Hypothermia

Effects of cold exposure in a confined environment: an original case of suicide by freezing

The authors present a case involving a 37-year-old woman discovered in an operating freezer. Suicide hypothesis has been considered from the beginning. Due to the exceptional scene circumstances, a forensic autopsy was performed. Apart from some non-specific hypothermia and asphyxia signs, the autopsy revealed several skull fractures, prompting extensive anatomopathological and histological analyses. These analyses confirmed the fractures origin and determined whether they were ante-mortem or post-mortem, thus ruling out the possibility of a criminal act disguised as suicide. The authors also describe the challenges in determining the cause of death, particularly the issues related to the post-mortem diagnosis of lethal hypothermia and asphyxia. This case is the first in the literature to describe suicide by exposure to cold in a confined environment. It highlights the importance of close collaboration between forensic pathologists, histologists, toxicologists, and police investigators to answer judicial inquiries.

Immunohistochemical insights into hypothermia-related deaths: a systematic review

PURPOSE

Hypothermia occurs when core body temperature drops below 35 °C. The purpose of this review was to identify and analyze studies on the topic of hypothermia from an immunohistochemical perspective to determine robust markers of fatal hypothermia.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. It has been registered with Prospero (registration number: CRD42024572782).

RESULTS

In total, 2618 publications met the search criteria. A total of 63 duplicate articles were excluded and a further 2489 publications were excluded for not meeting the inclusion criteria, leaving 29 full-text articles. Furthermore, from the bibliographies of the included articles, four more publications were selected, which also respected the established inclusion and exclusion criteria. Only six studies identified a statistically significant correlation between immunohistochemical patterns and hypothermia-related deaths.

CONCLUSION

The existing literature examined appears fragmented and lacks robust statistical validation. Therefore, there is an evident need for more comprehensive and methodologically rigorous research to develop reliable diagnostic criteria.

Thermodynamic Assessment of the Causes of the Death of the People Under the Debris in an Earthquake

Mortality rate of the crush victims in the Marmara earthquake of August 1999 was compared with the conclusions arrived after making thermodynamic assessment of the data acquired in the previous earthquakes. Entropic age concept was found very helpful while assessing the data. Mortality rate in the age group of 0-9 years old crush victims was 0 because the basal metabolic rate (BMR) of these children was low. The earthquake happened at 3:03 a.m. in the morning and it was probably at the coldest time of the day; therefore, the victims were losing sufficient heat to avoid hyperpraxia, where body temperature reaches to 40°C or above. As the population and the age of the victims increase more people died and the survival rate decreased. The highest mortality rate was in the 60+ age group. According to the entropic age concept, these group of victims had already accumulated a lot of entropy (e.g., heath problems) in their bodies in previous stages of their lives; therefore, they were more prone to death.

The Postmortem Pathology of Sudden Death in Chronic Alcohol Exposure and Acute Alcohol Intoxication: A Review of Medicolegal Considerations, Traumatic and Systemic Pathology, and Biochemical Mechanisms

ABSTRACT

Chronic alcohol exposure is common in all societies and is seen at high rates during coronial (medicolegal) postmortem examinations. In both setting of acute alcohol intoxication and chronic misuse, a wide range of pathologies and mechanisms of death may be encountered, particularly with regard to sudden, unexpected or violent deaths. These warrant special attention. In this review, we examine the approach to postmortem examination where alcohol is likely to have played a key role in death. Attention is given to the scene of death, patterns of traumatic injury, systemic pathology (particularly of chronic alcohol exposure), seizures related to alcohol, and appropriate biochemical investigations.

Basal vacuolization of renal tubules in hypothermia: A comprehensive pathological study based on 79 forensic autopsy cases

This study investigated the usefulness of histopathological examination in diagnosing ketoacidosis in hypothermia cases. Out of 79 cases (38 females), 30 showed basal vacuolization (BV), a representative histopathological finding of ketoacidosis, in their hematoxylin and eosin (H&E)-stained specimens. Through the use of both lipid staining with osmium tetroxide postfixation and immunohistochemistry for adipophilin (ADFP-IHC), BV pattern pathology was identified in 43 cases. Serum was available in 75 cases, with 37 having serum β-hydroxybutyrate levels exceeding 1000 μmol/L. Serum β-hydroxybutyrate concentrations showed a significantly negative correlation with age and tended to be lower in outdoor hypothermia cases than in indoor cases. When comparing serum β-hydroxybutyrate levels with histopathological findings, all but one of the BV-positive cases on H&E staining were serologically diagnosed as ketoacidosis. However, when combining multiple staining methods, six cases were histologically positive but serologically negative. Using multiple staining methods increases BV detection sensitivity, but it may also detect findings of unknown pathological significance. Therefore, identifying a distinct BV pattern in H&E-stained specimens is crucial for suspecting ketoacidosis in the usual practice of forensic pathology, and ADFP-IHC is useful for confirming lipid droplet presence. Our results suggest that BV positivity rates are strongly influenced by the case characteristics of the study cohort, particularly the proportion of older adults. Thus, the extent to which BV is complicated by hypothermia should be examined and understood on a country-by-country or region-by-region basis.

Cold shock proteins CIRBP and RBM3 may indicate hypothermia death: A case report

Cold-inducible RNA-binding protein (CIRBP) and RNA binding motif protein 3 (RBM3) are both members of the cold shock protein family expressed in response to low-temperature induction. However, their usefulness in the diagnosis of fatal hypothermia in forensic has not been reported. In this study, we report the case of a female who died of fatal hypothermia. Through detailed case investigation, scene examination, autopsy testing and tissue observation, we ultimately determined that the woman died of hypothermia. We further examined the expression of CIRBP and RBM3 in the postmortem brain, heart, lung and kidney via immunohistochemistry. The high expression of CIRBP and RBM3 in the brain, lungs, and kidneys suggested the possibility of hypothermia. This study may provide new auxiliary diagnostic indicators for the diagnosis of fatal hypothermia in forensic medicine.

Biomarker patterns and mechanistic insights into hypothermia from a postmortem metabolomics investigation

Postmortem metabolomics holds promise for identifying crucial biological markers relevant to death investigations and clinical scenarios. We aimed to assess its applicability in diagnosing hypothermia, a condition lacking definitive biomarkers. Our retrospective analysis involved 1095 postmortem femoral blood samples, including 150 hypothermia cases, 278 matched controls, and 667 randomly selected test cases, analyzed using UHPLC-QTOF mass spectrometry. The model demonstrated robustness with an R2 and Q2 value of 0.73 and 0.68, achieving 94% classification accuracy, 92% sensitivity, and 96% specificity. Discriminative metabolite patterns, including acylcarnitines, stress hormones, and NAD metabolites, along with identified pathways, suggest that metabolomics analysis can be helpful to diagnose fatal hypothermia. Exposure to cold seems to trigger a stress response in the body, increasing cortisol production to maintain core temperature, possibly explaining the observed upregulation of cortisol levels and alterations in metabolic markers related to renal function. In addition, thermogenesis seems to increase metabolism in brown adipose tissue, contributing to changes in nicotinamide metabolism and elevated levels of ketone bodies and acylcarnitines, these findings highlight the effectiveness of UHPLC-QTOF mass spectrometry, multivariate analysis, and pathway identification of postmortem samples in identifying metabolite markers with forensic and clinical significance. The discovered patterns may offer valuable clinical insights and diagnostic markers, emphasizing the broader potential of postmortem metabolomics in understanding critical states or diseases.

Hypothermic sepsis in time since death estimation - a case report

Both hyper- and hypothermia are problematic in temperature based forensic time since death estimation. Hyperthermia may occur in infection, traumatic brain injury, and intoxication. Hypothermia is encountered predominantly in exposure. Sepsis may present itself clinically as hypothermic. Sepsis is not uncommon in the forensic setting and mostly occurs in the context of malpractice accusations. There is usually little overlap between sepsis and typical forensic time since death estimation scenarios of violent or otherwise suspicious deaths. In the presented case, hypothermia and time since death estimations did collide. An inmate was found dead in his jail cell. Wardens claimed they had visually approached him alive relatively shortly prior. Rectal temperature measurements, using two separate crime scene thermometers as well as temperature loggers, revealed low rectal temperature at relatively high ambient temperature. These findings suggested a much longer postmortem interval and consequently raised doubts about the stated timeline. The wardens' claims were however confirmed by camera recordings, which also allowed a reasonable estimate of the true time of death. The cause of death was confirmed as septic organ failure at autopsy, which explained low rectal temperature. The presence of WISCHNEWSKI-spots was noted. When the PRISM-method was applied to the temperature recordings, low rectal temperature at the time of death was detected successfully. However, adaptation of the underlying equation for lower "starting temperature" did not produce satisfactory results. It is concluded that even though hypothermia at the time of death may possibly be detected from temperature data, attempts at time since death estimation for cases of hypothermia by adaptation of the equation should be avoided.

Identifying hypothermia death in a mouse model by ATR-FTIR

The identification of hypothermia death (HD) is difficult for cadavers, especially the distinction from death due to alternative causes. A large number of studies have shown that brown adipose tissue (BAT) plays critical roles in thermoregulation of mammals. In this study, BAT of mice was used for the discrimination of HD using attenuated total reflection-Fourier transform infrared spectroscopy (ATR-FTIR). A modified mouse HD model conducted by Feeney DM was used in this study to obtain infrared spectra of BAT. Principal component analysis (PCA), partial least squares discriminant analysis (PLS-DA), and orthogonal partial least squares discriminant analysis (OPLS-DA) were used to establish discrimination models. The PLS-DA and OPLS-DA models exhibit prominent discriminative efficiency, and the accuracy of HD identification using fingerprint regions and ratios of absorption intensity is near 100% in both the calibration and validation sets. Our preliminary study suggests that BAT may be an extremely effective target tissue for identification of cadavers of HD, and ATR-FTIR spectra combined with chemometrics have also shown potential for cadaver identification in forensic practice in a fast and accurate manner.

Deaths due to suspected hypothermia in sheep and alpacas on a Manawatū farm in New Zealand in mid-summer

CASE HISTORY

In mid-summer (February), 42 of a flock of 68 ram hoggets (approximately 5 months of age) and two of a group of 14 alpacas on a farm in the Manawatū region of New Zealand were found recumbent or dead following a period of persistent rain, strong winds and relatively low temperatures. The hoggets and alpacas had been shorn 4 and 53 days previously, respectively, and were in adequate to good body condition with access to ad libitum pasture. Post-mortem and histological examinations were undertaken on four hoggets and two alpacas.

CLINICAL FINDINGS

Apart from hypothermic body temperatures from four recumbent hoggets, nothing of significance was identified on clinical or gross pathological examination. Histological changes of vacuolar hepatopathy, renal tubular degeneration and pulmonary congestion were present in all animals examined.

DIAGNOSIS

Based on the history and clinical and pathological findings, hypothermia was highly probable to have been the cause of the deaths.

CLINICAL RELEVANCE

These cases emphasise the importance of shelter for recently shorn sheep and alpacas regardless of the season.

To the extreme! How biological anthropology can inform exercise physiology in extreme environments

The fields of biological anthropology and exercise physiology are closely related and can provide mutually beneficial insights into human performance. These fields often use similar methods and are both interested in how humans function, perform, and respond in extreme environments. However, these two fields have different perspectives, ask different questions, and work within different theoretical frameworks and timescales. Biological anthropologists and exercise physiologists can greatly benefit from working together when examining human adaptation, acclimatization, and athletic performance in the extremes of heat, cold, and high-altitude. Here we review the adaptations and acclimatizations in these three different extreme environments. We then examine how this work has informed and built upon exercise physiology research on human performance. Finally, we present an agenda for moving forward, hopefully, with these two fields working more closely together to produce innovative research that improves our holistic understanding of human performance capacities informed by evolutionary theory, modern human acclimatization, and the desire to produce immediate and direct benefits.

19 F VT NMR: Novel Tm3+ and Ce3+ Complexes Provide New Insight into Temperature Measurement Using Molecular Sensors

In the past few decades, magnetic resonance spectroscopy (MRS) and MR imaging (MRI) have developed into a powerful non-invasive tool for medical diagnostic and therapy. Especially 19 F MR shows promising potential because of the properties of the fluorine atom and the negligible background signals in the MR spectra. The detection of temperature in a living organism is quite difficult, and usually external thermometers or fibers are used. Temperature determination via MRS needs temperature-sensitive contrast agents. This article reports first results of solvent and structural influences on the temperature sensitivity of 19 F NMR signals of chosen molecules. By using this chemical shift sensitivity, a local temperature can be determined with a high precision. Based on this preliminary study, we synthesized five metal complexes and compared the results of all variable temperature measurements. It is shown that the highest 19 F MR signal temperature dependence is detectable for a fluorine nucleus in a Tm3+ -complex.

Effects of Seawater Immersion on Lethal Triad and Organ Function in Healthy and Hemorrhagic Shock Rats

INTRODUCTION

Marine casualties are increasing, and mortality from trauma associated with immersion in seawater is high. However, the associated pathophysiological characteristics remain unclear, limiting research into the early emergency treatment strategy.

METHODS

Healthy and 50% hemorrhagic shock rats were soaked in 15°C and 21°C seawater for 2 h, 4 h and 6 h, respectively, and the effects on vital signs, internal environment, tissue metabolism, lethal triad, vital organ functions and survival were observed.

RESULTS

Immersion in seawater can cause death in healthy rats. Rats with hemorrhagic shock in 15°C seawater showed a lower survival rate than the corresponding groups in 21°C seawater. Moreover, compared with 21°C seawater, 15°C seawater played a more remarkable role in decreasing mean arterial pressure, heart rate, and respiration rate, increasing water content and decreasing Na⁺/K⁺-ATPase activity in the brain and lung; increase in plasma osmolality, Na⁺, K⁺, Cl^-, and the occurrence of the lethal triad manifested by a decrease in core body temperature, pH, lactate, and an increase in coagulation parameters, as well as damage to cardiac, intestinal, hepatic, and renal functions in rats with hemorrhagic shock.

CONCLUSIONS

Immersion in seawater at low temperatures could be lethal to healthy rats, causing the occurrence of a lethal triad and damage to vital organs. Furthermore, 15°C-seawater had a more significant effect than 21°C-seawater on aggravating the imbalance of internal environment and tissue metabolism, resulting in a higher incidence of the lethal triad and thus aggravating the dysfunctions of vital organs, which eventually resulted in higher mortality in rats with hemorrhagic shock.

Bioprotective role of platelet-derived microvesicles in hypothermia: Insight into the differential characteristics of peripheral and splenic platelets

BACKGROUND

Most platelets are present in peripheral blood, but some are stored in the spleen. Because the tissue environments of peripheral blood vessels and the spleen are quite distinct, the properties of platelets present in each may also differ. However, no studies have addressed this difference. We previously reported that hypothermia activates splenic platelets, but not peripheral blood platelets, whose biological significance remains unknown. In this study, we focused on platelet-derived microvesicles (PDMVs) and analyzed their biological significance connected to intrasplenic platelet activation during hypothermia.

METHODS

C57Bl/6 mice were placed in an environment of -20 °C, and their rectal temperature was decreased to 15 °C to model hypothermia. Platelets and skeletal muscle tissue were collected and analyzed for their interactions.

RESULTS

Transcriptomic changes between splenic and peripheral platelets were greater in hypothermic mice than in normal mice. Electron microscopy and real-time RT-PCR analysis revealed that platelets activated in the spleen by hypothermia internalized transcripts, encoding tissue repairing proteins, into PDMVs and released them into the plasma. Plasma microvesicles from hypothermic mice promoted wound healing in the mouse myoblast cell line C2C12. Skeletal muscles in hypothermic mice were damaged but recovered within 24 h after rewarming. However, splenectomy delayed recovery from skeletal muscle injury after the mice were rewarmed.

CONCLUSIONS

These results indicate that PDMVs released from activated platelets in the spleen play an important role in the repair of skeletal muscle damaged by hypothermia.

Forensic application of aquaporins

Aquaporins (AQPs) are a family of water channel proteins that primarily elicit the basic functions of water transport and osmotic homeostasis. To date, at least 17 mammalian AQPs have been identified, AQP-0 to -12 have been found in higher orders including human, and AQP-13 to -16 have been described in older lineages. Moreover, these proteins have recently been shown to regulate many biological processes through unique activities, such as cell proliferation, migration, apoptosis, and mitochondrial metabolism. Several studies have focused on the involvement of AQPs in cell biology aspect, showing that they are involved in a variety of physiological processes and pathophysiological conditions. Furthermore, in the field of forensic medicine, studies on whether AQPs can be a useful marker for diagnosing various causes of death have been conducted using autopsy samples and animal experiments, which have produced interesting results. Herein, we review certain observations regarding AQPs and discuss their potential to contribute to the future practice of forensic research.

Attenuated total reflection-Fourier transform infrared spectroscopy: a universal analytical technique with promising applications in forensic analyses

Contemporary criminal investigations are based on the statements made by the victim and the eyewitnesses. They also rely on the physical evidences found in the crime scene. These evidences, and more particularly biological ones, have a great judicial value in the courtroom. They are usually used to revoke the suspect's allegations and confirm or refute the statements made by the victim and the witnesses. Stains of body fluids are biological evidences highly sought by forensic investigators. In many criminal cases, the success of the investigation relies on the correct identification and classification of these stains. Therefore, the adoption of reliable and accurate forensic analytical methods seems to be of vital importance to attain this objective. Attenuated total reflection-Fourier transform infrared spectroscopy (ATR-FTIR) is a modern and universal analytical technique capable of fingerprint recognition of the analyte using minimal amount of the test sample. The current systematic review aims to through light on the fundamentals of this technique and to illustrate its wide range of applications in forensic investigations. ATR-FTIR is a nondestructive technique which has demonstrated an exceptional efficiency in detecting, identifying and discriminating between stains of various types of body fluids usually encountered in crime scenes. The ATR-FTIR spectral data generated from bloodstains can be used to deduce a wealth of information related to the donor species, age, gender, and race. These data can also be exploited to discriminate between stains of different types of bloods including menstrual and peripheral bloods. In addition, ATR-FTIR has a great utility in the postmortem investigations. More particularly, in estimating the postmortem interval and diagnosing death caused by extreme weather conditions. It is also useful in diagnosing some ambiguous death causes such as fatal anaphylactic shock and diabetic ketoacidosis.

Fluorescent probes for biomolecule detection under environmental stress

The use of fluorescent probes in visible detection has been developed over the last several decades. Biomolecules are essential in the biological processes of organisms, and their distribution and concentration are largely influenced by environmental factors. Significant advances have occurred in the applications of fluorescent probes for the detection of the dynamic localization and quantity of biomolecules during various environmental stress-induced physiological and pathological processes. Herein, we summarize representative examples of small molecule-based fluorescent probes that provide bimolecular information when the organism is under environmental stress. The discussion includes strategies for the design of smart small-molecule fluorescent probes, in addition to their applications in biomolecule imaging under environmental stresses, such as hypoxia, ischemia-reperfusion, hyperthermia/hypothermia, organic/inorganic chemical exposure, oxidative/reductive stress, high glucose stimulation, and drug treatment-induced toxicity. We believe that comprehensive insight into the beneficial applications of fluorescent probes in biomolecule detection under environmental stress should enable the further development and effective application of fluorescent probes in the biochemical and biomedical fields.

Successful Pre-Rewarming Resuscitation after Cardiac Arrest in Severe Hypothermia: A Retrospective Cohort Study from the International Hypothermia Registry

The aim of our study is to investigate successful pre-rewarming resuscitation after hypothermic cardiac arrest (HCA). The hypothermic heart may be insensitive to defibrillation when core temperature is below 30 °C and after successful defibrillation, sinus rhythm often returns into ventricular fibrillation. Recurrent defibrillation attempts may induce myocardial injury. Discrepancy exists concerning pre-rewarming defibrillation between the guidelines of the European Resuscitation Council and American Heart Association. The International Hypothermia Registry (IHR) gathers hypothermia cases. The primary outcome was survival. Secondary outcomes were the characteristics of defibrillation, the effect of Adrenaline administration under 30 °C, and the duration of CPR. Of the 239 patients, eighty-eight were in cardiac arrest at arrival of the rescue team. Successful pre-rewarming resuscitation was obtained in 14 patients. The outcome showed: seven deaths, one vegetative state, two patients with reversible damage, and four patients with full recovery. A total of five patients had a shockable rhythm, and defibrillation was successful in four patients. The response rate to Adrenaline was reported as normal in six patients. There were no statistically significant differences in the presence of a shockable rhythm, the success of defibrillation, and the effect on Adrenaline administration between the survivors and non-survivors. Successful resuscitation in severe hypothermia is possible before active rewarming and arrival in the hospital, thus improving the chance of survival.

Renal expression of Hsp27, 60, and 70 in cases of fatal hypothermia

Macromorphological findings can be missing in cases of fatal hypothermia when the agonal period is very short because of a large difference between environmental and core body temperatures. Expression of heat shock proteins (Hsps) increases under endogenous and exogenous cellular stresses such as thermal stress. These stress proteins can be revealed by immunohistochemical staining. Forty-five cases of death due to hypothermia and a control group of 100 deaths without any antemortem thermal stress were examined for Hsp27, 60, and 70 expression in renal tissue because renal tissue is sensitive to cellular stress. The results revealed no significant difference between Hsp27, 60, and 70 expression in both groups (28.8% positive staining in the study group and 19.0% positive staining in the control group), which is contradictory to a previous study on expression of Hsp70 in renal tissue in cases of fatal hypothermia. Hence, it is currently unclear whether immunohistochemical staining of Hsps supports a morphological diagnosis of fatal hypothermia.

Renal Tubular Epithelial Subnuclear Vacuolization in Hypothermia and Diabetic Ketoacidosis-A Retrospective Autopsy Study

ABSTRACT

Subnuclear vacuolization of the renal tubular epithelium refers to discrete lipid vacuoles displacing the nuclei toward the lumen. This phenomenon has been associated with conditions sharing fatal ketoacidosis as a common denominator. This retrospective study aimed to investigate renal tubular epithelial subnuclear vacuolization and other postmortem examination findings in fatal hypothermia and diabetic ketoacidosis (DKA) cases.Fourteen cases with hypothermia and 19 cases with DKA were included. More cases with DKA had focal or diffuse subnuclear vacuolization compared with hypothermia cases (89% vs 43%; P = 0.007). In 6 cases with DKA, formalin pigment was detected within subnuclear vacuoles, whereas no case with hypothermia had formalin pigment deposition. Comparative analyses of hypothermia and DKA cases revealed further differences: Vitreous beta-hydroxybutyrate was higher in the DKA group compared with the hypothermia group (P = 0.044), whereas blood ethanol concentrations were higher in the latter (P = 0.008). Hypothermia cases were older compared with the DKA cases (P = 0.022).When all cases were included in the statistical analysis, cases with subnuclear vacuolization had higher vitreous beta-hydroxybutyrate and blood ethanol concentrations (P = 0.029 and 0.023, respectively). The findings corroborate the results of previous studies suggesting a link between subnuclear vacuolization and increased levels of ketoacidosis.

Histopathological, histochemical and biochemical postmortem changes in induced fatal hypothermia in rats

Reaching a postmortem diagnosis of hypothermia is challenging in forensic practice. Therefore, this study was conducted to detect the histopathological, histochemical and biochemical changes that occur in adult albino rats following exposure to induced fatal hypothermia. Twenty-four adult albino rats were divided into the negative control, moderate hypothermia, severe hypothermia and hypoxia groups. Rats in the control group were euthanized when those in the moderate hypothermic group died. Blood samples were collected via heart puncture, and the cerebrum, heart, suprarenal gland, kidney, liver and skeletal muscle were removed to investigate the biochemical, histochemical and histopathological changes. Postmortem assessment depicted significant changes in lipid peroxidation, represented by increased malondialdehyde levels in the studied organs of the rats in hypothermic and hypoxia groups. Histopathological examination of the rats’ organs revealed degeneration and necrosis in the hypothermia and hypoxia groups. Sections taken from the severe hypothermic rats revealed a loss of normal cardiac tissue architecture, necrotic changes in the pyramidal cells in the cerebral cortex, and massive necrosis, mainly in the tubules of the renal cortex and medulla. These findings suggest that histological changes might be used as biochemical markers for postmortem diagnosing of fatal hypothermia, particularly in severe hypothermic conditions.

Key points

Death by hypothermia is a serious public health problem worldwide.

Confirming a diagnosis and determining the cause of death in cases of hypothermia are among the most difficult practices in forensic medicine.

Death by hypothermia might be associated with structural abnormalities in various organs.

Studies using different tissue staining techniques will enable an overall illustration of the role of histopathological changes in body organs as indicators of hypothermia.

Application of the Frailty Framework among Vulnerable Populations to Hospitalization Outcomes of Individuals Experiencing Homelessness in Long Beach, California

BACKGROUND

Individuals experiencing homelessness have a high prevalence of infectious diseases that may result in hospitalization. However, low ability to navigate the healthcare system and lack of health insurance may mean that those who are experiencing homelessness may not receive the healthcare that they need.

OBJECTIVES

This study uses risk factors at baseline to predict hospitalization at follow-up. This paper also presents the associations between reporting homelessness and selected infectious diseases.

RESEARCH DESIGN

Longitudinal study of baseline and follow-up conducted August 2000 through July 2014.

SUBJECTS

4916 Not experiencing homelessness mean age 37.9 years, 29% female, and 2692 experiencing homelessness age 42.1 years, 29% female received services from a research/service center in a low-income, high-crime area of Long Beach, CA.

MEASURES

Risk Behavior Assessment, Risk Behavior Follow-up Assessment, laboratory testing for hepatitis A, hepatitis B, hepatitis C, syphilis, chlamydia, and gonorrhea.

RESULTS

Predictors of hospitalization at follow-up were ever use of crack cocaine, income from Social Security or disability, reporting homelessness, female, and those who identify as Black compared to White race/ethnicity.

CONCLUSIONS

Income from the safety net of Social Security or disability appears to provide the participant with experience that transfers to being able to obtain healthcare. A higher proportion of those experiencing homelessness, compared to those not experiencing homelessness, appear to be hospitalized at follow-up. Women, those who identified as Black, and those who used crack at baseline are more likely to be hospitalized at follow-up whether or not they were experiencing homelessness. We recommend coordination with substance abuse treatment programs for discharge planning for homeless patients. Our findings support use of the Frailty Framework when working with individuals experiencing both homelessness and hospitalization.

Death following extreme temperature exposure: Histological, biochemical and immunohistochemical markers

INTRODUCTION

Defining extreme temperatures as the cause of death remains challenging. It is mostly based on circumstantial, macroscopic and microscopic features.

METHODS

We retrospectively compared groups of cases of fatal hypothermia, fatal hyperthermia and non-extreme temperature-related deaths. We analysed specific histological findings, focusing on samples from the liver, pancreas and kidney.

RESULTS

Between 1 January 2013 and 31 December 2016, 15 autopsies were performed for deaths related to extreme temperatures. They included 11 cases of fatal hypothermia (group A), four cases of fatal hyperthermia (group B) and eight controls (group C). Perinuclear hepatocyte vacuolisation was observed in seven cases of hypothermia, one case of hyperthermia and four controls. Pancreatic cytoarchitecture was well preserved in two cases of hypothermia, one case of hyperthermia and two controls. No particular microscopic feature was found in pancreatic samples. Renal epithelial tubular cell vacuolisation was observed in seven cases of hypothermia and one case of hyperthermia, while it was absent in all controls. Chromogranin A (CgA) was markedly positive in the pancreatic tissue of five cases of fatal hypothermia and one control, and mildly positive in one case of fatal hyperthermia. No significant p-values were observed for any comparisons (p > 0.05), except when hypothermia cases group were compared to the control group for the Armanni-Ebstein phenomenon test (p = 0.0078).

CONCLUSIONS

Although our study did not find a specific microscopic marker, hepatocyte vacuolisation, the Armanni-Ebstein phenomenon and pancreatic CgA positivity, taken together, may be useful tools to confirm hypo- and hyperthermia-related deaths, in addition to circumstantial and macroscopic findings.

Cold Water Swimming-Benefits and Risks: A Narrative Review

Cold water swimming (winter or ice swimming) has a long tradition in northern countries. Until a few years ago, ice swimming was practiced by very few extreme athletes. For some years now, ice swimming has been held as competitions in ice-cold water (colder than 5 °C). The aim of this overview is to present the current status of benefits and risks for swimming in cold water. When cold water swimming is practiced by experienced people with good health in a regular, graded and adjusted mode, it appears to bring health benefits. However, there is a risk of death in unfamiliar people, either due to the initial neurogenic cold shock response or due to a progressive decrease in swimming efficiency or hypothermia.

DNA microarray analysis of hypothermia-exposed murine lungs for identification of forensic biomarkers

We used DNA microarray technology to analyze the pulmonary transcriptome of mice killed by hypothermia. This analysis identified significant differential regulation of 4094 genes; specifically, 1699 genes were upregulated, and 2395 were downregulated in response to hypothermia. The gene encoding cathelicidin antimicrobial peptide was the most upregulated gene, and that encoding BAI1-associated protein 2-like 1 was the most downregulated. Gene-set analysis identified significant hypothermia-induced variations in 101 pathways, and we discovered that pathways related to immunity are involved in the pulmonary pathogenesis of hypothermia. The present findings demonstrate some of the acute pulmonary responses to hypothermia and indicate several pulmonary genes as candidate forensic biomarkers of hypothermia. Furthermore, the present findings suggest that host defense is induced in hypothermic lungs. The present microarray data may facilitate the development of protein analyses for human forensics by immunohistochemistry, western blotting and enzyme-linked immunosorbent assay and may be beneficial in clinical research of hypothermia.

The Effect of Low Temperatures on Environmental Radiation Damage in Living Systems: Does Hypothermia Show Promise for Space Travel?

Low-temperature treatments (i.e., hypothermia) may be one way of regulating environmental radiation damage in living systems. With this in mind, hibernation under hypothermic conditions has been proposed as a useful approach for long-term human space flight. However, the underlying mechanisms of hypothermia-induced radioresistance are as yet undetermined, and the conventional risk assessment of radiation exposure during hibernation remains insufficient for estimating the effects of chronic exposure to galactic cosmic rays (GCRs). To promote scientific discussions on the application of hibernation in space travel, this literature review provides an overview of the progress to date in the interdisciplinary research field of radiation biology and hypothermia and addresses possible issues related to hypothermic treatments as countermeasures against GCRs. At present, there are concerns about the potential effects of chronic radiation exposure on neurological disorders, carcinogenesis, ischemia heat failures, and infertility in astronauts; these require further study. These concerns may be resolved by comparing and integrating data gleaned from experimental and epidemiological studies.

Lethal hypothermia due to impalement

Impalement injuries in the region of large blood vessels can lead to extensive and even lethal blood loss. However, they can also lead to forced positions from which the affected persons cannot free themselves. This 85-year-old woman was found dead in a prone position in her garden. A metal bar had penetrated deeply into the front of her right thigh, while the other end of the bar was stuck firmly in the soil. The metal bar had merely displaced the woman's muscles and the larger blood vessels without causing major blood loss. There were typical findings of lethal hypothermia, including Wischnewski spots of the gastric mucosa and frost erythema on both knees and the left lower leg. The fall onto the metal bar caused an impalement injury leading to a forced position from which the woman could not free herself where she finally succumbed to lethal hypothermia.

Cortisol levels after cold exposure are independent of adrenocorticotropic hormone stimulation

We previously showed that postmortem serum levels of adrenocorticotropic hormone (ACTH) were significantly higher in cases of hypothermia (cold exposure) than other causes of death. This study examined how the human hypothalamic-pituitary-adrenal axis, and specifically cortisol, responds to hypothermia. Human samples: Autopsies on 205 subjects (147 men and 58 women; age 15-98 years, median 60 years) were performed within 3 days of death. Cause of death was classified as either hypothermia (cold exposure, n = 14) or non-cold exposure (controls; n = 191). Cortisol levels were determined in blood samples obtained from the left and right cardiac chambers and common iliac veins using a chemiluminescent enzyme immunoassay. Adrenal gland tissues samples were stained for cortisol using a rabbit anti-human polyclonal antibody. Cell culture: AtT20, a mouse ACTH secretory cell line, and Y-1, a corticosterone secretory cell line derived from a mouse adrenal tumor, were analyzed in mono-and co-culture, and times courses of ACTH (in AtT20) and corticosterone (in Y-1) secretion were assessed after low temperature exposure mimicking hypothermia and compared with data for samples collected postmortem for other cases of death. However, no correlation between ACTH concentration and cortisol levels was observed in hypothermia cases. Immunohistologic analyses of samples from hypothermia cases showed that cortisol staining was localized primarily to the nucleus rather than the cytoplasm of cells in the zona fasciculata of the adrenal gland. During both mono-culture and co-culture, AtT20 cells secreted high levels of ACTH after 10-15 minutes of cold exposure, whereas corticosterone secretion by Y-1 cells increased slowly during the first 15-20 minutes of cold exposure. Similar to autopsy results, no correlation was detected between ACTH levels and corticosterone secretion, either in mono-culture or co-culture experiments. These results suggested that ACTH-independent cortisol secretion may function as a stress response during cold exposure.

Molecular mechanisms of Wischnewski spot development on gastric mucosa in fatal hypothermia: an experimental study in rats

Numerous dark-brown-coloured small spots called “Wischnewski spots” are often observed in the gastric mucosa in the patients dying of hypothermia, but the molecular mechanisms through which they develop remain unclear. We hypothesised that hypothermia may activate the secretion of gastric acid and pepsin, leading to the development of the spots. To investigate this, we performed experiments using organotypic rat gastric tissue slices cultured at 37 °C (control) or 32 °C (cold). Cold loading for 6 h lowered the extracellular pH in the culture medium. The mRNA expression of gastrin, which regulates gastric acid secretion, increased after cold loading for 3 h. Cold loading increased the expression of gastric H⁺,K⁺-ATPase pump protein in the apical canalicular membrane and resulted in dynamic morphological changes in parietal cells. Cold loading resulted in an increased abundance of pepsin C protein and an elevated mRNA expression of its precursor progastricsin. Collectively, our findings clarified that cold stress induces acidification by activating gastric H⁺,K⁺-ATPase pumps and promoting pepsin C release through inducing progastricsin expression on the gastric mucosa, leading to tiny haemorrhages or erosions of the gastric mucosa that manifest as Wischnewski spots in fatal hypothermia.

Four cases of death involving the novel synthetic cannabinoid 5F-Cumyl-PEGACLONE

Purpose

Cumyl-PEGACLONE was the first synthetic cannabinoid (SC) with a γ-carbolinone core structure detected in forensic casework and, since then, it has dominated the German SC-market. Here the first four cases of death involving its fluorinated analog, 5F-Cumyl-PEGACLONE, a recently emerged γ-carbolinone derived SC, are reported.

Methods

Complete postmortem examinations were performed. Postmortem samples were screened by immunoassay, gas chromatography mass spectrometry (GC–MS) or liquid chromatography tandem mass spectrometry. For quantification of SCs, the standard addition method was employed. Herbal blends were analyzed by GC–MS. In each case of death, the Toxicological Significance Score (TSS) was assigned to the compound.

Results

5F-Cumyl-PEGACLONE was identified at concentrations ranging 0.09–0.45 ng/mL in postmortem femoral blood. In case 1, signs of hypothermia and kidney bleedings were noted. Despite a possible tolerance due to long term SC use, a TSS of 3 was assigned. In case 2, an acute heroin intoxication occurred and a contributory role (TSS = 1) of 5F-Cumyl-PEGACLONE was suggested. In case 3, a prisoner was found dead. GC–MS analysis of herbal blends, retrieved in his cell together with paraphernalia, confirmed the presence of 5F-Cumyl-PEGACLONE and a causative role was deemed probable (TSS = 2). In case 4, the aspiration of gastric content due to a SC-induced coma was observed (TSS = 3).

Conclusions

5F-Cumyl-PEGACLONE is an emerging and extremely potent SC which raises serious public health concerns. A comprehensive analysis of circumstantial, clinical, and postmortem findings, as well as an in-depth toxicological analysis is necessary for a valid interpretation and for the assessment of the toxicological significance.

Vital reactions - An updated overview

The question whether an injury was sustained during life or not is one of the most important subjects in forensic medicine. Therefore, vital reactions have been a main research topic in forensic medicine for a long period and many renowned forensic pathologists have devoted important papers to this field. The research area ranges from macroscopically visible organ reactions, over tissue alterations (enzyme histochemistry, later on immunohistochemistry with a wide range of enzymes and other analytes, molecular pathology) to biochemical responses to injury. Especially in the field of immunohistochemistry and molecular pathology much progress has been achieved in the last years (e.g. heat-shock-proteins or positive aquaporine3-staining in mechanical skin trauma). Furthermore, 20 years after its implementation postmortem imaging also contributes to the detection and visualization of vital signs. The aim of the present review is to provide an update on forensically relevant vital signs/vital reactions. Systemic vital reactions especially of the circulatory and respiratory system as well as local vital reactions will be addressed. Vital reactions of different organ systems will be discussed in detail regarding pathogenesis and possible postmortem evolution. Current research on immunohistochemically detectable vital reactions (heat-shock-protein expression, aquaporine3-staining in mechanical trauma of the skin) will be addressed as well as biochemical vital reactions (agonochemical stress reaction, myoglobine in electrocution death, hypoxanthine as marker of hypoxia).

Updated review of postmortem biochemical exploration of hypothermia with a presentation of standard strategy of sampling and analyses

Hypothermia is defined as a core body temperature below 35°C and can be caused by environmental exposure, drug intoxication, metabolic or nervous system dysfunction. This lethal pathology with medico-legal implications is complex to diagnose because macroscopic and microscopic lesions observed at the autopsy and the histological analysis are suggestive but not pathognomonic. Postmortem biochemical explorations have been progressively developed through the study of several biomarkers to improve the diagnosis decision cluster. Here, we present an updated review with novel biomarkers (such as catecholamines O-methylated metabolites, thrombomodulin and the cardiac oxyhemoglobin ratio) as well as some propositional interpretative postmortem thresholds and, to the best of our knowledge, for the first time, we present the most adapted strategy of sampling and analyses to identify biomarkers of hypothermia. For our consideration, the most relevant identified biomarkers are urinary catecholamines and their O-methylated metabolites, urinary free cortisol, blood cortisol, as well as blood, vitreous humor and pericardial fluid for ketone bodies and blood free fatty acids. These biomarkers are increased in response either to cold-mediated stress or to bioenergetics ketogenesis crisis and significantly contribute to the diagnosis by exclusion of death by hypothermia.

Postmortem diagnosis of fatal hypothermia/hyperthermia by spectrochemical analysis of plasma

Postmortem diagnosis of extreme-weather-related deaths is a challenging forensic task. Here, we present a state-of-the-art study that employed attenuated total reflection (ATR) Fourier transform infrared (FTIR) spectroscopy in combination with Chemometrics for postmortem diagnosis of fatal hypothermia/hyperthermia by biochemical investigation of plasma in rats. The results of principal component analysis (PCA) and spectral analysis revealed that plasma samples from the fatal hypothermia, fatal hyperthermia, and control groups, are substantially different from each other based on the spectral variations associated with the lipid, carbohydrate and nucleic acid components. Two partial least squares-discriminant analysis (PLS-DA) classification models (hypothermia-nonhypothermia and hyperthermia-nonhyperthermia binary models) with a 100% accuracy rate were constructed. Subsequently, internal cross-validation was performed to assess the robustness of these two models, which resulted in 98.1 and 100% accuracy. Ultimately, classification predictions of 42 unknown plasma samples were performed by these two models, and both models achieved 100% accuracy. Additionally, our results demonstrated that hemolysis and postmortem hypothermic/hyperthermic effects did not weaken the prediction ability of these two classification models. In summary, this work demonstrates ATR-FTIR spectroscopy's great potential for postmortem diagnosis of fatal hypothermia/hyperthermia.

Biochemical detection of fatal hypothermia and hyperthermia in affected rat hypothalamus tissues by Fourier transform infrared spectroscopy

It is difficult to determinate the cause of death from exposure to fatal hypothermia and hyperthermia in forensic casework. Here, we present a state-of-the-art study that employs Fourier-transform infrared (FTIR) spectroscopy to investigate the hypothalamus tissues of fatal hypothermic, fatal hyperthermic and normothermic rats to determine forensically significant biomarkers related to fatal hypothermia and hyperthermia. Our results revealed that the spectral variations in the lipid, protein, carbohydrate and nucleic acid components are highly different for hypothalamuses after exposure to fatal hypothermic, fatal hyperthermic and normothermic conditions. In comparison with the normothermia group, the fatal hypothermia and hyperthermia groups contained higher total lipid amounts but were lower in unsaturated lipids. Additionally, their cell membranes were found to have less motional freedom. Among these three groups, the fatal hyperthermia group contained the lowest total proteins and carbohydrates and the highest aggregated and dysfunctional proteins, while the fatal hypothermia group contained the highest level of nucleic acids. In conclusion, this study demonstrates that FTIR spectroscopy has the potential to become a reliable method for the biochemical characterization of fatal hypothermia and hyperthermia hypothalamus tissues, and this could be used as a postmortem diagnostic feature in fatal hypothermia and hyperthermia deaths.

The risk factors, frequency and diagnosis of atypical antipsychotic drug-induced hypothermia: practical advice for doctors

Hypothermia is unpredictable and life-threatening adverse effect of atypical antipsychotic drug (APD) treatment, which has been little described. The aim of this article is to increase the awareness that hypothermia induced by APD drugs is more common than the current published case reports may suggest, and risk factors increase its development. Moreover, valuable guidelines regarding how to detect the early stages of hypothermia in clinical practice are included. A literature search for reports on APD-induced hypothermia in PubMed, Academic Search Complete, Medline Complete and eHealthMe databases was conducted. The literature search apart from eHealthMe database resulted in 524 articles, which included 34 case reports. Hypothermia was mostly induced by olanzapine (14) and risperidone (10). However, the data from Food and Drug Administration reports revealed several dozen more cases of APD-induced hypothermia (591case reports) compared with the published case reports (e.g. olanzapine-262 and risperidone-161). Hypothermia, mostly mild (61% of cases), has developed mainly in men (71%) having schizophrenia, a few hours after commencement of treatment or in the presence of risk factors. Owing to the increased risk of hypothermia development during APD treatment, doctors should routinely measure body temperature of patients, especially during the first days of the therapy. Early diagnosis of hypothermia and appropriate treatment may prevent death.

Earth, Air, Water, and Fire: Histopathology of Environmental Death

Interpretation of deaths in hostile environments may be informed by postmortem microscopic examination of injured tissues. In context with their macroscopic correlates, the commonly observed histologic changes seen in environmental deaths are reviewed-these include exposure (i.e., hypothermia and hyperthermia), fire, electrocution, and water. Rarely observed pathognomonic findings are highlighted. While it may not yield specific findings, microscopic examination is one of the necessary steps of a thorough postmortem examination.

Identification of potential markers of fatal hypothermia by a body temperature-dependent gene expression assay

Diagnosis of fatal hypothermia is considered to be difficult in forensic practice and even if findings due to cold exposure are evident, cold exposure is not necessarily a direct cause of death. Identification of useful molecular markers for the diagnosis of fatal hypothermia has not been successful. In this study, to identify novel molecular markers that inform the diagnosis of fatal hypothermia, we focused on skeletal muscle, which plays a role in cold-induced thermogenesis in mammals. We made rat models of mild, moderate, and severe hypothermia and performed body temperature-dependent gene expression analysis in the iliopsoas muscle using next-generation sequencing (NGS). NGS showed that after severe hypothermia, the expression levels of 91 mRNAs were more than double those in mild and moderate hypothermia and control animals. Gene ontology (GO) analysis indicated that these mRNAs are involved in a number of biological processes, including response to stress and lipids, and cellular response to hypoxia. The expression of four genes [connective tissue growth factor (Ctgf), JunB proto-oncogene, AP-1 transcription factor subunit (Junb), nuclear receptor subfamily 4, group A, member 1 (Nr4a1), and Syndecan 4 (Sdc4)] and the level of one protein (CTGF) were induced only by severe hypothermia. These genes and protein are involved in muscle regeneration, tissue repair, and lipid metabolism. These results indicate that heat production to maintain body temperature in a process leading to fatal hypothermia might be performed by the iliopsoas muscle, and that Ctgf, Junb, Nr4a1, and Sdc4 genes are potential diagnostic markers for fatal hypothermia.

Accidental hypothermia

Accidental hypothermia causes profound changes to the body's physiology. After an initial burst of agitation (e.g., 36-37°C), vital functions will slow down with further cooling, until they vanish (e.g. <20-25°C). Thus, a deeply hypothermic person may appear dead, but may still be able to be resuscitated if treated correctly. The hospital use of minimally invasive rewarming for nonarrested, otherwise healthy patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionized the management of hypothermic cardiac arrest, with survival rates approaching 100%. Hypothermic patients with risk factors for imminent cardiac arrest (i.e., temperature <28°C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS center. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanic CPR can be helpful. Intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern postresuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimize prehospital triage, transport, and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and postresuscitation care.