Postmortem biochemistry in deaths from ischemic heart disease.

Ischemic heart disease (IHD) is one of the leading causes of morbidity and sudden cardiac death worldwide and is an important public health problem. The presence of ischemia in clinical applications can be detected by ECG, biochemical markers, and radiological methods. Myocardial infarction is also frequently encountered in forensic autopsies. Postmortem diagnosis is determined as a result of histopathological examinations and additional exclusionary examinations (toxicology, microbiology, etc.). However, routine histopathological examinations are insufficient, especially when death occurs in the early period of ischemia. It creates a problem for forensic pathologists and forensic medicine specialists in such cases of sudden cardiac death. Postmortem biochemistry is one of the important and promising disciplines in which forensic applications work in order to diagnose these cases correctly. The issue of whether biomarkers used in the diagnosis of myocardial infarction in clinical studies can be used reliably in postmortem cases has been discussed by forensic medicine researchers for some time. This manuscript aims to review and summarize biomarkers belonging to various categories that have been studied in IHD-related deaths, in biological fluids taken at autopsy, or in animal experiments. Our study shows that the postmortem use of biochemical markers in the diagnosis of IHD yields promising results. However, it should not be forgotten that postmortem biochemistry is different from clinical applications due to its dynamics and that the body causes unpredictable changes in markers in the postmortem process. Therefore, comprehensive studies are needed to evaluate the postmortem stability of these markers in different biological fluids, their significance among various causes of death, and whether they are affected by any variable (Cardiopulmonary resuscitation, Postmortem interval, medications, etc.) before they are routinely applied. It is suggested by the authors that the cut-off values of biomarkers whose significance has been proven by these studies should be determined and that they should be used in this way in routine applications.

Significance of postmortem biomarkers and multimarker strategy in sudden cardiac death.

The most common cause in the etiology of sudden cardiac death (SCD) is ischemic heart disease due to atherosclerosis. Postmortem diagnosis can be made by histopathological examinations, but routine histopathological examinations are limited, especially in the early period of postmortem ischemia. For this reason, many methods are being investigated for the postmortem diagnosis of ischemia, and postmortem biochemical studies are promising. In our study, we evaluated the biochemical markers; hs-cTnT, NT-proBNP, H-FABP, pentraxin-3, copeptin, ischemic modified albumin (IMA), and PAPP-A in postmortem serums. In forensic pathology practice, it was investigated whether it would be useful to go to the diagnosis by measuring more than one marker in a single biological fluid in SCD cases. The study included 35 sudden cardiac death cases and 24 control cases and as a result of our study, hs-cTnT, NT-proBNP, and H-FABP values were found to be significantly higher in the SCD group than in the control group. Within the scope of the multi-marker strategy, models were tried to be developed in which the markers were used together, and it was concluded that the model consisting of the myocardial ischemia marker hs-cTnT, the myocardial stress marker NT-proBNP, and the inflammation marker pentraxin 3 was the most accurate combination by correctly classifying the cases at a rate of 94.9%. As a result, it was thought that it would be appropriate to use the multi-marker strategy which is widely used in clinical applications, also in forensic medicine applications.

[A Case of Suicide Related with COVID-19]. / COVID-19 ile Iliskili Bir Özkiyim Olgusu.

The worldwide public health problem of suicide, requires a multidisciplinary assessment, given its economic, cultural, social and psychological aspects. The global COVID-19 pandemic that originated from the Peoples Republic of China in the last months of 2019 has the potential to trigger mental disorders and even suicidal attemps through fear, psychosocial pressures and as a result of disruption of the customary daily life styles. In this report we discuss a case of completed suicide of a 34-year old male who had confined himself to his home, after stocking up large amounts of food, drinking water and cleaning materials in response to the COVID-19 pandemic in our country using site investigation reports, medico-legal autopsy and psychological authopsy of the deceased. It was found out that the victim was following the internet and the television daily for news on the COVID-19 outbreak in the country. One week before the event, he had left his workplace telling his colleagues that he would confine himself to his home for 15-20 days to clean up the premises. Washed banknotes and blister tablets were found in the house as well as stocked water and cooked food. The deceased had twice consulted hospitals for fear of COVID-19 infection 2 days before his demise. It was discussed that he might have the diagnosis of "mixed anxiety and depression". Evaluation of his experiences, discourses and behaviours within the span of 3-4 days before the act and the site investigation have suggested that he might have attempted suicide as a response to stress.

Sex determination with morphological characteristics of the skull by using 3D modeling techniques in computerized tomography.

Sex determination is a major area of investigation in forensic anthropology. As technology has advanced, imaging methods such as computed tomography and magnetic resonance imaging are being investigated as alternatives to conventional forensic anthropological research techniques. This study aimed to investigate the suitability of three-dimensional (3D) modeling of volumetric cranial computed tomography (CCT) images for sex estimation from skull morphology. In this study, CCT angiography images from the Department of Radiology 2017 archives were used retrospectively, and 3D images were obtained after the reconstruction of 85 cases of CCT images. The sex-dependent morphological characteristics of the skull were evaluated by three blinded observers and scored on a scale of 1-5 points according to the "Standards for Data Collection from Human Skeletal Remains". The accurate sex estimation rates of the first, second and third observers were 91.8, 92.9 and 92.9%, respectively. The rate of accurate sex estimation for males was 98-100%, while this rate varied between 83.3-86.1% for females. Consistency in sex estimation between the three observers was 83.5%, with a Kappa value of 0.763 (z = 12.2; p = 0.0001*). The glabella was the most effective morphological trait used to estimate sex. The results of this study show that sex can be estimated from morphological features in volume-rendered CCT 3D images. Thus, sex can be estimated by digital images without the need for maceration processes, and the transfer of digital data in place of physical material will make it possible to gain expert opinions in forensic anthropology.

Evaluation of human pineal gland acetylserotonin O-methyltransferase immunoreactivity in suicide: A preliminary study.

Disorders of the serotonergic system are especially known to be present in the neurobiology of suicidal behavior. Studies investigating melatonin levels show that changes in pineal gland functions may also play a role in the pathogenesis of suicide. However, to our knowledge, there are no studies evaluating the activity of pinealocytes responsible for melatonin synthesis in suicide. This preliminary study aimed to investigate the relationship among pinealocyte, acetylserotonin O-methyltransferase (ASMT) immunoreactivity, and suicide. Samples of pineal gland, cerebrospinal fluid, blood, and urine were obtained from 21 suicide and 21 non-suicide cases on which medicolegal autopsies were performed. Expression of ASMT in human pineal gland was evaluated by immunohistochemical methods. A scoring system was used to define the anti-ASMT-positive staining in the sections. Enzyme-linked immunosorbent assays were employed to assess serum and cerebrospinal fluid melatonin levels and blood and urine noradrenaline levels. The ASMT-immunopositive pinealocyte count was observed to be lower in suicide cases compared to the non-suicide cases. With the exception of two cases (with moderate staining), all graded scores were 3 (strong staining) in non-suicide group, whereas scores were 1 (mild staining) or 2 (moderate staining) in the suicide group. Melatonin levels in the blood were lower among the suicide victims. These results support decreased pineal gland activity in suicide. However, further studies are needed to assess whether these changes are related to a psychiatric disorder.

Estimation of stature and sex from sternal lengths: an autopsy study.

The aim of this study was to derive regression equations for estimating stature and further to estimate sex from four measured sternal lengths. This study included intact sterna from 65 males and 30 females, aged between 25 and 40 years, obtained during medico-legal autopsies. Stature and four sternal lengths, length of the manubrium (LM), length of the body (LB), length of the manubrium and body (LMB) and total sternal length, of each cadaver were measured. Stature and all measured sternal lengths were greater in males compared to females (p < 0.001). All sternal lengths were positively correlated with stature in sexes. LMB had the highest correlation coefficient in both males and females (correlation coefficient: 0.721 and 0.740, respectively). In both sexes, linear regression analysis for stature estimation revealed equations with the highest R (2) values when derived from LMB (R (2) = 0.521 for males and R (2) = 0.547 for females). On the other hand, only the multiple linear regression equation derived from the combination of the LB and LMB had the higher R (2) value (R (2) = 0.640) for stature estimation in females. Receiver-operating curve analysis for all measurements was statistically significant (p < 0.05 for all). These findings suggested that measured sternal lengths can be used for estimation of sex. However, LB and LMB measurements were found to be the most reliable sternal lengths for estimating sex with an accuracy rate of 90 %. Our results revealed that the sternum is a useful tool for estimating stature and sex when other skeletal bones are not available.

Anatomopathological findings in hangings: a retrospective autopsy study.

BACKGROUND: In this retrospective autopsy study, we aimed to review the anatomopathological findings observed in cases of hanging death for a five year period and to evaluate the role of contributing factors such as age, sex, type of hanging and localization of the ligature knot. METHODS: Autopsy reports of 102 hanging cases performed by the Department of Forensic Medicine, Faculty of Medicine of Pamukkale University, between January 2007 and September 2011, were retrospectively reviewed. RESULTS: In the 102 hanging cases 73 of the victims were males (71.6%) and 29 (28.4%) were females, with a mean age of 40.97 ± 17.41 years. All cases were suicidal hanging. Fifty four cases (52.9%) were typical hanging, with the ligature knot located posteriorly. There were petechial hemorrhage on the face and eye lids in 46 (45.1%), ecchymoses of the cervicale muscles in 43 (42.2%), and fractures of the neck structure(s) in 69 cases (67.6%). CONCLUSIONS: The incidence of neck structure fractures increased with age. In addition, there was no correlation between the incidence of neck structure fractures and sex or type of hanging.

Caspase 1, caspase 3, TNF-alpha, p53, and Hif1-alpha gene expression status of the brain tissues and hippocampal neuron loss in short-term dichlorvos exposed rats.

Dichlorvos (DDVP) is an organophosphate compound that causes neurotoxicity. Apoptosis plays an important role in neurotoxic cell death in the brain. The aim of this study was to examine caspase 1, caspase-3 and also cell apoptosis related genes as p53, Tumor Necrosis Factor-alpha, Hypoxia Inducible Factor 1-alpha expressions in hippocampus, cerebellum, cortex, and to estimate total hippocampal neuron number in DDVP treated rats. Ten female albino rats were divided into control (n:5) and dose (n:5) groups. In dose group, single dose of DDVP (25 mg/kg) was administered to the animals via oral gavage. A week later, brains were removed and total neuron number was estimated in the left hippocampus using by optical fractionator method. The right part of the brain was used for gene expression analysis. In dose group, total hippocampal neuron number was significantly decreased compared to control group (p = 0.008). Caspase 1 and TNF-alpha gene expression were increased in all brain tissues and p53 gene expression was decreased in only hippocampus tissue in dose group. Short-term exposure to dichlorvos leads to neuronal loss in hippocampus and TNF-alpha rapidly and potently induces apoptosis and also several caspases as possible participants in the apoptotic cascade.

Elderly deaths associated with balneotherapy in Denizli, Turkey province: three autopsy cases.

BACKGROUND: Turkey is one of the richest countries in the world in terms of balneotherapy resources. Thermomineral water baths are preferred by the elderly because of their positive beneficial effects over regulation of musculoskeletal system functions. However, existing cardiovascular and respiratory system diseases may constitute a risk and trigger ischemic changes in the heart. METHODS: In this study, 2 cases are presented who suffered sudden cardiac death while having a thermal bath and 1 drowning case that was precipitated by chronic myocardial infarction. While 1 case was 63 years old, 2 cases were above 65 years of age. Two (2) cases had atherosclerotic coronary artery disease, whereas 1 case had heart failure. RESULTS: The success of spa treatment, which is based on stimulation/harmonization therapy, restores bodily harmony and depends on the health of organs and functions playing a role in this process. CONCLUSIONS: In the elderly, some conditions, particularly limited pulmonary and cardiovascular functionality, should be taken into consideration while applying those treatments.

The relationship between adrenal gland morphometric changes and postmortem interval in rats: a stereological study.

The importance of determining time of death is crucial to forensic cases. The ability to use adrenal gland volume changes and adrenal medulla chromaffin cell counts to obtain the postmortem interval was examined in this study. A total of 15 rats were sacrificed by cervical dislocation and divided into three groups. The left adrenal glands were quickly excised in the first group at 0 h, in the second group at 12 h and in the third group at 24 h. Subsequently, the samples were fixed in 10% formalin solution and embedded in paraffin according to standard procedures. Ten to fifteen sections were obtained from each left adrenal gland by taking 30 µm thick sections; then, the sections were stained with hematoxylin-eosin (HE). The adrenal cortex and medullar volumes were calculated by Cavalieri's principle, which is a stereological method. The adrenal medullary chromaffin cell count was evaluated by the optical fractionator method. The total volume of the adrenal gland was determined as 4.82±1 mm(3) at 0 h, 6.32±0.28 mm(3) at 12 h and 8.35±1.73 mm(3) at 24 h. Increases in the adrenal cortex, adrenal medulla and the total volume of the adrenal gland at 12 and 24 h postmortem compared with at 0 h were statistically significant (p<0.05). The difference between the groups in terms of the total number chromaffin cells was statistically significant (p<0.05). In this preliminary study, we evaluated the total volume of the adrenal gland and the number of chromaffin cells of the adrenal medulla. We concluded that these parameters could be used reliably in determining the postmortem interval.

[Evaluation of medicolegal reports written by physicians in the emergency unit with regard to deficiencies and mistakes]. / Acil servis hekimleri tarafindan düzenlenen adli raporlarin eksiklik ve yanlisliklar yönünden degerlendirilmesi.

BACKGROUND: Doctors working in emergency services often fulfill the task of preparing judicial reports. For a number of reasons, these reports have undesirable mistakes that become problematic in subsequent judicial processes. This study aimed to evaluate the judicial reports that were prepared over a certain period at a university hospital with regard to any mistakes or deficiencies. METHODS: The distribution of the judicial reports prepared between 01 June 2005 and 30 June 2009 in the emergency service of a University Research and Training Hospital was determined with respect to the types of cases, and their contents were studied for mistakes, deficiencies and legibility. Out of 3499 visits to the emergency service during the specified period, 3219 judicial reports that were accessible were considered in the evaluation. RESULTS: It was determined that the most frequent types of cases were traffic accidents and injuries by sharp and penetrating instruments. Furthermore, many mistakes were made frequently regarding the presence of life-threatening conditions, and personal identification information and times of the event and examination were often incomplete. CONCLUSION: The fact that the doctors largely failed to prepare precise reports and tended to write unsatisfactory reports even for cases with adequate information and findings was attributed to their insufficient training in this area. At the same time, mistakes in life-threatening situations and in treatment by using simple medical interventions stem from lack of training and sensibility. Pre- and post-graduate forensic medicine education must be considered highly important, and periodic on-the-job training must be organized, creating a better awareness among doctors regarding their legal responsibilities.

Immunohistochemical demonstration of nerve endings in iliolumbar ligament.

STUDY DESIGN: Immunohistochemical study on fresh cadaver specimens. OBJECTIVE: Assessment of mechanoreceptor and nociceptor levels and distribution in iliolumbar ligament. SUMMARY AND BACKGROUND DATA: The function of iliolumbar ligament and its role in low back pain has not been yet fully clarified. Understanding the innervation of this ligament should provide a ground which enables formation of stronger hypotheses. METHODS: Bilateral 30 iliolumbar ligaments of 15 fresh cadavers were included in the study. Morphologic properties were recorded and the ligaments were examined by focusing on 3 main parts: ligament, bone insertions, and tendon body. Assessment of mechanoreceptor and nociceptor levels and their distribution in iliolumbar ligament were performed on the basis of immunohistochemistry using the S-100 antibody specific for nerve tissue. RESULTS: Iliac wing insertion was found to be the richest region of the ligament in terms of mechanoreceptors and nociceptors. Pacinian (type II) mechanoreceptor was determined to be the most common (66.67%) receptor followed by Ruffini (type I) (19.67%) mechanoreceptor, whereas free nerve endings (type IV) and Golgi tendon organs (type III) were found to be less common, 10.83% and 2.83%, respectively. CONCLUSION: Immunohistochemical staining has shown that iliolumbar ligament had a rich nerve tissue. Those results indicate that ILL plays an important role in proprioceptive coordination of lumbosacral region alongside its known biomechanic support function. Moreover, the presence of type IV nerve endings suggest that the injury of this ligament might contribute to the low back pain.

Hippocampal neuron loss due to electric injury in rats: a stereological study.

Electric injury may cause different changes from minimal damage (e.g. small burns) to severe complications up to death. Several morphological changes of the skin and the internal organs are used for the diagnosis of electrical injury. However, macroscopic findings and histological changes of the internal organs and the skin may be absent in many cases. Furthermore, neuropsychological changes including deficits of cognitive functions may be seen in survivor victims. The aim of the present study is to examine whether electric injury causes decreasing in the number of pyramidal neurons in the rat hippocampus and whether this decreasing can be demonstrated by stereological method. The rats were separated into three groups: first group, native control group; second group, the points of electrical contact were on the back skin in this group; third group, the points of electrical contact were on the temporal region in this group. The current was the usual city current (110V, 50Hz, 100A AC). On the third day, the rats were decapitated; the brains were removed, and sectioned horizontally through the hippocampus and samples chosen according to the systematic random sampling strategy. Afterwards the samples were stained by H&E and optical fractionator method, one of the unbiased stereological methods, was used to estimate the total pyramidal neuron number. The results showed that the total number of pyramidal neurons in three subdivision of the hippocampus (CA3-2 and CA1) was 242,141+/-31,167, 193,388+/-24,795 and 187,448+/-28,300 in the first, second and third groups, respectively. The differences between first and second-third groups were statistically significant (p<0.05). There was not any significant difference between the second and the third groups. In conclusion, electrocution causes loss of the pyramidal neuronal in CA3-2 and CA1 subdivisions of the rat hippocampus in this study.

[Frequency of skeletal chest injuries associated with cardiopulmonary resuscitation: forensic autopsy]. / Kardiyopulmoner resüsitasyona bagli gögüs kafesi hasarlanmalarinin sikligi: Adli otopsi sonuçlari.

BACKGROUND: Fractured ribs and sternum are frequent complications of thoracic compression during CPR (cardiopulmonary resuscitation) in adults. This study was conducted to determine the incidence of rib and sternal fractures after conventional closed-chest compression in the treatment of cardiac arrest. METHODS: We reviewed the forensic autopsy findings of 231 deaths referred to the Pamukkale University Department of Forensic Medicine over a 12-month period, 2004-2005. CPR-related chest injuries comprising rib and sternum fractures, ecchymosis and subcostal hemorrhage were compared retrospectively in 104 patients. RESULTS: Ninety-one (87.5%) of the 104 patients were adults, and 13 patients (12.5%) were children. The mean (SD) age in the pediatric group (5F/8M) was 5.48 (+/-5.96) and in the adult group (18F/73M) was 44.88 (+/-18.31). Forty-four (42.3%) of the 104 patients died of traumatic cause and 60 (57.7%) of non-traumatic cause. Ecchymosis was present in 26 (28.8%) patients, subcostal hemorrhage in 16 (17.6%) patients and fractures (sternal and costal) in 12 (13.2%) patients in adults. There were no significant differences between groups according to age, sex and traumatic-nontraumatic cause in terms of skeletal chest injuries associated with CPR in adult patients (p>0.05). CONCLUSION: This study shows a low incidence of rib and sternal fracture after closed-chest compression in the treatment of cardiac arrest in forensic autopsy cases.

Violence toward health care workers in emergency departments in Denizli, Turkey.

This study sought to determine the frequency and types of violence that occurred during the previous year against health care workers in emergency departments in Denizli, Turkey, and to discern the views of workers on the prevention of such aggressive behavior. This study was conducted from March 1 to April 15, 2003, and included a group of 79 health care workers from the emergency departments of 3 hospitals in Denizli, namely, the Hospital of Pamukkale University Medical Faculty, the City Hospital of Denizli, and the Hospital of the Social Insurance Foundation. Data were collected from a self-administered questionnaire. In all, 88.6% of participants had been subjected to or had witnessed verbal violence, and 49.4% of them had been subjected to or had witnessed physical violence during the previous year. The most frequent reason (31.4%) for violence was abuse of alcohol and drugs by perpetrators. The second most frequent reason (24.7%) was the long waiting times typical of emergency departments. The most common type of violence was loud shouting; swearing, threatening, and hitting were the next most frequent violent behaviors. In all, 36.1% of subjects who had experienced violence reported that they developed psychological problems after the incident. Most participants commented on the insufficiency of currently available security systems within emergency departments and on the need for further training about violence. All health care personnel within emergency departments should be aware of the risk of violence and should be prepared for unpredictable conditions and events; in addition, security systems should be updated so that violence within emergency departments can be prevented.

Foreign body asphyxiation in children.

We aimed to investigate the frequency and epidemiological features of deaths due to foreign body asphyxiation (FBA) in childhood, over 1990-2003. Of the victims, 14 (63.6%) were male and 8 (36.4%) females. The mean age of the victims was 2.2 +/- 0.6 years. There were 20 (90.9%) children between 1 and 3 years, and two other cases at 2/12 and 5 years of ages. All aspirations had occurred at home. Eight (36.4%) of the victims were dead on arrival, 11 (50%) on intervention, and 3 (13.6%) after complications. Food material was the most commonly aspirated foreign body in 81.8% of the cases, nuts being the most common (50%). Food asphyxiation remains a common problem particularly in children between 1 and 3 years of age in our region. These fatal accidents can be prevented by parental education and early recognition and management of the situation.

Child pedestrian fatalities in Diyarbakir, Turkey.

OBJECTIVE: As there is an increase in modernization, transportation, unskilled, and drunk drivers, injuries from traffic accidents have taken on an epidemic form all over the world. The present study aims to describe the demographic data of childhood pedestrian fatalities in a large urban area in Turkey. METHODS: The demographic data of childhood pedestrian fatalities in a large urban area in Turkey was described retrospectively, with respect to age, gender, injury pattern and location. Cases less than 16 years of age were collected retrospectively from the files of the Branch of the Council of Forensic Medicine in Diyarbakir between 1998 and 2003. RESULTS: There were 232 childhood pedestrian fatalities among a total of 267 children involved in lethal traffic accidents. The mean age of the victims was 7.2 years, most of them being in the 6-10 years of age group (49.1%). Male predominated among our victims (76.3%). With regard to injury location, the most common site was the head (73.7%). There was an increase in pedestrian fatalities in the summer season (33.6%). There was no difference in rates of pedestrian deaths between years. CONCLUSION: Child pedestrian deaths have constituted a significant percentage of all child fatalities due to traffic accidents in our region. There were 6.4 deaths per 100,000 populations, and this rate was also higher than in other populations.