the affected thighs. The latter presented as extensively spread suppurative inflammation with soft tissue necrosis. In case 1, subtle skin erythema was present in the left groin, with a wound suggestive of a recent abscess incision and injection-related scarring. However, dissection revealed that inguinal regions and deep soft tissue (including the muscle sheets) of the left thigh, gluteal region, and lower third of the anterior abdominal wall were inflamed with pus, alongside fibrinopurulent peritonitis. Case 2 had pronounced erythema and swelling of the thigh and knee. Diffuse suppuration was observed upon dissection in the inguinal regions, which extended into the iliopsoas muscles, with soft tissue and muscle necrosis. In the abdominal cavity, we detected 150 mL of serofibrinous exudate. Only case 3 had a prominent, 4 × 3.5-cm necrotic skin defect through which pus spontaneously drained. In contrast to the other two, although extensive pus collection within predominantly necrotic thigh's soft tissue was present, the inflammation did not expand above the inguinal ligament, and peritonitis was not observed. Toxicology analysis excluded acute heroin intoxications.

Hyposphagma, positional asphyxia, and acute intoxication with psychoactive substances.

Hyposphagma or subconjunctival hemorrhage is extensive confluent bleeding located between the conjunctiva and episclera. It can develop after trauma or the Valsalva maneuver and hemorrhagic diathesis and vascular diseases, hypertension, arteriosclerosis, and diabetes are the predisposing causes. It may also appear as part of the so-called congestion syndrome of the face and neck in crush or mechanical asphyxia and ligature strangulation, as well as in head-down positional asphyxia. We present two cases of heavily intoxicated individuals who were both, at the time of death, in the position with their trunks bent at the waist over their thighs and their heads down between the legs. They both had severe facial congestion with pronounced hyposphagma. The formation of extensive subconjunctival bleeding or hyposphagma resulted in hemodynamic dysregulation, a consequence of the head-down position, with a decreased venous return of blood to the heart. Since it requires preserved circulation, this finding cannot be considered solely as a mere postmortem phenomenon. Thus, in the presented cases, and especially in other cases where the blood level of psychoactive substances alone may be insufficient to explain the death, positional asphyxia, including the head-down position, could be considered a contributing cause. In such cases, hyposphagma could prove to be a valuable marker of positional asphyxia.

Three-dimensional mapping of cortical porosity and thickness along the superolateral femoral neck in older women.

Although several studies have analyzed inter-individual differences in the femoral neck cortical microstructure, intra-individual variations have not been comprehensively evaluated. By using microCT, we mapped cortical pore volume fraction (Ct.Po) and thickness (Ct.Th) along the superolateral femoral neck in 14 older women (age: 77.1 ± 9.8 years) to identify subregions and segments with high porosity and/or low thickness-potential "critical" spots where a fracture could start. We showed that Ct.Po and Ct.Th significantly differed between basicervical, midcervical, and subcapital subregions of the femoral neck (p < 0.001), where the subcapital subregion showed the lowest mean Ct.Th and the highest mean Ct.Po. These cortical parameters also varied substantially with age and with the location of the analyzed microsegments along the individual's neck (p < 0.001), showing multiple microsegments with high porosity and/or low thickness. Although the highest ratio of these microsegments was found in the subcapital subregion, they were also present at other examined subregions, which may provide an anatomical basis for explaining the fracture initiation at various sites of the superolateral neck. Given that fractures likely start at structurally and mechanically weaker spots, intra-individual variability in Ct.Po and Ct.Th should be considered and the average values for the entire femoral neck should be interpreted with caution.

Increased Cortical Porosity, Reduced Cortical Thickness, and Reduced Trabecular and Cortical Microhardness of the Superolateral Femoral Neck Confer the Increased Hip Fracture Risk in Individuals with Type 2 Diabetes.

Individuals with diabetes mellitus type 2 (T2DM) have approximately 30% increased risk of hip fracture; however, the main cause of the elevated fracture risk in those subjects remains unclear. Moreover, micromechanical and microarchitectural properties of the superolateral femoral neck-the common fracture-initiating site-are still unknown. We collected proximal femora of 16 men (eight with T2DM and eight controls; age: 61 ± 10 years) at autopsy. After performing post-mortem bone densitometry (DXA), the superolateral neck was excised and scanned with microcomputed tomography (microCT). We also conducted Vickers microindentation testing. T2DM and control subjects did not differ in age (p = 0.605), body mass index (p = 0.114), and femoral neck bone mineral density (BMD) (p = 0.841). Cortical porosity (Ct.Po) was higher and cortical thickness (Ct.Th) was lower in T2DM (p = 0.044, p = 0.007, respectively). Of trabecular microarchitectural parameters, only structure model index (p = 0.022) was significantly different between T2DM subjects and controls. Control group showed higher cortical (p = 0.002) and trabecular bone microhardness (p = 0.005). Increased Ct.Po and decreased Ct.Th in T2DM subjects increase the propensity to femoral neck fracture. Apart from the deteriorated cortical microarchitecture, decreased cortical and trabecular microhardness suggests altered bone composition of the superolateral femoral neck cortex and trabeculae in T2DM. Significantly deteriorated cortical microarchitecture of the superolateral femoral neck is not recognized by standard DXA measurement of the femoral neck.