A probability model for estimating age in young individuals relative to key legal thresholds: 15, 18 or 21-year.

Age estimations are relevant for pre-trial detention, sentencing in criminal cases and as part of the evaluation in asylum processes to protect the rights and privileges of minors. No current method can determine an exact chronological age due to individual variations in biological development. This study seeks to develop a validated statistical model for estimating an age relative to key legal thresholds (15, 18, and 21 years) based on a skeletal (CT-clavicle, radiography-hand/wrist or MR-knee) and tooth (radiography-third molar) developmental stages. The whole model is based on 34 scientific studies, divided into examinations of the hand/wrist (15 studies), clavicle (5 studies), distal femur (4 studies), and third molars (10 studies). In total, data from approximately 27,000 individuals have been incorporated and the model has subsequently been validated with data from 5,000 individuals. The core framework of the model is built upon transition analysis and is further developed by a combination of a type of parametric bootstrapping and Bayesian theory. Validation of the model includes testing the models on independent datasets of individuals with known ages and shows a high precision with separate populations aligning closely with the model's predictions. The practical use of the complex statistical model requires a user-friendly tool to provide probabilities together with the margin of error. The assessment based on the model forms the medical component for the overall evaluation of an individual's age.

Examining the use of alternative light sources in medico-legal assessments of blunt-force trauma: a systematic review.

The ability to analyze blunt-force trauma is crucial for deciphering valuable clues concerning mechanisms of injury and as evidence for medico-legal investigations. The use of alternate light sources (ALS) has been studied over the past decade, and is proposed to outperform conventional white light (CWL) during bruise assessments. In response to the growing interest of the technology worldwide, a systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to address the ability of ALS to detect and visualize bruising. From an initial 4055 records identified, ten studies met the eligibly criteria and were selected for this review. Evaluation also included a novel framework, referred to as SPICOT, to further systematically assess both scientific evidence and risk of bias in forensic literature. Analysis reveals that narrowband wavelengths within in the infrared or ultraviolet spectral ranges do not significantly outperform CWL in visualizing or detecting bruising. However, wavelengths within the visible spectrum, particularly 415 nm combined with longpass or bandpass yellow filters, are more effective. However, the majority of selected studies only address the sensitivity of ALS, and therefore, results may only be considered valid when the location of a bruise is known. Further investigation is required to understand the specificity of ALS, in particular how the use of topical cosmetic products, previous wounds/scar-tissue, tattoos, moles and freckles may affect detection. The ethical concern regarding the interpretation of enhanced visualized trauma should also be considered in prospect discussions prior to implementing ALS into routine practice. Nevertheless, this review finds that narrowband ALS within the visible spectrum demonstrates potential for improved injury documentation, outperforming CWL in the detection and visualization of bruising.

Swedish child homicide investigations: A population-based study 1998 to 2017.

BACKGROUND: Child homicide investigations are intricate, and the forensic examinations are of paramount importance in such cases. Despite this, the forensic profile of child homicides remains unexplored. OBJECTIVE: Our objective was to provide an overview of the forensic aspects and investigational challenges in Swedish child homicide cases spanning from 1998 to 2017, with a specific focus on enhancing investigative methods. PARTICIPANTS AND SETTING: 70 cases with 82 victims (41 girls, 41 boys) aged between 0 and 14 were included. METHOD: Police, crime scene and autopsy reports of solved Swedish child homicides were retrospectively reviewed. RESULTS: On average, 3.5 cases (4.1 victims) occurred annually, primarily within families (79 %). Notably, the number of cases increased by 10 % during the latter half of the study period (2008-2017) compared to the initial decade (1998-2007). In nearly 29 % of instances, the perpetrators followed the homicides with their own suicides. A majority of child deaths (89 %) resulted from concentrated acts of violence, most frequently involving blunt or sharp force. Furthermore, 66 % of the homicides took place within the parental home. Adequate crime scene processing, including documentation and evidence collection, occurred in 74 % of cases. The investigation unveiled several complicating factors: 22 % of victims and 47 % of crime scenes displayed no obvious signs of violence. Moreover, offenders often made physical (27 %) and verbal (26 %) attempts to mislead investigators. CONCLUSIONS: In conclusion, most child homicides are familial in nature and associated with investigational complexities that can lead to misdirection. This research may inform procedural recommendations for child homicide investigations, but further exploration is needed to better understand the forensic characteristics of suspicious child deaths.

Postmortem CT analysis of paranasal sinuses using an experimental model of drowning.

Fluid-filled paranasal sinuses are suggested to be a valuable tool to distinguish between drowning and non-drowning postmortem, yet the mechanisms governing fluid entry remains unknown. We investigate if fluid-filled paranasal sinuses are caused by a passive influx from submersion or an active aspiration mechanism during drowning. The ovine nasal cavity and maxillary sinuses are remarkably similar anatomically to humans, and have been used for endoscopic surgical training in recent decades. We submerged 15 decapitated ovine heads from agricultural waste at a depth of 2 m in flowing water for 1, 8, and 24 h and 7 days. Paranasal sinuses were CT imaged and compared pre- and post-submersion to non-submerged controls. Furthermore, we examined the paranasal sinuses of a single homicide case of a non-drowned submerged subject. Results demonstrate that fluid passively enters the maxillary sinus postmortem in the non-drowned ovine heads following 1 h of submersion. Fluid volume was independent of submersion time and influenced by time out of water as well as handling, since volume was reduced between consecutive CT scans. In contrast to our hypothesis, the filling of the paranasal sinuses is due to passive influx of fluid from submersion rather than an active aspiration during drowning. The observation that paranasal sinuses were fluid-filled in a single medico-legal case of postmortem submersion supports the finding of passive influx. Consequently, careful interpretation of fluid-filled paranasal sinuses is required when bodies are found in water, as the finding cannot distinguish between postmortem submersion and drowning.

Cardiac troponin T as a postmortem biomarker for acute myocardial infarction.

The diagnosis of acute myocardial infarction (AMI), especially within the first hours after onset of ischemia, poses a challenge to the forensic pathologist. During this time, the infarction is generally not visible macroscopically nor with routine histology. Whilst cardiac Troponin T (cTnT) is a well-established biomarker for AMI clinically, its use as a postmortem diagnostic tool is less conclusive, warranting further investigation. The aim of this study was to investigate the sensitivity and specificity of cTnT as a postmortem diagnostic marker of AMI and the impact of postmortem interval (PMI) and cardiopulmonary resuscitation (CPR) on cTnT-concentrations. Samples from 64 subjects, 15 AMI cases and 49 controls, were collected at the Department of Forensic Medicine in Stockholm and analyzed for cTnT: one femoral blood sample was taken at arrival of the body to the morgue, and again during autopsy. Pericardial fluid (PCF) was only collected during autopsy. Sensitivity and specificity for serum cTnT were calculated to be 86.7 %/67.3 % and for pericardial fluid 86.7 %/44.9 %. cTnT samples taken during autopsy were generally higher than samples taken upon arrival to the morgue. A CPR-dependent elevation in serum cTnT was noted (P = .005). With a cut off at 56 n/L, serum cTnT can be used to rule out AMI. The postmortem interval and CPR must be taken into consideration when interpreting postmortem cTnT.

A probability model for assessing age relative to the 18-year old threshold based on magnetic resonance imaging of the knee combined with radiography of third molars in the lower jaw.

OBJECTIVE: This study aims to generate a statistical model based on magnetic resonance imaging of the knee and radiography of third molars in the lower jaw, for assessing age relative to the 18-year old threshold. METHODS: In total, 58 studies correlating knee or tooth development to age were assessed, 5 studies for knee and 7 studies for tooth were included in the statistical model. The relation between the development of the anatomical site, based on a binary system, and age were estimated using logistic regression. Separate meta-populations for knee and tooth were generated from the individual based data for men and women. A weighted estimate of probabilities was made by combining the probability densities for knee and tooth. Margin of errors for males and females in different age groups and knee and tooth maturity were calculated within the larger framework of transition analysis using a logit model as a base. Evidentiary values for combinations of knee and tooth maturity were evaluated with likelihood ratios. RESULTS: For males, the sensitivity for the method was calculated to 0.78 (probability of correctly classifying adults), the specificity 0.90 (probability of correctly classifying minors), the negative predictive value 0.80 (proportion identified minors are minors) and the positive predictive value 0.89 (proportion identified adults are adults) indicating a model better at identifying minors than adults. The point at which half the female population has reached closed knee lies before the 18-year threshold, adding the knee as an indicator lowers specificity and increases sensitivity. The sensitivity when using tooth as an indicator for females is 0.24 and specificity 0.97, signifying few minors misclassified as adults but also a low probability of identifying adults. The negative predictive value for women when using tooth as the sole indicator is 0.56 and positive predictive value 0.88. Probabilities were calculated for males and females assuming a uniform age distribution between 15 and 21years. The calculated margin of error of minors classified as adults in a population between 15 and 21 years with the model was 11% for males and 12% for females. Further, the evidentiary value as well as margin of error vary for different combinations of knee and tooth maturity. CONCLUSION: The statistical model based on the combination of MRI knee and radiography of mandibular third molars is a valid method to assess age relative to the 18-year old threshold when applied on males and of limited value in females.

Criminal mutilation in Sweden from 1991 to 2017.

We identified 43 cases of mutilation homicides in a nationwide population-based study in Sweden during the period of 1991-2017. 70% of cases were classified as defensive mutilations where the main motive was disposal of the body, while 30% were classified as offensive, that is, due to an expression of strong aggression, necro-/sexual sadism, or psychiatric illness. In comparison with a previous study covering mutilation homicides in Sweden between 1961 and 1990, we noted an increase in incidence. The percentage of cases involving mutilation had increased from 0.5% of all homicides in the 1960s to 2.4% in the 2010s. The most common cause of death was sharp force, but in 28% of the cases, the cause of death could not be determined. The clearance rate in cases of mutilation homicide was 67%, and in a large majority of the cases, the offender was known to the victim. With regards to gender women made up 44% of the victims, whilst men constituted 56% of the victims and a total of 95% of the offenders. Half of the offenders had a personality disorder, however, only 13% were sentenced to forensic psychiatric care.

Fatal anaphylactic shock: A review of postmortem biomarkers and diagnostics.

Diagnosing anaphylactic shock postmortem is challenging since differential diagnoses exist and the forensic pathologist often faces subtle findings and lacks relevant information which prevents reaching an opinion of certainty. This review provides an overview of the literature covering research and existing recommendations on the postmortem diagnosis of anaphylactic shock. In order to harmonize the approach and provide guidance for diagnosing deaths from anaphylactic shock in the six forensic centers in Sweden, a guidance protocol aligned with the notion of a holistic view in the approach was devised. Areas in need of further studies include both immunohistological and biochemical investigations to stratify quantitative approaches based on condition and anaphylactic trigger and to lay the ground for and possibly establish alternative matrices.

A Rapid Method for Postmortem Vitreous Chemistry-Deadside Analysis.

Vitreous fluid is commonly collected for toxicological analysis during forensic postmortem investigations. Vitreous fluid is also often analyzed for potassium, sodium, chloride and glucose for estimation of time since death, and for the evaluation of electrolyte imbalances and hyperglycemia, respectively. Obtaining such results in the early phase of a death investigation is desirable both in regard to assisting the police and in the decision-making prior to the autopsy. We analyzed vitreous fluid with blood gas instruments to evaluate/examine the possible impact of different sampling and pre-analytical treatment. We found that samples from the right and left eye, the center of the eye as well as whole vitreous samples gave similar results. We also found imprecision to be very low and that centrifugation and dilution were not necessary when analyzing vitreous samples with blood gas instruments. Similar results were obtained when analyzing the same samples with a regular multi-analysis instrument, but we found that such instruments could require dilution of samples with high viscosity, and that such dilution might impact measurement accuracy. In conclusion, using a blood gas instrument, the analysis of postmortem vitreous fluid for electrolytes and glucose without sample pretreatment produces rapid and reliable results.

Postmortem diagnosis of ketoacidosis: Levels of beta-hydroxybutyrate, acetone and isopropanol in different causes of death.

Data from 496 autopsy cases with positive beta hydroxybutyrate (BHB), acetone or isopropanol in blood were investigated. The cases were divided into different groups according to cause of death. Cases with cause of death due to diabetic ketoacidosis (DKA, n=54) had the highest levels of BHB (median 1085mg/L) and acetone (median 330mg/L). Cases with cause of death due to alcoholic ketoacidosis (AKA, n=57) had high levels of BHB (median 500mg/L) and acetone (median 110mg/L). Cases with cause of death due to hypothermia (n=12) had similar BHB and acetone levels as the AKA group (median BHB 520mg/L and acetone 80mg/L). Cases with cause of death due to isopropanol intoxication (n=17) had high levels of isopropanol (median 430mg/L) and acetone (330mg/L), but undetected or low levels of BHB. Cases with cause of death due to other than the above mentioned (n=349) had median BHB levels of 100mg/L and median acetone levels of 20mg/L. BHB analysis is crucial for the diagnosis of postmortem ketoacidosis, since it is the main marker of ketoacidosis and helps distinguish between different causes of death. Acetone levels correlate with BHB levels in endogenous ketoacidosis, so acetone can be used as an initial screening marker to identify cases where BHB analysis should be performed, but positive acetone threshold should be maximum 20mg/L. Positive BHB is proof of endogenous ketoacidosis, whereas negative BHB indicates isopropanol intoxication or postmortem acetone/isopropanol formation by microorganisms in cases of decomposition. There is no correlation between BHB and the postmortem interval, and no sign of postmortem formation, so BHB analysis is useful even in cases of severe decomposition.

Brister i utfärdande av dödsorsaksintyg - Stort mörkertal av dödliga fallolyckor.

According to the Swedish National Board of Health and Welfare, about 3200 people a year die due to accidents. Around 900 of these are classified as "Accidental exposure to other and unspecified factors". A more precise classification with the board has not been recorded in these cases due to incomplete death certificates. This study examined the death certificates for this group in 2016 and compared it to patient records. This study showed that most cases of incomplete classification are in instances of elderly persons who sustained a fall and subsequently died due to complications of the resulting injury. The doctor has in most cases not perceived the death as accidental.This study showed that there is a lack of knowledge among doctors in how to accurately complete a death certificate.

A Case of Fatal Dehydration During Police Custody.

In the forensic literature, fatal dehydration predominantly concerns young children or incapacitated elderly persons. The postmortem diagnosis of fatal dehydration can be challenging to confirm, especially if the preceding circumstances are unknown. Here presented is a case of a 23-year-old man who died while held in an isolation cell during police custody for 18 days. Autopsy findings were unspecific, but vitreous fluid analysis showed 192 mmol/L sodium, 179 mmol/L chloride, 16 mmol/L potassium, 352 µmol/L (3.98 mg/dL) creatinine, and 81 mmol/L (226.9 mg/dL) urea nitrogen. Based on the findings and circumstances, the cause of death was determined as severe dehydration and manner of death accident. This case illustrates the importance of performing postmortem biochemistry.

Fatal Fat Embolism After Penis Enlargement by Autologous Fat Transfer: A Case Report and Review of the Literature.

Fat embolism is an incidental finding in cases of long bone fractures or other trauma, but it is also associated with liposuction and autologous fat transfer, a procedure where fat from liposuction is injected back into the same patient's face, breast, buttocks or penis. We here present a case of sudden death by fat embolism in a healthy young male, caused by a simple penis enlargement procedure, in which fat was injected into the penis shaft. We suggest that the risk of fat embolization might be higher when pretraumatized tissue is subjected to fat injection, like in this case, where a penis elongation was performed before the fat injection.

Risk Factors for Fatal Hyperglycaemia Confirmed by Forensic Postmortem Examination - A Nationwide Cohort in Sweden.

AIMS/HYPOTHESIS: The aim of this study was to identify risk factors associated with confirmed fatal hyperglycaemia, which could predispose potentially preventable deaths in individuals on glucose lowering drugs. METHODS: A retrospective register-based case-control study conducted on a nationwide cohort with individuals who died due to hyperglycaemia as determined by forensic postmortem examination, in Sweden August 2006 to December 2012. Vitreous glucose was used to diagnose hyperglycaemia postmortem. The forensic findings stored in the National Forensic Medicine Database were linked to nationwide registers. Cases that died due to confirmed hyperglycemia with dispensed glucose lowering drugs were identified and living controls with dispensed glucose lowering drugs were randomly selected in the Swedish prescribed drug register and matched on age and sex. Information on comorbidities, dispensed pharmaceuticals, clinical data and socioeconomic factors were obtained for cases and controls. Adjusted multiple logistic regression models were used to identify risk factors associated with fatal hyperglycaemia. RESULTS: During the study period 322 individuals, mostly males (79%) with the mean age of 53.9 years (SD.± 14) died due to confirmed hyperglycaemia. Risk factors for fatal hyperglycaemia included; insulin treatment (OR = 4.40; 95%CI,1.96, 9.85), poor glycaemic control (OR = 2.00 95%CI,1.23, 3.27), inadequate refill-adherence before death (OR = 3.87; 95%CI,1.99, 7.53), microvascular disease (OR = 3.26; 95% CI, 1.84, 5.79), psychiatric illness (OR = 2.30; 95% CI,1.32, 4.01), substance abuse (OR = 8.85; 95%CI,2.34, 35.0) and/or living alone (OR = 2.25; 95%CI,1.21, 4.18). CONCLUSIONS/INTERPRETATION: Our results demonstrate the importance of clinical attention to poor glycaemic control in subjects with psychosocial problems since it may indicate serious non-adherence, which consequently could lead to fatal hyperglycaemia.