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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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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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Peden AE, Taylor DH, Franklin RC. Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:8863. [PMID: 35886717 PMCID: PMC9324568 DOI: 10.3390/ijerph19148863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022]
Abstract
Medical conditions can increase drowning risk. No prior study has systematically reviewed the published evidence globally regarding medical conditions and drowning risk for adults. MEDLINE (Ovid), PubMed, EMBASE, Scopus, PsycINFO (ProQuest) and SPORTDiscus databases were searched for original research published between 1 January 2005 and 31 October 2021 that reported adult (≥15 years) fatal or non-fatal drowning of all intents and pre-existing medical conditions. Conditions were grouped into the relevant International Classifications of Diseases (ICD) codes. Eighty-three studies were included (85.5% high-income countries; 38.6% East Asia and Pacific region; 75.9% evidence level III-3). Diseases of the nervous system (n = 32 studies; 38.6%), mental and behavioural conditions (n = 31; 37.3%) and diseases of the circulatory system (n = 25; 30.1%) were the most common categories of conditions. Epilepsy was found to increase the relative risk of drowning by 3.8 to 82 times, with suggested preventive approaches regarding supervised bathing or showering. Drowning is a common suicide method for those with schizophrenia, psychotic disorders and dementia. Review findings indicate people with pre-existing medical conditions drown, yet relatively few studies have documented the risk. There is a need for further population-level research to more accurately quantify drowning risk for pre-existing medical conditions in adults, as well as implementing and evaluating population-level attributable risk and prevention strategies.
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Affiliation(s)
- Amy E. Peden
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Kensington, NSW 2052, Australia;
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia;
| | - Danielle H. Taylor
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia;
| | - Richard C. Franklin
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia;
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Jakobsen SR, Hansen IB, Harders SW, Thomsen AH, Pedersen CCE, Boel LWT, Hansen K. Quantitative analysis of pulmonary structures in PMCT; Stereological comparison of drowning compared to opioid-overdose cases. FORENSIC IMAGING 2022. [DOI: 10.1016/j.fri.2022.200486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
In Japan, deaths in bathtubs or bathtub deaths are frequently investigated as unnatural deaths. About 19,000 bathtub deaths occur annually in Japan. This pattern of death has become a social issue in forensic pathology and emergency medicine and public health. It is assumed that the death of an adult by drowning in a bathtub cannot be avoided due to disturbance of consciousness. The PubMed database was used for literature search using the retrieval words, "bathing "OR" bathtub "AND" submersion "OR" drowning "OR" death "OR" cardiopulmonary arrest". From the epidemiological characteristics and pathophysiological findings of bath mortality in Japan, three etiologies of impaired consciousness have been proposed: acute ischemic heart failure, heatstroke, and blood pressure fluctuation. Moreover, other causes such as epilepsy and alcohol or drug intake cannot be ignored as potential risks for death in a bathtub. It is also important to note the possibility of suicide and, although extremely rare, homicide in a bathtub. Despite research, the exact causal relationship between bathtub bathing and death remains unclear. Further, the cause of death by postmortem investigation is not always easily determined. Hence, it is desirable to carry out a field survey of causes of death, including bathing conditions, and, wherever possible, a complete autopsy survey. An exclusion of critical cases such as crime-related death, suicide, drug poisoning, and carbon monoxide poisoning is optimal. Of the many hypotheses about the causes of bathtub mortality, the most consistent hypothesis will be medically inferred from the death history, case findings, and test results.
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Affiliation(s)
- Yoshimasa Kanawaku
- Department of Forensic Medicine, Graduate School of Medicine, Nippon Medical School
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Chatzaraki V, Ebert LC, Thali MJ, Haidich AB, Ampanozi G. Evaluation of the mediastinal-thoracic volume ratio on postmortem computed tomography. Int J Legal Med 2021; 135:1903-1912. [PMID: 33909145 PMCID: PMC8354949 DOI: 10.1007/s00414-021-02593-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/01/2021] [Indexed: 12/01/2022]
Abstract
Objectives The aim of this study was to measure the mediastinal-thoracic volume ratio (CTR_VOL) on PMCT as a more accurate version of traditional CTR, in order to assess the terminal positional relationship between the heart and lungs in the different causes of death with regard to age, gender, BMI, cardiomegaly, and lung expansion. Materials Two hundred fifty consecutive postmortem cases with pre-autopsy PMCT and full forensic autopsy were retrospectively evaluated. The lungs and the mediastinum were manually segmented on the PMCT data and the correspondent volumes were estimated in situ. CTR_VOL was calculated as the ratio of the mediastinal to the thoracic volume. The volume measurements were repeated by the same rater for the evaluation of the intrarater reliability. Age, gender, body weight and height, heart weight at autopsy, and cause of death were retrieved from the autopsy reports. Presence of lung expansion was radiologically evaluated in situ. Results CTR_VOL was positively associated with age and BMI but not with gender and was higher for cardiomegaly compared to normal hearts, lower for asphyxiation-related deaths compared to cardiac deaths and intoxications, and lower for cases with lung expansion. The intrarater reliability was excellent for the calculated volumes of both lungs and mediastinum. Conclusion The results of the present study support CTR_VOL as a tool to assess the relationship between the heart and lungs in situ, which differs significantly between the studied cause of death categories. Supplementary Information The online version contains supplementary material available at 10.1007/s00414-021-02593-0.
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Affiliation(s)
- Vasiliki Chatzaraki
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland. .,Department of Radiology, Kantonsspital Baden, Baden, Switzerland.
| | - Lars C Ebert
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Michael J Thali
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Garyfalia Ampanozi
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
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Kodama S, Hata J, Kanawaku Y, Nakagawa H, Oshiro H, Saiki E, Okano J H, Iwadate K. Determining the effect of water temperature on the T1 and T2 relaxation times of the lung tissue at 9.4 T MRI: A drowning mouse model. Leg Med (Tokyo) 2021; 49:101836. [PMID: 33476946 DOI: 10.1016/j.legalmed.2020.101836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/21/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Japanese individuals have a unique culture of soaking in a bathtub, and forensic pathologists have experienced fatal cases due to drowning. However, T1 and T2 relaxation times of a drowning lung are poorly documented. In the present study, we investigated the relationship between drowning water temperature and T1 and T2 relaxation times of drowning lung tissues at 9.4 T MRI (Bruker, BioSpec94/20USR). The mice used as animal drowning models were directly submerged in freshwater. Water temperature was set to 8 °C-10 °C (cold), 20 °C-22 °C (normal), 30 °C, and 45 °C. The regions of interest (ROIs) on the axial section of the third slice were set at the central and peripheral areas of each-the left and the right-lung. T1 relaxation times measured immediately after death differed by the presence or absence of soaking water, except in case of cold water temperature. In the drowning groups, T1 relaxation time showed a linear dependency on water temperature. By contrast, T2 relaxation time was almost constant regardless of the presence of drowning under the same temperature condition; when compared in the lung areas of the same individuals, the times were uniformly reduced in drowning models. To minimize the effects of hypostasis and decomposition, we performed measurements immediately after death and were able to determine the noticeable difference in drowning water temperature. These results may be useful for qualitative assessments of a drowning lung and may serve as a basis when imaging the human body during forensic autopsy cases.
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Affiliation(s)
- Saki Kodama
- Department of Forensic Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Junichi Hata
- Division of Regenerative Medicine, The Jikei University School of Medicine, Tokyo, Japan; RIKEN Center for Brain Science, Saitama, Japan.
| | | | - Hiroshi Nakagawa
- Department of Forensic Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | | | - Erisha Saiki
- Laboratory Animal Facilities, The Jikei University School of Medicine, Tokyo, Japan.
| | - Hirotaka Okano J
- Division of Regenerative Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kimiharu Iwadate
- Department of Forensic Medicine, The Jikei University School of Medicine, Tokyo, Japan.
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Herr N, Lombardo P, Jackowski C, Zech WD. Diagnosis of pulmonary infarction in post-mortem computed tomography and post-mortem magnetic resonance imaging-a technical note. Int J Legal Med 2020; 134:1817-1821. [PMID: 32239316 DOI: 10.1007/s00414-020-02273-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 03/12/2020] [Indexed: 12/22/2022]
Abstract
Pulmonary thromboembolism may be accompanied by pulmonary infarction. Even though pulmonary thromboembolism (PTE) is a frequently found cause of death at autopsy, pulmonary infarction accompanying PTE is a less common finding and may therefore easily be misinterpreted as infectious or cancerous lung disease. Appearance of pulmonary infarction in post-mortem imaging and acquisition parameters helping to identify pulmonary infarctions are not described yet. Based on a case of a 50-year-old man who died due to PTE and presented pulmonary infarction, we suggest using a pulmonary algorithm in post-mortem computed tomography combined with post-mortem magnetic resonance imaging of the lungs using conventional T1- and T2-weighted sequences.
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Affiliation(s)
- Nicolas Herr
- Institute of Forensic Medicine, University of Bern, Bühlstrasse 20, 3012, Bern, Switzerland
| | - Paolo Lombardo
- Institute of Forensic Medicine, University of Bern, Bühlstrasse 20, 3012, Bern, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology, University of Bern, Inselspital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Christian Jackowski
- Institute of Forensic Medicine, University of Bern, Bühlstrasse 20, 3012, Bern, Switzerland
| | - Wolf Dieter Zech
- Institute of Forensic Medicine, University of Bern, Bühlstrasse 20, 3012, Bern, Switzerland.
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Kakiuchi Y, Nagao R, Ochiai E, Kakimoto Y, Osawa M. The Impact of Discontinuation of the Medical Examiner System: Cases of Drowning in the Bathtub at Home. J Forensic Sci 2019; 65:974-978. [DOI: 10.1111/1556-4029.14251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/18/2019] [Accepted: 11/18/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Yasuhiro Kakiuchi
- Department of Forensic Medicine Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259‐1193 Japan
- Department of Health and Welfare Management The University of Fukuchiyama 3370 Hori Fukuchiyama Kyoto 620‐0886 Japan
| | - Ryoko Nagao
- Department of Forensic Medicine Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259‐1193 Japan
| | - Eriko Ochiai
- Department of Forensic Medicine Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259‐1193 Japan
| | - Yu Kakimoto
- Department of Forensic Medicine Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259‐1193 Japan
| | - Motoki Osawa
- Department of Forensic Medicine Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259‐1193 Japan
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State of the art in post-mortem computed tomography: a review of current literature. Virchows Arch 2019; 475:139-150. [PMID: 30937612 DOI: 10.1007/s00428-019-02562-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 02/06/2019] [Accepted: 03/12/2019] [Indexed: 12/14/2022]
Abstract
Computed tomography (CT) and other advanced diagnostic imaging techniques are gaining popularity in forensic pathology. This paper aims to define and offer complete and easily accessible "state of the art" for post-mortem computed tomography (PMCT), by reviewing the latest international literature. The proposed format answers the "five Ws" that follows: (1) What: We report the different kinds of CT scan and settings generally used in post-mortem imaging. The machine most employed is a 8/16-slice spiral CT, usually without contrast enhancement. The introduction of some variables, such as CT-guided biopsies, post-mortem ventilation, and PMCT angiography is becoming increasingly useful. (2) Why: Literature highlights the many advantages of PMCT. Limitations can be partly overcome by modern imaging techniques and combined evaluation with traditional autopsy. (3) Who: Most authors agree that collaboration between different specialists, i.e., radiologists and pathologists, is the best scenario, since radiologic, anatomic, and forensic skills are needed simultaneously. The most important human factor is "teamwork". (4) When: Literature provides no absolute limits for performing PMCT. Some authors have tested PMCT as a replacement for conventional autopsy but found some limitations. Others evaluated PMCT as a guide or screening tool for traditional autopsy. (5) Where: Many research groups around the world have performed studies on the use of PMCT. Although few countries adopt PMCT in routine practice, its use is rapidly spreading.
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