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Tyr A, Zilg B, Gelius T, Möllby R, Heldring N. Postmortem CT analysis of paranasal sinuses using an experimental model of drowning. Int J Legal Med 2024; 138:1401-1409. [PMID: 38351206 PMCID: PMC11164805 DOI: 10.1007/s00414-024-03173-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/22/2024] [Indexed: 06/12/2024]
Abstract
Fluid-filled paranasal sinuses are suggested to be a valuable tool to distinguish between drowning and non-drowning postmortem, yet the mechanisms governing fluid entry remains unknown. We investigate if fluid-filled paranasal sinuses are caused by a passive influx from submersion or an active aspiration mechanism during drowning. The ovine nasal cavity and maxillary sinuses are remarkably similar anatomically to humans, and have been used for endoscopic surgical training in recent decades. We submerged 15 decapitated ovine heads from agricultural waste at a depth of 2 m in flowing water for 1, 8, and 24 h and 7 days. Paranasal sinuses were CT imaged and compared pre- and post-submersion to non-submerged controls. Furthermore, we examined the paranasal sinuses of a single homicide case of a non-drowned submerged subject. Results demonstrate that fluid passively enters the maxillary sinus postmortem in the non-drowned ovine heads following 1 h of submersion. Fluid volume was independent of submersion time and influenced by time out of water as well as handling, since volume was reduced between consecutive CT scans. In contrast to our hypothesis, the filling of the paranasal sinuses is due to passive influx of fluid from submersion rather than an active aspiration during drowning. The observation that paranasal sinuses were fluid-filled in a single medico-legal case of postmortem submersion supports the finding of passive influx. Consequently, careful interpretation of fluid-filled paranasal sinuses is required when bodies are found in water, as the finding cannot distinguish between postmortem submersion and drowning.
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Affiliation(s)
- Alexander Tyr
- Swedish National Board of Forensic Medicine, Retzius v. 5, 171 65, Stockholm, Sweden.
| | - Brita Zilg
- Swedish National Board of Forensic Medicine, Retzius v. 5, 171 65, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Retzius v. 3, 171 77, Stockholm, Sweden
| | - Tobias Gelius
- Swedish National Board of Forensic Medicine, Retzius v. 5, 171 65, Stockholm, Sweden
| | - Rasmus Möllby
- Swedish National Board of Forensic Medicine, Retzius v. 5, 171 65, Stockholm, Sweden
| | - Nina Heldring
- Swedish National Board of Forensic Medicine, Retzius v. 5, 171 65, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Retzius v. 3, 171 77, Stockholm, Sweden
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Vieira MGDM, da Trindade RQ, Vieira RB, Vicentin-Junior CA, Damascena NP, Silva MC, Araujo APD, Santiago BM, Martins-Filho PR, Machado CEP. Differences in volume, density, electrolyte concentration, and total proteins in the fluid of the paranasal sinuses of freshwater and saltwater drowning victims: a systematic review and meta-analysis. Forensic Sci Med Pathol 2023:10.1007/s12024-023-00761-9. [PMID: 38148467 DOI: 10.1007/s12024-023-00761-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 12/28/2023]
Abstract
This study summarized the available evidence on the differences in volume, density, electrolyte concentration, and total proteins in paranasal sinus fluid between freshwater and saltwater drowning victims. A systematic search was conducted in electronic databases and gray literature, resulting in the inclusion of five studies with 234 drowning victims (92 saltwater incidents and 142 freshwater incidents). Meta-analyses using the inverse-of-variance method and a random-effects model were performed, reporting effect sizes as standardized mean differences (SMD) with 95% confidence intervals (CI). The findings showed a significantly higher sinus density in saltwater drowning cases compared to freshwater drowning cases (SMD 0.91, 95% CI 0.50 to 1.32). However, no significant differences were observed in sinus fluid volume. Saltwater drowning victims exhibited higher electrolyte concentrations (sodium: SMD 3.77, 95% CI 3.07 to 4.48; potassium: SMD 0.78, 95% CI 0.07 to 1.49; chloride: SMD 3.48, 95% CI 2.65 to 4.31; magnesium: SMD 4.01, 95% CI 3.00 to 5.03) and lower total protein concentrations (SMD - 1.20, 95% CI - 1.82 to - 0.58) in sinus fluid compared to freshwater drowning victims. This meta-analysis highlights the importance of analyzing the characteristics and composition of sinus fluid in forensic investigations of drowning cases. While no differences were found in sinus fluid volume, saltwater drowning victims exhibited higher sinus density, elevated electrolyte concentrations, and lower total protein concentrations compared to freshwater drowning victims.
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Affiliation(s)
| | - Rafael Queiroz da Trindade
- Graduate Program in Oral Biology, Piracicaba Dental School, State University of Campinas, UNICAMP, São Paulo, Brazil
| | - Raíssa Bastos Vieira
- Graduate Program in Pathology, Ribeirão Preto Medical School, University of São Paulo, USP, São Paulo, Brazil
| | | | - Nicole Prata Damascena
- Investigative Pathology Laboratory, Federal University of Sergipe, Rua Cláudio Batista, S/N. Sanatório, Aracaju, Sergipe, Brazil
| | - Melina Calmon Silva
- National Center for the Dissemination of Forensic Sciences, Brazilian Federal Police, Distrito Federal, Brazil
| | - Analany Pereira Dias Araujo
- National Center for the Dissemination of Forensic Sciences, Brazilian Federal Police, Distrito Federal, Brazil
- National Institute of Criminalistics, Brazilian Federal Police, Distrito Federal, Brazil
| | | | - Paulo Ricardo Martins-Filho
- Investigative Pathology Laboratory, Federal University of Sergipe, Rua Cláudio Batista, S/N. Sanatório, Aracaju, Sergipe, Brazil.
| | - Carlos Eduardo Palhares Machado
- National Center for the Dissemination of Forensic Sciences, Brazilian Federal Police, Distrito Federal, Brazil
- National Institute of Criminalistics, Brazilian Federal Police, Distrito Federal, Brazil
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da Trindade RQ, Duarte Morais Vieira MG, Vieira RB, Vicentin-Junior CA, Damascena NP, Santiago BM, Martins-Filho PR, Palhares Machado CE. The role of paranasal sinus fluid in determining drowning as the cause of death: A systematic review and meta-analysis. J Forensic Leg Med 2023; 99:102591. [PMID: 37717366 DOI: 10.1016/j.jflm.2023.102591] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/21/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023]
Abstract
Drowning is a significant global cause of unintentional injury fatalities, and accurate forensic diagnosis of drowning remains a challenge due to the nonspecific nature of post-mortem findings obtained through classical autopsy methods. Our manuscript addresses this issue by focusing on the emerging use of paranasal sinus fluid as a valuable tool in determining the cause of death, specifically in distinguishing drowning from non-drowning cases. The study provided a comprehensive summary of available evidence from observational studies that compared findings in the paranasal sinuses between drowning and non-drowning victims, analyzing parameters such as the presence of fluid, fluid volume, and density. The study encompassed a total of 14 selected studies involving 1044 subjects and utilized rigorous risk of bias assessment and data synthesis techniques. The meta-analysis demonstrated a strong association between the presence of fluid in the paranasal sinuses and drowning (OR = 17.1; 95% CI 7.2 to 40.5; p < 0.001). In addition, drowning victims had a significantly greater volume of fluid (SMD = 0.8; 95% CI 0.5 to 1.2; p < 0.001) and lower fluid density (SMD = -1.4; 95% -2.5 to -0.4; p = 0.008) compared to non-drowning cases. The results support the utility of paranasal sinus fluid analysis as a valuable diagnostic method in cases where drowning is suspected but cannot be definitively confirmed through traditional approaches.
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Affiliation(s)
- Rafael Queiroz da Trindade
- Graduate Program in Oral Biology, Piracicaba Dental School, State University of Campinas, UNICAMP, São Paulo, Brazil
| | | | - Raíssa Bastos Vieira
- Graduate Program in Pathology, Ribeirão Preto Medical School, University of São Paulo, USP, São Paulo, Brazil
| | | | | | | | - Paulo Ricardo Martins-Filho
- Graduate Program in Health Sciences, Federal University of Sergipe, Sergipe, Brazil; Investigative Pathology Laboratory, Federal University of Sergipe, Sergipe, Brazil.
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Vavilov AY, Khalikov AA, Rykunov IA, Kuznetsov KO, Sagidullin RH. [Determination of the corpse's stay in the water duration according to maceration degree of its skin]. Sud Med Ekspert 2023; 66:64-68. [PMID: 37192463 DOI: 10.17116/sudmed20236603164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
A serious problem during the postmortem examination of a corpse extracted from the water can be a significant determination of its stay in the water duration. First of all, the signs indicating the presence of a corpse in the water include maceration, according to the severity of which forensic experts often determine how long the corpse stayed in the water. The aim of the study is to summarize the available literature data and propose ways to objectify the determination of a corpse's stay in water duration by the severity of skin maceration. In this article, based on the analysis of literature, the process of skin maceration is described, as well as the timing and speed of its development according to various authors. The presence of quite a large number of external and internal factors affecting the process of skin maceration and the subjectivity of its severity assessment is indicated. This article provides examples of the biophysical methods usage for the study of biological objects in forensic medical examination, allowing to objectively record changes in the researcher's parameter of interest. The use of skin impedancemetry to objectify the severity of skin maceration.
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Affiliation(s)
| | | | - I A Rykunov
- Izhevsk State Medical Academy, Izhevsk, Russia
| | - K O Kuznetsov
- Bashkir State Medical University, Ufa, Russia
- N.I. Pirogov Russian National Research Medical University, Moscow, Russia
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Torimitsu S, Yajima D, Inokuchi G, Makino Y, Motomura A, Chiba F, Yamaguchi R, Hoshioka Y, Tsuneya S, Iwase H. Electrolyte analysis of pleural effusion for discrimination between seawater and freshwater drowning in decomposed bodies. J Forensic Leg Med 2022; 90:102389. [DOI: 10.1016/j.jflm.2022.102389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 11/15/2022]
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Onitsuka D, Nakamae T, Katsuyama M, Miyamoto M, Higo E, Yatsushiro M, Hayashi T. Epidemiological analysis of intramuscular hemorrhage of respiratory and accessory respiratory muscles in fatal drowning cases. PLoS One 2021; 16:e0261348. [PMID: 34941921 PMCID: PMC8699964 DOI: 10.1371/journal.pone.0261348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/30/2021] [Indexed: 11/19/2022] Open
Abstract
The postmortem diagnosis of drowning death and understanding the mechanisms leading to drowning require a comprehensive judgment based on numerous morphological findings in order to determine the pathogenesis and epidemiological characteristics of the findings. Effortful breathing during the drowning process can result in intramuscular hemorrhage in respiratory and accessory respiratory muscles. However, the characteristics of this phenomenon have not been investigated. We analyzed the epidemiological characteristics of 145 cases diagnosed as drowning, in which hemorrhage, not due to trauma, was found in the respiratory muscles and accessory respiratory muscles. Hemorrhage was observed in 31.7% of these cases, and the incidence did not differ by gender or drowning location. The frequency of hemorrhage was significantly higher in months with a mean temperature below 20°C than in months above 20°C, suggesting a relationship between the occurrence of hemorrhage and low environmental temperature. Moreover, the frequency of hemorrhage was significantly higher in the elderly (aged ≥65 years) compared to those <65 years old. In the elderly, the weakening of muscles due to aging may contribute to the susceptibility for intramuscular hemorrhage. Moreover, these intramuscular hemorrhages do not need to be considered in cases of a potential bleeding tendency due to disease such as cirrhosis or medication such as anticoagulants. Our results indicate that intramuscular hemorrhage in respiratory and accessory respiratory muscles can serve as an additional criterion to differentiate between fatal drowning and other causes of death, as long as no cutaneous or subcutaneous hematomas above the muscles with hemorrhages are observed. In addition, the epidemiological features that such intramuscular hemorrhage is more common in cold environments and in the elderly may provide useful information for the differentiation.
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Affiliation(s)
- Daiko Onitsuka
- Department of Legal Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
- Kushikino Coast Guard Office, Tenth Regional Coast Guard Headquarters, Japan Coast Guard, Kagoshima, Japan
| | - Takuma Nakamae
- Department of Legal Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Midori Katsuyama
- Department of Legal Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Machiko Miyamoto
- Department of Legal Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Eri Higo
- Department of Legal Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Masahiko Yatsushiro
- Department of Legal Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takahito Hayashi
- Department of Legal Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
- * E-mail:
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Simonit F, Da Broi U, Colatutto A, Desinan L. Submerged corpses of an elderly couple retrieved from a canal with alcohol detected in their blood: A rare case of murder-suicide by drowning? J Forensic Leg Med 2021; 80:102153. [PMID: 33831651 DOI: 10.1016/j.jflm.2021.102153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/07/2021] [Accepted: 03/23/2021] [Indexed: 11/29/2022]
Abstract
The body of an elderly man and his disabled wife were found submerged in a canal in open country one afternoon. They had last been seen alive that morning. The man's car was parked close to the canal and the woman's wheelchair was located in a stable position a few meters from the canal bank, facing away from the water. There were abrasions and bruises on the woman's forearms and hands and lower left leg, and the man's body displayed a bruise on the left hand and an abrasion of the left thumb likely caused by a fingernail. Other observations included frothy fluid exuding from the nose and in the airways, overdistended lungs with rib impressions and clear watery fluid in the stomach of both victims. Ethanol was detected in the peripheral blood of both corpses (1.0 g/L in the woman, 0.25 g/L in the man). The man was known to be stressed and depressed: he cared for his ailing spouse, who was affected by severe cognitive impairment and he had on several occasions expressed a desire to put an end to their misery. The hypotheses of a suicide pact or a double accident were in contrast with the woman's mental state and with the position of the wheelchair, respectively. The manner of death was consistent with a spousal murder-suicide involving a double drowning. Papers reporting similar cases are infrequent in the literature.
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Affiliation(s)
- Francesco Simonit
- Dipartimento di Area Medica, Medicina Legale, Università degli Studi di Udine, p. le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Ugo Da Broi
- Dipartimento di Area Medica, Medicina Legale, Università degli Studi di Udine, p. le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Antonio Colatutto
- Dipartimento di Medicina di Laboratorio, Laboratorio Analisi d'Elezione, Presidio Ospedaliero Universitario "Santa Maria della Misericordia", p.le Santa Maria della Misericordia 15, 33100, Udine, Italy
| | - Lorenzo Desinan
- Dipartimento di Area Medica, Medicina Legale, Università degli Studi di Udine, p. le S. Maria della Misericordia 15, 33100, Udine, Italy
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Macromorphological findings in cases of death in water: a critical view on "drowning signs". Int J Legal Med 2020; 135:281-291. [PMID: 33237456 PMCID: PMC7782435 DOI: 10.1007/s00414-020-02469-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/12/2020] [Indexed: 01/28/2023]
Abstract
Death in water is a challenging issue in forensic pathology since from natural death to homicide all circumstances of death in water are conceivable. Therefore, the correct interpretation of all abnormal autopsy findings is important. In order to determine a death by drowning, numerous internal and external signs of drowning are already described. However, these are supposed to be influenced by various factors reducing their significance and evidence. Moreover, the autopsy of water corpses often reveals further pathological findings that should not be underestimated for determining the cause of death. The aim of this study was to set frequencies of the observed drowning signs in context to the forensic literature and to identify possible influencing factors. In this study, we observed that pathological organ changes of the cardiovascular system were significantly more common in corpses after shortened (atypical) drowning processes than in classical drowned victims. Furthermore only a complete formation of external foam, immediately after the corpse’s recovery, was exclusively found in drowning victims. All other drowning signs were either also observed in non-drowning deaths in water or no information could be provided with reasonable assurance. In addition, many of the examined drowning signs were negatively affected by prolonged postmortem intervals, putrefaction, or resuscitation attempts. It can be concluded from our analysis that morbidity is an important factor in deaths in water. Morbidity can support a death by drowning in case of incidents in water. For the examined drowning signs, no high diagnostic certainty could be observed. Nevertheless, these findings can increase their diagnostic value—if forensic physicians take influencing factors into consideration.
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Ellis LT, Opsahl M, Duff DJ, Stacy CC. Application of the Drowning Index to Opioid & Multidrug Intoxication Deaths: A Retrospective Analysis. Acad Forensic Pathol 2019; 9:44-50. [PMID: 34394790 DOI: 10.1177/1925362119851115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 11/07/2018] [Indexed: 11/16/2022]
Abstract
Introduction Drowning deaths present a challenge for forensic pathologists, because the autopsy findings may occur in many nondrowning scenarios. Previous studies have attempted to identify patterns in organ weights that may be specific for drowning. The drowning index (DI) has been defined as the weight ratio of the lungs and pleural effusion fluid to the spleen. Studies have suggested DI may be useful in confirming drowning as the cause of death. No studies have yet compared autopsy findings in drownings to those in drug-related deaths, in spite of their qualitative similarities. Materials and Methods We compared the lung and pleural effusion weight, spleen weight, and DI from 536 autopsies ruled drowning, opioid, or multidrug intoxication, or hanging in Columbia, Missouri, from 2011 to 2016. Results Opioid overdoses result in heavier lungs and spleens than drownings, multidrug overdoses, or hangings. There is no DI value at which a death can be definitively ascribed to drowning. The median DI was significantly higher in drownings than in opioid intoxications, multidrug intoxications, or hangings (P < .0001; P = .001; P = .005). However, very few drowning cases (13.33%) had a DI >14.1. Additionally, many opioid and multidrug overdoses had a DI >14.1. The highest calculated DI value (DI = 33) was associated with multidrug intoxication. Conclusion In our opinion, the DI has little, if any, utility in distinguishing between drowning and drug-related deaths.
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Hayakawa A, Terazawa K, Matoba K, Horioka K, Fukunaga T. Diagnosis of drowning: Electrolytes and total protein in sphenoid sinus liquid. Forensic Sci Int 2017; 273:102-105. [PMID: 28260644 DOI: 10.1016/j.forsciint.2017.02.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 10/20/2022]
Abstract
In this study, electrolyte (sodium (Na), chlorine (Cl), and magnesium (Mg)) and total protein (TP) concentrations and volume of liquid in the sphenoid sinus were examined to determine their usefulness to elucidate whether drowning occurred in freshwater or seawater. We examined 68 cases (seawater drowning group: 27 cases, freshwater drowning group: 21 cases, non-drowning group: 20 cases). There was a significant difference in Na, Cl, Mg, and TP concentrations of liquid in the sphenoid sinus among the three groups (seawater drowning, freshwater drowning, and non-drowning groups). To distinguish freshwater drowning from seawater drowning, Na, Cl, and Mg concentrations of liquid in the sphenoid sinus might serve as useful indicators.
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Affiliation(s)
- Akira Hayakawa
- Tokyo Medical Examiner's Office, Tokyo Metropolitan Government, Tokyo, Japan; Department of Forensic Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Koichi Terazawa
- Department of Forensic Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kotaro Matoba
- Department of Forensic Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kie Horioka
- Department of Forensic Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tatsushige Fukunaga
- Tokyo Medical Examiner's Office, Tokyo Metropolitan Government, Tokyo, Japan
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Detection of chlorine and bromine in free liquid from the sphenoid sinus as an indicator of seawater drowning. Leg Med (Tokyo) 2015; 17:299-303. [PMID: 26415653 DOI: 10.1016/j.legalmed.2015.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 08/11/2015] [Accepted: 08/27/2015] [Indexed: 11/20/2022]
Abstract
We have investigated the usefulness of elemental analysis by energy-dispersive X-ray spectroscopy (EDX) in the examination of free liquid from the sphenoid sinus of drowning victims. We detected both chlorine and bromine in liquid taken from the sphenoid sinus of seawater drowning victims. Because these elements were below the quantification limit in freshwater cases, we could easily distinguish seawater from freshwater drowning cases. Detection of these elements from the liquid in the sphenoid sinuses of drowning victims may be useful as a supportive measure for seawater drowning.
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Hemolytic staining of the endocardium of the left heart chambers: a new sign for autopsy diagnosis of freshwater drowning. Forensic Sci Med Pathol 2014; 11:65-8. [DOI: 10.1007/s12024-014-9620-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2014] [Indexed: 10/24/2022]
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