Death following cylindrical battery ingestion associated with toxic manganese levels.

Cases of battery ingestion are well documented in the scientific literature, especially concerning button cell battery ingestion in children. In this instance, the authors present an atypical case of a young man who voluntarily ingested a cylindrical alkaline battery containing manganese. The patient died approximately a week later, despite not exhibiting any specific symptoms. The battery was found in the cecum during the autopsy, showing deterioration at its positive pole. The cecal mucosa exhibited two ulcerations without perforation. Histological analysis revealed intestinal ischemia in the cecum, with no microscopic lesions in other organs. Toxicology reports indicated high levels of manganese in both cardiac and peripheral blood. Considering all the results from the additional analyses, the experts concluded that the death was likely of multifactorial origin, associated with a toxic blood concentration of manganese. To the best of our knowledge, this is the first recorded death following the ingestion of a cylindrical battery, and the first instance of manganese intoxication resulting from the ingestion of an alkaline battery. The authors will present the case and provide a literature review to assess the extent to which the presence of manganese may have contributed to the fatality.

Selective postmortem arterial angiography of head and neck using digital x-ray or computed tomography: A practical and rapid method to identify vascular injuries.

Identification of vascular injuries is crucial for complete postmortem evaluation and understanding of trauma deaths by the Medical Examiner. Some vascular injuries are difficult to evaluate due to challenging anatomic locations, especially in the head and neck. Documenting injuries of the facial and vertebral arteries is challenging and necessitates time-consuming dissections that can create artifacts and disfigurement. In busy medical examiner offices with a significant number of traumatic injuries, finding a creative solution to employ reliable postmortem angiography is desirable. At the Office of the Chief Medical Examiner for the State of Maryland (OCME), we created and effectively implemented a selective angiography procedure using traditional indwelling Foley catheters and water-soluble barium swallow contrast to evaluate arterial injuries using either digital radiography or computed tomography imaging modalities. This technique and imaging interpretation can be performed by a medical examiner or forensic pathology fellow after basic technical training and basic radiology training. This study outlines the technique, methods, and utilization of the procedure and describes the findings of six deaths due to vascular lesions from different injury mechanisms and disease processes and describes the ease of implementation on a broader scale in busy Medical Examiner's offices.

Orofacial assessment as digital path for forensic and legal evidence record.

In forensic scenarios, such as armed conflicts or mass disasters, the oral cavity can be a valuable source of identification information relevant to legal issues. In many European Union countries, it is mandatory to register dental records for identification purposes. A pilot and quasi-experimental study was performed. The study aims to analyze two methodologies, photography and wireless intraoral (IO) laser scanner, in the scope of the orofacial record in forensic pathology, highlighting their impact on human identification. The IO scanner i700 (Medit, Lusobionic, Portugal) and Canon 5D-Full Frame equipment were used to record the individual status, living patients (n = 5), and forensic cases (n = 5). IO and extraoral anatomical structures were recorded following six parameters: time, mineralized and soft detail, communication, extra devices, and distortion. The statistical analysis was performed in accordance with a scoring system and Mann-Whitney (P < 0.05) analysis. The photography method recorded extraoral data for all samples (score range between 15 and 23). The time elapsed to complete an IO scan in forensic cases was shorter than with photography, without requiring additional sources of light or mirror devices. Living patients and corpses identified statistically significant differences. It can be concluded that laser scanners are a valuable tool in the field of forensic pathology and can be used to record and analyze anatomic-morphological data for identification purposes accurately. Key points: Human identification engages in orofacial details records.Photographic and laser scans record intraoral and extraoral anatomic structures.Forensic cases assessed by intraoral scanner technology are accurate and less time-consuming, optimizing the orofacial data for identification.

Review of the lethal mechanism of insulin poisoning and the characteristic of forensic identification.

Insulin, as the only hypoglycemic hormone in the body, plays a key role in blood sugar control. However, excessive insulin intake can lead to insulin poisoning and even death, which often occurs in clinical and forensic work. At present, some researches on insulin poisoning have been carried out at home and abroad, however, it seems that the mechanism and forensic characteristics of insulin poisoning are not clear and complete. Therefore, in this paper, we reviewed the potential mechanism of insulin poisoning, the methods of insulin detection and the forensic identification of poisoning cases, aiming at providing services for the forensic identification of insulin poisoning.

Cardiac rhabdomyoma: an uncommon culprit in sudden infant death.

Sudden death in infants remains a common and poorly understood cause of childhood mortality in the USA. Pediatric cardiac tumors, although rare, may underlie some cases of unexplained sudden infant death. Autopsy is a crucial diagnostic step in these cases, as both gross and microscopic examination of the heart may uncover occult cardiac tumors. Rhabdomyomas are the most common cardiac tumors in childhood and may result in arrythmia and sudden death. We present a case of sudden death in a healthy 5-month-old infant which initially appeared "SIDS-like" until thorough histological analysis revealed an underlying cardiac rhabdomyoma. The case is of particular importance in that the gross examination of the heart was considered completely normal, and the tumor only involved certain portions of the heart microscopically. Had a single random section of myocardium been the only heart section examined microscopically, the diagnosis might have been missed. This case emphasizes the importance of thorough microscopic examination in infant cases, especially in cases where the heart appears grossly normal.

Heart proteomic profiling discovers MYH6 and COX5B as biomarkers for sudden unexplained death.

Sudden unexplained death (SUD) is not uncommon in forensic pathology. Yet, diagnosis of SUD remains challenging due to lack of specific biomarkers. This study aimed to screen differentially expressed proteins (DEPs) and validate their usefulness as diagnostic biomarkers for SUD cases. We designed a three-phase investigation, where in the discovery phase, formalin-fixed paraffin-embedded (FFPE) heart specimens were screened through label-free proteomic analysis of cases dying from SUD, mechanical injury and carbon monoxide (CO) intoxication. A total of 26 proteins were identified to be DEPs for the SUD cases after rigorous criterion. Bioinformatics and Adaboost-recursive feature elimination (RFE) analysis further revealed that three of the 26 proteins (MYH6, COX5B and TNNT2) were potential discriminative biomarkers. In the training phase, MYH6 and COX5B were verified to be true DEPs in cardiac tissues from 29 independent SUD cases as compared with a serial of control cases (n = 42). Receiver operating characteristic (ROC) analysis illustrated that combination of MYH6 and COX5B achieved optimal diagnostic sensitivity (89.7 %) and specificity (84.4 %), with area under the curve (AUC) being 0.91. A diagnostic software based on the logistic regression formula derived from the training phase was then constructed. In the validation phase, the diagnostic software was applied to eight authentic SUD cases, seven (87.5 %) of which were accurately recognized. Our study provides a valid strategy towards practical diagnosis of SUD by integrating cardiac MYH6 and COX5B as dual diagnostic biomarkers.

Forensic Assessment of Alcohol Intoxication in Cases of Fatal Road Traffic Accidents in Lithuania.

Background: There is strong evidence that alcohol consumption is a significant risk factor for fatal road traffic accidents. It is estimated that the number of alcohol-related road accidents remains high in the past few years in Lithuania. This study aims to examine the prevalence of alcohol in blood samples collected from the autopsy results of road traffic accident victims. Materials and methods: A retrospective study of 136 road traffic accident victims was performed in State Forensic Medicine Service of Lithuania in the period of 2013 to 2023. We analyzed blood alcohol concentration (BAC) in relation to sex, age, road user type, place and time of the day at death. Results: 31% of the victims were under influence of alcohol at the time of death, with mean BAC 1.99 ± 0.92‰. The mean BAC was 2.16 ± 0.8‰ in male and 1.18 ± 1.12‰ in female group. By the type of road users, 23% of the pedestrians (mean BAC 2.45 ± 0.71‰), 32% of car drivers (mean BAC 2.13 ± 0.75‰), 41% of vehicle passengers (mean BAC of 1.73 ± 1.19‰), 37% of the motorcycle riders (mean BAC of 1.28 ± 0.53‰), 37% of the cyclists (mean BAC of 1.15 ± 0.75‰) were found to be intoxicated during the time of accident. Highest mean blood alcohol concentration was found during the night time hours (9 p. m. - 5 a. m.) 2.28 ± 0.91, comparing to in afternoon hours (12 p. m. - 5 p. m.) 1.49 ± 0.99, evening hours (5 p. m. - 9 p. m.) 2.10 ± 0.73 and morning hours (5 a. m. - 12 p. m.) 1.94 ± 1.00. The mean BAC in road traffic accidents during summer was 1.48 ± 0.71‰, spring 2.25 ± 0.76‰, autumn 2.12 ± 1‰, winter 2.42 ± 1‰. Conclusions: Alcohol consumption by road users is a significant contributing factor in road traffic accidents and their outcomes in Lithuania.

Deaths during Sexual Activity.

Background: Deaths during sexual activities are rarely identified phenomena in forensic medicine practice. Most often, such deaths are classified as accidents or deaths due to the manifestation of certain diseases during sexual activity. It is important to rule out homicide or suicide as the cause of death when investigating sexual deaths. Determining the cause of death requires a comprehensive assessment of the evidence and circumstances and should not be based solely on autopsy findings. When determining the cause of death, it is necessary to evaluate the circumstances of the discovery, important evidence found near the body, the position of the deceased, the place where the deceased was found, and the characteristics of the environment. Cases: Case 1: A 65-year-old male was clothed in women's underwear and was found hanging in a noose in a bedroom after a house fire. The autopsy revealed a ligature mark on the neck, bruises in neck muscles, tears in carotid arteries, and signs of acute pulmonary distension. The cause of death was determined to be suffocation due to neck compression by a ligature, compounded by significant alcohol intoxication, with additional postmortem burns covering 30% of the body surface area likely occurring after death.Case 2: A 55-year-old naked male was found without external injuries but with a plastic tube inserted into the rectum, causing a 2.5 cm rupture in the ileum. The perforation led to complications, including purulent diffuse peritonitis, intoxication, and acute cardiac and respiratory failure, resulting in death within 3-6 hours after insertion. Concurrent findings included atherosclerotic changes in the heart, internal organ hyperemia and edema, hepatic steatosis, renal cyst, and a lack of ethyl alcohol in blood but 0.17 ‰ presence in urine according to toxicology analysis. Conclusions: A detailed evaluation of all the evidence is very important in the forensic examination of the deceased during sexual activity. Therefore, to determine the cause of death, not only the autopsy data, toxicological and microscopic examinations of the deceased are important, but also the evaluation of all findings at the scene. The most common cause of death of an autoerotic nature is asphyxia, and the most commonly identified group of the dead are men aged around 40 years.

Atypical suicide by single incising cut to the throat without hesitation marks: Case report and review of the literature.

Several studies have been performed to recognize the main features in homicide and suicide sharp wound-related death, revealing that a single cutting wound to the neck is an infrequent event in suicide cases, and several hesitation marks near the fatal injury are usually present. We report a case of an atypical self-inflicted cutthroat injury without tentative marks involving a 79-year-old female. The weapon used, a kitchen knife, was found at the crime scene. The wound had clean margins, and no other incisions were found. Scene circumstances, namely the absence of signs of a break-in, the victim found on the bed, the knife located near the body, the vital wound in an accessible site, and the absence of defense injuries, collectively support a likely suicide. A literature review was also performed to compare forensic data of the case presented with the other 6 cases reported regarding atypical suicide characterized by a single incising cut to the throat without hesitation marks. Given the few cases reported and the lack of gross descriptions and histopathological data available in the literature, additional knowledge of such a case may help forensic pathologists in the identification of suicidal events when a single neck injury is observed. In this frame, suicide by a unique single incising cut to the throat without hesitation marks near the lethal injury may be observed as an atypical presentation, and the crime scene investigation, together with additional background information of the deceased, aid in the identification of the manner of the death.

8-oxoguanine DNA glycosylase-1 may serve as biomarker of mechanical asphyxia.

AIM: To identify mtDNA and OGG1 as potential biomarker candidates for mechanical asphyxia. METHOD: The human tissues are divided into experimental group (hanging and strangulation) and control groups (hemorrhagic shock, brain injury group, and poisoning group). Detected the expression of OGG1 and integrity of mtDNA in cardiac tissue of each group. We used over-OGG1 vector and siRNA-OGG1 transfecting H9C2 cell line to observe the function of OGG1 in hypoxic cells. RESULTS: 1. mtDNA integrity decreased in the mechanical asphyxia group, OGG1 expression increased in mechanical asphyxia groups. They can be biomarkers for mechanical asphyxia. 2. OGG1 increased first and decreased in hypoxia-induced H9C2 cells. OGG1 upregulated the TFAM, NRF1, and Bcl2 in hypoxia-induced H9C2. OGG1 downregulated cleaved-Caspase3 in hypoxia-induced H9C2 cells. 3. In the normoxia condition, NAC maintained mtDNA integrity and decreased the mitochondrial membrane potential and amount of ATP. CONCLUSION: mtDNA integrity and OGG1 expression can be biomarkers for mechanical asphyxia. OGG1 can maintain mtDNA integrity and maintain the stability of the mitochondrial membrane.

Formulating policies and procedures for managing diving related deaths: a whole of state engagement from frontline and hospital services in Tasmania.

Introduction: Tasmania is a small island state off the southern edge of Australia where a comparatively high proportion of the 558,000 population partake in recreational or occupational diving. While diving is a relatively safe sport and occupation, Tasmania has a significantly higher diving death rate per head of population than other States in Australia (four times the national diving mortality rate). Methods: Three compressed gas diving deaths occurred in seven months between 2021-2022 prompting a review of the statewide approach for the immediate response of personnel to diving-related deaths. The review engaged first responders including the Police Marine and Rescue Service, hospital-based departments including the Department of Hyperbaric and Diving Medicine, and the mortuary and coroner's office. Results: An aide-mémoire for all craft groups, digitalised checklists for first responders (irrespective of diving knowledge), and a single-paged algorithm to highlight inter-agency communication pathways in the event of a diving death were designed to enhance current practices and collaboration. Conclusions: If used, these aids for managing diving related deaths should ensure that time-critical information is appropriately captured and stored to optimise information provided for the coronial investigation.

Pathological alterations and COHb evaluations as tools for investigating fire-related deaths in veterinary forensic pathology.

Fire-related deaths are usually a consequence of carbon monoxide (CO) poisoning or shock from thermal injuries. In humans, high levels of carboxyhemoglobin (COHb) concentrations in the blood can support a diagnosis of CO poisoning. In veterinary medicine, few studies investigated the pathological changes and blood COHb% in fire victims, and no data are available on post-mortem changes in blood gas composition due to fire. This study aims to investigate the pathological changes and COHb levels in both animal victims of fire and cadavers experimentally exposed to fire. For this purpose, dogs were selected and subdivided into three groups. Group A comprised 9 adult dogs, and Group B comprised 7 puppies that died under fire-related conditions. Group C was represented by 4 dog cadavers experimentally exposed to heat and smoke. A complete macroscopic, histological, and COHb evaluation were performed on each animal. Animals in Groups A and B showed cherry-red discoloration, thermal-injuries and soot deposits along the respiratory tract. Animals in Group C showed thermal injuries and soot deposits limited to the upper respiratory tract. The mean COHb% values in cadavers in Group C were lower than those observed in the other groups but higher compared to the values detected before the heat and smoke treatment. These findings suggest that both pathological changes and COHb analysis are valid tools for investigating fire-related deaths in dogs. However, the increase of COHb levels in cadavers exposed post-mortem to heat and smoke highlights how the COHb analysis should always be evaluated together with macroscopical and microscopical findings to avoid significant misjudgments in investigating fire-related fatalities in veterinary forensic practice.

Massive gastropathy due to gallstone obstruction of the duodenum (Bourveret syndrome).

Gallstones are common in the general population and are often asymptomatic, but they can also cause complications such as cholecystitis and pancreatitis. In rare instances, they can lead to the formation of a cholecystoduodenal fistula and gallstone ileus. Gastric dilatation and distension following gallstone ileus are extremely uncommon and have rarely been reported in the literature. We report a fatal case of massive gastropathy as a result of Bouveret syndrome secondary to gallstone obstruction.

An atypical case of fatal 'esophageal apoplexy': post-mortem findings and differential diagnosis.

Forensic pathologists need to have comprehensive knowledge of a large variety of causes of sudden natural death. We describe a case of sudden and unexpected death in woman in her sixties due to rupture of a large paraesophageal hematoma. The post-mortem examination and differential diagnosis are discussed. The combined findings of whole-body post-mortem CT imaging (PMCT), targeted PMCT angiography, autopsy, and histology are most in keeping with 'esophageal apoplexy'; a rare cause of hemorrhage in the esophageal wall. A review of the literature indicates that most cases of esophageal apoplexy are self-limiting and that fatal complications are exceedingly rare. Our case demonstrates that esophageal apoplexy can present as sudden unexpected death.

Rare case of multiple self-inflicted gunshot wounds to the chest in Poland.

Multiple gunshot suicides are relatively rare and present significant challenges for investigators and forensic pathologists. In such cases, assessing the possibility of more than one shot being fired can be crucial in distinguishing homicide from suicide. We present a rare case of multiple self-inflicted gunshot wounds to the chest with severe injury to the heart and left lung. Both the sudden, unexpected death of the man, the unknown source of the firearm, and the number and nature of the injuries sustained seemed quite unusual. The investigation revealed that the wounds were self-inflicted at close range, and the interval between successive shots (estimated by witnesses at up to 2 min) suggests that even multiple gunshot wounds perforating the heart and lungs may not necessarily cause immediate incapacitation. Forensic investigations in such cases should be multi-faceted and include full autopsy and ballistics expertise, as well as witness testimony and medical history.

Post-blast histological changes to three animal bones exposed to close-range chemical detonation.

A range of investigative practices to aid explosive-related death investigations currently exist, although the use of histopathological bone samples to diagnose blast exposure and the distance of individuals from the blast source has not been previously reported. Forensic histopathology has been used effectively on soft tissue samples to define blast-related injuries effectively, analysing human organs such as the lungs, brain, liver, and skeletal muscles, providing important and useful forensic pathology interpretations. However, no studies currently exist examining the post-blast histological changes in human or animal bones subjected to blasts for forensic pathology practice, despite the opportunity that hard tissue bone samples present, given their significantly lower rate of decomposition over soft tissue. This study presents the first evidence-based findings on the post-blast histological changes in three animal bones when exposed to close-range chemical detonation (C4). The study's qualitative findings highlight critical changes in the tissue architecture of three different animal bone sources due to blast effects with range from the blast source. This emphasises the potential use of histopathological bone sample analysis in future blast-related death investigations, while providing ideas to further explore this work using larger-scale experiments and post-blast case studies in aid of applying this work to human samples and forensic pathology practice.

A case report of complex suicide in physician: attempt drugs poisoning and adhesive tape asphyxia.

Complex suicides are rare occurrences that can be categorized into planned (or primary) cases and unplanned (or secondary) cases. Additionally, individuals often select suicide methods based on their availability and accessibility. The body of a 58-year-old man was discovered deceased inside his medical office. He was found seated on the waiting room sofa, with his airways obstructed by several layers of adhesive tape wrapped around his head. An intravenous needle was observed in his left arm, and on the table in front of him, an empty 50 ml syringe, two empty vials of 10 ml potassium chloride, and an empty 10 mg vial of Valium (diazepam) were found. A roll of adhesive tape, similar to the one around his head, was also present. The autopsy, conducted 36 h after the body's discovery, revealed therapeutic concentrations of diazepam and its metabolite nordiazepam in the blood samples, while potassium chloride was not detected. Integrating forensic findings obtained from autopsy, histology, and other postmortem investigation, including toxicological analysis, can aid in defining suicidal behavior and preventing misinterpretation, particularly in differentiating diagnosis between homicide and suicide. It is crucial to consider circumstantial data and professional knowledge in such cases.

Intimate partner femicide (IPF): Medico-legal investigation at the Institutes of Legal Medicine of Freiburg (Germany) and Padova (Italy).

Violence against women is a significant public health concern, with femicide as its most extreme manifestation. This crime is often perpetrated by current or former intimate partners, thus taking the name of intimate partner femicide (IPF). Although international comparisons are essential for prevention policies, cross-country comparative studies are scarce in this context. The aim of this study was to evaluate and compare clinical, epidemiological and medico-legal characteristics of IPF autopsy cases investigated at the Institutes of Legal Medicine of two Western European cities, in order to identify a potential medico-legal pattern of IPF. Autopsy and police reports of IPF cases occurred in the judicial district of Freiburg (Germany) and Padova (Italy) from 2000 to 2022 were analyzed. Data relating to victims, perpetrators, relationship context, and circumstantial and pathological-forensic characteristics of the homicide were collected. Statistical analyses were performed to explore potential relationships between the data collected. Additionally, a review of the literature dealing with autopsy-based studies on IPF was performed. Overall, 82 cases of IPF were analyzed, 39 from Freiburg and 43 from Padova. A total of 6 papers fulfilled the review inclusion criteria. Our study identified a medico-legal pattern of IPF and demonstrated that it did not vary substantially between the two European Countries considered, suggesting that certain IPF characteristics are shared at the European level. However, a significant finding emerged regarding the higher prevalence of firearm-related IPFs in Italy compared to Germany. Forensic pathology research might contribute to developing targeted prevention policies to protect women from this lethal form of violence.

Could synovial fluid be a useful substrate for the forensic analysis of diatoms?

To date, synovial fluid has not been the subject of targeted analysis as a possible substrate to search for the presence of diatoms in the forensic context of drowning. However, its unique characteristics of production and isolation from the external environment could make it suitable for this purpose, similar to what has already been demonstrated in the literature for vitreous humor. By considering this, synovial fluid was analyzed in a specific case that came to our attention, where the coexisting signs of polytrauma and drowning were documented during autopsy, demonstrating a period of vitality during immersion. After a thin smear of the supernatant was obtained from the centrifugation of the synovial fluid sample, diatoms were successfully detected, consistent with those found in other organs and the water of the canal. The detection of diatoms in the synovial fluid was an objective finding, but its generalizability is limited because this was a pilot application. However, in cases where death by drowning is suspected and the body has multiple areas breached by trauma, the technique of analyzing diatoms in the synovial fluid could have great potential. Therefore, it is appropriate to further explore this technique in order to obtain more forensic evidence in such a setting.

Assessment of urine drug screen utility at autopsy to predict laboratory postmortem blood toxicology.

When faced with increasing drug-related deaths and decline in practicing forensic pathologists, the need to quickly identify toxicology-related deaths is evident in order to appropriately triage cases and expedite turnaround times. Lateral flow immunoassays conducted pre-autopsy offer quick urine drug screen (UDS) results in minutes and are used to inform the need for autopsy. Over 1000 medicolegal cases were reviewed to compare UDS results to laboratory enzyme-linked immunosorbent assay (ELISA) blood results to evaluate how well autopsy UDS predicted laboratory findings. Mass spectral analysis was performed on ELISA-positive specimens and these data were used to investigate UDS false-negative (FN) results when possible. Five different UDS devices (STAT One Step Drug of Abuse dip card and cassette, Premiere Biotech multi-drug and fentanyl dip cards and ATTEST 6-acetylmorphine (6-AM) dip card) were tested encompassing 11 drug classes: 6-AM, amphetamine/methamphetamine, benzodiazepines, benzoylecgonine, fentanyl, methadone, opioids, phencyclidine, and delta-9-tetrahydrocannabinol. Sensitivity, specificity, efficiency, and positive and negative predictive values >80% indicated that UDS was useful for predicting cases involving benzoylecgonine, methadone, methamphetamine, and phencyclidine. UDS was unreliable in predicting amphetamine, benzodiazepines, fentanyl, and opiates-related cases due to a high percentage of FN (up to 11.2%, 8.0%, 12.4%, and 5.5%, respectively) when compared to ELISA blood results. For the later analytes, sensitivities were as low as 57.5%, 60.0%, 72.2%, and 66.7%, respectively. Overall results support that UDS cannot replace laboratory testing. Because UDS is subject to false-positive and FN results users must understand the limitations of using UDS for triage or decision-making purposes.