Benefits and outcomes of a new multidisciplinary approach for the management and financing of sudden unexplained death cases in a forensic setting in Switzerland.

Sudden cardiac death (SCD) is an important public health issue. In young persons aged between 1 and 40 years, most SCDs are caused by potentially inherited cardiac diseases, often not detectable during conventional medico-legal investigations and therefore termed as sudden unexplained deaths (SUD). In this study, we describe the implementation, feasibility and importance of a standardized procedure to investigate SUD cases within the forensic framework at the Zurich Institute of Forensic Medicine in Switzerland. This new approach involves a multidisciplinary collaboration including forensic autopsy, second pathology expert opinion, post-mortem molecular genetic testing, cardiac counselling of relatives, and a tentative financing. This procedure is in line with the published Swiss and European recommendations on the management of SCDs. During a two-year pilot project, 39 sudden and unexpected death cases were collected, whereof 10 deceased remained without any identifiable cause of death after medico-legal investigation and second expert evaluation. Molecular autopsy, including 393 genes involved in cardio-vascular and metabolic diseases, identified eight pathogenic or likely pathogenic genetic variants in five out of the 10 deceased (50%). Cardio-genetic follow-up investigations in the families of the 10 deceased revealed phenotype-positive relatives in four families and required specific therapies, including an implantable cardioverter defibrillator (ICD) for primary prevention. Multidisciplinary collaboration is crucial for an optimal management of sudden unexplained death cases, to identify additional relatives at risk, and to prevent other tragic deaths within a family.

Cinematic rendering of a burst sagittal suture caused by an occipito-frontal gunshot wound.

The computed tomography (CT) scan of a 19-year-old man who died from an occipito-frontal gunshot wound presented an impressive radiating fracture line where the entire sagittal suture burst due to the high intracranial pressure that arose from a near-contact shot from a 9 mm bullet fired from a Glock 17 pistol. Photorealistic depictions of the radiating fracture lines along the cranial bones were created using three-dimensional reconstruction methods, such as the novel cinematic rendering technique that simulates the propagation and interaction of light when it passes through volumetric data. Since the brain had collapsed, depiction of soft tissue was insufficient on CT images. An additional magnetic resonance imaging (MRI) examination was performed, which enabled the diagnostic assessment of cerebral injuries.

CT and MRI of a transcardiac gunshot wound with an annular distribution of bullet fragments surrounding an exit-re-entrance wound after the bullet burst from a floor tile upon exiting the lying body.

This case report describes medicolegal examinations of a decedent with a fatal gunshot wound. The decedent lied on the floor as a bullet was fired into his chest. Computed tomography (CT) and magnetic resonance imaging (MRI) were performed as part of the judicial investigation. The MRI examination was valuable for delineating the wound channel through the left ventricle, which was deemed the main cause for internal bleeding and fatal blood loss. The diagnostic value of CT for the detection of injuries was low in this case. However, CT allowed for the virtual investigation of bullet fragments. According to CT-based dual-energy index calculations, it could be inferred that the fragments were most likely made of lead matching .357 Magnum R-P cartridges that were found at the scene. The bullet fragments were located underneath the skin at the suspected exit wound. The exit wound was actually an exit-re-entrance wound, as it can be assumed that the fragments re-entered the body after the bullet burst from hard ground upon exiting the body of the decedent, who was lying on the floor. CT visualized an uncommon annular distribution pattern for the bullet fragments surrounding the exit-re-entrance wound. The formation of such an annular distribution pattern of bullet fragments and the relevant conclusions that may be drawn from such a distribution pattern are discussed in this article.

Postmortem Computed Tomography and Magnetic Resonance Imaging of an Abdominal Gunshot Wound.

The use of postmortem computed tomography (CT) has been described in many articles concerning gunshot injuries. Postmortem magnetic resonance imaging (MRI) for better assessment of soft tissue injuries has also been mentioned in the literature, albeit much less often. The use of postmortem MRI for abdominal gunshot wounds has not been previously presented in the literature. The present case report describes the findings of an abdominal gunshot wound detected by postmortem CT and MRI, followed by an autopsy. The main imaging findings on CT were a hyperdense ring at the entrance wound, which indicated the muzzle imprint mark, a hyperdense region beneath the skin, which was suggestive of combustion residue, gas cavities surrounding the bullet path, which might be related to the temporary cavity, and a fracture of the 13th rib on the left. Magnetic resonance imaging provided a clear depiction of defects in the muscle tissue and peritoneal fat, as well as an injury to the left kidney and a large volume of blood in the abdominal cavity. Computed tomography combined with MRI provided a descriptive presentation of the intracorporeal trajectory noninvasively. Autopsy confirmed the radiologic findings but additionally revealed further relevant findings, which were not detected radiologically, such as a duodenal perforation. Autopsy also detected subendocardial hemorrhages and shock kidney, which were consistent with severe blood loss.The imaging findings and their interpretations are discussed in this case report, as well as the role of CT and MRI in the assessment of abdominal gunshot wounds compared with autopsy.

Persistence and detection of touch DNA and blood stain DNA on pig skin exposed to water.

As it is unclear if and how long DNA evidence can persist on submerged skin, we examined the potential for recovery of touch DNA and blood stain DNA from skin samples immersed in different aquatic environments and temperatures for forensic purposes in this proof-of-concept study. We used pig skin, either smeared with human blood or held firmly for 30 s by two test-persons, before immersing it in either cold, room-temperature or warm water as well as in a stream and a pond for up to seven days prior to DNA testing. The samples were then typed at 16 STR loci. Cold water samples yielded the most promising results, as shown by the recovery of the full set of 16 reproducible STR loci from the touch DNA sample of one test-person after 7 days. For blood stains, we were able to recover all 16 reproducible STRs after 2 days. Room-temperature water and warm water yielded varying results for both blood stain DNA and touch DNA. For pond and stream samples, DNA recovery was possible only within two days. While the pond and stream samples were at relatively cold temperatures, DNA recovery may have been affected by the presence of water insects and snails in the pond and mud in the stream. Our findings show the potential of using immersed samples, particularly those immersed in cold water, as we could detect a complete DNA profile from blood stains and from touch DNA after several days. Our study opens the way for future in-depth studies, examining larger datasets and a wider range of conditions.

Hidden shot pellets on postmortem computed tomography and their utilization for radiologic identification of decedents.

We describe the case of a decomposed male cadaver found in an apartment who was transported to our institute for identification purposes. Computed tomography (CT) was performed to assess the possibility of a radiologic identification of the decedent (RadID) by dental implants or orthopedic implants. Surprisingly, the CT examination revealed seven spherical foreign bodies (diameter: 0.4 to 0.5 cm / 0.16 to 0.20 in) and one flat foreign body (diameter: 0.7 cm / 0.28 in; thickness 0.2 cm / 0.08 in) inside the cadaver. The foreign bodies were located extracranially in the soft tissue of the head (n = 1), the neck (n = 2), the abdomen (n = 2), the right upper arm (n = 1) and both thighs (n = 2) and were determined to be shot pellets according to their shape and high radiopacity. Immediately, the decedent was externally reexamined for entrance wounds according to the location of the shot pellets on CT. A thorough external examination revealed scarred entrance wounds on the head and neck. For the identification of the decedent, radiologic data from the renter of the apartment were requested from the municipal hospital. The radiology department provided a clinical CT scan of the abdomen of the suspected person, a 70-year-old man. An antemortem abdomen CT also demonstrated two shot pellets at the same location in the body. The decedent was radiologically identified by comparing the position of the retained shot pellets on antemortem and postmortem computed tomography. This case report presents a rare case of numerous retained shot pellets and the extraordinary RadID based on these retained shot pellets, which were only revealed because a postmortem CT scan was performed.

Fatal poisoning involving cyclopropylfentanyl - Investigation of time-dependent postmortem redistribution.

A growing number of fatal overdoses involving opioid drugs, in particular involving fentanyl and its analogues, pose an immense threat to public health. Postmortem casework of forensic toxicologists in such cases is challenging, as data on pharmacodynamic and pharmacokinetic properties as well as reference values for acute toxicities and data on potential postmortem redistribution (PMR) mechanisms often do not exist. A fatal case involving cyclopropylfentanyl was investigated at the Zurich Institute of Forensic Medicine and the Zurich Forensic Science Institute; an unknown powder found at the scene was reliably identified as cyclopropylfentanyl by gas chromatography-infrared spectroscopy (GC-IR). Femoral blood samples were collected at two time points after death; 11h postmortem (t1) and during the medico-legal autopsy 29h after death (t2). At the autopsy, additional samples from the heart blood, urine and gastric content were collected. Cyclopropylfentanyl was quantified using a validated liquid chromatography-tandem mass spectrometric (LC-MS/MS) method. Femoral blood concentration of cyclopropylfentanyl at autopsy was 19.8ng/mL (t1=15.7ng/mL; heart blood concentration at autopsy=52.4ng/mL). In the light of the current literature and under the exclusion that no other morphological findings could explain the cause of death, contribution of cyclopropylfentanyl to death was proposed (polydrug use). Significant postmortem concentration increases of cyclopropylfentanyl in femoral blood during 18h after the first sampling were observed, thus indicating a relevant potential to undergo PMR. A central-to-peripheral blood concentration ratio of 2.6 supports this. Consequently, the current case suggests that postmortem cyclopropylfentanyl concentration should always be interpreted with care.

Rapid and reliable detection of previous freezing of cerebral tissue by computed tomography and magnetic resonance imaging.

Due to slowing or even inhibition of postmortem processes, freezing may make an estimation of the time-since-death very difficult. This is also true in previously frozen and subsequently thawed bodies. Knowledge of prior freezing is important, as it may lead to a different assessment of the time since death. Twelve pig heads were frozen at -20 °C, and 6 heads were either kept at room temperature (approximately 20 °C) or in a cooling cell (approximately 5 °C). The frozen brains and cadavers were thawed at either room temperature or in a cooling cell. All specimens underwent repeated CT and MRI scanning until the brains were sampled for histological examination. Two radiologists assessed the images and two pathologists reviewed the histological slides with regard to thawing artifacts and putrefaction. All raters were blinded regarding whether the samples had been frozen, for how long and how they had been thawed. Imaging revealed distinct, tiny bubble-like artifacts only in previously frozen specimens. Histology also revealed artifacts only seen in such cases, namely very distinct, columnar bubbles in the cerebral cortex. All raters successfully identified previously unfrozen brains (100% specificity) and nearly all previously frozen brains. Our results suggest that initial post-mortem imaging can be of enormous importance in everyday forensic practice by identifying possible cases of previous freezing - cases that would therefore warrant closer scrutiny and thus raise caution regarding the time of death.

Pandora's box.

Suitcases or other containers are occasionally involved in forensic investigations. If there is a suspicion that human remains are hidden inside such a container, medico-legal examinations are required. However, these containers are occasionally locked. Forced opening of a locked suitcase or container may cause damage to its contents. Additionally, the safety of the investigator has to be considered as such containers may be booby-trapped or contain other hazardous material. An overview of the contents before opening is desirable in order to avoid the possibility of encountering a Pandora's box. In forensic medicine, an established approach to examine the inside of a body before opening at autopsy is postmortem computed tomography (CT). However, there may be a reluctance to use this approach for suitcases or containers with metallic components because of the assumption that severe metal artifacts will result in inadequate images. In this article, we present a forensic case in which a CT scan of a metallic suitcase was performed in order to examine its contents. Additionally, we performed an experimental scan of a conventional safe in order to determine if CT is able to reveal the contents of such a highly radiopaque storage box.

Injury potential of thrown sharp kitchen and household utensils.

We examined the possibility of inflicting serious injuries with sharp objects in an experimental setting by throwing four sharp objects from different distances and with different throwing techniques. Using an overarm-handle (OA/H), overarm-blade (OA/B), underarm-handle (UA/H), underarm-blade (UA/B) and thrust (T/H) throwing technique, 10 adults (sex ratio 1:1) threw a chef's knife, a skinning knife, a paring knife and office scissors from 4 m and 2 m distance at synthetic abdomen models made of 10% gelatin covered with synthetic skin. The amount of hits and penetrations of the target and their penetration depth were noted, as was the rotation of the blade tip towards the target along its flight trajectory. The chef's knife injury/hit ratio was 0.167/4 m and 0.160/2 m; the skinning knife recorded an injury/hit ratio of 0.087/4 m and 0.153/2 m; the paring knife of 0.087/4 m and 0.113/2 m; and the scissors 0.087/4 m and 0.067/2 m. Mean penetration depths were as follows: the chef's knife: 4 m, 4.42 cm, 2 m, 3.41 cm; the skinning knife: 4 m, 4.19 cm, 2 m, 4.11 cm; the paring knife: 4 m, 1.62 cm, 2 m, 1.55 cm; and the scissors: 4 m, 2.08 cm, 2 m, 0.95 cm. Handle-throw penetration-depths were: 4 m: 3.77 cm and 2 m: 2.86 cm; blade-throw depths were: 4 m: 3.14 cm and 2 m: 2.69 cm. Overarm-throw penetration-depths were: 4 m: 3.62 cm and 2 m: 3.25 cm; and underarm-throw penetration-depths were 4 m: 3.30 cm and 2 m: 2.30 cm. No thrust-throws with the paring knife and scissors could pierce the target. The tips pointed toward the target at angles of 60°-120°, earlier in handle-throws than blade-throws, especially with the paring knife and the scissors. When thrown, especially with a handle-held technique, heavier objects pierced more often and more deeply. Thrust-throws at short distances are unlikely to pierce a human.

Tension pneumopericardium following suicidal stab wounds to the chest.

Pneumopericardium (PPC) and Tension Pneumopericardium (TPPC) refer to collections of gas in the pericardial cavity, the latter resulting in air tamponade and cardiac compromise. Following penetrating chest injuries, PPC and TPPC appear to be uncommon findings associated with a high mortality and correlated with other thoracic trauma. Diagnosis of PPC and TPPC is difficult relying on conventional autopsy alone, while postmortem computed tomography (PMCT) shows a high sensitivity for the detection of internal gas collections. Possibly due to difficulty in detection, PPC and TPPC have not been discussed from a forensic point of view and many lethal cases of PPC and TPPC might have been missed in medicolegal investigations. In this report, we present a case with suicidal, penetrating stab wounds to the chest resulting in a TPPC with lethal air tamponade documented by PMCT.

Postmortem distribution and redistribution of MDAI and 2-MAPB in blood and alternative matrices.

Intoxication cases involving new psychoactive substances (NPS) provide several challenges for forensic toxicologists as data on pharmacodynamic and pharmacokinetic properties are lacking, especially on potency and toxicity. Furthermore, reference values and information on postmortem redistribution (PMR) do not exist so far for most NPS. A fatal case involving the amphetamine-derivatives MDAI (5,6-methylenedioxy-2-aminoindane) and 2-MAPB (1-(benzofuran-2-yl)-N-methylpropan-2-amine) was investigated at the Zurich Institute of Forensic Medicine. At admission at the institute approx. 11h after death (first time point, t1), femoral and heart blood (right ventricle) was collected using computed tomography (CT)-guided biopsy sampling. At autopsy (t2), samples from the same body regions as well as various tissue samples were collected manually. In addition, an antemortem blood sample collected 6h before death was available. MDAI and 2-MAPB were quantified using a validated LC-MS/MS method. A significant concentration decrease between the antemortem and the first peripheral postmortem blood sample was observed, which most probably can be explained by remaining metabolism and excretion within the last 6h prior to death. No significant concentration change was observed between the two postmortem heart blood and peripheral blood samples. Accordingly, MDAI and 2-MAPB did not seem to undergo relevant postmortem redistribution in peripheral and heart blood in the presented case. This is the first study on postmortem redistribution of the new psychoactive substances MDAI and 2-MAPB. However, more studies covering more cases are necessary to generate universal statements on the PMR with these two NPSs.

Unexpected brain finding in pre-autopsy postmortem CT.

A case is presented in which pre-autopsy postmortem computed tomography (PMCT) revealed an unexpected brain abscess with a related frontal sinusitis and an erosion of the posterior wall of the frontal sinus. PMCT findings enabled the forensic pathologists to adapt protective measures during autopsy and protect their health from infection. Pre-autopsy PMCT has been also useful in the early differential diagnosis procedure. The complementary use of postmortem imaging and autopsy can improve the quality of forensic death investigations.

Movement of steel-jacketed projectiles in biological tissue in the magnetic field of a 3-T magnetic resonance unit.

PURPOSE: The fact that ferromagnetic bullets can move in air or gelatine when subjected to magnetic resonance (MR) units is well known. A previous study showed that the movement of 7.5-mm GP 11 Suisse bullets also depends on their orientation toward the gantry. In order to compare the movement in gelatine to that in real tissue, we decided to measure the movement of these bullets, as well as 9-mm Luger bullets, in the brain and liver. METHODS: The GP 11 and 9-mm Luger bullets were inserted into the fresh calf brain or pig liver either vertically or horizontally in the x- or z-axis to the gantry. Before and after exposure to a 3-T MR unit, their position was documented by CT. RESULTS: GP 11 bullets rotated more readily and in general proved to be more mobile than the 9-mm Luger. All GP 11 bullets and a large amount of the 9-mm Luger bullets exited the brain. Sliding toward the gantry was easier for 9-mm Luger bullets in the brain than in the liver. CONCLUSIONS: The orientation of a ferromagnetic object influences its mobility in a strong magnetic field. Tipping is easier than sliding for longish ferromagnetic projectiles, probably due to the lesser tissue resistance. The bullets moved more readily in biological tissue, especially brain tissue, compared to gelatine, thus implying that gelatine is not a suitable substitute for soft tissues when examining the movement of ferromagnetic objects in MR units.

Role of Survival Time and Injury Severity in Fatal Pulmonary Fat Embolism.

Pulmonary fat embolism (PFE) is frequent in blunt trauma and may occasionally lead to death. A correlation between fracture grade and severity and PFE grade has been described before, but no correlation between PFE and survival time, fat crushing extent, fat crush grade, or number of body regions with fractures could be noted in this small study. To further examine this, we decided to examine the aforementioned points in a far larger study group.Autopsy protocols of 188 nonresuscitated fatalities with blunt trauma and without right heart injury, which underwent whole body dissection, were retrospectively reviewed concerning the presence and the severity of PFE, injuries, survival time, age, sex, and the body mass index.The fracture grade, the fracture severity, and the number of the fractured regions correlated very well with the grade of PFE, but the crushed regions, crush grade, and crush severity did not. We observed a time correlation between survival time and PFE only in the sense that very rapid deaths were often PFE negative. High-grade PFE was observed most often in patients having died less than 6 hours after the incident, and PFE grades of 2 or more were occasionally noted even after 48 hours.

Stabbing energy and force required for pocket-knives to pierce ribs.

PURPOSE: In addition to reconstructing the course of events, the medical examiner will often have to answer questions regarding the force necessary to inflict a certain injury in stabbing incidents. Several groups have examined the force needed to penetrate soft-tissue and clothing; however, no studies addressing the energy needed for penetrating ribs exist. Therefore, we decided to investigate this force on an animal model. METHOD: Ribs from healthy, 8 to 10-month-old pigs were used as a substitute for human ribs. These ribs were then stabbed either transversely or longitudinally with two different pocket-knife blades, namely a Swiss Army pocket knife and a sturdier pocket knife (Classic Schnitzmesser, Herbertz Solingen) dropped from a drop-tower at defined heights and therefore defined energies. RESULTS: Longitudinally orientated stabs showed complete piercing of the ribs at approximately 11 Joules (J) or with a stabbing force in excess of 906 Newton (N) for both blade types. Transversely orientated stabs, however, displayed complete piercing between 11 and 16 J, or in excess of 1198 N, with the sturdy pocket knife tending to require a little more energy than the Swiss army pocket knife. CONCLUSIONS: Young adult porcine ribs are completely pierced by pocket knife blades at energies between 11 and 16 J. Assuming the porcine ribs are comparable to those ribs of young adult humans, our results indicate that a complete penetration of the chest wall through the ribs by stabbing with a pocket knife is rather easily achieved.

[Wound Ballistics ­ a Brief Overview]. / Wundballistik - eine Kurzübersicht.

Wound ballistics examines the specific effect, namely the wound profile, of bullets on the body by firing at synthetic models made of ordnance gelatine, glycerin soap and synthetic bones, validated with real cases from (battlefield) surgery and forensic pathology. Wound profile refers to the penetration depth, the bullet deformation/ fragmentation, the diameter of the permanent and the temporary wound cavity. Knowing these features and the used ammunition a surgeon can rapidly assess the amount damage within a patient. The forensic pathologist can draw conclusions as to the used ammunition based on the wound profile. By measuring of the destructive capability of different ammunition types, wound ballistics lays the foundation for guidelines concerning the maximum effect of military ammunition.