Showing papers in "Medicine Science and The Law in 2018"

Post-mortem computed tomography: Technical principles and recommended parameter settings for high-resolution imaging:

Abstract: Post-mortem computed tomography (PMCT) has become a standard procedure in many forensic institutes worldwide. However, the standard scan protocols offered by vendors are optimised for clinical radiology and its main considerations regarding computed tomography (CT), namely, radiation exposure and motion artefacts. Thus, these protocols aim at low-dose imaging and fast imaging techniques. However, these considerations are negligible in post-mortem imaging, which allows for significantly increased image quality. Therefore, the parameters have to be adjusted to achieve the best image quality. Several parameters affect the image quality differently and have to be weighed against each other to achieve the best image quality for different diagnostic interests. There are two main groups of parameters that are adjustable by the user: acquisition parameters and reconstruction parameters. Acquisition parameters have to be selected prior to scanning and affect the raw data composition. In contrast, reconstruction parameters affect the calculation of the slice stacks from the raw data. This article describes the CT principles from acquiring image data to post-processing and provides an overview of the significant parameters for increasing the image quality in PMCT. Based on the CT principles, the effects of these parameters on the contrast, noise, resolution and frequently occurring artefacts are described. This article provides a guide for the performance of PMCT in morgues, clinical facilities or private practices.

Factors involved in the assessment of paediatric traffic injuries and deaths

Abstract: Motor-vehicle collisions are the leading cause of unintentional injury and death in children in many parts of the world, including Europe, North America and Australia. The number of fatal collisions has decreased considerably in countries where safety measures such as child restraints, seat belts and air bags have been introduced, providing protection for children within vehicles, although it is recognised that there have been concomitant improvements in emergency responses and techniques, and in hospital treatments. Helmets and changes in external vehicle designs have been implemented to protect paediatric pedestrians and cyclists. However, despite the development of safety guidelines and technologies, injuries still occur. This paper provides an overview of the role of motor-vehicle collisions in paediatric morbidity and mortality to analyse the nature and aetiology of common fatal and non-fatal injuries in children that may present for forensic assessment as passengers, pedestrians or cyclists.

Molecular markers used in forensic genetics

Abstract: Forensic genetics is a field that has become subject to increasing interest in recent years. Both the technology and the markers used for forensic purposes have changed since the 1980s. The minisatellite sequences used in the famous Pitchfork case introduced genetics to the forensic sciences. Minisatellite sequences have now been replaced by more sensitive microsatellite markers, which have become the basis for the creation of genetic profile databases. Modern molecular methods also exploit single nucleotide polymorphisms, which are often the only way to identify degraded DNA samples. The same type of variation is taken into consideration in attempting to establish the ethnicity of a perpetrator and to determine phenotypic traits such as the eye or hair colour of the individual who is the source of the genetic material. This paper contains a review of the techniques and molecular markers used in human and animal forensic genetics, and also presents the potential trends in forensic genetics such as phenotyping.

Complex regional pain syndrome type 1 in the medico-legal setting: High rates of somatoform disorders, opiate use and diagnostic uncertainty.

Abstract: ObjectiveThe aim of this study was to review demographic and clinical characteristics of patients with complex regional pain syndrome type 1 (CRPS) seen in a UK medico-legal setting – particularly ...

A forensic evaluation of impalement injuries.

Abstract: Impalement injuries transfix a victim in an inescapable or helpless position. A study was undertaken at Forensic Science SA from 2002 to 2016 of all impalement deaths. There were six vehicle accidents (M:F=5:1; age 14-67 years, average age 38.5 years) involving impalements with a tree branch ( n=2; groin and chest), a metal pipe ( n=2; leg and head), a metal bridge railing (groin) and a metal fence post (chest). Two cases (both males, aged 47 and 18 years) had slipped on fences/gates, with impalements of the ankle and groin. A case of suicide (male, aged 80 years) was impaled through the head on a bolt fixed to the floor. A homicide case (male, aged 27 years) involved impalement through the chest by a spear from a spear gun. In certain cases (e.g. with anogenital injuries), differentiating accidental from inflicted impalement injuries may be difficult. In equivocal cases, adequate scene evaluations with photographic documentation are required prior to autopsy, ideally with the object available for examination.

Toxicological hair analysis: Pre-analytical, analytical and interpretive aspects.

Abstract: Background and aims Hair analysis for drug detection is one of the widely accepted imperative techniques in the field of forensic toxicology. The current study was designed to investigate the efficacy of chromatography for detection of drugs of abuse in hair. Method A comprehensive review of articles from last two decades on hair analyses via PubMed and similar resources was performed. Issues concerning collection, decontamination and analytical techniques are summarised. Physiochemical nature of hair, mechanism of drug incorporation and its stability in hair are briefly discussed. Furthermore, various factors affecting results and interpretation are elucidated. Result A hair sample is chosen over traditional biological samples such blood, urine, saliva or tissues due to its inimitable ability to provide a longer time frame for drug detection. Its collection is almost non-invasive, less cumbersome and does not involve any specialised training/expertise. Recent advances in analytical technology have resulted in better sensitivity, reproducibility and accuracy, thus providing a new arena of scientific understanding and test interpretation. Conclusion Though recent studies have yielded many insights into drug binding and drug incorporation in hair, the major challenge in hair analysis lies in the interpretation of results, which may be affected by external contamination and thus lead to false-positives. Therefore, there is a need for more sensitive and selective analysis methods to be developed in order to minimise factors that induce the effect of melanin, age and so on, and this would certainly provide a new dimension to hair analysis and its applications.

Observations on self-incineration characteristics in 24 years (1993-2016) of autopsies in the city of Milan.

Abstract: Self-incineration is one of the most dramatic and lethal suicide methods. It is rarely reported in Western countries and is more frequent in developing regions. We illustrate the forensic cases of ...

Gastrointestinal causes of sudden unexpected death: A review.

Abstract: Gastrointestinal conditions are a less common cause of sudden unexpected death when compared to other conditions such as cardiovascular conditions, but they are equally important. Various congenital and acquired gastrointestinal conditions that have resulted in sudden unexpected death are discussed. The possible lethal mechanisms behind each condition, along with any associated risk factors or secondary diseases, have been described. Through this article, we aim to highlight the need for physicians to prevent death in such conditions by ensuring that subclinical cases are diagnosed correctly before it is too late and by providing timely and efficacious treatment to the patient concerned. In addition, this review would certainly benefit the forensic pathologist while dealing with cases of sudden unexpected death due to gastrointestinal causes. This article is a review of the major gastrointestinal causes of sudden unexpected death. In addition, related fatal cases encountered occasionally in forensic autopsy practice are also included. There are several unusual and rare causes of life-threatening gastrointestinal bleeding that may lead to sudden unexpected death to cover all the entities in detail. Nevertheless, this article is a general guide to the topic of gastrointestinal causes of sudden unexpected death.

Detention under section 136: Why is it increasing?

Abstract: There has been a significant increase in the use of section 136 of the Mental Health Act 1983 in England and Wales, particularly over the past 10 years, but the reasons for this increase remain unclear. This paper presents a history of English mental-health legislation and the current evidence relating to the use of section 136. It suggests that changing police attitudes, socio-economic factors and diminished resources amongst both the police and mental-health services may have contributed towards its increase. The strain placed on health services may have also resulted in a greater reliance on the police force as an access point to NHS care and could result in the inappropriate use of section 136. With the principle of the 'least restrictive option' at the heart of the Mental Health Act, this advocates the need for reform.

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

Abstract: 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

Patient perspectives of being detained under section 136 of the Mental Health Act: Findings from a qualitative study in London

Abstract: Introduction Detention under section 136(1) of the Mental Health Act 1983 allows for the police to arrest a person from a public place and remove them to a 'place of safety', typically an emergency department or mental-health unit if it is 'in the interests of that person or for the protection of other persons in immediate need of care or control'. Aims/objective: The aim of this study was to describe the views and perceptions of the process for people with lived experience of mental distress who have been detained under section 136 of the Mental Health Act 1983. Method Semi-structured interviews were conducted with a non-probability sample of people with lived experience of mental distress who have been detained under section 136 across Greater London. Interviews were transcribed and thematically analysed using grounded theory. Fifty-eight people with lived experience of mental distress detained under section 136, including four carers, participated in this study. Results Three interwoven themes were identified: (a) process or procedural issues; (b) the professional-patient relationship; and (c) the importance of a supportive therapeutic environment. Conclusion The length of time, multiple assessment points and processes juxtapose against the need for a humane physical environment and supportive therapeutic interactions from all professional agencies. It is unclear how changes proposed in the Policing and Crime Act 2017 will address these patient needs.

Sudden death due to an invasive mole in a young primigravida: Precipitous presentation masquerading the natural manner:

Abstract: Pulmonary metastasis is a well-known complication of an invasive mole. However, sudden death due to haemoptysis resulting from a metastatic invasive mole is extremely rare. We report the sudden une...

Faith in thy threshold

Abstract: The current study focussed on the decision-making processes of jurors. The study investigated how jurors make a decision, if they integrate information within their decision-making process and if cue utilisation thresholds promote confirmation bias. To do this, 108 participants listened to one of nine cases. These participants were asked to give a likelihood of guilt rating after each piece of evidence, to state what the last piece of information was that they needed to make a decision and to give a final verdict at the end of a trial. The results highlighted that threshold decision making was being utilised, that information integration may allow thresholds to be reached and that thresholds may promote confirmation bias to reduce cognitive dissonance. In conclusion, this suggests that jurors integrate information until they reach a leading verdict, then the evaluation of information is distorted to support the leading threshold. Implications relate to legal instructions for jurors.

Histological indicators of cutaneous lesions caused by electrocution, flame burn and impact abrasion.

Abstract: Cutaneous electrocution marks are the key indicator that aid forensic pathologists in establishing electrocution as the cause of death, especially when crime scene and internal autopsy findings do not provide significant information. The gross findings of electrocution mark are often confused with impact abrasion and the burns produced by high voltage flash are often indistinguishable with flame burns. The present study aims to identify cutaneous light microscopic histological indicators, which are peculiar to electrocution marks, burns and impact abrasions. Cutaneous tissue samples from injury sites and healthy areas were collected from 45 autopsy cases and examined under light microscope. The histological changes observed were intra-epidermal separation of cells, sub-epidermal separation, coagulative necrosis in the epidermis and dermis, epidermal and dermal cell nuclear elongation and streaming, pyknotic tightly packed epidermal nuclei, dark staining of epidermal nuclei, homogenization of dermal collagen, and vascular dilatation, congestion, hemorrhage and thrombosis. The study revealed that certain histological changes are helpful in differentiating electrocution mark from other types of injuries, which present themselves in various types morphologically and thus facilitate correct diagnosis during autopsy. Pyknotic and tightly packed epidermal nuclei was found characteristic of electrocution mark produced by high voltage current.

Lethal explosions in a non-terrorist civilian setting.

Abstract: A study was undertaken to investigate the range and nature of deaths that may result from explosions in a civilian population that has not been exposed to terrorist attacks or significant military activities. A search was conducted of autopsy files at Forensic Science SA, Adelaide, Australia, from July 2000 to June 2017 for all cases where death had been attributed to an explosion. Twenty cases were identified, consisting of 10 accidents, five suicides, two homicides, one murder-suicide with two decedents and one case where the manner of death was undetermined. Explosives were involved in nine deaths, petrol in seven and propane/butane/natural gas in a further four. Deaths caused by explosions were a rare event, with most cases being caused by accidents in a domestic or industrial environment. Although suicides formed the next most-common group, it is possible that explosions caused by petrol in cases of self-immolation were not intended.

Twenty-three years (1993-2015) of homicide trends in the Transkei region of South Africa.

Abstract: BackgroundTranskei is regarded as a rural part of South Africa. It was one of the black homelands where rigorous apartheid was practised. The incidence of firearm-related deaths used to be very hig...

A retrospective cohort study describing the characteristics of patients under 18 years old in one section 136 suite.

Abstract: Section 136 of the Mental Health Act 1983 is an authority allowing police officers to remove a person 'who appears to him to be suffering from mental disorder' from a public area. There has been much media coverage regarding the inappropriate detention of minors under section 136 and the suggestion that many were taken to police cells, as there were no suitable places of safety. Although previous studies describe characteristics of a typical individual detained under section 136, few distinguish the differences between adults and adolescents. Profiling these adolescents can help to identify adolescents at risk, allowing for earlier intervention and prevent the inappropriate detention of individuals. Data were collected retrospectively for all patients under 18 years of age who were brought to a section 136 suite in south-west London over a five-year period. The typical profile of an adolescent presenting to this suite was a 16-year-old female of white ethnicity who was sectioned in a public area due to attempted suicide or deliberate self-harm. The individual is more likely to have mental or behavioural difficulties, a history of abuse, be under the care of local authorities and have had previous convictions compared to adolescents in the general population.

Blow/trauma to the chest and sudden cardiac death: Commotio cordis and contusio cordis are leading causes.

Abstract: BackgroundIn forensic practice, a blow to the chest can lead to sudden cardiac death (SCD) Commotio cordis and contusio cordis are leading causesMethodsFrom a database of 4678 patients who suffer

The importance of scene photography in routine coronial practice: Results of an audit with an illustrative case of suspected suicidal fatal air embolism.

Abstract: Pathologists providing a coronial autopsy service are very reliant on the information, including that concerning the body at the scene, provided prior to the post-mortem examination. This ensures t...

A risk-factor analysis of medical litigation judgments related to fall injuries in Korea.

Abstract: The aim of this study was to find out the risk factors through analysis of seven medical malpractice judgments related to fall injuries. The risk factors were analysed by using the framework that a...

Accidental cut-throat injuries from the broken windshield of an auto rickshaw: Two unusual cases.

Abstract: Accidental cut-throat injuries are extremely rare and usually involve a sharp-edged weapon. In this paper, two cases of a cut-throat wound to two auto-rickshaw drivers are presented where the broken windshield of the auto-rickshaws was responsible for the wounds. In both the cases, fatal incised wounds were present over the neck, cutting the soft tissue along with the major vessels. The death occurred due to exsanguination caused by neck-vessel injury in one case and trachea along with neck-vessel injury in the second case. Although the wounds on the neck initially suggested homicide, they were found to have occurred accidentally as a result of a road traffic accident involving a head-on collision of auto rickshaws. The injuries were inflicted by the shattered glass of the windshield.

Twenty-three-year trend in firearm deaths in the Transkei subregion of South Africa (1993-2015).

Abstract: Background Firearm-related deaths are a serious public-health problem in South Africa, which has the second-highest rate of firearm-related deaths in the world. Objective The aim of this study was to examine the trend in firearm deaths in the Transkei subregion of South Africa. Method An autopsy record review study was conducted at the Forensic Pathology Laboratory at Mthatha over a period of 23 years (1993-2015). Results Over a 23-year period (1993-2015), 27,036 autopsies were performed at the Mthatha Forensic Pathology Laboratory on people who had died from unnatural causes. Of these, 3935 (14.2%) deaths were related to firearm injuries. The average gunshot death rate during the study period was 29/100,000 of the population annually. The majority (3236; 82%) were males, among whom the death rate was 24.4/100,000 of the population per year. The rate of gunshot deaths was 27/100,000 of the population in 1993, while in 2015 it was 12.8/100,000. About a third (1207; 31%) of victims were between 21 and 30 years of age. Conclusion The gunshot death rate is at an unacceptably high level in the Transkei subregion of South Africa, especially among young people.

Time-dependent changes in kidney histopathology in ethylene glycol poisoning.

Abstract: Ethylene glycol (EG) may be acutely toxic following ingestion. In fatal cases, microscopic examination of urine and kidney specimens can establish a post-mortem diagnosis of EG poisoning. We describe the main renal histopathologic changes during different stages of EG poisoning, which might be helpful when dating the EG poisoning itself. A single-centre retrospective study conducted on all EG poisoning cases demonstrated that in an early stage of EG poisoning, fine dust-like crystals were deposited to the tubular cell basement membrane, followed by internalisation of calcium oxalate crystals into the epithelial cells. Later, the crystals formed larger aggregates within the epithelial cells. As the changes became advanced, pronounced tubular epithelial damage occurred, with detachment of epithelial cells from the basement membrane. In the final stage, coarse calcium oxalate crystals were recognised in the tubular lumen, with cellular debris from damaged epithelial cells. Our study shows that the time-dependent histological changes described follow the clinical stages of EG poisoning and may therefore provide a rough estimate of the time of EG ingestion before death.

Double suicide in modern Japan (in Kanagawa prefecture): Comparison with those in post-war Japan and other countries.

Abstract: Double-suicide cases have long been common in Japan, particularly among lovers. Classical studies conducted in the 1950s are well known. According to a report by Ohara, the double-suicide rate in J...

The doctor, negligence and causation: A lawyer's exposition to doctors, scientists and lawyers.

Abstract: The brief history of causation in medicine and science. The law. Setting the scene. Negligence but no causation. Duty to warn. Prognosis. Loss of opportunity. Consecutive negligence. Indivisible in...

Petechial haemorrhages as a consequence of very short-term strangulation during suicidal fall from a height: Case reconstruction.

Abstract: We present the case of a 64-year-old woman who committed suicide by jumping from the open bedroom window of her second-floor apartment. However, during a head-first fall, the victim’s head was caug...

Lethal phlegmonous duodenitis.

Abstract: A recent case report titled ‘Lethal phlegmonous colitis’ by Gilbert and Byard highlighted this rare infectious condition involving the colon. As discussed, this phlegmonous inflammatory condition of the intestine is associated with viral or alcohol hepatitis, cirrhosis and immunosuppression, and runs a very fulminant course with high mortality. The post-mortem macroscopic findings of this condition involving the colon are described as ‘thickening of the caecum and ascending colon’, with likely no characteristic changes in the mucosal surface. The diagnosis is made on microscopy with oedema, florid acute inflammatory infiltration and organisms in the submucosa. It is, however, surprising that there is an even greater paucity of case reports in the forensic literature of this condition involving the stomach and small intestine, given that it more commonly involves the upper gastrointestinal tract. We would like to report another case of lethal phlegmonous inflammation involving the duodenum which had similar pathology and highlights the possible difficulties in diagnosing this condition at autopsy. The deceased was a 40-year-old man with significant background history of chronic alcohol abuse, diabetes mellitus type 2, high blood pressure, chronic pancreatitis, common bile duct stricture (awaiting stent insertion) and liver cirrhosis. He had been described to be ‘deteriorating’ leading up to his death. On the day of his death, he had multiple episodes of vomiting and subsequently became unconscious and passed away in the presence of ambulance staff. Apart from the significant chronic disease identified in keeping with the clinical history, phlegmonous inflammation of the duodenum was identified. At post-mortem, the duodenum was slightly discoloured and felt thickened, and histology confirmed phlegmonous duodenitis (Figure 1). The duodenal mucosa is commonly ‘discoloured’ at postmortem, giving a congested appearance which is often attributed to post-mortem bile staining. The thickness of the duodenal wall is difficult to assess at postmortem due to its anatomical position and surrounding structures. Therefore, the appreciation of this pathology in this region may be challenging, and the sampling and subsequent diagnosis is made by a high level of suspicion. It is our opinion that phlegmonous inflammation of the intestinal tract may be underappreciated at postmortem. We agree with Gilbert and Byards’s opinion that this condition should be considered at

Death caused by appendicular knotting and small-bowel strangulation in a child: A case report and review:

Abstract: Acute appendicitis is one of the most common surgical emergencies in paediatrics. However, acute appendicitis in early infancy is an uncommon condition. Furthermore, strangulation of the small intestine through appendicular knotting is described as very unusual in the literature and is generally not well-diagnosed in the clinical context. This article reports the case of a 23-month-old girl who entered the emergency department with a three-day history of abdominal symptoms and who died in less than 24 hours without receiving surgical intervention. The case turned judicial at the request of the parents who claimed lack of clarity in the diagnosis. A medico-legal autopsy was ordered to clarify the cause and manner of death. The autopsy documented herniation, strangulation and torsion of a 70 cm segment of the jejunum/ileum through an appendicular knot caused by the attachment of the distal end of the inflamed appendage to the ileum. The case is relevant because it is the first case of death by appendicular knot and strangulation of small bowel in an infant reported in the literature. The importance of autopsy to clarify the clinical diagnosis is noted.

A particular case of accidental asphyxiation.

Abstract: The case reported involved a 60-year-old man with psychiatric illness who was found dead at his home. He was almost naked and showed signs of death by violent asphyxiation, which led to the suspicion of homicide. Autopsy findings showed foreign material in the trachea and larynx. However, the partially digested content in his stomach, the study of the gastric content and the microscopic analysis of the airways made it possible to define this as accidental death due to inhalation of material from a diaper. Toxicological analysis detected the presence of phenytoin, valproic acid, and phenobarbital in his blood, with values within the therapeutic ranges. This is certainly a peculiar case, as particularly evident after careful review of the literature on deaths by asphyxiation in psychiatric patients. Furthermore, this study highlights the importance of a full autopsy and microscopic evaluation of any foreign bodies.

Lethal phlegmonous colitis

Abstract: A 52-year-old man died soon after admission to hospital with a severe metabolic acidosis and likely sepsis. He had a past history of alcohol abuse with withdrawal seizures. An abdominal computed tomography scan showed thickened bowel loops but no obvious ischaemic changes, and a blood culture yielded a pure growth of Escherichia coli. At autopsy, the liver showed well-established micro-nodular cirrhosis with steatosis. The peritoneal cavity contained 200 mL of turbid yellow-brown fluid, and the caecum and ascending colon were unusually thickened. Microscopy of the caecum and ascending colon showed oedema, with a florid submucosal acute inflammatory infiltrate and large numbers of rod-shaped bacilli typical of phlegmonous colitis. This rare acute infectious condition predominately involves the caecum and ascending colon and is associated with liver cirrhosis. It should therefore always be considered at autopsy in individuals with cirrhosis, with careful examination and microscopic sampling of the caecum and proximal ascending colon, including ancillary blood/fluid bacterial cultures if the condition is suspected based on the macroscopic findings and/or history.