Are autopsies on minors a taboo?: The experience of Milan in a 19-year retrospective study.

Forensic autopsy is an important tool for the proper management of non-natural deaths in minors. However, it seems that autopsy in minors is a practice which may not be performed routinely. In this framework, we conducted a study analyzing autopsies of minors (under 18 years of age in Italy) performed at the Institute of Forensic Medicine in Milan in the period 2001-2019. For the period 2015-2019, we extrapolated all deaths due to non-natural causes in minors to investigate how many and which of these deaths were not subjected to forensic autopsy. Of the total, 344 minors (235 males and 109 females) underwent autopsies, with an overall downward trend of about 80% since 2004. Most autopsies occurred between the ages of 0 and 1 year, and the fewest between the ages of 5 and 9 years. The place of death was home in most cases, and accidental death was most common, followed by natural death, suicide, and homicide, with prevalence varying by age group. Blunt force trauma predominated among accidental death in all age groups, followed by asphyxia. Similar findings were observed for suicides, although there was a more differentiated pattern for suicides between the ages of 15 and 17 years. Among homicides, blunt force trauma, asphyxia, and gunshot wounds were fairly evenly distributed across all age groups. Between 2015 and 2019, a total of 86 minors died of a non-natural cause, and a forensic autopsy was performed in only 33 cases (38%). Our data shows that fewer and fewer autopsies are being performed over the last years, which indicates a dangerous lack of forensic investigation of children and adolescent deaths, with enormous implications for prevention of child abuse.

Investigating cardiac genetic background in sudden infant death syndrome (SIDS).

Sudden infant death syndrome (SIDS) is still the leading cause of death for newborns in developed countries. The pathophysiological mechanisms have not been fully clarified, but in some of SIDS cases variants of genes associated with inherited cardiac conditions are found. In this study, an analysis of SCD-related genes was performed to determine the prevalence of rare pathogenic (P) or likely pathogenic (LP) variants that could provide an unambiguous explanation for the fatal event. A cohort of 76 SIDS cases underwent Next-Generation Sequencing (NGS) analysis with a custom panel of SCD-related genes. Rare variants were classified according to the guidelines provided by the American College of Medical Genetics and Genomics (ACMG) and the specifications of the ClinGen association. Post-mortem genetic testing identified 50 (65.8%) carriers of at least one variant in SCD genes. 104 rare genetic variants were found, 65.4% in genes encoding structural proteins. Only 4 out of 76 cases (5.3%) hosted at least a P or LP variant found in genes with structural or structural/arrhythmogenic functions (SLC22A5, SCN5A, MYL3and TTN). 99 variants were classified as of uncertain significance (VUS). The difference in the distribution of variants between gene groups by function was not statistically significant (chi square, p = 0,219). Despite this, most of the variants concerned structural genes that were supposed to have a close interaction with ion channels, thus providing an explanation for the arrhythmic event. Segregation analysis, reclassification of VUS variants and identification of new associated genes could clarify the implications of the current findings.

Forensic application of three interstitial pneumonia markers: search for new pneumonia markers in dead bodies.

In forensic cases, detailed identification of pneumonia is important. Our objective was to statistically determine the applicability of three interstitial lung disease (ILD) markers for forensic diagnosis using serum collected from dead bodies with various postmortem intervals (PMIs). We retrospectively analyzed the levels of postmortem serum Krebs von den Lungen-6 (KL-6) and pulmonary surfactant-associated proteins A and D (SP-A and SP-D) using 221 samples obtained during forensic autopsy at our facility from 2019 to 2023. We evaluated the diagnostic efficacy of ILD markers for various pneumonias against the pathological diagnosis, and examined the assessment of the severity of ILD. When comparing the ILD group with bacterial pneumonia (BP) versus the control group, there was a significant increase in KL-6 in the ILD group. When comparing the severe ILD (SILD) group with the mild ILD (MILD) group, there was a significant increase in KL-6 and SP-D in the SILD group. The optimal cutoff values for differentiating SILD were 607.0 U/mL for KL-6, 55.5 ng/mL for SP-A, and 160.0 ng/mL for SP-D, and the sensitivity/specificity (%) of KL-6, SP-A, and SP-D for SILD were 84.1/95.2, 55.6/85.7, and 66.7/74.6, respectively. This is the first study to examine KL-6 in postmortem serum in forensic medicine. By analyzing dead bodies with various PMIs, our results confirmed statistically that postmortem serum KL-6 specifically detects ILD, postmortem serum SP-A has high sensitivity to lung injury, and postmortem serum SP-D is potentially useful in assessing the severity of ILD.

Prediction model for anabolic androgenic steroid positivity in forensic autopsy cases - a new tool to the autopsy room.

Non-prescription use of anabolic androgenic steroids (AAS) is associated with an increased risk of premature death. However, these substances are seldom screened in connection with forensic cause-of-death investigation, unless the forensic pathologist specifically suspects use, often based on a positive AAS use history. Since AAS use is often concealed from others, this practice may lead to mistargeting of these analyses and significant underestimation of the true number of AAS positive cases undergoing forensic autopsy. Thus, more accurate diagnostic tools are needed to identify these cases. The main objective of this study was to determine, whether a multivariable model could predict AAS urine assay positivity in forensic autopsies. We analyzed retrospectively the autopsy reports of all cases that had been screened for AAS during forensic cause-of-death investigation between 2016-2019 at the Finnish Institute for Health and Welfare forensic units (n = 46). Binary logistic regression with penalized maximum likelihood estimation was used to generate a nine-variable model combining circumferential and macroscopic autopsy-derived variables. The multivariable model predicted AAS assay positivity significantly better than a "conventional" model with anamnestic information about AAS use only (area under the receiver operating characteristic curve [AUC] = 0.968 vs. 0.802, p = 0.005). Temporal validation was conducted in an independent sample of AAS screened cases between 2020-2022 (n = 31), where the superiority of the multivariable model was replicated (AUC = 0.856 vs. 0.644, p = 0.004). Based on the model, a calculator predicting AAS assay positivity is released as a decision-aiding tool for forensic pathologists working in the autopsy room.

A case of hemoperitoneum after percutaneous radiofrequency ablation in a patient with hepatocellular carcinoma.

We report a case of hemoperitoneum after percutaneous radiofrequency ablation in a patient with hepatocellular carcinoma. A 60-year-old female was hospitalized for the treatment of thrombasthenia and cirrhosis caused by chronic Hepatitis C, and computed tomography revealed hepatocellular carcinoma, which was treated by percutaneous radiofrequency ablation. After the ablation, hemoperitoneum was suspected because of the low hemoglobin level with abdominal pain. Approximately 6 h after the ablation treatment, the patient suddenly fell into a shock state and died. In this case, medical treatment-related death including malpractice was suspected, and forensic autopsy was performed. The abdominal cavity contained 910 mL of dark red fluid blood and 210 g of soft hemocoagula. Moreover, several puncture marks were observed on the liver surface and diaphragm, and there was no clear damage to the main arteries and veins. Considering the macroscopic and microscopic findings, the cause of death was assumed as hemorrhagic shock due to the hemoperitoneum caused by the damage to the liver by radiofrequency ablation. It is important to consider all the indications and adverse effects of radiofrequency ablation.

Molecular autopsy for sudden death in Japan.

Japan has various death investigation systems; however, external examinations, postmortem computed tomography, macroscopic examinations, and microscopic examinations are performed regardless of the system used. These examinations can reveal morphological abnormalities, whereas the cause of death in cases with non-morphological abnormalities can be detected through additional examinations. Molecular autopsy and postmortem genetic analyses are important additional examinations. They are capable of detecting inherited arrhythmias or inherited metabolic diseases, which are representative non-morphological disorders that cause sudden death, especially in infants and young people. In this review, we introduce molecular autopsy reports from Japan and describe our experience with representative cases. The relationships between drug-related deaths and genetic variants are also reviewed. Based on the presented information, molecular autopsy is expected to be used as routine examinations in death investigations because they can provide information to save new lives.

Genomic analysis of SARS-CoV-2 in forensic autopsy cases of COVID-19.

Numerous genomic analyses of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been conducted, highlighting its variations and lineage transitions. Despite the importance of forensic autopsy in investigating deaths due to coronavirus disease 2019 (COVID-19), including out-of-hospital deaths, viral genomic analysis has rarely been reported due in part to postmortem changes. In this study, various specimens were collected from 18 forensic autopsy cases with SARS-CoV-2 infection. Reverse-transcription quantitative polymerase chain reaction revealed the distribution of the virus in the body, primarily in the respiratory organs. Next-generation sequencing determined the complete genome sequences in 15 of the 18 cases, although some cases showed severe postmortem changes or degradation of tissue RNA. Intrahost genomic diversity of the virus was identified in one case of death due to COVID-19. The accumulation of single-nucleotide variations in the lung of the case suggested the intrahost evolution of SARS-CoV-2. Lung of the case showed diffuse alveolar damage histologically and positivity for SARS-CoV-2 by immunohistochemical analysis and in situ hybridization, indicating virus-associated pneumonia. This study provides insights into the feasibility of genomic analysis of SARS-CoV-2 in forensic autopsy cases and the potential for uncovering important information in COVID-19 deaths, including out-of-hospital deaths.

Heart weight must not be measured before dissection during autopsies.

During autopsies, weighing the heart is a standard procedure. In addition to myocardial pathologies, heart size, and ventricular wall thickness, heart weight is a common parameter to describe cardiac pathology and should be recorded as accurately as possible. To date, there exists no standard for recording heart weight at autopsy, although some authors recommend weighing the heart after dissection and removal of blood and blood clots. In the study presented, the hearts of 58 decedents were weighed after being dissected out of the pericardial sac (a), after dissection using the short-axis or inflow-outflow method with manual removal of blood and blood clots (b), and after rinsing and drying (c). Depending on the dissection method, the heart weight was 7.8% lower for the inflow-outflow method and 11.6% lower for the short-axis method after dissection compared to before and correspondingly 2.9% to 5% lower again after rinsing and drying respectively. Accordingly, the heart should be dissected, blood and blood clots removed, rinsed with water, and dried with a surgical towel after dissection, before weighing.

Pulmonary capillaritis as a cause of lethal diffuse alveolar hemorrhage.

Lethal pulmonary hemoptysis is a common finding in forensic medicine. Since hemoptysis does not necessarily occur before death and its previous symptoms are usually unspecific, indicative signs or findings at the site of a corpse may be completely absent. If lethal acute alveolar hemorrhage is found in the post-mortem examination, a differential diagnosis should be made for traumatic, substance-related, infectious, or organic causes. Cocaine-associated pulmonary hemorrhage and drug reactions are in the foreground. For organic causes, autoimmune diseases should be considered in addition to cardiac, haematological, and infectious causes. The following two cases show similarities both in the sudden, unexpected deaths and the anamnesis of the two deceased women. One of the deceased received a Corona vaccination a few months earlier. In each case, the post-mortem examination revealed an acute diffuse pulmonary hemorrhage caused by acute inflammation of the lung capillaries. This case presentation demonstrates the necessity of a complete autopsy including toxicological and histological analyses. The documentation and publication of rare causes of death are essential for medical research and practice in order to critically consider and discuss the possibility of to date unknown associations in similar cases.

Evaluation of a Set of miRNAs in 26 Cases of Fatal Traumatic Brain Injuries.

In forensic medicine, identifying novel biomarkers for use as diagnostic tools to ascertain causes of death is challenging because of sample degradation. To that aim, a cohort (n = 26) of fatal traumatic brain injuries (TBIs) were tested for three candidate miRNAs (namely, miR-124-3p, miR-138-5p, and miR144-3p). For each case, three FFPE specimens (coup area (CA), contrecoup area (CCA), and the corpus callosum (CC)) were investigated, whereas the FFPE brain tissues of 45 subjects (deceased due to acute cardiovascular events) were used as controls. Relative quantification via the ∆∆Ct method returned significantly higher expression levels of the three candidate miRNAs (p < 0.01) in the TBI cases. No difference was detected in the expression levels of any miRNA investigated in the study among the CA, CCA, and CC. Furthermore, the analyzed miRNAs were unrelated to the TBI samples' post-mortem intervals (PMIs). On the contrary, has-miR-124-3p ahashsa-miR-144-3p were significantly correlated (p < 0.01) with the agonal time in TBI deaths. Since the RNA was highly degraded in autoptic FFPE tissues, it was impossible to analyze the mRNA targets of the miRNAs investigated in the present study, highlighting the necessity of standardizing pre-analytical processes even for autopsy tissues.

How much does a forensic autopsy cost in Spain?

INTRODUCTION AND OBJECTIVES: The autopsy is considered the gold standard in death investigation. Performing an autopsy requires human and material resources that must be programmed in order to meet the demands of the judicial system. However, as far as we know, the cost of forensic autopsy in Spain has not been determined. Thus, the aim of this study was to estimate the cost of a standard autopsy in order to organise Forensic Pathology Services more efficiently. MATERIAL AND METHODS: A micro-cost analysis was carried out. The nominal group technique was applied using a panel of 10 forensic experts in order to identify and quantify the resources associated with a forensic autopsy. RESULTS: The results showed that analysis and studies are the most important item in the total cost (54.7%), followed by staff (20.5%), preservation of body (14%), single-use products (7%), equipment and stock (1.6%), cleaning and disinfection (1.5%), facilities maintenance (0.5%) and IT (0.2%). CONCLUSIONS: The total cost of a standard autopsy was €1501.45, which is lower than the European average. This study is the first in Spain to calculate the unit price of a forensic autopsy by means of micro-cost analysis. This may help to address the way forensic pathology centres are organised at different levels of complexity.

Vehicle-assisted ligature decapitation - an unusual case report.

Suicide by vehicle-assisted strangulation resulting in decapitation is a rare occurrence, characterized by a high kinetic energy mechanism that produces a clean-cut appearance in the decapitation area. Often resembling an incisive wound, this particular finding can mislead local authorities into investigating the case as a homicide. This case report describes an adult male who accelerated his vehicle after tying a nylon rope around his neck and securing it to a metallic structure on the wall. Furthermore, we conducted a brief review of cases published within the last ten years, summarizing the most prevalent findings associated with these incidents. By analyzing previously reported cases alongside our own, we aim to consolidate the prevailing patterns observed in vehicle-assisted strangulation cases. This underscores the paramount importance of thorough scene analysis by the medico-legal team and emphasizes the significance of subsequent necropsy findings in accurately discerning the manner of death.

Suicide by sharp force associated with major self-mutilation and self-cannibalism.

Self-stabbing and self-cutting represents an uncommon method of suicide. We present a case of a 30-year-old man who was found dead in the forest. The body was naked and showed multiple cut and stab wounds on different parts of the body (face, neck, chest, abdomen, and extremities). A single-edged kitchen knife was found approximately 20 m from the body. Parts of both ears, the fifth toe of the right foot, and the scrotum were cut off. At the autopsy, two of the severed body parts-the toe and the part of the left ear-were found in the stomach. The cause of death was asphyxiation due to blood aspiration resulting from a cut throat injury. A police investigation uncovered a history of substance abuse and two previous suicidal attempts using a knife. Upon complex analysis of all the evidence, the manner of death was ruled a suicide, which was preceded by actions of major self-mutilation and self-cannibalism, both considered rare behavioral patterns.

Acute subdural hematoma caused by rupture of a mycotic aneurysm due to meningitis associated with infectious endocarditis: comparison of autopsy findings with postmortem computed tomography.

Forensic pathologists often encounter cases of acute subdural hematoma (SDH) due to trauma, whereas those attributable to endogenous causes are rare. Here, we report a case of the latter type in a 42-year-old man who was found dead at home after several months of fever and malaise. Postmortem computed tomography (PMCT) and autopsy were undertaken to clarify the cause of death. PMCT images revealed a fatal SDH and a localized hyper-density area in the right parietal lobe; macroscopic and microscopic examinations revealed SDH due to rupture of a mycotic aneurysm (MA) associated with meningitis. The PMCT images also indicated thickening and calcification of the mitral valve, while autopsy demonstrated infective endocarditis (IE). In addition, PMCT demonstrated a low-density area in the spleen, which was shown to be a splenic abscess at autopsy. PMCT also demonstrated tooth cavities. Based on the findings of autopsy, the cause of death was considered to be SDH due to rupture of the MA resulting from meningitis with IE and splenic abscess. Although PMCT was unable to clarify the significance of any individual feature, a retrospective review of the PMCT images might have suggested IE, bacteremia, or ruptured MA leading to SDH. This case suggests that, instead of interpreting individual features demonstrated on PMCT images, integrated interpretation of overall PMCT findings might provide clues for identifying causes of death, despite the fact that PMCT lacks diagnostic accuracy for infectious diseases such as IE and meningitis.

Evaluation of forensic autopsy cases with substance use detected in Izmir, Turkey.

Using postmortem toxicological analyses, we aimed to determine the origin and cause of death and type of substance used in substance use-related deaths. A total of 7475 autopsies were performed between January 2015 and December 2017 in Izmir, Turkey. In our retrospective analysis, substance use was detected in 449 (6.0%) autopsies. The majority (96.4%) were male. The most frequent deaths (18.5%) occurred in the 25-29 age group. Of the 55.2% of the cases that died of unnatural causes, accident-related events (22.9%) were most frequent. Trauma/injury caused death in 37.0% of cases and substance intoxication in 24.7%. Cannabis use was detected in 34.3% of the samples, and multiple substance use in 25.4%. Accordingly, It is thought that a multidisciplinary approach can be successful in preventing substance use and related problems.

SARS-CoV-2 viral load and replication in postmortem examinations.

We examined 29 autopsy cases (investigated between October 2020 and February 2021) whose postmortem swabs tested positive for SARS-CoV-2. Twenty-two of 29 cases died while hospitalized (H), while the remaining 7 cases were not hospitalized (NH). Since we included only cases in which the time since death was known (excluding unwitnessed NH deaths), the interval between death and postmortem swab(s) was registered, with a mean NH value of 5.50 days and a mean H value of 3.98 days. The mean age of NH was 65 years, while H were older (mean age: 73 years). Twenty-eight nasopharyngeal and 27 lungs postmortem swabs were obtained and real-time reverse transcriptase‒polymerase chain reaction assay for total and replicative SARS-CoV-2 RNA and mRNA detection was performed. Although the mean death-postmortem swabs interval was higher in NH than in H, the mean viral load of NH was higher than that of H (2.53 × 1011 copies/mL vs 9.31 × 108 copies/mL). In 13/29 cases (6 NH and 7 H), indicators of active replication were found. The relationship between the presence of replicative mRNA and death without hospitalization and that between the minimum cycle threshold value of SARS-CoV-2 RNA and the cycle threshold value of replicative SARS-CoV-2 mRNA were found to be statistically significant (with respective P values of 0.013 and 0.000). Therefore, especially in NH, full compliance with guidelines on biological safety in the autopsy room is essential, and no autopsy can be performed on infected cases in a structure that does not meet the established safety criteria.

Asphyxia homicides in Denmark 1992-2016.

In this retrospective study , we present the findings in 250 homicides by asphyxia in Denmark in a 25-year period, with a particular focus on the autopsy findings in strangulation. Our intention is for the results to be used in future death investigations, where difficulties in interpretation of findings in potential asphyxial deaths arise. Asphyxia homicides showed a strong bias with respect to sex, age, and homicide type. The frequent female victim was typically an adult, whereas the rarer male victim was most often a child. Female offenders most often killed their children, and male offenders most often killed their female partner. Generally, most asphyxia homicides took place in a domestic setting. Manual strangulation and ligature strangulation were the most common mechanisms of asphyxia homicides (81.6%). A lack of petechial hemorrhages, especially in the conjunctiva, was rare in homicidal strangulation, but there were exceptions, especially when there was postmortem decomposition, making it impossible to verify them. Most victims of strangulation had skin lesions in the face (including the jawline) or on the neck, with accompanying hemorrhages in muscle and connective tissue, but the findings could be subtle or compounded by decomposition. Fractures of the laryngo-hyoid complex were common in strangulation, particularly in manual strangulation (chi-sq = 4.0993, df = 1, P < 0.05) and were clearly related to the age of the victim (chi-sq = 82.193, df = 4, P < 0.001). In children and young adults dying from homicidal strangulation, a lack of fractures is to be expected, while a lack of fractures is unusual, but not entirely unexpected, for adults and aged people.

Forensic autopsies in Norway 1996-2017: A retrospective study of factors associated with deaths undergoing forensic autopsy.

AIMS: Forensic autopsies are important for the investigation of deaths with a legal or public-health interest, as well as being a source for cause-of-death statistics. The aim of this study was to investigate the use of forensic autopsies in Norway, with a special emphasis on geographical variation. METHODS: Data from the Norwegian Cause of Death Registry for the years 1996-2017 included 920,232 deaths and 37,398 forensic autopsies. We used logistic regression to identify factors that were associated with the proportion of forensic autopsies, grouped according to the registered cause of death. Explanatory variables were age and sex, place of death, police district, population size and urbanity level of the municipality and distance to the autopsy facility. RESULTS: The proportion of deaths undergoing forensic autopsy was 4.1%, with the highest being homicides (96.6%) and the lowest being deaths from natural causes (1.7%). Variation between police districts was 0.9-7.8%, and the span persisted during the study period. The most important explanatory variables across the strata were place of death (there were few autopsies of deaths in health-care facilities), police district and age of the deceased. Distance to the autopsy facility, sex, population size and the level of urbanity had only a minor influence. The variation between police districts was not fully accounted for by the other investigated factors. CONCLUSIONS: Unjustified differences in the frequency of autopsies may lead to insufficient investigation of possible unnatural deaths. In worst-case scenarios, homicides or other criminal cases might remain undetected. It may also introduce spurious shifts in the cause-of-death statistics.

Eosinophilic Infiltration of the Sino-Atrial Node in Sudden Cardiac Death Caused by Long QT Syndrome.

Sudden death is defined as the unexpected death of a healthy person that occurs within the first hour of the onset of symptoms or within 24 h of the victim being last seen alive. In some of these cases, rare deleterious variants of genes associated with inherited cardiac disorders can provide a highly probable explanation for the fatal event. We report the case of a 21-year-old obese woman who lost consciousness suddenly in a public place and was pronounced dead after hospital admission. Clinical autopsy showed an inconclusive gross examination, while in the histopathological analysis an eosinophilic inflammatory focus and interstitial fibrosis in the sino-atrial node were found. Molecular autopsy revealed an intronic variant in the KCNQ1 gene (c.683 + 5G > A), classified as likely pathogenic for long QT syndrome according to the guidelines provided by the American College of Medical Genetics and Genomics. Therefore, there were many anomalies that could have played a role in the causation of the sudden death, such as the extreme obesity, the cardiac anomalies and the KNCQ1 variant. This case depicts the difficult interpretation of rare cardiac structural abnormalities in subjects carrying rare variants responsible for inherited arrhythmic disorders and the challenge for the forensic pathologist to make causal inferences in the determinism of the unexpected decease.

[Forensic autopsies and pathological examination: Current practice in Montpellier's jurisdiction. A retrospective study of 630 autopsies]. / Autopsies judiciaires et expertises anatomopathologiques complémentaires : état des pratiques sur le ressort de la cour d'appel de Montpellier. Étude rétrospective de 630 autopsies.

INTRODUCTION: In France, pathological examination is not systematically required in forensic autopsies. The factors affecting the decision to carry out a pathological expertise have not yet been defined. The aim of this study was to describe in which conditions a pathological expertise was required after forensic autopsy by the high court of Montpellier. METHODS: This study included and analyzed retrospectively all of the autopsy elements, of all forensic autopsies carried out over a year. These elements were classified: pre-autopsy, per-autopsy, and post-autopsy. RESULTS: A pathological expertise was required in 19.2% of 630 cases, among which 31% in a context of undetermined cause of death and in 14% of cases of determined causes of death. The forensic practitioner recommended a pathological expertise in 10 to 31% of autopsies. Overall, 64 pathological examinations were realized out of 121 recommended examinations (52.9%), this rate varied from 25 to 73% depending on the court. The magistrate tended to favor anatomopathological expertise in cases of determined causes of death, and in certain manner of death (80% homicide versus 35% natural). The pathologist's expertise enabled to change the cause of death in 22% of cases and the manner of death in 19%. The pathological approach was a major asset in the 65% of unknown manner of deaths and in the 20% of natural, whereas the expertise did not help in cases of homicides, suicides and accidents. The cause of death was modified in 5.6% of initially determined causes of death, against 42.9% in case of initially unknown cause. CONCLUSION: The use of pathologic examination in forensic autopsies is scarce and uneven. The factors resulting to its request are not directly linked to its scientific assets. A conjoint work between forensic and pathologist practitioners would be beneficial.