Filamin C (FLNC) truncating mutation in a fatal arrhythmogenic left ventricular cardiomyopathy (ALVC).

Forensic pathologists are frequently asked to investigate cases of sudden death (SD), and identifying the cause of death can be of particular importance, especially where it may be necessary to perform family screening among the relatives of the victim. A multidisciplinary approach inclusive of genetic analysis is therefore strongly recommended. According to forensic practice, arrhythmogenic cardiomyopathy (ACM) is a well-known cause of SD. However, cases of SD caused by a left ventricular pattern of ACM diagnosed at autopsy are rarely reported in the literature. We present the case of an apparently healthy, 37-year-old male found dead at his home. At autopsy, multiple foci of epicardial and mid-wall fibrous and fibro-adipose tissue were observed within the left ventricle and, to a lesser extent, within the interventricular septum. Toxicology was negative, whereas a filamin C truncating mutation was detected through genetic analysis. To our knowledge, this is the first instance of arrhythmogenic left ventricular cardiomyopathy being diagnosed at autopsy.

Medicolegal Implications of Deaths due to Agricultural Accidents.

ABSTRACT: Agriculture encompasses a variety of activities that carry with them a variety of different risks. The unsafe use of vehicles, machinery, and tools as well as animal husbandry, working at heights, and exposure to chemical, biological, and weather events may result in the deaths of agricultural workers. Inexperienced operators and/or their inappropriate conduct may lead to avoidable fatalities. Forensic pathologists operating with the support of agricultural engineers or other professionals must evaluate the death scene, the case background and circumstances, the autopsy findings, and the toxicological data to establish the factors and dynamics responsible for such accidents and deaths.The aim of this review is to focus on the diagnostic approach required, by means of an interdisciplinary approach, to identify the cause of some typical agricultural fatalities, to confirm that death was accidental, and to help exclude the possibility of homicide or suicide.

Manner of death determination in a case of gastric mucosal tears.

Gastric tears are rarely described in the forensic pathological literature, although they can lead to a fatal acute exsanguination. Such lesions can arise from several conditions leading to an increased intragastric pressure, such as Mallory Weiss syndrome, cardiopulmonary resuscitation, acute barotrauma and operative procedures, showing peculiar morphological features. We present a case of a 32-year-old drug addicted white woman found dead in a pool of blood in the house of her drug dealer, after taking a dose of intravenous heroin. At autopsy, abundant bloody gastric content and multiple and long gastric tears, extending from the cardias and fundus regions to the gastric corpus were observed; one of them involved the subserous region, resulting in a gastric wall rupture. The victim had no history of recent vomiting and of gastro-intestinal pathologies. Drugs and ethanol levels detected in the specimens of the victim were not consistent with lethal concentrations, thus the death was attributed to acute exsanguination. After reviewing the literature, it turned out that morphological aspects of the gastric tears, such as number, size and topographical distribution, observed at autopsy were atypical compared to those of typical gastric lacerations.

A charred body inside a burning car with a garden hose connected to the exhaust pipe: Post-mortem self-immolation, a complex or a complicated suicide after the ingestion of alcohol? The importance of an interdisciplinary approach.

The analysis of charred bodies represents a serious challenge for forensic pathologists, and an interdisciplinary approach is often the only way to determine the cause and manner of death. We present an unusual case in which the charred body of a 61-year-old man was found inside his burning vehicle. In order to determine cause and manner of death, an interdisciplinary team was employed, with experts in forensic pathology, forensic radiology, toxicology and fire investigations. Post-mortem computed tomography, autopsy and toxicology ruled out the presence of trauma injury and detected signs of vital exposure to fire and blood alcohol levels. On the other hand, according to fire investigations, the fire started inside the car and partially burned fragments of a garden hose were found along the right side of the car. A suicide could therefore be hypothesized, with the man having attempted to poison himself with the car's exhaust fumes and having set the car on fire. The death was consistent with a complicated suicide in which the victim, in a state of reduced capability, accidentally set his car on fire and was unable to escape. The hypothesis of a complex suicide, with the car having been set deliberately on fire, could not, however, be ruled out.

Autopsy findings in fire deaths in relation to manner of death: Analysis of autopsy records in Friuli, Italy (1993-2020).

The determination of the cause and manner of death can be particularly difficult in burned and charred bodies and autopsy remains a key element in the investigation. In this study, 39 autopsy records of fire deaths were reviewed in relation to the manner of death (25 accidents, 8 suicides, 3 homicides and 3 instances in which the manner of death remained undetermined). The analysis focused on the study of the burns, the degree to which the bodies were consumed by fire and the evidence of signs of vital exposure to fire and of non-fire-related injuries. Total surface body area (TBSA) was found to be significantly higher (p = 0.02) in suicides than in accidents. Moreover, the degree of destruction according to the Crow-Glassman Scale and the presence of a pugilistic posture tended to be higher in suicides compared to accidental deaths, whereas such parameters were found to be variable in homicides. With regard to the anatomical distribution of burns, in contrast with the literature, the feet were affected by burning in all suicides, with a significantly higher prevalence than in accidents (p < 0.01). Traumatic non-fire related injuries were noted in all homicides (with no signs of vital exposure to fire), 1 complicated suicide, 1 undetermined death and 13 accidents. We found that very few studies have focused on the analysis of burn distribution and extension according to manner of death and that there is currently no standardised anatomical model with which to study these variables for forensic purposes.

Binucleated Myocytes and Heart Weight: A Preliminary Study Linking Cardiac Hypertrophy and Myocyte Hypertrophy.

ABSTRACT: Hypertrophy of the heart is assessed by heart weight (and dimensions) and myocyte hypertrophy. Establishing an association between the two may be useful in assessing hypertrophy in cases where there are limitations in assessing the heart weight. This preliminary study explored the association between the number of binucleated myocytes (a feature of myocyte hypertrophy) in a randomly chosen single high-power field of the left ventricular free wall and heart weight in an adult White population. It also compared the number of binucleated myocytes between cases with increased heart weight (>400 g in female and >500 g in male) and cases with normal heart weight. Heart weight and number of binucleated myocytes correlated significantly in male only. Increased heart weight had a significantly higher number of binucleated myocytes, with 8.5 binucleated myocytes being able to segregate cases with increased heart weight (74% sensitivity and 79% specificity). The results of this study showed the number of binucleated myocytes may have a complementary role in assessing hypertrophy of the heart.

Gross Heart Dimensions From Postmortem Computed Tomography and Postmortem Examination Measurements: Heart Weight and Cardiac Hypertrophy.

ABSTRACT: An increased heart weight (cardiac hypertrophy) is associated with underlying heart disease and sudden cardiac death. Gross heart dimensions can be used to estimate heart weight as a surrogate for cardiac hypertrophy. These dimensions can be obtained from either postmortem computed tomography or postmortem examination. This study compared the gross heart dimensions, heart weight estimations, and ability to determine cardiac hypertrophy (>400 and >500 g) between these 2 methods. The results showed that gross dimensions from postmortem computed tomography were significantly smaller and overall had less accuracy in estimating heart weight than dissection. In terms of cardiac hypertrophy, both methods were comparable and had reasonably high sensitivity and specificity, albeit having slightly varied characteristics, to determine whether the heart showed hypertrophy.

Medicolegal Implications of Fatalities Because of Entanglement in the Augers of Feed Mixer Wagons.

ABSTRACT: Feed mixer or total mixed ration mixer wagons are powerful agricultural machines used to shred and mix silage with other ingredients and deliver it direct to the feeding troughs on livestock farms. Fatalities involving these feed mixers may occur when operators become trapped in the augers or, less frequently, are crushed by moving wagons. Death can occur very rapidly because of dismemberment, multiple lesions, or crushing. The aim of this review is to focus on the diagnostic evaluations that need to be performed to confirm that the death was accidental and to exclude a hypothesis of murder or suicide. Forensic investigations in such cases must involve the detailed analysis of the death scene and the mechanical characteristics of the machinery with an accurate postmortem and toxicological examination.

Screening for Fatal Traumatic Brain Injuries in Cerebrospinal Fluid Using Blood-Validated CK and CK-MB Immunoassays.

A single, specific, sensitive biochemical biomarker that can reliably diagnose a traumatic brain injury (TBI) has not yet been found, but combining different biomarkers would be the most promising approach in clinical and postmortem settings. In addition, identifying new biomarkers and developing laboratory tests can be time-consuming and economically challenging. As such, it would be efficient to use established clinical diagnostic assays for postmortem biochemistry. In this study, postmortem cerebrospinal fluid samples from 45 lethal TBI cases and 47 controls were analyzed using commercially available blood-validated assays for creatine kinase (CK) activity and its heart-type isoenzyme (CK-MB). TBI cases with a survival time of up to two hours showed an increase in both CK and CK-MB with moderate (CK-MB: AUC = 0.788, p < 0.001) to high (CK: AUC = 0.811, p < 0.001) diagnostic accuracy. This reflected the excessive increase of the brain-type CK isoenzyme (CK-BB) following a TBI. The results provide evidence that CK immunoassays can be used as an adjunct quantitative test aid in diagnosing acute TBI-related fatalities.

Submerged corpses of an elderly couple retrieved from a canal with alcohol detected in their blood: A rare case of murder-suicide by drowning?

The body of an elderly man and his disabled wife were found submerged in a canal in open country one afternoon. They had last been seen alive that morning. The man's car was parked close to the canal and the woman's wheelchair was located in a stable position a few meters from the canal bank, facing away from the water. There were abrasions and bruises on the woman's forearms and hands and lower left leg, and the man's body displayed a bruise on the left hand and an abrasion of the left thumb likely caused by a fingernail. Other observations included frothy fluid exuding from the nose and in the airways, overdistended lungs with rib impressions and clear watery fluid in the stomach of both victims. Ethanol was detected in the peripheral blood of both corpses (1.0 g/L in the woman, 0.25 g/L in the man). The man was known to be stressed and depressed: he cared for his ailing spouse, who was affected by severe cognitive impairment and he had on several occasions expressed a desire to put an end to their misery. The hypotheses of a suicide pact or a double accident were in contrast with the woman's mental state and with the position of the wheelchair, respectively. The manner of death was consistent with a spousal murder-suicide involving a double drowning. Papers reporting similar cases are infrequent in the literature.

Classifying Microscopic Acute and Old Myocardial Infarction Using Convolutional Neural Networks.

ABSTRACT: Convolutional neural network (CNN) has advanced in recent years and translated from research into medical practice, most notably in clinical radiology and histopathology. Research on CNNs in forensic/postmortem pathology is almost exclusive to postmortem computed tomography despite the wealth of research into CNNs in surgical/anatomical histopathology. This study was carried out to investigate whether CNNs are able to identify and age myocardial infarction (a common example of forensic/postmortem histopathology) from histology slides. As a proof of concept, this study compared 4 CNNs commonly used in surgical/anatomical histopathology to identify normal myocardium from myocardial infarction. A total of 150 images of the myocardium (50 images each for normal myocardium, acute myocardial infarction, and old myocardial infarction) were used to train and test each CNN. One of the CNNs used (InceptionResNet v2) was able to show a greater than 95% accuracy in classifying normal myocardium from acute and old myocardial infarction. The result of this study is promising and demonstrates that CNN technology has potential applications as a screening and computer-assisted diagnostics tool in forensic/postmortem histopathology.

Medicolegal Implications of Biphasic Anaphylaxis.

ABSTRACT: Biphasic anaphylaxis is an uncommon IgE-mediated condition whose pathophysiological mechanisms, risk factors, and predictive signs are not properly understood. Fortunately, the lethality of biphasic anaphylaxis, although probably underestimated, is low. Preventive clinical measures for biphasic anaphylaxis are neither standardized nor commonly applied. Furthermore, there are no laboratory protocols or anaphylactic markers to help identify the onset of biphasic anaphylaxis in clinical settings. The aim of this review is to highlight the medicolegal difficulties facing coroners and forensic pathologists in terms of the diagnosis and assessment of harm for victims and survivors of biphasic anaphylaxis.

Differences Between Central and Peripheral Postmortem Tryptase Levels.

ABSTRACT: Postmortem tryptase is a commonly used biochemical test to aid in the diagnosis of fatal anaphylaxis, which is currently recommended to be sampled from peripheral (femoral) veins because of a research showing comparatively elevated levels from central blood sources. Previous studies have used nonstandardized or nondocumented sampling methods; however, more recent research demonstrates that tryptase levels may vary depending on the sampling method. This study used the recommended sampling method of aspirating the femoral vein after clamping and compared in a pairwise comparison with aspiration of central venous and arterial blood sources (inferior vena cava and aorta) in 2 groups of 25 nonanaphylactic deaths. We found no statistically significant differences in postmortem tryptase between central and femoral vein blood; however, sporadic outliers in central blood (particularly aortic blood reaching levels above documented cutoffs for fatal anaphylaxis) were observed. Our findings provide evidence for the existing recommendations that femoral vein blood remains the preferred sample for postmortem tryptase over central blood.

Post mortem tryptase: A review of literature on its use, sampling and interpretation in the investigation of fatal anaphylaxis.

Post mortem tryptase is a commonly-used ancillary test in the investigation of possible anaphylactic deaths. Ante mortem tryptase interpretation differs from post mortem interpretation due to differing priorities, biochemical behaviours and capacity for follow-up. Additionally, post mortem tryptase sampling site, method and even cut-off levels are not standardised between facilities. This review of the literature investigates the existing research and recommendations on the use of post mortem tryptase in suspected anaphylactic deaths. Currently, autopsy recommendations suggest early sampling, standardised sampling technique with clamping of and aspiration from the femoral vein, and for the results to be interpreted within the wider autopsy and clinical context. Areas in need of further research include the effects of cytolysis on tryptase levels and studies to stratify differing tryptase levels based on type of death and anaphylactic trigger.

Determinants of surgeon choice in cases of suspected implant rupture following mastectomy or aesthetic breast surgery: Clinical implications.

Implant ruptures may be diagnosed by physical examination, ultrasound (US), and magnetic resonance imaging (MRI). The absence of standard guidelines to approach to implant ruptures may cause unnecessary surgical revisions in the absence of radiological confirmation of prosthetic damages.The purpose of this study was to analyze the diagnostic procedures applied to patients with suspected prosthetic rupture and surgeon choices to perform a revision or to plan a clinical and radiological follow-up.We conducted a retrospective study on 62 women submitted to revision surgery due to radiological diagnosis of suspected implant rupture, following mastectomy or aesthetic reconstruction, and admitted to a Plastic Surgery Department between 2008 and 2018.Seventy-three implants, believed to be ruptured, were explanted. One-third of these were intact and unnecessarily explanted. US associated with MRI evaluation resulted in the most helpful diagnostical method.A standardized clinical and radiological approach is essential to manage breast implant ruptures successfully. An innovative protocol is proposed in order to: ensure the appropriate management of implant ruptures and prevent unnecessary surgical revisions; reduce the risk of claims for medical malpractice in cases of unsatisfactory final aesthetic results or worse than before.

A burned body with a gunshot wound in the mouth and a suicide note: A complex or complicated suicide?

The body of a 53-year-old man was found in a burning car. The ignition key was in start position and the accelerator pedal was held down by his right foot. Autopsy revealed a gunshot entrance wound in the hard palate, a bullet track through the anterior cranial fossa and a projectile lodged in the left frontal lobe. The brain stem was free of lesions and any signs of secondary brain injury, such as brain oedema and intracranial haemorrhage, were not significant. Soot deposits and thermal injury to the mucosa were observed in the airways below the glottis and carboxyhaemoglobin (COHb) saturation was 40%. A single bullet case and a handgun were recovered next to the driver's seat. Fire investigators identified the motor as the beginning of the burning: therefore, the conclusion was that the car had caught fire due to overheating of the engine. Differential diagnosis between complex and complicated suicide was essential. The cause of death was identified as carbon monoxide intoxication, and the injuries to the brain were not felt to be immediately fatal. The case has been classified as a complicated suicide. There are no other published cases of a complicated suicide involving exposure to fire or the use of firearms.

The role of self-immolation in complex suicides: A neglected topic in current literature.

Suicides involving more than one suicide method are termed "complex suicides" and need to be differentiated from murders. Self-immolation is the action of setting fire to oneself and is an infrequent method of suicide method in Western countries. However, burned corpses must be carefully examined because setting fire to a body after death can be a way of covering up a crime. Complex suicides involving self-immolation are rare, but careful analysis is necessary if we are to identify the manner of death. A systematic search of the literature concerning self-incineration in cases of complex suicides was carried out. This covered the age, gender and psychiatric condition of the victims, any history of previous suicide attempts, the existence of suicide notes, evidence of fire accelerants, signs of vital exposure to the fire, toxicology, the other suicide methods used in combination with burning and the characteristics of the burns. 46 cases were found in 22 papers published since 1985, but few of these studies provide any detailed analysis and in several cases many important data were missing. There is, therefore, a need to study this topic and to use an approach based on careful examination of the corpse, detailed investigation of the scene, toxicological examination and an evaluation of the victim's physical and psychiatric state.

Postmortem Tryptase Level in 120 Consecutive Nonanaphylactic Deaths: Establishing a Reference Range as <23 µg/L.

Postmortem tryptase is a useful biochemical test to aid the diagnosis of anaphylaxis. Multiple perimortem and postmortem factors have been documented to cause an elevation in postmortem tryptase level. One factor that was recently recognized to have an impact on postmortem tryptase level is correct sampling technique. A recent study recommended aspirating blood samples from a clamped femoral/external iliac vein to be used for reliable postmortem tryptase analysis. This study sampled 120 consecutive nonanaphylactic deaths in which all the peripheral bloods were sampled as recommended. Postmortem interval, resuscitation, different nonanaphylactic causes of death, sex, and age did not show any statistical significant relation to postmortem tryptase level in Student t test, Pearson correlation, and univariate and multivariate analyses. The mean (SD) postmortem tryptase level was 8.4 (5.2) µg/L (minimum, 1.0 µg/L; maximum, 36.1 µg/L; median, 7.3 µg/L). Using nonparametric methods, the postmortem tryptase reference range in nonanaphylactic death was established as <23 µg/L (97.5th percentile).

Medicolegal Investigations in Cases of Double Suicidal Gunshots to the Head Using 2 Different Handguns: A Report of an Unusual Case.

Suicides committed by firing 2 gunshots to the head are rare events and pose a significant challenge for coroners and forensic pathologists. The evaluation of the victim's ability to fire 2 shots simultaneously, or to act after a first gunshot, is crucial for the reconstruction of the death scene and to differentiate between homicide and suicide. We report an unusual case of suicide involving 2 gunshot wounds to the head. The medicolegal investigations hypothesized that the victim had either fired 2 shots near simultaneously or he suffered from rapid incapacitation after the first gunshot but was still able to fire a second consecutive and fatal shot to the head. This article focuses on the diagnostic difficulties involved, together with analysis of the death scene and autopsy findings, in cases where the courts demand confirmation that a double gunshot to the head is in fact a case of suicide.