Day-of-the-week variation of sudden unexpected cardiac death

Background

There has been some controversy about the day-of-the-week (septadian) variation of unexpected sudden cardiac death (SCD).

Methods

We evaluated the incidence of unexpected SCD on different days of the week in a consecutive series of 5869 SCD victims from Northern Finland [the FINGESTURE study (Finnish Genetic Study of Arrhythmic Events)]. As it is mandatory in Finland, a medico-legal autopsy was performed on all unexpected sudden death victims. The autopsies were performed between the years 1998-2017.

Results

The mean incidence of unexpected SCD was higher at weekends (during the days from Friday to Sunday, peaking on Saturday) than during the days from Monday to Thursday (8.54 ± 0.72 vs. 7.22 ± 0.19 SCDs per day of the week per 100,000 inhabitants per year, p < 0.001). Regardless of sex or ischemic versus non-ischemic etiology of SCD, the distribution of the occurrence of SCD among the days of the week was similar compared with the whole SCD cohort.

Conclusion

The incidence of unexpected SCD was highest at weekends (during the days from Friday to Sunday, peaking on Saturday).

Seasonal variation in medico-legal autopsies in Finland-a nationwide analysis of the period 2016-2021

Both natural and unnatural mortality have seasonal variation. In spite of the established link between season and mortality, it is unclear whether medico-legal autopsies are subject to similar variation. Building on a nationwide dataset from the years 2016-2021, this short report aimed to analyse whether medico-legal autopsies are subject to seasonal variation in Finland. An electronic information system was queried for the monthly numbers of performed autopsies. Monthly and yearly trends were estimated with Kruskal-Wallis test and linear regression. A total of 50,457 medico-legal autopsies were performed during the 6-year study period. There were on average 29 to 47 autopsies per day, with an estimated annual decline of 1.8% (95% confidence interval 0.7-2.9%) over the study period. Monthly and yearly variation in autopsies was mostly minor and irregular; statistically significant differences were only observed between January and September as well as January and November (p < 0.05). As such, there appears to be little seasonal variation in medico-legal autopsies in Finland. A mild declining trend in the number of autopsies was observed. Future studies are invited to explore patterns of seasonality in other medico-legal systems, for example in those with generally lower autopsy rates than in Finland.

External challenges for specialists dealing with forensic autopsies

BACKGROUND

In addition to poor infrastructure, and human resource constraints, forensic medicine specialists in developing countries face many external challenges.

OBJECTIVES

We aimed to investigate the prevalence, type, and source of external challenges confronting them including sex, age, religion, deceased's place of residence and the number of accompanying relatives.

MATERIALS AND METHODS

This cross-sectional, observational study was conducted between August 2020 and July 2022 at the Mortuary of AIIMS, Bhubaneswar with the approval of the ethical committee.

RESULTS

Of note, forensic medicine specialists faced external challenges in about one in five cases (20.5%). Most demands were to either minimise the autopsy procedure (n = 65) or to conduct the autopsy at inappropriate times (n = 58). The demands to minimise the autopsy procedure were significantly associated with the deceased's age (p = 0.046), religion (p = 0.010), socioeconomic class (p = 0.020) and manner of death (p = 0.019).

CONCLUSIONS

Our study found that forensic medicine specialists in India face significant external challenges. Avoiding unnecessary complete autopsies, implementing night autopsies, and embracing minimally invasive autopsies are recommended to mitigate these challenges.

Prevalence of blood-borne infections in forensic samples: Epidemiology in areas of Chiba, Japan

OBJECTIVES

To statistically clarify the prevalence and risk factors of infections in forensic autopsy cases in Chiba Prefecture, Japan. The aim was to improve preventive measures against infection in forensic autopsies.

METHODS

We retrospectively investigated the positive detection rates of five infections (hepatitis B, HBV; hepatitis C, HCV; human immunodeficiency virus, HIV; human T-lymphotropic virus, HTLV; Treponema pallidum, TP) using 1491 samples obtained in forensic autopsy at our facility from 2014 to 2018. In addition, risk factors related to infection such as methamphetamine and tattoos were analyzed. Pearson's chi-square test was used for statistical analysis, and the difference was judged to be significant at p < 0.05.

RESULTS

Among our samples, 9.0% of cadavers tested positive for infection, and the prevalence rates for HBV, HCV, HIV, HTLV, and TP were 1.0%, 6.7%, 0.3%, 0.7%, and 1.1% respectively. Statistically, cadavers linked to information about methamphetamine use had a 7.2 times higher rate of infection, and those with tattoos had a 5.6 times higher rate of infection, with HCV being the predominant cause.

CONCLUSIONS

To limit the risk of infection among autopsy workers, cadavers and samples should be handled on the presupposition that the bodies are at risk of infections. It is also important to obtain as much information as possible about the medical history and potential illegal drug use to help assess the risk of infection in a patient during forensic autopsy. We propose that all autopsy cases should be screened for infections whenever possible.

The incidence of iatrogenic deaths in the Finnish cause-of-death statistics; a retrospective study

PURPOSE

An adverse event in health care leading to death is a significant event when assessing patient safety. This study was designed in order to assess, how many iatrogenic deaths are registered in Finland annually, and what type of treatment they are mostly related to.

METHODS

Material was collected using cause of death-statistics that includes "manner of death"-classification in Finland in 2014-2015.

RESULTS

There were 350 cases that met the criteria of the study. In a majority of the cases (264, 75%), a medico-legal autopsy was performed. This represents only 1.4% of all medicolegal autopsies during the study period in Finland. The cases were most often related to medication (30%) or known high-risk procedures such as gastrointestinal surgery (23%) and cardiothoracic surgery (11%). Only 12% of the cases had no prior significant medical history. Patient characteristics were somewhat different among the surgical disciplines, probably reflecting treatment practices.

CONCLUSION

Deaths that are classified as iatrogenic are mostly related to known high-risk surgery or medication. Further studies are needed to assess the true incidence of malpractice among this material.

Forensic medicine in Nepal: Past, present, and future

The practice of autopsy for medico-legal purposes in Nepal was started during the 1960s when jail doctors used to perform the autopsy. However, the medico-legal service in clinical forensic settings is less than three decades old. In Nepal, a police inquest is done for all the unnatural deaths who then subjects the body for medico-legal autopsy at the nearest government hospital. Except for a few hospitals where forensic medicine experts are available, the medico-legal work in Nepal is done by medical officers most of who have no forensic qualification. For a country with a population of nearly 30 million, there are less than 50 forensic medicine experts who are currently practicing. There are 21 medical colleges in Nepal each having a forensic medicine department engaged in teaching forensic medicine as a separate subject in the undergraduate medical curriculum. Currently, postgraduate courses are also offered in the country. However, there is a lack of uniformity in the curriculum set by different universities for both postgraduate and undergraduate education. Due to the lack of forensic medicine faculty members in some medical colleges, the undergraduate students of medicine have to undertake the exam being taught by some guest lectures and without witnessing a single medico-legal autopsy. To standardize the medico-legal services and forensic medicine education, the Medico-Legal Society of Nepal was established with an aim to conduct regular seminars, conferences, and CMEs and also various training programs for the non-forensic medicine experts who deal with medico-legal cases. This paper aims to provide a brief history of medico-legal practice in Nepal, the current situation, and future plans to improve the medico-legal service of the country.

Association of non-shockable initial rhythm and psychotropic medication in sudden cardiac arrest

Background

Asystole (ASY) and pulseless electrical activity (PEA) have a poor outcome during sudden cardiac arrest (SCA). Psychotropic medication has been associated with a risk for sudden cardiac death (SCD). Our aim was to study the association of psychotropic medication with ASY/PEA during SCA.

Methods and results

A total of 659 SCA subjects were derived from the emergency data of Oulu University Hospital (2007-2012). Subjects with non-cardiac origin of SCA and over 30-minute delay to rhythm recording were excluded. Population included 222 subjects after exclusions (mean age 64 ± 14 years, 78% males). Initial rhythm was ventricular fibrillation (VF) or ventricular tachycardia (VT) in 123 (55%), ASY in 67 (30%) and PEA in 32 (14%) subjects. The delay (collapse to rhythm recording) was similar in VF/VT and ASY/PEA subjects (median 8 min [1st-3rd quartile 3-12 min] versus 10 [0-14] minutes, p = 0.780). Among VF/VT subjects underlying cardiac disease was more often ischemic compared to ASY/PEA subjects (85% versus 68%, p = 0.003). Psychotropic medication was associated with ASY/PEA rhythm (OR 3.18, 95%CI 1.40-7.23, p = 0.006) after adjustment for gender, age and underlying cardiac disease. Subsequently, antipsychotics (OR 4.27, 95%CI 1.28-14.25, p = 0.018) were more common in the ASY/PEA group. Benzodiazepines and antidepressants were not associated with ASY/PEA.

Conclusion

Psychotropic medication and especially antipsychotics are associated with non-shockable rhythm during SCA and may lower the possibility of survival from the event. This might partly explain the risk of SCD related to psychotropic medication.

Presumed adverse events in health care are a frequent indication for medico-legal autopsy in Finland

The medico-legal autopsy is an essential tool in investigating deaths caused by an adverse event in health care, for both clinical risk management and for professional liability issues. However, there are no statistics available regarding the frequency of autopsies performed due to suspected adverse events. This study aimed to determine the number of medico-legal autopsies done because of presumed adverse events, whether these events were unintentional, medical errors or cases in which malpractice was suspected. Furthermore, differences in treatment types, causes and manner of death were analyzed. The data was obtained from all medico-legal autopsies performed in Northern Finland and Lapland during 2014-2015 (n = 2027). Adverse events were suspected in 181 (8.9%) cases. The suspicions of an adverse event occurring were most often related to medication, gastrointestinal surgery and orthopedic surgery. The manner of death was classified as medical (or surgical) treatment or investigative procedure in 22 (12.2%) cases. The causes of death were completely unrelated to the suspected adverse event in 41 (22.7%) cases. In conclusion, the frequency of presumed adverse events was quite high in this data set, but in the majority of the cases, the suspicion of an adverse event causing death was disproved by an autopsy. Nonetheless, proper investigation of these cases is essential to ensure legal protection of the deceased, next of kin and health care personnel, as well as to support clinical risk management.

Significant decrease in the rate of fatal alcohol poisonings in Finland validated by blood alcohol concentration statistics

BACKGROUND

Alcohol may cause death directly by acute poisoning, as well as induce illnesses or accidents that lead to death. Our research question was whether the current decreasing trend in acute fatal alcohol poisonings in Finland is a real phenomenon or an artefact caused by possible changes in the process of determining the cause of death.

METHODS

All cases in the national post-mortem toxicology database in which the underlying cause of death was acute alcohol poisoning in 1987-2018 were investigated in terms of blood alcohol concentration (BAC), age and gender. The number of acute alcohol poisonings was compared to the number of deaths from alcohol induced illness in the post-mortem toxicology database.

RESULTS

A total of 12 126 acute alcohol poisoning cases were retrieved. Between 2004 and 2017 the number of acute alcohol poisonings decreased 60.1 %. At the same time the number of alcohol induced illnesses in the study material remained stable or decreased marginally. The median BAC in all acute alcohol poisonings was 3.2 g/kg. The annual median BAC values showed a small but significant decrease over the study period. The proportion of women in acute alcohol poisonings increased significantly over the study period, from 17.1%-22.3%. Women were on average 2.5 years older than men.

CONCLUSIONS

On grounds of the BAC statistics and supporting evidence, we conclude that the significant decrease in the number of fatal alcohol poisonings is true and likely reflects changes in the overall consumption of alcohol.

Drugs in fall versus non-fall accidents with major trauma - A population-based clinical and medico-legal autopsy study

BACKGROUND

The main aim of the present population-based study was to compare drugs in fall versus non-fall accidents causing major trauma, including both clinical and medico-legal autopsy data.

METHODS

All individuals with accidents resulting in major trauma, a new injury severity score (NISS)>15 or lethal outcome was identified at hospital and/or the Department of Forensic Medicine between 2011 and 2013. Modified Downton Fall Risk Index ranged from 0 to 7, and was based on specific pharmaceuticals (max 5 points), previous fall (1 point) and cognitive impairment (1 point).

RESULTS

One hundred and four individuals with major traumatic accidents were identified, 38 (36.5%) died. The median modified Downton Fall Risk Index was 2 for fall accidents and 0 for non-fall accidents (p < 0.001). Modified Downton Fall Risk Index was an age-independent factor associated with fall accident (p < 0.001). The medico-legal autopsy rate for in-hospital patients was 50% (6/12) for fatal fall accidents in comparison with 92.3% (12/13) for fatal non-fall accidents (p = 0.03). In individuals undergoing medico-legal autopsy, the proportion of individuals with any detected drug was 77% in fall accidents compared to 39% in non-fall accidents (p = 0.036). The presence of sedatives (p = 0.002) and bensodiazepines (p = 0.023) were higher for fall accidents compared to non-fall accidents.

CONCLUSION

This population-based study on accidents with major trauma showed that drugs had high impact on fall accidents with major trauma. It seems warranted from a public health perspective to study if implementation of medication review guidelines at hospital managing polypharmacy issues may prevent fall accident recidivism.

Sudden Death of a Teenager Caused by Actinomyces israelii: A Case Report

Actinomycosis is a rare bacterial infection, caused by a group of Gram-positive bacteria which form the normal flora of oral cavity, gastrointestinal tract, and female genital tract. We present a rare case met in 2016 at Legal Medicine Bihor County Service, Romania of a 14 yr old boy in infection with Actinomyces israelii was able to produce sudden death. Infection with A. israelii was diagnosed with the help of histological exam, after medico-legal autopsy. Most probably, A. israelii was aspirated from the level of the oropharynx, it arrived into the lungs, and using the haematological way it spread into the heart, causing sudden death.

Usefulness of unenhanced post mortem computed tomography - Findings in postmortem non-contrast computed tomography of the head, neck and spine compared to traditional medicolegal autopsy

INTRODUCTION/BACKGROUND

Post-mortem CT (PMCT) is becoming an essential tool available to forensic pathologists worldwide, but its validity with respect to evidence for legal purposes still requires more comprehensive large-scale studies, comparing PMCT to autopsy. This article compares PMCT and autopsy findings of the head, neck, and spine during a period of five years.

MATERIALS AND METHODS

The study included 203 cases for which both autopsy and PMCT were performed. All relevant findings were extracted from the reports and divided into 30 categories based on anatomical location and tissue characteristics. Data were evaluated quantitatively in a binary fashion.

RESULTS/FINDINGS

A high level of agreement was noted for skull fractures, intraventricular- and subarachnoid hemorrhages, bullet trajectories, and intracranial shrapnel. A fair correlation was demonstrated for brain atrophy or herniation, and findings in the facial soft tissues. PMCT had higher sensitivity to brain edema, presence of gas in tissues or cavities, and findings in the spinal column and spinal canal, whereas autopsy better demonstrated pathologies in the brain tissue, hemorrhages in the neck and fractures of the larynx and hyoid bone. A relatively low correlation was noted for subdural and epidural hematomata.

CONCLUSIONS/INTERPRETATION

For several locations, structures, and specific findings in the head, neck and spine, autopsy remains indispensable. However, PMCT better demonstrated some findings in locations that are difficult to access by autopsy, or structures that might be damaged due to autopsy procedure. For the examinations of these, PMCT may in specific cases serve as an alternative to autopsy. Generally, however, due to the vast and fundamental differences that distinguish each case from the next, and the different purposes that autopsy may serve, we propose that the decision as to which method (or a combination of both) should be used, be made according to the circumstances and expected findings of each case.

Back to the Future - Part 1. The medico-legal autopsy from ancient civilization to the post-genomic era

Part 1 of the review "Back to the Future" examines the historical evolution of the medico-legal autopsy and microscopy techniques, from Ancient Civilization to the Post-Genomic Era. In the section focusing on "The Past", the study of historical sources concerning the origins and development of the medico-legal autopsy, from the Bronze Age until the Middle Ages, shows how, as early as 2000 BC, the performance of autopsies for medico-legal purposes was a known and widespread practice in some ancient civilizations in Egypt, the Far East and later in Europe. In the section focusing on "The Present", the improvement of autopsy techniques by Friedrich Albert Zenker and Rudolf Virchow and the contemporary development of optical microscopy techniques for forensic purposes during the 19th and 20th centuries are reported, emphasizing, the regulation of medico-legal autopsies in diverse nations around the world and the publication of international guidelines or best practices elaborated by International Scientific Societies. Finally, in "The Future" section, innovative robotized and advanced microscopy systems and techniques, including their possible use in the bio-medicolegal field, are reported, which should lead to the improvement and standardization of the autopsy methodology, thereby achieving a more precise identification of natural and traumatic pathologies.

Necessity of including medico-legal autopsy data in epidemiological surveys of individuals with major trauma

BACKGROUND

It is rare that epidemiological surveys of patients with major trauma include both those admitted to the emergency department and those sent for medico-legal autopsy. The main aim of the present population-based study of major trauma was to examine the importance of medico-legal autopsy data.

METHODS

A new injury severity score (NISS)>15 or lethal outcome was used as criteria for major trauma and to identify patients at the emergency, anaesthesiology and forensic departments and/or being within the jurisdiction of the Malmö police authority and subjected to a medico-legal autopsy between 2011 and 2013. According to Swedish legislation all trauma related deaths should be reported to the police who refer these cases for medico-legal autopsy.

RESULTS

Among the 174 individuals included, 92 (53%) died and 81 (47%) underwent medico-legal autopsy. One hundred twenty-six patients were primarily admitted to hospital and 48 died before admission to hospital and were sent directly for medico-legal autopsy. Forty-four in-hospital deaths occurred, of whom 33 (75%) were sent to medico-legal autopsy. In those sent directly to the department of forensic medicine the proportion of accidents was lower (p<0.001), self-inflicted injuries higher (p<0.001) and gunshot wounds higher (p=0.002) in comparison with those sent to hospital. The most prevalent drugs detected by forensic toxicology screening in the 81 fatalities were ethanol (20%), sedatives (16%), anti-depressives (15%) and illicit narcotics (9%). Forty-four cases (54%) were positive for at least one drug, and twenty-eight cases (35%) were positive for two or more drugs. Factors associated with a lower rate of medico-legal autopsies among trauma-related deaths at hospital were high age (p<0.001), lower NISS (p<0.001), a longer duration between trauma and death (p<0.001), falls (p=0.030) and trauma-related infections (p<0.001).

CONCLUSION

This population based study covering clinical and forensic data shows that more than half of the individuals sustaining major trauma died. An additional 25% of the in-hospital fatalities should have undergone medico-legal autopsy according to legislation, but did not. The high proportion of positive toxicological findings among fatalities examined at medico-legal autopsy implies that toxicology screening should be routine in major trauma patients, in order to improve treatment and prevention.

Myths and misconceptions about medico-legal autopsies among the people of Tamilnadu, India

BACKGROUND

Medico-legal autopsies are conducted as a part of necessary investigation in all unnatural deaths. In India, the awareness about medico-legal autopsies among the population is still at incipient stage. The procedure is largely stigmatised due to various myths and misconceptions. Apprehension about the procedure brings about various emotional reactions of relatives. Hence the study was carried out to know those myths and misconceptions.

OBJECTIVES

To find out the various myths and misconceptions about the medico-legal autopsies among the people. To make a lay person aware of the importance of medico-legal autopsies.

METHODS

This is a descriptive cross sectional study conducted in central part of Tamilnadu, India. About 600 participants of age 18 to 80 years were included. Their responses were obtained by semistructured questionnaires.

RESULT

There is a significant difference noted on various views among this population.

INTERPRETATION

Administration should strive to rescind these misapprehensions and myths. The medical staff, mass and electronic media should also come forward to educate them.

CONCLUSION

Stipulation of health education about the medico-legal autopsies is must for a lay person.

Forensic medicine experts' opinion on medico-legal autopsies in hospital deaths: a questionnaire survey

OBJECTIVE

Medico-legal autopsy is conducted routinely in some countries and selectively in others in hospital deaths. This study was conducted to evaluate the views of the forensic medicine experts regarding this matter.

METHODS

A questionnaire pro forma was sent to sixty-five forensic medicine experts practicing in different medical institutions all around India. Designations and experiences of the participants were noted by requests in the same questionnaire. Their specific experience in conducting medico-legal autopsy in hospital deaths was also requested for. Responses were charted in frequency distribution tables and analyzed using SPSS, version 17.0.

RESULTS

One-third of the participants felt that a medico-legal autopsy was necessary in all the hospital death cases as defined in the present study. Ten percent of the participants opined that a medico-legal autopsy was unnecessary in hospital deaths. The majority of the experts mentioned finding the cause of death, followed by finding the manner of death and collecting the evidentiary materials, as the reasons for medico-legal autopsy in hospital deaths. Twenty percent of the participants felt that internal findings at autopsy poorly matched with the case records. All the experts agreed that external autopsy findings matched with the hospital case records. Nearly two-third of the participants felt that it was difficult in some cases to interpret the autopsy findings without case records from the hospital where the deceased was treated.

CONCLUSION

Our findings suggest that the exercise of carrying out medico-legal autopsy routinely in every hospital death as evident in the Indian framework is often unnecessary as per the experts' opinion. Autopsy findings in hospital deaths often correlate with hospital case records.

An autopsy case of a primary aortoenteric fistula: A pitfall of the endoscopic diagnosis

A primary aortoenteric fistula (PAEF), defined as a communication between the native aorta and the gastrointestinal tract, is a rare cause of gastrointestinal bleeding. The preoperative diagnosis of PAEF is extremely difficult. Consequently, PAEF may cause sudden and unexpected death. We present an autopsy case of a 68-year-old man who died of massive gastrointestinal bleeding due to a PAEF. Autopsy revealed a pinhole rupture located on the third part of the duodenal mucosa and fistulized into the adjacent abdominal aortic aneurysm (AAA). Our case indicates that the aortoenteric fistula can result in fatal gastrointestinal bleeding. Consequently, a PAEF should be included in the differential diagnosis of gastrointestinal bleeding.