Difficulties associated with the interpretation of post-mortem toxicology.

While post-mortem (PM) toxicology results provide valuable information towards ascertaining both the cause and manner of death in coronial cases, there are also significant difficulties associated with the interpretation of PM drug levels. Such difficulties are influenced by several pharmacokinetic and pharmacodynamic factors including PM redistribution, diffusion, site-to-site variability in drug levels, different drug properties and metabolism, bacterial activity, genetic polymorphisms, tolerance, resuscitation efforts, underlying conditions and the toxicity profile of cases (i.e. single- or mixed-drug toxicity). A large body of research has been dedicated to better understanding and even quantifying the influence of these factors on PM drug levels. For example, several investigative matrices have been developed as potential indicators of PM redistribution, but they have limited practical value. Reference tables of clinically relevant therapeutic, toxic and potentially fatal drug concentrations have also been compiled, but these unfortunately do not provide reliable reference values for PM toxicology. More recent research has focussed on developing databases of peripheral PM drug levels for a variety of case-types to increase transferability to real-life cases and improve interpretations. Changes to drug levels after death are inevitable and unavoidable. As such, guidelines and practices will continue to evolve as we further our understanding of such phenomena.

Does citing early SIDS research skew contemporary conclusions?

Research on infants who have allegedly succumbed to sudden infant death syndrome (SIDS) has been of variable quality over the years. Even now peer-reviewed papers are being published on cases termed 'SIDS' without autopsies having been performed, despite this being a requirement of the three major definitions for over five decades. Clearly cases used in earlier research studies could not have complied with the requirements of as-yet unpublished definitions/guidelines. For this reason care must be taken in citing initial papers as their results may have been skewed by the presence of non-SIDS cases. This may have particular relevance for meta analyses. Reviewing the literature on substance P and its relationship to SIDS provides an excellent example of how diametrically opposed conclusions were reached at different time points. Early studies on SIDS, and studies that use cases that were classified before the standard NICHD and San Diego definitions, should, therefore, be approached with a degree of scepticism and not cited in contemporary papers or at meetings as they have the potential to confuse rather than clarify.

Domestic violence and chronic traumatic encephalopathy (CTE) - a forensic perspective.

Chronic Traumatic Encephalopathy, or CTE, is an entity characterized by neurological deficits that are thought to arise from repetitive episodes of blunt head trauma. It has gained considerable attention recently in those who have engaged in contact sports. However, given that it is caused by mechanical cerebral strain from nonspecific blunt impact, it seems reasonable to assume that it could arise from a multitude of causes, such as craniocentric domestic violence. While the literature is somewhat contradictory, the possibilities are that CTE may be caused by either the incremental additive effects of less severe trauma, or from more forceful impacts, or from a combination of both of these mechanisms. Another issue to consider is the degree of acceleration/rotation trauma associated with particular events. Careful study of the chronology, nature and dose-relationships of previous head impacts in victims of inflicted lethal head trauma will, therefore, be required. This will help to clarify its significance in cases of domestic violence and also specifically whether it can be additive from more minor impacts, or whether there is a threshold of force required before it occurs.

Cardiac tamponade - a rare cause of sudden death in autoimmune polyglandular syndrome.

A 27-year-old male died suddenly due to cardiac tamponade arising from pericarditis complicating autoimmune polyglandular syndrome (APS) type 2. He had a history of primary Addison disease and autoimmune hypothyroidism which were corroborated at autopsy. In addition a florid fibrinous pericarditis was associated with 287 g of turbid fluid in the pericardial sac. Although pericarditis with tamponade is a potential complication of APS, it has rarely if ever, been reported as a cause of sudden death. Lethal mechanisms may involve both compressive and restrictive effects.

The role of alcohol in infant cosleeping deaths.

The well-established epidemiological and neuropathological differences between infants who die alone compared to those in shared sleeping environments indicate that these cohorts have differences. Risk factors in both situations depend on both exogenous and endogenous factors. Although parental consumption of alcohol continues to be cited as a risk factor for sudden infant death syndrome (SIDS) it is difficult to understand how a substance which impairs parental consciousness rather than infant arousal could contribute to SIDS. Surely a more logical mechanism to explain these deaths would be suffocation by a sedated adult rather than evoking predisposing factors for SIDS.

Identifying and documenting osseous trauma from shark attacks by post mortem CT examination and autopsy.

A 15-year-old male was attacked by a large white shark while surfing. CT examination revealed an above-knee amputation of the right lower extremity with stripping of soft tissues from the groin distally. 3-dimensional volume rendering did not show any fragments of shark teeth but did reveal linear gouges, areas of shaving of cortical bone and an inverted 'V'-shaped defect at the distal margin of the femoral shaft. At autopsy these injuries were confirmed in addition to areas with fine parallel cross-striations matching the marginal serrations of the teeth of a white shark. Thus, while post mortem CT with 3-dimensional reconstruction at high resolution can show the nature and number of the bony injuries following shark attack, it is complimented by pathological examination which may find fine parallel grooves from teeth serrations. Post mortem 3-dimensional volume rendering may also help to find or exclude fragments of teeth, and silicone casting may provide a permanent record of bone lesions.

Recent trends in an uncommon method of carbon monoxide suicide.

PURPOSE: The most prevalent method of carbon monoxide (CO) suicide is inhalation of vehicle exhaust (VE). However, a new method of CO suicide has recently emerged involving charcoal burning (CB) in a confined space to produce fatal CO levels. This method has been reported from countries in Asia, associated with economic instability and media reporting of high-profile celebrity cases. The current study was undertaken to analyze rates and characteristics of CB suicides in South Australia (SA) for comparison with respect to their characteristics and scene, autopsy and toxicology findings. METHODS: A search was undertaken for all intentional fatal carbon monoxide poisonings in SA between 2000 and 2019. Collected variables included age, sex, cause of death, location of death, decedent histories, scene, autopsy and toxicology findings and manner of death. Statistical analyses were performed using R (version 4.2.3). RESULTS: There was a significant decrease in VE suicides (p < 0.05) and a significant increase in CB suicides (p < 0.001) over the 20-year period. Those who used CB were found to be, on average, between 1.5 and 15.8 years younger than those who used VE (p = 0.017). The risk factors for CB suicide included psychological/psychiatric conditions and financial problems, while VE suicides were associated with a history of physical problems and contact with the legal system. External and internal autopsy findings were consistent with the literature. CONCLUSION: CB suicide is perceived to be widely accessible and painless and is therefore becoming a popular suicide method. Monitoring future trends will be important to determine whether intervention is required.

Acanthosis nigricans - a potentially useful clue to the presence of significant occult disease at autopsy.

A 19-year-old male was found dead in his apartment. At autopsy he was morbidly obese (Body mass index; BMI - 40.5) with multiple areas of velvety pigmented thickening of the skin in folds around the neck, in the axillae, in the inframammary regions, over the anterior waistline and groin regions and over the dorsal aspects of the feet. These had the typical appearance of acanthosis nigricans. Internal examination revealed aspiration of gastric contents into the airways. Vitreous humour biochemistry showed markedly elevated levels of both glucose (62.9 mmol/L) and ß-hydroxybutyrate (13.54 mmol/L). Death was, therefore, due to aspiration pneumonia complicating diabetic ketoacidosis on a background of morbid obesity. The initial indicator of underlying diabetes, in conjunction with obesity had been acanthosis nigricans.

Cardiac amyloid deposition and the forensic autopsy - A review and analysis.

Although amyloid material in the heart is not infrequently encountered at autopsy it may on occasion be difficult to determine the significance in terms of possible contributions to the terminal mechanisms of death. A review was undertaken of the literature and of autopsy cases at Forensic Science SA over a 20-year-period (2003-2022) for all cases where significant amyloid material had been encountered on microscopy of the heart. Sixteen cases were found consisting of 11 cases where cardiac amyloid was involved in the lethal episode, and five where it was considered an incidental feature. Of the 11 lethal cases, there were three where cardiac amyloidosis was the cause of death, and eight where it was a contributing factor, along with ischaemic heart disease (N = 7) and bronchopneumonia (N = 1). The age range was 47-92 years, average 78.6 years, with a male to female ratio of 10:1. The weights of the hearts ranged from 496 to 1059 g - average 648 g. Of the five cases where it was considered an incidental finding, the causes of death were blunt head trauma (N = 2), small intestinal ischaemia (N = 2) and small intestinal obstruction (N = 1). The weights of the hearts ranged from 299 to 487 g, average 369 g. The most relevant types of amyloidosis in forensic cases tend to be light chain amyloidosis, senile cardiac amyloidosis and familial amyloid cardiomyopathy. Other forms of amyloidosis that affect the heart, which include reactive amyloidosis, haemodialysis-related amyloidosis and isolated atrial amyloidosis, either have minimal or no clinical significance, or are of uncertain significance. While it may be difficult to determine the prognostic significance of amyloid material at autopsy clinicopathological correlation may provide useful supportive information.

Concealed Homicides-A Postmortem Study and Review.

ABSTRACT: A study was undertaken at Forensic Science SA, Adelaide, South Australia, of all cases of homicide (January 2003-December 2022) where the victims' bodies had been concealed. Three hundred twenty-six homicides were identified, which included 27 cases where bodies had been deliberately hidden (8%) (age range, 2-82 years; ave, 34.9 years; M:F = 1.5:1). Deaths were due to blunt force trauma (n = 11), sharp force trauma (n = 4), asphyxia (n = 4), gunshot wound (n = 2), and a combination of drowning and asphyxia (n = 1). In 5 cases, the cause of death was not determinable. The methods of concealment (which were sometimes overlapping) included the following: dumping at a hidden/isolated location (n = 8), burial (n = 7), dismembering (n = 3), incinerating (n = 3), hiding in a wheeled garbage bin (n = 2), disposing in garbage resulting in the remains being located at waste disposal facilities (n = 2), hiding in a shed (n = 1), under a concrete floor (n = 1), in a suitcase (n = 1), in a river (n = 1), in a mine shaft (n = 1), and in a septic tank (n = 1). Although it has been asserted that concealed homicides are rarely encountered in forensic practice, the current study has demonstrated that the bodies in at least 8% of victims of homicide in South Australia have undergone some form of concealment.

Cable ties in forensic practice.

Cable or zip ties are mass produced inexpensive nylon fasteners, which have a locking mechanism to prevent them from being loosened. Their use in medicolegal cases is infrequent, being involved in situations of neck compression or restraint. The Forensic Science SA Pathology Database (in Adelaide, Australia) and search engines PubMed, Google Scholar and Google were examined for cases where cable ties were documented as either causing death or being potentially lethal, being a contributor to death, or having been used for restraint purposes. Neck compression resulting in ligature strangulation was found in cases of homicide and suicide in adults. Accidental neck compression was rarely reported in children. Cases of restraint again occurred in both homicides and suicides, with nonlethal wrist restraint being used by law enforcement officers in lieu of traditional handcuffs. Cable ties may also be used to fasten ligatures to suspension points in case of hanging. Despite their ready availability, cable ties are only relatively rarely involved in medicolegal cases. More traditional forms of manual or ligature neck compression are still favoured possibly because they require less dexterity.

The death of Rasputin-A forensic evaluation.

Grigori Yefimovich Rasputin, a confidant of Tsar Nicholas and his wife, was murdered by Prince Yussupov and his co-conspirators in the cellar of the prince's Moika Palace in St Petersburg, Russia, on the evening of December 30th, 1916 (December 17th in the Russian calendar). The narrative of his death is largely based on Prince Yussupov's published memoirs and has Rasputin being poisoned with cyanide, shot, bludgeoned, and finally drowned. A review of the available forensic material, however, shows a photograph with a contact gunshot wound to Rasputin's forehead. This would indicate that he was dead prior to being dropped into the Little Nevka River. His distaste for sweet foods and the absence of poison at autopsy would also suggest that the story of cyanide toxicity was fabricated. Yussupov's description of Purishkevich firing at Rasputin from a distance as he ran across the courtyard in an attempt to escape would also not be consistent with the post mortem photograph. The simplest version of the events would be that Rasputin was executed by a contact gunshot wound to the forehead when he visited the Yussupov Palace. While it appears that the events of that fateful evening have been embellished, it is certainly not uncommon for perpetrators of homicides to provide histories that are later shown to be at odds with the truth. Re-evaluation of historic cases may provide compelling evidence for alternative interpretations to the popular historic record.

Death and injuries caused by cattle: A forensic overview.

Lethal episodes arising from interactions with cattle may be the result of a response of the animals to simple handling and herding, or from reactions to deliberate provocation or goading intended to incite aggressive behavior for public entertainment purposes. Deaths may be considered to be unprovoked and unanticipated, or provoked and predictable. Cattle cause significant numbers of deaths globally and are considered the most dangerous large animal in Britain. Behavior may be unpredictable even in apparently docile domesticated animals, and attacks may be by a single animal or a herd and result in injuries from kicking, head/butting/charging, stomping, goring, and crushing. Craniofacial injuries may involve fractures of the spine or skull with cerebral contusions and lacerations associated with subarachnoid, subdural, and extradural hemorrhages. Chest injuries are also characterized by fractures which may be multiple with flail chest, hemo- and pneumothoraces, and organ disruption. Injuries to the abdomen and perineum include intestinal perforations, splenic rupture, perineal and vaginal tears, urethral lacerations and avulsions, and bladder and rectal perforations. Significant vascular injuries include complete and partial transections and lacerations. Males living in rural areas are most at risk of a fatal encounter.

Hidden Coronary Artery Ostium and Sudden Death.

A 1-week-old girl died suddenly and unexpectedly. At autopsy the major finding was of a right dominant coronary artery circulation with an inapparent left coronary artery ostium. After careful examination, an anomalous origin of the left coronary artery was found with the ostium located in the non-coronary cusp immediately adjacent to the commissure of the non- and left coronary cusps. The ostium was of small caliber with an obliquely oriented artery (<45°) with no ostial ridges. The artery coursed anteriorly past the left coronary cusp between the aorta and the left atrial appendage to then follow its usual course inferiorly along the anterior aspect of the left ventricle. The reminder of the autopsy was unremarkable. Death was, therefore, attributed to an anomalous and hypoplastic left coronary artery (and ostium) with an acute angle of take-off. Tracing coronary arteries in the very young may be technically difficult due to their small size, thus identifying the location of ostia is important. This may be difficult when the ostium was located close to a commissure.

Characteristics of acid attacks involving children in India.

Aim: To examine the characteristics of acid attack survivors who were aged ≤16 years at the time of the assault. Methods: Case files from the Chhanv and the Laxmi Foundations in India were accessioned for cases of acid attacks involving children and adolescents (≤16 years). Details of the age, sex, reason for the attack, injuries sustained and possible outcomes were recorded. Results: Ten cases were identified that involved eight girls (aged 3-16 years) and two boys (12 and 14 years). The head and neck were the primary targets in all cases. The primary reasons for the attacks involving adolescent girls were punishment for refusing sexual advances from older males and family violence/child abuse. The two male victims were assaulted as part of property dispute and gang violence. Penalties varied greatly with prison sentences (when handed down) ranging from <1 year to 10 years. Conclusion: The number of cases of paediatric acid attacks appear small, with motivations for the attacks including responses to spurned sexual advances, domestic violence/child abuse, criminal gang activities and ostensibly at random. Nongovernment organisations are vital in the rehabilitation of victims. It is of concern that dissemination on social networks and publicity through the media may lead to an increase in number of cases.

Increased incidence of mixed drug toxicity deaths involving tapentadol - A forensic study.

Tapentadol is a relatively new synthetic opioid analgesic prescribed for the management of moderate to severe pain. While tapentadol has been shown to be more effective than traditional opioid analgesics, it still carries the risk of addiction, abuse, and misuse. In Australia, tapentadol has become one of the top five most commonly prescribed opioid drugs, with prescriptions increasing by approximately 150,000 each year since it first became available. The rapid increase in tapentadol prescriptions has occurred in parallel to an increasing number of post-mortem tapentadol detections in South Australia (SA). While the number of deaths in SA related to tapentadol use was low in the current study, findings suggest that an increasing trend of deaths involving tapentadol will continue in parallel to a rapidly increasing number of prescriptions, mirroring trends associated with traditional opioids in SA. As a comparatively new opioid analgesic, monitoring future trends will be important to determine if additional prescribing education, intervention, or restrictions are required.

Understanding the immune profile of sudden infant death syndrome - proteomic perspectives.

AIM: The aim of this study was to investigate a panel of immune proteins in cases of sudden infant death syndrome (SIDS). It was hypothesised that, in at least a subset of SIDS, a dysregulated immune response may be a contributing factor leading to death. METHODS: The subjects included 46 SIDS cases and 41 controls autopsied at the Department of Forensic Sciences, Norway. The causes of death in the controls were accidents/trauma. Samples of cerebrospinal fluid (CSF) were analysed quantitatively by Proximity Extension Assay (PEA). RESULTS: Initial results revealed that normalised protein expression differed in 35 proteins. For the purposes of this report five proteins that are involved in immune system were selected for analysis: IFNLR1 (p = 0.003), IL10 (p = 0.007), IRAK4 (p < 0.001) and IL6 (p = 0.035); all had lower protein concentrations in SIDS cases compared to controls except for CD28 (p = 0.024) which had higher protein concentrations in SIDS cases. CONCLUSION: The results confirm previous studies indicating that a dysregulation of the immune system may be a predisposing factor for SIDS. The results may indicate that these aberrant protein concentrations could lead to an inadequate response to immune triggers and uncontrolled defence mechanisms towards the common cold or other non-fatal infections.