Journal of Forensic and Legal Medicine

Aims & Scope/Editorial Board

2012-05-01

Acute mesenteric ischaemia and unexpected death

Roger W. Byard — 2012-05-01

Abstract: Acute mesenteric ischaemia is a vascular emergency that arises when blood flow to the intestine is compromised leading to tissue necrosis. It is primarily a condition of the elderly associated with significant morbidity and mortality. Causes include arterial thromboembolism, venous thrombosis and splanchnic vasoconstriction (so-called nonocclusive mesenteric ischaemia). Reperfusion injury and breakdown of the intestinal mucosal barrier lead to metabolic derangements, sepsis and death from multiorgan failure. The diagnosis may be difficult to make clinically and numbers of cases are increasing due to ageing of the population. The clinical and pathological features are reviewed with discussion of predisposing conditions. Careful dissection of the mesenteric vasculature is required at autopsy with appropriate histologic sampling and documentation of associated comorbidities. Other organs need to be checked for thrombi and the possibility of testing for inherited thombophilias should be considered. Toxicological evaluation, particularly in younger individuals, may reveal evidence of cocaine use. On occasion no obstructive lesions will be demonstrated, however the confounding effects of post-mortem autolytic and putrefactive changes may mean that nonocclusive mesenteric ischaemia may be difficult to diagnose.

Testamentary capacity: A practical guide to assessment of ability to make a valid will

K.M. Kennedy — 2012-05-01

Abstract: Medical practitioners are occasionally requested to provide opinions on people’s ability to make a valid will. Moreover, if a will is challenged subsequent to the death of the testator, the evidence of a medical practitioner may be pivotal to a decision by the courts on the validity of the will. Litigation can be avoided if a well-founded expert opinion, based on thorough medical assessment, is available. The combination of an aging population, a consequent increase in the prevalence of dementia, an increase in per capita wealth, and more complex family structures with increasing rates of divorce and remarriage, is likely to result in a greatly increased frequency of demands on medical practitioners to provide opinion in this regard. In order for the result of a medical assessment of testamentary capacity to be legally valid, it is imperative that medical practitioners have adequate guidance on what is expected of them in their assessment. As there is no standardised tool for medical practitioners to which to refer, a synthesis of relevant literature is presented to guide medical practitioners in the assessment of testamentary capacity. Medical practitioners’ roles in this medico-legal process are elaborated and elucidated.

Abusing female children by circumcision is continued in Egypt

Abeer Ahmed Zayed, Abla Abdelrahman Ali — 2012-05-01

Summary: Female circumcision is a frank picture of female child abuse that is practised widely in many countries especially in Africa. This procedure is considered a fundamental violation of human rights. The procedure is expected to be declining in Egypt in response to the recent medicolegal litigation in 2007. The aim of this study is to record the prevalence of female circumcision in 2010, in the region of Cairo and Giza, seeking to show if there is difference in the practice after the change in the law and banning of the procedure. A formatted questionnaire for 244 female volunteers was conducted. Statistical analysis revealed that 63.9% of the sample had been victimised by circumcision. The mean age of circumcision was 10.846±1.98 years. Circumcision took place at victim’s home in 56.5%, private clinics in 38.5% or at hospitals in 5%. The procedure was performed by medical personnel in the majority of cases. The motivation behind the practice was primarily traditional beliefs (64.1%) followed by religious considerations (35.9%). Experienced complications were emotional trauma in 94.9%, haemorrhage in 33.3% and dysuria in 7.7%. Sexual problems were exclusively reported by the victimised subjects in 72.7% of sexually experienced subjects.

Osmium impregnation detection of pulmonary intravascular fat in sudden death: A study of 65 cases

Patrick J.H. Kim, Michael S. Pollanen — 2012-05-01

Abstract: Pulmonary fat embolism is widely recognised in forensic pathology. Pulmonary fat embolism requires mobilisation of free fat, entry of free fat into the circulation and lodging of fat globules in fine venous capillaries. This paradigm of fat embolisation has been used to support the evidence of antemortem fat depot disruption when the presence of intravascular fat is confirmed at autopsy. However, sporadic reports of intravascular fat in various medical conditions, which contradict the above mechanism, have opened questions about the alternative pathogenesis. In this study, 65 cases of sudden deaths were examined for the presence of pulmonary intravascular fat (PIF) by osmium impregnation. Cases were selected based on the criteria that were designed to eliminate the possible confounding effect from medical intervention or postmortem changes. Slides were graded based on their ease of search and only the fat droplets confined by the blood vessel or capillary wall were considered as a positive finding. The results show surprisingly high PIF incidences of varying degrees in all the categories of sudden deaths. Further study is needed to devise criteria for diagnosis of fatal fat embolism since the histological appearance of the high-grade PIF in natural sudden death may not be easily distinguishable from the traumatic fat embolism.

Study of defence injuries in homicidal deaths – An autopsy study

Basappa S. Hugar, S. Harish, Y.P. Girish Chandra, S. Praveen, S.H. Jayanth — 2012-05-01

Abstract: In order to determine specific patterns and distribution of defence injuries, this study was conducted on 121 homicidal deaths which showed defence injuries in 40 (33%) cases. Of these 40 victims, 72.5% were males and 27.5% were females. Maximum numbers of victims were in the age group of 20–29 years. In 70% of cases, more than one assailant was involved. It was found that in 77.5% cases, sharp weapons were alone used, whereas, in 10% and 12.5% of victims, blunt weapons and multiple (sharp and blunt) weapons, respectively, were used. Fatal wounds were seen most commonly on the head and neck region. In 42.5% of cases, defence injuries were seen on the right side only, whereas in 27.5% of cases both sides were involved. Victim’s right forearm and hand were more commonly involved because these are nearest to the perpetrator and consistent with the preponderance of right-handed individuals in the population.

Multiplication factor versus regression analysis in stature estimation from hand and foot dimensions

Kewal Krishan, Tanuj Kanchan, Abhilasha Sharma — 2012-05-01

Abstract: Estimation of stature is an important parameter in identification of human remains in forensic examinations. The present study is aimed to compare the reliability and accuracy of stature estimation and to demonstrate the variability in estimated stature and actual stature using multiplication factor and regression analysis methods. The study is based on a sample of 246 subjects (123 males and 123 females) from North India aged between 17 and 20 years. Four anthropometric measurements; hand length, hand breadth, foot length and foot breadth taken on the left side in each subject were included in the study. Stature was measured using standard anthropometric techniques. Multiplication factors were calculated and linear regression models were derived for estimation of stature from hand and foot dimensions. Derived multiplication factors and regression formula were applied to the hand and foot measurements in the study sample. The estimated stature from the multiplication factors and regression analysis was compared with the actual stature to find the error in estimated stature. The results indicate that the range of error in estimation of stature from regression analysis method is less than that of multiplication factor method thus, confirming that the regression analysis method is better than multiplication factor analysis in stature estimation.

Evaluating the functional impairment of assault survivors in a judicial context – A retrospective study

Thomas Lefèvre, Hugo Briffa, Guy Thomas, Patrick Chariot — 2012-05-01

Abstract: Background: The description of traumatic injuries and the outcome on functioning are major items of the evaluation of assault survivors. French law quantifies the seriousness of committed violence through the duration of the victims’ inability to fulfil their usual daily activities, in days of ‘Total incapacity to work’ (TIW). Physicians are provided with a limited number of recommendations. In this study, we searched for determinants of TIW.Methods: We reviewed 1145 consecutives files of victims evaluated between 10/01/2010 and 11/22/2010. People reporting repeated assaults, or assessed more than 30 days after the facts were excluded. Data collected were: gender, age, TIW, type of traumatic injuries, time to evaluation, patient category, type of assailant, and presence of aggravating factors. Univariate associations with TIW were assessed, while generalised linear models including relevant covariables were proposed.Results: The population (718 men, 427 women, median age 29) included 236 detainees, 74 police officers, and 835 other individuals. Mean duration of TIW was 4.3 days. The time to evaluation was correlated to TIW. Patient category (police officers, detainees, or other individuals), presence of traumatic injuries, and type of assailant were associated with TIW. In patients presenting no evidence of bone fracture, duration of TIW (2.0 days vs. 2.6 and 3.8, p < 0.001) and time to evaluation (10.9 h vs. 21.2 and 58.5, p < 0.001) differed in detainees, police officers, and other individuals.Conclusion: We suggest that the outcome of assaults should be evaluated in similar conditions in all victims, including time to evaluation.

The value of radius bone in prediction of sex and height in the Iranian population

2012-05-01

Abstract: Objective: Measurement of anthropometric parameters of long bones can be applied in sex determination and height prediction. The aim of this study was to investigate the value of length of the radius in forensic identification.Materials and methods: Cross-sectional analysis of anthropometric parameters of the radius was done by Legal Medicine Organization of Tehran, Iran studying fresh cadavers of Iranian population during 2009 and 2010.Results: This study surveyed length of radius of 106 fresh Iranian cadavers, 61 men and 45 women, in the age range of 10–85 years old. The study showed that genders can be distinguished using the length of radius with a sensitivity of 83% and specificity of 96%. Using the regression test, there was significant relation between the height of persons and the length of radius bone. The equations were obtained to estimate the height of the individuals on the basis of radius bone length in different age groups, with an exception in females of 40–64 Years old.Conclusion: In the cases of fresh cadavers, by using the length of radius, we could be able to determine the length of height and gender with high confidence.

Postmortem burning of the corpses following homicide

2012-05-01

Abstract: Although there have been a great number of studies focussing on antemortem burns or fire-related deaths, the present study is the first dealing exclusively with postmortem burnings aiming to cover up a homicidal action. This study aims to draw attention to postmortem burning following homicide by determining the general characteristics of a series of burned corpses.Thirteen cases of homicide involving postmortem burning were included in the scope of the study. The cases were examined with regard to age, gender, place of death or discovery, autopsy findings, accompanying injuries and manner of death. Eleven of the cases were male and two were female. Victims’ ages ranged between 24 and 62 years with a mean age of 43.5 years. All of the victims were discovered in unfamiliar places. Autopsy findings indicated postmortem burning of corpses to cover homicide.Discovering a burned body in an unfamiliar, outdoor or abandoned place, scene or autopsy findings attributable to a violent death, presence of accelerant use and absence of vitality signs are factors indicative of postmortem burning following homicide.

Medico-legal considerations in a case of splenic injury that occurred during colonoscopy

Chiara Zandonà, Stefania Turrina, Nicole Pasin, Domenico De Leo — 2012-05-01

Abstract: Colonoscopy has became the gold standard diagnostic and therapeutic treatment for rectum and colon diseases. The splenic injury is a rare complication of colonoscopy and relatively few cases (less than 70) have been reported in the literature so far. Here we present a case of splenic rupture identified in an 80 year-old man few hours after an apparently uneventful colonoscopy. Acknowledging a causal relationship between the lesion and the diagnostic procedures, we discuss the possible medico-legal implications with regard to professional liability considering the exceptional nature of such an event and the stance recently taken by the Italian law.

Homicidal smothering on toilet paper: A case report

Pauline Saint-Martin, Thierry Lefrancq, Anny Sauvageau — 2012-05-01

Abstract: Toilet paper is a ubiquitous personal hygiene product that is usually considered harmless. It was reported however to have been used as a mean of self-destruction in two unusual suicides, and is here reported to have been used to commit homicide. The body of a 91-year-old woman suffering from Alzheimer’s disease was found in the bedroom of her nursing home, a roll of toilet paper near the body and toilet paper protruding from the mouth. At autopsy, pellets of toilet paper were impacted in the buccal cavity and the laryngopharynx above the epiglottis. The cause of death was established as smothering on toilet paper, whereas the manner of death was ruled as homicidal. Non-lethal blunt head injuries were considered to be a contributive factor, by lowering the victim’s resistance. The perpetrator was another elderly woman, also suffering from Alzheimer’s disease.

Adenomyomatous polyp of the uterus: Report of an autopsy case and review of the literature

2012-05-01

Abstract: Adenomyomatous polyps of the endometrium are a rare subtype of endometrial polyps. In addition to the usual features of endometrial polyps, they also contain a smooth muscle component. Grossly they appear no different than ordinary endometrial polyps. In the case reported herein, a 23-year-old nulliparous female was killed in a traffic accident. In the course of the medicolegal autopsy, a small pedunculated growth was identified in the fundus of the endometrial cavity. Histologically the mass consisted of endometrial glands intimately mixed with smooth muscle and thick walled blood vessels, consistent with an adenomyomatous polyp. There was no history of tamoxifen use in this individual. To our knowledge this is the first report of post-mortem diagnosis of an adenomyomatous polyp. Furthermore, this is the first report of an individual with this diagnosis younger than the fourth decade. In the medicolegal setting, forensic pathologists are constantly faced with entities that, while they may not have caused death, may serve to educate practitioners about rare lesions. This individual’s finding serves as one of those entities. This case reiterates the importance of the autopsy as not only the answer to an individual’s death, but as an avenue for the discovery of entities that may have relevance to those who are still living.

Tobacco toxicity ignored as a cause of death. Why?

William Patrick Tormey — 2012-05-01

Under the UK Births and Deaths Registration Act 1953, the Medical Certificates of the cause of death stratify those causes into (a) the disease or condition directly leading to death followed by other disease or conditions, if any, leading to that main cause. There is also a space to list other significant conditions contributing to the death but not related to the disease or condition. In 2010 in England, almost 20% of deaths of people over the age of 35 years were due to smoking. The leading two causes of death in males are ischaemic heart disease and malignancies of the trachea, bronchus and lung and in females, ischaemic heart disease leads the way and airways cancers are fifth. A poison is defined as “a substance that when introduced into or absorbed by a living organism causes death or injury,”. Cigarette smoke contains 43 known carcinogens and about 400 other toxins including nicotine, tar and carbon monoxide. Therefore tobacco smoke is poisonous. Yet the UK’s Office for National Statistics excludes alcohol and tobacco from the table of deaths related to drug misuse citing International Classification of Diseases, Tenth Revision codes as the rationale. The far fewer cases of lethal poisonings from opiates, amphetamines, antidepressants, benzodiazepines and others are listed. In 1992, the UK regulations were changed to allow any doctor issuing a death certificate to include tobacco smoking among the causes of death. There was a large increase in citing smoking on death certificates after the change but by 1997, smoking was again ignored. In 1998, Robinson et al reminded doctors that smoking should be mentioned as a cause of death on death certificates.

An alternative model of a forensic autopsy service

Ken Obenson — 2012-05-01

New Brunswick is an Eastern Canadian province with a population of approximately 720,000 and a low homicide rate (1.6/100,000 in 2009). Like some other jurisdictions in North America, death investigations operate on a Coroner system, but there is no formal “Forensic Science Institute” or a dedicated Coroners facility-based morgue. The actual practice of forensic pathology is hospital based where health care is provided by single payer, government-funded universal medical coverage system (Medicare). These factors provide New Brunswick with distinct advantages allowing forensic services to “piggy-back” on services available to the living.

Reponse to: L. Love., “My experience of the DFCASA exam including recommendations to potential candidates” [J Forensic Legal Med 2011;19:4]

Trevor Beedham — 2012-05-01

I felt very much encouraged by the above article and hope that I may be permitted to respond. Examinations are stressful and even if rigorous they only sample the skills, knowledge, attitudes and beliefs of candidates. Normally a candidate’s satisfactory completion of a formal training programme is confirmed by summative examination. In the absence of such a programme it is necessary to assemble evidence in other ways. The Relfective Portfolio and the COVE were devised for this purpose. Assembling these elements and coping with modern examination techniques adds to the challenge of the DFCASA, but the Committee is mindful that the examination must not become just a test of endurance.

On ‘atypical suicidal’ cut throat injuries

Giulia Pintore, Emine Meral Inelmen, Enzo Manzato — 2012-05-01

It was with great interest that we read the article by Shetty et al., particularly concerning the differential diagnostic issue of whether it was an unusual case of suicide or homicide. Shetty et al. presented a rare case of self-inflicted cut throat injury in a 45-year-old ex-military man (with no tentative cuts on the neck) caused by a curved, sharp weapon. Suicide committed by cutting one's own throat with no sign of hesitation remains highly unusual and only a handful of cases have been reported in the forensic literature, probably due also to underreporting of cases. We also reported on an unusual failed suicide attempt made by a woman more than 90 years old, who cut her own throat with a pair of scissors. Her suicide attempt was unsuccessful only because her son-in-law unexpectedly returned to the house. Ours was another case of this rare violent suicide modality being implemented without hesitation, as in the case described by Shetty et al. In both cases, the injury was inflicted with unfaltering determination. The chosen weapon differed, however, being a sharp curved knife with a wooden handle in the case described by Shetty et al., and a pair of scissors in ours. Moreover, the person described in the Shetty case report had numerous family problems and debts, whereas our elderly lady had no family or economic issues and met the criteria for successful ageing (she was in excellent physical and mental health and involved in social, family and churchgoing activities). An important aspect of the Shetty case concerns the problem of the differential diagnosis vis-à-vis homicide, which was ruled out in our case because the patient had prepared a suicide note. We praise these authors for emphasising the exceptional nature of such a suicidal method and the issues relating to its distinction from homicides.

Alcimedes

2012-05-01

A Canadian meta-analysis study published in the BMJ has further fuelled the “Cannabis debate” by claiming that cannabis users are approximately twice as likely to cause a vehicle crash as non-users. The authors combined comparable data from nine studies and demonstrated that there was an increased risk of both fatal and non-fatal collisions in cannabis users who had smoked within 3 h of the collision. Such data is likely to be of interest to the UK Government that is considering new legislation on drink and drug driving, in light of Sir Peter North's report from 2010.