Study of risk factors for injuries due to cardiopulmonary resuscitation with special focus on the role of the heart: A machine learning analysis of a prospective registry with multiple sources of information (ReCaPTa Study).

Background: The study of thoracic injuries and biomechanics during CPR requires detailed studies that are very scarce. The role of the heart in CPR biomechanics has not been determined. This study aimed to determine the risk factors importance for serious ribcage damage due to CPR. Methods: Data were collected from a prospective registry of out-of-hospital cardiac arrest between April 2014 and April 2017. This study included consecutive out-of-hospital CPR attempts undergoing an autopsy study focused on CPR injuries. Cardiac mass ratio was defined as the ratio of real to expected heart mass. Pearson's correlation coefficient was used to select clinically relevant variables and subsequently classification tree models were built. The Gini index was used to determine the importance of the associated serious ribcage damage factors. The LUCAS® chest compressions device forces and the cardiac mass were analyzed by linear regression. Results: Two hundred CPR attempts were included (133 manual CPR and 67 mechanical CPR). The mean age of the sample was 60.4 ± 13.5, and 56 (28%) were women. In all, 65.0% of the patients presented serious ribcage damage. From the classification tree build with the clinically relevant variables, age (0.44), cardiac mass ratio (0.26), CPR time (0.22), and mechanical CPR (0.07), in that order, were the most influential factors on serious ribcage damage. The chest compression forces were greater in subjects with higher cardiac mass. Conclusions: The heart plays a key role in CPR biomechanics being cardiac mass ratio the second most important risk factor for CPR injuries.

Intervención forense en el accidente de autobús con 13 víctimas mortales en Freginals, Tarragona, España / Forensic intervention in the bus accident with 13 fatalities in Freginals, Tarragona, Spain

La identificación de cadáveres en sucesos con múltiples víctimas es un reto y una de las actividades principales de la patología forense. De la correcta identificación y gestión de identificación se derivan repercusiones legales, humanitarias y sociales generando un gran impacto.El objetivo del presente trabajo es presentar el proceso de gestión e identificación de las 13 víctimas mortales del accidente de autobús ocurrido en la autopista AP7 en marzo de 2016, en Freginals (Tarragona, España). Se analizan las rápidas identificaciones de las víctimas mortales, los diferentes mecanismos de control de calidad empleados, la atención a los familiares, así como la gestión propia de la catástrofe con los recursos humanos y materiales disponibles.A pesar de la nacionalidad extranjera de todas las víctimas, que determinó el método de identificación, todas ellas fueron identificadas rápidamente mediante odontología, huellas dactilares o ADN y fueron rápidamente retornadas a sus familias y países de origen. Italia fue el país de donde procedían un mayor número de víctimas. Se destaca la participación de los médicos forenses en la recuperación de datos antemortem. (AU)

Corpses identification in events with multiple victims is a challenge and one of the main activities of Forensic Pathology. Legal, humanitarian and social repercussions are derived from the correct identification and also its management, generating a great impact.The objective of this paper is to present the management and identification process of the 13 deaths that occurred in the bus accident on the AP7 motorway in March 2016 in Freginals (Tarragona, Spain). The rapid identification of fatalities, the different quality control mechanisms used, attention to family members, as well as the proper management of the catastrophe with the human and material resources available are analysed.Despite the foreign nationality of all the victims, which determined the method of identification, all of them were quickly identified by dentistry, fingerprinting or DNA and were quickly returned to their families and countries of origin. Italy was the country where the largest number of victims came from. The participation of forensic doctors in ante mortem data recovery is highlighted. (AU)

Molecular autopsy: Twenty years of post-mortem diagnosis in sudden cardiac death.

In the forensic medicine field, molecular autopsy is the post-mortem genetic analysis performed to attempt to unravel the cause of decease in cases remaining unexplained after a comprehensive forensic autopsy. This negative autopsy, classified as negative or non-conclusive, usually occurs in young population. In these cases, in which the cause of death is unascertained after a thorough autopsy, an underlying inherited arrhythmogenic syndrome is the main suspected cause of death. Next-generation sequencing allows a rapid and cost-effectives genetic analysis, identifying a rare variant classified as potentially pathogenic in up to 25% of sudden death cases in young population. The first symptom of an inherited arrhythmogenic disease may be a malignant arrhythmia, and even sudden death. Early identification of a pathogenic genetic alteration associated with an inherited arrhythmogenic syndrome may help to adopt preventive personalized measures to reduce risk of malignant arrhythmias and sudden death in the victim's relatives, at risk despite being asymptomatic. The current main challenge is a proper genetic interpretation of variants identified and useful clinical translation. The implications of this personalized translational medicine are multifaceted, requiring the dedication of a specialized team, including forensic scientists, pathologists, cardiologists, pediatric cardiologists, and geneticists.

Chest wall mechanics during mechanical chest compression and its relationship to CPR-related injuries and survival.

Aim: To determine compression force variation (CFV) during mechanical cardiopulmonary resuscitation (CPR) and its relationship with CPR-related injuries and survival. Methods: Adult non-traumatic OHCA patients who had been treated with mechanical CPR were evaluated for CPR-related injuries using chest X-rays, thoracic computed tomography or autopsy. The CFV exerted by the LUCAS 2 device was calculated as the difference between the maximum and the minimum force values and was categorised into three different groups (high positive CFV ≥ 95 newton (N), high negative CFV ≤ -95 N, and low variation for intermediate CFV). The CFV was correlated with the CPR injuries findings and survival data. Results: Fifty-two patients were included. The median (IQR) age was 57 (49-66) years, and 13 (25%) cases survived until hospital admission. High positive CFV was found in 21 (40.4%) patients, high negative CFV in 9 (17.3%) and a low CFV in 22 (42.3%). The median (IQR) number of rib fractures was higher in the high positive and negative CFV groups compared with the low CFV group [7(1-9) and 9 (4-11) vs 0 (0-6) (p = 0.021)]. More bilateral fracture cases were found in the high positive and negative CFV groups [16 (76.2%) and 6 (66.7%) vs 6 (27.3%) (p = 0.004)]. In the younger half of the sample more patients survived until hospital admission in the low CFV group compared with the high CFV groups [5 (41.7%) vs 1 (7.1%) (p = 0.037)]. Conclusions: High CFV was associated with ribcage injuries. In the younger patients low CFV was associated with survival until hospital admission.

Clinical outcomes and safety of passive leg raising in out-of-hospital cardiac arrest: a randomized controlled trial.

BACKGROUND: There are data suggesting that passive leg raising (PLR) improves hemodynamics during cardiopulmonary resuscitation (CPR). This trial aimed to determine the effectiveness and safety of PLR during CPR in out-of-hospital cardiac arrest (OHCA). METHODS: We conducted a randomized controlled trial with blinded assessment of the outcomes that assigned adults OHCA to be treated with PLR or in the flat position. The trial was conducted in the Camp de Tarragona region. The main end point was survival to hospital discharge with good neurological outcome defined as cerebral performance category (CPC 1-2). To study possible adverse effects, we assessed the presence of pulmonary complications on the first chest X-rays, brain edema on the computerized tomography (CT) in survivors and brain and lungs weights from autopsies in non-survivors. RESULTS: In total, 588 randomized cases were included, 301 were treated with PLR and 287 were controls. Overall, 67.8% were men and the median age was 72 (IQR 60-82) years. At hospital discharge, 3.3% in the PLR group and 3.5% in the control group were alive with CPC 1-2 (OR 0.9; 95% CI 0.4-2.3, p = 0.91). No significant differences in survival at hospital admission were found in all patients (OR 1.0; 95% CI 0.7-1.6, p = 0.95) and among patients with an initial shockable rhythm (OR 1.7; 95% CI 0.8-3.4, p = 0.15). There were no differences in pulmonary complication rates in chest X-rays [7 (25.9%) vs 5 (17.9%), p = 0.47] and brain edema on CT [5 (29.4%) vs 10 (32.6%), p = 0.84]. There were no differences in lung weight [1223 mg (IQR 909-1500) vs 1239 mg (IQR 900-1507), p = 0.82] or brain weight [1352 mg (IQR 1227-1457) vs 1380 mg (IQR 1255-1470), p = 0.43] among the 106 autopsies performed. CONCLUSION: In this trial, PLR during CPR did not improve survival to hospital discharge with CPC 1-2. No evidence of adverse effects has been found. Clinical trial registration ClinicalTrials.gov: NCT01952197, registration date: September 27, 2013, https://clinicaltrials.gov/ct2/show/NCT01952197 .

Decreasing temporal trends of polychlorinated dibenzo-p-dioxins and dibenzofurans in adipose tissue from residents near a hazardous waste incinerator.

Polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) are very toxic chemicals which are emitted in waste incineration and whose exposure has important adverse effects for the human health. In 2019, adipose tissue samples were collected from 15 individuals with a median age of 61 years, who had been living near a hazardous waste incinerator in Constantí (Spain). The content of PCDD/Fs in each sample was analyzed. The results were compared with data from previous studies, conducted before (1998) and after (2002, 2007 and 2013) the facility started to operate, and based on populations of similar age. In 2019, the mean concentration of PCDD/Fs in adipose tissue was 6.63 pg WHO-TEQ/g fat, ranging from 0.95 to 12.95 pg WHO-TEQ/g fat. A significant reduction was observed with respect to the baseline study (1998), when a mean PCDD/Fs concentration of 40.1 pg WHO-TEQ/g fat was found. Moreover, the current level was much lower than those observed in the 3 previous studies (9.89, 14.6 and 11.5 pg WHO-TEQ/g fat in 2002, 2007 and 2013, respectively). The body burdens of PCDD/Fs were strongly correlated with age. The significant reduction of PCDD/Fs levels in adipose tissue fully agreed with the decreasing trend of the dietary intake of PCDD/Fs by the population of the zone (from 210.1 pg I-TEQ/day in 2018 to 8.54 pg WHO-TEQ/day in 2018). Furthermore, a similar decrease has been also observed in other biological, such as breast milk and plasma. The current data in adipose tissue, as well as those in other biological monitors, indicate that the population living near the HWI is not particularly exposed to high levels of PCDD/Fs. However, biomonitoring studies cannot differentiate the impact of the HWI emissions from food consumption patterns. This question can be only solved by conducting complementary investigations and contrasting the results of monitoring and epidemiological studies.

La especialidad de Medicina Legal y Forense en España: La consolidación por el sistema de residencia / Legal and Forensic Medicine Specialty in Spain: the consolidation by the medical residency system

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Aspectos médico-legales de la pandemia por COVID-19 / Medico-legal issues of COVID-19 pandemic

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Evaluación de las periciales extrajudiciales en Cataluña (España) en 2016-2017 / Evaluation of extrajudicial expert advice in Catalonia (Spain) in 2016-2017

INTRODUCCIÓN: Desde la entrada en vigor de la Ley 35/2015, los Institutos de Medicina Legal y Ciencias Forenses realizan periciales extrajudiciales a petición de particulares para la resolución de las reclamaciones por accidentes de circulación. El objetivo es analizar los aspectos médico-legales más relevantes de estas periciales. MATERIAL Y MÉTODO: Se trata de un estudio descriptivo retrospectivo de las periciales extrajudiciales en las divisiones de Barcelona y l'Hospitalet y Tarragona del Instituto de Medicina Legal y Ciencias Forenses de Cataluña durante los años 2016-2017. Los datos se obtuvieron de los registros de periciales extrajudiciales de ambas divisiones. RESULTADOS: Se realizaron 547 informes médico-forenses. Los accidentes fueron mayoritariamente causados por colisión por alcance entre turismos en trayectos urbanos. Las lesiones fueron en su mayoría de carácter leve, siendo la afectación cervical la más frecuente. En un alto porcentaje, se resolvió con tratamiento conservador en una media de 69 días, asociándose la aparición de secuelas leves en casi la mitad de los casos. El perjuicio estético se informó en el 14%. No hubo diferencias entre ambas divisiones. CONCLUSIÓN: Las periciales extrajudiciales resultan una fuente de información valiosa para la valoración de los perjuicios causados a las víctimas de accidentes de circulación. Como en otros estudios, la mayoría de lesiones son de carácter leve y se asocian a colisiones entre turismos, causando secuelas en la mitad de los casos. Parece que la vía extrajudicial es eficaz en las reclamaciones por accidentes de circulación, pero son necesarios más estudios para obtener una visión más completa

INTRODUCTION: Since the application of Law 35/2015, the Legal and Forensic Medicine Institutes provide extrajudicial expert advice at the request of individuals for the resolution of traffic accident claims. The objective is to analyze the most relevant medical-legal aspects of this expert advice. MATERIAL AND METHOD: This is a retrospective descriptive study of the extrajudicial expert advice in the divisions of Barcelona and l'Hospitalet, and Tarragona of the Catalonian Legal and Forensic Medicine Institute from 2016-2017. The data was obtained from the extrajudicial expert records of both divisions. RESULTS: 547 medical-forensic reports were made. The accidents were mainly caused by a rear collision between cars on urban routes. The injuries were mostly minor, with cervical involvement being the most frequent. A high percentage were resolved with conservative treatment in an average of 69 days, there were mild sequelae in almost half of the cases. Aesthetic damage was reported in 14%. There were no differences between the two divisions. CONCLUSION: Extrajudicial expert advice is a valuable source of information for assessing the damage caused to traffic accident victims. As in other studies, most injuries are mild and are associated with collisions between cars, causing sequelae in half of the cases. It seems that the extrajudicial route is effective in helping resolve traffic accident claims, but more studies are needed to obtain a more complete vision

Respuesta de los autores: Reanimación cardiopulmonar extrahospitalaria / Author’s reply: Out-of-hospital cardiopulmonary resuscitation

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