Medico-Legal Death Investigation Systems \u2013 Belgium

Abstract: The Belgian criminal justice system, and hence its death investigation system, is based on the French Code Napol\ue9on from 1808. It is characterized by an inquisitory (secret) nature being mostly led by an investigating judge. Most deaths are certified (so-called Model IIIc) by general physicians with very limited forensic knowledge or experience. There are no legal restrictions as to which physician can certify any death. Only when the nature of death is considered \u2018suspicious\u2019 or \u2018violent\u2019 by these physicians, the public prosecutor will ask for a more in-depth investigation by a doctor trained in forensic medicine. If necessary, a forensic autopsy will be commissioned by an investigating judge who investigates both \ue0 charge et \ue0 d\ue9charge. Overall the autopsy rate (forensic and clinical) is low in Belgium (estimated up to 1-2% of +/- 110.000 annual deaths). Residency training and specialization in forensic medicine takes 5 years and the candidates are trained both in clinical forensic medicine and forensic pathology (regulated by the Ministerial Decree of February 27th 2002)

Hoe waarheidsgetrouw zijn verklaringen over middelengebruik in het rijgeschiktheidsonderzoek?

Abstract: How truthful are statements about substance use in the fitness to drive examination? In Belgium, the court can order a fitness to drive examination on indication. One is not fit to drive if there has been excessive alcohol and/or drug use in the past 6 months. Chronic excessive alcohol use corresponds to an average consumption of 65 6 units per day or 65 42 units per week over several months. Toxicologically, 30 pg/mg ethylglucuronide (direct alcohol marker) in scalp hair strongly suggests this. For drugs, it is sufficient to demonstrate this substance in one of the samples. The anamnesis and toxicology were compared with a McNemar test. The sensitivity, specificity and positive/negative predictive value of the anamnesis as a diagnostic test were calculated. People are more likely to be unfit to drive based on the toxicological analysis than based on the anamnesis (respectively 60% versus 40%). The greatest discrepancy is seen regarding alcohol consumption. In addition, toxicologically more cases of drug use were detected. This study shows that statements regarding alcohol and drug use within the fitness to drive examination are not reliable

Two case studies on fatal head injury in e-scooter or s-pedelec falls : medico-legal consideration

Abstract: Emergency departments are facing increasing numbers of accidents related to electric two-wheeler use, resulting in craniocerebral and maxillofacial trauma. This article reports two cases of fatal neurotrauma after e-scooter/speed pedelec (s-pedelec) falls. Both cases were referred to the centre of forensic medicine because the related circumstances were unclear and to rule out hit-and-run accidents. Case 1: A 23-year-old man was found lifeless next to his s-pedelec. Resuscitation was attempted but to no avail. Autopsy confirmed an occipital fracture with accompanying subdural hemorrhage. Toxicological analysis revealed a blood alcohol concentration (BAC) of 0.15% ( 150mg/dL g/L (Suggest to include here the relevant legal limit for alcohol concentration in this jurisdiction)). Case 2: A 31-year-old man was found unconscious (GCS 3/15) next to his e-scooter. A CT scan revealed a fracture following the coronal suture across the vertex with accompanying subdural hemorrhage and a fracture of the right zygomatic arch. Despite urgent neurosurgical decompression, intracerebral pressure continued to rise. On admission, the patient was intoxicated with a BAC of 0.24% ( 240mg/dL). In Belgium, when riding an e-scooter with a maximum speed of 25 km/h, there is no obligation to wear a helmet. The recently established minimum age for use is 16 years. S-pedelecs with a maximum speed of 45 km/h, are considered mopeds. Drivers must be over 16 years of age, required to have a driving license and to wear a helmet. In both fatalities, the drivers did not wear a helmet. Public campaigns have been started to draw attention to this risk . The Belgian legal framework for alcohol use is similar to that for driving a car. Relevant legislation in different continents is compared, along with recommended advocacy for international harmonization of the legal framework

Added value of postmortem mri in sudden unexpected infant death cases

Abstract: We aimed to investigate the potential added value of postmortem MRI (PMMRI) in sudden unexpected infant death (SUID) cases referred to our center between September 2020 and June 2023. Ultimately, 19 SUID cases underwent PMMRI alongside standard autopsy procedures, which included technical examinations such as postmortem CT (PMCT). Four radiologists, two with prior PMMRI experience, provided structured reports following consensus. For each case, the responsible forensic medicine specialist documented the cause of death before and after reviewing the PMMRI report. Additionally, they assessed the overall impact of the PMMRI report and had the opportunity to provide written comments. The results of our study indicate that none of the PMMRI reports altered the prior determined cause of death, which included cases of infection, asphyxia, and sudden infant death syndrome (SIDS). However, we observed a moderate impact in one case and a low impact in 10 cases. The moderate impact arose from the PMMRI report identifying hypoxic-ischemic changes, where histologic examination of the brain was perceived as normal. Conversely, in the 10 cases with a low impact, the PMMRI reports supported the autopsy findings, specifically indicating brain injury and intra-alveolar cellular infiltrates. In conclusion, our study suggests that while PMMRI may not be pivotal in determining the cause of death in SUID cases, it could aid in detecting hypoxic-ischemic changes and reinforcing brain and lung observations. However, distinguishing genuine lung pathology from postmortem changes using PMMRI remains challenging. Further research is warranted to clarify the role of PMMRI in forensic SUID investigations

Changes in heart rate variability after transcranial direct current stimulation in patients with refractory epilepsy

Cathodal transcranial direct current stimulation (c-tDCS) is a non-invasive option for treatment of refractory epilepsy. However, it is still unknown whether this therapy has a positive stabilizing effect on the vegetative function of these patients. Heart Rate Variability (HRV) is considered an efficient tool to monitor the cardiac autonomic system, which has been correlated with the risk of Sudden Unexpected Death in Epilepsy (SUDEP). In this study, changes in HRV are investigated after c-tDCS of six patients (34.50 +/- 11.10 years) with refractory epilepsy, which have been selected at the University Hospital, LMU Munich. Patients were categorized as responders (n=2), non-responders (n=3) and uncategorized (n=1). We analyzed 24 hours of electrophysiological data recorded before and after treatment, and computed HRV metrics (AVNN, SDNN, RMSD, pNN20, pNN50, LH/HF, 0V, 1V, 2LV, 2UV, SD1 and SD2). All patients revealed a change in almost all HRV metrics post stimulation. Grouped all patients, there was a significant (p<0.05) change in RMSSD, pNN50, SD1 and LH/HF. For responders there was an increase in all time domain and nonlinear metrics, which was not seen for non-responders. These results suggest that tDCS exerts significant changes in cardiovascular autonomic system in patients with refractory epilepsy. HRV metrics may also serve as biomarkers of the response to tDCS stimulation. A larger dataset is being gathered for further analysis