Forenzički aspekti postmortalne analize transferina s nedostatkom ugljenih hidrata kao markera zloupotrebe alkohola

Introduction Carbohydrate-deficient transferrin (CDT) has been suggested as one of alcohol abuse indicators having produced good results in forensic medicine for years. Objective The aim of the study was to identify correlation between present methodology of alcohol abuse diagnosis at autopsy (macroscopic and microscopic findings) and CDT examination using the method of isoelectrofocusing (IEF) in polyacrylamide gel electrophoresis (PAGE). We also analyzed if the time interval between the moment of death and blood sample collection influences CDT findings. Methods The method used for CDT analysis was IEF-PAGE. Sera of 49 males and 11 females aged 14-87 years, average age 46.85 +/- 18.53, were used in this study. Control group consisted of five patients who died after medical treatment that lasted longer than 15 days, and five patients who started Disulfiram therapy in controlled hospital environment. Results The results obtained in CDT examination in dead bodies' sera showed sensitivity 59% and specificity 71%. A high incidence of falsely positive CDT result was noticed in liver failure and cirrhosis of non-alcoholic origin. CDT analysis is also possible to be done in samples collected postmortem up to 76 hours. Conclusion In forensic medicine, the method of CDT determination is reliable for the diagnosis of alcohol abuse.Uvod. Poslednjih godina transferin s nedostatkom ugljenih hidrata (engl. carbohydrate-deficient transferrin - CDT) jedan je od markera zloupotrebe alkohola koji je pokazao najbolje rezultate u sudskoj medicini. Cilj rada. Cilj studije je bio da se odredi korelacija između aktuelne metodologije dijagnoze zloupotrebe alkohola na postmortalnom materijalu (makroskopski i mikroskopski nalaz) i određivanja CDT korišćenjem metode isoelektrofokusiranja (engl. isoelectric focusing - IEF) u poliakrilamidnom gelu (engl. polyacrylamide gel electrophoresis - PAGE). Utvrđivano je da li interval između vremena smrti i uzimanja uzoraka za CDT analizu utiče na nalaz CDT. Metode rada. Za analizu CDT korišćena je metoda IEF-PAGE. Za studiju su analizirani serumi 49 muškaraca i 11 žena prosečne starosti od 46,85±18,53 godina (raspon 14-87 godina). Kontrolnu grupu činilo je pet pacijenata koji su umrli nakon bolničkog lečenja koje je trajalo duže od 15 dana i pet pacijenata kod kojih je u kontrolisanim bolničkim uslovima počelo lečenje disulfiramom. Rezultati. Dobijeni rezultati pokazuju da ova metoda analize CDT na postmortalnom materijalu ima senzitivnost od 59% i specifičnost od 71%. Visoka učestalost lažno pozitivnih rezultata utvrđena je kod oboljenja jetre i ci- roze nealkoholnog porekla. Analizu CDT je moguće raditi i iz uzoraka uzetih do 76 sati nakon smrti. Zaključak. U sudskomedicinskoj praksi ova metoda analize CDT može se koristiti za dijagnostikovanje hronične zloupotrebe alkohola

FAT LUNG EMBOLISM AS A PRECIPITATING FINAL CAUSE OF DEATH IN POLVTRAUMATIZED PATIENTS

Two studies analyzing the autopsy material of the Institute for ForensicMedicine in Belgrade have been done. The first study (group A) was a prospectivehistological one and it comprised the examined in which lung fat embolism was notrecorded as a cause of death in the autopsy protocol conclusion but was confirmed bythe microscopic examination in all the cases. Ali these poly traumatized patients hadan injury that could be an outcome of fat embolism. The second group (group B) wasa retrospective autopsy one and it analyzed autopsy protocols and čaše histories ofthepatients who died of the fat embolism syndrome (FES) that was the only or competingcause of death. The autopsy records and the čaše histories of ali the patients wereanalyzed; the groups were compared with respect to gender and age, way of gettinginjured, an injury severity score (ISS) and the period of living after the injury. Ali theobtained data were processed by corresponding statistic methods. The data analysisled to the conclusion that in the poly traumatized patients the fat lung embolism couldbe a precipitating and flam cause of death either as a singular or as a competitive onecombined with some other. It is obvious that the fat embolism of the lungs and thesystem fat embolism could be accepted as a consequence of every more serious injuryof the fat depots in the organism while a possible later development of the fatembolism syndrome would represent a complication of the injury

Accident after accident - unusual death of a patient in hospital

The authors present a case of accidental fatal laryngopharyngeal obstruction with bolus of food, in hospital, in a patient who has been treated for twenty days because of injuries sustained in a traffic accident. The injuries were multiple fractures and brain contusions that were not clinically diagnosed, while their simptomatology (somnolence) was attributed to morbous lesions - multifocal brain infarction. Mechanical asphyxiation and death occurred when the patient was fed in hospital by his brother. Unofficially we got an information that whole event was very dramatical, and that medical staff tried to attempt re-suscitative measures but without any written note about that in medical documentation. The terminal phase of his chronic desompensated cardiomyopathia was clinically announced as a cause of death. For forensic pathologists it was relatively easy task to prove mechanical asphyxiation due to laringopharyngeal blockage as a real cause of death on medicolegal autopsy

Correlation between outliving period and trauma severity in persons died from posttraumatic fat embolism

INTRODUCTION Posttraumatic fat embolism follows the injury. The fat emboli in circulation could cause death in three ways: isolated lung fat embolism, systemic fat embolism and fat embolism syndrome (FES). In forensic pathology, only two trauma scores, based on disintegration of anatomic structures, could be used for objectivization, comparison and establishment of severity of injuries. One of them is Injury Severity Score - ISS, based on Abbreviated Injury Scale - AIS. The second one is Hannover Polytrauma Score - HPTS, based on the total sum of all injuries and age of the injured person. OBJECTIVE The objectives of this paper were to establish the correlation between outliving period and trauma severity (based on ISS and HPTS values), in persons died from posttraumatic fat embolism and/or its complications, and to establish which of these score systems could be better for prediction of development of the posttraumatic fat embolism. METHOD The retrospective autopsy study was performed and it included the material of the Institute of Forensic Medicine in Belgrade for period 1988-2001. The autopsy reports and clinical medical data were analyzed, for persons died from posttraumatic fat embolism and/or its complications. In all cases, the fat embolism was the single cause of death, verified by autopsy. In each case, ISS and HPTS values were obtained. The sample was statistically prepared (x2 test, correlation coefficient, regression line). RESULTS AND DISCUSSION The sample included 50 persons: 41 males and 9 females. The proportion of men was statistically significant (x2=20.480; p<0.001). Average age of male was 55.26 years (SD=21.39) and of female was 55.78 (SD=17.45). There was no statistically significant disproportion among the age distribution of the sample (x2=6-4; p>0.05).The outliving period varied from 1-14 days: the average was 5.92 (SD=3.39; Med. 5.50; Mod. 2). The average value of ISS was 19 (SD=7.70; Med. 19; Mod. 14), and for HPTS average value was 28.16 (SD=12.87; Med. 26.50; Mod. 12). In literature, there have been data about critical ISS value: 12-20. HPTS value of 20 to 35 was lethal in 25%. Each injured of our sample had, at least, one long bone or pelvic fracture. There was negligible negative correlation between outliving period and ISS and HPTS values in our sample: coefficient of linear correlation r=-0.117, t=0.83 and r=-0.088, t=0.59. Our sample was representative (t=8.37). These data pointed out that the outliving period of the observed patients, died from posttraumatic fat embolism, was not in relation to general severity of injuries but to fat embolism per se and its consequences. There was low positive correlation between ISS and HPTS values: r=0.296, t=2.147, coefficient of determination r2=0.0876 and linear regression HPTS=18.7588+0.4948 ISS. These data indicated that direct correlation between scores was only about 9% and the rest of correlation i.e. 91% depended on other factors. CONCLUSION There was negative negligible correlation between outliving period and severity of injury based on ISS and HPTS, in patients died from posttraumatic fat embolism. So, these score systems are useless for prediction of duration of the outliving period in the injured died from fat embolism as well as for prediction of posttraumatic fat embolism as cause of death

Factors that could influence the severity of post-traumatic lung fat embolism - a prospective histological study -

INTRODUCTION Each fracture of long or pelvic bones as well as large contusions of subcutaneous fat tissue cause releasing of fat globules that rapidly penetrate into circulation through the ruptured veins of the injured tissue, and reach the lung circulation [1,2]. During the first phase, fat emboli block the functional lung circulation by their mechanical effect in capillaries producing so called isolated post-traumatic lung fat embolism [3]. The surface layer of a fat embolus, which is practically in liquid state, behaves as a membrane of very high density, i.e., as it is under high pressure which obstruct the blood stream [4] that is finally stopped at the level of lung blood vessels with diameter of approximately 20 µ [5].This pathophysiological mechanism produces cor pulmonale acutum, with poor pathological findings [8]. Nowadays, the post-mortem diagnosis of lung fat embolism is based on microscopical examination of tissue specimens, usually prepared with special histological staining (Sudan III) [9]. The grading of fat embolism according to Sevitt's criteria is generally accepted [10]. Taking of slices from apicoventral areas of the lungs has been recommended [11]. With longer outliving period, the total number of fat emboli in the lung circulation gradually decreases, due to their disintegration and resorption. It has been stated that fat globules completely disappear about 4-6 weeks after injury, and that they should not be searched for microscopically in this post-traumatic phase [11]. OBJECTIVES The aim of our work was to determine whether the age of injured, their gender, total severity of trauma, outliving period, and hypovole-mic shock that develops after injuring, may induce development of more severe forms of post-traumatic lung fat embolism. MATERIAL AND METHODS A prospective histological study was performed on the autopsy material of the Institute of Forensic Medicine in Belgrade. The analyzed sample consisted of individuals with injuries that might be a source of fat emboli (fractures of long bones, large contusions of subcutaneous fat tissue). The lung slices were systematically taken and stained with special fat staining (Sudan III). In each particular case, the grade of lung fat embolism was counted on the basis of microscopical appearance, according to Sevitt's criteria. The total severity of trauma was estimated by calculation of the Injury Severity Score (ISS) [13,14]. In no cases from the analyzed sample, the fat embolism was mentioned as either singular or plural cause of death. The obtained results were analyzed by means of appropriates statistical methods (ANOVA LSD-test, x2 test, Man-Whitney test, Fischer's test of correct probability). RESULTS AND DISCUSSION The analyzed sample included 58 fatally injured individuals, 39 males and 19 females. The average age was 54.10 years (SD=16.56), the average value of ISS was 34.69 (SD=5.88), and the average outliving period was 3.74 days (SD=5.88). However, all these data look differently when the analyzed sample has been stratified and analyzed according to the estimated grade of lung fat embolism. It was not showed that severity of lung fat embolism depends on sex of the injured (^2=0.842 p>0.05). The groups with the slightest and the most severe grade of lung fat embolism are statistically significantly different in relation to age of individuals (ANOVA, p=0.017). By means of LSD test, it has been showed that the group with the most severe grade of lung fat embolism (grade III) is statistically significantly different comparing to other two groups (with grade I and II) in relation to the age of injured (the values are p=0.16 and p=0.19 respectively, and the both groups are less than p=0.05). In the group with the most severe grade of lung fat embolism, the older individuals are statistically significantly represented comparing to othertwo groups. CONCLUSION The analysis of our sample showed that the most severe grade of post-traumatic lung fat embolism (microscopical grade III according to Sevitt's criteria) was determined in older individuals, more severely injured, and with shorter outliving period. The severity of fat embolism depends neither on sex of the injured, nor on development of post-traumatic hypovolemic shock. The obtained results related to the influence of hypovolemic shock on severity of fat embolism should be accepted with a caution. Namely, sometimes there is an intention to simplify a procedure of creating of autopsy conclusion about the cause of death, so that loss of blood is not mentioned at all, in spite of fact that it could have been a concurrent cause of death, while in other cases exsanguination is designated as a sole cause of death, forgetting the possibility that fat embolism could have really been the immediate cause of death

Myocardial bridges: A prospective forensic autopsy study

Introduction When the coronary artery, located subepicardially, submerges into the myocardium and appears again subepicardially after a short intramural course, it represents an embedded coronary artery, while the part of the myocardium above is a myocardial bridge. Objective We investigated the frequency of the embedded left coronary artery (LAD) in the autopsy material considering the descending branch of the LAD to be the most important one in the nourishment of the myocardium and myocardial bridges to be the most frequent in its area, as well as clinically important. Methods A prospective autopsy study of 975 cases was performed, including both, natural (21.33%) and violent (78.67%) deaths. The sample consisted of 74.56% males and 25.44% females. In order to discover myocardyal bridges and their characteristics, the hearts were examined by both transverse cuts and longitudinal openings of the LAD. Results Myocardial bridge was found in 78 cases (8.00%), more commonly in males (9.35%) than females (4.03%). The average length of the myocardial bridge was 21.85±16.10mm and thickness 3.744±1.48 mm. The common localization of the myocardial bridge was the proximal half of the LAD (89.74%). The upper part of the artery, proximal to the bridge, was a common site of atherosclerotic changes. Myocardial bridge was found in 12.50% of natural deaths, but in 13.38% out of all cases of sudden cardiac deaths. Conclusion Therefore, the presence of the myocardial bridge by itself is not predominant, but it is certainly a contributing factor to a sudden cardiac death.Uvod 'Poniruća koronarna arterija' je pojam koji se odnosi na slučaj kada koronarna arterija - inače lokalizovana subepikardno - ponire u miokard i ponovo se pojavljuje subepikardno, posle kratkog puta kroz mišić, pri čemu se mišić iznad nje naziva 'miokardni most'. Cilj rada Istraživali smo učestalost poniruće descendentne grane leve koronarne arterije u autopsijskom materijalu imajući u vidu da je ona najvažnija u ishrani srčanog mišića, da najčešće ponire u srčani mišić i da je vrlo značajna i s kliničkog aspekta. Metode rada Urađena je prospektivna autopsijska studija 975 slučajeva prirodnih (21,33%) i nasilnih smrti (78,67%). Uzorak je obuhvatio 74,56% osoba muškog i 25,44% ženskog pola. Radi otkrivanja miokardnog mosta i analize njegovih osobenosti, nishodna grana leve koronarne arterije otvarana je uzdužnim i poprečnim obdukcionim rezovima. Rezultati Miokardni most je utvrđen u 78 slučajeva (8,00%), češće kod muškaraca (9,35%) nego kod žena (4,03%). Prosečna dužina miokardnog mosta bila je 21,85±16,10 mm, a debljina 3,744±1,48 mm. Najčešća lokalizacija miokardnog mosta bila je u predelu proksimalne polovine descendentne grane leve koronarne arterije (89,74%), a aterosklerotske promene su najčešće ustanovljene ushodno od miokardnog mosta. Miokardni most je postojao u 12,50% slučajeva prirodnih smrti, odnosno u 13,38% slučajeva tzv. naprasnih srčanih smrti. Zaključak Postojanje miokardnog mosta nije predominantni činilac za pojavu naprasne srčane smrti, ali je njegovo postojanje faktor rizika za njen nastanak

Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe

Background Little is known about the incidence of severe critical events in children undergoing general anaesthesia in Europe. We aimed to identify the incidence, nature, and outcome of severe critical events in children undergoing anaesthesia, and the associated potential risk factors. Methods The APRICOT study was a prospective observational multicentre cohort study of children from birth to 15 years of age undergoing elective or urgent anaesthesia for diagnostic or surgical procedures. Children were eligible for inclusion during a 2-week period determined prospectively by each centre. There were 261 participating centres across 33 European countries. The primary endpoint was the occurence of perioperative severe critical events requiring immediate intervention. A severe critical event was defined as the occurrence of respiratory, cardiac, allergic, or neurological complications requiring immediate intervention and that led (or could have led) to major disability or death. This study is registered with ClinicalTrials.gov, number NCT01878760. Findings Between April 1, 2014, and Jan 31, 2015, 31 127 anaesthetic procedures in 30 874 children with a mean age of 6.35 years (SD 4.50) were included. The incidence of perioperative severe critical events was 5.2% (95% CI 5.0-5.5) with an incidence of respiratory critical events of 3.1% (2.9-3.3). Cardiovascular instability occurred in 1.9% (1.7-2.1), with an immediate poor outcome in 5.4% (3.7-7.5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10 000. This was independent of type of anaesthesia. Age (relative risk 0.88, 95% CI 0.86-0.90; p<0.0001), medical history, and physical condition (1.60, 1.40-1.82; p<0.0001) were the major risk factors for a serious critical event. Multivariate analysis revealed evidence for the beneficial effect of years of experience of the most senior anaesthesia team member (0.99, 0.981-0.997; p<0.0048 for respiratory critical events, and 0.98, 0.97-0.99; p=0.0039 for cardiovascular critical events), rather than the type of health institution or providers. Interpretation This study highlights a relatively high rate of severe critical events during the anaesthesia management of children for surgical or diagnostic procedures in Europe, and a large variability in the practice of paediatric anaesthesia. These findings are substantial enough to warrant attention from national, regional, and specialist societies to target education of anaesthesiologists and their teams and implement strategies for quality improvement in paediatric anaesthesia