Suicide in Pretoria: A retrospective review, 2007 - 2010.

BACKGROUND: The World Health Organization has declared suicide a global ealth crisis, predicting that ~1.53 million people will commit suicide annually by 2020. OBJECTIVE: A study from South Africa reviewed 1 018 suicide cases in Pretoria over 4 years (1997 - 2000). Our study was undertaken to establish whether there have been substantial changes in the profile of suicide victims who died in Pretoria a decade later. METHODS: Case records at the Pretoria Medico-Legal Laboratory were reviewed retrospectively from 2007 to 2010. RESULTS: A total of 957 suicide cases were identified. Hanging was the most common method of suicide, followed by self-inflicted firearm injury. The true incidence of suicidal intake of prescription drugs/medication was difficult to determine, because of a backlog at the state toxicology laboratories. White males and females appeared to be over-represented among suicide victims, but there has been an increase in suicide among blacks. There seems to have been a substantial decrease in the use of firearms to commit suicide - possibly reflecting a positive outcome of gun control legislation that has been introduced in the interim. CONCLUSION: Suicide continues to constitute almost 10% of all fatalities admitted to the Pretoria Medico-Legal Laboratory, confirming suicide as a major cause of mortality in our society. Further research is needed to clarify the profile of suicidal deaths, with a view to informing resource allocation and to improve preventive strategies.

Case Report: Lightning-Induced Pneumomediastinum.

We present the case of a 41-year-old woman who was fatally injured during a witnessed lightning strike event and in whom autopsy revealed the unusual keraunopathological finding of overt pneumomediastinum. The possible pathophysiological mechanism(s) of causation of this phenomenon are discussed, with specific reference also to the "Macklin" effect and the role of blast overpressures associated with lightning strike. It is suggested that the latter may lead to sudden alveolar rupture, with subsequent rapid tracking of air along bronchovascular sheaths in a centripetal manner toward the hilum of the lung and thus into the mediastinum. A review of the blast literature suggests that this victim would have been exposed to a blast pressure wave of approximately 29-psi (200 kPa) to 72-psi (500 kPa) magnitude.

South Africa: Vulnerable Persons and Groups in a Vulnerable Democracy - Can Forensic Medical Services Help to Ensure Justice in Critical Times?

The role and contribution of an objective and professional medicolegal death investigation service should be valued and strengthened, especially in countries and communities where institutional and governmental corruption, incompetence, and abuse of power may exist, and where there are weak civil watchdog agencies such as a free press. South Africa is a fledgling democracy and is now at a critical juncture from a sociopolitical perspective. A number of incidents and historical perspectives are presented, all of which have specific relevance to the forensic medical community and which serve to illustrate the importance of ensuring the protection of the rights of vulnerable groups and persons who may easily suffer from disregard and abuse by state agencies and their representatives and which may ultimately impact very negatively on the broader society. Strengthening the organizational and legislative framework within which forensic pathologists can function is vital to ensure effective investigation in matters such as deaths in custody and of institutionalized persons/patients as well as deaths associated with police action and mob killings, to name but a few.

Managing the remains of fetuses and abandoned infants: A call to urgently review South African law and medicolegal practice.

This article reviews South African (SA) law and its impact on the medicolegal management of fetal remains emanating from elective and therapeutic termination of pregnancies, stillbirths and miscarriages and the remains of abandoned or exposed infants. It was found that remains are treated differently, some constituting medical waste while others have sufficient status in law to allow for burial. This approach results in some women or couples being denied a choice with regard to disposal via culturally relevant practices, and is insensitive to the fact that all remains ultimately constitute human remains. The article argues that SA law is in urgent need of reform, and turns to foreign law and forensic practice to shed light on possible alternative approaches that could assist with developing the SA position and thereby improve the practical management of fetal and infant remains in SA.

"Death at the wheel" due to tuberculosis of the myocardium: a case report.

According to the World Health Organization, an estimated 9 million people contracted tuberculosis (TB) with approximately 25% of TB cases being from Africa. TB was reported as the number one cause of natural death for the period 2011-2013 in South Africa. The first reported case of myocardial TB was in 1664 by Maurocordat and the first reported case of sudden cardiac death due to TB was made in 1977. We present a case report of myocardial TB in an apparently healthy, 35-year-old male who died suddenly while driving his car. The problems associated with the diagnosis of TB of the myocardium and an overview of the relevant literature is provided.

Deaths from bee stings: a report of three cases from Pretoria, South Africa.

In South Africa bee stings are most commonly caused by either Apis mellifera capensis or A. mellifera scutellata, indigenous species which are notoriously aggressive when compared to European honey bees. According to Statistics South Africa, 109 deaths were documented for the period 2001-2011 as having been caused by hornets, wasps, and bees (ICD10-X26). This appears to be a small number but, as was reported in Australia, these statistics might be inaccurate due to either over- or underreporting of cases. We report 3 cases of fatalities due to bee stings, including one with postmortem features of diffuse intravascular coagulopathy. A brief overview of the venom of the honey bee, reactions following a bee sting and possible mechanisms of death are presented. Confirming the diagnosis in these cases may be very problematic for the forensic pathologist, as in many cases minimal history is available and both external and internal examination could fail to reveal any specific signs of bee sting or other obvious morphologic abnormalities. Thus, there is a need for reliable confirmatory or supportive diagnostic tests.

The prevalence of HIV in the sudden, unexplained and unexpected death population at the Pretoria Medico-Legal Laboratory.

PURPOSE: To determine the prevalence of HIV in the sudden, unexplained and unexpected (SUU) death population admitted to the Pretoria Medico-Legal Laboratory. METHODS: This study was conducted at the Pretoria Medico-Legal Laboratory. Blood samples were obtained from decedents who died suddenly and/or unexpectedly, during autopsy, by a forensic pathologist. Sample collection continued until 100 valid samples were analysed for HIV antibodies. The data collected included demographic details and case-related information. RESULTS AND CONCLUSION: SUU deaths accounted for 14% of all cases admitted to the Pretoria Medico-Legal Laboratory. The HIV prevalence in the SUU deaths was 43%, which is 17% higher than the general mortuary population in Pretoria (p = 0.0045). The majority of these deaths were due to respiratory disease processes, with 12 cases having HIV/TB co-infection.

The Prevalence of HIV in the Sudden; Unexplained and Unexpected Death Population at the Pretoria Medico-Legal Laboratory

Purpose: To determine the prevalence of HIV in the sudden; unexplained and unexpected (SUU) death population admitted to the Pretoria Medico-Legal Laboratory.Methods: This study was conducted at the Pretoria Medico-Legal Laboratory. Blood samples were obtained from decedents who died suddenly and/or unexpectedly; during autopsy; by a forensic pathologist. Sample collection continued until 100 valid samples were analysed for HIV antibodies. The data collected included demographic details and case-related information.Results and Conclusion: SUU deaths accounted for 14% of all cases admitted to the Pretoria Medico-Legal Laboratory. The HIV prevalence in the SUU deaths was 43%; which is 17% higher than the general mortuary population in Pretoria ( p = 0.0045). The majority of these deaths were due to respiratory disease processes; with 12 cases having HIV/TB co-infection

The application of imaging technologies in the detection of trace evidence in forensic medical investigation.

In a country notorious for violent crime, it seems that South African medico-legal laboratories make minimal application of technology in the death investigation process and little attention is given to trace evidence. Non-destructive, non-invasive, portable and cost-effective tools are required. This study was conducted at the Pretoria Medico-Legal Laboratory. The surface area of the bodies and clothing of victims of fatal interpersonal violence were examined using a torch, magnifying lamp, portable digital microscope and alternate light source to gauge their potential for trace evidence detection. Most studies apply these and similar tools to inert surfaces, with few focusing on their application to human skin. There was a statistically significant difference in the detection of many of the evidence types between the naked-eye observation of the pathologists and the technologies. The different imaging technologies were compared as to their cost, evidence detection ability and ease of use. The most common evidence types discovered on the bodies and clothing of victims of fatal interpersonal violence, as well as the propensity of each tool to detect these, was evaluated in order to devise the best option for incorporation into the Pretoria Medico-Legal Laboratory routine. The digital microscope performed best overall followed by the magnifying lamp, torch and the Polilight(®). This study aimed to justify the investment of more time, effort and funding into trace evidence recovery in the South African mortuary environment.

A retrospective analysis of alcohol in medico-legal autopsied deaths in Pretoria over a 1 year period.

The misuse of alcohol has a particularly detrimental effect and is one of the most significant public health problems in South Africa and it also has an impact on the criminal justice system with evidence of association between high levels of alcohol and risk-taking behaviour, committing crimes, or being a victim of crime. A global trend has been set worldwide with alcohol being one of the most common drugs found in post mortem specimens and especially with regard to cases admitted for medico-legal autopsies. The influence of alcohol on the cause of death is either a contributory or an underlying factor in a substantial number of violent deaths. We retrospectively reviewed 1455 cases, in which alcohol was taken, of 2344 medico-legal autopsies done in 2009. We found that 47% of the cases tested positive for alcohol, with the reported blood alcohol concentrations varying from 0.01 to 0.95g per 100ml (mean=0.16±0.11g per 100ml) with the highest proportion being in the 0.10-0.19g per 100ml range. A breakdown of the results showed that road traffic accidents, assaults and firearm-related deaths predominated the alcohol-positive cases. The results showed that there was a definite correlation between alcohol consumption and the incidence of other that natural deaths.

Fatal head injuries in children under the age of 5 years in Pretoria.

The incidence of fatal injuries in children has been reported to be highest among children aged 1 to 4 years. Major causes of head injury include road traffic accidents, falls, and intentional or inflicted injury (such as nonaccidental injury syndrome). This study reviewed the profile of children (under 5 years of age) who had been admitted to a large urban medicolegal mortuary (in Pretoria, the capital city of South Africa), after having suffered fatal head injuries. This study was conducted over a 5-year period (from January 2004 through December 2008), and a total of 107 cases were identified for inclusion. These cases constituted nearly a fifth of admissions in this age group. The male-to-female ratio was 56%:44%, and the peak age of injury was less than 1 year. Most head injuries were sustained in road traffic accidents (70%) followed by falls (10%) and other types of blunt force injuries (9%). Only 1 case of nonaccidental injury syndrome (child abuse) was found. The great majority of deaths were deemed to have been accidental in nature (91%) with 6 (6%) homicides. Urgent review pertaining to the use of child restraint devices and the safety of pedestrians is required, and the institution of childhood injury registers could aid in reducing childhood fatalities in South Africa.

Bone marrow embolism to the lung in electrocution: two case reports.

Bone marrow embolism in electrocution was first described in the literature by Rappaport et al (Am J Pathol. 1951;27(3):407-433) in 1951. Two case studies demonstrating this phenomenon are reported here, one involving high-voltage exposure with associated skeletal injuries and the other involving domestic current and without evidence of skeletal injury. Both cases demonstrated bone marrow embolism on histologic examination of the lungs. The purposes of this article are to reiterate the existence of this unusual phenomenon and to consider possible pathogenetic mechanisms.

Toward a standardized investigation protocol in sudden unexpected deaths in infancy in South Africa: a multicenter study of medico-legal investigation procedures and outcomes.

INTRODUCTION: South Africa manifests a socio-economic dichotomy that shows features of both a developed and developing country. As a result of this, areas exist where a lack of resources and expertise prevents the implementation of a highly standardized protocol for the investigation of sudden and unexpected deaths in infants (SUDI). Although the medico-legal mortuaries attached to academic centers have the capacity to implement standardized protocols, a previous study conducted at two large medico-legal mortuaries indicated otherwise. This study also revealed that the exact number and incidence of sudden infant death syndrome (SIDS) cases was unknown. These findings prompted a multicenter study of the medico-legal investigation procedures and outcomes in five academic centers in South Africa. METHODS: A retrospective case audit was conducted for a 5-year period (2005-2009) at medico-legal laboratories attached to universities in Bloemfontein, Cape Town-Tygerberg, Durban, Johannesburg, and Pretoria. The total case load as well as the total number of infants younger than 1 year of age admitted to these mortuaries was documented. The case files on all infants younger than 1 year of age who were admitted as sudden and unexpected or unexplained deaths were included in the study population. Data collected on the target population included demographic details, the nature and scope of the post-mortem examinations, as well as the final outcome (cause of death). RESULTS: A total case load of 80,399 cases were admitted to the mortuaries over the 5 year period with a total of 3,295 (6.5 %) infants. In the infant group, 591 (0.7 %) died from non-natural causes and 2,704 (3.3 %) cases of sudden, unexpected and/or unexplained deaths in infants were admitted and included in the detailed case analysis study. One hundred and ninety-nine babies were between 0 and 7 days of age and 210 babies between 8 and 30 days. The remaining 2,295 infants were between 1 month and 12 months of age. Death scene investigation was done in a total of 14 (0.5 %) cases. Discrepancies were present in the extent of the macroscopic post-mortem examinations, as well as the type and extent of the ancillary investigations performed. The investigations were completed in 2,583 of the cases. The majority of these infants died from natural disease processes [1,976 infants (76.5 %)]. Bronchopneumonia was the leading cause of natural deaths at all the mortuaries [674 cases (26.1 %)]. SIDS was diagnosed in only 224 cases (8.7 %) and in 383 (14.8 %) cases, where a full post-mortem examination with ancillary investigations was conducted; the cause of death was recorded as "unascertained." CONCLUSIONS: This study indicated that the admission criteria (to medico-legal mortuaries) and the investigative process/protocols in cases of SUDI differ greatly among 5 of the largest academic medical institutions in South Africa. Establishing and implementing standardized admission criteria (to medico-legal mortuaries) and implementing uniform investigative and autopsy protocols would appear to be an essential prerequisite to gain better understanding of the mystery of SIDS in South Africa.

The incidence, pathology of trauma and victim profiles of homicidal deaths in Pretoria, South Africa (2007-2008).

This study aimed to establish the incidence of homicide, associated pathology of trauma and victim profiles in cases admitted to or managed as homicidal deaths at the Pretoria Medico-Legal Laboratory (PMLL) over the period of 2007-2008. A total of 1088 cases were reviewed. Homicides accounted for 22.7% of all cases admitted to the PMLL. The majority of homicide victims were male individuals (87.0%). The most common cause of death was gunshot wounds (42.6%), followed by blunt force trauma (25.1%). Homicides are most likely to occur at the victim's place of residence (28.5%) and only 37.4% of victims survive long enough to receive hospital care. The results of this study seem to concur with international findings for the most part, with a few interesting deviations. Highlighting at-risk groups, as well as dangerous locations and incident times, creates the potential to decrease the occurrence of unnecessary deaths by generating an awareness of the trends.

Lightning medicine in South Africa.

South Africa has a rich history of lightning research; however, research on the clinical and pathological effects and features of lightning-related injury (keraunomedicine or lightning medicine) remains neglected locally. By providing an overview of keraunomedicine and focussing on South African perspectives, we hope to raise awareness and propose that a concerted and co-ordinated attempt be made to report and collate data regarding lightning strike victims in South Africa.