Technical note: Temperature estimation accuracy based on colourimetry of embalmed human and fresh non-human burned bone.

Estimation of the exposure temperature of skeletal remains can be done by means of colourimetry and a previously published decision model for the colourimetric data, resulting in clusters that represent a range of exposure temperature. The method was based on thermally altered freshly burned human skeletal remains. However, in practice the origin or pre-burning condition of (possibly fragmentary) burned remains can be unknown. Further, in order to use the colourimetric analysis, and accompanying decision model, it is important to have a reference or test set. Fresh human material is not available for this purpose in all countries. Hence, the classification accuracy of the decision model was tested for, in some countries more readily available substitutes for fresh bone; embalmed human bone and non-human bone. The model yielded high accuracies for these sample materials, making it possible to create a reference or test set from fresh non-human and embalmed human bone as substitute for human, and also to use the decision model for these deviating samples in practice.

Using case vignettes to study the presence of outcome, hindsight, and implicit bias in acute unplanned medical care: a cross-sectional study.

BACKGROUND AND IMPORTANCE: Various biases can impact decision-making and judgment of case quality in the Emergency Department (ED). Outcome and hindsight bias can lead to wrong retrospective judgment of care quality, and implicit bias can result in unjust treatment differences in the ED based on irrelevant patient characteristics. OBJECTIVES: First, to evaluate the extent to which knowledge of an outcome influences physicians' quality of care assessment. Secondly, to examine whether patients with functional disorders receive different treatment compared to patients with a somatic past medical history. DESIGN: A web-based cross-sectional study in which physicians received case vignettes with a case description and care provided. Physicians were informed about vignette outcomes in a randomized way (no, good, or bad outcome). Physicians rated quality of care for four case vignettes with different outcomes. Subsequently, they received two more case vignettes. Physicians were informed about the past medical history of the patient in a randomized way (somatic or functional). Physicians made treatment and diagnostic decisions for both cases. SETTING AND PARTICIPANTS: One hundred ninety-one Dutch emergency physicians (EPs) and general practitioners (GPs) participated. OUTCOME MEASURES AND ANALYSIS: Quality of care was rated on a Likert scale (0-5) and dichotomized as adequate (yes/no). Physicians estimated the likelihood of patients experiencing a bad outcome for hindsight bias. For the second objective, physicians decided on prescribing analgesics and additional diagnostic tests. MAIN RESULTS: Large differences existed in rated quality of care for three out of four vignettes based on different case outcomes. For example, physicians rated the quality of care as adequate in 44% (95% CI 33-57%) for an abdominal pain case with a bad outcome, compared to 88% (95% CI 78-94%) for a good outcome, and 84% (95% CI 73-91%) for no outcome ( P  < 0.01). The estimated likelihood of a bad outcome was higher if physicians received a vignette with a bad patient outcome. Fewer diagnostic tests were performed and fewer opioids were prescribed for patients with a functional disorder. CONCLUSION: Outcome, hindsight, and implicit bias significantly influence decision-making and care quality assessment by Dutch EPs and GPs.

[Retrospective study of 20 years of post-mortem examination of young adults]. / De meerwaarde van postmortaal onderzoek.

OBJECTIVE: This study is designed to gain insight into the cause of death in deceased young adults, by analyzing autopsies and other post-mortem examinations including their contribution into finding the cause of death DESIGN: Retrospective cohort study. METHOD: Included were adults aged between 18-45 years old who underwent a clinical autopsy at the Isala Klinieken in Zwolle between January 2000 and October 2022. Included patients had a natural cause of deaths and were divided into two categories: expected and unexpected deaths. For each patient the post-mortem examination and their contribution to diagnose the cause of death were determined, among other things. Collected data was processed in a database and analyzed. RESULTS: Between January 2000 and October 2022, 212 autopsies were performed in the 18-45 age group. Of these 212 patients, 54 (25,5%) were expected deaths and 158 (74,5%) unexpected deaths. 116 patients had an unknown cause of death (7 expected vs. 109 unexpected). After post-mortem examination, this number has decreased to 15 deaths (expected 0 vs. unexpected 15). This is a reduction form 54,7% to 7,1%. Of the 96 presumed diagnoses/causes of death for autopsy, 16 (16,7%) cases were reclassified as Goldman score 1 discrepancies. CONCLUSION: Performing post-mortem examinations contributes to reducing the number of unknown causes of death. Post-mortem examinations also provide knowledge about illnesses, the clinical course of syndromes and the actual cause of death in (young) adults, even when mortality is expected.

Subaerial Decomposition of Small-Sized Remains in The Netherlands: Important Findings Regarding the PMI of a Four-Year Taphonomic Study.

Studying post-mortem changes based on signs of decomposition (e.g., using scoring models) is one of the methods used in scientific studies to relate observable changes to the post-mortem interval (PMI). The majority of the studies on cadaver decomposition are based on large cadavers. There is limited literature on the decomposition pattern and rate of small cadavers, even though it is at least as important to be able to estimate the PMI for infants and subadults. Therefore, it is crucial to acquire knowledge of the decomposition process of child-sized remains. To fill this knowledge gap, a season-based subaerial outdoor decomposition study was conducted with small pig cadavers at the Forensic Anthropological Outdoor Research Facility located in Den Ham, The Netherlands, over a period of 4 years. Den Ham is located in the eastern part of the Netherlands, close to the German border, and has a temperate maritime climate, with a Cfb classification according to the Köppen-Geiger system. Salient findings were acquired during the decomposition study, specifically regarding a deviating decomposition rate during winter and the subsequent spring, reproducibility, the effect of body weight, post-mortem movement, the effect of heavy rainfall on insect activity, delayed bloating, the interaction of different insect species, and invertebrate activity. This article includes a systemic review of the results obtained during this four-year decomposition study and discusses the impact of the findings on the estimation of the PMI.

Mechanical or thermal damage: differentiating between underlying mechanisms as a cause of bone fractures.

To investigate the differences between pre- and post-fire fractures, 30 human forearm bones were subjected to either blunt-force impact, burning, or both. Bones, covered in soft tissue and wrapped in clothing, were burned in a reconstructed house fire. The burning context and dynamics led to differential burning, that was equal amongst the three groups. To evaluate the damage to the bones, a data collection sheet was developed based on the current literature on fracture features. To analyze the relation between exposure temperature and fracture class and occurrence, color was measured to estimate the exposure temperature. Observable and measurable changes on bone, and fracture surfaces, were macro- and microscopically analyzed. Many features overlapped between the three groups, and thus are not usable for differentiation. Fractures caused by blunt force impact (post-mortem, pre-fire) showed a rough fracture surface with smoothness in curved/slanted regions near the margin after burning, while heat-induced bone fractures showed a smooth fracture surface. The margins and surface of bone fractures that originated after the fire (indirect heat-induced) were evenly discolored, whereas heat-induced bone fractures showed uneven discoloration of the fracture margin and surface. Although there were generally more heat-induced fractures in the 450-700 °C range, no other distinctive trend was observed between exposure temperature and class of fractures.

[Hardly any objection from patients against medical information feedback among healthcare workers in the acute care]. / Nauwelijks bezwaar van SEH-patiënten tegen terugkoppeling medische gegevens.

OBJECTIVE: Feedback of patients' medical information among healthcare workers within the acute care could improve the quality of care during an Emergency Department (ED) visit. However, in practice, feedback among healthcare workers leads to juridical discussions. Therefore, this study explores whether ED patients agree with medical information feedback among healthcare workers in the acute care, such as the ambulance staff and ED physicians, and whether this was different from permission for feedback to the general practitioner. METHOD: Multicenter cross-sectional study in three EDs in the Netherlands. Patients ≥18 years old, presented per ambulance between May 3rd and June 12th 2021, filled in a questionnaire asking whether they agree with medical information feedback to ambulance staff and reviewing medical files for follow-up by ED physicians. RESULTS: A total of 369 patients were included with a mean age of 68 years (SD 18). In total, 98,9% of patients agreed with medical information feedback to ambulance staff, which was not significantly different from the 99,2% of patients who agreed with feedback to the general practitioner (p=1.00). CONCLUSION: All but a few ED patients agreed with medical information exchange to ambulance personnel and follow-up by ED-physicians. During ED-visits, medical information feedback to the general practitioner is a standard procedure, with the possibility of an opt-out. In our opinion, feedback and exchange of medical information within the acute care should be arranged similarly.

High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the Netherlands.

PURPOSE: Between 0.1-3% of injured children who present at a hospital emergency department ultimately die as a result of their injuries. These events are typically reported as unnatural causes of death and may result from either accidental or non-accidental trauma (NAT). Examples of the latter include trauma that is inflicted directly or resulting from neglect. Although consultation with a forensic physician is mandatory for all deceased children, the prevalence of fatal inflicted trauma or neglect among children is currently unclear. METHODS: This is a retrospective study that included children (0-18 years) who presented and died at one of the 11 Level I trauma centers in the Netherlands between January 1, 2014, and January 1, 2019. Outcomes were classified based on the conclusions of the Child Abuse and Neglect team or those of forensic pathologists and/or the court in cases referred for legally mandated autopsies. Cases in which conclusions were unavailable and there was no clear accidental cause of death were reviewed by an expert panel. RESULTS: The study included 175 cases of childhood death. Seventeen (9.7%) of these children died due to inflicted trauma (9.7%), 18 (10.3%) due to neglect, and 140 (80%) due to accidents. Preschool children (< 5 years old) were significantly more likely to present with injuries due to inflicted trauma and neglect compared to older children (44% versus 6%, p < 0.001, odds ratio [OR] 5.80, 95% confidence interval [CI] 2.66-12.65). Drowning accounted for 14 of the 18 (78%) pediatric deaths due to neglect, representing 8% of the total cases. Postmortem radiological studies and autopsies were performed on 37 (21%) of all cases of childhood death. CONCLUSION: One of every five pediatric deaths in our nationwide Level I trauma center study was attributed to NAT; 44% of these deaths were the result of trauma experienced by preschool-aged children. A remarkable number of fatal drownings were due to neglect. Postmortem radiological studies and autopsies were performed in only one-fifth of all deceased children. The limited use of postmortem investigations may have resulted in missed cases of NAT, which will result in an overall underestimation of fatal NAT experienced by children.

The time of death in Dutch court; using the Daubert criteria to evaluate methods to estimate the PMI used in court.

When a capital crime is committed the post-mortem interval (PMI) is of particular importance in investigating a suspect's alibi in court. A forensic expert can use different methods to estimate the PMI. This research focuses on who is considered an expert in court and whether the methods used to estimate the PMI are reliable. In this study, the methods used to estimate the PMI and the experts consulted, available in Dutch jurisprudence, in the period 2010-2019 were investigated. Ninety-four judicial cases were included and multiple experts and methods of estimating the PMI were found. As part of this study, the methods that were used to estimate the PMI in court were subjected to the Daubert criteria. Of these methods, only the Henssge nomogram and entomological methods met the Daubert criteria. However, the methods are only useful when applied by the right forensic expert and in the right manner. Unfortunately, this was not always the case.

Validation of a new method for saliva cortisol testing to assess stress in first responders.

BACKGROUND: Acute or chronic stress can lead to physical and mental disorders. Measuring cortisol can objectify the degree of stress. Cortisol is traditionally measured in serum, but recently the relevant fraction of free cortisol can be reliably measured in saliva, using the very sensitive liquid chromatography tandem mass spectrometry (LC-MS/MS) method. The use of saliva is non-invasive and allows easy serial testing around stressful events. The main objective of this study is to investigate whether serial saliva cortisol determinations using the LC-MS/MS method can be used to assess the stress response that first responders may experience during moments of acute professional deployment in their daily work. METHODS: Healthy first responders (police officers, firefighters, rapid response team, ambulance personnel, first aid and emergency medical personnel) were recruited to participate in a Euregional high-reliability simulation training ('Be Aware'-scenario training, 19 April 2018). At three time points, simultaneous venous blood samples and saliva samples were obtained. These time points were 1 hour before, immediately after and 10 hours after the simulation training. The correlation between changes in saliva cortisol measured by LC-MS/MS and serum cortisol at all three time points was determined. Results were compared with spectators not directly participating in the simulation. RESULTS: 70 subjects participated in the simulation. There was a strong correlation between the changes in saliva and blood cortisol at the three time points. A significant increase in blood and saliva cortisol was shown 1 hour after the experienced stress moments. The levels had almost completely returned to baseline in all healthy volunteers 10 hours later. Cortisol in spectators was unaffected. CONCLUSION: Serial saliva cortisol measurements using LC-MS/MS is a reliable and fast non-invasive functional stress assay, which can be easily collected in daily practice and used for investigation and monitoring of stress response in front line responders.

Phosphorescence of thermally altered human bone.

Bone has photoluminescent characteristics that can aid the analysis of thermally altered human skeletal remains as part of the forensic anthropological investigation. Photoluminescence stands collectively for fluorescence and phosphorescence. Because the difference in lifetime between fluorescence and phosphorescence is usually in the range of nano- to microseconds, it is only possible to visually determine whether bone phosphoresces when the lifetime is long enough to be observed. For this study, a distinction was made between long-decay and short-decay phosphorescence. So far, it was unknown whether (thermally altered) human bone emits long-decay phosphorescence after being illuminated and, thus, whether phosphorescence contributes to the observed photoluminescence. If so, whether the observable phosphorescence is dependent on temperature, exposure duration, surrounding medium, bone type, skeletal element, and excitation light and could aid the temperature estimation of heated bone fragments. In this study, bone samples were subjected to heat in the range of from room temperature to 900 °C for various durations in either air or adipose as surrounding medium. In addition, different skeletal elements of a human cadaver were recollected after cremation in a crematorium. Both sample collections were illuminated with light of different bandwidths and visually inspected for phosphorescence and photoluminescence. The samples were scored by means of a scoring index for the intensity of long-decay phosphorescence and photographically documented. The results show that thermally altered human bone fragments do phosphoresce. The observed phosphorescence is more dependent on temperature than on exposure duration, surrounding medium or skeletal element. Of the used wavelength bands, ultraviolet light provided the most temperature-related information, showing changes in both phosphorescence intensity and emission spectrum. Long-decay phosphorescence and fluorescence with short-decay phosphorescence coincide; however, there are also temperature-dependent differences. It is therefore concluded that phosphorescence contributes to the observable photoluminescence and that the visibly observable phosphorescent characteristics can aid the temperature estimation of cremated human skeletal fragments.

Suicide by helium inhalation in the Netherlands between 2012 and 2019.

INTRODUCTION: In 2012 and 2013 a movie and a book about a 'dignified end of life' were published in the Netherlands. These items described suicide using an 'exit bag' to establish asphyxiation using helium (the helium method). 'Right-to-die-organisations' inform the elderly about this method. The purpose of this study is to investigate whether the use of suicidal asphyxiation by means of the helium method substituted other, related, methods following its publication in the Netherlands. MATERIAL AND METHODS: We analysed suicides in the Netherlands over the period from 1 July 2012 to 30 June 2019. We compared the number of deaths caused by the helium method with other, related, cases. Secondly, we related these deaths to the total number of inhabitants and suicides recorded by Statistics Netherlands. RESULTS: The study showed a stable trend in the use of the helium method in the period 2012-2019 and this was the same for the other, related methods. Individuals using the helium method were significantly younger than those using other, related, methods. At the scene of death, information about suicide and suicide notes were found more often at 'helium method' cases than with the 'other, related, methods' cases. Family was significantly more often present during a helium method suicide than during suicide by other, related, methods. DISCUSSION: The number of suicides by the helium method and other, related, cases is stable in the Netherlands over the past years. Therefore, we conclude that there is no substitution effect within this category of suicides. Whilst 'right-to-die-organisations' strive to inform the old and sick of the helium method, it is noteworthy that the individuals using the helium method are significantly younger than the individuals who choose other, related, methods.

Amsterdam Research Initiative for Sub-surface Taphonomy and Anthropology (ARISTA) - A taphonomic research facility in the Netherlands for the study of human remains.

A taphonomic research facility for the study of human remains was recently realized in Amsterdam, the Netherlands, to systematically investigate the decomposition of the human body under known conditions. Governmental authorization was obtained to make use of the body donation program of the Amsterdam University Medical Centers, location Academic Medical Center, for this specific purpose. In contrast to the small number of comparable initiatives elsewhere, this facility specifically allows for the study of buried bodies e.g. with the use of telemetry and remote sensing. Here, we discuss the concept of body donation in the Netherlands, its role in taphonomic research, and the sequence of events that preceded the realization of this facility, which is the first of its kind in Europe. In addition to offering novel research options to the scientific community, we hope that it will also pave the way for the successful realization of similar initiatives in other locations.

Colourimetric analysis of thermally altered human bone samples.

At this moment, no method is available to objectively estimate the temperature to which skeletal remains have been exposed during a fire. Estimating this temperature can provide crucial information in a legal investigation. Exposure of bone to heat results in observable and measurable changes, including a change in colour. To determine the exposure temperature of experimental bone samples, heat related changes in colour were systemically studied by means of image analysis. In total 1138 samples of fresh human long bone diaphysis and epiphysis, varying in size, were subjected to heat ranging from room temperature to 900 °C for various durations and in different media. The samples were scanned with a calibrated flatbed scanner and photographed with a Digital Single Lens Reflex camera. Red, Green, Blue values and Lightness, A-, and B-coordinates were collected for statistical analysis. Cluster analysis showed that discriminating thresholds for Lightness and B-coordinate could be defined and used to construct a model of decision rules. This model enables the user to differentiate between seven different temperature clusters with relatively high precision and accuracy. The proposed decision model provides an objective, robust and non-destructive method for estimating the exposure temperature of heated bone samples.

The risk of emerging new psychoactive substances: The first fatal 3-MeO-PCP intoxication in The Netherlands.

Structural analogs of classic drugs, also called designer drugs, are a booming market due to the easy accessibility on the internet and their legal status. One of those 'legal highs' is an analog of phencyclidine, namely 3-methoxyphencyclidine (3-MeO-PCP). Very few fatalities have been reported where 3-MeO-PCP contributed to the death of an individual. We present the first fatal case in the Netherlands and one of the few worldwide. Postmortem biological samples and the presumed abused unknown substance, sold as ant poison, were obtained. 3-MeO-PCP was detected, and the resulting concentration was 152 µg/l in whole blood. The presumed taken unknown sample was identified as 3-MeO-PCP and thus linked to the victim. The cause of death was a combination of 3-MeO-PCP, amphetamine, and alcohol. Improved diagnostic skills are necessary to face these emerging novel psychoactive substances also in light of public health and social risks.

Correction to: The value of postmortem computed tomography in paediatric natural cause of death: a Dutch observational study.

When first published, this article inadvertently listed the Dutch NODO group individually within the author list without specifying the names of the collaborators. The collaborators have been listed within the Acknowledgements section only. The corrected author list is presented in this Correction.

Evaluation of postmortem biochemical markers: Completeness of data and assessment of implication in the field.

Throughout the years an increase has been observed in research output on biochemical markers for determining the postmortem interval (PMI). However, to date, a complete overview is missing on the results of postmortem biochemical markers (PBM's) for PMI estimation. In this paper, literature was reviewed in order to identify the knowledge lacunae of PBM research from a practical point of view. A three-step approach was undertaken in order to achieve the set goal. Literature was collected, the PBM's were evaluated for completeness by means of a scorings index based on set criteria, and PBM's were subsequently evaluated in light of the Daubert &Frye criteria for scientific evidence in court. Seven PBM's were found to be well investigated, from which potassium had the highest completion score. However, none of these PBM's could be qualified as suitable for court evidence. Further, this study revealed that the majority of PBM's (94%) is not well investigated. Consequently, these PBM's did not meet Daubert &Frye criteria. In order to improve the assessment for use of PBM's as evidence in court regarding PMI estimation, PBM's should be investigated more thoroughly and data should be made readily available.

The correlation between the Aquatic Decomposition Score (ADS) and the post-mortem submersion interval measured in Accumulated Degree Days (ADD) in bodies recovered from fresh water.

The Aquatic Decomposition Score (ADS) made by van Daalen et al., was developed to approximate the Post-Mortem Submersion Interval (PMSI) in bodies recovered in salt water. Since the decomposition process in salt water differs from the process in fresh water due to salinity, the temperature, and the depth of the water, we wanted to investigate whether there is a correlation between the ADS and the PMSI and if the ADS can be used to make an estimation of the PMSI in bodies recovered from fresh water. For the latter, the PMSI was measured using Accumulated Degree Days (ADD). In our study we included seventy-six human remains found outdoors in fresh water. Their decomposition was measured using the ADS. A strong correlation was found between the ADS and the PMSI. Also, it was found that the ADS can significantly estimate the ADD. Despite the more varied circumstances under which bodies in fresh water are found when compared to those found in salt water, the ADS can be used to measure the decomposition and accurately estimate the ADD, and thus the PMSI. More research is needed to validate our method and make a prediction model with smaller confidence intervals.

Temperature estimations of heated bone: A questionnaire-based study of accuracy and precision of interpretation of bone colour by forensic and physical anthropologists.

The colour of thermally altered bone, recovered from archaeological and forensic contexts, is related to the temperature(s) to which it was exposed. As it is heated bone changes in colour from ivory white, to brown and black, to different shades of grey and chalky white. It should be possible to estimate exposure temperature based on visually observable changes in colour. In forensic casework the temperature that human remains have been subjected to can reveal information about the existence and nature of foul play. Therefore, it is important to understand the accuracy and precision of visual methods of temperature estimation. Twenty-eight forensic and/or physical anthropologists estimated the temperature that fourteen bone samples had been subjected to based only on their colour via an online questionnaire. Bone samples shown in the questionnaire ranged from unheated to having been heated at 1200°C. Respondents were given two options to base their estimates on, resulting in a multiple response analysis. The results suggest it is difficult to identify the correct temperature range based solely on colour. Most respondents felt confident enough to opt for a single option, which may have contributed to a relatively high number of incorrect estimates. Low accuracy and precision were found for most of the temperature ranges, especially in the lower and middle categories. This study demonstrates that caution should be taken in the reliance upon temperature estimates of thermally induced colour changes in bone and the need for further research and improved methods.

The value of postmortem computed tomography in paediatric natural cause of death: a Dutch observational study.

BACKGROUND: Postmortem CT is a relatively new field of interest within paediatric radiology. This paper focusses on its value in cases of unexpected natural death. OBJECTIVE: We report on an observational Dutch study regarding the value of postmortem CT in children with an assumed natural unexpected death because postmortem CT is part of the Dutch NODO (additional investigations of cause of death) procedure. MATERIALS AND METHODS: We included consecutive children who fulfilled criteria for the NODO procedure and were therefore referred to one of the centres for the procedure. Postmortem CT was performed in all cases and skeletal survey was performed in all children ages <5 years. The cause of death was defined in a consensus meeting. RESULTS: We included a total of 54 children (30 boys, median age 1.1 years, and 24 girls, median age 0.8 years). A definitive cause of death was established in 38 cases. In 7 cases the cause of death could be identified on postmortem CT. In 7 cases imaging findings were clinically relevant but did not lead to a cause of death. In the remaining 40 cases postmortem CT did not add to the diagnostic workup. CONCLUSION: Our study shows that in a group of children who unexpectedly died of an assumed natural cause of death and in whom a cause of death was found at autopsy, postmortem CT detected the cause of death in a minority of cases (12.9%). In the majority of cases (74.1%) postmortem CT did not add value in diagnosing the cause of death.