Fat embolism after intraosseous catheters in pediatric forensic autopsies.

In our center, we performed the autopsy of a child who died from drowning and presented, at autopsy, a major pulmonary fat embolism (PFE). A cardiopulmonary resuscitation (CPR) was performed, including infusion by intraosseous catheter (IIC). No other traumatic lesions and diseases classically related to a risk of PFE were detected. According to some animal studies, we considered the IIC as the only possible cause for PFE. However, we could not find literature to confirm this hypothesis in humans, especially in a pediatric population. To verify the occurrence of PFE after IIC in a pediatric population, we retrospectively selected 20 cases of pediatric deaths autopsied in our center, in which a CPR was performed, without bone fractures or other possible causes of PFE: 13 cases with IIC (group A) and 7 cases without IIC (group B). Several exclusion criteria were considered. The histology slides of the pulmonary tissue were stained by Oil Red O. PFE was classified according to the Falzi scoring system. In group A, 8 cases showed PFE: 4 cases with a score 1 of Falzi and 4 cases with a score 2 of Falzi. In group B, no case showed PFE. The difference between the two groups was statistically significant. The results of our study seem to confirm that IIC can lead to PFE in a pediatric population and show that the PFE after IIC can be important (up to score 2 of Falzi). To the best of our knowledge, our study is the first specifically focused on the occurrence of PFE after IIC in a pediatric population by using autoptic data.

Can the size of the contact area body-ground influence the presence of acute pulmonary emphysema in cases of incomplete hanging?

In a recently published study, we showed that acute pulmonary emphysema (APE) was present in cases of death by incomplete hanging and absent in cases of complete hanging. This result suggested a possible role of the hanging position on the respiratory distress of these victims. To further investigate this hypothesis, in the present study, we compared cases of incomplete hanging with a small contact area between body and ground (group A) to cases of incomplete hanging with a large contact area (group B). As positive and negative control group, we investigated cases of freshwater drowning (group C) and acute external bleeding (group D) respectively. Pulmonary samples were histologically examined, and the mean alveolar area (MAA) for each group was measured by digital morphometric analysis. MAA was 23,485 µm2 for group A and 31,426 µm2 for group B (p < 0.05). MAA of group B was similar to MAA of positive control group (33,135 µm2) and MAA of group A was similar to MAA of negative control group (21,991 µm2). These results seem to confirm our hypothesis and suggest that the size of the contact area between body and ground influences the presence of APE. Furthermore, the present study showed that APE can be proposed as a vitality sign in incomplete hanging, but only in cases with a large contact area between body and ground.

Creation of a Forensic Pathology Biobank in Switzerland: which issues and research opportunities?

A biobank is a collection of biological material associated with health database. The field of biobanking has significantly developed over the past 30 years. Research based on biobank material gives access to data of a large number of people and can often significantly accelerate the understanding of disease and improve the quality of care. In the University Center of Legal Medicine Lausanne-Geneva, samples collected during autopsies are used for forensic investigations. The legal and ethical framework to use these samples for research is often complex and confused, which is unfortunate given the potential of these biospecimens. Indeed, forensic samples are valuable for research because they originate in part from young (including pediatrics cases) and healthy people who are poorly represented in worldwide institutional biobanks. In this context at the beginning of the year 2019, the Forensic Pathology Biobank was created. Creation of a forensic pathology biobank is the best way to standardize local conservation practices and improve personal data management, thus providing a very valuable biological material for scientific projects. Its development gives rise to many questions about technical standards, ethical and legal issues but also many research opportunities.

Practical application of synthetic head models in real ballistic cases.

In shooting crimes, ballistics tests are often recommended in order to reproduce the wound characteristics of the involved persons. For this purpose, several "simulants" can be used. However, despite the efforts in the research of "surrogates" in the field of forensic ballistic, the development of synthetic models needs still to be improved through a validation process based on specific real caseworks. This study has been triggered by the findings observed during the autopsy performed on two victims killed in the same shooting incident, with similar wounding characteristics; namely two retained head shots with ricochet against the interior wall of the skull; both projectiles have been recovered during the autopsies after migration in the brain parenchyma. The thickness of the different tissues and structures along the bullets trajectories as well as the incident angles between the bullets paths and the skull walls have been measured and reproduced during the assemblage of the synthetic head models. Two different types of models ("open shape" and "spherical") have been assembled using leather, polyurethane and gelatine to simulate respectively skin, bone and soft tissues. Six shots have been performed in total. The results of the models have been compared to the findings of post-mortem computed tomography (PMCT) and the autopsy findings.Out of the six shots, two perforated the models and four were retained. When the projectile was retained, the use of both models allowed reproducing the wounds characteristics observed on both victims in terms of penetration and ricochet behaviour. However, the projectiles recovered from the models showed less deformation than the bullets collected during the autopsies. The "open shape" model allowed a better controlling on the shooting parameters than the "spherical" model. Finally, the difference in bullet deformation could be caused by the choice of the bone simulant, which might under-represent either the strength or the density of the human bone. In our opinion, it would be worth to develop a new, more representative material for ballistic which simulates the human bone.

Helium poisoning: new procedure for sampling and analysis.

An increasing number of suicidal asphyxiation with a plastic bag with inert gases, and in particular helium (He), have been reported from numerous countries over the last decade. These cases are differently managed and lead to different and variable interpretations. Based on the 12 last cases analysed in the laboratory and on the review of the most recent literature about this topic, updated autopsy guidelines for sampling have been proposed regarding to the samples choice and analytical challenges required by the gaseous state of this substance. Biological samples from airways (lungs lobe) followed by brain and cardiac blood are the best matrices to take during the autopsy to diagnose He exposure. Gaseous samples from trachea, pulmonary bronchi, gastric and cardiac areas are also recommended as alternative samples. The anatomical site of sampling must be carefully detailed, and to this end, forensic imaging constitutes a beneficial tool. Even if He detection is sufficient to conclude to He exposure, He concentrations in samples may be related to He exposure conditions (duration, breathing rate, etc.). A quantification in biological samples could be helpful to document more precisely the case. He concentrations in gaseous samples are reported up to 6.0 µmol/mL (tracheal gas), 2.4 µmol/mL (pulmonary gas), 0.64 µmol/mL (cardiac gas) and 12 µmol/mL (gastric gas). He concentrations in solid/liquid samples are reported up to 28 µmol/g (lungs) and 0.03 µmol/g (cardiac blood). The other matrices usually sampled during autopsy such as urine, peripheral blood, liver, fat matter and kidney appear as not relevant.

Different degrees of ischaemic injury in the right and left ventricle in cases of severe, nonfatal, pulmonary embolism.

Pulmonary fat embolism (PFE) is a common complication of blunt force traumas with bone fractures. Severe forms cause impedance to right ventricular (RV) ejection, with eventual right heart ischaemia and failure. In a prospective study, we have investigated 220 consecutive autopsy cases (73 females, 147 males, mean age 52.1 years, min 14 years, max 91 years). PFE was detected in 52 cases that were divided into three groups according to the degree of PFE (1-3). A fourth group of cases of violent death without PFE was used for comparison. In each case, histology (H&E, Masson) and immunohistochemistry (fibronectin and C5b-9) were performed on six cardiac samples (anterior, lateral and posterior wall of both ventricles). The degree of cardiac damage was registered in each sample and the mean degree of damage was calculated in each case at the RV and left ventricle (LV). Moreover, a parameter ∆ that is the difference between the mean damage at the RV and the LV was calculated in each case. The results were compared within each group and between the groups. In the present study, we could not detect prevalent RV damage in cases of high degree PFE as we did in our previous investigation. In the group PFE3 the difference of the degree of damage between the RV and LV was higher than the one observed in the groups PFE0-2 with the antibody anti-fibronectin. Prevalent right ventricular stress in cases of severe PFE may explain this observation.

An extraordinary case of an intracranial foreign body after a gunshot to the head.

Intermediate targets (IT) can modify the morphology of an entrance wound, the trajectory of the bullet, and contaminate the path with fragments or material from the target. The penetration into the body of big fragments or even of an entire IT is exceptional and only rarely reported in the literature. The interpretation of a gunshot wound after contact of the bullet with IT can sometimes be very tricky as the classical morphology can be missing. The presented case is a rare example of atypical entrance wound and path due to a surprising intermediate target of a gunshot fired against the head.

Fatal mycotic aneurysm caused by Pseudallescheria boydii after near drowning.

Pseudallescheria boydii is a rare cause of mycotic infection. Factors predisposing to systemic infection include traumas, immunosuppression, and near drowning. We report a case of multiple aneurysms caused by this hyalohyphomycete, occurred after near drowning. The car driven by a 53-year-old woman plunged into a canal in The Netherlands. After a 20-min-long submersion, the woman was rescued. At hospital, a severe aspiration of muddy water and a mycotic pneumonia were diagnosed. Despite the immediate prescription of a long-term antimycotic therapy and the initial good response, the patient died 4 months later. The autopsy showed a mycotic aneurysm of the abdominal aorta and multiple ruptured mycotic aneurysms of the circle of Willis with fatal subarachnoid bleeding.

Right heart ischemia in cases of sepsis.

Data from the literature suggest that cases of sepsis complicated by right ventricular (RV) dysfunction have poorer prognosis. In these cases progressive hypoperfusion associated to increasing, injury-related, pulmonary vascular resistance account for RV ischemia. In the present analysis, we wanted to evaluate whether prevalent RV cardiac ischemic damage could be detected in a series of fatal sepsis cases. We retrospectively investigated 20 cases of sepsis that underwent forensic autopsy (study group-11♀, 9♂, mean age 57 years) and compared them to a group of 20 cases of hanging (hanging group-4 ♀, 16 ♂, mean age 44 years) as well as to a group of 20 cases of myocardial infarction (MI group-9 ♀, 11 ♂, mean age 65 years), as examples of cardiac damage due to global hypoxia during agony and ischemic damage, respectively. We performed immunohistochemistry with the antibodies anti-fibronectin and C5b-9. The reactions were semiquantitively classified and the groups were compared. In 30% of the cases of sepsis prevalent RV ischemic damage could be detected with the antibody anti-fibronectin. This expression was significantly different from that observed in cases of MI (p=0.028) and hanging (p<0.001). Our study showed that, in cases of fatal sepsis, prevalent RV ischemic damage occurred in a substantial minority of cases.

Antidote treatment for cyanide poisoning with hydroxocobalamin causes bright pink discolouration and chemical-analytical interferences.

Here we report the case of a 70-year-old woman who committed suicide by cyanide poisoning. During resuscitation cares, she underwent an antidote treatment by hydroxocobalamin. Postmortem investigations showed marked bright pink discolouration of organs and fluids, and a lethal cyanide blood concentration of 43 mg/L was detected by toxicological investigation. Discolouration of hypostasis and organs has widely been studied in forensic literature. In our case, we interpreted the unusual pink coloration as the result of the presence of hydroxocobalamin. This substance is a known antidote against cyanide poisoning, indicated because of its efficiency and poor adverse effects. However, its main drawback is to interfere with measurements of many routine biochemical parameters. We have tested the potential influence of this molecule in some routine postmortem investigations. The results are discussed.

A glass fragment for a dagger--never mind your own hand.

A case of homicide is reported where a woman was killed by her boyfriend. He used a dagger-like fragment of a broken window glass to cause 10 atypical stab wounds to the neck and face and several incised wounds in other body regions. The cause of death was exsanguination, mainly from a severed internal jugular vein. The morphology of glass fragment injuries, both in the victim and perpetrator, is discussed and the possibility of homicide in such cases, which commonly represent accidents, is stressed. The use of an unsuited sharp force weapon carrying a high potential for self-injury can be explained by an excited state of mind.

Self-inflicted gunshot injury simulating a criminal offence.

An extraordinary case of a young woman with a gunshot wound to her left hand is presented. A typical near-contact entrance wound at the palm of the hand, extensive soft tissue destruction including nerve and vessel injury and a large stellate exit wound at the back of the hand were diagnosed and surgically treated. The woman initially stated that she had tried to repulse the pistol when a man shot her from close-range, which is consistent with the injury findings. After questioned thoroughly, however, she confessed self-infliction using a 8 mm blank pistol. This case demonstrates that a self-inflicted injury simulating a criminal offence can be present even if very atypical features such as the use of a firearm and mutilating or defence-like injuries clearly speak against it.

The morphology of cutaneous burn injuries and the type of heat application.

The morphology of burn injuries in 120 consecutive patients from the Department of Plastic and Reconstructive Surgery, CHR, Hospital B in Lille was correlated to the etiology and type of heat. Analysis identified five typical patterns of cutaneous burn injuries. Jet of flame-pattern from methylated spirits and gasoline detonations: superficial burn injuries; sparing of skin wrinkles and the submental region; absence or small amounts of soot; preference of exposed body regions, esp. the face and hands. Explosion-pattern from explosions and electrothermal injuries: superficial burn injuries; sparing of skin wrinkles but not of the submental region; soot; preference of exposed body regions. Alveolar soot arrangement and metallisation in electrothermal injuries. Considerable third-degree burns in dust explosions. Flame-pattern from direct flame effects due to burning gasoline or oil, open fires or ignited clothing: nonuniform depth including large third-degree burns; no sparing of the submental region; soot; preference of body regions covered by clothing. Immersion-pattern: superficial (bullous) injuries; blurred junction between scalded and unscalded areas; extremities, buttocks, and back are favourite sites; cave child abuse: waterlines and zebra-burns. Spilling-pattern: superficial injuries; sharp junction between scalded and unscalded areas; head, anterior trunk, and upper extremities are favourite sites; running off and splashing stains. Consideration of these patterns can assist the reconstruction in fire investigations or unclear scaldings. In cases of suspected arson, a typical burn injury pattern or a single finding not compatible with the rest of the pattern can disprove a suspect or raise the level of suspicion.

An X-STR meiosis study in Kurds and Germans: allele frequencies and mutation rates.

X-linked short tandem repeats (X-STRs) play an important supplementary role in the field of forensic genetics, especially in deficiency cases. This paper presents population genetic data for the microsatellite markers DXS8378, DXS6800, DXS101, HPRTB, and DXS8377 in a German and a Kurdish population sample. Buccal swabs were obtained from 217 unrelated healthy German individuals (107 women and 110 men) from the area of Münster and 208 unrelated Kurdish individuals (103 women and 105 men), immigrants mainly from Northern Iraq. Additionally, more than 1,200 meiotic transfers (419 paternal and 819 maternal meioses) were investigated in the systems DXS6800, DXS101, and DXS8377. Five mutations were found in the system DXS8377. With the power of discrimination in females [PD(F)] ranging from 0.81 (DXS8378 in Kurds) to 0.99 (DXS8377 in Germans), the investigated X-STRs systems turned out to be highly informative in the two populations.

Bloodstain pattern analysis--casework experience.

The morphology of bloodstain distribution patterns at the crime scene carries vital information for a reconstruction of the events. Contrary to experimental work, case reports where the reconstruction has been verified have rarely been published. This is the reason why a series of four illustrative cases is presented where bloodstain pattern analysis at the crime scene made a reconstruction of the events possible and where this reconstruction was later verified by a confession of the offender. The cases include various types of bloodstains such as contact and smear stains, drop stains, arterial blood spatter and splash stains from both impact and cast-off pattern. Problems frequently encountered in practical casework are addressed, such as unfavourable environmental conditions or combinations of different bloodstain patterns. It is also demonstrated that the analysis of bloodstain morphology can support individualisation of stains by directing the selection of a limited number of stains from a complex pattern for DNA analysis. The complexity of real situations suggests a step-by-step approach starting with a comprehensive view of the overall picture. This is followed by a differentiation and analysis of single bloodstain patterns and a search for informative details. It is ideal when the expert inspecting the crime scene has also performed the autopsy, but he definitely must have detailed knowledge of the injuries of the deceased/injured and of the possible mechanisms of production.

Fatalities related to medical restraint devices-asphyxia is a common finding.

A total of seven detailed death investigations is reported where death occurred while being restrained by a belt or a protective cover. The casualties were elderly persons who mostly showed considerable pre-existing diseases, especially dementia and coronary atherosclerosis. Concerning the cause of death, three groups were differentiated: (I) mechanical asphyxia from strangulation. (II) Mechanical asphyxia from thoracic/abdominal compression. (III) Compression of thorax/abdomen without clear signs of asphyxia. Subgroups II and III each involved one case of rib fractures without preceding resuscitation. In subgroup III, the presence of considerable compression of the trunk and the absence of a natural cause of death strongly indicate a causal connection between compression and death, e.g. from a shortened course of fatal asphyxia, endocrine stress reactions or a head-down-position: cardiac arrest in a helpless situation. The method of restraint was inadequate in most cases in that only one device was used which did not restrict the capability to move sufficiently. A good clinical documentation including medical indication, duration and method of restraint and a description/photograph of the original on-site appearance is essential but was not present in most cases. Therefore, prophylaxis is based on a clear medical indication, the proper use of restraint devices, detailed instructions of the nursing personnel and close monitoring. The forensic investigation should aim at a complete reconstruction based on autopsy, histology, toxicology and inspection of the scene and the medical records.

Clotted blood as sign of alcohol intoxication: a retrospective study.

A total of 138 autopsies performed at the Institute of Legal Medicine of the University of Münster between 1994 and 2006 were subdivided into two groups: (1) 69 asphyxial deaths with a blood alcohol level (BAL) > 1 per thousand and (2) 69 asphyxial deaths with a BAL of 0.00 per thousand. The coagulation state in the central vessels was registered in all cases as fluid, compactly clotted or loosely clotted, and the post-mortem interval was recorded. Histology investigations were performed on the liver to analyze the incidence of hepatic fibrosis/cirrhosis. Fisher's exact test was performed to check for statistical significance. The blood was found to be clotted in 49.3% of the cases of group (1) and in 5.8% of group (2) (p < 0.01). The post-mortem interval did not have any influence on the coagulation state as observed in both groups. Liver fibrosis/cirrhosis was a rare finding detected in three cases in group 1 and in two cases in the control group 2 and, therefore, not relative to our observations. A distinctly positive BAL is often associated with heavy stages of blood coagulation as observed during autopsy. Distinctly positive alcohol concentrations have an influence on the fibrinolytic process and, hence, on the coagulation status.

Sudden death due to subarachnoid bleeding from ecchordosis physaliphora.

Ecchordosis physaliphora (EP) is a rare intracranial mass derived from ectopic notochordal tissue. It is usually a fortuitous finding at autopsy or by computed tomography/magnetic resonance imaging. Very few authors have described an EP-associated symptomatology. In this study, we report a case of the sudden and unexpected death of a 48-year-old woman. At autopsy, the cause of death was subarachnoid bleeding, the origin of which was identified as a gelatinous mass stemming from the dura mater and occupying the prepontine space. Further histological and immunohistochemical investigations allowed the diagnosis of EP.

Two unusual stab injuries to the neck: homicide or self-infliction?

A 31-year-old woman was found dead by her daughter, lying in the living room which showed a large pool of blood, secondary droplets and stains from arterial blood spatter, dropping and contact. This bloody scene and two puncture wounds at the anterior aspect of the neck, one of them transecting the left common carotid artery leading to exsanguination, arose suspicion of homicide. However, the wound morphology including notches and a parallel skin incision as well as microradiography demonstrated that the two puncture wounds had been produced by glass. At the scene, a broken wine glass with two dagger-like tips had been standing on a table in front of a sofa where the woman had been sitting, and she most likely sustained the injury when she suddenly moved her head downwards, thus moving into the protruding tips. This self-inflicted accident demonstrates that inspection of the scene and synthesis of autopsy and scene findings can be crucial for a successful medico-legal reconstruction. The mechanism of producing the accidental injury is very extraordinary, in that the woman actively moved into a shattered wine glass instead of falling into an intact architectural glass surface.