Fatal injury of a skier during school training - case report.

The authors present the case of a fatal accident of a 16-year-old skier who crashed into a tree during a downhill skiing lesson at school. Although the skier was wearing a protective helmet at the time of the accident and his condition did not appear to be too serious immediately after the accident, he later died in hospital as a result of a craniocerebral injury with cerebral contusion and intracranial haemorrhage. His life could not be saved even by immediate neurosurgery, during which fragments of the broken protective helmet were removed from his cranial cavity. By analysing the international literature, the authors identify head and brain injuries as the most common immediate cause of death in downhill skiing and provide insights into the possibilities of preventing these injuries by simple technical means on the part of ski area operators. These means are in particular protective covers for lift columns and protective nets placed in front of fixed, non-movable obstacles on the track.

Modern suicide trend from internet.

INTRODUCTION: The most common suicide methods vary slightly from country to country, partly related to the availability of effective means. Societal development over the years and especially the advent of the Internet has enabled the sudden spread of new suicide methods. Recently, especially since 2019, intentional sodium nitrite poisoning has appeared on many social networks as an increasingly popular method of suicide. MATERIAL AND METHODS: There was performed a retrospective-prospective study of the autopsy protocols of the Medico-Legal Departments of the Healthcare Surveillance Authority in Slovakia, in a period of 15 years (2008-2022). We performed the analysis of cases of death due to nitrite poisoning, focusing on cases of intentional self-harm. In all selected cases, we present complete information, including photo documentation from the place of death, as well as the results of the performed autopsy and the results of additional laboratory examinations. RESULTS: We did not record any fatal cases of unintentional, accidental consumption of sodium nitrite in Slovakia, nor any fatal cases of homicidal poisoning by this substance. However, there were three cases of intentional self-harm (completed suicide) by sodium nitrite poisoning (in 2019, 2020 and 2022). CONCLUSIONS: The correct diagnosis of the cases of sodium nitrite poisoning deaths is possible only based on evaluating all the information obtained, a thorough examination of the body and the crime scene, and the correct interpretation of the findings found during a subsequent autopsy and the results of the toxicological analysis.

A Comparative Study of Intravital CT and Autopsy Findings in Fatal Traumatic Injuries.

Objectives: Traumatic injuries are one of the severe health problems of our time. In the 21st Century, approximately 4.5 million people worldwide die each year due to trauma. Computed tomography (CT) is widely used to diagnose injuries and offers information on the specific location and extent of organ and tissue damage. In cases of severe trauma, whole-body CT is increasingly used as a standard diagnostic technique. An autopsy is the final diagnostic examination and is still considered the gold standard in diagnostic methods in medicine. The aim of the study was to assess the reliability and accuracy of CT scan results, as well as limits in detecting trauma for forensic purposes. It aims to compare traumatic findings in the antemortem CT results to those observed at autopsy. Materials and Methods: We conducted a retrospective-prospective study involving 510 deaths due to trauma. We compared selected traumatic changes in the antemortem CT scan results with the autopsy findings. We obtained data with a detailed analysis of autopsy protocols, photographic documentation from the autopsies, and the interpretation of CT scans from medical documentation. In cases of discrepancies in the findings, we borrowed CT scans, which were repeatedly reviewed by clinical radiologists. Results: By comparing the findings of selected injuries detected by antemortem CT and autopsy, we found a correlation of findings in 75.3% and a discrepancy of findings in 24.7% in a set of 510 cases. After repeated targeted assessment of CT images by clinical radiologists in cases of discrepancies in the findings, which were detected by autopsy and undescribed by CT, the discrepancy decreased to 17%. Conclusions: The results of the study are comparable with data from many studies and professional publications. They show that CT compared to autopsy is a good method for diagnosing gunshot wounds to the head and bone fractures, with a limited diagnosis of cranial base fractures, while an autopsy is better for detecting minor injuries to organs and soft tissues.

Morphological Peculiarities of the Pelvic Autonomic Nervous System and Their Impact on Clinical Interventions in the Lesser Pelvic Region.

Background: The aim of the work is to define the morphological peculiarities of the pelvic autonomic nervous system (ANS) and their importance in the clinical and surgical interventions in the lesser pelvis. Material and methods: Anatomical variations in the formation of the pelvic ANS were observed in 20 cadavers. The study included 17 men (85%), aged 18 to 84, and 3 women, aged 27 to 86. The average age was 53.8 years. The subjects most often died by violent death in car accidents, by asphyxia, or by sudden death. The study was approved by the Ethics Committee of the Health Care Surveillance Authority, Bratislava, Slovakia. We studied cadavers without congenital or detected anomalies, cancer, deformities of the body, or spinal or abdominal surgeries within 24 h of death. We observed a relationship between the dimensions and the number of ganglia, as well as the number and course of nerve branches and anastomoses. In the pelvic area, we observed the hypogastric plexus superior, hypogastric plexus inferior, and the truncus sympathicus. In all cadavers, we clarified the lumbosacral plexuses after evisceration. In the lumbosacral region, the roots were defined based on their participation in the formation of the plexuses. To show the intimate relationship between both systems, we also focused on the details of the structure (rami communicantes) related to the connections of the ANS with the spinal nervous system. Results: Anatomical variations in the formation of the pelvic ANS were observed in all cases. We included cases with more than two truncus sympathicus ganglia as the segmental type. The segmental form occurred in 14 (70%) cases, and was concentrated in 6 (30%) cases. Rami communicantes provided anastomoses to the spinal nerves. Small ganglia were observed on the rami communicantes. With the concentrated type, we observed the division of the sympathetic and parasympathetic systems. With the segmental and concentrated forms, symptoms of the "diffuse form" may occur, which we observed in all cases. We observed significant right-left asymmetry and differences in the formation of ganglia and anastomoses. Conclusions: This study allowed us to identify and describe the morphological peculiarities of the pelvic ANS and their possible influence on the clinical picture. Asymmetry and dependence of their occurrence on the type of ANS was observed. The variations were frequent. Their preoperative diagnosis is difficult to impossible. The absence or lack of intraoperative vigilance can lead to the damage of pelvic ANS during operations and blockades of the pelvic plexus. The acquired knowledge can be helpful in clarifying clinical signs and symptoms of these conditions.

Suicides by ingestion of pure caffeine powder. New challenge for public health?

OBJECTIVES: Intentional or unintentional caffeine abuse due to excessive intake of energy beverages is frequent. Fatalities due to caffeine intoxication are presented rarely. Over the last years, cases of caffeine ingestion for purposes of committing suicide have been reported in scientific literature. DESIGN: The aim of this case study is to report a fatal case of a 26-year-old man who intentionally ingested pure caffeine powder. METHODS: Standard autopsy, microscopic examination and toxicological examination using screening method, TLC, GC, and GC/MS were performed. RESULTS AND CONCLUSIONS: The presence of caffeine only at the concentration of 362 ug/mL in blood and 187 ug/mL in urine was revealed. The cause of death was cardiac arrest most likely due to ventricular dysrhythmia. The concentration of caffeine determined in the femoral blood of the decedent was three times higher than the lethal concentrations reported in other published case studies. Based on the investigated circumstances, the manner of death was evaluated as a suicide.

Extraordinary features of the intraspinal extradural and intradural nerve root courses.

OBJECTIVES: Very few studies have reported occasional intradural and extradural communications between adjacent nerve roots. These studies mostly focus on lumbosacral regions followed by cervical regions, and rarely in the thoracic region. DESIGN: The aim of this work is to point out some extraordinary extradural and intradural features of the intraspinal nerve root courses and their possible participation in radiculopathy. SUBJECTS AND METHODS: The anatomical study was performed in 43 cadavers. All intradural and extradural rami communicantes between nerve roots were examined histologically for the presence or absence of nervous tissue. RESULTS: Findings of the normotype of plexus formation occurred in 30 cases (69.8%). Variations in its formation were observed in 13 cases (30.2%). Anatomical preparations revealed intradural rami communicantes in all cases of the lumbosacral plexus; 28 times (65.1%) in cases of cervical roots and in the thoracic region 4 times (9.3%). Extradural anatomical variations occurred in 26 cases (60.5%). In 9 cases (20.9%) current occurence of intraspinal extradural and intradural communicating branches in the spinal canal were observed. Multiple extradural rami communicantes were observed in 6 cases (13.95%), including the simultaneous occurrence of multiple intradural and extradural ones in 5 cases (11.6%). CONCLUSIONS: This study allowed us to identify and describe current occurence of intraspinal extradural and intradural communicating branches in the spinal canal with their potential influence on the clinical picture. Anatomical preparations revealed a higher incidence of intraspinal intradural variations, particularly between sacral roots. The reliance of their incidence of the type of plexus was observed.

Occurrence of periadrenal brown adipose tissue in adult Slovak population.

OBJECTIVES: The brown adipose tissue is distributed only in specific locations of the mammalian body. Evidence has been presented that the brown fat occurs in human foetuses and new-borns. At later stages of life, most brown fat cells disappear and only persist in the perirenal and periaortic adipose tissue. However, detailed data on the occurrence of brown adipose tissue in adult humans differ among existing studies. DESIGN: The aim of this study was to determine the prevalence of brown adipose tissue in adult Slovak population. SUBJECTS AND METHODS: The samples of periadrenal adipose tissue were taken from 379 consecutive autopsies of subjects aged between 26 and 94 years, fixed in formalin, processed by routine methods and stained with hematoxylin-eosin. The sections were examined by light microscopy. RESULTS AND CONCLUSIONS: Brown adipose tissue cells were found in 240 (63%) cases. The prevalence of brown adipose tissue decreases below the age of 50 and later slightly increases. No significant differences in the prevalence of brown adipose tissue between men and women were found. With the exception of Germany, this study is currently the first extensive morphological autopsy study of brown adipose tissue prevalence in adults in Central and Eastern Europe.

Unusual mechanism of injury in a case of suicide by the jump from height.

Investigation of fatal cases of falls from height as well as jumps from height in suicidal ideation makes up an integral part of forensic practice. In Slovakia, a method of suicide by jumping from height is after hanging the second most chosen method of ending life. In about one third of the cases, the influence of addictive substances is determined. The basic mechanism of injury is a sudden deceleration of body movement when hitting a solid surface. Several factors influence the nature, localization, severity, and frequency of injuries. In most cases, there occur multiple injuries to the skeleton and internal organs caused by blunt objects. The authors demonstrate the case of an unusual mechanism of injury in a 55-year-old man who committed suicide by jumping from the seventh floor of a block of flats. A stepped fall from height resulted in the through knee amputation of both legs by hitting posterior thigh area and knee joints on the railing of the terrace of the block of flats on the ground floor level. The body was found in the basement. In contact with the railing, the mans trousers and pants were pulled off. The autopsy determined the immediate cause of death as polytrauma. Additional toxicological-chemical examination of blood and urine samples collected at autopsy revealed ethanol at the concentration within the extent of laboratory error, caffeine, and nicotine in toxicologically insignificant concentrations and traces of acetone. Motivation of mans suicide remains unknown.

Sudden and unexpected death due to intracranial sellar extramedullary plasmacytoma.

The incidence of sudden death caused by undiagnosed primary intracranial neoplasm in young adults is extremely low. The aim of the work is to present a case report of the sudden death of a 24-year-old woman. The autopsy has revealed enlargement of sella turcica with an intrasellar tumorous mass extending into the adjacent basal parts of the brain. A tumour was diagnosed as an extramedullary plasmacytoma. The cause of death was established as a failure of the central nervous system. Toxicological analyses of biological materials were negative. According to the case history, a woman reportedly had no serious health problems. Finding of an extensive intracranial tumour in the sella turcica was random and surprising. The presented case is an extremely rare case of sudden death caused by intracranial intrasellar extramedullary plasmacytoma without previous clinical manifestation.

Long-term self-inflicted craniocerebral penetrating injury with a fatal outcome.

A case of long-term continual self-inflicted penetrating craniocerebral injury to a 59-year-old man with a fatal outcome is reported. The man suffered from paranoid psychosis and alcohol dependence. Over five months, he continually scalped the skin and subcutaneous tissue of his head with a knife until he perforated the skull and dura mater and injured his brain. He eventually sought medical advice, but died after 10 days of hospitalization despite complex conservative treatment. The immediate cause of death was a combination of central nervous system failure and heart failure. The original case presented is sporadic in the forensic literature due to atypical long-term continual self-harm to the head and brain using a sharp object that resulted in perforation of the skull and a fatal outcome. This case also highlights the importance of autopsy to determine the mechanism of injury and cause of death.

Accidental fatal craniocerebral injury caused by broken chain of sawing tool.

The case of an accidental fatal penetrating craniocerebral injury to a 26-year-old man at work when cutting wood is reported. There was used an angle grinder with an accessory for cutting similar to a chainsaw. The injury was caused by a fragment of the broken chain. The chain fragment broke through the facial part of the head to the left and penetrated the brain in the region of the left parietal bone of the cranial vault. The immediate cause of death was a failure of the central nervous system (brain death). The toxicological analysis of biological materials was negative. The death occurred as a result of a triple violation of safety precautions. The presented case is extremely rare in terms of fatal injuries caused by power tools for sawing having been published in the forensic literature.

[Parallel investigations of blood and alveolar air in the diagnosis of lethal carbon monoxide poisoning]. / Súbezné vysetrovanie krvi a alveolárneho vzduchu v diagnostike letálnych intoxikácií oxidom uholnatým.

Carbon monoxide poisonings are the most frequent among fatal gas and volatile substances intoxications. The authors present diagnostic options of fatal carbon monoxide poisoning by parallel blood investigations for the content of karbonylhaemoglobin and determining of the concentration of carbon monoxide in the alveolar air. The analysis of 160 cases of lethal poisonings with carbon monoxide over a period of 20 years was carried out. The cases were divided into subgroups according to the place of death to poisonings in flats, garages, bathrooms, in fires, road traffic accidents and mining accidents. Tabular cases were divided into poisonings with a dominant share of carbon monoxide; the lethal concentration (0.075 % volume percentage or more) in the alveolar air was found in 75 % of cases. By pairs of victims different concentrations of carbon monoxide in the alveolar air were found. It confirms the fact that the course of intoxication and time of death also depends on the state of health of an individual. In 25 % of cases composite action with other toxic substances and factors (cyanide ions, ethanol, carbon dioxide, smoke inhalation solids, burns etc.) was detected. The obtained results point to an important and irreplaceable role of the toxicological - chemical analysis of the alveolar air in the context of additional laboratory investigations at autopsy in the diagnosis of fatal carbon monoxide poisoning. Investigation of the alveolar air should be the standard methodological procedure in the diagnosis of fatal poisonings by gases and volatile substances.

[Addictive substances in fatal cases of fall/jump from height]. / Návykové látky vo fatálnych prípadoch pádov/skokov z výsky.

The aim of the study is to analyse causes of fatal cases of falls from height focusing on the occurrence of addictive substances. The authors performed a retrospective analysis of cases dealing with falls/jumps autopsied at the Institutes of Forensic Medicine in Bratislava in the years 2005-2014 accounting for a catchment area with approximately 1.2 m population. Selection criteria were met in 360 cases, i.e. approximately 4 % of all cases autopsied. There were 68 % of men and 32 % of women involved. The age interval ranged from 10 up to 93 years (mean age 50 years). Addictive substances were found in a total of 32 % of cases, ethanol alone in 22 % of cases. The cases were divided into groups according to the cause as follows: accidental falls (24%) also involving occupational accidents (11 %), jumps in suicidal ideation (63 %) and cases with the unspecified cause of falling (13 %). Most of the cases with detected addictive substances were in the group of suicidal jumps (35 %). In this group, 32 % of patients were treated for psychiatric disorders. The most common diagnosis was a depressive disorder and schizophrenia. In the group of occupational accidents, ethanol was found in 25 % of cases. The results of the study show that it is essential to pay more attention to psychiatric patients as not even regular psychiatric care and treatment can always prevent suicide. Accordingly, there is a need to strictly monitor the ban on alcohol consumption at work and the observance of safety regulations for working at heights, and thus to minimise the occurrence of falls with fatal outcomes.

[Multiple firearm injury caused with a blank pistol]. / Viacnásobné strelné poranenie spôsobené expanznou strelnou zbranou.

The authors present a case of a complex suicide of a 60-year-old woman found dead on her bed. A blank pistol Umarex caliber 9-mm, several blank cartridges and a lot of drug packages were discovered near the body. The woman suffered from a psychiatric depression. There were three gunshot wounds on the body: in the right temporal region, on the palatum of the mouth and on the left chest wall. The gunshot wounds in the right temporal region and in the mouth had central circle defects with the margins of stellate or star-like appearance and blackening. In the right temporal region the temporal muscle was contused but skull and intracranial tissues were without any injury. On the palatum of the mouth there was neither facial skeleton nor skull injury. The numerous small tears of lips and contusions of buccal mucosa were observed. On the left chest wall there was an abrasion with a bruise on the skin and contusion of thoracic muscles. Neither ribs nor intrathoracic organs were inflicted. At autopsy blood in the amount of 600 ml and a few tablets were found in the stomach as well as an insignificant blood aspiration into lungs. In spite of the fact that all the gunshot wounds were caused by shots fired at contact range they were not lethal. The woman died of lethal intoxication with tramadol and dibenzepin. Although this report differs from the ones published in literature, the authors believe that can contribute to the issue of gunshot wounds caused by gas weapons.

[Post mortem investigation of alveolar air in forensic practice]. / Vysetrovanie alveolárneho vzduchu post mortem v súdnolekárskej praxi.

Exhaled air from biological materials is used for the purpose of toxicologico-chemical analysis particularly in detecting of alcohol influence in traffic or within a working process. Similarly, still a more and more actual requirement seems to be a necessity to analyse alveolar air from necroptic material. This necessity is emphasised not only by the fact, that inhalant intoxications in the form of poisoning represent their substantial part, but also a demand to evidence exactly a noxious agent both specifically and also in at least two materials. And particularly this is sometimes a subject to search for evidence in alveolar air. The authors present their authors certificates for Isolation of alveolar air from autopsy material, issued by the Office for Patents and Inventions in Prague, verified in practice, both by destruction of lung tissue, both the evacuation of alveolar air into a defined volume, hermetically closed space that is used for the toxicological analysis of gaseous and volatile xenobiotics. They propose experimentally verified procedures and conditions obtained by time-consuming examination. To isolation procedures were subjected an adequate number of lung lobes from lungs removed in 201 autopsy cases. The authors practically tested the presupposed amount of alveolar air in individuals according to gender and age. Gradually they have validated various prototypes and optimization methods and their application in solving particular inhaled lethal intoxications and deaths in the irrespirable environment.

The analysis of dyadic deaths.

In the work we analyze three cases of unusual dyadic deaths when the perpetrator of homicide committed suicide shortly after the murder. In the first case a man stabbed his girlfriend with a knife and subsequently committed a car crash suicide. In the second case an apparent simultaneous hanging of a married couple turned out to be homicide-suicide act. In the last case a man shot his ex-wife while she was on a walk with their dog and in a short time turned the gun against himself.

[Confrontation of knowledge on alcohol concentration in blood and in exhaled air]. / Konfrontácia poznatkov o koncentrácii alkoholu v krvi a vo vydychovanom vzduchu.

The authors of the paper give a brief historical overview of the development of experimental alcohology in the former Czechoslovakia. Enhanced attention is paid to tests of work quality control of toxicological laboratories. Information on results of control tests of blood samples using the method of gas chromatography in Slovakia and within a world-wide study "Eurotox 1990" is presented. There are pointed out the pitfalls related to objective evaluation of the analysis results interpreting alcohol concentration in biological materials and the associated need to eliminate a negative influence of the human factor. The authors recommend performing analyses of alcohol in biological materials only at accredited workplaces and in the case of samples storage to secure a mandatory inhibition of phosphorylation process. There are analysed the reasons of numerical differences of analyses while taking evidence of alcohol in blood and in exhaled air. The authors confirm analysis accuracy using the method of gas chromatography along with breath analysers of exhaled air. They highlight the need for making the analysis results more objective also through confrontation with the results of clinical examination and with examined circumstances. The authors suggest a method of elimination of the human factor, the most frequently responsible for inaccuracy, to a tolerable level (safety factor) and the need of sample analysis by two methods independent of each other or the need of analysis of two biological materials.