Death by anaphylactic shock in an institution: an accident or negligence?

This is a description of a man, institutionalised for learning difficulties, known to have an allergy to seafood. After eating a pie, the patient quickly developed dyspnoea and vomiting. The staff at the institution administered epinephrine and called the emergency services. Despite cardiopulmonary resuscitation, the patient died shortly after being admitted to the emergency department of the University Hospitals of Geneva. In the light of the circumstances of the death and of a discrepancy between the information given to the police by the staff at the institution looking after the patient on the one hand, and the preliminary elements of the investigation on the other hand, it was suspected that there was failure in care of the patient and our institute was asked to carry out an autopsy. Basing on all the investigations carried out, the cause of death was anaphylactic reaction following the ingestion of seafood, contrary to what had been alleged by the staff at the home.

Factors Influencing the Filing of Complaints, Their Investigation, and Subsequent Legal Judgment in Cases of Sexual Assault.

In Geneva, examination of victims of sexual assault is performed by a gynecologist and a medical examiner. 48% of the victims file a complaint and we wanted to investigate the factors leading to file a complaint, those leading the Prosecutor to go to trial, and those influencing a conviction. Between 2006 and 2012, 676 victims of sexual assault were investigated (averaged age 26 year, mean 22). Information on injuries, perpetrators, and circumstances of the assault was collected and analyzed. The attacker being the ex-spouse or a friend and the presence of semen were factors leading to file a complaint. The assailant being a family member or ex-spouse and the presence of genital/anal lesions were factors influencing the Prosecutor. The presence of nongenital lesions, the assailant being known by the victim, influenced conviction. This study shows that the medical examiner plays a vital role in the investigation of cases of sexual assault.

Postmortem biochemistry in suspected starvation-induced ketoacidosis.

Significantly increased blood ketone body levels can be occasionally observed in the forensic setting in situations other than exposure to cold, diabetic or alcoholic ketoacidosis. Though infrequent, these cases do occur and deserve thorough evaluation in order to establish appropriate differential diagnoses and quantify the role that hyperketonemia may play in the death process. Starvation ketoacidosis is a rare cause of metabolic acidosis and is a phenomenon that occurs normally during fasting, as the body switches from carbohydrate to lipid energy sources. The levels of ketonemia in starvation ketoacidosis is usually mild in comparison to those seen in diabetic or alcoholic ketoacidosis. In the clinical setting, several cases of starvation-induced ketoacidosis mainly associated with gastric banding, pregnancy, malnutrition and low-carbohydrate diets have been reported. However, starvation ketosis causing severe metabolic acidosis has been rarely described in the medical literature. In the realm of forensic pathology, starvation-induced hyperketonemia has been rarely described. In this paper we present the postmortem biochemical results observed in situations of suspected starvation-induced hyperketonemia that underwent medico-legal examination. In all these cases, the diagnosis of starvation induced-hyperketonemia and the subsequent ketoacidosis was established per exclusionem based on all postmortem investigation findings. A review of the literature pertaining to the clinical diagnosis of starvation ketoacidosis is also provided.

Philemon and Baucis deaths: case reports and postmortem biochemistry contribution.

The death of a person as a reaction to the death of another is known as Philemon and Baucis death and may represent a difficult challenge for pathologists, especially due to the decompositional changes that often characterized these situations. In this article, we describe two cases of Philemon and Baucis deaths, the first concerning a married couple and the second concerning a father and son. Postmortem investigations including radiology and biochemistry were performed. Based on the results of all investigations, deaths were attributed to natural causes. Third-party involvement could be excluded in both situations. In one case, biochemical analysis results revealed potentially contributing causes of death. The reported cases emphasize the importance of correlating findings from different postmortem investigations to identify causes of death, precipitating conditions and predisposing disorders, thus allowing the conclusion of natural death to be reached and third-party involvement to be excluded.

Neurobiology of suicide: do biomarkers exist?

Clinical risk factors have a low predictive value on suicide. This may explain the increasing interest in potential neurobiological correlates and specific heritable markers of suicide vulnerability. This review aims to present the current neurobiological findings that have been shown to be implicated in suicide completers and to discuss how postmortem studies may be useful in characterizing these individuals. Data on the role of the main neurobiological systems in suicidality, such as the neurotransmitter families, hypothalamic-pituitary-adrenal axis, neurotrophic factors, and polyamines, are exposed at the different biochemical, genetic, and epigenetic levels. Some neuroanatomic and neuropathological aspects as well as their in vivo morphological and functional neuroimaging correlates are also described. Except for the serotoninergic system, particularly with respect to the polymorphism of the gene coding for the serotonin transporter (5-HTTLPR) and brain-derived neurotrophic factor, data did not converge to produce a univocal consensus. The possible limitations of currently published studies are discussed, as well as the scope for long-term prospective studies.

Gunshot deaths in Geneva, Switzerland: 2001 to 2010.

We have conducted a retrospective study of all gunshot deaths that occurred in Geneva, Switzerland, over a 10-year period (2001-2010). The 133 cases reviewed were classified according to the manner of death, that is, suicide (106 cases), homicide (25 cases), and accident (2 cases). Various data from police authorities and the medicolegal examinations of the bodies were studied, including the age and sex of the victims, location of the event, type of firearm used, concomitant use or nonuse of alcohol and/or other drugs, seasonality, and entry site. These various elements were compared with data found in the literature.

Fatality in a wine vat.

Intoxication with carbon dioxide (CO2), a nonexplosive, colorless, and odorless gas does not cause any clinical symptoms or signs, with the occasional exception of sudation. Carbon dioxide is principally used in the food industry (70% of CO2 production), in particular to preserve foods and to carbonate beverages. Most fatalities resulting from CO2 intoxication are accidental and occur either in closed spaces or when dry ice is used in the food industry. In this case report, a 42-year-old male winemaker engineer was found dead, his head inside a wine vat that had been filled with grapes on the previous day and supplemented with dry ice to improve the taste of wine.

Medical confidentiality and the competent patient.

Confidentiality is both a fundamental principle of medical ethics and a legal obligation. In exceptional situations not covered by legal provisions, doctors may want to waive confidentiality against the wishes of the patient. Swiss law calls for an authority to rule on such cases. In the Canton of Geneva this authority is the Commission for Professional Confidentiality. This paper concerns 41 cases managed by this commission. The study shows that the majority of these requests to the Commission concern the reporting of patients who are not incompetent but need the protection of a legal guardianship. In rare cases, there is another interest higher than confidentiality: public order or functioning of justice. The Commission found that the measure requested was justified in the majority of cases brought before it. This study focuses on exceptional cases but it throws into relief the conflict between the principle of autonomy on the one hand and the need for patient protection and social justice on the other.

Debates about assisted suicide in Switzerland.

Assisted suicide is allowed in 3 states of the United States (Oregon, Washington, Montana) but only if performed by a physician.On the opposite, in Switzerland, at the beginning of the 20th century, the Swiss Penal Code referred to assisted suicide in the context of honor or an unhappy love affair. It was only in 1985 that Exit Deutsche Schweiz (Exit for German-speaking Switzerland) "medically" assisted the first patient to end his life.Even if authorized by the Swiss law upon certain conditions, assisted suicide is subject to debates for ethical reasons. The Swiss Academy of Medical Sciences described directives to guide physicians on this difficult subject.Different studies showed an increase in the number of medical-assisted suicide in Switzerland since the 1990s. Now, this number seems to be quite stable. Assisted suicide is authorized in a few hospitals under strict conditions (especially when returning home is impossible).Thus, according to the Swiss law, any person could perform assisted suicide; this is essentially performed by 3 main associations, using pentobarbital on medical prescription as lethal substance.Generally speaking, the Swiss population is rather in favor of assisted suicide. Among politics, the debate has been tough until 2010, when the Federal Council decided not to modify the Swiss Penal Code concerning assisted suicide.

Protein levels of ß-catenin and activation state of glycogen synthase kinase-3ß in major depression. A study with postmortem prefrontal cortex.

BACKGROUND: The Wnt/GSK3ß signaling pathway was implicated in mood disorders. Beta-catenin is a protein targeted by this signaling axis. We aimed to examine whether there is an abnormality in this signaling axis in major depression. METHODS: Postmortem brains from 20 depressed and 20 non-depressed subjects were used. In both groups, suicide and non-suicide were included in equal number. Protein levels of ß-catenin, tGSK3ß and ser(9)-pGSK3ß were determined in prefrontal cortex. RESULTS: ANOVA yielded significant variations between groups in ß-catenin (F(3,36)=19.5; p<0.001) and pGSK3ß protein (F(3,36)=14.3; p<0.001) and in tGSK3ß-to-pGSK3ß ratio (F(3,36)=10.9; p<0.001). Fisher tests showed decrease in both groups of MDD and MDD with suicide (MDD+S) for ß-catenin (p<0.001) and pGSK3ß levels (p<0.001) respectively. The tGSK3ß-to-pGSK3ß ratio was increased in MDD and MDD+S subjects (p<0.001). A negative correlation was observed between ß-catenin levels and the activation state of the GSK3ß (r2=0.358; p<0.005). LIMITATIONS: The sample was small and only a fraction of s(9)-pGSK3ß, albeit significant, was used and; the mood state at the time of death was unknown. CONCLUSIONS: The study observed a dysregulation of Wnt/GSK3ß signaling associated with a lifetime of major depression. The study may have relevance in further development of drugs based on GSK3ß inhibition.

Alterations in phosphatidylinositol 3-kinase activity and PTEN phosphatase in the prefrontal cortex of depressed suicide victims.

BACKGROUND: Recent studies have reported alterations in protein kinase B (PKB)/Akt and in its downstream target, glycogen synthase kinase 3ß, in depression and suicide. The aim of the present study was to investigate possible impairment of the upstream regulators, namely phosphatidylinositol 3-kinase (PI3K) and PTEN. METHODS: The ventral prefrontal cortex (Brodmann's area 11) of 24 suicide victims and 24 drug-free nonsuicide subjects was used. The antemortem diagnoses of major depression disorder were obtained from the institutional records or psychological autopsy, and toxicological analyses were performed. Protein levels of PI3K and PTEN were assayed using the immunoblot method, and the kinase activity of PI3K and Akt was determined by phosphorylation of specific substrates. RESULTS: A decrease was observed in the enzymatic activity of PI3K [ANOVA: F(3, 44) = 9.20; p < 0.001] and Akt1 [ANOVA: F(3, 44) = 13.59; p < 0.001], without any change in protein levels, in both depressed suicide victims and depressed nonsuicide subjects (p < 0.01 and p < 0.002, respectively). PTEN protein levels were increased in the same groups [ANOVA: F(3, 44) = 10.5; p < 0.001]. No change was observed in nondepressed suicide victims. CONCLUSION: This study concludes that attenuation of kinase activity of PKB/Akt in depressed suicide victims may be due to the combined dysregulation of PTEN and PI3K resulting in insufficient phosphorylation of lipid second messengers. The effect is associated with major depression rather than with suicide per se. Given the cellular deficits reported in major depression, the study of enzymes involved in cell survival and neuroplasticity is particularly relevant to neurotrophic factor dysregulation in depression.

A half century retrospective study of homicide-suicide in Geneva--Switzerland: 1956-2005.

This study provides a retrospective review from the forensic files of the University Centre of Legal Medicine in Western Switzerland in Geneva, from January 1956 to December 2005. The studied homicide-suicide cases cover a period of half a century (50 years). As a rule, all police-ordered forensic examinations of violent death cases in the Canton of Geneva are conducted by the University Centre of Legal Medicine. All of the data necessary for an exhaustive retrospective study are thus readily available. During the period covered in this work, 228 homicides were perpetrated in Geneva. In 23 cases, the homicide was followed by the suicide of the aggressor. The 34 victims of these homicides (18 women, 1 man and 15 children) had either an intimate or filial relationship with the perpetrator. Most of the suicidal perpetrators were men that killed their spouses or intimate partners, with children as additional victims in some cases. Shooting was the most common means to kill, followed by stabbing. The majority of the victims and perpetrators were Swiss nationals. This retrospective study shows that in the last 50 years, homicide-suicide cases in the Canton of Geneva have been a rare and an episodic phenomena with a very variable frequency from 1 year to another.

[Post-mortem partial skeletization of the face and neck by an Appenzell mountain dog]. / Postmortale Teilskelettierung der Gesichts- und Halsregion durch einen Appenzeller Sennenhund.

An 81-year-old man died unexpectedly from a cardiac cause. His wife, who lived in the same house and suffered from Alzheimer's disease, did not realize his death. When the body was found at the foot of the stairs 2-3 days afterwards, extensive soft tissue defects with notched wound edges, but no signs of vitality, were observed on the head and neck. The site where the body was found showed almost no traces of blood. In view of the injuries and their obviously post-mortem origin it was assumed that they had been caused by the man's Appenzell mountain dog which also lived in the house. By means of DNA typing, swabs from the wound edges of the soft-tissue defects could be assigned to the deceased's dog.

Alteration in kinase activity but not in protein levels of protein kinase B and glycogen synthase kinase-3beta in ventral prefrontal cortex of depressed suicide victims.

BACKGROUND: Past studies in the neurobiology of suicide have reported alterations in serotonin and downstream effectors, such as Akt/protein kinase B. In this study, we aimed to examine possible abnormality in the Akt/glycogen synthase kinase-3beta (GSK-3beta) axis of depressed suicide victims' brains. METHODS: Twenty suicide victims and 20 drug-free non-suicide subjects were included for a postmortem study. The ventral prefrontal cortex area (BA'11) was used, and antemortem diagnoses of major depression disorder (MDD) (DSM-IV) were made from Institution's records. The protein levels of GSK-3alpha/beta and Akt-1 were assayed with the Western blot method, and the kinase activity of Akt and GSK-3alpha/beta were determined by phosphorylation of specific substrates. RESULTS: There was no change either in GSK-3alpha/beta and Akt-1 protein levels or in lithium-inhibitable total GSK-3alpha/beta enzyme activity of the ventral prefrontal cortex. The enzyme activity of Akt decreased significantly [analysis of variance (ANOVA): F(3,36)=5.372; p= .003], whereas GSK-3beta activity increased significantly [ANOVA: F(3,36)=8.567; p= .002] in depressed suicide victims and non-suicide subjects but not in non-depressed suicide victims. CONCLUSIONS: This study indicated that the activity rather than the protein levels of Akt and GSK-3beta was altered. The alteration was associated with MDD rather than with suicide per se.

Thoracic aortic dissection associated with cocaine abuse.

Cardiovascular complications of cocaine abuse include myocardial ischemia and infarction, dysrhythmias, cardiomyopathies and aortic dissection. The case in point pertains to a 26-year-old, Caucasian male, substance abuser who suffered a thoracic aortic dissection following the use of crack cocaine. The autopsy and histological findings showed a connective tissue abnormality including a focal microcystic medial necrosis and a fragmentation of the elastic fibers in the arterial walls. Blood concentrations of cocaine and benzoylecgonine, taken individually, were considered to be within a potentially toxic range. Blood concentrations of methadone also indicated use of this drug at the same time. The small amounts of morphine found in the blood and urine were compatible with heroine or morphine use more than 24 h before death.