Proper death certification in the time of the COVID-19 pandemic: Forensic perspective.

It is well known that the quality of death certificates determines the accuracy of public health mortality data. In the light of a pandemic, forensic pathologists must understand the true definition of a COVID-19 death and the requirements for filling out the death certificate, as these are critical for maintaining accurate and trustworthy mortality data. To determine the scope and evolution of the COVID-19 epidemic, accurate death certification is critical. We believe that COVID-19 should be enlisted under part II or section "note" (if it exists in DC form in a particular country) of the DC in all suicide instances and putrefied bodies with positive autopsy swabs for SARS-CoV-2. In addition to our suggestions for the completion of the DC in some COVID-19 instances, we feel that forensic pathologists should follow the WHO criteria for proper DC completion in COVID-19 cases. Better physician education at this stage of the pandemic would increase adherence to existing (WHO and CDC) standards. As a result, forensic pathologists with competence in death certification could help by teaching treating physicians in this area.

Case Report: Post-mortem Histopathological and Molecular Analyses of the Very First Documented COVID-19-Related Death in Europe.

In Europe, the first case of coronavirus disease (COVID-19) and the first COVID-19-related death were reported in France on January 24th and February 15th, 2020, respectively. Officially, the first case of COVID-19 infection in the Republic of Serbia was registered on March 6th. Herein, we presented the first case of retrospective detection of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in the post-mortem-obtained vitreous humor (VH), which took place on February 5th, 2020. This is the first death in Europe proven to be caused by COVID-19 by means of post-mortem histopathological and molecular analyses. Based on this finding, it appears that SARS-CoV-2 has been spreading faster and started spreading much earlier than it had been considered and that COVID-19 was probably the cause of the much-reported pneumonia of unknown origin in January and February 2020.

Is the role of forensic medicine in the covid-19 pandemic underestimated?

We believe that forensic medicine should play a significant role in the COVID-19 pandemic. Forensic pathologists should ask and answer various questions through autopsy cases during the COVID-19 period, thus providing a significant contribution to science. Some of the potential roles of forensic medicine in this issue include: determining the exact cause of death among the deceased who were SARS-CoV-2 positive, contribution to the accuracy of mortality statistics, understanding pathological mechanisms of COVID-19, tracking the presence of the virus over time, survival of the virus after death as well as dealing with medicolegal issues. A detailed multidisciplinary analysis of autopsy samples would undoubtedly help understand this new illness and its clinical management. Therefore, autopsies during the COVID-19 pandemic should not be an exception, but certainly a rule.

The significance of post-mortem vitreous calcium concentration in forensic practice.

Calcium, as one of the main extracellular ions, maintains a key role in numerous biologic functions. For forensic purposes, it was analyzed mostly for estimation of postmortem interval (PMI). We have designed our experiment with the concept that the repetitive withdrawal of vitreous humor (VH) might clarify the postmortem metabolism of calcium in greater detail to estimate the PMI. Accordingly, 248 samples of VH from 31 autopsy cases were evaluated over three years; samples (0,1 mL of VH) were taken and analyzed at equal time intervals after death-every three hours until 24 h after death. Each sample was centrifuged and analyzed using the ARCHITECT C SYSTEM 8000. Moreover, functional relationship between PMI and calcium concentration was established: PMI (hours) = [Ca2+] × 13.696-7.843. Although the concentration of calcium in VH in the analyzed group increases with time, the coefficient of variation for the regression (CVreg = 46.8%) indicates that this correlation is not so strong, meaning that the level of predictiveness of calcium for estimation of time since death is poor when is not used in combination with other relevant substances.

Polymorphisms in ACE and ACTN3 Genes and Blood Pressure Response to Acute Exercise in Elite Male Athletes from Serbia.

Physiological adaptations to various types of prolonged and intensive physical activity, as seen in elite athletes from different sports, include changes in blood pressure (BP) response to acute exercise. Also, functional polymorphisms of the angiotensin I converting enzyme (ACE) and alfa-actinin-3 (ACTN3) genes are shown to be associated with BP parameters changes, both in athletes and sedentary population. In this study, an Alu insertion (I)/deletion (D) polymorphism in ACE gene, as well as nonsense mutation in the gene encoding ACTN3 have been scored in 107 elite Serbian athletes classified according to their sporting discipline to power/sprint (short distance runners/swimmers), endurance (rowers, footballers, middle-distance swimmers) or mixed sports (water polo, handball, volleyball players). Presence of nonfunctional allele in ACTN3 is associated with significantly increased maximal systolic BP (SBPmax, p = 0.04). Athletes with Alu insertion in ACE had significantly (p = 0.006) larger decline of systolic BP after 3 minutes of recovery (SBPR3), calculated as the percentage of maximal SBP response during exercise stress testing. Concomitant presence of non-functional variant in ACTN3 gene decreased this beneficiary effect of ACE mutation on SBPR3. Long term enrollment in power/sprint sports significantly increased resting diastolic BP (DBPrest: 74 mmHg) and SBPmax (197 mmHg) and improved SBPR3 (74.8%) compared to enrolment in endurance (72 mmHg; 178 mmHg; 81.1%) and mixed sports (69 mmHg; 185 mmHg; 80.0%). Lack of the effect of genotype by sport interaction on BP parameters suggests that the long-term effects of different disciplines on BP are not mediated by these two genes.

The training type influence on male elite athletes' ventilatory function.

BACKGROUND/AIM: To assess and compare measured ventilatory volumes (forced expiratory volume in 1 s (FEV1), peak expirium flow (PEF) and maximal voluntary ventilation (MVV)), ventilatory function capacities (forced vital capacity (FVC) and vital capacity (VC)) and FEV1/VC ratio in a sample of power and endurance elite athletes and their age-matched and sex-matched sedentary control group. METHODS: A cross-sectional study was applied on male elite athletes (n=470) who were classified according to the type of the predominantly performed exercise in the following way: group 1: endurance group (EG=270), group 2: power athletes group (SG=200) and group 3: sedentary control group (CG=100). The lung VC, FVC, FEV1, FEV1/FVC ratio, PEF and MVV were measured in all of the observed subjects, who were also classified with regard to body mass index (BMI) and the percentage of the body fat (BF%). RESULTS: The CG had the highest BF% value, while the endurance group had the lowest BMI and BF% value, which is significantly different from the other two groups (p<0.05). The observed values of VC, FVC and FEV1 in the EG were significantly higher than those from the other two groups (p<0.05). There were no differences concerning the observed FEV1/FVC ratio. CONCLUSIONS: A continued endurance physical activity leads to adaptive changes in spirometric parameters (VC, FVC and FEV1), highlighting the fact that there is a need for specific consideration of different respiratory 'pattern' development in different types of sport, which also has to be further evaluated.

Analysis of Closed Soft Tissue Subcutaneous Injuries-"Impact Décollement" in Fatal Free Falls From Height-Forensic Aspect.

The aim of this study was to assess the frequency of "décollement," traumatic lesions of subcutaneous soft tissue, among victims fatally injured because of falls from different heights. Three hundred seventy-five cases of fatalities due to injuries acquired when falling from various heights onto a solid, flat surface, in which the complete forensic autopsy was performed, were analyzed. Décollement was noted in 125 (33%) of the cases. Comparative analysis of groups with and without décollement and observed factors has shown that the height of fall and the manner of death have statistically significant influence on décollement appearance. With regard to suicidal, accidental, or undefined origin of death décollement is statistically more common in accidental deaths. Décollement provides important clues for forensic reconstruction and could be a significant indicator of the body's position at primary impact and the height from which the victim has either jumped or fallen.

Myocardial bridges: a prospective forensic autopsy study.

INTRODUCTION: When the coronary artery, located subepicardially, submerges into the myocardium and appears again subepicardially after a short intramural course, it represents an embedded coronary artery, while the part of the myocardium above is a myocardial bridge. OBJECTIVE: We investigated the frequency of the embedded left coronary artery (LAD) in the autopsy material considering the descending branch of the LAD to be the most important one in the nourishment of the myocardium and myocardial bridges to be the most frequent in its area, as well as clinically important. METHODS: A prospective autopsy study of 975 cases was performed, including both, natural (21.33%) and violent (78.67%) deaths. The sample consisted of 74.56% males and 25.44%females. In order to discover myocardyal bridges and their characteristics, the hearts were examined by both transverse cuts and longitudinal openings of the LAD. RESULTS: Myocardial bridge was found in 78 cases (8.00%), more commonly in males (9.35%) than females (4.03%).The average length of the myocardial bridge was 21.85±16.10mm and thickness 3.744±1.48 mm. The common localization of the myocardial bridge was the proximal half of the LAD (89.74%).The upper part of the artery, proximal to the bridge, was a common site of atherosclerotic changes. Myocardial bridge was found in 12.50% of natural deaths, but in 13.38% out of all cases of sudden cardiac deaths. CONCLUSION: Therefore, the presence of the myocardial bridge by itself is not predominant, but it is certainly a contributing factor to a sudden cardiac death.

Suicides among Serbian War Veterans - An Autopsy Study.

INTRODUCTION: The risk of suicide among war veterans is a controversial issue, where findings so far have been contradictory. OBJECTIVE: This study focusses on suicide in Serbian veterans from the wars in former Yugoslavia in the 1990s in order to create appropriate preventive measures and reduce the number of these fatal cases. METHODS: The autopsy protocols of all 44 suicides committed by war veterans in the Belgrade District population over a period between 1992 and 2000 were investigated. Data were obtained from autopsy records, results of toxicological investigations and psychological autopsy protocols. RESULTS: Symptoms of posttraumatic stress disorder were present in 27.3%, major depression in 9.1% and schizophrenia in 6.8% of veterans. The majority of suicides (84.1%) were committed by recruits in the Yugoslav National Army, spending between three and eight months in the zone of war operations. Six committed suicide during the first 30 days after their war activities, while the majority of suicides occurred between five and six years after combat. The most frequent manner of suicide was the use of handguns (56.8%) and bombs (18.2%). CONCLUSION: The results of this research may give useful information about the individuals with the highest suicidal risk in order to alleviate the consequences of war psychotraumas in veterans and prevent their growth into a permanent handicap or suicide.

The role of vitreous magnesium quantification in estimating the postmortem interval.

The use of magnesium as a parameter to estimate the time of death is controversial. In 32 traumatic deaths with known postmortem intervals (PMIs), small quantities of vitreous humor (VH) were sampled repetitively every 3 h until 24 h postmortem. The bodies were kept at the constant ambient temperature of 20°C (68°F). The concentrations of magnesium were in the range of 0.47-1.15 mM. A statistically significant correlation of the concentration of magnesium with the PMI was observed (r = 0.453, p < 0.01), but with small predictive value--coefficient of variation for regression was 45.5%; the average of the paired differences between the estimated and actual PMIs was 5.24 + 3.19 h. Although useful results might be expected due to the large transmembrane gradient for magnesium, the results of this study strongly disprove the usefulness of measuring magnesium in VH to estimate the time of death.

Estimation of the postmortem interval by analyzing potassium in the vitreous humor: could repetitive sampling enhance accuracy?

The relationship between the postmortem interval and the potassium concentration in the vitreous humor has been described by different authors. A limitation of most previous studies might be that all of the vitreous humor has been extracted in 1 sample from different subjects and that the sample was therefore inhomogeneous. In 32 traumatic deaths with known postmortem intervals, small quantities of vitreous humor have been sampled repetitively in 3-hour interval. The bodies were stored at 20°C. The average concentrations of potassium in relation to the postmortem interval were 6.11 to 14.46 mmol/L. An equation that allows accurate prediction of the postmortem interval was established: postmortem interval (h) = 2.749 × [K] - 11.978.

Pulmonary thromboembolism after air travel: two case reports, the review of literature and forensic implications.

Air travel as a risk factor for pulmonary thromboembolism (PTE) is rarely described in forensic literature. Two cases of PTE after air travel are presented in this report. Each flight was intercontinental and lasted for more than 10 h, resulting in typical "traveler's thrombosis" within 2 weeks. In both cases, the risk factors were age, duration of flight and also peripheral circulation problems caused by heart (hypertension, arrhythmia), and varicose veins failures. Possible pathophysiological mechanisms of thrombus formation in these cases were blood flow stasis from prolonged recumbence, reduced function of the lower leg muscle pump, dehydration, and hypobaric hypoxia. Legal aspects of death due to PTE after air travel and possible responsibility of air companies are discussed.

Could lactates in vitreous humour be used to estimate the time since death?

Vitreous humour (VH) is a useful medium for postmortem analysis. During the supravital period, anaerobic glycolysis that occurs results in the increased lactate concentration (L) in cytosol. We analysed the concentration of lactic acid in 567 samples of VH from 63 autopsy cases by a repetitive withdrawal of VH from the same corpse, while the outside temperature remained constant. The samples were taken from the same eye in intervals of three hours for the period of 24 hours. The subjects were divided into two groups: group 1 included individuals who died during winter and were kept for analysis at 40C, while group 2 consisted of those who died during spring and autumn (continental climate) and were stored at 200C. Only the cases of a sudden traumatic death of previously healthy individuals were included in the study. Statistically significant correlation of L against postmortem interval (PMI) was observed in the group 1 experiment (r = 0.675; P < 0.01), but the effect of hypothermia made the estimation of PMI practically impossible. A much stronger correlation of L against PMI was observed in group 2 (r = 0.866, P < 0.01); a functional relationship between PMI and L were demonstrated using the formula PMI = 1.696 x L - 10.562, which enabled more accurate prediction of the PMI.

A case of a fatal Himalayan black bear attack in the zoo.

We present a case of a 22-year-old male, who was found inside the cage of Himalayan black bears in the Belgrade Zoo. The victim attended the Belgrade Beer festival the previous night, drinking a lot of beer and acting aggressively. A medico-legal autopsy was performed at the Institute of Forensic Medicine in Belgrade. Autopsy findings showed numerous excoriations all over the body surrounded by bruises, as well as spindle-shaped, oval, and partly irregular wounds of variable size, large defects of skin and subcutaneous soft tissue, fractures of the thyroid and cricoid cartilage, and fracture of ribs. Postmortem toxicological analysis revealed the presence of ethanol in vitreous humor and urine and 11-nor Δ9 tetrahydrocannabinolic acid found in the urine. We discussed similar cases from the available literature in different regions of the world. In conclusion, we pointed out that the presented case does not follow the general pattern of Himalayan bear attacks.

Firearm suicide committed using an unusual combination of tandem missiles: a bullet, a nail, and a screw.

An interesting case of firearm suicide carried out using an unusual type of handmade weapon and a peculiar combination of tandem missiles is presented. A nail and a screw were placed in the rifle barrel ahead of a bullet, and all 3 were simultaneously discharged. The inflicted injury began with 1 common channel, which later split in 2 separate channels, both directed backwards and upwards; one was caused by the screw, ending in the epistropheal body, and the other, caused by the bullet and the nail, penetrated into the cranial cavity, where it bifurcated in 2 branches, one from the bullet, ending in the cerebellar tissue, and the other from the nail, penetrated through the brain stem. The established site of the entrance suicidal wound, the appearance of the weapon, and the unusual missiles are discussed with regard to the available references dealing with different types of nail injuries to the head.

Mechanisms of aortic blunt rupture in fatally injured front-seat passengers in frontal car collisions: an autopsy study.

We tried to explain the mechanisms of the aortic blunt ruptures in fatally injured drivers and front passengers, unrestrained by seatbelts, by analyzing the frequencies of both aortic ruptures and concomitant injuries to 12 organs and body regions. The sample consisted of 393 subjects: 251 drivers and 142 front passengers (325 male and 68 female passengers, the mean age 41.0 +/- 15.5). The total number of the complete blunt aortic ruptures in the sample was 116 (80 in the drivers and 36 in the front passengers). The weakest part of the aorta seems to be the isthmus (47 isthmus ruptures in the drivers and 27 in the front passengers). The statistically significant concomitant injured organs and body regions with the aortic ruptures were the liver, the sternum, and the diaphragm in the car drivers and the head and the neck in the front passengers. According to these results, the mechanisms of thoracic aorta rupture are different for fatally injured drivers and front passengers. For car drivers, they are associated and simultaneous with both thoracic and abdominal compression due to deceleration of the body at the moment when the driver's body slides forward and flexes across and against the steering wheel. For the front passengers, the mechanism is the caudorostral hyperextension of the thoracic aorta at the moment when the body is stopped by a dashboard, but the head continues forward with great velocity: the carotid vessels pull the aortic arch forward at the same time as the intercostal arteries fix the thoracic part of the aorta and pull it downwards.

[Suicide by electrocution--2 case reports]. / Samoubistva elektricnom strujom--prikazi dva slucaja.

Suicides by electrocution are extremely rare in our country. In these cases, specific or characteristic external lesions caused through contact with conductors at the sites of entry and exit of the current, as well as general autopsy findings, and excluding the other possible causes of death, are important to elucidate them. Dilemma if death was suicidal, homicidal or accidental in manner, could be solved through good police investigation, and properly explained circumstantial events. Herein, we reported two cases of suicidal deaths, caused by electrocution. In the first case, it was a male, age of 32, who wrapped the electrical cord around his wrists, and killed himself by plugging it in. In second case, it was a female, age of 46, abused by her husband, who committed suicide by putting the switched hear-dryer into the water in bathtub.

[Analysis of causes of death in long-term survivors of injuries sustained in traffic accidents]. / Analiza uzroka smrti bolesnika koji su dugotrajno nadzivljavali povredu zadobijenu u saobracju.

INTRODUCTION: The manner of death, i.e. if death is moros or violent, is the most important fact for the court and therefore, the most important part of the finding of autopsy reports [1]. To recognize the manner of death in cases with long outliving period after injury could be difficult for forensic pathologists. In such cases, the dissector should be able to point out the direct relationship between initial injury and death by using his (her) own experience and medical knowledge. Could the deaths provoked by low injuries be prevented? These injuries have score of 3 by Abbreviated Injury Scale (AIS) i.e. 12-20 by injury Severity Score (ISS) [3-5]. PURPOSE: The purpose of this paper is to suggest the measures for improvement of postmortem autopsy diagnosis of causes of death in cases with long outliving period (more than 15 days) after initial traffic injury. MATERIAL AND METHOD: A retrospective autopsy study was performed. It included the material of the Institute of Forensic Medicine in Belgrade for 1998. The autopsy report and accessible clinical medical data were analyzed for persons fatally injured in traffic accidents who outlived trauma more than 15 days. The sample was statistically prepared (chi 2 test, correlation coefficient). RESULTS AND DISCUSSION: The sample included 31 persons injured in traffic accidents with outliving period longer than 15 days: 21 males and 10 females (chi 2 = 0.047; p > 0.1). Average age was 49.90 years (SD = 18.28). All persons in our sample were over the age of 19. The most commonly injured persons were pedestrians (16). The mean outliving period was 41.19 days (SD = 12.60). There was a weak positive correlation between outliving period and age in our sample (coefficient of linear correlation r = 0.35). The authors combined the autopsy and available clinical data in order to get the ISS value for each case. The mean ISS value was 36.18 (SD = 8.70). There was no correlation between outliving period and severity of trauma (coefficient of linear correlation r < 0.14). All deaths in our sample were violent according to autopsy reports. In autopsy reports, dissectors always noted only one injured body region: head and neck injuries in 21 cases, chest injuries in 3, trauma of locomotor system in 5 and in 2 cases abdominal injuries. However, by analyzing these reports, the authors emphasized that in 22 cases one body region was severely injured, in 7 cases two body regions and three regions in 2 cases. According to the authors severe injury has score 3 or more by 3. In four cases the dissectors pointed no complication of initial injuries as a competitive cause of death. In 15 cases they mentioned it as general, and in the rest of cases as decided (e.g. pneumonia, sepsis, thromboembolism, etc.). In five cases, the complications of initial injury were the precipitated and immediate cause of death (the initial injury in all these cases was less than 16 by ISS i.e. severe but not critical). The seven cases were treated microscopically. These microscopical findings only proved the already established microscopical autopsy findings and were not crucial for case solution. It was alarming, that one third of cases in our sample were completed without considering the clinical medical data. This is forensic vitium artis. Nowadays, there are a few syndromes which could be the cause of death i.e. fat embolism syndrome [7], multiple organ failure) [8, 9] and systemic inflammatory response syndrome [9, 10]. The diagnosis of these syndromes is possible only clinically: the autopsy and histological findings are not specific. CONCLUSION: As long as a direct chain of events can be traced from the injury to the death, then the initial injury must be considered to be the basic cause of death, and this fact may have profound legal implications for both civil compensation and criminal responsibility. Some of the most difficult problems in forensic pathology concern deaths from which posttraumatic complications are disputed as being fatal causative factors. The agony and dying are irreversible dynamic pathophysiological processes. By autopsy only the morphological consequences of these processes could be noted by dissector. The dynamics of dying, direct correlation between initial injury and death, as well as appearance and development of complications provoked by trauma could be established only by clinical medical data. Therefore, medical clinical data are crucial for forensic pathologists and for solving the problems about the mode and manner of death in cases with long outliving period. Microscopical findings have only academic and scientific importance and are less useful in daily practice. The authors suggest that all complications of injury must be generally involved in autopsy reports, and all severe injuries should separately be registered both in medical data and autopsy reports. The finding of cause of death must include all observed severe injuries and not only one of the most severe injuries and its complications.