Dementia in the Forensic Setting: Diagnoses Obtained Using a Condensed Protocol at the Office of Chief Medical Examiner, New York City.

Individuals with dementia may come to forensic autopsy, partly because of non-natural deaths (e.g. fall-related), and/or concerns of abuse/neglect. At the New York City Office of Chief Medical Examiner (NYC OCME), brains from such cases are submitted for neurodegenerative disease (ND) work-up. Seventy-eight sequential cases were evaluated using a recently published condensed protocol for the NIA-AA guidelines for the neuropathologic assessment of Alzheimer disease (AD), a cost-cutting innovation in diagnostic neuropathology. ND was identified in 74 (94.9%) brains; the most common were AD (n = 41 [52.5%]), primary age-related tauopathy (n = 26 [33.3%]), and Lewy body disease ([LBD], n = 25 [32.1%]). Others included age-related tau astrogliopathy, hippocampal sclerosis of aging, progressive supranuclear palsy, multiple system atrophy, amyotrophic lateral sclerosis, argyrophilic grain disease, and Creutzfeldt-Jakob disease. 26.8% of AD cases involved a non-natural, dementia-related death, versus 40.0% for LBD. Finally, 70 (89.7%) cases had chronic cerebrovascular disease, 53 (67.9%) being moderate-to-severe. We present a diverse distribution of NDs notable for a high rate of diagnoses associated with falls (e.g. LBD), a potential difference from the hospital neuropathology experience. We also report a high burden of cerebrovascular disease in demented individuals seen at the NYC OCME. Finally, we demonstrate that the aforementioned condensed protocol is applicable for a variety of ND diagnoses.

Reevaluation of the US Pathologist Workforce Size.

Importance: There is currently no national organization that publishes its data that serves as the authoritative source of the pathologist workforce in the US. Accurate physician numbers are needed to plan for future health care service requirements. Objective: To assess the accuracy of current pathologist workforce estimates in the US by examining why divergency appears in different published resources. Design, Setting, and Participants: This study examined the American Board of Pathology classification for pathologist primary specialty and subspecialties and analyzed previously published reports from the following data sources: the Association of American Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), a 2013 College of American Pathologists (CAP) report, a commercially available version of the American Medical Assoication (AMA) Physician Masterfile, and an unpublished data summary from June 10, 2019. Main Outcomes and Measures: Number of physicians classified as pathologists. Results: The most recent AAMC data from 2017 (published in 2018) reported 12 839 physicians practicing "anatomic/clinical pathology," which is a subset of the whole. In comparison, the current AMA Physician Masterfile, which is not available publicly, listed 21 292 active pathologists in June 2019. The AMA Physician Masterfile includes all pathologists in 15 subspecialized training areas as identified by the ACGME. By contrast, AAMC's data, which derive from the AMA Physician Masterfile data, only count physicians primarily associated with 3 general categories of pathologists and 1 subspecialty category (ie, chemical pathology). Thus, the AAMC pathology workforce estimate does not include those whose principal work is in 11 subspecialty areas, such as blood banking or transfusion medicine, cytopathology, hematopathology, or microbiology. An additional discrepancy relates to the ACGME residency (specialties) and fellowship (subspecialties) training programs in which pathologists with training in dermatopathology appear as dermatologists and pathologists with training in molecular genetic pathology appear as medical geneticists. Conclusions and Relevance: This analysis found that most sources reported only select categories of the pathologist workforce rather than the complete workforce. The discordant nature of reporting may pertain to other medical specialties that have undergone increased subspecialization during the past 2 decades (eg, surgery and medicine). Reconsideration of the methods for determining the pathologist workforce and for all workforces in medicine appears to be needed.

Effects of peri-mortem infection on the entomofauna of decomposing buried human remains - a metadata analysis.

The role of infectious disease as a cause of death is undeniable. The affect infectious disease may have on decomposition after death is less well established. Furthermore, virtually no information is available regarding the effects of burial conditions in such circumstances, despite that numerous clandestine burials occur each year. Although many aspects of post-mortem pathology are well understood and provide frequent insight in medicolegal investigation, where buried bodies are concerned, there is great variation in the decomposition processes, depending on extrinsic and intrinsic conditions. Criminal burials and hurriedly dug clandestine graves are seldom deeper than 120 cm allowing access to certain invertebrates, excluding others that only develop in unburied bodies. Numerous studies have reported on such clandestine graves with a purpose to facilitate forensic investigation, but our knowledge of decomposition in deeper graves lags behind, despite several often-cited papers of over a century ago. The poor level of detail in deep-grave knowledge is in part due to resource deficiencies and ethical considerations, but in part due to lack of thorough investigation of the data in papers of often cited prior work. To this end, a metadata analysis assessed a paper written by Dr. Murray Galt Motter in 1898, providing detail of 150 disinterment events with linked medical records from City of Washington cemeteries. This paper, written more than a hundred years ago, was largely descriptive and the detailed data provided in a summary table were never fully analysed. The paper is often quoted despite these obvious oversights. The present study revisits this work, applying a frequency statistical analysis conducted using categorical data and chi-squared analysis. This new analysis reveals patterns and relationships so long 'locked-up' within the body of the table and provides greater understanding of the effect of infectious disease on the abundance of species in the entomofauna associated with deeply buried remains. The data confirm that the presence of adipocere (saponification) is detrimental to development of soil entomofauna ((X2 = 6·64, df = 1, p < 0·01)). Some species, in particular Proisotoma sepulcralis (Collembola), Eleusis pallida (Coleoptera) and Conicera tibialis (Diptera), were positively influenced by association with infectious disease cases (p < 0·01) while only Piophila casei (Diptera) demonstrated a negative association (p < 0·05). Furthermore, the presence of peri-mortem infectious disease, while not necessarily a cause of death, influences post-mortem colonisation of the buried body by insects. The abundance of some species is enhanced, suggesting that bacterial burdens enhance decomposition in a manner favourable to insect feeding and hence abundance, by releasing compounds that the entomofauna feeds on.

The influence of undetermined deaths on suicides in Shanghai, China.

PURPOSE: In global forensic practice, some suicides were misclassified as undetermined deaths, leading to suicide underreporting. In this study, we aimed to explore the influence of undetermined deaths on suicides in Shanghai, China. METHODS: The police records on suicide verdicts and undetermined deaths in Pudong, Shanghai, from 2004 to 2016 were used. In this study, undetermined deaths have been classified into three levels of suicide possibilities namely, probable, possible, and highly unlikely. Probable suicides were presumed as misclassified suicides. Poisson regression was used to calculate the rate ratio ("RR") of probable suicides compared to suicide verdicts. Poisson regression was also used to calculate the annual percentage change ("APC") of the original suicide rates (crude suicide rates based on the suicide verdicts) and adjusted suicide rates (crude suicide rates based on the suicide verdicts and probable suicides). RESULTS: Among the 1,318 underdetermine deaths, 560 (42.5%) were classified as probable suicides. The overall RR was 0.23 (95% CI 0.21-0.26): 0.15 (0.13-0.17) for the locals' RR and 0.22 (0.19-0.26) for the migrants' RR. The APCs of the original and adjusted suicide rates were - 2.0 (- 3.1 to - 0.9) and - 2.9 (- 3.8 to - 2.0), respectively, for the overall population. CONCLUSIONS: The number of suicides could be 23% higher than the reported cases. Suicides were more likely to be underreported in migrants than in the locals. Thus, it is important to improve suicide monitoring and the surveillance systems in China.

[The forensic medical characteristic of the non-identified corpses based on the materials of Bureau of Forensic Medical Expertise of the Moscow Health Department]. / Sudebno-meditsinskaia kharakteristika neopoznannykh trupov po dannym Biuro sudebno-meditsinskoi ékspertizy Departamenta zdravookhraneniia Moskvy.

We undertook the analysis of the archive data of forensic medical expertises of the non-identified corpses accumulated at the tanatological divisions of the Moscow Bureau of Forensic Medical Expertise for the period from 2012 till 2016. Special attention was given to sex and age composition of the deceased as well as the structure of mortality and the traces of ethyl alcohol, if any, present in the blood. It was shown that the majority of the unidentified bodies were those of the young men, with the main cause of the non-violent deaths being the cardiovascular pathology. Ethyl alcohol was found in the blood of 43% of the corpses. The analysis encompassed also the most frequently used methods for personality identification based on the data available from the medical-criminalistic department of the Bureau of Forensic Medical Expertise. The statistical treatment of the results of the study provided materials making it possible to envision the tendencies of the further development and improvement of the methods for personality identification for the purpose of forensic medical expertise and judicial practice.

[Alcohol-associated mortality in Russia (based on the materials for the period from 2011 till 2016)]. / Alkogol'-assotsiirovannaia smertnost' v Rossii (po materialam 2011-2016 gg.).

The objective of the present study was to evaluate the frequency of alcoholic drunkenness documented during forensic medical expertises (investigations) of the corpses carried out in this country throughout the period from 2011 till 2016. The investigations were conducted with the use of medical statistics methods by calculating the fractional difference, dynamics, and rates of detection of the cases of alcoholic intoxication depending on the cause of death. The study has demonstrated the high frequency of the cases of alcoholic drunkenness revealed during forensic medical expertises (investigations) of the corpses that amounted to 30.5% [15, 16]. The total number of the corpses examined in 2016 was 8.6% higher than in 2011. The frequency of the documented cases of alcoholic drunkenness during the same period decreased by 19.7%. The frequency of the documented cases of alcoholic drunkenness in the cases of violent death was 2.8 times that in the cases of death from various diseases (52.8 and 19.0% respectively). The enhanced frequency of alcoholic drunkenness in relation to the number of the conducted forensic medical expertises was documented in the cases of death by drowning and from hypothermia whereas the lowest frequency of alcoholic intoxication was recorded for the corpses of the people who had died from malignant tumours and diseases of the nervous system. Various regions of Russia differed in terms of the frequency of alcoholic drunkenness recorded among the recently deceased people.

Sudden and unexpected childhood deaths investigated at the Pretoria Medico-Legal Laboratory, South Africa, 2007 - 2011.

BACKGROUND:  Sudden and unexpected death is well known to occur in infants, and although sudden deaths are less frequent after the first birthday, they still account for a significant proportion of childhood deaths. In 2009, 1.9% of the total deaths in the USA were childhood deaths. In South Africa (SA) this proportion was much higher at 11.85%. According to the law, sudden and unexpected deaths are generally investigated as unnatural deaths. Establishing an exact underlying anatomical cause of death will depend on available resources and can be difficult in a substantial proportion of cases. METHODS:  A retrospective descriptive case audit was conducted at the Pretoria Medico-Legal Laboratory (PMLL), SA, from 1 January 2007 through to 31 December 2011. All children aged 1 - 18 years who died suddenly and unexpectedly were included. RESULTS:  Ninety-eight cases were identified, which constituted nearly 1% of total admissions to the PMLL. The majority of the deaths were of children aged 1 - 5 years, and the male/female ratio was 1.04:1. In the largest proportion of cases (n=28, 28.6%), the medicolegal investigation, including autopsy and ancillary investigations, did not establish an underlying anatomical cause of death. In the cases where a cause of death was established, pneumonia was the most common diagnosis (n=22, 22.4%). CONCLUSION:  The fact that the cause of the largest proportion of deaths could not be ascertained emphasises the need for consideration of additional investigative techniques, such as molecular/genetic screening, which have provided an underlying cause of death in a significant number of cases in other countries. There is a lack of published research on the causes and incidence of sudden unexpected deaths in children in SA, and further research in this area is needed.

[The age-specific features of palm dermatoglyphics in the adults subjects].

This article was designed to consider the congenital age-specific features of palm dermatoglyphics in the adults subjects (including the type of the papillary patterns, axial tri-radii, the termini of palmar main lines, the rudiments of palmar lines, the dermatoglyphic ridge count between the stable anatomical structures). The objective of the study was to look for the new diagnostic markers of the biological age. It included the identification of the palm prints obtained from 180 Caucasoid men and 120 women at the age varying from 16 to 80 years. The results of the mathematical and statistical analysis provided the basis for drawing up the list of 18 attributes of palm dermatoglyphics significantly (p<0.05) differing in the frequency of occurrence between the representatives of individual age groups. The methods are proposed allowing to use these findings for the expert evaluation of the age of unknown subjects.

The First Survey of Forensically Important Entomofauna Collected from Medicolegal Autopsies in South Korea.

Forensic entomology applies insect evidence to legal problems such as the estimation of minimum postmortem interval (mPMI). For this purpose, knowledge of the insect fauna that are attracted to human cadavers in each geographic region is a prerequisite. Despite many studies investigating the insect fauna attracted to meat, there has been no survey of the entomofauna on human cadavers in the East Asian temperate climate zone, particularly in Korea. Therefore, this study reports the entomofauna collected from medicolegal autopsies in northeastern Seoul and its suburbs. Insect samples were collected from 35 medicolegal autopsies in 2010, 2011, and 2013. Molecular and morphological methods were utilized for taxonomic identification. Among 1398 individual samples belonging to 3 orders, 13 families, 18 genera, and 32 species, the dominant family and species were Calliphoridae and Lucilia sericata, respectively. Despite its limited scale, this study provides a snapshot of the general entomofauna that are attracted to human cadavers in this region.

[Relationship between alcohol consumption and external causes of death based on the forensic autopsy cases in Yamaguchi].

We analyzed forensic autopsy cases to assess the relationship between alcohol consumption and external causes of death. We divided 605 autopsy cases which had been performed from 2000 to 2011 at our department into Alcohol group (n = 172, 28.4%) and Non-alcohol group (n = 433, 71.6%) according to whether alcohol could be detected in the deceased's blood. The individuals' sex and age, season when the death occurred, cause of death, type of death and circumstances of death were analyzed. Alcohol group had a significantly higher ratio of males and younger ages (both p < 0.05). There was no significant between-group difference regarding the seasons when the deaths occurred. Alcohol group had significantly greater rates of spinal injuries, abdominal injuries, traffic accidents, and accidental drowning. "Bicycling" was revealed as a related factor of the traffic accidents only in Alcohol group. In contrast, "accident on the expressway," "riding a motorcycle," and "a passenger in a vehicle" were related factors only in Non-alcohol group. We concluded that the factors of male gender and middle-to-senior age are responsible for the increased risk of external causes of death after alcohol consumption, and that alcohol consumption is one of the risk factors for accidental death. In Japan, drunk-driving-related accidents have shown a downward trend whereas bicycling-related accidents have shown an upward trend, and similar results were obtained in the present study. The low awareness of drinking-induced pitfalls may be responsible for drinking-related bicycle accidents.

Dead infants and unmarried women--from forensic pathology reports 1910-12.

The lack of access to contraceptives and poor control over their own pregnancies represented a major problem for women 100 years ago. An unwanted pregnancy could lead to social exclusion and loss of paid work, and clandestine births and infanticide thus posed a social problem. A review of the archives of the Norwegian Board of Forensic Medicine in the period 1910 to 1912 shows that one-fifth of all expert opinions were related to infants and pregnancy. Autopsies performed on children constituted over one-third of all forensic autopsies during this period. Although the reports provide a timely reminder of the value of hard-earned rights in Norway, the lack of control over their own sexuality and unwanted pregnancies are unfortunately still the reality for a large proportion of the world's women.

Forensic cases of bruises in pigs.

Bruises in pigs inflicted by blunt trauma are a significant animal welfare problem, and affected skin and underlying muscle are regularly submitted for forensic investigation. Central to the evaluation is an assessment of the age of the bruises. This paper presents cases of bruises in pigs sent for forensic investigation that were collected retrospectively. Data comprised photographs of the gross lesions, slides for histology, and written reports. The time from collecting the animals at the farms and delivery to the slaughterhouse was recorded together with the time of slaughter. Since 2005 there has been an increase in cases, with a peak in 2008 and 2009 of 40 cases for each year. At gross examination, the pattern of bruises often reflected the type of object which caused them. Histologically, haemorrhage and cellular infiltrations were frequently present. Currently, the age of bruises may be estimated to be more or less than four hours based on a porcine bruise model. In bruises more than four hours old, estimations of two-hour intervals are used based on studies of wound healing. The time from collecting the pigs at the farms until slaughter was between one and four hours in 44.1 per cent of cases, during which time the pigs had been handled by several people. In addition, in 22.0 per cent of cases of bruising an inflammatory response was absent, making it impossible to estimate the age of the bruise.

Causes of death in forensic autopsy cases of malnourished persons.

PURPOSE: Medical examiners and forensic pathologists often encounter emaciated bodies in postmortem examinations. However, the main disease that caused death is often not clear and measures to prevent the unexpected death of malnourished persons have not been established. In this study, we examined the underlying causes of death among a large number of forensic autopsy cases that showed emaciation to clarify the features of sudden, unexpected death in malnourished persons. METHODS: Documents of autopsy cases without putrefaction handled during 2007-2010 by the Tokyo Medical Examiner's Office were reviewed (n=7227). The body mass index (BMI) was calculated for each case. The causes of death for cases with severe malnutrition (BMI<16; n=885) were closely examined. RESULTS: About 70% of all deaths in malnourished cases (BMI<16) was due to disease, and the causative diseases are more varied than in those with less severe malnutrition and those without malnutrition (BMI⩾16). A higher proportion of malnutrition as the cause of death was observed in younger persons for both sexes, and a higher proportion of having a history of psychiatric diseases was observed in younger deceased women. In addition, a higher proportion of alcohol-related digestive diseases was observed especially in younger men, some of whom had a history of alcohol dependence. On the other hand, the proportion of organic diseases, such as neoplasms and gastroduodenal ulcer, was higher in older deceased persons, especially among men. Around 70% of all respiratory diseases comprised pneumonia in both sexes. Among non-disease-related causes of death, poisoning was the most frequent cause in women under 55years old (35.3%), with the majority having had a history of psychiatric disease. CONCLUSIONS: Because autopsy cases of malnourished persons show various causes of death, physicians have to pay more attention in making death diagnosis in such cases. From a preventative point of view, early detection of organic diseases, a better approach toward managing psychiatric diseases, and implementation of vaccination for pneumonia will contribute to reduction of future unexpected deaths among malnourished persons.

Patterns of injuries in domestic violence in a Romanian population.

In Romania, the quantification of traumatic injuries is achieved in medical- legal services; therefore, each domestic violence (DV) victim needs a medical-legal certificate to prove in a court of law the presence of traumatic injuries. In this study, we aimed to determine the pattern of traumatic injuries in DV. A total of 219 consecutive DV cases were included. For each victim, a detailed medical-legal examination was performed, including specialized consults, if needed. Results were analyzed statistically using the SPSS software. Traumatic injuries in DV cases were usually located in the head, face, and neck areas and had a low severity index. Severe lesions were found in less than 10% and no sexual aggression was found. The severity increases with age and is higher for males than females. The pattern of DV-associated injuries we have encountered is similar to the one found in other similar studies. Knowing this pattern may be useful in clinical practice to detect cases of DV.

Audit of custodial deaths in Karachi--an autopsy-based study.

OBJECTIVE: To assess the causes and manner of custodial deaths in Karachi, and to determine the factor of negligence on the part of the custodians behind such deaths. METHODS: The cross-sectional study involved the deaths in custody undergoing autopsy at Civil Hospital, Karachi, from January 2005 to December 2010. Autopsy was followed by histological examination, X-ray or CT scan wherever required. A proforma was also filled as per the standard autopsy protocol. RESULTS: There were 61 custodial deaths in Karachi during the six-year study period which met the inclusion criterion. There were 58 (95.1%) males and 3 (9.4%) females. Natural causes accounted for a majority of deaths (n = 36; 59%), the most common disease being coronary artery disease (n = 13; 21.3%). Unnatural causes accounted for 25 (41%) deaths, comprising 13 (21.3%) homicidal, 7 (11.5%) suicidal and 5 (8.2%) accidental. Deaths were more frequent in the age group ranging from 30-39 years (34.4%), while the overall age-range was from 19 to 75 years. DISCUSSION: Measures need to be taken to provide a wholesome environment for the prisoners. Code of conduct for the prisoners should be followed and judicial procedures shall be conducted at a quick pace. Torture should be avoided under all circumstances, and proper vigilance shall be kept to prompt suicidal deaths.

Profile of medicolegal autopsies in Pekanbaru, Indonesia 2007-2011.

Medicolegal autopsy should be carried out for all unnatural deaths to ascertain facts pertaining to death. A retrospective 5-year study was carried out by the Forensic Medicine and Medicolegal Department, Faculty of Medicine, University of Riau to describe the profile of medicolegal autopsies in Pekanbaru, Indonesia. There were 613 unnatural deaths and 73 (11.9%) medicolegal autopsies recorded between 2007 and 2011. The number of unnatural deaths showed a decreasing trend whereas the number of medicolegal autopsies increased over the years. The percentage of unnatural deaths subjected to medicolegal autopsy varied between 2.2% and 23.1% per year. Of the 73 medicolegal autopsy subjects, 68.5% (n = 50) were male and 31.5% (n = 23) females. The ages of victims ranged from newborn babies to 72 years, with a median of 28 years. 61.6% of cases were in the 20-39 years age-group. Sixty (82.2%) had unnatural deaths. The leading cause of death was blunt force (30.1%) and sharp force (20.5%). Homicide was the predominant manner of death. Our study highlights that the main interest of the police in requesting a medicolegal autopsy is for investigation of homicide. Recognizing that autopsy has an important role in the investigation of unnatural deaths, further studies should be carried out to understand the factors that impact on the low percentage of medicolegal autopsies in unnatural deaths, so that solutions may be found for the future.

[Dermatoglyphic features in suicidents: characteristic and implications for the solution of forensic medical problems].

The objective of the present work was to study dermatoglyphic signs in suicidents (n=50) and in the subjects who were either killed or died as a result of an accident. It was shown that the correlation between selected dermatoglyphic signs and predisposition to suicide is either insignificant or moderately significant. The specific features of suicidal predisposition can be traced down to dermatoglyphics of all the friction ridged skin areas (fingers, palms, toes, and soles of the feet). Suicidal residents of the northwestern regions of Russia have been found to possess specific dermatoglyphic features. The effectiveness of the mathematical models of suicidal predisposition developed based on the 20 most informative dermatoglyphic characteristics amounts to 88%.

[The possibility and mechanism of spontaneous redistribution of acute intracranial subdural hematomas].

The author has undertaken the systematic search for the description of isolated and serial cases of spontaneous redistribution of acute intracranial subdural hematomas with their mandatory computed and magneto-resonance neurovisualization. Based on the results of the search and metaanalysis of statistical data, it is concluded that acute intracranial subdural are likely to undergo any possible dislocation over the surface of the large hemispheres of the brain as well as downward transtentorial and spinal migration. The non-linear regression analysis allowed to determine the spinal migration rate of acute intracranial subdural hematomas. At the same time, the analysis gave no evidence of the possibility of the upward transtentorial redistribution of acute intracranial subdural hematomas across the falx of the cerebrum. It is concluded that the results of the present study can be used for the porpose of practical forensic medical expertise and the identification of the sources of spontaneous redistribution of acute intracranial subdural hematomas.