Forensic Pathology

FORENSIC
PATHOLOGY/BIOLOGY
Proceedings 2002-2011
Forensic
Pathology/
Biology
American Academy of Forensic Sciences

Proceedings 2002-p1
Index ii
Forensic
Pathology /
Biology
Index iii
AMERICAN ACADEMY OF FORENSIC SCIENCES
410 North 21st Street
Colorado Springs, CO 80904
www.aafs.org
The Proceedings of the American Academy of Forensic Sciences is an official publication of the American Academy of
Forensic Sciences (AAFS) and includes various areas of the forensic sciences such as pathology, toxicology, physical anthropology,
psychiatry, odontology, jurisprudence, criminalistics, questioned documents, digital sciences, engineering sciences and other
disciplines. The proceedings herein are from the Pathology/Biology section for the years 2002 to 2011.
As with the Proceedings in which these abstracts were originally published, there is no implication or assertion that the
AAFS, any of its sections, or any member of the AAFS have verified the statements and/or conclusions of the abstracts. The views
expressed in this publication are not those of the AAFS or individual members. In short, the data and opinions appearing in the
abstracts are the responsibility of the individual authors alone.
All contents copyright 2002-2011 by the AAFS. Unless stated otherwise, noncommercial reproduction of material
contained herein is permitted by the AAFS provided that the copying is faithful to the original. No other reproduction of any form may
be done without prior written permission from the AAFS. Printed in the United States of America.
Index iv
Preface
The American Academy of Forensic Sciences (AAFS) is a multi-disciplinary
professional organization created and maintained to provide leadership in the application
of science to the legal system. A premier forensic science organization, its specific
objectives are to promote professionalism, integrity, competency and education, and to
foster scientific research, improvements in the practice of forensic science, and
collaboration within the many fields of forensic science.
For sixty-three years, since its founding in 1948, the AAFS has served a
distinguished and diverse membership. It comprises eleven different sections representing
the broad range of expertise and interest of its members, now numbering over 6200.
Included among them are physicians, attorneys, dentists, toxicologists, physical
anthropologists, document examiners, psychiatrists, physicists, engineers, criminalists,
educators, and digital evidence specialists. Representing all fifty US states, all ten
Canadian provinces and 61 other countries from all corners of the world, AAFS members
actively practice forensic science. In many cases, AAFS members also teach and conduct
research in the field, producing hundreds of refereed publications and books.
Index v
The editors express gratitude to the past and present AAFS leadership, especially
to the AAFS staff headed by Executive Director Anne Warren, to the AAFS Presidents
since 1949, and to our section’s directors and chair persons.
Academy Presidents
Robert E. Barsley, DDS, JD 2012-13
Douglas H. Ubelaker, PhD 2011-12 Lowell J. Levine, DDS 1980-81
Joseph P. Bono, MA 2010-11 June K. Jones, MS 1979-80
Thomas L. Bohan, PhD, JD 2009-10 Kurt M. Dubowski, PhD 1978-79
Carol E. Henderson, JD 2008-09 B. Edward Whittaker, BS 1977-78
Bruce A. Goldberger, PhD 2007-08 James T. Weston, MD 1976-77
James G. Young, MD 2006-07 Robert J. Joling, JD 1975-76
Edmund R. Donoghue, MD 2005-06 David A. Crown, DCrim 1974-75
Ronald L. Singer, MS 2004-05 Morton F. Mason, PhD 1973-74
Kenneth E. Melson, JD 2003-04 Douglas M. Lucas, MSc, DSc 1972-73
Graham R. Jones, PhD 2002-03 Cyril H. Wecht, MD, JD 1971-72
Mary Fran Ernst, BLS 2001-02 Edwin C. Conrad, JD, PhD 1970-71
John D. McDowell, DDS, MS 2000-01 James W. Osterburg, MPA 1969-70
Patricia J. McFeeley, MD 1999-00 Maier I. Tuchler, MD 1968-69
Barry A.J. Fisher, MS, MBA. 1998-99 Charles S. Petty 1967-68
Michael A. Peat, PhD 1997-98 Jack L. Sachs, JD 1966-67
Richard Rosner, MD 1996-97 Robert B. Forney, PhD 1965-66
Haskell M. Pitluck, JD 1995-96 Dwight M. Palmer, MD 1964-65
Steven C. Batterman, PhD 1994-95 Oliver C. Schroeder, Jr., JD 1963-64
Enrico N. Togneri, BA 1993-94 Milton Helpern, MD 1962-63
Marina Stajic, PhD. 1992-93 S.R. Gerber, MD, LLB 1961-62
Homer R. Campbell, Jr., DDS 1991-92 Russel S. Fisher, MD 1960-61
Ellis R. Kerley, PhD. 1990-91 Ordway Hilton, MA 1959-60
Richard C. Froede, MD 1989-90 John F. Williams, BS 1958-59
Richard S. Frank, BS 1988-89 Val B. Satterfield, MD 1957-58
Yale H. Caplan, PhD 1987-88 Alan R. Moritz 1956-57
Don Harper Mills, JD, MD 1986-87 Fred E. Inbau, BS, LLB, 1955-56
Arthur D. Goldman, DMD 1985-86 A.W. Freireich, MD 1954-55
Maureen Casey Owens, AB 1984-85 Louis P. Regan, MD, LLB 1953-54
George E. Gantner, MD 1983-84 R.N. Harger, PhD 1952-53
Anthony Longhetti, BA 1982-83 S.A. Levinson, MD, PhD 1951-52
Joseph H. Davis, MD 1981-82 R.B.H. Gradwohl, MD 1949-51
Index vi
Pathology/Biology Section
Board of Directors Representatives and Chairs
Director Chair
2011-2012 Gregory G. Davis, MD Jeffery K. Tomberlin, PhD

2010-2011 Victor W. Weedn, MD, JD Kim A. Collins, MD
2009-2010 Victor W. Weedn, MD, JD Craig T. Mallak, JD, MD
2008-2009 Tracey S. Corey, MD J. Scott Denton, MD
2007-2008 Tracey S. Corey, MD Andrew M. Baker, MD
2006-2007 Julia C. Goodin, MD Victor W. Weedn, MD, JD
2005-2006 Julia C. Goodin, MD Karen F. Ross, MD
2004-2005 Julia C. Goodin, MD John C. Hunsaker, III, MD, JD
2003-2004 Julia C. Goodin, MD Gregory G. Davis, MD
2002-2003 Julia C. Goodin, MD Lynda Biedrzycki, MD
2001-2002 Julia C. Goodin, MD Tracey S. Corey, MD
2000-2001 Edmund R. Donoghue, MD Joseph A. Prahlow, MD
1999-2000 Edmund R. Donoghue, MD Corinne L. Fligner, MD
1998-1999 Edmund R. Donoghue, MD Julia C. Goodin, MD
1997-1998 Edmund R. Donoghue, MD Patrick E. Lantz, MD
1996-1997 Edmund R. Donoghue, MD M. Lee Goff, PhD
1995-1996 Edmund R. Donoghue, MD Jay Dix, MD
1994-1995 Patricia J. McFeeley, MD Randy L. Hanzlick, MD
1993-1994 Patricia J. McFeeley, MD Stephen D. Cohle, MD
1992-1993 Patricia J. McFeeley, MD Michael A. Graham, MD
1991-1992 Patricia J. McFeeley, MD Edmund R. Donoghue, Jr., MD
1990-1991 Ali Z. Hameli, MD Brian D. Blackbourne, MD
1989-1990 Ali Z. Hameli, MD Patricia J. McFeeley, MD
1988-1989 Ali Z. Hameli, MD J.E. Smialek, MD
1987-1988 William G. Eckert, MD Joshua A. Perper, MD, LLB
1986-1987 William G. Eckert, MD Thomas F. Hegert, MD
1985-1986 William G. Eckert, MD Robert J. Stein, MD
1984-1985 Richard C. Froede, MD James S. Bell, MD
1983-1984 Richard C. Froede, MD Ali Z. Hameli, MD
1982-1983 Richard C. Froede, MD Robert L. Catherman, MD
1981-1982 Richard C. Froede, MD Werner U. Spitz, MD
1980-1981 George E. Gantner, MD Irvin M. Sopher, MD, DDS
1979-1980 George E. Gantner, MD Robert C. Hendrix, MD
1978-1979 George E. Gantner, MD Frank O. Raasch, Jr., MD
Index vii
1977-1978 George E. Gantner, MD John Pfaff, Jr., MD
1976-1977 George E. Gantner, MD David K. Wiecking, MD
1975-1976 George E. Gantner, MD Richard C. Froede, MD
1974-1975 Michael M. Baden, MD Joseph H. Davis, MD
1973-1974 Michael M. Baden, MD Frank P. Cleveland, MD
1972-1973 Michael M. Baden, MD Werner U. Spitz, MD
1971-1972 Joseph H. Davis, MD Michael M. Baden, MD
1970-1971 Joseph H. Davis, MD Charles J. Stahl, III, MD
1969-1970 Joseph H. Davis, MD William Q. Sturner, MD
1968-1969 Charles S. Sweet, MD Cyril H. Wecht, MD, LLB
1967-1968 Thomas T. Noguchi, MD
1966-1967 William G. Eckert, MD
1965-1966 Robert W. Bonifaci, MD
1964-1965 Henry H. Sweets, Jr., MD
1963-1964 Joseph E. Campbell, MD
1962-1963 Sidney B. Weinberg, MD
1961-1962 Joseph H. Davis, MD
1960-1961 E. H. Johnston, MD
1959-1960 Charles S. Petty, MD
1958-1959 Arthur E. O'Dea, MD
1957-1958 Frank P. Cleveland, MD
1956-1957 Samuel R. Gerber, MD, LLB
1955-1956 Russell S. Fisher, MD
1954-1955 Russell S. Fisher, MD
1953-1954 Geoffrey T. Mann, LLB, MD
1952-1953 William E.B. Hall, MD
1951-1952 William E.B. Hall, MD
1950-1951 Milton Helpern, MD
Our heartfelt thanks to the Academy Staff for managing the proceedings process
that results in the highest standards of quality including Sonya Bynoe, Publications &
Website Coordinator; Debbie Crockett, Finance Manager; Sondra Doolittle, Meetings &
Exposition Manager; Phyllis Gilliam, Receptionist; Salena Grant, Assistant Meetings
Manager; Cheryl Hunter, Membership Coordinator; Nancy Jackson, Director of
Index viii
Development & Accreditation; Tracie McCray, Accounting Assistant; Christie Vigil,
Membership Assistant; and Kimberly Wrasse, Executive Assistant.
This further acknowledges the excellent work of Pathology/Biology authors
worldwide who are willing to share their work for education.
Victor W. Weedn, MD, JD

Gregory G. Davis, MD
Jeffery K. Tomberlin, PhD
Prepared by:
Laura L. Liptai, PhD 1
Engineering Sciences
1
The Executive Committee of The American Academy of Forensic Sciences has directed Laura Liptai,
Ph.D. of the Engineering Sciences Section to prepare this volume for publication.
Index ix
Table of Contents
Index of Title by Year

2011 ..................................................................................................................................................................Index 1
2010 ............................................................................................................................................................... Index 19
2009 ............................................................................................................................................................... Index 33
2008 ............................................................................................................................................................... Index 48
2007 ............................................................................................................................................................... Index 60
2006 ............................................................................................................................................................... Index 73
2005 ............................................................................................................................................................... Index 85
2004 ............................................................................................................................................................... Index 97
2003 .............................................................................................................................................................Index 106
2002 .............................................................................................................................................................Index 116
Index by Presenting Author ............................................................................ Index 125
Proceedings by Year
2011 ...............................................................................................................................................................................1
2010 ............................................................................................................................................................................78
2009 ......................................................................................................................................................................... 144
2008 ......................................................................................................................................................................... 208
2007 ......................................................................................................................................................................... 261
2006 ......................................................................................................................................................................... 325
2005 ......................................................................................................................................................................... 382
2004 ......................................................................................................................................................................... 437
2003 ......................................................................................................................................................................... 484
2002 ......................................................................................................................................................................... 536
Index x
Index of Title by Year
2011
Fatality Involving Complications of Mary H. Dudley, MD*, Jackson County Medical 1
Bupivacaine Toxicity and Hypersensitivity Examiner’s Office, 660 East 24th Street, Kansas City, MO
Reaction: A Case Report 64108; Steven W. Fleming, MS, Children Mercy Hospital,
Toxicology Laboratory, 2401 Gillham Road, Kansas City,
MO 64108; Uttam Garg, PhD, Children’s Mercy Hospital,
Department of Pathology, 2401 Gillham Road, Kansas City,
MO 64108; and Jason M. Edwards, PhD, University of
Missouri Kansas City School of Medicine, 2411 Holmes
Street, Kansas City, MO 64108
Undiagnosed, Untreated Natural Disease Lucia Tattoli, PhD*, Sabrina Leonardi, MD, and Biagio 1
Mistaken for Lethal Child Neglect: Solarino, PhD, Section of Legal Medicine - University of
Liability of the Family in Determining Bari, Pizza Giulio Cesare 11, Bari, 70124, ITALY
Child’s Death
Sudden Unexpected Cardiac Deaths: An Tanuj Kanchan, MD*, Kasturba Medical College, 2
Autopsy Based Study From Mangalore, Department of Forensic Medicine, Light House Hill Road,
South India Mangalore, 575 001, INDIA
Periventricular Leukomalacia in a 2- Baiyang Xu, MD*, 1520 Penn Avenue, Pittsburgh, PA 2
Month-Old Infant Who Was Born With 15222; Todd M. Luckasevic, DO, Alleghey County Medical
Cocaine Addiction: A Case Report Examiner’s Office, 1520 Penn Avenue, Pittsburgh, PA
15222; and Abdulrezak M. Shakir, MD, and Karl Williams,
MD, Allegheny County Medical Examiner Office, 542
Fourth Avenue, Pittsburgh, PA 15219
A Man Without a Head: Postmortem Claas T. Buschmann, MD, Institute of Legal Medicine and 3
Decapitation by German Shepherd Dogs Forensic Sciences, Turmstrasse 21, Building L, Berlin,
10559, GERMANY; Biagio Solarino, PhD*, Università
degli Studi di Bari, Sezione di Medicina Legale, Pizza
Giulio Cesare, 11, Bari, 70125, ITALY; and Michael
Tsokos, MD, Institute of Legal Medicine & Forensic
Sciences, Turmstr 21, Haus L, Berlin, 10559, GERMANY
Responses of Mast Cells in the Dura to Kazuhiko Kibayashi, MD*, Tokyo Women’s Medical 3
Traumatic Brain Injury in an Animal University, Department of Legal Medicine, School of
Model Medicne, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666,
JAPAN; and Ryo Shimada, PhD, and Rui Furutani, PhD,
Tokyo Women’s Medical University, 8-1 Kawada-cho,
Shinjyuku-ku, Tokyo, 162-8666, JAPAN
Plastic Bag Asphyxia: Suicide and Cristina Cordeiro, MSc*, Instituto Nacional De Medicina 4
Literature Legal, Largo Da Se Nova, Coimbra, 3000-213,
PORTUGAL; and Duarte N.P. Vieira, PhD, Rua Antonio
Jose de Almeida, No 117, Coimbra, 3000-044, PORTUGAL
Index 1
The Bone Collector: When Reality Luigi Cipolloni, MD, Manuela Rosini, MSc, Silvia Zoppis, 4
Overcomes Fantasy MD*, Department of Legal Medicine University of Rome
“Sapienza”, Viale Regina Elena 336 00161, Rome, ITALY;
Fabio Verginelli, PhD, Department of Oncology and
Experimental Medicine, G. d’Annunzio University, Via dei
Vestini 31, 66100, Chieti, ITALY; Michaela Lucci, PhD,
Alfredo Coppa, Department of Environmental Biology,
University of Rome “Sapienza”, P.le A. Moro 5, 00185,
Rome, ITALY; Filippo Terrasi, Circe, Innova and
Department of Environmental Sciences, 2nd University of
Naples, Via Vivaldi 43, 81100, Caserta, ITALY; and Carla
Vecchiotti, Department of Legal Medicine University of
Rome “Sapienza”, Viale Regina Elena 336, 00161, Rome,
ITALY
Cancer Patient mtDNA Forensic Fabio Verginelli, PhD, Department of Oncology and 5
Identification: A Case Report Experimental Medicine, G. d’Annunzio University, Via dei
Vestini 31, 66100, Chieti, ITALY; Manuela Rosini, MSc,
Department of Legal Medicine, Viale Regina Elena 336,
00161, Rome, ITALY; Silvia Zoppis, MD*, Department of
Legal Medicine University of Rome “Sapienza”, Viale
Regina Elena 336 00161, Rome, ITALY; and Carla
Vecchiotti, Department of Legal Medicine, Viale Regina
Elena 336, 00161, Rome, ITALY
Method of Concealment of Corpses in Massimo Grillo, MD*, Filippo M. Cascino, MD*, 5
Mafia Related Homicides: Melting in Department of Biotechnology and Legal Medicine, Section
Strong Acids of Legal Medicine, Via del Vespro 129, Palermo, 90127,
ITALY; and Valentina Murgo, MD, Palermo University, Via
Del Vespro, n. 127, Palermo, 90100, ITALY; Livio Milone,
Via Del Vespro, n. 127, Palermo, 90100, ITALY
When Ribs Penetrate the Heart in Blunt Tanuj Kanchan, MD*, Kasturba Medical College, 6
Chest Wall Trauma Department of Forensic Medicine, Light House Hill Road,
Mangalore, 575 001, INDIA
Examination of Sexually Abused Children: Annie Vesterby, MD, DMSc*, Institute of Forensic 6
Presentation of the First Danish Center for Medicine, University of Aarhus, Brendstrupgårdsvej 100,
the Investigation and Care of Abused 8200 Aarhus N, DK-8000, DENMARK
Children
Index 2
An Innovative Proteomic Approach for the Domenica Scumaci, PhD, Magna Græcia University of 6
Identification of Novel Plasma Biomarkers Catanzaro, Laboratory of Proteomics and Mass
in Patients With Brugada Syndrome Spectrometry, Department of Experimental and Clinical
Medicine, Salvatore Venuta University Campus, viale “S.
Ve, Catanzaro, 88100, ITALY; Simona Grasso, Antonio
Curcio, PhD, and Marco Gaspari, PhD, Magna Græcia
University of Catanzaro, Salvatore Venuta University
Campus, Viale Europa, Catanzaro, AL 88100, ITALY; Silvia
Priori, PhD, Molecular Cardiology Laboratory, IRCCS, Via
Ferrata 8, Pavia, AL 27100, ITALY; Ciro Di Nunzio,
Institute of Legal Medicine, School of Medicine, Magna
Graecia University, Viale Europa Germaneto, Catanzaro,
88100, ITALY; Antonio Oliva, PhD, and Francesco
Ausania, MD, Institute of Forensic Medicine, Catholic
University, School of Medicine, Largo Francesco Vito 1,
Rome, 88100, ITALY; Ciro Indolfi, PhD, Magna Graecia
University, Viale S Venuta, Catanzaro, AL 88100, ITALY;
Pietrantonio Ricci, PhD, Università degli Studi Magna
Grecia Catanzaro, Viale Europa - Località Germaneto,
Catanzaro, 88100, ITALY; and Giovanni Cuda, PhD*,
Magna Graecia University of Catanzaro, Viale S. Venuta,
Catanzaro, AL 88100, ITALY
A Case of Lethal Peripartum Eosinophilic Maria Carolina Romanelli, MD*, Eloisa Maselli, MD, 7
Myocarditis Biagio Solarino, PhD, Section of Legal Medicine -
University of Bari, Piazza Giulio Cesare, 11, Bari, 70124,
ITALY; and Giancarlo Di Vella, PhD, Sezione di Medicina
Legale, DIMIMP, University of Bari, Policlinico, Piazza G.
Cesare, Bari, 70121, ITALY
The Bodies of Two Missing Children in an Francesco Introna, PhD, Antonio De Donno, PhD, Valeria 8
Enclosed Underground Environment Santoro, PhD, Section of Legal Medicine - DiMIMP, P.zza
Giulio Cesare n.11, Bari, 70124, ITALY; Simona Corrado,
MD, Sezione di Medicina Legale, Bari, 70100, ITALY; Vito
Romano, MD, Medicina Legale Miulli, Acquaviva delle
Fonti, Acquaviva delle Fonti - Bari, 70100, ITALY;
Francesco Porcelli, PhD, Section of Entomology and
Zoology (Di.B.C.A.), University of Bari (Italy), Via G
Amendola, Bari, 70126, ITALY; and Carlo P. Campobasso,
PhD*, University of Molise, Via De Sanctis, Snc,
Campobasso, 86100, ITALY
Diagnosis Of Drowning: The Contribution Pistolesi Luca, MD*, Institute of Legal Medicine, Via Del 8
Of Microbiological Investigations Giochetto Snc, Perugia, ID 06100, ITALY
Butane Inhalation and Sudden Death: A Maria Celeste Landolfa, MD*, Michela Cicconi, MD, 8
Case Report Massimo Gallo, MD, and Andrea Gianelli Castiglione, MD,
Department of Legal and Forensic Medicine, Via de Toni
12, Genova, I-16132, ITALY; and Francesco Ventura, MD,
Department of Forensic Pathology, University of Genova,
Via de’ Toni, 12, Genova, 16132, ITALY
Index 3
Case Report of a Fatal Intoxication by Dori M. Franco, DO*, OAFME, 1413 Research Boulevard, 9
Nucynta Building 102, Rockville, MD 20904; Zabiullah Ali, MD,
Barry S. Levine, PhD, Office of the Chief Medical
Examiner, 111 Penn Street, Baltimore, MD 21201; Robert
A. Middleberg, PhD, Annette Ervin, BS, Francis X.
Diamond, BS, NMS Labs, 3701 Welsh Road, Willow Grove,
PA 19090; and David R. Fowler, MD, Office of the Chief
Medical Examiner, 111 Penn Street, Baltimore, MD 21201
Nasal Mucociliary Motility: New Forensic Biagio Solarino, PhD*, Università degli Studi di Bari, 10
Tool for Estimating Time Since Death Sezione di Medicina Legale, P.zza Giulio Cesare, 11, Bari,
70125, ITALY; Carolina Romanelli, MD, Lucia Tattoli, MD,
and Giancarlo Di Vella, PhD, Section of Legal Medicine -
University of Bari, P.zza G. Cesare 11, Bari, 70124, ITALY;
and Luisa Fiorella, MD, and Matteo Gelardi, MD,
Department of Otolaryngology II - University of Bari, P.zza
G. Cesare 11, Bari, 70124, ITALY
Fatal Spontaneous Non-Traumatic Christina J. Tatum, MD*, 522 Cliff Place, Homewood, AL 10
Subdural Hematoma and Terson 35209; and Constance A. Stanton, MD, and Patrick E.
Syndrome Lantz, MD, Wake Forest University Health Sciences,
Department of Pathology, Medical Center Boulevard,
Winston-Salem, NC 27157-1072
A Fatal Complication of Vacuum-Assisted Lezah P. McCarthy, MD*, Wake Forest University Baptist 11
Vaginal Delivery Medical Center, Medical Center Boulevard, Winston Salem,
NC 27157; and Constance A. Stanton, MD, and Patrick E.
Lantz, MD, Wake Forest University Health Sciences,
The Relationship of Back Surgery to Emily F. Gorman, MD*, University of Alabama at 12
Overdose at Autopsy Birmingham, Department of Pathology, P220 West
Pavilion, Birmingham, AL 35233- 7331; Robert M. Brissie,
MD, Medical Examiner Office, 1515 6th Avenue, South,
Birmingham, AL 35233; and Gregory G. Davis, MD,
Jefferson County Medical Examiner’s Office, 1515 6th
Avenue, South, Room 220, Birmingham, AL 35233-1601
The Use of Raman Spectroscopic Imaging Victor W. Weedn, MD, Maryland State Office of the Medical 12
in Cases of Ethylene Glycol Toxicity Examiner, 111 Penn Street, Baltimore, MD 21201; Mary G.
Ripple, MD, 68 Bluebird Road, Port Deposit, MD 21904;
Sara Nedley, MS, ChemImage, 7301 Penn Avenue,
Pittsburgh, PA 15208; and David R. Fowler, MD, and
Kristin A. Johnson, MD*, Office of the Chief Medical
Examiner, 111 Penn Street, Baltimore, MD 21201
Death From Severe Anorectal Injury of a Dennis Rhee, MD*, and Lynn A. Salzberger, MD, Southwest 13
Jet Ski Passenger Institute of Forensic Sciences, 5230 Southwestern Medical
Avenue, Dallas, TX 75235
Index 4
Sudden Unexpected Infant Death: Stephen Lenfest, MD*, Wake Forest University Baptist 13
Peripheral Retinal Hemorrhages Medical Center Department of Pathology, Medical Center
Associated With Accidental Positional Boulevard, Winston Salem, NC 27157; Candace H.
Asphyxiation (Wedging) Schoppe, MD, Wake Forest University School of Medicine,
Winston Salem, NC 27157; Constance A. Stanton, MD,
Department of Pathology, Wake Forest University Health
Sciences, Medical Center Boulevard, Winston Salem, NC
27157; Donald R. Jason, JD, Wake Forest University
School of Medicine, Medical Center Boulevard, Winston-
Salem, NC 27157-1072; and Patrick E. Lantz, MD, Wake
Forest University Health Sciences, Department of
Pathology, Medical Center Boulevard, Winston- Salem, NC
27157-1072
Antiepileptic Drug Intoxication: Report of Ana R. Pereira, MD*, Ladeira das Alpenduradas nº13A, 14
One Case and a Forensic Pathologist’s Coimbra, 3030- 167, PORTUGAL; Paula C. Oliveira, MD*,
Approach Konara Gunathilake, MD, Bruno M. Santos, MSc, Paula
Proenca, PharmD, and Miguel Franco, MSc, Largo da Sé
Nova, Coimbra, 3000-213, PORTUGAL; Maria C.
Mendonca, PhD, Instituto Nacional de Medicina Legal,
Largo Sé Nova, Coimbra, 3000, PORTUGAL; and Duarte
N.P. Vieira, PhD, Rua Antonio Jose de Almeida, No 117,
Coimbra, 3000-044, PORTUGAL
Are Peripapillary Intrascleral Candace H. Schoppe, MD*, Wake Forest University Baptist 15
Hemorrhages Pathognomonic for Abusive Medical Center, Department of Pathology, Medical Center
Head Trauma? Boulevard, Winston Salem, NC 27157; Constance A.
Stanton, MD, Department of Pathology, Wake Forest
University Health Sciences, Medical Center Boulevard,
Winston Salem, NC 27157; and Patrick E. Lantz, MD, Wake
Forest University of Health Science, Department of
Pathology, Medical Center Boulevard, Winston-Salem, NC
27157-1072
The Correlation of Serum Stress Hormone Robert C. Shaler, PhD*, 30 Spring Street, Flemington, NJ 15
Levels With Cause and Circumstance of 08822; Dominic Flaim, PMFS, Pennsylvania State
Death University, 107 Whitmore Lab, State College, PA 16802;
and Thomas Andrew, MD, Office of the State Chief Medical
Examiner, 246 Pleasant Street, Concord, NH 03301
Stippling Mimics — Differentiating Jeffery G. Gofton, MD*, and Wendy M. Gunther, MD*, 16
Pseudostippling From Stippling: A Report Office of the Chief Medical Examiner, Tidewater District,
of Four Cases 830 Southampton Avenue, Suite 100, Norfolk, VA 23510-
1046
DNA Extraction From Paraffin Blocks: Alex John, MD*, Harris County Institute of Forensic 16
Organ Selection and Pre-Embedding Sciences, 1885 Old Spanish trail, Houston, TX 77054;
Fixation Times – Practical Implications for Dwayne A. Wolf, PhD, Harris County Medical Examiner’s
Forensic Pathologists Office, JAJ Forensic Center, 1885 Old Spanish Trail,
Houston, TX 77054; Jennifer Petrash, MS, Shahida Flores,
BS, Dustin Foley, MS, Lisa Gefrides, MS, and Roger Kahn,
PhD, Harris County Institute of Forensic Sciences, 1885
Old Spanish Trail, Houston, TX
Index 5
The Potential Value of Bone Marrow Biagio Solarino, PhD*, Lucia Tattoli, PhD, Eloisa Maselli, 17
Analysis for Forensic Purposes: Evaluation MD, and Maria C. Romanelli, MD, Section of Legal
of Needle Aspiration and Biopsy Taken Medicine, University of Bari, Piazza Giulio Cesare, 11,
From the Sternum Bari, 70122, ITALY; Michael Tsokos, PhD, Institute of
Legal Medicine and Forensic Sciences, University of Berlin,
Turmstr. 21, Building L, 10559, Berlin, 10559, GERMANY;
Alessandro Dell Erba, PhD, Section of Legal Medicine,
ITALY; and Mario Delia, PhD, Hematology Section,
ITALY
2009 H1N1 Fatalities: The New Mexico Erin G. Brooks, MD*, Office of the Medical Investigator, 17
Experience MSC11 6030, 1 University of New Mexico, Albuquerque,
NM 87131; Clare H. Cunliffe, MD, Office of Medical
Investigator, 700 Camino de Salud Northeast, Albuquerque,
NM 87106; Catherine Avery, Chad Smelser, MD, and
Deborah Thompson, MD, New Mexico Department of
Health, 1190 South Saint Francis Drive, Santa Fe, NM
87502; and Kurt B. Nolte, MD, Office of Medical
Investigator, MSC11 6030, 1 University of New Mexico,
Albuquerque, NM 87131-0001
The Potential Use of Aquatic Invertebrate Simona Corrado, MD*, Sezione di Medicina Legale, Bari, 18
for Postmortem Submersion Interval 70100, ITALY; Lucio Rositani, PhD, Laboratory of Marine
(PMSI) Determination Biology, Molo Pizzoli, Bari, 70100, ITALY; Maurizio
Scarpa, MD, Piazza G. Cesare 11 Università di Bari, Bari,
70100, ITALY; and Francesco Introna, PhD, Section of
legal Medicine - DiMIMP, Piazza Giulio Cesare n.11, Bari,
70124, ITALY
Epidemic Outbreak of Meningococcal Alessandro Bonsignore, MD*, Francesca Fossati, MD, 18
Meningitis in a Nursery: Two Fatal Cases Federica Portunato, MD, Francesco Ventura, PhD, and
of Waterhouse-Friderichsen Syndrome Francesco De Stefano, MD, Department of Legal and
Forensic Medicine, University of Genova, Via de Toni 12,
Genova, 16132, ITALY
Postmortem Animal Injuries: A Forensic Ana R. Pereira, MD*, Ladeira das Alpenduradas nº13A, 19
Pathologist’s Perspective Coimbra, 3030- 167, PORTUGAL; Bruno M. Santos, MSc,
Largo da Sé Nova, Coimbra, 3000-213, PORTUGAL;
Carmen Barbu, MD, Instituto de Medicina Legal de Sf.
Gheorghe, Romania, Bucharest, ROMANIA; Pedro A.
Rezende, MSc, Jardim Carrilho Videira, Porto,
PORTUGAL; Paula C. Oliveira, MD*, Largo da Sé Nova,
Coimbra, 3000-213, PORTUGAL; Jorge C. Santos, PhD,
South Branch National Institute of Legal Medicine, R.
Manuel Bento de Sousa, nº 3, 1150-219 Lisboa, Lisboa,
Neck Findings in Hanging and Ahmet Hilal, MD*, Necmi Cekin, MD, Mete K. Gulmen, 20
Strangulation Cases That Underwent PhD, and Kemal C. Yildirim, MD, Cukurova University
Autopsy in Adana, Turkey School of Medicine, Department of Forensic Medicine,
Balcali, Adana, 01330, TURKEY
Index 6
Evaluation of Cardiac Conduction System Mete K. Gulmen, PhD*, Cukurova University School of 20
Pathologies in Sudden Deaths in Adana Medicine, Department of Forensic Medicine, Adana, 01330,
Region TURKEY; Ramazan Karanfil, MD, Kahramanmaras Sutcu
Imam University, School of Medicine, Department of
Forensic Medicine, Kahramanmaras, 46100, TURKEY; and
Ahmet Hilal, MD, and Necmi Cekin, MD, Cukurova
University School of Medicine, Department of Forensic
Medicine, Balcali, Adana, 01330, TURKEY
A Peculiar Fatal Lightning Strike Inside a Federica Portunato, MD*, Manuela Botto, MD, and 21
Cottage Alessandro Bonsignore, MD, University of Genova,
Department of Legal and Forensic Medicine, Via de’ Toni
University of Genova, Department of Forensic Pathology,
Enterobacter Cloacae Peritonitis Elena Bulakhtina, MD*, Allegheny County Medical 21
Secondary to Hemorrhagic Cystitis in a Examiner’s Office, 1520 Penn Avenue, Pittsburgh, PA
Long-Term Substance Abuser 15222; Zhuo Wang, MD, Conemaugh Valley Memorial
Hospital, 1020 Franklin Street, Johnstown, PA 15905; Todd
M. Luckasevic, DO, Baiyang Xu, MD, and Abdulrezak M.
Shakir, MD, Allegheny County Medical Examiner’s Office,
1520 Penn Avenue, Pittsburgh, PA 15222; and Karl E.
Williams, MD, MPH, Allegheny County Medical Examiner’s
Office, 542 Fourth Avenue, Pittsburgh, PA 15219
Two Suicidal Deaths From Head Injuries Patricia A. Aronica-Pollak, MD*, and Mary G. Ripple, MD, 22
Caused by Unusual Sharp Force Office of the Chief Medical Examiner, 111 Penn Street,
Instruments and Review of the Literature Baltimore, MD 21201; Juan C. Troncoso, MD, Department
of Pathology, Johns Hopkins University School of Medicine,
600 North Wolfe Street, Baltimore, MD 21287; Kyle C.
Shaw, MBBS, District 5 Medical Examiner’s Office, 809
Pine Street, Leesburg, FL 34748; and David R. Fowler,
MD, Office of the Chief Medical Examiner, 111 Penn Street,
Baltimore, MD 21201
Iatrogenic Laceration of a Pulmonary Paolo Fais, MD*, and Giovanni Cecchetto, MD, Via 23
Angiomatoid Lesion: Fatal Complication or Falloppio 50, Padova, 35121, ITALY; Guido Viel, MD,
Medical Error? University of Padua, Via Falloppio 50, PADOVA, 35121,
ITALY; Rossella Snenghi, MD, and Rafael Boscolo-Berto,
MD, Via falloppio 50, Padova, 35121, ITALY; Andrea Zuin,
MD, Via Giustiniani 2, Padova, ITALY; and Massimo
Montisci, PhD, Via Falloppio 50, Padova, 35121, ITALY
Pedestrian Fatalities in Maryland: How Ana Rubio, PhD*, Carol H. Allan, MD, and David R. 23
Many, Who, When, Where, Why, How, and Fowler, MD, Office of the Chief Medical Examiner, 111
Ways to Prevent Them Penn Street, Baltimore, MD 21201
Sudden Cardiac Death in an Athlete: A Damien Mauillon, MD*, Service de Médecine Légale, 24
Case Report Centre Hospitalier Universitaire, 4 rue Larrey, Angers
Cedex 9, 49933, FRANCE; Nathalie Jousset, MD, Centre
Hospitalier Universitaire, 4 rue Larrey, Angers Cedex 9,
49933, FRANCE; Paul Fornes, PhD, Hospital Robert
Debre, Avenue du General Koeing, Reims, 51100,
FRANCE; and Clotilde Rouge-Maillart, PhD, Centre
Hospitalier Universitaire, Service de Médecine Légale, 4
rue Larrey, Angers Cedex 9, 49933, FRANCE
Myocarditis With Giant Cells in an Infant: Tera A. Jones, MD*, Douglas County Coroner’s Office, 24
A Case Report and Review of the 4000 Justice Way, Castle Rock, CO 80109
Literature
Index 7
Massive Systemic Fat Embolism Detected Patricia M. Flach, MD; Steffen G. Ross, MD; Garyfalia 25
by Postmortem Imaging and Biopsy Ampanozi, MD; Stephan A. Boliger, MD; Gary M. Hatch,
MD; Michael Thali, MD; and Tanja Germerott, MD,
Institue of Forensic Medicine, University of Bern- Virtopsy,
Buehlstrasse 20, Bern 3012 SWITZERLAND
Radiocarbon and Stable Isotope Results of Kaelyn M. Ormsby, BS*, and Guaciara M. Santos, PhD, 25
Fingernails of Breastfed Mother-Infant KCC-AMS Preparation Laboratory, University of
Pairs to Investigate Deviation of Year-of- California, Irvine, B321 Croul Hall, Irvine, CA 92697; and
Birth Determinations Due to Diet Benjamin T. Fuller, PhD, Max Planck Institute for
Evolutionary Anthropology, Department of Human
Evolution, Deutscher Platz 6, Leipzig, D-04103, GERMANY
The Effect of Cultural Cranial Deformation Anna Williams, PhD*, and Mitzi A. Richards, MSc, 26
on Neurological Development: A Beneficial Cranfield University, Defence Academy of the UK,
or Disadvantageous Practice? Shrivenham, SN6 8LA, UNITED KINGDOM
Morphological Identification of Right Tony Fracasso, MD*, University Center of Legal Medicine, 27
Ventricular Ischemia Determining Right CMU - CURML, Rue Michel-Servet 1, Geneva, 1211,
Heart Failure in Cases of Fatal Pulmonary SWITZERLAND; Heidi Pfeiffer, PhD, University Hospital
Thromboembolism Münster, Röntgenstr 23, Münster, 48149, GERMANY;
Cristina Sauerland, University of Münster, Domagstr 9,
Münster, 48149, GERMANY; and Andreas Schmeling, PhD,
University Hospital Münster, Röntgenstr. 23, Münster,
48149, GERMANY
Autopsy Performance in Transfusion Stephen L. Sgan, MD*, District 2 Medical Examiner’s 27
Recipient Fatalities Reported to the United Office, PO Box 14389, Tallahassee, FL 32317
States Food and Drug Administration
(FDA) During Fiscal Year 2008
A Case of Atypical Chronic Subdural Renaud Clement, MD*, 1 Rue Gaston Veil, Nantes, 28
Hematoma: A Spontaneous Rupture of FRANCE
Dural Lymphoma Nodule?
A Comparison of Trauma Associated With Deborrah C. Pinto, PhD*, Harris County Institute of 28
Manual and Automated Cardiopulmonary Forensic Sciences, 1885 Old Spanish Trail, Houston, TX
Resuscitation 77054; Kathryn Haden-Pinneri, MD, Harris County
Medical Examiner’s Office, 1885 Old Spanish Trail,
Houston, TX 77054; and Jennifer C. Love, PhD, Harris
County Institute of Forensic Sciences, 1885 Old Spanish
Trail, Houston, TX 77054
Sudden Unexpected Death Associated With Silvia Tambuscio, PhD*, University of Verona, via 29
Undiagnosed Lymphocytic Thyroiditis: Rezzonico, 24, 35131, Padova, ITALY; Jennifer Pascali,
Report of a Case and Literature Review PhD, University of Verona, Piazzale L.A. Scuro 10, Verona,
IL 37100, ITALY; Andrea Galassi, MD, S.Bortolo Vicenza
Hospital, via Rodolfi 37, Vicenza, IL , ITALY; Federica
Alessandrini, PhD, Università Politecnica delle Marche, via
Conca 6 Torrette, Ancona, IL 60126, ITALY; and Fiorella
Calabrese, MD, University of Padova, via A.Gabelli61,
Padova, 35121, ITALY
The Pattern of Immunoreactivity for von Stacey A Simons, MD*, Miami Dade County Medical 30
Willebrand Factor in a Variety of Examiner Department, Number One on Bob Hope Drive,
Thrombotic States Miami, FL 33136; Paul E. Swanson, MD, University of
Washington Division of Anatomic Pathology, 1959
Northeast Pacific Street, Seattle, WA 98195; and Aldo J.
Fusaro, DO, King County Medical Examiner’s Office, 908
Jefferson Street, Seattle, WA 98104
Index 8
Giant Cell Myocarditis as a Cause of Steven M. White, PhD*, Mitra B. Kalelkar, MD, and James 30
Sudden or Unexpected Death: A Report of A. Filkins, JD, PhD, Office of the Medical Examiner,
Two Cases and a Review of the Literature County of Cook, 2121 West Harrison Street, Chicago, IL
60612
Death Due to Atrial Septum Defect Eugenia Di Stefano, MD*, Via Raffaello N°9, Palermo, 31
Repaired by Transcatheter Closure: Who 90100, ITALY; Filippo Maria Cascino, MD*, Department of
Failed? Biotechnology and Legal Medicine, Section of Legal
Medicine, Via del Vespro 129, Palermo, 90127, ITALY; and
Graziana Farina, MD, Roberto Guarino, MD, Nunzia
Albano, MD, and Emiliano Maresi, Via Del Vespro 127,
Palermo, 90100, ITALY
Dissecting Intramural Hematoma of the Cristoforo Pomara, PhD*, University of Foggia, 31
Esophagus: A Rare Case of Sudden Death Department of Forensic Pathology, Viale Degli Aviatori 1,
Foggia, 71100, ITALY; Alessandra De Salvia, PhD,
University of Verona, Department of Forensic Pathology,
Policlinico G. B. Rossi, Verona, 71100, ITALY; Antonio
Nieddu, MD, University of Sassari, Department of Forensic
Pathology, Sassari, Sassari, ITALY; and Stefano D’Errico,
PhD, University of Foggia, Department of Forensic
Pathology, Viale Degli Aviatori, Foggia, 71100, ITALY
Anaphylactic Shock and Postmortem Exam César L. Santos, MD*, and Beatriz S. Silva, MD, 32
– A Systematic Approach Portuguese National Institute of Legal Medicine, Delegação
do Centro do INML, IP, Largo da Sé Nova, 3000-213,
Coimbra, PORTUGAL; and Duarte N.P. Vieira, PhD, Rua
Antonio Jose de Almeida, No 117, Coimbra, 3000-044,
PORTUGAL
Spontaneous Pulmonary Arterial Margherita Neri, PhD*, Stefania Bello, MD, Raffaella 32
Dissection: A Case Report Bisceglia, MD, and Carmela Fiore, MD, Department of
Forensic Pathology, University of Foggia, Viale degli
Aviatori 1, Foggia, 71100, ITALY
Inherited Cardiac Diseases and Molecular Katarzyna Michaud, MD*, Centre Universitaire Romand 33
Autopsy: Perspectives and Limitations de, Medecine Legale, Rue du Bugnon 21, Lausanne, 1005,
SWITZERLAND; Florence Fellmann, PhD, University
Service of Medical Genetics, Lausanne, 1010,
SWITZERLAND; and Patrice Mangin, PhD, Centre
Universitaire, Romand de Medecine Legale, Rue du Bugnon
21, Lausanne, CH-1011, SWITZERLAND
Sudden, Unexpected Death Due to Irene Riezzo, PhD*, University of Foggia, Osp D’Avanzo, 34
Glioblastoma: Three Fatal Cases Department of Forensic Pathology, Viale Degli Aviatori, 1,
Foggia, 71100, ITALY; Santina Cantatore, Benedetta Di
Battista, MD, Ruggero Parente, MD, and Francesco
Ventura, MD, University of Genova, Department of
Forensic Pathology, Via de’ Toni, 12, Genova, 16132,
ITALY
Postmortem Tryptase Levels of Marc D. Bollmann, MD*, Centre Universitaire Romand de 35
Anaphylactic and Non-Anaphylactic Medecine Legale, Rue du Bugnon 21, Lausanne, CH-1011,
Deaths SWITZERLAND; Olaf Drummer, Noel W.F. Woodford, MD,
Victorian Institute of Forensic Medicine, 57-83 Kavanagh
Street, Southbank, Victoria, 3006, AUSTRALIA; Bettina
Schrag, MD, University Center of Legal Medicine
Lausanne-Geneva, Bugnon 21, Lausanne, 1011,
SWITZERLAND; and Dimitri Gerostamoulos, Victorian
Institute of Forensic Medicine, 57-83 Kavanagh Street,
Southbank, Victoria, 3006, AUSTRALIA
Index 9
Murder-Suicide in Fulton County, Georgia: Randy L. Hanzlick, MD*, and Stacey L. Smith, MD, Fulton 35
1992-2006 County Medical Examiner’s Office, 430 Pryor Street
Southest, Atlanta, GA 30312
Homicidal Deaths in the Western Suburbs Jérôme Cros, MD, AP-HP, Jean-Claude Alvarez, PharmD, 36
of Paris: A 15-Year-Study With Special AP-HP, Raymond Poincaré Hospital, 104, Bd Raymond
Focus on Survival Time Poincaré, Garches, F- 92380, FRANCE; Emilie Sbidian,
MD, AP-HP, Department of Clinical Research and Public
Health, Henri Mondor Hospital, 51 av du Maréchal de
Tassigny, Créteil, F-94010, FRANCE; and Philippe
Charlier, PhD, AP-HP, and Geoffroy Lorin de la
Grandmaison, PhD*, AP-HP, Raymond Poincaré Hospital,
104, Bd Raymond Poincaré, Garches, F-92380, FRANCE
Pattern of Limb Lesions in Suicidal Anne Desjarlais, BSc*, 7101 De La Roche, Montreal, QC 36
Hanging: A Criteria Tool in the Distinction H2S2E6, CANADA; Anny Sauvageau, MD, Office of the
of Suspicious Cases Chief Medical Examiner, 7007 - 116 Street, Edmonton, AB
T6H 5R8, CANADA; and Jean-Pierre Guay, PhD,
University of Montreal, CP 6128, Succ. Centre-ville,
Montréal, QC H2S 2E7, CANADA
Decubitus Ulcers and Ligature Marks as Miran Coklo, PhD, Valter Stemberga, PhD, Drazen 37
Evidence in a Homicide Case Cuculic, PhD*, and Alan Bosnar, PhD, Rijeka University
School of Medicine, Department of Forensic Medicine,
Brace Branchetta 20, Rijeka, 51000, CROATIA
Soccer Scams, Search Engines, Scientists, Stuart J. Hamilton, MB ChB*, 9 Troon Close, Consett, DH8 37
and Slaughter: Investigating a Complex 5XF, UNITED KINGDOM
Double Homicide in North-East England
Death Certification of “Suicide by Cop” Amber R. Neitzel, BS*, 550 East Van Buren Street, Phoenix, 38
AZ 85004; and James R. Gill, MD, Office of the Chief
Medical Examiner, 520 First Avenue, New York, NY 10016
Study of Lethal and Non-Lethal Filmed Anny Sauvageau, MD*, Office of the Chief Medical 38
Hangings: New Insight Into the Examiner, 7007 - 116 Street, Edmonton, AB T6H 5R8,
Pathophysiology of Hanging CANADA
Pitfalls in the Interpretation of the Hyoid João S. Pinheiro, MS*, Instituto Nacional de Medicina 39
and Thyroid Fractures in Strangulation: Legal, Delegação do Centro, Largo da Sé Nova, Coimbra,
The Importance of Anatomical Variations 3000, PORTUGAL; and Anny Sauvageau, MD, Office of the
Chief Medical Examiner, 7007 - 116 Street, Edmonton, AB
T6H 5R8, CANADA
A Comparison Study of Homicides Between Lin Chang, MD*, China University of Political Science and 39
Beijing, China and the State of Maryland, Law, 116 Lugu Road, Shijingshan Distric, Beijing, 100040,
United States PEOPLES REPUBLIC OF CHINA; Li Liu, MD, Beijing
Municipal Public Security Bureau, No.1 Qinghe Longgang
Road Haidian District, Beijing, 100192, PEOPLES
REPUBLIC OF CHINA; and Xiang Zhang, MD, David R.
Fowler, MD, Eleanor J. Thomas, and Ling Li, MD, Office of
the Chief Medical Examiner, State of Maryland, 111 Penn
Street, Baltimore, MD 21201
Blood at the Scene of Death Due to Surendra K. Kumar, MD*, Army College of Medical 40
Hanging: Artifact or Antemortem Sciences, Delhi Cantonment, New Delhi, 110010, INDIA
The Influence of the Meteorological Factors Zalina Muzafarova*, Main Bureau of Forensic Medicine, 40
on Occurrence of the Suicide Cases Mirakhmedov Street, 143, Tashkent, UZBEKISTAN
Complex Suicide: An Unusual Case With Stojan Petkovic, PhD*, Miljen Maletin, MD, MSc, and Maja 41
Six Methods Applied Durendic- Brenesel, PhD, Klinicki Centar Vojvodine,
Department of Forensic Medicine, Clinical Center of
Vojvodina, Hajduk Veljkova 5-7, Novi Sad, 21000, SERBIA
AND MONTENEGRO
Index 10
Bitten by Snake Shot: Attempted Homicide Todd M. Luckasevic, DO*, and Baiyang Xu, MD, Allegheny 41
and Successful Suicide With Multiple County Medical Examiner’s Office, 1520 Penn Avenue,
Gunshot Wounds Pittsburgh, PA 15222; and Abdulrezak M. Shakir, MD, and
Karl E. Williams, MD, MPH, Office of the Medical
Examiner - Allegheny County, 542 Fourth Avenue,
Pittsburgh, PA 15219
Survived Strangulation: A Case Report Paula C. Oliveira, MD*, Portuguese National Institute of 42
Legal Medicine, Largo da Sé Nova, Coimbra, 3000-213,
PORTUGAL; Ana R. Pereira, MD*, Ladeira das
Alpenduradas nº13A, Coimbra, 3030-167, PORTUGAL;
Rosario L. Silva, MD, and Graca Santos Costa, MD,
Portuguese National Institute of Legal Medicine, Largo da
Sé Nova, Coimbra, 3000-213, PORTUGAL; and Duarte
Cause of Sudden Death Due to Cardiac Sabina Di Donato, PhD*, University of Foggia, Department 42
Rhabdomyoma in an 11-Month-Old Baby of Forensic Pathology, Viale Aviatori, 1, Foggia, 71100,
ITALY; Michele Nolè, A.O.R. “San Carlo” Hospital, Via
Potito Petrone, 6, Potenza, 85100, ITALY; Irene Riezzo,
PhD, University of Foggia, Osp D‘Avanzo, Department of
Forensic Pathology, Viale degli Aviatori, 1, Foggia, 71100,
ITALY; Sara Vita, MD, University of Foggia, Department of
Forensic Pathology, Viale Aviatori, 1, Foggia, 71100,
ITALY; and Rocco A.G. Maglietta, MD, San Carlo Hospital
Potenza, Section of Legal Medicine, via P. Petrone n.6,
Potenza, 85100, ITALY
Suicide by Table Saw — A Slice of Jeffrey Racette, MD*, Baiyang Xu, MD, Todd M. 43
Interpretation Luckasevic, DO, Alleghey County Medical Examiner Office,
1520 Penn Avenue, Pittsburgh, PA 15222; and Abdulrezak
M. Shakir, MD, Allegheny County and Karl E. Williams,
MD, Office of the Medical Examiner - Allegheny County,
542 Fourth Avenue, Pittsburgh, PA 15219
The Significance of Gross Adrenal Lee M. Tormos, MD*, Medical and Forensic Autopsy, 43
Hemorrhage — Undiagnosed Waterhouse- Pathology and Laborat Medicine, 171 Ashley Avenue, Suite
Friderichsen Syndrome: A Case Series 309, MSC908, Charleston, SC 29425-9080; and Cynthia A.
Schandl, PhD, Medical University of South Carolina, 171
Ashley Avenue, Suite 309, MSC-908, Charleston, SC 29425
Metastatic Calcification of AV-Node as a Joseph K. White, DO*, University of Colorado Denver 44
Cause of Complete Heart Block and Death School of Medicine, 660 Bannock Street, Denver, CO
80204; and Amy Martin, MD, Denver Office of the Medical
Examiner, 660 Bannock Street, Denver, CO 80204
Postmortem Interval and Cardiac Ziya Kir, MD, and Coskun Yorulmaz, MD*, Istanbul 44
Troponin Effect University Cerrahpasa School of Medicine, Department of
Forensic Medicine, Cerrahpasa, Istanbul, 34099, TURKEY;
Murat Bolayirli, MD, Istanbul University Cerrahpasa
School of Medicine, Department of Biochemistry,
Cerrahpasa, Istanbul, 34099, TURKEY; Haluk Ince, PhD,
Council of Forensic Medicine, Chairperson of the Counsil
of Forensic Medicine, Istanbul, 34197, TURKEY; and Mete
K. Gulmen, PhD, Cukurova University School of Medicine,
Department of Forensic Medicine, Adana, 01330, TURKEY
Index 11
Ante- and Postmortem In-Human Cocaine Patricia Mildred Flach, MD*, and Steffen G. Ross, MD, 45
Packs Detected by Computed Tomography Institute of Forensic Medicine, Center of Forensic Imaging
“Virtopsy”, Buehlstrasse 20, Bern, 3012, SWITZERLAND;
Garyfalia Ampanozi, MD, Ulrich Preiss, MD, Tanja
Germerott, MD, Gary M. Hatch, MD, and Michael Thali,
MD, University of Bern, Institute of Forensic Medicine,
Buehlstrasse 20, Bern, 3012, SWITZERLAND; and Michael
Patak, MD, University of Bern, Radiology, Freiburgstrasse,
Bern, 3010, SWITZERLAND
Decomposition in a Closed Vehicle Shari L. Forbes, PhD*, Helene LeBlanc, PhD*, Katelynn 45
Environment in Southern Ontario Perrault, BSc, and Alicia Buetter, BSc, University of
Ontario Institute of Technology, 2000 Simcoe Street North,
Oshawa, ON L1H7K4, CANADA
Child Abusive Head Trauma in Portugal Agostinho Santos, PhD*, North Branch of the National 46
Institute of Legal Medicine, Jardim Carrilho Videira, Porto,
4050-167, PORTUGAL; Liliana Santos, MD, Jardim
Carrilho Videira, Porto, 4050-167, PORTUGAL; Teresa
Magalhães, PhD, North Branch of the National Institute of
Legal Medicine, Jardim Carrilho Videira, Porto, 4050-167,
PORTUGAL; Francisco Corte-Real, PhD, Center Branch
National Institute of Legal Medicine, Largo da Sé Nova,
Manuel Bento de Sousa, nº 3, Lisboa, 1150-219,
Gravesoil Microbial Community Structure Amy E. Maile, BS*, and David O. Carter, PhD, University 47
During Carcass Decomposition of Nebraska, Lincoln, Department of Entomology, 202
Entomology Hall, Lincoln, NE 68583-0816; and Rhae A.
Drijber, PhD, University of Nebraska-Lincoln, Department
of Agronomy and Horticulture, 279 Plant Sciences Hall,
Lincoln, NE 68583-0915
Laceration of the Inferior Vena Cava Carlos F. Chavez-Arias, MD*, Puerto Rico Institute of 47
Following Blunt Abdominal Trauma in a Forensic Sciences, PO BOX 11878, Caparra Heights
Case of Child Abuse Station, San Juan, PR 00922-1878; and Javier G. Serrano,
MD, Puerto Rico Institute of Forensic Sciences, Calle Maga
Esquina Casia #9, Urb. Reparto Metropol, San Juan, PR
00921
Inferior Vena Cava Compression: A Jeffrey D. Ho, MD, Hennepin County Medical Center, 48
Possible Mechanism for Arrest Related Department of Emergency Medicine, 701 Park Avenue
Death South, Minneapolis, MN 55415; Donald M. Dawes, MD*,
Lompoc Valley Medical Center, 1515 East Ocean Avenue,
Lompoc, CA 93436; and Johanna C. Moore, MD, and
James R. Miner, MD, Hennepin County Medical Center,
Department of Emergency Medicine, 701 Park Avenue
South, 1431 Lakeview Avenue South, Minneapolis, MN
55415
Intra-Abdominal Hemorrhage Associated Carlos F. Chavez-Arias, MD*, Puerto Rico Institute of 48
to an Intrapartum Rupture of the Forensic Sciences, PO BOX 11878, Caparra Heights
Umbilical Cord: A Case Report Station, San Juan, PR 00922-1878; and Javier G. Serrano,
00921
Index 12
Aortic Aneurysm Rupture Into the Lung Carlos F. Chavez-Arias, MD, Puerto Rico Institute of 49
With Formation of Pseudoaneurysm Forensic Sciences, PO BOX 11878, Caparra Heights
Station, San Juan, PR 00922-1878; and Javier G. Serrano,
MD*, and Edda Rodriguez, MD, Puerto Rico Institute of
Forensic Sciences, Calle Maga Esquina Casia #9, Urb.
Reparto Metropol, San Juan, PR 00921
Is DNA Purified From Forensic Autopsy Iana Lesnikova, PhD*, Department of Forensic Pathology 50
Material Suitable for Molecular Biological of University of Aarhus, Denmark, Brendstrupgaardsvej
Studies? 100, Aarhus N, 8200, DENMARK; Jakob Hansen, PhD,
Department of Forensic Medicine, University of Aarhus,
Brendstrupgaardsvej 100, Aarhus N, 8200, DENMARK;
and Jytte B. Lundemose, Department of Forensic Pathology,
University of Aarhus, Denmark, Brendstrupgaardsvej 100,
Aarhus N, AK 8200, DENMARK
Evaluation of a New Approach for Liliana Santos, MD*, Jardim Carrilho Videira, Porto, 50
Estimating the Postmortem Interval Based 4050-167, PORTUGAL; João Lopes, PhD, Faculty of
on the Direct Skin Surface Analysis Using Pharmacy, Rua Aníbal Cunha 164, Porto, 4050-047,
FTIR Spectroscopy PORTUGAL; Agostinho Almeida, PhD, 2REQUIMTE,
Department of Chemistry-Physics, Faculty, Rua Aníbal
Cunha 164, Porto, 4050-047, PORTUGAL; and Agostinho
Santos, PhD, and Teresa Magalhães, PhD, North Branch of
the National Institute of Legal Medicine, Jardim Carrilho
Videira, Porto, 4050-167, PORTUGAL
Unusual Style Cut Throat Injury: A Case Suresh K. Shetty, MD*, Kasturba Medical College, Light 51
Report House Hill Road, Mangalore, 575001, INDIA
Mass Fatality Management: A Multi- Ann H. Ross, PhD, North Carolina State University, 51
National Perspective Department of Sociology & Anthropology, Campus Box
8107, Raleigh, NC 27695- 8107; and Jason H. Byrd, PhD*,
Maples Center for Forensic Medicine, University of
Florida, 4800 Southwest 35th Drive, Gainesville, FL 32608
Improving Evidence and Victim Recovery Dennis C. Dirkmaat, PhD*, Luis L. Cabo-Pérez, MS, 51
Protocols at the Mass Fatality Incident Michael W. Kenyhercz, MS, Allison M. Nesbitt, MS,
Alexandra R. Klales, MS, and Erin Chapman, MS,
Mercyhurst College, Department of Applied Forensic
Sciences, 501 East 38th Street, Erie, PA 16546
Telluric Movements of Death: The Cristoforo Pomara, PhD*, and Gianpaolo Di Peri, MD, 52
Cemetery of Gargano’s Mafia Inside the University of Foggia, Department of Forensic Pathology,
Ravine of Zazzano (Foggia, Italy) Viale Degli Aviatori, Foggia, 71100, ITALY; Giuseppe
Guglielmi, PhD MD, University of Foggia, Department of
Radiology, Viale Pinto, Foggia, 71100, ITALY; Emilio
Nuzzolese, DDS, PhD, Viale J.F. Kennedy 77, Bari, 70124,
ITALY; and Stefano Derrico, PhD, University of Foggia,
Department of Forensic Pathology, Via Luigi Pinto, 1,
Foggia, 71100, ITALY
Use of Multidetector Computed Edward L. Mazuchowski, PhD*, and Philip J. Berran, JD, 53
Tomography (MDCT) in the Evaluation of Office of the Armed Forces Medical Examiner, 1413
Gunshot Wounds Research Boulevard, Building 102, Rockville, MD 20850;
and Howard T. Harcke, MD, Armed Forces Instiute of
Pathology, 6825 16th Street Northwest, Washington, DC
20306
Gunshot Wounds Covered by Different Giovanni Cecchetto, MD*, Alessandro Amagliani, MD, 53
Textiles: Determination of GSR Through Guido Viel, MD, and Paolo Fais, MD, University of Padua,
Micro-CT Analysis Via Falloppio 50, Padova, 35121, ITALY; Giampietro
Feltrin, MD, Via Giustiniani 2, Padova, 35121, ITALY;
Index 13
Santo Davide Ferrara, PhD, University of Padua - Section
of Legal Medicine and Forensic Toxicology, Via Falloppio
50, Padua, 35121, ITALY; and Massimo Montisci, PhD,
University of Padua, Via Falloppio 50, Padova, 35121,
ITALY;
Child Abuse vs. Cachexia: Do Healing and Steven A. Symes, PhD, Mercyhurst College, 501 East 38th 54
Acute Rib Fractures Trump a Diagnosis of Street, Erie, PA 16546-0001; and Dianne R. Vertes, PhD,
Probable Cardiac Dysrhythmia Due to MD, Erie County Medical Examiner’s Office, 462 Grider
Electrolyte Abnormalities Street, Buffalo, NY 14215
The Identification of French Victims in the Stephane Malbranque, MD*, French-DVI, Chu Fort-De- 54
Massive Earthquake on January 12, 2010 France, Hop. La Meynard, BP 632, Fort-De-France cedex,
in Haiti 97261, MARTINIQUE
Comparison of Methods for Measuring Michael K. Humphreys, MS*, Yolo County Sheriff/Coroner 55
Decomposition of Submerged Carrion in Office, 2500 East Gibson Road, Woodland, CA 95616;
Fresh Water Edward Panacek, MD, MPH, University of California -
Davis, Department of Emergency Medicine, 4150 V Street,
Patient Support Services Building, Suite 2100, Sacramento,
CA 95817; William Green, MD, California Clinical
Forensic Medical Training Center, University of California
- Davis Medical Center, 3671 Business Drive, Sacramento,
CA 95820; and Elizabeth A. Albers, MD, Sacramento
County Coroner’s Office, 4800 Broadway, Sacramento, CA
95820
Fatal Sexual Violence Against Women: Sharon R. Crowley, MN*, FCNS, 122 Emeline Avenue, 56
Normative, Baseline Studies of Postmortem Santa Cruz, CA 95060
Genital Anatomy — What Can We Say
About Normal?
The Effects of Household Chemicals on Kristi N. Bugajski, MS*, 929 King Street, Lafayette, IN 57
Blow Fly Oviposition and Development 47905; and Ralph E. Williams, PhD, Purdue University
Using Human Cadavers Department of Entomology, 901 West State Street, West
Lafayette, IN 47907
Mass Disaster Procedures: Forensic Paola A. Magni, MS, F.E.LAB ASL TO1, c/o Civico 57
Pathology and Genetic Techniques Used to Obitorio di Torino, Via Bertani 112/A, Torino, 10137,
Locate Nine Missing People in the Calabria ITALY; Giulio Di Mizio, PhD*, Policlinico Universitario
Region (Southern Italy) Camp, Germaneto, Edificio Clinico, Sec. Foren Med, Viale
Europa, Catanzaro, 88100, ITALY; Federica Colosimo,
MD, Magna Graecia University of Catanzaro, Viale Europa
Loc. Germaneto, Catanzaro, 88100, ITALY; Sergio
Schiavone, PhD*, RIS Carabinieri, S.S. 114 Km 3,400,
Messina, 98128, ITALY; Carlo G. Romano, MSc, RIS
Carabinieri, S.S. 114 Km 6,400, Messina, 98128, ITALY;
Ciro Di Nunzio, Institute of Legal Medicine, School of
Medicine, Magna Graecia University, Viale Europa
Germaneto, Catanzaro, 88100, ITALY; Ian Dadour, PhD,
Centre for Forensic Science, University of Western
Australia, 35 Stirling Highway, Nedlands, 6009,
AUSTRALIA; and Pietrantonio Ricci, MD, Università degli
Studi Magna Grecia Catanzaro, Viale Europa - Località
Germaneto, Catanzaro, ITALY
Variance in Growth Rates of Calliphora Bridget R. McSweeney, BA*, 1629 South Shenandoah 58
vomitoria on Different Tissue Types: Mass Street, Los Angeles, CA 90035; and Tal Simmons, PhD,
Raised vs. Single Raised School of Forensic & Investigative Sciences, University of
Central Lancashire, Preston, PR1 2HE, UNITED
KINGDOM
Index 14
Identification of Two Homicide Victims William C. Rodriguez III, PhD*, and Laura A. Regan, PhD, 58
and Linking of Separate Crimes Solved by Armed Forces Medical Eaminer System, 1413 Research
Radiographic Discovery of a Healed Bullet Boulevard, Building 102, Rockville, MD 20850; and
Wound. Humphrey H. Germaniuk, MD, Trumbull County Coroner’s
Office, 1863 East Market Street, Warren, OH 44483
Utilizing Multi-Detector Computerized Robert A. Kurtzman, DO, Community Hospital, 2021 North 59
Tomography to Evaluate Concrete-Encased 12th Street, Grand Junction, CO 81501; and Casey P.
Human Remains Bitting, BS*, 1700 Bassett Street, #2114, Denver, CO 80202
Use of Multidetector Computed Howard T. Harcke, MD*, Armed Forces Institute of 60
Tomography (MDCT) in the Medicolegal Pathology, 6825 16th Street Northwest, Washington, DC
Investigation of Human Remains After a 20306; and Edward L. Mazuchowski, PhD, and Philip J.
Natural Disaster Berran, JD, Office of the Armed Forces Medical Examiner,
1413 Research Boulevard, Building 102, Rockville, MD
20850
Evaluation of the Randox Whole Blood Poppy McLaughlin, MSc*, Bournemouth University, Fern 60
Drugs of Abuse (DOA) Microchip Arrays Barrow, Talbot Campus, Poole, BH12 5BB, UNITED
for Use With Alternative Postmortem KINGDOM; Derrick J. Pounder, MB, University of Dundee,
Samples as a Rapid Near-Body Screen Department of Forensic Medicine, Dundee, DD1 4HN,
UNITED KINGDOM; and Michael D. Osselton,
Bournemouth University, Fern Barrow, Talbot Campus,
Poole, BH12 5BB, UNITED KINGDOM
Postmortem Vitreous Beta- Michael Heninger, MD*, Fulton County Medical 61
Hydroxybutyrate: Interpretation in a Examiner’s Office, 430 Pryor Street, Atlanta, GA 30312
Forensic Setting
The Rising Trend of Ecstasy and Mimic Larry Silveira, MS*, Santa Clara County Department of 61
Drugs Among Teenagers in Santa Clara Alcohol and Drug Services, 2101 Alexian Drive, Suite 110,
County, California — A Guide and San Jose, CA 95116; and Michelle A. Jorden, MD, Santa
Awareness for Medical Examiners, Clara Medical Examiner, 850 Thorton Way, San Jose, CA
Coroners, and Toxicologists 95128
Laboratory Variation and Postmortem Clarissa Krinsky, MD*, University of New Mexico School 62
Redistribution in the Interpretation of Of Medicine, MSC11 6030, 1 University of New Mexico,
Postmortem Fentanyl Levels Albuquerque, NM 87131; and Sarah Lathrop, PhD, DVM,
and Ross E. Zumwalt, MD, University of New Mexico,
Office of Medical Investigator, MSC 11 6030, 1 University
of New Mexico, Albuquerque, NM 87131-0001
Toxicology and Pathology of 149- Sébastien Prat, MD*, Service de Médecine Légale, Hôpital 62
Methadone-Related Deaths Trousseau, Centre Régional Hospitalier Universitaire de
Tours, Tours, MB 37000, FRANCE; Patrice Mangin, PhD,
Centre Universitaire, Romand de Medecine Legale, Rue du
Bugnon 21, Lausanne, CH-1011, SWITZERLAND; Marc
Augsburger, PhD, University Center of Legal Medicine,
Bugnon 21, Lausanne, 1010, SWITZERLAND; and
Katarzyna Michaud, MD, Centre Universitaire Romand de
Medecine Legale, Rue du Bugnon 21, Lausanne, 1005,
SWITZERLAND
Deaths in Unlicensed Alcohol Lawrence Nguyen, MD, Los Angeles County Department of 63
Rehabilitation Facilities Coroner, 1104 North Mission Road, Los Angeles, CA
90033; and Christopher B. Rogers, MD*, Los Angeles
County Medical Examiner’s Office, 1104 North Mission
Road, Los Angeles, CA 90033
Index 15
Was This Drug Overdose Due to Johan A. Duflou, MM*, Department of Forensic Medicine, 63
Intravenous Injection or Oral Ingestion of PO Box 90, Glebe, Sydney, 2037, AUSTRALIA; Shane
Heroin — Can You Tell? Darke, PhD, National Drug and Alcohol Research Centre,
University of New South Wales, Sydney, 2052, AUSTRALIA;
and Jennifer Easson, BSc, Division of Analytical
Laboratories, Sydney West Area Health Service, Joseph
Street, Lidcombe, 2141, AUSTRALIA
First Reported Case of Bromo-Dragonfly Michelle A. Jorden, MD*, Santa Clara Medical Examiner, 64
Fatality in the United States, San Jose, 850 Thorton Way, San Jose, CA 95128; Lee M. Blum, PhD,
California, County of Santa Clara NMS Labs, 3701 Welsh Road, Willow Grove, PA 19090;
and Joseph Corvo, BS, NMS Labs, 3701 Welsh Road,
Willow Grove, PA 19090
Sudden Unexpected Infant Death: Patrick E. Lantz, MD*, Wake Forest University, School of 64
Lymphocytic Meningoencephalitis With Medicine, Department of Pathology, Medical Center
Multiple Retinal Hemorrhages Boulevard, Winston-Salem, NC 27157-1072; Amy M.
Durso, MD, Professional Pathology Services, One Science
Court, Suite 200, Columbia, SC 29203; and Ryan T. Mott,
MD, Department of Pathology/Wake Forest University
Health Sciences, Medical Center Buolevard, Winston Salem,
NC 27157-1072
Parietal Pseudofracture in Children Pauline Saint-Martin, MD*, and Camille Rerolle, MD, 65
Suggesting Non-Accidental Trauma: A Hopital Trousseau, Service de Medecine Legale, CHRU
Report of Two Cases and Review of the TOURS, TOURS, 37000, FRANCE; Thierry Lefrancq, MD,
Literature Le Vauban, BP 549, 16 rue Clerget, NEVERS, 58009,
FRANCE; and Patrick O. Byrne, MD, Service de Medecine
Legale, Hopital Trousseau, CHRU TOURS, TOURS, 37000,
FRANCE
Methadone and Cocaine Related Death in Francesco Ausania, MD, Institute of Forensic Medicine, 66
A Young Boy: A Case Report Catholic University, School of Medicine, Ro, largo
Francesco Vito 1, Rome, ITALY; Massimo Senati, PhD,
Largo Francesco Vito 1, Rome, ITALY; Nadia Fucci, PhD,
largo francesco vito 1, Rome, ITALY; Antonio Oliva, PhD*,
Institute of Forensic Medicine, Catholic University, School
of Medicine, Ro, Largo Francesco Vito 1, Rome, ITALY;
and Pietrantonio Ricci, PhD, Università degli Studi Magna
Catanzaro, ITALY
Sudden Death Due to Dengue Fever in an Mohd Shafie Bin Othman, MD*, Forensic Department 66
8-Month-Old Baby Hospital Raja Permaisuri Bainun, Jalan Hospital 30450,
Ipoh, 31350, MALAYSIA; and Santina Cantatore, Dania De
Carlo, MD, and Margherita Neri, PhD, Department
Sudden Death in the First Year of Life: The Francesco Paolo Busardo, MD*, Institute of Legal 67
Importance of Pancreatic Medicine, Via Del Vespro, 129, Palermo, 90100, ITALY;
Histomorphological Analysis Stefania Zerbo, MD, Institute of Legal Medicine, Via Del
Vespro, 127, Palermo, 90100, ITALY; Antonina Argo, Via
Del Vespro 127, Palmero, 90100, ITALY; Liliya Gutsul,
MD, Instituto, Via Del Vespro, 127, Palmero, 90100,
ITALY; Paolo Procaccianti, Palermo University, Via Del
Vespro, N. 127, Palermo, 90100, ITALY; and Emiliano
Maresi, Via Del Vespro 127, Palermo, 90100, ITALY
Index 16
Isolated Coronary Anomalies and Sudden Emiliano Maresi*, and Livio Milone, PhD, Via Del Vespro, 68
Death in the Young N. 127, Palermo, 90100, ITALY; Paola Pugnetti, MD,
Department of Biotechnology and Legal Medicine, Section
of Legal Medicine, Via Del Vespro, n. 129, Palermo, 90127,
ITALY; Francesco P. Busardo, MD, Institute of Legal
Medicine, Via Del Vespro, 129, Palermo, 90127, ITALY;
Nunzia Albano, MD, Pierangela Fleres, MD, Via Del
vespro 127, Palermo, 90100, ITALY; and Paolo
Procaccianti, Palermo University, Via Del Vespro, n. 127,
Pathologic and Anthropologic Pramod Gumpeni, MD*, Jason M. Wiersema, PhD, and 68
Manifestations of Documented Repetitive Luis A. Sanchez, MD, Harris County Institute of Forensic
Blunt Trauma in a Child Abuse Case Sciences, 1885 Old Spanish Trail, Houston, TX 77054
Pregnancy, Caesarean, and Isabelle Plu, PhD*, Denis Barrès, MD, and Dominique 69
Pheochromocytoma: A Case Report With a Lecomte, PhD, Institut Médico-Légal, 2 place Mazas, Paris,
Fatal Outcome 75012, FRANCE
Infant Death Evaluation: What is the M.G.F. Gilliland, MD*, Brody School of Medicine at East 69
Constellation of Abusive Injuries? Carolina University, Pathology & Lab Medicine, Brody 7S-
10, Greenville, NC 27858-4354
Utility of Whole Body Postmortem Zabiullah Ali, MD*, Office of the Chief Medical Examiner, 70
Computed Tomography Imaging in 111 Penn Street, Baltimore, MD 21201; Barry Daly, MD,
Detection of Elder Abuse: Comparison and Nancy Knight, PhD, University of Maryland Medical
With and Potential Substitution for Center, Radiology Department, 22 South Greene Street,
Standard Autopsy Baltimore, MD 21201; and David R. Fowler, MD, Office of
the Chief Medical Examiner, 111 Penn Street, Baltimore,
MD 21201
Findings of the Examinations of Suspected Ubicelio Martin-Orozco, EDV*, Ciudad Juarez 71
Animal Cruelty Cases Submitted to the Autonomous University, Benjamin Franklin# PRONAF
Birmingham Jefferson County Animal Zone, Juarez, 32315, MEXICO; Barbara Benhart, DVM,
Control Jefferson County Animal Control, 6227 5th Avenue North,
Birmingham, AL 35212; and Elizabeth A. Gardner, PhD,
University of Alabama Department of Justice, UBOB 210,
1530 3rd Avenue, South, Birmingham, AL 35294-4562
Fatal Tiger Attack on a Zoo Patron: Ellen Moffatt, MD*, City & County of San Francisco Office 71
Patterns and Types of Injuries in Large of the Medical Examiner, 850 Bryant Street, San Francisco,
Predatory Cats CA 94103; Gregory L. Mar, DDS*, Hall of Justice, 850
Bryant Street, Room 442, San Francisco, CA 94103; Duane
E. Spencer, DDS*, 1855 San Miguel Drive, Suite 9, Walnut
Creek, CA 94596-5282; John K. Berk, DDS, 20652
Redwood Road, Castro Valley, CA 94546; James D. Wood,
DDS, 102 South Main Street, Cloverdale, CA 95425;
Freeland Dunker, DVM, California Academy of Sciences,
Steinhart Aquarium, 55 Music Concourse Drive, San
Francisco, CA 94118; and Jacqueline Jencek, DVM, San
Francisco Zoollogical Society, 1 Zoo Road, San Francisco,
CA 94132-1098
The Utility of Skeletal Examination in Jason M. Wiersema, PhD*, Jennifer C. Love, PhD, Sharon 71
Recognition of Occult Skeletal Injury M. Derrick, PhD, and Luis A. Sanchez, MD, Harris County
Institute of Forensic Sciences, 1885 Old Spanish Trail,
Houston, TX 77054
Index 17
Interpretation of Anogenital Findings in Patrícia Jardim, MD*, José M. Fernandes, MD, Dina 72
Forensic Autopsy: Problems and Almeida, MD, Liliana Santos, MD, MSc, Agostinho Santos,
Challenges PhD, and Teresa Magalhães, PhD, North Branch of the
National Institute of Legal Medicine, Jardim Carrilho
Videira, 4050-167, Porto, PORTUGAL
When Lightning Strikes: 17 Fatal Alice J. Briones, DO*, 1107 Canvasback Lane, Denton, MD 73
Lightning Strikes in New Mexico 21629; and Michelle B. Aurelius, MD, Office of the Medical
Investigator, MSC 11 6030, 1 University of New Mexico,
Albuquerque, NM 87131
Drag Racing of Snowmobiles on Asphalt: A Abraham T. Philip, MD*, Brian P. Ehret, and Robert 73
Novel Cause for Sudden Violent Death Stoppacher, MD, Onondaga County Medical Examiner’s
Office, 100 Elizabeth Blackwell Street, Syracuse, NY 13210
Blast Overpressure After Tire Explosion: A Stefano Derrico, PhD*, University of Foggia, Department 74
Fatal Case of Forensic Pathology, Via Luigi Pinto, 1, Foggia, 71100,
ITALY; Gabriela Perilli, MD, University of Foggia,
Department of Forensic Pathology, Viale Degli Aviatori 1,
Foggia, 71100, ITALY; Umberto Volpe, Bari, Bari, , ITALY;
Natascha Pascale, MD, University of Foggia, Department
of Forensic Pathology, Viale Degli Aviatori, Foggia, 71100,
ITALY; and Irene Riezzo, PhD, University of Foggia, Osp
D’Avanzo, Department of Forensic Pathology, Viale Degli
Aviatori, 1, Foggia, 71100, ITALY
TASER® XREP™: A Case Study Ogbonna Chinwah, MD*, Department of the Coroner, 1104 74
North Mission Road, Los Angeles, CA 90033; and
Christopher B. Rogers, MD, and Lakshmanan
Sathyavagiswaran, MD, Los Angeles County Medical
Examiner’s Office, 1104 North Mission Road, Los Angeles,
CA 90033
3D in Forensics: TIM Synthetic MRI and Michael Thali, MD*, VIRTOPSY Team, University of Bern, 75
Virtobot – Forensic Imaging Workflow of Institute of Forensic Medicine, Buehlstrasse 20, Bern, 3012,
the Future SWITZERLAND
Transition to Digital in the Forensic Jason M. Wiersema, PhD*, Diane Logan, MBA, and Luis A. 75
Morgue: Lessons Learned on the Pathway Sanchez, MD, Harris County Institute of Forensic Sciences,
to Greater Efficiency 1885 Old Spanish Trail, Houston, TX 77054
Postmortem Computed Tomography as a Seija Ylijoki-Soerensen, MD*, Department of Forensic 76
Valuable Tool for Diagnosing Trauma Medicine, Brendstrupgaardsvej 100, Aarhus N, 8200,
Prior to Medicolegal Autopsy DENMARK; Iana Lesnikova, MD, Department of Forensic
Pathology of University of Aarhus, Brendstrupgaardsvej
100, Aarhus N, 8200, DENMARK; Lars Uhrenholt, PhD,
Institute of Forensic Medicine, Department of Forensic
Medicine, University of Aarhus, Brendstrupgaardsvej 100,
Aarhus N, 8200, DENMARK; and Annie Vesterby, MD,
DMSc, Institute of Forensic Medicine, University of Aarhus,
Brendstrupgårdsvej 100, 8200 Aarhus N, DK-8000,
DENMARK
Traumatic Injuries in Fatal Tire Explosions Chris Milroy, MD*, University of Ottawa, The Ottawa 77
Hospital, 501 Smyth Road, Box 117, 4th Floor CCW,
Ottawa, ON K1H 8L6, CANADA; and Alison Edgecombe,
MD, The University of Ottawa, Departemnt of Pathology
and Laboratory Medicine, PO Box 117, 4th Floor CCW,
501 Smyth Road, Ottawa, ON, CANADA
Index 18
2010
Retinal and Optic Nerve Sheath Evan Matshes, MD*, Southwestern Institute of Forensic 78
Hemorrhages Are Not Pathognomonic of Sciences, 5230 Southwestern Medical Avenue, Dallas, TX
Abusive Head Injury 75235
Child Abuse vs. Accidental Falls: Judicial James A.J. Ferris, MD*, Department of Forensic 78
Outcomes in Alleged Child Abuse Pathology, LabPlus, 85 Park Road, Grafton, PO Box
110031, Auckland, NEW ZEALAND
Pediatric Deaths in Harris County Kathryn H. Haden-Pinneri, MD*, and Sharon M. Derrick, 78
PhD, Harris County Medical Examiner’s Office, 1885 Old
Spanish Trail, Houston, TX 77054
What Is the Frequency of Finding Lethal M.G.F. Gilliland, MD*, Brody School of Medicine at East 79
Injury When a SIDS-Like Death Is Carolina University, Pathology & Lab Medicine, Brody 7S-
Reported? 10, Greenville, NC 27858-4354
Cardiac Channelopathies Linked to Dawei Wang, PhD*, and Donald Siegel, PhD, New York 80
Sudden Infant Death Syndrome/Sudden City Office of the Chief Medical Examiner, 421 East 26
Unexplained Death Syndrome Street, New York, NY ; and Yingying Tang, MD, PhD,
Mechthild K. Prinz, PhD, and Barbara A. Sampson, MD,
PhD, Office of Chief Medical Examiner, Department of
Forensic Biology, 421 East 26th Street, New York, NY
10016
Fatal Acute Intracranial Injury With Patrick E. Lantz, MD*, Department of Pathology, Wake 80
Subdural Hematoma and Retinal Forest University, School of Medicine, Medical Center
Hemorrhages in an Infant Due to Stairway Boulevard, Winston- Salem, NC 27157-1072; and Daniel E.
Fall Couture, MD, Department of Neurosurgery, Wake Forest
University School of Medicine, Medical Center Boulevard,
Winston Salem, NC 27157
Morbidity and Mortalities Related to TV Marvin S. Platt, MD, JD*, 5050 La Jolla Boulevard, 81
Tip Over Apartment 2G, San Diego, CA 92109; and Christina
Stanley, MD, San Diego County Medical Examiner’s Office,
5555 Overland Avenue, Suite 1411, San Diego, CA 92123
Hanging Deaths in Children: An Julie Adams, DO*, 1234 Big Bend Crossing Drive, Valley 81
Investigation of Manner of Death Park, MO 63088
Does a Draft Really Influence Postmortem Michal R. Kaliszan, PhD*, Medical University of Gdansk, 82
Body Cooling? Debowa 23, Gdansk, 80-286, POLAND
Forensic Medicine in Dubai, United Arab Fawzi A. Benomran, MD*, Dubai Police, Dubai Medical 82
Emirates College, PO Box 39844, Dubai, UNITED ARAB EMIRATES
Injuries to Abdominal Organs in Fatal Lars Uhrenholt, PhD*, Louise Moller Andersen, and Freja 83
Road Traffic Crash Victims Gaborit, Department of Forensic Medicine, Faculty of
Health Sciences, University of Aarhus, Brendstrupgaardsvej
100, Aarhus N, 8200, DENMARK
Case Example: Cerebral Dural Venous Ariel Goldschmidt, MD*, Jackson County Medical 83
Sinus Thrombosis Following a Motor Examiner’s Office, 1700 Forum Boulevard, Apartment 509,
Vehicle Accident Columbia, MO 65203; Adrian Baron, MD, and Megan
Minniear, BS, 660 East 24th Street, Kansas City, MO 64108
A Death Due to Subinvolution of the Ruth E. Kohlmeier, MD*, El Paso County Coroner’s Office, 84
Uteroplacental Arteries: A Case Report 2743 East Las Vegas Street, Colorado Springs, CO 80906;
and Literature Review and Norma J. Farley, MD, Valley Forensics, 200 South 10th
Street, McAllen, TX 78501
Index 19
Case Studies of Cranial Trepanation in Emilio Nuzzolese, DDS, PhD*, Ambulatorio Nuzzolese, 84
Apulia (Southern Italy) Through Forensic viale J.F. Kennedy 77, Bari, 70124, ITALY; Sandro Sublimi
Imaging Saponetti, BSc, and Vito Scattarella, BS, Department of
Animal and Environmental Biology, Università degli Studi
di Bari, Bari, 70100, ITALY; and Marino Capece, MD,
Imaging Department, ASL BA, Monopoli, 70100, ITALY;
Nunzio Di Nunno, PhD, Università del Salento, Lecce,
73100, ITALY
Systemic Lupus Erythematosus and Fatal Irene Riezzo, MD*, Stefania Bello, MD, Margherita Neri, 85
Cardiac Failure Due to Pancarditis in a PhD, and Cristoforo Pomara, PhD, Department of Forensic
Young Man Pathology University of Foggia, Viale degli Aviatori 1,
Autopsy Investigation and Bayesian Antonio Oliva, PhD*, and Sara Merigioli, PhD, Institute of 86
Approach to Coronary Artery Disease Forensic Medicine, Catholic University, School of
(CAD) in Victims of Motor Vehicle Medicine, Largo Francesco Vito 1, Rome, ITALY; Jose
Accidents Flores, MD, Montreal Heart Institute. University, Montreal,
Quebec, Canada, Montreal, CANADA; Francesca Cittadini,
PhD, Sara Partemi, MD, and Vincenzo L. Pascali, PhD,
Institute of Forensic Medicine, Catholic University, largo
Francesco Vito 1, Rome, ITALY; and Ramon Brugada, MD,
Montreal Heart Institute, Montreal Quebec, Canada,
Montreal, CANADA
An Unusual “In-Custody” Death Brian Drewry, BS*, Iowa and Jerri McLemore, MD, Iowa 86
Office of the State Medical Examiner, 2250 South Ankeny
Boulevard, Ankeny, IA 50023; Dennis Klein, MD, Iowa
Depaartment of Public Health, 2250 South Ankeny
Boulevard, Ankeny, IA 50023
Analysis of Female Firearm Homicides in Janaki Warushahennadi, MD*, and Richard C. Harruff, 86
King County, Washington 2000 - 2007 PhD, King County Medical Examiner’s Office, 325 Ninth
Avenue, HMC Box 359792, Seattle, WA 98116
Genetic Aspects of Sudden Death in Youth: Maiken K. Larsen, MD*, Department of Forensic Medicine, 87
A Retrospective Study of Familial Brendstrupgårdsvej 100, DK-8200 Aarhus N, DENMARK;
Hypercholesterolemia Peter H. Nissen, MSc, Department of Clinical Biochemistry,
Aarhus University Hospital, Tage Hansens Gade, DK-8200
Aarhus N, DENMARK; Ingrid B. Kristensen, MD,
Department of Forensic Medicine, Brendstrupgaardsvej
100, DK-8200 Aarhus N, DENMARK; Henrik K. Jensen,
MSc, Department of Cardiology, Aarhus University
Hospital, Skejby, Brendstrupgaardsvej 100, DK-8200
Aarhus N, DENMARK; and Jytte B. Lundemose, PhD,
Faculty of Health Sciences Aarhus University, Department
of Forensic Medicine, Brendstrupgårdsvej 100, DK-8200
Århus N, , DENMARK
Index 20
An Unusual Death of a Masochist: Accident Biagio Solarino, PhD*, Sezione di Medicina Legale, 88
or Suicide? Università degli Studi di Bari, P.zza Giulio Cesare, 11, Bari
70125, ITALY; Lucia Tattoli, MD, Sezione di Medicina
Legale, Univerisity of Bari, Bari, ITALY; Ignazio
Grattagliano, PsyD, Section of Forensic Psychiatry,
University of Bari, Piazza Giulio Cesare, Bari 70124,
ITALY; Claas T. Buschmann, MD, Institute of Legal
Medicine and Forensic Sciences, Turmstrasse 22, Berlin
10439, GERMANY; Michael Tsokos, MD, Institute of Legal
Medicine & Forensic Sciences, Turmstr 21, Haus L, Berlin
10559, GERMANY; and Giancarlo Di Vella, PhD, Sezione
di Medicina Legale, DIMIMP, University of Bari,
Policlinico, piazza G. Cesare, Bari 70121, ITALY
Numerous Rhabdomyomata and Cortical Iyare Izevbaye, PhD*, State University of New York, 88
Tubers in a Possible Case of SIDS Buffalo, 100 High Street, Buffalo, NY 14203; and Fazlollah
Loghmanee, MD, Erie County Medical Examiner’s Office,
111 Lehn Spring Drive, Williamsville, NY 14221-6920
Fatal Subarachnoid Hemorrhage During Federica Portunato*, Maria Celeste Landolfa, MD, 88
Sexual Activity: A Case Report Manuela Botto, MD, and Francesco De Stefano, MD,
Department of Legal and Forensic Medicine, Via De Toni
via de’ Toni, 12, Genova, 16132, ITALY
Occurrence of MRSA in the Peritoneal Nicole Singer, BS*, 206 South 13th Street Apartment 702, 89
Cavity Following PEG Tube Insertion Philadelphia, PA 19107; and Fredric N. Hellman, MD,
Office of the Medical Examiner, Fair Acres, Route 352,
Lima, PA 19037
Two Cases of Generalized Myxedema Meredith A. Lann, MD*, and Jeffrey J. Barnard, MD, 90
Southwestern Institute of Forensic Sciences, 5230
Southwestern Medical Drive, Dallas, TX 75235
Adipositas Cordis and Iatrogenic Death: Guido Viel, MD*, and Giovanni Cecchetto, MD, University 90
Fatal Complication or Medical Error? of Padua, Via Falloppio 50, Padova, 35121, ITALY; Ann S.
Schroder, MD, and Nadine Wilke, MD, Eppendorf -
Hamburg, Hamburg,, GERMANY; Massimo Montisci, PhD,
Via Falloppio 50, Padova, ITALY; and Klaus Pueschel,
PhD, Eppendorf - Hamburg, Hamburg,, GERMANY
Public Death From Orally Ingested Drugs Gilbert E. Corrigan, PhD*, 11801 Hidden Lake, Saint 91
During a One Year Period in Louisiana as Louis, MO 63138
Analyzed by a Single Forensic Toxicology
Laboratory
Complex Suicide: A Case Report Cristina G. Cordeiro, MD*, and Duarte N.P. Vieira, PhD, 92
Instituto Nacional de Medicina Legal, IP, Largo da Sé
Nova, Coimbra, 3000-213, PORTUGAL
Fire Death of Two Lovers: An Paolo Fais, MD*, Guido Viel, MD, Massimo Montisci, 92
Immunohistochemical and Toxicological PhD, Alessandro Nalesso, Silvano Zancaner, MD, and
Study Giovanni Cecchetto, MD, University of Padua, Via
Falloppio 50, Padova, 35121, ITALY
Non-Traumatic Subdural Hematoma in Carolyn H. Revercomb, MD*, and Sarah M. Colvin, MD, 93
Adults Office of the Chief Medical Examiner, District of Columbia,
1910 Massachusetts Avenue Southeast, Washington, DC
20003; and Marie L. Pierre-Louis, MD, 6404 Luzon
Avenue, Northwest, Washington, DC 20012
Index 21
Accidental Carbon Monoxide Poisoning: A Kristinza R. Woodard, MD*, University of Washington 93
Review of Environmental and Cultural Pathology and Lab Medicine, 1959 Northeast Pacific Street,
Risk Factors of Fatal Cases in King County PO Box 356100, Seattle, WA 98195; and Richard C.
Harruff, MD, PhD, King County Medical Examiner’s
Office, 325 9th Avenue, Box 359792, Seattle, WA 98104
Differences in Scene Reenactment of Marianna Sandomirsky, MD*, and Jane W. Turner, PhD, 94
Pediatric Death: Homicide Versus Others MD, St. Louis City Medical Examiner’s Office, 1300 Clark
Street, St. Louis, MO 63103
Suicide by Multiple Gunshots From Paul Uribe, MD*, 7807 Mineral Springs Drive, 94
Automatic Weapons Gaithersburg, MD 20877
EBV (+) T-Cell Lymphoproliferative Mark A. Super, MD*, Sacramento County Coroner’s Office, 95
Disorder of Childhood Causing Sudden 4800 Broadway, Suite 100, Sacramento, CA 95820-1530;
Death: A Case Report and Karimireddy J. Reddy, MD*, University of California,
Davis, Department of Pathology, 4400 V Street,
Sacramento, CA 95817
Temporal Variation of Ethanol Related Rameen S. Starling-Roney, MD*, Anna Rubio, MD, Donna 95
Firearm Deaths M. Vincenti, MD, and David R. Fowler, MD, State of
Maryland Office of the Chief Medical Examiner, 111 Penn
Axonal Injury in Pediatric Head Trauma: Michael W. Johnson, MD, PhD*, and Anna Rubio, MD, 96
A Study of the Interpretation of ß-Amyloid State of Maryland Office of the Chief Medical Examiner,
Precursor Protein (ß-APP) Expression in 111 Penn Street, Baltimore, MD 21201; Juan Troncoso,
Trauma and Non-Trauma Cases MD, The Johns Hopkins University, School of Medicine,
558 Ross Building, 720 Rutland Avenue, Department of
Neuropatholyg, Baltimore, MD 21205; and David R.
Fowler, MD, and Ling Li, MD, State of Maryland Office of
MD 21201
Association of Retinal Hemorrhages With Candace H. Schoppe, MD*, and Patrick E. Lantz, MD, 96
Fatal Head Injuries in Infant Monkeys Wake Forest University School of Medicine, Department of
Pathology, Medical Center Boulevard, Winston Salem, NC
27157; Kurt A. Schoppe, MD, and Jonathan Burdette, MD,
Wake Forest University School of Medicine, Department of
Radiology, Medical Center Boulevard, Winston Salem, NC
27157; Keith G. Mansfield, DVM, Harvard Medical School,
New England Primate Research Center, 1 Pine Hill Drive,
Southborough, MA; and Constance A. Stanton, MD, Wake
Forest University School of Medicine, Department of
27157
Postmortem Pulmonary Findings by Lene W. Boel, PhD*, Institute of Forensic Medicine, 97
Computed Tomography Compared With University of Aarhus, Brendstrupgaardsvej 100, Aarhus N,
Conventional Autopsy 8200, DENMARK; Lars Uhrenholt, PhD, Institute of
Forensic Medicine, Department of Forensic Medicine,
University of Aarhus, Brendstrupgaardsvej 100, Aarhus N,
8200, DENMARK; Rita Ullerup, Institute of Forensic
Medicine, Brendstrupgaardsvej 100, Aarhus N, 8200,
DENMARK; and Anne Grethe Jurik, DSc, Department of
Radiology Aarhus University Hospital, Noerrebrogade 44,
Aarhus C, 8000, DENMARK
Index 22
Forensic Imaging: Yes, We Scan! New Alexendre Dominguez*, Haute Ecole Cantonale Vaudoise 98
Challenges for a Radiographer de la Santé, Avenue de Beaument 21, Lausanne,
SWITZERLAND; Francesco Doenz, Service de
Radiodiagnostic et de Radiologie Interventionnelle, Rue du
Bugnon 46, Lausanne, Richard Dirnhofer, MD, and Beat
Steger, Fumedica AG, Luzernerstrasse 91, Muri,
SWITZERLAND; Barbara Sollberger, Department for
Cardiovascular Surgery, University Hospital Bern,
Hochschulstrasse 4, Bern, SWITZERLAND; Erich Gygax,
Department for Cardiovascular Surgery, Hochschulstrasse
4, Bern, SWITZERLAND; Reto Meuli, Service de
Bugnon 46, Lausanne, 1011, SWITZERLAND; and Patrice
Mangin, MD, PhD, and Silke Grabherr, Centre
Universitaire Romand de Médecine Légale, Rue du Bugnon
Benefits and Limitations of Postmortem Kerstin Aschenbroich, MD*, Institute of Forensic Medicine, 98
Multislice Computed Tomography as Buehlstrasse 20, Bern, 3012, SWITZERLAND; Steffen G.
Adjunct to the Perinatal and Pediatric Ross, MD, Institute of Forensic Medicine, Center of
Autopsy Forensic Imaging “Virtopsy”, Buehlstrasse 20, Bern, 3012,
SWITZERLAND; Michael Thali, MD, MBA, University of
Bern, Institute of Forensic Medicine, Buehlstrasse 20, Bern,
3012, SWITZERLAND; and Harald Bonell, MD, Institute of
Diagnostic Radiology, Inselspital Bern, Bern, 3010,
SWITZERLAND
Multidetector Computed Tomographic Theodore Harcke, MD, Craig T. Mallak, JD, MD, and 99
(MDCT) Autopsy in Suicide by Gunshot to Terrill Top, MD*, Armed Forces Institute of Pathology,
the Head 1413 Research Boulevard, Rockville, MD 21771
Classification of Asphyxia: The Need for Anny Sauvageau, MD*, Office of the Chief Medical 99
Standardization Examiner, 7007, 116 Street, Edmonton, AB T6H 5R8,
CANADA
Discrimination of Falls and Blows in Blunt Anny Sauvageau, MD*, Office of the Chief Medical, 100
Head Trauma: A Multi-Criteria Approach Examiner, 7007, 116 Street, Edmonton, AB T6H 5R8,
CANADA
Glioblastoma – Cause of Sudden Death on Jerónimo F.S. Silva*, National Institute of Legal Medicine - 100
an Apparently Healthy Woman Portugal, Bairro de Santa Justa, 10, Coimbra, 3000-356,
PORTUGAL
Stab Wounds, Incised Wounds, or Blunt João S. Pinheiro, MS*, Rosario L. Silva, MD, and Claudia 101
Trauma With Single or Multiple Weapons Marques, MD, Institute Nacional Medicina Legal,
– How to Read Soft Tissue and Bone Delegação do Centro, Largo da Sé Nova, Coimbra, 3000,
Injuries PORTUGAL; José Elísio P.A. de Campos e Sousa, MD,
Largo da Sé Nova, Coimbra, 3000-213 COIMBRA,
PORTUGAL; and Francisco C. Real, PhD, Institute
Nacional Medicina Legal, Delegação do Centro, Largo da
Sé Nova, Coimbra, 3000, PORTUGAL
Index 23
Sudden Infant Death Syndrome and Infant Djordje M. Alempijevic, PhD*, Faculty of Medicine 101
Mortality in Serbia University of Belgrade, Institute of Forensic Medicine, 31a
Deligradska Street, Belgrade, 11000, SERBIA AND
MONTENEGRO; Ana Milenkovic, and Nikola Vukelic,
Faculty of Medicine University of Belgrade, 8 Drive
Subotica Street, Belgrade, 11000, SERBIA AND
MONTENEGRO; and Dragan S. Jecmenica, PhD, Snezana
Pavlekic, PhD, Aleksandra V. Nedeljkov, MD, and Branimir
V. Aleksandric, PhD, Institute of Forensic Medicine,
Faculty of Medicine, University of Belgrade, 31a
MONTENEGRO
Fatty Versus Fibrofatty Involvement of the Lise A.M. Matzke, MSc*, and William M. Elliott, PhD, 101
Myocardium in Sudden Death and Heart UBC-James Hogg iCAPTURE, University of British
Failure Columbia/Providence Health Care, Saint Paul’s Hospital
Room 166, 1081 Burrard Street, Vancouver, V6H 1P9,
CANADA; Crystal Leung, BMLSc, James Hogg iCapture
Centre for Cardiovascular and Pulmonary Research, Saint
Paul’s Hospital, Room 166 1081 Burrard Street,
Vancouver, V6Z 1Y6, CANADA; Carol Lee, MD, 2165
Fraserview Drive, Vancouver, V5P 2N2, CANADA; Charles
Lee, MD, Vancouver General Hospital, Department of
Forensic Pathology, 855 West 12th Avenue, Room 1352,
Vancouver, BC V5Z 1M9, CANADA; Bruce M. McManus,
PhD, James Hogg iCAPTURE Centre, Saint Paul’s
Hospital, 1081 Burrard Street, Vancouver, V6H 1P9,
CANADA; and Michael Allard, MD, James Hogg iCapture
Centre for Cardiovascular and Pulmonary Research, 1081
Burrard Street, Vancouver, BC V6Z 1Y6, CANADA
A Homicide Due to an Atypical Margherita Neri, PhD*, Santina Cantatore, Gabriela 102
Asphyxiation Tool: A Rolling Pin Perilli, MD, and Irene Riezzo, MD, Department of Forensic
Pathology, University of Foggia, viale degli Aviatori, 1,
Use of Volatile Organic Compounds and John W. McIlroy, BS*, Michigan State University, 103
Chemometric Procedures to Determine Chemistry Building, East Lansing, MI 48824; and Ruth
Postmortem Interval Waddell Smith, PhD, Michigan State University, School of
Criminal Justice, 560 Baker Hall, East Lansing, MI 48824
Comparison of Drug-Related Deaths in Lucile B. Tennant, JD*, Marc A. Krouse, MD, and Nizam 103
Tarrant County, Texas, With Law Peerwani, MD, Tarrant County Medical Examiner’s Office,
Enforcement Seizures of Illicit Substances 200 Feliks Gwozdz Place, Fort Worth, TX 76104-4919
Over a Similar Time Frame
Nocturnal Oviposition of Blow Flies Jaime S. Prevolsek, BSc*, and Gail S. Anderson, PhD, 104
(Diptera: Calliphoridae) in the Lower Simon Fraser University, School of Criminology, 8888
Mainland of British Columbia, Canada University Drive, Burnaby, BC V5A 1S6, CANADA
Index 24
Blood Aspiration as a Vital Sign Detected Laura Filograna, MD*, and Steffen G. Ross, MD, Institute 104
by CT Imaging and Postmortem CT of Forensic Medicine Center of Forensic Imaging
Guided Biopsy “Virtopsy”, Buehlstrasse 20, Berne, AL 3012,
SWITZERLAND; Stephan Bolliger, MD, and Tanja
Germerott, MD, University of Berne Institute of Forensic
Medicine, Buehlstrasse 20, Bern, AL 3012,
SWITZERLAND; Patricia M. Flach, MD, Institute of
Forensic Medicine Bern / Virtopsy, Buehlstrasse 20, Bern,
SWITZERLAND; and Michael Thali, MD, University of
3012, SWITZERLAND
Brain Tissue Responses After Traumatic Kazuhiko Kibayashi, MD*, Ken-ichiro Nakao, MS, and Ryo 105
Brain Injury in Animal Models Shimada, PhD, Department of Legal Medicine, School of
Medicine, Tokyo Women’s Medical University, 8-1
Kawada-cho, Shinjuku-ku, Tokyo, 162- 8666, JAPAN
Determination of Procalcitonin, C-Reactive Cristian Palmiere, MD*, Bettina Schrag, Marc D. 105
Protein, Tumor Necrosis Factor-Alpha, Bollmann, MD, and Patrice Mangin, PhD, Centre
Interleukin-6, and Interleukin-8 Levels in Universitaire, Romand de Medecine Legale, Rue du Bugnon
Serum, Vitreous Humor, and 21, Lausanne, CH-1011, SWITZERLAND
Cerebrospinal Fluid as Markers of Sepsis
Sudden Death Due to Mesothelioma of the Géraldine Maulean, MD*, Alain Tabib, PhD, Daniel 106
Atrio-Ventricular Node Malicier, and Laurent Fanton, PhD, Institut of Legal
Medicine, 12 Avenue Rockefeller, Lyon, 69008, FRANCE
Accidental Drowning Deaths in a Coastal Tanuj Kanchan, MD*, Kasturba Medical College, 107
Region of South India – A Ten Year Study Department of Forensic Medicine, Light House Hill Road,
Sudden Death From Atypical Pneumonia in Sabina Di Donato, MD*, Ospedale San Carlo - U.O. 107
a Healthy Adolescent Medicina Legale, Via Potito Petrone, s.n.c., Potenza,
85100, ITALY; Margherita Neri, PhD, Department Forensic
Pathology, University of Foggia, Viale degli Aviatori 1,
Foggia, 71100, ITALY; and Rocco A. Maglietta, MD,
C.R.O.B. - Rionero in Vulture (Pz), via Padre Pio, 1,
Rionero in Vulture (Pz), 85100, ITALY
Virtopsy Project - Postmortem Needle Laura Filograna, MD*, Institute of Forensic Medicine, 108
Biopsy of the Lungs: A Feasible Tool for Centre of Forensic Imaging and Virtopsy, Buehlstrasse, 20,
the Study of Fat Embolism as Vital Berne, SWITZERLAND; Stephan Bolliger, MD, University
Reaction of Berne Institute of Forensic Medicine, Buehlstrasse 20,
Bern, AL 3012, SWITZERLAND; Danny Spendlove, MD,
Institute of Forensic Medicine, Centre of Forensic Imaging
and Virtopsy, Buehlstrasse, 20, Berne, AL 3012,
SWITZERLAND; and Ulrich Preiss, MD, and Michael
Thali, MD, University of Bern, Institute of Forensic
Medicine, Buehlstrasse 20, Bern, 3012, SWITZERLAND
Cerebral Artery Thrombosis After Renaud Clement, MD*, 1 Rue Gaston Veil, Nantes, 44093, 108
Penetrating Oral Trauma: An Exceptional FRANCE
Autopsy Case
Does Embalming Impact Vitreous Glucose Stephany Fiore, MD*, County of Sacramento, Coroner’s 109
Levels? Office, 4800 Broadway, Suite 100, Sacramento, CA 95820-
1530; and Charlotte A. Wacker, MS*, University of
California, Davis Body Donation Program, 4800
Broadway, Suite 100, Sacramento, CA 95820
Index 25
Analysis of an Unusual Misfire of a Janaki Warushahennadi, MD*, King County Medical 109
Common Handgun Examiner’s Office, 325 9th Avenue, HMC Box 359792,
Seattle, WA 98104; Brian J. Smelser, BS, Washington State
Patrol Crime Laboratory, Washington State Patrol, 2203
Airport Way South, Building A Suite 250, Seattle, WA
98134; Richard T. Wyant, MS, Washington State Patrol
CLD, 2203 Airport Way, South, Suite 250, Seattle, WA
98134; and Timothy L. Williams, MD, King County Medical
Examiner’s Office, 325 - 9th Avenue, Box 359792, Seattle,
WA 98104-2499
Fatal Cardiac Perforation During Alessandro Bonsignore, MD*, Massimo Gallo, MD, 109
Percutaneous Treatment in Iliac Artery Francesco Ventura, PhD, and Francesco De Stefano, MD,
Occlusion Department of Legal and Forensic Medicine, University of
Genova, Via De Toni 12, Genova, 16132, ITALY
Swiss Virtobot (Virtual Autopsy) Steffen G. Ross, MD, Institute of Forensic Medicine Center 110
Documentation and Analysis: Work Flow of forensic imaging “Virtopsy”, Buehlstrasse 20, Bern, AE
and Procedure 3012, SWITZERLAND; Lars Ebert, University Bern, IRM,
Buehlstrasse 20, Bern, AE 3012, SWITZERLAND; Silvio
Näther, Institute of Forensic Medicine, Centre of Forensic
Imaging, Bühlstrasse 20, Bern, 3012, SWITZERLAND; and
Stephan Bolliger, MD, and Michael Thali, MD*, University
of Bern, Institute of Forensic Medicine, Buehlstrasse 20,
Mortuary Management in the Aftermath of Jodie J. Leditschke, PhD*, Victorian Institute of Forensic 110
the 2009 Australian Bush Fires Medicine, 57- 83 Kavanagh Street, Southbank, Melbourne,
3006, AUSTRALIA
A Uniform Protocol to Address the Rapidly Marzena H. Mulawka, MFS*, Forensic Sciences Program, 111
Accumulating Unidentified Human National University, 11255 North Torrey Pines Road, La
Remains and Missing Persons in the United Jolla, CA 92037-1011; Ismail M. Sebetan, MD, PhD, 12752
States — A Nation’s Silent Mass Disaster Via Nieve, San Diego, CA 92130; and Paul Stein, PhD,
25757 Bellemore Drive, Ramona, CA 92065
Request for Uniform Autopsy Protocols on Gerald N. Nance, BA*, National Center for Missing and 112
Certain Drowning Victims Exploied Children (NCMEC), 699 Prince Street,
Alexandria, VA 22314
MAPS: How a Statewide Pharmaceutical Shawn A. Silver*, Sparrow Forensic Pathology, 1215 East 112
Database Improves Death Investigation Michigan Avenue, Lansing, MI 48909; Joyce L. deJong,
DO, Sparrow Health Systems, Forensic Pathology, 1322
East Michigan Avenue, Suite 118, Lansing, MI 48909; and
Philip R. Croft, MD, Michael A. Markey, MD, and Michelle
P. Elieff, MD, Sparrow Forensic Pathology, 1215 East
Michigan Avenue, Lansing, MI 48909
Death Investigation and Organ and Tissue Alane Olson, MD*, Clark County Coroner’s Office, 1704 113
Donation in Clark County, Nevada Pinto Lane, Las Vegas, NV 89106
Fatal Sexual Violence Database for Sharon R. Crowley, MN*, FCNS, 122 Emeline Avenue, 113
Postmortem Genital Examinations With Santa Cruz, CA 95060
Colposcopy
Grant Solicitations: New Opportunities for Marcella F. Fierro, MD*, Fierro Forensics, 8702 114
Medical Examiners and Coroners – Tips on Berwickshire Drive, Henrico, VA 23229-7833
the Process
Index 26
Development of Standard Operating Jeffery K. Tomberlin, PhD*, Department of Entomology, 114
Procedures for Conducting Arthropod TAMU 2475, College Station, TX 77843-2475; and Jason
Succession Studies: Improving Postmortem H. Byrd, PhD*, Maples Center for Forensic Medicine,
Estimates Through Ecology University of Florida, 4800 Southwest 35th Drive,
Gainesville, FL 32608
Using Biolog EcoPlatesTM as an M. Eric Benbow, PhD*, University of Dayton, Department 115
Economical Approach to Determining of Biology, 300 College Park, Dayton, OH 45469-2320;
Postmortem Body Dump Sites Through Jeffery K. Tomberlin, PhD, Department of Entomology,
Microbial Community Level Physiological TAMU 2475, College Station, TX 77843- 2475; Tawni L.
Profiling Crippen, PhD, Southern Plains Agricultural Research
Center, Agricultural Research Service, U.S. Department of
Agriculture, College Station, TX 77845; Andrew Lewis, BS,
University of Dayton, Department of Biology, 300 College
Park, Dayton, OH 45469-2320; and Jennifer Pechal, MS,
TAMU 2475, Texas A&M University, College Station, TX
77843-2475
Microbes Associated With Decomposing Jeffery K. Tomberlin, PhD*, Department of Entomology, 115
Remains Regulate Insect Colonization TAMU 2475, College Station, TX 77843-2475; M. Eric
Benbow, PhD*, University of Dayton, Department of
Biology, 300 College Park, Dayton, OH 45469- 2320;
Tawni Crippen, PhD, 2881 F&B Road, College Station, TX
77843; Charity Owings, BS, 2475 TAMU, College Station,
TX 77845; Francisco I. Ortiz, BS, 1818 South 2nd Street,
Apartment 62, Waco, TX 76706; and Jill C. Ross, BS, 110
Hillview Avenue, Millersville, PA 17551
Lower Temperature Threshold for Black Leslie A. Holmes, BS*, and Sherah L. Van Laerhoven, PhD, 116
Soldier Fly (Diptera: Stratiomyidae) Egg University of Windsor, Department of Biology, 401 Sunset
and Adult Eclosion Avenue, Room 119 Bio, Windsor, ON N9B 3P4, CANADA;
and Jeffery K. Tomberlin, PhD, Department of Entomology,
TAMU 2475, College Station, TX 77843-2475
Colonization Behavior of Forensically Jennifer Y. Rosati, BSc*, and Sherah L. Van Laerhoven, 116
Important Blow Fly Species: Implications PhD, University of Windsor, Department of Biology, 401
for Postmortem Interval Estimations Sunset Avenue, Room 119 Bio, Windsor, ON N9B 3P4,
CANADA
Petechiae in Hanging: A Retrospective Renaud Clement, MD*, 1 Rue Gaston Veil, Nantes, 44093, 117
Study of Contributing Variables FRANCE; and Anny Sauvageau, MD, Office of the Chief
Medical Examiner, 7007 116 Street, Edmonton, AB T6H
5R8, CANADA
Fractures of the Neck Structures in Anny Sauvageau, MD*, Office of the Chief Medical 117
Suicidal Hangings: A Retrospective Study Examiner, 7007, 116 Street, Edmonton, AB T6H 5R8,
on Contributing Variables CANADA; and Renaud Clement, MD, 1 Rue Gaston Veil,
Nantes, 44093, FRANCE
Precision of Autopsy Body Length William Oliver, MD, MPA*, Leone Lisa, MA, and Colleen 118
Measurements Tetterton, PA, Brody School of Medicine at East Carolina
University, Division of Forensic Pathology, Department of
Pathology and Laboratory Medicine, 7S-10 Brody Medical
Sciences Building, Greenville, NC 27858
“Goodness Gracious Great Balls of Fire”: William S. Smock, MD*, University of Louisville Hospital, 119
Genital Thermal Injuries From Airbag Department of Emergency Medicine, 530 South Jackson
Exhaust Street, Louisville, KY 40202
Index 27
Histologic Diagnosis of Amniotic Fluid Philip R. Croft, MD, Sparrow Forensic Pathology, 1215 119
Embolism: Providing Context Through East Michigan Avenue, Lansing, MI 48909-7980; Michael
Immunohistochemistry A. Markey, MD*, Sparrow Forensic Services, Sparrow
Hospital, 1215 East Michigan Avenue, Lansing, MI 48912;
Joyce L. deJong, DO, Sparrow Health Systems, Forensic
Pathology, 1322 East Michigan Avenue, Suite 118, Lansing,
MI 48909; and Michelle P. Elieff, MD, Sparrow Forensic
Pathology, 1215 East Michigan Avenue, Lansing, MI 48909
Utility of Large Bowel Examination in Michael R. Condron, MD*, and Mary L. Anzalone, MD, 120
Medicolegal Death Investigation Harris County Medical Examiner, 1885 Old Spanish Trail,
Houston, Texas 77054; and Dwayne A. Wolf, MD, PhD,
Harris County Medical Examiner, JAJ Forensic Center,
1885 Old Spanish Trail, Houston, TX 77054
Detection of KCNQ1 Genetic Variations by Audrey Farrugia, MD*, Christine Keyser, PhD, and 120
High Resolution Melting Analysis for the Bertrand Ludes, MD, PhD, Institut de Medecine Legale, 11
Diagnosis of Channelopathies in rue Humann, Strasbourg Cedex, 67085, FRANCE
Postmortem Investigations
Cardioinhibitory Reflex Cardiac Arrest – Bettina Schrag*, Rue du Bugnon 21, Lausanne, 121
Myth or Reality?: A Systematic Review SWITZERLAND
From Cases
Differentiation of Bullet Type Based on Ruth N. Udey, BS*, Michigan State University, 209 121
Analysis of Gunshot Residue Using Biochemistry, East Lansing, MI 48824; Brian C. Hunter,
Inductively Coupled Plasma Mass MD, 630 South Saginaw Street, Flint, MI 48502; and Ruth
Spectrometry Waddell Smith, PhD, Michigan State University, School of
Vehicular Emissions Systems and Their Mark E. Goodson, PE*, 1500 Spencer Road, Denton, TX 122
Effects on Suicides and Attempted Suicides 76205-5105
by Carbon Monoxide
Pseudostrangulation Thomas W. Young, MD*, Heartland Forensic Pathology, 123
LLC, 12717 Oakmont Drive, Kansas City, MO 64145
Investigation and Autopsy Procedures in Mary G. Ripple, MD*, David R. Fowler, MD, and Ling Li, 123
Cases Involving Conducted Energy Devices MD, Office of the Chief Medical Examiner, State of
(CEDs) in the State of Maryland Maryland, 111 Penn Street, Baltimore, MD 21201
Postmortem CT-Angiography Using Silke Grabherr*, Centre Universitaire Romand de Médecine 124
Angiofil® Légale, Rue du Bugnon 21, Lausanne, 1011,
Bugnon 46, Lausanne, , SWITZERLAND; Alexandre
Dominguez, Haute Ecole Cantonale Vaudoise de la Santé,
Filière Technique en Radiologie Médicale, Avenue du
Beaument 21, Lausanne, , SWITZERLAND; Richard
Dirnhofer, and Beat Steger, Fumedica AG, Luzernerstrasse
91, Muri, 5630, SWITZERLAND; Barbara Sollberger, and
Erich Gygax, Department for Cardiovascular Surgery,
University Hospital Bern, Hochschulstrasse 4, Bern, 3012,
SWITZERLAND; Reto Meuli, Service de Radiodiagnostic et
de Radiologie Interventionnelle, Rue du Bugnon 46,
Lausanne, 1011, SWITZERLAND; and Patrice Mangin,
MD, PhD, Centre Universitaire, Romand de Medecine
Legale, Rue du Bugnon 21, Lausanne, CH-1011,
SWITZERLAND
Index 28
Radiological Interpretation of Postmortem Francesco Doenz*, Service de Radiodiagnostic et de 124
CT-Angiography Radiologie Interventionnelle, Rue du Bugnon 46, Lausanne,
SWITZERLAND; Alexendre Dominguez, Haute Ecole
Cantonale Vaudoise de la Santé, Avenue de Beaument 21,
Lausanne, SWITZERLAND; Richard Dirnhofer, and Beat
SWITZERLAND; Erich Gygax, and Barbara Sollberger,
Department for Cardiovascular Surgery, University
Hospital Bern, Hochschulstrasse 4, Bern, SWITZERLAND;
Reto Meuli, Service de Radiodiagnostic et de Radiologie
Interventionnelle, Rue du Bugnon 46, Lausanne, 1011,
SWITZERLAND; and Patrice Mangin, PhD, and Silke
Grabherr, Centre Universitaire Romand de Médecine
Légale, Rue du Bugnon 21, Lausanne, 1011,
SWITZERLAND
Perfusion Technique for Postmortem CT- Erich Gygax*, and Barbara Sollberger, Department for 125
Angiography Cardiovascular Surgery, University Hospital Bern,
Hochschulstrasse 4, Bern, SWITZERLAND; Alexandre
Dominguz, Haute Ecole Cantonale Vaudoise de la Santé,
Avenue de Beaument 21, Lausanne, SWITZERLAND;
Richard Dirnhofer, and Beat Steger, Fumedica AG,
Luzernerstrasse 91, Muri, SWITZERLAND; Francesco
Doenz, and Reto Meuli, Service de Radiodiagnostic et de
Radiologie Interventionnelle, Rue du Bugnon 46, Lausanne,
1011, SWITZERLAND; and Patrice Mangin, PhD, and Silke
SWITZERLAND
The Role of Microscopic Postmortem Study Lars Uhrenholt, PhD*, Institute of Forensic Medicine, 126
in Explaining Traffic-Crash Related Neck Department of Forensic Medicine, University of Aarhus,
Injury: A Case Review Brendstrupgaardsvej 100, Aarhus N, 8200, DENMARK;
and Michael Freeman, PhD, 205 Liberty Street, Northeast,
Suite B, Salem, OR 97301
Lethal Consequences Arising From the William J. Bonner, BA*, 1100 South Broad Street, Unit 127
Rupture of an Undetected Large Ductus 402B, Philadelphia, PA 19146; and Fredric N. Hellman,
Arteriosus Aneurysm During a T-12 MD, Office of the Medical Examiner, Fair Acres, Route 352,
Kyphoplasty Procedure Lima, PA 19037
Exploring the Potential for Nocturnal Timothy E. Huntington, PhD*, Concordia University 127
Colonization of Fresh Cadavers by Carrion Nebraska, 800 North Columbia Avenue, Seward, NE 68434;
Flies in the Central United States and Leon G. Higley, PhD, University of Nebraska, 706
Hardin Hall, Lincoln, NE 68583-0987
Suicide by Extraordinarily Numerous Dollett T. White, MD*, and Leszek Chrostowski, MD, 128
Blade Wounds Hillsborough County Medical Examiner Department, 11025
North 46th Street, Tampa, FL 33617
A DNA Database for Species Identification Trevor I. Stamper, PhD*, 3516 State Route 222, Batavia, 128
of Forensically Important Flesh Flies OH 45103- 9708; Alice E. Timm, PhD, Department of
(Diptera: Sarcophagidae) in the Biological Sciences, University of Cincinnati, Cincinnati,
Continental United States OH 45221-006; Gregory A. Dahlem, PhD, Department of
Biological Sciences, Northern Kentucky University,
Highland Heights, KY 41099; and Ronald W. DeBry, PhD,
Department of Biological Sciences, University of
Cincinnati, Cincinnati, OH 45221-0006
Index 29
NMR and Bioinformatic Studies on the Joshua R. McMillen, BS*, 4715 Garden Ranch Drive, 129
Metabolic Effects of Acetaminophen in Apartment 308, Colorado Springs, CO 80918
Rat’s and Human’s in Urine: A
Metabonomic Approach
A Cold Case: A Forensic Review Nine Luigi Saravo, PhD, Reparto Carabinieri Investigazioni 129
Years After the Crime Scientifiche, Viale Tor di Quinto 151, Roma, 00190, ITALY;
Gennaro Aprea, PhD, Università degli Studi di Napoli
“Federico II”, Complesso Monte Sant’Angelo, Via Cinthia,
Napoli, 80126, ITALY; and Paola A. Magni, MS*, F.E.LAB
ASL TO1, c/o Civico Obitorio di Torino, Via Bertani 112/A,
Torino, 10137, ITALY
Dead Men in Wells: How Forensic Science Paola A. Magni, MS*, F.E.LAB ASL TO1, c/o Civico 129
Was Used to Solve a Crime in an Aquatic Obitorio di Torino, Via Bertani 112/A, Torino, 10137,
Environment ITALY; and Mario A. Apostol, PhD, SC Medicina Legale
ASL TO4, Via C. Bertetti 10A, Torre Canavese (TO), 10100,
ITALY
Fatal Rescue Burns Tanuj Kanchan, MD*, Manipal University, Department of 130
Forensic Medicine, Kasturba Medical College, Light House
Hill Road, Mangalore, 575001, INDIA
Sports Tool as a Weapon of Assault: A B. Suresh K. Shetty, MD*, Kasturba Medical College, Light 130
Case Report House Hill Road, Mangalore, 575001, INDIA
Unusual Case of Blunt Chest Trauma Javier Serrano, MD*, Puerto Rico Institute of Forensic 131
Without Rib Fractures Leading to a Major Sciences, Calle Maga Esquina Casia #9, Urb. Reparto
Pulmonary Laceration Metropol, San Juan, PR 00921; and Carlos F. Chavez-
Arias, MD, Puerto Rico Institute of Forensic Sciences, PO
Box 11878, Caparra Heights Station, San Juan, PR 00922-
1878
Postmortem Analysis of Vitamin D Using Geza Bodor, PhD, Denver VA Medical Center, 1055 131
Liquid Chromatography Tandem Mass Clermont Street, Denver, CO 80220; John Carver, JD, City
Spectroscopy and County of Denver, 660 Bannock Street, Denver, CO
80204; and Amy Martin, MD, and Michael A. Burson,
PhD*, City and County of Denver, Office of the Medical
An Unusual Case of Homicide by Knife, Sabina Di Donato, MD*, Ospedale San Carlo - U.O. 132
Screwdriver, and a Kitchen Fork Medicina Legale, Via Potito Petrone, s.n.c., Potenza,
85100, ITALY; Aldo Di Fazio, Section of legal medicine -
Matera Hospital, via Montescaglioso n.5, Matera, 75100,
ITALY; and Rocco Maglietta, CROB Rionero in Vulture
(Potenza), via Padre Pio n. 1, Rionero in Vulture (Pz),
85028, ITALY
Love and a Bullet: Autoerotic Accident or Kelly L. Rose, MD*, and Kim A. Collins, MD, Fulton 132
Intentional Suicide? County Medical Examiner’s Office, 430 Pryor Street
Southwest, Atlanta, GA 30312
Laryngeal and Hyoid Bone Trauma Carlos F. Chavez-Arias, MD*, Puerto Rico Institute of 133
Resulting From Forces Other Than Forensic Sciences, PO Box 11878, Caparra Heights Station,
Compression of the Neck San Juan, PR 00922- 1878; Dario Sanabria, MD, Puerto
Rico Institute of Forensic Sciences, Department of
Pathology, PO Box 11878, Caparra Heights Station, San
Juan, PR 00922-1878; and Javier Serrano, MD, Puerto
Rico Institute of Forensic Sciences, Calle Maga Esquina
Casia #9, Urb. Reparto Metropol, San Juan, PR 00921
Index 30
The Evolving Distribution of Cause and Sharon M. Derrick, PhD*, Harris County Medical 134
Manner of Death in HIV Positive Medical Examiner’s Office, Harris County Medical Examiner’s
Legal Cases: Links Between ART and Office, 1885 Old Spanish Trail, Houston, TX 77054
Traditional Categories of Chronic Disease
Death in a Wine Vat Romano La Harpe, MD*, Sandra E. Burkhardt, MD, and 134
Kebede Shiferaw, MD, Institut de Medecine Legale, 9 Av de
Champel (CMU), Geneva, 1206, SWITZERLAND
Nailing the Diagnosis: Features of Fatal Hilary S. McElligott, MD*, Cook County Office of the 135
Injury Inflicted By Unusual Projectiles and Medical Examiner, 2121 West Harrison Street, Chicago, IL
Firearms 60612-3705
Please, Don’t Get Angry! Two Fatal Cases Stefano D. Errico, MD*, Benedetta Di Battista, MD, 135
of Emotional Stress-Related Death in Left Carmela Fiore, MD, and Cristoforo Pomara, MD, PhD,
Ventricular Apical Ballooning Syndrome Department of Forensic Pathology, University of Foggia,
(Tako Tsubo Cardiomyopathy) Viale degli Aviatori 1, Foggia, 71100, ITALY
A Case of Anaphylactoid Syndrome of Jennifer L. Shuttlesworth, MD*, Ana E. Lopez, MD, and 136
Pregnancy Luis A. Sanchez, MD, Harris County Medical Examiner’s
Office, 1885 Old Spanish Trail, Houston, TX 77054
Pheochromocytoma Causing Unexpected Jacqueline L. Parai, MD*, Ontario Forensic Pathology 137
Death – Two Unusual Presentations Services, Division of Anatomical Pathology, The Ottawa
Hospital, 501 Smyth Road, Box 117 4th Floor, Ottawa, ON
K1H 8L6, CANADA; and Iris Teo, MD, Itrat Ahmed, MD,
and Christopher M. Milroy, MD, The Ottawa Hospital, 501
Smyth Road, Box 117 4th Floor, Ottawa, ON K1H 8L6,
CANADA
Digital UV/IR Photography for Tattoo William Oliver, MD, MPA*, and Leone Lisa, MA, Brody 137
Evaluation in Mummified Remains School of Medicine at East Carolina University,
Department of Pathology and Laboratory Medicine,
Division of Forensic Pathology, 7S-10 Brody Medical
Undiagnosed, Untreated Acute Pauline Saint-Martin, MD*, and Patrick O Byrne, MD, 138
Promyelocytic Leukemia Presenting as Service de Medecine Legale, CHRU Tours, Tours, 37000,
Suspicious Sudden Death FRANCE; Jean Michel Gaulier, PhD, Service de
Pharmacologie et Toxicologie, CHRU Dupuytren, 2 avenue
Martin Luther King, Limoges, 87042, FRANCE; and Sophie
Martin Dupont, MD, Agnès Peyclit, MD, and François
Paraf, PhD, Service de Medecine Legale, CHRU
Dupuytren, 2 Avenue Martin Luther King, LIMOGES,
87042, FRANCE
Death of a Bodybuilder: A Case Report of Wendy M. Gunther, MD*, Office of the Chief Medical 139
Mixed Drug Overdose With Lethal Examiner, Tidewater District, 830 Southampton Avenue,
Gamma- Hydroxybutyrate Level Suite 100, Norfolk, VA 23510-1046
Hara-Kiri or Homicide? Wendy M. Gunther, MD*, Office of the Chief Medical 139
Examiner, Tidewater District, 830 Southampton Avenue,
Suite 100, Norfolk, VA 23510-1046
Two Cases of Novel Influenza A (H1N1) Abraham T. Philip, MD*, Onondaga County Medical 140
Virus (“Swine Flu”) Infection: Clinical Examiner’s Office, 100 Elizabeth Blackwell Street,
Presentations, Autopsy Protocol With Syracuse, NY 13210; Kerry Whiting, BS, and Sanjay
Findings, and Review of Literature Mukhopadhyay, MD, State University of New York - Upstate
Medical University, 766 Irving Avenue, Syracuse, NY
13210; and Robert Stoppacher, MD, Onondaga County
Medical Examiner’s Office, 100 Elizabeth Blackwell Street,
Syracuse, NY 13210
Index 31
An Unusual Case of “Piggyback” Geoffrey P. Smith, MD, Kelly L. Rose, MD*, and Randy L. 141
Sandwiched Projectiles Caused by a Hanzlick, MD, Fulton County Medical Exam Center, 430
Round- Nose Bullet Shot Through a Door Pryor Street, Southwest, Atlanta, GA 30312
Newborn Kidnapping by Crude Cesarean Todd M. Luckasevic, DO*, Laine L. Frazier, BS, Abdulrezak 141
Section M. Shakir, MD, Baiyang Xu, MD, and Karl E. Williams,
MD, MPH, Allegheny County Medical Examiner’s Office,
1520 Penn Avenue, Pittsburgh, PA 15222
An Unusual Case of Accidental Poisoning: Cristian Palmiere, MD*, Christophe Brunel, MD, Frank 141
Fatal Methadone Inhalation Sporkert, MD, and Patrice Mangin, MD, PhD, Centre
Fatalities Occurring With Ingestion of James R. Gill, MD*, Office of Chief Medical Examiner, 520 142
Ibogaine First Avenue, New York, NY 10016; and Kenneth R. Alper,
MD, New York University School of Medicine, 403 East
34th street, 4th Floor EPC, New York, NY 10016
Acetaminophen Induced Death of a Fetus Jeffrey K. Racette, MD*, Todd M. Luckasevic, DO, Baiyang 143
With Maternal Survival: An Unusual Case Xu, MD, Abdulrezak M. Shakir, MD, and Karl E. Williams,
of a Suicide Attempt Resulting in Fetal MD, MPH, Allegheny County Medical Examiner’s Office,
Death 1520 Penn Avenue, Pittsburgh, PA 15222
Index 32
2009
Exertional Collapse in a Youth With Elise F. Arbefeville, MD*, and Vernard I. Adams, MD, 144
Hemoglobin SE Hillsborough County Medical Examiner Department, 401
South Morgan Street, Tampa, FL 33602
Machinery-Related Occupational Death: Giovanni Cecchetto, MD*, Via Falloppio 50, Padova, 144
The Relevance of Workplace Investigation 35121, ITALY; Guido Viel, MD, and Federica De Lotto,
and Antemortem Radiological Data in MD, University of Padua, Via Falloppio 50, Padova, 35121,
Forensic Reconstruction ITALY; Renzo Manara, MD, Istituto di Neuroradiologia,
Padova, 35121, ITALY; Massimo Montisci, PhD, Via
Falloppio 50, Padova, 35121, ITALY; and Silvano
Zancaner, MD, Sede di Medicina Legale - Università degli
Studi di Padova, Via Falloppio 50, Padova, 35121, ITALY
Impetigo Contagiosa Simulating Non- Fleres Pierangela*, Insitute of Legal Medicine, Via del 145
Accidental Injuries in a Pregnant Woman Vespro, n. 127, Palermo, 90100, ITALY; Farina Graziana,
Using Intravenous Drug MD, Institute of Legal Medicine of Palermo, Via del Vespro,
n. 129, Palermo, 90100, ITALY; Antonina Argo, via
Narbone n. 13, Palermo, , ITALY; Paola Pugnetti,
of Legal Medicine, Via del Vespro, n. 129, Palermo, 90127,
ITALY; Paolo Procaccianti, Palermo University, Via del
Vespro, n. 127, Palermo, 90100, ITALY; and Emiliano
Maresi, Via del Vespro, n. 127, Palermo, 90100, ITALY
HPLC Analysis of Benzocaine in “Green Harminder S. Bhawara, PhD*, fsl, S/O Shri A.S. Bhawara, 145
Products” Shanti Nagar, Near Ram Mandir, Raipur (C.G), INDIA
Child Deaths Due to Television Falls With Evan Matshes, MD, c/o Dr. Amy Gruszecki, Southwestern 146
Injury Patterns That Mimic Child Abuse Institute, of Forensic Sciences, 5230 Medical Center Drive,
Dallas, TX 75235; Reade A. Quinton, MD, University of
Texas Southwestern, Department of Pathology, 5323 Harry
Hines Boulevard, Dallas, TX 75390; and Amy C. Gruszecki,
DO, and Jeremy Deisch, MD*, Southwestern Institute, of
Forensic Sciences, 5230 Medical Center Drive, Dallas, TX
Application of Forensic Engineering for the Daniele Gibelli, MD*, Istituto di Medicina Legale e delle 146
Reconstruction of Manner of Death: A Assicurazioni di Milano, V. Mangiagalli, 37, Milan, ITALY;
Nautical Accident Angela Cantatore, BE, and Remo Sala, BE, Politecnico di
Milano, P.zza Leonardo da Vinci, Milan, ITALY; and
Salvatore Andreola, MD, and Cristina Cattaneo, PhD,
Istituto di Medicina Legale e delle Assicurazioni di Milano,
V. Mangiagalli, 37, Milan, ITALY
Homicide, Suicide, and the Missing William C. Rodriguez III, PhD*, Armed Forces Medical 147
Mother: The Mysterious and Tragic Deaths Examiner, 1413 Research Boulevard, Building 102,
of a Latino Family Rockville, MD 20850; and Carroll Allen, Donna Vicente,
and David R. Fowler, MD, Office of the Chief Medical
Sudden Death in Epilepsy: A Review of 51 Rudy J. Castellani, MD*, University of Maryland, 148
Consecutive Cases Department of Pathology, 22 South Greene Street
Baltimore, MD 21201; Heather F. Grothous, BS, Michigan
State University College of Osteopathic Medicine, A306
East Fee Hall, East Lansing, MI 48824; Philip R. Croft,
MD, 1215 East Michigan Avenue, Lansing, MI 48909-7980;
Michael A. Markey, MD, Sparrow Forensic Services,
Sparrow Hospital, 1215 East Michigan Ave, Lansing, MI
48909-7980; and Joyce L. de Jong, DO, Sparrow Forensic
Index 33
Spontaneous Coronary Artery Dissection – Dario Sanabria, MD*, Puerto Rico Institute of Forensic 148
An Isolated Eosinophilic Vasculitis?: Sciences, Department of Pathology, PO Box 11878,
Report of Two Sudden Death Cases Caparra Heights Station, San Juan, 00922-1878; Carlos F.
Chavez-Arias, MD, Puerto Rico Institute of Forensic
Sciences, PO Box 11878, Caparra Heights Station, San
Juan, 00922-1878; Lee M. Tormos, MD, Instituto de
Ciencias Forenses, PO Box 11878, Caparra Heights
Station, San Juan, 00926; and Jose Rodriguez-Orengo,
PhD, Puerto Rico Institute of Forensic Sciences, PO Box
11878, San Juan, 00922-1878
Fibromuscular Dysplasia of Pulmonary Stefania Zerbo, MD*, and Rosa Liotta, MD, Institute of 149
Arteries: Report of Two Cases Legal Medicine, Via del Vespro, 127, Palermo, 90100,
ITALY; Antonina Argo, PhD, Via Narbone n.13, Palermo,
ITALY; Cettina Sortino, Via del Vespro, 129, Palermo,
ITALY; Antonino Bonifacio, MD, Institute of Legal
Medicine, Via del Vespro, n. 127, Palermo, 90100, ITALY;
Eugenia Di Stefano, Via Raffaello n.9, Palermo, ITALY; and
Emiliano Maresi, PhD, Via del Vespro, 127, Palermo,
90100, ITALY
Sudden Death From Arteritis Involving a Marc A. Krouse, MD*, Tarrant County Medical Examiner, 149
Surgically Repaired Coronary Artery - 200 Feliks Gwozdz Place, Fort Worth, TX 76104-4919
Right Atrium Fistula
Ephemeral Petechial-Like Spots in a Victim Russell T. Alexander, MD*, and David R. Fowler, MD, 150
of a House Fire Office of the Chief Medical Examiner, 111 Penn Street,
Baltimore, MD 21201
Forensic Identification of Microbial Joshua K. Stone, BS*, and Raleigh W. Parrott, MS, Federal 150
Mixtures Via ESI-TOF Mass Spectrometry Bureau of Investigation, CFSRU, 2501 Investigation
Parkway, Quantico, VA 22135; Jason D. Bannan, PhD, and
Bruce Budowle, PhD, Federal Bureau of Investigation
Laboratory, 2501 Investigation Parkway, Quantico, VA;
and James M. Robertson, PhD, and Brian A. Eckenrode,
PhD, Federal Bureau of Investigation, CFSRU, Federal
Bureau of Investigation Academy, Building 12, Quantico,
VA 22135
Environmental Scanning Electron Paolo Fais, MD*,and Giovanni Cecchetto, MD, Via 151
Microscopy and Other Techniques in Falloppio 50, Padova, ITALY; Guido Viel, MD, University
Cutting Crime Investigation: Case Report of Padua, Via Falloppio 50, PADOVA, 0 35121, ITALY;
and Review of the Literature Attilio Cecchetto, PhD, Istituto Anatomia Patologica, Via
Gabelli 61, Padova, 35121, ITALY; Claudio Furlan, MD,
Via Falloppio, Padova, ITALY; and Massimo Montisci,
PhD, Via Falloppio 50, Padova, ITALY
Exploration of Non-Cardiogenic Marrah E. Lachowicz, MFS*, University of California 151
Pulmonary Edema With Chronic Opiate Davis, One Shields Avenue, UCDSOM, Tupper Hall 4112,
Use: Case Studies and Scientific Review Davis, CA 95616-8643
Is Toxicological Analysis Necessary in D. Kimberley Molina, MD*, Bexar County, Medical 152
Postmortem External Examinations? Examiner’s Office, 7337 Louis Pasteur Drive, San Antonio,
TX 78229; and Meredith A. Lann, MD*, UCDHSC, AIP -
Department of Pathology, 12605 East 16th Avenue, Room
3026, Aurora, CO 80045
TASER® Wound Progression in Two Donald M. Dawes, MD*, Lompoc Valley Medical Center, 152
Deployment Modes 518 East Hickory Avenue, Lompoc, CA 93436; and Jeffrey
D. Ho, MD, Hennepin County Medical Center, 701 Park
Avenue South, Department of Emergency Medicine,
Minneapolis, MN 55415
Index 34
Rat Bite Fever: A Fatal Case of Priya Banerjee, MD*, The Johns Hopkins Hospital 153
Streptobacillus moniliformis Infection in a Department of Pathology, 600 North Wolfe Street,
14-Month-Old Boy Carnegie/Pathology 401, Baltimore, MD 21287; and David
R. Fowler, MD, and Zabiullah Ali, MD, Office of the Chief
Contributions From Forensic Imaging to Lars Uhrenholt, PhD, and Lene W. Boel, PhD*, University 153
the Investigation of Fatal Upper Cervical of Aarhus, Institute of Forensic Medicine,
Fractures Brendstrupgaardsvej 100, Aarhus N, 8200, DENMARK
Contributions From Forensic Imaging to Asser H. Thomsen, MD*, Lars Uhrenholt, PhD, and Annie 154
the Investigation of Fatal Upper Cervical Vesterby, MD, DMSc, Institute of Forensic Medicine,
Fractures University of Aarhus, Brendstrupgaardsvej 100, Aarhus N,
DK-8000, DENMARK
An Unsolved Cold Case in Iowa: A Dawnie W. Steadman, PhD*, Binghamton University, 154
Probable Case of Dragging SUNY, Department of Anthropology, Binghamton
University, PO Box 6000, Binghamton, NY 13902-6000;
Dennis Klein, MD, Iowa Department of Public Health, 321
East 12th Street, Des Moines, IA 50319-0075; and Blythe
Bloemendaal, BA, Lyon County Sheriff’s Office, 410 South
Boone, Rock Rapids, IA 51246
An Unusual Death Involving a Sensory Meredith A. Lann, MD*, University of Colorado at Denver 155
Deprivation Tank Health Sciences Center, AIP - Department of Pathology,
12605 East 16th Avenue, Room 3026, Aurora, CO 80045;
and Amy Martin, MD, Denver Office of the Medical
Preliminary Analyses of Carrion JeAnna R. Redd, BS*, University of Central Oklahoma, 100 155
Colonization of Necrophagous Flies North University Drive, Evans Hall 101 (Box 208),
(Diptera: Calliphoridae) in Central Edmond, Oklahoma 73034; and Wayne D. Lord, PhD,
Oklahoma Forensic Science Institute, University of Central Oklahoma,
100 North University Drive, Edmond, OK 73034
Two Fatal Cases of Hidden Pneumonia in Francesco Ventura, MD, and Alessandro Bonsignore, MD*, 156
Young People Department of Forensic Pathology, University of Genova,
Via De Toni, 12, 16132, Genova, 16132, ITALY; Raffaella
Gentile, MD, Department of Clinical Pathology, University
of Genova, Largo Rosanna Benzi, 10, Genova, 16132,
ITALY; and Francesco De Stefano, MD, Department of
Forensic Pathology, University of Genova, Via De Toni, 12,
Methodologies for Heteroplasmy Simona Ricci, MD*, Department of Legal Medicine, Viale 157
Identification Regina Elena 336, Roma, ITALY
Internal Validation of Quantifiler™ DUO María J. Illescas, BS*, Virginia Commonwealth University, 157
DNA Quantification Kit and AmpFℓSTR® 1000 West Cary Sreet,, PO Box 842012, Richmond, VA
Yfiler™ PCR Amplification Kit 23284-2012; Fernando Mercedes, MS*, Institute of
Forensic Science of Puerto Rico, Calle Maga Esq. Casia,
Urb. Reparto Metropolitano, San Juan, PR 00922; Tracey
Dawson Cruz, PhD*, 1000 West Cary Street, PO Box
842012, Virginia Commonwealth Univeristy, Richmond, VA
23284; and Carmen A. Tirado, MS*, Institute of Forensic
Science of Puerto Rico, Calle Maga Esq. Casia, Urb.
Reparto Metropolitano, San Juan, PR 00922
The Effect of Clothing on Scavenger Visits Amanda J. Marshall, BS*, Jennifer R. Simon, BS*, and 158
and Decomposition Phillip L. Watson, PhD*, Ferris State University,
Department of Biology, 2004 ASC, 808 Campus Drive, Big
Rapids, MI 49307
Index 35
Foreign Bodies: Three Cases of Projectile Duarte N.P. Vieira, PhD*, Carlos Abreu, MD, and Cristina 158
Maintenance Without Complications Cordeiro, MSci, Instituto Nacional de Medicina Legal,
Largo da Sé Nova, Coimbra, LB 3000-213, PORTUGAL
The Persistence of an Elevated Brianna F. Anderson*, and Jessica D. Wilkerson, 158
Concentration of Ninhydrin-Reactive University of Nebraska-Lincoln, 202 Entomology Hall, PO
Nitrogen in Grave Soil Box 830816, Lincoln, NE 68583-0816; and David O.
Carter, PhD, University of Nebraska, Lincoln, Department
of Entomology, 202 Plant Industry Building, Lincoln, NE
68583-0816
The Application of DNA Identification Jeff Rodzen, PhD, California Department of Fish and Game 159
Technology to Large Wildlife Carnivore Wildlife Forensic Laboratory, 1701 Nimbus Road, Rancho
Attacks on Humans Cordova, CA 95670; Elizabeth Thompson, BS*, Orange
County Sheriff-Coroner Department, Forensic Science
Services, 320 North Flower Street, Santa Ana, CA 92703;
James D. Banks, BS, and Erin Meredith, MS, California
Department of Fish and Game Wildlife Forensic
Laboratory, 1701 Nimbus Road, Rancho Cordova, CA
95670; Hailu Kinde, DVM, California Animal Health and
Food Safety Laboratory System, 105 Carousel Mall, San
Bernardino, CA 92401; Joseph J. Halka, MD, Orange
Coounty Sheriff-Coroner Department, Forensic Science
Center, 1071 West Santa Ana Boulevard, Santa Ana, CA
92703; and Pennie Laferty, MS, and John M. Hartmann,
MBA, Orange County Sheriff- Coroner Department,
Forensic Science Services, 320 North Flower Street, Santa
Ana, CA 92703
Sudden Unexplained Death Due to Ritesh G. Menezes, MD*, Kasturba Medical College, 159
Disseminated Malaria Mangalore, India, Department of Forensic Medicine, Light
House Hill Road, Mangalore, Karnataka 575001, INDIA
Chloride Levels of Sphenoid Sinus Fluid in Nicole Stalter, MSFS*, Chaminade University, 3140 159
Salt and Fresh Water Drownings on the Waialae Avenue, Forensic Science Department, Honolulu,
Island of Oahu, Hawaii HI 96816; Gayle Suzuki, MD, and Erin Mitsunaga, BA,
Honolulu Medical Examiner, 835 Iwilei Road, Honolulu, HI
96817; and M. Lee Goff, PhD, Forensic Sciences Program,
Chaminade University of Honolulu, 3140 Waialae Avenue,
Honolulu, HI 96816-1578
Recovery of Transplantable Organs After Nathalie Jousset, MD*, Arnaud Gaudin, MD, Damien 160
Cardiac Arrest in France Mauillon, MD, and Clotilde G. Rougé-Maillart, MD, CHU,
Service de Médecine Légale, 4 rue Larrey, Angers, 49000,
FRANCE
Index 36
Veterinary Forensic Science: Jason H. Byrd, PhD*, University of Florida, Department of 160
Documentation, Processing, and Agriculture & Consumer Services, University of Florida,
Interpretation of Physical Evidence at PO Box 147100, Gainesville, FL 32614-7100; Kenneth F.
Scenes of Animal Crimes Cohrn, DDS*, Heritage Dental of Central Florida, 422
Teague Trail, Lady Lake, FL 32159; Jeffery K. Tomberlin,
PhD, Department of Entomology, TAMU 2475, College
Station, TX 77843-2475; David W. Hall, PhD*, David Hall
Consultant, Inc., 3666 NW 13th Place, Gainesville, FL
32605; John J. Schultz, PhD*, University of Central
Florida, Department of Anthropology, PO Box 25000,
Orlando, FL 32816; Melinda Merck, DVM*, ASPCA, 6175
Hickory Flat Highway Suite 110-2, Canton, GA 30115; and
Randall Lockwood, PhD*, ASPCA, 2214 Tulip Drive, Falls
Church, VA 22046; Micah Flores, BSc*, Texas A&M, 2475
TAMU, College Station, TX 77840
Natural Causes of Sudden Unexpected Ling Li, MD*, Office of the Chief Medical Examiner, State 161
Infant Death: A Seven Year Retrospective of Maryland, 111 Penn Street, Baltimore, MD 21201; Lan
Forensic Autopsy Study in Hubei, China Zhou, BM, Department of Forensic Medicine, Tongji
Medical College, Huazhong University of Science and
Technolohy, Wuhan, 430030, PEOPLES REPUBLIC OF
CHINA; Xiang Zhang, MD*, Office of the Chief Medical
Examiner, 111 Penn Street, Baltimore, MD 21201; Liang
Lui, MD, Tongji Medical College, 13 Hong Kon Road,
Wuhan, Hubei 430030, PEOPLES REPUBLIC OF CHINA;
Lin Chang, MD, Key Laboratory of Evidence Science,
China University of Political Science and Law, Beijing, MD
100040, PEOPLES REPUBLIC OF CHINA; Guangzhao
Huang, BM, Department of Forensic Medicine, Tongji
Technology, Wuhan, MD 430030, PEOPLES REPUBLIC
OF CHINA; and David R. Fowler, MD, Office of the Chief
Biomedical Engineering in Root Cause Bruce H. Barkalow, PhD*, William E. Grant, MA, and 161
Analysis – Example: Assessing Infant Farrah J. Curran, BS, B.H. Barkalow, PC, 490 Quarterline
Apnea-Related Deaths St., Newaygo, MI 49337-9125
In Utero Traumatic Head Injuries During a Sean A. Swiatkowski, DO*, 1 Middlebridge Court, Silver 162
Motor Vehicle Collision: Case-Report and Spring, MD 20906; Anna Rubio, MD, Office of the Chief
Review of the Literature Medical Examiner, 111 Penn Sreet, Baltimore, MD 21201;
Michael Johnson, MD, and Juan C. Troncoso, MD, Johns
Hopkins University School of Medicine, 111 Penn Street,
Baltimore, MD 21201; and David R. Fowler, MD, Office of
MD 21201
Return of an Old Acquaintance - A Case of Karen B. Looman, DO*, Hamilton County Coroner’s 162
Septic Abortion Office, 3159 Eden Avenue, Cincinnati, OH 45219
Index 37
Fatal Rupture of Splenic Artery Aneurysm Slobodan Savic, MD, PhD*, School of Medicine, University 163
in a Pregnant Woman With Portal of Belgrade, Institute of Forensic Medicine, Deligradska
Hypertension 31a, Belgrade, 11000, SERBIA AND MONTENEGRO;
Djordje Alempijevic, PhD, Institute of Forensic Medicine,
Faculty of Medicine, 31 A Deligradska St., Belgrade,
11000, SERBIA AND MONTENEGRO; Irina Damjanjuk,
MD, Institute of Forensic Medicine, Belgrade, OR 11000,
SERBIA AND MONTENEGRO; Stojan Petkovic, MD PhD,
Klinicki Centar Vojvodina, Department of Forensic
Medicine, Clinical Center of Vojvodina, Hajduk Veljkova 5-
7, Novi Sad, 21000, SERBIA AND MONTENEGRO; and
Radmila Stevanovic, MD, Institute of Pathology, School of
Medicine, University of Belgrade, 8 Dr Subotica St.,
Belgrade, 11000, SERBIA AND MONTENEGRO
How Often is Pre-Existing Disease Found M.G.F. Gilliland, MD*, Brody School of Medicine at East 163
in Child Deaths? Carolina University, Pathology & Laboratory Medicine,
Brody Building, Greenville, NC 27858-4354
Lymphogenic Cardiomyopathy: A Possible Antonio Bonifacio, MD*, Stefania Zerbo, MD, Cettina 164
Cause of Non-Immune Fetal Hydrops Sortino, Pierangela Fleres, MD, and Emiliano Maresi,
PhD, Department of Biotechnology and Legal Medicine,
Section of Legal Medicine, Via del Vespro, n. 129, Palermo,
90127, ITALY
Prolonged Survival Time Following Lauren E. Moser, MD*, Office of the Chief Medical 165
Duodenal Transection in a Child With Examiner, 111 Penn Street, Baltimore, MD 21201; Mary G.
Abdominal Trauma Ripple, MD, 68 Bluebird Road, Port Deposit, MD 21904;
Role of Scene Reconstruction in the Richard C. Harruff, PhD, and Pamela S. Ulmer, DO*, King 165
Medicolegal Investigation of Sudden County Medical Examiner’s Office, 325 9th Avenue, HMC
Unexpected Infant Deaths Box 359792, Seattle, WA 98104-2499
Death by INR: A Case of Vitamin K O.C. Smith, MD*, Conscience and Science in Medicine, 166
Deficiency Bleeding Masquerading as LLC 9639 Rosemark Road, Atoka, TN 38004; and Jennifer
Shaken Baby Syndrome Griffith, MS, Lani Collins, MS, and Linda Williford, PhD,
The University of Tennessee Clinical Laboratory Sciences,
930 Madison Avenue, Memphis, TN 38163
Index 38
Malicious Use of Nonprescription Cough Jody L. Green, PhD*, Denver Health Rocky Mountain 167
and Cold Medications in Children Poison & Drug Center, 777 Bannock Street, MC 0180,
Denver, CO 80204; William Banner, PhD, Oklahoma
Poison Control Center, 4822 East 112th Street, Tulsa, OK
74137; Randall Bond, MD, Cincinnati Drug & Poison
Information Center, 660 Lincoln Avenue, Cincinnati, OH
45206; Ralph Kauffman, MD, University of Missouri-
Kansas City, Department of Pediatrics, 2919 NW 86th
Terrace, Kansas City, MO 64154; Anthony Manoguerra,
PharmD, University of Californis at San Diego, School of
Pharmacy, 9500 Gilman Drive, MC 0657, La Jolla, CA
92093; Robert B. Palmer, PhD, Toxicology Associates,
2555 South Downing Street, Suite 260, Denver, CO 80210;
Ian M. Paul, MD, Penn State College of Medicine, 500
University Drive, HMC; Pediatrics; H085, Hershey, PA
17033; Barry Rumack, MD, University of Colorado,
Anshutz Medical Campus, Denver, CO 80045; David C.
Winston, PhD, Forensic Science Center, 2825 East District
Street, Tucson, AZ 85714; and Richard C. Dart, PhD,
Denver Health Rocky Mountain Poison & Drug Center, 777
Bannock Street, MC 0180, Denver, CO 80204
Wrongful Convictions and Pediatric Jeffrey R. Manishen, BA*, Ross & McBride LLP, 1 King 167
Forensic Pathology: The Canadian Street West, 10th Floor, PO Box 907, Hamilton,, L8N 3P6,
Experience CANADA
The Possibilities and Limitations of Jan E. Leestma, MD*, 1440 North Kingbury Street, Suite 168
Neuropathology in Exhumation Autopsies 210, Chicago, IL 60622
Pathology/Odontology: The Team John E. Filippi, DDS*, 1325 North 127th Avenue, Omaha, 168
Approach to a Forensic Autopsy NE 68154; and Mary H. Dudley, MD*, Jackson County
Medical Examiner’s Office, 660 East 24th Street, Kansas
City, MO 64108
Making the Best of Death Chantal Ferraro, PhD*, Long Island University, 168
Sociology/Anthropology, CW Post, Brookville, NY 11548;
and O. C. Smith, MD, Conscience and Science in Medicine,
Atoka, TN 38004
Building the Communication/Language for Vincent E. Hill, MD*, Mortuary Medical Services, 3003 169
Collaboration Between the Forensic Van Ness Street, North West, Suite 106, Washington, DC
Pathologist and Funeral 20008
Director/Embalmer
Sickle Cell Trait Associated Deaths: A Case Christopher Wilson, MBBS, Jon R. Thogmartin, MD*, Noel 169
Series With a Spectrum of Clinical A. Palma, MD, and Susan S. Ignacio, MD, Medical
Presentations Examiner’s Office, District 6, 10900 Ulmerton Road, Largo,
FL 33778; Barbara C. Wolf, MD, and Wendy A. Lavezzi,
MD, Office of the Medical Examiner, District 5, 809 Pine
Street, Leesburg, FL 34748; and Mark J. Shuman, MD,
Miami Dade County, Medical Examiner Department,
Number One on Bob Hope Road, Miami, FL 33136
Commotio Cordis: A Forensic Science Ariel Goldschmidt, MD*, Steven T. Hensley, and Mary H. 170
Perspective Dudley, MD, Jackson County Medical Examiner’s Office,
660 East 24th Street, Kansas City, MO 64108
Corpora Amylacea and Sudden Death: A Timothy L. Williams, MD*, and R. Ross Reichard, MD, New 170
Case of Adult Polyglucosan Body Disease Mexico Office of the Medical Investigator, MSC11 6030, 1
Diagnosed at Forensic Autopsy University of New Mexico, Albuquerque, NM 87131-0001
Index 39
Trends in Forensic Investigations Into the Morris Tidball-Binz, MD*, Ute Hofmeister, MA, and Shuala 171
Missing: Observations From the ICRC M. Drawdy, MA, International Committee of the Red Cross,
19 Avenue de la Paix, Geneva, 1202, SWITZERLAND
Evidence-Based, Medical-Legal Sharon R. Crowley, MN*, FCNS, 122 Emeline Avenue, 171
Documentation of the Postmortem Santa Cruz, CA 95060
Anogenital Examination
Postmortem Recognition of Sickle Cell Kathryn H. Haden-Pinneri, MD*, and Sara Nunez-Doyle, 172
Trait MD, Harris County Medical Examiner’s Office, 1885 Old
An Angel Dies on the Needle: Fatality After Abraham T. Philip, MD*, Onondaga County Medical 173
Injection Sclerotherapy for Prolapse Examiner, 100 Elizabeth Blackwell Street, Syracuse, NY
Rectum in a Child 13210; and Jeanna M. Marraffa, PharmD, Upstate New
York Poison Center, 250 Harrison Street, Syracuse, NY
1302
MDMA Neurotoxicity Irene Riezzo, MD, Viale Degli Aviatori, 1, Department of 174
Forensic Pathology, University of Foggia, Foggia, 71100,
ITALY; Vittorio Fineschi, PhD, Chair Forensic Pathology,
University of Foggia, Ospedale Colonnello D’Avanzo,
Foggia, I-71100, ITALY; Carmela Fiore, MD, and Stefano
Derrico, MD, University of Foggia, Department of Forensic
Pathology, Viale Degli Aviatori 1, Foggia, 71100, ITALY;
and Steven B. Karch, MD*, PO Box 5139, Berkeley, CA
94705-0139
Levorphanol, Dextromethorphan, and a Philip Croft, MD*, Sparrow Health Systems, 1215 East 174
Case of (Probable) Mistaken Identity Michigan Avenue, Lansing, MI 48912; Joyce L. de Jong,
DO, Sparrow Forensic Pathology, 1215 East Michigan
Avenue, Lansing, MI 48909; Michael A. Markey, MD,
Sparrow Hospital, Sparrow Forensic Services, 1215 East
Michigan Avenue, Lansing, MI 48909; and Michael Smith,
PhD, Sparrow Health Systems, 1215 East Michigan Avenue,
Lansing, MI 48912
Fentanyl-Related Drug Deaths in Virginia William T. Gormley, PhD*, Office of the Chief Medical 175
(2000-2006) Examiner, 400 East Jackson Street, Richmond, VA 23219;
and Anna Noller, PhD, Virginia Department of Health,
Office of the Chief Medical Examiner, 400 East Jackson
Street, Richmond, VA 23219
Deaths Involving Stress Jeffery J. Gofton, MD, 901 North Stonewall, Oklahoma 175
City, OK 73117- 1218; and Wendy M. Gunther, MD*,
Office of the Chief Medical Examiner, Tidewater District,
830 Southampton Avenue, Suite 100, Norfolk, VA 23510-
1046
Investigation of Acute Oxymorphone Andrew W. Sexton, DO*, 24 Regency Park Drive, Agawam, 176
(Opana® ER) and Ethyl Alcohol MA 01001
Intoxication
Deaths During Police Chases Jeffery J. Gofton, MD*, 901 North Stonewall, Oklahoma 176
City, OK 73117-1218; and Wendy M. Gunther, MD*, Office
of the Chief Medical Examiner, Tidewater District, 830
Southampton Avenue, Suite 100, Norfolk, VA 23510-1046
Variations on a Theme: Inhalant Abuse Abraham T. Philip, MD*, Onondaga County Medical 177
Related Fatalities in Central New York — Examiner’s Office, 100 Elizabeth Blackwell Street,
An 11 Year Review Syracuse, NY 13210
Index 40
A New Framework for Guiding Research M. Eric Benbow, PhD*, University of Dayton, Department 177
in Forensic Entomology: Improving the of Biology, 300 College Park, Dayton, OH 45469-2320; and
Science Relevant to PMI Estimates Jeffery K. Tomberlin, PhD, and Rachel Mohr, MS,
Department of Entomology, Texas A&M University, 2475
The Activity of Calliphora vicina (Diptera: Amanda Fujikawa, BS*, University of Nebraska-Lincoln, 178
Calliphoridae) Can Alter the Morphology 202 Entomology Hall, Lincoln, NE 68583-0816; Larry
and Presumptive Chemistry of High Barksdale, MA, Lincoln Police Department, 575 South 10th
Impact Bloodstains Street, Lincoln, NE 68508; and David O. Carter, PhD,
University of Nebraska-Lincoln, Department of
Entomology, 202 Entomology Hall, Lincoln, NE 68583-
0816
Rehydrating Dried Blow Fly Larvae to Michelle R. Sanford, MS*, Jennifer L. Pechal, MS, and 179
Reclaim Their Usefulness in Forensic Jeffery K. Tomberlin, PhD, 2475 TAMU, Department of
Investigations Entomology, Texas A&M University, College Station, TX
77843
Patterns of Adult Blow Fly Attraction to Rachel M. Mohr, MS*, and Jeffery K. Tomberlin, PhD, 179
Carrion Over Time Department of Entomology, Texas A&M University, 2475
TAMU, College Station, TX 77843-2475
The Effect of Soil Compaction on Pupation Jonathan A. Cammack, BS*, and Peter H. Adler, PhD, 180
Depth of Lucilia sericata in Soil Department of Entomology, Soils, and Plant Sciences,
Clemson University, 114 Long Hall Box 345315, Clemson,
SC 29634; Jeffery K. Tomberlin, PhD, Department of
Entomology, Texas A&M University, TAMU 2475, College
Station, TX 77843-2475; Yuji Arai, PhD, Department of
Entomology, Soils, and Plant Sciences, Clemson University,
270 Poole Agriculture Center, Clemson, SC 29634; and
William C. Bridges Jr., PhD, Department of Applied
Economics and Statistics, Clemson University, 243 Barre
Hall, Clemson, SC 29634
Feeding Patterns of American (Periplaneta Lindsay A. Bright*, 1500 Olympia Way #12, College 180
americana) and German (Blattella Station, TX 77840; and Jeffery K. Tomberlin, PhD, and
germanica) Cockroaches on Pig Skin Roger Gold, PhD, Department of Entomology, TAMU 2475,
College Station, TX 77843-2475
Attraction of Two Forensically Important Adrienne L. Brundage, MS*, Texas A&M University, 2001 181
Fly Species: Chrysomya rufifacies Cobblestone Lane, Bryan, TX 77807; and Jeffery K.
(Macquart) and Cochliomyia macellaria Tomberlin, PhD, Texas A&M University, Department of
(Fabricius) to Inter- and Intraspecific Eggs Entomology, TAMU 2475, College Station, TX 77843-2475
Effects of Resource Age and Sterilization Francisco I. Ortiz, BS*, 1818 South 2nd Street, Apartment 181
on the Attraction of Cochliomyia 62, Waco, TX 76706; and Jeffery K. Tomberlin, PhD,
macellaria (Fabricius) and Chrysomya Department of Entomology, TAMU 2475, College Station,
rufifacies (Macquart) TX 77843-2475
Factors Affecting the Rate of R. Christopher O’Brien, MFS*, Faculty of Science, UOIT, 182
Decomposition of Pig (Sus scrofa) Oshawa, ON L1H 7K4, CANADA; Ian Dadour, PhD,
Carcasses During a Period of Drought in Centre for Forensic Science, University of Western
Southern-Western Australia Australia, 35 Stirling Highway, Nedlands, 6009,
AUSTRALIA; Jan Meyer, PhD, Mailbag M309, 35 Stirling
Highway, Crawley, 6009, AUSTRALIA; and Shari Forbes,
PhD, University of Ontario Institute of Technology, 2000
Simcoe Street North, Oshawa, L1H7K4, CANADA
Index 41
Associative Learning of Cochliomyia Stacy A. Boatright, BS*, 2304 Cornell, College Station, TX 182
macellaria in Response to Larval Resource: 77840; and Jeffery K. Tomberlin, PhD, Department of
Inter- and Intraspecific Resource Entomology, TAMU 2475, College Station, TX 77843-2475
Interaction, and Presence of Inter- and
Intraspecific Larvae on a Resource
Attraction and Repellance of Blow Flies to Melinda K. Dooley*, and Jeffery K. Tomberlin, PhD, 183
Intra- and Interspecific Fecal Bacteria Department of Entomology, TAMU 2475, College Station,
TX 77843-2475; and Adrienne L. Brundage, MS, 2001
Cobblestone Lane, Bryan, TX 77807
Three Dimensional Polygonal Model Jeffrey R. Christiansen, BS*, Halff Associates, 1201 North 184
Visualization of Lucila sericata From SEM Bowser Road, Richardson, TX 75081; and Jeffery K.
and Stereomicroscopic Data Tomberlin, PhD, Department of Entomology, TAMU 2475,
An Unusual Case of Homicidal Chest Carlos F. Chavez-Arias, MD, Puerto Rico Institute of 184
Trauma Using a Golf Club as a Weapon Forensic Sciences, PO Box 11878, Caparra Heights Station,
San Juan, Puerto Rico 00922- 1878; Javier Serrano, MD*,
Puerto Rico Institute of Forensic Sciences, Calle Maga
00921; Dario Sanabria, MD, Puerto Rico Institute of
Forensic Sciences, Department of Pathology, PO Box
11878, Caparra Heights Station, San Juan, Puerto Rico
00922-1878; and Jose F. Rodriguez, PhD, Institute of
Urb. Reparto Metropolitano, San Juan, PR 00922
Non-Chemical Suffocation Deaths in Silvia Tambuscio, MD*, Legal Medicine for the Court of 185
Forensic Setting: A Six Year Retrospective Padova, Via Rezzonico, 24, Padova, LA 35131, ITALY; and
Study of Environmental Suffocation, Anny Sauvageau, MD, Lab de Sciences Judiciaires et de
Smothering, Choking, Traumatic, and Medecine Legale, 1701, Parthenais Street, 12th Floor,
Positional Asphyxia Montreal, Quebec H2K 3S7, CANADA
Death by Electrocution: Unusual Findings Sandra Cornetta, MD*, Sezione di Meidcina Legale - 185
in a “Love Nest” Università di Bari, piazza Giulio Cesare, 11, Bari, 70124,
ITALY; Fiorenza Zotti, PhD, Section of Legal Medicine,
Place G. Cesare, Bari, 70124, ITALY; Roberto Gagliano-
Candela, AS, University of Bari, Cattedra Tossicologia
Forense, Policlinico, Piazza G. Cesare 11, Bari, 70124,
ITALY; Andrea Marzullo, MD, Sezione di Anatomia
Patologica - Università di Bari, piazza Giulio Cesare, n.11,
Bari, 70124, ITALY; and Alessandro D. Erba, Sezione di
Medicina Legale - Università di Bari, piazza Giulio Cesare,
n.11, via Prospero Petroni, n.37, Bari, 70124, ITALY
A Fatal Case Due to a Pitchfork Margherita Neri, PhD*, Santina Cantatore, and Cristoforo 186
Penetrating Head Injury Pomara, PhD, Department of Forensic Pathology
University of Foggia, Viale degli Aviatori 1, Foggia, 71100,
ITALY
Head Injury Associated With Posterior Audrey Farrugia, MD, Annie Geraut, MD*, Bertrand 186
Distraction of the Spine in a 4.5 Months Ludes, MD, PhD, and Jean Sebastien Raul, MD,PhD,
Old Baby: Analysis of the Lesional Medico-Legal Institute, 11 Rue Humann, Strasbourg,
Mechanisms 67065, FRANCE
Genetic Testing of Sudden Cardiac Death Katarzyna Michaud, MD*, Centre Universitaire Romand de 187
Victims: From a Forensic to a Médecine Légale, Rue du Bugnon 21, Lausanne, 1005,
Multidisciplinary Approach SWITZERLAND; and Bernice Elger, PhD, Centre
Universitaire Romand de Médecine Légale, 1211 Genève,
Rue Michel-Servet 1, Genève, SWITZERLAND
Index 42
Unexpected Death of 24-Year-Old Male Stojan Petkovic, PhD*, Department of Forensic Medicine, 187
With a Phenotype Strongly Suggestive of Clinical Center of Vojvodina, Hajduk Veljkova 5-7, Novi
Lujan-Fryns Syndrome Sad, 21000, SERBIA AND MONTENEGRO; Branislav
Budakov, MD PhD, Hajduk Veljkova 3, Novi Sad, 21000
SERBIA AND MONTENEGRO; Slobodan Savic, PhD,
School of Medicine, University of Belgrade, Institute of
Forensic Medicine, Deligradska 31a, Belgrade, 11000,
SERBIA AND MONTENEGRO; and Isidora Samojlik, MD,
Department of Pharmacology and Toxicology, Faculty of
Medicine, Hajduk Veljkova 3, Novi Sad, 21000, SERBIA
AND MONTENEGRO
Fatal Air Embolism During Hemodialysis B.G. Brogdon, MD*, University of South Alabama Medical 188
Center, Department of Radiology, 2451 Fillingim Street,
Mobile, AL 36617; and LeRoy Riddick, MD*, University of
South Alabama Medical Center, Department of Pathology,
2451 Fillingim Street, Mobile, AL 36609
Traffic Accident Deaths? The Importance Duarte N.P. Vieira, PhD*, Instituto Nacional, de Medicina 189
of Autopsy Legal, Coimbra, 3000-213, PORTUGAL; Cristina
Cordeiro, MSci, Instituto Nacional de Medicina Legal,
Largo da Sé Nova, Coimbra, FL, PORTUGAL; and Helena
Garcia, MD, CEDAP, Av. Calouste Gulbenkian, Coimbra,
3000, PORTUGAL
Undiagnosed Preeclampsia-Eclampsia William J. Bonner, BA*, 1100 South Broad Street, Unit 189
Leading to Maternal Death 402B, Philadelphia, PA 19146; John E. Tomaszewski, MD,
Hospital of the University of Pennsylvania, 3400 Spruce
Street, Philadelphia, PA 19104; and Fredric N. Hellman,
MD, Office of the Medical Examiner, Fair Acres, Rte 352,
Lima, PA 19037
Rupture of the Left Ventricle Due to Blunt Francois Paysant, MD*, Chu, Hopital Michallon, BP 217, 189
Trauma - A Pediatric Case Study 38043 Grenoble Cedex 9, Grenoble, FRANCE
Postmortem Examination of Coronary Christopher Tape, MD*, and Patrick E. Lantz, MD, 189
Artery Stents Using a Hand-Held Rotary Department of Pathology, Wake Forest University, SOM,
Tool Medical Center Boulevard, Winston-Salem, NC 27157-1072
Detection of Wild Game DNA in Maggot Jill C. Ross, BS*, and John R. Wallace, PhD, Department of 190
Tissue Biology, Millersville University, Millersville, PA 17551;
and Jane E. Huffman, PhD, Northeast Wildlife DNA
Laboratory, East Stoudsburg University, East Stroudsburg,
PA 18301
Conversion of the Wyoming State Crime Timmy L. Neece, BS, BA*, 1239 9th Street, Apartment 1, 190
Laboratory From FM-BIO Slab Gel Huntington, WV 25701
Technology to the AB 3130 Genetic
Analyzer for CODIS and Casework Sample
Analysis
A Rapid Penta STR Screening Method by Maurice J. Aboud, BSc*, 10720 North West 66th Street, 191
Microchip Capillary Electrophoresis Apartment #113, Miami, FL 33178
How Does Season Affect the Release of Jessica D. Wilkerson*, and Brianna F. Anderson, 191
Ninhydrin - Reactive Nitrogen Into Grave University of Nebraska-Lincoln, 202 Entomology Hall, PO
Soil? Box 830816, Lincoln, NE 68583-0816; and David O.
68583-0816
Index 43
Consumption of Fly Artifacts After Becca Striman*, 1347 North 37th Street, Lincoln, NE 192
Deposition and Translocation of 68503; Amanda Fujikawa, BS, 202 Entomology Hall,
Bloodstains by Calliphora vicina (Diptera: University of Nebraska-Lincoln, Lincoln, NE 68583-0816;
Calliphoridae) Larry Barksdale, MA, Lincoln Police Department, 575
South 10th Street, Lincoln, NE 68508; and David O. Carter,
PhD, University of Nebraska, Lincoln, Department of
Entomology, 202 Plant Industry Building, Lincoln, NE
68583-0816
Decomposition of Child-Sized Remains in Kevin M. Willis, BS*, Washington County Sheriff’s Office, 192
Dumpsters 1535 Colfax Street, Blair, NE 68008
Inadvertent Administration of Lidocaine: Cettina Sortino*, Via del Vespro 129, Palermo, ITALY; 193
Illustration of Two Cases Fleres Pierangela, Insitute of Legal Medicine, Via del
Vespro, n. 127, Palermo, Italia 90100, ITALY; Paola
Pugnetti, Department of Biotechnology and Legal Medicine,
90127, ITALY; Antonino Bonifacio, MD, Institute of Legal
Massimo Grillo, and Valentina Triolo, Department of
Biotechnology and Legal Medicine, Section of Legal
and Paolo Procaccianti, PhD, Palermo University, Via del
Vespro, n. 127, Palermo, 90100, ITALY
Asphyxia by Confinement: The Death of a Cettina Sortino*, Antonino Bonifacio, MD, Sergio Cinque, 194
Man Kidnapped and Segregated in a Small MD, Stefania Zerbo, MD, Livio Milone, PhD, and Paolo
Underground Cistern Proccianti, PhD, Department of Biotechnology and Legal
Medicine, Section of Legal Medicine, Via del Vespro, n.
129, Palermo, 90127, ITALY
50 Years Later: How Insect Evidence is Cettina Sortino*, Antonino Bonifacio, MD, Sergio Cinque, 194
Key in Turning Over a Wrongful MD, Stefania Zerbo, MD, Livio Milone, PhD, and Paolo
Conviction in Canada’s Most Notorious Proccianti, PhD, Department of Biotechnology and Legal
Case – Regina v. Steven Truscott Medicine, Section of Legal Medicine, Via del Vespro, n.
First Insect Succession Study on a Human Jennifer L. Pechal, MS*, Texas A&M University, 2475 195
Cadaver in Texas TAMU, College Station, TX 77843-2475; Adrienne L.
Brundage, MS, 2001 Cobblestone Ln, Bryan, TX 77807;
Elizabeth T. Brandt, BA, 232 Evans Liberal Arts,
Anthropology Dept, 601 University Drive, San Marcos, TX
78666; Connie L. Parks, BS, 8802 Featherhill Road, Austin,
TX 78737; Jeffery K. Tomberlin, PhD, Department of
Entomology, TAMU 2475, College Station, TX 77843-2475;
and Jerry Melbye, PhD, Department of Anthropology, 601
University Drive, ELA 273, Texas State University- San
Marcos, San Marcos, TX 78666-4616
Comparison of Biological Sensors to Detect Glen C. Rains, PhD*, University of Georgia, PO Box 748, 195
Human Remains: Canine Versus Tifton, GA 31793; Ben Alexander, MS, Texas A&M
Hymenopteran University, TAMU 2475, College Station, TX 77843; Jeffery
K. Tomberlin, PhD, Department of Entomology, TAMU
2475, College Station, TX 77843-2475; and Jerry Melbye,
PhD, Department of Anthropology, 601 University Drive,
ELA 273, Texas State University-San Marcos, San Marcos,
TX 78666-4616
Index 44
Generating Development Data for Anne E. Nichols, BS*, West Virginia University, 1367 196
Forensically Important Flies That Are Stewartstown Road, Apartment W-7, Morgantown, WV
Difficult to Rear in the Laboratory 26505; Neal H. Haskell, PhD, 425 Kannal Avenue,
Rensselaer, IN 47978; and Jeffrey D. Wells, PhD, West
Virginia University, Department of Biology, Life Sciences
Building, Room 3135, 53 Campus Drive, PO Box 6057,
Morgantown, WV 26506-6057
Insect Pupal Cases as Decay-Resistant Gregory W. Hodgins, DPhil*, University of Arizona, 196
Reservoirs of Human Soft Tissue Department of Physics, 1118 East Fourth Street, Tucson,
Radiocarbon Content AZ 85721
Reconstruction of Decay Processes of a Heike Klotzbach, PhD*, Institute of Legal Medicine, 197
Dead Child’s Body in a Plastic Garbage Fürstengraben 23, D-07743 Jena, GERMANY
Bag
Unusual Methods of Suicide in Chicago, Michelle A. Jorden, MD*, James A. Filkins, MD, JD, PhD, 197
Illinois, Cook County and Tera A. Jones, MD, Cook County Medical Examiner
Office, 2121 West Harrison Street, Chicago, IL 60612
Mass Fatality Investigation Due to J.C. Upshaw Downs, MD*, and Edmund R. Donoghue, MD, 198
Combustible Dust Related Industrial Regional Medical Examiner, Georgia Bureau Investigation,
Explosion and Fire 925 A Mohawk Street, Savannah, GA 31419-1796
Worker Fatalities by Hydrogen Sulfide Biagio Solarino, PhD*, Sezione di Medicina Legale, 199
Poisoning: Autopsy and Toxicological Università Degli Studi di Bari, P.zza Giulio Cesare, 11,
Findings Bari, 70125, ITALY; Giancarlo Di Vella, PhD, Sezione di
Medicina Legale, DIMIMP, University of Bari, Policlinico,
Piazza G. Cesare, Bari, 70121, ITALY; Lucia Tattoli, MD,
Sezione di Medicina Legale, University of Bari, Bari, ,
ITALY; Claudia Liuzzi, MD, Sezione di Medicina Legale,
Università Degli Studi di Bari, Bari, 70100, ITALY;
Giuseppe Strisciullo, BES, University of Bari, Policlinico,
Piazza G. Cesare,11, Bari, 70124, ITALY; and Roberto
Gagliano-Candela, PhD, University of Bari, Cattedra
Tossicologia Forense, Policlinico, Piazza G. Cesare 11,
Bari, 70124, ITALY
Suicide by Hanging in Harris County, Sara Nunez-Doyle, MD*, and Sharon M. Derrick, PhD, 199
Texas Harris County Medical Examiner’s Office, 1885 Old
Death in a Tanker Truck Christopher B. Rogers, MD*, Los Angeles County, Medical 200
CA 90033; John Kades, BA, Los Angeles County,
Department of Coroner, 1104 North Mission Road, Los
Angeles, CA 90033; and Lakshmanan Sathyavagiswaran,
MD, Los Angeles County, Medical Examiner’s Office, 1104
North Mission Road, Los Angeles, CA 90033
Agonal Sequences in Eight Filmed Anny Sauvageau, MD*, Lab de Sciences Judiciaires, et de 200
Hangings: Analysis of Respiratory and Medecine Legale, 1701, Parthenais St, 12th Fl, Montreal,
Movement Responses to Asphyxia by QE H2K 3S7, CANADA; Romano La Harpe, MD, Institut de
Hanging Medecine Legale, 9 Av de Champel (CMU), Geneva, 1206,
SWITZERLAND; and Vernon J. Geberth, MS, MPS, P.H.I.
Investigative Consultant Inc., PO Box 197, Garnerville, NY
10923
Index 45
Dead Victim Identification: Age Henrik Druid, PhD*, Department of Forensic Medicine, 201
Determination by Analysis of Bomb-Pulse Karolinska Institutet, Retzius v. 3, Stockholm, SE-171 77,
Radiocarbon in Tooth Enamel SWEDEN; Kanar Alkass, BSc, Department of Forensic
Medicine, Retzius v 3, 171 77, Stockholm, SWEDEN; Kirsty
Spalding, PhD, Department of Cell and Molecular Biology,
Medical Nobel Institute, Karolinska Institutet, Stockholm,
SWEDEN; and Bruce Buchholz, PhD, Lawrence livermore
National Laboratory, 7000 East Avenue, Livermore, CA
94550
Postmortem Injury Detection in an David M. DeLonga, PhD*, Naval Medical Center 201
Aviation Mishap: Computed Tomography Portsmouth, 6513 Harbour Pointe Drive, Suffolk, VA
Imaging Versus Autopsy 23435; Angela D. Levy, MD, United States Army,
Department of Radiology and Radiological Sciences,
Uniform Services University of the Health Sciences, 4301
Jones Bridge Road, Bethesda, MD 20814; and Howard T.
Harcke, MD, Department of Radiologic Pathology, Armed
Forces Institute of Pathology, 3205 Coachman Road,
Wilmington, DE 19803
Usefulness of Systematic Histological Geoffroy Lorin de la Grandmaison, PhD*, AP-HP, Philippe 202
Examination in Routine Forensic Autopsy Charlier, PhD, AP-HP, and Michel Durigon, PhD, AP-HP,
104 Boulevard Raymond Poincaré, Raymond Poincaré
Hospital, Garches, F-92380, FRANCE
Radiology Students and Morgues: A Nancy S. Adams, BS*, 202 Milford Street, #155, Tupelo, MS 202
Mutually Beneficial Relationship 38801
CT Autopsy Imaging in the State Medical Kyle Shaw, MBBS*, David R. Fowler, MD, Zabiullah Ali, 203
Examiner Setting: Logistic Issues, MD, and Jack M. Titus, MD, Office of the Chief Medical
Techniques, and Findings Examiner, 111 Penn Street, Baltimore, MD 21201; Mary G.
Barry Daly, MD, Radiology Department, University of
Maryland Medical Center, 22 South Greene Street,
Baltimore, MD 21201; and Clint W. Sliker, MD, University
of Maryland Medical Center, Diagnostic Imaging
Department, 22 South Greene Street, Baltimore, MD 21201
Intersecting Fractures of the Skull and Guido Viel, MD*, University of Padua, Via Falloppio 50, 203
Gunshot Wounds: Case Report and Padova, 35121, ITALY; Axel Gehl, MD, Department of
Literature Review Forensic Pathology - Institute of Le, Hamburg, GERMANY;
Giovanni Cecchetto, MD, University of Padua, Via
Falloppio 50, Padova, 35121, ITALY; Massimo Montisci,
PhD, University of Padua, Via Falloppio 50, Padova,
35121, ITALY; and Jan P. Sperhake, MD, Department of
Forensic Pathology - Institute of Le, Hamburg, GERMANY
Sudden Cardiac Death Due to Atrophy and Massimo Grillo*, Department of Biotechnology and Legal 204
Fibrous and/or Fatty Substitution of Right Medicine – Section of Legal Medicine, Via del Vespro, n.
Ventricle: Pathologic Substrates and 129, Palermo, 90127, ITALY; Pierangela Fleres, MD, and
Postmortem High Resolution MRI Cettina Sortino, Via del Vespro, n. 129, Palermo, , ITALY;
Antonino Bonifacio, MD, Institute of Legal Medicine, Via
del Vespro, n. 129, Palermo, 90127, ITALY; Livio Milone,
PhD, Via del Vespro, n. 129, Palermo, 90127, ITALY;
Paolo Procaccianti, PhD, Palermo University, Via del
Maresi, PhD, Via del Vespro, n. 129, Palermo, 90127,
ITALY
Index 46
Autopulse® Associated Injuries Kathryn H. Haden-Pinneri, MD*, Harris County Medical 204
Examiner’s Office, 1885 Old Spanish Trail, Houston, TX
77054; Dwayne A. Wolf, MD, PhD, Harris County Medical
Examiner’s Office, JAJ Forensic Center, 1885 Old Spanish
Trail, Houston, TX 77054; and Jennifer C. Love, PhD, and
Roger A. Mitchell, Jr., MD, Harris County Medical
77054
Migration of a Bullet in the Lumbosacral Audrey Farrugia, MD*, Bertrand Ludes, PhD, Annie 205
Spinal Canal: A Case Report and Review of Geraut, MD, and Jean Sebastien Raul, PhD, Medicolegal
the Literature Institute, 11 Rue Humann, Strasbourg, 67065, FRANCE
Homicide-Suicide in Tours France: 2000- Pauline Saint-Martin, MD*, and Patrick O. Byrne, MD, 205
2007 Service de Medecine Legale, Hopital Trousseau, Centre
Hospitalier Régional Universitaire de Tours, Tours, 37000,
FRANCE
Sudden Deaths Associated With Sexual Albert Y. Chu, MD*, Sharon M. Derrick, PhD, and Luis A. 206
Activity Sanchez, MD, Harris County Medical Examiner’s Office,
Sex Killer: Sexually Related Trauma and Gilles Tournel, PhD*, IML de Lille, 1, Place de Verdun, 206
Deaths - Forensic Aspects Faculté de Médecine, Lille, 59045, FRANCE; and Valery
Hedouin, PhD, Cédric Houssaye, MD, Frédéric Grimopont,
Antoine Stelandre, Anne Becart, PhD, Viviane Gnemmi,
Sandrine Depret, MD, IML de Lille, Lille, 59045, FRANCE;
and Didier Gosset, PhD, IML de Lille, Faculte de Medecine,
Lille, 59045, FRANCE
Conducted Electrical Weapons — A Donald M. Dawes, MD*, Lompoc Valley Medical Center, 207
Review of the Medical Literature 518 East Hickory Avevue Lompoc, CA 93436; and Jeffrey
D. Ho, MD*, Hennepin County Medical Center, 701 Park
Avemue South, Department of Emergency Medicine,
Index 47
2008
Decapitation Due to Car Accident: Francesco Ausania, MD, Antonio Oliva, MD, PhD*, Fidelia 208
Description of a Case and Review of the Cascini, MD, Massimo Senati, MD, Vincenzo L. Pascali,
Literature MD, PhD, and Francesca Cittadini, PhD, Catholic
University, School of Medicine, Institute of Forensic
Medicine, Largo Francesco Vito 1, Rome, ITALY
Unusual Gunshot Wound Death of a Sex Karen B. Looman, DO*, Tidewater Office of the Chief 208
Offender on the Way to Jail in the World of Medical Examiner, 830 Southampton Avenue, Suite 100,
CSI Norfolk, VA 23510
The Effect of Clothing on Decomposition Phillip L. Watson, PhD*, Ferris State University, 808 209
Rate: A Teaching Model Campus Drive, 2004 ASC, Big Rapids, MI 49307
Improved Estimation of Time Since Death Behnoush Memari, MS*, Kenneth G. Furton, PhD, and 209
With Multiple Protein Markers and Alberto Sabucedo, Florida International University, 11200
Automated Analytical Methods South West 8th Street, Miami, FL 33199
The Effect of Environmental Degradation Matt Buettner, BS*, Kerry Opel, BS, Bruce R. McCord, 210
on DNA With Respect to Time and PhD, International Forensic Research Institute, Department
Conditions of Chemistry, Florida International University 11200 SW
8th St, Miami, FL 33199; and Lee Jantz, PhD, 250 South
Stadium Hall, Knoxville, TN 37996
The Role of Scene Investigation in Jerri McLemore, MD, and Steven Tvrdik, BS*, Iowa Office 210
Uncovering Staged Suicides of the State Medical Examiner, 2250 South Ankeny
Intrauterine Sudden Death: Study of the Emiliano Maresi*, Antonina Argo, Pierangela Fleres, 211
Fetal Morphological Substrates Paolo Procaccianti, and Michele Spicola, Palermo
University, Via del Vespro, n. 127, Palermo, 90100, ITALY
Fatty Acid Methyl Ester Profiling of Christopher Ehrhardt, PhD*, Counterterrorism and 211
Bacterial Spores for Microbial Forensics Forensic Science Research Unit, Federal Bureau of
Investigation Academy, Building 12, Quantico, VA 22135;
Mark Reimers, PhD, Alcon Laboratories, Inc., 6201 South
Freeway, Fort Worth, TX 76134; Mathew Ducote, PhD,
Midwest Research Institute, 1470 Treeland Boulevard South
East, Palm Bay, FL 32909; James Robertson, PhD,
Counterterrorism and Forensic Science Research Unit,
Federal Bureau of Investigation Academy, Building 12,
Quantico, VA 22135; and Jason Bannan, PhD, Federal
Bureau of Investigation, Laboratory Division, 2501
Investigation Parkway, Quantico, VA 22135
Suicidal Intoxication by Copper Sulphate Jerónimo Fonte Santa Silva*, Bairro de Santa Justa, 10, 212
Visceral Leishmaniasis in Turkey: Hüseyin Cakan, PhD*,and Vecdet Oz, PhD, Istanbul 212
Sociocultural Issues in Forensic University, Institute of Forensic Sciences, Adli Tip
Epidemiology Enstitusu, Cerrahpasa Kampusu, PK10, Istanbul, 34303,
TURKEY; Mustafa Aslan, PhD, Istanbul University,
Cerrahpasa Medical Faculty, Tip Fakultesi, Mikrobiyoloji
ABD, Istanbul, 34303, TURKEY; T. Mehmet Karayel, BS,
Ismail Cakir, PhD*, H. Bulent Uner, PhD*, and M. Yasar
Iscan, Ph.D, Istanbul Univ, Istanbul Universitesi, Adli Tip
Enstitusu, Cerrahpasa Kampusu, PK.10, 34303, Istanbul,
34098, TURKEY
Index 48
Child Abuse: Practical Case of Autopsical, Fabrice Dedouit, MD*, and Céline Guilbeau Frugier, MD, 213
Radiological, and Anatomo-Pathological Caroline Capuani, and Annick Sevely, MD, Service de
Studies Neuroradiologie, Hôpital de Purpan, 1 Avenue du
Professeur Jean Poulhès, TSA 50032, Toulouse Cedex 9,
31059, FRANCE; Philippe Otal, PhD, Hervé Rousseau,
PhD, and Francis Joffre, PhD, Service de Radiologie
Générale, Hôpital de Rangueil, 1 Avenue du Professeur
Jean Poulhès, TSA 50032, Toulouse Cedex 9, AL 31059,
FRANCE; Bernadette Delisle, PhD, Service d’anatomie
Pathologique, Hôpital de Rangueil, 1 Avenue du Professeur
Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059,
FRANCE; and Daniel Rouge, PhD, and Norbert Telmon,
PhD, Service de Médecine Légale, Hôpital de Rangueil,, 1
Avenue du Professeur Jean Poulhès, TSA 50032, Toulouse
Cedex 9, 31059, FRANCE
Posterior Rib Fractures in Infants Jolene R. Clouse, MD*, and Patrick E. Lantz, MD, Wake 214
Associated With Cardiopulmonary Forest University, School of Medicine, Department of
Resuscitation Pathology, Medical Center Boulevard, Winston-Salem, NC
27157-1072
Role of Preoperative 3D-CT Guido Viel, MD*, and Giovanni Cecchetto, MD, University 215
Reconstruction in Depressed Skull of Padua, Via Falloppio 50, Padova, 35121, ITALY; Renzo
Fractures Treated With Craniectomy: A Manara, MD, Istituto di Neuroradiologia, Padova, ITALY;
Case Report of Forensic Interest and Donata Favretto, PhD, and Massimo Montisci, PhD,
ITALY
Subway Train Related Fatalities in New Peter T. Lin, MD*, and James R. Gill, MD, Office of Chief 216
York City: Accident vs. Suicide Medical Examiner, 520 First Avenue, New York, NY 10016
Cardiovascular Trauma in Motor Vehicle Kelly L. Rose, MD*, and Kim A. Collins, MD, Medical 216
Collisions: A 20 Year Retrospective Study University of South Carolina, Department of Pathology and
and Review of the Literature Laboratory Medicine, 165 Ashley Avenue, Suite 309, PO
Box 250908, Charleston, SC 29425
Right Ventricular Lipomatosis and Fibrous Carol Kaluen Lee, MD*, New Mexico Office of the Medical 217
Tissue in Cases of Non-Cardiac Deaths and Investigator, MSC11 6030, 1 University of New Mexico,
Arrhythmogenic Right Ventricular Albuquerque, NM 87131-0001; Charles Lee, MD,
Cardiomyopathy Vancouver General Hospital, Department of Forensic
Pathology, 855 West 12th Avenue, Room 1352, Vancouver,
BC V5Z 1M9, CANADA; and Michael Allard, MD, James
Hogg iCapture Centre for Cardiovascular and Pulmonary
Research, Room 387, St. Paul’s Hospital, 1081 Burrard
Street, Vancouver, BC V6Z 1Y6, CANADA
Index 49
Sodium Channelopathies Linked to Sudden Antonio Oliva, MD, PhD*, Catholic University, Italy, Largo 217
Cardiac Death (SCD) - What is the Francesco Vito 1, Rome, 00168, ITALY; Preben
Meaning of Carrying a Genetic Mutation? Bjerregaard, MD, St Louis University Hospital, Cardiology
Department, 3635 Vista Avenue, St. Louis, MO 63110; Kui
Hong, MD, PhD, Nanchang University, Jiangxi Province,
235 Nanjing East Road, Jiangxi; Steven Evans, MD, Beth
Israel Medical Center, Cardiology Division, First Avenue at
16th Street, New York, NY 10001; Kevin Vernooy, MD,
PhD, Academic Hospital, Maastricht, Department of
Cardiology, Maastricht, NETHERLANDS; Jorge
McCormack, MD, Pediatric Cardiology Associates, Tampa,
FL; Josep Brugada, MD, PhD, Hospital Clinic Barcelona,
Arrhythmia Unit, Villaroel 32, Barcelona, SPAIN; Pedro
Brugada, MD, PhD, Free University of Brussels,
Department of Cardiology, Brussel, BELGIUM; Vincenzo
L. Pascali, MD, PhD, Catholic University, Institute of
Forensic Medicine, Largo f. Vito 1, Rome, ITALY; and
Ramon Brugada, MD, Montreal Heart Institute, Montreal,
CANADA
SCN5A Gene Mutation Associated With Antonio Oliva, MD, PhD*, Catholic University, School of 218
Acute Myocardial Infarction Medicine, Institute of Forensic Medicine, Largo Francesco
Vito 1, Rome, ITALY; Dan Hu, MD, PhD, Masonic Medical
Research Laboratory, 2150 Bleecker Street, Utica, NY
13501-1738; Sami Viskin, MD, PhD, Department of
Cardiology, Tel- Aviv Sourasky Medical Center, 6
Weizmann Street, Utica, ISREAL; and Jonathan M.
Cordeiro, PhD, Tabitha Carrier, BS, Hector Barajas-
Martinez, PhD, Yuesheng Wu, MS, Elena Burashnikov, BS,
Serge Sicouri, MD, and Ramon Brugada, MD, Masonic
Medical Research Laboratory, 2150 Bleecker Street, Utica,
NY 13501-1738; and Rafael Rosso, MD, Sackler School of
Medicine, Tel-Aviv University, 6 Weizmann Street, Tel Aviv,
ISREAL; and Alejandra Guerchicoff, PhD, Guido D.
Pollevick, PhD, and Charles Antzelevitch, PhD, Masonic
NY13501-1738
Arrhythmogenic Right Ventricular Juan A. Merayo-Rodriguez, MD*, Frank Braza, and Jeffrey 218
Dysplasia/Cardiomyopathy a Not So West, Danbury Hospital, 24 Hospital Avenue, 2 Tower Lab,
Infrequent Cause of Sudden Death - A Danbury, CT
Danbury Hospital Five Year Experience
(June 2002 - June 2007)
Sudden Cardiac Death in Professional Laurent Fanton, MD*, Alain Tabib, MD, Stéphane Tilhet- 218
Sports Persons: Natural vs. Anabolic Coartet, MD, Maire Joly, and Daniel Malivier, MD, Institut
Steroid Induced Lesions and Experimental of Legal Medicine, 12 Avenue Rockefeller, Lyon, 69008,
Rabbit Model FRANCE
Cocaine Induced Intracerebral Daniel G.K. Phillips, MD*, University of Maryland, 219
Hemorrhage in a Patient With Cerebral Baltimore, Department of Pathology, 22 South Greene
Amyloid Angiopathy: A New Risk Factor Street, Baltimore, MD 21201; Joyce L. deJong, DO, and
for Stroke in Cocaine Users Michael A. Markey, MD, Sparrow Forensic Services,
Sparrow Hospital, 1215 East Michigan Avenue, Lansing,
MI 48909-7980; and Rudy J. Castellani, MD, University of
Maryland, Department of Pathology, 22 South Greene
Index 50
Can Immunohistochemical Stains Aid to Antonina Argo*, Rosa Liotta, Emiliano Maresi, Stefania 219
Rule Out Pitfalls in Suffocation Deaths? Zerbo, Rosaria Vitale, Pierangela Fleres, and Paolo
Procaccianti, Via del Vespro, n. 127, Palermo, 90100,
ITALY
Alcohol Related Accidental Drowning in Shane Chittenden, DO*, Anna Noller, PhD, and Marnie 220
Virginia: An Epidemiological Review Wood, MD*, Office Chief Medical Examiner, 400 East
Jackson Street, Richmond, VA 23219
Cytomegalovirus Enteritis With Profuse Benjamin J. Havard, MD*, Kelly L. Rose, MD, and Kim A. 220
Gastrointestinal Bleeding Diagnosed at Collins, MD, Medical University of South Carolina,
Autopsy: A Case Report and Review of the Department of Pathology and Laboratory Medicine, 165
Literature Ashley Avenue, Suite 309, PO Box 250908, Charleston, SC
29425
Ethyl Chloride Toxicity in a Case of Valerie S. Green, MD*, Stephen K Wilson, MD, Terry J. 220
Unsuspecting Abuse Danielson, PhD, Ashraf Mozayani, PhD, and Luis A.
Sanchez, MD, Harris County, Medical Examiner’s Office,
Motorcycle Fatalities in the State of Erin G. Brooks, MD*, University of Vermont, Fletcher Allen 221
Vermont: 1995-2005 Health Care, Department of Pathology, 111 Colchester
Avenue, Burlington, VT 05401- 1473; and Steven L.
Shapiro, MD, and Brittany N. Philbin, BS*, Vermont Office
of the Chief Medical Examiner, 111 Colchester Avenue,
Baird 1, Burlington, VT 05401
Progressive Isolated Hypoglossal Nerve Emiliano Maresi*, Antonina Argo, Massimo Grillo, 222
Palsy and Sudden Asphyxial Death Valentina Murgo, Filippo M. Cascino, and Paolo
Procaccianti, Palermo University, Via del Vespro, n. 127,
Medico-Legal Importance of Posttraumatic Vladimir Zivkovic, MD, MSc, Djordje Alempijevic, MD, 222
Hypopituitarism PhD, Slobodan Savic, MD, PhD*, Ivanka Baralic, Dragan
Jecmenica, MD, PhD, and Branimir Aleksandric, University
of Belgrade, School of Medicine Institute of Forensic
Sciences, Faculty of Medicine, 31a Deligradska Street,
Belgrade, 11000, SERBIA AND MONTENEGRO; and Vera
Popovic, PhD, Institute of Endocrinology, Clinical Centre
of Serbia, Dr. Subotic Street 13, Belgrade, , SERBIA AND
MONTENEGRO
Massive Fat Pulmonary Embolization Jose A. Garza-Leal, MD*, Alberto Montemayor-Martinez, 222
Secondary to a Liposuction Procedure MD*, and Magadalena Gomez*, Medfor-Lab S.A. DE C.V.,
With Tumescent Technique Diagnosed Cholula 106, Colonia Mitras Centro, Monterrey, 64460,
Postmortem in an Embalmed and Buried MEXICO
Body
Lethal Inhalation of Isomers of Butylene: A Giovanni Cecchetto, MD*, and Guido Viel, MD, University 223
Case Report of Padua, Via Falloppio 50, Padova, 35121, ITALY; and
Attilio Cecchetto, PhD, Istituto Anatomia Patologica, Via
Gabelli 61, Padova, 35121, ITALY; Claudio Terranova,
University of Padova, Section of Legal Medicine, via
Falloppio n.50, Padova, 35121, ITALY; and Massimo
Montisci, PhD, and Santo Davide Ferrara, PhD, University
of Padua, Section of Legal Medicine and Forensic
Toxicology, Via Falloppio 50, Padua, 35121, ITALY
Index 51
Lethal Neglect: A Case of Extreme Biagio Solarino, MD*, University of Bari, Sezione di 223
Intrafamilial Child Torture Medicina Legale, Piazza Giulio Cesare,11, Bari, 70100,
ITALY; Vito Romano, MD, U.O.C. di Medicina Legale -
Ospedale “Miulli”, Acquaviva delle Fonti, (Bari), 70021,
ITALY; Giuseppe Troccoli, MD, University of Bari,
Department of Criminology and, Forensic Psychiatry,
Largo Giordano Bruno 65, Bari, 70121, ITALY; Ignazio
Grattagliano, PsyD, and Roberto Catanesi, MD, University
of Bari, Section of Forensic Psychiatry, Piazza Giulio
Multiple Histories: A Statistically M.G.F. Gilliland, MD*, Brody School of Medicine at ECU, 224
Significant Indicator of Non-Accidental Pathology & Lab Medicine, Brody Building, Greenville, NC
Injury in Children 27858-4354
Recognizing Classic Metaphyseal Lesions Jennifer C. Love, PhD*, and Luis A. Sanchez, MD, Harris 224
in Child Abuse: An Autopsy Technique County, Medical Examiner’s Office, 1885 Old Spanish
Comprehensive Molecular Genetic Testing Yingying Tang, MD, PhD*, Erik T. Bieschke, MS, Erin 225
for the Cardiac Channelopathy Genes in 42 Labitzke, Jennifer D’Andrea, MSFS, Stacey Sainte-Marie,
Cases of Sudden Infant Death and Sudden MSFS, Dawei Wang, Jean Jeudy, Yoonhee A. Kim,
Unexplained Death in the City of New York Stephanie Pack, Lucy En, Barbara A. Sampson, and
Revealed High Mutation Rate Mechthild K. Prinz, PhD, Office of Chief Medical Examiner,
Department of Forensic Biology, 421 East 26th Street, New
York, NY 10016
Primitive Neuroectodermal Tumor (PNET) Michael J. Caplan, MD, and Kelly Rose, MD*, Medical 225
Masquerading as Non Accidental Head University of South Carolina, Department of Pathology and
Trauma in an Infant: Lessons for Multiple Laboratory Medicine, 165 Ashley Avenue, Suite 309, PO
Disciplines Box 250908, Charleston, SC 29425
Sudden Death of a 17-Year-Old Boy Due to Stojan Petkovic, MD*, Clinical Center Vojvodina, Institute 226
Suspected Williams Syndrome - A Case of Forensic Medicine, Hajduk Veljkova 5, Novi Sad, 21000,
Report SERBIA A ND MONTENEGRO; Slobodan Savic, MD, PhD,
University of Belgrade, School of Medicine, Institute of
SERBIA AND MONTENEGRO; and Milan Simic, MD,
PhD, Clinical Center Vojvodina, Institute of Forensic
AND MONTENEGRO
Sudden Cardiac Death in Professional Laurent Fanton, MD, Alain Tabib, MD, Stéphane Tilhet- 227
Sports Persons: Natural vs. Anabolic Coartet, MD, Maire Joly, and Daniel Malicier, MD*,
Steroid Induced Lesions, and Experimental Institut Medico Legal, 12 Avenue Rockfeller, Lyon, 69007,
Rabbit Model FRANCE
Cocaine Skin Popping: A Fatal Case Margherita Neri, MD*, and Carmela Fiore, MD, University 227
of Foggia, Department of Forensic Pathology, Viale Pinto
1, Foggia, 71100, ITALY
Erroneous Diagnosis of Cadmium Karl E. Williams, MD, MPH*, Office of the Medical 228
Poisoning Based on Postmortem Toxicology Examiner, Allegheny County, 542 Fourth Avenue,
The Continued Role of Over the Counter Anna C. Noller, PhD*, and Marcella F. Fierro, MD, Office 228
Drugs in Drug Related Deaths of the Chief Medical Examiner, 400 East Jackson Street,
Richmond, VA 23219
Index 52
Exceptional Suicide by Sharp Force During Clotilde G. Rougé-Maillart, MD*, and A. Tracqui, MD, 229
Mefloquine Therapy: A Case of Drug Service de Médecine Légale, CHU, 4 rue Larrey, Angers,
Induced Psychosis? 49000, FRANCE; A. Le Bouil, MD, and A. Turcant, MD,
Institut de Médecine Légale, Faculté de Médecine,
Strasbourg, France; and M. Penneau, MD, PhD, Service de
Médecine Légale, CHU, 4 rue Larrey, Angers, 49000,
FRANCE
Determination of β — Phenylethylamine Wen-Ling Lin*, and Kai-Ping Shaw, MD, PhD*, Institute of 229
Blood Levels in Carbon Monoxide Forensic Medicine, Ministry of Justice, 166-1, Sect. 2,
Intoxicated-Related Fatalities Keelung Road, Taipei (106), Taiwan, ROC
The Development of a Model to Assess the Amanda O. Esquivel, MS*, and Cynthia Bir, PhD, Wayne 230
Effects of Conducted Electrical Weapons in State University, 818 West Hancock, Detroit, MI 48201
a Stressful State
Exsanguination Due to Disruption of the Wieslawa Tlomak, MD*, Milwaukee County Medical 230
Left Popliteal Artery and Vein Due to Examiner Office, 933 West Highland Avenue, Milwaukee,
Posterior Dislocation of the Left Knee WI 53233
Prosthesis: A Case Report and Review of
the Literature
What Lies Beneath: An Unusual Kathryn H. Haden-Pinneri, MD*, Jason M. Wiersema, 230
Congenital Anomaly in an Assault Victim PhD, and Jennifer C. Love, PhD, Harris County, Medical
77054-2098
Forensic Pathology of the Rupture of an Maurice G. Rogev, MBChB*, 11/1 Zamenhof Street, Tel 231
Enlarged Spleen Aviv, Jaffo 64373, ISRAEL
Clinical and Pathological Spectrum of Lise A.M. Matzke, MSc*, Michael Allard, MD, and Bruce 231
Fatty Cardiomyopathy in Sudden Cardiac M. McManus, James Hogg iCapture Centre for
Death Cardiovascular and Pulmonary Research, St. Paul’s
Hospital, 1081 Burrard Street, Vancouver, BC V6H 1P9,
CANADA; Carol K. Lee, MD, New Mexico Office of the
Medical Investigator, MSC11 6030, 1 University of New
Mexico, Albuquerque, NM 87131-0001; and Charles Lee,
MD, Vancouver General Hospital, Deptartment of Forensic
BC V5Z 1M9, CANADA
Sudden Death and Fatty Liver Disease Michael E. Archer, MA*, New York Forensics, Inc., 1039 232
Main Street, PO Box 28, Fishkill, NY 12524-0028; and
Dennis J. Chute, MD, and Kari B. Reiber, MD, Office of the
Medical Examiner, Dutchess County Department of Health,
387 Main Street, Poughkeepsie, NY 12601
Hypertensive Heart Disease May Ariel Goldschmidt, MD*, and Jane W. Turner, MD, St. 232
Compound the Risk of Death From Louis City Medical Examiner’s Office, 1300 Clark Street,
Medication and Contrast Media-Induced St. Louis, MO 63103
Anaphylactic Shock
Diffuse Axonal Injury in Medico-Legal Djordje Alempijevic, MD, PhD, Dragan Jecmenica, MD, 233
Practice PhD, Vladimir Zivkovic, MD, Snezana Pavlekic, MD, PhD,
and Slobodan Savic, MD, PhD*, University of Belgrade,
School of Medicine, Institute of Forensic Medicine, 31a
MONTENEGRO
Index 53
Placental Site Trophoblastic Tumor Catia Colecchi, MD, Catholic University, Institute of 233
(PSTT) With Lung Metastases as Cause of Forensic Medicine, Rome, ITALY; Ezio Fulcheri, MD,
Death in a Young Patient: Autopsy University of Genova, Department of Pathology, Genova,
Findings and Medico-Legal Implications ITALY; Sara Partemi, MD, and Fabio De Giorgio MD,
Catholic University, School of Medicine, Institute of
Forensic Medicine, Largo Francesco Vito 1, Rome, ITALY;
Giovan Battista Serra, MD, Catholic University,
Department of Obstetrics and Gynecology, Rome, ITALY;
and Vincenzo L. Pascali, MD, PhD, and Antonio Oliva,
MD, PhD*, Catholic University, School of Medicine,
Institute of Forensic Medicine, Largo Francesco Vito 1,
Rome, ITALY
Identification of Human Body Fluids: Simona Ricci, MD*, Department of Legal Medicine, Viale 234
Comparison Between Two Commercial Regina Elena 336, Rome, ITALY; Fabio Verginelli,
Kits for Detection of Semen Department of Oncology and Neuroscience University
“G.d’Annunzio” and Center of Excellence on Aging
(Ce.S.I.), D.d’Annunzio Foundation, Chieti, ITALY; Andrea
Mele, MD, Department of Legal Medicine University
“Sapienza” Viale Regina Elena 336, Rome, ITALY; and
Manuela Rosini, and Carla Vecchiotti, MD, PhD,
Laboratory Genetic of the Department of Legal Medicine
University “Sapienza”, Viale Regina Elena 336 00161
Rome, ITALY
A Brush With Death: Suicidal Ingestion of Rebecca Irvine, MD*, 808 Shire Street, South West, 235
Toothpaste Albuquerque, NM 87121; and Susan Kunkle, PharmD, New
Mexico Poison and Drug Information Center, MSC11 3060,
1 University of New Mexico, Albuquerque, NM 87131-0001
Toxicological Implications in Heat Related Kimberly McCall-Tackett, BS*, Maricopa County, Forensic 235
Deaths in Phoenix, Arizona: Case Reports Science Center, 701 West Jefferson Street, Phoenix, AZ
From the Office of the Medical Examiner 85050; Ann L. Bucholtz, MD, 6643 East Sweetwater
Avenue, Scottsdale, AZ 85254; Amy L. Lais, BS, Maricopa
County Forensic Science Center, 701 West Jefferson Street,
Phoenix, AZ 85007; and Norman A. Wade, MS, Office of the
Medical Examiner, Forensic Science Center, 701 West
Jefferson Street, Phoenix, AZ 85007
Firearm Deaths by Law Enforcement in James R. Gill, MD, Office of Chief Medical Examiner’s 236
New York City Office, 520 First Avenue, New York, NY 10016; and Melissa
Pasquale-Styles, MD*, New York City, Office of Chief
Medical Examiner’s Office, 599 Winthrop Street, Brooklyn,
NY 11203
Postmortem Genital Examinations With Sharon R. Crowley, RN, MN*, 122 Emeline Avenue, Santa 236
Colposcopy in the Evaluation of Fatal Cruz, CA 95060
Sexual Violence Against Women
The Serial Killer of Elderly Women: Carlo P. Campobasso, MD, PhD*, University of Molise, via 237
Analysis of a Multi-Victim Homicide De Sanctis, snc, Campobasso, 86100, ITALY; and Massimo
Investigation F. Colonna, MD, Felice Carabellese, MD, Ignazio
Grattagliano, PsyD, Chiara Candelli, MD, and Roberto
Catanesi, MD, University of Bari, Section of Forensic
Psychiatry, Piazza Giulio Cesare, Bari, 70124, ITALY
Index 54
One Entrance Wound, Three Bullets, and Todd M. Luckasevic, DO*, Alleghey County, Office of the 237
Four Pulls of the Trigger: An Unusual Case Medical Examiner, 542 Fourth Avenue, Pittsburgh, PA
of a Suicidal Gunshot Wound of the Head 15219; Kenneth Clark, MD, University of Pittsburgh
Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213;
and Abdulrezak M. Shakir, MD, and Karl E. Williams, MD,
MPH, Alleghey County, Office of the Medical Examiner,
Suicidal Shotgun Wound Using a Shotgun Brian S. Linert, BS*, 2102 North Meridian Street, 238
Barrel, a Shotgun Shell, and a BB Apartment 9, Indianapolis, IN 46202; Janis Regnier,
Portage Police Department, Portage, IN ; Barrett W. Doyle,
Porter County Coroner’s Office, Valparaiso, IN; and
Joseph A. Prahlow, MD, South Bend Medical Foundation,
530 North Lafayette Boulevard, South Bend, IN 46601
Characteristics of Suicidal Gunshot Lakshmanan Sathyavagiswaran, MD*, Christopher B. 238
Wounds to the Mouth in Women Rogers, MD, Frances Hicks, and Donald Boger, MD, Los
Angeles County, Medical Examiner’s Office, 1104 North
Mission Road, Los Angeles, CA 90033
Victimization of Children, Adolescents, and Vasilios S. Stoukas*, Telamonos 25, Anthoupoli, Peristeri, 239
Young Adults by Physical and/or Sexual Athens, 12135, GREECE; Angeliki Tsiola, MD, Patras,
Abuse in Northwestern Greece: A Three GREECE; and Anastasia Varvarigou, MD, University of
Year Study Patras, Medical School, GREECE
Aneurysms and Old Lace: A Ruptured Sam Simmons, MD*, and Gregory J. Davis, MD, University 239
Splenic Artery Mycotic Aneurysm of Kentucky, Medical Center, MS 117, 800 Rose Street,
Masquerading as Arsenic Poisoning Lexington, KY 40536-0298
Lymphocytic Hypophysitis Associated With Rudy J. Castellani, MD*, and Luis F. Gonzalez-Cuyar, MD, 240
Sudden Unexpected Death in a Young University of Maryland, Baltimore, Department of
Woman Pathology, 22 South Greene Street, Baltimore, MD 21201;
Fabio Tavora, MD, Johns Hopkins Hospital, 600 North
Wolfe Street, Baltimore, MD 21205 ; Kyle Shaw, MD,
University of Maryland, Baltimore, Department of
Pathology, 22 South Greene Street, Baltimore, MD 21201;
and Joyce L. deJong, DO, Sparrow Forensic Pathology,
1215 East Michigan Avenue, Lansing, MI 48909
Medico-Legal Aspects of Posttraumatic Slobodan Savic, MD, PhD*, School of Medicine, University 240
Gastroduodenal Ulcers of Belgrade, Institute of Forensic Medicine, Deligradska
31a, Belgrade, YT 11000, SERBIA AND MONTENEGRO;
Radmila Stevanovic, MD, MSc, Institute of Pathology,
School of Medicine, University of Belgrade, 8 Dr Subotica
Street, Belgrade, 11000, SERBIA AND MONTENEGRO;
Djordje Alempijevic, MD, PhD, Institute of Forensic
Medicine, 31a Deligradska Street, Belgrade, Serbia 11000,
SERBIA AND MONTENEGRO; and Stojan Petkovic, MD,
MSc, Clinical Center of Vojvodina, Institute of Forensic
Medicine, 5 Hajduk Veljkova Street, Novi Sad, 21000,
SERBIA AND MONTENEGRO
Death Caused by Cardioinhibitory Reflex: Bettina Schrag, MD*, Béat Horisberger, MD, and Patrice 241
Myth or Reality? Mangin, MD, PhD, University Lausanne, Institute of Legal
Medicine, Rue du Bugnon 21, Lausanne, SWITZERLAND
Ehlers-Danlos Syndrome Type IV James L. Caruso, MD*, Armed Forces Medical Examiner 241
(Vascular): An Atypical Presentation and System, U.S. Naval Hospital, Okinawa, Japan, PSC 482 Box
Unexpected Diagnosis in a Medical 2560, FPO, AP 96362
Examiner Setting
Index 55
Mechanisms of Delayed Splenic Rupture: A Sarathchandra Kodikara, MBBS, MD, DLM*, NIL, 242
New Hypothesis Department of Forensic Medicine, Faculty of Medici,
Peradeniya, SRI LANKA; and Murugapillai
Sivasubramanium, MBBS, MD, DLM, Teaching Hospital,
Kegalle, Sri Lanka
Death of a Vampire?: Case of Exhumation William C. Rodriguez III, Ph.D. *, Office of the Armed 243
and Mutilation of a Corpse in Rural Forces Medical Examiners Office, Armed Forces Institute of
Romania Pathology, 1413 Research Blvd. Building 102, Rockville,
MD 20850
Sickle Cell Disease and Sudden Death Michelle A. Jorden, MD*, Jennifer A. McReynolds, PhD, 243
and Adrienne E. Segovia, MD, Cook County Medical
Examiner, 2121 West Harrsion Street, Chicago, IL 60612
The Biochemical Alteration of Soil by Shari L. Forbes, PhD*, University of Ontario Institute of 244
Decomposition Products Technology, 2000 Simcoe Street North, Oshawa, Ontario,
L1H 7K4, CANADA; David O. Carter, PhD, University of
Nebraska, Department of Entomology, 202 Plant Industry
Building, Lincoln, NE 68583-0816; and Laura A.
Benninger, BSc, University of Ontario Institute of
Technology, 2000 Simcoe Street North, Oshawa, Ontario,
L1H 7K4, CANADA
A Cadaver Encased Within Concrete: A Gilles Tournel, MD, PhD*, Anne Becart-Robert, DDS, 244
Case Report Benoît Bourel, PhD, Axelle Balgairies, Cédric Houssaye,
Valéry Hedouin, PhD, and Didier Gosset, MD, PhD, Institut
de Médecine Légale de Lille, 1, place de Verdun, Faculté de
Médecine, Lille, 59045, FRANCE
A Degloving Experiment to Suggest Turhon A. Murad, PhD*, California State University, 245
Postmortem Interval: Give the Department of Anthropology, 400 West First Street, Chico,
Anthropologist Some Hands From CA 95929-0400
Freshwater
Parasitic Wasps: Succession, Development, Sasha C. Voss, BSc*, and Ian Dadour, PhD, Centre for 246
and Forensic Importance as PMI Forensic Science, University of Western Australia, 35
Indicators Stirling Highway, Nedlands, Western Australia 6009,
AUSTRALIA
Difficulties in Determining Sex From the Krista E. Latham, MS, MA*, Temple University, 246
Skull: Considering Conflicting Lines of Anthropology Department, Philadelphia, PA 19122; Carlos
Evidence J. Zambrano, MS, C.A. Pound Human ID Lab, 5231 North
West 56th Court, Gainesville, FL 32653; and Laurel E.
Freas, MA, 3425 South West 2nd Avenue, #246, Gainesville,
FL 32607
Molecular Genetic Testing in 323 Cases of Yingying Tang, MD, PhD*, Erik T. Bieschke,MS, Stacey 247
Fatal Pulmonary Thromboembolism in the Sainte- Marie, MSFS, Jean Jeudy, Yoonhee A. Kim,
City of New York Revealed Racial Stephanie Pack, Barbara A. Sampson, and Mechthild Prinz,
Stratification PhD, Office of Chief Medical Examiner, Department of
10016
The Pathologist’s Role in Preserving Suzanne D. Parisian, MD*, Medical Device Assistance, 247
Implanted Pacemakers and Cardiac Inc., 7117 North 3rd Street, Phoenix, AZ 85020; and Bruce
Defibrillators or How Not to Get Shocked! H. Barkalow, PhD*, and William E. Grant, MA, B.H.
Barkalow, P.C., 490 Quarterline Road, Newaygo, MI
49337-9125
Index 56
Postmortem Angiography in Support of H. Theodore Harcke, MD*, Armed Forces Institute of 248
Radiologic Assisted Autopsy Pathology, 3205 Coachman Road, Wilmington, DE 19803;
and Carol Solomon, MD, and Scott Luzi, MD, Office of the
Chief Medical Examiner, 1413 Research Boulevard,
Building 102, Rockville, MD 20850
CSI Halifax in Miami: The Importance of Tanya R. Peckmann, PhD*, Saint Mary’s University, 248
Practical Courses in the Forensic Sciences Department of Anthropology, McNally South 208, 923
Robie Street, Halifax, Nova Scotia B3H 3C3, CANADA; and
Dr. Bruce A. Hyma, MD, Miami-Dade County Medical
Examiner’s Office, 1 Bob Hope Road, Miami, FL 33136
Can Renal Acute Tubular Necrosis Be Johan A. Duflou, MBChB, MMed*, and Linda Kocovski, 248
Differentiated From Autolysis at Autopsy? BSc, Department of Forensic Medicine, PO Box 90, Glebe,
2037, AUSTRALIA
The Effects of a New Level 1 Trauma Martha J. Burt, MD, District 8, Medical Examiner Office, 249
Center on the Local Medical Examiner 606 South West 3rd Avenue, Gainesville, FL 32601; and
Office Charlotte J. Stevens, BA*, 6417 South West 9th Avenue,
Apartment A, Gainesville, FL 32607
Mapping the Literature in Forensic Anny Sauvageau, MD*, A. Godin, S. Desnoyers, C. Kremer, 250
Pathology and Legal Medicine: A MSc, and S. Racette, BSc, Lab de Sciences Judiciaires, et de
Bibliometric Study of North-American Medecine Legale, 1701, Parthenais Street, 12th Floor,
Journals From 1980 to 2005 Montreal, PQ H2K 3S7, CANADA
Purtscher Retinopathy Detected by Patrick E. Lantz, MD*, Department of Pathology, Wake 250
Postmortem Monocular Indirect Forest University, SOM, Medical Center Boulevard,
Ophthalmoscopy Winston-Salem, NC 27157-1072; Constance A. Stanton,
MD, Department of Pathology,Wake Forest University of
Health Sciences, Medical Center Boulevard, Winston Salem,
NC 27157; and Marshall E. Tyler, Department of
Ophthalmology, Wake Forest University of Health Sciences,
Medical Center Boulevard, Winston Salem, NC 27157
Sudden Death Due to a Cardiac Irene Riezzo, MD*, and Stefano D’Errico, MD, University 251
Sarcoidosis: Histopathological Helping of Foggia, Department of Forensic Pathology, via Luigi
Evidences Pinto, 1, Foggia, 71100, ITALY; and Francesco Ventura,
MD, University of Genova, Department of Forensic
Pathology, Via de’ Toni, 12, Genova, 16132, ITALY
A Diagnosis of Chagas Disease at Autopsy Ana E. Lopez, MD*, Harris County Medical Examiner’s 251
Office, 1885 Old Spanish Trail, Houston, TX 77054; L.
Maximiliam Buja, MD, University of Texas-Houston Health
Science Center, 7000 Fannin, Suite 1715, Houston, TX
77030; and Luis A. Sanchez, MD, Harris County Medical
77054
Dysplasia of the Atrioventricular Nodal Clarissa Krinsky, MD*, 3908 Silver, South East, 252
Artery: A Case Report and Review of the Albuquerque, NM 87108; Sam W. Andrews, MD, Office of
Literature Chief Medical Examiner, 4070 Bowness Road North West,
Calgary, Alberta T3B 3R7, CANADA; and Rebecca Irvine,
MD, 808 Shire Street, South West, Albuquerque, NM 87121
Index 57
Subaortic Aneurysm of the Left Ventricle Pauline Saint-Martin, MD*, Service de Medecine Legale, 252
Complicating Staphylococcal Endocarditis Hopital Trousseau, Centre Hospitalier Regional
Universitaire de Tours, Tours, 37000, FRANCE;
Christopher B. Rogers, MD, and Eugene Carpenter, MD,
Los Angeles County, Medical Examiner’s Office, 1104
North Mission Road, Los Angeles, CA 90033; Michael C.
Fishbein, MD, Department of Pathology and Laboratory
Medicine, David Geffen School of Medicine at University of
California, Los Angeles, CA 90095; and Lakshmanan
CA 90033
A Rare Case of Cardiac Failure Due to Stefano Derrico, MD*, Irene Riezzo, MD, and Cristoforo 253
Hypertensive Crisis in Pheocromocytoma: Pomara, MD, Department of Forensic Pathology,
A Methodological Approach for Diagnosis University of Foggia, via Luigi Pinto, 1, Foggia, Italy
71100, ITALY
Arrhythmogenic Right Ventricular Frank Braza, MD, PhD*, Juan A. Merayo-Rodriguez, MD, 253
Dysplasia (ARVD): A Not So Rare Cause of and Jeffrey West, Danbury Hospital, 24 Hospital Avenue, 2
Sudden Death in Young Adults Tower Lab, Danbury, CT 06810
Cardiac Death in Anabolic Steroid Abuse: Claudio Terranova*,and Massimo Montisci, PhD, 254
A Pathological and Toxicological Study University of Padova, Section of Legal Medicine, via
Falloppio n.50, Padova - Italy, Padova, 35121, ITALY;
Cristina Basso, and Gaetano Thiene, via Gabelli 61,
Padova, 35121, ITALY; and Santo Davide Ferrara, PhD,
University of Padua - Section of Legal Medicine and
Forensic Toxicology, Via Falloppio 50, Padua, 35121,
ITALY
A “Café Coronary” in a 2-Year-Old: Case Jennifer L. Shuttlesworth, MD*, University of Texas 255
Report Medical Branch, 301 University Boulevard, Route 0743,
Galveston, TX 77555; and Stephen M. Pustilnik, MD,
Galveston County Medical Examiner’s Office, 6607
Highway 1764, Texas City, TX 77591
Identification of Twenty Charred Victims Laurent Martrille, MS, MD*, Service de Medecine Legale, 255
of a Helicopter Accident, Africa CHU Lapeyronie, 191 Avenue, du Doyen Gaston Giraud,
Montpellier, CEDEX 5 34295, FRANCE; Charles Georget,
DMD, Stéphane Chapenoire, MD, Jean Paul Tissier, MS,
and Laurent Chartier, PhD, CTGN, IRCGN, 1 Boulevard T
Sueur, Rosny Sous Bois, 93111, FRANCE; Didier Buiret,
MS, SCIJ, 31 av Franklin Roosevelt, Ecully, 69134,
FRANCE; Géréard De Lassus, MS, IJPN, Paris, 75000,
FRANCE; and Eric Baccino, MD, 371, av du Doyen Gaston
GIRAUD, 34295 Montpellier, Hopital Lapeyronie, Cedex 5,
FRANCE
Risk Factors for Pedestrian Deaths William T. Gormley, MD, PhD*, and Anna Noller, PhD, 256
Office of the Chief Medical Examiner, Commonwealth of
Virginia, 400 East Jackson Street, Richmond, VA, 23219
Index 58
Cervical Spine Injuries in Fatal Traffic Lars Uhrenholt, DC*, and Annie Vesterby Charles, DMSc, 256
Crash Victims: Microscopy and Diagnostic University of Aarhus, Institute of Forensic Medicine, Peter
Imaging Findings Sabroes Gade 15, Aarhus C, Europe 8000, DENMARK;
Ellen Hauge, MD, PhD, Research Unit for Rheumatology
and Bone Biology, Aarhus University Hospital, Aarhus
Sygehus (NBG), Denmark; and Markil Gregersen, DMSc,
University of Aarhus, Institute of Forensic Medicine, Peter
Sabroes Gade 15, Aarhus C, Europe 8000, DENMARK
Reconstruction of a Fatal Dragster Crash Michael J. Shkrum, MD*, London Health Sciences Centre, 257
Department of Pathology, 339 Windermere Road, London,
Ontario, N6A 5A5, CANADA; Kevin J. McClafferty, BESc*,
Multi-Disciplinary Accident Research Team, Faculty of
Engineering, University of Western Ontario, London,
Ontario N6A 5B9, CANADA; and John R. Fernandes,
MDCM, Forensic Pathology Unit, Hamilton Health
Sciences, 237 Barton Street, East, Hamilton, Ontario L8L
2X2, CANADA
Death Due to Aquatic Erotic Asphyxia - Andrea Zaferes, BA*, PO Box 211, Hurley, NY 12443; and 257
Accident or Homicide? Kari B. Reiber, MD, and Dennis J. Chute, MD, Office of the
Bear Facts Alaska: The Good, The Bad, Kathleen Day, MA, MS*, University of Alaska, Anchorage, 258
and the U PO Box 670276, Chugiak, AK 99567; and Franc Fallico,
MD, Office of the Chief Medical Examiner, State of Alaska,
4500 South Boniface Parkway, Anchorage, AK 99567
Concussive Head Injury and Alcohol Jane Willman Turner, PhD, MD*, St. Louis University 258
School of Medicine, 1402 South Grand Boulevard, St. Louis,
MO 63104
Preliminary Study and Potential Role of Barry Daly, MD*, and Clint W. Sliker, MD, University of 258
CT Imaging Autopsy in the Investigation of Maryland Medical Center, Diagnostic Imaging Department,
Death Due to Accidental Blunt Trauma 22 South Greene Street, Baltimore, MD 21201; Zabiullah
Ali, MD, Dawn Zulauf, RN, and Jack M. Titus, MD, Office
of the Chief Medical Examiner, 111 Penn Street, Baltimore,
MD 21201; Mary G. Ripple, MD, 68 Bluebird Road, Port
Deposit, MD 21904; and David R. Fowler, MD, Office of
MD 21201
Stairway Related Deaths: An Analysis of Joyce L. deJong, DO*, and Michael A. Markey, MD, 259
Autopsy Findings of Individuals Found Sparrow Forensic Services, Sparrow Hospital, 1215 East
Dead at the Bottom of a Stairway Michigan Avenue, Lansing, MI 48909-7980; and Rudy J.
Castellani, MD, University of Maryland, Department of
Pathology, 22 South Greene Street, Baltimore, MD 21201
Discrimination of Falls and Blows in Blunt Anny Sauvageau, MD*, S. Racette, BSc, and C. Kremer, 259
Head Trauma: Assessment of Predictability MSc, Laboratoire de sciences judiciaires et de médecine
Through Combined Criteria légale, 1701 Parthenais Street, 12th Floor, Montreal,
Quebec H2K 3S7, CANADA
Unusual Death of a Transsexual Alessandro DellErba*, Sandra Cornetta, MD, Fiorenza 260
(Identification of Damaging Means and Zotti, PhD, and Annalisa Addante, MD, PHD, Section of
Death Time) Legal Medicine, Place G. Cesare, BARI, 70124, ITALY
Index 59
2007
Sudden Unexpected Death in a Case of Hydow Park, MD*, Atlantic County Medical Examiner’s 261
Human Immunodeficiency Virus (HIV) Office, 201 Shore Road, Northfield, NJ 08225-2319
and Myocobacterium Infection Diagnosed
Postmortem
Assisted Suicide as Practiced in the French Sandra E. Burkhardt, MD*, Jerome Sobel, MD, and 261
Part of Switzerland Romano La Harpe, MD, Institute of Forensic Medicine, 9,
Avenue de Champel, Geneva, 1206, Switzerland
Firearms Injuries: Beyond Entry and Exit Rosa Falamingo, MD, PhD, and Francesco Vinci, MD, 261
Wounds Section of Legal Medicine (Di.M.I.M.P.) - University of
Bari, Piazza Giulio Cesare, Policlinico, Bari, 70124, Italy;
and Carlo P. Campobasso, MD, PhD*, Department of
Health Sciences (Di.S.pe.S), University of Molise, via De
Sanctis, snc, Campobasso, 86100, Italy
The Mummified Corpse Found in a Carlo P. Campobasso, MD, PhD*, Department of Health 262
Domestic Setting Sciences (Di.S.pe.S.), University of Molise, via De Sanctis,
snc, Campobasso, Italy 86100, Italy; and Rosa Falamingo,
MD, PhD, Domenica Laviola, MD, Claudia Liuzzi, MD, and
Francesco Vinci, MD, Section of Legal Medicine
(Di.M.I.M.P.) - University of Bari, Piazza Giulio Cesare,
Policlinico, Bari, 70124, Italy
Acute Hemorrhagic Leukoencephalopathy Kenneth D. Hutchins, MD*, Miami-Dade County Medical 262
(Weston-Hurst Disease): A Natural Disease Examiner Department, Number 1 Bob Hope Road, Miami,
Presents as Head Trauma FL 33136; and Lyla E. Perez, MD, Southern Regional
Medical Examiner Office, 1175 DeHirsch Avenue,
Woodbine, NJ 08270
Weight That Kills: Adults With Natural Ana Rubio, MD, PhD*, and David Reisz, BS, State of 263
Deaths are Heavier Than Those Dying Maryland Office of the Chief Medical Examiner, 111 Penn
Non-Naturally — A Cross-Sectional Study Street, Baltimore, MD 21201; Christopher Cox, PhD,
Bloomberg School of Public Health, Johns Hopkins
University, Monument Street, Baltimore, MD 21205; and
David M. Fowler, MD, State of Maryland Office of the
Chief Medical Examiner, 111 Penn Street, Baltimore, MD
21201
Forensic Science “Case Derived” Gilbert E. Corrigan, MD, PhD*, East Baton Rouge 263
Templates Formulated With Relational Coroner’s Office, 4030 T.B. Hearndon Drive, Baton Rouge,
Database Software LA 70807; and Sarah P. Corrigan, MS, Jefferson Parish
Forensic Laboratory, Jefferson Parish Government,
Metaire, LA 70001
Three Unusual Neuropathologic-Related Dennis J. Chute, MD*, and Kari Reiber, MD, Dutchess 264
Causes of Sudden Death County Medical Examiner’s Office, 387 Main Street,
Poughkeepsie, NY 12601
Ruptured Cerebral Artery Aneurysm Albert Y. Chu, MD, MHS*, and Luis A. Sanchez, MD, 264
Mimicking Home Invasion and Assault Harris County Medical Examiner’s Office, 1885 Old
Checking In to Check Out: The New Rebecca A. Irvine, MD*, University of New Mexico, Office 265
Mexico Experience of Suicide Occurring in of the Medical Investigator, MSC 11 6030, 1 University of
Hotels New Mexico, Albuquerque, NM 87131-0001
Liver Laceration as a Result of Ellen G. Moffatt, MD*, Office of the Chief Medical 265
Resuscitation in an Adult Man Examiner, 850 Bryant Street, San Francisco, CA 94103
Index 60
The Epidemiology of Sudden Cardiac Sharon M. Derrick, PhD*, Stacey A. Mitchell, MSN, RN, 266
Death in Young Decedent Medical and Luis A. Sanchez, MD, Harris County Medical
Examiner Cases Examiner’s Office, 1885 Old Spanish Trail, Houston, TX
77054
Significance of Blood Neopterine Takaki Ishikawa, MD, PhD*, Department of Legal 266
Measurement in Forensic Autopsy Cases Medicine, Osaka City University Medical School, Asahi-
machi 1-4-3, Abeno, Osaka, 545-8585, Japan; Marianne
Hamel, MD, PhD, Thomas Jefferson University Hospital,
Department of Pathology, 132 South 10th Street, Suite 285
Main Building, Philadelphia, PA 19107; and Bao-Li Zhu,
MD, PhD, and Hitoshi Maeda, MD, PhD, Department of
Legal Medicine, Osaka City University Medical School,
Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan
Evaluation of Nasoharyngeal Viral Swabs Wendy A. Stroh, DO*, and Deborah Kay, MD, Office of the 267
in Infants Dying of Natural Causes Chief Medical Examiner, 400 East Jackson Street,
Richmond, VA 23219
Succession of Microfungi in Grave Soil Shari L. Forbes, PhD*, University of Ontario Institute of 267
Technology, 2000 Simcoe Street North, Oshawa, Ontario
L1H 7K4, Canada; Trevor Lumley, PhD, Environment
Canada, Environment Technology Centre, 335 River Road,
Ottawa, Ontario K1A0H3, Canada; and David Carter,
PhD, University of Nebraska Lincoln, 202 Plant Industry
Building, Lincoln, NE 68583-0816
Improved Estimation of Postmortem Behnoush Memari, MS*, Kenneth G. Furton, PhD, and 268
Interval With Multiple Protein Markers Alberto Sabucedo, PhD, Florida International University,
and Improved Analytical Methods Department of Chemistry and Biochemistry, 11200 SW 8th
Street University Park CP-345, Miami, FL 33199
Drowning of a Child With a Cardiac Darshan R. Phatak, MD*, and Luis A Sanchez, MD, Harris 268
Fibroma of the Interventricular Septum County Medical Examiner Office, 1885 Old Spanish Trail,
Houston, TX 77054
Estimating Time of Death From Livor William Massello III, MD*, Office of the Chief Medical 269
Mortis Patterns: A Case Presentation Examiner, 6600 Northside HS Road, Roanoke, VA 24019
Dispersion of Hesitation Marks and Stéphanie Racette, BSc*, Célia Kremer, MSc, Anne 269
Defense Wounds: A New Criterion of Desjarlais, and Anny Sauvageau, MD, Laboratoire de
Differentiation of Sharp Force Suicide and Sciences Judiciaires et de Médecine Légale, 1701,
Homicide Parthenais Street, 12th floor, Montreal, Quebec H2K 3S7,
Canada
Neck and Scleral Hemorrhage Due to Russell T. Alexander, MD*, and Jeffrey M. Jentzen, MD, 270
Drowning Milwaukee County Medical Examiner’s Office, 933 West
Highland Avenue, Milwaukee, WI 53233
Papillomacular Folds: Whiplash Patrick E. Lantz, MD*, Wake Forest University Health 270
Maculopathy or Postmortem Artifact? Sciences, Department of Pathology, Medical Center
Boulevard, Winston Salem, NC 27157
To Dye or Magnify! A Proposal to Study Sharon R. Crowley, RN, MN*, 122 Emeline Avenue, Santa 271
the Efficacy of Toluidine Blue Dye vs. Cruz, CA 95060
Colposcopy in the Postmortem Anogenital
Examination
Virtopsy - Virtual Autopsy, Where We Go? Michael J. Thali, MD*, University Bern, Centre Forensic 272
Imaging and Virtopsy, Buehlstrasse 20, Bern, Bern 3012,
Switzerland
Index 61
Female Firearm-Related Suicides: A Kevin D. Whaley, MD*, Anna Noller, PhD, and William T. 272
Reappraisal Gormley, MD, PhD, Central District, Office of the Chief
Medical Examiner, Commonwealth of Virginia, 400 East
Agonal Sequences in Four Filmed Anny Sauvageau, MD*, and Stéphanie Racette, BSc, 273
Hangings: Analysis of Respiratory and Laboratoire de Sciences Judiciaires et de Médecine Légale,
Movement Responses to Asphyxia by 1701 Parthenais Street, 12th Floor, Montreal, Quebec H2K
Hanging 3S7, Canada
The Methods of Committing and Alcohol Alan Bosnar, MD, PhD*, Valter Stemberga, MD, Miran 273
Intoxication of Suicides in the Coklo, MD, and Sanja Dobi Babic, BSc, Department of
Southwestern Croatia From 1996 to 2005 Forensic Medicine, Rijeka University School of Medicine,
B. Branchetta 20, Rijeka, 51000, Croatia; and Emina
Grgurevic, MD, Public Health Institute of Primorsko-
Goranska County, Kresimirova 52a, Rijeka, 51000, Croatia
Suicide by Self Immolation in Cook Ponni Arunkumar, MD*, J. Scott Denton, MD, and Edmund 274
County, Illinois, USA R. Donoghue, MD, Cook County Medical Examiners Office,
2121 West Harrison Street, Chicago, IL 60612
Seasonal Incidence of Suicides in Crete Marianna Kalyva, MD*, University of Crete, Department of 274
Island: A Five Year Study Forensic Sciences, Medical School, Heraklion, 71110,
Greece; Vasilios Stoukas, Telamonos 25, Anthoupoli,
Peristeri, Athens 12135, Greece; and Anna Mavroforou,
PhD, Elena F. Kranioti, MD, Panagiotis Mylonakis, MD,
Antonios Papadomanolakis, MD, and Manolis
Michalodimirakis, MD, JD, University of Crete, Medical
School, Department of Forensic Sciences, Heraklion,
71110, Greece
Suicidal Electrocution in Australia Peter Y. Chan, BSc*, and Johan A. Duflou, MBChB, MMed, 275
Department of Forensic Medicine, PO Box 90, Glebe, NSW
2037, Australia
Open Fractures in Pedestrians Mimicking Melissa A. Brassell, MD*, Mary G. Ripple, MD, and David 275
Gunshot Wounds R. Fowler, MD, Office of the Chief Medical Examiner, State
of Maryland, 111 Penn Street, Baltimore, MD 21201
Homicide in a Surgical Intensive Care Unit A. Thambirajah Balachandra, MBBS*, Johanna Abbott, and 276
Carol Youngson, RN, Office of the Chief Medical Examiner,
Manitoba Justice, 210-1 Wesley Avenue, Winnipeg,
Manitoba R3C 4C6, Canada; John Burchill, Hate Crimes
Unit Coordinator/Major Crimes Analyst, Winnipeg Police
Service, PO Box 1680, 151 Princess Street, Winnipeg,
Manitoba R3C 2Z7, Canada; and N.D.N. Asela Mendis,
MBBS, and Sholeh Barooni, MD, Office of the Chief
Medical Examiner, Manitoba Justice, 210-1 Wesley Avenue,
Winnipeg, Manitoba R3C 4C6, Canada
Subdural Hemorrhage, Subarachnoid Veena D. Singh, MD, MPH*, University of New Mexico 277
Hemorrhage, and a Healing Tibia Health Sciences Center, Department of Pathology MSC08
Fracture: Abuse or Complications of 4640, 1 University of New Mexico, Albuquerque, NM
Leukemia? 87131; and Kurt B. Nolte, MD, and Ross Reichard, MD,
Office of the Medical Investigator, MSC11 6030, 1
University of New Mexico, Albuquerque, NM 87131
Index 62
An Exceptional Case of Death Due to Nunzio Di Nunno, MD, PhD*, Università degli Studi di 277
Lesions of Water Nozzle Lecce, Via G. Dorso n. 9, Bari, 70125, Italy; Luigi Viola,
MD, Università degli Studi di Bari, Sezione di Medicina
Legale, DIMIMP, Policlinico di Bari, Piazza G Cesare 11,
Bari, 70124, Italy; Fulvio Costantinides, MD, Università
degli Studi di Trieste, San Pelagio n. 45, Duino-Aurisina,
34100, Italy; and Giandomenico Maria Battista, MD, and
Cosimo Di Nunno, MD, Università degli Studi di Bari,
Sezione di Medicina Legale, DIMIMP, Policlinico di Bari,
Piazza G. Cesare 11, Bari, 70124, Italy
Hanging Deaths in Ontario: Retrospective Elena Tugaleva, MD*, and Michael J. Shkrum, MD, 277
Analysis of 755 Cases Department of Pathology, London Health Sciences Centre,
339 Windermere Road, London, Ontario N6A 5A5, Canada;
Donald R. Gorassini, PhD, Department of Psychology,
King’s University College at The University of Western
Ontario, 266 Epworth Avenue, London, Ontario N6A 2M3,
Canada; and Barry A. McLellan, MD, Office of the Chief
Coroner, 26 Grenville Street, Toronto, Ontario M7A 2G9,
Canada
Maternity and Paternity Testing of a Jian Tie, MD, PhD*, Yuka Serizawa, BS, and Sesaku 278
Discarded Dead Neonate Involving a Young Uchigasaki, MD, PhD, Department of Legal Medicine,
Girl and Her Father Nihon University School of Medicine, 30-1 Oyaguchi
Kamimachi, Tokyo, 173-8610, Japan; Yoshihiro Mitsugi,
Criminal Investigation Laboratory, Saitama Prefectural
Police Headquarters, 3-10-1 Kizaki Urawa-ku, Saitama,
Saitama 330-0042, Japan; and Shigemi Oshida, MD, PhD,
Department of Legal Medicine, Nihon University School of
Medicine, 30-1 Oyaguchi Kamimachi, Tokyo, 173-8610,
Japan
Undetected Polyglandular Autoimmune Michael S. Lantier*, Villanova University, 800 Lancaster 278
Syndrome Type II (Schmidt Syndrome) as Avenue, Villanova, PA 19085; and Fredric N. Hellman,
a Cause of Sudden Death MD, MBA, Office of the Medical Examiner, Delaware
County, Route 352-Fair Acres, Lima, PA 19037
Suicide by Ingestion of Carbamate Lucas D. Duke, BS*, Drexel School of Medicine, 2125 279
Insecticide: Case Report and Regional Spring Garden Street, #3R, Philadelphia, PA 19130;
Variations Sepideh Samzadeh, BS, Drexel University School of
Medicine, 135 South 20th Street, Apartment #1506,
Philadelphia, PA 19103; and Fredric N. Hellman, MD,
MBA, Office of the Medical Examiner, Delaware County,
Route 352-Fair Acres, Lima, PA 19037
Chemical Asphyxia and Bondage: Heather A. Cannon*, Mercyhurst College, 501 East 38th 279
Autoerotic Fatality Induced by Chloroform Street, Erie, PA 16546; and Fredric N. Hellman, MD, MBA,
Inhalation Office of the Medical Examiner, Delaware County, Route
352-Fair Acres, Lima, PA 19037
Hemophagocytic Lymphohistiocytosis: A Julia M. Braza, MD*, and Meghan Delaney, DO, Beth 280
Case Report and Review of the Literature Israel Deaconess Medical Center and Harvard Medical
School, 330 Brookline Avenue, Boston, MA 02215
Snake-Shot From a Handgun: An Unusual Karen B. Looman, DO*, and Wendy M. Gunther, MD, 281
Gunshot Wound Suicide Tidewater Office of the Chief Medical Examiner, 830
Southampton Avenue, Suite 100, Norfolk, VA 23510
Index 63
Non-Traumatic Homicide Following Patricia A. Aronica-Pollak, MD*, Jack M. Titus, MD, and 281
Assault: 16 Cases - A Review of David R. Fowler, MD, Office of the Chief Medical Examiner
Investigation, Pathology, Toxicology, and State Of Maryland, 111 Penn Street, Baltimore, MD 21201
Judicial Outcome
Death by Cue in the Parietal Pocket: An Valerie S. Green, MD*, Mary L. Anzalone, MD, Dwayne A. 282
Unusual Injury Pattern Caused by the Use Wolf, MD, PhD, and Luis A. Sanchez, MD, Harris County
of a Blunt Object Medical Examiner’s Office, 1885 Old Spanish Trail,
Houston, TX 77054
Pediatric Malignancies Presenting as Allison S. Nixdorf-Miller, MD*, Tracey S. Corey, MD, 282
Sudden Death: A Case Series Barbara Weakley- Jones, MD, and William R. Ralston, MD,
Office of the Chief Medical Examiner, 810 Barrett Avenue,
Louisville, KY 40204
An Experimental Comparison of Bone Bryce O. Anderson, PhD*, and Tyler A. Kress, PhD, BEST 283
Wound Ballistics of Non-Lead and Lead Engineering, 2312 Craig Cove, Knoxville, TN 37919; Anne
Bullets M. Kroman, MA, University of Tennessee, Department of
Anthropology, Knoxville, TN 37996; David J. Porta, PhD,
Bellarmine University, Department of Biology, 2001
Newburg Road, Louisville, KY 40205; and John C.
Hungerford, PhD, University of Tennessee, 208 ESH,
Knoxville, TN 37996
Model Protocol for Forensic Medical Djordje M. Alempijevic, MD, PhD*, Dragan S. Jecmenica, 284
Examination of Victims of Trafficking in MD, PhD, Snezana Pavlekic, MD, PhD, Slobodan N. Savic,
Human Beings MD, PhD, and Branimir V. Aleksandric, MD, PhD, Institute
of Forensic Medicine, Faculty of Medicine, University of
Belgrade, 31a Deligradska Street, Belgrade, 11000, Serbia
The Role of Postmortem Cardiac Enzymes Nick I. Batalis, MD*, and Bradley J. Marcus, MD, Christine 284
in the Diagnosis of Acute Cardiac Deaths N. Papadea, PhD, and Kim A. Collins, MD, Medical
University of South Carolina, 165 Ashley Avenue, Main
Hospital, Suite 281, PO Box 250108, Charleston, SC 29425
Histologic Evidence of Repetitive Blunt Daniel W. Dye, MD*, University of Arkansas for Medical 285
Force Abdominal Trauma in Three Sciences Department of Pathology, 4301 West Markham,
Pediatric Fatalities Slot #517, Little Rock, AR 72205; and Charles P. Kokes,
MD, Arkansas State Crime Laboratory, 2 Natural
Resources Drive, Little Rock, AR 72211
Death by Suicide in Maryland: A Cross- Jonrika M. Malone, MD*, Ana Rubio, MD, PhD, Corey 285
Sectional Study, 2002 to 2005 Tayman, and David M. Fowler, MD, State of Maryland
Office of the Chief Medical Examiner, 111 Penn Street,
Baltimore, MD 21201
Can Mandibular Fractures Occur in Non- Edward L. Mazuchowski, MD, PhD*, Office of the Armed 285
Oral Contact Shotgun Wounds of the Forces Medical Examiner, 1413 Research Boulevard,
Head? Rockville, MD 20850; Mary G. Ripple, MD, Office of the
21201; Craig T. Mallak, JD, MD, Office of the Armed
Forces Medical Examiner, 1413 Research Boulevard,
Rockville, MD 20850; and David R. Fowler, MD, Office of
MD 21201
A Retrospective Review of Youth Suicide in Veena D. Singh, MD, MPH*, University of New Mexico 286
New Mexico Health Sciences Center, Department of Pathology MSC08
4640, 1 University of New Mexico, Albuquerque, NM
87131; and Jeffrey S. Nine, MD, and Sarah Lathrop, DVM,
PhD, Office of the Medical Investigator, MSC11 6030, 1
Index 64
A Homicide Due to a “Disguised Mail Margherita Neri, MD*, Irene Riezzo, MD, and Emanuela 287
Bomb” Turillazzi, MD, PhD, Department of Forensic Pathology
University of Foggia, Viale Pinto 1, Foggia, 71100, Italy
Ocular Study in Pediatric Deaths Under Jorge L. Arredondo Marin, MD*, John R. Fernandes, MD, 287
Two Years of Age With Novel Findings in and Chitra Rao, MBBS, McMaster University, Department
the Retina of Children Who Died of Sudden of Pathology and Molecular Medicine, Regional Forensic
Infant Death Syndrome (1994 – 2004) Pathology Unit, Hamilton Health Sciences Centre, 237
Barton Street East , Hamilton, Ontario L8L 2X2, Canada
Exsanguination Associated With Vascular Donna M. Vincenti, MD*, and Patricia A. Aronica-Pollak, 288
Access Sites in Hemodialysis Patients MD, Office of the Chief Medical Examiner, 111 Penn Street,
Baltimore, MD 21201; Joshua M. Sharfstein, MD, City of
Baltimore Health Department, 210 Guilford Avenue,
Executive Suite, 3rd Floor, Baltimore, MD 21202; and
David R. Fowler, MD, Office of the Chief Medical
Potential Errors in Autopsy Reports of Mark W. Kroll, PhD*, University of Minnesota, Box 23, 288
Custodial Deaths Temporally Associated Crystal Bay, MN 55323; Dorin Panescu, PhD, St. Jude
With Electronic Control Devices: A Medical Cardiac Rhythm Management Division, 705 East
Cardiovascular Perspective Evelyn Avenue, Sunnyvale, CA 94086; Jeffrey Ho, MD,
Department of Emergency Medicine, Hennepin County
Medical Center, 730 8th Street South, Minneapolis, MN
55415; Richard M. Luceri, MD, Holy Cross Hospital, 4725
North Federal Highway, Ft. Lauderdale, FL 33308; Igor R.
Efimov, PhD, Washington University, 1 Brookings Drive, St.
Louis, MO 63130; Hugh Calkins, MD, Johns Hopkins
Hospital, 601 North Caroline Street, Baltimore, MD 21287;
and Patrick J. Tchou, MD, Cleveland Clinic Foundation,
9500 Euclid Avenue, Cleveland, OH 44195
Headache and Sudden Death in a Young Adrienne Segovia, MD*, and Michelle A. Jorden, MD, 289
Adult: An Unexpected Finding at Autopsy Office of the Cook County Medical Examiner, 2121 West
Harrison Street, Chicago, IL 60612
Sudden Death in Duchenne Muscular Michael J. Caplan, MD*, and Kelly Rose, MD*, Medical 290
Dystrophy With Noncompaction of the University of South Carolina, Department of Pathology &
Ventricular Myocardium: A New Laboratory Medicine, Suite 309, 165 Ashley Avenue,
Cardiomyopathy or a Compensatory Charleston, SC 29425
Regression to Fetal Myocardiogenesis?
Death By Giant Cells: Report of Two Cases Rebecca A. Hamilton, MD*, Office of the District 21 291
of Sudden Cardiac Death Due to Giant Cell Medical Examiner, 70 Danley Drive, Fort Myers, FL
Inflammatory Processes 33907; Linda Sullivan, BS, Wuesthoff Reference
Laboratory, 6800 Spyglass Court, Melbourne, FL 32940;
and Barbara C. Wolf, MD, Office of the District 21 Medical
Examiner, 70 Danley Drive, Fort Myers, FL 33907
Sudden Death and Keratoderma Christopher M. Milroy, MD, LLB*, and Sacha Kolar, 291
Associated Cardiomyopathy: An “Affray” MBChB, Forensic Science Service, The Medico-Legal
of the Heart Center, Watery Street, Sheffield, South Yorkshire S3 7ES,
United Kingdom; and Kim Survana, MBChB, Sheffield
Teaching Hospitals, Northern General Hospital, Herries
Road, Sheffield, South Yorkshire S5 7AU, United Kingdom
Correlations for Expected Heart Weight William T. Gormley, MD, PhD*, Deborah Kay, MD, and 292
Anna Noller, PhD*, Office of the Chief Medical Examiner,
Commonwealth of Virginia, 400 East Jackson Street,
Richmond, VA 23219
Index 65
Gagging, Strangulation By Single/ Double João Pinheiro, MD, MSci*, and Duarte Nuno Vieira, PhD, 292
Ligature …or Incaprettamento? Instituto Nacional de Medicina Legal, Largo Sé Nova,
Coimbra, 3000 213, Portugal
A Case Report of an Unexpected Christopher K. Poulos, MD*, Indiana University 292
Accidental Electrocution Department of Pathology and Laboratory Medicine, 521
West McCarty Street, Indianapolis, IN 46225; Michele
Catellier, MD, Forensic Pathology Associates of Indiana,
521 West McCarty Street, Indianapolis, IN 46225; Elena F.
Bishop, MD, Indiana University Department of Pathology
and Laboratory Medicine, Clarian Pathology Laboratory,
350 West 11th Street, Indianapolis, IN 46225; and Stephen
S. Radentz, MD, Forensic Pathology Associates of Indiana,
521 West McCarty Street, Indianapolis, IN 46225
Death From Truck Tire Servicing: A Patrick Cho, MD*, Aldo Fusaro, DO, and Richard C. 293
Report of Three Cases and Review of the Harruff, MD, PhD, King County Medical Examiner’s
Literature Office, 325 Ninth Avenue, Seattle, WA 98104
A Rare Injuring Tool in a Dyadic Death Sabina Di Donato, MD*, Giovanni Paolo Di Peri, MD, and 293
Carmina Dambra, MD, Institute of Forensic Pathology,
University of Foggia - Italy, Ospedali Riuniti, Viale L. Pinto
n. 1 - 71100 Foggia - Italy, Foggia, 71100, Italy
Independence Day Explosion on Lovers Brett E. Harding, MBA*, and Barbara C. Wolf, MD, Office 294
Key of the District 21 Medical Examiner, 70 Danley Drive, Fort
Myers, FL 33907
Identifying the “Iceman” Sarah L. Bettinger, MSFS*, Devon R. Pierce, BS, and 295
Suzanne M. Barritt, MS, Armed Forces DNA Identification
Laboratory, 1413 Research Boulevard, Building 101,
Rockville, MD 20850; Alexander F. Christensen, PhD, Joint
POW/MIA Accounting Command, Central Identification
Laboratory, 310 Worchester Avenue, Hickam AFB, HI
96853; and Louis N. Finelli, DO, Armed Forces DNA
Identification Laboratory, 1413 Research Boulevard,
Caddisfly Cases Assist Homicide Case: John R. Wallace, PhD*, Millersville University, Department 295
Determining a Postmortem Submersion of Biology, Millersville, PA 17551; Richard W. Merritt,
Interval (PMSI) Using Aquatic Insects PhD, Ryan K. Kimbaraskas, MS, Mark E. Benbow, PhD,
and Mollie McIntosh, PhD, Michigan State University,
Department of Entomology, 243 Natural Science, East
Lansing, MI 48824-1115; and Joyce deJong, MD, Sparrow
Hospital, Forensic Pathology Department, Lansing, MI
48824
A Standardized Field Protocol for Kenneth G. Schoenly, PhD*, California State University, 296
Experimentally Investigating Variability in Stanislaus, Department of Biological Sciences, 801 West
Entomology-Based Postmortem Intervals Monte Vista Avenue, Turlock, CA 95382; Jeffery K.
Over Multiple Sites and Years: A Proposal Tomberlin, PhD, Texas A&M University, Texas Cooperative
Extension, 1229 North U.S. Highway 281, Stephenville, TX
76401; John R. Wallace, PhD, Millersville University,
Department of Biology, Millersville, PA 17551; M. Lee
Goff, PhD, Chaminade University, 3140 Waialae Avenue,
Honolulu, HI 96816; Jeffrey D. Wells, PhD, West Virginia
University, Biological Sciences, Morgantown, WV 26506;
and Richard W. Merritt, PhD, Michigan State University,
Department of Entomology, 243 Natural Science Building,
East Lansing, MI 48824
Index 66
Characteristics of Fatal All Terrain Vehicle Michele Eichenmiller, MS, James A. Kaplan, MD*, David J. 297
(ATV) Accidents Clay, BA, Myron A. Gebhardt, MS, Brandon Lewis, BS,
Nabila A. Haikal, MD, James C. Kraner, PhD, Office of the
Chief Medical Examiner, 619 Virginia Street West,
Charleston, WV 25302
Using Ninhydrin to Detect Grave Soil David O. Carter, PhD*, Department of Entomology, 297
University of Nebraska-Lincoln, 202 Plant Industry
Building, Lincoln, NE 68583- 0816; David Yellowlees, PhD,
School of Pharmacy and Molecular Sciences, James Cook
University, Townsville, QLD 4811, Australia; and Mark
Tibbett, PhD, Centre for Land Rehabilitation, School of
Earth and Geographical Sciences, University of Western
Australia, Crawley, WA 6009, Australia
Insects and Time Since Death: What Do M. Lee Goff, PhD*, Division of Natural Sciences and 298
We Really Estimate? Mathematics, Chaminade University of Honolulu, 3140
Waialae Avenue, Honolulu, HI 96816-1578
Dying of the Cold in a Warm Climate - Johan A. Duflou, MMed*, and Cathy Lim, MBBS, 298
Hypothermia Deaths in Sydney, Australia Department of Forensic Medicine, 42-50 Parramatta Road,
Glebe, NSW 2037, Australia
The Postmortem Picnic Kathryn Haden-Pinneri, MD*, Mary Lynn Anzalone, MD, 299
and Luis A. Sanchez, MD, Office of the Medical Examiner
of Harris County, Joseph A. Jachimiczyk Forensic Center,
Applying Statistical Principles to the Bart J. Harvey, MD, PhD, MEd*, University of Toronto, 299
Entomological Estimation of Postmortem 407-263 McCaul Street, Toronto, Ontario M5T 1W7,
Interval Canada; Sherah L. VanLaerhoven, PhD, University of
Windsor, Room 23, Biology Building, 401 Sunset Avenue,
Windsor, Ontario N9B 3P4, Canada; and Paul N. Corey,
PhD, University of Toronto, Department of Public Health
Sciences, 6th Floor, 155 College Street, Toronto, Ontario
M5T 3M7, Canada
The Validation of Gene Expression as a Aaron M. Tarone, BS*, Department of Zoology, Michigan 300
Means of Predicting the Age of the Blow State University, 203 Natural Sciences, East Lansing, MI
Fly Lucilia sericata 48824; and David R. Foran, PhD, Forensic Science
Program, Michigan State University, 560 Baker Hall, East
Lansing, MI 48824
Have I Eaten Here Before? Considering Timothy E. Huntington, MS*, and Leon G. Higley, PhD, 301
Multigenerational Colonization of Remains University of Nebraska, Department of Entomology, 202
by Blow Flies Plant Industry Building, Lincoln, NE 68583
The Investigation of Animal Tissue as an Kathryn L. Stokes, BSc*, Centre for Forensic Science, 301
Analogue for Human Tissue in University of Western Australia, 35 Stirling Highway,
Decomposition Studies in Soil Nedlands, Perth, Western Australia 6009, Australia; Shari
Forbes, PhD, University of Ontario Institute of Technology,
Faculty of Science, University of Ontario Institute of
Technology, 2000 Simcoe Street North, Oshawa, ON L1H
7K4, Canada; and Mark Tibbett, PhD, Centre for Land
Rehabilitation, School of Earth and Geographical Sciences,
Faculty of Natural and Agricultural Sciences, University of
Western Australia, 35 Stirling Highway, Nedlands, Perth,
Western Australia 6009, Australia
Index 67
Ndrangheta’ Homicide (Executions)! Cristoforo Pomara, MD, Department of Forensic 302
Pathology, University of Foggia, Ospedali Riuniti, via L.
Pinto 1, Foggia, 71100, Italy; Floriana Monciotti, MD,
Department of Forensic Pathology, University of Siena,
Policlinico Le Scotte, Siena, 53100, Italy; and Marianna Di
Padua, MD, and Carmela Fiore, MD, Department of
Forensic Pathology, University of Foggia, Ospedali Riuniti,
via L.Pinto 1, Foggia, 71100, Italy
Pig-Mentation: Postmortem Iris Color Elizabeth J. Abraham, MA, MSc*, University Health 302
Change in the Eyes of Sus Scrofa Network, MedWest, 750 Dundas Street West, 2nd Floor,
Suite 279, Toronto, Ontario M6J 3S3, Canada; Margaret
Cox, PhD, Inforce Foundation, Melbury House, 1-3 Oxford
Road, Bournemouth, Dorset BH8 8ES, United Kingdom;
and David Quincey, MSc, Bournemouth University, Institute
of Health and Community Studies, Royal London House, 1st
Floor, Christchurch Road, Bournemouth, Dorset BH1 3LH,
United Kingdom
Child and Adolescent Victims in Forensic Anny Sauvageau, MD*, and Stéphanie Racette, BSc, 303
Autopsy: A Five Year Retrospective Study Laboratoire de Sciences Judiciaires ET de Médecine
Légale, 1701, Parthenais Street, 12th Floor, Montreal,
Quebec H2K 3S7, Canada
Hemoglobin SC Disease Presenting as Wendy A. Lavezzi, MD*, and Mitra B. Kalelkar, MD, Cook 303
Sickle Crisis After Outpatient Surgery: A County Medical Examiner’s Office, 2121 West Harrison
Case Report Street, Chicago, IL 60612
Hola Camp Massacre Kenya 1959 Maurice G. Rogev, MB ChB, MD*, Zamenhof St.11/1, Tel- 304
Aviv-Jafo, 64373, Israel
Comparison of Wound Severity Between Jennifer H. Park, DO*, Miami Dade County Medical 304
Center-Fire Rifle Projectiles and Shotgun Examiner Department, 1851 NW 10th Avenue, Miami, FL
Slugs 33136-1133; and Richard C. Harruff, MD, PhD, King
County Medical Examiner’s Office, 325 Ninth Avenue,
HMC, Box 359792, Seattle, WA 98104
A Comparison of Penetration Distances for David J. Porta, PhD*, Drew H. Duerson, and Bill Tietjen, 305
Five Ballistic Gelatins to a BB Gunshot PhD, Bellarmine University, Department of Biology, 2001
Wound to a Live Human Forearm Newburg Road, Louisville, KY 40205; and Tyler A. Kress,
PhD, BEST Engineering, 2312 Craig Cove Road, Knoxville,
TN 37919
Suicidal and Homicidal Sharp Force Stéphanie Racette, BSc*, Célia Kremer, MSc, and Anny 305
Injury: A Five Year Retrospective Sauvageau, MD, Laboratoire de Sciences Judiciaires et de
Comparative Study of Hesitation Marks Médecine Légale, 1701, Parthenais Street, 12th floor,
and Defense Wounds Montreal, Quebec H2K 3S7, Canada
Estimation of Postmortem Interval Using Beat Horisberger, MD*, and Patrice Mangin, MD, PhD, 306
Bioelectrical Impedance of the Human Institute of Legal Medicine, University of Lausanne, 21, Rue
Body du Bugnon, Lausanne, CH-1005, Switzerland
Postmortem Skeletal Survey Use in Antoinette L. Laskey, MD, MPH, Children’s Health Services 306
Pediatric Forensic Autopsies: A National Research, Indiana University School of Medicine, The
Survey Regenstrief Institute for Health Care, 1001 West 10th Street,
Bryce 2112, Indianapolis, IN 46202; and Michele J.
Catellier, MD*, Forensic Pathology Associates of Indiana,
LLC, 521 West McCarty Street, Indianapolis, IN 46225
Index 68
Near Miss Incidents in Police Custody Jason Payne-James, MBBS*, Forensic Healthcare Services 307
Suites in London, UK: A One Year Ltd., 19 Speldhurst Road, London, E97EH, United
Prospective Study Kingdom; Rebecca Teers, BA, Independent Police
Complaints Commission, 90 High Holborn, London, WC1V
6BH, United Kingdom; Stefania Menin, MSc, Independent
Police Complaints Commission, 90 High Holborn, London,
WC1V 6BH, United Kingdom; and Margaret Stark, LLM,
MBBS, Forensic Medicine Unit, St. George’s Hospital,
London, SW12, United Kingdom
Probability and Pathological Findings in Michael D. Freeman, PhD*, Oregon Health and Science 308
Suicidal Versus Homicidal Hanging University School of Medicine, 205 Liberty Street,
Deaths: A Case Study in Forensic Northeast, Suite B, Salem, OR 97301
Epidemiology
Accuracy of Death Certification and Kelly A. Dakin Hache, MD, PhD, Anatomical Pathology, 308
Medical Examiner Notification in Nova Dalhousie University, 5788 University Avenue, Halifax,
Scotia Nova Scotia B3H 2Y9, Canada; Petra A. Rahaman*,
Forensic Science-Biology, University of Toronto, 107
Linnsmore Crescent, Toronto, Ontario M4J 4K5, Canada;
and Matthew J. Bowes, MD, Nova Scotia Medical Examiner
Service, 5670 Spring Garden Road, Suite 701, Halifax,
Nova Scotia B3J 1H7, Canada
Comparative Analysis of Medical Michael J. Caplan, MD*, and Bamidele Adeagbo, MD*, 309
Examiner and Coroner Systems of Medical University of South Carolina, Department of
Medicolegal Death Investigation: Is There a Pathology and Laboratory Medicine, Suite 309, 165 Ashley
Bias Toward Manner of Death? Avenue, Charleston, SC 29425
Preliminary Findings of the Bureau of Matthew J. Hickman, PhD, and Kristen A. Hughes, MA, 310
Justice Statistics 2005 Census of Medical U.S. Department of Justice, Bureau of Justice Statistics, 810
Examiner and Coroner Offices 7th Street NW, Washington, DC 20531; and Jeri D. Ropero-
Miller, PhD*, and Kevin J. Strom, PhD, RTI International,
3040 Cornwallis Road, Research Triangle Park, NC 27709
Pituitary Macroadenoma Presenting as Michelle A. Jorden, MD*, Adrienne Segovia, MD, and 310
Hypothermia: A Case Report Edmund R. Donoghue, MD, Cook County Medical
Examiner’s Office, 2121 West Harrison Street, Chicago, IL
60647
Diatoms and Their Forensic Significance Ismail M. Sebetan, MD, PhD*, and Irelise C. Clendenin, 311
MFS, National University, 11255 North Torrey Pines Road,
La Jolla, CA 92037
Evaluation of NT-proBNP as Marker of Katarzyna Michaud, MD*, and Marc Augsburger, PhD, 311
Heart Failure in Postmortem Examination Institut Universitaire de Médecine Légale, Bugnon 21,
Lausanne, 1005, Switzerland; Nicolas Donzé, Consilia,
Grand Champsec86, Sion, 1950, Switzerland; and Marc
Bollmann, MD, Béat Horisberger, MD, Bettina Schrag,
MD, and Patrice Mangin, PhD, Institut Universitaire de
Médecine Légale, Bugnon 21, Lausanne, 1005, Switzerland
An Unusual Case of Sudden Death Luisa F. Florez, MD*, Baylor College of Medicine, One 312
Baylor Plaza, Houston, TX 770303; Mary Anzalone, MD,
Harris County Medical Examiner’s Office, 1885 Old
Spanish Trail, Houston, TX 77054; and Carolina Gutierrez,
MD, and Mario Cervantes, MD, Baylor College of
Medicine, One Baylor Plaza, Houston, TX 77030; Kathy
Haden-Pinneri, MD, Maximillian Buja, MD, and Luis A.
Sanchez, MD, Harris County Medical Examiner’s Office,
Index 69
Use of Beta-APP Stain in a Case of Fatal Paul L. Morrow, MD*, and Michael Rodriguez, MBBS, 312
Dog Attack Department of Forensic Medicine, 42-50 Parramatta Road,
Glebe, New South Wales 2037, Australia
The Postmortem Diagnosis of Diabetic Jørgen L. Thomsen, DMJ*, and Peter M. Leth, PhD, 313
Coma University of Southern Denmark, Winsløwparken 17,
Odense, DK-5000, Denmark
Forensic Diaphanoscopy Imaging: A New Beat Horisberger, MD*, University of Lausanne, Institute of 313
Tool in Clinical Forensic Medicine Legal Medicine, 21 Rue du Bugnon, Lausanne, CH-1005,
Switzerland; Sebastien Tanniger, School of Business and
Engineering Vaud, HEIG-VD, 1 Route de Cheseaux,
Yverdon-les-Bains, CH-1401, Switzerland; and Patrice
Mangin, MD, PhD, University of Lausanne, Institute of
Legal Medicine, 21 Rue du Bugnon, Lausanne, CH-1005,
Switzerland
“Drop Dead”: An Epidemic of Intravenous J. Scott Denton, MD*, Edmund R. Donoghue, MD, Mitra B. 314
Fentanyl Deaths in Cook County, Illinois: Kalelkar, MD, and Nancy Wu Chen, PhD, Cook County
2005 to Present Medical Examiner’s Office, 2121 West Harrison Street,
Chicago, IL 60612-3705
Bidding for Poison: The New Availability Rebecca A. Irvine, MD*, University of New Mexico, Office 315
of Poisons and How to Use Them of the Medical Investigator, MSC 11 6030, University of
New Mexico, Albuquerque, NM 87131-0001
Cluster of Fentanyl-Tainted Heroin Deaths Mary G. Ripple, MS, MD*, Barry S. Levine, PhD, and 315
in a Three-Week Period in Maryland Rebecca Jufer- Phipps, PhD, Office of the Chief Medical
Examiner, State of Maryland, 111 Penn Street, Baltimore,
MD 21201; Erin Artigiani, Center for Drug Abuse
Research, 4321 Hartwick Road, Suite 501, College Park,
MD 20742; Suzanne Doyon, MD, Maryland Poison Center,
20 North Pine Street, Baltimore, MD 21201; and David R.
Fowler, MD, Office of the Chief Medical Examiner, State of
Maryland, 111 Penn Street, Baltimore, MD 21201
Suicidal Caffeine Overdose Wendy M. Gunther, MD*, Tidewater District Office of the 316
Chief Medical Examiner, 830 Southampton Avenue, Suite
100, Norfolk, VA 23510; Connie M. Luckie, PhD,
Department of Forensic Sciences, Commonwealth of
Virginia, 830 Southampton Avenue, Suite 400, Norfolk, VA
23510; and Karen B. Looman, DO, Tidewater District
Office of the Chief Medical Examiner, 830 Southampton
Avenue, Suite 100, Norfolk, VA 23510
Abuse of Prescription Narcotics: A Look Gretchen A. Grisbaum, JD*, Quick & Associates, Inc., 316
Beyond Prescription Monitoring Programs 21449 Marion Lane, Suite 6, Mandeville, LA 70471; and
Karen Ross, MD, Jefferson Parish Forensic Center, 2018
8th Street, Harvey, LA 70058
Murder By Poison: Experiences of a Christopher Swalwell, MD*, Office of the Medical 317
Medical Examiner’s Office Examiner, 5555 Overland Avenue, Suite 1411, San Diego,
CA 92123
Vaccine Death: A Rare Case of Stefano D’Errico, MD*, Francesco Maria Morreale, MD, 317
Anaphylactic Shock After Hexavalent and Raffaella Bisceglia, MD, Institute of Legal Medicine,
Immunization University of Foggia, Ospedali Riuniti, via L.Pinto 1,
Foggia, 71100, Italy; and Rossi Giuseppina, MD, Institute
of Legal Medicine, University of Siena, Policlinico Le
Scotte, Siena, 53100, Italy
Index 70
Pattern of Injury in Child Fatalities Ann H. Ross, PhD, North Carolina State University, 318
Resulting from Child Abuse Department of Sociology and Anthropology, CB 8107,
Raleigh, NC 27695-8107; Suzanne M. Abel, PhD,
Charleston County Coroner’s Office, 4050 Bridgeview
Drive, North Charleston, SC 29405; Deborah Radisch, MD,
MPH, Office of the Chief Medical Examiner, CB 7580,
Chapel Hill, NC 27599-7580; Beth Murnane, MD, Sunrise
Pediatric Associates, 3909 Sunset Ridge Road, Suite 103,
Raleigh, NC 27607; and Sheena Harris, BA, and Kelsie
Ballance, North Carolina State University, Department of
Sociology and Anthropology, CB 8107, Raleigh, NC 27695-
8107
Histopathology of Antemortem Infant Bone Murray K. Marks, PhD*, University of Tennessee, 319
Fractures: Estimation of Time Since Insult Department of Anthropology, 250 South Stadium Hall,
Knoxville, TN 37996-0720; and Darinka X. Mileusnic, MD,
PhD, Regional Forensic Center, University of Tennessee
Medical Center, 1924 Alcoa Highway, Knoxville, TN 37920
The Likelihood of Inflicted Injury Is Better M.G.F. Gilliland, MD*, Brody SOM at ECU, Department 319
Evaluated by the Use of Inconsistent Pathology and Laboratory Medicine, Brody 7 S 10,
Histories With the Constellation of the Greenville, NC 27858
Triad of Findings: Subdural Hemorrhage,
Brain Swelling, and Retinal Hemorrhages
Compressional Asphyxia Due to Prone Robert F. Corliss, MD*, Andrew M. Baker, MD, and 320
Restraint Hold in a Child Kathryn K. Berg, MD, Hennepin County Medical
Examiner’s Office, 530 Chicago Avenue, Minneapolis, MN
55415
Combined Types of Violence in Child Wendy M. Gunther, MD*, Leah L. Bush, MD, Elizabeth L. 320
Abuse: Report of Three Cases Kinnison, MD, Department of Legal Medicine, Virginia
Commonwealth University, Medical College of Virginia,
Tidewater Office of the Chief Medical Examiner,
Commonwealth of Virginia, 830 Southampton Avenue, Suite
100, Norfolk, VA 23510-1046; and Karen B. Looman, DO,
Tidewater Office of the Chief Medical Examiner, 830
Brainstem Axonal Injury and Retinal Rudy J. Castellani, MD*, University of Maryland, 321
Hemorrhages as a Substrate for Sudden Baltimore, 22 South Greene Street, NBW-81, Baltimore,
Death in Second Impact Syndrome: A Case MD 21201; and Joyce L. deJong, DO, Division of Forensic
Report Pathology, Sparrow Health System, 1215 East Michigan
Avenue, Lansing, MI 48912
Sexual Abuse: Hymenal Findings in Girls Annie Vesterby, MD, DMsc*, and Lene A. Hansen, MD, 322
With a History of Vaginal Penetration Institute of Forensic Medicine, University of Aarhus, Peter
Sabroes Gade 15, Aarhus C, 8000, Denmark; and Svend
Sabroe, MD, Institute of Public Health, Dept. of
Epidemiology, University of Aarhus, Vennelyst Boulevard 6,
Aarhus C, 8000, Denmark
A Chest Full of Blood: Hemothorax as a 26 Karen B. Looman, DO*, and Wendy M. Gunther, MD, 322
Year Delayed Consequence of Repair of Tidewater Office of the Chief Medical Examiner, 830
Transposition of the Great Vessels Southampton Avenue, Suite 100, Norfolk, VA 23510
Suicidal Hanging of a Postpartum Woman Gregory L. Hess, MD*, Jeffery M. Jentzen, MD, and Russell 323
Who Discontinued Anti- Depressant T. Alexander, MD, Milwaukee County Medical Examiner
Medication During Pregnancy Office, 933 West Highland Avenue, Milwaukee, Wisconsin
53233
Index 71
A Simple Model for Teaching Postmortem Terrill L. Tops, MD*, and Patrick E. Lantz, MD, Wake 323
Monocular Indirect Ophthalmoscopy Forest University Health Sciences, Department of
27157
A Case of Fatal Water Intoxication in a Nadia L. Krupp, MD, Indiana University School of 324
Toddler Medicine, 702 Barnhill Drive, Indianapolis, IN 46202;
Michele J. Catellier, MD*, Forensic Pathology Associates
of Indiana, LLC, 521 West McCarty Street, Indianapolis, IN
46225; and Antoinette L. Laskey, MD, MPh, Indiana
University School of Medicine, 702 Barnhill Drive,
Indianapolis, IN 46202
Index 72
2006
Otologic Injury as a Consequence of Blast Carol J. Solomon, MS, MD*, Louis N. Finelli, DO, and 325
Trauma; Evaluated by Postmortem John M. Getz, BS, Office of the Armed Forces Medical
Otoscopic and Computed Tomography Examiner, 1413 Research Boulevard, Building 102,
Examination Rockville, MD 20850
Natural Central Nervous System (CNS) Gregory L. Hess, MD*, University of Arizona Health 325
Causes of Death: A Ten Year Retrospective Sciences Center, 1501 North Campbell Avenue, PO Box
Review (1994-2003) 245108, Tucson, AZ 85724-5108; and David C. Winston,
MD, PhD, Pima County Forensic Science Center, 2825 East
District Street, Tucson, AZ 85714
Frequency of Cases of Fatal Gunshot Daniel W. Dye, MD*, University of Arkansas for Medical 325
Wound Victims With Retained “Old” Sciences, 4301 W Markham, Slot 517, Little Rock, AR
Projectiles From Previous Penetrating 72205; and Charles P. Kokes, MD, Arkansas State Crime
Gunshot Wounds Laboratory, #3 Natural Resources Drive, PO Box 8500,
Little Rock, AR 72215
Small Cell Carcinoma of the Lung Carl W. Wigren, MD*, and J. Matthew Lacy, MD, King 326
Contributing to Pulmonary Barotrauma County Medical Examiner’s Office, 325 Ninth Avenue,
With Air Embolism in a Recreational HMC Box 359792, Seattle, WA 98104
Diver: A Case Report
Serum Levels of Pulmonary Surfactant M. Essam E. El-Sheikh, MD, PhD*, and Taisseur M. 326
Associated Proteins A and D (SP-A & SP- Mostafa, MD, PhD, Farwania, PO Box 1747, Kuwait, 1747,
D) in Some Causes of Death Kuwait
Gliomatosis Cerebri as a Cause of Sudden Timothy L. Williams, MD*, and William F. Hickey, MD, 327
Death in a Young Woman Dartmouth- Hitchcock Medical Center, Department of
Pathology, One Medical Center Drive, Lebanon, NH 03756;
and Thomas Andrew, MD, Office of the Chief Medical
Death in a Confined Space Nunzio Di Nunno, MD, PhD*, Universita’ di Lecce, Via G. 327
Dorso n. 9, Bari, 70125, Italy; Francesco Vimercati, MD,
Universita’ di Bari, Sezione di Medicina Legale, Piazza G.
Cesare n. 11, Bari, 70125, Italy; Fulvio Costantinides, MD,
Universita’ di Trieste, P.zza Ospedale, Trieste, 34100, Italy;
and Sandra Cornetta, MD, and Di Nunno Cosimo, MD,
Cesare n. 11, Bari, 70125, Italy
Primary Hyperoxaluria: A Case Report Julia M. Braza, MD and Karoly Balogh, MD, Beth Israel 328
and Review of the Literature Deaconess Medical Center, Pathology Department, 330
Brookline Avenue, Boston, MA 02215
Planned Complex Suicide: Report of Two Cristian Palmiere, MD, Institut Universitaire de Médecine 329
Cases Légale, 9 Avenue de Champel, Genève, 1211, Switzerland;
Francesco Ventura, MD, and Daniela Picchioni, MD,
Dipartimento di Medicina Legale, Via de Toni 12, Genova,
16132, Italy; and Maria del Mar Lesta, MD, and Romano
La Harpe, MD*, Institut Universitaire de Médecine Légale,
9 Avenue de Champel, Genève, 1211, Switzerland
Effect of Toilet Detergent on Morphological Jian Tie, MD, PhD*, Yuka Serizawa, BS, and Shigemi 329
Change of Spermatozoa Oshida, MD, PhD, Department of Legal Medicine, Nihon
University School of Medicine, 30- 1 Oyaguchi Kamimachi,
Itabashi-Ku, Tokyo 173-8610, Japan
An Unusual Death of a Child at the Albert Y. Chu, MD*, and Luis A. Sanchez, MD, Harris 330
Obstetrician’s Office County Medical Examiner’s Office, 1885 Old Spanish Trail,
Houston, TX 77054
Index 73
Methadone Treatment and Drug Overdose Guillaume Perret, MD*, Institut Universitaire de Medecine 330
in Geneva, Switzerland, From 1994 to 2003 Legale de Geneve, 9 av. de Champel, CMU, Geneva, 1211,
Switzerland; Ann Ho, PhD, and Mary Jeanne Kreek, MD,
Laboratory of the Biology of Addictive Diseases,
Rockefeller University, 1320 York Avenue, New York, NY
10021; and Romano La Harpe, MD, Institut Universitaire
de Medecine Legale de Geneve, CMU, 9 av. de Champel,
Geneva,1211, Switzerland
Pathological Changes Associated With Lise A.M. Matzke, MSc*, and Courtney Young, BSc*, James 331
Aortic Valve Stenosis C Hogg iCAPTURE Centre, Room 166, 1081 Burrard
Street, Vancouver, BC V6Z 1Y6, Canada
Fatal CO2 Suicidal Poisoning Gilles Tournel, MD*, Fabrice Dedouit, MD, Anne Becart- 331
Robert, DDS, PhD, Pierre Dutrieux, MD, Valéry Hedouin,
MD, PhD, and Didier Gosset, MD, PhD, Institut de
Médecine Légale, Faculté de Médecine, 1, place de Verdun,
Lille, 59000, France
Case Report – Sudden Death Due to Cystic Carlos F. Chavez Arias, MD*, Kathyrn Haden-Pinneri, 332
Tumor of the Atrioventricular Node MD, Maximiliam Buja, MD, and Luis A. Sanchez, MD,
Harris County Medical Examiner’s Office, Joseph J.
Jachimcyzk Forensic Center, 1885 Old Spanish Trail,
Houston, TX 77054
Sudden Death in a Healthy 37-Year-Old Wendy M. Gunther, MD*, Department of Legal Medicine, 332
Man While Driving: Spontaneous Virginia Commonwealth University, Medical College of
Dissection of the Posterior Segment of the Virginia, 1101 E Marshall Street, Richmond, VA 23298-
Right Coronary Artery 0568; and Jonrika M. Malone, MD, Office of the Chief
Medical Examiner, Tidewater District, 830 Southampton
Avenue, Suite 100, Norfolk, VA 23510-1046
Fibrosis of the Cardiac Conduction System Katarzyna Michaud, MD*, Thomas Krompecher, MD, 333
as a Possible Cause of Death in Chronic Frank Sporkert, PhD, Franco Taroni, PhD, Béat
Cocaine Addicts Horisberger, MD, Marc Augsburger, PhD, and Patrice
Mangin, MD, PhD, Institut Universitaire de Médecine
Légale, Bugnon 21, Lausanne, 1005, Switzerland
Fatal Venous Air Embolism in a Erik D. Christensen, MD*, Office of the Greenville County 333
Postmenopausal Female During Medical Examiner, 890 West Faris Road, Suite 110,
Consensual Sexual Intercourse: A Case Greenville, SC 29605
Report and Review of the Literature
Incidence of Laryngeal and Hyoid Dana Austin, PhD, and Marc A. Krouse, MD, Tarrant 334
Fractures in Hangings and Strangulations County Medical Examiner, 200 Feliks Gwozdz Place, Fort
Using Enhanced Examination Procedures Worth, TX 76104-4919
Agonal Sequences in a Filmed Suicidal Anny Sauvageau, MD, MSc*, Laboratoire de Sciences 334
Hanging: Analysis of Respiratory and Judiciaires et de Médecine Légale, 1701 Parthenais Street,
Movement Responses to Asphyxia by 12th Floor, Montreal, Quebec H2K 3S7, Canada; Stéphanie
Hanging Racette, BSc, Laboratoire de Sciences Judiciaires et de
Médecine Légale, 1701 Parthenais Street, 12th Floor,
Montreal, Quebec H2K 3S7, Canada
Visual Misidentifications of Human Joyce L. deJong, DO*, Sparrow Hospital, 1215 East 335
Remains: Lessons Learned Michigan Avenue, Lansing, MI 48909-7980
Index 74
Identifying Corpses of Foreigners in the Heike Klotzbach, MD, PhD*, Institute of Legal Medicine, 336
State of Advanced Decomposition: Sri Stiftsplatz 12, Bonn, 53111, Germany; Klaus Benedix,
Lanka After the Tsunami 2004 DMD, Dental Services German Air Forces, Dachauer
Strasse 128, München, Bavaria 80637, Germany; Guido
Beutler, Embassy of the Federal Republic of Germany, 6/50
Shantipath, Chanakyapuri, New Delhi, 110 021, India; and
Thomas Lubnau, and Kerstin Schneider, Federal Criminal
Police Office, Georg- Marshall-Strasse 20, Wiesbaden,
65173, Germany; Stephan Klein, Federal Criminal Police
Office, Georg-Marshall-Strasse 20, Wiesbaden, 65173,
Germany
Mass Disaster Victim Identification: The Sawait Kanluen, MD*, Chulalongkorn University, 336
Tsunami Disaster Department of Forensic Sciences, 254 Phayathai Road,
Patumwan, Bangkok 10330, Thailand; and Tony Kanluen,
MD, Henry Ford Hospital, Department of Emergency
Medicine, 2799 W Grand Boulevard, Detroit, MI 48202
Victim Trauma as an Identification Tool in Maurice G. Rogev, MD, MBChB*, 11/1 Zamenhof Street, 337
Mass Disasters Tel-Aviv-Jaffo, 64373, Israel
Differential Diagnosis: Antemortem vs. Nermin Sarajlic, MD, PhD*, International Commission on 337
Postmortem Bone Trauma Missing Persons, Alipasina 45A, Sarajevo, 71000, Bosnia
and Herzegovina; John Clark, MRCPath, University of
Glasgow, Joseph Black Building, Glasgow, Scotland G12
8QH, UK; and Eva-Elvira Klonowski, PhD, International
Commission on Missing Persons, Alipasina 45A, Sarajevo,
71000, Bosnia and Herzegovina
Personal Identification by Morphometric Francesco Introna, MD, PhD*, and Antonio De Donno, 338
Analyses of Retinal Vascular Pattern MD, Section of Legal Medicine (Di.M.I.M.P.), University of
Bari, P.zza Giulio Cesare n.11, Bari, 70124, Italy; Carlo
Sborgia, MD, and Francesco Boscia, MD, Section of
Ophthalmology, University of Bari, P.zza Giulio Cesare
n.11, Bari, 70124, Italy; Giuseppe Mastronardi, PhD,
Electronic and Electrotecnic DPT, Via Orabona n.4, Bari,
Bari, Italy; and Francesca Bellomo, MD, and Domenico
Urso, MD, Section of Legal Medicine (Di.M.I.M.P.),
University of Bari, P.zza Giulio Cesare n.11, Bari, 70124,
Italy
Laryngeal Nerve Iatrogenic Lesions Luigi Viola, MD*, Marina Albano, MD, Francesco 338
Vimercati, MD, and Nunzio Di Nunno, MD, PhD,
Università di Lecce, Via G. Dorso n. 9, Bari, 70125, Italy
Electrocution by Arcing: A Non Fatal Case Biagio Solarino, MD*, Giancarlo Di Vella, MD, PhD, and 339
Study Alessandra Arpaio, MD, Sezione di Medicina Legale -
Di.M.I.M.P., Università degli Studi di Bari - Policlinico,
Bari, 70125, Italy
Abrasion or Gunshot Wound? The Giancarlo Di Vella, MD, PhD*, and Biagio Solarino, MD, 339
Primary Role of Forensic Pathologist Sezione di Medicina Legale - Di.M.I.M.P., Università degli
Studi di Bari - Policlinico, Bari, 70125, Italy
Sudden Death in Toddlers Due To Kristen Landi, MD*, and Andrea Coleman, MD, Office of 340
Influenza B Infection: A Report of Two the Chief Medical Examiner, 520 First Avenue, New York,
Cases and a Review of the Literature NY 10016
Index 75
Neuropathology of Pre-Teen Homicides in Ana Rubio, MD, PhD*, State of Maryland Office of the 341
the State of Maryland: 1994-2004 Chief Medical Examiner, 111 Penn Street, Baltimore, MD
21201; Miguel A. Riudavets, MD, Department of Pathology
(Neuropathology), Johns Hopkins University School of
Medicine, Baltimore, MD 21201; Ling Li, MD, State of
Street, Baltimore, MD 21201; Christopher Cox, PhD,
Department of Epidemiology, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD 21201; David
Reisz, BA, and David R. Fowler, MD, State of Maryland
Baltimore, MD 21201; and Juan C. Troncoso, MD,
Department of Pathology (Neuropathology), Johns Hopkins
University School of Medicine, Baltimore, MD 21201
Transplacental Intrauterine Herpes Sam D. Simmons, MD, MBA*, Ashley O’Bannon, MD, and 341
Simplex Virus Infection Resulting in Subodh Lele, MD, University of Kentucky, Department of
Cutaneous Calcifications in an Infant Pathology and Lab Medicine, 800 Rose Street, MS 117,
Lexington, KY 40504
Killer Hairdryer Francesco Introna, MD, PhD, Section of Legal Medicine 342
(Di.M.I.M.P.), University of Bari, Policlinico - P.zza Giulio
Cesare, 11, Bari, 70124, Italy; Simona Corrado, MD*,
Section of Legal Medicine (Di.M.I.M.P.), Bari University,
Policlinico - Piazza G. Cesare, 11, Bari, 70124, Italy; and
Vitantonio Amoruso, Dipartimento di Elettrotecnica ed
Elettronica, Politecnico di Bari, Via Orabona, 4, Bari,
70125, Italy
Pyelonephritis—Sudden and Unexpected Cristin M. Rolf, MD*, University of Kentucky, Office of the 343
Death in Infancy Associate Chief Medical Examiner, 100 Sower Boulevard,
Suite 202, Frankfort, KY 40601-8272; and Bonnie Mitchell,
MD, University of Kentucky, Department of Pathology and
Laboratory Medicine, 800 Rose Street, UKMC MS 117,
Lexington, KY 40536-0298
Necrotizing Fasciitis: Manifestations, Nancy M. Dunbar, BA*, Carl Wigren, MD, and Richard C. 343
Microbiology and Connection With Black Harruff, MD, PhD, King County Medical Examiner’s
Tar Heroin Office, HMC Box 359792, 325 Ninth Avenue, Seattle, WA
98104
Was the Shawnee War Chief Blue Jacket a Carolyn Rowland, MS*, Forensic Bioinformatic Services, 344
Caucasian? Inc., 2850 Presidential Drive, Suite 150, Fairborn, OH
45371; Dan E. Krane, PhD, Wright State University,
Department of Biological Sciences, 2640 Colonel Glenn
Highway, Dayton, OH 43435; Marc S. Taylor, MS,
Technical Associates, Inc., 4125 Market Street, Suite 3,
Ventura, CA 93003; and Robert Van Trees, BA, 589
Westwood Drive, Fairborn, OH 45324
Using Multiplexed Microsatellite Markers Maria Angelica Mendoza, MS*, Heather Erek, BS*, and 344
of Cannabis sativa to Determine Genetic José R. Almirall, PhD, 11200 SW 8th Street, CP194, Miami,
Diversity FL 33199
Co-Amplification of Cytochrome B and D- Dongya Yang, PhD*, Department of Archaeology, Simon 345
loop mtDNA Fragments for More Reliable Fraser University, 8888 University Drive, Burnaby, BC V5A
Species Identifications 1S6, Canada; and Speller Camilla, MA, Department of
Archaeology, Simon Fraser University, 8888 University
Drive, Burnaby, BC V5A 1S6, Canada
Index 76
Sternal Shard From Bystander Bullet: A Wendy M. Gunther, MD*, Office of the Chief Medical 345
Rare Mechanism of Homicide Examiner, Tidewater District, 830 Southampton Avenue,
Suite 100, Norfolk, VA 23510
False Positive Diagnosis of Subarachnoid Sangeeta Sandhu, MD*, St. Luke’s-Roosevelt Hospital, 515 346
Hemorrhage and Subdural Hemorrhage by West 59 Street, #4K, New York, NY 10019; Stephen deRoux,
Computerized Tomography MD, and Beverly Leffers, MD, Office of Chief Medical
Examiner (Brooklyn), 520 First Avenue, New York, NY
10016-6402; and Thomas Gilson, MD, Office of Chief
Medical Examiner (Manhattan), 520 First Avenue, New
York, NY 10016-6402
TASER-Related Fatalities: Case Report Amy T. Sheil, MD*, and Kim A. Collins, MD, Medical 346
and Review of the Literature University of South Carolina, Department of Medical and
Forensic Autopsy, 165 Ashley Avenue, Suite 309,
Charleston, SC 29425
A Demographic Analysis of Youth and Melissa A. Brassell, MD*, Carol H. Allan, MD, Mary G. 347
Teen Suicide in Maryland (1994-2003) Ripple, MD, and David R. Fowler, MD, Office of the Chief
Effectiveness of Death Investigation in Diane C. Peterson, MD*, and Richard E. Powers, MD, 347
Cases of Potential Elder Abuse P220 West Pavilion, Department of Pathology, 619 19th
Street South, Birmingham, AL 35233; James N. Robinson,
BA, University of Alabama at Birmingham Medical School,
VH P-100, 1530 3rd Avenue South, Birmingham, AL 35294;
and Gregory G. Davis, MD, Jefferson County
Coroner/Medical Examiner Office, 1515 Sixth Avenue
South, Room 611, Birmingham, AL 35233-1601
Use of CT as an Aid in the Recovery of Edward A. Reedy, PhD, MD*, John M. Getz, PhD, Lisa 348
Metallic Foreign Bodies at Autopsy Pearse, MD, Craig T. Mallak, MD, JD, and James L.
Caruso, MD, Armed Forces Medical Examiner System,
20850
Antemortem and Postmortem Toxicological Sunil K. Prashar, MD*, State of Maryland, Office of the 348
Findings in Motor Vehicle Accidents, Chief Medical Examiner, 111 Penn Street, Baltimore, MD
Maryland (2003-2004): Does Impairment 21201; Jami L. Grant, PhD, University of Baltimore, 1420
Equal Death? North Charles Street, Baltimore, MD 21201; Susan R.
Hogan, MD, David R. Fowler, MD, and Mary G. Ripple,
MD, State of Maryland, Office of the Chief Medical
Examiner, 111 Penn Street, Baltimore, MD 21201; and
Mary E. Kramer, RN, R. Adams Cowley Shock Trauma
Center, 22 S Greene Street, Baltimore, MD 21201
Descriptive Study on the Causes of Death of Andrea L. Dickens, MD*, and Richard E. Powers, MD, 349
Residents of Boarding Homes P220 West Pavilion, Department of Pathology, 619 19th
The Death of an Italian Soldier in Iraq: Margherita Neri, MD*, Marianna Di Padua, MD, 349
Murder or Fatality? Cristoforo Pomara, MD, and Emanuela Turillazzi, MD,
PhD, Department of Forensic Pathology, University of
Foggia, Viale Pinto 1, Foggia, 71100, Italy
Index 77
Prevention of Accidental Strangulation of Kathrin Gerlach, MD*, Department of Legal Medicine, 350
Children in Their Sleeping Bags: Pestalozzistrasse 22, Basel, 4056, Switzerland; Beat
Development of a New Sleeping Bag Horisberger, MD, Department of Legal Medicine, Rue du
Bugnon 2, CH-1005 Lausanne, Switzerland, Walter Bar,
MD, Department of Legal Medicine, Winterthurerstrasse
190, CH-8091 Zürich, Switzerland; and Volker Dittmann,
MD, and Daniel Wyler, MD, Department of Legal Medicine,
Pestalozzistrasse 22, CH- 4056 Basel, Switzerland
VIRTOPSY (Virtual Autopsy) - Past, Michael J. Thali, MD*, University of Berne, Institut 350
Present, and Future Forensic Science, Buehlstrasse 20, Bern, Switzerland; Peter
Vock, MD, University of Berne, Radiology Department,
Berne, 3005, Switzerland; and Richard Dirnhofer, MD,
University of Berne, Institut of Forensic Medicine, Berne,
Berne 3012, Switzerland
Professional Quality in a Forensic Medical Paul P.S. Chui, MBBS, DMJ, MBA*, and Clarence T. Tan, 351
Setting: The Singapore Experience MBBS, Health Sciences Authority, 11 Outram Road,
Singapore, 169078, Singapore
Insects of the Grave: A Cold Case History Richard W. Merritt, PhD*, Michigan State University, 351
Involving Insects 27 Years After Death Department of Entomology, 243 National Science Building,
East Lansing, MI 48824; Mark E. Benbow, PhD,
Department of Biology, DePauw University, Greencastle,
IN 46135; Ryan K. Kimbirauskas, MS, Michigan State
University, Department of Entomology, East Lansing, MI
48824; Joyce L. deJong, DO, Sparrow Hospital, 1215 East
Michigan Avenue, Lansing, MI 48909; and Richard Snider,
PhD, Michigan State University, Department of Zoology,
Seasonal Effects on Blow Fly Species Jennifer Y. Rosati, BSc*, and Sherah L. VanLaerhoven, 352
Composition and Behavior PhD, University of Windsor, Rm 119 Bio, 401 Sunset
Avenue, Windsor, Ontario N9B 3P4, Canada
Improving Postmortem Interval Estimates Aaron M. Tarone, BS*, Department of Zoology, 203 Natural 352
in Forensic Entomology: Blowfly Gene Sciences Building, Michigan State University, East Lansing,
Expression and Development MI 48824; and Kimberly C. Jennings, BS, and David R.
Foran, PhD, School of Criminal Justice, 560 Baker Hall,
Michigan State University, East Lansing, MI 48824
The Developmental Studies of The Green Kc L. Deaver, MS*, 2704 72nd Avenue, SE, Mercer Island, 352
Bottle Fly, Phaenicia coeruleiviridis WA 98040; and Jerry Cook, PhD, Sam Houston State
(Diptera: Calliphoridae) University, Department of Biological Sciences, 300 Lee
Drain, Box 2116, Huntsville, TX 77341
Effects of Fluctuating Temperature and Ian Dadour, PhD*, and Sasha Voss, BSc, University of 353
Larval Density on Calliphora dubia Western Australia, Centre for Forensic Science, 35 Stirling
(Diptera: Calliphoridae) Implications for Highway, Nedlands, 6009, Australia
Postmortem Interval Estimation
The Composition and Succession of Soil David O. Carter, PhD*, Department of Plant Pathology, 353
Microbial Communities Following Cadaver University of Nebraska-Lincoln, 406 Plant Sciences Hall,
(Rattus rattus L.) Burial Lincoln, NE 68583-0722; David Yellowlees, PhD, School of
Pharmacy and Molecular Sciences, James Cook University,
Douglas, QLD 4811, Australia; and Mark Tibbett, PhD,
School of Earth and Geographical Sciences, University of
Western Australia, Crawley, WA 6009, Australia
Index 78
Nematode Community Dynamics David O. Carter, PhD*, Department of Plant Pathology, 354
Associated With Cadaver (Sus scrofa L.) University of Nebraska-Lincoln, 406 Plant Sciences Hall,
Decomposition and Insect Activity on the Lincoln, NE 68583-0722; Timothy E. Huntington, MSc, and
Soil Surface Leon G. Higley, PhD, Department of Entomology,
University of Nebraska-Lincoln, 202 Plant Industry,
Lincoln, NE 68583-0816; and Thomas O. Powers, PhD,
Department of Plant Pathology, University of Nebraska-
Lincoln, 406 Plant Sciences Hall, Lincoln, NE 68583-0722
Characterization of Adipocere Formation Shari L. Forbes, PhD*, University of Ontario Institute of 354
in Animal Species Technology, Faculty of Science, 2000 Simcoe Street, N,
Oshawa, Ontario L1H 7K4, Canada; and Barbara H.
Stuart, PhD, and Boyd B. Dent, PhD, University of
Technology, Sydney, Department of Environmental
Sciences, PO Box 123, Broadway, NSW 2007, Australia
Maggot Development During Morgue Timothy E. Huntington, MS*, Leon G. Higley, PhD, and 355
Storage and the Effects on Estimating the Frederick P. Baxendale, PhD, University of Nebraska,
Postmortem Interval Department of Entomology, 202 Plant Industry Building,
Lincoln, NE 68583
An Unusual Postmortem Change in a Child Paul P.S. Chui, MBBS, DMJ, MBA*, Health Sciences 355
Homicide—Leaching Authority, 11 Outram Road, Singapore, 289160, Singapore
Comparison Study of Various Protocols to Daniel E. Katz, MFS*, Delaware Office of the Chief 355
Release Maximal Amounts of Amplifiable Medical Examiner, 200 South Adams Street, Wilmington,
DNA From Decomposed Soft Tissue DE 19801; Timothy McMahon, PhD, Armed Forces DNA
Exposed to Different Environmental Identification Laboratory, 1413 Research Boulevard,
Conditions Building #101, 2nd Floor, Rockville, MD 20850; Arthur
Young, BS, National Medical Services, 3701 Welsh Road,
Willow Grove, PA 19090; Rebecca A. Kennedy, Cedar Crest
College, 100 College Drive, Allentown, PA 18104; Michelle
Malley, MSFS, Armed Forces DNA Identification
Laboratory, 1413 Research Boulevard, Building #101, 2nd
Floor, Rockville, MD 20850; and Rebecca E. Wallman, BS,
MS, Delaware Office of the Chief Medical Examiner, 200
South Adams Street, Wilmington, DE 19801
Eagles Syndrome: Case of an Elongated William C. Rodriguez III, PhD*, Office of the Armed Forces 356
and Ossified Stylohyoid Ligament in an Medical Examiner, 1413 Research Boulevard, Building 102,
Elderly Female Rockville, MD 20850; and Jack M. Titus, MD, and David R.
Fowler, MD, Office of the Chief Medical Examiner, 111
Penn Street, Baltimore, MD 21201
Where is the Head? A Case of Homicidal Sabina Di Donato, MD*, Carmela Fiore, MD, and 357
Decapitation Emanuela Turillazzi, MD, PhD, Department of Forensic
Pathology, University of Foggia, Viale Luigi Pinto, n.1,
Foggia, 71100, Italy
Simple Tissue Preservation Methods That Corinne L. Michaud, BS*, and David R. Foran, PhD, 357
Result in Reliable DNA Analyses Forensic Science Program, School of Criminal Justice, 560
Baker Hall, Michigan State University, East Lansing, MI
48824
Quantification and Amplification of Rayna L. Hebard, BS*, and Bruce R. McCord, PhD, Florida 358
MtDNA From Chemically Treated Hair International University, International Forensic Research
Institute, 11200 SW 8th Street, Miami, FL 33199; and
DeEtta K. Mills, PhD, Florida International University,
Forensic DNA Profiling Facility, 11200 SW 8th Street,
Miami, FL 33199
Index 79
What is Forensic Informatics? Gilbert E. Corrigan, MD, PhD*, East Baton Rouge 358
Coroner’s Office, 4030 T.B. Herndon Road, Baton Rouge,
LA 70808; and Sarah P. Corrigan, MS*, Reliagene
Technologies, Inc., 5525 Mounes Street, Suite 101, New
Orleans, LA 70123
Death in Custody: A Historical Analysis Jami R. Grant, PhD*, University of Baltimore, Forensic 359
Studies, 1420 North Charles Street, Baltimore, MD 21201;
Pamela E. Southall, MD*, and David R. Fowler, MD,
Maryland State Office of the Chief Medical Examiner, 111
Penn Street, Baltimore, MD 21201; and Shauna R. Scott,
University of Baltimore, Forensic Studies, 1420 N Charles
Simultaneous Diabetic Ketoacidosis and Erik D. Christensen*, Office of the Greenville County 359
Neuroleptic Malignant Syndrome in a Medical Examiner, 890 West Faris Road, Suite 110,
Patient on Olanzapine Greenville, SC 29605
An Unusual Case of Child Head Injury by Biagio Solarino, MD*, Sezione di Medicina Legale - 360
Coat Hanger Di.M.I.M.P. Universita degli Studi di Bari - Policlinico,
Bari, 70125, Italy; Amy M. Burrows-Beckham, MD, Office
of the Chief Medical Examiner, 810 Barret Avenue,
Louisville, KY 40204; and Kathy Recktenwald, RN, Clinical
Forensic Medicine, University of Louisville, 810 Barret
Avenue, Louisville, KY 40204
Adolescent Suicide Trends in the Third Andrea J. Harrison, BSN, RN*, Harris County Medical 360
Largest County in the United States Examiners Office, 1885 Old Spanish Trail, Houston, TX
77054; Sharon M. Derrick, PhD, Harris County Public
Health and Environmental Services, 2223 West Loop South,
Houston, TX 77027; and Stacey A. Mitchell, MSN, RN, and
Luis A. Sanchez, MD, Harris County Medical Examiners
Intraspecific Competition in the Blowfly Sandra Pearson*, Criminal Justice Program, Chaminade 361
Chrysomya megacephala (Diptera: University of Honolulu, 3140 Waialae Avenue, Honolulu,
Calliphoridae) Reared at Different HI 96816-1578; and M. Lee Goff, PhD, Chaminade
Densities University of Honolulu, 3140 Waialae Avenue, Honolulu,
HI 96816-1578
Comparison of Early Decomposition Reupena Sheck*, and M. Lee Goff, PhD, Chaminade 361
Between Domestic Pig Carcasses Hanging University of Honolulu, 3140 Waialae Avenue, Honolulu,
and in Contact With the Ground on Oahu HI 96816-1578
Island, Hawaii
A Preliminary and Pilot Study About Tsun-Ying Huang, MS*, Institute of Forensic Medicine, 361
Mitochondrial DNA Deletion in Sudden Ministry of Justice, 16, Lane 175, Tong-Hwa Street, Taipei,
Infant Death Syndrome: An Endemic 106, Taiwan, Republic of China; Chia-Tung Shun, AP,
Study in Taiwan National Taiwan University, College of Medicine, No. 1,
Jen Ai Road Section 1, Taipei, 100, Taiwan, Republic of
China; Jui-Ming Li, BS, Institute of Forensic Medicine,
Ministry of Justice, 16, Lane 175, Tong-Hwa Street, Taipei,
106, Taiwan, Republic of China; and Shu-Huei Kao, PhD,
Institute of Biomedical Technology, Taipei Medical
University, 250, Wu-Xing Street, Taipei, 110, Taiwan,
Republic of China
Index 80
Expression of Heat Shock Protein (hsp) 70 Heike Klotzbach, MD, PhD*, and Johanna Preuss, MD, 362
in Tissue of Different Human Organs After Institute for Legal Medicine, Stiftsplatz 12, Bonn, 53111,
Burn Fatalities Germany; Eberhard Lignitz, MD, PhD, Institute for Legal
Medicine, Kuhstrasse 30, Greifswald, 17489, Germany; and
Burkhard Madea, MD, PhD, Institute for Legal Medicine,
Stiftsplatz 12, Bonn, 53111, Germany
“Coca-Cola Man”: Sudden Death in a Wendy M. Gunther, MD*, Department of Legal Medicine, 362
Jailed Mentally Retarded Man After an Virginia Commonwealth University, Medical College of
Altercation Involving Police Virginia, 1101 East Marshall Street, Richmond, VA 23298-
0568
Estimating Time-of-Death by Body Anthony T. Paganini, PhD*, Michigan State University, 363
Temperature Analyses - A New A519 East Fee Hall, Division of Anatomy, Department of
Mathematical Strategy Radiology, East Lansing, MI 48824; and Thomas Adams,
PhD, Michigan State University, Department of Physiology,
2240B Biophysical Sciences Building, East Lansing, MI
48824
Photography of Abuse: Is There a Best Lynette Landon-Chellemi*, PO Box 523, 59-076 Pupukea 363
Method? Road, Haleiwa, HI 96712; and Wilson T. Sullivan III, MPA,
Chaminade University of Honolulu, Forensic Science
Department, 3140 Waialae Avenue, Honolulu, HI 96816
The Cave Man in the 21st Century: Cristoforo Pomara, MD*, Stefano D’Errico, MD, Sabina Di 364
Chronicle of an Announced Tragedy: Donato, MD, Marianna Di Padua, MD, Francesco M.
Preventive Measures and Repeating Risk Morreale, MD, Irene Riezzo, MD, and Margherita Neri,
MD, Institute of Forensic Pathology, Foggia University,
V.le Luigi Pinto 1, Foggia, 71100, Italy; and Giulio Zizzo,
MD, Radiology Department Ospedali Riuniti, V.le Luigi
Pinto 1, Foggia, 71100, Italy
Hypothermia-Related Deaths in Cook Wendy A. Lavezzi, MD*, Clare H. Cunliffe, MD, and 364
County, Illinois From November 2000 to Edmund R. Donoghue, MD, Cook County Medical
February 2005 Examiner’s Office, 2121 West Harrison Street, Chicago, IL
60612
Analysis of Gene Expression Patterns to Rixun Fang, PhD, Christine Shulse, BS, Pius Brzoska, PhD, 365
Identify Tissue and Body Fluid Specific and Manohar R. Furtado, PhD*, Applied Biosystems, 850
mRNA Species Using Real Time PCR Lincoln Center Dr., Foster City, CA 94404; and Chitra F.
Assays Manohar, PhD, Lawrence Livermore National Laboratory,
7000 East Ave, Livermore, CA 94550
Caveat Emptor: A Series of Deaths Related Morna L. Gonsoulin, MD*, Ashraf Mozayani, PhD, Terry 366
to Subcutaneous Silicone Injections in Danielson, PhD, and Luis A Sanchez, MD, Harris County
Transgender Males Medical Examiner’s Office, 1885 Old Spanish Trail,
Houston, TX 77054-2098
Anogenital Anatomy: Colposcopy to Study Sharon R. Crowley, MN, RN*, Forensic Clinical Nurse 366
the Appearance and Changes During the Specialist, 122 Emeline Avenue, Santa Cruz, CA 95060
Postmortem Interval
Unusual Suicide With Chain Saw: A Case Gilles Tournel, MD*, Fabrice Dedouit, MD, Anne Becart- 367
Report Robert, DDS, PhD, Nicolas Pety, MD, Valéry Hedouin,
Suicidal Hangings: A Growing Trend in Erin E. Falconer, MFS*, Danielle L. McLeod, MFS, and 368
Northern Virginia Todd M. Luckasevic, DO, Northern Virginia Office of the
Chief Medical Examiner, 9797 Braddock Road, Suite 100,
Fairfax, VA 22032
Index 81
DNA Done Right: Manner of Death Leah L. Bush, MD*, and Wendy M. Gunther, MD, Office of 368
Determination, Based on Evidence the Chief Medical Examiner, Tidewater District, 830
Obtained From a Belt at a Complex Scene Southampton Avenue, Suite 100, Norfolk, VA 23510
Involving a Decomposed Body
Guns That Fire Themselves: Report of Elizabeth L. Kinnison, MD*, and Wendy M. Gunther, MD, 369
Three Cases Department of Legal Medicine, Virginia Commonwealth
University, Medical College of Virginia, 1101 E Marshall
Street, Richmond, VA 23298-0568
Handgun to the Head: Suicide Trends in Erin E. Falconer, MFS, Danielle L. McLeod, MFS, and 369
Northern Virginia Todd M. Luckasevic, DO*, Northern Virginia Office of the
Fairfax, VA 22032
Evaluation of Less-Lethal Impact Richard T. Wyant, MS*, Washington State Patrol, 2203 370
Munitions Airport Way South, Suite 250, Seattle, WA 98134; and Chris
Myers, and Tom Burns, Seattle Police Department, 810
Virginia Street, Seattle, WA 98101
A First Time for Everything: Homicide Amy Tharp, MD*, and Donald Jason, MD, JD, Department 370
Involving the Brenneke® Super Sabot of Pathology, Wake Forest University Baptist Medical
Shotgun Slug Center, Medical Center Boulevard, Winston-Salem, NC
27157
Death by a Radio-Controlled Helicopter Ana E. Lopez, MD*, Harris County Medical Examiner, 370
1885 Old Spanish Trail, Houston, TX 77054; Luis A.
Sanchez, MD, Harris County Medical Examiner, 1885 Old
A Fatality Due to Atomoxetine - The First Kathryn Haden-Pinneri, MD*, 21827 Hollow Field Lane, 371
Known Case Katy, TX 77450
Methadone Deaths are on the Increase in Mary G. Ripple, MD*, Office of the Chief Medical 371
Maryland (1998-2004) Examiner, State of Maryland, 111 Penn Street, Baltimore,
MD 21201; Cheryl Rinehart*, Margaret Hsu, Erin
Artigiani, and Eric Wish, PhD, Center for Drug Abuse
MD 20740; and David R. Fowler, MD, Office of the Chief
Medical Examiner, State of Maryland, 111 Penn Street,
Baltimore, MD 21201
Methadone-Related Deaths: A Review of Lisa B. Shields, MD*, Donna M. Hunsaker, MD, and 372
Medical Examiner Cases in a Large Tracey S. Corey, MD, Office of the Chief Medical Examiner,
Metropolitan Area Urban Government Center, 810 Barret Avenue, Louisville,
KY 40204; John C Hunsaker III, MD, JD, Office of the
Associate Chief Medical Examiner, University of Kentucky
Department of Pathology and Laboratory Medicine, 100
Sower Boulevard, Suite 202, Frankfort, KY 40601-8272;
and Michael K Ward, MS, Kentucky Medical Examiner’s
Program, Office of Forensic Toxicology, 100 Sower Blvd
Suite 202, Frankfort, KY 40601
The Value of Expanded Postmortem Luis E. Remus III, PhD, MD*, Ashraf Mozayani, PhD, 373
Toxicology Testing Menu Terry Danielson, PhD, and Luis A, Sanchez, MD, Harris
County Medical Examiners Office, 1885 Old Spanish Trail,
Houston, TX 77054
Arteriovenous Malformation and its Anny Sauvageau, MD, MSc*, Laboratoire de Sciences 373
Implications in Forensic Pathology: A Case Judiciaires et de Médecine Légale, 1701 Parthenais Street,
Report 12th Floor, Montreal, Quebec H2K 3S7, Canada
Index 82
Sudden Death in the Young in Australia Johan A. Duflou, MBChB, MMed *, Department of Forensic 374
Medicine, PO Box 90, Glebe, NSW 2037, Australia; and
Rajesh Puranik, MBBS, Clara K. Chow, MBBS, Michael J.
Kilborn, DPhil and Mark A. McGuire, MBBS, PhD,
Department of Cardiology, Royal Prince Alfred Hospital,
Missenden Road, Camperdown, NSW 2050, Australia
Suicide Among 10 to 20 Year Olds in Cook Adrienne E. Segovia, MD, Clare H. Cunliffe, MD*, Mitra B. 374
County, Illinois: A Retrospective Review Kalelkar, MD, and Michelle Jorden, MD, Office of the
Medical Examiner, County of Cook, 2121 West Harrison
Street, Chicago, IL 60612
Immunohistochemical Examination of α- Annalisa Addante, MD, PhD*, Fiorenza Zotti, PhD, Andrea 375
Lactalbumin in SIDS (Sudden Infant Death Marzullo, MD, Alessandro Dell’Erba, MD, PhD, and
Syndrome) Massimo Collonna, MD, Section of Legal Medicine,
University of Bari, Piazza Giulio Cesare, Bari, 70124, Italy
Forensic Approach in a Case of Francesco M. Morreale, MD*, Irene Riezzo, MD, Stefano 376
Simultaneous Sudden Infant Death D’Errico, MD, and Raffaella Bisceglia, MD, Institute of
Syndrome Forensic Pathology Foggia University, V.le Luigi Pinto 1,
Infant Position and the Assessment of Risk Melissa A. Pasquale-Styles, MD*, Wayne County Medical 376
Factors for Asphyxia: A Review of 209 Examiner Office, 1300 East Warren Avenue, Detroit, MI
Sudden Unexpected Infant Deaths 48207; Patricia L. Tackitt, RN, MS, Michigan Public Health
Institute, 2438 Woodlake Circle, Suite 240, Okemos, MI
48864; and Carl J. Schmidt, MD, Wayne County Medical
Examiner Office, 1300 East Warren Avenue, Detroit, MI
48207
Hyperglycemic Hyperosmolar Nonketotic Mary E. Carr, MD*, and Andrew M. Baker, MD, Hennepin 377
Syndrome in a Sixteen-Month Old Child County Medical Examiner’s Office, 530 Chicago Avenue,
With Rotaviral Diarrhea Minneapolis, MN 55415
Starvation – Interpretation of Véronique Henn*, and Manfred Kleiber, PhD, Insitute of 377
Morphological Findings and Pitfalls Forensic Medicine Martin-Luther-University,
Franzosenweg 1, Halle, 06112, Germany; and Eberhard
Lignitz, PhD, Insitute of Forensic Medicine Ernst-Moritz-
Arndt-University, Kuhstr. 30, Greifswald, 17489, Germany
Perimacular Circular Folds in the Eyes of M.G.F. Gillland, MD*, Brody SOM at East Carolina 378
Injured Children University, Department of Pathology & Laboratory
Medicine, Brody 7 South 10, Greenville, NC 27834
Postmortem Detection and Evaluation of Patrick E. Lantz, MD*, and Constance A. Stanton, MD, 379
Retinal Hemorrhages Department of Pathology, Wake Forest University Health
Sciences, Medical Center Boulevard, Winston-Salem, NC
27157-1072
Examination of Sexually Abused Child: Nathalie S. Jousset, MD*, Department of Forensic 379
What is the Impact on Judgment? Medicine, University Hospital, Angers, 49033, France; and
Hubert C. Poirout, MD, Arnaud N. Gaudin, MD, Michel
Penneau, MD, PhD, and Clotilde G. Rougé- Maillart, MD,
Department of Forensic Medicine, 4 rue Larrey, Angers,
49033, France
Index 83
Sensitivity of Autopsy and Radiological Cristina Cattaneo, PhD, MD,* and Eloisa Marinelli, MD, 380
Examination in Detecting Bone Fractures Istituto di Medicina Legale, Università degli Studi, via
in an Animal Model: Implications for the Mangiagalli 37, Milano, 20133, Italy; Alessia Di
Assessment of Fatal Child Physical Abuse Giancamillo, DVM, PhD, Dipartimento di Scienze e
Tecnologie Veterinarie per la Sicurezza Alimentare, via
Celoria 10, Milano, 20133, Italy; Mauro Di Giancamillo,
DVM, and Olga Travetti, DVM, Dipartimento di Scienze
Cliniche Veterinarie, via Celoria 10, Milano, 20133, Italy;
and Laura Viganò, BSc, Pasquale Poppa, BSc, Davide
Porta, BSc, Andrea Gentilomo, MD, PhD, and Marco
Grandi, MD, Istituto di Medicina Legale, via Mangiagalli
37, Milano, 20133, Italy
“Homicide by Heart Attack” - An Unusual Dwayne A. Wolf, MD, PhD*, Harris County Medical 380
Pediatric Death Examiner Office, 1885 Old Spanish Trail, Houston, TX
77054
Index 84
2005
Deaths From Accidental Steam Inhalation Bhanwar Lal Bhootra, MD*, Department of Health, PO Box 382
During African Traditional Therapy 1944, Polokwane, Limpopo 0700, South Africa
Firearm Injuries in Angers: 1990 - 2000 Arnaud Gaudin, MD*, and Nathalie Jousset, MD, Service 382
de Médecine Légale, Centre Hospitalier Universitaire - 4
Rue Larrey, Angers, 49100 Cedex 01, France; Gilles
Tournel, MD, Service de Médecine Légale, Institut Médico-
Légal - Place Deverdun, Lille, 59000, France; and Michel
Penneau, MD, and Clotilde Rougé-Maillart, MD, Service de
Médecine Légale, Centre Hospitalier Universitaire - 4 rue
Larrey, Angers, 49100 Cedex 01, France
Evaluation of a Novel Tagging and Tissue Martin Grassberger, MD, PhD*, and Christina Stein, PhD, 382
Preservation System for Human Remains Department for Forensic Medicine, Medical University of
Vienna, Sensengasse 2, Vienna, A-1090, Austria; Stefan
Hanslik, PhD, Identilab Forensic Services, Handelskai 94-
96, Vienna, A-1200, Austria; and Manfred Hochmeister,
MD, Department for Forensic Medicine, Medical University
of Vienna, Sensengasse 2, Vienna, A-1090, Austria
Lesch-Nyhan Syndrome and Child Abuse Andrea M. Berzlanovich, MD*, Institute of Forensic 383
Medicine, University of Vienna, Sensengasse 2, Vienna,
1090, Austria; Martin Kraupp, MD, Department of Medical
Chemistry, Medical University of Vienna, Währinger Straße
10, Vienna, A - 1090, Austria; Johannes A. Hainfellner,
MD, and Herbert Budka, MD, Institute of Neurology,
Medical University of Vienna, Währinger Gürtel 18-20,
Vienna, A -1090, Austria; Wolfgang A. Keil, MD, Institute
of Forensic Medicine, University of Munich,
Frauenlobstraße 7a, Munich, D -80337, Germany; and
Barbara Fazeny-Dörner, MD, Department of Medicine I,
Medical University Vienna, Währinger Gürtel 18-20,
Vienna, A -1090, Austria
Determining a Postmortem Submersion John R. Wallace, PhD, Kathryn Zimmerman*, and Erin 384
Interval (PMSI) Based on Algal/Diatom High, Department of Biology, Caputo Hall, Millersville
Diversity on Decomposing Mammalian University, Millersville, PA 17551
Carcasses in Brackish Ponds in Delaware
Immunocompromised Female, Age 67, Darshan R. Phatak, MD*, Beth Israel Deaconess Medical 384
With an Angioinvasive Pulmonary Fungal Center, Pathology Department, 330 Brookline Avenue,
Abcess Boston, MA 02215
Teen Fatality by Train: A Multidisciplinary Mary H. Dudley, MD*, Sedgwick County Regional Forensic 385
Approach to Determination of Manner of Science Center, 1109 North Minneapolis, Wichita, KS
Death 67214
A Fatal Case Due to Abdominal Margherita Neri, MD*, Marianna Di Padua, MD, and 385
Compartment Syndrome (ACS) Emanuela Turillazzi, MD, PhD, Department of Forensic
Pathology, University of Foggia, Viale Pinto 1, Foggia,
71100, Italy
Index 85
Cane Corsos Attack: Two Fatal Cases Sabina Di Donato, MD*, and Emanuela Turillazzi, MD, 386
PhD, Institute of Forensic Medicine, University of Foggia,
Viale Luigi Pinto, 1, Foggia, 71100, Italy; Fernando
Panarese, MD, Department of Experimental and Clinical
Medicine, University of Magna Grecia, Policlinico
Universitario Catanzaro, Via Tommaso Campanella 115,
Catanzaro, 88100, Italy; Pietrantonio Ricci, MD,
Department of Experimental and Clinical Medicine
University of Magna Grecia, Policlinico Universitario
Catanzaro, Via Tommaso Campanella 115, Catanzaro,
88100, Italy
Fatal Dog Maulings Associated With Infant Albert Y. Chu, MD, MHS*, Carol Allan, MD, Mary G. 387
Swings Ripple, MD, Tasha Z. Greenberg, MD, and David R.
Contribution of Burn Injury in a Blunt John B. Davis, BS*, Eastern Virginia Medical School, 700 387
Trauma Case With Incineration West Olney Road, Norfolk, VA 23507-1607; and Leah L.
Bush, BS, and Wendy M. Gunther, MD, Office of the Chief
A Field Study of the Foraging Behavior of David L. Gibo, PhD*, and Deana Hathout, BSc, University 388
Blowfly Maggots of Toronto at Mississauga, 3359 Mississauga Road North,
Mississauga, Ontario L5L 1C6, Canada; Brent Walker, BA,
Conestoga College, Law and Security/Police Foundations,
School of Health Sciences and Community Services, 299
Doon Valley Drive, Kitchener, Ontario N2G 4M4, Canada;
and Brian Dixon, PhD, 1645 Howat Crescent, Mississauga,
Ontario L5J 4G6, Canada
Cavotricuspid Isthmus Rupture and Ezra Ellis, MD*, and Patrick E. Lantz, MD, Department of 388
Hemopericardium: A Delayed Pathology, Wake Forest University Health Sciences,
Complication of Cardiac Radiofrequency Medical Center Boulevard, Winston-Salem, NC 27157
Catheter Ablation
Sudden Death of a Fourteen-Year-Old Victor V. Frolov, MD*, Jeffrey M. Jentzen, MD, and John R. 389
Female With Hb S-C Disease Teggatz, MD, Milwaukee County Medical Examiner Office,
933 West Highland Avenue, Milwaukee, WI 53233
Interpreting Lesions to the Conduction Katarzyna Michaud, MD*, Thomas Krompecher, MD, Béat 389
System of the Heart in Case of Death Horisberger, MD, Marc Augsburger, PhD, Frank Sporkert,
Pursant to Cocaine Ingestion PhD, and Patrice Mangin, MD, PhD, Institut Universitaire
de Médecine Légale, Bugnon 21, Lausanne, 1005,
Switzerland
Defibrillator/Pacemaker Evaluation in the Lakshmanan Sathyavagiswaran, MD*, Daniel Rieders, MD, 390
Los Angeles County Medical Examiner and Joseph Muto, Department of Coroner, Los Angeles
Office County, 1104 North Mission Road, Los Angeles, CA 90033
Traumatic Cardiovascular Complications Edward J. Tweedie, MD*, London Health Sciences Centre, 390
of Catheter-Based Procedures: Relevance 339 Windermere Road, London, Ontario N6A 5A5, Canada
to Medicolegal Death Investigation
Index 86
Increasing Heart Valve Donation by Susan J. Roe, MD*, Regina Medical Center, 1175 Nininger 391
Utilization of a Cardiovascular Registry Road, Hastings, MN 55033; Shannon Mackey-Bojack, MD,
and Rachel M. Meuleners, Jesse E. Edwards
Cardiovascular Registry, 333 North Smith Avenue, Suite
4625, St. Paul, MN 55102; Lindsey C. Thomas, MD, Regina
Medical Center, 1175 Nininger Road, Hastings, MN 55033;
and Jack L. Titus, MD, PhD, Jesse E. Edwards
4625, St. Paul, MN 55102
A Review of Pathologic Findings in Shannon M. Mackey-Bojack, MD*, Jesse E. Edward’s 391
Specimens Following Heart Valve Donation Registry of Cardiovascular Disease, John Nasseff Heart
Hospital, 333 North Smith Avenue, Suite 4625, St. Paul, MN
55102; Susan J. Roe, MD, Rachel M. Meuleners, and
Lindsey C. Thomas, MD, Regina Medical Center, 1175
Nininger Road, Hastings, MN 55033; and Jack L. Titus,
MD, PhD, Jesse E. Edwards Registry of Cardiovascular
Disease, John Nasseff Heart Hospital, 333 North Smith
Avenue, Suite 4625, St. Paul, MN 55102
Sudden Death in a Calipatria State Prison Darryl J. Garber, MD*, Imperial County, California, Los 392
Inmate With a Single Coronary Artery Angeles County Coroner’s Office/Department of Medical
Examiner, 1104 North Mission Road, Los Angeles, CA
90033; and Henry Proo, Imperial County, California, 328
Applestill Road, El Centro, CA 92243
An Accident Waiting to Happen: The Aldo J. Fusaro, DO*, J. Scott Denton, MD, Adrienne E. 393
Chicago Porch Collapse of 2003 Segovia, MD, Edmund R. Donoghue, MD, and Eupil Choi,
MD, Cook County Medical Examiner’s Office, 2121 West
Harrison Street, Chicago, IL 60612; J. Lawrence Cogan,
MD, LA County Medical Examiner’s Office, 1104 North
Mission Road, Los Angeles, CA 90033; Mitra B. Kalelkar,
Forensic Medicine in France Eric Baccino, MD*, Laurent Martille, MD, and Anne 393
Dorandeu, MD, Service de Medecine Legale Chu de
Montpellier, Hospital Lapeyronie 371 av du Doyen G.
Giraud, Montpellier, 34295, France
Near Miss Incidents: Feasibility Studies David Best, PhD, Institute of Psychiatry, King’s College, De 394
Assessing Forensic Physicians’ Perceptions Crespigny Park, London, SE5 8AF, United Kingdom;
of Near Misses in Police Custody Suites in Siobhan Havis, MSc, Police Complaints Authority, 10 Great
London, United Kingdom George Street, London, SW1P 3AE, United Kingdom; and
Jason Payne-James, LLM, MB, FRCS, DFM*, Forensic
Healthcare Services, Ltd, 19 Speldhurst Road, Victoria
Park, London, E9 7EH, United Kingdom
Fatal Pulmonary Thromboembolism and James R. Gill, MD,and Susan F. Ely, MD*, OCME, 520 394
Hereditary Thrombophilias First Avenue, New York, NY 10016
An Expert Witness Requests Re-evaluation Anita K.Y. Wonder, MA*, Wonder Institute, PO Box 1051, 395
of SOP in Autopsy Reporting, Supported Carmichael, CA 95609-1051
With Case Examples
Index 87
Sudden Death Following Brief John W. Eisele, MD*, Forensic Consultants Medical Group, 395
Compression of the Neck 2291 March Lane, Suite 179E, Stockton, CA 95207; Gerald
J. Berry, MD, Stanford Pathology Consultants, 300 Pasteur
Drive, Room H-2110, Stanford, CA 94305; and Michael J.
Ackerman, MD, PhD, and David J. Tester, BS, Long QT
Syndrome Clinic and Sudden Death Genomics Laboratory,
Mayo Clinic College of Medicine, 200 First Street, SW,
Hilton 11, Rochester, MN 55905
The Spontaneous Oesophagus Perforation: Renaud Clement*, and Olivier Rodat, PhD, Department of 396
A Forensic Point of View Forensic Medicine, University of Nantes, 1 Rue Gaston
Viel, Cedex, 44 093, France
Human Wicks: The Almost Complete Phillip M. Burch, MD*, Office of the Medical Examiner, 396
Destruction of Major Portions of the 1300 Clark Avenue, St. Louis, MO 63117
Human Body by Fire Fueled at Least
Partly by the Body Fat of the Victim
DNA Extraction and Anthropological Nunzio Di Nunno, MD, PhD*, Sezione di Medicina Legale, 396
Aspects From 6th to 7th Century A.D. Bone Bari University, Piazza G. Cesare n. 11, Bari, 70125, Italy;
Remains Vito Scattarella, BSc, Sandro Sublimi Saponetti, BSc, and
Patrizia Emanuel, BSc, Bari University, Piazza G. Cesare n.
11, Bari, 70125, Italy; and Stefania Lonero Baldassarra,
BSc, and Cosimo Di Nunno MD, Sezione di Medicina
Legale, Bari University, Piazza G. Cesare n. 11, Bari,
70125, Italy
Risk Factor Analysis and Characteristics in Julia M. Braza, MD*, Karoly Balogh, MD,; and Anthony 397
Community Acquired MRSA Martyniak, MD, Beth Israel Deaconess Medical Center at
Harvard Medical School, 330 Brookline Avenue, Boston,
MA 02215
Commotio Cordis: Sudden Death Among Sunil K. Prashar, MD*, and Karoly Balogh, MD, Beth 397
Young People During Sporting and Israel Deaconess Medical Center, 330 Brookline Avenue,
Recreational Activities ES-112, Boston, MA 02115
Guidelines and Medical Malpractice in Luigi Viola, MD*, Nunzio Di Nunno, MD, PhD, Roberto 398
Minor Head Injury Management Quaranta, MD, Alessandro Dell’Erba, MD, PhD, and
Francesco Vimercati, MD, Bari University, Piazza Giulio
Cesare, 11, Bari, 70124, Italy
Sudden Death Due to Bilateral Joseph A. Felo, DO*, Cuyahoga County Coroner’s Office, 398
Spontaneous Pneumothoraces in a 11001 Cedar Avenue, Cleveland, OH 44106
Marijuana User
Venous Bullet Embolism of a Large Caliber Mary G. Ripple, MD*, and David R. Fowler, MD, Office of 399
Bullet From the Right External Iliac Vein the Chief Medical Examiner, State of Maryland, 111 Penn
to the Heart: Case Report and Review of Street, Baltimore, MD 21201
the Literature
Factors Affecting the Formation of Shari L. Forbes, BSc, PhD*, Centre for Forensic Science, 399
Adipocere in Soils University of Western Australia, M420, 35 Stirling
Highway, Crawley, WA 6009, Australia; Barbara Stuart,
PhD, Department of Chemistry, Materials and Forensic
Science, University of Technology, Sydney, PO Box 123,
Broadway, Australia, 2007; Boyd Dent, PhD, Department
of Environmental Sciences, University of Technology,
Sydney, PO Box 123, Broadway, Australia, 2007; and Ian
R. Dadour, BSc, PhD, Centre for Forensic Science,
University of Western Australia, M420, 35 Stirling
Highway, Crawley, WA 6009, Australia
Index 88
Seasonal Distribution and Abundance of Adrienne Brundage, MS*, 1250 A Edgewood Road, 400
Forensically Important Flies in Santa Clara Redwood, CA 94062
County
Establishing a Protocol Between Clinical Miguel Lorente, MD, PhD*, and A. Carrasco, Institute of 400
and Forensic Institutions to Treat and Legal Medicine of Granada (Spain), Av.Sur, 5, Granada,
Investigate Violence Against Women Cases 18071, Spain; José A. Lorente, MD, PhD, University of
Granada, Department of Forensic Medicine, Granada,
18012, Spain; Enrique Villanueva, MD, PhD, Department
of Legal Medicine, University of Granada, Avda. Madrid,
sn/, Granada, 18071, Spain
Analytical Electron Microscopic Detection Sarah M. Colvin, MD*, Carol Allan, MD, Laron Locke, 401
of Aluminum Received Intravenously MD, Mary G. Ripple, MD, and David R. Fowler, MD,
Office of the Chief Medical Examiner, State of Maryland,
111 Penn Street, Baltimore, MD 21201; and Victor Roggli,
MD, Duke University Health Systems, Department of
Pathology, Box 3712, DUMC, Durham, NC 27710
Evaluation of Clinical Diagnostic Accuracy Marianne Hamel, MD, PhD*, Department of Pathology, 401
in Post-Coronary Artery Bypass Graft Anatomy and Cell Biology, Thomas Jefferson University
Surgery Mortality Hospital, 125 South 11th Street, Suite 204 Foerderer
Pavilion, Philadelphia, PA 19107-4998; Johan A. Duflou,
MMed, Department of Forensic Medicine, Central Sydney
Laboratory Service, 42-50 Parramatta Road, Glebe, NSW
2037, Australia
Adolescent Death: A 15-Year Retrospective Nick I. Batalis, MD*, and Kim A. Collins, MD, Medical 402
Study University of South Carolina, 165 Ashley Avenue, Main
Hospital, Room 281, Charleston, SC 29425
Heightened Awareness of Bioterrorism: John A. Stash, DO*, Zabiullah Ali, MD, Carol Allan, MD, 402
Three Cases of Unusual Skin Lesions Ana Rubio, MD, Mary G. Ripple, MD, and David R.
Amended Cause and Manner of Death Philip R. Croft, MD*, Sarah L. Lathrop, DVM, PhD, and 403
Certification: A Six-Year Review of the Ross E. Zumwalt, MD, Office of the Medical Investigator,
New Mexico Experience MSC11 6030, 1 University of New Mexico, Albuquerque,
NM 87131-0001
The Relationship of Drug Abuse to Amy C. Gruszecki, DO*, Jefferson County Coroner Medical 403
Unexplained Sudden Death Examiner Office, 1515 6th Avenue South, Suite 611,
Birmingham, AL 35233; Gerald McGwin, Jr., PhD,
Department of Epidemiology, School of Public Health,
University of Alabama, Birmingham, AL 35233; C. Andrew
Robinson, PhD, Department of Pathology, Forensic
Division, University of Alabama, Birmingham, AL 35233;
and Gregory G. Davis, MD, MSPH, Jefferson County
Coroner Medical Examiner Office, 1515 6th Avenue South,
Suite 611, Birmingham, AL 35233
Natural Causes of Death Among a Federal Peter T. Lin, MD*, and Eric A. Pfeifer, MD, Mayo Clinic, 404
Medical Center Prison Population 200 First Street, SW, Hilton 11, Rochester, MN 55905
Distribution Pattern of Pulmonary Carlo P. Campobasso, MD, PhD*, Alessandro S. 405
Surfactant Protein A (SP-A) in Drowning Dell’Erba, MD, PhD, Annalisa Addante, MD, PhD,
and Opiate-Related Deaths Fiorenza Zotti, PhD, Sara Sblano, MD, and Massimo F.
Colonna, MD, LLB, Section of Legal Medicine
(Di.M.I.M.P.), University of Bari, Piazza Giulio Cesare,
Policlinico di Bari, Bari, 70124, Italy
Index 89
Drowning vs. Trauma and Other Causes of Karen B. Looman, DO*, Pathology Residency Program, 405
Asphyxia in Deaths in Water Eastern Virginia Medical School, 700 West Olney Road,
Norfolk, VA 23507-1607; Wendy M. Gunther, MD, Office of
the Chief Medical Examiner, Tidewater District, 830
Southampton Avenue, Suite 100, Norfolk, VA 23510-1046;
and E.L. Kinnison, Office of the Chief Medical Examiner,
Tidewater District, 830 Southampton Avenue, Suite 100,
Norfolk, VA 23510-1046
Study of the Diagnostic Value of Iron in Geoffroy Lorin de la Grandmaison, MD*, M. Lettereux, 406
Freshwater Drowning PharmD, K. Lasseguette, MD, J.C. Alvarez, PharmD,
Philippe de Mazancourt, MD, PhD, and Michel Durigon,
MD, PhD, Department of Forensic Pathology, Raymond
Poincare Hospital, Garches, 92 380, France
Elder Abuse and Neglect Death Review: Christopher Swalwell, MD*, Medical Examiner’s Office, 406
Use of an Interagency Team San Diego County, 5555 Overland Avenue, Building 14, San
Diego, CA 92123
Adolescent and Young Adult Suicide: A Lisa B. Shields, MD*, and Donna M. Hunsaker, MD, Office 407
Ten-Year Retrospective Review of of the Chief Medical Examiner, 810 Barret Avenue,
Kentucky Medical Examiner Cases Louisville, KY 40204; John C. Hunsaker III, JD, MD, Office
of the Associate Chief Medical Examiner, Department of
Pathology & Laboratory Medicine, 100 Sower Boulevard,
Suite 202, Frankfort, KY 40601-8272; and Michael K.
Ward, BS, Kentucky Forensic Toxicology Laboratory,
Office of Forensic Toxicology, 100 Sower Blvd, Frankfort,
KY 40601
Which Field Method is Best? A Kenneth G. Schoenly, PhD*, Department of Biological 407
Comparative Study of Four Entomological Sciences, California State University, Stanislaus, Turlock,
Methods for Sampling Forensically CA 95382; Neal H. Haskell, PhD, Department of Biology,
Important Arthropods on Human and Saint Joseph’s College, Rensselaer, IN 47978; and Robert
Porcine Remains at the Anthropology D. Hall, PhD, JD, Department of Entomology, 1-87
Research Facility in Knoxville, Tennessee Agriculture Building, University of Missouri, Columbia,
MO 65211
The Decomposition of a Pig Carcass in a Anthony R. Russo, PhD*, Chaminade University of 408
Mesophytic Biotope, Oahu, Hawaii Honolulu, Forensic Science, 3140 Waialae Avenue,
Honolulu, HI 96816
A Comparison of Pig and Human Tissue in Charlotte A. Wacker, MS*, University of California, Davis- 408
Studies of Decomposition: Can Flies Tell Department of Cell Biology and Human Anatomy, One
the Difference? Shields Avenue, Tupper Hall Room 3301, Davis, CA 95616;
Lawrence Stutler, MS, University of New Haven, School of
Public Safety and Professional Studies, 300 Orange Avenue,
West Haven, CT 06516; Brandi J. Schmitt, MS, University
of California, Davis-Department of Cell Biology and
Human Anatomy, One Shields Avenue, Tupper Hall Room
3301, Davis, CA 95616; and Rebecca A. Bullard, MS and
Robert B. Kimsey, PhD, University of California, Davis,
Department of Entomology, One Shields Avenue, Davis, CA
95616
Index 90
Inter-Observer Variability in Entomology- Rebecca A. Bullard, MS*, University of California, Davis, 409
Based PMI Estimates: A Single Blind Study Department of Entomology, One Shields Avenue, Davis, CA
95616; Kenneth G. Schoenly, PhD, California State
University, Stanislaus, Department of Biological Sciences,
Turlock, CA 95382; and Robert Kimsey, PhD, University of
California, Davis, Department of Entomology, One Shields
Avenue, Davis, CA 95616
Viral Testing of Adult Mosquitoes Justin M. Godby, BS*, Marshall University, 1401 Forensic 409
Collected in West Virginia for West Nile Science Drive, Huntington, WV 25701
Virus Using NASBA Assay
An Instructional DVD on Collecting Ryan K. Kimbirauskas, MS*, Richard W. Merritt, PhD, and 409
Entomological Evidence for Court Eric M Benbow, PhD, Michigan State University, 243
Natural Science Building, East Lansing, MI 48824; John R.
Wallace, PhD, Millersville University, 1 South George
Street, Millersville, PA 17551; and Jeff K. Tomberlin, PhD,
Texas A & M University, 1229 North U.S. Highway 281,
Stephenville, TX 76401
How Cadaver Decomposition in Soil is Mark Tibbett, PhD*, Centre for Land Rehabilitation, School 410
Affected by Moisture: Part I: A Field of Earth and Geographical Sciences, University of Western
Experiment to Investigate Seasonal Effects Australia, Crawley, WA 6009, Australia; and David O.
Carter, MSc, and David Yellowlees, PhD, School of
Douglas, QLD 4811, Australia
How Cadaver Decomposition in Soil is David O. Carter, MSc*, School of Pharmacy and Molecular 410
Affected by Moisture: Part II: A Sciences, James Cook University, Douglas, QLD 4811,
Controlled Laboratory Experiment Australia; Mark Tibbett, PhD, Centre for Land
University of Western Australia, Crawley, WA 6009,
Australia; and David Yellowlees, PhD, School of Pharmacy
and Molecular Sciences, James Cook University, Douglas,
QLD 4811, Australia
Clinically Stable Skull Fracture and Fatal Christie L. Elliott, MD*, Forensic Pathology Consultants, 411
Acute Pneumonia: An Unexpected PO Box 12815, Reno, NV 89510-2815
Combination
The Dangers of Dumpster Diving: Deaths Leah L. Bush, MD*, Office of the Chief Medical Examiner, 411
Associated With Garbage Collection in the Tidewater District, Commonwealth of Virginia, 830
Tidewater Region of Virginia Southampton Avenue, Suite 100, Norfolk, VA 23510-1046;
and Wendy M. Gunther, MD, Office of the Chief Medical
The Differential Diagnosis Between Maurice Rogev, MD*, Zamenhof 11, Tel Aviv 64373, Israel 412
Bioterrorism and Zoonosis and Spread to
Humans: A Patholical Evaluation
Suicides Among Youth in Geneva, Guillaume Perret*, Département de Psychiatrie, Clinique 412
Switzerland From 1993 to 2002 de Psychiatrie Adulte, HÙG, Secteur Jonction, Bvd Saint-
Georges 16-18, Geneva, 1205, Switzerland; Abliz
Abudureheman, MD, Institut Universitaire de Médecine
Légale de Genève, 9 Av de Champel, Geneva, 1211,
Switzerland; Maja Perret-Catipovic, PhD, Département de
Psychiatrie, Unité, Bd de la Cluse 51, Geneva, 1205,
Switzerland; and Romano La Harpe, MD, Institut
Universitaire de Médecine Légale de Genève, C.M.U, 9 av
de Champel, Geneva, 1211, Switzerland
Index 91
Suffocation by Mistaken Use of a K. Alan Stormo, MD*, Jeffrey M. Jentzen, MD, Mary K. 413
Biohazard Hood as a “Spit” Hood Mainland, MD, John R. Teggatz, MD, and Victor V. Frolov,
MD, Milwaukee County Medical Examiner, 933 West
Unsuspected Pheochromocytoma Sophie Gromb, PhD*, Nadia Khaldi, MD, Larbi Benali, 413
Discovered During Autopsy After Sudden MD, Mathurin Djodjo, MD, and Alain Miras, PhD,
and Unexpected Death in an Expectant Department of Forensic Medicine - EA 3676 - IFR 99 of
Mother Public Health, CHU Pellegrin - Place Amélie Raba- Léon,
Bordeaux, 33076, France
Modeling Languages in Forensic Pathology Gilbert E. Corrigan, MD, PhD*, East Baton Rouge 413
Coroner’s Office, 4030 T.B. Hearndon Avenue, Baton
Rouge, LA 70807
Polyarteritis Nodosa as a Rare Case of Wolfgang A. Keil, MD*, and Felicitas Dahlmann, MD, 414
Sudden Death in Postmortem Diagnosis Institute of Forensic Medicine, Ludwig-Maximilians-
University Munich, Frauenlobstraße 7a, Munich, D80337,
Germany; and Andrea M. Berzlanovich, MD, Institute of
Forensic Medicine, Medical University Vienna, Sensengasse
2, Vienna, A1090, Austria
Autopsy Findings in Hypothermia: A Five Patricia A. Aronica-Pollak, MD*, Jack M. Titus, MD, and 414
Year Retrospective Study David R. Fowler, MD, Office of the Chief Medical
MD 21201
Color Me Guilty: The Role of Paint Diane Scala-Barnett, MD*, and Julie M. Saul, BA, Lucas 415
Transfer in Weapon Linkage County Coroner’s Office, 2595 Arlington Avenue, Toledo,
OH 43614-2674
The Role of Forensic Insects in Deposition Rebecca J. Kirby*, Anita L. Guedea, Phillip L. Watson, 415
of Pollen at a Death Scene PhD, Roger E. Mitchell, PhD, and Scott M. Herron, PhD,
Ferris State University, Department of Biology, Big Rapids,
MI 49307
Experimental Evaluation of Rigor Mortis - Thomas Krompecher, MD*, André Gilles, MD, Conxita 416
The Influence of the Central Nervous Brandt- Casadevall, MD, Beat Horisberger, MD, and
System on the Evolution of the Intensity of Patrice Mangin, MD, Institut Universitaire de Médecine
Rigor Mortis Légale, Rue du Bugnon 21, Lausanne, 1005, Switzerland
β—Phenylethylamine as a Biomarker in Wen-Ling Lin, PhD*, and Kai-Ping Shaw, MD, PhD*, 416
Mechanical Asphyxia-Related Fatalities Institute of Forensic Medicine, Ministry of Justice, Republic
of China, 161-1, Section 2, Keelung Road, Taipei, 106,
Taiwan, Republic of China
Forensic Pathologists and the NICHD Ling Li, MD*, David R. Fowler, MD, and Ana Rubio, MD, 417
Brain and Tissue Bank for Developmental Office of the Chief Medical Examiner, State of Maryland,
Disorders 111 Penn Street, Baltiomre, MD 21201; and Ronald Zielke,
PhD, University of Mayland, Department of Pediatrics,
Brain, and Tissue Bank for Developmental Disorders, 655
West Baltimore Street, Baltimore, MD 21201
Causes of Death Among People in the Gilles Tournel, MD*, Anne A. Bécart-Robert, DDS, PhD, 417
Prison of Loos (Northern France), 1997- Valéry C. Hédouin, MD, PhD, and Didier Gosset, MD,
2003 PhD, Institut de Médecine Légale, 1, Place de Verdun, Lille,
59 000, France
Rathke’s Cleft Cyst: Alleged “Brain Bridget B. Eutenier, BS*, and Karen B. Looman, Pathology 418
Tumor” in a Middle-Aged Cocaine Abuser Resident Program, Eastern Virginia Medical School, 700
West Olney Road, Norfolk, VA 23510-1046; Wendy M.
Gunther, MD, Office of the Chief Medical Examiner,
Index 92
Microscopic Soft Tissue Decomposition and Murray K. Marks, PhD*, and Mariateresa A. Tersigni, MA, 418
Time Since Death University of Tennessee, Department of Anthropology, 250
South Stadium Hall, Knoxville, TN 37996; and Darinka X.
Mileusnic, MD, PhD, University of Tennessee Medical
Center, Knox County Medical Examiner’s Office, 1924
Alcoa Highway, Knoxville, TN 37920
An Atypical Gunshot Wound With Absence Clare H. Cunliffe, MD*, Office of the Medical Examiner, 419
of a Weapon? The Value of a Thorough County of Cook, 2121 West Harrison Street, Chicago, IL
Scene Investigation 60612
Suicide or Homicide - The Importance of Giancarlo Di Vella, MD, PhD*, Alessandra Arpaio, MD, 419
Forensic Evidence: A Case Study Claudia Liuzzi, MD, and Francesco Vinci, MD, University
of Bari, Di.M.I.M.P. - Sezione di Medicina Legale -
Determination of Range of Fire in Skeletal Kathryn Haden, MD*, Office of the Chief Medical 420
Remains Examiner, Northern Virginia District, 9797 Braddock Road,
Fairfax, VA 22032; Jill Urban, MD, and Karen Hendley,
The Southwestern Institute for Forensic Sciences, 5230
Medical Center Drive, Dallas, TX 75235
A Modern “Martyr’s Crown”: A Fatal Francesco Maria Morreale, MD*, Christoforo Pomara, 421
Case of Multiple Self-Inflicted Nail Gun MD, and Stefano D’Errico, MD, Institute of Legal
Shots Medicine, University of Foggia, Ospedali Riuniti, via L.
Pinto 1, Foggia, I-71100, Italy; and Rocco Maglietta, MD,
Hospital San Carlo, Potenza, I-85100, Italy
.17 HMR – It’s Not Your Father’s .22 J.C. Upshaw Downs, MD*, Coastal Regional Laboratory 421
Georgia Bureau of Investigation, 925A Mohawk Street,
Savannah, GA 31419; and Ron Van Fleet, BS, Donelle L.
Pyle, MS, and Shannon Walden, Georgia Bureau of
Investigation, 925A Mohawk Street, Savannah, GA 31419
A Shot In the Dark? Investigating J.C. Upshaw Downs, MD*, Donelle L. Pyle, MS, Ron Van 421
Accidental Gunshot Wounds Fleet, BS, and Shannon Walden, Coastal Regional
Laboratory Georgia Bureau of Investigation, 925A Mohawk
Street, Savannah, GA 31419
Utilization of Automated Fingerprint Kelly L. Hickey, MD*, Marcella F. Fierro, MD, and 422
Identification System (AFIS) to Aid in the Timothy A. Powell, MPH, Office of the Chief Medical
Identification of Unknown Perpetrators to Examiner, 400 East Jackson Street, Richmond, VA 23219;
Close Unsolved Cases andRobin Young, Division of Forensic Science, 700 North
5th Street, Richmond, VA 23219
Dead Hits: Matching Decedents’ DNA to Todd M. Luckasevic, DO*, Marcella F. Fierro, MD, and 422
Unsolved Crime Scenes Timothy A. Powell, MPH, Office of the Chief Medical
Examiner, 400 East Jackson Street, Richmond, VA 23219;
and George C. Li, MS, Linda Johnston, BS, and Deanne F.
Dabbs, MFS, Division of Forensic Science, 700 North 5th
To Dye or Not to Dye: A Tale of the Blues Sharon R. Crowley, RN, MN *, 122 Emeline Avenue, Santa 423
Cruz, CA 95060; Brian L. Peterson, MD, Forensic Medical
Group, 1860 Pennsylvania Avenue, Fairfield, CA 94533
Postmortem Monocular Indirect Patrick E. Lantz, MD*, Department of Pathology, Wake 424
Ophthalmoscopy Forest University Health Sciences, Medical Center
Boulevard, Winston-Salem, NC 27157; and Gill G.W.
Adams, BSc, MBChB, Moorfields Eye Hospital, 162 City
Road, London, EC1V 2PD, United Kingdom
Index 93
Multislice Computed Tomography In Klaus Poulsen, MD*, and Jørn Simonsen, MD, Institute of 424
Forensic Pathology Forensic Medicine, Frederik Vs Vej 11, Copenhagen, 2100,
Denmark
Murder in the Ancient Castle: A XIV Cristoforo Pomara, MD*, Institute of Legal Medicine, 425
Century Warrior Virtual Autopsy University of Foggia, Viale Pinto 1, Foggia, 71100, Italy;
Angelo Marrone, MD, Diagnostic Immaging Department,
ASL Foggia 2, Cerignola (Fg), Via Trinitapoli, Foggia,
71042, Italy; Stefano Ricci, MD, PhD, Anthropological
Laboratory, Department of Environmental Science,
University of Siena, Via Mattioli n. 4, Siena, 53100, Italy;
Irene Riezzo, MD, Institute of Legal Medicine, University of
Foggia, Viale Luigi Pinto, 1, Foggia, 71100, Italy
19th Century Autopsy Techniques: Failing O’Brian C. Smith, MD*, and Teresa A. Campbell, MD, 381 425
to Meet 21st Century Forensic Science Cherry Hollow CV, Cordova, TN 38018; Elayne J. Pope,
Needs MA, Department of Anthropology, University of Arkansas,
Fayetteville, AR 72701; Chantal Ferraro, PhD, C.W. Post
Campus, Long Island University, Brookville, NY 11548; and
Alexandr Senilnikov, MD PhD, Regional Forensic Center,
1060 Madison AV, Memphis, TN 38104
Diesel Fumes Do Kill: A Case of Fatal Sean M. Griffin, MS*, and Donna M. Hunsaker, MD, Office 426
Carbon Monoxide Poisoning Directly of the Chief Medical Examiner and the University of
Attributed to Diesel Fuel Exhaust Louisville Department of Pathology and Laboratory
Medicine, 810 Baxter Avenue, Louisville, KY 40204-1702;
Kiran Charturvedi, MD, University of Kentucky Medical
Center Department of Pathology and Laboratory Medicine,
University of Kentucky, 800 Rose Street, Lexington, KY
40536; Michael K. Ward, BS, KY State Forensic Toxicology
Laboratory, 100 Sower Boulevard, Frankfort, KY 40601;
and Andrea R. Terrell, PhD, American Institute of
Toxicology, 2265 Executive Drive, # A, Indianapolis, IN
46241
Sublingual Tablet Thwarts Opioid William Vilensky, DO, RPh*, Forensic & Educational 426
Addiction Consultants, 2113 Harbourside Drive, Longboat Key, FL
34228
An Analysis of 35 Ethylene Glycol J. Scott Denton, MD*, Valerie Arangelovich, MD, Michel 427
Fatalities in Cook County, Illinois From Humilier, MD, and Edmund R. Donoghue, MD, Cook
1993 Through 2003 County Medical Examiner’s Office, 2121 West Harrison
Patterns of Illicit Drug Use of Prisoners in Jason Payne-James, LLM, MB, FRCS, DFM*, Ian Wall, 428
Police Custody in London, United Kingdom LLM, MRCGP, and Caroline Bailey, Forensic Healthcare
Services, Ltd., 19 Speldhurst Road, Victoria Park, London,
E9 7EH, United Kingdom
Child Homicides in Hong Kong: A Philip S.L. Beh, MBBS, DMJ*, Department of Pathology, 428
Retrospective Review of a Ten-Year Period The University of Hong Kong, Room 126, University
From 1989-1998 Pathology Building, Queen Mary Hospital, Hong Kong,
Hong Kong SAR, China; and R.G. Broadhurst, Department
of Sociology, The University of Hong Kong, Room 126,
Hong Kong SAR, China
Index 94
Evolution of the Intentional Injury Infant Gilles Tournel, MD*, Institut de Médecine Légale, 1, Place 429
Syndrome in Northern France de Verdun, Lille, 59 000, France; Marie Desurmont, MD,
Institut de Médecine Légale, 10 Rue F Villon, Lille, 59 000,
France; Valéry C. Hédouin, MD, PhD, Institut de Médecine
Légale, 1, Place de Verdun, Lille, 59 000, France; Didier
Gosset, MD, PhD, Institut de Médecine Légale, 10 Rue F
Villon, Lille, 59000, France
Breath Holding Spells Associated With Kathryn K. Berg, MD*, Daniel W. Davis, MD, and Andrew 429
Unexpected Sudden Childhood Death M. Baker, MD, Hennepin County Medical Examiner’s
Office, 530 Chicago Avenue, Minneapolis, MN 55415
An Interdisciplinary Approach for Heike Klotzbach, MD, PhD*, Institute of Legal Medicine, 430
Diagnosis and Age Estimation of Infants’ Hamburg University, Butenfeld 34, Hamburg, 22529,
Fractures in the Course of the Autopsy Germany; Guenther Delling, PhD, Institute of Pathology,
Department of Osteo-Pathology, Hamburg University,
Lottestrasse 2, Hamburg, 22529, Germany; Erich Richter,
PhD, Institute of Radiology, Department of Pediatric
Radiology, Martinistrasse 52, Hamburg, 20246, Germany;
and Klaus Pueschel, PhD, Institute of Legal Medicine,
Hamburg University Butenfeld 34, Hamburg, 22529,
Germany
Are Retinal Hemorrhages Diagnostic of Christopher J. Plourd, JD*, 1168 Union Street, Suite 303, 430
Shaken Baby Syndrome? What Really San Diego, CA 92101-3818
Killed Baby Cooper
Fatal Craniocerebral Trauma With Amy M. Tharp, MD*, and Patrick E. Lantz, MD, 431
Hemorrhagic Retinopathy in an Infant: Department of Pathology, Wake Forest University Health
Abuse or Accident? Sciences, Medical Center Boulevard, Winston-Salem, NC
27157
The Evidence-Based Medicine Paradigm M.G.F. Gilliland, MD*, Brody School of Medicine at East 431
Shift and Forensic Pathology Carolina, Department Pathology and Laboratory Medicine,
Brody 7 S 10, Greenville, NC 27834
Sequential SIDS or Double Homicide? Stacy A. Drake, MSN, RN*, Teresa Royer, MSN, RN, 432
Challenges of Delayed Investigation of Stephen K. Wilson, MD, Dwayne A. Wolf, MD, PhD, Ashraf
Potential “Subtle” Child Homicides Mozayani, PharmD, PhD, and Luis A. Sanchez, MD, Harris
County Medical Examiner Office, 1885 Old Spanish Trail,
Houston, TX 77054
Case Presentation: Infant Death Due to Eugene L. Hart, MD*, Bonita Fung, MD, Ana Lopez, MD, 433
Epidermolysis Bullosa and Luis A. Sanchez, MD, Harris County Medical
77054-2098
Child Abuse by Another Child: Can it Darinka Mileusnic-Polchan, MD, PhD*, University of 433
Happen? Tennessee Medical Center, Knox County Medical
Examiner’s Office, 1924 Alcoa Highway, Knoxville, TN
37920; and Sharon O’Connor, Cook County Office of the
Medical Examiner, 2121 West Harrison Street, Chicago, IL
60612
Acute Pancreatitis in a 2½-Year-Old Child: Cristin M. Rolf, MD*, and Heather Worne, BS, University 433
A Fatal Therapeutic Complication of of Kentucky, Department of Pathology and Laboratory
Polyethylene Glycol (PEG)-L-Asparaginase Medicine/ Office of the Associate Chief Medical Examiner,
Kentucky Justice and Public Safety Cabinet, 100 Sower
Boulevard, Suite 202, Frankfort, KY 40601-8272
Index 95
Increased Risk of Sudden Infant Death D. Larry Sparks, PhD*, Sun Health Research Institute, 434
Syndrome (SIDS) Among Infants 10515 West Santa Fe Drive, Sun City, AZ 85351; Rob
Harboring the Apolipoprotein E-4 Allele: Friedland, MD, Bob Petersen, PhD, Ellen Grady, MS, and
Genetic and Pathologic Similarities to Sandra Richardson, PhD, Case Western Reserve University,
Alzheimer’s Disease (AD) 10900 Euclid Avenue, Cleveland, OH 44106; and Cristin M.
Rolf, MD, and John C. Hunsker III, MD, JD, Division of
Medical Examiner Services, Kentucky Justice and Public
Safety Cabinet, 100 Sower Boulevard, Suite 202, Frankfort,
KY 40601-8272
Ano-Genital Findings in Sexually Abused Lene Aagaard Nielsen, MD, and Soren J. Mikkelsen, MD, 435
Children in Cases With a Conviction Children and Adolescent Psychiatric Hospital, University
Hospital of Aarhus, 66 H. Selmersvej, Risskov, DK-8000,
Denmark; and Annie Vesterby, MD, DMSci*, Department of
Forensic Medicine, University of Aarhus, Children abd
Adolescent Psychiatric Hospital of Aarhus, P. Sabroes
Gade 15, Aarhus, DK-8000, Denmark
The Contribution of Computerized Image Beat Horisberger, MD*, and Patrice Mangin, MD, PhD, 435
Analysis to the Diagnosis of Munchausen Institute of Legal Medicine, University of Lausanne, Rue du
Syndrome by Proxy Bugnon 21, Lausanne, 1005, Switzerland
Index 96
2004
Penetrating Wound of Head by Slingshot: Bhanwar Lal Bhootra, MD*, Forensic Pathology Services, 437
Medicolegal Aspects Limpoo Province, PO Box 1944, Polokwane, 0700, South
Africa
Suicide by Hanging in Children Ziadi Arbia* and Chadly Ali, MD, Department of Forensic 437
Medicine, University Hospital Fattouma Bourguiba,
Monastir, 5000, Tunisia
The Effects of Liquid Bleach on Pig Lauren E. Way* and John R. Wallace, PhD, Department of 437
Decomposition in Southeastern Biology, Millersville University, PO Box 1002, Millersville,
Pennsylvania PA 17551
The Use of Whole Body Donors in Forensic Charlotte A. Wacker, MS* and Brandi J. Schmitt, MS, 438
Research University of California, One Shields Avenue, 3301 Tupper
Hall, Davis, CA 95616
Pediatric Homicides Related to Burn William F. Zaloga, DO*, Wake Forest University Baptist 438
Injury Medical Center, Department of Pathology, Medical Center
Drive, Winston- Salem, NC 27157; Kimberly A. Collins,
MD, Medical University of South Carolina, 171 Ashley
Avenue, Charleston, SC 29425
Insect Succession Studies on Pig Carrion in Kimberly L. Tabor, BA, MS*, Richard D. Fell, PhD, and 438
Southwest Virginia and the Effects of Carlyle C. Brewster, PhD, Virginia Tech, 216 Price Hall,
Antemortem Ethanol Ingestion on Insect Blacksburg, VA 24061; Kevin Pelzer, DVM, Virginia Tech
Succession and Development School of Veterinary Medicine, Blacksburg, VA 24061;
George S. Behonick, PhD, Department of Criminal Justice
Services, Division of Forensic Sciences, 6600 Northside
High School Road, Roanoke, VA 24019
The Detection of Saliva: Factors Affecting Melissa S Kell, BSc*, Wendy Lalonde, BSc, Roger Frappier, 439
the Phadebas® Press and Tube Tests MSc, and Jonathan Newman, BSc, Centre of Forensic
Sciences, 25 Grosvenor Street, Toronto, ON M7A 2G8,
Canada
Places to Commit Suicide Istvan F. Szentmariay, MD*, Institute of Forensic Medicine, 440
Semmelweis University, Ulloi UT 93, Budapest, H-1091,
Hungary
Dramatic Rise in Methadone-Related Ronalod F. Distefano, DO*, Office of the Chief Medical 440
Deaths in Oklahoma 1990-2002 Examiner, State of Oklahoma, 1115 West 17th Street, Tulsa,
OK 74107
Fatal Botox®-Induced Anaphylaxis? A Melissa Li, MD*, University of Florida College of 440
Case Report Medicine, PO Box 100275, 1600 SW Archer Road,
Gainesville, FL 32610-0275; Bruce A. Goldberger, PhD,
University of Florida, PO Box 100275, Gainesville, FL
32610-0275; Carolyn Hopkins, MD, District 8 Medical
Examiner’s Office, 606 SW 3rd Avenue, Gainesville, FL
32601
Significant Trends in Work-Related Deaths Gordon K. Murphy, MD*, 814 Hathaway Road, Dayton, 441
— United States OH 45419-3555
Over Diagnosis of Low Voltage Ronald K. Wright, BS, MD, JD*, 2101 SW 29th Avenue, 441
Electrocution Fort Lauderdale, FL 33312
Accidental Parachuting Death Due to Martha J. Burt, MD and Matthew J. Bowes, MD*, Miami- 442
Equipment Failure Dade County Medical Examiner Department, Number One
on Bob Hope Road, Miami, FL 33136
Index 97
The Richard Cory Phenomenon: Suicide Thomas W. Young, MD*, Jackson County Medical 443
and Socioeconomic Status in Kansas City, Examiner, 660 East 24th Street, Kansas City, MO 64108;
Missouri Suzanna Wooden, University of Missouri, Kansas City
School of Medicine, 2411 Holmes, Kansas City, MO 64108;
Jinwen Cai, MD and Gerald L. Hoff, PhD, Kansas City
Missouri Health Department, 2400 Troost, Kansas City,
MO 64108; Paul C. Dew, MD, MPh, University of Health
Sciences, 1750 Independence Avenue, Kansas City, MO
64106
Suicide: A Ten-Year Retrospective Review Lisa B. Shields, MD*, Donna M. Hunsaker, MD, and John 443
of Kentucky Medical Examiner Cases M. Hunsaker III, MD, JD, Office of the Associate Chief
Medical Examiner, 100 Sower Boulevard, Frankfort, KY
40601
Homicidal Cerebral Artery Aneurysm Joseph A. Prahlow, MD*, c/o South Bend Medical 444
Rupture Foundation and Indiana University School of Medicine, 530
North Lafayette Boulevard, South Bend, IN 46601
Death by Defibrillator: A Unique Homicide Kendall V. Crowns, MD* and Adrienne Segovia, MD, Cook 445
by Electrocution County Medical Examines Office, 2121 W. Harrison Street,
Chicago, IL 60612
The Influence of Violence in the Media on Karin A. Margolius, MD, LLB* and Gerard A. Cadden, 445
Unusual Methods of Murder and Suicide MD, PathCentre, Locked Bag 2009, Nedlands, Perth, WA
6009, Australia
Use of the Impact Baton or So-Called Darryl J. Garber, MD* and Irwin Golden, MD, County of 446
“Rubber Bullet” as Less Lethal Force in Los Angeles Department of Coroner/Medical Examiner,
Air vs. Water 1104 N Mission Road, Los Angeles, CA 90033; Lakshmanan
Sathyavagiswaran, MD, Chief Medical Examiner-Coroner,
Los Angeles County, 1104 N Mission Road, Los Angeles,
CA 90033
Dissection, Preservation and Sexual Abuse Martin Bauer, MD* and Thomas Tatschner, MD, University 446
of Bodies and Body Parts – An Exceptional of Wuerzburg, Institute of Legal Medicine, Versbacher Str.
Case of Necrophilia 3, Wuerzburg 97078, Germany; Michael Roesler, MD,
Institute of Forensic Psychology and Psychiatry, Saarland
University, Kirrberger Straße, Homburg 66421, Germany;
Dieter Patzelt, MD, Institute of Legal Medicine, University
of Wuerzburg, Versbacher Str. 3, Wuerzburg 97078,
Germany
Too Many Causes of Death: What’s the Wendy M. Gunther, MD*, Office of the Chief Medical 447
Manner? Examiner and Department of Legal Medicine, Virginia
Commonwealth University, 830 Southampton Avenue, Suite
100, Norfolk, VA 23510
Postmortem Analysis of Anastomotic Judy Melinek, MD, New York City Office of Chief Medical 447
Suture Line Disruption Following Carotid Examiner, 520 First Avenue, New York, NY 10016; Patrick
Endarterectomy Lento, MD*, Mount Sinai Hospital Medical Center, 1190
Fifth Avenue, New York, NY 10029; John Moalli, ScD*,
Exponent Failure Analysis Associates, 149 Commonwealth
Drive, Menlo Park, CA 94025
Index 98
Advanced Flow Cytometric DNA Erica Williams, MD*, Hospital of the University of 448
Degradation Analysis: Utility in Pennsylvania, Department of Pathology and Laboratory
Postmortem Interval Estimation Medicine, 6 Founder Building, 3400 Spruce Street,
Philadelphia, PA 19104; Andrew Bantly, BS, Hospital of the
University of Pennsylvania, Abramson Cancer Center Flow
Cytometry and Cell Sorting Shared Resource, 3400 Spruce
Street, Philadelphia, PA 19104; Jesse Chittams, MS,
University of Pennsylvania School of Medicine, Department
of Biostatistics and Epidemiology, 3400 Spruce Street,
Philadelphia, PA 19104; Jonni Moore, PhD, Hospital of the
Street, Philadelphia, PA 19104
The Impact of Dermatologic Consultation Carrie L. Kovarik, MD*, UT Clay J. Cockerell, MD, Sheila 448
in Autopsy Examination: A Case of D. Spotswood, MD, and Jeffrey J. Barnard, MD, University
Pseudoxanthoma Elasticum of Texas Southwestern Medical School - Forensic Science,
5323 Harry Hines Boulevard, Dallas, TX 75390
Homicidal Injury or Resuscitation Amy P. Hart, MD*, Venus J. Azar, MD, and Boyd G. 449
Artifact? Stephens, MD, Medical Examiner’s Office, City and County
of San Francisco, 850 Bryant Street, San Francisco, CA
94103
Screening Items of Evidence for the Melissa Kell, BSc, Sobia Malik, MSc, Gerry Alderson, 449
Presence of Body Fluids/DNA in Forensic MSc*, and Andrew Greenfield, MSc, Centre of Forensic
Biology Casework — A Hypothesis-Driven Sciences, 25 Grosvenor Street, Toronto, Ontario M7A 2G8,
Approach Canada
Fatal Kawasaki Disease Associated With Erik K. Mont, MD*, Miami-Dade County Medical Examiner 450
Cardiac Rhabdomyomas in an Infant Department, Number One on Bob Hope Road, Miami, FL
33136; Allen P. Burke, MD, Armed Forces Institute of
Pathology, Department of Cardiovascular Pathology, 6825
16th Street, NW, Building 54, Room 2005, Washington, DC
20306
Hmong Cultural Aversion to Forensic Thomas K. Resk, MD*, PO Box 3215, Chico, CA 95927- 451
Autopsy: Bridging Communication and 3215; Thomas A. Rudd, MD, PO Box 332, Highwood, IL
Cultural Barrier 60040-0332
Postmortem Diagnosis of Genetic Carolyn H. Revercomb, MD*, Northern District Office of 452
Arrhythmia Syndromes the Chief Medical Examiner, Fairfax, Virginia, and
Department of Legal Medicine, Virginia Commonwealth
University School of Medicine, 9797 Braddock Road,
Fairfax, VA 22032
Is Hypertension a Risk Factor for Fatal Ana Rubio, MD, PhD*, Office of the Chief Medical 452
Rupture of Intracranial Aneurysms? Examiner, 111 Penn Street, Baltimore, MD 21201;
Christopher Cox, PhD, Division of Epidemiology, Statistics
and Prevention, National Institute of Child Health and
Human Development; DHHS, 6100 Executive Boulevard,
Room 7B05, Bethesda, MD 20892; David Fowler, MD,
Baltimore, MD 21201; Juan Troncoso, MD,
Neuropathology Unit; Department of Pathology, Johns
Hopkins School of Medicine, 720 Rutland Avenue,
Baltimore, MD 21205
Index 99
Fatal Acute Thrombosis of Anomalous Supriya Kuruvilla, MD*, Harris County Medical Examiner 453
Right Coronary Artery Arising From the Office and University of Texas Health Science Center, J.A.
Left Sinus of Valsalva Jachimczyk Forensic Center, 1885 Old Spanish Trail,
Houston, TX 77054; Antonio Neto, MD, University of Texas
Health Science Center, 6431 Fannin, MSB 2.120, Houston,
TX 77030; Dwayne A. Wolf, MD, PhD, Harris County
Medical Examiner Office, J.A. Jachimczyk Forensic Center,
Undiagnosed Cardiac Sarcoidosis and Carol H. Allan, MD*, Ling Li, MD, Susan Hogan, MD, and 453
Sudden Death: Report of 14 Cases Mary G. Ripple, MD, Office of the Chief Medical Examiner,
State of Maryland, 111 Penn Street, Baltimore, MD 21201;
Allan Burke, MD, Department of Defense, Armed Forces
Institute of Pathology, 14th & Alaska Avenue Northwest,
Washington, DC 20306; David Fowler, MD, Office of the
Chief Medical Examiner, State of Maryland, 111 Penn
Accidental Insulin Overdose Nick I. Batalis, MD*, Medical University of South Carolina, 454
1032 Yorktown Drive, Charleston, SC 29412; Joseph A.
Prahlow, BS, MD, South Bend Medical Foundation, 530
Unexplained Sudden Death and the Amy C. Gruszecki, MSFS, DO* and Gregory G. Davis, MD, 454
Likelihood of Drug Abuse MSPH, Jefferson County Coroner/Medical Examiner Office,
1515 Sixth Avenue South, Room 611, Birmingham, AL
35233-1601
Acute Bacterial Meningitis With Reade A. Quinton, MD*, University of Texas Southwestern 455
Predominance of Immature Granulocytes Medical Center, Department of Pathology, 5323 Harry
Hines Boulevard, Dallas, TX 75390-9073; Loren Clarke,
MD and Javad Towfighi, MD, Penn State Milton S. Hershey
Medical Center, Department of Anatomic Pathology -
H179, 500 University Drive, PO Box 850, Hershey, PA
17033-0850; Jeffrey J. Barnard, MD, Southwestern Institute
of Forensic Sciences, 5230 Medical Center Drive, Dallas,
TX 75390; Rene L. Galindo, MD, PhD and Philip J. Boyer,
MD, PhD, University of Texas Southwestern Medical
Center, Department of Neuropathology, 5323 Harry Hines
Boulevard, Dallas, TX 75390
Coronary Artery Anomalies and Sudden Margherita Neri, MD*, Department of Forensic Pathology, 456
Death: Two Case Reports in Young People University of Foggia, Viale Pinto 1, Foggia 71100, Italy; M.
Di Pudua, MD, Institute of Forensic Medicine, University of
Foggia, Ospedali Riuniti Via Luigi Pinto n. 1, Foggia
71100, Italy
Neurofibromatosis Type 1 Associated With Sabina Di Donato, MD*, Arcangela Marucci, MD, and 457
Hydrocephalus and Acute Cardiac Failure: Francesco M. Morreale, MD, Department of Forensic
A Fatal Case Pathology University of Foggia, Viale Pinto n.1, Foggia,
Puglia 71100, Italy
Index 100
A Cluster of Child Deaths: A Medical Mary Jo Martin, MD*, Office of the Chief Medical 458
Examiner System Participates in an Examiner, 400 East Jackson Street, Richmond, VA 23219;
Epidemiologic Investigation in Virginia Wendy M. Gunther, MD*, Office of the Chief Medical
Examiner, 830 Southampton Avenue, Suite 100, Norfolk, VA
23510; Lisa A. Weymouth, PhD*, Virginia Division of
Consolidated Laboratory Services, 600 North 5th Street,
Richmond, VA 23219; Elizabeth L. Kinnison, MD, Office of
the Chief Medical Examiner, 830 Southampton Avenue,
Suite 100, Norfolk, VA 23510; Deborah Kay, MD, Office of
the Chief Medical Examiner, 400 East Jackson Street,
Richmond, VA 23219; William T. Gormley, MD and
Marcella F. Fierro, MD, Office of the Chief Medical
Examiner, 400 East Jackson Street, Richmond, VA 23219
Police Custody Deaths in the State of Pamela E. Southall, MD*, Ling Li, MD, and David Fowler, 458
Maryland: Passing the Torch MD, Office of the Chief Medical Examiner, State of
Characterization of Recent Cocaine and Elizabeth J. Miller, MD*, Caddo Parish Coroner’s Office, 459
Methadone-Related Death Trends in 1704 Market Street, Shreveport, LA 71101; Sharon Brooks,
Caddo Parish, Louisiana, With Jacksonville State University, Jacksonville, AL 36265;
Comparison to National Trends Patricia Dooley-Netherland, and George M. McCormick III,
MD, PHD, Caddo Parish Coroner’s Office, 1704 Market
Street, Shreveport, LA 71101
Positional Asphyxia and Alcoholism: Elizabeth L. Kinnison, MD* and Wendy M. Gunther, MD, 460
Review of Three Cases Office of the Chief Medical Examiner, 830 Southampton
Causes of Death in Chronic Alcoholics: A Martha J. Burt, MD*, Matthew J. Bowes, MD, and Mark J. 460
Comprehensive Retrospective Analysis of Shuman, MA, MD, Miami-Dade County Medical Examiner
Medical Examiner Cases Department, Number One on Bob Hope Road, Miami, FL
33136
FluiDDB.com: A Model Database for Michael C. Britt, BS* and Marta U. Coburn, MD, District 461
Unidentified Bodies Twenty Medical Examiner, 3838 Domestic Avenue, Naples,
FL 34104
Compressional Asphyxia Due to a Crowd Adrienne Segovia, MD, Mitra B. Kalelkar, MD*, Aldo J. 461
Stampede: The E2 Nightclub Disaster Fusaro, DO, Scott Denton, MD, Edmund R. Donoghue, MD,
Kendall V. Crowns, MD, Eupil Choi, MD, J. Lawrence
Cogan, MD, Ronald Knoblock, MD, Cyndi D. Gardner,
MD, and Barry D. Lifschultz, MD, Cook County Medical
Examiners Office, 2121 West Harrison Street, Chicago, IL
60612
Perspectives on the Variety of Mass Charles H. Brenner, PhD*, Consultant in Forensic 462
Identification Projects Mathematics, 6568 Sobrante Road, Oakland, CA 94611-
1123
Investigation, Identification, and Craig T. Mallak, MD JD*, Office of the Armed Forces 463
Repatriation of Contaminated Fatalities Medical Examiner, Armed Forces Institute of Pathology,
1413 Research Boulevard, Rockville, MD 20850; Elspeth C.
Ritchie, MD*, USUHS, Department of Psychiatry, Room
B3068, 4301 Jones Bridge Road, Bethesda, MD 20814
When is SIDS Over-Laying? W.P. Ryan, MBBS*, PO Box 267, Nowra, NSW 2541, 463
Australia
Unexpected Death From Ureterocele in an Joyce L. de Jong, DO*, Sparrow Hospital, Forensic 463
Infant Pathology, 1215 East Michigan Avenue, Lansing, MI 48909
Index 101
An Unusual Motorized Vehicle Fatality Russell T. Alexander, MD*, John Turner, MD, and Louis 464
Dibernardo, MD, Duke University Medical Center,
Department of Pathology, DUMC Box 3712, Durham, NC
27710
Three Unusual Cases of Sudden Tasha L. Zemrus, MD* and David R. Fowler, MD, Office of 464
Unexpected Death in Pregnancy Occurring the Chief Medical Examiner, State of Maryland, 111 Penn
in One Week in the State of Maryland Street, Baltimore, MD 21201-1020
Compressed Gas Cylinder Related Nabila A. Haikal, MD*, and Richard C. Harruff, MD, PhD, 465
Injuries: Case Report of a Fatality King County Medical Examiner’s Office, 325 9th Avenue,
Associated With a Recreational Paintball HMC Box 359792, Seattle, WA 98104
Gun, Review of the Literature and Safety
Recommendations
Cerebral Air Embolism: An Uncommon Bret M. Wehrli, MD*, London Health Sciences Centre, 339 466
Complication of a Common Procedure Windermere Road, Department of Pathology, Room A3-147,
London, Ontario N6A 5A5, Canada; Sidney Siu, MD, 827
Richmond Street, London, Ontario N6A 3H7, Canada;
Edward Tweedie, MD and Michael J. Shkrum, MD, London
Health Sciences Centre, 339 Windermere Road, London,
Ontario N6A 5A5, Canada
Legal Outcome of Sexual Assault Cases, Marianne C. Rohde, MD*, Jytte Banner, MD, PhD, and 466
The County of Aarhus, Denmark Annie Vesterby, MD, MDSc, Department of Forensic
Medicine, University of Aarhus, Peter Sabroes Gade 15,
Aarhus 8000 C, Denmark
Boating People Pathology Francesco Introna, MD*, Alberto Tortorella, MD, Roberto 467
Vaglio, MD, and Antonio De Donno, MD, Sezione di
Medicina Legale-DIMIMP, P.zza Giulio Cesare, 11, Bari,
70100, Italy
Do Centenarians Die Healthy? – An Andrea M. Berzlanovich, MD*, Department of Forensic 467
Autopsy Study Medicine, University of Vienna, Sensengasse 2, Vienna,
Austria A – 1090 Austria; Thomas Waldhoer, PhD,
Department of Epidemiology, Institute of Cancer Research,
University of Vienna, Borschkegasse 8a, Vienna, Austria A -
1090, Austria; Ernst Sim, MD, Meidling Traumatology
Center, Kundratstraße 37, Vienna, Austria A - 1120,
Austria; Peter Fasching, MD, Geriatric Center
Baumgarten, Baumgartner Höhe 1, Vienna, Austria A -
1140, Austria
Degenerative Changes of the Conduction Michaud Katarzyna, MD*, Béat Horisberger, MD, and 467
Tissue in Drug Addicts Patrice Mangin, PhD, Institut Universitaire de Médecine
Légale, Rue du Bugnon 21, Lausanne, Vaud 1005,
Switzerland
Systemic Amyloidosis in an Intravenous Jennifer J. Prutsman-Pfeiffer, MA*, Strong Memorial 468
Drug Abuser Hospital, Neuropathology and Postmortem Medicine, Box
626, 601 Elmowwd Avenue, Rochester, NY 14642
Photographic Imaging of Handgun Gas D’Michelle P. DuPre, BA, MD*, Miami-Dade County 469
Clouds Compared to Gunshot Residue Medical Examiner’s Office, Number One Bob Hope Road,
Swabs Miami, FL 33136- 1133; Joe Castorenga, Bexar County
Forensic Science Center, 7337 Louis Pasteur Drive, San
Antonio, TX
Who was Driving: A Case Report Ersi Abaci-Kalfoglou, PhD*, Hulya Yukseloglu, PhD, Tanýl 469
Baskan, PhD, and Sevil Atasoy, PhD, Istanbul University,
Institute of Forensic Sciences, Cerrahpasa, Istanbul 34303,
Turkey
Index 102
The Contribution of Researching DNA Anne Dorandeu, MD*, Eric Baccino, MD, and Maguy 469
Breaks to the Evaluation of Postmortem Ursule, MD, Lapeyronie University Hospital, 371 Avenue
Delay du Doyen Gaston Giraud, Montpellier, Herault 34295,
France
From VIRTOPSY to VIRTOBOT: Michael J. Thali, MD* and Marcel Braun, University of 470
Photogrammetry Based Optical Surface Berne, Buehlstrasse 20, Berne 3012, Switzerland; Buck
Scanning and Radiological Virtual Autopsy Ursula, Emin Aghayev, MD, and Christian Jackowski, MD,
University of Berne, Buehlstrasse 20, Berne 3012; Martin
Sonnenschein, MD, University of Berne, Inselspital, Berne
3012, Switzerland; Peter Vock, MD and Richard Dirnhofer,
MD, University of Berne, Buehlstrasse 20, Bern 3012,
Switzerland
Comparative Study of DNA Yield and STR Shelly A. Steadman, MS*, Sedgwick County Regional 470
Profile Quality Obtained From Various Forensic Science Center, 1109 North Minneapolis, Wichita,
Tissue Types of a Decomposed Body KS 67214; Jaime L. Oeberst, MD, Sedgwick County
Regional Forensic Science Center, 1109 North Minneapolis,
Wichita, KS 67214; Daniel J. Fahnestock, MS, Sedgwick
County Regional Forensic Science Center, 1109 North
Minneapolis, Wichita, KS 67214
Experimental Evaluation of Rigor Mortis Thomas Krompecher, MD*, Andre Gilles, MD, Conxita 471
Nysten’s Law: Does it Apply to Rats? Brandt- Casadevall, MD, and Patrice Mangin, MD, Institut
Universitaire de Médecine Légale, Rue du Bugnon 21,
Lausanne, Vaud 1005, Switzerland
Microbial Processes in Soils Associated David O. Carter, MSc*, James Cook University, School of 472
With Skeletal Muscle Tissue and Cadaver Pharmacy & Molecular Sciences, Douglas, Queensland
Decomposition at Different Temperatures 4814, Australia; Mark Tibbett, PhD, University of Western
Australia, Soil Science and Plant Nutrition, School of Earth
and Geographical Sciences, Crawley, Western Australia
6907, Australia; David Yellowlees, PhD, James Cook
University, School of Pharmacy and Molecular Sciences,
Douglas, Queensland 4811, Australia
Does Carcass Enrichment Alter Kenneth G. Schoenly, PhD*, Department of Biological 473
Community Structure of Predaceous and Sciences, California State University, Stanislaus, Turlock,
Parasitic Arthropods? A Second Test of the CA 95382; Adam Shahid, MS, University of Missouri,
Arthropod Saturation Hypothesis at the Department of Entomology, 320 Connaway Hall, Columbia,
Anthropology Research Facility in MO 65211; Neal H. Haskell, PhD, Department of Biology,
Knoxville, Tennessee Saint Joseph’s College, Rensselaer, IN 47978; Robert D.
Hall, PhD, JD, University of Missouri, Department of
Entomology, 1-87 Agriculture Building, Columbia, MO
65211
Trends in Forensic Entomology in the Jeffery K. Tomberlin, PhD, Department of Entomology, 473
United States and Abroad Texas A&M University, 1229 North U.S. Highway 281,
Stephenville, TX 76401; Jason Byrd, PhD*, Office of the
Medical Examiner, 1360 Indian Lake Road, Daytona Beach,
FL 32164; John Wallace, PhD*, Department of Biology,
Millersville University, Fredrick Street, Science and
Technology Building, Millersville, PA 17551
Temperature-Dependent Development of Timothy E. Huntington, BS; Leon G. Higley, PhD, and 474
the Blow Fly Calliphora Vicina (Diptera: Frederick P. Baxendale, PhD, University of Nebraska,
Calliphoridae) and the Effects on the Department of Entomology, 202 Plant Industry, Lincoln, NE
Estimation of the Postmortem Interval 68583
Index 103
Evidence for Neglect of Children and Mark Benecke, PhD, MSc*, International Forensic 474
Elderly Persons by Use of Forensic Research & Consulting, Postfach 250411 Cologne, NRW
Entomology 50520, Germany
DNA-Based Identification of Forensically Michelle L. Harvey, BSc, BA* and Ian R. Dadour, PhD, 475
Significant Blowflies of Australia and Centre for Forensic Science, University of Western
Southern Africa Australia, Stirling Highway, Nedlands, Perth, Western
Australia 6009, Australia; Martin H. Villet, PhD,
Department of Zoology and Entomology, Rhodes University,
Grahamstown 6140, South Africa; Mervyn W. Mansell,
PhD, Plant Protection Research Institute, Private Bag
X134, Pretoria, Gauteng 0001, South Africa
Fatal Pediatric Head Impact Biomechanics: John B. Lenox, MD, PhD, PE*, Design Excellence, Inc, 435 475
Homicide vs. Accident Isom Road, Suite 224, San Antonio, TX 78216-5144
The Enigma of SIDS: Variations in Peter Vasilenko, PhD*, Michigan State University, College 476
Diagnosis and Recommendations of Human Medicine, Department of Obstetrics, Gynecology,
and Reproductive Biology, 227 West Fee Hall, East
Lansing, MI 48824; Joyce de Jong, DO and Brian Hunter,
MD, E.W. Sparrow Hospital, Department of Pathology,
Investigations and Eye Findings in Crush M.G.F. Gilliland, MD*, Brody School of Medicine at East 477
and Other Accidental Traumas in Lethally Carolina University, Department of Pathology, Forensic
Injured Infants and Children Division, Greenville, NC 27858-4354
Meningitis Mimicking Inflicted Abusive Christie L. Elliott, MD* and Ellen G.I. Clark, MD, Forensic 478
Head Trauma Pathology Consultants, 475 Kirman Avenue, Reno, NV
89502
Fatal Hyponatremia, Cerebral Edema and Patrick E. Lantz, MD*, Department of Pathology, Wake 478
Seizures Associated With Bilateral Forest University School of Medicine, Medical Center
Peripheral Retinal Hemorrhages in a 20- Boulevard, Winston- Salem, NC 27157-1072
Month-Old Child Following Hypotonic
Fluid Administration for Dehydration:
Case Report with Critical Appraisal of the
Current Literature
Delayed Jejunal Rupture in a Three-Year- Leah L.E. Bush, MD, Office of the Chief Medical Examiner, 479
Old Child After Minor Blunt Impact 830 Southampton Avenue, Suite 100, Norfolk, VA 23510-
1046; Wendy M. Gunther, MD*, Office of the Chief Medical
Examiner and Department of Legal Medicine, Virginia
100, Norfolk, VA 23510; Gregory Raczniak, MPhil, Eastern
Virginia Medical School, 714 Woodis Avenue, Norfolk, VA
23510
Virulence Factors in Neisserial Wendy M. Gunther, MD, Office of the Chief Medical 479
Meningococcemia Examiner and Department of Legal Medicine, Virginia
100, Norfolk, VA 23510-1046; Gregory Racszniak, MPhil*,
Eastern Virginia Medical School, 714 Woodis Avenue,
Norfolk, VA 23510; Elizabeth L. Kinnison, MD, Office of
SARS, Monkeypox, West Nile, Dengue, and Saul B. Wilen, MD*, International Horizons 480
Plague: Pitfalls of Globalization Unlimited/Litigation Strategies Group, PO Box 40578, San
Antonio, TX 78229
Index 104
Pure Group A Beta Streptococcal Sally S. Aiken, MD*, Spokane County Medical Examiner, 480
Peritonitis in a Child With Inflammatory 5901 North Lidgerwood, Suite 24B, Spokane, WA 99208
Bowel Disease
Acute Dissection of the Left Subclavian Cristin M. Rolf, MD*, University of Kentucky/Office of the 481
Artery in a Patient With Ehlers-Danlos Associate Chief Medical Examiner, Commonwealth of
Syndrome Kentucky, 100 Sower Boulevard, Suite 202, Frankfort, KY
40601-8272
A Case of Sudden Death in a 3-Year-Old Cristoforo Pomara, MD*, Department of Forensic 481
Infant With Prader Willi Syndrome Pathology, University of Foggia, Viale Pinto n°1, Foggia
71100, Italy; Stefano D’Errico, MD and Irene Riezzo, MD,
Institute of Legal Medicine, University of Foggia, Ospedali
Riuniti, via L.Pinto 1, Foggia 71100, Italy
Pediatric Asthma Mortality in the Cook Eupil Choi, MD* and Edmund R. Donoghue, MD, Cook 482
County Medical Examiner’s Office, 1 to 14 County Medical Examiner’s Office, 2121 West Harrison
Years: 1998 - 2002 Street, Chicago, IL 60612
Fatal Accidental Intravascular Injection of Angela R. Wetherton, MD* and Tracey S. Corey, MD, 483
Air in Infants Office of the Chief Medical Examiner, 810 Barret Avenue,
Lucid Interval Revisited: Delayed Onset of Darinka Mileusnic, MD, PhD*, Knox County Medical 483
Unconsciousness in an Impacted Child Examiner’s Office, University of Tennessee Medical Center,
Department of Pathology, Knoxville, TN 37922; Edmund R.
Donoghue, MD, Cook County Office of the Medical
Examiner, Chief Medical Examiner, 2121 West Harrison
Index 105
2003
Investigation of Infant Fatalities in Ling Li, MD*, and David R. Fowler, MD, Office of The 484
Maryland (1990-1999) Chief Medical Examiner, State of Maryland, Baltimore,
MD; Liang Liu, MD, Tongji, Medical University, Wuhan,
China; and Mary G. Ripple, MD, Zoe Lambros, RN, JD,
Havre de Grace, MD, and John E. Smialek, MD, Office of
The Chief Medical Examiner, State of Maryland, Baltimore,
MD
Sudden Infant Death Syndrome in North Russell Alexander, MD*, Duke University Medical Center, 484
Carolina From 1999-2000: The Prevalence Department of Pathology, Box 3712, Durham, NC; Krista
of Risk Factors and Its Relation to 2000 Ragan, BS, Castleton State College, Castleton, VT;
Census Data on a County by County Basis Deborah Radisch, MD, MPH, Office of the Chief Medical
Examiner, Campus Box 7580, Chapel Hill, NC; and Robin
Vollmer, MD, Veterans Affairs Medical Center, Department
of Pathology, 508 Fulton Street, Durham, NC
Epidemiological Study of SIDS in an Nunzio Di Nunno, MD*, and Luigi Vimercati, MD, Sezione 485
Apulian Population di Medicina Legale, Dipartimento di Medicina Interna e
Medicina Pubblica, Università degli Studi di Bari,
Policlinico, Piazza G. Cesare n. 11, Bari, Italy; Barbara
Boninfante BSc, Dipartimento di Scienze Statistiche,
Facoltà di Economia e Commercio, Università degli Studi
di Bari, Italy; and Francesco Vimercati, MD, Sezione di
Medicina Legale, Dipartimento di Medicina Interna e
Policlinico, Piazza G. Cesare n.11 Bari, Italy
A Five Year Retrospective Study of Paul Peng Sun Chui, MBBS, DMJ, MRCPath, MBA*, 486
Unnatural Deaths in Children 12 Years and Centre for Forensic Medicine, Health Sciences Authority,
Younger in Singapore From 1997-2001 11 Outram Road, Singapore
Bone Scintigraphy and Battered Children: Laurent Martrille*, Anne Dorandell, MD, Lauren 486
Limit and Indication About a Case Report Boismenu, Oliver Cougnenc, and Eric Baccino, MD, Service
de Médecine Légale, CHU Lapeyronie, 191 av, Montpellier,
France
Fatal Capnocytophaga Infection Associated Mary H. Dudley, MD*, Lawrence A. Czarnecki, DO, and 486
With Splenectomy Mark A. Wells, BS, Sedgwick County Regional Forensic
Science Center, 1109 North Minneapolis, Wichita, KS
Look Until You See: An Unexpected Julie Wilson Lemmon, MD*, Tripler Army Medical Center, 487
Delayed Death Following a Motor Vehicle Tripler Army Medical Center, Tripler AMC, HI; Cynthia D.
Accident Gardner, MD, Department of Forensic Pathology,
University of Tennessee Health Science Center, 1060
Madison Avenue, Memphis, TN
Basketball-Related Sudden Deaths in Dennis J. Chute, MD*, Division of Neuropathology, UCLA 488
Young Adults: A Medical Examiner Study Medical Center, 650 Charles Young Drive, South, Room 18-
126, Los Angeles, CA; and David R. Fowler, MD, Office of
Street, Baltimore, MD
The Significance of Tattoos in Forensic Oguz Polat, MD, Bulent Sam, MD, and Esra Saka, MD, The 488
Autopsy State Institute of Forensic Medicine, Ministry of Turkey,
Istanbul, Turkey; and Nevzat Alkan, MD, Istanbul
University, Istanbul Medical Faculty, Department of
Forensic Medicine, Istanbul, Turkey
Index 106
Epilepsy—A Major But Disregarded Annie Vesterby, MD, DMSc*, Department of Forensic 488
Health Problem Medicine, Peter Sabroes Gade 15, Aarhus, Denmark; Soren
Dalager-Petersen, MD, Department of Forensic Medicine,
Aarhus University Hospital, Aarhus, Denmark; Simona
Tigaran, MD, PhD, Department of Neurology, Aarhus
University Hospital, Aarhus, Denmark; and Ulrik
Baandrup, MD, Department of Pathology, Aarhus
University Hospital, Aarhus, Denmark
Death at Dinner: Foreign Body Andrea M. Berzlanovich, MD*, Institute of Forensic 489
Asphyxiation – An Unknown Cause of Medicine, University of Vienna, Sensengasse 2, A - 1090
Death in the Elderly? Vienna, Austria; Thomas Waldhoer, Institute of Cancer
Research, Department of Epidemiology, University of
Vienna, Borschkegasse 8a, A - 1090 Vienna, Austria; Ernst
Sim, MD, Meidling Traumatology Center, Kundratstraße
37, A - 1120 Vienna, Austria; Peter Fasching, Geriatric
Center Baumgarten, Huetteldorferstraße 188, A - 1140
Vienna, Austria; and Manfred A. Muhm, Department of
Cardiothoracic Anesthesia and Intensive Care Medicine,
University of Vienna, Waehringerstraße 18 - 20, A - 1090
Vienna, Austria
Death During EMS Transportation Istvan F. Szentmariay, MD, DMJ*, and Gyorgy Dunay, MD, 489
Institute of Forensic Medicine, Semmelweis University,
Budapest, Hungary, Ullio Street 93, Budapest, Hungary
Sudden Asphyxial Death Due to Tasha Zemrus, MD*, Assistant Medical Examiner, Office of 490
Regurgitation of a Pedunculated the Chief Medical Examiner, 111 Penn Street, Baltimore,
Esophageal Lipoma: A Case Report and MD; Adrienne Segovia, MD, Deputy Medical Examiner,
Review of the Literature Office of the Cook County Medical Examiner, 2121 West
Harrison Street, Chicago, IL
First Report of Fatal Outcome by Gilles Tournel, MD*, Anne Becart-Robert, DDS, Philippe 490
Accidental Intrathecal Injection of Courtin, MD, Valéry Hedouin, MD, and Didier Gosset, MD,
Vindesine PhD, Forensic Department, Institut de Médecine Légale de
Lille, Lille, France
The Importance of an Interdisciplinary Jason M. Wiersema, MA*, and Eric J. Bartelink, MA, 491
Review Process in the World Trade Center Department of Anthropology, Texas A&M University,
Mass Disaster Investigation Department of Anthropology, College Station, TX; Zoran
Budimlija, MD, PhD, Mechthild Prinz, PhD, Robert Shaler,
PhD, and Amy Zelson Mundorff, MA, Office of Chief
Medical Examiner, New York City, 520 First Avenue, New
York, NY; and Gaille MacKinnon, MS, Department of
Conservation Sciences, University of Bournemouth,
Bournemouth, England, United Kingdom
Media Relations and the Identification of Christopher C. Kelly, MMgmt*, Armed Forces Institute of 491
the September 11 Pentagon Terrorist Pathology, 6825 16th Street, NW, Building 54, Room 1106,
Attack Victims: The Perspective of the Washington, DC
Office of the Armed Forces Medical
Examiner
Index 107
Victim Identification Following the Crash Paul S. Sledzik, MS*, Region III DMORT, National Museum 492
of United Airlines Flight 93 of Health and Medicine, Armed Forces Institute of
Pathology, 6825 16th Street, NW, Washington, DC; Wallace
Miller, BA, Somerset County Coroner’s Office, 555 Tayman
Avenue, Somerset, PA; Dennis C. Dirkmaat, PhD,
Mercyhurst Archaeological Institute, Mercyhurst College,
501 East 38th Street, Erie, PA; Joyce L. de Jong, DO,
Sparrow Hospital Pathology, 1215 East Michigan Avenue,
Lansing, MI; Patricia J. Kauffman, MD, GlaxoSmithKline,
2187 Harts Lane, Whitemarsh, PA; David A. Boyer, MFS,
Department of Defense DNA Registry, 1413 Research
Boulevard, Armed Forces Institute of Pathology, Rockville,
MD; Fedric N. Hellman, MD, Delaware County Coroner’s
Office, Fair Acres, Lima, PA
Domestic Homicide or International Phillip M. Burch, MD*, Saint Louis University, 1300 Clark 493
Terrorism? A St. Louis Murder Crosses the Avenue, St. Louis, MO
Line
Smallpox and the Medical Donald R. Jason, MD, JD*, Wake Forest University School 493
Examiner/Coroner System of Medicine, Department of Pathology, Medical Center
Boulevard, Winston-Salem, NC
Autopsy Procedure and Findings in a Case Mary G. Ripple, MD*, Jack M. Titus, MD, and David R. 494
of Inhalational Anthrax Fowler, MD, Office of the Chief Medical Examiner, State of
Maryland, 111 Penn Street, Baltimore, MD
Discrepancy Between the Legal and Jeffrey M. Jentzen, MD*, Milwaukee County Medical 494
Medical Definitions of Homicide Examiner’s Office, 933 West Highland Avenue, Milwaukee,
WI; Ayako Kobayahi, University of Wisconsin at
Milwaukee, 1-3-4 Nozawa, Setagaya-ku, Tokyo, Japan;
Eileen Weller, RN, MHA, Milwaukee County Medical
Examiner’s Office, 933 West Highland Avenue, Milwaukee,
WI; and Mallory O’Brien, PhD, Harvard School of Public
Health, 2501 East Menlo Boulevard, Shorewood, WI
Rape/Sadistic-Homicide vs. Accidental Dominique Lecomte, MD*, and Paul Fornes, PhD, Forensic 495
Death During Voluntary Violent Sexual Institute of Paris, Medical School Cochin Port-Royal, Paris,
Activity: Three Case Reports Illustrating France
Difficulties in Assessing the Circumstances
of the Deaths
Postmortem Genital Examinations and Sharon R. Crowley, RN, MN*, Forensic Clinical Nurse 495
Evidentiary Protocol With Colposcopy Specialist, 122 Emeline Avenue, Santa Cruz, CA
Validation of the Anthropology Research Adam Shahid, MS, University of Missouri, Columbia, 496
Facility in Knoxville, TN, as a Research Department of Entomology, 1-87 Agriculture Building,
and Training Site For Forensic Entomology Columbia, MO; Kenneth G. Schoenly, PhD*, California
State University, Stanislaus, Department of Biological
Sciences, Turlock, CA; Neal H. Haskell, PhD, Forensic
Entomology Consultant, 425 Kannal Avenue, Rensselaer,
IN; and Robert D. Hall, PhD, JD, University of Missouri,
Columbia, Department of Entomology, 1-87 Agriculture
Building, Columbia, MO
Extracting Human DNA From the Crops of Jason G. Linville, BS*, Department of Biology, University 497
Maggots That Have Been Collected During of Alabama at Birmingham, 2909 Highland Avenue, S
Different Stages of Development and Apartment 207, Birmingham, AL; Jeffrey D. Wells, PhD,
Preserved Using Different Methods Department of Justice Sciences, University of Alabama at
Birmingham, 901 15th Street South, Birmingham, AL
Index 108
Bioterrorism Response and Training: Richard J. Evans, MD*, Office of the Chief Medical 497
Building Upon Mass Disaster and Multiple Examiner, 720 Albany Street, Boston, MA; Ann Marie
Fatality Preparedness at the Office of the Mires, PhD, Office of the Chief Medical Examiner, 7416
Chief Medical Examiner, Boston, MA Falmouth Street, Boston, MA; and Alexander Chirchov,
MD, PhD, Faryl Sandler, MD, and William M. Zane, MD,
Office of the Chief Medical Examiner, 720 Albany Street,
Boston, MA
Computerization of the Autopsy Report Coleen Crawford, MFA*, and William M. Zane, MD, 498
“How to Build Your Own Desktop” OCME Commonwealth of Massachusetts, 720 Albany
Street, Boston, MA
Using STR Analysis to Detect Human DNA Kelly J. Esslinger, MS*, 1805 Arbor Lane, #304, Crest Hill, 498
From Exploded Pipe Bomb Devices IL; Jay A. Siegel, PhD, School of Criminal Justice,
Michigan State University, 560 Baker Hall, East Lansing,
MI; and Heather Spillane, BS, and Shawn Stallworth,
Michigan State Police Crime Laboratory - Northville,
42145 West Seven Mile Road, Northville, MI
An Atypical STR Genotype, Including a Sobia Malik, MSc*, Centre of Forensic Sciences, 25 499
Three-Banded Allelic Pattern, From a Grosvenor Street, 4th Floor, Toronto, Ontario, Canada
Biopsy Tissue Sample
DNA Databank Hits: Identification of the Sarah Johnston, MSc*, Roger Frappier, MSc, and Jonathan 499
Perpetrator? Newman, BSc, Centre of Forensic Sciences, 25 Grosvenor
Street, 4th Floor, Toronto, Ontario, Canada
Everything Old is New Again: A Program Linda Parker, MSc, Jack Laird, MSc, Elida Kafarowski, 500
to Examine “Cold” Sexual Assault Cases MSc, Brian Peck, MSc*, Suzanne Lima, MSc, and Jonathan
Newman, BSc, Centre of Forensic Sciences, 25 Grosvenor
Street, 4th floor, Toronto, Ontario, Canada
Bone Extraction Procedure for Nuclear Zoran M. Budimlija*, MD, PhD, Bianca Nazzaruolo, MA, 501
DNA Analysis Used in World Trade Center Sheila M. Estacio, BS, Mechthild K. Prinz, PhD, and Robert
Human Identification Project C. Shaler, PhD, Office of Chief Medical Examiner,
Department of Forensic Biology, 520 First Avenue, New
York, NY
Digestion Time of Human Mitochondrial Paula M. Do*, California State University, Bakersfield 501
DNA in Blowfly Larvae, Calliphora vicina 2001 Stockdale Highway, Bakersfield, CA
Postmortem Interval (PMI) Determined by Sonja L. Peters, BS*, 5333 Southwest 75th Street, Apt. S- 502
Analyzing Temperature Variations of 105, Gainesville, FL; Jerry F. Butler, PhD, Department of
Maggot Masses Entomology & Nematology, University of Florida, P.O. Box
110620, Gainesville, FL; Jerome A. Hogsette, PhD, USDA-
ARS, CMAVE, P.O. Box 14565, Gainesville, FL; Anthony B.
Falsetti, PhD, Anthropology Department, C.A. Pound
Human Identification Laboratory, P.O. Box 117305,
Gainesville, FL; and Roxanne Rutledge, PhD, Florida
Medical Entomology Laboratory, 200 9th Street, SE, Vero
Beach, FL
A Summer Carrion Study in the North of Mirella Gherardi, MD*, Gabriella Costantini, and Marina 502
Italy Caligara, Institute of Legal Medicine - University of Milan,
Via Mangiagalli, 37, Milan, Italy; Giancarlo Belluzzi,
Veterinary Service, ASL, via Ghinaglia, 6, Cremona, Italy;
and Massimo Boldini, Experimental Zooprophylactict
Institute, Cremona, Italy
Index 109
Of Leaves and Men: Botanical Evidence Rebecca A. Bullard, MS*, Department of Entomology, 503
Leads Investigators to a Missing Girl’s University of California, Davis, Department of Entomology,
Body University of California at Davis, Davis, CA; and Kristina
A. Schierenbeck, PhD, Department of Biological Sciences,
California State University, Chico, Department of
Biological Sciences, California State University at Chico,
Chico, CA
A Study of Three Suicidal Hangings in Jail Reade A. Quinton, MD*, University of Texas Southwestern 504
Using Telephone Cords Medical Center Department of Pathology, 5323 Harry
Hines Boulevard, Dallas, TX; David Dolinak, MD, Dallas
County Medical Examiner, 5230 Medical Center Drive,
Dallas, TX
Diabetic Ketoacidosis—A Silent Death Zabiullah Ali, MD*, Office of the Chief Medical Examiner, 504
State of Maryland, 111 Penn Street, Baltimore, MD; Mary
G. Ripple, MD, 68 Bluebird Road, Port Deposit, MD; and
Barry S. Levine, PhD, and David R. Fowler, MD, Office of
Investigation of Time Interval For Tracey S. Corey, Office of the Chief Medical Examiner, 505
Recovery of Semen and Spermatozoa From Department of Pathology and Laboratory Medicine,
Female Internal Genitalia University of Louisville School of Medicine; Angela R.
Wetherton, MD*, Department of Pathology and Laboratory
Medicine, University of Louisville School of Medicine;
Pamela J. Froncek, RN, Office of the Chief Medical
Examiner; and Dawn Katz, BS, Kentucky State Police
Forensic Science Laboratory, Louisville KY
The Role of Hyponatremia in Fresh Water Kenneth S. Snell, MD* Medical Examiner, Mecklenburg 505
Drowning and Water Intoxication: Making County Medical Examiner’s Office, Charlotte, NC; Keith C.
the Distinction at Autopsy Kocis, MD, MS, Associate Professor of Pediatrics,
Department of Pediatrics, University of North Carolina at
Chapel Hill, Chapel Hill, NC; and Deborah L. Radisch,
MD, MPH, Associate State Medical Examiner, Office of the
Chief Medical Examiner, Chapel Hill, NC
An Unusual Cause of Sudden Death in Marie E. Cannon, MD*, Office of the Chief Medical 506
Infancy: Hypertrophic Cardiomegaly Examiner, 720 Albany Street, Boston, MA; Eva Patalas,
MD, Massachusetts General Hospital, 55 Fruit Street,
Boston, MA; and Alexander Chirkov, MD, PhD, Office of
the Chief Medical Examiner, 720 Albany Street, Boston, MA
Use of Expert Consultation in the Stephen L. Sgan, MD*, and Shobha Sharma, MD, 507
Evaluation of Tissue Donors With a Department of Pathology and Laboratory Medicine, Emory
Postmortem Diagnosis of “Hepatitis” to University School of Medicine, 1364 Clifton Road, NE,
Determine Eligibility For Transplantation Atlanta, GA; and Judith Woll, MD, and Lance D. Trainor,
MD, Community Blood Center / Community Tissue
Services, 349 South Main Street, Dayton, OH
Determining the Cause of Death and James L. Caruso, MD*, Office of the Armed Forces Medical 508
Contributing Factors in Fatal Recreational Examiner, The Armed Forces Institute of Pathology,
SCUBA Diving Accidents Washington, DC
Sphenoid Sinus Petechiae: Incidence and Kathryn H. Haden, MD*, and David Dolinak, MD, 508
Significance Southwestern Institute of Forensic Sciences and the
University of Texas Southwestern Medical Center, Dallas,
TX
Index 110
Homicide in the Elderly— Paris and Its M. Berroukeche, MD, Paul Fornes, MD, PhD*, and 509
Suburbs, 1996-2001 Dominique Lecomte, MD, Forensic Institute of Paris,
Medical School Cochin Port Royal, Paris, France
Abuse and Neglect: A 10-Year Review of Lisa B.E. Shields, MD *, and Donna M. Hunsaker, MD, 509
Mortality in Elders Office of the Chief Medical Examiner, University of
Louisville School of Medicine, Louisville, KY; and John C.
Hunsaker III, MD, JD, Office of the Associate Chief
Medical Examiner, University of Kentucky College of
Medicine, Frankfort and Lexington, KY
Elderly Neglect/Abuse Kanthi von Guenthner, MD*, Chief Medical Examiner, 510
Department of the Medical Examiner, City and County of
Honolulu, 835 Iwilei Road, Honolulu, HI
Morphological Considerations of the Hyoid Joanne L. Devlin, PhD*, Department of Anthropology, 510
Bone University of Tennessee, 250 South Stadium Hall,
University of Tennessee, Knoxville, TN
Relevance of the Autopsy as a Medical Jody E. Hooper, MD*, U.S. Navy, General Medical Officer, 510
Tool: A Large Database of Physician Branch Medical Clinic, Naval Air Station, North Island,
Attitudes Coronado, CA
Analysis of Five Thousand Forensic Istvan F. Szentmariay, MD, DMJ, Marta Hubay, MD, and 511
Medical Expert Opinions Gyorgy Dunay, MD*, Institute of Forensic Medicine,
Semmelweis University, Budapest, Hungary, Ulloi Street 93,
Budapest, Budapest, Hungary
The Happy Land Homicides: 87 Deaths Lara B. Goldfeder, BS, MD*, James R. Gill, MD, and 512
Due to Smoke Inhalation Marina Stajic, PhD, Office of the Chief Medical Examiner,
520 First Avenue, New York, NY
Documenting Patterns of Injury in Fire O’ Brian C. Smith, MD*, Regional Forensic Center of the 512
Victims University of Tennessee, 1060 Madison Avenue, Memphis,
TN; and Elayne J. Pope, MA, University of Arkansas, 330
Old Main, Fayetteville, AR
Suicide Attempt Using a Self-Made Rifle Jean-Sebastien Raul, MD*, Antoine Tracqui, MD, PhD, and 513
Bertrand Ludes, MD, PhD, Institut de Medecine Legale, 11
rue Humann, Strasbourg, Framce
Suicidal Jumping Istvan Szentmariay, MD, DMJ*, and Gyorgy Dunay, MD, 513
Budapest, Hungary, Ulloi Street 93, Budapest, Budapest,
Hungary
Suicide in Eastern Crete Katerina Kanaki, MD*, Researcher, Department of 513
Forensic Sciences, University of Crete, Heraklion, Greece;
Ersi Abaci Kalfoglu, PhD, Professor, Institute of Forensic
Sciences, University of Istanbul, Istanbul, Turkey; and
Manolis Michalodimitrakis, MD, Professor, Department of
Forensic Sciences, University of Crete, Heraklion, Greece
Postmortem Findings in 22 Victims Due to Sophie Gromb, MD, JD, PhD*, and Koffi Bott, Service of 514
Two Grain Silo Explosions in France Forensic Sciences, University of Bordeaux, Bordeaux,
France; and Alain Miras, MD, University of Lyon, IML
Avenue Rockefeller, Lyon, France
Injuries of an Armored Vehicle Occupant Giancarlo Di Vella, MD, PhD*, Rosa Falamingo, MD, 514
During Armed Robbery: A Case Report PhD, Maura Belviso, MD, PhD, and Francesco Vinci, MD,
Section of Legal Medicine - University of Bari - Italy,
Policlinico, piazza G. Cesare, 70124 – Bari, Italy
Roll-Over Automobile Accident Survived Gordon K. Murphy, MD*, 814 Hathaway Road, Dayton, 515
By the Author as a Passenger OH
Index 111
Intracranial Internal Carotid Laceration at Kristin Gilmore, MD*, Department of Pathology, Kings 515
the Site of an Atherosclerotic Plaque: A County Hospital, Brooklyn, NY; David Kindleberger, MD,
Case Report SUNNY Health Science Center College of Medicine,
Brooklyn, NY; and Charles A. Catanese, MD, Office of the
Chief Medical Examiner, Brooklyn, NY
An Unusual Case of Crossbow Homicide Sabina Di Donato, MD, Marianna Di Padua, MD, Floriana 515
Monciotti, MD, Francesco Maria Morreale, MD,
Margherita Neri, MD, and Cristoforo Pomara, MD*,
Department of Forensic Pathology, University of Foggia,
Viale Pinto 1, Foggia, Italy
Body Found in the Waterway of Lille— Gilles Tournel, MD*, Sandrine Gaulon, Anne Becart- 516
Accident, Suicide, or Homicide? Robert, DDS, Valéry Hedouin, MD, and Didier Gosset, MD,
PhD, Forensic Department, Institut de Médecine Légale de
Pink Teeth in a Series of Bodies Recovered Carlo Pietro Campobasso, MD, PhD*, Giancarlo Di Vella, 517
From a Single Shipwreck MD, PhD, and Antonio De Donno, MD, Section of Legal
Medicine, University of Bari, Piazza Giulio Cesare, Bari,
Italy; Giorgia Girone, DDS, and Gianfranco Favia, MD,
School of Dentistry, University of Bari, Piazza Giulio
Cesare, Bari, Italy; and Francesco Introna, MD, Section of
Legal Medicine, University of Bari, Piazza Giulio Cesare,
Bari, Italy
Calcified Primary and Metastatic Joseph P. O’Hara, MD*, and Debra Komar, PhD, 517
Pancreatic Carcinoma Discovered in University of New Mexico Health Sciences Center, Office of
Skeletonized Remains the Medical Investigator, Albuquerque, NM
Undefeated by Surgery: The Utility of Post- Dorothy E. Dean, MD*, Franklin County Coroner’s Office, 518
Surgical Foot and Ankle Radiographs for Columbus, OH; Nancy E. Tatarek, PhD, Ohio University,
Identification: Focus on the Ankle Athens, OH; Jeremy Rich, DPM, Brigham and Women’s
Hospital, Boston, MA; Robert H. Powers, PhD, Hamilton
County Coroner’s Office, Cincinnati, OH; B.G. Brogdon,
MD, University of South Alabama Medical Center, Mobile,
AL; and Bradley J. Lewis, MD, Franklin County Coroner’s
Office., Columbuzs, OH
To Rave or Not to Rave: A Report of Three John R. Fernandes, MDCM*, Regional Forensic Unit, 237 518
Fatal GHB Poisonings Barton Street East, Hamilton, Ontario, Canada; Marcella
F. Fierro, MD, Office of Chief Medical Examiner, 400 East
Jackson Street, Richmond, VA; and James Cairns, DRCOG,
Office of Chief Coroner, 26 Brenville Street, Toronto,
Ontario, Canada
Methadone-Related Deaths in Palm Beach Barbara C. Wolf, MD*, Palm Beach County Medical 519
County Examiner’s Office, 6065 Ellis Lane, Loxahatchee, FL;
Wendy A. Lavezzi, MD, Albany Medical College, 47 New
Scotland Avenue, Albany, NY; and Lisa M. Flannagan, MD,
Palm Beach County Medical Examiner’s Office, 3126 Gun
Club Road, West Palm Beach, FL
Comparison of the Distribution of Fentanyl Jaime L. Oeberst, MD*, and Timothy P. Rohrig, PhD, 519
in Deaths Related to Use and Abuse of the Sedgwick County Regional Forensic Science Center, 1109
Duragesic® Patch and Intravenous North Minneapolis, Wichita, KS
Administration of Patch Contents
Index 112
Sufentanil Toxicity in Healthcare Douglas Posey, MD*, Joye M. Carter, MD, and Jessie 520
Professionals Adame, MD, Harris County Medical Examiner Office, 1885
Old Spanish Trail, Houston, TX; and Ashraf Mozayani,
PharmD, PhD, Autopsy and Pathology Services, Inc., P.O.
Box 920903, Houston, TX
Acute Fatal Propafenone Toxicity: Drug Dwayne A. Wolf, MD, PhD*, and Ashraf Mozayani, 521
Concentration, Distribution, and Clinical PharmD, PhD, Harris County Medical Examiner’s Office,
Features in Two Suicides Joseph A. Jachimczyk Forensic Center, 1885 Old Spanish
Trail, Houston, TX; and Christopher LaVergne, MD, North
Houston Heart Center, 800 Peakwood, Suite 8A, Houston,
TX
Flecainide: A Suicidal Pharmacist’s Choice Dwayne A. Wolf, MD, PhD*, and Ashraf Mozayani, 521
PharmD, PhD, Harris County Medical Examiner Office,
Joseph A. Jachimczyk Forensic Center, 1885 Old Spanish
Trail, Houston, TX
The Use of Lidocaine to Commit Homicide: Brian C. Hunter, MD*, 1215 East Michigan Avenue, 522
A Case Report and Review of the Lansing, MI; John H. Trestrail III, BS, RPh, Regional
Literature Poison Center, Grand Rapids, MI; and Stephen D. Cohle,
MD, Spectrum Health East Campus, Pathology Department,
Grand Rapids, MI
The Normal Heart Weight: Diagnostic Paul Fornes, PhD*, and Dominique Lecomte, MD, Forensic 523
Criteria for Cardiomyopathies Institute of Paris, Medical School Cochin Port Royal, Paris,
France
Isolated Noncompaction of the Left Kendell V. Crowns, MD*, and Adrienne Segovia, MD, Cook 523
Ventricle: A Rare Cause of Sudden Death County Medical Examiner’s Office, 2121 West Harrison
Street, Chicago, IL
Normal Fat in the Right Ventricle vs. Paul Fornes, PhD*, and Dominique Lecomte, MD, Forensic 523
Arrhythmogenic Right Ventricular Institute of Paris, Medical School Cochin Port Royal, Paris,
Cardiomyopathy/Dysplasia France
Trauma-Related Hemorrhage vs. Dominique Lecomte, MD*, and Paul Fornes, PhD, Forensic 524
Spontaneous Rupture of Vascular Institute of Paris, Medical School Cochin Port Royal, Paris,
Malformation: Three Case Reports France
Illustrating Medico-Legal Aspects
Esophageal and Pharyngeal Injury Robert Stoppacher, MD, MS, BS*, Milwaukee County 524
Associated With the Esophageal-Tracheal Medical Examiner’s Office 933 West Highland Avenue,
Combitube® Milwaukee, WI
Determination of Time Since Death— Alberto J. Sabucedo*, PhD, and Kenneth G. Furton, PhD, 524
Cardiac Troponin I Department of Chemistry and International Forensic
Research Institute, Florida International University,
University Park, Miami, FL
Quantitative Measurement of Ribonucleic Ira Gramlich, Dieter Patzelt, MD, and Martin Bauer, MD*, 525
Acid Degradation as a Possible Indicator of Institute of legal Medicine, University of Wuerzburg,
Postmortem Interval Versbacher Str. 3, Wuerzburg, Germany
Experimental Evaluation of Rigor Mortis: Thomas Krompecher, MD*, André Gilles, MD, Conxita 526
The Influence of the Breaking (Mechanical Brandt- Casadevall, MD, and Patrice Mangin, MD, Institut
Solution) on the Development of Rigor universitaire de Médecine légale, Rue du Bugnon 21, 1005
Mortis Lausanne, Switzerland
Index 113
Evaluation of a Putative Snuff Film William R. Oliver, MD*, Armed Forces Institute of 526
Pathology, 1413 Research Boulevard, Rockville, MD; Peter
G. Lawson, Naval Criminal Investigative Service, 620 John
Paul Jones Circle, Portsmouth, VA; William C. Rodriguez
III, PhD, Armed Forces Institute of Pathology, 1413
Research Boulevard, Rockville, MD; and Douglas Knittel,
MD, Naval Medical Center, 630 John Paul Jones Circle,
Portsmouth, VA
Analysis of Electric Injury Patterns in Michael Thali, MD*, Office of the Armed Forces Medical 527
Human Skin by Magnetic Resonance Examiner, Rockville, MD, and Institute of Forensic
Microscopy Medicine, University of Berne, Berne, Switzerland; William
R. Oliver, MD, and William C. Rodriguez III, PhD, Armed
Forces Institute of Pathology, Rockville MD; Richard
Dirnhofer, MD, Institute of Forensic Medicine, University
of Berne, Berne, Switzerland; and Kimberlee Potter, PhD,
Armed Forces Institute of Pathology, Rockville, MD
Coins as Intermediate Targets: Michael Thali, MD*, Office of the Armed Forces Medical 527
Reconstructive Analysis With Body Models Examiner, Armed Forces Institute of Pathology, Rockville,
MD, and Institute of Forensic Medicine, University of
Berne, Berne, Switzerland; Beat P. Kneubuehl, PhD,
Institute of Forensic Medicine, University of Berne, Berne,
Switzerland; William C. Rodriguez III, PhD, Office of the
Armed Forces Medical Examiner, Armed Forces Institute of
Pathology, Rockville, MD; James Smirniotopoulos, MD,
Uniformed Services University of the Health Sciences,
Bethesda, MD; A. Charles Richardson, DDS, National
Naval Medical Center, Department of Radiology, Bethesda,
MD; David R. Fowler, MD, Offices of the Medical
Examiner of the State Maryland, Baltimore, MD; Michael
L. Godwin, BS, and Aaron Jurrus, Office of the Armed
Forces Medical Examiner, Armed Forces Institute of
Pathology, Rockville, MD; Doug Fletcher, PhD, National
Naval Medical Center, Department of Radiology, Bethesad,
MD; and Craig T. Mallak, MD, Office of the Armed Forces
Medical Examiner, Armed Forces Institute of Pathology,
Rockville, MD
Two Gunshots to the Head: Suicide or Jean-Sebastien Raul, MD*, Institut de Medecine Legale, 11 528
Homicide? A Biomechanical Study rue Humann, Strasbourg, France; C. Deck, and F. Meyer,
Institut de Mécanique des fluides - ULP-CNRS 7507,
Strasbourg, France; Annie Geraut, and Antoine Tracqui,
MD, PhD, Institut de Medecine Legale, 11 rue Humann,
Strasbourg, France; R. Willinger, Institut de Mecanique des
Fluides, ULP-CNRS 7507, Strasbourg, France; and
rue Humann, Strasbourg, France
Application of Biomechanics to the Robert O. Andres, PhD*, Ergonomic Engineering, Inc., 20 529
Interpretation of Pathology Data Gulf Road, Pelham, MA; and Joseph H. Davis, MD*, 8905
Southwest 115 Terrace, Miami, FL
Evaluation of Iron and Macrophages in Ellen G.I. Clark, MD, 475 Kirman, Reno, NV; Kathy P. 529
Meninges of Infants Dying Suddenly and Raven, MD*, King County Medical Examiner's Office, 325
Unexpectedly Ninth Avenue, Box 359792, Seattle, WA; Daniel Anderson-
Wooley, 475 Kirman, Reno, NV; and Richard C. Harruff,
MD, PhD, 325 Ninth Avenue, Seattle, WA
Index 114
Extent and Distribution of Retinal M.G.F. Gilliland, MD*, Brody School of Medicine East 529
Hemorrhages in Abusive and Non-Abusive Carolina University Department of Pathology and
Head Injury Laboratory Medicine, Brody 7510, Greenville, NC
Perimacular Retinal Folds and the Shaken Patrick E. Lantz, MD*, Wake Forest University Health 530
Baby Syndrome: Critical Appraisal Testing Sciences, Medical Center Boulevard, Winston-Salem, NC
of the Current Medical Literature
Neuropathology of Abusive Head Injury Mary E.S. Case, MD*, Saint Louis University Health 531
Sciences Center, 6039 Helen Avenue, St. Louis, MO
Pediatric Injury Evaluation: A Clinical Lora A. Darrisaw, MD*, Julie P. Gardiner, BA, Geoffrey P. 531
Forensic Pathology Program in Georgia Smith, MD, and Kris L. Sperry, MD, Georgia Bureau of
Investigation, 3121 Panthersville Road, Decatur, GA
Physical Findings in Confessed Homicidal Tracey S. Corey, MD, and Deirdre Schluckebier, MD*, 532
Suffocation of Children: A Case Series Office of the Chief Medical Examiner and University of
Louisville School of Medicine, OCME, 810 Barret Avenue,
Louisville, KY
Escalated Homicide: Cultural Changes Chantal Ferraro, PhD*, Long Island University at 532
Produce a New Type of Child Death Brookeville, Brookeville, NY; and O'Brian C. Smith, MD,
University of Tennessee at Memphis, 1060 Madison Avenue,
Memphis, TN
Magnetic Resonance Microscopy as an Andrew M. Baker, MD*, Office of The Hennepin County 533
Adjunct in The Evaluation of Infant Rib Medical Examiner, 530 Chicago Avenue, Minneapolis, MN;
Fractures and Kimberlee Potter, PhD and William R. Oliver, MD,
Armed Forces Institute of Pathology, 14th and Alaska
Avenue, Northwest, Washington, DC
Mother/Infant Co-Sleeping/Bed-Sharing James J. McKenna, PhD*, University of Notre Dame, 613 534
and Sudden Infant Death Syndrome Flanner, South Bend, IN; and Joseph A. Prahlow, MD*,
South Bend Medical Foundation & Indiana University
School of Medicine, 530 North Lafayette, South Bend, IN
Death Certification in Sudden Infant Death Joseph A. Prahlow, MD*, South Bend Medical Foundation 534
Syndrome and Related Infant Deaths & Indiana University School of Medicine, 530 North
Lafayette, South Bend, IN; and Randy L. Hanzlick, MD,
Fulton County Medical Examiners Office, 430 Pryor Street,
SW, Atlanta, GA
Pediatric Mortality in the Cook County Eupil Choi, MD*, and Edmund R. Donoghue, MD, Office of 535
Medical Examiner's Office, 1 to 4 Years: the Medical Examiner, Cook County, 2121 West Harrison
2000-2001 Street, Chicago, IL
Suicide in Children: A 12-Year Jeffrey M. Jentzen, MD*, and Eileen Weller, RN, MHA, 535
Retrospective Study Milwaukee County Medical Examiner's Office, 933 West
Highland Avenue, Milwaukee, WI; and Adam Ruck,
University of Wisconsin-Milwaukee, 2465 Oakland Ave,
Milwaukee, WI
Index 115
2002
Overview of Suicide Cases in Geneva, Romano La Harpe, MD*, Institut Universitaire de Médecine 536
Switzerland During a Twenty-five Year Légale, Av. de Champel 9 (CMU), Genève 4, Switzerland
Period (1971-1995)
An Unusual Presentation of a Rare Entity: Reade A. Quinton, MD*, UT Southwestern Medical Center, 536
Exsanguination by Ruptured Left Department of Pathology, 5323 Harry Hines Boulevard,
Subclavian Aneurysm Dallas, TX; and Joni L McClain, MD, Southwestern
Institute of Forensic Sciences, 5230 Medical Center Drive,
Dallas, TX
An Unusual Cause of Sudden Death in Frank Evangelista, MD*, Office of the Chief Medical 537
Infancy: Histiocytoid Cardiomyopathy, Examiner, 720 Albany Street, Boston, MA; Melissa P.
Report of an Autopsy Case Upton, MD, Beth Israel Deaconess Medical Center-
Deparment of Pathology, 330 Brookline Avenue, Boston,
MA; Richard J. Evans, MD, Eva Patalas, MD, and
Alexander M. Chirkov, MD, PhD, Office of the Chief
Medical Examiner, 720 Albany Street, Boston, MA
The Changing Faces of the Medico-Legal Aurelian Nicolaescu, MD*, Office of the Chief Medical 537
Autopsies at the Office of the Chief Medical Examiner, State of Maryland, 111 Penn Street, Baltimore,
Examiner of the State of Maryland— A MD; Joseph A. Kufera, MA, National Study Center for
Decade of Experience Trauma and EMS, 701 West Pratt Street, Baltimore, MD;
Jack M. Titus, MD, and David R. Fowler, MB, ChB, Office
of the Chief Medical Examiner, State of Maryland, 111
Penn Street, Baltimore, MD
Malaria Deaths in the United States: Case Robert Stoppacher, MD*, Milwaukee County Medical 538
Report and Review of Deaths, 1979-1998 Examiner’s Office, 5258 North, Bay Ridge Avenue, White
Fish Bay, WI; and Stephen P. Adams, MD, Vermont Office
Burlington, VT
North Carolina’s Death Investigation D’Michelle P. DuPre, MD*, Duke University Medical 538
Database Center, PO Box 3712, Durham, NC; and Kenneth S. Snell,
MD, and Thomas B. Clark III, MD, Office of the Chief
Medical Examiner, Chapel Hill, NC
“Homicide by Heart Attack” Revisited Staci D. Turner, MD*, Jeffrey J. Barnard, MD, and Sheila 539
D. Spotswood, MD, Southwestern Institute of Forensic
Sciences, 5230 Medical Center Drive., Dallas, TX; and
Joseph A. Prahlow, MD, South Bend Medical Foundation
and Indiana University School of Medicine, University of
Notre Dame, South Bend, IN
The Significance of Pulmonary Interstitial Wendy A. Lavezzi, MD*, Department of Pathology and 540
Emphysema in Fetal and Infant Autopsies Laboratory Medicine, 56 South Westcott Road,
Schenectady, NY; and Barbara C. Wolf, MD, Forensic
Medicine, PC, Albany, NY
Motor Vehicle Collision-Related Death Due Ana E. Lopez, MD*, Jeffrey J. Barnard, MD, and Charles L. 540
to Delayed-Onset Subarachnoid White III, MD, Southwestern Institute of Forensic Sciences,
Hemorrhage Associated With 5230 Medical Center Drive, Dallas, TX; Jaime L. Oeberst,
Anticoagulant Therapy MD, Sedgwick County Regional Forensic Science Center,
Wichita, KS; and Joseph A. Prahlow, MD, South Bend
Medical Education, University of Notre Dame, South Bend,
IN
Index 116
A Comprehensive Analysis of Forensic J. Keith Pinckard, MD, PhD*, Division of Laboratory 541
Science Training in Forensic Pathology Medicine, Washington University School of Medicine, Box
Fellowship Programs 8118, 660 South Euclid Avenue, Saint Louis, MO; Donna
M. Hunsaker, MD, Office of the Chief Medical Examiner,
810 Barrett Avenue, Louisville, KY; and Victor W. Weedn,
MD, JD, Carnegie Mellon University, 4400 Fifth Avenue
Mellon Institute, Room 292, Pittsburgh, PA
Postmortem Microbiology: Friend or Foe? Kathryn H. Haden, MD*, Lisette L. Lester, MD, JD, Sandra 542
K. Elkins, MD, and Mark Cole, University of Tennessee
Medical Center, 1924 Alloa Highway, Box U-108,
Knoxville, TN
Sufentanil Toxicity in Healthcare Jessie Adame, MD, Autopsy and Pathology Services, PO 542
Professionals Box 920903, Houston, TX; Douglas H. Posey, MD*, Joye
Carter, MD, and Ashraf Mozayani, PharmD, PhD, Harris
Houston, TX
Oxycodone (OxyContin) Related Deaths in Ellen C. Riemer, MD, JD*, Barry S. Levine, PhD, Jack M. 543
Maryland 1998-2000 Titus, MD, and David R. Fowler, MB, ChB, Office of the
Chief Medical Examiner of the State of Maryland, 111 Penn
Deaths Related to Conduction System Katarzyna Michaud, MD*, Nathalie Romain, MD, and 543
Pathology Patrice Mangin, MD, PhD, Institut Universtaire de
Médecine Légale, Rue du Bugnon 21, Lausanne,
Switzerland
Commotio Cordis Intermedius: Digital William Q. Sturner, MD*, Office of the Medical Examiner, 544
Interposition Between Projectile and Arkansas State Crime Laboratory, PO Box 8500, Little
Thorax Rock, AR
Genetics of Sudden Cardiac Death: Pekka J. Karhunen, MD, PhD*, University of Tampere, 544
Prothrombotic Mutations of Blood Platelet POB 602, Tampere, Finland; J. Mikkelsson, Schools of
Glycoprotein Receptors are Common Medicine and Public Health, University and University
Among Men Who Die of Prehospital Hospital of Tampere, Tampere, Finland; M. Perola,
Myocardial Infarction at Early Middle Age Department Human. Molecular Genetic, National Public
Health, Institute Tampere, Helsinki; P. Laippala, Schools of
Medicine and Public Health University and University
Hospital of Tampere Department Clinic Pathology and
Forensic Medicine, Tampere, Finland; and A. Penttila,
Department. Forensic Medicine, University of Helsinki,
Tampere, Helsinki
Under Reporting of Fatal Child Abuse by Mary H. Dudley, MD*, and Shari L. Beck, BA, Chief 545
State Vital Statistics ICD-9 Codes Medical Investigator, Sedgwick County Regional Forensic
Science Center, Wichita, KS; Larry Czarnecki, DO, Office
of the Medical Investigator, and University of New Mexico
School of Medicine, Albuquerque, NM
Venous Air Embolism— A Difficult Mitra B. Kalelkar, MD*, Kendall Crowns, MD, and 545
Postmortem Diagnosis Edmund R. Donoghue, MD, Chief Medical Examiner, Cook
County Medical Examiner’s Office, 2121 West Harrison
Street, Chicago, IL
Index 117
Virtopsy—New Horizons in Forensic Michael J. Thali, MD*, Office of the Armed Forces Medical 546
Radiology: Documentation and Analysis of Examiner, AFIP - Annex, 1413 Research Boulevard,
Gunshot Victims With Postmortem Multi- Building 102, Rockville, MD; K. Yen, Wolf Schweitzer, and
Slice Computer Tomography and Magnetic E. Scheurer, Institute of Forensic Medicine, University of
Resonance Berne, Buchlstrasse 20, Berne, Switzerland; P. Vock,
Institute of Diagnostic Radiology, University of Berne,
Berne, Switzerland; C. Ozdoba, and G. Schroth,
Department of Neuroradiology, University of Berne, Berne,
Switzerland; M. Sonnenschein, Institute of Diagnostic
Radiology, University of Berne, Berne, , Switzerland; Ch.
Boesch, Department. Clinical Research, Magnetic
Resonance Spectroscopy, University of Berne, Berne,
Switzerland; M. Ith, Department of Neuroradiology,
University of Berne, Berne, , Switzerland; K. Brugger,
Department. Clinical Research, Magnetic Resonance
Spectroscopy, University of Berne, Berne, Switzerland; E.
Spielvogel, Institute of Diagnostic Radiology, University of
Berne, Berne, Switzerland; U. Koenigsdorfer, and R. Dorn,
Institute of Forensic Medicine, University of Berne,
Buchlstrasse 20, Berne, Switzerland; and R. Dirnhofer,
Berne, Switzerland
Evaluation of 122 Forensic Autopsies of Georges Krompecher, MD, Thomas Krompecher, MD, 546
Unprotected Victims Killed in Traffic PhD*, and Patrice Mangin, MD, PhD, Institut Universitaire
Accidents de Médecine Légale, Rue du Bugnon 21, Lausanne,
Switzerland
Undefeated by Surgery: The Utility of Post- Jeremy Rich, DPM*, Harvard Medical School, Beth Israel 547
Surgical Foot and Ankle Radiographs as a Deaconess Medical Center, 330 Brookline Avenue, Boston,
Basis for Identification MA; Nancy E. Tatarek, PhD, Ohio University, 293 Lindley
Hall, Athens, OH; Robert H. Powers, PhD, Hamilton
County Coroner’s Office, 3159 Eden Avenue, Cincinnati,
OH; Bradley J. Lewis, MD, and Dorothy E. Dean, MD,
Franklin County Coroner’s Office, 520 King Avenue,
Columbus, OH
Paraphyly in Lucilia Cuprina (Diptera: Jamie R. Stevens, PhD, University Exeter, Biological 548
Calliphoridae) Mitochondrial DNA: Science, Prince of Wales Road, Exeter, United Kingdom;
Implication for Forensic Entomology and Richard Wall, PhD, University Bristol, Biological Sciences,
Evidence for an Ancient Hybridization Woodland Road, Bristol, United Kingdom; and Jeffrey D.
Event Wells, PhD*, University of Alabama Birmingham, Justice
Science, 901 15th Street South, Birmingham, AL
Investigation of Italy’s Deadliest Building Carlo Pietro Campobasso, MD, PhD*, Rosa Falamingo, 548
Collapsed: Forensic Aspects of a Mass MD, and Francesco Vinci, MD, Section of Legal Medicine
Disaster (DIMIMP), University of Bari, Policlinico, Plaza Giulio
Cesare, Bari, Italy
Differential Decomposition I: Partial Kathryn H. Haden, MD, Department of Anthropology; and 549
Ground Contact Murray K. Marks, PhD*, Department of Pathology, The
University of Tennessee Medical Center, 250 South Stadium
Hall, Knoxville, TN
Are Autopsies Necessary in Centenarians? Andrea M. Berzlanovich, MD*, Ernst Sim, MD, Peter 549
Fasching, MD, and Manfred A. Muhm, MD, Department of
Forensic Medicine, University of Vienna, Sensengasse 2,
Vienna, Austria
Index 118
In-Hospital Deaths for Forensic Autopsy Istvan F. Szentmariay, MD*, and Gyorgy Dunay, MD, 550
Ulloi Ut 93, Budapest, Hungary
Characteristics of Different Types of Fatal Erin H. Kimmerle, MA*, University of Tennessee, 121 West 550
Head Trauma and the Factors That Jackson Avenue North, Knoxville, TN; Matthias Okoye, MD,
Influence Survival Time and Activity Prior JD, Pathology Medical Services, PC Lincoln General
to Death Hospital, 2300 South 16th Street, Lincoln, NE; and Sue
Gabriel, RN, BSN, Nebraska Wesleyan University, Lincoln,
NE
Seizure Associated Fatalities: An Analysis Michael A. Stier, MD*, University of Wisconsin-Madison, 550
of Cases in Milwaukee County Department of Pathology, 1300 University Avenue,
Madison, WI; and John R. Teggatz, MD, Milwaukee County
Medical Examiner’s Office, 933 West Highland Avenue,
Milwaukee, WI
Homicide by Second Impact Syndrome... or Dwayne A. Wolfe, MD, PhD*, Office of Medical Examiner 551
Unfortunate Coincidence? of Harris County, Joseph A. Jachimczyk Forensic Center,
1885 Old Spanish Trail, Houston, TX
A New Technique to Estimate a James Haefner, and John B. Wallace, PhD*, Department of 551
Postmortem Submersion Interval (PMSI) Biology, Millersville University, Millersville, PA; and
Using Algal Growth Rates Richard W. Merritt, PhD, Department of Entomology,
Michigan State University, East Lansing, MI
Assisting the Living Butch M. Huston, MD*, and Janis C. Amatuzio, MD, 552
Midwest Forensic Pathology, 3960 Coon Rapids Boulevard,
Suite LL21, Coon Rapids, MN
Some Empirical Data on the Past and Jody E. Hooper, MD*, United States Navy, General 552
Future of the Autopsy Medical Officer, 5240 Fiore Terrace, San Diego, CA
The Postmortem Diagnosis of Skull and Kathrin Yen, MD*, Wolf Schweitzer, MD, Eva Scheurer, 553
Brain Injuries by Imaging Methods (MRI, MD, and Michael J. Thali, MD, Institute of Forensic
Multi-Slice CT) Medicine, University of Berne, Buehlstrasse 20, 3012 Berne,
Switzerland; Christoph Ozdoba, MD, Gerhard Schroth,
MD, and Martin Sonnenschein, MD, Departement of
Neuroradiology, University of Berne, Freiburgstrasse, 3010
Berne, Switzerland; Chris Boesch, MD, PhD, Michael Ith,
PhD, and Karin Brugger, MR-Spectroscopy Center,
University of Berne, 3010 Berne, Freiburgstrasse,
Switzerland; Elke Spielvogel, Department of
Neuroradiology, University of Berne, 3010 Berne,
Freiburgstrasse, Switzerland; and Richard Dirnhofer, MD,
Buehlstrasse20, 3012 Berne, Switzerland
Use of Magnetic Resonance Microscopy for William R. Oliver, MD*, and Kimberlee Potter, PhD, 553
Evaluation of Retinal Hemorrhage Armed Forces Institute of Pathology, Washington, DC; J.C.
Upshaw Downs, MD, Director, Alabama Department of
Forensic Sciences and Chief Medical Examiner, PO Box
3510, Auburn, AL; and David R. Fowler, MB, ChB, Office
Penn Street., Baltimore, MD
Phenylpropanolamine and Acute Yvonne I. Milewski, MD*, Office of Chief Medical 554
Intracerebral Hemorrhage Examiner, 520 First Avenue, New York, NY
Index 119
The Use of Lidocaine to Commit Homicide Brian C. Hunter, BA, MD*, Department of Pathology, 554
Sparrow Health System, 1215 East Michigan Avenue,
Lansing, MI; John Trestrail III, BS, RPh, Regional Poison
Center, Grand Rapids, MI; and Stephen D. Cohle, MD,
Spectrum Health East Campus, Pathology Department,
Grand Rapids, MI
Where Do People Die Suddenly and Istvan F. Szentmariay, MD*, Gyorgy Dunay, MD, and 555
Unexpectedly? Marta Hubay, MD, Institute of Forensic Medicine,
Semmelweis University, Ulloi Ut 93, Budapest, Hungary
The “Holy Crown United” Southern Italian Francesco Introna, MD*, Francesco Faggiano, MD, 555
Mafia Organization Homicides Alberto Tortorella, MD, and Antonio De Donno, MD,
University of Bari, Italy, Istituto di Medicina Legale,
Policlinico, Bari, Italy
Homicide Attempt With a Japanese Jean-Sebartien Raul, MD*, Laurent Berthelon, MD, Annie 556
Samurai Sword Geraut, MD, Antoine Tracqui, MD, PhD, and Bertrand
Ludes, MD, PhD, Institut de Médecine Légale, 11 Rue
Humann, Starsbourg Cedex, France
Sharp Force Injury Fatalities in New York James R. Gill, MD*, and Charles Catanese, MD, New York 556
City City of Chief Medical Examiner and Department of
Forensic Medicine, 520 First Avenue, New York, NY
No Homicide on Christmas Eve !? — Case Martin Bauer, MD*, and Dieter Patzelt, MD, Institute of 557
Report of an Unusual Stab Wound of the Legal Medicine, University of Wuerzburg, Versbacher Str.
Brain 3, Wuerzburg, Germany
Accidental Hanging Death of a 10-Year- J. Scott Denton, MD, Cook County Medical Examiner’s 557
Old Boy From a Lanyard Key Chain Office, 2121 West Harrison Street, Chicago, IL
Sudden Death in Baseball: A Case Report Abraham T. Philip, MD*, Alexander M. Chirkov, MD, and 558
and Review of Literature Richard J. Evans, MD, Office of the Chief Medical
Examiner, 720 Albany Street, Boston, MA
Post Collision Vehicular Fires— Joseph L. Burton, MD* and Paul R. Lewis, Jr., MS, BME, 558
Determination of Probability of Occupant Burton & Associates, 13784 Highway 9, Alpharetta, GA
Survival Post Impact
Decapitation by Motorized Shoulder Thomas W. Young, MD*, C. Chase Blanchard, MD, and 559
Harness: A Case Report Ronald E. Brasfield, Office of the Jackson County Medical
Examiner, 660 East 24th Street, Kansas City, M0
The Memorials at the Lockerbie and Gordon K. Murphy, MD*, 814 Hathaway Road, Dayton, 559
Ermenonville Forest Air Disaster Sites OH
Experiences Following the Crash of Kai-Ping Shaw, PhD*, John M. Fong, ME, John Wang, ME, 560
Singapore Airlines SQ006 Boeing 747-400 Ching Hu, ME, Ming-Houng Chen, ME, Chiang-Shin Liu,
in Taipei ME, Tse-Hua Lo, ME, and Chia-Tung Shung, Ministry of
Justice Investigation Bureau; and Chang-En Pu, MS,
Institute of Forensic Medicine, Ministry of Justice, Taipei,
Taiwan
Mortality Estimate for the 1994 Northridge Christopher A. Rogers, MD*, and Lakshmanan 560
Earthquake Sathyavagiswaran, MD, Department of Coroner, 1104
North Mission Road, Los Angeles, CA
Death in the Desert: Multiple Fatalities as a Bruce O. Parks, MD*, Eric D. Peters, MD, Cynthia M. 561
Consequence of Environmental Exposure Porterfield, DO, Diane Karluk, MD, Walter H. Birkby,
PhD, and Bruce E. Anderson, PhD, Office of the Medical
Examiner, Forensic Science Center, 2825 East District
Street, Tucson, AZ
Index 120
The Role of the Forensic Anthropologist in Brian C. Hunter, MD*, Department of Pathology Sparrow 561
Determining the Manner of Death in Health System, 1215 Michigan Avenue, Lansing, MI;
Suicidal Shotgun Wound to the Back of the Norman J. Sauer, PhD, and Todd W. Fenton, PhD,
Head Department of Anthropology, Michigan State University,
East Lansing, MI; Joyce L. de Jong, DO, Department of
Pathology, Forensic Pathology Division, Sparrow Health
System, 1215 Michigan Avenue, Lansing, MI; and Michael
G. Koot, BA, Department of Anthropology, Michigan State
University, East Lansing, MI
Sudden Death Due to Myocardial Infarct Joyce L. de Jong, DO*, and Brian C. Hunter, MD, Sparrow 562
Associated With Systemic Lupus Health System - Forensic Division, 1215 East Michigan
Erythematosus: Two Case Reports and a Avenue, Lansing, MI
Review of the Literature
Unexpected Multicystic Encephalopathy Giancarlo Di Vella, MD, PhD*, Maura Belviso, MD, 562
After Accidental Intoxicaction by a Sazione di Medicina Legale, DIMIMP, University of Bari,
Corrosive Agent: Case Report Italy; Gabriella Serio, MD, PhD, Giuseppe Parisi, MD,
Roberto De Blasi, MD, Unità Opeativa di Neuroradiologia,
University of Bari Italy, Policlinico, piazza G. Cesare, Bari,
Italy
Notochord Regression Failure Initially Patricia A. Aronica-Pollak, MD*, 2708 Neonlight Drive, 563
Suspected as an Abusive Fracture in an York, PA, Vincent H. Stefan, PhD, Department of
Infant Anthropology, Lehman College, CUNY, Bronx, NY, Jerri
McLemore, MD, Office of the Medical Investigator,
University of New Mexico School of Medicine, Albuquerque,
NM, and Madelyn Stazzone, MD, Radiology Department,
University of New Mexico School of Medicine, Albuquerque,
NM
The Clinical and Pathological Features of Stephany Fiore, MD*, and Vernon Armbrustmacher, MD, 564
Fatal Concussion Office of Chief Medical Examiner, 520 First Avenue, New
York, NY
Doctors as Detectives” (1987 - 2001): Frank P. Saul, PhD*, Regional Commander, USPHS 565
Fifteen Years of Introducing Forensic DMORT 5, OH; Julie Mather Saul, BA, Director, Forensic
Medical Science to High School Students in Anthropology Laboratory, James R. Patrick, MD, Lucas
Northwest Ohio and Southeast Michigan County Coroner, Diane Scala-Barnett, MD, Deputy Lucas
County Coroner, Robert B. Forney, Jr., PhD, Director of
Toxicology, and Robert A. Burns, DDS, MS, Consultant,
Forensic Odontology, Lucas County Coroner’s Office and
Medical College of Ohio, 2529 Arlington Avenue, Toledo,
OH; Jerome DeBruin, PhD, Professor of Education,
University of Toledo, 2801 West Bancroft, Toledo, OH
Exsanguination From a Dialysis Catheter: Michael A. Trimpe, BS, Robert R. Pfalzgraf, MD, and Carl 565
Trace Evidence Examination in L. Parrott, Jr., MD*, Hamilton County Coroner’s Office,
Determining Manner of Death 3159 Eden Avenue, Cincinnati, OH
Sudden Death Due to Idiopathic Giant Cell Maryanne Gaffney-Kraft, DO*, Hong Yin, MD, and Patrick 566
Myocarditis: Case Report and Literature E. Lantz, MD, Department of Pathology, Wake Forest
Review University Baptist Medical Center, Medical Center
Index 121
Immunopathological Study of Fang-Chun Chung, MS*; Chang-En Pu, MS, Section Chief; 566
Methamphetamine (MAP)-Induced Way-Lin Lin, Associate Researcher, Institute of Forensic
Fatalities Medicine, 40-11, Lane 103 Hsing-An Street, Taipei, Taiwan
(Roc); Way-Hwa Lee, Professor; John M. Fong; and, Kai-
Ping Shaw, Chairman, Department Forensic Pathology,
Institute of Forensic Medicine, 40-11, Lane 103 Hsing-An
Street, Taipei, Taiwan (ROC)
Experiences of Human Bodies Identified by Chang-En Pu, MS*, Ministry Justice Investigation Bureau, 567
DNA Typing in Singapore Airlines SQ006 PO Box 3562, Taipei, Taiwan; Chi-Hsiang Chao, Division
Crash in Taipei Chief, Ministry Justice Investigation Bureau, Taipei,
Taiwan; Fang-Chin Wu, Wen-Hsiung Ho, Kuo-Chun Wu,
Ling-Min Meng, Researcher, Ministry Justice Investigation
Bureau, Taipei, Taiwan; and Kai-Ping Shaw, Director of
Forensic Pathology, Institute of Forensic Medicine,
Ministry of Justice, Taipei, Taiwan
A Case Report of Sudden Death in a Cristin M. Rolf, MD*, University of Kentucky Department 567
Patient With Kartagner Syndrome of Pathology & Laboratory Medicine, Central Laboratory
Facility, 100 Sower Boulevard, Suite 202, Frankfort, KY
Micro-Computed Tomography: An Michael J. Thali, MD*, Office of the Armed Forces Medical 568
Advantageous Tool for the Analysis of Examiner, Armed Forces Iinstitute of Pathology - Annex,
Patterned Tool Marks in Bones 1413 Research Boulevard, Building 102, Rockville, MD;
Ulrike Taubenreuther, Institute of Medical Physics,
University of Erlangen, Germany; Marcel Braun, Institute
of Forensic Medicine, University of Berne, Berne,
Switzerland; Nicolette Scholz, Institute of Medical Physics,
University of Erlangen, Germany; Walter Brueschweiler,
Switzerland; Willi Kalender, Institute of Medical Physics,
University of Erlangen, Germany; Richard Dirnhofer, MD,
Switzerland
Immunohistochemical Study for Mona M.A. Hassan, MD* and Ragaa T. Darwish, MD, 568
Determining the Time of Injury to Rats Department of Forensic Medicine & Toxicology,
Following Stab Wounds and Blunt Trauma Alexandria, Egypt; and Samar M. El-Sheikh, PhD,
to the Brain Department of Pathology, Faculty of Medicine, University
of Alexandria, 33, Safeya Zaghloul St. #52, Alexandria,
Egypt
Postmortem Interval Decomposition Arpad A. Vass, PhD*, Stacy-Ann Barshick, PhD, Gary 569
Chemistry of Human Remains: A New Sega, PhD, John Canton, PhD, James T. Skeen, Jennifer C.
Methodology for Determing the Love, PhD, and Jennifer A. Synstelien, BA, Oak Ridge
Postmortem Interval National Laboratory, PO Box 2008, Oak Ridge, TN
Effect of Ant Activity on Decompositional William C. Rogriguez, III, PhD*, Office of the Armed 569
Rates and Estimation of Postmortem Forces Medical Examiner, Armed Forces Institute of
Interval: A Case Study Pathology, 1413 Research Boulevard. Biulding 102,
Rockville, MD
Forensic Entomology: Decomposition in Ian Dadour, PhD*, Centre for Forensic Science, University 570
Cars of Western Australia, Nedlands, Australia, Western
Australia
Index 122
Deceased, Dismembered, and Disarranged: John M. Andrews, MD*, Jeffrey P. Gutstadt, MD, Hideo H. 570
Central Nervous System Consequences of Itabashi, MD, Steven J. Dowell, BS, Mark S. Schuchardt,
an Unusual Body Disposal Strategy Department of Coroner, County of Los Angeles, 1104 North
Mission Road, Los Angeles, CA; and Elizabeth A. Miller,
PhD, Department of Anthropology, California State
University, Los Angeles, CA
Detection of Chemical Signals by the Jeffery K. Tomberlin, PhD*, W. Joe Lewis, PhD, Marco 571
Parasitic Wasp Microplitis Croceipes D’Alessandro, BS, and Moukaram Tertuliano, PhD,
Department of Biological and Agricultural Engineering, PO
Box 748, Tifton, GA
Suicidal Air Rifle Wound of the Head Jennie V. Duval MD*, Dallas County Medical Examiner’s 572
Office Southwestern Institute of Forensic Science, Susan B.
Allen BS, Dustin S. Engel BA, Criminal Investigation
Laboratory Firearms Section, and Jeffrey J. Barnard MD,
Dallas County Medical Examiner’s Office, 5230 Medical
Center Drive, Dallas, TX
Pediatric Injuries: Can CPR Related Chitra Rao, MBBS*, Forensic Pathologist, Regional 572
Injuries Mimic Inflicted Injuries? Forensic Pathology Unit, General Site -HHS, 237 Barton
Street East, Hamilton, Ontario, L8L 2X2, Canada
When “Non -Terminal” Is Fatal–Medical Carolyn Bertrand, PhD, Forensic Psychology Research 572
Examiner Cases of Fibromyalgia Fatalities Fellow, County of San Diego, Mark J. Shuman, MD, MS*,
Deputy Medical Examiner, County of San Diego, and Brian
D. Blackbourne, MD, Chief Medical Examiner County of
San Diego, San Diego, CA
Rapid Death From Phlegmonous Gastritis Lakshmanan Sathyavagiswaran, MD*, Chief Medical 573
Associated With Lymphoma Examiner, Coroner, Los Angeles County, 1104 North
Mission Road, Los Angeles, CA
Victim-Offender Relationship in Florida Shuala S. Martin, MA*, C A. Pound Human Identification 573
Medical Examiner District 8 Laboratory, University of Florida, 124 Fisherman Road,
Satsuma, FL
Medical Malpractice: A Case History Study Nunzio Di Nunno, MD*, Alessandro Dell’ Erba, MD, 574
by the Forensic Medicine Section From Francesco Vinci, MD, Stanislao Mangiatordi, MD, Luigi
Bari Viola, MD, and Francesco Vimercati, MD, Sesione di
Medicina Pubblica, Bari University, Policlinico, Piazza G.
Cesere n. 11, Bari, Italy
Nuclear and Mitochondrial DNA Analyses J.C. Upshaw Downs, MD*, Alabama Department of 574
Following X- and Gamma-irradiation Forensic Sciences, PO Box 3510, Auburn, AL, S. Elaine
Scott, MS, Alabama Department of Forensic Sciences, 2451
Fillingim Street, Mobile, AL, William Jones, Armed Forces
Institute of Pathology, 2451 Fillingim Street, Mobile, AL,
Robert Neyland, PhD, Maria Jacobsen, and Paul
Mardikian, Warren Lasch Conservation Center, Former
Charleston Naval Base1250 Supply Street, Building 255,
North Charleston, SC; Sudhir K. Sinha, PhD, ReliaGene,
5525 Mounes Street, New Orleans, LA; and Douglas W.
Owsley, PhD, National Museum of Natural History,
Smithsonian Institution, Department of Anthropology,
Washington, DC
Recovery and Processing of Co-Mingled J.C. Upshaw Downs, MD*, Alabama Department of 575
Remains Following Extended Submersion Forensic Sciences, PO Box 3510, Auburn, AL; and William
Period Facilitated by Computer Animation R. Oliver, MD, Armed Forces Institute of Pathology,
Washington, DC
Index 123
Comparison of Drug Concentration in Mirella Gherardi, MD*, Marina Caligara, PharmD, and 575
Blowflies (Diptera: Calliphoridae) and Luca Sironi, PharmD, PhD, Institute of Legal Medicine -
Human Tissues University of Milan, Via L. Mangiagalli, 37, Milan, Italy
Removing External Contamination of Jason G. Linville, BS*, Department of Biology, and Jeffrey 576
Maggots With a Bleach Solution Without D. Wells, PhD*, Department of Justice Sciences, University
Inhibiting Genetic Analysis of Maggot of Alabama at Birmingham, Birmingham, AL
Crop Contents
The Child Abuse Works of Ambroise C. Ferraro, PhD, University of Long Island, Brookville, NY; 576
Tardieu…Had We Only Taken French and O’Brian C. Smith, MD*, Steven A. Symes, PhD,
Cynthia D. Gardner, MD, and T.A. Campbell, MD,
University of Tennessee, Memphis, 1060 Madison Avenue
Memphis, TN
Coming of Age in Memphis... How Our C. Ferraro, PhD*, Long Island University, Brookville, NY; 577
Children Die O’Brian C. Smith, MD, Steven A. Symes, PhD, Cynthia D.
Gardner, MD, and T.A. Campbell, MD, University of
Tennessee, Memphis, 1060 Madison Avenue Memphis, TN
Bruises in Infancy: How Many Are Too Betty S. Spivack, MD*, University of Louisville, Kentucky 578
Many? Justice Cabinet, Office of the Chief Medical Examiner 810
Barret Avenue, Louisville, KY
Child Abuse Autopsy Technique... What O’Brian C. Smith, MD*, Steven A. Symes, PhD, Cynthia D. 578
Works for Us Gardner, MD, Susan B. Patton, MNSc, and T. A. Campbell,
MD, University of Tennessee, Memphis, 1060 Madison
Avenue, Memphis, TN; and C. Ferraro, PhD, Long Island
University, Brookeville, NY
Index 124
Index by Presenting Author
Author by Last Name Title Page
Abaci-Kalfoglou, Ersi PhD*, Hulya Yukseloglu, PhD, Tanýl Who was Driving: A Case Report 469
Baskan, PhD, and Sevil Atasoy, PhD, Istanbul University,
Institute of Forensic Sciences, Cerrahpasa, Istanbul 34303,
Turkey
Aboud, Maurice J. BSc*, 10720 North West 66th Street, A Rapid Penta STR Screening Method by 191
Apartment #113, Miami, FL 33178 Microchip Capillary Electrophoresis
Abraham, Elizabeth J. MA, MSc*, University Health Pig-Mentation: Postmortem Iris Color Change 302
Network, MedWest, 750 Dundas Street West, 2nd Floor, in the Eyes of Sus Scrofa
Suite 279, Toronto, Ontario M6J 3S3, Canada; Margaret
Cox, PhD, Inforce Foundation, Melbury House, 1-3 Oxford
Road, Bournemouth, Dorset BH8 8ES, United Kingdom;
and David Quincey, MSc, Bournemouth University, Institute
of Health and Community Studies, Royal London House, 1st
Floor, Christchurch Road, Bournemouth, Dorset BH1 3LH,
United Kingdom
Adame, Jessie MD, Autopsy and Pathology Services, PO Sufentanil Toxicity in Healthcare 542
Box 920903, Houston, TX; Douglas H. Posey, MD*, Joye Professionals
Carter, MD, and Ashraf Mozayani, PharmD, PhD, Harris
Houston, TX
Adams, Julie DO*, 1234 Big Bend Crossing Drive, Valley Hanging Deaths in Children: An Investigation 81
Park, MO 63088 of Manner of Death
Adams, Nancy S. BS*, 202 Milford Street, #155, Tupelo, MS Radiology Students and Morgues: A Mutually 202
38801 Beneficial Relationship
Addante, Annalisa MD, PhD*, Fiorenza Zotti, PhD, Andrea Immunohistochemical Examination of α- 375
Marzullo, MD, Alessandro Dell’Erba, MD, PhD, and Lactalbumin in SIDS (Sudden Infant Death
Massimo Collonna, MD, Section of Legal Medicine, Syndrome)
University of Bari, Piazza Giulio Cesare, Bari, 70124, Italy
Aiken, Sally S. MD*, Spokane County Medical Examiner, Pure Group A Beta Streptococcal Peritonitis 480
5901 North Lidgerwood, Suite 24B, Spokane, WA 99208 in a Child With Inflammatory Bowel Disease
Alempijevic, Djordje M. MD, PhD*, Dragan S. Jecmenica, Model Protocol for Forensic Medical 284
MD, PhD, Snezana Pavlekic, MD, PhD, Slobodan N. Savic, Examination of Victims of Trafficking in
MD, PhD, and Branimir V. Aleksandric, MD, PhD, Institute Human Beings
of Forensic Medicine, Faculty of Medicine, University of
Belgrade, 31a Deligradska Street, Belgrade, 11000, Serbia
Alempijevic, Djordje M. PhD*, Faculty of Medicine Sudden Infant Death Syndrome and Infant 101
University of Belgrade, Institute of Forensic Medicine, 31a Mortality in Serbia
MONTENEGRO; Ana Milenkovic, and Nikola Vukelic,
Faculty of Medicine University of Belgrade, 8 Drive
Subotica Street, Belgrade, 11000, SERBIA AND
MONTENEGRO; and Dragan S. Jecmenica, PhD, Snezana
Pavlekic, PhD, Aleksandra V. Nedeljkov, MD, and Branimir
V. Aleksandric, PhD, Institute of Forensic Medicine,
Faculty of Medicine, University of Belgrade, 31a
MONTENEGRO
Index 125
Alempijevic, Djordje MD, PhD, Dragan Jecmenica, MD, Diffuse Axonal Injury in Medico-Legal 233
PhD, Vladimir Zivkovic, MD, Snezana Pavlekic, MD, PhD, Practice
and Slobodan Savic, MD, PhD*, University of Belgrade,
School of Medicine, Institute of Forensic Medicine, 31a
MONTENEGRO
Alexander, Russell MD*, Duke University Medical Center, Sudden Infant Death Syndrome in North 484
Department of Pathology, Box 3712, Durham, NC; Krista Carolina From 1999-2000: The Prevalence of
Ragan, BS, Castleton State College, Castleton, VT; Risk Factors and Its Relation to 2000 Census
Deborah Radisch, MD, MPH, Office of the Chief Medical Data on a County by County Basis
Examiner, Campus Box 7580, Chapel Hill, NC; and Robin
Vollmer, MD, Veterans Affairs Medical Center, Department
of Pathology, 508 Fulton Street, Durham, NC
Alexander, Russell T. MD*, and David R. Fowler, MD, Ephemeral Petechial-Like Spots in a Victim 150
Office of the Chief Medical Examiner, 111 Penn Street, of a House Fire
Baltimore, MD 21201
Alexander, Russell T. MD*, and Jeffrey M. Jentzen, MD, Neck and Scleral Hemorrhage Due to 270
Milwaukee County Medical Examiner’s Office, 933 West Drowning
Alexander, Russell T. MD*, John Turner, MD, and Louis An Unusual Motorized Vehicle Fatality 464
Dibernardo, MD, Duke University Medical Center,
Department of Pathology, DUMC Box 3712, Durham, NC
27710
Ali, Zabiullah MD*, Office of the Chief Medical Examiner, Utility of Whole Body Postmortem Computed 70
111 Penn Street, Baltimore, MD 21201; Barry Daly, MD, Tomography Imaging in Detection of Elder
and Nancy Knight, PhD, University of Maryland Medical Abuse: Comparison With and Potential
Center, Radiology Department, 22 South Greene Street, Substitution for Standard Autopsy
MD 21201
Ali, Zabiullah MD*, Office of the Chief Medical Examiner, Diabetic Ketoacidosis—A Silent Death 504
State of Maryland, 111 Penn Street, Baltimore, MD; Mary
G. Ripple, MD, 68 Bluebird Road, Port Deposit, MD; and
Barry S. Levine, PhD, and David R. Fowler, MD, Office of
Allan, Carol H. MD*, Ling Li, MD, Susan Hogan, MD, and Undiagnosed Cardiac Sarcoidosis and Sudden 453
Mary G. Ripple, MD, Office of the Chief Medical Examiner, Death: Report of 14 Cases
State of Maryland, 111 Penn Street, Baltimore, MD 21201;
Allan Burke, MD, Department of Defense, Armed Forces
Institute of Pathology, 14th & Alaska Avenue Northwest,
Washington, DC 20306; David Fowler, MD, Office of the
Chief Medical Examiner, State of Maryland, 111 Penn
Anderson*, Brianna F. and Jessica D. Wilkerson, The Persistence of an Elevated Concentration 158
University of Nebraska-Lincoln, 202 Entomology Hall, PO of Ninhydrin-Reactive Nitrogen in Grave Soil
Box 830816, Lincoln, NE 68583-0816; and David O.
68583-0816
Index 126
Anderson, Bryce O. PhD*, and Tyler A. Kress, PhD, BEST An Experimental Comparison of Bone 283
Engineering, 2312 Craig Cove, Knoxville, TN 37919; Anne Wound Ballistics of Non-Lead and Lead
M. Kroman, MA, University of Tennessee, Department of Bullets
Anthropology, Knoxville, TN 37996; David J. Porta, PhD,
Bellarmine University, Department of Biology, 2001
Newburg Road, Louisville, KY 40205; and John C.
Hungerford, PhD, University of Tennessee, 208 ESH,
Knoxville, TN 37996
Andres, Robert O. PhD*, Ergonomic Engineering, Inc., 20 Application of Biomechanics to the 529
Gulf Road, Pelham, MA; and Joseph H. Davis, MD*, 8905 Interpretation of Pathology Data
Southwest 115 Terrace, Miami, FL
Andrews, John M. MD*, Jeffrey P. Gutstadt, MD, Hideo H. Deceased, Dismembered, and Disarranged: 570
Itabashi, MD, Steven J. Dowell, BS, Mark S. Schuchardt, Central Nervous System Consequences of an
Department of Coroner, County of Los Angeles, 1104 North Unusual Body Disposal Strategy
Mission Road, Los Angeles, CA; and Elizabeth A. Miller,
PhD, Department of Anthropology, California State
University, Los Angeles, CA
Arbefeville, Elise F. MD*, and Vernard I. Adams, MD, Exertional Collapse in a Youth With 144
Hillsborough County Medical Examiner Department, 401 Hemoglobin SE
South Morgan Street, Tampa, FL 33602
Arbia*, Ziadi nd Chadly Ali, MD, Department of Forensic Suicide by Hanging in Children 437
Medicine, University Hospital Fattouma Bourguiba,
Monastir, 5000, Tunisia
Archer, Michael E. MA*, New York Forensics, Inc., 1039 Sudden Death and Fatty Liver Disease 232
Main Street, PO Box 28, Fishkill, NY 12524-0028; and
Dennis J. Chute, MD, and Kari B. Reiber, MD, Office of the
Argo*, Antonina Rosa Liotta, Emiliano Maresi, Stefania Can Immunohistochemical Stains Aid to Rule 219
Zerbo, Rosaria Vitale, Pierangela Fleres, and Paolo Out Pitfalls in Suffocation Deaths?
Procaccianti, Via del Vespro, n. 127, Palermo, 90100,
ITALY
Aronica-Pollak, Patricia A. MD*, 2708 Neonlight Drive, Notochord Regression Failure Initially 563
York, PA, Vincent H. Stefan, PhD, Department of Suspected as an Abusive Fracture in an Infant
Anthropology, Lehman College, CUNY, Bronx, NY, Jerri
McLemore, MD, Office of the Medical Investigator,
University of New Mexico School of Medicine,
Albuquerque, NM, and Madelyn Stazzone, MD, Radiology
Department, University of New Mexico School of Medicine,
Albuquerque, NM
Aronica-Pollak, Patricia A. MD*, and Mary G. Ripple, MD, Two Suicidal Deaths From Head Injuries 22
Office of the Chief Medical Examiner, 111 Penn Street, Caused by Unusual Sharp Force Instruments
Baltimore, MD 21201; Juan C. Troncoso, MD, Department and Review of the Literature
of Pathology, Johns Hopkins University School of Medicine,
600 North Wolfe Street, Baltimore, MD 21287; Kyle C.
Shaw, MBBS, District 5 Medical Examiner’s Office, 809
Pine Street, Leesburg, FL 34748; and David R. Fowler,
MD, Office of the Chief Medical Examiner, 111 Penn Street,
Baltimore, MD 21201
Aronica-Pollak, Patricia A. MD*, Jack M. Titus, MD, and Non-Traumatic Homicide Following Assault: 281
David R. Fowler, MD, Office of the Chief Medical 16 Cases - A Review of Investigation,
Examiner State Of Maryland, 111 Penn Street, Baltimore, Pathology, Toxicology, and Judicial Outcome
MD 21201
Index 127
Aronica-Pollak, Patricia A. MD*, Jack M. Titus, MD, and Autopsy Findings in Hypothermia: A Five 414
David R. Fowler, MD, Office of the Chief Medical Year Retrospective Study
MD 21201
Arredondo Marin, Jorge L. MD*, John R. Fernandes, MD, Ocular Study in Pediatric Deaths Under Two 287
and Chitra Rao, MBBS, McMaster University, Department Years of Age With Novel Findings in the
of Pathology and Molecular Medicine, Regional Forensic Retina of Children Who Died of Sudden
Pathology Unit, Hamilton Health Sciences Centre, 237 Infant Death Syndrome (1994 – 2004)
Barton Street East , Hamilton, Ontario L8L 2X2, Canada
Arunkumar, Ponni MD*, J. Scott Denton, MD, and Edmund Suicide by Self Immolation in Cook County, 274
R. Donoghue, MD, Cook County Medical Examiners Office, Illinois, USA
2121 West Harrison Street, Chicago, IL 60612
Aschenbroich, Kerstin MD*, Institute of Forensic Medicine, Benefits and Limitations of Postmortem 98
Buehlstrasse 20, Bern, 3012, SWITZERLAND; Steffen G. Multislice Computed Tomography as Adjunct
Ross, MD, Institute of Forensic Medicine, Center of to the Perinatal and Pediatric Autopsy
Forensic Imaging “Virtopsy”, Buehlstrasse 20, Bern, 3012,
SWITZERLAND; Michael Thali, MD, MBA, University of
3012, SWITZERLAND; and Harald Bonell, MD, Institute of
Diagnostic Radiology, Inselspital Bern, Bern, 3010,
SWITZERLAND
Ausania, Francesco MD, Antonio Oliva, MD, PhD*, Fidelia Decapitation Due to Car Accident: 208
Cascini, MD, Massimo Senati, MD, Vincenzo L. Pascali, Description of a Case and Review of the
MD, PhD, and Francesca Cittadini, PhD, Catholic Literature
University, School of Medicine, Institute of Forensic
Medicine, Largo Francesco Vito 1, Rome, ITALY
Ausania, Francesco MD, Institute of Forensic Medicine, Methadone and Cocaine Related Death in A 66
Catholic University, School of Medicine, Ro, largo Young Boy: A Case Report
Francesco Vito 1, Rome, ITALY; Massimo Senati, PhD,
Largo Francesco Vito 1, Rome, ITALY; Nadia Fucci, PhD,
largo francesco vito 1, Rome, ITALY; Antonio Oliva, PhD*,
Institute of Forensic Medicine, Catholic University, School
of Medicine, Ro, Largo Francesco Vito 1, Rome, ITALY;
and Pietrantonio Ricci, PhD, Università degli Studi Magna
Catanzaro, ITALY
Austin, Dana PhD, and Marc A. Krouse, MD, Tarrant Incidence of Laryngeal and Hyoid Fractures 334
County Medical Examiner, 200 Feliks Gwozdz Place, Fort in Hangings and Strangulations Using
Worth, TX 76104-4919 Enhanced Examination Procedures
Baccino, Eric MD*, Laurent Martille, MD, and Anne Forensic Medicine in France 393
Dorandeu, MD, Service de Medecine Legale Chu de
Montpellier, Hospital Lapeyronie 371 av du Doyen G.
Giraud, Montpellier, 34295, France
Baker, Andrew M. MD*, Office of The Hennepin County Magnetic Resonance Microscopy as an 533
Medical Examiner, 530 Chicago Avenue, Minneapolis, MN; Adjunct in The Evaluation of Infant Rib
and Kimberlee Potter, PhD and William R. Oliver, MD, Fractures
Armed Forces Institute of Pathology, 14th and Alaska
Avenue, Northwest, Washington, DC
Index 128
Balachandra, A. Thambirajah MBBS*, Johanna Abbott, Homicide in a Surgical Intensive Care Unit 276
and Carol Youngson, RN, Office of the Chief Medical
Examiner, Manitoba Justice, 210-1 Wesley Avenue,
Winnipeg, Manitoba R3C 4C6, Canada; John Burchill,
Hate Crimes Unit Coordinator/Major Crimes Analyst,
Winnipeg Police Service, PO Box 1680, 151 Princess
Street, Winnipeg, Manitoba R3C 2Z7, Canada; and N.D.N.
Asela Mendis, MBBS, and Sholeh Barooni, MD, Office of
the Chief Medical Examiner, Manitoba Justice, 210-1
Wesley Avenue, Winnipeg, Manitoba R3C 4C6, Canada
Banerjee, Priya MD*, The Johns Hopkins Hospital Rat Bite Fever: A Fatal Case of 153
Department of Pathology, 600 North Wolfe Street, Streptobacillus moniliformis Infection in a
Carnegie/Pathology 401, Baltimore, MD 21287; and David 14-Month-Old Boy
R. Fowler, MD, and Zabiullah Ali, MD, Office of the Chief
Barkalow, Bruce H. PhD*, William E. Grant, MA, and Biomedical Engineering in Root Cause 161
Farrah J. Curran, BS, B.H. Barkalow, PC, 490 Quarterline Analysis – Example: Assessing Infant Apnea-
St., Newaygo, MI 49337-9125 Related Deaths
Batalis, Nick I. MD*, and Bradley J. Marcus, MD, The Role of Postmortem Cardiac Enzymes in 284
Christine N. Papadea, PhD, and Kim A. Collins, MD, the Diagnosis of Acute Cardiac Deaths
Medical University of South Carolina, 165 Ashley Avenue,
Main Hospital, Suite 281, PO Box 250108, Charleston, SC
29425
Batalis, Nick I. MD*, and Kim A. Collins, MD, Medical Adolescent Death: A 15-Year Retrospective 402
University of South Carolina, 165 Ashley Avenue, Main Study
Hospital, Room 281, Charleston, SC 29425
Batalis, Nick I. MD*, Medical University of South Carolina, Accidental Insulin Overdose 454
1032 Yorktown Drive, Charleston, SC 29412; Joseph A.
Prahlow, BS, MD, South Bend Medical Foundation, 530
Bauer, Martin MD* and Thomas Tatschner, MD, University Dissection, Preservation and Sexual Abuse of 446
of Wuerzburg, Institute of Legal Medicine, Versbacher Str. Bodies and Body Parts – An Exceptional Case
3, Wuerzburg 97078, Germany; Michael Roesler, MD, of Necrophilia
Institute of Forensic Psychology and Psychiatry, Saarland
University, Kirrberger Straße, Homburg 66421, Germany;
Dieter Patzelt, MD, Institute of Legal Medicine, University
of Wuerzburg, Versbacher Str. 3, Wuerzburg 97078,
Germany
Bauer, Martin MD*, and Dieter Patzelt, MD, Institute of No Homicide on Christmas Eve !? — Case 557
Legal Medicine, University of Wuerzburg, Versbacher Str. Report of an Unusual Stab Wound of the
3, Wuerzburg, Germany Brain
Beh, Philip S.L. MBBS, DMJ*, Department of Pathology, Child Homicides in Hong Kong: A 428
The University of Hong Kong, Room 126, University Retrospective Review of a Ten-Year Period
Pathology Building, Queen Mary Hospital, Hong Kong, From 1989-1998
Hong Kong SAR, China; and R.G. Broadhurst, Department
of Sociology, The University of Hong Kong, Room 126,
Hong Kong SAR, China
Benbow, M. Eric PhD*, University of Dayton, Department A New Framework for Guiding Research in 177
of Biology, 300 College Park, Dayton, OH 45469-2320; Forensic Entomology: Improving the Science
and Jeffery K. Tomberlin, PhD, and Rachel Mohr, MS, Relevant to PMI Estimates
Department of Entomology, Texas A&M University, 2475
Index 129
Benbow, M. Eric PhD*, University of Dayton, Department Using Biolog EcoPlatesTM as an Economical 115
of Biology, 300 College Park, Dayton, OH 45469-2320; Approach to Determining Postmortem Body
Jeffery K. Tomberlin, PhD, Department of Entomology, Dump Sites Through Microbial Community
TAMU 2475, College Station, TX 77843- 2475; Tawni L. Level Physiological Profiling
Crippen, PhD, Southern Plains Agricultural Research
Center, Agricultural Research Service, U.S. Department of
Agriculture, College Station, TX 77845; Andrew Lewis, BS,
University of Dayton, Department of Biology, 300 College
Park, Dayton, OH 45469-2320; and Jennifer Pechal, MS,
TAMU 2475, Texas A&M University, College Station, TX
77843-2475
Benecke, Mark PhD, MSc*, International Forensic Evidence for Neglect of Children and Elderly 474
Research & Consulting, Postfach 250411 Cologne, NRW Persons by Use of Forensic Entomology
50520, Germany
Benomran, Fawzi A. MD*, Dubai Police, Dubai Medical Forensic Medicine in Dubai, United Arab 82
College, PO Box 39844, Dubai, UNITED ARAB EMIRATES Emirates
Berg, Kathryn K. MD*, Daniel W. Davis, MD, and Andrew Breath Holding Spells Associated With 429
M. Baker, MD, Hennepin County Medical Examiner’s Unexpected Sudden Childhood Death
Office, 530 Chicago Avenue, Minneapolis, MN 55415
Berroukeche, M. MD, Paul Fornes, MD, PhD*, and Homicide in the Elderly— Paris and Its 509
Dominique Lecomte, MD, Forensic Institute of Paris, Suburbs, 1996-2001
Medical School Cochin Port Royal, Paris, France
Bertrand, Carolyn PhD, Forensic Psychology Research When “Non -Terminal” Is Fatal–Medical 572
Fellow, County of San Diego, Mark J. Shuman, MD, MS*, Examiner Cases of Fibromyalgia Fatalities
Deputy Medical Examiner, County of San Diego, and Brian
D. Blackbourne, MD, Chief Medical Examiner County of
San Diego, San Diego, CA
Berzlanovich, Andrea M. MD*, Department of Forensic Do Centenarians Die Healthy? – An Autopsy 467
Medicine, University of Vienna, Sensengasse 2, Vienna, Study
Austria A – 1090 Austria; Thomas Waldhoer, PhD,
Department of Epidemiology, Institute of Cancer Research,
University of Vienna, Borschkegasse 8a, Vienna, Austria A -
1090, Austria; Ernst Sim, MD, Meidling Traumatology
Center, Kundratstraße 37, Vienna, Austria A - 1120,
Austria; Peter Fasching, MD, Geriatric Center
Baumgarten, Baumgartner Höhe 1, Vienna, Austria A -
1140, Austria
Berzlanovich, Andrea M. MD*, Ernst Sim, MD, Peter Are Autopsies Necessary in Centenarians? 549
Fasching, MD, and Manfred A. Muhm, MD, Department of
Forensic Medicine, University of Vienna, Sensengasse 2,
Vienna, Austria
Berzlanovich, Andrea M. MD*, Institute of Forensic Death at Dinner: Foreign Body Asphyxiation 489
Medicine, University of Vienna, Sensengasse 2, A - 1090 – An Unknown Cause of Death in the
Vienna, Austria; Thomas Waldhoer, Institute of Cancer Elderly?
Research, Department of Epidemiology, University of
Vienna, Borschkegasse 8a, A - 1090 Vienna, Austria; Ernst
Sim, MD, Meidling Traumatology Center, Kundratstraße
37, A - 1120 Vienna, Austria; Peter Fasching, Geriatric
Center Baumgarten, Huetteldorferstraße 188, A - 1140
Vienna, Austria; and Manfred A. Muhm, Department of
Cardiothoracic Anesthesia and Intensive Care Medicine,
University of Vienna, Waehringerstraße 18 - 20, A - 1090
Vienna, Austria
Index 130
Berzlanovich, Andrea M. MD*, Institute of Forensic Lesch-Nyhan Syndrome and Child Abuse 383
Medicine, University of Vienna, Sensengasse 2, Vienna,
1090, Austria; Martin Kraupp, MD, Department of Medical
Chemistry, Medical University of Vienna, Währinger Straße
10, Vienna, A - 1090, Austria; Johannes A. Hainfellner,
MD, and Herbert Budka, MD, Institute of Neurology,
Medical University of Vienna, Währinger Gürtel 18-20,
Vienna, A -1090, Austria; Wolfgang A. Keil, MD, Institute
of Forensic Medicine, University of Munich,
Frauenlobstraße 7a, Munich, D -80337, Germany; and
Barbara Fazeny-Dörner, MD, Department of Medicine I,
Medical University Vienna, Währinger Gürtel 18-20,
Vienna, A -1090, Austria
Best, David PhD, Institute of Psychiatry, King’s College, Near Miss Incidents: Feasibility Studies 394
De Crespigny Park, London, SE5 8AF, United Kingdom; Assessing Forensic Physicians’ Perceptions of
Siobhan Havis, MSc, Police Complaints Authority, 10 Great Near Misses in Police Custody Suites in
George Street, London, SW1P 3AE, United Kingdom; and London, United Kingdom
Jason Payne-James, LLM, MB, FRCS, DFM*, Forensic
Healthcare Services, Ltd, 19 Speldhurst Road, Victoria
Park, London, E9 7EH, United Kingdom
Bettinger, Sarah L. MSFS*, Devon R. Pierce, BS, and Identifying the “Iceman” 295
Suzanne M. Barritt, MS, Armed Forces DNA Identification
Laboratory, 1413 Research Boulevard, Building 101,
Rockville, MD 20850; Alexander F. Christensen, PhD, Joint
POW/MIA Accounting Command, Central Identification
Laboratory, 310 Worchester Avenue, Hickam AFB, HI
96853; and Louis N. Finelli, DO, Armed Forces DNA
Identification Laboratory, 1413 Research Boulevard,
Bhawara, Harminder S. PhD*, fsl, S/O Shri A.S. Bhawara, HPLC Analysis of Benzocaine in “Green 145
Shanti Nagar, Near Ram Mandir, Raipur (C.G), INDIA Products”
Bhootra, Bhanwar Lal MD*, Department of Health, PO Deaths From Accidental Steam Inhalation 382
Box 1944, Polokwane, Limpopo 0700, South Africa During African Traditional Therapy
Bhootra, Bhanwar Lal MD*, Forensic Pathology Services, Penetrating Wound of Head by Slingshot: 437
Limpoo Province, PO Box 1944, Polokwane, 0700, South Medicolegal Aspects
Africa
Bin Othman, Mohd Shafie MD*, Forensic Department Sudden Death Due to Dengue Fever in an 8- 66
Hospital Raja Permaisuri Bainun, Jalan Hospital 30450, Month-Old Baby
Ipoh, 31350, MALAYSIA; and Santina Cantatore, Dania De
Carlo, MD, and Margherita Neri, PhD, Department
Boatright, Stacy A. BS*, 2304 Cornell, College Station, TX Associative Learning of Cochliomyia 182
77840; and Jeffery K. Tomberlin, PhD, Department of macellaria in Response to Larval Resource:
Entomology, TAMU 2475, College Station, TX 77843-2475 Inter- and Intraspecific Resource Interaction,
and Presence of Inter- and Intraspecific
Larvae on a Resource
Bodor, Geza PhD, Denver VA Medical Center, 1055 Postmortem Analysis of Vitamin D Using 131
Clermont Street, Denver, CO 80220; John Carver, JD, City Liquid Chromatography Tandem Mass
and County of Denver, 660 Bannock Street, Denver, CO Spectroscopy
80204; and Amy Martin, MD, and Michael A. Burson,
PhD*, City and County of Denver, Office of the Medical
Index 131
Boel, Lene W. PhD*, Institute of Forensic Medicine, Postmortem Pulmonary Findings by 97
University of Aarhus, Brendstrupgaardsvej 100, Aarhus N, Computed Tomography Compared With
8200, DENMARK; Lars Uhrenholt, PhD, Institute of Conventional Autopsy
Forensic Medicine, Department of Forensic Medicine,
University of Aarhus, Brendstrupgaardsvej 100, Aarhus N,
8200, DENMARK; Rita Ullerup, Institute of Forensic
Medicine, Brendstrupgaardsvej 100, Aarhus N, 8200,
DENMARK; and Anne Grethe Jurik, DSc, Department of
Radiology Aarhus University Hospital, Noerrebrogade 44,
Aarhus C, 8000, DENMARK
Bollmann, Marc D. MD*, Centre Universitaire Romand de Postmortem Tryptase Levels of Anaphylactic 35
Medecine Legale, Rue du Bugnon 21, Lausanne, CH-1011, and Non-Anaphylactic Deaths
SWITZERLAND; Olaf Drummer, Noel W.F. Woodford, MD,
Victorian Institute of Forensic Medicine, 57-83 Kavanagh
Street, Southbank, Victoria, 3006, AUSTRALIA; Bettina
Schrag, MD, University Center of Legal Medicine
Lausanne-Geneva, Bugnon 21, Lausanne, 1011,
SWITZERLAND; and Dimitri Gerostamoulos, Victorian
Institute of Forensic Medicine, 57-83 Kavanagh Street,
Southbank, Victoria, 3006, AUSTRALIA
Bonifacio, Antonio MD*, Stefania Zerbo, MD, Cettina Lymphogenic Cardiomyopathy: A Possible 164
Sortino, Pierangela Fleres, MD, and Emiliano Maresi, Cause of Non-Immune Fetal Hydrops
PhD, Department of Biotechnology and Legal Medicine,
90127, ITALY
Bonner, William J. BA*, 1100 South Broad Street, Unit Lethal Consequences Arising From the 127
402B, Philadelphia, PA 19146; and Fredric N. Hellman, Rupture of an Undetected Large Ductus
MD, Office of the Medical Examiner, Fair Acres, Route Arteriosus Aneurysm During a T-12
352, Lima, PA 19037 Kyphoplasty Procedure
Bonner, William J. BA*, 1100 South Broad Street, Unit Undiagnosed Preeclampsia-Eclampsia 189
402B, Philadelphia, PA 19146; John E. Tomaszewski, MD, Leading to Maternal Death
Hospital of the University of Pennsylvania, 3400 Spruce
Street, Philadelphia, PA 19104; and Fredric N. Hellman,
MD, Office of the Medical Examiner, Fair Acres, Rte 352,
Lima, PA 19037
Bonsignore, Alessandro MD*, Francesca Fossati, MD, Epidemic Outbreak of Meningococcal 18
Federica Portunato, MD, Francesco Ventura, PhD, and Meningitis in a Nursery: Two Fatal Cases of
Francesco De Stefano, MD, Department of Legal and Waterhouse-Friderichsen Syndrome
Forensic Medicine, University of Genova, Via de Toni 12,
Bonsignore, Alessandro MD*, Massimo Gallo, MD, Fatal Cardiac Perforation During 109
Francesco Ventura, PhD, and Francesco De Stefano, MD, Percutaneous Treatment in Iliac Artery
Department of Legal and Forensic Medicine, University of Occlusion
Genova, Via De Toni 12, Genova, 16132, ITALY
Bosnar, Alan MD, PhD*, Valter Stemberga, MD, Miran The Methods of Committing and Alcohol 273
Coklo, MD, and Sanja Dobi Babic, BSc, Department of Intoxication of Suicides in the Southwestern
Forensic Medicine, Rijeka University School of Medicine, Croatia From 1996 to 2005
B. Branchetta 20, Rijeka, 51000, Croatia; and Emina
Grgurevic, MD, Public Health Institute of Primorsko-
Goranska County, Kresimirova 52a, Rijeka, 51000, Croatia
Index 132
Brassell, Melissa A. MD*, Carol H. Allan, MD, Mary G. A Demographic Analysis of Youth and Teen 347
Ripple, MD, and David R. Fowler, MD, Office of the Chief Suicide in Maryland (1994-2003)
Brassell, Melissa A. MD*, Mary G. Ripple, MD, and David Open Fractures in Pedestrians Mimicking 275
R. Fowler, MD, Office of the Chief Medical Examiner, State Gunshot Wounds
of Maryland, 111 Penn Street, Baltimore, MD 21201
Braza, Frank MD, PhD*, Juan A. Merayo-Rodriguez, MD, Arrhythmogenic Right Ventricular Dysplasia 253
and Jeffrey West, Danbury Hospital, 24 Hospital Avenue, 2 (ARVD): A Not So Rare Cause of Sudden
Tower Lab, Danbury, CT 06810 Death in Young Adults
Braza, Julia M. MD and Karoly Balogh, MD, Beth Israel Primary Hyperoxaluria: A Case Report and 328
Deaconess Medical Center, Pathology Department, 330 Review of the Literature
Braza, Julia M. MD*, and Meghan Delaney, DO, Beth Hemophagocytic Lymphohistiocytosis: A 280
Israel Deaconess Medical Center and Harvard Medical Case Report and Review of the Literature
School, 330 Brookline Avenue, Boston, MA 02215
Braza, Julia M. MD*, Karoly Balogh, MD,; and Anthony Risk Factor Analysis and Characteristics in 397
Martyniak, MD, Beth Israel Deaconess Medical Center at Community Acquired MRSA
Harvard Medical School, 330 Brookline Avenue, Boston,
MA 02215
Brenner, Charles H. PhD*, Consultant in Forensic Perspectives on the Variety of Mass 462
Mathematics, 6568 Sobrante Road, Oakland, CA 94611- Identification Projects
1123
Bright*, Lindsay A. 1500 Olympia Way #12, College Feeding Patterns of American (Periplaneta 180
Station, TX 77840; and Jeffery K. Tomberlin, PhD, and americana) and German (Blattella germanica)
Roger Gold, PhD, Department of Entomology, TAMU 2475, Cockroaches on Pig Skin
Briones, Alice J. DO*, 1107 Canvasback Lane, Denton, MD When Lightning Strikes: 17 Fatal Lightning 73
21629; and Michelle B. Aurelius, MD, Office of the Medical Strikes in New Mexico
Investigator, MSC 11 6030, 1 University of New Mexico,
Albuquerque, NM 87131
Britt, Michael C. BS* and Marta U. Coburn, MD, District FluiDDB.com: A Model Database for 461
Twenty Medical Examiner, 3838 Domestic Avenue, Naples, Unidentified Bodies
FL 34104
Brogdon, B.G. MD*, University of South Alabama Medical Fatal Air Embolism During Hemodialysis 188
Center, Department of Radiology, 2451 Fillingim Street,
Mobile, AL 36617; and LeRoy Riddick, MD*, University of
South Alabama Medical Center, Department of Pathology,
2451 Fillingim Street, Mobile, AL 36609
Brooks, Erin G. MD*, Office of the Medical Investigator, 2009 H1N1 Fatalities: The New Mexico 17
MSC11 6030, 1 University of New Mexico, Albuquerque, Experience
NM 87131; Clare H. Cunliffe, MD, Office of Medical
Investigator, 700 Camino de Salud Northeast, Albuquerque,
NM 87106; Catherine Avery, Chad Smelser, MD, and
Deborah Thompson, MD, New Mexico Department of
Health, 1190 South Saint Francis Drive, Santa Fe, NM
87502; and Kurt B. Nolte, MD, Office of Medical
Investigator, MSC11 6030, 1 University of New Mexico,
Albuquerque, NM 87131-0001
Index 133
Brooks, Erin G. MD*, University of Vermont, Fletcher Motorcycle Fatalities in the State of Vermont: 221
Allen Health Care, Department of Pathology, 111 1995-2005
Colchester Avenue, Burlington, VT 05401- 1473; and
Steven L. Shapiro, MD, and Brittany N. Philbin, BS*,
Vermont Office of the Chief Medical Examiner, 111
Colchester Avenue, Baird 1, Burlington, VT 05401
Brundage, Adrienne L. MS*, Texas A&M University, 2001 Attraction of Two Forensically Important Fly 181
Cobblestone Lane, Bryan, TX 77807; and Jeffery K. Species: Chrysomya rufifacies (Macquart)
Tomberlin, PhD, Texas A&M University, Department of and Cochliomyia macellaria (Fabricius) to
Entomology, TAMU 2475, College Station, TX 77843-2475 Inter- and Intraspecific Eggs
Brundage, Adrienne MS*, 1250 A Edgewood Road, Seasonal Distribution and Abundance of 400
Redwood, CA 94062 Forensically Important Flies in Santa Clara
County
Budimlija*, Zoran M. MD, PhD, Bianca Nazzaruolo, MA, Bone Extraction Procedure for Nuclear DNA 501
Sheila M. Estacio, BS, Mechthild K. Prinz, PhD, and Robert Analysis Used in World Trade Center Human
C. Shaler, PhD, Office of Chief Medical Examiner, Identification Project
Department of Forensic Biology, 520 First Avenue, New
York, NY
Buettner, Matt BS*, Kerry Opel, BS, Bruce R. McCord, The Effect of Environmental Degradation on 210
PhD, International Forensic Research Institute, Department DNA With Respect to Time and Conditions
of Chemistry, Florida International University 11200 SW
8th St, Miami, FL 33199; and Lee Jantz, PhD, 250 South
Stadium Hall, Knoxville, TN 37996
Bugajski, Kristi N. MS*, 929 King Street, Lafayette, IN The Effects of Household Chemicals on Blow 57
47905; and Ralph E. Williams, PhD, Purdue University Fly Oviposition and Development Using
Department of Entomology, 901 West State Street, West Human Cadavers
Lafayette, IN 47907
Bulakhtina, Elena MD*, Allegheny County Medical Enterobacter Cloacae Peritonitis Secondary to 21
Examiner’s Office, 1520 Penn Avenue, Pittsburgh, PA Hemorrhagic Cystitis in a Long-Term
15222; Zhuo Wang, MD, Conemaugh Valley Memorial Substance Abuser
Hospital, 1020 Franklin Street, Johnstown, PA 15905; Todd
M. Luckasevic, DO, Baiyang Xu, MD, and Abdulrezak M.
Shakir, MD, Allegheny County Medical Examiner’s Office,
1520 Penn Avenue, Pittsburgh, PA 15222; and Karl E.
Williams, MD, MPH, Allegheny County Medical
Examiner’s Office, 542 Fourth Avenue, Pittsburgh, PA
15219
Bullard, Rebecca A. MS*, Department of Entomology, Of Leaves and Men: Botanical Evidence 503
University of California, Davis, Department of Entomology, Leads Investigators to a Missing Girl’s Body
University of California at Davis, Davis, CA; and Kristina
A. Schierenbeck, PhD, Department of Biological Sciences,
California State University, Chico, Department of
Biological Sciences, California State University at Chico,
Chico, CA
Bullard, Rebecca A. MS*, University of California, Davis, Inter-Observer Variability in Entomology- 409
Department of Entomology, One Shields Avenue, Davis, CA Based PMI Estimates: A Single Blind Study
95616; Kenneth G. Schoenly, PhD, California State
University, Stanislaus, Department of Biological Sciences,
Turlock, CA 95382; and Robert Kimsey, PhD, University of
California, Davis, Department of Entomology, One Shields
Avenue, Davis, CA 95616
Index 134
Burch, Phillip M. MD*, Office of the Medical Examiner, Human Wicks: The Almost Complete 396
1300 Clark Avenue, St. Louis, MO 63117 Destruction of Major Portions of the Human
Body by Fire Fueled at Least Partly by the
Body Fat of the Victim
Burch, Phillip M. MD*, Saint Louis University, 1300 Clark Domestic Homicide or International 493
Avenue, St. Louis, MO Terrorism? A St. Louis Murder Crosses the
Line
Burkhardt, Sandra E. MD*, Jerome Sobel, MD, and Assisted Suicide as Practiced in the French 261
Romano La Harpe, MD, Institute of Forensic Medicine, 9, Part of Switzerland
Avenue de Champel, Geneva, 1206, Switzerland
Burt, Martha J. MD and Matthew J. Bowes, MD*, Miami- Accidental Parachuting Death Due to 442
Dade County Medical Examiner Department, Number One Equipment Failure
on Bob Hope Road, Miami, FL 33136
Burt, Martha J. MD*, Matthew J. Bowes, MD, and Mark J. Causes of Death in Chronic Alcoholics: A 460
Shuman, MA, MD, Miami-Dade County Medical Examiner Comprehensive Retrospective Analysis of
Department, Number One on Bob Hope Road, Miami, FL Medical Examiner Cases
33136
Burt, Martha J. MD, District 8, Medical Examiner Office, The Effects of a New Level 1 Trauma Center 249
606 South West 3rd Avenue, Gainesville, FL 32601; and on the Local Medical Examiner Office
Charlotte J. Stevens, BA*, 6417 South West 9th Avenue,
Apartment A, Gainesville, FL 32607
Burton, Joseph L. MD* and Paul R. Lewis, Jr., MS, BME, Post Collision Vehicular Fires— 558
Burton & Associates, 13784 Highway 9, Alpharetta, GA Determination of Probability of Occupant
Survival Post Impact
Busardo, Francesco Paolo MD*, Institute of Legal Sudden Death in the First Year of Life: The 67
Medicine, Via Del Vespro, 129, Palermo, 90100, ITALY; Importance of Pancreatic Histomorphological
Stefania Zerbo, MD, Institute of Legal Medicine, Via Del Analysis
Vespro, 127, Palermo, 90100, ITALY; Antonina Argo, Via
Del Vespro 127, Palmero, 90100, ITALY; Liliya Gutsul,
MD, Instituto, Via Del Vespro, 127, Palmero, 90100,
ITALY; Paolo Procaccianti, Palermo University, Via Del
Vespro, N. 127, Palermo, 90100, ITALY; and Emiliano
Maresi, Via Del Vespro 127, Palermo, 90100, ITALY
Buschmann, Claas T. MD, Institute of Legal Medicine and A Man Without a Head: Postmortem 3
Forensic Sciences, Turmstrasse 21, Building L, Berlin, Decapitation by German Shepherd Dogs
10559, GERMANY; Biagio Solarino, PhD*, Università
degli Studi di Bari, Sezione di Medicina Legale, Pizza
Giulio Cesare, 11, Bari, 70125, ITALY; and Michael
Tsokos, MD, Institute of Legal Medicine & Forensic
Sciences, Turmstr 21, Haus L, Berlin, 10559, GERMANY
Bush, Leah L. MD*, and Wendy M. Gunther, MD, Office of DNA Done Right: Manner of Death 368
the Chief Medical Examiner, Tidewater District, 830 Determination, Based on Evidence Obtained
Southampton Avenue, Suite 100, Norfolk, VA 23510 From a Belt at a Complex Scene Involving a
Decomposed Body
Bush, Leah L. MD*, Office of the Chief Medical Examiner, The Dangers of Dumpster Diving: Deaths 411
Tidewater District, Commonwealth of Virginia, 830 Associated With Garbage Collection in the
Southampton Avenue, Suite 100, Norfolk, VA 23510-1046; Tidewater Region of Virginia
and Wendy M. Gunther, MD, Office of the Chief Medical
Index 135
Bush, Leah L.E. MD, Office of the Chief Medical Examiner, Delayed Jejunal Rupture in a Three-Year- Old 479
830 Southampton Avenue, Suite 100, Norfolk, VA 23510- Child After Minor Blunt Impact
1046; Wendy M. Gunther, MD*, Office of the Chief Medical
Examiner and Department of Legal Medicine, Virginia
100, Norfolk, VA 23510; Gregory Raczniak, MPhil, Eastern
Virginia Medical School, 714 Woodis Avenue, Norfolk, VA
23510
Byrd, Jason H. PhD*, University of Florida, Department of Veterinary Forensic Science: Documentation, 160
Agriculture & Consumer Services, University of Florida, Processing, and Interpretation of Physical
PO Box 147100, Gainesville, FL 32614-7100; Kenneth F. Evidence at Scenes of Animal Crimes
Cohrn, DDS*, Heritage Dental of Central Florida, 422
Teague Trail, Lady Lake, FL 32159; Jeffery K. Tomberlin,
PhD, Department of Entomology, TAMU 2475, College
Station, TX 77843-2475; David W. Hall, PhD*, David Hall
Consultant, Inc., 3666 NW 13th Place, Gainesville, FL
32605; John J. Schultz, PhD*, University of Central
Florida, Department of Anthropology, PO Box 25000,
Orlando, FL 32816; Melinda Merck, DVM*, ASPCA, 6175
Hickory Flat Highway Suite 110-2, Canton, GA 30115; and
Randall Lockwood, PhD*, ASPCA, 2214 Tulip Drive, Falls
Church, VA 22046; Micah Flores, BSc*, Texas A&M, 2475
Cakan, Hüseyin PhD*,and Vecdet Oz, PhD, Istanbul Visceral Leishmaniasis in Turkey: 212
University, Institute of Forensic Sciences, Adli Tip Sociocultural Issues in Forensic
Enstitusu, Cerrahpasa Kampusu, PK10, Istanbul, 34303, Epidemiology
TURKEY; Mustafa Aslan, PhD, Istanbul University,
Cerrahpasa Medical Faculty, Tip Fakultesi, Mikrobiyoloji
ABD, Istanbul, 34303, TURKEY; T. Mehmet Karayel, BS,
Ismail Cakir, PhD*, H. Bulent Uner, PhD*, and M. Yasar
Iscan, Ph.D, Istanbul Univ, Istanbul Universitesi, Adli Tip
Enstitusu, Cerrahpasa Kampusu, PK.10, 34303, Istanbul,
34098, TURKEY
Cammack, Jonathan A. BS*, and Peter H. Adler, PhD, The Effect of Soil Compaction on Pupation 180
Department of Entomology, Soils, and Plant Sciences, Depth of Lucilia sericata in Soil
Clemson University, 114 Long Hall Box 345315, Clemson,
SC 29634; Jeffery K. Tomberlin, PhD, Department of
Entomology, Texas A&M University, TAMU 2475, College
Station, TX 77843-2475; Yuji Arai, PhD, Department of
Entomology, Soils, and Plant Sciences, Clemson University,
270 Poole Agriculture Center, Clemson, SC 29634; and
William C. Bridges Jr., PhD, Department of Applied
Economics and Statistics, Clemson University, 243 Barre
Hall, Clemson, SC 29634
Campobasso, Carlo P. MD, PhD*, Alessandro S. Distribution Pattern of Pulmonary Surfactant 405
Dell’Erba, MD, PhD, Annalisa Addante, MD, PhD, Protein A (SP-A) in Drowning and Opiate-
Fiorenza Zotti, PhD, Sara Sblano, MD, and Massimo F. Related Deaths
Colonna, MD, LLB, Section of Legal Medicine
(Di.M.I.M.P.), University of Bari, Piazza Giulio Cesare,
Policlinico di Bari, Bari, 70124, Italy
Index 136
Campobasso, Carlo P. MD, PhD*, Department of Health The Mummified Corpse Found in a Domestic 262
Sciences (Di.S.pe.S.), University of Molise, via De Sanctis, Setting
snc, Campobasso, Italy 86100, Italy; and Rosa Falamingo,
MD, PhD, Domenica Laviola, MD, Claudia Liuzzi, MD,
and Francesco Vinci, MD, Section of Legal Medicine
(Di.M.I.M.P.) - University of Bari, Piazza Giulio Cesare,
Campobasso, Carlo P. MD, PhD*, University of Molise, via The Serial Killer of Elderly Women: Analysis 237
De Sanctis, snc, Campobasso, 86100, ITALY; and Massimo of a Multi-Victim Homicide Investigation
F. Colonna, MD, Felice Carabellese, MD, Ignazio
Grattagliano, PsyD, Chiara Candelli, MD, and Roberto
Catanesi, MD, University of Bari, Section of Forensic
Psychiatry, Piazza Giulio Cesare, Bari, 70124, ITALY
Campobasso, Carlo Pietro MD, PhD*, Giancarlo Di Vella, Pink Teeth in a Series of Bodies Recovered 517
MD, PhD, and Antonio De Donno, MD, Section of Legal From a Single Shipwreck
Medicine, University of Bari, Piazza Giulio Cesare, Bari,
Italy; Giorgia Girone, DDS, and Gianfranco Favia, MD,
School of Dentistry, University of Bari, Piazza Giulio
Cesare, Bari, Italy; and Francesco Introna, MD, Section of
Legal Medicine, University of Bari, Piazza Giulio Cesare,
Bari, Italy
Campobasso, Carlo Pietro MD, PhD*, Rosa Falamingo, Investigation of Italy’s Deadliest Building 548
MD, and Francesco Vinci, MD, Section of Legal Medicine Collapsed: Forensic Aspects of a Mass
(DIMIMP), University of Bari, Policlinico, Plaza Giulio Disaster
Cesare, Bari, Italy
Cannon*, Heather A. Mercyhurst College, 501 East 38th Chemical Asphyxia and Bondage: Autoerotic 279
Street, Erie, PA 16546; and Fredric N. Hellman, MD, MBA, Fatality Induced by Chloroform Inhalation
Office of the Medical Examiner, Delaware County, Route
352-Fair Acres, Lima, PA 19037
Cannon, Marie E. MD*, Office of the Chief Medical An Unusual Cause of Sudden Death in 506
Examiner, 720 Albany Street, Boston, MA; Eva Patalas, Infancy: Hypertrophic Cardiomegaly
MD, Massachusetts General Hospital, 55 Fruit Street,
Boston, MA; and Alexander Chirkov, MD, PhD, Office of
the Chief Medical Examiner, 720 Albany Street, Boston, MA
Caplan, Michael J. MD*, and Bamidele Adeagbo, MD*, Comparative Analysis of Medical Examiner 309
Medical University of South Carolina, Department of and Coroner Systems of Medicolegal Death
Pathology and Laboratory Medicine, Suite 309, 165 Ashley Investigation: Is There a Bias Toward Manner
Avenue, Charleston, SC 29425 of Death?
Caplan, Michael J. MD*, and Kelly Rose, MD*, Medical Sudden Death in Duchenne Muscular 290
University of South Carolina, Department of Pathology & Dystrophy With Noncompaction of the
Laboratory Medicine, Suite 309, 165 Ashley Avenue, Ventricular Myocardium: A New
Charleston, SC 29425 Cardiomyopathy or a Compensatory
Caplan, Michael J. MD, and Kelly Rose, MD*, Medical Primitive Neuroectodermal Tumor (PNET) 225
University of South Carolina, Department of Pathology and Masquerading as Non Accidental Head
Laboratory Medicine, 165 Ashley Avenue, Suite 309, PO Trauma in an Infant: Lessons for Multiple
Box 250908, Charleston, SC 29425 Disciplines
Carr, Mary E. MD*, and Andrew M. Baker, MD, Hennepin Hyperglycemic Hyperosmolar Nonketotic 377
County Medical Examiner’s Office, 530 Chicago Avenue, Syndrome in a Sixteen-Month Old Child With
Minneapolis, MN 55415 Rotaviral Diarrhea
Index 137
Carter, David O. MSc*, James Cook University, School of Microbial Processes in Soils Associated With 472
Pharmacy & Molecular Sciences, Douglas, Queensland Skeletal Muscle Tissue and Cadaver
4814, Australia; Mark Tibbett, PhD, University of Western Decomposition at Different Temperatures
Australia, Soil Science and Plant Nutrition, School of Earth
and Geographical Sciences, Crawley, Western Australia
6907, Australia; David Yellowlees, PhD, James Cook
University, School of Pharmacy and Molecular Sciences,
Douglas, Queensland 4811, Australia
Carter, David O. MSc*, School of Pharmacy and Molecular How Cadaver Decomposition in Soil is 410
Sciences, James Cook University, Douglas, QLD 4811, Affected by Moisture: Part II: A Controlled
Australia; Mark Tibbett, PhD, Centre for Land Laboratory Experiment
University of Western Australia, Crawley, WA 6009,
Australia; and David Yellowlees, PhD, School of Pharmacy
and Molecular Sciences, James Cook University, Douglas,
QLD 4811, Australia
Carter, David O. PhD*, Department of Entomology, Using Ninhydrin to Detect Grave Soil 297
University of Nebraska-Lincoln, 202 Plant Industry
Building, Lincoln, NE 68583- 0816; David Yellowlees,
PhD, School of Pharmacy and Molecular Sciences, James
Cook University, Townsville, QLD 4811, Australia; and
Mark Tibbett, PhD, Centre for Land Rehabilitation, School
of Earth and Geographical Sciences, University of Western
Australia, Crawley, WA 6009, Australia
Carter, David O. PhD*, Department of Plant Pathology, The Composition and Succession of Soil 353
University of Nebraska-Lincoln, 406 Plant Sciences Hall, Microbial Communities Following Cadaver
Lincoln, NE 68583-0722; David Yellowlees, PhD, School of (Rattus rattus L.) Burial
Douglas, QLD 4811, Australia; and Mark Tibbett, PhD,
School of Earth and Geographical Sciences, University of
Western Australia, Crawley, WA 6009, Australia
Carter, David O. PhD*, Department of Plant Pathology, Nematode Community Dynamics Associated 354
University of Nebraska-Lincoln, 406 Plant Sciences Hall, With Cadaver (Sus scrofa L.) Decomposition
Lincoln, NE 68583-0722; Timothy E. Huntington, MSc, and and Insect Activity on the Soil Surface
Leon G. Higley, PhD, Department of Entomology,
University of Nebraska-Lincoln, 202 Plant Industry,
Lincoln, NE 68583-0816; and Thomas O. Powers, PhD,
Department of Plant Pathology, University of Nebraska-
Lincoln, 406 Plant Sciences Hall, Lincoln, NE 68583-0722
Caruso, James L. MD*, Armed Forces Medical Examiner Ehlers-Danlos Syndrome Type IV (Vascular): 241
System, U.S. Naval Hospital, Okinawa, Japan, PSC 482 Box An Atypical Presentation and Unexpected
2560, FPO, AP 96362 Diagnosis in a Medical Examiner Setting
Caruso, James L. MD*, Office of the Armed Forces Medical Determining the Cause of Death and 508
Examiner, The Armed Forces Institute of Pathology, Contributing Factors in Fatal Recreational
Washington, DC SCUBA Diving Accidents
Case, Mary E.S. MD*, Saint Louis University Health Neuropathology of Abusive Head Injury 531
Sciences Center, 6039 Helen Avenue, St. Louis, MO
Index 138
Castellani, Rudy J. MD*, and Luis F. Gonzalez-Cuyar, MD, Lymphocytic Hypophysitis Associated With 240
University of Maryland, Baltimore, Department of Sudden Unexpected Death in a Young
Pathology, 22 South Greene Street, Baltimore, MD 21201; Woman
Fabio Tavora, MD, Johns Hopkins Hospital, 600 North
Wolfe Street, Baltimore, MD 21205 ; Kyle Shaw, MD,
University of Maryland, Baltimore, Department of
Pathology, 22 South Greene Street, Baltimore, MD 21201;
and Joyce L. deJong, DO, Sparrow Forensic Pathology,
Castellani, Rudy J. MD*, University of Maryland, Brainstem Axonal Injury and Retinal 321
Baltimore, 22 South Greene Street, NBW-81, Baltimore, Hemorrhages as a Substrate for Sudden Death
MD 21201; and Joyce L. deJong, DO, Division of Forensic in Second Impact Syndrome: A Case Report
Pathology, Sparrow Health System, 1215 East Michigan
Avenue, Lansing, MI 48912
Castellani, Rudy J. MD*, University of Maryland, Sudden Death in Epilepsy: A Review of 51 148
Department of Pathology, 22 South Greene Street Consecutive Cases
Baltimore, MD 21201; Heather F. Grothous, BS, Michigan
State University College of Osteopathic Medicine, A306
East Fee Hall, East Lansing, MI 48824; Philip R. Croft,
MD, 1215 East Michigan Avenue, Lansing, MI 48909-7980;
Michael A. Markey, MD, Sparrow Forensic Services,
Sparrow Hospital, 1215 East Michigan Ave, Lansing, MI
48909-7980; and Joyce L. de Jong, DO, Sparrow Forensic
Cattaneo, Cristina PhD, MD,* and Eloisa Marinelli, MD, Sensitivity of Autopsy and Radiological 380
Istituto di Medicina Legale, Università degli Studi, via Examination in Detecting Bone Fractures in
Mangiagalli 37, Milano, 20133, Italy; Alessia Di an Animal Model: Implications for the
Giancamillo, DVM, PhD, Dipartimento di Scienze e Assessment of Fatal Child Physical Abuse
Tecnologie Veterinarie per la Sicurezza Alimentare, via
Celoria 10, Milano, 20133, Italy; Mauro Di Giancamillo,
DVM, and Olga Travetti, DVM, Dipartimento di Scienze
Cliniche Veterinarie, via Celoria 10, Milano, 20133, Italy;
and Laura Viganò, BSc, Pasquale Poppa, BSc, Davide
Porta, BSc, Andrea Gentilomo, MD, PhD, and Marco
Grandi, MD, Istituto di Medicina Legale, via Mangiagalli
37, Milano, 20133, Italy
Cecchetto, Giovanni MD*, Alessandro Amagliani, MD, Gunshot Wounds Covered by Different 53
Guido Viel, MD, and Paolo Fais, MD, University of Padua, Textiles: Determination of GSR Through
Via Falloppio 50, Padova, 35121, ITALY; Giampietro Micro-CT Analysis
Feltrin, MD, Via Giustiniani 2, Padova, 35121, ITALY;
Santo Davide Ferrara, PhD, University of Padua - Section
of Legal Medicine and Forensic Toxicology, Via Falloppio
50, Padua, 35121, ITALY; and Massimo Montisci, PhD,
ITALY;
Index 139
Cecchetto, Giovanni MD*, and Guido Viel, MD, University Lethal Inhalation of Isomers of Butylene: A 223
of Padua, Via Falloppio 50, Padova, 35121, ITALY; and Case Report
Attilio Cecchetto, PhD, Istituto Anatomia Patologica, Via
Gabelli 61, Padova, 35121, ITALY; Claudio Terranova,
University of Padova, Section of Legal Medicine, via
Falloppio n.50, Padova, 35121, ITALY; and Massimo
Montisci, PhD, and Santo Davide Ferrara, PhD, University
of Padua, Section of Legal Medicine and Forensic
Toxicology, Via Falloppio 50, Padua, 35121, ITALY
Cecchetto, Giovanni MD*, Via Falloppio 50, Padova, Machinery-Related Occupational Death: The 144
35121, ITALY; Guido Viel, MD, and Federica De Lotto, Relevance of Workplace Investigation and
MD, University of Padua, Via Falloppio 50, Padova, Antemortem Radiological Data in Forensic
35121, ITALY; Renzo Manara, MD, Istituto di Reconstruction
Neuroradiologia, Padova, 35121, ITALY; Massimo
Montisci, PhD, Via Falloppio 50, Padova, 35121, ITALY;
and Silvano Zancaner, MD, Sede di Medicina Legale -
Università degli Studi di Padova, Via Falloppio 50,
Chan, Peter Y. BSc*, and Johan A. Duflou, MBChB, MMed, Suicidal Electrocution in Australia 275
Department of Forensic Medicine, PO Box 90, Glebe, NSW
2037, Australia
Chang, Lin MD*, China University of Political Science and A Comparison Study of Homicides Between 39
Law, 116 Lugu Road, Shijingshan Distric, Beijing, 100040, Beijing, China and the State of Maryland,
PEOPLES REPUBLIC OF CHINA; Li Liu, MD, Beijing United States
Municipal Public Security Bureau, No.1 Qinghe Longgang
Road Haidian District, Beijing, 100192, PEOPLES
REPUBLIC OF CHINA; and Xiang Zhang, MD, David R.
Fowler, MD, Eleanor J. Thomas, and Ling Li, MD, Office
Penn Street, Baltimore, MD 21201
Chavez Arias, Carlos F. MD*, Kathyrn Haden-Pinneri, Case Report – Sudden Death Due to Cystic 332
MD, Maximiliam Buja, MD, and Luis A. Sanchez, MD, Tumor of the Atrioventricular Node
Harris County Medical Examiner’s Office, Joseph J.
Jachimcyzk Forensic Center, 1885 Old Spanish Trail,
Houston, TX 77054
Chavez-Arias, Carlos F. MD*, Puerto Rico Institute of Laryngeal and Hyoid Bone Trauma Resulting 133
Forensic Sciences, PO Box 11878, Caparra Heights From Forces Other Than Compression of the
Station, San Juan, PR 00922- 1878; Dario Sanabria, MD, Neck
Puerto Rico Institute of Forensic Sciences, Department of
Pathology, PO Box 11878, Caparra Heights Station, San
Juan, PR 00922-1878; and Javier Serrano, MD, Puerto
Rico Institute of Forensic Sciences, Calle Maga Esquina
Casia #9, Urb. Reparto Metropol, San Juan, PR 00921
Chavez-Arias, Carlos F. MD*, Puerto Rico Institute of Laceration of the Inferior Vena Cava 47
Forensic Sciences, PO BOX 11878, Caparra Heights Following Blunt Abdominal Trauma in a Case
Station, San Juan, PR 00922-1878; and Javier G. Serrano, of Child Abuse
00921
Index 140
Chavez-Arias, Carlos F. MD*, Puerto Rico Institute of Intra-Abdominal Hemorrhage Associated to 48
Forensic Sciences, PO BOX 11878, Caparra Heights an Intrapartum Rupture of the Umbilical
Station, San Juan, PR 00922-1878; and Javier G. Serrano, Cord: A Case Report
00921
Chavez-Arias, Carlos F. MD, Puerto Rico Institute of Aortic Aneurysm Rupture Into the Lung With 49
Forensic Sciences, PO BOX 11878, Caparra Heights Formation of Pseudoaneurysm
Station, San Juan, PR 00922-1878; and Javier G. Serrano,
MD*, and Edda Rodriguez, MD, Puerto Rico Institute of
Forensic Sciences, Calle Maga Esquina Casia #9, Urb.
Chavez-Arias, Carlos F. MD, Puerto Rico Institute of An Unusual Case of Homicidal Chest Trauma 184
Forensic Sciences, PO Box 11878, Caparra Heights Using a Golf Club as a Weapon
Station, San Juan, Puerto Rico 00922- 1878; Javier
Serrano, MD*, Puerto Rico Institute of Forensic Sciences,
Calle Maga Esquina Casia #9, Urb. Reparto Metropol, San
Juan, PR 00921; Dario Sanabria, MD, Puerto Rico Institute
of Forensic Sciences, Department of Pathology, PO Box
11878, Caparra Heights Station, San Juan, Puerto Rico
00922-1878; and Jose F. Rodriguez, PhD, Institute of
Urb. Reparto Metropolitano, San Juan, PR 00922
Chinwah, Ogbonna MD*, Department of the Coroner, 1104 TASER® XREP™: A Case Study 74
North Mission Road, Los Angeles, CA 90033; and
Christopher B. Rogers, MD, and Lakshmanan
CA 90033
Chittenden, Shane DO*, Anna Noller, PhD, and Marnie Alcohol Related Accidental Drowning in 220
Wood, MD*, Office Chief Medical Examiner, 400 East Virginia: An Epidemiological Review
Cho, Patrick MD*, Aldo Fusaro, DO, and Richard C. Death From Truck Tire Servicing: A Report 293
Harruff, MD, PhD, King County Medical Examiner’s of Three Cases and Review of the Literature
Office, 325 Ninth Avenue, Seattle, WA 98104
Choi, Eupil MD* and Edmund R. Donoghue, MD, Cook Pediatric Asthma Mortality in the Cook 482
County Medical Examiner’s Office, 2121 West Harrison County Medical Examiner’s Office, 1 to 14
Street, Chicago, IL 60612 Years: 1998 - 2002
Choi, Eupil MD*, and Edmund R. Donoghue, MD, Office of Pediatric Mortality in the Cook County 535
the Medical Examiner, Cook County, 2121 West Harrison Medical Examiner's Office, 1 to 4 Years:
Street, Chicago, IL 2000-2001
Christensen*, Erik D. Office of the Greenville County Simultaneous Diabetic Ketoacidosis and 359
Medical Examiner, 890 West Faris Road, Suite 110, Neuroleptic Malignant Syndrome in a Patient
Greenville, SC 29605 on Olanzapine
Christensen, Erik D. MD*, Office of the Greenville County Fatal Venous Air Embolism in a 333
Medical Examiner, 890 West Faris Road, Suite 110, Postmenopausal Female During Consensual
Greenville, SC 29605 Sexual Intercourse: A Case Report and
Christiansen, Jeffrey R. BS*, Halff Associates, 1201 North Three Dimensional Polygonal Model 184
Bowser Road, Richardson, TX 75081; and Jeffery K. Visualization of Lucila sericata From SEM
Tomberlin, PhD, Department of Entomology, TAMU 2475, and Stereomicroscopic Data
Index 141
Chu, Albert Y. MD*, and Luis A. Sanchez, MD, Harris An Unusual Death of a Child at the 330
County Medical Examiner’s Office, 1885 Old Spanish Trail, Obstetrician’s Office
Houston, TX 77054
Chu, Albert Y. MD*, Sharon M. Derrick, PhD, and Luis A. Sudden Deaths Associated With Sexual 206
Sanchez, MD, Harris County Medical Examiner’s Office, Activity
Chu, Albert Y. MD, MHS*, and Luis A. Sanchez, MD, Ruptured Cerebral Artery Aneurysm 264
Harris County Medical Examiner’s Office, 1885 Old Mimicking Home Invasion and Assault
Chu, Albert Y. MD, MHS*, Carol Allan, MD, Mary G. Fatal Dog Maulings Associated With Infant 387
Ripple, MD, Tasha Z. Greenberg, MD, and David R. Swings
Chui, Paul P.S. MBBS, DMJ, MBA*, and Clarence T. Tan, Professional Quality in a Forensic Medical 351
MBBS, Health Sciences Authority, 11 Outram Road, Setting: The Singapore Experience
Singapore, 169078, Singapore
Chui, Paul P.S. MBBS, DMJ, MBA*, Health Sciences An Unusual Postmortem Change in a Child 355
Authority, 11 Outram Road, Singapore, 289160, Singapore Homicide—Leaching
Chung, Fang-Chun MS*; Chang-En Pu, MS, Section Chief; Immunopathological Study of 566
Way-Lin Lin, Associate Researcher, Institute of Forensic Methamphetamine (MAP)-Induced Fatalities
Medicine, 40-11, Lane 103 Hsing-An Street, Taipei, Taiwan
(Roc); Way-Hwa Lee, Professor; John M. Fong; and, Kai-
Ping Shaw, Chairman, Department Forensic Pathology,
Institute of Forensic Medicine, 40-11, Lane 103 Hsing-An
Street, Taipei, Taiwan (ROC)
Chute, Dennis J. MD*, and Kari Reiber, MD, Dutchess Three Unusual Neuropathologic-Related 264
County Medical Examiner’s Office, 387 Main Street, Causes of Sudden Death
Poughkeepsie, NY 12601
Chute, Dennis J. MD*, Division of Neuropathology, UCLA Basketball-Related Sudden Deaths in Young 488
Medical Center, 650 Charles Young Drive, South, Room 18- Adults: A Medical Examiner Study
126, Los Angeles, CA; and David R. Fowler, MD, Office of
Cipolloni, Luigi MD, Manuela Rosini, MSc, Silvia Zoppis, The Bone Collector: When Reality 4
MD*, Department of Legal Medicine University of Rome Overcomes Fantasy
“Sapienza”, Viale Regina Elena 336 00161, Rome, ITALY;
Fabio Verginelli, PhD, Department of Oncology and
Experimental Medicine, G. d’Annunzio University, Via dei
Vestini 31, 66100, Chieti, ITALY; Michaela Lucci, PhD,
Alfredo Coppa, Department of Environmental Biology,
University of Rome “Sapienza”, P.le A. Moro 5, 00185,
Rome, ITALY; Filippo Terrasi, Circe, Innova and
Department of Environmental Sciences, 2nd University of
Naples, Via Vivaldi 43, 81100, Caserta, ITALY; and Carla
Vecchiotti, Department of Legal Medicine University of
Rome “Sapienza”, Viale Regina Elena 336, 00161, Rome,
ITALY
Clark, Ellen G.I. MD, 475 Kirman, Reno, NV; Kathy P. Evaluation of Iron and Macrophages in 529
Raven, MD*, King County Medical Examiner's Office, 325 Meninges of Infants Dying Suddenly and
Ninth Avenue, Box 359792, Seattle, WA; Daniel Anderson- Unexpectedly
Wooley, 475 Kirman, Reno, NV; and Richard C. Harruff,
MD, PhD, 325 Ninth Avenue, Seattle, WA
Index 142
Clement*, Renaud and Olivier Rodat, PhD, Department of The Spontaneous Oesophagus Perforation: A 396
Forensic Medicine, University of Nantes, 1 Rue Gaston Forensic Point of View
Viel, Cedex, 44 093, France
Clement, Renaud MD*, 1 Rue Gaston Veil, Nantes, 44093, Cerebral Artery Thrombosis After Penetrating 108
FRANCE Oral Trauma: An Exceptional Autopsy Case
Clement, Renaud MD*, 1 Rue Gaston Veil, Nantes, 44093, Petechiae in Hanging: A Retrospective Study 117
FRANCE; and Anny Sauvageau, MD, Office of the Chief of Contributing Variables
Medical Examiner, 7007 116 Street, Edmonton, AB T6H
5R8, CANADA
Clement, Renaud MD*, 1 Rue Gaston Veil, Nantes, A Case of Atypical Chronic Subdural 28
FRANCE Hematoma: A Spontaneous Rupture of Dural
Lymphoma Nodule?
Clouse, Jolene R. MD*, and Patrick E. Lantz, MD, Wake Posterior Rib Fractures in Infants Associated 214
Forest University, School of Medicine, Department of With Cardiopulmonary Resuscitation
27157-1072
Coklo, Miran PhD, Valter Stemberga, PhD, Drazen Decubitus Ulcers and Ligature Marks as 37
Cuculic, PhD*, and Alan Bosnar, PhD, Rijeka University Evidence in a Homicide Case
School of Medicine, Department of Forensic Medicine,
Brace Branchetta 20, Rijeka, 51000, CROATIA
Colecchi, Catia MD, Catholic University, Institute of Placental Site Trophoblastic Tumor (PSTT) 233
Forensic Medicine, Rome, ITALY; Ezio Fulcheri, MD, With Lung Metastases as Cause of Death in a
University of Genova, Department of Pathology, Genova, Young Patient: Autopsy Findings and
ITALY; Sara Partemi, MD, and Fabio De Giorgio MD, Medico-Legal Implications
Catholic University, School of Medicine, Institute of
Forensic Medicine, Largo Francesco Vito 1, Rome, ITALY;
Giovan Battista Serra, MD, Catholic University,
Department of Obstetrics and Gynecology, Rome, ITALY;
and Vincenzo L. Pascali, MD, PhD, and Antonio Oliva,
MD, PhD*, Catholic University, School of Medicine,
Institute of Forensic Medicine, Largo Francesco Vito 1,
Rome, ITALY
Colvin, Sarah M. MD*, Carol Allan, MD, Laron Locke, Analytical Electron Microscopic Detection of 401
MD, Mary G. Ripple, MD, and David R. Fowler, MD, Aluminum Received Intravenously
Office of the Chief Medical Examiner, State of Maryland,
111 Penn Street, Baltimore, MD 21201; and Victor Roggli,
MD, Duke University Health Systems, Department of
Pathology, Box 3712, DUMC, Durham, NC 27710
Condron, Michael R. MD*, and Mary L. Anzalone, MD, Utility of Large Bowel Examination in 120
Harris County Medical Examiner, 1885 Old Spanish Trail, Medicolegal Death Investigation
Houston, Texas 77054; and Dwayne A. Wolf, MD, PhD,
Harris County Medical Examiner, JAJ Forensic Center,
Cordeiro, Cristina G. MD*, and Duarte N.P. Vieira, PhD, Complex Suicide: A Case Report 92
Instituto Nacional de Medicina Legal, IP, Largo da Sé
Nova, Coimbra, 3000-213, PORTUGAL
Cordeiro, Cristina MSc*, Instituto Nacional De Medicina Plastic Bag Asphyxia: Suicide and Literature 4
Legal, Largo Da Se Nova, Coimbra, 3000-213,
Index 143
Corey, Tracey S. MD, and Deirdre Schluckebier, MD*, Physical Findings in Confessed Homicidal 532
Office of the Chief Medical Examiner and University of Suffocation of Children: A Case Series
Louisville School of Medicine, OCME, 810 Barret Avenue,
Louisville, KY
Corey, Tracey S. Office of the Chief Medical Examiner, Investigation of Time Interval For Recovery 505
Department of Pathology and Laboratory Medicine, of Semen and Spermatozoa From Female
University of Louisville School of Medicine; Angela R. Internal Genitalia
Wetherton, MD*, Department of Pathology and Laboratory
Medicine, University of Louisville School of Medicine;
Pamela J. Froncek, RN, Office of the Chief Medical
Examiner; and Dawn Katz, BS, Kentucky State Police
Forensic Science Laboratory, Louisville KY
Corliss, Robert F. MD*, Andrew M. Baker, MD, and Compressional Asphyxia Due to Prone 320
Kathryn K. Berg, MD, Hennepin County Medical Restraint Hold in a Child
Examiner’s Office, 530 Chicago Avenue, Minneapolis, MN
55415
Cornetta, Sandra MD*, Sezione di Meidcina Legale - Death by Electrocution: Unusual Findings in a 185
Università di Bari, piazza Giulio Cesare, 11, Bari, 70124, “Love Nest”
ITALY; Fiorenza Zotti, PhD, Section of Legal Medicine,
Place G. Cesare, Bari, 70124, ITALY; Roberto Gagliano-
Candela, AS, University of Bari, Cattedra Tossicologia
Forense, Policlinico, Piazza G. Cesare 11, Bari, 70124,
ITALY; Andrea Marzullo, MD, Sezione di Anatomia
Patologica - Università di Bari, piazza Giulio Cesare, n.11,
Bari, 70124, ITALY; and Alessandro D. Erba, Sezione di
Medicina Legale - Università di Bari, piazza Giulio Cesare,
n.11, via Prospero Petroni, n.37, Bari, 70124, ITALY
Corrado, Simona MD*, Sezione di Medicina Legale, Bari, The Potential Use of Aquatic Invertebrate for 18
70100, ITALY; Lucio Rositani, PhD, Laboratory of Marine Postmortem Submersion Interval (PMSI)
Biology, Molo Pizzoli, Bari, 70100, ITALY; Maurizio Determination
Scarpa, MD, Piazza G. Cesare 11 Università di Bari, Bari,
70100, ITALY; and Francesco Introna, PhD, Section of
legal Medicine - DiMIMP, Piazza Giulio Cesare n.11, Bari,
70124, ITALY
Corrigan, Gilbert E. MD, PhD*, East Baton Rouge Modeling Languages in Forensic Pathology 413
Coroner’s Office, 4030 T.B. Hearndon Avenue, Baton
Rouge, LA 70807
Corrigan, Gilbert E. MD, PhD*, East Baton Rouge Forensic Science “Case Derived” Templates 263
Coroner’s Office, 4030 T.B. Hearndon Drive, Baton Rouge, Formulated With Relational Database
LA 70807; and Sarah P. Corrigan, MS, Jefferson Parish Software
Forensic Laboratory, Jefferson Parish Government,
Metaire, LA 70001
Corrigan, Gilbert E. MD, PhD*, East Baton Rouge What is Forensic Informatics? 358
Coroner’s Office, 4030 T.B. Herndon Road, Baton Rouge,
LA 70808; and Sarah P. Corrigan, MS*, Reliagene
Technologies, Inc., 5525 Mounes Street, Suite 101, New
Orleans, LA 70123
Corrigan, Gilbert E. PhD*, 11801 Hidden Lake, Saint Public Death From Orally Ingested Drugs 91
Louis, MO 63138 During a One Year Period in Louisiana as
Analyzed by a Single Forensic Toxicology
Laboratory
Index 144
Crawford, Coleen MFA*, and William M. Zane, MD, Computerization of the Autopsy Report “How 498
OCME Commonwealth of Massachusetts, 720 Albany to Build Your Own Desktop”
Street, Boston, MA
Croft, Philip MD*, Sparrow Health Systems, 1215 East Levorphanol, Dextromethorphan, and a Case 174
Michigan Avenue, Lansing, MI 48912; Joyce L. de Jong, of (Probable) Mistaken Identity
DO, Sparrow Forensic Pathology, 1215 East Michigan
Avenue, Lansing, MI 48909; Michael A. Markey, MD,
Sparrow Hospital, Sparrow Forensic Services, 1215 East
Michigan Avenue, Lansing, MI 48909; and Michael Smith,
PhD, Sparrow Health Systems, 1215 East Michigan Avenue,
Lansing, MI 48912
Croft, Philip R. MD*, Sarah L. Lathrop, DVM, PhD, and Amended Cause and Manner of Death 403
Ross E. Zumwalt, MD, Office of the Medical Investigator, Certification: A Six-Year Review of the New
MSC11 6030, 1 University of New Mexico, Albuquerque, Mexico Experience
NM 87131-0001
Croft, Philip R. MD, Sparrow Forensic Pathology, 1215 Histologic Diagnosis of Amniotic Fluid 119
East Michigan Avenue, Lansing, MI 48909-7980; Michael Embolism: Providing Context Through
A. Markey, MD*, Sparrow Forensic Services, Sparrow Immunohistochemistry
Hospital, 1215 East Michigan Avenue, Lansing, MI 48912;
Joyce L. deJong, DO, Sparrow Health Systems, Forensic
Pathology, 1322 East Michigan Avenue, Suite 118, Lansing,
MI 48909; and Michelle P. Elieff, MD, Sparrow Forensic
Cros, Jérôme MD, AP-HP, Jean-Claude Alvarez, PharmD, Homicidal Deaths in the Western Suburbs of 36
AP-HP, Raymond Poincaré Hospital, 104, Bd Raymond Paris: A 15-Year-Study With Special Focus
Poincaré, Garches, F- 92380, FRANCE; Emilie Sbidian, on Survival Time
MD, AP-HP, Department of Clinical Research and Public
Health, Henri Mondor Hospital, 51 av du Maréchal de
Tassigny, Créteil, F-94010, FRANCE; and Philippe
Charlier, PhD, AP-HP, and Geoffroy Lorin de la
Grandmaison, PhD*, AP-HP, Raymond Poincaré Hospital,
104, Bd Raymond Poincaré, Garches, F-92380, FRANCE
Crowley, Sharon R. MN*, FCNS, 122 Emeline Avenue, Fatal Sexual Violence Against Women: 56
Santa Cruz, CA 95060 Normative, Baseline Studies of Postmortem
Genital Anatomy — What Can We Say About
Normal?
Crowley, Sharon R. MN*, FCNS, 122 Emeline Avenue, Fatal Sexual Violence Database for 113
Santa Cruz, CA 95060 Postmortem Genital Examinations With
Colposcopy
Crowley, Sharon R. MN*, FCNS, 122 Emeline Avenue, Evidence-Based, Medical-Legal 171
Santa Cruz, CA 95060 Documentation of the Postmortem Anogenital
Examination
Crowley, Sharon R. MN, RN*, Forensic Clinical Nurse Anogenital Anatomy: Colposcopy to Study 366
Specialist, 122 Emeline Avenue, Santa Cruz, CA 95060 the Appearance and Changes During the
Postmortem Interval
Crowley, Sharon R. RN, MN *, 122 Emeline Avenue, Santa To Dye or Not to Dye: A Tale of the Blues 423
Cruz, CA 95060; Brian L. Peterson, MD, Forensic Medical
Group, 1860 Pennsylvania Avenue, Fairfield, CA 94533
Crowley, Sharon R. RN, MN*, 122 Emeline Avenue, Santa Postmortem Genital Examinations With 236
Cruz, CA 95060 Colposcopy in the Evaluation of Fatal Sexual
Violence Against Women
Index 145
Crowley, Sharon R. RN, MN*, 122 Emeline Avenue, Santa To Dye or Magnify! A Proposal to Study the 271
Cruz, CA 95060 Efficacy of Toluidine Blue Dye vs.
Colposcopy in the Postmortem Anogenital
Examination
Crowley, Sharon R. RN, MN*, Forensic Clinical Nurse Postmortem Genital Examinations and 495
Specialist, 122 Emeline Avenue, Santa Cruz, CA Evidentiary Protocol With Colposcopy
Crowns, Kendall V. MD* and Adrienne Segovia, MD, Cook Death by Defibrillator: A Unique Homicide 445
County Medical Examines Office, 2121 W. Harrison Street, by Electrocution
Chicago, IL 60612
Crowns, Kendell V. MD*, and Adrienne Segovia, MD, Cook Isolated Noncompaction of the Left Ventricle: 523
County Medical Examiner’s Office, 2121 West Harrison A Rare Cause of Sudden Death
Street, Chicago, IL
Cunliffe, Clare H. MD*, Office of the Medical Examiner, An Atypical Gunshot Wound With Absence 419
County of Cook, 2121 West Harrison Street, Chicago, IL of a Weapon? The Value of a Thorough Scene
60612 Investigation
D’Errico, Stefano MD*, Francesco Maria Morreale, MD, Vaccine Death: A Rare Case of Anaphylactic 317
and Raffaella Bisceglia, MD, Institute of Legal Medicine, Shock After Hexavalent Immunization
University of Foggia, Ospedali Riuniti, via L.Pinto 1,
Foggia, 71100, Italy; and Rossi Giuseppina, MD, Institute
of Legal Medicine, University of Siena, Policlinico Le
Scotte, Siena, 53100, Italy
Dadour, Ian PhD*, and Sasha Voss, BSc, University of Effects of Fluctuating Temperature and 353
Western Australia, Centre for Forensic Science, 35 Stirling Larval Density on Calliphora dubia (Diptera:
Highway, Nedlands, 6009, Australia Calliphoridae) Implications for Postmortem
Interval Estimation
Dadour, Ian PhD*, Centre for Forensic Science, University Forensic Entomology: Decomposition in Cars 570
of Western Australia, Nedlands, Australia, Western
Australia
Dakin Hache, Kelly A. MD, PhD, Anatomical Pathology, Accuracy of Death Certification and Medical 308
Dalhousie University, 5788 University Avenue, Halifax, Examiner Notification in Nova Scotia
Nova Scotia B3H 2Y9, Canada; Petra A. Rahaman*,
Forensic Science-Biology, University of Toronto, 107
Linnsmore Crescent, Toronto, Ontario M4J 4K5, Canada;
and Matthew J. Bowes, MD, Nova Scotia Medical Examiner
Service, 5670 Spring Garden Road, Suite 701, Halifax,
Nova Scotia B3J 1H7, Canada
Daly, Barry MD*, and Clint W. Sliker, MD, University of Preliminary Study and Potential Role of CT 258
Maryland Medical Center, Diagnostic Imaging Department, Imaging Autopsy in the Investigation of
22 South Greene Street, Baltimore, MD 21201; Zabiullah Death Due to Accidental Blunt Trauma
Ali, MD, Dawn Zulauf, RN, and Jack M. Titus, MD, Office
of the Chief Medical Examiner, 111 Penn Street, Baltimore,
MD 21201; Mary G. Ripple, MD, 68 Bluebird Road, Port
Deposit, MD 21904; and David R. Fowler, MD, Office of
MD 21201
Darrisaw, Lora A. MD*, Julie P. Gardiner, BA, Geoffrey P. Pediatric Injury Evaluation: A Clinical 531
Smith, MD, and Kris L. Sperry, MD, Georgia Bureau of Forensic Pathology Program in Georgia
Investigation, 3121 Panthersville Road, Decatur, GA
Davis, John B. BS*, Eastern Virginia Medical School, 700 Contribution of Burn Injury in a Blunt 387
West Olney Road, Norfolk, VA 23507-1607; and Leah L. Trauma Case With Incineration
Bush, BS, and Wendy M. Gunther, MD, Office of the Chief
Index 146
Dawes, Donald M. MD*, Lompoc Valley Medical Center, TASER® Wound Progression in Two 152
518 East Hickory Avenue, Lompoc, CA 93436; and Jeffrey Deployment Modes
D. Ho, MD, Hennepin County Medical Center, 701 Park
Avenue South, Department of Emergency Medicine,
Dawes, Donald M. MD*, Lompoc Valley Medical Center, Conducted Electrical Weapons — A Review 207
518 East Hickory Avevue Lompoc, CA 93436; and Jeffrey of the Medical Literature
D. Ho, MD*, Hennepin County Medical Center, 701 Park
Avemue South, Department of Emergency Medicine,
Day, Kathleen MA, MS*, University of Alaska, Anchorage, Bear Facts Alaska: The Good, The Bad, and 258
PO Box 670276, Chugiak, AK 99567; and Franc Fallico, the U
MD, Office of the Chief Medical Examiner, State of Alaska,
4500 South Boniface Parkway, Anchorage, AK 99567
deJong, Joyce L. DO*, and Brian C. Hunter, MD, Sparrow Sudden Death Due to Myocardial Infarct 562
Health System - Forensic Division, 1215 East Michigan Associated With Systemic Lupus
Avenue, Lansing, MI Erythematosus: Two Case Reports and a
deJong, Joyce L. DO*, Sparrow Hospital, Forensic Unexpected Death From Ureterocele in an 463
Pathology, 1215 East Michigan Avenue, Lansing, MI 48909 Infant
Dean, Dorothy E. MD*, Franklin County Coroner’s Office, Undefeated by Surgery: The Utility of Post- 518
Columbus, OH; Nancy E. Tatarek, PhD, Ohio University, Surgical Foot and Ankle Radiographs for
Athens, OH; Jeremy Rich, DPM, Brigham and Women’s Identification: Focus on the Ankle
Hospital, Boston, MA; Robert H. Powers, PhD, Hamilton
County Coroner’s Office, Cincinnati, OH; B.G. Brogdon,
MD, University of South Alabama Medical Center, Mobile,
AL; and Bradley J. Lewis, MD, Franklin County Coroner’s
Office., Columbuzs, OH
Deaver, Kc L. MS*, 2704 72nd Avenue, SE, Mercer Island, The Developmental Studies of The Green 352
WA 98040; and Jerry Cook, PhD, Sam Houston State Bottle Fly, Phaenicia coeruleiviridis (Diptera:
University, Department of Biological Sciences, 300 Lee Calliphoridae)
Drain, Box 2116, Huntsville, TX 77341
Dedouit, Fabrice MD*, and Céline Guilbeau Frugier, MD, Child Abuse: Practical Case of Autopsical, 213
Caroline Capuani, and Annick Sevely, MD, Service de Radiological, and Anatomo-Pathological
Neuroradiologie, Hôpital de Purpan, 1 Avenue du Studies
Professeur Jean Poulhès, TSA 50032, Toulouse Cedex 9,
31059, FRANCE; Philippe Otal, PhD, Hervé Rousseau,
PhD, and Francis Joffre, PhD, Service de Radiologie
Générale, Hôpital de Rangueil, 1 Avenue du Professeur
Jean Poulhès, TSA 50032, Toulouse Cedex 9, AL 31059,
FRANCE; Bernadette Delisle, PhD, Service d’anatomie
Pathologique, Hôpital de Rangueil, 1 Avenue du Professeur
Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059,
FRANCE; and Daniel Rouge, PhD, and Norbert Telmon,
PhD, Service de Médecine Légale, Hôpital de Rangueil,, 1
Avenue du Professeur Jean Poulhès, TSA 50032, Toulouse
Cedex 9, 31059, FRANCE
deJong, Joyce L. DO*, and Michael A. Markey, MD, Stairway Related Deaths: An Analysis of 259
Sparrow Forensic Services, Sparrow Hospital, 1215 East Autopsy Findings of Individuals Found Dead
Michigan Avenue, Lansing, MI 48909-7980; and Rudy J. at the Bottom of a Stairway
Castellani, MD, University of Maryland, Department of
Index 147
deJong, Joyce L. DO*, Sparrow Hospital, 1215 East Visual Misidentifications of Human Remains: 335
Michigan Avenue, Lansing, MI 48909-7980 Lessons Learned
DellErba*, Alessandro Sandra Cornetta, MD, Fiorenza Unusual Death of a Transsexual 260
Zotti, PhD, and Annalisa Addante, MD, PHD, Section of (Identification of Damaging Means and Death
Legal Medicine, Place G. Cesare, BARI, 70124, ITALY Time)
DeLonga, David M. PhD*, Naval Medical Center Postmortem Injury Detection in an Aviation 201
Portsmouth, 6513 Harbour Pointe Drive, Suffolk, VA Mishap: Computed Tomography Imaging
23435; Angela D. Levy, MD, United States Army, Versus Autopsy
Department of Radiology and Radiological Sciences,
Uniform Services University of the Health Sciences, 4301
Jones Bridge Road, Bethesda, MD 20814; and Howard T.
Harcke, MD, Department of Radiologic Pathology, Armed
Forces Institute of Pathology, 3205 Coachman Road,
Wilmington, DE 19803
Denton, J. Scott MD*, Edmund R. Donoghue, MD, Mitra B. “Drop Dead”: An Epidemic of Intravenous 314
Kalelkar, MD, and Nancy Wu Chen, PhD, Cook County Fentanyl Deaths in Cook County, Illinois:
Medical Examiner’s Office, 2121 West Harrison Street, 2005 to Present
Chicago, IL 60612-3705
Denton, J. Scott MD*, Valerie Arangelovich, MD, Michel An Analysis of 35 Ethylene Glycol Fatalities 427
Humilier, MD, and Edmund R. Donoghue, MD, Cook in Cook County, Illinois From 1993 Through
County Medical Examiner’s Office, 2121 West Harrison 2003
Denton, J. Scott MD, Cook County Medical Examiner’s Accidental Hanging Death of a 10-Year-Old 557
Office, 2121 West Harrison Street, Chicago, IL Boy From a Lanyard Key Chain
Derrick, Sharon M. PhD*, Harris County Medical The Evolving Distribution of Cause and 134
Examiner’s Office, Harris County Medical Examiner’s Manner of Death in HIV Positive Medical
Office, 1885 Old Spanish Trail, Houston, TX 77054 Legal Cases: Links Between ART and
Traditional Categories of Chronic Disease
Derrick, Sharon M. PhD*, Stacey A. Mitchell, MSN, RN, The Epidemiology of Sudden Cardiac Death 266
and Luis A. Sanchez, MD, Harris County Medical in Young Decedent Medical Examiner Cases
77054
Derrico, Stefano MD*, Irene Riezzo, MD, and Cristoforo A Rare Case of Cardiac Failure Due to 253
Pomara, MD, Department of Forensic Pathology, Hypertensive Crisis in Pheocromocytoma: A
University of Foggia, via Luigi Pinto, 1, Foggia, Italy Methodological Approach for Diagnosis
71100, ITALY
Derrico, Stefano PhD*, University of Foggia, Department Blast Overpressure After Tire Explosion: A 74
of Forensic Pathology, Via Luigi Pinto, 1, Foggia, 71100, Fatal Case
ITALY; Gabriela Perilli, MD, University of Foggia,
Department of Forensic Pathology, Viale Degli Aviatori 1,
Foggia, 71100, ITALY; Umberto Volpe, Bari, Bari, ,
ITALY; Natascha Pascale, MD, University of Foggia,
Department of Forensic Pathology, Viale Degli Aviatori,
Foggia, 71100, ITALY; and Irene Riezzo, PhD, University
of Foggia, Osp D’Avanzo, Department of Forensic
Pathology, Viale Degli Aviatori, 1, Foggia, 71100, ITALY
Desjarlais, Anne BSc*, 7101 De La Roche, Montreal, QC Pattern of Limb Lesions in Suicidal Hanging: 36
H2S2E6, CANADA; Anny Sauvageau, MD, Office of the A Criteria Tool in the Distinction of
Chief Medical Examiner, 7007 - 116 Street, Edmonton, AB Suspicious Cases
T6H 5R8, CANADA; and Jean-Pierre Guay, PhD,
University of Montreal, CP 6128, Succ. Centre-ville,
Montréal, QC H2S 2E7, CANADA
Index 148
Devlin, Joanne L. PhD*, Department of Anthropology, Morphological Considerations of the Hyoid 510
University of Tennessee, 250 South Stadium Hall, Bone
University of Tennessee, Knoxville, TN
Dickens, Andrea L. MD*, and Richard E. Powers, MD, Descriptive Study on the Causes of Death of 349
P220 West Pavilion, Department of Pathology, 619 19th Residents of Boarding Homes
Dirkmaat, Dennis C. PhD*, Luis L. Cabo-Pérez, MS, Improving Evidence and Victim Recovery 51
Michael W. Kenyhercz, MS, Allison M. Nesbitt, MS, Protocols at the Mass Fatality Incident
Alexandra R. Klales, MS, and Erin Chapman, MS,
Mercyhurst College, Department of Applied Forensic
Sciences, 501 East 38th Street, Erie, PA 16546
Distefano, Ronalod F. DO*, Office of the Chief Medical Dramatic Rise in Methadone-Related Deaths 440
Examiner, State of Oklahoma, 1115 West 17th Street, Tulsa, in Oklahoma 1990-2002
OK 74107
Do*, Paula M. California State University, Bakersfield Digestion Time of Human Mitochondrial 501
2001 Stockdale Highway, Bakersfield, CA DNA in Blowfly Larvae, Calliphora vicina
Doenz*, Francesco Service de Radiodiagnostic et de Radiological Interpretation of Postmortem 124
Radiologie Interventionnelle, Rue du Bugnon 46, Lausanne, CT-Angiography
SWITZERLAND; Alexendre Dominguez, Haute Ecole
Cantonale Vaudoise de la Santé, Avenue de Beaument 21,
Lausanne, SWITZERLAND; Richard Dirnhofer, and Beat
SWITZERLAND; Erich Gygax, and Barbara Sollberger,
Department for Cardiovascular Surgery, University
Hospital Bern, Hochschulstrasse 4, Bern, SWITZERLAND;
Reto Meuli, Service de Radiodiagnostic et de Radiologie
Interventionnelle, Rue du Bugnon 46, Lausanne, 1011,
SWITZERLAND; and Patrice Mangin, PhD, and Silke
SWITZERLAND
Dominguez*, Alexendre Haute Ecole Cantonale Vaudoise Forensic Imaging: Yes, We Scan! New 98
de la Santé, Avenue de Beaument 21, Lausanne, Challenges for a Radiographer
Bugnon 46, Lausanne, Richard Dirnhofer, MD, and Beat
SWITZERLAND; Barbara Sollberger, Department for
Cardiovascular Surgery, University Hospital Bern,
Hochschulstrasse 4, Bern, SWITZERLAND; Erich Gygax,
Department for Cardiovascular Surgery, Hochschulstrasse
4, Bern, SWITZERLAND; Reto Meuli, Service de
Bugnon 46, Lausanne, 1011, SWITZERLAND; and Patrice
Mangin, MD, PhD, and Silke Grabherr, Centre
Universitaire Romand de Médecine Légale, Rue du Bugnon
Index 149
Donato, Sabina Di MD*, and Emanuela Turillazzi, MD, Cane Corsos Attack: Two Fatal Cases 386
PhD, Institute of Forensic Medicine, University of Foggia,
Viale Luigi Pinto, 1, Foggia, 71100, Italy; Fernando
Panarese, MD, Department of Experimental and Clinical
Medicine, University of Magna Grecia, Policlinico
Universitario Catanzaro, Via Tommaso Campanella 115,
Catanzaro, 88100, Italy; Pietrantonio Ricci, MD,
Department of Experimental and Clinical Medicine
University of Magna Grecia, Policlinico Universitario
Catanzaro, Via Tommaso Campanella 115, Catanzaro,
88100, Italy
Donato, Sabina Di MD*, Arcangela Marucci, MD, and Neurofibromatosis Type 1 Associated With 457
Francesco M. Morreale, MD, Department of Forensic Hydrocephalus and Acute Cardiac Failure: A
Pathology University of Foggia, Viale Pinto n.1, Foggia, Fatal Case
Puglia 71100, Italy
Donato, Sabina Di MD*, Carmela Fiore, MD, and Where is the Head? A Case of Homicidal 357
Emanuela Turillazzi, MD, PhD, Department of Forensic Decapitation
Pathology, University of Foggia, Viale Luigi Pinto, n.1,
Donato, Sabina Di MD*, Giovanni Paolo Di Peri, MD, and A Rare Injuring Tool in a Dyadic Death 293
Carmina Dambra, MD, Institute of Forensic Pathology,
University of Foggia - Italy, Ospedali Riuniti, Viale L. Pinto
n. 1 - 71100 Foggia - Italy, Foggia, 71100, Italy
Donato, Sabina Di MD*, Ospedale San Carlo - U.O. An Unusual Case of Homicide by Knife, 132
Medicina Legale, Via Potito Petrone, s.n.c., Potenza, Screwdriver, and a Kitchen Fork
85100, ITALY; Aldo Di Fazio, Section of legal medicine -
Matera Hospital, via Montescaglioso n.5, Matera, 75100,
ITALY; and Rocco Maglietta, CROB Rionero in Vulture
(Potenza), via Padre Pio n. 1, Rionero in Vulture (Pz),
85028, ITALY
Donato, Sabina Di MD*, Ospedale San Carlo - U.O. Sudden Death From Atypical Pneumonia in a 107
Medicina Legale, Via Potito Petrone, s.n.c., Potenza, Healthy Adolescent
85100, ITALY; Margherita Neri, PhD, Department
Aviatori 1, Foggia, 71100, ITALY; and Rocco A. Maglietta,
MD, C.R.O.B. - Rionero in Vulture (Pz), via Padre Pio, 1,
Rionero in Vulture (Pz), 85100, ITALY
Donato, Sabina Di MD, Marianna Di Padua, MD, Floriana An Unusual Case of Crossbow Homicide 515
Monciotti, MD, Francesco Maria Morreale, MD,
Margherita Neri, MD, and Cristoforo Pomara, MD*,
Department of Forensic Pathology, University of Foggia,
Viale Pinto 1, Foggia, Italy
Donato, Sabina Di PhD*, University of Foggia, Department Cause of Sudden Death Due to Cardiac 42
of Forensic Pathology, Viale Aviatori, 1, Foggia, 71100, Rhabdomyoma in an 11-Month-Old Baby
ITALY; Michele Nolè, A.O.R. “San Carlo” Hospital, Via
Potito Petrone, 6, Potenza, 85100, ITALY; Irene Riezzo,
PhD, University of Foggia, Osp D‘Avanzo, Department of
Forensic Pathology, Viale degli Aviatori, 1, Foggia, 71100,
ITALY; Sara Vita, MD, University of Foggia, Department of
Forensic Pathology, Viale Aviatori, 1, Foggia, 71100,
ITALY; and Rocco A.G. Maglietta, MD, San Carlo Hospital
Potenza, Section of Legal Medicine, via P. Petrone n.6,
Potenza, 85100, ITALY
Index 150
Dooley*, Melinda K. and Jeffery K. Tomberlin, PhD, Attraction and Repellance of Blow Flies to 183
Department of Entomology, TAMU 2475, College Station, Intra- and Interspecific Fecal Bacteria
TX 77843-2475; and Adrienne L. Brundage, MS, 2001
Cobblestone Lane, Bryan, TX 77807
Dorandeu, Anne MD*, Eric Baccino, MD, and Maguy The Contribution of Researching DNA 469
Ursule, MD, Lapeyronie University Hospital, 371 Avenue Breaks to the Evaluation of Postmortem
du Doyen Gaston Giraud, Montpellier, Herault 34295, Delay
France
Downs, J.C. Upshaw MD*, Alabama Department of Nuclear and Mitochondrial DNA Analyses 574
Forensic Sciences, PO Box 3510, Auburn, AL, S. Elaine Following X- and Gamma-irradiation
Scott, MS, Alabama Department of Forensic Sciences, 2451
Fillingim Street, Mobile, AL, William Jones, Armed Forces
Institute of Pathology, 2451 Fillingim Street, Mobile, AL,
Robert Neyland, PhD, Maria Jacobsen, and Paul
Mardikian, Warren Lasch Conservation Center, Former
Charleston Naval Base1250 Supply Street, Building 255,
North Charleston, SC; Sudhir K. Sinha, PhD, ReliaGene,
5525 Mounes Street, New Orleans, LA; and Douglas W.
Owsley, PhD, National Museum of Natural History,
Smithsonian Institution, Department of Anthropology,
Washington, DC
Downs, J.C. Upshaw MD*, Alabama Department of Recovery and Processing of Co-Mingled 575
Forensic Sciences, PO Box 3510, Auburn, AL; and William Remains Following Extended Submersion
R. Oliver, MD, Armed Forces Institute of Pathology, Period Facilitated by Computer Animation
Washington, DC
Downs, J.C. Upshaw MD*, and Edmund R. Donoghue, MD, Mass Fatality Investigation Due to 198
Regional Medical Examiner, Georgia Bureau Investigation, Combustible Dust Related Industrial
925 A Mohawk Street, Savannah, GA 31419-1796 Explosion and Fire
Downs, J.C. Upshaw MD*, Coastal Regional Laboratory .17 HMR – It’s Not Your Father’s .22 421
Georgia Bureau of Investigation, 925A Mohawk Street,
Savannah, GA 31419; and Ron Van Fleet, BS, Donelle L.
Pyle, MS, and Shannon Walden, Georgia Bureau of
Downs, J.C. Upshaw MD*, Donelle L. Pyle, MS, Ron Van A Shot In the Dark? Investigating Accidental 421
Fleet, BS, and Shannon Walden, Coastal Regional Gunshot Wounds
Laboratory Georgia Bureau of Investigation, 925A Mohawk
Street, Savannah, GA 31419
Drake, Stacy A. MSN, RN*, Teresa Royer, MSN, RN, Sequential SIDS or Double Homicide? 432
Stephen K. Wilson, MD, Dwayne A. Wolf, MD, PhD, Ashraf Challenges of Delayed Investigation of
Mozayani, PharmD, PhD, and Luis A. Sanchez, MD, Harris Potential “Subtle” Child Homicides
Houston, TX 77054
Drewry, Brian BS*, Iowa and Jerri McLemore, MD, Iowa An Unusual “In-Custody” Death 86
Office of the State Medical Examiner, 2250 South Ankeny
Boulevard, Ankeny, IA 50023; Dennis Klein, MD, Iowa
Depaartment of Public Health, 2250 South Ankeny
Index 151
Druid, Henrik PhD*, Department of Forensic Medicine, Dead Victim Identification: Age 201
Karolinska Institutet, Retzius v. 3, Stockholm, SE-171 77, Determination by Analysis of Bomb-Pulse
SWEDEN; Kanar Alkass, BSc, Department of Forensic Radiocarbon in Tooth Enamel
Medicine, Retzius v 3, 171 77, Stockholm, SWEDEN; Kirsty
Spalding, PhD, Department of Cell and Molecular Biology,
Medical Nobel Institute, Karolinska Institutet, Stockholm,
SWEDEN; and Bruce Buchholz, PhD, Lawrence livermore
National Laboratory, 7000 East Avenue, Livermore, CA
94550
Dudley, Mary H. MD*, and Shari L. Beck, BA, Chief Under Reporting of Fatal Child Abuse by 545
Medical Investigator, Sedgwick County Regional Forensic State Vital Statistics ICD-9 Codes
Science Center, Wichita, KS; Larry Czarnecki, DO, Office
of the Medical Investigator, and University of New Mexico
School of Medicine, Albuquerque, NM
Dudley, Mary H. MD*, Jackson County Medical Fatality Involving Complications of 1
Examiner’s Office, 660 East 24th Street, Kansas City, MO Bupivacaine Toxicity and Hypersensitivity
64108; Steven W. Fleming, MS, Children Mercy Hospital, Reaction: A Case Report
Toxicology Laboratory, 2401 Gillham Road, Kansas City,
MO 64108; Uttam Garg, PhD, Children’s Mercy Hospital,
Department of Pathology, 2401 Gillham Road, Kansas City,
MO 64108; and Jason M. Edwards, PhD, University of
Missouri Kansas City School of Medicine, 2411 Holmes
Street, Kansas City, MO 64108
Dudley, Mary H. MD*, Lawrence A. Czarnecki, DO, and Fatal Capnocytophaga Infection Associated 486
Mark A. Wells, BS, Sedgwick County Regional Forensic With Splenectomy
Science Center, 1109 North Minneapolis, Wichita, KS
Dudley, Mary H. MD*, Sedgwick County Regional Forensic Teen Fatality by Train: A Multidisciplinary 385
Science Center, 1109 North Minneapolis, Wichita, KS Approach to Determination of Manner of
67214 Death
Duflou, Johan A. MBChB, MMed *, Department of Sudden Death in the Young in Australia 374
Forensic Medicine, PO Box 90, Glebe, NSW 2037,
Australia; and Rajesh Puranik, MBBS, Clara K. Chow,
MBBS, Michael J. Kilborn, DPhil and Mark A. McGuire,
MBBS, PhD, Department of Cardiology, Royal Prince
Alfred Hospital, Missenden Road, Camperdown, NSW
2050, Australia
Duflou, Johan A. MBChB, MMed*, and Linda Kocovski, Can Renal Acute Tubular Necrosis Be 248
BSc, Department of Forensic Medicine, PO Box 90, Glebe, Differentiated From Autolysis at Autopsy?
2037, AUSTRALIA
Duflou, Johan A. MM*, Department of Forensic Medicine, Was This Drug Overdose Due to Intravenous 63
PO Box 90, Glebe, Sydney, 2037, AUSTRALIA; Shane Injection or Oral Ingestion of Heroin — Can
Darke, PhD, National Drug and Alcohol Research Centre, You Tell?
University of New South Wales, Sydney, 2052, AUSTRALIA;
and Jennifer Easson, BSc, Division of Analytical
Laboratories, Sydney West Area Health Service, Joseph
Street, Lidcombe, 2141, AUSTRALIA
Duflou, Johan A. MMed*, and Cathy Lim, MBBS, Dying of the Cold in a Warm Climate - 298
Department of Forensic Medicine, 42-50 Parramatta Road, Hypothermia Deaths in Sydney, Australia
Glebe, NSW 2037, Australia
Index 152
Duke, Lucas D. BS*, Drexel School of Medicine, 2125 Suicide by Ingestion of Carbamate 279
Spring Garden Street, #3R, Philadelphia, PA 19130; Insecticide: Case Report and Regional
Sepideh Samzadeh, BS, Drexel University School of Variations
Medicine, 135 South 20th Street, Apartment #1506,
Philadelphia, PA 19103; and Fredric N. Hellman, MD,
MBA, Office of the Medical Examiner, Delaware County,
Route 352-Fair Acres, Lima, PA 19037
Dunbar, Nancy M. BA*, Carl Wigren, MD, and Richard C. Necrotizing Fasciitis: Manifestations, 343
Harruff, MD, PhD, King County Medical Examiner’s Microbiology and Connection With Black Tar
Office, HMC Box 359792, 325 Ninth Avenue, Seattle, WA Heroin
98104
DuPre, D’Michelle P. BA, MD*, Miami-Dade County Photographic Imaging of Handgun Gas 469
Medical Examiner’s Office, Number One Bob Hope Road, Clouds Compared to Gunshot Residue Swabs
Miami, FL 33136- 1133; Joe Castorenga, Bexar County
Forensic Science Center, 7337 Louis Pasteur Drive, San
Antonio, TX
DuPre, D’Michelle P. MD*, Duke University Medical North Carolina’s Death Investigation 538
Center, PO Box 3712, Durham, NC; and Kenneth S. Snell, Database
MD, and Thomas B. Clark III, MD, Office of the Chief
Medical Examiner, Chapel Hill, NC
Duval MD*, Jennie V. Dallas County Medical Examiner’s Suicidal Air Rifle Wound of the Head 572
Office Southwestern Institute of Forensic Science, Susan B.
Allen BS, Dustin S. Engel BA, Criminal Investigation
Laboratory Firearms Section, and Jeffrey J. Barnard MD,
Dallas County Medical Examiner’s Office, 5230 Medical
Center Drive, Dallas, TX
Dye, Daniel W. MD*, University of Arkansas for Medical Histologic Evidence of Repetitive Blunt Force 285
Sciences Department of Pathology, 4301 West Markham, Abdominal Trauma in Three Pediatric
Slot #517, Little Rock, AR 72205; and Charles P. Kokes, Fatalities
MD, Arkansas State Crime Laboratory, 2 Natural
Resources Drive, Little Rock, AR 72211
Dye, Daniel W. MD*, University of Arkansas for Medical Frequency of Cases of Fatal Gunshot Wound 325
Sciences, 4301 W Markham, Slot 517, Little Rock, AR Victims With Retained “Old” Projectiles
72205; and Charles P. Kokes, MD, Arkansas State Crime From Previous Penetrating Gunshot Wounds
Laboratory, #3 Natural Resources Drive, PO Box 8500,
Little Rock, AR 72215
E. El-Sheikh, M. Essam MD, PhD*, and Taisseur M. Serum Levels of Pulmonary Surfactant 326
Mostafa, MD, PhD, Farwania, PO Box 1747, Kuwait, 1747, Associated Proteins A and D (SP-A & SP-D)
Kuwait in Some Causes of Death
Ehrhardt, Christopher PhD*, Counterterrorism and Fatty Acid Methyl Ester Profiling of Bacterial 211
Forensic Science Research Unit, Federal Bureau of Spores for Microbial Forensics
Investigation Academy, Building 12, Quantico, VA 22135;
Mark Reimers, PhD, Alcon Laboratories, Inc., 6201 South
Freeway, Fort Worth, TX 76134; Mathew Ducote, PhD,
Midwest Research Institute, 1470 Treeland Boulevard South
East, Palm Bay, FL 32909; James Robertson, PhD,
Counterterrorism and Forensic Science Research Unit,
Federal Bureau of Investigation Academy, Building 12,
Quantico, VA 22135; and Jason Bannan, PhD, Federal
Bureau of Investigation, Laboratory Division, 2501
Investigation Parkway, Quantico, VA 22135
Index 153
Eichenmiller, Michele MS, James A. Kaplan, MD*, David J. Characteristics of Fatal All Terrain Vehicle 297
Clay, BA, Myron A. Gebhardt, MS, Brandon Lewis, BS, (ATV) Accidents
Nabila A. Haikal, MD, James C. Kraner, PhD, Office of the
Chief Medical Examiner, 619 Virginia Street West,
Charleston, WV 25302
Eisele, John W. MD*, Forensic Consultants Medical Sudden Death Following Brief Compression 395
Group, 2291 March Lane, Suite 179E, Stockton, CA 95207; of the Neck
Gerald J. Berry, MD, Stanford Pathology Consultants, 300
Pasteur Drive, Room H-2110, Stanford, CA 94305; and
Michael J. Ackerman, MD, PhD, and David J. Tester, BS,
Long QT Syndrome Clinic and Sudden Death Genomics
Laboratory, Mayo Clinic College of Medicine, 200 First
Street, SW, Hilton 11, Rochester, MN 55905
Elliott, Christie L. MD* and Ellen G.I. Clark, MD, Forensic Meningitis Mimicking Inflicted Abusive Head 478
Pathology Consultants, 475 Kirman Avenue, Reno, NV Trauma
89502
Elliott, Christie L. MD*, Forensic Pathology Consultants, Clinically Stable Skull Fracture and Fatal 411
PO Box 12815, Reno, NV 89510-2815 Acute Pneumonia: An Unexpected
Combination
Ellis, Ezra MD*, and Patrick E. Lantz, MD, Department of Cavotricuspid Isthmus Rupture and 388
Pathology, Wake Forest University Health Sciences, Hemopericardium: A Delayed Complication
Medical Center Boulevard, Winston-Salem, NC 27157 of Cardiac Radiofrequency Catheter Ablation
Errico, Stefano D. MD*, Benedetta Di Battista, MD, Please, Don’t Get Angry! Two Fatal Cases of 135
Carmela Fiore, MD, and Cristoforo Pomara, MD, PhD, Emotional Stress-Related Death in Left
Department of Forensic Pathology, University of Foggia, Ventricular Apical Ballooning Syndrome
Viale degli Aviatori 1, Foggia, 71100, ITALY (Tako Tsubo Cardiomyopathy)
Esquivel, Amanda O. MS*, and Cynthia Bir, PhD, Wayne The Development of a Model to Assess the 230
State University, 818 West Hancock, Detroit, MI 48201 Effects of Conducted Electrical Weapons in a
Stressful State
Esslinger, Kelly J. MS*, 1805 Arbor Lane, #304, Crest Hill, Using STR Analysis to Detect Human DNA 498
IL; Jay A. Siegel, PhD, School of Criminal Justice, From Exploded Pipe Bomb Devices
Michigan State University, 560 Baker Hall, East Lansing,
MI; and Heather Spillane, BS, and Shawn Stallworth,
Michigan State Police Crime Laboratory - Northville,
42145 West Seven Mile Road, Northville, MI
Eutenier, Bridget B. BS*, and Karen B. Looman, Pathology Rathke’s Cleft Cyst: Alleged “Brain Tumor” 418
Resident Program, Eastern Virginia Medical School, 700 in a Middle-Aged Cocaine Abuser
West Olney Road, Norfolk, VA 23510-1046; Wendy M.
Gunther, MD, Office of the Chief Medical Examiner,
Evangelista, Frank MD*, Office of the Chief Medical An Unusual Cause of Sudden Death in 537
Examiner, 720 Albany Street, Boston, MA; Melissa P. Infancy: Histiocytoid Cardiomyopathy,
Upton, MD, Beth Israel Deaconess Medical Center- Report of an Autopsy Case
Deparment of Pathology, 330 Brookline Avenue, Boston,
MA; Richard J. Evans, MD, Eva Patalas, MD, and
Alexander M. Chirkov, MD, PhD, Office of the Chief
Medical Examiner, 720 Albany Street, Boston, MA
Index 154
Evans, Richard J. MD*, Office of the Chief Medical Bioterrorism Response and Training: Building 497
Examiner, 720 Albany Street, Boston, MA; Ann Marie Upon Mass Disaster and Multiple Fatality
Mires, PhD, Office of the Chief Medical Examiner, 7416 Preparedness at the Office of the Chief
Falmouth Street, Boston, MA; and Alexander Chirchov, Medical Examiner, Boston, MA
MD, PhD, Faryl Sandler, MD, and William M. Zane, MD,
Office of the Chief Medical Examiner, 720 Albany Street,
Boston, MA
Fais, Paolo MD*, and Giovanni Cecchetto, MD, Via Iatrogenic Laceration of a Pulmonary 23
Falloppio 50, Padova, 35121, ITALY; Guido Viel, MD, Angiomatoid Lesion: Fatal Complication or
University of Padua, Via Falloppio 50, PADOVA, 35121, Medical Error?
ITALY; Rossella Snenghi, MD, and Rafael Boscolo-Berto,
MD, Via falloppio 50, Padova, 35121, ITALY; Andrea Zuin,
MD, Via Giustiniani 2, Padova, ITALY; and Massimo
Montisci, PhD, Via Falloppio 50, Padova, 35121, ITALY
Fais, Paolo MD*, Guido Viel, MD, Massimo Montisci, Fire Death of Two Lovers: An 92
PhD, Alessandro Nalesso, Silvano Zancaner, MD, and Immunohistochemical and Toxicological
Giovanni Cecchetto, MD, University of Padua, Via Study
Falloppio 50, Padova, 35121, ITALY
Fais, Paolo MD*,and Giovanni Cecchetto, MD, Via Environmental Scanning Electron Microscopy 151
Falloppio 50, Padova, ITALY; Guido Viel, MD, University and Other Techniques in Cutting Crime
of Padua, Via Falloppio 50, PADOVA, 0 35121, ITALY; Investigation: Case Report and Review of the
Attilio Cecchetto, PhD, Istituto Anatomia Patologica, Via Literature
Gabelli 61, Padova, 35121, ITALY; Claudio Furlan, MD,
Via Falloppio, Padova, ITALY; and Massimo Montisci,
PhD, Via Falloppio 50, Padova, ITALY
Falamingo, Rosa MD, PhD, and Francesco Vinci, MD, Firearms Injuries: Beyond Entry and Exit 261
Section of Legal Medicine (Di.M.I.M.P.) - University of Wounds
Bari, Piazza Giulio Cesare, Policlinico, Bari, 70124, Italy;
and Carlo P. Campobasso, MD, PhD*, Department of
Health Sciences (Di.S.pe.S), University of Molise, via De
Falconer, Erin E. MFS*, Danielle L. McLeod, MFS, and Suicidal Hangings: A Growing Trend in 368
Todd M. Luckasevic, DO, Northern Virginia Office of the Northern Virginia
Fairfax, VA 22032
Falconer, Erin E. MFS, Danielle L. McLeod, MFS, and Handgun to the Head: Suicide Trends in 369
Todd M. Luckasevic, DO*, Northern Virginia Office of the Northern Virginia
Fairfax, VA 22032
Fang, Rixun PhD, Christine Shulse, BS, Pius Brzoska, PhD, Analysis of Gene Expression Patterns to 365
and Manohar R. Furtado, PhD*, Applied Biosystems, 850 Identify Tissue and Body Fluid Specific
Lincoln Center Dr., Foster City, CA 94404; and Chitra F. mRNA Species Using Real Time PCR Assays
Manohar, PhD, Lawrence Livermore National Laboratory,
7000 East Ave, Livermore, CA 94550
Fanton, Laurent MD*, Alain Tabib, MD, Stéphane Tilhet- Sudden Cardiac Death in Professional Sports 218
Coartet, MD, Maire Joly, and Daniel Malivier, MD, Institut Persons: Natural vs. Anabolic Steroid Induced
of Legal Medicine, 12 Avenue Rockefeller, Lyon, 69008, Lesions and Experimental Rabbit Model
FRANCE
Fanton, Laurent MD, Alain Tabib, MD, Stéphane Tilhet- Sudden Cardiac Death in Professional Sports 227
Coartet, MD, Maire Joly, and Daniel Malicier, MD*, Persons: Natural vs. Anabolic Steroid Induced
Institut Medico Legal, 12 Avenue Rockfeller, Lyon, 69007, Lesions, and Experimental Rabbit Model
FRANCE
Index 155
Farrugia, Audrey MD*, Bertrand Ludes, PhD, Annie Migration of a Bullet in the Lumbosacral 205
Geraut, MD, and Jean Sebastien Raul, PhD, Medicolegal Spinal Canal: A Case Report and Review of
Institute, 11 Rue Humann, Strasbourg, 67065, FRANCE the Literature
Farrugia, Audrey MD*, Christine Keyser, PhD, and Detection of KCNQ1 Genetic Variations by 120
Bertrand Ludes, MD, PhD, Institut de Medecine Legale, 11 High Resolution Melting Analysis for the
rue Humann, Strasbourg Cedex, 67085, FRANCE Diagnosis of Channelopathies in Postmortem
Investigations
Farrugia, Audrey MD, Annie Geraut, MD*, Bertrand Head Injury Associated With Posterior 186
Ludes, MD, PhD, and Jean Sebastien Raul, MD,PhD, Distraction of the Spine in a 4.5 Months Old
Medico-Legal Institute, 11 Rue Humann, Strasbourg, Baby: Analysis of the Lesional Mechanisms
67065, FRANCE
Felo, Joseph A. DO*, Cuyahoga County Coroner’s Office, Sudden Death Due to Bilateral Spontaneous 398
11001 Cedar Avenue, Cleveland, OH 44106 Pneumothoraces in a Marijuana User
Fernandes, John R. MDCM*, Regional Forensic Unit, 237 To Rave or Not to Rave: A Report of Three 518
Barton Street East, Hamilton, Ontario, Canada; Marcella Fatal GHB Poisonings
F. Fierro, MD, Office of Chief Medical Examiner, 400 East
Jackson Street, Richmond, VA; and James Cairns, DRCOG,
Office of Chief Coroner, 26 Brenville Street, Toronto,
Ontario, Canada
Ferraro, C. PhD*, Long Island University, Brookville, NY; Coming of Age in Memphis... How Our 577
O’Brian C. Smith, MD, Steven A. Symes, PhD, Cynthia D. Children Die
Gardner, MD, and T.A. Campbell, MD, University of
Tennessee, Memphis, 1060 Madison Avenue Memphis, TN
Ferraro, C. PhD, University of Long Island, Brookville, NY; The Child Abuse Works of Ambroise 576
and O’Brian C. Smith, MD*, Steven A. Symes, PhD, Tardieu…Had We Only Taken French
Cynthia D. Gardner, MD, and T.A. Campbell, MD,
University of Tennessee, Memphis, 1060 Madison Avenue
Memphis, TN
Ferraro, Chantal PhD*, Long Island University at Escalated Homicide: Cultural Changes 532
Brookeville, Brookeville, NY; and O'Brian C. Smith, MD, Produce a New Type of Child Death
University of Tennessee at Memphis, 1060 Madison Avenue,
Memphis, TN
Ferraro, Chantal PhD*, Long Island University, Making the Best of Death 168
Sociology/Anthropology, CW Post, Brookville, NY 11548;
and O. C. Smith, MD, Conscience and Science in Medicine,
Atoka, TN 38004
Ferris, James A.J. MD*, Department of Forensic Child Abuse vs. Accidental Falls: Judicial 78
Pathology, LabPlus, 85 Park Road, Grafton, PO Box Outcomes in Alleged Child Abuse
110031, Auckland, NEW ZEALAND
Fierro, Marcella F. MD*, Fierro Forensics, 8702 Grant Solicitations: New Opportunities for 114
Berwickshire Drive, Henrico, VA 23229-7833 Medical Examiners and Coroners – Tips on
the Process
Filippi, John E. DDS*, 1325 North 127th Avenue, Omaha, Pathology/Odontology: The Team Approach 168
NE 68154; and Mary H. Dudley, MD*, Jackson County to a Forensic Autopsy
Medical Examiner’s Office, 660 East 24th Street, Kansas
City, MO 64108
Index 156
Filograna, Laura MD*, and Steffen G. Ross, MD, Institute Blood Aspiration as a Vital Sign Detected by 104
of Forensic Medicine Center of Forensic Imaging CT Imaging and Postmortem CT Guided
“Virtopsy”, Buehlstrasse 20, Berne, AL 3012, Biopsy
SWITZERLAND; Stephan Bolliger, MD, and Tanja
Germerott, MD, University of Berne Institute of Forensic
Medicine, Buehlstrasse 20, Bern, AL 3012,
SWITZERLAND; Patricia M. Flach, MD, Institute of
Forensic Medicine Bern / Virtopsy, Buehlstrasse 20, Bern,
SWITZERLAND; and Michael Thali, MD, University of
3012, SWITZERLAND
Filograna, Laura MD*, Institute of Forensic Medicine, Virtopsy Project - Postmortem Needle Biopsy 108
Centre of Forensic Imaging and Virtopsy, Buehlstrasse, 20, of the Lungs: A Feasible Tool for the Study of
Berne, SWITZERLAND; Stephan Bolliger, MD, University Fat Embolism as Vital Reaction
of Berne Institute of Forensic Medicine, Buehlstrasse 20,
Bern, AL 3012, SWITZERLAND; Danny Spendlove, MD,
Institute of Forensic Medicine, Centre of Forensic Imaging
and Virtopsy, Buehlstrasse, 20, Berne, AL 3012,
SWITZERLAND; and Ulrich Preiss, MD, and Michael
Thali, MD, University of Bern, Institute of Forensic
Medicine, Buehlstrasse 20, Bern, 3012, SWITZERLAND
Fiore, Stephany MD*, and Vernon Armbrustmacher, MD, The Clinical and Pathological Features of 564
Office of Chief Medical Examiner, 520 First Avenue, New Fatal Concussion
York, NY
Fiore, Stephany MD*, County of Sacramento, Coroner’s Does Embalming Impact Vitreous Glucose 109
Office, 4800 Broadway, Suite 100, Sacramento, CA 95820- Levels?
1530; and Charlotte A. Wacker, MS*, University of
California, Davis Body Donation Program, 4800
Broadway, Suite 100, Sacramento, CA 95820
Flach, Patricia M. MD; Steffen G. Ross, MD; Garyfalia Massive Systemic Fat Embolism Detected by 25
Ampanozi, MD; Stephan A. Boliger, MD; Gary M. Hatch, Postmortem Imaging and Biopsy
MD; Michael Thali, MD; and Tanja Germerott, MD,
Institue of Forensic Medicine, University of Bern- Virtopsy,
Buehlstrasse 20, Bern 3012 SWITZERLAND
Flach, Patricia Mildred MD*, and Steffen G. Ross, MD, Ante- and Postmortem In-Human Cocaine 45
Institute of Forensic Medicine, Center of Forensic Imaging Packs Detected by Computed Tomography
“Virtopsy”, Buehlstrasse 20, Bern, 3012, SWITZERLAND;
Garyfalia Ampanozi, MD, Ulrich Preiss, MD, Tanja
Germerott, MD, Gary M. Hatch, MD, and Michael Thali,
MD, University of Bern, Institute of Forensic Medicine,
Buehlstrasse 20, Bern, 3012, SWITZERLAND; and Michael
Patak, MD, University of Bern, Radiology, Freiburgstrasse,
Florez, Luisa F. MD*, Baylor College of Medicine, One An Unusual Case of Sudden Death 312
Baylor Plaza, Houston, TX 770303; Mary Anzalone, MD,
Spanish Trail, Houston, TX 77054; and Carolina Gutierrez,
MD, and Mario Cervantes, MD, Baylor College of
Medicine, One Baylor Plaza, Houston, TX 77030; Kathy
Haden-Pinneri, MD, Maximillian Buja, MD, and Luis A.
Sanchez, MD, Harris County Medical Examiner’s Office,
Index 157
Forbes, Shari L. BSc, PhD*, Centre for Forensic Science, Factors Affecting the Formation of Adipocere 399
University of Western Australia, M420, 35 Stirling in Soils
Highway, Crawley, WA 6009, Australia; Barbara Stuart,
PhD, Department of Chemistry, Materials and Forensic
Science, University of Technology, Sydney, PO Box 123,
Broadway, Australia, 2007; Boyd Dent, PhD, Department
of Environmental Sciences, University of Technology,
Sydney, PO Box 123, Broadway, Australia, 2007; and Ian
R. Dadour, BSc, PhD, Centre for Forensic Science,
University of Western Australia, M420, 35 Stirling
Highway, Crawley, WA 6009, Australia
Forbes, Shari L. PhD*, Helene LeBlanc, PhD*, Katelynn Decomposition in a Closed Vehicle 45
Perrault, BSc, and Alicia Buetter, BSc, University of Environment in Southern Ontario
Ontario Institute of Technology, 2000 Simcoe Street North,
Oshawa, ON L1H7K4, CANADA
Forbes, Shari L. PhD*, University of Ontario Institute of Succession of Microfungi in Grave Soil 267
Technology, 2000 Simcoe Street North, Oshawa, Ontario
L1H 7K4, Canada; Trevor Lumley, PhD, Environment
Canada, Environment Technology Centre, 335 River Road,
Ottawa, Ontario K1A0H3, Canada; and David Carter,
PhD, University of Nebraska Lincoln, 202 Plant Industry
Forbes, Shari L. PhD*, University of Ontario Institute of The Biochemical Alteration of Soil by 244
Technology, 2000 Simcoe Street North, Oshawa, Ontario, Decomposition Products
L1H 7K4, CANADA; David O. Carter, PhD, University of
Nebraska, Department of Entomology, 202 Plant Industry
Building, Lincoln, NE 68583-0816; and Laura A.
Benninger, BSc, University of Ontario Institute of
Technology, 2000 Simcoe Street North, Oshawa, Ontario,
L1H 7K4, CANADA
Forbes, Shari L. PhD*, University of Ontario Institute of Characterization of Adipocere Formation in 354
Technology, Faculty of Science, 2000 Simcoe Street, N, Animal Species
Oshawa, Ontario L1H 7K4, Canada; and Barbara H.
Stuart, PhD, and Boyd B. Dent, PhD, University of
Technology, Sydney, Department of Environmental
Sciences, PO Box 123, Broadway, NSW 2007, Australia
Fornes, Paul PhD*, and Dominique Lecomte, MD, The Normal Heart Weight: Diagnostic 523
Forensic Institute of Paris, Medical School Cochin Port Criteria for Cardiomyopathies
Royal, Paris, France
Fornes, Paul PhD*, and Dominique Lecomte, MD, Normal Fat in the Right Ventricle vs. 523
Forensic Institute of Paris, Medical School Cochin Port Arrhythmogenic Right Ventricular
Royal, Paris, France Cardiomyopathy/Dysplasia
Fracasso, Tony MD*, University Center of Legal Medicine, Morphological Identification of Right 27
CMU - CURML, Rue Michel-Servet 1, Geneva, 1211, Ventricular Ischemia Determining Right
SWITZERLAND; Heidi Pfeiffer, PhD, University Hospital Heart Failure in Cases of Fatal Pulmonary
Münster, Röntgenstr 23, Münster, 48149, GERMANY; Thromboembolism
Cristina Sauerland, University of Münster, Domagstr 9,
Münster, 48149, GERMANY; and Andreas Schmeling, PhD,
University Hospital Münster, Röntgenstr. 23, Münster,
48149, GERMANY
Index 158
Franco, Dori M. DO*, OAFME, 1413 Research Boulevard, Case Report of a Fatal Intoxication by 9
Building 102, Rockville, MD 20904; Zabiullah Ali, MD, Nucynta
Barry S. Levine, PhD, Office of the Chief Medical
Examiner, 111 Penn Street, Baltimore, MD 21201; Robert
A. Middleberg, PhD, Annette Ervin, BS, Francis X.
Diamond, BS, NMS Labs, 3701 Welsh Road, Willow Grove,
PA 19090; and David R. Fowler, MD, Office of the Chief
Freeman, Michael D. PhD*, Oregon Health and Science Probability and Pathological Findings in 308
University School of Medicine, 205 Liberty Street, Suicidal Versus Homicidal Hanging Deaths:
Northeast, Suite B, Salem, OR 97301 A Case Study in Forensic Epidemiology
Frolov, Victor V. MD*, Jeffrey M. Jentzen, MD, and John Sudden Death of a Fourteen-Year-Old Female 389
R. Teggatz, MD, Milwaukee County Medical Examiner With Hb S-C Disease
Office, 933 West Highland Avenue, Milwaukee, WI 53233
Fujikawa, Amanda BS*, University of Nebraska-Lincoln, The Activity of Calliphora vicina (Diptera: 178
202 Entomology Hall, Lincoln, NE 68583-0816; Larry Calliphoridae) Can Alter the Morphology and
Barksdale, MA, Lincoln Police Department, 575 South 10th Presumptive Chemistry of High Impact
Street, Lincoln, NE 68508; and David O. Carter, PhD, Bloodstains
University of Nebraska-Lincoln, Department of
Entomology, 202 Entomology Hall, Lincoln, NE 68583-
0816
Fusaro, Aldo J. DO*, J. Scott Denton, MD, Adrienne E. An Accident Waiting to Happen: The Chicago 393
Segovia, MD, Edmund R. Donoghue, MD, and Eupil Choi, Porch Collapse of 2003
Harrison Street, Chicago, IL 60612; J. Lawrence Cogan,
MD, LA County Medical Examiner’s Office, 1104 North
Mission Road, Los Angeles, CA 90033; Mitra B. Kalelkar,
Gaffney-Kraft, Maryanne DO*, Hong Yin, MD, and Patrick Sudden Death Due to Idiopathic Giant Cell 566
E. Lantz, MD, Department of Pathology, Wake Forest Myocarditis: Case Report and Literature
University Baptist Medical Center, Medical Center Review
Garber, Darryl J. MD* and Irwin Golden, MD, County of Use of the Impact Baton or So-Called 446
Los Angeles Department of Coroner/Medical Examiner, “Rubber Bullet” as Less Lethal Force in Air
1104 N Mission Road, Los Angeles, CA 90033; vs. Water
Lakshmanan Sathyavagiswaran, MD, Chief Medical
Examiner-Coroner, Los Angeles County, 1104 N Mission
Garber, Darryl J. MD*, Imperial County, California, Los Sudden Death in a Calipatria State Prison 392
Angeles County Coroner’s Office/Department of Medical Inmate With a Single Coronary Artery
Examiner, 1104 North Mission Road, Los Angeles, CA
90033; and Henry Proo, Imperial County, California, 328
Applestill Road, El Centro, CA 92243
Garza-Leal, Jose A. MD*, Alberto Montemayor-Martinez, Massive Fat Pulmonary Embolization 222
MD*, and Magadalena Gomez*, Medfor-Lab S.A. DE C.V., Secondary to a Liposuction Procedure With
Cholula 106, Colonia Mitras Centro, Monterrey, 64460, Tumescent Technique Diagnosed Postmortem
MEXICO in an Embalmed and Buried Body
Index 159
Gaudin, Arnaud MD*, and Nathalie Jousset, MD, Service Firearm Injuries in Angers: 1990 - 2000 382
de Médecine Légale, Centre Hospitalier Universitaire - 4
Rue Larrey, Angers, 49100 Cedex 01, France; Gilles
Tournel, MD, Service de Médecine Légale, Institut Médico-
Légal - Place Deverdun, Lille, 59000, France; and Michel
Penneau, MD, and Clotilde Rougé-Maillart, MD, Service de
Médecine Légale, Centre Hospitalier Universitaire - 4 rue
Larrey, Angers, 49100 Cedex 01, France
Gerlach, Kathrin MD*, Department of Legal Medicine, Prevention of Accidental Strangulation of 350
Pestalozzistrasse 22, Basel, 4056, Switzerland; Beat Children in Their Sleeping Bags:
Horisberger, MD, Department of Legal Medicine, Rue du Development of a New Sleeping Bag
Bugnon 2, CH-1005 Lausanne, Switzerland, Walter Bar,
MD, Department of Legal Medicine, Winterthurerstrasse
190, CH-8091 Zürich, Switzerland; and Volker Dittmann,
MD, and Daniel Wyler, MD, Department of Legal
Medicine, Pestalozzistrasse 22, CH- 4056 Basel,
Switzerland
Gherardi, Mirella MD*, Gabriella Costantini, and Marina A Summer Carrion Study in the North of Italy 502
Caligara, Institute of Legal Medicine - University of Milan,
Via Mangiagalli, 37, Milan, Italy; Giancarlo Belluzzi,
Veterinary Service, ASL, via Ghinaglia, 6, Cremona, Italy;
and Massimo Boldini, Experimental Zooprophylactict
Institute, Cremona, Italy
Gherardi, Mirella MD*, Marina Caligara, PharmD, and Comparison of Drug Concentration in 575
Luca Sironi, PharmD, PhD, Institute of Legal Medicine - Blowflies (Diptera: Calliphoridae) and
University of Milan, Via L. Mangiagalli, 37, Milan, Italy Human Tissues
Gibelli, Daniele MD*, Istituto di Medicina Legale e delle Application of Forensic Engineering for the 146
Assicurazioni di Milano, V. Mangiagalli, 37, Milan, ITALY; Reconstruction of Manner of Death: A
Angela Cantatore, BE, and Remo Sala, BE, Politecnico di Nautical Accident
Milano, P.zza Leonardo da Vinci, Milan, ITALY; and
Salvatore Andreola, MD, and Cristina Cattaneo, PhD,
Istituto di Medicina Legale e delle Assicurazioni di Milano,
V. Mangiagalli, 37, Milan, ITALY
Gibo, David L. PhD*, and Deana Hathout, BSc, University A Field Study of the Foraging Behavior of 388
of Toronto at Mississauga, 3359 Mississauga Road North, Blowfly Maggots
Mississauga, Ontario L5L 1C6, Canada; Brent Walker, BA,
Conestoga College, Law and Security/Police Foundations,
School of Health Sciences and Community Services, 299
Doon Valley Drive, Kitchener, Ontario N2G 4M4, Canada;
and Brian Dixon, PhD, 1645 Howat Crescent, Mississauga,
Ontario L5J 4G6, Canada
Gill, James R. MD*, and Charles Catanese, MD, New York Sharp Force Injury Fatalities in New York 556
City of Chief Medical Examiner and Department of City
Forensic Medicine, 520 First Avenue, New York, NY
Gill, James R. MD*, Office of Chief Medical Examiner, 520 Fatalities Occurring With Ingestion of 142
First Avenue, New York, NY 10016; and Kenneth R. Alper, Ibogaine
MD, New York University School of Medicine, 403 East
34th street, 4th Floor EPC, New York, NY 10016
Gill, James R. MD, Office of Chief Medical Examiner’s Firearm Deaths by Law Enforcement in New 236
Office, 520 First Avenue, New York, NY 10016; and Melissa York City
Pasquale-Styles, MD*, New York City, Office of Chief
Medical Examiner’s Office, 599 Winthrop Street, Brooklyn,
NY 11203
Index 160
Gill, James R. MD,and Susan F. Ely, MD*, OCME, 520 Fatal Pulmonary Thromboembolism and 394
First Avenue, New York, NY 10016 Hereditary Thrombophilias
Gilliland, M.G.F. MD*, Brody School of Medicine at East Investigations and Eye Findings in Crush and 477
Carolina University, Department of Pathology, Forensic Other Accidental Traumas in Lethally Injured
Division, Greenville, NC 27858-4354 Infants and Children
Gilliland, M.G.F. MD*, Brody School of Medicine at East Infant Death Evaluation: What is the 69
Carolina University, Pathology & Lab Medicine, Brody 7S- Constellation of Abusive Injuries?
Gilliland, M.G.F. MD*, Brody School of Medicine at East What Is the Frequency of Finding Lethal 79
Carolina University, Pathology & Lab Medicine, Brody 7S- Injury When a SIDS-Like Death Is Reported?
Gilliland, M.G.F. MD*, Brody School of Medicine at East How Often is Pre-Existing Disease Found in 163
Carolina University, Pathology & Laboratory Medicine, Child Deaths?
Brody Building, Greenville, NC 27858-4354
Gilliland, M.G.F. MD*, Brody School of Medicine at East The Evidence-Based Medicine Paradigm Shift 431
Carolina, Department Pathology and Laboratory Medicine, and Forensic Pathology
Brody 7 S 10, Greenville, NC 27834
Gilliland, M.G.F. MD*, Brody School of Medicine at ECU, Multiple Histories: A Statistically Significant 224
Pathology & Lab Medicine, Brody Building, Greenville, NC Indicator of Non-Accidental Injury in
27858-4354 Children
Gilliland, M.G.F. MD*, Brody School of Medicine East Extent and Distribution of Retinal 529
Carolina University Department of Pathology and Hemorrhages in Abusive and Non-Abusive
Laboratory Medicine, Brody 7510, Greenville, NC Head Injury
Gilliland, M.G.F. MD*, Brody SOM at ECU, Department The Likelihood of Inflicted Injury Is Better 319
Pathology and Laboratory Medicine, Brody 7 S 10, Evaluated by the Use of Inconsistent Histories
Greenville, NC 27858 With the Constellation of the Triad of
Findings: Subdural Hemorrhage, Brain
Swelling, and Retinal Hemorrhages
Gillland, M.G.F. MD*, Brody SOM at East Carolina Perimacular Circular Folds in the Eyes of 378
University, Department of Pathology & Laboratory Injured Children
Medicine, Brody 7 South 10, Greenville, NC 27834
Gilmore, Kristin MD*, Department of Pathology, Kings Intracranial Internal Carotid Laceration at the 515
County Hospital, Brooklyn, NY; David Kindleberger, MD, Site of an Atherosclerotic Plaque: A Case
SUNNY Health Science Center College of Medicine, Report
Brooklyn, NY; and Charles A. Catanese, MD, Office of the
Chief Medical Examiner, Brooklyn, NY
Godby, Justin M. BS*, Marshall University, 1401 Forensic Viral Testing of Adult Mosquitoes Collected 409
Science Drive, Huntington, WV 25701 in West Virginia for West Nile Virus Using
NASBA Assay
Goff, M. Lee PhD*, Division of Natural Sciences and Insects and Time Since Death: What Do We 298
Mathematics, Chaminade University of Honolulu, 3140 Really Estimate?
Waialae Avenue, Honolulu, HI 96816-1578
Gofton, Jeffery G. MD*, and Wendy M. Gunther, MD*, Stippling Mimics — Differentiating 16
Office of the Chief Medical Examiner, Tidewater District, Pseudostippling From Stippling: A Report of
830 Southampton Avenue, Suite 100, Norfolk, VA 23510- Four Cases
1046
Gofton, Jeffery J. MD*, 901 North Stonewall, Oklahoma Deaths During Police Chases 176
City, OK 73117-1218; and Wendy M. Gunther, MD*, Office
of the Chief Medical Examiner, Tidewater District, 830
Southampton Avenue, Suite 100, Norfolk, VA 23510-1046
Index 161
Gofton, Jeffery J. MD, 901 North Stonewall, Oklahoma Deaths Involving Stress 175
City, OK 73117- 1218; and Wendy M. Gunther, MD*,
Office of the Chief Medical Examiner, Tidewater District,
830 Southampton Avenue, Suite 100, Norfolk, VA 23510-
1046
Goldfeder, Lara B. BS, MD*, James R. Gill, MD, and The Happy Land Homicides: 87 Deaths Due 512
Marina Stajic, PhD, Office of the Chief Medical Examiner, to Smoke Inhalation
520 First Avenue, New York, NY
Goldschmidt, Ariel MD*, and Jane W. Turner, MD, St. Hypertensive Heart Disease May Compound 232
Louis City Medical Examiner’s Office, 1300 Clark Street, the Risk of Death From Medication and
St. Louis, MO 63103 Contrast Media-Induced Anaphylactic Shock
Goldschmidt, Ariel MD*, Jackson County Medical Case Example: Cerebral Dural Venous Sinus 83
Examiner’s Office, 1700 Forum Boulevard, Apartment 509, Thrombosis Following a Motor Vehicle
Columbia, MO 65203; Adrian Baron, MD, and Megan Accident
Minniear, BS, 660 East 24th Street, Kansas City, MO 64108
Goldschmidt, Ariel MD*, Steven T. Hensley, and Mary H. Commotio Cordis: A Forensic Science 170
Dudley, MD, Jackson County Medical Examiner’s Office, Perspective
660 East 24th Street, Kansas City, MO 64108
Gonsoulin, Morna L. MD*, Ashraf Mozayani, PhD, Terry Caveat Emptor: A Series of Deaths Related to 366
Danielson, PhD, and Luis A Sanchez, MD, Harris County Subcutaneous Silicone Injections in
Medical Examiner’s Office, 1885 Old Spanish Trail, Transgender Males
Houston, TX 77054-2098
Goodson, Mark E. PE*, 1500 Spencer Road, Denton, TX Vehicular Emissions Systems and Their 122
76205-5105 Effects on Suicides and Attempted Suicides
by Carbon Monoxide
Gorman, Emily F. MD*, University of Alabama at The Relationship of Back Surgery to 12
Birmingham, Department of Pathology, P220 West Overdose at Autopsy
Pavilion, Birmingham, AL 35233- 7331; Robert M. Brissie,
MD, Medical Examiner Office, 1515 6th Avenue, South,
Birmingham, AL 35233; and Gregory G. Davis, MD,
Jefferson County Medical Examiner’s Office, 1515 6th
Avenue, South, Room 220, Birmingham, AL 35233-1601
Gormley, William T. MD, PhD*, and Anna Noller, PhD, Risk Factors for Pedestrian Deaths 256
Office of the Chief Medical Examiner, Commonwealth of
Virginia, 400 East Jackson Street, Richmond, VA, 23219
Gormley, William T. MD, PhD*, Deborah Kay, MD, and Correlations for Expected Heart Weight 292
Anna Noller, PhD*, Office of the Chief Medical Examiner,
Commonwealth of Virginia, 400 East Jackson Street,
Richmond, VA 23219
Gormley, William T. PhD*, Office of the Chief Medical Fentanyl-Related Drug Deaths in Virginia 175
Examiner, 400 East Jackson Street, Richmond, VA 23219; (2000-2006)
and Anna Noller, PhD, Virginia Department of Health,
Office of the Chief Medical Examiner, 400 East Jackson
Index 162
Grabherr*, Silke Centre Universitaire Romand de Postmortem CT-Angiography Using 124
Médecine Légale, Rue du Bugnon 21, Lausanne, 1011, Angiofil®
Bugnon 46, Lausanne, , SWITZERLAND; Alexandre
Dominguez, Haute Ecole Cantonale Vaudoise de la Santé,
Filière Technique en Radiologie Médicale, Avenue du
Beaument 21, Lausanne, , SWITZERLAND; Richard
Dirnhofer, and Beat Steger, Fumedica AG, Luzernerstrasse
91, Muri, 5630, SWITZERLAND; Barbara Sollberger, and
Erich Gygax, Department for Cardiovascular Surgery,
University Hospital Bern, Hochschulstrasse 4, Bern, 3012,
SWITZERLAND; Reto Meuli, Service de Radiodiagnostic et
de Radiologie Interventionnelle, Rue du Bugnon 46,
Lausanne, 1011, SWITZERLAND; and Patrice Mangin,
MD, PhD, Centre Universitaire, Romand de Medecine
Legale, Rue du Bugnon 21, Lausanne, CH-1011,
SWITZERLAND
Gramlich, Ira Dieter Patzelt, MD, and Martin Bauer, MD*, Quantitative Measurement of Ribonucleic 525
Institute of legal Medicine, University of Wuerzburg, Acid Degradation as a Possible Indicator of
Versbacher Str. 3, Wuerzburg, Germany Postmortem Interval
Grant, Jami R. PhD*, University of Baltimore, Forensic Death in Custody: A Historical Analysis 359
Studies, 1420 North Charles Street, Baltimore, MD 21201;
Pamela E. Southall, MD*, and David R. Fowler, MD,
Maryland State Office of the Chief Medical Examiner, 111
Penn Street, Baltimore, MD 21201; and Shauna R. Scott,
University of Baltimore, Forensic Studies, 1420 N Charles
Grassberger, Martin MD, PhD*, and Christina Stein, PhD, Evaluation of a Novel Tagging and Tissue 382
Department for Forensic Medicine, Medical University of Preservation System for Human Remains
Vienna, Sensengasse 2, Vienna, A-1090, Austria; Stefan
Hanslik, PhD, Identilab Forensic Services, Handelskai 94-
96, Vienna, A-1200, Austria; and Manfred Hochmeister,
MD, Department for Forensic Medicine, Medical University
Index 163
Green, Jody L. PhD*, Denver Health Rocky Mountain Malicious Use of Nonprescription Cough and 167
Poison & Drug Center, 777 Bannock Street, MC 0180, Cold Medications in Children
Denver, CO 80204; William Banner, PhD, Oklahoma
Poison Control Center, 4822 East 112th Street, Tulsa, OK
74137; Randall Bond, MD, Cincinnati Drug & Poison
Information Center, 660 Lincoln Avenue, Cincinnati, OH
45206; Ralph Kauffman, MD, University of Missouri-
Kansas City, Department of Pediatrics, 2919 NW 86th
Terrace, Kansas City, MO 64154; Anthony Manoguerra,
PharmD, University of Californis at San Diego, School of
Pharmacy, 9500 Gilman Drive, MC 0657, La Jolla, CA
92093; Robert B. Palmer, PhD, Toxicology Associates,
2555 South Downing Street, Suite 260, Denver, CO 80210;
Ian M. Paul, MD, Penn State College of Medicine, 500
University Drive, HMC; Pediatrics; H085, Hershey, PA
17033; Barry Rumack, MD, University of Colorado,
Anshutz Medical Campus, Denver, CO 80045; David C.
Winston, PhD, Forensic Science Center, 2825 East District
Street, Tucson, AZ 85714; and Richard C. Dart, PhD,
Denver Health Rocky Mountain Poison & Drug Center, 777
Bannock Street, MC 0180, Denver, CO 80204
Green, Valerie S. MD*, Mary L. Anzalone, MD, Dwayne A. Death by Cue in the Parietal Pocket: An 282
Wolf, MD, PhD, and Luis A. Sanchez, MD, Harris County Unusual Injury Pattern Caused by the Use of a
Medical Examiner’s Office, 1885 Old Spanish Trail, Blunt Object
Houston, TX 77054
Green, Valerie S. MD*, Stephen K Wilson, MD, Terry J. Ethyl Chloride Toxicity in a Case of 220
Danielson, PhD, Ashraf Mozayani, PhD, and Luis A. Unsuspecting Abuse
Sanchez, MD, Harris County, Medical Examiner’s Office,
Griffin, Sean M. MS*, and Donna M. Hunsaker, MD, Office Diesel Fumes Do Kill: A Case of Fatal 426
of the Chief Medical Examiner and the University of Carbon Monoxide Poisoning Directly
Louisville Department of Pathology and Laboratory Attributed to Diesel Fuel Exhaust
Medicine, 810 Baxter Avenue, Louisville, KY 40204-1702;
Kiran Charturvedi, MD, University of Kentucky Medical
Center Department of Pathology and Laboratory Medicine,
University of Kentucky, 800 Rose Street, Lexington, KY
40536; Michael K. Ward, BS, KY State Forensic Toxicology
Laboratory, 100 Sower Boulevard, Frankfort, KY 40601;
and Andrea R. Terrell, PhD, American Institute of
Toxicology, 2265 Executive Drive, # A, Indianapolis, IN
46241
Grillo*, Massimo Department of Biotechnology and Legal Sudden Cardiac Death Due to Atrophy and 204
Medicine – Section of Legal Medicine, Via del Vespro, n. Fibrous and/or Fatty Substitution of Right
129, Palermo, 90127, ITALY; Pierangela Fleres, MD, and Ventricle: Pathologic Substrates and
Cettina Sortino, Via del Vespro, n. 129, Palermo, , ITALY; Postmortem High Resolution MRI
Antonino Bonifacio, MD, Institute of Legal Medicine, Via
del Vespro, n. 129, Palermo, 90127, ITALY; Livio Milone,
PhD, Via del Vespro, n. 129, Palermo, 90127, ITALY;
Paolo Procaccianti, PhD, Palermo University, Via del
Maresi, PhD, Via del Vespro, n. 129, Palermo, 90127,
ITALY
Index 164
Grillo, Massimo MD*, Filippo M. Cascino, MD*, Method of Concealment of Corpses in Mafia 5
Department of Biotechnology and Legal Medicine, Section Related Homicides: Melting in Strong Acids
of Legal Medicine, Via del Vespro 129, Palermo, 90127,
ITALY; and Valentina Murgo, MD, Palermo University, Via
Del Vespro, n. 127, Palermo, 90100, ITALY; Livio Milone,
Via Del Vespro, n. 127, Palermo, 90100, ITALY
Grisbaum, Gretchen A. JD*, Quick & Associates, Inc., Abuse of Prescription Narcotics: A Look 316
21449 Marion Lane, Suite 6, Mandeville, LA 70471; and Beyond Prescription Monitoring Programs
Karen Ross, MD, Jefferson Parish Forensic Center, 2018
8th Street, Harvey, LA 70058
Gromb, Sophie MD, JD, PhD*, and Koffi Bott, Service of Postmortem Findings in 22 Victims Due to 514
Forensic Sciences, University of Bordeaux, Bordeaux, Two Grain Silo Explosions in France
France; and Alain Miras, MD, University of Lyon, IML
Avenue Rockefeller, Lyon, France
Gromb, Sophie PhD*, Nadia Khaldi, MD, Larbi Benali, Unsuspected Pheochromocytoma Discovered 413
MD, Mathurin Djodjo, MD, and Alain Miras, PhD, During Autopsy After Sudden and
Department of Forensic Medicine - EA 3676 - IFR 99 of Unexpected Death in an Expectant Mother
Public Health, CHU Pellegrin - Place Amélie Raba- Léon,
Bordeaux, 33076, France
Gruszecki, Amy C. DO*, Jefferson County Coroner Medical The Relationship of Drug Abuse to 403
Examiner Office, 1515 6th Avenue South, Suite 611, Unexplained Sudden Death
Birmingham, AL 35233; Gerald McGwin, Jr., PhD,
Department of Epidemiology, School of Public Health,
University of Alabama, Birmingham, AL 35233; C. Andrew
Robinson, PhD, Department of Pathology, Forensic
Division, University of Alabama, Birmingham, AL 35233;
and Gregory G. Davis, MD, MSPH, Jefferson County
Coroner Medical Examiner Office, 1515 6th Avenue South,
Suite 611, Birmingham, AL 35233
Gruszecki, Amy C. MSFS, DO* and Gregory G. Davis, MD, Unexplained Sudden Death and the 454
MSPH, Jefferson County Coroner/Medical Examiner Likelihood of Drug Abuse
Office, 1515 Sixth Avenue South, Room 611, Birmingham,
AL 35233-1601
Guenthner, Kanthi von MD*, Chief Medical Examiner, Elderly Neglect/Abuse 510
Department of the Medical Examiner, City and County of
Honolulu, 835 Iwilei Road, Honolulu, HI
Gulmen, Mete K. PhD*, Cukurova University School of Evaluation of Cardiac Conduction System 20
Medicine, Department of Forensic Medicine, Adana, 01330, Pathologies in Sudden Deaths in Adana
TURKEY; Ramazan Karanfil, MD, Kahramanmaras Sutcu Region
Imam University, School of Medicine, Department of
Forensic Medicine, Kahramanmaras, 46100, TURKEY; and
Ahmet Hilal, MD, and Necmi Cekin, MD, Cukurova
University School of Medicine, Department of Forensic
Medicine, Balcali, Adana, 01330, TURKEY
Gumpeni, Pramod MD*, Jason M. Wiersema, PhD, and Pathologic and Anthropologic Manifestations 68
Luis A. Sanchez, MD, Harris County Institute of Forensic of Documented Repetitive Blunt Trauma in a
Sciences, 1885 Old Spanish Trail, Houston, TX 77054 Child Abuse Case
Gunther, Wendy M. MD*, Department of Legal Medicine, Sudden Death in a Healthy 37-Year-Old Man 332
Virginia Commonwealth University, Medical College of While Driving: Spontaneous Dissection of the
Virginia, 1101 E Marshall Street, Richmond, VA 23298- Posterior Segment of the Right Coronary
0568; and Jonrika M. Malone, MD, Office of the Chief Artery
Index 165
Gunther, Wendy M. MD*, Department of Legal Medicine, “Coca-Cola Man”: Sudden Death in a Jailed 362
Virginia Commonwealth University, Medical College of Mentally Retarded Man After an Altercation
Virginia, 1101 East Marshall Street, Richmond, VA 23298- Involving Police
0568
Gunther, Wendy M. MD*, Leah L. Bush, MD, Elizabeth L. Combined Types of Violence in Child Abuse: 320
Kinnison, MD, Department of Legal Medicine, Virginia Report of Three Cases
Commonwealth University, Medical College of Virginia,
Tidewater Office of the Chief Medical Examiner,
Commonwealth of Virginia, 830 Southampton Avenue, Suite
100, Norfolk, VA 23510-1046; and Karen B. Looman, DO,
Tidewater Office of the Chief Medical Examiner, 830
Gunther, Wendy M. MD*, Office of the Chief Medical Too Many Causes of Death: What’s the 447
Examiner and Department of Legal Medicine, Virginia Manner?
Gunther, Wendy M. MD*, Office of the Chief Medical Sternal Shard From Bystander Bullet: A Rare 345
Examiner, Tidewater District, 830 Southampton Avenue, Mechanism of Homicide
Gunther, Wendy M. MD*, Office of the Chief Medical Death of a Bodybuilder: A Case Report of 139
Examiner, Tidewater District, 830 Southampton Avenue, Mixed Drug Overdose With Lethal Gamma-
Suite 100, Norfolk, VA 23510-1046 Hydroxybutyrate Level
Gunther, Wendy M. MD*, Office of the Chief Medical Hara-Kiri or Homicide? 139
Gunther, Wendy M. MD*, Tidewater District Office of the Suicidal Caffeine Overdose 316
Chief Medical Examiner, 830 Southampton Avenue, Suite
100, Norfolk, VA 23510; Connie M. Luckie, PhD,
Department of Forensic Sciences, Commonwealth of
Virginia, 830 Southampton Avenue, Suite 400, Norfolk, VA
23510; and Karen B. Looman, DO, Tidewater District
Office of the Chief Medical Examiner, 830 Southampton
Gunther, Wendy M. MD, Office of the Chief Medical Virulence Factors in Neisserial 479
Examiner and Department of Legal Medicine, Virginia Meningococcemia
100, Norfolk, VA 23510-1046; Gregory Racszniak, MPhil*,
Eastern Virginia Medical School, 714 Woodis Avenue,
Norfolk, VA 23510; Elizabeth L. Kinnison, MD, Office of
Gygax*, Erich and Barbara Sollberger, Department for Perfusion Technique for Postmortem CT- 125
Cardiovascular Surgery, University Hospital Bern, Angiography
Hochschulstrasse 4, Bern, SWITZERLAND; Alexandre
Dominguz, Haute Ecole Cantonale Vaudoise de la Santé,
Avenue de Beaument 21, Lausanne, SWITZERLAND;
Richard Dirnhofer, and Beat Steger, Fumedica AG,
Luzernerstrasse 91, Muri, SWITZERLAND; Francesco
Doenz, and Reto Meuli, Service de Radiodiagnostic et de
Radiologie Interventionnelle, Rue du Bugnon 46, Lausanne,
1011, SWITZERLAND; and Patrice Mangin, PhD, and Silke
SWITZERLAND
Index 166
Haden, Kathryn H. MD*, and David Dolinak, MD, Sphenoid Sinus Petechiae: Incidence and 508
Southwestern Institute of Forensic Sciences and the Significance
University of Texas Southwestern Medical Center, Dallas,
TX
Haden, Kathryn H. MD*, Lisette L. Lester, MD, JD, Sandra Postmortem Microbiology: Friend or Foe? 542
K. Elkins, MD, and Mark Cole, University of Tennessee
Medical Center, 1924 Alloa Highway, Box U-108,
Knoxville, TN
Haden, Kathryn H. MD, Department of Anthropology; and Differential Decomposition I: Partial Ground 549
Murray K. Marks, PhD*, Department of Pathology, The Contact
University of Tennessee Medical Center, 250 South Stadium
Hall, Knoxville, TN
Haden, Kathryn MD*, Office of the Chief Medical Determination of Range of Fire in Skeletal 420
Examiner, Northern Virginia District, 9797 Braddock Road, Remains
Fairfax, VA 22032; Jill Urban, MD, and Karen Hendley,
The Southwestern Institute for Forensic Sciences, 5230
Medical Center Drive, Dallas, TX 75235
Haden-Pinneri, Kathryn H. MD*, and Sara Nunez-Doyle, Postmortem Recognition of Sickle Cell Trait 172
MD, Harris County Medical Examiner’s Office, 1885 Old
Haden-Pinneri, Kathryn H. MD*, and Sharon M. Derrick, Pediatric Deaths in Harris County 78
PhD, Harris County Medical Examiner’s Office, 1885 Old
Haden-Pinneri, Kathryn H. MD*, Harris County Medical Autopulse® Associated Injuries 204
77054; Dwayne A. Wolf, MD, PhD, Harris County Medical
Examiner’s Office, JAJ Forensic Center, 1885 Old Spanish
Trail, Houston, TX 77054; and Jennifer C. Love, PhD, and
Roger A. Mitchell, Jr., MD, Harris County Medical
77054
Haden-Pinneri, Kathryn H. MD*, Jason M. Wiersema, What Lies Beneath: An Unusual Congenital 230
PhD, and Jennifer C. Love, PhD, Harris County, Medical Anomaly in an Assault Victim
77054-2098
Haden-Pinneri, Kathryn MD*, 21827 Hollow Field Lane, A Fatality Due to Atomoxetine - The First 371
Katy, TX 77450 Known Case
Haden-Pinneri, Kathryn MD*, Mary Lynn Anzalone, MD, The Postmortem Picnic 299
and Luis A. Sanchez, MD, Office of the Medical Examiner
of Harris County, Joseph A. Jachimiczyk Forensic Center,
Haefner, James and John B. Wallace, PhD*, Department of A New Technique to Estimate a Postmortem 551
Biology, Millersville University, Millersville, PA; and Submersion Interval (PMSI) Using Algal
Richard W. Merritt, PhD, Department of Entomology, Growth Rates
Michigan State University, East Lansing, MI
Haikal, Nabila A. MD*, and Richard C. Harruff, MD, PhD, Compressed Gas Cylinder Related Injuries: 465
King County Medical Examiner’s Office, 325 9th Avenue, Case Report of a Fatality Associated With a
HMC Box 359792, Seattle, WA 98104 Recreational Paintball Gun, Review of the
Literature and Safety Recommendations
Index 167
Hamel, Marianne MD, PhD*, Department of Pathology, Evaluation of Clinical Diagnostic Accuracy in 401
Anatomy and Cell Biology, Thomas Jefferson University Post-Coronary Artery Bypass Graft Surgery
Hospital, 125 South 11th Street, Suite 204 Foerderer Mortality
Pavilion, Philadelphia, PA 19107-4998; Johan A. Duflou,
MMed, Department of Forensic Medicine, Central Sydney
Laboratory Service, 42-50 Parramatta Road, Glebe, NSW
2037, Australia
Hamilton, Rebecca A. MD*, Office of the District 21 Death By Giant Cells: Report of Two Cases 291
Medical Examiner, 70 Danley Drive, Fort Myers, FL of Sudden Cardiac Death Due to Giant Cell
33907; Linda Sullivan, BS, Wuesthoff Reference Inflammatory Processes
Laboratory, 6800 Spyglass Court, Melbourne, FL 32940;
and Barbara C. Wolf, MD, Office of the District 21 Medical
Examiner, 70 Danley Drive, Fort Myers, FL 33907
Hamilton, Stuart J. MB ChB*, 9 Troon Close, Consett, DH8 Soccer Scams, Search Engines, Scientists, and 37
5XF, UNITED KINGDOM Slaughter: Investigating a Complex Double
Homicide in North-East England
Hanzlick, Randy L. MD*, and Stacey L. Smith, MD, Fulton Murder-Suicide in Fulton County, Georgia: 35
County Medical Examiner’s Office, 430 Pryor Street 1992-2006
Southest, Atlanta, GA 30312
Harcke, H. Theodore MD*, Armed Forces Institute of Postmortem Angiography in Support of 248
Pathology, 3205 Coachman Road, Wilmington, DE 19803; Radiologic Assisted Autopsy
and Carol Solomon, MD, and Scott Luzi, MD, Office of the
Chief Medical Examiner, 1413 Research Boulevard,
Harcke, Howard T. MD*, Armed Forces Institute of Use of Multidetector Computed Tomography 60
Pathology, 6825 16th Street Northwest, Washington, DC (MDCT) in the Medicolegal Investigation of
20306; and Edward L. Mazuchowski, PhD, and Philip J. Human Remains After a Natural Disaster
Berran, JD, Office of the Armed Forces Medical Examiner,
20850
Harcke, Theodore MD, Craig T. Mallak, JD, MD, and Multidetector Computed Tomographic 99
Terrill Top, MD*, Armed Forces Institute of Pathology, (MDCT) Autopsy in Suicide by Gunshot to
1413 Research Boulevard, Rockville, MD 21771 the Head
Harding, Brett E. MBA*, and Barbara C. Wolf, MD, Office Independence Day Explosion on Lovers Key 294
of the District 21 Medical Examiner, 70 Danley Drive, Fort
Myers, FL 33907
Harpe, Romano La MD*, Institut Universitaire de Overview of Suicide Cases in Geneva, 536
Médecine Légale, Av. de Champel 9 (CMU), Genève 4, Switzerland During a Twenty-five Year
Switzerland Period (1971-1995)
Harpe, Romano La MD*, Sandra E. Burkhardt, MD, and Death in a Wine Vat 134
Kebede Shiferaw, MD, Institut de Medecine Legale, 9 Av de
Champel (CMU), Geneva, 1206, SWITZERLAND
Harrison, Andrea J. BSN, RN*, Harris County Medical Adolescent Suicide Trends in the Third 360
Examiners Office, 1885 Old Spanish Trail, Houston, TX Largest County in the United States
77054; Sharon M. Derrick, PhD, Harris County Public
Health and Environmental Services, 2223 West Loop South,
Houston, TX 77027; and Stacey A. Mitchell, MSN, RN, and
Luis A. Sanchez, MD, Harris County Medical Examiners
Harruff, Richard C. PhD, and Pamela S. Ulmer, DO*, King Role of Scene Reconstruction in the 165
County Medical Examiner’s Office, 325 9th Avenue, HMC Medicolegal Investigation of Sudden
Box 359792, Seattle, WA 98104-2499 Unexpected Infant Deaths
Index 168
Hart, Amy P. MD*, Venus J. Azar, MD, and Boyd G. Homicidal Injury or Resuscitation Artifact? 449
Stephens, MD, Medical Examiner’s Office, City and County
of San Francisco, 850 Bryant Street, San Francisco, CA
94103
Hart, Eugene L. MD*, Bonita Fung, MD, Ana Lopez, MD, Case Presentation: Infant Death Due to 433
and Luis A. Sanchez, MD, Harris County Medical Epidermolysis Bullosa
77054-2098
Harvey, Bart J. MD, PhD, MEd*, University of Toronto, Applying Statistical Principles to the 299
407-263 McCaul Street, Toronto, Ontario M5T 1W7, Entomological Estimation of Postmortem
Canada; Sherah L. VanLaerhoven, PhD, University of Interval
Windsor, Room 23, Biology Building, 401 Sunset Avenue,
Windsor, Ontario N9B 3P4, Canada; and Paul N. Corey,
PhD, University of Toronto, Department of Public Health
Sciences, 6th Floor, 155 College Street, Toronto, Ontario
M5T 3M7, Canada
Harvey, Michelle L. BSc, BA* and Ian R. Dadour, PhD, DNA-Based Identification of Forensically 475
Centre for Forensic Science, University of Western Significant Blowflies of Australia and
Australia, Stirling Highway, Nedlands, Perth, Western Southern Africa
Australia 6009, Australia; Martin H. Villet, PhD,
Department of Zoology and Entomology, Rhodes
University, Grahamstown 6140, South Africa; Mervyn W.
Mansell, PhD, Plant Protection Research Institute, Private
Bag X134, Pretoria, Gauteng 0001, South Africa
Hassan, Mona M.A. MD* and Ragaa T. Darwish, MD, Immunohistochemical Study for Determining 568
Department of Forensic Medicine & Toxicology, the Time of Injury to Rats Following Stab
Alexandria, Egypt; and Samar M. El-Sheikh, PhD, Wounds and Blunt Trauma to the Brain
Department of Pathology, Faculty of Medicine, University
of Alexandria, 33, Safeya Zaghloul St. #52, Alexandria,
Egypt
Havard, Benjamin J. MD*, Kelly L. Rose, MD, and Kim A. Cytomegalovirus Enteritis With Profuse 220
Collins, MD, Medical University of South Carolina, Gastrointestinal Bleeding Diagnosed at
Department of Pathology and Laboratory Medicine, 165 Autopsy: A Case Report and Review of the
Ashley Avenue, Suite 309, PO Box 250908, Charleston, SC Literature
29425
Hebard, Rayna L. BS*, and Bruce R. McCord, PhD, Quantification and Amplification of MtDNA 358
Florida International University, International Forensic From Chemically Treated Hair
Research Institute, 11200 SW 8th Street, Miami, FL 33199;
and DeEtta K. Mills, PhD, Florida International University,
Forensic DNA Profiling Facility, 11200 SW 8th Street,
Miami, FL 33199
Heninger, Michael MD*, Fulton County Medical Postmortem Vitreous Beta- Hydroxybutyrate: 61
Examiner’s Office, 430 Pryor Street, Atlanta, GA 30312 Interpretation in a Forensic Setting
Henn*, Véronique and Manfred Kleiber, PhD, Insitute of Starvation – Interpretation of Morphological 377
Forensic Medicine Martin-Luther-University, Findings and Pitfalls
Franzosenweg 1, Halle, 06112, Germany; and Eberhard
Lignitz, PhD, Insitute of Forensic Medicine Ernst-Moritz-
Arndt-University, Kuhstr. 30, Greifswald, 17489, Germany
Hess, Gregory L. MD*, Jeffery M. Jentzen, MD, and Russell Suicidal Hanging of a Postpartum Woman 323
T. Alexander, MD, Milwaukee County Medical Examiner Who Discontinued Anti- Depressant
Office, 933 West Highland Avenue, Milwaukee, Wisconsin Medication During Pregnancy
53233
Index 169
Hess, Gregory L. MD*, University of Arizona Health Natural Central Nervous System (CNS) 325
Sciences Center, 1501 North Campbell Avenue, PO Box Causes of Death: A Ten Year Retrospective
245108, Tucson, AZ 85724-5108; and David C. Winston, Review (1994-2003)
MD, PhD, Pima County Forensic Science Center, 2825
East District Street, Tucson, AZ 85714
Hickey, Kelly L. MD*, Marcella F. Fierro, MD, and Utilization of Automated Fingerprint 422
Timothy A. Powell, MPH, Office of the Chief Medical Identification System (AFIS) to Aid in the
Examiner, 400 East Jackson Street, Richmond, VA 23219; Identification of Unknown Perpetrators to
andRobin Young, Division of Forensic Science, 700 North Close Unsolved Cases
5th Street, Richmond, VA 23219
Hickman, Matthew J. PhD, and Kristen A. Hughes, MA, Preliminary Findings of the Bureau of Justice 310
U.S. Department of Justice, Bureau of Justice Statistics, 810 Statistics 2005 Census of Medical Examiner
7th Street NW, Washington, DC 20531; and Jeri D. Ropero- and Coroner Offices
Miller, PhD*, and Kevin J. Strom, PhD, RTI International,
3040 Cornwallis Road, Research Triangle Park, NC 27709
Hilal, Ahmet MD*, Necmi Cekin, MD, Mete K. Gulmen, Neck Findings in Hanging and Strangulation 20
PhD, and Kemal C. Yildirim, MD, Cukurova University Cases That Underwent Autopsy in Adana,
School of Medicine, Department of Forensic Medicine, Turkey
Balcali, Adana, 01330, TURKEY
Hill, Vincent E. MD*, Mortuary Medical Services, 3003 Building the Communication/Language for 169
Van Ness Street, North West, Suite 106, Washington, DC Collaboration Between the Forensic
20008 Pathologist and Funeral Director/Embalmer
Ho, Jeffrey D. MD, Hennepin County Medical Center, Inferior Vena Cava Compression: A Possible 48
Department of Emergency Medicine, 701 Park Avenue Mechanism for Arrest Related Death
South, Minneapolis, MN 55415; Donald M. Dawes, MD*,
Lompoc Valley Medical Center, 1515 East Ocean Avenue,
Lompoc, CA 93436; and Johanna C. Moore, MD, and
James R. Miner, MD, Hennepin County Medical Center,
Department of Emergency Medicine, 701 Park Avenue
South, 1431 Lakeview Avenue South, Minneapolis, MN
55415
Hodgins, Gregory W. DPhil*, University of Arizona, Insect Pupal Cases as Decay-Resistant 196
Department of Physics, 1118 East Fourth Street, Tucson, Reservoirs of Human Soft Tissue
AZ 85721 Radiocarbon Content
Holmes, Leslie A. BS*, and Sherah L. Van Laerhoven, PhD, Lower Temperature Threshold for Black 116
University of Windsor, Department of Biology, 401 Sunset Soldier Fly (Diptera: Stratiomyidae) Egg and
Avenue, Room 119 Bio, Windsor, ON N9B 3P4, CANADA; Adult Eclosion
and Jeffery K. Tomberlin, PhD, Department of Entomology,
TAMU 2475, College Station, TX 77843-2475
Hooper, Jody E. MD*, U.S. Navy, General Medical Officer, Relevance of the Autopsy as a Medical Tool: 510
Branch Medical Clinic, Naval Air Station, North Island, A Large Database of Physician Attitudes
Coronado, CA
Hooper, Jody E. MD*, United States Navy, General Some Empirical Data on the Past and Future 552
Medical Officer, 5240 Fiore Terrace, San Diego, CA of the Autopsy
Horisberger, Beat MD*, and Patrice Mangin, MD, PhD, Estimation of Postmortem Interval Using 306
Institute of Legal Medicine, University of Lausanne, 21, Rue Bioelectrical Impedance of the Human Body
du Bugnon, Lausanne, CH-1005, Switzerland
Horisberger, Beat MD*, and Patrice Mangin, MD, PhD, The Contribution of Computerized Image 435
Institute of Legal Medicine, University of Lausanne, Rue du Analysis to the Diagnosis of Munchausen
Bugnon 21, Lausanne, 1005, Switzerland Syndrome by Proxy
Index 170
Horisberger, Beat MD*, University of Lausanne, Institute of Forensic Diaphanoscopy Imaging: A New 313
Legal Medicine, 21 Rue du Bugnon, Lausanne, CH-1005, Tool in Clinical Forensic Medicine
Switzerland; Sebastien Tanniger, School of Business and
Engineering Vaud, HEIG-VD, 1 Route de Cheseaux,
Yverdon-les-Bains, CH-1401, Switzerland; and Patrice
Mangin, MD, PhD, University of Lausanne, Institute of
Legal Medicine, 21 Rue du Bugnon, Lausanne, CH-1005,
Switzerland
Huang, Tsun-Ying MS*, Institute of Forensic Medicine, A Preliminary and Pilot Study About 361
Ministry of Justice, 16, Lane 175, Tong-Hwa Street, Taipei, Mitochondrial DNA Deletion in Sudden
106, Taiwan, Republic of China; Chia-Tung Shun, AP, Infant Death Syndrome: An Endemic Study in
National Taiwan University, College of Medicine, No. 1, Taiwan
Jen Ai Road Section 1, Taipei, 100, Taiwan, Republic of
China; Jui-Ming Li, BS, Institute of Forensic Medicine,
Ministry of Justice, 16, Lane 175, Tong-Hwa Street, Taipei,
106, Taiwan, Republic of China; and Shu-Huei Kao, PhD,
Institute of Biomedical Technology, Taipei Medical
University, 250, Wu-Xing Street, Taipei, 110, Taiwan,
Republic of China
Humphreys, Michael K. MS*, Yolo County Sheriff/Coroner Comparison of Methods for Measuring 55
Office, 2500 East Gibson Road, Woodland, CA 95616; Decomposition of Submerged Carrion in
Edward Panacek, MD, MPH, University of California - Fresh Water
Davis, Department of Emergency Medicine, 4150 V Street,
Patient Support Services Building, Suite 2100, Sacramento,
CA 95817; William Green, MD, California Clinical
Forensic Medical Training Center, University of California
- Davis Medical Center, 3671 Business Drive, Sacramento,
CA 95820; and Elizabeth A. Albers, MD, Sacramento
County Coroner’s Office, 4800 Broadway, Sacramento, CA
95820
Hunter, Brian C. BA, MD*, Department of Pathology, The Use of Lidocaine to Commit Homicide 554
Sparrow Health System, 1215 East Michigan Avenue,
Lansing, MI; John Trestrail III, BS, RPh, Regional Poison
Center, Grand Rapids, MI; and Stephen D. Cohle, MD,
Spectrum Health East Campus, Pathology Department,
Grand Rapids, MI
Hunter, Brian C. MD*, 1215 East Michigan Avenue, The Use of Lidocaine to Commit Homicide: 522
Lansing, MI; John H. Trestrail III, BS, RPh, Regional A Case Report and Review of the Literature
Poison Center, Grand Rapids, MI; and Stephen D. Cohle,
MD, Spectrum Health East Campus, Pathology
Department, Grand Rapids, MI
Hunter, Brian C. MD*, Department of Pathology Sparrow The Role of the Forensic Anthropologist in 561
Health System, 1215 Michigan Avenue, Lansing, MI; Determining the Manner of Death in Suicidal
Norman J. Sauer, PhD, and Todd W. Fenton, PhD, Shotgun Wound to the Back of the Head
Department of Anthropology, Michigan State University,
East Lansing, MI; Joyce L. de Jong, DO, Department of
Pathology, Forensic Pathology Division, Sparrow Health
System, 1215 Michigan Avenue, Lansing, MI; and Michael
G. Koot, BA, Department of Anthropology, Michigan State
University, East Lansing, MI
Index 171
Huntington, Timothy E. BS; Leon G. Higley, PhD, and Temperature-Dependent Development of the 474
Frederick P. Baxendale, PhD, University of Nebraska, Blow Fly Calliphora Vicina (Diptera:
Department of Entomology, 202 Plant Industry, Lincoln, Calliphoridae) and the Effects on the
NE 68583 Estimation of the Postmortem Interval
Huntington, Timothy E. MS*, and Leon G. Higley, PhD, Have I Eaten Here Before? Considering 301
University of Nebraska, Department of Entomology, 202 Multigenerational Colonization of Remains
Plant Industry Building, Lincoln, NE 68583 by Blow Flies
Huntington, Timothy E. MS*, Leon G. Higley, PhD, and Maggot Development During Morgue Storage 355
Frederick P. Baxendale, PhD, University of Nebraska, and the Effects on Estimating the Postmortem
Department of Entomology, 202 Plant Industry Building, Interval
Lincoln, NE 68583
Huntington, Timothy E. PhD*, Concordia University Exploring the Potential for Nocturnal 127
Nebraska, 800 North Columbia Avenue, Seward, NE 68434; Colonization of Fresh Cadavers by Carrion
and Leon G. Higley, PhD, University of Nebraska, 706 Flies in the Central United States
Hardin Hall, Lincoln, NE 68583-0987
Huston, Butch M. MD*, and Janis C. Amatuzio, MD, Assisting the Living 552
Midwest Forensic Pathology, 3960 Coon Rapids Boulevard,
Suite LL21, Coon Rapids, MN
Hutchins, Kenneth D. MD*, Miami-Dade County Medical Acute Hemorrhagic Leukoencephalopathy 262
Examiner Department, Number 1 Bob Hope Road, Miami, (Weston-Hurst Disease): A Natural Disease
FL 33136; and Lyla E. Perez, MD, Southern Regional Presents as Head Trauma
Medical Examiner Office, 1175 DeHirsch Avenue,
Woodbine, NJ 08270
III, William Massello MD*, Office of the Chief Medical Estimating Time of Death From Livor Mortis 269
Examiner, 6600 Northside HS Road, Roanoke, VA 24019 Patterns: A Case Presentation
Illescas, María J. BS*, Virginia Commonwealth University, Internal Validation of Quantifiler™ DUO 157
1000 West Cary Sreet,, PO Box 842012, Richmond, VA DNA Quantification Kit and AmpFℓSTR®
23284-2012; Fernando Mercedes, MS*, Institute of Yfiler™ PCR Amplification Kit
Urb. Reparto Metropolitano, San Juan, PR 00922; Tracey
Dawson Cruz, PhD*, 1000 West Cary Street, PO Box
842012, Virginia Commonwealth Univeristy, Richmond, VA
23284; and Carmen A. Tirado, MS*, Institute of Forensic
Science of Puerto Rico, Calle Maga Esq. Casia, Urb.
Reparto Metropolitano, San Juan, PR 00922
Introna, Francesco MD*, Alberto Tortorella, MD, Roberto Boating People Pathology 467
Vaglio, MD, and Antonio De Donno, MD, Sezione di
Medicina Legale-DIMIMP, P.zza Giulio Cesare, 11, Bari,
70100, Italy
Introna, Francesco MD*, Francesco Faggiano, MD, The “Holy Crown United” Southern Italian 555
Alberto Tortorella, MD, and Antonio De Donno, MD, Mafia Organization Homicides
University of Bari, Italy, Istituto di Medicina Legale,
Policlinico, Bari, Italy
Introna, Francesco MD, PhD*, and Antonio De Donno, Personal Identification by Morphometric 338
MD, Section of Legal Medicine (Di.M.I.M.P.), University of Analyses of Retinal Vascular Pattern
Bari, P.zza Giulio Cesare n.11, Bari, 70124, Italy; Carlo
Sborgia, MD, and Francesco Boscia, MD, Section of
Ophthalmology, University of Bari, P.zza Giulio Cesare
n.11, Bari, 70124, Italy; Giuseppe Mastronardi, PhD,
Electronic and Electrotecnic DPT, Via Orabona n.4, Bari,
Bari, Italy; and Francesca Bellomo, MD, and Domenico
Urso, MD, Section of Legal Medicine (Di.M.I.M.P.),
University of Bari, P.zza Giulio Cesare n.11, Bari, 70124,
Italy
Index 172
Introna, Francesco MD, PhD, Section of Legal Medicine Killer Hairdryer 342
(Di.M.I.M.P.), University of Bari, Policlinico - P.zza Giulio
Cesare, 11, Bari, 70124, Italy; Simona Corrado, MD*,
Section of Legal Medicine (Di.M.I.M.P.), Bari University,
Policlinico - Piazza G. Cesare, 11, Bari, 70124, Italy; and
Vitantonio Amoruso, Dipartimento di Elettrotecnica ed
Elettronica, Politecnico di Bari, Via Orabona, 4, Bari,
70125, Italy
Introna, Francesco PhD, Antonio De Donno, PhD, Valeria The Bodies of Two Missing Children in an 8
Santoro, PhD, Section of Legal Medicine - DiMIMP, P.zza Enclosed Underground Environment
Giulio Cesare n.11, Bari, 70124, ITALY; Simona Corrado,
MD, Sezione di Medicina Legale, Bari, 70100, ITALY; Vito
Romano, MD, Medicina Legale Miulli, Acquaviva delle
Fonti, Acquaviva delle Fonti - Bari, 70100, ITALY;
Francesco Porcelli, PhD, Section of Entomology and
Zoology (Di.B.C.A.), University of Bari (Italy), Via G
Amendola, Bari, 70126, ITALY; and Carlo P. Campobasso,
PhD*, University of Molise, Via De Sanctis, Snc,
Campobasso, 86100, ITALY
Irvine, Rebecca A. MD*, University of New Mexico, Office Checking In to Check Out: The New Mexico 265
of the Medical Investigator, MSC 11 6030, 1 University of Experience of Suicide Occurring in Hotels
Irvine, Rebecca A. MD*, University of New Mexico, Office Bidding for Poison: The New Availability of 315
of the Medical Investigator, MSC 11 6030, University of Poisons and How to Use Them
Irvine, Rebecca MD*, 808 Shire Street, South West, A Brush With Death: Suicidal Ingestion of 235
Albuquerque, NM 87121; and Susan Kunkle, PharmD, New Toothpaste
Mexico Poison and Drug Information Center, MSC11 3060,
1 University of New Mexico, Albuquerque, NM 87131-0001
Ishikawa, Takaki MD, PhD*, Department of Legal Significance of Blood Neopterine 266
Medicine, Osaka City University Medical School, Asahi- Measurement in Forensic Autopsy Cases
machi 1-4-3, Abeno, Osaka, 545-8585, Japan; Marianne
Hamel, MD, PhD, Thomas Jefferson University Hospital,
Department of Pathology, 132 South 10th Street, Suite 285
Main Building, Philadelphia, PA 19107; and Bao-Li Zhu,
MD, PhD, and Hitoshi Maeda, MD, PhD, Department of
Legal Medicine, Osaka City University Medical School,
Asahi-machi 1-4-3, Abeno, Osaka, 545-8585, Japan
Izevbaye, Iyare PhD*, State University of New York, Numerous Rhabdomyomata and Cortical 88
Buffalo, 100 High Street, Buffalo, NY 14203; and Fazlollah Tubers in a Possible Case of SIDS
Loghmanee, MD, Erie County Medical Examiner’s Office,
111 Lehn Spring Drive, Williamsville, NY 14221-6920
Jardim, Patrícia MD*, José M. Fernandes, MD, Dina Interpretation of Anogenital Findings in 72
Almeida, MD, Liliana Santos, MD, MSc, Agostinho Santos, Forensic Autopsy: Problems and Challenges
PhD, and Teresa Magalhães, PhD, North Branch of the
National Institute of Legal Medicine, Jardim Carrilho
Videira, 4050-167, Porto, PORTUGAL
Jason, Donald R. MD, JD*, Wake Forest University School Smallpox and the Medical Examiner/Coroner 493
of Medicine, Department of Pathology, Medical Center System
Jentzen, Jeffrey M. MD*, and Eileen Weller, RN, MHA, Suicide in Children: A 12-Year Retrospective 535
Milwaukee County Medical Examiner's Office, 933 West Study
Highland Avenue, Milwaukee, WI; and Adam Ruck,
University of Wisconsin-Milwaukee, 2465 Oakland Ave,
Milwaukee, WI
Index 173
Jentzen, Jeffrey M. MD*, Milwaukee County Medical Discrepancy Between the Legal and Medical 494
Examiner’s Office, 933 West Highland Avenue, Milwaukee, Definitions of Homicide
WI; Ayako Kobayahi, University of Wisconsin at
Milwaukee, 1-3-4 Nozawa, Setagaya-ku, Tokyo, Japan;
Eileen Weller, RN, MHA, Milwaukee County Medical
Examiner’s Office, 933 West Highland Avenue, Milwaukee,
WI; and Mallory O’Brien, PhD, Harvard School of Public
Health, 2501 East Menlo Boulevard, Shorewood, WI
John, Alex MD*, Harris County Institute of Forensic DNA Extraction From Paraffin Blocks: Organ 16
Sciences, 1885 Old Spanish trail, Houston, TX 77054; Selection and Pre-Embedding Fixation Times
Dwayne A. Wolf, PhD, Harris County Medical Examiner’s – Practical Implications for Forensic
Office, JAJ Forensic Center, 1885 Old Spanish Trail, Pathologists
Houston, TX 77054; Jennifer Petrash, MS, Shahida Flores,
BS, Dustin Foley, MS, Lisa Gefrides, MS, and Roger Kahn,
PhD, Harris County Institute of Forensic Sciences, 1885
Old Spanish Trail, Houston, TX
Johnson, Michael W. MD, PhD*, and Anna Rubio, MD, Axonal Injury in Pediatric Head Trauma: A 96
State of Maryland Office of the Chief Medical Examiner, Study of the Interpretation of ß-Amyloid
111 Penn Street, Baltimore, MD 21201; Juan Troncoso, Precursor Protein (ß-APP) Expression in
MD, The Johns Hopkins University, School of Medicine, Trauma and Non-Trauma Cases
558 Ross Building, 720 Rutland Avenue, Department of
Neuropatholyg, Baltimore, MD 21205; and David R.
Fowler, MD, and Ling Li, MD, State of Maryland Office of
MD 21201
Johnston, Sarah MSc*, Roger Frappier, MSc, and Jonathan DNA Databank Hits: Identification of the 499
Newman, BSc, Centre of Forensic Sciences, 25 Grosvenor Perpetrator?
Street, 4th Floor, Toronto, Ontario, Canada
Jones, Tera A. MD*, Douglas County Coroner’s Office, Myocarditis With Giant Cells in an Infant: A 24
4000 Justice Way, Castle Rock, CO 80109 Case Report and Review of the Literature
Jorden, Michelle A. MD*, Adrienne Segovia, MD, and Pituitary Macroadenoma Presenting as 310
Edmund R. Donoghue, MD, Cook County Medical Hypothermia: A Case Report
Examiner’s Office, 2121 West Harrison Street, Chicago, IL
60647
Jorden, Michelle A. MD*, James A. Filkins, MD, JD, PhD, Unusual Methods of Suicide in Chicago, 197
and Tera A. Jones, MD, Cook County Medical Examiner Illinois, Cook County
Office, 2121 West Harrison Street, Chicago, IL 60612
Jorden, Michelle A. MD*, Jennifer A. McReynolds, PhD, Sickle Cell Disease and Sudden Death 243
and Adrienne E. Segovia, MD, Cook County Medical
Examiner, 2121 West Harrsion Street, Chicago, IL 60612
Jorden, Michelle A. MD*, Santa Clara Medical Examiner, First Reported Case of Bromo-Dragonfly 64
850 Thorton Way, San Jose, CA 95128; Lee M. Blum, PhD, Fatality in the United States, San Jose,
NMS Labs, 3701 Welsh Road, Willow Grove, PA 19090; California, County of Santa Clara
and Joseph Corvo, BS, NMS Labs, 3701 Welsh Road,
Willow Grove, PA 19090
Jousset, Nathalie MD*, Arnaud Gaudin, MD, Damien Recovery of Transplantable Organs After 160
Mauillon, MD, and Clotilde G. Rougé-Maillart, MD, CHU, Cardiac Arrest in France
Service de Médecine Légale, 4 rue Larrey, Angers, 49000,
FRANCE
Jousset, Nathalie S. MD*, Department of Forensic Examination of Sexually Abused Child: What 379
Medicine, University Hospital, Angers, 49033, France; and is the Impact on Judgment?
Hubert C. Poirout, MD, Arnaud N. Gaudin, MD, Michel
Penneau, MD, PhD, and Clotilde G. Rougé- Maillart, MD,
Department of Forensic Medicine, 4 rue Larrey, Angers,
49033, France
Index 174
K. Shetty, B. Suresh MD*, Kasturba Medical College, Light Sports Tool as a Weapon of Assault: A Case 130
House Hill Road, Mangalore, 575001, INDIA Report
Kalelkar, Mitra B. MD*, Kendall Crowns, MD, and Venous Air Embolism— A Difficult 545
Edmund R. Donoghue, MD, Chief Medical Examiner, Cook Postmortem Diagnosis
County Medical Examiner’s Office, 2121 West Harrison
Street, Chicago, IL
Kaliszan, Michal R. PhD*, Medical University of Gdansk, Does a Draft Really Influence Postmortem 82
Debowa 23, Gdansk, 80-286, POLAND Body Cooling?
Kalyva, Marianna MD*, University of Crete, Department of Seasonal Incidence of Suicides in Crete 274
Forensic Sciences, Medical School, Heraklion, 71110, Island: A Five Year Study
Greece; Vasilios Stoukas, Telamonos 25, Anthoupoli,
Peristeri, Athens 12135, Greece; and Anna Mavroforou,
PhD, Elena F. Kranioti, MD, Panagiotis Mylonakis, MD,
Antonios Papadomanolakis, MD, and Manolis
Michalodimirakis, MD, JD, University of Crete, Medical
School, Department of Forensic Sciences, Heraklion,
71110, Greece
Kanaki, Katerina MD*, Researcher, Department of Suicide in Eastern Crete 513
Forensic Sciences, University of Crete, Heraklion, Greece;
Ersi Abaci Kalfoglu, PhD, Professor, Institute of Forensic
Sciences, University of Istanbul, Istanbul, Turkey; and
Manolis Michalodimitrakis, MD, Professor, Department of
Forensic Sciences, University of Crete, Heraklion, Greece
Kanchan, Tanuj MD*, Kasturba Medical College, Sudden Unexpected Cardiac Deaths: An 2
Department of Forensic Medicine, Light House Hill Road, Autopsy Based Study From Mangalore, South
Mangalore, 575 001, INDIA India
Kanchan, Tanuj MD*, Kasturba Medical College, When Ribs Penetrate the Heart in Blunt Chest 6
Department of Forensic Medicine, Light House Hill Road, Wall Trauma
Kanchan, Tanuj MD*, Kasturba Medical College, Accidental Drowning Deaths in a Coastal 107
Department of Forensic Medicine, Light House Hill Road, Region of South India – A Ten Year Study
Kanchan, Tanuj MD*, Manipal University, Department of Fatal Rescue Burns 130
Forensic Medicine, Kasturba Medical College, Light House
Hill Road, Mangalore, 575001, INDIA
Kanluen, Sawait MD*, Chulalongkorn University, Mass Disaster Victim Identification: The 336
Department of Forensic Sciences, 254 Phayathai Road, Tsunami Disaster
Patumwan, Bangkok 10330, Thailand; and Tony Kanluen,
MD, Henry Ford Hospital, Department of Emergency
Medicine, 2799 W Grand Boulevard, Detroit, MI 48202
Karhunen, Pekka J. MD, PhD*, University of Tampere, Genetics of Sudden Cardiac Death: 544
POB 602, Tampere, Finland; J. Mikkelsson, Schools of Prothrombotic Mutations of Blood Platelet
Medicine and Public Health, University and University Glycoprotein Receptors are Common Among
Hospital of Tampere, Tampere, Finland; M. Perola, Men Who Die of Prehospital Myocardial
Department Human. Molecular Genetic, National Public Infarction at Early Middle Age
Health, Institute Tampere, Helsinki; P. Laippala, Schools of
Medicine and Public Health University and University
Hospital of Tampere Department Clinic Pathology and
Forensic Medicine, Tampere, Finland; and A. Penttila,
Department. Forensic Medicine, University of Helsinki,
Tampere, Helsinki
Katarzyna, Michaud MD*, Béat Horisberger, MD, and Degenerative Changes of the Conduction 467
Patrice Mangin, PhD, Institut Universitaire de Médecine Tissue in Drug Addicts
Légale, Rue du Bugnon 21, Lausanne, Vaud 1005,
Switzerland
Index 175
Katz, Daniel E. MFS*, Delaware Office of the Chief Comparison Study of Various Protocols to 355
Medical Examiner, 200 South Adams Street, Wilmington, Release Maximal Amounts of Amplifiable
DE 19801; Timothy McMahon, PhD, Armed Forces DNA DNA From Decomposed Soft Tissue Exposed
Identification Laboratory, 1413 Research Boulevard, to Different Environmental Conditions
Building #101, 2nd Floor, Rockville, MD 20850; Arthur
Young, BS, National Medical Services, 3701 Welsh Road,
Willow Grove, PA 19090; Rebecca A. Kennedy, Cedar
Crest College, 100 College Drive, Allentown, PA 18104;
Michelle Malley, MSFS, Armed Forces DNA Identification
Laboratory, 1413 Research Boulevard, Building #101, 2nd
Floor, Rockville, MD 20850; and Rebecca E. Wallman, BS,
MS, Delaware Office of the Chief Medical Examiner, 200
South Adams Street, Wilmington, DE 19801
Keil, Wolfgang A. MD*, and Felicitas Dahlmann, MD, Polyarteritis Nodosa as a Rare Case of 414
Institute of Forensic Medicine, Ludwig-Maximilians- Sudden Death in Postmortem Diagnosis
University Munich, Frauenlobstraße 7a, Munich, D80337,
Germany; and Andrea M. Berzlanovich, MD, Institute of
Forensic Medicine, Medical University Vienna,
Sensengasse 2, Vienna, A1090, Austria
Kell, Melissa BSc, Sobia Malik, MSc, Gerry Alderson, Screening Items of Evidence for the Presence 449
MSc*, and Andrew Greenfield, MSc, Centre of Forensic of Body Fluids/DNA in Forensic Biology
Sciences, 25 Grosvenor Street, Toronto, Ontario M7A 2G8, Casework — A Hypothesis-Driven Approach
Canada
Kell, Melissa S BSc*, Wendy Lalonde, BSc, Roger Frappier, The Detection of Saliva: Factors Affecting the 439
MSc, and Jonathan Newman, BSc, Centre of Forensic Phadebas® Press and Tube Tests
Sciences, 25 Grosvenor Street, Toronto, ON M7A 2G8,
Canada
Kelly, Christopher C. MMgmt*, Armed Forces Institute of Media Relations and the Identification of the 491
Pathology, 6825 16th Street, NW, Building 54, Room 1106, September 11 Pentagon Terrorist Attack
Washington, DC Victims: The Perspective of the Office of the
Armed Forces Medical Examiner
Kibayashi, Kazuhiko MD*, Ken-ichiro Nakao, MS, and Ryo Brain Tissue Responses After Traumatic 105
Shimada, PhD, Department of Legal Medicine, School of Brain Injury in Animal Models
Medicine, Tokyo Women’s Medical University, 8-1
Kawada-cho, Shinjuku-ku, Tokyo, 162- 8666, JAPAN
Kibayashi, Kazuhiko MD*, Tokyo Women’s Medical Responses of Mast Cells in the Dura to 3
University, Department of Legal Medicine, School of Traumatic Brain Injury in an Animal Model
Medicne, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666,
JAPAN; and Ryo Shimada, PhD, and Rui Furutani, PhD,
Tokyo Women’s Medical University, 8-1 Kawada-cho,
Shinjyuku-ku, Tokyo, 162-8666, JAPAN
Kimbirauskas, Ryan K. MS*, Richard W. Merritt, PhD, and An Instructional DVD on Collecting 409
Eric M Benbow, PhD, Michigan State University, 243 Entomological Evidence for Court
Natural Science Building, East Lansing, MI 48824; John R.
Wallace, PhD, Millersville University, 1 South George
Street, Millersville, PA 17551; and Jeff K. Tomberlin, PhD,
Texas A & M University, 1229 North U.S. Highway 281,
Stephenville, TX 76401
Kimmerle, Erin H. MA*, University of Tennessee, 121 West Characteristics of Different Types of Fatal 550
Jackson Avenue North, Knoxville, TN; Matthias Okoye, Head Trauma and the Factors That Influence
MD, JD, Pathology Medical Services, PC Lincoln General Survival Time and Activity Prior to Death
Hospital, 2300 South 16th Street, Lincoln, NE; and Sue
Gabriel, RN, BSN, Nebraska Wesleyan University, Lincoln,
NE
Index 176
Kinnison, Elizabeth L. MD* and Wendy M. Gunther, MD, Positional Asphyxia and Alcoholism: Review 460
Office of the Chief Medical Examiner, 830 Southampton of Three Cases
Kinnison, Elizabeth L. MD*, and Wendy M. Gunther, MD, Guns That Fire Themselves: Report of Three 369
Department of Legal Medicine, Virginia Commonwealth Cases
University, Medical College of Virginia, 1101 E Marshall
Street, Richmond, VA 23298-0568
Kir, Ziya MD, and Coskun Yorulmaz, MD*, Istanbul Postmortem Interval and Cardiac Troponin 44
University Cerrahpasa School of Medicine, Department of Effect
Forensic Medicine, Cerrahpasa, Istanbul, 34099, TURKEY;
Murat Bolayirli, MD, Istanbul University Cerrahpasa
School of Medicine, Department of Biochemistry,
Cerrahpasa, Istanbul, 34099, TURKEY; Haluk Ince, PhD,
Council of Forensic Medicine, Chairperson of the Counsil
of Forensic Medicine, Istanbul, 34197, TURKEY; and Mete
K. Gulmen, PhD, Cukurova University School of Medicine,
Department of Forensic Medicine, Adana, 01330, TURKEY
Kirby*, Rebecca J. Anita L. Guedea, Phillip L. Watson, The Role of Forensic Insects in Deposition of 415
PhD, Roger E. Mitchell, PhD, and Scott M. Herron, PhD, Pollen at a Death Scene
Ferris State University, Department of Biology, Big Rapids,
MI 49307
Klotzbach, Heike MD, PhD*, and Johanna Preuss, MD, Expression of Heat Shock Protein (hsp) 70 in 362
Institute for Legal Medicine, Stiftsplatz 12, Bonn, 53111, Tissue of Different Human Organs After Burn
Germany; Eberhard Lignitz, MD, PhD, Institute for Legal Fatalities
Medicine, Kuhstrasse 30, Greifswald, 17489, Germany; and
Burkhard Madea, MD, PhD, Institute for Legal Medicine,
Stiftsplatz 12, Bonn, 53111, Germany
Klotzbach, Heike MD, PhD*, Institute of Legal Medicine, An Interdisciplinary Approach for Diagnosis 430
Hamburg University, Butenfeld 34, Hamburg, 22529, and Age Estimation of Infants’ Fractures in
Germany; Guenther Delling, PhD, Institute of Pathology, the Course of the Autopsy
Department of Osteo-Pathology, Hamburg University,
Lottestrasse 2, Hamburg, 22529, Germany; Erich Richter,
PhD, Institute of Radiology, Department of Pediatric
Radiology, Martinistrasse 52, Hamburg, 20246, Germany;
and Klaus Pueschel, PhD, Institute of Legal Medicine,
Hamburg University Butenfeld 34, Hamburg, 22529,
Germany
Klotzbach, Heike MD, PhD*, Institute of Legal Medicine, Identifying Corpses of Foreigners in the State 336
Stiftsplatz 12, Bonn, 53111, Germany; Klaus Benedix, of Advanced Decomposition: Sri Lanka After
DMD, Dental Services German Air Forces, Dachauer the Tsunami 2004
Strasse 128, München, Bavaria 80637, Germany; Guido
Beutler, Embassy of the Federal Republic of Germany, 6/50
Shantipath, Chanakyapuri, New Delhi, 110 021, India; and
Thomas Lubnau, and Kerstin Schneider, Federal Criminal
Police Office, Georg- Marshall-Strasse 20, Wiesbaden,
65173, Germany; Stephan Klein, Federal Criminal Police
Office, Georg-Marshall-Strasse 20, Wiesbaden, 65173,
Germany
Klotzbach, Heike PhD*, Institute of Legal Medicine, Reconstruction of Decay Processes of a Dead 197
Fürstengraben 23, D-07743 Jena, GERMANY Child’s Body in a Plastic Garbage Bag
Index 177
Kodikara, Sarathchandra MBBS, MD, DLM*, NIL, Mechanisms of Delayed Splenic Rupture: A 242
Department of Forensic Medicine, Faculty of Medici, New Hypothesis
Peradeniya, SRI LANKA; and Murugapillai
Sivasubramanium, MBBS, MD, DLM, Teaching Hospital,
Kegalle, Sri Lanka
Kohlmeier, Ruth E. MD*, El Paso County Coroner’s Office, A Death Due to Subinvolution of the 84
2743 East Las Vegas Street, Colorado Springs, CO 80906; Uteroplacental Arteries: A Case Report and
and Norma J. Farley, MD, Valley Forensics, 200 South Literature Review
10th Street, McAllen, TX 78501
Kovarik, Carrie L. MD*, UT Clay J. Cockerell, MD, Sheila The Impact of Dermatologic Consultation in 448
D. Spotswood, MD, and Jeffrey J. Barnard, MD, University Autopsy Examination: A Case of
of Texas Southwestern Medical School - Forensic Science, Pseudoxanthoma Elasticum
5323 Harry Hines Boulevard, Dallas, TX 75390
Krinsky, Clarissa MD*, 3908 Silver, South East, Dysplasia of the Atrioventricular Nodal 252
Albuquerque, NM 87108; Sam W. Andrews, MD, Office of Artery: A Case Report and Review of the
Chief Medical Examiner, 4070 Bowness Road North West, Literature
Calgary, Alberta T3B 3R7, CANADA; and Rebecca Irvine,
MD, 808 Shire Street, South West, Albuquerque, NM 87121
Krinsky, Clarissa MD*, University of New Mexico School Laboratory Variation and Postmortem 62
Of Medicine, MSC11 6030, 1 University of New Mexico, Redistribution in the Interpretation of
Albuquerque, NM 87131; and Sarah Lathrop, PhD, DVM, Postmortem Fentanyl Levels
and Ross E. Zumwalt, MD, University of New Mexico,
Office of Medical Investigator, MSC 11 6030, 1 University
of New Mexico, Albuquerque, NM 87131-0001
Kroll, Mark W. PhD*, University of Minnesota, Box 23, Potential Errors in Autopsy Reports of 288
Crystal Bay, MN 55323; Dorin Panescu, PhD, St. Jude Custodial Deaths Temporally Associated
Medical Cardiac Rhythm Management Division, 705 East With Electronic Control Devices: A
Evelyn Avenue, Sunnyvale, CA 94086; Jeffrey Ho, MD, Cardiovascular Perspective
Department of Emergency Medicine, Hennepin County
Medical Center, 730 8th Street South, Minneapolis, MN
55415; Richard M. Luceri, MD, Holy Cross Hospital, 4725
North Federal Highway, Ft. Lauderdale, FL 33308; Igor R.
Efimov, PhD, Washington University, 1 Brookings Drive,
St. Louis, MO 63130; Hugh Calkins, MD, Johns Hopkins
Hospital, 601 North Caroline Street, Baltimore, MD 21287;
and Patrick J. Tchou, MD, Cleveland Clinic Foundation,
9500 Euclid Avenue, Cleveland, OH 44195
Krompecher, Georges MD, Thomas Krompecher, MD, Evaluation of 122 Forensic Autopsies of 546
PhD*, and Patrice Mangin, MD, PhD, Institut Universitaire Unprotected Victims Killed in Traffic
de Médecine Légale, Rue du Bugnon 21, Lausanne, Accidents
Switzerland
Krompecher, Thomas MD*, André Gilles, MD, Conxita Experimental Evaluation of Rigor Mortis: The 526
Brandt- Casadevall, MD, and Patrice Mangin, MD, Institut Influence of the Breaking (Mechanical
universitaire de Médecine légale, Rue du Bugnon 21, 1005 Solution) on the Development of Rigor Mortis
Lausanne, Switzerland
Krompecher, Thomas MD*, Andre Gilles, MD, Conxita Experimental Evaluation of Rigor Mortis 471
Brandt- Casadevall, MD, and Patrice Mangin, MD, Institut Nysten’s Law: Does it Apply to Rats?
Universitaire de Médecine Légale, Rue du Bugnon 21,
Lausanne, Vaud 1005, Switzerland
Krompecher, Thomas MD*, André Gilles, MD, Conxita Experimental Evaluation of Rigor Mortis - 416
Brandt- Casadevall, MD, Beat Horisberger, MD, and The Influence of the Central Nervous System
Patrice Mangin, MD, Institut Universitaire de Médecine on the Evolution of the Intensity of Rigor
Légale, Rue du Bugnon 21, Lausanne, 1005, Switzerland Mortis
Index 178
Krouse, Marc A. MD*, Tarrant County Medical Examiner, Sudden Death From Arteritis Involving a 149
200 Feliks Gwozdz Place, Fort Worth, TX 76104-4919 Surgically Repaired Coronary Artery - Right
Atrium Fistula
Krupp, Nadia L. MD, Indiana University School of A Case of Fatal Water Intoxication in a 324
Medicine, 702 Barnhill Drive, Indianapolis, IN 46202; Toddler
Michele J. Catellier, MD*, Forensic Pathology Associates
of Indiana, LLC, 521 West McCarty Street, Indianapolis, IN
46225; and Antoinette L. Laskey, MD, MPh, Indiana
University School of Medicine, 702 Barnhill Drive,
Indianapolis, IN 46202
Kumar, Surendra K. MD*, Army College of Medical Blood at the Scene of Death Due to Hanging: 40
Sciences, Delhi Cantonment, New Delhi, 110010, INDIA Artifact or Antemortem
Kurtzman, Robert A. DO, Community Hospital, 2021 North Utilizing Multi-Detector Computerized 59
12th Street, Grand Junction, CO 81501; and Casey P. Tomography to Evaluate Concrete-Encased
Bitting, BS*, 1700 Bassett Street, #2114, Denver, CO 80202 Human Remains
Kuruvilla, Supriya MD*, Harris County Medical Examiner Fatal Acute Thrombosis of Anomalous Right 453
Office and University of Texas Health Science Center, J.A. Coronary Artery Arising From the Left Sinus
Jachimczyk Forensic Center, 1885 Old Spanish Trail, of Valsalva
Houston, TX 77054; Antonio Neto, MD, University of Texas
Health Science Center, 6431 Fannin, MSB 2.120, Houston,
TX 77030; Dwayne A. Wolf, MD, PhD, Harris County
Medical Examiner Office, J.A. Jachimczyk Forensic Center,
Lachowicz, Marrah E. MFS*, University of California Exploration of Non-Cardiogenic Pulmonary 151
Davis, One Shields Avenue, UCDSOM, Tupper Hall 4112, Edema With Chronic Opiate Use: Case
Davis, CA 95616-8643 Studies and Scientific Review
Landi, Kristen MD*, and Andrea Coleman, MD, Office of Sudden Death in Toddlers Due To Influenza 340
the Chief Medical Examiner, 520 First Avenue, New York, B Infection: A Report of Two Cases and a
NY 10016 Review of the Literature
Landolfa, Maria Celeste MD*, Michela Cicconi, MD, Butane Inhalation and Sudden Death: A Case 8
Massimo Gallo, MD, and Andrea Gianelli Castiglione, MD, Report
Department of Legal and Forensic Medicine, Via de Toni
Landon-Chellemi*, Lynette PO Box 523, 59-076 Pupukea Photography of Abuse: Is There a Best 363
Road, Haleiwa, HI 96712; and Wilson T. Sullivan III, MPA, Method?
Chaminade University of Honolulu, Forensic Science
Department, 3140 Waialae Avenue, Honolulu, HI 96816
Lann, Meredith A. MD*, and Jeffrey J. Barnard, MD, Two Cases of Generalized Myxedema 90
Southwestern Institute of Forensic Sciences, 5230
Southwestern Medical Drive, Dallas, TX 75235
Lann, Meredith A. MD*, University of Colorado at Denver An Unusual Death Involving a Sensory 155
Health Sciences Center, AIP - Department of Pathology, Deprivation Tank
12605 East 16th Avenue, Room 3026, Aurora, CO 80045;
and Amy Martin, MD, Denver Office of the Medical
Lantier*, Michael S. Villanova University, 800 Lancaster Undetected Polyglandular Autoimmune 278
Avenue, Villanova, PA 19085; and Fredric N. Hellman, Syndrome Type II (Schmidt Syndrome) as a
MD, MBA, Office of the Medical Examiner, Delaware Cause of Sudden Death
County, Route 352-Fair Acres, Lima, PA 19037
Index 179
Lantz, Patrick E. MD*, and Constance A. Stanton, MD, Postmortem Detection and Evaluation of 379
Department of Pathology, Wake Forest University Health Retinal Hemorrhages
Sciences, Medical Center Boulevard, Winston-Salem, NC
27157-1072
Lantz, Patrick E. MD*, Department of Pathology, Wake Postmortem Monocular Indirect 424
Forest University Health Sciences, Medical Center Ophthalmoscopy
Boulevard, Winston-Salem, NC 27157; and Gill G.W.
Adams, BSc, MBChB, Moorfields Eye Hospital, 162 City
Lantz, Patrick E. MD*, Department of Pathology, Wake Fatal Hyponatremia, Cerebral Edema and 478
Forest University School of Medicine, Medical Center Seizures Associated With Bilateral Peripheral
Boulevard, Winston- Salem, NC 27157-1072 Retinal Hemorrhages in a 20-Month-Old
Child Following Hypotonic Fluid
Administration for Dehydration: Case Report
with Critical Appraisal of the Current
Literature
Lantz, Patrick E. MD*, Department of Pathology, Wake Fatal Acute Intracranial Injury With Subdural 80
Forest University, School of Medicine, Medical Center Hematoma and Retinal Hemorrhages in an
Boulevard, Winston- Salem, NC 27157-1072; and Daniel E. Infant Due to Stairway Fall
Couture, MD, Department of Neurosurgery, Wake Forest
University School of Medicine, Medical Center Boulevard,
Winston Salem, NC 27157
Lantz, Patrick E. MD*, Department of Pathology, Wake Purtscher Retinopathy Detected by 250
Forest University, SOM, Medical Center Boulevard, Postmortem Monocular Indirect
Winston-Salem, NC 27157-1072; Constance A. Stanton, Ophthalmoscopy
MD, Department of Pathology,Wake Forest University of
Health Sciences, Medical Center Boulevard, Winston
Salem, NC 27157; and Marshall E. Tyler, Department of
Ophthalmology, Wake Forest University of Health Sciences,
Medical Center Boulevard, Winston Salem, NC 27157
Lantz, Patrick E. MD*, Wake Forest University Health Papillomacular Folds: Whiplash Maculopathy 270
Sciences, Department of Pathology, Medical Center or Postmortem Artifact?
Boulevard, Winston Salem, NC 27157
Lantz, Patrick E. MD*, Wake Forest University Health Perimacular Retinal Folds and the Shaken 530
Sciences, Medical Center Boulevard, Winston-Salem, NC Baby Syndrome: Critical Appraisal Testing of
the Current Medical Literature
Lantz, Patrick E. MD*, Wake Forest University, School of Sudden Unexpected Infant Death: 64
Medicine, Department of Pathology, Medical Center Lymphocytic Meningoencephalitis With
Boulevard, Winston-Salem, NC 27157-1072; Amy M. Multiple Retinal Hemorrhages
Durso, MD, Professional Pathology Services, One Science
Court, Suite 200, Columbia, SC 29203; and Ryan T. Mott,
MD, Department of Pathology/Wake Forest University
Health Sciences, Medical Center Buolevard, Winston
Salem, NC 27157-1072
Index 180
Larsen, Maiken K. MD*, Department of Forensic Medicine, Genetic Aspects of Sudden Death in Youth: A 87
Brendstrupgårdsvej 100, DK-8200 Aarhus N, DENMARK; Retrospective Study of Familial
Peter H. Nissen, MSc, Department of Clinical Biochemistry, Hypercholesterolemia
Aarhus University Hospital, Tage Hansens Gade, DK-8200
Aarhus N, DENMARK; Ingrid B. Kristensen, MD,
Department of Forensic Medicine, Brendstrupgaardsvej
100, DK-8200 Aarhus N, DENMARK; Henrik K. Jensen,
MSc, Department of Cardiology, Aarhus University
Hospital, Skejby, Brendstrupgaardsvej 100, DK-8200
Aarhus N, DENMARK; and Jytte B. Lundemose, PhD,
Faculty of Health Sciences Aarhus University, Department
of Forensic Medicine, Brendstrupgårdsvej 100, DK-8200
Århus N, , DENMARK
Laskey, Antoinette L. MD, MPH, Children’s Health Postmortem Skeletal Survey Use in Pediatric 306
Services Research, Indiana University School of Medicine, Forensic Autopsies: A National Survey
The Regenstrief Institute for Health Care, 1001 West 10th
Street, Bryce 2112, Indianapolis, IN 46202; and Michele J.
Catellier, MD*, Forensic Pathology Associates of Indiana,
LLC, 521 West McCarty Street, Indianapolis, IN 46225
Latham, Krista E. MS, MA*, Temple University, Difficulties in Determining Sex From the 246
Anthropology Department, Philadelphia, PA 19122; Carlos Skull: Considering Conflicting Lines of
J. Zambrano, MS, C.A. Pound Human ID Lab, 5231 North Evidence
West 56th Court, Gainesville, FL 32653; and Laurel E.
Freas, MA, 3425 South West 2nd Avenue, #246,
Lavezzi, Wendy A. MD*, and Mitra B. Kalelkar, MD, Cook Hemoglobin SC Disease Presenting as Sickle 303
County Medical Examiner’s Office, 2121 West Harrison Crisis After Outpatient Surgery: A Case
Street, Chicago, IL 60612 Report
Lavezzi, Wendy A. MD*, Clare H. Cunliffe, MD, and Hypothermia-Related Deaths in Cook County, 364
Edmund R. Donoghue, MD, Cook County Medical Illinois From November 2000 to February
Examiner’s Office, 2121 West Harrison Street, Chicago, IL 2005
60612
Lavezzi, Wendy A. MD*, Department of Pathology and The Significance of Pulmonary Interstitial 540
Laboratory Medicine, 56 South Westcott Road, Emphysema in Fetal and Infant Autopsies
Schenectady, NY; and Barbara C. Wolf, MD, Forensic
Medicine, PC, Albany, NY
Lecomte, Dominique MD*, and Paul Fornes, PhD, Trauma-Related Hemorrhage vs. Spontaneous 524
Forensic Institute of Paris, Medical School Cochin Port Rupture of Vascular Malformation: Three
Royal, Paris, France Case Reports Illustrating Medico-Legal
Aspects
Lecomte, Dominique MD*, and Paul Fornes, PhD, Rape/Sadistic-Homicide vs. Accidental Death 495
Forensic Institute of Paris, Medical School Cochin Port- During Voluntary Violent Sexual Activity:
Royal, Paris, France Three Case Reports Illustrating Difficulties in
Assessing the Circumstances of the Deaths
Leditschke, Jodie J. PhD*, Victorian Institute of Forensic Mortuary Management in the Aftermath of 110
Medicine, 57- 83 Kavanagh Street, Southbank, Melbourne, the 2009 Australian Bush Fires
3006, AUSTRALIA
Index 181
Lee, Carol Kaluen MD*, New Mexico Office of the Medical Right Ventricular Lipomatosis and Fibrous 217
Investigator, MSC11 6030, 1 University of New Mexico, Tissue in Cases of Non-Cardiac Deaths and
Albuquerque, NM 87131-0001; Charles Lee, MD, Arrhythmogenic Right Ventricular
Vancouver General Hospital, Department of Forensic Cardiomyopathy
BC V5Z 1M9, CANADA; and Michael Allard, MD, James
Hogg iCapture Centre for Cardiovascular and Pulmonary
Research, Room 387, St. Paul’s Hospital, 1081 Burrard
Street, Vancouver, BC V6Z 1Y6, CANADA
Leestma, Jan E. MD*, 1440 North Kingbury Street, Suite The Possibilities and Limitations of 168
210, Chicago, IL 60622 Neuropathology in Exhumation Autopsies
Lemmon, Julie Wilson MD*, Tripler Army Medical Center, Look Until You See: An Unexpected Delayed 487
Tripler Army Medical Center, Tripler AMC, HI; Cynthia D. Death Following a Motor Vehicle Accident
Gardner, MD, Department of Forensic Pathology,
University of Tennessee Health Science Center, 1060
Madison Avenue, Memphis, TN
Lenfest, Stephen MD*, Wake Forest University Baptist Sudden Unexpected Infant Death: Peripheral 13
Medical Center Department of Pathology, Medical Center Retinal Hemorrhages Associated With
Boulevard, Winston Salem, NC 27157; Candace H. Accidental Positional Asphyxiation
Schoppe, MD, Wake Forest University School of Medicine, (Wedging)
Winston Salem, NC 27157; Constance A. Stanton, MD,
Department of Pathology, Wake Forest University Health
Sciences, Medical Center Boulevard, Winston Salem, NC
27157; Donald R. Jason, JD, Wake Forest University
School of Medicine, Medical Center Boulevard, Winston-
Salem, NC 27157-1072; and Patrick E. Lantz, MD, Wake
Forest University Health Sciences, Department of
Pathology, Medical Center Boulevard, Winston- Salem, NC
27157-1072
Lenox, John B. MD, PhD, PE*, Design Excellence, Inc, 435 Fatal Pediatric Head Impact Biomechanics: 475
Isom Road, Suite 224, San Antonio, TX 78216-5144 Homicide vs. Accident
Lesnikova, Iana PhD*, Department of Forensic Pathology Is DNA Purified From Forensic Autopsy 50
of University of Aarhus, Denmark, Brendstrupgaardsvej Material Suitable for Molecular Biological
100, Aarhus N, 8200, DENMARK; Jakob Hansen, PhD, Studies?
Department of Forensic Medicine, University of Aarhus,
Brendstrupgaardsvej 100, Aarhus N, 8200, DENMARK;
and Jytte B. Lundemose, Department of Forensic
Pathology, University of Aarhus, Denmark,
Brendstrupgaardsvej 100, Aarhus N, AK 8200, DENMARK
Li, Ling MD*, and David R. Fowler, MD, Office of The Investigation of Infant Fatalities in Maryland 484
Chief Medical Examiner, State of Maryland, Baltimore, (1990-1999)
MD; Liang Liu, MD, Tongji, Medical University, Wuhan,
China; and Mary G. Ripple, MD, Zoe Lambros, RN, JD,
Havre de Grace, MD, and John E. Smialek, MD, Office of
The Chief Medical Examiner, State of Maryland, Baltimore,
MD
Li, Ling MD*, David R. Fowler, MD, and Ana Rubio, MD, Forensic Pathologists and the NICHD Brain 417
Office of the Chief Medical Examiner, State of Maryland, and Tissue Bank for Developmental Disorders
111 Penn Street, Baltiomre, MD 21201; and Ronald Zielke,
PhD, University of Mayland, Department of Pediatrics,
Brain, and Tissue Bank for Developmental Disorders, 655
West Baltimore Street, Baltimore, MD 21201
Li, Ling MD*, Office of the Chief Medical Examiner, State Natural Causes of Sudden Unexpected Infant 161
Index 182
of Maryland, 111 Penn Street, Baltimore, MD 21201; Lan Death: A Seven Year Retrospective Forensic
Zhou, BM, Department of Forensic Medicine, Tongji Autopsy Study in Hubei, China
Technolohy, Wuhan, 430030, PEOPLES REPUBLIC OF
CHINA; Xiang Zhang, MD*, Office of the Chief Medical
Examiner, 111 Penn Street, Baltimore, MD 21201; Liang
Lui, MD, Tongji Medical College, 13 Hong Kon Road,
Wuhan, Hubei 430030, PEOPLES REPUBLIC OF CHINA;
Lin Chang, MD, Key Laboratory of Evidence Science,
China University of Political Science and Law, Beijing, MD
100040, PEOPLES REPUBLIC OF CHINA; Guangzhao
Huang, BM, Department of Forensic Medicine, Tongji
Technology, Wuhan, MD 430030, PEOPLES REPUBLIC
OF CHINA; and David R. Fowler, MD, Office of the Chief
Li, Melissa MD*, University of Florida College of Fatal Botox®-Induced Anaphylaxis? A Case 440
Medicine, PO Box 100275, 1600 SW Archer Road, Report
Gainesville, FL 32610-0275; Bruce A. Goldberger, PhD,
University of Florida, PO Box 100275, Gainesville, FL
32610-0275; Carolyn Hopkins, MD, District 8 Medical
Examiner’s Office, 606 SW 3rd Avenue, Gainesville, FL
32601
Lin*, Wen-Ling and Kai-Ping Shaw, MD, PhD*, Institute of Determination of β — Phenylethylamine 229
Forensic Medicine, Ministry of Justice, 166-1, Sect. 2, Blood Levels in Carbon Monoxide
Keelung Road, Taipei (106), Taiwan, ROC Intoxicated-Related Fatalities
Lin, Peter T. MD*, and Eric A. Pfeifer, MD, Mayo Clinic, Natural Causes of Death Among a Federal 404
200 First Street, SW, Hilton 11, Rochester, MN 55905 Medical Center Prison Population
Lin, Peter T. MD*, and James R. Gill, MD, Office of Chief Subway Train Related Fatalities in New York 216
Medical Examiner, 520 First Avenue, New York, NY 10016 City: Accident vs. Suicide
Lin, Wen-Ling PhD*, and Kai-Ping Shaw, MD, PhD*, β—Phenylethylamine as a Biomarker in 416
Institute of Forensic Medicine, Ministry of Justice, Republic Mechanical Asphyxia-Related Fatalities
of China, 161-1, Section 2, Keelung Road, Taipei, 106,
Taiwan, Republic of China
Linert, Brian S. BS*, 2102 North Meridian Street, Suicidal Shotgun Wound Using a Shotgun 238
Apartment 9, Indianapolis, IN 46202; Janis Regnier, Barrel, a Shotgun Shell, and a BB
Portage Police Department, Portage, IN ; Barrett W. Doyle,
Porter County Coroner’s Office, Valparaiso, IN; and
Joseph A. Prahlow, MD, South Bend Medical Foundation,
530 North Lafayette Boulevard, South Bend, IN 46601
Linville, Jason G. BS*, Department of Biology, and Jeffrey Removing External Contamination of 576
D. Wells, PhD*, Department of Justice Sciences, University Maggots With a Bleach Solution Without
of Alabama at Birmingham, Birmingham, AL Inhibiting Genetic Analysis of Maggot Crop
Contents
Index 183
Linville, Jason G. BS*, Department of Biology, University Extracting Human DNA From the Crops of 497
of Alabama at Birmingham, 2909 Highland Avenue, S Maggots That Have Been Collected During
Apartment 207, Birmingham, AL; Jeffrey D. Wells, PhD, Different Stages of Development and
Department of Justice Sciences, University of Alabama at Preserved Using Different Methods
Birmingham, 901 15th Street South, Birmingham, AL
Looman, Karen B. DO*, and Wendy M. Gunther, MD, Snake-Shot From a Handgun: An Unusual 281
Tidewater Office of the Chief Medical Examiner, 830 Gunshot Wound Suicide
Looman, Karen B. DO*, and Wendy M. Gunther, MD, A Chest Full of Blood: Hemothorax as a 26 322
Tidewater Office of the Chief Medical Examiner, 830 Year Delayed Consequence of Repair of
Southampton Avenue, Suite 100, Norfolk, VA 23510 Transposition of the Great Vessels
Looman, Karen B. DO*, Hamilton County Coroner’s Return of an Old Acquaintance - A Case of 162
Office, 3159 Eden Avenue, Cincinnati, OH 45219 Septic Abortion
Looman, Karen B. DO*, Pathology Residency Program, Drowning vs. Trauma and Other Causes of 405
Eastern Virginia Medical School, 700 West Olney Road, Asphyxia in Deaths in Water
Norfolk, VA 23507-1607; Wendy M. Gunther, MD, Office of
the Chief Medical Examiner, Tidewater District, 830
Southampton Avenue, Suite 100, Norfolk, VA 23510-1046;
and E.L. Kinnison, Office of the Chief Medical Examiner,
Looman, Karen B. DO*, Tidewater Office of the Chief Unusual Gunshot Wound Death of a Sex 208
Medical Examiner, 830 Southampton Avenue, Suite 100, Offender on the Way to Jail in the World of
Norfolk, VA 23510 CSI
Lopez, Ana E. MD*, Harris County Medical Examiner, Death by a Radio-Controlled Helicopter 370
1885 Old Spanish Trail, Houston, TX 77054; Luis A.
Sanchez, MD, Harris County Medical Examiner, 1885 Old
Lopez, Ana E. MD*, Harris County Medical Examiner’s A Diagnosis of Chagas Disease at Autopsy 251
Office, 1885 Old Spanish Trail, Houston, TX 77054; L.
Maximiliam Buja, MD, University of Texas-Houston Health
Science Center, 7000 Fannin, Suite 1715, Houston, TX
77030; and Luis A. Sanchez, MD, Harris County Medical
77054
Lopez, Ana E. MD*, Jeffrey J. Barnard, MD, and Charles Motor Vehicle Collision-Related Death Due 540
L. White III, MD, Southwestern Institute of Forensic to Delayed-Onset Subarachnoid Hemorrhage
Sciences, 5230 Medical Center Drive, Dallas, TX; Jaime L. Associated With Anticoagulant Therapy
Oeberst, MD, Sedgwick County Regional Forensic Science
Center, Wichita, KS; and Joseph A. Prahlow, MD, South
Bend Medical Education, University of Notre Dame, South
Bend, IN
Lorente, Miguel MD, PhD*, and A. Carrasco, Institute of Establishing a Protocol Between Clinical and 400
Legal Medicine of Granada (Spain), Av.Sur, 5, Granada, Forensic Institutions to Treat and Investigate
18071, Spain; José A. Lorente, MD, PhD, University of Violence Against Women Cases
Granada, Department of Forensic Medicine, Granada,
18012, Spain; Enrique Villanueva, MD, PhD, Department
of Legal Medicine, University of Granada, Avda. Madrid,
sn/, Granada, 18071, Spain
Index 184
Lorin, Geoffroy e la Grandmaison, MD*, M. Lettereux, Study of the Diagnostic Value of Iron in 406
PharmD, K. Lasseguette, MD, J.C. Alvarez, PharmD, Freshwater Drowning
Philippe de Mazancourt, MD, PhD, and Michel Durigon,
MD, PhD, Department of Forensic Pathology, Raymond
Poincare Hospital, Garches, 92 380, France
Lorin, Geoffroy e la Grandmaison, PhD*, AP-HP, Philippe Usefulness of Systematic Histological 202
Charlier, PhD, AP-HP, and Michel Durigon, PhD, AP-HP, Examination in Routine Forensic Autopsy
104 Boulevard Raymond Poincaré, Raymond Poincaré
Hospital, Garches, F-92380, FRANCE
Love, Jennifer C. PhD*, and Luis A. Sanchez, MD, Harris Recognizing Classic Metaphyseal Lesions in 224
County, Medical Examiner’s Office, 1885 Old Spanish Child Abuse: An Autopsy Technique
Luca, Pistolesi MD*, Institute of Legal Medicine, Via Del Diagnosis Of Drowning: The Contribution Of 8
Giochetto Snc, Perugia, ID 06100, ITALY Microbiological Investigations
Luckasevic, Todd M. DO*, Alleghey County, Office of the One Entrance Wound, Three Bullets, and 237
Medical Examiner, 542 Fourth Avenue, Pittsburgh, PA Four Pulls of the Trigger: An Unusual Case of
15219; Kenneth Clark, MD, University of Pittsburgh a Suicidal Gunshot Wound of the Head
Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213;
and Abdulrezak M. Shakir, MD, and Karl E. Williams, MD,
MPH, Alleghey County, Office of the Medical Examiner,
Luckasevic, Todd M. DO*, and Baiyang Xu, MD, Allegheny Bitten by Snake Shot: Attempted Homicide 41
County Medical Examiner’s Office, 1520 Penn Avenue, and Successful Suicide With Multiple
Pittsburgh, PA 15222; and Abdulrezak M. Shakir, MD, and Gunshot Wounds
Karl E. Williams, MD, MPH, Office of the Medical
Examiner - Allegheny County, 542 Fourth Avenue,
Luckasevic, Todd M. DO*, Laine L. Frazier, BS, Newborn Kidnapping by Crude Cesarean 141
Abdulrezak M. Shakir, MD, Baiyang Xu, MD, and Karl E. Section
Williams, MD, MPH, Allegheny County Medical
Examiner’s Office, 1520 Penn Avenue, Pittsburgh, PA
15222
Luckasevic, Todd M. DO*, Marcella F. Fierro, MD, and Dead Hits: Matching Decedents’ DNA to 422
Timothy A. Powell, MPH, Office of the Chief Medical Unsolved Crime Scenes
Examiner, 400 East Jackson Street, Richmond, VA 23219;
and George C. Li, MS, Linda Johnston, BS, and Deanne F.
Dabbs, MFS, Division of Forensic Science, 700 North 5th
Mackey-Bojack, Shannon M. MD*, Jesse E. Edward’s A Review of Pathologic Findings in 391
Registry of Cardiovascular Disease, John Nasseff Heart Specimens Following Heart Valve Donation
Hospital, 333 North Smith Avenue, Suite 4625, St. Paul, MN
55102; Susan J. Roe, MD, Rachel M. Meuleners, and
Lindsey C. Thomas, MD, Regina Medical Center, 1175
Nininger Road, Hastings, MN 55033; and Jack L. Titus,
MD, PhD, Jesse E. Edwards Registry of Cardiovascular
Disease, John Nasseff Heart Hospital, 333 North Smith
Avenue, Suite 4625, St. Paul, MN 55102
Magni, Paola A. MS*, F.E.LAB ASL TO1, c/o Civico Dead Men in Wells: How Forensic Science 129
Obitorio di Torino, Via Bertani 112/A, Torino, 10137, Was Used to Solve a Crime in an Aquatic
ITALY; and Mario A. Apostol, PhD, SC Medicina Legale Environment
ASL TO4, Via C. Bertetti 10A, Torre Canavese (TO),
10100, ITALY
Index 185
Magni, Paola A. MS, F.E.LAB ASL TO1, c/o Civico Mass Disaster Procedures: Forensic Pathology 57
Obitorio di Torino, Via Bertani 112/A, Torino, 10137, and Genetic Techniques Used to Locate Nine
ITALY; Giulio Di Mizio, PhD*, Policlinico Universitario Missing People in the Calabria Region
Camp, Germaneto, Edificio Clinico, Sec. Foren Med, Viale (Southern Italy)
Europa, Catanzaro, 88100, ITALY; Federica Colosimo,
MD, Magna Graecia University of Catanzaro, Viale Europa
Loc. Germaneto, Catanzaro, 88100, ITALY; Sergio
Schiavone, PhD*, RIS Carabinieri, S.S. 114 Km 3,400,
Messina, 98128, ITALY; Carlo G. Romano, MSc, RIS
Carabinieri, S.S. 114 Km 6,400, Messina, 98128, ITALY;
Ciro Di Nunzio, Institute of Legal Medicine, School of
Medicine, Magna Graecia University, Viale Europa
Germaneto, Catanzaro, 88100, ITALY; Ian Dadour, PhD,
Centre for Forensic Science, University of Western
AUSTRALIA; and Pietrantonio Ricci, MD, Università degli
Studi Magna Grecia Catanzaro, Viale Europa - Località
Germaneto, Catanzaro, ITALY
Maile, Amy E. BS*, and David O. Carter, PhD, University Gravesoil Microbial Community Structure 47
of Nebraska, Lincoln, Department of Entomology, 202 During Carcass Decomposition
Entomology Hall, Lincoln, NE 68583-0816; and Rhae A.
Drijber, PhD, University of Nebraska-Lincoln, Department
of Agronomy and Horticulture, 279 Plant Sciences Hall,
Malbranque, Stephane MD*, French-DVI, Chu Fort-De- The Identification of French Victims in the 54
France, Hop. La Meynard, BP 632, Fort-De-France cedex, Massive Earthquake on January 12, 2010 in
97261, MARTINIQUE Haiti
Malik, Sobia MSc*, Centre of Forensic Sciences, 25 An Atypical STR Genotype, Including a 499
Grosvenor Street, 4th Floor, Toronto, Ontario, Canada Three-Banded Allelic Pattern, From a Biopsy
Tissue Sample
Mallak, Craig T. MD JD*, Office of the Armed Forces Investigation, Identification, and Repatriation 463
Medical Examiner, Armed Forces Institute of Pathology, of Contaminated Fatalities
1413 Research Boulevard, Rockville, MD 20850; Elspeth C.
Ritchie, MD*, USUHS, Department of Psychiatry, Room
B3068, 4301 Jones Bridge Road, Bethesda, MD 20814
Malone, Jonrika M. MD*, Ana Rubio, MD, PhD, Corey Death by Suicide in Maryland: A Cross- 285
Tayman, and David M. Fowler, MD, State of Maryland Sectional Study, 2002 to 2005
Baltimore, MD 21201
Manishen, Jeffrey R. BA*, Ross & McBride LLP, 1 King Wrongful Convictions and Pediatric Forensic 167
Street West, 10th Floor, PO Box 907, Hamilton,, L8N 3P6, Pathology: The Canadian Experience
CANADA
Maresi*, Emiliano and Livio Milone, PhD, Via Del Vespro, Isolated Coronary Anomalies and Sudden 68
N. 127, Palermo, 90100, ITALY; Paola Pugnetti, MD, Death in the Young
of Legal Medicine, Via Del Vespro, n. 129, Palermo, 90127,
ITALY; Francesco P. Busardo, MD, Institute of Legal
Medicine, Via Del Vespro, 129, Palermo, 90127, ITALY;
Nunzia Albano, MD, Pierangela Fleres, MD, Via Del
vespro 127, Palermo, 90100, ITALY; and Paolo
Procaccianti, Palermo University, Via Del Vespro, n. 127,
Index 186
Maresi*, Emiliano Antonina Argo, Massimo Grillo, Progressive Isolated Hypoglossal Nerve Palsy 222
Valentina Murgo, Filippo M. Cascino, and Paolo and Sudden Asphyxial Death
Procaccianti, Palermo University, Via del Vespro, n. 127,
Maresi*, Emiliano Antonina Argo, Pierangela Fleres, Intrauterine Sudden Death: Study of the Fetal 211
Paolo Procaccianti, and Michele Spicola, Palermo Morphological Substrates
University, Via del Vespro, n. 127, Palermo, 90100, ITALY
Margolius, Karin A. MD, LLB* and Gerard A. Cadden, The Influence of Violence in the Media on 445
MD, PathCentre, Locked Bag 2009, Nedlands, Perth, WA Unusual Methods of Murder and Suicide
6009, Australia
Marks, Murray K. PhD*, and Mariateresa A. Tersigni, MA, Microscopic Soft Tissue Decomposition and 418
University of Tennessee, Department of Anthropology, 250 Time Since Death
South Stadium Hall, Knoxville, TN 37996; and Darinka X.
Mileusnic, MD, PhD, University of Tennessee Medical
Center, Knox County Medical Examiner’s Office, 1924
Alcoa Highway, Knoxville, TN 37920
Marks, Murray K. PhD*, University of Tennessee, Histopathology of Antemortem Infant Bone 319
Department of Anthropology, 250 South Stadium Hall, Fractures: Estimation of Time Since Insult
Knoxville, TN 37996-0720; and Darinka X. Mileusnic, MD,
PhD, Regional Forensic Center, University of Tennessee
Medical Center, 1924 Alcoa Highway, Knoxville, TN 37920
Marshall, Amanda J. BS*, Jennifer R. Simon, BS*, and The Effect of Clothing on Scavenger Visits 158
Phillip L. Watson, PhD*, Ferris State University, and Decomposition
Department of Biology, 2004 ASC, 808 Campus Drive, Big
Rapids, MI 49307
Martin, Mary Jo MD*, Office of the Chief Medical A Cluster of Child Deaths: A Medical 458
Examiner, 400 East Jackson Street, Richmond, VA 23219; Examiner System Participates in an
Wendy M. Gunther, MD*, Office of the Chief Medical Epidemiologic Investigation in Virginia
Examiner, 830 Southampton Avenue, Suite 100, Norfolk, VA
23510; Lisa A. Weymouth, PhD*, Virginia Division of
Consolidated Laboratory Services, 600 North 5th Street,
Richmond, VA 23219; Elizabeth L. Kinnison, MD, Office of
Suite 100, Norfolk, VA 23510; Deborah Kay, MD, Office of
the Chief Medical Examiner, 400 East Jackson Street,
Richmond, VA 23219; William T. Gormley, MD and
Marcella F. Fierro, MD, Office of the Chief Medical
Examiner, 400 East Jackson Street, Richmond, VA 23219
Martin, Shuala S. MA*, C A. Pound Human Identification Victim-Offender Relationship in Florida 573
Laboratory, University of Florida, 124 Fisherman Road, Medical Examiner District 8
Satsuma, FL
Martin-Orozco, Ubicelio EDV*, Ciudad Juarez Findings of the Examinations of Suspected 71
Autonomous University, Benjamin Franklin# PRONAF Animal Cruelty Cases Submitted to the
Zone, Juarez, 32315, MEXICO; Barbara Benhart, DVM, Birmingham Jefferson County Animal
Jefferson County Animal Control, 6227 5th Avenue North, Control
Birmingham, AL 35212; and Elizabeth A. Gardner, PhD,
University of Alabama Department of Justice, UBOB 210,
1530 3rd Avenue, South, Birmingham, AL 35294-4562
Martrille*, Laurent Anne Dorandell, MD, Lauren Bone Scintigraphy and Battered Children: 486
Boismenu, Oliver Cougnenc, and Eric Baccino, MD, Limit and Indication About a Case Report
Service de Médecine Légale, CHU Lapeyronie, 191 av,
Montpellier, France
Index 187
Martrille, Laurent MS, MD*, Service de Medecine Legale, Identification of Twenty Charred Victims of a 255
CHU Lapeyronie, 191 Avenue, du Doyen Gaston Giraud, Helicopter Accident, Africa
Montpellier, CEDEX 5 34295, FRANCE; Charles Georget,
DMD, Stéphane Chapenoire, MD, Jean Paul Tissier, MS,
and Laurent Chartier, PhD, CTGN, IRCGN, 1 Boulevard T
Sueur, Rosny Sous Bois, 93111, FRANCE; Didier Buiret,
MS, SCIJ, 31 av Franklin Roosevelt, Ecully, 69134,
FRANCE; Géréard De Lassus, MS, IJPN, Paris, 75000,
FRANCE; and Eric Baccino, MD, 371, av du Doyen Gaston
GIRAUD, 34295 Montpellier, Hopital Lapeyronie, Cedex 5,
FRANCE
Matshes, Evan MD*, Southwestern Institute of Forensic Retinal and Optic Nerve Sheath Hemorrhages 78
Sciences, 5230 Southwestern Medical Avenue, Dallas, TX Are Not Pathognomonic of Abusive Head
75235 Injury
Matshes, Evan MD, c/o Dr. Amy Gruszecki, Southwestern Child Deaths Due to Television Falls With 146
Institute, of Forensic Sciences, 5230 Medical Center Drive, Injury Patterns That Mimic Child Abuse
Dallas, TX 75235; Reade A. Quinton, MD, University of
Texas Southwestern, Department of Pathology, 5323 Harry
Hines Boulevard, Dallas, TX 75390; and Amy C. Gruszecki,
DO, and Jeremy Deisch, MD*, Southwestern Institute, of
Forensic Sciences, 5230 Medical Center Drive, Dallas, TX
Matzke, Lise A.M. MSc*, and Courtney Young, BSc*, James Pathological Changes Associated With Aortic 331
C Hogg iCAPTURE Centre, Room 166, 1081 Burrard Valve Stenosis
Street, Vancouver, BC V6Z 1Y6, Canada
Matzke, Lise A.M. MSc*, and William M. Elliott, PhD, Fatty Versus Fibrofatty Involvement of the 101
UBC-James Hogg iCAPTURE, University of British Myocardium in Sudden Death and Heart
Columbia/Providence Health Care, Saint Paul’s Hospital Failure
Room 166, 1081 Burrard Street, Vancouver, V6H 1P9,
CANADA; Crystal Leung, BMLSc, James Hogg iCapture
Centre for Cardiovascular and Pulmonary Research, Saint
Paul’s Hospital, Room 166 1081 Burrard Street,
Vancouver, V6Z 1Y6, CANADA; Carol Lee, MD, 2165
Fraserview Drive, Vancouver, V5P 2N2, CANADA; Charles
Lee, MD, Vancouver General Hospital, Department of
Forensic Pathology, 855 West 12th Avenue, Room 1352,
Vancouver, BC V5Z 1M9, CANADA; Bruce M. McManus,
PhD, James Hogg iCAPTURE Centre, Saint Paul’s
Hospital, 1081 Burrard Street, Vancouver, V6H 1P9,
CANADA; and Michael Allard, MD, James Hogg iCapture
Centre for Cardiovascular and Pulmonary Research, 1081
Burrard Street, Vancouver, BC V6Z 1Y6, CANADA
Matzke, Lise A.M. MSc*, Michael Allard, MD, and Bruce Clinical and Pathological Spectrum of Fatty 231
M. McManus, James Hogg iCapture Centre for Cardiomyopathy in Sudden Cardiac Death
Cardiovascular and Pulmonary Research, St. Paul’s
Hospital, 1081 Burrard Street, Vancouver, BC V6H 1P9,
CANADA; Carol K. Lee, MD, New Mexico Office of the
Medical Investigator, MSC11 6030, 1 University of New
Mexico, Albuquerque, NM 87131-0001; and Charles Lee,
MD, Vancouver General Hospital, Deptartment of Forensic
BC V5Z 1M9, CANADA
Index 188
Mauillon, Damien MD*, Service de Médecine Légale, Sudden Cardiac Death in an Athlete: A Case 24
Centre Hospitalier Universitaire, 4 rue Larrey, Angers Report
Cedex 9, 49933, FRANCE; Nathalie Jousset, MD, Centre
Hospitalier Universitaire, 4 rue Larrey, Angers Cedex 9,
49933, FRANCE; Paul Fornes, PhD, Hospital Robert
Debre, Avenue du General Koeing, Reims, 51100,
FRANCE; and Clotilde Rouge-Maillart, PhD, Centre
Hospitalier Universitaire, Service de Médecine Légale, 4
rue Larrey, Angers Cedex 9, 49933, FRANCE
Maulean, Géraldine MD*, Alain Tabib, PhD, Daniel Sudden Death Due to Mesothelioma of the 106
Malicier, and Laurent Fanton, PhD, Institut of Legal Atrio-Ventricular Node
Medicine, 12 Avenue Rockefeller, Lyon, 69008, FRANCE
Mazuchowski, Edward L. MD, PhD*, Office of the Armed Can Mandibular Fractures Occur in Non-Oral 285
Forces Medical Examiner, 1413 Research Boulevard, Contact Shotgun Wounds of the Head?
Rockville, MD 20850; Mary G. Ripple, MD, Office of the
21201; Craig T. Mallak, JD, MD, Office of the Armed
Forces Medical Examiner, 1413 Research Boulevard,
Rockville, MD 20850; and David R. Fowler, MD, Office of
MD 21201
Mazuchowski, Edward L. PhD*, and Philip J. Berran, JD, Use of Multidetector Computed Tomography 53
Office of the Armed Forces Medical Examiner, 1413 (MDCT) in the Evaluation of Gunshot
Research Boulevard, Building 102, Rockville, MD 20850; Wounds
and Howard T. Harcke, MD, Armed Forces Instiute of
Pathology, 6825 16th Street Northwest, Washington, DC
20306
McCall-Tackett, Kimberly BS*, Maricopa County, Forensic Toxicological Implications in Heat Related 235
Science Center, 701 West Jefferson Street, Phoenix, AZ Deaths in Phoenix, Arizona: Case Reports
85050; Ann L. Bucholtz, MD, 6643 East Sweetwater From the Office of the Medical Examiner
Avenue, Scottsdale, AZ 85254; Amy L. Lais, BS, Maricopa
County Forensic Science Center, 701 West Jefferson Street,
Phoenix, AZ 85007; and Norman A. Wade, MS, Office of the
Medical Examiner, Forensic Science Center, 701 West
Jefferson Street, Phoenix, AZ 85007
McCarthy, Lezah P. MD*, Wake Forest University Baptist A Fatal Complication of Vacuum-Assisted 11
Medical Center, Medical Center Boulevard, Winston Salem, Vaginal Delivery
NC 27157; and Constance A. Stanton, MD, and Patrick E.
McElligott, Hilary S. MD*, Cook County Office of the Nailing the Diagnosis: Features of Fatal 135
Medical Examiner, 2121 West Harrison Street, Chicago, IL Injury Inflicted By Unusual Projectiles and
60612-3705 Firearms
McIlroy, John W. BS*, Michigan State University, Use of Volatile Organic Compounds and 103
Chemistry Building, East Lansing, MI 48824; and Ruth Chemometric Procedures to Determine
Waddell Smith, PhD, Michigan State University, School of Postmortem Interval
McKenna, James J. PhD*, University of Notre Dame, 613 Mother/Infant Co-Sleeping/Bed-Sharing and 534
Flanner, South Bend, IN; and Joseph A. Prahlow, MD*, Sudden Infant Death Syndrome
South Bend Medical Foundation & Indiana University
School of Medicine, 530 North Lafayette, South Bend, IN
Index 189
McLaughlin, Poppy MSc*, Bournemouth University, Fern Evaluation of the Randox Whole Blood Drugs 60
Barrow, Talbot Campus, Poole, BH12 5BB, UNITED of Abuse (DOA) Microchip Arrays for Use
KINGDOM; Derrick J. Pounder, MB, University of With Alternative Postmortem Samples as a
Dundee, Department of Forensic Medicine, Dundee, DD1 Rapid Near-Body Screen
4HN, UNITED KINGDOM; and Michael D. Osselton,
Bournemouth University, Fern Barrow, Talbot Campus,
Poole, BH12 5BB, UNITED KINGDOM
McLemore, Jerri MD, and Steven Tvrdik, BS*, Iowa Office The Role of Scene Investigation in 210
of the State Medical Examiner, 2250 South Ankeny Uncovering Staged Suicides
McMillen, Joshua R. BS*, 4715 Garden Ranch Drive, NMR and Bioinformatic Studies on the 129
Apartment 308, Colorado Springs, CO 80918 Metabolic Effects of Acetaminophen in Rat’s
and Human’s in Urine: A Metabonomic
Approach
McSweeney, Bridget R. BA*, 1629 South Shenandoah Variance in Growth Rates of Calliphora 58
Street, Los Angeles, CA 90035; and Tal Simmons, PhD, vomitoria on Different Tissue Types: Mass
School of Forensic & Investigative Sciences, University of Raised vs. Single Raised
Central Lancashire, Preston, PR1 2HE, UNITED
KINGDOM
Melinek, Judy MD, New York City Office of Chief Medical Postmortem Analysis of Anastomotic Suture 447
Examiner, 520 First Avenue, New York, NY 10016; Patrick Line Disruption Following Carotid
Lento, MD*, Mount Sinai Hospital Medical Center, 1190 Endarterectomy
Fifth Avenue, New York, NY 10029; John Moalli, ScD*,
Exponent Failure Analysis Associates, 149 Commonwealth
Drive, Menlo Park, CA 94025
Memari, Behnoush MS*, Kenneth G. Furton, PhD, and Improved Estimation of Time Since Death 209
Alberto Sabucedo, Florida International University, 11200 With Multiple Protein Markers and
South West 8th Street, Miami, FL 33199 Automated Analytical Methods
Memari, Behnoush MS*, Kenneth G. Furton, PhD, and Improved Estimation of Postmortem Interval 268
Alberto Sabucedo, PhD, Florida International University, With Multiple Protein Markers and Improved
Department of Chemistry and Biochemistry, 11200 SW 8th Analytical Methods
Street University Park CP-345, Miami, FL 33199
Mendoza, Maria Angelica MS*, Heather Erek, BS*, and Using Multiplexed Microsatellite Markers of 344
José R. Almirall, PhD, 11200 SW 8th Street, CP194, Miami, Cannabis sativa to Determine Genetic
FL 33199 Diversity
Menezes, Ritesh G. MD*, Kasturba Medical College, Sudden Unexplained Death Due to 159
Mangalore, India, Department of Forensic Medicine, Light Disseminated Malaria
House Hill Road, Mangalore, Karnataka 575001, INDIA
Merayo-Rodriguez, Juan A. MD*, Frank Braza, and Jeffrey Arrhythmogenic Right Ventricular 218
West, Danbury Hospital, 24 Hospital Avenue, 2 Tower Lab, Dysplasia/Cardiomyopathy a Not So
Danbury, CT Infrequent Cause of Sudden Death - A
Danbury Hospital Five Year Experience (June
2002 - June 2007)
Merritt, Richard W. PhD*, Michigan State University, Insects of the Grave: A Cold Case History 351
Department of Entomology, 243 National Science Building, Involving Insects 27 Years After Death
East Lansing, MI 48824; Mark E. Benbow, PhD,
Department of Biology, DePauw University, Greencastle,
IN 46135; Ryan K. Kimbirauskas, MS, Michigan State
University, Department of Entomology, East Lansing, MI
48824; Joyce L. deJong, DO, Sparrow Hospital, 1215 East
Michigan Avenue, Lansing, MI 48909; and Richard Snider,
PhD, Michigan State University, Department of Zoology,
Index 190
Michaud, Corinne L. BS*, and David R. Foran, PhD, Simple Tissue Preservation Methods That 357
Forensic Science Program, School of Criminal Justice, 560 Result in Reliable DNA Analyses
48824
Michaud, Katarzyna MD*, and Marc Augsburger, PhD, Evaluation of NT-proBNP as Marker of Heart 311
Institut Universitaire de Médecine Légale, Bugnon 21, Failure in Postmortem Examination
Lausanne, 1005, Switzerland; Nicolas Donzé, Consilia,
Grand Champsec86, Sion, 1950, Switzerland; and Marc
Bollmann, MD, Béat Horisberger, MD, Bettina Schrag,
MD, and Patrice Mangin, PhD, Institut Universitaire de
Médecine Légale, Bugnon 21, Lausanne, 1005, Switzerland
Michaud, Katarzyna MD*, Centre Universitaire Romand de Genetic Testing of Sudden Cardiac Death 187
Médecine Légale, Rue du Bugnon 21, Lausanne, 1005, Victims: From a Forensic to a
SWITZERLAND; and Bernice Elger, PhD, Centre Multidisciplinary Approach
Universitaire Romand de Médecine Légale, 1211 Genève,
Rue Michel-Servet 1, Genève, SWITZERLAND
Michaud, Katarzyna MD*, Centre Universitaire Romand Inherited Cardiac Diseases and Molecular 33
de, Medecine Legale, Rue du Bugnon 21, Lausanne, 1005, Autopsy: Perspectives and Limitations
SWITZERLAND; Florence Fellmann, PhD, University
Service of Medical Genetics, Lausanne, 1010,
SWITZERLAND; and Patrice Mangin, PhD, Centre
Michaud, Katarzyna MD*, Nathalie Romain, MD, and Deaths Related to Conduction System 543
Patrice Mangin, MD, PhD, Institut Universtaire de Pathology
Médecine Légale, Rue du Bugnon 21, Lausanne,
Switzerland
Michaud, Katarzyna MD*, Thomas Krompecher, MD, Béat Interpreting Lesions to the Conduction 389
Horisberger, MD, Marc Augsburger, PhD, Frank Sporkert, System of the Heart in Case of Death Pursant
PhD, and Patrice Mangin, MD, PhD, Institut Universitaire to Cocaine Ingestion
de Médecine Légale, Bugnon 21, Lausanne, 1005,
Switzerland
Michaud, Katarzyna MD*, Thomas Krompecher, MD, Fibrosis of the Cardiac Conduction System as 333
Frank Sporkert, PhD, Franco Taroni, PhD, Béat a Possible Cause of Death in Chronic Cocaine
Horisberger, MD, Marc Augsburger, PhD, and Patrice Addicts
Mangin, MD, PhD, Institut Universitaire de Médecine
Légale, Bugnon 21, Lausanne, 1005, Switzerland
Mileusnic, Darinka MD, PhD*, Knox County Medical Lucid Interval Revisited: Delayed Onset of 483
Examiner’s Office, University of Tennessee Medical Center, Unconsciousness in an Impacted Child
Department of Pathology, Knoxville, TN 37922; Edmund R.
Donoghue, MD, Cook County Office of the Medical
Examiner, Chief Medical Examiner, 2121 West Harrison
Mileusnic-Polchan, Darinka MD, PhD*, University of Child Abuse by Another Child: Can it 433
Tennessee Medical Center, Knox County Medical Happen?
Examiner’s Office, 1924 Alcoa Highway, Knoxville, TN
37920; and Sharon O’Connor, Cook County Office of the
Medical Examiner, 2121 West Harrison Street, Chicago, IL
60612
Milewski, Yvonne I. MD*, Office of Chief Medical Phenylpropanolamine and Acute Intracerebral 554
Examiner, 520 First Avenue, New York, NY Hemorrhage
Index 191
Miller, Elizabeth J. MD*, Caddo Parish Coroner’s Office, Characterization of Recent Cocaine and 459
1704 Market Street, Shreveport, LA 71101; Sharon Brooks, Methadone-Related Death Trends in Caddo
Jacksonville State University, Jacksonville, AL 36265; Parish, Louisiana, With Comparison to
Patricia Dooley-Netherland, and George M. McCormick National Trends
III, MD, PHD, Caddo Parish Coroner’s Office, 1704
Market Street, Shreveport, LA 71101
Milroy, Chris MD*, University of Ottawa, The Ottawa Traumatic Injuries in Fatal Tire Explosions 77
Hospital, 501 Smyth Road, Box 117, 4th Floor CCW,
Ottawa, ON K1H 8L6, CANADA; and Alison Edgecombe,
MD, The University of Ottawa, Departemnt of Pathology
and Laboratory Medicine, PO Box 117, 4th Floor CCW,
501 Smyth Road, Ottawa, ON, CANADA
Milroy, Christopher M. MD, LLB*, and Sacha Kolar, Sudden Death and Keratoderma Associated 291
MBChB, Forensic Science Service, The Medico-Legal Cardiomyopathy: An “Affray” of the Heart
Center, Watery Street, Sheffield, South Yorkshire S3 7ES,
United Kingdom; and Kim Survana, MBChB, Sheffield
Teaching Hospitals, Northern General Hospital, Herries
Road, Sheffield, South Yorkshire S5 7AU, United Kingdom
Moffatt, Ellen G. MD*, Office of the Chief Medical Liver Laceration as a Result of Resuscitation 265
Examiner, 850 Bryant Street, San Francisco, CA 94103 in an Adult Man
Moffatt, Ellen MD*, City & County of San Francisco Office Fatal Tiger Attack on a Zoo Patron: Patterns 71
of the Medical Examiner, 850 Bryant Street, San Francisco, and Types of Injuries in Large Predatory Cats
CA 94103; Gregory L. Mar, DDS*, Hall of Justice, 850
Bryant Street, Room 442, San Francisco, CA 94103; Duane
E. Spencer, DDS*, 1855 San Miguel Drive, Suite 9, Walnut
Creek, CA 94596-5282; John K. Berk, DDS, 20652
Redwood Road, Castro Valley, CA 94546; James D. Wood,
DDS, 102 South Main Street, Cloverdale, CA 95425;
Freeland Dunker, DVM, California Academy of Sciences,
Steinhart Aquarium, 55 Music Concourse Drive, San
Francisco, CA 94118; and Jacqueline Jencek, DVM, San
Francisco Zoollogical Society, 1 Zoo Road, San Francisco,
CA 94132-1098
Mohr, Rachel M. MS*, and Jeffery K. Tomberlin, PhD, Patterns of Adult Blow Fly Attraction to 179
Department of Entomology, Texas A&M University, 2475 Carrion Over Time
TAMU, College Station, TX 77843-2475
Molina, D. Kimberley MD*, Bexar County, Medical Is Toxicological Analysis Necessary in 152
Examiner’s Office, 7337 Louis Pasteur Drive, San Antonio, Postmortem External Examinations?
TX 78229; and Meredith A. Lann, MD*, UCDHSC, AIP -
Department of Pathology, 12605 East 16th Avenue, Room
3026, Aurora, CO 80045
Mont, Erik K. MD*, Miami-Dade County Medical Examiner Fatal Kawasaki Disease Associated With 450
Department, Number One on Bob Hope Road, Miami, FL Cardiac Rhabdomyomas in an Infant
33136; Allen P. Burke, MD, Armed Forces Institute of
Pathology, Department of Cardiovascular Pathology, 6825
16th Street, NW, Building 54, Room 2005, Washington, DC
20306
Morreale, Francesco M. MD*, Irene Riezzo, MD, Stefano Forensic Approach in a Case of Simultaneous 376
D’Errico, MD, and Raffaella Bisceglia, MD, Institute of Sudden Infant Death Syndrome
Forensic Pathology Foggia University, V.le Luigi Pinto 1,
Index 192
Morreale, Francesco Maria MD*, Christoforo Pomara, A Modern “Martyr’s Crown”: A Fatal Case of 421
MD, and Stefano D’Errico, MD, Institute of Legal Multiple Self-Inflicted Nail Gun Shots
Medicine, University of Foggia, Ospedali Riuniti, via L.
Pinto 1, Foggia, I-71100, Italy; and Rocco Maglietta, MD,
Hospital San Carlo, Potenza, I-85100, Italy
Morrow, Paul L. MD*, and Michael Rodriguez, MBBS, Use of Beta-APP Stain in a Case of Fatal Dog 312
Department of Forensic Medicine, 42-50 Parramatta Road, Attack
Glebe, New South Wales 2037, Australia
Moser, Lauren E. MD*, Office of the Chief Medical Prolonged Survival Time Following Duodenal 165
Examiner, 111 Penn Street, Baltimore, MD 21201; Mary G. Transection in a Child With Abdominal
Ripple, MD, 68 Bluebird Road, Port Deposit, MD 21904; Trauma
Mulawka, Marzena H. MFS*, Forensic Sciences Program, A Uniform Protocol to Address the Rapidly 111
National University, 11255 North Torrey Pines Road, La Accumulating Unidentified Human Remains
Jolla, CA 92037-1011; Ismail M. Sebetan, MD, PhD, 12752 and Missing Persons in the United States — A
Via Nieve, San Diego, CA 92130; and Paul Stein, PhD, Nation’s Silent Mass Disaster
25757 Bellemore Drive, Ramona, CA 92065
Murad, Turhon A. PhD*, California State University, A Degloving Experiment to Suggest 245
Department of Anthropology, 400 West First Street, Chico, Postmortem Interval: Give the Anthropologist
CA 95929-0400 Some Hands From Freshwater
Murphy, Gordon K. MD*, 814 Hathaway Road, Dayton, Roll-Over Automobile Accident Survived By 515
OH the Author as a Passenger
Murphy, Gordon K. MD*, 814 Hathaway Road, Dayton, The Memorials at the Lockerbie and 559
OH Ermenonville Forest Air Disaster Sites
Murphy, Gordon K. MD*, 814 Hathaway Road, Dayton, Significant Trends in Work-Related Deaths 441
OH 45419-3555 — United States
Muzafarova*, Zalina Main Bureau of Forensic Medicine, The Influence of the Meteorological Factors 40
Mirakhmedov Street, 143, Tashkent, UZBEKISTAN on Occurrence of the Suicide Cases
Nance, Gerald N. BA*, National Center for Missing and Request for Uniform Autopsy Protocols on 112
Exploied Children (NCMEC), 699 Prince Street, Certain Drowning Victims
Alexandria, VA 22314
Neece, Timmy L. BS, BA*, 1239 9th Street, Apartment 1, Conversion of the Wyoming State Crime 190
Huntington, WV 25701 Laboratory From FM-BIO Slab Gel
Technology to the AB 3130 Genetic Analyzer
for CODIS and Casework Sample Analysis
Neitzel, Amber R. BS*, 550 East Van Buren Street, Phoenix, Death Certification of “Suicide by Cop” 38
AZ 85004; and James R. Gill, MD, Office of the Chief
Medical Examiner, 520 First Avenue, New York, NY 10016
Neri, Margherita MD*, and Carmela Fiore, MD, University Cocaine Skin Popping: A Fatal Case 227
of Foggia, Department of Forensic Pathology, Viale Pinto
1, Foggia, 71100, ITALY
Neri, Margherita MD*, Department of Forensic Pathology, Coronary Artery Anomalies and Sudden 456
University of Foggia, Viale Pinto 1, Foggia 71100, Italy; Death: Two Case Reports in Young People
M. Di Pudua, MD, Institute of Forensic Medicine,
University of Foggia, Ospedali Riuniti Via Luigi Pinto n. 1,
Foggia 71100, Italy
Neri, Margherita MD*, Irene Riezzo, MD, and Emanuela A Homicide Due to a “Disguised Mail Bomb” 287
Turillazzi, MD, PhD, Department of Forensic Pathology
University of Foggia, Viale Pinto 1, Foggia, 71100, Italy
Index 193
Neri, Margherita MD*, Marianna Di Padua, MD, and A Fatal Case Due to Abdominal Compartment 385
Emanuela Turillazzi, MD, PhD, Department of Forensic Syndrome (ACS)
Pathology, University of Foggia, Viale Pinto 1, Foggia,
71100, Italy
Neri, Margherita MD*, Marianna Di Padua, MD, The Death of an Italian Soldier in Iraq: 349
Cristoforo Pomara, MD, and Emanuela Turillazzi, MD, Murder or Fatality?
PhD, Department of Forensic Pathology, University of
Foggia, Viale Pinto 1, Foggia, 71100, Italy
Neri, Margherita PhD*, Santina Cantatore, and Cristoforo A Fatal Case Due to a Pitchfork Penetrating 186
Pomara, PhD, Department of Forensic Pathology Head Injury
University of Foggia, Viale degli Aviatori 1, Foggia, 71100,
ITALY
Neri, Margherita PhD*, Santina Cantatore, Gabriela A Homicide Due to an Atypical Asphyxiation 102
Perilli, MD, and Irene Riezzo, MD, Department of Forensic Tool: A Rolling Pin
Pathology, University of Foggia, viale degli Aviatori, 1,
Neri, Margherita PhD*, Stefania Bello, MD, Raffaella Spontaneous Pulmonary Arterial Dissection: 32
Bisceglia, MD, and Carmela Fiore, MD, Department of A Case Report
Nguyen, Lawrence MD, Los Angeles County Department of Deaths in Unlicensed Alcohol Rehabilitation 63
Coroner, 1104 North Mission Road, Los Angeles, CA Facilities
90033; and Christopher B. Rogers, MD*, Los Angeles
County Medical Examiner’s Office, 1104 North Mission
Nichols, Anne E. BS*, West Virginia University, 1367 Generating Development Data for 196
Stewartstown Road, Apartment W-7, Morgantown, WV Forensically Important Flies That Are
26505; Neal H. Haskell, PhD, 425 Kannal Avenue, Difficult to Rear in the Laboratory
Rensselaer, IN 47978; and Jeffrey D. Wells, PhD, West
Virginia University, Department of Biology, Life Sciences
Building, Room 3135, 53 Campus Drive, PO Box 6057,
Morgantown, WV 26506-6057
Nicolaescu, Aurelian MD*, Office of the Chief Medical The Changing Faces of the Medico-Legal 537
Examiner, State of Maryland, 111 Penn Street, Baltimore, Autopsies at the Office of the Chief Medical
MD; Joseph A. Kufera, MA, National Study Center for Examiner of the State of Maryland— A
Trauma and EMS, 701 West Pratt Street, Baltimore, MD; Decade of Experience
Jack M. Titus, MD, and David R. Fowler, MB, ChB, Office
Penn Street, Baltimore, MD
Nielsen, Lene Aagaard MD, and Soren J. Mikkelsen, MD, Ano-Genital Findings in Sexually Abused 435
Children and Adolescent Psychiatric Hospital, University Children in Cases With a Conviction
Hospital of Aarhus, 66 H. Selmersvej, Risskov, DK-8000,
Denmark; and Annie Vesterby, MD, DMSci*, Department
of Forensic Medicine, University of Aarhus, Children abd
Adolescent Psychiatric Hospital of Aarhus, P. Sabroes
Gade 15, Aarhus, DK-8000, Denmark
Nixdorf-Miller, Allison S. MD*, Tracey S. Corey, MD, Pediatric Malignancies Presenting as Sudden 282
Barbara Weakley- Jones, MD, and William R. Ralston, MD, Death: A Case Series
Office of the Chief Medical Examiner, 810 Barrett Avenue,
Noller, Anna C. PhD*, and Marcella F. Fierro, MD, Office The Continued Role of Over the Counter 228
of the Chief Medical Examiner, 400 East Jackson Street, Drugs in Drug Related Deaths
Richmond, VA 23219
Index 194
Nunez-Doyle, Sara MD*, and Sharon M. Derrick, PhD, Suicide by Hanging in Harris County, Texas 199
Nunno, Nunzio Di MD*, Alessandro Dell’ Erba, MD, Medical Malpractice: A Case History Study 574
Francesco Vinci, MD, Stanislao Mangiatordi, MD, Luigi by the Forensic Medicine Section From Bari
Viola, MD, and Francesco Vimercati, MD, Sesione di
Medicina Pubblica, Bari University, Policlinico, Piazza G.
Cesere n. 11, Bari, Italy
Nunno, Nunzio Di MD*, and Luigi Vimercati, MD, Sezione Epidemiological Study of SIDS in an Apulian 485
di Medicina Legale, Dipartimento di Medicina Interna e Population
Policlinico, Piazza G. Cesare n. 11, Bari, Italy; Barbara
Boninfante BSc, Dipartimento di Scienze Statistiche,
Facoltà di Economia e Commercio, Università degli Studi
di Bari, Italy; and Francesco Vimercati, MD, Sezione di
Policlinico, Piazza G. Cesare n.11 Bari, Italy
Nunno, Nunzio Di MD, PhD*, Sezione di Medicina Legale, DNA Extraction and Anthropological Aspects 396
Bari University, Piazza G. Cesare n. 11, Bari, 70125, Italy; From 6th to 7th Century A.D. Bone Remains
Vito Scattarella, BSc, Sandro Sublimi Saponetti, BSc, and
Patrizia Emanuel, BSc, Bari University, Piazza G. Cesare
n. 11, Bari, 70125, Italy; and Stefania Lonero Baldassarra,
BSc, and Cosimo Di Nunno MD, Sezione di Medicina
Legale, Bari University, Piazza G. Cesare n. 11, Bari,
70125, Italy
Nunno, Nunzio Di MD, PhD*, Università degli Studi di An Exceptional Case of Death Due to Lesions 277
Lecce, Via G. Dorso n. 9, Bari, 70125, Italy; Luigi Viola, of Water Nozzle
MD, Università degli Studi di Bari, Sezione di Medicina
Legale, DIMIMP, Policlinico di Bari, Piazza G Cesare 11,
Bari, 70124, Italy; Fulvio Costantinides, MD, Università
degli Studi di Trieste, San Pelagio n. 45, Duino-Aurisina,
34100, Italy; and Giandomenico Maria Battista, MD, and
Cosimo Di Nunno, MD, Università degli Studi di Bari,
Sezione di Medicina Legale, DIMIMP, Policlinico di Bari,
Piazza G. Cesare 11, Bari, 70124, Italy
Nunno, Nunzio Di MD, PhD*, Universita’ di Lecce, Via G. Death in a Confined Space 327
Dorso n. 9, Bari, 70125, Italy; Francesco Vimercati, MD,
Cesare n. 11, Bari, 70125, Italy; Fulvio Costantinides, MD,
Universita’ di Trieste, P.zza Ospedale, Trieste, 34100, Italy;
and Sandra Cornetta, MD, and Di Nunno Cosimo, MD,
Cesare n. 11, Bari, 70125, Italy
Nuzzolese, Emilio DDS, PhD*, Ambulatorio Nuzzolese, Case Studies of Cranial Trepanation in Apulia 84
viale J.F. Kennedy 77, Bari, 70124, ITALY; Sandro Sublimi (Southern Italy) Through Forensic Imaging
Saponetti, BSc, and Vito Scattarella, BS, Department of
Animal and Environmental Biology, Università degli Studi
di Bari, Bari, 70100, ITALY; and Marino Capece, MD,
Imaging Department, ASL BA, Monopoli, 70100, ITALY;
Nunzio Di Nunno, PhD, Università del Salento, Lecce,
73100, ITALY
Index 195
O’Brien, R. Christopher MFS*, Faculty of Science, UOIT, Factors Affecting the Rate of Decomposition 182
Oshawa, ON L1H 7K4, CANADA; Ian Dadour, PhD, of Pig (Sus scrofa) Carcasses During a Period
Centre for Forensic Science, University of Western of Drought in Southern-Western Australia
AUSTRALIA; Jan Meyer, PhD, Mailbag M309, 35 Stirling
Highway, Crawley, 6009, AUSTRALIA; and Shari Forbes,
PhD, University of Ontario Institute of Technology, 2000
Simcoe Street North, Oshawa, L1H7K4, CANADA
O’Hara, Joseph P. MD*, and Debra Komar, PhD, Calcified Primary and Metastatic Pancreatic 517
University of New Mexico Health Sciences Center, Office of Carcinoma Discovered in Skeletonized
the Medical Investigator, Albuquerque, NM Remains
Oeberst, Jaime L. MD*, and Timothy P. Rohrig, PhD, Comparison of the Distribution of Fentanyl in 519
Sedgwick County Regional Forensic Science Center, 1109 Deaths Related to Use and Abuse of the
North Minneapolis, Wichita, KS Duragesic®Patch and Intravenous
Administration of Patch Contents
Oliva, Antonio MD, PhD*, Catholic University, Italy, Largo Sodium Channelopathies Linked to Sudden 217
Francesco Vito 1, Rome, 00168, ITALY; Preben Cardiac Death (SCD) - What is the Meaning
Bjerregaard, MD, St Louis University Hospital, Cardiology of Carrying a Genetic Mutation?
Department, 3635 Vista Avenue, St. Louis, MO 63110; Kui
Hong, MD, PhD, Nanchang University, Jiangxi Province,
235 Nanjing East Road, Jiangxi; Steven Evans, MD, Beth
Israel Medical Center, Cardiology Division, First Avenue at
16th Street, New York, NY 10001; Kevin Vernooy, MD,
PhD, Academic Hospital, Maastricht, Department of
Cardiology, Maastricht, NETHERLANDS; Jorge
McCormack, MD, Pediatric Cardiology Associates, Tampa,
FL; Josep Brugada, MD, PhD, Hospital Clinic Barcelona,
Arrhythmia Unit, Villaroel 32, Barcelona, SPAIN; Pedro
Brugada, MD, PhD, Free University of Brussels,
Department of Cardiology, Brussel, BELGIUM; Vincenzo
L. Pascali, MD, PhD, Catholic University, Institute of
Forensic Medicine, Largo f. Vito 1, Rome, ITALY; and
Ramon Brugada, MD, Montreal Heart Institute, Montreal,
CANADA
Oliva, Antonio MD, PhD*, Catholic University, School of SCN5A Gene Mutation Associated With 218
Medicine, Institute of Forensic Medicine, Largo Francesco Acute Myocardial Infarction
Vito 1, Rome, ITALY; Dan Hu, MD, PhD, Masonic Medical
Research Laboratory, 2150 Bleecker Street, Utica, NY
13501-1738; Sami Viskin, MD, PhD, Department of
Cardiology, Tel- Aviv Sourasky Medical Center, 6
Weizmann Street, Utica, ISREAL; and Jonathan M.
Cordeiro, PhD, Tabitha Carrier, BS, Hector Barajas-
Martinez, PhD, Yuesheng Wu, MS, Elena Burashnikov, BS,
Serge Sicouri, MD, and Ramon Brugada, MD, Masonic
NY 13501-1738; and Rafael Rosso, MD, Sackler School of
Medicine, Tel-Aviv University, 6 Weizmann Street, Tel Aviv,
ISREAL; and Alejandra Guerchicoff, PhD, Guido D.
Pollevick, PhD, and Charles Antzelevitch, PhD, Masonic
NY13501-1738
Index 196
Oliva, Antonio PhD*, and Sara Merigioli, PhD, Institute of Autopsy Investigation and Bayesian 86
Forensic Medicine, Catholic University, School of Approach to Coronary Artery Disease (CAD)
Medicine, Largo Francesco Vito 1, Rome, ITALY; Jose in Victims of Motor Vehicle Accidents
Flores, MD, Montreal Heart Institute. University, Montreal,
Quebec, Canada, Montreal, CANADA; Francesca Cittadini,
PhD, Sara Partemi, MD, and Vincenzo L. Pascali, PhD,
Institute of Forensic Medicine, Catholic University, largo
Francesco Vito 1, Rome, ITALY; and Ramon Brugada, MD,
Montreal Heart Institute, Montreal Quebec, Canada,
Montreal, CANADA
Oliveira, Paula C. MD*, Portuguese National Institute of Survived Strangulation: A Case Report 42
Legal Medicine, Largo da Sé Nova, Coimbra, 3000-213,
PORTUGAL; Ana R. Pereira, MD*, Ladeira das
Alpenduradas nº13A, Coimbra, 3030-167, PORTUGAL;
Rosario L. Silva, MD, and Graca Santos Costa, MD,
Portuguese National Institute of Legal Medicine, Largo da
Sé Nova, Coimbra, 3000-213, PORTUGAL; and Duarte
Oliver, William MD, MPA*, and Leone Lisa, MA, Brody Digital UV/IR Photography for Tattoo 137
School of Medicine at East Carolina University, Evaluation in Mummified Remains
Division of Forensic Pathology, 7S-10 Brody Medical
Oliver, William MD, MPA*, Leone Lisa, MA, and Colleen Precision of Autopsy Body Length 118
Tetterton, PA, Brody School of Medicine at East Carolina Measurements
University, Division of Forensic Pathology, Department of
Pathology and Laboratory Medicine, 7S-10 Brody Medical
Oliver, William R. MD*, and Kimberlee Potter, PhD, Use of Magnetic Resonance Microscopy for 553
Armed Forces Institute of Pathology, Washington, DC; J.C. Evaluation of Retinal Hemorrhage
Upshaw Downs, MD, Director, Alabama Department of
Forensic Sciences and Chief Medical Examiner, PO Box
3510, Auburn, AL; and David R. Fowler, MB, ChB, Office
Penn Street., Baltimore, MD
Oliver, William R. MD*, Armed Forces Institute of Evaluation of a Putative Snuff Film 526
Pathology, 1413 Research Boulevard, Rockville, MD; Peter
G. Lawson, Naval Criminal Investigative Service, 620 John
Paul Jones Circle, Portsmouth, VA; William C. Rodriguez
III, PhD, Armed Forces Institute of Pathology, 1413
Research Boulevard, Rockville, MD; and Douglas Knittel,
MD, Naval Medical Center, 630 John Paul Jones Circle,
Portsmouth, VA
Olson, Alane MD*, Clark County Coroner’s Office, 1704 Death Investigation and Organ and Tissue 113
Pinto Lane, Las Vegas, NV 89106 Donation in Clark County, Nevada
Ormsby, Kaelyn M. BS*, and Guaciara M. Santos, PhD, Radiocarbon and Stable Isotope Results of 25
KCC-AMS Preparation Laboratory, University of Fingernails of Breastfed Mother-Infant Pairs
California, Irvine, B321 Croul Hall, Irvine, CA 92697; and to Investigate Deviation of Year-of- Birth
Benjamin T. Fuller, PhD, Max Planck Institute for Determinations Due to Diet
Evolutionary Anthropology, Department of Human
Index 197
Ortiz, Francisco I. BS*, 1818 South 2nd Street, Apartment Effects of Resource Age and Sterilization on 181
62, Waco, TX 76706; and Jeffery K. Tomberlin, PhD, the Attraction of Cochliomyia macellaria
Department of Entomology, TAMU 2475, College Station, (Fabricius) and Chrysomya rufifacies
TX 77843-2475 (Macquart)
Paganini, Anthony T. PhD*, Michigan State University, Estimating Time-of-Death by Body 363
A519 East Fee Hall, Division of Anatomy, Department of Temperature Analyses - A New Mathematical
Radiology, East Lansing, MI 48824; and Thomas Adams, Strategy
PhD, Michigan State University, Department of Physiology,
2240B Biophysical Sciences Building, East Lansing, MI
48824
Palmiere, Cristian MD*, Bettina Schrag, Marc D. Determination of Procalcitonin, C-Reactive 105
Bollmann, MD, and Patrice Mangin, PhD, Centre Protein, Tumor Necrosis Factor-Alpha,
Universitaire, Romand de Medecine Legale, Rue du Bugnon Interleukin-6, and Interleukin-8 Levels in
21, Lausanne, CH-1011, SWITZERLAND Serum, Vitreous Humor, and Cerebrospinal
Fluid as Markers of Sepsis
Palmiere, Cristian MD*, Christophe Brunel, MD, Frank An Unusual Case of Accidental Poisoning: 141
Sporkert, MD, and Patrice Mangin, MD, PhD, Centre Fatal Methadone Inhalation
Palmiere, Cristian MD, Institut Universitaire de Médecine Planned Complex Suicide: Report of Two 329
Légale, 9 Avenue de Champel, Genève, 1211, Switzerland; Cases
Francesco Ventura, MD, and Daniela Picchioni, MD,
Dipartimento di Medicina Legale, Via de Toni 12, Genova,
16132, Italy; and Maria del Mar Lesta, MD, and Romano
La Harpe, MD*, Institut Universitaire de Médecine Légale,
9 Avenue de Champel, Genève, 1211, Switzerland
Parai, Jacqueline L. MD*, Ontario Forensic Pathology Pheochromocytoma Causing Unexpected 137
Services, Division of Anatomical Pathology, The Ottawa Death – Two Unusual Presentations
Hospital, 501 Smyth Road, Box 117 4th Floor, Ottawa, ON
K1H 8L6, CANADA; and Iris Teo, MD, Itrat Ahmed, MD,
and Christopher M. Milroy, MD, The Ottawa Hospital, 501
Smyth Road, Box 117 4th Floor, Ottawa, ON K1H 8L6,
CANADA
Parisian, Suzanne D. MD*, Medical Device Assistance, The Pathologist’s Role in Preserving 247
Inc., 7117 North 3rd Street, Phoenix, AZ 85020; and Bruce Implanted Pacemakers and Cardiac
H. Barkalow, PhD*, and William E. Grant, MA, B.H. Defibrillators or How Not to Get Shocked!
Barkalow, P.C., 490 Quarterline Road, Newaygo, MI
49337-9125
Park, Hydow MD*, Atlantic County Medical Examiner’s Sudden Unexpected Death in a Case of 261
Office, 201 Shore Road, Northfield, NJ 08225-2319 Human Immunodeficiency Virus (HIV) and
Myocobacterium Infection Diagnosed
Postmortem
Park, Jennifer H. DO*, Miami Dade County Medical Comparison of Wound Severity Between 304
Examiner Department, 1851 NW 10th Avenue, Miami, FL Center-Fire Rifle Projectiles and Shotgun
33136-1133; and Richard C. Harruff, MD, PhD, King Slugs
County Medical Examiner’s Office, 325 Ninth Avenue,
HMC, Box 359792, Seattle, WA 98104
Parker, Linda MSc, Jack Laird, MSc, Elida Kafarowski, Everything Old is New Again: A Program to 500
MSc, Brian Peck, MSc*, Suzanne Lima, MSc, and Jonathan Examine “Cold” Sexual Assault Cases
Newman, BSc, Centre of Forensic Sciences, 25 Grosvenor
Street, 4th floor, Toronto, Ontario, Canada
Index 198
Parks, Bruce O. MD*, Eric D. Peters, MD, Cynthia M. Death in the Desert: Multiple Fatalities as a 561
Porterfield, DO, Diane Karluk, MD, Walter H. Birkby, Consequence of Environmental Exposure
PhD, and Bruce E. Anderson, PhD, Office of the Medical
Examiner, Forensic Science Center, 2825 East District
Street, Tucson, AZ
Pasquale-Styles, Melissa A. MD*, Wayne County Medical Infant Position and the Assessment of Risk 376
Examiner Office, 1300 East Warren Avenue, Detroit, MI Factors for Asphyxia: A Review of 209
48207; Patricia L. Tackitt, RN, MS, Michigan Public Health Sudden Unexpected Infant Deaths
Institute, 2438 Woodlake Circle, Suite 240, Okemos, MI
48864; and Carl J. Schmidt, MD, Wayne County Medical
Examiner Office, 1300 East Warren Avenue, Detroit, MI
48207
Payne-James, Jason LLM, MB, FRCS, DFM*, Ian Wall, Patterns of Illicit Drug Use of Prisoners in 428
LLM, MRCGP, and Caroline Bailey, Forensic Healthcare Police Custody in London, United Kingdom
Services, Ltd., 19 Speldhurst Road, Victoria Park, London,
E9 7EH, United Kingdom
Payne-James, Jason MBBS*, Forensic Healthcare Services Near Miss Incidents in Police Custody Suites 307
Ltd., 19 Speldhurst Road, London, E97EH, United in London, UK: A One Year Prospective
Kingdom; Rebecca Teers, BA, Independent Police Study
Complaints Commission, 90 High Holborn, London, WC1V
6BH, United Kingdom; Stefania Menin, MSc, Independent
Police Complaints Commission, 90 High Holborn, London,
WC1V 6BH, United Kingdom; and Margaret Stark, LLM,
MBBS, Forensic Medicine Unit, St. George’s Hospital,
London, SW12, United Kingdom
Paysant, Francois MD*, Chu, Hopital Michallon, BP 217, Rupture of the Left Ventricle Due to Blunt 189
38043 Grenoble Cedex 9, Grenoble, FRANCE Trauma - A Pediatric Case Study
Pearson*, Sandra Criminal Justice Program, Chaminade Intraspecific Competition in the Blowfly 361
University of Honolulu, 3140 Waialae Avenue, Honolulu, Chrysomya megacephala (Diptera:
HI 96816-1578; and M. Lee Goff, PhD, Chaminade Calliphoridae) Reared at Different Densities
University of Honolulu, 3140 Waialae Avenue, Honolulu,
HI 96816-1578
Pechal, Jennifer L. MS*, Texas A&M University, 2475 First Insect Succession Study on a Human 195
TAMU, College Station, TX 77843-2475; Adrienne L. Cadaver in Texas
Brundage, MS, 2001 Cobblestone Ln, Bryan, TX 77807;
Elizabeth T. Brandt, BA, 232 Evans Liberal Arts,
Anthropology Dept, 601 University Drive, San Marcos, TX
78666; Connie L. Parks, BS, 8802 Featherhill Road, Austin,
TX 78737; Jeffery K. Tomberlin, PhD, Department of
Entomology, TAMU 2475, College Station, TX 77843-2475;
and Jerry Melbye, PhD, Department of Anthropology, 601
University Drive, ELA 273, Texas State University- San
Marcos, San Marcos, TX 78666-4616
Peckmann, Tanya R. PhD*, Saint Mary’s University, CSI Halifax in Miami: The Importance of 248
Department of Anthropology, McNally South 208, 923 Practical Courses in the Forensic Sciences
Robie Street, Halifax, Nova Scotia B3H 3C3, CANADA;
and Dr. Bruce A. Hyma, MD, Miami-Dade County Medical
Examiner’s Office, 1 Bob Hope Road, Miami, FL 33136
Index 199
Pereira, Ana R. MD*, Ladeira das Alpenduradas nº13A, Postmortem Animal Injuries: A Forensic 19
Coimbra, 3030- 167, PORTUGAL; Bruno M. Santos, MSc, Pathologist’s Perspective
Largo da Sé Nova, Coimbra, 3000-213, PORTUGAL;
Carmen Barbu, MD, Instituto de Medicina Legal de Sf.
Gheorghe, Romania, Bucharest, ROMANIA; Pedro A.
Rezende, MSc, Jardim Carrilho Videira, Porto,
PORTUGAL; Paula C. Oliveira, MD*, Largo da Sé Nova,
Manuel Bento de Sousa, nº 3, 1150-219 Lisboa, Lisboa,
Pereira, Ana R. MD*, Ladeira das Alpenduradas nº13A, Antiepileptic Drug Intoxication: Report of 14
Coimbra, 3030- 167, PORTUGAL; Paula C. Oliveira, One Case and a Forensic Pathologist’s
MD*, Konara Gunathilake, MD, Bruno M. Santos, MSc, Approach
Paula Proenca, PharmD, and Miguel Franco, MSc, Largo
da Sé Nova, Coimbra, 3000-213, PORTUGAL; Maria C.
Mendonca, PhD, Instituto Nacional de Medicina Legal,
Largo Sé Nova, Coimbra, 3000, PORTUGAL; and Duarte
Perret*, Guillaume Département de Psychiatrie, Clinique Suicides Among Youth in Geneva, 412
de Psychiatrie Adulte, HÙG, Secteur Jonction, Bvd Saint- Switzerland From 1993 to 2002
Georges 16-18, Geneva, 1205, Switzerland; Abliz
Abudureheman, MD, Institut Universitaire de Médecine
Légale de Genève, 9 Av de Champel, Geneva, 1211,
Switzerland; Maja Perret-Catipovic, PhD, Département de
Psychiatrie, Unité, Bd de la Cluse 51, Geneva, 1205,
Switzerland; and Romano La Harpe, MD, Institut
Universitaire de Médecine Légale de Genève, C.M.U, 9 av
de Champel, Geneva, 1211, Switzerland
Perret, Guillaume MD*, Institut Universitaire de Medecine Methadone Treatment and Drug Overdose in 330
Legale de Geneve, 9 av. de Champel, CMU, Geneva, 1211, Geneva, Switzerland, From 1994 to 2003
Switzerland; Ann Ho, PhD, and Mary Jeanne Kreek, MD,
Laboratory of the Biology of Addictive Diseases,
Rockefeller University, 1320 York Avenue, New York, NY
10021; and Romano La Harpe, MD, Institut Universitaire
de Medecine Legale de Geneve, CMU, 9 av. de Champel,
Geneva,1211, Switzerland
Peters, Sonja L. BS*, 5333 Southwest 75th Street, Apt. S- Postmortem Interval (PMI) Determined by 502
105, Gainesville, FL; Jerry F. Butler, PhD, Department of Analyzing Temperature Variations of Maggot
Entomology & Nematology, University of Florida, P.O. Box Masses
110620, Gainesville, FL; Jerome A. Hogsette, PhD, USDA-
ARS, CMAVE, P.O. Box 14565, Gainesville, FL; Anthony B.
Falsetti, PhD, Anthropology Department, C.A. Pound
Human Identification Laboratory, P.O. Box 117305,
Gainesville, FL; and Roxanne Rutledge, PhD, Florida
Medical Entomology Laboratory, 200 9th Street, SE, Vero
Beach, FL
Index 200
Peterson, Diane C. MD*, and Richard E. Powers, MD, Effectiveness of Death Investigation in Cases 347
P220 West Pavilion, Department of Pathology, 619 19th of Potential Elder Abuse
Petkovic, Stojan MD*, Clinical Center Vojvodina, Institute Sudden Death of a 17-Year-Old Boy Due to 226
of Forensic Medicine, Hajduk Veljkova 5, Novi Sad, 21000, Suspected Williams Syndrome - A Case
SERBIA A ND MONTENEGRO; Slobodan Savic, MD, PhD, Report
University of Belgrade, School of Medicine, Institute of
SERBIA AND MONTENEGRO; and Milan Simic, MD,
PhD, Clinical Center Vojvodina, Institute of Forensic
AND MONTENEGRO
Petkovic, Stojan PhD*, Department of Forensic Medicine, Unexpected Death of 24-Year-Old Male With 187
Clinical Center of Vojvodina, Hajduk Veljkova 5-7, Novi a Phenotype Strongly Suggestive of Lujan-
Sad, 21000, SERBIA AND MONTENEGRO; Branislav Fryns Syndrome
Budakov, MD PhD, Hajduk Veljkova 3, Novi Sad, 21000
SERBIA AND MONTENEGRO; Slobodan Savic, PhD,
School of Medicine, University of Belgrade, Institute of
SERBIA AND MONTENEGRO; and Isidora Samojlik, MD,
Department of Pharmacology and Toxicology, Faculty of
AND MONTENEGRO
Petkovic, Stojan PhD*, Miljen Maletin, MD, MSc, and Complex Suicide: An Unusual Case With Six 41
Maja Durendic- Brenesel, PhD, Klinicki Centar Vojvodine, Methods Applied
Department of Forensic Medicine, Clinical Center of
Vojvodina, Hajduk Veljkova 5-7, Novi Sad, 21000, SERBIA
AND MONTENEGRO
Phatak, Darshan R. MD*, and Luis A Sanchez, MD, Harris Drowning of a Child With a Cardiac Fibroma 268
County Medical Examiner Office, 1885 Old Spanish Trail, of the Interventricular Septum
Houston, TX 77054
Phatak, Darshan R. MD*, Beth Israel Deaconess Medical Immunocompromised Female, Age 67, With 384
Center, Pathology Department, 330 Brookline Avenue, an Angioinvasive Pulmonary Fungal Abcess
Boston, MA 02215
Philip, Abraham T. MD*, Alexander M. Chirkov, MD, and Sudden Death in Baseball: A Case Report and 558
Richard J. Evans, MD, Office of the Chief Medical Review of Literature
Examiner, 720 Albany Street, Boston, MA
Philip, Abraham T. MD*, Brian P. Ehret, and Robert Drag Racing of Snowmobiles on Asphalt: A 73
Stoppacher, MD, Onondaga County Medical Examiner’s Novel Cause for Sudden Violent Death
Office, 100 Elizabeth Blackwell Street, Syracuse, NY 13210
Philip, Abraham T. MD*, Onondaga County Medical An Angel Dies on the Needle: Fatality After 173
Examiner, 100 Elizabeth Blackwell Street, Syracuse, NY Injection Sclerotherapy for Prolapse Rectum
13210; and Jeanna M. Marraffa, PharmD, Upstate New in a Child
York Poison Center, 250 Harrison Street, Syracuse, NY
1302
Philip, Abraham T. MD*, Onondaga County Medical Variations on a Theme: Inhalant Abuse 177
Examiner’s Office, 100 Elizabeth Blackwell Street, Related Fatalities in Central New York — An
Syracuse, NY 13210 11 Year Review
Index 201
Philip, Abraham T. MD*, Onondaga County Medical Two Cases of Novel Influenza A (H1N1) 140
Examiner’s Office, 100 Elizabeth Blackwell Street, Virus (“Swine Flu”) Infection: Clinical
Syracuse, NY 13210; Kerry Whiting, BS, and Sanjay Presentations, Autopsy Protocol With
Mukhopadhyay, MD, State University of New York - Findings, and Review of Literature
Upstate Medical University, 766 Irving Avenue, Syracuse,
NY 13210; and Robert Stoppacher, MD, Onondaga County
Medical Examiner’s Office, 100 Elizabeth Blackwell Street,
Syracuse, NY 13210
Phillips, Daniel G.K. MD*, University of Maryland, Cocaine Induced Intracerebral Hemorrhage in 219
Baltimore, Department of Pathology, 22 South Greene a Patient With Cerebral Amyloid Angiopathy:
Street, Baltimore, MD 21201; Joyce L. deJong, DO, and A New Risk Factor for Stroke in Cocaine
Michael A. Markey, MD, Sparrow Forensic Services, Users
Sparrow Hospital, 1215 East Michigan Avenue, Lansing,
MI 48909-7980; and Rudy J. Castellani, MD, University of
Maryland, Department of Pathology, 22 South Greene
Pierangela*, Fleres Insitute of Legal Medicine, Via del Impetigo Contagiosa Simulating Non- 145
Vespro, n. 127, Palermo, 90100, ITALY; Farina Graziana, Accidental Injuries in a Pregnant Woman
MD, Institute of Legal Medicine of Palermo, Via del Using Intravenous Drug
Vespro, n. 129, Palermo, 90100, ITALY; Antonina Argo, via
Narbone n. 13, Palermo, , ITALY; Paola Pugnetti,
of Legal Medicine, Via del Vespro, n. 129, Palermo, 90127,
ITALY; Paolo Procaccianti, Palermo University, Via del
Maresi, Via del Vespro, n. 127, Palermo, 90100, ITALY
Pinckard, J. Keith MD, PhD*, Division of Laboratory A Comprehensive Analysis of Forensic 541
Medicine, Washington University School of Medicine, Box Science Training in Forensic Pathology
8118, 660 South Euclid Avenue, Saint Louis, MO; Donna Fellowship Programs
M. Hunsaker, MD, Office of the Chief Medical Examiner,
810 Barrett Avenue, Louisville, KY; and Victor W. Weedn,
MD, JD, Carnegie Mellon University, 4400 Fifth Avenue
Mellon Institute, Room 292, Pittsburgh, PA
Pinheiro, João MD, MSci*, and Duarte Nuno Vieira, PhD, Gagging, Strangulation By Single/ Double 292
Instituto Nacional de Medicina Legal, Largo Sé Nova, Ligature …or Incaprettamento?
Coimbra, 3000 213, Portugal
Pinheiro, João S. MS*, Instituto Nacional de Medicina Pitfalls in the Interpretation of the Hyoid and 39
Legal, Delegação do Centro, Largo da Sé Nova, Coimbra, Thyroid Fractures in Strangulation: The
3000, PORTUGAL; and Anny Sauvageau, MD, Office of the Importance of Anatomical Variations
Chief Medical Examiner, 7007 - 116 Street, Edmonton, AB
T6H 5R8, CANADA
Pinheiro, João S. MS*, Rosario L. Silva, MD, and Claudia Stab Wounds, Incised Wounds, or Blunt 101
Marques, MD, Institute Nacional Medicina Legal, Trauma With Single or Multiple Weapons –
Delegação do Centro, Largo da Sé Nova, Coimbra, 3000, How to Read Soft Tissue and Bone Injuries
PORTUGAL; José Elísio P.A. de Campos e Sousa, MD,
Largo da Sé Nova, Coimbra, 3000-213 COIMBRA,
PORTUGAL; and Francisco C. Real, PhD, Institute
Nacional Medicina Legal, Delegação do Centro, Largo da
Sé Nova, Coimbra, 3000, PORTUGAL
Index 202
Pinto, Deborrah C. PhD*, Harris County Institute of A Comparison of Trauma Associated With 28
Forensic Sciences, 1885 Old Spanish Trail, Houston, TX Manual and Automated Cardiopulmonary
77054; Kathryn Haden-Pinneri, MD, Harris County Resuscitation
Medical Examiner’s Office, 1885 Old Spanish Trail,
Houston, TX 77054; and Jennifer C. Love, PhD, Harris
County Institute of Forensic Sciences, 1885 Old Spanish
Platt, Marvin S. MD, JD*, 5050 La Jolla Boulevard, Morbidity and Mortalities Related to TV Tip 81
Apartment 2G, San Diego, CA 92109; and Christina Over
Stanley, MD, San Diego County Medical Examiner’s Office,
Plourd, Christopher J. JD*, 1168 Union Street, Suite 303, Are Retinal Hemorrhages Diagnostic of 430
San Diego, CA 92101-3818 Shaken Baby Syndrome? What Really Killed
Baby Cooper
Plu, Isabelle PhD*, Denis Barrès, MD, and Dominique Pregnancy, Caesarean, and 69
Lecomte, PhD, Institut Médico-Légal, 2 place Mazas, Paris, Pheochromocytoma: A Case Report With a
75012, FRANCE Fatal Outcome
Polat, Oguz MD, Bulent Sam, MD, and Esra Saka, MD, The The Significance of Tattoos in Forensic 488
State Institute of Forensic Medicine, Ministry of Turkey, Autopsy
Istanbul, Turkey; and Nevzat Alkan, MD, Istanbul
University, Istanbul Medical Faculty, Department of
Forensic Medicine, Istanbul, Turkey
Pomara, Cristoforo MD*, Department of Forensic A Case of Sudden Death in a 3-Year-Old 481
Pathology, University of Foggia, Viale Pinto n°1, Foggia Infant With Prader Willi Syndrome
71100, Italy; Stefano D’Errico, MD and Irene Riezzo, MD,
Institute of Legal Medicine, University of Foggia, Ospedali
Riuniti, via L.Pinto 1, Foggia 71100, Italy
Pomara, Cristoforo MD*, Institute of Legal Medicine, Murder in the Ancient Castle: A XIV Century 425
University of Foggia, Viale Pinto 1, Foggia, 71100, Italy; Warrior Virtual Autopsy
Angelo Marrone, MD, Diagnostic Immaging Department,
ASL Foggia 2, Cerignola (Fg), Via Trinitapoli, Foggia,
71042, Italy; Stefano Ricci, MD, PhD, Anthropological
Laboratory, Department of Environmental Science,
University of Siena, Via Mattioli n. 4, Siena, 53100, Italy;
Irene Riezzo, MD, Institute of Legal Medicine, University of
Foggia, Viale Luigi Pinto, 1, Foggia, 71100, Italy
Pomara, Cristoforo MD*, Stefano D’Errico, MD, Sabina Di The Cave Man in the 21st Century: Chronicle 364
Donato, MD, Marianna Di Padua, MD, Francesco M. of an Announced Tragedy: Preventive
Morreale, MD, Irene Riezzo, MD, and Margherita Neri, Measures and Repeating Risk
MD, Institute of Forensic Pathology, Foggia University,
V.le Luigi Pinto 1, Foggia, 71100, Italy; and Giulio Zizzo,
MD, Radiology Department Ospedali Riuniti, V.le Luigi
Pinto 1, Foggia, 71100, Italy
Pomara, Cristoforo MD, Department of Forensic Ndrangheta’ Homicide (Executions)! 302
Pathology, University of Foggia, Ospedali Riuniti, via L.
Pinto 1, Foggia, 71100, Italy; Floriana Monciotti, MD,
Department of Forensic Pathology, University of Siena,
Policlinico Le Scotte, Siena, 53100, Italy; and Marianna Di
Padua, MD, and Carmela Fiore, MD, Department of
Forensic Pathology, University of Foggia, Ospedali Riuniti,
via L.Pinto 1, Foggia, 71100, Italy
Index 203
Pomara, Cristoforo PhD*, and Gianpaolo Di Peri, MD, Telluric Movements of Death: The Cemetery 52
University of Foggia, Department of Forensic Pathology, of Gargano’s Mafia Inside the Ravine of
Viale Degli Aviatori, Foggia, 71100, ITALY; Giuseppe Zazzano (Foggia, Italy)
Guglielmi, PhD MD, University of Foggia, Department of
Radiology, Viale Pinto, Foggia, 71100, ITALY; Emilio
Nuzzolese, DDS, PhD, Viale J.F. Kennedy 77, Bari, 70124,
ITALY; and Stefano Derrico, PhD, University of Foggia,
Department of Forensic Pathology, Via Luigi Pinto, 1,
Pomara, Cristoforo PhD*, University of Foggia, Dissecting Intramural Hematoma of the 31
Department of Forensic Pathology, Viale Degli Aviatori 1, Esophagus: A Rare Case of Sudden Death
Foggia, 71100, ITALY; Alessandra De Salvia, PhD,
University of Verona, Department of Forensic Pathology,
Policlinico G. B. Rossi, Verona, 71100, ITALY; Antonio
Nieddu, MD, University of Sassari, Department of Forensic
Pathology, Sassari, Sassari, ITALY; and Stefano D’Errico,
PhD, University of Foggia, Department of Forensic
Pathology, Viale Degli Aviatori, Foggia, 71100, ITALY
Porta, David J. PhD*, Drew H. Duerson, and Bill Tietjen, A Comparison of Penetration Distances for 305
PhD, Bellarmine University, Department of Biology, 2001 Five Ballistic Gelatins to a BB Gunshot
Newburg Road, Louisville, KY 40205; and Tyler A. Kress, Wound to a Live Human Forearm
PhD, BEST Engineering, 2312 Craig Cove Road, Knoxville,
TN 37919
Portunato*, Federica Maria Celeste Landolfa, MD, Fatal Subarachnoid Hemorrhage During 88
Manuela Botto, MD, and Francesco De Stefano, MD, Sexual Activity: A Case Report
Department of Legal and Forensic Medicine, Via De Toni
via de’ Toni, 12, Genova, 16132, ITALY
Portunato, Federica MD*, Manuela Botto, MD, and A Peculiar Fatal Lightning Strike Inside a 21
Alessandro Bonsignore, MD, University of Genova, Cottage
Department of Legal and Forensic Medicine, Via de’ Toni
University of Genova, Department of Forensic Pathology,
Posey, Douglas MD*, Joye M. Carter, MD, and Jessie Sufentanil Toxicity in Healthcare 520
Adame, MD, Harris County Medical Examiner Office, 1885 Professionals
Old Spanish Trail, Houston, TX; and Ashraf Mozayani,
PharmD, PhD, Autopsy and Pathology Services, Inc., P.O.
Box 920903, Houston, TX
Poulos, Christopher K. MD*, Indiana University A Case Report of an Unexpected Accidental 292
Department of Pathology and Laboratory Medicine, 521 Electrocution
West McCarty Street, Indianapolis, IN 46225; Michele
Catellier, MD, Forensic Pathology Associates of Indiana,
521 West McCarty Street, Indianapolis, IN 46225; Elena F.
Bishop, MD, Indiana University Department of Pathology
and Laboratory Medicine, Clarian Pathology Laboratory,
350 West 11th Street, Indianapolis, IN 46225; and Stephen
S. Radentz, MD, Forensic Pathology Associates of Indiana,
521 West McCarty Street, Indianapolis, IN 46225
Poulsen, Klaus MD*, and Jørn Simonsen, MD, Institute of Multislice Computed Tomography In 424
Forensic Medicine, Frederik Vs Vej 11, Copenhagen, 2100, Forensic Pathology
Denmark
Index 204
Prahlow, Joseph A. MD*, c/o South Bend Medical Homicidal Cerebral Artery Aneurysm 444
Foundation and Indiana University School of Medicine, 530 Rupture
Prahlow, Joseph A. MD*, South Bend Medical Foundation Death Certification in Sudden Infant Death 534
& Indiana University School of Medicine, 530 North Syndrome and Related Infant Deaths
Lafayette, South Bend, IN; and Randy L. Hanzlick, MD,
Fulton County Medical Examiners Office, 430 Pryor Street,
SW, Atlanta, GA
Prashar, Sunil K. MD*, and Karoly Balogh, MD, Beth Commotio Cordis: Sudden Death Among 397
Israel Deaconess Medical Center, 330 Brookline Avenue, Young People During Sporting and
ES-112, Boston, MA 02115 Recreational Activities
Prashar, Sunil K. MD*, State of Maryland, Office of the Antemortem and Postmortem Toxicological 348
Chief Medical Examiner, 111 Penn Street, Baltimore, MD Findings in Motor Vehicle Accidents,
21201; Jami L. Grant, PhD, University of Baltimore, 1420 Maryland (2003-2004): Does Impairment
North Charles Street, Baltimore, MD 21201; Susan R. Equal Death?
Hogan, MD, David R. Fowler, MD, and Mary G. Ripple,
MD, State of Maryland, Office of the Chief Medical
Examiner, 111 Penn Street, Baltimore, MD 21201; and
Mary E. Kramer, RN, R. Adams Cowley Shock Trauma
Center, 22 S Greene Street, Baltimore, MD 21201
Prat, Sébastien MD*, Service de Médecine Légale, Hôpital Toxicology and Pathology of 149- 62
Trousseau, Centre Régional Hospitalier Universitaire de Methadone-Related Deaths
Tours, Tours, MB 37000, FRANCE; Patrice Mangin, PhD,
Centre Universitaire, Romand de Medecine Legale, Rue du
Bugnon 21, Lausanne, CH-1011, SWITZERLAND; Marc
Augsburger, PhD, University Center of Legal Medicine,
Bugnon 21, Lausanne, 1010, SWITZERLAND; and
Katarzyna Michaud, MD, Centre Universitaire Romand de
Medecine Legale, Rue du Bugnon 21, Lausanne, 1005,
SWITZERLAND
Prevolsek, Jaime S. BSc*, and Gail S. Anderson, PhD, Nocturnal Oviposition of Blow Flies (Diptera: 104
Simon Fraser University, School of Criminology, 8888 Calliphoridae) in the Lower Mainland of
University Drive, Burnaby, BC V5A 1S6, CANADA British Columbia, Canada
Prutsman-Pfeiffer, Jennifer J. MA*, Strong Memorial Systemic Amyloidosis in an Intravenous Drug 468
Hospital, Neuropathology and Postmortem Medicine, Box Abuser
626, 601 Elmowwd Avenue, Rochester, NY 14642
Pu, Chang-En MS*, Ministry Justice Investigation Bureau, Experiences of Human Bodies Identified by 567
PO Box 3562, Taipei, Taiwan; Chi-Hsiang Chao, Division DNA Typing in Singapore Airlines SQ006
Chief, Ministry Justice Investigation Bureau, Taipei, Crash in Taipei
Taiwan; Fang-Chin Wu, Wen-Hsiung Ho, Kuo-Chun Wu,
Ling-Min Meng, Researcher, Ministry Justice Investigation
Bureau, Taipei, Taiwan; and Kai-Ping Shaw, Director of
Forensic Pathology, Institute of Forensic Medicine,
Ministry of Justice, Taipei, Taiwan
Quinton, Reade A. MD*, University of Texas Southwestern A Study of Three Suicidal Hangings in Jail 504
Medical Center Department of Pathology, 5323 Harry Using Telephone Cords
Hines Boulevard, Dallas, TX; David Dolinak, MD, Dallas
County Medical Examiner, 5230 Medical Center Drive,
Dallas, TX
Index 205
Quinton, Reade A. MD*, University of Texas Southwestern Acute Bacterial Meningitis With 455
Medical Center, Department of Pathology, 5323 Harry Predominance of Immature Granulocytes
Hines Boulevard, Dallas, TX 75390-9073; Loren Clarke,
MD and Javad Towfighi, MD, Penn State Milton S. Hershey
Medical Center, Department of Anatomic Pathology -
H179, 500 University Drive, PO Box 850, Hershey, PA
17033-0850; Jeffrey J. Barnard, MD, Southwestern Institute
of Forensic Sciences, 5230 Medical Center Drive, Dallas,
TX 75390; Rene L. Galindo, MD, PhD and Philip J. Boyer,
MD, PhD, University of Texas Southwestern Medical
Center, Department of Neuropathology, 5323 Harry Hines
Boulevard, Dallas, TX 75390
Quinton, Reade A. MD*, UT Southwestern Medical Center, An Unusual Presentation of a Rare Entity: 536
Department of Pathology, 5323 Harry Hines Boulevard, Exsanguination by Ruptured Left Subclavian
Dallas, TX; and Joni L McClain, MD, Southwestern Aneurysm
Institute of Forensic Sciences, 5230 Medical Center Drive,
Dallas, TX
Racette, Jeffrey K. MD*, Todd M. Luckasevic, DO, Baiyang Acetaminophen Induced Death of a Fetus 143
Xu, MD, Abdulrezak M. Shakir, MD, and Karl E. Williams, With Maternal Survival: An Unusual Case of
MD, MPH, Allegheny County Medical Examiner’s Office, a Suicide Attempt Resulting in Fetal Death
1520 Penn Avenue, Pittsburgh, PA 15222
Racette, Jeffrey MD*, Baiyang Xu, MD, Todd M. Suicide by Table Saw — A Slice of 43
Luckasevic, DO, Alleghey County Medical Examiner Office, Interpretation
1520 Penn Avenue, Pittsburgh, PA 15222; and Abdulrezak
M. Shakir, MD, Allegheny County and Karl E. Williams,
MD, Office of the Medical Examiner - Allegheny County,
Racette, Stéphanie BSc*, Célia Kremer, MSc, and Anny Suicidal and Homicidal Sharp Force Injury: A 305
Sauvageau, MD, Laboratoire de Sciences Judiciaires et de Five Year Retrospective Comparative Study
Médecine Légale, 1701, Parthenais Street, 12th floor, of Hesitation Marks and Defense Wounds
Racette, Stéphanie BSc*, Célia Kremer, MSc, Anne Dispersion of Hesitation Marks and Defense 269
Desjarlais, and Anny Sauvageau, MD, Laboratoire de Wounds: A New Criterion of Differentiation
Sciences Judiciaires et de Médecine Légale, 1701, of Sharp Force Suicide and Homicide
Parthenais Street, 12th floor, Montreal, Quebec H2K 3S7,
Canada
Rains, Glen C. PhD*, University of Georgia, PO Box 748, Comparison of Biological Sensors to Detect 195
Tifton, GA 31793; Ben Alexander, MS, Texas A&M Human Remains: Canine Versus
University, TAMU 2475, College Station, TX 77843; Jeffery Hymenopteran
K. Tomberlin, PhD, Department of Entomology, TAMU
2475, College Station, TX 77843-2475; and Jerry Melbye,
PhD, Department of Anthropology, 601 University Drive,
ELA 273, Texas State University-San Marcos, San Marcos,
TX 78666-4616
Rao, Chitra MBBS*, Forensic Pathologist, Regional Pediatric Injuries: Can CPR Related Injuries 572
Forensic Pathology Unit, General Site -HHS, 237 Barton Mimic Inflicted Injuries?
Street East, Hamilton, Ontario, L8L 2X2, Canada
Raul, Jean-Sebartien MD*, Laurent Berthelon, MD, Annie Homicide Attempt With a Japanese Samurai 556
Geraut, MD, Antoine Tracqui, MD, PhD, and Bertrand Sword
Ludes, MD, PhD, Institut de Médecine Légale, 11 Rue
Humann, Starsbourg Cedex, France
Index 206
Raul, Jean-Sebastien MD*, Antoine Tracqui, MD, PhD, and Suicide Attempt Using a Self-Made Rifle 513
rue Humann, Strasbourg, Framce
Raul, Jean-Sebastien MD*, Institut de Medecine Legale, 11 Two Gunshots to the Head: Suicide or 528
rue Humann, Strasbourg, France; C. Deck, and F. Meyer, Homicide? A Biomechanical Study
Institut de Mécanique des fluides - ULP-CNRS 7507,
Strasbourg, France; Annie Geraut, and Antoine Tracqui,
MD, PhD, Institut de Medecine Legale, 11 rue Humann,
Strasbourg, France; R. Willinger, Institut de Mecanique des
Fluides, ULP-CNRS 7507, Strasbourg, France; and
rue Humann, Strasbourg, France
Redd, JeAnna R. BS*, University of Central Oklahoma, 100 Preliminary Analyses of Carrion Colonization 155
North University Drive, Evans Hall 101 (Box 208), of Necrophagous Flies (Diptera:
Edmond, Oklahoma 73034; and Wayne D. Lord, PhD, Calliphoridae) in Central Oklahoma
Forensic Science Institute, University of Central Oklahoma,
100 North University Drive, Edmond, OK 73034
Reedy, Edward A. PhD, MD*, John M. Getz, PhD, Lisa Use of CT as an Aid in the Recovery of 348
Pearse, MD, Craig T. Mallak, MD, JD, and James L. Metallic Foreign Bodies at Autopsy
Caruso, MD, Armed Forces Medical Examiner System,
20850
Remus, Luis E.III, PhD, MD*, Ashraf Mozayani, PhD, The Value of Expanded Postmortem 373
Terry Danielson, PhD, and Luis A, Sanchez, MD, Harris Toxicology Testing Menu
County Medical Examiners Office, 1885 Old Spanish Trail,
Houston, TX 77054
Resk, Thomas K. MD*, PO Box 3215, Chico, CA 95927- Hmong Cultural Aversion to Forensic 451
3215; Thomas A. Rudd, MD, PO Box 332, Highwood, IL Autopsy: Bridging Communication and
60040-0332 Cultural Barrier
Revercomb, Carolyn H. MD*, and Sarah M. Colvin, MD, Non-Traumatic Subdural Hematoma in Adults 93
Office of the Chief Medical Examiner, District of Columbia,
1910 Massachusetts Avenue Southeast, Washington, DC
20003; and Marie L. Pierre-Louis, MD, 6404 Luzon
Avenue, Northwest, Washington, DC 20012
Revercomb, Carolyn H. MD*, Northern District Office of Postmortem Diagnosis of Genetic Arrhythmia 452
the Chief Medical Examiner, Fairfax, Virginia, and Syndromes
Department of Legal Medicine, Virginia Commonwealth
University School of Medicine, 9797 Braddock Road,
Fairfax, VA 22032
Rhee, Dennis MD*, and Lynn A. Salzberger, MD, Southwest Death From Severe Anorectal Injury of a Jet 13
Institute of Forensic Sciences, 5230 Southwestern Medical Ski Passenger
Avenue, Dallas, TX 75235
Ricci, Simona MD*, Department of Legal Medicine, Viale Methodologies for Heteroplasmy 157
Regina Elena 336, Roma, ITALY Identification
Index 207
Ricci, Simona MD*, Department of Legal Medicine, Viale Identification of Human Body Fluids: 234
Regina Elena 336, Rome, ITALY; Fabio Verginelli, Comparison Between Two Commercial Kits
Department of Oncology and Neuroscience University for Detection of Semen
“G.d’Annunzio” and Center of Excellence on Aging
(Ce.S.I.), D.d’Annunzio Foundation, Chieti, ITALY; Andrea
Mele, MD, Department of Legal Medicine University
“Sapienza” Viale Regina Elena 336, Rome, ITALY; and
Manuela Rosini, and Carla Vecchiotti, MD, PhD,
Laboratory Genetic of the Department of Legal Medicine
University “Sapienza”, Viale Regina Elena 336 00161
Rome, ITALY
Rich, Jeremy DPM*, Harvard Medical School, Beth Israel Undefeated by Surgery: The Utility of Post- 547
Deaconess Medical Center, 330 Brookline Avenue, Boston, Surgical Foot and Ankle Radiographs as a
MA; Nancy E. Tatarek, PhD, Ohio University, 293 Lindley Basis for Identification
Hall, Athens, OH; Robert H. Powers, PhD, Hamilton
County Coroner’s Office, 3159 Eden Avenue, Cincinnati,
OH; Bradley J. Lewis, MD, and Dorothy E. Dean, MD,
Franklin County Coroner’s Office, 520 King Avenue,
Columbus, OH
Riemer, Ellen C. MD, JD*, Barry S. Levine, PhD, Jack M. Oxycodone (OxyContin) Related Deaths in 543
Titus, MD, and David R. Fowler, MB, ChB, Office of the Maryland 1998-2000
Chief Medical Examiner of the State of Maryland, 111 Penn
Riezzo, Irene MD*, and Stefano D’Errico, MD, University Sudden Death Due to a Cardiac Sarcoidosis: 251
of Foggia, Department of Forensic Pathology, via Luigi Histopathological Helping Evidences
Pinto, 1, Foggia, 71100, ITALY; and Francesco Ventura,
MD, University of Genova, Department of Forensic
Pathology, Via de’ Toni, 12, Genova, 16132, ITALY
Riezzo, Irene MD*, Stefania Bello, MD, Margherita Neri, Systemic Lupus Erythematosus and Fatal 85
PhD, and Cristoforo Pomara, PhD, Department of Forensic Cardiac Failure Due to Pancarditis in a Young
Pathology University of Foggia, Viale degli Aviatori 1, Man
Riezzo, Irene MD, Viale Degli Aviatori, 1, Department of MDMA Neurotoxicity 174
Forensic Pathology, University of Foggia, Foggia, 71100,
ITALY; Vittorio Fineschi, PhD, Chair Forensic Pathology,
University of Foggia, Ospedale Colonnello D’Avanzo,
Foggia, I-71100, ITALY; Carmela Fiore, MD, and Stefano
Derrico, MD, University of Foggia, Department of Forensic
Pathology, Viale Degli Aviatori 1, Foggia, 71100, ITALY;
and Steven B. Karch, MD*, PO Box 5139, Berkeley, CA
94705-0139
Riezzo, Irene PhD*, University of Foggia, Osp D’Avanzo, Sudden, Unexpected Death Due to 34
Department of Forensic Pathology, Viale Degli Aviatori, 1, Glioblastoma: Three Fatal Cases
Foggia, 71100, ITALY; Santina Cantatore, Benedetta Di
Battista, MD, Ruggero Parente, MD, and Francesco
Ventura, MD, University of Genova, Department of
Forensic Pathology, Via de’ Toni, 12, Genova, 16132,
ITALY
Ripple, Mary G. MD*, and David R. Fowler, MD, Office of Venous Bullet Embolism of a Large Caliber 399
the Chief Medical Examiner, State of Maryland, 111 Penn Bullet From the Right External Iliac Vein to
Street, Baltimore, MD 21201 the Heart: Case Report and Review of the
Literature
Index 208
Ripple, Mary G. MD*, David R. Fowler, MD, and Ling Li, Investigation and Autopsy Procedures in 123
MD, Office of the Chief Medical Examiner, State of Cases Involving Conducted Energy Devices
Maryland, 111 Penn Street, Baltimore, MD 21201 (CEDs) in the State of Maryland
Ripple, Mary G. MD*, Jack M. Titus, MD, and David R. Autopsy Procedure and Findings in a Case of 494
Fowler, MD, Office of the Chief Medical Examiner, State of Inhalational Anthrax
Maryland, 111 Penn Street, Baltimore, MD
Ripple, Mary G. MD*, Office of the Chief Medical Methadone Deaths are on the Increase in 371
Examiner, State of Maryland, 111 Penn Street, Baltimore, Maryland (1998-2004)
MD 21201; Cheryl Rinehart*, Margaret Hsu, Erin
Artigiani, and Eric Wish, PhD, Center for Drug Abuse
MD 20740; and David R. Fowler, MD, Office of the Chief
Medical Examiner, State of Maryland, 111 Penn Street,
Baltimore, MD 21201
Ripple, Mary G. MS, MD*, Barry S. Levine, PhD, and Cluster of Fentanyl-Tainted Heroin Deaths in 315
Rebecca Jufer- Phipps, PhD, Office of the Chief Medical a Three-Week Period in Maryland
MD 21201; Erin Artigiani, Center for Drug Abuse
MD 20742; Suzanne Doyon, MD, Maryland Poison Center,
20 North Pine Street, Baltimore, MD 21201; and David R.
Rodriguez, William C.III, Ph.D. *, Office of the Armed Death of a Vampire?: Case of Exhumation 243
Forces Medical Examiners Office, Armed Forces Institute and Mutilation of a Corpse in Rural Romania
of Pathology, 1413 Research Blvd. Building 102, Rockville,
MD 20850
Rodriguez, William C.III, PhD*, and Laura A. Regan, PhD, Identification of Two Homicide Victims and 58
Armed Forces Medical Eaminer System, 1413 Research Linking of Separate Crimes Solved by
Boulevard, Building 102, Rockville, MD 20850; and Radiographic Discovery of a Healed Bullet
Humphrey H. Germaniuk, MD, Trumbull County Coroner’s Wound.
Office, 1863 East Market Street, Warren, OH 44483
Rodriguez, William C.III, PhD*, Armed Forces Medical Homicide, Suicide, and the Missing Mother: 147
Examiner, 1413 Research Boulevard, Building 102, The Mysterious and Tragic Deaths of a Latino
Rockville, MD 20850; and Carroll Allen, Donna Vicente, Family
Rodriguez, William C.III, PhD*, Office of the Armed Forces Eagles Syndrome: Case of an Elongated and 356
Medical Examiner, 1413 Research Boulevard, Building Ossified Stylohyoid Ligament in an Elderly
102, Rockville, MD 20850; and Jack M. Titus, MD, and Female
Index 209
Rodzen, Jeff PhD, California Department of Fish and Game The Application of DNA Identification 159
Wildlife Forensic Laboratory, 1701 Nimbus Road, Rancho Technology to Large Wildlife Carnivore
Cordova, CA 95670; Elizabeth Thompson, BS*, Orange Attacks on Humans
County Sheriff-Coroner Department, Forensic Science
Services, 320 North Flower Street, Santa Ana, CA 92703;
James D. Banks, BS, and Erin Meredith, MS, California
Department of Fish and Game Wildlife Forensic
Laboratory, 1701 Nimbus Road, Rancho Cordova, CA
95670; Hailu Kinde, DVM, California Animal Health and
Food Safety Laboratory System, 105 Carousel Mall, San
Bernardino, CA 92401; Joseph J. Halka, MD, Orange
Coounty Sheriff-Coroner Department, Forensic Science
Center, 1071 West Santa Ana Boulevard, Santa Ana, CA
92703; and Pennie Laferty, MS, and John M. Hartmann,
MBA, Orange County Sheriff- Coroner Department,
Forensic Science Services, 320 North Flower Street, Santa
Ana, CA 92703
Roe, Susan J. MD*, Regina Medical Center, 1175 Nininger Increasing Heart Valve Donation by 391
Road, Hastings, MN 55033; Shannon Mackey-Bojack, MD, Utilization of a Cardiovascular Registry
and Rachel M. Meuleners, Jesse E. Edwards
4625, St. Paul, MN 55102; Lindsey C. Thomas, MD, Regina
Medical Center, 1175 Nininger Road, Hastings, MN 55033;
and Jack L. Titus, MD, PhD, Jesse E. Edwards
4625, St. Paul, MN 55102
Rogers, Christopher A. MD*, and Lakshmanan Mortality Estimate for the 1994 Northridge 560
Sathyavagiswaran, MD, Department of Coroner, 1104 Earthquake
North Mission Road, Los Angeles, CA
Rogers, Christopher B. MD*, Los Angeles County, Medical Death in a Tanker Truck 200
CA 90033; John Kades, BA, Los Angeles County,
Department of Coroner, 1104 North Mission Road, Los
Angeles, CA 90033; and Lakshmanan Sathyavagiswaran,
MD, Los Angeles County, Medical Examiner’s Office, 1104
North Mission Road, Los Angeles, CA 90033
Rogev, Maurice G. MB ChB, MD*, Zamenhof St.11/1, Tel- Hola Camp Massacre Kenya 1959 304
Aviv-Jafo, 64373, Israel
Rogev, Maurice G. MBChB*, 11/1 Zamenhof Street, Tel Forensic Pathology of the Rupture of an 231
Aviv, Jaffo 64373, ISRAEL Enlarged Spleen
Rogev, Maurice G. MD, MBChB*, 11/1 Zamenhof Street, Victim Trauma as an Identification Tool in 337
Tel-Aviv-Jaffo, 64373, Israel Mass Disasters
Rogev, Maurice MD*, Zamenhof 11, Tel Aviv 64373, Israel The Differential Diagnosis Between 412
Bioterrorism and Zoonosis and Spread to
Humans: A Patholical Evaluation
Rogriguez, William C. III, PhD*, Office of the Armed Effect of Ant Activity on Decompositional 569
Forces Medical Examiner, Armed Forces Institute of Rates and Estimation of Postmortem Interval:
Pathology, 1413 Research Boulevard. Biulding 102, A Case Study
Rockville, MD
Rohde, Marianne C. MD*, Jytte Banner, MD, PhD, and Legal Outcome of Sexual Assault Cases, The 466
Annie Vesterby, MD, MDSc, Department of Forensic County of Aarhus, Denmark
Medicine, University of Aarhus, Peter Sabroes Gade 15,
Aarhus 8000 C, Denmark
Index 210
Rolf, Cristin M. MD*, and Heather Worne, BS, University Acute Pancreatitis in a 2½-Year-Old Child: A 433
of Kentucky, Department of Pathology and Laboratory Fatal Therapeutic Complication of
Medicine/ Office of the Associate Chief Medical Examiner, Polyethylene Glycol (PEG)-L-Asparaginase
Kentucky Justice and Public Safety Cabinet, 100 Sower
Boulevard, Suite 202, Frankfort, KY 40601-8272
Rolf, Cristin M. MD*, University of Kentucky Department A Case Report of Sudden Death in a Patient 567
of Pathology & Laboratory Medicine, Central Laboratory With Kartagner Syndrome
Facility, 100 Sower Boulevard, Suite 202, Frankfort, KY
Rolf, Cristin M. MD*, University of Kentucky, Office of the Pyelonephritis—Sudden and Unexpected 343
Associate Chief Medical Examiner, 100 Sower Boulevard, Death in Infancy
Suite 202, Frankfort, KY 40601-8272; and Bonnie Mitchell,
MD, University of Kentucky, Department of Pathology and
Laboratory Medicine, 800 Rose Street, UKMC MS 117,
Lexington, KY 40536-0298
Rolf, Cristin M. MD*, University of Kentucky/Office of the Acute Dissection of the Left Subclavian 481
Associate Chief Medical Examiner, Commonwealth of Artery in a Patient With Ehlers-Danlos
Kentucky, 100 Sower Boulevard, Suite 202, Frankfort, KY Syndrome
40601-8272
Romanelli, Maria Carolina MD*, Eloisa Maselli, MD, A Case of Lethal Peripartum Eosinophilic 7
Biagio Solarino, PhD, Section of Legal Medicine - Myocarditis
ITALY; and Giancarlo Di Vella, PhD, Sezione di Medicina
Legale, DIMIMP, University of Bari, Policlinico, Piazza G.
Rosati, Jennifer Y. BSc*, and Sherah L. Van Laerhoven, Colonization Behavior of Forensically 116
PhD, University of Windsor, Department of Biology, 401 Important Blow Fly Species: Implications for
Sunset Avenue, Room 119 Bio, Windsor, ON N9B 3P4, Postmortem Interval Estimations
CANADA
Rosati, Jennifer Y. BSc*, and Sherah L. VanLaerhoven, Seasonal Effects on Blow Fly Species 352
PhD, University of Windsor, Rm 119 Bio, 401 Sunset Composition and Behavior
Avenue, Windsor, Ontario N9B 3P4, Canada
Rose, Kelly L. MD*, and Kim A. Collins, MD, Fulton Love and a Bullet: Autoerotic Accident or 132
County Medical Examiner’s Office, 430 Pryor Street Intentional Suicide?
Southwest, Atlanta, GA 30312
Rose, Kelly L. MD*, and Kim A. Collins, MD, Medical Cardiovascular Trauma in Motor Vehicle 216
University of South Carolina, Department of Pathology and Collisions: A 20 Year Retrospective Study
Laboratory Medicine, 165 Ashley Avenue, Suite 309, PO and Review of the Literature
Box 250908, Charleston, SC 29425
Ross, Ann H. PhD, North Carolina State University, Mass Fatality Management: A Multi- 51
Department of Sociology & Anthropology, Campus Box National Perspective
8107, Raleigh, NC 27695- 8107; and Jason H. Byrd, PhD*,
Maples Center for Forensic Medicine, University of
Florida, 4800 Southwest 35th Drive, Gainesville, FL 32608
Index 211
Ross, Ann H. PhD, North Carolina State University, Pattern of Injury in Child Fatalities Resulting 318
Department of Sociology and Anthropology, CB 8107, from Child Abuse
Raleigh, NC 27695-8107; Suzanne M. Abel, PhD,
Charleston County Coroner’s Office, 4050 Bridgeview
Drive, North Charleston, SC 29405; Deborah Radisch, MD,
MPH, Office of the Chief Medical Examiner, CB 7580,
Chapel Hill, NC 27599-7580; Beth Murnane, MD, Sunrise
Pediatric Associates, 3909 Sunset Ridge Road, Suite 103,
Raleigh, NC 27607; and Sheena Harris, BA, and Kelsie
Ballance, North Carolina State University, Department of
Sociology and Anthropology, CB 8107, Raleigh, NC 27695-
8107
Ross, Jill C. BS*, and John R. Wallace, PhD, Department of Detection of Wild Game DNA in Maggot 190
Biology, Millersville University, Millersville, PA 17551; Tissue
and Jane E. Huffman, PhD, Northeast Wildlife DNA
Laboratory, East Stoudsburg University, East Stroudsburg,
PA 18301
Ross, Steffen G. MD, Institute of Forensic Medicine Center Swiss Virtobot (Virtual Autopsy) 110
of forensic imaging “Virtopsy”, Buehlstrasse 20, Bern, AE Documentation and Analysis: Work Flow and
3012, SWITZERLAND; Lars Ebert, University Bern, IRM, Procedure
Buehlstrasse 20, Bern, AE 3012, SWITZERLAND; Silvio
Näther, Institute of Forensic Medicine, Centre of Forensic
Imaging, Bühlstrasse 20, Bern, 3012, SWITZERLAND; and
Stephan Bolliger, MD, and Michael Thali, MD*, University
of Bern, Institute of Forensic Medicine, Buehlstrasse 20,
Rougé-Maillart, Clotilde G. MD*, and A. Tracqui, MD, Exceptional Suicide by Sharp Force During 229
Service de Médecine Légale, CHU, 4 rue Larrey, Angers, Mefloquine Therapy: A Case of Drug Induced
49000, FRANCE; A. Le Bouil, MD, and A. Turcant, MD, Psychosis?
Institut de Médecine Légale, Faculté de Médecine,
Strasbourg, France; and M. Penneau, MD, PhD, Service de
Médecine Légale, CHU, 4 rue Larrey, Angers, 49000,
FRANCE
Rowland, Carolyn MS*, Forensic Bioinformatic Services, Was the Shawnee War Chief Blue Jacket a 344
Inc., 2850 Presidential Drive, Suite 150, Fairborn, OH Caucasian?
45371; Dan E. Krane, PhD, Wright State University,
Department of Biological Sciences, 2640 Colonel Glenn
Highway, Dayton, OH 43435; Marc S. Taylor, MS,
Technical Associates, Inc., 4125 Market Street, Suite 3,
Ventura, CA 93003; and Robert Van Trees, BA, 589
Westwood Drive, Fairborn, OH 45324
Rubio, Ana MD, PhD*, and David Reisz, BS, State of Weight That Kills: Adults With Natural 263
Maryland Office of the Chief Medical Examiner, 111 Penn Deaths are Heavier Than Those Dying Non-
Street, Baltimore, MD 21201; Christopher Cox, PhD, Naturally — A Cross-Sectional Study
Bloomberg School of Public Health, Johns Hopkins
University, Monument Street, Baltimore, MD 21205; and
David M. Fowler, MD, State of Maryland Office of the
21201
Index 212
Rubio, Ana MD, PhD*, Office of the Chief Medical Is Hypertension a Risk Factor for Fatal 452
Examiner, 111 Penn Street, Baltimore, MD 21201; Rupture of Intracranial Aneurysms?
Christopher Cox, PhD, Division of Epidemiology, Statistics
and Prevention, National Institute of Child Health and
Human Development; DHHS, 6100 Executive Boulevard,
Room 7B05, Bethesda, MD 20892; David Fowler, MD,
Baltimore, MD 21201; Juan Troncoso, MD,
Neuropathology Unit; Department of Pathology, Johns
Hopkins School of Medicine, 720 Rutland Avenue,
Baltimore, MD 21205
Rubio, Ana MD, PhD*, State of Maryland Office of the Neuropathology of Pre-Teen Homicides in the 341
Chief Medical Examiner, 111 Penn Street, Baltimore, MD State of Maryland: 1994-2004
21201; Miguel A. Riudavets, MD, Department of Pathology
(Neuropathology), Johns Hopkins University School of
Medicine, Baltimore, MD 21201; Ling Li, MD, State of
Street, Baltimore, MD 21201; Christopher Cox, PhD,
Department of Epidemiology, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD 21201; David
Reisz, BA, and David R. Fowler, MD, State of Maryland
Baltimore, MD 21201; and Juan C. Troncoso, MD,
Department of Pathology (Neuropathology), Johns Hopkins
Rubio, Ana PhD*, Carol H. Allan, MD, and David R. Pedestrian Fatalities in Maryland: How Many, 23
Fowler, MD, Office of the Chief Medical Examiner, 111 Who, When, Where, Why, How, and Ways to
Penn Street, Baltimore, MD 21201 Prevent Them
Russo, Anthony R. PhD*, Chaminade University of The Decomposition of a Pig Carcass in a 408
Honolulu, Forensic Science, 3140 Waialae Avenue, Mesophytic Biotope, Oahu, Hawaii
Honolulu, HI 96816
Ryan, W.P. MBBS*, PO Box 267, Nowra, NSW 2541, When is SIDS Over-Laying? 463
Australia
Sabucedo*, Alberto J. PhD, and Kenneth G. Furton, PhD, Determination of Time Since Death— 524
Department of Chemistry and International Forensic Cardiac Troponin I
Research Institute, Florida International University,
University Park, Miami, FL
Saint-Martin, Pauline MD*, and Camille Rerolle, MD, Parietal Pseudofracture in Children 65
Hopital Trousseau, Service de Medecine Legale, CHRU Suggesting Non-Accidental Trauma: A
TOURS, TOURS, 37000, FRANCE; Thierry Lefrancq, MD, Report of Two Cases and Review of the
Le Vauban, BP 549, 16 rue Clerget, NEVERS, 58009, Literature
FRANCE; and Patrick O. Byrne, MD, Service de Medecine
Legale, Hopital Trousseau, CHRU TOURS, TOURS, 37000,
FRANCE
Saint-Martin, Pauline MD*, and Patrick O Byrne, MD, Undiagnosed, Untreated Acute Promyelocytic 138
Service de Medecine Legale, CHRU Tours, Tours, 37000, Leukemia Presenting as Suspicious Sudden
FRANCE; Jean Michel Gaulier, PhD, Service de Death
Pharmacologie et Toxicologie, CHRU Dupuytren, 2 avenue
Martin Luther King, Limoges, 87042, FRANCE; and Sophie
Martin Dupont, MD, Agnès Peyclit, MD, and François
Paraf, PhD, Service de Medecine Legale, CHRU
Dupuytren, 2 Avenue Martin Luther King, LIMOGES,
87042, FRANCE
Index 213
Saint-Martin, Pauline MD*, and Patrick O. Byrne, MD, Homicide-Suicide in Tours France: 2000- 205
Service de Medecine Legale, Hopital Trousseau, Centre 2007
Hospitalier Régional Universitaire de Tours, Tours, 37000,
FRANCE
Saint-Martin, Pauline MD*, Service de Medecine Legale, Subaortic Aneurysm of the Left Ventricle 252
Hopital Trousseau, Centre Hospitalier Regional Complicating Staphylococcal Endocarditis
Universitaire de Tours, Tours, 37000, FRANCE;
Christopher B. Rogers, MD, and Eugene Carpenter, MD,
Los Angeles County, Medical Examiner’s Office, 1104
North Mission Road, Los Angeles, CA 90033; Michael C.
Fishbein, MD, Department of Pathology and Laboratory
Medicine, David Geffen School of Medicine at University of
California, Los Angeles, CA 90095; and Lakshmanan
CA 90033
Sanabria, Dario MD*, Puerto Rico Institute of Forensic Spontaneous Coronary Artery Dissection – 148
Sciences, Department of Pathology, PO Box 11878, An Isolated Eosinophilic Vasculitis?: Report
Caparra Heights Station, San Juan, 00922-1878; Carlos F. of Two Sudden Death Cases
Chavez-Arias, MD, Puerto Rico Institute of Forensic
Sciences, PO Box 11878, Caparra Heights Station, San
Juan, 00922-1878; Lee M. Tormos, MD, Instituto de
Ciencias Forenses, PO Box 11878, Caparra Heights
Station, San Juan, 00926; and Jose Rodriguez-Orengo,
PhD, Puerto Rico Institute of Forensic Sciences, PO Box
11878, San Juan, 00922-1878
Sandhu, Sangeeta MD*, St. Luke’s-Roosevelt Hospital, 515 False Positive Diagnosis of Subarachnoid 346
West 59 Street, #4K, New York, NY 10019; Stephen deRoux, Hemorrhage and Subdural Hemorrhage by
MD, and Beverly Leffers, MD, Office of Chief Medical Computerized Tomography
Examiner (Brooklyn), 520 First Avenue, New York, NY
10016-6402; and Thomas Gilson, MD, Office of Chief
Medical Examiner (Manhattan), 520 First Avenue, New
York, NY 10016-6402
Sandomirsky, Marianna MD*, and Jane W. Turner, PhD, Differences in Scene Reenactment of 94
MD, St. Louis City Medical Examiner’s Office, 1300 Clark Pediatric Death: Homicide Versus Others
Street, St. Louis, MO 63103
Sanford, Michelle R. MS*, Jennifer L. Pechal, MS, and Rehydrating Dried Blow Fly Larvae to 179
Jeffery K. Tomberlin, PhD, 2475 TAMU, Department of Reclaim Their Usefulness in Forensic
Entomology, Texas A&M University, College Station, TX Investigations
77843
Santa Silva*, Jerónimo Fonte Bairro de Santa Justa, 10, Suicidal Intoxication by Copper Sulphate 212
Index 214
Santos, Agostinho PhD*, North Branch of the National Child Abusive Head Trauma in Portugal 46
Institute of Legal Medicine, Jardim Carrilho Videira, Porto,
4050-167, PORTUGAL; Liliana Santos, MD, Jardim
Carrilho Videira, Porto, 4050-167, PORTUGAL; Teresa
Magalhães, PhD, North Branch of the National Institute of
Legal Medicine, Jardim Carrilho Videira, Porto, 4050-167,
PORTUGAL; Francisco Corte-Real, PhD, Center Branch
National Institute of Legal Medicine, Largo da Sé Nova,
Manuel Bento de Sousa, nº 3, Lisboa, 1150-219,
Santos, César L. MD*, and Beatriz S. Silva, MD, Anaphylactic Shock and Postmortem Exam – 32
Portuguese National Institute of Legal Medicine, Delegação A Systematic Approach
do Centro do INML, IP, Largo da Sé Nova, 3000-213,
Coimbra, PORTUGAL; and Duarte N.P. Vieira, PhD, Rua
Antonio Jose de Almeida, No 117, Coimbra, 3000-044,
PORTUGAL
Santos, Liliana MD*, Jardim Carrilho Videira, Porto, Evaluation of a New Approach for Estimating 50
4050-167, PORTUGAL; João Lopes, PhD, Faculty of the Postmortem Interval Based on the Direct
Pharmacy, Rua Aníbal Cunha 164, Porto, 4050-047, Skin Surface Analysis Using FTIR
PORTUGAL; Agostinho Almeida, PhD, 2REQUIMTE, Spectroscopy
Department of Chemistry-Physics, Faculty, Rua Aníbal
Cunha 164, Porto, 4050-047, PORTUGAL; and Agostinho
Santos, PhD, and Teresa Magalhães, PhD, North Branch of
the National Institute of Legal Medicine, Jardim Carrilho
Videira, Porto, 4050-167, PORTUGAL
Sarajlic, Nermin MD, PhD*, International Commission on Differential Diagnosis: Antemortem vs. 337
Missing Persons, Alipasina 45A, Sarajevo, 71000, Bosnia Postmortem Bone Trauma
and Herzegovina; John Clark, MRCPath, University of
Glasgow, Joseph Black Building, Glasgow, Scotland G12
8QH, UK; and Eva-Elvira Klonowski, PhD, International
Commission on Missing Persons, Alipasina 45A, Sarajevo,
71000, Bosnia and Herzegovina
Saravo, Luigi PhD, Reparto Carabinieri Investigazioni A Cold Case: A Forensic Review Nine Years 129
Scientifiche, Viale Tor di Quinto 151, Roma, 00190, ITALY; After the Crime
Gennaro Aprea, PhD, Università degli Studi di Napoli
“Federico II”, Complesso Monte Sant’Angelo, Via Cinthia,
Napoli, 80126, ITALY; and Paola A. Magni, MS*, F.E.LAB
ASL TO1, c/o Civico Obitorio di Torino, Via Bertani 112/A,
Torino, 10137, ITALY
Sathyavagiswaran, Lakshmanan MD*, Chief Medical Rapid Death From Phlegmonous Gastritis 573
Examiner, Coroner, Los Angeles County, 1104 North Associated With Lymphoma
Mission Road, Los Angeles, CA
Sathyavagiswaran, Lakshmanan MD*, Christopher B. Characteristics of Suicidal Gunshot Wounds 238
Rogers, MD, Frances Hicks, and Donald Boger, MD, Los to the Mouth in Women
Angeles County, Medical Examiner’s Office, 1104 North
Mission Road, Los Angeles, CA 90033
Sathyavagiswaran, Lakshmanan MD*, Daniel Rieders, MD, Defibrillator/Pacemaker Evaluation in the Los 390
and Joseph Muto, Department of Coroner, Los Angeles Angeles County Medical Examiner Office
County, 1104 North Mission Road, Los Angeles, CA 90033
Index 215
Saul, Frank P. PhD*, Regional Commander, USPHS Doctors as Detectives” (1987 - 2001): Fifteen 565
DMORT 5, OH; Julie Mather Saul, BA, Director, Forensic Years of Introducing Forensic Medical
Anthropology Laboratory, James R. Patrick, MD, Lucas Science to High School Students in Northwest
County Coroner, Diane Scala-Barnett, MD, Deputy Lucas Ohio and Southeast Michigan
County Coroner, Robert B. Forney, Jr., PhD, Director of
Toxicology, and Robert A. Burns, DDS, MS, Consultant,
Forensic Odontology, Lucas County Coroner’s Office and
Medical College of Ohio, 2529 Arlington Avenue, Toledo,
OH; Jerome DeBruin, PhD, Professor of Education,
University of Toledo, 2801 West Bancroft, Toledo, OH
Sauvageau, Anny MD*, A. Godin, S. Desnoyers, C. Kremer, Mapping the Literature in Forensic Pathology 250
MSc, and S. Racette, BSc, Lab de Sciences Judiciaires, et de and Legal Medicine: A Bibliometric Study of
Medecine Legale, 1701, Parthenais Street, 12th Floor, North-American Journals From 1980 to 2005
Montreal, PQ H2K 3S7, CANADA
Sauvageau, Anny MD*, and Stéphanie Racette, BSc, Agonal Sequences in Four Filmed Hangings: 273
Laboratoire de Sciences Judiciaires et de Médecine Légale, Analysis of Respiratory and Movement
1701 Parthenais Street, 12th Floor, Montreal, Quebec H2K Responses to Asphyxia by Hanging
3S7, Canada
Sauvageau, Anny MD*, and Stéphanie Racette, BSc, Child and Adolescent Victims in Forensic 303
Laboratoire de Sciences Judiciaires ET de Médecine Autopsy: A Five Year Retrospective Study
Légale, 1701, Parthenais Street, 12th Floor, Montreal,
Quebec H2K 3S7, Canada
Sauvageau, Anny MD*, Lab de Sciences Judiciaires, et de Agonal Sequences in Eight Filmed Hangings: 200
Medecine Legale, 1701, Parthenais St, 12th Fl, Montreal, Analysis of Respiratory and Movement
QE H2K 3S7, CANADA; Romano La Harpe, MD, Institut Responses to Asphyxia by Hanging
de Medecine Legale, 9 Av de Champel (CMU), Geneva,
1206, SWITZERLAND; and Vernon J. Geberth, MS, MPS,
P.H.I. Investigative Consultant Inc., PO Box 197,
Garnerville, NY 10923
Sauvageau, Anny MD*, Office of the Chief Medical Study of Lethal and Non-Lethal Filmed 38
Examiner, 7007 - 116 Street, Edmonton, AB T6H 5R8, Hangings: New Insight Into the
CANADA Pathophysiology of Hanging
Sauvageau, Anny MD*, Office of the Chief Medical Classification of Asphyxia: The Need for 99
Examiner, 7007, 116 Street, Edmonton, AB T6H 5R8, Standardization
CANADA
Sauvageau, Anny MD*, Office of the Chief Medical Fractures of the Neck Structures in Suicidal 117
Examiner, 7007, 116 Street, Edmonton, AB T6H 5R8, Hangings: A Retrospective Study on
CANADA; and Renaud Clement, MD, 1 Rue Gaston Veil, Contributing Variables
Nantes, 44093, FRANCE
Sauvageau, Anny MD*, Office of the Chief Medical, Discrimination of Falls and Blows in Blunt 100
Examiner, 7007, 116 Street, Edmonton, AB T6H 5R8, Head Trauma: A Multi-Criteria Approach
CANADA
Sauvageau, Anny MD*, S. Racette, BSc, and C. Kremer, Discrimination of Falls and Blows in Blunt 259
MSc, Laboratoire de sciences judiciaires et de médecine Head Trauma: Assessment of Predictability
légale, 1701 Parthenais Street, 12th Floor, Montreal, Through Combined Criteria
Quebec H2K 3S7, CANADA
Sauvageau, Anny MD, MSc*, Laboratoire de Sciences Arteriovenous Malformation and its 373
Judiciaires et de Médecine Légale, 1701 Parthenais Street, Implications in Forensic Pathology: A Case
12th Floor, Montreal, Quebec H2K 3S7, Canada Report
Index 216
Sauvageau, Anny MD, MSc*, Laboratoire de Sciences Agonal Sequences in a Filmed Suicidal 334
Judiciaires et de Médecine Légale, 1701 Parthenais Street, Hanging: Analysis of Respiratory and
12th Floor, Montreal, Quebec H2K 3S7, Canada; Stéphanie Movement Responses to Asphyxia by
Racette, BSc, Laboratoire de Sciences Judiciaires et de Hanging
Médecine Légale, 1701 Parthenais Street, 12th Floor,
Savic, Slobodan MD, PhD*, School of Medicine, University Fatal Rupture of Splenic Artery Aneurysm in 163
of Belgrade, Institute of Forensic Medicine, Deligradska a Pregnant Woman With Portal Hypertension
31a, Belgrade, 11000, SERBIA AND MONTENEGRO;
Djordje Alempijevic, PhD, Institute of Forensic Medicine,
Faculty of Medicine, 31 A Deligradska St., Belgrade,
11000, SERBIA AND MONTENEGRO; Irina Damjanjuk,
MD, Institute of Forensic Medicine, Belgrade, OR 11000,
SERBIA AND MONTENEGRO; Stojan Petkovic, MD PhD,
Klinicki Centar Vojvodina, Department of Forensic
Medicine, Clinical Center of Vojvodina, Hajduk Veljkova 5-
7, Novi Sad, 21000, SERBIA AND MONTENEGRO; and
Radmila Stevanovic, MD, Institute of Pathology, School of
Medicine, University of Belgrade, 8 Dr Subotica St.,
Belgrade, 11000, SERBIA AND MONTENEGRO
Savic, Slobodan MD, PhD*, School of Medicine, University Medico-Legal Aspects of Posttraumatic 240
of Belgrade, Institute of Forensic Medicine, Deligradska Gastroduodenal Ulcers
31a, Belgrade, YT 11000, SERBIA AND MONTENEGRO;
Radmila Stevanovic, MD, MSc, Institute of Pathology,
School of Medicine, University of Belgrade, 8 Dr Subotica
Street, Belgrade, 11000, SERBIA AND MONTENEGRO;
Djordje Alempijevic, MD, PhD, Institute of Forensic
Medicine, 31a Deligradska Street, Belgrade, Serbia 11000,
SERBIA AND MONTENEGRO; and Stojan Petkovic, MD,
MSc, Clinical Center of Vojvodina, Institute of Forensic
Medicine, 5 Hajduk Veljkova Street, Novi Sad, 21000,
SERBIA AND MONTENEGRO
Scala-Barnett, Diane MD*, and Julie M. Saul, BA, Lucas Color Me Guilty: The Role of Paint Transfer 415
County Coroner’s Office, 2595 Arlington Avenue, Toledo, in Weapon Linkage
OH 43614-2674
Schoenly, Kenneth G. PhD*, California State University, A Standardized Field Protocol for 296
Stanislaus, Department of Biological Sciences, 801 West Experimentally Investigating Variability in
Monte Vista Avenue, Turlock, CA 95382; Jeffery K. Entomology-Based Postmortem Intervals
Tomberlin, PhD, Texas A&M University, Texas Over Multiple Sites and Years: A Proposal
Cooperative Extension, 1229 North U.S. Highway 281,
Stephenville, TX 76401; John R. Wallace, PhD, Millersville
University, Department of Biology, Millersville, PA 17551;
M. Lee Goff, PhD, Chaminade University, 3140 Waialae
Avenue, Honolulu, HI 96816; Jeffrey D. Wells, PhD, West
Virginia University, Biological Sciences, Morgantown, WV
26506; and Richard W. Merritt, PhD, Michigan State
University, Department of Entomology, 243 Natural Science
Building, East Lansing, MI 48824
Index 217
Schoenly, Kenneth G. PhD*, Department of Biological Does Carcass Enrichment Alter Community 473
Sciences, California State University, Stanislaus, Turlock, Structure of Predaceous and Parasitic
CA 95382; Adam Shahid, MS, University of Missouri, Arthropods? A Second Test of the Arthropod
Department of Entomology, 320 Connaway Hall, Columbia, Saturation Hypothesis at the Anthropology
MO 65211; Neal H. Haskell, PhD, Department of Biology, Research Facility in Knoxville, Tennessee
Saint Joseph’s College, Rensselaer, IN 47978; Robert D.
Hall, PhD, JD, University of Missouri, Department of
Entomology, 1-87 Agriculture Building, Columbia, MO
65211
Schoenly, Kenneth G. PhD*, Department of Biological Which Field Method is Best? A Comparative 407
Sciences, California State University, Stanislaus, Turlock, Study of Four Entomological Methods for
CA 95382; Neal H. Haskell, PhD, Department of Biology, Sampling Forensically Important Arthropods
Saint Joseph’s College, Rensselaer, IN 47978; and Robert on Human and Porcine Remains at the
D. Hall, PhD, JD, Department of Entomology, 1-87 Anthropology Research Facility in Knoxville,
Agriculture Building, University of Missouri, Columbia, Tennessee
MO 65211
Schoppe, Candace H. MD*, and Patrick E. Lantz, MD, Association of Retinal Hemorrhages With 96
Wake Forest University School of Medicine, Department of Fatal Head Injuries in Infant Monkeys
27157; Kurt A. Schoppe, MD, and Jonathan Burdette, MD,
Wake Forest University School of Medicine, Department of
Radiology, Medical Center Boulevard, Winston Salem, NC
27157; Keith G. Mansfield, DVM, Harvard Medical School,
New England Primate Research Center, 1 Pine Hill Drive,
Southborough, MA; and Constance A. Stanton, MD, Wake
Forest University School of Medicine, Department of
27157
Schoppe, Candace H. MD*, Wake Forest University Baptist Are Peripapillary Intrascleral Hemorrhages 15
Medical Center, Department of Pathology, Medical Center Pathognomonic for Abusive Head Trauma?
Boulevard, Winston Salem, NC 27157; Constance A.
Stanton, MD, Department of Pathology, Wake Forest
University Health Sciences, Medical Center Boulevard,
Winston Salem, NC 27157; and Patrick E. Lantz, MD, Wake
Forest University of Health Science, Department of
27157-1072
Schrag*, Bettina Rue du Bugnon 21, Lausanne, Cardioinhibitory Reflex Cardiac Arrest – 121
SWITZERLAND Myth or Reality?: A Systematic Review From
Cases
Schrag, Bettina MD*, Béat Horisberger, MD, and Patrice Death Caused by Cardioinhibitory Reflex: 241
Mangin, MD, PhD, University Lausanne, Institute of Legal Myth or Reality?
Medicine, Rue du Bugnon 21, Lausanne, SWITZERLAND
Index 218
Scumaci, Domenica PhD, Magna Græcia University of An Innovative Proteomic Approach for the 6
Catanzaro, Laboratory of Proteomics and Mass Identification of Novel Plasma Biomarkers in
Spectrometry, Department of Experimental and Clinical Patients With Brugada Syndrome
Medicine, Salvatore Venuta University Campus, viale “S.
Ve, Catanzaro, 88100, ITALY; Simona Grasso, Antonio
Curcio, PhD, and Marco Gaspari, PhD, Magna Græcia
University of Catanzaro, Salvatore Venuta University
Campus, Viale Europa, Catanzaro, AL 88100, ITALY;
Silvia Priori, PhD, Molecular Cardiology Laboratory,
IRCCS, Via Ferrata 8, Pavia, AL 27100, ITALY; Ciro Di
Nunzio, Institute of Legal Medicine, School of Medicine,
Magna Graecia University, Viale Europa Germaneto,
Catanzaro, 88100, ITALY; Antonio Oliva, PhD, and
Francesco Ausania, MD, Institute of Forensic Medicine,
Catholic University, School of Medicine, Largo Francesco
Vito 1, Rome, 88100, ITALY; Ciro Indolfi, PhD, Magna
Graecia University, Viale S Venuta, Catanzaro, AL 88100,
ITALY; Pietrantonio Ricci, PhD, Università degli Studi
Magna Grecia Catanzaro, Viale Europa - Località
Germaneto, Catanzaro, 88100, ITALY; and Giovanni Cuda,
PhD*, Magna Graecia University of Catanzaro, Viale S.
Venuta, Catanzaro, AL 88100, ITALY
Sebetan, Ismail M. MD, PhD*, and Irelise C. Clendenin, Diatoms and Their Forensic Significance 311
MFS, National University, 11255 North Torrey Pines Road,
La Jolla, CA 92037
Segovia, Adrienne E. MD, Clare H. Cunliffe, MD*, Mitra B. Suicide Among 10 to 20 Year Olds in Cook 374
Kalelkar, MD, and Michelle Jorden, MD, Office of the County, Illinois: A Retrospective Review
Medical Examiner, County of Cook, 2121 West Harrison
Segovia, Adrienne MD*, and Michelle A. Jorden, MD, Headache and Sudden Death in a Young 289
Office of the Cook County Medical Examiner, 2121 West Adult: An Unexpected Finding at Autopsy
Segovia, Adrienne MD, Mitra B. Kalelkar, MD*, Aldo J. Compressional Asphyxia Due to a Crowd 461
Fusaro, DO, Scott Denton, MD, Edmund R. Donoghue, Stampede: The E2 Nightclub Disaster
MD, Kendall V. Crowns, MD, Eupil Choi, MD, J. Lawrence
Cogan, MD, Ronald Knoblock, MD, Cyndi D. Gardner,
MD, and Barry D. Lifschultz, MD, Cook County Medical
Examiners Office, 2121 West Harrison Street, Chicago, IL
60612
Serrano, Javier MD*, Puerto Rico Institute of Forensic Unusual Case of Blunt Chest Trauma Without 131
Sciences, Calle Maga Esquina Casia #9, Urb. Reparto Rib Fractures Leading to a Major Pulmonary
Metropol, San Juan, PR 00921; and Carlos F. Chavez- Laceration
Arias, MD, Puerto Rico Institute of Forensic Sciences, PO
Box 11878, Caparra Heights Station, San Juan, PR 00922-
1878
Sexton, Andrew W. DO*, 24 Regency Park Drive, Agawam, Investigation of Acute Oxymorphone 176
MA 01001 (Opana® ER) and Ethyl Alcohol Intoxication
Sgan, Stephen L. MD*, and Shobha Sharma, MD, Use of Expert Consultation in the Evaluation 507
Department of Pathology and Laboratory Medicine, Emory of Tissue Donors With a Postmortem
University School of Medicine, 1364 Clifton Road, NE, Diagnosis of “Hepatitis” to Determine
Atlanta, GA; and Judith Woll, MD, and Lance D. Trainor, Eligibility For Transplantation
MD, Community Blood Center / Community Tissue
Services, 349 South Main Street, Dayton, OH
Index 219
Sgan, Stephen L. MD*, District 2 Medical Examiner’s Autopsy Performance in Transfusion 27
Office, PO Box 14389, Tallahassee, FL 32317 Recipient Fatalities Reported to the United
States Food and Drug Administration (FDA)
During Fiscal Year 2008
Shahid, Adam MS, University of Missouri, Columbia, Validation of the Anthropology Research 496
Department of Entomology, 1-87 Agriculture Building, Facility in Knoxville, TN, as a Research and
Columbia, MO; Kenneth G. Schoenly, PhD*, California Training Site For Forensic Entomology
State University, Stanislaus, Department of Biological
Sciences, Turlock, CA; Neal H. Haskell, PhD, Forensic
Entomology Consultant, 425 Kannal Avenue, Rensselaer,
IN; and Robert D. Hall, PhD, JD, University of Missouri,
Columbia, Department of Entomology, 1-87 Agriculture
Building, Columbia, MO
Shaler, Robert C. PhD*, 30 Spring Street, Flemington, NJ The Correlation of Serum Stress Hormone 15
08822; Dominic Flaim, PMFS, Pennsylvania State Levels With Cause and Circumstance of
University, 107 Whitmore Lab, State College, PA 16802; Death
and Thomas Andrew, MD, Office of the State Chief Medical
Shaw, Kai-Ping PhD*, John M. Fong, ME, John Wang, ME, Experiences Following the Crash of 560
Ching Hu, ME, Ming-Houng Chen, ME, Chiang-Shin Liu, Singapore Airlines SQ006 Boeing 747-400 in
ME, Tse-Hua Lo, ME, and Chia-Tung Shung, Ministry of Taipei
Justice Investigation Bureau; and Chang-En Pu, MS,
Institute of Forensic Medicine, Ministry of Justice, Taipei,
Taiwan
Shaw, Kyle MBBS*, David R. Fowler, MD, Zabiullah Ali, CT Autopsy Imaging in the State Medical 203
MD, and Jack M. Titus, MD, Office of the Chief Medical Examiner Setting: Logistic Issues,
Examiner, 111 Penn Street, Baltimore, MD 21201; Mary G. Techniques, and Findings
Barry Daly, MD, Radiology Department, University of
Maryland Medical Center, 22 South Greene Street,
Baltimore, MD 21201; and Clint W. Sliker, MD, University
of Maryland Medical Center, Diagnostic Imaging
Department, 22 South Greene Street, Baltimore, MD 21201
Sheck*, Reupena and M. Lee Goff, PhD, Chaminade Comparison of Early Decomposition Between 361
University of Honolulu, 3140 Waialae Avenue, Honolulu, Domestic Pig Carcasses Hanging and in
HI 96816-1578 Contact With the Ground on Oahu Island,
Hawaii
Sheil, Amy T. MD*, and Kim A. Collins, MD, Medical TASER-Related Fatalities: Case Report and 346
University of South Carolina, Department of Medical and Review of the Literature
Forensic Autopsy, 165 Ashley Avenue, Suite 309,
Shetty, Suresh K. MD*, Kasturba Medical College, Light Unusual Style Cut Throat Injury: A Case 51
House Hill Road, Mangalore, 575001, INDIA Report
Shields, Lisa B. MD*, and Donna M. Hunsaker, MD, Office Adolescent and Young Adult Suicide: A Ten- 407
of the Chief Medical Examiner, 810 Barret Avenue, Year Retrospective Review of Kentucky
Louisville, KY 40204; John C. Hunsaker III, JD, MD, Office Medical Examiner Cases
of the Associate Chief Medical Examiner, Department of
Pathology & Laboratory Medicine, 100 Sower Boulevard,
Suite 202, Frankfort, KY 40601-8272; and Michael K.
Ward, BS, Kentucky Forensic Toxicology Laboratory,
Office of Forensic Toxicology, 100 Sower Blvd, Frankfort,
KY 40601
Index 220
Shields, Lisa B. MD*, Donna M. Hunsaker, MD, and John Suicide: A Ten-Year Retrospective Review of 443
M. Hunsaker III, MD, JD, Office of the Associate Chief Kentucky Medical Examiner Cases
Medical Examiner, 100 Sower Boulevard, Frankfort, KY
40601
Shields, Lisa B. MD*, Donna M. Hunsaker, MD, and Methadone-Related Deaths: A Review of 372
Tracey S. Corey, MD, Office of the Chief Medical Medical Examiner Cases in a Large
Examiner, Urban Government Center, 810 Barret Avenue, Metropolitan Area
Louisville, KY 40204; John C Hunsaker III, MD, JD, Office
of the Associate Chief Medical Examiner, University of
Kentucky Department of Pathology and Laboratory
Medicine, 100 Sower Boulevard, Suite 202, Frankfort, KY
40601-8272; and Michael K Ward, MS, Kentucky Medical
Examiner’s Program, Office of Forensic Toxicology, 100
Sower Blvd Suite 202, Frankfort, KY 40601
Shields, Lisa B.E. MD *, and Donna M. Hunsaker, MD, Abuse and Neglect: A 10-Year Review of 509
Office of the Chief Medical Examiner, University of Mortality in Elders
Louisville School of Medicine, Louisville, KY; and John C.
Hunsaker III, MD, JD, Office of the Associate Chief
Medical Examiner, University of Kentucky College of
Medicine, Frankfort and Lexington, KY
Shkrum, Michael J. MD*, London Health Sciences Centre, Reconstruction of a Fatal Dragster Crash 257
Department of Pathology, 339 Windermere Road, London,
Ontario, N6A 5A5, CANADA; Kevin J. McClafferty, BESc*,
Multi-Disciplinary Accident Research Team, Faculty of
Engineering, University of Western Ontario, London,
Ontario N6A 5B9, CANADA; and John R. Fernandes,
MDCM, Forensic Pathology Unit, Hamilton Health
Sciences, 237 Barton Street, East, Hamilton, Ontario L8L
2X2, CANADA
Shuttlesworth, Jennifer L. MD*, Ana E. Lopez, MD, and A Case of Anaphylactoid Syndrome of 136
Luis A. Sanchez, MD, Harris County Medical Examiner’s Pregnancy
Shuttlesworth, Jennifer L. MD*, University of Texas A “Café Coronary” in a 2-Year-Old: Case 255
Medical Branch, 301 University Boulevard, Route 0743, Report
Galveston, TX 77555; and Stephen M. Pustilnik, MD,
Galveston County Medical Examiner’s Office, 6607
Highway 1764, Texas City, TX 77591
Silva*, Jerónimo F.S. National Institute of Legal Medicine - Glioblastoma – Cause of Sudden Death on an 100
Portugal, Bairro de Santa Justa, 10, Coimbra, 3000-356, Apparently Healthy Woman
PORTUGAL
Silveira, Larry MS*, Santa Clara County Department of The Rising Trend of Ecstasy and Mimic 61
Alcohol and Drug Services, 2101 Alexian Drive, Suite 110, Drugs Among Teenagers in Santa Clara
San Jose, CA 95116; and Michelle A. Jorden, MD, Santa County, California — A Guide and
Clara Medical Examiner, 850 Thorton Way, San Jose, CA Awareness for Medical Examiners, Coroners,
95128 and Toxicologists
Silver*, Shawn A. Sparrow Forensic Pathology, 1215 East MAPS: How a Statewide Pharmaceutical 112
Michigan Avenue, Lansing, MI 48909; Joyce L. deJong, Database Improves Death Investigation
DO, Sparrow Health Systems, Forensic Pathology, 1322
East Michigan Avenue, Suite 118, Lansing, MI 48909; and
Philip R. Croft, MD, Michael A. Markey, MD, and Michelle
P. Elieff, MD, Sparrow Forensic Pathology, 1215 East
Index 221
Simmons, Sam D. MD, MBA*, Ashley O’Bannon, MD, and Transplacental Intrauterine Herpes Simplex 341
Subodh Lele, MD, University of Kentucky, Department of Virus Infection Resulting in Cutaneous
Pathology and Lab Medicine, 800 Rose Street, MS 117, Calcifications in an Infant
Lexington, KY 40504
Simmons, Sam MD*, and Gregory J. Davis, MD, University Aneurysms and Old Lace: A Ruptured 239
of Kentucky, Medical Center, MS 117, 800 Rose Street, Splenic Artery Mycotic Aneurysm
Lexington, KY 40536-0298 Masquerading as Arsenic Poisoning
Simons, Stacey A MD*, Miami Dade County Medical The Pattern of Immunoreactivity for von 30
Examiner Department, Number One on Bob Hope Drive, Willebrand Factor in a Variety of Thrombotic
Miami, FL 33136; Paul E. Swanson, MD, University of States
Washington Division of Anatomic Pathology, 1959
Northeast Pacific Street, Seattle, WA 98195; and Aldo J.
Fusaro, DO, King County Medical Examiner’s Office, 908
Jefferson Street, Seattle, WA 98104
Singer, Nicole BS*, 206 South 13th Street Apartment 702, Occurrence of MRSA in the Peritoneal Cavity 89
Philadelphia, PA 19107; and Fredric N. Hellman, MD, Following PEG Tube Insertion
Office of the Medical Examiner, Fair Acres, Route 352,
Lima, PA 19037
Singh, Veena D. MD, MPH*, University of New Mexico A Retrospective Review of Youth Suicide in 286
Health Sciences Center, Department of Pathology MSC08 New Mexico
4640, 1 University of New Mexico, Albuquerque, NM
87131; and Jeffrey S. Nine, MD, and Sarah Lathrop, DVM,
PhD, Office of the Medical Investigator, MSC11 6030, 1
Singh, Veena D. MD, MPH*, University of New Mexico Subdural Hemorrhage, Subarachnoid 277
Health Sciences Center, Department of Pathology MSC08 Hemorrhage, and a Healing Tibia Fracture:
4640, 1 University of New Mexico, Albuquerque, NM Abuse or Complications of Leukemia?
87131; and Kurt B. Nolte, MD, and Ross Reichard, MD,
Office of the Medical Investigator, MSC11 6030, 1
Sledzik, Paul S. MS*, Region III DMORT, National Museum Victim Identification Following the Crash of 492
of Health and Medicine, Armed Forces Institute of United Airlines Flight 93
Pathology, 6825 16th Street, NW, Washington, DC;
Wallace Miller, BA, Somerset County Coroner’s Office, 555
Tayman Avenue, Somerset, PA; Dennis C. Dirkmaat, PhD,
Mercyhurst Archaeological Institute, Mercyhurst College,
501 East 38th Street, Erie, PA; Joyce L. de Jong, DO,
Sparrow Hospital Pathology, 1215 East Michigan Avenue,
Lansing, MI; Patricia J. Kauffman, MD, GlaxoSmithKline,
2187 Harts Lane, Whitemarsh, PA; David A. Boyer, MFS,
Department of Defense DNA Registry, 1413 Research
Boulevard, Armed Forces Institute of Pathology, Rockville,
MD; Fedric N. Hellman, MD, Delaware County Coroner’s
Office, Fair Acres, Lima, PA
Smith, Geoffrey P. MD, Kelly L. Rose, MD*, and Randy L. An Unusual Case of “Piggyback” Sandwiched 141
Hanzlick, MD, Fulton County Medical Exam Center, 430 Projectiles Caused by a Round- Nose Bullet
Pryor Street, Southwest, Atlanta, GA 30312 Shot Through a Door
Smith, O.C. MD*, Conscience and Science in Medicine, Death by INR: A Case of Vitamin K 166
LLC 9639 Rosemark Road, Atoka, TN 38004; and Jennifer Deficiency Bleeding Masquerading as Shaken
Griffith, MS, Lani Collins, MS, and Linda Williford, PhD, Baby Syndrome
The University of Tennessee Clinical Laboratory Sciences,
930 Madison Avenue, Memphis, TN 38163
Index 222
Smith, O’Brian C. MD*, and Teresa A. Campbell, MD, 381 19th Century Autopsy Techniques: Failing to 425
Cherry Hollow CV, Cordova, TN 38018; Elayne J. Pope, Meet 21st Century Forensic Science Needs
MA, Department of Anthropology, University of Arkansas,
Fayetteville, AR 72701; Chantal Ferraro, PhD, C.W. Post
Campus, Long Island University, Brookville, NY 11548;
and Alexandr Senilnikov, MD PhD, Regional Forensic
Center, 1060 Madison AV, Memphis, TN 38104
Smith, O’ Brian C. MD*, Regional Forensic Center of the Documenting Patterns of Injury in Fire 512
University of Tennessee, 1060 Madison Avenue, Memphis, Victims
TN; and Elayne J. Pope, MA, University of Arkansas, 330
Old Main, Fayetteville, AR
Smith, O’Brian C. MD*, Steven A. Symes, PhD, Cynthia D. Child Abuse Autopsy Technique... What 578
Gardner, MD, Susan B. Patton, MNSc, and T. A. Campbell, Works for Us
MD, University of Tennessee, Memphis, 1060 Madison
Avenue, Memphis, TN; and C. Ferraro, PhD, Long Island
University, Brookeville, NY
Smock, William S. MD*, University of Louisville Hospital, “Goodness Gracious Great Balls of Fire”: 119
Department of Emergency Medicine, 530 South Jackson Genital Thermal Injuries From Airbag
Street, Louisville, KY 40202 Exhaust
Snell, Kenneth S. MD* Medical Examiner, Mecklenburg The Role of Hyponatremia in Fresh Water 505
County Medical Examiner’s Office, Charlotte, NC; Keith C. Drowning and Water Intoxication: Making
Kocis, MD, MS, Associate Professor of Pediatrics, the Distinction at Autopsy
Department of Pediatrics, University of North Carolina at
Chapel Hill, Chapel Hill, NC; and Deborah L. Radisch,
MD, MPH, Associate State Medical Examiner, Office of the
Chief Medical Examiner, Chapel Hill, NC
Solarino, Biagio MD*, Giancarlo Di Vella, MD, PhD, and Electrocution by Arcing: A Non Fatal Case 339
Alessandra Arpaio, MD, Sezione di Medicina Legale - Study
Di.M.I.M.P., Università degli Studi di Bari - Policlinico,
Bari, 70125, Italy
Solarino, Biagio MD*, Sezione di Medicina Legale - An Unusual Case of Child Head Injury by 360
Di.M.I.M.P. Universita degli Studi di Bari - Policlinico, Coat Hanger
Bari, 70125, Italy; Amy M. Burrows-Beckham, MD, Office
of the Chief Medical Examiner, 810 Barret Avenue,
Louisville, KY 40204; and Kathy Recktenwald, RN, Clinical
Forensic Medicine, University of Louisville, 810 Barret
Avenue, Louisville, KY 40204
Solarino, Biagio MD*, University of Bari, Sezione di Lethal Neglect: A Case of Extreme 223
Medicina Legale, Piazza Giulio Cesare,11, Bari, 70100, Intrafamilial Child Torture
ITALY; Vito Romano, MD, U.O.C. di Medicina Legale -
Ospedale “Miulli”, Acquaviva delle Fonti, (Bari), 70021,
ITALY; Giuseppe Troccoli, MD, University of Bari,
Department of Criminology and, Forensic Psychiatry,
Largo Giordano Bruno 65, Bari, 70121, ITALY; Ignazio
Grattagliano, PsyD, and Roberto Catanesi, MD, University
of Bari, Section of Forensic Psychiatry, Piazza Giulio
Index 223
Solarino, Biagio PhD*, Lucia Tattoli, PhD, Eloisa Maselli, The Potential Value of Bone Marrow 17
MD, and Maria C. Romanelli, MD, Section of Legal Analysis for Forensic Purposes: Evaluation of
Medicine, University of Bari, Piazza Giulio Cesare, 11, Needle Aspiration and Biopsy Taken From
Bari, 70122, ITALY; Michael Tsokos, PhD, Institute of the Sternum
Legal Medicine and Forensic Sciences, University of Berlin,
Turmstr. 21, Building L, 10559, Berlin, 10559, GERMANY;
Alessandro Dell Erba, PhD, Section of Legal Medicine,
ITALY; and Mario Delia, PhD, Hematology Section,
ITALY
Solarino, Biagio PhD*, Sezione di Medicina Legale, An Unusual Death of a Masochist: Accident 88
Università degli Studi di Bari, P.zza Giulio Cesare, 11, Bari or Suicide?
70125, ITALY; Lucia Tattoli, MD, Sezione di Medicina
Legale, Univerisity of Bari, Bari, ITALY; Ignazio
Grattagliano, PsyD, Section of Forensic Psychiatry,
University of Bari, Piazza Giulio Cesare, Bari 70124,
ITALY; Claas T. Buschmann, MD, Institute of Legal
Medicine and Forensic Sciences, Turmstrasse 22, Berlin
10439, GERMANY; Michael Tsokos, MD, Institute of Legal
Medicine & Forensic Sciences, Turmstr 21, Haus L, Berlin
10559, GERMANY; and Giancarlo Di Vella, PhD, Sezione
di Medicina Legale, DIMIMP, University of Bari,
Policlinico, piazza G. Cesare, Bari 70121, ITALY
Solarino, Biagio PhD*, Sezione di Medicina Legale, Worker Fatalities by Hydrogen Sulfide 199
Università Degli Studi di Bari, P.zza Giulio Cesare, 11, Poisoning: Autopsy and Toxicological
Bari, 70125, ITALY; Giancarlo Di Vella, PhD, Sezione di Findings
Medicina Legale, DIMIMP, University of Bari, Policlinico,
Piazza G. Cesare, Bari, 70121, ITALY; Lucia Tattoli, MD,
Sezione di Medicina Legale, University of Bari, Bari, ,
ITALY; Claudia Liuzzi, MD, Sezione di Medicina Legale,
Università Degli Studi di Bari, Bari, 70100, ITALY;
Giuseppe Strisciullo, BES, University of Bari, Policlinico,
Piazza G. Cesare,11, Bari, 70124, ITALY; and Roberto
Gagliano-Candela, PhD, University of Bari, Cattedra
Tossicologia Forense, Policlinico, Piazza G. Cesare 11,
Bari, 70124, ITALY
Solarino, Biagio PhD*, Università degli Studi di Bari, Nasal Mucociliary Motility: New Forensic 10
Sezione di Medicina Legale, P.zza Giulio Cesare, 11, Bari, Tool for Estimating Time Since Death
70125, ITALY; Carolina Romanelli, MD, Lucia Tattoli,
MD, and Giancarlo Di Vella, PhD, Section of Legal
Medicine - University of Bari, P.zza G. Cesare 11, Bari,
70124, ITALY; and Luisa Fiorella, MD, and Matteo
Gelardi, MD, Department of Otolaryngology II - University
of Bari, P.zza G. Cesare 11, Bari, 70124, ITALY
Solomon, Carol J. MS, MD*, Louis N. Finelli, DO, and Otologic Injury as a Consequence of Blast 325
John M. Getz, BS, Office of the Armed Forces Medical Trauma; Evaluated by Postmortem Otoscopic
Examiner, 1413 Research Boulevard, Building 102, and Computed Tomography Examination
Rockville, MD 20850
Sortino*, Cettina Antonino Bonifacio, MD, Sergio Cinque, Asphyxia by Confinement: The Death of a 194
MD, Stefania Zerbo, MD, Livio Milone, PhD, and Paolo Man Kidnapped and Segregated in a Small
Proccianti, PhD, Department of Biotechnology and Legal Underground Cistern
Medicine, Section of Legal Medicine, Via del Vespro, n.
Index 224
Sortino*, Cettina Antonino Bonifacio, MD, Sergio Cinque, 50 Years Later: How Insect Evidence is Key 194
MD, Stefania Zerbo, MD, Livio Milone, PhD, and Paolo in Turning Over a Wrongful Conviction in
Proccianti, PhD, Department of Biotechnology and Legal Canada’s Most Notorious Case – Regina v.
Medicine, Section of Legal Medicine, Via del Vespro, n. Steven Truscott
Sortino*, Cettina Via del Vespro 129, Palermo, ITALY; Inadvertent Administration of Lidocaine: 193
Fleres Pierangela, Insitute of Legal Medicine, Via del Illustration of Two Cases
Vespro, n. 127, Palermo, Italia 90100, ITALY; Paola
Pugnetti, Department of Biotechnology and Legal Medicine,
90127, ITALY; Antonino Bonifacio, MD, Institute of Legal
Massimo Grillo, and Valentina Triolo, Department of
Biotechnology and Legal Medicine, Section of Legal
and Paolo Procaccianti, PhD, Palermo University, Via del
Southall, Pamela E. MD*, Ling Li, MD, and David Fowler, Police Custody Deaths in the State of 458
MD, Office of the Chief Medical Examiner, State of Maryland: Passing the Torch
Sparks, D. Larry PhD*, Sun Health Research Institute, Increased Risk of Sudden Infant Death 434
10515 West Santa Fe Drive, Sun City, AZ 85351; Rob Syndrome (SIDS) Among Infants Harboring
Friedland, MD, Bob Petersen, PhD, Ellen Grady, MS, and the Apolipoprotein E-4 Allele: Genetic and
Sandra Richardson, PhD, Case Western Reserve University, Pathologic Similarities to Alzheimer’s
10900 Euclid Avenue, Cleveland, OH 44106; and Cristin Disease (AD)
M. Rolf, MD, and John C. Hunsker III, MD, JD, Division of
Medical Examiner Services, Kentucky Justice and Public
Safety Cabinet, 100 Sower Boulevard, Suite 202, Frankfort,
KY 40601-8272
Spivack, Betty S. MD*, University of Louisville, Kentucky Bruises in Infancy: How Many Are Too 578
Justice Cabinet, Office of the Chief Medical Examiner 810 Many?
Barret Avenue, Louisville, KY
Stalter, Nicole MSFS*, Chaminade University, 3140 Chloride Levels of Sphenoid Sinus Fluid in 159
Waialae Avenue, Forensic Science Department, Honolulu, Salt and Fresh Water Drownings on the Island
HI 96816; Gayle Suzuki, MD, and Erin Mitsunaga, BA, of Oahu, Hawaii
Honolulu Medical Examiner, 835 Iwilei Road, Honolulu, HI
96817; and M. Lee Goff, PhD, Forensic Sciences Program,
Chaminade University of Honolulu, 3140 Waialae Avenue,
Honolulu, HI 96816-1578
Stamper, Trevor I. PhD*, 3516 State Route 222, Batavia, A DNA Database for Species Identification of 128
OH 45103- 9708; Alice E. Timm, PhD, Department of Forensically Important Flesh Flies (Diptera:
Biological Sciences, University of Cincinnati, Cincinnati, Sarcophagidae) in the Continental United
OH 45221-006; Gregory A. Dahlem, PhD, Department of States
Biological Sciences, Northern Kentucky University,
Highland Heights, KY 41099; and Ronald W. DeBry, PhD,
Department of Biological Sciences, University of
Cincinnati, Cincinnati, OH 45221-0006
Starling-Roney, Rameen S. MD*, Anna Rubio, MD, Donna Temporal Variation of Ethanol Related 95
M. Vincenti, MD, and David R. Fowler, MD, State of Firearm Deaths
Stash, John A. DO*, Zabiullah Ali, MD, Carol Allan, MD, Heightened Awareness of Bioterrorism: Three 402
Ana Rubio, MD, Mary G. Ripple, MD, and David R. Cases of Unusual Skin Lesions
Index 225
Steadman, Dawnie W. PhD*, Binghamton University, An Unsolved Cold Case in Iowa: A Probable 154
SUNY, Department of Anthropology, Binghamton Case of Dragging
University, PO Box 6000, Binghamton, NY 13902-6000;
Dennis Klein, MD, Iowa Department of Public Health, 321
East 12th Street, Des Moines, IA 50319-0075; and Blythe
Bloemendaal, BA, Lyon County Sheriff’s Office, 410 South
Boone, Rock Rapids, IA 51246
Steadman, Shelly A. MS*, Sedgwick County Regional Comparative Study of DNA Yield and STR 470
Forensic Science Center, 1109 North Minneapolis, Wichita, Profile Quality Obtained From Various Tissue
KS 67214; Jaime L. Oeberst, MD, Sedgwick County Types of a Decomposed Body
Regional Forensic Science Center, 1109 North
Minneapolis, Wichita, KS 67214; Daniel J. Fahnestock, MS,
Sedgwick County Regional Forensic Science Center, 1109
North Minneapolis, Wichita, KS 67214
Stefano, Eugenia Di MD*, Via Raffaello N°9, Palermo, Death Due to Atrial Septum Defect Repaired 31
90100, ITALY; Filippo Maria Cascino, MD*, Department by Transcatheter Closure: Who Failed?
of Biotechnology and Legal Medicine, Section of Legal
Medicine, Via del Vespro 129, Palermo, 90127, ITALY; and
Graziana Farina, MD, Roberto Guarino, MD, Nunzia
Albano, MD, and Emiliano Maresi, Via Del Vespro 127,
Stevens, Jamie R. PhD, University Exeter, Biological Paraphyly in Lucilia Cuprina (Diptera: 548
Science, Prince of Wales Road, Exeter, United Kingdom; Calliphoridae) Mitochondrial DNA:
Richard Wall, PhD, University Bristol, Biological Sciences, Implication for Forensic Entomology and
Woodland Road, Bristol, United Kingdom; and Jeffrey D. Evidence for an Ancient Hybridization Event
Wells, PhD*, University of Alabama Birmingham, Justice
Science, 901 15th Street South, Birmingham, AL
Stier, Michael A. MD*, University of Wisconsin-Madison, Seizure Associated Fatalities: An Analysis of 550
Department of Pathology, 1300 University Avenue, Cases in Milwaukee County
Madison, WI; and John R. Teggatz, MD, Milwaukee County
Medical Examiner’s Office, 933 West Highland Avenue,
Milwaukee, WI
Stokes, Kathryn L. BSc*, Centre for Forensic Science, The Investigation of Animal Tissue as an 301
University of Western Australia, 35 Stirling Highway, Analogue for Human Tissue in
Nedlands, Perth, Western Australia 6009, Australia; Shari Decomposition Studies in Soil
Forbes, PhD, University of Ontario Institute of Technology,
Faculty of Science, University of Ontario Institute of
Technology, 2000 Simcoe Street North, Oshawa, ON L1H
7K4, Canada; and Mark Tibbett, PhD, Centre for Land
Faculty of Natural and Agricultural Sciences, University of
Western Australia, 35 Stirling Highway, Nedlands, Perth,
Western Australia 6009, Australia
Stone, Joshua K. BS*, and Raleigh W. Parrott, MS, Federal Forensic Identification of Microbial Mixtures 150
Bureau of Investigation, CFSRU, 2501 Investigation Via ESI-TOF Mass Spectrometry
Parkway, Quantico, VA 22135; Jason D. Bannan, PhD, and
Bruce Budowle, PhD, Federal Bureau of Investigation
Laboratory, 2501 Investigation Parkway, Quantico, VA;
and James M. Robertson, PhD, and Brian A. Eckenrode,
PhD, Federal Bureau of Investigation, CFSRU, Federal
Bureau of Investigation Academy, Building 12, Quantico,
VA 22135
Index 226
Stoppacher, Robert MD*, Milwaukee County Medical Malaria Deaths in the United States: Case 538
Examiner’s Office, 5258 North, Bay Ridge Avenue, White Report and Review of Deaths, 1979-1998
Fish Bay, WI; and Stephen P. Adams, MD, Vermont Office
Burlington, VT
Stoppacher, Robert MD, MS, BS*, Milwaukee County Esophageal and Pharyngeal Injury Associated 524
Medical Examiner’s Office 933 West Highland Avenue, With the Esophageal-Tracheal Combitube®
Milwaukee, WI
Stormo, K. Alan MD*, Jeffrey M. Jentzen, MD, Mary K. Suffocation by Mistaken Use of a Biohazard 413
Mainland, MD, John R. Teggatz, MD, and Victor V. Frolov, Hood as a “Spit” Hood
MD, Milwaukee County Medical Examiner, 933 West
Stoukas*, Vasilios S. Telamonos 25, Anthoupoli, Peristeri, Victimization of Children, Adolescents, and 239
Athens, 12135, GREECE; Angeliki Tsiola, MD, Patras, Young Adults by Physical and/or Sexual
GREECE; and Anastasia Varvarigou, MD, University of Abuse in Northwestern Greece: A Three Year
Patras, Medical School, GREECE Study
Striman*, Becca 1347 North 37th Street, Lincoln, NE Consumption of Fly Artifacts After 192
68503; Amanda Fujikawa, BS, 202 Entomology Hall, Deposition and Translocation of Bloodstains
University of Nebraska-Lincoln, Lincoln, NE 68583-0816; by Calliphora vicina (Diptera: Calliphoridae)
Larry Barksdale, MA, Lincoln Police Department, 575
South 10th Street, Lincoln, NE 68508; and David O. Carter,
PhD, University of Nebraska, Lincoln, Department of
Entomology, 202 Plant Industry Building, Lincoln, NE
68583-0816
Stroh, Wendy A. DO*, and Deborah Kay, MD, Office of the Evaluation of Nasoharyngeal Viral Swabs in 267
Chief Medical Examiner, 400 East Jackson Street, Infants Dying of Natural Causes
Richmond, VA 23219
Sturner, William Q. MD*, Office of the Medical Examiner, Commotio Cordis Intermedius: Digital 544
Arkansas State Crime Laboratory, PO Box 8500, Little Interposition Between Projectile and Thorax
Rock, AR
Sun Chui, Paul Peng MBBS, DMJ, MRCPath, MBA*, A Five Year Retrospective Study of Unnatural 486
Centre for Forensic Medicine, Health Sciences Authority, Deaths in Children 12 Years and Younger in
11 Outram Road, Singapore Singapore From 1997-2001
Super, Mark A. MD*, Sacramento County Coroner’s Office, EBV (+) T-Cell Lymphoproliferative 95
4800 Broadway, Suite 100, Sacramento, CA 95820-1530; Disorder of Childhood Causing Sudden
and Karimireddy J. Reddy, MD*, University of California, Death: A Case Report
Davis, Department of Pathology, 4400 V Street,
Sacramento, CA 95817
Swalwell, Christopher MD*, Medical Examiner’s Office, Elder Abuse and Neglect Death Review: Use 406
San Diego County, 5555 Overland Avenue, Building 14, of an Interagency Team
San Diego, CA 92123
Swalwell, Christopher MD*, Office of the Medical Murder By Poison: Experiences of a Medical 317
Examiner, 5555 Overland Avenue, Suite 1411, San Diego, Examiner’s Office
CA 92123
Swiatkowski, Sean A. DO*, 1 Middlebridge Court, Silver In Utero Traumatic Head Injuries During a 162
Spring, MD 20906; Anna Rubio, MD, Office of the Chief Motor Vehicle Collision: Case-Report and
Medical Examiner, 111 Penn Sreet, Baltimore, MD 21201; Review of the Literature
Michael Johnson, MD, and Juan C. Troncoso, MD, Johns
Hopkins University School of Medicine, 111 Penn Street,
MD 21201
Index 227
Symes, Steven A. PhD, Mercyhurst College, 501 East 38th Child Abuse vs. Cachexia: Do Healing and 54
Street, Erie, PA 16546-0001; and Dianne R. Vertes, PhD, Acute Rib Fractures Trump a Diagnosis of
MD, Erie County Medical Examiner’s Office, 462 Grider Probable Cardiac Dysrhythmia Due to
Street, Buffalo, NY 14215 Electrolyte Abnormalities
Szentmariay, Istvan F. MD*, and Gyorgy Dunay, MD, In-Hospital Deaths for Forensic Autopsy 550
Ulloi Ut 93, Budapest, Hungary
Szentmariay, Istvan F. MD*, Gyorgy Dunay, MD, and Where Do People Die Suddenly and 555
Marta Hubay, MD, Institute of Forensic Medicine, Unexpectedly?
Semmelweis University, Ulloi Ut 93, Budapest, Hungary
Szentmariay, Istvan F. MD*, Institute of Forensic Medicine, Places to Commit Suicide 440
Semmelweis University, Ulloi UT 93, Budapest, H-1091,
Hungary
Szentmariay, Istvan F. MD, DMJ*, and Gyorgy Dunay, Death During EMS Transportation 489
MD, Institute of Forensic Medicine, Semmelweis University,
Budapest, Hungary, Ullio Street 93, Budapest, Hungary
Szentmariay, Istvan F. MD, DMJ, Marta Hubay, MD, and Analysis of Five Thousand Forensic Medical 511
Gyorgy Dunay, MD*, Institute of Forensic Medicine, Expert Opinions
Semmelweis University, Budapest, Hungary, Ulloi Street 93,
Budapest, Budapest, Hungary
Szentmariay, Istvan MD, DMJ*, and Gyorgy Dunay, MD, Suicidal Jumping 513
Budapest, Hungary, Ulloi Street 93, Budapest, Budapest,
Hungary
Tabor, Kimberly L. BA, MS*, Richard D. Fell, PhD, and Insect Succession Studies on Pig Carrion in 438
Carlyle C. Brewster, PhD, Virginia Tech, 216 Price Hall, Southwest Virginia and the Effects of
Blacksburg, VA 24061; Kevin Pelzer, DVM, Virginia Tech Antemortem Ethanol Ingestion on Insect
School of Veterinary Medicine, Blacksburg, VA 24061; Succession and Development
George S. Behonick, PhD, Department of Criminal Justice
Services, Division of Forensic Sciences, 6600 Northside
High School Road, Roanoke, VA 24019
Tambuscio, Silvia MD*, Legal Medicine for the Court of Non-Chemical Suffocation Deaths in Forensic 185
Padova, Via Rezzonico, 24, Padova, LA 35131, ITALY; and Setting: A Six Year Retrospective Study of
Anny Sauvageau, MD, Lab de Sciences Judiciaires et de Environmental Suffocation, Smothering,
Medecine Legale, 1701, Parthenais Street, 12th Floor, Choking, Traumatic, and Positional Asphyxia
Montreal, Quebec H2K 3S7, CANADA
Tambuscio, Silvia PhD*, University of Verona, via Sudden Unexpected Death Associated With 29
Rezzonico, 24, 35131, Padova, ITALY; Jennifer Pascali, Undiagnosed Lymphocytic Thyroiditis:
PhD, University of Verona, Piazzale L.A. Scuro 10, Verona, Report of a Case and Literature Review
IL 37100, ITALY; Andrea Galassi, MD, S.Bortolo Vicenza
Hospital, via Rodolfi 37, Vicenza, IL , ITALY; Federica
Alessandrini, PhD, Università Politecnica delle Marche, via
Conca 6 Torrette, Ancona, IL 60126, ITALY; and Fiorella
Calabrese, MD, University of Padova, via A.Gabelli61,
Tang, Yingying MD, PhD*, Erik T. Bieschke, MS, Erin Comprehensive Molecular Genetic Testing 225
Labitzke, Jennifer D’Andrea, MSFS, Stacey Sainte-Marie, for the Cardiac Channelopathy Genes in 42
MSFS, Dawei Wang, Jean Jeudy, Yoonhee A. Kim, Cases of Sudden Infant Death and Sudden
Stephanie Pack, Lucy En, Barbara A. Sampson, and Unexplained Death in the City of New York
Mechthild K. Prinz, PhD, Office of Chief Medical Revealed High Mutation Rate
Examiner, Department of Forensic Biology, 421 East 26th
Street, New York, NY 10016
Index 228
Tang, Yingying MD, PhD*, Erik T. Bieschke,MS, Stacey Molecular Genetic Testing in 323 Cases of 247
Sainte- Marie, MSFS, Jean Jeudy, Yoonhee A. Kim, Fatal Pulmonary Thromboembolism in the
Stephanie Pack, Barbara A. Sampson, and Mechthild Prinz, City of New York Revealed Racial
PhD, Office of Chief Medical Examiner, Department of Stratification
10016
Tape, Christopher MD*, and Patrick E. Lantz, MD, Postmortem Examination of Coronary Artery 189
Department of Pathology, Wake Forest University, SOM, Stents Using a Hand-Held Rotary Tool
Medical Center Boulevard, Winston-Salem, NC 27157-1072
Tarone, Aaron M. BS*, Department of Zoology, 203 Improving Postmortem Interval Estimates in 352
Natural Sciences Building, Michigan State University, East Forensic Entomology: Blowfly Gene
Lansing, MI 48824; and Kimberly C. Jennings, BS, and Expression and Development
David R. Foran, PhD, School of Criminal Justice, 560
48824
Tarone, Aaron M. BS*, Department of Zoology, Michigan The Validation of Gene Expression as a 300
State University, 203 Natural Sciences, East Lansing, MI Means of Predicting the Age of the Blow Fly
48824; and David R. Foran, PhD, Forensic Science Lucilia sericata
Program, Michigan State University, 560 Baker Hall, East
Lansing, MI 48824
Tattoli, Lucia PhD*, Sabrina Leonardi, MD, and Biagio Undiagnosed, Untreated Natural Disease 1
Solarino, PhD, Section of Legal Medicine - University of Mistaken for Lethal Child Neglect: Liability
Bari, Pizza Giulio Cesare 11, Bari, 70124, ITALY of the Family in Determining Child’s Death
Tatum, Christina J. MD*, 522 Cliff Place, Homewood, AL Fatal Spontaneous Non-Traumatic Subdural 10
35209; and Constance A. Stanton, MD, and Patrick E. Hematoma and Terson Syndrome
Tennant, Lucile B. JD*, Marc A. Krouse, MD, and Nizam Comparison of Drug-Related Deaths in 103
Peerwani, MD, Tarrant County Medical Examiner’s Office, Tarrant County, Texas, With Law
200 Feliks Gwozdz Place, Fort Worth, TX 76104-4919 Enforcement Seizures of Illicit Substances
Over a Similar Time Frame
Terranova*, Claudio nd Massimo Montisci, PhD, Cardiac Death in Anabolic Steroid Abuse: A 254
University of Padova, Section of Legal Medicine, via Pathological and Toxicological Study
Falloppio n.50, Padova - Italy, Padova, 35121, ITALY;
Cristina Basso, and Gaetano Thiene, via Gabelli 61,
Padova, 35121, ITALY; and Santo Davide Ferrara, PhD,
University of Padua - Section of Legal Medicine and
Forensic Toxicology, Via Falloppio 50, Padua, 35121,
ITALY
Thali, Michael J. MD* and Marcel Braun, University of From VIRTOPSY to VIRTOBOT: 470
Berne, Buehlstrasse 20, Berne 3012, Switzerland; Buck Photogrammetry Based Optical Surface
Ursula, Emin Aghayev, MD, and Christian Jackowski, MD, Scanning and Radiological Virtual Autopsy
University of Berne, Buehlstrasse 20, Berne 3012; Martin
Sonnenschein, MD, University of Berne, Inselspital, Berne
3012, Switzerland; Peter Vock, MD and Richard Dirnhofer,
MD, University of Berne, Buehlstrasse 20, Bern 3012,
Switzerland
Index 229
Thali, Michael J. MD*, Office of the Armed Forces Medical Virtopsy—New Horizons in Forensic 546
Examiner, AFIP - Annex, 1413 Research Boulevard, Radiology: Documentation and Analysis of
Building 102, Rockville, MD; K. Yen, Wolf Schweitzer, and Gunshot Victims With Postmortem Multi-
E. Scheurer, Institute of Forensic Medicine, University of Slice Computer Tomography and Magnetic
Berne, Buchlstrasse 20, Berne, Switzerland; P. Vock, Resonance
Berne, Switzerland; C. Ozdoba, and G. Schroth,
Department of Neuroradiology, University of Berne, Berne,
Switzerland; M. Sonnenschein, Institute of Diagnostic
Radiology, University of Berne, Berne, , Switzerland; Ch.
Boesch, Department. Clinical Research, Magnetic
Resonance Spectroscopy, University of Berne, Berne,
Switzerland; M. Ith, Department of Neuroradiology,
University of Berne, Berne, , Switzerland; K. Brugger,
Department. Clinical Research, Magnetic Resonance
Spectroscopy, University of Berne, Berne, Switzerland; E.
Spielvogel, Institute of Diagnostic Radiology, University of
Berne, Berne, Switzerland; U. Koenigsdorfer, and R. Dorn,
Buchlstrasse 20, Berne, Switzerland; and R. Dirnhofer,
Berne, Switzerland
Thali, Michael J. MD*, Office of the Armed Forces Medical Micro-Computed Tomography: An 568
Examiner, Armed Forces Iinstitute of Pathology - Annex, Advantageous Tool for the Analysis of
1413 Research Boulevard, Building 102, Rockville, MD; Patterned Tool Marks in Bones
Ulrike Taubenreuther, Institute of Medical Physics,
University of Erlangen, Germany; Marcel Braun, Institute
of Forensic Medicine, University of Berne, Berne,
Switzerland; Nicolette Scholz, Institute of Medical Physics,
University of Erlangen, Germany; Walter Brueschweiler,
Switzerland; Willi Kalender, Institute of Medical Physics,
University of Erlangen, Germany; Richard Dirnhofer, MD,
Switzerland
Thali, Michael J. MD*, University Bern, Centre Forensic Virtopsy - Virtual Autopsy, Where We Go? 272
Imaging and Virtopsy, Buehlstrasse 20, Bern, Bern 3012,
Switzerland
Thali, Michael J. MD*, University of Berne, Institut VIRTOPSY (Virtual Autopsy) - Past, Present, 350
Forensic Science, Buehlstrasse 20, Bern, Switzerland; Peter and Future
Vock, MD, University of Berne, Radiology Department,
Berne, 3005, Switzerland; and Richard Dirnhofer, MD,
University of Berne, Institut of Forensic Medicine, Berne,
Berne 3012, Switzerland
Index 230
Thali, Michael MD*, Office of the Armed Forces Medical Coins as Intermediate Targets: Reconstructive 527
Examiner, Armed Forces Institute of Pathology, Rockville, Analysis With Body Models
MD, and Institute of Forensic Medicine, University of
Berne, Berne, Switzerland; Beat P. Kneubuehl, PhD,
Switzerland; William C. Rodriguez III, PhD, Office of the
Armed Forces Medical Examiner, Armed Forces Institute of
Pathology, Rockville, MD; James Smirniotopoulos, MD,
Uniformed Services University of the Health Sciences,
Bethesda, MD; A. Charles Richardson, DDS, National
Naval Medical Center, Department of Radiology, Bethesda,
MD; David R. Fowler, MD, Offices of the Medical
Examiner of the State Maryland, Baltimore, MD; Michael
L. Godwin, BS, and Aaron Jurrus, Office of the Armed
Forces Medical Examiner, Armed Forces Institute of
Pathology, Rockville, MD; Doug Fletcher, PhD, National
Naval Medical Center, Department of Radiology, Bethesad,
MD; and Craig T. Mallak, MD, Office of the Armed Forces
Medical Examiner, Armed Forces Institute of Pathology,
Rockville, MD
Thali, Michael MD*, Office of the Armed Forces Medical Analysis of Electric Injury Patterns in Human 527
Examiner, Rockville, MD, and Institute of Forensic Skin by Magnetic Resonance Microscopy
Medicine, University of Berne, Berne, Switzerland; William
R. Oliver, MD, and William C. Rodriguez III, PhD, Armed
Forces Institute of Pathology, Rockville MD; Richard
Dirnhofer, MD, Institute of Forensic Medicine, University
of Berne, Berne, Switzerland; and Kimberlee Potter, PhD,
Armed Forces Institute of Pathology, Rockville, MD
Thali, Michael MD*, VIRTOPSY Team, University of Bern, 3D in Forensics: TIM Synthetic MRI and 75
Institute of Forensic Medicine, Buehlstrasse 20, Bern, 3012, Virtobot – Forensic Imaging Workflow of the
SWITZERLAND Future
Tharp, Amy M. MD*, and Patrick E. Lantz, MD, Fatal Craniocerebral Trauma With 431
Department of Pathology, Wake Forest University Health Hemorrhagic Retinopathy in an Infant: Abuse
Sciences, Medical Center Boulevard, Winston-Salem, NC or Accident?
27157
Tharp, Amy MD*, and Donald Jason, MD, JD, Department A First Time for Everything: Homicide 370
of Pathology, Wake Forest University Baptist Medical Involving the Brenneke® Super Sabot
Center, Medical Center Boulevard, Winston-Salem, NC Shotgun Slug
27157
Thomsen, Asser H. MD*, Lars Uhrenholt, PhD, and Annie Contributions From Forensic Imaging to the 154
Vesterby, MD, DMSc, Institute of Forensic Medicine, Investigation of Fatal Upper Cervical
University of Aarhus, Brendstrupgaardsvej 100, Aarhus N, Fractures
DK-8000, DENMARK
Thomsen, Jørgen L. DMJ*, and Peter M. Leth, PhD, The Postmortem Diagnosis of Diabetic Coma 313
University of Southern Denmark, Winsløwparken 17,
Odense, DK-5000, Denmark
Tibbett, Mark PhD*, Centre for Land Rehabilitation, How Cadaver Decomposition in Soil is 410
School of Earth and Geographical Sciences, University of Affected by Moisture: Part I: A Field
Western Australia, Crawley, WA 6009, Australia; and Experiment to Investigate Seasonal Effects
David O. Carter, MSc, and David Yellowlees, PhD, School
of Pharmacy and Molecular Sciences, James Cook
University, Douglas, QLD 4811, Australia
Index 231
Tidball-Binz, Morris MD*, Ute Hofmeister, MA, and Shuala Trends in Forensic Investigations Into the 171
M. Drawdy, MA, International Committee of the Red Cross, Missing: Observations From the ICRC
19 Avenue de la Paix, Geneva, 1202, SWITZERLAND
Tie, Jian MD, PhD*, Yuka Serizawa, BS, and Sesaku Maternity and Paternity Testing of a 278
Uchigasaki, MD, PhD, Department of Legal Medicine, Discarded Dead Neonate Involving a Young
Nihon University School of Medicine, 30-1 Oyaguchi Girl and Her Father
Kamimachi, Tokyo, 173-8610, Japan; Yoshihiro Mitsugi,
Criminal Investigation Laboratory, Saitama Prefectural
Police Headquarters, 3-10-1 Kizaki Urawa-ku, Saitama,
Saitama 330-0042, Japan; and Shigemi Oshida, MD, PhD,
Department of Legal Medicine, Nihon University School of
Medicine, 30-1 Oyaguchi Kamimachi, Tokyo, 173-8610,
Japan
Tie, Jian MD, PhD*, Yuka Serizawa, BS, and Shigemi Effect of Toilet Detergent on Morphological 329
Oshida, MD, PhD, Department of Legal Medicine, Nihon Change of Spermatozoa
University School of Medicine, 30- 1 Oyaguchi Kamimachi,
Itabashi-Ku, Tokyo 173-8610, Japan
Tlomak, Wieslawa MD*, Milwaukee County Medical Exsanguination Due to Disruption of the Left 230
Examiner Office, 933 West Highland Avenue, Milwaukee, Popliteal Artery and Vein Due to Posterior
WI 53233 Dislocation of the Left Knee Prosthesis: A
Case Report and Review of the Literature
Tomberlin, Jeffery K. PhD*, Department of Entomology, Development of Standard Operating 114
TAMU 2475, College Station, TX 77843-2475; and Jason Procedures for Conducting Arthropod
H. Byrd, PhD*, Maples Center for Forensic Medicine, Succession Studies: Improving Postmortem
University of Florida, 4800 Southwest 35th Drive, Estimates Through Ecology
Tomberlin, Jeffery K. PhD*, Department of Entomology, Microbes Associated With Decomposing 115
TAMU 2475, College Station, TX 77843-2475; M. Eric Remains Regulate Insect Colonization
Benbow, PhD*, University of Dayton, Department of
Biology, 300 College Park, Dayton, OH 45469- 2320;
Tawni Crippen, PhD, 2881 F&B Road, College Station, TX
77843; Charity Owings, BS, 2475 TAMU, College Station,
TX 77845; Francisco I. Ortiz, BS, 1818 South 2nd Street,
Apartment 62, Waco, TX 76706; and Jill C. Ross, BS, 110
Hillview Avenue, Millersville, PA 17551
Tomberlin, Jeffery K. PhD*, W. Joe Lewis, PhD, Marco Detection of Chemical Signals by the 571
D’Alessandro, BS, and Moukaram Tertuliano, PhD, Parasitic Wasp Microplitis Croceipes
Department of Biological and Agricultural Engineering, PO
Box 748, Tifton, GA
Tomberlin, Jeffery K. PhD, Department of Entomology, Trends in Forensic Entomology in the United 473
Texas A&M University, 1229 North U.S. Highway 281, States and Abroad
Stephenville, TX 76401; Jason Byrd, PhD*, Office of the
Medical Examiner, 1360 Indian Lake Road, Daytona
Beach, FL 32164; John Wallace, PhD*, Department of
Biology, Millersville University, Fredrick Street, Science
and Technology Building, Millersville, PA 17551
Tops, Terrill L. MD*, and Patrick E. Lantz, MD, Wake A Simple Model for Teaching Postmortem 323
Forest University Health Sciences, Department of Monocular Indirect Ophthalmoscopy
27157
Index 232
Tormos, Lee M. MD*, Medical and Forensic Autopsy, The Significance of Gross Adrenal 43
Pathology and Laborat Medicine, 171 Ashley Avenue, Suite Hemorrhage — Undiagnosed Waterhouse-
309, MSC908, Charleston, SC 29425-9080; and Cynthia A. Friderichsen Syndrome: A Case Series
Schandl, PhD, Medical University of South Carolina, 171
Ashley Avenue, Suite 309, MSC-908, Charleston, SC 29425
Tournel, Gilles MD*, Anne A. Bécart-Robert, DDS, PhD, Causes of Death Among People in the Prison 417
Valéry C. Hédouin, MD, PhD, and Didier Gosset, MD, of Loos (Northern France), 1997-2003
PhD, Institut de Médecine Légale, 1, Place de Verdun, Lille,
59 000, France
Tournel, Gilles MD*, Anne Becart-Robert, DDS, Philippe First Report of Fatal Outcome by Accidental 490
Courtin, MD, Valéry Hedouin, MD, and Didier Gosset, MD, Intrathecal Injection of Vindesine
Tournel, Gilles MD*, Fabrice Dedouit, MD, Anne Becart- Unusual Suicide With Chain Saw: A Case 367
Robert, DDS, PhD, Nicolas Pety, MD, Valéry Hedouin, Report
Tournel, Gilles MD*, Fabrice Dedouit, MD, Anne Becart- Fatal CO2 Suicidal Poisoning 331
Robert, DDS, PhD, Pierre Dutrieux, MD, Valéry Hedouin,
Tournel, Gilles MD*, Institut de Médecine Légale, 1, Place Evolution of the Intentional Injury Infant 429
de Verdun, Lille, 59 000, France; Marie Desurmont, MD, Syndrome in Northern France
Institut de Médecine Légale, 10 Rue F Villon, Lille, 59 000,
France; Valéry C. Hédouin, MD, PhD, Institut de Médecine
Légale, 1, Place de Verdun, Lille, 59 000, France; Didier
Gosset, MD, PhD, Institut de Médecine Légale, 10 Rue F
Villon, Lille, 59000, France
Tournel, Gilles MD*, Sandrine Gaulon, Anne Becart- Body Found in the Waterway of Lille— 516
Robert, DDS, Valéry Hedouin, MD, and Didier Gosset, MD, Accident, Suicide, or Homicide?
Tournel, Gilles MD, PhD*, Anne Becart-Robert, DDS, A Cadaver Encased Within Concrete: A Case 244
Benoît Bourel, PhD, Axelle Balgairies, Cédric Houssaye, Report
Valéry Hedouin, PhD, and Didier Gosset, MD, PhD,
Institut de Médecine Légale de Lille, 1, place de Verdun,
Faculté de Médecine, Lille, 59045, FRANCE
Tournel, Gilles PhD*, IML de Lille, 1, Place de Verdun, Sex Killer: Sexually Related Trauma and 206
Faculté de Médecine, Lille, 59045, FRANCE; and Valery Deaths - Forensic Aspects
Hedouin, PhD, Cédric Houssaye, MD, Frédéric Grimopont,
Antoine Stelandre, Anne Becart, PhD, Viviane Gnemmi,
Sandrine Depret, MD, IML de Lille, Lille, 59045, FRANCE;
and Didier Gosset, PhD, IML de Lille, Faculte de
Medecine, Lille, 59045, FRANCE
Trimpe, Michael A. BS, Robert R. Pfalzgraf, MD, and Carl Exsanguination From a Dialysis Catheter: 565
L. Parrott, Jr., MD*, Hamilton County Coroner’s Office, Trace Evidence Examination in Determining
3159 Eden Avenue, Cincinnati, OH Manner of Death
Index 233
Tugaleva, Elena MD*, and Michael J. Shkrum, MD, Hanging Deaths in Ontario: Retrospective 277
Department of Pathology, London Health Sciences Centre, Analysis of 755 Cases
339 Windermere Road, London, Ontario N6A 5A5, Canada;
Donald R. Gorassini, PhD, Department of Psychology,
King’s University College at The University of Western
Ontario, 266 Epworth Avenue, London, Ontario N6A 2M3,
Canada; and Barry A. McLellan, MD, Office of the Chief
Coroner, 26 Grenville Street, Toronto, Ontario M7A 2G9,
Canada
Turner, Jane Willman PhD, MD*, St. Louis University Concussive Head Injury and Alcohol 258
School of Medicine, 1402 South Grand Boulevard, St.
Louis, MO 63104
Turner, Staci D. MD*, Jeffrey J. Barnard, MD, and Sheila “Homicide by Heart Attack” Revisited 539
D. Spotswood, MD, Southwestern Institute of Forensic
Sciences, 5230 Medical Center Drive., Dallas, TX; and
Joseph A. Prahlow, MD, South Bend Medical Foundation
and Indiana University School of Medicine, University of
Notre Dame, South Bend, IN
Tweedie, Edward J. MD*, London Health Sciences Centre, Traumatic Cardiovascular Complications of 390
339 Windermere Road, London, Ontario N6A 5A5, Canada Catheter-Based Procedures: Relevance to
Medicolegal Death Investigation
Udey, Ruth N. BS*, Michigan State University, 209 Differentiation of Bullet Type Based on 121
Biochemistry, East Lansing, MI 48824; Brian C. Hunter, Analysis of Gunshot Residue Using
MD, 630 South Saginaw Street, Flint, MI 48502; and Ruth Inductively Coupled Plasma Mass
Waddell Smith, PhD, Michigan State University, School of Spectrometry
Uhrenholt, Lars DC*, and Annie Vesterby Charles, DMSc, Cervical Spine Injuries in Fatal Traffic Crash 256
University of Aarhus, Institute of Forensic Medicine, Peter Victims: Microscopy and Diagnostic Imaging
Sabroes Gade 15, Aarhus C, Europe 8000, DENMARK; Findings
Ellen Hauge, MD, PhD, Research Unit for Rheumatology
and Bone Biology, Aarhus University Hospital, Aarhus
Sygehus (NBG), Denmark; and Markil Gregersen, DMSc,
University of Aarhus, Institute of Forensic Medicine, Peter
Sabroes Gade 15, Aarhus C, Europe 8000, DENMARK
Uhrenholt, Lars PhD*, Institute of Forensic Medicine, The Role of Microscopic Postmortem Study 126
Department of Forensic Medicine, University of Aarhus, in Explaining Traffic-Crash Related Neck
Brendstrupgaardsvej 100, Aarhus N, 8200, DENMARK; Injury: A Case Review
and Michael Freeman, PhD, 205 Liberty Street, Northeast,
Suite B, Salem, OR 97301
Uhrenholt, Lars PhD*, Louise Moller Andersen, and Freja Injuries to Abdominal Organs in Fatal Road 83
Gaborit, Department of Forensic Medicine, Faculty of Traffic Crash Victims
Health Sciences, University of Aarhus, Brendstrupgaardsvej
100, Aarhus N, 8200, DENMARK
Uhrenholt, Lars PhD, and Lene W. Boel, PhD*, University Contributions From Forensic Imaging to the 153
of Aarhus, Institute of Forensic Medicine, Investigation of Fatal Upper Cervical
Brendstrupgaardsvej 100, Aarhus N, 8200, DENMARK Fractures
Uribe, Paul MD*, 7807 Mineral Springs Drive, Suicide by Multiple Gunshots From 94
Gaithersburg, MD 20877 Automatic Weapons
Index 234
Vasilenko, Peter PhD*, Michigan State University, College The Enigma of SIDS: Variations in Diagnosis 476
of Human Medicine, Department of Obstetrics, Gynecology, and Recommendations
and Reproductive Biology, 227 West Fee Hall, East
Lansing, MI 48824; Joyce de Jong, DO and Brian Hunter,
MD, E.W. Sparrow Hospital, Department of Pathology,
Vass, Arpad A. PhD*, Stacy-Ann Barshick, PhD, Gary Postmortem Interval Decomposition 569
Sega, PhD, John Canton, PhD, James T. Skeen, Jennifer C. Chemistry of Human Remains: A New
Love, PhD, and Jennifer A. Synstelien, BA, Oak Ridge Methodology for Determing the Postmortem
National Laboratory, PO Box 2008, Oak Ridge, TN Interval
Vella, Giancarlo Di MD, PhD*, Alessandra Arpaio, MD, Suicide or Homicide - The Importance of 419
Claudia Liuzzi, MD, and Francesco Vinci, MD, University Forensic Evidence: A Case Study
of Bari, Di.M.I.M.P. - Sezione di Medicina Legale -
Vella, Giancarlo Di MD, PhD*, and Biagio Solarino, MD, Abrasion or Gunshot Wound? The Primary 339
Sezione di Medicina Legale - Di.M.I.M.P., Università degli Role of Forensic Pathologist
Vella, Giancarlo Di MD, PhD*, Maura Belviso, MD, Unexpected Multicystic Encephalopathy 562
Sazione di Medicina Legale, DIMIMP, University of Bari, After Accidental Intoxicaction by a Corrosive
Italy; Gabriella Serio, MD, PhD, Giuseppe Parisi, MD, Agent: Case Report
Roberto De Blasi, MD, Unità Opeativa di Neuroradiologia,
University of Bari Italy, Policlinico, piazza G. Cesare, Bari,
Italy
Vella, Giancarlo Di MD, PhD*, Rosa Falamingo, MD, Injuries of an Armored Vehicle Occupant 514
PhD, Maura Belviso, MD, PhD, and Francesco Vinci, MD, During Armed Robbery: A Case Report
Section of Legal Medicine - University of Bari - Italy,
Policlinico, piazza G. Cesare, 70124 – Bari, Italy
Ventura, Francesco MD, and Alessandro Bonsignore, MD*, Two Fatal Cases of Hidden Pneumonia in 156
Department of Forensic Pathology, University of Genova, Young People
Via De Toni, 12, 16132, Genova, 16132, ITALY; Raffaella
Gentile, MD, Department of Clinical Pathology, University
of Genova, Largo Rosanna Benzi, 10, Genova, 16132,
ITALY; and Francesco De Stefano, MD, Department of
Forensic Pathology, University of Genova, Via De Toni, 12,
Verginelli, Fabio PhD, Department of Oncology and Cancer Patient mtDNA Forensic 5
Experimental Medicine, G. d’Annunzio University, Via dei Identification: A Case Report
Vestini 31, 66100, Chieti, ITALY; Manuela Rosini, MSc,
Department of Legal Medicine, Viale Regina Elena 336,
00161, Rome, ITALY; Silvia Zoppis, MD*, Department of
Legal Medicine University of Rome “Sapienza”, Viale
Regina Elena 336 00161, Rome, ITALY; and Carla
Vecchiotti, Department of Legal Medicine, Viale Regina
Elena 336, 00161, Rome, ITALY
Vesterby, Annie MD, DMsc*, and Lene A. Hansen, MD, Sexual Abuse: Hymenal Findings in Girls 322
Institute of Forensic Medicine, University of Aarhus, Peter With a History of Vaginal Penetration
Sabroes Gade 15, Aarhus C, 8000, Denmark; and Svend
Sabroe, MD, Institute of Public Health, Dept. of
Epidemiology, University of Aarhus, Vennelyst Boulevard 6,
Aarhus C, 8000, Denmark
Index 235
Vesterby, Annie MD, DMSc*, Department of Forensic Epilepsy—A Major But Disregarded Health 488
Medicine, Peter Sabroes Gade 15, Aarhus, Denmark; Soren Problem
Dalager-Petersen, MD, Department of Forensic Medicine,
Aarhus University Hospital, Aarhus, Denmark; Simona
Tigaran, MD, PhD, Department of Neurology, Aarhus
University Hospital, Aarhus, Denmark; and Ulrik
Baandrup, MD, Department of Pathology, Aarhus
University Hospital, Aarhus, Denmark
Vesterby, Annie MD, DMSc*, Institute of Forensic Examination of Sexually Abused Children: 6
Medicine, University of Aarhus, Brendstrupgårdsvej 100, Presentation of the First Danish Center for the
8200 Aarhus N, DK-8000, DENMARK Investigation and Care of Abused Children
Vieira, Duarte N.P. PhD*, Carlos Abreu, MD, and Cristina Foreign Bodies: Three Cases of Projectile 158
Cordeiro, MSci, Instituto Nacional de Medicina Legal, Maintenance Without Complications
Largo da Sé Nova, Coimbra, LB 3000-213, PORTUGAL
Vieira, Duarte N.P. PhD*, Instituto Nacional, de Medicina Traffic Accident Deaths? The Importance of 189
Legal, Coimbra, 3000-213, PORTUGAL; Cristina Autopsy
Cordeiro, MSci, Instituto Nacional de Medicina Legal,
Largo da Sé Nova, Coimbra, FL, PORTUGAL; and Helena
Garcia, MD, CEDAP, Av. Calouste Gulbenkian, Coimbra,
3000, PORTUGAL
Viel, Guido MD*, and Giovanni Cecchetto, MD, University Adipositas Cordis and Iatrogenic Death: Fatal 90
of Padua, Via Falloppio 50, Padova, 35121, ITALY; Ann S. Complication or Medical Error?
Schroder, MD, and Nadine Wilke, MD, Eppendorf -
Hamburg, Hamburg,, GERMANY; Massimo Montisci, PhD,
Via Falloppio 50, Padova, ITALY; and Klaus Pueschel,
PhD, Eppendorf - Hamburg, Hamburg,, GERMANY
Viel, Guido MD*, and Giovanni Cecchetto, MD, University Role of Preoperative 3D-CT Reconstruction 215
of Padua, Via Falloppio 50, Padova, 35121, ITALY; Renzo in Depressed Skull Fractures Treated With
Manara, MD, Istituto di Neuroradiologia, Padova, ITALY; Craniectomy: A Case Report of Forensic
and Donata Favretto, PhD, and Massimo Montisci, PhD, Interest
ITALY
Viel, Guido MD*, University of Padua, Via Falloppio 50, Intersecting Fractures of the Skull and 203
Padova, 35121, ITALY; Axel Gehl, MD, Department of Gunshot Wounds: Case Report and Literature
Forensic Pathology - Institute of Le, Hamburg, GERMANY; Review
Giovanni Cecchetto, MD, University of Padua, Via
Falloppio 50, Padova, 35121, ITALY; Massimo Montisci,
PhD, University of Padua, Via Falloppio 50, Padova,
35121, ITALY; and Jan P. Sperhake, MD, Department of
Forensic Pathology - Institute of Le, Hamburg, GERMANY
Vilensky, William DO, RPh*, Forensic & Educational Sublingual Tablet Thwarts Opioid Addiction 426
Consultants, 2113 Harbourside Drive, Longboat Key, FL
34228
Vincenti, Donna M. MD*, and Patricia A. Aronica-Pollak, Exsanguination Associated With Vascular 288
MD, Office of the Chief Medical Examiner, 111 Penn Street, Access Sites in Hemodialysis Patients
Baltimore, MD 21201; Joshua M. Sharfstein, MD, City of
Baltimore Health Department, 210 Guilford Avenue,
Executive Suite, 3rd Floor, Baltimore, MD 21202; and
Viola, Luigi MD*, Marina Albano, MD, Francesco Laryngeal Nerve Iatrogenic Lesions 338
Vimercati, MD, and Nunzio Di Nunno, MD, PhD,
Università di Lecce, Via G. Dorso n. 9, Bari, 70125, Italy
Index 236
Viola, Luigi MD*, Nunzio Di Nunno, MD, PhD, Roberto Guidelines and Medical Malpractice in Minor 398
Quaranta, MD, Alessandro Dell’Erba, MD, PhD, and Head Injury Management
Francesco Vimercati, MD, Bari University, Piazza Giulio
Cesare, 11, Bari, 70124, Italy
Voss, Sasha C. BSc*, and Ian Dadour, PhD, Centre for Parasitic Wasps: Succession, Development, 246
Forensic Science, University of Western Australia, 35 and Forensic Importance as PMI Indicators
Stirling Highway, Nedlands, Western Australia 6009,
AUSTRALIA
Wacker, Charlotte A. MS* and Brandi J. Schmitt, MS, The Use of Whole Body Donors in Forensic 438
University of California, One Shields Avenue, 3301 Tupper Research
Hall, Davis, CA 95616
Wacker, Charlotte A. MS*, University of California, Davis- A Comparison of Pig and Human Tissue in 408
Department of Cell Biology and Human Anatomy, One Studies of Decomposition: Can Flies Tell the
Shields Avenue, Tupper Hall Room 3301, Davis, CA 95616; Difference?
Lawrence Stutler, MS, University of New Haven, School of
Public Safety and Professional Studies, 300 Orange
Avenue, West Haven, CT 06516; Brandi J. Schmitt, MS,
University of California, Davis-Department of Cell Biology
and Human Anatomy, One Shields Avenue, Tupper Hall
Room 3301, Davis, CA 95616; and Rebecca A. Bullard, MS
and Robert B. Kimsey, PhD, University of California,
Davis, Department of Entomology, One Shields Avenue,
Davis, CA 95616
Wallace, John R. PhD*, Millersville University, Department Caddisfly Cases Assist Homicide Case: 295
of Biology, Millersville, PA 17551; Richard W. Merritt, Determining a Postmortem Submersion
PhD, Ryan K. Kimbaraskas, MS, Mark E. Benbow, PhD, Interval (PMSI) Using Aquatic Insects
and Mollie McIntosh, PhD, Michigan State University,
Department of Entomology, 243 Natural Science, East
Lansing, MI 48824-1115; and Joyce DeJong, MD, Sparrow
Hospital, Forensic Pathology Department, Lansing, MI
48824
Wallace, John R. PhD, Kathryn Zimmerman*, and Erin Determining a Postmortem Submersion 384
High, Department of Biology, Caputo Hall, Millersville Interval (PMSI) Based on Algal/Diatom
University, Millersville, PA 17551 Diversity on Decomposing Mammalian
Carcasses in Brackish Ponds in Delaware
Wang, Dawei PhD*, and Donald Siegel, PhD, New York Cardiac Channelopathies Linked to Sudden 80
City Office of the Chief Medical Examiner, 421 East 26 Infant Death Syndrome/Sudden Unexplained
Street, New York, NY ; and Yingying Tang, MD, PhD, Death Syndrome
Mechthild K. Prinz, PhD, and Barbara A. Sampson, MD,
PhD, Office of Chief Medical Examiner, Department of
10016
Warushahennadi, Janaki MD*, and Richard C. Harruff, Analysis of Female Firearm Homicides in 86
PhD, King County Medical Examiner’s Office, 325 Ninth King County, Washington 2000 - 2007
Avenue, HMC Box 359792, Seattle, WA 98116
Index 237
Warushahennadi, Janaki MD*, King County Medical Analysis of an Unusual Misfire of a Common 109
Examiner’s Office, 325 9th Avenue, HMC Box 359792, Handgun
Seattle, WA 98104; Brian J. Smelser, BS, Washington State
Patrol Crime Laboratory, Washington State Patrol, 2203
Airport Way South, Building A Suite 250, Seattle, WA
98134; Richard T. Wyant, MS, Washington State Patrol
CLD, 2203 Airport Way, South, Suite 250, Seattle, WA
98134; and Timothy L. Williams, MD, King County Medical
Examiner’s Office, 325 - 9th Avenue, Box 359792, Seattle,
WA 98104-2499
Watson, Phillip L. PhD*, Ferris State University, 808 The Effect of Clothing on Decomposition 209
Campus Drive, 2004 ASC, Big Rapids, MI 49307 Rate: A Teaching Model
Way*, Lauren E.and John R. Wallace, PhD, Department of The Effects of Liquid Bleach on Pig 437
Biology, Millersville University, PO Box 1002, Millersville, Decomposition in Southeastern Pennsylvania
PA 17551
Weedn, Victor W. MD, Maryland State Office of the The Use of Raman Spectroscopic Imaging in 12
Medical Examiner, 111 Penn Street, Baltimore, MD 21201; Cases of Ethylene Glycol Toxicity
Mary G. Ripple, MD, 68 Bluebird Road, Port Deposit, MD
21904; Sara Nedley, MS, ChemImage, 7301 Penn Avenue,
Pittsburgh, PA 15208; and David R. Fowler, MD, and
Kristin A. Johnson, MD*, Office of the Chief Medical
Wehrli, Bret M. MD*, London Health Sciences Centre, 339 Cerebral Air Embolism: An Uncommon 466
Windermere Road, Department of Pathology, Room A3- Complication of a Common Procedure
147, London, Ontario N6A 5A5, Canada; Sidney Siu, MD,
827 Richmond Street, London, Ontario N6A 3H7, Canada;
Edward Tweedie, MD and Michael J. Shkrum, MD, London
Health Sciences Centre, 339 Windermere Road, London,
Ontario N6A 5A5, Canada
Wetherton, Angela R. MD* and Tracey S. Corey, MD, Fatal Accidental Intravascular Injection of Air 483
Office of the Chief Medical Examiner, 810 Barret Avenue, in Infants
Whaley, Kevin D. MD*, Anna Noller, PhD, and William T. Female Firearm-Related Suicides: A 272
Gormley, MD, PhD, Central District, Office of the Chief Reappraisal
Medical Examiner, Commonwealth of Virginia, 400 East
White, Dollett T. MD*, and Leszek Chrostowski, MD, Suicide by Extraordinarily Numerous Blade 128
Hillsborough County Medical Examiner Department, 11025 Wounds
North 46th Street, Tampa, FL 33617
White, Joseph K. DO*, University of Colorado Denver Metastatic Calcification of AV-Node as a 44
School of Medicine, 660 Bannock Street, Denver, CO Cause of Complete Heart Block and Death
80204; and Amy Martin, MD, Denver Office of the Medical
White, Steven M. PhD*, Mitra B. Kalelkar, MD, and James Giant Cell Myocarditis as a Cause of Sudden 30
A. Filkins, JD, PhD, Office of the Medical Examiner, or Unexpected Death: A Report of Two Cases
County of Cook, 2121 West Harrison Street, Chicago, IL and a Review of the Literature
60612
Index 238
Wiersema, Jason M. MA*, and Eric J. Bartelink, MA, The Importance of an Interdisciplinary 491
Department of Anthropology, Texas A&M University, Review Process in the World Trade Center
Department of Anthropology, College Station, TX; Zoran Mass Disaster Investigation
Budimlija, MD, PhD, Mechthild Prinz, PhD, Robert Shaler,
PhD, and Amy Zelson Mundorff, MA, Office of Chief
Medical Examiner, New York City, 520 First Avenue, New
York, NY; and Gaille MacKinnon, MS, Department of
Conservation Sciences, University of Bournemouth,
Bournemouth, England, United Kingdom
Wiersema, Jason M. PhD*, Diane Logan, MBA, and Luis A. Transition to Digital in the Forensic Morgue: 75
Sanchez, MD, Harris County Institute of Forensic Sciences, Lessons Learned on the Pathway to Greater
1885 Old Spanish Trail, Houston, TX 77054 Efficiency
Wiersema, Jason M. PhD*, Jennifer C. Love, PhD, Sharon The Utility of Skeletal Examination in 71
M. Derrick, PhD, and Luis A. Sanchez, MD, Harris County Recognition of Occult Skeletal Injury
Institute of Forensic Sciences, 1885 Old Spanish Trail,
Houston, TX 77054
Wigren, Carl W. MD*, and J. Matthew Lacy, MD, King Small Cell Carcinoma of the Lung 326
County Medical Examiner’s Office, 325 Ninth Avenue, Contributing to Pulmonary Barotrauma With
HMC Box 359792, Seattle, WA 98104 Air Embolism in a Recreational Diver: A
Case Report
Wilen, Saul B. MD*, International Horizons SARS, Monkeypox, West Nile, Dengue, and 480
Unlimited/Litigation Strategies Group, PO Box 40578, San Plague: Pitfalls of Globalization
Antonio, TX 78229
Wilkerson*, Jessica D. and Brianna F. Anderson, How Does Season Affect the Release of 191
University of Nebraska-Lincoln, 202 Entomology Hall, PO Ninhydrin - Reactive Nitrogen Into Grave
Box 830816, Lincoln, NE 68583-0816; and David O. Soil?
68583-0816
Williams, Anna PhD*, and Mitzi A. Richards, MSc, The Effect of Cultural Cranial Deformation 26
Cranfield University, Defence Academy of the UK, on Neurological Development: A Beneficial
Shrivenham, SN6 8LA, UNITED KINGDOM or Disadvantageous Practice?
Williams, Erica MD*, Hospital of the University of Advanced Flow Cytometric DNA 448
Pennsylvania, Department of Pathology and Laboratory Degradation Analysis: Utility in Postmortem
Medicine, 6 Founder Building, 3400 Spruce Street, Interval Estimation
Philadelphia, PA 19104; Andrew Bantly, BS, Hospital of
the University of Pennsylvania, Abramson Cancer Center
Flow Cytometry and Cell Sorting Shared Resource, 3400
Spruce Street, Philadelphia, PA 19104; Jesse Chittams, MS,
University of Pennsylvania School of Medicine, Department
of Biostatistics and Epidemiology, 3400 Spruce Street,
Philadelphia, PA 19104; Jonni Moore, PhD, Hospital of the
Street, Philadelphia, PA 19104
Williams, Karl E. MD, MPH*, Office of the Medical Erroneous Diagnosis of Cadmium Poisoning 228
Examiner, Allegheny County, 542 Fourth Avenue, Based on Postmortem Toxicology
Williams, Timothy L. MD*, and R. Ross Reichard, MD, New Corpora Amylacea and Sudden Death: A Case 170
Mexico Office of the Medical Investigator, MSC11 6030, 1 of Adult Polyglucosan Body Disease
University of New Mexico, Albuquerque, NM 87131-0001 Diagnosed at Forensic Autopsy
Index 239
Williams, Timothy L. MD*, and William F. Hickey, MD, Gliomatosis Cerebri as a Cause of Sudden 327
Dartmouth- Hitchcock Medical Center, Department of Death in a Young Woman
Pathology, One Medical Center Drive, Lebanon, NH
03756; and Thomas Andrew, MD, Office of the Chief
Medical Examiner, 246 Pleasant Street, Concord, NH
03301
Willis, Kevin M. BS*, Washington County Sheriff’s Office, Decomposition of Child-Sized Remains in 192
1535 Colfax Street, Blair, NE 68008 Dumpsters
Wilson, Christopher MBBS, Jon R. Thogmartin, MD*, Noel Sickle Cell Trait Associated Deaths: A Case 169
A. Palma, MD, and Susan S. Ignacio, MD, Medical Series With a Spectrum of Clinical
Examiner’s Office, District 6, 10900 Ulmerton Road, Presentations
Largo, FL 33778; Barbara C. Wolf, MD, and Wendy A.
Lavezzi, MD, Office of the Medical Examiner, District 5,
809 Pine Street, Leesburg, FL 34748; and Mark J. Shuman,
MD, Miami Dade County, Medical Examiner Department,
Number One on Bob Hope Road, Miami, FL 33136
Wolf, Barbara C. MD*, Palm Beach County Medical Methadone-Related Deaths in Palm Beach 519
Examiner’s Office, 6065 Ellis Lane, Loxahatchee, FL; County
Wendy A. Lavezzi, MD, Albany Medical College, 47 New
Scotland Avenue, Albany, NY; and Lisa M. Flannagan, MD,
Palm Beach County Medical Examiner’s Office, 3126 Gun
Club Road, West Palm Beach, FL
Wolf, Dwayne A. MD, PhD*, and Ashraf Mozayani, Flecainide: A Suicidal Pharmacist’s Choice 521
PharmD, PhD, Harris County Medical Examiner Office,
Joseph A. Jachimczyk Forensic Center, 1885 Old Spanish
Trail, Houston, TX
Wolf, Dwayne A. MD, PhD*, and Ashraf Mozayani, Acute Fatal Propafenone Toxicity: Drug 521
PharmD, PhD, Harris County Medical Examiner’s Office, Concentration, Distribution, and Clinical
Joseph A. Jachimczyk Forensic Center, 1885 Old Spanish Features in Two Suicides
Trail, Houston, TX; and Christopher LaVergne, MD, North
Houston Heart Center, 800 Peakwood, Suite 8A, Houston,
TX
Wolf, Dwayne A. MD, PhD*, Harris County Medical “Homicide by Heart Attack” - An Unusual 380
Examiner Office, 1885 Old Spanish Trail, Houston, TX Pediatric Death
77054
Wolfe, Dwayne A. MD, PhD*, Office of Medical Examiner Homicide by Second Impact Syndrome... or 551
of Harris County, Joseph A. Jachimczyk Forensic Center, Unfortunate Coincidence?
1885 Old Spanish Trail, Houston, TX
Wonder, Anita K.Y. MA*, Wonder Institute, PO Box 1051, An Expert Witness Requests Re-evaluation of 395
Carmichael, CA 95609-1051 SOP in Autopsy Reporting, Supported With
Case Examples
Woodard, Kristinza R. MD*, University of Washington Accidental Carbon Monoxide Poisoning: A 93
Pathology and Lab Medicine, 1959 Northeast Pacific Review of Environmental and Cultural Risk
Street, PO Box 356100, Seattle, WA 98195; and Richard C. Factors of Fatal Cases in King County
Harruff, MD, PhD, King County Medical Examiner’s
Office, 325 9th Avenue, Box 359792, Seattle, WA 98104
Wright, Ronald K. BS, MD, JD*, 2101 SW 29th Avenue, Over Diagnosis of Low Voltage Electrocution 441
Fort Lauderdale, FL 33312
Wyant, Richard T. MS*, Washington State Patrol, 2203 Evaluation of Less-Lethal Impact Munitions 370
Airport Way South, Suite 250, Seattle, WA 98134; and
Chris Myers, and Tom Burns, Seattle Police Department,
810 Virginia Street, Seattle, WA 98101
Index 240
Xu, Baiyang MD*, 1520 Penn Avenue, Pittsburgh, PA Periventricular Leukomalacia in a 2- Month- 2
15222; Todd M. Luckasevic, DO, Alleghey County Medical Old Infant Who Was Born With Cocaine
Examiner’s Office, 1520 Penn Avenue, Pittsburgh, PA Addiction: A Case Report
15222; and Abdulrezak M. Shakir, MD, and Karl Williams,
MD, Allegheny County Medical Examiner Office, 542
Yang, Dongya PhD*, Department of Archaeology, Simon Co-Amplification of Cytochrome B and D- 345
Fraser University, 8888 University Drive, Burnaby, BC loop mtDNA Fragments for More Reliable
V5A 1S6, Canada; and Speller Camilla, MA, Department of Species Identifications
Archaeology, Simon Fraser University, 8888 University
Drive, Burnaby, BC V5A 1S6, Canada
Yen, Kathrin MD*, Wolf Schweitzer, MD, Eva Scheurer, The Postmortem Diagnosis of Skull and Brain 553
MD, and Michael J. Thali, MD, Institute of Forensic Injuries by Imaging Methods (MRI, Multi-
Medicine, University of Berne, Buehlstrasse 20, 3012 Slice CT)
Berne, Switzerland; Christoph Ozdoba, MD, Gerhard
Schroth, MD, and Martin Sonnenschein, MD, Departement
of Neuroradiology, University of Berne, Freiburgstrasse,
3010 Berne, Switzerland; Chris Boesch, MD, PhD, Michael
Ith, PhD, and Karin Brugger, MR-Spectroscopy Center,
University of Berne, 3010 Berne, Freiburgstrasse,
Switzerland; Elke Spielvogel, Department of
Neuroradiology, University of Berne, 3010 Berne,
Freiburgstrasse, Switzerland; and Richard Dirnhofer, MD,
Buehlstrasse20, 3012 Berne, Switzerland
Ylijoki-Soerensen, Seija MD*, Department of Forensic Postmortem Computed Tomography as a 76
Medicine, Brendstrupgaardsvej 100, Aarhus N, 8200, Valuable Tool for Diagnosing Trauma Prior
DENMARK; Iana Lesnikova, MD, Department of Forensic to Medicolegal Autopsy
Pathology of University of Aarhus, Brendstrupgaardsvej
100, Aarhus N, 8200, DENMARK; Lars Uhrenholt, PhD,
Institute of Forensic Medicine, Department of Forensic
Medicine, University of Aarhus, Brendstrupgaardsvej 100,
Aarhus N, 8200, DENMARK; and Annie Vesterby, MD,
DMSc, Institute of Forensic Medicine, University of Aarhus,
Brendstrupgårdsvej 100, 8200 Aarhus N, DK-8000,
DENMARK
Young, Thomas W. MD*, C. Chase Blanchard, MD, and Decapitation by Motorized Shoulder Harness: 559
Ronald E. Brasfield, Office of the Jackson County Medical A Case Report
Examiner, 660 East 24th Street, Kansas City, M0
Young, Thomas W. MD*, Heartland Forensic Pathology, Pseudostrangulation 123
LLC, 12717 Oakmont Drive, Kansas City, MO 64145
Young, Thomas W. MD*, Jackson County Medical The Richard Cory Phenomenon: Suicide and 443
Examiner, 660 East 24th Street, Kansas City, MO 64108; Socioeconomic Status in Kansas City,
Suzanna Wooden, University of Missouri, Kansas City Missouri
School of Medicine, 2411 Holmes, Kansas City, MO 64108;
Jinwen Cai, MD and Gerald L. Hoff, PhD, Kansas City
Missouri Health Department, 2400 Troost, Kansas City,
MO 64108; Paul C. Dew, MD, MPh, University of Health
Sciences, 1750 Independence Avenue, Kansas City, MO
64106
Index 241
Zaferes, Andrea BA*, PO Box 211, Hurley, NY 12443; and Death Due to Aquatic Erotic Asphyxia - 257
Kari B. Reiber, MD, and Dennis J. Chute, MD, Office of the Accident or Homicide?
Zaloga, William F. DO*, Wake Forest University Baptist Pediatric Homicides Related to Burn Injury 438
Medical Center, Department of Pathology, Medical Center
Drive, Winston- Salem, NC 27157; Kimberly A. Collins,
MD, Medical University of South Carolina, 171 Ashley
Avenue, Charleston, SC 29425
Zemrus, Tasha L. MD* and David R. Fowler, MD, Office of Three Unusual Cases of Sudden Unexpected 464
the Chief Medical Examiner, State of Maryland, 111 Penn Death in Pregnancy Occurring in One Week
Street, Baltimore, MD 21201-1020 in the State of Maryland
Zemrus, Tasha MD*, Assistant Medical Examiner, Office of Sudden Asphyxial Death Due to 490
the Chief Medical Examiner, 111 Penn Street, Baltimore, Regurgitation of a Pedunculated Esophageal
MD; Adrienne Segovia, MD, Deputy Medical Examiner, Lipoma: A Case Report and Review of the
Office of the Cook County Medical Examiner, 2121 West Literature
Harrison Street, Chicago, IL
Zerbo, Stefania MD*, and Rosa Liotta, MD, Institute of Fibromuscular Dysplasia of Pulmonary 149
Legal Medicine, Via del Vespro, 127, Palermo, 90100, Arteries: Report of Two Cases
ITALY; Antonina Argo, PhD, Via Narbone n.13, Palermo,
ITALY; Cettina Sortino, Via del Vespro, 129, Palermo,
ITALY; Antonino Bonifacio, MD, Institute of Legal
Eugenia Di Stefano, Via Raffaello n.9, Palermo, ITALY;
and Emiliano Maresi, PhD, Via del Vespro, 127, Palermo,
90100, ITALY
Zivkovic, Vladimir MD, MSc, Djordje Alempijevic, MD, Medico-Legal Importance of Posttraumatic 222
PhD, Slobodan Savic, MD, PhD*, Ivanka Baralic, Dragan Hypopituitarism
Jecmenica, MD, PhD, and Branimir Aleksandric, University
of Belgrade, School of Medicine Institute of Forensic
Sciences, Faculty of Medicine, 31a Deligradska Street,
Belgrade, 11000, SERBIA AND MONTENEGRO; and Vera
Popovic, PhD, Institute of Endocrinology, Clinical Centre
of Serbia, Dr. Subotic Street 13, Belgrade, , SERBIA AND
MONTENEGRO
Index 242
Index 243
CHICAGO 2011 CHICAGO 2011
PATHOLOGY/BIOLOGY
G1 Fatality Involving Complications of injection may increase the risk of adverse effects including seizures,
bradycardia, and cardiac arrest as seen in this case.
Bupivacaine Toxicity and Hypersensitivity Postmortem toxicology also included analysis of tryptase. This
Reaction: A Case Report analysis revealed an elevated cardiac total tryptase concentration and a
normal subclavian total tryptase concentration. The discrepancy
Mary H. Dudley, MD*, Jackson County Medical Examiner’s Office, 660 between the cardiac and subclavian tryptase concentrations may also be
East 24th Street, Kansas City, MO 64108; Steven W. Fleming, MS, due to intraventricular blood stasis resulting from cardiopulmonary
Children Mercy Hospital, Toxicology Laboratory, 2401 Gillham Road, bypass; whereas subclavian blood was actively circulating throughout
Kansas City, MO 64108; Uttam Garg, PhD, Children’s Mercy Hospital, intervention. Furthermore, tryptase peaks within 15 to 120 minutes post
Department of Pathology, 2401 Gillham Road, Kansas City, MO 64108; exposure to the allergen and follows first-order kinetics with a half life
and Jason M. Edwards, PhD, University of Missouri Kansas City School of 1.5 to 2.5 hours; therefore, approximately 3 half-lives had elapsed
of Medicine, 2411 Holmes Street, Kansas City, MO 64108 between symptomatic onset and blood collection. Thus, obtained
subclavian serum tryptase concentrations are expected to be much lower
After attending this presentation, attendees will understand the than values at symptomatic onset if in fact an anaphylactic reaction
complications from use of bupivacaine local anesthesia when occurred. The moderately elevated cardiac tryptase concentration in
administered in the head and neck region, including CNS, cardiac conjunction with the cardiac arrest and rapid onset of seizure activity
sequelae, and death. post injection of bupivacaine indicates the possibility of an anaphylactic
This presentation will impact the forensic science community in reaction. However, it is possible that the moderate increase in cardiac
understanding the possible adverse effects of local nerve block tryptase is due to lysis of mast cells in the tissue of the chest. At autopsy
anesthesia when administered in the head and neck region, the actions, the chest had massive hemorrhages due to prolonged cardiopulmonary
pharmacokinetics, contraindications, and toxicity of bupivacaine are resuscitation.
detailed. In addition a hypersensitivity reaction may result from In summary this unintentional death of a 37-year-old male during
bupivacaine as measured by postmortem tryptase. The importance of a elective shoulder surgery was determined to be due to complications of
complete forensic autopsy and forensic toxicological analysis to bupivacaine. The moderately elevated cardiac tryptase concentration
accurately certify the cause and manner of death is emphasized. raises the possibility of anaphylaxis that may have contributed to the
This case represents unusual findings of elevated bupivacaine and cause of death.
tryptase concentrations following local anesthetic, bupivacaine, Forensic Pathology, Bupivacaine Toxicity, Postmortem Tryptase
administered as a scalene nerve block for elective rotator cuff repair
surgery. The patient exhibited almost immediate seizure activity,
bradycardia, and cardiac arrest following bupivacaine injection. G2 Undiagnosed, Untreated Natural Disease
Resuscitative efforts including cardiopulmonary bypass restored a
cardiac rhythm. However, the clinical medical status of the decedent
Mistaken for Lethal Child Neglect:
progressively declined and he died seven hours following administration Liability of the Family in Determining
of the local anesthetic. An autopsy was performed and various biological Child’s Death
specimens were collected for toxicological analysis. Autopsy revealed
several abnormalities of the heart including cardiomegaly, myocardial Lucia Tattoli, PhD*, Sabrina Leonardi, MD, and Biagio Solarino, PhD,
bridging, and lipomatous hypertrophy of the intra-atrial septum. The Section of Legal Medicine - University of Bari, Pizza Giulio Cesare 11,
cardiac findings may have contributed to bradycardia and arrhythmia. Bari, 70124, ITALY
Autopsy findings associated with hypersensitivity reactions such as
urticaria or laryngeal edema were not observed at autopsy. The absence After attending this presentation, attendees will understand that in
of these findings alone does not rule out a suspected case involving a cases in which there is a potential component of neglect or abuse, careful
hypersensitivity reaction. scene investigation, review of medical records, complete autopsy with
Postmortem toxicology results revealed an elevated cardiac skeletal survey, toxicology, chemical and metabolic testing should be
bupivacaine and tryptase concentration. An elevated concentration of requested.
bupivacaine in the blood taken seven hours post-injection is indicative of This presentation will impact the forensic science community by
an intravascular injection. When taking into account that the patient was emphasizing the fact that even if lethal neglect is a rare cause of death in
alive for seven hours post-injection of bupivacaine and the half-life of industrialized countries, natural disease being mistaken for child abuse is
bupivacaine is about two hours, it was estimated that the subclavian rare too. As a matter of fact there are many potential organic diseases
blood concentration of bupivacaine was most likely much higher at the which may mimic neglect or abuse and an appropriate histological
time of seizure activity than at the time of sample collection. However, examination of all organs should be undertaken to assist in ruling out
the postmortem cardiac blood analyzed had a similar bupivacaine organic disease.
concentration at the time of seizure activity due to intraventricular blood A case is presented of a 4-month-old infant who was found
stasis resulting from cardiopulmonary bypass for approximately five unresponsive at home and transported at a local hospital, where he
hours. expired in the Emergency Department. Physicians noted child’s
Patients receiving local scalene nerve block anesthesia that is in cachectic state; the mother stated he had fever, vomiting, and diarrhea for
close proximity to the carotid artery may be at greater risk of CNS and seven days but she was afraid to seek medical care because was fearful
cardiac toxicity due to a greater risk of inadvertent intravascular of legal action against her. Further investigations revealed a completely
injection or an injection into a highly vascular tissue area. This would inappropriate and inadequate diet of meat, homogenized milk, and
result in rapid absorption of the local anesthetic into the systemic oatmeal from his birth. The infant was never breastfed.
circulation causing cardiac and CNS sequelae. Therefore, this type of
1 * Presenting Author
Crime scene investigation showed the extremely poor living autopsy based retrospective research was conducted to determine the
conditions of the apartment where the 22-year-old mother lived with her causes and the epidemiological aspects of sudden cardiac deaths in
parents and her sons. The family was occasionally followed by social Mangalore, a coastal township in South India. The study was conducted
care workers. The infant had never been followed by a pediatrician. at the Department of Forensic Medicine, Kasturba Medical College,
The child weighed 4,000 g and was 62 cm long. His clothing and Mangalore. All the cases recorded in the departmental file as sudden
bedding were urine-soaked and vomit-covered. Whole body deaths from January 2005 to December 2007 were included in the study
radiographic examination showed no fractures. At autopsy, there were and autopsy case files of the same were studied in detail. The data was
clear signs of malnutrition and dehydration, like skin tenting and analyzed using statistical software.
wrinkled loose skin, sunken fontanels and ocular globes, depressed During the study period a total of 1864 autopsies were conducted,
cranial sutures, focal alopecia, prominent ribs and bony planes, and dry of which 207 cases were classified as sudden unexplained deaths.
serosal and mucous membranes. Partial lack of subcutaneous and deep Sudden cardiac deaths constituted of 39.6% of the total sudden deaths
fat deposits with a severe atrophy of skeletal muscles was found. during the study period (n=82). Males were predominantly affected
Brownish material was found in gastrointestinal tract. There was a (91.5%). Age of victims varied from 19 to 80 years, mean age of the
severe atrophy of skeletal muscles, heart, liver, spleen, and kidneys; the victims being 49.96 years. Majority of deaths were reported in the 5th
small intestinal wall appeared swollen, with reddish discolored mucosa. and 6th decade of life. Mean BMI was 20.8 kg/m2. The monthly
Further histological examination showed a T-cell lymphoblastic distribution revealed that most of the sudden cardiac deaths were
massive infiltrate of the liver, kidneys, and other organs with multiple reported in May followed by February. Weight of heart varied from 210
foci of bronchopneumonia in lungs, and sporadic evidence of aspiration. to 560 grams (Mean=335.4 grams). Coronary artery diseases remained
Immunocytochemical studies confirmed the diagnosis of acute the most common cause of sudden cardiac deaths followed by cardiac
lymphoblastic leukemia of childhood. Toxicological examination hypertrophy, cardiomyopathy, myocarditis, and valvular diseases. More
revealed no substances in blood or urine. The cause of death was than 50% occlusion of the coronary arteries was evident in
attributed to an Acute Lymphoblastic Leukemia (ALL) – related approximately half of the cases. Left anterior descending artery was the
cachexia, worsened by malnutrition and dehydration. most commonly affected. Atherosclerotic changes were observed in the
The ALL is rare under one year and the youngest infants (ages 0 to great vessels in most of the cases.
6 months) have the worst outcome. At diagnosis of childhood ALL, Cardiac causes are responsible for most of the sudden deaths in this
anorexia-cachexia syndrome may occur, presenting with anorexia, region and coronary artery diseases are responsible for most of the
weight loss, wasting of muscle and adipose tissue, hyperlipidemia, and cardiac deaths. Atherosclerotic changes were observed in the great
other metabolic abnormalities. vessels in most of the cases in our study. Atherosclerosis is responsible
In the case presented here, an early recognition with appropriate for significant cardiovascular morbidity and mortality worldwide.
treatment of ALL would probably have given the child a chance of Medicolegal autopsies are an important source of epidemiological data
survival. In fact, despite the progressive improvements in outcomes that should effectively be used in planning the preventive strategies.
achieved for the children treated on chemotherapy, the outcome is Modifying the stressful life style and screening those at high risk are the
positive in less than 25% of cases. measures to be emphasized to prevent such deaths.
Cases of suspected child abuse which ultimately are determined to Sudden Death, Cardiac Death, Coronary Artery Disease
result from natural diseases are extremely rare. Moreover, although it is
important to suspect child abuse when the history and examination are
consistent with the diagnosis, it is equally important to think of other G4 Periventricular Leukomalacia in a 2-
potential diagnoses, considering legal medico-legal aspects related the
liability of the parents in determining child’s death.
Month-Old Infant Who Was Born With
Lethal Neglect, Acute Lymphoblastic Leukemia, Malnutrition Cocaine Addiction: A Case Report
Baiyang Xu, MD*, 1520 Penn Avenue, Pittsburgh, PA 15222; Todd M.
G3 Sudden Unexpected Cardiac Deaths: An Luckasevic, DO, Alleghey County Medical Examiner’s Office, 1520 Penn
Avenue, Pittsburgh, PA 15222; and Abdulrezak M. Shakir, MD, and Karl
Autopsy Based Study From Mangalore, Williams, MD, Allegheny County Medical Examiner Office, 542 Fourth
South India Avenue, Pittsburgh, PA 15219
Tanuj Kanchan, MD*, Kasturba Medical College, Department of After attending this presentation, attendees will be aware of the
Forensic Medicine, Light House Hill Road, Mangalore, 575 001, INDIA neuropathologic sequela in a 2-month-old infant born with addiction to
cocaine. The prenatal history and the scenario surrounding the infant’s
After attending this presentation, attendees will be able to identify death will be presented. Common outcomes of the effects of cocaine on
with the pattern and trend of sudden cardiac deaths in a coastal region of the fetus and newborn are reviewed.
South India. This presentation will impact the forensic science community by
This presentation will impact the forensic science community by demonstrating that cystic periventricular leukomalacia is one of the
developing an understanding of the burden of sudden cardiac deaths in irreversible neurological complications that directly or indirectly may
the coastal region. This presentation defines the problem status of occur in cocaine-exposed fetuses and the dilemma in considering the
sudden cardiac deaths in the region and emphasizes the importance of cause and manner of death of the similar cases will be discussed.
forensic pathologists in diagnosing the same at autopsy. Case presentation: The decedent was a 2-month-old African
Forensic pathologists deal not only with unnatural deaths, but also American female who was born precipitously in an ambulance at 30
with a wide range of natural deaths, especially, if the death occurs weeks gestational age to a 29-year-old mother who had a history of
suddenly in apparently healthy individuals. Cardiovascular diseases are cocaine and marijuana abuse and used crack cocaine the day she gave
reportedly the most important cause of sudden natural deaths. Sudden birth. She had no prenatal care for this pregnancy. She had given birth
cardiac death is defined as death due to cardiac causes, heralded by to three live children, including the decedent, and all three were born
abrupt loss of consciousness within one hour of the onset of acute addicted to cocaine. She also gave birth to one stillborn (female). This
symptoms, in an individual who may have known preexisting heart decedent’s birth weight was 1,034 grams and length was 19 inches. She
disease but in whom the time and mode of death are unexpected. This was diagnosed with cocaine addiction and respiratory failure, was on
* Presenting Author 2
mechanical ventilation for the first two days of her life, and stayed in This presentation will impact the forensic science community by
hospital for 20 days before being discharged home. The discharge emphasizing that postmortem injury by domestic animals is only rarely
diagnosis includes bilateral periventricular leukomalacia. The infant was documented in the literature therefore lacking knowledge regarding
adopted by her biological mother’s sister. The decedent’s condition was morphologic features and the criteria for the differentiation of such
stable and she was fed with formula. At 20:04 on the day of the postmortem soft tissue destruction may cause considerable
incidence, when lying supine on the couch in the living room with her complications in clarifying the cause of death. This is particularly true
adoptive mother, the decedent suddenly exhaled and stopped breathing. when postmortem animal depredation is caused by a domestic dog’s
The adoptive mother started to gently rub the decedent’s chest and the activity.
decedent still did not get breath. 911 was called and the decedent was A case of a 55-year-old man will be presented who was found
transported to a hospital by ambulance with an admission diagnosis of putrefied in the bedroom of his apartment; head and neck of the body
cardiac arrest. CT scans/X-rays revealed a large right pneumothorax and were missing. The rest of the body, in particular the hands, was intact.
pneumoperitoneum. An emergency chest tube placement and Also his well-feed two German shepherd dogs (8 and 11/2 years old)
exploratory laparotomy were performed in the operating room. The were in the flat. The flat was locked with the windows closed. He had
decedent was taken to the intensive care unit and her condition been seen for the last time one week before the incident. The public
deteriorated. Pronouncement was made at 13:40 the next day after the health service had been called one year earlier because the man and his
incident. two dogs had not left the dwelling for eight weeks. Policemen were
Autopsy findings included a poorly developed 2-month-old black called to the scene as the dogs had been barking for four days. In the
female with less than 5th percentile of body weight and length. No hallway and the living room they remarked several remnants of small
traumatic injuries were identified. The lungs exhibited atelectasis. The supposed human bone parts and crowned teeth in puddles of feces and
brain exhibited bilateral cystic periventricular leukomalacia and severe vomitus. The flat was in messy condition with garbage, emptied alcohol
hypoxic/ischemic encephalopathy. Accessory tests were non- bottles, and moldy food in every room. Lots of accessible dog food was
contributory. also found. The dogs are brought to pet asylum, and an autopsy of the
Discussion: Effects of cocaine on the developing central nerve incomplete body is ordered. Autopsy showed a fatal gastrointestinal
system of a fetus may cause different pathologic changes, such as bleeding by rupture of esophageal varicose veins (while head and neck
germinal matrix hemorrhage or cystic changes, introventricular were still missing). Furthermore, signs of chronic alcoholism could be
hemorrhage, and periventricular leukomalacia. However, those changes determined. Toxicological examinations led to no specific findings. At
are difficult to interpret as the sole consequence of the effects of cocaine postmortem, animal depredation signs, canine-like bite traces and tissue
because risk factors in cocaine abusing pregnant women tend to cluster defects were found surrounding the collar region. The right pleural
together and interact, such as multiple drug use, poor maternal nutrition, cavity was opened by animal depredation; parts of the right pulmonary
lack of prenatal care, infectious disease, placental insufficiency, impaired lobe were missing as well as the cervical vertebral bodies 1-6. The
fetal oxygenation, fetal intrauterine growth retardation, and premature clavicles, the scapulae and 7th cervical vertebral body showed extensive
birth. All the above CNS pathological changes can also be present in the gnawing traces. After autopsy, the apartment was searched again for
premature newborn without intrauterine cocaine exposure. In addition, head and neck of the man by forensic scientists and police; still the
the premature infants with or without intrauterine cocaine-exposed tends missing parts could not be found. From forensic point of view, it must
similarly to be poorly grown, easily susceptible to infection and be presumed that the dogs ate head and neck of the corpse completely.
vulnerable for sudden infant death. Cause of Death: Although a Postmortem Injuries, German Shepherd Dogs, Animal Depredation
definitive cause and effect relationship between these conditions and
cocaine use is difficult to reach, the fact of intrauterine exposure of
cocaine could not be ignored in this case. The cause of death was the G6 Responses of Mast Cells in the Dura
complication of premature born with addiction to cocaine associated
with cerebral cystic periventricular leukomalacia and severe
to Traumatic Brain Injury in an
hypoxic/ischemic encephalopathy. Manner of Death: Detailed history Animal Model
of the mother’s cocaine abuse and the circumstances surrounding the
decedent’s addiction to cocaine at the time of birth were unclear, even Kazuhiko Kibayashi, MD*, Tokyo Women’s Medical University,
though thorough investigation was performed and the death occurred Department of Legal Medicine, School of Medicne, 8-1 Kawada-cho,
two months after birth. In addition, constitutional issues may preclude Shinjuku-ku, Tokyo, 162-8666, JAPAN; and Ryo Shimada, PhD, and Rui
criminal prosecution in many of these kinds of cases. The manner of Furutani, PhD, Tokyo Women’s Medical University, 8-1 Kawada-cho,
death was classified as “Undetermined.” Shinjyuku-ku, Tokyo, 162-8666, JAPAN
Cocaine, Fetus, Periventricular Leukomalacia
After this presentation, attendees will understand the responses of
mast cells in the dura to traumatic brain injury (TBI), the histamine-
G5 A Man Without a Head: Postmortem mediated brain damage after TBI, and the significance of histological
examinations of the dura in cases of head trauma.
Decapitation by German Shepherd Dogs This presentation will impact the forensic science community by
providing evidence for changes in the dural mast cells after TBI and the
Claas T. Buschmann, MD, Institute of Legal Medicine and Forensic role of dural mast cells in the development of brain injuries. This
Sciences, Turmstrasse 21, Building L, Berlin, 10559, GERMANY; Biagio presentation will also emphasize the need for histological examinations
Solarino, PhD*, Università degli Studi di Bari, Sezione di Medicina of the dura in autopsies of head trauma cases.
Legale, Pizza Giulio Cesare, 11, Bari, 70125, ITALY; and Michael Mast cells secrete stored histamine in response to extrinsic stimuli.
Tsokos, MD, Institute of Legal Medicine & Forensic Sciences, Turmstr Histamine plays a role in the formation of brain edema and induces
21, Haus L, Berlin, 10559, GERMANY histamine receptor expression in the brain. Histamine receptors exert a
protective effect against histamine neurotoxicity. Because the dura
After attending this presentation, attendees will understand that in contains mast cells, it is hypothesized that blunt force to the head
cases of postmortem animal depredation of human corpses or remains, activates dural mast cells, leading to the release of their histamine and
physicians and crime scene investigators not experienced in the field of exacerbation of brain injury. Therefore, the time-dependent changes in
forensic medicine are often unable to attribute the questioned injuries to dural mast cells and histamine receptor expression in the brain after TBI
their true origin. in a rat controlled cortical impact model was investigated.
Male adult rats (7-10-weeks-old) weighing 200−310 g were used in Suicide Using Plastic Bag. Some pills were also found, as well as letters
this study. Under general anesthesia, a craniotomy of 6.0 mm in expressing his suicide intentions and last will.
diameter was performed over the left parietal bone taking care not to The need, in such situations, of a high index of suspicion for the
penetrate the dura. A blunt force impact was applied to the craniotomy diagnosis of this entity is emphasized. When numerous petechiae are
site using a pneumatic impact device and generated a cortical contusion present, particularly in the conjunctivae, an attempt to identify their
on the left cerebral hemisphere. In sham-operated rats, the same surgical origin should be made to exclude other manner of the death, such
procedures were performed, but no impact was applied. Rats were strangulation. So, a full and careful autopsy, including toxicological
perfused transcardially with phosphate-buffered saline under general analysis, combined with the investigation of the evidence at the death
anesthesia at 1, 4, 7, or 14 days after the surgery. Toluidine blue staining scene is mandatory in these cases.
for mast cells and immunohistochemistry for histamine receptor H3 were Plastic Bag, Asphyxia, Suicide
performed on paraffin sections of the dura and cerebrum. Real-time
PCR analysis of histamine receptor H3 mRNA expression was
performed on total RNA extracts from the cerebrum. G8 The Bone Collector: When Reality
The number of toluidine blue-stained dural mast cells at the site of
impact was significantly decreased at one and four days after the trauma.
Overcomes Fantasy
The immunoreactivity and mRNA expression of histamine receptor H3
at the cortical contusion of the cerebrum were significantly increased at Luigi Cipolloni, MD, Manuela Rosini, MSc, Silvia Zoppis, MD*,
one and four days after the trauma. A previous report showed that Department of Legal Medicine University of Rome “Sapienza”, Viale
activated mast cells release histamine-containing vesicles and appear Regina Elena 336 00161, Rome, ITALY; Fabio Verginelli, PhD,
unstained with toluidine blue. Therefore, the present results indicate that Department of Oncology and Experimental Medicine, G. d’Annunzio
blunt force to the head causes dural mast cell degranulation and induces University, Via dei Vestini 31, 66100, Chieti, ITALY; Michaela Lucci,
histamine receptor H3 expression in the cerebrum. The findings further PhD, Alfredo Coppa, Department of Environmental Biology, University
indicate that a decreased number of toluidine blue-stained mast cells in of Rome “Sapienza”, P.le A. Moro 5, 00185, Rome, ITALY; Filippo
the dura provide evidence of head trauma, suggesting that histological Terrasi, Circe, Innova and Department of Environmental Sciences, 2nd
examinations of the dura may help to diagnose blunt force impacts to University of Naples, Via Vivaldi 43, 81100, Caserta, ITALY; and Carla
the head. Vecchiotti, Department of Legal Medicine University of Rome
Forensic Neuropathology, Head Injury, Dura “Sapienza”, Viale Regina Elena 336, 00161, Rome, ITALY
After attending this presentation, attendees will understand the

importance of the application of a multidisciplinary approach in
G7 Plastic Bag Asphyxia: Suicide and Literature challenging cases of identification of human remains.
This presentation will impact the forensic science community by
Cristina Cordeiro, MSc*, Instituto Nacional De Medicina Legal, Largo Da demonstrating that a case that may apparently seem simple may instead
Se Nova, Coimbra, 3000-213, PORTUGAL; and Duarte N.P. Vieira, PhD, reveal great methodological and interpretative challenges, making it
Rua Antonio Jose de Almeida, No 117, Coimbra, 3000-044, PORTUGAL imperative to use a multidisciplinary approach with methods that require
specific professional expertise in various specialties (e.g., pathology,
The goal of this presentation is to show: (1) the importance of a genetics, anthropology, physics, chemistry).
careful autopsy in cases of asphyxia; (2) the importance of the death All who work in the forensic field know that the more crucial the
scene traces; and, (3) the influence of the literature in some cases of biological samples to be analyzed are (charred remains in an advanced
suicide. state of decomposition, fragments of tissues, bones, etc.), the more
This presentation will impact the forensic science community by complex personal identification is. In these challenging cases it is
showing how the literature and media could influence and help someone extremely important to apply a multidisciplinary approach for
to commit a suicide. identification.
Asphyxial deaths using plastic bags are not common. Most A case that came under their observation in July 2007 in Rome will
frequently classified as suicide or accident (usually involving children, be presented. A skeleton was discovered by firefighters after
volatile inhalants, and autoerotic situations), they also can have a extinguishing a fire in a grassy field. The skeleton was almost complete
homicide origin. The death may be caused by mechanisms such and its right side was charred because of the flames. Beside the skeleton,
obstruction of the external air passages, usually called smothering, a bag containing a bunch of keys and an identity card was found,
and/or oxygen deprivation, included in the general group of mechanical fortunately not destroyed by the fire. These items belonged to an elderly
asphyxia by suffocation. man who disappeared in that area four years before.
The cases of suicide using plastic bags have increased with the Genetic tests were performed on a left femoral bone sample in order
publication, in March 1991, of the book Final Exit: The Practicalities of to confirm the presumed identity of the skeleton and instead provided a
Self-Deliverance and Assisted Suicide for the Dying written by Derek genetic profile that was not compatible with the sons of the missing man.
Humphry. The book describes this method of suicide, in combination Thus, other samples were taken from different bones and examined
with drugs, as a painless way for those suffering from a terminal illness resulting in five different genetic profiles, corresponding to three women
to end their lives. In New York City asphyxia deaths using plastic bags and two men, and none of them was compatible with the sons of the
increased by more than 300% immediately following the publication of missing man.
the book. However, these deaths have only been responsible for less Therefore the prosecutor asked for an anthropological expertise,
than 5% of all suicides in the year after the book was released. In many who confirmed morphologically that the skeleton was composed by
other countries, like Portugal, this method of suicide is however rarely bones belonging to different individuals and could also give a range for
used. the approximate age of these individuals at the time of death.
The death scene investigation may be crucial to determine a suicidal Thus, the prosecutor asked for the time-of-death estimation of these
aetiology. As a matter of fact, if the plastic bag has been removed, and individuals and, at this request, specific investigations on the bone
as in such cases the external evidence of injury could be minimal, the remains were carried out based on the measure of the isotopic ratio of 14C
death may be initial understood as a natural death. in lipids and collagen by Accelerator Mass Spectrometry (AMS), which
A case of suicide using plastic bag is presented, in which the victim, can provide a dating for the remains in exam.
a retired translator, left nearby the book Final Exit open to the chapter
So far, five DNA profiles have been identified but not all the bones G10 Method of Concealment of Corpses in Mafia
available have been genetically examined yet, so it is possible that the
genetic profiles, and therefore the number of individuals involved in the
Related Homicides: Melting in
case, may be more. Strong Acids
Identification, Multidisciplinary, Approach
Massimo Grillo, MD*, Filippo M. Cascino, MD*, Department of
Biotechnology and Legal Medicine, Section of Legal Medicine, Via del
G9 Cancer Patient mtDNA Forensic Vespro 129, Palermo, 90127, ITALY; and Valentina Murgo, MD,
Palermo University, Via Del Vespro, n. 127, Palermo, 90100, ITALY;
Identification: A Case Report Livio Milone, Via Del Vespro, n. 127, Palermo, 90100, ITALY
Fabio Verginelli, PhD, Department of Oncology and Experimental After attending this presentation, attendees will learn about some
Medicine, G. d’Annunzio University, Via dei Vestini 31, 66100, Chieti, awful methods of concealing corpses used by Mafia criminal
ITALY; Manuela Rosini, MSc, Department of Legal Medicine, Viale organizations.
Regina Elena 336, 00161, Rome, ITALY; Silvia Zoppis, MD*, Department This presentation will impact the forensic science community by
of Legal Medicine University of Rome “Sapienza”, Viale Regina Elena showing experimental data to help attendees better understand how
336 00161, Rome, ITALY; and Carla Vecchiotti, Department of Legal strong acids and bases could melt a body; in particular, it will be shown
Medicine, Viale Regina Elena 336, 00161, Rome, ITALY using sulfuric acid activated with water, both soft tissues and bones could
colliquate in few days, in contrast with pure sulfuric acid.
After attending this presentation, attendees will understand how to The criminal organization called “Cosa Nostra” has implemented
manage a forensic identification case in a cancer patient, when only brutal approach to commit murders over the past years, with dramatic
neoplastic tissue is available for the genetic analyses. symbolic implications, in order to prolong the agony of the victims,
This presentation will impact the forensic science community by extract useful information, and no only to cause death as quickly and
demonstrating that, because of the frequency of mutations in mtDNA is bloody as possible, but also to facilitate the concealment and the
higher than in nuclear DNA in a variety of human cancers (as suggested disappearance of the corpse itself. In the mafia, ritual murder must be
from several studies), the mtDNA profiling should not be applied as the view beyond the event itself, even the meaning of such gestures, take
unique analysis in cases of forensic identification of cancer patients value as a warning to strike terror. Regarding the concealment of the
when only neoplastic tissue is available. Moreover, direct automated corpses, nothing was known until the “pentiti” (those Mafiosi who
sequencing lacks adequate resolution to detect mtDNA heteroplasmy turned informant) began to tell the dramatic episodes of which they
when, as in cancer cells, the somatic mutation tend to homoplasmy. witnessed or participated in from time to time, shedding light on a
Mitochondrial genome mutations are described in many kinds of particular aspect of the phenomenology in Mafia’s homicides known as
human malignancies, including lung cancer. These mutations can be “lupara bianca” (literally “white shotgun”): the disappearance of a
base substitutions, insertion, or deletions, and the 1.1 kb d-loop region subject who was known to be dead, but without knowledge of where his
has been recently identified as a mutational “hot spot” in the corpse was.
mitochondrial DNA (mtDNA) of neoplastic tissue. Cancer cells harbor To hide the bodies of the victims tortured and killed, criminals used
homoplasmic rather than heteroplasmic mutations; therefore, somatic various methods, like burial in land, immersion in seawater with weights
mutant mtDNA appears as a single copy among a majority of wild-type tied to the victims to get them to the bottom, disposal of corpses in
mtDNA molecules and becomes dominant in the cancer cell probably natural caves or wells, or burning of bodies in ovens or cars. But the
due to the growth/survival advantages that such mutation confers to the most chilling and ingenious method was destruction by “melting” by
cell. using strong acids or bases. In particular, some pentiti spoke about a
A case of forensic identification will be presented in which a widow “death’s chamber,” property of the criminal clan of Brancaccio and his
claimed medical malpractice by the physicians that had taken care of her boss, Filippo Marchese, called “u milinciana” (the eggplant, because of
husband, who was affected by a malignant lung disease. The wife his skin’s color), where the police found some tanks full of acid, torture
thought that he had been wrongly diagnosed with cancer and, therefore, instruments, and human remains.
he had undergone massive and inappropriate therapies that finally led This report’s goal, therefore, is to verify experimentally the use of
him to death. strong acids (sulfuric acid) for the dissolution of biological tissues
In this case, the prosecutor ordered the seizure of the neoplastic animals, and also observing the macroscopic changes that the soft tissues
histological samples attributed to the deceased and the comparison of the and bones undergo over the time, in order to verify the claims of the
genetic profile obtained from these samples with those of the relatives, Mafia’s “pentiti” in their statements. In particular, two different tests
in order to establish the presence or absence of genetic compatibility were conducted: in the first, dipping a pork knuckle weighing 160 grams
among the neoplastic tissue and the relatives of the deceased. in a glass bowl containing pure sulfuric acid of known concentration,
To this end, autosomal markers were analyzed and compared with highly caustic, water-soluble, and able to carbonize organic matter. In
those of the two daughters of the deceased, while Y-chromosome this case, after only 30 minutes, the piece of pork appeared to be
markers and mtDNA were analyzed and compared with those of his “cooked,“ with brownish color, in two days the muscle structures were
brother. loose, while after only six days, the bone began to be eroded, although it
While both autosomal and Y-chromosome markers confirmed the remained essentially integrated. The second test was made by dipping
correspondence of the histological samples to the deceased, in the case the knuckle of pork into a bath of 700 cc of sulfuric acid activated with
of mtDNA a difference at nucleotide 16093 of HVRI region has been water. In this case, the muscle-cartilaginous component disappeared
highlighted: in fact the brother had a C while the lung tissue examined after only 12 hours and after two days the bone appeared dissolved in the
showed a transition from C to T. In order to ascertain the full genetic liquid component.
compatibility it was therefore necessary to study the nature of this These experimental test made have thus demonstrated that it
nucleotide difference by cloning of PCR products. appears unlikely that an entire body can be dissolved in few minutes (as
Sequencing of PCR cloning products thus allowed highlighting a reported by some “pentiti”) using the normal commercially available
heteroplasmic site (tending to homoplasmy) at nt.16093 in tumor cells sulfuric acid, but in any case it’s likely that, in several days, a corpse
with respectively 75% of mutated mtDNA and only 25% of germ-line could be colliquated and made unrecognizable.
mtDNA compatible with the brother reference sequence. Mafia’s Homicide, Concealment, Melting
mtDNA Profiling, Heteroplasmy, Neoplastic Tissue
G11 When Ribs Penetrate the Heart in Blunt G12 Examination of Sexually Abused Children:
Chest Wall Trauma Presentation of the First Danish Center
for the Investigation and Care of
Tanuj Kanchan, MD*, Kasturba Medical College, Department of
Forensic Medicine, Light House Hill Road, Mangalore, 575 001, INDIA
Abused Children
After attending this presentation, attendees will be able to identify Annie Vesterby, MD, DMSc*, Institute of Forensic Medicine, University of
with the possible mechanism of penetrating trauma caused directly to the Aarhus, Brendstrupgårdsvej 100, 8200 Aarhus N, DK-8000, DENMARK
heart by the fractured ends of the ribs in run over traffic mishaps.
This presentation will impact the forensic science community by After attending this presentation, attendees will understand how the
illustrating a type of injury that is well known but rare. The injury is first Danish Child Protection Center was organized, and the importance
reported for the first time in a run over traffic accident. Cardiac of the participation of the forensic department and the forensic
lacerations caused directly as a result of rib fractures although a rare pathologist.
phenomenon in blunt force trauma to the chest, its possibility should be This presentation will impact the forensic science community by
explored so that prompt and early treatment saves the patient from a fatal showing the importance of the involvement of the forensic pathologist in
outcome. the investigation of child sexual abuse.
Cardiac damage in non-penetrating chest trauma is uncommon. The prevalence of sexual abuse of children in the Nordic countries
Direct penetrating injuries to the heart are commonly observed in stab is unknown, but has been estimated to be around 5%. Very few cases of
and gunshot wounds. The fractured ends of the ribs are very rarely sexual abuse are reported to the police. The police may request a
reported to cause penetrating injuries to the heart. One such rare case medical examination to document or verify the child’s testimony.
where the sharp ends of fractured ribs has caused extensive damage to Until now, the child and the child’s family have had to go to the
the heart in a run over vehicular accident is reported. The reported rare police station to give a videotaped interview to the police, go to a
case illustrates the possible mechanism of direct cardiac injuries from medical or a forensic doctor with examination rooms located elsewhere,
broken sharp jagged fractured ends of ribs in blunt force trauma to the followed by pediatric evaluation and treatment and psychosocial follow-
chest in run over traffic mishaps. up at yet another place.
A 45-year-old male fell from a moving bus while trying to get off. In November 2007, the first Danish centre for the protection of
By the time brakes were applied, the moving bus had run over the left abused children was established at Aarhus University Hospital, Skejby.
side of his chest, neck, and head. The victim died instantly and the body The Center, which receives all kinds of child abuse cases, is located
was subjected to medicolegal autopsy. On external examination, the in a building neighboring the Department of Forensic Medicine, Aarhus,
head and face of the victim was deformed. Underlying comminuted and headed by a steering group with representatives from the Pediatric
skull fractures were palpable. No external injuries were evident on the Department, the police, and the Department of Forensic Medicine; the
chest region. Avulsed lacerations were present on the lower limbs. Center is managed by a pediatric consultant.
Internal examination revealed multiple fractures of the cranial vault and Videotaped interviews by the police are performed at the centre as
base of the skull with diffuse subdural and subarachnoid hemorrhage, well as the forensic medical examination, pediatric and psychosocial
intraventricular bleeding, and extensive brain damage. Fractures of the evaluation and follow-up.
2nd to 6th ribs in anterior axillary line on the left side, and fracture of 1st Experience and perspectives from the first Danish child protection
and 2nd ribs in mid-clavicular line on the right side with corresponding centre for the forensic community will be presented.
chest wall muscle contusions were present. Pleura contained 300 and Sexual Abuse, Child Protection Center, Forensic Pathology
400 ml of frank blood in the right and left sides respectively.
Pericardium was torn and extensive damage to the left ventricle was
evident. The heart weighed 280 grams. Transmural lacerations of the G13 An Innovative Proteomic Approach for the
left ventricle were present, corresponding to the pointed fractured ends Identification of Novel Plasma Biomarkers
of the ribs on the left side. Peritoneal cavity contained 200 ml of blood.
Multiple lacerations over the right liver lobe were present. All visceral
in Patients With Brugada Syndrome
organs were pale on cut section. Lungs escaped any major trauma in the
reported case. Domenica Scumaci, PhD, Magna Græcia University of Catanzaro,
The rib cage acts as a protection for the thoracic organs and support Laboratory of Proteomics and Mass Spectrometry, Department of
for the vertebral column. Penetrating injuries to the heart in blunt chest Experimental and Clinical Medicine, Salvatore Venuta University
trauma thus remain uncommon. Even when the ribs are fractured recoil Campus, viale “S. Ve, Catanzaro, 88100, ITALY; Simona Grasso,
of the intercostal muscles keeps the architecture of the rib cage intact Antonio Curcio, PhD, and Marco Gaspari, PhD, Magna Græcia
preventing subsequent injuries to the thoracic organs. Fractured ribs at University of Catanzaro, Salvatore Venuta University Campus, Viale
times may act as a weapon of offense causing damage to the underlying Europa, Catanzaro, AL 88100, ITALY; Silvia Priori, PhD, Molecular
organs directly. In the present case of a run-over traffic mishap, no Cardiology Laboratory, IRCCS, Via Ferrata 8, Pavia, AL 27100, ITALY;
external injuries or deformity were apparent on the chest wall. On Ciro Di Nunzio, Institute of Legal Medicine, School of Medicine, Magna
internal examination, intercostal muscle contusions were present but Graecia University, Viale Europa Germaneto, Catanzaro, 88100, ITALY;
apparently the rib cage had retained its shape due to recoil of the Antonio Oliva, PhD, and Francesco Ausania, MD, Institute of Forensic
intercostal muscles. It was only on further dissection that the major Medicine, Catholic University, School of Medicine, Largo Francesco
insult to the pericardium and the heart was observed. It is illustrated how Vito 1, Rome, 88100, ITALY; Ciro Indolfi, PhD, Magna Graecia
the sharp jagged ends of the fractured ribs move medially on external University, Viale S Venuta, Catanzaro, AL 88100, ITALY; Pietrantonio
pressure to cause penetrating injuries to the heart. It is proposed that as Ricci, PhD, Università degli Studi Magna Grecia Catanzaro, Viale
a consequence of the transient phenomenon of deformation of chest Europa - Località Germaneto, Catanzaro, 88100, ITALY; and Giovanni
cavity under pressure in run over traffic mishaps, the projecting fractured Cuda, PhD*, Magna Graecia University of Catanzaro, Viale S. Venuta,
ends of the ribs penetrate the underlying thoracic organs causing Catanzaro, AL 88100, ITALY
fatal injuries.
Ribs, Heart, Run Over Traffic Mishap After attending this presentation, attendees will understand how
plasma potentially carries important information whose knowledge
could help to improve early disease detection and prognosis in Brugada eosinophils within the myocardium. This phenomenon may be
syndrome. associated with a variety of disease such as idiopathic hypereosinophilic
This presentation will impact the forensic science community by syndrome (IHES), hypersensitivity myocarditis, giant cell myocarditis,
providing potential new tools for the correct diagnosis of “at risk” toxic myocarditis, Churg-Strauss syndrome, or parasitic infection.
individuals with Brugada syndrome carrying specific gene mutations. Clinical presentation includes a wide spectrum of nonspecific signs
The molecular signature obtained by the study of plasma proteome will and symptoms: chest pain, fever, shortness of breath, chills, cough, but
complement genomic information therefore increasing the chance of they are not always present at the same time and sometimes unusual
disease detection in these individuals who are exposed to a dramatic risk symptoms, such as epigastric pain, can be the only indication of a
of sudden cardiac death. pathological state. They can be also associated with peripheral
Brugada syndrome (BS) is a polygenic inherited cardiac disease eosinophilia and transient or persistent left ventricular dysfunction.
characterized by life threatening arrhythmias and high incidence of EM is considered, together with coronary heart dissection, one of
sudden death. In the family enrolled in the present study, the disorder is the clinical presentations of peripartum cardiomyopathy that usually
caused by Q1118X-mutation in the SCN5A gene, encoding the cardiac occurs one month before to six months following delivery. EM etiology
sodium channel. 2D-PAGE was used to investigate specific changes in and pathogenesis are unknown: eosinophils may be present and
the plasma proteome of BS affected patients and family members sharing activated because of the systemic hormonal perturbation occurring
the same gene mutation, compared to healthy controls, with the goal to during the period of uterine involution.
identify potentially specific disease biomarkers. A major problem is that EM is rarely recognized clinically and is
In order to reduce plasma sample complexity, the combinatorial often first discovered only at postmortem examination.
hexapeptide ligand libraries were used.1 The use of the beads prior 2D- A correct diagnostic approach in these patients should include an
PAGE enabled detection of many new protein spots and increased echocardiogram study (with evidence of low ejection fraction and
resolution and intensity of low abundance proteins. decreased left ventricular systolic function) and an endomyocardial
Approximately 900 protein spots were detected in each gel. biopsy (confirming eosinophils as a major inflammatory cell
Proteins, whose expression was significantly different among the two component).
groups, were excised, trypsin-digested and analyzed by LC-MS/MS. If successfully diagnosed, EM can be treated with beta-blockers and
Data showed that the levels of several proteins were significantly ACE inhibitors to support heart failure and corticosteroids to reduce the
altered in BS patients compared with controls. In particular, inflammatory process that is involving the myocardium. Prognosis is
Apolipoprotein E, Prothrombin, Vitronectin, Complement-factor H, strictly linked to ventricular function recovery because those patients
Vitamin-D-binding protein, Voltage-dependent anion-selective channel with severe myocarditis-induced heart failure have less survival chances
protein 3, and Clusterin were considerably increased in plasma sample of if normal cardiac function is not restored.
BS patients, whereas Alpha-1-antitrypsin, Fibrinogen, and Few EM cases are reported in literature and most of them are based
Angiotensinogen were considerably decreased; moreover, post- only on autopsy diagnosis.
translational modification of Antithrombin-III was detected in all A case is reported of a 29-year-old woman who was admitted to
affected individuals. critical care unit in respiratory and cardiac failure, three weeks after
In the light of these results, it is hypothesized that these proteins giving birth. Patient clinical history was non-existent for allergy or
might be considered as potential markers for the identification of disease autoimmune diseases. The third day after birth, she complained of
status in BS. Further analysis is being conducted in our laboratory in thoracic pain but echocardiogram was negative. During hospitalization
order to validate these findings in a larger number of cases and to physicians treated her with antacids and gastric inhibitors and then she
elucidate the pathogenetic role of these proteins in this specific cardiac was discharged with prescription of proton pump inhibitors with the
disease. suggestion of gastroenterology visit. The following three weeks where
Reference: characterized by growing anterior and back thoracic pain associated with
1.
Boschetti E, Righetti PG. The ProteoMiner in the proteomic general discomfort, but neither specific symptoms nor peripheral
arena: anon-depleting tool for discovering low-abundance eosinophils increase were present; only inflammatory indexes (velocity
species. J Proteomics. 2008 Aug 21;71(3):255-64. Epub 2008 Jun of erythrocyte sedimentation, VES, and creatine kinase, CK) were
20. Review slightly increased. With progressive and worsening clinical symptoms,
Brugada Syndrome, Plasma Biomarkers, Proteomics she was finally sent to emergency room in critical condition: dyspnea,
confusion, fever, and tachycardia. Echocardiogram showed severe left
ventricular systolic dysfunction and 25% of ejection fraction; chest
G14 A Case of Lethal Peripartum radiograph and TC displayed pleural effusion with general edema. The
young woman died after seven hours of cardio-respiratory failure and no
Eosinophilic Myocarditis medical approach was effective. External examination of the body was
completely negative. Autopsy revealed bilateral pleural effusions,
Maria Carolina Romanelli, MD*, Eloisa Maselli, MD, Biagio Solarino, increased lung weights, and hepatomegaly. Heart was normal in size and
PhD, Section of Legal Medicine - University of Bari, Piazza Giulio shape, but myocardium and papillary muscles showed malacic areas.
Cesare, 11, Bari, 70124, ITALY; and Giancarlo Di Vella, PhD, Sezione Histological examination pointed out massive eosinophilic infiltrates,
di Medicina Legale, DIMIMP, University of Bari, Policlinico, Piazza G. more evident in cardiac samples. The cause of death was indeed
Cesare, Bari, 70121, ITALY attributed to peripartum eosinophilic myocarditis.
The role of “peripartum” in the etiopathogenesis of such
The goal of this presentation is to report an uncommon case of cardiomyopathy as well as possible medical liability in lacking diagnosis
lethal peripartum cardiomyopathy in a young woman. A complete and treatment of myocarditis will be discussed.
forensic approach was performed through autopsy, histological, and Eosinophilic Myocarditis, Peripartum, Heart Failure
microbiological examinations and final results showed that the cause of
death was due to an Eosinophilic Myocarditis (EM).
This presentation will impact the forensic science community
showing that eosinophilic myocarditis is a rare, potentially fatal disease
if left untreated.
Eosinophilic myocarditis is a histological diagnosis characterized
by a mixed inflammatory cell infiltrate containing a variable amount of
G15 The Bodies of Two Missing Children in an This presentation will impact the forensic science community by
introducing an alternative test that could be useful in drowning
Enclosed Underground Environment diagnosis.
To investigate the effectiveness of marine bacteria and/or bacterial
Francesco Introna, PhD, Antonio De Donno, PhD, Valeria Santoro, indicators of water fecal pollution as a new marker of drowning, an
PhD, Section of Legal Medicine - DiMIMP, P.zza Giulio Cesare n.11, experimental protocol was performed to identify bacteria on samples of
Bari, 70124, ITALY; Simona Corrado, MD, Sezione di Medicina Legale, drowned victims recovered from umor vitreo (UV) and blood of different
Bari, 70100, ITALY; Vito Romano, MD, Medicina Legale Miulli, anatomic sites such as: right ventricular blood (RV), left ventricular
Acquaviva delle Fonti, Acquaviva delle Fonti - Bari, 70100, ITALY; blood (LV) and peripheral blood (P). The study, performed in 2008 and
Francesco Porcelli, PhD, Section of Entomology and Zoology 2009, was performed on ten victims: six drowned victims (two cases in
(Di.B.C.A.), University of Bari (Italy), Via G Amendola, Bari, 70126, sea water, three in rivers or lake; one in rainwater collection tank) (study
ITALY; and Carlo P. Campobasso, PhD*, University of Molise, Via De group), and four subjects who died from causes other than drowning
Sanctis, Snc, Campobasso, 86100, ITALY (three cases of heart attack and one case of death by vehicle collision)
(control group). From all groups at least 0.5 ml of each sample were
The goal of this presentation is to illustrate a little-known but obtained and the tests were calibrated by considering the water fecal
noteworthy case concerning the wrongful conviction of a Southern Italy pollution rates. Selective culture media were used to detect bacterial
father whose two missing children were found dead in enclosed growth. Each samples of control or study groups (RV, LV, P and UV) or
environment after approximately 1.5 years since their disappearance. water samples (all 100 ml) were incubated in Tryptic soy broth (TSB) for
This presentation will impact the forensic science community by 48 h at 37°C and 5% CO2. After incubation, evaluation of bacterial
warning and improving search operation, methods of investigation, and growth was assessed by plating 100 ml of each sample onto: Todd
indictment process, based on the autopsy findings and physical evidence Hewitt and Marine agars, selective for marine bacteria, m-FC agar,
collected on the scene and from the bodies. selective for fecal coliforms (FC) and KF Streptococcus agar, selective
Two young kids, 13- and 11-years-old respectively, originally from for fecal streptococci (FS). The plates were incubated for 24 h at 44°C
a small town in Southern Italy, were missing on June 5, 2006 (06:30 and for 48 h at 37°C and 5% CO2 to determine FC and FS growth,
p.m.). Soon after their disappearance, a “missing child” search began. respectively. The presence of FC was indicated by the development of
Broadcasters promptly aired a description of the missing children blue colonies, whereas the presence of FS was indicated by the
pushing the entire community to assist in the search and safe recovery of development of red colonies. The absence of blue and red colonies
the child. But every effort was in vain for more than one year. During indicated a negative result, i.e., no blood fecal pollution. The presence
the search, the investigators collected enough evidence against the father of marine bacteria was evaluated through the observation of their growth
who was arrested 17 months after the disappearance. He was indicted on selective culture media. Results showed that in the samples of
for kidnapping, homicide, and concealment of the two bodies. He never drowned victims in sea water there is growth of marine bacteria, as
confessed the crimes and he claimed to be innocent. evidenced by the presence of colonies on TH4% and MA culture media
Three months after the conviction, a fireman found the two corpses for LV and P blood samples, for the case 1, and for P and UV samples
in a subterranean dry cistern next to a more than 20-meter-high well for the case 2. Moreover, the case 2 showed growth of FS and FC
water. The bodies were well preserved, almost mummified with only bacterial colonies. Regarding drowned victims in rivers or lake water,
few body-parts skeletonized. Based on dental records they were the analysis of case 4 showed the presence of marine bacteria from RV
identified as those of the two children missing 1.5 years before. Signs of blood sample; on the other hand the case 5 resulted positive to marine
a very low insect activity were present, reasonably consistent with a bacteria and fecal streptococci. Surprisingly, case 3 was negative for
rapid skin dehydration. The autopsy showed no signs of defense injuries marine bacteria and fecal streptococci. All anatomic sites of case 6,
or ligature consistent with strangulation or captivation except for drowned victim in rainwater collection tank, resulted positive to all the
fractures of the axial skeleton at a number of points consistent with a fall bacterial species considered. Bacteriological analysis of RV, LV, P and
from a low-medium height. The body of the elder brother (CP) presented UV samples of the control group evidenced a total absence of bacteria.
major injuries with signs of recent hemorrhages and gut content analysis This result showed the reliability of the microbiological test. All the
consistent with the last meal which provided enough evidence to water samples obtained from locations where corpses were found
ascertain a very short survival time. The younger brother (TP) showed showed a bacterial presence according to samples obtained from the
minor injuries, signs of old hemorrhage, gastric and intestine emptying related victims. Applied method is sensitive since a very few bacteria
time consistent with a longer survival time of approximately 3-4 days, aspirated at follow drowning can be evidenced. Positive results obtained
spent alone in the dark and cold cistern. No evidence of body removal for various anatomic sites (RV, LV, P, and UV) can be an internal control
or corpse displacement following death was observed. A long of the sampling procedure to avoid the possibility of bacterial
postmortem interval (PMI) of approximately 20 months was estimated contamination during blood and umor vitreo sampling. Notably, umor
mainly from the pattern of insect succession. Based on such physical vitreo as a new sample for the microbiological test of drowning diagnosis
evidence, on March 4, 2008, four months after conviction and 40 days was used.
after the recovery of the two bodies, the father was released from prison Drowning Diagnosis, Microbiological Test, Umor Vitreo
and exonerated from previous indictment of homicide.
Missing Children, Wrongful Conviction, Postmortem Interval
G17 Butane Inhalation and Sudden Death:
G16 Diagnosis Of Drowning: The Contribution A Case Report
Of Microbiological Investigations Maria Celeste Landolfa, MD*, Michela Cicconi, MD, Massimo Gallo,
MD, and Andrea Gianelli Castiglione, MD, Department of Legal and
Pistolesi Luca, MD*, Institute of Legal Medicine, Via Del Giochetto Snc, Forensic Medicine, Via de Toni 12, Genova, I-16132, ITALY; and
Perugia, ID 06100, ITALY Francesco Ventura, MD, Department of Forensic Pathology, University
of Genova, Via de’ Toni, 12, Genova, 16132, ITALY
After attending this presentation, attendees will gain knowledge of
the effectiveness of marine bacteria and/or bacterial indicators of water After attending this presentation, attendees will have learned about
fecal pollution as a new marker of drowning. a case of sudden death due to butane inhalation in a young inmate.
This presentation will impact the forensic science community by therapeutic concentrations of benzodiazepines and 0,5 g/L of ethanol in
stressing the importance of combining autopsy data and the detection of blood samples. The cause of death was ascribed to n-butane poisoning
volatile substances in blood and tissues in all cases of unclear death of inducing fatal cardiac arrhythmia.
young people. In conclusion, abuse of volatile substances is a serious problem
This presentation will inform attendees of something they do not do because it is not illegal and agents are easily available and cheap. Thus,
correctly–the misdiagnosed problem of sudden death due to abuse of the risk of sudden death due to abuse of volatile substances in an
volatile substances, especially in adolescents and people living in remote environment with no witnesses should be taken into consideration in all
communities. In the current practice, forensic pathologists don’t often cases of unclear death of young people. It is recommended that
consider that volatile substances are very easily accessible, and lethal if medicolegal death investigators become familiar with the principles of
abused. They should learn how to detect halogenated hydrocarbons, and detection of volatile substances in blood and tissues, especially in those
when it is correct to analyze the concentrations of these volatile cases with unspecific macroscopic and histological findings.
substances in blood and tissues. This kind of investigation should be Volatile Substance Abuse, Butane, Sudden Death
performed in order to avoid mistakes, especially in cases of sudden death
of young people with aspecific pathological findings or unremarkable
histological examinations. G18 Case Report of a Fatal Intoxication
The deliberate inhalation of volatile substances has been reported
from most parts of the world, mainly among adolescents, individuals
by Nucynta®
living in remote communities, and those whose job gives easy access to
these substances, with a higher incidence in Countries with large rural Dori M. Franco, DO*, OAFME, 1413 Research Boulevard, Building
populations. Although it is less widespread than twenty years ago, 102, Rockville, MD 20904; Zabiullah Ali, MD, Barry S. Levine, PhD,
inhalant use still remains a problem today ranging from 10% to 15% Office of the Chief Medical Examiner, 111 Penn Street, Baltimore, MD
among U.S. teenagers and young people (M.R. Marsolek et al., 2010). 21201; Robert A. Middleberg, PhD, Annette Ervin, BS, Francis X.
Solvents from contact adhesives, typewriter correction, dry Diamond, BS, NMS Labs, 3701 Welsh Road, Willow Grove, PA 19090;
cleaning fluids, cigarette lighter refills, petrol (gasoline), halogenated and David R. Fowler, MD, Office of the Chief Medical Examiner, 111
solvents, and aerosol propellants are commonly abused in this way, but Penn Street, Baltimore, MD 21201
cigarette lighter refills and butane-containing cans for portable cooking
stoves are the most frequently abused ones. Although aliphatic After attending this presentation, attendees will learn about a case,
hydrocarbons are considered safe as aerosol propellants, the acute in which, Nucynta®, a newly released analgesic, a Schedule II controlled
inhalation of these substances, particularly n-butane, may potentially substance, comparable to tramadol, was fatally ingested.
cause severe damage in healthy hearts (M. Ago et al., 2002). This presentation will impact the forensic science community by
Volatile substance abuse gives rise to dose-related effects similar to raising the awareness of the toxicity of novel drugs, which is essential for
those of hypnosedatives. Small doses can rapidly lead to euphoria and medical examiners and forensic toxicologists.
other behavior disturbances similar to those caused by ethanol (alcohol), Tapentadol (Nucynta®) is a centrally acting opioid analgesic
and may also induce delusions and hallucinations. Higher doses may prescribed for the treatment of moderate to severe acute pain. Its
produce life-threatening effects such as seizures, coma, and sudden death efficacy is believed to be due to mu-opioid receptor agonist activity and
(R.J. Flanagan et al., 1994). The mechanism of sudden death directly inhibition of norepinephrine reuptake resulting in increased
related to volatile abuse includes cardiac arrhythmia, hypoxia, and norepinephrine concentrations. Metabolism of tapentadol is via
respiratory depression. glucoronidation to inactive metabolites. There are no cases in the
Butane is a gaseous aliphatic hydrocarbon, also called n-butane, literature relating to the toxicity of this agent or reports of fatalities. This
with the “n” designating it as normal butane. Its other isomer is report documents a case in which tapentadol was identified as the cause
isobutene, but the name butane is used collectively to denote both n- of death. The decedent was a 40-year-old obese male who was found at
butane and isobutane (R.L. Myers, 2007). N-butane and isobutane have home by his girfriend. He had been prescribed Nucynta® (tapentadol) for
an anesthetic or narcotic effect on the central nervous system, and induce shoulder pain, Lexapro (citalopram), and amitriptyline. There appeared
fatal arrhythmia at 0.5–15% concentrations in the air (H. Sugie et al., to be more tablets missing than expected. At autopsy, there were early
2004). It has been reported that many n-butane or isobutane abusers decomposition changes and hepatomegaly with fatty change.
experienced fatal ventricular fibrillation immediately after a sudden Routine volatile, therapeutic drug, and abused drug testing was
fright or intense muscular exercise such as running and sexual activity performed on the heart blood in this case. This included: (1) methanol,
(C. Jackowski et al., 2005. H. Sugie et al, 2004). A few cases of suicide ethanol, acetone, and isopropanol analysis by head space gas
by propane-butane inhalation have been reported too (A. Gross et al., chromatography (GC); (2) acid/neutral drug screen by GC-nitrogen-
2002). phosphorus detection (NPD); (3) alkaline drug screen by GC-NPD; (4)
A case of sudden death of a 22-year-old male inmate is described. acetaminophen and salicylate by color test; and, (5) morphine and
He had a history of drug addiction, depression, and multiple self- benzodiazepines by enzyme-linked immunosorbent assay (ELISA). The
inflicted superficial incised wounds. His cellmates reported that the blood ethanol concentration was 0.01 g/dL; the vitreous humor ethanol
body was found in the bathroom of the cell. The bathroom smelled of concentration was negative. The alkaline drug screen was positive for
gas. The body was lying on the bidet, with his back leaning against the diphenhydramine (0.6 mg/L), amitriptyline (1.1 mg/L), nortriptyline
wall; a butane-containing can and a portable cooking stove were found (<0.1 mg/L), and citalopram (0.3 mg/L). All were confirmed by full scan
on the floor adjacent to the body. A complete medicolegal autopsy was electron ionization gas chromatography/mass spectrometry and
performed. The external examination showed marked livor mortis, quantified by GC-NPD.
nosebleed, and some parallel linear scars on the forearms; no signs of Given the case history, the heart blood was sent to a reference
recent injuries or trauma were observed. The internal examination laboratory for tapentadol analysis. Tapentadol was quantified by liquid
revealed marked lung congestion; the other organs showed no chromatography – mass spectrometry/mass spectrometry (LC-MS/MS)
pathological findings, but evidence of congestion. Histological using D5-tapentadol as internal standard. Extraction of tapentadol from
examinations were unremarkable. Blood samples were collected and blood involved addition of carbonate buffer followed by methyl-tert-
analyzed for halogenated hydrocarbons and drugs, using gas butylether (MBTE). After taking the MTBE layer to dryness, methanol
chromatography. A concentration of about 0.5 μg/ml for n-butane, with was added and then transferred to an autosampler vial for injection. The
traces of isobutane and butene was measured; drug screening revealed limit of detection (LOD) and limit of quantitation (LOQ) of the assay
were 0.06 ng/mL and 0.5 ng/mL, respectively.
The therapeutic range for tapentadol is 5-300 ng/mL. The contrast microscopy. Three different samples at different postmortem
tapentadol concentration found in the heart blood submitted in this case intervals were carried out: between 4 and 6 h (T1), between 10 and 12 h
was 6600 ng/mL; more than 20 times the upper limit of the therapeutic (T2) and after 24 h (T3). Then CBF (beat number/second) was classified
range. Possible mechanisms of death include respiratory depression, in: present (3-4/sec), hypo-valid (1-2/sec) and absent.
CNS depression, and serotonin syndrome. Results demonstrated that, except for those cases which showed
Based on the scene investigation and autopsy findings in this case, fungal or bacterial infections, at T1 motility was present in the majority
the medical examiner determined that the cause of death was narcotic of cases; at T2 motility was still present, but it was hypo-valid in a higher
(Nucynta®) intoxication and the manner-of-death was undetermined. percentage. Ciliary activity was absent at T3. It is believed that all these
Tapentadol, Nucynta®, Overdose findings can be explained with progressive metabolic reserves lowering:
the more time passes after death, the more ciliated cells loose energetic
substrates for ciliary motility.
G19 Nasal Mucociliary Motility: New Forensic In conclusion, mucociliary motility seems to be linked to PMI and
thus nasal scraping can be considered as a new, easy, cheap, and efficient
Tool for Estimating Time Since Death objective tool in detecting PMI; further studies are required.
Nasal Scraping, Mucociliary Motility, Time Since Death
Biagio Solarino, PhD*, Università degli Studi di Bari, Sezione di
Medicina Legale, P.zza Giulio Cesare, 11, Bari, 70125, ITALY; Carolina
Romanelli, MD, Lucia Tattoli, MD, and Giancarlo Di Vella, PhD,
Section of Legal Medicine - University of Bari, P.zza G. Cesare 11, Bari,
G20 Fatal Spontaneous Non-Traumatic
70124, ITALY; and Luisa Fiorella, MD, and Matteo Gelardi, MD, Subdural Hematoma and Terson Syndrome
Department of Otolaryngology II - University of Bari, P.zza G. Cesare
11, Bari, 70124, ITALY Christina J. Tatum, MD*, 522 Cliff Place, Homewood, AL 35209; and
Constance A. Stanton, MD, and Patrick E. Lantz, MD, Wake Forest
After attending this presentation, attendees will understand the University Health Sciences, Department of Pathology, Medical Center
potential contributions of postmortem investigation of nasal mucociliary Boulevard, Winston-Salem, NC 27157-1072
motility in time of death estimation.
This presentation will impact the forensic science community by After attending this presentation, attendees will learn that a ruptured
emphasizing the potential role of nasal scraping that could become a cerebral aneurysm can cause a compressive acute subdural hematoma
routine procedure in estimating time-since-death. without concomitant subarachnoid hemorrhage.
Postmortem interval (PMI) estimation is one of the most difficult This presentation will impact the forensic science community by
issues in forensic medicine. Time-of-death is usually appreciated by expanding the attendees knowledge base by increasing awareness of
recognizing early postmortem changes to the body prior to the onset of causes of non-traumatic subdural hematomas and retinal hemorrhages.
gross decomposition phenomena: algor mortis, rigor mortis, and livor This presentation will inform attendees of something that they do
mortis. not know. While most acute subdural hemorrhages are the result of
The study of these physical processes is strictly connected to the trauma, forensic pathologists must be aware that a ruptured cerebral
operator’s subjectivity hence it can be source of confusion in estimating saccular aneurysm can cause a spontaneous non-traumatic subdural
PMI. Moreover these body changes can be altered by several internal hemorrhage along with associated retinal hemorrhages (Terson
and external factors: body temperature at death time, subcutaneous fat, syndrome).
muscular mass, clothes, environmental temperature, humidity, and Cerebral saccular aneurysms frequently rupture into the
ventilation. subarachnoid space, accounting for 70-80% of non-traumatic
There have been many proposed innovative methods in attempts to subarachnoid hemorrhages (SAH); however, aneurismal rupture also
avoid this trouble defining PMI objectively as possible. The goal of may result in concomitant intraparenchymal, intraventricular, or
these new techniques is to find a link between PMI and objectively subdural hemorrhage. Most acute subdural hematomas (SDH) in adults
detectable values such as infrared tympanic thermography, skin are due to traumatic head injuries, although less common causes include
fluorescence, electrolyte concentration in cerebro-spinal fluid, coagulopathies, non-traumatic intracranial hemorrhage, intracranial
pericardial fluid or vitreous humor. All these samples, on the other hand, hypotension, or post-surgical complications. A ruptured cerebral berry
present practical difficulties in performing and require invasive methods (saccular) aneurysm causing only an acute SDH is rare, representing <
and long time waiting. 0.5 - 2% of all ruptured aneurysms in several large case series. In 1881,
Some studies have been published about nasal scraping role in Litten first described intra-retinal hemorrhage associated with SAH.
clinical practice (ciliary dyskinesia, NARES, allergic rhinosinusitis), but However, Terson’s description in 1900 of vitreous hemorrhage following
no studies have never been performed in cadavers for PMI estimation. SAH is now associated with this syndrome. Although originally defined
A study concerning the examination of ciliary motility as residual by the presence of vitreous hemorrhage in association with SAH, Terson
life phenomenon, realizing a study on time of death evaluation using a syndrome now encompasses any intraocular hemorrhage associated with
new, rapidly available requiring substrate: nasal mucosa is presented. intracranial hemorrhage and elevated intracranial pressures.
Nasal mucosa is composed by numerous cell types (globet cells, A case of 46-year-old woman who died suddenly and unexpectedly
basal cells, ciliated and not ciliated cells) and can be easily obtained by at her residence is presented. Found on the bathroom floor, she had no
nasal scraping, a technique commonly used in otolaryngology; it consists obvious injuries. According to investigations by the medical examiner
of a curette crept on nasal mucosa and cells picked up in this way are and law enforcement, she had a vague past medical history significant
then observed. for hypertension but did not consume alcoholic beverages or use illicit
From June 2009 to June 2010, nasal scraping in 70 cadavers was drugs. Subsequent toxicological analysis did not reveal any licit or illicit
performed. Age ranged from 24 to 95 years and the cause of death was drugs.
most frequently due from ischemic cardiopathy, septic shock, and car At autopsy, she appeared well nourished and had a body weight,
accident. The only exclusion criteria of this study was nose bleeding. length ,and body mass index of 49.1 kg, 160 cm, and 19.1, respectively.
A specimen of ciliated epithelium was obtained by scraping from Postmortem monocular indirect ophthalmoscopy revealed bilateral
the middle third of the inferior turbinate with a spoon-shaped nasal probe retinal hemorrhages. The right and left fundi exhibited 25-35 and 15-20
(Rhinoprobe). An in vitro evaluation of ciliary movement was flamed-shaped and dot retinal hemorrhages over the posterior poles,
performed. Ciliary beat frequency (CBF) was analyzed by phase- respectively.
A 1.5 cm subscalpular contusion was left of the vertex over the An Edinburgh professor of obstetrics, James Young Simpson, first
parietal area. No subgaleal extravasated blood or skull fractures were introduced a successful obstetric vacuum extractor in 1849. Technical
present. Diffuse liquid and clotted subdural blood covered the cerebral difficulties limited its effectiveness and vacuum extraction (VE) fell
convexities (R > L) and weighed 67 gm. The calvarial dura had adherent from clinical interest until 1956 when the stainless steel cup vacuum
non-organizing blood over the right and left frontoparietal regions. The device was introduced. While common in Europe, VE did not gain
leptomeninges were thin and translucent without any extravasated blood. continued popularity in the United States until the 1980s. Early studies
Compression of the midbrain involved the inferomedial temporal lobes showed no significant traumatic complications attributed to VE when
and 2 x 1.5 x 0.3 cm dusky area of hemorrhage was in the inferomedial limited to 15 minutes and/or two “pop-offs” of the vacuum cap. The
right temporal lobe (medial to the groove caused by transtentorial “pop-off” presumably served as a safety valve that would protect the
herniation). The arteries of the circle of Willis were in the usual neonate from excessive tractional forces. The development of the soft
anatomic configuration and patent. A 0.5 x 0.2 x 0.2 cm ruptured cup VE device with its implied safety caused VE to gain increasing
saccular aneurysm projected from the callosal side of the bifurcation of popularity. Currently forceps and VE are used as delivery instruments,
the left pericallosal and callosal marginal arteries. The brainstem but over the past decade VE has replaced forceps as the main delivery
contained Duret hemorrhages in the pons and midbrain. instrument in assisted vaginal deliveries. However, controversy
Ophthalmological examination revealed bilateral diffuse optic continues concerning which instrument is the best to use in specific
nerve sheath hemorrhages and extravasasted blood within the perineural clinical situations. VE remains popular because of its relative ease of
fat. The right and left fundi had 75-100 and 25-35 flame-shaped and dot use, lower maternal morbidity, and supposed safety. Nevertheless,
retinal hemorrhages, respectively. These involved all four quadrants and severe neonatal complications can occur. The reported incidence of fetal
extended past the equator but did not abut the ora serrata. The fundal death or severe fetal injury from VE ranges from 0.1-3 cases per 1,000
hemorrhages were in all retinal layers and scant blood was in the vitreous assisted deliveries. Three cases are presented of neonates who died from
of both globes. complications following vacuum-assisted vaginal delivery.
A non-traumatic SDH can occur due to the rupture of cerebral Case 1: Delivered by vacuum-assisted vaginal delivery, a 2.8 kg,
saccular aneurysm. Most of these aneurysms are located on the internal 37-weeks-gestational age neonate had Apgar scores of 7 and 8 at 1 and 5
carotid artery followed by the middle cerebral artery and anterior minutes, respectively. His initial hemoglobin (Hgb) was 17.4 gm/dL, but
communicating artery, but only rarely arise from the distal anterior 5 hours later when he began grunting and developed hypothermia his
cerebral artery. Four mechanisms have been proposed by which blood Hgb was 6.8 gm/dL. He was transferred to a medical center with
from a ruptured cerebral aneurysm causes a SDH: admitting diagnoses of subgaleal hemorrhage, anemia, hypotension,
1. Successive small hemorrhages allow adhesions to develop disseminated intravascular coagulopathy, and respiratory failure. After
and the final rupture dissects between the subarachnoid and three weeks in the intensive care unit, the family withdrew care due to
subdural layers his increasingly poor prognosis. At autopsy, he had severe anasarca and
2. The arachnoid membrane is breached by the rapidly hypoxic-ischemic/re-perfusion injury to his heart, liver, spleen, kidneys,
accumulating blood from the rupturing aneurysm and brain. An organizing subgaleal hematoma measured 15 cm and
3. A massive hemorrhage ruptures the cortex and breaches the weighed 77 gm. No retinal hemorrhages (RHs) were identified by
arachnoid membrane postmortem monocular indirect ophthalmoscopy (PMIO) and he had no
4. A carotid artery aneurysm located between the arachnoid layer documented clinical fundal examination.
and dura mater ruptures causing a SDH Case 2: Born by vacuum-assisted vaginal delivery due to an
Subarachnoid hemorrhage almost invariably develops following the arrested second stage of labor and shoulder dystocia, a 4.36 kg term
rupture of a cerebral aneurysm and only extremely rarely does a SDH neonate had Apgar scores of 0 at 1, 5, and 10 minutes and 2 at 15
occur without an associated SAH. While most acute subdural minutes. She experienced immediate respiratory distress, hemodynamic
hemorrhages are the result of trauma, forensic pathologists must be instability, and presumed sepsis. Her initial Hgb was 14.9 gm/dL that
aware that a ruptured cerebral saccular aneurysm can cause a later decreased to 10.7 gm/dL. An electroencephalogram demonstrated
spontaneous non-traumatic SDH along with associated retinal severe encephalopathy and her condition continued to decline until she
hemorrhages (Terson syndrome). died a day later. At autopsy, she had large subgaleal and subscalpular
Acute Non-Traumatic Subdural Hematoma, Cerebral Aneurysm, hematomas that were 20 cm in greatest dimension and weighed 54 gm.
Retinal Hemorrhages No skull fractures were present but she had bilateral subdural hematomas
as well as subarachnoid hemorrhage. A clinical fundal examination was
not done, but PMIO detected extensive bilateral multi-layered RHs.
G21 A Fatal Complication of Vacuum-Assisted Case 3: Delivered by cesarean section after a failed vacuum-
assisted delivery, a 3.8 kg term neonate had Apgar scores of 3, 5, and 7
Vaginal Delivery at 1, 6, and 10 minutes, respectively. He had respiratory distress,
hemodynamic instability, and developed disseminated coagulopathy.
Lezah P. McCarthy, MD*, Wake Forest University Baptist Medical The parents withdrew care the following day. At autopsy, extensive
Center, Medical Center Boulevard, Winston Salem, NC 27157; and subgaleal and subscalpular extravasated blood was present measuring 35
Constance A. Stanton, MD, and Patrick E. Lantz, MD, Wake Forest cm in greatest dimension and weighing 140 gm. No skull fractures,
University Health Sciences, Department of Pathology, Medical Center epidural, or subdural hemorrhage was identified. PMIO revealed
Boulevard, Winston-Salem, NC 27157-1072 extensive RHs in the right globe and 1 RH in the left fundus; however,
no clinical fundal examination was documented in the medical record.
After attending this presentation, attendees will learn of a fatal The most common extracranial injuries associated with VE are
complication following vacuum-assisted vaginal delivery. superficial scalp abrasions, lacerations, and hemorrhage that can occur in
The presentation will impact the forensic science community by 10% of neonates. Two major types of scalp injury are the common, but
expanding the familiarity with a fatal complication of vacuum-assisted clinically unimportant, cephalohematomas and the relatively rare, but
vaginal delivery, neonatal mortality, and conditions associated with potentially life threatening, subgaleal (SG) hemorrhage where
retinal hemorrhages. extravasated blood dissects between the periosteum of the skull and the
This presentation will inform attendees of something they do not galea aponeurotica. The mortality rate of SG hemorrhage following VE
know–that fatal neonatal subgaleal hemorrhage can result from birth is estimated at 20%. Vacuum-assisted vaginal delivery is a relatively
assisted vacuum extraction and have associated extensive retinal common procedure and most often benign. However, forensic
hemorrhages.
pathologists must be aware that a fatal SG hemorrhage can result from results. The confidence interval is large because of the few cases in the
VE and have associated extensive RHs. study; a larger study will narrow the confidence interval.
Vacuum-Assisted Vaginal Delivery, Subgaleal Hemorrhage, Conclusion: This study shows that, when found at postmortem
Retinal Hemorrhages examination, the presence of a linear scar in the midline of the back of
the sort following laminectomy is a powerful marker for a drug related
death. In a practice where toxicology is not routinely performed on all
G22 The Relationship of Back Surgery to cases, the presence of a laminectomy scar should lead to toxicological
analysis for that case.
Overdose at Autopsy Back Scar, Drug Overdose, Intoxication
Emily F. Gorman, MD*, University of Alabama at Birmingham,

Department of Pathology, P220 West Pavilion, Birmingham, AL 35233-
7331; Robert M. Brissie, MD, Medical Examiner Office, 1515 6th
G23 The Use of Raman Spectroscopic Imaging in
Avenue, South, Birmingham, AL 35233; and Gregory G. Davis, MD, Cases of Ethylene Glycol Toxicity
Jefferson County Medical Examiner’s Office, 1515 6th Avenue, South,
Room 220, Birmingham, AL 35233-1601 Victor W. Weedn, MD, Maryland State Office of the Medical Examiner,
111 Penn Street, Baltimore, MD 21201; Mary G. Ripple, MD, 68
The goal of this presentation is to define the relationship between Bluebird Road, Port Deposit, MD 21904; Sara Nedley, MS, ChemImage,
the presence of a scar in the midline of the back, indicating a history of 7301 Penn Avenue, Pittsburgh, PA 15208; and David R. Fowler, MD, and
laminectomy, with drug intoxication sufficient to cause death. Kristin A. Johnson, MD*, Office of the Chief Medical Examiner, 111
This presentation will impact the forensic science community by Penn Street, Baltimore, MD 21201
discussing how presence of a laminectomy scar is a powerful marker for
a drug related death. In a practice where toxicology is not routinely After attending this presentation, attendees will have reviewed
performed on all cases, the presence of a laminectomy scar should lead ethylene glycol toxicity, the pathophysiology and histology of ethylene
to toxicological analysis for that case. glycol poisoning, and be introduced to the concept of Raman imaging
Rationale: Individuals who have died suddenly and unexpectedly and how it can be used to identify calcium oxalate crystals in tissues.
in which examination reveals a scar in the midline of the back of the sort This presentation will impact the forensic science community by
left by a lumbar or cervical laminectomy are regularly received. Because introducing a new method to identify crystalline deposits in the kidneys
the cause of death in such individuals is frequently intoxication with when ethylene glycol is suspected.
some drug, it is hypothesized that death due to a drug overdose is more The American Association of Poison Control Centers reported
common in individuals with evidence of a previous laminectomy than in 6,077 exposures to ethylene glycol in the United States, resulting in 40
individuals with no prior laminectomy. Therefore, we tested the null deaths in 2002. The State of Maryland had 15 cases of ethylene glycol
hypothesis. There is no difference in the frequency of death from a drug intoxication from 1996-2009. Ethylene glycol is a colorless, odorless
overdose in a study group with a linear scar in the midline of the back liquid which is the principal component of antifreeze. The toxic dose
when compared to the frequency of drug overdose in cases evaluated at varies but more than 0.1 ml/kg body weight is the reported toxic dose
the medical examiner office in which no scar is found on the midline of requiring medical treatment. The primary symptoms are CNS
the back. depression followed by a cardiopulmonary stage with eventual renal
Methods: A retrospective case-control study of deaths in 2008 failure. The lethal dose is approximately 100 ml in an adult. It is
investigated by the Jefferson County Coroner/Medical Examiner Office, metabolized to oxalic acid which binds the calcium in the body forming
Alabama was conducted. The study group consisted of decedents 18 calcium oxalate crystals that eventually lead to the renal failure. In
years of age or older who had a linear scar in the midline of the back; as addition, it does not show up on toxicologic analysis in a routine volatile
determined by review of the autopsy protocol (body diagram or written screen.
report). The control group was chosen from all the decedents examined Forensic pathologists may be presented with a death without an
at the Jefferson County Coroner/Medical Examiner Office, Alabama in obvious cause, but crystals may be seen in the kidneys that suggest
2008. Controls were matched to the study cases by age, race, and sex. ethylene glycol poisoning with initial negative toxicology. Four cases
Race and sex were matched exactly. Age was matched to the same year involving probable ethylene glycol ingestion and the use of Raman
in 21 cases, to within one year in five cases, and to within two years in imaging to identify calcium oxalate crystals are presented. The cases
three cases. When more than one control was available the control used presented include three cases of known ethylene glycol toxicity and one
was determined randomly the throw of a die. The charts of both the case of suspected ethylene glycol toxicity with negative ethylene glycol
study group (back scar) and of the control group (no scar) were reviewed and glycolic acid blood analyses and crystals in the kidneys.
for the cause of death and evidence of intoxication. All toxicology The case that prompted the use of Raman imaging was that of a 52-
results were noted in the decedents, including the presence of cocaine, year-old black male found deceased with vomitus on a pillow next to him
any other drugs or medications, and ethanol. Bodies charred by fire (six in his father’s vacant home. The decedent had no known psychiatric or
cases) or recovered as skeletal remains (two cases) were excluded from past medical history. At autopsy an anomalous right coronary artery and
the study. This project was approved by the medical Institutional Review dull green stomach contents were found. Microscopic examination of
Board of the University of Alabama at Birmingham. the kidneys revealed multiple polarizable crystals consistent with
Results: For all decedents 18 years of age or older in 2008, the calcium oxalate. This prompted additional police investigation revealing
likelihood of death being due to a drug overdose was 12.8%. The study the subject was estranged from his family. No additional medical or
group of decedents with a linear back scar consisted of 27 decedents, social history was gained. Toxicologic analysis of blood for ethylene
nine of whom died as a result of acute intoxication with some substance glycol and oxalic acid was negative. Raman imaging showed that the
of abuse. In the matched control group one decedent died of acute crystals were indeed calcium oxalate. The cause of death was anomalous
intoxication with a substance of abuse. Decedents with a back scar were right coronary artery complicated by oxalosis and the manner classified
thirteen times (odds ratio 13.0; 95% confidence interval 1.9-85; p= as Undetermined. Three other cases of known ethylene glycol toxicity
0.011) more likely to die of a drug overdose than the controls. In other underwent Raman imaging. In all cases, toxicologic analysis of the
words, a body with a laminectomy scar is 13 times more likely to die as blood was positive for ethylene glycol, autopsy showed crystals in the
a result of an overdose than is another body without a laminectomy scar. kidneys, and the cause of death was ethylene glycol intoxication and
Given the small p-value, chance is an unlikely explanation for these manner was undetermined.
Raman molecular imaging is a method used to identify molecular fixed obstructions. The decedent was initially conscious in the water, but
structures. It is a physical phenomenon involving the interaction of light became unresponsive shortly after being pulled to shore. Bloody
with molecules. This method is based on inelastic (Raman) scattering of drainage was seen from her perineum, and her wound was extensively
monochromatic light from a source such as a visible laser, a near infrared packed. Despite this, resuscitation was unsuccessful.
laser, or near ultraviolet laser. The laser interacts with phonons in the A review of her medical history revealed a recent c-section. Her
system, resulting in the energy of the laser photons being shifted up or obstetrician reported that her c-section had been uncomplicated.
down. The shift in energy is then related as data concerning the phonons Autopsy supported this as her gynecologic organs were intact. No other
in the system being studied. The unstained aluminum slide is injuries were identified. The combination of history, literature, and
illuminated with a laser beam, light from this spot is collected with a autopsy findings indicated that the cause of death in this case was due to
lens, and then sent through a monochromator. Wavelengths similar to severe anorectal trauma from the water thrust of a jet ski.
the laser are filtered out, and the rest of the light is collected into a Risk factors for injury in this case included the fact that the
detector. A given solid material has characteristic phonon modes that can decedent was a passenger and fell straight backward. When a passenger
help to identify it. falls from a jet ski, the throttle does not shut off automatically as it would
Raman molecular imaging was able to characterize the unknown for a driver who fell. Further, the decedent was wearing a bathing suit at
crystals as calcium oxalate in all four cases of suspected ethylene glycol the time of the accident. A wetsuit may have provided more protection.
toxicity. The confirmation of the calcium oxalate crystals in the kidneys While occasional case reports of similar, non-fatal injuries from jet
in the case with negative blood ethylene glycol and oxalic acid was ski accidents have been documented in the surgical literature, such a case
helpful. In this case, the inability of investigation to establish clear social has never been reported in the forensic literature to our knowledge. In
and medical history or the source of the oxalosis left the possibility of the surgical cases reported, patients who sustained vaginal and/or rectal
primary or secondary hyperoxaluria or an exogenous ingestion. lacerations underwent successful repair with recovery of
Therefore, the manner was best certified as Undetermined. normal function.
This case series demonstrates the utility of Raman imaging to Anorectal, Trauma, Jet Ski
confirm the presence of calcium oxalate crystals in the kidneys. The
correlation of these crystals to ethylene glycol intoxication requires
complete toxicologic analysis and thorough investigation. Raman G25 Sudden Unexpected Infant Death:
imaging could have many broad applications in the forensic pathology
community and to the forensic community in general in the identification
Peripheral Retinal Hemorrhages Associated
of unknown substances in tissues of all types. With Accidental Positional
Raman Imaging, Ethylene Glycol, Calcium Oxalate Asphyxiation (Wedging)
Stephen Lenfest, MD*, Wake Forest University Baptist Medical Center
G24 Death From Severe Anorectal Injury of a Department of Pathology, Medical Center Boulevard, Winston Salem,
Jet Ski Passenger NC 27157; Candace H. Schoppe, MD, Wake Forest University School of
Medicine, Department of Pathology, Medical Center Boulevard, Winston
Dennis Rhee, MD*, and Lynn A. Salzberger, MD, Southwest Institute of Salem, NC 27157; Constance A. Stanton, MD, Department of Pathology,
Forensic Sciences, 5230 Southwestern Medical Avenue, Dallas, TX 75235 Wake Forest University Health Sciences, Medical Center Boulevard,
Winston Salem, NC 27157; Donald R. Jason, JD, Wake Forest University
After attending the presentation, attendees will understand the basic School of Medicine, Medical Center Boulevard, Winston-Salem, NC
principles of jet ski propulsion and the potential for hydrostatic injury to 27157-1072; and Patrick E. Lantz, MD, Wake Forest University Health
the perineum. Sciences, Department of Pathology, Medical Center Boulevard, Winston-
This presentation will impact the forensic science community by Salem, NC 27157-1072
bringing awareness to an unusual mechanism of injury in jet ski
accidents. Such knowledge would prevent initial confusion and After attending this presentation, attendees will learn that peripheral
unnecessary use of resources to investigate other causes. In addition, it retinal hemorrhages extending to the ora serrata are not specific for
would serve to promote better safety practices in the use of jet skis. abusive head trauma (shaken baby syndrome) and can be associated with
This presentation will highlight the unusual case of a young woman accidental positional asphyxia (wedging).
who sustained lethal anorectal trauma after falling from the back of a This presentation will impact the forensic science community by
jet ski. emphasizing the importance of routine retinal examinations (postmortem
It is recognized that both the popularity of personal watercraft and monocular indirect ophthalmoscopy) in infants dying suddenly and
injuries related to their use have been increasing. Non-lethal lacerations, unexpectedly.
contusions, sprains, and fractures make up the majority of these injuries. This presentation will inform attendees of something they do not
Rare, but more serious injuries include closed head injury and intra- know–multiple retinal hemorrhages, involving the peripheral retina and
abdominal injury involving high velocity and rapid deceleration. The extending to the ora serrata in infants, are not specific for abusive head
latter types of injury are typically those which result in fatality involving trauma (shaken baby syndrome).
personal watercraft. Current data (1999 -2007) from the Centers for Disease Control
In the case presented, the autopsy showed a midline laceration lists accidental suffocation as the leading cause of unintentional death in
posterior to the vaginal introitus which passed through the anus. The infants. Of those deaths 65.7% were due to accidental asphyxiation in
laceration extended to involve the deep soft tissues and the distal rectum bed (all mechanisms). Accidental positional asphyxia from wedging
was seen to be transected and free in the pelvic cavity. The full extent of often occurs when an infant becomes entrapped between the mattress
her injury became apparent when the laceration was seen to extend and wall, headboard, or bed frame of an adult bed. Despite the number
within the retroperitoneal space to a level above the kidneys. of unintentional wedging deaths in infants, to find published reports of
Given the extensive injury, initial suspicion surrounded possible retinal hemorrhages (RHs) associated with accidental positional
impalement by a solid object. Witnesses at the scene as well the operator asphyxia (wedging) were not found. A number of authors have asserted
of the jet ski reported that the decedent fell straight back into that multiple retinal hemorrhages (RHs) involving the peripheral retina
unobstructed water. A subsequent review of the accident site revealed no and extending to the ora serrata occur only in abusive head trauma
(AHT) or rarely with severe head injuries from motor vehicular
collisions or crush head injuries. This reports two infants who died G26 Antiepileptic Drug Intoxication: Report
suddenly and unexpectedly from wedging who had multiple RHs
including peripheral RHs extending to the ora serrata.
of One Case and a Forensic
Case 1: A father had been sleeping in an adult bed with his Pathologist’s Approach
previously healthy 4-month-old infant son while the mother slept in
another room with one of the infant’s two older siblings. During the Ana R. Pereira, MD*, Ladeira das Alpenduradas nº13A, Coimbra, 3030-
night the father heard the 3-year-old sibling wake up; he got up to check 167, PORTUGAL; Paula C. Oliveira, MD*, Konara Gunathilake, MD,
on her, but fell asleep her room. At 8:00 a.m., the mother found the Bruno M. Santos, MSc, Paula Proenca, PharmD, and Miguel Franco,
infant unresponsive, wedged head down between the mattress and MSc, Largo da Sé Nova, Coimbra, 3000-213, PORTUGAL; Maria C.
headboard of the bed. Paramedics pronounced him dead at the scene. At Mendonca, PhD, Instituto Nacional de Medicina Legal, Largo Sé Nova,
autopsy, he had parallel lines on his forehead corresponding to the Coimbra, 3000, PORTUGAL; and Duarte N.P. Vieira, PhD, Rua Antonio
mattress edging and ticking. Postmortem monocular indirect Jose de Almeida, No 117, Coimbra, 3000-044, PORTUGAL
ophthalmoscopy (PMIO) revealed multiple RHs in the right fundus
mainly over the equatorial region and two RHs in the left fundus at the After attending this presentation, attendees, will learn a better
mid-periphery. Microscopically, the right-sided RHs extended to the ora forensic approach in investigating fatal cases where there is suspicion of
serrata and primarily involved the nerve fiber layer with focal antiepileptic drug misusage.
involvement of the inner and outer nuclear layers. The left eye had one This presentation will impact the forensic science community by
tiny retinal hemorrhage in the inner nuclear layer. No optic nerve sheath showing a fatal case of intoxication with valproic acid. In addition,
hemorrhages were identified grossly or microscopically. The dura mater further discussion is made in order to clarify and systematize forensic
had remote subdural membranes over the right and left frontal and left approaches (crime scene investigation and autopsy procedure) in cases
parietal regions. The brain had no ischemic or traumatic lesions. His involving suspicion of antiepileptic drug misusage, fatal consequences of
postmortem radiographic skeletal survey revealed no acute or healing antiepileptic drug, particularly valproic acid, including its direct toxic
fractures. effects, adverse reactions and interactions with others drugs, possible
Case 2: A previously healthy 6-month-old infant was sleeping in mechanisms, causes and manners of death in these type of cases, and
bed with her mother and was last seen alive at 2:00 a.m. Her mother promotion of prevention measures with physicians to avoid fatal cases in
found her wedged between the mattress and wall, face down on a stuffed patients taking antiepileptic drugs.
animal, at about 6:00 a.m. She immediately drove her to the local Valproic acid is formally an antiepileptic drug but currently it has
emergency department where resuscitative efforts were unsuccessful. wider clinical uses, including treatment of some psychiatric disorders,
The infant was born at term by cesarean section without complication. such as bipolar and affective disorders. Since prescription of valproic
At autopsy no scalp or subgaleal hemorrhages, skull fractures, cerebral acid has been growing, it is becoming an increasingly common agent to
edema, or epidural, subdural or subarachnoid hemorrhages were present. be used in intentional overdoses. Although considered a relatively safe
PMIO revealed bilateral RHs. Ocular examination disclosed 30-50 drug, it is known to cause hepatotoxicity and pancreatitis, amongst other
flame-shaped and dot hemorrhages circumferentially located from the adverse reactions. In patients co-ingesting other medications,
mid equator to the ora serrata on the right side. The left eye displayed specifically, those acting as CNS depressants, side effects and toxicity
two posterior RHs measuring approximately ¼ disc diameter in size, can become more dangerous and even fatal for the patient.
located inferior and nasal to the fovea at the 3:00 position and 1 disc This study presents a 45-year-old blind female, who was found dead
diameter from the optic nerve head at the 5:00 position, respectively. In by her husband inside their house. The forensic pathologist called to the
addition, from the mid equator to the ora serrata were 40-60 pinpoint to scene, found five empty blisters-packs of valproic acid. Previous
flame-shaped or dot hemorrhages extending to, and focally abutting, the pathologic history included epilepsy, bipolar disorder, and chronic
ora serrata in all 4 quadrants. No optic nerve sheath hemorrhages were alcohol abuse with prior suicide threats. At autopsy, external and internal
observed grossly or microscopically. Intradural extravasated blood examination didn’t reveal significant traumatic lesions. The organs
involved the falx cerebri and the right calvarial dura. The brain had age- showed generalized congestion, the liver was significantly enlarged, the
appropriate development with no ischemic or traumatic lesions. Her pancreas showed no macroscopic abnormalities and a whitish substance
postmortem radiographic skeletal survey revealed no acute or healing was present in the stomach.
fractures. Histological ancillary investigation confirmed congestion in the
These two cases with reliable histories of positional asphyxia lungs and kidneys, and also, mild hepatic steatosis. Toxicological results
demonstrate the importance of routine postmortem ocular examination revealed high concentrations of valproic acid (556.0 µg/mL); therapeutic
of infants to better appreciate the spectrum of RHs seen in this age group. concentrations of other psychiatric drugs (tiapride, mirtazapine,
Multiple retinal hemorrhages in an infant, involving the peripheral retina nordiazepam, and oxazepam) and blood ethyl alcohol concentration of
and extending to the ora serrata, are not specific for AHT. 1.34 g/L.
Sudden Unexpected Infant Death, Retinal Hemorrhages, Accidental After excluding death due to natural or traumatic causes, a direct
Positional Asphyxia (Wedging) toxic effect by valproic acid was considered. Taking into account the
autopsy, histopathology and toxicological findings, along with the
circumstantial evidence, the cause of death was attributed to suicide by
intoxication with valproic acid in association with other CNS
depressants.
In conclusion, this case illustrates that is crucial for forensic
pathologists to: (1) participate or have detailed information from the
crime scene, prior to autopsy; (2) know the deceased´ complete medical
history and prescribed medication; (3) do a careful postmortem
examination to exclude natural and traumatic causes of death; (4) study
target organs of valproic acid action by macroscopic and microscopic
approach; and, (5) do toxicological studies and exclude other causes of
death.
When prescribing multiple CNS depressant drugs to patients with
alcohol abuse and suicidal ideation, physicians should always be
particularly aware of the risk of valproic acid toxicity, interactions with diameters. The largest of these measured approximately three disc
other drugs and possible adverse reactions, besides the potential diameters and was nearly confluent between the fovea and the superior
accidental or intentional intoxication. temporal vascular arcade. No hemorrhages were evident past the equator
Forensic Pathology, Antiepileptic Drug Intoxication, Valproic Acid on the right. On the left, the fundus had 10-15 flame-shaped RHs in all
four quadrants, located mainly posteriorly, measuring approximately ¼
disc diameter in size. Two faint RHs at the 7:00 and 8:00 positions were
G27 Are Peripapillary Intrascleral Hemorrhages flame-shaped and located 3-4 disc diameters from the ora serrata.
Papilledema was not evident on either side. She had been delivered by
Pathognomonic for Abusive Head Trauma? cesarean section at 38-weeks estimated gestation age.
Both neonates had been delivered by emergency cesarean section
Candace H. Schoppe, MD*, Wake Forest University Baptist Medical following the involvement of their respective mothers in motor vehicle
Center, Department of Pathology, Medical Center Boulevard, Winston collisions. Both had Apgar scores of 0 at 1, 5, and 10 minutes and
Salem, NC 27157; Constance A. Stanton, MD, Department of Pathology, required prolonged resuscitation lasting 20 minutes and 14 minutes,
Wake Forest University Health Sciences, Medical Center Boulevard, respectively, before a heart rate was established. In the first case, the
Winston Salem, NC 27157; and Patrick E. Lantz, MD, Wake Forest mother, a passenger in the vehicle, was ejected in a single vehicle
University of Health Science, Department of Pathology, Medical Center rollover accident. She suffered only minor injuries. In the second case,
Boulevard, Winston-Salem, NC 27157-1072 the mother was the restrained driver of a van that crossed over the
midline and hit an oncoming car. Extraction was prolonged and the
After attending this presentation, attendees will learn that mother suffered multiple pelvic fractures but no other serious injuries. In
peripapillary intrascleral hemorrhages are not diagnostically specific for both cases the babies’ heads were engaged in the pelvis at the time of the
abusive head trauma (shaken baby syndrome). accidents. No uterine or placental injuries were found in either case and
The presentation will impact the forensic science community by the mothers were not in labor at the time of the accidents. Neither
stressing the necessity for consistent postmortem ocular examinations of neonate had a documented clinical fundal examination while
infants and young children to identify all conditions associated with hospitalized in the intensive care unit.
certain ocular findings such as peripapillary intrascleral hemorrhages. In-utero skull fractures with severe brain injury are uncommon but
This presentation will inform attendees of something they do not well documented. It is believed, RHs with peripapillary intrascleral
know–that peripapillary intrascleral hemorrhages are not diagnostically hemorrhages have not been previously reported in neonates sustaining
specific for abusive head trauma (shaken baby syndrome) and exemplify in-utero skull fractures and traumatic brain injuries. These cases
the need for unbiased consistent ocular examinations, both clinically and demonstrate that peripapillary intrascleral hemorrhages are not
at autopsy. diagnostically specific for abusive head trauma and exemplify the need
The American Academy of Pediatrics’ Committee on Child Abuse for consistent, unbiased ocular examinations, both clinically and
and Neglect, Section on Ophthalmology, has acknowledged that at autopsy.
searching for retinal hemorrhages (RHs) only in infants suspected of Peripapillary Intrascleral Hemorrhages, Accident, Intrauterine
abuse creates a selection bias. However, they have also stated that Traumatic Brain Injury
postmortem eye removal might not be indicated “in children who have
clearly died from witnessed severe accidental head trauma or otherwise
readily diagnosed systemic medical conditions.” Although infrequently
described in the child abuse literature, peripapillary intrascleral
G28 The Correlation of Serum Stress Hormone
hemorrhages have been considered “probably pathognomonic” for Levels With Cause and Circumstance of Death
abusive head trauma (shaken baby syndrome) due to severe repetitive
acceleration-deceleration forces with or without blunt head trauma. Robert C. Shaler, PhD*, 30 Spring Street, Flemington, NJ 08822;
Case 1: A 2-day-old male neonate had significant blunt force head Dominic Flaim, PMFS, Pennsylvania State University, 107 Whitmore
trauma including bilateral subgaleal hemorrhages, right subscalpular Lab, State College, PA 16802; and Thomas Andrew, MD, Office of the
hemorrhage, bilateral parietal skull fractures, diastatic separation of the State Chief Medical Examiner, 246 Pleasant Street, Concord, NH 03301
sutures, subdural and subarachnoid hemorrhages, cerebral edema, and
hypoxic ischemic brain injury. Indirect ophthalmoscopy revealed 30-50 The goal of this presentation is to alert forensic professionals that
flame-shaped and dot RHs involving all four quadrants of the left globe, biological markers have the potential to provide significant information
extending anteriorly from the posterior pole past the equator to the ora concerning the psychological state and stress levels of someone just
serrata. Peripapillary intrascleral hemorrhages were in the left eye in before death.
addition to bilateral optic nerve sheath hemorrhages and bilateral This presentation will impact the forensic science community by
periorbital soft tissue hemorrhage. The right globe had an artifactual providing medical examiners and the courts a mechanism to understand
papillomacular fold but no RHs. Neither eye exhibited papilledema. the degree of stress someone was going through immediately prior to
Hemothoraces and bilateral rib fractures were present. He had been death.
delivered by cesarean section at 36-weeks estimated gestational age. Interleukin 6 (IL-6) is a major regulator of immune function, and
Case 2: A 3-day-old female neonate had severe blunt force head has been shown to increase due to both physical and psychological
trauma. She had a small contusion on the right side of her forehead plus stress. Knowledge of whether or not an individual was under
faint abrasions and ecchymoses overlying the right mastoid process. She psychological stress prior to death may be important in many cases. In
had bilateral subgaleal hemorrhages, bilateral parietal skull fractures, this study, levels of IL-6 and its soluble receptor (sIL6-r) with an
and a diastatic fracture of the left lambdoid suture. Subdural and assumed level of psychological stress prior to death was correlated.
subarachnoid hemorrhages, cerebral cortical contusions, cerebral edema Postmortem serum samples were obtained from the New Hampshire
and diffuse hypoxic-ischemic brain injury were identified. Indirect Medical Examiner’s Office and analyzed using ELISA to determine
ophthalmoscopy revealed multiple bilateral RHs. Subsequent concentration of both sIL-6r and IL-6. The raw data for the soluble
examination of the orbital structures demonstrated bilateral preretinal, receptor could be placed into four groups. However, these groupings
intraretinal, and subretinal hemorrhages, optic nerve sheath were inconsistent with stress levels based on a study of the case histories
hemorrhages, peripapillary intrascleral hemorrhages and perineural of the decedents. The data for IL-6 however correlated well with the
extravasated blood. The right fundus had 15-20 flame-shaped RHs level of psychological and emotional stress an individual was under prior
radiating from the optic nerve head for a distance of two to four disc to death. This study shows that measurement of postmortem serum IL-
6 can be a potentially useful technique for determination of G30 DNA Extraction From Paraffin Blocks:
psychological and emotional stress prior to death.
Stress Hormones, Interleukin 6, Circumstance of Death
Organ Selection and Pre-Embedding
Fixation Times – Practical Implications for
Forensic Pathologists
G29 Stippling Mimics — Differentiating
Pseudostippling From Stippling: A Report Alex John, MD*, Harris County Institute of Forensic Sciences, 1885 Old
Spanish trail, Houston, TX 77054; Dwayne A. Wolf, PhD, Harris County
of Four Cases Medical Examiner’s Office, JAJ Forensic Center, 1885 Old Spanish Trail,
Houston, TX 77054; Jennifer Petrash, MS, Shahida Flores, BS, Dustin
Jeffery G. Gofton, MD*, and Wendy M. Gunther, MD*, Office of the Foley, MS, Lisa Gefrides, MS, and Roger Kahn, PhD, Harris County
Chief Medical Examiner, Tidewater District, 830 Southampton Avenue, Institute of Forensic Sciences, 1885 Old Spanish Trail, Houston, TX
After attending this presentation, attendees will gain an
After attending this presentation, attendees will be able to recognize understanding of which organs or tissues are optimal for paraffin
factors from scene investigation, history, autopsy, and histology which archival for the purposes of subsequent DNA extraction; attendees will
may help in reliably differentiating stippling from stippling mimics, and recognize the importance of the length of formalin fixation prior to
understand the role of history and investigation as well as direct paraffin embedding.
observation in differentiating stippling from stippling mimics. This presentation will impact the forensic science community by
This presentation will impact the forensic science community by helping attendees to be able to direct histologic sampling to one or two
assisting forensic pathologists in recognizing patterned injuries which tissue types (in decomposed and non-decomposed bodies) for the
may mimic stippling, and in utilizing history and scene investigation purposes of DNA sampling. Attendees will understand the critical time
integrated with observation to draw valid conclusions about the origin of parameter for pre-embedding formalin fixation.
apparent stippling. Synopsis: In recent years re-examination of old death investigation
A valid outcome results from valid input. A forensic pathologist cases in the form of prosecutorial post-conviction review, defense review
who relies only on observation, whether gross or microscopic, may draw (prompted by the Innocence Project and others), law enforcement cold
invalid conclusions from what appear to be readily classifiable patterns case initiatives (often with federal grant support), and ancestry inquiries
of injury. Integrating history and scene findings into the decision- is increasingly frequent. These reviews are aided and sometimes
making process may allow the pathologist to come to reliable and valid initiated by the existence of advanced DNA technology that may not
conclusions about the source of a patterned injury that appears to be have existed until after conclusion of the original investigation.
stippling. Therefore the ability to obtain usable DNA evidence from items stored
A 20-year-old man died in a parking lot from a gunshot wound to for extended periods is increasingly important. While standard forensic
the face, less than three weeks after sustaining nonfatal gunshot wound practices vary with regard to storage times for various pathology
injury. Initial observation of the fatal gunshot wound, which entered the specimens (formalin fixed wet tissues in particular), forensic centers and
cranium through the tip of the nose, suggested a band or outline of hospital pathology services often retain paraffin embedded tissue blocks
stippling above the eyebrow, consistent with wearing a pair of glasses or indefinitely; current National Association of Medical Examiners
sunglasses at the time he was shot. Multiple witnesses reported that the (NAME) accreditation guidelines require a retention time of at least 10
decedent was shot by an assailant from a car across the parking lot, far years. Consequently, paraffin blocks are an available resource for stored
outside any possible stippling range. Scene re-investigation showed that DNA evidence. However, forensic pathology practice varies regarding
the marks of pseudostippling matched the gravel in the parking lot. number of organs sampled for paraffin preservation, and even whether or
There were no glasses. not sections are taken in all types of cases; NAME accreditation
A 25-year-old male front-seat passenger in a vehicle, along with the guidelines allow discretion as to types of cases in which slides are
driver was fatally shot by police during a chaotic incident that resulted produced but do recommend a one-year retention of paraffin embedded
from a confrontation following a police chase. The driver’s body tissues when slides are not produced. To address the question of which
showed typical distant gunshot wounds, but the passenger, who was shot tissue would be optimal for DNA recovery using modern methods, these
twice, had one distant gunshot wound, and one gunshot wound of the experiments were designed to determine whether decomposition changes
face surrounded by a dense 3” x 3” oval of apparent stippling. History that answer, and whether the length of pre-embedding fixation is a
and scene investigation suggested glass fragmentation injury from a critical variable.
bullet which passed through the passenger’s window prior to striking Tissue obtained at autopsy was divided into three groups based on
him. A similar finding was noted in a homicide a year later when the formalin fixation times of 1, 5, and 12 days prior to dehydration and
driver of another vehicle was found dead in the front seat. paraffin embedding. Sections of each organ were deparaffinized with
A 22-year-old woman was shot by her ex-boyfriend in a homicide- heat and DNA was purified from the residual tissue via organic
suicide event. The shooting was partially witnessed. The boyfriend shot extraction. Subsequent purification was accomplished by one of several
the victim from a balcony of an outside staircase on which he stood two different methods. Extracted DNA was quantified then amplified using
stories above her. He died immediately afterwards in the same location a PCR amplification kit and separated by 3130xl capillary
from a characteristic gunshot wound to the right temple. The decedent electrophoresis. The electropherograms were analyzed for DNA
appeared to have stippling to the left axilla, and wounds suggestive of profiles.
blunt to sharp force trauma across the neck, torso, and thigh. Extensive Tissues compared were heart muscle, skeletal muscle (psoas), liver,
scene investigation was performed and co-ordinated with the autopsy spleen, and brain. Cases included both non-decomposed and
findings to explain the apparent discrepancy between the locations of the decomposed bodies. Preliminary results for quantitiative DNA recovery
shooter and the victim, and the victim’s wounds. indicate that spleen is superior to liver, heart or skeletal muscle. A
These case reports are utilized, along with examples of true striking loss of recoverable DNA is observed between pre-embedding
stippling for comparison, to demonstrate the dangers of invalid fixation times of 5 to 12 days. The loss of DNA with increasing fixation
conclusions about patterned injuries when only observation is times is maximum in spleen and skeletal muscle followed by liver and
relied upon. heart, but the differences between organs are small. Studies are ongoing,
Stippling, Pseudostippling, Glass Fragmentation Patterns but preliminary data suggest that although quantitative DNA recovery is
greatest from spleen, the degree of degradation may also be greatest with the light to underline the potential value of BM analysis for forensic
spleen. Studies comparing brain to the other tissue types and the effects purposes.
of decomposition are ongoing. Assuming that by using sternum evaluation, the limit of poor
Impact: This project was undertaken to better define which tissue samples possibly obtained by iliac aspiration, especially in postmortem
types are the best for extraction of DNA from paraffin blocks using work-up, might be avoided. Moreover, cytomorphological evaluation on
modern DNA technology. With this knowledge forensic pathologists sternum smears might offer more elements than those obtained by just
will be able to selectively sample organs in order to efficiently preserve histopatological examination, because of the less frequent postmortem
DNA evidence while minimizing the expense of embedding multiple alterations frequently described in bone marrow biopsy. In fact, BM is
tissues and organs from all cases. surrounded by solid cortical bone, which results in mechanical stability,
DNA Extraction, Paraffin, Formalin Fixation Time this makes it more secure than other organs, e.g., against postmortem
changes. Finally, sampling from sternum can easily be performed in
larger amounts, easily accessible in routine autopsies, without changing
G31 The Potential Value of Bone Marrow the structure of the corpse in a relevant way.
The goal of this preliminary study is to demonstrate the presence of
Analysis for Forensic Purposes: Evaluation bone marrow postmortem activated cells in various causes of death as
of Needle Aspiration and Biopsy Taken well as to analyze, for the first time in the literature, the sternum as the
From the Sternum most important site for studying cells of such lymphoid organ
in cadavers.
Biagio Solarino, PhD*, Lucia Tattoli, PhD, Eloisa Maselli, MD, and Bone Marrow, Postmortem, Immunology
Maria C. Romanelli, MD, Section of Legal Medicine, University of Bari,
Piazza Giulio Cesare, 11, Bari, 70122, ITALY; Michael Tsokos, PhD,
Institute of Legal Medicine and Forensic Sciences, University of Berlin, G32 2009 H1N1 Fatalities: The New
Turmstr. 21, Building L, 10559, Berlin, 10559, GERMANY; Alessandro Mexico Experience
Dell Erba, PhD, Section of Legal Medicine, University of Bari, Piazza
Giulio Cesare, 11, Bari, 70122, ITALY; and Mario Delia, PhD,
Hematology Section, University of Bari, Piazza Giulio Cesare, 11, Bari, Erin G. Brooks, MD*, Office of the Medical Investigator, MSC11 6030,
70122, ITALY 1 University of New Mexico, Albuquerque, NM 87131; Clare H. Cunliffe,
MD, Office of Medical Investigator, 700 Camino de Salud Northeast,
After attending this presentation, attendees will understand the Albuquerque, NM 87106; Catherine Avery, Chad Smelser, MD, and
potential contributions of postmortem investigations of bone marrow Deborah Thompson, MD, New Mexico Department of Health, 1190
(BM) taken from sternum in order to validate the diagnosis of some type South Saint Francis Drive, Santa Fe, NM 87502; and Kurt B. Nolte, MD,
of death. Office of Medical Investigator, MSC11 6030, 1 University of New
This presentation will impact the forensic science community by Mexico, Albuquerque, NM 87131-0001
emphasizing the potential contributions of postmortem BM evaluation
that should become a routine procedure, especially if the forensic After attending this presentation, attendees will be able to describe
pathologist can not detect real cause of death during autopsy. the clinical and epidemiologic features associated with H1N1 fatalities,
The importance of studying the bone marrow in clinical practice is recognize the spectrum of histologic features that can be seen in H1N1
well known and techniques such as marrow needle biopsies, smears from fatalities gain a familiarity with laboratory diagnostic options in cases of
aspirate, and imprint preparations, allow the diagnosis of several blood suspected H1N1, and recognize the importance of the autopsy in tracking
disorders. On the other hand, many studies have explored the the epidemiology of infectious disease.
involvement of bone marrow also in systemic illnesses, including This presentation will impact the forensic science community by
metastatic involvement with tumors, granulamatous diseases, AIDS, in raising awareness of which subgroups have greater H1N1 influenza
staging of carcinomas, and for the follow-up evaluation of patients mortality risk, and therefore may benefit from early antiviral treatment.
undergoing chemotherapy or transplantation. Other studies have It will also illustrate that H1N1 fatalities with a relatively rapid disease
strongly suggested that inflammatory cells originating from the BM course may have far subtler respiratory histologic findings than those of
contribute to sustain pathophysiological processes, e.g., allergy, sepsis, previously published studies.
healing wounds. For example, in allergies, progenitor cells migrate to Hypothesis: New Mexico is an ethnically and racially diverse state
the site of allergic inflammation via blood, where they differentiate into with a large Native American population, among others. It is
tissue-dwelling and classic effector cells, such as mast cells and hypothesized that this population heterogeneity may predict a similar
eosinophils. These modifications are probably secondary to the diversity of clinical and pathologic findings in 2009 New Mexico H1N1
production of various cytokines which either block or stimulate the fatalities.
proliferation of hematopoietic stem cells (growth factors) and their Methods: A retrospective review of hospital, laboratory, field
differentiation. investigative, and autopsy reports of all H1N1 positive influenza
A number of studies has been published in recent years about the fatalities reported to the New Mexico Department of Health in 2009 was
use of BM specimens taken from iliac crest and rib as alternative tissue performed. In those cases in which autopsies were performed, all
in forensic toxicology, concerning the detection of postmortem alcohol available microscopic slide sections were independently reviewed by a
and drug content. Nevertheless, there is a lack of studies regarding an study pathologist. All respiratory sections were additionally reviewed by
alternative role of the sternum aspiration and needle biopsy which can a study pathologist with pulmonary pathology expertise.
help to understand pathophysiological changes in response to stress, Results: There were 52 H1N1 deaths reported to the New Mexico
infection, or other external stimuli. Department of Health in 2009: of these, 14 were autopsied. In two
A study based on BM samples (needle aspiration and biopsy) taken autopsied cases, H1N1 infection was determined to not be the cause of
from the sternum which were obtained from 70 autopsy cases performed death. These cases were excluded from further study. In 3 out of 12
in the Section of Legal Medicine, Bari University, from subjects died due autopsied cases, the diagnosis of H1N1 influenza was made via
several causes (cardiovascular diseases, craniocerebral trauma, sepsis, antemortem studies, while in 9 out of 12 cases it was made at autopsy via
etc) will be presented. The histopathological results will be discussed in reverse-transcriptase PCR on nasopharyngeal specimens +/- viral
nasopharyngeal/lung cultures. The most common respiratory histologic of the body. Six pairs of thoracic, biramous cirri bordered with chaetae
findings were alveolar edema (75%), interstitial inflammation (100%), are visible through an aperture present in the mantle cavity. In the mantle
bronchitis/bronchiolitis (83.3%), tracheitis (87.5%), and cavity, there is a short head, a thorax with six thoracic, biramous limbs,
bronchopneumonia (66.7%). Of the total autopsied and non-autopsied a mouth, and a long, setose penis. The length of pedunculated barnacles
fatalities, race/ethnicity was 42% Hispanic, 36% Caucasian, and 22% ranged between 0.7 and 2 cm.
Native American. Ages ranged from 2 months – 89 years, with peaks in These barnacles belong to the family of Lepadidae, genus Lepas,
the 40 (18%) and 50 (26%) year decades. species Lepas anatifera, order peduncolate barnacles.
Conclusions: This study highlights the importance of the autopsy The Lepas anatifera live in tropical and subtropical waters, and
in tracking the epidemiology of infectious disease: in 9/12 (75%) cases, after attachment to the substrate is increased by an average of 1mm/die
H1N1 influenza was not known to be the cause of death until after in seabed with temperatures between 15°C and 30°C. The growth of the
autopsy. Most other studies of H1N1 pulmonary histopathology report barnacle is blocked at temperatures below 15°C or above 30°C.
diffuse alveolar damage (DAD) in the majority of autopsied fatalities Therefore stratification found on the surface of long bones of the
(74%-100%). In this series, only 2 out of 12 (16.7%) cases manifested lower limbs of Lepas anatifera, require at least 20-30 days at water
DAD. Also, the majority had a relatively rapid disease course: time from temperatures between 15 º C to 30º C for achieving the maximum size
onset of symptoms to death in autopsied cases ranged from 1-12 d (avg observed in this case (2 cm).
3.5 d) vs. the other largest published series’ range of 2-44 d (median 7 d). The average temperature estimated in the Ionian Sea in February
These findings may indicate that New Mexico H1N1 influenza fatalities 2009 was 10.7°C, so it can be assumed that seawater temperature along
generally did not survive long enough to develop the more classic the Ionian coast drops below 15 degrees for November-March. Hence,
pulmonary manifestations. Native Americans comprised 2 out of 12 in November 2008 the corpse was already skeletonized and already
(16.7%) of autopsied fatalities and 9out of 38 (23.7%) of non-autopsied converted into adipocere since the colonization of barnacles was already
fatalities. As the overall New Mexico population is only 9.6% Native present on skeletonized limbs. This data suggested the amount of time
American, Native Americans are disproportionately represented among the body was in standing water was at least six months/one year prior to
the 2009 NM H1N1 fatalities. attachment barnacles (October 2008) and, as a consequence, the range of
H1N1, Influenza, Autopsy immersion was identified in a period between October and November
2007 and March/April 2008.
The use of aquatic invertebrate in this case suggests a new avenue
G33 The Potential Use of Aquatic Invertebrate of basic research that forensic investigators can apply to cases involving
submersed and/or floating human remains. In fact, the study of biology
for Postmortem Submersion Interval of aquatic invertebrates along with a timeframe of decomposition in the
(PMSI) Determination aquatic environments, can provide important clues on the length of soak
time, however influenced by a high number of variables can potentially
Simona Corrado, MD*, Sezione di Medicina Legale, Bari, 70100, influence this process (e.g., temperature, water depth, currents, tides,
ITALY; Lucio Rositani, PhD, Laboratory of Marine Biology, Molo season, dissolved oxygen, debris, substrate type, salinity, acidity,
Pizzoli, Bari, 70100, ITALY; Maurizio Scarpa, MD, Piazza G. Cesare 11 interactions between chemical and physical processes, and micro and
Università di Bari, Bari, 70100, ITALY; and Francesco Introna, PhD, macrofauna activity).
Section of legal Medicine - DiMIMP, Piazza Giulio Cesare n.11, Bari, Adipocere, Marine Biology, Barnacle
70124, ITALY
After attending this presentation, attendees will understand that in G34 Epidemic Outbreak of Meningococcal
cases in which a human body is found in aquatic environments, careful
aquatic scenes investigation, review of medical records, complete
Meningitis in a Nursery: Two Fatal Cases of
autopsy with skeletal survey, marine biology, and taphonomy testing are Waterhouse-Friderichsen Syndrome
required.
This presentation will impact the forensic science community by Alessandro Bonsignore, MD*, Francesca Fossati, MD, Federica
emphasizing the fact that although estimating postmortem interval in Portunato, MD, Francesco Ventura, PhD, and Francesco De Stefano,
terrestrial environments are standardized and widely accepted in courts MD, Department of Legal and Forensic Medicine, University of Genova,
of law, estimating immersion interval in aquatic environments are largely Via de Toni 12, Genova, 16132, ITALY
unexplored. The Postmortem Submersion Interval (PMSI) in aqueous
environments refers to the time period from when the body enters the The goal of this presentation is to focus on two fatal cases of
water to the point of discovery, noting that the body may be totally undiagnosed meningitis occurring simultaneously in two children from
submerged for all or part of the time period. Understanding the growth the same nursery. A forensic approach by means of autopsy, microscopic
phases of aquatic plants and animals that attach themselves to submerged examination, and microbiological studies led to the conclusion that the
remains is particularly valuable information and can be used to estimate cause of death in both infants was septic shock due to meningococcal
a minimum PMSI. meningitis in association with hemorrhagic adrenalitis.
A case of an adult human body discovered on an Ionian coast (South This presentation will impact the forensic science community by
Italy) in February 2009, whose soft parts were converted into adipocere demonstrating how important a thorough forensic investigation is to
with partial skeletonization and disarticulation and showed the presence reach the correct postmortem diagnosis, as well as, by showing how
of barnacle stratification on bone surfaces is presented. rapidly children can develop a fatal meningococcal infection as well as
Barnacles specimens collected from bone surface consisted of a explaining the importance of an early clinical diagnosis in order to avoid
body divided into two regions: (1) the peduncle (stalk); and, (2) the unexpected death and epidemic outbreaks.
capitulum. The peduncle is fleshy, large, and long, and it attaches to the Waterhouse-Friderichsen syndrome (WFS), first described in the
substrate using the first antennae. The body is compressed laterally, early 1900s in England and Denmark, is the most severe form of
covered by two folds of mantle, where five thin calcareous plates are meningococcal septicemia. The infection leads to massive hemorrhage
attached. The carina is a dorsal unpaired plate, which forms a central in one or usually both adrenal glands. It is most commonly caused by
keel. Paired scuta are large, and are located at the anterior region of the Neisseria meningitidis (NM) but many other species of bacteria and also
body. Paired terga are short and are located at the posterior-most region viruses are associated with WFS.
The onset of a meningococcal infection is non-specific with G35 Postmortem Animal Injuries: A Forensic
symptoms of fever, rigor, vomiting, and headache. Soon a rash appears;
first macular, then rapidly becoming petechial and purpuric. In most
Pathologist’s Perspective
cases the resulting hypotension rapidly leads to septic shock. In WFS,
meningitis generally does not occur but if present, many clinical signs Ana R. Pereira, MD*, Ladeira das Alpenduradas nº13A, Coimbra, 3030-
can be found such as hypoglycemia with hyponatriaemia and 167, PORTUGAL; Bruno M. Santos, MSc, Largo da Sé Nova, Coimbra,
hyperkalemia, thrombocytopenia and typical markers of diffuse 3000-213, PORTUGAL; Carmen Barbu, MD, Instituto de Medicina
intravascular coagulation. Legal de Sf. Gheorghe, Romania, Bucharest, ROMANIA; Pedro A.
Only microbiological studies can lead to the final diagnosis through Rezende, MSc, Jardim Carrilho Videira, Porto, PORTUGAL; Paula C.
culturing of blood or cerebrospinal fluid (CSF). Oliveira, MD*, Largo da Sé Nova, Coimbra, 3000-213, PORTUGAL;
Fulminate meningococcemia is a medical emergency and needs to Jorge C. Santos, PhD, South Branch National Institute of Legal
be treated with adequate antibiotics as fast as possible, also in order to Medicine, R. Manuel Bento de Sousa, nº 3, 1150-219 Lisboa, Lisboa,
prevent an epidemic outbreak. The administration of corticosteroids can PORTUGAL; and Duarte N.P. Vieira, PhD, Rua Antonio Jose de
sometimes reverse the adrenal shock. Almeida, No 117, Coimbra, 3000-044, PORTUGAL
Case 1: A 21-month-old child, previously in good health,
developed high fever (40°C) on a Sunday morning. Paracetamol was After attending this presentation, attendees, will become aware of
administered twice during the day but both times with a low response. how traumatic injuries, especially those arising after suspicion of assault,
Few hours after the onset of the fever, the child began to vomit. In the could be instead, inflicted by local fauna where the body was found.
evening the parents noticed a red\black “purpura” on the abdomen and This presentation will impact the forensic science community by
the back. However, at the time, the child seemed to feel better, ate with showing several cases involving postmortem traumatic lesions produced
a good appetite, and was afterward sleeping normally. Early the next by different animals, which can lead to misdiagnosis, since they may
morning the father found him lifeless in his bed. resemble, inflicted and non-inflicted antemortem lesions. Therefore,
Case 2: A healthy 19-month-old child, later discovered to be taken postmortem animal injuries must always be taken in consideration by
care of in the same nursery as the previous child, had a very similar forensic pathologists, with the objective of avoiding mistakes in the
clinical history. On the same Sunday afternoon, he developed high fever initial investigation and further autopsy conclusions.
(39°C) and was treated with paracetamol but with a weak response. The Postmortem animal predation on human death bodies is an
next morning, after a normal night’s sleep, he suddenly started to vomit important taphonomic phenomenon in forensic pathology, since animals,
and became cyanotic. The parents immediately called an ambulance but depending on their size and environment (land, water, or air), can
the baby died on the way to the hospital. produce a great variety of lesions. These type of animal injuries can be
Complete postmortem autopsy of both children were performed 24 produced during early and/or late postmortem period creating some
hours after death. Gross examinations revealed that they were age- forensic implications and difficulties, including: (1) mimicking
accordingly developed. They were covered with purple petechial spots antemortem lesions, particularly when they are produced shortly after
all over the body but no other remarkable external findings were death; (2) modifying antemortem injuries, with loss of identifying
observed. features, which may lead to interpretation problems; and, (3) mistaken
Autopsies showed cerebral oedema and venous congestion, diffuse for signs of assault due to differential diagnostic problems.
whitish and milky subpial exudation, adrenal glands with massive This study presents several cases of postmortem injuries produced
hemorrhagic infiltration of the parenchyma, and polyvisceral stasis. No by animals from different environments, including ants, cats, dogs, sea
other significant abnormalities were found. and river fauna with the corpses being found indoors (home) or outdoors
The macroscopic appearance led to the suspicion of meningeal (forest, sea marine and river). The postmortem animal lesions didn’t
infection and hence, CSF, buccal, pharyngeal, and nasal swabs, as well show any vital signs and the majority were located in unprotected body
as blood samples were taken for microbiological studies. These showed extremities, like face, upper and lower limbs. In these cases, autopsy
NM DNA positive for NM serotype B. Furthermore, all samples were findings allowed to identify both natural and violent causes of death,
culture positive after 72 hours of incubation. No other pathogenic agents including two cases of asphyxia by drowning.
were present. In conclusion, cases like those presented, illustrate that forensic
The microscopic histological study, performed by using formalin- pathologists need to have specific and especially attention when
fixed paraffin embedded tissue sectioned at 4 μm and stained with postmortem animal injuries may be present. Apart from the crime scene
haematoxylin-eosin, revealed subpial and cortical oedema, mild investigation and the autopsy procedure, it is essential that the
inflammatory infiltration along penetrating, deep brain vessels. The pathologist: (1) have knowledge of local fauna, in particular from his
adrenal glands showed massive hemorrhagic infiltration, the lungs focal own geographic area in order to better understand characteristic injury
oedema, and there was polyvisceral stasis. patterns produced by different animals; (2) always make a careful and
In conclusion, two infants died one shortly after the other 72 hours detailed examination of the traumatic lesions, including morphological
after they had last been in the same nursery and 24 hours after the onset features and topographical distribution, so an accurate trauma etiology
of their symptoms. In both cases, a multidisciplinary approach revealed diagnosis can be done; and, (3) make a correct differential diagnosis
the cause of death to be septic shock due to acute meningococcal which may clarify between antemortem and postmortem lesions.
infection with hemorrhagic adrenalitis (Waterhouse- Forensic Pathology, Postmortem Injuries, Animal Predation
Friderichsen Syndrome).
Waterhouse-Friderichsen Syndrome, Epidemic Outbreak,
Forensic Diagnosis
G36 Neck Findings in Hanging and observed in one case and hemorrhage into soft tissues was observed in
five cases. It was determined that the neck findings were higher in
Strangulation Cases That Underwent hanging cases as compared to the strangulation cases. Toxicological
Autopsy in Adana, Turkey analyses revealed that ethanol was present in 18 cases with a range
34mg/dl to 334mg/dl. This present study was performed to put forward
Ahmet Hilal, MD*, Necmi Cekin, MD, Mete K. Gulmen, PhD, and Kemal the prevalence of neck findings in the hanging and strangulation cases
C. Yildirim, MD, Cukurova University School of Medicine, Department that are frequently come across by the forensic medicine specialists, as
of Forensic Medicine, Balcali, Adana, 01330, TURKEY well as to discuss the results with the information in the literature.
Hanging, Hyoid Fracture, Thyroid Fracture
The goal of this presentation is to demonstrate the neck findings in
hanging and strangulation cases.
This presentation will impact the forensic science community by G37 Evaluation of Cardiac Conduction System
presenting macro-morphological findings in hanging and strangulation
cases during the autopsy performance. Pathologies in Sudden Deaths in
Deaths due to the mechanical forces applied to the neck area are Adana Region
frequently encountered in forensic medicine practices. Among these,
hanging accounts for the majority of the forensic cases. It is seen in the Mete K. Gulmen, PhD*, Cukurova University School of Medicine,
majority of the studies performed in various regions of the world that Department of Forensic Medicine, Adana, 01330, TURKEY; Ramazan
hanging is the leading method of suicide. Strangulation cases are also Karanfil, MD, Kahramanmaras Sutcu Imam University, School of
seen though not common. The origin of the event is sometimes Medicine, Department of Forensic Medicine, Kahramanmaras, 46100,
suspicious in the case where the crime scene has been altered, or in the TURKEY; and Ahmet Hilal, MD, and Necmi Cekin, MD, Cukurova
case that the corspes had been pulled down or had fallen down because University School of Medicine, Department of Forensic Medicine,
the string had broken. Balcali, Adana, 01330, TURKEY
In these cases, different problems may be in question and the
direction of the inquest may change. Regarding the frequently
The goal of this presentation is to encourage the forensic
encountered death cases due to the mechanical forces applied to the neck
pathologists in evaluating the cardiac conduction tissues in sudden death
area caused by the above mentioned reasons, assessment and
cases.
interpretation of the neck findings have important place for the forensic
medicine. The consistency of these findings with the inquest and the
presenting the microscopical findings of the cardiac conduction tissues
information about the crime scene, as well as the method used and the
in sudden cardiac death cases.
presence, type, and characteristic of the traumatic findings in the neck
A forensic pathologist is frequently asked to find the cause of death
area gain special importance. Fracture in the bone and cartilage tissues
in cases of sudden unexpected deaths in adults. Approximately 50% of
of this area and hemorrhage into the soft tissues are of great importance
all medico–legal deaths are due to natural causes. Approximately 1-5%
for the diagnosis as well as for the etiology to be exposed. These lesions
of all those cases remain as negative autopsies. Sudden cardiac death is
are considered the indicators of a mechanical force applied to this area.
usually defined as death from cardiac causes without apparent
Therefore, forensic medicine specialists carefully examine the neck
antecedent symptoms or within the first hour after onset of symptoms.
during autopsies, remove the hyoid bone and thyroid cartilage, and
Studies of morbidity and mortality related to cardiac disease estimate
completely evaluate. This present study was conducted in Adana
that there are between 300,000 and 400,000 sudden cardiac deaths
province that is located in South Turkey, has a population of 2.5 million
annually in the United States. On the other hand, Turkey does not have
with high rate of unemployed subjects, and is exposed to high rate of
a serial study of cardiac diseases as autopsy findings. Therefore, this
internal migration because of extensive land available for agriculture.
preliminary study was planned. Examination of the cardiac conduction
The records of the autopsies performed at the Group Presidency of
system is often looked upon as a last resort in the evaluation of a victim
Adana Institute of Forensic Medicine (IFM) between the years 2008 and
of sudden death. It is reasonable to conclude, then, that unfamiliarity
2009 were retrospectively reviewed. One-hundred and seventy cases
with conduction system anatomy and pathology and lack of experience
(6.2%) that were assessed to have died due to a mechanical force
with the examination techniques are the true reasons for this reluctance,
(hanging or strangulation) were included in the study among 2,726 cases.
which is not surprising because many anatomic pathology and forensic
Of the cases, 159 died of hanging and 11 died of strangulation. It was
medicine residents complete their training without learning about the
determined that 104 of the cases (61.2%) were male and 66 were female,
cardiac conduction system. This lack of training is symptomatic of the
hanging accounted for 93.5% and strangulation accounted for 6.5%, all
ongoing decline of the autopsy as a teaching tool. Careful case selection
of the hangings were suicidal, whereas the strangulations were murder.
for conduction system analysis, coupled with a sensible approach to
The age of the cases ranged between 4 and 86 years; the majority of the
dissection and histological sampling, will result in an increased yield of
cases (n=37, 21.7%) were between 21 and 30 years of age, whereas 32
diagnostically specific, potentially lethal lesions with only a minimal
cases were between 11 and 20 years of age. It was determined that two
increase in the expenditure of time or money.
girls between the ages 0 and 10 years died of strangulation. It was
Twenty-seven SUD and four known cause of death forensic cases
observed that 121 of the hanging cases were typical (the node was behind
had been chosen for this study. The autopsies held in the Morgue of the
the neck), whereas 38 were atypical. Thyroid cartilage fracture was
Adana Branch of the Turkish Forensic Medicine Council. The cardiac
determined in 43 cases (25.3%) from hanging and strangulation, whereas
tissue and coronary artery samples were dissected as described by the
hyoid bone fracture was determined in 25 cases (14.7%) and both thyroid
CAP and the Cardiac Conduction System examined as already has been
cartilage fracture and hyoid bone fracture were determined in 11 cases
described by Cohle et al and Gulino Sam. Harris’ H+E, Masson’s
(6.5%). Fracture or dislocation in cervical vertebra was observed in
Trichrome, Verhoeff’s elastic Van Gieson and also for amiloidosis,
seven cases. A total of 86 cases (50.6%) had thyroid cartilage, hyoid
Lieb’s Crystal Violet stains had been used histochemicaly.
bone, and cervical vertebra findings. It was determined that, 90 of the
The 31 autopsy cases differed in age from age of 17 to 78 years with
cases (52.9%) had hemorrhage into the soft tissues either with or without
an average 41.7. Fifteen cases had serious atherosclerotic changes in the
fracture and that 60 cases (35.3%) had no finding other than skin lesions.
coronaries. In 13 cases there were infarctions. In this study cardiac
Both thyroid cartilage and hyoid bone fractures were observed in 2 cases
conduction tissue pathologies in the 11 was revealed.
(18.2%) died of strangulation, whereas only hyoid bone fracture was
Serious fibrotic and remarkable adipose tissue changes in the SA The risk of being struck by lightning is also a function of population
and AV nodes were found. Many of the similar studies show parallel density and it comprises terrain features that may protect or not
results with this study. The difference in between these serials can be occupants of an area (Ritenour AE et al, 2008).
explained by the difference of the countries, socio–cultural specifics, life According to literature review, data appears to be significantly
conditions, environment, nutrition, and genetic variations. Hypoxic affected by underreporting when comparing Meteorological Offices to
changes of the myocardial tissue may also cause conduction system medical and death-certificate databases (Cherington M et al, 1999).
pathologies. Myocardial infarctions were present in four of the SA nodes Five most common mechanism of injury were described: direct
and two of the AV nodes of all cases. This is an important finding to strike, ground current, flash discharge, contact strike, and blunt trauma.
understand and reveal the conduction system effects of the early and late A 53-year-old man started to renovate his own cottage after lunch.
myocardial infarctions. Amyloidosis was not found case in this serial. In the evening, receiving no answer from him, the family called the
Any significant pathologic changes in any of the control cases was not police. When they arrived, with the forensic pathologist, the scene
noticed. In some of the SUD cases, the pathology is not morphological investigation revealed the man lifeless lying on his right side between
yet functional. Yet, still in some cardiac rhythm disturbances cases, two metal sawhorses. The body was covered by burnt pieces of his
some may find cardiac conduction tissue pathology histologicaly. The working clothes. The man presented diffuse second, third, and fourth
relationships between cardiac conduction tissue morphological degree burns in several areas of the body but especially in the abdominal
pathologies and cardiac rhythm disturbances will only be demonstrated region, in the root of the thighs, and on his genitals.
clearly by clinico-pathologic evaluations with in large serial studies. There was complete carbonization of beard and hairs all over the
Further study is needed of the cardiac conduction tissue on larger body and the scalp. The surrounding environment showed no signs of
SUD serials, and to understand the pathologies and mechanisms of burning. His working tools were scattered around and there was a
deaths in especially young SUD cases at our region and country. The generator that had been set up to perform the work. However, the
findings in this model study are very important in demonstrating the firefighter technical assistant found no damage to the generator or
young SUD cases and its relation with the conduction tissue pathologies. electrical malfunction.
Therefore, examination of the cardiac conduction system can be a very The Meteorological Office reported that in the same area, few hours
useful adjunct to the examination of the heart in cases of sudden cardiac before, there had been a thunderstorm. Moreover, another person had
death especially in our region. Careful case selection, proper technique, been simultaneously injured by a lightning strike while crossing a bridge
and mindfulness of nonspecific findings or normal variants increase the in the same village.
likelihood of identifying abnormalities that may serve as the The cottage presented a rudimentary system of walls containment
morphologic substrate for sudden cardiac death. with steel beams pointing from outside to the center of the premises
Sudden Cardiac Death, Conduction Tissue, Histochemistry through the roof. The beams might have played a decisive role in the
conduction of an electrical atmospheric discharge. This was further
facilitated in the room by the presence of metal working tools directed
G38 A Peculiar Fatal Lightning Strike Inside toward the ceiling.
All investigation data suggested that a lightning had entered into the
a Cottage cottage thorough the beams creating an arc in the point where the victim
was working.
Federica Portunato, MD*, Manuela Botto, MD, and Alessandro Necropsy and histological findings confirmed the suspicion of
Bonsignore, MD, University of Genova, Department of Legal and lightning strike.
Forensic Medicine, Via de’ Toni 12, Genova, I-16132, ITALY; and In conclusion, a detailed analysis of crime scene investigation,
Francesco Ventura, MD, University of Genova, Department of Forensic environmental, and autopsy data led to the correct determination of the
Pathology, Via de’ Toni, 12, Genova, 16132, ITALY real nature of the suspicious death which could be related to other
different causes which may also be not accidental.
After attending this presentation, attendees will learn about a case Lightning Strike, Fatal Injury, Crime Scene Investigation
of instantaneous death due to a peculiar form of lightning storm.
stressing the importance of crime scene investigation in order to assess
real causes and means of death.
G39 Enterobacter Cloacae Peritonitis Secondary
Lightning strike is a fascinating and unpredictable natural to Hemorrhagic Cystitis in a Long-Term
phenomenon with potentially devastating effects and represents one of Substance Abuser
the most common causes of deaths from environmental phenomena. The
incidence of fatalities had been estimated in the United States to be Elena Bulakhtina, MD*, Allegheny County Medical Examiner’s Office,
around 150-300 cases/year (Duclos PJ et al, 1990), representing a third 1520 Penn Avenue, Pittsburgh, PA 15222; Zhuo Wang, MD, Conemaugh
of all lightning strikes (Sheela SR et al, 2000). Valley Memorial Hospital, 1020 Franklin Street, Johnstown, PA 15905;
Benjamin Franklin first demonstrated 200 years ago that lightning Todd M. Luckasevic, DO, Baiyang Xu, MD, and Abdulrezak M. Shakir,
consists of a gigantic electrical discharge. The physical processes that MD, Allegheny County Medical Examiner’s Office, 1520 Penn Avenue,
take place in and around a thundercloud occur at the micro-particle level Pittsburgh, PA 15222; and Karl E. Williams, MD, MPH, Allegheny County
and at a much larger scale that involves the entire Earth as an electrical Medical Examiner’s Office, 542 Fourth Avenue, Pittsburgh, PA 15219
circuit. Lightning happens when the difference in voltage between a
cloud and the ground or another object exceeds 2 million V/m. The goal of this presentation is to illustrate an unusual case of
Afterwards, an arc occurs and there is the release of a great amount of peritonitis caused by hemorrhagic cystitis.
electrical energy that can cause severe damage to organs, also resulting This presentation will impact the forensic science community by
in high mortality (Copper MA et al, 2001). illustrating the need for microbilogical cultures and routine histology in
The most vulnerable subjects for lightning strike are individuals cases of peritonitis where an obvious source or rupture site is not
who work in open fields such as farmers or swimmers; additionally, it is identified.
more rare for lightning to strike inside a building as in the case hereby Introduction: The major causes of peritonitis are appendicitis,
presented. perforations associated with diverticulitis, peptic ulcers, gangrenous
gallbladder, gangrenous obstruction of the small bowel, incarcerated G40 Two Suicidal Deaths From Head Injuries
hernia, and volvulus. Peritonitis secondary to cystitis is a rare, life
threatening condition due to the unique anatomic characteristics of the
Caused by Unusual Sharp Force
urinary tract. Predisposing factors include anatomic anomalies of the Instruments and Review of the Literature
urinary tract, vascular impairment, previous surgery, irradiation and high
virulence pathogens. Making a diagnosis of peritonitis due to cystitis is Patricia A. Aronica-Pollak, MD*, and Mary G. Ripple, MD, Office of the
difficult and the prognosis is usually poor. Chief Medical Examiner, 111 Penn Street, Baltimore, MD 21201; Juan
Materials and Methods: This case involves a 47-year-old African- C. Troncoso, MD, Department of Pathology, Johns Hopkins University
American female with a long standing history of alcohol, heroin, and School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287; Kyle
cocaine abuse, who was found dead in her secure apartment. According C. Shaw, MBBS, District 5 Medical Examiner’s Office, 809 Pine Street,
to witnesses, she experienced flu-like symptoms for the past few days. Leesburg, FL 34748; and David R. Fowler, MD, Office of the Chief
The examination of the scene revealed a cluttered and unkempt dwelling Medical Examiner, 111 Penn Street, Baltimore, MD 21201
with numerous empty and full malt liquor cans. Dark colored stains
were noted on the bed and the floor, and a bucket with vomitus was After attending this presentation, attendees will become familiar
discovered near the deceased. with unusual penetrating sharp force wounds of the head, the external
Results: Postmortem examination revealed a poorly nourished wounds and wound types produced, and internal wound trauma created.
African-American female, weighing 102 pounds and measuring 65.5 This presentation will impact the forensic science community by
inches (BMI – 16.5). Signs of prior drug abuse, i.e., multiple remote reporting the first suicidal death by a meat thermometer to the head and
circular scars (“skin popping” sites), were noted on the upper and lower by reviewing the literature of other sharp force penetrating suicidal
extremities. At autopsy, the abdominal cavity contained 500 cc of serous wounds that have resulted in death.
fluid. Fibrinous exudate was observed on the dusky red small and large Deaths due to sharp force penetrating wounds of the head are
intestines. The urinary bladder contained 20 cc of dark-brown blood and uncommon due to the thickness of the cranium and the difficulty of
exhibited a markedly thickened, hemorrhagic mucosal surface. No gross penetration to the brain. Even with brain penetration, individuals may
perforation was identified. survive with or without neurological deficits. These types of injuries are
Microscopic examination revealed severe full thickness acute and most often self-inflicted but homicide must be considered especially if
chronic inflammation, focal hemorrhage, and necrosis of the urinary the injury implementing instrument is no longer present in the wound.
bladder. Both kidneys displayed acute tubulointerstitial nephritis. Two unusual suicidal deaths due to penetrating head injuries will be
Peritoneal fluid and urine cultures grew Enterobacter Cloacae. presented. One case is that of a 44-year-old man who had previously
Postmortem toxicology was positive for Ethanol (0.011% in the blood; served time in prison for second degree murder. He was at his residence
0.020% in the vitreous fluid). when law enforcement officers arrived in order to arrest him on new
No other pathologic abnormalities or trauma were identified during molestation charges. They received no response after knocking at the
the autopsy. door. Another resident arrived and entered the residence. The police
Conclusion: Secondary peritonitis follows contamination of the remained outside of the dwelling. She found the man, unresponsive but
peritoneum by organisms released from the infected organs or perforated still breathing, lying on the bed with a meat thermometer impaled into
viscera. Peritonitis due to acute cystitis is a rare occurrence with only a the right temple area of his head. Survival time was 26 hours but non-
handful of reports published in the medical literature. Most of the cases survivability was determined within the first few hours of the hospital
involved gangrenous inflammation of the urinary bladder with or stay following the CT scans. The thermometer was left in place until
without perforation. autopsy. Postmortem radiograph revealed the thermometer traversed the
In this case, integrity of the bladder wall was preserved. The majority of the right side of the skull and brain. Autopsy revealed a 1/8”
significant amount of blood in the bladder cavity and severe acute round puncture/stab wound on the right temple following removal of the
transmural inflammation with hemorrhage and focal necrosis supported thermometer. The right temporal lobe and basal forebrain were lacerated
the diagnoses of hemorrhagic cystitis. with massive hemorrhage of the basal forebrain with extension into the
Hemorrhagic cystitis results from damage of the transitional ventricular system. A laceration of a dural blood vessel, basilar
epithelium and blood vessels by infection (bacteria, viruses) and non- subarachnoid hemorrhage, focal epidural hemorrhage, and cerebral
infection etiologies (drugs, toxins, radiation). In this case, Enterobacter edema at the entrance defect were also noted. Postmortem toxicology
Cloacae colonies were isolated from urine and peritoneal fluid. It is for ethanol and drugs was negative.
worth noting, that in adults Enterobacter affects individuals with The second case was that of a 47-year-old man with a history of
underlying physical or structural anomalies, metabolic disorders or schizophrenia. He had been to many doctors in the past trying to “get the
immunodeficiency causing complicated urinary tract infections. wires out of his head.” After a request was made by his parents for a
Enterobacter comprises 1.9% to 9.6% of all UTI pathogens. welfare check, police found him in his secure residence in his bathtub
The past history of the deceased played an important role in the filled halfway with water mixed with blood. The shower curtain was
evolution of what started as an innocent urinary tract infection (UTI) to pulled from the wall and located partially beneath the decedent. On the
a fatal condition. A number of studies have shown that drugs of abuse, sink was a plugged in electrical drill with an attached 1-1/2” hole saw
including cocaine, opiates, and alcohol, alter not only drill bit with skin and hair in the teeth. On the top of the head was a
neuropsychological and pathophysiological responses of individuals but roughly circular scalp defect and underlying 1-1/2” circular skull injury
also immune functions. This decedent’s extensive history of with central 1/4” drill hole. Blood spatter on the walls indicated the
polysubstance abuse and malnutrition (BMI of 16.5; normal 18-24) decedent likely stood in front of the mirror at the sink while inserting the
apparently caused severe debilitation of the immune system with rapidly drill into his head and prior to collapsing into the tub. Drug
progressive infection and the resultant grim outcome. paraphernalia was present at the scene and postmortem toxicology was
Peritonitis, Hemorrhagic Cystitis, Cocaine User positive for morphine.
In addition to these cases, a review of the literature will evaluate
other unusual cases of penetrating injury of the head with special focus
on the regions of the brain and skull injured and the survivability of
the injuries.
Heat Thermometer, Electric Drill, Suicide
G41 Iatrogenic Laceration of a Pulmonary injury, but its removal generated a profuse and extensive bleeding into
the pleural space.
Angiomatoid Lesion: Fatal Complication or The treatment of choice in such cases is an emergency resuscitative
Medical Error? thoracotomy, defined as a thoracotomy performed immediately in the
emergency room/department or in the operating room, because it enables
Paolo Fais, MD*, and Giovanni Cecchetto, MD, Via Falloppio 50, a fast identification and suture of the vascular injury. However, when
Padova, 35121, ITALY; Guido Viel, MD, University of Padua, Via huge and dilated vessels are lacerated with subsequent extensive pleural
Falloppio 50, PADOVA, 35121, ITALY; Rossella Snenghi, MD, and hemorrhage (as in the reported case), the outcome is very poor. Thus, the
Rafael Boscolo-Berto, MD, Via falloppio 50, Padova, 35121, ITALY; most important thing is to prevent similar emergency conditions by
Andrea Zuin, MD, Via Giustiniani 2, Padova, ITALY; and Massimo choosing the blunt dissection technique instead of the more dangerous
Montisci, PhD, Via Falloppio 50, Padova, 35121, ITALY trocar insertion method, particularly in patients affected by adult
respiratory distress syndrome or pulmonary hypertension that show an
After attending this presentation, attendees will understand the increased incidence of peripheral venous ectasias.
diagnosed lesion. It is believed that the case could be of interest for the forensic
This presentation will impact the forensic science community by community not only for the singularity of the reported lesion, but also for
stressing the importance of performing histological examination in any underlining once again the importance of performing histological
iatrogenic deaths to recognize underlying diseases and their eventual examination in any iatrogenic deaths to recognize underlying diseases
causal role in determining the fatality. and their eventual causal role in determining the fatality.
Percutaneous tube thoracostomy is a standard therapy for a number Forensic Pathology, Angiomatoid Lesion, Iatrogenic Death
of pulmonary disorders. Even if it remains the most widely performed
procedure to manage blunt or penetrating chest traumatism, and it is
generally considered a simple procedure, this life-saving maneuver can G42 Pedestrian Fatalities in Maryland: How
be frequently associated with several complications, such as lung or
heart perforations, arterial or venous injuries, neurological dysfunctions,
Many, Who, When, Where, Why, How, and
injuries to the oesophagus, phrenic nerve and abdominal organs, Ways to Prevent Them
bronchocutaneous fistula, and perforations of the mediastinal pleura with
subsequent contralateral pneumothorax. Ana Rubio, PhD*, Carol H. Allan, MD, and David R. Fowler, MD, Office
A case of a 76-year-old man, admitted to a peripheral hospital after of the Chief Medical Examiner, 111 Penn Street, Baltimore, MD 21201
a car accident, presenting bilateral flail chest, and subcutaneous
emphysema is presented. Bilateral chest tubes were placed between the After attending this presentation, attendees will have a clear picture
anterior and the mid-axillary lines. On the 3rd and 9th day of of the characteristics of pedestrian fatalities in Maryland. The
hospitalization the patient underwent surgical stabilization of bilateral presentation includes social, geographic, medical, and traffic related data
flail chest with Kirshner wires and metal plates. The postoperative from the previous five years.
recovery was characterized by multiple recurrences of pneumothorax This presentation will impact the forensic science community by
and subcutaneous emphysema with oxygen desaturation. For these discussing how understanding the nature and causes of a problem in its
reasons several bilateral drains were inserted with the trocar technique, totality (in this case pedestrian deaths in an entire state), is the first step
the last one on the 25th day of hospitalization. A control CT scan showed in correcting it. This presentation will suggest implementations for
that the tip of the chest tube, inserted between the anterior and the mid- reducing the rate of fatal pedestrian accidents in the State.
axillary line, was located in the parenchyma of the left lung. How Many: In the last five years, a total of 400 pedestrian
Immediately after the withdrawal of the drainage tube the patient became fatalities were studied at the State of Maryland Office of the Chief
unstable with low blood pressure and tachycardia, and was intubated Medical Examiner (OCME). The majority of the cases had a complete
with a double-lumen tracheal device. A fibrobronchoscopy performed postmortem examination (97.5 %), with toxicologic analysis (for the
through the tracheal tube revealed profuse hemorrhagic secretions. presence of volatiles in 99% and drugs screening performed in 92%).
Because of the severe clinical conditions, the patient was transferred to Who: The majority of the victims were male (69.5%), aged 1 to 89
our hospital where, despite multiple blood transfusions, he arrived years (mean and standard deviation: 43.9 and 19.9 respectively). 179
pulseless and died after 60 minutes of cardiopulmonary resuscitation. individuals (44.8%) were African-American, 168 (42%) Caucasian, 36
At autopsy the victim was found to be affected by an extensive (9%) Hispanic, 10 (2.5) Asian, and 7 (1.7%) belonged to other
hemothorax resulting from the laceration of a dilated vessel on the racial/ethnic groups. More than half of the victims (54.3%) were
anterior surface of the inferior lobus of the left lung. Histology revealed transported to the hospital before they were pronounced dead (data is
that the vessel consisted of an “angiomatoid lesion,” the distal skewed due to a few cases with long survival; median survival of 59
component of a plexiform complex, the hallmark of plexogenic minutes, mean of 34.6 days), and 181 individuals (45.2%) were
pulmonary arteriopathy, an idiopathic disease that may accompany pronounced at the scene (15.6 minutes after the accident on average;
primary pulmonary hypertension. median of 7 minutes). Another individual died at home three and a half
The risk of lung perforation during tube thoracostomy depends on days following the accident, and another at a nursing home, three months
several factors related to the patient (pulmonary contusion, pleural after the accident.
adhesion, adult respiratory distress syndrome, age above 60, mechanical How: Most (more than 90%) events were witnessed and had a
ventilation) or to the method used for the insertion of the chest tube. single vehicle involved. The impacting vehicle was recorded in 339
Particularly, lung perforations have been reported more frequently with cases (85%), 181 (53.4%) were passenger cars, 62 (18.3%) SUVs, 28
the trocar technique, where the insertion is determined by a metal rod (8.3%) pick-up trucks, 25 (7.4%) vans, 22 (6.5%) other trucks, 9 (2.6%)
projecting slightly from the tip of the tube, rather than the blunt buses, 8 (2.4%) trains, 3 (0.8%) motorcycles and 1 (0.2%) was a bicycle.
dissection technique, where the penetration of the tube through the chest The manner of death in the majority of the death certificates were listed
wall is prepared with a Kelley clamp. as accident (98.3%); there were 2 homicides, 3 suicides, and 2 deaths
In the reported case, even if the trocar insertion procedure was were undetermined. The cause of death was listed as: multiple injuries
performed correctly, the penetration of the metal rod into the lung in 349 cases (87.3%), head or head and neck injuries only in 27 cases
parenchyma produced a tear of a sub-pleural angiomatoid lesion. (6.8%), and complications of multiple injuries in 14 cases (4 %), with a
Initially the catheter blocked the blood flow through the iatrogenic variety of other causes listed in the remaining 10 cases. Ethanol in blood
was positive in 146 cases (36.7%) with a mean concentration of 0.16% • Limited right ventricular hypertrophy with replacement of the
(+/- 0.09; range: 0.01 to 0.39%). Toxicologic screening for drugs was myocardium by fibrofatty tissue in restricted expanse, which is a
positive in 107 cases; 28 individuals (7%) had narcotics in blood (12 feature of ARVC.
morphine, 8 methadone, 5 tramadol, and 3 oxycodone), 21 (5.1%) Those findings allow the conclusion that rhythm disorder caused death.
cocaine or cocaine metabolites, and 6 (1.5%) had PCP. The association of ARVC and CAD in athlete is really unusual.
When: In the five years studied, there was no clear change in the Arrhythmogenic right ventricular cardiomyopathy is a myocardial
incidence rate. The highest incidence was found in December (12% of disease characterized by fibrofatty replacement and ventricular
all cases), and November (11.75%), and the lowest in January (5.7%) arrhythmias. ARVC is a hereditary disease with autosomal dominant
and July (6.5%). Saturday (19.7%) and Friday (17%) had rates up to 1.8 transmission in at least 50% of cases. It occurs specifically in athletes
times higher than Thursday (9.3%) or Tuesday. The majority of the and affects predominantly men. The prevalence in the general
accidents occurred at night (70.3%), 6.2% happened at dusk, 4.5% at population varies between 1 in 1,000 to 1 in 5,000. Diagnosis rests on
dawn, and 19% during the day light. criteria including signs such as severe segmental dilatation of the right
Where: Graphical representation of the location of incidents ventricle and fibrofatty replacement of myocardium on endomyocardial
throughout the State is provided. Location was also classified according biopsy for example. This disease leads to sudden death by ventricular
to road type and presence or absence of traffic signals at intersections. arrhythmias.
Why: Attempts to determine possible causes for the accident were Atherosclerotic disease is primarily responsible for sudden death in
made. Detailed examination of the incident description, police report, athletes older than 35 years. Traditional markers of CAD are widely
and in some cases complete accident reconstruction specified which was known, like hypertension, obesity, smoking, diabetes, and lipid
the party at fault (whether the pedestrian or the driver of the motor abnormalities. Cardiac effects of cocaine chronic abuse also exist. It is
vehicle), weather conditions, light, etc. associated with CAD by multiple pathogenic mechanisms: elevation in
Conclusion: Nearly 100 pedestrians die each year in Maryland. blood pressure, acceleration of atherosclerosis, increase of thrombosis
Possible ways to prevent or decrease the rate are provided based on the risk by activating platelets, and vasoconstriction.
data collected in the prior five years. To conclude, this case report brings to light unusual arrhythmogenic
Pedestrian Fatalities, Who, Prevention factor leading to sudden death in athlete.
Sudden Death, Athlete, Arrhythmogenic Right Ventricular
Cardiomyopathy
G43 Sudden Cardiac Death in an Athlete:
A Case Report
G44 Myocarditis With Giant Cells in an Infant:
Damien Mauillon, MD*, Service de Médecine Légale, Centre A Case Report and Review of the Literature
Hospitalier Universitaire, 4 rue Larrey, Angers Cedex 9, 49933,
FRANCE; Nathalie Jousset, MD, Centre Hospitalier Universitaire, 4 rue Tera A. Jones, MD*, Douglas County Coroner’s Office, 4000 Justice
Larrey, Angers Cedex 9, 49933, FRANCE; Paul Fornes, PhD, Hospital Way, Castle Rock, CO 80109
Robert Debre, Avenue du General Koeing, Reims, 51100, FRANCE; and
Clotilde Rouge-Maillart, PhD, Centre Hospitalier Universitaire, Service After attending this presentation, attendees will be able to recognize
de Médecine Légale, 4 rue Larrey, Angers Cedex 9, 49933, FRANCE the various entities associated with myocarditis with giant cells, most
notably idiopathic giant cell myocarditis, and its clinico-pathologic
After attending this presentation, attendees will learn of a case features.
showing unusual cardiac cause of sudden death in an athlete, including This presentation will impact the forensic science community by
arrhythmogenic right ventricular cardiomyopathy (ARVC), and coronary highlighting a case of an uncommon disease entity which is commonly
artery disease (CAD) after chronic cocaine use. fatal, and generally affects young, healthy adults, but can also affect the
This presentation will impact the forensic science community by pediatric population.
revealing various histological cardiac lesions observed after a sudden The subject was a 26-day-old, Asian female infant born at 31 weeks
death in a retired doping athlete. gestation with no complications at birth. While under the care of her
Cardiovascular diseases represent the most frequent causes of parents, she vomited once and then was reported to be feeding poorly.
sudden death in athletes, including hypertrophic cardiomyopathy, She was taken to her pediatrician’s office where she was “sick
anomalous coronary artery anatomy, arrhythmogenic right ventricular appearing.” In the clinician’s office she became unresponsive, was
cardiomyopathy, and aortic aneurysm. Disorder of cardiac rhythm and subsequently admitted to the nearest hospital, and died within four hours.
stenosis of the coronary arteries are physiopathological mechanisms that Family history included a “head cold” in an older sibling and her mother
can explain cardiac arrest. was believed to suffer from an autoimmune-type disease which was
This case involved a 36-year-old man who was a two-time world undiagnosed.
champion while he was cocaine-dependant. He participated in triathlons At autopsy, the subject’s growth parameters were between the 10th
after his career as a recreational sport without taking cocaine. He had to 90th percentiles when corrected for prematurity, her skin was free of
neither medical history nor cardiovascular risk factor except tobacco. He rashes, and her abdomen was distended. Within the abdominal cavity,
died suddenly during sleep. A complete postmortem examination was there was 60 cc of ascites. The lungs were congested and heavy with a
performed. The descendant was 172 cm tall and weighed 77 kg (BMI combined weight of 53 grams. The heart weighed 16 grams; it was
26). The autopsy showed several cardiac lesions: normally formed, and had a probe patent ductus arteriosus. Externally,
• A cardiomegaly (520g) with a symmetric left ventricular the epicardium of the heart was mottled pale tan to erythematous. Cut
hypertrophy usually expected in elite athlete; there was no sections of the myocardium were equally mottled. The other major
dilatation and no architectural disorganization. organs were appropriate weights and unremarkable for an infant of her
• An epicardial coronary stenosis of the left anterior descending age. No lymphadenopathy was identified. Blood cultures obtained from
artery and the first diagonal branch (80-90%) with recent the hospital and at autopsy were negative. Toxicology and vitreous
thrombosis on the surface of an atheromatous plaque; there is no electrolytes were unremarkable.
acute myocardial infarction. Histological sections of the heart revealed patchy myocyte necrosis
• Several areas of fibrosis in left ventricular, resulting from an with mononuclear cells, a prominent collection of eosinophils, and
ancient ischemia. scattered multinucleate giant cells. No granulomas were identified. The
intramyocardial vessels and epicardial fat were free of inflammation. administered. No disorder of lipid metabolism or transport or renal
Histological sections of the other organs were free of granulomatous failure was known. The body underwent whole-body PMCT (Somatom
inflammation, viral cytopathic effect, or vasculitis. Emotion 6, Siemens, Erlangen, Germany) with subsequent cannulation
Myocarditis with giant cells is seen in association with many via an unilateral inguinal incision and contrast application by a modified
recognized entities including tuberculosis, fungal infections, rheumatic heart-lung machine. PMCTA was then performed with an arterial and
myocarditis, measles, syphilis, foreign body reaction, Wegener’s venous injection. The body was moved from the supine to prone position
granulomatosis, hypersensitivity reaction, and sarcoidosis. Idiopathic to improve filling of nondependant vessels. After PMCT and PMCTA,
giant cell myocarditis is as the name implies a myocarditis with giant image-guided biopsy of the lung was obtained. The harvested specimens
cells, but of unknown etiology. It is a rare, but commonly fatal form of were stained to detect fat embolism.
myocarditis which has been recognized since the beginning of the 20th Results: Unenhanced PMCT revealed a distinct fat level on top of
century. This disease generally affects previously healthy, young adults sedimented layers of corpuscular blood particles and serum in the
(mean age 42 years); however, approximately 16 cases have been systemic arterial system and the pulmonary trunk. This finding was
reported in the pediatric population. The youngest to date was 6-weeks- measured (Hounsfield Unit) and compared to possible small position-
of-age; however, the majority of reported pediatric patients are dependent air embolism and evaluated as negative. PMCTA showed no
teenagers. Symptoms generally are due to congestive heart failure, clotting suggesting pulmonary thrombembolism. The triple layered
although numerous other symptoms have been reported including intravascular finding was reproducible after PMCTA and after turning of
sudden death and palpitations. Diagnosis has classically been made at the corpse. Autopsy showed no evidence of patency of the foramen
autopsy, although, the disease is being diagnosed by endomyocardial ovale that would account for paradoxical embolism. In addition, there
biopsy and following cardiac transplant. Gross identification of the were no autopsy findings other than fatal fat embolism that were relevant
disease ranges from “normal” to serpiginous areas of myocardial to the cause of death. There were no petechial rash or kidney changes
necrosis. Histology demonstrates myocyte necrosis, with visible. There was no evidence for cholesterol embolism, e.g. triggered
lymphoplasmacytic inflammation with eosinophils and multinucleate by anticoagulation. Both image-guided biopsy and histopathological
giant cells. While the disease generally affects previously healthy specimens confirmed the findings of PMCT/PMCTA demonstrating
people, approximately 20% of patients have immunologic disorders severe FE (Grade IV).
including inflammatory bowel disease, optic myocytis, thyroid Conclusion: PMCT/PMCTA established the cause of death as
disorders, systemic lupus erythematosus, Takayasu’s arteritis, systemic fatal FE. It is believed that this is the first description of these
myasthenia gravis as well as others. The most successful treatment unusual systemic imaging findings in the postmortem setting. Autopsy
consists of cardiac transplantation with immunosuppression. Giant cell and histopathological specimens validated imaging and biopsy findings.
myocarditis has, however, been known to recur post-cardiac transplant at Fat Embolism, Postmortem Computed Tomography, CT
a rate of 20-25%. Without treatment, the average survival time from
diagnosis to either death or cardiac transplantation is 5.5 months.
Based on the history including no known exposure to any drugs, G46 Radiocarbon and Stable Isotope Results of
maternal history of an autoimmune disease, and following review of the
histology and other studies, the cause of death of this infant is due to
Fingernails of Breastfed Mother-Infant
idiopathic giant cell myocarditis. Based on the literature review, this is Pairs to Investigate Deviation of Year-of-
the youngest reported patient with the disease. Birth Determinations Due to Diet
Myocarditis, Heart Failure, Sudden Death in Infants
Kaelyn M. Ormsby, BS*, and Guaciara M. Santos, PhD, KCC-AMS
Preparation Laboratory, University of California, Irvine, B321 Croul
G45 Massive Systemic Fat Embolism Detected Hall, Irvine, CA 92697; and Benjamin T. Fuller, PhD, Max Planck
by Postmortem Imaging and Biopsy Institute for Evolutionary Anthropology, Department of Human
Patricia M. Flach, MD; Steffen G. Ross, MD; Garyfalia Ampanozi, MD;
Stephan A. Boliger, MD; Gary M. Hatch, MD; Michael Thali, MD; and The goal of this presentation is to find a possible explanation to
Tanja Germerott, MD, Institue of Forensic Medicine, University of Bern- justify outliers in 14C results from a recent pilot experiment measuring
Virtopsy, Buehlstrasse 20, Bern 3012 SWITZERLAND human tissues to determine the year-of-birth of deceased individuals of
known birth records.
After attending this presentation the participants will learn about This presentation will impact the forensic science community by
systemic fat embolism and the characteristic image features of systemic exploring new methods and techniques to aid in human identification.
fat embolism on pre-autopsy computed tomography compared to Researchers have investigated the possibility of acquiring the year-
autopsy and histopathological findings. of-birth and year-of-death dates by using radiocarbon (14C)
This presentation will impact the forensic science community by measurements from a broad range of human tissues. This is possible due
raising awareness of the feasibility to detect systemic fat emoslism on to high concentration of radiocarbon in the earth’s atmosphere during the
postmortem computed tomography prior to autopsy. Finding on thermonuclear bomb testing carried out between 1953 and 1963, and its
computed tomography were significant and serve as quality propagation into the food chain through photosynthesis. Measuring the
improvement to forensic procedures. magnitude of this 14C concentration allows year-of-birth determinations
Purpose: The purpose of our case study is to describe the findings for individuals that were born in this period. Recently, Hodgins (2009)1
of lethal systemic fat embolism (FE) on postmortem unenhanced studied human tissues of 36 deceased individuals of known birth dates.
computed tomography (PMCT), PMCT-Angiography (PMCTA), and To estimate the year-of-birth, Hodgins measured 14C of tooth enamel.
image-guided lung biopsy, with correlation to conventional autopsy and More than 50% of his results were consistent with the true birth dates,
histopathology. and uncertainties for most were as good as 1.5 years. However, a
Materials and methods: An 89-year-old woman with traumatic significant percentage of the measurements yielded estimated birth dates
femoral neck fracture died due to cardiac arrest during implantation of a off as much as 4 years. Since diet life histories of individuals were
cemented total hip prosthesis. The patient was under long-term unknown, Hodgins speculated that a 14C depleted marine diet may have
anticoagulation for atrial arrhythmia. In the course of the hip trauma, played a role in explaining some of these date deviations. Since some
anticoagulation had to be stopped and antidote (vitamine K) was human non-turnover tissue, such as eye lens crystalline and tooth
enamel, start forming while in utero and stop at approximately age of 3 not artificial cranial deformation practiced by past and extant peoples has
and 17 years, respectively, this notion raises the question of how much an effect on neurological function. It aims to refute or support the
an individual’s childhood diet can affect the age determinations. To hypothesis that cranial deformation must have an effect on the
examine this possibility isotopes d13C, d15N, and 14C in fingernails development of the brain and the skull and therefore affect neurological
collected from breast milk fed infants and their mothers from before birth function in an observable way.
through the weaning period were measured. In this study, the mother- Intentional artificial cranial deformation, practiced for a variety of
infant pairs were from the same region in the United States and their cultural reasons, is of great interest to anthropologists due to its value for
protein diet was recorded during the course of sampling. Samples that reconstructing aspects of past and contemporary social systems, as well
would most likely show some differences from one another since they as understanding modern medical conditions. Deformations have been
were from individuals with different protein dietary preferences were carried out for many social and aesthetic purposes, ranging from
chose, but in this preliminary investigation no significant variability was increasing perceived beauty to encouraging obedience in infants. It is
observed. This may be attributable in part to the fact that the individuals associated with instilling ethnic identity and social stratification. This
sampled were from the same region, and so a more diverse population paper addresses the question of whether artificial cranial deformation of
would possibly produce more variability. To further investigate the infant skulls, as practiced with boards, pads, stones, or bandages, had any
outliers that were observed by Hodgins, and to determine the magnitude adverse or beneficial consequences for neurological development, and
of any dietary biases on 14C measurements to estimate the year-of-birth, whether these were ignored or embraced by the societies practicing the
future research should be done directly on non-turnover tissue of tradition.
individuals of varied recorded diets from different locations. Previous research has not made links between cranial modification
References: and ethnographic evidence of abnormal neurological function (whether
1.
Hodgins, Greg. “Measuring atomic bomb-derived 14C levels in impaired or improved); however, papers written comparing the skull
human remains to determine Year of Birth and/or Year of Death”. morphology of modern pathological specimens and ethnographic
2009. National Institute of Justice Final Report. examples of artificially deformed specimens have shown that some
Isotopes, Diet, Fingernails features appear different to un-modified skulls, for example, the patterns
of venous sinuses and meningeal vessels, which may affect neurological
function.4 The resulting consequences of possible neurological change
G47 The Effect of Cultural Cranial Deformation have not been compared to ethnographic data. The paucity of such
research may have implications for wider anthropology, as cultural or
on Neurological Development: A Beneficial social phenomena such as tribal demise or proliferation, or shared
or Disadvantageous Practice? spiritual experience may be attributed to neurological modification as a
result of artificially-induced cranial deformation. Some traits and
Anna Williams, PhD*, and Mitzi A. Richards, MSc, Cranfield University, idiosyncrasies peculiar to distinct peoples may have a neurological
Defence Academy of the UK, Shrivenham, SN6 8LA, UNITED KINGDOM foundation.
A study was conducted using two types of artificially deformed
After attending this presentation, attendees will gain an appreciation crania from the Natural History Museum, London, to examine whether
of the different methods of cultural cranial deformation and the existing changes in cranial foramina morphology could explain some of the
medical conditions that cranial deformation simulates. There are clear symptoms observed in ethnographic accounts. Cephalic indices and
similarities between cranial development in individuals with culturally- ethnographic accounts of observed effects of artificial cranial
induced cranial deformation and individuals with different forms of the deformation were collated, and compared to measurements and
congenital condition craniosynostosis. Attendees will understand the documented symptoms and CT scans of individuals exhibiting the
implications of cranial deformation for the neurological development of medical condition craniosynostosis which appears to express similar
the individual, and these will be compared with those with morphological changes to the skull. The cephalic indices of artificially
craniosynostosis. Ethnographic material written through participant deformed skulls were found to be similar to those of skulls with
observation amongst societies that practice cranial deformation, and craniosynostosis, which is known to cause an increase in intracranial
medical reports of function in craniosynostotic individuals will be pressure and precipitate conditions such as strokes and 3rd, 4th, and 6th
examined to determine whether the practice has a beneficial or cranial nerve palsy. This supports the hypothesis that the symptoms
disadvantageous affect on individuals’ neurological function. exhibited by individuals with artificial cranial deformation would be
This presentation will impact the forensic science community by similar to those with craniosynostosis, and the explanations for the
detailing the effect of artificial or culturally-induced cranial deformation observed symptoms of cranial deformation substantiate the theory that
on the neurological function of the individuals. This is of significance to brain function is affected.
forensic anthropologists as it is a method of body modification that has This study represents original research that has not been undertaken
implications for the survival of the participants. Neurological conditions elsewhere, and constitutes a valuable contribution to anthropological
are known to affect bone morphology, for example bone atrophy due to knowledge. It will further the understanding of the nature of cranial
paralysis. It also allows an appreciation of cranial growth processes and deformation, neurological development and pathology, with significant
the interrelationships between the cranial vault, base, and face, as well as implications for socio-cultural anthropology, forensic anthropology, and
the foramina that conduct the cranial nerves. An analysis of the medicine.
morphological changes to the nerve foramina, coupled with an References:
1.
examination of ethnographic accounts of the physical symptoms Dingwall E. (1931) Artificial Cranial Deformation, London,
exhibited by the individuals has not been attempted before, and John Bale, Sons & Danielsson, UK.
2.
constitutes a novel contribution to our understanding of cranial Schijman E. (2005) Artificial cranial deformation in newborns in
deformation in past and existing societies. The modern condition of the pre-Columbian Andes. Childs Nervous System 21(11): 945-50.
3.
craniosynostosis can inhibit neurological development, and can offer the Cheverud J. Kohn L. Konigsberg L. and Leigh S. (1992) Effects
forensic anthropologist insight into the physiological consequences of of fronto-occipital artificial vault modification on the cranial base
the social practice. This has implications for investigations of human and face. American Journal of Physical Anthropology, 88:323-345.
4.
rights violations and the recognition of how social and cultural practices Dean, V. (1995b) Sinus and meningeal vessel pattern changes
can dramatically affect human physiology. inducued by artificial cranial deformation. International Journal
This project builds on previous research conducted by Dingwall,1 of Osteoarchaeology 5:1-14.
Schijmane,2 and Cheverud et al,3 among others, to determine whether or Cranial Deformation, Neurological Function, Craniosynostosis
G48 Morphological Identification of Right transfusion-recipient fatality data relevant to forensic practice, especially
regarding autopsy performance and medical errors. This presentation
Ventricular Ischemia Determining Right will inform attendees of something they do not know/do: (1) how to
Heart Failure in Cases of Fatal approach the investigation of deaths potentially related to transfusion of
Pulmonary Thromboembolism blood products; and, (2) how to contribute to the national investigation
of transfusion-associated fatalities by the FDA transfusion fatality
Tony Fracasso, MD*, University Center of Legal Medicine, CMU - program through increased awareness, vigilance, autopsy performance,
CURML, Rue Michel-Servet 1, Geneva, 1211, SWITZERLAND; Heidi and reporting.
Pfeiffer, PhD, University Hospital Münster, Röntgenstr 23, Münster, Background: Many deaths investigated by medical
48149, GERMANY; Cristina Sauerland, University of Münster, Domagstr examiner/coroner (ME/C) systems are associated with a blood
9, Münster, 48149, GERMANY; and Andreas Schmeling, PhD, University transfusion shortly before death. Complications of transfusion may
Hospital Münster, Röntgenstr. 23, Münster, 48149, GERMANY occur and are occasionally fatal. The transfusion service is required to
report fatal complications of transfusions to the FDA Center for
After attending this presentation, attendees will be aware of the Biologics Evaluation and Research (CBER). A CBER Medical Officer
possibility of detecting right ventricular failure due to ischemia in cases (CMO) reviews submitted information and determines to what extent, if
of pulmonary thromboembolism any, the transfusion may have contributed to death. CBER publishes an
This presentation will impact the forensic science community by annual summary of the reported fatalities. As part of its investigation,
making the public aware about the possibility of detecting morphological FDA requests the reporting facility to provide information on whether or
signs of right ventricular failure due to right heart ischemia. not an autopsy was performed, but autopsy data have never been
Pulmonary thromboembolism is a medical emergency that may published in the annual summary.
potentially determine right ventricular failure. Even if the Hypotheses: (1) Transfusion-associated fatalities reported to the
pathophysiology of this phenomenon has been widely investigated, no FDA are under-reported to ME/C systems, despite the fact that several of
morphological demonstration of right ventricular ischemic damage these deaths are due to medical errors and therefore likely be certified as
determining right ventricular failure in cases of fatal pulmonary Accidental in manner of death; (2) a significant number of these cases
embolism has been reported till now. would also otherwise typically fall under ME/C jurisdiction, such as
An immunohistochemical investigation was performed with the cases involving transfusion for traumatic injuries; (3) there is a very low
antibodies against Fibronectin and C5b-9 in 26 cases of fatal pulmonary autopsy rate in these cases; and, (4) for the group of fatalities in which
thromboembolism (16 ♀, 10 ♂, mean age 56.4 years) as well as in 25 the FDA could not rule out transfusion as contributing to the death, a
cases of acute myocardial infarction (16♀, 9♂, mean age 60.8 years) and higher autopsy rate could have potentially helped to determine the cause
20 cases of hanging (3♀, 17♂, mean age 40.8 years). In each case at of death with a higher degree of certainty and therefore allowed more
least one tissue slide from both cardiac ventricles (wall of the right definitive classification of some of these cases as either transfusion-
ventricle, anterior and/or posterior wall of the left ventricle) was related or not.
available. The reactions were semi-quantitatively classified and the Methods: After review of the 2008 U.S. FDA Annual Summary
expressions in the groups were compared. In cases of pulmonary report of fatalities following transfusion, the most recent year for which
thromboembolism the occurrence of positive reactions at the right data had been published at the initiation of the project, a Freedom of
ventricle was significantly higher than in cases of myocardial infarction Information Act request was submitted to CBER for the “Table of Final
and global hypoxia due to hanging. This may indicate the primary Conclusions” prepared by a CMO for each of the 72 reported
ischemic involvement of the right ventricle and be interpreted as transfusion-recipient deaths. Sixty-nine individual reports with some
morphological sign of right ventricular failure. data redacted were received, as three cases had been withdrawn prior to
Right Ventricular Failure, Acute Pulmonary Hypertension, CMO review. Available documents were mined for data that would
Immunohistochemistry address the hypotheses and potentially be of interest to participants of
death investigation systems.
Results: Of the transfusion-recipient deaths reported (N=69), there
were 35 males (51%), 33 females (48%), and 1 sex unspecified. Age
G49 Autopsy Performance in Transfusion ranged from 6 weeks to 97 years (median=66 years). The overall
Recipient Fatalities Reported to the United reported autopsy rate was 26% (18/69). Performance of an autopsy was
States Food and Drug Administration reported in 24% (11/46) of cases in which transfusion was determined by
the CMO to have contributed to the death and in 43% (6/14) of cases in
(FDA) During Fiscal Year 2008 which transfusion was determined to be unrelated to the death, but in
only 11% (1/9) of cases in which transfusion could not be ruled out or
Stephen L. Sgan, MD*, District 2 Medical Examiner’s Office, PO Box confirmed as contributing to the death. Human errors in pre-transfusion
14389, Tallahassee, FL 32317 specimen collection, compatibility testing or blood administration
accounted for 30% (14/46) of transfusion-related deaths; all of these
After attending this presentation, attendees will learn recent updates were due to hemolytic transfusion reactions (HTRs). Ninety percent
regarding the classification of fatal transfusion reactions, review recent (90%, 9/10) of the deaths due to ABO incompatibility (ABO HTRs)
transfusion-recipient fatality data relevant to forensic practice, especially occurred when Type A donor red blood cells were erroneously transfused
regarding autopsy performance and medical errors, consider approaches to non-A recipients, 89% (8/9) of whom were Type O. Of the deaths due
to the investigation of deaths potentially related to transfusion of blood to incompatibility of non-ABO red blood cell antigens (non-ABO
products, and learn how to contribute to the national investigation of HTRs), 71% (5/7) were due to errors that occurred in the blood bank
transfusion-associated fatalities through the FDA transfusion fatality during compatibility testing. Autopsy performance was reported in only
program. 14% (2/14) of the deaths due to human error. Trauma patients accounted
This presentation will impact the forensic science community by for 6% (four cases) of all reported deaths, and for each of these a
sharing how findings suggest that ME/C systems can provide important transfusion complication was determined to contribute to the death (three
contributions to the investigation of transfusion-related fatalities through cases) or could not be ruled out (one case). For five of the eight deaths
increased awareness, vigilance, autopsy performance, and reporting. without an autopsy in which transfusion could not be ruled out or
This presentation will inform attendees of something they do not confirmed as a contributing factor, the CMO listed a differential
know: (1) classification of fatal transfusion reactions; and, (2) recent
diagnosis that suggested autopsy findings may have helped with further a predisposing factor. In these circumstances, the development of a SDH
classification. involves necessary the intervention of trauma. It can be minimal such as
Conclusions: In this study, a significant number of reported some encountering in the impacts of everyday life. In the medical
transfusion-related deaths were due to human error. Transfusion literature, several cases of atypical chronic SDH characterized by the
complications may cause or contribute to death in cases that would presence of pre-existing pathological dural lesions, especially cancerous
typically otherwise fall under ME/C jurisdiction, including trauma cases. ones, have been described. These tumors of the dura mater can result
Lack of autopsy findings may impede the determination of whether or from primitive neoplasias of the central nervous system in the meninges
not a transfusion contributed to death and thereby prevent or from dural metastases of cancers. In the present case history, several
definitive classification. forensic medical elements contributed to the atypical nature of this
Transfusion, Fatal, Autopsy chronic SDH: no major or minor traumas were identified in this young
woman of forty years; she was non-menopausal; and she was not a
chronic or acute consumer of alcohol and/or medications that could
G50 A Case of Atypical Chronic Subdural interfere with hemostasis or coagulation. In some previous published
cases, the hypothesis of trauma, even if minimal, leading to displacement
Hematoma: A Spontaneous Rupture of of the brain within the cranial space was suggested and could not be
Dural Lymphoma Nodule? excluded. And spontaneous chronic SDH have been described. This
presentation will review the possible mechanisms which rupture the
Renaud Clement, MD*, 1 Rue Gaston Veil, Nantes, FRANCE lesion and will discuss the fact that if trauma could not be completely
excluded, the entity of spontaneous chronic SDH could be created in
After attending this presentation, attendees will understand the call forensic medicine.
for creating an entity of spontaneous chronic subdural hematoma. Subdural Hemorrhage, Forensic Medicine, Spontaneous
This presentation will impact the forensic scientist community by
presenting a case report about chronic subdural hematoma (SDH) and
the different causes of bleeding beneath the dura. G51 A Comparison of Trauma Associated
Introduction: SDH is usually associated with brain injury
following trauma. Hemorrhage resulted from the rupture of the cerebral
With Manual and Automated
bridge veins of the meninges, from a tear of superficial cortical arteries Cardiopulmonary Resuscitation
or from a focus of intraparenchymal hemorrhage associated with an
overlying contusion such as in temporal lobe which ruptures through the Deborrah C. Pinto, PhD*, Harris County Institute of Forensic Sciences,
contused cortical area. Acute SDH is due to direct impact trauma or 1885 Old Spanish Trail, Houston, TX 77054; Kathryn Haden-Pinneri,
sudden acceleration-deceleration of the head without injury of the head. MD, Harris County Medical Examiner’s Office, 1885 Old Spanish Trail,
Chronic SDH may be traumatic or may rise spontaneously. Houston, TX 77054; and Jennifer C. Love, PhD, Harris County Institute
Case Report: A 40-year-old Caucasian woman traveled to an of Forensic Sciences, 1885 Old Spanish Trail, Houston, TX 77054
African country. Her medical history included local radiation therapy,
several years beforehand, for the treatment of breast cancer. She had After attending this presentation, attendees will be able to associate
been in complete remission for more than a couple of years. This certain injury distribution patterns with the type of CPR administered.
woman’s status of health presented no constitutional or acquired This presentation will impact the forensic science community by
hemostasis disorders. She was completely free of medicine. She had no assisting medical examiners in identifying fracture distribution patterns
known addictive tendencies. Several days after her arrival, she presented associated with automated CPR specifically ZOLL AutoPulse®
paroxysmal hyperthermia, accompanied a few hours later by Noninvasive Cardiac Support Pump use. Posterior fractures such as
photophobia, difficulty in walking and confusion. Neurological state those observed with AutoPulse® CPR are generally noticed in cases of
worsened with the appearance of coma (Glasgow score of 6). She was inflicted trauma. By understanding the fracture pattern associated with
hospitalized and resuscitation measures did not prevent the patient’s AutoPulse® CPR, a potentially erroneous interpretation of therapeutic
death. Following cold storage, the victim’s body was repatriated to injuries as inflicted can be avoided.
France, where an autopsy was performed to determine the primary cause This presentation will detail the results of a retrospective study of
of death because liability could be assigned against insurance (transfer the effects of therapeutic intervention with manual cardiopulmonary
with delay time between neurological deterioration and hospitalization). resuscitation (CPR) compared to the effects of automated mechanical
On opening the cranial space, a subdural hematoma forming a right CPR device use. After this presentation, attendees will be able to
hemispheric biconvex lens was discovered. It weighed 90 grams, was associate certain injury distribution patterns with the type of CPR
wine red in color and consisted of an encased fluid mass. No traumatic administered.
lesion was found during external or internal examination of the skull. In 2007, Houston TX was selected as a test site for the ZOLL
Histological investigations then uncovered a multi-organ generalized AutoPulse® Noninvasive Cardiac Support Pump. According to ZOLL,
lymphoid infiltration. Examination of the cerebral cortex showed these the benefits of this device include continuous CPR without fatigue, relief
lymphoid infiltrations as well. A small-cell lymphoid nodule, disrupted for EMS personnel who are then free to perform other life-saving tasks,
by erythrocytes was found in the falx cerebri of the meninges. Following and improved blood flow for patients with cardiac distress. The purpose
these additional investigations the main cause of death was a chronic of this study was to identify the trauma associated with AutoPulse® use,
right circumferential SDH. This hematoma could originate with the particularly how it compares to standard manual CPR. Expanding on
“spontaneous” hemorrhagic rupture of a nodule of lymphoid infiltrate in previous research that found upper body skin abrasions associated with
the meninges of the falx cerebri. This nodule was a dural metastasis of AutoPulse® use, this study also included the occurrence of hard tissue
a multi-organ lymphoma. trauma between the two forms of CPR. It is well established that manual
Discussion: Chronic SDH is well known as incidental finding CPR can result in rib and sternal fractures. A comparison of the
during forensic autopsy. In forensic medicine, the formation of chronic distribution and frequency of manual CPR fractures to AutoPulse®
SDH is always linked to trauma. The entity of spontaneous SDH doesn’t fractures as well as abrasion occurrence can potentially help rule out
exist in forensic medicine. Chronic subdural hematomas occur more erroneous interpretations of inflicted trauma.
frequently in men, in the elderly, and in patients using anticoagulant or Autopsy records from 137 decedents brought to the Harris County
platelet aggregation inhibiting drugs. The consumption of alcohol is also Institute of Forensic Science, Houston TX, between the years 2006 to
2009 were analyzed. According to the sample records, manual CPR was In this perspective a careful gross examination and an adequate
performed on 49 individuals (24 males, 25 females) and AutoPulse® CPR sampling of the thyroid gland are mandatory. Findings obtained by
was used on 88 individuals (52 males, 36 females). The median age for histology and updated tissue analyses should be always interpreted in
the manual CPR group was 48 years and the AutoPulse® CPR group was relation to complex data coming from a multidisciplinary approach,
54 years. The distribution of rib fractures from the anterior, lateral, and finally leading per exclusionem to the diagnosis of sudden death due to
posterior compartments as well as sternal fractures and skin abrasions an episode of transient thyrotoxicosis. Silent (painless) thyroiditis is
were recorded. Kruskal-Wallis ANOVA comparisons between fractures regarded as follicular destruction-induced hyperthyroidism resulting in
from the manual CPR group and the AutoPulse® CPR group the release of stored thyroid hormones in the circulation. The above
demonstrated a statistically significant difference (p<0.05) between the mentioned disease is characterized by a transient hyperthyroidism with
number of anterior fractures, lateral fractures, posterior fractures, sternal spontaneous resolution in two to five months, even though cases of
fractures, and skin abrasions. In manual CPR, anterior fractures had the relapse can occur quite often. The thyrotoxic phase of this syndrome is
highest frequency followed by lateral fractures. Posterior fractures were short and requires no, or only symptomatic therapy, but it is assumed that
only found in one case, secondary to body placement during manual untreated thyrotoxicosis might lead to sudden death by several
CPR. In AutoPulse® CPR, anterior fractures had the highest frequency mechanisms (cardiac arrhythmia, hyperpyrexia, electrolyte disturbances,
followed by posterior fractures and lastly, lateral fractures. Sternal and epileptic seizures). Macroscopically the thyroid glands are normal
fractures were found at a higher frequency in the manual CPR group than sized and non tender; histologically, focal, or diffuse lymphocytic
the AutoPulse® group. Skin abrasions were more common in the thyroiditis is present. In some cases anti-thyroid antibodies can be
AutoPulse® CPR group, located primarily along the anterior chest, lateral detected, indicating an autoimmune pathogenesis and postmortem
chest, and shoulder. In the few cases that abrasions were observed in the dosage of thyroid hormones, when interpreted in relation to the
manual CPR group, they were located along the sternum. histological findings, can provide further information about the
The results of this study identify the distribution patterns of functional status during life.
fractures associated with manual and automated CPR. When rib In the present case a previously healthy 18-years-old woman was
fractures are found in the anterior or lateral rib cage in association with found dead prone near the entrance of her house, where she was living
sternal fractures, they are consistent with manual CPR. When rib alone. The crime scene investigation did not offer any significant
fractures are found in the anterior and posterior compartments with chest finding, and external examination of the body showed a single contusion
skin abrasions, they are consistent with automated CPR resulting from at the forehead, consistent with an accidental fall from the standing
AutoPulse® use (and not other types of devices, which were not included position. Clinical history was unremarkable, but information regarding
in this study). It should be noted that it is mandatory for Houston EMS a possible family history of thyroid disease was not available.
personnel to initially administer manual CPR before AutoPulse® use and Full autopsy was carried out including a detailed
this combination may account for the anterior rib fractures observed in macroscopic/microscopic cardiac examination, tissue molecular
the AutoPulse® CPR group. During manual CPR, chest compressions analyses for viral detection, chemical analyses, and toxicology. At the
are administered for an extended period of time, thus causing sternal autopsy all internal organs were unremarkable and the thyroid gland was
fractures. The small number of sternal fractures seen in AutoPulse® macroscopically normal. The one relevant pathological finding was a
CPR is likely due to the short duration of manual CPR. The significance prominent lymphocytic infiltration with follicular disruptions, rare
of this study to the forensic community is in the importance of oxyphilic changes and low grade fibrosis. Since the histological picture
identifying fracture distribution patterns associated with AutoPulse® use. was consistent with lymphocytic thyroiditis, immunophenotype
Posterior fractures such as those observed with AutoPulse® CPR are characterization and lymphocyte clonality analyses were performed in
generally noticed in cases of inflicted trauma. By understanding the order to rule out the diagnosis of hematologic malignant neoplasm.
fracture pattern associated with AutoPulse® CPR, medical examiners can In this case the lymphocytic thyroiditis could by exclusion offer a
avoid a potentially erroneous interpretation of therapeutic injuries reasonable explanation of the sudden unexpected death occurred during
as inflicted. an episode of transient thyrotoxicosis, cardiac arrhythmia being the most
Trauma, Cardiopulmonary Resuscitation, Fractures likely mechanism of death.
In consideration of the autoptical findings, further investigation into
the medical history was carried out, revealing that the deceased a few
G52 Sudden Unexpected Death Associated With days before death complained chest pain to the general practitioner;
moreover, three months before she required the prescription for
Undiagnosed Lymphocytic Thyroiditis: psychoactive drugs, due to the recent onset of insomnia and unexplained
Report of a Case and Literature Review anxiety; contemporaneously, she was noticed loosing weight.
Since the young woman had one sister and one brother, at the end
Silvia Tambuscio, PhD*, University of Verona, via Rezzonico, 24, 35131, of the medico-legal investigation a clinical diagnostic protocol on the
Padova, ITALY; Jennifer Pascali, PhD, University of Verona, Piazzale relatives was recommended to the general practitioner.
L.A. Scuro 10, Verona, IL 37100, ITALY; Andrea Galassi, MD, S.Bortolo In conclusion: the presented case highlights to forensic pathologists
Vicenza Hospital, via Rodolfi 37, Vicenza, IL , ITALY; Federica the importance of sampling and careful studying the thyroid gland to
Alessandrini, PhD, Università Politecnica delle Marche, via Conca 6 evaluate the possible role of a thyrotoxic episode related to a silent
Torrette, Ancona, IL 60126, ITALY; and Fiorella Calabrese, MD, thyroid disease, as a cause of sudden death in otherwise unexplained
University of Padova, via A.Gabelli61, Padova, 35121, ITALY fatalities. Review of the literature reported only a few cases of
lymphocytic thyroiditis as a possible cause of death, but in such cases a
After attending this presentation, attendees will have a better full multidisciplinary approach (with special regard to biomolecular and
understanding of the significance of pathological changes in the thyroid chemical analyses) was not carried out.
gland in determining the cause of death, since in many patients thyroid Furthermore, the present case investigation, first aiming to the
dysfunction remains undetected during life, due to the lack of clinical solution of forensic concerns, also represented the start up for diagnostic
signs and symptoms characterizing some nosographic entities, such as protocol on the relatives, at that time still asymptomatic, with final
silent (painless) thyroiditis, or the Hashimoto disease. possible positive outcome on their health care.
This presentation will impact the forensic science community by Silent Thyroiditis, Sudden Death, Thyrotoxicosis
emphasizing the importance of taking all natural diseases into proper
account when investigating sudden deaths, even if clinical records are
not indicative or when the anamnesis is poor.
G53 The Pattern of Immunoreactivity for von control case, internal positive controls (arterial endothelium), and
internal negative controls (hepatic veins and sinusoids). In TTP, there
Willebrand Factor in a Variety of was dense, relatively homogeneous staining of the entire vWF-rich
Thrombotic States thrombus. In NBTE, there was variably dense, granular staining of
characteristically platelet-rich bland vegetations (both on valves and in
Stacey A Simons, MD*, Miami Dade County Medical Examiner embolized material). In renal allograft rejection, there was
Department, Number One on Bob Hope Drive, Miami, FL 33136; Paul heterogeneous staining, most dense in areas of vascular damage, with
E. Swanson, MD, University of Washington Division of Anatomic only minimal peripheral staining of the thrombi.
Pathology, 1959 Northeast Pacific Street, Seattle, WA 98195; and Aldo In HUS, there was minimal peripheral staining of thrombi. In
J. Fusaro, DO, King County Medical Examiner’s Office, 908 Jefferson disseminated intravascular coagulation (DIC), and in stasis thrombosis
Street, Seattle, WA 98104 (the latter secondary to a myocardial infarct), there was focal dense
staining only within the more cellular “layered” regions of organizing
After attending this presentation, attendees will understand the role thrombi, where platelets may become entrapped.
of von Willebrand Factor (vWF) in thrombotic thrombocytopenic Tissue from the presented case demonstrated vWF-rich thrombi in
purpura (TTP) and recognize variations in patterns of cardiac and renal vessels as well as in rare small cerebellar vessels, and
immunohistochemical staining against von Willebrand Factor antigen in looked most similar to the mixed immune-TTP control tissue, supporting
thromboemboli from thrombotic thrombocytopenic purpura, hemolytic myocardial necrosis secondary to TTP as the cause of death.
uremic syndrome, disseminated intravascular coagulation, non-bacterial Overall, this case with its corresponding array of tissue controls
thrombotic endocarditis, renal allograft vascular rejection, and stasis represents a spectrum of patterns that correlates well with the
thrombosis. pathophysiology of each specific pathologic entity. In conclusion, when
This presentation will impact the forensic science community in interpreted in combination with anatomic findings at autopsy, vWF
cases of precipitous deaths with little or no antemortem workup that are staining provides support for a diagnosis of TTP even when the clinical
characterized by a thrombotic state. Although previous reports have history is limited or atypical.
discussed the value of immunohistochemical staining against von TTP, von Willebrand, Hemolysis
Willebrand Factor antigen in deaths where thrombotic thrombocytopenic
purpura is suspected, this is the first case report to provide images that
demonstrate the staining patterns of several other entities within the G54 Giant Cell Myocarditis as a Cause of
differential diagnosis.
Although previous reports have detailed the value of this stain in
Sudden or Unexpected Death: A Report of
deaths where TTP is suspected, this is the first case report to provide Two Cases and a Review of the Literature
images that demonstrate the staining patterns of several other entities
within the differential diagnosis. The variations appear to reflect the Steven M. White, PhD*, Mitra B. Kalelkar, MD, and James A. Filkins,
etiology of the thromboemboli and their relative content of vWF. The JD, PhD, Office of the Medical Examiner, County of Cook, 2121 West
visual references included here will be especially helpful to the medical Harrison Street, Chicago, IL 60612
examiner in cases of precipitous death when there has been little or no
antemortem workup. After attending this presentation, attendees will have an awareness
TTP is a thrombotic microangiopathy, historically requiring a of giant cell myocarditis as a cause of sudden or unexpected death and
pentad of symptoms for clinical diagnosis: microangiopathic hemolytic its diagnosis.
anemia; thrombocytopenia with or without purpura; acute renal This presentation will impact the forensic science community by
insufficiency; fever; and neurologic abnormalities. It is now understood increasing knowledge and awareness of an uncommon cause of sudden
that few patients present with all features; however, the presence of or unexpected death with two case presentations.
neurologic abnormalities is often helpful in distinguishing TTP from Giant cell myocarditis (GCM), formerly known as Fiedler’s
hemolytic uremic syndrome (HUS). myocarditis, is an inflammatory process of unknown etiology restricted
The case of an adult male is presented with microangiopathic to the heart, typically occuring in young and middle-aged adults. There
hemolytic anemia, thrombocytopenia, and an episode of hematuria two is no clear gender predilection, but the prevalence of GCM is higher in
days prior to hospital admission. The patient did not report diarrhea or caucasians than in other races. Because of its isolation to the heart and
fever, and did not exhibit neurologic symptoms. Pulseless electrical fulminant clinical course resulting in sudden or unexpected death, GCM
activity and renal failure were present at the time of admission. The is usually diagnosed at autopsy, and therefore may be encountered in a
patient had a rapid clinical decline and died before a diagnosis could be forensic setting. Gross findings at autopsy are variable.
made. Autopsy did not reveal significant gross pathology. Histologic Microscopically, there is myocyte necrosis associated with an
sections contained myocardial necrosis with relatively widespread inflammatory infiltrate composed of histiocytic giant cells, lymphocytes,
microthrombi in small cardiac vessels and, less frequently, microthrombi and scattered eosinophils. The differential diagnoses of GCM include
within glomeruli and renal arterioles. Vascular lesions also included other forms of granulomatous myocarditis, such as sarcoidosis and
intimal thickening and disruption, and fragmented red cells. infectious etiologies. In contrast with sarcoidosis, GCM is typically
TTP is currently thought to be driven by a deficiency in ADAMTS- localized to the heart and has a fulminant clinical course. Infectious
13, a metalloprotease that cleaves vWF to render it ineffective in its role etiologies can be excluded with the use of special stains. GCM is a rare
in intravascular platelet aggregation. Deficiencies may be inherited or cause of sudden or unexpected death with a very low prevalence as
acquired, and may lead to unchecked formation of vWF-rich thrombi in reported by other studies.
those vessels subject to shear stress (including arterioles and capillaries). A search of the records of the Cook County Medical Examiner’s
Because vWF is produced in arterial endothelial cells and Office identified 72 cases in which myocarditis was the principle or
megakaryocytes, thrombotic lesions in TTP, non-bacterial thrombotic contributing factor to death in adults aged 18 and older. The search
endocarditis (NBTE) and allograft vascular rejection will demonstrate covered the period from January 1, 2000 through July 15, 2010. Of these
immunoreactivity to vWF antigen. The characteristically fibrin-rich 72 cases, only two were cases of giant cell myocarditis. The remaining
thromboemboli formed in states that are not mediated by vWF will 70 cases consisted of neutrophilic, lymphocytic, or mixed inflammatory
exhibit minimal-to-no immunoreactivity. infiltrates.
Tissue controls in the current report included a single example of The first case is a 39-year-old African-American female with a
each aforementioned disease entity, including a mixed immune-TTP history of hypertension and obesity, who presented to the emergency
room with shortness of breath and sinus tachycardia. Two days prior to External examination revealed a drainage located in left hemithorax
this event, she was seen in the emergency room with fever, malaise, and in the first intercostal space; another one in the right hemithorax in the
an elevated white blood cell count, and was discharged. Soon after fifth intercostal space, two needle marks in the left third intercostal space
presentation to the emergency room, she developed pulseless ventricular and in the right second intercostal space; cyanosis of finger nails of both
tachycardia despite pharmacologic therapy. Following synchronized hands was present.
cardioversion and a brief period of asystole, she developed sinus Internal examination revealed emphysema in subcutaneous soft
bradycardia. Transcutaneous pacing was attempted, but she progressed tissue of the thoracic and abdominal regions, in greater omentum and in
to ventricular fibrillation, then asystole. She died within two hours of the visceral adipose tissue. Also observed marked mediastinal
admission. At autopsy, the heart was enlarged, weighing 487 grams. emphysema, bilateral pneumothorax and reduced volume of the lungs.
Grossly, there was concentric left ventricular hypertrophy and the The macroscopic examination of the heart showed collapse of the
myocardium was uniformly red/brown with the exception of the fossa ovalis, redundant, with diameter of 2.5 centimeters and with two
papillary muscles of the left ventricle, which were pale yellow/gray. perforations: the first one with maximum diameter of 1 centimeter and
Microscopic examination of the heart revealed foci of myocyte loss, the second one of 0.5 centimeter, divided by fibro-muscolar biceps. The
fibrosis, and chronic inflammation with scattered giant cells right ventricle was dilated with thin walls (0.3 centimeter maximum
predominantly in the papillary muscle. Other findings at autopsy thickness), left ventricle slightly dilated with a free wall of 1.5
included cerebral edema, splenomegaly, and chronic passive congestion centimeters.
of the liver. Toxicologic studies were negative for ethanol, opiates, or The observation of air breath showed in the right intermedium
cocaine. bronchus an “S”-shaped laceration with frayed margins slightly that
The second case is a 33-year-old African-American female with no involved, in the point of the bifurication with medium lobe, in the
prior medical history, who collapsed suddenly at a nightclub. At autopsy, extraparenchymal intrapleuric tract, half circumference of the bronchus.
her heart was enlarged, weighing 426 grams. Grossly, there were The dissection of the lungs revealed congestion and hemorrhagic
geographic areas of pallor from base to apex involving the myocardium edema. There was hypoxic ischemic multiorgan damage.
of the anterior, lateral, and septal walls of the left ventricle. Histologic assays showed massive right endo-bronchial bleeding
Microscopically, there was extensive fibrosis and inflammation with and the site of the bronchial lesion was characterized by incomplete
numerous giant cells and only small islands of preserved myocardium. breakup of a cartilaginous ring in correspondence of one of the
Other findings at autopsy included pulmonary congestion and an extremities; the adjacent pulmonary vein with massive blood infiltration
incidental ovarian teratoma. Toxicologic studies were negative for of the nearest soft tissues. The borders of the vascular breakup were
opiates or cocaine. irregularly dissected and infiltrated by blood cells; in the context of the
These cases are reported to demonstrate the variation in clinical vascular wall other breaches were observed with partial tonaca media’s
presentation and autopsy findings of GCM, as well as to illustrate that dissection. Hemorragic edema was found in pulmonary parenchyma
GCM remains a rare cause of sudden or unexpected death even in a busy, with red cells infiltration of the nearest soft tissues and sub-pleural
urban medical examiner’s office. tissues, in association with emphysematous blebs.
Myocarditis, Sudden or Unexpected Death, Heart Disease On the macro-microscopic evidences the cause of the death has
been attributed to an acute respiratory insufficiency by severe
pneumothorax following bronchial breakup; the typology of death is
G55 Death Due to Atrial Septum Defect attributable to “therapeutic complication.”
Along with the histological assays, the authors have verified the
Repaired by Transcatheter Closure: iatrogenic nature of the breakup; besides, using the classic forensic
Who Failed? criteria the pathologists have attributed the professional liability to one
of the professional figures (echocardiographist, hemodinamist,
Eugenia Di Stefano, MD*, Via Raffaello N°9, Palermo, 90100, ITALY; anesthetist) involved in the management of the young patient.
Filippo Maria Cascino, MD*, Department of Biotechnology and Legal Transcatheter Closure, Atrial Septum Defect, Bronchial Lesion
Medicine, Section of Legal Medicine, Via del Vespro 129, Palermo,
90127, ITALY; and Graziana Farina, MD, Roberto Guarino, MD,
Nunzia Albano, MD, and Emiliano Maresi, Via Del Vespro 127, Palermo, G56 Dissecting Intramural Hematoma of the
90100, ITALY
Esophagus: A Rare Case of Sudden Death
After attending this presentation, attendees will learn about the role
of the forensic pathologist in transcatheter procedures and professional Cristoforo Pomara, PhD*, University of Foggia, Department of
liability. Forensic Pathology, Viale Degli Aviatori 1, Foggia, 71100, ITALY;
This presentation will impact the forensic science community by Alessandra De Salvia, PhD, University of Verona, Department of
showing a case report regarding a bronchial lesion following Forensic Pathology, Policlinico G. B. Rossi, Verona, 71100, ITALY;
transcatheter procedure. Antonio Nieddu, MD, University of Sassari, Department of Forensic
A 13-year-old Caucasian male, with past medical history of ostium Pathology, Sassari, Sassari, ITALY; and Stefano D’Errico, PhD,
secundum atrial septal defect previously treated using septal occlusion University of Foggia, Department of Forensic Pathology, Viale Degli
device with no success. Aviatori, Foggia, 71100, ITALY
After a period of time, a new surgical access procedure was
performed on the young man using transcatheter closure procedure. The After attending this presentation, attendees will learn that dissecting
device should be placed in the atrial septum via catheter introduced into intramural hematoma of the esophagus is a rare condition with excellent
femoral vein. The access was monitored with transesophageal prognosis when treated conservatively. Spontaneous ruptures of
echocardiography. The medical record states that twenty minutes after hematoma are rarely described as well as sudden death due to DIHO.
the start of surgery, a sudden decrease of oxygen saturation, and This presentation will impact the forensic science community by
contemporaneous sub-cutaneous emphysema occurred. In spite of presenting the rarity of the fatal events due to DIHO and the autopsy
cardio-polmunary resuscitation maneuvers and following placement of technique performed in visualizing rupture, preserving anatomical
the trocar and thoracic drainage system, the young man died, because of relationship between cervic-thoracic organs.
a contemporaneous ventricular fibrillation. Dissecting intramural hematoma of the oesophagus (DIHO) is a
rare condition in which intramural hemorrhage leads to submucosal
dissection of the oesophageal wall. It is usually associated with a rapid G57 Anaphylactic Shock and Postmortem Exam
increase in intraoesophageal pressure, trauma or a coagulation disorder.
The clinical presentation is with chest pain, hematemesis and
– A Systematic Approach
dysphagia/odynophagia and an accurate history is vital to help
distinguish it from other causes of acute chest pain, such as myocardial César L. Santos, MD*, and Beatriz S. Silva, MD, Portuguese National
infarction, aortic dissection or oesophageal perforation. The three Institute of Legal Medicine, Delegação do Centro do INML, IP, Largo da
different types of acute oesophageal injury are a mucosal tear (Mallory– Sé Nova, 3000-213, Coimbra, PORTUGAL; and Duarte N.P. Vieira, PhD,
Weiss syndrome), full-thickness rupture (Boerhaave’s syndrome) and Rua Antonio Jose de Almeida, No 117, Coimbra, 3000-044, PORTUGAL
dissecting intramural hematoma. Neither the Mallory-Weiss nor the
Boerhaave lesions are associated with submucosal hematomas or After attending this presentation, attendees will have an insight
dissections. In some cases the first event may be hemorrhage into the about the efforts being made by the Portuguese National Institute of
submucosa with secondary rupture into the lumen. The differential Legal Medicine in order to harmonize the methodology of forensic
diagnosis includes other causes of central chest pain and it is vital to autopsies, since not all the medical forensic experts have the specialty of
obtain an accurate history of both gastrointestinal and cardiovascular legal medicine.
symptoms. Analysis of the precipitating factors suggests that there are This presentation will impact the forensic science community by
three main subgroups. Firstly, a sudden pressure change in the informing attendees of the attempt to establish specific rules concerning
oesophagus (e.g., swallowing, vomiting) perhaps associated with a the approach of fatal cases of suspect anaphylactic reactions.
temporary disruption in the normal co-ordinated opening mechanism of The anaphylactic shock is classified as a type I of hypersensitivity
the upper and lower oesophageal sphincters. Secondly, direct injury reaction that occurs due to the release of biologically active agents,
following an endoscopic therapeutic intervention (e.g., oesophageal among them, histamine. It is due to exposure to allergens of different
dilatation). Thirdly, about one fifth of patients appear to have a truly types, like drugs, food, animal sting, animal fur. If not promptly
spontaneous origin although this may be associated with an underlying reversed, the outcome can be fatal.
predisposition to abnormal pressure changes within the oesophagus (e.g., The relevance of available circumstantial information, namely
achalasia) or a bleeding disorder (e.g., due to anti-platelets, anti- context and symptoms prior to death, previous medical history and
coagulants or thrombolytics). The pathophysiology is characterized by possible life support procedures applied will be discussed.
submucosal hemorrhage that dissects the submucosa and classically The need for a thorough external examination of the corpse is also
occurs in the distal oesophagus because this region is least supported by addressed, in order to search, for instance, for possible sting marks or
adjacent structures such as the trachea or heart. hives-like lesions that may help to support the diagnostic.
A rare case is presented of sudden death due to spontaneous rupture Overall, postmortem findings, either in the external and internal
of DIHO occurred in a 42-year-old woman presented at local emergency examination, are usually nonexistent or nonspecific, the forensic expert
department with a 24 hour history of sudden onset severe central chest should collect all body samples that may be needed later on to reach a
and interscapular pain associated with dysphagia and odynophagia. more accurate diagnosis.
There was no history of vomiting, hematemesis or trauma. There was Therefore, besides the routine histology (heart, lungs, liver and
little previous medical history of note and he was not taking any regular kidneys), the collection of samples from other organs with known
medication. On examination, vital signs were: blood pressure, 104/49 increased mastocyte cells population is recommended. Toxicological
mmHg with no differential between arms; pulse, 125 beats/min; exams should contemplate drugs, abuse drugs and/or pesticides,
respiratory rate, 24 breaths/min; body temperature was normal. There according to the specificity of the case.
was no abdominal tenderness and no maelena. EKG was unremarkable Also highlighted is the relevance of collecting peripheral blood for
as well as cardiac enzymes. Clinical conditions suddenly got worse; the IgE and tryptase concentration levels and that this task should be
woman collapsed and resuscitation maneuvers were unsuccessful. undertaken as soon as possible after the judiciary’s authorization for the
Autopsy was performed the day after death. Massive hemothorax was autopsy.
recorded. Thoracic and abdominal organs were removed en masse Because of the lack of relevant findings, death by anaphylactic
according to Letulle technique and fixed in 10% buffered formalin for a shock is considered a diagnosis of exclusion, that is achieved through the
detailed macroscopic examination. All other organs examination was evaluation of the available circumstantial information, the findings (or
unremarkable except for cerebral oedema. Vessels were poor of blood. their nonexistence) in the external and internal examination and results
Lungs were increased in volume and size, with few subpleural of ancillary investigation, namely, histology, in some cases
hemorrhagic spots. Mild white foam on the main bronchi was also complemented by immunohistochemical techniques (anti-tryptase and
detected. Heart was normal in size and volume, with conical shape. anti-CD117), toxicology and serology (IgE and tryptase).
Coronaries examination was unremarkable. A large bluish/red Based on the most recent scientific knowledge, a comprehensive
intramural haematoma of the posterior wall of the oesofagus extending protocol was designed with the purpose of being applied to this situation
from just below the cricopharyngeous to the gastro-oesophageal junction and serve as a guideline to forensic autopsies.
was recorded with a complete rupture of the oesophagus wall in the Forensic Autopsy, Anaphylaxis, Protocol
proximal third. Mild cerebral odema and focal pulmonary oedema were
observed at histological examination with standard H&E staining.
Histological examination of heart was unremarkable except for few foci G58 Spontaneous Pulmonary Arterial
of contraction band necrosis. Sample of oesophagus dissection was Dissection: A Case Report
collected excluding recognizable abnormality in the muscle layers,
except for rupture. A complete immunohistochemical panel has been Margherita Neri, PhD*, Stefania Bello, MD, Raffaella Bisceglia, MD,
performed on esophagus samples. Genetic investigations had been and Carmela Fiore, MD, Department of Forensic Pathology, University
performed also. of Foggia, Viale degli Aviatori 1, Foggia, 71100, ITALY
DIHO, Spontaneous rupture, Sudden Death
The goal of this presentation is to present a fatal case of
spontaneous pulmonary arterial dissection with a wide
immunohistochemical study about alteration of pulmonary wall.
This presentation will impact the forensic science community for
the rarity of the deaths due a spontaneous dissection of the pulmonary
trunk.
Unlike dissection in systemic arteries, pulmonary artery or main A fatal hemopericardium caused by spontaneous pulmonary artery
pulmonary branche dissection, is usually lethal. So the diagnosis of this dissection was recorded as the cause of death. The histological
condition is very rarely made during life and most commonly diagnosed investigation of the pulmonary artery samples revealed the absence of
at autopsy in cases of sudden and unexpected death. Hemorrhagic hypertensive arterial changes and the immunohistochemical showed the
pericardial effusion and cardiac tamponade usually follow the outward absence of any connective tissue disease of the pulmonary trunk. So the
rupture of the proximal main pulmonary artery. presented case illustrates a very rare cause of sudden death in a
With regard to pathogenesis, pulmonary artery dissection is spontaneous dissection of a normal pulmonary trunk.
strongly associated with primary and much more frequently, secondary Spontaneous Pulmonary Dissection, Sudden Death,
pulmonary hypertension. Secondary pulmonary hypertension most often Immunohistochemistry
results from congenital cardiac lesions, above all with various forms of
left-to-right shunting, most commonly patent ductus arteriosus, or
congenital ventricular septal defect. These cardiac conditions predispose G59 Inherited Cardiac Diseases and Molecular
individuals to the development of pulmonary artery aneurysm by
generating sustained high pulmonary flow rates and pulmonary artery
Autopsy: Perspectives and Limitations
pressure. However, other possible causes are Marfan syndrome and
other connective tissue diseases, infectious processes and inflammatory Katarzyna Michaud, MD*, Centre Universitaire Romand de, Medecine
conditions, such as Behcet disease. Anyway pulmonary artery dissection Legale, Rue du Bugnon 21, Lausanne, 1005, SWITZERLAND; Florence
is exceedingly rare in the absence of pulmonary hypertension or other Fellmann, PhD, University Service of Medical Genetics, Lausanne,
pathologic conditions. 1010, SWITZERLAND; and Patrice Mangin, PhD, Centre Universitaire,
The clinical presentation of pulmonary artery dissection is highly Romand de Medecine Legale, Rue du Bugnon 21, Lausanne,
variable and the symptoms are nonspecific, most frequently chest pain, CH-1011, SWITZERLAND
dyspnea, cyanosis, and hemodynamic compromise. Diagnostic
instruments for this condition are noninvasive imaging techniques, After attending this presentation, attendees will understand the
including echocardiography, CT, and magnetic resonance imaging importance of postmortem genetic testing, as well its limitations for the
(MRI). diagnosis of sudden cardiac death in young adult or in sudden infant
The vascular histopathologic changes associated with the majority death sysdrom (SIDS) cases.
of pulmonary artery dissections involve medial degeneration, with This presentation will impact the forensic science community by
fragmentation of elastic fibers. These changes may represent an intrinsic presenting the practical approach to a new diagnostic tool in cases of
weakness in the vessel wall which is compounded by the increased sudden death in the forensic context.
hemodynamic shear stresses of pulmonary hypertension, thereby Cardiac diseases of genetic origin are often the cause of sudden
predisposing an intimal tear. The pathogenetic mechanism of dissection death, especially in young individuals. Postmortem genetic testing, also
in absence of histopathologic alterations remains substantially unclear. known as molecular autopsy, is recommended in cases of sudden cardiac
The case presented concerns sudden death due to spontaneous death with a negative autopsy. These deaths are currently considered to
pulmonary artery dissection. be due to sudden arrhythmic death syndrome, and are reported in up to
A 72-year-old woman was admitted to the Emergency Department 40% of sudden cardiac deaths of young adults. The studies performed
for chest pain, spread to mandible, dyspnea, and jugular tightness, and on cases of sudden infant death syndrome (SIDS) indicate that
she referred these symptoms after bleach inhalation during approximately 5–10% of SIDS is due to defective cardiac ion channels.
housecleaning. Rhythm disturbances observed in genetically determined cardiac
Physical examination, ECG and CT were unremarkable. Cardiac diseases are not always lethal, but can have dramatic consequences if the
ultrasonography showed concentric ventricular hypertrophy and individual is driving or swimming, for example.
ascending thoracic aorta ectasia (50 mm). Laboratory blood values Several cases of sudden death resulting from different genetically
demonstrated neutrophilia, lymphopenia, monocytosis and increased determined cardiac pathologies will be presented. In some cases, a
erythrosedimentation rate. Two days later she died. morphological substrate, such as arrhythmogenic right ventricular
A postmortem examination was performed and revealed a large dysplasia/cardiomyopathy (ARVD/C) or hypertrophic cardiomyopathy
hemorrhagic area in left posterior mediastinum and pericardial sac (HCM) was observed at autopsy and confirmed by histological
containing approximately 150 ml of blood and 250 g of clotted blood. examination. In others cases without any pathology observed during
The source of hemorrhage was readily identified as a 2 cm tear in the standard autopsy procedures, and after a negative toxicological analysis,
wall of the pulmonary trunk and so dissection and rupture of the artery. mutations in the three genes most frequently implicated in inherited
Microscopic sections of the pulmonary artery revealed regular arrhythmias SCN5A, KCNQ1, and KCNH2 were found. In the
morphology of the wall layers. The medial layer showed fragmentation remaining cases even the molecular autopsy was negative.
of elastic fibers, marked fibrosis and copious erythrocytes. In a section The first case is a 33-year-old man who died after losing control of
the intimal tear was identified as initial site of dissection. his vehicle. ARVD/C was found at autopsy. No traumatic lesions were
The immunohistochemical investigation of the pulmonary artery observed and it was determined to be a natural death. The second case
samples in whole artery wall and in laminar dissection was performed is an 18-year-old man who died after a football match. The only
with antibodies anti TGF-beta-1, TGFBR1 (ALK-5) e TGFBR2, ALK-1, significant finding at autopsy was the ARVD/C. In this case, an
fibrillin and endoglin. Fibrillin showed a massive and diffuse positive electrocardiogram recorded a few weeks before his death showed
reaction of the whole pulmonary artery near the dissection, but it showed pathological patterns pathognomic for the ARVD/C. In one SIDS case,
negative reaction in laminar dissection; Endoglin showed a weak the molecular autopsy showed mutations in the KCNH2 gene and in
positive reaction in the whole artery and a negative reaction in the another SIDS case a genetic variant in the SCN5A gene. Both have been
laminar dissection; TGF-beta1 revealed a weak positive reaction in the described in long QT-cases. In the last presented SIDS case, molecular
whole pulmonary artery and a strong reaction in the laminar dissection; autopsy was negative but a positional asphyxia was evoked after scene
TGFBR1 and ALK-1 showed a moderate positive reaction in the whole investigation and a cartilaginous meta-hyperplasia of the cardiac
pulmonary artery wall and a massive positive reaction in laminar conduction system was observed.
dissection; TGFBR2 revealed a massive positive reaction of the whole The major limitations of the molecular autopsy in forensic practice
pulmonary artery, but it showed moderate reaction in laminar dissection. are the cost of the analyses, the accessibility of a competent laboratory
and the legal aspects of postmortem genetic testing. The interpretation
of the results and their transmission to the families can also prove to be temporal lobe with massive oedema and compression phenomena on
problematic. Due to the heritability of genetically determined cardiac occipital and temporal lobe and midline shift. The patient was then
disease, the autopsy diagnosis is very important for any living relatives. referred for neurosurgical consultation, but the day before surgery he
Collaboration with cardiologists and geneticists allows proposing suddenly died. General autopsy performed 48 hours after death was
multidisciplinary consultations to them. unremarkable. The brain weighed 1600 g and measured (cm 22x16x6.5)
In conclusion, the molecular diagnosis of cardiac arrhythmias showed diffusely swollen cerebral hemispheres and an increase in
represents a very useful and attractive tool in cases of sudden death. volume of the left temporal lobe. There was no herniation of the
However, even if the case is presumed to be related to a hereditary temporal lobe unci or cerebellar tonsils. On coronal section, after
cardiac disease the classical guidelines of autopsy practice should be fixation, the left temporal lobe showed a large mass lesion, which
respected (scene investigation, histological examination, toxicological measured 3x2.5x2.2, hemorrhagic and surrounded by necrotic and
analyses etc.) to avoid the over interpretation of the results of the oedematous tissue.
molecular autopsy. Moreover, due to the heritability of genetically Case 3: a 71-year-old-Caucasian man, with a past history of
determined cardiac disease, the potential implications for living relatives hyposthenia of the right arm, cervical spine surgery, chronic kidney
must be taken into consideration and genetic counseling should be disease, and hepatic steatosis. During his detention, showed headache,
proposed to the family. confusional state, and difficulty in walking therefore he was transferred
Molecular Autopsy, Sudden Cardiac Death, Channelopathies to the local hospital. The neurological examination revealed poor
general condition, marked weight loss, ataxia and ideomotor slowing,
depressive syndrome, apathy, fatigue, and lack of initiative. The
G60 Sudden, Unexpected Death Due to laboratory examination of blood and liquor was negative for infection-
inflammatory disease. To diagnose a multi-infarct dementia the patient
Glioblastoma: Three Fatal Cases was scheduled for TC and magnetic resonance imaging of the brain and
the entire spine, but suddenly died prior to the imaging. At autopsy a
Irene Riezzo, PhD*, University of Foggia, Osp D’Avanzo, Department of moderate pulmonary edema and polyvisceral stasis were observed. The
Forensic Pathology, Viale Degli Aviatori, 1, Foggia, 71100, ITALY; brain weighed 1550 g and showed massive edema. A spherical
Santina Cantatore, Benedetta Di Battista, MD, Ruggero Parente, MD, gelatinous solid mass, measuring 1 cm in diameter was attached in the
and Francesco Ventura, MD, University of Genova, Department of right medulla. On coronal sections, the right temporal lobe showed a
Forensic Pathology, Via de’ Toni, 12, Genova, 16132, ITALY reddish-rusty mass lesion, measuring 1x2 cm and the third ventricle was
compressed and dislocated.
The goal of this presentation is to present three cases of sudden, The etiopathogenetic definition was outlined by histological
unexpected death due to glioblastoma, with different brain localization examinations performed on brain tissue samples using haematoxylin-
and expression. eosin (H&E) and Perl’s and revealed the presence of diffuse and marked
This presentation will impact the forensic science community by cytotoxic and vasogenic brain edema, and in samples taken from left
disussing how a complete methodological forensic approach by means of frontal lobe (case I), left temporal lobe (case II), right medulla and
autopsy, histological and immunohistochemical examinations let us to temporal lobe (case III) foci of central necrosis surrounded by neoplastic
conclude for an acute central dysregulation caused by glioblastoma and cells with nuclear pleomorphism, pseudopalisading, multinucleated cells
relative complication with rapid increase of intracranial pressure as (“giant cells glioblastomas”) and vascular proliferation. Areas of
cause of death. extensive haemorrhage near tumor cells were also observed.
Glioblastoma is the most common malignant primary brain The immunohistochemical examination of the brain specimens
neoplasm, representing about 12-20% of all intracranial tumors and revealed a positive reaction for antibodies anti-GFAP (glial fibrillary
accounting for about 50-60% of all astrocytic gliomas. In the most acidic protein), CD68, vimentin and S-100; NSE (neuron-specific
European and North American countries, the incidence is approximately enolase), smooth muscle actin, CD34, cytokeratins MNF 116, EMA
2-3 new cases per 100,000 people per year. The incidence of sudden (epithelial membrane antigen), synaptophysin, HMB45 (Human
death due to undiagnosed primary intracranial tumor is low in forensic Melanoma Black) were negative. The positive reaction for GFAP was
autopsy and is an uncommon event. In fact only 12% of all cases of confirmed by Western blotting. The other organs showed signs of central
sudden unexpected death due to primary intracranial tumors are due to dysregulation (pulmonary oedema).
glioblastomas. The death was attributed in the first and second case to brain edema
Three cases of sudden unexpected death due to glioblastoma and massive hemorrhage into the glioblastoma from arrosion of vessels,
according to WHO grade IV are reported. with an increase in intracranial pressure and compression of
Case 1: a 43-year-old Polish man was found dead in a slope near cerebrospinal fluid circulation, whereas in the third case death can be
the track of the railway. Death scene investigation was unremarkable. A explained by distortion and compression of the medulla by the tumor
complete autopsy was performed 48 hours after death. The external with consequent acute central dysregulation due to glioblastoma
examination revealed only same abrasions and bruises on the face, and corresponding to WHO grade IV.
the upper and lower limbs. The internal examination revealed Glioblastoma, Sudden Death, Immunohistochemistry Stains and
polyvisceral stasis, heavy lungs and reddish colored foam on trachea and Western Blotting
the main bronchi. The skull was entire. The examination of the brain
(cm 21x16x6, g 1630) after fixation in buffered formalin revealed a
cerebral edema and an increase in volume of the left frontal lobe. On
coronal sections, the cerebral hemispheres were asymmetrical with
deviation of midline structures from left toward right. In the left frontal
lobe a spherical mass (cm 3.5x3x1.5), with variegated appearance and
contained regions of necrosis and hemorrhage was found. The blood
alcohol concentration was 0.8 g/l.
Case 2: a 79-year-old Caucasian man, with a history of ischemic
heart disease and hypertension, was brought to the hospital in the
neurological unit for symptoms such as confusion, slackening,
sleepiness, and tremor of the upper limbs start few days before. The
brain CT scanner examination shows a large hypodense mass in the left
G61 Postmortem Tryptase Levels of G62 Murder-Suicide in Fulton County, Georgia:
Anaphylactic and Non-Anaphylactic Deaths 1992-2006
Marc D. Bollmann, MD*, Centre Universitaire Romand de Medecine Randy L. Hanzlick, MD*, and Stacey L. Smith, MD, Fulton County
Legale, Rue du Bugnon 21, Lausanne, CH-1011, SWITZERLAND; Olaf Medical Examiner’s Office, 430 Pryor Street Southest, Atlanta, GA 30312
Drummer, Noel W.F. Woodford, MD, Victorian Institute of Forensic
Medicine, 57-83 Kavanagh Street, Southbank, Victoria, 3006, After attending this presentation, attendees will understand the
AUSTRALIA; Bettina Schrag, MD, University Center of Legal Medicine characteristics of murder-suicides occurring during a 15-year-period in
Lausanne-Geneva, Bugnon 21, Lausanne, 1011, SWITZERLAND; and Fulton County, Georgia, with emphasis on circumstances and
Dimitri Gerostamoulos, Victorian Institute of Forensic Medicine, 57-83 relationships of perpetrators and victims.
Kavanagh Street, Southbank, Victoria, 3006, AUSTRALIA This presentation will impact forensic science community by
detailing the features of murder-suicide events and reviewing relevant
After attending this presentation, attendees will understand the literature, wih the goal of providing information relevant to prevention
importance and some limitations of the analysis of serum tryptase in the strategies.
postmortem diagnosis of anaphylactic shock. Background: Murder-suicide typically involves one or more
This presentation will impact the forensic science community by homicides followed shortly thereafter (usually at the same time but
helping the forensic pathologists in the interpretation of postmortem sometimes later) by suicide of the perpetrator. The Fulton County
serum tryptase levels. In addition to that, the number of anaphylaxis Medical Examiner’s Office previously reported a series of twelve
cases presented here is big, given the rarity of this cause of death. murder-suicide cases which occurred in the years 1988-1991. This
Introduction: Anaphylactic reactions are encountered very rarely report is a follow up study of murder-suicide cases in Fulton County,
as cause of death in forensic practice and the postmortem diagnosis can Georgia, which occurred in the 15-year period of 1992 through 2006.
be difficult, given the unspecific autopsy findings. The diagnosis is Current data are compared with data from the earlier study and other
usually based on several criteria, including an elevated serum tryptase studies reported in the literature.
level. The established clinical normal values for serum tryptase can Methods: The Fulton County Medical Examiner’s Office
however not be used in the postmortem setting and need to be adapted maintains a comprehensive database which includes data items to record
for postmortem cases. The interpretation of postmortem serum tryptase companion cases and for the past seven years, indication of whether
levels may be tricky. So it is well known that some conditions other than death was part of a murder-suicide event. The data base was searched to
anaphylaxis can lead to high tryptase levels and also false negative detect murder-suicide events and to collect demographic, cause of death,
results can be encountered. and circumstantial information for each case. Results are compared with
Aims: The presented study is aimed at describing the diagnostic our previous study, the literature, and the incidents are classified in the
criteria, including serum tryptase levels that were used to diagnose context of a previously published classification scheme.
twelve anaphylactic deaths. Moreover, a postmortem normal value for Results: 40 incidents occurred during the 15-year period. There
serum tryptase from controls is computed and compared to the published were 40 suicides and 46 homicides for a total of 86 decedents. The
data in the literature. number of incidents per year ranged from 1 to 6 with an average of 2.6,
Methods: Twelve anaphylactic deaths, investigated in the and the number of decedents per year ranged from 2 to 17 with an
Victorian Institute of Forensic Medicine in Melbourne (AUS), have been average of 5.5 per year. There were two decedents in 38 of the incidents,
retrospectively analyzed concerning the diagnostic criteria, autopsy three decedents in one incident, and seven decedents in one incident.
findings and postmortem serum tryptase levels. The findings and the There was at least one murder-suicide event each year.
serum tryptase levels were compared to those of a control group In every case, the perpetrator was male. Fourteen of the
consisting of 33 cases with identified, non-anaphylactic causes of death. perpetrators (34%) tested positive for ethanol, five of the homicide
To better represent the reality of forensic practice, the control group has victims (11%) tested positive for ethanol, and in three cases (7%), both
been increased by 17 individuals with unascertained causes of death, for the perpetrator and victim were positive for ethanol. In 8 cases (26%),
a second comparison. The obtained cut-off level was compared to the the perpetrator was positive for stimulant drugs such a cocaine or
published data. methamphetamine.
Results: The postmortem diagnosis of anaphylaxis in the 12 cases In 34 incidents (85%), the perpetrator and victim were both shot.
was mainly based on the circumstantial information surrounding the One incident involved sharp force injuries of both decedents, another
death, the medical history, and the exclusion of other causes of death. incident involved thermal burns of both decedents, and in four incidents
Laryngeal oedema was found in 83% of the anaphylaxis cases and in a combination of methods was used. 27 (66%) incidents occurred in or
17% of the controls. None of them had a skin rash. The tryptase levels on the property of the perpetrator’s place of residence. The most
of the controls will be presented with known causes of death and of the common circumstance was a boyfriend killing a girlfriend (n=13) or ex-
increased control group after including unascertained cases. Some cases girlfriend (n=3). The second most common was a husband killing his
with surprisingly high or low levels will be discussed. wife or ex-wife (n=11). An employee killed a coworker in three
Conclusion: Serum tryptase obtained from peripheral blood is the incidents. In two incidents, one male killed another male during an
strongest aid in the diagnosis of anaphylaxis as a cause of death. The argument.
majority of anaphylaxis cases have tryptase levels of well above 100µg/l, Of the perpetrators (all male), 9 (23%) were White, 6 (15%) were
whereas the other causes of death had tryptase levels generally under Hispanic/Latino, and 25 (63%) were Black. Both Hispanics and Blacks
41µg/l. A grey zone clearly exists, and a number of elements should be were overrepresented in comparison with their prevalence (43% and 8%
present to make the diagnosis of anaphylaxis. Even a strongly positive respectively) in the county population while whites were under-
tryptase result should not automatically lead to the diagnosis of represented (account for about 50% of the population). In 37 incidents
anaphylactic shock. In most cases, other elements can be found to (93%), all decedents were of the same race. In three cases, the
support or reject the diagnosis. Other conditions with elevated tryptase perpetrator was Hispanic/Latino and the victim was White (non-
levels exist and should be considered in cases with high levels. Hispanic). A male killed one or more females in 34 of the 40 incidents
Tryptase, Anaphylaxis, Postmortem (85% of cases).
The number of days between incidents ranged from 12 to 483 with
a median of 125 days and a mean of 142 days. Thus, evidence of short
term clustering was minimal except for two incidents in late June and
early July of 1999. The same year which had the maximum number of represented respectively 10.7% and 8.2% of the cases. Offenders were
incidents (n=6). male in 88% of the cases. Male and female assailants showed distinct
Comparison of the present study to our previous study shows only homicide patterns: females were involved more frequently in familial
slight differences in the trends observed, which may relate mainly to the quarrel and child abuse. They never killed a stranger and committed
much larger size of the most recent case series. homicide exclusively in a private place with a predominance of sharp
Using the classification scheme of Marzuk, Tardiff, and Hirsch, the weapons. Males in contrast assaulted almost equally a stranger or an
most common type of incident (71% of incidents) was “Spousal or acquaintance, often in a public place with a predominance of firearm.
Consortial” (in which we included spouses, former spouses, girlfriends, The victim knew the assailant(s) in 57% of the cases. Homicides mostly
and ex-girlfriends) and the most common motive (27% of incidents) was took place at the residence of the assailant or the victim. Homicide
“Amorous Jealousy.” A similar portion of cases involved some form of motive was clearly determined in 71% of the cases. Argument was the
argument or relationship problem which was not further clarified. Of most common motive in 44% of the cases. Sexual assault was rarely
note, 12 cases (30% of incidents) involved motives that were not found (ten cases). Gunshot wounds were the most common cause of
apparent. This finding points out the difficulty in clarifying the motive death (37%), followed by stab wounds (27%), blunt trauma (19%) and
when the people who might be able to explain what happened are dead asphyxia (13%). A decrease of gunshot wounds as a cause of death was
and further specific information cannot be determined. found over the studied period. Alcohol was the most common toxic
All but three incidents involved circumstances in which the deaths detected in blood victim, in 48.5% of the cases when toxicological
of the victims and perpetrators had a close temporal relationship. In one results were available. Blood alcohol concentration ranged from 1 to
case, the perpetrator died in the hospital after a two months stay for his 500 mg/dL with a mean value of 150 mg/dL. Survival time was
self inflicted gunshot wound. In a second and atypical case, the determined in 162 cases and ranged from 0 minute to 25 days. The mean
perpetrator committed suicide in jail several months after being arrested ISS was different according to the cause of death: 3.4 for deaths by
for the murder of the victim. In the third case, the homicide victim died asphyxia, 38.6 for deaths by stab wounds, 39.6 for deaths by blunt
about five months after the incident from ongoing complications of her trauma and 60 for deaths by gunshot wounds. ISS and survival time
gunshot wounds. showed a significant correlation (r=-0.56; p<0.05) only for short survival
Conclusions: Similar to other studies, murder-suicides in Fulton time (less than three hours) and after exclusion of deaths by asphyxia
County, Georgia show a low but stable rate of occurrence with a (n=58). Correlation was weaker when there was a long time of
predominance of male perpetrators, female homicide victims, same-race resuscitation.
victims, two deceased persons, a victim-perpetrator relationship such a In conclusion, this autopsy series research pointed out that homicide
spouse or girlfriend, and causes of death which predominantly involve pattern strongly differed according to the sex of the victim and of the
gunshot wounds. assailant. ISS could be used to help in estimating the victim’s survival
Murder-Suicide, Homicide-Suicide, Violent Death time, taking into account the compounding factor of resuscitation.
Homicide, ISS, Survival Time
G63 Homicidal Deaths in the Western Suburbs

of Paris: A 15-Year-Study With Special G64 Pattern of Limb Lesions in Suicidal
Focus on Survival Time Hanging: A Criteria Tool in the Distinction
of Suspicious Cases
Jérôme Cros, MD, AP-HP, Jean-Claude Alvarez, PharmD, AP-HP,
Raymond Poincaré Hospital, 104, Bd Raymond Poincaré, Garches, F- Anne Desjarlais, BSc*, 7101 De La Roche, Montreal, QC H2S2E6,
92380, FRANCE; Emilie Sbidian, MD, AP-HP, Department of Clinical CANADA; Anny Sauvageau, MD, Office of the Chief Medical Examiner,
Research and Public Health, Henri Mondor Hospital, 51 av du Maréchal de 7007 - 116 Street, Edmonton, AB T6H 5R8, CANADA; and Jean-Pierre
Tassigny, Créteil, F-94010, FRANCE; and Philippe Charlier, PhD, AP-HP, Guay, PhD, University of Montreal, CP 6128, Succ. Centre-ville,
and Geoffroy Lorin de la Grandmaison, PhD*, AP-HP, Raymond Poincaré Montréal, QC H2S 2E7, CANADA
Hospital, 104, Bd Raymond Poincaré, Garches, F-92380, FRANCE
After attending this presentation, attendees will have a better
After attending this presentation, attendees will understand understanding of the usual pattern of lesions in suicidal hangings and
homicide trends in an area around Paris and the value of Injury Severity will be aware of the pattern of lesions to be considered suspicious.
Score (ISS) for the estimation of survival time. This presentation will impact the forensic science community by
This presentation will impact the forensic science community by providing tools to improve the screening of suicidal hangings for
helping forensic pathologists in homicide case investigations when possible suspicious cases.
questions about victim’s survival time are raised. Introduction: In this era of limited resources, hanging cases are
The goal of this study was to analyze the homicide pattern in the investigated in several jurisdictions by a limited scene analysis and a
western suburbs of Paris and its evolution between 1994 and 2008. ISS rapid external examination of the body. Full body autopsies are
was also assessed to see if it was correlated with the survival time of becoming less and less frequent in these cases, based on the assumption
homicide victims. that hangings are virtually always suicide. Homicidal hangings are
All autopsy reports regarding homicides from January 1, 1994 to therefore at serious risk to be missed, particularly since they are difficult
December 31, 2008 were retrospectively reviewed. All autopsies were to detect. However, to recommend a full body autopsy on all hanging
performed in the Department of Forensic Medicine and Pathology of victims is not realistic considering the limited human and financial
Garches. Out of 4,842 autopsy cases reviewed, 511 homicide cases were resources.
selected. The following data were recorded: assailants’ and victims’ In a recent six-year retrospective study on the pattern of limb
characteristics, crime scene location, homicide motive, cause of death, bruises in hanging conducted in the Province of Quebec, Canada, it was
postmortem toxicological results, ISS, and estimated survival time. suggested that the presence of bruises on the anterior upper limb and the
Homicide rate steadily declined over the period at the exception of presence of bruises on both the upper and lower limbs were two criteria
the number of homicide-suicide per year which remained constant. that should alert the pathologist to be more cautious. The presence of
Homicide victims remained unidentified after medico-legal bruises on the posterior lower limb was initially proposed as an
investigations in 2% of the cases. Child and elder homicide cases additional criterion of suspicion, but failed to reach statistical
significance. The present study aims at evaluating the validity of these was taken away. Crime police found adhesive tapes and linen strap near
criteria on a different population and to further investigate the usual the bed. Insensitive behavior of the household aroused suspicion and
pattern of limb lesions in suicidal hangings. demanded careful pursuit of the following medicolegal investigation.
Material and Methods: A total of 214 suicidal hangings, External examination of the body revealed three different types of
investigated at the Office of the Chief Medical Examiner in Alberta, injuries: decubitus ulcers (pressure sores), scabs (as ligature marks), and
were reviewed for the presence and localization of bruises, abrasions and bruises of various ages. The decubitus ulcers stage II and III of the
lacerations. An age- and gender-matched control group of non-hanging coccyx-sacrum region and on the both sides of the buttocks, ulcers stage
homicidal strangulations, composed of 51 cases, was similarly studied. II of the left elbow and the left ankle, ulcers stage I of the left trochanter
Results: Incidence of limb lesions: Bruises were found in 6% of and over the pectoral spine near the left shoulder blade were described.
suicidal hanging victims, abrasions in 5% and lacerations in 1%. The circular scabs around the neck, and both wrists indicated ligature
Compared to homicidal strangulation victims, suicidal hanging victims marks, so as the necrosis of the II-III fingers on the left hand. The
are less likely to present bruises (χ2=84.301; p=.000; Phi=.564), bruises of various colors were presented on the left hand and upper arm,
abrasions (χ2=75.231; p=.000; Phi=.533) and lacerations (χ2=8.123; as well as along both medial femoral regions. The autopsy findings
p=.023; Phi=.175). showed that the sacro-coccigeal ulcers extended into the subcutaneous
Usual pattern of limb bruises in suicidal hanging: The usual tissue and secondary resulted in bronchopneumonia with purulent
pattern of limb lesions in suicidal hanging victims was confirmed to be effusion into the left thoracic cavity. The lipofuscin pigmentation of
the following: bruises and abrasions are mostly found on the posterior hepatocytes and myocytes as histopathological changes indicated a state
part of upper limbs, on the anterior aspect of lower limbs, and on either of long time deprivation of food. The forensic pathologist pronounced
the upper or lower limb but not to both in a single case. It was also found the cause of death violent death by bronchopneumonia caused by
that bruises are commonly found on the anterior part of upper arms, but infected decubitus ulcers.
not on the anterior part of forearms. The comparative pattern in It is believed that no similar cases described in the recent literature
homicidal non-hanging strangulation does not display this preferential have been found. Homicide of a young woman by the infliction of
concentration. decubitus ulcers caused by immobility and fixation of the victim’s body
Suspicion criteria for limb bruises: Three criteria were statistically with ligature (tapes and strap) including elements of social and physical
confirmed to be in favor of an homicidal strangulation: the presence of separation combined with starvation has not yet been described in the
bruises and/or abrasions (i) on the anterior forearms (bruises: χ2=16.500; criminal records in Croatia.
p=.001; Phi=.250; abrasions: χ2=16.224; p=.001; Phi=.247), (ii) on the The forensic psychiatry expert determined the specific relations
posterior aspect of lower limbs (bruises: χ2=39.092; p=.000; Phi=.384; between the victim and the perpetrators. This study concluded that the
abrasions: χ2=25.642; p=.000; Phi=.312), and (iii) on both upper and perpetrators didn’t act alone. The male perpetrator was a drug addict
lower limbs in a single case (bruises: χ2=51.043; p=.000; Phi=.439; who had permanent schizotypal disorder of personality, with
abrasions: χ2=24.682; p=.000; Phi=.305). characterization of egocentrism, latent aggression, lower tolerance
Conclusion: In the evaluation of a given case, the presence of the threshold and emotional coldness. His mother was a person with
following distribution of bruises or abrasions should alert the pathologist dominantly narcistic and dissocial personality disorder, with an intention
to be more cautious and to further investigate the case: the presence of to control the life of her son. The victim was a person with
bruises or abrasions on the anterior forearms, on the posterior legs, or on predominantly passive-dependent personality disorder, psychologically
both upper and lower limbs in a single case. Of course, the localization and socially predetermined to victimization. Forensic psychiatrist
of bruises and abrasions is not to be interpreted without all other scene concluded that the perpetrators planned the crime together, carried on by
elements and autopsy findings. the motive of jealousy.
Hanging, Bruise, Abrasion According to Croatian Penal Code the perpetrators of a criminal
offence were convicted of intentional murder to 30 years imprisonment.
The case presented shows the importance of a detailed crime
G65 Decubitus Ulcers and Ligature Marks as investigation and close cooperation between crime police and forensic
pathologist, especially if the presumed course of events is ambiguous.
Evidence in a Homicide Case Recognition of the relatively rare injury patterns and understanding the
mechanism of death seems to be the most important factor in elucidation
Miran Coklo, PhD, Valter Stemberga, PhD, Drazen Cuculic, PhD*, and of the presented homicide case.
Alan Bosnar, PhD, Rijeka University School of Medicine, Department of Decubitus Ulcers, Ligature, Homicide
Forensic Medicine, Brace Branchetta 20, Rijeka, 51000, CROATIA
After attending this presentation, attendees will better understand

the application of medicolegal investigation, specifically the role of
G66 Soccer Scams, Search Engines, Scientists,
forensic pathologist during homicide investigation. In addition, and Slaughter: Investigating a Complex
attendees will become familiar with the relatively rare injury patterns in Double Homicide in North-East England
forensic practice.
This presentation will impact the forensic science community by Stuart J. Hamilton, MB ChB*, 9 Troon Close, Consett, DH8 5XF,
providing knowledge to medicolegal investigators, especially in UNITED KINGDOM
deciding cause and manner of death in equivocal death investigations.
This presentation will increase the competence of the medicolegal After attending this presentation, attendees will see the value of
examiners and forensic pathologists in examination of complicated using relevant subspecialty expertise in forensic pathology and the
cases, when the autopsy findings may become unique evidence in the benefits of good communication between the various experts and
following legal action and adjudication. investigating authorities in ensuring that evidence given in court is
The 30-year-old woman was found dead in the house where she was reliable and supported by validated scientific principles.
living with her fiancée and her mother-in-law. At initial inspection, bad This presentation will impact the forensic science community by
condition and exhaustion of the body suggested natural death by showing how a complex case can be brought to a satisfactory conclusion
malignant disease with no preview of medical history. Some unusual by methodical examination of the available evidence.
circumstances aroused suspicion. The victim was isolated in the dark
room with no possibility to call for help, because her private cell phone
In 2008, two Chinese nationals who had been students at Newcastle then the manner of death is more appropriately certified as “suicide” in
University were found dead in their home. They had clearly been the these instances despite the fact that the decedent did not pull the trigger.
victims of homicide and a pet had also been killed. There was virtually For police shootings, the conventional certification remains
no evidence at the outset as to when or why the murders had occurred “homicide” in the absence of other compelling circumstances. But just
and no suspect existed. Scene examination showed that both victims had because these deaths occur at the hand of another, there should not be an
been bound and suffered significant blunt force trauma. At autopsy, automatic homicide determination in all instances. Suicide should be
evidence of incised wounds was identified in one victim and signs of considered in these deaths. Despite the absence of direct self-infliction,
asphyxia in the other. there is overwhelming evidence that these five individuals intended to
The brains were submitted to a forensically experienced end their own lives. Their use of an unusual method to accomplish this
neuropathologist who provided valuable evidence with respect to the goal may inappropriately result in a reflexive certification of homicide.
survival period after injury. The meal that one of the victims had eaten Instances of suicide by cop and contend that these types of deaths are
when last seen alive had been at the restaurant where she worked. The best certified as suicides will be presented.
nature of this meal was known and the gastric contents of this victim Suicide, Police, Manner
were examined by both the pathologist and a scientist to attempt to
identify the components of the stomach contents and the degree of
digestion. G68 Study of Lethal and Non-Lethal Filmed
Although a national appeal was made on television for information,
a suspect was developed by an unusual method. A strong case including
Hangings: New Insight Into the
DNA evidence was made and ultimately this individual was convicted on Pathophysiology of Hanging
two counts of murder.
Good communication between the experts and police led to the Anny Sauvageau, MD*, Office of the Chief Medical Examiner, 7007 -
development of a powerful and reliable case assisted by relevant 116 Street, Edmonton, AB T6H 5R8, CANADA
subspecialist expertise.
Blunt Trauma, Homicide, Organized Crime After attending this presentation, attendees will have a better
understanding of the pathophysiology of hanging, of the effect of the
type of suspension and ischemic habituation on the agonal sequence, and
G67 Death Certification of “Suicide by Cop” on the appropriate scientific answer to the time to die by hanging.
Amber R. Neitzel, BS*, 550 East Van Buren Street, Phoenix, AZ 85004; providing new insight into the pathophysiology of hanging, based on the
and James R. Gill, MD, Office of the Chief Medical Examiner, 520 First ongoing study of the working group on human asphyxia.
Avenue, New York, NY 10016 Introduction: Contemporary understanding of the
pathophysiology of hanging is still largely based on old writings and
After attending this presentation, attendees will understand the experimentation from the end of the 19th century and beginning of the
concept of “suicide by cop” and the criteria used to certify these deaths 20th. Apart from a few animal studies that gave very limited information
as suicides. on the pathophysiology of hanging in human, there was little new
This presentation will impact the forensic science community by development on this issue until the creation of the Working Group on
discussing examples of “suicide by cop” and why suicide (and not Human Asphyxia in 2006. Here presented are the newest results from
homicide) is the appropriate manner for these deaths. this ongoing study.
A death certification of “suicide by cop” is controversial among Material and Methods: Fourteen lethal filmed hangings (nine
some medical examiners and coroners (ME/C). These are often complex autoerotic accidents, four suicides, and one homicide) were analyzed, as
investigations and the opinions of the medical examiner must take into well as three non-lethal filmed hangings by an autoerotic asphyxia
consideration all relevant issues. Five such deaths are presented that practitioner.
were certified as suicides and discuss the medicolegal issues involved Results and Discussion: Lethal filmed hangings: In the fourteen
with these certifications. In order to certify such a death as a suicide, lethal filmed hangings, the following sequence of agonal responses was
certain criteria should be met. The five criteria used to make this observed: rapid loss of consciousness in 10 s ± 3 s, mild generalized
certification include evidence of: (1) suicidal intent; (2) intent to be shot convulsions in 14 s ± 3 s, decerebrate rigidity in 19 s ± 5 s, beginning of
by law enforcement; (3) possession of a lethal weapon or facsimile; (4) deep rhythmic abdominal respiratory movements in 19 s ± 5 s,
intentional escalation of the encounter; and, (5) legal use of force by law decorticate rigidity in 38 s ± 15 s, loss of muscle tone in 1 min 17 s ± 25
enforcement. These legal actions of law enforcement are what s, end of deep abdominal respiratory movements in 1 min 51 s ± 30 s,
distinguish these deaths from other instances of “assisted-suicide” that and last muscle movement in 4 min 12 s ± 2 min 29 s.
would be certified as homicides if they involved the illegal actions of Effect of the type of suspension: A comparison of time delay for
another. agonal responses in complete suspension and incomplete suspension do
All of the decedents were male and their average age was 34 years not reveal impressive differences. These results suggest that the type of
(range 26 to 43). Both ethanol and cocaine were detected in two of the suspension may not be an important factor in the timing of agonal
decedents and the other three had a history of psychiatric illness. All of responses and therefore in the time to irreversible damage and death.
the decedents possessed weapons or a facsimile of a weapon. There were Effect of ischemic habituation: Considering that autoerotic
three handguns, two knives, and one silver cigarette lighter in the form practitioners might develop over time a certain ischemic habituation over
of a gun. time, it is theoretically possible that these cases present a deceleration of
Suicide by cop is a circumstance that involves the completion of the sequence. On the other hand, since they often play for a longer
intentional acts that may result in dichotomous determinations of the period with the hanging process before the final hanging, it could be
manner of death. In some jurisdictions, these deaths are certified as argue that on the contrary, their hanging sequence will be accelerated.
homicide. Since these deaths occur at the hand of another, the invoked Overall, the time delays for the early responses to hanging seem to be
reasoning is that homicide therefore dominates the certification. But relatively similar between both groups, with the exception of an
what if there was reliable evidence that a person wanted to die and accelerated start of deep abdominal respiratory movements in the
committed an intentional act to further that goal? If the death was the autoerotic practitioners. As for the late responses to hanging, they seem
result of an intentional act to do self harm or cause death of one’s self, to be decelerated in autoerotic practitioners.
Non-lethal filmed hangings: In the three non-lethal filmed also constitute pitfalls in the interpretation of fractures of the thyroid
hangings, a loss of consciousness was observed in 8 to 16 seconds, cartilage. In the hyoid bone, the forensic pathologist should be aware of
followed by convulsions in 9 to 26 seconds. Decerebration rigidity was the following possible variations: unusually long great horn,
observed in one non-lethal filmed hanging (at 20 seconds). The ligature, uncommonly long lesser horns, difference in the fusion time of the
which was not tied tightly to the shower rod, then detached from it, greater horns to the body, and calcification of the stylohyoid ligament.
causing the fall of the man and the interruption of the hanging. Upon The consistency of the hyoid bone and thyroid cartilage in relation to the
interruption of the hanging, the man quickly regained consciousness and victim’s age should also be taken into consideration in the interpretation
seemed to present a full recovery without any noticeable symptoms. of autopsy findings.
Estimation of the time to irreversibility and to die by hanging: The Forensic pathologists should be aware of the anatomical variations
scientific basis for the generalized assumption that death by hanging of the hyoid bone and thyroid cartilage and should be trained in
occur in three to five minutes will be reviewed. There is no forensic recognizing them, in order to avoid erroneous interpretation of autopsy
study to sustain this estimate of five minutes to die. In fact, this number findings. The role of x-ray and computed tomography as ancillary
seems to be based on three types of studies: a series of near-hanging techniques will be discussed, but the importance of a proper manual
victims in emergency medicine, studies of carotid endarterectomy, and dissection, with palpation of the fractures, will be reinforced. After
physiopathological studies of brain ischemia. Though this estimation of removing the viscera from the chest and abdominal cavities and
the time is certainly precise and accurate enough for the needs of removing the brain (dry neck dissection), it is recommended to dissect in
clinicians, it will be demonstrated that scientific evidence are not strong situ the muscles layers and then to remove the neck organs from the
enough to be used in court. So how long does it take to suffer mouth and cervical column, in order to perform a dissection ex-situ of
irreversible damage by hanging or by strangulation? The only honest the hyoid and thyroid cartilage. Ultimately, the hands and eyes of the
and scientifically valid answer is not known. pathologist constitute an invaluable tool, provided there is proper
Asphyxia, Hanging, Pathophysiology training and knowledge. The dissection technique to assist in the
discrimination of anatomical variations versus fractures of the neck
structures will be further described.
G69 Pitfalls in the Interpretation of the Hyoid Despite the tremendous importance of correct interpretation of
anatomical variations in the identification of fractures of the neck
and Thyroid Fractures in Strangulation: structures in strangulation, this issue has not been properly discussed in
The Importance of Anatomical Variations the forensic literature so far. This presentation is aimed to fulfill this gap.
Hyoid, Thyroid Cartilage, Strangulation
João S. Pinheiro, MS*, Instituto Nacional de Medicina Legal, Delegação
do Centro, Largo da Sé Nova, Coimbra, 3000, PORTUGAL; and Anny
Sauvageau, MD, Office of the Chief Medical Examiner, 7007 - 116 Street, G70 A Comparison Study of Homicides Between
Edmonton, AB T6H 5R8, CANADA
Beijing, China and the State of Maryland,
After attending this presentation, attendees will have a better United States
knowledge of the importance of anatomical variations in the
interpretation of fractures of the hyoid bone and thyroid cartilages. Lin Chang, MD*, China University of Political Science and Law, 116
This presentation will impact the forensic science community by Lugu Road, Shijingshan Distric, Beijing, 100040, PEOPLES REPUBLIC
developing and increasing awareness of the pitfalls associated with OF CHINA; Li Liu, MD, Beijing Municipal Public Security Bureau, No.1
anatomical variations of the hyoid bone and the thyroid cartilage in Qinghe Longgang Road Haidian District, Beijing, 100192, PEOPLES
strangulation cases. REPUBLIC OF CHINA; and Xiang Zhang, MD, David R. Fowler, MD,
Strangulation is defined as asphyxia by closure of the blood vessels Eleanor J. Thomas, and Ling Li, MD, Office of the Chief Medical
and/or air passages of the neck as a result of external pressure on the Examiner, State of Maryland, 111 Penn Street, Baltimore, MD 21201
neck. Three subtypes are recognized: hanging, ligature strangulation,
and manual strangulation. After attending this presentation, attendees will have learned the
A proper neck dissection is a key element in the investigation of epidemiological characteristics of homicides in Beijing, China and the
these deaths. Despite the usefulness of x-ray and computed tomography state of Maryland, United States.
as ancillary techniques, manual dissection of the neck structures remains This presentation will impact the forensic science community by
the most widely used technique to assess the integrity of neck structures. illustrating the differences in the pattern of homicides between China and
Considering the relative complexity of the neck dissection, it is the United States, and by discussing the influence of cultural dimensions
important that it is performed by a trained forensic pathologist. and socioeconomic development on violent crime.
Apart from basic anatomical background and technical skills, A retrospective comparison study was conducted on homicides
forensic pathologists are in general well trained in recognizing occurring in 2008 comparing Beijing, China and the State of Maryland,
postmortem artifacts encountered during the neck dissection. United States. Beijing, the capital of China, with a population of 16,
Unfortunately, anatomical variations as pitfalls in the interpretation of 950,000, covering 6.489 square miles, is made up of two suburban
fractures of the hyoid bone and thyroid cartilage are however unknown counties and 16 urban districts. Maryland, with a population of
to most. This comes to no surprise considering that forensic textbooks 5,633,597 and a total area of 12,407 square miles, comprises twenty-
and the forensic literature have failed to pay any attention to these three counties and Baltimore City. In 2008, a total of 398 homicides
anatomical variations. occurred in Beijing. The homicide rate was 2.34 homicides per 100,000
The anatomists have described several anatomical variations of the population. Maryland, however, had 536 homicides (9.51 per 100,000
hyoid bone and thyroid cartilage that are of great interest to forensic population), which was more than four times as high as the homicide rate
pathologists. The triticea, a very small cartilage located in the thyroid- in Beijing. Males were much more likely to become homicide victims
hyoid membrane, is encountered in approximately 13 to 16% of than females in Maryland (Male: Female = 5.2:1, based on the rate),
individuals. This cartilage can easily be mistaken as a fracture of the when compared with homicides in Beijing (Male: Female = 1.4: 1). The
superior horns of the thyroid cartilage. Asymmetrical length of the age distribution of homicide victims was similar between Beijing and
superior horns of the thyroid cartilage, morphological differences Maryland, with the majority of the victims in their 20’s to 40’s.
between horns, and unilateral absence of one horn are all variations that The most common cause of homicide in Beijing was sharp force
injury (52.8%), followed by blunt force injury (24.1%), asphyxia due to of a thread like ligature mark around her neck with the fresh bleeding cut
suffocation/strangulation (17.8%). Only two deaths were caused by throat injury and bleeding sharp weapon injuries on both the wrists
firearm injury combined with sharp force injury. On the other hand, the remained a mystery. One of these or both of these were the cause of
most common cause of homicide in Maryland was firearm injury deaths remained the issue. Death was due to ligature strangulation
(74.8%), followed by sharp force injury (10.3%), blunt force injury became the diagnosis that blood had come out of the injuries which were
(5.0%), and suffocation/strangulation (3.5%). There was a significant caused by shaving blade after the death.
difference between Beijing and Maryland regarding the homicide death Antemortem looking postmortem blood raised issues to challenge
scene location. More than 71% of the homicide victims in Beijing were the credibility of the autopsy opinion and or police investigation in three
found inside of buildings, such as residential houses (44.2%), cases. A case study to show how misinterpretations of blood at the scene
business/government offices (10.0%), stores (7.5%), night clubs (6.5%), discredited family version as well as autopsy opinion of hanging in the
and other facilities (2.8%). However, only 37.9% of the homicide case of two suicidal deaths will be presented. Inference indicating
victims in Maryland were found inside of buildings with fewer than 30% ligature strangulation appeared weak and ineffective so long as
of the victims found in residential houses. The majority of Maryland antemortem appearing injuries were found to be postmortem cuts in the
homicide victims were found either on the street (42.9%), or in the third case. It is recommended that death investigators be familiar with
park/wood/field (12.9%), or other outside locations. The possible the sensitivity to exclude the probability of blood at the scene being
motives of homicide in both regions will also be discussed. postmortem and unrelated to the actual mechanism of death.
Forensic Science, Homicide, Epidemiology Antemortem, Postmortem, Blood
G71 Blood at the Scene of Death Due to G72 The Influence of the Meteorological Factors
Hanging: Artifact or Antemortem on Occurrence of the Suicide Cases
Surendra K. Kumar, MD*, Army College of Medical Sciences, Delhi Zalina Muzafarova*, Main Bureau of Forensic Medicine, Mirakhmedov
Cantonment, New Delhi, 110010, INDIA Street, 143, Tashkent, UZBEKISTAN
After attending this presentation, attendees will understand the The goal of this presentation is to demonstrate the correlation of the
distinctive difference between antemortem and postmortem collection of dependency between meteorological factors in defining the reasoning in
blood, the dynamics of blood collecting at the scene, principles of suicides for forming training for prevention and alertness.
artifacts, importance of determining that the blood at the scene of crime This presentation will impact the forensic science community by
was not antemortem but was a postmortem phenomenon, correlating the assisting in increasing the understanding of suicide.
blood with the injuries, and example of dubious presentation of suicidal During the investigation of suicide cases, the focus is ordinarily on
and homicidal deaths due to asphyxia. the location of the event, the type of death, personal information and
This presentation will impact the forensic science community by additional documents but it is also important to study other factors
showing how suspicion and or allegations of not reporting injuries or influencing the death, factors like meteorological conditions. Full–
reporting incorrectly are related to the evidence of blood at the scene of fledged suicide has many affects on society and many scientists pay very
crime. Blood oozing out of injuries sustained during medical treatment close attention to it, but most of the significance is that suicide is a social
needs to be differentiated from those injuries that were inflicted after the and medical problem.
death of an individual. Misinterpretations can be reduced and scope and Meteorological and heliophysics factors as well as socio–economic
diagnostic accuracy could be enhanced by the exclusion of antemortem events have a great influence on the emotional state of an individual, and
nature of blood at the scene of occurrence. may also be factors in the occurrence of several diseases. Moreover, they
In India, those who do autopsies are generally not supposed to visit may also increase the occurrence of suicide.
the crime scene. Autopsy opinions about cause and manner of death are Factors such as atmospheric pressure, air temperature, humidity,
sometimes in conflict with the opinion of those who had observed blood and solar radiation have been fully analyzed with respect to the influence
at the scene. In order to set aside an autopsy opinion of “suicidal on suicide. Reports from suicide cases with conclusions of medical
hanging” and to believe that of “ligature strangulation” in three different examiners for a five-year period were provided by the Main Bureau of
cases, proving how blood at the scene could be postmortem was a big Forensic Medicine in Tashkent, Uzbekistan. Information about
challenge. temperature, humidity, atmospheric pressure, rain, and magnetic storm
Manner in which the blood at the scene had been perceived during indices in Tashkent city were obtained from Uzhydromet, the
the investigation or even some time after the occurrence and Hydrometeorological Services Center in Tashkent.
investigation was significant. Such a perception formed the basis to Study results were analyzed for significance using the Student t-test
confront the autopsy opinion in three controversial cases. Baring the method.
truth that blood at the scene was not that had oozed out of the injuries The results of the analysis of both suicide cases and meteorological
sustained during life in these cases makes an interesting case. In the first factors have been combined and adequate statistics had been created.
case of suicidal hanging, bleeding was from the injury that was inflicted After certain procedures it had been highlighted that the correlation
after the death by the tip of a scissors used to cut ligature material around between two types of factors is indirect. This correlation was worked out
the neck. The second case relates to a probe into the reinvestigation of a by Health Institute of the Ministry of Health of the Republic of
suicidal death of a hanged victim who had been discovered dead on the Uzbekistan for early prognosis of suicide occurrences affected by many
fifth day. Earlier investigation and autopsy opinion of hanging were factors.
considered botched. The contention was that the victim had injuries; This study of the effects of meteorological factors on suicide rates
these injuries were not reported and had been missed deliberately both showed a strong correlation only with atmospheric pressure and air
by the investigators and in the autopsy. The blood at the scene was the temperature. The method of direct correlative relationship (2, 3) worked
result of collection from constant dribbling due to postmortem out by the Republican Information Analytical Center was applied to this
hypostasis. It was not as was being presumed to have collected at the data to study the effect of many meteorological factors on suicide rates.
scene from some missed injury on the front of the body of hanged victim. The results of this study allowed for the creation of a formula for
The third case was of a lady found dead in her own house. Co-existence predicting the number of suicides cases as a function of air temperature
and atmospheric pressure: Х = 0,014198 { Т (0С)} - 0,0000708 { Р The stab wounds to the head were determined to be the cause of
(GPa)} + 0,65990; where, X= number of expected suicides per day; T= death, while external hemorrhage and hypothermia were contributing
expected air temperature; P= expected atmospheric pressure. factors. This is the first case of complex suicide reviewed in literature
According to given equation, the average fluctuation of the number of where six suicide methods were applied. This particular case is
expected occurrences is ± 0, 05, at a confidence of 95%. interesting because the victim used a screwdriver as a tool for inflicting
The above study shows that there is a certain relationship between stab wounds to the head, which is a rare suicidal method.
meteorological factors such as air temperature and atmospheric pressure Complex Suicide, Traumatic Brain Injury, Screwdriver
with the occurrence of suicide cases. The developed formula based on
the combination of meteorological factors makes it possible to predict
the expected suicide states and take preventive measures. G74 Bitten by Snake Shot: Attempted Homicide
Forensic Pathology, Suicide, Meteorological Factor
and Successful Suicide With Multiple
Gunshot Wounds
G73 Complex Suicide: An Unusual Case With
Todd M. Luckasevic, DO*, and Baiyang Xu, MD, Allegheny County
Six Methods Applied Medical Examiner’s Office, 1520 Penn Avenue, Pittsburgh, PA 15222;
and Abdulrezak M. Shakir, MD, and Karl E. Williams, MD, MPH, Office
Stojan Petkovic, PhD*, Miljen Maletin, MD, MSc, and Maja Durendic- of the Medical Examiner - Allegheny County, 542 Fourth Avenue,
Brenesel, PhD, Klinicki Centar Vojvodine, Department of Forensic Pittsburgh, PA 15219
Medicine, Clinical Center of Vojvodina, Hajduk Veljkova 5-7, Novi Sad,
21000, SERBIA AND MONTENEGRO The goal of this presentation is to illustrate an unusual case of an
attempted homicide and successful suicide with a revolver and multiple
After attending this presentation, attendees will be acquainted with snake shot cartridges.
complex suicide, potential methods applied, determination of main- This presentation will impact the forensic science community by
dominant cause of death, and will be provided with more details about illustrating the need for close collaboration between the forensic
traumatic brain injury caused by screwdriver. pathologist and the firearm examiner when dealing with cases of unusual
This presentation will impact the forensic science community gunshot wounds.
describing six methods in committing complex suicide that should be of Introduction: Suicide is one of the most important public health
great interest in common forensic practice. issues in the United States. Suicide represents the eleventh leading cause
Complex suicides are committed by using more than one method. of death in the United States. Suicides comprise approximately 12% of
They account for 1.5% to 5% of all suicides. Depending on the time the caseload of the Allegheny County Medical Examiner’s Office in
delay between the employed suicidal mechanisms they can be defined as Pittsburgh, Pennsylvania. Suicide rates for this country have been
‘‘primary complex suicides’’ if the mechanisms are applied relatively stable over the past decade averaging approximately ten per
simultaneously and “secondary complex suicides” if the mechanisms are 100,000 populations. The most common method of suicide in the United
applied in quick chronological sequence. States is the use of a firearm.
The report presents a case of complex suicide of a 44-year-old male, Homicide-followed-by-suicide (referred to as “homicide-suicide”)
found dead in the vicinity of his car, in a deserted frozen field few incidents are rare events but can have a profound impact on families and
kilometers away from the nearest town. The doors of the car were communities. The National Violent Death Reporting System based on
opened, and victim’s head and clothes were soaked in blood. Blood 2003-2005 data, revealed 408 homicide-suicide incidents in 17
spots were found on both front car seats. Neither weapons nor any tools participating states. Most incidents were committed with a firearm
were found around his body outside the car. A farewell letter was hand- (88.2%) and perpetrated by males (91.4%), those over 19 years of age
written on two sheets of paper and was found on the dashboard of the car. (97.6%), and those of white race (77.0%). Over 55% of male homicide-
The motive for committing suicide was not given in this letter. On the suicide perpetrators had prior intimate partner conflicts.
right front car seat there were blood spots, a screwdriver handle, an Materials and Methods: The case involved a 53-year-old
automobile crane, one razor blade, one cell phone, car keys, a pencil, and Caucasian male and his wife with a long standing history of domestic
a woolen hat. In front of this seat there were two half-emptied red plastic violence. The couple began to argue when suddenly the decedent pulled
bottles with hydrochloric acid, and one almost empty transparent plastic out a revolver and shot his wife in the face several times. The wife ran
bottle with traces of liquid of unknown origin. A single receipt from the downstairs, exited the house, and ran to the neighbor’s house for help.
nearby town supermarket was found in the car. One screwdriver, pack She was transported to a local hospital, treated for three gunshot wounds
of razor blades, and two bottles of concentrated hydrochloric acid were to her face and then subsequently released weeks later.
listed in the receipt. Police investigation excluded homicide and no The decedent was found in the upstairs bedroom in bed with a
medical data confirmed mental illnesses. revolver lying on his left leg. Two wounds were noted to the left and
The autopsy revealed wrist cuts, neck cuts, acid burns in the GI right sides of his head.
tract, multiple stab wounds to the head by screwdriver, and several Results: The external examination revealed a Caucasian male with
uncertain signs of hypothermia. In the parietal region, along the midline, two contact penetrating gunshot wounds to both sides of his head. Dense
there was an epidural hematoma measuring 5x1 cm in diameter. The soot deposits were present on the skin and within the wound tracks.
brain was swollen, with flattened gyri and narrowed sulci, measuring Faint muzzle abrasions with micro-stretch lacerations were identified
1.64 kg. Marked indentations on the ventral surface of cerebellum, surrounding the entrance wounds. Gunpowder residue was grossly
indicating tonsillar herniation were found. The brain tissue along all visible on both the left and right hands. Radiographs of the head
wound tracts was destructed, but there were no diffuse injuries in white revealed two separate aggregates of pellets. Autopsy revealed a gunshot
matter, nor were concentric zones of necrosis around the tracts noticed. wound of entrance just lateral and slightly superior to the right orbit. The
Toxicology analysis (GC-MS) of gastric and intestinal content revealed path of the pellets was leftward through the orbital rim, posterior, and
Cypermethrin (synthetic pyrethroid used as an insecticide in commercial inferior to the orbital globe and came to rest in the sphenoid sinus. The
agricultural applications), while analysis of blood, urine and bile was second entrance wound entered superior and anterior to the left ear. The
negative. The same substance was identified in liquid from transparent path of the pellets was rightward through the frontal bone and frontal
plastic bottle, taken from the scene. lobe of the brain where they were recovered.
The firearm used by the decedent was a revolver made in West G76 Cause of Sudden Death Due to Cardiac
Germany chambered in 22 long rifle. The ammunition in the revolver
consisted of five spent rounds and one live cartridge of .22 caliber long
Rhabdomyoma in an 11-Month-Old Baby
rifle shotshells loaded with number (size) 12 shot.
Conclusions: Collaboration between the pathologist and firearms Sabina Di Donato, PhD*, University of Foggia, Department of Forensic
examiner concluded that the decedent shot himself near his right orbit Pathology, Viale Aviatori, 1, Foggia, 71100, ITALY; Michele Nolè,
first and then changed hands and shot the lethal round into the left frontal A.O.R. “San Carlo” Hospital, Via Potito Petrone, 6, Potenza, 85100,
region of his head. This is supported by gunshot residue on both hands ITALY; Irene Riezzo, PhD, University of Foggia, Osp D‘Avanzo,
and autopsy evidence that the path of the pellets on the right side of the Department of Forensic Pathology, Viale degli Aviatori, 1, Foggia,
head did no major damage. A literature review revealed only two 71100, ITALY; Sara Vita, MD, University of Foggia, Department of
published papers pertaining to the use of snake shot or shot shells. This Forensic Pathology, Viale Aviatori, 1, Foggia, 71100, ITALY; and Rocco
case report offers to further build upon the knowledge of terminal A.G. Maglietta, MD, San Carlo Hospital Potenza, Section of Legal
ballistics of handgun shot shells. Medicine, via P. Petrone n.6, Potenza, 85100, ITALY
Snake Shot, Handgun, Suicide
After attending this presentation, attendees will become familiar
with the possibility that a completely asymptomatic benign cardiac
tumor may induce sudden death in a previously healthy infant.
G75 Survived Strangulation: A Case Report This presentation will impact the forensic science community by
making attendees aware of the insidious development of benign cardiac
Paula C. Oliveira, MD*, Portuguese National Institute of Legal tumors also in infants and children, focusing the possible responsible
Medicine, Largo da Sé Nova, Coimbra, 3000-213, PORTUGAL; Ana R. mechanisms of sudden death in such cases and providing a reference for
Pereira, MD*, Ladeira das Alpenduradas nº13A, Coimbra, 3030-167, additional study on these subjects.
PORTUGAL; Rosario L. Silva, MD, and Graca Santos Costa, MD, Neoplasms of the heart can be characterized as primary and
Portuguese National Institute of Legal Medicine, Largo da Sé Nova, secondary. Primary cardiac neoplasms occur infrequently in both adult
Coimbra, 3000-213, PORTUGAL; and Duarte N.P. Vieira, PhD, Rua and pediatric age groups. In the general population, their incidence
Antonio Jose de Almeida, No 117, Coimbra, 3000-044, PORTUGAL ranges between 0.17% and 0.19% in unselected autopsy series. In infants
and children, cardiac tumors were reported at a frequency of 0.027%.
The goal of this presentation is to analyze and discuss the injury Approximately 75% of primary cardiac tumors are benign, and 25% are
pattern potentially associated with situations of survived strangulation malignant, in the general population. Benign lesions usually
and the various consequences that may result from them, based on real predominate, making up more than 90% of all pediatric tumors.
cases. This presentation will also attempt to determine, if findings and Approximately 50% of the benign tumors are myxomas, and about 75%
symptoms of victims can be intensity of the assault and the severity of of the malignant tumors are sarcomas.
strangulation and if general evaluation criteria can be established on the Rhabdomyoma is the most frequently occurring cardiac tumor in
basis of objective findings. children. It usually presents during the first few days after birth. It is
This presentation will impact the forensic science community by associated strongly with tuberous sclerosis, a hereditary disorder
presenting severe survived strangulation cases researched, and characterized by hamartomas in various organs, epilepsy, mental
introducing other cases described in literature. Difficulties usually exist deficiency, and sebaceous adenomas. Fifty percent of patients with
in clinical forensic medicine regarding the interpretation of the findings tuberous sclerosis have rhabdomyoma, but more than 50% of patients
in reference to the intensity and duration of the assault and, ultimately, with rhabdomyoma have or will develop tuberous sclerosis. The
the threat it represented for victim´s life. This assessment is particularly exceptional patient is one with a solitary, single rhabdomyoma who does
important when conclusions must be drawn in the context of penal law, not have or develop tuberous sclerosis.
in order to allow the court to decide about the life risk involved in Over 90% of rhabdomyomas are multiple and occur with
situations of aggression. approximately equal frequency in both ventricles. The atrium is involved
Cases Report: Several cases are presented involving different in fewer than 30% of patients. Pathologically, these tumors are firm,
situations, from victims of assault to incidences of accidental self- gray, and nodular and tend to project into the ventricular cavity.
inflected strangulation. The majority the cases presented are of severe Micrographs show myocytes of twice normal size filled with glycogen
life-threatening strangulation that is cases with petechial bleedings on and containing hyperchromatic nuclei and eosinophilic-staining
conjunctivae, mucosal surfaces and facial skin, as well as otorrhea, loss cytoplasmic granules. Scattered bundles of myofibrils can be seen
of consciousness, loss of urine, vomiting, etc. within cells by electron microscopy.
Conclusions: The interpretation and significance of the injury The most common presentation is heart failure caused by tumor
pattern is discussed as well has the contribution that this pattern may give obstruction of cardiac chambers or valvular orifice flow. Clinical
to a differential diagnosis between assault and self-inflected findings may mimic valvular or subvalvular stenosis. Arrhythmias,
strangulation and to the evaluation of the severity of the situation and the particularly ventricular tachycardia and sudden death, may be a
threat to life. Also stressed is the fact that forensic assessment must be presenting symptom. Atrial tumors may produce atrial arrhythmias. The
as detailed as possible, due to the fact of a rapid change of the lesions diagnosis is suggested by clinical features of tuberous sclerosis and is
pattern, with the risk of becoming impossible a correct interpretation of made by echocardiography.
the facts. Finally, the transitory physical consequences of these Benign cardiac tumors in childhood have an excellent prognosis
situations and of the permanent results that may result from them, as well when completely excised and appear to have a good short-term
as of their contribution to an appreciation of the severity of the prognosis even when excision is incomplete. Symptomatic tumors often
aggression will be discussed. The analysis of these cases also stress the are both multiple and extensive, particularly in patients with tuberous
importance, as previously stated by Plattner et al (2005), of a clinical and sclerosis, who unfortunately, have a dismal long-term outlook. In such
radiological examination in addition to the forensic examination. It also circumstances, surgery offers little benefit.
shows that applicability in forensic practice of the classification in three Case Report: A mother was bathing her 11-month-old baby.
different degrees of severity of these situations, proposed by Plattner et Suddenly the infant showed a worsening dyspnoea. Parents
al (2001). accompanied the baby to the emergency room immediately, but despite
Strangulation, Injury Pattern, Survival the reanimation manoeuvres, the doctor could only pronounce the death.
The infant had a negative obstetric, remote and recent pathological
anamnesis, except for a documented fall two days before. Also the The investigation of the scene revealed a plugged in table saw. The
familiar history was negative for sudden death. body was lying on a large pool of blood about five feet away from the
A complete postmortem examination was performed within 48 table saw. The walls of the garage were extensively covered with blood
hours after death. The body was that of a regularly developed 11-month- spatter in a pattern of arterial spray. The table saw itself had been
old infant. External examination was insignificant, except for the overturned and had blood on both the saw blade, and on the upper and
presence of a little and superficial wound on the sternal region. lower surfaces of the saw.
The internal examination revealed a peduncolated mass at the The autopsy on the decedent noted an oblique, Y-shaped incised
cardiac apex, a second superficial subepicardial neoformation at the wound in the right side of his neck. The wound was located on the
posterior wall of the left ventricle and a third transmural nodule of the superior anterolateral aspect of the neck, beneath the right mandible and
posterior wall of the left ventricle. A polyvisceral congestion, cerebral measured 14 cm in total length, 0.4 cm in width, and 3.5 cm in maximal
and pulmonary oedema, with a massive increase in lung weight were depth. The edges of the wound are abraded along the superior margin
also evident. and smooth along the inferior margin. The wound transected the right
The histological examination of cardiac specimens, stained with jugular vein and the right external carotid artery and penetrates into the
haematoxylin–eosin, showed a demarcation and separation of the three right sternocleiodmastoid muscle. The cause of death was
masses from the surrounding regular parenchyma. The striated muscle exsanguinations due to the incised wound of the neck. Postmortem
cells appeared diffusely vacuolized, enlarged, with round to oval slightly toxicology study was negative.
irregular nuclei and variable cytoplasmatic clearing. There were Discussion: Investigation was emphasis on ruled out the wife or
occasional spider cells; muscular tissue residues were also visible. The others might have been involved in the death of her husband due to the
immunohistochemical studies documented a positive expression of initial findings at the scene, the absence of a suicide note and the unusual
myoglobin, Actin, Vimentin, Desmin, CD34. The result with antibodies means used. Further interview of the wife revealed that decedent and his
Anti-Ki67, -S100 was negative. This microscopic examination was wife had a discussion of ending their own lives with a murder-suicide
consistent with rhabdomyoma. fashion. The 6-14 inch table circular saw used in this case had double
Cultural tests and toxicological screening resulted negative. There protective features to prevent self injury. Further study indicated there is
were no signs of sclerosi tuberosa. the possibility that the saw can be used by self to produce the similar
It was concluded that the infant had three cardiac lesions consistent injury as the decedent sustained. It can also be explained that people
with a primary cardiac tumor, the rhabdomyoma, which caused the keep consciousness and moving their bodies within short of time after
sudden death. In particular one tumoral mass occupied almost the whole sudden loss of large amount of blood.
posterior wall of the left ventricle, rising from the apex to the valvular Conclusions: Suicide itself is much more common in individuals
level, so compromising the regular contraction of the left ventricle. The with long standing psychological problems, including bipolar mood
neoplasms probably had caused two days before a near syncopal episode disorders, depression, and schizophrenia. Violent means of suicide have
that the parents erroneously referred as a fall. been more closely associated with bipolar disorders with tendency
Sudden Infant Death, Cardiac Rhabdomyoma, Benign Cardiac Tumors towards self mutilating behavior. A differential thought process must be
considered to interpret the pattern of events surrounding the scene of a
death by violent means. Cooperation between the forensic pathologists,
G77 Suicide by Table Saw — A Slice the police and crime scene investigators made it possible to reconstruct
the unusual situation and to exonerate a third party.
of Interpretation Suicide, Forensic Pathology, Table Saw
Jeffrey Racette, MD*, Baiyang Xu, MD, Todd M. Luckasevic, DO,

Alleghey County Medical Examiner Office, 1520 Penn Avenue,
Pittsburgh, PA 15222; and Abdulrezak M. Shakir, MD, Allegheny County
G78 The Significance of Gross Adrenal
and Karl E. Williams, MD, Office of the Medical Examiner - Allegheny Hemorrhage — Undiagnosed Waterhouse-
County, 542 Fourth Avenue, Pittsburgh, PA 15219 Friderichsen Syndrome: A Case Series
The goal of this presentation is to illustrate an unusual means of Lee M. Tormos, MD*, Medical and Forensic Autopsy, Pathology and
suicide with a home radial arm circular table saw. Laborat Medicine, 171 Ashley Avenue, Suite 309, MSC908, Charleston, SC
This presentation will impact the forensic science community by 29425-9080; and Cynthia A. Schandl, PhD, Medical University of South
illustrating the need for close collaboration between the forensic Carolina, 171 Ashley Avenue, Suite 309, MSC-908, Charleston, SC 29425
pathologist and the scene investigators (in combination with careful
photography) to elucidate the sequence of events and to rule out the After attending this presentation, attendees will understand the
involvement of other individuals in unusual cases involving violent, non- importance of finding gross adrenal hemorrhage at autopsy, and that
firearm related, means. further laboratory studies and clinical-pathologic correlation is
Introduction: Suicide represents a common manner of death in the warranted to identify the signs and symptoms of pre mortem adrenal
United States. A painful means (with or without the expectation of a dysfunction.
rapid loss of consciousness) are uncommon. The use of a electrical saws This presentation will impact the forensic science community by
for suicidal purposes is documented in the literature, but remains a very addressing how bilateral adrenal hemorrhage can complicate severe
rare event. The use of violent means of suicide is even more uncommon sepsis of various origins, not only severe meningococcemia. Clinical
in individuals with no significant prior history of psychological suspicion of sepsis and septic shock warrants clinical studies to diagnose
disorder(s). adrenal hemorrhage and insufficiency. Undiagnosed adrenal
Case Presentation: The subject of this case is a 50-year-old hemorrhage will result in an unfavorable outcome despite adequate
Caucasian male who became recently depressed due to debt problems. treatment.
The man and his wife had discussed the possibility of dying together in Adrenal hemorrhage and clinical adrenal insufficiency is classically
a murder-suicide. It is in question whether the wife reported a domestic associated with meningococcemia as part of the Waterhouse-
assault on the same morning which she managed to escape from her Friderichsen syndrome. It is proposed that non-traumatic adrenal
husband, before calling the police. The decedent was found dead in his hemorrhage in cases of sudden unexplained death are associated with
garage shortly thereafter on the morning of November 24, 2009.
bacterial sepsis of various etiologies and that undiagnosed adrenal duration. She had not been feeling well enough at home to perform her
insufficiency may contribute to the fulminant clinical course. dialysis for the past two days. At admission she had a GFR of 2, was
Adrenal hemorrhage and resultant clinical adrenal insufficiency has hyperkalemic (6.3 mEq/L), anemic with thrombocytosis and
been reported in literature as an uncommon complication of bacterial leukocytosis (23.5 K/uL) and a left shift. She had developed a new third-
sepsis and is generally associated with an unfavorable outcome in the degree heart block with a ventricular rate in the 30’s. Her troponin-I was
majority of cases. Other causes named in the literature include stress, elevated at 1.56 ng/mL. Her total calcium was 9.4 mg/dL and her
anticoagulation therapy, and hypotensive events. Therefore, the finding phosphorus was also elevated at 18.6 mg/dL for a calcium x phosphorus
of adrenal hemorrhage at autopsy is not necessarily associated with product of 174.8 mg2/dL2. She was transferred to the ICU where she
sepsis and premortem functional adrenal insufficiency, as is seen in became asystolic for 5-6 seconds, but had a spontaneous return of
Waterhouse-Friderichsen syndrome. Four cases of non-traumatic gross circulation. A transvenous pacemaker was placed emergently with good
adrenal hemorrhage are identified in 800 consecutive forensic autopsies capture and effective right ventricular pacing. However, she quickly
and are described and analyzed, with particular attention paid to the became hypotensive, lost conciousness, and became pulseless. After 35
patient’s signs and symptoms possibly secondary to adrenal failure and minutes of unsuccessful resuscitative efforts she was pronounced dead.
the clinical course. It was found that patients with this grossly The case was referred to the Office of the Medical Examiner due to her
identifiable adrenal hemorrhage die suddenly as a consequence of acute sudden and somewhat unexpected clinical decline.
illness of several days duration. All subjects were males, of different At autopsy, the left ventricle demonstrated a uniform mottled pail-
ethnicities, and with ages ranging from 2 to 47. All subjects have a yellow process. The coronary arteries had thin, pliable vascular walls
clinical history suggestive of sepsis. At autopsy the most relevant with widely patent lumina. Microscopic exam revealed widespread
findings are in the lungs, where findings range from heavy, congested calcium deposits in the myocardium including the conduction system.
lungs to gross findings of necrotizing pneumonia with abscess formation There was also evidence of acute myocardial ischemia. Cardiovascular
and empyema. Postmortem cultures yielded positive results in three out complications are the leading cause of death in patients with end-stage-
of four cases, with Staphylococcus aureus, Streptocoocus pneumonia, renal-disease (ESRD). Derangements of calcium and phosphate
and Pseudomonas aeruginosa determined to be the definitive agent and metabolism are known to lead to soft tissue calcification. The
the underlying cause of death in each case respectively. The fourth case calcification of the coronary arteries in patients with ESRD is a common
had a positive culture with yeast and a coagulase negative cause of morbidity and mortality. The National Kidney Foundation
staphylococcus. No cases had a positive culture for Neisseria recommends that the calcium-phosphate product be maintained below 55
meningitidis. In each case, signs and symptoms compatible with mg2/dL2 to minimize the risk of metastatic calcification of soft tissue and
premortem adrenal insufficiency were reported; in no instance was the vasculature. In patients with a severely elevated calcium-phosphate
adrenal hemorrhage clinically identified. The precise mechanism(s) of product the deposition of calcium can be rapid. If the deposition occurs
adrenal hemorrhage in sepsis or other initiating condition(s) is unclear. in the cardiac conduction system sudden cardiac death can occur without
However, once adrenal hemorrhage ensues, significant morbidity and the presence of coronary artery calcification.
mortality may result from adrenal crisis including shock and death. The Pathologists should be aware of this potential complication of
pediatric population is statistically at increased risk for this complication. ESRD in cases of sudden death in patients with elevated calcium and
In light of the clinical information and autopsy findings, a component of phosphate or in cases in which the values were not obtained near the time
adrenal failure may have contributed to the grave consequences of of death or known at the time of autopsy.
infection. Herein, the causes and potential consequences are discussed Dialysis, Calcification, AV-Node
of adrenal hemorrhage by reviewing a series of four cases in light of the
available published literature and conclude that additional autopsy and
clinical studies may be warranted to determine the clinico-pathologic G80 Postmortem Interval and Cardiac
correlation of this postmortem finding.
Adrenal Hemorrhage, Waterhouse-Friderichsen, Sepsis
Troponin Effect
Ziya Kir, MD, and Coskun Yorulmaz, MD*, Istanbul University
Cerrahpasa School of Medicine, Department of Forensic Medicine,
G79 Metastatic Calcification of AV-Node as a Cerrahpasa, Istanbul, 34099, TURKEY; Murat Bolayirli, MD, Istanbul
Cause of Complete Heart Block and Death University Cerrahpasa School of Medicine, Department of Biochemistry,
Cerrahpasa, Istanbul, 34099, TURKEY; Haluk Ince, PhD, Council of
Joseph K. White, DO*, University of Colorado Denver School of Forensic Medicine, Chairperson of the Counsil of Forensic Medicine,
Medicine, 660 Bannock Street, Denver, CO 80204; and Amy Martin, Istanbul, 34197, TURKEY; and Mete K. Gulmen, PhD, Cukurova
MD, Denver Office of the Medical Examiner, 660 Bannock Street, University School of Medicine, Department of Forensic Medicine,
Denver, CO 80204 Adana, 01330, TURKEY
After attending this presentation, attendees will have a better The goal of this presentation is to show the cardaic troponin effects
understanding of the mechanism, and the common and uncommon in PMI and its value in daily forensic use.
complications associated with dialysis-associated myocardial This presentation will impact the forensic science community by
calcification. demonstrating the statistical data of the cardiac troponins experimentally
This presentation will impact the forensic science community by and the estimation of PMI accordingly and also the daily use of it.
increasing awareness of some of the possible complications of renal In clinical practices, cardiac troponins (cardiac myofibril-
failure, such as myocardial calcification and conduction abnormalities, specificproteins) are specific markers of myocardial damage. In addition,
in individuals on dialysis. measurements of cardiac isoform of troponin are recognized as
Metastatic calcium deposition into soft tissue is a well documented important tests in the postmortem diagnosis of myocardial necrosis when
phenomenon that occurs rarely in people treated with dialysis. The such a lesion is suspected but cannot be established. Previous studies
pattern of calcification and the organs involved is highly variable and have suggested the possible application of these markers in the
thus the symptoms are myriad. A case is presented of a 37-year-old postmortem diagnosis of acute myocardial infarction. However, some
woman on nightly ambulatory peritoneal dialysis for 20 months. She reports showed that elevated postmortem cardiac troponin I (cTnT)
had stage 4 renal failure due to uncontrolled hypertension. She presented levels in cardiac tissue and pericardial fluid may reflect postmortem
to the hospital complaining of shortness of breath and cough of two days’ interval. Postmortem interval may provide valuable information for
evaluation cases in both criminal and civil law pursuits, for their G81 Ante- and Postmortem In-Human Cocaine
elucidation as well. Time-since-death markers have lagged behind the
progress in technology of the past years. Since the earlier attempts,
Packs Detected by Computed Tomography
failed to meet the definite postmortem interval, for variable reasons with
much success, the postmortem biochemical changes in various body Patricia Mildred Flach, MD*, and Steffen G. Ross, MD, Institute of
fluids and tissue have been tried for the estimation of time of death. The Forensic Medicine, Center of Forensic Imaging “Virtopsy”,
degradation of cardiac Troponin I in myocardial tissue and pericardial Buehlstrasse 20, Bern, 3012, SWITZERLAND; Garyfalia Ampanozi,
fluid has been investigated. The goal of this study is to investigate the MD, Ulrich Preiss, MD, Tanja Germerott, MD, Gary M. Hatch, MD, and
potential use of myocardial tissue and pericardial fluid cTnI level as an Michael Thali, MD, University of Bern, Institute of Forensic Medicine,
estimator of postmortem interval. Cases selected from routine Buehlstrasse 20, Bern, 3012, SWITZERLAND; and Michael Patak, MD,
necropsies performed in the Council of Forensic Medicine, Istanbul. University of Bern, Radiology, Freiburgstrasse, Bern, 3010,
Samples were obtained from 98 deceased, where exact postmortem SWITZERLAND
interval was known. Isolation of cTnI from heart tissue and pericardial
fluid was chosen because it is found in a highly protected internal After attending the presentation, attendees will understand how to
location. detect intra-corporal cocaine packs on CT. The differences of body
The findings were elucidated according to patient records, scene of packing, stuffing, or pushing will be elaborated and the varying
death, autopsy, and complementary toxicological and histological appearance of the packs in CT will be demonstrated. Further, the
studies, depending on the probable intensity of myocardial damage and necessity of a tight collaboration of the custody ward, the forensic
cause of death. No statistically significant difference was found between institute, and the radiology department will be shown.
cause of death and titration alterations of cTnI in cardiac tissue and This presentation will impact the forensic science community by
pericardial fluid speciments (p>0.05). On the other hand, alteration in raising awareness of the difficulties and pitfalls on CT imaging of drug
the level of cTnI in the pericardial fluid dependent on the period of time mules, understanding the variety of drug containers, and the upcoming
after death showed statistically significant positive correlation (r=0.523 medicolegal issues.
p<0.0001). Especially differentiation between period of first 12 hours Purpose: The goal of this presentation is to depict the findings on
after death and interval beyond could be established within confidency computed tomography (CT) in detection of concealed cocaine – filled
interval of 95% using the estimation of pericardial fluid cTnI level. packs in the alimentary tract of living and dead human transporters.
Meaningful statistical correlation in between the pericardial effusion and Materials and Methods: The study population consisted of 15
cardiac tissue cTnl titrations(r=0.427 p<0.0001) was noticed. This result antemortem and one postmortem CT exams with detected intra-corporal
shows us the protein degrading effect of the PM autolysis to the cocaine containers. The images were assessed retrospectively by
pericardial effusion. This is a similar finding with the similar studies and investigators with special training and experience in reading images of
it is very valuable to show the autolytic degradation instead of the drug carriers. Radiological findings were compared with listed evidence
reflection of the tissue necrosis. The positive correlation between the in the feces or alimentary tract of each detained suspect or deceased
level of pericardial fluid cTnI and the postmortem interval and victim.
discriminative properly of this marker for estimation of the postmortem Results: Cocaine-filled containers were detected by CT in each
interval should provide a superior tool for this purpose. The data case. The appearance and morphologic shape were compared to the
presented demonstrates that this technique represents a major advance in evidence secured on a custody ward or during autopsy. Window leveling
time since death determination providing reliable quantitative from abdominal window to lung window of the CT images was crucial
biochemical markers from a protected organ versus estimates such as and allowed for correct diagnoses.
those based on direct temperature measurements. Conclusion: Reading CT images of drug mules needs special
Furthermore, it could be shown that cardiac tissue is not influenced knowledge of the appearance of the various drug containers and of the
by autolytic changes in the postmortem interval to a considerable extent. important window leveling in order to detect even hypodense or tiny
Although previous forensic pathological studies have suggested the packs within the alimentary tract. A reliable and fast method such as CT
possible application of cardiac troponins in the diagnosis of myocardial is needed due to the limited space at custody wards to triage holding,
infarction, there appears to be insufficient data with regard to its discharge or transfer to regional prison. During the last years, forensic
influence of postmortem interval. These results suggest that immune and medical issues have lead to an increasing number of if needed,
enzymatic studies concerning postmortem differential diagnosis of judicially warranted CT examinations. Pre-autopsy postmortem scans
myocardial infarction may provide considerably reliable data with allow for exact localization of incidental or suspected findings of foreign
probability of false positive results on a negligible level. In forensic bodies such as in-human drug containers. Obviously, the radiologist
medicine, there is a need for more sensitive biochemical markers for needs to be well schooled in the appearance of the drug containers in
estimation of postmortem interval and diagnosis of myocardial injury. A order to diagnose those correctly – therefore a tight collaboration with
study of the distribution of biochemical markers in different fluids is of the custody ward, the associated forensic institute and the radiology
great significance in postmortem diagnosis, because their distribution department is desirable.
depends on the location of tissue damage and release kinetics. Further Body Packer, Cocaine, CT
studies are required to compare these results and create the possibility for
new conclusions.
Postmortem Interval, Cardiac Troponin I, Forensic Autopsy G82 Decomposition in a Closed Vehicle
Environment in Southern Ontario
Shari L. Forbes, PhD*, Helene LeBlanc, PhD*, Katelynn Perrault, BSc,
and Alicia Buetter, BSc, University of Ontario Institute of Technology,
2000 Simcoe Street North, Oshawa, ON L1H7K4, CANADA

importance of chemical and entomological evidence associated with
decomposing remains concealed in a closed vehicle environment. This
presentation will impact the forensic community by providing new G83 Child Abusive Head Trauma in Portugal
information regarding the decomposition process in a vehicle trunk in
southern Ontario and providing more accurate estimates of time since Agostinho Santos, PhD*, North Branch of the National Institute of Legal
death in this unique environment. Medicine, Jardim Carrilho Videira, Porto, 4050-167, PORTUGAL;
A body placed in a closed vehicle environment will undergo a Liliana Santos, MD, Jardim Carrilho Videira, Porto, 4050-167,
distinctly different process and rate of decomposition than a body placed PORTUGAL; Teresa Magalhães, PhD, North Branch of the National
in an outdoor environment. A closed vehicle has the potential to Institute of Legal Medicine, Jardim Carrilho Videira, Porto, 4050-167,
significantly affect decomposition processes by reducing entomological PORTUGAL; Francisco Corte-Real, PhD, Center Branch National
access to the body, increasing ambient temperatures, and promoting Institute of Legal Medicine, Largo da Sé Nova, Coimbra, 3000-213,
desiccation and mummification of the remains. In Canada, there is PORTUGAL; Jorge C. Santos, PhD, South Branch National Institute of
currently no published literature which has studied the effect of a closed Legal Medicine, R. Manuel Bento de Sousa, nº 3, Lisboa, 1150-219,
vehicle environment on entomological activity and the chemical PORTUGAL; and Duarte N.P. Vieira, PhD, Rua Antonio Jose de
processes which occur during soft tissue decomposition. This Almeida, No 117, Coimbra, 3000-044, PORTUGAL
information would be valuable to forensic pathologists and coroners
when estimating time since death in forensic investigations involving The goal of this presentation is to better understand how child
decomposed remains recovered from a vehicle. Abusive Head Trauma (AHT) is managed in Portugal.
The goal of this study was to investigate the chemical process of This presentation will impact the forensic science community by
soft tissue decomposition and the entomological evidence associated filling the void of epidemiology background concerning fatal AHT in
with a body placed in the trunk of a vehicle. The study was conducted Portugal, and will allow comprehensive knowledge of the Portuguese
in the southern region of Ontario, Canada during the summer months of experience on this issue. Only then will it be possible to develop
June and July. Two pig carcasses of similar biomass were used in the assertive and coordinated policies and strategies for action in this field in
study. The experimental carcass was placed in the trunk of a dark- order to minimize the number of cases as well as its consequences. Until
colored vehicle and sealed. The control carcass was placed on the soil now, in Portugal, only isolated and non-articulated studies have been
surface approximately ten meters from the vehicle. A data logger was made on this issue, reflecting only loco-regional incidences or even only
placed in the vehicle to record temperature and humidity. A weather the numbers of one organization. For these reasons, it is not possible to
station was placed near the control carcass to record ambient infer what is really going on at a national level.
temperature, humidity, and rainfall. Soft tissue samples were collected The absence of a systematic approach on child abuse (CA) makes it
from the upper and lower torso region of the carcasses. Entomological impossible to have the real knowledge of the prevalence and incidence
evidence was collected directly from the carcasses and from pitfall traps of this problem in the Portuguese population. Currently there are no
surrounding the carcasses. Samples were collected at regular intervals more than estimates of certain entities, certainly underestimating, from
until the carcasses reached the skeletonization or dry remains stage. the Ministry of Justice, the National Commission for the Protection of
Decomposed soft tissue was analyzed using gas chromatography- Children and Young People at Risk (CNCJR), the National Institute of
mass spectrometry to determine the lipid degradation process and Legal Medicine (INML), the criminal police forces, the victims’ support
resulting fatty acid content within the samples. Unsaturated and associations, or the health care services. Furthermore, the most
saturated long-chain fatty acids were identified at all stages of the important problem is that the referred data represents only a portion of
decomposition process. Variations in the lipid degradation pathways incidences because frequently cases are not reported. However,
were evident between the experimental and control carcasses. Adult and gathering such sort of data is vital in order to find the proper and most
immature insects were collected from the carcasses in order to determine suitable approach to these situations in Portugal.
the succession throughout decomposition. An important delay of insect In AHT cases, it was verified that in the last years there has been an
colonization was observed in the vehicle as well as a significant decrease important increase in the number of published reports in the international
in species composition. medical literature describing AHT (Hymel KP, 2002) and considering
Observational measurements confirmed that the decomposition that it represents the most frequent cause of death due to CA, the main
process was distinctly different in the closed trunk of the vehicle when cause of traumatic death in children under 1-year-old (Duhaime AC e
compared to the decomposition process on the soil surface. The col, 1999) and the cause of significant morbidity, with up to 50% of
chemical, entomological, and environmental data provided additional survivors having permanent neurologic sequelae (Duhaime AC e col,
confirmation of the distinct process in which a decomposing body will 1996). Between 24% and 33% of traumatic brain injuries (TBI) hospital
undergo in a closed vehicle environment. This information will be admissions in children under 2-years-of-age are from AHT (Duhaime AC
valuable to law enforcements agencies and forensic pathologists and e col, 1987; Dashti SR e col, 1999). The incidence of severe inflicted
may aid in providing more accurate estimations of time since death. TBI in Scotland is 24.6 infants per 100 000 person-years which is
Forensic Entomology, Decomposition Chemistry, Closed comparable with epidemiologic data in the United States, where this
Vehicle Environment incidence is 29.7 infants per 100 000 person years (Barlow KM, Minns
RA, 2003; Keenan HT e col, 2003). In fact, it is known that for AHT up
to 30% of the cases are difficult to be initially recognized (Jenny C e col,
1999), mainly because victims, almost under 2-years-of-age, cannot
describe the abuse (Bechtel K e col, 2004), and because many cases are
of mild or moderate severity (Berger RP e col, 2004).
However, in spite of all these difficulties, the various forms of AHT
(including shaken baby syndrome (SBS)) are now well recognized and
diagnosed in most countries (Barlow KM e col, 2005) which cases are
being identified and reported; however, doesn’t seem to be the case in
Portugal. The intervention in a situation of CA can be initiated by
multiple kinds of professionals of different institutions. Among those
professionals teachers, childhood educators, physicians (mostly
pediatricians, practitioners, and gynecologists), nurses, psychologists,
policemen/women, and social workers are highlighted. According to the
Portuguese Criminal Law these professionals are mandatory reporters
and according to the Protective Law and the Deontological Code (in content of the inoculated sand was maintained at 55% every 3-4 days by
what physicians concern), they have the duty to report suspected cases. adding distilled water. Carcass decomposition was monitored every 24
The problem is that there are numerous initial referral sources, multiple hours for 35 days using a decomposition scoring system. In addition,
professionals (with different formations and awareness, presenting carcass mass loss was measured at 7, 14, 21, 28, and 35 days
possible “prejudices” and non-official instructions and forms for postmortem. A destructive harvest design was used to avoid the
reporting cases. influence of carcass disturbance on the rate of decomposition. Following
In Portugal there are no published data concerning non-fatal AHT, carcass harvest, inoculated sand was collected and analyzed for lipid
and this work represents the first national approach regarding fatal cases phosphorus, fatty acid methyl esters, pH, total nitrogen, and total carbon.
due to this kind of abuse. Analyzing the fatal cases of suspected CA This experiment was replicated four times and controls (inoculated sand
observed in the medico-legal services of Portugal, between 2005 and with no carcass) were used. Results and discussion will be presented to
2008, it has been verified that AHT represented only 12.5% of the demonstrate the effectiveness of soil microbial ecology to act as an
suspected CA causes of death (1.2 infants per 100,000 person years), estimator of PMI.
despite in the literature, AHT represents the most frequent cause of death Forensic Taphonomy, Extended Postmortem Interval, Ecology
due to CA. The single diagnosed case of SBS will be presented.
These Portuguese results must be carefully analyzed and compared
with other foreign studies, which are completely different. According to G85 Laceration of the Inferior Vena Cava
the facts, it is presumed that an important number of cases of AHT is still
undiagnosed or underdiagnosed in Portugal (being diagnosed only when
Following Blunt Abdominal Trauma in a
specifically looked for), or remain unreported or underreported by the Case of Child Abuse
health professionals.
Child Abuse, Abusive Head Trauma, Shaken Baby Syndrome Carlos F. Chavez-Arias, MD*, Puerto Rico Institute of Forensic
Sciences, PO BOX 11878, Caparra Heights Station, San Juan, PR
00922-1878; and Javier G. Serrano, MD, Puerto Rico Institute of
G84 Gravesoil Microbial Community Structure Forensic Sciences, Calle Maga Esquina Casia #9, Urb. Reparto
Metropol, San Juan, PR 00921
During Carcass Decomposition
The goal of this presentation is to describe and discuss a child abuse
Amy E. Maile, BS*, and David O. Carter, PhD, University of Nebraska, case with multiple blunt injuries that include blunt abdominal trauma
Lincoln, Department of Entomology, 202 Entomology Hall, Lincoln, NE with laceration of the inferior vena cava (IVC).
68583-0816; and Rhae A. Drijber, PhD, University of Nebraska-Lincoln, This presentation will impact the forensic science community by
Department of Agronomy and Horticulture, 279 Plant Sciences Hall, demonstrating an uncommon finding resulting from blunt trauma in a
Lincoln, NE 68583-0915 child abuse case.
The majority of injuries to the IVC are due to penetrating trauma.
After attending this presentation, attendees will understand that Only 10% of these injuries will be caused by blunt trauma. This may be
there is potential for the use of fatty acids to characterize gravesoil due to the fact that the IVC is a retroperitoneal organ and is therefore
microbial community with the ultimate goal of estimating postmortem relatively protected from injury. Injury as a result of blunt trauma would
interval (PMI). only result from a force of great magnitude.
This presentation will impact the forensic science community by This case involved a 22-month-old, Hispanic, male infant who
the development of an additional method to determine extended PMI. arrived dead to the emergency room. The stepfather stated that he
This additional method can be used in conjunction with other methods to witnessed the infant falling to the ground while walking and hitting his
estimate PMI, such as forensic entomology. head against the adjacent wall. The stepfather tried to resuscitate the
Estimating PMI is important for every death investigation. It allows child but he continued to lose consciousness. He waited for the infant’s
for the acceptance or rejection of alibis as well as helping to identify mother to arrive home and they took the child to the emergency room.
victims. At present forensic entomology is arguably the most reliable His social history revealed that he lived with his mother and the
means to accurately estimate PMI at outdoor death scenes. However, stepfather and there was no family history of child protective services
active blowfly larvae, which are critical to insect based estimates of PMI, involvement. At the time of the event, he was under the stepfathers’ care.
can leave a body as early as ten days postmortem. When active blowfly The stepfather denied any physical abuse against the child.
larvae are not present at a death scene, forensic science is often ill At autopsy the body corresponded to a well-developed and well-
equipped to estimate PMI accurately. nourished male infant. He was 33 inches tall and weighed 31 pounds.
A controlled laboratory experiment was conducted to determine if External examination of his face and head showed multiple recent
soil microbial ecology has the potential to be used as an estimator of contusions and abrasions over the face and scalp. Multiple foci of
PMI. To do this incubation units were constructed that comprised petri subgaleal hemorrhage were present over the skull. The brain had mild
dishes (150 mm x 25 mm) filled with 360 grams (g) of washed sand subarachnoid hemorrhage over the left parietal and occipital lobes.
inoculated with 40 g of Pawnee clay loam soil. Soil was collected from Examination of the brain disclosed no other trauma. The head had no
Nine Mile Prairie, a natural tall-grass prairie ecosystem, which is located fractures. The torso also revealed multiple recent contusions. The
approximately nine miles northwest of Lincoln, Nebraska. Soil of the abdomen was moderately distended. After entering the peritoneal cavity,
Pawnee series is a fine, montmorillonitic, mesic Aquic Argiudoll 150 mL of liquid blood and 35 grams of blood clots were noted. There
(Mollisol). These incubation units were calibrated to a water holding was a laceration to the proximal suprahepatic segment of IVC with
capacity of 55% and left to equilibrate for seven days in plastic presence of blood clots adjacent to the laceration. Moderate
containers (20 cm x 34 cm x 11 cm) that contained methanol washed pea hemorrhagic infiltrate was present in the subintimal layer of the IVC
gravel and distilled water (100 ml) to regulate humidity. along the supradiaphragmatic segment of the vein extending to the right
After seven days, a mouse carcass (killed with carbon dioxide) was atrium of the heart. Gross examination of the abdominal viscera found
placed on its left side on the inoculated sand within 30 minutes of death. no other source of bleeding. The right pleural space had 40 mL of liquid
Nylon mesh (0.1 mm x 0.1 mm) was then used to cover the plastic blood. The right and left lungs had multiple contusions. Small
container to prevent insect colonization. The temperature was kept at lacerations were present next to the hilum of the right lung. Examination
approximately 20˚C during the experimental period and the water
of the extremities showed multiple recent contusions and no fractures. uniformly to all subjects. IVC values were measured with a handheld
Toxicological evaluation was negative for alcohol, cocaine, opioids, and ultrasound with a phased array (5-2MHz) transducer, operated by an
canabinoids. The cause of death was blunt force injuries and the manner RDMS sonographer. Data were analyzed using descriptive statistics and
of death was ruled a homicide. k sample for equality of medians test.
Intra-abdominal hemorrhage is most commonly associated with a There were 24 subjects that completed the study protocol. The
clear history of trauma. In young children, the liver and spleen are the median (interquartile range) IVC measurements for all positions are as
most common abdominal viscera to sustain a traumatic injury. follows:
Lacerations of the inferior vena cava resulting from blunt trauma are • Longitudinal maximum was 1.86 cm standing (1.57-2.16), 1.67 cm
relatively rare, but extremely serious with a high mortality and may be prone (1.05-2.26), 1.205 cm with 100 lbs compression (0.83-
difficult to repair. The majority of injuries of the IVC are due to 1.58), and 0.805 cm with147 lbs compression (0.46-1.29),
penetrating trauma and only a small percentage is caused by blunt (p < 0.0001).
trauma. Lacerations to the IVC are uncommon injuries in the pediatric • Longitudinal minimum was 1.21 cm standing (1.01-1.51), 1.14 cm
population. Lacerations of this vessel indicate a force of great magnitude prone (0.64-1.61), 0.70 cm with 100 lbs compression (0.45-1.02),
with a profound level of injury. The presented case has evidence of blunt and 0.28 cm with 147 lbs compression (0.0-0.79), (p<0.0001).
trauma in multiple regions of the body. The abdomen and thorax were • Transverse maximum was 1.63 cm standing (1.43-1.93), 1.45 cm
the most severely affected regions. The unique feature of this case is the prone (1.17-2.02), 1.12 cm with 100 lbs compression (0.76-1.65),
finding of IVC laceration with no other abdominal viscera involvement. and 0.74 cm with 147 lbs compression (0.46-1.13), (p<0.0001).
In this case intr-athoracic and intra-abdominal tensional forces produced • Transverse minimum was 1.18 cm standing (0.93-1.39), 1.01 cm
by blunt trauma to the torso could explain the lacerations of the IVC and prone (0.77-1.47), 0.38 cm with 100 lbs compression (0.0-1.15),
hilar area of the right lung. 0.31 cm with 147 lbs compression (0.0-0.52), (p<0.0001).
Laceration of Inferior Vena Cava, Blunt Trauma, Child Abuse There was significant difference between the IVC size in the
longitudinal and transverse planes at maximum and minimum between
all positions. The IVC size was greatest while standing. It became
G86 Inferior Vena Cava Compression: sequentially smaller with prone positioning and application of weight
A Possible Mechanism for Arrest force. It was smallest while lying prone with 147 lbs of thorax
compression. These findings support a possible pathophysiologic
Related Death mechanism of ARDs that has not previously been reported. Further
study in this area is recommended.
Jeffrey D. Ho, MD, Hennepin County Medical Center, Department of Arrest Related Death, In-Custody Death, Sudden Death
Emergency Medicine, 701 Park Avenue South, Minneapolis, MN 55415;
Donald M. Dawes, MD*, Lompoc Valley Medical Center, 1515 East
Ocean Avenue, Lompoc, CA 93436; and Johanna C. Moore, MD, and G87 Intra-Abdominal Hemorrhage Associated to
James R. Miner, MD, Hennepin County Medical Center, Department of
Emergency Medicine, 701 Park Avenue South, 1431 Lakeview Avenue an Intrapartum Rupture of the Umbilical
South, Minneapolis, MN 55415 Cord: A Case Report
After attending this presentation, attendees will understand a Carlos F. Chavez-Arias, MD*, Puerto Rico Institute of Forensic
potential pathophysiologic mechanism of arrest related death (ARD) not Sciences, PO BOX 11878, Caparra Heights Station, San Juan, PR
previously studied or discussed in the literature. 00922-1878; and Javier G. Serrano, MD, Puerto Rico Institute of
This presentation will impact the forensic science community by Forensic Sciences, Calle Maga Esquina Casia #9, Urb. Reparto
providing a possible explanation for sudden, arrest-related death that is Metropol, San Juan, PR 00921
not yet established in the literature.
The physiology of sudden ARDs proximal to restraint has not been The goal of this presentation is to describe and discuss a case of an
elucidated. Prior work has not suggested a relationship between intrapartum rupture of the umbilical cord leading to an intra-abdominal
position, restraint, or thorax compression up to 50 lbs with regard to hemorrhage and newborn death.
clinical impact on respiration. However, the impact of these variables on This presentation will impact the forensic science community by
Central Venous Return (CVR) has not been studied. Decreased CVR is demonstrating an uncommon case of intra-abdominal hemorrhage and
a theoretical concern in a subject with tachycardia from resistive death of the newborn as a complication of the rupture of the umbilical
exertion, mental excitement, or sympathomimetic ingestions. A sudden cord in a precipitous delivery.
change in CVR could cause an acute decrease of cardiac preload leading Intra-abdominal hemorrhage in the newborn is uncommon.
to possible decreased coronary artery perfusion pressure and ischemia or Bleeding from umbilical vessels in the cord can occur in the perinatal
the induction of a maladaptive neuro-cardiogenic reflex. This, in turn, period, the predisposing factors being a short cord, varices, velamentous
could lead to a brady-asystolic cardiac arrest. This study used ultrasound insertion of the cord, or true knot of the cord. Even more uncommon is
to measure the size of the Inferior Vena Cava (IVC) as a surrogate bleeding secondary to rupture of the umbilical cord.
marker of CVR when positional change and thoracic compression A 25-year-old gravida 6, para 4, came in active labor at 36 6/7
occurs. weeks of gestation. The mother had a late prenatal care and vaginal
This was a prospective study of human volunteers. Subjects had infection. The case was complicated at delivery due to violent expulsion
ultrasounds of their IVC in transverse and longitudinal planes performed of the baby girl who was caught by the physician attending the delivery.
in four positions. Maximum and minimum measurement values were The umbilical cord ruptured causing hemorrhage to the baby and the
obtained in each position after accounting for respiratory variability. The mother. Apgar scores were 1, 4, and 6 at 1, 5, and 10 minutes,
four positions were: (1) standing; (2) lying prone; (3) lying prone with respectively. The baby was in respiratory distress, pale with poor
100 lbs of weight applied uniformly to the upper back; and, (4) lying response to bag-mask ventilation. Neonatologist intubated the baby in
prone with 147 lbs of weight applied uniformly to the upper back. The delivery room and she was transferred to Neonatal Intensive Care Unit
weight was meant to simulate thoracic compression during a restraint (NICU). Initial work up showed blood gases results as follows: PH
procedure. A custom table and weight mechanism was used to allow 7.35, pCO2 32 mmHg, and pO2 54 mmHg. Hemoglobin was 15.7 and
access to visualize the IVC in the prone position and to apply the weight
Hematocrit 44.1%. Skeletal survey was negative and Head Ultrasound Rupture of thoracic aneurysm into the lung with formation of
showed mild left ventricle dilation and no evidence of intraventricular pseudoaneurysm is rare. There are few reported cases discussing the
hemorrhage. The next day the baby continued with respiratory distress diagnostic approach and management of this complication. In the
with significant anemia, Hb was 10.9 and Hct 30.4%. Despite blood researched literature there are no reports of this complication as an
transfusions and other therapeutic measures the baby remained critically autopsy finding.
ill with marked hypoxia and poor perfusion. On the 3rd and 4th days at This case involved 72-year-old, black Hispanic male with history of
NICU, a tense abdomen was noted with paleness below the level of the poorly controlled arterial hypertension and two cerebrovascular
diaphragm and plethoric upward, suggestive of compartment syndrome accidents. He was a heavy smoker and occasional alcohol drinker. He
secondary to aortic compression due to hemoperitoneum. A Penrose was found lying supine on the street. The paramedics pronounced him
drain was placed for abdominal decompression but patient did not dead at scene after evaluation. There were no signs of violence or foul
improved and died. play at scene.
At autopsy the body corresponded to a female preterm baby. She At autopsy the body corresponded to a well-developed and well-
was 18.7 inches tall and weighed 6.2 pounds. External examination did nourished adult male. He was 66-inches tall and weighed 152 pounds.
not show signs of trauma. Among the medical intervention there was an External examination showed no significant evidence of trauma.
umbilical arterial catheter in place without disruption of the artery. After Reflection of the skin over the anterior thorax showed no significant
entering the peritoneal cavity, 30 ml of liquid blood was noted and some hemorrhagic infiltrates or fractures. On internal examination the left
blood clots in the right subdiaphragmatic area. As the peritoneal cavity thoracic cavity contained 700 grams of clotted blood and 600 ml of
was entered, it was noted that the umbilical vein and falciform ligament liquid blood. Examination of the thoracic organs revealed that the source
were disrupted. A hematoma was noted at the site of disruption adjacent of bleeding was a ruptured aneurysm of the middle third of the
to the peritoneal surface. The liver had a non-ruptured subcapsular descending thoracic aorta. The aortic aneurysm ruptured into the
hematoma at the anterior and superior surfaces of the left lobe without parenchyma of the lower lobe of the left lung forming a
lacerations of the parenchyma. The rest of the thoracic and abdominal pseudoaneurismatic structure that contained a fusiform mural organized
organs had no signs of trauma. The brain had no hemorrhages or lesions. thrombus that measured 16.5 x 6.5 x 5.0 cm. Cut sections of the affected
The placenta weighted 509 grams with a centrally inserted umbilical tri- pulmonary parenchyma demonstrated that the cavitary lesion was
vascular cord that measured 11 x 1.3 cm. On microscopic examination surrounded by a well formed and circumscribed wall. Sections of the
revealed acute chorioamnionitis. Toxicological evaluation was negative thrombus showed a surface with a multilayered arrangement. Focal
for alcohol, cocaine, heroin and canabinoids. areas of hemorrhage were present in the pulmonary parenchyma
The normal umbilical cord resists trauma, the forces of normal surrounding the cavity. The aorta showed severe atherosclerosis with
delivery, and does not bleed. However, in dysmature infants the cord is calcification and focal ulceration of the atherosclerotic plaques.
thin and weak and liable to rupture. In precipitous delivery, a rapid Histopathologically the aorta had no evidence of inflammation; however,
increase in cord tension can rupture the fetal aspect of the cord. Short or degenerative changes were recognized near the possible rupture site.
entangled cords may rupture, as may abnormal cords, such as those with The heart weighed 300 grams and had mild left ventricular hypertrophy.
velamentous insertion on the placenta. Although birth trauma involving The rest of the thoracic and abdominal organs had no remarkable
intra-abdominal organs is also uncommon, it must be suspected in the macroscopic pathology. Postmortem toxicological evaluation was
newborn with pallor, abdominal distension, anemia, and shock without negative for alcohol, cocaine, opioids, and cannabinoids. Serological
evidence of external blood loss, intracranial hemorrhage, or test for syphilis was negative.
gastrointestinal bleeding. The size of the infant and the presentation at Reports of patients with aortic aneurysm rupturing into the lung
delivery are important risk factors for abdominal trauma. The liver is the with formation of pseudoaneurysm are few. There are no reported cases
abdominal organ most commonly injured in the birth process. in the researched literature describing the presence of this condition as an
Subcapsular hematomas rather than hepatic lacerations are more apt to autopsy finding. An aortic aneurysm or dissection that ruptures into the
occur. lung parenchyma or erodes into a bronchus can lead to acute, massive
In this case, several recognizable factors increased the risk of hemoptysis, hemothorax and death. This case is particular because the
umbilical cord rupture, such as prematurity of the infant combined with aneurysm ruptured into the visceral pleura and lung parenchyma forming
a precipitous delivery. Disruption of the umbilical vein represented the a pseudoaneurysmatic structure where the blood lodged. Two factors
source of intra-abdominal bleeding. The subcapsular hematoma could appeared to combine and contribute in the formation of this
be attributed to the abdominal birth trauma or be part of the tensional pseudoaneurysmatic structure, delaying the free extravasation of blood
injury secondary to the rupture of the umbilical cord. to the pleural cavity and imminent death. First is the anatomic location
Umbilical Cord Rupture, Intra-Abdominal Hemorrhage, of the aortic aneurysm. In this case the aneurysm was located in the mid
Subcapsular Hematoma portion of the descending segment, adjacent to the medial aspect of the
lower lobe of the left lung. The second factor is the elasticity of the lung
parenchyma that cushioned the aortic aneurysm wall, allowing a slow
G88 Aortic Aneurysm Rupture Into the Lung passage of blood with formation of the cavity. Rupture and extravasation
of blood to the pleural cavity occurred when the intracavitary pressure
With Formation of Pseudoaneurysm exceeded the elastic capacity of the tissues surrounding the
pseudoaneurysmatic structure. Fibrous tissue attachment between the
Carlos F. Chavez-Arias, MD, Puerto Rico Institute of Forensic Sciences, lung and aorta could have also played a role, but it was not clearly
PO BOX 11878, Caparra Heights Station, San Juan, PR 00922-1878; demonstrated at autopsy.
and Javier G. Serrano, MD*, and Edda Rodriguez, MD, Puerto Rico Aortic Aneurysm, Pseudoaneurysm, Lung Parenchyma
Institute of Forensic Sciences, Calle Maga Esquina Casia #9, Urb.
The goal of this presentation is to describe and discuss a case of

aortic aneurysm rupture into the lung parenchyma with formation of
pseudoaneurysm.
demonstrating a rare complication of a thoracic aortic aneurysm.
G89 Is DNA Purified From Forensic Autopsy G90 Evaluation of a New Approach for
Material Suitable for Molecular Estimating the Postmortem Interval Based
Biological Studies? on the Direct Skin Surface Analysis Using
FTIR Spectroscopy
Iana Lesnikova, PhD*, Department of Forensic Pathology of University
of Aarhus, Denmark, Brendstrupgaardsvej 100, Aarhus N, 8200, Liliana Santos, MD*, Jardim Carrilho Videira, Porto, 4050-167,
DENMARK; Jakob Hansen, PhD, Department of Forensic Medicine, PORTUGAL; João Lopes, PhD, Faculty of Pharmacy, Rua Aníbal
University of Aarhus, Brendstrupgaardsvej 100, Aarhus N, 8200, Cunha 164, Porto, 4050-047, PORTUGAL; Agostinho Almeida, PhD,
DENMARK; and Jytte B. Lundemose, Department of Forensic 2REQUIMTE, Department of Chemistry-Physics, Faculty, Rua Aníbal
Pathology, University of Aarhus, Denmark, Brendstrupgaardsvej 100, Cunha 164, Porto, 4050-047, PORTUGAL; and Agostinho Santos, PhD,
Aarhus N, AK 8200, DENMARK and Teresa Magalhães, PhD, North Branch of the National Institute of
Legal Medicine, Jardim Carrilho Videira, Porto, 4050-167, PORTUGAL
After attending this presentation, attendees will understand more
about the suitability of DNA, purified from forensic autopsy samples for The goal of this presentation is to determine with accurate methods
advanced molecular research. the Postmortem Interval (PMI).
This presentation will impact the forensic science community by This presentation will impact the forensic science community by
providing information about how decomposition and time from death to facing one of the main issues in forensic sciences, the estimation of time
autopsy affects the usability of DNA for molecular studies. Knowledge since death (postmortem interval). Most methods currently employed
about the degree of DNA fragmentation and degradation is an important have considerable inaccuracy. To be able to determine PMI is one
tool for planning of future molecular biological studies. challenge that can change a forensic investigation, and give answers, that
The quality of molecular-biological studies obviously depends on until now were not properly supported in court.
the tissue in which the markers must be investigated. At forensic The estimation of postmortem interval is a main issue in forensic
laboratories, a large number of frozen, biological samples are stored sciences. Most methods currently employed have considerable
(collected at the autopsies), which can be used as templates for molecular inaccuracy.
biological studies. These samples are extremely valuable for all types of Most of these methods are based on medical knowledge. With this
molecular biological studies in both diagnostic and research purposes. work we intend to solve a forensic problem with the help of other areas
The decomposition and thereby the following changes in quality of DNA of science not usually involved in medical studies.
occur shortly after death. Degradation and fragmentation of DNA The interaction of infrared (IR) electromagnetic radiation with the
purified from autopsy material depends on several factors, such as time matter is a widely established technique to probe the chemical
since death to autopsy, the degree of postmortem changes, the keeping of composition of materials.
the corpse, external and environmental influences, storage of samples, The IR spectrum is divided into three zones; near- (14000-4000 cm-
and the addition of the chemicals to blood samples and other tissues for 1), mid- (4000-400 cm-1) and far-infrared (400-10 cm-1). The mid-
storage. It is believed there are no studies on this issue. The current infrared (MIR) region is used to analyze the fundamental vibrations of
study is a pilot for a major project, which is to define the molecular molecules and is strongly absorbed so materials have to be analyzed as
biological markers for sudden unexpected death. The suitability of thin films or in small path length cells (e.g., milk analysis).
purified DNA from tissues taken at autopsies including frozen blood Near-infrared (NIR) spectroscopy is based on molecular overtone
with or without additional chemicals and paraffin embedded and frozen and combination vibrations, which are forbidden by the selection rules of
tissue is validated, as template for molecular biological studies in order quantum mechanics. This means that NIR can penetrate much further
to define the main risk factors for DNA fragmentation and degradation. into materials than MIR. This makes NIR very useful in probing bulk
By using PCR primer sets that amplify DNA fragments of varying length material with little or no sample preparation.
and DNA extracted from tissue samples with different degree of Because NIR probes the overtone and combination bands the
postmortem decomposition. Using the internal autopsy database the spectra are usually very complex. Individual bands can not be assigned
study group is defined consisting of tissue samples without signs of to specific features as with MIR. This means multiple wavelength
decomposition of tissue, with moderate decomposition of tissue and with (multivariate) calibration techniques are used to extract structural
severe decomposition. Frozen tissue samples of the detected cases information. The design of powerful software packages, such as
(blood samples and muscle tissue) are available as well as frozen blood PLSplus/IQ, allows users with minimal chemometric experience the
samples with the addition of potassium fluoride. DNA from tissue opportunity to generate and maintain their own calibration models
samples were purified using commercially available kits. Ten different without relying on general models from a third party that are not specific
PCR primer sets were designed to amplify 100 to 1000 basepair long to their materials.
fragments of human genomic DNA. PCR products were analyzed by The increased processing power of computers has allowed the
agarose gel electrophoresis and ethidium bromide DNA staining. introduction of Fourier Transform (FT) infrared analyzers. Prior to this
Preliminary results suggest that the degree of fragmentation and technology instruments either had to either use filters to look at the
degradation of DNA after death increases corresponding to grade of absorption of specific wavelengths or use diffraction gratings to scan
decomposition of tissue. The lengths of DNA fragments in samples with through the wavelengths and measure the changing absorptions. FT
high grade of decomposition are significantly shorter than in samples technology uses interferometers that allow all the information at all
without decomposition of tissue. It was possible to generate DNA wavelengths to be collected simultaneously. This means much more
fragments of at least 1,000 basepair lengths from samples taken from information can be collected in a shorter time.
individuals that died within one week before autopsy was performed. On Fourier transform near-infrared (FT-NIR) spectroscopy is an
the other hand DNA samples from individuals that died at least two analytical technique that has gained great popularity in recent years. It
weeks before autopsies only could generate PCR product up to 600 is an effective tool for investigating chemical changes at molecular level
basepair long. and its major strengths include fast and easy equipment operation, good
Validation, DNA Fragmentation, Tissue Decomposition accuracy and precision, and the potential to perform nondestructive
analyses. In its reflectance mode, FT-NIR spectroscopy is widely used
to study, for example, the human skin and other tissues. And in the last
few years, using fiber-optic technology, the direct real-time in situ G92 Mass Fatality Management: A Multi-
analysis became possible.
The utilization of FT-NIIR spectroscopy is being studied here to
National Perspective
directly test the human skin in order to, in combination with
chemometric data analysis (PCA – principal component analysis; PLS – Ann H. Ross, PhD, North Carolina State University, Department of
partial least-squares models), look for possible surface chemical changes Sociology & Anthropology, Campus Box 8107, Raleigh, NC 27695-
occurring after death that may correlate with PMI. Studies performed to 8107; and Jason H. Byrd, PhD*, Maples Center for Forensic Medicine,
date (20 cases) showed promising results. Figure 1A shows typical University of Florida, 4800 Southwest 35th Drive, Gainesville, FL 32608
spectra obtained from six corpses in the 48 hours postmortem period and
Figure 1B shows the correlation between the predicted PMI versus the After attending this presentation, attendees will understand the
known (real) time since dead. challenges faced a multi-national recovery and identification effort.
presenting lessons learned from the field in a multi-national mass
fatalities incident, which can be applied to a future incidence response.
In response to the Haiti Earthquake, several international
organizations responded to assist in fatality management and repatriation
of non-Haitian human remains. Each of the fatality management and
response organizations was dispatched by a governmental agency, but
with little coordination between the organizations. Initially, the
prohibitive conditions of an entire Haitian infrastructure in disarray and
the extreme difficulty of providing for the logistical requirements of
supporting a deployable morgue unit without local support was the
primary factor limiting human identification efforts. However, difficulty
in determining jurisdiction and logistics of repatriation of multi-national
This study shows the usefulness of coupled with chemometric data citizens became one of the primary difficulties in the response effort. A
analysis for estimating PMI, and the importance of the interaction major complexity in the recovery and victim identification of foreign
between different areas of knowledge. nationals was the number of independent countries on the ground
Postmortem Interval, FTIR Spectroscopy, Accuracy attempting to identify their own citizens for repatriation. Another major
factor was the actual recovery of the victims that were buried under tons
of rubble, which were a safety hazard for recovery personnel.
Not only was the logistical aspect of this operation complex, but the
G91 Unusual Style Cut Throat Injury: A recovery and initial identification of the multi-national victims was
Case Report extremely difficult. This is the first global mass fatality incident where
an attempt had to be made to determine the nationality of the victims
Suresh K. Shetty, MD*, Kasturba Medical College, Light House Hill prior to recovery to ensure accurate identification, repatriation and
Road, Mangalore, 575001, INDIA disposition of the remains. The coordination of antemortem biological
information was crucial to this effort and it took a great deal of
After attending this presentation, attendees will understand the coordination between countries.
circumstances and possibilities of injuries in a rare case of self-inflicted This presentation will discuss how to more effectively coordinate a
cut throat injury. mass fatality response in the event of future disasters involving multi-
This presentation will impact the forensic community by helping national populations from multiple countries with varying capabilities
officials responsible for the maintenance of law and order to administer for fatality response as well as the complexity of victim identification in
justice. this scenario.
Suicide is one of the leading causes of death in the world. The Fatality Management, Mass Disaster, Mortuary Operations
incidence and pattern of suicide vary from country to country where
cultural, religious, and social values play a vital role. Hanging,
poisoning, drowning are the common methods of committing suicide. G93 Improving Evidence and Victim Recovery
Suicide by incising one’s own throat without hesitation marks remains a
rare, and only few cases have been reported in forensic literature. An
Protocols at the Mass Fatality Incident
unusual and rare case of self-inflicted cut throat injury of a 45-year-old
ex-military man without tentative cuts over the neck, which has resulted Dennis C. Dirkmaat, PhD*, Luis L. Cabo-Pérez, MS, Michael W.
from a curved sharp weapon is presented. Kenyhercz, MS, Allison M. Nesbitt, MS, Alexandra R. Klales, MS, and
A case report of self-inflicted cut throat injury without tentative Erin Chapman, MS, Mercyhurst College, Department of Applied
cuts, a rare event is presented. Such cases are rare to be reported in Forensic Sciences, 501 East 38th Street, Erie, PA 16546
forensic literature. It is recommended that medico legal death
investigators be aware and familiar with such injuries in a detailed After attending this presentation, attendees will understand
autopsy, which may ultimately prove or disprove the case, which may be problems faced by coroner and medical examiners relative to their
of significant value to the investigating authority. responsibility to properly recover and identify plane crash victims.
Self-Inflicted, Cut Throat Injury, Hesitation Marks Attendees will be presented with effective strategies and protocols for
dealing with these scenes.
describing efficient and effective evidence and victim recovery protocols
applicable to large-scale, widely-dispersed mass fatality scenes
The crash of a major airliner results in an extremely chaotic
situation. After the first responders have dealt with survivors and fire
resulting from the crash, the processing of the scene can commence. The
primary goals of this processing effort are: (1) determining the cause of
the crash; (2) comprehensively recovering the victims and their personal G94 Telluric Movements of Death: The
effects; (3) determining the identity of all of the biological tissue; and,
(4) removing all of the debris from the site.
Cemetery of Gargano’s Mafia Inside the
With respect to the first goal, in the United States; if the cause is Ravine of Zazzano (Foggia, Italy)
likely accidental (vehicular malfunction or human error), the National
Transportation Safety Board (NTSB) will be in charge of the Cristoforo Pomara, PhD*, and Gianpaolo Di Peri, MD, University of
investigation. If it is instead determined that criminal intent may have Foggia, Department of Forensic Pathology, Viale Degli Aviatori,
been involved, the Federal Bureau of Investigation (FBI) will take Foggia, 71100, ITALY; Giuseppe Guglielmi, PhD MD, University of
custody of the scene. Foggia, Department of Radiology, Viale Pinto, Foggia, 71100, ITALY;
The efforts of both the NTSB and FBI are focused on the non- Emilio Nuzzolese, DDS, PhD, Viale J.F. Kennedy 77, Bari, 70124,
human evidence at the scene. The recovery, identification and ITALY; and Stefano Derrico, PhD, University of Foggia, Department of
interpretation of the human remains (Goal 2) are the province of the Forensic Pathology, Via Luigi Pinto, 1, Foggia, 71100, ITALY
Medical Examiner/Coroner (ME/C). While nearly all ME/C offices can
deal with the morgue component of victim identification on their own or, The goal of this presentation is to offer a multidisciplinary approach
they can request the services of federal groups such as DMORT, most in forensic investigation that presents identification of victims as
offices do not possess the training, expertise, experience, or protocols to belonging to victims of local criminal organization. Skeletal remains of
deal with a large scale scene containing the highly fragmented and four different cadavers were recovered in a ravine, a surprising movie of
commingled remains of large numbers of victims. This presentation will this recovery completes the peculiarity of the case.
demonstrate that the best approach to the processing of outdoor crime This presentation will impact the forensic science community by
scenes, especially large-scale scenes such as a plane crash, is to employ discussing how skeletal remains recovery requires a multidisciplinary
forensic archaeological methods. A new set of protocols for the approach in forensic activity, and identification of missing represents the
processing of large-scale disaster scene will be presented. principal aim.
The new protocols are based on the Weldon Spring protocols The Gargano, also known as Spur of Italy is a subregion of Italy
developed during the past decade (Dirkmaat and Hochrein 2000). The which coincides with the headland stretching in the North of Puglia and
Weldon Spring Protocols are based on a systematic sequence of search, corresponds to the East of the Province of Foggia. It is entirely
documentation, and recovery methods that is intended to result in the surrounded by the Adriatic Sea except in the West, bordering the
most efficient and effective scene processing effort. By effectiveness we Tavoliere. The frequent and constant carsic erosions in this area
refer to the proportion of physical and contextual evidence identified, produced cavities that, in time, due to telluric movements created
documented, and recovered at the scene, while efficiency relates to the grottoes, dolins, and ravines hundreds meters underground. A ravine is
time and personnel required for effective recovery completion under a a small valley—almost like a canyon but narrower—which is often the
particular protocol. The goal of the present study was to optimize these product of stream cutting erosion. Ravines are typically classified as
two factors through the logistic and technological enhancement of the larger in scale than gullies, although smaller than valleys. A ravine is
Weldon Spring protocols. To attain this, different technological generally a slope landform of relatively steep (cross-sectional) sides, on
configurations, affecting all the components of the protocol, from the order of twenty to seventy percent in gradient. Ravines may or may
evidence location to data acquisition and recordation, were developed not have active streams flowing along the down slope channel which
and tested in terms of their efficiency and effectiveness at real forensic originally formed them; moreover, often they are characterized by
cases and realistic mock scenes. Comprehensive guidelines for needs intermittent streams, since their geographic scale may not be sufficiently
assessment and decision-making, targeting the identification and large to support a perennial watercourse. The ravine of Zazzano is
resolution of trade-offs related to technology availability and located on the Gargano area. The ravine is a 30 meter large ravine, 107
amortization, budgetary and personnel constraints, and training were meters deep underground which was used in the past as abusive rubbish
also developed, in an attempt to offer different configuration alternatives dump. Old and wrecked cars were also put down the ravines, stacking
to fit the needs and resources of a wide array of agencies without on each other in column. During a cleaning operation, local authorities,
significant effectiveness losses. a team of speleologists found human skeletal remains and activities were
The technological enhancements include high-resolution GPS units interrupted. A prosecutor was immediately alerted and forensic
for the quick recordation of precise spatial recording, bar code scanning pathologists were called for scene investigation, skeletal remains
for data entry and sharing, and the utilization of wireless networks at the recovery, and identification. In a wrecked car, one completely
scene. The combination of these elements resulted in a reduction of skeletonized cadaver was found with its clothes; a reddish rope still tied
recording times from minutes to just a few seconds, higher data integrity, to the arms bones and the head found inside a plastic bag. A second
with a standardization of evidence codes and the virtual elimination of completely skeletonized cadaver was found later in another wrecked car
any risk of reference duplication. This translates into an almost some meters down the previous one. Bones of a third cadaver were
automatic coordination of all the recovery teams involved, in a manner recovered on the ground of the ravine, partially covered by mud. The
that not only reduces the amount of time required by each team to locate, cadaver lying in a prone position; head, thorax, and upper arms were
map, document and recover each evidentiary item, but also allows more found inside a jute bag, a reddish rope still tied lower arms. A fourth
teams to be deployed simultaneously at the scene. cadaver, completely buried under the mud was found, lying in supine
Mass Fatality Incident, Forensic Archaeology, Victim Recovery position; the head was found inside a plastic bag. Recovery activities
were completed in three days. A video recording of recovery was
performed and is presented. Local authorities identified the owners of
recovered wrecked cars. Forensic activities involved radiological
investigation by means of standard approach and total body multislice
TC scan contributing in determining causes of death: suffocation,
gunshot wounds and efforts of mutilation, variously combined.
Anthropological investigation determined sex and race of skeletons;
dental records and dental casts were performed by forensic
odontologists. DNA profile has been developed for identification. At the
end of forensic examination all the fourth cadavers were identified as
belonging to men suddenly missed in the nineties, suspected as victims G96 Gunshot Wounds Covered by Different
of the local criminal organization. The gravine is now famous with the
name of cemetery of the Gargano’s mafia.
Textiles: Determination of GSR Through
Skeletal Remains, Ravine, Homicide Micro-CT Analysis
Giovanni Cecchetto, MD*, Alessandro Amagliani, MD, Guido Viel, MD,
G95 Use of Multidetector Computed and Paolo Fais, MD, University of Padua, Via Falloppio 50, Padova,
35121, ITALY; Giampietro Feltrin, MD, Via Giustiniani 2, Padova,
Tomography (MDCT) in the Evaluation of 35121, ITALY; Santo Davide Ferrara, PhD, University of Padua -
Gunshot Wounds Section of Legal Medicine and Forensic Toxicology, Via Falloppio 50,
Padua, 35121, ITALY; and Massimo Montisci, PhD, University of
Edward L. Mazuchowski, PhD*, and Philip J. Berran, JD, Office of the Padua, Via Falloppio 50, Padova, 35121, ITALY;
Armed Forces Medical Examiner, 1413 Research Boulevard, Building
102, Rockville, MD 20850; and Howard T. Harcke, MD, Armed Forces After attending this presentation, attendees will have novel
Instiute of Pathology, 6825 16th Street Northwest, Washington, DC 20306 information on the role of Micro-CT analysis of gunshot wounds for
estimating the firing range.
After attending this presentation, attendees will understand the This presentation will impact the forensic science community by
process used by the Armed Forces Medical Examiner System (AFMES) adding new data on the estimation of the firing distance of intermediate-
to integrate MDCT into the evaluation of gunshot wounds. Attendees range gunshot wounds in clothed victims, through a micro-CT analysis
will be able to describe the advantages and limitations of utilizing of the gunshot residue.
MDCT in the evaluation of gunshot wounds. Estimation of the firing range is often critical for reconstructing
This presentation will impact the forensic science community by gunshot fatalities, where the main measurable evidence consists of the
detailing a novel approach to overcome the limitation of the visualizing gunshot residue (GSR). Several techniques and methods have already
entrance and exit gunshot wounds with MDCT. been used for characterizing GSR, such as Atomic Absorption
Postmortem forensic imaging is a critical tool in the evaluation of Spectroscopy, Neutron Activation Analysis, Autoradiography, Routine-
gunshot wounds. Traditionally, fluoroscopy and digital/plan film x-rays CT, Scanning Electron Microscopy, and Histochemistry. Recently, a
have been utilized to document and locate bullets and bullet fragments in novel approach, based on the use of Micro-CT, proved to be an objective,
cases of gunshot wounds. In the last several years, traditional imaging reliable, rapid, and inexpensive tool for estimating the firing range in
techniques in conjunction with postmortem MDCT has made it possible intermediate-range shots.
to obtain precise three-dimensional localization of bullets and bullet Aim of the Study: It is well known that the presence of clothes
fragments. In addition, this technique has been shown to be an effective covering the body heavily affects the distribution of GSR on the entrance
method for aiding in the documentation of gunshot wound paths and wound, hindering the estimation of the firing range on the basis of the
evaluation of internal organ injury prior to autopsy. sole macroscopic inspection.
One of the main limitations of utilizing MDCT in the evaluation of The goal of the present study was to evaluate the differential
gunshot wound paths is the inability of MDCT to precisely locate the distribution of GSR, with regard to the different kinds of textiles
surface entry and exit wounds. Although the presence of gas in the soft covering the skin, by means of micro-CT analysis, with the final purpose
tissue and disruption of tissue surfaces may be helpful in the precise of reconstructing the firing distance.
location of these wounds, the collapse of the temporary cavities, Materials and methods: Human legs, surgically amputated, were
compression of soft tissue defects and the position of the of the body on cleaned of dried blood and any other contaminants, and cut into sections
the scanning table can limit the detection of the entry and exit wounds. of approximately 6 cm in length.
In order to overcome this limitation, a novel technique was A total of 60 sections were selected; each section was covered with
developed utilizing radio-opaque markers. Briefly, the body is first a single type of textile, chosen among cotton fabric (n = 15), jeans (n =
imaged by digital x-rays to identify any bullets or bullet fragments in the 15), leather (n = 15), and waterproof synthetic fabric (n = 15). Bare skin
body or clothing. Next, digital photographs of the body and gunshot sections were used as controls (n = 15).
wounds are taken and the locations of the gunshot wounds are marked Firing was carried out perpendicularly at distances of 5, 15, and 30
with a 1.5 millimeter radiopaque marker. The body is then imaged with cm, using a .32 pistol loaded with full-jacketed bullets. A total of 75
MDCT. The resulting images are processed with imaging software to shots were performed (five replicates for each distance). After each
produce a three-dimensional image of the body with the precise location firing test, the gunshot wounds were photographed and formalin fixed.
of the entry and exit wounds on the skin surface. Reconstructed images The skin specimens, comprising the epidermis, dermis, and
are manipulated to obtain any desired orientation of the body and wound subcutaneous fat, were cut into parallelepipeds (height 1 cm, side 1 cm)
pathway. These images can then be used to demonstrate the gunshot with a lancet. Samples were scanned following standard processing
wound pathways in medicolegal proceedings. It must be noted that this procedures, using a high resolution scanner.
technique does not overcome the limitation of MDCT in distinguishing The acquired raw data were reconstructed with reconcilliation
entrance gunshot wounds form exit gunshot wounds. This distinction is software, which uses the back-projection algorithm to reconstruct axial
made by combining the postmortem forensic imaging with the findings subsequent images saved as bitmap format. The bitmap images were
from the external inspection and internal dissection of the body. analyzed by a CT analysis software: the selected volume of interest
Computed Tomography, Gunshot Wounds, Virtual Autopsy (VOI side of 1 cm and height of 3.8 mm) was focused in the centre of the
specimen in order to have the entire entry wound positioned in the
middle. All the samples were binarized using the same parameters.
The percentage of GSR deposit was calculated analyzing all
particles with a density higher than 1000 Hu (particles with a density
lower than 1000 Hu were excluded to reduce iron artefacts). The 3D
images were reconstructed through a Ct-Vox Software.
Results: The visual inspection of the skin did not allow the
estimation of the firing distance for the covered gunshot-wounds; the
morphological features of the entrance wounds (blackening and The anthropologist was called in at the first recognition of skeletal
tattooing) were, indeed, not discernible. trauma. At that point it was decided to remove all ribs, both clavicles,
The micro-CT analysis revealed that: and vertebrae C-7 through L-4 after extensive photographic
• GSR particles were less represented in cases compared documentation. These were processed free of obvious soft tissue, but
to controls; preserved in anatomical position to give a better idea of three
• In cases GSR particles were distributed inside the cavity and the dimensional relationships of the complicated trauma to bone.
fatty tissue of the entrance wound, while in controls they were Dry bone examination combined with faxitron radiographs indicate
present mainly on the skin around the hole; and, numerous rib fractures as listed in Table 1.
• Increasing the firing range, the radiological detection of GSR Table 1. Summary of rib fractures in 3-month-old infant.
progressively decreased in both cases and controls, allowing a
good discrimination of the firing distances tested in the RIB FRACTURES
present study. Acute Chronic Stable Chronic Acute On Chronic Other Procedure
15* 6 10 (3 questionable) 2 1 (tissue bank)
Conclusions: Micro-CT analysis might be useful for the forensic
assessment of the firing range, particularly when the morphological *All rib head apex tears
features of intermediate-range wounds are not visually discernible (i.e.,
black people or clothed victims). As one would guess, the anthropological report documents and
Forensic Pathology, Gunshot Wounds, Firing Range describes the 33 insults to bone that clearly point to non-accidental
trauma, with the history as reported. However, from a medical examiner
point of view, this case was everything but a clear case of child abuse.
G97 Child Abuse vs. Cachexia: Do Healing and It is ruled the death of this 3-month-old as attributed to probable
Acute Rib Fractures Trump a Diagnosis of cardiac dysrhythmia due to electrolyte abnormalities. Postmortem
testing for calcium and vitreous sodium yielded abnormally low levels.
Probable Cardiac Dysrhythmia Due to Multiple blunt force injuries in the form of acute and chronic rib
Electrolyte Abnormalities fractures were also noted at autopsy. No external signs of trauma are
seen on the body. Differential diagnoses of the infant’s abnormalities
Steven A. Symes, PhD, Mercyhurst College, 501 East 38th Street, Erie, PA include natural and non-natural causes. Neglect and child abuse cannot
16546-0001; and Dianne R. Vertes, PhD, MD, Erie County Medical be ruled out, however, nor can a natural cause such as a metabolic
Examiner’s Office, 462 Grider Street, Buffalo, NY 14215 disorder be eliminated. To complicate issues, the infant had been taken
to the pediatrician regularly and they were treating the low body weight.
After attending this presentation, attendees will gain an awareness The last physician visit was 16 days before death. In view of these
of potential differential diagnoses between forensic anthropologists and issues, the manner of death is best certified as “Undetermined.”
medical examiners/coroners on child deaths becomes evident. Maybe the question in this case should be formulated, “Do
This presentation will impact the forensic science community by diagnoses of probable cardiac dysrhythmia due to electrolyte
informing attendees of the difficulties that accompany abnormalities trump healing and acute rib fractures?” To the
medical/anthropological diagnoses of child abuse, and the complications anthropologist perspective, this is an unsettling thought. To the medical
that arise when specialists attempt to contribute to cause and manner of examiner/coroner, while still unsettling, their responsibilities are medical
death in infants. interpretations of cause and manner of death, not simply biomechanic
One of the most difficult tasks confronted by forensic pathologists interpretations of bone fracture. The repercussions of a homicide ruling
is the determination of cause and manner of death in suspected child without a traumatic cause of death are immense. Thus, the debate
abuse cases. In the last 15 years, forensic anthropology has goes on.
demonstrated a potential for contributing to the cause of death, by Child Abuse, Cachexia, Healing Rib Fractures
systematically examining questionable skeletal areas after processing the
skeletal elements free of soft tissue for a close look. Certainly, an
accurate analysis of acute and healing fractures contributes immensely to G98 The Identification of French Victims in the
a final diagnosis of infant’s deaths. But do the two professions, with
different approaches and diverse responsibilities, ever conflict in Massive Earthquake on January 12, 2010
diagnoses? Of course they do. Below is a case where such a conflict in Haiti
arises.
An unembalmed body of a well developed, poorly-nourished Stephane Malbranque, MD*, French-DVI, Chu Fort-De-France, Hop.
female was examined and autopsied. The body appears younger than the La Meynard, BP 632, Fort-De-France cedex, 97261, MARTINIQUE
reported three-months. Inanition is evidenced. The pale skin shows no
acute injuries, or scars, nor were there any indications of trauma from the The goal of this presentation is to give attendees a clear
external exam. A V-shaped incision was performed previously by a understanding of France’s structure and procedures in terms of
tissue harvest team to remove the heart and proximal aorta. The clavicle identification of its nationals in the event of a major natural disaster and
and first rib on the right side were sectioned for this procedure. The first to demonstrate that the international response is as efficient and effective
indication of skeletal injuries is first discovered during the internal as it is at a national level.
examination of the ribs, where hemorrhage, acute, and possible healing This presentation will impact the forensic science community by
rib fractures are visible. showing the successful collaboration between a forensic scientist and a
Pathologic diagnoses documents small body size, where height and first response rescue team. To illustrate this, the French national team of
weight are diagnosed as in the 3rd percentile for age. Morgue identification was followed on site at Port-Au-Prince from January 13,
examination weight is 7 lbs 6 oz, where birth weight was 6 lbs 3 oz. This 2010 until April 1, 2010. It also demonstrates that an early intervention
presents neglect or failure to thrive. Also noticed is documented is key to optimizing the effectiveness of the identification process and to
dehydration and small organ weights. Finally, blunt force skeletal achieving the overall success of the operation.
injuries are present, with acute, chronic, and acute-on-chronic rib The earthquake that struck Haiti’s capital Port-au-Prince caused
fractures. History indicates that aunt called 911 at 15:30 after last seeing more than 200,000 deaths. The major contributing factors to such high
the child alive at 8:30 that morning. The aunt is the legal guardian. casualties were primarily its incredible strength and secondly the
instability of the existing infrastructure. The challenges that had to be G99 Comparison of Methods for Measuring
overcome were the significant increase of sanitary requirements and the
issue of corpses’ management. Identifying such a high number of
Decomposition of Submerged Carrion in
victims proved extremely difficult firstly because of such a large volume Fresh Water
of corpses and secondly because of their high levels of depreciation. The
success of this operation was only made possible due to a thorough Michael K. Humphreys, MS*, Yolo County Sheriff/Coroner Office, 2500
preparation combined with a structured and systematic approach. East Gibson Road, Woodland, CA 95616; Edward Panacek, MD, MPH,
In response to similar events, France has a national DVI team University of California - Davis, Department of Emergency Medicine,
(Unité Nationale d’Identification des Victimes de Catastrophes – 4150 V Street, Patient Support Services Building, Suite 2100,
UNIVC) since 1992. It was established by the Criminal Research Sacramento, CA 95817; William Green, MD, California Clinical
Institute of the National Gendarmerie (IRCGN). The team is made up of Forensic Medical Training Center, University of California - Davis
specialists from the Criminal Identification Department who are able to Medical Center, 3671 Business Drive, Sacramento, CA 95820; and
be deployed on site very quickly and are trained to be adaptable and Elizabeth A. Albers, MD, Sacramento County Coroner’s Office, 4800
responsive to any given situation. Broadway, Sacramento, CA 95820
Since 2006, authorities based in the French island of Martinique, in
the West Indies, have been focusing on contingency and emergency The goal of this presentation is to determine a method for measuring
plans due to the island’s major exposure to natural risks and its remote submerged decomposition experimentally that limits contamination to
location. These revised response procedures were put into practice for the carrion.
the first time in Haiti in 2009 to such great effect that it has subsequently This presentation will impact the forensic science community by
brought about modifications of the national strategy (plan ORSEC). discussing how, currently, there is no standard for measuring submerged
This strategy encompasses a forensic scientist, with expertise in mass decomposition in situ. This study compared current proposed methods
deceased management, as part of the initial first aid response team. for experimentally measuring the amount of decomposition undertaken
The first evaluation reported at least 70,000 deceased in PORT-AU- by carrion underwater, and hopefully, the results may guide future
PRINCE 24 hours after the earthquake. The police’s chief of the United underwater decomposition research, using more standardized techniques
Nations and the Haitian Prime Minister, who were actually themselves that limit contamination of the decomposition process.
survivors of the disaster, were immediately contacted to organize the Continuous monitoring of decomposition and calculations of the
clearance and logistic requirements, as well as the coordination of the postmortem submersion interval (PMSI) of carrion at depth can be
mass burial of corpses in common graves commencing 36 hours after the problematic for forensic investigators due to risk contamination of the
earthquake. carrion caused by the extraction from the experimental environment and
Communication was a key factor in this operation not only with the weighing processes. Underwater photography and evaluation utilizing
population, to dispel the myth that corpses in a disaster can cause the the Heaton et al. total aquatic decomposition (TAD) score at depth was
rapid spread of diseases, but also with the international nursing staff to compared to weighing the carrion before and after submersion, as well
reiterate that sanitary precautions in the movement of bodies. as full forensic necropsies. The actual time of submersion was known
The second major objective was to perform an accurate census of for each carrion. Perinatal piglets were used as human analogues for
the deceased French nationals by locating and collating their position at experimental purposes. This study suggests that weighing the piglets
the time for the purposes of identification and repatriation to families. after they have been submerged in fresh (stagnant) water yields
This was achieved by setting up an “antemortem“ unit at the French inconsistent results due to the unpredictability of algae growth in water
embassy for the registration of missing persons and reported fatalities. ecosystems with high algal contamination. In addition, while
Between 72 and 96 hours, 30 names were indexed. Survivors were underwater photography does reveal some evidence of decomposition in
then contacted and advised on the best practices for the storage of the situ, usefulness is limited by required training, expensive equipment, and
deceased prior to burial. These instructions also gave details on how to further algal growth issues which can obscure the visual data. The
preserve vital evidence i.e. ensuring personal effects of the corpses were results of this study indicate that in order to objectively measure
not removed, drawing up an accurate map to locate corpses, collecting decomposition over time, the carrion should be examined either at depth
local and national coordinate. using the TAD scoring system, or a set of piglets should be submerged
As a result, all French deceased nationals (33 of approximately with one piglet harvested from the experimental environment over set
1,200 present) were identified by the end of March 2010 and placed in a periods. This piglet should then undergo a pathological examination
temporary mortuary at the French embassy with thanks to the close (with histological sampling and TAD scoring, as was done in this study),
cooperation of the American and Canadian DVI. rather than relying on underwater photography. This allows for
Identification, Mass Disaster, Earthquake normalization between piglets and excludes weight and algal growth
issues, thereby showing the amount of decomposition over time. The
acquired TAD score can then be used with the calculated Accumulated
Degree-Days (ADD) to determine an approximate PMSI. These results
may not be generalizable to other submersion conditions in water
ecosystems with different salinity, temperature, degree of algae growth,
and amount of other animal activity.
Underwater Decomposition, Postmortem Submersion Interval,
Visual Scoring System
G100 Fatal Sexual Violence Against Women: body, race and ethnicity per CDC definitions, cause and manner of death,
and contributory and/or concomitant medical and gynecological
Normative, Baseline Studies of Postmortem conditions, especially those presenting lesions.
Genital Anatomy — What Can We Say The 30 female cases from Group I range in age from 60-99 years.
About Normal? The mean age is 83.1 years old. This is a largely homogeneous group;
93% of the sample is Non-Hispanic/White. The majority of Group I
Sharon R. Crowley, MN*, FCNS, 122 Emeline Avenue, Santa Cruz, CA 95060 presented to the forensic science morgue within 24 hours. Postmortem
mucosal autolysis was present at a minimum of one out of the 12
After attending this presentation, attendees will better understand anatomic sites in 80% of the sample. Postmortem skin slip in the
the nature and appearance of the postmortem anogenital tissues; be able anogenital area was present in 16.6%. A 1% Toluidine blue dye solution
to discuss findings from control groups of normative, baseline studies for was applied and decolorized with a dilute acetic acid solution in 21 of the
comparison with cases of fatal sexual violence; and discuss taxonomy, 30 body donor cases. There was a false positive uptake in 100% of the
examination adjuncts, and database variables useful in the postmortem cases. This was true regardless of the anatomic site of dye application.
sexual assault evaluation. The age range for the 18 cases in Group II was 32 months to 89
This presentation will impact the forensic science community by years of age. The mean age was 47.87 in this Group. The ethnicity and
improving the diagnostic acumen of the forensic examiner, helping avoid race distribution was as follows: Non-Hispanic/White (66.6%);
ambiguity of interpretation of clinical findings in postmortem genital NonHispanic/Asian Pacific Islander (5.5%); Hispanic/White (11%), and
examinations, and improving knowledge about fatal sexual violence African American (16.6%). The postmortem interval to arrival at the
against women. forensic science morgue was ≤ 24 hours in 88.8%, 96 hours in 5.5%, and
Until recently, a paucity of data existed on the “normal” appearance ≥ 5 days (active decay) in 5.5%. Postmortem mucosal autolysis was
of the genital anatomy during the postmortem interval. There is a lack present in greater than 50% of Group II. Toluidine blue dye was not
of data from scrutiny and photodocumentation of the postmortem applied to any in this sample.
anogenital tissues. The use of colposcopy is well established for both Discussion: The postmortem arena superimposes a unique set of
adult and child living victims. During the autopsy, gross visualization factors. Many were not previously studied or documented in the
alone may not allow the detection of the more subtle findings that usually literature. Analysis of results from baseline studies allows eventual
constitute genital trauma in sexual assault (Crowley-AAFS: 2003). comparison to genital injuries sustained by both sexual homicide victims
Comparisons to either living sexual assault victims or postmortem cases and living sexual assault victims. A relational database was described
of non-sexual etiology were extremely difficult. (Crowley, AAFS: 2010) as a method to simplify and quantify data for
This presentation proposes to describe ongoing research on interpretation, analysis, and linkage to other cases.
postmortem genital anatomy. These cases constitute the first normative, Taxonomy germane to the postmortem arena should incorporate
baseline data on the anogenital tissues during the postmortem interval. salient terms that will be consistent and universally applicable and
The focus of the present discussion is to describe the findings from two acceptable within the forensic community (Crowley & Peterson: AAFS,
normative, baseline control groups, with a total sample of 48 female 2004). Postmortem artifact, such as mucosal autolysis and skin slip,
cases. visualized in the anogenital tissues, is documented for each anatomic
Group I consists of 30 female cases drawn from the Body Donation site. Inclusion into case documentation permits aggregate summaries of
Program, at the University of California, Davis, California. Most donors individual and population-based summaries. Appropriate taxonomy and
are received ≤ 24 hours of death. All cases selected for this baseline correct identification of “normal” will help improve our diagnostic
study are fresh, or fresh-frozen, vs. embalmed. Cases are examined acumen and increase the reliability of our methodology.
based upon availability, i.e., female gender and received by the program The significantly false positive results obtained from application of
in a time frame compatible with access by the primary investigator. Toluidine Blue dye on the postmortem anogenital tissues should
Group II consists of 18 coroners’ cases, from another jurisdiction. preclude any recommendation for its use in the postmortem sexual
These were also examined using the mobile colposcopy and examination assault examination. It appears to be consistently picked up by the
system described by Crowley (JFS: 2004). The manner of death was shedding tissues that comprise part of the normal artifact. The
accidental in seven cases and natural in 11. inexperienced examiner might misconstrue this for a significant finding.
Materials and Methods: This research project is an observational It is certainly true that in equivocal cases, the forensic pathologist
study, with a cross-sectional design. The examination methodology can simply remove en bloc, for dissection and microscopic evaluation,
employs photocolposcopy at 7.5X, 15X magnification, or both, plus 35 the tissues germane to genital findings. However, it may prove to be
mm photography via the colposcope. In most cases, additional beneficial to have an initial in situ examination of the anogenital
photographs are taken with a 35mm single lens reflex (SLR) manual or anatomy, via colposcopy. The ultimate goal of this research is to
digital camera, for comparison to colposcopy. Inspection and improve our understanding of what is normal, and what is not, during the
photodocumentation of specific anogenital sites is employed, prior to postmortem interval for the anogenital tissues. In this manner, the
manipulation of the genital tissues. On select cases, concomitant capacity and understanding of fatal sexual violence against women will
application of a 1% solution of toluidine blue dye has also been continue to grow.
incorporated, in order to evaluate the reliability of this general nuclear Fatal Sexual Violence Against Women, Body Donation Program,
stain as an adjunct to the postmortem examination. The same 12 Colposcopy
anatomic sites are visualized, inspected, and photographed in both
controls and sexual homicide cases. These include the labia majora,
peri-clitoral area, peri-urethral area, labia minora, hymen, vagina, cervix,
perineum, fossa navicularis, posterior fourchette, anus, and rectum.
There are some core data elements germane to both control and
sexual homicide groups. These include age and reproductive status,
(pre-pubertal, reproductive age, peri-menopausal, and post-menopausal)
and genital examination techniques. Other common variables include
the unique case identifier, date and time of the examination, interval
from death to arrival in forensic science morgue, general condition of
G101 The Effects of Household Chemicals on G102 Mass Disaster Procedures: Forensic
Blow Fly Oviposition and Development Pathology and Genetic Techniques Used to
Using Human Cadavers Locate Nine Missing People in the Calabria
Region (Southern Italy)
Kristi N. Bugajski, MS*, 929 King Street, Lafayette, IN 47905; and
Ralph E. Williams, PhD, Purdue University Department of Entomology, Paola A. Magni, MS, F.E.LAB ASL TO1, c/o Civico Obitorio di Torino,
901 West State Street, West Lafayette, IN 47907 Via Bertani 112/A, Torino, 10137, ITALY; Giulio Di Mizio, PhD*,
Policlinico Universitario Camp, Germaneto, Edificio Clinico, Sec.
After attending this presentation, attendees will have a better Foren Med, Viale Europa, Catanzaro, 88100, ITALY; Federica
understanding of the effects that household chemicals have on the Colosimo, MD, Magna Graecia University of Catanzaro, Viale Europa
insect’s role in the decomposition of the human body. This research was Loc. Germaneto, Catanzaro, 88100, ITALY; Sergio Schiavone, PhD*,
inspired from a murder that occurred in Lafayette, Indiana where the RIS Carabinieri, S.S. 114 Km 3,400, Messina, 98128, ITALY; Carlo G.
perpetrator sprayed Raid® on the body of the victim. This led researchers Romano, MSc, RIS Carabinieri, S.S. 114 Km 6,400, Messina, 98128,
to question what effects Raid® and other household chemicals have on ITALY; Ciro Di Nunzio, Institute of Legal Medicine, School of Medicine,
blow fly activity and subsequently estimations of the postmortem Magna Graecia University, Viale Europa Germaneto, Catanzaro, 88100,
interval (PMI). ITALY; Ian Dadour, PhD, Centre for Forensic Science, University of
This presentation will impact the forensic science community by Western Australia, 35 Stirling Highway, Nedlands, 6009, AUSTRALIA;
exploring the hypothesis that bodies treated with the chemical ammonia and Pietrantonio Ricci, MD, Università degli Studi Magna Grecia
would not significantly vary from bodies with no treatment and bodies Catanzaro, Viale Europa - Località Germaneto, Catanzaro, ITALY
treated with Raid® would significantly vary. This hypothesis was based
on the results of previous research conducted on swine. After attending this presentation, attendees will understand the
Six human bodies, (four male and two female), were obtained for importance of a unified and well organized multidisciplinary approach
use in this study and frozen prior to placement in the field. This research resulting in a set of guidelines useful during a mass exhumation.
was conducted at the Anthropological Research Facility at the University This presentation will impact the forensic science community by
of Tennessee in Knoxville. The field research started on July 18, 2010 documenting the management of the first mass exhumation and DNA
and concluded on August 6, 2010. The bodies were placed in the field identification of one hundred corpses. This procedure will be useful in
in sealed body bags and allowed to thaw for a period of 48 hours prior to the future following an actual mass disaster event.
treatment with chemicals. After the bodies were removed from the bags The Public Prosecutor’s Office of the city of Paola (CS, Calabria
they were checked for any evidence of insect activity and none was Region, Southern Italy) opened an investigation into a number of
observed. Two bodies (male) were not treated with chemicals and served criminal offenses that have repeatedly occurred in aged care facilities
as controls. Two bodies (one male, one female) were coated with 1275 where people with physical and psychological handicaps are managed.
g (3 cans) of Raid for Flying Insects, (active ingredients 0.05% The aged care facility manager was a suspect and due to his
permethrin, 17.5% tetramethrin, 0.05% d-cis/trans allethrin). Coating irregular management was arrested.
involved spraying the bodies with Raid until runoff occurred. Two In different periods over recent years nine residents had gone
bodies (one male, one female) were coated with 9.45 L (5 bottles) of missing from the house. The resident’s families reported this to the legal
Great Value brand household ammonia. The ammonia was poured onto authorities about their missing relatives to the legal authorities.
the body until runoff occurred. Treatments were randomly assigned Moreover the families expressed concern that during the last meeting
using a random number generator. The bodies were monitored and when they saw their relatives, they were all injured.
photographed twice daily and notes were taken to document blow fly An investigation was organized in order to find the missing patients.
activity. The following major stages of insect activity were noted: adult This was concentrated in the local cemetery where the police found
flies, fly eggs, fly larvae, migrating fly larvae, presence of beetles, and unmarked graves without any identification.
the end of maggot migration (characterized by the absence of observable The public prosecutor gave permission to the Legal Medicine
larvae on the body). This allowed researchers to document differences Department of Magna Graecia University of Catanzaro to exhume the
in development time as well as the initial onset of blow fly life stages. unmarked graves and examine each corpse so they could be identified.
Adults and larvae were collected following standard operating In a period of 15 days, 101 corpses were exhumed for identification
procedures outlined in Haskell and Williams (2008) each day to using DNA and to determine if any trauma had occurred either
document any differences in species composition or development among antemortem or perimortem.
treatments. Larvae were collected in KAA (composed of 95% Ethanol The medico-legal task force which was multi-disciplinary consisted
(77%), Acetic Acid (15%) and Kerosene (8%)) and adults in 70% EtOH. of three phases: a planning phase; a pre-analytical phase; and, an
The research was still in progress during the writing of this abstract, analytical phase.
but the results and conclusions of the study will be discussed during the Planning Phase: During this phase mass disaster operative
presentation. procedures were enacted. A medico-legal camp was built close to the
Forensic entomologists are often asked by law enforcement cemetery area. Briefing meetings were organized to coordinate the
agencies to provide an estimation of the PMI using insects. If chemicals schedule of pathologists, molecular biologists, entomologists,
are applied to a body and that has an effect on the blow fly activity, then mechanical engineers, computer scientists, physics, and law enforcement
the estimation of the PMI is therefore compromised. The data obtained agents (Arma dei Carabinieri and fire brigade).
from this research will impact the forensic science community by Pre-Analytical Phase: Under the direction of the coordinating
helping to overcome this obstacle when chemicals are involved and yield pathologist, pneumatic tents were positioned courtesy of the fire brigade.
more accurate assessments by forensic entomologists. Each tent had its own purpose (external inspection, x-ray, autopsy,
Forensic Entomology, Chemicals, PMI biological laboratory). The camp site was powered by portable electric
generators. Moreover, the camp set up was established in order to
prevent the infestation of insects attracted by human remains which
would complicate or invalidate the medico-legal analyses.
Approximately 40 people worked each day in the camp.
Analytical phase: This phase was developed in the Genetic This experiment examined the growth rates of single versus group
Laboratory of the RIS, Carabinieri Messina. The methodology was raised maggots (N=100) on various tissue types. Growth rate differences
previously validated at the Forensic Genetic Laboratory of Magna were measured in two ways: mean maggot size, and instar stage. Larvae
Graecia University where techniques had been previously established to were procured from eggs laid in the lab by a mixture of wild caught and
extract DNA from old and badly preserved bones. The main difficulty of lab raised C. vomitoria. Larvae were laid on kidney, liver, heart, lung, or
this work was the DNA extraction from corpses in colliquative, brain before being transferred within an hour of hatching to the tissue on
corification, and scheletonization stages. which they were to be raised. All larvae were transported from the tissue
A piece of femur diaphysis (4 cm length) was sampled from each on which they were laid to either a piece of the same tissue type or a
corpse and fixed in alcohol. Subsequently all muscle tissue and internal different tissue type. By this means, it could be seen if a variation in
trabeculae (if present), was removed from the bone. The bone was then origin tissue and sustenance tissue for a larvae during the first instar
washed in water-alcohol-ether, then pulverized and demineralized. stage had an effect on the rate at which it matured.
The pulverization of 0.5 g of bone was achieved by impact and Each tissue type had three replicates of masses being born and
friction using 30 Hz frequency and spun together with a single tungsten raised on the same tissue type and three replicates of larvae being born
carbide ball inside a cylindrical steel container. and raised on differing tissue types, for six replicates in total. Single
The bone powder demineralization was obtained using an EDTA raised larvae were replicated in groups of twenty for each origin tissue,
solution 0.5 M pH 8,0. resulting in batches of forty replicates total per a raising tissue type. All
After chloroform extraction, the DNA purification was completed larvae were killed approximately six days after hatching and were
using silica gel columns. measured by length from mouth to instar markings to the nearest .01 µm.
The quantity of obtained DNA was determined by REAL-TIME Whether the tissue type on which a larva was born was switched
PCR technique. during first instar was not statistically significant. However, the
The DNA personal profiles were obtained with multiplex relationship between size, tissue type, and whether a larva was mass
amplification and subsequent separation in capillary electrophoresis. grown or single grown was significant. In PMI studies larvae are used
The results obtained allowed the DNA identification of the corpses to determine PMI based on length at time of death, or time needed to
regardless of their stage of decay. The obtained DNA profiles were grow them to adulthood in a laboratory setting combined with
compared with relatives to confirm the identity of the exhumed bodies. accumulated degree days. The variations in growth seen in this study
Mass Disasters, Forensic Pathology, Forensic Genetics differ from those seen with previously studied species, signifying that
tissue based variations in growth rates are species specific. The wider
variance in lengths noted in mass raised larvae as compared to single
G103 Variance in Growth Rates of Calliphora raised larvae indicates that size is not the best determinant of age as
previously presumed. These results could mean a significant change in
vomitoria on Different Tissue Types: Mass the way fly larvae are viewed and utilized in the field of taphonomy and
Raised vs. Single Raised forensic entomology for determining PMI.
Development Rate, Forensic Entomology, Postmortem Interval
Bridget R. McSweeney, BA*, 1629 South Shenandoah Street, Los
Angeles, CA 90035; and Tal Simmons, PhD, School of Forensic &
Investigative Sciences, University of Central Lancashire, Preston, PR1 G104 Identification of Two Homicide Victims and
2HE, UNITED KINGDOM
Linking of Separate Crimes Solved by
After attending this presentation, attendees will have a better Radiographic Discovery of a Healed
understanding of the variances in growth rates for Calliphora vomitoria Bullet Wound.
that occur not only when raised on differing tissue types, but also when
raised in mass versus single. William C. Rodriguez III, PhD*, and Laura A. Regan, PhD, Armed
This presentation will impact the forensic science community by Forces Medical Eaminer System, 1413 Research Boulevard, Building
demonstrating the need for further understanding of larvae activity and 102, Rockville, MD 20850; and Humphrey H. Germaniuk, MD, Trumbull
growth rates on differing tissue types. County Coroner’s Office, 1863 East Market Street, Warren, OH 44483
Without a more thorough understanding of larvae species and their
possible species specific growth rates and interactions with tissue types, The goal of this presentation is to provide details on the
the use of them in determining postmortem intervals (PMI) is suspect. investigation, and forensic examination of two separate homicide cases
Recent studies show that there are significant differences in maggot which were solved based on the radiographic discovery of an old healed
growth rates depending on what type of tissue they consume. While bullet wound. A primary point of discussion of this presentation will be
previous studies have determined that the structure of the tissue didn’t how the smallest and least suspected piece of evidence can be utilized to
make a difference, what exactly causes the variation in growth rates has solve a difficult case or cases. The importance of detailed forensic
not yet been discovered. Since most comparison studies have been anthropological examination in skeletonized or badly decomposed cases
conducted using lab raised larvae (commonly grown on cow liver or pig will be noted during the presentation.
liver), there may be significant problems with using such larvae to This presentation will impact the forensic science community by
determine PMI in real cases. To better understand the implications of the providing present and future forensic investigations insight as to the
variation in growth and development, development rates of larvae raised forensic analysis of decomposed and skeletonized remains so as
on various tissue types need to be explored more completely. This raises determine the identity of deceased as well as the possible cause and
the question of whether the specific tissue consumed, or a change within manner of death. The forensic audience attending the presentation will
the mass’s activity, causes a change in growth rate. become more aware of the importance of old healed injuries in the
A comparison between single raised larvae and mass raised larvae identification process as well as possibly identifying past activities or
was used to judge the possible connection between being raised in mass linking criminal activity.
and differences in growth rates on varying tissue types. If the difference In the summer of 2006 near Warren, Ohio skeletonized remains of
in growth rates between different tissue types was not related to being an adult individual were discovered in a heavily vegetated area near a
mass raised, then single raised larvae and mass raised larvae from the water treatment facility. The remains of the deceased were noted to be
same tissue type would show the same variations in growth rates. without any associated clothing or foot ware. Forensic anthropological
examination of the remains found them to be consistent with that of a Case Report: the decedent is a 41-year-old male homicide victim
Negroid male who was in his fifth decade of life at death. Based on the whose dismembered remains were concealed with concrete in two five-
environmental conditions at the scene and the decompositional state of gallon plastic buckets. According to police reports, the decedent was
the remains a postmortem PMI of approximately six to eight months was killed by his son who later confessed and led police to his father’s
assigned. The lack of soft tissues, absence of skeletal trauma in addition remains which had been stored in a shed for approximately two months
to the absence of clothing and location of the remains were noted as following the homicide and dismemberment. Unable to determine the
extremely suspicious by the coroner’s pathologist. veracity of the reported circumstances, the presence of human remains
Approximately two years passed while the remains of the deceased was confirmed using MDCT. The remains were limited to the decedent’s
remained unidentified. In June of 2008, another set of skeletonized head with cervical spine, hands, feet, and heart. The imaging also served
remains were discovered near Warren, Ohio. The remains discovered to establish preliminary forensic findings, namely the presence of a
were recovered from several plastic garbage bags that were located along bullet in the left orbit. In addition, fractures of the left and right orbital
a highway. Each of the garbage bags recovered contained various plates were noted, while the remainder of the calvarium was intact.
portions of a highly decomposed body that had been dismembered. Other osseous findings include a fracture of the left distal second
Forensic anthropological examination of the dismembered remains metacarpal and left distal first phalange, as well as a metal plate in the
revealed them to represent a single individual that of a Negroid male who left orbit. In order to remove the remains from the buckets with minimal
was in his mid to late twenties at death. damage, the outside of the buckets were marked to indicate the
Detailed examination of the remains revealed that the orientation of the remains. A circular saw with a concrete cutting blade
dismemberment had been accomplished with a saw. The sawing was used to cut into the concrete along predetermined planes of
dismemberment was noted as unusual as the cuts were made along the predetermined depth. The properly oriented concrete incisions allowed
longitudinal/saggital plane of the body. A major portion of the middle for coronal separation around the head providing anterior and posterior
and lower vertebral column had been cut longitudinally including a near intact concrete mold halves. External examination of the head revealed
perfect halving of the sacrum. A single gunshot wound was noted on the that the skin and portions of soft tissue had been removed prior to
skull and considered to be the probable cause of death. encasement. The ears and eyelids were missing, and the eyes were
While conducting an examination of the innominates for aging and sunken and softened due to decomposition. A small caliber, slightly
sexing purposes a very slight and almost unnoticeable small depression deformed bullet was recovered from the left frontal sinus/superior orbital
was noted along the inferior side of one of the innominates. The slight ridge. Due to the intentional removal of the decedent’s facial skin and
depression which was adjacent to the inferior side of the sciatic notch at postmortem change, the entry wound was not visible and range of fire
first appeared to represent a simple skeletal anomaly attributed to human could not be determined; however, absence of soot from sections around
skeletal variation. Radiographic examination of the innominate revealed the remaining soft tissue likely exclude a contact gunshot wound. In the
the presence of a fairly intact nine millimeter bullet. The bullet was absence of postmortem MDCT or conventional radiographs, it is entirely
removed from the innominate utilizing a small craft saw and submitted possible that the presence of a gunshot wound could have been
as evidence of an old healed bullet wound. overlooked. While the extent of brain decomposition precluded its
The discovery of the old healed bullet wound served as a key lead examination, the MDCT and gross examination findings indicate that the
to the identification of the homicide victim. Identification of the victim bullet did not penetrate the cranial cavity. Examination of the outer table
led police on an investigation that in turn resulted in the identification of of the left orbital ridge of the calvarium revealed hemorrhage in the soft
the prior unknown remains discovered near the water treatment facility. tissue. Neck and throat examination indicate the unlikelihood of
Further investigation of this case revealed that the earlier death was also strangulation based on the presence of an intact hyoid bone, thyroid
a homicide and led to the arrest of the killer. cartilage, and thyroid cornu and absence of hemorrhage of the laryngeal
Anthropology, Ballistics, Human Identification mucosa. Because of the limited amount of remains available for
examination, trauma to the remainder of the decedent’s body could not
be evaluated and therefore the cause of death was classified as
G105 Utilizing Multi-Detector Computerized undetermined. The manner of death was classified as homicide. Positive
identification of the remains was established by comparison with
Tomography to Evaluate Concrete-Encased antemortem dental records and confirmation of an orthopedic metal plate
Human Remains in the left brow.
In summary due to the location of our morgue facility, MDCT is
Robert A. Kurtzman, DO, Community Hospital, 2021 North 12th Street, readily available and was utilized to confirm the presence of human
Grand Junction, CO 81501; and Casey P. Bitting, BS*, 1700 Bassett remains concealed in concrete. Furthermore, MDCT permitted
Street, #2114, Denver, CO 80202 orientation of the remains for optimal removal, documented orthopedic
devices to augment identification, and assisted in the evaluation of
After attending this presentation, attendees will recognize the value injury. This defendant pled guilty and the case did not appear in court.
of postmortem multi-detector computerized tomography (MDCT) If court proceedings had ensued, the use of a three dimensional
evaluation of an unusual case of human dismemberment followed by volumetric MDCT rendering would have been utilized to present
encasement in concrete; appreciate the value of MDCT osseous information to the jury. It is believed, a three dimensional volumetric
examination and documentation; learn methods to utilize MDCT rendering provides objective detailed visual imagery without the graphic,
analysis of concealed biologic remains and review procedures utilized frequently repulsive appearance of wound photographs, and MDCT is
for orientation and extraction of human remains from concrete. useful in the evaluation of selected postmortem examinations.
This presentation will impact the forensic science community by Multi-Detector Computerized Tomography, Gunshot Wound, Homicide
expanding the scenarios in which the use of MDCT may be utilized to
improve postmortem evaluation and will demonstrate opportunities to
utilize MDCT in medical examiner/coroner facilities where MDCT is
reasonably available.
The Mesa County Coroner’s Office is situated in rural Western
Colorado at Community Hospital in Grand Junction, Colorado. Because
the morgue is located within the hospital, state of the art radiographic
equipment and ancillary staff are available.
G106 Use of Multidetector Computed G107 Evaluation of the Randox Whole Blood
Tomography (MDCT) in the Medicolegal Drugs of Abuse (DOA) Microchip Arrays
Investigation of Human Remains After a for Use With Alternative Postmortem
Natural Disaster Samples as a Rapid Near-Body Screen
Howard T. Harcke, MD*, Armed Forces Institute of Pathology, 6825 Poppy McLaughlin, MSc*, Bournemouth University, Fern Barrow,
16th Street Northwest, Washington, DC 20306; and Edward L. Talbot Campus, Poole, BH12 5BB, UNITED KINGDOM; Derrick J.
Mazuchowski, PhD, and Philip J. Berran, JD, Office of the Armed Pounder, MB, University of Dundee, Department of Forensic Medicine,
Forces Medical Examiner, 1413 Research Boulevard, Building 102, Dundee, DD1 4HN, UNITED KINGDOM; and Michael D. Osselton,
Rockville, MD 20850 Bournemouth University, Fern Barrow, Talbot Campus, Poole, BH12
5BB, UNITED KINGDOM
process used by the Armed Forces Medical Examiner System (AFMES) The goal of this presentation is to illustrate a rapid and simple tissue
to integrate multi-detector computerized tomography (MDCT) in the preparation method which allows drugs of abuse (DOA) to be screened
handling of human remains recovered from the natural disaster in Haiti. using the Randox whole blood DOA microchip arrays.
Attendees will be able to describe strengths and limitations of the process This presentation will impact the forensic science community as the
model employed. entire process can be undertaken and results obtained in the mortuary
This presentation will impact the forensic science community by whilst the postmortem is taking place. Also the quantity of sample
offering one alternative for processing human remains following a needed to screen may obviate the need to remove large tissue samples for
natural disaster or other mass casualty event. laboratory analysis, saving time and costs, especially in negative cases.
A disaster mortuary is established both to identify victims and A procedure is described that allows small aliquots of postmortem
determine cause and manner of death. Conventional radiography has samples of blood, urine, vitreous humor, liver, and psoas major muscle
been routinely used to screen for foreign bodies, personal effects and to be analyzed for the following drugs, simultaneously: acetaminophen,
anatomic, dental, or surgical findings. MDCT has proved to be a useful amphetamine, barbiturates, benzodiazepines, benzoylecgonine,
technique in support of forensic examination in military and civilian buprenorphine, cannabinoids, fentanyl, ketamine, lysergic acid
mortuaries. The disaster in Haiti provided the AFMES the opportunity diethylamide (LSD), methadone, methaqualone, methylamfetamine,
to utilize MDCT in the processing of victims of that event. methylenedioxymethamfetamine (MDMA), opioids, phencyclidine
The three step processing model used employed: (1) digital (PCP), propoxyphene, tricyclic antidepressants, zaleplon, zolpidem, and
radiography and whole body MDCT; (2) visual external inspection of the zopiclone.
body; and, (3) forensic autopsy if steps one and two did not establish Femoral blood, urine, vitreous humor, liver, and psoas muscle were
reasonable explanation for cause and manner of death or produced obtained from forensic autopsies, ranging from suicides to natural
findings that required internal examination (e.g., ballistic fragments, causes. Tissue samples were cut into 1 centimeter cubes and
external wounds). homogenised with 1 millilitre SPE diluent. The homogenates were
There were 28 cases received and 27 processed using the model centrifuged for ten minutes at 3000 rpm and 70 microlitres of supernatant
(one case did not have MDCT). In 20 cases MDCT and visual inspection transferred to Eppendorf tubes. The samples were then diluted 1:3 with
showed evidence of blunt force injury and no suspicious findings. The SPE diluent. Femoral blood, urine and vitreous humour were prepared
medical examiner did not perform an autopsy and cause/manner of death and applied to the assay following the manufacturer’s protocol for whole
was “blunt force injury/accident.” In 19 of 20 non-autopsied cases blood. Femoral blood from each case subsequently underwent
MDCT gave more information than digital radiology, the exception confirmatory analysis using high performance liquid chromatography
being a case where disarticulated bones were received. Key findings with diode array detection (HPLC-DAD) and liquid chromatography
were skeletal injuries to the head/neck, spine, thorax, and pelvis. In tandem mass spectrometry (LC-MS/MS).
seven cases MDCT and visual inspection was judged inconclusive and Over 100 postmortems were screened for a combination of the
complete autopsy was performed. These cases were signed out as previously mentioned drugs of abuse. A good agreement was obtained
“probable positional asphyxia/accident” (2), “cardiac arrhythmia/natural between the Randox assays and HPLC-DAD and LC-MS/MS analyses.
(2), blunt force injury/accident” (2) and “complications of a natural Of the positive cases, urine and liver samples had a greater percentage
disaster/accident” (1). None of the 27 cases showed internal metallic agreement with confirmatory analyses than femoral blood, vitreous
fragments or suspicious external wounds. In 23 of 27 cases, moderate to humor, and psoas muscle. The discrepancies between assay screening
severe decomposition was present and our prior forensic experience was and confirmatory analysis may reflect differences in drug distribution
helpful in distinguishing changes related to postmortem decomposition, between tissues as well as confirmatory analyses detecting
recovery and handling from acute injury sustained during the event. concentrations below the assay’s cut-offs.
In conclusion, the use of MDCT together with external visual In conclusion, the Randox whole blood DOA arrays can be used to
inspection by a medical examiner provided sufficient information to alternative postmortem samples rapidly and simply. The simple
establish cause and manner of death in 74% of the cases sent to the procedure will benefit the forensic community as the entire process can
AFMES during recovery operations in Haiti. This related directly to the be undertaken and results obtained in the mortuary while the postmortem
ability of MDCT to determine findings consistent with blunt force injury is taking place. Also the quantity of sample needed to screen may
not apparent on digital radiographs. This model using MDCT and visual obviate the need to remove large tissue samples for laboratory analysis,
inspection offers a rapid alternative for investigating human remains saving time and costs, especially in negative cases.
recovered after a natural disaster. It is believed that MDCT alone Drug Sceening, Postmortem, Alternative Samples
without external visual inspection by a medical examiner would not be
adequate. It is also recognized that a medical examiner may deem a full
autopsy to be required for a variety of other reasons (e.g., statutes, policy
directives).
Computed Tomography, Natural Disaster, Virtual Autopsy
G108 Postmortem Vitreous Beta- G109 The Rising Trend of Ecstasy and Mimic
Hydroxybutyrate: Interpretation in a Drugs Among Teenagers in Santa Clara
Forensic Setting County, California — A Guide and
Awareness for Medical Examiners,
Michael Heninger, MD*, Fulton County Medical Examiner’s Office, 430
Pryor Street, Atlanta, GA 30312
Coroners, and Toxicologists
After attending this presentation, attendees will be aware of the Larry Silveira, MS*, Santa Clara County Department of Alcohol and
range and frequency of postmortem vitreous beta-hydroxybutyrate Drug Services, 2101 Alexian Drive, Suite 110, San Jose, CA 95116; and
(BHB) levels likely to be encountered in a forensic setting. Michelle A. Jorden, MD, Santa Clara Medical Examiner, 850 Thorton
This presentation will impact the forensic science community by Way, San Jose, CA 95128
providing a more thorough basis for interpreting vitreous BHB levels.
Beta-hydroxybutyrate is one of three ketone-related substances The goal of this presentation is to educate the forensic community
commonly measured in the clinical laboratory and is also useful in about the rise of ecstasy use and mimic drugs in California.
postmortem testing. Ketones increase when the primary metabolic fuel This presentation will impact the forensic science community by
source switches from glucose to fatty acids. Ketones are most useful as presenting a comprehensive report detailing the current growing trend of
a marker for diabetic ketoacidosis and are also increased in alcoholic illicit pill ingestion among teenagers in Santa Clara County to include
ketoacidosis, starvation states, and severe infectious disease processes. ecstasy, as well as, other mimic drugs (phenylpiperazines) which may
They can be measured in many body fluids including blood, urine, and escape detection in a basic toxicologic analysis. At the end of the
vitreous fluid during postmortem investigations. presentation, attendees will be introduced and will be able to appreciate
The medical examiner is often faced with an elevated vitreous BHB the new trend of “thizzin” and “popping” by teenagers in this county as
level that appears to have little or no bearing on the case. When can well as nationwide. This presentation will also reiterate the importance
elevated vitreous ketones be safely ignored? This retrospective study of complete toxicologic screens on fatal overdoses to help identify
was undertaken in order to gain a better understanding of the frequency common and not so common drugs of abuse and/or cutting agents.
and usefulness of postmortem vitreous BHB levels in the forensic According to 2001 data collected by the Substance Abuse and
setting. Moderately elevated levels were common and were not often Mental Health Services Administration (SAMHSA), there have been
related to the cause of death. More severely elevated levels of BHB were approximately 100 deaths resulting from ecstasy overdoses in the United
related to the cause of death with increasing frequency as the levels States. Nationwide, ecstasy abuse seems to outweigh methamphetamine
increased. Markedly elevated vitreous BHB coupled with elevated abuse and only lags behind alcohol, marijuana, and cocaine as a popular
vitreous glucose usually indicated diabetic ketoacidosis. When vitreous drug of abuse among 12th graders. What is most disturbing is the
BHB was elevated and the vitreous glucose was low, an alcohol related indiscriminate ingestion of different colored and shaped pills (“thizzin”)
death was common. advertised to teenagers as ecstasy, when in reality, some of the ecstasy
A computer database was searched for postmortem vitreous beta- pills may be cut with cocaine, heroin, phenylpiperazines, and talc, just to
Hydroxybutyrate (BHB) levels measured in 1,795 forensic cases over a mention a few agents. In Santa Clara County, a rise is being seen in
six year period (2003 to 2009) in the normal course of death teenagers abusing ecstasy and ingesting pills which may be composed of
investigation. Levels ranged from 0 to 22.7 mmol/L and averaged 1.2 various drugs, some which may evade the basic toxicology screen. In the
mmol/L. 562 (31.3%) were less than 0.4mmol/L . 637 (35.5%) were past year, Santa Clara County has seen two deaths resulting from ecstasy
between 0.4 and 1.2 mmol/L. 439 (24.5%) were between 1.2 and 2 intoxication or complications thereof. Recently, a male who attended a
mmol/L. 105 (5.85%) were between 2 and 6 mmol/L. 52 (2.9%) were rave party in a surrounding county died of an acute ecstasy overdose.
greater than 6 mmol/L. Comparison of vitreous BHB with vitreous A retrospective search over the past nine years at the Santa Clara
glucose levels in 1,781 cases showed moderately good correlation County Medical Examiner/Coroner Office disclosed a total of five
r=0731. Comparison with blood alcohol levels in 1,561 cases showed no ecstasy overdoses, two within the past year. In April 2009, a 22-year-old
correlation r= -0.053. Diabetic ketoacidosis was diagnosed in 76.9% of female was found deceased in a motel room after partying all night and
the cases with vitreous BHB above 6 mmol/L; 37.5% to 13.5% of cases ingesting ecstasy. During the course of the evening, she complained of
with decreasing BHB levels from six to two mmol/L and less than 2% of headaches and began vomiting. Her friends left her alone in the motel
cases with BHB less than 2.0 mmol/L. Alcoholic ketoacidosis appeared room only to find her deceased hours later. The autopsy examination
in only 4 cases. Conditions thought to be ketogenic (diabetes, revealed a morbidly obese woman with an unremarkable internal
alcoholism, severe infections) were found in over 92% of the cases with examination except for marked brain swelling and pulmonary edema.
BHB above 6 mmol/L and a third of the cases with BHB levels below Toxicology revealed the peripheral blood was positive for MDMA at 140
2.0, 1.2, and 0.4 mmol/L. Cases of sudden violent death, age 20-40 and ng/mL (non-lethal) and its metabolite MDA at 20 ng/mL. Vitreous
less than 90 minutes from incident to pronouncement time, and with no electrolytes revealed a profound electrolyte abnormality that consisted of
obvious reason for elevated BHB amounted to 11 cases and showed hyponatremia. The cause of death was attributed to ecstasy-associated
vitreous BHB levels closer to normal with an average of 0.57 mmol/L. hyponatremia.
The BHB level was elevated (0.4 – 1.72 mmol/L) in 32 of 34 SIDS-like In January 2010, a 16-year-old adolescent was ingesting ecstasy
cases included in the study. with friends and had ingested a total of four tablets along with energy
Beta-Hydroxybutyrate, Death Investigation, Sudden Infant drinks when she became unresponsive shortly thereafter. Autopsy
Death Syndrome examination revealed that both coronary ostia arose from the same semi-
lunar cusp but the coronary arteries pursued a normal anatomic course,
along with findings of marked pulmonary and cerebral edema.
Toxicology revealed the peripheral blood was positive for MDMA at
3200 ng/mL (fatalities arise at 1000 ng/mL) and its metabolite MDA at
140 ng/mL. Death was attributed to an ecstasy overdose.
After this period of recent fatalities, a survey of 1,852 students was
conducted at two large comprehensive high schools and two continuation
high schools located in Santa Clara County. A one-page anonymous
questionnaire to identify use of various mind altering substances was The spearman correlation coefficient was similar (0.41) for the field
administered from March 24, 2010 to May 12, 2010 to students ranging and autopsy specimens from as single case analyzed at laboratory #1 as
from ages 14-19. the coefficient for a single heart blood sample run at laboratory #1 and
In all, 25.32% of all respondents admitted to “ever use” of ecstasy laboratory #2 (0.62) and a single autopsy peripheral blood sample run at
(469 out of 1852) which is 390% higher than the teens responding to the laboratory #1 and laboratory #2 (0.57). Thus, the variation in values was
national 2009 Monitoring the Future Survey (MTF) and nearly twice the similar between the same specimen analyzed at two different laboratories
level from the national 2009 Parents and Teens Attitude Tracking Study and between samples drawn from different sites and at different times.
Report (Partnership for a Drug Free America) (PATS). Additionally, Other evaluations of the heart:femoral blood ratio of fentanyl and
8.48% of the teen respondents admitted to the use of ecstasy in the past measurements of correlation and variation will be discussed.
30 days; 471% higher than the MTF results and 41% higher than the Fentanyl, Postmortem Redistribution, Interlaboratory Variation
PATS results. Students who had taken ecstasy admitted to maximum
doses ranging from one to ten tablets with an average of four tablets.
Results from the review of pictures of pills from www.ecstasydata.org by G111 Toxicology and Pathology of 149-
a smaller subgroup of 30 students confirmed that 70% contained
phenylpiperazines
Methadone-Related Deaths
For at least local teen populations and perhaps growing
geographical regions, it is hypothesized that the drug’s ease of Sébastien Prat, MD*, Service de Médecine Légale, Hôpital Trousseau,
availability, reduction in its cost, limited awareness of the risks and risk Centre Régional Hospitalier Universitaire de Tours, Tours, MB 37000,
of death, growing teen permissive attitudes and enabling behaviors from FRANCE; Patrice Mangin, PhD, Centre Universitaire, Romand de
their social subculture, appear to have pushed this drug to their third Medecine Legale, Rue du Bugnon 21, Lausanne, CH-1011,
most frequently used drug surpassed only by marijuana and alcohol. SWITZERLAND; Marc Augsburger, PhD, University Center of Legal
Complete toxicological screens are suggested in this population given Medicine, Bugnon 21, Lausanne, 1010, SWITZERLAND; and Katarzyna
their extreme dosing behaviors and the apparent frequent presence Michaud, MD, Centre Universitaire Romand de Medecine Legale, Rue
of phenylpiperazines. du Bugnon 21, Lausanne, 1005, SWITZERLAND
Ecstasy, Mimic Drugs, Rise in Use
After attending this presentation, attendees will understand that
careful interpretation of methadone related deaths in the presence of
concomitant drug intake and pathological changes is very important.
G110 Laboratory Variation and Postmortem This presentation will impact the forensic science community by
Redistribution in the Interpretation of illustrating the difficulty of interpreting postmortem methadone blood
Postmortem Fentanyl Levels levels due to the possible interaction with others drugs acting on the QT-
interval or on the cytochrome P450, as well as the presence of
Clarissa Krinsky, MD*, University of New Mexico School Of Medicine, pathological changes.
MSC11 6030, 1 University of New Mexico, Albuquerque, NM 87131; and Methadone-related deaths are often difficult to interpret, especially
Sarah Lathrop, PhD, DVM, and Ross E. Zumwalt, MD, University of in the presence history of chronic drug use, concomitant intoxications
New Mexico, Office of Medical Investigator, MSC 11 6030, 1 University and if pathological changes are observed. Historically, the presence of
of New Mexico, Albuquerque, NM 87131-0001 methadone was often considered to be an incidental finding of the
postmortem examination, unrelated to the cause of death. It was recently
After attending this presentation, attendees will understand the reported that methadone may prolong the QT interval, resulting in
principles of postmortem redistribution and interlaboratory variation and torsade de pointes. Sudden deaths with therapeutic levels of this
how to best utilize those concepts when evaluating postmortem fentanyl synthetic opioid have been reported. Moreover, clinicians are
levels in central and peripheral samples. increasingly aware of interactions between methadone and others drugs
This presentation will impact the forensic science community by that prolong the QT interval or decrease the elimination rate of
providing an understanding the importance of using caution when methadone.
interpreting very small, quantified fentanyl levels in postmortem The goal of this study was to evaluate methadone related deaths by
samples. dividing them into three groups according to the peripheral blood level
The concept of postmortem redistribution has been extensively of methadone: lower than 200 µg/L, 200 to 1000 µg/L, and higher than
studied in some drugs, such as amitriptyline. The concept has also been 1000 µg/L. The primary purpose of the study was to determine whether
looked at in regards to fentanyl, which due to its transdermal delivery differences exist between the presence of illicit drugs, drugs acting on
mechanism, has interesting and unique pharmacokinetics and likely QT interval and drugs metabolised by cytochrome P450. This study also
undergoes postmortem redistribution. It is hypothesized that fentanyl aimed to determine whether there are differences between the cardiac,
levels drawn from peripheral samples in the field, hours before autopsy, hepatic and pulmonary pathology of the three groups.
would be significantly lower than fentanyl levels in peripheral and Materials and Methods: Methadone-related cases were reviewed
central blood samples drawn at autopsy. retrospectively. The age of the victims ranged between 17 and 65 years.
For this study, ten cases had fentanyl levels drawn in the field by Most of the cases were male (109 cases). For all cases the complete
investigators. The fentanyl level in this sample was compared to the autopsy, including histological examination and a full toxicological
level of fentanyl in peripheral and central samples taken at autopsy 15- screening, was performed.
24 hours later. Fentanyl levels are measured in very small quantities, Results: The methadone blood levels were lower than 200 µg/L in
ng/ml. At these very small amounts, the standard laboratory error could 37 cases; between 200 and 1000 µg/L in 89 cases; and higher than 1000
also greatly impact the values reported by the laboratory. In the process µg/L in 23 cases. In the last group methadone was detected in hair for
of comparing field and autopsy specimens and autopsy peripheral and all victims. Hair analysis was performed in 61 cases: 49 cases tested
central samples, we also sent most samples to a second accredited positive for methadone (80.3%) and 39 cases were positive for cocaine.
forensic toxicology lab. The ratios between the field and autopsy Higher methadone blood levels were observed in men (p-value 0.052)
specimens and the heart and femoral blood levels were compared, and and did not differ significantly by age.
the interlaboratory variation was evaluated as well. Only in five cases methadone was alone, in 90 cases other drugs
metabolised by cytochrome P450 were found, without significant
differences between the three group (p-value 0.81). Illicit drugs were G113 Was This Drug Overdose Due to
found in 62 cases (p-value 0.29), drugs acting on QT interval in 79 cases
(p-value 0.07) and respiratory depressant drugs, mostly benzodiazepines,
Intravenous Injection or Oral Ingestion of
in 139 cases (p-value 0.38). Heroin — Can You Tell?
Different pathological changes (cardiac, pulmonary, hepatic) were
observed in 97 cases (p-value 0.24). Coronary disease was observed in Johan A. Duflou, MM*, Department of Forensic Medicine, PO Box 90,
60.6% of chronic methadone or cocaine abusers. Glebe, Sydney, 2037, AUSTRALIA; Shane Darke, PhD, National Drug
Discussion: This study illustrates the difficulty of interpreting and Alcohol Research Centre, University of New South Wales, Sydney,
postmortem methadone blood levels due to the possible interaction with 2052, AUSTRALIA; and Jennifer Easson, BSc, Division of Analytical
others drugs acting the QT-interval or on the cytochrome P450, as well Laboratories, Sydney West Area Health Service, Joseph Street,
as the presence of pathological changes. The various interactions Lidcombe, 2141, AUSTRALIA
between drugs remain unclear and do not appear to be related to the
methadone blood level. Genetic variability may exist in the response of After attending this presentation, attendees will be alerted to and
sub-group of individuals to the drug and its metabolism, making them understand potential pitfalls associated with interpreting opioid levels in
more susceptible to an overdose. More postmortem studies should be various body fluids and other matrices. This will be illustrated by
performed in order to further understand and prevent fatalities which are presentation of a recent case where a question requiring an answer was
mostly often observed during substitutive programmes or during whether heroin had been taken intravenously or orally. Research data
illicit intake. will be presented followed by an explanation of the various mechanisms
Methadone, QT Interval, Overdose thought to cause these apparently anomalous findings.
informing attendees of the pharmacokinetics of opioids in the
G112 Deaths in Unlicensed Alcohol gastrointestinal system, and alerting them to the dangers of not fully
understanding the behavior of these drugs in the body.
Rehabilitation Facilities Death due to heroin overdose is almost always the result of
intravenous injection of the drug in Australia. A case is described where
Lawrence Nguyen, MD, Los Angeles County Department of Coroner, a heroin overdose was initially thought to be the result of oral ingestion
1104 North Mission Road, Los Angeles, CA 90033; and Christopher B. of the drug, primarily as a result of higher concentrations of morphine in
Rogers, MD*, Los Angeles County Medical Examiner’s Office, 1104 stomach contents than in blood. During the subsequent criminal trial and
North Mission Road, Los Angeles, CA 90033 investigation, however, the issue of the entero-hepatic circulation of
morphine was raised as a possible reason for the presence of morphine
After attending this presentation, attendees will be aware of the risk in the stomach contents.
of death in unlicensed alcohol rehabilitation facilities. For many drugs and poisons, a simple way of making the distinction
This presentation will impact the forensic science community by between oral and parenteral administration is to analyze the stomach
making pathologists aware of a series of deaths of alcohol abusers in contents and compare the levels of the drug in the stomach with those in
unlicensed facilities, and making the public aware of the risks of alcohol blood; a higher stomach contents concentration of the drug would
withdrawal without medical intervention. generally be strong supportive evidence for the assertion that the drug or
A series of 17 deaths in alcohol rehabilitation facilities occurred in poison was administered orally. Morphine; however, in common with a
Los Angeles County between 1996 and 2010. In each an intoxicated range of other drugs, undergoes entero-hepatic circulation as part of the
Spanish-speaking alcoholic man was dropped off at an alcohol metabolism and elimination of the drug. The entero-hepatic circulation
rehabilitation group by his family. The individuals remained at the is a complex mechanism whereby chemicals that have undergone
facilities for varying periods of time and underwent several procedures conjugation reactions in the liver, such as morphine, once in the
for detoxification gastrointestinal tract, may be subject to passive re-uptake, entering the
Reported treatment methods have included use of restraints, forcing circulation via the hepatic portal vein, returning to the liver where the
the victim to drink ethanol or isopropanol, restraint with forced ingestion chemical can be biotransformed again and then re-eliminated. Morphine
of alcohol, application of onions to the feet, and inserting a spoon in the may undergo several cycles of entero-hepatic circulation resulting in a
victim’s mouth. significant increase in the retention time and its consequent duration of
In three cases there was a history of restraint use. Two additional action. Further, both during life and in the perimortem and postmortem
decedents had both ethanol and isopropanol in the blood, although it was period, the pyloric sphincter offers at best a partial barrier to reflux of
unclear whether the isopropanol was given at the facility. The causes of morphine-containing gastrointestinal contents from the duodenum to the
death included alcohol overdose, alcohol withdrawal, hemoperitoneum stomach.
due to cirrhosis and a ruptured splenic vein, and diabetic ketoacidosis These mechanisms would explain the presence of significant
related to chronic pancreatitis. Most cases were closed as accident or concentrations of morphine in the stomach contents of intravenous
natural, although three cases involving restraint were moded homicide. heroin users and we hypothesised that such physiological mechanisms
In some cases, other members of the group were charged with can result in higher concentrations of morphine in stomach contents than
involuntary manslaughter and false imprisonment. in blood, despite the drug having been administered intravenously.
The police are familiar with these groups and are able to close the This study reports on the distribution of opioids in blood, stomach
facilities. However, new groups often form at the same addresses, contents, urine, liver and bile in 29 deaths due to intravenous heroin
requiring additional police action. Los Angeles County has disseminated overdose. The mean total and free blood morphine concentrations were
a public health warning about these centers and has published a list of 57 0.60 mg/L and 0.32 mg/L, respectively, and the mean stomach contents
alcohol treatment centers using non-medical methods of detoxification. total morphine concentration was 1.16 mg/kg. All cases had detectable
However, it has been difficult to eradicate these groups. morphine in the stomach contents, and 24 of 29 cases had higher
It is recommended that medicolegal death investigators be aware of concentrations of total morphine in stomach contents than in blood. The
this information, as similar groups may exist in other areas. mean total morphine concentration in bile was approximately 100 times
Alcoholism, Investigation, Detoxification that in blood, and the liver total morphine concentration averaged twice
that of blood levels.
Morphine was detected in the stomach contents in all cases in this to the drug and its effects was gained by searching a online library, a
study, and in 83% of cases the stomach morphine level was higher than website suggested by the decedent’s father. During this time, the
that in blood. This would indicate that the entero-hepatic circulation comprehensive toxicology screen on the peripheral blood reported the
materially affects morphine levels in the body, and that reflux of presence of phentermine at a concentration consistent with therapeutic
morphine from the duodenum into the stomach appears to be the norm, levels, marijuana, nicotine and cotinine, and atropine, most likely due to
at least after death. Furthermore, even if the gall bladder had been resuscitative attempts. The medical examiner remained suspicious that
removed surgically at some prior time, stomach morphine concentrations this death represented an acute drug overdose, especially in light of the
can still be higher than the blood total morphine levels, as illustrated in circumstances surrounding the death, and consultation with a
one case. toxicologist was pursued.
It’s concluded that the current study demonstrated that stomach Further information gathered later in the course of the investigation
morphine levels cannot be relied upon to determine whether heroin had revealed that in October 2009, a batch of Bromo-DragonFLY, purchased
been orally or intravenously administered. Given the large number of from Denmark, was distributed as the less active compound 2C-B-FLY,
drugs and poisons which undergo entero-hepatic circulation, it would with a packaging label of “batch b1,” one of which was purchased by the
appear prudent to not make comment on route of administration of such decedent’s brother. Toxicological analysis specifically for 2C-B-FLY
drugs unless definite evidence of oral ingestion of the drug can be and Bromo-DragonFLY was undertaken. The analytical technique used
obtained, for example through visualization of appropriate for this work was gas chromatography/mass spectrometry (GC/MS).
pill fragments. 2C-B-FLY was not detected in any of the specimens. Only Bromo-
Heroin Overdose, Illicit Drug Use, Pharmacokinetics DragonFLY was detected in each of the specimens at the following
concentrations: in peripheral blood 22 nanog/mL; in gastric fluid 38
nanog/mL; in urine 28 nanog/mL; and in bile 350 nanog/mL. Bromo-
G114 First Reported Case of Bromo-Dragonfly DragonFLY levels in beta-glucuronidase treated urine and bile were 49
ng/mL and 470 ng/mL, respectively. Review of the literature revealed
Fatality in the United States, San Jose, one paper from Denmark in 2009 of an 18-year-old woman who died of
California, County of Santa Clara a fatal Bromo-DragonFLY overdose and the reported femoral blood
concentration was 4.7 ng/mL (MF Andreasen et al., 2009).
Michelle A. Jorden, MD*, Santa Clara Medical Examiner, 850 Thorton Since October 2009, rare lethal overdoses were reported from the
Way, San Jose, CA 95128; Lee M. Blum, PhD, NMS Labs, 3701 Welsh distributed batch and to our knowledge this case represents the only
Road, Willow Grove, PA 19090; and Joseph Corvo, BS, NMS Labs, 3701 United States fatality resulting from Bromo-DragonFLY. The decedent’s
Welsh Road, Willow Grove, PA 19090 brother and his girlfriend were admitted to the hospital for observation,
and luckily recovered from their drug trip, although both were
The goal of this presentation is to educate the forensic community experiencing effects of the drug hours later. Both parties reported the
of overdoses with rare chemicals used by young adults. drug trip was long lasting and not a comfortable experience.
This presentation will impact the forensic science community by In summary, this case illustrates the combined efforts of the medical
illustrating and emphasizing the importance of a thorough scene examiner-coroner office and the toxicologist to identify the substance
investigation, keeping an open mind to the curiosity of young adults and which led to the sudden death of a young adult experimenting with a
drug experimentation, and good communication with the consulting purchased, non-controlled drug from overseas. Although our case
laboratory. represents the only reported fatality from Bromo-DragonFLY in the
Like LSD, Bromo-DragonFLY is a psychedelic hallucinogenic drug United States, it serves to illustrate and emphasize the importance of the
that is extremely potent. In 1998, Matthew Parker synthesized Bromo- combined efforts of different agencies to help render a cause and manner
DragonFLY and because the molecule’s structure resembled a fly, it was of death.
nicknamed FLY. Bromo-DragonFLY is a psychedelic phenethylamine Bromo-Dragonfly, Overdose, Drug Expermientation
and a non-subtype selective 5-HT2 (serotonin) agonist, considered less
potent than LSD, but exhibits a longer duration of action and can last for
up to two to three days. G115 Sudden Unexpected Infant Death:
The drug is ingested and the mechanism of drug toxicity is unclear,
but based on numerous reports from individuals experimenting with this Lymphocytic Meningoencephalitis With
particular drug and their side effects, the mechanism of action appears to Multiple Retinal Hemorrhages
involve a severe peripheral vasoconstriction. Delayed onset of seizures,
gangrenous extremity involvement, and extremely bad trips have been Patrick E. Lantz, MD*, Wake Forest University, School of Medicine,
reported with one drug trip being described as “It was like being dragged Department of Pathology, Medical Center Boulevard, Winston-Salem,
to hell and back again many times. It is the most evil thing I’ve ever NC 27157-1072; Amy M. Durso, MD, Professional Pathology Services,
tried. It lasted an eternity.” One Science Court, Suite 200, Columbia, SC 29203; and Ryan T. Mott,
In September 2009, the Santa Clara County Medical Examiner MD, Department of Pathology/Wake Forest University Health Sciences,
Office was called to the scene involving the sudden death of an otherwise Medical Center Buolevard, Winston Salem, NC 27157-1072
healthy 18-year-old white male. According to the investigation, he was
experimenting with and ingesting a new drug called 2C-B-FLY, which After attending this presentation, attendees will learn how multiple
had been purchased through the internet, with his brother and his retinal hemorrhages extending to the ora serrata are not diagnostically
brother’s girlfriend. The decedent’s brother stated that the decedent specific for abusive head trauma (shaken baby syndrome).
ingested the least amount of the drug. Over the next two to three hours, The presentation will impact the forensic science community by
the decedent appeared to be having a “difficult trip” then underwent expanding the list of conditions in infants associated with multiple
seizure-like activity and became unresponsive. The decedent could not retinal hemorrhages that extend to the periphery of the retina.
be resuscitated by emergency services and expired. The autopsy This presentation will inform attendees of something they do not
examination revealed an unkempt white male whose autopsy was know–multiple retinal hemorrhages, involving the peripheral retina and
unremarkable except for marked pulmonary edema, a non-specific extending to the ora serrata in infants, are not specific for abusive head
finding seen in drug overdose cases and a thymic cyst. Because the trauma (shaken baby syndrome).
medical examiner had no experience with 2C-B-FLY, additional insight
Numerous authors contend that specific ophthalmological findings apparent despite IHC and PCR testing for enteroviruses and
in infants and young children with abusive head trauma (AHT) include parechoviruses. Of particular interest, this infant had numerous retinal
numerous retinal hemorrhages that extend far into the periphery of the hemorrhages in the left globe distributed posteriorly, equatorially, and
retina. Listed non-traumatic causes of retinal hemorrhages— peripherally—a finding considered by many authors unique to AHT and
coagulopathy, sepsis, meningitis, vasculopathies, increased intracranial indicative of repetitive acceleration-deceleration injury (shaken baby
pressure, and cardiopulmonary resuscitation—reportedly do not result in syndrome). It is imperative that forensic pathologists not equate multiple
the multiplicity and peripheral distribution of the hemorrhages retinal hemorrhages with a peripheral distribution exclusively with AHT.
associated with AHT. Postmortem ocular findings must not be interpreted in isolation, but
This case presents a 7¾-month-old male infant with multiple retinal correlated with the circumstances of the death plus the anatomic and
hemorrhages extending to the ora serrata who died suddenly and histopathologic findings.
unexpectedly from severe, diffuse lymphocytic meningoencephalitis. Retinal Hemorrhages, Lymphocytic Meningoencephalitis, Abusive
He had had rhinorrhea and upper respiratory congestion for about two Head Trauma
weeks. His mother had been giving him acetaminophen every four
hours. Otherwise, he had been healthy. He was placed down for a nap
around 2:30 p.m. and was found unresponsive at about 3:00 p.m. G116 Parietal Pseudofracture in Children
Resuscitative efforts were begun immediately. A call was made to 911
at 3:05 p.m. and EMS arrived at 3:13 p.m. He was transported to the
Suggesting Non-Accidental Trauma: A
emergency department (ED) and arrived at 3:35 p.m. He was Report of Two Cases and Review of
pronounced dead at 4:07 p.m. following 32 minutes of resuscitative the Literature
efforts in the ED.
The medicolegal autopsy was performed 17 hours after he was Pauline Saint-Martin, MD*, and Camille Rerolle, MD, Hopital Trousseau,
pronounced dead. There was no evidence of trauma, skull fractures, Service de Medecine Legale, CHRU TOURS, TOURS, 37000, FRANCE;
intracranial hemorrhages or injury of the brain or spinal cord. Thierry Lefrancq, MD, Le Vauban, BP 549, 16 rue Clerget, NEVERS,
Microbiological cultures of blood, trachea and lung were non- 58009, FRANCE; and Patrick O. Byrne, MD, Service de Medecine
contributory. A skeletal survey did not reveal any evidence of acute or Legale, Hopital Trousseau, CHRU TOURS, TOURS, 37000, FRANCE
healing fractures. Subsequent toxicological analysis did not detect any
licit or illicit drugs that caused or contributed to his death. After attending this presentation, attendees will learn the
Postmortem monocular indirect ophthalmoscopy detected multiple characteristics of variation in sutures of the pediatric skull that may make
retinal hemorrhages. The fundal hemorrhages in the left eye were over it difficult to distinguish from real fractures based on imaging criteria
the posterior pole extending past the equator and abutting the ora serrata alone.
in all four quadrants; three small retinal hemorrhages were in the right This presentation will impact the forensic science community by
globe. emphasizing the legal complications caused by mistaking normal
His calvarial dura was smooth with areas of hyperemia and variation of the pediatric skull for fracture and by aiding in better
congestion of dural vessels, but no subdural extravasated blood or understanding of these pseudofractures of the skull in infants.
membranes were present. The dural venous sinuses were patent and the Introduction: Two cases of infants who died at home are reported.
leptomeninges had no areas of extravasated blood. The cerebrum had a Both were previously healthy and had no history of trauma according to
well-defined grey-white junction with no lesions in the cortex, white the parents. As in all suspected cases of SIDS, a complete autopsy was
matter, or subcortical nuclei. The cerebral ventricles were of normal performed. For both cases, radiographic or computed tomography (CT)
caliber and the ependymal lining of the ventricles appeared normal for scan findings were initially interpreted as parietal fractures and raised the
age. The brainstem was normally developed with no gross possibility of non accidental trauma.
abnormalities. The cerebellum exhibited normal folia, white matter, and Case reports: The first case was a 3-month-old female child who
dentate nuclei. The spinal cord had no areas of hemorrhage or exudates. was found dead at home by her mother. An autopsy was performed the
Microscopically, the cerebrum, brainstem, and cerebellum showed same day. A skeletal radiographic survey showed two linear
a multifocal lymphocytic infiltrate with numerous microglial nodules radiolucencies in the parietal region mimicking a fracture of the right
and neuronophagia. The inflammatory process involved the cerebral parietal bone. At autopsy there was an H-shaped abnormality of the right
grey and white matter (including the basal ganglia), brainstem grey parietal bone with no associated soft tissue swelling. The brain was
matter, and cerebellar white matter. The brainstem involvement was normal. There were severe pulmonary lesions and a test for the
diffuse, with inflammatory foci in the midbrain, pons, and medulla; the respiratory syncytial viral antigen was positive. Histological sections of
spinal cord was not involved. No viral inclusions or areas of necrosis the parietal bone showed two vertically unossified membranous strips
were seen. There was lymphocytic involvement of the cerebral linked by a horizontal membranous strip. Death was attributed to
leptomeninges and small perivascular lymphocytic collections were just pulmonary infection. The second case was a 6-month-old male child
deep to the ependyma. No significant ventriculitis was present. who was found dead at home by his mother. An autopsy was performed.
Immunohistochemical (IHC) stains for CD4 and CD8 showed a A bone window CT scan showed a linear defect in the left parietal bone.
multifocal T-cell inflammatory infiltrate within the cerebral parenchyma At autopsy, no scalp swelling or bruising was noted. The rest of the
and around blood vessels. An IHC stain for CD20 highlighted a smaller autopsy was normal. Microscopic sections of the decalcified parietal
number of B-cells around blood vessels and within the parenchyma. The bone demonstrated neither inflammatory infiltrate nor periosteal
ICH stain for CD68 highlighted the microglial nodules and IHC stains reaction. The findings were consistent with an unossified membranous
for CMV, HSV-1, and HSV-2 were negative. The Centers for Disease strip. Cause of death was not identified.
Control performed IHC testing for panentero viruses and EV71 plus Discussion: According to the literature, the parietal bone is the
polymerase chain reaction (PCR) for enterovirus and parechovirus—all most common fracture site in children, in both accidental and non-
were negative. accidental trauma. However, an extensive study of the embryogenesis of
Meningoencephalitis is a rare complication of common infantile the parietal bone was made by an author who discovered a variety of
viral infections. Most viral infections with central nervous system anomalous parietal suture, described as failure of ossification of a strip
manifestations cause either meningeal involvement, namely aseptic of membranous parietal tissue. These normal variations or
meningitis, or a mild clinical syndrome of meningoencephalitis rather pseudofractures are rare and may simulate skull fractures, especially in
than a fatal form of encephalitis. The causative agent in this case was not live infants when histological examination is not available. Overlooking
a fracture of the pediatric skull is a serious situation, but to mistake pharmacodynamic drug interactions mechanism and the possible
normal variation for a skull fracture may cause legal complications as explanation in determining the cause of death in this case will
well. Awareness of differential diagnosis such as vascular markings, be discussed.
sutures, and artifacts that may masquerade radiographically as skull Methadone, Cocaine, Synergic Effect
fractures in infants is essential for the forensic pathologist.
Membranous Unossified Strip, Skull Fracture, Non-Accidental
Trauma G118 Sudden Death Due to Dengue Fever in an
8-Month-Old Baby
G117 Methadone and Cocaine Related Death in A Mohd Shafie Bin Othman, MD*, Forensic Department Hospital Raja
Young Boy: A Case Report Permaisuri Bainun, Jalan Hospital 30450, Ipoh, 31350, MALAYSIA; and
Santina Cantatore, Dania De Carlo, MD, and Margherita Neri, PhD,
Francesco Ausania, MD, Institute of Forensic Medicine, Catholic Department Forensic Pathology, University of Foggia, Viale degli
University, School of Medicine, Ro, largo Francesco Vito 1, Rome, Aviatori 1, Foggia, 71100, ITALY
ITALY; Massimo Senati, PhD, Largo Francesco Vito 1, Rome, ITALY;
Nadia Fucci, PhD, largo francesco vito 1, Rome, ITALY; Antonio Oliva, The goal of this presentation is to present a case of postmortem
PhD*, Institute of Forensic Medicine, Catholic University, School of diagnosis of dengue related death in a suspect sudden infant death
Medicine, Ro, Largo Francesco Vito 1, Rome, ITALY; and Pietrantonio syndrome.
Ricci, PhD, Università degli Studi Magna Grecia Catanzaro, Viale This presentation will impact the forensic science community for
Europa - Località Germaneto, Catanzaro, ITALY the postmortem diagnosis of dengue fever like cause of death in a suspect
case of SIDS.
After attending this presentation, attendees will learn of the Dengue virus (DENV) infection is caused by one of four
possibility of cases where a synergic effect of cocaine and methadone antigenically distinct but related single stranded, positive-sense RNA
could be assumed as the cause of death. viruses in the family Flaviviridae. This virus is transmitted by mosquito
This presentation will impact the forensic science community by vectors, primarily Aedes aegypti. Four serotypes (DENV-1, DENV-2,
the discussion regarding pharmacokinetic and pharmacodynamic drug DENV-3, and DENV-4) circulate worldwide. Dengue fever is one of the
interactions between cocaine and methadone. most significant re-emerging tropical diseases; it is now endemic in more
Background and Learning Objective: In recent years, a than 100 countries in Africa, the Americas, the Eastern Mediterranean,
significant increase in the number of fatal intoxications with methadone South-East Asia, and the Western Pacific. South-East Asia and the
has been reported in Italy. The abuse of methadone is most frequently Western Pacific are the most seriously affected. Dengue causes a severe
seen in conjunction with the abuse of other drugs. Cocaine and flu-like illness and sometimes a potentially lethal complication called
methadone are rarely co-intoxicants in cases of combined drug toxicity. dengue hemorrhagic fever (DHF). Dengue hemorrhagic fever (DHF) is
The interpretation of blood methadone concentrations alone or combined a potentially deadly complication that is characterized by high fever,
with other psychoactive drugs requires careful and accurate often with enlargement of the liver, and in severe cases circulatory
consideration of the subject’s potential chronic use of and tolerance to failure. The illness often begins with a sudden rise in temperature
the drug. Moreover, determining the cause of death in methadone and accompanied by facial flush, and other flu-like symptoms. The fever
cocaine positive cases requires a strong correlation with autopsy results usually continues for two to seven days and can be as high as 41°C,
and investigative findings. The goal of this study is to discuss the possibly with convulsions and other complications. Frequently fatal
possible mechanisms and eventually the synergic effect of cocaine and cases of dengue death occur in the hospital. The clinical features of
methadone in causing the death of a young boy. dengue fever vary according to the age of the patient. Infants and young
Case Report: A 15-year-old young man was found dead during the children may have a fever with rash. Older children and adults may have
early morning in his bed at home. Police investigations ordered by the either a mild fever or the classical incapacitating disease with abrupt
public prosecutor revealed that the young boy, the night before, had used onset and high fever, severe headache, pain behind the eyes, muscle and
cocaine and methadone for the first time. joint pains, and rash. Some cases develop much milder symptoms which
Results: At the autopsy, lungs were edematous and congested with can be misdiagnosed as influenza or other viral infection when no rash
absence of major diseases. Main findings at the histological or retro-orbital pain is present. When dengue infections proceed to DHF
investigation were widespread myocardial interstitial edema and focal symptoms, DHF causes vascular leak syndrome which includes fluid in
vascular congestion. Toxicological analysis detected cocaine, the blood vessels leaking through the skin and into spaces around the
methadone, and related metabolites at the following concentrations. lungs and belly. This fluid loss and severe bleeding can cause blood
Blood: benzoylecgonine = 50 nanograms/ml; cocaine=40 pressure to fall, then Dengue Shock Syndrome (DSS) sets in, which has
nanograms/ml; methadone=274 nanograms/ml; EDDP = 166 a high mortality rate. In babies a pauci-symptomatic fatal case could be
nanograms/ml. Urine: benzoylecgonine = 9000 nanograms / ml, cocaine confused with a SIDS or a homicide. The case presented concerns an 8-
= 153 nanograms / ml methadone = 300 nanograms/ ml; EDDP = 200 month-old male infant was found unresponsive during a nap in his
nanograms/ml. Traces of cocaine were also found in the nasal mucosa. nursery school. The baby was quickly taken by ambulance but was
Conclusions: It is well known in forensic field that it can be very declared dead on arrival at the hospital. Body was cold. The police took
difficult to determine what mechanism(s) are responsible for drug information by the nursery school teacher: three hours prior to death, the
interactions especially in cases as such, where the deceased cannot be child was given plain water through a bottle before being put to sleep on
considered as habitual drug-user. Moreover, it should be taken into a mattress on the floor, the baby frequently slept in prone position. The
account that the presence of methadone is often an incidental finding infant had been cared for by the nursery school since the age of three
during postmortem examination which is unrelated to the cause of death months. There was a history of mild fever illness for the previous weeks
and that postmortem measurements of methadone or its metabolite before the death and he was being treated with antipyretic drugs. The
cannot be used in isolation to identify which deaths are associated with prosecutor began an investigation of the nursery school, arranged the
methadone toxicity. Very little information is available from the autopsy on the body to clarify the exact mechanism of death: SIDS,
literature regarding methadone-cocaine co-intoxications. In our case we accident, or homicide? The autopsy was performed six hours after death.
can only hypothesize an interaction between these drugs on different The infant was well hydrated and well nourished, with body length of 68
organs, such as heart and central nervous system. Pharmacokinetic and cm and weighed 6920 g. He was pale with mild peripheral cyanosis
noted. Faint lividity was still noticeable at front part of body. There was cases); respiratory (15 cases); endocrine/ metabolic (12 cases);
blood-stained fluid oozing out of the nostrils and mouth on turning the gastrointestinal (4 cases); central nervous system (4 cases).
body. There wasn’t a rash or petechial hemorrhages on the skin. Fundal Autopsy protocol were based on Perinatal Autopsy Manual.
ophthalmoscopic examination didn’t show retinal hemorrhage. No signs Washington, D.C.: Armed Forces Institute of Pathology, 1983, and on
of external injury were detected, with the exception of puncture marks at Paediatric Autopsy Techniques - Enid Gilbert-Barness and Diane E.
the dorsum of both hands in a temptative of resuscitation. All the Debich-Spicer in Handbook of Pediatric Autopsy Pathology, Humana
internal organs were congested. Pleural cavities contained 12 cc of Press pp.7-74, 2005. From a histological point of view, according to
yellow fluid. The lungs were edematous with areas of hemorrhage 2,875 fetal and pediatric autopsies, the following morphological
mainly seen on the right side. The upper airway was filled with froth and pancreatic parameters were examined: (1) lobular architecture; (2)
admixed with blood-stained fluid. Pericardial cavity contained 2 cc of interstitial thickness; (3) number, branch and volume of ductular-acinar
yellow fluid. The heart showed few epicardial petechiae. Abdominal units; (4) number, size and cytology arrangement of islet (quantitative
cavity contained 15 cc of yellow fluid. Stomach was empty. Liver was relation between α, β, and δ cells); (5) inflammatory infiltrates; and, (6)
congested and had beefy appearance on cut sections. Other organs were heterotopic erythropoiesis.
unremarkable except of edema. Histopathologic examination showed in This analysis was performed on serial sections stained with
heart samples wide foci of early contraction bands necrosis, colliquative hematoxylin-eosin, Alcian-PAS, Mallory’s trichrome and Giemsa and
myocytolysis grade II, perivascular and interstitial infiltration of partly investigated immunohistochemistry using antibodies anti-insulin
lymphocytes, monocytes and plasmacells. Lungs present alveolar septa and anti-glucagon.
mildly thickened by edema and capillary congestion, alveolar edema; Results: In the context of explained sudden natural death in the
lymphocytes, monocytes and plasma cells infiltrates septa and bronchial first year of life, pancreatic histological examination has allowed us to
walls. In some fields, also numerous endoalveolar erythrocytes were identify 11 cases related to endocrine/metabolic disease, of which, in
observed. In liver, kidney, and spleen samples, there were perivascular nine cases, were interested the islets of Langerhans (endocrinous
mononuclear cells infiltration. An immunohistochemical study using pancreas), and in two cases ductular-acinar units (exocrine pancreas).
antibody anti CD 3, CD4, CD 8, CD 20 and CD68 for the tipization of The endocrine/metabolic diseases involving endocrinous pancreas
leucocytes infiltrations was performed. Serological dengue screening were: glycogenosis (type 1b and 2)(five cases); maternal diabetes (2
using captured ELISA was positive for IgM but negative for IgG. The cases); nesidioblastosis (2 cases (1 case in monochorionic twin)). The
case showed that dengue infection may be asymptomatic or endocrine/metabolic diseases involving the exocrine pancreas were:
paucisyntomatic before a sudden death, so dengue fever should be cystic fibrosis (2 cases) macronesia and polynesia were observed in
included in the differential when a forensic pathologist must discern pancreas of both patients with glycogenosis and in children of diabetic
between a SIDS a homicide or a death related-dengue, particularly in mothers, these aspects were due to hyperplasia of the α-cells in patients
endemic areas for dengue, like Malaysia. with glycogenosis, and β-cell hyperplasia in children of diabetic
Dengue Fever, Histological Findings, Postmortem Diagnosis mothers.
In these cases also present were cytoatipism of β-cell and
eosinophilic granulocyte infiltration of the islets. In subjects with
G119 Sudden Death in the First Year of Life: The nesidioblastosis there was only a diffuse polynesia neoformation of islet
from duct epithelium.
Importance of Pancreatic The cystic ectasia of the ductular-acinar structures associated with
Histomorphological Analysis pink inspissated secretion was observed in cystic fibrosis.
Discussion and Conclusion: A complete autopsy is essential to
Francesco Paolo Busardo, MD*, Institute of Legal Medicine, Via Del establish the causes of sudden explained death in the first year of life.
Vespro, 129, Palermo, 90100, ITALY; Stefania Zerbo, MD, Institute of This approach allows to sample, for histomorphological examination,
Legal Medicine, Via Del Vespro, 127, Palermo, 90100, ITALY; Antonina organs such as the pancreas that are almost always free of
Argo, Via Del Vespro 127, Palmero, 90100, ITALY; Liliya Gutsul, MD, macroscopically visible changes.
Instituto, Via Del Vespro, 127, Palmero, 90100, ITALY; Paolo The results of the study show that, in addition to the consolidated
Procaccianti, Palermo University, Via Del Vespro, N. 127, Palermo, sampling of pancreas in autopsy, a complete and focused
90100, ITALY; and Emiliano Maresi, Via Del Vespro 127, Palermo, histomorphological study as suggested, allowing the identification of
90100, ITALY endocrine-metabolic anomalies, such as glycogenosis, nesidioblastosis,
and cystic fibrosis, only rarely reported in the literature as a cause of
After attending this presentation, attendees will be able to better sudden death in the first year of life.
understand the importance of pancreatic histomorphological This research demonstrated that, glucose postmortem levels in
examination after a complete autopsy in sudden infant death, to plasma and vitreous are not reliable for identifying potential endocrine-
discriminate between the explained natural sudden death and natural metabolic diseases, certainly the histomorphological data of the pancreas
idiopathic sudden death (SIDS). is the most reliable.
This presentation will impact the forensic science community by Glycogenosis, Nesidioblastosis, Sudden Infant Death
discussing the role of endocrine/metabolic pancreas disease as cause of
sudden infant death, providing valid evaluation parameters to the
diagnosis.
Material and Method: From 1990 to 2009, 175 autopsies (137
males and 43 females) were performed on infants suddenly dying of
natural causes within the first year of life. The diagnosis of sudden
natural death has been established through a complete autopsy and
investigation including scene examination, review of family, social and
medical history and toxicology studies. The age ranged between 2 and
273 days (median 42 days).
In 19 cases, death was unexplained (SIDS) while in 156 cases, it
was due to congenital or acquired diseases (explained sudden infant
death), primarily involving different systems: cardiovascular (121
G120 Isolated Coronary Anomalies and Sudden manifestation of the disease, it is precipitated by effort and depends on
ischemic damage within the related myocardium. Recognition during
Death in the Young life of these anomalies, by the use of non-invasive procedures, is
mandatory to prevent the risk of SD and to plan the screening in
Emiliano Maresi*, and Livio Milone, PhD, Via Del Vespro, N. 127, competitive athletes.
Palermo, 90100, ITALY; Paola Pugnetti, MD, Department of Coronary Artery Anomalies, Juvenile Sudden Death, Forensic
Biotechnology and Legal Medicine, Section of Legal Medicine, Via Del Pathology
Vespro, n. 129, Palermo, 90127, ITALY; Francesco P. Busardo, MD,
Institute of Legal Medicine, Via Del Vespro, 129, Palermo, 90127,
ITALY; Nunzia Albano, MD, Pierangela Fleres, MD, Via Del vespro 127,
Palermo, 90100, ITALY; and Paolo Procaccianti, Palermo University,
G121 Pathologic and Anthropologic
Via Del Vespro, n. 127, Palermo, 90100, ITALY Manifestations of Documented Repetitive
Blunt Trauma in a Child Abuse Case
After attending this presentation, attendees will be able to better
understand the importance of coronary examination (origin, course, and Pramod Gumpeni, MD*, Jason M. Wiersema, PhD, and Luis A. Sanchez,
lumen canalization) during autopsy of young people suddenly dead, to MD, Harris County Institute of Forensic Sciences, 1885 Old Spanish
identify coronary artery anomalies. Trail, Houston, TX 77054
improving knowledge of natural causes of juvenile sudden death (SD). After attending this presentation, attendees will see the pathologic
Background: Coronary artery anomalies (CAAs) had been some and anthropologic manifestations of repetitive blunt trauma to the ribs of
of the most confusing, neglected topics in cardiology. In the 1990s, the child.
subject of CAAs underwent to profound evolution related to substantive This presentation will impact the forensic science community by
methodological changes regarding the definition, incidence, illustrating the utility of a collaborative effort in the interpretation of
morphology, clinical presentation, diagnostic work-up, prognosis, and repeated injury.
treatment. CAAs are most frequently found in association with The child had been in the care of the birth mother for the first six
congenital hearth diseases (great arteries transposition, tetralogy of years of his life and had reached all appropriate mental and physical
Fallot, common artery trunk) and hypertrophic or dilated developmental milestones. The mother placed the decedent in the care
cardiomyopathy, but can also occur in the absence of other of the decedent’s father (with whom the child had no prior contact)
cardiovascular diseases (“isolated coronary artery anomalies”). Isolated fifteen days prior to his death in the interest of fostering a paternal
CAAs are rare, found in: 0.2–2.2% of autopsies of all ages; 0.5% of relationship.
pediatric autopsies; 0.6–1.3% of coronary angiograms in adults. CAAs The decedent presented to the Harris County Institute of Forensic
represent common causes of exercise-related sudden death (SD) in Sciences (HCIFS) following his demise at a local hospital. The terminal
young people (< 35 years of age). The mechanism of SD is believed to history, provided to the HCIFS investigator by the father’s girlfriend was
be episodic myocardial ischemia. that the decedent had been repeatedly beaten about the chest by the father
Objectives: The goal of the current study is to detect the frequency, for an approximate 8-hour-period. The beating was apparently
type, and possible pathophysiology due to “isolated” CAAs in an precipitated by the child’s refusal to go to sleep. The father reported that
autopsy population of the young, suddenly dead for cardiovascular the child began exhibiting seizure-like activity after which emergency
diseases (CSD). medical services were contacted. The unresponsive decedent was
Methods: In the time interval from January 1990 to December transported to the hospital, where he was pronounced six minutes after
2009, 236 consecutive cases were collected of cardiovascular sudden arrival.
death in young people. In all of the cases, the analysis of death The birth father and his female acquaintance ultimately confessed
circumstance (most of the deaths analyzed were testified), the complete that the child was beaten in a similar manner for the duration of the two
autopsy and the toxicological essays let us establish that death was: week period during which he was in their custody. They stated that the
natural, violent, sudden. The juvenile CSD was defined as unexpected decedent would be made to sit on his knees, with his arms held up while
death as a result of natural cardiovascular causes within one hour of the father would repeatedly punch him in the left axilla and chest. After
initial symptoms in persons < 35 years of age. several days, the child exhibited pain, and the father began punching the
Results: Forty nine sudden deaths in young people were reported, decedent in the right axilla and back. In addition, the female
identified solely at autopsy and due to: right coronary artery from the left acquaintance admitted to the use of a belt to strike the decedent on the
sinus (n = 15); right coronary artery above anterior commissure (n = 11); back. The father ultimately stated that he pushed the decedent forcibly
left coronary artery from right coronary sinus (n = 3); intramyocardial into the shower, striking the back of the decedent’s head against the wall
course (n = 10); obstructive valve-like ridge in the Valsalva’s sinus and immediately prior to the onset of his seizure-like symptoms.
intra-right coronary ostium (n = 9); left anterior descending artery from Autopsy of the child showed numerous confluent contusions over
right coronary sinus (n = 1). The CAAs was either isolated (n = 43, the decedent’s torso, predominantly in the left and right axilla extending
87.8%) and associated to hypertrophic cardiomyopathy (n = 6, 12.2%). down to the flank, the upper chest, and over the mid and lower back.
In all patients (43 males and 6 female, age ranging from 13 months to 35 There were numerous abrasions over the extremities. Several contusions
years; median, 22.6), sudden death was the first manifestation of the were present over the scalp, with brain contusions identified on internal
disease and familial history was negative. The fatal outcome occurred examination. A large fibrous mass lesion consisting of resolving
after physical effort (n = 27, 55%), at rest (n = 16, 32.6%), or after hematoma, granulation tissue, and early callous formation was found in
emotional stress (n = 6, 12.4%). Unquestionable ischemic damage the left upper axilla involving the anterior bodies of left ribs 2-4. There
within the related myocardium, in the absence of obstructive coronary were also bilateral pleural effusions, with 550 cc of serosanguinous fluid
atherosclerosis or other cardiac diseases, was observed in all cases: in the left pleural cavity, and lacerations of the liver and right adrenal,
acute myocardial infarction (n = 29, 59.2%), healing myocardial with marked retroperitoneal hemorrhage. Initial x-rays of the chest
infarction (n = 4, 8.2%), healed myocardial infarction (n = 16, 32.6%). showed a heterogeneous mass lesion in the left upper chest.
In this study of Juvenile CSD, death was precipitated by isolated CAAs Per HCIFS protocol, the decedent underwent a complete skeletal
in 21% of cases. examination in search of skeletal injury. This process involved resection
Conclusion: Data from this collection confirms that isolated CAAs of the muscle and periosteum overlying the long bones, ribs, and
may account for juvenile CSD and that fatal event is frequently the first
scapulae. Skeletal trauma was limited to the ribs, and the rib cage was investigations and medical supervision for three days. All
recovered for anthropological analysis. There were multiple series of medical investigations were normal and all abnormalities
serial rib fractures displaying morphology consistent with direct disappeared spontaneously. A delivery by C-section was
impact(s) at the site(s) of the fractures. The fractures were in varied scheduled at 37 weeks of pregnancy because of previously scared
stages of healing, ranging from acute fractures with sharp margins and uterus and gestational diabetes mellitus. The woman was
no visible callus formation to the presence of large, disorganized soft admitted to the hospital one day before. The C-section delivered
calluses overlying complete transverse fractures. The array of skeletal a dead newborn who was successfully resuscitated. The mother
injuries was consistent with repeated impacts to the anterior and lateral died after resistant cardiac arrest.
chest. This case is interesting from both a medical and medico-legal point
This case provides a unique view of the effects of repetitive blunt of view.
injury directed to specific regions of the body over the span of two Pheochromocytoma is a rare tumor of the adrenal glands which
weeks, and the physiological consequences of such trauma to both bone secretes catecholamine. It can be diagnosed by the classic triad of
and soft tissue. It also illustrates the utility of a detailed terminal history symptoms —headache, sweating, and tachycardia— which result from
in the interpretation of blunt force injury. arterial hypertension, paroxysmal high blood pressure, acute pulmonary
Repetitive Injury, Blunt Trauma, Child Abuse edema, and fatal cardio-pulmonary failure. In pregnant women, the
incidence of pheochromocytoma is very low, and its symptoms can
mimic gestational hypertension, preeclampsia, or eclampsia. Diabetes
G122 Pregnancy, Caesarean, and mellitus can be due to pheochromocytoma in pregnancy, but is seldom
the only symptom. Because of the low incidence of pheochromocytoma
Pheochromocytoma: A Case Report With a in pregnancy, any systematic/mass screening by urinary catecholamine
Fatal Outcome measurement is not requested in pregnant women, except in cases of
refractory hypertension.
Isabelle Plu, PhD*, Denis Barrès, MD, and Dominique Lecomte, PhD, From a medico legal point of view, we can presume, with hindsight,
Institut Médico-Légal, 2 place Mazas, Paris, 75012, FRANCE that the gestational diabetes mellitus was a symptom of the
pheochromocytoma, as was the malaise and the low blood pressure
After attending this presentation, attendees will be aware of the which happened during the gestations. However these features are not
clinical, physiological, diagnostic, and therapeutic features of specific to pheochromocytoma, and are frequent in pregnancy, which
pheochromocytoma during pregnancy. explains the difficulty in diagnosis.
This presentation will impact the forensic science community by Conclusion: This case is unusual. First, it led to maternal death;
explaining how pheochromocytoma can cause sudden death (maternal and, second, the diagnosis of the tumor was postmortem, being
and fetal death) in pregnant women if the condition is undiagnosed and unnoticed during the management of pregnancy. It can also presumed
left untreated. From this case report, attendees will be able to identify that the pheochromocytoma was asymptomatic between the two
the clinical milestones which can indicate medical malpractice and pregnancies of the patient since no medical history was reported in her
which can determine whether the fatal outcome was predictable. medical records.
The subject of this presentation is a 43-year-old full term pregnant Pheochromocytoma, Cesarean, Maternal Death
woman who was scheduled for a cesarean delivery in October 2009. At
the start of the C-section, she developed a sudden and malignant high
blood pressure with hemoptysis, sweat, and tachycardia. The C-section G123 Infant Death Evaluation: What is the
delivered a dead newborn who was successfully resuscitated. The
mother died after persistent cardiac arrest.
Constellation of Abusive Injuries?
A judicial autopsy was requested. It revealed an acute pulmonary
edema which explained the death and a voluminous tumor of the left M.G.F. Gilliland, MD*, Brody School of Medicine at East Carolina
adrenal gland which was necrotic and hemorrhagic suggesting a University, Pathology & Lab Medicine, Brody 7S-10, Greenville, NC
pheochromocytoma. The diagnosis of pheochromocytoma was 27858-4354
confirmed by pathological analyses.
The magistrate requested the obstetrical records of the patient be After attending this presentation, attendees will be able to identify
studied. The patient’s first pregnancy was in 2005-2006 and her last components of a constellation of abusive injuries that can be used to
pregnancy was in 2009. According to these medical records, the woman reliably identify a subset of abusive injuries.
had a no serious medical history: This presentation will impact the forensic science community by
providing knowledge of components of a constellation of abusive
• During her first pregnancy (2005-2006), the patient developed injuries that can be used to reliably identify a subset of abusive injuries
gestational diabetes mellitus which was successfully treated by allowing them to more competently perform determinations of cause and
controlling diet. Throughout the follow-up during the pregnancy, manner of death.
blood pressure and cardiac rhythm were stable. At 31 weeks of Hypothesis: No single finding is pathognomonic of abusive
pregnancy + 5 days, the patient had an episode of malaise during injuries to infants and children. Findings suggestive of abusive injuries
a fetal ultrasound, which resolved spontaneously. must be used in conjunction with other information to reliably determine
• The baby was delivered by C-section before labor in January that a death is the result of abusive injuries. Additional investigative
2006. C-section was performed because of low fetal heart rate information about the reliability or number of histories provided by
and failure to induce labor. The newborn was healthy and the caregivers has been described as useful in this regard. Investigative
patient’s diabetes mellitus disappeared after the delivery. information about delays in seeking medical attention has been seen
• During her second pregnancy (2009), the patient developed more commonly in abusive injuries.
gestational diabetes mellitus which was treated by controlling her Materials: Information about the circumstances surrounding
diet and insulin (16 weeks of pregnancy). In July 2009 (at 29 collapse or death, medical treatment, past medical history, law
weeks of pregnancy + 6 days), the patient had a drop in blood enforcement investigation, and social service information (when
pressure with hypoglycemia and a low fetal heart rate was available) was used in a prospective study of 169 child deaths with
detected. The patient was admitted to hospital for further autopsy and postmortem ocular examinations to make cause and manner
determinations. The patterns of ocular and systemic injuries in children
dying as the result of non-accidental injury were compared with those G124 Utility of Whole Body Postmortem
found in injuries from motor vehicle accidents, falls, asphyxia and in
natural disease. The immediate causes of death included: 76 (45%)
Computed Tomography Imaging in
intentional injuries, 36 (21%) inadvertent injuries, 47 (28%) natural Detection of Elder Abuse: Comparison
causes, and 10 (6%) undetermined causes. With and Potential Substitution for
Results: The triad of findings of subdural hemorrhage, brain
edema, and retinal hemorrhages was seen in 47 of the total 76 (62%)
Standard Autopsy
non-accidental injury deaths and in eight inadvertent injury deaths of the
total 36 (22%). The triad was not seen in any of the 46 natural deaths or Zabiullah Ali, MD*, Office of the Chief Medical Examiner, 111 Penn
any of the ten classified as undetermined deaths. Treating these three Street, Baltimore, MD 21201; Barry Daly, MD, and Nancy Knight, PhD,
findings (the “triad”) as a “laboratory test” to identify abusive injuries University of Maryland Medical Center, Radiology Department, 22 South
did not meet criteria for reliability of diagnosis. The sensitivity of the Greene Street, Baltimore, MD 21201; and David R. Fowler, MD, Office
presence of the triad was only 62% in detecting non-accidental injuries. of the Chief Medical Examiner, 111 Penn Street, Baltimore, MD 21201
The specificity of the absence of the triad in inadvertent injuries
was 78%. After attending this presentation, attendees will be familiar with the
Histories of the circumstances of change of status have been value of CT Imaging in the detection or exclusion of injuries associated
important in identifying abusive injury. The original recognition of the with elder abuse.
“battered baby” followed inquiry into the phenomenon of absent or This presentation will impact the forensic science community by
changing histories in the presence of subdural hemorrhages and demonstrating how whole body CT imaging can be an efficient triage
extremity fractures. In this population, the sensitivity of finding tool that assists the medical examiner’s decision on whether to proceed
inconsistent histories with the presence of the triad was 80%. The to conventional autopsy in suspected cases of elder abuse.
negative predictive value of finding a consistent history when the triad Elder abuse (EA) contributing to death is a crime that is difficult to
was absent was 88%. The relative risk of the triad being found with an exclude without a full conventional autopsy (CA), even where
inconsistent history was 4.56 with confidence limits of 2.53-8.20 and a- allegations of abuse are limited to non-physical issues. The potential for
value << 0.01. use of whole-body postmortem CT (PMCT) as a triage tool to determine
Delay in seeking treatment has also been identified as a marker of the need for CA based on detection of injuries suggestive of physical
abusive injuries. In this population information was available to identify abuse was investigated.
the interval between onset of symptoms and presentation for medical Method and Materials: Fifty-two decedents (12 M, 40 F; mean
attention in 127 deaths. This information was then used to look at the age 76 y, range 52-93 y) with associated allegations of EA had PMCT
deaths with the triad of retinal hemorrhages, subdural bleeding, and brain and subsequent CA by state medical examiners within 24 hours of death.
swelling. PMCT scans were interpreted by radiologists experienced in forensic
imaging. Sensitivity of PMCT for injuries suspicious for abuse and other
Triad < 24 hours 24-72 hours > 72 hours Total major findings were determined with CA as the standard of reference.
No triad 55 14 4 73 Results: PMCT was concordant with CA for evidence or absence
Triad 38 13 3 54 of elder abuse in all cases. PMCT demonstrated multiple previously
Total 93 27 7 127 unreported fractures of varying age consistent with EA in only 1/52
cases. Recent fractures consistent with cardiac resuscitation (CPR) or
Additional investigative information was used to determine the typical accidental trauma were noted on PMCT in 18/52 (35%) and 5/52
cause and manner of death to distinguish abusive injuries from (10%), respectively, but at CA were undetected in 7/18 (39%) and 4/5
accidental injuries. Among children having the triad, delay in seeking (80%), respectively. PMCT misinterpreted an undisplaced cervical
treatment was only seen with abusive injuries. fracture in the setting of severe degenerative disease. Cause of death was
determined by PMCT in 24/52(46%) and by CA in 50/52(96%) cases.
Manner < 24 hours 24-72 hours > 72 hours Total Conclusion: PMCT is reliable for the detection or exclusion of
Abusive 30 13 3 46 skeletal injuries suspicious for elder abuse and may be used in
Non-abusive 8 0 0 8 correlation with history and external examination to determine the need
Total 38 13 3 54 for CA where allegations or suspicion of abuse are raised. Acute upper
anterior bilateral rib fractures were noted in all decedents who underwent
Summary: Deaths with an inconsistent history, delay in seeking full CPR, likely related to osteopenia/osteoporosis. PMCT was not
medical attention, and autopsy findings including the triad of subdural reliable for determination of specific cause of death in this
hemorrhage, brain edema, and retinal hemorrhages can be reliably used decedent group.
to identify deaths which are more likely to be the result of inflicted Elder Abuse, Computed Tomography, Autopsy
injury. Thorough investigation and complete autopsy findings must be
used to establish whether or not a particular child’s death was caused by
inflicted injuries.
Review of the findings and investigative information in this study
allows identification of a constellation of reliable markers of abusive
injuries, and components of the constellation needed to avoid wrongful
accusations of injury. The components include: triad of retinal
hemorrhages, subdural bleeding, and brain swelling; inconsistent or
multiple histories; and delay in seeking medical attention.
Abusive Injuries, Wrongful Accusation, Child Deaths
G125 Findings of the Examinations of Suspected This presentation will impact the forensic science community by
emphasizing the expected wound locations and patterns inflicted by large
Animal Cruelty Cases Submitted to members of the cat and dog families.
the Birmingham Jefferson County On December 25, 2007, a four-year-old Siberian female tiger
Animal Control escaped its enclosure in the San Francisco Zoo and focused its attack on
two young males. One of the males was fatally mauled while his
Ubicelio Martin-Orozco, EDV*, Ciudad Juarez Autonomous University, companion was injured. Responding San Francisco Police Department
Benjamin Franklin# PRONAF Zone, Juarez, 32315, MEXICO; Barbara officers came in contact with the escaped tiger and used their service
Benhart, DVM, Jefferson County Animal Control, 6227 5th Avenue pistols to subdue it.
North, Birmingham, AL 35212; and Elizabeth A. Gardner, PhD, The victim was autopsied at the San Francisco Medical Examiner’s
University of Alabama Department of Justice, UBOB 210, 1530 3rd Office and showed evidence of large animal bites and crushing trauma
Avenue, South, Birmingham, AL 35294-4562 typical for a large cat attack including biting of the posterior upper
body/neck, fracturing of the neck, and “abrasion rings” surrounding the
After attending this presentation, attendees will understand some of incisor wounds. Toxicology was positive for cannabinoids and ethanol.
the basic principles of the elements necessary in the investigation of A necropsy of the tiger was done by the San Francisco Zoo
animal cruelty, including characteristic injury patterns and examples of veterinarian, with pertinent body parts (head, paws, stomach contents,
the practical application of comparative forensic pathology. and tail) delivered to the San Francisco Medical Examiner’s Office. The
This presentation will impact the forensic science community by stomach contents contained no body parts, and the back claws showed
shedding new light on an old technique by showing how both evidence of shredding of the nails which most likely occurred as the tiger
macroscopic and microscopic injuries are a key aspect of an animal propelled itself up the textured cement wall of the enclosure. It was
cruelty or animal abuse investigation. The techniques developed in this determined that the tiger was struck three times by gunfire (once in the
project have the potential to be applied in crime profiling to track animal left frontal sinus, twice in the thoracic cavity with one of the shots being
abuse, which may be a predictor for child abuse or domestic violence. the fatal strike to the heart and lung). The bullet in the frontal sinus was
The objective of this project was to establish routine performance of recovered at the San Francisco Medical Examiner’s Office before
medical examinations, necropsies, and histopathology as the first step in impressions were taken of both the maxillary and mandibular jaws.
establishing a solid case of animal abuse. Plaster casts of the jaws were made for metric comparison to the
Comparing the changes in the morphology of the lesions observed patterned injury of the deceased young man.
in this study with the ones that are in current forensic pathology provided Large feline attacks on humans are quite rare, with the most
a unique opportunity to record the differences between human pathology common attacks by mountain lions in the western United States. This
and animal pathology. The increase in knowledge in the field of forensic presentation will demonstrate features typical of large predatory cat
veterinary medicine gives this study merit, because those differences are attack, as well as techniques used in taking impressions of the tiger’s
currently underdeveloped in veterinary science. jaws to fabricate study models. Also briefly compared will be large cat
In general pathology, it is assumed that humans and animals often attacks to large dog attacks.
exhibit similar physiopathology. For example, in gunshot cases, there This is the first known attack by a captive large cat at a zoo in the
are many similarities in the entrance and exit wounds in humans and United States on a zoo patron not in the animal’s enclosure. A second
animals. However, differences occur because of the animal’s fur, which documented large cat fatal mauling occurred in 2008 at the Denver Zoo
can hide a wound, and the structure of the blood vessels, which can on a trained keeper by a jaguar.
change the bleeding patterns. In the case of a dog with an embedded Fatal, Tiger, Attack
collar, there will be edema in the cervical area above the collar. By
combining the principles of general pathology with special veterinary
pathology, animal abuse can be accurately documented. G127 The Utility of Skeletal Examination in
As part of this project, medical examinations, necropsies, and Recognition of Occult Skeletal Injury
histopathology were performed on more than 50 animals at Birmingham
Jefferson County Animal Control during the summer of 2010. Jason M. Wiersema, PhD*, Jennifer C. Love, PhD, Sharon M. Derrick,
Animal Abuse, Comparative Pathology, Necropsy PhD, and Luis A. Sanchez, MD, Harris County Institute of Forensic
Sciences, 1885 Old Spanish Trail, Houston, TX 77054
G126 Fatal Tiger Attack on a Zoo Patron: The goal of this presentation is to illustrate the effectiveness of the
Patterns and Types of Injuries in Large skeletal examination method at locating otherwise obscure fractures in
children.
Predatory Cats This presentation will impact the forensic science community by
illustrating particularly to forensic pathologists the effectiveness of the
Ellen Moffatt, MD*, City & County of San Francisco Office of the skeletal examination method in the recognition otherwise occult
Medical Examiner, 850 Bryant Street, San Francisco, CA 94103; fractures in children.
Gregory L. Mar, DDS*, Hall of Justice, 850 Bryant Street, Room 442, The Harris County Institute of Forensic Sciences (HCIFS) has been
San Francisco, CA 94103; Duane E. Spencer, DDS*, 1855 San Miguel conducting skeletal examination, an autopsy method for recognizing
Drive, Suite 9, Walnut Creek, CA 94596-5282; John K. Berk, DDS, skeletal fractures in children, described by Love and Sanchez in 2009,
20652 Redwood Road, Castro Valley, CA 94546; James D. Wood, DDS, since March of 2007. The method involves incising and reflecting the
102 South Main Street, Cloverdale, CA 95425; Freeland Dunker, DVM, skeletal muscle and periosteum overlying the long bones, scapulae, and
California Academy of Sciences, Steinhart Aquarium, 55 Music ribs of infants and children with medical history and/or soft tissue
Concourse Drive, San Francisco, CA 94118; and Jacqueline Jencek, injuries that are suspicious for inflicted trauma. The current study is a
DVM, San Francisco Zoollogical Society, 1 Zoo Road, San Francisco, retrospective analysis of the utility of this method in the recognition of
CA 94132-1098 subadult skeletal injury.
The method is intended to expose occult fractures typically not
After attending this presentation, attendees will gain a better recognized during standard radiograph surveys and autopsy (Love and
understanding of fatal attacks on humans by large predatory cats. Sanchez 2009). The traditional autopsy protocol provides good visibility
of the skull and thoracic skeleton but not the appendicular skeleton. For Sexual violence is a current topic that has been thoroughly studied,
this reason, an increase in the number of long bone fractures, particularly leading to numerous publications. However, these papers deal, almost
classic metaphyseal lesions, was expected in cases that have undergone exclusively, with the study of living victims. The few publications about
this method, relative to those that predate it. However, a significant postmortem anogenital examination and related findings advocate that
increase in the number of either skull or rib fractures was not expected. this expertise and related injuries interpretation should be similar to the
Following HCIFS protocol, a skeletal examination is performed on one performed in living victims. However, in daily practice, the major
all children with a history, or autopsy findings suspicious for inflicted difficulty for medical legal experts in the interpretation of sexual
injury aged three years and younger. Fifty-four total cases have violence injuries, lies in the fact that currently there are no published
undergone the procedure since March of 2007. This presentation studies allowing us to obtain a rigorous differential diagnosis between
considers only those cases that were ultimately classified as homicides these injuries and anogenital tissues appearance in the postmortem
with blunt injury included in the cause of death. HCIFS anthropologists interval caused by postmortem phenomena, like, cadaveric lividity,
have completed 41 such cases (experimental sample). These cases were dehydration, and putrefaction which could lead to over or
compared to the same number of consecutive cases with the same criteria misinterpretation of macroscopic sexual violence signs in
(41) that predate adoption of the method (control sample). All cases in anogenital area.
the control sample underwent complete autopsies as defined in the Autopsy case reports of five female homicide victims, performed in
National Association of Medical Examiners standards, but were not the North Branch of the Portuguese National Institute of Legal Medicine
subjected to anthropological skeletal examinations. between June 2009 and June 2010 are reported.
Of the 41 cases that have undergone skeletal examination, skull The victims’ age ranged from 9 to 89 years old. In all of the cases,
fractures were noted in 22 (53%), compared to 20 (49%) in the control anogenital injuries with multiple severity degrees, from bruises to
sample. Seventeen (41%) of the 41 cases in the experimental sample had vaginal and uterus perforation, were found. Depending on the type and
thoracic fractures (ribs, vertebrae, clavicles or scapulae), compared to 16 severity of the injuries:
(39%) of the 41 in the control sample. Both of these numbers are a) Two different postmortem technical approaches were performed:
expectedly similar between the control and experimental samples. macroscopic anogenital examination (four cases); and
However, the number of long bone fractures recognized per case since abdominopelvic amputation (one case). The colposcope was not
the method was adopted has increased significantly. Long bone fractures used in any of the cases and blue toluidine coloration was
were noted in 17 of the 41 (41%) cases in the experimental sample, as performed in one of the cases;
compared to 6 of the 41 (14%) in the control sample. Worth noting is the b) Several complementary procedures were performed:
fact that the fractures noted in four of the six cases in the control sample toxicological, in five cases; genetic, in five cases; and
were complete fractures mentioned in the medical records prior to histological, in three cases.
autopsy. The fractures recognized in the experimental sample are Photographic documentation was performed in all cases.
predominantly classic metaphyseal lesions. In addition, both the number Complementary procedures results revealed drugs intoxication in
of cases with multiple fractures and the number of fractures per case is two cases, a male profile in three cases and uterus and vaginal vital
appreciably higher in the experimental sample than in the control laceration in one case.
sample. The average number of rib fractures identified in cases with In autopsy daily practice, medical legal doctors have many
multiple rib fractures is 13 for the control sample and 22 for the difficulties, especially in technical, methodological, and interpretation
experimental sample. The average number of long bone fractures areas.
identified in cases with at least one long bone fracture is one for the Postmortem phenomena, as rigor mortis often make the cadaver
control sample and four for the experimental sample. manipulation and positioning difficult, not allowing adequate anogenital
These preliminary results indicate that skeletal examination affords view. Cadaveric lividity, dehydration and putrefaction phenomena could
the anthropologist or pathologist the means to better recognize fractures mimic sexual violence injuries, as abrasions, bruises, hematomas, among
that are difficult to appreciate on radiographs, and has increased the others or even hide them, leading to over or misinterpretation of
degree to which fractures in infants and young children, particularly of macroscopic sexual violence signs.
the long bones can be recognized, described, and interpreted. An To overcome these difficulties, autopsy should be performed as
additional benefit of skeletal examination is that it also facilitates soon as possible, before washing the corpse by a medical legal doctor
interpretation of the degree of healing and the forces associated with with expertise in sexual violence in order to prevent loss of biological
individual fractures. evidence.
Skeletal Examination, Child Abuse, Fractures The forensic examination must follow the methodology for the
same type of examination in living victims, through: the use of suitable
materials, such as the speculum and anoscope; techniques for image
G128 Interpretation of Anogenital Findings magnification macroscopic, such as colposcopy; staining techniques,
such as blue toluidine, and photographic documentation.
in Forensic Autopsy: Problems There must be collected histological and biological samples, in
and Challenges order to exclude various disorders that can mimic signs of inflicted
genital trauma or sexually transmitted infection and rule out postmortem
Patrícia Jardim, MD*, José M. Fernandes, MD, Dina Almeida, MD, artifact and to search for heterologous biological material (DNA profile).
Liliana Santos, MD, MSc, Agostinho Santos, PhD, and Teresa If evidence of trauma is found, special dissection is necessary so
Magalhães, PhD, North Branch of the National Institute of Legal that the rectum, anus and perianal tissues are removed en bloc with the
Medicine, Jardim Carrilho Videira, 4050-167, Porto, PORTUGAL perineum, uterus, vagina and vulva being included in the female.
Given the paucity information on the nature and appearance of the
The goal of this presentation is to highlight the difficulties in anogenital tissues in the postmortem interval, the opinion here is that
anogenital examination during autopsy and in interpretation of sexual scientific research is essential to improve knowledge about genital
violence signs. anatomy and variants, sexual violence physical indicators and their
This presentation will impact the forensic science community by lesional mechanisms, differential diagnosis and, above all, interference
raising awareness of the difficulties in establishing the medical legal of postmortem phenomena in these anatomical areas.
diagnosis of sexual crimes on deceased victims, and to outline the Sexual Violence, Medical Legal Autopsy, Postmortem Interval
importance of scientific research in postmortem genital and anal
changes.
G129 When Lightning Strikes: 17 Fatal G130 Drag Racing of Snowmobiles on Asphalt: A
Lightning Strikes in New Mexico Novel Cause for Sudden Violent Death
Alice J. Briones, DO*, 1107 Canvasback Lane, Denton, MD 21629; and Abraham T. Philip, MD*, Brian P. Ehret, and Robert Stoppacher, MD,
Michelle B. Aurelius, MD, Office of the Medical Investigator, MSC 11 Onondaga County Medical Examiner’s Office, 100 Elizabeth Blackwell
6030, 1 University of New Mexico, Albuquerque, NM 87131 Street, Syracuse, NY 13210
The goals of this presentation are to describe the prevalence of fatal After attending this presentation, attendees will learn about a
lightning strikes, familiarize attendees with the most frequent decedent summer acivity, a variation on what was previously known to done
and scene demographics identified in fatal lightning strike scenes and exclusively during winter, and about the fatal consequences that it
autopsies, and have attendees recognize the importance of thorough lead to.
scene investigation and full autopsy examination with histology and This presentation will impact the forensic science community by
specific examinations in lighting strike fatalities. providing insights on a topic about which there is almost no information
This presentation will impact the forensic science community by in the forensic literature, as this case report details the sudden violent
providing data identified in lighting strikes fatalities and suggesting death of a participant in timed trials of a snowmobile which was used to
investigative steps to provide the most thorough scene and autopsy race on asphalt.
examination. Snowmobiles were initially developed to move people and supplies
Hypothesis: There are specific demographics with lightning in regions where heavy snow prohibited the use of more conventional
fatalities in New Mexico that may help identify risk factors and target a vehicles. Today snow-mobiling is a popular wintertime recreational
population or region for preventative measures. lifestyle activity in several parts of the world. There are millions of
Methods: A retrospective review of all fatal lightning strikes in registered snowmobiles users and the recreation/manufacturing complex
New Mexico between January 1979 and December 2009 was performed generates billions of winter tourism dollars for the snow belt areas of
using an electronic database searching the key words “lightning” and North America.1 More than 50% of snowmobile owners surveyed
“electrocution.” Cases of electrocution that were not from lightning consider use of the vehicle as a family sport.1 With the increasing
were eliminated. Demographics evaluated included county of strike, popularity of this recreational activity, there has been an increasing
underlying health conditions, month and time of day of strike, activities incidence of injuries and deaths, the inevitable consequence of human
performed, toxicology, exam findings and the age, sex, and race of the interaction with high performance vehicles. Until the tail end of the last
decedent. millennium, the snowmobile remained a stationary fixture in one’s
Results: During this 30-year time period, 17 lightning strike garage or side of the lawn during the months of May to November. A
fatalities were identified. Fill autopsies were performed on 14 cases and fact that unfortunately changed in the early 1990’s with the introduction
three were external only examinations. The cases were distributed over of asphalt drag strip racing for snowmobiles.
14 different counties; with the highest number of cases in a single county Drag racing traditionally has been an acceleration contest between
being two. All (17/17) of the cases were male. The majority of cases two car drivers, to determine which vehicle has the better speed related
(52%) of the cases fell between 31-50 years. 52.9% (9/17) of the cases performance. The vehicles start from a stationary position and takeoff
had underlying health conditions. 56% percent of the cases occurred usually after a signal from a set of “christmas tree lights,” and race on a
between 2:00 p.m. and 6:00 p.m. 62% of occurred in opens spaces, track 1/8 or a 1/4 mile long. Drag racing started in the 1930s, when
roadways and parking lots. Exam findings included the classic competitors raced along deserted stretches of roads to see who’s vehicle
arborizing Lichtenberg figures (35%), burns and singed hair (50%), and was faster. The National Straightline Snowmobiling Racing (NSSR) is
blunt force injuries (24%). Only four of the 14 full autopsies an organization started in 1986, to verify and certify results of dragstrip
documented examination of the tympanic membranes. On cases where snowmobile races. In 1993, it included asphalt drag racing as one of the
toxicology was performed (70.5%), no drugs of abuse or ethanol were competitive classes that it arbitrated on.
detected. The Empire State Timing Association has operated a Safety Park
Conclusions: Full scene investigation including weather reports, Dragstrip in the Central New York since the 1960s. It is a 1/4 mile racing
location of strike, time of day, month, activities performed, equipment strip, with a long stretch of road to allow cars to slow down. The time-
used during the strike, and a thorough medical history should be slip booth provides the participants data about how long it took to get to
collected when evaluating a fatal lightning strike. A full autopsy should various points down the track as well show data on how fast the vehicle
include not only documentation of all external and internal injuries with was traveling at the half way point (1/8 mile) and at the finish line (1/4
evaluation of the tympanic membranes but identify natural disease. mile) as well as who won the race, if it was a competition.
Intoxication does not appear to be a factor in the lightning deaths This case report is about a 24-year-old man who was operating a
reviewed. To prevent lightning deaths, public service announcements in custom made asphalt snowmobile on a timed trial on the race track. He
New Mexico for lighting warnings should be targeted towards males reportedly had been asphalt racing for the last four years. It was his first
during spring and summer and emphasize the avoidance of open spaces. day of using his new sled, and he started his third trial run down the
The goal of this review was to compare the epidemiology of track. He was clocked at 161 mph at the 1/4th mile point. He
lightning strike fatalities in New Mexico to those previously described in unfortunately lost control of the vehicle, which struck a guardrail. He
national studies, and provide suggestions for the standardization of was ejected off the sled and his body came to rest in a wooded area
autopsy evaluation of lighting strike fatalities so that data may be used approximately 300 feet from the initial collision point. The sled, after
for prevention strategies. multiple ongoing collisions with the guardrails on either side, finally
Lightning, Autopsy, Prevention came to rest approximately 500 feet from where the body rested. The
external examination, with full body x-rays, revealed devastating head
injuries, despite the use of a helmet, traumatic avulsion of left forearm,
open fractures of left proximal humerus, open fracture dislocation of the
right ankle and closed dislocation of the left knee.
A search of the literature revealed no published information on this
type of a sudden violent death.
References: multidisciplinary approach with engineers let us to establish blast
1.
Pierz JL: Snowmobile injuries in North America; Clinical overpressure after tire explosion. After that, impact of blast wave on the
Orthopedics and Related Research; 2003; 409; p29 – 36. thorax produced chest and pulmonary injuries (primary blast injuries).
Snowmobile Accidents, Drag Racing on Asphalt, Sudden Death Also abdominal viscera injuries were also attributed to blast
overpressure effect. The displacement of the body on the ground and
environmental structures after explosion produced scalp laceration,
G131 Blast Overpressure After Tire Explosion: A subarachnoid hemorrhage, and cranium fractures (tertiary blast injuries).
Blast Injuries, Tire Explosion, Overpressure
Fatal Case
Stefano Derrico, PhD*, University of Foggia, Department of Forensic
Pathology, Via Luigi Pinto, 1, Foggia, 71100, ITALY; Gabriela Perilli,
G132 TASER® XREP™: A Case Study
MD, University of Foggia, Department of Forensic Pathology, Viale
Degli Aviatori 1, Foggia, 71100, ITALY; Umberto Volpe, Bari, Bari, , Ogbonna Chinwah, MD*, Department of the Coroner, 1104 North
ITALY; Natascha Pascale, MD, University of Foggia, Department of Mission Road, Los Angeles, CA 90033; and Christopher B. Rogers, MD,
Forensic Pathology, Viale Degli Aviatori, Foggia, 71100, ITALY; and and Lakshmanan Sathyavagiswaran, MD, Los Angeles County Medical
Irene Riezzo, PhD, University of Foggia, Osp D’Avanzo, Department of Examiner’s Office, 1104 North Mission Road, Los Angeles, CA 90033
Forensic Pathology, Viale Degli Aviatori, 1, Foggia, 71100, ITALY
The goal of this presentation is to present a rare case of fatal tire with the TASER® XREP™ device, a new less lethal tool for law
explosion, the rarity of the event and the typical histopathological enforcement.
findings make the case peculiar. This presentation will impact the forensic science community by
This presentation will impact the forensic science community by alerting the community to the existence of a new TASER® weapon, and
presenting an integrated study in association with engineers helping to the need for caution in handling it.
investigate damaging effects of blast overpressure, in a world where tire- TASER® XREP (eXternal Range Electronic Projectile) is a self-
blast injuries are not so common and the injuries of the nature described contained wireless electronic control device that deploys from a 12-
are quite rare and are hardly reported in forensic literature. gauge pump action shotgun. It delivers a neuromuscular incapacitation
Blast Overpressure (BOP) is defined as the increased pressure over (NMI) bio-effect similar to that of the handheld TASER® X26TM. The
atmospheric pressure which is associated with a blast from explosives or TASER® XREPTM can be delivered to a maximum effective rang
weapons. BOP may cause primary, secondary, tertiary, and quaternary approaching 100 feet. The battery supply is incorporated into the main
injuries. Primary blast injury occurs from an interaction of the pressure chassis and provides the power to propel the XREP projectile.
wave and the body. Secondary blast injury results from other object The TASER® XREPTM device consists of a triple-redundant
invested by the pressure wave impact against the body surface. Tertiary incapacitation system, each part of the system generating a highly
blast injuries occur when the body is accelerated from the blast wave at refined NMI waveform that incapacitates the subject. The system
first and is then abruptly decelerated on rigid objects. Quaternary blast completes the circuit when the front probes make skin contact combined
injuries are defined as those injuries of victims of explosions that due to with the cholla electrodes, conductive hand trap, or rear facing barbs.
the collapse of a building where the explosion took place. Tire-blast The system is composed mainly of the following:
injuries are not so common and the injuries of the nature described are a. Nose Assembly – the entire detachable nose section which
quite rare and are hardly reported in forensic literature. A case of a fatal includes the nose frame, frontal probes, fracture pins and reflex
tire explosion occurred after tire repair and inflation will be presented. engagement electrodes
Explosion occurred suddenly, strictly close the man who was put five b. Conductive Hand Trap Wire – connects the engine to the frontal
meters far from his site. Rescue maneuvers were unsuccessful and death probes (the insulated wire is wound with the conductive wire)
was declared. Forensic pathologist’s crew investigated the crime scene: c. Cholla Electrodes – electrodes attached to the chassis. The
a 44 cm in length tear was recorded on tire. Blood stains on the ground electrodes are constrained beneath the sheath during flight,
and environmental structures were also detected. A complete extend after impact, and are conductive.
postmortem examination was performed the day after death. Large scalp The nose assembly contains four forward-facing barbed electrodes.
laceration was detected at external examination. Bruises on face and When the TASER® device is deployed, the nose assembly impacts the
chest were also recorded. At gross examination, cranium vault was subject and the frontal probes make contact with the skin and are stuck
unremarkable except for a mild hemorrhagic infiltration of the galea to the body. The energy from the impact breaks a series of fracture pins
capitis. Brain was normal in size and volume with mild cerebral edema. that release the main chassis of the XREP projectile, which remains
Diffuse subarachnoid hemorrhage was observed in both hemispheres. connected to the nose by a nonconductive tether. A conductive hand trap
Linear fracture of the skull base was detected. Multiple bilateral rib wire also connects the frontal probes to the TASER® XREPTM engine and
fractures with mild hemothorax were recorded. Lungs were increased in has capacity to deliver NMI. The projectile autonomously generates
size and volume, reddish colored, both; hemorrhagic foam was detected NMI for 20 continuous seconds. As the chassis falls away, six cholla
on the main bronchi. Hemoperitoneum was also recorded; multiple electrodes automatically deploy to deliver the NMI effect over a greater
lacerations of liver, kidney, and spleen, deeping into the parenchyma of body mass. The subject instantly loses muscular control of the body and
the viscera were detected. At histological examination with H&E cannot perform coordinated action. The subject usually falls to the
subarachnoid and intraparenchimal hemorrhage were detected on brain. ground. After the signal stops, the subject typically regains all muscle
Acute emphysema, pulmonary edema, and hemorrhages were also control. Whereas other less-lethal weapons rely on pain compliance to
described with intense congestion of the septum vessel. Venous air stop the subject, with neuromuscular incapacitating weapons pain may
embolism was also recorded and investigated by means of be short-lived and may aggravate the subject even further or cause
immunohistochemistry (antibodies anti-CD 61 and fibrinogen). serious long-lasting injuries.
Capsular multiple tears and subcapsular and intraparenchimal This case is that of an actor suspected of fatally stabbing a former
hemorrhages were also detected at liver, spleen and kidneys microscopic coworker and wounding two others during a violent rampage about a
examination. Polivisceral stasis was recorded. Intoxication of alcohol or week earlier. On discovering that he was a wanted suspect, the police
drugs of abuse was excluded at toxicological investigation. Acute tried to apprehend him. He fled to a nearby hill and stood on the cliff
respiratory failure was indicated as the cause of death. A wielding a samurai sword. A 20-page handwritten suicide note was
discovered in the abandoned vehicle of the suspect. In the note he For the past 15 years, the Forensic Institute of the University of
indicated sunset as the time he would end his life. A daylong standoff Bern has been concerned with imaging problems in forensics. In 2009
with police ensued with extensive news media coverage. Helicopters the robot-supported automated system integration of 3D surface
hovered over the scene most of the time. Crisis negotiators were called scanning and multislice CT with postmortem biopsies was successful as
in. They joined in the efforts to get the suspect to surrender. For about a “Virtobot” developed. After what is now five years, the over 100
eight hours (9:30 a.m. to 5:00 p.m.) he stayed on the edge of the cliff with postmortem angiographies show impressive results from the research
his sword, taunting and threatening the police. With the approach of activities at the University Bern. In the early part of 2010, our Total
dusk, a decision was made to subdue him with a less than lethal weapon. Imaging Total Matrix TIM-MRI system that has been in operation since
The TASER® XREPTM device was deployed. He was hit and he plunged 2009 could be extended with the so-called synthetic MRI software. The
off the edge of the cliff to his death about 45 feet below. advantage of this TIM synthetic MRI system lies in the fact that in one
Autopsy findings, mode, and health and safety issues will examination step various MRI sequences (such as T1-T2-PD, etc.) could
be reviewed. be performed from tip to toe without any change of the surface traces. In
Electronic Control Device, Neuromuscular Incapacitation, Police the daily forensic service applications it has become evident that through
applying this approach a increase in quality and a improvement in the
forensic diagnostics can be achieved and the examination results based
G133 3D in Forensics: TIM Synthetic MRI and on the imaging are often quicker and, thanks to a more visual 3D
reconstruction, can be displayed in a way that lay persons can understand
Virtobot – Forensic Imaging Workflow of and comprehend. Momentarily, in terms of workflow and process, this
the Future Virtopsy-system integration is the only forensic examination track in a
forensic institute that has brought together all the modalities and
Michael Thali, MD*, VIRTOPSY Team, University of Bern, Institute of technologies in this form for daily use and research. With “Axon
Forensic Medicine, Buehlstrasse 20, Bern, 3012, SWITZERLAND Shadow,” the interdepartmental forensic IT structure, now being
developed at our Institute, which comprises the functionalities of “ERP,”
After attending this presentation, attendees will know the basic of “LIMS” and document management, the forensic processes of all the
virtual autopsy and the development in forensic 3D imaging of human IFM departments are displayed and supported in a workflow-
corspes in the future. oriented manner.
This presentation will impact the forensic science community by Virtopsy, Virtual Autopsy, CT and MRI
covering new validated practical knowledge, and the professional
practice gap in the area of virtual autopsy (CME/ACCME criteria).
Imaging has changed the world and greatly influenced modern G134 Transition to Digital in the Forensic
medicine.
In the 2009 National Academy of Sciences Report, “Medical
Morgue: Lessons Learned on the Pathway
Examiners and Coroners Systems: Current and Future Needs” modern to Greater Efficiency
imaging technologies (Virtual autopsy, Virtopsy) was suggested as
having a great potential to detect forensic relevant findings. Jason M. Wiersema, PhD*, Diane Logan, MBA, and Luis A. Sanchez,
The advent of high resolution multi-detector row CT scanners and MD, Harris County Institute of Forensic Sciences, 1885 Old Spanish
fast MRI scanners in the last decade has allowed the development of Trail, Houston, TX 77054
imaging techniques that have greatly enhanced the diagnostic potential
of these two imaging modalities. While conventional radiographs have After attending this presentation, attendees will have a better
played a valuable role in forensic diagnosis and practice for over a understanding of the advantages of and obstacles to the transition to
century, recent investigations with both CT and MRI suggest that these digital technology in the forensic morgue.
imaging tools are capable of much greater contributions. A major This presentation will impact the forensic science community by
innovation is the ability to display imaging findings in 2D and 3D planes illustrating the advantages and elucidating the difficulties of the
that closely replicate the findings at conventional autopsy and make the transition to digital fingerprint, radiograph, and photographic
interpretation of the studies more easily understood by non-radiologists. technology.
CT and MRI may be used to supplement traditional autopsy techniques, Maximizing efficiency in the postmortem examination process is
to provide a complete anatomic assessment prior to limited autopsy, or in critical to the daily operations of a busy medical examiner’s office, and
certain circumstances to replace it, such as in blunt accidental trauma, or is also of particular importance to effective mass fatality preparedness
drowning deaths. These studies may also provide options in the setting planning. The Harris County Institute of Forensic Sciences (HCIFS)
of religious and cultural objections to conventional autopsy. uses technology to maximize the efficiency and accuracy with which it
While CT has the advantage of providing rapid whole body imaging can complete the autopsy process. These technological advancements
of great anatomic detail in a short time, the superior contrast resolution include the acquisition of a digital radiograph system, a digital
of MR provides soft tissue characterization that is not achievable by CT. fingerprinting system, and digital photography. This presentation will
MRI is less widely available and more time consuming but may be detail the advantages of each of these technologies as well as the
applied to the postmortem evaluation of specific body parts to aid in the obstacles that complicated the transition to each. Generally, the most
diagnosis of specific causes of death that may be characterized by subtle significant advantages of these technologies are increased efficiency, less
soft tissue changes. Both CT and MRI provide a permanent pictorial waste, greater security, and enhanced user benefit. The most significant
record of anatomic findings that may be retained and analyzed for obstacles involve adaptation to the specific constraints and requirements
medical and legal purposes postmortem and offer advantages in quality of the medical examiner/morgue setting. There is little precedent for the
assurance that may be difficult to replicate with conventional autopsy. use of some of these technologies in the medical examiners context, and
The forensic science and medical examiner communities have this was reflected in our effort to adopt them.
shown interest in the use of CT and MR autopsy imaging. However, The HCIFS completed its transition from conventional film
while CT and MR imaging are widely available in the clinical care of the radiography to digital computed radiography in December 2009. The
living, forensic facilities face problems of access to autopsy imaging due digital system includes a central x-ray generator and digital processor, a
to financial, technical, transportation, interpretation, and related dedicated server, and a web-based viewing software package that is
difficulties. accessible from each of seven autopsy suites, and from the doctors
(pathologists and anthropologists) office and laboratory computers. The G135 Postmortem Computed Tomography as a
advantages of the system include: greater image quality, more functional
user interface (with contrast, brightness and annotation capabilities)
Valuable Tool for Diagnosing Trauma Prior
multi-image split screen viewing, enhanced archival security, and the to Medicolegal Autopsy
elimination of the expense, waste, and space requirements associated
with film radiography. The most significant obstacles to the transition to Seija Ylijoki-Soerensen, MD*, Department of Forensic Medicine,
digital x-ray technology were: the lack of an existing system that was Brendstrupgaardsvej 100, Aarhus N, 8200, DENMARK; Iana Lesnikova,
appropriately configured for medical examiner use, the consequent MD, Department of Forensic Pathology of University of Aarhus,
development of user workflow, an unfamiliar user interface and image Brendstrupgaardsvej 100, Aarhus N, 8200, DENMARK; Lars Uhrenholt,
format, and training necessary for use of the software by non- PhD, Institute of Forensic Medicine, Department of Forensic Medicine,
radiologists\radiographers. Additionally, the HCIFS developed a means University of Aarhus, Brendstrupgaardsvej 100, Aarhus N, 8200,
to copy, and label the images in a format that can be accessed by the DENMARK; and Annie Vesterby, MD, DMSc, Institute of Forensic
Harris County District Attorney’s Office. Medicine, University of Aarhus, Brendstrupgårdsvej 100, 8200 Aarhus
Digital fingerprint technology has enhanced the efficiency of the N, DK-8000, DENMARK
decedent identification process. The HCIFS system is essentially an
extension of the Harris County Sheriff’s Office (HCSO) AFIS network, After attending this presentation, attendees will understand the
and includes six AFIS stations, each comprised of two types of importance of computed tomography, which provide the detailed picture
fingerprint scanners and a 37” all-in-one touch screen computer. The of trauma before a medicolegal autopsy in traumatic deaths.
fingerprints are transferred directly to the HCSO server rather than being This presentation will impact the forensic science community by
stored at HCIFS, and HCIFS Investigations and Morgue staff utilize a increasing knowledge about the benefit of the combination of whole
custom web-based software interface to receive and search fingerprint body postmortem computed tomography with a medicolegal autopsy.
results. The advantages of the digital fingerprint system include: This procedure gives high quality and specificity in diagnosing fractures
increased print quality relative to the previous method; more efficient and other traumas in a deceased. The 3D reconstruction helps to assess
transfer of prints and receipt of results (five minute average turnaround); the extent of damage and trauma mechanisms. It is also shown how a
infinite upgrade-ability; and more secure archiving. The primary medico-legal autopsy on a deceased with many traumas is best
obstacles to the transition to digital fingerprint technology were: performed with an ancillary computed tomography. The computed
ensuring compatibility between the HCIFS system and the databases tomography without medico-legal autopsy cannot provide the sufficient
with which it communicates; lack of an existing system that is diagnostic information.
appropriately configured for medical examiner use, and; configuring and A case of a traffic accident with two victims is presented. A car with
using a system that has not yet been tested elsewhere. The HCIFS is four people was hit from the left side by a fast-moving car with two
currently incorporating satellite based scanners into the system to people inside. Driver and passenger sitting in the front of the car with
facilitate use of the system by HCIFS Investigators in the field. four people were killed instantly. Whole-body computed tomography
The HCIFS transitioned to exclusive use of digital photography at was performed before medico-legal autopsies were performed in the
the both the scene and in the morgue in 2005. Conversion from film to Department of Forensic Medicine, Aarhus. The driver suffered fatal
digital photography has increased quality control and accessibility, while traumas in the form of multiple fractures on the left side of thorax,
reducing processing and duplication costs. The system required the laceration of diaphragm, fractures in cervical column, contusions in the
acquisition of digital cameras, a dedicated photo server and the left side of the brain, pelvic fractures, and fractures in the left ankle. The
infrastructure necessary to make use of the images in a variety of settings passenger on his right side suffered traumas in his thorax, in column and
(the morgue, daily case triage meetings, case review sessions, and pre- fractures of the pelvis. The two other passengers sitting in the back got
trials). Secure remote access was provided to the district attorney’s minor traumas. Driver and passenger in the other car were practically
office eliminating time and supplies required for duplication. The most without traumas.
significant difficulty with the digital photography system is the ever With this case are shown photos of the two cars involved in this
increasing need for storage, and constant oversight is needed to ensure accident, 3D reconstructions made from the computed tomography
image security and reduce unnecessary image duplication. scanning results and the subsequent clinical photos from the medico-
The conversion to these digital systems has increased the efficiency legal autopsies. It is shown that with these documents the trauma
of HCIFS daily operations and has resulted in a concomitant increase in mechanisms can be evaluated with high reliability. Some of the
its capacity to accommodate mass fatality investigations. Each of the diagnosis of traumas in this case could have been lost without a
systems was funded by preparedness grants awarded by the United postmortem computed tomography scanning. Also a computed
States Department of Homeland Security and the transition process can tomography scanning before a medico-legal autopsy saves time and
serve as a template for other medical examiner jurisdictions. resources for the forensic examiner and the dissection of the deceased is
Digital Fingerprint System, Digital Radiograph System, not necessarily as comprehensive as it can be without an ancillary
Digital Photography scanning.
This case will be presented as an example to highlight how with a
whole-body postmortem computed tomography, it is possible to achieve
comprehensive information about traumas and the trauma mechanisms.
It improves the quality of a medico-legal autopsy and is recommended to
be used in cases of fatal traumas.
Postmortem, Computed Tomography, Trauma
G136 Traumatic Injuries in Fatal Tire Explosions
Chris Milroy, MD*, University of Ottawa, The Ottawa Hospital, 501
Smyth Road, Box 117, 4th Floor CCW, Ottawa, ON K1H 8L6, CANADA;
and Alison Edgecombe, MD, The University of Ottawa, Departemnt of
Pathology and Laboratory Medicine, PO Box 117, 4th Floor CCW, 501
Smyth Road, Ottawa, ON, CANADA
After attending this presentation, attendees will appreciate the

patterns of injuries from tire explosions and the circumstances where
fatal tire explosions can cause danger.
The presentation will impact the forensic science community by
illustrating the nature and extent of explosion injuries that may result
from burst tires.
Tire explosions during servicing may cause severe trauma. The
severity of injury depends on the tire size, air pressure, and distance from
the blast. The blast injury has been compared to that of a grenade or land
mine, but without the chemical or thermal effects. Overall mortality is
significant (19-29%), mostly attributed to head injuries. Two cases of
truck tire blasts in which fatal injuries were sustained are reported.
Case 1: A 29-year-old male was inflating a large truck tire which
was lying flat on the ground. He was leaning over the tire when it
ruptured under his chest. He was projected against a garage wall four
feet away with his shoulder striking the wall nine feet from the ground.
He was pronounced dead at the scene.
At autopsy, there were multiple stippled abrasions and bruises on
the face, trunk, and upper and lower extremities, typical of blast injury.
The right arm was almost amputated. The rib cage and sternum were
extensively fractured. Contusions were seen on the lungs and the left
diaphragm was ruptured. The 3rd and 4th cervical vertebrae were
dislocated. At the base of the skull, there was a hinge fracture with
cerebellum protruding through the fracture site. The brain stem was
transected in two places.
Case 2: A 28-year-old male was testing a large truck that had
reports of a faulty speedometer. A jack was placed under the third axle
of the vehicle and the engine was accelerated. At 40 mph, one of the rear
tires exploded. The victim’s proximity to the tire blast was not witnessed
but he was ambulatory briefly before collapsing. In hospital, a lacerated
spleen with hemoperitoneum was managed surgically. After
hemodynamic stabilization, the patient suffered cardiovascular collapse.
Resuscitation was not successful.
The autopsy revealed primarily left sided trauma with left elbow,
left hip, and rib cage fractures. Bilateral hemothoraces were
documented. The left lower lobe of the lung was contused and the left
hemidiaphragm was bruised. The left ventricle epicardial surface was
bruised and traumatic rupture of the anterior papillary muscle had
occurred. Subsequent examination of the spleen post-splenectomy
confirmed the presence of lacerations. Lacerations were seen in the left
kidney with bleeding into the perinephric fat.
Conclusion: The cause of death in both cases was attributed to
multiple injuries. In case one, the brain stem transection would have
been immediately fatal. In case two, acute papillary muscle rupture led
to cardiovascular collapse. Tire explosions show similar injuries to
bomb blasts with typical blast injuries seen. Fatalities are common;
however, postmortem findings are infrequently reported in the literature.
Tire, Explosion, Fatal
PATHOLOGY/BIOLOGY
Seattle 2010 Seattle 2010
G1 Retinal and Optic Nerve Sheath that the head injuries were as a result of short distance accidental falls
(40-120cm) or relatively minor head impact trauma.
Hemorrhages Are Not Pathognomonic of The nature and extent of the pathology will be presented and the
Abusive Head Injury incidence of subdural and retinal hemorrhage will be presented. Twelve
cases were found to have unilateral subdural hemorrhage and in two
Evan Matshes, MD*, Southwestern Institute of Forensic Sciences, 5230 cases the subdural hemorrhage was bilateral. Eight cases had bilateral
Southwestern Medical Avenue, Dallas, TX 75235 retinal hemorrhages and four cases had ipse-lateral retinal hemorrhages.
There were three cases of skull fracture but in one case with bilateral
After attending this presentation, attendees will understand the skull fractures no retinal hemorrhages were described. In four cases
limited value of eye evaluation in child death investigation. there was evidence of a prior head injury.
This presentation will impact the forensic science community by Cerebral edema or raised intracranial pressure was documented in
bringing clarity to the controversial topic of retinal and optic nerve 12 cases. However, in one case, a six-week-old infant born seven weeks
sheath hemorrhages. premature with several documented hypoxic episodes, who had
For many years, the dogma of pediatric forensic pathology was apparently fallen 60 cm from a bed, had unilateral subdural hematoma,
“retinal and optic nerve sheath hemorrhages are pathognomonic of bilateral retinal hemorrhages and no evidence of increased intracranial
abusive head injury”, including especially, the Shaken Baby Syndrome pressure.
(SBS). Growing controversy surrounding the existence of SBS has lead The evidential basis for the respective arguments by the prosecution
to questioning of that dogma. A retrospective review of all child deaths and defense will be presented and the possible reasons for the verdicts
(≤ 36 months of age) at a metropolitan medical examiner (ME) will be analyzed. It may be significant to note that in two cases there was
department was undertaken to establish the spectrum of retinal (RH) and a history of minor shaking as attempt at resuscitation after the infant had
optic nerve sheath hemorrhages (ONSH) encountered in a medical exhibited signs of collapse and seizing. The defense council decided to
examiner’s population. In this office, pediatric eye removal is routine, plead his client guilty to shaking as he was afraid to expose the accused
and all eyes are evaluated by consultant ophthalmologic pathologists. to a jury because of the widespread adverse publicity related to Shaken
The medical Examiner’s database had 137 cases that met age criteria Baby Syndrome.
over a five year period; complete case files were available on 123 cases. The problems relating to the presentation in court of the
Of those 123 cases, 18 cases (15%) had RH and/or ONSH; eight cases controversies relating to the pathogenesis and interaction of hypoxia and
had both RH and ONSH, seven had only RH, and three had only ONSH. raised intracranial pressure on the development of subdural hemorrhage
Of these 18 cases, two were certified as natural deaths, eight were and retinal hemorrhages will be discussed.
certified as accidents, and eight were certified as homicides. Evaluation The influence of these current controversies, particularly relating to
of the data demonstrated statistically significant relationships between Shaken Baby Syndrome, had on the outcome of each case will
RH/ONSH and: restitution of a perfusing cardiac rhythm following be discussed.
advanced cardiac life support (with short term survival); and cerebral Child Abuse, Head Injury, Accidental Falls
edema (regardless of etiology). Of those children who died without head
trauma, but with eye pathology, 6 of 7 received advanced cardiac life
support. Qualitative assessment of hemorrhage severity suggests G3 Pediatric Deaths in Harris County
slightly more severe retinal hemorrhages in children whose deaths were
ruled homicides; these children were also more likely to have more Kathryn H. Haden-Pinneri, MD*, and Sharon M. Derrick, PhD, Harris
lengthy post-injury survival periods and brain swelling. In conclusion, County Medical Examiner’s Office, 1885 Old Spanish Trail,
RH/ONSH are not limited to children who die of inflicted head injuries; Houston, TX 77054
instead, they may be seen in a wide variety of situations, and may be
linked to cerebral edema, and sequelae of advanced cardiac life support. After attending this presentation, attendees will gain a better
Retinal Hemorrhages, Shaken Baby Syndrome, Pediatric Forensic understanding of the types of pediatric deaths investigated in Harris
Pathology County, Texas and will be exposed to the extensive pediatric death
investigation and autopsy procedures employed in our office.
This presentation will impact the forensic community through the
G2 Child Abuse vs. Accidental Falls: Judicial documentation and discussion of almost 900 pediatric deaths.
Outcomes in Alleged Child Abuse Pediatric deaths pose a unique and sometimes complex set of
challenges for forensic investigators. As is typical in other cases,
James A.J. Ferris, MD*, Department of Forensic Pathology, LabPlus, 85 information is gathered from family members regarding the events
Park Road, Grafton, PO Box 110031, Auckland, NEW ZEALAND leading up to the death. In infant deaths, the parents must be interviewed
with as much detail as possible in order to document the correct set of
After attending this presentation, attendees will learn that the circumstances. This is often very difficult to do when the parents are
incidence of accidental head injuries in infants and children is greater extremely distraught and when they are the potential suspects. Because
than previously accepted. babies and small children may have injuries that aren’t apparent at the
This presentation will impact the forensic science community by scene or emergency room, all deaths need to be thoroughly investigated
demonstrating how accidental short distance falls may simulate child beginning as soon as proper officials are notified. This can sometimes
abuse. cause emotional duress and resistance to talk on the part of the parents.
This presentation will review the trial outcomes in 14 cases from With experience, understanding, and a standard infant death
personal case files of alleged child abuse in which the defense claimed investigation procedure, these obstacles can be overcome.
The Harris County Medical Examiner’s Office (HCMEO) is located as well as adjacent Justice of the Peace jurisdictions in north central
in Houston, Texas, serving a population of 3.9 million (per 2008 data Texas. Investigations included: scene circumstances, medical records,
from the Office of the State Demographer, Texas State Data Center). investigative information from law enforcement and social services,
Additionally, contract services are provided to seven counties in the autopsies with ocular examinations, toxicologic studies, and radiographs
surrounding area. Approximately 16,000 deaths are reported each year when indicated.
and an average of one-fourth are brought in for either an external Results: SIDS-like histories were reported in 36 of the 84 infants,
examination or a full autopsy. Discussed in this presentation will be the 42.9% of the total group. Infants with SIDS-like histories were found to
extensive investigative and autopsy procedures, including photographic have injuries playing a role or causing their deaths in eight cases of this
documentation of the scene, special techniques and consultant group, 22.2%. Seven of these were attributed to non-accidental injuries
assistance. when no adequate explanation was provided once internal lethal injuries
Over a four year period beginning January 2005, the HCMEO were found at autopsy. Three of these non-accidentally injured infants
assumed jurisdiction of 870 deaths involving children 10 years of age or had no external injuries. Three others had only small facial or scalp
younger, 12.3% of which were homicides. Deaths in which an infant is injuries which were concerning in the context of a SIDS-like history.
found dead or unresponsive while sleeping with an adult are classified as The seventh infant of the non-accidental death group was slightly
undetermined (co-sleeping) in our office, allowing for tracking of this decomposed and had visible injuries in spite of the SIDS-like initial
risky behavior. Documented wedging or overlays are classified as history. The accidental death occurred in an infant who had sustained a
accidents. The diagnosis of Sudden Infant Death Syndrome (SIDS) is simple skull fracture when his stroller rolled down hill and crashed into
utilized when all investigative and autopsy findings fail to reveal a cause a wall three days prior to death. He was treated and released and found
of death in a child under the age of one. The average rate of SIDS deaths unresponsive in the morning. He had a healing small head abrasion.
over the four year study period is 12% (104). As expected, non-motor Laryngeotracheobronchitis was considered a significant contributing
vehicle related accidents account for the majority of the deaths, with an factor in his death.
average of 21.6% (188). Seven of the infants’ deaths in the SIDS-like history group were
Statistics will be reviewed in detail for each year of the study and ruled undetermined, 19.4%. None of them had external injuries or
discuss the significance of the trends with regards to co-sleeping, internal injuries sufficient to cause death and none had sufficient natural
asphyxial deaths, drowning, and child abuse. An unfortunate occurrence disease to account for death.
in our hot climate is the yearly cluster of heat related deaths due to Sufficient gross and/or microscopic findings to attribute death to
children being left in motor vehicles and the increasing number of natural diseases were found in eight infant deaths. Six died of
drownings. An alarming statistic discovered from this study is that the respiratory tract illnesses and two died of other illnesses for a total of
number of child deaths due to homicide is higher than those due to motor 22.2% of the total group.
vehicles. Preventable deaths need to be targeted and all reasonable The diagnosis of exclusion, SIDS, was reserved for 13 of the
attempts need to be made to educate parents and caregivers of the infants, 36.1%. None of these infants had any external injuries. At the
dangers of leaving children in hot cars, unsupervised in swimming pools, time of the study the SIDS definition did not include extensive metabolic
co-sleeping with small infants, and other inappropriate sleeping and radiologic studies. Scene circumstances, medical and social services
conditions that may result in a child’s death. information, complete autopsy, and toxicologic studies for child deaths
Pediatric Deaths, Homicides, Co-Sleeping between one month and one year of age were used to define SIDS in this
study. As has been found in most studies of SIDS deaths, ten of the
infants were three months old or less, 76.9%.
G4 What Is the Frequency of Finding Lethal
Accidental Non-accidental Natural Undetermined TOTAL
Injury When a SIDS-Like Death Head Injury 1 7 0 0 8
Undetermined 0 0 0 7 7
Is Reported? Respiratory 0 0 6 0 6
Other Natural 0 0 2 0 2
M.G.F. Gilliland, MD*, Brody School of Medicine at East Carolina SIDS 0 0 1 0 13
University, Pathology & Lab Medicine, Brody 7S-10, Greenville, NC 1 7 21 7 36
27858-4354
Conclusion: Although more than half of sudden unexpected deaths
After attending this presentation, attendees will understand how of infants less than one year of age were attributed to natural causes 15
frequently lethal injuries were found in a group of infants less than one of the 36 deaths this study (41.7%) required additional law enforcement
year of age initially reported to have been found dead after sleep. activity. Non-accidental injuries were found in 19.4% of deaths and a
Attendees will also understand how important it is to thoroughly similar percentage could not be attributed to natural causes
investigate infant deaths. (undetermined cause and manner). Sudden unexpected infant deaths
This presentation will impact the forensic science community by must be thoroughly investigated; many will be the result of natural
providing a scientific basis for the need to perform an autopsy, even if causes, but a significant number will be unnatural deaths. Any external
there is parental objection in infant deaths. Attendees will have scientific injury is an indication that an autopsy must be performed. The absence
support for thorough law enforcement investigation of unexpected of external injuries did not accurately predict natural deaths. Autopsies
deaths in infancy. are still necessary to exclude trauma. This study did not address high-
Sudden unexpected deaths of infants less than a year of age are resolution radiographic virtual autopsy techniques to allow examination
concerning to families and law enforcement. The frequency of finding in the face of parental objection to autopsy.
evidence of lethal injury when the history is that of Sudden Infant Death SIDS, Non-Accidental Injury, Infant Deaths
Syndrome – child found unresponsive after sleep – is important in
determining the extent of investigative effort required.
Method: Examination of a database of prospectively studied child
death investigations from the Southwestern Institute of Forensic
Sciences in Dallas, Texas from 1981-1989 identified 84 infants less than
one year of age. These infants were part of a larger study of 169 children
less than ten years of age. The deaths were from Dallas city and county
G5 Cardiac Channelopathies Linked to Sudden G6 Fatal Acute Intracranial Injury With
Infant Death Syndrome/Sudden Subdural Hematoma and Retinal
Unexplained Death Syndrome Hemorrhages in an Infant Due to
Stairway Fall
Dawei Wang, PhD*, and Donald Siegel, PhD, New York City Office of
the Chief Medical Examiner, 421 East 26 Street, New York, NY ; and Patrick E. Lantz, MD*, Department of Pathology, Wake Forest
Yingying Tang, MD, PhD, Mechthild K. Prinz, PhD, and Barbara A. University, School of Medicine, Medical Center Boulevard, Winston-
Sampson, MD, PhD, Office of Chief Medical Examiner, Department of Salem, NC 27157-1072; and Daniel E. Couture, MD, Department of
Forensic Biology, 421 East 26th Street, New York, NY 10016 Neurosurgery, Wake Forest University School of Medicine, Medical
Center Boulevard, Winston Salem, NC 27157
The goal of this presentation is to describe the use of genetic testing
to assist medical examiners in determining cause of death in The goals of this presentation are to discuss the significance of
undetermined cases. After attending the presentation, attendees will retinal hemorrhages in an infant with a traumatic brain injury and an
understand the definition of sudden infant death syndrome (SIDS) and acute subdural hematoma and the discordance of published articles about
sudden unexplained death syndrome (SUDS), the procedures of serious injuries or fatalities in infants and young children associated with
SIDS/SUDS investigations, and the SIDS/SUDS genetic testing method. stairway or short falls.
An example of a SUDS case investigation will be presented. This presentation will impact the forensic science community by
This presentation will impact the forensic science community by emphasizing the importance of a meticulous investigation required when
emphasizing the need for and use of genetic testing in the determination an infant or young child dies following a history of a short fall coupled
of unexplained deaths. Discovery of the new mutations presented here with a critical examination of the current literature on short fall fatalities.
will also enrich cardiac ion channel mutation databases and hopefully Mistaking a fatal accidental head injury in a young child for abusive
lead to better understanding of the pathogenesis of these diseases, their head trauma can cause serious and protracted consequences. A case of
diagnosis and treatment. an infant with an acute subdural hematoma (SDH) and severe
SIDS is defined as sudden unexplained death under the age of one hemorrhagic retinopathy due to a fatal accidental head injury from a
year. SUDS is defined as sudden unexplained death from one year of age short fall down carpeted steps will be described. The clinical, autopsy,
through adulthood. In both syndromes a thorough scene investigation, and investigative findings of this case refute the pervasive belief of many
complete autopsy, and review of the circumstances of death and clinical physicians that a short fall down stairs by infants and young children are
history are required. invariably trivial events and cannot cause serious intracranial injuries
Both environmental risk factors and genetic risk factors are and extensive retinal hemorrhages.
believed to contribute to SIDS and SUDS. Environmental factors According to the mother, her 7¾-months-old son had been active,
involved in SIDS include bedding, bed sharing, and sleeping in the prone playful, and crawling on the floor when she heard a loud thud and found
position. SUDS can be triggered by vigorous exercise, swimming, him supine on the basement steps’ landing. He was transported by
emotional stress, and auditory stimuli. Genetic risk factors of SIDS and ambulance to the medical center’s emergency department. The child was
SUDS include genes that can contribute to arrhythmias. Studies have in extremis and cranial computed tomography revealed a left-sided acute
shown that cardiac arrhythmia may constitute up to fifteen percent or SDH with a midline shift. He was taken immediately to the operating
more of SIDS/SUDS cases. Since mutations on six cardiac ion channel room; however, in the surgical suite he became asystolic. The
genes- KCNQ1, KCNH2, KCNE1, KCNE2, SCN5A, and RyR2 are neurosurgeon evacuated the blood but resuscitative efforts were
major causes of cardiac arrhythmias, current genetic testing for unsuccessful.
SIDS/SUDS is to sequence all exons of these six genes. Neuropathological examination verified the radiological findings of
Testing of SIDS and SUDS cases in the New York City Office of an acute intracranial injury with compressive effects from a left-sided
Chief Medical Examiner has identified genetic variants that are acute SDH. He had bilateral multilayered retinal hemorrhages (left >
consistent with a cause of death due to cardiac arrhythmias. Fifty-one right), optic nerve sheath hemorrhages, macular edema and microscopic
SIDS cases and thirty-four SUDS cases have been tested. Thirty percent retinal detachments.
of tested SIDS cases and twenty two percent of tested SUDS cases carry The upper half of the stairway from the hallway to the landing was
possible disease causing mutations on one of the six cardiac ion channel a flight of six carpeted steps with a carpet over hardwood landing (total
genes describe above. Among the fifty-one SIDS cases, twelve percent units of rise = 7). The stairway pitch was 37° and the rise of each step
carry mutations on SCN5A, 8% of cases carry mutations on each was 0.2032 m with a total rise of 1.42 meters. The oak runners and
KCNQ1 and KCNH2, and two percent of cases carry mutations on landing were 2.0 cm thick and the synthetic carpet and pad over the steps
RyR2. Among thirty-four SUDS cases, eleven percent of cases carry and landing measured 1.9 cm in thickness.
mutations on SCN5A, five percent of cases carry mutations on KCNQ1, The accounts of the incident by the mother were repeatedly
and three percent of cases carry mutations on each KCNH2 and RyR2. consistent and unchanging as provided to the emergency dispatcher,
These results appear to confirm a link between cardiac channelopathies paramedics, emergency department physicians and nurses,
and SIDS/SUDS deaths. neurosurgeon, detectives, and medical examiner. A multidisciplinary
A SUDS case investigation will be presented as an example how team of medical professionals and law enforcement personnel reviewed
genetic testing could help medical examiners determine cause of death the investigative reports, scene images plus clinical and autopsy
when autopsy findings are negative. It is recommended that SIDS/SUDS findings. All concurred that his injuries were due exclusively to the
genetic testing become a routine procedure in undetermined stairway fall.
death investigations. Published studies on stairway falls and serious injuries or fatalities
Sudden Unexplained Deaths, Genetics, Arrhythmias from short falls involving young children are discordant. Joffe and
Ludwig (1988) maintained that falls down stairs seldom result in serious
injury. In contrast, Chiaviello et al. (1994) concluded that while most
stairway-related injuries in young children are minor, severe head injury
can occur. Hall et al. (1988) reported that falls accounted for 5.9% of
childhood deaths due to trauma and 41% of the falls were minor.
Williams (1991) reported that falls witnessed by two or more people or a sibling playing in the room. The TV fell on the decedent and caused
by a non-related person were associated with less severe injuries multiple fractures of the calvarium and base of the skull. One posterior
suggesting alternate mechanisms in the unwitnessed group. Chadwick et fracture intersected with the foramen magnum and caused atlanto-
al. (1991) described seven children who died in short falls and had other occipital hemorrhage and cerebral injuries resulting in rapid death. In
injuries (5/7 with retinal hemorrhages). They concluded that when the third case an 11-month-old infant was struck by a falling TV when
children incur fatal injuries in falls of < 4 ft, the history is false. Reiber her older siblings tried to climb a dresser serving as a TV stand. She
(1993) reviewed coroner’s records (1983-1991) and analyzed relevant sustained massive skull fractures, destruction of her right frontal lobe
articles. He concluded that while children on occasion suffer fatal head and basal ganglia, and impaired perfusion of her left cerebrum. These
injuries from short falls, such events are rare. Plunkett (2001) described cases were distinguished from AHT by comparing the data obtained from
18 head injury deaths resulting from playground falls in the National the scene investigation and interviewing the parties at the scene and
Electronic Injury Surveillance System database over 12 years (1988– matching the patterns of injury with the characteristics of the TV sets and
1999). He concluded that an infant or child can sustain a fatal head their stands and positions, and noting the absence of any prior injuries at
injury with retinal hemorrhages from a fall of less than three meters. the postmortem examination and on x-rays.
Wang et al. (2001) reported on low and high-level falls in a pediatric A review of the literature for the past ten years indicated that
population and found a mortality rate of 1% for low-level (<15 feet) crushing head injuries and fatalities from falling TV’s and standup
falls. Chadwick et al. (2008) reviewed the current literature plus a appliances are increasing while the manufacture of larger TV’s with
statewide injury database and asserted that the best current estimate of inadequate support appliances is also increasing. However, there is a
short fall mortality rate for infants and young children was <0.48 deaths need to critically examine the reporting methods of these cases since the
per one million young children per year. data may not be complete or accurate. There is also a need for better
The clinical, radiographic, autopsy and investigative findings of this public education about this problem and for the development of
case will be presented followed by a critical examination of published standards so as to prevent these injuries. One may consider requiring
articles on stairway-related injuries and fatalities from short falls manufacturers to give notice to purchasers of the dangers of TV-stand
involving young children. Lastly, caution is urged in attributing an acute tip-over by placing warning notices on the products, developing more
SDH and traumatic brain injury with extensive retinal hemorrhages stable TV support appliances, and consider better ways to anchor TV’s
solely to abusive head trauma in an infant or young child following a on their stands.
stairway or short fall based on the current medical literature. Television Injuries, Head Injuries, Children
Short Fall, Subdural Hematoma, Retinal Hemorrhages
G8 Hanging Deaths in Children: An

G7 Morbidity and Mortalities Related to TV Investigation of Manner of Death
Tip Over
Julie Adams, DO*, 1234 Big Bend Crossing Drive,
Marvin S. Platt, MD, JD*, 5050 La Jolla Boulevard, Apartment 2G, San Valley Park, MO 63088
Diego, CA 92109; and Christina Stanley, MD, San Diego County
Medical Examiner’s Office, 5555 Overland Avenue, Suite 1411, San After attending this presentation, attendees will understand that
Diego, CA 92123 investigations into pediatric hanging deaths require a very thorough
scene investigation, research into the decedent’s psychiatric, medical,
The goals of this presentation is to increase awareness of incidence and social history, and a complete forensic postmortem examination in
of injuries from TV tip over, provide guidelines for distinguishing these order to determine the manner of death. Clearly, the determination of the
injuries from abusive head trauma, and emphasize risk factors and need manner of death in these cases can be controversial and can have a
for prevention. tremendous impact on the child’s family. Our research supports the
This presentation will impact the forensic science community by hypothesis that hanging deaths in children aged eight to twelve years of
demonstrating how the incidence of injuries related to TV tip over is age are less likely to have suicide as the manner of death compared to
increasing. hanging deaths in those aged thirteen to eighteen years of age.
This presentation will emphasize how the incidence of injuries This presentation will impact the forensic science community by
related to TV tip over is increasing. It will present the scene helping medical examiners and forensic investigators elucidate
investigation and autopsy findings from three fatal cases and information which will help determine the manner of death in these
demonstrate how a forensic pathologist can distinguish them from difficult cases.
abusive head injury. Recent literature of this phenomenon will also be Background: Suicide in children unfortunately is not an
presented. uncommon phenomenon. Suicide is the fourth most common overall
The San Diego County Medical Examiner’s Office investigated cause of death of children aged ten through nineteen years of age in the
three fatal cases within a nine month interval from December 2007 to United States. However, suicide attempts and completions are rare in
September 2008. Rady Children’s Hospital in San Diego treated an pre-pubertal children. The rate of suicide deaths increases with
additional twenty-six children with non fatal injuries from the same increasing age after the onset of puberty.
mechanism in the two years prior to September 2008. The workup of The number of suicide deaths in the United States for those aged
each case will illustrate how it was distinguished from abusive head fifteen through nineteen has doubled in the past 40 years, and has tripled
trauma (AHT). for those in the ten to fourteen year age group. However, not all deaths
In the first case a 3-year-old girl attempted to reach for items on a by hanging in children are suicides. Asphyxial “contests” such as the
TV and/or the dresser on which the TV was positioned. The dresser and “choking game” have emerged in the past few years as increasing
TV tipped over impacting her face. She had a fractured orbit and concern with hanging deaths involving children. Additionally, many of
subarachnoid hemorrhage as a result of a probable vertebral artery injury the children whose hanging deaths are deemed accidental have histories
when her neck was hyperextended. She had a brief period of of attention deficit disorder and impulsive behavior.
consciousness prior to transport to a hospital where she was diagnosed Investigations into pediatric hanging deaths require a very thorough
with nonsurvivable head injuries. The second case involved the death of scene investigation, research into the decedent’s psychiatric, medical,
a 21-month-old child in which a TV on a shelf held up by three and social history, and a complete forensic postmortem examination in
unsecured wooden dowels in an entertainment cabinet was dislodged by order to determine the manner of death. Clearly, the determination of the
manner of death in these cases can be controversial and can have a of the first part of the study to assess the magnitude of the difference
tremendous impact on the child’s family. Our hypothesis is that hanging between the parameters. It was demonstrated that the moderate airflow
deaths in children aged eight to twelve years of age are less likely to have (draft) present in the experimental conditions did not significantly affect
suicide as the manner of death compared to hanging deaths in those aged the course of cooling of the investigated body sites. Despite moderate
thirteen to eighteen years of age. wind generated in the room, it appeared that the air movement close to
Design: Using the medical examiner’s computer registry, all the pigs bodies was in fact minimal. Therefore, in order to evaluate the
hanging deaths from the past ten years involving children aged 18 years TOD most precisely, one should first have reliable data on the actual
of age and younger will be identified. This will include all applicable velocity of air in the direct vicinity of the body rather than relying on the
deaths in St. Louis City and surrounding counties. All the aspects subjective sensation of the air velocity and using various unnecessary
surrounding the deaths, will be analyzed including the decedent’s corrective factors.
medical, social, and psychiatric history. The results will then be Time of Death (TOD), Postmortem Body Cooling, Draft
compiled and presented in two groups divided by age, 8-12 and 13-18.
Data will then be analyzed to show whether our hypothesis is supported.
Results and Conclusion: These findings support the hypothesis G10 Forensic Medicine in Dubai, United
that hanging deaths ultimately ruled suicides in children aged 8-12 years
of age is an unusual phenomenon and is more likely to be accidental in
Arab Emirates
nature compared to hanging deaths in children aged 13-18. Since
research in this area of hanging deaths in children is lacking, our goal in Fawzi A. Benomran, MD*, Dubai Police, Dubai Medical College, PO
this retrospective review is to help elucidate information which will help Box 39844, Dubai, UNITED ARAB EMIRATES
medical examiners determine the manner of death in these cases. Further
research will help to illuminate the issues surrounding these deaths and The goal of this presentation is to present the medicolegal features
will assist forensic pathologists in determining the manner of death in of the United Arab Emirates with different culture and spectrum. Interest
these cases. to the audience would include the type of cases examined compared to
Hanging, Child Deaths, Asphyxial Deaths that of their own countries, and this presentation will contain some
interesting statistical information.
presenting information on a topic where little information is published
G9 Does a Draft Really Influence Postmortem about this region of the world, as far as forensic science is concerned.
Body Cooling? Various characteristics of the medicolegal scene in Dubai are
described, along with an overview of all cases examined over a period of
Michal R. Kaliszan, PhD*, Medical University of Gdansk, Debowa 23, six years. During the period of study, a total of 17,683 cases were
Gdansk, 80-286, POLAND examined in the Department of Forensic Medicine of Dubai Police
General Headquarters. This constituted a yearly average of (2,947). The
After attending this presentation, attendees will become familiar average annual increment was 11.13%, the percentage of increase
with the process of body cooling after death in various body sites, between 2002 and 2007 being 68.96%. This rate of increase represents
conditions which could influence this process, and the estimation of the the actual increase of referral by the prosecution and the police, as well
Time Of Death (TOD). as the increase due to population growth of 7% to 8% annually. Clinical
This presentation will impact the forensic science community by cases of injuries were found in 10,165 (57.48%), 5,404 (30.56%)
showing the possibility of estimation of the TOD by measuring the postmortem examinations, 1,525 (8.62%) clinical cases of sexual crimes,
postmortem temperature of the eye together with the analysis of the body 409 (2.3%) age estimations, 58 (0.32%) medical responsibility, 20
cooling process in different environmental conditions, including still air (0.11%) criminal abortion, 61 (0.34%) civil actions, and 38 (0.21%)
and the presence of draft in the experimental room. miscellaneous cases. Males represented 4,846 (89.7%) of postmortem
The postmortem body temperature decrease is a key factor in examination; females 558 (10.3%). The age ranged from (0-90) years,
determining the time of death in humans and temperature-based methods with a mean age of 40.5 years. The peak incidence was in the age group
of the TOD estimation are deemed to be most precise during the first (20-50) years, where the extremes of age were least represented. Only
several hours after death. The study focused on verification of the in 361 cases (6.68% of the grand total) the deceased was a local citizen.
significance of the effects of airflow (draft) present in the room where Autopsies amounted to 394 cases, which constituted 7.29% of the total
the corpse is found, on the cooling process of specific body sites, and deaths examined. The four manners of death in descending order of
hence on determination of the TOD. The study was carried out in pigs. frequency were natural 3003 (55.57%), accidental 1,727 (32%), suicidal
The investigations were commenced 75 min after the pigs had been 498 (9.2%), homicidal 164 (3%). The manner was undetermined in 12
killed and involved computerized recording of the cooling process of the (0.22%) of the cases over the six-year period.
eyeball interior (the vitreous humour), soft tissues of the orbit, muscles, As anywhere else, interesting cases have been seen occasionally.
and the recta, measured with thermal pin probes. The first part of the These include all manners of death, even a natural manner of death that
study was performed in still air; the second, with airflow generated by air occurs in circumstances that puzzle the crime scene investigators.
conditioners and a fan. Unusual cases previously reported include a case of homicidal
The data was processed with Matlab® Software version 7.0. The strangulation that was staged by the perpetrators to simulate suicidal
estimation was done via the least squares method implemented in hanging; masking and bondage in suicidal hanging; accidental death due
Matlab’s nnlinfit function. The precision of the parameters estimated was to inhalation of sulfuric acid fumes; postmortem sole incisions in a
assessed by calculating the coefficient of variation (% CV) using the morphine overdose; an unusual case of accidental positional asphyxia;
nlparci function. The influence of air flow on the cooling rate and the and, accidental sand inhalation which was misdiagnosed by the doctor in
initial temperature was tested comparing the individual estimates of the the hospital. Unpublished cases of note are several: a man was found
cooling rate in the first and the second part of the study. A t-test was dead in the passenger seat of his own car, which was locked and his
performed to test the hypothesis that individual estimates of cooling rate trousers and pants were half way down his thighs, which was found later
with and without air flow are independent random samples from the to be due to massive cardiac infarction: a man alleged by his family to
same normal distribution with equal mean and variance. Additionally, have been found dead in his bed was discovered later to have committed
the relative difference (RD) was calculated as a difference between the suicide by hanging and the family cut him down and put him in bed to
mean individual estimates of both parts of the study divided by the value avoid loss of life insurance policy if the fact of suicide death was known;
and in the drug scene arena, during 2008 three accidental fatalities from other types of abdominal injury. Alcohol test was positive in 38% of 146
misuse of Tramadol (Ultram) tablets were reported for the first time. tested subjects (55/146), and 39% of 46 tested subjects (18/46) were
Bloody death scenes are often found when the police suspect homicide, positive for drugs/medication.
but the forensic evidence confirmed that the death was suicidal. In one Table 1 Incidence of abdominal injuries according to mode of
case self mutilation was so extensive that it really took some courage transportation by grouping “Soft group”; MC, moped and bicycles,
from the forensic medical examiner to face the suspicious and skeptical “Hard group”; passenger car, n=180
crime scene officers.
Forensic Medicine, Dubai, United Arab Emirates
G11 Injuries to Abdominal Organs in Fatal Road

Traffic Crash Victims
Lars Uhrenholt, PhD*, Louise Moller Andersen, and Freja Gaborit,
Department of Forensic Medicine, Faculty of Health Sciences,
University of Aarhus, Brendstrupgaardsvej 100, Aarhus N, 8200,
DENMARK
After attending this presentation, attendees will have learned about

the types and distribution of abdominal injuries detected in a study of Discussion: Injuries to the liver and spleen were found to be the
fatal road traffic crash victims at a large department of forensic medicine. most common abdominal injuries following fatal road traffic crashes.
The types of injuries, their incidence, distribution, and relationship to the Interestingly, only minor differences were observed in the incidence of
mode of transportation will be presented and the relevance to the forensic abdominal injury in car passengers versus less protected road users
community will be discussed. (motorcycle, moped and bicycle). The significantly higher risk of injury
This presentation will impact the forensic science community by to the spleen among passengers in motor vehicles is probably due to the
augmenting future forensic studies and supplying forensic scientific data generally higher energy transfer to occupants in passengercar crashes.
for the purpose of improving traffic safety, injury prevention, and clinical Similarly, the increased risk of injury in lateral impact is in agreement
management. with previous studies. The high number of positive tests for alcohol and
Introduction: In clinical settings, abdominal injuries can be drugs/medication in this population is similar to figures reported in the
challenging and knowledge of common topographic distribution of literature. Although abdominal injuries are not necessarily fatal by
injuries may be helpful. There is literature suggesting that injuries to the definition, they often contribute significantly to the cause of death. The
abdominal organs are common following automobile accidents, and that presence, location, and severity of these injuries therefore remain of
the symptomatology of these injuries may range from significant to more importance to the medicolegal investigation.
occult clinical presentation. Abdominal injuries have been found to be Conclusions: This study showed that injuries to the abdominal
common among people killed in road traffic crashes. The characteristics organs are very common following fatal road traffic crashes. Injuries to
of fatal and non-fatal abdominal injuries are both correlated with the use the liver and spleen were the most common types of injury affecting
of safety belts and the direction of impact. This study examined the about a third of the deceased. The incidence rates and distribution of
impact of factors such as mode of transportation and type of crash abdominal injuries were found to correlate to the direction of impact and
scenario on abdominal injury in a group of people killed in road traffic mode of transportation. Future investigations into the mechanisms and
crashes who subsequently underwent autopsy. pathology of abdominal injury are needed in order to improve traffic
Methods: Autopsies performed during the period 2000-2004, safety issues, injury prevention and clinical management.
involving road traffic crash victims were included. Data from autopsy Abdominal Injury, Fatal Road Traffic Crash, Postmortem
and police records were retrieved from an internal database and Investigation
evaluated with regard to the mode of transportation, the type of crash
(i.e., passengercar, motorcycle, moped, and bicycles), and presence of
injury to abdominal organs (i.e., liver, spleen, kidneys, and
intestines/mesentery). Details concerning age, gender, influence of
G12 Case Example: Cerebral Dural Venous
alcohol, and drugs/medication were retrieved. Sinus Thrombosis Following a Motor
Results: A total of 180 road traffic crash fatalities (133 passenger Vehicle Accident
car occupants, 5 motorcycle, 19 moped, and 23 bicycles) were included.
Overall, 53% of the subjects had injury to one or more abdominal organ, Ariel Goldschmidt, MD*, Jackson County Medical Examiner’s Office,
the liver being the most commonly affected, followed by the spleen, 1700 Forum Boulevard, Apartment 509, Columbia, MO 65203; Adrian
intestines, and kidneys. After grouping into “hard” (passenger car) and Baron, MD, and Megan Minniear, BS, 660 East 24th Street,
“soft” (MC, moped, and bicycle) victims, a significantly higher risk of Kansas City, MO 64108
injury to the spleen was found among car passengers *(RR=2.41 [1.10-
5.32], p<0.05), whereas no statistically significant differences were After attending this presentation, attendees will understand general
found for other types of injury in relation to this grouping (Table 1). principles related to cerebral dural venous sinus thrombosis, especially
Frontal collision was the most common crash vector in passenger car those impacting the forensic science community, including presenting
crashes. For all types of abdominal organ injury lateral impact increased signs and symptoms, risk factors, clinical diagnostic tests, potential
the likelihood of injury in passengercar victims. Injuries were more autopsy findings, and pathophysiology. Additionally, a specific case
common among passenger car victims compared with other road users. example from the Jackson County Medical Examiner’s office illustrating
Safety belt use was positively identified in 20 (36%) of a total of 55 many of the above principles will be presented.
recorded cases. Among the safety belt users, there was a higher risk of This presentation will impact the forensic science community by
intestinal/mesentery injury, but a tendency towards a reduced risk of all reviewing findings related to cerebral dural venous sinus thrombosis that
could easily be overlooked by medicolegal investigators, clinicians, bleeding such as gestational trophoblastic disease, retained placenta,
and/or forensic pathologists unfamiliar with this potentially fatal placenta accreta, and endometritis. Subinvolution of the placental site is
condition. an important cause of secondary postpartum bleeding and is defined by
Once familiar with this condition, medicolegal professionals will be either a partial or complete lack of the normal involution of the
less likely to overlook subtle diagnostic clues in a decedent’s medical superficial modified spiral arteries at the placental implantation site.
history and/or postmortem examination. Microscopically, the spiral arteries in the superficial myometrium are
Among the information presented in this presentation will be large and dilated and are partially occluded with thrombi. In addition,
anatomical diagrams and images illustrating the cerebral dural venous cytotrophoblasts are identified within and surrounding the vessels and
sinus system and potential areas of thrombosis. The potential for can be highlighted using low molecular cytokeratin
cerebral dural venous sinus thrombosis to cause a fatal cerebral infarct immunohistochemistry staining.
will be discussed. Risk factors including traumatic head injury and The physiologic and anatomic changes that occur in the uterine
hypercoagulability from various medical conditions including vessels during pregnancy and in the postpartum period are complex. In
dehydration from diabetes mellitus will be discussed. Images from a the beginning of pregnancy, the cytotrophoblasts derived from the
case example will be used to show petechial hemorrhages in the brain, a placenta invade and surround the maternal spiral arteries, transforming
common autopsy finding in cerebral dural venous sinus thrombosis. them into large vessels that accommodate the increased blood flow
Additional images from the case example will show scattered pulmonary needed by the placenta and fetus. The findings are most striking at the
thromboemboli; pulmonary thromboemboism is a rare and serious site where the placenta has inserted into the uterus. In the normal
potential complication of cerebral dural venous sinus thrombosis of postpartum period, involution of the arteries occurs. Involution involves
which many medicolegal professionals are undoubtedly unaware. the modification of the arteries back to the non-gestational state and
A complete case example from the Jackson County Medical eventual removal of the arteries from the uterus. The changes in the
Examiner’s Office will be presented, including scene investigation arteries include fibrointimal thickening, endarteritis, thrombosis,
findings, medical history including CT and MRI radiologic findings, and replacement of the cytotrophoblasts within the vessels by maternal
gross autopsy findings as described above. endothelial cells and regeneration of the internal elastic lamina. There is
Sinus, Thrombosis, Thromboembolism also a disappearance of the cytotrophoblasts from the myometrium
interstitium. This process, in addition to the sloughing of the decidua in
the superficial endomymetrium and the uterine smooth muscle
G13 A Death Due to Subinvolution of the contraction, is necessary to avoid abnormal postpartum bleeding.
The clinical symptoms are delayed postpartum bleeding usually
Uteroplacental Arteries: A Case Report and within two weeks of delivery. There is an abrupt onset of increased
Literature Review uterine bleeding that may require a hysterectomy in some cases.
The exact pathophysiology of subinvolution is not known. Some
Ruth E. Kohlmeier, MD*, El Paso County Coroner’s Office, 2743 East suspect an immune component leading to abnormal interaction between
Las Vegas Street, Colorado Springs, CO 80906; and Norma J. Farley, the maternal and fetal tissues.
MD, Valley Forensics, 200 South 10th Street, McAllen, TX 78501 Subinvolution of the uterine arteries at the placental implantation
site is the result of the modified spiral arteries refusing to convert to a
After attending this presentation, attendees will be educated on non pregnant state. This can lead to significant postpartum bleeding, and
subinvolution of the uteroplacental arteries, the risk of delayed if not suspected, may result in death as in our case. The pathophysiology
postpartum hemorrhage with subinvolution, associated morbidity with behind subinvolution is unknown but speculated that an immune
subinvolution, and pathophysiology of subinvolution. etiology with miscommunication between the maternal and fetal tissues.
This presentation will impact the forensic science community by Although it is a common suspect in delayed postpartum bleeding and can
providing education as to the morbidity and mortality of the pospartum cause significant morbidity, the mortality rate due to subinvolution
patient with subinvolution of the uteroplacental arteries. is unknown.
Postpartum hemorrhage remains one of the major causes of Postpartum Hemorrhage, Subinvolution, Uteroplacental Arteries
postpartum morbidity and mortality and is defined as blood loss > 500
mL in vaginal deliveries and > 1000 mL for cesarean births.
Hemorrhage within the first twenty four hours after the birth is more G14 Case Studies of Cranial Trepanation
common, and referred to as primary or early postpartum hemorrhage.
Primary and secondary postpartum hemorrhage share many of the same
in Apulia (Southern Italy) Through
causes and can include uterine atony, retained placenta, placental accrete Forensic Imaging
or percreta, endometrial infection, inherited coagulation disorders,
consumptive coagulopathy, and lacerations of the perineum. Secondary Emilio Nuzzolese, DDS, PhD*, Ambulatorio Nuzzolese, viale J.F.
postpartum hemorrhage, however, has received less attention, most Kennedy 77, Bari, 70124, ITALY; Sandro Sublimi Saponetti, BSc, and
likely because it complicates only about one percent of all pregnancies Vito Scattarella, BS, Department of Animal and Environmental Biology,
and is more frequently associated with maternal morbidity rather than Università degli Studi di Bari, Bari, 70100, ITALY; and Marino Capece,
mortality. However, secondary postpartum bleeding may be fatal, as is MD, Imaging Department, ASL BA, Monopoli, 70100, ITALY; Nunzio Di
the case in this individual, and because the increase uterine bleeding Nunno, PhD, Università del Salento, Lecce, 73100, ITALY
occurs between one to two weeks after delivery and the patient is often
home and unaware that the hemorrhage is significant. After attending this presetation, attendees will have a greater
The etiology of secondary postpartum bleeding often remains understanding and interpretation of trepanated skulls.
unknown if the patient can be treated conservatively; however, if This presentation will impact the forensic science community by
bleeding is severe, a hysterectomy may be performed or the individual allowing a differential diagnose between traumatic and intentional ante
may not survive and require an autopsy to determine the cause of the or postmortem trepanation.
bleeding. In subinvolution of the placental site, the uterus is grossly Cranial trepanation is a practice known since prehistory in various,
enlarged and boggy. Multiple microscopic sections of the placental often geographically distant populations, from Europe to Peru. It seems
implantation site should be taken to determine the cause of the to have been mainly spread during the Bronze Age and underwent a
hemorrhage and to rule out other causes of secondary postpartum partial decline during the Iron Age. Also during the Roman Era this
practice is well attested by detailed description of specific surgical clinical manifestation of SLE. Autopsy series in diagnosed SLE patients
techniques and tools. It consists of several surgical treatments performed showed 62% pericardial involvement, 50% valvular involvement
with various tools with the aim of opening a hole in the cranial vault for (Libman-Sacks lesions and infective endocarditis) and 40% myocarditis,
therapeutic purposes on living individuals. It is believed that this surgery but all have been underdiagnosed clinically.
was intended to cure cerebral disturbances related to vascular A 28-year-old Caucasian man, with systemic lupus erythematosus
pathologies, migraines caused by intracranial pressure, or edema (SLE) treated with hydroxychloroquine and systemic glucocorticoids,
drainage after a severe skull trauma or as a religious ritual to drive out was admitted to the emergency department for an arm-ache after an
the evil spirit, to obtain bone powder to be used in curative potions, to accidental fall. Admission radiographs revealed a spiroid diaphyseal
obtain a bone disc as an amulet against disease, to fill the skull with humeral fracture at the mid-distal third, which was treated by surgical
incorruptible substances, or as a victory sign on dead enemies. internal fixation with a locked antegrade intramedullary nail, and then it
Differential diagnosis and the interpretation of trepanated skulls can was replaced by an external fixation. An ECG showed sinus bradycardia
be particularly difficult. It is necessary to distinguish between traumatic (58/min), QRS axial left deviation in the frontal plane, incomplete right
or intentional and ante or postmortem trepanation. bundle branch block, marked ST-T segment elevation.
In case studies two early trepaned skulls who are being evaluated After few days he was discharged to continue anticoagulant and
through radiological imaging are presented. Both skulls were found in antibiotic therapy at home, but three days later he was admitted again to
Apulia (Italy). The first skull comes from Canosa (6th–7th AD) and the the same hospital for high fever (39.5–40.5°C). The clinical examination
second is from Vieste (3rd BC). Both skulls present perforation, although revealed pharyngeal hyperaemia, cervical lymphadenopathy and the
at different stage of healing. The radiological analysis confirmed that the classical “butterfly” erythematosus rash on the face and on the neck.
skull perforation was a consequence of a therapeutic operation following Hematologic studies revealed anaemia, neutropenia, lymphopenia and
trauma in the Vieste skull, while the perforation was a pathologic process thrombocytopenia; the morphological examination of peripheral blood
in the Canosa skull. and the research for viruses with cardiac and lung tropism were negative.
The radiological analysis was performed with a portable X-ray On the eighth day the diagnosis of reactivation of SLE was made and
device (Nomad) combined with a digital sensor and computerized axial higher doses of glucocorticoid, antipyretic, and antibiotic therapy were
tomography with 3D reconstruction. Signs of healing reaction and bone administered.
apposition around the perforations were recognized in the Vieste skull, On the fourteenth day, an echocardiography was performed
but not in the Canosa skull. The Vieste skull perforation can therefore be showing normal atrioventricular and semilunar valves, the ventricles
referred to as a therapeutic operation following trauma, while the lesions were dilated and hypocontractile, with a 33% ejection fraction; the
of the Canosa skull suggest a pathological process or a postmortem ritual Doppler examination revealed the mitral valve regurgitation. He was
practice. transferred to the Department of Cardiology but few hours later he
The case study indicates the value of a forensic imaging approach suddenly collapsed; blood gas analysis revealed metabolic acidosis.
in order to improve data analysis for a complete osteological evaluation Vasoactive drugs (dopamine and noradrenaline), bicarbonate, and fluids
of skulls. were administered. The next morning he collapsed again but
Forensic Science, Cranial Trepanation, Forensic Imaging cardiopulmonary resuscitation was unsuccessful and the man was
pronounced dead.
A postmortem examination was performed 48 hours after death.
G15 Systemic Lupus Erythematosus and Fatal The external examination revealed only malar erythematosus cutaneous
rash. Internal examination was unremarkable except for heavy lungs and
Cardiac Failure Due to Pancarditis in a reddish colored foam on trachea and the main bronchi and a cerebral
Young Man edema.
The heart had a normal shape (15x13x5cm) and a weight of 495g.
Irene Riezzo, MD*, Stefania Bello, MD, Margherita Neri, PhD, and The left ventricular wall thickness was 1.9cm and the right ventricular
Cristoforo Pomara, PhD, Department of Forensic Pathology University wall thickness was 0.8cm. The atrial chambers were normal, the
of Foggia, Viale degli Aviatori 1, Foggia, 71100, ITALY ventricules ones were dilated, and the myocardium was flaccid. Cross
sectioning of extramural coronary arteries showed no significant stenosis
The goal of this presentation is to present a case of sudden cardiac or thrombotic occlusion. The atrioventricular and semilunar valves were
failure and death in a 28-year-old Caucasian male, with reactivation of normal except for mitral valve, which showed abnormal leaflet
Systemic Lupus Erythematosus (SLE). A complete methodological thickening with a decreased mobility.
forensic approach by means of autopsy, histological, and The histological examination of the heart was performed using
immunohistochemical examinations lead investigators to conclude an haematoxylin-eosin (H&E) and revealed pericardial spots (lymphocytic
acute congestive heart failure due to pancarditis as cause of death. infiltrates); the myocardium showed focal and rare lymphocytic
This presentation will impact the forensic science community by infiltration in perivascular areas, patchy fibrosis, rare foci of irreversible
discussing a definitive diagnosis of acute congestive heart failure with hypercontraction with myofibrillar break and anomalous cross band
dilated cardiomyopathy after pancarditis was made, as a fatal and rare formation, and focal interstitial hemorrhages in subendocardial layers
complication of Systemic Lupus Erythematosus. (reflow areas). The mitral cusps showed diffuse fibrosis and
SLE is an inflammatory, autoimmune disease of unknown etiology, lymphocytic infiltrates.
characterized by the production of autoantibodies and the deposition of The immunohistochemical examination of the heart specimens
immune complexes in various organs. Cardiac involvement occurs revealed a positive reaction in cardiac myocytes for antibodies anti-TNF-
frequently, although it is often mild enough not to cause clinical concern. α and IL-8, and a stronger positive reaction for antibodies anti-IL-15 and
Pericarditis is most commonly seen, with a reported prevalence of 60%. IL-10.
Myocardial involvement is present in only a minority of patients and Furthermore, the expression of CD-4 and CD-8 showed a strong
valvular abnormalities can be demonstrated in an increasing number of positive reaction in pericardium, valvular endocardium, and less positive
patients. Although most of the valvular lesions will be present without in myocardial specimens.
any symptoms, valve incompetence can result in congestive heart failure. Examination of the other organs was unremarkable except for
Myocardial involvement usually accompanies other cardiac lesions. cytotoxic cerebral edema, massive pulmonary edema and polyvisceral
Isolated myocarditis, or dilated cardiomyopathy, is a rare and usually late stasis.
A definitive diagnosis of acute congestive heart failure with dilated G17 An Unusual “In-Custody” Death
cardiomyopathy after pancarditis was made, as a fatal and rare
complication of Systemic Lupus Erythematosus. Brian Drewry, BS*, Iowa and Jerri McLemore, MD, Iowa Office of the
Lupus, Pancarditis, Dilated Cardiomyopathy State Medical Examiner, 2250 South Ankeny Boulevard, Ankeny, IA
50023; Dennis Klein, MD, Iowa Depaartment of Public Health, 2250
South Ankeny Boulevard, Ankeny, IA 50023
G16 Autopsy Investigation and Bayesian
Approach to Coronary Artery Disease After attending this presentation, attendees will have learned
possible symptoms related to pheochromocytomas and learn basic
(CAD) in Victims of Motor guidelines for investigating in-custody deaths.
Vehicle Accidents This presentation will impact the forensic science community by
providing basic information required by the medical examiner or coroner
Antonio Oliva, PhD*, and Sara Merigioli, PhD, Institute of Forensic for deaths that occur in the presence of law enforcement officials. The
Medicine, Catholic University, School of Medicine, Largo Francesco presentation will also provide information of symptoms related to an
Vito 1, Rome, ITALY; Jose Flores, MD, Montreal Heart Institute. adrenal gland tumor.
University, Montreal, Quebec, Canada, Montreal, CANADA; Francesca In-custody deaths or deaths that occur in the presence of police
Cittadini, PhD, Sara Partemi, MD, and Vincenzo L. Pascali, PhD, officers are usually high-profile cases that have the potential to become
Institute of Forensic Medicine, Catholic University, largo Francesco Vito politically charged events. Scene investigation is vital to these types of
1, Rome, ITALY; and Ramon Brugada, MD, Montreal Heart Institute, deaths and should include acquisition of any video of the event,
Montreal Quebec, Canada, Montreal, CANADA eyewitness’ statements, investigation of the event by an independent
agency, and autopsy of the decedent. Because of the potential for rumors
After attending this presentation, attendees will understand the of foul-play or police misconduct to be propagated within a community,
importance of coronary artery disease in causing motor vehicle an autopsy should be performed on individuals who die while interacting
accidents. Each year 1.2 million people die world-wide as a result of with law enforcement officials even if the deaths seem “straight
motor-vehicle accidents and the prevalence of injuries is estimated at 50 forward.”
million, representing a tremendous burden to health. The objective of This presentation presents the sudden death of a woman with long-
this study was to define the prevalence of coronary disease and its standing hypertension during detainment by a peace office for a traffic
possible role in motor-vehicle accidents. violation. During her detainment, which caused her considerable stress,
This presentation will impact the forensic science community by she complained of having a “panic attack,” chest pains, and shortness of
discussing the data regarding the important percentage of evidence of breath. She became increasingly confused and would not respond to the
acute myocardial ischemia in traffic accidents. peace officer’s questions. She became unresponsive shortly after
Consecutive cases of non-hospital sudden death autopsies between emergency medical services arrived at the scene. According to the peace
2002 – 2006 were examined. The research focused on those individuals officer, at no point was the woman physically restrained. Autopsy
victims of motor vehicle accidents. A total group of 1,260 individuals in findings were remarkable for lack of trauma, cardiomegaly with left
the area of West Quebec were identified. Severe coronary artery disease ventricular hypertrophy, hypertensive changes in the kidneys, and a
(CAD) was defined as a narrowing of ≥ 75% cross-sectional area or tumor in the left adrenal gland that was diagnosed as a
acute plaque events in major epicardical coronary arteries. In order to pheochromocytoma. Pheochromocytomas can produce a variety of
evaluate the probability of fatal accidents caused by the presence of symptoms including hypertension and have been associated with sudden
significant coronary disease, a Probabilistic Expert System (PES) was death. Physical and emotional stress may precipitate hypertensive crises
applied. in individuals with these tumors. In this case, the woman’s unfortunate
Motor-vehicle accidents were responsible for a total of 123 deaths death happened to be in the presence of a police officer. Although the
(63%); 100 (81.3%) were males and 23 (18.7%) were females. In death was regarded as a probable natural manner of death from the onset,
individuals over 40 there was significant coronary artery disease in an autopsy was mandated to confirm this initial impression by
64.1%, with evidence of acute myocardical ischemia in 12%. In establishing an exact cause of death and to quell any possible accusations
decedents older than 60 years, the prevalence of significant coronary of misconduct by the peace officer.
disease and ischemia were 84.6% and 18.18% respectively. Two-thirds In-Custody Deaths, Investigation, Pheochromocytoma
of the coronary patients were identified as having erratic driving
behavior by bystanders before the accident. ETOH was detected in
11.8% and drugs in 4.9% of the drivers. Statistical analysis showed that G18 Analysis of Female Firearm Homicides in
an individual affected by coronary artery disease has an accident with a
probability of 0.09 (9%).
King County, Washington 2000 - 2007
This research data shows that there is a very high prevalence of
severe coronary artery disease in individuals who have suffered a motor- Janaki Warushahennadi, MD*, and Richard C. Harruff, PhD, King
vehicle accident. In an important percentage there is evidence of acute County Medical Examiner’s Office, 325 Ninth Avenue, HMC Box
myocardial ischemia. In contrast with previous statements, a large group 359792, Seattle, WA 98116
of the coronary drivers who died, had no time to control and stop the car
before the accident. This evidence has important implications for After attending this presentation, attendees will be able to describe
driving safety. distinctive features of female homicides due to firearm injuries.
Motor Vehicle Accident, Coronary Artery Disease, Autopsy This presentation will impact the forensic science community by
Investigation delineating the demographics, modalities, circumstances, and
motivations that characterize female homicides.
Materials and Methods: The records of the King County Medical
Examiner’s Office (KCMEO) in Seattle, Washington, were searched to
locate homicide victims from 2000 through 2007. These records were
analyzed with respect to demographics and cause of death to compare
male and female homicide victims. Those cases in which the decedent
was female and the cause of death was firearm injury were analyzed in G19 Genetic Aspects of Sudden Death in Youth:
more detail and were used to construct a database comprising essential
medical examiner information. Investigative records from the Homicide
A Retrospective Study of Familial
Investigation Tracking System (HITS) of the Washington Attorney Hypercholesterolemia
General’s Office were incorporated into this same database to include
details regarding the victim, circumstances, and perpetrator of her death. Maiken K. Larsen, MD*, Department of Forensic Medicine,
Analysis of this database was the basis of the results of this study. Brendstrupgårdsvej 100, DK-8200 Aarhus N, DENMARK; Peter H.
Results: From 2000 through 2007, there were a total of 618 Nissen, MSc, Department of Clinical Biochemistry, Aarhus University
homicides investigated by KCMEO; 490 were male and 128 were Hospital, Tage Hansens Gade, DK-8200 Aarhus N, DENMARK; Ingrid
female. Asphyxia, blunt force injuries, sharp force injuries, firearm B. Kristensen, MD, Department of Forensic Medicine,
injuries, and mixed modalities were identified as causes of death. Brendstrupgaardsvej 100, DK-8200 Aarhus N, DENMARK; Henrik K.
Considering deaths due to firearm injuries only, 334 (68.2%) of the male Jensen, MSc, Department of Cardiology, Aarhus University Hospital,
homicides were due to firearm injuries, compared to 52 (40.6%) of the Skejby, Brendstrupgaardsvej 100, DK-8200 Aarhus N, DENMARK; and
female homicides. This difference is highly statistically significant Jytte B. Lundemose, PhD, Faculty of Health Sciences Aarhus University,
(p<0.0001). In the group of 52 female firearm homicides, ages ranged Department of Forensic Medicine, Brendstrupgårdsvej 100, DK-8200
from 5 to 93 years with an average of 41.7 years; 23 were married, 17 Århus N, , DENMARK
single, 8 divorced, 2 widowed, and 2 of unknown marital status; 21 were
employed outside the home, 7 were homemakers, 5 students, 5 retired, After attending this presentation, attendees will understand some
and 2 unemployed. Blood alcohol levels in the decedents were positive principles of genetic heart disease and the advantage of genetic
in 21 cases and ranged from 3 to 24 mg/dL. In 34 cases, the shooting examination in selected forensic autopsies of sudden death. Preliminary
occurred inside a residence, 2 in unspecified buildings other than a results of premature ischemic heart disease will be presented as an
residence, 8 on the street, 3 in vehicles, 2 at worksites, and 1 in a tavern. example.
In 27 cases, the homicide was a consequence of domestic violence. This presentation will impact the forensic science community by
Other motivations and/or circumstances included 6 reckless or serving as a key aspect of sudden cardiac death investigation as it can
unintentional shootings, 4 for financial gain, 2 in “heat of anger”, 2 augment traditional means of investigation by including postmortem
“mercy killings”, 2 police officer involved shootings, 1 gang-related, 1 genetic examination in order to reveal familial hypercholesterolemia
“recreational”, 1 child abuse, and 1 due to ethnic hatred. Sexual assault (FH) in young people dying from coronary athero-thrombotic disease.
did not appear to be a motivation in any case. Seven of the decedents Several cases of sudden death due to basis of genetic heart disease
were from incidents involving multiple homicides. Perpetrators were have inspired this newly started retrospective study. The goal of the
identified as 15 husbands; 17 boyfriends, ex-boyfriends, male room- study is to examine inherited heart disease from selected forensic
mates or male acquaintances; 8 family members (child, parent, or other autopsies.
family member); 9 strangers, unknown assailants or unspecified male; Purified DNA from blood of approximately 230 selected autopsies;
and 1 female acquaintance. In 20 cases the perpetrator shot himself aged 0-40 will be examined. The following genetic heart diseases will
immediately after killing the female. be emphasized: Ischemic heart disease due to FH caused by defects in
Conclusions: In this study, firearm injuries accounted for less than the low density lipoprotein receptor (LDLR) and apo – lipoprotein B
half of all female homicides and occurred most commonly in a setting of (ApoB) gene; Long QT-syndrome and Brugada syndrome due to defects
domestic or intimate partner violence. Typically the decedent was a in cardiac ion channel proteins; catecholaminergic polymorph
mature woman and had stable employment. Perpetrators were nearly all ventricular tachycardia due to defects in the ryanodine receptor;
males with a close or intimate relationship with his victim. Most arrhythmogenic right ventricular cardiomyopathy due to defects in the
instances occurred in homes, but it was not unusual for an ex-partner to desmosome proteins; hypertrophic, and dilated and restrictive
make a deliberate attack elsewhere, such as at a worksite. Although cardiomyopathies due to defects in the contractile proteins.
attacks were often directed at intimate partners or ex-partners, sexual Preliminary results of the study concerning premature ischemic
assault was not a factor in any case. Nevertheless, the emotional context heart disease will be presented. Examination of approximately forty
of these homicides was evident in that nearly forty percent of the cases of death in youth due to ischemic heart disease is being examined
perpetrators shot themselves after killing the female. These findings for defects in the LDLR and ApoB gene.
support the conclusion that domestic violence and firearms are a Mutations in the genes of the above mentioned proteins are known
dangerous combination. to present as arrhythmia or sudden death. Diagnosed cases of sudden
Firearm Injuries, Female Homicides, Domestic Violence cardiac death in the Danish population are few, despite the estimated
higher number of cases in the literature. The perspective of the study is
to determine the molecular cause of sudden cardiac death in order to
intervene and prevent sudden cardiac death in relatives to cases with
proven genetic heart disease.
Sudden Cardiac Death in Youth, Genetic Heart Disease, Familial
Hypercholesterolemia
G20 An Unusual Death of a Masochist: Accident including the presence of cancer, does not rule out that the death may
have indeed been suicidal.
or Suicide? Masochism, Asphyxia, Autoerotic
Biagio Solarino, PhD*, Sezione di Medicina Legale, Università degli

Studi di Bari, P.zza Giulio Cesare, 11, Bari 70125, ITALY; Lucia Tattoli,
MD, Sezione di Medicina Legale, Univerisity of Bari, Bari, ITALY;
G21 Numerous Rhabdomyomata and Cortical
Ignazio Grattagliano, PsyD, Section of Forensic Psychiatry, University Tubers in a Possible Case of SIDS
of Bari, Piazza Giulio Cesare, Bari 70124, ITALY; Claas T. Buschmann,
MD, Institute of Legal Medicine and Forensic Sciences, Turmstrasse 22, Iyare Izevbaye, PhD*, State University of New York, Buffalo, 100 High
Berlin 10439, GERMANY; Michael Tsokos, MD, Institute of Legal Street, Buffalo, NY 14203; and Fazlollah Loghmanee, MD, Erie County
Medicine & Forensic Sciences, Turmstr 21, Haus L, Berlin 10559, Medical Examiner’s Office, 111 Lehn Spring Drive, Williamsville, NY
GERMANY; and Giancarlo Di Vella, PhD, Sezione di Medicina Legale, 14221-6920
DIMIMP, University of Bari, Policlinico, piazza G. Cesare, Bari
70121, ITALY After attending this presentation, attendees will exercise different
difficult possible manners of death in cases of SIDS.
The goal of this presentation is to describe a very unusual case of This presentation will impact the forensic sience community by the
the death of a masochist resulting from autoerotic behavior. importance of fact findings through detailed investigations; medical,
This presentation will impact the forensic science community by interviews with family members, etc.
bringing attention to the unusual practice of compressing the neck and Sudden Infant Death Syndrome (SIDS) is the leading cause of death
chest during masochistic activities, along with other information related for infants between the ages of one month to one year. This position has
to basic crime scene investigation, reconstruction of events, and autopsy remained unchanged despite risk reduction campaigns and the resulting
findings in these type cases. decline in prevalence in the past two decades. The rate of SIDS in the
Fatal masochistic asphyxia is a relatively rare phenomenon United States is 0.539 per 1000 livebirths in 2005, accounting for 7.8 %
secondary to the malfunction of apparatus used to provide sexual of all infant death. SIDS is defined as the “sudden death of an infant less
pleasure. The basic mechanism of sexual asphyxia is the creation of than one year of age, with onset of the fatal episode apparently occurring
cerebral hypoxia which, according to the literature, is generally brought during sleep that remains unexplained after a thorough investigation,
about by constriction of the neck by use of a ligature. In a small including performance of a complete autopsy, review of the
percentage of cases, less typical methods of sexual asphyxia involving circumstances of death, and the clinical history. SIDS, a diagnosis of
chest and abdominal compression are also employed. In all such cases, exclusion, can only be made after other explanations for unexpected
hypotheses of suicide and homicide must not be ruled out. death have been ruled out. Such explanations include Tuberous sclerosis
A case of a 52-year-old man found dead in the house where he lived and infantile asphyxia.
alone is reported here. The corpse was found in his study, lying supine Tuberous sclerosis complex is an autosomal dominant syndrome
on the floor, underneath an open chair bed with a 1.3 x 3.2 meter that is occasionally the findings in these patients with unexpected infant
mattress. The victim’s head protruded from under the mattress and was death. Infantile asphyxiation is an important condition that results from
partially covered by two blankets. One of the legs of the chair-bed was unsafe sleeping conditions and must be ruled out before a diagnosis of
discovered pressing perpendicularly into his throat, between which a SIDS can be made. Unsafe sleeping conditions include excess soft
rubber slipper was positioned, and whose sole was facing the anterior beddings, adult beds, chairs, sofas, waterbeds etc.
portion of his neck in midline. An iron support bar, which made up part A case of an unexpected infant death during sleep with multiple
of the bed frame, was pressed against the chest and upper abdomen, factors that confound the cause of death will be discussed. Factors and
causing the bed frame to be elevated off floor. He was wearing typical attempts to delineate their contributions to arrive at a cause and
men’s pajamas, underneath which he wore boxer shorts with the fly mechanism of death will also be discussed.
open. Autopsy revealed the clear imprint of the slipper’s sole on the Cerebral Tuberous Sclerosis Cardiac Rhabdomymata,
anterior side of the neck. There was no fracture of the hyoid bone or Undetermined Manner of Death, Final Fatal Mecanism of Death
thyroid cartilage, but several deep muscle bruises of the neck were
identified. Histological analysis revealed a hemorrhage of the jugular
vein and injury to the vagus nerve. An examination of the lungs revealed G22 Fatal Subarachnoid Hemorrhage During
a large solid mass (7 cm in diameter) occupying the inferior lobe of the
right lung; nodules and sclerotal patches involving the omentum were
Sexual Activity: A Case Report
observed, along with the presence of very large adhesions of the
peritoneum together with sub-obstructions of the bowel. Toxicological Federica Portunato*, Maria Celeste Landolfa, MD, Manuela Botto,
examination revealed no substances of abuse in the blood or urine. The MD, and Francesco De Stefano, MD, Department of Legal and Forensic
cause of death was attributed to asphyxia by external compression of Medicine, Via De Toni 12, Genova, I-16132, ITALY; and Francesco
breathing apparatus Ventura, MD, Department of Forensic Pathology, University of Genova,
Further investigation of the victims’ history revealed that he was via de’ Toni, 12, Genova, 16132, ITALY
under the care of a psychologist, due to the fact that he the had habit of
placing heavy objects (especially books and chairs) onto his chest or After attending this presentation, attendees will have learned about
abdomen with the purpose of engaging in masochistic sexual a case of sudden death immediately after coitus.
gratification. This practice interfered with his ability to become This presentation will impact the forensic science community by
intimately involved with women, and so he sought out psychological explaining that sexual activity, in susceptible subjects may be a trigger of
help to free him from this behavior. The victims’ medical history is medical emergencies with a real risk of sudden death.
unknown, including the fact that he had cancer. As far as is known, no Particularly, the anatomical and physiological responses to coitus
suicidal ideation was ever expressed by the victim. may determine many acute and severe complications. Among these,
These findings suggest that the manner of death should be classified cardiovascular, neurological and urological diseases, soft tissue and
as accidental. However, the unusual circumstances involved in this case, immunological consequences may arise in patients with predisposing
risk factors, even if asymptomatic (A. Banerjee, 1996).
Many cases of sudden and unexpected death during autoerotic peritonitis does not increase the significant mortality for the patient to a
activity have been reported in literature; the majority of these may be greater extent than from mixed aerobic gram negative organisms or from
considered accidental deaths, especially by asphyxial mechanism. Only anaerobic infection. It is nonetheless important for the forensic
few cases are reported as due to natural causes (N. Beahrendt pathologist to appreciate the potential for nosocomial spread of MRSA
et al., 2002). to both the respiratory tract as well as into the peritoneal cavity, with the
Studies on sexual related deaths show that cardiovascular diseases skin often colonized by MRSA when internal isolates of this
and cerebral hemorrhages are the most important causes of death microorganism are detected. Proper understanding of the mode of
connected to sexual activity. transmission will hopefully facilitate the development of guidelines to
Coronary artery disease (CAD), myocardial infarction and help prevent peritoneal nosocomial spread of Methicillin-resistant
reinfarction, dissection of aortic aneurysms along with cardiomypathy – Staphylococcus aureus.
with or without heart failure – are more frequently associated with This presentation will examine the transition of MRSA as a skin
coital death. commensal both to the respiratory tract of an immunologically
Even if intracerebral bleeding during sexual activity is rare, coitus compromised individual as well as to the peritoneal cavity following the
has also been considered to trigger subarachnoidal bleeding, because of insertion of a percutaneous endoscopic gastrostomy tube. This is the
the transient rise in blood-pressure. case of a 46-year-old white male who had a history of severe mental
As any form of physical exercise, sexual intercourse increases heart retardation/Down Syndrome and upper respiratory problems including
rate and blood-pressure. In the majority of cases of natural death dysphagia, being discharged from a regional hospital on January 20,
combined with sexual activity, the victims are generally male (W. 2009 after having a percutaneous endoscopic gastrostomy tube inserted
Janssen et al., 2005). for feeding. Upon returning to his place of residence, he suffered
Although the gender differences in the incidence of CAD and SAH respiratory arrest, with resuscitative efforts to no avail. The decedent
are statistically not significative, the male dominance of CAD has been was pronounced dead at 9:15 p.m. on January 20, 2009, only several
showed. On the contrary, the female dominance of SAH has been hours after being discharged from the hospital. Autopsy examination
demonstred (S. Lee et al., 2006). demonstrated a peritonitis that tested positive for Methicillin-resistant
Many authors described a “malignant coital headache,” so that it Staphylococcus aureus, with an excess of 300 ml of purulent tan fluid
can be considered a common feature of cerebral vascular accident (M. within the peritoneal cavity as well as coating visceral surfaces, and with
Sutton Brown et al., 2006). fibrinous adhesions extending between bowel loops. Present as well was
A case of sudden and unexpected death of a homeless 45-year-old a gastrostomy tube inserted within the pyloric region of the stomach that
woman is described. During the questioning of the circumstances of readily slipped out of the insertion point upon removal of the viscera
death, the partner reported that they were on the beach, lying under a from the abdominal cavity. Other significant findings included chronic
boat, around 1:00 p.m. The woman suddenly presented severe dyspnea pancreatitis, with an extensively sclerotic pancreas, cortical contusions
and rigidity of the body just after sexual intercourse. Medical assistance of the inferior orbital gyri of the left cerebral hemisphere, and extensive
was immediately called but the woman died despite attempts at fenestrations of all aortic valve cusps, with extensive epicardial scarring
resuscitation. According to the antemortem data obtained from the of the surface of the heart. The cause of death was determined to be
police report and relatives, it showed that the deceased was apparently acute pneumonitis, with aspiration complicated by Methicillin-resistant
healthy and did not show any prior symptoms of cardiovascular disease. Staphylococcus aureus-positive acute peritonitis, with significant
No signs of serious headache were present at all in the clinical history. contributing factors being inanition and dehydration, history of severe
Because the cause of death remained unknown in order to investigate the mental retardation/Down Syndrome, dysphagia, and chronic
partner’s report, a complete medicolegal autopsy was performed. The pancreatitis. The manner of death was rendered undetermined.
external examination was unremarkable and no signs of injuries or Percutaneous endoscopic gastrostomy tubes are used to provide long
trauma were observed. The internal examination revealed pulmonary term hydration and nutrition to patients who are no longer capable of
edema and lung congestion. There was massive subarachnoid receiving nutrition through oral means. Infections such as peritonitis
hemorrhage due to a basilar artery aneurysm rupture. No other important may arise upon gastrointestinal perforation, but may also develop after
pathological findings were observed. In conclusion, subarachnoid percutaneous placement of gastrostomy feeding tubes in patients
hemorrhage secondary to a cerebral aneurysm rupture is still an afflicted with commensal skin involvement by pathogenic bacteria.
important cause of death despite steady advances in diagnosis and Typical bacteria cultured from the peritoneal cavity in circumstances of
treatment. Although transient hemodynamic changes associated with gastrointestinal perforation (e.g.,-perforated diverticuli, gastric
sexual activity seem to play some role in the pathogenesis of ulcerations, etc.) include mainly a mix of aerobic gram negative bacteria
subarachnoid hemorrhage, the mechanism of physical activity induced (primary) and anaerobes (secondary). Isolation of a pure culture of
subarachnoid hemorrhage is still not completely known. MRSA is no longer an uncommon event in cases of bacterial peritonitis,
Sexual Activity, Subarachnoid Hemorrhage, Sudden Death however, likely a consequence of percutaneous nosocomial transfer of
these organisms. Prior MRSA infections in an individual increase the
likelihood of developing future such events. The insertion of a PEG tube
G23 Occurrence of MRSA in the Peritoneal facilitates MRSA spread into the peritoneal cavity, presumably through
nosocomial spread from the skin. Bacterial peritonitis is always a life-
Cavity Following PEG Tube Insertion threatening event; MRSA as the source of bacterial peritonitis
underscores both the ubiquity of this microorganism and the dangers
Nicole Singer, BS*, 206 South 13th Street Apartment 702, Philadelphia, associated with introduction of catheters into the peritoneal cavity within
PA 19107; and Fredric N. Hellman, MD, Office of the Medical Examiner, this context. The occurrence of MRSA as an isolate in bacterial
Fair Acres, Route 352, Lima, PA 19037 peritonitis does not increase the significant mortality for the patient to a
greater extent than from mixed aerobic gram negative organisms or from
After attending this presentation, attendees will become familiar anaerobic infection. It is nonetheless important for the forensic
with the means of transmission of methicillin-resistant staphylococcus pathologist to appreciate the potential for nosocomial spread of MRSA
aureus (MRSA) to the peritoneal cavity, proper percutaneous endoscopic to both the respiratory tract as well as into the peritoneal cavity, with the
gastrostomy (PEG) tube insertion procedures, and potential pitfalls, skin often colonized by MRSA when internal isolates of this
peritonitis, and a situation that links all previously mentioned aspects. microorganism are detected. Proper understanding of the mode of
This presentation will impact the forensic science community by transmission will hopefully facilitate the development of guidelines to
explaining that the occurrence of MRSA as an isolate in bacterial
help prevent peritoneal nosocomial spread of Methicillin-resistant appropriate serologic studies in order to correctly determine cause
Staphylococcus aureus. of death.
PEG Tube, Peritonitis, MRSA Forensic Pathology, Myxedema, Hypothyroid
G24 Two Cases of Generalized Myxedema G25 Adipositas Cordis and Iatrogenic Death:
Fatal Complication or Medical Error?
Meredith A. Lann, MD*, and Jeffrey J. Barnard, MD, Southwestern
Institute of Forensic Sciences, 5230 Southwestern Medical Drive, Guido Viel, MD*, and Giovanni Cecchetto, MD, University of Padua,
Dallas, TX 75235 Via Falloppio 50, Padova, 35121, ITALY; Ann S. Schroder, MD, and
Nadine Wilke, MD, Eppendorf - Hamburg, Hamburg,, GERMANY;
After attending this presentation, attendees will be able to Massimo Montisci, PhD, Via Falloppio 50, Padova, ITALY; and Klaus
summarize the clinical manifestations of hypothyroidism, recognize Pueschel, PhD, Eppendorf - Hamburg, Hamburg,, GERMANY
various autopsy findings associated with the hypothyroid state,
appropriately utilize ancillary testing to support their diagnosis, and After attending this presentation, attendees will learn some basic
discuss pathophysiologic aberrancies which may lead to death in this information regarding the risk of pacing maneuvers, and the role of fatty
type of case. infiltration of the right ventricle in causing delayed cardiac laceration.
This presentation will impact the forensic science community by This presentation will impact the forensic science community by
providing education about this medical condition and photographic discussing the utility of an integrated analysis of clinical, radiological
representation of several autopsy findings, as well as underscore the and histological data for identifying any eventual medical error during
diagnostic importance of performing a complete medicolegal autopsy pacing maneuvers.
with ancillary studies. It is well-known that the hearts of most adults in western countries
Hypothyroidism is rarely diagnosed in the forensic setting. Two contain varying physiological amounts of fat, found mainly in the
cases of hypothyroidism with generalized myxedema were diagnosed at subepicardial region of the anterolateral wall of the right ventricle. In the
the SWIFS between 2006-2009 and will be discussed in the presentation. normal heart the boundary between the inner myocardium and the outer
Generalized myxedema is also known as Gull disease, as it was first subepicardial fat is usually distinct, although a slight fuzzy border may
linked to the hypothyroid state in 1873 by Sir William Gull. The clinical be observed. On the contrary, in the fatty infiltration of the right
manifestations of hypothyroidism varies with age of onset. Children ventricle irregular islands of adipose tissue may extend from the
present with cretinism. Adults; however, suffer from relatively epicardium to the endocardium with the interposition of only few
nonspecific manifestations such as generalized fatigue, apathy, and muscle fibers.
mental sluggishness, slowing of speech and intellectual function. In such cases the risk of cardiac rupture after myocardial infarction
Constipation, decreased sweating, cold intolerance, and weight gain are as well as the risk of ventricular laceration after cardiac surgery is
common. Skin involved by myxedema takes on a thickened and waxy notably increased.
appearance. The skin may become cool and pale due to decreased blood The case of a 70-year-old woman who died of an acute pericardial
flow and/or an anemic state. Reduced cardiac output contributes to tamponade due to a delayed laceration of the right ventricle after
symptomatology of shortness of breath and decreased exercise capacity. pacemaker implantation is reported. The autopsy finding of a severe
The hair often becomes thinned, coarse, and dry-appearing. fatty infiltration of the right ventricle, its causal role in determining the
There are two forms of myxedema – generalized and pretibial. fatal pericardial effusion and the legal responsibilities of the physicians
Generalized myxedema is often seen in persons with hypothyroidism, who performed the implantation are critically discussed under a forensic
whereas pretibial myxedema is associated with a hyperthyroid state. point of view.
Histologic changes are similar in both forms, as the affected skin shows Myocardial perforation by pacing electrodes or Implantable
accumulation of matrix substances (glycosaminoglycans and hyaluronic Cardioverter-Defibrillator (ICD) leads is a well-known and documented
acid), with the separation of collagen bundles in the reticular dermis. In complication, occurring at a rate of about 0.4-2.0%. The largest part of
generalized myxedema, matrix accumulation occurs in deeper the injuries are clearly related to the impacting maneuvers peculiar to the
subcutaneous tissues and visceral sites, therefore involvement of the manipulation of pacing catheters and are recognized intraoperatively or
heart may directly lead to death in some cases. in the early postoperative period. Even if the complication is
In cases of generalized myxedema, a thorough scene investigation misdiagnosed or the rupture is delayed, due to the “self-sealing”
and medical history should be obtained. In addition, a full medicolegal properties of the myocardium and to the fact that generally the lead
autopsy to include toxicologic and ancillary serologic analyzes should be closes up the ventricular perforation (avoiding a massive bleeding), life-
performed. Thyroid stimulating hormone (TSH) is the most sensitive threatening pericardial or pleural effusions are rare.
screening method for the diagnosis of hypothyroidism, and TSH levels In our case, the presence of an extended fatty infiltration of the
in the serum of both adults and children are reliable up to twenty four lateral wall of the right ventricle (35% of the myocardium was displaced
hours after death. It is important to note that in cases of secondary or by adipose tissue) forced the operator to move the implantation lead back
tertiary hypothyroidism (i.e., pituitary or hypothalamic disease), the TSH and forth to obtain a valid electric signal. In that manner, because of the
level will not be increased. Thyroxine (T4) levels will be decreased in enhanced fragility of the right ventricle, the surgeon produced three
all cases of hypothyroidism. Hypothyroidism is easily treatable and micro-perforations, one of them localized on the lateral wall above the
carries a low mortality if one is given timely and sufficient hormone insertion of the anterior papillary muscle, and two of them localized near
therapy. the apex. All the perforations were of small dimensions and had “self-
Although a diagnosis of generalized myxedema is rare in the sealed” soon after the lead damage because the echocardiography
forensic setting, it is critical for the forensic pathologist to be able to performed thirty minutes after the implantation did not reveal pericardial
correctly identify this disease. There are many variations and subtle effusion and the patient was totally asymptomatic during the afternoon
findings which may easily be missed by the uneducated pathologist. One and the evening of the operative day.
must be able to recognize the various abnormalities at the time of Clinical and radiological data suggest that the fatal ventricular
autopsy, critically examine tissue by light microscopy, and select the laceration has formed during the late evening or night. Indeed, the
granulocyte infiltration along the margins of the tear dates the lesion All of this makes it easier for individuals to combine medications
between four and six hours before death. with alcohol and/or street drugs. But despite this shift, few if any studies
Considering the size and morphology of the injury as well as the have looked at drug errors outside clinical settings. Almost 50 million
extensive transmural fatty infiltration observed in that point of the death certificates were filed in the United States between January 1, 1983
ventricle, the most probable explanation is that the micro-perforation, and December 31, 2004, with 224,355 of them involving fatal
produced by the lead, progressively enlarged due to the presence of medication errors (FMEs). After examining all of these documents, it
multiple adipose cells that reduced the adhesion forces between the was discovered that the overall death rate from fatal medical errors
myocytes. Therefore, the fatty infiltration not only favored the lead- increased by 360.5 percent during that time period.
related injuries, but also played a key-role in causing the rapid and fatal The surge in FMEs differed by type. FMEs occurring at home and
pericardial bleeding. combined with alcohol and/or street drugs increased the most, by 3,196
Regarding the site and method of pacemaker implantation as well as percent. FMEs not happening at home and not involving alcohol and/or
the post-operative clinical monitoring, it is believed that several street drugs showed the smallest increase, at 5 percent.
questionable choices have been made. Meanwhile, at-home FMEs not involving alcohol and/or street
Attempting multiple maneuvers (i.e., making several punctures) to drugs increased by 564 percent, while at-home FMEs involving alcohol
find a site to place an active fixation lead at the apex is extremely or street drugs increased by 555 percent.
dangerous, above all if the patient suffers from a fatty infiltration of the Overall, the increase in FMEs was particularly pronounced among
right ventricle. people aged 40 to 59, where the increase was 890.8 percent. “People
Moreover, even if the echocardiography performed thirty minutes should no longer just focus on medication errors in clinical settings and
after the intervention did not reveal any pericardial effusion, considering caused by clinical staff,” Phillips said. “There’s a whole new world out
the complicated implant procedure, the patient should have been there that needs to be investigated, that is to say, fatal medication errors
cautiously monitored in a coronary unit, instead of being transferred to occurring at home and not in clinical settings, and apparently influenced
an internistic department. A proper postoperative surveillance would by patients and not by staff.”
have prevented the fatal outcome with a high degree of probability. Another expert agreed.
Fatty Infiltration of the Right Ventricle, Delayed Cardiac Rupture, “Most of the information we have about medication errors and their
Hemopericardium effect take place within the hospital setting,” noted Lisa Killam-Worrall,
director of drug information and assistant professor of pharmacy practice
at Texas A&M Health Science Center Irma Lerma Rangel College of
Pharmacy.
G26 Public Death From Orally Ingested Drugs But she said there’s a real challenge in finding out exactly what
During a One Year Period in Louisiana as substances people might be taking along with their prescription
medications.
Analyzed by a Single Forensic Toxicology “As pharmacists, we always try to counsel people when
Laboratory medications could interact with alcohol or other medications, but there
aren’t that many studies looking at interactions with street drugs,”
Gilbert E. Corrigan, PhD*, 11801 Hidden Lake, Saint Louis, MO 63138 Killam-Worrall said. “We normally don’t ask people, ‘Are you using
street drugs and which ones are you using?’ We normally try to ask
After attending this presentation, attendees will learn about a people, “What other medications are you taking, prescription, over-the-
population-based timed study of death by oral ingestion of drugs. counter, herbal supplements?’ But usually with illicit drug use, you’re
This presentation will impact the forensic science community by not going to garner a lot of information.”
teaching the necessity of scientific precision in all aspects of a forensic The findings also have policy implications in terms of patient care ,
study. Phillips added.
Monday, July 28 (HealthDay News) – Researchers have discovered “Asking patients to be part of the quality-control team is not
a soaring increase in the number of fatal medication errors that occur in something you can just automatically do,” he said. “It’s true that keeping
people’s homes. shorter times in hospitals saves money, but it apparently loses lives, and
The report incidentally follows the death earlier this year of Heath a way to try to ameliorate that would be to spend more time in educating
Ledger, the 28-year-old actor who died from an accidental overdose of the patient about the risks of taking these powerful medicines and the
prescription drugs in his apartment in New York City. risks, particularly, of taking these powerful medicines in conjunction
“[There was] large-scale evidence that the death rate from with alcohol and/or street drugs.”
prescription errors was going up very fast, but I didn’t know until this Public death as a studied scientific phenomenon provides a unique
paper that they were going up extremely fast in particular circumstances, opportunity for the understanding of the human condition and its
namely at home and when alcohol and/or street drugs are involved,” said attributes. This study of the death during the year 2008 of a small cluster
study author David P. Phillips, a professor of sociology at the University of Louisianians whose death became public as determined by their
of California at San Diego. willful consumption of controlled substances and drugs will provide the
“I also didn’t know from this paper that the number of years of reader with a privileged insight into these actions. The study has defined
potential life lost from potential medication errors are greater than the boundaries.
number of years of potential life lost from all accidents combined, The deaths are in single geopolitical area, under a single authority,
including falls and drowning,” he said. had no pre-established descriptors save that the deaths are secondary to
According to background information in the paper, published in the drug use investigation, were in a precise timeframe of one year, had a
July 28 issue of the Archives of Internal Medicine, there has recently uniform management in all details, and most importantly had
been a dramatic shift in fatal overdoses away from inpatient settings to professional scientific establishment of the cause and the nature of the
outpatient settings. More and more medications are taken outside of the death through detailed pathological and toxicological studies. The
hospital or clinic, with far less oversight from health-care professionals, expenses of the study are secondary to the established budgetary
the researchers said. standards of this government. These high standards are dictated by the
At the same time, more medications that once were available only important and constant use of the data and the conclusions derived
by prescription are now bought over-the-counter, and more people are therefrom to maintain the order of a complicated modern society.
taking more than one medication.
More information of an integrated analysis of histological and toxicological data to
The U.S. Food and Drug Administration has more on medication errors. determine the manner and the cause of death in such cases.
SOURCES: David P. Phillips, Ph.D., professor, sociology, University of This presentation will impact the forensic science community by
California at San Diego, La Jolla; Lisa Killam-Worrall, Pharm.D., BCPS, underlining the importance of sampling and analyzing burned materials
director, drug information and assistant professor, pharmacy practice, when phosgene intoxication is suspected. This compound is not
Texas A&M Health Science Center, Irma Lerma Rangel College of detectable in body fluids and tissues due to its rapid conversion to
Pharmacy, Kingsville, Tex; July 28, 2008, Archives of Internal Medicine hydrochloric acid.
Copyright © 2008 ScoutNews, LLC. All rights reserved. The rate of annual deaths related to fire is about 13 per million
2008-07-28 16:00:00 inhabitants in the United States and Canada. These are mostly accidents
Public Death, Fatal Oral Ingestion, Population Studies followed by suicides. Homicides with subsequent burning of the victim
or killings by burning are comparatively rare in Europe just as in the
United States and Japan and are reported more often from India or South
G27 Complex Suicide: A Case Report Africa.
The morphological findings in burned bodies may cover a broad
Cristina G. Cordeiro, MD*, and Duarte N.P. Vieira, PhD, Instituto spectrum. They can range from minor, local, superficial burns of the
Nacional de Medicina Legal, IP, Largo da Sé Nova, Coimbra, skin to calcined skeletal remains without any soft tissue left and total
3000-213, PORTUGAL incineration. In most cases the effects of heat on the body continue
beyond death, consequently, the changes found are largely of
After attending this presentation, attendees will appreciate the need postmortem origin. The forensic investigation of deaths related to fire is
of a high index of suspicion for the diagnosis of a complex suicide and important in order to determine the manner and cause of death and the
the importance of a full and careful autopsy. vitality of the findings. The issues of vitality and cause of death are
This presentation will impact the forensic science community by closely linked: the basis of the assessment is a careful evaluation of
describing the diagnosis of complex suicides. autopsy findings to distinguish morphological consequences of the
In 1974, Marcinkowski had proposed a general division of suicide. effects of heat during life and after death.
In this classification, suicides are first divided into simple versus A case will be presented where two burned bodies found early in the
complex. The term “complex suicide” refers to suicides in which more morning inside a joust (largely made of polyvinyl chloride – PVC and
than one suicide method is applied and usually a distinction is made named “Wrestling labyrinth”), that burned in a town square after a
between planned and unplanned complex suicides. In planned complex festival. The victims were reportedly lovers (the boy 20 and the girl 16-
suicides, the combination of two or more methods of suicide are years-old).
previously planned and employed simultaneously in order to make sure At external examination the corpses showed a typical boxer’s
that death will occur even if one method fails. On the other hand, in attitude with general incineration, exposure of body cavities, bone
unplanned complex suicides, several other methods of suicide are tried fractures and partial amputation of extremities. To analyze the
after the first method chosen failed, if death occurs too slowly or when it morphology of the fractures and their location a high-resolution
proves to be too painful. computed tomography (CT) was performed, indicating that all fractures
In planned complex suicides, typically two of the common methods were a result of thermal effect.
of suicide (e.g., ingestion of hypnotics or other medicaments, hanging, Major internal findings consisted of hemorrhagic pulmonary edema
drowning, use of firearms, jumping from a height) are combined. In and “puppet organs.” Foam and soot particle depostis were detected
unplanned complex suicides, injuries by sharp force, especially cutting inside the respiratory tract of both victims.
the wrists, are often found as the primary act of suicide and then an At histological examination of the lungs, ninety-five percent of the
appropriated method of suicide is use, more frequently hanging or alveoli were flooded with edema and erythrocytes. There was no
jumping from a height. evidence of fibrin and inflammatory infiltrates. Immunohistochemistry,
A case of a complex suicide is presented where the victim shot using epithelial (epithelial membrane antigen and cytokeratin) and
himself in the head and hanged himself. The death scene investigation endothelial (CD-34 and F-VIII) markers, revealed severe alveolar
associated with the findings at the autopsy was very important to classify necrosis without endothelial damage of the vessels.
this complex suicide as an unplanned one. Systematic toxicological analyzes, performed on postmortem blood
The need, in some situations, of a high index of suspicion for the and urine, excluded alcohol and drugs intoxication. Monoxide-
diagnosis of this entity is emphasized. So, a full and careful autopsy, hemoglobin (CO-Hb) and cyanides concentrations were well below
including toxicological analysis, combined with the investigation of the lethal values.
death scene is mandatory in these cases. First, to exclude the possibility The presence of soot deposits and mucus inside the respiratory tract
of intervention of another person in the death; and second, to allow a (not occluding the airways) along with a heat damage of the mucosa of
distinction between planned and unplanned complex suicide. the upper respiratory tract (edema, mucosal bleeding and vesicular
Suicide, Complex, Autopsy detachment) suggest that the victims were alive during the fire and
breathed fire-fumes.
The combined analysis of histological and immunohistochemical
findings led us to identify the origin of the lung damage in the inhalation
G28 Fire Death of Two Lovers: of an irritative gas. Laboratory tests, performed on burned samples of
An Immunohistochemical and the joust (collected at death scene) and on samples of a similar
Toxicological Study undamaged joust, demonstrated an extensive production of phosgene
during experimental burning.
Paolo Fais, MD*, Guido Viel, MD, Massimo Montisci, PhD, Alessandro Phosgene is a combustion, thermal decomposition or
Nalesso, Silvano Zancaner, MD, and Giovanni Cecchetto, MD, photodecomposition product of certain volatile chlorinated hydrocarbons
University of Padua, Via Falloppio 50, Padova, 35121, ITALY (for example, trichloroethylene or perchloroethylene). These chlorinated
hydrocarbon compounds can evolve phosgene if they come into contact
After attending this presentation, attendees will understand with very hot metal, flame, or ultraviolet light. Phosgene is a colorless,
investigation of deaths due to phosgene intoxication and the importance extremely volatile gas which, at low concentrations, smells sweet, like
freshly mown hay, whereas at high concentration has a pungent and
objectionable odor. When aspirated, it combines with the water of the radiologic data when available, autopsy findings and a review of the
mucous membranes being rapidly converted to hydrochloric acid, with literature. The information presented will enhance the efficiency and
subsequent injury to the lungs (hemorrhagic pulmonary edema). accuracy of investigation and certification of deaths from
In this cases, even in the presence of extensive direct thermal subdural bleeding.
injuries, the integration of histological and immunohistochemical Subdural Hematoma, Death Investigation, Neuropathology
findings suggests as principal mechanism of death an asphyxia by airway
submersion related to the inhalation of phosgene (called “dry land
drowning”). Indeed, the detected hemorrhagic pulmonary edema was of G30 Accidental Carbon Monoxide Poisoning:
such an extension (involving more than ninety five percent of the
alveolar space) to be clearly incompatible with life, and capable of
A Review of Environmental and Cultural
causing a rapid death. Risk Factors of Fatal Cases in King County
In conclusion, the reported cases highlight the following teaching
messages: Kristinza R. Woodard, MD*, University of Washington Pathology and
1. Histological and immunohistochemical investigations may Lab Medicine, 1959 Northeast Pacific Street, PO Box 356100, Seattle,
enhance the identification of the real cause and mechanism of WA 98195; and Richard C. Harruff, MD, PhD, King County Medical
death in fire accidents. Examiner’s Office, 325 9th Avenue, Box 359792, Seattle, WA 98104
2. Sampling and analyzing burned materials may be of
valuable importance when dealing with phosgene After attending the presentation, the attendees will be able to
intoxications. This compound is not detectable in body identify certain environmental and cultural factors that may increase
fluids and tissues due to its rapid conversion to accidental death by carbon monoxide inhalation.
hydrochloric acid. This presentation will impact the forensic science community by
Phosgene Intoxications, Fire Deaths, Immunohistochemistry increasing awareness of environmental and cultural factors that influence
the misuse of carbon monoxide producing devices and will suggest ways
to decrease the incidence of accidental deaths.
G29 Non-Traumatic Subdural Hematoma Introduction: Carbon monoxide (CO) is an odorless, colorless gas
that forms as a result of incomplete combustion of carbon-containing
in Adults fuels. While trace levels of CO are found in the atmosphere, fatal levels
are found in exhaust from multiple sources including automobiles,
Carolyn H. Revercomb, MD*, and Sarah M. Colvin, MD, Office of the generators, propane heaters and charcoal burning grills. Accidental
Chief Medical Examiner, District of Columbia, 1910 Massachusetts carbon monoxide poisoning is responsible for up to fifty percent of the
Avenue Southeast, Washington, DC 20003; and Marie L. Pierre-Louis, yearly carbon monoxide related fatalities in King County (five accidental
MD, 6404 Luzon Avenue, Northwest, Washington, DC 20012 deaths in ten total carbon monoxide deaths in 2007).
Purpose: Risk factors of accidental CO related deaths in King
The goal of this presentation is to provide attendees with knowledge County from 1996 to 2008 were reviewed in an attempt to reveal
of the range of causes of subdural hematoma in adults and the key preventable causes.
clinical and anatomic features that distinguish nontraumatic from Methods and materials: Between 1995 and 2008, 221 cases of
traumatic subdural bleeding. carbon monoxide poisoning were identified between 1995 and 2008
This presentation will impact the forensic science community by within the King County Medical Examiner’s information database.
enhancing the efficiency and accuracy of investigation and certification Forty-three of which were results of accidental CO poisoning between
of deaths from subdural bleeding. 1996 and 2008. These cases were analyzed with respect to scene
While head trauma is the commonest cause of subdural hematoma investigation reports and circumstances surrounding fatality.
both in hospital and in medicolegal autopsy settings, some patients Findings: CO producing devices were found placed within single
presenting with subdural hemorrhage have a non-traumatic etiology. family residences in 19 of the 43 accidental deaths. Eleven cases
Because rapid demise may preclude angiography and other procedures to involved CO producing products within vehicles used for residence
establish the source of subdural blood, these cases often come to the including trailers, RVs, campers, and vans. Seven of the deceased were
attention of the medical examiner. Distinguishing such “spontaneous” found in their cars in their garage, four died from house fires, and the
subdural hemorrhage from the more common traumatic subdural exact location of the source of CO was unclear in two cases (outside
hematoma rapidly and with confidence can be a challenge to the forensic versus inside the home). Further review indicated generator exhaust as
and neuropathologist. Complete radiologic reports often are not the most common source of accidental CO poisoning, with 18 of 43 total
available at the time of the report of death, allegations of head impact accidental deaths. Other sources of CO in decreasing incidence included
during collapse may complicate the investigation, and neuropathologic exhaust from vehicles (7), heaters (6), charcoal burning (6), house fires
examination of the brain at autopsy is best preceded by fixation of the (4), furnaces (2), a hot water heater (1), and an engine from an industrial
brain prior to dissection. Certain historical and gross autopsy findings carpet-cleaning machine. Nine deaths were due to generator exhaust or
should prompt a heightened index of suspicion of nontraumatic etiology charcoal burning during power outages, including eight during a
in subdural hemorrhage. The entities most often associated with windstorm during December 2006. Four incidents included deaths of
spontaneous subdural bleeding include subdural extension of more than one individual with three paired deaths (6 total deaths) and
intracerebral hemorrhage, cerebral arteriovenous malformations and one Vietnamese family (5 total deaths). 69% (30) of the CO victims
aneurysms, and metastatic tumors. Impaired coagulation from during this time were White, 7% (3) were Black, 7% (3) were Hispanic
medications or from natural conditions such as hematologic or hepatic and 16% (7) were Asian/Pacific Islander. The majority of these cases
disorders also can result in subdural hemorrhage. In cases of involve people who are unfamiliar with the proper use of generators or
nontraumatic subdural hemorrhage, the face and scalp will lack charcoal products, either due to inexperience or inability to gain
abrasions or contusions. When the brain is examined grossly on information about certain products in their native language. No carbon
removal, focal, thick subarachnoid hemorrhage, especially if located monoxide monitors were identified in any scene investigation reports.
other than in the parasagittal cerebrum, is suggestive of a source of Discussion: The most significant environmental and cultural risk
subdural hemorrhage within the brain rather than from rupture of factors identified were unfamiliarity with CO producing products and the
bridging veins as is usual in trauma. Five cases of non-traumatic inability to receive information about these products in various
subdural hemorrhage in adults are presented with case histories,
languages. Preventing accidental deaths in cities with multiple ethnic Social Services titled Death Scene Investigative Checklist for Child
groups begins with increased availability of educational information in Fatalities. The form covers minimum necessary information which
several languages. Many of these products are purchased directly before maybe used later on in the death certification process. It covers key
power outages in a rush to provide heat and power and the proper points such as prenatal history, events surrounding death, condition and
educational information is not exchanged. The Vietnamese family position of the child, as well as social and environmental conditions.
mentioned earlier, had a receipt for their generator, which was purchased While natural, accidental and undetermined manner of death is
one day prior to death. distressing to the family, homicide has its own caveats. The perpetrator
After identifying these products in stores, many of the instructions is frequently known to the family and is usually not biologically related
and warning labels are written in English and Spanish, however, warning to the deceased. Most pediatric homicides are crimes of spontaneous
labels in less frequently spoken languages may help prevent CO impulsive behavior. The killing is not usually premeditated, but rather a
poisoning. Ways to educate consumers include increasing awareness via reaction to the child’s behavior such as loud crying or poor feeding.
television, the internet through downloadable brochures available in Most frequently the assailant uses their own body (i.e., hands, feet, torso)
multiple languages and product education including the additional or to inflict the fatal injuries onto the child. The troubling aspect of
paired purchase of carbon monoxide monitors, especially prior to pediatric death for medicolegal investigators, law enforcement and
anticipated power outages. While the most important time to discuss forensic pathologists is that homicide within this population does not
product education occurs during the purchase of the product, education always exhibit overt trauma. In instances of mechanical asphyxia and
about CO producing products should occur through multiple methods. unusual poisoning, even a diligent postmortem examination and standard
Carbon Monoxide, Poisoning, Accidental Death toxicology panel may not reveal the cause and manner of death.
Therefore, we must rely on either keen investigative techniques or await
G31 Differences in Scene Reenactment of perpetrator’s confession. While in most sudden infant deaths, the parents
or caretakers appear distressed, the stories and reenactments of in cases
Pediatric Death: Homicide Versus Others of homicide frequently shift during the investigation. Investigations in
these deaths often reveal an inconsistency or improbability during the
scene reenactment.
Marianna Sandomirsky, MD*, and Jane W. Turner, PhD, MD, St. Louis Scene Reenactment, Pediatric Death Investigation, Manner of Death
City Medical Examiner’s Office, 1300 Clark Street, St. Louis, MO 63103
After attending this presentation, attendees will be able to critically

apply information gathered from the experience of the City of St. Louis
G32 Suicide by Multiple Gunshots From
Medical Examiner’s office. The main goal is to help differentiate Automatic Weapons
homicide from other manners of death such as accident and
undetermined when dealing with pediatric death. Scene reenactment as Paul Uribe, MD*, 7807 Mineral Springs Drive, Gaithersburg, MD
part of the investigation is an invaluable tool in assessing these 20877
difficult cases.
This presentation will impact the forensic science community by After attending this presentation, attendees will be able to describe
discussing key differences observed while investigating pediatric deaths the characteristics of selective fire and “full-auto” weapons and become
with the aid of scene reenactment. familiar with the patterns of injury associated with self-inflicted injuries
Pediatric deaths can be complicated cases for the medicolegal using these types of weapons.
system, not to mention the families involved. Determination of cause This presentation will impact the forensic science community by
and manner of death is the driving principle behind the investigation. providing a case series of a self-influcted pattern of injury that has rarely
Key parts of the investigation consist of scene investigation, postmortem been discussed in the forensic literature.
studies including autopsy, radiographs, ancillary studies such as Eight cases of suicide from multiple gunshot wounds by use of
toxicology, and if pertinent, microbiology testing. Thorough automatic weapons will be discussed. Automatic weapons are either
photographic documentation during the initial visit to the scene as well solely automatic or have selective fire mechanisms. Selective fire
as at the time of the autopsy is vital to assessing pediatric deaths. Scene mechanisms include settings for semi-automatic, three round burst, and
investigation is usually performed by medicolegal death investigators “full-auto” modes of fire. Weapons with either selective fire settings or
who may conduct their inquiry either via telephone or actual visit to that are solely automatic can rapidly discharge multiple rounds in
the scene. immediate succession when the trigger is pulled. In this case series,
All pediatric cases (ages 0-5) referred to the St. Louis City Medical there was a strong predilection for wounds of the head (7/8) and only one
Examiner’s office during a five-year period, from January 2003 to (1/8) had recovery of the projectile fragments. The recoil produced from
December 2008 were analyzed. The cases were stratified according to firing an automatic weapon can produce considerable distance between
the manner of death of either homicide, accident, or undetermined. The entrance wounds. In all of the cases studied, two or more rounds
differences in cases that underwent scene reenactments and correlated discharged and each had at least two entrance wounds; however, in two
them with the postmortem studies were compared. Some of the cases cases the number of rounds discharged could not be determined due to
were investigated with phone interviews, usually due to traveling or the extent of the injuries, co-mingling of trajectory paths, and shared
jurisdictional constraints. Telephone interview investigation findings entrance and exit wounds. Thorough scene investigation is essential in
will also be discussed. these cases to in an effort to determine how many shots were fired, what
One of the most difficult aspects of pediatric deaths for the family type weapon was used, and if a selective fire setting was used.
is that the event is generally unexpected, unless there is history of natural Reconstructive computed tomography can also be useful in illustrating
disease. SIDS (Sudden Infant Death Syndrome) is a diagnosis of wound paths and assisting the determination of how many shots
exclusion, reserved for cases for which no cause of death is found after were fired.
a thorough investigation. The scene reenactments conducted in our Suicide, Gunshots, Automatic
office frequently demonstrate bed sharing or positional asphyxia as a
cause of the child’s death. These cases are no longer classified as SIDS
as a result of this investigative tool. Additionally, our investigators use
a standardized questionnaire published by Missouri Department of
G33 EBV (+) T-Cell Lymphoproliferative Neuropathologic examination performed after brain fixation
revealed hypoxic encephalopathy with marked swelling and cerebellar
Disorder of Childhood Causing Sudden tonsillar herniation. Alzheimer type II astrocytes were noted in globus
Death: A Case Report pallidus, neostriatum, thalamus, medulla and cerebellar dentate nucleus
consistent with hepatic encephalopathy.
Mark A. Super, MD*, Sacramento County Coroner’s Office, 4800 In the work-up of sudden unexpected deaths in children and young
Broadway, Suite 100, Sacramento, CA 95820-1530; and Karimireddy J. adults with similar presentations, especially in Asians, EBV positive T-
Reddy, MD*, University of California, Davis, Department of Pathology, cell lymphoproliferative disorder should be considered. Since the
4400 V Street, Sacramento, CA 95817 clinical course is usually rapid and the mortality rate is high, medical
examiner/coroners are often involved in investigating the cause of death.
After attending this presentation, attendees will become familiar Antemortem EBV serology and relevant histological evaluation of liver,
with this unusual disorder that can have a rapid course with high spleen, lymph nodes, and bone marrow aid in the initial diagnostic work-
mortality such that medical examiner/coroners (ME/Cs) are involved in up. Immunohistochemistry, EBER-ISH & T-cell receptor gene
the investigation. Attendees will learn the value of special testing in rearrangement studies that can all be performed on paraffin embedded
autopsy cases, such as immunohistochemistry, EBER-ISH, and T-cell blocks are additional valuable tools in clinching the diagnosis.
receptor gene rearrangement studies. Epstein-Barr Virus, T-cell Lymphoproliferative Disorder,
This presentation will impact the forensic science community by EBER-ISH
stressing the need for access by medical examiner/coroner’s offices of
good immunohistochemistry testing, in-situ hybridization testing, and
gene rearrangement studies. Lack of access to these modern techniques G34 Temporal Variation of Ethanol Related
can lead to many death investigations remaining unsolved,
or misdiagnosed.
Firearm Deaths
Systemic Epstein-Barr virus (EBV) positive T-cell
Lymphoproliferative disorder (LPD) of childhood is a life-threatening Rameen S. Starling-Roney, MD*, Anna Rubio, MD, Donna M. Vincenti,
illness of children that may be associated with chronic active EBV MD, and David R. Fowler, MD, State of Maryland Office of the Chief
infection or following a primary acute EBV infection. This entity is most Medical Examiner, 111 Penn Street, Baltimore, MD 21201
prevalent in Asia and rarely reported in the West. Common sites of
involvement include the liver, spleen, lymph nodes, bone marrow, skin After attending this presentation, attendees will understand the
and lungs. It has a fulminant clinical course with development of potential risk of ethanol use and subsequent homicidal death by firearms
hepatosplenomegaly, liver failure, lymphadenopathy, rapidly (gunshot and shotgun), and the seasonal temporal variation in homicides
progressing to multiorgan failure. Other complications such as in which the decedent was under the influence of ethanol.
hemophagocytic syndrome and sepsis can occur. The prognosis in most This presentation will impact the forensic community by examining
cases is dismal with death resulting in days to weeks. the association between ethanol intoxication and firearm related
We present a case of a 3½-year-old, previously healthy, Hmong girl homicides. Previous reports have shown a direct correlation between
who presented with to a hospital ER with nausea and vomiting. Initial ethanol intoxication and suicides and accidental deaths (specifically
CBC revealed leukocytosis with an absolute neutrophilia and motor-vehicle accidents). However, a definitive association between
lymhocytosis. Over the next twenty-four hours, the decedent developed ethanol intoxication and homicides has not been established.
rapidly progressive hepatic failure, became lethargic and unresponsive. A review of all homicides in the State of Maryland between 2003
Her hematological parameters were as follows: Fibrinogen=152, and 2007 was performed for cases in which death was due to firearms
PTT=41.8, PT=32.1, INR=3, D-dimers: 1869 (n<250ng/ml). Her liver and in which heart blood was available and evaluated for toxicology
function tests were markedly elevated AST: 4770, ALT: 5030, Ammonia: (cases in which complications occurred were omitted). Cases were
421. Mushroom poisoning was strongly considered. Immunoassays for classified by whether the decedent’s heart blood ethanol level was above
RSV, Influenza A & B, Adenovirus and Hepatitis A & B were negative. or below the legal limit of intoxication (0.08 g/dl). Predictors of elevated
EBV serology showed antibodies to EBV (EBV VCA IgG: 1185 blood ethanol were examined by logistic regression analysis with
(Normal<100) and EBVNA IgG: 1392 (Normal <100). On day two of multiple independent variables including age, gender, week of the year,
admission, a CT scan of the head showed cerebral edema with tonsilar day of the week, month, and season. Statistical significance was
herniation. Due to the extremely poor prognosis of the critically ill determined by likelihood ratio tests. The numbers of total homicides
patient, care was ultimately withdrawn. were compared for different days of the week and month of the year by
Significant findings at autopsy were cerebral edema with tonsilar Poisson regression analysis, aggregating the five years of the study
herniation, hepatic necrosis, splenomegaly (96.9 grams) and massive period.
mesenteric lymphadenopathy. Multiple matted mesenteric lymph nodes A total of 1,571 cases were identified using the above criteria. The
were noted; the largest measuring 3 cm in greatest dimension. Sections median age for the cases was 26-years-old, 91.4% of the decedents were
revealed homogenous tan-pink cut surfaces. male and 86.4% were African-American. Statistically significant
Microscopic examination of the liver showed moderate portal acute temporal variation was noted in the aggregate number of homicides by
and chronic inflammation with hepatocellular necrosis. Sections of day of the week (greater on Saturday) and month of the year (greater in
spleen showed atypical lymphoid cell infiltrates. Histological July and January). Of all cases, 271 (17.3 percent) had a blood ethanol
examination of an enlarged mesenteric lymph node revealed complete level of 0.08% g/dl or greater. There was statistically significant
effacement of nodal architecture by medium to large, atypical temporal variation in ethanol related homicides by day of week
lymphocytes with irregular nuclear contours and occasional nucleoli, and (increased on Saturday and Sunday) and month of the year (increased
abundant mitoses. Immunohistochemical stains performed on the lymph between May and August with peaks in June and July). In addition there
node showed a predominant T-cell population (CD3+/CD5+ cells) with was a significant increase in ethanol related homicides in the summer
high proliferation index (MIB-1: 70-80%) and a small population of when compared to the remaining seasons. No temporal variation was
scattered B-cells (CD20+). EBV encoded RNA (EBER) was positive by seen in non-alcohol related homicides. A direct relationship was not seen
in-situ hybridization (ISH) in the mesenteric lymph node and spleen. A between increased ethanol related homicides and increased total
T-cell receptor gene rearrangement study was performed confirming a homicides when compared to month of the year and season, however a
clonal population of T-cells. trend was seen when compared to the day of the week (increased
on Saturday).
In conclusion this study shows temporal variations in overall not, with certainty, differentiate these cases from the five homicides by
firearm homicides and ethanol related firearm homicides. However a immunohistochemical staining alone.
direct association in terms of increased ethanol consumption was The specifics of the cases to illustrate the complexities involved in
not established. interpreting β-APP deposition in cerebral tissues and to make
Ethanol, Firearm, Temporal Variation recommendations regarding the use of adjunct immunohistochemical
studies in suspicious infantile deaths will be discussed. Perspective of
trends, since 1999, in the evaluation of SIDS versus sudden unexplained
G35 Axonal Injury in Pediatric Head Trauma: death of an infant (SUDI)—especially with regards to co-sleeping
factors that might result in asphyxia and hypoxic ischemic injury will
A Study of the Interpretation of ß-Amyloid also be discussed. Data confirms that while β-APP staining can be useful
Precursor Protein (ß-APP) Expression in and corroborative, immunohistochemistry cannot be used independently
Trauma and Non-Trauma Cases to determine the presence or absence of traumatic injury
Amyloid Precursor Protein, Axonal Injury, Trauma
Michael W. Johnson, MD, PhD*, and Anna Rubio, MD, State of
Maryland Office of the Chief Medical Examiner, 111 Penn Street,
Baltimore, MD 21201; Juan Troncoso, MD, The Johns Hopkins G36 Association of Retinal Hemorrhages With
University, School of Medicine, 558 Ross Building, 720 Rutland Avenue, Fatal Head Injuries in Infant Monkeys
Department of Neuropatholyg, Baltimore, MD 21205; and David R.
Fowler, MD, and Ling Li, MD, State of Maryland Office of the Chief Candace H. Schoppe, MD*, and Patrick E. Lantz, MD, Wake Forest
Medical Examiner, 111 Penn Street, Baltimore, MD 21201 University School of Medicine, Department of Pathology, Medical
Center Boulevard, Winston Salem, NC 27157; Kurt A. Schoppe, MD, and
After attending this presentation, attendees will understand that Jonathan Burdette, MD, Wake Forest University School of Medicine,
although beta amyloid precursor protein expression (β-APP) can be Department of Radiology, Medical Center Boulevard, Winston Salem,
useful in confirming axonal injury, its presence or absence cannot in and NC 27157; Keith G. Mansfield, DVM, Harvard Medical School, New
of itself, prove or disprove traumatic injury. England Primate Research Center, 1 Pine Hill Drive, Southborough,
This presentation will impact the forensic community by illustrating MA; and Constance A. Stanton, MD, Wake Forest University School of
the complexities of interpretation of amyloid precursor protein Medicine, Department of Pathology, Medical Center Boulevard, Winston
expression as evidence of axonal injury Salem, NC 27157
The purpose of this presentation is to illustrate the utility of β-APP
immunohistochemistry as morphologic evidence of traumatic brain After attending this presentation, attendees will gain familiarity
injury. Often special studies are suggested and/or warranted to rule out with the use of animal models for shaking injuries and appreciate the
the possibility of occult trauma in cases of sudden unexpected death of potential for further study of retinal hemorrhages using accidental head
young children. A number of reports, over the past decade, have injuries in infant monkeys.
described various patterns of β-APP expression in axonal injury. Brain This presentation will impact the forensic science community by
material from a group of twenty-seven young children in order to test the providing objective scientific data about the natural history of retinal
application and interpretation of β-APP immunohistochemical staining hemorrhages, which will assist forensic pathologists, pediatricians,
were examined. ophthalmologists, and emergency medicine physicians by offering a
In 1999, the State of Maryland Office of the Chief Medical better understanding of the pathogenesis of retinal hemorrhages.
Examiner (OCME) investigated 153 deaths of subjects three years of age Published studies about the specificity of retinal hemorrhages for
or younger. Of these, 97 deaths were natural [including 56 cases Abusive Head Trauma (Shaken Baby Syndrome) are controversial. A
attributed to Sudden Infant Death Syndrome (SIDS)], 24 were diagnosis of child abuse based on the presence, number and distribution
accidental, 18 were homicides, and 14 were undetermined. Among the of retinal hemorrhages has serious consequences, and thus deserves
homicides, seven children sustained blunt force injuries to the head. The unbiased scientific investigation. Some authors claim that retinal
staining pattern of β-APP in multiple brain regions (frontal, temporal, hemorrhages are virtually pathognomonic of a shaking (acceleration-
and parietal cortices, cingulate cortex/corpus callosum, and the deceleration) injury, but for such a purportedly specific finding, this
cervicomedullary junction) was evaluated. Compared, in a blinded claim has never been scientifically proven. Many papers have been
fashion, the β-APP staining of the homicide cases to similar brain regions written on the subject; however, disproportionately few have had
from seven age matched cases, in which death was due to a nonsignificant substantive value. To date, no reasonably scientific, reliable
traumatic disease (other than SIDS), and ten cases with similar ages, and ethical animal model for retinal hemorrhages has been identified.
from the same calendar year in which death was attributed to SIDS. Consequently, an exhaustive list of situations and conditions in which
Three reviewers achieved consensus regarding the β-APP staining retinal hemorrhages can be seen has not been established. Based on the
by using a simplified semi-quantitative scoring method based on 1) experience of this institution, observational data suggests that retinal
staining density per high power microscopic field and 2) the presence or hemorrhages occur fairly commonly in the absence of shaking or other
absence of multifocal staining within a single microscopic slide from a non-accidental injury. The goal of this study is to help elucidate these
single brain region. Upon consensus interpretation, the reviewers agreed situations though the use of a natural animal model for retinal
that significant β-APP axonal expression was present in five of the seven hemorrhages. This study is intended to serve as a pilot study to evaluate
homicides (71%). Subsequent unblinded review of autopsy records the possibility of using baby monkeys that have died as a result of trauma
demonstrated that in these cases there was gross evidence of intracranial to demonstrate the presence of retinal hemorrhages in the absence of
hemorrhage at the time of autopsy. In the other two homicides cases, the shaking.
reviewers agreed there was not evidence of axonal injury by Trauma is a well-documented cause of neonatal and infant mortality
immunohistochemistry. These two homicide cases had superficial in certain non-human primate breeding colonies. One mechanism of
cranial injuries with significant traumatic injury only to the thoracic trauma is related to changes in the carrying behavior of captive dams,
spinal cord, determined at autopsy. Two (2) of the SIDS cases and one including more frequent cradling of the infant monkeys. Cradling of the
of the non-trauma cases displayed axonal immunostaining with density infants has resulted in an increased number of fatal accidental head
and pattern similar to that in the traumatic cases, and the reviewers could
injuries in these monkeys. The injury occurs when the mother’s chest The presentation will impact the forensic science community by
touches the ground as she jumps and lands, thus allowing the infant’s demonstrating an important contribution to the new practical knowledge
head to hit the ground with significant force. Previously published that the forensic pathologist should know regarding the role of CT
necropsy data for infant squirrel monkeys (Saimiri sciureus) has revealed scanning in autopsy (virtopsy) with reference to the new ACCME
both open and closed skull fractures. No non-lethal or incidental skull criteria.
fractures have been reported in any captive monkey populations. Postmortem CT scanning (PMCT) is becoming an increasingly
Unfortunately, none of these studies examined the eyes of the infant important supplement to the medicolegal autopsy. It contributes
monkeys for the presence of retinal hemorrhages. significantly to the description of skeletal lesions, thereby clarifying the
The heads of seventeen infant monkeys (Callithrix jacchus or mechanisms of trauma. Gas and foreign bodies are readily identified,
Saguinus oedipus) who died from either trauma or natural disease were and it provides insight in the process of decomposition, in case of which
provided by the New England Primate Center following necropsy and visualization of organs such as the brain is also improved. Interpretation
selective histological examination (KGM). Information initially of the CT images acquired from dead people is in many ways different
provided to the primary investigators (CHS, PEL, CAS, KAS and JHB) as compared to living people. Evidently, the circulation stopped,
included the species, animal number and necropsy number. All monkey resulting in reduced blood filling in the arterial system and sedimentation
heads received CT scans (KAS, JHB) using the Siemens MicroCT of blood and other body fluids in the soft tissues. Decomposition of the
[Resolution: Bin x 4 = .0732 (73 micron)] followed by pathological body begins and is clearly visible as air formation in the soft tissues at a
examination (CHS, PEL, CAS) including external examination, gross very early stage. It can be difficult to discern the various postmortem
dissection and microscopic examination of the brains and eyes. Findings changes from pathological conditions in the organs and other soft tissues,
were digitally photographed including all brains and retinas. The especially because experience with PMCT is very limited in contrast to
examinations demonstrated eleven animals with apparent head injuries. the widespread knowledge in clinical CT scanning.
Nine monkeys had skull fractures; five fractures were identified both The purpose of this study was to compare the findings in the lungs
radiographically and grossly, three fractures were only identified grossly by PMCT with the findings and diagnosis made by conventional autopsy,
and one fracture was only identified radiographically. Microscopically and to learn how to identify common postmortem changes in the lungs
evident retinal hemorrhages were present in at least one eye in all in PMCT and to distinguish them from pathological changes developed
specimens with skull fractures and were unilaterally present in one before death. Internal lividity can be present in all organs, but they are
specimen without evidence of a head injury. Because of poor easier to recognize in the lungs both at the autopsy table as well as on
preservation, several of the retinas were fragmented, thus hindering PMCT images, because the presence of air in the lung tissue acts as a
interpretation. Following completion of the examinations, the age, date contrast to the denser appearance of blood and tissue. Internal lividity of
of birth, date of death, dam and sire numbers, type of postmortem the lungs is often seen in the posterior parts due to the frequently supine
examinations originally performed, postmortem interval, and cause of positioning of the body. In many cases, internal lividity is easily
death for each animal was revealed. All animals were born and died in recognized as such. However, differential diagnoses should always be
2002, with a mean and median age of 1.88 and 2 days at death, considered, e.g. pneumonia, edema, contusion, and infarction.
respectively. The majority of animals (13/17) died or were euthanized The material consisted of 100 forensic cases which were autopsied
(5) as a result of suspected parental neglect and inanition. Of the in 2008-2009 at the Institute of Forensic Medicine, preceded by PMCT
remainder, two died of infection, one was stillborn and one died of by using an in-house Siemens Definition 64 slice scanner. Whole-body
unspecified cause(s). Postmortem interval was less than twelve hours scanning was performed in all cases. The torso scanning was obtained
with the exception of the euthanatized animals, which were examined with 140 kV and 500 mAs; a beam collimation of 1 mm and pitch 0.75.
with in two hours. Based on the above information, this study From the PMCT data axial images were made using different algorithms
demonstrates a possible association between skull fractures and retinal (H20S smooth and H60S sharp) provided by the manufacturer.
hemorrhages. Although more studies are necessary to identify a causal Evaluation of the axial images was supplemented by secondary
relationship between accidental head injuries and retinal hemorrhages, multiplanar reconstructions obtained with available software at the
these results suggest that this type of animal model may be of use in workstation. The PMCT images were initially evaluated by an
studying retinal hemorrhages not associated with alleged experienced forensic pathologist and in selected cases a senior
shaking incidents. radiologist with postmortem radiology experience also evaluated the
Retinal Hemorrhages, Abusive Head Trauma, Animal Model images. Following the initial evaluation all thoracic axial slices obtained
in each of the cases were reviewed by the authors in order to complete a
detailed description of the lungs with respect to internal lividity and
G37 Postmortem Pulmonary Findings by pathological findings, using the standard settings for viewing of the
lungs (window width 1200 HU, center -600 HU) and the mediastinum
Computed Tomography Compared With (window width 400 HU, center 40 HU). The results of the PMCT were
Conventional Autopsy compared with the macro- and microscopic findings at autopsy.
The results will be presented and discussed.
Lene W. Boel, PhD*, Institute of Forensic Medicine, University of Postmortem CT Scanning, Virtopsy, Lung Pathology
Aarhus, Brendstrupgaardsvej 100, Aarhus N, 8200, DENMARK; Lars
Uhrenholt, PhD, Institute of Forensic Medicine, Department of Forensic
Medicine, University of Aarhus, Brendstrupgaardsvej 100, Aarhus N,
8200, DENMARK; Rita Ullerup, Institute of Forensic Medicine,
Brendstrupgaardsvej 100, Aarhus N, 8200, DENMARK; and Anne
Grethe Jurik, DSc, Department of Radiology Aarhus University
Hospital, Noerrebrogade 44, Aarhus C, 8000, DENMARK
After attending this presentation, attendees will improve their

knowledge about interpretation of postmortem CT scanning images of
the lungs and to distinguish them from pathological changes developed
before death.
G38 Forensic Imaging: Yes, We Scan! New The radiographer represents a profession that is necessary to
guaranty good quality of radiological examinations and allows a rapid
Challenges for a Radiographer investigation, which is important to implement biopsies and angiography
in the daily routine of forensic medicine. This collaboration is well
Alexendre Dominguez*, Haute Ecole Cantonale Vaudoise de la Santé, accepted in the forensic team. The interdisciplinary exchange of forensic
Avenue de Beaument 21, Lausanne, SWITZERLAND; Francesco Doenz, pathologists, radiologist and radiographers leads to fructuous discussions
Service de Radiodiagnostic et de Radiologie Interventionnelle, Rue du and successful collaborations between those specialists. Regarding the
Bugnon 46, Lausanne, Richard Dirnhofer, MD, and Beat Steger, increase of radiological exams in forensic departments, this new
Fumedica AG, Luzernerstrasse 91, Muri, SWITZERLAND; Barbara radiographer allows to save much time in the daily routine.
Sollberger, Department for Cardiovascular Surgery, University Hospital Radiographer, Forensic Imaging, Postmortem Angiography
Bern, Hochschulstrasse 4, Bern, SWITZERLAND; Erich Gygax,
Department for Cardiovascular Surgery, Hochschulstrasse 4, Bern,
SWITZERLAND; Reto Meuli, Service de Radiodiagnostic et de
Radiologie Interventionnelle, Rue du Bugnon 46, Lausanne, 1011,
G39 Benefits and Limitations of Postmortem
SWITZERLAND; and Patrice Mangin, MD, PhD, and Silke Grabherr, Multislice Computed Tomography as
Centre Universitaire Romand de Médecine Légale, Rue du Bugnon 21, Adjunct to the Perinatal and
Lausanne, CH-1011, SWITZERLAND
Pediatric Autopsy
After attending this presentation, attendees will be able to
understand the role of radiographers in forensic imaging regarding CT Kerstin Aschenbroich, MD*, Institute of Forensic Medicine,
(computed tomography) angiography and will know the different Buehlstrasse 20, Bern, 3012, SWITZERLAND; Steffen G. Ross, MD,
responsibilities of forensic radiographers such as sample collection for Institute of Forensic Medicine, Center of Forensic Imaging “Virtopsy”,
toxicological analyzes (postmortem liquid puncture), sample collection Buehlstrasse 20, Bern, 3012, SWITZERLAND; Michael Thali, MD,
for additional analysis such as histology or bacteriology (postmortem MBA, University of Bern, Institute of Forensic Medicine, Buehlstrasse
biopsy), and the performance of postmortem angiography including the 20, Bern, 3012, SWITZERLAND; and Harald Bonell, MD, Institute of
use of a perfusion machine. Diagnostic Radiology, Inselspital Bern, Bern, 3010, SWITZERLAND
displaying the first experiences and future possibilities of this new After attending this presentation, attendees will understand the
opportunity. It will also introduce the radiographer and his skills to the basics of the radiologic investigation of perinatal and pediatric death by
medicolegal public. Multislice Computed Tomography (MSCT) as well as the advantages
It is a logical fact, that the implication of a radiographer into a team and the limitations of this method.
of forensic radiologist and pathologists can increase the radiological This presentation will impact the forensic science community by
quality of examinations. With the application of postmortem serving as an introduction of postmortem MSCT as a useful noninvasive
angiography in forensic cases, the importance of such a specialist is adjunct to classic autopsy or even as a potential replacement in cases
again increasing, because this examination is complex and needs when autopsy is refused by the next of kin.
experience in handling a CT-scan. Additionally, it brings other needs Perinatal and pediatric autopsy provides essential diagnostic
with it, such as the necessity to perform sample collection for information not only for parents but also for medical audit and clinical
toxicological analysis, before injecting a contrast agent into the corpse. trials. The autopsy rate is decreasing throughout the world for numerous
These responsibilities can be fulfilled by the radiographer. His technical reasons. Medical imaging has always been part of the autopsy process,
knowledge facilitates also the control of the perfusion machine, which is but in the last decade there has been increased interest in imaging as
necessary for postmortem angiography. additional to or a replacement for autopsy. A retrospective data analysis
Sample collection for toxicological analyzes: During the process of of thirty child autopsies will be presented with correlation in all cases
postmortem angiography, a contrast agent is injected into the corpse and with previously performed MSCT. Postmortem whole body six slice CT
the blood is rinsed out of the vascular system. Such treatment could imaging was performed on average of twenty-three hours after death.
eventually alter the findings in toxicological analysis. To avoid this Reconstructions in 1.25mm thickness (soft tissue and lung kernel).
problem, samples of liquids used for these analyzes are collected before Radiological diagnosis was carried out by two radiologists, each with
angiography. To get samples of vitreous humour, bile, urine, cardiac three years experience in postmortem/pediatric radiology. The
blood and peripheral blood, punctures are done manually by the comparison between autopsy and cross sectional imaging showed a high
radiographer. diagnostic accuracy for intracranial hemorrhage, pulmonary pathologies,
Postmortem biopsy: For some additional analyzes such as the visualization of other (partly) gas containing structures like the
histology (especially search for fatty embolism) or bacteriology, samples intestines and bony pathologies like fractures or tumor caused erosions
can be collected already before performing angiography in order to avoid of bony structures. Obvious weaknesses of the unenhanced CT imaging
contamination of the tissue of interest. For this purpose, postmortem lied in the detection of cardiovascular vascular pathologies and subtle
biopsies can be performed by the radiographer. pathologies of the central nervous system. CT imaging does not provide
Performance of postmortem angiography: After sample collection, a histological diagnosis, although histopathologic examination
the radiographer performs the postmortem angiography. He prepares the contributes often important information regarding the cause of death.
perfusion machine and the body. The body-preparation includes the This is clearly a crucial issue if CT is to be used to replace autopsy. A
correct positioning on the CT-table as well as preparation of the femoral possible solution is the application of CT-guided biopsies to gain
vessels and inserting cannulas into them. After connecting the perfusion histological specimens. The emerging field of postmortem CT
machine with those cannulas, the postmortem angiography is performed. angiography could help to close the gap in vascular imaging. This study
Hereby, CT-acquisition and the perfusion machine have to be well shows that postmortem CT imaging alone is not a sufficient complete
synchronized. replacement of classic autopsy in the perinatal and pediatric death.
For a radiographer, the switch from living patients to dead bodies Despite the drawbacks, we are convinced of the potential of this method
might be difficult in the beginning. With skills in technology (imaging as a planning tool and complement to the classical pediatric autopsy and
acquisition, reconstruction of 2D and 3D images, etc.) and anatomical as the method of choice when autopsy is refused by the next of kin.
knowledge, (vascular anatomy, positioning of the body, etc.) the Postmortem CT, Perinatal Autopsy, Pediatric Autopsy
radiographer is predisposed to become a member of a forensic team.
G40 Multidetector Computed Tomographic to objectively establish the cause and manner of death in cases involving
self inflicted, perforating GSW of the head.
(MDCT) Autopsy in Suicide by Gunshot to Suicide, MCDT Autopsy, GSW to Head
the Head
G41 Classification of Asphyxia: The Need
Thoedore Harcke, MD, Craig T. Mallak, JD, MD, and Terrill Top, MD*,
Armed Forces Institute of Pathology, 1413 Research Boulevard,
for Standardization
Rockville, MD 21771
Anny Sauvageau, MD*, Office of the Chief Medical Examiner, 7007, 116
After attending this presentation, attendees will be able to discuss Street, Edmonton, AB T6H 5R8, CANADA
the ability of MDCT to identify critical forensic elements in suicide by
gunshot to the head. The discussion will include both strengths and After attending this presentation, attendees will better understand
limitations of MDCT imaging. the lack of uniformity in the classification of asphyxia and the need for
This presentation will impact the forensic science community by standardization.
showing the potential for postmortem MDCT imaging to simplify cause This presentation will impact the forensic science community by
of death determination in selected cases of suicide. proposing a unified system of classification of asphyxia.
Postmortem MDCT has been showed to be accurate in the Introduction: Asphyxial deaths are common in forensic practice.
evaluation of gunshot wounds with regard to presence of ballistic Unfortunately, the classification of asphyxia and the definition of its
fragments, entry and exit wound determination, and determination of subtypes are far from being uniform, varying widely from one textbook
wound track. Two-dimensional and three-dimensional CT images from to another and from one paper to the next. This presentation will begin
a consecutive series of ten cases (nine male, one female; age range 19- by summarizing the definitions that are currently described in the
32 years) with history of self-inflicted gunshot wound(s) to the head by literature and highlighting their discrepancies. An attempt will then be
small arms were studied retrospectively by a radiologist and forensic made to draw on the mainstream definitions to create a unified system of
pathologist. Neither individual had knowledge of the autopsy findings. classification.
Using a computer workstation to view axial images and 2D/3D computer Classification and definition of types of asphyxia in the
reconstructions, determinations of number of shots, entry and exit literature: A comprehensive review of the different classifications of
wounds, soot/stippling, beveling, and wound direction were ascertained. asphyxia found in the literature will be presented as well as a thorough
The results were compared to the autopsy findings. All autopsies were compilation of definitions of each term. From this complete review, the
performed by board certified medical examiners with access to 2D most widely accepted views will be drawn. The following
radiographic images. recommendations will be discussed, with their underlying rationale:
The radiographic conclusion that all cases were single shot a) Unified classification model: It is proposed that asphyxia should
perforating wounds (one with residual metal fragments) agreed with be classified into four main categories: suffocation, strangulation,
autopsy reports. There was agreement in designation of all entry and exit mechanical asphyxia, and drowning. Suffocation subdivides into
wounds (20); entry wounds were submental (1), glabellar area (3), right smothering, choking and confined spaces/ entrapment/ vitiated
temporal region (5) and intraoral (1). Three-dimensional surface atmosphere. Strangulation includes three separate forms: manual,
rendering of scalp wounds was not as helpful as skull findings in ligature and hanging. Mechanical asphyxia encompasses positional as
classifying wounds. Presence of soot was not mentioned in any of the well as traumatic asphyxia.
radiographic assessments but was described at autopsy in all cases. b) Suffocation: Some authors confusingly use this term
Stippling was not noted in either the MDCT or autopsy findings. synonymously with smothering. Considering the lack of specificity of
Presence of beveling was agreed upon at 9/18 sites, in 8/18 sites MDCT this term, its use is strongly discouraged in death certificates and requires
was positive for beveling but not mentioned or called negative in the replacement with a more precise descriptor.
autopsy report. At one entry site, the autopsy noted beveling whereas the c) Smothering and choking: There is no consensus as to the
radiology review did not call it (intraoral and submental entry sites are anatomical landmark serving as a boundary between these entities. The
often not subject to beveling). epiglottis is proposed as a standardized anatomical landmark. If
There was agreement in 10/10 cases regarding the track direction confronted with an obstruction extending above as well as below the
(anterior vs posterior, left vs right, up vs down) with only a minor epiglottis, it is recommended to use the lowest level of airway
variance in one case (horizontal track by MDCT vs downward by obstruction in classifying the case.
autopsy measure from vertex). The internal description of brain injury d) Mechanical asphyxia: Mechanical asphyxia has been defined by
reflected some differences in terminology. While the MDCT tended to different authors as either a specific entity characterized by restriction of
describe direction and distribution of bone fragments and pathway, respiratory movements by external pressure on the chest or abdomen or
autopsy was more descriptive of hemorrhage and brain anatomy but as a broad term encompassing several types of asphyxia caused by
overall the pathways were in agreement. various mechanical means. To avoid confusion, it is recommended to
Self inflicted, perforating GSW’s of the head were correctly keep the phrase mechanical asphyxia as a specific term to designate
described by MDCT in regard to number of shots, entry and exit wound asphyxia by restriction of respiratory movements.
determination and description of wound direction and track. Significant e) Strangulation and hanging: The classification of hanging is
limitations of MDCT are its inability to assess the external soft tissue controversial: several authors consider hanging to be a type of
findings at entry and exit sites and in particular to determine the presence strangulation or a subtype of ligature strangulation, whereas other
of soot. This study shows that MDCT adds objective information to the authors consider strangulation and hanging as different entities. It is
invasive part of the cranial autopsy in cause of death determination for recommended that hanging should be regarded as a type of strangulation,
cases of suicide with perforating GSW’s; however, it cannot replace along with manual and ligature strangulation. Some authors believe that
external assessment of wounds. accidental hanging can also occur without a ligature: it is however
However, the combination of hands-on external/internal autopsy recommended to restrict the appellation of hanging for cases involving
assessments and non-invasive internal evaluation by MDCT are not some type of ligature tightened by the weight of the body. Furthermore,
enough. The knowledge of the circumstances leading up to the death and it is recommended that all asphyxial deaths caused by external pressure
laboratory tests are required to strengthen the medical examiner’s ability on the neck structures should be labeled strangulation and terms such as
positional asphyxia should be avoided in these circumstances. If a osseous and visceral trauma; and the quantity of alcohol (mg/100ml)
strangulation does not fall into the category of manual, ligature or when toxicology reports were available. The HBL definition used in this
hanging it should be labeled as strangulation NOS (not otherwise study is the following: the area located between two lines parallel to a
specified). line inspired by the Frankfort horizontal plane (horizontal plane passing
f) Drowning: It is recommended that drowning should be included through right and left porion points and the left orbitale), the superior
in the forensic classification of asphyxia. However, this inclusion does margin passing through the glabella (G line) and the inferior margin
not necessarily mean that the entity should be discussed in the chapter of passing through the center of the external auditory meatus (EAM line).
asphyxia in textbooks or formal teaching. A better approach would be to Results and Conclusion: A total of 113 cases were studied: 29
include drowning in the classification of asphyxia but discuss it further cases of falls from one’s own height, 21 cases of falls downstairs, and 63
in the context of the investigation of bodies recovered in water. cases of homicidal blows. Cases of falls downstairs revealed a
Conclusion: At this point in time, there is so much variation in the male:female ratio of 6:1 with an average age of 50 (± 14.3 years ranging
classification and definitions of terms that research and practice are from 26 to 79 years), while the ratio for falls from one’s own height was
inevitably tainted by confusion. Unfortunately, similar research designs 8.7:1 with an average age of 51.5 (± 17.5 years ranging from 15 to 85
can lead to totally different results depending on the definitions used. years). Cases of blunt head trauma to the head showed a male:female
Closely comparable cases are called differently by equally competent ratio of 2.9:1 with an average age of 44 (± 19.8 years ranging from 9 to
forensic pathologists. The proposed unified model in this study was 81 years).
designed in an effort to standardize the classification of asphyxia in the The goal of this study was to improve the discrimination between
forensic context. falls and homicidal blows by a blunt weapon in a forensic pathology
Forensic Pathology, Asphyxia, Classification setting. The request to give an expert opinion on this distinction is a
common and crucial one given the legal consequences. Overall, based
on the present study as well as previous ones, the criteria pointing
G42 Discrimination of Falls and Blows in Blunt towards blows are:
1. More than three lacerations
Head Trauma: A Multi-Criteria Approach 2. Laceration length of seven cm or more
3. Comminuted or depressed calvarial fractures
Anny Sauvageau, MD*, Office of the Chief Medical, Examiner, 7007, 116 4. Lacerations or fractures located above the HBL
Street, Edmonton, AB T6H 5R8, CANADA 5. A left side lateralization of lacerations or fractures
6. More than four facial contusions or lacerations
After attending this presentation, attendees will have better 7. Presence of ear lacerations
knowledge of the criteria pointing towards blows or falls in blunt 8. Presence of facial fractures
head trauma. 9. Presence of post-cranial osseous and/or visceral trauma
This presentation will impact the forensic science community by Blunt Head Trauma, Falls, Homicide
providing tools to improve the discrimination between falls and blows.
The distinction between accidental falls and homicidal blows is an
important one in forensic pathology as it occurs frequently, but most G43 Glioblastoma – Cause of Sudden Death on
importantly, because of the legal branching related to a homicide. an Apparently Healthy Woman
Indeed, autopsy findings are often used to corroborate or complement
investigative information. In the discrimination of falls versus blows,
Jerónimo F.S. Silva*, National Institute of Legal Medicine - Portugal,
the hat brim line (HBL) rule is mentioned in several textbooks as the
Bairro de Santa Justa, 10, Coimbra, 3000-356, PORTUGAL
most useful single criterion. According to this rule, an injury located at
the level where the brim of a hat would lie is more likely the result of a
After attending this presentation, attendees will learn the
fall, while a blow would generally produce a wound above this line.
importance of performing a complete autopsy in cases of sudden
Recent studies however have found that the HBL rule is only moderately
unexpected death, completed with a meticulous neuropathological
valid and that its use on its own is not recommended. The HBL rule
examination, mainly in the cases where an extracranial cause of death
should instead be used in conjunction with other tested criteria, such as
was not found.
the side lateralization and number of lacerations and the length of
lacerations. The purpose of this research is first to find additional
the report of a very rare case of sudden unexpected death by an
individually useful criteria in the distinction of falls from blows, and
undiagnosed glioblastoma.
second to construct a decision tree by selecting and combining criteria
Sudden unexpected deaths due to primary brain tumors are very
with the highest predictability rates.
rare in forensic pathology practice. Nowadays, most fatal brain tumors
Materials and Methods: This retrospective study used autopsy
are diagnosed before a fatal outcome, based upon neurological
cases from the Montreal Laboratoire de sciences judiciaires et de
manifestations and imaging techniques, such as computed tomography
médecine légale spanning a six-year period (2000-2005). The selected
and magnetic resonance imaging. Gliobastomas are the most common
cases represented falls downstairs, falls from one’s own height and
primary brain neoplasms and account for more than fifty percent of the
homicidal blows to the head by a blunt weapon. Designation of cases as
malignant gliomas. Usually they cause headaches, seizures and focal
falls or blows was not solely based on head examination but on a
neurological deficits according to their anatomic location in the brain.
thorough case review, including scene investigation, witness testimony,
A case of a 44-year-old woman, who was found dead in her bed,
perpetrators confession and other autopsy findings. The cases where a
resting naked with her body lying down ventrally. According to
victim was struck while lying on the ground were excluded from the
relative’s statement she was apparently a healthy woman.
sample. For each case, the following features were compiled: the
The autopsy revealed a vast “froth mushroom” covering her mouth
number of lacerations, the location of lacerations and fractures in relation
and nostrils, as well as a marked cerebral edema with a cystic yellow
to the HBL, the side lateralization of lacerations and fractures, scalp
lesion on the white matter of the right fronto-parietal lobe, surrounded by
laceration length; calvaria fracture type; number of facial abrasions,
hemorrhagic foci. Neuropathological examination established the
contusions, and lacerations (including mouth lesions); presence of
diagnosis of glioblastoma, grade IV according to WHO (World Health
lacerations on the ear; presence of facial fractures; pattern of post-cranial
Organization).

The importance of performing a complete autopsy in cases of It was concluded that, facing complex and contradictory lesions
sudden unexpected death, complemented with a meticulous such as the ones presented in our case, the pathologist should interpret
neuropathological examination, mainly in the cases where an them all, provide information about the weapon or weapons probably
extracranial cause of death wasn’t found will be highlighted. involved, determine those that produced the death, and the position of the
Glioblastoma, Brain Tumor, Sudden Death aggressor vs. the victim, among other objectives that may appear during
the investigation. He/she must be prepared, experienced, and able to
read the wound language written in different morphological supports,
G44 Stab Wounds, Incised Wounds, or Blunt including skin, soft tissues, and bone.
Cut Marks, Blunt, Shovel
Trauma With Single or Multiple Weapons –
How to Read Soft Tissue and Bone Injuries
G45 Sudden Infant Death Syndrome and Infant
João S. Pinheiro, MS*, Rosario L. Silva, MD, and Claudia Marques,
MD, Institute Nacional Medicina Legal, Delegação do Centro, Largo da
Mortality in Serbia
Sé Nova, Coimbra, 3000, PORTUGAL; José Elísio P.A. de Campos e
Sousa, MD, Largo da Sé Nova, Coimbra, 3000-213 COIMBRA, Djordje M. Alempijevic, PhD*, Faculty of Medicine University of
PORTUGAL; and Francisco C. Real, PhD, Institute Nacional Medicina Belgrade, Institute of Forensic Medicine, 31a Deligradska Street,
Legal, Delegação do Centro, Largo da Sé Nova, Coimbra, 3000, Belgrade, 11000, SERBIA AND MONTENEGRO; Ana Milenkovic, and
PORTUGAL Nikola Vukelic, Faculty of Medicine University of Belgrade, 8 Drive
Subotica Street, Belgrade, 11000, SERBIA AND MONTENEGRO; and
The goal of this presentation is to remind attendees of the Dragan S. Jecmenica, PhD, Snezana Pavlekic, PhD, Aleksandra V.
importance of careful observation in all autopsies performed (either on Nedeljkov, MD, and Branimir V. Aleksandric, PhD, Institute of Forensic
the skin or internally in soft tissues, organs and even bones), in order to Medicine, Faculty of Medicine, University of Belgrade, 31a Deligradska
know how to correctly classify injuries, as well as to establish a Street, Belgrade, 11000, SERBIA AND MONTENEGRO
relationship between both the external and internal injuries and the
weapon(s) involved. By combining the knowledge of all these elements, After attending this presentation, attendees will understand possible
the pathologist will then be able to better read the wounds’ language. pitfalls in infant death evaluation, in particular, related to sudden infant
This presentation will impact the forensic science community by death syndrome (SIDS). The attendees should also become familiar with
advocating a return to the basics in the analysis of wounds. Also major gaps in data integration between forensic pathology institution and
defended is the need for pathologists to be highly trained in clearly public health system.
distinguishing incised, blunt and ballistic trauma, and to be prepared to This presentation will impact the forensic science community by
solve difficult cases with mixed and atypical injuries, such as the one providing figures on SIDS cases for a ten-year period (1998-2007). Data
presented here. It is argued that the best interpretation of autopsies will from two sources, autopsy records from the Institute of Forensic
come from those who use all these capacities and experience in every Medicine in Belgrade and the State Office of Statistics are provided,
case, providing good answers to the questions aroused from the criminal compared, and commented.
investigation. A review of 93 cases of SIDS will be presented within a ten years
A young woman that was found dead in her home, laying on the period where 6,980 deaths of children under the age of one year have
bed, dressed; the body, clothing, and sheets stained of blood. Profuse been recorded. Issues of SIDS autopsy diagnostic and current legislation
blood spatters were visible on the walls and floor. Fragments of cement pertinent to postmortem examination is widely discussed.
were found aside of the left hip. The victim presented at autopsy with Infant Death Evaluation, Sudden Infant Death Syndrome, Public
typical incised wounds in the arms, neck and in the scalp, some of them Health
with a tail. The scalp wounds had an internal translation as bone cut
marks. However, these marks had different shapes and particular
patterns. Underneath one of the incised scalp wounds there was also a G46 Fatty Versus Fibrofatty Involvement of
skull fracture of the right zygomatic and frontal bones and cerebral the Myocardium in Sudden Death and
laceration.
The injuries of the head, neck, and arms, suggested at first a knife.
Heart Failure
However, after examination of the deeper head injuries, it was found that
although they appeared incised, the margins were not so clean as usual, Lise A.M. Matzke, MSc*, and William M. Elliott, PhD, UBC-James Hogg
and some of the bone cut marks showed one clear cut margin and little iCAPTURE, University of British Columbia/Providence Health Care,
splinters on the other margin. Consequently, the knife assumption was Saint Paul’s Hospital Room 166, 1081 Burrard Street, Vancouver, V6H
discarded and instead, an axe or a similar tool was considered as a 1P9, CANADA; Crystal Leung, BMLSc, James Hogg iCapture Centre for
hypothesis, reinforced by the blunt trauma seen on the right side of the Cardiovascular and Pulmonary Research, Saint Paul’s Hospital, Room
skull. Nevertheless, one abraded tangential lesion of the skull and the 166 1081 Burrard Street, Vancouver, V6Z 1Y6, CANADA; Carol Lee,
undulated shape of one of the cut marks lead us to look for another MD, 2165 Fraserview Drive, Vancouver, V5P 2N2, CANADA; Charles
weapon that could produce blunt trauma and incised-blunt trauma at the Lee, MD, Vancouver General Hospital, Department of Forensic
same time – or to consider two different weapons. Pathology, 855 West 12th Avenue, Room 1352, Vancouver, BC V5Z 1M9,
This presentation will discuss the possible weapon(s) used to CANADA; Bruce M. McManus, PhD, James Hogg iCAPTURE Centre,
produce the different and complex injuries described, matched to the Saint Paul’s Hospital, 1081 Burrard Street, Vancouver, V6H 1P9,
skin, subcutaneous tissues, organs and bones patterns of wound. The CANADA; and Michael Allard, MD, James Hogg iCapture Centre for
lethal wounds will be identified and possible defense lesions among the Cardiovascular and Pulmonary Research, 1081 Burrard Street,
multiple injuries observed. Hypothesizing the existence of one or more Vancouver, BC V6Z 1Y6, CANADA
aggressors and estimating the position versus the victim is also debated.
The solution of this case was found by the police in the main After attending this presentation, attendees will recognize the
suspect’s van (the victim´s husband) near other material that as a builder, pattern of pathologic and histologic findings as correlated to clinical
worked with: a bloody shovel – that fit with all the injuries found. information from cases within the spectrum of fatty cardiomyopathy
including arrhythmogenic right ventricular cardiomyopathy.
This presentation will impact the forensic science community by analysis of immunohistochemical staining for plakoglobin suggests that
reviewing clinical and pathological data as well as associated histology such staining may aid in the assessment and distinction of these two
for sudden cardiac death cases from the spectrum of fatty conditions.
cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. ARVC/ Fatty Cardiomyopathy, Cardiovascular Pathology, Sudden
Forensic and cardiovascular pathologists, as well as other forensic Cardiac Death
scientists, may find this information useful for comparison with
observations from their home institutions and practices.
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a G47 A Homicide Due to an Atypical
genetically determined heart muscle disease characterized by fibrofatty
replacement of myocardium in the right ventricle (RV) and to lesser
Asphyxiation Tool: A Rolling Pin
degree in the left ventricle. ARVC is commonly associated with sudden
death and heart failure. Isolated infiltration of the RV by fat alone is also Margherita Neri, PhD*, Santina Cantatore, Gabriela Perilli, MD, and
believed to be associated with sudden death. However, the ARVC Irene Riezzo, MD, Department of Forensic Pathology, University of
phenotype versus that characterized by isolated fatty infiltration alone Foggia, viale degli Aviatori, 1, Foggia, 71100, ITALY
have an unclear separation. Such lack of clarity makes pathological
evaluation of sudden death in these circumstances very challenging. The goal of this presentation is to present an unusual case of
While genetic testing for mutations in genes known to be associated with homicide asphyxia due to an atypical compression of the neck by a
ARVC would aid in rendering a diagnosis, that approach is not practical rolling pin.
in everyday pathology practice. One other possible strategy in better This presentation will impact the forensic community by dicussing
delineating phenotypic variation might be immunohistochemical the rarity of the deaths due to rolling pins utilized as an asphyxiation
staining and quantitative evaluation of proteins related to genetic tool, the particular features of macroscopic lesions caused by the tool,
mutations underlying some ARVC phenotypes. and for the importance of a careful autopsy examination with an
Purpose and Approach: In this study, heart case materials from immunohistochemical study in order to clarify the exact mechanism of
autopsy (8) and cardiac transplantation (2) from patients with ARVC and the death.
fatty infiltration of the RV are characterized. Each case was accessioned Death by asphyxia can present in various different ways. It is
in the iCAPTURE Cardiovascular (CV) Biobank at St. Paul’s usually determined by typical actions imputable to an asphyxial agent of
Hospital/University of British Columbia and each case was referred to a compression on the neck, usually classified as throttling, strangulation,
cardiovascular pathologist at the CV Biobank for assessment. Under hanging, and mugging. All these tools can cause an external
approved ethics protocols, patient data were obtained from medical compression of the neck. Various atypical forms have been described,
records or referring pathologists. The CV Biobank, a research and caused by rods or sticks used to compress the neck anteroposteriorly, by
educational tool, was established in 1982 and includes cardiovascular wooden rods with cords or screws attached to their extremities used in
tissue specimens from surgery and autopsy, along with their garroting, by violent pulling of the neck backwards in a pincer
accompanying annotations and data held in a secure database. movement between the forearm and arm in mugging, or by compression
Methods & Results: The Ten sets of case materials were archived of the victim’s neck by the aggressor’s knee or foot. In this case, the tool
between 1993 and 2008. All hearts were assessed for their macroscopic used to kill was a rolling pin.
and microscopic features with confirmation by at least two observers. On December 1, 2008, at 3:00 p.m., a man called the police and said
The specimens were found to fit into one of two patterns. Nearly two- that he found his wife dead. The police and the forensic pathologist went
thirds demonstrated fibrofatty (6 male, age = 17-36 years) replacement to the crime scene and found the body of a 74-year-old Caucasian
of the RV myocardium, while about a 1/3 showed a pattern of woman inside of the kitchen of her own house. The woman lived in the
predominantly fatty replacement (2 male, 2 female; age = 15-64 years). house with her husband and her only son. The corpse was lying supine
Within the fatty replacement group, individuals died during non- on the floor. She was fully and tidily dressed, the head rested on a pillow,
strenuous activity and at rest. In this group, one individual had a history the arms were adduced to the trunk, the forearms were on the abdomen,
of fainting and clinical intervention for arrhythmia and one patient had a and the legs were extended and slightly spread.
history of anorexia and bulimia. In the fibrofatty replacement, group Close to the shoulder of the woman, on the floor, under a metallic
patients died following non-strenuous activity, during strenuous activity feet-stool, was a brown wood rolling pin with a length of 79.5 cm,
and at rest. This group of patients included one individual with maximum circumference of 11 cm, diameter of 3.5 cm, and weight of
documented familial ventricular tachycardia for which he received 530 g. The thanatological data recorded by the forensic pathologist
treatment, one patient with dilated cardiomyopathy and mitral valve called to the scene stated that, at the time of discovery (4,00 p.m.), the
regurgitation, and one individual with sudden death of a brother due to corpse did not show rigor mortis, and the hypostasis blanched with finger
an unspecified “aneurysm”. Quantitative computer-assisted pressure but was congruous with body position. The rectal temperature
morphometric analysis confirmed two pathological phenotypes, was 35 °C and ambient temperature was 24 °C. The prosecutor arranged
fibrofatty and fatty. Of interest, the distribution and extent of for an autopsy because the circumstances of the death suggested that it
involvement differed substantially between fibrofatty and fatty patterns, was an homicide, and made inquiries about the son and the husband.
with changes being more extreme and widely distributed in the fibrofatty A complete autopsy was performed twenty-four hours after death.
group, while localized to the anterolateral apex and lateral base in the The external examination showed a remarkable cyanosis of the face, lips
fatty category. None of the hearts studied had a notable cellular and nails; skin petechial hemorrhages in frontal and periorbital region,
inflammatory element. Further, immunohistochemical staining was and mucosal petechiae on the oral vestibule and conjunctivae. On the
performed on all heart cases for desmosomal protein plakoglobin, a neck were two parallel, horizontal, oval shape, mild blue bruise areas, the
protein that links adhesion molecules at the intercalated disk to the first on the anterior face of the neck (measuring 2,3 cm x 1.8 cm) and the
cytoskeleton and is thought to aid in the evaluation of ARVC. second on the left mandibular region (measuring 2,8 cm x 2.4 cm).
Summary and Conclusion: Fibrofatty replacement of the RV, Dissection of the neck revealed thin hemorrhages in the subcutaneous
characteristic of ARVC, and fatty infiltration of the RV alone are tissues and in both sternohyoid and sternothyroid muscles and right
distinctive phenotypes in the setting of sudden cardiac death and heart thyrohyoid muscle. The esophagus, larynx, and trachea were
failure. The distinctly different extent and distribution of involvement unremarkable. Subpericardial and subpleural petechiae were observed.
between the two morphological patterns supports the concept that they The other organs did not show specific alterations except for an intense
represent different disease processes. Further, preliminary quantitative vascular congestion. Skin sections for histological examination were
removed at the neck in long strips perpendicular to bruises. Sample of
muscle tissue were also taken at the neck (sternohyoid, sternothyroid and in abundance of these biomarkers in each viscus, over time, were
thyrohyoid muscle). The histological examination showed mild observed and used to create a model that could be used to estimate the
hemorrhages in the cutaneous and subcutaneous tissues, and in the PMI. Samples from each viscus were collected from both pigs over time
muscles. The stratum corneum of the epidermidis was detached and the and analyzed by GC-MS. The abundances of the VOC biomarkers were
dermis was split from the epidermis. An immunohistochemical study normalized to an internal standard and plotted as a function of
was performed to assess the vitality of the skin injury with antibodies to accumulative degree days (ADDs) in order to estimate the PMI. The
CD 15, IL15, and tryptase and the microscopical observations showed a results of these studies will be presented and discussed along with the
strong positivity of tryptase, IL15 and weaker reaction to CD 15. implications for PMI determinations using the developed model.
Moreover, histological investigation of other organs showed mild Postmortem Interval, Chemometrics, Volatile Organic Compounds
cerebral and pulmonary edema, focal emphysema, and perivascular and
intra-alveolar hemorrhages. The toxicological analysis was negative.
According to the examination of neck bruises, autopsy findings and G49 A Comparison of Drug-Related Deaths in
histological data, the mechanisms of death was consistent with asphyxia.
Death was attributed to an external neck compression, and the tool that
Tarrant County, Texas, With Law
caused the death was perfectly compatible with the rolling pin found on Enforcement Seizures of Illicit Substances
the floor near the body. Fingerprints belonging to the son were identified Over a Similar Time Frame
on the rolling pin. Detailed examination of the crime scene and autopsy,
along with the investigation of the psychological background of the son Lucile B. Tennant, JD*, Marc A. Krouse, MD, and Nizam Peerwani, MD,
produced clear evidence that killer was the son and few days he Tarrant County Medical Examiner’s Office, 200 Feliks Gwozdz Place,
confessed to the murder. Fort Worth, TX 76104-4919
Rolling Pin, Athypical Asphyxia, Vitality Lesions
After attending this presentation, attendees will have an awareness
of the most recent pattern of abuse of illicit substance use in Tarrant
G48 Use of Volatile Organic Compounds and County and understand which substances are responsible for the most
Chemometric Procedures to Determine lethal intoxications in this Texas county.
Postmortem Interval sharing recent information on substance abuse and lethal intoxication in
one community. It should also encourage similar studies and the sharing
John W. McIlroy, BS*, Michigan State University, Chemistry Building, of this information between law enforcement and forensic
East Lansing, MI 48824; and Ruth Waddell Smith, PhD, Michigan State laboratory personnel.
University, School of Criminal Justice, 560 Baker Hall, East Lansing, Hypothesis: There is a change in the pattern of drug-related deaths
MI 48824 and substance abuse in Tarrant County.
Methods: Information covering the last twelve months, from three
After attending this presentation, attendees will be familiar with the laboratories which do testing for law enforcement agencies in Tarrant
use of volatile organic compounds and chemometric procedures for the County, Texas have been gathered and synthesized. These laboratories
estimation of postmortem interval (PMI). perform toxicological analysis on autopsy fluid and tissue, and on
This presentation will impact the forensic science community by evidence seized by law enforcement officers. The results and pattern of
further developing a chemical method to estimate the postmortem substances in fatal intoxications and in drug seizures over a related
interval, which can be applied to death investigations, when traditional period of time have been compared.
PMI estimations may fail. Results: Tarrant County is a Texas county with a population of
An important aspect of any death investigation is to determine time approximately 1.7 million which includes its largest two cities, Fort
since death, or postmortem interval (PMI). Establishing the PMI is Worth and Arlington which have populations of approximately 650,000
important for identifying and eliminating suspects as well as helping to and 650, 000 respectively. The county covers an area of 897 square
reconstruct the crime. However, unless eye-witnesses are known, it is miles, over thirty incorporated cities and towns and covers urban and
difficult to establish when the death occurred. Many of the current rural territory. The demographics of the population include a diverse
methods that are used for PMI estimation involve gross changes to the racial and age makeup and includes more than fifteen different school
body and are only useful for the first few days after death. However, districts. The Tarrant County Medical Examiner’s Office, along with
after death, chemical changes also occur within a body. This research two regional labs serves over 100 county law enforcement agencies. All
has focused on the chemical changes that occur in individual viscera to three labs have cooperated to produce this data.
estimate the PMI. The purpose of this initial work was to identify Although there are differences in the statistics gathered by each
biomarkers that can be useful for the estimation of the PMI. laboratory, all have seen a distinct change in the pattern of drug abuse
An initial in vitro study was conducted on four viscera (heart, lung, over the last few years. These changes include the emerging popularity
liver, and kidney) harvested from two different pigs. Samples were of certain prescription drugs as well as illicit drugs, and the appearance
collected from all viscera and from different areas within each viscus of new designer drugs such as “cheese”, benzylpiperazine (BZP), 3-
throughout the decomposition process. All samples were homogenized trifluoromethylphenylpiperazine (TFMPP) and others. The three
in a tissue grinder, extracted, and derivatized prior to analysis by gas laboratories serve different size towns and cities and the drugs seized
chromatography-mass spectrometry (GC-MS). Total ion chromatograms from these communities follow certain trends, so the laboratories see a
(TICs) were assessed initially and, through mass spectral interpretation, different spread of cases in seizures from the small towns than in seizures
major volatile organic compounds (VOCs) that are potentially important from the larger communities. In the small towns, law enforcement
biomarkers, were identified. Principal components analysis (PCA) was seizures tend to yield the highest incidence of methamphetamine, ecstasy
then applied to identify differences in VOCs for samples collected from and pharmaceuticals. The larger towns and cities’ cases more frequently
different areas of the same viscus, as well as differences in VOCs in involve cocaine and heroin. These findings are consistent with national
different viscera. Compounds that showed minimal variation within a reports.
viscus and between viscera were selected as biomarkers for PMI Conclusion: The pattern of drug-related deaths and abuse of illicit
estimation. It is important to identify biomarkers that do not have wide substances has changed through the years. This study reports some of
variability, in order to allow for accurate PMI estimation. The changes the changes seen recently. These include the increase in popularity of

certain prescription drugs and the appearance of “new” drugs of abuse Justice System and local forensic entomologists is likely to be accurate.
and a change in the drugs responsible for acute intoxication and As a result, this research will allow forensic entomologists to estimate
fatal overdose. time of death in future B.C. homicide investigations with greater
Substance Abuse, Lethal Intoxication, Illegal Substances accuracy and confidence.
Forensic Entomology, Nocturnal Oviposition, Blow Flies
G50 Nocturnal Oviposition of Blow Flies

(Diptera: Calliphoridae) in the Lower G51 Blood Aspiration as a Vital Sign Detected by
Mainland of British Columbia, Canada CT Imaging and Postmortem CT
Guided Biopsy
Jaime S. Prevolsek, BSc*, and Gail S. Anderson, PhD, Simon Fraser
University, School of Criminology, 8888 University Drive, Burnaby, BC Laura Filograna, MD*, and Steffen G. Ross, MD, Institute of Forensic
V5A 1S6, CANADA Medicine Center of Forensic Imaging “Virtopsy”, Buehlstrasse 20,
Berne, AL 3012, SWITZERLAND; Stephan Bolliger, MD, and Tanja
After attending this presentation, attendees will better understand Germerott, MD, University of Berne Institute of Forensic Medicine,
the nocturnal egg-laying behavior of several of the blow fly (Diptera: Buehlstrasse 20, Bern, AL 3012, SWITZERLAND; Patricia M. Flach,
Calliphoridae) species that commonly inhabit suburban regions of the MD, Institute of Forensic Medicine Bern / Virtopsy, Buehlstrasse 20,
Lower Mainland of British Columbia, Canada. Bern, SWITZERLAND; and Michael Thali, MD, University of Bern,
This presentation will impact the forensic science community as it Institute of Forensic Medicine, Buehlstrasse 20, Bern, 3012,
will discuss the potential implications of nocturnal oviposition of blow SWITZERLAND
flies (Diptera: Calliphoridae) on postmortem interval (PMI) estimations
in human homicide investigations. After attending this presentation, attendees will have learned about
The most important and common use of forensic entomology is to the possible contribution of multi-detector computed tomography in
estimate the elapsed time since death. Specifically, the postmortem forensic investigations on blood aspiration.
interval (PMI), defined as the minimum time that has elapsed since This presentation will impact the forensic science community by
death, is determined through the analysis and identification of the suggesting that the execution of a CT scanning prior to autopsy in cases
forensically important insect species present at the crime scene. An suspected for occurrence of blood aspiration may avoid misdiagnoses
accurate PMI estimation has been proven very valuable in homicide and provide an easier and immediate visualization of distribution and
investigations as it points the investigators toward the correct time frame. severity of aspiration.
Nocturnal oviposition of blow flies has not been investigated in Based on the proved efficient role of the modern cross-sectional
Canada; therefore, the potential effect of its presence on the PMI was techniques as complementary/additional tool to traditional forensic
unknown. If some or all of the blow fly species in British Columbia were methods, the aim of this study was to examine the value of postmortem
found to lay eggs at night, this could have major implications in the CT imaging in evaluating pulmonary findings related to blood aspiration,
Canadian Criminal Justice System, as the presence of nocturnal compared to traditional forensic pathology techniques.
oviposition could alter the PMI by up to eight to twelve hours. Such an Identification and correct interpretation of blood aspiration is of
error rate could lead to the appeal of previous cases in which conviction substantial importance in forensic cases, as this finding can provide the
was based on the assumption that nocturnal oviposition does not occur. forensic pathologist with information on whether an injury occurred
This may also play a role in unsolved homicides, as suspects would have intravital or postmortem, and give suggestions on the cause of death.
originally been interrogated based on a time of death that was incorrect. Between January 2005 and December 2008, at the Institute of
In this study, six beef liver baited inverted cone traps were put Forensic Medicine in Bern a total of 359 human corpses underwent
outside in a suburban garden on individual days in July and August in MSCT scanning prior to autopsy, within the project. Thirty-seven non-
order to monitor the egg-laying behavior of local blow fly species. decomposed bodies where blood aspiration was documented with the
Individual experimental days were chosen based on an expected traditional examinations, or where blood or bloody fluids were found in
nocturnal minimum temperature of greater than 12ºC. Oviposition was the airways from larynx to small bronchi were selected. A total of thirty-
monitored over twenty-four hour periods in two locations, one with one cases had demonstration of aspiration in lung parenchyma on
complete darkness nocturnally and one in the presence of artificial light autopsy inspection or on histological analysis. The remaining six cases
produced from a high pressure sodium street light. The bait was replaced all showed blood or bloody fluids in the airways. Blood aspiration was
with fresh bait every four hours and the number of eggs was visually reported in final autopsy reports as being the primary, assisting or
estimated. The eggs were then reared to adulthood at the Centre for competing cause of death in seven cases. All cases underwent body CT
Forensic Research at Simon Fraser University, for species identification. scanning on a six slice scanner. Two- and three-dimensional
The use of these traps also allowed for the nocturnal activity levels of reconstructions were obtained at a workstation. The images were
blow flies to be assessed as active adults were caught in the plastic bag assessed for presence, entity, density and composition of material in the
attached to the top of the trap. airways, and for presence, entity and distribution of lung density
In this experiment, no eggs were ever found after sunset or prior to alterations. The possibility to consider blood aspiration as cause or
sunrise on any of the experimental days. The artificial street light was assisting cause of death was also assessed.
not sufficient to stimulate egg laying at night. The three species that In one exemplary case, biopsy-specimens from abnormal regions of
were primarily caught were Calliphora vicina (Robineau-Desvoidy), the lungs have been obtained under CT fluoroscopy guidance for
Lucilia sericata (Meigen), and Lucilia illustris (Meigen). No calliphorid histological examination.
adults were caught after sunset or before sunrise, except on one night, in The thirty-one cases with traditional demonstration of aspiration in
which three L. sericata adults were caught post sunset in two different lung parenchyma had ground glass opacities suggestive for blood
traps. Based on these results, forensically-important blow fly species in aspiration on pulmonary CT imaging. In the six remaining cases CT
this region do not nocturnally oviposit or remain active at night. imaging detected pulmonary abnormalities suspected for blood
This experiment is the first of its kind to be done in Canada and aspiration that was not mentioned in the final autopsy reports. In two
therefore, these results suggest that the assumption of no nocturnal cases among these, the route of aspiration was evaluated on the basis of
oviposition that has been used for many years by the Canadian Criminal injuries detected by whole body CT images as being anterograde and of

scarce severity, in one case retrograde, and in three combined. The accompanied with neuronal degeneration and glial cell proliferation.
biopsy specimens obtained in the one case confirmed the occurrence of The amount of SYP remained unchanged in brains after trauma. These
blood aspiration. The concordance between post-mortal CT imaging and findings indicated that after trauma, SYP accumulates at injured sites of
traditional techniques in attributing primary, assisting or competing neurons without any change in SYP content. The increased SYP
cause of death to blood aspiration was of 71%. immunoreactivity in the cerebral cortex following traumatic injury
Our results show the superior sensitivity of post-mortal CT imaging reflects an inhibition of synaptic vesicle transportation and synaptic
in detecting areas suspected for blood aspiration in some particular cases dysfunction, thus providing a histological substrate for
of blood aspiration of scarce severity, or when pulmonary injuries are brain dysfunction.
associated. In these circumstances, the typical macroscopical findings In cases of open head injuries, a foreign body may remain in the
on the lung inspection may be absent or be largely concealed by other brain for a period of time after the trauma. A animal model incorporating
alterations. Thus, postmortem CT can be excellently used in these cases a foreign body in the brain was developed. The time-dependent brain
to guide the forensic pathologist during lung tissue investigation, and to changes caused by a foreign body was studied. A lead or a glass ball was
provide focused specimens for the histological examination. used as the foreign body and was implanted in the cerebral cortex of rats.
Moreover, postmortem two and three dimensional CT techniques Brains were analyzed at various times between twelve hours and four
have been proven by this study to be a great device to better analyze weeks after implantation. Results from brains with a lead ball were
distribution and amount of aspirated blood and to document and conduce compared with those with a glass one. The number of macrophages
hypothesises on the cause of death. With the traditional diagnosis of a increased significantly with increasing time after implantation of a lead
fatal blood aspiration (made through the analysis of just few slices of the ball. Multinucleated giant cells appeared at three weeks in brains with a
lung tissues considered representative for the whole pulmonary volume) lead ball. The immunoreactivity of metallothionein, a metal binding
information about the real extent and distribution of this phenomenon is protein, increased significantly in astrocytes and endothelial cells with
lost. On the contrary, CT imaging techniques can provide a complete increasing time after implantation of a lead ball. Moreover, apoptotic
collection and documentation. cells were identified at two weeks, but had mostly disappeared at four
The analysis of post-mortal CT images of lungs and airways alone weeks after implantation of a lead ball. Apoptotic cells were not
doesn’t offer in many cases enough data to distinguish with certainty observed in brains with a glass ball. This study showed that lead leached
pulmonary findings due to blood aspiration and lung alterations due to from a lead ball induces macrophage infiltration, metallothionein
other causes. Nevertheless, it should be considered a fundamental, expression and apoptosis in the brain.
highly suggested complementary tool to traditional autopsy techniques Forensic Neuropathology, Head Injury, Experimental Model
in cases of blood aspiration to avoid misdiagnoses and to provide
complete and exhaustive description of the severity of the phenomenon.
Blood Aspiration, Postmortem CT, Postmortem Needle Biopsy
G53 Determination of Procalcitonin, C-Reactive
Protein, Tumor Necrosis Factor-Alpha,
G52 Brain Tissue Responses After Traumatic Interleukin-6, and Interleukin-8 Levels in
Brain Injury in Animal Models Serum, Vitreous Humor, and Cerebrospinal
Fluid as Markers of Sepsis
Kazuhiko Kibayashi, MD*, Ken-ichiro Nakao, MS, and Ryo Shimada,
PhD, Department of Legal Medicine, School of Medicine, Tokyo
Cristian Palmiere, MD*, Bettina Schrag, Marc D. Bollmann, MD, and
Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-
Patrice Mangin, PhD, Centre Universitaire, Romand de Medecine
8666, JAPAN
Legale, Rue du Bugnon 21, Lausanne, CH-1011, SWITZERLAND
After attending this presentation, attendees will more clearly
The goal of this presentation is to evaluate the potential role of
understand the types of animal models of traumatic brain injury (TBI),
procalcitonin, C-reactive protein, tumor necrosis factor alpha,
the significance of experimental studies of TBI and the mechanisms of
interleukin-6 and interleukin-8 levels in different biological fluids
brain damage after TBI.
(serum, vitreous humor and cerebrospinal fluid) as markers of sepsis, to
This presentation will impact the forensic science community in
evaluate the stability of these markers at different measurement times
aiding the understanding of the mechanisms of brain damage after closed
after collection, and to evaluate additional benefits of combined analysis
and open head injuries. These studies also show the sequential changes
of the mentioned markers compared to procalcitonin and C-reactive
occurring in the brain after TBI: changes that should be useful for
protein alone.
estimating the time after trauma in cases of head injury.
TBI can be caused both directly, by immediate mechanical
evaluating different markers that can be useful in postmortem diagnosis
disruption of brain tissue, and indirectly, by delayed injury mechanisms
of sepsis.
that include intracranial hemorrhage, brain edema, and hypoxic/ischemic
In forensic pathology routine, a well-documented medical history is
damage. Whereas human TBI is a highly complex multifactorial
often not available for a deceased person and sepsis as the cause of death
disorder, animal models of TBI are able to focus on various specific
remain difficult to diagnose. In fact, postmortem blood cultures are often
factors involved in TBI and so have helped develop a better
contaminated by putrefaction processes and macroscopic postmortem
understanding of pathophysiology after brain injury, including changes
findings (such as myocardial ischemia, pulmonary edema and
in cellular and molecular pathways. The commonly used models that
hemorrhages, hypoxic liver damage, mesenteric and gastrointestinal
replicate human closed head injuries are fluid percussion, controlled
hemorrhages, spleen infarctions and septic spleen alterations, kidney
cortical impact, weight drop and freeze injury models. Utilizing these
ischemia, and brain edema), as well as routine histological findings, may
models allows us to produce a controlled range of severity of brain
have an infectious or non-infectious origin and are neither specific nor
injury.
sensitive for recognizing sepsis-associated fatalities.
The magnitude- and time-dependent changes after TBI in a rat fluid
The observation by Assicot and coworkers that serum procalcitonin
percussion model was studied. The focus was on synaptophysin (SYP),
levels increase above normal values in patients with bacterial sepsis, but
a molecular marker of synapse. SYP immunoreactivity increased in both
not in patients with viral infection or without infection, has generated
the cortex and subcortical white matter with increasing magnitude of
considerable interest in this marker.
injury and time after trauma. Increased SYP immunoreactivity was
A large number of clinical studies have investigated procalcitonin from sudden death to an asymptomatic patient. This presentation is the
levels and courses of procalcitonin levels under various clinical third case of sudden death in patients with pace makers. The role played
conditions and they concluded that procalcitonin is valuable as a marker by primitive cardiac tumors in sudden deaths is small as their prevalence
of serious bacterial sepsis and show a good correlation with the severity is estimated to 0.05% of autopsies. Among such lesions, mesothelioma
of the disease. In different groups of patients with sepsis, procalcitonin of the atrio-ventricular node is rare and has only been reported about
was compared to C-reactive protein (CRP), tumor necrosis factor alpha seventy-five times since its first description in 1911.
(TNF-α), interleukin-6 (IL-6), interleukin-2 (IL-2), interleukin-10 (IL- Case: A 35-year-old man was found dead in the early morning by
10) and interleukin-8 (IL-8) as a diagnostic and prognostic parameter. one of his friends, while he was lying on his sofa, after having lived it up
The results commonly showed that procalcitonin exhibits a greater with some friends. The emergency physician could only certify death.
sensitivity and specificity in differentiating patients with systemic Six years previously, the man had a syncopal episode while coming out
inflammatory response syndrome (SIRS) from those with sepsis. from his truck. Electrocardiography showed a type I second degree
Tsokos and co-workers have investigated procalcitonin, C-reactive atrioventricular block. Echocardiography was normal and no curable
protein and interleukin-6 in postmortem serum as a marker of sepsis. etiology could be found. He finally had a duel-chamber pacemaker fitted
Their results show that serum procalcitonin levels can be considered as a few weeks later, which had been reliably effective and well tolerated
a valuable postmortem marker to distinguish sepsis-associated fatalities up to his sudden death. Considering the young age of the man and the
from other non-septic causes of death. Compared to other potential sudden character of his death, a medicolegal autopsy was ordered to
biochemical postmortem markers of sepsis, procalcitonin has several determine the cause of death.
advantages: in contrast to tumor necrosis factor alpha and interleukin-6, On external examination, the body was that of a young Caucasian
procalcitonin has a long half-life (25 to 30 hours); in comparison to man, 164 cm in height and 80 kg in weight. Nonspecific abrasions were
cytokines, procalcitonin is a very stable protein, even at room detected on both the right and left frontal scalp. Toxicological
temperature; procalcitonin concentrations do not differ in arterial and investigations, including alcohol, were negative. At autopsy, the only
venous blood samples from living persons; repeated freezing and gross abnormality was a left atrophic kidney, which was 24 g in weight.
unfreezing of the blood samples does not significantly influence The heart weighted 420 g; there was no abnormality in the epicardium or
procalcitonin concentration. in the valves. The coronary arteries only showed a few lipidic striae.
Levels of C-reactive protein and interleukin-6 may increase very One endocavitary pacemaker lead was found located in the atrial cavity,
rapidly in response to inflammation of infectious origin; however, and was involved by noninfectious vegetations. The other pacemaker
significantly elevated C-reactive protein and interleukin-6 levels can also lead, which was observed in the right ventricular cavity, was also
be demonstrated in a large number of life-threatening clinical conditions, affected by some fibrosis. The myocardium showed fibrosis blocks and
such as major trauma, extensive surgical procedures or burn injury, as a recent left subendocardic ischemia. Left and right ventricular walls were
result of the systemic inflammatory response syndrome, irrespective respectively 18 and 8 mm thick. Histopathological examination revealed
whether the patient develops a sepsis or not. an extensive infiltration of the atrioventricular node and of the his bundle
Statement of the Method: Postmortem blood, vitreous humour trunk, corresponding to a benign tumor called a mesothelioma. This
and cerebrospinal fluid samples were collected at autopsy. Two study tumor consisted in tubular adenoid micronodules of various sizes, lined
groups were formed according to whether there was an underlying septic by mesothelial cells. In the lumens, pseudo colloid eosinophilic material
condition as the cause of death based on the subject medical records as was found. Some areas of the tumor also showed a moderate degree of
well as autopsy findings. Marker levels were measured at different times fibrosis.
after collection. In the sepsis group, cause of death was multiple organ On the basis of these findings, arrhythmia-related death was
failure. In the non-sepsis group, cardiopulmonary resuscitation was not diagnosed, directly caused by a mesothelioma of the atrioventricular
attempted in any case. Autopsy findings did not give any cause to node, despite the presence of a pace maker.
suspect an underlying infectious disease. Discussion: The clinical presentation of a mesothelioma of the
Results will be presented and compared with published results in atrioventricular node is nonspecific and may considerably vary from
the literature. sudden death to asymptomatic patient, including syncopal episodes
Postmortem Chemistry, Sepsis, Diagnostics related to severe atrioventricular block, with a possible familial
occurrence discussed by Travers. No correlation was found in the
literature between the size of the tumor and the symptomatology
G54 Sudden Death Due to Mesothelioma of the observed.
This explains that the precise incidence of such a disease is quite
Atrio-Ventricular Node difficult to estimate, as much as diagnosis is most often done after death
when an autopsy is ordered, only nine cases having been successfully
Géraldine Maulean, MD*, Alain Tabib, PhD, Daniel Malicier, and treated antemortem.
Laurent Fanton, PhD, Institut of Legal Medicine, 12 Avenue Rockefeller, Conclusion: This report is the third case of sudden death in
Lyon, 69008, FRANCE patients with pace maker. Despite its rareness, mesothelioma of the
atrioventricular node should be considered in the differential diagnosis of
After attending this presentation, attendees will gain much heart block in children or young adults.
knowledge on sudden cardiac deaths, and understand that sudden cardiac Sudden Death, Mesothelioma, Atrio-Ventricular Node
deaths constitute a major health problem as one of the central topics in
forensic literature. Although most cases are still attributed to
complications of cardiomyopathies or coronary artery diseases,
functional dysregulations are nowadays reported with an increasing
frequency, due to the development of molecular autopsy. The role
played by primitive cardiac tumors in sudden deaths is smaller as their
prevalence is estimated to 0.05% of autopsies. Despite its rareness,
mesothelioma of the atrioventricular node should be considered in the
differential diagnosis of heart block in children or young adults.
informing attendees that the clinical presentation of a mesothelioma of
the atrio-ventricular node is non-specific and may considerably vary
G55 Accidental Drowning Deaths in a Coastal The most common causes of atypical pneumonia are Mycoplasma
pneumoniae, Chlamydophila pneumoniae and Legionella pneumophila
Region of South India – A Ten Year Study which cause fifteen percent to as much as fifty percent of cases of
community-acquired pneumonia. Other organisms include viruses; few
Tanuj Kanchan, MD*, Kasturba Medical College, Department of cases are due to zoonotic agents like Chlamydophila psittaci, Coxiella
Forensic Medicine, Light House Hill Road, Mangalore, 575 001, INDIA burneti and Francisella tularensis. Clinical and pathological patterns
range from mild upper respiratory infection to severe lower respiratory
After attending this presentation, attendees will identify with the tract disease. Atypical pneumonia generally is benign, with systemic
pattern and trend of drowning deaths in a coastal region of South India. complaints often more prominent than respiratory ones; fever, headache
This presentation will impact the forensic science community by and myalgia are common. Although the clinical course is often self-
developing an understanding of the burden of accidental drowning in the limited, these pathogens can cause severe community-acquired
coastal region and to develop preventive strategies so that precious pneumonia. The inflammatory reaction is localized in the alveolar septa
human lives are saved. that appear thickened, edematous, with infiltrates of leukocytes. In
Accidental drowning constitutes a significant public health problem severe cases, fibrinous thrombi inside alveolar capillaries and
that is often neglected in our country. This study will describe the haemorrhagic necrosis of alveolar walls are visible. Alveoli may contain
epidemiology and pattern of accidental drowning deaths in Manipal, a scant exudate. Fibrin and hyaline membranes line the denudated
coastal region in South India. This study is a registry based descriptive alveolar walls, due to diffuse alveolar damage. Superimposed bacterial
research spanning over a period of ten years from January 1998 to infection is common.
December 2007. All medicolegal autopsy case records were Case Report: A 16-year-old boy who spent all the day with his
retrospectively reviewed and the cases of death due to drowning were family, went to sleep after dinner. His brother checked on him after one
studied. The information obtained from autopsy reports, police hour and found him agonizing in an anomalous prone position, with the
investigations and toxicological analysis was registered in a database and legs out of bed. Immediately he turned the body supine, called the
analyzed. All deaths where the manner was recorded as suicidal or ambulance, and tried to resuscitate him. When the doctor arrived, after
homicidal were excluded from the study. the attempting with reanimation maneuvers, pronounced the adolescent
During the study period forty cases of drowning deaths were dead. The boy had a negative history (except for a mild headache) and
reported. Males accounted for 82.5% of cases, male- female ratio being a negative family history for sudden death. He was a basketball player
4.7:1. Majority of the victims were in 2nd and 3rd decades, together on the school team and was not known as a drug abuser. Death scene
accounting for 55% of drowning deaths followed by children in the first investigation was unremarkable. External examination was insignificant
decade (15%). Fresh water drowning was reported in 70% cases. Rivers except for the presence of a little superficial wound on the right frontal
constituted the most common sites of drowning (35%) followed by sea scalp. The internal examination revealed polyvisceral congestion,
(27.5%). Wells, canals, lakes, ponds, and water tanks were the other sites cerebral and pulmonary edema, free fluid in the pleural cavities, and
of drowning. Most (87.5%) victims of drowning were found dead. The release of foamy material on sectioning of both lungs. The left ventricle
remaining five cases died in hospitals later on. The maximum period of showed a concentric hypertrophy (anterior wall 2 cm, lateral 2.4 cm,
stay in hospital before a fatal outcome was three and a half days. Most posterior 2 cm, septal 2.2 cm). The histological examination showed a
of the accidental drownings (45%) were reported in the post monsoon pattern of massive diffuse interstitial pneumonia with markedly
period. Nearly one-third (30%) of the total drowning deaths were thickened alveolar septa with extreme congestion of capillaries, the
reported in the years 2006 and 2007. presence of abundant eosinophilic material, and infiltrates of leukocytes.
Drowning is a major global public health problem which is In the adjacent fields there were some amorphous eosinophilic material
amenable to prevention. The study highlights the pattern of accidental and erythrocytes inside the alveoli. The immunohistochemical stains
drowning deaths in Manipal, a coastal region of South India. Morbidity revealed that the pulmonary infiltrates consisted of lymphocytes,
and mortality due to drowning can be prevented by understanding its histiocytes and plasma cells. There were some foci of leukocytes within
epidemiology, common patterns and educating people about prevention. the epicardium, and focal areas of patchy myocardial fibrosis and
This is especially when hindsight often shows that many deaths from perivascular fibrosis were visible, with a mild degree of myocardial
drowning are preventable. hypertrophy. The encephalon showed leukocytic meningitis with
Drowning, Accidents, South India subarachnoid infiltrates of lymphocytes and mild perivascular edema.
The immunohistochemical analsysis (RSV, HSV1, HSV2,VZV,CMV,
HHV A and B, Parainfluenza Virus 1, 2 and 3, Adenovirus, Aspergillus
G56 Sudden Death From Atypical Pneumonia in spp., P. carinii, T. gondii) gave negative results. Additional tests were
a Healthy Adolescent carried out to identify possible pathogenic agents through
microbiological studies. Toxicological screening was negative.
Sabina Di Donato, MD*, Ospedale San Carlo - U.O. Medicina Legale, Molecular genetic analysis was conducted and excluded underlying
Via Potito Petrone, s.n.c., Potenza, 85100, ITALY; Margherita Neri, heritable diseases. The decedent’s parents indicated that the boy did not
PhD, Department Forensic Pathology, University of Foggia, Viale degli have the scalp injury before going to sleep, so it’s possible that the boy
Aviatori 1, Foggia, 71100, ITALY; and Rocco A. Maglietta, MD, suddenly fell to the bed, striking the bedside table and arresting in the
C.R.O.B. - Rionero in Vulture (Pz), via Padre Pio, 1, Rionero in Vulture anomalous position described by his brother. To explain the occurrence
(Pz), 85100, ITALY of sudden death in this case, two possible mechanisms of acute
respiratory failure are hypothesized: (1) the underlying respiratory
After attending this presentation, attendees will become familiar acidosis (well tolerated by a young active boy, by means of an induced
with the possibility that a completely asymptomatic atypical pneumonia tachypnoea) and hypoxemia may have conducted to tachycardia and
may induce sudden death, even in a previously healthy adolescent, with deteriorating hemodynamics. This instability may have elicited a lethal
absence of histological signs of diffuse alveolar damage. ventricular arrhythmia supported by a mechanism of re-entry,
This presentation will impact the forensic science community by considering that the boy’s heart showed diffuse areas of patchy fibrosis;
making attendees aware of the insidious development of atypical and (2) the irritation of the adjacent cerebral cortex by inflamed
pneumonia in immunocompetent subjects, focusing the possible meninges may have caused epileptic seizures. Seizure activity can
responsible mechanisms of sudden death in such cases, in the absence of disrupt normal physiological regulation and control of respiratory and
ARDS and histological signs of diffuse alveolar damage. cardiac activity (similar to mechanisms operating in cases of sudden

death in epilepsy), precipitating the unstable equilibrium present at lung both techniques. With respect to the assigned grading score, a
level (reduction in gas exchange due to massive interstitial pneumonia), statistically relevant discrepancy between the results of the histological
causing an acute respiratory insufficiency. examination conducted on samples by the needle biopsy and double edge
Sudden Death, Atypical Pneumonia, Meningitis knife techniques was found in six cases. Nevertheless, the discrepancy
was not systematic, because in three cases the analysis conducted with
needle biopsy gave results bigger than that with double edge knife, and
G57 Virtopsy Project - Postmortem Needle in the other three smaller.
In conclusion, this study demonstrates that postmortem pulmonary
Biopsy of the Lungs: A Feasible Tool for the biopsy, if compared with double edge knife technique, can represent a
Study of Fat Embolism as Vital Reaction feasible method of specimen collection for detecting and analyzing
pulmonary fat embolism as vital reaction.
Laura Filograna, MD*, Institute of Forensic Medicine, Centre of Although further studies are needed, the application of post-mortal
Forensic Imaging and Virtopsy, Buehlstrasse, 20, Berne, percutaneous needle biopsy methods to forensic investigations on fat
SWITZERLAND; Stephan Bolliger, MD, University of Berne Institute of embolism as vital reaction could be able to improve the diagnostic
Forensic Medicine, Buehlstrasse 20, Bern, AL 3012, SWITZERLAND; accuracy of postmortem imaging examinations, and even more, the
Danny Spendlove, MD, Institute of Forensic Medicine, Centre of possibility of a minimally invasive virtual autopsy can be envisaged for
Forensic Imaging and Virtopsy, Buehlstrasse, 20, Berne, AL 3012, select cases.
SWITZERLAND; and Ulrich Preiss, MD, and Michael Thali, MD, Pulmonary Fat Embolism, Percutaneous Needle Biopsy,
University of Bern, Institute of Forensic Medicine, Buehlstrasse 20, Postmortem Imaging
After attending this presentation, attendees will learn how to G58 Cerebral Artery Thrombosis After
overcome the diagnostic gap of postmortal cross-sectional imaging in
detecting the occurrence of fat embolism as vital reaction, by using
Penetrating Oral Trauma: An Exceptional
percutaneous needle biopsy techniques. Autopsy Case
demonstrating how percutaneous needle biopsy technique can improve Renaud Clement, MD*, 1 Rue Gaston Veil, Nantes, 44093, FRANCE
the diagnostic accuracy of postmortem imaging investigations on
pulmonary fat embolism as vital reaction within the concept of a After attending this presentation, attendees will understand the
minimally invasive virtual autopsy. mechanisms of interruption of intracranial cerebral circulation by
Pulmonary fat embolism, usually, and pulmonary embolism of bone thrombosis arising in the anterior cerebral artery as a result of penetrating
marrow, always, can be considered indicative for antemortem violence. oral trauma.
In fact, it is a vital phenomenon after trauma, depending on the pumping This presentation will impact the forensic science community by
action of the heart and an intact circulation. The postmortem diagnosis presenting the forensic examination supported by the histological
of pulmonary fat embolism is traditionally based on the histological findings. Microscopic examination made it possible to establish the
demonstration and analysis of fat droplets within the lung exact causes and vascular consequences of the impalement; they explain
microcirculation. perfectly the clinical symptomatology, as well as its
The study population consisted of twenty-six randomly selected neurologic evolution.
autopsy cases examined from September 2008 to November 2008, A young man fell onto a metal rod at a construction site. The
delivered to the Institute of Forensic Medicine of the University accident resulted in perforation of the oropharynx. After several hours,
of Berne. right hemiplegia developed.
In each case, probes from both lungs were obtained using two Complementary examinations revealed left middle cerebral artery
different sampling methods. Prior to the autopsy, multiple postmortem thrombosis. Forensic autopsy performed after the death of the patient
biopsies from both lungs were executed using clinically approved and revealed left sylvian artery thrombosis extending into the left intracranial
postmortem tested ACN-III biopsy core needles (14 gauge -160 mm) carotid sulcus, into the left internal carotid artery and into the left
with an automatic pistol device. Then, during the traditional autopsy of anterior cerebral artery. Skull base exploration demonstrated a fracture
the same cases, other thin slices of lung tissue from both lungs were of the left internal tip of the petrous bone. There was a breach of the
taken, using a double-edge knife technique. The double-edge knife intima in the anterior communicating artery and extensive thrombosis
consists of a blade sharpened on one or both slides to which a second extending to the anterior, middle and internal cerebral arteries, and to the
blade, similar in size and shape, is added on the side, folded out by means internal carotid arteries. As the adventitia was spared, this indicated
of a joint. A knurled nut regulates the distance between the blades, and indirect injury to the anterior communicating cerebral artery. This is the
thus the slice thickness. first description of cerebral artery thrombosis caused by indirect
All the samples were subjected to water storage and Sudan III traumatic injury to this artery. Although the case is clinically similar to
staining. The microscopical examination was then performed by six internal carotid arterial thrombosis by perforating trauma of the palate in
board certified forensic pathologists, and scores were assigned according young children, the initial clinical symptoms and signs were different,
to the grading scale by Falzi et al. A comparison was made between the with hypoesthesia in the territories of the V2 and V3 branches of the fifth
results of the histological examinations on both lung specimens from the cranial nerve. These clinical findings indicated traumatic injury to the
twenty-six death cases, obtained with postmortem needle biopsy and base of the skull.
double edge knife techniques respectively. A statistical analysis of the Anterior Communicating Cerebral Artery, Thrombotic Process,
results was performed. Penetrating Trauma
The statistical analysis conducted separately for each sampling
technique showed no significant differences in the grading score for the
samples from both lungs obtained with the two techniques. Moreover, it
was demonstrated that the six forensic pathologists evaluated
homogeneously the slides obtained by both lungs. Absence of
pulmonary fat embolism was detected in the same cases investigated by

G59 Does Embalming Impact Vitreous Conclusion: Embalming does not interfere with the analysis of
glucose in the vitreous fluid when using the Beckman Coulter Synchron
Glucose Levels? System with the GLUCm reagent. This study supports what has been
previously published in the literature.
Stephany Fiore, MD*, County of Sacramento, Coroner’s Office, 4800 Autopsy, Embalm, Glucose
Broadway, Suite 100, Sacramento, CA 95820-1530; and Charlotte A.
Wacker, MS*, University of California, Davis Body Donation Program,
4800 Broadway, Suite 100, Sacramento, CA 95820
G60 Analysis of an Unusual Misfire of a
After attending this presentation, attendees will understand how Common Handgun
embalming may impact the level of glucose found in vitreous fluid
obtained during autopsy. Janaki Warushahennadi, MD*, King County Medical Examiner’s Office,
This presentation will impact the forensic science community by 325 9th Avenue, HMC Box 359792, Seattle, WA 98104; Brian J. Smelser,
educating the viewer on the utility of analyzing vitreous glucose in BS, Washington State Patrol Crime Laboratory, Washington State Patrol,
embalmed decedents and by informing people of the valuable resource 2203 Airport Way South, Building A Suite 250, Seattle, WA 98134;
of human body donors and how they can be used to further forensic Richard T. Wyant, MS, Washington State Patrol CLD, 2203 Airport Way,
science. South, Suite 250, Seattle, WA 98134; and Timothy L. Williams, MD, King
This case involves an 80-year-old female who was known to be a County Medical Examiner’s Office, 325 - 9th Avenue, Box 359792,
brittle diabetic. Because of a presumed natural cause of death, the body Seattle, WA 98104-2499
was originally released to the funeral home. Adult Protective Services
requested the coroner perform an investigation into the death due to After attending this presentation, attendees will be informed of an
allegations of elder abuse/neglect by a home care provider. The decedent unusual mechanism accounting for the misfire of a common handgun.
was embalmed six days prior to autopsy using Ultra 27 (Pierce This presentation will impact the forensic science community by
Chemicals/Royal Bond, Inc) as the arterial preservative and Restorative illustrating the utility of cooperation between experts from different
(The Dodge Company); both fluids are rich tissue hydrators. Most disciplines in reconstructing incidents.
mortuary chemicals use glycerol as the main humectant. The vitreous There are many circumstances in which an apparent live cartridge
glucose was analyzed at University of California Davis Medical Center may misfire even though the firing pin has struck the primer. Factors that
using a GLUCm reagent on a Beckman Coulter Synchron System. The contribute to those circumstances include design, manufacture, and
concentration of glucose is determined by measuring the rate of oxygen condition of the ammunition and firearm as well as the actions of the
consumption based on the following chemical reaction: individuals involved in the case.
Vitreous fluid collected at autopsy had an elevated level of glucose In this report, a case will be illustrated in which two unusual
(544 mg/dL). The cause of death was determined to be from misfired cartridges were found at the scene of the suicide of a 53-year-
hyperglycemia due to diabetes mellitus with hypertensive cardiovascular old woman by means of gunshot using a Glock 9 millimeter handgun.
disease listed as a contributing condition. The caregiver, a registered Expert examination of the firearm and ammunition involved
nurse, is facing criminal charges of elder abuse/neglect for failing to determined that the main factors contributing to the misfiring of the
provide medical care. cartridges were likely the design of the firearm in conjunction with the
It is not uncommon for the forensic pathologist to perform an actions of the decedent. The examination supported the conclusion that
autopsy on an individual who has already been embalmed. The the misfires were caused by the decedent pressing the firearm slightly
interpretation of tests perform on the blood is clearly limited due to the against her head in such a way that a safety mechanism was activated.
dilution effects of the embalming process, but what about the vitreous Questions outside of particular investigators’ areas of expertise can
fluid within the eyes? Is this fluid protected from the embalming process arise during any investigation. In such cases, cooperation between
and can it be used to aid in postmortem examination? Can the value of experts from different disciplines is essential to understand the
an elevated glucose level in a post-embalmed individual be trusted or is complexities of reconstructing incidents.
the result falsely elevated due to contamination by an embalming fluid Misfire, Handgun, Glock
with high glycerol content? Was the analytical method used to measure
the glucose specific for this analyte or was it unable to distinguish
glycerol from glucose? G61 Fatal Cardiac Perforation During
An experiment was designed to test the vitreous glucose levels on a
body donor before and after embalming. The body donor was a 78-year-
Percutaneous Treatment in Iliac
old female, average height and weight that died from respiratory failure Artery Occlusion
and interstitial lung disease. Standard anatomical embalming was
performed. The donor remains were arterially injected, and the Alessandro Bonsignore, MD*, Massimo Gallo, MD, Francesco Ventura,
preservation was supplemented by hypodermic injection to poorly PhD, and Francesco De Stefano, MD, Department of Legal and Forensic
preserved areas. The total amount of fluid injected was 951oz., much Medicine, University of Genova, Via De Toni 12, Genova, 16132, ITALY
more than the funeral home had injected. The embalming solution used
consists of various preservatives, disinfectants, water correctives, and After attending this presentation, attendees will have learned of an
humectants. A total of three samples of vitreous were obtained; the first extremely rare complication of percutaneous transluminal angioplasty
an unadulterated sample from the un-embalmed donor, the second, also (PTA) and stenting for iliac artery occlusive disease; attendees will also
from the un-embalmed donor, was “spiked” with embalming solution by understand the cause of the error and verify the professional liability
adding a drop to the test tube, and the final sample was obtained post- profiles derived from this case.
embalming. All samples were sent for glucose testing by the same This presentation will impact the forensic science community by
service that tested the autopsy sample. reminding researchers of this rare complication and the opportunity to
Results: There was a very slight increase in the post-embalming avoid this event.
glucose level compared to the pre-embalming samples (15 mg/dL vs. 7 Only a complete forensic approach by means of autopsy and
mg/dL), but not enough to be clinically significant. Both pre-embalming microscopy examination led to the conclusion for cardiac tamponade due
samples (neat and spiked) had the exact same result (7 mg/dL). to left ventricular wall rupture.

Aortoiliac occlusive disease (AIOD) is a common manifestation of literature. The complications rate for angioplasty selective stenting,
atherosclerosis that may lead to lower limb ischemia. In this case the indeed, is generally very low both for perioperative deaths (0,03-0,06%
Trans Atlantic Inter-Society Consensus (TASC) offers guidelines for the - Aburahma et al, 2007) and immediate total complications (0,7% - Kudo
treatment of such disease. In particular total unilateral iliac occlusions et al, 2005).
should be treated by primary stenting, reducing the risk of embolisation Iliac Artery Occlusion, Percutaneous Transluminal Angioplasty,
in iliac stenoses, and moreover the periprocedural morbidity and Fatal Left Ventricular Rupture
mortality rates. In addition, primary stenting is indicated in the presence
of specific risk factors as ulcer/gangrene, smoking history, and chronic
renal failure with hemodialysis. Following these directives the use of G62 Swiss Virtobot (Virtual Autopsy)
endovascular interventions for arterial occlusive lesions continues to
increase consequently causing the detriment of open surgical
Documentation and Analysis: Work Flow
revascularization. A careful evaluation of the various restraining and Procedure
parameters should precede the choice of surgical approach, to ensure the
selection of the most suitable technique in each individual patient on the Steffen G. Ross, MD, Institute of Forensic Medicine Center of forensic
grounds of clinical presentation of the disease. For example, TASC imaging “Virtopsy”, Buehlstrasse 20, Bern, AE 3012, SWITZERLAND;
lesions type A or B are best treated with angioplasty and stenting, while Lars Ebert, University Bern, IRM, Buehlstrasse 20, Bern, AE 3012,
TASC lesions type C and D show better results with surgical treatment. SWITZERLAND; Silvio Näther, Institute of Forensic Medicine, Centre of
Technically PTA provides for an ipsilateral, or less frequently Forensic Imaging, Bühlstrasse 20, Bern, 3012, SWITZERLAND; and
controlateral, common femoral artery access, crossing the lesion with a Stephan Bolliger, MD, and Michael Thali, MD*, University of Bern,
guide wire, dilating the vessel with an angioplasty balloon catheter and Institute of Forensic Medicine, Buehlstrasse 20, Bern, 3012,
placing a self-expandable stent. Sometimes a brachial approach is SWITZERLAND
preferred, especially when many lower limb vessels are impaired. In this
kind of approach it is important to pay attention at some neurological The goal of this presentation is to discuss the 2009 report
complications (i.e., hematoma that compresses the brachial plexus concerning “Medical Examiners and Coroners Systems: Current and
leading to a sensory-motor deficit) and vascular ones (i.e., Future Needs“ of the “National Academy of Sciences“, it is written, that
pseudoaneurysm, local thrombosis or distal embolism) which have a low modern imaging technologies (Virtual autopsy, Virtopsy,
incidence, estimated between 2 and 13,4% (Tsetis et al, 2008). www.virtopsy.com) has a great potential to detect forensic relevant
A 68-year-old male smoker presented to the hospital with a history findings. In the lecture, based on the experiences obtained up until now,
of bilateral and severe lower limb arterial disease. He was suffering a the possibilities and realization of a process-optimized forensic
left common iliac arterial occlusive lesion as showed by the examination procedure, including the subsequent analysis process, are
arteriographic examination. The patient was treated with PTA and illustrated.
stenting through the left brachial artery, instead of controlateral femoral This presentation will impact the forensic science community by
approach, due to the presence of small lesions in the right leg vessels. presenting an overview of the techniques of forensic imaging and virtual
During the procedure, the radiologist used videoscopic to help to see the autopsy and the effect to forensics in future and in correlation with the
part of the iliac artery concerned the occlusion without following the 2009 National Academy of Sciences report concerning, “Medical
entire route taken by the guide wire. By doing this he did not notice that Examiners and Coroners Systems: Current and Future Needs”.
he had taken a wrong direction, passing through the ascending aorta and Over ten years ago, the Virtopsy Project with its systematic
then going into the cardiac chambers; in a second attempt he finally was integration of various technologies and modalities, such as
able to enter the descending aorta and reach the left common iliac artery photogrammetric 3D surface scanning, computer tomography and
where the stent was successfully located. magnetic resonance scanning as well as in the area of clinical and
Two hours after PTA the patient suddenly died. An autopsy was postmortem forensic medicine as well as postmortem biopsy and
arranged for investigating any professional liability profiles. A complete angiography and synthetic somatic modeling development, was
postmortem examination was performed three days after death. perceived by professional circles as being revolutionary.
External examination was insignificant. The internal examination After a decade, these technologies at the University Forensic
revealed a cardiac tamponade without identifying the breaking point, but Institute Bern have been integrated as an evolutionary process
with evidence of hemorrhagic infiltration area in the epicardium and development in daily forensic practice.
throughout the thickness of the myocardium at the distal part of the left The almost completed documentation procedure in the postmortem
ventricle. At the aortic cone level a small area of hemorrhagic area has also influenced future image-based documentation and analysis
infiltration, in contact with the fibrous pericardium, was found. The processes in clinical forensic medicine.
presence of a correctly positioned stent in the left common iliac artery Forensic Imaging, Virtual Autopsy, Virtopsy
was observed. Other findings concerned polyvisceral congestion,
cerebral, and pulmonary edema.
The histological heart examination, performed with routine G63 Mortuary Management in the Aftermath of
hematoxylin-eosin, revealed hemorrhagic dissection of myocardial
tissue at left ventricle level consistent with a rupture of the heart,
the 2009 Australian Bush Fires
excluding natural causes of death as myocardial infarction.
In conclusion, the cause of death was attributed to a cardiac Jodie J. Leditschke, PhD*, Victorian Institute of Forensic Medicine, 57-
tamponade due to traumatic left ventricular rupture during PTA 83 Kavanagh Street, Southbank, Melbourne, 3006, AUSTRALIA
procedure.
This case, which has attracted medicolegal interest because of After attending this presentation, attendees will have a greater
medical liability profiles that were assumed as the doctors’ fault, shows understanding of the principles and logistics behind mortuary
a fatal PTA complication particularly uncommon, as reported by management following a mass fatality incident.

This presentation will impact the forensic science community by activation of an emergency response, timely identifications, and
serving as a reference for improving the management of the dead and ultimately some degree of closure for the victim’s families.
encouraging greater emergency preparedness within communities. Mortuary, Disaster, Bush Fires
The Victorian Institute of Forensic Medicine (VIFM) is a statutory
body with the responsibility to provide forensic pathological, clinical
forensic medical, and related services to the State of Victoria, Australia. G64 A Uniform Protocol to Address the Rapidly
This includes the conduct of postmortem examinations and the provision
of a range of forensic scientific investigations in cases referred by
Accumulating Unidentified Human
the coroner. Remains and Missing Persons in the United
One of the roles of the VIFM is to provide scientific services in the States — A Nation’s Silent Mass Disaster
event of multiple fatalities within the State of Victoria and extending to
around Australia where necessary. Some of these past incidents include Marzena H. Mulawka, MFS*, Forensic Sciences Program, National
the 1996 Port Arthur Massacre, 2003 Bali Bombing, 2004 Tsunami and University, 11255 North Torrey Pines Road, La Jolla, CA 92037-1011;
the Australian Embassy bombing in Jakarta. Ismail M. Sebetan, MD, PhD, 12752 Via Nieve, San Diego, CA 92130;
On February 8, 2009 now known as Black Saturday, the State of and Paul Stein, PhD, 25757 Bellemore Drive, Ramona, CA 92065
Victoria, Australia suffered the deadliest bushfires recorded in its history.
There were 173 fatalities and over 2,200 homes were destroyed. Over After attending this presentation, attendees will understand the
the following days 298 suspected human remains were admitted problems involved with the investigation of unidentified human remains
to VIFM. (UHR). The strengths and limitations of current technologies and
On the day of the fires VIFM activated its emergency plan. Within resources available for investigating UHR cases will be discussed as well
48-hours, a temporary mortuary was constructed adjacent to the existing as presenting for the first time, a uniform protocol and procedures for the
mortuary facility. This temporary mortuary had the capacity to store up identification of UHR.
to 300 deceased persons. It was linked to the main building by a series The presentation of this protocol will impact the forensic science
of marquee walkways, was completely undercover and surrounded by community by serving as a guideline as it can expedite and augment
security fencing. Additional catering and office spaces were UHR identification efforts by presenting the resources available in an
also constructed. organized and consistent format. As a direct result, utilization of this
Pathologists, anthropologists, odontologists, police, and mortuary protocol may help identify the tens of thousands of UHR that are
assistants responded from all around Australia, New Zealand and currently being held within medical examiner/coroner’s (ME/C) offices
Indonesia. The mortuary facility and staff were divided into two areas: throughout the United States. More importantly, families of these
DVI (Disaster Victim Identification) and “normal operations.” deceased individuals will no longer wonder what happened to their loved
A high priority for the mortuary was to ensure all “normal” ones and struggle with the agony of possibly never having the ability of
admissions of deceased persons (those cases which were not related to laying their loved ones to rest.
the bushfires) were handled concurrently and in a timely manner. The Statistical data from UHR cases at the San Diego County Medical
VIFM examines approximately 3,000 deceased persons per year and in Examiner’s Office (SDMEO) from 1997-2007 will impact the forensic
2005 a multi-slice CT scanner was installed. This scanner has become science community by demonstrating the effectiveness of this
integral to the day to day operations of the VIFM and played a major role new protocol.
in the identification of the victims. No uniform protocol or procedure exists describing every avenue
On admission, each bush fire victim was given both a unique DVI currently available to facilitate the identification of UHR. Therefore,
and a coroner’s case number. The case was CT scanned, examined by a many jurisdictions lack consistent guidelines for pursuing the
pathology team, an anthropologist, an odontologist, and in some identification of UHR and continue to be unaware of the most current
instances a fingerprint expert. Where possible a DNA sample was taken. resources available to aid in their investigations. This study was
All processes, samples, labels, and paperwork underwent a quality conducted to determine whether a uniform protocol could be developed
assurance check prior to the case completion. Regular audits were to aid in streamlining the process of identification. Many avenues
conducted. The majority of postmortem examinations were completed currently available to aid in the identification of UHR were examined
within twenty days of admission and combined to create a comprehensive and universal procedure that
Occupational health and safety issues of the staff were paramount; can be followed by any agency or organization in the forensic science
this included correct manual handling, infection control, and community tasked with the identification of unidentified persons.
psychological debriefings. During the operation it was found that some During a brief time period from January 2007 to January 2008,
remains were contaminated with asbestos. Procedures were set in place when components of the uniform protocol were used for the
to manage these cases individually and each was isolated to reduce the investigation of specific UHR cases at the San Diego County Medical
exposure to staff. Examiner’s Office (SDMEO), there were seventeen “cold” UHR cases
On May 1, 2009 the identifications of all missing persons was from the 1997-2007 time period that were identified. Furthermore, there
complete. Of the 164 missing persons, 163 were found, identified, and were only four UHR cases recorded in 2007, a significant decrease from
the remains returned to the families. Nine deceased persons died in the average number of fourteen UHR cases per year. An obvious decline
hospital or related circumstances and did not undergo the formal DVI in the number of unidentified persons was yielded, which correlated to
process. the utilization of components of the uniform protocol.
This operation identified a number of significant challenges, in A uniform protocol as will be presented can be created to assist in
particular the management of multiple parts of human remains for one the identification of current and “cold case” UHR and linking them to
individual. A new procedure was developed to ensure all human missing person cases, which can further assist law enforcement in any
remains, where possible, were reconciled with deceased persons prior to related criminal investigations.
the release to the funeral director. Collaboration and organized, consistent protocols among local,
Finally, no mass disaster operation can function successfully state, and federal agencies tasked with the identification of missing and
without a close working relationship between police, mortuary, medical unidentified persons will expedite the collection and distribution of
examiners, and coronial staff. This operation highlighted the value of information crucial to these investigations. Thus, a consistency of
cultivating this relationship during the “quiet” times to ensure efficient

incoming information will be established, allowing the searching and under a defined set of circumstances can provide vital forensic clues
correlating of case information and as a result, increasing the probability regarding the MOD, and potential prevent serial or repeat murders.
of UHR cases being linked to missing person cases. This will likely Drowning, Protocols, Homicide
result saving millions of dollars and countless hours of time that could be
used more efficiently by the agencies involved with the identification G66 MAPS: How a Statewide Pharmaceutical
of UHR.
Specific resources and supporting data for the application of the
Database Improves Death Investigation
uniform protocol in ME/C offices in the United States will be presented.
It is recommended that ME/C offices and agencies tasked with the Shawn A. Silver*, Sparrow Forensic Pathology, 1215 East Michigan
identification of UHR become familiar with the various UHR Avenue, Lansing, MI 48909; Joyce L. deJong, DO, Sparrow Health
identification avenues available that the protocol will exhibit. Systems, Forensic Pathology, 1322 East Michigan Avenue, Suite 118,
Unidentified Human Remains, Missing Persons, Investigation Lansing, MI 48909; and Philip R. Croft, MD, Michael A. Markey, MD,
and Michelle P. Elieff, MD, Sparrow Forensic Pathology, 1215 East
G65 Request for Uniform Autopsy Protocols on After attending this presentation, the attendee will have a better
Certain Drowning Victims understanding of the benefits of using a controlled substance
pharmaceutical database such as the Michigan Automated Prescription
Gerald N. Nance, BA*, National Center for Missing and Exploied System (MAPS) when obtaining a decedent’s medical history. Attendees
Children (NCMEC), 699 Prince Street, Alexandria, VA 22314 will be presented with several case studies illustrating how the MAPS
system can provide missing information and potentially change the cause
The attendees will learn indicators that may determine whether and/or manner of death.
drowning victims may require additional forensic examination to assess This presentation will impact the forensic science community by
whether the drowning is in fact a homicide staged to look like an raising awareness among all parties involved in death investigation,
accident. Attendees can anticipate implementing autopsy protocols that specifically medical examiners, by describing the Michigan Automated
help identify the need to conduct examinations that assist law Prescription System (MAPS) and its use in aiding in the investigation of
enforcement in investigating suspicious or inadequately corroborated deaths reported to medical examiners.
deaths while proactively addressing potential threats to vulnerable Accurate patient medical history is essential to the success of every
populations of abuse/neglect. death investigation. However, gaps in patient histories and medical
This presentation will impact the forensic science community by records can sometimes lead to incorrect interpretation of data and may
providing key indicators to identify drowning cases of interest, compromise the opinion rendered by the medical examiner. Obtaining
improving their understanding of a certain class of victim (victims of accurate information regarding a decedent is critical to a high quality
unobserved and inadequately corroborated drowning) resulting in investigation and the interpretation of postmortem toxicology. The
improved forensic evidence collection, enhancing the accuracy and Michigan Automated Prescription System allows the medical examiner
utility of the autopsy on these victims, and increasing the ability for law to gather information regarding controlled substances prescribed to the
enforcement to respond and investigate viable/scientifically-driven time decedent for months before the death.
sensitive leads. MAPS grants physicians with a DEA number the ability to access
Use of Indicators for Positive Impact: A plan of action to pharmaceutical dispensing data statewide to determine all controlled
improve forensic evidence collection related to victims of unobserved or substances dispensed to a particular patient. The MAPS requires
inadequately corroborated drowning will enhance the utility of the pharmacists, veterinarians, and dispensing physicians to report
autopsy, and positively impact the medical examiner (M.E.)/forensic electronically (or by mail) all controlled substances dispensed in
scientist community, law enforcement (L.E.) partners, victims’ families Schedules 2-5. Michigan launched the service in its current form in
and the safety of both children and adults. Oftentimes, the M.E./forensic January 2003, and any previously existing prescription, patient, and
scientist community is best situated to provide investigators tools to healthcare provider data were entered into the new system. With over
recognize a homicide staged to look like an accident; excluding natural, 1.2 million prescriptions reported each month, the MAPS system was
traumatic, and toxicological factors in the medical cause of death (COD) built for ease of use, fast report generation (average turnaround time for
are critically important. individual reports is less than ten minutes), and prescription trend
Preservation of Forensic Evidence: Frequently, forensic evidence watching.
indicating criminal conduct is destroyed or washed away in victims of In cases of suspected drug overdose due to a controlled substance
unobserved or suspicious drowning. While the accurate assessment of with “positive” toxicology, the medical examiner makes an inquiry into
autopsy findings requires thorough examination of circumstances the database using the name and date-of-birth of the decedent. The
preceding death and circumstances of recovery – without advance report generated may indicate no information is available for an
evidence of foul play, when victims are recovered from the water, the individual with the particular information. More commonly, the report
circumstances, manner of death (MOD), and water entry point often lack generates a list of the controlled substances(s) prescribed, the quantity
thorough examination. NCMEC request consistent initial drowning dispensed, the date dispensed, the prescribing physician(s), and the
examinations to complement L.E. efforts nationwide – as timely dispensing pharmacy(s).
information on MOD can lead L.E. to water entry point analysis and The use of information provided by MAPS led to the prospective
other investigative leads prior to the disappearance of critical evidence. review of seventeen deaths since February 2009. Of the seventeen
Methodology Changes: NCMEC request the AAFS support the deaths, the MAPS report in three deaths did not change the opinion or
establishment of uniform nationwide protocols for the examination of assist the medical examiner in the investigation, the report in ten
unobserved drowning victims and for victims recovered in the water confirmed or supported the medical examiner’s opinion, and in four
under suspicious or inadequately corroborated circumstances. Treating cases, a change of the cause and/or manner of death occurred based on
these investigations as homicides from initiation is vital to judicious information contained in the MAPS report.
evidence recovery and adoption of certain examinations (including Example cases will be presented in detail to demonstrate how the
testing for sexual assault, subcutaneous bruising, predatory drugs, etc.) information available in a database of controlled substances dispensed to

patients contributes to the investigation of deaths of individuals with terminology, e.g., terms used in forensic pathology and forensic
postmortem drug screens “positive” for prescription medications in odontology; and to study the reliability of previously-presented
which drug intoxication may have caused or contributed to the death. methodology for postmortem genital examinations, with colposcopy.
Death investigators should be aware of this advantageous tool. This presentation will impact the forensic science community by
With a better understanding of the patient’s history, investigators can improving the diagnostic acumen of the forensic examiner and serve as
paint a more accurate picture of the life of the decedent, which, in turn, a format for quality improvement; providing a framework for the
gives the medical examiner better tools to properly evaluate the situation evaluation of fatal sexual violence against women; and increasing the
and return a more confident ruling regarding cause and manner of death. reliability and validity of both taxonomy and techniques (methodology)
Toxicology, Death Investigation, Drug Related Fatalities used to examine victims of fatal sexual violence.
This paper describes ongoing clinical research of postmortem
genital anatomy and a methodology to capture data gleaned both from
G67 Death Investigation and Organ and Tissue baseline studies and presenting cases of fatal sexual violence.
The nature of these crimes, coupled with a lack of a detailed history
Donation in Clark County, Nevada from the victim, predicates adoption of the most accurate methodology
and technology available; these victims are not available for follow-up
Alane Olson, MD*, Clark County Coroner’s Office, 1704 Pinto Lane, examinations.
Las Vegas, NV 89106 A fatal sexual violence database provides a relational system in
which to record, analyze, and compare data from both baseline studies of
After attending this presentation, attendees will be acquainted with normal anogenital anatomy and cases of sexual homicide. While it is
alternatives and compromises which have been adopted between a helpful for the forensic examiner to be cognizant of previous
medicolegal death investigation agency and the local organ procurement classification systems used to describe findings in living subjects
organization in an effort to optimize medicolegal death investigations (Fraser: WHO, 1999), a taxonomy germane to the postmortem arena
and organ and tissue procurement. should incorporate salient terms that will be consistent and universally
The presentation will impact the forensic science community by applicable and acceptable within the forensic community (Crowley &
providing knowledge of some successful alternatives in meeting the Peterson: AAFS, 2004). Inclusion of these findings into a relational
needs of coroner/medical examiner offices and organ procurement database will permit aggregate summaries of individual and population-
organizations. based summaries.
During its 2007 session, the Nevada Legislature considered model Materials and Methods: Initial case documentation for the
legislation to modify the Uniform Anatomical Gift Act. At the same baseline clinical study conducted at the Donated Body Program of
time, the Clark County Office of the Coroner/Medical Examiner and the University of California Davis, Sacramento, is via the Postmortem
Nevada Donor Network initiated discussions aimed at tailoring the Genital Examination Case Worksheet. A hardcopy of this form is
model legislation to better accommodate specific needs and existing completed in the morgue. It contains all data fields, with essential
relationships. As a result of these activities, the legislation finally elements of the case, methods of examination, and summary of findings.
enacted contains provisions which, among other things, allow the For these cases of normative controls, some fields in the database
coroner’s office to refuse organ and tissue donation if it will interfere will not be populated; other variables are common to both sexual
with the death investigation, attend the procurement if necessary, be homicide and control groups. Because the strictest efforts are enacted by
reimbursed for attending the procurement, and obtain video and the Donated Body Program to protect identifying data and personal
photographic documentation before, during, and after the procurement. information of the donors, some information is simply not available, e.g.,
In order to accommodate the anticipated need for photo documentation, date of birth (only age is used), address, disposition of the body, time
the coroner’s office formed the Forensic Investigative Rapid Support body found, position of the body, social history and lifestyle,
Team (FIRST), which is composed of experienced autopsy technicians gynecological history, clothing, and other personal items on the body at
who are on-call and available to respond to hospitals in conjunction with the time of death. Conversely, for cases of sexual violence, the
the coroner investigator for the purpose of photographing prospective aforementioned variables, plus date of birth, elements of the crime scene,
donors. When the coroner’s office is notified of a request for donation, restraints and bindings, body positioning, nongenital trauma, including
on-call medical examiner is responsible for deciding if the procurement bitemarks and other patterned injuries, genital trauma, and all biological
can take place, and the FIRST team is activated at his/her discretion. The and forensic specimens for the Sexual Assault Evidence Kit are germane
coroner’s office and organ procurement organization consider this a to the case composite. Some techniques for examination would be
reasonable compromise between optimizing recovery of organs and relevant to medical-legal cases, but might not routinely be available for
tissues, and the requirements for conducting thorough medicolegal normative studies, e.g., Wood’s Lamp, alternate light source, or
death investigations. reflective light imaging.
Death Investigation, Organ Procurement, Legislation Some variables common to both normative and sexual homicide
cases include age and reproductive status, (pre-pubertal, reproductive
age, peri-menopausal, and post-menopausal) and genital examination
G68 Fatal Sexual Violence Database for techniques (gross visualization, colposcopy, single lens reflex (SLR)
Postmortem Genital Examinations camera photography, speculum and anoscopic examination, and the use
of balloon-tipped swabs). Also, the same twelve anatomic sites are
With Colposcopy visualized, inspected, and photographed: labia majora, peri-clitoral
area, peri-urethral area, labia minora, hymen, vagina, cervix, perineum,
Sharon R. Crowley, MN*, FCNS, 122 Emeline Avenue, Santa Cruz, fossa navicularis, posterior fourchette, anus, and rectum.
CA 95060 Other common variables include the unique case identifier, date and
time of the examination, interval from death to arrival in forensic science
The goals of this presentation are to provide a systematic method of morgue (£ 24 hrs., 24-48 hrs., 48-72 hrs., 72-96 hrs., ³ 5 days); general
data collection and storage that will enable us to better understand the condition of body; race and ethnicity (per CDC definitions); cause of
nature and appearance of the anogenital tissues at various postmortem death, and contributory and/or concomitant medical and gynecological
intervals; to integrate a taxonomy that is consistent with conventional conditions, especially those presenting lesions.

Postmortem artifact, such as mucosal autolysis and skin slip that is and coroners do not have much experience in preparing grant
visualized in the anogenital tissues is documented for each anatomic site solicitations. With new funding available, this presentation will impact
where it is noted. the forensic science community by demonstrating how medical
Initially, a spreadsheet was utilized for its capability to easily examiners could benefit from some tips on pitfalls in the process.
record, sort, and organize the various data elements. A relational Grant funding for medical examiners and coroners has previously
database, e.g., ACCESSâ, permits data to be divided into many subject been limited. New federal funding sources are now available with more
fields and represented only once. Divided information can be re- expected in the future. Preparing a grant solicitation may appear to be a
synthesized via common, related subject-based tables. This will remove daunting task. This presentation will offer some simple tips to make a
data redundancy and help ensure accurate information. The rows and grant solicitation more appealing to reviewers and some pitfalls to avoid.
columns in the tables are expanded data collections of the postmortem Grant Solicitations, Grant Pitfalls, Grant Tips
examination worksheets for documentation of data during the course of
the clinical examination. Data can eventually be exported into other data
systems, e.g., SPSSâ, for more advanced statistical analysis. G70 Development of Standard Operating
Discussion: In addition to the multiple variables present during any
female genital examination, the postmortem arena superimposes a
Procedures for Conducting Arthropod
unique set of factors onto the scene. Many of these were not previously Succession Studies: Improving Postmortem
been studied or sufficiently documented in the literature. A fatal sexual Estimates Through Ecology
violence database serves as an efficient repository of data accumulated
during the Donated Body Program baseline study, in addition to any Jeffery K. Tomberlin, PhD*, Department of Entomology, TAMU 2475,
concomitant, presenting sexual homicide cases. College Station, TX 77843-2475; and Jason H. Byrd, PhD*, Maples
Missing data may also be significant e.g., the fact that a body of a Center for Forensic Medicine, University of Florida, 4800 Southwest
Jane Doe found without any identifying information, e.g., driver’s 35th Drive, Gainesville, FL 32608
license, passport, could be a potential link to human trafficking
(Crowley: AAFS, 2009). Records of actual fatal sexual violence cases The goal of this presentation is to provide attendees with a better
will have many variables that are not germane to the baseline controls. understanding of experimental design as it relates to arthropod-based
Thus, a relational database is an ideal method to simplify and quantify decomposition studies.
data for interpretation, analysis, and linkage to other cases. This presentation will impact the forensic science community by
Storage and evaluation of data will help avoid ambiguity in the demonstrating the development of standard operating procedures for
interpretation of findings for this target population. Analysis and conducting arthropod succession studies in the field.
interpretation of data will increase the diagnostic acumen of the forensic The period of insect activity (PIA) encompasses the time from
examiner. It will also facilitate effective and reliable communication discovery of human remains to when the remains were actually
within the forensic and legal community, via a more descriptive colonized. Therefore, the PIA in most cases represents the minimum
taxonomy. An effective database will allow eventual comparison of the postmortem interval (minimum-PMI). The amount of the PMI
genital findings in fatal sexual homicide victims to a control group of encompassed by the PIA can vary depending on a number of variables
individuals who died of other causes, i.e., natural, accidental, suicide, such as wind, rain, temperature, or if arthropods are excluded from the
and non-sexual homicide. remains due to a physical barrier (i.e. wrapping, enclosed in a car or
Finally, the ultimate goal of this research is to improve our home). Consequently, understanding the variability the actual time of
understanding of what is normal, and what is not, for the anogenital colonization as it relates to the actual time of death is of great
anatomy during the postmortem interval. To this end, data gleaned from importance.
a fatal sexual violence database can be used to expand and enhance our Arthropod succession studies are conducted for a number of
knowledge. The forensic examiner is presented with the challenge to reasons. The majority of these studies are done to determine the species
“capture” in hardcopy and electronic systems, a myriad of variables and composition for a given location during a particular time of year to
conditions presented by each body in the morgue. Until recent years, a provide data that can be used to determine the “postmortem interval” of
paucity of information existed on the appearance of the anogenital a decedent discovered in the same vicinity of the study site, and to
tissues during the postmortem interval. Comparisons to either living determine the variation in time of initial colonization of remains.
sexual assault victims or postmortem cases of non-sexual etiology were A review of the forensic entomology literature indicates that a
extremely difficult. Thus, it is paramount that the examiner always be standard operating procedure is needed to in order to glean as much
cognizant of the need to perform these examinations with optimal levels information from these decomposition studies as possible. Such
of expertise and to permanently chronicle vital information. In this information could lead to a better understanding of the succession and
manner, our capacity and understanding of fatal sexual violence against decomposition variability in different geographic regions and greater
women will continue to grow. explanation of variables delaying arthropod colonization patterns on
Fatal Sexual Violence, Colposcopy, Forensic Clinical Nurse human remains. Furthermore, developing consistent practices could lead
Specialist to data sets that can be combined in meta-analyses.
The following variables are suggested for inclusion in a SOP for
arthropod succession studies:
G69 Grant Solicitations: New Opportunities for 1. Actual time of death of the remains used in the study
Medical Examiners and Coroners – Tips on 2. Storage of remains prior to use (i.e., frozen)
the Process 3. Method used for euthanasia
4. Actual time of initial colonization
5. Identification of species initiating colonization
Marcella F. Fierro, MD*, Fierro Forensics, 8702 Berwickshire Drive,
6. Environmental conditions at the time of colonization
Henrico, VA 23229-7833
(temperature, rain, shade, etc)
7. GPS coordinates of study site
After attending this presentation, attendees will be able to avoid
Forensic Entomology, Ecology, Period of Insect Activity
pitfalls in the process of preparing grant solicitations.
The availability of Federal grants for medical examiners and
coroners has been limited. In contrast to academics, medical examiners
G71 Using Biolog EcoPlatesTM as an hypothesized to change as a function of succession, and identified stages
of succession could be used to determine the stage of decomposition and
Economical Approach to Determining the spatial and temporal positioning of remains on a rural forest floor.
Postmortem Body Dump Sites Through Further, we hypothesized that microbial successional dynamics
Microbial Community Level Physiological (community structure rate and sequence of change) would impact initial
species-specific blow fly oviposition and colonization. We predicted that
Profiling MCLPPs could be matched and calibrated with genomic-based methods
of describing microbial communities, providing a more economical
M. Eric Benbow, PhD*, University of Dayton, Department of Biology, approach for use in crime scene investigations.
300 College Park, Dayton, OH 45469-2320; Jeffery K. Tomberlin, PhD, For this study, microbial samples were taken from carrion (swine)
Department of Entomology, TAMU 2475, College Station, TX 77843- (N = 3–9) and the soil underneath (treatment soil) and at two distances
2475; Tawni L. Crippen, PhD, Southern Plains Agricultural Research lateral (0.25 and 1.0 m) of each carcass (control soil). To understand
Center, Agricultural Research Service, U.S. Department of Agriculture, microbial community structure differences on the carcass, swabs of the
College Station, TX 77845; Andrew Lewis, BS, University of Dayton, buccal, urogential and shoulder skin were evaluated, and all samples
Department of Biology, 300 College Park, Dayton, OH 45469-2320; and were described using Biolog EcoPlatesTM. This study was done in two
Jennifer Pechal, MS, TAMU 2475, Texas A&M University, College seasons and two geographic locations to understand variability and
Station, TX 77843-2475 generality of these techniques. In one location, matched samples of each
individual sample, or composite sample, were taken and evaluated using
After attending this presentation attendees will have a better the Roche 454 FLX pyrosequencing platform. Each of the samples were
understanding of the role microbial communities play in the rate and analyzed using the bacterial tagged encoded FLX amplicon
ecological dynamics of decomposing remains, and how this information pyrosequencing (bTEFAP) method to identify patterns of organisms
can be used to better understand the timing and postmortem placement occurring on the decomposing tissue during the longitudinal study and
of human remains in the environment. Attendees will learn how changes calibrated to MCLPPs from the EcoPlatesTM.
in microbial community level physiological profiles (MCLPPs), during Preliminary results found substantial change in microbial
community succession on a body and in the soil beneath, can be utilized communities both on the carcass and in the soil beneath the carcass, with
to predict the location and duration of decomposing remains. little change in the control soil communities over time. Variation of
This novel approach will impact the forensic sciences community MCLPPs among body regions was minimal and could be combined to
by providing a more in-depth understanding of the ecological principles provide an average body MCLPP signature. During the decay stage of
governing microbial community succession. Its cost-effective decomposition, MCLPPs were significantly different in soil beneath
framework makes it ideal for use in crime scene investigations. On a compared to soil lateral of the body; this supported the hypothesis that
broader scope this technique will provide insight into the influence of the MCLPP have the potential to differentiate soil communities where
microbial composition and metabolic products on insect colonization of decomposition has been occurring, and possibly predict the time since
decomposing remains (i.e., forensic entomology), thus improving the placement. Further, there was substantial MCLPP variation among inter-
science behind estimates of the period of insect activity (PIA), and replicate body communities, indicating different volatile signatures
hence, that of the postmortem interval (PMI). which could be important to initial blow fly attraction and oviposition
Microbial communities are a substantial component of the location; creating “founder” conditions that could influence subsequent
decompositional ecology and processing of organic material, such as intra- and inter-specific competition, the duration of PIA and, thus,
carrion and human remains. Studies in both aquatic and terrestrial estimates of PMI. Calibration of MCLPPs with metagenomic
systems have shown that microbial communities follow a pattern of sequencing is on-going. We will continue to evaluate these communities
succession by metabolizing and modifying resources in a way that makes during multiple seasons and habitats, providing new data important for a
them usable or undesirable to other organisms, such as insects. While better understanding of the ecology of decomposition, and its relevant
there have been studies describing the succession and diversity of application to forensic science.
microbial communities involved in carrion decomposition, none have Biolog EcoPlatesTM, Forensic Entomology, Microbial Communities
evaluated their potential use for determining the postmortem spatial and
temporal placement of decomposing remains in the natural environment.
Further, most forensic entomology studies of insect succession suggest
that volatile metabolic by-products of this community cue initial blow
G72 Microbes Associated With Decomposing
fly attraction and colonization. Postmortem structural and functional Remains Regulate Insect Colonization
changes in these microbial communities may thus affect the PIA on
decomposing remains, having applied importance to estimates of Jeffery K. Tomberlin, PhD*, Department of Entomology, TAMU 2475,
the PMI. College Station, TX 77843-2475; M. Eric Benbow, PhD*, University of
One established and economical method for understanding changes Dayton, Department of Biology, 300 College Park, Dayton, OH 45469-
in environmental microbial communities is the use of Biolog 2320; Tawni Crippen, PhD, 2881 F&B Road, College Station, TX
EcoPlatesTM. EcoPlatesTM have 31 different carbon sources represented 77843; Charity Owings, BS, 2475 TAMU, College Station, TX 77845;
in triplicate on each plate, and were designed for describing entire Francisco I. Ortiz, BS, 1818 South 2nd Street, Apartment 62, Waco, TX
microbial communities from environmental samples such as soil. The 76706; and Jill C. Ross, BS, 110 Hillview Avenue, Millersville, PA 17551
pattern, or signature, of carbon resource utilization by the microbial
communities provides MCLPPs. The MCLPPs, calibrated with The goal of this presentation is to give attendees a better
temperature and genomic sequencing, has the potential to provide understanding of the role microbes play in regulating colonization of
ecological data that can predict how long a body has been decomposing, decomposing remains by blow flies (Diptera: Calliphoridae).
and for how long at a particular location (e.g., on soil). This presentation will impact the forensic sciences community by
The objectives of this study were to describe microbial community providing a more in depth understanding of the ecological principles
changes over time (i.e., succession), in a variety of environmental governing insect succession of human remains.
settings and throughout multiple seasons, using Biolog EcoPlatesTM in Explaining why insects delay their colonization of human remains
conjunction with pyrosequencing of the microbial genome. MCLPPs in some instances while colonizing immediately in others is a
from communities on decomposing remains and the soil beneath were fundamental question in forensic entomology. Two of the authors of this

presentation, Tomberlin and Benbow, along with others have developed This presentation will impact the forensic science community by
and proposed a new framework for studying human decomposition. providing valuable insight into variation in developmental thresholds
They point out that a majority of past research focuses on the post- with respect to insect development and its application in calculating the
colonization interval (post-CI) which extends backwards in time from minimum time to colonization.
the discovery of the insect infested remains to the point that the insects Black soldier flies, Hermetia illucens (L.) (Diptera: Stratiomyidae)
initially colonized the remains. The time of colonization estimation is are of particular interest for their applications in forensic entomology.
viewed as the period of insect activity (PIA) and is often considered the Initially thought to be a late colonizer (20-30 d postmortem) of carrion,
minimum postmortem interval (minimum PMI). The time frame prior to recent evidence indicates they will colonize a corpse within the first
colonization has been termed the pre-colonization interval (pre-CI). week after death. Black soldier flies are native to warmer environments,
Speculations as to why insects delay colonization have been suggested including North and South America, and therefore studies on black
and small advancements explaining this ecological unknown have been soldier fly development have primarily focused on determining the
made. Known abiotic factors, such as temperature, wind, and rain play higher temperature thresholds and optimal temperatures for
a role in regulating colonization of human remains. It is hypothesized development. This study determined the lower temperature thresholds
that microbial populations associated with human remains represent a for egg and adult eclosion. Preliminary studies indicate temperatures
major biotic factor regulating insect colonization. facilitating successful egg eclosion do not necessarily result in larval
Human remains represent nutrient rich resources for many development and adult eclosion. For that reason, the black soldier fly
organisms ranging from microbes to vertebrate scavengers. Microbes has two different lower developmental thresholds; one supporting egg
were initially thought of only as nutrient recyclers. However, recently hatch, and one supporting egg hatch and larval development to the adult
other hypotheses have been suggested. Some researchers speculated that stage. In relation to the postmortem interval, not differentiating these
microbes were resource competitors with other consumers, including two temperature thresholds could result in errors in calculating larval age
insects. Microbes may alter food resources and produce toxins that and retrospectively, time of colonization. Black soldier fly eggs were
affect the “appeal” of the resources, and themselves, to other consumers. collected in corrugated cardboard clutches from an established colony
It is hypothesized that volatiles emitted by microbes associated with outdoors, at the Texas A&M University’s F.L.I.E.S. facility in College
carrion, regulate the attraction to and diversity of colonization of the Station, Texas and placed in three growth chambers, each maintaining a
remains by insects. It is futher hypothesized that volatiles emitted by 70% RH, 14:10 [L:D] photoperiod respectively. Each growth chamber
microbes associated with and physiological by-products produced by was set at 12ºC, 15ºC or 18ºC. Egg clutches were randomly assigned to
blow fly larvae feeding on the remains influence the attraction and each treatment. Percent hatch and survivorship to the adult stage were
colonization of the resource by future blow fly species. It has been recorded. Larvae were provided bovine liver ad libitum and allowed to
demonstrated that many saprophagous insects feed directly on microbes develop without disturbance. Egg eclosion, length of development, and
associated with decomposing material as part of their diet. In addition, adult eclosion was recorded daily.
microbes can have a mutualistic relationship with these arthropods. It is Black Soldier Fly, Lower Developmental Threshold, Forensic
hypothesized that specific bacterial species which survive digestion and Entomology
pupation with one fly species, may not with another fly species.
Therefore, bacterial proliferation and dispersal is mitigated by
colonization patterns of fly species. Such an association could, however, G74 Colonization Behavior of Forensically
prove detrimental to both microbe and associated fly if the volatiles
emitted also attract predators. Basically, it would be a two-way
Important Blow Fly Species: Implications
ecological chess match where the pawns are the insects and the players for Postmortem Interval Estimations
are the associated microbes. But, these roles can be reversed depending
on those involved. This model examines if the volitles emitted by the Jennifer Y. Rosati, BSc*, and Sherah L. Van Laerhoven, PhD, University
native species, Cochliomyia macellaria, larvae (the prey) and associated of Windsor, Department of Biology, 401 Sunset Avenue, Room 119 Bio,
bacteria attract the introduced predatory blow fly, Chrysomya rufifacies. Windsor, ON N9B 3P4, CANADA
A series of laboratory experiments were conducted examining the
interactions between microbes associated with carrion (beef liver) and After attending this presentation, attendees will have a better
the attraction of C. rufifacies and C. macellaria adults. Furthermore, two understanding of ecological interactions between various forensically
field experiments were conducted examining the interaction of microbes important blow fly species and how this relates to PMI estimation.
on carrion with the attraction of blow flies as well as the role of This presentation will impact the forensic community by providing
excretions/secretions of blow flies on the attraction of Diptera. These insight into the importance of understanding species interactions and
results will be provided in this presentation and will hopefully shed light individual colonization events and how these behaviors can impact one’s
on biotic factors governing the time span of the pre-CI. estimation of the MTC. This presentation will highlight the importance
Forensic Entomology, Microbes, Trophic Interactions of rigorous scientific testing in order to validate current assumptions in
the field with respect to delays in colonization prior to their incorporation
into estimations of colonization events and, ultimately, PMI estimations.
G73 Lower Temperature Threshold for Black Blow fly species are known to be among the primary colonizers of
remains and as a result, blow fly species composition, colonization
Soldier Fly (Diptera: Stratiomyidae) Egg events and successional patterns are important aspects to consider in the
and Adult Eclosion determination of the postmortem interval (PMI) and minimum time of
colonization (MTC). Previous research and case studies have indicated
Leslie A. Holmes, BS*, and Sherah L. Van Laerhoven, PhD, University that certain blow fly species may experience a delay in colonization (i.e.,
of Windsor, Department of Biology, 401 Sunset Avenue, Room 119 Bio, Phormia regina (Meigen) and Chrysomya rufifacies (Macquart)). These
Windsor, ON N9B 3P4, CANADA; and Jeffery K. Tomberlin, PhD, findings have led to a debate within the field of forensic entomology as
Department of Entomology, TAMU 2475, College Station, TX to whether or not these delays should or should not be incorporated into
77843-2475 MTC and PMI estimations.
It was hypothesized that the colonization behaviour of blow flies
After attending this presentation, attendees will learn the lower (i.e., P. regina and C. rufifacies) would be altered based upon the
developmental threshold dynamics of temperature that either facilitate or presence or absence of an additional blow fly species (i.e. Lucilia
impede black soldier fly egg and adult eclosion. sericata (Meigen)). The colonization behaviour of three forensically
important blow fly species were examined: L. sericata, P. regina and C. added about whether or not the victim had received cardiopulmonary
rufifacies. Specifically, gravid adult females of L. sericata and P. regina resuscitatative maneuvers.
and L. sericata and C. rufifacies were allowed to colonize fetal pig Results: Incidence of petechiae in relation to cardiopulmonary
carcasses, Sus scrofa (Linnaeus), however, their arrival order varied resuscitation maneuvers: Of the 206 hanging victims, thirty-six
according to one of five different treatment conditions. Species were underwent attempts at cardiopulmonary resuscitation (CPR). No
allowed to colonize either on their own, in the presence of an additional significant difference existed between the two groups (χ2 =.34, df = 1,
species, and prior to and subsequent to an additional species. N=206, p=.56 ).
colonization events and behaviour were recorded from the time of arrival Incidence of petechiae in relation to the type of hanging: Of the 170
to forty hours postmortem. Upon removal of the carcasses, egg masses victims without reanimation manoeuvres, 128 died of an incomplete
were examined and depth measurements were recorded. The eggs hanging and 42 of complete suspension. The incidence of petechiae in
masses were then photographed and volumetric measurements were incomplete hanging (50%) was significantly higher than in complete
obtained using the Image J software program. A linear regression was hanging (29%) (χ2 =5.87, df = 1, N=170, p=.02 ). The age and sex
carried out (using SPSS) with volume (mm3) versus total number of eggs distribution was similar between both groups.
in known egg masses in order to predict the number of eggs based upon Incidence of petechiae in relation to the type of ligature: The type
the volumetric measurements recorded. of ligature was known in all 170 cases of hanging victims without
It was determined that the colonization behaviour varied with reanimation manoeuvres: 72 ropes, 28 electrical cords, 27 pieces of
respect to time of first colonization, location of colonization, and total clothing, 30 bed sheets, and 13 shoe strings. These types of ligatures
number of eggs laid on an individual species basis. In particular, P. were regrouped into two broad categories: narrow and wide. The
regina experienced a significant decrease in time to first colonization and incidence of petechiae was similar (χ2 =.66, df = 1, N=170, p=.42 ) for
laid more eggs in the presence of L. sericata, which indicates that the wide and narrow ligatures (47% and 40% respectively).
presence of an additional blow fly species could act to facilitate the Incidence of petechiae in relation to age: The incidence of
colonization of P. regina. Thus, the colonization behavior of blow flies petechiae decreased slightly with age, from 61% in teens to 40% in
should be examined on an individual basis. Furthermore, ecological adults over forty years of age. However, the differences between the
interactions between other blow fly species could play an important role three age groups was not statistically significant (χ2 =2.41, df = 2,
in altering a species colonization behavior, specifically with respect to N=170, p=.30 ), and neither was the statistical comparison of victims
the time and location of colonization, as well as the amount of eggs laid. older to younger than 40-years-old (χ2 =.66, df = 1, N=170, p=.42 ).
Blow Fly, Postmortem Interval, Minimum Time of Colonization Incidence of petechiae in relation to the BMI: In the studied
population, only two hangings occurred in underweight individuals. For
the remaining 204 there was no statistically significant difference
G75 Petechiae in Hanging: A Retrospective between the incidence of petechiae in normal weight individuals and
overweight individuals (χ2 =.13, df = 1, N=204, p=.71 ). The
Study of Contributing Variables comparison between the three groups (normal weight, overweight and
obese) was not statistically significant either (χ2 =.82, df = 2, N=204,
Renaud Clement, MD*, 1 Rue Gaston Veil, Nantes, 44093, FRANCE; p=.67 ).
and Anny Sauvageau, MD, Office of the Chief Medical Examiner, 7007 Incidence of petechiae in relation to height: The incidence of
116 Street, Edmonton, AB T6H 5R8, CANADA petechiae varied inversely with the height of the victims: 77% in victims
of less than 1.60 m, 44% in victims between 1.60 and 1.79 m and 35%
After attending this presentation, attendees will better understand in victims of 1.80 m or more (χ2 =5.36, df = 2, N=204, p=.07 ). This is
the variables contributing to the development of petechiae in hanging. not merely attributable to a difference in the proportion of complete vs.
This presentation will impact the forensic science community by incomplete hangings in the different height groups. Among incomplete
providing evidence-based data on the contributing variables to the hanging victims, a similar inverse relationship with height was noted (χ2
development of petechiae in hanging. =4.64, df = 2, N=155, p=.10 ).
Introduction: It is often stated in the literature that petechiae are Asphyxia, Hanging, Petechiae
more frequently observed in cases of hanging where part of the body is
supporting the victim’s weight, i.e., cases of incomplete hanging,
because it is believed that the jugular veins become occluded while the
deeper and less compressible carotid and vertebral arteries remain patent.
G76 Fractures of the Neck Structures in Suicidal
The present study is intended to evaluate the relationship between Hangings: A Retrospective Study on
petechiae and the type of hanging (complete vs. incomplete) as well as Contributing Variables
several other variables: victim’s age, height, weight, the body mass index
(BMI), type of ligature and cardiopulmonary resuscitation. Anny Sauvageau, MD*, Office of the Chief Medical Examiner, 7007, 116
Material and Methods: A total of 309 suicidal hanging deaths Street, Edmonton, AB T6H 5R8, CANADA; and Renaud Clement, MD, 1
were autopsied in the province of Quebec (Canada) over an 8.5-year Rue Gaston Veil, Nantes, 44093, FRANCE
period. Of these, one case was excluded since it was not a typical
hanging but a hanging from height, with dislocation of neck vertebrae After attending this presentation, attendees will better understand
(hanging after jumping from a bridge). Additionally, fifty cases were the variables contributing to the development of neck structures fractures
excluded from the analysis because postmortem changes interfered with in hanging.
the evaluation of petechiae (significant decomposition, skeletal and This presentation will impact the forensic science community by
charred bodies). Finally, fifty two cases were also excluded because the contributing to a better understanding of important factors to the
type of hanging was not specified in the autopsy files, thus making their development of fractures of the thyroid cartilage and hyoid bone in
analysis not applicable to the present study. Overall, a total of 206 cases hangings.
were analyzed for the presence of conjunctival, palpebral, gingival and Introduction: Fractures of the neck structures figure among the
facial petechiae. For each case, the following information was also classic autopsy findings in suicidal hangings. Several factors may play
compiled: gender and age, height and weight, the type of hanging a role in the development of fractures of the neck structures in hanging.
(complete or incomplete), the type of ligature used (rope, wire, clothes, It has been repetitively demonstrated that the incidence of fractures
sheet or lace) and the presence of alcohol or drugs. A note was also increases with age. The role of gender is less clear: some authors found

a male predominance of fractures, whereas other observed a female G77 Precision of Autopsy Body
predominance or no significant difference between genders. Similarly,
studies on the role of several other factors have shown opposite results
Length Measurements
for the type of hanging (incomplete or complete suspension), the type of
ligature, the location of the knot, the highest suspension point and the William Oliver, MD, MPA*, Leone Lisa, MA, and Colleen Tetterton, PA,
suspension time. However, most of these studies evaluated these factors Brody School of Medicine at East Carolina University, Division of
independently of the age of the victims. Considering that age is probably Forensic Pathology, Department of Pathology and Laboratory
the most important factor in the development of neck structures Medicine, 7S-10 Brody Medical Sciences Building, Greenville,
fractures, all other contributing factors should be studied in relation to NC 27858
age. The goal of the study is to evaluate the role of contributing factors
to the development of neck structures fractures, taking age categories After attending this session, attendees will learn the precision of
into account. body length measurements at autopsy and its importance in medicolegal
Material and Methods: Overall, a total of 206 suicidal hangings death investigation. In addition they will learn how this compares to
were analyzed for the presence and localization of fracture of the neck height determination precision in antemortem clinical practice.
structures. For each case, the following information was also compiled: This presentation will impact the forensic science community by
gender and age, height and weight, type of hanging (complete or introducing quantitative measures of error in an important determination
incomplete), type of ligature used (rope, wire, clothes, sheet or lace) and made at autopsy.
localization of the knot (anterior, right, left or posterior). In many cases, the height of a decedent is important in the
Results: Incidence of fracture in relation to age and gender: The investigation of his of her death. For instance, prosecutors may wish to
incidence of neck structures fractures increased with age (χ2=21.851; posit hypotheticals and ask if it is physically possible for a person of a
p=.000). Victims of less than forty years of age presented an incidence given height to commit suicide with a particular weapon, such as a long
of fracture of 18% whereas this incidence increased significantly to 49% gun. In these cases, autopsy body length measurements are sometimes
in victims of forty years or more. The average age of victims without used as ground truth for antemortem height. This study attempts to
fractures of the neck structures was 31.7 compared to 42.6 for victims provide a bounds on the precision of autopsy body length measurements
presenting fractures (t=5.66; p<.001; D=.88). As for gender, the in one facility.
incidence rate of fracture is significantly higher in male victims (31.4%) Methods/Data collection: For a period of approximately two and
compared to female ones (11.8%) (χ2=5.408; p=.020). one-half months (83 days) as cases were sequentially brought into the
Incidence of fracture in relation to the height, weight and BMI: The morgue facility, all staff members on duty and available in the autopsy
incidence of fractures varied significantly with the height (t=2.19; area were asked to independently measure the length of each body.
p=.031; D=.33), weight (t=4.38; p<.001; D=.89) and BMI (t=3.84; Measurement was done with a standard metal tape measure
p<.001; D=.60) (Table 3). The average height of hanging victims with (Metric/English, 8m/26’). This particular facility is an academic facility
fractures of the neck structures was of 1.74 m compared to 1.71 m for with permanent staff members, student workers, resident physicians in
victims without fractures. As for the average weight and BMI of victims training, and attending physicians. In most cases, only one or two staff
with fractures, it was of 78.2 kg and 25.6 respectively, compared to 68.6 members were available, but for those cases in which three or more were
kg and 23.2 in victims without fractures. available, the body length measures were recorded. Each observer was
Incidence of fracture in relation to the type of hanging and the type blinded to the measurement results of other observers. The measurement
of ligature: The incidence of fractures did not vary significantly with the by the assistant assigned to the case was recorded as the nominal
type of hanging (χ2=.05; p=.828; Phi=.015) and the type of ligature “correct” body length measurement for the autopsy report. The bodies
(χ2=3.12; p=.077; Phi=.077). However, when taking the age of the were weighed on a calibrated scale, and body mass index (BMI) was
victims into account, a different picture was revealed: in individuals aged calculated using the official length recorded in the autopsy report. Visual
forty years or more, victims with complete suspension of the body evaluation was done to estimate the degree of body deformation due to
presented with a significantly higher incidence of petechiae (63.2%) rigor or pugilistic pose in charred remains, and recorded on a subjective
compared to victims with incomplete suspension (31.0%) (χ2=6.79; scale of one (straight) to five (full fetal or pugilistic pose) by the second
p=.009; Phi=.318). This difference was not present in individuals of less author, blinded to the measurements.
than forty years of age (χ2=.52; p=.471; Phi=.061). As for the type of Study Population: A total of 74 cases had three or more
ligature, no significant difference was found in individuals of less than measurements. Of these, 73 were adult cases. A total of eight observers
forty years of age (χ2=.11; p=.737; Phi=.028) as well as in older victims were involved, including two certified Pathology Assistants, two full-
(χ2=.01; p=.936; Phi=.010) time staff members, two student workers and two resident physicians.
Incidence of fracture in relation to the localisation of the knot: The Twenty-six cases had three measurements, 33 cases had four
incidence of fractures did not vary significantly with the localisation of measurements, 12 cases had five measurements, two cases had six
the knot (χ2=4.11; p=.250; Phi=.141). The side lateralization of fracture measurements, and one case had seven measurements.
in relation to the position of the knot will also be presented. Results: The average range of measurements was 1.86 inches (4.72
Conclusion: Apart from age, several other factors seem to play an cm) with a standard deviation of 1.2 inches (2.99 cm). The range varied
important role in the development of fractures of the neck structures: from 0 to 5.5 inches (0-13.97 cm, Figure 1). No individual observer
height, weight and BMI. The type of hanging is also an important factor displayed significant systematic error (Table 1). The average range did
in victims of more than forty years of age. not vary significantly with the number of measurements( Chi-square
Hanging, Thyroid Cartilage, Fracture p=0.54), body length (Pearson’s r = 0.08), or body deformation
(Spearman’s r= 0.15, two-tailed p= 0.2). There was a moderate
correlation with BMI (Pearson’s r = 0.27, two-tailed p=0.019).
Discussion: Autopsy body length measurements are prone to
numerous errors. There are issues of posture, with some bodies being
straight and other being held in flexion by rigor, heat effect, or other
constraints. Obese bodies may have an artificially increased body length
if the tape is laid over the panniculus. Charred and fragmented bodies
may not have all body parts. The position of the feet may cause the heel
to rise or fall. Hair may cause observers to incorrectly estimate the exact

position of the top of the head. Different observers may measure with rapid burning of sodium azide, is exhausted from inside the airbag
different care. through vent holes in the airbag. The temperature of the exhaust gases
This study attempted to evaluate the precision of body length has been measured to be between 200 and 500 °C.
measurement within one facility. This was specifically not an attempt to The 180-degree rotation of the steering wheel at the time of impact
estimate accuracy, not merely because the nominal antemortem height resulted in the vents and the associated hot exhaust gases being
was generally not known, but also because antemortem height discharged directly toward the driver’s pants in the area of his groin and
measurements are themselves variable. The concept of “ground truth” in left thigh. The synthetic composition of the pants, 75% polyester and
body length measurements may be inappropriate. 25% rayon, melted and produced a flame based upon the patient’s history
Studies on antemortem height measurement show significant and confirmed from inspection of the clothing. The melting point of
variation for measurements of a single individual. Antemortem height Rayon is 120 to 170 °C and 225 °C for polyester.
can vary over time. It can vary significantly with posture. Further, The extremely hot gases associated with airbag deployment pose a
antemortem height measurements are themselves fraught with error. risk of burns to vehicle occupants. Thermal injuries to the male genitals
Studies of the measurement of height routinely show that observer and inguinal area from the exhaust gases have not been reported in the
variation provides enough error to make them uninterpretable for medical literature. Consideration of modifying the direction of hot
some purposes. vented gases from the airbag by the automotive industry and airbag
Precision, Error, Autopsy manufactures maybe warranted in light of the severity of injuries
sustained in this patient.
Airbag, Thermal Injury, Airbag Exhaust
G78 “Goodness Gracious Great Balls of Fire”:
Genital Thermal Injuries From
G79 Histologic Diagnosis of Amniotic Fluid
Airbag Exhaust
Embolism: Providing Context Through
William S. Smock, MD*, University of Louisville Hospital, Department Immunohistochemistry
of Emergency Medicine, 530 South Jackson Street, Louisville, KY 40202
Philip R. Croft, MD, Sparrow Forensic Pathology, 1215 East Michigan
After attending this presentation, attendees will understand the Avenue, Lansing, MI 48909-7980; Michael A. Markey, MD*, Sparrow
potential for thermal injuries from airbag exhaust. Forensic Services, Sparrow Hospital, 1215 East Michigan Avenue,
This presentation will impact the forensic community by expanding Lansing, MI 48912; Joyce L. deJong, DO, Sparrow Health Systems,
the investigators knowledge of airbag induced injuries, in particular Forensic Pathology, 1322 East Michigan Avenue, Suite 118, Lansing, MI
second and third degree burns. 48909; and Michelle P. Elieff, MD, Sparrow Forensic Pathology, 1215
Burns, thermal and chemical, from the hot gases and chemical by- East Michigan Avenue, Lansing, MI 48909
products of deploying airbags account for approximately 7-8% of all
airbag-induced injuries. Three mechanisms for thermal injuries have After attending this presentation, attendees will understand that a
been described: (1) the direct skin exposure to hot gases expelled from substantial amount of cytokeratin-positive cellular material is
the airbag vents; (2) the melting of fibers or burning of clothing from consistently present in the vasculature of lung sections obtained at
exposure to the hot gases; and, (3) direct contact with a hot airbag. autopsy from non-gravid women, complicating the utility of keratin
A 25-year-old restrained driver was transferred to an urban trauma immunohistochemistry in the evaluation of cases of suspected amniotic
center from a suburban emergency department for evaluation of thermal fluid embolism. This cytokeratin-positive material is likely an autopsy
injuries to his penis, scrotum, thighs and arm. The patient reported that artifact, as corroborated by the presence of TTF-1-positive cells within
he was involved in a single-vehicle collision on his way work after a deer vascular spaces in the same lung sections. The caliber of vessel in which
ran into his path. He stated he turned his steering wheel 180-degrees to cytokeratin-positive material is found may help to identify true
the right when the front of his vehicle impacted the rear of a parked circulating keratin.
vehicle at approximately 20 mph. Moments later he noticed two areas of This presentation will impact the forensic science community by
flames coming from his pants, one in the area of his upper left thigh and using immunohistochemistry to characterize the intravascular cellular
the other over his groin. The driver quickly removed his seat belt and material in postmortem lung specimens from non-gravid women in order
attempted to smother the flames with his hands and arms. He exited the to provide the appropriate context in which to assess the same
driver’s door, dropped to the ground and rolled to smother the remaining immunohistochemical stains when they are employed in the evaluation
flames. He stated he was not wearing any underwear. of suspected cases of amniotic fluid embolism.
Examination of the patient’s skin revealed first and second degree Amniotic fluid embolism (AFE) is among the most common natural
thermal injuries to the following areas: left forearm, left thigh, left causes of maternal death in the United States, yet AFE remains an
inguinal area, scrotum and penis. Blisters were noted on the glans, enigmatic condition that is difficult to diagnose, the identification or
scrotum and medial aspect of the left thigh. Arm and pubic hair were confirmation of which often rests on the autopsy pathologist. The
also burned to the skin level in some areas. The patient’s pants microscopic examination of multiple lung sections is essential when
demonstrated two areas with melted and charred fibers over the groin evaluating for AFE, with the identification of squamous cells, keratin
and left anterior thigh. debris, mucus, and other presumably fetal cellular debris, usually in the
The vehicle, a 2009 Dodge Charger was examined within hours of lungs, widely considered diagnostic in the appropriate clinical setting.
the event. The airbag vents are located at the 1 and 11 o’clock position Identifying these cellular elements, in particular circulating squamous
when the steering wheel is in a straight ahead position and in the 5 and 7 cells or keratin, can be challenging despite extensive tissue sampling and
o’clock position when the wheel is turned 180-degrees. Examination of thorough microscopic examination.
the airbag vents revealed melted nylon airbag fibers around both vent The difficulty in finding circulating keratinocytes is compounded
openings and charred material, presumed to be fibers from the pants, by other cellular debris that may mimic their appearance, such as
around one vent. sloughed endothelial cells and pneumocytes. Immunohistochemistry, in
Hot gas is generated within an airbag from an exothermic reaction particular cytokeratin AE1/AE3, has been advocated as a means to
that occurs when sensors within the vehicle are activated during a sudden identify circulating keratinocytes. However, cytokeratin immunostains
deceleration. The gas, principally nitrogen that is a byproduct from the are not specific for fetal keratinocytes, and the immunohistochemical

profile of intra-vascular cellular material in autopsy lung specimens from G80 Utility of Large Bowel Examination
women who are not pregnant has not been formally described. To this
end, three immunohistochemical stains–cytokeratin AE1/AE3, Thyroid
in Medicolegal Death Investigation
Transcription Factor-1 (TTF-1) and CD34–were used to characterize the
intravascular cellular debris in postmortem lung sections from non- Michael R. Condron, MD*, and Mary L. Anzalone, MD, Harris County
gravid women in order to provide the appropriate context in which to Medical Examiner, 1885 Old Spanish Trail, Houston, Texas 77054; and
interpret such stains in the evaluation of suspected cases of AFE. Dwayne A. Wolf, MD, PhD, Harris County Medical Examiner, JAJ
Fourteen cases of women who died without penetrating injuries or Forensic Center, 1885 Old Spanish Trail, Houston, TX 77054
identifiable peri-mortem needle punctures, who were not pregnant, and
who were not decomposed at the time of autopsy were selected. Lung After attending this presentation, attendees will understand the
tissue was fixed in formalin and embedded in paraffin as part of the contribution to medicolegal death investigation of examination of the
routine histologic sampling of each autopsy. Hematoxylin and eosin lumen and mucosal surface of large bowels.
(H&E), TTF-1, cytokeratin AE1/AE3 and CD34 stains were performed This presentation will impact the forensic science community by
on sections of each block of lung tissue. For purpose of comparison, showing what additional information can be contributed to medicolegal
H&E stains and the same three immunohistochemical stains were also autopsies by examination of the large bowel.
performed on blocks of lung tissue from a known case of unequivocal The mucosal surface of the large intestine is not always directly
amniotic fluid embolism and a case of a deceased neonate with abundant examined in cases where findings in the bowels are not suspected to be
intra-alveolar amniotic fluid. The H&E sections were evaluated for the a cause or contributing cause of death. Some pathologists opt to examine
presence of intra-vascular material consistent with or resembling the serosal surfaces and palpate the colon while others routinely open all
squamous cells or keratin debris. The immunostains were evaluated for colons during the course of the autopsy. Numerous disease processes
the presence or absence of positive-staining intra-vascular cellular such as ischemia, ulceration, colitis or diverticulitis, which may have
material. contributed to death, may be overlooked if the colon is not thoroughly
All fourteen lung sections from non-gravid women contained examined. Additionally, the autopsy provides an opportunity for
elongate cellular material and debris by H&E staining, most of which surveillance for colon carcinoma or precancerous lesions. Routine
appeared to be sloughed endothelial cells and only superficially thorough examination of the colon can potentially provide valuable
resembled epidermal squamous cells and keratin when compared to the information to the family members of the decedent if a hereditary natural
known AFE case and the neonatal lung. Rarely, fragments of bronchial disease is found, and can also provide general epidemiological data on
epithelium were located in intra-vascular spaces. In both the known AFE the prevalence of early precancerous lesions in the population younger
and the neonatal lung sections, keratin characterized by distinct than the age currently recommended for screening by colonoscopy. To
basophilic, “glassy” flakes of material, often in aggregates, was easily study the utility of opening colons in medicolegal autopsies, we present
identifiable by H&E staining. No such material was identified in the a series of over 200 colons examined from sets of sequential autopsies
lungs of the non-gravid women. All fourteen lung sections also performed at our institution. Colons were opened, rinsed of their
contained intra-vascular keratin-positive cellular material, usually in contents, and examined along their entire length internally and
great abundance. This material consisted of round cells and debris, some externally. Correlation of findings with decedent’s age, sex, and cause
of which was reminiscent of keratin. However, the keratin-positive and manner of death are presented. The most common pathological
material in these lung sections was present only in larger caliber vascular finding is diverticulosis, and after examination of over 100 colons in this
spaces and not in capillaries and arterioles. By contrast, the keratin- ongoing study, no carcinomas have been identified.
positive material in the known AFE case was present in both large and Colon, Examination, Large Bowel
small caliber vessels, including capillaries and arterioles. Eleven of
fourteen cases had TTF-1 positive cellular material in intra-vascular
spaces, although always a small amount and consisting only of round G81 Detection of KCNQ1 Genetic Variations by
cells. All fourteen cases had abundant intra-vascular CD-34 positive High Resolution Melting Analysis for the
material, consisting of elongate cells and debris.
Most intra-vascular cellular material that even superficially
Diagnosis of Channelopathies in
resembled circulating squamous cells and keratin in the lung sections Postmortem Investigations
from fourteen non-gravid women was sloughed endothelium as
confirmed by CD34 immunostaining. The cytokeratin-positive intra- Audrey Farrugia, MD*, Christine Keyser, PhD, and Bertrand Ludes,
vascular cellular material in the lungs of the non-gravid women most MD, PhD, Institut de Medecine Legale, 11 rue Humann, Strasbourg
likely represented respiratory elements trans-located into the vascular Cedex, 67085, FRANCE
spaces as an autopsy artifact, an etiology corroborated by the presence of
TTF-1-positive cells within vascular spaces. The consistent abundance After attending this presentation, attendees will be informed of the
of intra-vascular cytokeratin-positive cellular material emphasizes the great interest of the high resolution melting method used for genetic
need for caution interpreting cytokeratin stains when evaluating autopsy variations screening in cardiac ion channel genes in postmortem
lung sections for amniotic fluid emboli. The caliber of vessel which investigations.
contains cytokeratin-positive material may help to differentiate true This presentation will impact the forensic science community by
circulating keratin from an autopsy artifact, as only the known AFE case demonstrating the application of a recently developed molecular
had keratin in capillaries and arterioles. technique, high resolution melting (HRM), for the detection of genetic
Amniotic Fluid, Immunohistochemistry, Maternal Mortality variant on genes implicated in channelopathies in postmortem
investigations.
In developed countries, sudden cardiac death (SCD) is one of the
most common causes of death. One of the largest epidemiological
studies of unexpected deaths in young people showed that more than half
of the deaths were of cardiac origin and in 29% no recognizable cause
was identified at postmortem (Tester et al., 2007).1
Potentially lethal ion channel disorders (channelopathies) such as
long QT syndromes, catecholaminergic polymorphic ventricular

tachycardia (CPTV) and the Brugada Syndrome may be responsible for cardioinhibitory reflex cardiac arrest due to short neck trauma and a
a portion of such cases of sudden death in young persons. proposal on how to diagnose it.
Postmortem genetic testing for sequence variations in cardiac ion This presentation will impact the forensic science community by
channel genes has become an important tool for elucidating the cause of presenting constructive evidence based guidelines to diagnose death
sudden cardiac death (Ackerman et al, 2001; Kauferstein et al., 2009).2 caused by death from a cardioinhibitory reflex due to short neck trauma
Formalin-fixed and paraffin-embedded tissue (FF-PET) as well as frozen will be proposed.
tissue could be used as source of DNA in postmortem investigations. If Background: Forensic physicians often evoke baroreflex cardiac
frozen tissue is undoubtedly the greatest source of intact DNA, in some arrest following short neck trauma as a cause of death. No clear evidence
cases FF-PET is the unique source of genetic material. is available to support this hypothesis.
In this context, the purpose of our study was first to validate a Objective: Construct evidence based guidelines to diagnose death
successful DNA extraction and purification method corresponding to the caused by death from a cardioinhibitory reflex due to a short
association of phenol-chloroform extraction and silica-based purification neck trauma.
protocols. This protocol was previously reported in ancient DNA studies Methods: A systematic review of the literature extracting case
on archaeological bones but had not been used for DNA extraction from studies or reports from cases using [Medline, ISI Web of Knowledge,
FF-PET. The second step consisted of genetic investigations on frozen and Embase.] Two independent reviewers selected and extracted data.
and FF-PE tissues in each case of sudden death involving adult younger From the available data, the four authors then discussed the most
than thirty-five years with no significant morphological anomalies probable cause of death for each case. A narrative approach was finally
particularly with no cardiac structural disease and with negatives used to define conditions and procedures to be followed to evoke
toxicological investigations. The samples studied were collected from cardioinhibitory death.
autopsy cases performed at the Institute of legal Medicine from Results: From the forty two cases (thirteen are anecdotes) which
Strasbourg (France). The autopsy practice and modalities of sampling mention cardioinhibitory reflex as a possible cause of death, twenty two
were realized according to the recommendations of the “European are most likely due to other causes (mechanical asphyxia, excited
Cardiovascular pathology Association” (Basso et al. 2008).3 The delirium and drug abuse). The twenty remaining cases were mainly men
KCNQ1 gene was chosen in a first approach. (15/20) and were from all ages (5 yrs to 74 yrs). From the fifteen who
Since, according to the literature, mutations on this gene are were autopsied, ten had local lesions at carotid bifurcation, seven had
randomly distributed, genetic screening was performed for each studied reported heart disease, and six were under the influence of alcohol.
case, with the HRM method on the LightCycler 480 (Roche). The HRM Conclusion: Death should only be attributed to cardioinhibitory
is a technique that can detect sequence changes in amplicon through reflex when sequence of events are known, duration of trauma is certain,
monitoring of the fluorescence of a double DNA binding dye which marcroscopic and microscopic findings reveals important subsequent
dissociates from DNA as it denatures with increasing temperature. If trauma lesions of the carotid bifurcation, and all other possible causes of
sequence changes are present within the amplicon, they cause a death are excluded, including excited delirium, and cerebral hypoxia due
difference in the melting profile compared with wild-type. The principle to substance abuse. Such cases are apparently extremely rare.
of this methodology will be more developed in the presentation. Neck Trauma, Baroreflex, Death
The comparison of results obtained with frozen and FF-PE samples
showed that the two types of samples have a great interest in the genetic
investigations. The advantages and limits of each type of samples will be G83 Differentiation of Bullet Type Based on
discussed in details. From this study, it appeared that the HRM is a rapid,
cost-effective and specific method allowing identification of KCNQ1
Analysis of Gunshot Residue Using
genetic variations and avoids systematic sequencing of the entire coding Inductively Coupled Plasma
region of gene of interest in postmortem investigation of sudden Mass Spectrometry
cardiac death.
References: Ruth N. Udey, BS*, Michigan State University, 209 Biochemistry, East
1
Tester DJ, Ackerman MJ. Postmortem long QT syndrome genetic Lansing, MI 48824; Brian C. Hunter, MD, 630 South Saginaw Street,
testing for sudden unexplained death in the young. J Am Coll Flint, MI 48502; and Ruth Waddell Smith, PhD, Michigan State
Cardiol, 2007, 49, 240-6. University, School of Criminal Justice, 506 Baker Hall, East Lansing,
2
Kauferstein S, Kiehne N, Neumann T, Pitschner HF, Bratzke H. MI 48824
Cardiac gene defects can cause sudden cardiac death in young
people. Dtsch Arztebl Int. 2009;106(4):41-7 The goal of this presentation is to demonstrate a chemical means to
3
Basso C, Burke M, Fornes P, Gallagher PJ, de Gouveia RH, differentiate gunshot residue (GSR) deposited by two different bullet
Sheppard M, Thiene G, van der Wal A; on behalf of the Association types throughout decomposition. Porcine tissue samples shot with full-
for European Cardiovascular Pathology. Guidelines for autopsy jacketed and non-jacketed bullets and analyzed using inductively
investigation of sudden cardiac death. Virchows Arch. Jan, 2008, coupled plasma mass spectrometry (ICP-MS) displayed differences in
452(1):11-8. chemical composition of the resulting GSR, allowing differentiation
High Resolution Melting, KCNQ1, Formalin-Fixed and Paraffin- between the two bullet types. Decomposing porcine tissue samples were
Embedded Tissue also analyzed to identify the most persistent elements to be used for
differentiation between the two bullet types at all stages of
decomposition.
G82 Cardioinhibitory Reflex Cardiac Arrest – These research findings will impact the forensic science community
Myth or Reality?: A Systematic Review by increasing the confidence of gunshot wound identification, aiding
pathologists and medical examiners in cause of death determination even
From Cases in corpses presented in an advanced state of decomposition. Identifying
wounds as gunshot wounds also aids law enforcement agencies in their
Bettina Schrag*, Rue du Bugnon 21, Lausanne, SWITZERLAND search for the perpetrator, and knowing the bullet type may provide a
link between a suspect and a crime.
After attending this presentation, attendees will be presented a In decomposing corpses, the presence of GSR can be difficult to
systematic review of literature concerning reported cases of death by visualize due to the decomposition process and larval activity, making

chemical means of GSR identification necessary. Solution ICP-MS has This presentation will impact the forensic science community by
been used for the determination of antimony (Sb), barium (Ba), and lead showing how to properly investigate deaths associated with vehicles left
(Pb), elements characteristic of GSR, from cotton swabs spiked with running in confined spaces.
these elements, from shooters’ hands, and from shot cotton tissue. Concerns about automotive emissions, greenhouse gasses, and fuel
Preliminary studies conducted in our laboratory have demonstrated the economy have led car manufacturers to decrease CO emissions from
utility of ICP-MS for the determination of Sb, Ba, and Pb in vehicles. Over the last thirty years, CO emissions levels from tailpipes
decomposing GSR-containing porcine tissue samples through all stages have dropped substantially. Corresponding with this drop in CO, the
of decomposition. However, in order to increase confidence in GSR presenter has seen a substantial drop in his caseload of deaths brought
determination in advanced stages of decomposition, the identification of about by acute CO intoxication (usually suicide) brought about by
additional elements, characteristic of the bullet or the interior of the running cars in enclosed garages.
barrel, is necessary. The goals of this research were to differentiate two The modern automotive engine (gasoline) makes use of an oxygen
different bullet types based on element profiles and to investigate the sensor to determine how close the engine is running at ideal
persistence of GSR in decomposing tissue as a function of bullet type. stoichiometry: - 14.75 parts air to one part fuel. The engine has one (or
In order to study the elemental composition of GSR deposited by several) O2 sensors placed in the exhaust stream to measure free oxygen.
different bullet types, three pigs were euthanized and control (unshot) In an open air atmosphere, the oxygen sensor and ECU (Engine Control
samples of skin removed from one. The other two pigs were then shot Unit) work together to insure that CO emissions are kept low.
using a .357 Smith & Wesson Magnum revolver. One pig was shot with For a person attempting suicide, the effects of the emissions system
ammunition cartridges containing full-jacketed bullets, and the other can have three outcomes:
with non-jacketed bullets. The fresh wounds were excised, and sections 1. Non event – no fatal levels reached
of each wound were microwave digested for ICP-MS analysis. Sections 2. Suicide – fatal COHb levels reached
of each wound type were also removed for histology analysis, and results 3. Suicide – minor to moderate COHb levels reached, but death
confirmed the presence of GSR in both wound types. The digests were caused by hyperthermia
initially analyzed in full mass scan mode to identify all elements present The non-event is perhaps the hardest for an medical examiner
at significant levels in the GSR-containing tissue but not present in the system to analyze, as there is neither a death or case report.
control tissue. A selected ion monitoring (SIM) method was then Empirically, testing of vehicles has shown that in some instances, a
developed to detect only the suite of characteristic elements from both garage has enough “leakage” and infiltration (air changes per hour) that
bullet types with greater sensitivity. The significance of variation in there is sufficient oxygen to keep the engine running clean and for CO
element concentrations among full-jacketed bullet wounds, among non- levels to stay at a minimum. This “non-event” can manifest itself in one
jacketed bullet wounds, and between full-jacketed and non-jacketed of three ways:
bullet wounds were assessed statistically. Differences in element 1. The emissions system ‘slowed’ down CO production so
concentrations between the wound tissue (both full-jacketed and non- much that the would-be suicide candidate changed
jacketed) and the control tissue were then assessed statistically. In this his/her mind.
way, the two bullet types were differentiated based on differences not 2. A fatal COHb level was never achieved because the vehicle
only terms of elements present but also based on differences in ran out of fuel, thwarting the suicide.
concentration of common elements. 3. The vehicle had enough free O2 (leaky building) that under
For this research to have any impact on the forensic science no circumstances would a fatal COHb level ever
community, the effect of decomposition on GSR persistence was be achieved.
investigated. Three euthanized pigs were obtained and wounded. One The fatal CO event is the easiest case to analyze. Grossly, the
was shot with full-jacketed bullets, one was shot with non-jacketed cherry red lividity is the telltale sign, along with supporting COHb levels
bullets, and one was stabbed to generate open wounds to serve as control at autopsy. But the fatal level raises the question: with modern cars
(unshot) tissue. Wounds and control tissue samples were collected running so clean, how does one ever achieve fatal results. Testing
throughout the decomposition process, and then digested for ICP-MS carried out shows the function of the O2 sensor in the exhaust stream.
analysis. Histology was also used to detect GSR throughout This sensor is a ratiometric device, comparing free O2 in the exhaust
decomposition, and results were compared with those from ICP-MS stream to free O2 in the atmosphere. The vehicle’s ECU will keep CO
analysis. The tissue digests were analyzed using the SIM method production to remarkably low levels for some time, but there reaches a
developed previously for ICP-MS analysis of the characteristic suite of point (in a well sealed garage) that the design assumptions (IE, 20% free
elements that differentiate the two bullet types. The most persistent O2 in the atmosphere) are invalid and the vehicle become very dirty.
elements throughout decomposition were identified, as they are the most Note that this fatal outcome is just an extension of one, above – CO
useful for discrimination of bullet type. production was slowed down, but the candidate’s ardor was not
Gunshot Residue, ICP-MS, Firearms inhibited; the death just took longer to achieve. Using empirical data, the
presenter has been able to model the CO production/accumulation as a
first order differential equation.
G84 Vehicular Emissions Systems and Their The fatal outcome with low CO is at first the most complex to
analyze. The body presents with CO levels more associated with high
Effects on Suicides and Attempted Suicides levels of cigarette smoke: 5 to 10%, possibly higher, but never at levels
by Carbon Monoxide associated with death. Testing done at our lab shows that temperatures
can be reached in garages (closed spaces) that are untenable. The
Mark E. Goodson, PE*, 1500 Spencer Road, Denton, TX 76205-5105 indicator that first led us to this area of inquiry was the existence of spray
cans (paint, insecticides) that had bulged at their seams. It was known at
After attending this presentation, attendees will understand the what internal pressures the cans would expand, as well as the nature of
workings of vehicular emissions systems and their ability (and inability) the propellant gas inside. This data shows the increase in temperature
to generate CO (Carbon Monoxide). As cars run cleaner, CO suicides in over time within various garages, and the factors that work for and
a closed space (garage) are more difficult to accomplish. The cleaner car against this type of hyperthermic event are presented. In these cases the
allows for more time for a “victim” to alter his intentions. The attendee manner of death is still suicide, but causation has changed from acute CO
will understand these timing issues, as well as the possibility that death intoxication to hyperthermia.
is brought on not by CO intoxication, but by hyperthermia. Suicide, Carbon Monoxide, Hyperthermia

G85 Pseudostrangulation G86 Investigation and Autopsy Procedures in
Cases Involving Conducted Energy Devices
Thomas W. Young, MD*, Heartland Forensic Pathology, LLC, 12717
Oakmont Drive, Kansas City, MO 64145
(CEDs) in the State of Maryland
After attending this presentation, attendees will recognize autopsy Mary G. Ripple, MD*, David R. Fowler, MD, and Ling Li, MD, Office of
findings that can be misinterpreted as due to homicidal strangulation. the Chief Medical Examiner, State of Maryland, 111 Penn Street,
Attendees will also learn how to avoid making false positive Baltimore, MD 21201
determinations of strangulation in cases where the body is found dead at
the scene. After attending this presentation, attendees will understand the
This presentation will impact the forensic science community by investigation and autopsy procedures necessary in cases involving the
instructing forensic pathologists how to avoid concluding falsely in any use of CED’s and the demographics of their use.
case that strangulation is the cause of death. Successful application of This presentation will impact the forensic community by reporting
these concepts by forensic pathologists will prevent injustices that come investigative and autopsy findings in a group of conducted energy
from false accusations made by police officers and prosecutors – device cases.
accusations that may lead to false convictions and imprisonments. Controversy exists over the possible contribution of CED use to
The investigation of the death of a person found unexpectedly dead sudden death. CEDs are primarily used as a restraint method by law
is critically important. Prosecuting attorneys and police officers rely on enforcement personnel on aggressive individuals. The typical scene
the knowledge and expertise of the forensic pathologist to determine the involves an acute onset of agitated and delusional behavior in a person
cause and manner of such deaths. Unfortunately, the unwary forensic with mental health issues and/or who is on drugs. An attempt is made to
pathologist may misinterpret findings in the head and neck areas of the control the uncooperative individual leading to a struggle at which some
dead person at autopsy and falsely conclude that strangulation is the point the person becomes unresponsive. Experience at the OCME has
cause of death and that the manner of death is homicide. Incorrect emphasized the necessity of complete investigation and autopsy in these
determinations such as these all too often lead to the arrests of innocent complex cases.
people on false charges, to confusion in the courtroom with the From 2004 until January 2009, the OCME autopsied 12 cases
presentation of misinterpreted evidence, and to false imprisonments. involving CEDs. The most commonly used CED in Maryland is the X26
Even in cases truly involving foul play, a falsely positive determination TASER®. The TASER® was used in drive stun mode only in 2/12 (16%)
of strangulation may lead to a misunderstanding of the chain of events cases, probe deployment only in 6/12 (50%) cases, and combination of
that led to the violent death. both in 4/12 (33%) cases. In 75% of the cases, the TASER® was used
The classic and typical autopsy findings for manual or ligature more than once. The average age of the individuals was 35 years old,
strangulation are well documented in the literature and in forensic 92% were male, 67% were black, and 33% were white. Manner of death
pathology textbooks, but simply relying on autopsy findings alone to was ruled undetermined in 58% of the cases, homicide in 25% of the
reach a proper conclusion will lead to mistakes. Without knowledge of cases, and accident and suicide in 8% each of the cases. In two of the
the witness evidence and other physical evidence in a case, a pathologist homicides, gunshot wounds were the cause of death when the X26
at the autopsy table may misinterpret certain head and neck findings, TASER® was ineffective. Excluding these two homicides, the accident
falsely concluding that they indicate homicidal strangulation. On the and the suicide, the TASER® probes were deployed in seven of the eight
other hand, knowledge of the witness evidence and other physical remaining cases. The time elapsed between deployment of the TASER®
evidence and the proper interpretation of this evidence will prevent the and the time the individual went unresponsive was several minutes in
pathologist from being misled at the autopsy table. four cases and in three cases it could not be determined with certainty.
Five general sources of confusion at autopsy will be presented. In the eight remaining cases, the cause of death was generally considered
These include: (1) confusion of ligature marks with band-like to be a combination of police restraint methods, the agitated/excited
discolorations from decomposition; (2) confusion of asphyxial findings delirium state of the individual, the presence of drugs or alcohol, and
with artifacts from postmortem hypostasis; (3) confusion of strap muscle heart disease when these were identified. In no case was the TASER®
hemorrhages caused by blunt or sharp force with strangulation; (4) considered the sole cause of death. Of these cases, 75% were considered
misinterpretation of blood extravasations posteriorly placed within the to be in an agitated/excited delirium (ED) state and 87.5% had ethanol or
neck; and, (5) misinterpretation of laryngeal petechiae. illicit drugs including cocaine, heroin, or phencyclidine in their systems.
The forensic pathologist may make an erroneous determination of Of the ED cases, all were obese and most had heart disease. The non-
strangulation when he or she attempts to surmise the past events that led ED cases included two thin individuals who struggled with police and
to the physical findings disclosed by autopsy without regard to the both cases had either ethanol or illicit drugs in their system. The
statements of the witness or witnesses, particularly if the witness is the temperature was not recorded in the majority of cases. The initial cardiac
defendant. In this presentation, why that approach leads to mistakes will rhythms recorded were also evaluated.
be demonstrated. The Also demonstrated is how to correctly test witness In June of 2008, in their interim report studying deaths following
accounts with the physical evidence in order to determine if the witness electromuscular disruption, the National Institute of Justice (NIJ)
accounts are truthful. published considerations in the performance of investigation and autopsy
The cases and illustrations used in this presentation come from the in CED cases. The OCME has adopted these considerations and added
author’s forensic pathology consultation practice. The forensic to them. Investigation should develop a timeline of events with
pathologists who originally performed the autopsies concluded in each emphasis on when the subject went unresponsive. A complete review of
case that strangulation caused each of the findings. past medical records and incident EMS, hospital, and police records,
Strangulation, Homicide, False Positive TASER® dataport download, types of restraint used, witness reports, and
any videos or photos must be performed. Autopsy procedures should
include: documentation of all injuries with both black and white and
color photographs, measurement of the distance between the injuries and
soft tissue injury, separate anterior and posterior neck dissections, cut
downs of the body, microscopic sections of organs and injury,
cardiovascular and neuropathology consultations, and a full
toxicology screen.

Recommendations in this report are based on the experience at the angiography is performed. The perfusion machine is started and
OCME and follow those put forth by the NIJ in their interim report. Angiofil® is introduced into the vascular system, entering by the femoral
These complex cases should each be evaluated on an individual basis, as artery. To demonstrate the venous part, the contrast agent is injected by
the correlation of the investigation and autopsy findings is critical in the femoral cannula and a further CT-acquisition is started.
order for the medical examiner to come to a determination of the cause As a third step, one or more further CT-acquisitions can be
and manner of death. performed after establishing a “postmortem circulation”. Hereby the
Conducted Energy Device, Investigation, Autopsy contrast agent is flowing from the arterial into the venous system and
quits the vascular system by the femoral vein.
Conventional autopsy: In the University Center of Legal Medicine
G87 Postmortem CT-Angiography Using Lausanne and Geneva the radiological findings are compared with those
obtained by conventional autopsy. This procedure is important to verify
Angiofil® the angiographic diagnoses and to define advantages and limitations of
the angiographic examination.
Silke Grabherr*, Centre Universitaire Romand de Médecine Légale, Rue Results: By performing a dynamic postmortem CT-angiography,
du Bugnon 21, Lausanne, 1011, SWITZERLAND; Francesco Doenz, the vascular system can be visualized in detail. Vascular pathologies
Service de Radiodiagnostic et de Radiologie Interventionnelle, Rue du such as ruptures of vessels, aortic dissection and cardiac tamponade can
Bugnon 46, Lausanne, , SWITZERLAND; Alexandre Dominguez, Haute be diagnosed. By comparing the different phases of angiography,
Ecole Cantonale Vaudoise de la Santé, Filière Technique en Radiologie information about the rapidity of extravasation and therefore about the
Médicale, Avenue du Beaument 21, Lausanne, , SWITZERLAND; quantity of blood loss can be gained.
Richard Dirnhofer, and Beat Steger, Fumedica AG, Luzernerstrasse 91, However, problems persist in the diagnosis of thrombosis and
Muri, 5630, SWITZERLAND; Barbara Sollberger, and Erich Gygax, embolism, since postmortem clots have the same appearance on
Department for Cardiovascular Surgery, University Hospital Bern, CT-images.
Hochschulstrasse 4, Bern, 3012, SWITZERLAND; Reto Meuli, Service Conclusion: Postmortem dynamic CT-angiography is of great
de Radiodiagnostic et de Radiologie Interventionnelle, Rue du Bugnon interest in forensic pathology, because the detailed mapping of the entire
46, Lausanne, 1011, SWITZERLAND; and Patrice Mangin, MD, PhD, vascular system is almost impossible with conventional autopsy tools.
Centre Universitaire, Romand de Medecine Legale, Rue du Bugnon 21, The presented method and the use of the recently developed perfusion
Lausanne, CH-1011, SWITZERLAND machine allow postmortem angiography in an easy and standardized
way. The new method using Angiofil® as a contrast agent allows to
After attending this presentation, attendees will know how to investigate blood vessels under pressure similar to real life conditions
perform a postmortem CT-Angiography using Angiofil®, will understand without creating artifacts due to extravasations and therefore without
the differences between this technique and other techniques of deforming the corpse. By performing different phases of angiography,
postmortem angiography, and will understand the advantages and information about the relation between the quantity of blood loss and
limitations of postmortem angiography. time can be gained.
This presentation will impact the forensic science community by Postmortem Angiography, Forensic Radiology, Postmortem CT
presenting a new technique of postmortem angiography which has the
potential to be largely used for postmortem radiological examinations.
The perfusion machine and other technical materials developed for the
method as well as a standardized protocol makes it easy applicable and G88 Radiological Interpretation of Postmortem
therefore interesting for postmortem examiners. CT-Angiography
Postmortem CT-angiography using Angiofil® is a minimally-
invasive technique that allows to map the vascular system of a decedent Francesco Doenz*, Service de Radiodiagnostic et de Radiologie
in detail and therefore to perform vascular diagnosis similar to clinical Interventionnelle, Rue du Bugnon 46, Lausanne, SWITZERLAND;
CT-angiography. Alexendre Dominguez, Haute Ecole Cantonale Vaudoise de la Santé,
Synopsis of Contents: Preparation of the corpse: To perform the Avenue de Beaument 21, Lausanne, SWITZERLAND; Richard Dirnhofer,
postmortem CT-angiography, the body is placed on the CT-table. There, and Beat Steger, Fumedica AG, Luzernerstrasse 91, Muri,
a small incision is made in the inguinal region to prepare the femoral SWITZERLAND; Erich Gygax, and Barbara Sollberger, Department for
vessels. Cannulas are inserted into the vascular lumina, and connected Cardiovascular Surgery, University Hospital Bern, Hochschulstrasse 4,
with the tubes of a special perfusion machine. Bern, SWITZERLAND; Reto Meuli, Service de Radiodiagnostic et de
Perfusion Machine: In the University Center of Legal Medicine Radiologie Interventionnelle, Rue du Bugnon 46, Lausanne, 1011,
Lausanne and Geneva, a special perfusion machine has been developed SWITZERLAND; and Patrice Mangin, PhD, and Silke Grabherr, Centre
that is easy to handle. Its special software gives further information Universitaire Romand de Médecine Légale, Rue du Bugnon 21,
about the pressure measured in different regions of the vascular system Lausanne, 1011, SWITZERLAND
and these parameters provide some information about the conditions of
the investigated vessels. After attending this presentation, attendees will have the knowledge
Contrast Agent: Angiofil® is a mixture of paraffin oil and iodized to distinguish normal from abnormal findings on postmortem CT-
linseed oil. Thanks to the hydrophobic abilities of this oily contrast angiography, to recognize the traumatic and non-traumatic pathologies,
agent, no extravasation through the intact vascular wall is observed. to understand the differences between clinical and postmortem CT-
Therefore, infiltratation of the surrounding tissue is avoided. This is angiography, and to know the limitation of diagnosis in postmortem CT-
important to increase the quality of the procedure and to avoid angiography.
deformation of the investigated body as it happens when using aqueous This presentation will impact the forensic science community by
contrast agents, especially when important quantities of aquaeus contrast demonstrating the key findings of traumatic and non-traumatic vascular
agent are injected. lesions allowing for an accurate diagnosis of the cause of death.
Technique of the Angiography: To start the angiographic Postmortem CT-angiography is a minimally invasive technique
examination, the cannulas are inserted into the femoral vessels and which enables the diagnosis of traumatic and non-traumatic vascular
connected with the tubes of the perfusion machine. The examination lesions with confidence. However, interpretation of postmortem CT-
consists of different phases. As a first step, the arterial phase of

angiography varies from clinical CT-angiography and demands special and software for most-mortem CT-angiography, and know the concept of
knowledge from the interpreting radiologist. an ideal ante- or retrograde perfusion.
This presentation will introduce the attendees to the general This presentation will impact the forensic science community by
principles of postmortem CT-angiographic interpretation describing the explaining the background and the development of a new technique and
normal and pathological presentation of the venous and arterial vascular new equipment for postmortem CT-angiography, which is easily
circulation. After a short introduction on the technique of opacification applicable and therefore interesting for everyone performing
we will first present the normal appearance of the organs during arterial postmortem analysis.
opacification, followed by the normal appearance during the venous By the use of special perfusion techniques and equipment,
opacification and in the end during systemic continuous circulation with important information about the status of the vascular system can be
the help of a perfusion pump. The description of the pathologic findings gained, even without performing radiological imaging. The combination
will distinguish the traumatic and non-traumatic pathologies with special of such adequate perfusion and imaging by CT-angiography provides
care, describing the false positive findings and how to distinguish them. images and physical data that allow diagnoses of the vascular system.
The most common pathologies responsible for death and visible in CT- In the University Center of Legal Medicine, Geneva – Lausanne, a
angiography are traumatic rupture of vessels, mostly aortic ruptures research group has been created with the goal to develop a standardized
followed by aortic dissection and aneurismal ruptures. Traumatic organ protocol and special equipment for postmortem CT-angiography.
lacerations are also a common finding, splenic lacerations being the most Therefore, a specialized perfusion machine that should ease the use of
frequent, followed by renal and hepatic lacerations. These organic the technique and that includes software giving information about the
lacerations are by themselves most of the time not the cause of death, but vascular status of the investigated body should be developed. With the
accompany more vital lesions, such as aortic, cerebral and knowledge of two European-board certified perfusionists, pressure
cardiopulmonary ones. On the venous side the most common pathology values obtained during the perfusion for postmortem angiography are
responsible for death are also ruptures due to trauma, followed by used for this development.
massive pulmonary embolism. This pathology is picturing the limitation In general, the postmortem perfusion can be obtained by a femoro-
of postmortem angiography because it is the origin of most of the femoral access. Therefore, the femoral artery and vein of one side are
diagnostic errors. The reason therefore is the presence of postmortem cannulated. Once the cannulas are connected to the tubes of the
blood clots which are often situated in the pulmonary vessels and the perfusion machine, the perfusion is started using the oily contrast agent
heart chambers. While small exemplars of these clots can be rinsed out Angiofil®. The arterial and the venous tubes are connected to the
by an ongoing perfusion, large ones can not be removed and imitates the pressure monitor to register the pressure variations and
radiological image of thrombosis or embolism. The importance of pressure gradients.
imaging during active circulation will be discussed to distinguish In the first phase of the perfusion, the arterial system is filled
embolism from postmortem thrombi, in the arterial as well venous antegrade under pressure control. In general, 1200 ml of contrast agent
circulation. are introduced during ninety seconds. Increasing pressure values
Conclusion: The advent of postmortem CT-angiography allows measured in the venous tube are signaling the integrity of the arterial
visualization of traumatic and non traumatic lesions of the arteries and system. Once the defined quantity of contrast agent is injected, the
veins. Clear advantages of postmortem angiography over conventional arterial and venous tubes are clamped to keep the pressure inside of the
autopsy are observed in detecting sources of bleeding. By the use of our vascular system steady and the perfusion machine is stopped. Under
method, which includes acquisition of data during a dynamic circulation, those “static conditions” (stopped perfusion), a first acquisition of CT-
it is even possible to quantify blood loss. This is important to confirm if images can be performed to visualize the arterial phase of angiography.
a lesion may have been the cause of death and if the injury may have led The same technique is repeated with the venous system, with the
to an immediate or a delayed death. The main limitation of the technique only difference that the veins are perfused retrograde. This second phase
is the inherent difficulty in differentiating pre and postmortem thrombi of the perfusion is made to visualize the venous phase of angiography.
and emboli. Another difficulty, due to the same mechanism, is to During the first to phases of postmortem angiography, the most
distinguish aortic dissection from sedimented postmortem blood clots, important perfusion value is the “delta p” which is indicating the
mainly in the descending thoracic aorta. Because of all these challenges pressure gradient form the arterial to the venous system. A low delta p,
in vascular diagnosis, the help of an experienced angiographer has during an arterial perfusion is a sign for an intact arterial system, during
proven useful to us. a venous perfusion it indicates the integrity of the venous system. If this
Postmortem Angiography, Postmortem CT, Forensic Radiology value increases, a leak of the arterial (during the arterial perfusion) or the
venous system (during the venous perfusion) has to be suspected.
As a third phase in postmortem angiography a dynamical perfusion
G89 Perfusion Technique for Postmortem can be performed, that means that further contrast agent is injected and
CT-data are obtained during the ongoing perfusion. Depending on the
CT-Angiography case, one or more acquisitions of images can be made. During the
perfusion, pressure gradients are measured under a volume-controlled
Erich Gygax*, and Barbara Sollberger, Department for Cardiovascular pump speed. This dynamic phase is especially useful if leaks of the
Surgery, University Hospital Bern, Hochschulstrasse 4, Bern, vascular system are identified. In those cases, it can allow to quantify
SWITZERLAND; Alexandre Dominguz, Haute Ecole Cantonale blood loss in cases of hemorrhages.
Vaudoise de la Santé, Avenue de Beaument 21, Lausanne, Conclusion: By performing a standardized perfusion technique
SWITZERLAND; Richard Dirnhofer, and Beat Steger, Fumedica AG, with adequate perfusion equipment, changes of perfusion values can
Luzernerstrasse 91, Muri, SWITZERLAND; Francesco Doenz, and Reto indicate leaks and show weather they are situated in the arterial or in the
Meuli, Service de Radiodiagnostic et de Radiologie Interventionnelle, venous part. By using a contrast agent as perfusate, the perfusion can be
Rue du Bugnon 46, Lausanne, 1011, SWITZERLAND; and Patrice used to perform postmortem angiography. The developed perfusion
Mangin, PhD, and Silke Grabherr, Centre Universitaire Romand de technique and special perfusion pump with integrated controller and
Médecine Légale, Rue du Bugnon 21, Lausanne, 1011, SWITZERLAND software allows the performance of postmortem CT-angiography and the
interpretation of the perfusion values, so that the technique becomes
After attending this presentation, attendees will understand the applicable in the routine of postmortem investigation.
interpretation of different pressure variations and gradients, understand Postmortem Angiography, Forensic Radiology, Postmortem
the concept of a specialized perfusion machine with integrated controller Perfusion

G90 The Role of Microscopic Postmortem Study
in Explaining Traffic-Crash Related Neck
Injury: A Case Review
Lars Uhrenholt, PhD*, Institute of Forensic Medicine, Department of
Forensic Medicine, University of Aarhus, Brendstrupgaardsvej 100,
Aarhus N, 8200, DENMARK; and Michael Freeman, PhD, 205 Liberty
Street, Northeast, Suite B, Salem, OR 97301
After attending this presentation, attendees can expect to understand

the state of the literature regarding the microscopic investigation of * References arise from one large-scaled study
histopathology of traffic crash-related neck injuries.
This presentation will impact the forensic science community by Results: Nine references were retrieved for review (Table 1). The
discussing how the histopathologic study of traffic crash related cervical number of subjects suffering from road traffic crash related deaths was
spine injuries indicate that imaging occult injury must be considered as not defined clearly in all studies. The microscopic procedures included
a possible source of symptoms in patients with apparently negative plain the evaluation of 2 to 2.5-mm thick slices using a dissecting microscope,
x-ray, CT or MRI studies. The relatively high false negative rate of and stereomicroscopy of 3-mm thick slices to microscopy of 3 to 100-
conventional imaging for injury to the cervical spine following traffic µm thick stained sections. The microscopic findings were defined in all
crash must be taken into account when a forensic medical review of such studies and included injuries to the osseous cervical spine (vertebral
injury is conducted. body, lamina and articular facets), surrounding soft tissues (muscles,
Introduction: Approximately fifty percent of occupants involved ligaments, joint capsules, and synovial folds), articular cartilage,
in a road traffic crash sustain a painful neck injury, ranging in severity bleeding in the joints, dorsal root ganglion injury, ventral root injury,
from short lived mild discomfort to long lasting pain syndromes. nerve root avulsion, and injury to the intervertebral disc. Diagnostic
Approximately ten percent of all injured patients are impaired to the imaging procedures were performed in five studies, including one or
point that they are disabled from their work duties. In the majority of more of the following procedures; conventional radiology, microfocus
patients objectively identifiable injury using medical imaging modalities radiography, computed tomography (CT) and magnetic resonance
such as x-ray, CT, and MRI are the exception rather than the norm. Since imaging (MRI).
the late 1980s it has been suggested by some authors that there are crash- Discussion: The current review of publication describing an
related spine injuries that cannot be visualized with conventional investigation of microscopic injuries to the cervical spine of occupants
medical imaging because they are too small. Subsequent postmortem subjected road traffic crashes identified nine studies for review. Discrete
studies describing microscopic investigations of cervical spine tissue in non-fatal injuries to the cervical spine were described in all nine studies.
decedents with a history of neck injury have demonstrated that such Injuries to the facet joints (synovial folds, articular cartilage, joint
imaging occult injuries do exist. The purpose of the current review is to capsule, and haemarthrosis) as well as the nerve roots were particularly
present a review of the literature describing histopathologic studies of common. The majority of injuries could not be identified using
the post-traumatic cervical spine. conventional plain x-rays nor could they be found using advanced
Methods: A MEDLINE search was conducted using the Mesh diagnostic imaging procedures such as CT and MRI. Although the
terms/keywords; “Accident, Traffic”, “Spine”, “Autopsy”, “Whiplash research described herein did not investigate whiplash injuries per se, the
Injuries”, and keywords; forensic imaging, imaging occult lesions, injuries identified in these postmortem studies were non-fatal in severity
postmortem, and cervical spine. Articles describing examination of the and potentially painful. The presence of similar injuries in survivors
cervical spine after fatal road traffic trauma using microscopic from road traffic crashes of different severities seems likely. Three
procedures of stained histological sections were included and retrieved studies were not included in the current review, as they did not utilize
articles were further crosschecked for relevant references. The included microscopical procedures but relied on macroscopic examination and
references were reviewed with regard to microscopical procedures used, evaluation of photographs.10-12 Even though these studies were not
microscopical findings, and diagnostic imaging procedures, to be included, they identified very similar findings of discrete injuries to
described in a table format. cervical spine structures and supported the finding of these being
imaging occult.
Table 1 Conclusions: The present review demonstrates the important role
that microscopic postmortem investigation can have in elucidating
traumatic pathology that is not apparent with conventional medical
imaging.
References:
1
Schonstrom N, Twomey L, Taylor J. The lateral atlanto-axial joints
and their synovial folds: an in vitro study of soft tissue injuries and
fractures. J.Trauma 1993;35:886-92.
2
Taylor JR, Twomey LT. Acute injuries to cervical joints. An autopsy
study of neck sprain. Spine 1993;18:1115-22.
3
Taylor JR, Taylor MM. Cervical spinal injuries: an autopsy study of
109 blunt injuries. J Musculoskeletal Pain 1996;4:61-79.
4
Taylor JR, Twomey LT, Kakulas BA. Dorsal root ganglion injuries
in 109 blunt trauma fatalities. Injury 1998;29:335-9.
5
Stäbler A, Eck J, Penning R et al. Cervical spine: postmortem
assessment of accident injuries—comparison of radiographic, MR
imaging, anatomic, and pathologic findings. Radiology
2001;221:340-6.

6
Yen K, Sonnenschein M, Thali MJ et al. Postmortem multislice The ductus arteriosus connects the aorta to the pulmonary artery
computed tomography and magnetic resonance imaging of and functions in the fetus to bypass the unexpanded lungs. Ordinarily,
odontoid fractures, atlantoaxial distractions and ascending this connection closes shortly after birth, but in some infants the ductus
medullary edema. Int.J.Legal Med. 2005;119:129-36. arteriosus remains patent. A patent ductus areteriosus creates a left-to-
7
Uhrenholt L, Hauge E, Charles AV et al. Degenerative and right shunt and can lead to complications like congestive heart failure,
traumatic changes in the lower cervical spine facet joints. Scand J infective endocarditis, and aneurysm with subsequent rupture. However,
Rheumatol. 2008;37:375-84. not all individuals with a patent ductus arteriosus become
8
Uhrenholt L, Nielsen E, Vesterby Charles A et al. Imaging occult symptomatically evident, and some people can live normal lives never
lesions in the cervical spine facet joints. Am.J.Forensic Med.Pathol. knowing they have this congenital abnormality. In the rare case of a
2009;30:142-7. patent ductus arteriosus aneurysm, the ductus must be repaired to prevent
9
Uhrenholt L, Vesterby A, Hauge E et al. Pathoanatomy of the lower rupture of the aneurysm. Rupture of a ductus arteriosus aneurysm is a
cervical spine facet joints in motor vehicle crash fatalities. J devastating event and often leads to a swift death.
Forensic Leg.Med. 2009;16:253-60. Detection of a large ductus arteriosus aneurysm can often be
10
Jonsson H, Jr., Bring G, Rauschning W et al. Hidden cervical spine accomplished through the acquisition of a chest x-ray, though
injuries in traffic accident victims with skull fractures. J.Spinal arteriography is the definitive technique if such an anomaly is suspected.
Disord. 1991;4:251-63. While multiple imaging studies of her chest had been conducted in the
11
Rauschning W, McAfee PC, Jonsson H, Jr. Pathoanatomical and past, the decedent’s large ductus arteriosus aneurysm was nonetheless
surgical findings in cervical spinal injuries. J.Spinal Disord. not identified. It is unclear what event prompted the sudden, lethal
1989;2:213-22. hypertensive event which led to aneurysm rupture, though an adverse
12
Yen K, Lovblad KO, Scheurer E et al. Postmortem forensic event arising from administered anaesthetic agents must be considered as
neuroimaging: correlation of MSCT and MRI findings with autopsy a potential etiology. The tragic consequences arising from this sad
results. Forensic Sci.Int. 2007;173:21-35. sequence of events is a sobering lesson that uncommon and unsuspected
Forensic Pathology, Microscopic Lesions, Imaging Occult diagnoses are far too commonly lethal.
Ductus Arteriosus, Aneurysm, Rupture
G91 Lethal Consequences Arising From the

Rupture of an Undetected Large Ductus G92 Exploring the Potential for Nocturnal
Arteriosus Aneurysm During a T-12 Colonization of Fresh Cadavers by Carrion
Kyphoplasty Procedure Flies in the Central United States
William J. Bonner, BA*, 1100 South Broad Street, Unit 402B, Timothy E. Huntington, PhD*, Concordia University Nebraska, 800
Philadelphia, PA 19146; and Fredric N. Hellman, MD, Office of the North Columbia Avenue, Seward, NE 68434; and Leon G. Higley, PhD,
Medical Examiner, Fair Acres, Route 352, Lima, PA 19037 University of Nebraska, 706 Hardin Hall, Lincoln, NE 68583-0987
After attending this presentation, attendees will appreciate the After attending this presentation, attendees will understand the
complications encountered with a patent ductus arteriosus, the necessity unlikelihood of nocturnal colonization of bodies by blow flies and how
for repair of the ductus, and a rare case of rupture of an undetected patent this affects estimates of the postmortem interval.
ductus arteriosus aneurysm. This presentation will impact the forensic science community by
This presentation will impact the forensic science community by demonstrating that while nocturnal colonization of human bodies by
addressing the importance of diligent diagnostic assessment of all carrion flies is conceivable, it remains highly improbable and nocturnal
patients. The decedent had undergone numerous prior imaging studies colonization of carrion by flies appears to be the exception rather than
with failed recognition of a large ductus arteriosus aneurysm, and failure the rule.
to detect such lesions can have disastrous consequences. Additionally, Forensic (or medicocriminal) entomology, the use of arthropods in
this case illustrates the importance of a thorough autopsy examination legal investigations, is most frequently employed to estimate the
with toxicologic assessment to clarify the circumstances of in- postmortem interval (PMI) of victims of violent crimes or suspicious
hospital/intraoperative deaths, recognizing the potential civil litigative deaths. The most commonly used method of PMI estimation employs
pitfalls should such an approach not be pursued. temperature-dependent developmental rates of blow fly larvae (Diptera:
The case of an 80-year-old white female who suffered hypertensive Calliphoridae). Retrospective scene temperatures, those temperatures
crisis and cardiovascular collapse during T-12 kyphoplasty is reported. which the insects experienced during development, are used in
The decedent had been admitted to the hospital for kyphoplasty to repair combination with known developmental rates of the species involved to
a T-12 compression fracture. She had a history of prior cerebrovascular estimate the age of the insects.
accident, hypertension, hyperlipidemia, and osteoporosis. During the Because forensically important flies are known to colonize cadavers
procedure, the decedent experienced a spike in blood pressure to very shortly after death (often within minutes), the age of their
approximately 200/100 mmHg, with sudden cardiovascular collapse. developing offspring found on a body often corresponds closely with the
Resuscitative efforts were unsuccessful. Autopsy examination revealed time of death. One exception to this standard has traditionally been
rupture of a large ductus arteriosus aneurysm producing a large left death occurring at night, when flies are not presumed to be actively
hemothorax. The aorta and its main branches showed marked searching for host carrion, and colonization is often assumed to be
arteriosclerotic change with Monckeberg calcific sclerosis, and the heart delayed. Recent studies both confirm and refute this assumption.
was enlarged, with biventricular hypertrophy. Additionally, examination However, none of the previous studies have actually examined whole
revealed arterionephrosclerosis and adrenal cortical hypertrophy. The carrion that has been freshly killed after dark. Previous work has been
cause of death was listed as massive left hemothorax due to rupture of a limited to butchered meats, thawed carcasses, or aged meats, all of which
large ductus arteriosus aneurysm associated with marked aortic do not adequately replicate the conditions often encountered during
arteriosclerotic change, with calcific sclerosis during kyphoplasty of T- medicocriminal investigations of human death; death occurring during
12, associated with intraoperative hypertensive crisis. the hours of darkness.

Live pigs (Sus scrofa), ranging from 23-32 kg each, were penetrated the pharynx, pericardium, heart, left lung, and the blood
euthanized at the study site via captive-penetrating bolt device to the vessels of the neck. The left wrist had multiple horizontally oriented
brain. Euthanization took place after astronomical twilight had passed, superficial cuts. The configuration of wounds, i.e., shape, depth,
ensuring that conditions were as dark as possible. Each night of the location, etc., in correlation with the scene findings and circumstances of
study, three pigs were placed at a site illuminated by a mercury vapor death indicated that the manner of death was suicide, despite the
lamp and three pigs were placed at a separate site that was kept dark. unusually high number of the injuries, and impressively complex blood
Periodic observations of the dark site were made using 3rd generation stain pattern at the scene.
night vision equipment to observe any insect activity. Exposure of the Multiple stab wounds are possible but not common with suicides.
cadavers continued until either astronomical twilight began or ambient This case demonstrates the importance of correlating terminal events,
air temperatures went below 5˚C, whichever came first, with a minimum scene investigations and autopsy findings in determining the manner of
period of exposure of four hours. Following exposure of the cadavers, death in a multiple stab wound case.
the body surface and orifices of each pig were closely examined under a Multiple, Stab Wound, Suicide
bright light for the presence of fly eggs, maggots, or fly artifacts (spots
caused by regurgitation or defecation).
After eighteen studies in both brightly lit and completely dark field G94 A DNA Database for Species Identification
settings with dense populations of necrophilous insects, no colonization
of the cadavers was observed at night. It is our opinion that estimates of
of Forensically Important Flesh Flies
PMI based on insect development should continue to exclude nighttime (Diptera: Sarcophagidae) in the Continental
as potential times for colonization. The data at hand from multiple United States
studies indicates nocturnal colonization of human bodies by carrion flies
is highly improbable and appears to be the exception rather than the rule. Trevor I. Stamper, PhD*, 3516 State Route 222, Batavia, OH 45103-
When applied to medicocriminal investigations, the data do not support 9708; Alice E. Timm, PhD, Department of Biological Sciences,
nocturnal colonization as a plausible scenario. University of Cincinnati, Cincinnati, OH 45221-006; Gregory A.
Forensic Entomology, Postmortem Interval, Nocturnal Colonization Dahlem, PhD, Department of Biological Sciences, Northern Kentucky
University, Highland Heights, KY 41099; and Ronald W. DeBry, PhD,
Department of Biological Sciences, University of Cincinnati, Cincinnati,
G93 Suicide by Extraordinarily Numerous OH 45221-0006
Blade Wounds
The goal of this presentation is to inform attendees of the basic
Dollett T. White, MD*, and Leszek Chrostowski, MD, Hillsborough content for a newly developed DNA database for the identification of
County Medical Examiner Department, 11025 North 46th Street, Tampa, carrion flies in the continental United States. In particular, emphasis is
FL 33617 placed upon the flesh flies (Diptera: Sarcophagidae), a hitherto largely
unusable resource due to the lack of expertise in species identification for
After attending this presentation, attendees will understand the either adults or immature (larval or pupal) stages.
importance of correlating terminal events, scene investigations, and This presentation will impact the forensic science community
autopsy findings in determining the manner of death in a multiple stab because with this tool, species identification of sarcophagid flies is
wound suicide. possible in a fast, precise method. This will then allow flesh flies,
This presentation will impact the forensic science community by species commonly encountered at carrion, to be used by forensic
outlining the findings of a case of uncommon method of suicide by entomologists in postmortem interval (PMI) estimation.
multiple stab wounds. Species were collected from as far across their United States
In the absence of any circumstantial information, the autopsy geographic range as possible. Geographic patterns of the mtDNA locus
finding of multiple stab wounds ordinarily creates the rebuttable as well as the utility of subdivisions of the locus for species identification
presumption of homicide. Classification of the manner of death always will be discussed.
requires integration of the terminal circumstances, scene investigation Additionally, data is also provided for other sarcophagid species
and autopsy findings. This case illustrates the importance of all three in that are believed to be closely related to forensically important species,
assigning manner of death. or might be confused for forensically important species from
The decedent was a 42-year-old man with a history of depression, morphological examination. In total, we report on twenty three
suicidal ideations and an involuntary admission to a behavioral health individual species, for a total of over 200 specimens. All specimens are
institution. On the day of his death, neighbors did not see or hear any vouchered in a collection that will be publicly available, allowing for
suspicious activity. He was found dead by his girlfriend on the garage future comparison of the original specimens if necessary.
floor of his undisturbed single family home, when she returned from This sarcophagid data joins the 300 plus specimens already
work. The body was lying at the edge of a very large stain of smeared sequenced from the families Calliphoridae and Muscidae to provide the
blood on the floor. A large, blood-stained, non-serrated, kitchen knife most comprehensive database to date for the sole purpose of species
was on the floor. The wall opposite the bay door had smeared hand identification of these flies and allows for the first time a rapid,
marks. The floor below had drops of blood with a pattern of vertical independent verification of almost every major species found actively
impact. Several bloody footprints were on the floor, and matched the involved in the decomposition process.
decedent’s shoes. The body was in a flexed position, face down on the Forensic Entomology, PMI, Diptera
floor, leaning to the right; numerous stab wounds to the neck, chest and
forearms were visible at the scene. The death was deemed of suspicious
circumstances by the police.
The autopsy revealed more than fifty four incised and stab wounds.
These included Twenty three stab wounds to the right side of the neck,
three stab wounds on the anterior aspect of the neck, eight stab wounds
on the left side of the neck, nineteen stab wounds on the anterior aspect
of the thorax, and one stab wound to the abdomen. The wounds

G95 NMR and Bioinformatic Studies on the Three days after the disappearance of a teenage girl from a small
city in the South of Italy the corpse of a girl was found in a wood not far
Metabolic Effects of Acetaminophen in from that city.
Rat’s and Human’s in Urine: A Immediately it was clear that the girl was murdered and moreover
Metabonomic Approach the crime scene appeared to be an execution. She was still clothed, but
her hands and feet were tied with wire, her head was covered with a
Joshua R. McMillen, BS*, 4715 Garden Ranch Drive, Apartment 308, supermarket plastic bag and her eyes were hidden by a plastic tape. The
Colorado Springs, CO 80918 murdered girl was recognized as the girl who disappeared.
The autopsy noted that she was not sexually abused, but there were
After attending this presentation, attendees will have learned how many contradictory observations about the cause of death. The head of
acetaminophen affects the body differently, depending on the individual, the girl sustained a bloody wound and the plastic bag over her head was
and how to identify biomarkers that are unique to that individual’s not sealed properly, so there was a large mass of fly larvae on the head
response to acetaminophen. wound and in the eyes. The entomological evidence was poorly sampled
This presentation will impact the forensic science community by and not used at the time, instead the level of humidity of the girl’s clothes
discussing how once unique biomarkers are identified and correlated, was used to determine a contradictory time of death. Many medicolegal
and how further study can be done to help determine which individual’s professionals were consulted and each one wrote a different conclusion.
will have adverse side effects to certain medications. Two years later, the investigation led to a male suspect who was
Acetaminophen is one of the most widely used analgesic drugs in found with a note written by the girl. However, after two years of
the United States today due to its therapeutic effects and high toxicity imprisonment he was exonerated.
threshold. This research aims to measure the effects of various The case was reopened six years later and the prosecutors who were
acetaminophen doses on rats and humans using 1H-NMR spectroscopy. handling the case decided to use another team of investigators and they
Previous work has been done to establish the therapeutic and toxic levels also decided that a forensic entomology analysis might be useful to
of acetaminophen and found them to be 10-15mg/kg and 150mg/kg determine the time of death.
respectively. The purpose of this research is to study the effects of All entomological samples collected during the autopsy were
acetaminophen on rats to determine if metabolic biomarkers can be destroyed some years before, so the work was performed with the
identified and then compare those biomarkers to those found in a human collaboration of old and new investigators and based only on reports,
study. This research will show that the unique metabolic biomarkers pictures, crime scene and autopsy video, the girl’s clothes and
found are due to the specific responses of exposure to the meteorological data from the area nearest to the crime scene.
acetaminophen. This particular experiment will involve three groups of Desiccated insect material was collected after eight years from the
five rats (control, low, and high dose) and two groups of five humans girl’s clothes and because of the state of this evidence a morphological
(control and low dose). Urine will be collected over the course of seven examination was not possible. Instead using mtDNA analyzes (COI) the
days post-dose. A pre-dose urine sample will also be collected and this insect material was determined to be Lucilia sericata (determined by
will act as another control. Once samples have been prepared and a taxonomist).
analyzed using a water suppression method, data analysis will begin. To identify the instar of the desiccated larvae a lab experiment was
The spectra will be analyzed using various bioinformatics methods to see designed in order to identify the original length of maggots before the
if changes occurred metabolically and what those changes were. These dehydration process. This experiment revealed that the larvae from the
results will then be compared to those found in the human study to see if body of the girl were 2nd instars of Lucilia sericata.
any correlations can be established. The biomarkers identified will This information together with the environmental parameters and
determine whether or not the subject in question is genetically the ecological data helped to determine when the eggs were deposited
predisposed in their metabolism of acetaminophen. This can then be and therefore the most probable time of death. The investigation is still
expanded to other medications, including those still undergoing clinical in progress.
trials, to help establish what biomarkers are indicative of certain adverse Investigation, Entomology, mtDNA
side effects of a medication. This will assist in prescribing medications
to individuals who will not exhibit the adverse side effects.
Metabonomics, Acetaminophen, Biomarkers G97 Dead Men in Wells: How Forensic Science
Was Used to Solve a Crime in an
Aquatic Environment
G96 A Cold Case: A Forensic Review Nine Years
After the Crime Paola A. Magni, MS*, F.E.LAB ASL TO1, c/o Civico Obitorio di Torino,
Via Bertani 112/A, Torino, 10137, ITALY; and Mario A. Apostol, PhD,
Luigi Saravo, PhD, Reparto Carabinieri Investigazioni Scientifiche, SC Medicina Legale ASL TO4, Via C. Bertetti 10A, Torre Canavese (TO),
Viale Tor di Quinto 151, Roma, 00190, ITALY; Gennaro Aprea, PhD, 10100, ITALY
Università degli Studi di Napoli “Federico II”, Complesso Monte
Sant’Angelo, Via Cinthia, Napoli, 80126, ITALY; and Paola A. Magni, The goal of this presentation is to provide information on how three
MS*, F.E.LAB ASL TO1, c/o Civico Obitorio di Torino, Via Bertani allied sciences (pathology, anthropology, and entomology) working
112/A, Torino, 10137, ITALY together can produce important information on a complex crime scene in
an obscure location. Furthermore, some understanding of the technical
The goal of this presentation is to provide information about difficulties of removing a corpse from an aquatic environment while still
potential capabilities and limits of forensic entomology analyses on an retaining corpse integrity.
old case in order to determine time of death. This presentation will impact the forensic science community by
This presentation will impact the forensic science community by underlining the importance of collaboration and dialogue between
underlining how our current understanding of the forensic sciences can forensic specialists. Moreover, this case demonstrates how important
help solve old cases and how important it is to have a DNA database of protocols are in crime scene recovery so fundamental information is not
forensically important insects. lost.

A corpse in an advanced stage of decomposition was found in late case of fatal rescue burns where a six month pregnant female committed
February at the bottom of a well. The well was a small hole in the suicide by pouring kerosene and igniting herself will be reported. The
ground covered by a large and heavy stone and it was situated in an open father-in-law of the deceased, in trying to rescue her, got entrapped in
roofed dwelling of an abandoned farmhouse not far from a lake in fire and sustained fatal rescue burns. As per the preliminary
northern Piedmont (Turin, Italy). investigations into the incident and eyewitnesses account, a young six
The extraction of the corpse was very difficult because the very month pregnant female poured kerosene and set herself ablaze following
small opening of the well (about 50 cm of diameter). The size was just an argument with the mother-in-law. The father-in-law, in an attempt to
sufficient for the entry of one man with his equipment and the air tank. rescue her, also sustained burn injuries. Subsequently both were rushed
The well was deep, a little more than 6 m and the corpse was floating in to the district hospital. The female aborted on the 4th day of the incident.
about 3 m of water. The victim (female) and the rescuer (father-in-law) expired later. The
The corpse was clothed but no documents were found. Because of pattern of burn injuries in the rescuer and the victim will be presented
the high decay of both tissue and bone the identity of the corpse was and the case details of the victims along with body involvement in burns
performed by anthropological and anthropometrical examination. It was will be discussed.
recorded that the man disappeared in May the year before. Self-immolation is a preferred method of suicide in Indian women.
Further pathological, histological, and SEM EDX examination of The death of married females due to thermal burns that is commonly
the bone marrow was performed to determine the presence of diatoms, reported in India is usually associated with the social evil of dowry. A
causes of death were identified. fatal thermal injury in married women in India hence is a major concern
Forensic entomology was used in order to calculate time of death for the investigating and law-enforcing authorities. It is a challenging
(colonization interval) and to investigate with a possible time frame in task for the medicolegal experts to discriminate homicidal and suicidal
mind as to whether following his murder he was dumped in the lake. burns in married women and comment on the manner of sustaining
This led to the lake being scoured for months by many civil defense and injuries in cases relating to dowry disputes. Pattern of distribution of
firemen volunteers. burns in different circumstances have been studied and a difference has
Entomological material was sampled both from the corpse and from been noted in between assault and self-immolation groups as well as
the water in the well which was pumped into large plastic tanks. between males and females. The issue becomes critical in case of
Numerous species of flies were identified including Calliphora vicina, thermal injuries sustained to the relatives and associates of the victim (a
Fannia sp., Muscidae, Trichoceridae, Sphaeroceridae and Psychodidae. young married woman) during such an incident. It is vital to ascertain if
Data on seasonal presence of Calliphoridae in the Piedmont region burns are sustained in an effort to save the victim or trying to commit
of Italy and stage of corpse decomposition (saponification) helped to the crime.
confirm that the time when the man first disappeared coincided with the An unprofessional rescuer of a burn victim is one who tries to save
beginning of insect colonization. Moreover, it was possible to the victim, in spite of the consequences of putting out the fire without
demonstrate that the corpse was never in the lake environment, thanks to any safety precautions. Menezes et al introduced the term ‘‘rescue
information gathered from the literature about the biology of the insects burns’’ for such thermal injuries as an option to allow easy tracking and
found on the corpse. This fact was supported by the absence of diatoms identification of such cases. They opined that difference between rescue
within the marrow of long bones, and by the presence in the internal burns, accidental burns, and suicidal burns can have profound
organs of the same silicates found in the water. ramifications to the family of the injured or deceased rescuer, or the
This case underlines the importance of collaboration and insurance company concerned in the case, as well as the judiciary. In
communication at crime scenes. In particular, when there are several India, dowry is a tradition; bride burning a social problem, hence cases
experts such as firemen, policemen, medical examiners and other of thermal burns in newly married females is an investigative challenge
different forensic scientists (entomologists, botanists, anthropologists) and identification of a rescuer can have serious medicolegal
present team work is essential. When a crime scene is conducted implications.
properly, relevant evidence is conserved and subsequently a complete Rescuers, under the influence of emotional distress and with great
analysis of the association of the human remains and the place of courage, try to save the victim. Efforts should be made so that a rescuer
recovery can be documented. does not become the next victim. To prevent the rescue burns general
Moreover, this case highlighted the importance of evidence public should be educated about precautions to be taken before trying to
recovery from water bodies and the scant information available on this prevent a victim especially during their early years of life. Identification
topic, in particular the lack of literature on protocols and equipment. of the rescuer is vital since it has profound medicolegal implications.
Aquatic Environment, Anthropology, Entomology Dowry Deaths, Rescuer, Rescue Burns
G98 Fatal Rescue Burns G99 Sports Tool as a Weapon of Assault:

A Case Report
Tanuj Kanchan, MD*, Manipal University, Department of Forensic
Medicine, Kasturba Medical College, Light House Hill Road, B. Suresh K. Shetty, MD*, Kasturba Medical College, Light House Hill
Mangalore, 575001, INDIA Road, Mangalore, 575001, INDIA
After attending this presentation, attendees will identify with the After attending this presentation, attendees will understand the
significance of identification of a rescuer in a case of burns to ascertain injuries produced by a rarely reported sports tool as a weapon of assault.
if burns are sustained in an effort to save the victim, or trying to commit This presentation will impact the forensic science community by
the crime. helping the officials responsible for the maintenance of law and order to
This presentation will impact the forensic science community by administer the justice.
understanding the need to prevent rescuers from becoming a victim of Trauma to different regions of the body using different types of
burn injuries, and the need to identify rescuers for medicolegal weapons is commonly seen in literature, but there is a dearth of cases
implications. reported about sports equipment as a weapon of assault. Here a case of
Dowry deaths in India are an investigative challenge and a moderately built male who had a homicidal attack with a hockey stick
identification of a rescuer can have serious medicolegal implications. A thus producing multiple injuries in head, abdomen, and genitals.

A case report will be presented of a sports tool as a weapon of occur in a central location of the lung and tend to be large as in this case.
assault, a rare event. It is recommended that medicolegal death Type 2 laceration results from severe compression of the pliable lower
investigators become familiar with such injuries in a detailed autopsy, thorax of younger patients. Sudden herniation of the lower lobe in front
which may ultimately prove or disprove the case, and may be of of the vertebral bodies causes a paravertebral shear injury with
significant value to the investigating authority. laceration. Type 3 lacerations result from direct puncture of the lung by
Sports Tool, Hockey Stick, Multiple Injuries a displaced rib fracture. Type 4 results from lung shearing at sites of
pleural adhesions.
This case represents a particular mechanism involved in a blunt
G100 Unusual Case of Blunt Chest Trauma chest trauma in which a high-energy non-penetrating injury was applied
to one hemithorax leading to a major unilateral pulmonary laceration
Without Rib Fractures Leading to a Major without other organ involvement
Pulmonary Laceration Pulmonary Laceration, Chest Trauma, Car Accident
Javier Serrano, MD*, Puerto Rico Institute of Forensic Sciences, Calle

Maga Esquina Casia #9, Urb. Reparto Metropol, San Juan, PR 00921; G101 Postmortem Analysis of Vitamin D Using
and Carlos F. Chavez-Arias, MD, Puerto Rico Institute of Forensic
Sciences, PO Box 11878, Caparra Heights Station, San Juan, PR
Liquid Chromatography Tandem
00922-1878 Mass Spectroscopy
The goal of this presentation is to describe and discuss a case of a Geza Bodor, PhD, Denver VA Medical Center, 1055 Clermont Street,
major pulmonary laceration after a blunt chest trauma without rib Denver, CO 80220; John Carver, JD, City and County of Denver, 660
fractures in an infant involved in a car accident as a passenger. Bannock Street, Denver, CO 80204; and Amy Martin, MD, and Michael
This presentation will impact the forensic science community by A. Burson, PhD*, City and County of Denver, Office of the Medical
demonstrating an infrequently discussed mechanism of lung laceration Examiner, 660 Bannock Street, Denver, CO 80204
due to a blunt chest trauma.
Pulmonary laceration is a common result of penetrating trauma but The goal of this presentation is to review physiology of vitamin D,
may also be caused by blunt trauma; broken ribs may perforate the lung, review current methodologies for measuring vitamin D, and understand
or the tissue may be torn due to shearing forces that result from different the utility of measuring vitamin D in postmortem blood samples.
rates of acceleration or deceleration of different tissues of the lung This presentation will impact the forensic science community by
This case involved a 6-year-old, Hispanic healthy female infant providing the framework to understand the utility of measuring vitamin
who was a partially restricted backseat passenger in a compact vehicle D in postmortem blood samples. With the recent debate regarding
that was traveling along a local highway. She was lying across the back vitamin D deficiency, bone fractures, and questions of child abuse it
seat when the driver suddenly fell asleep and collided with the back of a seems imperative to be able to address these issues as thoroughly as
large truck. As a result of the impact her body was thrown against the possible. Often is the case in forensic cases that antemortem blood
back of the passenger’s front seat and died instantaneously. samples are not available or specific questions have not been asked by a
At autopsy the body corresponded to a well-developed and well decedent’s physician prior to death. Thus, there is no way to know if a
nourished female infant. She was forty inches tall and weighed thirty vitamin D deficient state was present prior to death. The results study
two pounds. External examination of the anterior torso disclosed the will allow the forensic community to know whether or not a postmortem
presence of a horizontal linear abrasion over the superior aspect of the blood sample can or cannot be analyzed appropriately for vitamin D
left hemithorax. Also a small elliptical contusion was over the nutritional status.
superomedial aspect of the right hemithorax. Other small abrasions were Objective: To measure vitamin D in postmortem blood samples
present in the lateral aspects of the right upper and lower quadrants of the using our recently developed liquid chromatography-tandem mass
abdomen and posterior aspect of the right arm. The body had no other spectrometric (LCMSMS) method. Briefly, our current method provides
external signs of trauma. Upon reflection of the skin of the anterior for measurement of the 25-hydroxy derivatives of vitamin D, specifically
thorax, no hemorrhagic infiltrates were present. There were no rib 25(OH)-D2/D3, (OHD2, OHD3) in human serum. Increasingly, current
fractures. The left pleural space had 420 mL of liquid blood. The right clinical practice is to measure OHD2 and OHD3 to assess vitamin D
pleural space and pericardium had no hemorrhages. The left lung had an nutritional status. To our knowledge, methods have not been evaluated
extensive oblique laceration that practically transected the upper lobe, for measuring these analytes in postmortem samples. The most common
from the apex to the inferior medial aspect of the base. In addition assay platform used today is an immunobased assay, which relies on
multiple contusions were present over the anterior and posterior aspects antibodies which are known to cross-react with many vitamin D
of both lungs. The rest of the thoracic and abdominal organs had no metabolites. Such immunobased assays are particularly sensitive to
lesions. Toxicological evaluation was negative for alcohol, cocaine, sample integrity and it is likely that a postmortem blood sample may not
opioids and canabinoids. be appropriate due to hemolysis and other postmortem artifacts.
Major laceration of the lung is a rare and not a well recognized Hypothesis: Postmortem vitamin D concentration, measured with
complication of blunt chest trauma. Pulmonary laceration caused by a sensitive and specific assay such as LC-MSMS, will correlate well with
blunt high-energy trauma results from a mechanical shear or puncture antemortem concentrations. Such analysis will be helpful in those cases
that disrupts the parenchyma, creating a cleavage plane within the lung. where antemortem vitamin D levels have not been previously measured
The mechanism of development of pulmonary laceration after blunt in the primary care setting. Furthermore, with the recent debate over
chest trauma is usually thought to be the result of direct impact leading vitamin D deficiency (Rickets) and suspicious non-accidental bone
to rib fractures and thereafter, the broken ends of the ribs directly tearing fractures, such an assay will, without doubt be of interest in cases
the lung. However, the absence of rib fractures in this infant makes this questioning abuse.
mechanism unlikely. In 1988 a group led by R.B. Wagner divided Materials and Methods: In preliminary studies, three recent cases
pulmonary lacerations into four types based on the manner in which the of natural disease were selected. In each case, peripheral blood (iliac
person was injured. In type 1 the laceration results from sudden vein) was sampled within 24 hours of the time of pronouncement.
compression of the thorax causing rupture of the lung. They usually Approximately 8 ml of peripheral blood was drawn into a red-top tube

under gentle pressure to minimize hemolysis. Each sample was allowed decisive importance for the reconstruction of the sequence of events.
to clot at room temperature for one hour and then centrifuged for twenty Most homicides by sharp force are committed by males, often under the
five minutes. The serum was then transferred to a clean red-top tube and influence of alcohol. The most common tool used is a knife, but other
frozen at -10 C until assayed. Hexa-deuterated OHD2 and OHD3 pointed objects, such as scissors, ice picks, forks, or broken glass, may
(OHD2d6 and OHD3d6, Medical Isotopes, Inc.) were used as internal also be used. The victims are usually family members or acquaintances.
standards (IS). Calibrators were prepared in acetonitrile (ACN) at 5, 10, The death scene is most frequently the victim’s home. Fatal stabs are
20, 50, 100 and 150 ng/ml for each analyte (OHD2 and OHD3). usually located in the precordial or cervical region. The number of stabs
Samples and calibrators (500 ul) were spiked with 75 ng IS, extracted in does not allow the drawing of conclusions as to the mode of death, the
1 ml ACN and centrifuged. Thirty ul of supernatant was injected into a motive, or sex of the perpetrator. When the number of stabs is higher
Shimadzu HPLC at 70% H2O:30% ACN at 350 ul/min flow. Analytes than necessary to kill the victim, this is referred to as “overkill,” and may
were separated on a C18 column (100 mm x 2.1 mm x 3 um, RESTEK) point to a strong emotional conflict between the perpetrator and the
and then introduced into a triple quadrupole mass spectrometer (ABI victim.
3200 Q-trap) via an APCI source in the positive ion mode. The analytes Case Report: The lifeless body of a 18-year-old girl was found in
were eluted at 100% ACN over a 13 minute run. a mansard by the owner. He was giving hospitality to a friend since three
Results: Preliminary studies addressed whether or not vitamin D months. The girl was the former girlfriend of his guest. The body laid
analytes are stable in postmortem blood and if so whether they can be face down in a large pool of blood. Immediately he tried to help her and
measured with our LC-MSMS method. In each of the samples tested to called the ambulance, but she was pronounced dead. There was a great
date, successful and reproducible total vitamin D in levels ranging from confusion in the room, on the floor beneath the body a large pool of
6.43 ng/ml to 95.3 ng/ml have been detected and quantitated. We are blood was evident, with extensive blood spatter on the surface of the wall
confident in these results because the level of quantitation (LOQ) has on the right, of the cupboard on the left and of the bed, in the center of
previously established of these assay at 5 ng/ml. the room. The head of the decedent lied near a chest of drawers which
Summary: It can be shown that postmortem blood contains measurable surface was full of stripes of blood made by the girl’s fingers in an
vitamin D and can be accurately measured on our LC-MSMS platform. attempt to getting up from the floor. The postmortem examination
Immediate planned studies on adult and pediatric cases include: (1) a showed the face devastated by very numerous cross lesion of the cutis,
direct comparison of hospital admission antemortem blood with our 24 0.4 cm in length, ending in deep incision on the bone surface underneath.
hr postmortem blood samples; (2) a direct comparison of plasma and The same wounds were also on the thorax and on the dorsal face of the
serum samples; and, (3) a postmortem stability assay to characterize how hands. These wound appeared similar to the shape of a phillips
the postmortem interval affects our ability to accurately measure screwdriver tip. On the left side of the face and neck there were many
vitamin D. linear wound that appeared always paired and of the same length,
Vitamin D, Postmortem Analysis, LC-MSMS suggesting the use of a sharp and pointed object like scissors, kitchen
fork, etc. There were also numerous deep linear cutaneous wound on the
anterior surface of the neck, slightly oblique, with clear-cut divergent
G102 An Unusual Case of Homicide by Knife, margins, exposing the underlying structures, also sectioned, and ending
in linear superficial incisions at different vertebral bodies of the cervical
Screwdriver, and a Kitchen Fork spine. Other deep linear cutaneous wounds were localized on the right
emithorax; beneath these lesions the costal cartilage was sharply
Sabina Di Donato, MD*, Ospedale San Carlo - U.O. Medicina Legale, sectioned at many levels, with soft tissue bleeding underneath. No
Via Potito Petrone, s.n.c., Potenza, 85100, ITALY; Aldo Di Fazio, Section pulmonary lesions were found. On the hands and the forearm the girl
of legal medicine - Matera Hospital, via Montescaglioso n.5, Matera, showed many defense lesions made by the sharp and pointed object, and
75100, ITALY; and Rocco Maglietta, CROB Rionero in Vulture by a cross-tipped mean. Immunohistochemical studies were performed
(Potenza), via Padre Pio n. 1, Rionero in Vulture (Pz), 85028, ITALY on the cutaneous specimens for the determination of the vitality. The
evaluation of skin samples with confocal microscope allowed
After attending this presentation, attendees will be familiar with researchers to observe the three-dimensional model of the different
wound patterns inflicted by multiple unusual means. Only a few cases wounds. Toxicological analyzes were negative. On the basis of the
of homicide by screwdriver, knife, and kitchen fork are reported in autopsy results, the pathologists gave indications to policemen about
forensic literature. Sometimes it may be difficult for the forensic possible responsible weapons. A thorough investigation of the crime
pathologist to identify the penetrating weapon missing from the crime scene allowed the finding of a phillips screwdriver dried with blood and
scene. The importance of a thorough forensic investigation, including a kitchen fork in a drawer; no other weapons were found. The day after
crime scene evaluation, analysis of circumstantial data, autopsy findings, the body finding, the boyfriend, who was sought by police, crashed with
toxicological analysis, histological, and immunohistochemical studies his car while he was escaping along the highway. Inside his car police
is emphasized. discovered a knife, stained with blood, and locks of hair.
This presentation will impact the forensic science community by Knife, Screwdriver, Fork
presenting a homicide where the murderer assaulted the victim with a
screwdriver, a knife, and a kitchen fork. The unusual injuring tools and
the relevant injuries were studied and analyzed to approach the case. The
confocal microscope was utilized to verify the three dimensional
G103 Love and a Bullet: Autoerotic Accident or
appearance of the cutaneous lesions. Intentional Suicide?
Injuries caused by sharp or pointed objects are common. They
rarely cause fatal injuries; however, and the fatality rate is estimated to Kelly L. Rose, MD*, and Kim A. Collins, MD, Fulton County Medical
be 3% at most. Most fatalities caused by sharp force are homicides. The Examiner’s Office, 430 Pryor Street Southwest, Atlanta, GA 30312
ratio of homicide to suicide is estimated at 6:1 to 5:2. When
investigating deaths owing to sharp force, the forensic pathologist is The goal of this presentation is to highlight the potential for
expected to give an opinion on the following points: the type of injuries; confusion regarding manner of death by using an interesting example.
the number and anatomical distribution of injuries; the shape, size, This presentation will impact the forensic science community by
length, and depth of injuries; the object (weapon) used; the amount of highlighting the gray area of manner of death.
force needed to inflict the injuries; the extent of internal injuries; the Autoerotic deaths have traditionally been caused by asphyxia due to
cause of death; and the victim’s capability to act. These points are of hanging. To a lesser degree, trauma secondary to electrocution and
insertion of objects have resulted in death. Based on scene investigations Common autopsy findings for all cases included the presence of
and the autopsy findings in these more traditional autoerotic cases, hyoid bone and or laryngeal fractures associated with craneofacial
manner of death is best classified as accident. However, there does arise trauma with maxilla and mandible fractures.
within the forensic spectrum cases involving autoerotism where the The most common fractured site was the joint between the left
manner of death is more equivocal. It is in these fringe cases where greater cornu with the left side of the body of the hyoid bone. Five cases
excellent investigation of the scene and the victim’s past medical history, had only one fracture at the left side and two cases had bilateral fractures.
is paramount. We present here an unusual case of autoerotic death in One case had a unilateral fracture at the right side. Fractures of the hyoid
which the autoeroticism involved a gun. body were found in two cases, including one case with multiple fractures
The decedent, a 29-year-old man killed his father when he was of the hyoid bone. Cases with thyroid cartilage fractures included one
thirteen-years-old. Using a handgun, he shot his father because he was left superior cornu fracture and two cases with fractures of the right and
repeatedly abused by him. His mother encouraged the murder. As a left laminae. The cause of death for each of the ten cases was Blunt
young man, the decedent found titillation from a toy handgun. As he Force Injuries and the manner of death for nine of the cases was accident
grew older, he felt the need for a more powerful arsenal in order to and one case was homicide.
achieve sexual arousal. During his last years, the decedent not only Hyoid bone fractures secondary to trauma due to strangulation or
considered his silver .38 caliber Rossi handgun to be “sexy,” but he hanging are rare. In the forensic literature, little information of
smelled, fondled, and caressed it. The 38 Rossi was kept in a velvet bag laryngohyioid trauma in victims other than compression of the neck is
in his bedroom, retrieved easily to be used as a sexual and masturbatory available. Forensic pathologists look for a fractured hyoid bone as
aid. His sexual routine with his beloved Rossi escalated from dry firing evidence of strangulation. There are several reasons contributing to the
the empty gun, to leaving one bullet in the cylinder of the revolver while rarity of this fracture. The first is that the hyoid bone is well protected
pulling the trigger. Eventually, this repeated practice resulted in his by the mandible. Most trauma to the face results in fracture of the
death due to a self-inflicted contact range gunshot wound to his head. A mandible without hyoid bone fracture. The second is that hyoid bone is
further complication in this case is the decedents past psychiatric history. protected by its mobility in all directions, so the pressure may be
He had mild depression and suffered from bouts of insomnia. So this cushioned. The third is that it is not completely ossified in younger
case serves as a great illustration and topic for discussion regarding patients allowing for more flexibility and decreased rigidity.
aspects of autoeroticism, cause of death, manner of death, and the less In laryngohyoid fractures, three mechanisms could be involved.
clear distinction between suicide and accident. The first involves a direct impact of the neck structures. The second
Gunshot Wounds, Autoerotic, Manner of Death involves an indirect muscle strain on the hyoid bone or thyroid cartilage
resulting from hyperextension or hyperflexion of the neck or secondary
to associated local trauma such as mandible fractures. The third is a
G104 Laryngeal and Hyoid Bone Trauma combination of direct and indirect mechanisms.
These cases could represent similar mechanisms involved during a
Resulting From Forces Other Than blunt trauma in which hyoid bone and laryngeal fractures are the result
Compression of the Neck of high energy forces applied to the mandible strong enough to be
transmitted by its anatomical contiguity. Strong muscle strains on the
Carlos F. Chavez-Arias, MD*, Puerto Rico Institute of Forensic mylohyoid muscle could lead to hyoid bone lesions in case of mandible
Sciences, PO Box 11878, Caparra Heights Station, San Juan, PR 00922- fracture where this muscle is inserted. This could explain the common
1878; Dario Sanabria, MD, Puerto Rico Institute of Forensic Sciences, association of hyoid bone fractures with mandible fractures in this report.
Department of Pathology, PO Box 11878, Caparra Heights Station, San
Juan, PR 00922-1878; and Javier Serrano, MD, Puerto Rico Institute of Table 1: Ten Laryngeal and Hyoid Bone Trauma Cases
Forensic Sciences, Calle Maga Esquina Casia #9, Urb. Reparto
Metropol, San Juan, PR 00921
The goal of this presentation is to describe and discuss ten cases

associated with laryngeal and hyoid bone blunt trauma.
demonstrating the pathological features of this infrequently discussed
entity in the non-homicidal setting.
Hyoid bone fractures are usually the result of direct trauma to the
neck through manual strangulation or hanging. These fractures
secondary to blunt trauma other than strangulation are rarely reported
and discussed. This report discusses ten cases with hyoid bone or
laryngeal fractures associated to blunt trauma.
Ten head and neck trauma cases in which the autopsy disclosed the
presence of hyoid bone or laryngeal fractures were reviewed. These
cases occurred within the period 2008-2009 and examined at the Puerto Hyoid Bone Fracture, Laryngeal Fracture, Mandible Fracture
Rico Institute of Forensic Sciences. Cases with a diagnosis of
strangulation or hanging were excluded.
The ten cases are summarized in Table 1.
Eight of ten cases were male and two were women. All cases
corresponded to adults between 24 to 80 years. Half of the cases were
older than 50 years. Eight out of ten cases corresponded to motor vehicle
accidents; one case was a small plane crash accident and one case was a
homicidal blunt trauma to the head with a concrete block. The motor
vehicle accident cases included three motorcyclists, three pedestrians
and two car drivers.

G105 The Evolving Distribution of Cause and the belly area. Review of the medical records is underway to determine
the number of these decedents in ART at death. The racial/ethnic
Manner of Death in HIV Positive Medical composition is 44% black, 42% white, 13% Hispanic, and 2% Asian.
Legal Cases: Links Between ART and The age range is 18-81 years, with a median age of 47, a relatively
Traditional Categories of Chronic Disease middle-aged distribution. The leading causes of natural death are
complications of AIDS (11) and CVD (11).
Sharon M. Derrick, PhD*, Harris County Medical Examiner’s Office, As these preliminary results show, improved treatment of HIV
Harris County Medical Examiner’s Office, 1885 Old Spanish Trail, infection may lead to a higher number of deaths from CVD, fewer AIDS-
Houston, TX 77054 related causes of death, and fewer infectious findings at autopsy that
result in a request for an HIV serology by the forensic pathologist.
The goal of this presentation to describe and evaluate the impact of Medical examiner/coroners can prevent a negative impact on public
HIV infection, obesity, and two linked diseases, diabetes mellitus health surveillance of HIV infection in forensic cases through awareness
(diabetes), and cardiovascular disease (CVD), on the forensic practice of the changing epidemiology of HIV.
and public health roles of medical examiner/coroners. Attendees will References:
1
receive an epidemiological analysis of these diseases in medicolegal http://www.cdc.gov/hiv/topics/surveillance/resources.htm
2
(ML) cases presenting to a large urban-based medical examiner office. Texas Department of State Health Services Epidemiology and
Specific emphasis will be placed on the interrelationships between HIV Surveillance Branch 2008 Annual Report
infection and traditional categories of chronic disease and on the HIV, Medical Examiner, Epidemiology
implications of the study results for other medical examiner
offices nationally.
This presentation will impact the forensic science community by G106 Death in a Wine Vat
illustrating the evolving status of HIV infection as a chronic disease and
the effects of increased longevity of the HIV positive patient on the Romano La Harpe, MD*, Sandra E. Burkhardt, MD, and Kebede
composition of medicolegal caseloads. The role of medical examiner Shiferaw, MD, Institut de Medecine Legale, 9 Av de Champel (CMU),
offices as guardians of the public health and the practical aspects of Geneva, 1206, SWITZERLAND
public health reporting will be discussed.
In 2009 the Centers for Disease Control and Prevention (CDC) After attending this presentation, attendees will understand the
released the results of HIV/AIDS surveillance data collected from thirty necessity of good collaboration between the different institutions that
four reporting states. An estimated 552,000 adults and adolescents were work on an undetermined death crime scene and will become familiar
living with HIV/AIDS in these states in 2007, an increase of 16% over with the autopsy presentation of death by inhalation of carbon dioxide
2004.1 The increase in persons living with HIV infection is well- (CO2).
documented in the literature and it is associated with the implementation This presentation will impact the forensic science community by
of ART treatment (combined antiretroviral therapy and highly active increasing understanding the need for collaboration between the
antiretroviral therapy), prolonging the time interval from HIV infection different institutions (e.g., police, casualty department, national
to development of AIDS, and with increased HIV screening at point of toxicology department, local eco-toxicology department, regional wine
care, which can lead to earlier treatment. HIV positive patients are living institute) to get the cause of death in a unclear case.
longer through better disease management. However, ART produces A 42-year-old man was found unresponsive by his father with the
side effects that increase the HIV positive patient’s susceptibility to head and the left limb in a wine vat. The father could not remove the
obesity, (especially visceral fat around the waist), diabetes, body, so he immediately called for a help. The emergency responders
hyperlipidemia and CVD. found him in asystole and pronounced him dead after twenty minutes of
The population sample for this retrospective study consists of ML a resuscitation attempt.
cases investigated by the Harris County Medical Examiner’s Office The vat of 1,750 liters (455 gallons) was fuelled at 80% with grapes
(HCMEO), Houston, Texas in 2008-2009 that fall within these the day before. To give a better aroma and flavoring to the wine, 40 kg
parameters: 15+ years old, 60+ inches tall, and weight of 70+ pounds. (88 pounds) of dry ice were added into the grapes. The worker had to
Size limits are set to exclude young children and decedents in advanced then check the evolution of the must. For that, he had to regularly take
decomposition. The incidence of CVD and diabetes is obtained from the samples to look at the color, to smell and to taste the must, especially
primary and contributing causes of death, and HIV incidence from during the period of fermentation of alcohol (about 15 days).
medical history and HCMEO serology results reported to the local health Autopsy showed cyanosis of the face and the neck, conjunctival
authority. The data presented here reflect 5794 ML cases received from petechiae, cerebral edema, and signs of acute anoxia into the brain.
January 1, 2008 through July 22, 2009. The balance of the 2009 cases Toxicological analysis was negative. The National Toxicology
and the biostatistics results will be included in the final analysis and Department suggested that it could be an intoxication by carbon dioxide,
presentation. but could not prove it, because of the evaporation of the gas (CO2).
The population of Harris County, Texas is an ethnically diverse 3.9 The day after, the scene was visited with the police to try to
million residents, of which 29% are obese (BMI >30) and the average understand the events. The Local Eco-Toxicology Department was
BMI is 27-30. Approximately 8.3% of Harris County residents have asked to perform the analysis of the air on the top of the vat. They found
been diagnosed with CVD, 7% with diabetes, and 0.5% with HIV.2 In 100% of CO2. The Regional Wine Institute speculated that the addition
concordance with these data, 29% of the ML decedents have a BMI >30, of dry ice produce immediately a lot of CO2 and not progressively as in
with a range of 10-98 and an average BMI of 27, and in 7% of cases a normal fermentation. In this case, if someone breaths inside the vat,
diabetes is the cause or contributing cause of death. Due to the nature of loss of consciousness can come in a few seconds and then the death in a
ML cases and the efficacy of autopsy diagnosis, the percentages of CVD few minutes. Finally, as a result of the police investigations, a pair of
and HIV in the sample are higher at 31% and 0.9%, respectively, even glasses were found inside the vat when it was emptied after three
though these conditions may be under-reported in a forensic sample. months. It was concluded that the worker had lost his glasses into the vat
Among the fifty five HIV positive decedents, 13% (7) have a BMI and he tried to recover them.
>30. The average BMI is 24 and the range is 15-55. Examination The medical literature contain only a few cases of intoxications by
photographs reveal that 42% (23) have a concentration of visceral fat in carbon dioxide, occurring in ship holds, in the brewing industry, in silos,

tunnels, sewer shafts, and poultry plants that use dry ice, but rarely in injuries with complete or partial avulsion of the brain as well as thermal
wine industry. injury of the surrounding scalp and skin. The injuries were limited to the
The cause of death was not determined on the basis of the autopsy. head. This pattern of injury is consistent with that seen in suicidal
But the information received from the different institutions allow the fireworks injuries as described in the literature and highlights the
determination the cause of death as an acute intoxication by carbon importance of a scene investigation when investigating these deaths.
dioxide and the manner of death as a accident, due to the loss of glasses Perhaps due to the ready availability of more conventional
in the vat. weaponry, suicide using atypical projectiles and firearms remains rare.
Death, Wine Vat, Carbon Dioxide Despite their infrequency, it is important to recognize the pertinent
features of such cases. In nail gun suicide cases involving the head, both
bent and straight nails were identified. Many of the wounds in these
G107 Nailing the Diagnosis: Features of Fatal cases were very subtle and could easily be overlooked. In cases of
firearms loaded with atypical ammunition, the external appearance may
Injury Inflicted By Unusual Projectiles be that of a close-range or contact shotgun wound. Finally, cases of
and Firearms accidental fireworks deaths demonstrated injuries similar to those
described in suicidal fireworks deaths. All of these cases emphasize the
Hilary S. McElligott, MD*, Cook County Office of the Medical importance of obtaining a detailed history, radiographic studies, and
Examiner, 2121 West Harrison Street, Chicago, IL 60612-3705 performing a thorough scene investigation.
Nail Gun, Fireworks, Atypical Injury
After attending this presentation, attendees will recognize the
distinguishing features and potential diagnostic pitfalls of injuries
inflicted by uncommon projectiles and firearms. G108 Please, Don’t Get Angry! Two Fatal Cases
discussing the pertinent characteristics of a variety of wounds inflicted
of Emotional Stress-Related Death in Left
by atypical ammunition or firearms. A ten-year retrospective review of Ventricular Apical Ballooning Syndrome
case files at the Cook County Office of the Medical Examiner and a (Tako Tsubo Cardiomyopathy)
regional collar county yielded seven cases of suicide committed with
atypical projectiles or firearms. These include four cases of nail gun Stefano D. Errico, MD*, Benedetta Di Battista, MD, Carmela Fiore,
suicide and a case of an antique firearm loaded with Phillips head screws MD, and Cristoforo Pomara, MD, PhD, Department of Forensic
used to commit a double homicide-suicide. Additionally, two cases of Pathology, University of Foggia, Viale degli Aviatori 1, Foggia,
accidental death involving aerial fireworks mortars were identified 71100, ITALY
which are similar in many ways to two cases of suicidal fireworks
injuries that have been previously reported in the literature. The goal of this presentation is to present two cases of death due to
The use of a nail gun to commit suicide is extremely rare, with Tako Tsubo cardiomyopathy. The growing interest of the scientific
fewer than ten cases detailed in the literature. It has been previously community in understanding physiopathology, still far from a complete
reported that nails recovered from individuals who have committed definition and the amazing of videos presented, makes the presentation
suicide remain straight upon entering the body. This is in contrast to absolutely peculiar.
reports of accidental nail gun injury where recovered steel nails have This presentation will impact the forensic science community by
been observed to be curved or bent most commonly as a result of highlighting characteristics of syndrome and the importance of a
ricochet. It has been suggested that one may infer a given injury is complete postmortem examination in rare fatal cases. This presentation
accidental if the nails are bent and suicidal if the nails are straight. A case demonstrates the typical histological signs of catecholamine toxicity
of nail gun suicide is reported with recovery of both bent and straight (CBN), but further studies are still needed for further in-depth
nails. knowledge of TTC and stress-related cardiac physiopathology. In
The external evidence of injury inflicted by nail guns may be subtle particular structural alteration of the contractile and cytoskeletal proteins
and easily overlooked, especially if the nail is not visible externally. could also be investigated.
Blood may be minimal or absent both on the body and at the scene. Not Tako-tsubo cardiomyopathy (TTC) is also known as stress-induced
until the autopsy examination may the devastating extent of the injuries cardiomyopathy (SICMP) or left ventricular apical ballooning syndrome
be appreciated. In three cases of nail gun suicide involving the head and (LVABS), broken heart syndrome, and ampulla cardiomyopathy. It was
one involving the chest, the injuries were small entrance wounds first described in the early 1990s in Japan in which patients (generally
typically measuring 0.1 inch or less in diameter. The individual with postmenopausal women) complained of chest pain and dyspnea,
self-inflicted chest wounds was dead at the scene and the three remaining mimicking a coronary arterial disease. The name of “tako-tsubo”
cases had variable survival times. cardiomyopathy is derived from a pot with a short neck and a round
In contrast to the injuries produced by nail guns, the cases involving bottom used for octopus fishing in the Japanese sea, as this resembles the
the use of an antique firearm produced injuries deceptively similar to left ventriculogram during the acute phase of the disease. It is
close-range or contact shotgun wounds. Radiographic examination characterized by a transient akinesia of the apex and compensatory basal
identified the atypical nature of the projectiles, short Phillips head hyperkinesis, triggered by marked psychological or physiological stress
screws. Because the load was noncommercial, the number of projectiles in the absence of significant epicardial coronary artery disease. TTC has
(screws) varied between the cases. Additionally, from two cases, paper been recently classified as primary, acquired cardiomyopathy and
used as patching to contain the projectiles was recovered from within the diagnostic criteria have been proposed: reversible akinesis or dyskinesis
wound track. of the left ventricular apical and midventricular segments, with apical
Atypical projectiles can, of course, produce atypical patterns of ballooning extending beyond a single epicardial vascular territory, new
injury. Two cases of accidental death involving aerial fireworks mortars ECG ST-segment or T-wave abnormalities mimicking AMI, absence of
show that patterns of injury and soot deposition can be distinctive and, in exclusion criteria, including obstructive coronary disease or
the absence of additional information, may help identify the use of less angiographic evidence of acute coronary plaque rupture, recent
common incendiary powders. Although no cases of suicide involving significant head trauma, etc. Although precipitating stress is not always
fireworks were found, two cases of accidental death involving fireworks identifiable, the stressful trigger could be emotional or physical.
were identified. Both occurred outdoors and had massive craniocerebral Multivessel epicardial spasm, myocardial dysfunction triggered by

excess of cathecolamine levels, microvascular coronary spasm or G109 A Case of Anaphylactoid Syndrome
dysfunction and neurologically mediated myocardial stunning have been
proposed to explain TTC. Generally the prognosis is good but
of Pregnancy
complications including death have been reported with an extremely low
mortality rates. Deaths in these cases generally occur as a consequence Jennifer L. Shuttlesworth, MD*, Ana E. Lopez, MD, and Luis A. Sanchez,
of fatal ventricular arrhythmia (VF) or cardiogenic shock due to stress- MD, Harris County Medical Examiner’s Office, 1885 Old Spanish Trail,
related sudden severe ventricular dysfunction. Two fatal cases of TTC Houston, TX 77054
will be presented.
Case 1: A 52-year-old woman complained of thoracic pain and The goal of this presentation is to explain the use of the term
dyspnea after a quarrel with colleagues at the workplace. She had anaphylactoid syndrome of pregnancy and the difficulties one can
complained of the same symptoms a few months prior. Clinical encounter in making a diagnosis of amniotic fluid embolus.
examination on ED showed moderate high BP (160/90); pulse (90 bpm) This presentation will impact the forensic science cimmunity by
and oxygen saturation (96%) were normal. A 12 lead ECG registration illustrating a case of anaphylactoid syndrome of pregnancy and will
was immediately performed showing ST segment reduction mimicking include a discussion of the autopsy procedures necessary for
myocardial infarction. Cardiac markers were elevated on lab test (CK intrapartum deaths.
220, troponin 5.173). A severe ventricular failure was observed on A 19-year-old G2P1 Hispanic female presented to the emergency
echocardiography (EF < 30%). Cardiac catheterization was room with spontaneous rupture of membranes at 33-6/7 weeks gestation.
unremarkable for coronary obstruction. TTC was suspected, and She had no prior medical history and had undergone routine prenatal
confirmed at ventriculogram, where a typical systolic dysfunction care. Upon admission, fetal heart rate monitoring showed evidence of
involving left ventricular apex was recorded. Beta-blocker therapy was fetal distress, and a decision was made to deliver the fetus via Cesarean
introduced but few hours after charge on cardiology department, death section (the decedent had undergone a Cesarean section for a prior
suddenly occurred in spite of resuscitation maneuvers. delivery). During the C-section delivery with an epidural anesthetic, the
Case 2: A young 30-year-old suddenly collapsed after a violent patient suddenly became bradycardic and hypoxic at the point of fascial
altercation with colleagues at the workplace and immediately presented closure, following delivery of the fetus and placenta. Cardiopulmonary
to the emergency department of the local hospital. ECG was performed, resuscitation efforts were unsuccessful, and she died in the operating
showing ventricular fibrillation. The patient died few minutes after room. The male fetus survived and had no complications.
presentation. One week before, the young man complained thoracic pain At autopsy, she had an intact surgical site with no evidence of
and a 12 lead ECG was performed, showing ST segment reduction cardiac disease or pulmonary embolus related to deep venous
mimicking myocardial infarction. A complete postmortem examination thromboses. Microscopically, there were platelet and fibrin thrombi with
was performed few days after death, in both cases. External examination admixed neutrophils filling the small pulmonary vasculature. Thorough
was unremarkable. Internal examination showed mild cerebral edema sampling and special stains of the lungs failed to reveal squamous cells
and heavy lungs presenting white foam on the main bronchi, in both in the pulmonary vasculature, necessary for the diagnosis of amniotic
cases. Hearts were fixed in formalin. Cardiac sizes were normal, with fluid embolus. Examination of the placenta showed
conical shape. Macroscopic study (cut in cross-section 3 mm intervals) acute chorioamnionitis.
of coronary arteries were unremarkable, in both cases. Histological Even though the clinical features in this case pointed towards an
examination revealed polyvisceral stasis, mild cerebral edema; massive amniotic fluid embolus (i.e., sudden intrapartum bradycardia and
pulmonary edema was also detected. The pathological myocardial cardiopulmonary arrest), the diagnosis could not be made because
picture included multiple foci of contraction band necrosis; a few areas squamous cells were not identified in the pulmonary vasculature. A
of patch interstitial fibrosis were also detected. Cardiac microscopic review of the decedent’s medical records indicates that intraoperatively
study was completed by means of immunohistochemistry by means of her hemoglobin decreased from 9.0 to 5.2 to 4.5 gm/L. No source of
beta2 adrenergic receptor antibodies, showing expression on myocyte hemorrhage was identified at autopsy; therefore, the decrease in
membranes in both cases. Confocal laser 3D scans of myocytes was also hemoglobin and the pulmonary platelet and fibrin thrombi were likely
performed. No signs of cell death (apoptosis) was detected (TUNEL). related to disseminated intravascular coagulopathy (DIC). Instead of
Dosage of catecholamines and their metabolites on a blood and urine classifying the cause of death as “amniotic fluid embolism”, the cause of
samples was performed, showing high levels of catecholamines, death was classified as “intrapartum maternal demise with diffuse
metanephrine and vanillyl-mandelic acid. Toxicological examination pulmonary fibrin and platelet thrombi complicating Cesarean section for
was negative. Clinical data, autopsy findings, data collected from fetal distress, with acute chorioamnionitis.”
immunoistochemical and CLSM study of myocytes and laboratory The clinical and hemodynamic manifestations of amniotic fluid
analysis, led us to conclude that cardiogenic shock after intense embolism have been noted to be similar to those that are manifested in
emotional stress complicated by malignant arrhythmia (VF) in Tako- anaphylaxis and septic shock. The signs and symptoms include
tsubo cardiomyopathy was the main cause of death in both cases. hypotension, fetal distress, cardiopulmonary arrest, coagulopathy,
This research demonstrates typical histological signs of cyanosis, dyspnea, and seizures. The pathophysiological mechanism for
catecholamine toxicity (CBN) but further studies are still needed for the development of the amniotic fluid embolism begins with maternal
further in-depth knowledge of TTC and stress-related cardiac intravascular exposure to fetal elements, when there is a breach in the
physiopathology. In particular, structural alteration of the contractile and barrier between amniotic fluid and maternal circulation. This in turn
cytoskeletal proteins could be also be investigated. initiates an endogenous mediator response similar to an allergic reaction,
Tako Tsubo Cardiomyopathy, Emotional Stress-Related Death, with mast cell degranulation and activation of the complement pathway.
Cathecolamine Toxicity The diagnosis of amniotic fluid embolism has been traditionally
made by identifying squamous cells in the pulmonary vasculature;
however, fetal tissue or amniotic fluid components are not always found
in the women who present with the clinical signs and symptoms of
amniotic fluid embolism, as was the case in our autopsy. In light of the
apparent pathophysiological mechanisms involved and because
squamous cells may not always be identified in the pulmonary
vasculature, the term “anaphylactoid syndrome of pregnancy” has been
used to describe the syndrome of acute peripartum hypoxia,

hemodynamic collapse, and coagulopathy, which we believe this At autopsy a mass was found adjacent to the kidney but below the
case represents. adrenal gland 3.5 cm in diameter. Histology showed the characteristic
The postmortem diagnosis of amniotic fluid embolism can be appearance of a pheochromocytoma.
challenging to forensic pathologists. The gross findings are usually Pheochromocytomas secrete catecholamines which cause
nonspecific and can include pulmonary edema and atelectasis, evidence hypertension. They also modify glucose metabolism, which accounts for
of DIC, and pulmonary hyperinflation. Autopsy findings include fetal the hyperglycemia seen in the second case. Diagnosis depends on
squamous cells in the pulmonary vasculature and masses of neutrophils histology and the characteristic immunohistochemical appearance.
and fibrin thrombi in the small pulmonary vessels. Special stains such Malignancy cannot be reliably diagnosed by morphological features.
as cytokeratin and mucin may be helpful. The autopsy should include a These tumors may also be associated with genetic syndromes – such as
thorough sampling of the lungs, a proper evaluation of the uterine body multiple endocrine neoplasia (MEN) syndromes. Although traditionally
looking for the possibility of wall tears as well as examination of the known as the 10% tumor because 10 % are extraadenal and 10%
placenta. Thorough toxicology testing and a tryptase level are also malignant, a higher proportion of the cases, of the order of 25%, are
important procedures in the evaluation of intrapartum deaths when an malignant when associated with familial syndromes.
amniotic fluid embolism is suspected because the diagnosis is essentially In the two cases, their clinical presentations alone may have
one of exclusion, based on clinical presentation. resulted in their deaths being erroneously attributed to more common
Amniotic Fluid Embolism, Anaphylactoid Syndrome of Pregnancy, causes of sudden death, such as hypertensive or atherosclerotic
Intrapartum Death cardiovascular disease. An appreciation of the clinical and pathological
features of pheochromocytomas however properly diagnoses these
cases. As such, surviving relatives can be informed and screened.
G110 Pheochromocytoma Causing Unexpected Pheochromocytoma, Sudden Death, Adrenal
Death – Two Unusual Presentations
Jacqueline L. Parai, MD*, Ontario Forensic Pathology Services,
G111 Digital UV/IR Photography for Tattoo
Division of Anatomical Pathology, The Ottawa Hospital, 501 Smyth Evaluation in Mummified Remains
Road, Box 117 4th Floor, Ottawa, ON K1H 8L6, CANADA; and Iris Teo,
MD, Itrat Ahmed, MD, and Christopher M. Milroy, MD, The Ottawa William Oliver, MD, MPA*, and Leone Lisa, MA, Brody School of
Hospital, 501 Smyth Road, Box 117 4th Floor, Ottawa, ON K1H Medicine at East Carolina University, Department of Pathology and
8L6, CANADA Laboratory Medicine, Division of Forensic Pathology, 7S-10 Brody
Medical Sciences Building, Greenville, NC 27858
After attending this presentation, attendees will be able to
appreciate the postmortem pathology of pheochromocytomas and After attending this presentation, attendees will recognize an
sudden death. additional value of UV/IR imaging in the evaluation of
This presentation will impact the forensic science community by mummified remains.
presenting the medicolegal significance and varied clinical presentation This presentation will impact the forensic community by providing
of adrenal and extraadrenal pheochromocytomas including sudden an additional tool for postmortem identification.
death, their histological features and the possible genetic implications of The presence and location of tattoos can be an important component
their diagnosis. in the identification of remains in the extended postmortem period when
Pheochromocytomas are rare tumors of paraganglionic tissue. remnants of skin persist. However, when there is significant
Paraganglionic tissue is distributed throughout the body and tumors may mummification, elucidation of tattoos can be technically difficult due to
occur in multiple sites. Patients may present with severe headaches, skin discoloration and dehydration. Many methods have been proposed
nausea, excessive sweating, palpitations due to tachycardia and anxiety, to increase the visibility of tattoos in the extended postmortem interval,
tremors, pain in the lower chest and upper abdomen, and weight loss. including rehydration, hydrogen peroxide, and exposing subdural tissue.
These symptoms are due to the fact these tumors produce, store and All have some, but limited applicability.
secrete catecholamines (epinephrine, norepinephrine). Patients typically The use of ultraviolet and infrared photography has been of
have hypertension, which may be intermittent. Clinical diagnosis is significant interest in forensic science in general and of cyclical
made by urinary and plasma catecholamine measurement, along with published interest in forensic pathology and odontology. A large number
imaging. The tumors may present in the adrenal medulla and extra- of articles were published in the 1990s investigating the use of so-called
adrenal sites. They may rarely be associated with sudden death, and “alternate light” methods, including narrow band illumination,
catecholamine induced damage to the myocardium may be present, as fluorescence, and UV/IR photography for the evaluation of bite marks
the so called catecholamine cardiomyopathy. and trauma. There has been limited publication in the use of such
Two cases of sudden death due to pheochromcytomas are presented. methods for tattoo evaluation in the extended postmortem interval. One
Both patients were 34-year-old males. In the first case, the male study found utility in evaluating fluorescence of ink using narrow band
presented with abdominal pain. An ECG showed left bundle branch illumination. This study noted that infrared photographic evaluation,
block and changes of an inferior myocardial infarction. He was variably while slightly more useful than hydrogen peroxide, has traditionally been
hypertensive and hypotensive. He went into cardiac arrest while of limited utility because it “required photographic skills and was
undergoing radiological investigation. At autopsy there was a suprarenal difficult and time consuming.” Others have noted that the use of
mass measuring 8.5 x 7.5 x 4.5 cm, with 700 mL of blood in the ultraviolet photography was difficult because it is impossible to see what
peritoneal cavity along with retroperitoneal hemorrhage. On histology, is being photographed. With the use of film photography, the
the tumor had the characteristic appearance of a pheochromocytoma. opportunity for quick feedback and fine-tuning of photographic
There were typical Zellballen. The tumor cells stained positively with parameters was not available. The photographs were, literally,
neuroendocrine markers including chromogranin and synaptophysin. taken blind.
The supporting sustentacular cells showed some S100 positivity. In recent years, relatively inexpensive cameras sensitive to infrared
In the second case, the male had a witnessed collapse and died and ultraviolet light have been marketed for forensic use. Many low-cost
unexpectedly. He had been diagnosed as a non-insulin dependent consumer digital cameras are sensitive to the infrared or ultraviolet
diabetic five days previously. On the day of his death, he was described spectrum, and incorporate blocking filters for standard use. An
as well and his glucose level had been measured within the normal range. aftermarket has developed to market these cameras with the filters
removed. The availability of these relatively inexpensive cameras has back pain. A complete blood count was normal one month before his
spawned an active hobby market in artistic infrared and death. At scene, the police noticed multiple bruises of markedly different
ultraviolet photography. colors on the body. A forensic autopsy was requested by the Chief
In this report, a commercial forensic camera sensitive in the UV/IR Prosecutor because foul play was suspected. The external examination
range was used to visualize a tattoo that was not perceptible in the revealed multiple subcutaneous hemorrhages of different ages covering
visible spectrum. the whole body. The autopsy showed subarachnoid hemorrhage without
The nude body of an adult female was found prone unburied in the any skull fracture. There was no other significant finding. Toxicology
woods. A missing person’s report had been filed in a nearby city was negative. Histology revealed right-sided subarachnoid hemorrhage
approximately two months earlier and police investigators suspected and a cerebellar hematoma. As foul play was initially suspected, the
these were the missing person’s remains. At autopsy, the body was hyoid bone was removed. Histologic examination of the bone marrow
largely skeletonized, with mummification of the skin of the back and showed no normal hematopoietic cells. Myeloperoxidase staining
upper extremities. Anthropological evaluation was consistent with the revealed the diagnosis of acute promyelocytic leukemia (APL). Death
age, sex, and race of the missing person. Dental evaluation was was attributed to acute intracranial hemorrhage due to APL. The manner
consistent with the missing person, but was limited to do postmortem of death was ruled natural.
loss of teeth, which defied efforts at recovery. By history, the decedent Discussion: According to the literature, the most common tumors
was known to have a small tattoo of a heart on the back of her left hand, causing sudden unexpected death in adults include bronchogenic
though the exact location was uncertain. carcinoma, acute leukemia, gastric adenocarcinoma and adenocarcinoma
Examination of the left hand revealed marked mummification, but of the urinary bladder. Death is usually attributed to a variety of
the skin of the dorsal surface of the hand was intact. Visual examination mechanisms, including hemorrhage, thromboembolism and widespread
of the hand did not reveal any evidence of a tattoo. Attempts to increase dissemination. APL is characterized by the proliferation of abnormal
visualization by rehydration and washing were unsuccessful. Hydrogen promyelocytes and is classified as type M3 in the French-American-
peroxide was not applied. British (FAB) leukemia system. APL comprises approximately ten
Under both UV and IR photography, a small heart-shaped tattoo percent of the acute myeloblastic leukemias in adults. Because of the
was noted between the metacarpals of the thumb and index finger. The complicating disseminated intravascular coagulation and the likehood of
detail of the tattoo was visually similar in both spectra, though the UV threatening hemorrhage, APL is usually regarded as a medical
provided a more subjectively “realistic” appearance of the texture of emergency. This disease leads to a high rate of mortality, primarily from
the skin. intracranial hemorrhage. There could be a tendency to overlook the
This case demonstrates that at least with some inks, tattoos are diagnosis of this disease when a deceased presents multiple bruises that
clearly discernible using UV and IR photography. The almost immediate seem consistent with injuries. However, the French medicolegal system
feedback provided by digital photography allowed evaluation of each is different from the American system. In France, the decision to
image as taken to provide the optimum exposure. perform toxicology or histology after the autopsy is made the office of
The development of relatively inexpensive commercial digital the prosecutor and not by the pathologist. Due to financial
UV/IR cameras allows the immediate evaluation and optimization of considerations, it is quite frequent that no complimentary analyzes are
UV/IR photographs of postmortem tattoos. This, in turn, may make a made, even if the pathologist thinks it is necessary to determine the cause
previously rather esoteric method practical. of death. In our case, the circumstances of death and external
Ultraviolet, Infrared, Tattoo examination at the autopsy did not raise the diagnosis of a malignant
neoplasm in the hemopoeitic system. This type of case points out the
importance of a thorough autopsy, including microscopic examination to
G112 Undiagnosed, Untreated Acute protect innocent people from unwarranted prosecution. It is also
important to retain bone marrow to enable the testing to be done and to
Promyelocytic Leukemia Presenting as confirm the diagnosis if required.
Suspicious Sudden Death Forensic Pathology, Sudden Death, Acute Promyelocytic Leukemia
Pauline Saint-Martin, MD*, and Patrick O Byrne, MD, Service de

Medecine Legale, CHRU Tours, Tours, 37000, FRANCE; Jean Michel G113 Death of a Bodybuilder: A Case Report of
Gaulier, PhD, Service de Pharmacologie et Toxicologie, CHRU
Dupuytren, 2 avenue Martin Luther King, Limoges, 87042, FRANCE;
Mixed Drug Overdose With Lethal Gamma-
and Sophie Martin Dupont, MD, Agnès Peyclit, MD, and François Hydroxybutyrate Level
Paraf, PhD, Service de Medecine Legale, CHRU Dupuytren, 2 Avenue
Martin Luther King, LIMOGES, 87042, FRANCE Wendy M. Gunther, MD*, Office of the Chief Medical Examiner,
Tidewater District, 830 Southampton Avenue, Suite 100, Norfolk, VA
Leukemia as a cause of sudden death is rare, because symptoms are 23510-1046
usually present and treatment is initiated prior to death. After attending
this presentation, attendees can expect to learn about a rare differential After attending this presentation, attendees will learn an approach to
diagnosis of criminal death. evaluation of a multi-drug overdose primarily due to gamma-
This presentation will impact the forensic science community by hydroxybutyrate (GHB) with complex history and presentation; and, be
presenting a differential diagnosis of criminal death and reveals an aspect able to recognize the symptoms and signs of GHB poisoning when
of the French medicolegal system which can be unknown to the combined with lower levels of multiple other drugs. Consideration of
American audience and in competence as it enlightens the importance of the changes in drug levels possible with decomposition; and be able to
bone marrow removal during the autopsy. evaluate the role of confounding causes of death such as the possibility
Introduction: An autopsy case with acute promyelocytic leukemia of heat-related death in an enclosed car in a parking lot in the sun.
is reported in which foul play had been initially suspected. This presentation will impact the forensic science community by
Case Report: A 40-year-old male who was found dead in his assisting attendees to be able to recognize the signs and symptoms of
bedroom will be presented. He was working for the Brazilian Army and gamma-hydroxybutyrate use, abuse, and overdose, particularly when
was in France for a training period. He had a two-month history of lower exacerbated by the presence of multiple other drugs; compare to other

drug signs and symptoms when assessing a multi-drug overdose; and of fatal GHB overdose in a setting of multidrug use in a decedent who
evaluate the confounding effect of perimortem heat exposure with onset was otherwise probably healthier than the average person.
of decomposition. Gamma-Hydroxybutyrate, Perimortem Heat Exposure, Multi-Drug
A 29-year-old male bodybuilder with a history of utilizing gamma- Overdose
hydroxybutyrate (GHB or GBH) for its anabolic effect, was found dead
in the passenger seat of a car in an airport short-term parking lot, at 2:00
p.m. during the month of May. The windows of the car were closed. G114 Hara-Kiri or Homicide?
Although it had been slightly more than seven hours since he was last
seen alive, the decedent was in the early stages of decomposition. Wendy M. Gunther, MD*, Office of the Chief Medical Examiner,
The decedent had mentioned use of GHB to his employer as an Tidewater District, 830 Southampton Avenue, Suite 100, Norfolk, VA
event that occurred in the past. His father was also aware of his GHB 23510-1046
abuse, but believed it to have ended. In April, a drug screening had not
found any drugs in his system. He was known to have an intermittent After attending this presentation, attendees will be able to recognize
problem with alcohol abuse and had recently signed up for rehab. He factors from scene investigation, history, and autopsy which may help in
had sustained a significant fall not long before his death, for which he differentiating stab wound suicides from homicides.
was treated and released; he had multiple healing injuries. He was also This presentation will impact the forensic science community by
on regularly prescribed medications for a recent problem with sleep. reviewing an in-depth case presentation some of the factors that assist in
These medications included zolpidem, alprazolam, and mixed differentiation of stab wound suicide from homicide.
amphetamine salts. The body of a 49-year-old white male was found collapsed face
The week before his death, he hosted a friend from out of state, who down on the carpet of his bedroom during the afternoon of a Saturday in
was a physician. The night before death, which was also the last night April, about twenty hours after he had last been seen alive.
of his friend’s stay, the two of them went to a party which lasted for most The front door was secure, but the back door to the residence was
of the night. In the early morning hours, they had an argument. The unlocked and propped ajar. The decedent had been seen mowing his
victim called another friend asking for intervention; this friend noted that back yard on the evening prior to death, and all his mowing equipment
he seemed somewhat groggy on the phone. The other friend was not able was still out in the back yard. He was found clad in gray shorts without
to provide intervention. A neighbor saw the victim’s car depart in the shirt or shoes, appropriate for mowing. He was known to drink heavily
early morning with two men in it, but could not identify them through the when he mowed.
windows. It is possible that the friend who needed to go to the airport He was last seen alive by his girlfriend, with whom he had made
was driving the car, with the victim in the passenger’s seat, where he was arrangements to grill steaks on Saturday. She came to his house at the
found dead more than seven hours later. prearranged time, found the front door locked, knocked and called out
At autopsy, he was well developed and very muscular (5’8”, 236 for some time, but was unable to reach him; she did not think to check
lbs; BMI = 35.9). The BMI classification into “obese” is likely incorrect the back door. She left the scene, but continued to feel concern, and at
as the body fat percentage was probably low, based on body habitus. The last contacted police for a welfare check. Police found the body at
body showed evidence of early decomposition, with rigor passed, livor shortly after 1600h; emergency medical services pronounced him dead
fixed in a pattern consistent with his position slumped forward in his on the scene at 1643h.
seat, and extensive skin slip along the upper back. Small amounts of On initial examination, officers found a small fluctuant discolored
decomposition fluid in the body cavities were found on internal mass protruding from the left lower side of his abdomen, and guessed
examination, and tissues were moderately autolyzed on that it might be a tumor eroding through the skin. There was a small
histologic examination. amount of brown fluid on the carpet near the mass, but no blood. Based
The only autopsy findings besides decomposition were healing on this information and on history that the decedent carried the diagnosis
injuries of the face, hands, toes, heels, and left flank, which were of an unspecified aneurysm, while his twin had died prematurely at age
nonsignificant in death; and minor heart hypertrophy, which was thirty four of a myocardial infarct, the decedent’s doctor initially agreed
probably physiologic (exercise-related), as he was known to do extensive to sign the death certificate. It was not until a senior officer recognized
exercising, and there were no hypertensive changes to the myocardium the fluctuant mass as a loop of bowel protruding through a stab wound
on histology. Of note, the gastric mucosa was free of small hemorrhages. that patrol officers realized they should contact homicide detectives.
Toxicology provided the answer. There was present in his system The house was immaculate. The decedent was a martial artist, and
more than enough GHB to be lethal. There were also small amounts of the first floor of the house contained a room dedicated to multiple
four other drugs, amphetamine (likely due to Adderall), citalopram displays of numerous Eastern swords and daggers. As far as police could
(prescribed for depression), diphenhydramine (over-the-counter ascertain, no swords were missing. There was no obvious blood staining
antihistamine, sometimes used as a sleep aid), and trazodone (another or spatter, but there were too many swords in the room to ascertain on the
antidepressant). These four drugs likely contributed to death and likely day of death whether any had blood smears, or had been wiped.
contributed by making him sleepy, so that he did not exit the car nor There had been no 911 call nor was there any sign of a struggle. A
telephone to seek help. Amphetamine likely made him more vulnerable beagle dog in the house seemed to be in no distress, and had not been
to a cardiac arrhythmia in the setting of a lethal dose of GHB causing heard barking. Cash and expensive watches were in place where they
respiratory depression. Of note, no alcohol was present. The role of had been laid out with care equidistant and parallel on top of a dresser in
perimortem heat in accelerating his death could not be definitively the bedroom. The only item out of place was a box cutter, with a
determined by autopsy; this was a point of considerable significance to possible bloodstain on the blade, which was lying on the counter in the
the family, who were of the opinion that the physician friend was upstairs bathroom about eight feet from where the decedent was found
culpable for allowing the groggy victim to remain in the car with the collapsed. In the bedroom, about the same distance from him there was
windows rolled up when it was time for him to catch his plane. a tray table at the foot of the bed, on which was a tray with three sheathed
The time sequence of GHB intoxication, its effects in use, abuse, knives laid out carefully equidistant and parallel. Investigation showed
and overdose, and the likely mitigating or exacerbating effects of the wiped blood smear on one of the sheathed blades.
other drugs present, are considered in relation to the findings in this case

At autopsy, the decedent was muscular and slightly obese at 65” and swine-origin influenza virus, and known colloquially as “swine flu”) is
183 lbs. There were no defense injuries on his arms or hands. The now labeled a novel form of influenza. A virus resulting from a
fingernails were very cyanotic, but short and even, without chips or tears. combination of genes derived from two types of swine influenza, one of
There were scabbed healing superficial abrasions on the backs of the 2nd which was in turn a “reassortment “ of human, avian, and swine
and 3rd fingers, by the proximal interphalangeal joints. A number of influenza A strains.
linear scars were identified on the arms and hands. Scars on the backs The initial spike of cases started in La Gloria, Mexico, generally
of the hands appeared consistent with martial arts practice, but three regarded as the ground zero of this epidemic. The United States of
transverse superficial linear scars across the wrist suggested self- America soon after became the epicenter of this rapidly spreading
incision, and there were overlapping linear scars on the anterior left epidemic with a distinct pattern of disease incidence in relation to the
upper arm which also suggested self-cutting. A 3½” linear scar on the usually seasonal variety of Influenza. On June 11, 2009, the WHO
outer aspect of the left upper arm was initially attributed to an assault he proclaimed the H1NI infection as a global pandemic, based on its spread
told family he sustained many years prior. in several continents, especially in the southern hemisphere. Now in
The only sign of injury was a complex stab wound overlain by early November, North America has become the epicenter of the disease.
incised wounds in the left lower quadrant. The abdominal wall showed As of the of November 1, 2009, there have been more than 480 thousand
internal characteristics of perforation by more than one blade. The laboratory confirmed cases of pandemic influenza worldwide and over
wound, which was 1” long and about 6” deep, and therefore not six thousand deaths reported to the World Health Organization. The
consistent with the box cutter in the bathroom, perforated the abdominal week of October 25 to 31 saw spike of at least eighteen flu related
aorta and ended its course in the anterior ligament of the lumbar spine; it pediatric deaths, of which fifteen death were confirmed 2009 H1N1 and
caused death by internal bleeding. There was an extensive and bulging three were not sub-typed.
retroperitoneal hematoma, as well as 1400 cc of liquid blood and clots Described in htis presentation is the experience with cases
forming casts of the right and left colonic gutters. The blade passed very evaluated in two counties in Central New York. The clinical history,
close but without injury to the loop of bowel which eviscerated through hospital course and autopsy precautions and protocol followed, and
the stab wound. Evisceration had blocked the exit of blood through the diagnostic testing in cases seen by us are summarized in this Table # 1.
wound and was responsible for the lack of blood on the carpet at the Table # 1.
scene. Toxicology showed an ethanol level of 0.19% by weight by
volume in blood, 0.23% in vitreous humor. Of note, no aneurysm of the
cerebral, coronary, or aortic circulation was identified.
In the trash can in the bedroom was a letter to his girlfriend in his
handwriting. The letter was not a suicide note. It appeared to be an
angry letter of accusation. However, it had been crumpled and discarded
without signing.
The decedent’s complex history, involving decades of training in
martial arts, samurai stories and films, alcoholism, divorce, current plans
for remarriage, and the absence of support for his remote story of assault,
caused a scenario to develop suggesting that he had attempted to commit
hara-kiri as an honorable way out of an intolerable emotional situation.
The story unraveled at last when the family reported on reading years of
his journals, at which time a manner of death could be pronounced.
This complex history is presented in light of the autopsy findings and
scene investigation to illustrate why this case of attempted hara-kiri was
adjudged to be suicide rather than homicide.
Hara-Kiri, Stab Wound, Manner of Death
Besides the variation in risk factors, the H1NI infection itself has
raised many changes in business (loss of earning by the pig industry),
G115 Two Cases of Novel Influenza A (H1N1) changes in social mores, religious rituals and public behavior. It has also
raised questions, including how one defines epidemic and pandemic, and
Virus (“Swine Flu”) Infection: Clinical to what extent preventive strategies should be allowed to disrupt normal
Presentations, Autopsy Protocol With life and economic activity. In New York State the Public Health
Findings, and Review of Literature Department had promulgated laws mandating all health care workers to
receive the Seasonal and Novel Influenza vaccinations. Onondaga
Abraham T. Philip, MD*, Onondaga County Medical Examiner’s Office, County expanded the requirement to include all medical examiner
100 Elizabeth Blackwell Street, Syracuse, NY 13210; Kerry Whiting, BS, Personnel as well. These were later rescinded, and shortages of the
and Sanjay Mukhopadhyay, MD, State University of New York - Upstate vaccines became the dominant theme for conversation. Meanwhile there
Medical University, 766 Irving Avenue, Syracuse, NY 13210; and Robert are reports that the virus has mutated and developed resistance to
Stoppacher, MD, Onondaga County Medical Examiner’s Office, 100 commonly used anti retroviral medications.
Elizabeth Blackwell Street, Syracuse, NY 13210 This presentation will also review the most recent publications,
monitor and update the latest information about the spread of the
After attending this presentation attendees will be familiar about the infection as well as evaluate the public health response and lessons
origins, spread, autopsy procedures, and findings in seven cases of H1N1 learned from the epidemic/pandemic. The main focus of this
virus infection, that is currently designated a global pandemic. presentation will be to review the role of medical examiners/forensic
This presentation will impact the forensic science community by pathologists monitoring sentinel events which adversely influencing
organizing its preparation for a mass disaster situation involving a public health.
biological agent. The lessons learned from the way the nation and the Swine Flu, Bronchopneumonia, H1N1 Virus
world has responded will also be reviewed.
This novel infection, which has undergone a series of nomenclature
changes (including new influenza virus, swine-like influenza virus,

G116 An Unusual Case of “Piggyback” in 1987. Currently, there are a total of eleven reported cases in which the
fetus was abducted by a prenatal fetal snatcher between the years 1987
Sandwiched Projectiles Caused by a Round- and 2008.
Nose Bullet Shot Through a Door Materials and Methods: This case involves an 18-year-old
African-American female who was 38 weeks pregnant. The victim
Geoffrey P. Smith, MD, Kelly L. Rose, MD*, and Randy L. Hanzlick, MD, became acquainted with the abductor, a 38 year old African-American
Fulton County Medical Exam Center, 430 Pryor Street, Southwest, female, while visiting their respective male partners at the jail. On July
Atlanta, GA 30312 15, 2008, the women saw each other again at the jail and engaged in
conversation. The victim never returned to her home that evening. On
The goal of this presentation is to reinforce with an unusual the next day, the abductor presented to a local hospital claiming that she
example, the concept of intermediate targets and secondary projectiles as just gave birth in her apartment to a healthy baby boy.
they relate to gunshot injuries and in addition, to highlight the Results: The scene of the crime is a third floor apartment in
importance of correlating scene investigation with autopsy findings. Wilkinsburg, PA. There was a foul order coming from the apartment.
This presentation will impact the forensic science community by There were numerous flies around the windows. The decedent’s body
reinforcing the concept of secondary projectiles and highlighting the was located in an alcove off of the bedroom hidden by a mattress and
importance of correlating scene investigation with autopsy findings. head board. The body was that of a decomposing black female who was
The concept of an intermediate target and secondary projectiles wrapped in a comforter. Upon inspection, it was noted that the hands
causing bodily injuries has been well documented in relation to gunshot were bound behind the back with duct tape and the ankles were bound
wounds. An unusual case is presented in which a round-nose, copper together also with duct tape. The head was completely wrapped in duct
jacketed .40 caliber projectile perforated a foam-filled metal door and tape with a plastic bag and duct tape totally occluding the airway. There
carried two disc-like pieces of metal from the inner and outer lining of was an incised wound of the abdominal area with clearly exposed
the door to the victim’s body. Autopsy showed a distant type gunshot intestine and uterus. The placenta was clearly visible.
entry wound to the left front shoulder area and an adjacent superficial Further inspection of the apartment revealed a roll of duct tape with
laceration, as well as a second small laceration of the left flank. The a bloody fingerprint and a roll of plastic wrap. Loose pills were found
overlying clothing had corresponding defects from the bullet and on a shelf. All the above evidence was collected and submitted to the
fragments. On the adjacent skin and under the clothing, two metallic, forensic laboratory.
essentially circular, concave pieces of thin metal were found. A round- The autopsy revealed a well developed, well nourished African-
nose, copper jacketed .40 caliber bullet had perforated the spinal cord American female in a state of moderate decomposition. The body was
and was retrieved from the spine. The nose of the bullet was slightly identified via fingerprint comparison. The postmortem examination
flattened. The two disc-like pieces of metal were very close in diameter revealed a crude jagged edged incision of the lower pelvis and abdomen.
to the bullet’s diameter and fit nicely on top of each other on the flattened There was exposure of a gravid uterus with a vertical incision over its
nose of the bullet, having the same, slightly out-of-round shape as the anterior aspect. Loops of small intestine were exposed. A placenta was
underlying bullet nose. The fragments also had a similar thickness as the recovered from the comforter that covered the body. The distal edge of
metal surfaces on the door. Scene investigation and findings suggested the umbilical cord revealed a dog-eared cut surface. Inspection of the
that the man was shot through the door and the bullet carried the two cervix revealed that it was not dilated.
metal discs “piggyback” on its flattened nose toward the victim, then the There were no other pathologic abnormalities or trauma identified
fragments perforated the clothing causing the small lacerations. Wounds during the autopsy.
caused by materials from intermediate targets have been well described, Conclusions: The pills that were recovered from the scene were
but we have found no case reports of piggyback sandwiched fragments identified as Gabapentin. The decedent’s blood along with a sample of
carried on a round nose bullet such as we have described. By thoroughly the newborn baby’s urine was found to contain elevated levels of
analyzing the scene and the bullet, we were able to determine that the Gabapentin. The abductor’s fingerprints were recovered from the rolls
door fragments piggybacked on the bullet’s nose to the decedent. of duct tape and plastic wrap. Investigation revealed that the abductor
Therefore, this case highlights the importance of correlating scene recently had a miscarriage and had recently faked another pregnancy
investigation with autopsy findings and shows the benefit of maintaining going so far as to have a baby shower weeks before the abduction. The
persistence when trying to explain discovered peculiarities. cause of death was certified as asphyxiation due to smothering by plastic
Bullet Wounds, Intermediate Targets, Projectiles bag and duct tape with contributing conditions of exsanguination due to
partial evisceration of abdominal and pelvic contents and the presence of
Gabapentin in the victim’s blood.
G117 Newborn Kidnapping by Crude Pregnancy, Kidnapping, Cesarean Section
Cesarean Section
Todd M. Luckasevic, DO*, Laine L. Frazier, BS, Abdulrezak M. Shakir,
G118 An Unusual Case of Accidental Poisoning:
MD, Baiyang Xu, MD, and Karl E. Williams, MD, MPH, Allegheny Fatal Methadone Inhalation
County Medical Examiner’s Office, 1520 Penn Avenue, Pittsburgh,
PA 15222 Cristian Palmiere, MD*, Christophe Brunel, MD, Frank Sporkert, MD,
and Patrice Mangin, MD, PhD, Centre Universitaire, Romand de
The goal of this presentation is to illustrate an unusual case of fetal Medecine Legale, Rue du Bugnon 21, Lausanne, CH-1011,
abduction via crude cesarean section. SWITZERLAND
illustrating the need for close collaboration between the forensic After attending this presentation attendees will gain insight on a
pathologist and the forensic laboratory when dealing with cases that case of unusual accidental poisoning with methadone, occurring in a 38-
involve kidnapping, drugging and restraining. year-old man who inhaled a white powder bought on the black market.
Introduction: The number of missing children reported each year This presentation will impact the forensic science community by
in the United States remains astronomical. Between the years 1983 and presenting the dangers from using “home-made” drug preparations. To
2008, 256 infant abductions occurred in the United States. The first date and to our knowledge, no case of accidental death following
documented case of a newborn kidnapping by cesarean section occurred
methadone inhalation has been previously described up to the case G119 Fatalities Occurring With Ingestion
herein presented.
Methadone hydrochloride (3-heptanone, 6-(dimethylamino)-4, 4-
of Ibogaine
diphenyl-, hydrochloride) is a white, essentially odorless, bitter-tasting
crystalline powder. It is very soluble in water. James R. Gill, MD*, Office of Chief Medical Examiner, 520 First
It is a synthetic, long-lasting opioid with pharmacologic actions Avenue, New York, NY 10016; and Kenneth R. Alper, MD, New York
qualitatively similar to morphine and is active by oral and parenteral University School of Medicine, 403 East 34th street, 4th Floor EPC, New
routes of administration. It is primarily used for relief of moderate to York, NY 10016
severe pain. It is also used in the detoxification and maintenance of
patients who are dependent on opiates, particularly heroin. After attending this presentation, attendees will understand
Recreationally, it is abused for its sedative and analgesic effects. ibogaine, its uses, and issues that may arise with the investigation of
Methadone was synthesized by Ehrhart and Schaumann in these deaths.
Germany in 1941 in the Hoechst Laboratories and came into clinical use This presentation will impact the forensic pathology and toxicology
after the war. The use of methadone as a maintenance drug in heroin communities by increasing knowledge of ibogaine’s use, detection, and
addicts began only in 1964, when Dr Vincent Dole and Dr. Marie risk of death.
Nyswander pioneered the use of a particular form of synthetic opiate for The psychoactive indole alkaloid ibogaine is the focus of an
narcotic maintenance. alternative medical subculture in which it is used most often for opioid
It is primarily a µ-receptor agonist and may mimic endogenous detoxification, as well for individuals seeking psychotherapeutic insight
opioids and affect the release of other neurotransmitters (acetylcholine, or religious experience. Eighteen fatalities were reviewed that are
norepinephrine, substance P and dopamine). This accounts for its reported to have occurred since 1990 in individuals within seventy six
analgesic and antitussive properties, respiratory depression, sedation, hours of taking ibogaine. These deaths occurred in numerous countries
decrease in bowel motility, increase in biliary tone, hormone regulation and we reviewed all available autopsy, toxicologic, and
and increase of prolactin and growth hormone release, miotic pupils, investigative reports.
nausea, and hypotension. There were fourteen males and four females with a mean age of 39
As well as being an opioid receptor agonist, methadone acts as an years (range 24-54) years. Fourteen individuals took ibogaine for the
antagonist at the N-methyl-D-aspartate (NMDA) receptor. The NMDA indication of acute opioid withdrawal and 3 individuals were non-addicts
receptor system is a major excitatory central nervous system pathway who used it for spiritual/psychological reasons. The circumstances were
involved in the neurobiology of pain. Methadone’s ability to antagonize unknown in one decedent. Ibogaine was given as the HCl form in nine
the NMDA receptor system may explain its superior analgesic behavior instances at doses ranging from 4.5 to 29 mg/kg, and as an alkaloid
and why it can have effects in morphine resistant pain. extract in four. The concentrations determined in ten decedents ranged
Unlike other opiates, methadone is primarily administered orally from 0.24 to 6.6 mg/L. The time interval from the most recent ingestion
because of its good gastrointestinal absorption. It has high oral of ibogaine until death ranged from 1.5 to 76 hours. In addition,
bioavailability and minimally lower rectal bioavailability. It is commonly abused drugs (including benzodiazepines, cocaine, opiates,
commercially available in liquid form. Most pharmacies, however, and methadone) were detected in eight of eleven decedents. Seven of the
manufacture solutions, capsules or suppositories from less costly decedents had co-morbidities including: cirrhosis, hypertensive and
methadone powder. atherosclerotic cardiovascular disease, and obesity. Among the two
Methadone hydrochloride powder is for oral administration only decedents in which no other drugs of abuse were detected in postmortem
and is used in the preparation of a liquid by dissolving the powder in an toxicology analysis, one had advanced heart disease and another had
appropriate vehicle. This preparation must not be injected. cirrhosis of the liver. Full toxicology and autopsy results were not
The first fatality from methadone was recorded by Bieter and available in seven and three decedents, respectively. Among these 18
Hirsch (1948) in a 54-year-old man, who was given hypodermic decedents, the involved countries included the United States (5), Mexico
injections of methadone (50 mg) in three doses over eight hours and who (4), France (4), the Netherlands (2), Germany (1), the United Kingdom
developed cyanosis and hypotension. They also recorded severe (1), and South Africa (1).
respiration depression in a 15-year-old boy who was given, by mistake, The uncontrolled settings in which ibogaine is given make the
a 25 mg methadone hypodermic injection. causes of these deaths difficult to evaluate, and little is known regarding
After inhaling methadone powder, he developed a cardiopulmonary toxic concentrations of ibogaine in humans. Contributing causes of
arrest. Cardiac activity was restored only after prolonged resuscitative some of these deaths appear to have involved drug use during treatment
efforts. He was admitted to the local hospital and died after twenty-four and preexisting cardiovascular disease. There appeared to be no clinical
hours of intensive care due to cardiac arrest. or postmortem evidence suggestive of a characteristic syndrome of
An autopsy was performed at the University Center of Legal neurotoxicity. Cardiac monitoring may be a more important safety issue
Medicine in Lausanne. At external examination there were only signs of in view of published observations of bradycardia in animals and a recent
medical treatment. Internal examination showed congestion of internal case report of QT prolongation in an alcohol dependent woman
organs and cerebral and pulmonary edema. Histological examination following the ingestion of alkaloid extract, as well the common use of
showed moderate generalized congestion and hepatic steatosis. pretreatment EKGs and cardiac exclusion criteria, and in some medical
Toxicological tests included blood ethanol levels and screening for settings, implementation of cardiac monitoring during
common drugs and illegal substances by gas chromatography and mass ibogaine treatment.
spectrometry. This presentation will impact the forensic science Ibogaine, Intoxication, Substance Abuse
community by showing the dangers of using “home-made” drug
preparations. To date, case presentations of accidental death following
methadone inhalation have not been previously described.
Conclusion: The cause of death was determined to be methadone
intoxication, whose effects have been enhanced by the presence
of ethanol.
Substance Abuse, Methadone, Intoxication

G120 Acetaminophen Induced Death of a Fetus
With Maternal Survival: An Unusual Case
of a Suicide Attempt Resulting in
Fetal Death
Jeffrey K. Racette, MD*, Todd M. Luckasevic, DO, Baiyang Xu, MD,
Abdulrezak M. Shakir, MD, and Karl E. Williams, MD, MPH, Allegheny
County Medical Examiner’s Office, 1520 Penn Avenue, Pittsburgh,
PA 15222
After attending this presentation attendees will learn about an

unusual case of a suicide attempt with unexpected complications to an
unborn child.
This presentation will impact the forensic community by
illustrating the risks of acetaminophen overdose on fetal survival.
Introduction: Suicide represents one of the most common causes
of death in young women. Acetaminophen overdose represents one of
the most common methods used to attempt suicide. Suicide rates
among pregnant women are fortunately rare by comparison. However,
poisoning deaths, both suicidal and unintentional are rising.
Material and Methods: The subject of this case is a 32-year-old
caucasian woman who was pregnant with a healthy 35 week, 5 day
gestation fetus. The subject has a history of depression and is
prescribed Zoloft, although she was not compliant with her
medications. She has no prior suicide attempts or ideations. She had a
fight with her husband and exhibited increasing depressive symptoms.
She stated to her husband that she had taken ‘all her medicine’, but she
refused medical attention for approximately thirty six hours. Upon
admission to the hospital, she was found to be in liver failure. She was
treated with n-acetlycysteine. The next day, she started having uterine
contractions. She was not able to clot her blood due to acetaminophen
toxicity and liver failure, precluding a Cesarean section. Attempts to
delay the delivery were unsuccessful. The fetus became increasingly
bradycardic with labor progression and died shortly before spontaneous
vaginal delivery (approximately four and one half days after the initial
overdose event).
Results: The external and internal examination of the fetus was
consistent with a gestational age of 36 weeks. There were no gross
malformations, anomalies or evidence of external trauma to either the
fetus or to the placenta. Likewise, metabolic screening was negative
and postmortem tissue cultures were not helpful. Histologic sections of
the fetal tissue were unremarkable with no signs of placental
abnormalities or liver necrosis. Neuropathology of the brain revealed
findings consistent with fetal distress and hypoxia. Postmortem
toxicology on the fetal blood revealed an acetaminophen level of 8.55
mcg/ml.
Conclusion: The cause of death in the previously healthy fetus is
attributed directly to the high levels of maternal acetaminophen. In an
adult, an intake of 7000 mg or more is associated with death via liver
failure in the absence of treatment. The maternal intake in this case is
estimated to include 60 tablets of 500 mg each. Acetaminophen readily
crosses the placental barrier to alter the function of the immature fetal
liver which has only minimal abilities to safely metabolize the drug.
The fetus is thus placed at greater comparative risk by acetaminophen
than is the maternal source in cases of an acetaminophen overdose.
The mother ultimately survived, although she was placed on full
liver support for coagulopathy. She is currently on the liver
transplantation list. The fetus, despite survival to within minutes of
delivery, died in utero secondary to fetal distress complicated by
maternal acetaminophen toxicity.
Suicide, Acetaminophen Overdose, Fetal Complications

Denver ‘09 Denver ‘09
PATHOLOGY/BIOLOGY
G1 Exertional Collapse in a Youth With G2 Machinery-Related Occupational Death:

Hemoglobin SE The Relevance of Workplace Investigation
and Antemortem Radiological Data
Elise F. Arbefeville, MD*, and Vernard I. Adams, MD, Hillsborough
County Medical Examiner Department, 401 South Morgan Street,
in Forensic Reconstruction
Tampa, FL 33602
Giovanni Cecchetto, MD*, Via Falloppio 50, Padova, 35121, ITALY;
After attending this presentation, attendees will understand one of Guido Viel, MD, and Federica De Lotto, MD, University of Padua, Via
the potentially lethal sequelae of hemoglobinopathy SE. Falloppio 50, Padova, 35121, ITALY; Renzo Manara, MD, Istituto di
This presentation will impact the forensic community by helping Neuroradiologia, Padova, 35121, ITALY; Massimo Montisci, PhD, Via
forensic pathologists recognize occurrences of exertional death in Falloppio 50, Padova, 35121, ITALY; and Silvano Zancaner, MD, Sede
compound heterozygous SE hemoglobinopathy. di Medicina Legale - Università degli Studi di Padova, Via Falloppio 50,
Hemoglobin S is the most common abnormal hemoglobin. It Padova, 35121, ITALY
occurs in 10% of North Americans of West African descent.
Hemoglobin E is the second most frequent abnormal hemoglobin and is After attending this presentation, attendees will have a clear
found in persons of Southeast Asian ancestry. Because of the wide example of the utility of radiological data and workplace investigations
geographic separation of the original epicenters for these genotypes, the in reconstructing work-related deaths.
double heterozygous and manifesting as hemoglobinopathy SE is This presentation will impact the forensic community by
uncommon with less than 30 cases reported. Hemoglobinopathy SE is demonstrating the importance of taking into consideration radiological
typically asymptomatic. A twelve-year-old American boy was data (x-rays, computed tomography or nuclear magnetic resonance)
participating in football practice in the sun in summer when he collapsed obtained at hospital admission and of performing a detailed work-place
ill on the ground. When the paramedics arrived, he was alert, investigation when a work-related incident must be investigated.
hypotensive and in sinus tachycardia. His temperature was 97.3 degrees A “work-related death” is defined as “A person who was fatally
Fahrenheit. During transportation to the hospital his heart was unstable injured as a result of, or who died of a fatal condition caused by,
and several sternal rubs were performed. He initially responded to the exposure to their own or others’ activity or work factors; or who was
treatment but his heart rate dropped suddenly. He became unresponsive fatally injured whilst travelling to or from work.”
with pulseless electrical activity followed by asystole. Resuscitation In 2002, 1,478 Italian workers died from work-related injuries. In
efforts started by the paramedics and continued in the Emergency Room the same year 5,475 United States workers died due to traumatic injuries
were unsuccessful. On gross examination the spleen, lungs, brain, liver, related to their work.
and heart were unremarkable. Microscopically the cerebellum, heart, There are many potential contributing factors to any work-related
and kidney had sickled erythrocytes. Hemoglobin electrophoresis incidents, including aspects or characteristics of the working systems,
revealed 0.9% hemoglobin F, 57.4% hemoglobin S, 34.2% hemoglobin the equipment and material used, the environment, and the worker. For
E, and 7.5% other. Follow-up investigation determined that the these reasons it is very important to verify if any malfunctioning
decedent’s father was of West African ancestry and his mother had Thai equipments or any lack in safety measures have played a role in the
ancestry. This is an example of exertional collapse in a person with occupational injuries.
hemoglobinopathy SE with a clinical presentation similar to that In many cases reconstructing the event can be difficult because of
sometimes observed in persons with sickle cell trait. The the lack of detailed information about the circumstances of the incident
pathophysiology of sickling in persons heterozygous for hemoglobin S is and the design description of the machinery. Furthermore, the victim
discussed with particular reference to the mitigating and aggravating may not die at the workplace, but is admitted to the hospital and
effects of other abnormal hemoglobin haplotypes. undergoes neurosurgery. In such cases neurosurgeons, removing skull
Hemoglobinopathy SE, Exertional Collapse, Sudden Death fragments and generating new fracture lines, can complicate forensic
examination and sometimes prevent a clear identification of the etiology
of the lesions.
A case of a 40-year-old man who was involved in an injury while
performing his job in a manufacturing industry will be presented. The
victim, found unconscious by a colleague, was immediately transported
to the general hospital. In the emergency room he presented with severe
cranial trauma with bilateral skull fractures, a subarachnoid hemorrhage,
and multiple cortical and intraparenchymal contusions. Despite urgent
craniotomy and neurosurgical treatment the man died due to increased
intracranial pressure.
Forensic autopsy revealed:
● the laceration of the right ear;
● a curved surgical sutured incision at the left side of the head;
● a lack of part of the left parietal bone due to the craniectomy;
● a linear fracture of the right parietal bone;
● massive subarachnoid and fourth ventricular hemorrhage;
● hemorrhagic necrosis of the pons and medulla oblongata.
There were no witnesses watching the accident and the pictures of
the work place did not help the reconstruction. Moreover, the findings
collected at autopsy did not allow investigators to establish whether the “labor of preterm fetus.” At the clinical exam, the woman was in a very
skull had been struck by a blunt object or had hit the ground violently, bad general condition and not awake. She had widespread signs of
preventing a clear identification of the etiology of the cranial fractures. acupuncture, ecchymoses and bruises in the forearms, bruises and scrubs
To analyze the morphology of the fractures and their location a on both the thighs and the vulva. The fetus was in cephalic presentation
three-dimensional (3D) reconstruction (surface shaded display, SSD) and the membranes were broken and very bad smelling. The woman was
based on CT scans performed at admission to the emergency room was assisted during labor. However, the fetus, a male weighing 1,530g, was
employed. The analysis revealed a depressed skull fracture involving the terminal. Immediately after the labor, the woman exhibited cyanosis,
left sphenoid and temporal bones with penetration of bone fragments in marked hypocapnia, hypotension, and hypothermia. She was transferred
the left temporal lobe. to the intensive care unit where she arrived unconscious with tachypnea,
With the new information gained from the 3D-CT reconstruction of tachycardia, hypotension, metabolic acidosis, hyperkalemia, and
the skull, a second work-area investigation was performed. The fit- hypercreatinemia. Despite intubation, a sudden bradycardia arose
matching analysis between the components of the machinery and the evolving into asystole after about four hours. Resuscitation was
depressed skull fracture permitted to identify a metal parallelepiped as attempted but the patient died by electro-mechanical cardiac
the cause of the cranial staving and to reconstruct the event. dissociation. The external exam of the decedent showed extended
This case underlines the importance of taking into consideration bruises and abrasive injuries on the thighs and on the vulva, resulting in
radiological data (x-rays, computed tomography, or nuclear magnetic the hypothesis that the woman could have been a victim of violence. The
resonance) obtained during hospital admission and of performing a judicial authority, considering the clinical evolution of the patient and the
detailed work-place investigation when a work-related incident must be hypothesis of personal violence, ordered the autopsy of the woman and
investigated and reconstructed. fetus.
Machinery-Related Occupational Death, Forensic Radiology, Work- The autopsy and histological examinations revealed tricuspid valve
Place Investigation acute vegetating endocarditis by S. aureus, multiple septic pulmonary,
renal, encephalic, cardiac and cutaneous emboli, impetigo contagiosa
causing apparent cutaneous abrasions, ecchymoses, and consumption
coagulopathy. Similarly, the fetal autopsy showed that the cause of death
G3 Impetigo Contagiosa Simulating was a sepsis by S. aureus.
This case emphasizes the possibility of pitfalls in distinguishing
Non-Accidental Injuries in a Pregnant between pathological and traumatic injuries.
Woman Using Intravenous Drug Impetigo Contagiosa, Non-Accidental Injuries, Cutaneous Emboli
Fleres Pierangela*, Insitute of Legal Medicine, Via del Vespro, n. 127,

Palermo, 90100, ITALY; Farina Graziana, MD, Institute of Legal G4 HPLC Analysis of Benzocaine in
Medicine of Palermo, Via del Vespro, n. 129, Palermo, 90100, ITALY;
Antonina Argo, via Narbone n. 13, Palermo, , ITALY; Paola Pugnetti,
“Green Products”
Department of Biotechnology and Legal Medicine, Section of Legal
Medicine, Via del Vespro, n. 129, Palermo, 90127, ITALY; Paolo Harminder S. Bhawara, PhD*, fsl, S/O Shri A.S. Bhawara, Shanti Nagar,
Procaccianti, Palermo University, Via del Vespro, n. 127, Palermo, Near Ram Mandir, Raipur (C.G), INDIA
90100, ITALY; and Emiliano Maresi, Via del Vespro, n. 127, Palermo,
90100, ITALY After attending this presentation, attendees will understand some
principles of analyzing condoms that contains benzocaine as a
After attending this presentation, attendees will understand the desensitizer. Such a condom is commonly known as a “Benzocaine
possibility of pitfalls when distinguishing between pathological and condom.” Benzocaine is a compound that is prepared from 4-
traumatic injuries. aminobenzoic acid and ethanol. It is also the active ingredient in many
This case presentation will impact the forensic science community over-the-counter anesthetic ointments and is indicated for general use as
by emphasizing the possibility of these pitfalls when distinguishing a lubricant and topical anesthetic on intratracheal catheters, pharyngeal
between pathological and inflicted injuries. and nasal airways, sigmoidoscopes and vaginal specula.
This case confirms that for subjects using intravenous drugs, a A benzocaine condom is a completely unique condom in itself.
fulminating course of endocarditis by Staphylococcus aureus that These condoms have a small amount of benzocaine lubricant cream in
involves the left cardiac valves in association with systemic embolism of the tip. This cream helps to disperse the heat of the body. The main role
cutaneous vessels may cause dermal lesions simulating non-accidental of benzocaine is to desensitize the tip of the penis and prolongs the act
injuries. of lovemaking between couples. Benzocaine binds to sodium channel
Even though it is well known how the use of intravenous drug and reversibly stabilizes the neuronal membrane which decreases its
increases the risk of endocarditis, available data about the clinical permeability to sodium ions. Depolarization of the neuronal membrane
aspects related to the involved site and bacteriological characterization is inhibited thereby blocking the initiation and conduction of nerve
seem to be controversial. Staphylococcus aureus represents the most impulses, thus making the sexual encounter last longer.
frequently implicated microorganism (i.e., 76% of cases) that The condom is a widely used mechanical barrier contraceptive. It
significantly impacts the tricuspid valve. Different from the other is one of the oldest methods of birth control. They are available over the
etiologic forms, the endocarditis by S. aureus generally starts with counter as a non-prescription product and are procured very easily by
symptoms of sepsis and pulmonary embolism linked to a past use of sexual offenders. Sexual offenders often use condoms in the commission
intravenous drug which defines the so-called “diagnostic triad” of the of sexual assaults in order to prevent identification through deposited
tricuspid valve endocarditis. Cardiac insufficiency and neurological biological material. Even the detection of DNA is inhibited in cases of
signs are not usual symptoms. In endocarditis cases resulting from S. sexual assault involving condom use. In such circumstances trace
aureus, a fulminating course has been observed only if the left cardiac evidence, including condom lubricant residues viz. PEG, PDMS,
valves were involved, with systemic embolism and/or cardiac benzocaine, etc. provides the crucial associative evidence. The seminal
decompensation. The course is favorable in the remaining cases. fluid residue containing sperm, proteins, blood grouping factors, and
Case: A young woman, at the 32.2 week of amenorrhea was DNA helps in identification of sexual assault offenders. However,
assisted by first aid and admitted to the hospital with a diagnosis of perpetrators of sex crimes using condoms during the commission of
sexual assaults prevent identification through deposited biological
material. However, when assailants use condoms, they leave behind The father heard a crash, after which he entered the room and found the
other valuable evidence. child face-up on the floor with a 27-inch cathode ray tube-type television
Benzocaine, HPLC, Condom on the floor next to the child. EMS were summoned, the child was
transported to a local ED, and admitted to the ICU. An admission CT
scan demonstrated complex comminuted multifocal left-side skull base
G5 Child Deaths Due to Television Falls fractures, epi- and subdural hemorrhages, massive cerebral edema with
midline shift, and brainstem hemorrhage. Despite supportive measures,
With Injury Patterns That Mimic her neurologic condition rapidly declined, and a determination of brain
Child Abuse death was supported by clinical evaluation. She died two days after
hospital admission. Pertinent autopsy findings included bilateral bulbar
Evan Matshes, MD, c/o Dr. Amy Gruszecki, Southwestern Institute, of and palpebral conjunctival ecchymoses; left frontal scalp contusion;
Forensic Sciences, 5230 Medical Center Drive, Dallas, TX 75235; frontal and occipital subgaleal hemorrhages; large right epidural
Reade A. Quinton, MD, University of Texas Southwestern, Department of hematoma; cerebral edema with bilateral uncal herniation; fragmentation
Pathology, 5323 Harry Hines Boulevard, Dallas, TX 75390; and Amy C. of the cerebellar folia; multifocal cerebral and brainstem hemorrhages;
Gruszecki, DO, and Jeremy Deisch, MD*, Southwestern Institute, of left periorbital soft tissue hemorrhage; scant right perioptic nerve sheath
Forensic Sciences, 5230 Medical Center Drive, Dallas, TX hemorrhage; no retinal hemorrhages. The cause and manner of death
were certified as blunt force injuries to the head and accident,
After attending this presentation, attendees will have learned about respectively.
two cases illustrating the types of injuries sustained when televisions fall Child Abuse, Accident, Television
on small children and their similarity to inflicted child abuse trauma.
This presentation will impact the forensic community by explaining
how blunt trauma secondary to falling televisions is occasionally G6 Application of Forensic Engineering for the
reported in the clinical literature; however, descriptive reports of the
patterns of such injuries are limited and such cases may mimic those
Reconstruction of Manner of Death:
considered “typical” of inflicted trauma. A Nautical Accident
Data from the CDC indicate that accidents and inflicted trauma
account for 33 percent and 5-8 percent of childhood deaths, respectively. Daniele Gibelli, MD*, Istituto di Medicina Legale e delle Assicurazioni
Blunt trauma secondary to falling televisions is occasionally reported in di Milano, V. Mangiagalli, 37, Milan, ITALY; Angela Cantatore, BE, and
the clinical literature, however, descriptive reports of the patterns of such Remo Sala, BE, Politecnico di Milano, P.zza Leonardo da Vinci, Milan,
injuries at autopsy is limited. Data from the clinical literature indicate ITALY; and Salvatore Andreola, MD, and Cristina Cattaneo, PhD,
that under such circumstances, blunt head trauma is far more common Istituto di Medicina Legale e delle Assicurazioni di Milano, V.
than blunt chest or abdominal trauma. The severity and patterns of injury Mangiagalli, 37, Milan, ITALY
identified in such cases may mimic those considered ‘typical’ of inflicted
trauma. As such, careful integration of data collected from the death Attendees of this presentation will be presented with a case where
scene (including witness statements), from hospital records, and all the application of forensic engineering helped in reconstructing manner
components of the autopsy is necessary to ensure accurate and defensible of death and mode of lesion production in a nautical accident.
determination of cause and manner of death. Two cases will be This presentation will impact the forensic community by showing
presented to illustrate the types of injuries sustained when televisions fall how the application of forensic engineering to cases may result in
on small children. obtaining more precise data concerning the reconstruction of events.
Case #1: A 13-month-old male was at his aunt’s house, playing In forensic pathology it is sometimes necessary to reconstruct the
with other children. A family member heard a loud crash, after which he manner in which a victim fell or was hit, stabbed, or shot in order to
observed a 21-inch cathode ray tube-type television lying on the child’s verify the compatibility between the pattern of distribution of lesions and
head. Emergency Medical Services (EMS) was summoned, and the the dynamics of the lethal event. Reconstruction aids in acquiring
child was transported to the nearest Emergency Department (ED). After information which may help in determining homicide, accident, or
initial evaluation, he was admitted to the Intensive Care Unit (ICU). A suicide. More and more in these cases, forensic engineering assists the
computed tomography (CT) scan revealed left-side calvarial skull forensic pathologist. This case shows the importance of forensic
fractures, left orbital skull fracture with slight proptosis, laceration of the engineering in the reconstruction of events. The case concerns an
left transverse dural venous sinus, and expansile intracerebellar unmarried couple on a boating trip. One morning the man woke up to
hematoma, for which he underwent suboccipital craniotomy. Despite find his partner overboard in the water tied at the waist by a security
supportive measures, he expired 15 days after hospital admission. rope. He later reported that she must have fallen in the water during the
Pertinent autopsy findings included posterior scalp abrasions; night, when it had been her turn to steer and check on the boat. The
frontotemporoparietal and occipital scalp and subgaleal hemorrhages; woman underwent postmortem examination, which showed typical signs
simple linear, minimally displaced fractures of the left lateral aspect of of drowning, such as foam in the airways, overinflated lungs, and water
the frontal bone and orbital shelf; complex comminuted fractures of the in the stomach. Authorities initially classified the death as accidental.
left sphenoid and temporal bones; extensive comminuted fractures of the The woman’s family remained suspicious that the partner was
squamous portion of the occipital bone; subdural and subarachnoid responsible for the death since he had recently been made the sole
hemorrhages; cerebral edema; cerebellar sequelae of neurosurgical beneficiary of her will. Their accusations led to the exhumation of the
evacuation of intraparenchymal hematoma; bilateral optic nerve sheath corpse and a new autopsy was performed, which highlighted typical
hemorrhages; no retinal hemorrhages. Evaluation of 3-dimensional signs of blunt trauma, such as bruises distributed to the head, right
reconstructions of the admission head CT scan demonstrated that many thorax, right hand and shoulder, back, and linear abrasions on the
of the fractures identified at autopsy were altered (and thus appeared abdomen.
worse) by brain swelling, and sutural diastasis along a Mendosal suture. Microscopic analysis of the lungs showed signs of drowning, such
The cause and manner of death were certified as blunt head trauma and as oedema and expansion of the alveoli. Unfortunately no diatoms could
accident, respectively. be found (only fragmentary). The cause of death was identified as
Case #2: A 32-month-old female was at home with her father and mechanical asphyxia by drowning. Although the cutaneous signs of
four other children; she was unsupervised while watching television. blunt trauma observed during the postmortem examination could not

justify death by a traumatic cause, they could have been the signs of an and the other pair in a single bed in a separate bedroom covered by
aggression which may have caused the fall of the victim into the water. blankets. Placed above the bodies of the deceased children in each room
The main question was: could a simple fall from that boat explain the were religious pictures. An extensive search of the residence by police
pattern of lesions (anterior and posterior), or did they indicate an failed to locate the mother of the children. Autopsy and forensic
aggression? Initial experiments were performed with a dummy and a examination of the adult male who was identified as the father of the
boat of the same model. Different manners of precipitation in different children determined the cause of death to be asphyxiation and the
positions were then simulated, which provided the first general data manner of death suicide by means of hanging. Autopsy results for three
concerning the mechanisms of the fall. A more precise analysis was then of the children found death to have resulted from suffocation and the
conducted with computer-simulation software in order to obtain more fourth child to have died as the result of blunt force trauma. All four
reliable data concerning the physical characteristics of the boat and deaths of the children were determined to be homicides at the hands of
dummy model as well as the mutual interactions between the two. After their father. Initially it was thought that the reasoning behind the murder
recording every physical characteristic which may have had importance and suicide by the father was that he was despondent over his wife being
in the reference system and the virtual reconstruction of the environment, kidnapped, or possibly leaving him for another man.
different simulations of the fall were reconstructed. The position of skin As these seemingly senseless killings shocked the community,
lesions were considered as points of contact between the body and boat police were baffled as to the whereabouts of the missing mother. Various
during the fall. Three hypotheses of falling were then considered and speculations surfaced in the news media concerning the disappearance of
simulated. In the first case, the victim was facing the sea, in the second the mother. Some individuals suspected she abandoned her family and
she had the sea to her right, and in the third she had the sea behind her. ran off with another man, others claimed that she had been abducted by
In the first case, the simulation was concordant with all the lesions a Latino gang as retribution for not paying them for illegal assistance she
described but for the bruise on her back. In the second case the fall could may have received in entering the US. Reports had even been received
explain only the lesion on her right hand. The third type of fall explained from her sister who lived in the same community that she had returned
all lesions. to her native El Salvador. The case of the missing mother and the tragic
Results showed therefore that the pattern of lesions could be deaths of the father and children received so much media attention that
consistent with an accidental fall and may not have necessarily been the FBI was called in to assist in the investigation. Law enforcement
caused by an aggression. This experience strengthens the importance of officials were contacted in El Salvador who later reported possible
forensic engineering in the reconstruction of events. sightings of the mother in their country as well as bordering Honduras.
Forensic Pathology, Forensic Engineering, Nautical Accident The plausible leads and high profile nature of the case prompted the FBI
to send agents to El Salvador to investigate the sightings. Based on the
primary evidence gathered by law enforcement it was believed that the
G7 Homicide, Suicide, and the Missing Mother: mother had been kidnapped. An intensive national media blitz was
conducted to provide leads to police and the FBI in order to locate the
The Mysterious and Tragic Deaths of a mother.
Latino Family Human skeletal remains were discovered at a clandestine burial site
located in the same county in which the deceased family had resided
William C. Rodriguez III, PhD*, Armed Forces Medical Examiner, 1413 almost a year after the horrific discovery of the murdered children and
Research Boulevard, Building 102, Rockville, MD 20850; and Carroll their father’s suicide. The grave was located by a local real estate agent
Allen, Donna Vicente, and David R. Fowler, MD, Office of the Chief who was conducting a survey of a four acre parcel of land located along
Medical Examiner, 111 Penn Street, Baltimore, MD 21201 the edge of a major highway. While walking the property the real estate
agent discovered a skull and partial lower limbs exposed within the
After attending this presentation, attendees will have a better grave. Also discovered lying directly next to the grave was a snow
appreciation of the importance of joint investigation of complicated shovel and a large digging pick. The Office of the Chief Medical
cases involving skeletonized and decomposed remains by forensic Examiner was immediately called to the scene where the remains were
pathologists and anthropologists. In addition, the importance of proper carefully recovered.
recovery techniques at a burial site to insure complete recovery of all During the initial recovery of the remains anthropological analysis
skeletal remains and associated evidence will be discussed. Strong determined that the remains represented a Mongoloid / Hispanic female
emphasis will be placed on the importance of DNA maternal and who was in her early twenties at the time of death. Examination of the
fraternal posterior testing when known antemortem DNA comparative bones of the pelvis at the scene also determined that the deceased had
samples of a deceased parent are unavailable. given birth vaginally to multiple children as indicated by the presence of
This presentation will impact the forensic community by enforcing deep and extended parturitional pitting along the ventral surfaces of the
among forensic scientist to utilize a group approach when dealing with pubic bones of the inominates. Several jewelry items were located with
complicated homicides involving decomposed and skeletonized remains. the remains which included a gold religious symbol common to Central
Utilizing of individuals representing various forensic specialties can American coastal countries. Examination of the gravesite revealed it to
greatly increase the rate of success in an investigation. Use of be an incomplete burial, as the body was never fully covered possibly
anthropological skeletal markers such as parturitional pitting of the due to its close proximity and visibility from the highway, and the non-
pelvic bones can be very useful in possibly determining the status of a retrieval of the digging tools.
female as one who has given birth to children vs. a woman who has not Anthropological examination of the skeletal remains found them
given birth to a child. Such information can be extremely useful to law consistent with the biological profile for the missing mother. Due to the
enforcement when trying to identify a female victim. lack of antemortem dental or radiographic records, DNA analysis was
In late March of 2007 a gruesome discovery was made by police in conducted on the skeleton. Positive identification of the remains was
Frederick, MD as they entered a local residence. Discovered in the established by comparing the postmortem DNA profiles obtained from
house was the body of an adult Latino male who was suspended by a the children and the husband to that obtained from the bones of the
noose ligature along the stairwell leading up the upstairs level of the deceased in question. No skeletal injuries were noted on the remains
residence. A continued search of the residence led to the discovery of therefore cause of death was undetermined but manner signed out as
four children, ages one, three, four and nine. All four of the children homicide. Continued investigation of the case revealed that the woman
were found deceased and in an advanced state of decomposition. One and her husband had been having marital problems which arose from the
pair of the children was discovered in a single bed covered by blankets, wife seeing other men. As a result of the martial unrest it is believed that

the husband murdered his wife and buried her body along the interstate. G9 Spontaneous Coronary Artery Dissection –
Possibly despondent over his actions the father, knowing he would be
imprisoned and the deleterious affect it would have on his children, he
An Isolated Eosinophilic Vasculitis?:
chose to kill the children and then commit suicide. Report of Two Sudden Death Cases
Asphyxia, Buried Remains, Parturitional Pitting
Dario Sanabria, MD*, Puerto Rico Institute of Forensic Sciences,
Department of Pathology, PO Box 11878, Caparra Heights Station, San
G8 Sudden Death in Epilepsy: A Review of 51 Juan, 00922-1878; Carlos F. Chavez-Arias, MD, Puerto Rico Institute of
Forensic Sciences, PO Box 11878, Caparra Heights Station, San Juan,
Consecutive Cases 00922-1878; Lee M. Tormos, MD, Instituto de Ciencias Forenses, PO
Box 11878, Caparra Heights Station, San Juan, 00926; and Jose
Rudy J. Castellani, MD*, University of Maryland, Department of Rodriguez-Orengo, PhD, Puerto Rico Institute of Forensic Sciences, PO
Pathology, 22 South Greene Street Baltimore, MD 21201; Heather F. Box 11878, San Juan, 00922-1878
Grothous, BS, Michigan State University College of Osteopathic
Medicine, A306 East Fee Hall, East Lansing, MI 48824; Philip R. Croft, After attending this presentation, attendees will understand two
MD, 1215 East Michigan Avenue, Lansing, MI 48909-7980; Michael A. cases of spontaneous coronary artery dissection, recognize them as a
Markey, MD, Sparrow Forensic Services, Sparrow Hospital, 1215 East cause of sudden death, and discuss the role of an adequate gross
Michigan Ave, Lansing, MI 48909-7980; and Joyce L. de Jong, DO, recognition and histological examination with emphasis on the presence
Sparrow Forensic Pathology, 1215 East Michigan Avenue, Lansing, MI and significance of the eosinophilic inflammatory infiltrate that is
48909 frequently associated to this disorder.
This presentation will impact the forensic community by increasing
After attending this presentation, attendees will be able to list the the awareness of the existence of this rare natural disorder and
risk factors for sudden death in epilepsy, discuss pathophysiological demonstrating its pathological characteristics emphasizing in the gross
mechanisms for sudden death in epilepsy, and address the role recognition and histological presentation.
neuropathological examination in epilepsy cases. Spontaneous dissection of the coronary artery is a rare entity. It has
The presentation will impact the forensic community by providing an increased prevalence in women, especially in the peripartum state. It
a broader understanding of the role of seizures in sudden death as well as is defined as hemorrhagic separation of the media of the coronary artery
the role of detailed neuropathological examination in characterizing such with creation of a false lumen, in the absence of chest trauma, extension
cases. The presentation will also identify two additional subgroups of of aortic dissection or iatrogenic trauma.
epilepsy patients and provide attendees of an enhanced understanding of The first case involved a 55-year-old woman with no personal or
causes of death in epilepsy patients in general. family history of heart disease. History was also negative for systemic
Sudden unexpected death in epilepsy (SUDEP) is a well-known but disease, recent trauma, or drug abuse. She was last seen in her usual state
poorly understood phenomenon. While certain risk factors are of good health a few hours before her death. She was found
consistently associated with SUDEP, the pathophysiological mechanism unresponsive by family members at her apartment where she was
for sudden death remains speculative. Autopsy data from 51 consecutive pronounced dead after unsuccessful resuscitative measures.
cases with a history of “seizures” and who underwent complete autopsy, At autopsy the decedent was 167 cm tall and weighed 72 kg.
including toxicology and neuropathological examination were reviewed. Externally there were no signs of natural disease or trauma. The heart
A board-certified neuropathologist completed the neuropathological weighed 370 g without ventricular hypertrophy or gross ischemia. The
examination in 50 of the 51 cases. Of 51 cases, 24 (47%) met criteria for coronary arteries were free of atherosclerosis and had a normal
SUDEP (history of epilepsy, sudden unexpected death, no other cause of distribution. The left anterior descending coronary artery (LAD) had a
death, no status epilepticus). Of the cases meeting criteria for SUDEP, focal dissection within the media with a hematoma surrounding and
15 (63%) were male and nine (37%) were female, with a mean age of compressing the wall causing total occlusion of the lumen. The total
32.4. Fourteen were found in bed, none were found outside, and eight length of the dissection was 2 cm, and it started 3 cm from the origin of
were lying prone. Seven (29%) had evidence of tongue biting. Fourteen the LAD.
were treated with a single antiepileptic drug. Two were receiving The second case involved a 43-year-old woman whose medical
polytherapy. General autopsy revealed pulmonary edema in 17 (71 %) history was relevant for back pain, occasional episodes of tachycardia
cases. Twelve of 19 cases had childhood onset of epilepsy. and shortness of breath. She had no history of recent trauma or drug
Neuropathological examination revealed significant abnormalities in abuse. She was in her usual state of health when she complained of
67%. Among these were remote contusions, vascular malformations, increased back pain and shortness of breath. She was taken to the
hamartomas, mesial temporal sclerosis, and migration disturbances. Of emergency room by family members but was pronounced dead on
cases excluded from the SUDEP category, two groups were apparent: arrival. At autopsy the decedent was 165 cm tall and weighed 67 kg.
one with complex neurological disorders in children complicated by Externally there were no signs of natural disease or trauma. The heart
seizures (CND-S), and the second with atherosclerotic cardiovascular weighed 310 g without ventricular hypertrophy or gross ischemia. The
disease in older decedents complicated by seizures (ASCVD-S). No coronary arteries had a normal distribution with minimal atherosclerosis.
acute cause of death was apparent in a number of these cases, raising the The LAD showed a focal dissection within the media with a hematoma
possibility that seizures could have played a role. In conclusion: 1) cases compressing and occluding the lumen of the artery. The total length of
discussed indicate general SUDEP risk factors consistent with the the dissection was 1.5 cm at the distal third of the LAD.
published literature; 2) the percentage of cases with significant A common histological finding for both cases was a dense focal
neuropathological findings is higher than indicated in other studies, infiltration of the adventitia and the outer media of the dissected
emphasizing the need for detailed neuropathological examination coronary artery by inflammatory cells of predominantly eosinophilic
(formalin fixation and examination by a neuropathologist); and 3) two granulocytes with a few lymphocytes and mononuclear histiocytes.
additional subgroups, ASCVD-S and CND-S, are in need of further Polymorphonuclear granulocytes were infrequent. The inflammation did
study regarding the role of seizures in sudden death. not involve the inner media or intima. The non-dissected portions of the
Epilepsy, Sudden Death, Seizures LAD, the rest of the coronary arteries and the myocardium were free of
inflammatory infiltrates in both cases. No myocyte hypertrophy,
myocardial scarring, or small vessel disease was present.

Spontaneous Coronary Artery Dissection is a rare entity whose right pneumothorax. After the first day the patient refused hospital care
precise incidence, etiology and pathogenesis have not been clearly and discharged himself but a few hours later, he went to another hospital
established. Periadventitial and medial wall eosinophilic inflammation due to persistent pain. When he arrived was mildly dyspnoic and had
have been commonly observed, generating the hypothesis of an bilateral basal pleural effusion. During his second hospitalization, he
underlying localized inflammatory or vasculitic process that predisposes received antibiotics, anti-thromboembolic, anti-hypertensive, and
to this condition. This primary process could cause weakening of the gastroprotective therapies, and had progressive improvement of his
arterial wall and subsequent dissection. However it has also been clinical conditions. Six days after release, the patient suffered cardio-
proposed that such inflammation could be a consequence of dissection, respiratory arrest and was not responsive to rescue procedures. Autoptic
rather than its cause. histological finding were mainly in the lungs that showed conspicuous
These two cases illustrate that a detailed examination of not only the bilateral pulmonary hemorrhage associated with perimedial fibroplasia
affected coronary artery but also the rest of the vasculature and variant of FDM, with aneurismatic and dissecant patterns, in lack of
myocardial tissue is essential to identify and understand this process. In pulmonary embolism.
order to clarify the pathogenesis of this entity, it is necessary to perform Case 2: A 31-year-old female patient was scheduled for
future studies including cases of non-spontaneous dissection of the rhinoplasty. Presurgical hematochemical and cardiovascular
coronary artery. These cases are presented and discussed with a review examinations were normal and anesthesiological risk class was ASA1.
of the literature available to date. Twelve minutes after general anaesthesia induction and immediately
Spontaneous Coronary Artery Dissection, Sudden Death, after infiltration of nasal mucosa with mepivacaina and adrenalina, a
Eosinophilic Inflammation rapid decrease of both oxygen saturation and cardiac frequency occurred
until there was irreversible cardiocirculatory arrest, and no response to
rescue procedures. Autoptic histological finding were mainly in the
G10 Fibromuscular Dysplasia of Pulmonary lungs that showed vascular congestion and acute focally hemorrhagic
edema, associated with FDM, perimedial fibroplasia type. Chemical-
Arteries: Report of Two Cases toxicological analysis for research of Mepivacaina levels showed non-
toxic concentration.
Stefania Zerbo, MD*, and Rosa Liotta, MD, Institute of Legal Medicine, Conclusions: In both described cases death was referable to
Via del Vespro, 127, Palermo, 90100, ITALY; Antonina Argo, PhD, Via complications of FMD (aneurismatic dissection, arterial obstruction)
Narbone n.13, Palermo, ITALY; Cettina Sortino, Via del Vespro, 129, most likely triggered by chest trauma in the first case and by possible
Palermo, ITALY; Antonino Bonifacio, MD, Institute of Legal Medicine, cardiotoxicity due to association local/general anestesia.
Via del Vespro, n. 127, Palermo, 90100, ITALY; Eugenia Di Stefano, Via Fibromuscolar Dysplasia, Pulmonary Arteries, Histopathology
Raffaello n.9, Palermo, ITALY; and Emiliano Maresi, PhD, Via del
Vespro, 127, Palermo, 90100, ITALY
After attending this presentation, attendees will learn of a case

G11 Sudden Death From Arteritis Involving a
showing complications of fibromuscular dysplasia (FMD) (aneurismatic Surgically Repaired Coronary Artery -
dissection, arterial obstruction) most likely triggered by chest trauma and Right Atrium Fistula
by possible cardiotoxicity due to association local/general anesthesia.
FMD is a non-atherosclerotic and non-inflammatory vascular Marc A. Krouse, MD*, Tarrant County Medical Examiner, 200 Feliks
disease, with a familiarity of 10% (inheritance dominante autosomica), Gwozdz Place, Fort Worth, TX 76104-4919
and is characterized by fibrous or muscular or both types proliferation
subverting normal architecture of the arterial wall. Etiology of FMD is After attending this presentation, attendees will be informed of the
unknown although various hormonal and mechanical factors have been possibility of late complication of a repaired congenital coronary artery
suggested. Fibromuscular dysplasia generally affects women (94%) in anomaly by an independent pathologic process.
their fertile age; it is frequently associated with pregnancy or This presentation will impact the forensic science community by
hyperestrinism, but FMD can occur in any age, infancy included. revealing an unusual complication of surgically treated congenital
Clinical manifestations of FMD depend on involved arterial cardiac malformation, specifically coronary artery - right atrium fistula.
segment, histological type, and complications (obstructions, aneurysm After attending this presentation attendees will appreciate that an
rupture; embolism; sudden death). FMD commonly affects renal and anomalous coronary artery (coronary artery – right atrial fistula),
carotid arteries, and less frequently it’s observed in other small and successfully repaired many years prior, may be involved by
medium arteries; pulmonary localization is rare. Prevalence of independently occurring disease processes such as pan-arteritis and may
symptomatic renal FMD is about 4/1000 cases, twice as to that observed prove a cause of morbidity or mortality despite successful earlier
in carotid arteries. Histologically, FMD has been classified into three treatment.
distinct types: intimal fibroplasia; fibromuscular medial dysplasia The subject of this presentation was an 11-year-old male who had a
(medial hyperplasia, perimedial fibroplasia), and periarterial diagnosis of coronary artery – right atrium fistula some eight years prior.
(adventitial) fibroplasia. Angiographic classification includes The anomalous vessel was ligated at the distal (right atrium) end and he
multifocale type, related with histological variant “medial fibromuscular was followed, without complication, for a period of some two years. He
dysplasia”; tubular and focal types, both no related with specific was well and active until the day prior to his collapse and demise with
histological type. no complaints that could be related to cardiac disease. In early morning
In this study, two cases of unknown FDM involving pulmonary hours his family members responded to sounds of distress, he collapsed
arteries are described. Clinical manifestation occurred in one case and began dry vomiting before becoming unresponsive. Resuscitation
following a road accident related trauma and, in another case, following efforts, including ACLS protocol and emergency department treatment,
an anaesthetic induction and local anesthesia before surgical procedure. were unsuccessful and he was declared dead less than two hours after
Case 1: A 52-year-old obese man while driving a car got into an onset. His history of previous surgery was initially reported (incorrectly)
accident and suffered severe multiple trauma. He was taken to the as repair of an abnormal right coronary artery.
Emergency Room where he presented coherent and breathing (SpO2 At necropsy examination the body was normally developed. There
92%), with SBP/DBP 150/90 and CF 92b/m. were diffuse pericardial adhesions over the anterior and left side of the
Chest x-ray showed several rib fractures on the right side, heart. Serial sectioning of the left coronary artery circulation revealed a
associated with bilateral hydrothorax, upper pneumomediastinum; mild
slightly large (4-5 mm) left main coronary artery with a similar size to a blotchy red-purple area of drying skin, though some faint spots
anomalous branch passing posterior to the aortic root between the atria. remained. When intact epidermis along the edges of denuded skin was
In this area the vessel was markedly dilated (up to 2 cm) and filled with wiped away at this time, a new crop of petechial-like spots emerged.
layered, clotted blood. The firmer clot had propagated retrograde and Two hours later, the second set of spots had faded similar to the first.
gelatinous, acute clot was found throughout the proximal part of the Wiping away more epidermis made a third round of spots apparent. A
anomalous artery, into and occluding the left main coronary artery. The histologic section of skin showed congested dermal blood vessels,
left coronary artery ostium was also large, some 1 cm. Microscopic particularly adjacent to hair follicles.
sections of the coronary arteries and coronary artery fistula were notable Conjunctival and facial petechiae are thought to be due to increased
for active pan-arteritis and healed arteritis in the dilated area of the fistula cephalic venous pressure resulting in rupture of small blood vessels and
as well as layered blood clot without notable organization. There was no extravasation of blood; morphologically similar “Tardieu Spots” are
gross or microscopic evidence of ischemic myocardial injury. formed in areas of livor mortis when engorged blood vessels in
The gross appearance of the artery fistula was reminiscent of dependent portions of the body rupture (Ely and Hirsch, 1999). A
Kawasaki disease and the pan-arteritis points to a similar pathogenesis of literature review found only a single reference to petechiae in a fire
the vascular injury, aneurismal dilation and eventual thrombosis of the victim (Rao and Wetli, 1988). The petechial-like spots in the present
injured vessel. His recent medical history included only an episode of case are not related to lividity since they were equally prominent along
acute sinusitis with a four day course of an unknown prescribed the anterior and posterior surfaces of the body. The fading of the spots
medication, but in interviews with family a previous episode of a viral demonstrates that they are due to a congestive process and not
illness some four months prior was elicited. vasculature rupture; a finding confirmed by histologic examination. It is
This case study is presented to inform forensic and/or pediatric possible that rubbing the skin created physical traction that drew blood
pathologists of the possibility of a late complication of a successfully into the vasculature further accentuating the pattern. Blood flow out of
repaired anomalous coronary artery, presumably by an immune- intact vessels into surrounding tissues caused the spots to fade.
mediated vascular injury indistinguishable from typical Kawasaki This case demonstrates that inhalation of soot and smoke in a house
disease. fire can be associated with congestion of peri-follicular and adnexal
Coronary Artery Fistula, Arteritis, Sudden Death blood vessels resulting in a subtle petechial-like rash that will be
accentuated by wiping away of the epidermis. Furthermore, rupture of
capillaries and venules with extravasation of blood is not necessary for
G12 Ephemeral Petechial-Like Spots in a Victim the formation of petechial-like spots.
Fire, Petechiae, Autopsy
of a House Fire
Russell T. Alexander, MD*, and David R. Fowler, MD, Office of the Chief
G13 Forensic Identification of Microbial
Mixtures Via ESI-TOF Mass Spectrometry
After attending this presentation, attendees will be familiar with a
case of short-lived petechial-like spots on a woman who died due to Joshua K. Stone, BS*, and Raleigh W. Parrott, MS, Federal Bureau of
inhalation of soot and smoke in a house fire. Investigation, CFSRU, 2501 Investigation Parkway, Quantico, VA
This presentation will impact the forensic community by discussing 22135; Jason D. Bannan, PhD, and Bruce Budowle, PhD, Federal
the occurrence of transient petechial-like spots in fire related deaths. Bureau of Investigation Laboratory, 2501 Investigation Parkway,
A 33-year-old black female was found deceased within her Quantico, VA; and James M. Robertson, PhD, and Brian A. Eckenrode,
apartment after a house fire. Per report, she had been drinking alcohol PhD, Federal Bureau of Investigation, CFSRU, Federal Bureau of
that evening with a girlfriend. At approximately 3:25 a.m., her daughter Investigation Academy, Building 12, Quantico, VA 22135
heard the fire detector within their apartment go off. She opened her
bedroom door, saw thick black smoke, and then exited the apartment After attending this presentation, attendees will learn the basics of
through her bedroom window. The fire department responded and was ESI MS, the basic problems with current identification methods of
informed by the daughter that no one else was in the apartment because unknown microbes, and how ESI-TOF can correctly identify microbes
she thought her mother was still out drinking. The fire department based on DNA base composition.
extinguished a “small” fire in a loveseat located on the east end of the This presentation will impact the forensic community by explaining
living room. Extensive soot was deposited throughout the residence a novel method of identifying unknown microbes in a complex sample.
except for the daughter’s bedroom. The decedent was found “hiding” The growing threat of bioterror events is a significant problem for
behind a chair in the northwest corner of the living room. Her keys were the security of individuals worldwide. When an unknown biological
found underneath the burned loveseat. An ashtray with four cigarette agent is released, identification can be delayed due to complexity and
butts was on an end table within the living room. An investigation of the number of samples required. Whole genome sequencing (WGS) is a
fire revealed no evidence of foul play. possible solution; however this can be costly for complex mixtures.
At autopsy, soot was densely deposited on the face, within the nares Targeted methodologies search for specific bacterial agents and can be
and on the tongue. Less dense soot was deposited over much of the limited by the requirement to determine if the agent of interest is present
body. Partial thickness burns involved approximately a third of the body within the sample. An alternative to WGS and targeted methodologies
surface area. Internally, dense soot was deposited in the airways. No was developed by Ibis BioSciences using mass spectrometry (MS). This
thermal fixation was noted to the airways. The level of new MS-based method allows an analyst to determine initially which
carboxyhemoglobin in iliac blood was 62.2%. The iliac blood alcohol species are present in the sample, rather than asking if a certain species
content was 0.14 mg/dl. No other drugs were detected on a of bacteria is present. Further delineation is then possible by fine-tuning
comprehensive drug screen. the assay. The DNA base composition can be determined by mass
Washing of the body revealed a petechial-like rash on the eyelids, measurements using high resolution MS, which can detect differences in
face, shoulders, and back in areas where the epidermis was wiped away DNA and allow strains of bacteria to be identified. A primary goal of this
during cleaning. The spots appeared to have a follicular or peri-adnexal research is to determine the level of strain delineation possible amidst
distribution. A similar though quite subtle pattern of spots was on other strains of a select microbe using this MS-based method.
adjacent areas where the epidermis was intact. Reexamination of the Broadly conserved genes in bacteria were selected for amplification
body two hours later revealed that the petechial-like rash had often faded with specifically designed forward and reverse primers to Bacillus
subtilis. Genomic DNA was extracted from B. subtilis and amplified ● The evaluation of the time since death and of the time since
using PCR. These selected amplicons were analyzed via Electrospray dismemberment. Indeed, exsanguinations and
Ionization Time of Flight (ESI-TOF) MS. Using an integrated fluidics dismemberment of the body prevent an accurate evaluation of
system, DNA samples could be introduced to the ESI source at a high lividities and rigidity.
flow rate but then electrosprayed at a slower flow rate to improve ● The identification of the tools used to cut the body. Careful,
resolution. After deconvoluting the information from the mass thorough investigation is a key point to ensure that potential
spectrometer, the organism can be identified by comparison to a library physical evidence is not tainted or destroyed. In particular it is
using abundance estimation, joint maximum likelihood, and base essential to identify any potential sharp cutting weapons at the
composition analysis. The molecular weights from multiple strands, crime scene. Moreover, when saws are used to cut the body,
when combined, provide a unique molecular fingerprint which allows an characteristic tool marks are left on the bone. The nature of the
organism to be identified down to the species and strain-level. marks depends on the size, shape, width of the saw, and on the
A binary set of strains from B. subtilis were mixed at various sawing action of the user.
concentration levels to evaluate this MS-based approach in terms of Environmental Scanning Electron Microscopy (ESEM) may help in
speed and accuracy. An internal mass standard sequence of DNA was identifying the specific saw that has been used in the act of
used to allow the concentrations of microbial DNA to be calculated after dismemberment. ESEM can detect and measure different types of
amplification. When using single-stranded oligonucleotides, more than striations, paint traces (such as rust inhibitor paints) or metal residues
1200 base compositions could be reported. However, using the remaining on the bone after the cutting.
complement strand at low concentrations has shown to reduce In the case presented, the determination of potassium levels in the
complexity and error in the data, improving the accuracy of the result. vitreous humour and their time changes showed that the victim had been
An expansion and variation of the number of bacterial species and killed 20 – 25 hours before the death scene investigation.
strains tested will occur as time permits for this presentation. As a The absence of lividities combined to histological and
bioterror event could result in thousands of organisms present in a immunohistochemical investigation of the skin let investigators classify
sample, there will continue to be a need for methods which can select the the dismembering injuries as non-vital wounds and to estimate the time
correct organism, especially in the case of a novel strain for forensic interval between the death and the dismembering.
studies. However, the most interesting finding was the identification of the
ESI-TOF, Unknown Microbes, Base Composition tools used to cut the soft tissues and the bones of the victim.
Morphological and morphometrical analysis of the skin lesions pointed
out that the arms and the legs were cut with a sharp knife, whereas the
G14 Environmental Scanning Electron head was removed from the trunk by a woodworker saw. ESEM analysis
determined that the bone injuries were produced by a particular type of
Microscopy and Other Techniques in saw covered by rust-inhibitor paint.
Cutting Crime Investigation: Case Report Cutting Crime, ESEM, Dismembering
and Review of the Literature
Paolo Fais, MD*,and Giovanni Cecchetto, MD, Via Falloppio 50, G15 Exploration of Non-Cardiogenic
Padova, ITALY; Guido Viel, MD, University of Padua, Via Falloppio 50, Pulmonary Edema With Chronic Opiate
PADOVA, 0 35121, ITALY; Attilio Cecchetto, PhD, Istituto Anatomia
Patologica, Via Gabelli 61, Padova, 35121, ITALY; Claudio Furlan,
Use: Case Studies and Scientific Review
MD, Via Falloppio, Padova, ITALY; and Massimo Montisci, PhD, Via
Falloppio 50, Padova, ITALY Marrah E. Lachowicz, MFS*, University of California Davis, One
Shields Avenue, UCDSOM, Tupper Hall 4112, Davis, CA 95616-8643
After attending this presentation, attendees will understand some
principles of investigation of a dismembered body concerning the cause After attending this presentation, attendees will learn how to
of death and the identification of the tools used to separate arms and legs characterize non-cardiogenic pulmonary edema during autopsy caused
from the trunk. by opiate use. Additionally, attendees will learn about alternative opiate
This presentation will impact the forensic community by suggesting sources which may lead to cases of non-cardiogenic pulmonary edema.
a novel approach for the analysis of cutting crimes in general and Such cases may present during autopsy and potentially lead to
dismembering in particular. classification of a secondary cause of death or change in the
Herein investigators present the case of a 40-year-old female killed classification of manner of death.
by throat cutting and consequently dismembered. She was found cut into This presentation will impact the forensic community by providing
30 pieces inside three plastic bags in a garage. potential answers to cases in which underlying chronic opiate use
Dismemberment is the act of cutting, tearing, pulling, wrenching, or potentiates mortality. Chronic opiate use may synergistically lead to
otherwise removing the limbs from the trunk of a living or deceased fatal pathology not readily recognized when secondary to diseased states
object. It may be practiced upon human beings as a form of capital in the lung. The presentation focuses on the reliability of diagnosing
punishment, a result of a traumatic accident, or in connection with cause and manner of death during autopsy with the goal of increasing the
murder, suicide, or cannibalism. After killing the victim, the murderer validity of techniques, processes, and methods used in forensic medicine.
uses a very sharp cutting weapon (a saw, knife, axe, etc.) to sever the Use of opiate variants, including pain management medications
limbs and cut the body into pieces. The operation is generally carried out such as morphine and street drugs such as heroin, have all been
immediately after the crime, although more rarely a long time may pass implicated in causing acute respiratory distress marked by non-
between the two events. There are two types of dismemberment that are cardiogenic pulmonary edema (NCPE). Despite efforts to treat patients
commonly seen: localized, such as the removal of the head or hands in who develop NCPE through chronic use or acute over-dose; presentation
an attempt to hinder identification of the victim, or generalized at of NCPE stills has a mortality rate of 30-50%. With significant mortality
multiple sites (commonly bisection of limbs or disarticulation of the and the rise in cases, development of NCPE is increasingly significant to
joints) to aid in the disposal of the body. In these cases a new pattern of the forensic community. The molecular and cellular mechanisms by
investigation must support classical techniques to solve the following which opiates induce non-cardiogenic pulmonary edema (NCPE) remain
forensic issues: elusive. NCPE is a clinical hallmark of opiate use in long-term drug

users as well as patients treated with narcotics for chronic pain. Sporadic the cause of death appears to be readily apparent from the medical
cases of NCPE were recently reported with use of other medications: records and/ or circumstances of death and toxicology is not performed.
primarily drugs used to treat other forms of edema, regulate blood A retrospective review of all external examinations performed at the
volume, or blood pressure. Bexar County Medical Examiner’s Office during a five year period
Although the pathogenesis of NCPE is largely unknown it thought (2003 - 2007) was undertaken comparing cases in which: toxicology was
to be dose related—thus maybe a presentation of an abhorrent not performed; toxicology was performed but did not alter the cause and
cardiorespiratory response. Acute or chronic opiate use causes acute manner of death; and toxicology was performed and altered the cause
respiratory distress syndrome (ARDS) marked with pulmonary capillary and manner of death.
leak and exudation leading to NCPE. Data shows us of opiates, It was found that in cases where toxicology was performed, the
primarily heroin, is the primary cause of NCPE in patients under 40. As toxicology results altered the cause and/ or manner of death in an average
many as 50% of these patients are clinically defined as an overdose with of 1.8% of cases. If toxicology had been routinely ordered on all
as much as 20% of these cases will be fatal. Previous animal models and external examinations at the BCMEO, it would have theoretically altered
marginal human studies identified three active opioid receptors (δμκ) approximately 21 additional cases during the five- year period.
varying in distribution throughout the respiratory tract. The lung is a Toxicology, External Examination, Cause and Manner of Death
very complicated microenvironment. Several hypotheses regarding the
pathogenesis of NCPE indicate involvement of various cell and tissue
types throughout the respiratory tract. Local changes may cause G17 TASER® Wound Progression in Two
alterations to the alveolar epithelium direct or have effects on the
pulmonary capillary bed resulting in NCPE. The lung parenchyma co-
Deployment Modes
exists with the alveolar terminal air space where gas exchange occurs.
Studies indicate there are two distinct H3-morphine binding sites—with Donald M. Dawes, MD*, Lompoc Valley Medical Center, 518 East
the most abundant binding localized within alveolar walls. Therefore, Hickory Avenue, Lompoc, CA 93436; and Jeffrey D. Ho, MD, Hennepin
this is the site implicated as responsible for fluid clearance in the lungs. County Medical Center, 701 Park Avenue South, Department of
The exact mechanism by which activation of opiate receptors in this Emergency Medicine, Minneapolis, MN 55415
region leads to fluid influx is largely unknown. It is possible alveolar
tissue plays a role in the release of soluble mediators or recruitment of After attending this presentation, attendees will have a better
inflammatory cells leading to a cascade of events contributing to the understanding of the wounds created by the TASER® X26 device.
pathogenesis of NCPE. Dysregulation of solute and fluid clearance by This presentation will impact the forensic community by assisting
the alveolar epithelium itself may be altered by opiate receptor in the identification of characteristic wound patterns created by the
activation. Finally, long-term or acute aactivation of opiate receptors TASER® X26, the most commonly used conducted electrical weapon.
with may lead to significant alterations in the epithelial surface that are Introduction: Conducted electrical weapons are used by law
the basis local changes conducive to the onset of NCPE. enforcement to control violently resistive subjects. The TASER® X26 is
With underlying disease in the lungs or other chronic conditions the most commonly used conducted electrical weapon. It can be used in
which require use of opiates, these changes may not be easily the probe-deployment mode in which probes are fired from the device at
recognizable during autopsy. The goal of this poster is to demonstrate the subject, or it can be used in the drive-stun deployment mode in which
how opiate toxicology may induce local effects in the respiratory tract the device is physically touched to the subject. The two deployment
which ultimately results in direct changes to the pulmonary alveolar strategies can create different signature wound marks. To date, there is
epithelium contributing to underlying disease. Secondary pathology no study that has attempted to catalogue and describe these marks.
may contribute to cause and manner of death in forensic cases. Methods: Subjects were recruited from police training classes for
Understanding how opiates contribute to altered pathology will enhance the study. The subjects were to receive an exposure from a TASER X26
the methods by which forensic pathologists diagnose NCPE postmortem. as part of their training class. Subjects were allowed to choose between
Autopsy, Forensic Pathology, Pulmonary Toxicology the two deployment modes depending on the rules of their class.
Subjects completed a screening questionnaire that included the
Fitzpatrick scale. The exposures were five seconds or less. Subjects had
photographs of the wounds taken after the exposure immediately, and at
G16 Is Toxicological Analysis Necessary in 24, 48, and 72 hours, as well as at one month.
Postmortem External Examinations? Results: The two deployment strategies left differing marks. The
probe deployment mode generally created circular superficial partial
D. Kimberley Molina, MD*, Bexar County, Medical Examiner’s Office, thickness burns. The drive-stun mode created variable marks depending
7337 Louis Pasteur Drive, San Antonio, TX 78229; and Meredith A. on the movement of the subject which included irregular superficial
Lann, MD*, UCDHSC, AIP - Department of Pathology, 12605 East 16th partial thickness burns that may be paired at about 40 mm (the distance
Avenue, Room 3026, Aurora, CO 80045 between the metal contact points on the device), but not necessarily so.
This mode also created abrasions and contusions. Some subjects had
After attending the presentation, the attendee will understand the persistent hyperpigmented marks at one month.
decision process of performing an external examination versus a Conclusions: The two probe deployment modes left different
complete or partial autopsy in medicolegal cases and the potential marks. It may be important for forensic examiners to be able to
ramifications of not ordering a full toxicologic panel on cases where a distinguish these marks from other minor skin trauma. Studies such as
postmortem external examination was performed. these will help in this.
The presentation will impact the forensic community by serving as TASER®, Wound, Burns
a critical part in the decision making process of medical examiners in
deciding how to analyze medicolegal cases and will serve to augment the
literature used to establish the standard of practice for the performance
of external examinations.
In many jurisdictions, external examinations are performed rather
than complete autopsy examinations in certain types of medicolegal
cases. Deaths in elderly patients or deaths after a fall are just a couple
examples which may be included in such cases. In many of these cases,
G18 Rat Bite Fever: A Fatal Case of identification is essential to proper diagnosis. This paper shows the
importance of considering S. moniliformis as an etiology
Streptobacillus moniliformis Infection In all suspected cases, a complete autopsy should be performed and
in a 14-Month-Old Boy the microbiology lab should be contacted for guidance in submitting
blood, cerebrospinal fluid, and probably synovial fluid in appropriate
Priya Banerjee, MD*, The Johns Hopkins Hospital Department of media supplemented with 20% blood serum or ascitic fluid to prevent
Pathology, 600 North Wolfe Street, Carnegie/Pathology 401, Baltimore, growth inhibition of S. moniliformis.
MD 21287; and David R. Fowler, MD, and Zabiullah Ali, MD, Office of Rat Bite Fever, Streptobacillis moniliformis, Actinobacillus muris
the Chief Medical Examiner, 111 Penn Street, Baltimore, MD 21201
After attending this presentation, attendees will understand the G19 Contributions From Forensic Imaging
features of Streptobacillus moniliformis, are, under recognized infection
as they apply to a forensic setting through an autopsy case presentation.
to the Investigation of Fatal Upper
This presentation will impact the forensic sciences community by Cervical Fractures
highlighting the key features of S. moniliformis infection including the
clinical presentation, postmortem diagnosis of S. moniliformis infection, Lars Uhrenholt, PhD, and Lene W. Boel, PhD*, University of Aarhus,
and risk factors as they relate to a particular forensic autopsy case. Institute of Forensic Medicine, Brendstrupgaardsvej 100, Aarhus N,
After viewing this presentation attendees will understand the 8200, DENMARK
features of S. moniliformis, a rare, under recognized infection as they
apply to a forensic setting through an autopsy case presentation. After attending this presentation, attendees will understand the
Rat Bite Fever, caused by S. moniliformis infection, is an acute value of advanced diagnostic imaging procedures in forensic medical
syndrome of fever, rash, and migratory polyarthritis. In the United investigations of upper cervical spine fractures following trauma.
States, primarily children under the age of 12 years are infected with a This presentation will impact the forensic community by showing
total of less than 200 cases reported. Common vectors include rats and how upper cervical spine fractures are frequently seen in relation to fatal
mice, which are natural reservoirs. Transmission is predominantly from trauma to the head and neck, and where this anatomical region may be
a bite or scratch, but contact with or ingestion of food contaminated with difficult to evaluate during medicolegal autopsy, the contributions from
feces or saliva has also been reported. advanced diagnostic imaging procedures may be of great importance to
A previously healthy 14-month-boy died after a rapid decline after the investigation.
onset of fever and a diffuse rash over his face, trunk, and extremities. The purpose of this presentation is to present the value of advanced
Crime scene investigation revealed a disheveled, cluttered bedroom diagnostic imaging procedures in the forensic medical investigations of
where the child’s crib was located. Several markedly soiled animal upper cervical spine fractures following trauma.
cages were adjacent to the crib containing rabbits and ferrets. The room Upper cervical spine fractures are frequently seen in relation to fatal
was also infested with roaches, flies, and ticks over the floor, walls, trauma to the head and neck and, where this anatomical region may be
ceilings, and all of the bedding. A complete autopsy, including difficult to evaluate during medicolegal autopsy, the contributions from
laboratory testing, revealed a well-developed and well-nourished white advanced diagnostic imaging procedures may be of great importance to
male infant with normal age-adjusted height and weight. A red-pink the investigation.
macular and mostly confluent rash covered almost the entire body The upper cervical spine is clinically a very important anatomical
surface with prominence on the head including the scalp, neck, anterior region, where the high degree of mobility is obtained on the expense of
and posterior torso, anogenital region, and portions of the thighs without poor stability. Several types of fractures are possible at the atlas (C1) and
mucosal involvement. There was sparing of the bilateral legs, soles, axis (C2) vertebrae. Five cases have been retrieved where different types
palms and portions of the forearms, nose and mouth, except the left of trauma, (e.g., road traffic crash collisions, fall, blow to the head from
lateral corner of the mouth. The rash did not involve the buccal mucosa moving objects), had occurred causing fractures to the upper cervical
or gums. The right knee had a donut-shaped bite rash suspicious for a vertebrae. Each of the deceased was examined using advanced
bite mark. Internal examination revealed a mildly enlarged, congested computed tomography, an in-house Siemens Definition 64 slice dual-
liver and enlarged mesenteric lymph nodes. Microscopic examination of energy scanner facility, as adjunct to the medicolegal autopsy. The upper
the lungs showed interstitial pneumonitis with rare neutrophils and cervical spine was reconstructed using sub-millimeter slice thicknesses
edema. There were focal areas of gastric aspiration without associated and all images were examined in three planes (horizontal, coronal, and
vital reaction. The kidneys had fibrin micro-thrombi with focal fibrinoid axial) as well as using 3-dimensional reconstructions. The findings from
necrosis of the tubules, consistent with Disseminated Intravascular the CT-scanning were correlated with the findings from the medicolegal
Coagulopathy. Microbiologic culture of cerebrospinal fluid was positive autopsy and the contributions from the forensic imaging procedures to
for S. moniliformis while routine blood cultures were negative. Viral the medicolegal investigations were evaluated.
cultures were also negative. Routine toxicologic analysis of heart blood The review of five unique cases with upper cervical spine fractures
and liver revealed diphenhydramine administered during resuscitation. showed that forensic imaging procedures in combination with
In the United States, 55% of cases of Rat Bite Fever occur in medicolegal autopsy allow very detailed evaluation and categorization of
children less than 12 years of age. The demographics of the victims have fractures. Although fractures of the odontoid process were readily
broadened to include children, pet store workers, and laboratory identified during autopsy, the exact classification according to the system
technicians, because the rats have become popular pets and study by Anderson and D’Alonzo was made possible by examination of the
animals. The infection is associated with a mortality rate of 7-13%, if CT-images. The fractures of the atlas were more difficult to visualize
untreated. The actual rate of infection may be much higher, because it is during the medicolegal autopsy, particularly at the posterior arch,
not a reportable disease. Although easily treatable with antibiotics, the whereas the diagnostic imaging procedures allowed clear identification
diagnosis and treatment can be delayed due to a broad differential as well as classification of the fractures according to the system proposed
diagnosis which includes meningococcemia, Staphylococcus aureus or by Jefferson.
Streptococcus pyogenes septicemia, Rocky Mountain Spotted Fever, or This presentation of five trauma cases showed that advanced
other Rickettsial diseases, enterovirus infection, disseminated gonorrhea, diagnostic imaging procedures contributes significantly to the forensic
Lyme disease, ehrlichiosis, brucellosis, leptospirosis, and secondary medical investigations of upper cervical spine fractures following
syphilis. Given this differential of more common entities, laboratory trauma. This is important as implementation of such adjunct procedures

to the medicolegal autopsy may strengthen the degree of detail of the emboli were thought to come from the primary spinal fractures or the
investigation. Although this is a small group of selected trauma cases, secondary rib fractures caused by the resuscitation efforts.
this presentation highlights some of the major advantages achieved by Further investigation into the medical history, by requesting
expanding the forensic investigations to also include forensic imaging relevant hospital records, revealed that the deceased had received
procedures. treatment in an outpatient clinic nine years prior, due to ankylosing
A number of cases that have in common the presence of upper spondylitis with rigidity of the spine. He had furthermore been under
cervical spine fractures will be discussed. The contributions to the evaluation for lung sarcoidosis. The cause of death was ruled to be upper
medicolegal investigations from advanced computed-tomography cervical spinal cord injury due to upper cervical spine fractures,
scanning will be presented and it is recommended that forensic complicated by spinal rigidity secondary to ankylosing spondylitis. The
specialists become familiar with the potential of advanced imaging manner of death was ruled to be accidental.
procedures to the medicolegal investigations. This case report illustrates the fatal outcome of spinal injuries in an
Cervical Fracture, Forensic Imaging, Postmortem Autopsy individual who suffered from a structural skeletal disease, where the
ankylosing spondylitic changes acted as predisposing factors leading to
his death. Thus, knowledge of pre-existing skeletal disease is important
G20 Ankylosing Spondylitis in Traumatic Death: in the medicolegal evaluation, as diseases that are considered non-fatal
can contribute to the cause of death. In this case report the understanding
A Case Report of the conditions leading to death was recognized and supported by the
postmortem computed tomography.
Asser H. Thomsen, MD*, Lars Uhrenholt, PhD, and Annie Vesterby, MD, This presentation will impact the forensic community by reminding
DMSc, Institute of Forensic Medicine, University of Aarhus, it of the importance of taking all natural disease into account when
Brendstrupgaardsvej 100, Aarhus N, DK-8000, DENMARK investigating deaths, even those that are not normally considered fatal.
Furthermore, it will present the possibilities of advanced radiological
After attending this presentation, attendees will have a better imaging as a facilitator in death investigation in the evaluation of the
understanding of the possible impact of pre-existing structural skeletal mechanism and manner of death.
disease in traumatic death, illustrated by a case report. Ankylosing Spondylitis, Postmortem Examination,
This presentation will impact the forensic community by reminding Forensic Imaging
it of the importance of taking all natural disease into account when
investigating deaths, even those diseases not normally considered fatal.
Furthermore, it will present the possibilities of advanced radiological
imaging as a facilitator in death investigation in the evaluation of the
G21 An Unsolved Cold Case in Iowa:
mechanism and manner of death. A Probable Case of Dragging
Ankylosing spondylitis is a rheumatic disease which is associated
with tissue type HLA-B27 and is considered non-fatal. Main structural Dawnie W. Steadman, PhD*, Binghamton University, SUNY, Department
features in severely affected individuals are osseous fusion of the of Anthropology, Binghamton University, PO Box 6000, Binghamton, NY
sacroiliac joints, and rigidity of the spinal column caused by bone 13902-6000; Dennis Klein, MD, Iowa Department of Public Health, 321
bridging between vertebral bodies (syndesmophyte formation). Due to East 12th Street, Des Moines, IA 50319-0075; and Blythe Bloemendaal,
this rigidity there is an increased risk of spinal fractures, especially BA, Lyon County Sheriff’s Office, 410 South Boone, Rock Rapids, IA
cervical fractures, even from low energy trauma. 51246
A middle-aged man rode his bike home from a bar while
intoxicated. A witness saw him swaying and at low speed riding the bike After attending this presentation, attendees will learn about
into a curbstone. During the crash he went over the handlebars and differential diagnosis for trauma due to dragging. Dragging injuries to
collided with the pavement face first. His breathing ceased immediately, human remains is rarely described in the literature and is limited to
soon followed by cardiac arrest. Resuscitation efforts at the scene were accidental long-range towing behind large vehicles.
unsuccessful. Due to the rapidity of the cardiac arrest, the attending This presentation will impact the forensic community by describing
emergency physician ruled that it was a natural death caused by a the skeletal morphological changes associated with dragging from a
cardiovascular event secondary to the fall from the bike. According to different context than is currently found in the literature.
the antemortem information obtained from the police report and the Dragging injuries to human remains is rarely described in the
general practitioner, the deceased was healthy without prior literature and is limited to accidental long-range towing behind large
cardiovascular disease. Postmortem computed tomography scanning vehicles. The goal of this presentation is to provide a differential
revealed multiple fractures of the spine, including a fracture of the diagnosis for trauma due to dragging. This presentation will impact the
odontoid process of C2, disco-vertebral avulsion through C3-C4, and forensic community by describing the skeletal morphological changes
Th10-Th11. Associated with the upper cervical fractures there was associated with dragging from a different context than is currently found
displacement of fragments into the spinal canal affecting the spinal cord. in the literature.
Furthermore, there were ankylosing changes of the anterior longitudinal On October 4, 1978, decomposed human remains were found lying
ligament throughout the spinal column with extensive syndesmophyte face down in a ditch in a rural portion of Northwestern Iowa. The female
formation bilaterally, also known as bamboo spine configuration, victim was partially clad in knee-high white “go-go” boots with her
particularly in the lumbar spine. The sacroiliac joints were closed by panties and pants bunched up under the torso. Her arms were stretched
osseous fusion. All the radiological findings were in agreement with the over her head and her ankles were tied together with a knotted rope. An
diagnosis of ankylosing spondylitis. The medicolegal autopsy showed autopsy the following day revealed no obvious traumatic injuries to the
abrasions in the face, on the back, on hands, and legs; bleeding in and soft tissue or skeleton other than damage to the maxilla that was
around the spinal fractures; rib fractures with sparse bleeding; bone originally attributed to animal gnawing. The hands were retained and the
bridging of the intervertebral joints; an enlarged heart, insignificant skull, clavicles, pubic symphyses and possibly other bones were sent to
atherosclerosis; a fatty liver, and an enlarged spleen. Blood alcohol was a forensic anthropologist for analysis. Ultimately the identity of the
189 mg/dl. The microscopical examination revealed hypoxic changes in victim and the cause of death were unknown and the case became “cold.”
the brain, granuloma formation in the lungs consistent with sarcoidosis, Interest in the case was renewed nearly two decades later when, in
and bone marrow emboli in the pulmonary arteries. The bone marrow January 2006, the victim’s fingerprints were matched to those on a

fingerprint card of a woman arrested in California in 1973. Ovid MEDLINE search engines yielded no such cases; however,
Mitochondrial DNA tests of metacarpal bones of the victim positively recently a preliminary report on a similar case from Berkshire, UK was
matched the mtDNA of a known daughter of the California woman. The reported online in late 2007. This is the first known death associated
victim was identified as a 23-year old prostitute from California who was with a flotation tank to be reported in the medical literature.
last seen in Georgia in February of 1978. Throughout 2006 investigators Flotation REST (Reduced Environmental Stimulation Therapy) is
created a list suspects, including the victims’ ex-husband, but most of used by some as a modality for stress-reduction or for behavioral
these individuals were deceased or could not be found for questioning. modification programs. REST was initially a research tool for
In 2007 the remains were exhumed, the bones that had been sent to other neuropsychiatric studies in the 1960s, but became more popular in the
anthropologists were returned, and a new autopsy was ordered to further United States in 1970s-1980s when the tanks became available for
investigate the cause of death. commercial and personal use. Most recently some medical practitioners
The soft tissue of the dorsal aspect of the entire body was ascribe to its use as an alternative therapy for various medical illnesses,
remarkably well preserved while the ventral aspect (which had been in as it may reduce hypertension and alleviate chronic pain. The medical
contact with the ground) was skeletonized. A comprehensive drug panel literature discusses the effects of chamber REST for many psychiatric,
on decomposed skeletal muscle was positive only for caffeine and behavioral and addiction disorders; however controlled studies using
cotinine. Following the forensic pathological examination the bones flotation REST are very limited.
were macerated in warm water with detergent and examined by the A unique case in which a previously healthy 50-year-old woman
anthropologist. Bone loss of the maxillary alveolar bone, hard palate, apparently died while floating in a sensory deprivation tank within the
anterior nasal spine, and nasal aperture was extensive. Adherent bone basement of her own home will be described. The deceased reportedly
fragments, radiating fractures, tool marks, or animal gnawing were had not previously used the tank, although had purchased it
absent and the morphology was most consistent with abrasion. approximately three years previously, and was likely not familiar with
Similarly, abrasion injuries were apparent on the medial aspects of both the proper use of the tank. At the time of the scene investigation the
elbows (distal humeri and proximal ulnae) and the anterior iliac spine of unit’s filtration system, which was situated close to the flotation tank,
the right ilium. No bony modifications were observed below the pelvis. was noted to be on and running. The temperature of the water in the
The abrasion injuries are consistent with dragging in a prone flotation tank was elevated at 116 deg F, approximately 20 deg F higher
position with the arms over the head as the lower face, medial elbows than the usual target temperature for flotation sessions. Examination of
and one or both ilia would be in contact with the ground. The mandible the tank and accessories found all components operating within
and anterior rib cage are also expected to be affected but unfortunately specifications, with no malfunctions or electrical hazards identified.
these elements were not retained from the original autopsy. Only two There was no evidence the decedent drowned, as the nose and mouth
known cases of dragging are published in the literature and these involve were not submerged. A full medicolegal autopsy was performed. No
dragging behind or under a vehicle for significant distances (at least 2.5 anatomic cause of death was identified at autopsy. Postmortem
miles). One case (Klintschar et al. 2003) reports a body dragged prone laboratory studies demonstrated a vitreous creatinine of 5.2 mg/dl, a
by one foot with the arms over the head such that the medial aspect of blood ethanol level of 0.270%, an elevated blood doxylamine level, and
the elbows faced outwards. The medial humeri and ulnae as well as the the presence of sertraline and diphenhydramine. It has been concluded
lower teeth were extensively abraded. In the current case the injury that the deceased inadvertently left the pump on during her flotation
pattern, the position of the pants (pulled up under the torso), the position session, which resulted in the elevation of water temperature after she
of the ligature around the ankles and the final resting position of the body fell asleep during the session. The cause of death was determined as due
in the ditch suggest the victim was pulled by the feet while in a prone to acute mixed drug and ethanol toxicity with probable hyperthermia
position such that the legs were off the ground and the arms over the contributing. Manner was ruled as accident.
head. The remote location and terrain implies the victim may have been It is recommended that mind-altering or CNS depressant drugs
dragged by a vehicle down a gravel road but most likely was pulled by including alcohol not be used during flotation REST sessions. This case
hand. While coffin abrasion cannot be completely ruled out, these report and discussion will help the forensic community understand the
particular bones were not observed to be in direct contact with the metal use of flotation tanks and the risks associated with improper use.
sides when the coffin was unsealed. Thus, a mechanism of manual Investigation of deaths involving these unit or similar devices such as
dragging is proposed to explain the morphology and distribution of the bathtubs or spas should include special precautions aimed to prevent
skeletal injuries. harm to the investigation crew. In addition, full examination of the tank
Trauma, Forensic Pathology, Forensic Anthropology and accessories should be performed by professionals familiar with the
equipment to confirm any product malfunctions or other potential safety
hazards.
G22 An Unusual Death Involving a Sensory Sensory Deprivation Tank, Flotation Tank, Intoxication
Deprivation Tank
Meredith A. Lann, MD*, University of Colorado at Denver Health
Sciences Center, AIP - Department of Pathology, 12605 East 16th
G23 Preliminary Analyses of Carrion
Avenue, Room 3026, Aurora, CO 80045; and Amy Martin, MD, Denver Colonization of Necrophagous
Office of the Medical Examiner, 660 Bannock Street, Denver, CO 80204 Flies (Diptera: Calliphoridae) in
Central Oklahoma
intended use of sensory deprivation tanks and understand possible risks
associated with improper use. A practical investigative approach to JeAnna R. Redd, BS*, University of Central Oklahoma, 100 North
similar deaths involving water tanks and spas will be discussed. University Drive, Evans Hall 101 (Box 208), Edmond, Oklahoma 73034;
This presentation will impact the forensic community by and Wayne D. Lord, PhD, Forensic Science Institute, University of
familiarizing the forensic community about the use of sensory Central Oklahoma, 100 North University Drive, Edmond, OK 73034
deprivation or flotation tanks, as well as risks associated with improper
use. After attending this presentation, attendees will have a better
Deaths involving sensory deprivation tanks, also called flotation understanding of the colonization of carrion by necrophagous flies in
tanks, are very rare. A thorough literature search using PubMed and two suburban habitats in central Oklahoma. In addition, attendees will

better understand factors that impact necrophagous fly colonization of G24 Two Fatal Cases of Hidden Pneumonia
carrion and their diversity suburban habitat.
From this presentation, the forensic community will attain a better
in Young People
appreciation for carrion insects in central Oklahoma and environmental
conditions for postmortem interval (PMI) estimations of human remains Francesco Ventura, MD, and Alessandro Bonsignore, MD*, Department
based on associated arthropod fauna. of Forensic Pathology, University of Genova, Via De Toni, 12, 16132,
This presentation will impact the forensic community by Genova, 16132, ITALY; Raffaella Gentile, MD, Department of Clinical
demonstrating the potential influence of environmental factors on Pathology, University of Genova, Largo Rosanna Benzi, 10, Genova,
carrion colonization by necrophagous flies and vertebrate carcass 16132, ITALY; and Francesco De Stefano, MD, Department of Forensic
recycling in non-vegetated habitats in central Oklahoma, and the Pathology, University of Genova, Via De Toni, 12, Genova, 16132,
importance of insular suburban woodlots as a refuge and species pool for ITALY
dipteran decomposers. With the possible onset of global warming and
the continuing expansion of human habitation, maintaining suburban The goal of this presentation is to review two fatal cases of hidden
woodlots and vegetated green zones may prove critical for the pneumonia in young people.
preservation of terrestrial decomposer populations and other wildlife . This presentation will impact the forensic science community by
Necrophagous flies are important ecologically and forensically. demonstrating how accute respiratory distress syndrome (ARDS) can
Ecologically, carrion frequenting flies (Diptera: Calliphoridae) are result in death. Also young people generally, in cases of pneumonia, can
dominant members of the terrestrial decomposer community and, as be treated and consequently prevent death. Therefore, these cases
such, play a significant role in the recycling of vertebrate remains, illustrate the importance of early diagnosis of this condition.
improving public health. Additionally, analyses of immature and adult ARDS is a severe lung disease characterized by inflammation of the
flies colonizing remains can provide a broad spectrum of forensically lung parenchyma leading to impaired gas exchange with concomitant
meaningful information, including estimates of the minimum systemic release of cytokines and inflammatory mediators frequently
postmortem interval (PMI). Central to an understanding of the resulting in multiple organ failure (MOF). This condition usually
ecological and forensic significance of necrophagous Diptera is requires a rapid application of mechanical ventilation and admission to
knowledge of the environmental factors potentially limiting carrion an intensive care unit.
detection, access, and colonization. This study examined the impact of When the endothelium of lung capillaries and the alveolar
high temperatures and surface winds on the colonization of carrion epithelium are damaged, plasma and blood spread in the interstitial and
(liver) by necrophagous Diptera in two suburban Oklahoma habitats. intralveolar spaces. Such a change induces decreased lung compliance,
Standardized samples of beef liver (uniformed attractant) were placed in pulmonary hypertension, reduced functional capacity, modified
a suburban woodlot and turf grass field in Central Oklahoma. Wind ventilation/perfusion ratio, and hypoxemia. ARDS can occur within 24
speed, wind direction, and temperature were measured at each site and to 48 hours of an attack of acute illness. In such a case the patient usually
correlated with carrion fly colonization rates and species diversity. Over has shortness of breath and tachypnea.
100 replicates were conducted over the course of 8 weeks. Fly Typical histological presentation involves diffuse alveolar damage
colonization patterns were compared with commercial flytrap (DAD) and hyaline membrane formation in alveolar walls.
(Pherotech ®) and rodent carcass trials. If the underlying disease is not diagnosed and treated, the condition
Study results indicated a clear difference between habitats, with the of the patient will worsen resulting in shock and/or MOF potentially
turf field characterized by stronger winds, higher temperatures, more resulting in sepsis.
rapid carrion desiccation, reduced fly colonization rates, and lower Supposedly over 30% of ARDS cases are due to “sepsis syndrome,“
species abundance and diversity. Additionally, the turf field habitat was which is characterized by leukocytosis or leukopenia, fever, hypotension
characterized by a significantly greater number of days devoid of carcass and leading to the identification of a potential source of systemic
colonization by carrion flies. Vegetative stratification, characteristic of infection via positive blood culture for pathogenic agents.
the suburban woodlot habitat, provided mediation of wind and heat The rate of survival in case of severe ARDS with appropriate and
effects and facilitated increased carrion fly abundance, diversity, and early treatment is 50%. However, if the severe ARDS induced
activity. hypoxemia is not recognized or treated, or if the disease reaches is not
The study demonstrates the potential influence of environmental diagnosed until the terminal phase, cardio-respiratory arrest occurs in
factors on carrion colonization by necrophagous flies and vertebrate more than 90% of patients.
carcass recycling in non-vegetated habitats in central Oklahoma, and the Case 1: A 29-year-old man was found lifeless at home by his
importance of insular suburban woodlots as a refuge and species pool for girlfriend. Death scene investigation was unremarkable. He took
dipteran decomposers. With the possible onset of global warming and psychotropic drugs, and he was known to be an abuser of alcohol and
the continuing expansion of human habitation, maintaining suburban drugs. Family history was negative for sudden death. A complete
woodlots and vegetated green zones may prove critical to the postmortem examination was performed four days after death. External
preservation of terrestrial decomposer populations and other wildlife . examination was insignificant. The internal examination revealed
Forensic Entomology, Carrion Colonization, Necrophagous Diptera polyvisceral congestion, microthrombosis, cerebral and pulmonary
oedema. Free citrine liquid was found on both sides of the pleural
cavities.
Marked congestion and release of foamy material on sectioning of
both lungs was observed. Hydrostatic docimasia for large and small
fragments was positive in all fields such as an index of bilateral
consolidation. The histological lung examination, performed with
routine haematoxylin-eosin staining, revealed diffuse alveolar damage,
endobronchial and endoalveolar infiltrates of polymorphonuclear
neutrophilic leukocytes and focal emphysema. No fungal infections

were detected using slides by PAS and Grocott staining. Gram staining will be presented. In both cases heteroplasmies were present. The aim
didn’t reveal evidence of bacteria. Toxicology was negative for drugs of this work is to demonstrate the utility of these two techniques showing
and alcohol. the main indications and advantages for the forensic community.
Case #2: A 31-year-old man was with a history of pharingodinia, mtDNA, Heteroplasmy, Clonage vs. DHPLC
fever, and cough taken to the hospital. The clinical symptoms progressed
to acute onset of increasing shortness of breath rapidly progressing to
acute respiratory failure with haemoptysis. Chest x-ray demonstrated G26 Internal Validation of Quantifiler™ DUO
bilateral diffuse airspace opacification; the high resolution CT confirmed
the presence of bilateral diffuse airspace consolidation associated with
DNA Quantification Kit and AmpFℓSTR®
liquid in pleural cavities. The patient, with a severe leukopenia, was Yfiler™ PCR Amplification Kit
admitted to the intensive care unit, but died after a few hours. Two blood
cultures were positive for group A beta-hemolytic Streptococcus. No María J. Illescas, BS*, Virginia Commonwealth University, 1000 West
other pathogenic agents were present. An autopsy was performed within Cary Sreet,, PO Box 842012, Richmond, VA 23284-2012; Fernando
48 hours. The internal examination revealed an increase in lung weight Mercedes, MS*, Institute of Forensic Science of Puerto Rico, Calle
and findings were consistent with intense congestion attributable to a Maga Esq. Casia, Urb. Reparto Metropolitano, San Juan, PR 00922;
bilateral pneumonia. The histological examination of lung specimens Tracey Dawson Cruz, PhD*, 1000 West Cary Street, PO Box 842012,
showed a pattern of diffuse alveolar damage and the presence of Virginia Commonwealth Univeristy, Richmond, VA 23284; and Carmen
intralveolar bacterial and fungal colonies. In the kidneys a thrombotic A. Tirado, MS*, Institute of Forensic Science of Puerto Rico, Calle Maga
microangiopathy compatible with DIC was found. Esq. Casia, Urb. Reparto Metropolitano, San Juan, PR 00922
In conclusion, the cause of death was, in both cases an acute cardio-
respiratory failure secondary to acute bilateral pneumonia with DAD and After attending this presentation, attendees will learn about the
consequently ARDS, sepsis and DIC. methods and results from the validation study of two Y specific kits
Hidden Pneumonia, Diffuse Alveolar Damage, Adult Respiratory performed at the Institute of Forensic Science of Puerto Rico.
Distress Syndrome This presentation will impact the forensic community by
communicating the methods and results from a validation study of two
available forensic kits. Y-locus specific kits are an important forensic
G25 Methodologies for Heteroplasmy tool to aid in the discrimination of the male contribution in a sample,
such as rape cases.
Identification The DNA-Serology Laboratory of the Institute of Forensic Sciences
of Puerto Rico is the only Latin American laboratory accredited by
Simona Ricci, MD*, Department of Legal Medicine, Viale Regina Elena ASCLD-LAB. Y-STR’s have become an important forensic tool in cases
336, Roma, ITALY in which male-male or male-female mixtures arise, such as rape cases.
Y-locus STR’s have also gained importance in the clarification of
After attending this presentation, attendees will receive information erroneous Amelogenin tests from autosomal STR amplification kits.
about the detection and study of heteroplasmy in the forensic field. Quantitation of human male DNA and Y-STR analysis are not currently
This presentation will impact the forensic community because it performed in-house. Therefore, this study was designed to validate two
shows two caseworks in which different techniques were implemented to commercially available forensic kits, Quantifiler® Duo DNA
achieve good results. Quantification, and AmpFℓSTR® Yfiler™ PCR Amplification for in-
Mitocondrial DNA (mtDNA) sequencing has been considered a house quantitation of human male DNA and Y-STR detection. These kits
useful tool for forensic analysis, and it is typed routinely in forensic were validated for use with one real-time PCR instrument model for
analyses to assist in determining the source of old bones, teeth, hair DNA quantitation (ABI Prism® 7500 Sequence Detection System) and
shafts, and other biological samples where nuclear DNA content is too two capillary electrophoresis instrument models (ABI Prism® 3130xl
low or degraded to genotype by analyzing autosomal short tandem repeat and 3100-Avant Genetic Analyzers) for Y-STR detection.
(STR) loci. Quantifiler® Duo DNA Quantification Kit is designed to
Typically, forensic mtDNA data are obtained by sequencing (i.e. simultaneously quantify the total amount of amplifiable human DNA and
Sanger method, followed by electrophoresis and fluorescent detection) human male DNA in one reaction. The quantification assay combines
the two hypervariable regions (HV1 and HV2) of the noncoding control three 5’ nuclease assays, namely: target-specific human DNA assay,
region of the human mtDNA genome. Traditionally, sequencing has target-specific human male DNA assay, plus an internal PCR control
been the method of choice because all polymorphisms contained within (IPC). The human target is Ribonuclease P RNA Component H1
the amplified fragment can be detected. The definition of heteroplasmy (RPPH1) located at 14q11.2 and 140 bases long is detected by TaqMan®
is the existence of two types of mtDNA within an individual. It is known MGB probe labeled with VIC dye. The male target is the sex-
that the sensitivity of heteroplasmy detection is method-dependent, and determining region Y (SRY) located at Yp11.3 and 130 bases long is
the most fundamental approach to sampling the individual mtDNA detected by TaqMan® MGB probe labeled with FAM dye. The internal
present in an individual is achieved through cloning. PCR control is a synthetic sequence not found in nature. It is 130 bases
The most common form of heteroplasmy observed in the mtDNA long and is detected by TaqMan® MGB probe labeled with NED dye.
control region is length heteroplasmy. Depending on its extent, length AmpFℓSTR® Yfiler™ PCR amplification kit is a short tandem repeat
heteroplasmy may result in an inability to read or interpret sequence data multiplex for human male-specific DNA amplification that includes the
and must be compensated for with alternative sequencing strategies. European minimal haplotype loci (DYS19, DYS385a/b, DYS389I/II,
There are different methods to evaluate the mutation load of defective DYS390, DYS391, DYS392, and DYS 393), the SWGDAM
mtDNAs: primer extension, TTGE, RT-PCR, restriction fragment recommended loci (DYS 438 and DYS439), and additional highly
analysis and SSCP. In addition heteroplasmy using SSO typing, polymorphic loci (DYS437, DYS448, DYS456, DYS458, DYS635, and
DHPLC/nuclear loci and DGGE can be detected. These methods are Y GATA H4) for a total of 17 Y-STR loci in a single PCR reaction.
highly sensitive and can detect and sometimes quantitate heteroplasmy at Internal validation studies included: precision, accuracy, sensitivity,
levels lower than 1%. In this study, information regarding the male:male mixture evaluation, female:male mixture evaluation, stutter
management of different cases using clonage and DHPLC respectively determination for each locus, as well as forensic casework. Forensic

casework includes a double-rape case, an incest case, a proficiency test G28 Foreign Bodies: Three Cases of Projectile
from Collaborative Testing Services, Inc., and a case with null
Amelogenin typed with AmpFℓSTR® Identifiler™ PCR Amplification
Maintenance Without Complications
kit. In addition to these studies, 106 samples were used to create a Y-
STR database for Puerto Rico. All validation study data is being Duarte N.P. Vieira, PhD*, Carlos Abreu, MD, and Cristina Cordeiro,
analyzed and will be discussed. MSci, Instituto Nacional de Medicina Legal, Largo da Sé Nova,
Internal validation of available DNA typing kits for human Coimbra, LB 3000-213, PORTUGAL
identification allows for the evaluation of a procedure’s efficiency,
reliability, performance characteristics, and limitations. The internal After attending this presentation, attendees will learn about the
validation of the Y-locus specific kits (AmpFℓSTR® Yfiler™ and possibility of retention of foreign bodies, like projectiles, in the body
Quantifiler® Duo) will allow the Puerto Rico Institute of Forensic during long periods of time without any symptoms or evident
Science DNA laboratory to save time and money, as well as the ability to complications, and that are only accidentally discovered during an
offer reliable male DNA typing services. autopsy performed due to another cause of death. However, there are
Y-STR, Male Quantitation, Yfiler™ some cases where problems may occur, being the bullets the cause of
several symptoms and even sudden death. Thus, a regular follow up of
the victim must be done in these situations and sometimes a surgical
removal is needed.
G27 The Effect of Clothing on Scavenger Visits This presentation will impact the forensic community by showing
and Decomposition three cases where projectiles were maintained in the body for several
years, due to previous gunshot injuries. In one of these cases, the
Amanda J. Marshall, BS*, Jennifer R. Simon, BS*, and Phillip L. projectile was found during the autopsy of a traffic accident victim.
Watson, PhD*, Ferris State University, Department of Biology, 2004 Surprisingly it had remained in the pericardial cavity for 12 years! In the
ASC, 808 Campus Drive, Big Rapids, MI 49307 other two cases, concerning living persons, the projectiles stayed in the
corpse of a dorsal vertebra and in the sphenoid sinus, respectively, for
After attending this presentation, attendees will learn the many years.
differences clothing can make on the timing and frequency of scavenger The possible complications and risks of bullets maintenance in
visits to remains. Clothing will be shown to significantly affect when victim’s bodies are reviewed and the authors stress the particular
scavengers visit and alter the death event. attention that these situations demand during the medical forensic
This presentation will impact the forensic community by assessment of these individuals.
demonstrating how time of death is determined by many factors, the The retention of projectiles in the body is an unusual situation.
presence or absence of clothing does affect the timing of visits. Sometimes these projectiles are maintained for life in the body without
The presence or absence of clothing can alter the decomposition any symptoms or evident complications, and are only accidentally
rate (Anderson 2001, Kelly 2006). Quantifying the decomposition rate discovered during an autopsy performed due to another cause of death.
is difficult and complicated by the potential differences in timing of Foreign Bodies, Projectiles, Autopsy
scavenger visits and alterations to the death scene by those visits. This
study, which is a follow-up to one conducted in 2007, examined the rate
of decomposition on a clothed and unclothed pig as a function of summer G29 The Persistence of an Elevated
environmental conditions, but includes motion sensor cameras to capture
scavengers frequenting the sites. Insects were collected twice a day until
Concentration of Ninhydrin-Reactive
the dry remain stage occurred. Cameras were secured and pictures were Nitrogen in Grave Soil
obtained as motion was sensed by the camera. Temperature, relative
humidity, rainfall, and wind speed data were collected on an hourly Brianna F. Anderson*, and Jessica D. Wilkerson, University of
basis. The data show increased activity of forensically important insects Nebraska-Lincoln, 202 Entomology Hall, PO Box 830816, Lincoln, NE
as a function of temperature and clothing. The delay of the clothed 68583-0816; and David O. Carter, PhD, University of Nebraska,
victim to reach the dry remains stage was significantly different from the Lincoln, Department of Entomology, 202 Plant Industry Building,
delay for the victim without clothing. The development stages of larvae Lincoln, NE 68583-0816
collected from the clothed victim were also significantly smaller than the
unclothed victim at all collection dates until the unclothed victim was no After attending this presentation, attendees will understand that the
longer attractive to forensically important flies. The scavenger visits concentration of ninhydrin-reactive nitrogen (NRN) in grave soil
were significantly different between the two test animals in terms of time increases during the first year of decomposition while grave soil pH
and abundance as determine by motion sensor cameras. How scavengers decreases.
may be useful in determining state of decomposition will be discussed. This presentation will impact the forensic community by serving as
Data to be discussed will be the differences in larva size, insect a fundamental investigation into the estimation of extended PMI.
species composition on each pig over time and identity, frequency and As time progresses, however, NRN concentrations fluctuate less
timing of scavenger visits. Comparisons were done as an ANOVA test making it difficult to estimate postmortem interval (PMI) over an
and a species diversity comparison for all days. Results will be used to extended period of time. This presentation will impact the forensic
set up teaching mock crime scenes to illustrate the effects of clothing on community by serving as a fundamental investigation into the estimation
PMI calculations. of extended PMI. Accurate estimates of extended PMI are currently
Scavengers, Clothing, Insects difficult to achieve.
Although several methods to estimate postmortem interval (PMI)
have been developed, there is no one method that can be used in all
scenarios. Most of these methods focus on estimating early PMI (<30
days). As a consequence, relatively few methods have been developed
to estimate extended PMI (>30 days). Recent investigations have shown
that the decomposition of a body can have a significant effect on the
chemistry of associated soil (grave soil) that persists into the extended

PMI. One effect is an increase in the concentration of materials (organic The growth and encroachment of human populations into rural
nitrogen and ammonium) that react with ninhydrin. This material is areas, and the consequences of several years of drought, especially in the
referred to here as ninhydrin-reactive nitrogen (NRN). Eventually, western United States, has resulted in more frequent contact with large
(NRN) concentrations will return to basal levels and it is believed that predators such as mountain lions and bears, with sometimes fatal
this can be used to estimate PMI. To determine how long NRN persists consequences for one or both. Correct identification of the species and
in soil, and develop a tool to estimate extended PMI, the NRN individual animal is essential to ensuring public safety with minimal loss
concentrations of grave soil associated with decomposing cadavers (after of endangered wildlife. The application of modern DNA technology to
0, 1 or 3 years) were measured. a fatal mountain lion and non-fatal mountain lion and a recent bear attack
The experimental site was located at the University of Nebraska on humans with two-way and one-way transfers of DNA that enabled
Agricultural Research Development Center located approximately 48 certain identification of the predator will be presented.
km north of Lincoln, Nebraska, USA. The site is a pasture that is Forensic DNA, STR, Puma
intermittently grazed by cattle and horses. The soil at the site is a deep
silty clay loam of the Yutan series (Mollic Hapludalf). The climate is
temperate midcontinental characterized by hot summers, cold winters, G31 Sudden Unexplained Death Due to
and moderately strong surface winds. Average annual precipitation is
695 mm. Approximately 75% of the precipitation occurs between April
Disseminated Malaria
and September. Mean annual temperature is 9.8°C with mean minimum
and maximum temperatures ranging from 0°C (January) to 31°C (July). Ritesh G. Menezes, MD*, Kasturba Medical College, Mangalore, India,
The vegetation at site is dominated by non-native grass (smooth Department of Forensic Medicine, Light House Hill Road, Mangalore,
brougham) and forb (white clover) with some native vegetation, Karnataka 575001, INDIA
including daisy fleabane, yellowwood sorrel nut sedge, and pasture rose.
Swine (Sus scrofa) carcasses (~40 kg) plus a control (no cadaver) After attending this presentation, attendees will understand that the
were used. Swine were killed with blunt force trauma to the cranium and demonstration of parasitized red blood cells with malarial pigment in the
placed on their right side on the soil surface facing west. Soil samples blood capillaries of internal organs by histopathology is a reliable and
were collected (0-5 cm depth) from adjacent to the cadaver following 0 easy method of postmortem diagnosis of disseminated malaria.
years, 1 year, and 3 years of decomposition and analyzed for NRN and This presentation will impact the forensic community by
pH. This experiment was replicated three times, which resulted in a total understanding the possibility of disseminated malaria as a cause of
of six swine cadavers. sudden unexplained death in malaria-endemic regions.
A significantly (P < 0.01) greater concentration of NRN was Sudden unexplained deaths are mainly attributed to the
observed in grave soil after one year but not after three years. Also, a cardiovascular system and the respiratory system. A case study of
significantly (P < 0.01) lower pH was observed in grave soil after one sudden unexplained death due to disseminated malaria in an apparently
year but not after three years. The current results demonstrate that the healthy individual will be presented. In the present case,
concentration of grave soil NRN and soil pH associated with a 40 kg histopathological examination demonstrated the presence of parasitized
cadaver can return to basal levels between one and three years red blood cells with malarial pigment in the blood capillaries in the brain,
postmortem. Thus, the maximum PMI that can be estimated using an myocardium, pericardium, lungs, kidneys, liver, and the spleen.
increase in grave soil NRN or a decrease in grave soil pH is one year. Sudden Death, Disseminated Malaria, Forensic Histopathology
Further research should be conducted to increase the accuracy of these
approaches. In addition, other compounds and elements in grave soil
should be investigated for their use in estimating PMI greater than one G32 Chloride Levels of Sphenoid Sinus Fluid in
year. Salt and Fresh Water Drownings on the
Forensic Taphonomy, Extended Postmortem Interval,
Decomposition
Island of Oahu, Hawaii
Nicole Stalter, MSFS*, Chaminade University, 3140 Waialae Avenue,
Forensic Science Department, Honolulu, HI 96816; Gayle Suzuki, MD,
G30 The Application of DNA Identification and Erin Mitsunaga, BA, Honolulu Medical Examiner, 835 Iwilei Road,
Technology to Large Wildlife Carnivore Honolulu, HI 96817; and M. Lee Goff, PhD, Forensic Sciences Program,
Attacks on Humans Chaminade University of Honolulu, 3140 Waialae Avenue, Honolulu, HI
96816-1578
Jeff Rodzen, PhD, California Department of Fish and Game Wildlife
Forensic Laboratory, 1701 Nimbus Road, Rancho Cordova, CA 95670; After attending this presentation, attendees will walk away with
Elizabeth Thompson, BS*, Orange County Sheriff-Coroner Department, better knowledge of how chloride levels of sphenoid sinus fluid can help
Forensic Science Services, 320 North Flower Street, Santa Ana, CA support pathologist’s diagnosis of drowning as the cause of death.
92703; James D. Banks, BS, and Erin Meredith, MS, California This presentation will impact the forensic community by
Department of Fish and Game Wildlife Forensic Laboratory, 1701 broadening research about chloride levels of sphenoid sinus fluid in salt
Nimbus Road, Rancho Cordova, CA 95670; Hailu Kinde, DVM, and fresh water drownings.
California Animal Health and Food Safety Laboratory System, 105 There are many potential criteria to be evaluated in the pathologist’s
Carousel Mall, San Bernardino, CA 92401; Joseph J. Halka, MD, diagnosis of drowning as the cause of death. One of these involves the
Orange Coounty Sheriff-Coroner Department, Forensic Science Center, analysis of the sphenoid sinus fluid. In the drownings reported from the
1071 West Santa Ana Boulevard, Santa Ana, CA 92703; and Pennie island of Oahu, Hawaii, chloride levels of sphenoid sinus fluid in salt
Laferty, MS, and John M. Hartmann, MBA, Orange County Sheriff- water drownings are typically greater than 140 mmol/L and for fresh
Coroner Department, Forensic Science Services, 320 North Flower water drownings they are normally less than 65 mmol/L, however, to
Street, Santa Ana, CA 92703 date there has been little research on the topic. During July 2007 through
July 2008, there were 37 drownings reported on the island of Oahu.
The goal of this presentation is to demonstrate the use of DNA Nineteen of these had sphenoid sinus fluid removed and analyzed for the
typing to confirm the identity of wildlife predators in attacks on humans. chloride content, 14 salt water and five fresh water. Eight of the 14 salt
water cases had the expected chloride readings of greater than 140
mmol/L. Due to specific circumstances, including decomposition, the G34 Veterinary Forensic Science:
other six presented different results. Of the five fresh water cases, two
presented the expected chloride levels of less than 65 mmol/L, while
Documentation, Processing, and
three had concentrations greater than 65 mmol/L. Of these, two were Interpretation of Physical Evidence at
recovered from chlorinated swimming pools. Other factors that must be Scenes of Animal Crimes
taken into consideration for all cases include: time elapsed between
death/discovery of the individual and collection of samples; and Jason H. Byrd, PhD*, University of Florida, Department of Agriculture
hospitalization following discovery with death occurring later during & Consumer Services, University of Florida, PO Box 147100,
hospitalization. Gainesville, FL 32614-7100; Kenneth F. Cohrn, DDS*, Heritage Dental
Drowning, Sphenoid Sinus Fluid, Chloride Level of Central Florida, 422 Teague Trail, Lady Lake, FL 32159; Jeffery K.
Tomberlin, PhD, Department of Entomology, TAMU 2475, College
Station, TX 77843-2475; David W. Hall, PhD*, David Hall Consultant,
Inc., 3666 NW 13th Place, Gainesville, FL 32605; John J. Schultz,
G33 Recovery of Transplantable Organs After PhD*, University of Central Florida, Department of Anthropology, PO
Cardiac Arrest in France Box 25000, Orlando, FL 32816; Melinda Merck, DVM*, ASPCA, 6175
Hickory Flat Highway Suite 110-2, Canton, GA 30115; and Randall
Nathalie Jousset, MD*, Arnaud Gaudin, MD, Damien Mauillon, MD, Lockwood, PhD*, ASPCA, 2214 Tulip Drive, Falls Church, VA 22046;
and Clotilde G. Rougé-Maillart, MD, CHU, Service de Médecine Légale, Micah Flores, BSc*, Texas A&M, 2475 TAMU, College Station, TX
4 rue Larrey, Angers, 49000, FRANCE 77840
After attending this presentation, attendees see an explanation of After attending this presentation, attendees will gain an
French legislation and summarize ethical problems linked to understanding of the current issues faced by prosecutors, judges, law
transplantation of organs coming from non-heart beating donors enforcement officials, and veterinarians when attempting to bring cases
(NHBD). of animal cruelty and death to trial in the courtroom. Participants will
This presentation will impact the forensic community by comparing also gain a more detailed understanding of how modern forensic science
situations, legislation, ethical problems, between countries concerning as practiced at scenes of human death can be readily applied to the
NHBD transplantation. animal crime scene.
After being abandoned around the end of the 1960s, the This presentation will impact the forensic community by giving a
transplantation of an allograft recovered after cardiac arrest has been more detailed description of current problems and issues involved in the
resumed again in France in 2006 (decree of 2 August 2005: art R.1232- application of forensic science techniques to scenes of animal crime.
4-1,2 and 3 of the public health code). Additionally, the participant will gain an improved understanding of the
Recently, according to the international scale, five situations that needs within the veterinary community and will be better prepared to
could lead to the recovery of transplantable organs after cardiac arrest utilize their own knowledge and forensic specialty to provide assistance
were identified according to a classification called “Maastricht” which to those in the veterinary forensic science community.
describes the potential donors. In France, the donors of class III With the passage of many animal cruelty laws, the need to apply
(cessation of all medical care) were excluded. current forensic science methodologies to these investigations has
To achieve an effective transplantation, the donor has to be legally increased dramatically. Animals have many similarities to humans in
dead in the eyes of the law, and the organs still viable medically. A legal their response to traumatic injury with some noted exceptions. Forensic
definition of death, in the purpose of the recovery of the transplantable science techniques utilized at human crime scenes and applied human
organs of the “dead” donors comes up against this contradiction. victims can often be easily applied to scenes involving cruelty or death
In front of this issue, certain countries recommend against giving a to animals. This symposium will address the application of forensic
legal definition of the death criteria. It is not the orientation chosen by techniques developed for the investigation of human death to animal
France that continues to attempt to define a legal framework in order to cases and unique findings at animal crime scenes.
obtain the society acceptance of the recovery of transplantable organs of Veterinary Science, Veterinary Forensics, Animal Cruelty
“dead” donors.
Despite this, ethical questions arrise. Are criteria adopted to define
death enough? What is the place of non-heart beating donor
transplantation with new technical resuscitation as extracorporeal life
support for prolonged cardiac arrest? How does family and medical staff
support this protocol?
Non-Heart Beating Donors, Legislation, Ethical Reflection

G35 Natural Causes of Sudden Unexpected G36 Biomedical Engineering in Root Cause
Infant Death: A Seven Year Retrospective Analysis – Example: Assessing Infant
Forensic Autopsy Study in Hubei, China Apnea-Related Deaths
Ling Li, MD*, Office of the Chief Medical Examiner, State of Maryland, Bruce H. Barkalow, PhD*, William E. Grant, MA, and Farrah J. Curran,
111 Penn Street, Baltimore, MD 21201; Lan Zhou, BM, Department of BS, B.H. Barkalow, PC, 490 Quarterline St., Newaygo, MI 49337-9125
Forensic Medicine, Tongji Medical College, Huazhong University of
Science and Technolohy, Wuhan, 430030, PEOPLES REPUBLIC OF After attending this presentation, attendees will gain a better
CHINA; Xiang Zhang, MD*, Office of the Chief Medical Examiner, 111 understanding by example of how Biomedical Engineering can assist in
Penn Street, Baltimore, MD 21201; Liang Lui, MD, Tongji Medical root cause analysis by examining how testing of subject apnea monitors
College, 13 Hong Kon Road, Wuhan, Hubei 430030, PEOPLES and analyses of downloaded patient data can be useful in determining
REPUBLIC OF CHINA; Lin Chang, MD, Key Laboratory of Evidence device failure versus human error.
Science, China University of Political Science and Law, Beijing, MD This presentation will impact the forensic community by
100040, PEOPLES REPUBLIC OF CHINA; Guangzhao Huang, BM, demonstrating how Biomedical Engineering analysis can shed light on
Department of Forensic Medicine, Tongji Medical College, Huazhong important information involving medical devices. In this example,
University of Science and Technology, Wuhan, MD 430030, PEOPLES testing of subject apnea monitors and analyses of downloaded patient
REPUBLIC OF CHINA; and David R. Fowler, MD, Office of the Chief data can be useful in determining whether such devices have failed, or
Medical Examiner, 111 Penn Street, Baltimore, MD 21201 whether other factors (including human error) led to infant deaths.
Infants (primarily those of low birth weight) who are at risk for
After attending this presentation, attendees will become familiar Sudden Infant Death Syndrome (SIDS) are often prescribed apnea
with the common natural causes of sudden unexpected infant death in monitors for at-home use. Infant apnea monitors are designed to alert
Hubei province, China and will better understand the difference in the caregivers if a child has become apneic and/or has heart rate changes
diagnosis of sudden infant death between China and western countries. outside of the preset limits. These monitors are not fool proof, however,
This presentation will have an impact on the forensic science and every year some children who are being monitored die. When this
community as it suggests that further studies are needed to focus on the happens, it is the responsibility of the Medical Examiner to ascertain
differences in the diagnosis of sudden infant death between developing why the death occurred. Biomedical Engineers trained in this
countries and developed countries. technology can play a vital role in these death investigations.
The importance of a forensic investigation and autopsy in cases of Apnea in neonates and infants occurs most likely because of
sudden infant death has only recently received attention in China. An immaturity of their respiratory and neurologic systems. Though it is
analysis of forensic autopsy data on sudden infant deaths in Hubei, China common for infants to pause in their breathing for short periods, pauses
has never been undertaken. This report describes the epidemiological lasting longer than 20 seconds are cause for concern, as are pauses of
characteristics and pathological findings of sudden infant death cases shorter duration accompanied by decreased heart rate. Infant apnea
investigated by the Department of Forensic Medicine at the Tongji monitors are designed to detect increases and decreases in heart rate
Medical College in Hubei, China from 1999 to 2006. along with pauses in breathing, and sound an alarm if they occur. This
A retrospective study of forensic autopsy cases conducted at the is accomplished by attaching a belt with a series of electrodes around the
Department of Forensic Medicine, Tongji Medical College in China over infant’s chest. The electrodes are attached to the monitoring unit itself.
a seven year period between1999 and 2005 yielded a total of 68 infants Monitors should have a battery backup, a remote alarm, a power loss
who died suddenly and unexpectedly in Hubei province. The age ranged alarm, a battery charge or AC power indicator, a sibling alarm as well as
between newborn and 12 months. A total of 41 cases (60%) of the deaths an internal memory for event and physiological data storage.
occurred in the neonatal period, 13 (22%) infants in the first six months In cases where a child monitored with one of these devices has
of life, and the remaining 12 cases (18%) in the age between seven unexpectedly expired, a technical analysis should be performed by a
months and one year. There were 54 males and 14 females (M: F = trained Biomedical Engineer. A physical examination of the monitor
3.8:1). The most common cause of sudden neonatal death was itself should be conducted, along with an assessment of the electrical
pneumonia (N=14), followed by congenital abnormalities (N=9); circuitry and analysis of monitor-downloaded data. A combination of
asphyxia due to amniotic fluid aspiration (N=7); respiratory distress of downloaded patient and monitoring compliance data from the apnea
newborn (N=3); intrauterine hypoxia and birth asphyxia (N=3); monitor memory can be cross-correlated with events, such as feeding
complications of prematurity (N=2); newborn affected by complications schedules or EMS run sheets. Deaths of monitored infants have been
of cord (N=1), birth trauma (N=1); and tetanus (n=1); and one death with related to such issues as monitor hardware and software failures,
undetermined cause. obstructive apnea (often not detected), parental monitoring compliance,
The three leading causes of sudden death in infants, age 1 to 12 inability to hear the alarms, cardiac artifact in the transthoracic
months were pneumonia (N=11), congenital heart disease (N=3), and impedance signal, or electromagnetic interference, to name a few. If an
meningitis (N=2). Only one infant was diagnosed as SIDS death. apnea monitor is sent to the Medical Examiner’s office along with an
Infectious diseases are a frequent cause of death in infants who died infant who has expired, it should be maintained as evidence, and the
suddenly and unexpectedly in Hubei, China. These findings contrast stored data downloaded and analyzed along with statements of the
with those from developed countries in which Sudden Infant Death caregivers.
Syndrome is the commonest cause of sudden unexpected death in Case material corresponding to several of these failure-related
infancy. This study demonstrates that it is important to document issues will be presented to illustrate how a root cause approach can assist
autopsy-based data such as these in the planning of medical services in a in making sense of why such tragic events may have occurred.
developing country. Biomedical Engineering, Infant Apnea Monitor,
Sudden Infant Death, Forensic Investigation, Autopsy Sudden Infant Death Syndrome (SIDS)

G37 In Utero Traumatic Head Injuries During G38 Return of an Old Acquaintance - A Case of
a Motor Vehicle Collision: Case-Report Septic Abortion
and Review of the Literature
Karen B. Looman, DO*, Hamilton County Coroner’s Office, 3159 Eden
Sean A. Swiatkowski, DO*, 1 Middlebridge Court, Silver Spring, MD Avenue, Cincinnati, OH 45219
20906; Anna Rubio, MD, Office of the Chief Medical Examiner, 111
Penn Sreet, Baltimore, MD 21201; Michael Johnson, MD, and Juan C. After attending this presentation, attendees will become acquainted,
Troncoso, MD, Johns Hopkins University School of Medicine, 111 Penn or reacquainted, with septic abortion and some of the associated
Street, Baltimore, MD 21201; and David R. Fowler, MD, Office of the anatomical and microscopic findings.
Chief Medical Examiner, 111 Penn Street, Baltimore, MD 21201 This presentation will impact the forensic community by reminding
everyone of a time when illegal abortions, septicemia and death were
After attending this presentation, attendees will understand the more common in the United States. After Roe vs. Wade, the frequency
importance of fetal brain injury in utero after a motor vehicle collision of cases dwindled. New and seasoned medical examiners may benefit
which can lead to hypoxia, direct impact and acceleration-deceleration from a reminder of what to expect in a septic abortion case, especially in
injuries. A discussion of maternal restraint will also be presented. an ever changing political arena.
This presentation will impact the forensic community by On January 22, 1973, the Supreme Court decision regarding Roe vs.
highlighting the possible neurologic complications associated with Wade allowed women to have legal medical abortions in the United
motor vehicle collision and the fetal brain in utero, especially in relation States. In the past, women who were seeking an abortion for a reason
to acceleration-deceleration forces other than to protect the health of the mother were limited to often
Fetal brains differ from neonatal and infantile brains in questionably sterile and clandestine procedures. Cases of septic deaths
development and the environment surrounding them, namely the from improperly performed procedures and post-operational infections
protection offered by the amniotic fluid, uterus, and maternal abdominal were high. The numbers of such cases dropped off dramatically after the
wall. Head injuries inflicted during motor vehicle collision result from landmark legal decision. Some of the more experienced medical
both direct impact and from acceleration-deceleration forces. The effects examiners may remember physical and microscopic findings in such
of these forces on the fetal brain and eyes are poorly described in the cases. Less experienced doctors should be aware of some of the possible
literature. The American College of Obstetrician and Gynecologists and findings in a septic abortion case.
the National Highway Traffic Safety Administration recommend that A 31-year-old married woman, with four living children, was
pregnant women use a 3-point restraint system with the lap belt rushed to a local hospital after becoming hypotensive at a small medical
positioned under the uterus based on the hypothesis that the amount of clinic. She was presented to the clinic with a complaint of food
fetal head acceleration and abdominal force is significantly reduced. poisoning which included nausea, vomiting, diarrhea, and malaise. The
A 32-week pregnant, 31-year-old Hispanic woman was the clinic diagnosed pyelonephritis and gave her intramuscular ceftriaxone.
restrained front seat passenger in a mini van that was rear-ended by a full Within minutes, the woman complained of tongue swelling, shortness of
sized tractor-trailer. Following the collision she was alive but in a deep breath, and hypotension likely indicating an allergic reaction.
coma, tachycardiac and with a blood pressure of 119/62. She was The question of an allergic reaction to the antibiotics was never
intubated in the field and transported to the hospital. Fetal heart specifically addressed during her emergent stay in the hospital. The
monitoring revealed 40 beats per minute. An emergency C-section was emergency room doctors noted erythema and tense swelling of the
performed slightly more than one hour following the impact, and a 1,580 woman’s lower extremities. A serum pregnancy test was positive with a
gram baby girl with Apgar scores of 0, 0 and 0 was retrieved. human chorionic gonadotropin (hCG) level of 6124 mIU/ml (2-3 week
Examination of the uterus revealed placental abruption. Maternal gestation). She was transported to the intensive care unit in extremis.
injuries detected by CT included a complete torso passenger-site She was intubated and went into cardiac arrest. She was resuscitated
shoulder and lap seat-belt contusion with the lap section located on the once, but a second cardiac arrest was fatal.
pelvis, C4-C5 fractures with bilateral internal carotid injuries, fractured Significant medical history went back approximately one month
ribs, pneumo and hemothoraces, liver lacerations, fractured T3 and L1 prior when the woman was involved in a motor vehicle collision and
through L5 vertebrae, retroperitoneal hematoma and acetabular broke her foot. On her two week follow up, her primary doctor asked her
fractures. The mother was pronounced dead two and a half hours after if she had had a pregnancy test in the ER at the time of the accident. The
the collision. A complete postmortem examination of the stillborn female woman said yes and that she had been on her menses. A thorough record
was performed including neuropathologic and ophthalmic pathologic check did not show a pregnancy test was performed. On the day of the
assessment. The findings obtained at the autopsy of the stillborn, which terminal event, she had a tampon in place, noted on the pelvic exam.
will be presented, included the external and internal traumatic injuries, The woman’s mother reported that her daughter was going through
head and spinal injuries, including direct impact and acceleration- a “mid-life” crisis and acting wildly. She got several new tattoos and was
deceleration injuries to the brain, spinal cord, and eyes, grossly and having an affair. The mother stated it was entirely possible she became
microscopically. These findings will be discussed in relation to previous pregnant while having the affair because her husband had a vasectomy.
literature reports and the seat-belt recommendations for pregnant At autopsy, the tense swelling and erythema of the lower
women. extremities was noted to be in a trouser distribution. The legs had a
Hypoxia, direct impact, and acceleration-deceleration forces are the crepitus-like feel to them. Internal examination of the pelvis found that
usual components producing complex neuropathologic injuries. The the uterus had a slightly purple and erythematous fundus but no
resulting lesions depend on the age of the victim; the susceptibility of the perforation. The endometrial cavity was full of hemorrhagic debris but
immature brain to trauma and the resulting pattern of injuries differ no obvious fetal tissue was seen grossly. Microscopic examination of the
between fetal, childhood and adult brains. There are few reports in the debris revealed extensive autolysis with a few fragments resembling
literature of traumatic fetal brain injuries resulting from motor vehicle placental villi. Blood cultures had been performed at the hospital prior
collision, rare reports including autopsy or eye pathology findings. In to the cardiac arrest. Despite having received one dose of antibiotics at
addition, findings are correlated with the use of a 3-point restraint system the medical clinic, one of the blood cultures grew Clostridium
with the lap belt positioned under the uterus as recommended. perfringens, which can produce gas gangrene.
Fetus, Brain, Traumatic Putting the story together, it appeared the woman got pregnant and
either had an abortion or a spontaneous miscarriage with retention of
products of conception. There was no history she had been to any doctor
for an abortion. Neither her mother, friends, nor family knew anything bedroom. He immediately called an ambulance; they arrived promptly
about her being pregnant. If the decedent did get an abortion through a and attempted CPR but to no avail; she was declared dead at the scene.
clinic or through personal instrumentation, there were complications that The cause and manner of death were undetermined and the examining
were not addressed. If the uterine contents were retained products of magistrate requested a medicolegal autopsy.
conception from a miscarriage, the sepsis would be explained. There is The postmortem examination showed a female of moderate
no confirmation of her pregnancy before the last ER visit because a physique, 167cm in height, with external signs of pregnancy in keeping
pregnancy test was not performed at the time of her car accident. The with the gestational age of five months. The skin and conjunctivae were
sepsis caused a trouser distribution of swelling and erythema of her very pale and hypostasis was poorly developed. There was evidence of
lower extremities. The crepitus-like feel of the legs may be indicative of attempted resuscitation. There was no evidence of external trauma.
gas gangrene from Clostridium. Cause of death in this case is acute Internal examination of the cranial and chest cavities revealed only
sepsis due to uterine infection. pallor of all organs and tissues, but no other significant pathological
It is important to note that it would be unusual to find identifiable findings. Opening of the abdomen showed about 4500 ml of blood in the
fetal or placental tissue in a case such as this. The time that is required peritoneal cavity. Examination of the uterus and adnexa showed no
for the development of the sepsis is long enough for all such tissues to evidence of ruptures or other possible source of bleeding. Within the
autolyze and be unidentifiable under the microscope. Interviews with uterine cavity was a dead female fetus, normally developed according to
family and friends regarding medical and social history are very gestational age. The other possible site of hemorrhage was an extremely
important in understanding the background of the illness. Also helpful, enlarged spleen, which weighed 780 g, but showed no evidence of
are discussions with other medical examiners with more experience that rupture. Finally, the source of bleeding was discovered by examination
have seen a few of these cases. Their wisdom is invaluable. of the splenic artery, which was dilated throughout its course (with a
Abortion, Miscarriage, Septicemia circumference measuring up to 1.5 cm), tortuous, with one 1 cm long
fusiform and two big saccular aneurysms, measuring 4 cm and 2 cm in
diameter. The larger of the two saccular aneurysms showed a 0.5 cm
G39 Fatal Rupture of Splenic Artery long rupture, while attached to the smaller of the two was an accessory
spleen, measuring 1 cm in diameter. There were several further accessory
Aneurysm in a Pregnant Woman spleens in the vicinity, with a diameter varying between 0.5 cm and 1.5
With Portal Hypertension cm. The portal vein was almost completely obliterated by an old partly
calcified thrombus. Death was deemed natural, caused by
Slobodan Savic, MD, PhD*, School of Medicine, University of Belgrade, exsanguination due to a ruptured splenic artery aneurysm. During
Institute of Forensic Medicine, Deligradska 31a, Belgrade, 11000, interview with the deceased’s husband it became apparent that all the
SERBIA AND MONTENEGRO; Djordje Alempijevic, PhD, Institute of above mentioned severe pathological changes involving the splenic
Forensic Medicine, Faculty of Medicine, 31 A Deligradska St., Belgrade, artery, spleen and portal vein, with portal hypertension, had been
11000, SERBIA AND MONTENEGRO; Irina Damjanjuk, MD, Institute diagnosed both radiologically and clinically two years prior to the fatal
of Forensic Medicine, Belgrade, OR 11000, SERBIA AND outcome. According to the deceased’s medical records, this important
MONTENEGRO; Stojan Petkovic, MD PhD, Klinicki Centar Vojvodina, anamnestic information had not been disclosed to the obstetrician who
Department of Forensic Medicine, Clinical Center of Vojvodina, Hajduk controlled her pregnancy.
Veljkova 5-7, Novi Sad, 21000, SERBIA AND MONTENEGRO; and The important pathological, clinical, and medicolegal issues
Radmila Stevanovic, MD, Institute of Pathology, School of Medicine, concerning the reported case, mainly the causative relationship between
University of Belgrade, 8 Dr Subotica St., Belgrade, 11000, SERBIA pregnancy, portal hypertension, and splenic artery aneurysm, clinical
AND MONTENEGRO recommendations regarding pregnancy in women with diagnosed splenic
artery aneurysm as well as medicolegal problems connected to patient-
By attending this presentation, attendees will learn about important physician relationship, and potential accusations of medical negligence
pathological characteristics of splenic artery aneurysms, their causative and malpractice will be discussed.
correlation with pregnancy and portal hypertension, as well as clinical Splenic Artery Aneurysm, Pregnancy, Portal Hypertension
and medicolegal aspects of cases where their rupture leads to a fatal
outcome.
This presentation will impact the forensic community by G40 How Often is Pre-Existing Disease Found in
demonstrating how development of splenic artery aneurysm may be
connected with pregnancy and portal hypertension; it is a potential
Child Deaths?
source of profuse abdominal hemorrhage and sudden unexpected death,
sometimes in previously apparently healthy individuals. Also of M.G.F. Gilliland, MD*, Brody School of Medicine at East Carolina
importance in this particular case is the patient’s intention to hide a University, Pathology & Laboratory Medicine, Brody Building,
known disease from the attending physician, which may cause serious Greenville, NC 27858-4354
and potentially fatal errors in medical treatment.
Fatal complications of pregnancy and childbirth always attract After attending this presentation, attendees will be able to describe
special public and medical attention and are usually a serious challenge the frequency of finding pre-existing disease in a group of child death
for forensic pathologists, especially if death occurs suddenly and investigations and discuss the potential significance of such findings in
unexpectedly in a previously apparently healthy woman. This case individual cases.
concerns a 30-year-old female, five months pregnant with her first child, This presentation will impact the forensic community by
who was found dead in her flat. According to the statement of the demonstrating why the forensic science community needs a scientific
husband, cited in the initial police report, she had regular check-ups with basis for comparison of individual cases to a larger group of child deaths
her obstetrician. During pregnancy she did not complain of abdominal when providing information to triers of fact.
pain or any other discomfort. On the day in question the husband left the Forensic pathologists are often asked whether injured children have
flat at 7:00 p.m. while she stayed at home preparing a meal. When he pre-existing diseases when discussing findings in death investigations.
came back one hour later he found her lifeless, lying on the bed in their Commonly the pathologist is then asked to compare individual case

findings with findings in a larger population of children. The objective of G41 Lymphogenic Cardiomyopathy: A Possible
this study was to review a series of child death investigations and
determine the frequency of identifying pre-existing disease in the group.
Cause of Non-Immune Fetal Hydrops
A prospective study focused on the deaths of 169 of approximately
400 child deaths investigated by the Southwestern Institute of Forensic Antonio Bonifacio, MD*, Stefania Zerbo, MD, Cettina Sortino,
Sciences (SWIFS) in Dallas, TX from 1981-1989. Investigation of these Pierangela Fleres, MD, and Emiliano Maresi, PhD, Department of
deaths included information about the circumstances of death or Biotechnology and Legal Medicine, Section of Legal Medicine, Via del
collapse, prior medical and social history, autopsy examination with Vespro, n. 129, Palermo, 90127, ITALY
ocular examination, toxicologic investigation, radiography when
indicated, and additional investigations when questions remained. The After attending this presentation, attendees will gain knowledge of
study has been previously described and included: 19 asphyxial, 80 three particular cases of congenital and isolated cardiac
closed head injury, 13 trunk injury, 13 central nervous system disease, 13 lymphangiectasia manifested in utero with cardiac failure and hydrops.
sudden infant death syndrome, 21 other natural deaths, and 10 deaths This presentation will impact the forensic community by exploring
with undetermined cause and manner. The central nervous system how cardiac isolated lymphangiectasia might represent a new
diseases included meningitis, seizure disorders, spontaneous nosological entity that should be included among the primary
intraventricular and subarachnoid hemorrhages, and a brain tumor. The cardiomyopathies (lymphogenic cardiomyopathy). Consequently, this
other natural deaths included respiratory tract illnesses, sepsis, entity should be investigated among the possible causes of non-immune
congenital heart disease, myocarditis, a volvulus, and a dehydration hydrops foetalis (HF).
death. Demographics were similar to the child deaths investigated at It is the intent of this presentation that cardiac isolated
SWIFS: 78% were two years of age and under; 98 were white, 51 black, lymphangiectasia might represent a new nosological entity that should
16 Latino, and 4 other ancestry. Over half, 59%, were boys. Pre-existing be included among the primary cardiomyopathies (lymphogenic
disease was defined as diseases found at autopsy whether the disease cardiomyopathy). Consequently, this entity should be investigated
contributed to death or not. However, children with diseases resulting among the possible causes of non-immune hydrops foetalis.
from cardiovascular collapse were not included in the pre-existing HF is an aspecific and terminal sign of many fetal diseases that
disease group. Bronchopneumonia, myocardial ischemia, or watershed could be observed at any time during pregnancy. In fully developed HF,
infarcts were found in some of the children who were well until an injury there is subcutaneous oedema with fluid accumulations in peritoneal,
event occurred. These diseases were considered consequences of the pleural, and pericardial cavities. The umbilical cord and placenta are
collapse event and not included. Analysis of the data regarding also oedematous and there is polyhydramnios. In the early stages of HF,
bronchopneumonia has previously been reported for this study the fluid accumulations are not present in all compartments. HF is
population. Review of the 169 deaths identified 60 children with pre- caused by three main mechanisms: anemia, hypoproteinemia, and
existing diseases and 109 without such diseases. cardiac failure. Most cases fit within this classification, although some
The group was further subdivided by the mechanism of the cases remain unsolved under the name of “idiopathic HF.” Another
immediate cause of death. The distribution of pre-existing disease classification divides HF into treatable (27%) and untreatable (73%)
among unnatural, natural, and undetermined causes revealed: forms. The success of isoimmunization prevention programs
demonstrated that most cases of HF are now non-immune and depend on
cardiovascular diseases (22%), chromosomal abnormalities (13%),
thoracic causes (10%), anemia (homozygous α-thalassemia),
monochorionic twinning (6%), infections (5%), miscellaneous (16%),
not determined (20%). Cardiovascular HF seems to be more frequently
associated with structural and functional abnormalities that cause
Pre-existing disease was uncommon among injured children. For volume and/or pressure overload on the right atrium such as left heart
some of the intentional injury deaths investigation suggested that otitis syndrome, arrhythmias, myocarditis, cardiomyopathies, cardiac tumors,
media or retardation may have been a factor in increasing the caregiver’s myocardial infarction, and arterial calcification.
frustration with the child. The pre-existing diseases did not appear to Three unusual cases of congenital and isolated cardiac
increase the risk of injury in the inadvertent injury deaths and appeared lymphangiectasia (ICL) manifested in utero with cardiac failure and
to be incidental findings. The deaths attributed to natural causes hydrops will be presented.
identified diseases sufficient to account for the children’s deaths, and, as Case1: A male hydropic fetus with a gestational age of 14.2 weeks
such, had the greatest frequency of pre-existing disease by the definition without dysmorphia. The mother was 32-years-old and had four
used in this study. The 13 with no pre-existing disease included nine of pregnancies, one of them resulting in miscarriage due to unknown
the SIDS deaths which did not have sufficient disease or injury to causes. Ultrasound of the fetus and placenta showed regular heart rate
account for deaths. Review of scene and circumstances, medical with biventricular hypocontractility and without congenital cardiac and
records, and search for social service involvement revealed no concerns. extra-cardiac defects and polyhydramnios. Amniocentesis revealed a
In the 1980s such non-suspicious deaths were attributed to Sudden Infant normal karyotype.
Death Syndrome at SWIFS. The other four natural deaths with no pre- Case 2: A male hydropic fetus with a gestational age of 19.5 weeks
existing disease were diseases resulting from a prior remote injury from without dysmorphia. The mother was 29-years-old and had a previous
which the child had at least partially recovered. Undetermined deaths in miscarriage due to a premature rupture of the placental membranes
this study had neither adequate natural disease nor injury to account for (acute chorioamnionitis) at the 25th week of gestation. Ultrasound of the
the deaths and suspicious scenes, circumstances, medical records, or fetus and placenta showed regular heart rate with biventricular
social service histories. hypocontractility, without congenital cardiac, and extra-cardiac defects,
Review of a series of child deaths including both natural and and polyhydramnios. Amniocentesis revealed a normal karyotype.
unnatural causes and manners of deaths revealed that most natural deaths Case 3: A female non-hydropic fetus with a gestational age of 22
occurred in children with pre-existing disease and most unnatural deaths weeks without dysmorphia, except for the presence of a single head held
occurred in otherwise healthy children. Reporting such findings plica. The mother, 27-years-old, was at first pregnancy. Ultrasound of
provides a scientific basis for comparison of individual cases to a larger the fetus and placenta showed light pericardial effusions, regular heart
group of child deaths. rate with biventricular hypocontractility, without congenital cardiac and
Child Death, Child Abuse, Pre-Existing Disease extra-cardiac defects, and polyhydramnios. Amniocentesis revealed
Trisomia 21.
In all cases, fetal autopsies showed ultrasound findings conducted p.m. She was examined and released from a local hospital without
during pregnancy. At histology, the organs were normally structured having undergone imaging studies. According to the report, later that
except for the heart that showed a “moth-eaten” aspect in the ventricular evening, the child began vomiting and subsequently went to sleep. The
walls, due to severe, diffuse and transmural lymphangiectasia and next morning, she continued to feel nauseous and vomited in the
interstitial lymphedema. The interposed myocardium resulted morning. She went to bed around noon and was found unresponsive at
compressed, distorted, trabeculated, and with multifocal patchy 12:50 pm on 6/28/08. The child was pronounced dead at 1:47 pm on the
coagulative miofibrillolisis (contraction band necrosis). The same day. Investigation revealed no evidence of anything other than
morphological examination in situ of apoptosis highlighted in all cases unintentional injury. Autopsy revealed a laceration of the head with an
the presence of frequent apoptotic events in the endothelia of small underlying depressed skull fracture and focal epidural hemorrhage; focal
arteries and veins. minor contusions and abrasions of the torso; hemoperitoneum; duodenal
Discussion: ICL is an extremely rare entity and up-to-date the transection distal to the pylorus; contusion of the liver; intra-abdominal
literature reports describe only one case characterized by septal soft tissue hemorrhage of the ligamentum teres, greater and lesser
localization of this lesion causing septal hypertrophy and left ventricular omentum, and mesentery; petechial hemorrhages of the lower lobe of the
outflow obstruction mimicking hypertrophic cardiomyopathy. These right lung; peri-pancreatic soft tissue hemorrhage with bile staining; and
cases represent the first report of ICL involving diffusely the heart, minor abrasions and contusions of the extremities. Histologic
causing cardiac failure and hydrops of various degrees. The findings of examination revealed an abundance of neutrophils, fibrinous debris,
a marked apoptosis in the endothelial cells of blood vessels suggest that scattered monocytes, and an absence of hemosiderin laden macrophages,
interstitial lymphoedema and lymphatic overload is due to increase which confirmed the timeline of investigation. The cause of death in this
vascular permeability of the cardiac blood microcirculation. 9-year-old female was head and abdominal injuries sustained after
Hydrops Fetalis, Lymphangiectasia, Cardiomyopathy falling from a bicycle.
A common cause of accidental abdominal trauma in grade-school
children is due to impact with bicycle handlebars. This injury can mimic
G42 Prolonged Survival Time Following homicidal blunt force injury. The importance of histologic examination
of injuries in different tissues with a known timeline of events aids in
Duodenal Transection in a Child With predicting an unknown timeline in homicidal blunt force injury cases.
Abdominal Trauma Such trauma commonly causes lacerations of the duodenum, and in
many instances, severe internal organ damage is accompanied by a
Lauren E. Moser, MD*, Office of the Chief Medical Examiner, 111 Penn dramatic paucity of significant external injury. Abdominal organ injury
Street, Baltimore, MD 21201; Mary G. Ripple, MD, 68 Bluebird Road, has a poor prognosis due to delay in therapy. An appreciation for the
Port Deposit, MD 21904; and David R. Fowler, MD, Office of the Chief potential severity of blunt abdominal trauma, which can provoke more
Medical Examiner, 111 Penn Street, Baltimore, MD 21201 efficient diagnosis of the injury and hastened therapy, may save a
precious life.
After attending this presentation, attendees will be able to recognize Duodenum, Trauma, Survival
the symptomatology associated with abdominal trauma and will be able
to understand the correlation between symptoms and pathologic injury
correlating histologic examination of tissues with a timeline of events. G43 Role of Scene Reconstruction in the
This presentation will impact the forensic community by providing
valuable information about symptomatology associated with blunt
Medicolegal Investigation of Sudden
abdominal trauma. Seemingly minor external injuries may harbor Unexpected Infant Deaths
terminal internal pathology. Recognition of the potential severity of
these injuries may prompt clinicians to conduct more thorough patient Richard C. Harruff, PhD, and Pamela S. Ulmer, DO*, King County
examinations and pursue imaging studies to identify unexpected internal Medical Examiner’s Office, 325 9th Avenue, HMC Box 359792, Seattle,
injuries. In many cases of homicidal blunt force injury, forensic WA 98104-2499
pathologists are asked to estimate the time of injury despite the uncertain
circumstantial timeline of case investigation. In this case, a relatively After attending this presentation, attendees will recognize the value
accurate timeline was known. Hence, the correlation with microscopic of scene reconstruction as a routine component of infant death scene
sections of the injury can provide assistance in the evaluation of investigation.
previously published timelines for the inflammatory response. This presentation will impact the forensic community by showing
Upon completion of this presentation, attendees will have an how medicolegal death investigators can enhance the quality of their
appreciation for the clinical symptomatology associated with duodenal scene investigations and provide valuable information that may be used
transection following blunt abdominal trauma and the importance of to prevent or reduce future infant deaths.
histologic evaluation of this type of injury to foster the sequencing of Complete investigation of sudden unexpected infant deaths requires
events. Subtle symptoms can dissimilate potentially emergent, life- scene investigation, full autopsy, and review of the case history. Careful
threatening pathology. This particular case discussion exemplifies scene investigation is crucial, not only for understanding why one
prolonged (approximately 24 hrs) survival in a child that sustained a particular infant died, but also for developing valid strategies to prevent
duodenal transection injury after falling from a bicycle. A literature future infant deaths. This presentation examines the techniques and
review of comparable cases will also be performed. Case correlation value of doing scene reconstruction as part of a rigorous investigation of
may aid in establishing a time range of survival, which would portend a sudden unexpected infant death.
significant clinical value. Clinicians who are knowledgeable about the The King County Medical Examiner’s Office (KCMEO)
potential injuries caused by abdominal trauma are more likely to suspect investigates all sudden unexpected infant deaths using: (1) a
injury despite the absence of suggestive symptoms. Such analysis will standardized scene investigation protocol, (2) a complete autopsy
likely demonstrate that an official clinical diagnosis of intestinal including microscopic examinations, toxicology, metabolic screening,
laceration occurs when an individual’s symptoms are more severe and microbiological cultures when indicated, and (3) review of the case
(postulating that there is a period of survival status-post injury). history with police and child protective agencies. For this study, the
A 9-year-old Hispanic female sustained head and abdominal computerized KCMEO database from 1995 to 2008 was searched for all
injuries after falling from her bicycle on 6/27/08 at approximately 1-2 deaths of children between the ages of one week and three years. These

were then analyzed to group the deaths by manner of death and further the differential can lead to diagnostic errors and wrongful process.
subclassify natural death. In addition, the photographic records of This presentation will impact the forensic community by giving a
KCMEO were individually reviewed to find cases in which scene better understanding of the value of integrated investigations and their
investigation included scene reconstruction. The cases in which scene ability to serve justice.
reconstruction yielded information important for certifying cause and A 7-month-old child died at a pediatric hospital of “non-accidental
manner of death were then selected as examples to demonstrate the trauma.” The chart was given to the pathologist, and conversation from
techniques of this investigative tool and its value for the overall death the treating physician indicated intracranial and retinal hemorrhaging.
investigation. The pathologist recorded a cryptic entry: “INR=1.1.” An extensive
Between 1995 and 2008, 505 deaths of infants and young children medical chart dating back to the decedent’s third day of life was not
from one week to 3 years of age were recorded in the KCMEO database. disclosed.
Of these 505 deaths, 326 of these were classified natural, 107 accident, The decedent was the twin B of twins born at 35 1/2 weeks,
2 complication of therapy, 47 homicide, and 23 undetermined. There discordant from his twin sister by a birth weight 20% less. Severe reflux
were 232 deaths that were certified as SIDS. During this time period, disease was present since birth. He required a fundoplication and a
151 deaths were investigated using a doll or similar prop to reconstruct feeding tube through the abdomen. At birth he was in the 25th
the scene in which the caregiver found the child dead. The scene percentile, until his sixth month when it was in the 15th and terminally,
reconstruction included instances of natural deaths, accidents, and deaths had fallen to the 5th. Despite adequate nutritional intake, he no longer
certified as undetermined. absorbed the nutrients and was diagnosed with failure to thrive. Shortly
Scene reconstruction is an essential part of the investigation into the before death, he had the gastrostomy site cauterized for continual
death of an infant or young child. Invariably the death scene is disturbed bleeding.
and therefore requires a patient, well-trained, experienced, and The medical examiner ruled Shaken Baby Syndrome. The father
compassionate investigator to uncover the details surrounding the death. was arrested subsequent to his statement that after seeing his son on the
Using a fabricated, stuffed doll or similar prop, and working patiently floor with his aggressive 13-month-old daughter kneeling on the infant’s
with the caregiver is the best means for establishing the location and stomach and her hands at his neck; he separated them and found the
position in which the child was last seen, the usual position for sleeping, infant struggling to breathe. To revive the child, he “shook” it. He was
and the position when found unresponsive. Furthermore, this method charged with first degree murder. The defense desired a medical review.
supports a photographic record that is fairly acceptable to the Deconstruction revealed two different autopsy protocols, the
caregiver(s) and that can later be used to demonstrate the death scene in absence of an adequate neck dissection, the missed presence of prior
an emotionally neutral manner. Risk factors and hazards, including bed retinal hemorrhages, and the failure to observe a tongue tumor. The
sharing, present in the child’s environment can be readily documented presence of the gastrostomy and fundoplicaton went unexplained, as did
and demonstrated with respect to the specific hazard and the way in contusions the hospital reported, on the back. Significant hospital
which the hazard is responsible for the death. Witness reliability can also laboratory values included coagulation studies with a prolonged
be assessed with this technique. As important as scene reconstruction prothrombin time (PT) and a normal activated partial thromboplastin
proves to be, there are several obstacles in utilizing this method. time (aPTT). The International Normalized Ratio (INR) was 1.1, within
Emergency medical personnel frequently disrupt the integrity of the normal range. The timeline revealed an initial retinal examination with
scene by transporting babies that they know are dead to the hospital hemorrhage in the left eye, hours later both retinas were hemorrhagic.
emergency department; this practice must be strongly discouraged. The Iron stains of the eyes by the defense were positive, indicating remote
death investigator, agency, or otherwise well-meaning individuals may hemorrhage. Records of the organ procurement organization indicated
feel that scene reconstruction is too invasive into the caregiver(s) grief the use of vasopressors and anticoagulants, increasing the hemorrhages.
and privacy. Training, experience, and compassion are needed to The differential diagnosis when the PT is long and the aPTT is
overcome this obstacle. There is the valid concern that a caregiver or normal is divided between liver disease or a deficiency of vitamin K an
witness may not be reliable in reconstructing the scene for the essential vitamin that enables the liver to produce coagulation factors.
investigator(s). Again, experience has shown that patience and Vitamin K Deficiency Bleeding (VKDB) is a third world disease. The
compassion are the most valuable qualities for gaining witness trust and clinician relied upon the INR that no coagulopathy was present because
revealing the truth. In conclusion, scene reconstruction provides the INR was normal. This is an inappropriate practice as the INR is
invaluable information, and therefore, should be considered one of the intended only for those patients on coumadin therapy for periods greater
standards for a quality infant death investigation. than two weeks.
Medicolegal Investigation, Sudden Infant Death Syndrome, Studies from the University of Tennessee confirm clinicians rely
Scene Reconstruction upon the INR as an indicator of normal coagulation status. This practice
obscures the initial stages of coagulopathies. Ironically, other studies
ordered were not followed up, or were cancelled after death, thus
G44 Death by INR: A Case of Vitamin K preventing a definitive answer. The pediatricians remained adamant the
child was murdered. The defense presented this finding to the
Deficiency Bleeding Masquerading as prosecution, and settled via diversion.
Shaken Baby Syndrome Shaken Baby Syndrome, Deconstruction, Coagulopathy
O.C. Smith, MD*, Conscience and Science in Medicine, LLC 9639

Rosemark Road, Atoka, TN 38004; and Jennifer Griffith, MS, Lani
Collins, MS, and Linda Williford, PhD, The University of Tennessee
Clinical Laboratory Sciences, 930 Madison Avenue, Memphis, TN 38163
After attending this presentation, attendees will understand the need

for a deconstruction oriented approach when evaluating Shaken Baby
Syndrome cases; realize that differential diagnoses exist for most any
medical finding and that superficial observations and failure to develop

G45 Malicious Use of Nonprescription Cough concentration levels are rarely reported because appropriate specimens
are not routinely collected during autopsy. These body fluid/tissue drug
and Cold Medications in Children levels are often difficult to obtain due to limited specimen and analytical
challenges. They are also difficult to interpret due to postmortem effects
Jody L. Green, PhD*, Denver Health Rocky Mountain Poison & Drug including redistribution as well as limited peer-reviewed reference
Center, 777 Bannock Street, MC 0180, Denver, CO 80204; William ranges for the pediatric population. Interpretation of drug levels should
Banner, PhD, Oklahoma Poison Control Center, 4822 East 112th Street, be done with pharmacokinetic parameters and must not rely on published
Tulsa, OK 74137; Randall Bond, MD, Cincinnati Drug & Poison ranges which do not take into account the elapsed time since
Information Center, 660 Lincoln Avenue, Cincinnati, OH 45206; Ralph administration of the drug. Those performing investigations of pediatric
Kauffman, MD, University of Missouri-Kansas City, Department of deaths, especially in children less than 2 years of age, should consider
Pediatrics, 2919 NW 86th Terrace, Kansas City, MO 64154; Anthony overdose of cough and cold medications and other drugs, including
Manoguerra, PharmD, University of Californis at San Diego, School of instances of malicious use of these drugs by parents or caregivers.
Pharmacy, 9500 Gilman Drive, MC 0657, La Jolla, CA 92093; Robert B. Pediatric Deaths, Nonprescription Medications, Drug Toxicity
Palmer, PhD, Toxicology Associates, 2555 South Downing Street, Suite
260, Denver, CO 80210; Ian M. Paul, MD, Penn State College of
Medicine, 500 University Drive, HMC; Pediatrics; H085, Hershey, PA
17033; Barry Rumack, MD, University of Colorado, Anshutz Medical
G46 Wrongful Convictions and
Campus, Denver, CO 80045; David C. Winston, PhD, Forensic Science Pediatric Forensic Pathology:
Center, 2825 East District Street, Tucson, AZ 85714; and Richard C. The Canadian Experience
Dart, PhD, Denver Health Rocky Mountain Poison & Drug Center, 777
Bannock Street, MC 0180, Denver, CO 80204 Jeffrey R. Manishen, BA*, Ross & McBride LLP, 1 King Street West, 10th
Floor, PO Box 907, Hamilton,, L8N 3P6, CANADA
process and outcomes of a systematic evaluation of pediatric deaths After attending this presentation, attendees will understand of how
associated with nonprescription cough and cold drugs and will gain an inadequate training and supervision, difficulties in the communication of
awareness of the rare but apparent malicious use of these medications in opinion evidence, and problematic areas in pediatric forensic pathology
children. may result in wrongful convictions. Those in attendance will enhance
This presentation will impact the forensic community by increasing their understanding of the ways to improve the interaction between
awareness of the malicious use of these drugs and encourage more forensic scientists and the criminal justice system.
detailed investigations into all pediatric deaths. This presentation will impact the forensic community by exploring
The safety of nonprescription cough and cold medication use in the recommendations of the Inquiry into Pediatric Forensic Pathology
children less than 12 years of age has been questioned. To better conducted by appellate court Justice Stephen Goudge in Toronto,
understand the safety profile of these drugs, an independent expert panel Ontario, Canada, which are likely to have a significant impact on the
reviewed available death reports of children less than 12 years of age prevention of miscarriages of justice on an international level.
with mention of a cough/cold ingredient that were obtained from three As a result of the identification of serious errors in the postmortem
sources: English language medical literature (1949-2007), National reports and testimony of Dr. Charles Smith, a pathologist called by the
Poison Data System (1983-2007) and Manufacturer Safety Records prosecution in several child homicide cases in Ontario, Canada, the
(1980-2007). The panel assessed the causal relationship between each provincial government convened a public inquiry to address systemic
reported drug and death using predetermined definitions for “Definitely issues in order to prevent the recurrence of such tragedies. Between
Related”, “Likely Related”, “Possibly Related”, “Unlikely Related”, November 2007 and February 2008, the Commissioner heard from
“Definitely Not Related”, and “Unable to Determine”. These definitions government officials, prosecution and defense counsel, police officers,
were based upon clinical course, drug exposure history, body fluid/tissue judges, and law professors as well as the internationally recognized
analytical evidence, and alternative cause of death. The panel also forensic pathologists who were involved in the review of the specific
attempted to categorize the dose ingested (therapeutic/supratherapeutic), cases. Research papers on a variety of topics were received and policy
intent of administration (therapeutic/non-therapeutic) and potential roundtable discussions conducted. Dr. Smith himself also gave evidence
contributing factors for all deaths determined to be at least possibly regarding his efforts and explanations.
related to a cough and cold drug. The investigation of suspicious deaths in children presents many
Of 227 fatality reports reviewed, 92 (41%) deaths were judged at complex challenges for all concerned, including the need for proper
least possibly related to one or more nonprescription cough and cold training and certification of the forensic pathologist, evolving and
drugs. The panel determined that 79 of these involved a supratherapeutic sometimes controversial issues in pediatric forensic pathology, the
dose of the suspect drug. The dose could not be assessed in the difficulty in choosing appropriate language to characterize the level of
remaining 13 cases. There were no cases for which the panel suspected certainty of an opinion regarding cause of death and the dangers of
a therapeutic dose was involved. Of the 92 related deaths, 68 involved “tunnel vision.”
an overdose of the suspect drug administered by a caregiver. Ten such Evidence at the inquiry identified a variety of approaches to address
cases involved the administration of the drug in a daycare setting. these problems. The implementation of a comprehensive postmortem
Twenty-four reports (18 - age <2 years, 5 - age 2 to <6 years, 1 - age 6 report format detailing all opinions and the basis for same ensures a
to <12 years) indicated that the drug was given to the child without an standardized methodology for the timely communication of autopsy
appropriate therapeutic indication (i.e., not for cough or cold symptoms). findings. A vigorous peer review process prior to the release of such
The panel determined that malicious intent was a contributing factor in reports contributes significantly in validating the conclusions. The
20 cases. These were cases in which the drugs were used to either sedate principles of evidence-based medicine provide an important standard to
or intentionally harm the child. Other signs of child abuse including implement and ensure the requisite degree of reliability for a court
hematomas and healed fractures were evident in some cases. considering opinion evidence on issues involving pediatric forensic
The incidence of non-accidental child injuries, specifically death, pathology. Appropriate measures of accountability are necessary to
resulting from the misuse of nonprescription cough and cold medications identify and deal with those circumstances in which the pathologist’s
or other drugs is unknown, in part because there is no standard laboratory practices may be deficient. Continuing education for counsel and
testing during pediatric fatality investigations. Postmortem drug

experts will assist in avoiding misunderstanding of their respective roles provide concordance, to the issuing of a prompt death certificate for the
and participation in the trial process. next of kin, and can also be called upon to be an expert witness in a court
While the inquiry received considerable publicity in Canada, the of law.
lessons which may be learned from these unfortunate events should be This presentation will increase the awareness of the forensic
shared with the international forensic community in order to achieve the community and law enforcement agencies, in the attempt to show, how
objectives of fairness and justice for those charged with criminal both fields can work together in the forensic autopsy. The focus of this
offences. case presentation will highlight the forensic investigation of a high
Forensic, Pediatric, Pathology profile dual homicide case illustrating the forensic team approach. The
difficulty of the case stems from the young age of the two related
victims, the cause and manner of death, the history behind that
G47 The Possibilities and Limitations of investigation, and the final court decision. The presentation will include
how forensic anthropologists recovered the buried remains, how forensic
Neuropathology in Exhumation Autopsies pathologists determined the cause and manner of death, and how forensic
odontologists determined the chronological dental age and the final
Jan E. Leestma, MD*, 1440 North Kingbury Street, Suite 210, Chicago, rendering of a positive identification.
IL 60622 Skeletal remains were discovered in a shallow grave in a wooded
area in Missouri. Forensic Investigators first surveyed and photographed
After attending this presentation, attendees will understand the scene. A forensic anthropologist was then called to assist with the
important opportunities in difficult situations which commonly surround excavation. Two juvenile skeletal remains along with clothing fragments
exhumation autopsies. and projectiles were placed into evidence. The forensic pathologist
It is often assumed that exhumation autopsies will yield only determined that both children were shot in the back of the head, from an
marginal information, least of all to permit in-depth neuropathological indeterminate range, which was the cause of death. The skeletal remains
examinations. This presentation will impact the forensic science were further examined by the forensic anthropologist, who determined
community by demonstrating how five cases prove otherwise. This estimates of height, weight, and race. After procuring antemortem dental
information should be valuable to pathologists and the general forensic records, a positive identification was made by the forensic odontologist.
community, In addition, bone samples were collected and stored for DNA analysis.
Five cases are presented that offer a range of forensic/medical Discussion of the dental (oral) autopsy will reveal how the actual
issues in the context of exhumation autopsies. Four cases involved civil dental x-ray comparisons were made for a positive identification.
or criminal litigations and one case was done for personal reasons of a Specific reference will be made to the use of special dental technology,
family of a suicide victim. such as digital dental radiographs and the WINID dental charting
The durations of burial ranged from two to more than 18 years. All software program. These same dental protocols can also be developed in
individuals had been interred in either wooden or metal caskets, usually the SOP’s and applied by a medical examiner/coroner’s office, for future
within concrete burial vaults. All had been arterially embalmed. At issue multiple deaths or a mass fatality incident.
were the nature of the injuries or processes leading to death that usually Although this was a high profile homicide case, the routine
involved head trauma, but in one case involved possible Marchiafava- utilization of a forensic odontologist can provide additional evidentiary
Bignami syndrome. value to many cases involving skeletal, decomposed, or fragmented
Three of the cases had not been autopsied before, but two had. In remains. Forensic dentistry can provide support evidence for positive
general, preservation of the head, brain, and other organs was good to identification, when other modalities, such as fingerprints or time
excellent and permitted satisfactory case analysis both grossly and sensitive DNA analysis are not utilized.
microscopically. In conclusion, the ability to blend the two forensic sciences,
The opportunities and limitations of exhumation autopsy pathology and odontology, during a forensic autopsy, can be invaluable
neuropathology will be presented. to a medical examiner/coroner office in the investigation process,
Exhumation, Neuropathology, Autopsy criminal trial and for final closure for the victim’s families.
Pathology, Odontology, Positive Identification
G48 Pathology/Odontology: The Team

Approach to a Forensic Autopsy G49 Making the Best of Death
John E. Filippi, DDS*, 1325 North 127th Avenue, Omaha, NE 68154; Chantal Ferraro, PhD*, Long Island University,
and Mary H. Dudley, MD*, Jackson County Medical Examiner’s Office, Sociology/Anthropology, CW Post, Brookville, NY 11548; and O. C.
660 East 24th Street, Kansas City, MO 64108 Smith, MD, Conscience and Science in Medicine, Atoka, TN 38004
After attending this presenation the attendees will undertand the The goals of this presentation are to: (1) evaluate the existing
“dual role” the pathologist and odontologist have in determining the notion of social autopsy, (2) modify and expand it both conceptually and
cause of death and the development of a positive identification methodologically, and (3) integrate findings of physical and social
The presentation will impact the forensic community by increasing autopsies in order to establish a bridge between the forensics of the dead
the awareness of the medical legal system and law enforcement agencies and the forensics of the living.
regarding how the coordination of these two forensic sciences can This presentation will impact the forensic community by providing
support the investigation. a model that is applicable to any population in any community, the
A forensic pathologist performs autopsies to determine the cause understanding of which will make the study of the dead a powerful tool
and manner of death in situations falling under the jurisdiction of the of death prevention for the living.
Medical Examiner/Coroner Office. After the forensic autopsy is The term autopsy most commonly refers to the postmortem
completed, the forensic odontologist examines the dental structures, and examination of a deceased for medical or forensic reasons. In that
through a comparison analysis between the antemortem dental and the context, autopsy is synonymous with necropsy. Etymologically,
postmortem dental records, can render a “rapid onset” positive however, autopsy translates into “to see for oneself.” Recently, the
identification. When working together, both forensic professionals, can addition of modifiers, such as social or psychological, to the term reflects

the attempt to define new fields of inquiry based on the broader latter process should be well documented by words and photographs …”. As
meaning. A psychological autopsy examines the mental state of a stated above, forensic pathologists know the words of their fellow
deceased at time of death, and may contribute to the determination of the surgeons but are not trained in the words of the funeral
manner of death, especially in cases of suicide. The concept of social director/embalmer despite the fact that autopsies are performed on
autopsy is more confusing since its two applications belong to entirely embalmed bodies prior to interment and after disinterment. Since the
different spheres. According to Rick Lavoie (2005) a social autopsy is a conception of DMORT in the early 1980’s, national forensic teams have
pedagogical strategy to help a learning disabled child to see for himself been deployed to 24 mass disaster events. Three of these events
the cause/effect relationship between his social behavior and the exclusively involved cemetery floods, one involved a crematory, and
reactions of others. But for sociologist Eric Klinenberg, who studied the three involved floods that secondarily caused local flooding of
1995 lethal heat wave in Chicago, a social autopsy is a way to identify cemeteries. With disinterred remains the primary focus of the forensic
the social risks of a dependent population factors that led the isolated, the team is not in determining the cause of death but in finding positive
old and the poor to die by the hundreds. Although valid and useful in identification. With disinterred embalmed bodies, the presence of
their own right, these definitions are not adequate for us. embalming artifacts may be one of the main physical findings the
The model of social autopsy being discussed originates in the DMORT forensic pathologist will have for positive identification. If the
longitudinal study of child death which was presented at the 2002 AAFS forensic pathologist is unable to adequately describe the postmortem
meeting. The original study was based on the autopsy reports of the embalming changes that occur during arterial and cavity embalming he
Shelby County (TN) Medical Examiner’s office where over 1,500 cases or she could exclude or misinterpret a useful identifier. If the forensic
of child death were investigated, inclusive of all manners, over a period pathologist knows that the body was embalmed using a single-point
of ten years. The “Swiss Cheese” concept elicited by the Human Factors injection through the right common carotid artery with right jugular vein
Analysis and Classification System (HFACS) was incorporated where drainage or was embalmed by use of the restricted cervical method, this
defects in the layers of latent and active responsibilities, permit lethal level of knowledge would help expedite the identification process when
latent and active failures within individuals, society and cultures to be the local funeral director/embalmer compares their embalming reports
identified. This presentation will focus on homicidal deaths from 0 to 4 with the autopsy report. Since 29% of DMORT’s mass fatality events
years of age and accidental deaths from 0 to 18. Subsequent sociological involve disinterred remains, the affected community would be better
and anthropological research of the community in which these deaths served by having forensic pathologists who are able to speak and write
occurred allowed us to “see for oneself” the levels of failure and the the language of the local funeral director/embalmer.
failures within levels. From this evolves an understanding of what Forensic, Pathologist, Embalming
produces not just the death of each individual but identifies patterns that
anticipate future trauma or death, with its human and societal costs.
These patterns represent a framework of behaviors that must be altered G51 Sickle Cell Trait Associated Deaths:
or remedied by the community. It is the contention of the investigators
that a social autopsy is defined by its ability to reveal such patterns and
A Case Series With a Spectrum of
to highlight the line of failure. The necropsy exists to identify this “tip Clinical Presentations
of this iceberg” the social autopsy defines its magnitude.
Social Autopsy, Necropsy, Prevention Christopher Wilson, MBBS, Jon R. Thogmartin, MD*, Noel A. Palma,
MD, and Susan S. Ignacio, MD, Medical Examiner’s Office, District 6,
10900 Ulmerton Road, Largo, FL 33778; Barbara C. Wolf, MD, and
G50 Building the Communication/Language Wendy A. Lavezzi, MD, Office of the Medical Examiner, District 5, 809
Pine Street, Leesburg, FL 34748; and Mark J. Shuman, MD, Miami
for Collaboration Between the Dade County, Medical Examiner Department, Number One on Bob
Forensic Pathologist and Funeral Hope Road, Miami, FL 33136
Director/Embalmer
After attending this presentation, attendees will be educated with
Vincent E. Hill, MD*, Mortuary Medical Services, 3003 Van Ness Street, respect to the wide variety of clinical presentations persons with sickle
North West, Suite 106, Washington, DC 20008 cell trait manifest including clinical symptoms, laboratory abnormalities,
and gross anatomic and microscopic findings. This study also seeks to
After attending this presentation, attendees will be familiar with the show how simply the diagnosis can be made by the astute clinician or
language and techniques used in the funeral industry. forensic pathologist if only he or she will consider it in the differential
This presentation will impact the forensic community by arming the diagnosis.
forensic pathologist with the words to scientifically describe a body that This presentation will impact the forensic community by showing
has been embalmed. that sickle cell trait is a condition which is not restricted to conventional
This presentation will expose the forensic pathologist to the ethnic boundaries of Afro-Americans and that the diagnosis needs to be
language and embalming procedures used in preserving the dead body. seriously considered in individuals living in geographic locations in
The presentation will be useful to forensic pathologists who are members which the natural environment plays a prominent role in the
of FEMA’s Disaster Mortuary Operational Response Team (DMORT) or manifestation of the disease. Early recognition of the disease in such
work in jurisdictions where cemeteries are subject to flood waters. individuals can possibly result in a decline in mortality.
Forensic pathologists are known for their skill in turning the visual At the conclusion of this presentation, attendees will be educated
into words. They are able to explain orally and in writing the most with respect to the wide variety of clinical presentations persons with
complex surgical procedures despite the fact that they are not trauma sickle cell trait manifest including clinical symptoms, laboratory
surgeons, orthopedic surgeons, neurosurgeons or gynecologists. But, abnormalities, gross anatomic and microscopic findings. This study also
when it comes to the postmortem surgical procedure known as seeks to show how simply the diagnosis can be made by the astute
embalming, the forensic pathologist lacks knowledge of the words and clinician or forensic pathologist if only he or she will consider it.
technical procedures used by the funeral director/embalmer. Michael M. This presentation will hopefully have a significant impact on not
Baden, MD mentions, in Chapter III, Part 4, “Exhumation” (Medicolegal only the forensic community but also on humanity by showing that
Investigation of Death, 4th edition), “The entire exhumation and autopsy sickle cell trait is a condition which is not restricted to conventional
ethnic boundaries of Afro-Americans and that the diagnosis needs to be

seriously considered in individuals living in geographic locations in deaths do and do not constitute commotio cordis. Mention will be made
which the natural environment plays a prominent role in the of the prevalence of commotio cordis and common involved activities,
manifestation of the disease. Early recognition of the disease in such with specific published case examples involving sports activity and a
individuals can possibly result in a decline in mortality. low speed vehicle collision. Case reports resulting from a retrospective
As many as one in three Africans living in areas where malaria is search of cases in Missouri will be presented.
indigenous and approximately one in twelve Americans with African Attention will next be focused on animal models used for the study
ancestry have sickle cell trait. The affected individuals are generally of the pathophysiology of commotio cordis. The theory of “mechano-
asymptomatic and many are not even aware that they carry the gene. The electric coupling” of myocyte stretching and the opening of
general consensus of the public is that sickle cell trait is a relatively potassium/ATP channels will be discussed. Lessons learned from
benign condition and affected persons are at no increased risk of various experiments using animal models will be presented, including
morbidity or mortality because of their condition. However, the forensic the importance of hardness of sports objects and effectiveness of chest
community is cognizant that under the proper set of circumstances, protectors.
sickle cell trait can be potentially fatal. The presentation will include several issues of particular interest to
This study presents a series of 11 individuals with sickle cell trait medicolegal investigators and forensic pathologists. Typical as well as
and one with hemoglobin SC disease who died during various atypical case histories of commotio cordis will be presented, stressing
circumstances. All of the victims were subject to the warm and humid the importance of proper scene investigation and obtaining medical
climate of Florida. The onset and/or duration of symptoms varied from history. There will be a review of possible autopsy findings seen in cases
a few to several hours with many displaying a prolonged lucid interval of commotio cordis. Finally, controversies regarding manner of death in
with stable vital signs. Despite seeking medical treatment, sickle cell atypical cases of commotio cordis will be discussed.
trait related micro-occlusive crisis was never considered in the Commotio Cordis, Precordium, Manner of Death
differential diagnosis. Several cases were associated with sudden death.
In those deaths which were delayed, high anion gap and uncompensated
metabolic acidosis were typical. Also characteristic were large increases G53 Corpora Amylacea and Sudden Death:
in creatine phosphokinase, alanine aminotransferase and aspartate
aminotransferase along with myoglobinemia. Although the antemortem
A Case of Adult Polyglucosan Body
diagnosis of rhabdomyolysis was made, the underlying cause was never Disease Diagnosed at Forensic Autopsy
deduced by the clinicians. Of particular interest was a case of a fatal
splenic crisis due to sickle cell trait in a Caucasian and a victim with Timothy L. Williams, MD*, and R. Ross Reichard, MD, New Mexico
hemoglobin SC who died from a combination of mild traumatic injuries Office of the Medical Investigator, MSC11 6030, 1 University of New
and prolonged bodily inversion. In some cases, sickle cell trait was not Mexico, Albuquerque, NM 87131-0001
even considered in the original death certification.
In conclusion, this study demonstrates the varying characteristics After attending this presentation, attendees will learn about a case
and presentations of 11 cases of sickle cell trait and one case of of adult polyglucosan body disease diagnosed at forensic autopsy.
hemoglobin SC related deaths and shows that such deaths can be sudden This presentation will impact the forensic community by educating
or delayed. Conventional racial delineation of the sickle cell them about the first reported case of adult polyglucosan body disease
hemoglobinopathies should not deter one from considering it in the presenting as sudden death and diagnosed at forensic autopsy.
differential diagnosis especially if the patient is subjected to Adult polyglucosan body disease (APBD) is a rare
environmental and physical stressors which can potentiate the disease. neurodegenerative condition characterized by typical onset in middle
Furthermore, failure to consider sickle cell trait related crises as a age, progressive neurological impairment that is heterogeneous between
diagnosis can result in improper death certification. Greater efforts to those affected, and death within 1-14 years of diagnosis. The
educate the public especially athletes and coaches on the possible histopathological hallmark of the disease is massive deposition of
hazards of exercise induced sickle cell trait related micro-occlusive crisis corpora amylacea (designated polyglucosan bodies in this context) in the
hopefully will result in less morbidity and mortality. central nervous system, and variable deposition of similar material in
Sickle Cell Trait, Exertion, Metabolic Acidosis other sites. While the cause of the disease is as yet unknown, recent
research has identified mutations in proteins involved in glycogen
metabolism in a subset of cases. Some of these mutations are similar to
G52 Commotio Cordis: A Forensic mutations identified in cases of glycogen storage disease type IV (GSD
IV), a disease that classically is present in the first year of life, is of very
Science Perspective heterogeneous manifestation, and is also characterized by massive
deposition of corpora amylacea. The genetic and histopathological
Ariel Goldschmidt, MD*, Steven T. Hensley, and Mary H. Dudley, MD, similarities between these two conditions have lead to speculations that
Jackson County Medical Examiner’s Office, 660 East 24th Street, APBD may represent an adult form of GSD IV.
Kansas City, MO 64108 In this presentation, a case of sudden death is presented wherein
APBD was diagnosed at forensic autopsy. Scene details, relevant
After attending this presentation, attendees will have an enhanced medical and social history, and autopsy and histopathological findings
understanding of the prevalence, pathophysiology, and important are presented and richly illustrated with supporting images.
forensic science issues related to commotio cordis and the ability to The case provides an excellent example of a prolonged and
apply this knowledge to their practice should it become necessary. enigmatic presentation involving a complex interplay of medical, social,
This presentation will impact the forensic community by providing and forensic issues. The histopathology is particularly illustrative of this
a broad and thorough review of the current literature and scientific rare disease, showing massive deposition of corpora amylacea in the
knowledge about commotio cordis, with particular emphasis on key central nervous system, and marked accumulation of similar material in
issues relevant to forensic scientists. Included in the discussion will be the heart. The latter was determined to be the mechanism of death
several published case examples of commotio cordis, as well as several (cardiac arrhythmia) with APBD the underlying cause.
case examples of commotio cordis investigated in the State of Missouri. This presentation represents the first case of APBD reported in a
The presentation will begin with detailed criteria for what type of forensic context. APBD is reviewed and its relationship with other

diseases characterized by massive deposition of corpora amylacea is ● Increased incorporation of investigative practices regarding
outlined. The role of forensic autopsies in the diagnosis of rare ● The Missing into scientific literature, research and training;
conditions is discussed. and
Neuropathology, Corpora Amylacea, Sudden Death ● Growing expectations from bereaved families and the general
public for swift and positive results from forensic
investigations into The Missing.
G54 Trends in Forensic Investigations Into the These trends pose challenges and inherent opportunities for the
forensic community, including:
Missing: Observations From the ICRC ● Helping to meet growing needs worldwide for forensic
practitioners, institutions, and service providers for
Morris Tidball-Binz, MD*, Ute Hofmeister, MA, and Shuala M. Drawdy, investigations into The Missing. These should conform to
MA, International Committee of the Red Cross, 19 Avenue de la Paix, standards of professional best practice, quality assurance and
Geneva, 1202, SWITZERLAND control required for these investigations. Local capacity
building and ownership should be prioritized;
After attending this presentation, attendees will gain awareness of ● Empowering communication, coordination and cooperation, at
trends identified in the application of forensic medical sciences to regional and worldwide levels, between forensic practitioners,
investigations into the whereabouts and fate of persons missing as a institutions and service providers involved in and available for
result of armed conflict, internal violence, or catastrophes, as observed investigations into The Missing;
by the forensic unit of the International Committee of the Red Cross ● Supporting swift access to indispensable forensic know-how,
(ICRC). Attendees will also learn about the steps taken by the ICRC to technology and tools by practitioners and institutions operating
meet challenges posed by these trends. in under-resourced contexts; and
This presentation will impact the forensic community by outlining ● Sustained efforts in public awareness raising about the role,
emerging challenges posed to the wider forensic community by scope, value and limitations of forensic sciences applied to
investigations into persons gone missing as a result of armed conflict, investigations into The Missing.
internal violence or catastrophes, as observed by the ICRC. The trends The clarification of the whereabouts and fate of The Missing in
and challenges identified in this paper will assist in the design of armed conflicts and catastrophes is a humanitarian priority that requires
strategies for effective and efficient contribution to this emerging field a global and concerted effort, including from the forensic community.
by forensic practitioners, institutions, and service providers. Based on trends observed and lessons learned, the ICRC offers
In February 2003, the ICRC organized an International Conference recommendations for addressing the challenges identified in this paper
on The Missing in Geneva, Switzerland. Recommendations were and also for building on the opportunities which these challenges offer to
adopted to prevent and resolve the tragedy of persons unaccounted for as the forensic community.
a result of armed conflict and internal violence. These included Missing Persons, Humanitarian Identifications, International
recommendations on forensic best practices for the recovery, Committee of the Red Cross
management and identification of the dead in challenging contexts,
including: roles, duties, responsibilities and applicable ethical standards
for forensic practitioners and teams; guidelines for the recovery and
storage of human remains; criteria for forensic human identification;
G55 Evidence-Based, Medical-Legal
principles for ethical, effective and efficient information management; Documentation of the Postmortem
and advice on the relationship between forensic practitioners and Anogenital Examination
bereaved families and communities.
Following the International Conference, the ICRC established a Sharon R. Crowley, MN*, FCNS, 122 Emeline Avenue, Santa Cruz, CA
forensic unit to help implement the recommendations worldwide. Since 95060
its inception, the forensic unit has witnessed a sustained increase in the
application of forensic medical sciences to the search for The Missing After attending this presentation, attendees will understand how to
and has observed the following trends: incorporate an evidence-based methodology for the documentation of
● Growing awareness and understanding of the tragedy of The the postmortem genital examination. Attendees will also be able to
Missing in armed conflicts and catastrophes; facilitate incorporation of a previously proposed taxonomy, germane to
● Growing recognition of the importance of proper management the postmortem anogenital examination, in order to improve medical-
and identification of the dead in armed conflicts legal documentation and able to incorporate a theoretical framework for
and catastrophes; sexual murders, as a basis for the methodological examination of the
● Growing needs for experienced forensic practitioners for suspected sexual homicide victim.
investigations into The Missing; This presentation will impact the forensic community by
● Incorporation of recommendations from the 2003 International augmenting and enhancing the forensic examiner’s diagnostic acumen in
Conference on The Missing into international standards and this arena. Helping to avoid ambiguity among examiners in the
national legal and institutional frameworks related to interpretation of clinical findings and improve documentation and
The Missing; ultimately contribute to a better understanding of the etiology and
● Awareness of the need for sustainable local forensic capacity manifestations of fatal sexual violence against women.
to investigate The Missing; The interpretation of genital findings in the deceased remains a vital
● A role-shift from medicolegal practitioners (i.e. coroner, and timely issue. Until recently, a paucity of information existed on the
medical examiner, forensic doctor) towards multidisciplinary nature and appearance of the anogenital tissues during the postmortem
forensic teams in the recovery and identification of interval. Because the traditional genital examination consists of gross
The Missing; visualization, subtle findings were not easily detected. These findings
● Growing reliance on forensic DNA analysis; may constitute injury due to sexual assault, concomitant changes in the
● Demands for professional standards of best practice and anatomy due to postmortem processes of decomposition, or a
quality assurance and control from practitioners and combination of both. The theoretical framework for this proposed
institutions involved in investigations into The Missing; methodological documentation format is founded on:

● Sexual activity by the offender that culminates in the death of labial separation, in addition to routine speculum examination and
the victim. anoscopy.
● Current, ongoing baseline clinical studies on the nature and Appropriate and complete chain-of-custody must be documented
appearance of the anogenital anatomy during the postmortem and is included within the tool. A copy of the tool should be placed
interval. within the sexual assault evidence kit for the criminalist.
● Previously presented methodology for postmortem genital A supplemental narrated summary or dictation is recommended, to
examinations (Crowley, JFS, 2004). complement the standardized form. It also places events in
● Previously described taxonomy for the description and chronological order, incorporates more uniformly understood language,
classification of the appearance of the tissues during the and clarifies roles and responsibilities. The emphasis on teamwork and
postmortem anogenital examination. evaluation is crucial in an event that requires multi-disciplinary
Currently, a wide variation exists in methodology for examination cooperation.
of both antemortem and postmortem sexual assault victims. Postmortem The taxonomy for postmortem genital examinations has proved to
challenges vis-á-vis protocols and procedures may pose even greater be a useful classification system during clinical examination, case
significance, because there is no surviving victim to recount details of documentation, and database entry. This taxonomy has been
the assault, including sexual acts, threats, and other behaviors of the incorporated into the proposed medical-legal form, in order to
offender(s). differentiate postmortem artifact from concomitant findings that might
Currently, no standardized state, regional, or national form exists be suggestive of sexual trauma, i.e., blunt force injury, including
for the accurate and complete documentation of the postmortem lacerations, ecchymoses, and abrasions. This capacity is pivotal. Just as
anogenital examination. The clinical evaluation of the sexual homicide in living victims, it is essential to be able to distinguish benign
victim forms the basis for all related medical-legal reports. gynecological conditions from traumatic findings.
● The question of exam authorization may be an area of concern. Data to date from the analysis of ongoing, baseline controls has
However, no separate authorization should be needed, as these yielded useful information for the development of a template for
examinations fall under the jurisdiction of the Coroner or documentation. It is important to carefully describe the nature and
Medical Examiner. In addition, they are medically appearance of salient anatomic sites. Analysis of research data has
non-invasive procedures. reinforced the need for the examiner to avoid working in a vacuum. The
● The postmortem genital examination record is not a complete examiner whose sole prior experience lies in the antemortem arena may
medical record, as with other forms used to document the confuse normal postmortem artifact with traumatic findings. Common
sexual examinations of living sexual assault victims, e.g., benign gynecological findings, such as labial adhesions and punctate
California Office of Emergency Services, forms 923 and 930. lesions, are often present. Other findings, such as postmortem mucosal
Therefore, supplemental medical and/or gynecological records shedding at various sites within the anogenital tissues, have occurred
may be of benefit for further review. with sufficient frequency during the postmortem control study to warrant
The meaning and performance of the acts committed during a recognition as normal postmortem artifact.
sexual murder varies with the offender. Salient features of the crime may The ultimate goal is to better visualize and improve the
be evident, which may give information about the offender’s sexual understanding of what is normal in anogenital anatomy during the
motivation. A systematic, evidence-based approach to documentation is postmortem interval. To this end, careful scrutiny and meticulous
part of a consistent, methodological approach to the evaluation of this documentation will both add to individual case yield and enhance the
population. overall body of knowledge within this area.
Scrupulous documentation should provide as much data as is Postmortem Anogenital Examination, Sexual Homicide, Colposcopy
known about a given case. This includes the following general
categories: salient case and demographic data, disposition of the body,
available history, general physical assessment, clothing, toxicology, G56 Postmortem Recognition of Sickle Cell Trait
evaluation of nongenital trauma, components of the sexual assault
evidence kit, the genital and anal examination, and colposcopic Kathryn H. Haden-Pinneri, MD*, and Sara Nunez-Doyle, MD, Harris
examination. It is important to clarify where the primary responsibility County Medical Examiner’s Office, 1885 Old Spanish Trail, Houston, TX
for a portion of the examination and/or the documentation was not 77054
assumed, e.g., in the evaluation of nongenital trauma by a forensic nurse.
Select cases of fatal sexual violence provide actual examples of After attending this presentation, attendees will gain a better
traumatic injuries, consistent with blunt force trauma to the anogenital understanding of the importance of recognizing the incidental autopsy
tissues. Injuries can be categorized as to type, number, and anatomic findings related to sickle cell trait and the implications this diagnosis
site. In addition, normative studies of baseline controls were evaluated, may have on surviving family members.
using the sequential methodology for the postmortem genital This presentation will impact the forensic community through
examination with colposcopy, SART-TO-GO (Crowley, JFS, 2004). A knowledge gained about sickle cell trait and from insight regarding the
previously presented taxonomy was developed to describe the nature and importance of notification of surviving family members.
appearance of the postmortem genital anatomy (Crowley & Peterson, Sickle cell trait is defined as the heterozygous condition of having
AAFS, 2004) and to develop a standardized classification system for one gene for sickle cell hemoglobin and one for normal hemoglobin.
these previously undescribed findings. This taxonomy is incorporated in Patients with sickle cell trait tend to lead normal lives, without serious
the proposed protocol for the documentation of the medical-legal complications; therefore it is not regarded as a disease state. In certain
examination of sexual homicide victims. conditions; however, complications not only occur, but they may be
The postmortem genital anatomy worksheet consists of the same fatal. Deaths due to exertional sickling involving young athletes have
anatomic sites that are routinely examined in the living sexual assault made headline news on multiple occasions. When an individual with
victim. These include the peri-urethra/peri-clitoral area, labia majora, sickle cell trait becomes hypoxic, acidotic, dehydrated, or hypothermic,
labia minora, posterior fourchette, fossa navicularis, hymen, vagina, the typically silent sickle cell trait transforms into a syndrome that
cervix, perineum, anus, and rectum. Supplemental documentation is resembles sickle cell disease with widespread sickling and subsequent
included for both the adult male and the pre-pubertal child. vaso-occlusion.
All examination techniques and any adjuncts should be recorded, The presence or absence of intravascular sickled red blood cells in
such as use of balloon-covered swabs (Crowley, 1999), labial traction, or tissue specimens depends on the degree of oxygenation of the sample

prior to fixation. Intravascular sickling may occur due to terminal Prolapse rectum (PR) or protrusion of the rectum beyond the anus
hypoxemia in the setting of sickle cell trait. It is almost impossible to occurs frequently in populations at both extremes of age. In the pediatric
determine the role sickled cells may have played by the presence or population, PR is usually diagnosed before the age of three years, and in
absence of intravascular sickling in autopsy specimens. adults, the peak incidence of PR is after the fifth decade of life. The
The events surrounding a death due to exertional sickling will assist etiology of PR in developing countries is usually related to diarrheal
the pathologist in this diagnosis. Individuals with sickle cell trait who illnesses, parasitic infestations, and malnutrition. In the developed
die without a history of intense exercise prior to death may pose a world, a common cause is cystic fibrosis. Surgeons have shown
challenge to physicians in determining if the death is or is not related to considerable ingenuity in the search for the ideal operation for PR. Over
their genetic condition. A third possibility exists in which an individual 200 different procedures have been employed, suggesting that the ideal
may not be known to carry the sickle cell trait until sickled cells are seen surgical solution has remained elusive. Treatments include conservative
in biopsy or autopsy specimens. management, resection and fixation, levator ani repair, presacral
Three decedents autopsied at the Harris County Medical packing, Thiersch’s wire suture and injection sclerotherapy. The last is
Examiner’s Office, ranging in age from 28 to 49 were found to have considered an attractive treatment option because it is minimally
sickle cell trait. None of the individuals were known to have the trait and invasive.
when family members were contacted, only one had any knowledge that The case presented is of a 2-year-old female child, with PR, cystic
this condition existed in their family. The sickle cell trait was found to fibrosis, and Ebstein malformation of the tricuspid valve. Due to
be purely incidental in two of the three decedents and may or may not be refractory PR, the decision was made to treat her with injection
related to the cause of death in the third individual. sclerotherapy, using phenol as the sclerotherapeutic agent. In the
Two of the decedents were black males who were found operating room, and shortly after the injections, the baby had a sudden
unresponsive at work, one outside and one at a desk. One was 39-years- cardiac arrest, and received CPR for approximately 2 hours. She
old and the other was 49-years-old. Both had enlarged hearts with developed anoxic encephalopathy, rhabdomyolysis, non-hyperthermic
coronary artery atherosclerosis. Microscopic examination revealed elevated creatine kinase (CK) levels, and disseminated intravascular
sickled cells in the heart, liver, lungs, kidney, and brain of both men. coagulopathy (DIC). She died approximately 4 days after the surgery.
Hemoglobin electrophoresis performed on postmortem blood revealed An antemortem urine specimen submitted on the day after the surgery
the presence of hemoglobins A, S, F, and A2 in levels suggestive of had a total phenol concentration of 240mg/L. Phenol concentrations,
sickle cell trait with an underlying beta+ thalassemia. done as part of workplace testing, in unexposed and chronically
The third case involved a 28-year-old morbidly obese black female individuals should be below 10 and 30 mg/L.
(body mass index of 54.1) who became unresponsive shortly after At autopsy, the baby’s external appearance and internal organs were
complaining of shortness of breath and abdominal pain. Autopsy appropriate for age. There was a reddish discoloration around the anus,
findings included bilateral pulmonary thromboemboli, deep venous and separate reddish brown discoloration to the buttocks. Internally
thromboses, gallstones, and clear bile. Microscopic examination there were multiple punctuate hemorrhages on the mesentery and
revealed sickled cells in the kidney liver and brain. Hemoglobin capsule of internal organs. There was intraparenchymal hemorrhage
electrophoresis results are pending at this time. Family members were within the lungs and spleen, and red blood cell casts within the renal
contacted and reported knowledge of sickle cell trait in a sibling, but not pelvis. The anal canal was infarcted. The evaluation of the heart (48.2
in the decedent. grams) confirmed the Ebstein malformation. The muscle biopsy
All family members contacted were grateful for the information and revealed nonspecific congenital myopathic changes with decreased
most were planning a follow up visit with their physician to obtain myophosphorylase and glycogen. The section of liver showed PAS &
testing for sickle cell trait. With the exception of possibly the pulmonary PASD negative vacuolization of the hepatocytes. Examination of the
emboli, the finding of sickle cell trait was incidental to the determination brain revealed cerebral edema with acute hemorrhagic infarct of the left
of the cause and manner of death; however, the information was occipital cortex, and multifocal subarachnoid, cortical, and cerebellar
extremely important for the family members of the decedents. This hemorrhages.
finding underscores the responsibility of forensic pathologists to perform A variety of sclerosing agents have been used with varying success
autopsies with the intent of complete and thorough documentation of all rates. Phenol preparations have been used in dermatology and plastic
findings, not just determination of cause and manner of death. surgery for the treatment of acne and during chemical face peels. During
Autopsy, Sickle Cell Trait, Incidental cutaneous application of phenol, absorption of the chemical has occurred
with deleterious systemic effects, including cardiac arrhythmias have
been reported. The publications about the value of the use of Phenol as
G57 An Angel Dies on the Needle: Fatality sclerosing agent for PR have been mixed. One report indicated 90 to
100% cure rates after one or two injections and no complications.
After Injection Sclerotherapy for Prolapse Another report indicated complications, including mucosal sloughing
Rectum in a Child and perianal fistulae, in 27% of cases. No cases of fatality due to phenol
toxicity after injection sclerotherapy have been reported in the medical
Abraham T. Philip, MD*, Onondaga County Medical Examiner, 100 literature.
Elizabeth Blackwell Street, Syracuse, NY 13210; and Jeanna M. This case report describes the steps taken to establish the diagnosis
Marraffa, PharmD, Upstate New York Poison Center, 250 Harrison of phenol toxicity, and eliminate the other causes of sudden death
Street, Syracuse, NY 1302 suggested by the initial differential diagnosis. The forensic community
should be aware of the toxicity of phenol as it has multiple clinical uses,
After attending this presentation, attendees will be made aware of and can result in fatality.
the toxicity of phenol, a product with multiple clinical applications that Prolapse Rectum, Injection Sclerotherapy, Phenol Toxicity
resulted in a fatality during a non-invasive surgical procedure.
This presentation will impact the forensic community by increasing
its awareness about a previously unreported complication of use of
phenol as a sclerotherapeutic agent for prolapse of rectum.
The goal of this presentation is to discuss the findings in a case of
toxicity due to phenol toxicity that resulted in the death of child fatality
after a surgical procedure for a non-life threatening condition.

G58 MDMA Neurotoxicity of antioxidant enzymes (super oxide dismutase, SOD; glutathione
reductase, GR; glutathione peroxidase, GPx). Reduced and oxidized
Irene Riezzo, MD, Viale Degli Aviatori, 1, Department of Forensic glutathione (GSH and GSSG) were measured using a spectrophotometric
Pathology, University of Foggia, Foggia, 71100, ITALY; Vittorio assay. Ascorbic acid (AA) levels were determined reverse-phase HPLC
Fineschi, PhD, Chair Forensic Pathology, University of Foggia, method. Finally, lipid peroxidation was measured by quantitating the
Ospedale Colonnello D’Avanzo, Foggia, I-71100, ITALY; Carmela release of malonaldehyde (MDA) using UV-HPLC.
Fiore, MD, and Stefano Derrico, MD, University of Foggia, Department The acute administration of MDMA produces a decrease of
of Forensic Pathology, Viale Degli Aviatori 1, Foggia, 71100, ITALY; GSH/GSSG ratio and oxidative stress in all of the brain areas examined.
and Steven B. Karch, MD*, PO Box 5139, Berkeley, CA 94705-0139 SOD activity was significantly reduced after 3 hours in hippocampus (-
60.7%) and after 6 hours in striatum, hippocampus, and frontal cortex (-
After attending this presentation, attendees will gain knowledge on 43.3%, -86.1% and -23.4% respectively). GR and GPx activities were
how to characterize MDMA neurotoxicity in rat brain. reduced after 3 hours (-22%) and after 6 hours (-33.3%) in frontal cortex.
This presentation will impact the forensic community by AA levels strongly increased in striatum, hippocampus and frontal cortex
demonstrating how the results of even one single administration of after 3 (+159%, +84% and 17.6%) and 6 (+162%, +154% and +23.4%)
MDMA can significantly alter the brains cellular antioxidant defense hours respectively. High levels of MDA respect to control were
system and produce oxidative stress in both the striatum, and frontal measured in striatum after 3 hours (+276%) and 6 hours (162%); in
cortex. Thus one possible mechanism of MDMA neurotoxicity appears hippocampus (71.8%) and in frontal cortex (+18.22%) after 6 hours.
to be a direct toxic effect of MDMA or its red-ox active metabolites The results of even one single administration of MDMA can
3, 4-Methylenedioxymethamphetamine (MDMA or “Ecstasy”) is significantly alter the brains cellular antioxidant defence system and
an increasingly popular psychoactive and hallucinogenic drug of abuse. produce oxidative stress in both the striatum and frontal cortex. Thus
It acts on the CNS by increasing the release of serotonin and other one possible mechanism of MDMA neurotoxicity appears to be a direct
catecholamines in addition to preventing their reuptake. MDMA has toxic effect of MDMA or its redox active metabolites.
been shown, in both man and animal, to damage serotonergic and MDMA Neurotoxicity, Immunohistochemical, Oxidative Stress
dopaminergic nerve terminals and to cause neurodegeneration in
multiple areas of the brain, including the cortex, hippocampus, striatum
and thalamus. The closely related drug, methamphetamine (METH) and G59 Levorphanol, Dextromethorphan, and
its derivates have been shown to produce long-lasting depletion in a Case of (Probable) Mistaken Identity
dopamine and its metabolites, as well as dopamine reuptake sites in the
rat and primate striatum, but not in other dopamine rich areas such as the Philip Croft, MD*, Sparrow Health Systems, 1215 East Michigan
nucleus accumbens and the prefrontal cortex, in contrast to the Avenue, Lansing, MI 48912; Joyce L. de Jong, DO, Sparrow Forensic
neurotoxic effect of dopamine to striatal DA terminals. Two other Pathology, 1215 East Michigan Avenue, Lansing, MI 48909; Michael A.
important aspects of MDMA neurotoxicity have been identified: Markey, MD, Sparrow Hospital, Sparrow Forensic Services, 1215 East
hyperthermia and neurodegeneration. The former appears to be a direct Michigan Avenue, Lansing, MI 48909; and Michael Smith, PhD,
action of MDMA, while the later is due to the production of reactive Sparrow Health Systems, 1215 East Michigan Avenue, Lansing, MI
oxygen (ROS). Mounting evidence suggests that MDMA-induced 5HT 48912
neurotoxicity is due to the increased production of free radical induced
oxidative stress. Attempts were made to clarify the mechanisms of After attending this presentation, attendees will recognize that
MDMA in rats’ brain by administering a single dose of the drug and levorphanol and dextrorphan, a metabolite of dextromethorphan, are
studying the effects using combined toxicological, biochemical and stereoisomers that cannot be distinguished from each other by routine
immunohistochemical analysis. toxicology testing, and that forensic pathologists and others in receipt of
Fifty rats were used for the study, each weighing 200-250 grams. toxicology reports should be cognizant of this when interpreting
Twenty-five rats were used for the histopathological and toxicological toxicology results.
examination. They were divided into three experimental groups of seven This presentation will impact the forensic community by raising
animals each and administered one 20mg/Kg dose of MDMA awareness among both forensic pathologists and toxicologists of the
intraperitoneally. The four controls were injected with saline. The first laboratory’s limitations regarding levorphanol and dextrorphan
group of animals was sacrificed six hours after injection, the second at discrimination, thereby leading to improved communication between
16 hours, and the third at 24 hours. Plasma samples obtained pathologists and the laboratory along with a reduction in instances of
immediately after sacrificed, stored at – 80°C and then analyzed for misinterpreted toxicology results involving these compounds.
MDMA/MDA with gas chromatography/mass spectroscopy (GC-MS). Appropriate evaluation of toxicology results within the context of a
Histological sections of the brains were also obtained and forensic autopsy is vital, and relies, in part, on a laboratory’s ability to
immunohistochemical stains were used to localized MDMA and its detect, differentiate, and report individual compounds contained within
metabolites, MDA and MDEA, within the various areas of the brain. specimens collected during a postmortem examination. The existence of
Other immunohistochemical stains were used to localized growth pharmacologically active stereoisomers poses an additional challenge to
associated protein 43 (GAP43}, tryptophan hydroxylase (TrypH), both toxicologists and pathologists, as they cannot be differentiated in
markers of synaptic plasticity of the serotonergic innervation and the the laboratory by routine methods. This is the case with levorphanol, a
vesicular monoamine transporter -2 (VMAT2) as a stable marker of relatively potent prescription narcotic, and dextrorphan, the active
striatal dopaminergic terminal integrity. Microglial activation and metabolite of the commonly used over-the-counter antitussive
damage were measured using a different immunohistochemical stain for dextromethorphan.
glial fibrillary acid protein (GFAP), Heat shock proteins (Hsp 27, Hsp 70 A case involving a 70-year-old man with pneumonia and a history
and Hsp 90) and beta-amyloid precursor protein (βAPP). Apoptosis was of chronic ethanol abuse is presented to illustrate the importance of
measured using the tunnel assay, which identified apoptosis via DNA recognizing the laboratory’s general inability to differentiate levorphanol
fragmentation. For the evaluation of oxidative stress, the others twenty- from dextrorphan. Laboratory testing in this case showed a relatively
five rats, divided into three groups of seven male albino rats weighing high level of levorphanol along with other medications commonly found
200-250 g were used to analyze the effect of MDMA administration (20 in over-the-counter cold medications. The presence of levorphanol was
mg/Kg, i.p) on rats’ brain. Hippocampus, striatum, and frontal cortex unexpected within the context of the case, as the decedent was taking no
were removed 3 and 6 hours after treatment and analyzed for the activity prescription medications and had not seen a physician for years. The
levorphanol was initially considered a significant contributing factor in Only 12% of the deaths in this study were caused by fentanyl alone.
the man’s death. In the remaining cases other drugs were present and contributed to the
Re-evaluation of the toxicology findings, spurred by a second case death. The other drugs included prescription medications, street drugs,
with similar toxicology results under equally incongruous over the counter medications, and alcohol. Prescription medications
circumstances, uncovered the difficulty posed to toxicology testing by were involved in 85% of the cases and included analgesics, muscle
the structural similarity between levorphanol and dextrorphan. Given relaxants, and mental maintenance drugs. Prescription drugs were over-
this insight, the circumstances of both of these cases suggested that the estimated in this study since medications which may have been obtained
compound originally reported to be levorphanol was considered more illegally (i.e., oxycodone and methadone) were classified as prescription
likely to be the metabolite of dextromethorphan. Subsequently, drugs. Morphine was classified as prescription unless 6-acetylmorphine
“levorphanol intoxication” was discounted as a factor contributing to was also present. Street drugs were involved in 14% of cases, over-the-
death in the first case. The original toxicology reports were amended to counter drugs (acetaminophen, antihistamines, and dextromethorphan)
reflect the inability to distinguish between levorphanol and dextrorphan. in 8% and alcohol in 13%.
Subsequent review of in-house case files since 1999 revealed 13 This analysis documents the marked increase (17-fold) increase in
more cases in which levorphanol was reported to be in blood and/or urine fentanyl-related deaths over the last six years. The observation that most
along with other compounds often admixed with dextromethorphan in of the deaths are associated with other drugs suggests a role for increased
over-the-counter cold medications. These findings suggest that some, if caution by physicians in prescribing fentanyl, especially in combination
not all, of these earlier cases were more likely to represent the detection with other medications. Increased education of patients is essential with
of dextrorphan and not levorphanol. emphasis on the critical importance of using the medication as directed.
Toxicologists and pathologists should be aware that levorphanol Patients should also understand the danger of mixing fentanyl with non-
and dextromethorphan’s metabolite dextrorphan are stereoisomers, and prescribed substances such as street drugs, alcohol, and sedating over-the
that their structural similarity renders them indistinguishable by routine counter drugs.
laboratory testing. An understanding of these limitations is critical to the Fentanyl, Drug Death, Epidemiology
interpretation of toxicology results that may indicate the presence of one
or both of these compounds.
Levorphanol, Dextromethorphan, Isomers G61 Deaths Involving Stress
Jeffery J. Gofton, MD, 901 North Stonewall, Oklahoma City, OK 73117-
G60 Fentanyl-Related Drug Deaths in Virginia 1218; and Wendy M. Gunther, MD*, Office of the Chief Medical
(2000-2006) Examiner, Tidewater District, 830 Southampton Avenue, Suite 100,
William T. Gormley, PhD*, Office of the Chief Medical Examiner, 400 After attending this presentation, attendees will learn characteristics
East Jackson Street, Richmond, VA 23219; and Anna Noller, PhD, of traumatic and natural lesions identified in a series of cases presenting
Virginia Department of Health, Office of the Chief Medical Examiner, for medicolegal autopsy in which the medical examiner determined that
400 East Jackson Street, Richmond, VA 23219 stress played a role in death; will be able to evaluate the role of
toxicology, history, and time course in determining the cause and manner
After attending this presentation, attendees will recognize the of death in such cases; and will be able to evaluate impact of such
growing contribution of fentanyl to drug deaths, especially in characterization of cause and manner of death on courtroom testimony.
combination with other drugs and alcohol. This presentation will impact the forensic community by
This presentation will impact forensic scientists, primary care demonstrating how to utilize a case format series to evaluate the common
physicians, pharmacists, and patients by demonstrating the danger of factors which should be present in order to assign stress a role in
combining fentanyl with other medications, street drugs, or alcohols. certification of medicolegal death. Discuss the appropriate manner in
Fentanyl is an opiate analgesic with about 81 times the therapeutic each of several cases of stress-related death.
effect of morphine. Initially used mostly in hospital settings, fentanyl is Although most deaths presenting for medicolegal autopsy fall
increasingly used for outpatient management of chronic pain, especially readily into the categories of natural, accident, suicide, and homicide,
delivered transdermally or through mucous membranes. Over the past some deaths from natural disease appear to be influenced by stress,
years fentanyl has appeared more frequently in toxicology screens which raises the question of whether a manner of accident or homicide
associated with drug deaths. should be assigned to a death that is primarily from natural causes.
All deaths investigated by the Virginia Office of the Chief Medical Stress as defined in these cases may include participating in an
Examiner between January 1, 2000 and December 31, 2006 in which altercation, whether verbal or physical; suffering trivial injury, or
fentanyl was detected on toxicological examination were received. nontrivial injury which is nevertheless not fatal; being afraid for one’s
Cases where fentanyl was used therapeutically in natural deaths were life; fearing catastrophic outcomes to oneself or another; losing valued
excluded from this analysis. Cases where fentanyl was present but the personal property during an assault; or undergoing poisoning with
cause of death was a traumatic injury were excluded. varying substances to a degree which should not be fatal, while under
Analysis demonstrated a progressive increase in number of cases emotional stress from other causes.
from three in 2000 to 51 in 2006. Deaths involving fentanyl typically Stress is a vaguely defined word which has been used in the media,
occurred in the 3rd and 4th decade of life (average 40 years). There was in lay discussions, in psychology, in research, and in forensics. It has
a slight male predominance (about 60%), and 97% of the victims were multiple overlapping meanings more than one of which may be utilized
white. There was significant geographic disparity in the data. There are in a discussion, resulting in decreased communication clarity.
four District Offices in Virginia, each office serving approximately 25% Nevertheless the death of an individual during an emotionally violent
of the population. The relatively rural Western District had 51% of the incident from what appears to be natural disease, without sufficient
fentanyl-associated death cases. The more urban Central, Eastern, and trauma to explain death, may be difficult to describe without using the
Northern Districts had 15%, 19%, and 15% of the cases respectively. word stress.
Most of the deaths were classified as accidental (88%) with 10% suicidal Medical examiner opinion on the role of stress in such deaths
and 2% undetermined. varies. Some take the position that an influence as difficult to measure

as stress should not play a role in death certification. This series of cases Oxymorphone, a metabolite of oxycodone, exhibits limited cross
from a five-year period in the Tidewater district of the Commonwealth reactivity in this assay (at a 50 ng/mL positive cut-off concentration for
of Virginia illustrates examples of deaths which the medical examiner oxycodone approximately two and one-half times that concentration, or
felt were best certified with some reference to stress. The manner of 130 ng/mL oxymorphone, is needed to elicit a positive response). The
death in these cases, as well as the relevant history, toxicology, autopsy ELISA result for oxycodone was therefore negative.
findings, and scene investigation, is reviewed with an eye to developing The cause of death was certified as acute oxymorphone and ethyl
some common factors which belong in the evaluation of a death that is alcohol intoxication. Most notably, the drug’s manufacturer cautions
at least partly attributed to stress. contemporaneous use of alcohol since oxymorphone plasma
Stress, Altercation, Death concentrations may increase as much as 270% and causes fatal overdose.
Similar to OxyContin®, crushing or breaking Opana®ER tablets defeats
the extended release formulation and precipitates delivery of the drug’s
G62 Investigation of Acute Oxymorphone full dose into the blood.
This case underscores the significance of a coordinated,
(Opana® ER) and Ethyl interdisciplinary approach to competent death investigations. Absent or
Alcohol Intoxication superficial scene investigations, cursory or incomplete autopsy
examinations, and inadequate toxicological studies can undermine
Andrew W. Sexton, DO*, 24 Regency Park Drive, Agawam, MA 01001 accurate cause of death certifications.
Toxicology, Synthetic Opioids (Opana), ELISA
After attending this presentation, the attendees would appreciate the
significant impact of coordinated interdisciplinary approach in
determining an acute oyxmorphone (Opana) and ethyl alcohol G63 Deaths During Police Chases
intoxication.
The presentation will impact the forensic science community by Jeffery J. Gofton, MD*, 901 North Stonewall, Oklahoma City, OK
reporting the limitations of ELISA methodology for screening detection 73117-1218; and Wendy M. Gunther, MD*, Office of the Chief Medical
of oxymorphone (Opana®) Examiner, Tidewater District, 830 Southampton Avenue, Suite 100,
Scene investigation, circumstantial information together with Norfolk, VA 23510-1046
thorough autopsy/toxicology and ancillary studies constitute the triad of
a competent medicolegal death investigation. Herein is described the After attending this presentation, attendees will: (1) learn
death investigation of a 28-year-old Caucasian male, whose cause of characteristics of traumatic and natural lesions identified in decedents
death would be classified undetermined, had the systematic presenting for forensic evaluation after dying during police pursuit, (2)
aforementioned principles not been applied. The case is characterized by will be able to evaluate the role of toxicology, behavioral history, and
astute police investigative efforts, competent scene recovery and time course in determining the cause and manner of death, (3) and, will
awareness of synergistic drug effects between Opana®ER be able to distinguish injuries inflicted by police from accidental or
(oxymorphone) and ethanol. The decedent, accompanied by friends, suicidal injuries incurred during the course of police pursuit and evaluate
participated in a celebration at a local bar prior to a major social event. impact of such recognition on courtroom testimony.
Following a period of marked ethanol consumption, the decedent This presentation will impact the forensic community by assisting
returned to a friend’s house and retired. Approximately 6.5 hours later, participants in recognizing significant characteristics of trauma and other
attempts to awake the decedent were unsuccessful; he was found to be features of deaths during police pursuit by analysis of a case format
apneic and in asystole. Resuscitative efforts were initiated and ACLS presentation.
protocols followed as the decedent was transported to a nearby Deaths occurring during police chases require special attention at
emergency room. The decedent was pronounced shortly after arrival. forensic autopsy. A number of issues may be raised by death during
Autopsy findings revealed a well nourished, well developed 28- police pursuits which are relevant to the cause and manner of death.
year-old Caucasian male, measuring 71 inches long and weighing 160 Even issues which are not directly relevant to cause and manner may
pounds. No external or internal evidence of trauma was detected. All influence subsequent court decisions on police actions.
body organs revealed weights within normal limits, with the exception of The primary issue in many cases is whether police actions directly
heavy lungs indicating severe pulmonary edema. Initial postmortem caused death. In cases of police shootings, this is obvious; in car crashes,
toxicology indicated non-fatal concentrations of ethanol at 0.11%, it may be far from obvious, so much so that the question has gone as far
0.14%, and 0.25% respectively in blood, vitreous humor, and urine. The as the United States Supreme Court. In addition, the medical examiner
scene investigation did not indicate an unsafe sleeping environment. may be presented with a decedent who was not the person police were
Gross and microscopic examinations were negative for gastric contents chasing; passengers, innocent bystanders, and pedestrians have all been
or foreign body aspiration. killed during police pursuit.
The cause of death remained undetermined until a second review Death during pursuit is by no means only due to motor vehicle
and reassessment of the police investigation, including witness related trauma or police shootings. A decedent whose cause of death is
testimonies, raised suspicion for a drug-related event. In the area where clearly a gunshot wound may not have sustained it at police hands.
the decedent had been sleeping, a broken 40 mg tablet of Opana®ER was Sometimes more than one officer has shot a decedent and the question
found in a prescription vial on a shelf. The decedent’s friend stated to arises of which bullet is most responsible for death. In cases where
police he never crushed or broke the prescription tablets. Further, the gunshot wounds are not responsible, the cause and manner of death may
friend stated that on past occasion the decedent requested his medication vary widely. Blunt force trauma or sharp force trauma such as canine
for experimental use. The friend denied compliance with previous bites may be identified. These injuries may have been inflicted by
requests and no inquiry was made by the decedent the night of the party. police, by accident, or by another. Such blunt trauma may be primary in
Additional toxicological studies included directed analysis for death, contributing, or irrelevant. Other accidental means of death may
synthetic opioids by GCMS/SIM in blood and urine. The analysis supervene over police-inflicted injuries when suspects flee. The time
revealed oxymorphone concentrations of 95 ng/mL and 214 ng/mL in course from initiation of police chase to death is also significant and may
blood and urine, respectively. The UMass Forensic Toxicology not always be what is expected. Deaths have occurred after police chase
Laboratory employs ELISA technology, which includes a specific assay was called off that may nonetheless be related to the history of police
for oxycodone, in front line presumptive screening of postmortem blood. pursuit.

In examination of all deaths during police pursuit, careful Of the seven cases only one was the so-called prototypical inhalant
photographic documentation is essential along with a number of other abuser a 13-year-old male found with evidence of direct inhalation. The
methods of documentation only some of which are routine. Collection three female victims were aged between 18 & 21, while the remaining
of trace evidence may require a higher level of care than is applied in male victims were in the 4th and 5th decade of life. Besides the one case
routine cases. The medical examiner’s experience and judgment as well of direct inhalation, three cases had spray paint residue on the face, two
as observations are essential to separate trauma significant in death from cases had strong circumstantial evidence of inhalant abuse and in one
trauma not relevant to death, and to determine the likely origin of both case there was a past history of inhalant abuse. All cases below the
kinds of trauma. For example, the medical examiner is called on to median age had issues with scholastic performance and or depression.
identify injuries inflicted directly by police from injuries sustained by The cases above the median age had histories of illicit drug and alcohol
accident or at other hands. Natural disease, intoxication with drugs and abuse or psychiatric issues.
alcohol, and history of behavior such as previous flight from police or Toxicology was confirmatory in five (71%) of the seven cases. In
suicidal ideation prior to the incident, may all be relevant; each is likely one case the testing was limited by decomposition of the victim and in
to require careful assessment during the course of forensic evaluation. another case specimens were not submitted for an inhalant abuse test
Familiarity with a variety of traumatic lesions that have occurred during panel. The inhalant panel tests revealed 1-2 aromatic or halogenated
police pursuits ending in death assists the medical examiner with hydrocarbons and or ketones including the following compounds with
resolving questions of police responsibility and authority, and with cause the following frequency noted in parenthesis: benzene (1), toluene (3),
and manner of death. difluoroethane (1), and methyl ethyl ketone (2). Illicit drugs of abuse
This series of deaths during police pursuit provides a review of were identified in one case, lead was identified in the gasoline direct
accidental, suicidal, natural, and directly police-inflicted deaths inhalation case and multiple medications (predominantly psychiatric)
occurring over a five-year period in the Tidewater district of the were identified in four (57%) of the seven cases.
Commonwealth of Virginia. The causes of death include single gunshot In one case each the listed COD was: complications of solvent
wound, multiple gunshot wounds, motor vehicle collision-related abuse; inhalation of toxic products of combustion and thermal injury;
trauma, and drowning. The documentation of injuries and disease and multiple drug intoxication; and laceration like incised wounds to the
the process, of medical examiner reasoning which resulted in the neck due to circular saw. In three cases the COD was: asphyxia due to
determination of cause and manner of death are presented for each case. (1) inhalant abuse, (2) spray paint, and (3) drowning as the cause of
Police Chase, Death, Forensics death. Inhalant abuse was listed in the contributory conditions of the
drowning and neck trauma victims. The MOD in six cases (85.7%) was
accident and one was suicide. A further review of the autopsy report
G64 Variations on a Theme: Inhalant Abuse determined that inhalant abuse (or variant terms) was mentioned in the
summary of diagnostic finding. The cases in which the inhalant abuse
Related Fatalities in Central New York — was not mentioned included the victims of fire, drowning, and multiple
An 11 Year Review drug intoxication.
Education and preventive efforts focused not just on teenagers, but
Abraham T. Philip, MD*, Onondaga County Medical Examiner’s Office, targeted to older at risk adults, are required if inhalant abuse related
100 Elizabeth Blackwell Street, Syracuse, NY 13210 fatalities are to be eliminated. Furthermore, clinical services should
consider these findings to identify the at risk individuals.
After attending this presentation, the attendees will be made aware Inhalant Abuse, Huffing, Bagging
of the epidemiology of the inhalant abuse related fatalities evaluated by
the Onondaga County Medical Examiner’s Office from 1998 to 2008.
This presentation will impact the forensic community by examining
the variations in inhalant abuse related fatalities, and dispute the notion G65 A New Framework for Guiding Research
that it is usually a juvenile behavioral problem.
Inhalant abuse is the intentional or deliberate inhalation of chemical
in Forensic Entomology: Improving
vapors, often a household product, to achieve intoxication. The the Science Relevant to PMI Estimates
commonly used chemicals are volatile solvents, aerosols, glues, paints,
and lighter fluids. In inhalant abuse there is a progression from M. Eric Benbow, PhD*, University of Dayton, Department of Biology,
“Sniffing” - inhalation of vapors from an open container, to “Huffing” - 300 College Park, Dayton, OH 45469-2320; and Jeffery K. Tomberlin,
inhalation of vapors holding a piece of cloth that has been soaked in PhD, and Rachel Mohr, MS, Department of Entomology, Texas A&M
volatile substance against the nose and mouth, to “Bagging” - inhalation University, 2475 TAMU, College Station, TX 77843
from a plastic bag containing the desired substance. The prototypical
inhalant abuser is a young male, between 10 and 15 years of age, After attending this presentation, attendees will increase awareness
indulging in inhalant abuse during school vacation times. of specific basic research needs essential for refining estimates of the
A study was conducted examining the inhalant related fatalities period of insect activity (PIA) on human remains. Furthermore,
evaluated by the Onondaga County Medical Examiner’s Office from attendees will be introduced to a needed differentiation of semantics
1998 to 2008, to obtain data about demographic characteristics; intended to improve communication among forensic entomologists,
circumstances of the deaths; major autopsy findings; toxicology test other professionals of the forensic science community, members of the
results; and cause and manner of death (COD & MOD) formulations of judicial process, and the general public.
these cases. This presentation will impact the forensic science community by
There were nine possible cases identified by the initial searches, of presenting a new framework for describing the aspects of entomological
which two cases were deleted as not suitable for this study. Of the activity associated with human remains. After attending this
remaining seven cases (three female; four male) the mean age was 32.0 presentation, the attendees will understand the need for additional
years and the median age was 21. There were three cases in 2002, two research examining neglected study foci related to the PIA, specifically
in 2007, and one each in 2005 and 2008. There was one case each in the the interval of activity prior to physical colonization. This presentation
months of January, February, April, June, and August and two cases in will raise attendee awareness to specific basic research needs essential
July. for refining estimates of the PIA on human remains.

A major component of the nature and practice of forensic G66 The Activity of Calliphora vicina (Diptera:
entomology is assisting investigators in determining the postmortem
interval (PMI). To date, the initial time of colonization that begins the
Calliphoridae) Can Alter the Morphology
defined post-colonization interval (post-CI), and includes arthropod and Presumptive Chemistry of High Impact
occupation and use of the remains, has been the most relevant Bloodstains
information for entomologically-based PMI estimates, which is
concisely defined as the PIA; however, the time between death but Amanda Fujikawa, BS*, University of Nebraska-Lincoln, 202
before initial insect colonization is also a portion of the PIA and is Entomology Hall, Lincoln, NE 68583-0816; Larry Barksdale, MA,
important for cases that require accurate estimates within hours after Lincoln Police Department, 575 South 10th Street, Lincoln, NE 68508;
death. For this presentation, this portion of the PIA is defined as the pre- and David O. Carter, PhD, University of Nebraska-Lincoln, Department
colonization interval (pre-CI). of Entomology, 202 Entomology Hall, Lincoln, NE 68583-0816
The pre-CI encompasses the portion of the PIA from time of death
until initial physical colonization and use by insects for consumption or After attending this presentation, attendees will have a better
oviposition. Most studies that address the pre-CI have focused on understanding of fly artifacts, their importance when interpreting and
nocturnal oviposition, but few have addressed other processes that reconstructing a crime scene, and practical applications in locating and
influence initial insect contact and early colonizer oviposition; most identifying fly artifacts.
notably measurable behavioral characteristics that are influenced by both This presentation will impact the forensic community by increasing
biotic and abiotic factors in the environment. In addition, there is knowledge of outside influences, specifically Calliphora vicina, on
tremendous variation in the length of time and faunal succession crime scenes and the means of using this knowledge to make more
characteristics of insect activity on a body. The interface of the pre-CI accurate scene reconstructions.
and the post-CI is defined by the time when arthropods physically The study being presented examined the effect of Calliphora vicina
colonize and begin using the human remains as a resource; as an on high impact bloodstain patterns and to test presumptive blood tests
oviposition site, habitat for finding prey or primary consumption of that could be used to differentiate between blood spatter and fly artifacts.
tissues. This interface is preceded by an acceptance phase defined by The experiments were conducted in microscenes (.46 m3 wooden
behavioral patterns of body detection and evaluation for full boxes) that had two walls of glass and a ceiling of plexiglass to facilitate
colonization. The acceptance phase of the pre-CI has been all but observation and photography. Interchangeable inserts were made to
unstudied to date, but can affect estimates of the PIA. In the current state allow for surface changes in the microscenes. Surfaces used in this study
of knowledge regarding the PIA, limited scientific information can lead were combinations of indoor materials commonly found at crimes
to interpretative differences among forensic entomologists. scenes. Combinations of white linoleum with white textured and painted
The pre-CI in general, and the acceptance phase in particular, are walls (Combination 1), wood floor laminate with a wallpapered wall
broad areas of forensic entomology research that have been neglected, (Combination 2), and mid-grade carpet with light hued paneling
and require more rigorous and repeatable experimental design necessary (Combination 3) were used to demonstrate surface texture and its effect
to improve the entomological information relevant to total PIA, and on the flies’ ability to feed and deposit artifacts. High impact bloodstains
consequently further refinement of PMI estimates. However, a common were made from fresh (within 5 minutes of drawing) human blood on
language and framework among forensic entomologists is necessary to two walls and a pool was formed on the floor. The flies were placed in
facilitate and guide this research. To this end, a new conceptual holding cages that attached to the microscene. This design provided an
framework is introduced to identify areas of needed forensic opportunity for the flies to choose to enter the microscene. Flies entered
entomological research and propose standard terms when discussing the microscene within 30 minutes with combinations 1 and 2. They
entomological data used in investigations involving PMI estimates. This entered the microscene within 60 minutes with combination 3. The flies
framework divides the PMI into logical components from death to body remained in the microscenes for 48 hours. After they were removed,
discovery including but not limited to the following: death to initial measurements, photo documentation, and presumptive chemical tests
insect detection of the decomposing body (pre-CI exposure phase); the were performed. Four commonly used presumptive blood tests were
time from detection to location of the body (pre-CI detection phase); the used: phenolphthalein, Hemastix®, leucocrystal violet, and fluorescein.
time from body location to first oviposition (pre-CI acceptance phase); The deposition of artifacts was evenly distributed between floor and
and, the time from insect colonization of the body to discovery of the wall surfaces within a microscene. Both male and female flies fed on the
remains (post-CI). blood and deposited artifacts. Artifacts could range from completely
This framework identifies specific areas of research within each of clear, consisting mainly of water, to completely opaque, consisting
these entomological phases that involve the behavioral and physical mainly of blood. Regurgitation was the most common method of
stages of insect activity on a body, and suggests which abiotic and biotic deposition, but defecation did occur. Regurgitated artifacts were
factors influence these entomological processes that can be of focused generally small, 1-2 millimeters, with little or no tail. Defecated artifacts
and applied studies. It is the intention of the authors to facilitate a were of similar size to the regurgitated but generally had a tail from a few
common language and conceptual structure to improve the science of to over 20 mm in length.
forensic entomology, an important consideration for aiding criminal There was no difference in reaction time between blood spatter and
investigations involving estimates of the PMI. Accordingly, this artifacts when using phenolphthalein, Hemastix®, and fluorescein. The
platform is used as a method for developing a common path leading from reactions times with leucocrystal violet were generally similar although
basic to applied research in the field of forensic entomology. increased reaction time was seen in some instances. Artifacts that
Forensic Entomology, Arthropod, Insects consisted of less blood fluoresced under a blue/green light when viewed
through an orange filter without chemical enhancement.
Forensic Entomology, Insect Artifacts, Blow Fly

G67 Rehydrating Dried Blow Fly Larvae Studies on methods development in forensic entomology can
benefit the forensic sciences community by being used to define
to Reclaim Their Usefulness in protocols and standard operating procedures that can be cited and used
Forensic Investigations in legal proceedings.
Diptera, Method, Length
Michelle R. Sanford, MS*, Jennifer L. Pechal, MS, and Jeffery K.
Tomberlin, PhD, 2475 TAMU, Department of Entomology, Texas A&M
University, College Station, TX 77843 G68 Patterns of Adult Blow Fly Attraction to
After attending this presentation, attendees will learn methods for
Carrion Over Time
rehydrating dried larval insect specimens. The impact that initial
preservation coupled with drying and rehydrating of larval specimens on Rachel M. Mohr, MS*, and Jeffery K. Tomberlin, PhD, Department of
their length and weight as it relates to estimating period of insect activity Entomology, Texas A&M University, 2475 TAMU, College Station, TX
also will be discussed. 77843-2475
demonstrating how studies on methods development in forensic After attending this presentation, attendees will better understand
entomology can benefit the forensics community by being used to define about the length of time between the exposure of carrion to adult blow
protocols and standard operating procedures that can be cited and used flies and the onset of fly attraction to that carrion. Attendees will also
in legal proceedings. learn about the physiological age profile of adult flies attracted to carrion
Ethanol is commonly recommended for preserving larval blow fly over time.
specimens in forensic investigations. Alcohol is a volatile preservative This presentation will impact the forensic community because it
that can evaporate over time resulting in the dehydration of larval helps better quantify the length of time between exposure of a cadaver
specimens or the creation of crispy maggots which are difficult to and the onset of insect colonization.
identify and unreliable for measurements for age estimation. In this This presentation is intended to educate attendees about the length
study methods recommended for rehydrating dried museum specimens of time between the exposure of carrion to adult blow flies and the onset
were adapted and applied to crispy maggots of three common North of fly attraction to that carrion. Attendees will also learn about the
American blow fly species (Phormia regina (Meigen), Cochliomyia physiological age profile of adult flies attracted to carrion over time.
macellaria (Fabricus), and Chrysomya rufifacies (Macquart)). Length This information is significant for the forensic sciences community
and weight of the specimens were documented throughout the process. because it helps better quantify the length of time between exposure of a
The effect of initial preservation method was also observed by collecting cadaver and the onset of insect colonization.
replicate samples and preserving in 80% ethanol, 70% isopropyl alcohol, Forensic entomology’s most common application is to calculate the
or with fixation by hot water killing followed by preservation in 80% length of time that a cadaver has been deceased, the total postmortem
ethanol. Third instar larvae were collected over the course of nine interval (PMI). Most commonly, what is actually calculated is the
months from different animal carcasses used for teaching the Texas duration of immature insect inhabitation of the cadaver, based on the
A&M University forensic entomology course. Individual third instar known growth rate of particular insect species - what the authors are
larvae from each species (n = 90/species) were measured and weighed terming the post-colonization interval (post-CI). Little attention has
before the preservative was allowed to evaporate. Rehydration was been paid to the time between exposure of a body to insect activity and
attempted by soaking overnight in 80% ethanol, a commercial trisodium the onset of oviposition, and in this research, termed as the pre-
phosphate substitute solution, or 0.5% trisodium phosphate solution after colonization interval (pre-CI). However, under appropriate conditions
which specimens were again measured and weighed. Analysis of length such as a very fresh cadaver, or when high temperatures lead to rapid
and weight data with analysis of variance showed that for each species decay, the pre-CI may represent a substantial portion of the total PMI.
the impact of rehydration and the impact of the interaction between Adequately characterizing the behavior of the adult fly, particularly as a
initial preservation and rehydration treatment significantly affected final function of cadaver age and ambient temperature, could greatly assist
rehydrated length and weight among the different species. entomologists in calculating the total period of all insect activity on a
For all specimens, soaking in any of the rehydration treatment cadaver.
solutions restored a portion of the original larval length (mean percent Insects arrive at a cadaver in relatively predictable succession
difference initial–final across all species and preservatives: 80% patterns. Blow flies tend to arrive very early in the succession pattern,
ethanol: -10.6%; trisodium phosphate: -2.9%; trisodium phosphate often within 24 hours postmortem. Adult flies found around a very fresh
substitute: 1.1%) but none of the solutions were able to restore original cadaver are usually presumed to oviposit shortly after locating it.
larval weight. The original larval length and the final rehydrated larval However, since most blow flies require a protein meal in order to
length were used to estimate larval age using published data sets. These produce eggs, young flies may visit a cadaver long before they are
estimates agreed within a few hours in many cases with individual capable of ovipositing. The process of producing eggs by depositing
preservation by rehydration treatment combinations more closely vitellin (yolk protein) into the immature ovarioles allows the
agreeing for some species than others. A comparison between the physiological age of flies to be determined. By determining the ovarian
length-based larval age estimate and the known duration of the exposure status of flies, and the patterns of the groups’ relative carrion usage, it
of the animal carcasses revealed that there were large differences can be accurately assessed how long postmortem oviposition-ready flies
(percent difference between estimated and actual exposure: P. regina: are found at a cadaver. The rate of ovarian development is largely
74% lower than actual; C. macellaria: 51% lower than actual; C. dependent on fly metabolism, which in turn is significantly influenced by
rufifacies: 150% higher than actual) which probably reflect delays in, temperature. The higher the temperature, the faster ovaries develop, so
and barriers to, colonization coupled with differences in tissue types used long as the fly has obtained adequate dietary protein. Therefore,
in published studies and this experiment. temperature is an important factor to track when estimating either the
Overall the data show that crispy maggots can be rehydrated and rate of ovarian development or simply the overall physiological age.
suggest that their length can be measured to obtain a length-based age Experiments were performed evaluating the attractiveness of
estimate for period of insect activity estimates. Knowledge of the initial carrion to the common early-arriving blow flies, Cochliomyia macellaria
preservation method might also aid in selecting the most appropriate (Fabricius) and Chrysomya rufifacies (Macquart). Pigs were killed by
rehydration method. cranial stunning, and placed in an open field within one hour of death.
At hourly intervals between dawn and dusk of the next 72 hours, ambient
temperature observations were made, and adult flies were collected from times of these insects in soil when using development data from previous
the carcasses. Flies were identified to species and sexed. All flies were laboratory studies.
weighed and placed in different weight classes. Female flies were The utility of L. sericata in forensic entomology has long been
dissected, and their ovarian developmental status determined in order to recognized. It is an early colonizer of decomposing remains, occurring
place them into five separate age groups. The post-CI and behavior in the first sere of succession. Due to its nearly cosmopolitan
pattern was evaluated for each group. The post-CI of each age group will distribution, it has been widely studied in many locations worldwide, and
be discussed in relationship to temperature. Complicating or retarding can be considered a laboratory model for forensic entomology research.
environmental factors will also be discussed, as well as the limitations of Lucilia sericata has been studied for its forensic implications in the
the findings. However, the results of this study are expected to be useful context of temperature-related development, entomotoxicology,
in improving the accuracy of entomologically derived postmortem molecular identification, and now pupation behavior.
intervals. Furthermore, this research shows the importance of collecting Entomology, Pupation, Soil
adult insects as well as immatures at a body recovery site.
Forensic Entomology, Blow Flies, Postmortem Interval
G70 Feeding Patterns of American
(Periplaneta americana) and German
G69 The Effect of Soil Compaction on
(Blattella germanica) Cockroaches on
Pupation Depth of Lucilia sericata
Pig Skin
in Soil
Lindsay A. Bright*, 1500 Olympia Way #12, College Station, TX 77840;
Jonathan A. Cammack, BS*, and Peter H. Adler, PhD, Department of and Jeffery K. Tomberlin, PhD, and Roger Gold, PhD, Department of
Entomology, Soils, and Plant Sciences, Clemson University, 114 Long Entomology, TAMU 2475, College Station, TX 77843-2475
Hall Box 345315, Clemson, SC 29634; Jeffery K. Tomberlin, PhD,
Department of Entomology, Texas A&M University, TAMU 2475, After attending this presentation, the attendees will understand the
College Station, TX 77843-2475; Yuji Arai, PhD, Department of characteristics of Periplaneta americana (Linnaeus) (Blattodea:
Entomology, Soils, and Plant Sciences, Clemson University, 270 Poole Blattidae) and Blattella germanica (Linnaeus) (Blattodea: Blattellidae)
Agriculture Center, Clemson, SC 29634; and William C. Bridges Jr., feeding sites on epidermal tissue.
PhD, Department of Applied Economics and Statistics, Clemson This presentation will impact the forensic sciences community by
University, 243 Barre Hall, Clemson, SC 29634 educating attendees about cockroach feeding on human remains and
variables that can affect their associated feeding behavior.
After attending this presentation, attendees will understand the Cockroaches are voracious consumers of a wide variety of organic
effect that soil compaction has on the burrowing ability of post-feeding material and debris. They are also commonly found in and around
third instar larvae of Lucilia sericata (Meigen) (Diptera: Calliphoridae) human dwellings. Consequently, it is not uncommon to discover human
searching for a pupation site. remains exhibiting signs of cockroach feeding. Because cockroaches
When paired with information from post-feeding larval dispersal tend to feed on just the top layers of epidermis, their bites and feeding
studies, this information will impact the forensic sciences community by sites closely resemble second degree burns or abrasions. Postmortem
aiding investigators in locating entomological evidence at a body- injuries caused by cockroach feeding are often misinterpreted as
recovery scene. antemortem injuries which can lead to the suspicion of foul play even
After attending this presentation, attendees will understand the when none exists.
effect that soil compaction has on the burrowing ability of post-feeding The American and German cockroaches are two of the most
third instar larvae of Lucilia sericata (Meigen) (Diptera: Calliphoridae) common species of cockroach found in residential areas. The differences
searching for a pupation site. When paired with information from post- in feeding behavior between these two species of cockroach have not
feeding larval dispersal studies, this information will impact the forensic been characterized. Consequently, it is currently not possible to
science community and humanity by aiding investigators in locating determine which species fed on a given set of remains. Furthermore, no
entomological evidence at a body-recovery scene. Information from this information is available about the effects of temperature or population
study also can be used to decipher the relationship between ambient size on the feeding habits of either species.
temperature and soil temperature to better determine development of Studies were conducted to observe the effects of temperature and
insects that have dispersed from human remains and burrowed into the population size on the feeding behavior of both American and German
soil to pupate. This information will allow for a more precise estimate cockroaches. Pig epidermal tissue was used as a substitute for human
of the period of insect activity (PIA) as it relates to the time since initial epidermis. All cockroaches were starved for 24 h prior to the study and
insect colonization, or post-colonization interval (post-CI). cockroaches not used in previous trials were obtained for each replicate.
Locating the oldest insects that develop on human remains is crucial In order to understand the effects of population size on feeding behavior,
for accurate analysis of entomological evidence. If the remains are in a 100, 150, or 200 American and German cockroaches were exposed to a
late stage of decomposition, fly larvae from the first sere of succession 124.63 cm² area of pig epidermis for 48 h. The experiment was
might have left the remains and pupated in the surrounding soil. If this conducted at 27°C RH 80±10% and a photoperiod of 12:12 [L:D] h. Pig
has happened, a PIA estimate based on fly larvae collected from the epidermal tissue exposed to each species was examined individually and
remains will not accurately represent the post-CI. Therefore, not in mixed cultures. The effects of temperature on feeding behavior
investigators must be able to locate flies that have pupated in the soil to were tested using groups of 150 American or German cockroaches. One
obtain an accurate post-CI. hundred and fifty individuals of each species were kept in growth
In this study, post-feeding third instar larvae of L. sericata were chambers maintained at 15°C, 21°C, or 27°C. All growth chambers had
allowed to burrow into soil of different compactions. After adult RH 80±10% and a photoperiod of 12:12 [L:D] h. Pictures of the pig skin
emergence, the depth in the soil of empty puparia was recorded. Time from both studies were taken with a digital camera every 6 h for 48 h.
from egg to adult emergence also was recorded. Results from this Feeding sites were identified and measured using SigmaScan Pro 5, and
research will generate a standard operating procedure for collecting fly percent area damaged due to cockroach feeding was determined.
puparia in soil at a body recovery scene, as well as evaluate development

According to these studies, the amount of epidermis damaged due intimate knowledge of the community makeup, specific successional
to cockroach feeding was positively correlated to both density and patterns, and life histories of forensically important flies common in the
temperature. Epidermis that was exposed to 200 of either species of area of the crime.
cockroach was damaged far more than skin exposed to lesser densities. Ten forensically important species have been collected in Brazos
Both American and German cockroaches showed very little feeding County, Texas, USA and deserve further investigation: Calliphora
activity at 15°C, suggesting a minimum temperature for feeding. At livida, C. vicina, Cynomyopsis cadaverina, Lucilia cuprina, L. eximia, L.
27°C, both species of cockroach consumed the most area. It is coeruleiviridis, Cochliomyia macellaria, Chrysomya rufifacies, C.
anticipated that the outcome of these studies will be useful in better megacephala, and Phormia regina. Of these, Cochliomyia macellaria
identifying and understanding the interactions between anthropophagic and Chrysomya rufifacies dominate the maggot mass during the warmer
roaches and humans in forensic investigations. months, and are therefore important in time of colonization estimates.
Cockroach, Insect Feeding, Epidermis Recent studies have characterized an ovipositional phenomenon in
a family closely related to blow flies. Female Musca domestica
(Linnaeus) (Diptera: Muscidae) utilize bacterial volatiles present on
G71 Attraction of Two Forensically Important conspecific eggs to mediate oviposition preference. Due to the ubiquity
of bacterial symbionts in the insect realm and the related life histories of
Fly Species: Chrysomya rufifacies Muscidae and Calliphoridae, this same oviposition mechanism may be
(Macquart) and Cochliomyia macellaria present in forensically important blow flies, and may therefore be
(Fabricius) to Inter- and Intraspecific Eggs important to the post-CI. The current study was designed to test volatiles
emitted from Calliphoridae eggs.
Adrienne L. Brundage, MS*, Texas A&M University, 2001 Cobblestone In this study, the attractiveness of inter- and intraspecific eggs to
Lane, Bryan, TX 77807; and Jeffery K. Tomberlin, PhD, Texas A&M adult flies was investigated. A y-tube was used to present individual
University, Department of Entomology, TAMU 2475, College Station, TX males and females of each species with a choice between egg clusters of
77843-2475 each species and blank controls, and the preference recorded. The results
help elucidate the mechanism for oviposition choice and timing, and help
The goal of this presentation is to elucidate the attractive characterize the pre-colonization interval.
mechanism of inter- and intra-specific eggs to two forensically important Entomology, Diptera, Calliphoridae
fly species: Chrysomya rufifacies (Macquart) and Cochliomyia
macellaria (Fabricius). The evolutionary relationship between the two
species will also be discussed, as well as the potential for this
information to elucidate mechanisms used to initiate colonization of a G72 Effects of Resource Age and Sterilization
resource by blow flies at the conclusion of the pre-colonization interval on the Attraction of Cochliomyia macellaria
(pre-CI) which is described below.
This presentation will impact the forensic sciences community by:
(Fabricius) and Chrysomya rufifacies
(1) explaining the importance of the pre-CI when attempting to estimate (Macquart)
time of colonization, (2) examining the biology of, and interactions
between, two forensically important fly species, Chrysomya rufifacies Francisco I. Ortiz, BS*, 1818 South 2nd Street, Apartment 62, Waco, TX
and Cochliomyia macellaria, and (3) investigating one possible 76706; and Jeffery K. Tomberlin, PhD, Department of Entomology,
mechanism triggering and/or inhibiting their oviposition on a resource. TAMU 2475, College Station, TX 77843-2475
Carrion represents a temporary and ever-changing habitat and food
source for a wide variety of organisms. Previous studies indicate the first After attending this presentation, attendees will understand the
macrobiotic decomposers to discover ephemeral resources include blow attraction of two forensically important blow flies, Cochliomyia
flies (Diptera: Calliphoridae). However, their arrival does not macellaria (Fabricius) and Chrysomya rufifacies (Macquart) (Diptera:
necessarily translate into immediate colonization of the remains. Calliphoridae), to different resources. This presentation will also serve
Therefore, the period of insect activity (PIA) is broken into two portions. to educate attendees about the roles bacteria on dead tissue serve to
The pre-CI is from the time of death until arrival of arthropods on the attract flies.
corpse. The post-colonization interval is from colonization of the This presentation will impact the forensic community by
remains until discovery. Colonization can be defined as utilizing a demonstrating the need to exercise caution in estimating the period of
resource as a habitat or for offspring development. insect activity (PIA) because of the different rates of colonization by
Blow flies arrive in predictable patterns and are present for a different species. By understanding differences in colonization between
predictable time interval depending on abiotic and biotic factors. These species, more accurate period of insect activity (PIA) estimates may be
primary colonizers may colonize carrion within hours of death. The act developed.
of colonization starts a “biological clock” and given the collective C. macellaria and C. rufifacies are two species of forensically
knowledge of blow fly biology, it is possible to determine the post-CI of important blow flies whose interaction is important to understanding
the PIA. Since the majority of blow fly species do not colonize living both their behavior and their impact as evidence in forensic
tissue, exposure interval of the remains may be synonymous with the investigations. When both species are present on decomposing animals
post-CI or minimum postmortem interval (PMI). In some instances or bodies, C. rufifacies larvae commonly prey on C. macellaria larvae.
estimates of the post-CI are analogous to the PMI. Furthermore, studies on carrion succession suggest that C. macellaria is
The accuracy of estimating the pre-CI along with the full PIA may a primary colonizer of carrion, while C. rufifacies is a secondary
provide greater understanding of the period of exposure of the remains colonizer. However, these studies have all provided only anecdotal
and more accurate estimates of the PMI. While a great deal is known conclusions about their colonization behavior.
about a few species of forensically important arthropods, much more Blow flies locate carrion primarily through odor signals given off
research is needed. The community of necrophagous insects differs by the decomposing tissue which combine with visual cues to attract flies
between habitats and between geographical areas. These differences to a resource. Female flies use these signals to locate the most suitable
mean that general successional and life history studies may be of some oviposition location. The aim of this study was to examine the
use to all forensic entomologists, but accurate PIA is dependent upon preference of C. macellaria and C. rufifacies for resources at different

ages of decomposition; to determine if fly preference is due to the Estimation of time since death is an important factor in forensic
microbial content of the resource; and to determine if bacteria isolated investigations and the state of decomposition of a body is a prime basis
from the resource is attractive to blow flies. for such estimations. Environmental factors have been shown to have a
A Y-tube olfactometer was used in these experiments. In the first significant influence on the rates of decomposition; these factors can
experiment, males and females of both species were allowed to choose include temperature, solar radiation, rainfall, humidity, physical
between fresh and 3-day old beef liver. The second experiment consisted placement, coverings, and scavenging activity. Many studies have
of testing the preference between sterile and non-sterile beef liver of documented and quantified the influence of such factors on the
different ages. In the final experiment, both species were given the decomposition stages of human bodies and pig carcasses which serve as
choice between sterile nutrient agar and agar colonized with bacteria models of human bodies in North America. However the application of
from the liver. Initial choice, choice after 5 minutes, and residence time these types of investigations to an Australian environment is still rare.
at each resource was recorded in each experiment. This study provides a quantitative analysis of the impact of
Chi-square analyses of the data indicate no significant preference in environmental factors on the rate of decomposition of exposed pig
either species to a resource based initial response. Therefore, final carcasses in the southern region of Western Australia surrounding the
response (i.e. after 5 minutes) was tabulated. C. macellaria and C. capital city, Perth. Pig (Sus scrofa) carcasses of approximately 45 kg
rufifacies exhibited significant preference for fresh liver and 3-day old were placed in four different environments including native bushland
liver, respectively. Closer analyses of the data indicate males of both and suburban agricultural land. The carcasses were not protected and
species demonstrated a significant preference, but females did not. For had trauma from the headbolt or rifle shot to the skull. The
experiment two, neither initial nor final choice showed a significant decompositional process was monitored using time-lapse image capture
difference between species. Finally, neither species exhibited a from an infrared camera. Monitoring was conducted for 24 hr cycles
significant preference between sterile agar and agar treated with bacteria. until the carcasses reached the skeletonization stage of decomposition.
T-test analysis of residence time provided similar results to those The images were viewed to determine the stage of decomposition and to
determined with the Chi-square tests. Both species spent a significant identify any animal necrophagic activity. Weather data were collected
amount of time at a particular resource. C. macellaria resided a for each location which included temperature and rainfall. This research
significant amount of time on fresh liver while C. rufifacies had a greater found that temperature was the most influential factor in determining
residence time on 3-day old liver. Additionally, both species spent a rates of decomposition with summer having significantly faster rates
significantly greater amount of time on the bacteria and agar than on the than any other season. While winter had the slowest rates of
sterile agar. decomposition it was also the season with significantly higher levels of
The results from the first experiment support the assumptions that rainfall. Scavenging by native and introduced animals significantly
C. rufifacies is a secondary colonizer and C. macellaria is a primary affected the rate of decomposition in the cooler months of the year but
colonizer. While only anecdotal information was previously available, had no significant impact in the warmer months. The lack of rainfall in
the data collected in these studies provide a better understanding of the all seasons except winter made statistical analysis inconclusive as to the
behavior of these blow flies. In some cases, succession data are used to significance of rain on the rate of decomposition. During these
estimate the PIA. For instance, these data are useful in the case of experiments, southwestern Australia was experiencing one of the
predicting sequence of colonization by C. macellaria and C. rufifacies. greatest periods of drought in recorded history. Therefore the research
Data from the studies indicate that odors from decomposing remains as examines both the decompositional rates in Western Australia and these
well as associated bacteria might be regulating attraction and rates in periods of drought.
colonization by these species. This presentation will include methodology which can be used in
Forensic Entomology, Blow Flies, Period of Insect Activity other locations throughout the world to replicate the experimentation as
well as the results of the study illustrating the importance of such
research.
G73 Factors Affecting the Rate of Decomposition, Taphonomy, Western Australia
Decomposition of Pig (Sus scrofa)
Carcasses During a Period of Drought G74 Associative Learning of Cochliomyia
in Southern-Western Australia macellaria in Response to Larval Resource:
R. Christopher O’Brien, MFS*, Faculty of Science, UOIT, Oshawa, ON
Inter- and Intraspecific Resource
L1H 7K4, CANADA; Ian Dadour, PhD, Centre for Forensic Science, Interaction, and Presence of Inter- and
University of Western Australia, 35 Stirling Highway, Nedlands, 6009, Intraspecific Larvae on a Resource
AUSTRALIA; Jan Meyer, PhD, Mailbag M309, 35 Stirling Highway,
Crawley, 6009, AUSTRALIA; and Shari Forbes, PhD, University of Stacy A. Boatright, BS*, 2304 Cornell, College Station, TX 77840; and
Ontario Institute of Technology, 2000 Simcoe Street North, Oshawa, Jeffery K. Tomberlin, PhD, Department of Entomology, TAMU 2475,
L1H7K4, CANADA College Station, TX 77843-2475
After attending this presentation, attendees will have an After attending this presentation, attendees will understand the
understanding of the factors which affect the rate of decomposition of concept of associative learning as it pertains to the blow fly, Cochliomyia
pigs in southwestern Australia. These decompositional data can be used macellaria. Experiments assessing adult blow fly response to its larval
to better understand the factors which affect decomposition of a human food resource, exposure of both intra- and interspecies to a food
body. resource, and the presence of both intra- and interspecies larvae on a
This presentation will impact the forensic sciences community by food resource were examined.
illustrating the factors which will affect the time since death estimations This presentation will impact the forensic science community by
used by law enforcement agencies. These factors will significantly affect being the first to assess the importance of blow fly biology as it pertains
a body exposed to environmental variables for any amount of time in to the pre-colonization interval (pre-CI) in a forensic investigation.
Western Australia. The experimental methodology can be utilized in The pre-CI is the portion of the period of insect activity (PIA) prior
other parts of the world to determine the impact of local environmental to colonization of a food resource. The location phase begins when the
factors on the rate of decomposition. insect detects a body and is more than likely governed by volatile odors
not only from the corpse itself, but also from other adult blow flies and G75 Attraction and Repellance of Blow Flies to
their larvae present on the corpse. The acceptance phase begins when the
insect first makes physical contact with the food resource.
Intra- and Interspecific Fecal Bacteria
Understanding blow fly behavior under various conditions might allow
for more concise estimates of the pre-CI of a body; the current study Melinda K. Dooley*, and Jeffery K. Tomberlin, PhD, Department of
assesses C. macellaria’s behavioral response to three such conditions. Entomology, TAMU 2475, College Station, TX 77843-2475; and
The first experiment addressed whether C. macellaria adult flies Adrienne L. Brundage, MS, 2001 Cobblestone Lane, Bryan, TX 77807
will be more attracted to food resources on which they were raised. An
abundance of C. macellaria eggs was gathered from pre-existing After attending this presentation, attendees will have a greater
colonies and randomly distributed between bull testicles and beef liver understanding of the conspecific and interspecific interactions of blow
and kept under the same conditions. Once the flies reached the adult flies: specifically, the role of fly feces and related bacteria on the
stage, they were only provided with water and a powdered milk and attraction and repellence of forensically significant blow flies (Diptera:
sugar mixture ad libitum. Beginning on the seventh day post-emergence, Calliphoridae).
seven testicle-fed males and seven testicle-fed females were placed This presentation will impact the forensic community by improving
individually in a Teflon dual-choice olfactometer and their response to understanding of factors that can affect attraction and oviposition of two
the resources provided recorded; likewise, seven liver-fed males and of the most common blow flies in the summer in the southern United
seven liver-fed females were examined under the same circumstances. States, Cochliomyia macellaria (Fabricius) and Chrysomya rufifacies
Testicles were placed in containers connected to the dual-choice (Macquart).
olfactometer, while liver was placed in the other. Resources were rotated The most important duty of the forensic entomologist in a death
between arms with each replicate. The olfactometer was also cleaned investigation is to provide an estimate of the time of colonization, or
between sessions. This regime lasted for five consecutive days. The period of insect activity (PIA) which translates into a minimum
goal was to determine whether or not adult flies would associate with the postmortem interval (mPMI). Blow flies are the most significant insects
odors of the source on which they were raised, thus “choosing” that in death investigations because known patterns of larval development
particular resource. allow entomologists to determine how long a corpse has been colonized.
The second experiment determined whether C. macellaria flies are As blow flies generally only oviposit on a body after death occurs, the
equally attracted to a food resource that has been exposed to adults of the amount of time that has passed since eggs were laid is the minimum
predatory species, Chrysomya rufifacies. An equal number of male and length of time for which the victim has been dead. However, flies may
female C. macellaria were kept in one cage, while an equal number of not oviposit immediately at the instant of death. Rather, there are
male and female C. rufifacies were kept in a second cage, under the same elements that delay oviposition, especially in C. rufifacies, which has
conditions. Containers of beef liver were introduced to each cage, and been observed to arrive at the scene of death first, but only oviposit after
one from each of the cages was removed every 24 hours for five other species such as C. macellaria. These elements may include quality
consecutive days. Once one 24-hour exposed container was removed or decomposition of the resource, the presence or lack of certain bacteria,
from each cage, they were connected to separate arms of the dual-choice or conspecific and interspecific signals left in the secretions of flies.
olfactometer. Five female and male C. macellaria adults were tested to In this study, fly specks were gathered from recently emerged C.
see whether they were deterred from the liver that had been exposed to macellaria adults. A saline solution of the fecal matter was grown on
C. rufifacies. Other containers of liver were exposed to each of the fly nutrient agar, and the resulting bacteria were cultured and used in
species colonies for 72-hour time intervals, at which point they were also preference testing via Y-tube olfactometry. Based on odor alone, fecal
used in the olfactometer. All C. macellaria adults used in this bacteria do not produce volatiles strong enough to attract or repel adult
experiment were reared on beef liver. flies of either species. However, certain signals must be present to
The third experiment assessed whether the presence of intra- and trigger the beginning of oviposition of these two species on their
interspecies larvae affected C. macellaria’s attractiveness to a food respective timetables.
resource. This study is applicable to forensics because it addresses C. macellaria are typically one of the first species to colonize a
whether or not C. macellaria adults are less likely to lay their eggs on a resource in the southern United States. However, a few days after death,
cadaver that has already been infested with the predatory species, C. the majority of maggots on a body may be C. rufifacies. Although this
rufifacies. A similar experimental design with the olfactometer as species is often one of the first to arrive at a scene of death, adult females
described previously was used in this study. One container of beef liver will wait to oviposit until after other fly species have begun to colonize
containing third instar C. macellaria maggots and one container of beef the resource. It is possible that the presence of maggots of primary
liver colonized by C. rufifacies maggots were placed at the arms of the colonizers such as C. macellaria somehow prepares or alters the
olfactometer. Five C. macellaria adults from each sex were tested for resource, improving the viability of the later-colonizing C. rufifacies.
five consecutive days. The adult C. rufifacies may be waiting for some signal that the resource
These experiments are the first to assess the importance of blow fly has been colonized by other species before beginning oviposition, and
biology as it pertains to the pre-CI in a forensic investigation. In other this study investigates the role that C. macellaria feces and related
words, the current experiments take into consideration a variety factors bacteria may play in that signaling process.
which may influence the colonization of a food resource by the blow fly, By increasing understanding of what delays and triggers oviposition
C. macellaria. on a body, improved estimates of pre-colonization intervals will lead to
Forensic Entomology, Period of Insect Activity, Associative Learning more accurate estimates of the PMI.
Blow Fly, Postmortem Interval, Oviposition

G76 Three Dimensional Polygonal Model G77 An Unusual Case of Homicidal Chest
Visualization of Lucila sericata From SEM Trauma Using a Golf Club as a Weapon
and Stereomicroscopic Data
Carlos F. Chavez-Arias, MD, Puerto Rico Institute of Forensic Sciences,
Jeffrey R. Christiansen, BS*, Halff Associates, 1201 North Bowser Road, PO Box 11878, Caparra Heights Station, San Juan, Puerto Rico 00922-
Richardson, TX 75081; and Jeffery K. Tomberlin, PhD, Department of 1878; Javier Serrano, MD*, Puerto Rico Institute of Forensic Sciences,
Entomology, TAMU 2475, College Station, TX 77843-2475 Calle Maga Esquina Casia #9, Urb. Reparto Metropol, San Juan, PR
00921; Dario Sanabria, MD, Puerto Rico Institute of Forensic Sciences,
After attending this presentation, participants will be able to Department of Pathology, PO Box 11878, Caparra Heights Station, San
understand how a true color, three dimensional polygonal model Juan, Puerto Rico 00922-1878; and Jose F. Rodriguez, PhD, Institute of
visualization of Lucila sericata can be produced from SEM and Forensic Science of Puerto Rico, Calle Maga Esq. Casia, Urb. Reparto
stereoscopic photomicrograph data. Metropolitano, San Juan, PR 00922
This presentation will impact the forensic sciences community by
providing a tool for better anatomical training methods of forensically The goal of this presentation is to describe and discuss an unusual
important insect species. case of homicidal chest trauma caused by a single blow to the chest with
Blow flies (Diptera: Calliphoridae) are a cosmopolitan group of a golf club that was used as a weapon.
insects and often the first to colonize human remains. Therefore, they This presentation will impact the forensic sciences community by
are often collected as evidence. Analysis and prediction of their age often demonstrating an unusual mechanism of chest trauma and death
is interpreted as the period of insect activity (PIA). However, in order to produced by a golf club head without penetration of the thoracic cavity
utilize any insect collected from human remains as evidence, they must by the weapon.
first be identified. Skills necessary for identifying these insects are Different accidental injuries from golf equipment have been
gained primarily through courses taken while in college, graduate reported for adults and children. The vast majority of these reported
school, or workshops. Primary information utilized for identifying these cases were accidental blows to the head from clubs and balls. To this
insects is found in texts or research publications. These sources contain date there are no reported cases in the literature of homicidal chest
detailed taxonomic information about each of these species which trauma using a golf club as a weapon. Golf clubs are potentially lethal
enables their identification. However, few resources are available that weapons when used inappropriately. A golf club is particularly designed
provide three-dimensional imagery for teaching or identification to hit a golf ball. The club head is capable to accelerate to a great speed.
purposes. For this reason, a highlydetailed three-dimensional polygonal This speed is produced by body motion swinging the club in vertical,
model of the species has been created. The creation of an anatomical circular, and horizontal directions.
training tool that can be utilized by any age group would significantly This witnessed case involved an 18-year-old, black Hispanic
increase the awareness of discipline-specific species. While utilizing healthy man who received a single blow to the chest in the presternal
two different diagnostic microscopes (i.e. scanning electron microscope region with a club head during a fight. Immediately after he was hit he
(SEM) and dissecting microscope), a better understanding of the collapsed at the scene. Minutes later he was pronounced dead on arrival
anatomical characteristics and landmarks can be understood. The issue at the emergency room.
becomes, who else can benefit from the data acquired? Usually the At autopsy the body corresponded to a well-developed and well-
investigator is the only individual to benefit. From this stereoscopic data, nourished lean male. He was 67 inches tall and weighed 118 pounds.
an accurate three dimensional polygonal model was created using External examination of the anterior torso, disclosed the presence of two
computer software forming the basis of the three dimensional well-defined brown-tan abrasions in the medial aspect of the left pectoral
investigational/visualization tool. By combinatorial investigation, a tool region separated by a 1” by 1” inch contused area. One of the abrasions
can now be utilized by everyone in the form of three-dimensions, true was lateral and higher compared to the other. It measured 3/4” by 1/2”
color, high-definition imagery and movies. This proposed model is the and had a rectangular shape. The other abrasion measured 5/8” by 5/8”
first investigational process utilizing both stereoscopic and had a triangular configuration. The contused area had a triangular
photomicrographs and SEM data to generate a specie-specific three- shape with a vertex pointing to the medial aspect of the thorax. The body
dimensional polygonal model. Lucila sericata is a green bottle fly that had no other external signs of trauma. Upon reflection of the skin of the
is common throughout the United States during the warmer months of anterior thorax, a localized 1 ¼” by 1” hemorrhagic area was involving
the year and has been used in many studies to understand the biology and the presternal soft tissue and was associated to linear non-displaced
ecology of blow flies in general. Therefore, this species was selected for fractures of the anterior aspects of the left 5th and 6th ribs at the costo-
the study. sternal junction. The right pleural and pericardial spaces had 1000 ml
This study is also important because it allows forensic and 30 ml of liquid blood respectively. The pericardium had an
entomologists to better communicate blow fly anatomy to a wide array extensive laceration associated with two parallel transmural lacerations
of sciences including but not limited to pathology. The end result, a three of the anterior right ventricular wall, slightly parallel to the heart axis.
dimensional visualization of the blow fly, offers a compelling tool for There was no other cardiac involvement by trauma. The rest of the
teachers at all levels to introduce entomology in the classroom. This thoracic and abdominal organs had no lesions. Additional autopsy
concept will continued to be investigated for a further detailed polygonal findings were remarkable for right lung collapse and brain edema.
model, and to include other forensically significant species. Toxicological evaluation was negative for alcohol, cocaine, opioids, and
Lucila sericata, Visualization, SEM canabinoids.
Chest trauma is traditionally described as blunt or penetrating. The
trauma is classed as blunt when the chest wall remains intact and as
penetrating when the integrity of the chest wall is breached. Blunt
trauma is more common than penetrating chest injury, accounting for
more than 90% of thoracic injuries. Two mechanisms occur in blunt
trauma: by direct transfer of energy to the chest wall and thoracic organs
and by differential deceleration, experienced by thoracic organs at the
time of the impact. A direct blow to the thoracic wall produces crush and
shear injury associated with fractures of bones and soft tissue damage.
Ribs may be fractured at the point of impact and damage the underlying
thoracic organs by producing contusions or punctures. This case /positional asphyxia remained the leading type of
represent blunt chest trauma in which a great amount of energy was non-chemical suffocation in male victims. However, the type
applied over a small body surface causing a penetrating injury of the distribution of non-chemical asphyxia differed in female
heart by fractured ribs. An important feature of this injury is that the victims, smothering being the most common type (64%),
fractured ribs were not found displaced at autopsy examination. A relegating mechanical/positional asphyxia to second position
temporal displacement of these ribs could explain the nature of the heart (32%). Choking occupied third position in both gender, with
injury. 16% and 5% in males and females respectively. As for age, the
Factors such as golf club design and physics of chest trauma are average in each type of suffocation did not seem to differ
keys for understanding the mechanisms of trauma involved in this significantly.
unusual homicide case. Manner of death: Taken as a whole, manner of death in
Golf Club, Chest Trauma, Homicide non-chemical suffocation is generally ruled as accidental
(73%). In fact, all entrapment/ environmental suffocations and
traumatic/ positional asphyxia deaths were accidental, as well
G78 Non-Chemical Suffocation Deaths in as the vast majority of choking (85%). Smothering, in
contrast, is associated with a higher variability of manner of
Forensic Setting: A Six Year Retrospective death between cases: though suicide makes up the main core
Study of Environmental Suffocation, (17 cases), manner of death was ruled differently in 12 cases,
Smothering, Choking, Traumatic, and including six homicides and five accidents. The most common
form of smothering was from a plastic bag overhead (69%),
Positional Asphyxia with all suicidal smothering cases being related to this method.
In the last 15 years, evidence-based medicine has been advocated as
Silvia Tambuscio, MD*, Legal Medicine for the Court of Padova, Via a new paradigm, proclaiming that evidence from research is the best
Rezzonico, 24, Padova, LA 35131, ITALY; and Anny Sauvageau, MD, basis of clinical decisions and practice. In this global context, forensic
Lab de Sciences Judiciaires et de Medecine Legale, 1701, Parthenais pathology is no exception and is increasingly becoming a science and
Street, 12th Floor, Montreal, Quebec H2K 3S7, CANADA decreasingly an art. Nevertheless, there are still several areas of forensic
pathology mainly based on tradition, with textbooks describing common
After attending this presentation, attendees will be afforded a six- knowledge that is not supported by modern research data. The present
year review of forensic autopsies of non-chemical suffocation deaths in study is intended to contribute to evidence-based data on non-chemical
the province of Quebec, Canada. suffocation deaths. Despite several case reports, case series and a few
This presentation will impact the forensic community by providing studies on suffocation subsets, this is the first time non-chemical
evidence-based data to support common knowledge on non-chemical suffocation deaths are systematically studied. Taken as a whole, the
suffocation deaths. outcomes of this study corroborate the literature data, thus supporting the
Suffocation has been the object of several papers but mainly case common knowledge with evidence-based data.
reports or cases series. Studies of subsets of suffocation deaths, limited Asphyxia, Suffocation, Manner of Death
to a specific scenery or category, have also been reported, such as
suffocation in motor vehicle crashes, lethal crush/traumatic asphyxia,
fatal entrapments in on-farm grain storage bins, suffocation by plastic
bags, coffee thrombosis deaths, or overlaying and wedging deaths in
G79 Death by Electrocution: Unusual
children. However, no systematic study has ever portrayed non- Findings in a “Love Nest”
chemical suffocation deaths in forensic setting. A six year retrospective
study of all non-chemical suffocation cases in the laboratory in the Sandra Cornetta, MD*, Sezione di Meidcina Legale - Università di Bari,
forensic victim population aged of more than one year will be presented. piazza Giulio Cesare, 11, Bari, 70124, ITALY; Fiorenza Zotti, PhD,
In the province of Quebec (Canada), a single centralized forensic Section of Legal Medicine, Place G. Cesare, Bari, 70124, ITALY;
laboratory covers the entire 7.5 million province population. Over a six Roberto Gagliano-Candela, AS, University of Bari, Cattedra
year period (2000-2005) all autopsy cases performed at this laboratory Tossicologia Forense, Policlinico, Piazza G. Cesare 11, Bari, 70124,
were retrospectively reviewed for non-chemical suffocation deaths in the ITALY; Andrea Marzullo, MD, Sezione di Anatomia Patologica -
forensic victim population aged of more than one year. For each case, Università di Bari, piazza Giulio Cesare, n.11, Bari, 70124, ITALY; and
the type of suffocation, manner of death, gender, and age were compiled. Alessandro D. Erba, Sezione di Medicina Legale - Università di Bari,
In the case selection, cases of suffocation occurring in association with piazza Giulio Cesare, n.11, via Prospero Petroni, n.37, Bari, 70124,
another type of trauma, such as sharp or blunt weapon, were excluded. ITALY
Cases of suffocation in association with another category of asphyxia,
such as hanging combined with suffocation by a plastic bag overhead After attending this presentation, attendees will realize the
were also excluded. significance of a complete forensic examination of each case in order to
During the six year study period (2000-2005), a total of 96 non- understand the real cause of death. Sometimes the evidence found at the
chemical suffocation cases were autopsied in the forensic laboratory of crime scene could lead examiners to misunderstand the cause of death,
the two Lab Sciences Judiciaies. This represents 2.3% of all forensic but only by collecting pathological, toxicological, immunological, and
autopsies for the same period. Overall, cases were aged from two to 90- histological findings, you can be sure to correctly solve a case.
years-old (mean ± standard deviation, 46 ± 19), with similar averages for This presentation will impact the forensic science community by
men (46 ± 19) and women (48 ± 24). showing some unusual findings observed in an apartment that seemed to
Type of suffocation: Traumatic /positional asphyxia be a quiet love nest. Some of these findings seemed to suggest a
ranked as the leading type of non-chemical suffocation, with different cause of death from the real one that was obtained through
over half cases (54%). Smothering and choking followed, in histological examinations.
30% and 14% of cases respectively. Entrapment/ A 63-year-old married man with two children was found dead in an
environmental suffocation, on the other hand, was found in apartment in a suburb of Bari, Italy. The apartment turned out to be a
only 2% of cases. “love nest” of sorts, complete with nude pictures on the walls, erotic
Gender and Age: Overall, a strong male predominance books, and pornographic videos and magazines. A large quantity of
was observed, with two-thirds of male victims. Traumatic condoms and various types of sex toys were discovered in the drawers
throughout the premises. None of the family members of this man were the orbital bone in the right occipital region was present. Neurosurgical
aware of this apartment. treatment was performed for subarachnoid hemorrhage, but the man was
The body was found completely nude, lying prone on the floor pronounced dead four days after the penetrating stab trauma.
of the kitchenette with the knees and pelvis in a flexed position. On the Prosecutor arranged the autopsy on the body because the
wall were exposed electrical wires from the thermostat of the boiler, a circumstances of the wounding suggested that the death could have been
tool drawer on a shelf, and screwdrivers and pliers scattered on the floor a murder in connection with the father-in-law.
around the cadaver. External inspection of the body showed no presence A complete autopsy was performed 24 hours after death. The
of any significant traumatic lesions except for some oval, slightly external examination revealed a laceration in the external part of the
depressed, yellowish, grazed areas on the back of the right hand and on upper eyelid measuring approximately 0.5 cm x 0.4 cm and surrounded
the external malleolus of the right ankle which resembled parchment.
by traces of reddish color, a wide subconjunctival hemorrhage and in the
An autopsy revealed a diastasis between the IV and V cervical
upper lateral quadrant of cornea a 0.5 cm in diameter circular tear. This
vertebrae with light hemorrhage of the soft tissue which probably
happened just before the moment of death (limine vitae) due to the corneal lesion penetrated in the eyeball that was removed and revealed
anomalous position assumed by the cervical roots after the victim fell to on the lateral wall of the orbital bone a round bone defect measuring 0.5
the floor into a very confined space. It was later discovered that the cm in diameter that went through the orbit in the cranial cavity and exited
victim suffered from pre-existing cervical arthrosis. Immunological in the anterior cranial fossa with a circular tear of dura mater measuring
investigation was carried out on the suspicion that the death may have 0.5 cm in diameter. The brain was oedematous and was fixed for three
been the result of anaphylactic shock, but the findings were negative. weeks in 10% buffered formalin prior to being sectioned with coronal
Toxicological investigation showed the presence of nontoxic levels of cuts. Dissection revealed right to left shift of the midlines structure. A
Sildenafil (the principal active ingredient in Viagra®), along with high
circular injury measuring 0.5 cm was present in the right frontal region.
levels of some components of a cutaneous disinfectant used in the
This injury penetrated into the parenchyma from the base in the frontal
sterilization of medical surgical instruments.
These findings, which seemed quite curious, were attributed to the region upwards and maintained the same diameter through the frontal
possible transrectal absorption of the substance, most likely used in the end of the parietal lobes. The entire distance from the anterior cranial
disinfection of some of the autoerotic instruments discovered in the fossa bone defect to the parietal lobe measured 7 cm.
apartment. In the end, the definitive diagnosis of the cause of death was Wide foci of hemorrhages were present in the right hemisphere and
arrived at by means of histological verification carried out on fragments characteristic petechial hemorrhages continuing throughout coronal cuts.
of skin taken from the grazed areas of the right hand and ankle which Examination of the other organs was unremarkable. Routine histological
showed signs of the passage of electrical current. In particular, it was the investigation applying haematoxylin and eosin staining was performed
coagulative changes of the epidermis (i.e., cytoplasmic hyperesinophilia,
on various organs and revealed a detachment of the upper epidermal
lengthening of the nuclei) and congestion of the small blood vessels
areas mainly extends through the basal-cell layers with flattened and
which suggested that the subject died of electrocution.
Electrocution, Sex Toys, Transrectal Absorption stretched epidermis on the eyelid skin. The deeper parts of stratum
papillare and underlying upper layers of the corium were characterized
for wide erythrocytes accumulation. The eye samples collected on the
G80 A Fatal Case Due to a Pitchfork Penetrating round laceration were stained with trichromic dye and presented the
Head Injury discontinuation of corneoscleral coat, choroids, until posterior camera
and vitreous space with wide spread erythrocytes infiltration. Brain
Margherita Neri, PhD*, Santina Cantatore, and Cristoforo Pomara, sections showed intraparenchymal diffuse hemorrhages.
PhD, Department of Forensic Pathology University of Foggia, Viale The examination of the pitchfork showed a perfect compatibility
degli Aviatori 1, Foggia, 71100, ITALY with eye and intracranial lesions. No fingerprints from the father-in-law
were collected on the pitchfork.
After attending this presentation, attendees will have a better According to the autopsy findings and histological data, death was
understanding of an unusual fatal case of penetrating cranial stub injury attributed to brain hemorrhages. The tool that caused the death was the
due to pitchfork. pitchfork, and the mechanisms of trauma were consistent with an
This presentation will impact the forensic community due to the accidental trauma.
rarity of the deaths by pitchfork, the particular features of eye and Furthermore, the circumstantial data confirmed the hypothesized
intracranial lesions caused by the tool, and for the importance of a death scene: it was an accidentally self-inflicted stab penetrating injury
careful autopsy examination in order to clarify the exact mechanism of due to pitchfork.
the death. Pitchfork, Self-inflicted Stab Lesions, Penetrating Head Injuries
Penetrating head injuries can be the result of numerous intentional
or unintentional events, including missile wounds, stab wounds, and
motor vehicle or occupational accidents (nails, screwdrivers). The most G81 Head Injury Associated With Posterior
common wound is a knife injury, although bizarre craniocerebral-
perforating injuries have been reported that were caused by nails, metal
Distraction of the Spine in a 4.5 Months
poles, ice picks, keys, pencils, chopsticks, and power drills. Here is Old Baby: Analysis of the Lesional
presented a case where a farmer was wounded with a pitchfork. Mechanisms
In the rural area in southern Italy, a 56-year-old Caucasian farmer
was found unresponsive by his father-in-law a few meters from their Audrey Farrugia, MD, Annie Geraut, MD*, Bertrand Ludes, MD, PhD,
farmland, with a tine of the pitchfork penetrating the right eye. He was and Jean Sebastien Raul, MD,PhD, Medico-Legal Institute, 11 Rue
quickly taken by helicopter to the nearest hospital in serious clinical Humann, Strasbourg, 67065, FRANCE
condition and immediately accepted in the Intensive Care Unit. Glasgow
Coma Scale score was three. A penetrating circular wound in the right After attending this presentation, attendees will understand the
eye was detected. The cranium CT showed a large hemorrhagic area in analysis of lesional mechanisms in association with lesions of head and
the right frontal-temporal-parietal lobe, hemoventricle and right to left spine in a young baby.
brain shift. Subarachnoid hemorrhage and fractures of the lateral wall of
This case report concerns a 4.5-month-old boy measuring 62.5 cm related to genetically determined cardiac diseases. Some of them have a
and weighing 5.5 kg who was treated by an emergency team for a morphological substrate at autopsy as hypertrophic cardiomyopathy. But
cardio-respiratory arrest at the parent’s house. He was declared dead those related to channelopathies are impossible to detect without genetic
upon arrival at the hospital. The first explanation by the mother was analysis. Postmortem genetic testing referred to as molecular autopsy
that the child had been dropped and it suffered an accidental fall down was recently carried out by many authors in cases without morphological
the stairs. Quickly, the theory of an accident fall was denied by the two explanation of the sudden death and allowed to identify pathogenic
parents. mutations described already in clinically known arrhythmic syndromes.
The postmortem CT scan of the entire body showed a right However, it is also possible to perform genetic testing to refine the
parietooccipital fracture with cerebral lesions. The medicolegal diagnosis of a hypertrophic cardiomyopathy in cases without evident
autopsy found a contusion with abrasion of parietooccipital region with morphological substrate. The genetic cardiac disease may explain the
a bending of head, a huge hematoma associated with bone defect, death, but it may also be at the origin of a traffic accident with a loss of
diastatic fracture and extradural and subdural hemorrhage, cerebral car control or drowning. The channelopathies may also be involved in
contusions and oedema. Skin ecchymosis (three ecchymosis in right cases supposed to be related to intoxications. Therefore, it is important
temporal region and one ecchymosis in left frontal region) was also to consider the genetic screening in forensic investigations.
noted. The dissection of the spine by posterior incision showed a The legal and ethical aspects of genetic testing in forensic
fracture of the right part of the neural arch of T12 with extra and investigation are complex. In Switzerland, the investigating magistrate
subdural hemorrhage of the medullar cord associated with haematic may mandate genetic testing in the forensic context in order to determine
infiltration of the posterior part of the intersomatic spaces extensive on the cause of death. In fact, the particularity of medicolegal autopsy is
7 cm and a small ecchymosis of the anterior part of T12 body. Because that during the investigation procedure and in contrast to a clinical
of the initial story indicating the child fell, an opening of the joints of context the genetic tests can be carried out without the consent of the
the four limbs was performed and no macrocospical lesion were noted. dead person or proxy consent. The consent is however necessary for any
The knee and wrist joints were removed for anatomopathological research activity. Genetic screening is important to establish the cause
analysis. There was no congestion of the internal organs. but also to detect the asymptomatic carriers in order to prevent sudden
The anatomopathological findings confirm the macroscopical death in other family members. This prevention involves a
description consistent with premortem lesions. They pointed out an multidisciplinary collaboration. In Lausanne, such collaboration was
infra-clinical fracture of the right knee and a haematic infiltration of the established between services of cardiology, medical genetic, toxicology,
left radio-ulnar membranous. and forensic medicine.
The spine lesions were consistent with impact of the parieto- This presentation will be illustrated by autopsy cases for which the
occipital region associated with a violent anterior flexion of the spine interpretation of the results of the genetic screening is explained in the
leading to posterior distraction lesion of the spine. The infra-clinic light of other autopsy findings. The interdisciplinary collaboration as
lesion of the right knee and the left wrist suggest a violent projection of well as the juridical and ethical aspects of genetic analyses in cases of
the baby against a hard surface (like a wall) followed by a fall. sudden cardiac death will also be briefly discussed.
This case report shows the significance of carrying out a complete Sudden Cardiac Death, Channelopathies, Molecular Autopsy
dissection of the spine and the spinal cord and performing an opening
of the limb joints and a removal for anatomopathological analysis in
cases of suspected of non accidental injury in a baby. G83 Unexpected Death of 24-Year-Old Male
Child Abuse, Lesional Mechanisms, Head and Spine Injury
With a Phenotype Strongly Suggestive of
Lujan-Fryns Syndrome
G82 Genetic Testing of Sudden Cardiac Death
Stojan Petkovic, PhD*, Department of Forensic Medicine, Clinical
Victims: From a Forensic to a Center of Vojvodina, Hajduk Veljkova 5-7, Novi Sad, 21000, SERBIA
Multidisciplinary Approach AND MONTENEGRO; Branislav Budakov, MD PhD, Hajduk Veljkova
3, Novi Sad, 21000 SERBIA AND MONTENEGRO; Slobodan Savic,
Katarzyna Michaud, MD*, Centre Universitaire Romand de Médecine PhD, School of Medicine, University of Belgrade, Institute of Forensic
Légale, Rue du Bugnon 21, Lausanne, 1005, SWITZERLAND; and Medicine, Deligradska 31a, Belgrade, 11000, SERBIA AND
Bernice Elger, PhD, Centre Universitaire Romand de Médecine Légale, MONTENEGRO; and Isidora Samojlik, MD, Department of
1211 Genève, Rue Michel-Servet 1, Genève, SWITZERLAND Pharmacology and Toxicology, Faculty of Medicine, Hajduk Veljkova 3,
Novi Sad, 21000, SERBIA AND MONTENEGRO
After attending this presentation, attendees will learn a practical,
ethically, and legally acceptable approach to cases of sudden cardiac After attending this presentation, attendees will be acquainted with
death thought to be of genetic etiology. features of a rare genetic disorder which may be of great interest in
This presentation will impact the forensic community by common forensic practice, but at the same time is very difficult to be
demonstrating an interdisciplinary approach in cases of sudden cardiac recognized.
death believed to be related to channelopathies. This presentation will impact the forensic community
Sudden cardiac death is considered as the most important cause of demonstrating that in certain cases sudden and unexpected death could
death in western countries. In cases of sudden, unexpected deaths and be attributed to peculiar genetic disorder which has not been described
especially in young people, a forensic autopsy is required, frequently until now in forensic literature.
followed by complementary investigations, in order to determine the The presented case concerns unexpected death of a 24-year-old
cause of death. However, it happens that even after an autopsy is male shortly after his discharge from the hospital where he was admitted
performed in accordance with international recommendations, the cause due to severe psychiatric behavioral disorder. He had been treated in the
of death remains unexplained. Such cases, called also autopsy negative course of three months with the following final diagnoses: moderate
sudden deaths, are not rare (6% to 40%) and are often considered to be mental retardation, non-organic non-specified psychosis, and significant
due to a sudden cardiac arrhythmia. behavioral disorder which needs special care and treatment. He was sent
Thanks to the progress made in molecular biology, it is admitted home in the phase of psychiatric symptoms‘ remission.
that most cases of sudden cardiac death of children and young adults are Heteroanamnestic data obtained from the family members revealed his

cognitive and behavioral impairment many years before hospitalization; articles found by computer search even mentioning this complication are
in addition, they described the physical status of the young man two days from 1985 and 1989.[1, 2] This reflects the effectiveness of safety devices
after his hospital discharge-frequent vomiting, severe abdominal pain, built into hemodialysis systems in recent decades. Air embolism can
fever and exhaustion. Thus, he refused to eat and ante finem he even occur, however, in dialysis setting through improper use or technique
couldn’t open his mouth. Together with other family members, his with venous access outside the monitored system.
mother tried to help him by giving food and water, but all the efforts were A 53-year-old man had undergone renal dialysis thrice weekly for
in vain – he died in his bed. The police report confirmed all statements three years because of end-stage renal disease. While on dialysis his
given by the deceased’s family. general health otherwise was good. He was normotensive, without
The external examination showed distinct facial dysmorphism evidence of cardiac disease, and with normal blood glucose
(elongated narrow face, prominent forehead, long nose, maxillary determinations. He had been evaluated and approved as a candidate for
hypoplasia, and small mandible), as well as marfanoid stature with long renal transplantation and was awaiting a donor organ.
slender extremities. The internal examination disclosed aortic narrowing Early on a Saturday morning he reported to the dialysis facility for
(circumference of 4.5 cm at the valves level), right aortic arch, low heart his final session of the week, along with eleven other patients. This
weight (240 g) with normal thickness of the left and right ventricle wall. Saturday the facility was understaffed with one of two nurses (RNs)
The large intestine was widened, tensed, and full of gases and liquefied missing and one patient care technician (PCT) absent. Nevertheless, the
feces. No other pathological abnormalities were noticed in all other preparation and dialysis proceeded normally for the patient through the
examined organs. Microscopically, slight congestion and edema of all rinse-back phase. Disconnected from the dialysis machine, he had a
tissues were found; specific staining for elastic fibers (Verhoeff method) routine sitting blood pressure check recorded as 169/86. He then
showed rupture of elastic lamina and scarcity of elastic fibers with cystic positioned himself for the routine standing blood pressure check but
degeneration of aortic media. complained of lower extremity cramping (a common complaint in
The postmortem toxicological screening detected the presence of dialysis patients) and sat back down on the dialysis chair. The PCT
clozapine and fluphenazine (neuroleptics) in the blood and bile, as well hurriedly plugged in the line of a half-filled saline bag hanging on the
as clozapine and midazolam (benzodiazepine) in the stomach content. machine. This is a routine treatment for post-dialysis cramps or
These findings fitted well the data in the medical records informing that hypertension (a BP of 86/47 was recorded).
the man received depot intramuscular injection of fluphenazine It is important to note here that the patient is disconnected from the
decanoate (25 mg) three days before his release and was instructed to machine and its safeguards against air in the system. The saline bag
continue with his therapy at home by taking clozapine (50 mg three times (which should have been full) and its line are outside the machine and
a day), lorazepam (2.5 mg three times a day) and midazolam (15 mg have no air alarm. The line from the bag is connected to an existing
when needed at night). In the conclusion of the autopsy protocol, the venous access in the forearm. The bag ran empty or nearly so and was
cause of death was attributed to paralytic ileus due to antipsychotic hand pumped by the PCT to get every bit of saline out of it, while calling
therapy applied. for help. A full saline bag was quickly obtained and replaced the empty
On the basis of the case circumstances, collected medical records, one, but no one recalled having cleared the air from the new bag and its
heteroanamnestic data and the autopsy findings - including peculiar line.
facial appearance along with both macroscopical and microscopical The patient fell back in the chair, unconscious and unresponsive.
cardiovascular features (narrowing of aortic root and ascending aorta and He could not be revived. An ambulance was called and transported the
mediocystic degeneration of aortic wall), there was a strong suspicion on patient to a hospital. There was no venous access during transport. On
the Lujan-Fryns syndrome. In the available forensic literature the case admission, he remained unconscious and unresponsive. A non-contrast
of the Lujan-Fryns syndrome with fatal outcome is not found. CT of the head showed scattered small round low-density areas on the
The Lujan-Fryns syndrome is defined by X chromosome-linked convexity of the cerebral hemispheres suggesting air embolism. On two
mild to moderate mental retardation, distinct facial dysmorphism (long subsequent daily CT studies, the air shadows were gone but massive
narrow face, prominent forehead, long nose, maxillary hypoplasia, and swelling of the right cerebellum with subtentoral herniation consistent
small mandible), marfanoid stature with long slender extremities and with acute infarction.
behavioral problems. The genetic defect is not known; therefore the Electrocardiography suggested an anterior myocardial infarction. A
diagnosis is based on the presence of the clinical manifestations. cardiac catheterization showed ventricular changes consistent with
Lujan-Fryns Syndrome, Paralytic Ileus, Antipsychotics infarction, but coronary arteriography showed a remarkably clean
coronary arbotization, given his history, with only minimal to mild
atherosclerosis and no occlusive disease through five and six
G84 Fatal Air Embolism During Hemodialysis bifurcations. Patent coronary arteries and a subendocardial infarct were
confirmed at autopsy.
B.G. Brogdon, MD*, University of South Alabama Medical Center, The mechanism and route of systemic air embolism via venous
Department of Radiology, 2451 Fillingim Street, Mobile, AL 36617; and access will be discussed.
LeRoy Riddick, MD*, University of South Alabama Medical Center, References:
1
Department of Pathology, 2451 Fillingim Street, Mobile, AL 36609 Cohle SD, Graham MA. Sudden death in dialysis patients. J Forens
Sci 1985; 30:158-166.
2
By attending this presentation, attendees will learn of this extremely Air embolism associated with hemodialysis. Health Devices. 1989;
rare complication of dialysis, understand the most likely cause, and the 18(11) 406-7.
difficulties in verifying the diagnosis. Renal Dialysis, Fatal Complication, Air Embolism
reminding them of this rare complication (almost exclusively related to
human frailty thwarting an otherwise foolproof system), its presentation
and diagnosis.
Systemic air embolization during renal dialysis is so rare it is not
referenced in any major neurology text since 1976. The most recent

G85 Traffic Accident Deaths? The Importance examination revealing some well-known sequelae of preeclampsia-
eclampsia, including intracerebral hemorrhage and platelet and fibrin
of Autopsy microthrombi of the kidneys that indicated a thrombotic
microangiopathy. Hepatocellular necrosis was also observed. The
Duarte N.P. Vieira, PhD*, Instituto Nacional, de Medicina Legal, singleton pregnancy revealed an unresponsive male fetus with no evident
Coimbra, 3000-213, PORTUGAL; Cristina Cordeiro, MSci, Instituto developmental abnormalities. The cause of death was listed as
Nacional de Medicina Legal, Largo da Sé Nova, Coimbra, FL, complications of preeclampsia, with extensive intracerebral hemorrhage.
PORTUGAL; and Helena Garcia, MD, CEDAP, Av. Calouste Preeclampsia-Eclampsia, Maternal, Death
Gulbenkian, Coimbra, 3000, PORTUGAL
After attending this presentation, attendees will understand

Portuguese law which determines that a forensic autopsy in victims of
traffic accidents must always be performed in cases of immediate death
G87 Rupture of the Left Ventricle Due to Blunt
or death without medical assistance. The importance of the autopsy in Trauma - A Pediatric Case Study
these situations is obvious, since the accident is not always the cause of
death. Situations of apparent victims of traffic accidents that were Francois Paysant, MD*, Chu, Hopital Michallon, BP 217, 38043
suicides or homicides have been described as well as natural deaths. Grenoble Cedex 9, Grenoble, FRANCE
presenting several practical cases of apparent traffic accident victims in The goal of this presentation is to describe cardiac rupture
which the autopsy presented some surprises and totally different following thoracic or abdominal trauma, which is relatively unknown,
situations from those initially expected. particularly in the pediatric traumatology.
The need of a full autopsy and the demanding of complementary Cardiac tamponade due to traumatic rupture of the chambers of the
exams in these cases, namely histological, must be emphasized, heart, in particular the left ventricle, after blunt thoracic trauma is
reminding the fact that several judicial errors can occur in countries described only sparsely in the literature. Most cases involve multiple
where a forensic autopsy is not routinely performed. Insurance rewards thoracic trauma following motor vehicle accidents. To the best of
can be incorrectly taken into account, homicides cannot be detected, an knowledge, blunt traumatic injury following a household accident has
accidental aetiology can be given to a suicide situation. not been described.
Traffic Accidents, Autopsy, Natural Death The case study will be presented of a five-year-old victim of a
household accident, in which two concrete basins apparently fell on him.
He died quickly despite attempted resuscitation.
G86 Undiagnosed Preeclampsia-Eclampsia The autopsy showed an ecchymotic scrape in the lumbar region as
the only external lesion, with no bone injuries, bilateral pulmonary
Leading to Maternal Death contusions at the base of both lungs, hemorrhagic extravasation of the
diaphragm and mediastinum, hemopericardium, and massive damage to
William J. Bonner, BA*, 1100 South Broad Street, Unit 402B, the apex of the left ventricle. Pathological exam confirmed the traumatic
Philadelphia, PA 19146; John E. Tomaszewski, MD, Department of origin of the cardiac rupture, with no underlying pathology.
Pathology and Laboratory Medicine, Hospital of the University of The mechanisms described in the literature that result in such
Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104; and Fredric lesions, the mechanism which the authors believe most probable in this
N. Hellman, MD, Office of the Medical Examiner, Fair Acres, Rte 352, case, and the importance of background information will be discussed.
Lima, PA 19037 In this case study, lack of specific information concerning the accident
prevents a definitive conclusion of the exact mechanism that caused this
After viewing this presentation, attendees will appreciate how massive trauma particularly due to the fact that the external examination
common preeclampsia-eclampsia is, the necessity for early diagnosis of couldn’t find any lesion in favor of a thoracic or abdominal traumatism.
the disorder, and the dangers encountered when it goes undiagnosed. It is unknown if such an isolated case of a lesion causing almost
This presentation will impact the forensic community by bringing immediate death has previously been described in the literature.
attention to a frequent complication of pregnancy that can be deadly if Blunt Thoracic Trauma, Left Ventricular Rupture, Autopsy
overlooked by healthcare providers. With more attention and continuing
research, this disorder will be better understood, and future mothers who
suffer from the disorder will potentially be saved.
Preeclampsia-eclampsia is a common hypertensive disorder of
G88 Postmortem Examination of Coronary
pregnancy with significant global morbidity and mortality. This disorder Artery Stents Using a Hand-Held
can be effectively treated with early recognition, but imposes serious Rotary Tool
risks for both the mother and the fetus when left untreated. Physicians
sometimes fail to realize developing preeclampsia and, as a result, place Christopher Tape, MD*, and Patrick E. Lantz, MD, Department of
both the mother and fetus in grave danger. The cause of this disorder is Pathology, Wake Forest University, SOM, Medical Center Boulevard,
currently unknown, but many different ideas have been considered. Winston-Salem, NC 27157-1072
Perhaps with a better understanding of the etiology of preeclampsia-
eclampsia, physicians will less frequently overlook its warning signs. The goal of this presentation is to describe a practical technique for
The case of an 18-year-old pregnant black female found postmortem evaluation of coronary artery stents.
unresponsive on a pullout sofa in her apartment is reported. The This presentation will impact the forensic community by permitting
decedent had received regular prenatal care at a local hospital. Medical evaluation of intra-luminal patency, thrombosis, and restenosis of
records disclosed that she exhibited significant proteinuria of 8.8 g/24 hr coronary artery stents and assist in determination in assigning cause and
five days prior to her death, with relatively normal blood pressure manner of death.
measurements. Instead of being admitted to the hospital, her physician Since the development of the intra-luminal coronary artery stent in
elected to send her home on bed rest. Autopsy records revealed that the the late 1980’s the use of coronary stents has increased dramatically
decedent was 38 weeks pregnant at the time of death, with autopsy worldwide. In 2005 one or more stents were placed within coronary

arteries of 620,000 patients in the United States. Numerous clinical addition, insect evidence can be used to differentiate between human and
studies have shown the benefits of coronary artery stents in the treatment animal DNA through molecular analyses of the food stuffs in maggot
coronary artery disease; however, the main early complication with an crops. The purpose of this study was to examine maggot tissue (crop or
intra-luminal coronary artery stent is thrombosis, while the primary long- entire body) and determine if wild game DNA could be detected using
term complication is in-stent restenosis. Today, stent surfaces and PCR analysis. The objectives for this study were to develop protocols
coatings are designed to prevent thrombogenesis and many elute drugs using current PCR technology to identify and compare wild game DNA
that inhibit neointimal proliferation to reduce in-stent restenosis. Despite isolated from Dipteran larvae, and determine if larval developmental
advances in stent technology, stent thrombosis and in-stent restenosis stage influenced the isolation and identification of wild game DNA.
remain common complications that can lead to myocardial ischemia, Three species of forensically important flies were reared in the
infarction and possible death. Discovery of clinically significant stent laboratory (Calliphoridae: Calliphora vicina and Lucilia cuprina;
complications at autopsy can be crucial for the pathologist trying to Sarcophagidae: Sarcophaga haemorrhoidalis) on approximately 350 g
determine the cause or manner of death. However, evaluation of of deer, bear, coyote, bobcat livers. Bear, deer, coyote, fox, and bobcat
coronary artery stents at autopsy is challenging and has been limited to livers were obtained from either euthanized animals or vehicle strikes.
postmortem angiography, serially sectioning the stent with a low-speed They were frozen immediately after removal. Fly larvae were collected
diamond saw or simply by visual examination of the stent lumen and at mid-molt from each larval instar, preserved in 95% ethanol and
estimating any luminal narrowing. Most medical examiner offices identified for species and age confirmation. After identification,
cannot afford the expense, space, or training required for postmortem maggots were individually preserved in 1.5mL of 95% ethanol and
angiography or a low-speed diamond saw to examine coronary artery shipped in centrifuge tubes to the Wildlife Forensics Laboratory in East
stents. Stroudsburg University for PCR analysis.
A hand-held rotary tool can serially section coronary artery stents Before DNA extraction, maggots were washed to remove potential
with minimal deformation of the stent, distortion of the luminal space or external contaminants. Each maggot was individually soaked for 2 min
disruption of intra-luminal contents. The excised coronary artery stent is a 1.5mL tube containing 1mL of 20% bleach. The bleach was removed
serially sectioned in 2 -3 mm increments. When laid out in cross-section and each maggot was rinsed twice with 1 mL of sterile distilled water.
from proximal to distal, the sections of the stent and surrounding Each clean maggot was with iris scissors, then a ventral incision was
coronary artery can be assessed and photographed. Luminal contents made from the posterior to anterior end of the maggot. If possible, the
can be removed by careful dissection using 20-gauge needles. crop was removed with forceps. In some circumstances, either the entire
Subsequent histological evaluation can determine if the intra-luminal anterior inside of the maggot was removed or the entire maggot was
material is postmortem clot or premortem thrombus. Sectioning of extracted.
coronary stents with a hand-held rotary tool is affordable, easy to master, Amplifications were performed using Promega PCR Master Mix.
and permits objective assessment of intra-luminal coronary artery stent Each reaction included 1 μL of each primer (5 pmol/μL) and 5 μL
patency, thrombosis or restenosis. of DNA extract. The PCR program consisted of an initial denaturation
Forensic Science, Coronary Artery Stent, Hand-Held Rotary Tool cycle of 95ºC for 3 minutes, 45ºC for 1 min and 72ºC for 1 minute-30
seconds, then continued with 33 cycles of 94ºC for 1 minute, 45ºC for 1
minute and 72ºC for 1 minute-30 seconds, with a final extension at 72ºC
G89 Detection of Wild Game DNA in for 3 min 30 s. The success of PCR reactions was determined using an
agarose yield gel stained with ethidium bromide. Sequences were
Maggot Tissue aligned and edited using Sequence Navigator software (Applied
Biosystems). Quantitation of crop extractions showed the amount of
Jill C. Ross, BS*, and John R. Wallace, PhD, Department of Biology, DNA recovered varied with the species analyzed. The extractions
Millersville University, Millersville, PA 17551; and Jane E. Huffman, produced at least 1.0 ng/µL. The samples analyzed produced the correct
PhD, Northeast Wildlife DNA Laboratory, East Stoudsburg University, mtDNA haplotype for deer.
East Stroudsburg, PA 18301 Maggot Tissue, Wild Game, DNA
After attending this presentation, attendees will learn a new

technique to assist conservation or game officers in the identification of
illegally harvested wild game through the detection of DNA specific to
G90 Conversion of the Wyoming State Crime
several game species in maggot tissue. The attendee will learn how to Laboratory From FM-BIO Slab Gel
rear, collect and preserve maggots, identify insect developmental stages Technology to the AB 3130 Genetic Analyzer
as well as perform molecular analyses to identify non-human DNA.
This presentation will impact the forensic community as well as
for CODIS and Casework Sample Analysis
game law enforcement by demonstrating that entomological evidence
can be useful in criminal investigations other than determining a Timmy L. Neece, BS, BA*, 1239 9th Street, Apartment 1, Huntington, WV
minimum postmortem interval. To date, molecular analyses are useful to 25701
identify game species through their DNA; however, analyzing insect
tissue for the presence of animal/bird DNA may provide another After attending this presentation, attendees will have gained an
technique useful in wild game management and conservation. understanding of the work involving validation of the forensic
Poaching wildlife is a problem faced by many conservation and methodology used with an Applied Biosystems 3130 Genetic Analyzer
game officers and many people are caught and convicted each year, but for genotyping CODIS. This validation includes the study of precision,
it is a crime that even more offenders get away with. Annually, there are reproducibility, concordance, sensitivity and the ability to resolved
approximately 1,000 big game poaching cases prosecuted. mixtures of biological samples.
Unfortunately, many cases do not reach the court of law due to either the This presentation will impact the forensic community due to its
lack of personnel required to patrol over 26,000 square miles of forested validation of methodology for use on an instrument and associated kit
game lands or lack of evidence required to identify the game species in technologies is vital to obtaining precise and accurate profiles of genetic
question. The use of entomological evidence in human death-scene samples for case work or the CODIS database.
investigations in terms of estimating the minimum postmortem interval For a method to be validated for forensic analysis it must meet
has been well documented as well as to some degree with wildlife. In several guidelines put in place by the Scientific Working Group on DNA

Analysis Methods. The data must show a degree of precision and The design and development of such a portable system capable for
reproducibility based on known laboratory controls. To validate such a forensic DNA screening with high enough resolution for single allele
system it must be shown that there is no contamination between samples separation required that the following issues be investigated in order to
run on the instrument. A series of non-probative samples must be run to increase the resolution. First the analysis of the current Penta STR
verify that the protocols are suitable for samples that could be markers available from Promega Corporation and redesign of these
encountered during forensic casework. primer sets to reduce amplicon size and improve the mobility and
The validation was performed with the Profiler Plus™ and the separation within the micro-channel. Secondly, the development of a
COfiler™ allelic kits and all the samples were analyzed using the denaturing polymer for single stranded DNA separation to be used on the
Genemapper ID™ software. To ensure the reproducibility and precision microchip that would take advantage of the improved resolution in single
of the instrument a series of allelic ladders were injected. The allele calls stranded DNA assays. Finally, the development of a Penta multiplex
and the peak heights were analyzed and confirmed that the protocols STR kit that would increase the power of discrimination for forensic
performed by the Wyoming State Crime Laboratory (WSCL) were samples and become a more powerful forensic tool.
conservative enough to meet the stringent standards necessary for These studies were designed to overcome the limitations of current
forensic investigation. A series of fifteen samples were amplified, run microchip systems for portable forensic applications by trying to
and analyzed with the standard WSCL protocols. These samples had increase the resolution of the short micro-channels. It is with these
been analyzed before on the WSCL’s AB 310 genetic analyzer and had changes that the resolution of the system should be capable of separating
known profiles. The experimentation with the 3130 concluded that the between five base pair repeats accurately and robustly.
instrument was capable of producing profiles that matched the known This research will address the problems and limitations encountered
profile. These studies demonsrtated that no contamination between with the current systems such as poor resolution, large amplified DNA
samples injected on the instrument occurred. With each study, negative fragments, and the ability to only detect double stranded DNA on the
controls were performed across the board with each sample showing no currently commercial available microchip systems such as the Agilent
contamination. 2100 Bioanalyzer. As a result of this research the development of a multi
The data obtained from the validation of the Applied Biosystems loci penta DNA system in combination with an STR microchip
3130 at the WSCL. It is important for those using the AB 3130 genetic electrophoresis system should provide a new tool for quick and portable
analyzer to be familiar with how the instrument and associated kit screening in forensic DNA analysis.
technologies were validated and the experimentation that was performed. DNA, Penta STR, Microchip
3130, Validation, CODIS
G92 How Does Season Affect the Release

G91 A Rapid Penta STR Screening Method by of Ninhydrin - Reactive Nitrogen Into
Microchip Capillary Electrophoresis Grave Soil?
Maurice J. Aboud, BSc*, 10720 North West 66th Street, Apartment #113, Jessica D. Wilkerson*, and Brianna F. Anderson, University of
Miami, FL 33178 Nebraska-Lincoln, 202 Entomology Hall, PO Box 830816, Lincoln, NE
68583-0816; and David O. Carter, PhD, University of Nebraska,
After attending this presentation, attendees will understand the Lincoln, Department of Entomology, 202 Plant Industry Building,
development of a fast and portable DNA screening method that uses Lincoln, NE 68583-0816
microchip electrophoresis for forensic DNA applications. Attendees will
gain an understanding for how this system operates, the limitations of the After attending this presentation, attendees will understand that
system, and how these limitations were surmounted to achieved the seasonality can significantly affect the rate at which ninhydrin - reactive
desired resolution on the microchip. nitrogen (NRN) enters grave soil and that the dynamics of grave soil
This presentation will impact the forensic community by NRN can contribute to the estimation of postmortem interval (PMI).
development of a multi-loci penta DNA system in combination with an This presentation will impact the forensic community by serving as
STR micro-chip electrophoresis system that provides a new tool for a fundamental investigation into the estimation of extended PMI.
quick and portable screening in forensic DNA analysis. Accurate estimates of extended PMI are currently difficult to achieve.
Due to the ever-increasing forensic DNA caseloads and the During the summer months, when temperatures are warm, bodies
potential need for remote forensic DNA analysis, DNA analysis systems tend to decompose at a more rapid rate. Recent research has shown that
that are both quick and portable are needed. While short tandem repeat a body releases NRN into grave soil during decomposition. At present,
(STR) DNA analysis by capillary electrophoresis is capable of high few studies have investigated NRN in grave soil when decomposition
resolution and has a large power of discrimination in forensic begins during colder months. The release of NRN has primarily been
identification, these instruments are not portable and require a relatively used to locate graves, but more recently, has been investigated for its use
long sample run time. It is on this basis that this study aims to develop in estimating PMI. To investigate this use, researchers decomposed
a rapid and portable DNA screening method using a commercially carcasses in winter and summer to compare the release of NRN into
available microchip electrophoretic system. Generally speaking grave soil.
microfluidic systems require fairly long channels and complex detection The experimental site was located at the University of Nebraska
systems for proper resolution and identification of forensic DNA. Agricultural Research Development Center located approximately 48
However there currently exists commercially available systems, such as km north of Lincoln, Nebraska, USA. The site is a pasture that is
the Agilent 2100 Bioanalyzer, which have a small footprint and utilize intermittently grazed by cattle and horses. The soil at the site is a deep
chips with short channels and reduced resolution. Such portable systems silty clay loam of the Yutan series (Mollic Hapludalf). The climate is
might be valuable in situations where evidence screening is necessary in temperate midcontinental characterized by hot summers, cold winters,
remote locations. However due to its lower resolution, most STRs will and moderately strong surface winds. Average annual precipitation is
not properly separate on such a system. In this project the development 695 mm. Approximately 75 percent of the precipitation occurs between
of mini-Penta STRs as potential tools for microfluidic analysis was April and September. Mean annual temperature is 9.8°C with mean
investigated. These five base STRs should produce more consistent minimum and maximum temperatures ranging from 0 C (January) to
results in such circumstances. 31°C (July). The vegetation at site is dominated by non-native grass

(smooth brougham) and forb (white clover) with some native vegetation, artifacts that were observed were produced from defecation. No artifacts
including daisy fleabane, yellowwood sorrel nut sedge, and pasture rose. with long tails were made while the flies were exposed to light. Blow
Swine (Sus scrofa) carcasses (~40 kg) plus a control (no cadaver) flies were observed feeding on fly artifacts, sometimes within seconds of
were used. Swine were killed with blunt force trauma to the cranium and the deposition of the artifact. Some of the artifacts were completely
placed on their right side on the soil surface facing west. Swine were consumed by the flies. During the last half of the experiment, the flies
killed and placed on the soil surface during February 2008 (winter) and fed on artifacts in equal or greater proportion to the bloodstain pattern.
June 2008 (summer). Soil samples were collected (0-5 cm depth) from A small drop of blood was translocated by the mouthparts of the flies.
adjacent to the cadaver at intervals of 15 days for the initial 30 days. The mouthparts were swept across the wall in an arc, beginning at the
This experiment was replicated three times, which resulted in a total of original source and ending at the new droplet, without leaving a trail of
six cadavers. blood. The flies were observed feeding on the bloodstain pattern until
The concentration of NRN during the summer months was greater the experiment ended.
than during the winter months. Elevated levels of NRN were observed The consumption of fly artifacts may occur because the artifacts
during the summer months after 15 and 30 days postmortem. In contrast, could be easier to digest than pure blood, in the same way that
a significant increase in NRN was not observed during the initial 15 days regurgitated blood is easier to digest. However, defecated artifacts are
of decomposition during the winter months. These results demonstrate unlikely to be as nutritious as pure blood. Translocated blood droplets
that NRN would not be an accurate method to test for the presence of may cause additional confusion when analyzing bloodstain patterns,
grave soil during the initial 15 days of death. As decomposition in especially if a reliable method is developed to distinguish fly artifacts
terrestrial ecosystems is primarily biologically mediated, this influx was from human blood. It is unknown how common this behavior is or
likely more rapid during the summer months because of greater insect whether it could significantly alter the overall bloodstain pattern. It is
and microbial activity. A more accurate way to measure postmortem important for crime scene investigators to consider the behavior of blow
interval during the winter months would be to use degree days, which flies when attempting to reconstruct a crime scene based on bloodstain
will be presented along with measurements of NRN after 60 and 90 days. pattern analysis. However, many more experiments are needed before
Forensic Taphonomy, Postmortem Interval, Temperature this subject is thoroughly understood.
Forensic Entomology, Expirated Blood, Blow Fly
G93 Consumption of Fly Artifacts After

Deposition and Translocation of G94 Decomposition of Child-Sized Remains
Bloodstains by Calliphora vicina in Dumpsters
(Diptera: Calliphoridae) Kevin M. Willis, BS*, Washington County Sheriff’s Office, 1535 Colfax
Street, Blair, NE 68008
Becca Striman*, 1347 North 37th Street, Lincoln, NE 68503; Amanda
Fujikawa, BS, 202 Entomology Hall, University of Nebraska-Lincoln, After attending this presentation, attendees will have an increased
Lincoln, NE 68583-0816; Larry Barksdale, MA, Lincoln Police understanding of the decomposition of child-sized remains placed in a
Department, 575 South 10th Street, Lincoln, NE 68508; and David O. dumpster.
Carter, PhD, University of Nebraska, Lincoln, Department of This presentation will benefit the forensic community, as well as
Entomology, 202 Plant Industry Building, Lincoln, NE 68583-0816 those in the fields of the postmortem interval estimation and rate of
decomposition research. It may benefit investigations of children killed
By attending this presentation, attendees will learn of two newly and placed in dumpsters. The research demonstrates that a child-sized
observed behaviors through which Calliphora vicina can alter bloodstain carcass placed in a black plastic bag and in a closed dumpster will
patterns. decompose at a slower rate than one placed in a dumpster unbagged.
This presentation will impact the forensic community by Both pigs in dumpsters decompose more slowly than a control pig
contributing information to the current literature regarding the behavior outside the dumpster.
of Calliphora vicina when exposed to blood. Blow fly behavior can alter The results of this research will benefit forensic science in the fields
bloodstain patterns at crime scenes, which can lead to inaccurate crime of postmortem interval estimation and rate of decomposition research. It
scene reconstruction. may benefit investigations of children killed and placed in dumpsters.
The purpose of this study was to observe the behavior of C. vicina The research demonstrates that a child-sized carcass placed in a black
when exposed to an expirated bloodstain pattern and their effect on plastic bag and in a closed dumpster will decompose at a slower rate than
bloodstains on wallpaper, white textured wall, and white laminate floor. one placed in a dumpster unbagged. Both pigs in dumpsters decompose
The experiment was conducted using eight microscenes (0.46 m3 more slowly than a control pig outside the dumpster.
wooden boxes) that had two glass walls and a plexiglass ceiling to enable Research on child-sized remains has been done by depositing pigs
easy observation and documentation. The other surfaces consisted of a in a variety of ways including surface deposit, shallow grave, covered by
textured, white painted wall, a wallpapered wall, and a white laminate branches and debris, suspended by a rope, and rolled in carpet (Morton
floor. A holding cage was attached to each microscene, in which ten flies and Lord, 2002). However; there is not much study, if any, on the
were placed. Four of the microscenes were control scenes and no flies decomposition of child-sized remains in a dumpster, despite the forensic
were placed in their holding cages. The holding cages were designed to cases where children’s bodies have been disposed of in this fashion. The
allow the flies access to the microscene without human intervention. aim of the research is to understand the environmental and taphonomic
Fresh human blood was used within ten minutes of being drawn. In factors that affect the postmortem interval (PMI) on child-sized remains
each microscene, approximately three milliliters of blood were poured in a dumpster.
into a pool in a corner of the microscene. The donor then put three This thirty-day project began on June 15, 2008 and ended July 15,
milliliters of blood in his mouth and expirated blood into the microscene. 2008. Three small pigs, which were humanely dispatched, were used as
The blood was directed towards the interface between the wallpaper and child-sized remains. Pigs were chosen because their internal structures
white painted wall. The flies were allowed entry to the microscene for and progression of decomposition are similar to humans. Two pigs were
72 hours and had access to sugar and water. placed on plywood in individual dumpsters and the third was placed on
Flies moved from the holding cage into the microscene within 10 plywood on the ground as a control. The control pig was not covered but
minutes and began feeding on the blood within five hours. All deposited protected on all sides by a chain-link fence.
A four-lead temperature coupler was placed with each pig and complaint, by an order of the legal authorities, the external examination
programmed to take hourly temperature readings for the duration of the and the autopsy were performed two days later.
project. Each pig was weighed daily using a digital scale and their girths External examination: The man was 175 cm tall and his weight
measured. An incised wound was also placed behind the right shoulder was 76 kg. No injuries were found in his body; the external examination
of each pig. showed only some puncture marks on the right wrist, on the antecubital
Each board was weighed without a pig and then with a pig fossae and on the back of the left hand, and subcutaneous tumefaction in
subtracting the difference for obtaining the weight of each pig. The two right paravertebral lumbar region, on which there was a puncture mark 4
dumpsters were each two cubic yards in size with two plastic lids. The cm from the spinous apophysis of L5.
lids were kept closed except for collecting data. Autopsy findings: The forensic autopsy revealed brain edema and
The pigs in the dumpsters had temperature leads placed in the congestion of cerebral veins. There was no lesion in the scalp and in the
following locations: in the mouth, underneath the pig (between the pig galea capitis and no intracerebral hemorrhage was found. Pulmonary
and the plywood), hanging loose inside the dumpster and hanging edema, pancreas and kidney congestion were found. The heart showed
outside the dumpster. The control pig had a temperature lead in the hypertrophic left ventricular and septal wall and left ventricular chamber
ground approximately two inches in front of the pig in lieu of the dilatation. The section of subcutaneous tumefaction in right
temperature lead hanging loose inside the dumpster; other temperature paravertebral lumbar region, saw in the external examination, showed a
leads were placed in the same positions as with the pigs inside the rounded formation, circumscribed by a fine membrane, of soft and
dumpsters. Data collection was performed each day. Information elastic consistency, dark red complexion, contains a blood clot. The
recorded included weather conditions, body temperature, container section of lumbar vertebrae and the following extraction of the conus
temperature, and carcass weight loss. Photographs were also taken of medullaris allowed to find, at the level of the L5, a blood infiltration in
each carcass. the posterior dural sac and underlying arachnoid.
General decomposition patterns were observed on each of the Histological Findings: The microscopic examination showed
specimens. Fly succession following the usual pattern for the region was multivisceral congestion. Myocyte cellular hypertrophy and
noted on all three specimens. As measured by weight loss, the control contraction-band necrosis of left ventricular and septal wall were
pig decomposed at a faster rate than either pig in a dumpster. The pig in observed. Severe left anterior descending coronary artery stenosis,
a bag in the dumpster decomposed more slowly than the pig not in a bag softening of temporal cortex, white substance edema and neuronal
in the dumpster. The initial data suggests that the decomposition rate of cerebral and bulbar cytotoxic edema, spinal cervical cord edema were
remains placed in a dumpster is noticeably inhibited. also noted. The terminal conus medullaris at the level of the L5 showed
Decomposition, Dumpsters, Taphonomy blood infiltration in the posterior dural sac and underlying arachnoid,
soft and adipose tissue emorrhagic extravasation.
Case 2: In the second case, a 58-year-old woman who for ten years
G95 Inadvertent Administration of Lidocaine: had cervical pain due to protruding disk between C5-C6 was submitted
to lidocaine infiltration made laterally to the cervical spinous apophysis.
Illustration of Two Cases Soon after, the doctor noticed the progressive decrease of the radial
pulse, the loss of consciousness and the cardiac activity, so he started the
Cettina Sortino*, Via del Vespro 129, Palermo, ITALY; Fleres external cardiac massage. After 15 minutes, the emergency medical
Pierangela, Insitute of Legal Medicine, Via del Vespro, n. 127, Palermo, doctor made an intracardiac injection adrenaline, after which there was a
Italia 90100, ITALY; Paola Pugnetti, Department of Biotechnology and restarting of the cardiac activity. The woman was transferred to a
Legal Medicine, Section of Legal Medicine, Via del Vespro, n. 129, hospital where she felt into coma.
Palermo, 90127, ITALY; Antonino Bonifacio, MD, Institute of Legal The cerebral CAT showed many gas bubbles in the suprasellar,
Medicine, Via del Vespro, n. 127, Palermo, 90100, ITALY; Massimo perisellar, and temporal periencephalic space, left sylvian valley and
Grillo, and Valentina Triolo, Department of Biotechnology and Legal cornua of the lateral ventricles.
Medicine, Section of Legal Medicine, Via del Vespro, n. 129, Palermo, Currently the woman shows a serious situation of rigid-spastic
90127, ITALY; and Paolo Procaccianti, PhD, Palermo University, Via tetraparesis and loss of cognitive functions.
del Vespro, n. 127, Palermo, 90100, ITALY Discussion: In the first case, vascular-peridural iatrogenic
inoculation and the consequent sistemical diffusion permitted the
After attending this presentation, attendees will have viewed two neurotoxic damage lidocaine and epileptogenic action thiocolchicoside.
cases showing that the inadvertent administration of lidocaine can lead The toxical cerebral effects destabilized the pre-existing ischemic
respectively to death and to serious tetraparesis linked to loss of the cardiopathia, serious but clinically asymptomatic, causing the death of
cognitive functions. the man.
This presentation will impact the forensic community by describing In the second case, at first the anaesthetic damaged the cervical
two cases that show how the inadvertent administration of lidocaine can orthosympathetic chains nerve ending, leading to a reflex inhibition of
lead respectively to death and to serious tetraparesis linked to loss of the spinal cardiac-vasomotor centers and consequently to a hypovolemic
cognitive functions. shock, an then produced a direct neurotoxic damage of the S.N.C., both
Case 1: In the first case, a 35-year-old man who for many years has responsible of the quadriplegia.
been affected by protruded disk between L4-L5 causing right Lidocaine, Coma, Tetraparesis
lumbosciatic neuritis, during an orthopedic examination, was
administered lidocaine and Thiocolchicoside injection in right
paravertebral lumbar area.
Soon after the man started to feel worse, and over an hour, showed
sudden loss of consciousness, seizures, acute respiratory insufficiency,
arterial hypertension, and severe tachycardia. The man was transported
to the local emergency room where he arrived comatose. The cerebral
CAT showed small gas bubbles in the cornua of the lateral ventricles and
suprasella cistern.
Despite the pharmacological treatment, the man suffered serious
seizures with heart attack and subsequent death. After the family’s

G96 Asphyxia by Confinement: The Death of a fibrin blood clots. Histological examination of the heart showed only a
moderate atherosclerosis in coronary vessels.
Man Kidnapped and Segregated in a Small The toxicological tests carried out on tissues and fluids have ruled
Underground Cistern out the presence of drugs and/or psychotropic substances, and showed
the presence of 7% of carboxyhemoglobin.
Cettina Sortino*, Antonino Bonifacio, MD, Sergio Cinque, MD, Stefania On the basis of putrefaction, the presence larval and the conditions
Zerbo, MD, Livio Milone, PhD, and Paolo Proccianti, PhD, Department under which he was forced, it is estimated that the death could be traced
of Biotechnology and Legal Medicine, Section of Legal Medicine, Via del back presumably, in a variable range of about 20 days before its
Vespro, n. 129, Palermo, 90127, ITALY discovery. The increase in CO2 in the blood was responsible for a
respiratory acidosis with consequent iperpnea-vasodilation, sweating,
The goal of this presentation is to illustrate a particular case of dehydration, peripheral venous stasis, ispissatio sanguinis, red cell lung
homicide of a 68-year-old Caucasian man who was found dead inside an clots, and cardiorespiratory failure that led to the death the subject.
underground cistern, tied with ropes and chains. Asphyxia, Confinement, Kidnapping
This presentation will impact the forensic community by presenting
the unpredictability of death by asphyxiation from confinement of a man
unlawfully restrained for the purpose of extortion.
The air of confined environments can be subject to alteration by G97 50 Years Later: How Insect Evidence is Key
shares of various causes. Those persons who stay indoors need to have in Turning Over a Wrongful Conviction in
available a sufficient volume of air appropriately refreshed.
The sensitivity of the subject varies in relation with the temperature
Canada’s Most Notorious Case – Regina v.
of moving air (compared to room temperature), the direction of air Steven Truscott
current, and conditions of the subject.
In February 2007 a male corpse of the apparent age of 65-70 years Sherah L. Van Laerhoven, PhD*, University of Windsor, Department of
was found inside a cistern built underground, three meters deep, and used Biology, 401 Sunset Avenue, Room 119 Bio, Windsor, ON N9B 3P4,
to conduct the passage of water (size of 3x3x3 meters, closed tightly with CANADA; and Richard W. Merritt, PhD, and Ryan K. Kimbirauskas,
a metal lid of 63x63 cm). MS, Department of Entomology, 243 Natural Science Building,Michigan
The analysis of clothing made it possible to identify the victim; it State University, East Lansing, MI 48824
was a Caucasian 68-year-old man who had disappeared a month before
the discovery. After attending this presentation, attendees will understand the
From data carried out during inspection, the victim was lying on the history and cultural impact of R. v. Truscott, and the evidence that lead
ground and immobilized by the presence of several girdles consisting of to overturning this miscarriage of justice.
a rope and a chain. This presentation will impact the forensic community by illustrating
The rope, surrounding the sides, kept him in contact with water and the use of modern evidence in reanalysis of older cases, the importance
blocked any possibility of his movements. The chain consisted of steel of having forensic analyses based on scientific evidence and value of
mesh fixed at both of wrists and left ankle, as follows: the right wrist was recreation experiments.
linked to the left ankle at a distance of ten mesh chain links. This The body of 12-year-old Lynne Harper was discovered at 1:50 p.m.
position forced the bending of the left knee over 90° and the extension on June 11, 1959 in a woodlot northeast of Clinton, Ontario. She had
of the right arm, not allowing any movement of the arm or the leg. been raped and strangled using her blouse. Insect evidence was
The left wrist was also linked to the left ankle by a chain at a photographed and collected both at the scene and autopsy, and the insects
distance of 22 cm, allowing the bending of forearm and arm; this chain were reared to adult for identification. However, the insect evidence was
also passed below the rope tied to waist passing on the left side. not used in the 1959 trial or 1960 appeal. Stomach content analysis was
The external examination of the corpse showed chromatic- used to pinpoint a 45 minute period for the time of death, two days prior
emphysematous state of putrefaction; negroid face, with disjunction of (7:00 – 7:45 p.m., June 9, 1959). Based predominantly on this time
hair in large areas of the scalp, eyeballs completely concave for frame and some circumstantial evidence, Lynne’s classmate, 14-year-old
colliquation and evaporation, easy detaching of skin grafts; massive Steven Truscott was convicted of her murder and scheduled to be hanged
destruction of nasal cartilage and perioral soft tissues, with exposure of on December, 1959. A temporary reprieve on November 20, 1959
dental arches and jawbone. postponed his execution and on January 22, 1960, his death sentence was
There were also larvae in various stages of maturation (pupae of 1 commuted to life imprisonment. Truscott was the youngest person to be
and 2 stage) and skin erosions caused by their destructive action. Several sentenced to death in Canada, and his case provided the major impetus
skin areas were affected by the presence of fungal growth on the right toward abolition of the death penalty in Canada. Truscott always
side, in particular: the neck, the chin, the right auricle, the upper right maintained his innocence. After serving his sentence, Truscott was
region of chest, the stump of right shoulder, and the periumbilical region. released and in 2001, he filed for review of his 1959 murder conviction.
Some skin areas were blackish and partially wrinkled (head, neck, Fresh evidence was presented at hearings held at the Ontario Court of
upper region of chest, and upper limbs), while others were affected by Appeal in 2006-2007. This new evidence included testimony of three
phenomena of maceration with detachment of skin (hands, feet, right forensic entomologists, with three other forensic entomologists filing
thigh, and both legs). reports (but not called to testify) on the insect evidence. Based on the
There were no signs of constriction on the neck. Under the analysis of the insect evidence, a recreation experiment of insect
hypogastric area, umbilical region, right wrist and left wrist, there were evidence and a reanalysis of the pathology evidence on stomach content
impressions caused by the rope and the chain. The autopsy showed analysis, the original estimate of time of death was considered to be
advanced putrefaction in all organs, in particular in the brain, pancreas, unreliable. Truscott was with numerous witnesses prior to 1900 h and
and adrenal glands. after 8:00 p.m. on June 9, 1959, thus the estimate of time of death was
The histological examinations made it possible to detect signs of the most critical evidence in the original 1959 trial and the 2006-2007
vitality on the skin of wrists and, in particular, there was oedema and appeal. In 2007, his conviction was declared a miscarriage of justice and
intralveolare hemorrhage swelling and bleeding intralveolare and, inside Truscott was acquitted of the murder.
the blood wessels, the red blood cells seemed conglutinate with focal Forensic Entomology, Wrongful Conviction, Historical Cases

G98 First Insect Succession Study on a Human potential pests they carry. This study appears to have followed known
succession patterns expected for the arthropod species collected;
Cadaver in Texas however, this is the first study in the state of Texas to examine insect
succession patterns using a human cadaver.
Jennifer L. Pechal, MS*, Texas A&M University, 2475 TAMU, College This study is also important because it allows forensic
Station, TX 77843-2475; Adrienne L. Brundage, MS, 2001 Cobblestone entomologists to better assess delay in colonization estimations of insect
Ln, Bryan, TX 77807; Elizabeth T. Brandt, BA, 232 Evans Liberal Arts, activity on remains as it relates to the pre-CI. The specific time when a
Anthropology Dept, 601 University Drive, San Marcos, TX 78666; body is placed out into the field can be compared to estimations based on
Connie L. Parks, BS, 8802 Featherhill Road, Austin, TX 78737; Jeffery entomological development data. Establishing the accuracy of time
K. Tomberlin, PhD, Department of Entomology, TAMU 2475, College estimations using development data for those insects collected from the
Station, TX 77843-2475; and Jerry Melbye, PhD, Department of remains may lead to more refined methods for calculating how long a
Anthropology, 601 University Drive, ELA 273, Texas State University- body has been in a particular area prior to colonization. It is noted that
San Marcos, San Marcos, TX 78666-4616 this is a primary study with many more conditions to be replicated as
potential body recovery sites and thoroughly analyzed to gain a better
After attending this presentation, participants will be introduced to understanding of attraction, colonization time, development, and
the first succession of insects observed on a human cadaver in Texas. interactions among insect species on a human resource.
This presentation will impact the forensic community by providing Insect Succession, Human Cadaver, Texas
information on the succession patterns and abundances of forensically
important insect species attracted to a human cadaver.
These data can potentially be used to determine a more refined
estimate of the period of insect activity (PIA) on human remains
G99 Comparison of Biological Sensors to
discovered in the southwestern United States. Correctly identifying Detect Human Remains: Canine
arthropod species found associated with a body allows for time Versus Hymenopteran
approximations to be made based on development data and behaviors.
The PIA is divided into two ecological phases termed the pre- Glen C. Rains, PhD*, University of Georgia, PO Box 748, Tifton, GA
colonization (pre-CI) and post-colonization (post-CI) intervals. Insects 31793; Ben Alexander, MS, Texas A&M University, TAMU 2475, College
arrive at bodies in waves or seres. The pre-colonization interval (pre-CI) Station, TX 77843; Jeffery K. Tomberlin, PhD, Department of
is defined by insects being initially attracted to remains without Entomology, TAMU 2475, College Station, TX 77843-2475; and Jerry
colonizing the resource. Various species arrive at different times based Melbye, PhD, Department of Anthropology, 601 University Drive, ELA
on seasonality and abiotic factors. Insects are attracted to a body in a 273, Texas State University-San Marcos, San Marcos, TX 78666-4616
predictable pattern based on its stage of decomposition. Many of these
insects will colonize (post-CI) the resource once the remains are After attending this presentation, attendees will have a greater
discovered. Succession patterns may be influenced by the condition of understanding of principle of associative learning and its use to train
the body and the area in which it is located. The following factors about vertebrate and invertebrate species to detect human remains in unknown
the condition of the body may influence the rate of colonization, species samples.
richness, and abundance: direct sunlight, partially shaded, indoors, This presentation will impact the forensic community by providing
urban, rural, buried, or submerged. Applying the knowledge of arrival information on the use of canines and conditioned insects to screen soil
time (pre-CI), colonization patterns (post-CI), and associated behaviors samples for the presence of human remains.
allows for a better assessment to be made concerning approximations in A tremendous amount of effort in the scientific community has
the length of time a body may have been at a specific location. focused on deciphering how animals, as well as plants, receive and
Blow flies (Diptera: Calliphoridae) were initial colonizers of the interpret environmental stimuli. In regards to forensics, these efforts
human remains in this study. Over the duration of this study three blow have primarily targeted the development of biological sensors, such as
fly species were regularly collected in the vicinity of the body: canines, for tracking missing individuals or escapees from custody.
Cochliomyia macellaria, Chrysomya rufifacies, and Phormia regina. Other efforts have evaluated the use of canines to detect explosives or
There were also Piophilidae casei, as well as Muscidae and narcotics in places frequented by people.
Sarcophagidae species collected from the body. Coleoptera species also In recent years the U.S. Department of Defense has initiated
will colonize a body because of the readily available food resource of research examining the ability of arthropods to detect and locate
dipteran larvae as well as decomposing materials. Five beetle families compounds of human importance. Microplitis croceipes has served as a
were collected near or around the body: Cleridae, Histeridae, Silphidae, model for a number of studies to detect plant pathogens, explosives, and
Staphylinidae, and Dermestidae. human remains (Lewis & Martin, 1990; Takasu & Lewis, 1993, 1995,
C. macellaria is one of the initial colonizers in warmer temperatures 1996; Rains 2004, 2006). These efforts have translated into the
while P. regina is more active during cooler weather. The diversity of development of a biological sensor that is capable of detection at the
flies collected may be an indicator of the range of temperatures nanogram level.
experienced during the study. The hairy blow fly larva, C. rufifacies, is While the use of cadaver dogs in detecting human remains is widely
a facultative predator and will feed on larvae of previous colonizers such accepted, there is little research that scientifically validates the
as C. macellaria. The hairy maggot blow fly can be distinguished from capabilities or mechanisms by which the dogs function. This study
other maggots on a resource by the spine-like projects on each segment. compared cadaver dog performance to that of the trained wasps in terms
It was interesting to note that there was a delayed colonization of of threshold and accuracy. Five nationally certified and experienced
Calliphoridae. Abiotic factors such as temperature may have influenced cadaver dogs with “real world finds” were tested in two types of
the colonization times or other unaccounted factors may have influenced evaluation paradigms. The cadaver dogs varied in age from three to nine
the delay of oviposition but it is important to note that the body was not years and consisted of two Border Collies, one Rottweiler, one
immediately colonized. Various ants from the family Formicidae and Laborador Retriever, and one Doberman Pinscher. Cadaver dog
fleas, Xenopsylla cheopis, were also collected during this study. threshold was equal to M. croceipes as the dogs were able to detect and
Postmortem ant bites on a body have been previously documented in alert to the presence of human remains using 0.02 grams of soil from
other studies. Fleas collected near the body do not imply that the subject beneath a human cadaver mixed with 20 grams of background soil.
was infested; rather it may represent the environmental fauna and the

Two types of presentation trials were utilized. The first trial set conditions. Lucilia coeruleiviridis presents an even more difficult
consisted of singular jar presentation in a room. This matched the problem, in that post-feeding L. coeruleiviridis larvae, either collected
presentation to the conditioned wasps but was not a traditional method of from a corpse or obtained from a wild adult female, will not pupate under
training or evaluation for testing detector dogs. The second trial, which laboratory conditions. The larvae have been observed to go into an
was conducted upon the end of the first trial, consisted of a scent line-up extended wandering stage lasting several days only to eventually shrivel
with all four targets present. Targets were placed approximately three and die.
feet apart in a single row line. This is a traditional presentation utilized It was hypothesized that post-feeding L. coeruleiviridis larvae
in research and training of scent dogs. require a larger pupation medium volume than is typically used for
No type one errors were seen with the dogs; however, there were laboratory culture. The hypothesis that rearing L. coeruleiviridis eggs
type II errors. Training biases may account for some of the error margin. obtained from wild females in containers much larger than those used in
Target odors are most often placed into containers for preserving and this research would have an effect on their development was tested.
storing the target for continued use. Preservation of training aids Lucilia illustris was similarly investigated because of the lack of
necessitates the use of containers, cages, and other devices which can developmental data currently available for this species as well.
subsequently become a visual cue for the dog. Most research performed During midsummer at the study site in northwest Indiana, 11 piglet
on scent detection dogs involve line ups or concealed target odors to carcasses were exposed to short duration (max 2.5hrs) fly activity and
avoid visual cueing. Placing containers in plain sight may have lead to inspected for eggs every half hour. Once eggs were observed, the piglets
a bias based on expectations by the dog’s previous experience. Cadaver were individually placed on (approximately 0.11 m3) leaf litter, collected
dog training scenarios typically include at least one target odor within a on site, in large plastic storage tubs (approximately .16 m3). Breathable
designated search area; therefore the dog is expecting to find something. cloth-like material was immediately secured over the plastic tubs to
This defines a need for cadaver handlers to continue to train their canine exclude further oviposition. Ambient (outside) and interior container
partners on scenarios involving visual negative targets to reduce temperatures were monitored. Adult flies that emerged from a container
association between a visual target and alerting, thereby increasing their were collected daily and identified.
efficiency on real world searches. Aspects of development will be discussed for three of the blow flies
Cross contamination, residual scent, indoor ventilation systems, and that were successfully reared to adulthood in this experiment; L. illustris,
container placement may have also contributed to the type II errors. Lucilia sericata, and L. coeruleiviridis. Physiological time calculations
Cross contamination can also occur due to residual scent. A recent study for L. illustris were compared to those reported by other authors. Both
indicated that dogs can detect human remains odors of human corpses on L. coeruleiviridis and L. illustris developmental data were contrasted to
carpet squares even though the squares did not come into direct contact the extensively studied L. sericata, because some investigators have used
with the corpse (Oesterhelweg, 2008). Since so little is still known about L. sericata growth models to estimate L. coeruleiviridis age. Under
detector dogs, research that help define thresholds and other factors is these conditions L. coeruleiviridis total development time was
essential in increasing the effectiveness of these dogs. numerically longer than that of L. sericata. Total development time of L.
Canine, Microplitis Croceipes, Biological Sensor illustris was comparable but slightly more accelerated than that of L.
sericata.
The procedure used in this experiment provides forensic
G100 Generating Development Data for entomologists with a means of obtaining growth rate data for flies that
were previously difficult to rear. Having data on these forensically
Forensically Important Flies That Are important flies can be used to increase precision and accuracy of
Difficult to Rear in the Laboratory estimations of the postmortem interval.
Lucilia, Postmortem Interval, Forensic Entomology
Anne E. Nichols, BS*, West Virginia University, 1367 Stewartstown
Road, Apartment W-7, Morgantown, WV 26505; Neal H. Haskell, PhD,
425 Kannal Avenue, Rensselaer, IN 47978; and Jeffrey D. Wells, PhD, G101 Insect Pupal Cases as Decay-Resistant
West Virginia University, Department of Biology, Life Sciences Building,
Room 3135, 53 Campus Drive, PO Box 6057, Morgantown, WV
Reservoirs of Human Soft Tissue
26506-6057 Radiocarbon Content
After attending this presentation, attendees will learn how carrion Gregory W. Hodgins, DPhil*, University of Arizona, Department of
fly development data can be obtained for species that are not suitable for Physics, 1118 East Fourth Street, Tucson, AZ 85721
rearing under common laboratory methods.
This presentation will impact the forensic community by providing After attending this presentation, attendees will understand how
rearing techniques for blow flies that have minimal development data above-ground nuclear testing in the 1950s and early 1960s dramatically
due to their difficulty to rear in a laboratory setting. With these data increased environmental levels of radiocarbon. These elevated levels
forensic entomologist can generate more accurate development data for have been incorporated into all organisms living since that time and thus
commonly encountered forensically important blow flies leading to can serve as temporal markers. Potentially, radiocarbon measurements
increased accuracy and precision in postmortem interval estimations. of postmortem human tissues can be used forensically to establish year-
Forensic entomologists have so far been unsuccessful in their of-birth and/or year-of-death. One advantage of this approach is that it
attempts to establish laboratory colonies of some of the more commonly functions independently of chemical or biological methods for the
encountered carrion insect species. Therefore, it has been difficult to determination of postmortem interval or age-at-death and thus might
produce the growth models often used to estimate a minimum augment current methods for establishing these parameters.
postmortem interval based on specimen age of these species. Notable This presentation will impact the forensic community by outlining
examples of this technical problem in North America are the green bottle the possibility of determining year-of-death of human remains in
flies Lucilia illustris and Lucilia coeruleiviridis. It has been found that advanced stages of decay based on the radiocarbon content of insect
a wild-caught L. illustris female will lay eggs in a laboratory cage, but pupal cases obtained from the surrounding soil. Remains in advanced
the resulting f1 generation will not mate under these standard rearing stages of decay pose particular challenges for determining postmortem

interval, and other temporal parameters. The presentation has two grayish pink and foamy in sections, whereas the bare skeleton was
objectives: (1) to outline a hypothesis and an experimental design, and visible. The bones were complete and the arrangement of the skeleton
(2) to canvas the forensic science community for suitable samples. indicated that the body had originally been left in anteflexion with bent
Over the past sixty years, environmental levels of radiocarbon have knees. The foot bones were still inside the shoes and the underpants
been rapidly changing. Previous work in this laboratory has established were positioned around both ankles indicating preceding sexual abuse.
that radiocarbon levels in human soft tissues essentially reflect levels in No evidence as to mammalian-feeding defects neither to preceding blow
the contemporary environment. Therefore measuring radiocarbon levels fly (Diptera: Calliphoridae) activity was observed. Only some skipper
in postmortem tissues and correlating these with known levels in the past flies (Diptera: Piophilidae, “Cheese Skippers”), well known as late
environment can indicate Year-of-Death. Direct measurements on colonizers, were detected. Considering the climate of northern Germany
tissues from known age/known year-of-death donors have shown the question had to be answered. Could a dead body get into that
promise and quantified the potential precision of this approach to advanced state of decay within three months time without addition of any
approximately ± 2.5 years. chemical substances? Extensive toxicological investigations merely
The paradox of suggesting such an approach is that in many resulted in high concentrations of calcium (1120 mg/kg) in the liquefied
environments, soft tissues disappear within short spans of time due to tissue. The influence of hydrogen peroxide was considered but excluded
natural process of decay. What are required are decay-resistant proxies because large quantities of the long scalp hair were found still in its
of soft tissue radiocarbon content. The hypothesis of this study is insect original brown color.
pupal cases might fit the bill. Just as humans take on the radiocarbon Experiments with pig cadavers (n=14; 20-30 kg) in plastic bags
content of ingested foods, insect larvae feeding on decaying human under equivalent environmental conditions revealed that soft tissue was
remains take on the remains’ radiocarbon content. Although emergent liquefied equally with the skeleton left in anatomical position in those
adult insects leave, pupal cases are left behind. Large numbers are often cases without addition of any chemical substances (e.g., quick lime).
encountered in the soil surrounding decayed remains long after soft The pig cadavers where quick lime was added (1:3, 1:10, 1:30) were
tissues have disappeared. found with rather dry and hard soft tissue, aridity was increasing with the
Preliminary measurements on samples generated from field tests concentration of quick lime. By following investigations in a specialized
will be presented as well as measurements on paired samples of soft microbiological laboratory Clostridia species (C. limosum, C. novyi, C.
tissues and pupal cases obtained from a Medical Examiner’s Office sordellii, C. sporogenes) were detected in the remains of the child as well
archives. The design of future experiments will be discussed. in the liquefied porcine tissue. These Clostridia species are reported to
Admittedly, the approach is potentially complex. For example, produce both histolytic and cytolytic enzymes. Also the foamy
direct measurements of radiocarbon levels in different human tissues consistency of the soft tissue could be explained due to the well
show tissue-specific variation. These differences are the consequence of documented gas producing activity of Clostridia species. Furthermore
rapidly changing environmental levels and differences in metabolic high calcium levels equivalent to these in the original specimens were
turnover rates. Consequently, one might expect that insect larvae feeding determined in the liquefied porcine tissue.
on different tissues of the same individual might be differentially labeled. In summary it was concluded, that the body of the child inside the
On the one hand, this might reduce the precision of Year-of-Death plastic bag reached the state of liquefaction without addition of any
estimations. However, if species-specific differences in larvae feeding chemical substances. The environment inside the closed plastic bag
behaviors exist among the succession of insects that infest decaying without oxygen supply promoted a shift to benefit the development of
remains, this might result in species-specific differences in pupae the anaerobe bacteria like Clostridia species. Hence high concentrations
radiocarbon levels. Such differences might be exploited to advantage. of histolytic and cytololytic enzymes secreted by these microorganisms
Clearly experimental data is required. resulted in a relatively fast liquefaction of the soft tissue. These
The approach is intriguing. It would require a trivial modification conclusions were also in accordance with the crime scene analysis
of existing sample collection practice: merely collecting a larger than (closed plastic bag above ground, underpants around ankles of the
normal number of pupae. It is potentially a new avenue for the forensic corpse) indicating a fast disposal of the dead body after sexual abuse.
estimation of Year-of-Death. Decay Processes, Plastic Bag, Taphonomy
Radiocarbon, Year-of-Death, Pupal Cases
G103 Unusual Methods of Suicide in Chicago,

G102 Reconstruction of Decay Processes of Illinois, Cook County
a Dead Child’s Body in a Plastic
Garbage Bag Michelle A. Jorden, MD*, James A. Filkins, MD, JD, PhD, and Tera A.
Jones, MD, Cook County Medical Examiner Office, 2121 West Harrison
Heike Klotzbach, PhD*, Institute of Legal Medicine, Fürstengraben 23, Street, Chicago, IL 60612
D-07743 Jena, GERMANY
After attending this presentation, attendees will lean about some
After attending this presentation, attendees will know how unusual methods of suicide recently observed in Chicago, IL during the
important questions concerning a homicide case were answered by step- first half of 2008. This paper is being introduced during a time of
by-step reconstruction using pig cadavers and special knowledge of economic strain within the United States.
various disciplines. This presentation will impact the forensic community by making
This presentation will impact the forensic community by attendees aware of the unusual methods of suicide are being observed in
underlining the statement that “extraordinary” methods are sometimes Chicago, IL.
helpful in forensic taphonomy and moreover emphasize the cooperation In 2004, according to the National Institutes of Health (NIH),
of scientists form different disciplines. suicide was the eleventh (11th) leading cause of death in the United
The remains of a 10-year-old girl hidden in a plastic garbage bag in States, accounting for 32,439 deaths. The major risk factors for the
a wooded area in Northern Germany were recovered. The girl had been commission of suicide are well known and include a history of
reported missing three months earlier. Her body was in a stage of depression, substance abuse, stressful life events, family history of
advanced decay, the soft tissue had been entirely liquefied, colored suicide, and prior suicide attempt. Males are four times (4X) more likely
to commit suicide compared to females. Recent research has suggested

the risk of suicide may be the result of an imbalance of neurotransmitters G104 Mass Fatality Investigation Due to
in the brain, thus emphasizing the importance of diagnosis and the role
of antidepressants in the treatment of depression.
Combustible Dust Related Industrial
Firearms, suffocation, and poisoning were the most common Explosion and Fire
methods chosen by individuals to commit suicide, although the methods
differed between the sexes. Males tend to commit suicide using J.C. Upshaw Downs, MD*, and Edmund R. Donoghue, MD, Regional
firearms, whereas females commit suicide by poisons. Non-Hispanic Medical Examiner, Georgia Bureau Investigation, 925 A Mohawk Street,
whites commit suicide at the highest rate. Although some data is similar Savannah, GA 31419-1796
to that published by the NIH, the authors will introduce a total of eight
individuals who committed suicide by unusual methods rarely seen in a After attending this presentation, the attendee will recognize the
major metropolitan area. dangers of combustible dusts and their relation to industrial deaths, and
One case involves a white male with multiple shotgun wounds who better understand unique features of mass fatality investigation in an
was found in his secure residence. The second case involves a white industrial setting and an active fire scene.
male inflicting sharp force injury to his dialysis catheter causing This presentation will impact the forensic community by exposing
exsanguination and air embolism. Two cases, a white male and white practitioners to the under-recognized dangers of combustible dusts and
female, involved the “death by Hibachi” method, which is accomplished the complexities involved in mass fatality in an industrial/fire setting.
by carbon monoxide intoxication from burning charcoal in an enclosed Combustible dust is an under-recognized industrial hazard. The
environment. At autopsy, both cases revealed bright cherry-red lividity United States Chemical Safety Board identified over 280 events with
and the carbon monoxide level ranged from 54%-80% saturation. One 837 casualties (including 119 deaths) in the period 1980 to 2005. The
case involved a white female chemistry student who ingested industries involved are varied and include organic dusts (wood, sugar,
acetylferrocene, an orange crystalline powder that is extremely toxic grains, etc.), metal powders (magnesium, aluminum), chemical
once ingested, and who died of liver failure. One case involved a white manufacturing, plastic production, pharmaceutical production, and coal
male hanged with simultaneous electrocution from a manmade handling/processing. In fact, “any industrial process that reduces a
apparatus. One case involved a white male who used ligature combustible material and some normally noncombustible materials to a
strangulation as a means of suicide. Finally, the last case involving a finely divided state presents a potential for a serious fire or explosion”
white male is noteworthy and unusual in the sense that the commission (NFPA’s Industrial Fire Hazards Handbook). In fact, sugar may seem
of suicide was performed with the production of hydrogen sulfide gas. harmless but is recognized as a strong explosion hazard (Bureau of
This is a most unusual case of suicide from medical examiners office but Mines – “The Explosibility of Agricultural Dust”). In addition to the
deserves mention as this method is becoming increasingly popular usual fire-triangle components (fuel, fire, and oxygen), a combustible
overseas. dust explosion requires sufficient quantity and concentration of dust in a
Suicide notes were left at the scene in only three cases, a similar confined space. A major risk in such settings is the rapid dispersion of
frequency seen in prior reports. Two detailed suicide notes were previously quiescent depots of dust particles follows a lesser primary
recovered from individuals performing the “death by Hibachi” method. explosion. With a significant fuel reservoir abruptly literally shaken
The third suicide note was recovered from the male inflicting sharp force loose and into the ambient air, a more devastating secondary explosion
injury to his dialysis catheter. can be anticipated if the reservoir ignites. Safety procedures can reduce
With the introduction of the internet, old as well as new and more the risks associated with combustible dusts, especially related to the fuel,
unusual methods of committing suicide are available to the population. dispersion, and ignition but are less effective in controlling the
As seen in this research, the “death by Hibachi” method would take time confinement and ambient oxygen.
to plan and execute (i.e., spending time on the internet, buying and Shortly after 9 p.m., a series of explosions rocked the second largest
burning the charcoal, taping the doors in the room and writing detailed cane sugar refineries in the United States (responsible for ~15% of total
suicide notes). national production). The fires took days to extinguish due to the nature
All cases involved non-Hispanic white individuals, similar to that of the incident – a large depot of molten sugar remained ablaze in one of
seen in the NIH data. In this study, there was a preponderance of males three storage silos despite significant efforts to put it out. Up to an
committing suicide (6:2). In each of the cases, the reasons for estimated 100 personnel (of 472 total) were reported working in the
committing suicide coincide with the NIH data (i.e. depression, stressful affected plant area at the time of the blast. Of these, upwards of 40
life events). Although one of the cases involved a male using a firearm individuals were seriously injured and a total of eight individuals were
as a means of suicide and one case involved a female using a poison to eventually reported missing and presumed dead. Recovery efforts,
commit suicide, these were not common means of suicide as people including law enforcement and medical examiner staff, to locate the
seldom kill themselves by inflicting multiple shotgun wounds and presumed deceased proceeded while the silo fire was actively burning
ingesting acetylferrocene. Additionally, people seldom commit suicide and scene stability was questionable. Over the ensuing days and weeks,
via means of ligature strangulation. The remaining cases also illustrate the bodies of the dead were recovered and identified. The extensive
uncommon and unusual methods of suicide. In this small study, six of thermal damage to those who remained in the burning plant longest
the eight individuals had a prior documented suicide attempt. posed identification challenges due to fragmentation and calcination. At
Suicide is one of the most preventable deaths in the society and the the conclusion of the medicolegal investigation, all eight dead on scene
recognition and treatment of depression is underscored. However, the were identified and the remains were re-associated with the appropriate
medical examiner/coroner will continue to examine suicide deaths individual. An additional five fatalities occurred related to extensive
especially in economic hardship as recently experienced in the United burn injuries, for a total 13 deaths. The case resulted in extensive media
States. This paper serves to introduce some uncommon methods of scrutiny and eventually the third-largest fines in OSHA history.
suicide recently observed during the 2008 year. This presentation reviews the nature and dangers of combustible
Suicide, Unusual Methods, Chicago, IL dust related fires. Specific issues related to the death investigation
process and body recovery are addressed. The investigative outcomes,
including recognized risks and identified cause are presented.
Combustible dust, Explosion, Sugar

G105 Worker Fatalities by Hydrogen hemorrhagic edemas were found in all the workers, most notably in the
youngest victim who died 12 hours after the tragic event.
Sulfide Poisoning: Autopsy Toxicological results: Toxicological analyses of peripheral blood
and Toxicological Findings vessels (femoral) were negative for alcohol and illicit drugs in all of the
workers. Thiosulfate in the heart blood was quantified using a gas
Biagio Solarino, PhD*, Sezione di Medicina Legale, Università Degli chromatography-mass spectrometry (GC/MS) technique after
Studi di Bari, P.zza Giulio Cesare, 11, Bari, 70125, ITALY; Giancarlo Di derivatization with pentafluorobenzyl bromide. Each of the victims had
Vella, PhD, Sezione di Medicina Legale, DIMIMP, University of Bari, a blood thiosulfate level that, according to other international reports,
Policlinico, Piazza G. Cesare, Bari, 70121, ITALY; Lucia Tattoli, MD, was enough to determine that the cause of death was due to fatal
Sezione di Medicina Legale, University of Bari, Bari, , ITALY; Claudia hydrogen sulfide poisoning: thiosulfate levels ranged from 2.6 mg/l (first
Liuzzi, MD, Sezione di Medicina Legale, Università Degli Studi di Bari, worker in who entered into the tank) to 183 mg/l.
Bari, 70100, ITALY; Giuseppe Strisciullo, BES, University of Bari, The analyses performed on air samples collected from inside the
Policlinico, Piazza G. Cesare,11, Bari, 70124, ITALY; and Roberto truck tank, as well as analogous trunk tanks used for liquid sulfur
Gagliano-Candela, PhD, University of Bari, Cattedra Tossicologia transport revealed that H2S air concentration levels were high to have
Forense, Policlinico, Piazza G. Cesare 11, Bari, 70124, ITALY caused these occupational fatalities.
Hydrogen Sulfide, Worker Fatalities, Thiosulfate
After attending this presentation, attendees will have an
understanding of some particular aspects of Hydrogen Sulfide poisoning
which is an important cause of work-related death. G106 Suicide by Hanging in Harris County, Texas
emphasizing the fact that Hydrogen Sulfide (H2S) is a harmful and lethal Sara Nunez-Doyle, MD*, and Sharon M. Derrick, PhD, Harris County
chemical, and accidents may occur upon exposure to it in its natural Medical Examiner’s Office, 1885 Old Spanish Trail, Houston, TX 77054
gaseous state in various work environments.
The goal of this presentation is to recount the story of the deaths of After attending this presentation, attendees will have
five men who, while working in a truck tank which transported liquid comprehensively reviewed the features of suicidal hangings, including
sulfur, were poisoned by Hydrogen Sulfide. Variations in pathological demographic characteristics of the decedents, frequency and types of
and histological findings, coupled with toxicological results, and crime injuries identified at autopsy, ligature characteristics, and scene
scene investigations will be illustrated. investigation information. This review will provide the attendee with a
Hydrogen Sulfide is a powerful, rapidly acting, colorless, poisonous reference base for common and uncommon findings in suicidal
gas. H2S has a specific gravity (1.19) higher than air, and its presence hangings.
can be detected by its characteristic odor of rotten eggs. Acute This presentation will impact the forensic community by providing
occupational poisoning and fatalities have been reported from exposure insight into the case findings and epidemiological characteristics of
to H2S in industrial settings, sewage disposal facilities, and septic tanks. suicidal hangings presenting to the Harris County Medical Examiner’s
This gas is very unstable and thiosulfate is its major metabolized Office from the large diverse population of Harris County, Texas.
substance. For this reason, the presence of thiosulfate is known to be a Suicidal hangings comprise 19% (320) of the 1676 suicides that
useful indicator of Hydrogen Sulfide poisoning in forensic analysis. occurred in Harris County, Texas from January 1, 2004, through June 30,
Case History: Five workers were found motionless in an empty 2008. Hanging was the second most common method of suicide after
truck tank which had previously contained liquid sulfur. They were soon firearm wounds. An upward trend in the total number of hangings was
removed from the tanker; four of the five men had already died. The recorded over this four and one-half year period, with 51 hangings
fifth man, who was also the youngest, died at the hospital the following occurring in 2004, 73 in 2005, 71 in 2006, 81 in 2007, and 43 in the first
day. Crime scene investigation revealed that the first of the victims half of 2008. Although the total number of suicides in Harris County
began the cleaning operation of the truck tank when he became also increased over this period (from 298 in 2004 to 424 in 2007), the
unconscious. One by one, fellow colleagues attempted to rescue their percentage of hangings compared to total suicides increased, with
co-workers, each succumbing to the toxic gas, and each falling into hangings comprising 17.1% of the total suicides in 2004 and 21.8% of
unconsciousness, ultimately followed by death the total suicides in the first half of 2008. Accounting for the
Autopsy Findings: The workers had a mean age of 37.6 years approximated 7% population increase in Harris County from 2004
(range 20-64). External examination of the bodies revealed congestion through 2007, the actual rate of suicidal hangings increased slightly over
of the head, neck, and shoulders with cyanosis of lips and fingernails in this period, from 1.3 per 100,000 people in 2004 to 2.1 per 100,000 in
all cases. The ocular conjunctiva showed marked hyperemia and a few 2007, as did the rate of total suicides, from 8.1 per 100,000 in 2004 to
petechiae. Two workers displayed traces of solid yellow sulfur on their 10.8 per 100,000 in 2007.
faces and on the soles of their shoes. One of the workers, who was 23- The majority of the decedents who hanged themselves (81%) were
years-old, displayed a very characteristic greenish discoloration of his male, a trend that is common for other methods of suicide. Female
eyes, anterior cervical region, and precordia. Only one worker showed decedents comprised 19% of the suicidal hangings and 24% of the total
signs of putrefaction. Two of the men presented with blunt force injuries number of suicides in the period examined. The ages of decedents
on the occipital areas with subgaleal contusions which resulted from hanging themselves over the period studied ranged from 10 to 80.
falling. Children were over-represented in the hanging category when compared
Upon internal examination, it was noted that the lungs of all the to total suicides. Ten percent of the decedents hanging themselves were
workers were heavy with edema and congestion which was also present under the age of 18, compared to 3.8% of the decedents committing
in the kidneys and spleen. The 23-year-old worker displayed a greenish suicide by all methods. Senior citizens were under-represented.
discoloration both in the thorax muscles, as well as on the surface of the Decedents over the age of 65 comprised 2.5% of suicidal hangings
stomach. There were no remarkable findings related to the other organs compared to 11.5% of all suicides in the time period studied.
except for slight cerebral edema which was present in all five victims. In The majority of decedents who hanged themselves were Caucasion
addition, an aortocoronary bypass graft was present in the oldest victim. (54.4%), followed by Hispanic persons (31%), African-American
Microscopic examination revealed passive congestion which was persons (10.1%), and persons of other race/ethnicity (4.5 %). The
evident in the lungs, spleen, kidneys, and adrenal glands. Massive breakdown of ethnicity for people dying by suicide by all methods was

similar, with 68% white, 18% Hispanic, 11% black, and 3% other Autopsy showed pulmonary edema, and pulmonary and gastric
race/ethnicity. In suicidal hangings as well as suicide by all methods, hemorrhage. Toxicology was negative except for vitreous urea nitrogen
white persons appear to be over-represented when compared with the of 30 mg/dL.
population breakdown of Harris County, in which approximately 37% of The supervising Coroner’s investigator and Chief Medical
the population is white. Examiner-Coroner visited the scene and discussed the procedures used
Of the 320 suicidal hangings examined, 260 (81%) took place in the for cleaning the tank with employees of the transportation company. In
decedent’s residence or property immediately surrounding the residence addition, Coroner’s staff met with the involved police agency and
(yards, garages, utility sheds, and other outbuildings). Of the remaining representatives of California Department of Industrial Relations,
19% of cases, the more common locations of the hangings included Division of Occupational Safety and Health. The Material Safety Data
parks, fields, or wooded areas (15 cases), jails or other correctional Sheet for potassium hydroxide and the medical literature provided
facilities (13 cases), places of business (11 cases), and motels or hotels additional information.
(8 cases). Hanging was the only method of suicide used by incarcerated The cause of death was determined to be pulmonary edema due to
persons over the four and one-half year period studied. Approximately potassium hydroxide exposure and other undetermined factors.
one-fifth of the decedents (62 cases) were transported from the scene of Dehydration was given as a contributing condition.
the hanging and received medical care prior to being pronounced dead. The medical literature contains reports of chronic obstructive lung
The remaining four-fifths of the decedents were pronounced dead at the disease following sodium hydroxide inhalation. However, rapid death
scene of the hanging. after potassium hydroxide inhalation has not been reported. The
The types and frequency of injuries of the internal neck structures mechanism of death proposed for this case is that the caustic potassium
identified at autopsy such as hemorrhage of the neck musculature, hydroxide produced widespread pulmonary edema, with rapid
fractures of the hyoid bone, and fractures of the tracheal and laryngeal degradation of respiratory function. The exothermic reaction of
cartilages as well as injuries of the spine will be reviewed in detail. In potassium hydroxide and water may have contributed to death by heating
addition, the various types of ligatures recovered, ligature positioning, the inside of the tank.
and positions in which the decedents hanged themselves will be Given the non-specific autopsy and toxicology findings, additional
discussed. The prevalence of factors such as previously diagnosed investigation was essential in determining the cause of death for this
mental illness, physical illness, and prior suicide attempts in decedents decedent. Through cooperation between the Coroner, law enforcement,
who hanged themselves will also be examined. and occupational health agencies, the cause of death could be established
Hanging, Suicide, Epidemiology in this case.
Occupational Health, Potassium Hydroxide, Inhalation
G107 Death in a Tanker Truck

G108 Agonal Sequences in Eight Filmed
Christopher B. Rogers, MD*, Los Angeles County, Medical Examiner’s Hangings: Analysis of Respiratory
Office, 1104 North Mission Road, Los Angeles, CA 90033; John Kades,
BA, Los Angeles County, Department of Coroner, 1104 North Mission
and Movement Responses to Asphyxia
Road, Los Angeles, CA 90033; and Lakshmanan Sathyavagiswaran, by Hanging
MD, Los Angeles County, Medical Examiner’s Office, 1104 North
Mission Road, Los Angeles, CA 90033 Anny Sauvageau, MD*, Lab de Sciences Judiciaires, et de Medecine
Legale, 1701, Parthenais St, 12th Fl, Montreal, QE H2K 3S7, CANADA;
After attending this presentation, attendees will understand the need Romano La Harpe, MD, Institut de Medecine Legale, 9 Av de Champel
for thorough investigation of work-related fatalities and will be familiar (CMU), Geneva, 1206, SWITZERLAND; and Vernon J. Geberth, MS,
with the autopsy presentation of death by inhalation of caustic MPS, P.H.I. Investigative Consultant Inc., PO Box 197, Garnerville, NY
substances. 10923
This presentation will impact the forensic community by suggesting
strategies for investigating occupational deaths by using interagency After attending this presentation, attendees will have a better
communication and cooperation. understanding of the pathophysiology of human asphyxia by hanging.
In this case, a 23-year-old man was cleaning the inside of a tanker This presentation will impact the forensic community by providing
truck which had been used to carry 50% potassium hydroxide. The new insights into the body responses to asphyxia by hanging, based on
procedure for cleaning the tank included a confined space entry results from the Working Group on Human Asphyxia.
procedure, consisting of 21 pages of instructions. Introduction: In the conducting of investigations and trials,
The cleaner used spray head to flush the tank with water at least forensic pathologists are often asked questions related to body responses
four times, then used a fan to dry the tank. The tank would be checked in human asphyxia. Those questions are very difficult to answer
for adequate oxygen concentration using a digital meter. A worker considering the paucity of literature. Animal studies have been
would then go into the tank, using a safety harness, mask, ladder, conducted, but the extent to which those results can be applied to human
personal air monitor, personal motion detector, and protective is doubtful. As for direct human experimentation, it is of course out of
equipment. A second worker, acting as the safety attendant, remained question for obvious ethical concerns. To palliate these limitations, the
outside the tank. Ventilation was introduced by using an air hose inserted Working Group on Human Asphyxia was formed in 2006 at the 58th
into a small hatch in the tank. The worker would remove any remaining Meeting of the AAFS in Seattle. This working group has for main
chemical using a high-pressure water hose, hand dry the tank, and objective to regroup filmed hangings in order to give new insights into
inspect it for corrosion. During the cleaning procedure, the truck engine the pathophysiology of human hanging.
was off. Methods: A total of eight filmed hangings from three different
On the day this case occurred, the decedent was working alone. countries (Canada, Switzerland, and United-States) were analyzed: two
Fifteen minutes after he entered the tank, another worker checked on him filmed suicides and six autoerotic deaths. Hangings were of different
and found him unresponsive at the bottom of the tank. He was removed types: free hanging, hangings with feet on the ground, hanging kneeling
from the tank using his safety harness, and taken to a hospital, where he and hanging almost lying face-down. The hanging ligatures also varied
was pronounced dead. widely, from cloth band to ropes with or without padding and electric

cords. All victims were adult males. Those filmed hangings were enamel, so its 14C concentration reflects the level in the biosphere at the
compared in terms of loss of consciousness, convulsions, decortication time of enamel formation. Atmospheric testing of nuclear weapons
and decerebration rigidities, loss of muscle tone, last muscle movement, doubled the global 14CO2 level between 1955 and 1963. After adoption
and respiratory responses. The time frame at which each of these of the Partial Test Ban Treaty in 1963, the level of atmospheric 14CO2
responses occurred was taken by two judges. started to decrease exponentially with a mean life of about 16 years due
Results: With the time 0 representing the onset of hanging, rapid to transport into large carbon reservoirs such as the oceans and losses to
loss of consciousness was observed (at 8 – 18 seconds), closely followed space. The enhanced level of 14C worked its way up the food chain from
by appearance of convulsions (at 10 – 19 seconds) in all cases. A CO2 so that all living things are labeled with the pulse.
complex pattern of decerebration and decortication rigidity was then Material and Methods: The concentration of 14C in tooth enamel
observed in all cases. Last isolated muscle movement occurred between from individual teeth and related it to the known concentration in the
1 minute-2 seconds and 7 minutes-31 seconds. High similitude was atmosphere over time (1950 – present) to establish the time of tooth
observed for respiratory responses: onset of very deep respiratory formation was measured. The dates were then used to estimate the year
attempts between 13 and 24 seconds, last attempt between 1 minunte-02 of birth of the person. To this end, the crown of the tooth was cut away
seconds and 2 minutes-05 seconds. from the root at the level of the cervical line. The crown was then
nd : no data/– not observed immersed in 10N NaOH, before being placed in a water-bath sonicator.
The enamel was then washed with DDH2O and re-submersed in 10N
NaOH during approximately four days to remove all dentin until pre-
treated for accelerator mass spectrometry (AMS) analysis.
Results: The technique matched 14C content in enamel to known
age very well along the bomb spike curve. The absolute difference
between estimated age and true age was 1.1 ± 0.9 years for teeth from
Scandinavian subjects, implying a much higher precision than any
previous method. Analysis of teeth from deceased subjects from other
continents showed similar accuracy, suggesting that the geographical
variation of the bomb-pulse radiocarbon does not significantly influence
the readings. For teeth formed before 1955, the 14C analysis can only tell
that the person was born before the nuclear tests (birth year of person
Conclusion: Despite differences in the types of hanging, before 1945 - 1952, depending on type of tooth analyzed), but with
similarities could be revealed regarding rapid loss of consciousness and absolute certainty.
onset of convulsions, pattern of decortication rigidity and respiratory Conclusion: AMS analysis of teeth offers a precise age
responses. To date, this is a unique study of agonal movements in determination that can be applied in forensic casework, particularly to
asphyxia by hanging. The importance of inter-laboratory collaboration assist in investigations of unidentified human cadavers. If radiocarbon
in extending this project by adding other available filmed hangings is determination and aspartic acid racemization analysis of teeth are
discussed and the importance of the Working Group of Human Asphyxia combined, information of both the year of birth and the year of death can
(WGHA) is further emphasized. be established.
Asphyxia, Hanging, Physiopathology This work was supported by the Human Frontiers Science Program
and Wenner-Gren Foundation.
Age Determination, Radiocarbon, Tooth
G109 Dead Victim Identification: Age
Determination by Analysis of Bomb-Pulse
G110 Postmortem Injury Detection in an Aviation
Radiocarbon in Tooth Enamel
Mishap: Computed Tomography Imaging
Henrik Druid, PhD*, Department of Forensic Medicine, Karolinska Versus Autopsy
Institutet, Retzius v. 3, Stockholm, SE-171 77, SWEDEN; Kanar Alkass,
BSc, Department of Forensic Medicine, Retzius v 3, 171 77, Stockholm, David M. DeLonga, PhD*, Naval Medical Center Portsmouth, 6513
SWEDEN; Kirsty Spalding, PhD, Department of Cell and Molecular Harbour Pointe Drive, Suffolk, VA 23435; Angela D. Levy, MD, United
Biology, Medical Nobel Institute, Karolinska Institutet, Stockholm, States Army, Department of Radiology and Radiological Sciences,
SWEDEN; and Bruce Buchholz, PhD, Lawrence livermore National Uniform Services University of the Health Sciences, 4301 Jones Bridge
Laboratory, 7000 East Avenue, Livermore, CA 94550 Road, Bethesda, MD 20814; and Howard T. Harcke, MD, Department of
Radiologic Pathology, Armed Forces Institute of Pathology, 3205
After attending this presentation, attendees will understand how Coachman Road, Wilmington, DE 19803
biological samples produced in the past 60 years can be dated using the
radiocarbon bomb-pulse. Specifically, they will learn how the 14C After attending this presentation, attendees will understand the
content of dental enamel can be used to determine year of birth of utility and limitations of postmortem computed tomography (CT)
persons born after 1945. analysis of traumatic injury victims compared with standard autopsy.
This presentation will impact the forensic community by providing This presentation will impact the forensic community by
a technique that improves the accuracy in age determination of dead demonstrating how CT imaging can complement the conventional
victims, such as suspected homicides and victims of mass disasters. autopsy in the injury detection of aviation mishap victims.
Background: Determining the age of an individual is an important Purpose: This study compared and contrasted the sensitivity of CT
step in dead victim identification, particularly in suspected homicide imaging versus autopsy in the postmortem detection of injuries sustained
cases and in mass disaster work. Age determination can be performed in an aviation mishap.
with high precision up to adolescence by analysis of dentition, but Methods and Materials: Four male victims from an aviation
establishing the age of adults has remained difficult. The enamel of mishap were studied with whole-body CT examinations prior to
individual permanent teeth is formed at distinct, well-characterized time conventional autopsy. Autopsies were conducted by forensic
points during childhood. After being laid down, there is no turnover of pathologists and autopsy reports created without reference to the CT

imaging studies. Blinded to autopsy reports, two radiologists then majority of the cases were natural deaths (n=130, including 63 cases of
retrospectively interpreted each study in a consensus fashion. Images sudden death), followed by suicide (n=113), accident (n=104).
were evaluated for fractures, dislocations, and soft tissue abnormalities Homicide and undetermined manner of death were respectively found in
resulting from traumatic injury. Radiology interpretation was compared 40 and 41 cases. The most frequent causes of death were blunt force
to autopsy reports to determine the sensitivity of each method in injuries (n=73), cardio-vascular diseases (n=90), mechanical asphyxia
detecting these injuries. CT studies were then re-examined to review including drowning (n=62), acute intoxication (n=59) and gunshot
missed or discordant findings in order to determine if a successful wounds (n=47). No cause of death was found in 32 cases. Mechanism
imaging correlate with the autopsy results could be obtained. of death not shown by gross anatomic findings was discovered by
Results: Autopsy and CT imaging detected a total of 236 fractures histology in about 40% of the cases (n=173). The main mechanisms of
and dislocations. Autopsy detected 139 (59%) and CT imaging detected death found were respectively cardiac arrhythmogenic substrate (n=98),
231 (98%) of these findings. In regions of the body that were not fully acute myocardial ischaemia (n=17), pulmonary infection (n=17), vital
explored during the autopsy procedure (e.g., posterior vertebral body alimentary aspiration (n=14), fat embolism (n=13), pulmonary thrombo
elements, scapula, and ribs), the CT images frequently revealed fractures embolism (n=5), diffuse axonal injury (n=3), disseminated intra-vascular
not recorded on the autopsy reports. Autopsy and CT imaging detected coagulation (n=2) and sickle cell crisis (n=2). Cause of death was
a total of 56 soft tissue abnormalities. Autopsy detected 55 (98%) and established only by histology in 8.4 % of the cases (n=36). In the 32
CT imaging detected 14 (25%) of these findings. The detailed cases for which no cause of death was found, histology showed possible
description of soft tissue abnormalities found in the autopsy reports was mechanism of death in 11 cases corresponding to a cardiac
frequently not appreciated with CT imaging. Some of these soft tissue arrhythmogenic substrate. Microscopic findings affected the manner of
abnormalities were apparent in retrospect after being un-blinded to the death in 13% of the cases (n=56). Histology provided complementary
autopsy reports. information about prior medical condition of the deceased in about 49%
Conclusion: The use of CT imaging is a useful adjunct to autopsy of the cases (n=211). Traumatic lesions were better documented by
in the postmortem detection of injuries following an aviation mishap. histology in about 22% of the cases (n=94). The majority of
CT imaging demonstrates high sensitivity for the detection of fractures discrepancies between microscopic and gross autopsy findings involved
and dislocations but is currently limited in the detection of soft tissue the liver, the heart, and the lungs. According to these results,
injuries. microscopic findings are relevant if adequate sampling for histology is
The views expressed in this article are those of the authors and do performed during autopsy. In most of the studied cases, histology can be
not necessarily reflect the official policy or position of the Department of considered contributory regarding respectively mechanism, cause and
the Navy, Army, Department of Defense, or the United States manner of death, prior medical condition of the deceased and traumatic
Government. lesions documentation.
Computed Tomography, Traumatic Injury, Aviation Mishap Conclusions: According to the results of this study, systematic
standard histology for the main organs should be used in routine forensic
autopsies.
G111 Usefulness of Systematic Histological Forensic Autopsy, Histology, Cause of Death
Examination in Routine Forensic Autopsy
Geoffroy Lorin de la Grandmaison, PhD*, AP-HP, Philippe Charlier,
G112 Radiology Students and Morgues:
PhD, AP-HP, and Michel Durigon, PhD, AP-HP, 104 Boulevard A Mutually Beneficial Relationship
Raymond Poincaré, Raymond Poincaré Hospital, Garches, F-92380,
FRANCE Nancy S. Adams, BS*, 202 Milford Street, #155, Tupelo, MS 38801
After attending this presentation, attendees will be aware of the After attending this presentation, attendees will be better informed
considerable discrepancy rate between macroscopic and microscopic of the benefits that may be realized by affiliating with a radiologic
findings provided by standard histology in forensic autopsy. technology program to provide radiology students with clinical morgue
This presentation will impact the forensic community by showing experience.
that histology is an important feature regarding forensic autopsy quality This presentation will impact the forensic community by making
and is still essential to confirm, refine, or refute macroscopic findings. people aware of the improvements to radiographic image quality that
Material and Methods: A prospective study was carried out on may be accomplished when radiology students are allowed to observe
1,786 autopsies performed in the department of pathology and forensic autopsies and assist with forensic radiographs. A secondary benefit is
medicine at the Raymond Poincaré hospital from 2003 to 2007, for recognized in preparing the radiologic technologist to assist with other
which standard histological examination was systematic according to skills such as evidence collection and preservation.
autopsy protocol (including microscopic sections of the heart, lungs, Interest in the forensic sciences has grown significantly in recent
liver, kidneys, pancreas, spleen, thyroid, adrenal glands, prostate and years as events and the media have focused attention on forensic
neuropathological study after brain formalin fixation). Histological investigations, and the radiologic sciences are no exception. Due to most
sections were stained with haematoxylin and eosin. From all these morgues and medical examiner facilities being totally separate from
autopsy cases were randomly selected 428 cases for which microscopic hospitals today, the radiology student and radiology practitioner do not
sections were reviewed by two forensic pathologists. SIDS cases and have adequate experience in forensic imaging. As radiology equipment
skeleton cases were excluded from the study. For each case, information becomes more and more sophisticated, and imaging techniques such as
provided by histology regarding respectively cause and manner of death, virtual autopsies and 3D CT reconstruction are utilized more frequently,
death mechanism, prior medical condition of the deceased, and the skills of the board-certified technologist will be in greater demand.
documentation of eventual traumatic lesions were analyzed. Due to the nature of the work, it is important for the student to have some
Discrepancies between gross anatomic and microscopic findings were knowledge of the expectations and working conditions to aid in
also studied. determining if this is a field they may wish to pursue. Just as the student
Results: The mean age of the population was 46.2 years (range 5- obtains knowledge and experience in a broad range of imaging
91 years). The sex ratio (H/F) was equal to 2.46. Bodies showed modalities to decide on a career path after graduation, an introduction to
respectively putrefaction in 92 cases, mummification in one case and the morgue and forensic imaging should be available as well. Many
diffuse carbonization in 15 cases. Concerning manner of death, the times the radiologic technologist must image living and deceased
subjects in the emergency department, and if that technologist has some in the clinical care of the living. Sharing collective experience, both
forensic training and background, preservation of evidence would be positive and negative, in addressing these issues is important in
complied with, observation and interview skills would be enhanced, and identifying its long-term role in the medical examiner setting.
the images obtained would provide proper legal documentation. The logistic and technical challenges to the development of a CT
The morgue or medical examiner’s facility can benefit by having autopsy imaging service require educational efforts and infrastructure
students and instructors available who are well-versed in recognizing development. Imaging autopsy is an accurate tool for the detection of
imaging artifacts, equipment and image processing malfunctions, and are most major injuries and causes of death resulting from blunt trauma or
able to troubleshoot and correct or at least identify the problem. They drowning. CT imaging autopsy has the potential to replace conventional
can develop proper exposure techniques and set up guidelines; train ME autopsy in some deaths resulting from accidental blunt trauma and
morgue assistants in obtaining better images; recognize foreign objects may facilitate rapid retrieval of ballistic fragments in cases where
and implants; position to overcome superimposition of structures or forensic autopsy is required.
demonstrate an anatomical part more accurately. In addition, the CT Imaging, Autopsy, Logistics
instructors work with the students to compare ante-and postmortem
images and reproduce an antemortem position if necessary for
comparison. An additional benefit includes access to board-certified G114 Intersecting Fractures of the Skull
instructors who are available to the facility for consultation, physically
or electronically. A financial benefit to the facility may also be
and Gunshot Wounds: Case Report
considered, as the students and instructors are not paid employees, and and Literature Review
may assist in reducing overhead by maintaining the x-ray and image
processing equipment in proper working order. And as a final benefit, Guido Viel, MD*, University of Padua, Via Falloppio 50, Padova,
the facility may be able to recruit exceptional candidates for 35121, ITALY; Axel Gehl, MD, Department of Forensic Pathology -
employment, many of whom will have a bachelor’s degree and may seek Institute of Le, Hamburg, GERMANY; Giovanni Cecchetto, MD,
additional training as a multi-skilled individual. University of Padua, Via Falloppio 50, Padova, 35121, ITALY; Massimo
This presentation describes an arrangement between a radiologic Montisci, PhD, University of Padua, Via Falloppio 50, Padova, 35121,
technology program and a medical examiner’s facility and the mutual ITALY; and Jan P. Sperhake, MD, Department of Forensic Pathology -
benefits both groups have enjoyed to date, including the development of Institute of Le, Hamburg, GERMANY
a forensic radiography handbook suitable for both the novice
radiographer and the morgue assistant involved in taking forensic x-rays. After attending this presentation, attendees will have a clear
Radiology, Student, Education example of Puppe’s rule utility in gunshot wounds analysis and will learn
the advantages of a Multi-Slice Computed Tomography approach in such
cases.
G113 CT Autopsy Imaging in the State Medical This presentation will impact the forensic community by
demonstrating the ability of CT scanning to show gunshot wounds to the
Examiner Setting: Logistic Issues, skull vault including entrance wound, exit wound with beveling,
Techniques, and Findings direction of the bullet path as well as differentiation between entrance
and exit wounds using intersecting fractures (Puppe’s rule).
Kyle Shaw, MBBS*, David R. Fowler, MD, Zabiullah Ali, MD, and Jack This paper highlights the ability of CT scanning to show gunshot
M. Titus, MD, Office of the Chief Medical Examiner, 111 Penn Street, wounds to the skull vault including entrance wound, exit wound with
Baltimore, MD 21201; Mary G. Ripple, MD, 68 Bluebird Road, Port beveling, direction of the bullet path as well as differentiation between
Deposit, MD 21904; Barry Daly, MD, Radiology Department, entrance and exit wounds using Puppe’s rule.
University of Maryland Medical Center, 22 South Greene Street, This rule, established by the German forensic pathologist Puppe in
Baltimore, MD 21201; and Clint W. Sliker, MD, University of Maryland 1903, states that when two or more fracture lines of the skull produced
Medical Center, Diagnostic Imaging Department, 22 South Greene by different blunt forces intersect, it is possible to reconstruct the
Street, Baltimore, MD 21201 sequence of injuries.
The intact skull allows fracture lines to develop normally while the
The goals of this presentation are to describe this research presence of bone damages causes the subsequent injuries to stop in the
experience with logistic and technical aspects of the development of a point of intersection with the previous wounds. In other words this
CT autopsy imaging service for the state medical examiner’s (ME) means that fracture lines produced by subsequent impacts are arrested at
investigation of traumatic death, describe and compare CT imaging pre-existing fractures of the skull.
autopsy appearances with the ME’s autopsy findings, and consider the No exceptions to this rule have been found in systematic
future potential of CT imaging autopsy. investigations on skulls, glass, and eggs stricken with subsequent blows.
The logistic and technical challenges to the development of a CT Although multiple gunshots cause an extensive and sometimes very
autopsy imaging service require educational efforts and infrastructure complex pattern of fractures due to the hydrodynamic effect produced by
development. Imaging autopsy is an accurate tool for the detection of the bullet traversing the temporal cavity of the brain, in the majority of
most major injuries and causes of death resulting from blunt trauma or cases, Puppe’s rule can be usefully applied.
drowning. This presentation will impact the forensic science community This principle gains interest in sequencing multiple gunshot injuries
by demonstrating how CT imaging autopsy has the potential to replace and in determining the direction of fire. However, it may be useful also
conventional medical examiner autopsy in some deaths resulting from in differentiating entrance from exit wounds, especially if specific
accidental blunt trauma and may facilitate rapid retrieval of ballistic distinguishing features are absent (i.e., internal/ external beveling of the
fragments in cases where forensic autopsy is required. skull).
The medical examiner community has shown interest in the use of Herein a case of a 76-year-old man who shot himself in the mouth
CT autopsy imaging, but faces problems of access due to financial, with a Walther PPK 7.65 handgun (caliber 9x17 mm) is reported.
technical, transportation, interpretation, and related difficulties in Prior to autopsy a total body multislice computed tomography scan
incorporating this tool into regular practice as compared to CT imaging (MSCT) was performed. MSCT scanning was executed on a Mx 8000

Quad Diamond select unit (Philips Medical Systems, Andover, MA). In Sectorial or widespread atrophy of the myocardium of free wall of
areas of forensic importance, axial MSCT was performed with 4 x 1, 25 right ventricle is the typical morphologic case, with normal
mm collimation. The duration of MSCT scanning was approximately 15 characteristics of left ventricle and interventricular sept. Loss of
min. Using an open-source workstation (OsiriX version 3.1) it was myocardium set the trans-lightning of the wall, that appears to be
possible to calculate two-dimensional sagittal and coronal reformations yellowish for the fatty substitution and/or whithish for the fibrous
and three-dimensional reconstructions. substitution. Another constant find is the right ventricular dilatation,
Major radiological findings were: a bone defect of the hard palate, from mild to severe, with hypokinesia or akinesia of the muscle.
a complex pattern of fractures of the ethmoid bone with hemorrhagic Less frequent are noticed single or multiple right parietal
filling of the ethmoid sinus, an anterior pneumoencephalus, a fracture of aneurysms, more often at the back side, infundibulous or apex. Besides,
the anterior cranial fossa and a bone defect of the vault with external frequently there’s mural thrombosis of right ventricle and septal fibrosis.
beveling of the outer table. This can cause a consequent bilateral atrial dilatation with the high risk
The abrupt termination of a fracture line belonging to the exit of auricular thrombosis with possible systemic and pulmonary
wound pattern (parietal bone) at a pre-existing damage caused by the embolism.
entering bullet (temporal fracture originating from the entrance wound), From 1990 to 2006 474 autopsies of sudden cardiac death (SCD)
well documented by the 3D-CT reconstruction, was used as an were performed. In this series, ARVC accounted for 27 cases (16.4%),
adjunctive tool to better distinguish the entrance from the exit wound. including 21 males and 6 females (16 to 43 years old; median 26 years).
This paper describes a clear visual example of Puppe’s rule utility Circumstances of death were during physical exercise in 20 cases, and at
in the analysis of gunshot injuries of the skull and highlights the rest in seven cases. The family history of ARVC and/or SCD was
importance of postmortem forensic radiology. negative.
In fact, MSCT allowed the investigation of the anatomical sites that The transmural loss of the myocardium in the right ventricular free
are hardly accessible at autopsy (such as paranasal sinuses, temporal and wall was diffuse in 11 cases and segmental in 16 cases. External bulging
ethmoid bones, etc.) and offers different views and angles of imaging of right ventricular free wall and left ventricular was present in four and
improving the quality of the investigation. six cases respectively. The myocardial atrophy was replaced by fatty
Gunshot Wounds of the Skull, Intersecting Fractures, Puppe’s Rule tissue in 20 cases and by fibro-fatty tissue in seven cases. The interface
between residual cardiomyocytes and tissue replacing the myocardium
(fatty or fibro-fatty), was wave front (cardiomyopathic pattern) in 21
G115 Sudden Cardiac Death Due to Atrophy cases, and lacelike (infiltrative pattern) in six cases. Active myocarditis
was detectable in the fibro-fatty variant only. MRI describe the fatty
and Fibrous and/or Fatty Substitution replacement on T1-weighted images with moderate inter-intra observer
of Right Ventricle: Pathologic Substrates variability, thus sequende like “fat suppression” or “triple inversion
and Postmortem High Resolution MRI recovery” to evaluate fatty replacement might provide a significant
improvement in the diagnosis of ARVC.
Massimo Grillo*, Department of Biotechnology and Legal Medicine – The data showed highly frequent association between ARVC and
Section of Legal Medicine, Via del Vespro, n. 129, Palermo, 90127, the fatty variant with cardiomyopatic pattern. MRI is more sensitive to
ITALY; Pierangela Fleres, MD, and Cettina Sortino, Via del Vespro, n. detect the fatty variant with the caridomyopathic pattern rather than
129, Palermo, , ITALY; Antonino Bonifacio, MD, Institute of Legal fibro-fatty and/or infiltrative substrate.
Medicine, Via del Vespro, n. 129, Palermo, 90127, ITALY; Livio Milone, With this presentation cases reached to their attention in the last
PhD, Via del Vespro, n. 129, Palermo, 90127, ITALY; Paolo years, characterized by atrophy and fibrous and/or fatty substitution of
Procaccianti, PhD, Palermo University, Via del Vespro, n. 129, Palermo, right ventricle’s muscle, with consequent sudden cardiac arrhythmogenic
90100, ITALY; and Emiliano Maresi, PhD, Via del Vespro, n. 129, death will be discussed. Besides, authors will try to make differential
Palermo, 90127, ITALY diagnosis between different nosologic entities compatible with
histological findings, in order to reach the most probable diagnostic
After attending this presentation, attendees will be introduced to hypothesis.
some cases arrived to observation of Section of Legal Medicine of Sudden Cardiac Death, Arrhythmogenic Right Ventricular
Palermo about sudden cardiac arrhythmogenic death, in order to show Cardiomyopathy, Magnetic Resonance Imaging
the possible disease that can cause death. This presentation emphasizes
the difficulty of making diagnosis of Arrhythmogenic right ventricular
cardiomyopathy (ARVC) without genetic analysis: myocardial atrophy G116 Autopulse® Associated Injuries
and fatty/fibro-fatty substitution is diagnostic of ARVC at autopsy only
in absence of any other cardiac and extracardiac remarkable injuries. Kathryn H. Haden-Pinneri, MD*, Harris County Medical Examiner’s
This presentation will impact the forensic community by Office, 1885 Old Spanish Trail, Houston, TX 77054; Dwayne A. Wolf,
demonstrating how data showed highly frequent association between MD, PhD, Harris County Medical Examiner’s Office, JAJ Forensic
ARVC and the fatty variant with cardiomyopatic pattern. MRI is more Center, 1885 Old Spanish Trail, Houston, TX 77054; and Jennifer C.
sensitive to detect the fatty variant with the caridomyopatic pattern rather Love, PhD, and Roger A. Mitchell, Jr., MD, Harris County Medical
than fibro-fatty and/or infiltrative substrate. With this presentation Examiner’s Office, 1885 Old Spanish Trail, Houston, TX 77054
authors will show cases reached to their attention in the last years,
characterized by atrophy and fibrous and/or fatty substitution of right By attending this presentation, attendees will become familiar with
ventricle’s muscle, with consequent sudden cardiac arrhythmogenic the Autopulse® resuscitation device and the variety of internal injuries
death. Besides, authors will try to make differential diagnosis between that can be associated with its use.
different nosologic entities compatible with histological findings, in This presentation will impact the forensic community by educating
order to reach the most probable diagnostic hypothesis. forensic pathologists about the visceral and skeletal injuries associated
ARVC is a primitive disease of myocardium with not-well-known with the use of automated chest compression devices so that they are not
aetiology, characterized by structural and functional abnormalities of misinterpreted as perimortem trauma.
right ventricle, that consist in an hemodynamic, rhythmic and electric Automated devices have been utilized to assist with
disarrayes, due to progressive myocardial atrophy with fatty or fibro- cardiopulmonary resuscitation (CPR) for many years. The most
fatty substitution. commonly encountered device is an Automated External Defibrillator

(AED) which provides rapid defibrillation for those patients with G117 Migration of a Bullet in the
shockable rhythms. The newest device is a portable automatic external
chest compression device. The Autopulse® Non-Invasive Cardiac
Lumbosacral Spinal Canal:
Support Pump is one of these devices. Originally developed by the A Case Report and Review of
Revivant Corporation and subsequently purchased by Zoll Medical the Literature
Corporation, the Autopulse® provides consistent, uninterrupted chest
compressions through a load distributing band which squeezes the entire Audrey Farrugia, MD*, Bertrand Ludes, PhD, Annie Geraut, MD, and
chest. Utilizing the device frees the emergency medical technician Jean Sebastien Raul, PhD, Medicolegal Institute, 11 Rue Humann,
normally assigned to do chest compressions to perform other life saving Strasbourg, 67065, FRANCE
activities while transporting the patient.
This FDA-approved device consists of a short backboard and a load After attending this presentation, attendees will understand rare
distributing disposable compression band, called a LifeBand®. The cases in common medicolegal autopsy practice, descriptions of different
patient is placed on the board and the band is secured around his or her types of spinal canal migration reported in the literature, and
chest. The band automatically sizes the patient, calculating the size, mechanisms and conditions that could induce a bullet migration.
shape and compliance needed without requiring any patient information This presentation will impact the forensic community by explaining
to be entered. Once started, the Autopulse® rhythmically constricts the a well known but relatively rare phenomenon in common medicolegal
entire rib cage, compressing at a rate of approximately 80 beats per autopsy practice.
minute. The LifeBand® can be placed over AED pads, but must be Reported here is a case of a 22-year-old man who was hit by a
removed for standard paddle defibrillators. Compressions continue for gunshot on the left part of the chest in the sixth intercostal space. The
as long as necessary or until the device is stopped. Standard protocol is bullet had a previous course in a first victim.
for patients to receive manual chest compressions before the device is The X-Ray examination of the body of the 22-year-old man showed
started. a metallic object projected at the level of L1. At autopsy, examiners
Houston, Texas became a test center for the use of the Autopulse® described that the bullet during its trajectory induced a pulmonary lesion,
with devices installed in all Houston Fire Department first responder gastric perforation, pancreas, and hepatic lesion and left renal vein and
vehicles. During a two month period, the Autopulse® was utilized on artery perforation. The bullet then entered the spinal canal through the
264 patients, 156 (59%) of whom died and met criteria for medical L1-L2 intervertebral foramen. Classical laminectomy at the lumbar level
examiner jurisdiction. Of these cases, 54 (35%) were autopsied. Nearly was performed, the dura was opened, and the bullet was found at the L5-
all patients had the external stigmata associated with Autopulse® use, a S1 level. This case illustrates a bullet migration due to gravitational
finding previously reported in the literature. More importantly, though, forces as its kinetic energy decreased after an intermediary target (the
a significant number had internal injuries. The most common finding, first victim) and collision with body structures.
after the external abrasions, is posterior rib fractures associated with The different cases reported in the literature, particularly the
posterior intercostal muscle hemorrhage, an injury previously not different types of migration will be discussed. If migration of T10-S1
associated with manual chest compressions. Other injuries include liver seems to be more frequent, some authors reported a C1 to S2 or cranium
and spleen lacerations, hemoperitoneum, vertebral body fractures, and to L4 migration. In one case, a migration from S1 to L4 level in the
mesenteric lacerations. cranial direction, because of the patient’s position, was also described.
A subsequent study at the Harris County Medical Examiner’s Office The different mechanism of migration and the symptomatic effect of this
of patients who were resuscitated utilizing the Autopulse® was phenomenon will also be discussed.
undertaken to determine if body habitus or bone strength played a role in Bullet, Migration, Spinal Canal
occurrence of injuries. A total of 58 cases were reviewed and 36 (62%)
were found to have posterior rib fractures. Rib fractures occurred fairly
equally amongst younger individuals with robust bone as well as older
individuals with osteoporosis. Furthermore, the overall size of the chest
G118 Homicide-Suicide in Tours France:
did not appear to be associated with an increase or decrease in rib 2000-2007
fractures or visceral injuries. However, band placement, evidenced by
the characteristic skin abrasions, and body habitus were associated with Pauline Saint-Martin, MD*, and Patrick O. Byrne, MD, Service de
bone and visceral injuries. Medecine Legale, Hopital Trousseau, Centre Hospitalier Régional
Data is still being analyzed in the utility of the Autopulse® in Universitaire de Tours, Tours, 37000, FRANCE
mainstream resuscitation. Some studies have shown improvement in
survival over manual compressions, while others did not. Over 4300 After attending this presentation, attendees will learn about the
units have been installed and approximately 24000 LifeBandsTM have characteristics of homicide-suicide in a French rural area in an eight-year
been used clinically, and these numbers are likely to increase. A period, as only one study on these events has been conducted in France.
comprehensive understanding of biomechanics and resultant bone and This presentation will impact the forensic science community by
visceral injuries is crucial for forensic pathologists charged with the expanding knowledge of homicide-suicide in France. An important
responsibility to differentiate between Autopulse® and traumatic stage could be the creation of a national surveillance network, so that
injuries. It would be prudent to have a policy in place with the EMS studies could be conducted over the whole country and over a long time
responders in your area such that they are not used on patients with span, allowing the possibility of preventive intervention.
traumatic injuries and they should never be utilized on children. Introduction: Homicide-suicide (HS) has been defined by a
Autopulse®, Autopsy, Posterior Rib Fractures homicide committed by a person who subsequently commits suicide
within one week of the homicide. These events are relatively uncommon
but they have often drawn the media’s attention. HS occupies a distinct
epidemiological domain that overlaps with suicide and domestic
homicide. Two major classifications have been proposed. Both are
based on victim-offender relationship and motive. Few statewide studies
of HS events have been conducted, but no data from France are
available, except one Parisian study. This study of the characteristics of

all HS in Tours, France during an eight-year period was compared with Autopsies were performed in 29 of 35 (89.7%) of all cases and
results obtained in other international studies. toxicology testing (including at least a screen for stimulants) was
Material and Methods: Case records of the Institute of Forensic performed in 25 of 35 (71.4%) of all cases. The population was
Science of Tours were reviewed for 2000-2007. The age and sex of the overwhelmingly male, with a male to female ratio of 10.7 to 1. The
perpetrator and victim, the relationship between them, the method of mean age was 57.6 years. Atherosclerotic and/or hypertensive
death, and the circumstances were noted. cardiovascular disease represented the most common natural cause of
Results: Sixteen HS involving a total of 33 decedents occurred death, and was identified in 29 of 35 (82.9%) of all cases. The mean
during the 8-year period. It represents 11% of the total case of homicides heart weight was 543.9 grams among natural deaths and 490.0 grams
within this period, for a population of 871,000 persons. All offenders among deaths attributed to substance abuse.
were male, with a mean age of 68 years. In 11 events (68%), the offender Deaths were attributed to substance abuse in nine of 35 (25.7%) of
used a rifle for both the homicide and suicide. Most victims were female all cases and nine of 25 (36.0%) of cases in which toxicology testing was
(14/17), with a mean age of 64 years. Fourteen events occurred at home. performed. Of these, only five of nine (55.6%) had a known history of
Five were suicide pacts, during which one person killed the other before substance abuse. Among cases in which toxicology testing was
committing suicide. In these cases, a suicide note was always found. performed, substance abuse-related deaths occurred in five of 14
Discussion: Data were similar to those obtained in other studies. (35.7%) of individuals having sexual intercourse and four of nine
The victim was often a female who was younger than the offender and (44.4%) of individuals found in adult-oriented establishments. Cocaine
her intimate partner. The most frequent apparent motive was the was the most commonly identified drug of abuse, followed by
breakdown of the relationship. Suicide pacts were also frequent. methamphetamine and methylenedioxymethamphetamine. One case of
Shooting was the most frequent used method of both homicide and inhalant abuse (ethyl chloride) was identified. Atherosclerotic and/or
suicide. Availability of firearms in this rural area of France can be hypertensive cardiovascular disease was identified in six of nine (66.7%)
explained by an important activity of hunting. The percentage of HS of deaths attributed to substance abuse.
related to the total number of homicides was important and this result The high prevalence of cardiovascular disease that researchers
confirmed one epidemiological law of HS: the lower the homicide rate, observed is consistent with previous studies of myocardial infarction
the higher the percentage of HS. One limitation of study was the limited and/or sudden death associated with sexual activity. Less recognized by
number of cases. However, a research strategy should be developed in the existing medical literature is the significant prevalence of substance
France to expand knowledge of these events. A phase of this strategy abuse in this population, including those decedents with no known
could be the creation of a national surveillance network, as well as history of drug use. The results of this review suggest that a history of
preventive interventions. sudden death in association with sexual activity warrants at least a
Homicide-Suicide, Suicide Pact, Amorous Jealousy toxicologic analysis for stimulants in order to classify accurately the
cause and manner of death, even in the absence of a known history of
substance abuse.
G119 Sudden Deaths Associated With Sexual Sudden death, Sexual, Toxicology
Activity
Albert Y. Chu, MD*, Sharon M. Derrick, PhD, and Luis A. Sanchez, MD,
G120 Sex Killer: Sexually Related Trauma
Harris County Medical Examiner’s Office, 1885 Old Spanish Trail, and Deaths - Forensic Aspects
Houston, TX 77054
Gilles Tournel, PhD*, IML de Lille, 1, Place de Verdun, Faculté de
Attendees will review of non-homicidal sudden deaths associated Médecine, Lille, 59045, FRANCE; and Valery Hedouin, PhD, Cédric
with sexual activity that occurred in Harris County, Texas, from January Houssaye, MD, Frédéric Grimopont, Antoine Stelandre, Anne Becart,
2004 until the present. The goal of this presentation is to describe the PhD, Viviane Gnemmi, Sandrine Depret, MD, IML de Lille, Lille, 59045,
epidemiological characteristics, autopsy findings, and toxicology results FRANCE; and Didier Gosset, PhD, IML de Lille, Faculte de Medecine,
in this group of decedents. Lille, 59045, FRANCE
This presentation will impact the forensic community by describing
a population of decedents that commonly present to medical examiner After attending this presentation, attendees will know the
and coroner’s offices, including a description of the relatively high description of potentially dangerous sexual practices and their
prevalence of substance abuse in this population. consequences involving death.
Because deaths associated with sexual activity often occur suddenly This presentation will impact the forensic science community by
and outside of the care of a physician, they are frequently reported to the the knowledge and the awareness of these particular sexual practices and
local medical examiner or coroner’s office. The extent of the resulting their consequences involving death.
death investigation may range from no additional investigation to a full Introduction: Many men and women practice a broad range of
autopsy with histologic and toxicologic evaluation, depending on the voluntary sexual activities, most of which are harmless. Many minor
circumstances of the particular case, office-specific guidelines, and the injuries of the genital, oral, and anal areas do occur but most of them
judgment of the individual pathologist/investigator. To further only require symptomatic therapy. The only erotic activities with an
characterize this group of decedents and thereby aid in the investigation unacceptable risk for injury are vaginal insufflations during pregnancy,
of similar deaths in the future, a review of sudden deaths associated with and fist fornication. Some forensic deaths are indirectly linked to sexual
sexual activity was performed. activity. Three cases of deaths with unusual fatal mechanisms during
A review of cases from the Harris County Medical Examiner’s sexual activities are reported.
Office from January 2004 until the present identified 35 cases of sudden Materials and Methods: Forensic investigations of the crime
death associated with sexual activity (excluding homicides). These cases scene and the autopsy findings of three cases: two women and one man
fell into three broad categories: (1) collapse occurring either during or will be presented. Another living woman with important genital lesions
immediately around the time of sexual intercourse (22, 62.9 percent), (2) provoked by sexual activity was examined by a forensic pathologist and
individuals found unresponsive in adult-oriented establishments gynecologic doctor. The pelvic and abdominal lesions are described.
(theaters, video booths, etc) (11, 31.4 percent), and (3) cases of Results: In Case 1, a 35-year-old woman was found dead in her
autoerotic asphyxiation (2, 5.7%). bed. The death was attributed to asphyxia by strangulation. At autopsy,

anal and sphincter injuries and massive rectal hemorrhage were seen, due use-of-force continuum. There is controversy in the lay press and
to rectal fist insertion (fisting). Her husband was sentenced for murder by medical literature regarding the use of these weapons and the sudden, in-
strangulation and sexual assault. Case 2 presents a 42-year-old man was custody death phenomenon. Some groups have claimed that these
found dead in his car in the driver’s seat, his clothes (trousers and devices have caused several hundreds of deaths. This presentation is a
underpants) pulled down around his ankles. Police and forensic review of the existing medical literature on these devices. By attending
investigations supposed voluntary sexual practices with a prostitute, such this presentation, attendees will develop a comprehensive understanding
as oral sex. At autopsy, investigators observed an internal thoracic of the existing medical literature on conducted electrical weapons and
hemorrhage linked to a ruptured aortic aneurysm. The sexual activity will develop and understanding of questions that remain to be answered.
brought about the tearing of aortic tissue. Case 3 presents a 48-year-old The existing animal studies, case reports, and human prospective studies
woman performed voluntary sexual activities such as vaginal and rectal will be examined. The focus will be particularly on the existing
fist and foreign body insertion (alcohol bottle into the base) during prospective human research.
heterosexual activity. The surgeons observed haematomas of the vulva, The presentation will examine issues such as cardiac safety,
major labia, minor labia, and anal area. A colostomy was performed for respiratory effects, and the impact of the devices on other physiologic
the anal sphincter injuries and a surgical act to drain off the haematomas. parameters such as blood chemistries, pH, stress markers, and
In Case 4, a 37-year-old woman was found dead in her bed. A large temperature. The presentation will examine the use of these devices in
quantity of blood was observed between and over the thighs. Her the presence of cocaine, and in the presence of cardiac pacemakers and
husband specified that the blood resulted from menstruation. At autopsy, internal defibrillators. The difference between animal data and human
vaginal injuries and massive hemorrhage were observed, due to vaginal data will be discussed.
fist insertion (fisting). The cause of death was vaginal hemorrhage due It is important for the forensic community to be knowledgeable
to the fisting. Toxicological analysis showed she was drunk. Her about the existing research and the questions that are still not answered,
husband pretended that she consented to this sexual activity. He was particularly those individuals who make determinations of cause of
sentenced for sexual assault leading to the death by hemorrhage. death.
Discussion: Anal and/or vaginal fist or foreign bodies being Conducted Electrical Weapon, TASER, In-Custody Death
inserted are uncommon and potentially dangerous sexual practices.
Forensic investigations, the autopsy, toxicological and histopathological
findings, and the manner and the mechanism of death for three persons
will be discussed. The insertion of a clenched hand and forearm into the
vagina or rectum during heterosexual activity and indirect performing
aortic rupture on pre-existing lesions during oral sex are linked to the
cause of death. The frequency of such fatal outcomes or sexual activity
of anal and vaginal penetration, the injuries observed, the cause of death
due to theses acts (exsanguinations by traumatic damage to the canal anal
and to the vagina or/and air embolism), the consequences of these
practices, the relationship between the perpetrator and the victim and the
special features at the scene, are discussed and compared to the literature.
Indeed, foreign bodies, arm, and forearm inserted into the rectum and the
vagina with associated hemorrhage and perforation have been well
documented in medical literature. However, death following these acts
has very rarely been reported. Such cases remain rare but have to be
reported to alert the forensic pathologists, investigators, and coroners. In
a larger range, the public must be aware of the role of such sexual
activity and their consequences involving death.
Fisting, Hemorrhage, Erotic Death
G121 Conducted Electrical Weapons — A Review

of the Medical Literature
Donald M. Dawes, MD*, Lompoc Valley Medical Center, 518 East

Hickory Avevue Lompoc, CA 93436; and Jeffrey D. Ho, MD*, Hennepin
County Medical Center, 701 Park Avemue South, Department of
Emergency Medicine, Minneapolis, MN 55415
After attending this presentation, attendees will have gained a

working knowledge of the existing medical literature on conducted
electrical weapons such as the TASER X26.
The presentation will impact the forensics community by improving
knowledge of the existing medical research on conducted electrical
weapons which may be important especially for those who make
determination of death decisions.
Conducted electrical weapons are used to control violently resistive
subjects. The devices discharge a small electric current that stimulates
both afferent sensory neurons causing pain and efferent motor neurons
causing involuntary sub-tetanic muscle contraction. The use of these
devices is growing in the United States since it fills a large void in the

Celebrating
1948 ~ 2008
60 years
PATHOLOGY/BIOLOGY
G1 Decapitation Due to Car Accident: nesses, if any, should be the ideal situation to achieve a reliable medico-legal
analysis.
Description of a Case and Review
Road Accident, Decapitation, Neck Injuries
of the Literature
Francesco Ausania, MD, Antonio Oliva, MD, PhD*, Fidelia Cascini, MD,
Massimo Senati, MD, Vincenzo L. Pascali, MD, PhD, and Francesca
G2 Unusual Gunshot Wound Death
Cittadini, PhD, Catholic University, School of Medicine, Institute of of a Sex Offender on the Way to
Forensic Medicine, Largo Francesco Vito 1, Rome, ITALY Jail in the World of CSI
The occurrence of complete decapitation as consequence of car accident
is an extremely rare event, while suicidal decapitation by hanging has been Karen B. Looman, DO*, Tidewater Office of the Chief Medical Examiner,
reported sporadically in forensic literature. The goal of this presentation is 830 Southampton Avenue, Suite 100, Norfolk, VA 23510
to describe a case of decapitation with complete degloving injury of the neck After attending this presentation, attendees will learn to assess an unu-
in a man involved in a traffic accident and we review other similar cases sual case where the evidence at the scene makes it difficult for the medical
reported in literature. examiner to decide homicide, suicide or accident and to evaluate peculiar
This presentation will impact the forensic community by demonstrating scene circumstances involving ballistic evidence.
how in such deaths, the concordance of crime scene investigations, autopsy The presentation will impact the forensic community by showing how
findings and the presence of eyewitnesses if any, should be the ideal important it is to look at all the evidence at a scene and at an autopsy before
asituation to achieve a reliable medico-legal analysis. making a decision about the manner of death.
The occurrence of complete decapitation as consequence of car accident is A 36-year-old man was dropped off by his wife at a bus stop. He was
an extremely rare event, while suicidal decapitation by hanging has been taking the bus to jail for a nine year sentence in a juvenile sex offender case.
reported sporadically in forensic literature. Decapitation is usually seen in He was found two days later on the back road of a rural area. He was sitting
pedestrians run over by trains, and also in motorcyclists who impact against in the driver seat of the family car that had been in storage, suffering from a
the tail board of trucks. Complete transection of pedestrians and occupants gunshot wound to the leg. He had a tourniquet tied around the injured leg.
of cars is seen in road accidents with vehicles traveling at a high speed. In a He had been dead for an unknown period of time and had started to decom-
recent report, Kibayashi has described a case of decapitation of a front seat pose in the summer heat.
passenger in a single vehicle accident. Another report described the vertical Crime technicians noted an unusual finding. Although there were no
iron bar of a grill fence penetrating the neck and decapitating the driver of a bullet holes through the car, there was a handgun on the ground outside the
two-wheeler scooter. Here we describe a case of decapitation with complete driver’s door. There was a wooden dowel taped to the barrel of the gun, and
degloving injury to the neck, of a man involved in a traffic accident, and we a nylon string was tied to the trigger guard of the gun with the other end tied
review other similar cases reported in the literature. to the steering wheel. Lastly, there was an athletic sock covering the handle
A 55-year-old Caucasian man was driving his car at a speed of about of the gun.
120 km/h near the city of Rome when the vehicle skidded off the road, hit The autopsy was routine. The deceased was a healthy man, in the early
another vehicle coming from the opposite direction, and finally impacted the stages of decomposition. There was a gunshot wound to the right thigh that
road barriers. The decapitated body of the victim was extracted from the dri- entered the anterior medial thigh and exited the posterior medial thigh. Dis-
ver’s seat, and the head was recovered outside. The immediate police report section revealed that the bullet transected both the femoral artery and vein.
found that the victim was not wearing a seatbelt. At the autopsy, the body The cause of death was exsanguination from a gunshot wound to the leg.
was that of a Caucasian man, decapitated at the first cervical vertebrae. The The manner of death was less clear. What was the reason for the woo-
decapitation site had irregular, ragged and contused margins. Multiple abra- den dowel and the gun with the sock over the grip? There are several scena-
sions on the face along with closed fractures of the facial bones and mandi- rios possible. The first scenario is that the man was attempting suicide
ble were present. Internal examination of the head revealed diffuse because of his conviction and because his relationship with his wife was
subscalpular hemorrhages, and multiple fractures of the skull bones. The troubled, but did not want his death to look like a suicide. He used the sock
brain was edematous and slight subarachnoid hemorrhage was of the left to hide fingerprints and had the dowel taped to the gun so that he could hold
temporal lobe. There were compound fractures of both humeri, multiple the gun far enough away to look like a distant shot. Since he was holding the
fractures of the ribs on both sides, and closed injuries of the shaft of left gun by the taped dowel he needed the string to pull the trigger and then he
femur. Toxicological analysis revealed the presence of alcohol at the fol- may have intended to jettison the gun, string, and dowel.before dying. He
lowing blood concentration 2g/L. No other drugs were detected. Death was successfully shot himself in the leg, but died in the driver seat of the car
instantaneous owing to complete severing of vital neck structures. before he could get rid of the evidence.
Topography, morphologic nature of the wounds, and severity of the The second scenario is an attempt to look like a holdup or an assault.
injuries of car occupants depend on several factors such as speed at the mo- The individual again knows about fingerprints, gunshot residue and range
ment of impact, nature of the collision, active, and passive protection of the of fire determination. He rigged the gun to pull the trigger and shoot him-
occupants, and sitting position. Several efforts and experimental studies have self in an attempt to look like someone else shot him. Perhaps he wanted to
been made to explain the possible mechanisms provoking decapitation fol- go to the hospital and delay the start of his jail sentence or obtain sympathy
lowing vehicle accident. This injury, in the majority of cases, has been as- from his wife. But he shot himself in the wrong area of the thigh and
sociated with failure to use seat belts, fast driving speed, and road barriers. although he put a tourniquet on the leg, he bled to death before he could get
In this case, it is plausible that because of the high-speed crash, the decapi- help.
tation was provoked by an external object, such as road-barriers or structu- The third scenario is an accident. Perhaps he was doing something with
ral elements of the vehicle being pushed back into the cabin and acting as a the string and the dowel that could never be understood, unless the victim
sharp-force to the neck. It is believed that in such deaths, the concordance himself explained it, and he was accidentally shot. He lost too much blood
of crime scene investigations, autopsy findings, and the presence of eyewit- to drive himself to get help, and he died at the scene.
Questions remain unanswered as to what his motive was. Also, why G4 Improved Estimation of Time Since
was the string tied to the steering wheel? Did he use some of the string to
make a tourniquet and tie the end of the string to the steering wheel just to
Death With Multiple Protein Markers
prevent the string from blowing away? Why wasn’t he able to get help in and Automated Analytical Methods
time? Why was he in this rural area? It is also unclear where he acquired
his knowledge of ballistics, but the complex scenario suggests familiarity Behnoush Memari, MS*, Kenneth G. Furton, PhD, and Alberto Sabucedo,
with the world of CSI. Florida International University, 11200 South West 8th Street, Miami, FL
These are questions that may never have a final answer. But this is a 33199
good example of the need for thorough scene examination, background in-
After attending this presentation the attendee will learn how degrada-
vestigation, and straightforward autopsy technique. This presentation will di-
tion of cardiac Troponin I (cTnI) and Troponin T (cTnT) analysis can help
scuss the evidence for each manner of death in this unusual gunshot wound
forensic scientists narrow their estimate of postmortem interval.
case.
This presentation will impact the forensic community by improving the
Range of Fire, Ballistics, Unusual Death Scene precision and rate of postmortem interval (PMI) estimates using an automa-
ted analytical method to better assist law enforcement in many criminal, civil,
and forensic investigations.
Knowledge of the time since death (PMI) has enormous legal, crimi-
nological, and psychological impact; but currently suffers from uncertain-
ties on the order of days to weeks without mathematically defined confidence
information and a lack of technological advances. The main principle of the
determination of the time since death is the calculation of a measurable date
along a time-dependent curve back to the start point. Characteristics of the
G3 The Effect of Clothing on Decomposition curve slope and the start point are influenced by internal and external, ante-
Rate: A Teaching Model mortem and postmortem conditions which need to be taken into considera-
tion. Current methods utilize temperature-based algorithms intended to
model the cooling of the body after death in order to estimate the postmortem
Phillip L. Watson, PhD*, Ferris State University, 808 Campus Drive,
interval which introduces considerable inaccuracy due to influencing fac-
2004 ASC, Big Rapids, MI 49307
tors. Livor mortis, rigor mortis, and to a lesser degree, algor mortis also have
The goal of this presentation is to illustrate the difference in decompo- been used to estimate the postmortem interval. Forensic pathologists agree
sition rates and insect colonization under identical environmental conditions. that these characteristics only provide “postmortem windows.” Quantita-
The presence or absence of clothing can alter the decomposition rate. tion of the vitreous fluid potassium level has been of some value in evaluat-
This is a difficult concept to teach unless there is a method that can be du- ing the early postmortem interval, but the accuracy of this method is
plicated to show both conditions under identical conditions. This study will dependent on external conditions, the availability of vitreous fluid and the
impact the forensic science community by determining the rate of decom- purity of the sample. For practical purposes, a simple, relatively inexpensive
position of a clothed and unclothed pig as a function of summer environ- assay performed on readily available cardiac tissues, less dependent upon
mental conditions. external factors, and providing data that could be plotted on a reproducible
The presence or absence of clothing can alter the decomposition rate control curve would be of value in determining the postmortem interval ac-
(Anderson 2001, Kelly 2006). This is a difficult concept to teach unless there curately.
is a method that can be duplicated to study both scenarios under identical Cardiac Troponin I (cTnI) and cardiac Troponin T (cTnT) are proteins
conditions. This study was conducted to determine the rate of decomposi- found in heart tissue as selective markers of cardiac muscle damage, and in-
tion of a clothed and unclothed pig as a function of summer environmental vestigation of these proteins for determining time since death shows great
conditions. Insects were collected twice a day until the dry-remains stage oc- promise in mammalian heart tissue. These proteins are good substrates for
curred, and climate consisting of temperature, relative humidity, rainfall, and several enzymes released in cardiac tissue upon death (necrosis); the pro-
wind speed data was collected on an hourly basis. The data show increased teolytic breakdown of theses proteins in postmortem cardiac tissue can be ex-
activity of forensically important insects to be a function of both temperature ploited to determine the PMI. This technique takes a small sample of cardiac
and clothing. The delay of the clothed victim to reach the dry-remains stage tissue that is homogenized and the proteins are then extracted with magne-
was significantly different than the victim without clothing. The stages of lar- tic microparticles, separated by SDS-PAGE and visualized by Western blot,
vae collected from the clothed victim were also significantly smaller than which is probed with mouse monoclonal antibodies against cardiac TnI and
the larvae collected from the unclothed victim at all collection dates until the TnT. This step is followed by labeling and precipitation with a colored sub-
unclothed victim was no longer attractive to forensically important flies. strate to monitor degradation patterns. The area of the bands within a lane
Data collection to be demonstrated will be larva size and species com- is quantitated by scanning and digitizing the image using commonly availa-
position on each pig over time. Comparisons were done as an ANOVA test ble scanners. This methodology is also migrated to more automated capil-
and a species-diversity comparison for all days. Results will be used to set lary electrophoresis.
up teaching mock crime scenes to illustrate the effects of clothing on PMI cal- The results show a linear relationship between the percent protein de-
culations. graded and the log of the postmortem time. A fresh “reference” human heart
Clothing, Decomposition, Flies tissue obtained at time T0 was incubated to obtain a temporal degradation
profile. Comparison of human cardiac tissue samples with unknown time of
death can be evaluated qualitatively against the “reference” human heart tis-
sue. The time of death can be estimated by matching the “degradation fin-
gerprint”. Similarly, a calibration curve (r > 0.95) can be obtained with the
percent cTnI degraded plotted against the log of the time postmortem using
the reference human heart tissue. This curve can be used to estimate the time
of death relative to the “reference” tissue based on the percent degradation.
The data indicate that the degradation of cTnI in heart tissue shows very spe-

cific bands during a postmortem interval of a week. The Troponin T is a examine the relative levels of DNA degradation and these results were com-
more stable protein in comparison to Troponin I, so the degradation of cTnT pared with profiles of the extracted samples generated from an ABI Prism®
takes longer. Combining the data obtained from the cTnI and cTnT can then 310 Genetic Analyzer. Comparisons made between bone, blood and tissue
be used for extended PMI estimates. Frozen human cardiac tissue samples samples and corresponding non-degraded blood samples were used to esti-
at known times of death were analyzed by both the semi-quantitative and mate relative rates of degradation. Studies on the effects of inhibitors on
the qualitative techniques and both show similar agreement with the known these samples will also be discussed.
time of death. Overall, the data demonstrates that this technique represents The results of this study indicate that there is a timeline that degrada-
a major advance in time of death determination providing a fast and reliable tion follows as samples that were 8 weeks or older have, when compared to
semi-quantitative biochemical marker from a protected organ versus other more recent remains, a substantial reduction in the amount of extractable
measurements. Tissue cardiac Troponin I and Troponin T shows excellent DNA. This study also indicates relative rates of decompositions based on
characteristics as a time of death marker in the extended postmortem inter- sample conditions and helps provide a comparison of different extraction
val which is difficult to estimate with current methods. and amplification procedures using real samples with known history.
TnI (Troponin I), TnT (TroponinT), Postmortem Interval (PMI) DNA, Degradation, Environmental
G5 The Effect of Environmental G6 The Role of Scene Investigation

Degradation on DNA With Respect in Uncovering Staged Suicides
to Time and Conditions Jerri McLemore, MD, and Steven Tvrdik, BS*, Iowa Office of the State
Medical Examiner, 2250 South Ankeny Boulevard, Ankeny, IA 50023
Matt Buettner, BS*, Kerry Opel, BS, Bruce R. McCord, PhD, International
Forensic Research Institute, Department of Chemistry, Florida Internatio- After review of this presentation, the audience will understand the need
nal University 11200 SW 8th St, Miami, FL 33199; and Lee Jantz, PhD, for careful documentation of a death scene and retaining a healthy dose of
250 South Stadium Hall, Knoxville, TN 37996 skepticism when investigating apparent suicides. The audience will also un-
derstand the need for good communication between agencies in relaying di-
The goals of this presentation are to show the effects of environmental screpant findings and their potential significance in these investigations.
degradation of DNA due to environmental conditions and exposure over time This presentation will impact the forensic community especially death
and to show the development of degradation curves and a degradation time- scene investigators by emphasizing the need to adhere to standard guideli-
line based on type of burial. nes when investigating all death scenes and to treat each scene as a potential
This presentation will impact the forensic community by providing an homicide. This presentation will also impact the medical examiners’ offices
estimation of decomposition of rates of nuclear DNA and provide informa- that must provide justification for performing autopsies on suicides.
tion concerning the best method for recovery of information from degraded Scene investigation is a vital component along with findings from a po-
samples. stmortem examination in ascertaining the cause and manner of death. Fai-
The goal of this presentation is to show the effects of environmental lure to approach a scene with an open mind where the cause and manner of
degradation on DNA with respect to time and environmental conditions in death seem obvious results in an inability to recognize subtle discrepant clues
order to develop a better understanding of these effects on the analysis of or leads to irrevocable loss of valuable information. Careful investigations of
tissue and bone samples. Ultimately these studies will assist an analyst in de- death scenes where homicide is obvious are almost second nature for law
termining the relative age of an individual sample, whether a lack of PCR ac- enforcement officials and medical death investigators. Similar careful inve-
tivity is due to degradation or PCR inhibition, and what quantity of DNA stigations may be lacking where the manner of death looks like suicide, na-
must be recovered from the sample in order to generate an optimal genetic tural or accident especially when investigators have determined the manner
profile. of death before analyzing the scene. Such an approach to scene investiga-
This study will examine the rate of decomposition of human remains tion may lead to erroneous conclusions in homicides that have been staged
under a variety of conditions, focusing on the quality and quantity of DNA to look like suicides. Although these staged deaths have been discussed in
that can be recovered over time. Control blood samples will be utilized to the forensic literature, most of these cases involved the perpetrator staging the
provide a clear estimate of initial quality of the DNA. The effect of different scene to look like a hanging.
types of burial environments on DNA will then be investigated. Three types Two case studies of homicides that appeared to be suicides will be pre-
of samples will be obtained: above ground, in water, and underground bu- sented. One death involved a woman who had recently been diagnosed and
rials. The focus of this study will be to determine the rate of degradation of surgically treated for cancer who was found dead in bed with a gunshot
DNA between samples based on the type of burial and the environmental wound to her head. The other case involved a woman who was having ma-
conditions. Both real time PCR and STR amplification will be used to esti- rital difficulties and was found in her vehicle while the engine was running
mate these effects. Due to the advances in rtPCR techniques and the deve- in her closed garage. In both cases, the investigators recognized inconsi-
lopment of mini STR kits, current capabilities for the analysis of such stencies and processed each scene as if they were dealing with a potential ho-
samples have greatly improved. However, laboratories need guidance on micide. In the case of an apparent self-inflicted gunshot wound to the head,
when to use specialized analytical systems for degraded samples and when the investigator’s concern over blood stain patterns that were inconsistent
more traditional large multiplex kits can be used. Ultimately it is expected with the information that this investigator was obtaining from the home-
that these experiments will provide guidelines on how such samples should health nurse and decedent’s grandson led to the appropriate work-up of the
be prepared and analyzed. scene and, eventually, to the prosecution of the grandson for homicide. An
Tissue, blood, bone, and nail samples have been obtained from the Uni- investigator’s observation that a woman’s blouse was on backwards in the ap-
versity of Tennessee Anthropological Center and extracted using QIAGEN parent carbon monoxide poisoning, aided in the correct determination of
Blood and Tissue kits and amplified using an Alu based Real-Time PCR manner of death due to a more thorough examination of the vehicle, re-
method. The 25mg Lfor samples tissue samples typically yielded concen- mainder of the house, and decedent at the scene. Communication of the in-
trations of well over 1ng/μL less than 4 weeks old. For samples 4 to 6 weeks vestigators’ suspicions to the forensic pathologist in both cases enabled an
old, a yield of between 1.0ng/μL and 0.1ng/μL was observed. More highly even more careful examination and documentation of injuries.
degraded samples obtained after 8 weeks yielded even lower concentrations Death Investigation, Suicide, Blood Stains
of DNA. A variety of amplicon sizes were used with real time PCR to next

G7 Intrauterine Sudden Death: Study of G8 Fatty Acid Methyl Ester Profiling of
the Fetal Morphological Substrates Bacterial Spores for Microbial Forensics
Emiliano Maresi*, Antonina Argo, Pierangela Fleres, Paolo Procaccianti,
Christopher Ehrhardt, PhD*, Counterterrorism and Forensic Science Re-
and Michele Spicola, Palermo University, Via del
search Unit, Federal Bureau of Investigation Academy, Building 12,
Quantico, VA 22135; Mark Reimers, PhD, Alcon Laboratories, Inc., 6201
After attending this presentation, attendees will understand the risk South Freeway, Fort Worth, TX 76134; Mathew Ducote, PhD, Midwest
factors, causes, and prevention of many fetal deaths as well as ancillary Research Institute, 1470 Treeland Boulevard South East, Palm Bay, FL
studies utilized for proper diagnoses. 32909; James Robertson, PhD, Counterterrorism and Forensic Science
This presentation will impact the forensic community by serving as an Research Unit, Federal Bureau of Investigation Academy, Building 12,
educational resource through discussing sudden fetal death in such cases as Quantico, VA 22135; and Jason Bannan, PhD, Federal Bureau of Investi-
funicular thrombosis due to anticardiolipin antibodies, chorioamnionitis, gation, Laboratory Division, 2501 Investigation Parkway, Quantico, VA
deciduitis, cervicitis, and intrauterine Botallo’s duct clousure due to aspirin 22135
Healthy pregnancy derives from the anatomic and functional relation-
ship between all the components of the pregnancy including, the fetus, After attending this presentation, attendees will be familiar with the use
placenta, and the mother. If the normal relationship between these elements of fatty acid profiling to determine the source of bacterial spores grown on
fails because of intrinsic or extrinsic factors, a pathological pregnancy leading several different culture media and the forensic applications of gas chroma-
to fetal death may occur. To evaluate the morphological substrates leading to tographic (GC) techniques for examining the fatty acid composition of the
sudden death, an accurate evaluation of the fetal autopsy and examination of membranes of organisms isolated from biological evidence.
the placenta, together with the determination of chromosomal pattern, This presentation will impact the forensic community by introducing a
serological and microbiological evaluation, and total body X-rays are manda- technique that may assist investigators in determining the culture methods
tory for a correct diagnosis of the death. An exact diagnosis of fetal sudden employed to produce a microbial agent used in a biocrimes or act of bioter-
death may help prevent the event from recurring in future pregnancies. rorism.
For a pregnancy, to be normal, it needs a complex anatomical-functional Fatty acids are components of bacterial membranes that can be regula-
cooperation between three different biological systems: fetus, placenta, and ted by the cell in response to the types of available nutrients present in the cul-
pregnant mother. The interruption of this kind of connection, due to intrin- turing media. Therefore, genetically identical bacteria that are grown on
sic or extrinsic causes, produces a pathological pregnancy that can result in different media substrates can vary in their fatty acid composition. Previou-
fetal death. In olden times, fetal deaths were not considered a competence sly, fatty acid methyl ester (FAME) profiling has been used in clinical settings
of obstetricians, pediatricians, or pathologists, so it was not possible to for bacterial strain identification, but has not yet been applied for forensic ap-
establish the cause of death and identify the death-risks for subsequent preg- plications.
nancies. On February 2, 2006, the Italian government issued a law estab- In this research, three hypotheses were tested. First, whether a clinical
lishing the role of pathologists in the sudden fetal death after 25th week. method for FAME profiling of bacterial cells can be adapted for use with
According to this rule, the pathologist must identify all the anomalous bacterial spores. Second, can reproducible FAME profiles be produced from
morphologic substrates, by performing a careful autopsy examination, with minimal amounts of evidence (<3mg spores). Third, can a database of
total body X-rays of the fetus, serological/ microbiological tests, and FAME profiles of spores grown under a variety of well-established condi-
placental screening tests, in doing so to promote primary and secondary tions be used to reliably identify the medium used to grow the spores of an
prevention. An essential role is obtaining an accurate medical history. unknown sample.
This retrospective study describes the causes of 1836 fetal deaths For this work, 22 different culture formulations were used to prepare
occurring after the 25th week, from January 1987 through December 2006. and process Bacillus cereus T-strain (BcT) cultures. Fatty acid extraction
314 sudden fetal deaths (38.8%) were observed. In this group there were and GC profiling were performed on spores from each media preparation
176 males (56%) and 138 females (44%), ranging in age from 26 weeks to using two different analytical techniques: (1) the clinical FAME method
42 weeks of pregnancy; 127 (40.5%) fetal deaths occurred before the 37th (“Rapid Method”) which requires approximately 30 mg of biological mate-
week of pregnancy. 258 of 314 fetuses showed maceration due to intrauter- rial and two hours to process, and (2) the more forensically relevant method
ine death. Some fetuses of this group showed signs of distress. Maternal risk (“Instant Method”) which requires only 1 mg of biomaterial and approxi-
factors were identified in 251 (80%) of the fetal deaths including hyperten- mately 15 minutes of processing time. The effect of media substrate on spore
sion (35%), diabetes (20%), bigeminal pregnancy (18%), and central fatty acid composition was examined using Cluster Analysis (CA) and Prin-
placenta previa (7%). cipal Component Analysis (PCA) of all generated profiles.
The fetal sudden deaths were due to placental causes in 283 (90%) FAME profiles from both methods and each media substrate were used
cases, fetal causes in 16 (5.1%) cases, maternal causes in 10 (3.4%) cases and to construct two BcT strain spore databases. Similarity indices calculated
unknown causes in 5 (1.5%) cases. between FAME profiles with the Sherlock Microbial Identification System
The placental causes were: 130 (46%) funicular disorders; 54 (19.2%) (MIDI) software were used to evaluate the variability and reproducibility of
amniotic membrane disorders; 99 (35%) chorionic villi disorders. the spore database data.
The fetal causes were: 12 cardiomyophaties; 4 intrauterine Botallo’s The results of this research suggest that FAME profiles from spores
duct closure. grown on most of the surveyed media substrates can be statistically distin-
Maternal causes were: 7 mother’s sudden deaths due to amniotic and guished using CA and PCA. Oleic Acid appears to be specific for Columbia
thrombotic pulmonary embolism; 3 uterus ruptures. Blood Agar and Tryptic Soy Agar with Blood indicating that certain fatty
Most of sudden intrauterine fetal deaths are caused by funicular and acids may be diagnostic for specific media types. In addition, reproducible
chorionic villi disorders. It is possible to prevent sudden fetal death in cases fatty acid profiles were generated from less than 1mg of dry spores using the
of funicular thrombosis due to anticardiolipin antibodies, chorioamnionitis, “Instant Method.” Results will be presented for comparison of ‘blind’ spore
deciduitis, cervicitis, and intrauterine Botallo’s duct clousure due to aspirin. profiles against the profiles in the BcT spore-media databases. These studies
Genetic tests are important in the deaths due to cardiomyophaties. The will demonstrate the potential usefulness of FAME profiles for forensic mi-
sudden fetal deaths, occurring after 40° week, are related to maternal risk crobiology.
factors so it’s important advance the delivery. Fatty Acid, Bacillus, Bioterrorism
Fetal Sudden Death, Autopsy Guidelines, Prevention

G9 Suicidal Intoxication by Copper Sulphate G10 Visceral Leishmaniasis in Turkey:
Sociocultural Issues in Forensic
Jerónimo Fonte Santa Silva*, Bairro de Santa Justa, 10, Coimbra,
3000-356, PORTUGAL
Epidemiology
The goal of this presentation is to present a case of suicidal intoxication Hüseyin Cakan, PhD*,and Vecdet Oz, PhD, Istanbul University, Institute
by an unusual chemical compound. of Forensic Sciences, Adli Tip Enstitusu, Cerrahpasa Kampusu, PK10,
This presentation will impact the forensic community by demonstrating Istanbul, 34303, TURKEY; Mustafa Aslan, PhD, Istanbul University,
how Intoxications (accidental, suicidal or homicidal) with copper sulphate are Cerrahpasa Medical Faculty, Tip Fakultesi, Mikrobiyoloji ABD, Istanbul,
rare, as can be seen in the few cases described in forensic literature. 34303, TURKEY; T. Mehmet Karayel, BS, Ismail Cakir, PhD*, H. Bulent
Introduction: Portugal is traditionally an agricultural country; there- Uner, PhD*, and M. Yasar Iscan, Ph.D, Istanbul Univ, Istanbul Univer-
fore intoxications by pesticides are very common, especially with paraquat sitesi, Adli Tip Enstitusu, Cerrahpasa Kampusu, PK.10, 34303, Istanbul,
and organophosphorous. Copper sulphate is a fungicide used to control bac- 34098, TURKEY
terial and fungal diseases of fruit, vegetables, nut, and field crops. It can also
be applied in water treatment systems to control algae. This pesticide is After attending this presentation, attendees will appreciate how socio-
available as dust, wettable powder, and liquid concentrate. In Portugal its cultural and epidemiological issues are integrated into forensic sciences.
major application is in vine plantation. This presentation will impact the forensic community by demonstrating
Copper sulfate solutions may irritate eyes, skin, respiratory and mucous how a forensic scientist can participate in enlightening socio-cultural
membranes. Poisoning by this compound may affect the central nervous problems encountered by a developing nation.
system, liver, kidneys, and capillaries, frequently causing renal failure and Forensic epidemiology has been an emerging forensic science disci-
haemolytic anaemia. pline dealing with diseases that create legal issues. Recognition of any
Despite Portugal’s major wine production, intoxications (accidental, parasitic infections requires an understanding of factors such as clinical
suicidal, or homicidal) with this compound are relatively rare, as can be seen symptoms and anamnesis, migration, and geography of the human settle-
in the few cases described in forensic literature. ment. Among the parasitic diseases, Visceral Leishmaniasis (VL) is one of
An 81-year-old male, diabetic with chronic renal insufficiency was the most difficult agents to identify and control and in turn is an important
admitted at the hospital with suspicion of voluntary ingestion of copper disease for the population as a whole. Therefore to control its effect on
sulphate. Four days later he died. He was admitted in the Nephrology unit people, among the initial steps is to track the course of the disease and to
with acute renal failure and anaemia, and was treated with intensive plan the therapy. Furthermore, elapsed time during the diagnosis of the
hemodialysis and blood transfusions. Later on, he developed metabolic illness should be limited to a minimum. Because when the diagnosis is
acidosis and there was a worsening of his anaemia. During admittance a 1.5 delayed the treatment may take longer. This situation may kick back as a
mg/L copper concentration was detected in his blood. serious problem about the illness of the patient and the application of the
At the autopsy, it was possible to see a green coloration of the nails, treatment. In the meantime, problems encountered during treatment such as
ascitis, and pleural effusion on the right side. Samples from heart, kidneys, difficulties in diagnosing psychosocial disorders and inability to identify the
lungs and liver were taken for histopathological examination. The major problems in every health center, must be solved.
microscopic changes were bilateral severe lesions of chronic pyelonephritis, The purpose of this presentation is an epidemiological assessment of VL
renal arterioarteriolosclerosis, epithelial cytoplasmic vacuolization, and encountered by patients during the course of the illness and its sociocultural
basophilic discoloration of the renal proximal convoluted tubules, perivenular impact on their lives.
hepatotoxic lesions with necrosis, and mainly mononuclear sinusoidal and The study includes nineteen patients (with a range of 1-17 years with a
portal inflamatory cell infiltration. mean of 7.5 years) who were initially diagnosed as suffering from VL. From
Clinical features indicative of acute intoxication by copper sulphate each patient, blood samples (5 ml), bone marrow and a personal health
were renal failure, anaemia, and high copper concentration in blood (the nor- history (anamnesis) were obtained. The blood and marrow samples were
mal concentration being 1 mg/L). Nevertheless, autopsy findings weren’t analyzed using standard diagnostic tests designed for VL.
significant; the most common features like gastric and esophageal erythema Results of the diagnositic tests indicated that eleven (7 males, 4 females)
or ulceration were absent. The diagnosis was based on the microscopic of the nineteen patients showed VL. Of these affected people, six were from
alterations. In fact, not only was there evidence of renal histologic changes Istanbul, two from Kastamonu and the remaining from the cities of Kütahya,
related with diabetes and chronic renal insufficiency (arterioarterioloslerosis, Izmit and Hatay. Migration (change of residence) history was not known
chronic pyelonephritis), but also lesions suggesting copper sulfate poisoning: for six (2 male and 4 female) patients. History was known for five (4 males
epithelial cytoplasmic vacuolization and basophilic discoloration of the renal and 1 female) patients who moved to a different town. However, before
proximal convuluted tubules. Furthermore, the histopathologic lesions moving to a different town, children were first taken to a local hospital for
observed in the liver were another clue to determining the diagnosis. diagnosis. This visitation may have taken anywhere from 1.5 to 8 months.
Some parents were not content with the results and did not get the help they
Copper Sulphate, Intoxication, Suicide needed. Eventually, these families moved their residence to a place (with a
distance of 100 to 1,000 km from hometown) where they thought there were
better treatment facilities (state or university hospitals). In two cases families
changed their residence three times; one from Kütahya, Afyon and then to
Istanbul and the other from Bursa, Canakkale, and back to Istanbul). Parents
of three (affected by malaria, leptospirosis) of the remaining eight children
also moved their household to Istanbul where there are better healthcare
facilities. However, the decision to change residence from the eastern and
southeastern towns to Istanbul is a commonly seen migration pattern in the
country. Otherwise, almost all hospitals are well equipped to cope with
malaria and leptospirosis.
With the improvement in socioeconomic level and income, it has
become easy to change residence to far away places in Turkey. Yet such
migration has also made the transmission of disease agents relatively simple.
The study shows that VL is sporadically present in many parts of country.
There is no clear evidence of the transmission of this blood parasite from a
host to a person. In one case in Istanbul the host was thought to be a wild Projection (MIP) modes. 3D reconstructions were obtained
street dog living in a relatively poor residential area. The study indicates that using Volume Rendering Technique (VRT) mode. Image
the disease is haphazardly handled primarily due to a lack of medical proce- interpretations were performed by a board-certified
dure and guidelines to follow in dealing an infectious disease. Some parents radiologist.
of such victims seem to have spent their life’s earnings to search for a rem- • A focused cerebral postmortem MRI was also performed the
edy for their children by moving from one town to another in search of a day of death. Axial acquisitions were performed in spin-echo
better hospital or treatment center. In conclusion, it should be stated that in- T1-weighted, T2-weighted, and T1-weighted gradient echo
fectious diseases are extremely serious and must be handled by a state med- sequences. Image interpretations were performed by a board-
ical procedure. As an important aspect of forensic epidemiology, such certified pediatric neuroradiologist.
information must be communicated to all medical centers in and around the • A postmortem full body radiological study was performed in
country. This procedure in dealing with an infectious disease is also impor- the medico-legal department. This study consisted of skull
tant for doctors to avoid potential legal issues arising from wrong diagnoses radiographs (antero-posterior and lateral incidences), thorax,
and causing hardship for the patient and family. abdomen and pelvis radiographs (antero-posterior incidence),
Forensic Epidemiology, Medical Guidelines, Visceral Leishmaniasis upper and lower member radiographs.
Autoptical and anatomo-pathologic studies: autopsy was performed
by two board-certified forensic pathologists. All three body cavities
G11 Child Abuse: Practical Case of (cranium, thorax, and abdomen) were examined. Anatomo-pathology was
Autopsical, Radiological, and performed after a fixation in 10% formalin.
Results of the different explorations were finally compared:
Anatomo-Pathological Studies Imaging study:
• MSCT: On cranial CT, diffuse oedema was visible with loss
Fabrice Dedouit, MD*, and Céline Guilbeau Frugier, MD, Caroline of the gray/white matter differentiation. Spontaneous
Capuani, and Annick Sevely, MD, Service de Neuroradiologie, Hôpital de pericerebral hyperdensities were visible in left frontal and
Purpan, 1 Avenue du Professeur Jean Poulhès, TSA 50032, Toulouse right temporo-parietal areas. No skull or face fracture was
Cedex 9, 31059, FRANCE; Philippe Otal, PhD, Hervé Rousseau, PhD, visible.
and Francis Joffre, PhD, Service de Radiologie Générale, Hôpital de > On thoracic CT, no pleural or pericardic effusion was noted.
Rangueil, 1 Avenue du Professeur Jean Poulhès, TSA 50032, Toulouse Lungs appeared oedemato-congestive. Bone analysis revealed
Cedex 9, AL 31059, FRANCE; Bernadette Delisle, PhD, Service presence of 4 left rib fractures, with different MSCT aspects.
d’anatomie Pathologique, Hôpital de Rangueil, 1 Avenue du Professeur One fracture concerned the posterior arch of the 6th rib, with
Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, FRANCE; and osteosclerosis of its edges, attesting of the beginning of its
Daniel Rouge, PhD, and Norbert Telmon, PhD, Service de Médecine consolidation. Two concerned the anterior arc of the 7th and
Légale, Hôpital de Rangueil,, 1 Avenue du Professeur Jean Poulhès, TSA 8th rib with a MSCT visible callus, attesting to their old
50032, Toulouse Cedex 9, 31059, FRANCE productions. The last fracture was on the 9th rib, displaced,
The goal of this presentation is to illustrate the potential of postmortem without MSCT consolidation sign.
multislice computed tomography (MSCT) and magnetic resonance imaging > On abdominal and pelvic level, no bone traumatic lesions
(MRI) in cases of death secondary to child abuse. were visible. No visceral lesion was clearly visible, but the
This presentation will impact the forensic community by providing an natural contrast due to lack of internal fat (as is commonl in
example of forensic application of the MSCT and MRI. adult cases) was obviously bad. However spontaneous intra
A 17-month-old male baby was discovered pale and unconscious in his hyperdensities were visible within the mesenteric root and in
bed by her mother at home. An attempt of cardio-pulmonary massage was intra peritoneal situation behind the abdominal anterior wall.
immediately begun by the father of the child. The medical rescue team was They were interpreted as possible fresh blood.
called by the mother. The reanimation attempt was unsuccessful and the res- > The appendicular skeleton exploration confirmed the
cue physician could only objective the death of the child. The reanimation presence of a right humeral fracture with a callus, attesting to
performed was slight, with oxygen mask apposition and cardiac massage. its old production.
No injection was performed. The external examination performed at home • MRI: Bilateral subdural haematomas were visible in sub-
revealed that rigor mortis was already present and revealed the presence of fronto-parieto-temporal areas with varying signal intensities.
numerous ecchymoses. The explanation of the parents was thought to be They appeared as acute hematomas, with spontaneously
inconsistent with the corpse examination. The police investigators discov- hyper- and hyposignals on T2-weighted images. Subdural
ered that the family of the baby was known by the social services. Further- pericerebral hypersignal on gradient echo images were visible
more, a brother of the dead child had already been taken away from his in left frontal and right temporo-parietal areas. A right frontal
family because of neglect. The dead child had been hospitalized one month meningeal hemorrhage was also present. Inter pedoncular and
prior because of a left humeral fracture. The parents explained that the child intra ventricular haemorrhages were also noted. Petechial
suffered form minor beta thalassemia and heterozygous drepanocytosis. The haemorrhages within the posterior part of the corpus callosum
circumstances of home death of this baby were unclear and a medicolegal were suspected.
autopsy was ordered. Postmortem multi-slice computed tomography • Plain X-rays exploration: It confirmed the callus of the right
(MSCT) and magnetic resonance imaging (MRI) examinations were humeral shaft. Three left ribs fractures were noted, affecting
performed in order to determine cause of death of the baby and make an the 7th, the 8th and the 9th ribs. No other bone traumatic
exhaustive visceral and skeletal study. lesion was noted.
Imaging study: External inspection:
• A full body MSCT exploration was performed the day of The body was thin stout build, naked, measuring 79 cm tall,
death. Axial MSCT was performed with a 16 x 0.75 mm weighted 8.6 kg. An immobilisation of the right upper
collimation on a Sensation 16 unit (Siemens, Erlangen, member was noted, secondary to the fracture and the
Germany). Two- (2D) and three dimensional (3D) hospitalisation dating from one month. Anthropomorphic
reconstructions were obtained on a Leonardo workstation measurement revealed an increase cranial perimeter of 48 cm.
(Siemens, Germany). 2D reconstructions were obtained using Numerous ecchymoses were noted one the body. Red
Multi Plane Reconstruction (MPR) and Maximum Intensity ecchymoses were noted on the face, in peribuccal localisation,

and bi frontal regions. Ruptures of fraenulum, the tongue, and these authors, MRI findings were useful in directing the autopsy and brain
the superior lip were noted. Red ecchymotic lesions were also dissection to focal areas of abnormality. They found that postmortem MRI
visible on both lower members. Brown ecchymoses of 0.5 cm and autopsy were complementary and that each may disclose abnormalities
in diameter were noted at the anterior face of the left hemi missed by the other. In half of the eight cases of child abuse examined in this
thorax. study, the combination of MRI and autopsy added valuable information
Autopsy and anatomo-pathology: compared with the results of autopsy alone.
The scalp had a large hemorrhagic infiltration at its deep part, In this case, combination of MRI and MSCT were able to determine
in right fronto-parietal regions, more limited in left frontal and the diagnosis of child abuse. Indeed, multiple fractures, of different ages were
right occipital regions. The right temporal muscle presented a diagnosed. Skeletal fractures were suggestive of non accidental injuries
hemorrhagic infiltration. No endo or exo cranial skull fracture because of their localisations: posterior arch of one rib, and association of
was visible. However, a bilateral subdural hematoma was recent and old fractures. Presence of an old right spiral humeral fracture was
noted in fronto-parietal areas. A hematoma was also visible suggestive of child abuse; spiral fractures are classically secondary to
around the posterior fossa. The cervical spine was surrounded torsional force. Cranial MRI was highly suggestive of intentional trauma.
by epidural hematomas. The MRI aspects of peri-cerebral hematoma are clearly visible compared to
The chest exploration revealed presence hemorrhage around the 6th, MSCT images. This exploration confirmed the pericerebral bleeding and
7th, 8th, 9th left ribs. Three calluses were found for the 7th, 8th, 9th left ribs. objectified lesion not visible at the autopsy time as intra ventricular
A consolidated callus was noted for the 6th rib. The inferior part of the right hemorrhage.
lung presented a hemorrhagic infiltration. Limits of the MSCT are well illustrated by this case: the lack of tissue
A periumbilical ecchymosis at the deep part of the anterior abdominal contrast because of the lack of fatty tissue is the highest limit of the tech-
muscles was present. Many small bowel loops presented a superficial hem- nique. It does not permit a correct examination of the visceral trauma and le-
orrhagic infiltration. sions. However, diagnosis of intra peritoneal bleeding was possible and
A hematoma of the right kidney artery was found, continued by a retro confirmed by autopsy. For skeletal trauma evaluation, MSCT was more
peritoneal hematoma. A limited hemorrhagic intra peritoneal effusion was efficient in our case than plain X-Rays. However, Cattaneo stated that radi-
present. ology detected only 47%, autopsy 65%, while CT scans detected 34% of rib
Microscopic studies confirmed the existence of the rib fractures. The fractures. Rib fractures are quite unusual even in the setting of severe
fracture located to the 6th rib presented a remodelling bone callus. The frac- accidental trauma in infants and rarely if ever result from vigorous car-
tures of the 7th, 8th, 9th ribs presented cartilaginous callous. The right diopulmonary resuscitation. These injuries are usually clinically occult and
humeral shaft presented an ossifying cartilaginous callus. typically result from excessive anteroposterior compression of the chest
Haemorrhagic infiltration was confirmed around the aorta, within the during shaking or with impact. Involvement of the posterior arc of the rib is
mesenteric root, the tongue, and within the anterior abdominal wall. The most common, although fractures occur at all rib sites in abuse. Rib fractures
peri aortic, peri ombilical, and left flank haemorrhages were antemortem, tend to occur at multiple levels at similar points along the arcs of adjacent
contemporary of the death. The tongue lesions consisted of recent and old ribs, are often symmetric, and most frequently involve the middle ribs.
haemorrhages. The mesenteric root haemorrhage was antemortem, with In this case, the autopsy was superior to imaging for the diagnosis of
inflammatory elements, permitting determination that it dated from several hematoma of the right kidney with a retro peritoneal hematoma and cervical
hours before death. epidural spine hemorrhage. The anatomo-pathology study did not confirm
The subdural hematoma was confirmed to be acute. It presented poly- the suspected petechial haemorrhage within the posterior part of the corpus
morphonuclears and ischemic neuronal damage associated with a recent cer- callosum.
vical spine epidural haemorrhage. This case report illustrates the potential of MSCT and MRI concerning
Several authors have compared postmortem imaging and autopsy battered child exploration in terms of determination of cause of death,
results in neonatal death. MRI offers high resolution images of the entire visceral and skeletal evaluations, and age determination of lesions thus
neonate while leaving the body intact. Compared with other imaging tech- permitting the diagnosis of child abuse.
niques such as conventional x-ray and CT scan, the high spatial resolution AAFS, Forensic Sciences, Radiology
and the high tissue contrast that can be generated by MRI are advantages.
The different tissue contrasts that T1-, T2- or proton density weighted MR
sequences provide can give additional information about the lesions or dis-
ease processes. Compared with autopsy, postmortem MRI has proven to be
especially useful in the evaluation of the central nervous system. The high
G12 Posterior Rib Fractures in Infants
water content of the neonatal brain makes it difficult to handle during Associated With Cardiopulmonary
autopsy, even when adequately fixed. Subdural haemorrhages are the Resuscitation
commonest type of injury found and this is in keeping with pathological
evidence and studies using computed tomography. They are caused by Jolene R. Clouse, MD*, and Patrick E. Lantz, MD, Wake Forest Univer-
damage to the bridging veins, which drain from the cortex into the superfi- sity, School of Medicine, Department of Pathology, Medical Center Boule-
cial venous sinuses. It is important to note that different signal intensities of vard, Winston-Salem, NC 27157-1072
subdural haematomas do not necessarily indicate repeated bleeds at different
times. Subtemporal blood is not well seen on CT, especially with its The goals of this presentation are to: (1) describe the recommended
decreased multiplanar imaging capability. Extra-axial fluid collections can method of chest compressions for infants by the American Heart Association,
have the same density as cerebrospinal fluid on CT, and it is difficult to (2) describe the proposed mechanism causing posterior rib fractures due to
differentiate enlargement of the subarachnoid spaces and subdural effusions. child abuse, and (3) describe how chest compressions during cardiopulmo-
MR is superior to CT when differentiating these extra-axial collections. Iso- nary resuscitation in an infant could cause posterior rib fractures.
lated subarachnoid haemorrhages can be difficult to detect on MR studies. This presentation is intended to educate the attendees that posterior rib
MRI is useful at postmortem to direct the autopsy and brain cutting to focal fractures in infants can occur in circumstances other than child abuse; spe-
areas of axonal injury. cifically they can be associated with chest compressions performed during
Hart et al. in 1996 investigated the correlation between postmortem cardiopulmonary resuscitation (CPR). This study will impact the forensic
MRI of the head and autopsy findings in suspected child abuse. Autopsy community and humanity by demonstrating that posterior rib fractures can
was more effective in detection of subarachnoid hemorrhage, suture be related to CPR chest compressions and should not automatically assumed
separation, extracranial injuries and very small hematomas. According to to be a result of abuse without supporting evidence and investigation.

A commonly held belief by forensic pathologists, pediatricians and pe- monstrating how new radiological techniques and reconstruction can be uti-
diatric radiologists is that posterior rib fractures in infants are highly speci- lized to assist the forensic pathologist in assessing cranial trauma after sur-
fic for child abuse and rarely if ever result from chest compressions during gical intervention.
cardiopulmonary resuscitation. Those who concede that rib fractures may Patients affected by cranial trauma with depressed skull fractures and
very rarely occur due to CPR contend that the injuries involve the anterior or intracranial pressure increase generally undergo neurosurgical intervention.
anterior/lateral aspects of the rib. This issue is of particular importance as rib Since craniotomy and craniectomy remove skull fragments and generate new
fractures in small children are most commonly the result of non-accidental fracture lines, they complicate forensic examination and sometimes prevent
injury and therefore may be strong evidence in support of child abuse. A a clear identification of skull fracture etiology.
complete autopsy and a thorough investigation of circumstances are critical To overcome this kind of problems a 3D reconstruction based on preo-
in determining the manner of death in infants. Misclassification due to over- perative CT scanning, giving a picture of the “status quo” ante neurosurgery,
interpretation of a single finding could have devastating effects on caregivers can help the forensic examiner in identifying skull fracture origin and their
who may be falsely accused of abuse and therefore face litigation. means of production.
The normal immature infant skeleton has increased plasticity compared The authors report the case of a 41 year-old-man assaulted by his pu-
to the adult skeleton making it relatively resistant to fracture unless there are sher: he presented at the emergency room with severe cranial trauma with a
congenital or acquired disorders of the collagen matrix or mineralization. depressed skull fracture at the vertex, bilateral subdural hemorrhage, and
However, with enough force applied to the costovertebral angle, minute frac- multiple intraparenchymal contusions. The rapid impairment of GCS (Gla-
tures of the rib head and neck can occur. Current American Heart Associa- sgow Coma Score) from 14 to 8 forced the surgeons to perform a cranio-
tion guidelines suggest that CPR for infants given by health care providers tomy; despite such intervention neurological conditions kept on worsening
be performed using the two-handed method with thumbs on the sternum and (GCS of 4) and after a few hours a craniectomy was performed. The patient
fingers encircling the chest and back. In this manner, direct pressure not only died after 40 days of hospitalization in an Intensive Care Unit (ICU) for
depresses the sternum but also can lever the posterior ribs at their articula- multi-organ failure (MOF).
tion with the vertebral column at the transverse processes of the thoracic ver- The forensic autopsy revealed the absence of various bone fragments at
tebrae. In instances where untrained individuals provide CPR, improper the vertex (consequences of the craniectomy), bilateral fractures at the ante-
technique may also contribute to fractures. As acute fractures in many cases rior and medial fossa, bilateral cortical contusions at the frontal and parietal
are quite subtle and nondisplaced, they may be missed on antemortem and lobe, and a smaller cortical contusion at the right temporal lobe. Histologi-
postmortem radiographs even when critically examined. These fractures cal examination showed focal necrotic and hemorrhagic lesions surrounded
may also be missed at autopsy particularly if the parietal pleura is not remo- by gliosis and several hemosiderin-laden macrophages, dating the trauma at
ved. In fact, the true incidence of infant rib fractures may be underestima- about 30-50 days before autopsy.
ted due to the difficulty in their detection. Because of the absence of various bone fragments at the vertex the ne-
Presented here are the gross, radiographic, and microscopic findings croscopic examination didn’t allow a precise analysis of the skull fractures.
from four hospitalized neonates and infants, aged 1 day to 3 months, who Thus a 3D-CT reconstruction of the preoperative scanning was performed
died of natural causes but were noted to have posterior rib fractures at auto- with SSD (surface shaded display) and MIP (maximum intensity projections)
psy. Three cases showed evidence of acute fractures after terminal CPR at- technique.
tempts. In one case, remote fractures with callous formation were identified A comparative study between necroscopic and radiological data diffe-
in an infant with multiple previous CPR episodes due to complications re- rentiated the surgical from the traumatic lesions, which were produced by a
sulting from his premature birth. These infants and neonates spent the majo- cylindrical blunt object with a reduced area of impact.
rity of their lives within the hospital. In all cases the infants had no history A fit-matching analysis between virtual blunt objects and the skull frac-
of abuse, no outward evidence of inflicted injury, and no additional internal tures found out that the pusher had beaten the victim using a baton with a dia-
injuries consistent with child abuse. It is imperative that the presence of po- meter of 3 cm and a length of about 1.50 meters.
sterior rib fractures in an infant not be ascribed impulsively to child abuse These findings helped the police officers in searching for the crime wea-
until a thorough investigation is conducted including assessment of resusci- pon, which was found hidden in a bush not far from the site of the assault.
tative techniques. Computed tomography techniques with tridimensional reconstruction
Posterior Rib Fractures, Cardiopulmonary Resuscitation, Child Abuse have been developed over the last 10 years and have found various applica-
tions in the forensic field. The most recent development is multislice com-
puted tomography combined with photogrammetry-based surface optical
scanning and image rendering techniques. The combination of these diffe-
G13 Role of Preoperative 3D-CT Reconstruction rent techniques can be used to produce three-dimensional images of injury
patterns for comparison with suspect weapons.
in Depressed Skull Fractures Treated
With Craniectomy: A Case Report of This technology is generally used in postmortem examination to com-
Forensic Interest plete or replace forensic autopsy (Virtopsy®).
However, when patients suffering a trauma undergo surgical interven-
Guido Viel, MD*, and Giovanni Cecchetto, MD, University of Padua, Via tion, which modifies wound morphology and complicates forensic exami-
Falloppio 50, Padova, 35121, ITALY; Renzo Manara, MD, Istituto di Neu- nation, a 3D-CT reconstruction based on preoperative scanning gives a
roradiologia, Padova, ITALY; and Donata Favretto, PhD, and Massimo picture of the “status quo” before surgical procedures and thus helps the fo-
Montisci, PhD, University of Padua, Via Falloppio 50, Padova, 35121, rensic examiner in identifying wounds etiology and their means of produc-
ITALY tion.
Depressed Skull Fractures, 3D-CT, Craniectomy
The goal of this presentation is to describe a new approach to cranial
trauma treated with craniectomy: 3D-CT reconstruction based on preoper-
taive scanning.
This presentation will impact the forensic science community by de-

G14 Subway Train Related Fatalities in or undetermined manners. A suicide note, prior expression of intent, and
prior suicide attempt are other helpful factors. Physical injuries and toxico-
New York City: Accident vs. Suicide logy findings are, by themselves, non-specific, but in conjunction with other
factors, may be helpful. Torso transection and extremity amputation were
Peter T. Lin, MD*, and James R. Gill, MD, Office of Chief Medical Exami- more frequent in suicides, but occurred in accidental deaths as well. Antide-
ner, 520 First Avenue, New York, NY 10016 pressant medications were more frequently detected in suicides, whereas co-
This study aims to describe the characteristics of subway train-related caine and ethanol were more frequent in accidents. These factors should not
fatalities, including scene investigation, police investigation, autopsy, medi- be interpreted in isolation when determining the manner of death. Although
cal and psychiatric history, and toxicology studies. there is no pathognomonic autopsy finding that determines the definitive
This presentation will impact the forensic science community by con- manner of these deaths, these results may be weighed in the context of the
tributing to literature by attempting to identify factors which will be helpful entire evaluation along with other circumstantial and investigative findings.
in differentiating accidental from suicidal deaths. In un-witnessed deaths where additional information is unavailable or di-
Determination of the cause of death in subway train-related fatalities screpant, the most appropriate manner of death usually is undetermined.
usually is obvious. However, determination of the manner of death can be Subway, Accident, Suicide
challenging. A common dilemma is the differentiation between accidental
and suicidal death. In order to accurately determine the manner of death, all
relevant factors must be considered, including: eyewitness accounts, physi- G15 Cardiovascular Trauma in Motor Vehicle
cal injuries, medical and psychiatric history, scene investigation, and toxi-
cology results. The characteristics of subway train-related fatalities were Collisions: A 20 Year Retrospective
examined in order to determine which factors may be helpful in differentia- Study and Review of the Literature
ting accident from suicide. Subway train-related deaths with homicide and
undetermined manners also are included. Kelly L. Rose, MD*, and Kim A. Collins, MD, Medical University of South
A computerized search of all medical examiner death certificates is- Carolina, Department of Pathology and Laboratory Medicine, 165 Ashley
sued between January 1, 2003 and May 31, 2007 was performed for the Avenue, Suite 309, PO Box 250908, Charleston, SC 29425
words “subway”, “train”, or “tracks” to identify all subway train-related fa-
talities. The autopsy data, scene investigation report, police report, toxico- The goal of this presentation is to identify and classify cardiovascular
logy results, and other relevant documents in the OCME file were reviewed trauma and injuries sustained in motor vehicle collisions. The audience par-
for each case. ticipants will be able to determine cause of death due to cardiovascular inju-
Two-hundred and eleven (211) consecutive subway train-related fata- ries in motor vehicle collisions and become familar with injury patterns and
lities were investigated by the Office of Chief Medical Examiner of the City the corresponding motor vehicle collision scenarios. In addition, autopsy te-
of New York during the study period (approximately 1 per week). Of these chniques applicable to motor vehicle collsions will be reviewed.
211 deaths, 175 underwent autopsy and 36 were examined only externally. The motor vehicle collision has been, is, and will remain a major cause
External examination without full autopsy usually was done pursuant to a of death in the United States and internationally. Previous studies of motor
religious objection which must be honored under New York law unless there vehicle collsions have led to significant advances in automobile saftey and
is a suspicion of homicide or an imminent threat to public health. The di- safety precautions. This presentation will impact the forensic science com-
stribution of deaths by manner was: suicide (111), accident (76), undetermi- munity by demonstrating how it is essential to continue to study motor vehi-
ned (20), and homicide (4). The causes of death were either blunt trauma cle collisions, so that even greater saftey advancements and initiatives can be
(206) or electrocution (5). The average age was 44 years with a range of 14 developed.
to 85, and a male to female ratio of approximately 5 to 1. The motor vehicle collision (MVC) is the major cause of accidental
Witness accounts were available in 66% of the accidental deaths and injury and death in the United States and developed countries. Previous stu-
95% of the suicidal deaths. Ethanol was detected in 42% of the accidental dies of traumatic injuries sustained in MVC have led to significant advances
deaths with an average blood alcohol concentration of 0.20 gm%, compared in safety precautions and devices. Resultant cardiovascular trauma resulting
to 14% of suicides with an average blood alcohol concentration of 0.16 gm%. in death includes great vessel rupture, cardiac rupture, cardiac contusion,
Antidepressant medications were detected in 8% of the accidental deaths commotio cordis, and coronary artery dissection. The authors retrospectively
compared to 21% of the suicides. Cocaine and/or benzoylecgonine were de- reviewed all cases referred to the Forensic Pathology Section of the Medical
tected in 25% of the accidental deaths, compared to 3% of the suicides. University of South Carolina (Charleston, SC) over a twenty-year period
Head, torso, and extremity injuries occurred in 84%, 70%, and 62% of acci- from January 1988 through December 2007. Cases of MVC autopsies were
dental deaths compared to 90%, 80%, and 77% of suicides, respectively. examined for the presence or absence of any cardiovascular trauma. Car-
There were skull fractures in 53% of accidental deaths compared to 65% of diovascular trauma was defined as trauma to the heart proper as well as to the
suicides. Decapitation and torso transection occurred in 1% and 3% of ac- pulmonary arteries, vena cava, aorta, and major tributaries of the aorta. Other
cidental deaths compared to 7% and 8% of suicides, respectively. variables reviewed were the type of vehicle, number of vehicles involved, lo-
There were 20 deaths with an undetermined manner; all due to blunt cation in the car of the decedent, seat belt usage, element of ejection, airbag
trauma. Only 35% of the undetermined deaths were witnessed. There were deployment, type of collision, site of vehicle impact, decedent demographics,
four homicides of which two victims were pushed into the path of a subway injury-to-death time interval, cause and manner of death, and toxicological
train. In one homicide, the victim was chased into a tunnel and subsequen- findings. Cases in which the cardiovascular trauma was the cause of death
tly struck by a train. The remaining homicide involved an un-witnessed as- were further examined. Useful autopsy procedures and ancillary studies are
sault followed by a fall onto the subway tracks and electrocution by contact discussed.
with the third rail. Motor Vehicle Collision, Cardiovascular Trauma, Autopsy Techniques
Eyewitness accounts are the most helpful factor for determining the
manner of these deaths. The finding that suicides have a higher rate of
eyewitness accounts than accidents may be a reflection of the requirement to
demonstrate intent in order to certify a death as a suicide. Without evidence
of clear suicide intent, these deaths typically would be certified as accidents

G16 Right Ventricular Lipomatosis and
Fibrous Tissue in Cases of Non-Cardiac
Deaths and Arrhythmogenic Right G17 Sodium Channelopathies Linked to Sudden
Ventricular Cardiomyopathy Cardiac Death (SCD) - What is the Meaning
Carol Kaluen Lee, MD*, New Mexico Office of the Medical Investigator,
of Carrying a Genetic Mutation?
MSC11 6030, 1 University of New Mexico, Albuquerque, NM 87131-0001;
Charles Lee, MD, Vancouver General Hospital, Department of Forensic Antonio Oliva, MD, PhD*, Catholic University, Italy, Largo Francesco
Pathology, 855 West 12th Avenue, Room 1352, Vancouver, BC V5Z 1M9, Vito 1, Rome, 00168, ITALY; Preben Bjerregaard, MD, St Louis University
CANADA; and Michael Allard, MD, James Hogg iCapture Centre for Hospital, Cardiology Department, 3635 Vista Avenue, St. Louis, MO
Cardiovascular and Pulmonary Research, Room 387, St. Paul’s Hospital, 63110; Kui Hong, MD, PhD, Nanchang University, Jiangxi Province, 235
1081 Burrard Street, Vancouver, BC V6Z 1Y6, CANADA Nanjing East Road, Jiangxi; Steven Evans, MD, Beth Israel Medical Cen-
ter, Cardiology Division, First Avenue at 16th Street, New York, NY 10001;
Upon attending this presentation, the audience will have a better ap- Kevin Vernooy, MD, PhD, Academic Hospital, Maastricht, Department of
preciation for the fat and fibrous tissue content of the normal right ventricu- Cardiology, Maastricht, NETHERLANDS; Jorge McCormack, MD, Pedia-
lar myocardium, as compared to cases of arrhythmogenic right ventricular tric Cardiology Associates, Tampa, FL; Josep Brugada, MD, PhD, Hospi-
cardiomyopathy, and also appreciate the importance of selective sampling tal Clinic Barcelona, Arrhythmia Unit, Villaroel 32, Barcelona, SPAIN;
of the right ventricle to properly assess fat and fibrous tissue content. Pedro Brugada, MD, PhD, Free University of Brussels, Department of
This presentation will impact the forensic community by highlighting Cardiology, Brussel, BELGIUM; Vincenzo L. Pascali, MD, PhD, Catholic
the regional differences normally present in the heart, which significantly University, Institute of Forensic Medicine, Largo f. Vito 1, Rome, ITALY;
impact upon the diagnosis of arrhythmogenic right ventricular cardiomy- and Ramon Brugada, MD, Montreal Heart Institute, Montreal, CANADA
opathy, particularly in the posterior basal right ventricular myocardium.
Arrhythmogenic right ventricular cardiomyopathy (ARVC), defined as The goal of this presentation is to describe the use of genetic testing di-
variable replacement of the myocardium of the right ventricular (RV) free rected toward identifying sodium channel mutations linked to Sudden Car-
wall by fatty or fibrofatty tissue with degenerative changes in entrapped diac Death as a diagnostic tool in the forensic field.
myocytes, is a form of cardiomyopathy that is often familial and typically This presentation will impact the forensic community by developing
presents as sudden death in young healthy individuals. Currently, a defini- guidelines on how to approach the results of postmortem molecular analy-
tive pathologic diagnosis of ARVC diagnosis is often difficult because a cer- sis of Sudden Cardiac Death Cases and the immediate consequences of ge-
tain amount of fat is always present within the RV myocardium that tends to netic testing of the relatives.
increase with age, particularly in the anterior and lateral apical regions. We Mutations in the SCN5A gene have been linked to a variety of diseases
aim to quantitatively establish a normal range for regional RV lipomatosis causing sudden cardiac death, with important variability in expression and
and fibrous tissue to provide a basis for the pathologic diagnosis of ARVC. phenotypic overlap. With the availability of postmortem molecular analysis
Anterior, lateral, and posterior regions of apical and basal RV myocardium and genetic testing of family members, it is now possible to identify carriers
were sampled from autopsy cases where deaths were due to non-cardiac cau- based solely on the presence of the genetic defect. Clinical decision making
ses (control; n=10; age = 21-84 years) and from individuals who had docu- in this situation is complex and generates important ethical and medico-legal
mented ARVC (ARVC; n=10; age = 15-60 years). Area fractions of RV issues.
myocardium (%) occupied by myocytes, fat, fibrous tissue, or blood vessels Two families, 24-328 and 24-588, originally diagnosed with Brugada
were measured on trichrome-stained slides by computer-assisted point coun- syndrome after the probands experienced cardiac arrest. Clinical and gene-
ting, excluding epicardial adipose tissue and subendocardial trabeculations. tic analysis in their members were performed. Both families had members
The results highlight significant regional differences in lipomatosis nor- with various electrocardiographic abnormalities including some with Bru-
mally present in the heart, with apical regions having significantly more lipo- gada syndrome, long QT syndrome and conduction system disease. Both
matosis than corresponding basal regions of Control cases (p<0.05). The families had an important family history of sudden cardiac death. Direct se-
anterior apex showed the most lipomatosis (29.9 ± 4.2%), whereas the pos- quencing of exons and exon-intron boundaries of the sodium channel gene
terior base had the least lipomatosis (3.8 ± 1.1%). Comparatively, ARVC SCN5A identified mutations in both families.
cases had a significantly greater amount of fat than Control cases (p<0.05), These two families illustrate an increasingly common scenario when
which was most apparent between corresponding posterior regions, particu- encountering families with ion channelopathies. Because defibrillator is the
larly in the basal RV myocardium, which showed a seven-fold increase in only available therapeutic option at present in Brugada syndrome, physicians
lipomatosis (26.4 ± 8.5%; p<0.05). The large content of fat normally pres- and forensic pathologists will be faced with extremely difficult therapeutic
ent in anterior and lateral apical RV myocardium indicates that diagnosis of decisions that also have important legal, social and ethical implications, espe-
ARVC may be difficult if based solely upon lipomatosis in these areas. cially in children. These data indicate the need to develop guidelines on how
Significant regional differences in fibrous tissue were not seen in Control to approach the results of postmortem molecular analysis and genetic testing
hearts, but the amount of fibrous tissue within the posterior base of ARVC of the relatives as well, especially in asymptomatic individuals.
hearts was significantly higher than that of Control hearts (20.9 ± 3.7% and Sudden Cardiac Death, Genetics, Brugada Syndrome
12.2 ± 1.6%, respectively; p<0.05). Thus, the substantial amount and
regional variation of lipomatosis that exists in normal RV myocardium
indicate that changes in lipomatosis in posterior RV myocardium, particularly
at the base, are the most reliable means of making a definitive diagnosis of
ARVC. This interpretation also has relevance to cardiac imaging as it relates
to diagnosis of ARVC.
Arrhythmogenic Right Ventricular Cardiomyopathy, Lipomatosis,
Right Ventricle

G18 SCN5A Gene Mutation Associated G19 Arrhythmogenic Right Ventricular
With Acute Myocardial Infarction Dysplasia/Cardiomyopathy a Not So
Infrequent Cause of Sudden Death -
Antonio Oliva, MD, PhD*, Catholic University, School of Medicine, Insti-
tute of Forensic Medicine, Largo Francesco Vito 1, Rome, ITALY;
A Danbury Hospital Five Year
Dan Hu, MD, PhD, Masonic Medical Research Laboratory, 2150 Bleecker Experience (June 2002 - June 2007)
Street, Utica, NY 13501-1738; Sami Viskin, MD, PhD, Department of
Cardiology, Tel- Aviv Sourasky Medical Center, 6 Weizmann Street, Utica, Juan A. Merayo-Rodriguez, MD*, Frank Braza, and Jeffrey West, Dan-
ISREAL; and Jonathan M. Cordeiro, PhD, Tabitha Carrier, BS, Hector bury Hospital, 24 Hospital Avenue, 2 Tower Lab, Danbury, CT
Barajas-Martinez, PhD, Yuesheng Wu, MS, Elena Burashnikov, BS, Serge
The goal of this presentation is to increase the database of deaths due
Sicouri, MD, and Ramon Brugada, MD, Masonic Medical Research Labo-
to arrhythmogenic right ventricular dysplasia/cardiomyopathy in USA.
ratory, 2150 Bleecker Street, Utica, NY 13501-1738; and Rafael Rosso,
This presentation will impact the forensic science community by illu-
MD, Sackler School of Medicine, Tel-Aviv University, 6 Weizmann Street,
strating the victim, scenario, and autopsy findings of arrhythmogenic right
Tel Aviv, ISREAL; and Alejandra Guerchicoff, PhD, Guido D. Pollevick,
ventricular dysplasia/cardiomyopathy deaths so that proper cause and man-
PhD, and Charles Antzelevitch, PhD, Masonic Medical Research Labora-
ner of death can be classified and the epidemiology understood.
tory, 2150 Bleecker Street, Utica, NY13501-1738
Ten(10) cases of ARVD/Cardiomyopathy were reviewed that were au-
The goal of this presentation is to describe the first sodium channel mu- topsied at Danbury Hospital, CT, since June 2002 until June 2007. This num-
tation to be associated with the development of an arrhythmic storm during ber represents 3.75% of the total (270) adult full autopsies performed in our
acute ischemia. institution during the same period.
This presentation will impact the forensic science community by pre- Age, sex, and ethnic background were noted. Associated cardiac and
senting findings which suggest that a loss of function mutation in SCN5A non cardiac related diseases were reviewed.
gene (cardiac sodium channel) may predispose to ischemia-induced arrhyth- Medications, social and family history (sudden death of sibling), as well
mic storm and sudden cardiac death. as body habitus (obesity) were tabulated. Prior symptoms (fainting episodes,
Ventricular tachycardia and fibrillation (VT/VF) complicating Brugada palpitations) and pre-terminal circumstances (place of death) were exami-
syndrome, a genetic disorder linked to SCN5A mutations, and VF compli- ned. Autopsy findings (cardiovascular and systemic) were correlated. Con-
cating acute myocardial infarction (AMI) have both been linked to phase 2 clusions are compared with recent literature including review articles.
reentry. Because of these mechanistic similarities in arrhythmogenesis, the Arrhythmogenic, Right Ventricle, Dysplasia
contribution of SCN5A mutations to VT/VF complicating AMI were
examined.
Nineteen consecutive patients developing VF during AMI were
enrolled. Wild-type (WT) and mutant SCN5A genes were co-expressed with
SCN1B in TSA201 cells and studied using whole-cell patch-clamp tech-
G20 Sudden Cardiac Death in Professional
niques. Sports Persons: Natural vs. Anabolic
One missense mutation (G400A) in SCN5A was detected in a Steroid Induced Lesions and Experimental
conserved region among the cohort of 19 patients. A H558R polymorphism
was detected on the same allele. Unlike the other 18 patients who each
Rabbit Model
developed 1-2 VF episodes during acute MI, the mutation carrier developed
Laurent Fanton, MD*, Alain Tabib, MD, Stéphane Tilhet-Coartet, MD,
six episodes of VT/VF within the first 12 hours. All VT/VF episodes were
Maire Joly, and Daniel Malivier, MD, Institut of Legal Medicine, 12
associated with ST segment changes and were initiated by short-coupled
Avenue Rockefeller, Lyon, 69008, FRANCE
extrasystoles. A flecainide and adenosine challenge performed to unmask
Brugada and long QT syndromes were both negative. Peak G400A and This presentation will increase awareness of anabolic steroid-induced
G400A+H558R current were 70.7% and 88.4% less than WT current at - cardiac lesions in professional sports-persons and illustrate comparative
35mV (P≤0.001). G400A current decay was accelerated and steady-state lesions in the rabbit model.
inactivation was shifted -6.39 mV (V1/2=-98.9±0.1 mV vs. -92.5±0.1 mV, This presentation will impact the forensic science community by
P≤0.001). No mutations were detected in KCNH2, KCNQ1, KCNE1, or demonstrating that because controlling or banning doping in professional
KCNE2 in the G400A patient. sports is not feasible in the present state of affairs, treating with apoptosis
The first sodium channel mutation to be associated with the develop- inhibitors might hold out hope of limiting the incidence of severe evolutive
ment of an arrhythmic storm during acute ischemia is described. These cardiac lesions.
findings suggest that a loss of function in SCN5A may predispose to Out of 15,000 forensic autopsies performed on coroner’s orders over a
ischemia-induced arrhythmic storm and sudden cardiac death. 24-year period (Jan 1981-Dec 2003) in the area of Lyon, France (popula-
Sudden Cardiac Death, Myocardial Infarction, Ventricular tion: 2,000,000), WHO criteria identified 2,250 cases of unexpected sudden
Fibrillation cardiac death. Among these, 120 were found to have occurred during recre-
ational sport and 12 in professional sports persons. In the latter category, the
associated cardiac lesions were primitive: natural in 6 cases, and, according
to inquest findings, induced by anabolic steroids in the other six. To shed
light on the induced lesions, animal experiments were performed, adminis-
tering Norethandrolone to rabbits which were then sacrificed and subjected
to pathologic examination and caspase-3 assay by fluorometry on cardiac
fragments.
The natural primitive lesions were classical for such cases. The ana-
bolic steroid-induced lesions comprised coronary thrombosis associated with
left ventricle hypertrophy and lesions analogous to toxic or adrenergic my-
ocarditis. The same lesions were found, to varying degrees, in the rabbit
models, which showed significantly elevated Caspase-3 activity as compared G22 Can Immunohistochemical Stains Aid to
to controls.
Anabolic steroids would seem, to varying degrees, to induce lesions
Rule Out Pitfalls in Suffocation Deaths?
analogous to those found in myocardiopathy and toxic myocarditis. Their
elevated Caspase-3 activity makes these lesions apoptotic in nature. Antonina Argo*, Rosa Liotta, Emiliano Maresi, Stefania Zerbo, Rosaria
Vitale, Pierangela Fleres, and Paolo Procaccianti, Via del Vespro, n. 127,
Doping, Cardiac Lesions, Apoptosis Palermo, 90100, ITALY
The goal of this presentation is show the quantitative and qualitative
G21 Cocaine Induced Intracerebral Hemorrhage expression of selected markers in specimens of tissues that are affected by
various degrees of hypoxic insult using immunohistochemical methods.
in a Patient With Cerebral Amyloid This presentation will impact the forensic community by providing data
Angiopathy: A New Risk Factor for that may be helpful in determining the presence of early hypoxic tissue
Stroke in Cocaine Users damage via immunohistochemical methods.
In forensic practice, the identification of mechanical asphyxiation is
often very difficult, especially in cases of attempted masking of the homicide,
Daniel G.K. Phillips, MD*, University of Maryland, Baltimore, Depart-
or because of putrefactive alterations of the body. In addition, postmortem
ment of Pathology, 22 South Greene Street, Baltimore, MD 21201; Joyce
dissection artifacts of the neck and their differentiation from ante-mortem
L. deJong, DO, and Michael A. Markey, MD, Sparrow Forensic Services,
bruises sometimes leave doubts at the pathologist examination.
Sparrow Hospital, 1215 East Michigan Avenue, Lansing, MI 48909-7980;
The target of current research is focused on detecting severe tissue
and Rudy J. Castellani, MD, University of Maryland, Department of
hypoxia by a great battery of techniques now avalaible. However, even this
limited objective has not been yet obtained with the degree of reliability
The goals of this presentation are to: (1) understand the association required for legal purposes.
between intracerebral lesions and cocaine use, (2) recognize amyloid angio- Cell death, expecially in neurons or myocytes, due to hypoxic damage
pathy, it’s relationship with stroke as well as age, and it’s immunohistoche- is the most common focus for research. However, the main problem, in the
mical detection, and (3) recognize amyloid angiopathy as a possible forensic context, is that a considerable period of hypoxia – usually a
contributing factor for hemorrhage in cocaine use. minimum of many minutes or even hours - is needed before changes can be
Because this case represents the first reported association between co- detected. In autopsy samples the postmortem and agonal changes may
caine-induced hemorrhage and cerebral amyloid angiopathy, this presenta- interfere with the early changes of hypoxic damage.
tion will impact the forensic science community by bringing to light that Quantitative and qualitative expressions of selected markers in
amyloid angiopathy may be an under-recognized but significant risk factor specimens of tissues that are affected by various degrees of hypoxia insult
for hemorrhage in older cocaine users. were evaluated by immunohistochemical method. The relationships between
Hemorrhagic stroke is a common complication of recreational cocaine the expression of selected markers and temporal evolution in human tissues
use. The precise mechanism of hemorrhage in such patients is unclear, were evaluated: the antibody HIF-1α, as a marker of early myocardial
although vasospasm, ischemia, vascular thombi/thromboemboli, elevated ischemia, due to asphixia. HIF-1α is the major trascription factor involved
blood pressure, and vasculitis have all been implicated. Systemic hyperten- in adaptative cardiac response to hypoxia, whose expression can be a useful
sion and saccular aneurysms are generally accepted as predisposing factors tool in those cases with short survival period (as recently shown by Pampin
for cocaine-induced stroke. The authors report the case of a 62-year-old and Coll).
woman who suffered left parieto-occipital intracerebral hemorrhage with The authors also attempted to use TGF-β expression in neck skin, as a
herniation and death, following a cocaine binge. In addition to the gross marker of a vital lesion and duration of survival period. TGF-β plays a
neuropathological findings, microscopic examination showed marked cere- general function in skin response to injury, both in inflammation and in tissue
bral amyloid angiopathy in the vicinity of the hemorrhage as well as corti- repair; and it shows different immunohistochemical expression patterns in
cal areas. To explore the issue of chronic cocaine use as a risk factor for relation to post-injury time interval.
cerebral amyloid angiopathy per se, we additionally studied brain tissue in Finally, the number of pulmonary macrophages with CD68 immuno-
eight patients between the ages of 60 and 80 who were positive for cocaine histochemical stain was estimated.
metabolites at autopsy, with the presumption being that patients in this age The results were evaluated considering the possibility of false negative
group with evidence of cocaine use at autopsy were most likely chronic co- immunohistochemical staining in tissue with putrefactive alteration.
caine users. None of these additional subjects had vascular deposits of amy- A total of thirteen cases of suffocation death were studied: 5 cases of
loid-beta by immunohistochemistry. strangulation, 6 of hanging, 2 of choking. Negative controls were gained
In conclusion, to the best of our knowledge, this report represents the from cases of precipitous death in young people and positive controls from
first case of cerebral amyloid angiopathy-associated intracerebral he- cases of confirmed asphyxial deaths. HIF-1α was tested in myocardial
morrhage precipitated by cocaine. It is suspected that other cases occur but tissues, TGF-β in neck skin samples and CD68 in lung samples.
go under-reported, on the one hand because cocaine-induced stroke is widely The results of the retrospective analysis encourage the authors to
recognized and additional predisposing factors (e.g., amyloid angiopathy) continue this study in further cases in order to evaluate the applicability of
may not be specifically sought, and on the other because cocaine may not be these tests in routine forensic practice.
suspected in the advanced age at which amyloid angiopathy typically pre- Axphyxial Death, Putrefactive Alterations, Immunohistochemistry
sents. It is further suggested that cerebral amyloid angiopathy occurs inde-
pendently of the effects of cocaine, as no vascular labeling was found for
amyloid-beta in eight older subjects who were cocaine users.
Cocaine, Amyloid Angiopathy, Intracerebral Hemorrahge

G23 Alcohol Related Accidental Drowning in A diverse group of pathologic factors can produce profuse gastrointe-
stinal hemorrhage. Common causes include peptic ulcer disease, esopha-
Virginia: An Epidemiological Review geal varices, arteriovenous malformations, and Mallory-Weiss tears.
Aortoenteric fistulas, chemical ingestions, tumors and viruses are among the
Shane Chittenden, DO*, Anna Noller, PhD, and Marnie Wood, MD*, Of- rare entities that are associated with gastrointestinal hemorrhage. Often,
fice Chief Medical Examiner, 400 East Jackson Street, Richmond, when gastrointestinal hemorrhage is encountered at autopsy, the causality is
VA 23219 straight forward. However, at times, the cause of hemorrhage is more ob-
The goal of this presentation is to give viewers an understanding of the scure and the pathologist must consider those possibilities that are less com-
epidemiology of alcohol related accidental drowning in the Commonwealth mon in order to identify the etiology.
of Virginia over a ten year period. Viewers should understand the cohorts at We report a case of a 74-year-old African American female who suc-
increased risk, which may benefit from targeted prevention strategies. cumbed to profuse gastrointestinal bleeding secondary to cytomegalovirus
The impact of this poster on the forensic community and humanity is (CMV) enteritis. The decedent had a history of end stage renal disease se-
to identify those groups at most risk of alcohol associated accidental drow- condary to Wegener Granulomatosis. She had recently been diagnosed with
ning. Targeted preventative measures may reduce from three hundred and inflammatory bowel disease and diabetes. She was HIV negative. Prior to
sixty-three, the number of Virginians to die potentially preventable deaths her death she was hospitalized after undergoing right hip hemiarthroplasty for
over the next ten years. This data may also be used to develop studies and/or a right femoral fracture. Her immediate post operative hospital course was
preventative strategies in other jurisdictions. uneventful. However, while hospitalized she developed bilateral arm tre-
Certain racial, gender, and/or age groups are at higher risk of alcohol- mors, weakness, and decline in her mental status. She was given the preli-
related accidental drowning. minary diagnosis of encephalopathy and it was felt that this was due to her
The Office of the Chief Medical Examiner of Virginia database was chronic renal failure and a metabolic derangement. In the proceeding days,
queried for cases in which the fatal agency was drowning, resulting in 1129 her blood pressure became labile, and despite full medical treatment she died.
cases from January 1997 to December 2006. Of these, 972 were accidental At autopsy profuse gastrointestinal hemorrhage and multiple gastrointestinal
in manner. Data was collected from the database on the sex, race, age, al- ulcerations were found. Microscopic examination revealed transmural ne-
cohol presence, and blood alcohol level of those drowning accidentally. crosis and mucosal erosion of the large intestine and ulceration with chronic
Rates were calculated only for Virginia residents and based on population inflammation penetrating to the muscularis propria of the small intestine. In
data obtained from the Virginia Department of Health Office of Vital Stati- addition, scattered intestinal epithelial cells demonstrated “smudged” nu-
stics. The 2006 population data was estimated based on changes in the po- clear chromatin suggestive of viral infection. Subsequent special staining
pulation groups for the previous nine years. for cytomegalovirus was positive. Causes of profuse gastrointestinal he-
Accidental drownings comprised 86.2% of the total cases studied. Of morrhage and cytomegalovirus enteritis are discussed.
those, 37.3% were associated with alcohol. Males accounted for 92.3% of Gastrointestinal Hemorrhage, Cytomegalovirus (CMV), Autopsy An-
these cases. The highest number of alcohol associated accidental drownings cillary Studies
occurred in whites (63.3%), followed by blacks (29.8%), and Hispanics
(5.5%). Those aged 35 to 45 years represented 25.6% of alcohol associated
accidental drownings, those 45 to 54 years 19.8%, those 25-34 years 17.4%,
and 20 to 24 years 10.7%. Of those aged 18 to 64 years, 61.3% had a blood G25 Ethyl Chloride Toxicity in a Case
alcohol concentration at or above the Virginia legal limit of 0.08%w/v (for of Unsuspecting Abuse
driving a motor vehicle).
Of all alcohol associated accidental drowning, the great majority oc- Valerie S. Green, MD*, Stephen K Wilson, MD, Terry J. Danielson, PhD,
curred in males. Those aged 35 to 44 years comprised 25.6%, while 61% oc- Ashraf Mozayani, PhD, and Luis A. Sanchez, MD, Harris County, Medical
curred in those aged 20 to 54 years. This group may over-estimate their Examiner’s Office, 1885 Old Spanish Trail, Houston, TX 77054
ability to function safely around water while under the influence of alcohol.
Although the majority of these individuals had blood alcohol concentrations The goal of this presentation is to present a case study to increase the
at or above 0.08% w/v, 38.7% did not. Preventative measures should target awareness about the compound ethyl chloride, its medicinal and industrial
this potentially over looked cohort, and emphasize abstaining from alcohol uses, its abuse and potential toxicity to those who choose to abuse it, and its
while engaging in water-related activities. postmortem detection in blood and tissue samples.
This presentation will impact the forensic community by emphasizing
Drowning, Accidental, Alcohol that ethyl chloride is a potentially harmful and fatal chemical when abused
and can be mistaken for ethanol intoxication and may not be anticipated be-
cause of its uncommon association with death.
Ethyl chloride is a colorless gas with general anesthetic properties in hu-
G24 Cytomegalovirus Enteritis With Profuse mans and animals. Its use as a general anesthetic was discontinued because
Gastrointestinal Bleeding Diagnosed at of its flammability, cardiotoxicity, and possible severe respiratory depres-
sion. Its major uses are for tetraethyl lead production and as a solvent, alky-
Autopsy: A Case Report and Review of lating agent, refrigerant and topical anesthetic.
the Literature Ethyl chloride has gained increasing popularity since amyl nitrite and
other volatile alkyl nitrite substances have been removed from the lay market
Benjamin J. Havard, MD*, Kelly L. Rose, MD, and Kim A. Collins, MD, because of their high abuse potential. The three most common means of
Medical University of South Carolina, Department of Pathology and La- inhalation of ethyl chloride are “sniffing”, “huffing”, and “bagging”. Snif-
boratory Medicine, 165 Ashley Avenue, Suite 309, PO Box 250908, Char- fing is perhaps the most popular means of inhalation in those who are epi-
leston, SC 29425 sodic abusers. The individuals who chronically use inhalants prefer bagging
because of the higher concentration of the substance being inhaled. Ethyl ch-
The objectives of this presentation are to discuss the causes of ga-
loride can be purchased without prescription at underground establishments,
strointestinal hemorrhage and gastroenteritis with specific emphasis on the
on the internet and at places selling drug paraphernalia. It is sold as a video
diagnosis of CMV enteritis and its potentially fatal outcome.
head cleaner, which is a legitimate use, but it is also marketed as a means of
This case report and review of the literature will impact the forensic
experiencing a euphoric feeling and enhancement of sexual pleasure. Many
community by helping the medical and forensic community become aware
of the products containing ethyl chloride have provocative names such as
of the potentially fatal outcome of CMV enteritis.
Rush, Jungle Juice Plus, Maximum Impact, Black-Jac, and Macho and are
generally referred to as “poppers”. Acute exposure results in feelings of state of Vermont provides a practical example of how trends can be identi-
euphoria, drunkenness, ataxia, dysarthria, nystagmus, confusion, dizziness, fied, and recommendations derived.
hallucinations, impairment of short-term memory, and unconsciousness. The Motorcycle rider fatalities have been increasing nationwide since 1997,
long term effects of ethyl chloride in humans are unknown. according to the National Highway Traffic Safety Administration reports. In
The case presented is that of a 38-year-old Caucasian man found dead the State of Vermont, the number of endorsed motorcycle operators increa-
in an adult video store viewing room. Review of the store time records re- sed by 7,550 from 1995-2005, and the number of motorcycle fatalities re-
vealed that the man visited the store and returned to his vehicle six minutes ported to the Office of the Chief Medical Examiner (OCME) doubled (8 vs.
later. After being at his vehicle for one minute, he returned to the store again. 16 cases). Through a combination of review of medical examiner reports,
He was found alone in the viewing room approximately five hours later. No death certificates, hospital medical records, police reports, and Fatality
bottles or aerosol cans were found inside of the viewing room or on his per- Analysis Reporting System (FARS) Web-Based Encyclopedia, the OCME
son. Inspection of his vehicle revealed miscellaneous clothing, food contai- analyzed the 73 motorcycle fatalities who expired in Vermont from 1995-
ners, aerosol cans, construction equipment, and two child car seats. Several 2005.
bottles of exercise supplements were in the center console of the car. It is The majority of decedents (71%) held valid motorcycle licenses. None
unknown if any of the aerosol cans inside the vehicle contained ethyl chlo- had completed the Vermont Rider Education Program (VREP) – a voluntary
ride. There was no known prior illness or substance abuse history. His so- training program to improve motorcycle operator safety established in
cial history was unknown except the obvious visit to an adult video store. 1990—though one decedent had attempted, but failed the course. The state
An autopsy was performed approximately eight hours after death. His of Vermont has had a universal motorcycle helmet law since 1968, and the
autopsy findings consisted of pulmonary congestion and edema (combined majority of decedents (89%) were wearing helmets. Three of these helmets,
lung weight 1300 grams). The left ventricular wall of the heart was hyper- however, were not Department of Transportation (DOT) approved models.
trophied (1.4 – 1.5 centimeters in width). The major branches of the coro- Of those with no helmets, drug and/or alcohol screens were positive forty
nary arteries were without significant atherosclerotic change (less than 10% percent of the time. Overall, thirty-eight percent of decedents had positive
stenosis). drug and/or alcohol screens. The average blood alcohol concentration (BAC)
Ethanol, methanol, isopropanol and acetone were tested for by head was 0.15%: in four cases, the BAC was less than the legal intoxication limit
space injection on a dual column gas chromatograph (Restek BAC-1, BAC- of 0.08%. Six decedents had a history of prior DWI convictions, and of
2). An unidentified peak with a set time of 1.156 minutes on the BAC-2 co- these, five had elevated BACs at death. When examined in terms of deca-
lumn eluted at 1.243 minutes on the BAC-1 column as an overlying peak des, the largest group of fatalities occurred in the 20-29 year old population,
with the same retention time as ethanol. Gas chromatographic/mass spec- though the 40-49 year olds represented the fastest growing group.
trometric analysis of blood and liver identified this substance as ethyl chlo- The majority of motorcycle fatalities were not attributable to poor visi-
ride. An alcohol dehydrogenase method (DRI Ethyl Alcohol Assay, bility/weather, as most occurred during summer daylight hours on dry black-
Microgenics) was used for the quantitation of ethanol in the heart blood (0.09 top roads. Neither did traffic play a major role: in 86% of motorcycle
g/dL), the urine (0.8 g/dL), and in the vitreous humor (0.07 g/dL). Cocaine fatalities, the roadways were classified as rural rather than urban, and in grea-
metabolite(s), benzodiazepines, barbiturates, phencyclidine, ampheta- ter than two-thirds of cases, the rider was lone rather than in a group. In 51%
mine/methamphetamine, opiate(s), and methadone were not detected. of cases, the collision was with a stationary object (e.g. guardrail, tree,
This case illustrates the importance of careful toxicological analysis bridge). In 41% of cases, the primary impact was with other motor vehicles.
and scene investigation in an instance where inhalant abuse was not suspec- In 3% of cases, an animal was involved (e.g., deer, moose), and in 6% of
ted. Although ethyl chloride inhalation is not a common cause of death, it cases the primary impact site remains unknown. Excess speed and road cur-
can be lethal when abused. The forensic community needs to be aware of its vature showed a positive correlation with fatalities: per police report, 52% of
potential toxicity especially in cases such as this where there was no known decedents were driving too fast for road conditions and/or legal limits, and
history of “sniffing” or “huffing” and no obvious evidence of inhalant abuse greater than 70% of accidents occurred at road curves. In all cases, the cause
at the scene. of death was blunt impact injury—usually to the head—although concurrent
Ethyl Chloride, Inhalant, Poppers spinal, thoracic, abdominal, and extremity injuries were often seen.
While many factors contribute to motorcycle fatalities, those which are
most important in Vermont appear to be operator-dependant. Excess speed
and drug/alcohol use are two major modifiable risk factors for motorcycle fa-
talities in Vermont. All operators should be strongly encouraged to enroll in
rider safety courses where they can receive appropriate risk education. Pu-
G26 Motorcycle Fatalities in the blic safety advertising should be targeted toward the 20-29 and 40-49 year
State of Vermont: 1995-2005 old age groups.
Motorcycle, Crash, Fatal
Erin G. Brooks, MD*, University of Vermont, Fletcher Allen Health Care,
Department of Pathology, 111 Colchester Avenue, Burlington, VT 05401-
1473; and Steven L. Shapiro, MD, and Brittany N. Philbin, BS*, Vermont
Office of the Chief Medical Examiner, 111 Colchester Avenue, Baird 1,
Burlington, VT 05401
The goals of this presentation are to: (1) investigate the etiology and
demographics of motorcycle fatalities in the state of Vermont via review of
Office of the Chief Medical Examiner (OCME) forensics reports and Fata-
lity Analysis Reporting System (FARS) Web-Based Encyclopedia, (2) to
provide recommendations on how to reduce motorcycle fatalities and/or se-
rious motorcycle injuries in Vermont, and (3) to provide a model for similar
analysis of motorcycle fatalities in other states.
This presentation will impact the forensic community by illustrating
that nationwide motorcycle fatality trends are not necessarily the same as
those seen at the state level. Analysis of motorcycle fatality data from the

G27 Progressive Isolated Hypoglossal Nerve mean GH peak: 5.6±0.7 vs. 46.1±1.9 mg/L in healthy subjects; p<0.01), GH
insufficient or the so called “grey zone” group (GHI, n=17, mean GH peak:
Palsy and Sudden Asphyxial Death 15.9±0.7 vs. 46.1±1.9 mg/L; p<0.01), and those with normal GH secretory
capacity (GHS, n=76, mean GH peak: 44.4±2.4 vs. 46.1±1.9 mg/L; p>0.05).
Emiliano Maresi*, Antonina Argo, Massimo Grillo, Valentina Murgo, Results show that lower GH responses during the provocative test were as-
Filippo M. Cascino, and Paolo Procaccianti, Palermo University, Via del sociated with older age (p<0.01), higher BMI (p<0.01), lower IGF-1 (p<0.01)
Vespro, n. 127, Palermo, 90100, ITALY and the time since trauma (p=0.024), but unrelated to GCS scores (p=0.095),
The goal of this presentation is to illustrate the direct connection sex (p=0.628) or presence of traumatic subarachnoid haemorrhage (p=0.615).
between sudden asphyxial death and isolated hypoglossal nerve palsy These results also indicate that 6.4% of TBI patients had hypogonadism,
secondary of his dissection resulting from cranial trauma. 2.8% had hypothyreosis and 2.8% had hypocortisolemia; also 5.5% had
This presentation will impact the forensic community by illustrating hypoprolactinemia and 2.8% hyperprolactinemia.
sudden death due to cranial nerve damage. A significant number of patients (33.9%) express some form of
Unilateral hypoglossal nerve palsy is a rare clinical entity due to the hypopituitarism after traumatic brain injury, which is not related to severity
lesions of the nerve in one of its segments (medullar, cisternal, of the base of of injury. From medicolegal point these observations might be significant
the skull, carotid, sublingual). A Caucasian male who, during a struggle, both for criminal and civil cases.
received severe stab wounds to his head from a screwdriver resulting in Posttraumatic, Hypopituitarism, Medico-Legal
hemorrhage of the perimesencephalic cistern and the frontal portion of the
left cerebral ventricle. He was operated on to empty the cisternal hemorrage.
He had a normal postoperative course but showed considerable deglutition’s
incapacity and dysarthria. A few months after surgery, the man died while G29 Massive Fat Pulmonary Embolization
eating secondary to asphyxia due to sudden obstructive lingual palsy;
authopsy showed a hemorrhagic dissection of the hypoglossal nerve on his Secondary to a Liposuction Procedure
bulbar brainstem. This case report appears to be unique because the unilat- With Tumescent Technique Diagnosed
eral hypoglossal nerve palsy is not resulting from postoperative pneumo- Postmortem in an Embalmed and
cephalus (most frequently reported in literature), but rather from progressive
axonal dissection just distal to its bulbar origin, caused by a cisternal Buried Body
hematoma resulting from cranial trauma. The resulting ipsilateral tongue
palsy caused dysarthria and deglutition incapacity and occlusion of the Jose A. Garza-Leal, MD*, Alberto Montemayor-Martinez, MD*, and
proximal third of larynx by alimentary bolus. Incoordination of the muscles Magadalena Gomez*, Medfor-Lab S.A. DE C.V., Cholula 106, Colonia
innervated by the hypoglossal nerve resulted in fatal acute asphyxia. Mitras Centro, Monterrey, 64460, MEXICO
Stab Wound, Isolated Hypoglassal Nerve Palsy, Sudden Death After attending this presentation, attendees will understand that all
deaths occurred during whatever medical surgical procedure where death is
not expected should undergo a medico-legal autopsy and how to avoid
G28 Medico-Legal Importance of problems and complications produced by previously embalmed and buried
bodies with marked external and internal postmortem changes that obscure
Posttraumatic Hypopituitarism the true cause and manner of death. Attendees will additionally understand
that, though an autopsy initially was not performed, a thorough, methodical
Vladimir Zivkovic, MD, MSc, Djordje Alempijevic, MD, PhD, Slobodan postmortem investigation may be able to find the true cause and manner of
Savic, MD, PhD*, Ivanka Baralic, Dragan Jecmenica, MD, PhD, and death in many cases.
Branimir Aleksandric, University of Belgrade, School of Medicine Institute This presentation will impact the forensic community by serving as a
of Forensic Sciences, Faculty of Medicine, 31a Deligradska Street, Bel- methodical parameter in the evaluation and investigation of cases where the
grade, 11000, SERBIA AND MONTENEGRO; and Vera Popovic, PhD, In- deceased was previously embalmed and buried without an autopsy initially
stitute of Endocrinology, Clinical Centre of Serbia, Dr. Subotic Street 13, being performed.
Belgrade, , SERBIA AND MONTENEGRO A case of massive fat pulmonary embolization diagnosed 80 days post-
The goal of this presentation is to inform the public of existance of hy- mortem in a previously embalmed and buried body of a 32-year-old woman
popituitarism after traumatic brain injury and possible significance for both who underwent an elective liposuction plastic surgery with tumescent
criminal and civil cases. technique is presented. The patient received a pre-surgical medical and
This presentation will impact the forensic community by demonstrating laboratory evaluation by a cardiologist who considered that the patient was
how some form of hypopituitarism occurs in 35% of patients with moderate healthy enough for the elective surgery. General anesthesia was adminis-
to severe head injury. tered and the liposuction procedure was performed without complications;
Recent studies have demonstrated that different forms of hypopitu- however, at the end of the surgery the patient developed sudden cardiac
itarism are common among survivors of traumatic brain injury (TBI) tested arrest. Cardiopulmonary resuscitative measures were done with no response;
several months or years following trauma. simple chest x-rays were performed and showed suggestive changes of a
The results of endocrine evaluation in a group of 109 patients (68 male thromboembolic pulmonary process. The patient was declared dead and the
and 41 female, mean age 37.9±1.4 yrs.; body mass index (BMI) 24.8±0.5 surgeon erroneously signed the death certificate with the cause of death was
kg/m2) who had suffered moderate to severe TBI (Glasgow Coma Scale ≤13), a cardio-respiratory arrest. The body was embalmed with formaldehyde and
at least one year prior to the assessment (mean 3.4±0.5 yrs) are presented. buried the next day with no performance of an autopsy. The plastic surgeon
After fasting overnight, at 08:00, serum samples were taken for T4, TSH, was sued for medical malpractice and the body was exhumed and autopsied
FSH, LH, tesosterone (men), cortisol, and prolactin. GH/IGF-1 axis was 80 days later as evidence. In spite of the deceased being embalmed and
evaluated by a provocative GHRH+GHRP-6 test and IGF-1 measurement, buried previously with marked external and internal postmortem changes,
and results were compared with those from 85 healthy control subjects (59 the macro micro pathological findings correlated well with clinical
male and 26 female, mean age 36.5±1.4 yrs, BMI 24.2±0.4 kg/m2). symptoms, radiological changes, and toxicological studies and revealed that
Three groups of TBI patients were formed based on the established the cause of death was a massive pulmonary fat embolization, an inherent
normal peak GH cut-off (>20 mg/L) and cut-off for severe GH deficiency risk of the surgical procedure.
(<10 mg/L). These groups are defined as severe GH deficient (GHD, n=16, Pulmonary Fat Embolism, Fat Embolism, Liposuction

G30 Lethal Inhalation of Isomers stances need further investigations in toxicological and pathological fields.
of Butylene: A Case Report Isomers of Butylene, Lethal Inhalation, Toxicology
Giovanni Cecchetto, MD*, and Guido Viel, MD, University of Padua, Via
Falloppio 50, Padova, 35121, ITALY; and Attilio Cecchetto, PhD, Istituto
Anatomia Patologica, Via Gabelli 61, Padova, 35121, ITALY; Claudio Ter- G31 Lethal Neglect: A Case of Extreme
ranova, University of Padova, Section of Legal Medicine, via Falloppio Intrafamilial Child Torture
n.50, Padova, 35121, ITALY; and Massimo Montisci, PhD, and Santo Da-
vide Ferrara, PhD, University of Padua, Section of Legal Medicine and Biagio Solarino, MD*, University of Bari, Sezione di Medicina Legale,
Forensic Toxicology, Via Falloppio 50, Padua, 35121, ITALY Piazza Giulio Cesare,11, Bari, 70100, ITALY; Vito Romano, MD, U.O.C.
The goal of this presentation is to clarify the pathophysiology of buty- di Medicina Legale - Ospedale “Miulli”, Acquaviva delle Fonti, (Bari),
lene induced damage in humans by means of histological, histochemical and 70021, ITALY; Giuseppe Troccoli, MD, University of Bari, Department of
immunohistochemical investigation. Criminology and, Forensic Psychiatry, Largo Giordano Bruno 65, Bari,
This presentation will impact the forensic community by serving as an 70121, ITALY; Ignazio Grattagliano, PsyD, and Roberto Catanesi, MD,
educational resource on the pathophysiology and dangers of inhaling buty- University of Bari, Section of Forensic Psychiatry, Piazza Giulio Cesare,
lene isomers Bari, 70125, ITALY
There has been a steady increase in the number of deaths resulting from After attending this presentation, attendees will have an understanding
inhalation of volatile substances, which can be a suicide or an unintended of some peculiar aspects of intrafamilial child neglect ending in death from
consequence of “sniffing abuse”. Intentional inhalation of a volatile sub- starvation.
stance indeed is an under-recognized form of substance abuse in children This presentation will impact the forensic community by providing
and adolescents with a high morbidity and mortality. forensic evaluation of lethal child neglect as a consequence of combining
Fatal outcome of inhalant abuse has been discussed due to several me- forms of malnutrition, maltreatments, and psychological abuse levied by
chanisms: suffocation, trauma after dangerous behaviour, vagal inhibition, re- parents.
spiratory depression and the “sudden-sniffing death syndrome” following Deliberate starvation of an infant/child is a severe and rare form of child
cardiac arrhythmia. However, the reason of sudden death related to volatile abuse, especially in industrialized countries. The goal of this presentation is
sniffing is rarely clear even after toxicological analysis. In most cases, re- to highlight the importance of forensic assessment in complex cases of child
ported aerosol propellants, n-propane or n-butane or mixtures of n-propane, homicide.
n-butane, and isobutane are involved. Child neglect can be defined as the failure of a caregiver to provide a
Sudden death due to the inhalation of butylene isomers has not yet been child with the necessities of life, including physical safety and protection,
described in forensic literature. food, hydration, clothing, shelter and medical care. Failure to fulfil these
There are four isomers of butylene (α-butylene, cis-β-butylene, trans- responsibilities may constitute active or passive neglect. Forensic investiga-
β-butylene, isobutylene), which are all gases at room temperature and pres- tion of lethal child neglect requires complete autopsy findings, full investi-
sure, but can be liquefied by lowering the temperature or raising the pressure gation of scene and case history, past medical records, family history, and
on them, in a manner similar to pressurized butane. These gases are colour- social background.
less, but do have distinct odours, and are highly flammable. Although not na- This presentation reports a case concerning a female infant aged 16
turally present in petroleum in high percentages, they can be produced from months who was brought to the Emergency Department where physicians
petrochemicals or by catalytic cracking of petroleum. There are few reports established she was already dead. They noted the child cachectic state and
on the toxicology of this compounds in animals and humans; it is not clear multiple bruises over the whole body. The child’s mother stated she had not
if isomers of butylene can produce direct damage on lung endothelial cells been eating well in the last week.
or myocardial tissue like butane does, or if the injury is mediated by other me- Autopsy showed the child weighed 5700 grams (12.6 pounds) for a
chanisms. length of 76 cm (29.9 inches); she was severely dehydrated with the muscles
A 20-year-old male was found dead in his jail cell where a plastic bag of head, face, trunk, lower and upper extremities flaccid, redundant, wrinkled
and a portable cooking stove were present. skin, and resultant prominent bones. The orbital adipose tissue was essen-
Forensic autopsy revealed cerebral edema, hemorrhagic edema of the tially absent leaving sunken appearing eyes. Examination of the head
lungs, and acute congestion of all inner organs. Histology (E&E) confirmed revealed multiple abrasions and ecchymoses at varying healing stages and
autopsy’s results. focal alopecia.
Toxicological analysis on the cooking stove gas and on biological spe- Multiple cutting stab wounds were present on the left auricle and on
cimens (blood and tissues) were performed. The cooking stove gas was for- the neck. There were bruises located on the chest and on the upper extrem-
med by α-butylene (71%), cis-β-butylene (17%) and trans-β-butylene (12%). ities; radiographic examination revealed fracture of left forearm overlaying
Lormetazepam (85 ng/ml), GHB (800 ng/ml) and isomers of butylene (α- an old arm contusion. Decubitus ulcers were located on the lumbar area and
butylene = 550 ng/ml; cis-β-butylene = 130 ng/ml; trans-β-butylene = 270 pelvis.
ng/ml) were determined in blood samples collected during autopsy. The thymus had atrophied. The stomach and large intestine were empty
The histochemical (Van Gieson and Azan Mallory) and immunohisto- and exhibited some ulcerative lesions; there was a very little stool in the
chemical (myoglobin, actin, and desmin) investigations on myocardial sam- rectum. The weights of most of the child’s organs were markedly less than
ples showed interstitial fibrosis with acute necrosis and myocardial normal averages.
contraction bands. Microscopic findings showed acute bronchopneumonia, hepatic fibrosis
The immunohistochemical examination (CD-34 and VIII factor) on and no glycogen in the liver on PAS (para-amino-salicylic acid) stain.
lung specimens did not reveal endothelial damage. The child lived in a reconstituted family. The mother had two children
These results suggest an acute electrical myocardial death due to adre- from the first marriage and another one from the present husband. The victim
nergic overdrive as a pathophysiologic mechanism of butylene induced sud- was conceived during a brief affair between the mother and a man who left
den death. her soon after she got pregnant.
To the authors knowledge, this is the first case study of sudden death The other children were healthy and well nourished.
due to the inhalation of isomers of butylene described in literature. The lack Home inspection revealed the victim spent all day sitting in a stroller
of knowledge of the exact biological effects of this compounds and the steady located in the parents’ bedroom and placed in front of the wall.
increase in the number of deaths resulting from inhalation of volatile sub- The parents confessed they fed her intermittently with water and sugar,
small portions of milk occasionally adding breadcrumbs. Sometimes she history to explain the injuries. In two cases no one knew what had happened,
ate leftover food from the other children. When the victim cried because she and in one other misinformation provided two histories. Most (sixteen) of
was hungry, the “caregivers” would beat her or throw objects (biberon, toys, the accidental head injury deaths had one adequate history. In three others a
etc.) from their bed at her head. The parents pled guilty and received life second history was needed to conclude that the explanation was adequate.
sentence. All eight drownings had one adequate history.
In cases of malnutrition/starvation, only a complete forensic investiga- Only two of forty-one natural deaths had even one trauma history. One
tion may reveal that the caregivers history of the child not eating well for a child with a medulloblastoma had fallen off the couch a week prior to his
few days, is hiding a case of extreme intrafamilial child abuse. collapse. The other child suffered a spontaneous subarachnoid hemorrhage
Starvation, Child Abuse, Parental Rejection and hit her head when she collapsed.
In this group, 31/76 (40.8%) with non-accidental deaths had two or
more histories. For accidental and natural deaths (omitting the ten undeter-
mined deaths), 4/83 (4.8%) had more than one trauma history. In a 2x2 table
G32 Multiple Histories: A Statistically more than one history had a sensitivity of 40.8% for non-accidental injury
Significant Indicator of Non-Accidental deaths. The specificity of fewer than two histories and accidental or natural
Injury in Children disease was 95.2%. The predictive value of non-accidental injury when many
histories were provided was 88.6%. The predictive value of finding acci-
M.G.F. Gilliland, MD*, Brody School of Medicine at ECU, Pathology & dental or natural disease when fewer than two histories were provided was
Lab Medicine, Brody Building, Greenville, NC 27858-4354 64.8%. A Yates corrected Chi square is 23 with a P value of <<0.01 and odds
ratio of 0.11 (with confidence interval of 0.04-0.58) for non-accidental
After attending this presentation, attendees will be able to describe injuries being found when fewer than two histories are provided by the
circumstances under which multiple histories are provided by caregivers and caregiver.
describe the validity of using multiple histories as a marker of non-accidental
Non-Accidental Injury, Multiple Histories, Child Abuse
injuries in children.
allowing forensic scientists to have a scientific basis for the use of multiple
histories as a marker of non-accidental injuries in children.
Forensic pathologists are increasingly being asked to state the bases for G33 Recognizing Classic Metaphyseal Lesions
conclusions. How do we know that multiple histories are a marker of non- in Child Abuse: An Autopsy Technique
accidental injury in children? The early descriptive studies have shown that
many shifting histories are associated with the “Battered Baby” syndrome, Jennifer C. Love, PhD*, and Luis A. Sanchez, MD, Harris County, Medi-
recently described as non-accidental or inflicted injuries in children. In cal Examiner’s Office, 1885 Old Spanish Trail, Houston, TX 77054
individual cases, more than one history provided by the caregiver is excused
as the result of a caregiver feeling “upset” at the child’s injury and death, or The educational objectives of this presentation are to review the diffi-
simply a matter of providing an initially incomplete history. The usefulness culties associated with recognizing classic metaphyseal lesions in infants and
of considering the number of caregiver histories in a variety of causes of to present a new autopsy technique which enables the visualization and do-
death can be assessed by reviewing a group of child death investigations. cumentation of these fractures.
Examining the causes and manners of death, and the number of trauma This presentation will impact the forensic community by introducing a
histories for a group of 169 child deaths provides additional support for new autopsy technique developed to improve the recognition and documen-
suspicion raised by multiple histories. Cause and manner of death and the tation of injury pattern in child abuse.
number of trauma histories was gathered as part of investigations of a group Complete recognition and documentation of injury pattern is key in the
of 169 randomly selected child deaths examined over a seven year period. diagnosis of child abuse. Classic metaphyseal lesions (CML) in infants are
The child deaths occurred as the result of non-accidental injury as well as highly suggestive of child abuse but difficult to recognize. A CML is a pla-
motor vehicle collisions, falls, drownings, various asphyxial deaths, and nar fracture through the most immature portion of the metaphyseal primary
natural diseases. Non-accidental injury was distinguished from accidental spongiosa. It may occur as a partial or complete fracture and results in the
injury, undetermined causes, and natural disease by investigation of medical epiphyseal cap separating from the metaphysis. In infants the primary spon-
and social history, and circumstances surrounding collapse as well as autopsy giosa or newly formed trabecular bone at the chondro-osseous junction (COJ)
findings. is the weakest point of the long bone. The rapid rate at which the growing
The causes of death included: 11 asphyxias (6.5%), 13 central nervous bone lengthens generates relatively thin and weak metaphyseal trabeculae.
system diseases (7.7%), 80 head injuries (47.3%), 8 drownings (4.7%), 3 With age the growth rate decreases and the metaphyseal trabeculae become
heart diseases (1.8%), 5 infections (3.0%), 2 other disease deaths (one each: thicker and stronger. CML is typically the result of torsional and tractional
volvulus and dehydration, 1.2%), 11 respiratory diseases (6.5%), 13 Sudden forces applied in a direction perpendicular to the long axis of the bone as an
Infant Death Syndrome (7.7%), 13 blunt force injuries of trunk (7.7%), and infant is pulled or twisted by a limb, also by the acceleration and decelera-
10 undetermined (5.9%). tion as an infant is shaken (Kleinman 1998).
Only two of the asphyxial deaths were non-accidental injuries and in A CML is difficult to recognize both in radiographs and at autopsy. Ra-
both, one trauma history was provided. In one it was a confession, the other diographically, a CML may appear as a radiolucency in the sub-physeal re-
was unrelated to the cause of death. Most of the head injury deaths, 61, were gion of the metaphysis. However, it may not be visible in all views or if the
non-accidental. In 11, no history was provided. One and two histories were trabecular disruption is insufficient (Kleinman 1998). Crawford and
given in 21 and 22 cases respectively. “Multiple histories” (more than two) Al-Sayyad (2003) note that most distal tibia metaphyseal fractures are dia-
were found in seven death investigations: four cases had three histories, two gnosed as ankle sprains or strains on initial radiographs because no definite
cases had four histories, and one case had five. The 2nd through 5th histo- fracture can be identified. Furthermore, CML rarely causes hemorrhage at
ries were closer approximations of mechanisms of sufficient magnitude to the fracture site or in the surrounding tissue. Subperiosteal new bone for-
produce the injuries found at autopsy. All of the trunk injury deaths were mation is not prominent at a healing fracture site. Histologically, a CML ap-
non-accidental. Five cases had no trauma history, six cases had one trauma pears as a series of microfractures at the mineralized regions of the distal
history which was usually inadequate to account for the injuries found, but zone of hypertrophic chondrocytes of the physis and a thin portion of the
only two provided a second history. metaphyseal primary spongiosa, a difficult section to read (Kleinman 1998).
Most (six) of the nine accidental asphyxial deaths had one adequate In the healing bone, the CML may appear with chondrocytes deeper than

expected within the primary spongiosa or as a broad region of thickened hy- missense mutation, I1837T. In testing the KCNE 1&2 genes, we found that
pertrophic zone (Kleinman 1998). two cases carried two different known mutations, D85N (in KCNE1) and
As a result of the difficulty to recognize a CML, a new autopsy techni- Q9E (in KCNE2). These two mutations previously have been shown to be
que has been developed. The first step is to expose and visually examine associated with acquired Long QT syndrome. In testing the RyR2 gene, the
the COJ of the long bones by cutting the muscle from the long bone ends and authors found that one case carried an unknown, but likely pathogenic mis-
reflecting the periosteum. An acute CML appears as either an open fracture sense mutation, G4471R. Genetic testing for KCNQ1 gene is still in pro-
or a slight line of hemorrhage. A healing fracture may appear as an oddly gress. All of the mutations identified in this study are heterozygous.
shaped COJ. When a fracture is suspected but not obvious, the end of the Collectively, the pathogenic mutation rate is about 28% (12/42). Specifi-
long bone is removed and processed by soaking it in a water soap bath at a cally, the mutation rate is most frequent in SCN5A gene 21% (9/42), while
steady but elevated temperature (~60C) for 24 hours. The result is a me- the mutation rates in other genes are less common.
taphysis without the epiphyseal cartilage or periosteum. Partial and com- This study highlights the importance of implementing molecular gene-
plete CMLs are completely visible grossly. This technique is far more tic testing for the channelopathy genes in routine SIDS/SUDS investigations
invasive and time intensive than standard flaying of the dermis but yields to assist medical examiners in the determination of cause and manner of
excellent results and eliminates any question about the presence of a CML. death.
This technique is recommended for all infant deaths in which a non-acci- * SIDS is defined as the sudden death of an infant under one year of age,
dental traumatic cause of death is suspected. which remains unexplained after a thorough investigation, including perfor-
Classic Metaphyseal Fractures, Child Abuse, Autopsy Techniques mance of a complete autopsy, examination of the death scene, and review of
the clinical history.
* SUDS is the sudden death of an individual over one year of age and
like SIDS, the death remains unexplained after a thorough case investiga-
G34 Comprehensive Molecular Genetic Testing tion, which includes performance of a complete autopsy, examination of the
for the Cardiac Channelopathy Genes in death scene, and review of the clinical history.
42 Cases of Sudden Infant Death and Molecular Genetic Testing, Channelopathy, SIDS/SUDS
Sudden Unexplained Death in the City of
New York Revealed High Mutation Rate
Yingying Tang, MD, PhD*, Erik T. Bieschke, MS, Erin Labitzke, Jennifer
G35 Primitive Neuroectodermal Tumor (PNET)
D’Andrea, MSFS, Stacey Sainte-Marie, MSFS, Dawei Wang, Jean Jeudy, Masquerading as Non Accidental Head
Yoonhee A. Kim, Stephanie Pack, Lucy En, Barbara A. Sampson, and Me- Trauma in an Infant: Lessons for Multiple
chthild K. Prinz, PhD, Office of Chief Medical Examiner, Department of
Forensic Biology, 421 East 26th Street, New York, NY 10016
Disciplines
The goal of this presentation is to investigate the mutation rate of the Michael J. Caplan, MD, and Kelly Rose, MD*, Medical University of
channelopathy genes in the SIDS/SUDS population. South Carolina, Department of Pathology and Laboratory Medicine, 165
This presentation will impact the forensic science community by high- Ashley Avenue, Suite 309, PO Box 250908, Charleston, SC 29425
lighting the importance of implementing molecular genetic testing for the
channelopathy genes in routine SIDS/SUDS investigations to assist medical After attending this presentation, attendees will understand the process
examiners in the determination of cause and manner of death. of evaluating intracranial pathology in an infant and how to identify sponta-
Sudden infant death syndrome (SIDS)* and sudden unexplained death neous as well as traumatic causes of intracranial hemorrhage, specifically, he-
syndrome (SUDS)* are vexing challenges in the field of Forensic Pathology. morrhage resulting from a supratentorial primitive neuroectodermal tumor.
SIDS and SUDS are recognized as complex and multifactorial, requiring in- The ability to discriminate not only between nonaccidental and acci-
teraction between genetic and acquired risk factors during sensitive deve- dental head trauma, but also between spontaneous and traumatic etiologies
lopmental stages or growth phases. It has been reported that 2-5% of of intracranial hemorrhage, while keeping an open mind to all of the possi-
apparent SIDS/SUDS cases are in fact due to a group of cardiac arrhythmia bilities during the descision-making process, is among the most challenging
syndromes, collectively called channelopathies, where at least eight causa- of intellectual tasks that confront the froensic pathologist.
tive genes are known. Since the channelopathies affect the cardiac electric The appropriate recognition and accurate documentation of fatal no-
conduction system and cause arrhythmias, the diseases leave no structurally naccidental craniocerebral trauma in infants and young children are among
demonstrable autopsy findings. Currently, the only available means to allow the most important contributions to be made by a forensic pathologist.
postmortem diagnosis of channelopathies is through the use of molecular Equally crucial, however, is the ability to identify both accidental causes of
genetic testing to detect mutations in the causative genes. head trauma and spontaneous (nontraumatic) etiologies of intracranial patho-
In order to investigate the mutation rate of the channelopathy genes in logy.
the SIDS/SUDS population, our laboratory has validated methodologies in A rare cause of spontaneous intracerebral, subarachnoid, and subdural
genetic mutation analysis. Presented in this study is a comprehensive muta- hemorrhage in a 3-month-old child resulted from a supratentorial primitive
tional analysis of multiple channelopathy genes: a cardiac sodium channel neuroectodermal tumor (PNET) with glial differentiation, emphasizing that
gene, SCN5A; three cardiac potassium channel genes, KCNE1, KCNE2, and not all forms of intracranial pathology are inflicted, or even traumatic.
KCNQ1; and a cardiac ryanodine receptor gene, RyR2. The study population Furthermore, because the various interpretations of the imaging studies crea-
consisted of 42 cases with the cause of death certified as “SIDS” or “unde- ted significant controversy and disagreement regarding the assessment of the
termined” by the New York City Office of Chief Medical Examiner. The disease process findings, the potential problems that exist with neuroradio-
methods utilized were designed to be highly sensitive, specific, reproducible, logic interpretations of lesions in this age group are emphasized.
cost-effective and high throughput. This was accomplished using DNA- An 11-week-old male infant presented to the MUSC Pediatric Emer-
based PCR and cycle sequencing analysis to detect any nucleotide changes gency Department (ED) with a 2-day-long history of lethargy, decreased oral
in the protein coding region. Heart, liver and spleen samples were used. intake and urine output, and favoring of the left side of his face. His mother
In testing the SCN5A gene, five cases carried a known pathogenic mis- stated that his left eye had appeared “abnormal” for the past few weeks. In
sense mutation, S1103Y; one case carried a known pathogenic missense mu- the ED, he was found to have a bulging fontanelle and a fixed and dilated left
tation L619F; two cases carried an unknown, but likely pathogenic missense pupil with a minimally reactive right pupil. Of note, prenatal history was
mutation, P656L; and one case carried an unknown, but likely pathogenic unremarkable; he was born at 39 weeks gestation with 1- and 5-minute Apgar

scores of 9 and 9. He had been essentially healthy up to his current presen- nal). Finally, in order not to have only suspicion on some genetic disorder
tation. A head CT scan demonstrated obstructive hydrocephalus and tran- such as Williams syndrome, but to confirm it with the highest certainty, it is
stentorial herniation, prompting admission to the Pediatric Intensive Care necessary to assign the task to develop genetic tests like FISH.
Unit (PICU) with ventriculostomy placement for elevated intracranial pres- Sudden and unexpected death is one of the frequent problems in com-
sure (ICP). However, he succumbed to refractory intracranial hypertension mon medicolegal practice, which attracts special attention when it pertains
and was declared clinically brain dead on the 7th hospital day. Reports from young and previously apparently healthy individuals. One of the potential
imaging studies were notably discordant, with one interpreting the findings causes of such death could rarely be Williams syndrome (WS) due to speci-
as “multiple trauma of varying ages”, the other as a “mass”. Autopsy re- fic cardiovascular abnormalities. This syndrome was initially described by
vealed an extensively necrotic and hemorrhagic, supratentorial mass with Williams et al. in 1961, and Beuren et al. explained the phenotype. WS is a
resultant swelling, softening, and hemorrhage of the adjacent brain paren- sporadic genetic syndrome, with an estimated incidence of 1 in 20.000 live
chyma bilateral thin-layered subdural hemorrhages accompanied by thin- births, caused by a deletion of elastin gene and other contiguous genes at ch-
layered subarachnoid hemorrhage, both overlying the cerebral convexities; romosome 7, with variable phenotypic expression, associated with dy-
subgaleal edema and hemorrhage confined to the ventriculostomy site; and smorphic facies, neurological manifestations, idiopathic hypercalcemia, and
anasarca with bilateral serous pleural effusions (15 mL each), and serous cardiovascular features, particularly supravalvular aortic stenosis. Namely,
ascites (30 mL). There were no other injuries. The eyes were not examined. more than 90% of the patients with WS exhibit a submicroscopic deletion
Microscopic examination of the subdural hemorrhage revealed predomi- spanning at least 114 kb, at 7q11.23. Hemizygosity of the elastin gene could
nantly red blood cells with rare fibroblasts, and sparse hemosiderin-laden account for all connective tissue, especially the vascular, abnormalities seen
macrophages, consistent with a recent origin (of ~6 days’ duration). Sec- in WS.
tions of the mass demonstrated sheets of spindled to epithelioid cells with The case concerns the 17-year-old boy who was playing with his
large, eccentric nuclei, punctate, “salt and pepper” chromatin, and inconspi- brother in the yard of their family house during wintertime, when he sud-
cuous nucleoli; some cells contained eosinophilic, smooth, “glassy” cyto- denly fell down to the snow and died shortly after. Hetero-anamnestically,
plasm. The mass was accompanied by scattered hematoidin pigment and his mother stated that in his childhood, the boy suffered from abdominal
extensive, confluent necrosis. There was no significant nuclear atypia or va- pains periodically, denying however, any illness diagnosed by the physicians.
scular endothelial proliferation. An immunohistochemical battery employing In addition, she mentioned his constant problems with learning and rela-
antibodies to glial fibrillary acid protein (GFAP), synaptophysin, chromo- tionship with his friends as well (slight mental retardation and nervousness).
granin A, vimentin, smooth muscle actin (SMA), pancytokeratin (AE1/AE3), Since the boy had not been medically examined, no other clinical data could
low-molecular weight cytokeratin (CM 5.2), CD99, and epithelial membrane be obtained. At the autopsy, external examination revealed elfin face with
antigen (EMA) showed the tumor cells to express only GFAP and none of the short and slightly upturned nose, long filtrum and very bad dental condition
other antigens. The collective histopathologic features and immunohisto- – black-greenish coloration of the crowns of the front teeth. There were no
chemical profile of the tumor were most compatible with a PNET manife- signs of mechanical injuries on the body. Internal examination showed se-
sting purely glial differentiation. vere narrowing (the circumference 4 cm) of the ascending aorta, some 4 cm
Sound critical thinking and an open mind on the part of the forensic above the semilunar valves (supravalvular aortic stenosis) with mild enlar-
pathologist when confronted with significant intracranial pathology in an in- gement of the heart, weighted 340 grams and significant thickening of the left
fant is of great importance. Although the impressions of the imaging studies ventricular myocardium, measured 2,3 cm. With exception of hypertrophy
and the presence of bilateral thin-layered subdural and subarachnoid he- of the myocardial fibers, the histological findings disclosed no pathological
morrhages appropriately raised the suspicion of inflicted) head trauma, the abnormalities in all other organs. Toxicological screening was negative. Pri-
identification of a reasonable underlying etiology for the hemorrhage, the marily based upon the internal findings along with case circumstances, in
absence of injuries to suggest a pattern of repeated abuse, and the mother’s the autopsy record it was inferred that death of the teenager was of natural
description of neurologic signs entirely consistent with increasing ICP col- manner, the most probably due to inherited cardiovascular abnormalities
lectively provided strong evidence of a nontraumatic etiology for this baby’s (narrowing of the aorta and hypertrophy of the left ventricular myocardium).
condition. Regardless the fact that the case had been solved concerning manner and
Primitive Neuroectodermal Tumor, Nonaccidental Head Trauma, In- cause of death, yet the forensic pathologists posed a question to themselves
fants and Children – what might be the origin of such peculiar combination of external and in-
ternal autopsy findings. The attention was focused on his specific facial ap-
pearance together with the cardiovascular status and obtained
heteroanamnestic data, which raised a suspicion on Williams syndrome.
G36 Sudden Death of a 17-Year-Old Boy Since WS is a genetic disorder, besides the above mentioned clinical
manifesations and morphological findings, for definite diagnosis it is neces-
Due to Suspected Williams Syndrome - sary to perform specific genetic analysis - the FISH test, which is a type of
A Case Report specialized chromosome analysis utilizing specially prepared elastin probes.
Unfortunately, at the moment, neither the Institute of Forensic Medicine in
Stojan Petkovic, MD*, Clinical Center Vojvodina, Institute of Novi Sad, nor that in Belgrade is equipped for such test.
Forensic Medicine, Hajduk Veljkova 5, Novi Sad, 21000, SERBIA A Williams Syndrome, Sudden Death, FISH Test
ND MONTENEGRO; Slobodan Savic, MD, PhD, University of
Belgrade, School of Medicine, Institute of Forensic Medicine, Deligradska
31a, Belgrade, 11000, SERBIA AND MONTENEGRO;
and Milan Simic, MD, PhD, Clinical Center Vojvodina, Institute of Foren-
sic Medicine, Hajduk Veljkova 5, Novi Sad, 21000, SERBIA
AND MONTENEGRO
After attending this presentation attendees will be well acquainted with
the external and internal findings/characteristics of the rare genetic syndrome
– Williams syndrome which can cause sudden death in young population.
The presentation will impact the forensic community by the fact that
every case of sudden death must be scrutinized carefully both by reveling all
the circumstances of the case with collecting relevant heteroanamnestic data
and need to perform thorough examination of the body (external and inter-
G37 Sudden Cardiac Death in Professional On 3 September 2006 at 5 p.m., a car was discovered in a parking iso-
lated area in the outskirts of Foggia, Italy, far from urban traffic. A dead man
Sports Persons: Natural vs. Anabolic was seated in the driving seat, he had seatbelt fastened, and he lay down on
Steroid Induced Lesions, and Experimental the right hip. The deceased, a young adult man, was fully and tidily dressed,
Rabbit Model and was identified as a 29-year-old local resident. The car engine was turned
off. The car keys were in the ignition in the “off” position, the windows were
Laurent Fanton, MD, Alain Tabib, MD, Stéphane Tilhet-Coartet, MD, closed and the doors were locked from the inside: no damage was observed
Maire Joly, and Daniel Malicier, MD*, Institut Medico Legal, 12 Avenue inside or outside the car. On the floor of the car near the anterior right seat,
Rockfeller, Lyon, 69007, FRANCE there were five empty small packages; a cigarette filter; a syringe full of 1
milliliter of brownish liquid, its needle was smeared with dried blood.
The goal of this presentation is to report the anabolic steroid-induced Remote from the body, near his head, on the anterior right seat, there were a
cardiac lesions in professional sports-persons and in experimental study small metallic spoon, a needle plastic cap, and two other plastic packages
(rabbit model). full of white power. The thanatological data recorded by the forensic pathol-
This presentation will impact the forensic science community by ogist called to the scene (5:30 p.m. of 3 September 2006) stated that at the
demonstrating how controlling or banning doping in professional sports time of discovery, the cadaver showed rigor mortis, and hypostasis that was
being unfeasible in the present state of affairs, however, associating apoptosis partly mobile on digital pressure, but congruous with the position.
inhibitors might hold out hope of limiting the incidence of severe evolutive At the external examination, the left arm showed a round atrophic scar
cardiac lesions. and left forearm an healing ischemic ulcer. The right antecubital fossa had
Anabolic steroid-induced cardiac lesions in professional sport-persons pigmented pop-scars and swelling of the soft tissue with a necrotic area and
are compared with a rabbit model. Out of 15,000 forensic autopsies two needle punctures; the upper one was surrounded by an extensive
performed on coroner’s orders over a 24-year period (Jan 1981-Dec 2003) ecchymosis, the entire area measured cm 7x5.5.
in the area of Lyon, France (population: 2,000,000), WHO criteria identified A complete autopsy was performed 48 h after death. Internal exami-
2,250 cases of unexpected sudden cardiac death. Among these, 120 were nation revealed that the heart weighed 450 g, measured 14x13.5x5cm. The
found to have occurred during recreational sport and 12 in professional sports coronary arteries, the myocardium and the valvular apparatus were normal.
persons. In the latter category, the associated cardiac lesions were primitive: All the other organs did not show specific alterations except for an intense
natural in 6 cases, and, according to inquest findings, induced by anabolic vascular congestion.
steroids in the other 6. To shed light on the induced lesions, animal Routine histological investigations, applying hematoxilin and eosin
experiments were performed, administering Norethandrolone to rabbits staining, were performed on all organ samples. Lung sections showed
which were then sacrificed and subjected to pathologic examination and massive pulmonary oedema. Myocardium presented foci of fragmentation
caspase-3 assay by fluorometry on cardiac fragments. of entire myocytes in anomalous cross bands formed by segments of hyper-
The natural primitive lesions were classical for such cases. The contracted sarcomeres and myofibrillar rhexis. The histological examination
anabolic steroid-induced lesions comprised coronary thrombosis associated of the skin section, collected in right cubital fossa, showed a loss of the upper
with left ventricle hypertrophy and lesions analogous to toxic or adrenergic epidermal layers and accumulation of leukocytes, in particular polymor-
myocarditis. The same lesions were found, to varying degrees, in the rabbit phonuclear neutrophils, and erythrocytes in deeper epidermal and dermal
models, which showed significantly elevated Caspase-3 activity as compared layers. All these skin findings suggested for typical necrotizing ulcers. The
to controls. Anabolic steroids would seem, to varying degrees, to induce examination of other organs was unremarkable except for brain edema and
lesions analogous to those found in myocardiopathy and toxic myocarditis. generalized haemostasis.
Their elevated Caspase-3 activity makes these lesions apoptotic in nature. Cocaine was detected in the subject’s urine through immunoenzymatic
Doping, Cardiac Lesions, Apoptosis screening. Toxicological analysis by solid–liquid extraction and gas
chromatography–mass spectrometry (GC–MS), was carried out to identify
and quantify the individual substances present in the biological fluids and
organs. Total cocaine concentrations were as follows: blood 4.08 mcg/mL/g,
liver 10.19 mcg/mL/g, brain 6.19 mcg/mL/g, urine 57.00 mcg/mL/g, and
bile 17.72 mcg/mL/g. No other drugs or alcohol were detected.
The toxicological analysis of empty and full packages demonstrated
G38 Cocaine Skin Popping: A Fatal Case that the white power was cocaine and quinine (used as an adulterant), and the
brownish liquid in the syringe, collected in the car, was positive only for
cocaine. According to the crime scene data, autopsy and histological and
Margherita Neri, MD*, and Carmela Fiore, MD, University of Foggia,
toxicological findings, death was attributed to a fatal arrhythmia during
Department of Forensic Pathology, Viale Pinto 1, Foggia, 71100, ITALY
cocaine skin inoculation.
The death of a “skin popper” cocaine abuser is presented. Postmortem In cocaine skin inoculation, cutaneous necrosis and necrotizing ulcers
findings and cocaine distribution in fluids and tissues are discussed. The may develop as a result of several combined factors, including “skin
goal of this paper is to show an unusual fatal case of cocaine consumption. popping”, toxicity and the irritant properties of the drug and adulterants,
This presentation will impact the forensic community in the contribu- vascular thrombosis, and infection. Quinine used as an adulterant has known
tion of a careful crime scene investigation, toxicological and histological caustic effects. In addition cocaine has potent vasoconstrictive and throm-
examinations in drug-related death in order to clarify the exact mechanism botic effects. Various mechanisms such as cocaine-related increase in plasma
of the death. lipids, direct and indirect increase in endothelial permeability, higher
The most common routes of cocaine abuse are by inhalation, snorting, prevalence of mast-cells and other inflammatory cells in plaques may
and intravenous injection. Cocaine skin inoculation is rare and it’s used to contribute to the lesions. Typical are round atrophic scars, clustered
ovoid track marks or when peripheral veins are sclerosed and the addict, predominantly on the arms and legs, frequently seen in intravenous drug
unable to access a peripheral vein, injects substance by mistake or deliber- abusers, particularly cocaine abusers. These may represent healed abscesses,
ately, in subcutaneous tissue and muscle. Deliberate subcutaneous injection healed ischemic ulcers due to vasoconstrictive effect of cocaine, or the direct
(skin popping) is also used to avoid track marks which represent stigmata of toxic effects on capillary endothelium.
drug addiction. Cocaine, Skin Popping, Necrotizing Ulcer

G39 Erroneous Diagnosis of Cadmium Poisoning G40 The Continued Role of Over the Counter
Based on Postmortem Toxicology Drugs in Drug Related Deaths
Karl E. Williams, MD, MPH*, Office of the Medical Examiner, Allegheny Anna C. Noller, PhD*, and Marcella F. Fierro, MD, Office of the Chief
County, 542 Fourth Avenue, Pittsburgh, PA 15219 Medical Examiner, 400 East Jackson Street, Richmond, VA 23219
The goal of this presentation is to investigate the interpretation of cad- After attending this presentation, attendees will better understand the
mium levels in postmortem blood specimens. epidemiological characteristics of over-the-counter (OTC) drug deaths.
This presentation will impact the forensic science community by de- This presentation will impact the forensic community and public health
montrating how the observed evaluation of elevated levels of cadmium in po- agencies by: (1) serving as a reminder of the continued dangers of the pu-
stmortem specimens may lead to an interpretation of accidental or intentional blicly-perceived safe OTC drugs, and (2) the epidemiological trends of who
poisoning for what is actually a poorly described artifact of cadmium phar- is most likely impacted by these drugs which may help in creating public
macokinetics. Lack of knowledge of this artifact can lead to various effects ran- health safety messages and prevention strategies.
ging from unnecessary exhumations to civil and criminal legal cases. All cases from 2001-2005 in which OTC drugs contributed to the de-
In 2004, county coroner (County A) in Pennsylvania ordered a heavy cedents’ deaths were analyzed. The OTC drugs, in order of prevalence, were
metal screen on an autopsy case to investigate a case of suspected poisoning. diphenhydramine, acetaminophen, dextromethorphan, chlor-pheniramine,
The only analyte that was abnormal was markedly elevated cadmium. Su- salicylate, ethylene glycol (not an OTC drug but included in analysis), ibu-
spicion of either accidental or intentional poisoning caused the coroner to profen, methanol, ephedrine, and naproxen. All 292 cases were investigated
order 26 additional postmortem heavy metal studies as well as an exhumation. by the Virginia Office of the Chief Medical Examiner (OCME). The data ex-
A comparative population study of cadmium levels was performed on a retracted from the OCME database included age, sex, race, manner of death,
presentative living population in the same community, along with a postmor- residency, and toxicological results. OTC deaths were categorized into 5
tem study of a similar autopsy population. These studies confirmed that the types: OTC alone, OTC with prescription drug(s), OTC with illicit drug(s),
observed elevations of cadmium were postmortem artifact. OTC with prescription and illicit drugs, and OTC with carbon monoxide.
The laboratory results of cadmium were compared for the following Virginia residents were analyzed separately to obtain rates.
study groups: (1) twenty seven (27) cases of postmortem cadmium analysis Considering all drug poisonings, males tend to shoulder the burden of
performed for the Coroner of County A as part of his investigation of possi- drug-related deaths with an overall ratio of 1.8 to 1 compared to females.
ble poisoning, (2) nine (9) analyses of a separate autopsy population in a For accidents the ratio is 2.4:1 for males to females. Males and females have
nearby county (County B) that has a similar demographics and incidence of a similar amount of suicides via drug poisonings (1:1.1). These trends change
possible industrial cadmium exposure, and (3) forty seven (47) analyses of when looking at the role of OTC drugs. The female/male ratio is 1.45:1 and
a living out-patient population at the major medical center in County A. this ratio stays very similar when examining both accidents and suicides.
The average measured cadmium values were as follows: Suicides accounted for 51.4% of the OTC deaths, accidents for 46.6%
• Coroner’s cases of County A - 110μg/L and undetermined for 2%. The combination of OTC with prescription drugs
• Coroner’s cases of County B - 66.6μg/L accounted for 66.8% of OTC deaths. Interestingly, OTC alone deaths were
• Control (Out patients County A) - 1.5μg/L almost 3 times higher in suicides than accidents while OTC with illicit or
Applying a t-test to these results reveals no significant difference OTC with prescription and illicit drugs were 5 and 4.2 times higher, respec-
between the two autopsy populations. The difference between the postmor- tively in accidents than in suicides. Ethanol involvement was found to con-
tem studies in County A and the living control population of the county is si- tribute to death in 16.1% of cases, in 50% of the OTC with illicit drug deaths
gnificant to a p-value of 0.003. and in 17.2% of the OTC alone deaths.
Cadmium is a well described human toxic agent. Almost one hundred Virginia residents accounted for 95.2% (N=278) of the OTC drug
years of research based on industrial exposures has allowed precise and ex- deaths. The rate of all OTC drug deaths is 7.5 per million Virginia residents
tensive knowledge of toxicology of the compound. Cadmium is associated with female rates of 8.9 per million compared to 6.1 for males. Whites car-
with renal and pulmonary toxicity and is considered to have carcinogenic ried the burden of these deaths with a rate of 9.1 per million, which was 3.4
effects. Chronic environmental exposure in Japan, in the 1950’s, led to the times that of blacks and 5.2 that of Asians. The highest burden of OTC deaths
development of itai-itai disease. Normal ranges for cadmium are from 0.3- was in the 35-34 and 45-54 age groups with almost 2 times the rate of any
1.2μg/L in non-smokers to 0.6-3.9μg/L in the smoking population. The 1991 other age group. Remarkably, the rate for the infant age group (<1 year old)
OSHA standard for cadmium defines a blood cadmium value of 5.0μg/L as was 4 per million.
an action limit for exposed workers. Despite its chronic toxicity, cases of While most of the OTC drugs were all found in accidents, suicides, and
acute poisoning due to cadmium are exceedingly rare and occur mostly in the undetermined cases, some OTCs were detected in a higher percentage of a
context of acute fume inhalation in industry or suicidal ingestions. Even in particular manner than the others. Acetaminophen (70.9%), salicylate
these cases measured blood cadmium levels rarely exceed 30μg/L. Thus all (77.8%) ethylene glycol (85.7%), and ibuprofen (88.9%) were found more
the evidence suggests that the observed, massive elevation of postmortem frequently in suicides than accidents. Additionally, women were 3 and 1.8
cadmium was an artifact. This has been described only once before in the times more likely to have used ibuprofen or acetaminophen, respectively
medical literature, in an environmental journal. It is mostly likely due to a than males as all or part of their suicidal drug poisoning. However, males
postmortem disassociation of cadmium from its in vivo transport protein me- were 3 times more likely to use ethylene glycol than women and also ac-
tallothionein. counted for all the suicides due to diphenhydramine, alone or in combination.
Forensic practice relies heavily on the interpretation of postmortem che- Chlorpheniramine (70.8% of all usage) and dextromethorphan (66.7%) were
mistry values for the determination of cause and manner of death. Although more frequently associated with accidents than suicides. Males were two
this can often be a straight forward process, it requires knowledge of nume- times more likely to accidentally use ephedrine than females.
rous artifacts. In the case at hand, an erroneous interpretation of these cad- In conclusion, OTC drugs continue to be a source of both accidental
mium values could have easily led to considerations of either intentional or and suicidal deaths. Women are at a higher risk than men of dying from
accidental poisonings. OTC drugs either alone or in combination with other drugs. Whites also
In this particular part of the country, cadmium is still used in industrial have a higher rate of using a lethal amount of OTC drugs than other races.
processes and the possibility of environmental contamination was conside- OTC Drugs, Drug Deaths, Virginia
red. A well controlled and efficient population study confirmed that the ob-
served values were a postmortem artifact.
Cadmiun, Artifact, Postmortem
G41 Exceptional Suicide by Sharp Force and depression, and toxicological analyses should be the rule in ‘unusual’
suicides especially in subjects with no known psychiatric history.
During Mefloquine Therapy: A Case
Mefloquine Psychosis, Suicide, Sharp Force
of Drug Induced Psychosis?
Clotilde G. Rougé-Maillart, MD*, and A. Tracqui, MD, Service de
Médecine Légale, CHU, 4 rue Larrey, Angers, 49000, FRANCE; A. Le
Bouil, MD, and A. Turcant, MD, Institut de Médecine Légale, Faculté de
G42 Determination of β — Phenylethylamine
Médecine, Strasbourg, France; and M. Penneau, MD, PhD, Service de Blood Levels in Carbon Monoxide
Médecine Légale, CHU, 4 rue Larrey, Angers, 49000, FRANCE Intoxicated-Related Fatalities
The goal of this presentation is to present a case report about a special
suicide. Wen-Ling Lin*, and Kai-Ping Shaw, MD, PhD*, Institute of Forensic Me-
This presentation will impact the forensic science community by dicine, Ministry of Justice, 166-1, Sect. 2, Keelung Road, Taipei (106),
assisting in the understanding of drug-induced psychosis. Taiwan, ROC
Suicide by stabbing to the head and/or driving sharp objects into the The goal of this presentation is to study the β-Phenylethylamine (PEA)
skull is of extreme rarity. This paper reports the case of a 27-year-old man, blood levels and its metabolic enzyme, an oxygen-dependent monoamine
who committed suicide by multiple knife stabs and cuts to the head, torso and oxidase B (MAOB), during the hypoxic status induced by carbon monoxide
upper limbs. intoxication cases with or without oxygen resuscitation.
A 27-year-old man was found dead at home, lying on his bed. Doors PEA, a specific substrate of MAOB, is a biogenic amine that acts as a
were locked from the inside, and there was no evidence of violence in the flat. sympathomimetic amine through its release of dopamine. The rate-limiting
The deceased was completely naked, with abundant bloodstains on the whole step of the MAOB activity of monoamine deamination is a highly oxygen-
body surface. The 10-cm long handle of a kitchen knife, also stained with dependent phenomenon. Carbon monoxide (CO) has a high affinity for
blood, was present near the corpse with the blade broken at ca. 1 cm from the hemoglobin that is about 200 times greater than oxygen. CO causes a
guard. The rest of the blade was apparently missing. According to cadav- decrease of the oxygen-carrying capacity of the blood and induces a hypoxic,
eric signs and police findings, death was likely to have occurred the day be- irreversible status even after re-inhalation of oxygen during resuscitation.
fore. Autopsy showed two superficial cuts at the lower, anterior part of the The hypothesis is that reduction of the activity of MAOB during the hypoxic
neck, two stab wounds in the right temple, one stab wound in the precordium status could cause an accumulation of PEA and may be associated with the
area, one cut at the top of right shoulder near the acromion, one cut at the an- duration of hypoxic and agonal status. Elevation of PEA blood levels in
terior side of right forearm, one deep complex cross-shaped incised wound asphyxia-related fatalities may be related and can be reversed after additional
at the anterior side of left forearm and wrist a perforating wound of the skull, oxygen resuscitation.
the 10-cm long broken blade of the knife being still embedded in the right A retrospective study consisting of 67 cases of carbon monoxide
temporal lobe of the brain. The deceased had no history of psychiatric illness poison-related fatalities and 121 control cases of CO-unrelated asphyxia and
but was currently treated by mefloquine, a quinine derivative associated with cardiogenic fatalities were collected from the Institute of Forensic Medicine,
a high rate of psychiatric side-effects. Toxicology confirmed a recent intake Ministry of Justice during a medicolegal investigation in Taiwan. Gas
of mefloquine together with chloroquine, another antimalarial drug. Chromatography/Mass Spectrometry was performed to determine the PEA
Acute psychiatric reactions, in particular depressive disorders, have concentrations of each victim’s blood. Carboxyhemoglobin (COHb) satu-
been reported as a side-effect of a wide array of medications, including non- ration was determined by Oximeter. Data are reported as mean ± standard
steroidal anti-inflammatory drugs, antihypertensive drugs, anticonvulsants, error mean (SEM). The statistical analyses were carried out with ANOVA
steroids, or antimalarials. Among this latter group, Mefloquine distinguishes by SPSS and p values of less than 0.05 were considered to be statistically
itself by a high prevalence of various psychiatric side-effects pointed out significant in this study.
during the early postmarketing period. In 1989, the World Health Organi- Base on COHb saturation levels, PEA blood levels of groups of COHb
zation commissioned an investigation that confirmed the existence of such 20-50%, 50-70%, and higher than 70% were 140.72±41.81 (n= 16),
complications, with a prevalence estimated at 4.2/1000 treatments. In 60% 107.34±25.63 (n= 26) and 66.36±18.03 (n= 25) ìg/ml, respectively. The PEA
of reported cases, disorders appeared after the first intake of mefloquine. blood levels of asphyxia cases (including strangulation and suffocation)
Serious complications were noticed only for curative treatments with doses recognized as non-CO intoxicated-related fatalities with and without
equal to or greater than 1000 mg. To the authors knowledge, this is the first resuscitation were 1.6 ± 0.4 ìg/ml (n= 11) and 31. 7 ± 6.3 ìg/ml (n= 48),
report of a completed suicide with very strong evidence of mefloquine respectively. The PEA blood levels of CO poison related fatalities with and
implication. In the present observation there is a very strong presumption without resuscitation were 64.75 ± 32.42 ìg/ml (n= 9) and 105.49 ± 17.47
that mefloquine was a causative, or at least contributive, factor in the victim’s ìg/ml (n= 58), respectively. The mean PEA concentrations in the blood of
suicide. This statement is supported by the extraordinary method used to strangulation and suffocation cases were 83 and 98 fold higher than those of
commit suicide, the absence of psychiatric history in the victim, whereas control values, respectively.
most suicides par sharp force to the head have been reported in mentally In comparison with medical rescue group with decreases in the PEA
disturbed patients and prison populations, the close temporal relationship levels of non-CO intoxicated fatalities during oxygen resuscitation, the CO
between suicide and mefloquine intake, as documented by the detection of intoxicated cases with and without resuscitation both have significant
the drug in postmortem samples. In the present observation a contributive elevations in the PEA level. These results reveal that the reversible MAOB
role of chloroquine coingestion is difficult to assess because psychiatric side- activity during oxygen resuscitation can be blocked by the CO saturation of
effects encountered with this drug are much more unfrequent than with hemoglobin. The high affinity between CO and hemoglobin molecules and
mefloquine. However it may be noteworthy that at least one severe reaction, the sequential blocking of the oxygenation of hemoglobin can elevat the
including paranoia, hallucinations and suicidal ideation, has been reported in blood PEA of CO-intoxicated cases without reactivation of the MAOB
a subject without psychiatric history and successively treated by mefloquine activity after sequential oxygen re-inhalation. In conclusion, the PEA can
then by chloroquine. Discussion focuses upon mefloquine-induced play a crucial role of vital reaction in asphyxia-related fatalities. This study
psychiatric disorders and highlights the importance of performing strongly supports that the pathological elevation of PEA in the blood during
toxicological investigations in cases of ‘unusual’ suicides. a hypoxic-agonal status can be reversed by oxygen resuscitation but not in
Although such events fortunately remain quite infrequent, forensic CO-intoxicated fatalities.
pratictioners should keep in mind the possibility of drug-induced psychoses
β-Phenylethylamine, Asphyxia, Biomarker

G43 The Development of a Model to Assess G44 Exsanguination Due to Disruption of the
the Effects of Conducted Electrical Left Popliteal Artery and Vein Due to
Weapons in a Stressful State Posterior Dislocation of the Left Knee
Prosthesis: A Case Report and Review
Amanda O. Esquivel, MS*, and Cynthia Bir, PhD, Wayne State University,
818 West Hancock, Detroit, MI 48201
of the Literature
This presentation will educate attendees on the safety of conducted elec- Wieslawa Tlomak, MD*, Milwaukee County Medical Examiner Office,
trical weapons (CEWs) that are used in a physiologically stressful state by 933 West Highland Avenue, Milwaukee, WI 53233
examining their effects on swine that are hyperthermic, tachycardic, hypo-
tensive and have elevated catecholamine levels. The goal of this presentation is to report a case of a 75-year-old woman
The research findings presented will impact the forensic science com- who died from an exsanguination due to disruption of the left popliteal ar-
munity in guiding policy related to the use of CEWs in given operational tery and vein secondary to posterior dislocation of the left knee prosthesis.
scenarios. In addition, knowledge related to the physiological effects of This presentation will impact the forensic community because it is a
CEW use in compromised individuals is useful to emergency medical per- unique case of unexpected death due to posterior dislocation of the knee pro-
sonnel for determination of proper medical treatment and the development sthesis.
of treatment protocols. Dislocation after primary total knee arthroplasty is a rare but serious
Although the effects of CEWs on healthy, anesthetized swine appear complication. Knee prosthesis dislocation results in disruption of soft tissue,
to be transient, persons that are subjected to repeated exposures of a CEW are palsy of the sciatic or common peroneal nerve and rarely disruption of the po-
most likely in an agitated or combative state. This stimulation could lead to pliteal artery causing ischemia. Reported here is a case of a 75-year-old
a phenomenon known as excited delirium. In order to determine whether se- woman who received bilateral knee arthroplasty. Posterior dislocation of the
vere physiologic stress in combination with the use of a CEW would cause left knee prosthesis occurred seven years after operation. Dislocation resul-
a serious adverse physiological effect a controlled hemorrhage along with ted in disruption of soft tissue and left popliteal artery and vein. She died
external warming was performed. The hemorrhage was conducted to induce from exsanguinations due to disruption of the left popliteal artery and vein.
tachycardia, hypotension and catecholomine release as a compensatory me- Exsanguination, Total Knee Arthroplasty, Knee Prosthesis Dislocation
chanism. These signs, along with hyperthermia, are associated with excited
delirium.
Preliminary data was gathered in order to assess the effectiveness of G45 What Lies Beneath: An Unusual Congenital
the proposed methodology to simulate a state of excited delirium. Three
male swine (44 kg +/- 0.8 kg) were included in the study and one additional
Anomaly in an Assault Victim
“sham” (43.4 kg) to observe the effects of the stress only. Under a surgical
plane of anesthesia (2%-3% isoflurane) the animals were instrumented and Kathryn H. Haden-Pinneri, MD*, Jason M. Wiersema, PhD, and Jennifer
subjected to hemorrhage and hyperthermia. Hemorrhage was induced using C. Love, PhD, Harris County, Medical Examiner’s Office, 1885 Old Spa-
the Wiggers model in which blood is removed from the pig until a predeter- nish Trail, Houston, TX 77054-2098
mined mean arterial pressure (MAP) is reached. The average baseline pres- This goal of this presentation is to describe an unusual and unexpected
sure prior to hemorrhage was 70 mmHg. For the proposed effort, it was cervical vertebrae anomaly in a victim of assault and discuss its significance
determined that a MAP of 45 mmHg was sufficient in causing a stress from in the setting of a homicide.
the blood loss. The swine were covered in a warming blanket to bring their This presentation will impact the forensic community by reviewing the
core temperature up to 108°F. The normal temperature for the swine is 101° importance of a posterior neck dissection in blunt trauma victims and by il-
- 103°F (2.4° - 4.4° higher than humans). This increase in core body tem- lustrating the importance of on-site forensic anthropology services.
perature is consistent with the sign of hyperthermia often observed in the A 22-year-old black male was physically assaulted by another male
field and previously described. Exposures to a CEW were given 20 times (4 after an incident on a roadway. The victim became unresponsive immedia-
sets of 5 exposures) in 30 minutes. Cardiac and pulmonary parameters were tely after the assault in which he was struck multiple times on the head and
continuously monitored and blood samples were collected before and after torso by the suspect’s fists. No other weapon was utilized and the fight was
each set of exposures and at one hour intervals for four hours. witnessed. The incident lasted only a few minutes and the suspect left the
The MAP decreased from its baseline value to 39.8, 43.7 and 44.3 scene, unaware that his victim had collapsed. Emergency personnel re-
mmHg for each of the three animals subjected to exposures. Heart rate in- sponded to the scene within minutes and despite aggressive cardiopulmo-
creased on average from 112 to 185 beats per minute after the hemorrhage nary resuscitative measures, the victim was pronounced dead at the hospital
for the three animals subjected to exposures while the sham increased from shortly after arrival.
100 to 168 beats per minute. As expected, the heart rate remained elevated The victim was obese, weighing 309 pounds with a body length of 71
for the entire study for all animals. The baseline pH (7.44), PCO2 (41.4 inches (body mass index of 43.1). External examination revealed a few fa-
mmHg) and lactate (0.79 mM/L) values recorded were within the normal cial and extremity abrasions and contusions. Internal examination revealed
average values previously reported for swine. The pH decreased slightly after a 3½ inch subscalpular hemorrhage over the left parietal bone and no other
hemorrhage for all in the exposed group to 7.38 and all three in the exposed traumatic injuries, specifically, no subarachnoid hemorrhage. Incidentally,
group became acidodic during the exposures (average 7.25). Blood lactate in- the decedent was found to have a urogenital anomaly comprised of fusion of
creased above normal after the hemorrhage to 3.78 and increased further the kidneys which were located in the pelvis. The heart weighed 475 grams
after each set of exposures to 8.93 mM/L. Compared to a previous study in and was mildly dilated. The coronary arteries had a normal distribution and
which the same device was applied on healthy, anesthetized swine, these ani- no atherosclerosis. A complete back dissection performed to delineate any
mals were more acidodic and had a greater increase in blood lactate. subcutaneous hemorrhage that may have been obscured by lividity was ne-
This model successfully created a physiologically stressful state simi- gative. A posterior neck dissection was performed which revealed focal he-
lar to excited delirium. The warming blanket induced an increase in core morrhage around the upper cervical spinal cord between the first and second
body temperature and the hemorrhage induced tachycardia, hypotension and vertebral bodies, which were abnormal due to the presence of lateral fora-
dehydration. Epinephrine and norepinephrine were not directly measured mina at the level of the first vertebral pedicles. Further dissection ensued
in this preliminary study however, a compensatory mechanism of hypovo- with the assistance and guidance of our on-site forensic anthropologist.
lemic shock is a rise in these levels. The first through third cervical vertebrae were completely excised in
Electrical Weapons, Tasers, Less-Lethal Weapons order to examine and document the course of the vertebral artery. A small
amount of adventitial hemorrhage was noted at the level of the second cer- of the spleen. The nature, site and extent of the external injury will indicate
vical vertebrae; however the artery wall was intact throughout. A small epi- the severity of the violence inflicted on the body.
dural hemorrhage was identified over the posterior aspect of the cervical There is a clear analogy to the legal concept of the “paper-thin” skull,
spinal cord at the level of the first cervical vertebra. The vertebral arteries in which injury to an abnormally vulnerable part of the body can produce di-
were removed and submitted for microscopic examination by the pathologist sastrous consequences, disproportionate to the results that would have re-
and the forensic anthropologist cleaned and examined the cervical vertebrae. sulted if the violence had been inflicted on an individual who did not suffer
An atypical bilateral vertebral artery course was observed in the verte- from the particular abnormality. The name of the concept derives from the
brae. The vertebral arteries passed superiorly through the second vertebral classic example of a “paper-thin” skull in which a modest blow can produce
transverse foramina, turned nearly 90 degrees and took a posterior course, permanent brain damage.
doubled back at the level of the first vertebral laminae, then took a second 90 The importance of forensic medical evaluation is evident in cases where
degree turn to pass through the first vertebral transverse foramina and con- rupture of the spleen can be connected to an act of violence inflicted on the
tinued superiorly into the cranium. The associated anomalous skeletal cha- victim. In the presence of splenomegaly the severity of the act of violence
racteristics together result in an acutely angled course through which the must be assessed using the results of a complete autopsy and the special in-
vertebral arteries pass into the skull. vestigations to be recommended in this presentation.
Microscopic examination of the vertebral arteries revealed fragmenta- The presentation will discuss diagnostic procedures that will facilitate
tion and degeneration of the elastic laminae, which was confirmed with an the evaluation of the etiology of the splenomegaly and the pathological chan-
elastin stain. ges that predispose to rupture. The causes of splenomegaly are diverse, but
This degeneration is felt to be a ‘wear-and-tear’ type phenomenon due they may be conveniently grouped into the following categories:
to the abnormal course of the arteries through the vertebrae. Microscopic • Inflammatory splenomegaly: acute or chronic enlargement of the
sections of the heart revealed myocyte hypertrophy and patchy interstitial fi- spleen that develops in association with various infections or
brosis. Toxicology was negative. inflammatory processes. e.g., infectious mononucleosis.
Concomitant renal and cervical vertebrae anomalies are not uncommon • Hyper plastic splenomegaly: due to work hypertrophy resulting
and are seen in syndromes such as Klippel-Feil in which there are fused ver- from the removal of abnormal blood cells from the circulation or
tebrae and varying kidney abnormalities. The association between the uro- as the result of extramedullary hematopoiesis e.g., leukemia.
genital system and the skeletal system occurs during the early embryonic • Congestive splenomegaly: resulting from cirrhosis with portal
stages of development. During the 4th and 5th weeks of development, the hypertension, splenic vein occlusion (thrombosis), or congestive
start of renal development occurs in the cervical region of the embryo and heart failure (CHF) with increased venous pressure .e.g.,
then extends caudally. Any interruption in this stage of development can re- bilharzia, chronic alcoholism, cirrhosis caused by aflatoxin
sult in anomalies involving the spine, kidneys and/or scapulae. (from fungus aspergillus flavus and aspergillus parasiticus).
The vertebral artery course and microscopic appearance are quite ab- • infiltrative splenomegaly: caused by the engorgement of
normal; however are insufficient to account for the sudden death of this macrophages with indigestible materials (e.g., Gaucher`s disease
young man. Given the circumstances of the witnessed collapse following the or amyloidosis,) or by the infiltration by malignancy e.g.,
physical altercation, the manner of death was ruled a homicide and the cause Lymphoma.
of death was determined to be sudden death following physical altercation. Splenic filtering of blood-borne pathogens, such as parasites or enca-
Congenital Anomaly, Vertebral Artery, Cervical Vertebrae psulated organisms, may also lead to splenic enlargement (e.g., parasites cau-
sing malaria or kala azar (Leishmania).
A complete autopsy including a detailed description of the macrosco-
pic appearance of all organs is essential. Special examinations must include:
G46 Forensic Pathology of the Rupture • Histo-pathological examination of samples taken from the
organs and selected soft tissue and bone.
of an Enlarged Spleen • Toxicological examination to isolate toxic organic substances.
• Microbiological examination including isolation and
Maurice G. Rogev, MBChB*, 11/1 Zamenhof Street, Tel Aviv, Jaffo 64373, identification of bacteria, viruses, or parasites.
ISRAEL
Forensic, Splenomegaly, Rupture
The goal of this presentation is to demonstrate the importance of the
complete autopsy examination of bodies in whom death resulted from the
rupture of an enlarged spleen. The causes of the splenomegaly can be de- G47 Clinical and Pathological Spectrum
termined. The mechanism causing the rupture can be determined i.e., if the of Fatty Cardiomyopathy in Sudden
rupture was spontaneous of resulted from violence. The “thin skull’’ iegal
concept is relenent in these cases.
Cardiac Death
This presentation will impact the forensic community by drawing the
Lise A.M. Matzke, MSc*, Michael Allard, MD, and Bruce M. McManus,
attention of medical examiners to the various forensis medical aspects of
James Hogg iCapture Centre for Cardiovascular and Pulmonary Re-
deaths that can result from the rupture of enlarged spleens.The importance
search, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC V6H 1P9,
of complete autopsies in these cases will be clear. The autopsy will reveal
CANADA; Carol K. Lee, MD, New Mexico Office of the Medical Investi-
the many different circumstances in which ruptures of the spleen are likely
gator, MSC11 6030, 1 University of New Mexico, Albuquerque, NM
to occur.
87131-0001; and Charles Lee, MD, Vancouver General Hospital, Deptart-
Rupture of the spleen causes profuse intra-abdominal hemorrhage lea-
ment of Forensic Pathology, 855 West 12th Avenue, Room 1352, Vancou-
ding to hypovolemic shock, which, if undiagnosed and untreated, can be
ver, BC V5Z 1M9, CANADA
fatal. A medical examiner may occasionally be confronted by an autopsy
finding of death due to complications following rupture of an enlarged spleen After attending this presentation, attendees will recognize the pattern of
(splenomegaly). In such cases it is important to bear in mind that rupture of pathology findings as correlated to clinical information from cases within
the spleen can occur spontaneously with no history or external signs of the spectrum of fat cardiomyopathy including arrhythmogenic right ventri-
trauma to the left side of the chest or to the upper left abdomen. cular cardiomyopathy.
It is however, vitally important to examine for signs of external injury This presentation will impact the forensic community by reviewing cli-
which may have been caused by violence because, when splenomegaly is nical and pathological data for sudden cardiac death cases from the spectrum
present, even light violence suffered by a victim, can be the cause of rupture of fat cardiomyopathy. Forensic and cardiovascular pathologists, as well as

other forensic scientists, may find this information useful for comparison The prevalence of non-alcoholic fatty liver disease in the general po-
with observations from their home institutions and practices. pulation may signal an increase in the number of sudden deaths in which
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a primary fatty liver disease is the sole pathologic finding at autopsy. This presentation
heart muscle disease characterized by fibrofatty replacement of the right ven- will impact the forensic community by. The forensic pathologist should be
tricle (RV) that is commonly associated with sudden death. Infiltration of the prepared to carefully investigate these deaths, since the opportunity to bet-
RV by fat alone is also believed to be associated with sudden death. Howe- ter understand the mechanism of death in such cases may induce clinicians
ver, it is not yet fully known if both conditions are different or similar di- to recommend routine EKG studies in obese patients and alcohol abusers.
sease processes in the spectrum of fatty cardiomyopathy and to what extent The sudden death of a teenager with non-alcoholic fatty liver disease
fatty infiltration of the RV to contribute to sudden cardiac death. In this study, (NAFLD) prompted us to question the mechanism of death in individuals
the authors set to characterize the clinical and pathological characteristics of whose sole pathologic observation at autopsy is fatty liver disease. From a
thirteen necropsy hearts collected by the iCAPTURE Cardiovascular (CV) clinical stand point, NAFLD is recognized as a leading cause of chronic liver
Biobank at St. Paul’s Hospital/University of British Columbia and diagno- disease, and has been associated with obesity and insulin resistance. Accor-
sed with ARVC or right ventricular fatty infiltration from patients that died ding to recent studies, the prevalence of NAFLD in the United States now ex-
suddenly and unexpectedly. Each case was referred to a cardiovascular ceeds 30% and probably mirrors the prevalence of obesity in the general
pathologist at the CV Biobank for consultation and patient data were obtai- population. One would therefore expect forensic pathologists to see a surge
ned from medical records or the referring pathologist. The CV Biobank, of NAFLD cases at autopsy, regardless of the cause and manner of death.
established in 1993, is comprised of cardiovascular tissue specimens from A 17-year-old morbidly obese female non-drinker with an unsubstan-
surgery and autopsy (routine hospital and forensic) as well as accompanying tiated history of mild mental retardation, sleep apnea, and insulin resistance
annotated data which are securely stored in a database. This unique collec- died suddenly and unexpectedly. She was found face down on her futon-style
tion encompasses a wide array of cardiovascular diseases and is a powerful bed, clad in shorts and a tee-shirt. She was 5’5” tall and weighed more than
research and educational tool. 240 lbs. The only abnormal finding at autopsy was a 2490 g pale yellow-tan
These thirteen cases were collected by the CV Biobank during the years liver with greasy consistency. Microscopy showed marked fatty change with
1993 to 2006 and represent approximately 14% of our sudden death cases focal bridging fibrosis and spotty lobular inflammation. A toxicology the-
over this time period. Each of the thirteen cases were assessed in terms of rapeutic and abused drug screen was negative, and vitreous glucose was less
their macroscopic and microscopic features and were found to fit into one of than 20 mg/dl. In the absence of any other findings of significance, the me-
two patterns. Nearly two-thirds demonstrated fibrofatty (six male, two fe- chanism of death was assumed to be a cardiac arrhythmia, and the cause of
male; age = 17-36 years) replacement of the right ventricular myocardium, death was certified as “Sudden Death Associated with Non-alcoholic Fatty
while slightly more than ⅓ showed a pattern of predominantly fatty repla- Liver Disease and Morbid Obesity”.
cement (2 male, 3 female; age =15-64 years). Within the fatty replacement Forensic pathologists have long been familiar with cases of sudden, unex-
group, 80% of individuals died following non-strenuous activity and 20% pected, non-violent deaths in alcoholics with autopsy findings limited solely
died at rest. Patient histories for this group included one individual with hi- to fatty liver. The mechanism of death in such cases is not well understood.
story of fainting and clinical intervention for arrhythmia and one patient with In a review of the literature, one current theory proposes that a prolonged
a history of anorexia and bulemia. Within the fibrofatty replacement group, QT interval may be triggered by alcohol withdrawal induced hypoglycemia
over 57% of individuals died following non-strenuous activity; 28% during complicated by low potassium and magnesium concentrations.
strenuous activity and 14% at rest. Patient histories for this group include on The anatomic pathology of alcohol-related fatty liver disease and non-
individual with documented familial ventricular tachycardia for which he re- alcoholic fatty liver disease is the same. Absent any other factor contributing
ceived treatment; one history of dilated cardiomyopathy and mitral valve re- to death, the mechanism of death may also be the same.
gurgitation; and one individual with sudden death of a brother due to an A thorough medicolegal investigation of the circumstances of death and
unspecified aneurysm. Quantitative computer-assisted morphometric analy- medical history, a careful autopsy, and of standardized histologic grading sy-
sis in a subset of seven of the thirteen cases confirmed these two patterns. Of stems for fatty liver are recommended in all cases of sudden death with fatty
interest, the distribution and extent of involvement differed substantially liver disease as sole pathologic finding in order to better understand the me-
between fibrofatty and fatty patterns with changes being more extreme and chanism of death. An increase in NAFLD deaths may justify the need for
widely distributed in the fibrofatty pattern and localized to the anterolateral routine electrocardiograms in obese individuals and alcohol abusers of all
apex and lateral base in the fatty pattern. ages.
Thus, fibrofatty replacement of the RV, characteristic of ARVC, and Fatty Liver Disease, Prolonged QT Syndrome, Sudden Death
fatty infiltration of the RV alone are both significant findings in cases of sud-
den cardiac death evaluated at a regional cardiovascular pathology referral
centre. The distinctly differing extent and distribution of involvement G49 Hypertensive Heart Disease May
between the two morphological patterns supports the concept that they re-
present two different disease processes. Compound the Risk of Death From
Fat Cardiomyopathy/ARVC, Cardiovascular Pathology, Sudden Car- Medication and Contrast Media-Induced
diac Death Anaphylactic Shock
Ariel Goldschmidt, MD*, and Jane W. Turner, MD, St. Louis City Medical
G48 Sudden Death and Fatty Liver Disease Examiner’s Office, 1300 Clark Street, St. Louis, MO 63103
After attending this presentation, attendees will understand some prin-
Michael E. Archer, MA*, New York Forensics, Inc., 1039 Main Street, PO
ciples of the pathophysiology and epidemiology of lethal anaphylactic shock.
Box 28, Fishkill, NY 12524-0028; and Dennis J. Chute, MD, and Kari B.
Additionally, specific forensic autopsy findings related to anaphylactic shock
Reiber, MD, Office of the Medical Examiner, Dutchess County Department
will be reviewed.
of Health, 387 Main Street, Poughkeepsie, NY 12601
This presentation will impact the forensic community because in this
The objective of this presentation is to draw attention to the alarming retrospective case review, all autopsied cases of individuals with medication
prevalence of non-alcoholic fatty liver disease in the obese population and to or contrast media-induced anaphylactic shock included findings of cardiac
a potential increase in sudden fatty liver deaths. The need for a thorough abnormalities and, specifically, left ventricular hypertrophy was found in
medicolegal investigation and autopsy will be emphasized, since a better un- seven of eight cases.
derstanding of the mechanism of death in such cases may have clinical con- The pathophysiology of anaphylactic shock is complex, involving
sequences for both alcoholics and non-alcoholics with fatty liver disease. cross-linking of IgE receptors on the surface of mast cells, causing massive
degranulation and subsequent adverse effects on the cardiovascular and re- G50 Diffuse Axonal Injury in
spiratory systems. Circulatory collapse results from impaired venous tone
and venous return, as well as decreased cardiac output. Respiratory failure
Medico-Legal Practice
results from reactive airway changes as well as upper airway swelling and ob-
struction and pulmonary edema. Djordje Alempijevic, MD, PhD, Dragan Jecmenica, MD, PhD,
A review of several case series in the recent literature shows that deaths Vladimir Zivkovic, MD, Snezana Pavlekic, MD, PhD, and Slobodan
from medication and contrast media-induced anaphylaxis occur more often Savic, MD, PhD*, University of Belgrade, School of Medicine, Institute
in elderly individuals, especially those with comorbid diseases, and are more of Forensic Medicine, 31a Deligradska Street, Belgrade, 11000, SERBIA
common than deaths from anaphylaxis caused by Hymenoptera stings and AND MONTENEGRO
food allergies. Postmortem measurement of serum tryptase, a marker for The goal of this presentation is to present data that will provide
mast cell activation, has been found in several studies to be a sensitive and attendees with the important medicolegal and clinical characteristics of
specific test that can support a diagnosis of death from anaphylactic shock. diffuse axonal injury in closed head trauma that may contribute ultimately to
The purpose of this study was to determine whether a retrospective review fatal outcome.
of medical examiner cases in the greater St. Louis region would corroborate The presentation will impact the forensic community by the fact that in
the findings of previous case series reported in the literature. cases of closed head trauma, diffuse axonal injury (DAI) may contribute to
A computer search was utilized to find all cases in St. Louis City and overall brain damage and treatment outcome. On the other hand, these results
surrounding counties in the past twenty years in which the sole immediate indicate that in the cases of closed head injury, fatal outcome occurs over a
cause of death was listed as anaphylactic shock. Twenty-two such cases shorter period if DIA is present without contusions of the brain.
were found. In eleven cases, a complete autopsy was performed at the Me- Diffuse axonal injury (DAI) is a form of neural damage in close head
dical Examiner’s office; in one case, a complete hospital autopsy was perfor- trauma that may contribute to overall trauma severity as well as the progno-
med; in one case, an external examination only was performed; and in nine sis and course. For that reason, an autopsy study was performed to analyze
cases, the body was released after review of the medical investigator’s report. the extent and other important forensic and clinical characteristics of DAI.
Among the seventeen individuals with anaphylaxis induced by medi- The study was carried out prospectively during two years period when
cation or contrast media, thirteen were over the age of fifty. By contrast, of 3,012 autopsies were performed. According to defined criteria, 30 autopsy
the five individuals with “idiopathic” anaphylaxis or anaphylaxis related to cases of closed head trauma were selected (study group), while a
Hymenoptera stings or food allergies, four were under the age of fifty. Of the corresponding number of cases formed control group. Whole brain samples
twelve cases in which a complete autopsy was performed, three cases inclu- were fixed in formaldehyde and subsequently studied macroscopically and
ded individuals with a swollen tongue or lips; eight included findings of microscopically.
laryngeal edema; ten had cardiac abnormalities; seven had pulmonary ab- Data were obtained from medical records and autopsy findings. A
normalities; and two had mild cerebral edema. In the five cases in which po- contusion index (CI) was used for assessment of brain contusions. Tissue
stmortem serum trypase levels were measured, four showed levels above the density, as a measure of myelin sheet damage, was analyzed on luxol fast
upper limit of the normal reference range (13.5 ug/ml) and all five showed blue (LFB) stained sections of corpus callosum (CC) by laser scan
levels above 10 ug/ml. densitometry. The obtained results were analyzed by means of appropriate
Many of the individuals who died as a result of medication or contrast statistical methods.
media-induced anaphylactic shock suffered from comorbid diseases inclu- Optic density of LFB stained CC slices depends on myelin quantity.
ding obesity, diabetes, and atherosclerosis. Significantly, cardiac abnorma- Optic density of CC in controls was 1.02±0.05, while in studied subjects it
lities were found in all of these cases in which a complete autopsy was was 0.96±0.08. Observed difference in optic density of CC histological slices
performed. Specifically, the finding of left ventricular hypertrophy, which is was proofed to be of statistical significance (t=4.0035; p<0.05). In cases
strongly associated with hypertensive heart disease, was found in seven of with higher CI, i.e., where contusion injuries were more severe, optical
eight cases. density of CC was slightly lower in comparison to the cases of less severe
The findings of this study corroborated those of previous case series, contusions, and cases where brain contusions were absent. Optical density
which reported that death from medication or contrast media-induced of CC is significantly lower in cases with survival period up to 24 hours.
anaphylactic shock most commonly occurs in elderly individuals, many with
Medico-Legal Aspects, Diffuse Axonal Injury, Trauma
comorbid diseases. Interestingly, in this case review, all of these autopsied
cases included findings of cardiac abnormalities and, specifically, left ven-
tricular hypertrophy was found in seven of eight cases. The association of
hypertensive heart disease with death from anaphylactic shock merits further
investigation and could have broad implications for the medical community G51 Placental Site Trophoblastic Tumor (PSTT)
if confirmed in larger studies. With Lung Metastases as Cause of Death
Anaphylaxis, Hypertension, Hypertrophy in a Young Patient: Autopsy Findings and
Medico-Legal Implications
Catia Colecchi, MD, Catholic University, Institute of Forensic Medicine,
Rome, ITALY; Ezio Fulcheri, MD, University of Genova, Department
of Pathology, Genova, ITALY; Sara Partemi, MD, and Fabio De
Giorgio MD, Catholic University, School of Medicine, Institute of
Forensic Medicine, Largo Francesco Vito 1, Rome, ITALY; Giovan
Battista Serra, MD, Catholic University, Department of Obstetrics and
Gynecology, Rome, ITALY; and Vincenzo L. Pascali, MD, PhD, and
Antonio Oliva, MD, PhD*, Catholic University, School of Medicine,
Institute of Forensic Medicine, Largo Francesco Vito 1, Rome, ITALY
The goal of this presentation is to present the autopsy and histological
findings of placental trophoblastic tumor, which are very rarely described in
the literature.

This presentation will impact the forensic community by demonstrating G52 Identification of Human Body Fluids:
how medico-legal implications are related to the difficulties of the doctor
who faced this rare condition.
Comparison Between Two Commercial
Placental site trophoblastic tumour (PSTT) is a rare form of gestational Kits for Detection of Semen
trophoblastic disease (GTD) with unpredictable biological behaviour. It arises
from the transformation of intermediate trophoblastic cells that normally play Simona Ricci, MD*, Department of Legal Medicine, Viale Regina Elena
a critical role in implantation. PSTT was originally termed “atypical cho- 336, Rome, ITALY; Fabio Verginelli, Department of Oncology and
rioepithelioma” by Marchand in 1895. In 1976, under the title “trophobla- Neuroscience University “G.d’Annunzio” and Center of Excellence on
stic pseudotumor of the uterus”, Kurman et al. recognized the entity as a Aging (Ce.S.I.), D.d’Annunzio Foundation, Chieti, ITALY; Andrea
form of trophoblastic disease, distinct from choriocarcinoma. Five years Mele, MD, Department of Legal Medicine University “Sapienza” Viale
later, Scully and Young introduced the term “placental site trophoblastic Regina Elena 336, Rome, ITALY; and Manuela Rosini, and Carla Vec-
tumor” to indicate possible malignant behaviour. Since the first report, ap- chiotti, MD, PhD, Laboratory Genetic of the Department of Legal Medi-
proximately 90 cases of PSTT have been reported, formerly termed atypical cine University “Sapienza”, Viale Regina Elena 336 00161 Rome, ITALY
choriocarcinoma, chorio-epitheliosis or syncytioma. PSTT can occur after
The aim of our presentation is to show the results making a parallel
a normal pregnancy, abortion, term delivery, ectopic pregnancy or molar pre-
study to detect human semen on old and recent traces with these two different
gnancy. It displays a wide clinical spectrum, and when metastatic, can be dif-
commercial kits.
ficult to control even with surgery and chemotherapy. Unlike other forms of
GTD, PSTT is characterized by low beta-hCG levels because it is a neopla-
showing how it is possible to improve the knowledge about identification
stic proliferation of intermediate trophoblastic cells. Expression, however,
methods using new approach to detect traces.
of human placental lactogen (hPL) is increased on histologic section as well
The examination of living victims of sexual assaults is very important;
as in the serum. The most common presenting symptoms of PSTT are va-
the necessity to have markers to detect the presence of semen on clothes or
ginal bleeding and amenorrhoea. Diagnosis is confirmed by dilatation and
body fluids could be helpful in forensic science. Semen is the most common
curettage and hysterectomy but meticulous evaluation of metastasis is man-
form of body fluid evidence encountered in these cases; in screening or
datory.
examining sexual assault evidence, semen or other body fluids can be present
A 21-year-old woman, (gravida 1, para 0) at 25 weeks of amenorrhea
on a variety of surfaces including sample collection swabs, pieces of clothes,
was admitted to the hospital for hyperemesis, hepatic problems, and impor-
bed sheets, towel, flooring, condoms, and feminine products. The samples
tant weight loss registered during the last few months. Routine laboratory
can also be stored for many years: testing for body fluid identification and
tests such as liver function, haematics and coagulations markers were
DNA profiling should be able to reliably, and with high sensitivity detect
abnormal, whereas all fetal parameters were unremarkable. On examina-
semen from a variety of sources. In countries with sophisticated forensic
tion, the patient was cachectic looking. The per-abdominal examination was
science or laboratories, the pathologist will not be called upon to carry out
unremarkable. Few days after the admission the patient suddenly died before
actual techniques for detection of seminal fluids: he has to be a careful
the doctors can reach a diagnosis. A forensic investigation for medical
collector of samples and to be able to make an interpretation of the results,
malpractice was initiated. Microscopic examination of the samples collected
but sometimes even the pathologist has to be well informed and has to be able
from uterus revealed the presence of large trophoblastic cells with
to make these tests by himself. The detection of semen depends upon many
eosinophilic cytoplasm. Deposition of fibrinoid material was noticed
different methods as naked-eye and lens recognition; examination under
between trophoblastic cells. Tumor cells dissected through the myometrium
ultraviolet light, enzyme reactions (acid phosphatase activity), immuno-
and invaded into the vascular spaces. Specimens of the lungs revealed
logical methods, FISH method.
numerous small neoplastic emboli into the vessels.
Particularly the immunological methods are recently used in many
Placental site trophoblastic tumor is an uncommon member of GTD,
laboratories and they detect the presence of some antigens that normally can
with less than 100 cases having been reported in the English language lite-
be found also in seminal fluid: for example PSA and Semenogelin.
rature. PSTTs behave in a benign fashion, whereas approximately 10 –15%
PSA or prostate-specific antigen is a glycoprotein produced by the
were clinically malignant. Predicting which patients will develop metasta-
prostatic gland and it is found in seminal plasma, male urine, and blood, it
ses is difficult. The outcome is usually excellent after the simple hysterec-
could be present also in tissue or fluid of the female body but the concentra-
tomy. Unfortunately at the time of diagnosis our patient presented metastasis
tions are very low. A positive PSA test is a reliable indicator of semen
beyond the uterus. The management of disease with metastasis can be very
regardless the presence of spermatozoa or elevated acid phosphatase level.
difficult, for the relative insensitivity to chemioteraphy. Other important ad-
The other test detect a different protein that is present on semen,
verse prognostic factors are age >40 years and mitotic count>5 mf/10 HPF.
Semenogelin: it is the major component of human semen and together with
Gross autopsy and histological findings, which are very rarely described in
fibronectin, gives rise to he gel-like coagulum of newly ejaculated semen.
the literature, are demonstrated. The medico-legal implications related to the
Both of them are immunochromatographic assay tests that use mono-
great difficulties of the gynecologist who faced this rare condition in term of
clonal antibodies specific for the antigen and they use a strip test that can be
diagnosis and prediction of the biological behavior and outlining effective
manipulate easily.
therapeutic approaches are discussed.
The aim of our presentation is to show the results we had in our
Placental Site Trophoblastic Tumor, Lung Metastas, Medico-Legal Laboratory making a parallel study to detect human semen on old and recent
Implications traces with these two different commercial kits. This study has the purpose
to test also the sensitivity of these new methods because of the importance
they could have in forensic cases.
Identification, Human Semen, Immunological Kits

G53 A Brush With Death: hydrogen fluoride (HF). The HF causes adverse effects reported in large
ingestions, including nausea, vomiting, diarrhea, abdominal pain, and acute
Suicidal Ingestion of Toothpaste hemorrhagic gastroenteritis.
According to Annual Reports of the American Association of Poison
Rebecca Irvine, MD*, 808 Shire Street, South West, Albuquerque, NM
Control Centers, over 118 thousand poisoning exposures were reported to
87121; and Susan Kunkle, PharmD, New Mexico Poison and Drug Infor-
poison centers nationally during the five-year period ending in 2005. Of
mation Center, MSC11 3060, 1 University of New Mexico, Albuquerque,
these, 91 percent were unintentional exposures; roughly 90 percent involved
NM 87131-0001
children less than six years old. This case is unique in the respect that it was
The goal of this presentation is to describe the gross findings and the the sole fatality attributed to toothpaste ingestion during this period.
physiologic derangement resulting in death in toothpaste/fluoride toxicity.
Toothpaste, Fluoride, Poisoning
This presentation will impact the forensic community by making me-
dical examiners aware of the potential acute toxicity of [widely-available]
fluoridated toothpaste, its recognition and the high national incidence of non- G54 Toxicological Implications in Heat Related
fatal toothpaste poisonings Deaths in Phoenix, Arizona: Case Reports
This poster presentation will permit the attendee to brush up on the toxic
effects that accompany the ingestion of toothpaste with fluoride, an extremely From the Office of the Medical Examiner
common, if rarely fatal, poisoning event. After attending this presentation,
Kimberly McCall-Tackett, BS*, Maricopa County, Forensic Science Cen-
the attendee will be able to describe the gross findings in acute fluoride
ter, 701 West Jefferson Street, Phoenix, AZ 85050; Ann L.
poisoning, the circumstances in which toothpaste poisoning may occur and
Bucholtz, MD, 6643 East Sweetwater Avenue, Scottsdale, AZ 85254;
the physiologic derangement that results in injury or death.
Amy L. Lais, BS, Maricopa County Forensic Science Center, 701 West Jef-
A 51-year-old man was found unresponsive on his bed, by his wife,
ferson Street, Phoenix, AZ 85007; and Norman A. Wade, MS, Office of the
when she came home from work. The bedroom door was locked from the
Medical Examiner, Forensic Science Center, 701 West Jefferson Street,
inside. There was a history of domestic abuse, and reportedly the wife had
Phoenix, AZ 85007
assaulted him three days earlier, resulting in visible contusions on the right
eye and upper arm. Resuscitative attempts were unsuccessful and he was After attending this presentation, attendees will be afforded a three year
pronounced dead at the scene. There was no investigative evidence of acute review of the statistics, toxicology, and pertinent scene findings associated
trauma or foul play. with heat related deaths in the metropolitan Phoenix area.
Past medical history was significant for bipolar disorder, hypertension This presentation will impact the forensic community by raising awa-
and chronic back pain. The decedent was known to abuse cocaine and mul- reness of this public health issue.
tiple burnt copper pad fragments were identified throughout the house. The diagnosis of a heat related death rests on the importance of consi-
Two weeks earlier, the decedent, who was noted by his wife to be de- dering all factors involved for certifying the death when a person is found
pressed for several months, had uttered an isolated suicidal statement to the dead in a hot environment that can routinely be greater than 105 degrees du-
effect that when his medications arrived by mail he should “take them all”. ring summer months. In recent years, media scrutiny of the number of deaths
His medications (Depakote, bupropion and olanzapine) were irregularly out related to hyperthermia has reached headline proportions in our area, which
of count and some were in a pile on the bedside table, along with a Thermos. has prompted much public awareness and activism. Although these headli-
No note was found. nes are accurate in reporting deaths have occurred, they do not typically re-
Autopsy revealed an overweight male (BMI 28.5 kg/m2) with cardio- flect the true circumstances surrounding the deaths. This paper will discuss
megaly (600 grams), organized anterior infarct, marked concentric left ven- the headlines versus factual findings, retrospectively demonstrate the stati-
tricular hypertrophy and chronic lung disease with pulmonary hypertension. stics, and discuss an algorithmic approach to unify the certification for more
There was florid hemorrhagic necrosis of the entire gastric mucosa. The sto- accurate compilation of county health statistics. Data was collected from
mach contained frank blood (300 ml) and a 230-gram conglomerate of tran- May 1st to September 30th for years 2005 and 2006 (2007 data is still being
slucent blue-green paste (with a minty odor). collected). During this 2 year period, 168 deaths were certified as heat rela-
Follow-up investigation located an almost empty 119-gram tube of ted. Of these deaths, 52 % (87) had negative toxicology findings and were
toothpaste as well as multiple partially full tubes of toothpaste in the outdoor attributed to heat only. Of the remaining 48% (81 cases): 14% (24) had po-
trash. The wife indicated that the decedent had some level of sophistication sitive toxicology screens for ethanol, 16% (25) had positive screens for sti-
regarding medications, had a sibling who was a pharmacist, and would be mulants (cocaine or methamphetamine), 5% (8) were positive for
aware of the dangers of toothpaste ingestion, especially with the warning on psychotropic drugs, and 14% (24) had positive results for more than one
the package. these categories. Toxicology also plays a vital role in electrolyte determi-
Toxicological evaluation revealed the presence of cocaine and benzoy- nations. The levels of sodium, creatinine, and urea nitrogen must be consi-
lecgonine as well as bupropion and citalopram. A biochemical vitreous screen dered, if possible, when evaluating potential heat related deaths. In
was unremarkable. Fluoride was not detected in femoral blood. conclusion, vitreous analysis, scene variables, and decomposition all affect
The cause of death was: gastrointestinal hemorrhage due to massive in- the ability to evaluate results. The relevance of these findings in conjunction
gestion of fluoridated toothpaste, hypertensive heart disease, and cocaine in- with other variables used to make the diagnosis will be discussed. The pro-
toxication were significant contributing factors. posed algorithm will assist with the information gathering process and aid the
Given the history of suicidal intent, the concealment of the toothpaste forensic investigation by promoting categories for the deaths to be cataloged,
tubes and the noxiousness of ingestion, the manner of death was certified as so more accurate statistical, epidemiological and community prevention mea-
suicide. sures can be instituted. This retrospective analysis will demonstrate the mul-
Gastrointestinal signs and symptoms usually predominate upon tiple factors used to make a diagnosis of a heat related death and elicit
ingestion of toothpaste. Other observed effects have included headache, common problems encountered in evaluating a decomposed body in a po-
numbness, and electrolyte disturbances, especially hypocalcemia. tentially hot environment. From these findings, an algorithmic approach will
Hypotension and dysrhythmias are evident in severe poisonings. Toothpaste be proposed to further define the cause and manner of death in future inve-
often contains up to 5 mg of fluoride per teaspoon. The fluoride is the stigations and improve public health reporting. It is hypothesized that the
component of toothpaste associated with toxicity. In many cases, 3 to 5 cause and manner of death could be more definitively diagnosed by using a
milligrams per kilogram of elemental fluoride is a toxic dose. The more uniform information gathering process at the scene, during the autopsy
mechanism for toxicity following the ingestion fluoride-containing examination and from the toxicology findings. Specific case findings and
substances is thought to be a reaction between the sodium fluoride in the circumstances will be discussed.
toothpaste gastric acid, resulting in the production of highly corrosive Hyperthermia, Toxicology, Death
G55 Firearm Deaths by Law G56 Postmortem Genital Examinations With
Enforcement in New York City Colposcopy in the Evaluation of Fatal
Sexual Violence Against Women
James R. Gill, MD, Office of Chief Medical Examiner’s Office, 520 First
Avenue, New York, NY 10016; and Melissa Pasquale-Styles, MD*, New Sharon R. Crowley, RN, MN*, 122 Emeline Avenue, Santa Cruz, CA 95060
York City, Office of Chief Medical Examiner’s Office, 599 Winthrop Street,
Brooklyn, NY 11203 The goals of this presentation are: to help attendees better understand
the nature and appearance of the anogenital tissues at various postmortem in-
Upon completion of this presentation, participants should obtain an tervals; to compare the results from photocolposcopy at various magnifica-
overview of the circumstances and injury patterns seen with 42 police shoo- tions vs. single lens reflex (SLR) photography; and to determine if toluidine
tings. blue dye is a reliable and/or useful adjunct in the postmortem genital exa-
This presentation will impact the forensic science community by de- mination.
monstrating how although police shootings in which the decedent was unar- This presentation will impact the forensic science community by im-
med and/or sustained numerous gunshot wounds are widely reported by the proving the diagnostic acumen of the forensic examiner; avoiding ambiguity
lay press, these types of shootings were not typical in our study. of interpretation of clinical findings in postmortem genital examinations; and
The use of deadly force during law enforcement is a matter that com- providing a framework for the medical evaluation of fatal sexual violence
pels public scrutiny. There were 42 gunshot deaths caused by police over a against women.
4-year period in New York City. The decedents’ average age was 31 years This paper proposes to describe ongoing research on postmortem ge-
and ranged from 17 to 64 years. There were 41 males and 1 female; and 26 nital anatomy. These cases comprise a significant portion of a baseline study
Black, 9 Hispanic, and 7 White decedents. The majority (90%) of the dece- of postmortem genital examinations, to better study fatal sexual violence
dents possessed a weapon. There were 26 handguns, 6 knives, 1 axe, 1 metal against women. To this end, a detailed analysis of anogenital anatomy at va-
pipe, and 1 toy gun (carried by an adult impersonating a police officer). Vehi- rious postmortem intervals is being conducted.
cles were used as weapons in two incidents. Ethanol and/or drugs of abuse The focus of the present discussion is to describe the initial results of
were detected in 78% (31/40) of the decedents. The detected drugs of abuse cases drawn from the Donated Body Program, at University of California,
included: 15 cannabinoids, 14 ethanol, 10 cocaine/BE, and 1 amphetamine. Davis, California. A total of 30 cases will come from this population and will
Seven decedents had a history of psychiatric illness. form a subset of the final, larger project sample. Analysis of results from
The most common reason for the police presence was a response to a these baseline studies will allow eventual comparison to genital injuries su-
crime and for the shooting was the decedent’s possession/use of a weapon. stained by both sexual homicide victims and living sexual assault victims.
All but one of the decedents had injuries caused by handguns (one involved Data accumulated during this project will provide the core information for a
a handgun and rifle). A total of 177 bullets struck the 42 decedents. Four- Sexual Homicide Database (Crowley, AAFS/1998;2000; JFS/2004).
teen decedents sustained single gunshot wounds, and the remainder had mul- The operations base of the Donated Body Program at the University of
tiple gunshot wounds ranging from 2 to 21. In the majority of the cases in California, Davis, California, is at the Sacramento County Coroner’s Office
this study, the number of gunshot wounds of the body was 3 or fewer. There Morgue. Most donors are received by the Program ≤ 24 hours of death. All
were 112 penetrating, 55 perforating, and 8 graze wounds. Thirteen dece- cases selected for this baseline study are fresh, or fresh-frozen, vs. embalmed.
dents had at least one gunshot wound of the back or buttocks, accounting for Cases are examined based upon availability, i.e., female gender, and recei-
25 of the total 177 wounds, and four of the twelve had gunshot wounds of ved by the Program in a time frame compatible with examination by the pri-
only the back. With the exception of the upper extremities, gunshot wounds mary investigator.
of all locations were more likely to penetrate than perforate. A paucity of data exists on the “normal” appearance of the genital ana-
The location of the entrance wound is sometimes used as evidence to tomy during the postmortem interval. We lack data from scrutiny and pho-
support or dispute the justification for the use of force. A shooting is a dy- todocumentation of the postmortem anogenital tissues. In living sexual
namic process with split second decisions and movements. It has been de- assault victims, specific anogenital sites have been well-studied (Slaughter,
monstrated that a person can turn the torso completely in the milliseconds that Brown, Crowley, and Peck, 1997). The use of colposcopy is well established
it takes for one to decide to fire a gun and pull the trigger. Our data show a for both adult and child living victims. During the autopsy, gross visualiza-
wide range of entrance wound locations which would reflect this dynamic tion alone may not allow the detection of the more subtle findings that usually
process. constitute genital trauma in sexual assault. Crowley described a mobile sy-
Although these deaths may be high profile, the certification is typically stem for postmortem genital examinations with colposcopy (JFS, 2004).
straight forward and the cause (i.e., gunshot wound) and manner of death Previously, the use of 1% toluidine blue as an adjunctive tool in fatal
(homicide) are readily apparent. Since the medicolegal definition of homi- abuse cases was limited to select case examples. This nuclear stain has been
cide is death at the hand of another, the forensic pathologist is absolved of incorporated as a practice standard by many programs, for the medical legal
considering intent or the appropriateness of the use of force. Typically, those evaluation of living sexual assault victims. A review of the original metho-
issues are left to the legal investigation (e.g., grand jury investigation). Du- dologies was presented earlier (Crowley, AAFS/2005; 2007). Toluidine blue
ring this time, the medical examiner may play an important role in the cor- is specific for zones of parakeratosis and results can be due to inflammatory,
roboration of witness statements and other evidence by providing benign, or malignant vulvovaginal diseases. Following application of tolui-
information on the direction of the wound tracks, range of fire, and opining dine blue dye in vivo, false positive results may be caused by 23 benign vul-
on how the injuries may have affected the victim during the course of the vovaginal conditions, in addition to cervical mucous. In nongenital sites,
event. toluidine blue dye has been shown to yield positive results in granulation tis-
Although police shootings in which the decedent was unarmed and/or sue (Crowley, 2007).
sustained numerous gunshot wounds are widely reported by the lay press, Using Crowley’s mobile system of technology, the clinical phase of this
these types of shootings were not typical in our study. The vast majority of research project began in March, 2007, at the Donated Body Program at the
police-shootings occurred with the police responding to a crime in which the University of California, Davis, California. The research project is an ob-
decedent was armed. In addition, most of the decedents had 3 or fewer gun- servational study, with a cross-sectional design. The examination methodo-
shot wounds. logy employs photocolposcopy at 7.5X, 15X magnification, or both, plus 35
Forensic Pathology, Firearm, Police mm photography via the colposcope. Additional photographs are taken with
a 35mm single lens reflex (SLR) digital camera, for comparison. Inspection
and photodocumentation of specific anogenital sites is employed, prior to
manipulation of the genital tissues. On select cases, concomitant application
of a 1% solution of toluidine blue dye has also been incorporated, in order all attributed to Sebai. Most of the victims were stabbed multiple times on
to evaluate the reliability of this general nuclear stain as an adjunct to the po- the neck (min. 1, max. 20) with the exception of three cases in which the
stmortem examination. cause of death was manual strangulation. The assailant had sex with only one
Available demographic data is collected on each case, which is assi- victim and sperm traces were recovered on the body. All the victims were
gned a unique identifier, for entry into a modified version of the Sexual Ho- found in their own apartments with no sign of break-in. However, the
micide Database. Eleven anatomic sites are routinely evaluated and murders were connected to the theft of money and/or jewelry. The press
documented on the postmortem worksheet. Inspection, labial separation, alerted the public to the inability of the local police to seize the guilty party.
and labial traction are used to maximize visualization, in addition to specu- In the meantime a criminal profiling was requested to aid the local police in
lum insertion and anoscopy. The nature and pattern of postmortem genital refining their suspect list. The results showed that the murder pattern was
findings are described in a manner consistent with the proposed taxonomy completely inconsistent with the local criminal patterns, suggesting that the
for postmortem anatomy previously described by Crowley and Peterson perpetrator could be an illegal immigrant sexually motivated or prior arrested
(AAFS/2004). for sex-related incidents. On the 15th of September, 1997, Sebai was arrested
Currently, a wide variation exists in the methodology for the examina- while attempting to catch a train after his last murder. Sebai was recognized
tion of antemortem sexual assault victims. Protocols and procedures vary, by an 8-year-old child next-door neighbor of the victim while he was casting
especially with regards to adjunctive methods, e.g., application, timing, and off his blood-stained clothing. He was convicted of four murders and given
interpretation of toluidine blue dye. Postmortem challenges are multiface- life sentence.
ted; they may pose even greater significance than in living victims. Post- For the remaining homicides, other people were convicted; in most
mortem deposition of the victim’s remains usually precludes the opportunity cases they were relatives of the victims spurred by economical reasons. In
for a follow-up examination/re-evaluation. Moreover, when experts whose 2006, after nine years, Sebai admitted responsibility for the murders of four
sole expertise is with the antemortem victim are asked to collaborate in a more elderly women, for which nine other people had already been
sexual homicide case, even greater challenges arise. The expert must consi- convicted, among whom one had committed suicide in jail in 2005. The
der working as a team member, not in a vacuum; their frame of reference reasons of this posthumous confession are to be found in his willingness to
cannot solely reside in the antemortem arena. clear these people of a groundless charge and hand over the crime weapon
The higher magnification potential of the colposcope affords greater never found before. One year later, in 2007, he confessed to seven more
opportunity for careful scrutiny and photodocumentation. This improves murders,,with all 15 deaths occurring between 1994 and 1997. After first
both the diagnostic acumen of the examiner and the quality of the postmor- interviews with Sebai, a story of difficulty during childhood involving his
tem genital examination. Colposcopy facilitates peer review, salient to the grandmother; apparently she allowed his uncles to abuse him. His father was
scientific process and eventual applicability of the research endeavor. violent too. He hit Sebai on his feet after hanging him face down. Sebai’s
It is certainly true that in equivocal cases, the Forensic Pathologist can techniques were quite simple; once he studied the elderly women’s habits, he
simply remove en bloc, for dissection and microscopic evaluation, the tissues made sure that nobody was in and he intruded under the pretext of a sales-
germane to genital findings. However, it may prove to be beneficial to have man of holy pictures then burst into the house. He deliberately chose the
an initial in situ examination of the anogenital anatomy via colposcopy. victims, having no prior personal connection with them at all. The neck was
The ultimate goal is to better visualize, in order to improve our under- his favourite target because there the stab wounds can produce rapid death
standing of what is normal in the anogenital anatomy during the postmortem by exsanguination. With profuse bleeding, physical activity of the victim is
interval. also limited or lost rapidly preventing victims from screaming. He also
Forensic Clinical Nurse Specialist, Colposcopy, Donated Body Pro- confessed that at the end of each murder he used to ejaculate confirming the
gram previous hypothesis of homicides sexually motivated. Sebai’s criminal
profiling is still going on and further developments of this case cannot be
excluded.
G57 The Serial Killer of Elderly Women: Serial Killer, Multi-Victim Homicide Investigation, Criminal Profiling
Analysis of a Multi-Victim Homicide
Investigation G58 One Entrance Wound, Three Bullets, and
Carlo P. Campobasso, MD, PhD*, University of Molise, via De Sanctis,
Four Pulls of the Trigger: An Unusual Case
snc, Campobasso, 86100, ITALY; and Massimo F. Colonna, MD, Felice of a Suicidal Gunshot Wound of the Head
Carabellese, MD, Ignazio Grattagliano, PsyD, Chiara Candelli, MD, and
Roberto Catanesi, MD, University of Bari, Section of Forensic Psychiatry, Todd M. Luckasevic, DO*, Alleghey County, Office of the Medical Exami-
Piazza Giulio Cesare, Bari, 70124, ITALY ner, 542 Fourth Avenue, Pittsburgh, PA 15219; Kenneth Clark, MD, Uni-
versity of Pittsburgh Medical Center, 200 Lothrop Street,
After attending this presentation, the participants will learn: (1) the
Pittsburgh, PA 15213; and Abdulrezak M. Shakir, MD, and Karl E. Wil-
practical issues involved in investigating and analyzing the actions of a serial
liams, MD, MPH, Alleghey County, Office of the Medical Examiner, 542
murderer, and (2) the motives, methods of operation, victim selection,
injuries and body disposal scenarios highlighted through case examples never
presented before. The goal of this presentation is to illustrate an unusual case of suicide
This presentation will impact the forensic community by showing a with a revolver and multiple squib bullets.
little-known but noteworthy case of a serial killer murder of an elderly This presentation will impact the forensic community by illustrating
women occurring in Southern Italy ten years ago. the need for close collaboration between the forensic pathologist and the fi-
Ben Mohamed Ezzedine Sebai, is a convicted Italian serial killer. rearm examiner when dealing with cases of unusual gunshot wounds.
Originally from Kairouan (Tunisia), he immigrated illegally to Italy in 1990. Suicide is one of the most important public health issues in the United
In 1991 he was charged of attempted murder and rape and the police head- States. Suicide represents the eleventh leading cause of death in the United
quarters of Bolzano issued an expulsion order. He fled and took refuge in the States. Suicides comprise approximately 12% of the caseload of the Alle-
province of Foggia (Southern Italy), where he worked as farm laborer. He gheny County Medical Examiner’s Office in Pittsburgh, Pennsylvania. Sui-
begged for money and relied on voluntary organizations managed by cide rates for this country have been relatively stable over the past decade
religious institutions for food and shelter. Between 1994 and 1997, in the averaging approximately 10 per 100,000 populations. The most common
territories of Southern Italy, fifteen women aged over 70 were murdered. method of suicide in the United States is the use of a firearm.
One victim in 1994, two victims in 1995, three in 1996, nine in 1997, but not An elderly Caucasian male with a history of prostate cancer recently
learned that his prostate cancer had metastasized to his pancreas. Family friends who were helping him move out of his home. He was lying on the
members relayed that he made comments that he did not want to go through concrete floor with an obvious wound to his lower left chest. Emergency me-
radiation and chemotherapy treatment again. On the morning of his demise, dical personnel responded, as did police. He was pronounced dead at the
the decedent told his wife that “It just ain’t worth it anymore.” Later that scene. The coroner was notified. The police and coroner believed that the
morning his elderly wife heard a thump in the adjacent room. The decedent chest wound was the probable cause of death, and their initial impression
was found in the fetal position on top of his overturned walker. The wife cal- was that it represented some sort of impaling wound. The basement was re-
led her brother-in-law to help, at which time they found blood coming from latively empty, as the man and his friends had been moving his belongings
his head and a revolver in his right hand. out of the home. An old shotgun barrel was seen lying on the floor near the
The external examination revealed an elderly Caucasian male with a body, but it was not initially considered significant. Examination of the body
single contact penetrating gunshot wound of entrance to the right temple re- at autopsy revealed the true nature of the wound: a non-contact shotgun
gion of the head. Dense soot deposits were present on the skin and within wound with wad-petal abrasions and stippling. Close inspection of the shot-
the wound track. A faint muzzle abrasion was identified surrounding the en- gun barrel and scene disclosed a spent shotgun shell within the barrel, mul-
trance wound. Gunpowder residue was grossly visible on the left index fin- tiple small indentations on the base of the shell, including one on the primer,
ger. Radiographs of the head revealed three separate bullets. Autopsy and a BB pellet on the floor near where the man and the shotgun barrel were
revealed a single entrance with internal beveling of the right temple bone. discovered. It was surmised that the man, while bending at the waist and
The path of the bullets was leftward through the bilateral temporal lobes of leaning over, held the barrel in a vertical position, with the muzzle end di-
the brain. One .38 caliber slug was recovered from the left temporal lobe and rected upward toward his chest and the opposite end, containing a loaded
the other two slugs were recovered from the subcutaneous tissue of the left shell, toward the floor. By slamming the base of the shotgun shell on a BB
temporal scalp. on the floor, the man eventually hit the BB with the primer, causing the wea-
The firearms report found the Colt .38 special caliber revolver to be in pon to discharge.
good working order. The six shot cylinder of the revolver contained three The present case serves to remind death investigators of the importance
spent cartridges and three live cartridges. Interestingly, the three spent car- of a thorough scene investigation as well as the importance of maintaining an
tridges were in positions 1, 2, and 4. In position 3 was a live round with its open mind regarding the cause and manner of death. In this case, the initial
primer struck. The three slugs recovered from the decedent’s head were .38 concern was for a homicide with an impaling wound. Autopsy and subsequent
caliber lead wad cutter-type bullets that were found to be fired by the above investigation revealed the truth—a suicide employing a shotgun fired in a very
Colt revolver. unique manner. The case provides another example of how suicidal indivi-
Collaboration between the pathologist and firearms examiner conclu- duals can be very creative when it comes to discharging a weapon.
ded that the decedent used his right thumb to pull the trigger four times and Suicide, Shotgun, Barrel
his left hand was used to steady the revolver. The first two cartridges were
squibs that lodged in the barrel of the revolver. The third cartridge was a
dud; the primer was struck with the revolver’s firing pin but it did not di-
scharge. The fourth cartridge was live and when struck by the firing pin di-
G60 Characteristics of Suicidal Gunshot
scharged forcing itself and the two lodged squib bullets out of the barrel of Wounds to the Mouth in Women
the revolver and through the skull and brain of the decedent creating one
classic entrance wound and bullet path. The bases of the two squib bullets Lakshmanan Sathyavagiswaran, MD*, Christopher B. Rogers, MD, Fran-
confirm this scenario along with the deformation of the nose of the first squib ces Hicks, and Donald Boger, MD, Los Angeles County, Medical Exami-
slug and the relative pristine nature of the fourth live round. ner’s Office, 1104 North Mission Road, Los Angeles, CA 90033
Suicide, Handgun, Squib Bullets After attending this presentation, attendees will become familiar with
the characteristics of suicidal gunshot wounds to the mouth in women, par-
ticularly relating to the circumstances in which the decedent shot herself.
G59 Suicidal Shotgun Wound Using a Shotgun This presentation will impact the forensic community by drawing at-
Barrel, a Shotgun Shell, and a BB tention to an unusual case and reviewing factors which may be used to di-
stinguish homicide from suicide in female victims of oral gunshot wounds.
Brian S. Linert, BS*, 2102 North Meridian Street, Apartment 9, Indiana- In 2003, an unusual case occurred in which the decedent, a 40-year-old
polis, IN 46202; Janis Regnier, Portage Police Department, Portage, IN ; woman, sustained a gunshot wound of the mouth in another person’s resi-
Barrett W. Doyle, Porter County Coroner’s Office, Valparaiso, IN; and Jo- dence, and in his presence. Her skirt had been removed and folded in her
seph A. Prahlow, MD, South Bend Medical Foundation, 530 North La- purse, and the crowns of her central incisors were chipped. An important
fayette Boulevard, South Bend, IN 46601 forensic issue in this case was whether the mode of death was homicide or
After viewing this presentations individuals will be better able to reco- suicide.
gnize unusual patterns of suicide. These patterns include: homemade or im- In calendar years 2004-2006, the Los Angeles County Department of
provised firearms, unusual firing positions, and disguise of the suicide as a Coroner examined 755 victims of suicidal gunshot wounds. Of these, 80
murder. (11%) were female. Of the female victims, 72 (90%) used handguns and 8
This presentation will impact the forensic science community by pro- (10%) used rifles or shotguns.
viding another unusual example of the use of a firearm for suicidal purposes. The gunshot entry wound was located in the mouth in 24 individuals.
It also stresses the importance of good investigative technique as well as The ages of these 24 victims ranged from 34 to 90. A suicide note or equi-
maintaining an open mind throughout the duration of an investigation. valent (telephone call, estate documents left out) was present in 14 cases
Suicidal gunshot wounds are common in the United States. Many of (58%).
these cases involve handguns; however, the use of long guns such as rifles In virtually every case, the decedent was fully clothed (23/23 cases; one
or shotguns is also prevalent. Occasionally, an individual will employ the use case where amount of clothing was unknown) and the gunshot wound was
of a homemade firearm or ‘zip gun’. Creative or elaborate mechanisms for inflicted at the decedent’s home (21/24 cases, 88%). The shooting was
pulling the trigger are sometimes devised. Some individuals go to great unwitnessed in 22 cases (92%).
lengths to conceal the weapon, confusing the issue and making the suicide In 20 cases, the decedent did not sustain chip fractures of the tips of the
appear as a homicide. In this report, we describe an unusual suicidal shot- incisors by x-ray. In two cases the decedent was edentulous, and in two cases
gun wound, in which the victim used a shotgun barrel (without the rest of the the presence of fractures could not be ascertained because of extensive de-
gun), a shotgun shell, and a BB. struction of the mouth by the firearm wound.
A 54-year-old man was found dead in the basement of his home by The caliber of the gun varied widely. There were two injuries with .22
caliber weapons, one with a .25 caliber weapon, one with a .32 caliber wea- of 3 out of the 14 physically abused victims was characterized as dangerous
pon, three with 9 mm weapons, five with .357 caliber weapons, nine with .38 (2 females, 1 male) and 11 as simple or light (9 females, 2 males). The
caliber weapons, and one with a .45 caliber weapon. One decedent used a families of 15 victims resided in urban centres and the rest 3 in the country,
12 gauge shotgun, and one used a 20 gauge shotgun. respectively. As far as the nationality of the victims is concerned, one family
Suicidal gunshot wounds of the mouth are unusual in women, occurring was Eastern European while the rest (17 families) were Greek. The above
in 24/755 of our suicidal gunshot wounds in this series (3%). In the large categorization of physical and sexual abuse was performed according to the
majority of cases, the female victims of suicidal gunshot wounds to the Greek legal system (Greek Criminal Law).
mouth were fully clothed and committed suicide unobserved in their own Demographic and social characteristics of the victims included:
residences. Chip fractures of the tips of the incisors were not seen in our • Delay in Seeking Help: 38 (70%)
cases. Most victims in this case used handguns rather than rifles or shot- • “Difficult Child”: 24 (44.4%)
guns. On the other hand, presence of a suicide note and caliber of the gun • Unwanted Pregnancy: 21 (39%)
were not distinctive features of this group of cases. • Illegitimate Child: 7 (13%)
In determining the mode of death in a gunshot wound of the mouth in • Difficult Pregnancy and Delivery: 19 (35%)
a female victim, it may be valuable to note the circumstances in which the • Premature Child: 8 (14%)
injury occurred; particularly whether the decedent was clothed, whether the • Problem during the Neonatal Period: 15 (28%)
injury was observed, and whether the decedent was in her own residence. • Illness during the first months of life: 12 (22%)
Gunshot Wound, Suicide, Female Summarized medical findings in 18 cases of abused children,
adolescents and young adults included:
• Blunt Force Injuries: 23 (42.5%)
• Craniocerebral Injuries (including fractures): 19 (35.2%)
G61 Victimization of Children, Adolescents, • Fractures of Long Bones: 8 (15%)
and Young Adults by Physical and/or • Burns and Scalds: 7 (13%)
Sexual Abuse in Northwestern Greece: • Sharp Force Injuries: 5 (9.2%)
• Developmental Disorders: 15 (28%)
A Three Year Study • Psychomotor Retardation: 7 (13%)
• Congenital Malformations: 1 (1.8%)
Vasilios S. Stoukas*, Telamonos 25, Anthoupoli, Peristeri, Athens, 12135, • Other: 4 (7.4%)
GREECE; Angeliki Tsiola, MD, Patras, GREECE; and Anastasia * Several victims were diagnosed with more than one finding.
Varvarigou, MD, University of Patras, Medical School, GREECE There is no doubt that child abuse and neglect is manifested in
After attending this presentation, attendees will become familiar with Northwestern Greece with characteristics similar to those described in other
the epidemiologic, demographic, social and medical features of child, areas of Greece and in foreign countries. Nevertheless, in our study there was
adolescent and young adult victims of physical and/or sexual abuse in a high prevalence of females among the victims, an argument that comes in
Northwestern Greece. controversy with the standing esteems medical examiners have in Greece.
This presentation will impact the forensic community by demonstrating The relatively low number of reported cases (26 cases, less than 9 per year)
the value of data collection and interdisciplinary research work as an is primarily a result of lack of the Greek National Health System’s
important initial step in facing child abuse (either physical or sexual) organization, but may be also attributed to the nature of the Greek family
effectively. which precludes the maltreatment of children. Indisputably, there is wide
Child abuse is a worldwide problem, although its manifestations and denial of a child abuse problem among professionals in Greece, especially in
extent in specific regions may vary. It is far more prevalent and detrimental the medical profession. Notwithstanding, Greece is just making its initial
than is generally recognized, having both short and long-term physical, steps in identifying and facing the phenomenon of child abuse and neglect,
psychological, and social consequences. In Greece mild physical punishment and we are very optimistic that the situation will be ameliorated in the near
of children is considered to be a normal aspect of child rearing. Compared future.
to other countries (e.g., USA, United Kingdom or Japan) the reported Forensic Medicine, Child Abuse, Northwestern Greece
incidence of child abuse in Greece is minimal. It is probable, however, that
the rate is underestimated because of the lack of mandatory reporting of child
abuse, and also because of inadequate awareness among health care G62 Aneurysms and Old Lace: A Ruptured
providers. A priori, these circumstances make any effort of estimating the
true extent of child abuse in Greece even harder. Splenic Artery Mycotic Aneurysm
The incidence, gravity and the social and medical characteristics of the Masquerading as Arsenic Poisoning
reported cases of child, adolescent and young adult abuse in Northwestern
Greece were the parameters chosen to be investigated. A comparison was Sam Simmons, MD*, and Gregory J. Davis, MD, University of Kentucky,
also done to the characteristics found in other areas of Greece and foreign Medical Center, MS 117, 800 Rose Street, Lexington, KY 40536-0298
countries. Data survey was performed through the retrospective analysis of
child, adolescent and young adult abuse cases, for the period November 2004 After attending this presentation, attendees will gain a better under-
to December 2006, based on the archive files (forensic reports) of the Patras standing of the clinical presentations of patients with abdominal mycotic
Medical Examiner Office, which serves the entire region of North-western aneurysm and understand the usual clinical findings associated with arsenic
Greece. poisoning and its differential diagnosis.
Twenty-six (26) cases of child, adolescent and young adult abuse were This case study discussion will impact the forensic community and the
reported. The age of the victims ranged between 1 and 20 years old for both general medical community by highlighting the clinical signs and symptoms
sexes. From these 26 cases, 18 were identified as physical and/or sexual of a patient with a fatal ruptured splenic artery mycotic aneurysm, expan-
abuse. At the rest 8 cases neither physical nor sexual abuse findings were ding clinicians’ and investigators’ knowledge bases to heighten pre-mortem
established. Six (6) cases concerned rape or sexual abuse, and the victims’ suspicion of such cases, thus decreasing the mortality of mycotic aneurysms
age ranged between 5 and 15 years old. Four (4) victims were males and 4 and decreasing unfounded accusations of poisoning.
were females respectively. The 18 established cases of physical and/or sexual The term mycotic aneurysm is often used to describe infected aneury-
abuse included 4 victims of rape (3 were females), and 14 children and sms within the vascular system. These lesions are classically caused by bac-
adolescents physically abused. The significance of the injuries (see table 2) terial endocarditis when multiple downstream vessels are showered with and

seeded by bacterial emboli. In recent times, these aneurysms are seldom at- potentially lead to sudden unexpected death. Moreover, the definitive dia-
tributed to fungal organisms, and may also be referred to as infected aneury- gnosis requires histopathological examination of the pituitary gland. Given
sms. the inconsistent practice of pituitary sampling, this presentation will impact
A high level of clinical suspicion is often required, augmented by blood the forensic science community by presenting how lymphocytic hypophysi-
cultures, echocardiograms to identify endocardial vegetations, and additio- tis may be an underrecognized cause of sudden death.
nal imaging studies such as MRI or CT scans to identify specific emboli, Lymphocytic hypophysitis is an unusual inflammatory condition of the
aneurysms, or downstream infarcts. Treatment includes antibiotic therapy, pituitary gland, classically seen in females during the peripartum periods.
and often surgical removal of the aneurysm. Symptoms vary, depending on The clinical presentation is varied and depends on hormonal deficiencies and
the vessels or organs involved by the aneurysm. Mycotic aneurysms in the pathophysiological effects on the target organs. While involvement of the
splenic or mesenteric arteries may present with nonspecific abdominal pain, neurohypophysis and secondary diabetes insipidus are rare, progression to
or no pain at all. Due to the usual concurrent bacteremia, these patients often multiple organ endocrinopathies is common. Pathologically the condition is
complain of headaches, and demonstrate confusion or drowsiness. characterized by lymphocytic infiltration of the hypophysis with occasional
Similarly, victims of arsenic poisoning can have varying levels of cli- involvement of the thyroid and adrenal glands. In this report, we present the
nical symptoms, depending on the amount of arsenic ingested. The baseline case of a 23-year-old woman diagnosed at autopsy with lymphocytic hy-
health status of the patient will also affect his or her reaction to the poison. pophysitis, with concomitant infiltrates in the thyroid gland and adrenal me-
Low levels of arsenic can cause headaches and confusion. Diarrhea, vomi- dulla, who died suddenly and unexpectedly, with no other apparent cause of
ting, and stomach pain are more common with higher levels of poison. Be- death. While the precise mechanism of death is unclear, this case raises the
cause arsenic is a frequent component of daily household cleaning products possibility of endocrine dysfunction as a contributing factor to sudden death
and some food items, a low level of arsenic may be detected in many indi- and emphasizes the need for greater awareness of the entity and routinely
viduals. Individuals who are poisoned, either through accidental expo- sampling the pituitary gland in cases of sudden unexpected death.
sure/ingestion or due to purposeful poisoning by another person usually Lymphocytic Hypophysitis, Pituitary, Sudden Death
exhibit higher levels of detectable arsenic. Arsenic levels are generally de-
tected by chemical analysis of hair or urine. Hair samples may show falsely
elevated levels of arsenic, due to environmental accumulation of arsenic on
the hair. However, hair follicles retain arsenic for much longer periods than
G64 Medico-Legal Aspects of Posttraumatic
it can be detected in the urine. Nails and skin can also harbor arsenic for Gastroduodenal Ulcers
long periods of time.
An elderly gentleman lived in a nursing home and was the suspected Slobodan Savic, MD, PhD*, School of Medicine, University of Belgrade,
victim of arsenic poisoning at the hands of one of his children with whom Institute of Forensic Medicine, Deligradska 31a, Belgrade, YT 11000,
there had been a recent property dispute. The patient initially complained of SERBIA AND MONTENEGRO; Radmila Stevanovic, MD, MSc, Institute
nondescript but at times severe abdominal pain. Clinical specimens (hair of Pathology, School of Medicine, University of Belgrade, 8 Dr Subotica
samples) taken shortly before his death revealed no toxic levels of arsenic. Street, Belgrade, 11000, SERBIA AND MONTENEGRO; Djordje
Shortly thereafter, he died secondary to a ruptured splenic artery mycotic Alempijevic, MD, PhD, Institute of Forensic Medicine, 31a Deligradska
aneurysm. Street, Belgrade, Serbia 11000, SERBIA AND MONTENEGRO; and
At autopsy, the gentleman was found to have a hemoperitoneum and a Stojan Petkovic, MD, MSc, Clinical Center of Vojvodina, Institute of
large retroperitoneal hematoma in the area of the splenic artery, due to an Forensic Medicine, 5 Hajduk Veljkova Street, Novi Sad, 21000, SERBIA
apparent ruptured aneurysm. No endocardial vegetations were identified. AND MONTENEGRO
There was evidence of pyelonephritis in the kidneys. Pre-mortem arsenic le-
On the basis of presented data attendees will be well acquainted with the
vels were measured clinically via hair analysis, and were found to be within
important medicolegal and clinical characteristics of posttraumatic
normal limits.
gastroduodenal ulcers that can be very serious and even fatal complications
Further discussion will outline the incidence and various clinical pre-
of various types of injuries.
sentations of mycotic aneurysms, methods by which these aneurysms have
The presentation will impact the forensic community by the fact that in
been detected in other cases, and ensuing successful clinical interventions.
cases with development of posttraumatic stress ulcers medicolegal expertise
For the purposes of comparison, the typical findings of arsenic poisoning
of injuries may be very complicated, especially if fatal complications of stress
and their overlap with this case will be discussed.
ulcers occur (hemorrhage, perforation), since in such cases the causative
Aneurysm, Mycotic, Arsenic relationship between the primary injuries and fatal outcome should be
explained. On the other hand, the important influence on humanity may
have data that indicate the most risky injuries concerning development of
G63 Lymphocytic Hypophysitis Associated stress ulcers, as well as the importance of their adequate prevention during
the treatment of injured individuals.
With Sudden Unexpected Death in a The posttraumatic gastroduodenal ulcers (PGDU), so called stress
Young Woman ulcers, represent very important, sometimes life threatening or even fatal
complication of various types of injuries. Therefore, a broad autopsy study
Rudy J. Castellani, MD*, and Luis F. Gonzalez-Cuyar, MD, University of was performed in order to analyze frequency and other important forensic
Maryland, Baltimore, Department of Pathology, 22 South Greene Street, and clinical characteristics of PGDU.
Baltimore, MD 21201; Fabio Tavora, MD, Johns Hopkins Hospital, 600 The study was divided in a retrospective part (period 1996-2000, 5197
North Wolfe Street, Baltimore, MD 21205 ; Kyle Shaw, MD, University of autopsies), and a prospective part (period 2004-2005, 2356 autopsies). In
Maryland, Baltimore, Department of Pathology, 22 South Greene Street, the retrospective part of the study 157 autopsy cases with posttraumatic
Baltimore, MD 21201; and Joyce L. deJong, DO, Sparrow Forensic gastroduodenal ulcers were observed (experimental group), and 730 cases
Pathology, 1215 East Michigan Avenue, Lansing, MI 48909 without posttraumatic ulcers (control group). In the prospective part of the
study 45 autopsy cases with posttraumatic ulcers were analyzed
The goals of this presentation are to recognize clinical setting and patho- (experimental group), and 212 cases without posttraumatic ulcers (control
logical changes in lymphocytic hypophysitis, and to recognize importance of group).
sampling the pituitary for histopathology in young women with sudden unex- Data were obtained from autopsy protocols, anamnestic data from the
pected death. deceased’s family members and accessible medical records. Degree of the
Lymphocytic hypophysitis causes endocrine dysfunction that could injury severity was presented by ISS value. Furthermore, in the prospective
part of the study histological examination of small vessels of the abdominal death after mechanical pressure (such as strangulation, short-termed neck
organs was performed in order to investigate influence of atherosclerosis on trauma and/or other traumatic injuries) against the carotid sinus region were
development of PGDU. The obtained results were analyzed by means of published in the literature. The autopsy signs were the lack of local vital
appropriate statistical methods. signs (such as absence of congestion, cyanosis, petechiae), indicating a very
In both retrospective and prospective part of the study, the percentage short agony possibly due a reflex mechanism.
of occurrence of PGDU was approximately 17% among all cases with In recent times, there has been an observed increase in numbers of
potentially risky injuries. Posttraumatic ulcers are more common in males clinical forensic cases in which the victim have suffered neck compression.
(around 77% of all individuals with stress ulcers), as well as in older age Some victims show suggestive signs (e.g., petechiae, bruises). Other victims
(over 50 years). The outliving period ranged between 24 hours and 25 days, do not show any objective signs but anamnestic subjective symptoms are
but it was often no longer than 12 days (76%). From the preventive point of consistent with neck compression. The role of the forensic expert is to
view, it is important to point out that 16.5% out of all PGDU in the evaluate if there was life endangerment subsequent to compression based on
retrospective part, and 15.5% in the prospective part of the study, was found objective and subjective findings.
at autopsy in the injured individuals who outlived trauma less than 48 hours. The question whether ‘violence against the neck may cause life
The manner of trauma was mostly accidental with the vast majority of endangerment by cardio-inhibitory reflex’ is often the subject of discussion
traffic accidents (66%), and with the highest absolute number of pedestrians in medicolegal practice. The answer to this question may have important
(66). The main causes of death in the experimental group were as following: consequences in penal jurisprudence, particularly in cases in clinical forensic
damage to the vital brain centers (64%), chest injuries (13%), spinal cord medicine.
injuries (6%), burns (6%) and complications of injuries. The most of injured In order to evaluate this question we mailed six questions in the frame-
persons with posttraumatic ulcers sustained multiple injuries, that is poly- work of a qualitative and quantitative study to the members of different
trauma. Isolated craniocerebral injury was found in 25% cases with post- organisations of legal medicine: IALM, AAFS (International listing),
traumatic ulcers. In majority of cases with mechanical injuries, the calculated NAME, French Society of Legal Medicine, German Society of Legal
ISS value was ≥ 16. Medicine, and the Swiss Society of Legal Medicine.
The most risky injuries for development of PGDU appeared to be The survey was conducted by E-Questionnaire based on the opinion,
isolated spinal cord injuries. Namely, among all cases with isolated spinal experience, and collaboration of several experts from about thirty countries.
cord injuries, PGDU were diagnosed in 50% in the retrospective part, and in The two principle questions were: (1) can cardioinhibitory reflex
25% in the prospective part of this study. The other types of injuries with subsequent to neck injury cause death (forensic pathology)? And (2) can
high risk for development of PGDU were burns and scalds, isolated cardioinhibitory reflex subsequent to neck injury cause life endangerment
mechanical craniocerebral trauma, and mechanical polytrauma. This (clinical forensic medicine)?
investigation shows that small vessels changes of the stomach and other The questions required the participants to specify how often they made
abdominal organs are not very important factor in pathogenesis of posttrau- this kind of diagnosis and on which criteria they based their conclusions.
matic ulcers, while the most important suppose to be functional disturbances Criteria for forensic pathology included the following: provided information,
of microcirculation caused by the primary injuries. postmortem examination (macroscopic), histological examination,
The stomach was the most frequent localization of PGDU, mostly with complementary investigations (such as medical imaging), or by elimination.
numerous lesions (so called erosive gastritis). Duodenum was the most Criteria for clinical forensic medicine included the following: provided
frequent site of solitary ulcers, as well as exacerbated chronic peptic ulcers. information, subjective findings (such as spots before the eyes, loss of
Complications of PGDU were found at autopsy in 40% of all cases with consciousness), objective findings on the victim, complementary
stress ulcers, mostly in form of hemorrhage, and rarely as perforation, and investigations (such as medical imaging), or by elimination. Other variables
penetration. In 20% out of all 157 cases with PGDU in the retrospective part concerning the forensic experts were the following: active - emeritus, years
of the study, the postmortem diagnosed complications of PGDU were of experience in forensic pathology and/or clinical forensic medicine,
proclaimed to be a cause of violent death in the autopsy protocols (mostly principal discipline of activity: forensic pathology, clinical forensic medicine,
mutually with primary injuries). genetics, and toxicology.
In the medicolegal expertise of cases with PGDU, three main problems The preliminary analysis indicates that over two-thirds of the partici-
usually appear: (1) estimation of severity of primary injuries, (2) establish- pants believe that neck injury can induce a cardioinhibitory reflex and
ing of causative relationship between the primary injuries and lethal outcome therefore life endangerment is possible. About a third of the experts use the
in cases with fatal complications of PGDU (mostly hemorrhage with cardioinhibitory reflex in their medicolegal opinions to confirm life
resultant exsanguination), and (3) possible accusation of treating physicians endangerment in clinical forensic medicine or as a cause of death. They base
for medical negligence. their diagnosis on different criteria.
Medico-Legal Aspects, Stress Ulcer, Trauma Cardioinhibitory Reflex, Neck Compression, Life Endangerment
G65 Death Caused by Cardioinhibitory

Reflex: Myth or Reality? G66 Ehlers-Danlos Syndrome Type IV
(Vascular): An Atypical Presentation
Bettina Schrag, MD*, Béat Horisberger, MD, and Patrice
Mangin, MD, PhD, University Lausanne, Institute of Legal Medicine,
and Unexpected Diagnosis in a Medical
Rue du Bugnon 21, Lausanne, SWITZERLAND Examiner Setting
The goal of this presentation is to inform the medicolegal community
James L. Caruso, MD*, Armed Forces Medical Examiner System, U.S.
about the different practices in using the cardioinhibitory reflex.
Naval Hospital, Okinawa, Japan, PSC 482 Box 2560, FPO, AP 96362
informing the medicolegal community about the mainstream opinion. After attending this presentation, attendees will have a basic knowledge
It has been known for hundreds years that pressure applied to the carotid of the pathophysiology of the Ehlers-Danlos Syndrome, particularly the most
sinus region may result in unconsciousness and convulsions. Hering and severe form, Ehlers-Danlos Syndrome Type IV. They will also learn some
Heymans demonstrated that stimulation of the carotid sinus region results in of the basics of the genetic testing performed and be made aware of resour-
a number of reflexes, with effects on the cardiac rhythm, vascular tonus, and ces available should this diagnosis be suspected.
respiratory function. Ever since, a number of reports dealing with cases of Because Ehlers-Danlos Syndrome can result in premature death, which
may be related to trauma or even mistakenly thought to be due to trauma, this G67 Mechanisms of Delayed Splenic
presentation will impact the forensic science community by demonstrating
how it is important for medical examiners and forensic investigators to be
Rupture: A New Hypothesis
aware of this clinical entity and have a basic understanding of the pathophy-
siology. Sarathchandra Kodikara, MBBS, MD, DLM*, NIL, Department of Foren-
Ehlers-Danlos Syndrome is a group of genetically inherited defects in sic Medicine, Faculty of Medici, Peradeniya, SRI LANKA; and Muruga-
collagen synthesis characterized by a wide array of clinical manifestations pillai Sivasubramanium, MBBS, MD, DLM, Teaching Hospital, Kegalle,
and with diverse clinical presentations. Because Ehlers-Danlos Syndrome Sri Lanka
can result in premature death, which may be related to trauma or even mi- After attending this presentation, attendees will understand a new hy-
stakenly thought to be due to trauma, it is important for medical examiners pothesis which describes a potential mechanism of delayed splenic rupture.
and forensic investigators to be aware of this clinical entity and have a basic This presentation will impact the forensic community by introducing a
understanding of the pathophysiology. This presentation will accomplish new mechanism of delayed splenic rupture. Also it impacts the medical and
those goals using a recent case as an example. surgical communities as it guides to reduce the high mortality rate in delayed
There are six recognized major types of Ehlers-Danlos Syndrome, all splenic rupture.
of which vary somewhat in biosynthetic defect, mode of inheritance, and cli- A 46-year-old man was assaulted with a club to the face and chest and
nical presentation. The common feature among the subtypes is decreased tis- sustained multiple contusions. On admission there were no signs of circu-
sue tensile strength, particularly tissues rich in collagen. Elhers-Danlos latory shock. The abdominal examination was unremarkable. During his
Syndrome type IV is the most severe form because the defect involves type stay in hospital he had light diets due to pain and loss of appetite. He was
III collagen and may result in the rupture of large blood vessels or organs. managed symptomatically and discharged five days after the incident.
Complications include arterial and bowel rupture and, in pregnancy, rupture Two hours after discharge he was admitted again with a complain of se-
of the uterus at delivery. vere abdominal pain. He claimed that soon after his return to home, he ate
A recent case at the Office of the Armed Forces Medical Examiner-Pa- two full plates of rice and curry, three mangos, and drank two glasses of
cific Region demonstrated the importance of considering diseases like Eh- water as he was so hunger and developed appetite for home made food. Im-
lers-Danlos Syndrome in the differential diagnosis. An adolescent female mediately after the diet he experienced this abdominal pain.
developed right flank pain and was treated presumptively for a urinary tract On admission, he was pale with a pulse rate of 116 beats per minute and
infection. After a week of both outpatient and inpatient management her a blood pressure of 60/30 mmHg. There was a marked tenderness with ri-
condition did not improve. The patient collapsed while getting out of a vehi- gidity and guarding on abdominal palpation. Bowel sounds were attenuated.
cle and sustained a large scalp laceration. She subsequently went into car- Hemoglobin level had dropped to 7.2 g/ dl from a level of 10.5 g/dl within
diac arrest in the Emergency Department and died in the operating room of five hours. Two pints of blood were transfused. Although it was planned to
the local medical treatment facility. do an ultrasound scan of abdomen the patient was pronounced dead thirteen
During the autopsy the medical examiner was struck by the friability of hours after admission.
the patient’s connective tissue, particularly the mesentery. Multiple vascu- Autopsy revealed a generalized pallor. The abdomen was distended. A
lar defects and complete avulsion of one kidney with partial avulsion of the contusion of 8x3.5 cm was seen on left lower chest laterally. There were no
vascular pedicle of the other kidney were noted. A connective tissue abnor- rib fractures. A hemoperitoneum of 2300 ml was noted. The spleen was
mality, such as Ehlers-Danlos Syndrome, was suspected based on the gross within the normal range. A hematoma of 2.5x3x1.5 cm was seen overlying
anatomic findings. A microscopic examination demonstrated organizing he- a splenic laceration on the gastric area of the visceral surface. The laceration
morrhage outside of the adventitia of the right renal artery, indicating that was 1.25 cm in length with a depth of 0.25 cm, involving splenic capsule
the rupture had evolved over a period of time. and parenchyma. The body of the empty stomach was in contact with this
The medical examiner consulted with a research laboratory that spe- hematoma. Histological examination confirmed the perisplenic haematoma
cializes in the Ehlers-Danlos Syndromes. Frozen tissue specimens were proof otherwise normal spleen.
vided and spleen was used to extract DNA for analysis. The researchers The mechanism of this serious and possible life threatening complica-
identified a mutation in one allele of the COL3A1 gene that is located on ch- tion is still not fully understood. There are a number of potential mechani-
romosome two. The effect on the gene product was deletion of 18 amino sms for delayed splenic rupture.
acids from the protein, accounting for the clinical presentation and autopsy Intrasplenic hematomas, pseudoaneurysms of intraparenchymal splenic
findings. artery branches, and asymptomatic splenic pseudocysts all of which develop
In retrospect the family related that their daughter had always bruised following abdominal trauma and rupture, possibly days, months or years
easily and sustained unusually severe lacerations for seemingly minor trauma later are three mechanisms suggested in this context. Also bleeding from a
as a child. She also had some of the characteristic facial and skin features of splenic rupture could be tamponaded by surrounding organs and /or peri-
Ehlers-Danlos Syndrome as well as the classic finding of joint laxity. Rou- splenic haematoma formed at the time of injury, delaying its rupture at a later
tine laboratory studies performed years earlier to evaluate the problem of date.
easy bruising were all within normal limits. The visceral surface of the spleen consists of gastric, colic and renal
An accurate diagnosis was extremely important to provide closure for surfaces. The gastric surface is directly in contact with the body of the sto-
a family that was attempting to understand how their daughter could be dia- mach. Therefore a perisplenic hematoma which plugs the splenic laceration
gnosed with a urinary tract infection and die one week later. Establishing a on the gastric surface temporarily, may easily be dislodged by the mechani-
diagnosis was critical for the clinicians who took care of this patient, all of cal forces exerted by distending stomach, causing fatal intraperitoneal he-
whom were initially left wondering if there was anything they could have morrrhage. Such risk is imminent during the early period of regeneration of
done to change the outcome. It was also essential to recommend genetic splenic laceration where wound breaking strength is relatively low.
counseling for the parents and siblings of the deceased, particularly since In this case, the laceration occurred at the time of assault was plugged
Ehlers-Danlos Syndrome Type IV is typically inherited in an autosomal do- temporarily by the hematoma. On day five, pressure exerted by full stomach
minant mode. after the heavy solid meal, dislodged the hematoma causing hemorrhage
Special acknowledgement to Peter Byers, MD, Ulrike Schwartz, MD, from the site of laceration.
and Melanie Pipin, MS, in the Department of Pathology, University of Wa- The pressure exerted by full stomach after heavy solid meals may di-
shington, Seattle, Washington, for performing the genetic testing and provi- sturb perisplenic hematoma overlying a laceration on the gastric surface of
ding technical information and support. the spleen causing delayed splenic rupture leading to sudden fatal intraperi-
Collagen, Vascular, Genetic toneal hemorrhage.
It is advisable to maintain a light liquid/ semisolid diet instead of a

heavy solid meal during the period of recovery of the patients who are ha- members who had participated in the mutilation of the corpse were arrested
ving perisplenic haematomas due to lacerations on the gastric surface of the and sentenced to six months in jail. The arrest of the family members, grea-
site of laceration. tly angered local villagers who indicated that this was a practice that been
Delayed Rupture, Spleen, Mechanisms conducted by locals for many centuries. Many villagers praised the action
carried out by the six, noting that it was a great thing to take out his heart as
the people were in danger. Other villagers confessed to have taken the hearts
G68 Death of a Vampire?: Case of from the dead many times before, and to have drunk a solution containing the
Exhumation and Mutilation of ashes of the heart. In their own defense, the leader of the six family mem-
bers pleaded innocent, having done nothing wrong. The leader informed the
a Corpse in Rural Romania police that when they exhumed the corpse he had blood surrounding his
mouth, and that he moaned when they stabbed him with the pitch fork. Plea-
William C. Rodriguez III, Ph.D. *, Office of the Armed Forces Medical
ding with authorities the head family member stated that if he hadn’t con-
Examiners Office, Armed Forces Institute of Pathology, 1413 Research
ducted the ritual, that his son, wife, and daughter- in- law would have died.
Blvd. Building 102, Rockville, MD 20850
Decomposition, Postmortem Mutilation, Ritual
After attending this presentation, attendees will have a better under-
standing on how the misinterpretation of decompositional artifacts have
contributed to beliefs, superstitions and the myth about the existence of vam-
pires. Attendees will be shown a video clip of the actual forensic grave side G69 Sickle Cell Disease and Sudden Death
examination of a reported “vampire” who was put to his final death by family
members. Michelle A. Jorden, MD*, Jennifer A. McReynolds, PhD, and
Even before the famous classic tale of horror “Dracula”, written by Adrienne E. Segovia, MD, Cook County Medical Examiner, 2121 West
Bram Stoker in 1897, the belief of vampires can be traced back as far as the Harrsion Street, Chicago, IL 60612
fifteenth century to various parts of Europe. Of all the various countries and
regions steeped in the belief of vampires and the undead, none run so deep The goal of this presentation is to educate and alert the forensic com-
as in the country of Romania. The belief in vampires is rooted in many cul- munity to the common causes of death in sickle cell patients.
tural beliefs regarding the after life such as the acknowledgement of Satan This presentation will impact the forensic community by demonstra-
and his monstrous minions. Another important aspect of the belief in vam- ting the importance of recognizing pulmonary complications at autopsy that
pires is based on the mis-understanding of the changes that occur to the body are frequently seen in the sickle cell population and which are responsible for
as the result of the decompositional process. Misunderstood changes include causing sudden death. Lastly, the possibility of sickle cell disease should be
the postmortem purging of bloody fluids from mouth and nose which were entertained in any young African-American person who dies suddenly and
thought to be evidence of recent feeding, and the appearance that the hair unexpectedly without a known history of sickle cell disease.
and nails continue to grow after death. Other examples of mis-conception in- Sickle cell disease afflicts one of every 650 African Americans and an
clude the presence of guttural sounds from the deceased as the result of ex- estimated 8% of African Americans are heterozygous for the sickle cell gene.
pelled post mortem gases, and the postmortem pink and reddish Sickle cell anemia is attributed to profound morbidity as well as mortality to
discolorization of the skin which gave the appearance that a corpse had re- those afflicted with the disease. In the clinical setting, sickle cell anemia can
turned to life. present as recurrent infection especially in the younger population and as
A prime example of the deep seated cultural belief in vampires in parts sickle cell pain crisis, stroke, and sudden death in the adult population. In
of rural Romania is demonstrated in a recent case which involves the exhu- 1949, the discovery that sickle hemoglobin exhibited an abnormal elec-
mation, and mutilation of a corpse. In December of 2003 a seventy-six year trophoretic mobility has pioneered our current understanding that sickle cell
old retired school teacher in the rural Romanian village of Marotinul de Sus disease is a molecular disease/diagnosis. With the advent of immunizations
died. At his death, the elderly male was placed in a simple wooden coffin, and vaccinations, antibiotic therapy and the implementation of newborn
which was then buried in a shallow grave located below a make shift stone screening programs, the mortality rate of individuals with sickle cell disease
vault. Later in time various relatives of the deceased begin to fall ill and clai- has declined.
med to have had dreams in which the deceased had risen from the dead as a Although morbidity and mortality from sickle cell disease has declined
vampire to drink their blood. As a result of the unexplained illnesses, and ter- in recent years, a subset of patients die from sudden and unexpected deaths.
rifying dreams, several family members made the decision to follow the an- The most common causes of sudden death in individuals succumbing to
cient cultural tradition, and destroy their now believed undead family sickle cell disease are acute and chronic pulmonary complications that en-
member. compass pulmonary edema, pulmonary thromboembolism/thrombosis, and
In July of 2005 six family members traveled to the cemetery under dark- pulmonary hypertension. Although the literature comments on the presence
ness, and exhumed the body of their deceased relative. Waiting to the stroke of pulmonary thromboembolism as a frequent autopsy finding, the literature
of midnight a member of the group drove a pitchfork into the chest of the cor- is unclear as to whether these patients also exhibited deep venous thrombo-
pse, and then opened the chest cavity with a large knife, and removed the sis. Therefore, sickle cell patients may not share the same risk factors for de-
heart. The corpse was then repeatedly stabbed in various locations with woo- velopment of pulmonary thromboembolism as the rest of the population (i.e.,
den stakes, and garlic sprinkled over the body. The group departed the ce- recent surgery, obesity, and immobilization). Instead, sickle cell patients
metery with the heart impaled on the pitchfork, and proceeded to a near by may undergo pulmonary thrombosis as a consequence of in-situ sickling of
crossroads. At the crossroads, the family members burned the heart, then red blood cells within blood vessels during hypoxic episodes. For forensic
mixed the ashes with peppermint schnapps, and drank the concoction. As a pathologists who perform autopsies on all cases of sudden death, the history
result of their actions, they no longer felt ill, and their terrible dreams of their of sickle cell disease may be absent or may never have been diagnosed, espe-
vampire relative were no repeated. cially in athletic adolescents. Therefore, in those individuals who are of Afri-
Later in time, word of this macabre ritualistic act made its way to the can American race, younger age, and presenting with pulmonary
daughter of the deceased, and local authorities. A second exhumation of the thromboembolism/thrombosis in the absence of known associated risk fac-
corpse was ordered by authorities investigating the horrific act, in which a tors, the importance of a thorough autopsy examination including a detailed
grave side forensic examination was conducted by a forensic pathology gross and microscopic examination of the heart and lungs, and dissection of
team. The grave side examination by the forensic pathology team corrobo- the lower extremity veins, in conjunction with postmortem hemoglobin so-
rated the story of the mutilation, including the removal of the heart. A video lubility/electrophoresis tests are underscored.
clip of the actual grave side examination will be presented. During the past year at the Cook County Medical Examiner’s Office in
As a result of the seemingly indignant and horrid act, the six family Chicago, IL the authors have encountered two (2) cases of young African
American individuals (one female at 31 years old and one male at 38 years The study identified a significant increase in the amount of total nitro-
old) who carried a diagnosis of sickle cell disease and who were found un- gen and soil extractable phosphorous released into the soil. However, the
responsive with no known antecedent symptoms. After a complete autopsy, total available carbon did not increase significantly with time. Lipid-pho-
the cause of death in both cases was pulmonary thromboem-bolism/throm- sphate and fatty acid concentrations also increased with time confirming that
bosis in the absence of deep venous thrombosis. In both cases, the micro- there was a flux in the microbial biomass present in the soil. The pilot study
scopic sections displayed acute and organizing pulmonary thrombi. In was able to highlight the forensic potential of these techniques for estimating
addition, both cases displayed severe pulmonary hypertensive changes cha- the postmortem period and promoted ongoing studies in this area. The re-
racterized by thickened pulmonary arterioles and plexiform arteriopathy. sults have the potential to be used in a forensic investigation involving re-
Given these findings, the decision was made to pull all cases of young mains which have decomposed for an extended period in a soil environment.
African American individuals who died suddenly from pulmonary throm- Decomposition, Soil, Postmortem Period
boembolism/thrombosis without a known history of sickle cell disease over
a two year period. Three (3) additional cases were identified and consisted
of two females and one male (ages 20-40s). Hemoglobin solubility tests
were performed on the postmortem blood of these individuals. The hemo-
G71 A Cadaver Encased Within
globin solubility tests were negative in all three cases. Although the tests Concrete: A Case Report
were negative, we eliminated the possibility of sickle cell disease as a con-
tributory factor and upon further review of these cases, all these cases de- Gilles Tournel, MD, PhD*, Anne Becart-Robert, DDS, Benoît
monstrated deep venous thrombosis, and an identifiable risk factor was Bourel, PhD, Axelle Balgairies, Cédric Houssaye, Valéry Hedouin, PhD,
observed in one case. and Didier Gosset, MD, PhD, Institut de Médecine Légale de Lille, 1,
Sickle cell disease is a common disease that afflicts the African Ame- place de Verdun, Faculté de Médecine, Lille, 59045, FRANCE
rican population. For forensic pathologists, the findings of pulmonary th-
The goal of this presentation is to present an amazing case report on a
rombosis in the absence of deep venous thrombosis and associated risk
cadaver encased within concrete.
factors in the young African American population should alert the forensic
pathologist to the possibility of sickle cell disease and further laboratory te-
showing the particularities of the crime scene and the autopsy of this
sting of postmortem blood for hemoglobin solubility.
deceased person.
Sickle Cell Disease, Sudden Death, Pulmonary Complications Encasings within concrete are relatively rare forms of hiding or
disposing of a body. At first, these cases are often treated as “matters
involving a missing person”. In this case report, the circumstances and
G70 The Biochemical Alteration of Soil findings are described in which a body was encased within concrete. It is of
by Decomposition Products importance to note that the body may be preserved quite well in concrete,
which allows not only the identification of the victim but also the determi-
nation of the cause of death, even after a prolonged postmortem interval.
Shari L. Forbes, PhD*, University of Ontario Institute of Technology,
A male cadaver aged 65 is discovered in reinforced concrete in a cellar.
2000 Simcoe Street North, Oshawa, Ontario, L1H 7K4, CANADA; David
Circumstances of his death, circumstances of his burial, identification,
O. Carter, PhD, University of Nebraska, Department of Entomology, 202
autopsy findings, and the perpetrator’s behavior are described. In March
Plant Industry Building, Lincoln, NE 68583-0816; and Laura A. Bennin-
2003, Mr P’s brother goes to the Police Department and says he hasn’t seen
ger, BSc, University of Ontario Institute of Technology, 2000 Simcoe Street
his brother for five years. The police investigations lead to his wife. She says
North, Oshawa, Ontario, L1H 7K4, CANADA
her husband was very violent physically with herself and their son. Five
After attending this presentation, attendees will understand the impor- years ago, during summer, her husband fell on the floor in their house.
tance of soil analysis in cases involving decomposed remains, and the cor- Because she was afraid of his reactions, she went away from the house, came
relation of soil composition changes with the decomposition period. back three weeks later and discovered her husband dead, still at the same
This presentation will impact the forensic community by serving as a place. She decided alone to remove the body. With the help of her son, she
potential tool for estimating the postmortem period and may have implica- put her husband in her car, enveloped in several layers of tissues, and deposed
tions for both forensic and human rights investigations. him in a cellar of another house. She said she built a wall alone and placed
Decomposition chemistry refers to the chemical degradation processes the body under 70 centimeters of reinforced concrete.
which occur in soft tissue as decomposition proceeds. These processes in- Crime scene and autopsy findings are described. The body was found
volve the breakdown of the body’s main constituents including proteins, car- dressed like on the day of his death. His wife had put a plastic bag on his
bohydrates and lipids. Lipids represent an important biomarker of head and pins on his nose. She said it was to avoid a putrid flow. She
decomposition as they are not easily degraded and can be retained in the soil wrapped the body into several blankets. The body was putrefied (three weeks
environment for extended periods. Currently, there are few techniques which of putrefaction) and conserved in the same state. Identification was easy,
can provide an accurate estimation of the postmortem period. When a body rapid, and completed odontologically. No traumatic lesions were discovered
decomposes in a soil environment the currently available techniques become during the autopsy. Several hypotheses were proposed for the manner of the
even less accurate. death: toxic, natural or asphyxia by plastic bag. Anthropological analysis is
The aim of this study was to investigate the relationship between the re- detailed to determine the origin of the lesions. On the body, in the blankets,
lease of decomposition fluids into a soil environment and their potential cor- Calliphora vicinae larvae and Calliphora vomitaria pupae were discovered.
relation with the decomposition period. The study was conducted in the An entomologist expert tried to precisely determine the postmortem delay
southern region of Ontario, Canada during the summer months of July and since it was crucial for the investigations to conclude the delay between the
August. Pig carcasses were used as acceptable models for human decom- death and the encasing in the cellar. These findings are compared to police
position and were allowed to decompose on the surface of the soil until ske- investigations. These findings are compared to literature on bodies disposed
letonization occurred after approximately 100 days. Soil samples were in reinforced concrete, on the behavior of this woman. The body conservation
collected from the region directly beneath the carcass at varying decompo- is detailed according to different methods of burial. Moreover, after
sition intervals. The total microbial biomass was determined by measuring denunciation, selenium intoxication was suspected. The investigation and
the extractable lipid phosphate and the fatty acid content. Samples were findings on selenium are described.
analyzed by chromatography and spectroscopy techniques. The soils were This case is amazing, and has required a multidisciplinary approach to
characterized using particle size analysis and variations in total carbon, ni- be elucidated. The authors underline, one more time, the importance of the
trogen, phosphorous, pH and moisture content were also investigated. description of the death scene associated with the autopsy findings to
understand and to conclude on the cause and the manner of death. arms were submerged to slightly below the seals for the same reason.
Anthropology, Concrete, Entomology The arms were then monitored every six (6) to twelve (12) hours for
changes in color, odor, and general appearance, including the degree of skin-
slippage. Additionally, the water temperature was carefully monitored on
G72 A Degloving Experiment to Suggest each occasion the forearms and hands were checked. The observational pro-
cess was maintained throughout the first 42 hours of the experiment, after
Postmortem Interval: Give the which the arms and hands were checked only twice a day, in the early mor-
Anthropologist Some Hands From ning and early evening (i.e., at 600 and 1800 hrs.).
Freshwater During the entire experimental period the highest and lowest water bath
temperature achieved was 24°C and 18°C, (75.2oF and 64.4°F, respectively)
Turhon A. Murad, PhD*, California State University, Department of Anth- while the average water temperature was 20.5°C (68.9°F). Periodically water
ropology, 400 West First Street, Chico, CA 95929-0400 was removed from the bath and replaced with fresh, unchlorinated water of
an appropriate temperature to more accurately reflect the conditions descri-
Following the presentation, the attendee will know the results of a uni- bed by the Water Quality Control Board for the canal’s condition. Thus, every
que experiment to determine the minimum length of time necessary for a day from three to four liters, or approximately three to four quarts, of water
pair of human hands to be degloved after being submerged in freshwater at were removed and replaced.
21°C. Both hands acquired the classic “washer women’s appearance” during
This presentation will impact the forensic science community by using the first six hours and continued to worsen over the first 36 hour period. By
the degloving of human hands to suggest the postmortem interval. the end of the second day (i.e., 42 to 48 hours) deep wrinkles appeared and
A unique experiment was performed during spring 2007 in response to very minor skin-slippage began to appear. Photos were taken, and neither
an unusual request from a defense attorney. In late March 2007 an attorney hand was capable of being “degloved” at the end of 36 hours, nor at the end
inquired if human hands could be “degloved” after being submerged in fre- of 48 hours. By day four both hands had begun to become discolored (dark
shwater for a period of 36 hours at a water temperature of approximately pink), as gases and odor became apparent. During the fifth day (96-120 hrs.)
70°F. Of particular interest was the minimum length of time necessary for marbling of black and blue colors was acquired, odor increased, and marked
human hands to be “degloved” under the specified conditions. “Degloving,” bloat of gases was found at the proximal ends beneath the rubber seals (i.e.,
or the removal of the entire epidermal skin surface of human hands has been the ends where the disarticulation had occurred). During day six (by 141
well documented as resulting from both: (1) some types of accident, and hrs.) both hands had become increasing marbled black and blue as skin-slip-
(2) natural phenomena occurring after hands have been submerged for an page also increased. During the seventh day (between 160 and 168 hrs.) an
extended period. attempt to deglove the right hand failed but resulted in tearing the skin on the
In this particular instance specific aqueous parameters needed to be ad- dorsal surface. The left hand had developed a large blister at the anterior
dressed, such as the type of water (freshwater over that of a marine environ- wrist where putrid fluid had accumulated. Gases continued to be produced
ment), complete submergence of the hands, and a water temperature of at the proximal ends of both arms but to a greater extent on the right than the
approximately 21°C (70°F). Following a preliminary literature review it was left. Simply, the skin on the left hand was generally more firmly attached
determined that most information on degloving was anecdotal (Aggrawa than that of the right. Photos were taken of the tear and the blister as well as
2005, Anderson and Hobischak 2004, Boyle, Galloway and Mason 1997, the general deteriorating condition of both hands. On day eight (182 to190
Kovarik, Stewart and Cockerell 2005, Rodriguez, 1997). Therefore, a uni- hrs.) the degree of skin-slippage increased on the dorsal and anterior surfa-
que experiment was proposed, and ultimately agreed upon. ces but the skin of all the fingers remained moderately attached. There was
Over the next few weeks the University of California Davis Donated a marked difference between slippage on the right versus the left hand, with
Body Program (UCD-DBP) in central California was contacted. Specifi- the right hand proceeding more rapidly. During day nine (at 204 hrs. into the
cally, arrangements were made to acquire two freshly harvested human fo- experiment) the right hand was “degloved,” although the skin of some of the
rearms with the intent of soaking them in freshwater, and to the best degree fingers and all the fingernails remained attached. The left hand was still not
possible, emulating the conditions of a canal described by the attorney and ready to be “degloved” on day ten. However, at 256 hours into the experi-
documented by the relevant county’s Water Quality Control Board. It seems ment, or after 10.5 days, the left hand was “degloved,” although once again,
the canal, which is used for agricultural irrigation and thus well monitored, the skin of some of the fingers and all the fingernails remained attached.
passes through a county in which a decedent had previously been recovered. It was concluded that freshly acquired fleshed human hands submerged
At issue was the postmortem interval and thereby a possible alibi for the at- in freshwater at a temperature of 20.5°C could be “degloved” after a mini-
torney’s client. Water temperature and speed of water flow for the central Ca- mum period of nearly 200 hours. However, additionally, it was concluded
lifornia canal were recorded throughout the period relevant to the that because the skin of the fingers as well as the nails never become com-
investigation. pletely detach during the experiment (as they had in the questioned case) it
Thus, to determine the length of time necessary for degloving to occur would very likely take much longer for such degloving to occur. Since all
a controlled degloving experiment was initiated. By May 18, 2007 arrange- chemical and decomposition processes are temperature dependant the tem-
ments had been made to pick-up two forearms on that date from the UCD- perature of the water can be expect to play a critical role in the length of time
DBP. A left (UCD-07-048-UL-FL) and a right (UCD-07-048-UL-FR) necessary degloving to occur. Also of note, because the experimental hands
forearm was acquired from an 89 year-old female who had died from car- were acquired from an 89-year-old decedent (i.e., one much older than the
diopulmonary arrest shortly before becoming a part of the experiment. Both decedent prompting the experiment) a decedent’s age or health status needs
forearms had been removed from the decedent during the morning of there be considered in affecting the experimental result – the attachment and ela-
acquisition. They had been refrigerated until approximately 1400 hours sticity of connective tissue between the epidermis and dermas in younger
when they were then transported to the CSU, Chico Human Identification La- versus older persons could be expected to play a role. If that were the case
boratory for the experiment. By 1800 hours on May 18, both the forearms the length of time for degloving to occur in a young healthy male should be
had been prepared for being submerged in a stainless steel water bath main- expected well after the 36 hour period in question.
tained at a near constant water temperature of 21°C (70° F) for the next ten
Degloving, Postmortem Interval, Freshwater Death
days. Preparation included: initial photographs of both the arms and hands,
sealing the disarticulated proximal ends with rubber seals and additionally co-
vered with waxed polyseal, preparing the stainless water bath with a ther-
mometer, and filling the bath with un-chlorinated, room temperature, fresh
water. The proximal ends of both arms were sealed to prevent water from
entering beneath the skin from the disarticulated ends. Additionally, both
G73 Parasitic Wasps: Succession, Development, Entomology, Parastic Wasp, Postmortem Interval
and Forensic Importance as PMI Indicators G74 Difficulties in Determining Sex From
the Skull: Considering Conflicting
Sasha C. Voss, BSc*, and Ian Dadour, PhD, Centre for Forensic Science, Lines of Evidence
University of Western Australia, 35 Stirling Highway, Nedlands, Western
Australia 6009, AUSTRALIA Krista E. Latham, MS, MA*, Temple University, Anthropology Depart-
After attending this presentation, attendees will understand the potential ment, Philadelphia, PA 19122; Carlos J. Zambrano, MS, C.A. Pound
forensic value of parasitic wasps associated with decomposing remains in Human ID Lab, 5231 North West 56th Court, Gainesville, FL 32653; and
determining time since death. Aspects of parasitoid biology and behavior in Laurel E. Freas, MA, 3425 South West 2nd Avenue, #246, Gainesville, FL
regard to carcass attendance and insect development will also be discussed 32607
for use in the estimation of a postmortem interval (PMI). The goal of this presentation is to demonstrate that forensic scientists
This presentation will impact the forensic science community by. These should understand and employ all available scientific techniques when analy-
results provide biological and developmental data for forensically relevant zing human remains, as well as to emphasize that individuals performing fo-
species of parasitic wasp for use in determining time since death in forensic rensic osteological analysis must possess a firm understanding both of
investigations. Data gathered will improve the accuracy of PMI estimations modern human variation and of the theoretical subtleties of the methods em-
in cases where decomposition has advanced beyond the life cycle of flies, the ployed to study such variation.
traditional indicators of time since death. Discussion of the relevance of the This presentation will impact the forensic community by emphasizing
results presented here to forensic cases will establish the importance of the importance of: (1) a firm foundation in patterns of modern human bio-
parasitic wasps as forensic indicators of time since death and our findings logical variation, (2) an equally firm understanding of the theoretical and
provide reference data required for accurate PMI estimation. practical strengths and limitations of the methods employed in sex determi-
Knowledge of the predictable pattern of insect succession onto a carcass nation, (3) an education in statistics in order to realize that misclassification
and the relationship between temperature and larval development has proved is not random and can usually be traced to some morphological idiosyncrasy
invaluable in estimating PMI. To date forensic entomologists have focused of the remains in question, and (4) a demonstration of the value of using all
on the use of synanthropic flies, particularly Calliphorids as forensic indica- available scientific methods to determine biological sex from the human ske-
tors of time since death. However, where time since death extends beyond leton.
the larval development time of these commonly used species, only a mini- A common misconception held by non-anthropologists is that the de-
mum PMI can be estimated. For instance, where only empty fly pupae cases termination of biological sex from human skeletal remains is relatively easy
are recovered from a crime scene the time lapse between the emergence of and/or straightforward because there is a 50% chance of just “guessing” the
adult flies from the pupae cases and the discovery of the body is unknown. correct sex assignment. While it is true that forensic anthropologists are ex-
In such cases, the presence of parasitic wasp larvae within insect hosts such tremely accurate at sex determination, they are also aware of the potential
as fly pupae can be used to estimate an extended PMI. sources of error within their assessments, as well as the potential error asso-
The order Hymenoptera contains an extremely diverse range of insects, ciated with the external interpretation of their analyses.
including numerous parasitic wasps or more accurately “parasitoids.” The Determining sex from gross skeletal morphology can be accomplished
term “parasitoid” encompasses those arthropod species whose larvae feed via both non-metric and metric techniques. Non-metric techniques examine
exclusively on the body of an arthropod host, eventually killing it. Parasitoids sexually-dimorphic patterns of discrete skeletal trait expression to distin-
use a broad spectrum of hosts including necrophagous insects found in as- guish between males and females. Metric techniques rely on the quantifi-
sociation with decomposing remains (Archer & Elgar, 2003). cation of size and shape differences between males and females, as measured
Use of parasitoids as tools in criminal investigations requires; baseline from several diagnostic skeletal elements. The determination of sex using
data on the temperature-dependant development of both the host and parametric methods is most frequently accomplished via the discriminant func-
sitoid species; knowledge of the development stage at which the female wasp tions calculated by the FORDISC software (Ousley and Jantz, 1996). Both
parasitizes the host; and an understanding of the factors involved in host lo- non-metric and metric approaches to sex determination rely heavily on the
cation within a decomposition habitat. Currently, there is a paucity of rele- os coxa and cranium, which are the two most reliably-diagnostic skeletal
vant reference data and the research that is available is either geographically elements. Though the os coxa is the preferred element for sex assessment,
specific or is focused on parasitoid species used as biological control agents unfortunately this element is not always present in the remains available to
of filth flies rather than in a forensic context. forensic anthropologists for analysis. Indeed, many forensic anthropology
In this study, the species and biology of parasitic wasps associated with cases consist solely of isolated skulls or crania. Not surprisingly, accurate sex
decomposing remains in Western Australia and their relevant host species determination becomes increasingly difficult in instances of heavily frag-
were investigated. A monthly survey of relevant insect fauna frequenting mented or largely incomplete skeletons.
decomposing remains was conducted. Domestic guinea pig carcasses Regardless of the techniques or skeletal elements used in the analysis,
(Cavea porcellus) were used as an attractant. The stage of decomposition at the forensic anthropologist’s ability to accurately assess the sex of unidenti-
which the observed parasitoid species attended carcasses, species seasona- fied skeletal remains may be stymied by individuals who are atypically ske-
lity and rates of parasitization in the field were identified. Predominant spe- letally robust or gracile, or by individuals who originate from populations
cies identified included Tachinaephagus zealandicus Ashmead which are outside the forensic anthropologist’s sphere of experience. The
(Hymenoptera, Encyrtidae) and Nasonia vitripennis Walker (Hymenoptera, possibility of encountering such individuals therefore places several critical
Pteromalidae). Base-line reference data on the temperature-dependant de- demands on the forensic anthropologist, including: 1) a firm foundation in
velopment of both of these parasitoid species were also established under patterns of modern human biological variation, and 2) an equally firm un-
laboratory conditions. derstanding of the theoretical and practical strengths and limitations of the
These results provide biological and developmental data for forensi- methods employed in sex determination. Additionally, the forensic anthro-
cally relevant species of parasitic wasp for use in determining time since pologist should be well educated in statistics in order to realize that misclas-
death in forensic investigations. Data gathered will improve the accuracy of sification is not random, and can usually be traced to some morphological
PMI estimations in cases where decomposition has advanced beyond the life idiosyncrasy of the remains in question. Collectively, these considerations
cycle of flies, the traditional indicators of time since death. Discussion of the caution against the hasty interpretation of the results of anthropological
relevance of the results presented here to forensic cases will establish the im- analyses, as they may not always be as clear-cut as a cursory examination of
portance of parasitic wasps as forensic indicators of time since death and our the conclusions may suggest.
findings provide reference data required for accurate PMI estimation. This presentation will impact the forensic community by demonstra-
ting the value of using all available scientific methods to determine biologi- 9.8% of Asians), Blacks showed the highest incidences of fatal PE. Further
cal sex from the human skeleton. Two cases will be presented in which the research focused on delineating the genetic risks in black populations is war-
only skeletal element available for analysis was the skull. In the first exam- ranted. Detailed characterization of the mutation spectrum in fatal PE is vital
ple the non-metric analysis was suggestive of a female and was supported by for providing accurate diagnosis of cause of death and efficient preventative
FORDISC’s sex-only function; however, when ancestry was considered, the treatment to the high-risk family members.
specimen was classified as a male. In the second example, both the metric Molecular Genetic Testing, Fatal Pulmonary Thromboembolism, Ra-
and non-metric analyses suggested female. However, the individual’s ance- cial Stratification
stry was questionable and the skull may have represented a male from a po-
pulation of small, gracile individuals. The atypicality of both specimens
alerted the forensic anthropologist to possible interpretational issues which
warranted further investigation. In order to supplement the osteological
G76 The Pathologist’s Role in Preserving
analysis, samples from each individual were sent for genetic sex determina- Implanted Pacemakers and Cardiac
tion. While it is understood that there are also errors associated with gene- Defibrillators or How Not to Get Shocked!
tic sex determination, this reemphasizes the forensic anthropologist’s need to
understand modern human variation and the available scientific methods to Suzanne D. Parisian, MD*, Medical Device Assistance, Inc., 7117 North
study variation. Each case will be discussed with an emphasis on sex deter- 3rd Street, Phoenix, AZ 85020; and Bruce H. Barkalow, PhD*, and Wil-
mination by both osteological and genetic means, as well as a critical asses- liam E. Grant, MA, B.H. Barkalow, P.C., 490 Quarterline Road, Newaygo,
sment of the interpretational error associated with each. MI 49337-9125
Sex Determination, FORDISC, DNA
After attending this presentation, attendees will understand the stan-
dardization of techniques for safe and effective explantation of implanted
electric cardiac devices such as pacemakers, defibrillators, and leadwire sy-
G75 Molecular Genetic Testing in 323 Cases stems.
of Fatal Pulmonary Thromboembolism This presentation will impact the forensic science community by de-
in the City of New York Revealed Racial monstrating how careful adherence to recommended procedures by medical
examiners will minimize damage to retrieved implanted cardiac devices (pa-
Stratification cemaker, ICD, CRT-D and leads), and will facilitate postmortem device
analysis and cause of death determination. In addition, appropriate pre-ex-
Yingying Tang, MD, PhD*, Erik T. Bieschke,MS, Stacey Sainte- traction planning of methods for removing implanted defibrillator leads will
Marie, MSFS, Jean Jeudy, Yoonhee A. Kim, Stephanie Pack, Barbara A. reduce risk of electrical shock for personnel.
Sampson, and Mechthild Prinz, PhD, Office of Chief Medical Examiner, Permanent implantable electrical cardiac devices such as Pacemakers,
Department of Forensic Biology, 421 East 26th Street, New York, NY Implanted Cardiac Defibrillators (ICDs), and Cardiac Resynchronization
10016 Therapy-Defibrillators (CRT-D) are common therapies. On occasion, the
The goal of this presentation is to investigate the frequency of these ge- function or malfunction of such devices has been suspected in patient deaths,
netic risk factors in fatal PE and to understand the genotype and phenotype especially in view of recent large recalls. It is possible to determine what role,
correlation. if any, an implanted cardiac device could have played in a patient’s death
This presentation will impact the forensic science community by pre- from postmortem examination of a retrieved device, interrogation of stored
senting detailed characterization of the mutation spectrum in fatal PE is vital memory, and additional testing even several years after death. It is very im-
for providing accurate diagnosis of cause of death and efficient preventative portant that implanted electrical devices and associated leads be considered
treatment to the high-risk family members. for retrieval as a system. The goals for removal of pacemakers/ICDs/CRT-
Fatal pulmonary thromboembolism (PE) is a common cause of death Ds are: (1) keep as much of the total system together and intact as possible,
encountered in the forensic pathology setting and usually presents as a com- (2) identify the components for the device and how it was implanted before
plication of deep venous thrombosis (DVT). The pathogenesis of venous retrieval, (3) document throughout the retrieval process, and (4) keep ex-
thrombosis is multifactorial and requires interaction between both inherited planting personnel safe.
and acquired risk factors. Heterozygous or homozygous Factor V Leiden Before attempting removal of any implanted electrical device system,
(G1691A) or prothrombin (G20210A) mutations, and homozygous MTHFR it is advisable to familiarize yourself with how it is implanted, and possible
(C677T) variant have been recognized as common independent genetic risk risks. Whenever possible, review any x-ray or imaging that shows the device
factors in DVT. In order to investigate the frequency of these genetic risk and lead(s). Pacemakers, ICDs and CRT-Ds are surgically implanted in a
factors in fatal PE and to understand the genotype and phenotype correlation, similar manner, in a prominent palpable subcutaneous pocket located usually
we have validated a genetic testing method to detect the three common mu- on the left chest or abdomen. Electrical leadwires (leads) are attached to a
tations. pacemaker, ICD, CRT-D by screws in a “header.” Leads are usually tunne-
Testing was conducted using multiplex PCR-SNaPshot technologies led together upwards through the left chest and into the medial left subcla-
on postmortem tissue and blood samples. Between March 2005 and May vian vein and then to the appropriate areas of the atrium and ventricles.
2007, we tested 323 fatal PE cases from the New York City Office of Chief The lead carries electric current to the electrode attached to the patient’s
Medical Examiner. The authors found that 48 of the 323 cases were positive heart and carries sensed electrical information to the pacemaker/ICD/CRT-
for at least one mutation. The genetic testing results were categorized by the D. These signals are processed by an on-board computer and software for
demographic data and acquired contributing factors. The overall frequency interpretation and delivered therapy. The treating physician has prescribed
of three mutations in PE cases was found is highest in Whites (34.15 %), desired device performance by programming the device. An electrical lead
followed by Hispanics (28%), very low in Blacks (3%), and zero in Asians. is made of an outer layer of plastic insulation, an often intricate inner metal
In contrast, the number of fatal PE instances in our study is highest in Blacks wire core for carrying current, a terminal electrode attached to the heart’s
(54.8%), followed by Whites (25.4%), and Hispanics (15.5%), and very rare surface, and an attachment to the device’s header. Lead failures are known
in Asians (1.5%). Blacks were also associated with a high percentage of to account for approximately 50% or more of implanted electrical system
idiopathic PE with unknown acquired contributing factors. This study sug- failures. Therefore, it is vital that we attempt to optimize lead retrieval du-
gests that there are racial disparities in genetic risks contributing to fatal PE. ring postmortem examinations. Also of note, additional unattached leads
In addition, comparing the incidences of PE in different races to the racial may be found because when leads are replaced in patients often times origi-
composition in New York City residents (44.7% Whites, 26.6% Blacks, and nal leads are simply abandoned—and often it is the abandoned leads that are
of interest. Therefore, whenever possible both the pacemaker/ICD/CRT-D
and the attached lead should be extracted as a single device system, along Successful demonstration of a lacerated femoral artery (2 cases), lace-
with careful extraction of any abandoned leads. rated iliac artery and vein (1 case), intact vertebral artery (2 cases) and a la-
The pacemaker/ICD/CRT-D subcutaneous pouch should be documen- cerated vertebral artery (1 case) were accomplished. When performed in
ted by sketches or photographs looking for pre-mortem burns or charring of conjunction with RAA postmortem angiography has the potential to:
the walls, type and amount of fluid present, or evidence of fluid ingress into (1) allow the investigator to avoid unwanted dissections, and (2) optimiza-
the plastic header or metal pacemaker/ICD/CRT-D case. All findings and tion of autopsy resources.
clinical impressions about explanted lead(s) and attachment to pace- Angiography, Radiologic Assisted Autopsy, MDCT Virtual Autopsy
maker/ICD/CRT-D header should be documented for the record and photo-
graphed.
ICDs and CRT-Ds are about the same size as pacemakers and are im-
planted in a similar manner, but because defibrillators use high energy, they
G78 CSI Halifax in Miami: The Importance of
represent a significant safety issue. ICD/CRT-D leads have a special termi- Practical Courses in the Forensic Sciences
nal electrode attachment for defibrillation. For retrieval of ICD or CRT-Ds
which remain switched on, personnel must be aware to avoid inadvertent Tanya R. Peckmann, PhD*, Saint Mary’s University, Department of
contact with the lead’s terminal defibrillation electrode. The ICD/CRT-D Anthropology, McNally South 208, 923 Robie Street, Halifax, Nova Scotia
terminal electrodes resemble springs or coils and are attached to the end of B3H 3C3, CANADA; and Dr. Bruce A. Hyma, MD, Miami-Dade County
the lead attached to the heart, and must be assumed to be “hot” even after a Medical Examiner’s Office, 1 Bob Hope Road, Miami, FL 33136
patient’s death. Retrieval procedures can induce electrical signals in to the
Upon completion of this workshop, participants will gain insight into
ICD/CRT-D that, while artifact, may set the device up to deliver a shock. If
the importance of providing practical experiential learning opportunities for
an ICD/CRT-D is known to be implanted in a patient, prior to starting an au-
students in the forensic sciences and gain a better understanding of the
topsy or retrieval, identification of the make and model of the device and
collaborative effort involved with forensic investigations.
consultation with a cardiologist can help ensure the unit is switched to “off”
to reduce the risk of shock. A patient’s chart can also be examined to deter-
illustrating the need to develop hands-on courses as students, who want to
mine if the unit was switched to “off” prior to death. However, it is always
pursue careers in forensic science, need to understand the realities of the
best to handle a retrieved terminal electrode from a defibrillator as if it is still
training required and the job tasks as well as illustrating the desire for stu-
“hot” and capable of delivering an electrical shock.
dents to experience practical hands-on courses in the forensic sciences and
Brief background information on pacemakers and ICDs with appro-
therefore the importance for educators and practitioners to create such
priate references will be presented, along with a detailed suggested extrac-
courses. In addition, this presentation will illustrate the importance and need
tion protocol.
for international collaboration in the forensic sciences – students were unable
Implantable Cardioverter Defibrillator, Cardiac Resynchronization to gain this experience in Nova Scotia but were able to experience it in
Therapy Defibrillator, Pacemaker Miami-Dade County.
Student interest in forensic science has grown tremendously over the
past few years; however, a practical approach to the topic is very rare. Within
North America and Europe, forensic cases are highly guarded and treated as
G77 Postmortem Angiography in Support ‘top secret’ by police departments and coroner’s offices; only a select few
of Radiologic Assisted Autopsy individuals receive security clearance to examine and analyse human
remains, therefore making it almost impossible for a novice to gain this very
necessary ‘realistic’ forensic experience.
H. Theodore Harcke, MD*, Armed Forces Institute of Pathology, 3205
However, in May 2007, a unique and groundbreaking practical
Coachman Road, Wilmington, DE 19803; and Carol Solomon, MD, and
hands-on internship was created by the collaboration of Saint Mary’s
Scott Luzi, MD, Office of the Chief Medical Examiner, 1413 Research
University and the Miami-Dade County Medical Examiner’s Office. During
Boulevard, Building 102, Rockville, MD 20850
this course, students gained a rare and comprehensive knowledge of applied
Upon completion of this presentation, participants will be able to reco- forensics; they were exposed to the multidisciplinary nature of forensic
gnize the usefulness of digital radiography and computed tomography in the investigation and mentored by experts in the field of forensic science.
assesment of vascular injury. Postmortem studies may be preformed with an- Education, Experiential Learning, International Collaboration
tegrade or retrograde injection of contrast medium into the vessels under in-
vestigation, in conjunction with the standard forensic autopsy.
This presentation will impact the forensic science community by de-
monstrating the value of Radiologic Assisted Autopsy.
G79 Can Renal Acute Tubular Necrosis Be
Radiologic Assisted Autopsy (RAA) performed with digital radiographs Differentiated From Autolysis at Autopsy?
(DR) and multidetector computed tomography (MDCT) is limited in its abi-
lity to assess vascular integrity. Postmortem angiography has been proposed Johan A. Duflou, MBChB, MMed*, and Linda Kocovski, BSc, Department
as a technique to overcome this limitation, a variety of contrast agents and of Forensic Medicine, PO Box 90, Glebe, 2037, AUSTRALIA
techniques are being evaluated. This report outlines a method for perfor-
After attending this presentation, attendees will have an understanding
ming postmortem peripheral vascular assessment in conjunction with the
of the morphological characteristics used to define acute tubular necrosis
standard forensic autopsy.
(ATN) and how certain characteristics may be used to differentiate between
During autopsy the vessel of interest was isolated at its source or a con-
ischemic ATN and autolysis in postmortem samples.
venient location distal to the area of interest. Lower extremity arteries were
This presentation will impact on the forensic community by providing
cannulated with embalming trocars where they exited the open abdominal ca-
morphological characteristics to be used in the microscopic examination of
vity. Vertebral arteries were isolated in the posterior fossa after brain remo-
postmortem renal tissue to determine and/or confirm analyses of ATN as
val and cannulated with a 5F angiocatheter. Hand injection of contrast was
contributing to cause of death. The use of diagnostic criteria will augment
performed during MDCT imaging of the area of interest. Satisfactory visua-
the identification of ischemic ATN as distinct from the process of autolysis.
lization of peripheral arteries was achieved with a mixture of embalming
Acute tubular necrosis is the most common cause of acute renal failure
fluid and radiographic contrast [Omnipaque 320]; undiluted contrast was
and accounts for 50% of all cases of acute renal failure in hospitalised patients
injected retrograde into the vertebral arteries. Arteries can be injected post-
and greater than 75% of critical care/intensive care unit cases. Acute renal
mortem in either antegrade or retrograde direction.
failure affects about 5% of hospitalized patients and has a high mortality rate The goal of this study is to look at the change, if any, to the medical exa-
of 50%. It is a commonly held view amongst autopsy pathologists that it is miner case load and distribution following the opening of a new level 1
generally not possible to diagnose ATN at autopsy because of the presence trauma center. Factors evaluated included the increase or decrease in the
of autolysis, and that the only way the condition can be diagnosed is by iden- total number of medical examiner cases per year, the medical examiner di-
tifying mitotic figures in the tubular epithelium. This belief may lead to the stricts from which these cases are originating and what types of cases the
under-reporting of the condition as a finding upon microscopic analysis of trauma center is bringing into the district.
renal tissue. On October 1, 2004, the University of Florida & Shands Hospital in
The Department of Forensic Medicine, Glebe, Sydney autopsy data- Gainesville, Florida became a Level 1 Trauma Center. For a patient to be
base was queried for cases where an antemortem diagnosis of ATN was given trauma alert status, they must meet very specific criteria, such as two
made. Antemortem hospital medical charts for each case were searched for or more long bone fractures, ventilation beyond passive oxygen administra-
a diagnosis of ATN based on clinical and biochemical parameters. A total of tion, or 15% or more of body involved in second or third degree burns.
57 cases over a 5 year period were found. These cases were compared to a This new trauma center covers nine whole counties and seven partial
similar number of age and sex matched controls, who died suddenly as a re- counties. The counties with partial coverage are relatively equidistant
sult of self-inflicted hanging but were otherwise healthy. between two level 1 trauma centers, such that patients in these counties may
A total of 114 deidentified and randomized kidney sections were exa- go to one of two trauma centers for treatment. Of these sixteen counties co-
mined. Serial tissue sections from each case were stained with H&E, Mar- vered by the new trauma center, only seven are within the District 8 Medi-
tius Scarlet Blue (MSB), Masson’s Trichrome and anti-human Ki-67 cal Examiner’s jurisdiction. Even though the injury(s) may have occurred
immunoperoxidase. Morphological characteristics compared were prolife- outside the jurisdiction of District 8 Medical Examiner Office, when a trauma
rating epithelial cells (as visualized by Ki-67 positivity); fibrin thrombi in patient dies at the trauma center, the time and place of death is in Alachua
glomeruli; tubular epithelial whorls; mitoses in tubular epithelium; presence County. Because medical examiner jurisdiction in Florida is defined by place
of tubular casts; degree of autolysis; tubulorrhexis; tubular epithelial flatte- of death, not place of injury, such cases fall under the auspices of the District
ning; interstitial inflammation, and interstitial edema. 8 Medical Examiner Office.
All results were expressed as mean ± standard deviation. Differences The District 8 Medical Examiner Office case files were retrospectively
between groups were determined by two sample t-test. A p value < 0.05 was reviewed from January 1, 2002 to June 30, 2007. Only non-natural deaths
considered to be statistically significant. were included in the study population as natural deaths would not be affec-
Statistically significant differences were between the cases exhibiting ted by the presence or absence of a level 1 trauma center. The trauma cen-
ATN and the controls in the following morphological characteristics: num- ter began operating at level 1 status October 1, 2004, and this is the date used
ber of tubular epithelial whorls, proliferating cells, tubulorrhexis, and inter- to demarcate “before” and “after” data sets. During this time, 3156 total
stitial edema. The mean number of tubular epithelial whorls in ATN cases cases were investigated by the MEO and 2388 were autopsied. The annual
was 1.93 ± 5.15; no whorls were found in any control cases (p < 0.001). The case load has been steadily increasing, with the largest increase in 2005 (a
mean number of proliferating cells in ATN cases was 19.5 ± 29 and in con- 10% increase in total cases and a 22% increase in autopsies). Since October
trol cases was 5 ± 9.2 (p = 0.0001). The mean number of tubules exhibiting 1, 2004, 312 cases have been investigated that came through the trauma cen-
tubulorrhexis in ATN cases was 0.0309 ± 0.0826 and in control cases was ter as a trauma alert, with 275 investigated by the District 8 MEO. Roughly
0.007 ± 0.0258 (p = 0.041). The mean degree of interstitial edema (as de- 58% of the deaths coming through the trauma center were a result of motor
termined by proportion of fields exhibiting the condition) in ATN cases was vehicle crashes, by far the largest mechanism, followed by falls of all types
0.533 ± 0.412 and in control cases was 0.195 ± 0.312 (p < 0.001). (20%). Only 33% of the trauma center deaths had their corresponding inju-
The remaining morphological characteristics (fibrin thrombi, tubular ries within the District 8 medical examiner jurisdiction. Before the trauma
casts, degree of autolysis, mitotic figures, tubular epithelial flattening and center opened, approximately 15% of all non-natural investigations were
interstitial inflammation) were analysed and showed no statistically signifi- outside of the District 8 MEO, whereas afterwards, 26% were outside the
cant differences between the two groups. jurisdiction.
Acute tubular necrosis can be reliably differentiated from autolysis at This study has found that a much larger percent of the District 8 Medi-
autopsy. The presence of characteristic tubular epithelial whorls is highly cal Examiners case load is now coming from outside of the current jurisdic-
diagnostic of ATN. When taken together with tubulorrhexis, interstitial tion since the opening of the trauma center, which is associated with an
edema and epithelial proliferation, a diagnosis of ATN can be reliably made increase in the over all number of cases each year and an increase in the com-
at autopsy. plexity of the cases. Patients from the trauma center tend to have more com-
3
Autopsy, Acute Tubular Necrosis, Renal Pathology plex injuries resulting in longer autopsies and more time spent determining
causes of death. Additionally, a large percentage of the trauma cases are co-
ming from surrounding districts, cases that originally would have gone to
that outside district or a different one with a level 1 trauma center, such that
G80 The Effects of a New Level 1 Trauma Center trauma deaths are being redistributed throughout the region. The larger im-
on the Local Medical Examiner Office plication being that the opening of a Level 1 Trauma Center not only affects
the medical examiner district in which it resides, but also the surrounding
Martha J. Burt, MD, District 8, Medical Examiner Office, 606 South West medical examiner offices by reducing their case load.
3rd Avenue, Gainesville, FL 32601; and Charlotte J. Stevens, BA*, 6417 Medical Examiner, Trauma, Non-Natural Death
South West 9th Avenue, Apartment A, Gainesville, FL 32607
The goal of this presentation is to describe the changes in the medical
examiner non-natural case load in relation to the establishment of a level 1
trauma center.
This presentation will impact the forensic community and humanity by
providing insight into the effects of a level 1 trauma center on regional me-
dical examiner, which in turn affects law enforcement, families, funeral
homes and regional funding.

G81 Mapping the Literature in Forensic G82 Purtscher Retinopathy Detected by
Pathology and Legal Medicine: Postmortem Monocular Indirect
A Bibliometric Study of North-American Ophthalmoscopy
Journals From 1980 to 2005
Patrick E. Lantz, MD*, Department of Pathology, Wake Forest University,
Anny Sauvageau, MD*, A. Godin, S. Desnoyers, C. Kremer, MSc, and S. SOM, Medical Center Boulevard, Winston-Salem, NC 27157-1072; Con-
Racette, BSc, Lab de Sciences Judiciaires, et de Medecine Legale, 1701, stance A. Stanton, MD, Department of Pathology,Wake Forest University
Parthenais Street, 12th Floor, Montreal, PQ H2K 3S7, CANADA of Health Sciences, Medical Center Boulevard, Winston Salem, NC 27157;
and Marshall E. Tyler, Department of Ophthalmology, Wake Forest Uni-
The goal of this presentation is to describe the evolution of the litera-
versity of Health Sciences, Medical Center Boulevard, Winston Salem, NC
ture in forensic pathology and legal medicine for North-American journals
27157
over more than twenty-five years. More precisely, it will draw a picture of
our literature and describe developments and trends regarding numbers of The goals of this presentation are to: (1) describe the retinal features of
author(s) per article, represented countries and international collaborations, the Purtscher retinopathy, (2) list conditions and disorders associated with
types of articles and use of the scientific method. Purtscher retinopathy, and (3) describe the histological features of
This presentation will impact the forensic community by providing new Purtscher-flecken.
insight in the forensic pathology literature. A better knowledge of this body After attending this presentation, attendees will gain insight into the
of literature could help us assess our strengths and weaknesses, and better value of postmortem monocular indirect ophthalmoscopy (PMIO) in detec-
position ourselves on literature ethical issues. ting Purtscher retinopathy and subsequent histopathological description of
Bibliometric studies have increasingly being used over the last years. the observed retinal lesions. This presentation will impact the forensic com-
Those studies are useful to understand the evolution of literature or trends in munity by providing an introduction to non-hemorrhagic retinopathies de-
particular fields or within a geographical area. However, in forensic sciences, tectable by PMIO and consequent histopathological characterization.
bibliometry has barely been used yet and the few studies that have been per- In 1910, Dr. Otmar Purtscher described a patient with severe head
formed mainly focused on most highly cited articles, most prolific authors trauma who had a hemorrhagic and vaso-occlusive retinopathy characterized
and impact factors. Thus, the present study specifically aims at mapping the by multiple variably sized cotton-wool spots (Purtscher-flecken) plus reti-
literature in the field of forensic pathology and legal medicine. nal hemorrhages around the optic nerve head. Two years later he designa-
The two North-American leading journals in forensic sciences were ted the condition angiopathia retinae traumatica. Since then the term
selected: the Journal of Forensic Sciences and the American Journal of Purtscher retinopathy has been used to describe a clinical picture of angio-
Forensic Medicine and Pathology. All articles in the field of forensic pathia retinae traumatica even in the absence of known head trauma. Purt-
pathology and legal medicine published in those journals in 1980, 1985, scher-like retinopathy has been observed in a variety of conditions including
1990, 1995, 2000, and 2005 were retrospectively analysed, excluding compressive chest injuries, long bone fractures, retrobulbar anesthesia, con-
editorials, guest editorials, tributes, and book reviews. For each article, the nective tissue and vasculitic diseases, orthopedic surgery, acute pancreatitis,
following features were compiled: number of author(s), author’s country and strenuous childbirth, and battered child syndrome. The exact pathophysio-
international collaboration and type of article. Furthermore, it was assessed logic mechanism causing Purtscher or Purtscher-like retinopathy remains
if the article was using or not the scientific method, with testing of hypotheses controversial and published supportive histological descriptions are rare.
by statistical analysis. A total of 522 articles were examined from 1980 to Two cases are described of Purtscher retinopathy detected by postmortem
2005 at a 5-year interval: 215 articles from the Journal of Forensic Sciences monocular indirect ophthalmoscopy plus the histological features and im-
and 307 articles from the American Journal of Forensic Medicine and munohistochemical staining for β-amyloid precursor protein of observed
Pathology. The SPSS 15.0 software was used to perform statistical analyses Purtscher-flecken.
at a threshold of significance of 5%. Mean values were compared using Case 1: A 36-year-old man sustained a traumatic brain injury with im-
analysis of variance, while proportions were compared through Chi- mediate loss of consciousness following an assault in a parking lot. Cranial
square tests. computed tomography revealed subdural and subarachnoid hemorrhages.
Overall, the number of articles per year has passed from 55 articles in He remained comatose and died thirteen days after the injury. Neuropatho-
1980 to 89 in 2005. Meanwhile, the average number of author(s) per article logical examination revealed traumatic axonal injury, a cerebral contre-coup
has significantly increased (p=0.000, p<0.05), passing from 1.8 to 3.5. The contusion plus organizing subdural and subarachnoid hemorrhages. Prior to
relative contribution of other countries in comparison to the United States has autopsy PMIO identified retinal hemorrhages and multiple posterior, peri-
significantly increased from 9.3% to 57.3% (p=0.000, p<0.05). Articles from papillary, polygonal foci of retinal whitening (Purtscher-flecken) distributed
international collaboration were absent in 1980, passing to 5.62% of articles between retinal arterioles and veins. Histologically, these areas were col-
in 2005. As for the types of articles, the review article was the only type of lections of swollen, contracted axons (cytoid bodies) in the nerve fiber layer
article significantly decreasing (p<0.05). No significant differences was highlighted by immunohistochemical staining for β-amyloid precursor pro-
revealed for the remaining types of articles, although letters to the editor tein.
showed a tendency to decrease (p=0.069), while original studies showed a Case 2: A 27-year-old man had experienced nausea and vomiting for
tendency to increase (p=0.088). Finally, the number of studies using the a number of days. While at his girlfriend’s residence he collapsed following
scientific method did not significantly progressed from 1980 to 2005 an episode of vomiting. Resuscitative efforts were unsuccessful and he was
(p=0.416, p>0.05), passing from 10.9% to 15.7%. pronounced dead in the emergency department. Hepatosplenomegaly was
The literature in forensic pathology and legal medicine in North- present at autopsy and his hypercellular bone marrow contained > 20% mye-
American journals has expanded in number of articles per year from 1980 to loid blasts with Auer rods. The leukemic cells stained positively for CD68
2005. However, the relative proportion of pathology and legal medicine in and myeloperoxidase. Prior to autopsy PMIO revealed multiple bilateral re-
the forensic literature as a whole has stayed about the same. The significant tinal hemorrhages, many white-centered, plus posterior foci of small Purt-
increase in the average number of author(s) per article follows a similar trend scher-flecken. Histologically, these foci were cytoid bodies in the nerve fiber
in the forensic literature. Finally, it is surprising to see that while the use of layer that stained positively for β-amyloid precursor protein.
the scientific method has significantly progressed in the forensic literature No published reports of Purtscher retinopathy detected initially at au-
over the last twenty-five years, pathology and legal medicine literature has topsy are in the medical and scientific literature. Previous articles on the hi-
stayed behind on this aspect. This observation is a warning sign that stopathology of Purtscher retinopathy have been two case reports from
researchers and authors in our field should notice. patients with acute pancreatitis who died 6 and 23 days after the onset of
Forensic Pathology, Literature, Bibliometric their illness. Both had focal areas of retinal edema and loss of architecture
in the inner retinal layers with abrupt transition to normal retina. In the normal in size and weight. The left and right coronary arteries arose
author’s reported cases the detected Purtscher-flecken were cytoid bodies normally. No significant stenosis or thrombotic occlusion of the coronary
that stained positively for β-amyloid precursor protein. These inner retinal segment were detected. The atrio – ventricular and semilunar valves were
collections of swollen, contracted axons are relatively nonspecific and hi- normal. The myocardium showed an extensive fibrotic scarring, particu-
stopathologically similar to retinal cotton-wool spots and foci of axonal larly in the supero – anterior wall of the LV and the posteroseptal wall. The
injury observed throughout the nervous system commonly associated with a histological examination of the heart, performed with routine haematoxylin-
variety of traumatic and non-traumatic conditions. eosin revealed diffuse and extensive fibrosis with non-caseating granulomas
Purtscher Retinopathy, Traumatic Brain Injury, ß-Amyloid Precursor composed mainly of an aggregate of epithelioid cells and multinucleated
Protein giant cells in the centre surrounded by lymphocytes, plasmacells and
mastcells. The lungs and kidneys also showed the same non caseating
granulomas. An immunohistochemical examination of heart samples was
performed to confirm diagnosis. Mycobacterium tuberculosis and fungal
G83 Sudden Death Due to a Cardiac Sarcoidosis: infections were excluded on special stains. The remainder of the histological
Histopathological Helping Evidences examination was unremarkable. The diagnosis of sarcoidosis with massive
and extensive cardiac involvement was established as cause of death.
Irene Riezzo, MD*, and Stefano D’Errico, MD, University of Foggia, Cardiac Sarcoidosis, Sudden Death, Ventricular Arrhythmias
Department of Forensic Pathology, via Luigi Pinto, 1, Foggia, 71100,
ITALY; and Francesco Ventura, MD, University of Genova, Department
of Forensic Pathology, Via de’ Toni, 12, Genova, 16132, ITALY
G84 A Diagnosis of Chagas Disease at Autopsy
The goal of this presentation is to present an uncommon case of sudden
cardiac death in a 34-year-old. A complete methodological forensic approach Ana E. Lopez, MD*, Harris County Medical Examiner’s Office, 1885 Old
by means of autopsy, histological, and immunohistochemical examinations Spanish Trail, Houston, TX 77054; L. Maximiliam Buja, MD, University of
led us to conclusion of a systemic sarcoidosis with massive cardiac Texas-Houston Health Science Center, 7000 Fannin, Suite 1715, Houston,
involvement. TX 77030; and Luis A. Sanchez, MD, Harris County Medical Examiner’s
This presentation will impact the forensic science community by Office, 1885 Old Spanish Trail, Houston, TX 77054
demonstrating how the rarity of cardiac sarcoidosis makes the case peculiar;
The goal of this presentation is to become familiar with Chagas disease
in addition to clinical and lab tests, a complete forensic methodological
and to consider it as a diagnosis in the setting of chronic myocarditis and
approach by means of autopsy, histopathological examination and immuno-
sudden death
histochemical stain led us to confirm the diagnosis of cardiac sarcoidosis as
The forensic community will be presented with an interesting case of
the cause of death.
chronic myocarditis related to Chagas disease, raising awareness of the pre-
Sarcoidosis is a multisystem disorder of unknown aetiology, character-
sence of this disease in the United States, and its relation to sudden death.
ized by noncaseating epithelioid cell granulomas. The aetiology and
Chagas disease is caused by the parasite Trypanosoma cruzi, which is
pathogenesis are unclear, although many infectious, environmental and
a blood-dwelling and tissue-dwelling protozoan. The disease occurs in the
genetic factors have been implicated. Prognosis and clinical manifestations
Americas, primarily in Central and South America. It is transmitted to hu-
are dependent on the location and extend of granulomatous infiltrates. The
mans through the bite of the reduviid bug. The disease is commonly seen in
cardiac involvement is uncommon (at autopsy, cardiac involvement has been
children younger than five years who develop a skin lesion known as a cha-
reported in 20-30% of patients with sarcoidosis, although most studies
goma at the site of infection where the organisms proliferate in the skin. The
indicate that <5% of patients with sarcoidosis have symptoms related to car-
trypomastigotes (flagellate forms) may then spread via hematogenous or
diac involvement) and has a wide range of clinical manifestations
lymphatic routes and cause an acute illness characterized by lymphadeno-
(conduction disorder, ventricular arrhythmias, atrial arrhythmias, pericarditis,
pathy, fever, anorexia, and fatigue. After the acute phase, recovery may
valvular dysfunction, congestive heart failure). It is unusual for sarcoidosis
occur, or the disease may progress into a chronic phase, which is usually
to present with isolated cardiac involvement. In autopsy study, cardiac
seen in adults and older children. Chronic carriers of Trypanosoma cruzi
nvolvement proved to be the cause of death in 37% of the patients with
may develop chronic myocarditis and a cardiomyopathy or dilatation of the
sarcoidosis. Cardiac involvement associated with poorer prognosis and the
digestive tract, characterized by dysphagia and megacolon.
mortality rate may exceed 40% at 5 years and 55% within 10 years. The
Chagas disease is diagnosed at autopsy in a 66-year-old Hispanic male
presence of pulmonary involvement was associated with better survival.
originally from El Salvador who died in Houston while at work in the con-
Sudden death due ventricular tachyarrhythmia or conduction block accounts
struction of a residential apartment complex. He was found dead by his em-
for 25 to 65% of the deaths due to cardiac sarcoidosis.
ployer who had arrived at the job site to supervise him. He was found on the
A 34-year-old woman was found lifeless at home from by her parents.
floor inside of an apartment that was being renovated, and it appeared he had
Death scene investigation was unremarkable. The extended family hadn’t a
collapsed as he was preparing to perform some caulking. Per his family, he
history of sudden death. In her history a visit to the Emergency Room three
had no known medical or social history but had been complaining of dizzi-
months before death was recorded. She complained chest pain, non –
ness and palpitations over the past two weeks. At autopsy, he had an enlar-
sustained ventricular tachycardia and loss of consciousness. Body temper-
ged, 515-gram heart with left ventricular hypertrophy and focal thinning of
ature was normal. Subsequent cardiological evaluation with ECG showed
the left ventricular wall toward the apex. A 1.5-centimeter mural thrombus
sinusal rhythm with ventricular premature beat and intraventricular
was in the apex of the left ventricle, and the surrounding myocardium had dif-
conduction abnormalities. Echocardiography showed normal chamber di-
fuse scarring. Extensive myocardial fibrosis extended into the lateral and
mensions, no wall motion abnormalities. The research for viruses was
posterior left ventricle towards the base of the heart. The coronary arteries
negative. The laboratory findings were normal. During hospitalization she
showed mild atherosclerosis with 10% to 20% stenosis in the left anterior de-
presented some episodes of supraventricular paroxysmal tachycardia (160
scending and right coronary arteries. He also had remote embolic infarcts in
bpm) and non – sustained ventricular tachycardia. No others symptoms or
the kidneys and brain with 9-centimeter and 3-centimeter cortical scars in
apparatus failure were present. Family history was reportedly negative for
the kidneys and a 2-centimeter area of cortical encephalomalacia in the left
cardiac disease. An anti – arrhythmic treatment was prescribed.
occipital lobe. Microscopically, sections of the heart showed chronic inter-
A complete postmortem examination was performed two days after
stitial inflammation with lymphocytes and eosinophils associated with pat-
death. External examination was unremarkable. The internal examination
ches of mycoardial fibrosis. Toxicology was negative for drugs and alcohol.
revealed only a polivisceral congestion and pulmonary edema. All internal
Chagas disease was considered in the differential diagnosis of chronic myo-
organs were macroscopically normal. The heart had a normal shape and was
carditis in an adult male from Central America; therefore, serologic testing splasia within the vasculature supplying the conduction system, but the majo-
was requested through the Centers for Disease Control. An indirect fluore- rity of the literature linking fibromuscular dysplasia to a cause of death fo-
scent assay showed an IgG antibody titer of 1:512, which was positive for cuses on the disease process within the small coronary arteries. In fact, some
Chagas disease. controversy exists as to the presence of apparent dysplasia within the nodal
There are many different causes of myocarditis including infections, arteries in control subjects dying of other causes and whether the use of spe-
immune reactions, drug hypersensitivity, poststreptococcal, giant cell myo- cial stains can highlight specific alterations of the vessel wall that may lead
carditis, and sarcoidosis. Common infectious causes are typically viral such to an increased association with sudden death.
as coxsackieviruses, echoviruses, influenza, and adenovirus. Additionally, An example of atrioventricular nodal dysplasia is the cause of sudden
other protozoa such as toxoplasma and helminths can also affect the heart and death in a relatively healthy adolescent. It is important that the forensic com-
cause myocarditis. Although typically prevalent in South and Central Ame- munity be aware of this process, its characteristic histopathology, the distri-
rica, Chagas disease should be considered in individuals in the United Sta- bution and clinical consequences of similar lesions throughout the body, and
tes who present with cardiac arrhythmias, congestive heart failure, and its implications as a cause of sudden death. Pathologic processes involving
sudden death, especially in Texas, California, and throughout the South given the conduction system are often considered in the investigation of otherwise
the large immigrant population in these states. Trypanosoma cruzi can also healthy persons, and this presentation will present evidence for the syste-
be transmitted through blood transfusions, organ transplantation, transpla- matic examination of conduction system histology.
centally, and through breast milk. In 2006, the FDA approved a screening test Atrioventricular Node, Dysplasia, Sudden Death
for Chagas disease in the blood donation population, which is currently being
used for screening the donated blood in the Gulf Coast region of Texas.
Chagas Disease, Chronic Myocarditis, Autopsy
G86 Subaortic Aneurysm of the Left Ventricle
G85 Dysplasia of the Atrioventricular Nodal Complicating Staphylococcal Endocarditis
Artery: A Case Report and Review of Pauline Saint-Martin, MD*, Service de Medecine Legale, Hopital
the Literature Trousseau, Centre Hospitalier Regional Universitaire de Tours,
Tours, 37000, FRANCE; Christopher B. Rogers, MD, and Eugene
Clarissa Krinsky, MD*, 3908 Silver, South East, Albuquerque, NM 87108; Carpenter, MD, Los Angeles County, Medical Examiner’s Office, 1104
Sam W. Andrews, MD, Office of Chief Medical Examiner, 4070 Bowness North Mission Road, Los Angeles, CA 90033; Michael C. Fishbein, MD,
Road North West, Calgary, Alberta T3B 3R7, CANADA; and Rebecca Ir- Department of Pathology and Laboratory Medicine, David Geffen School
vine, MD, 808 Shire Street, South West, Albuquerque, NM 87121 of Medicine at University of California, Los Angeles, CA 90095; and
Lakshmanan Sathyavagiswaran, MD, Los Angeles County Medical
After reviewing this presentation, attendees will understand the
Examiner’s Office, 1104 North Mission Road, Los Angeles, CA 90033
pathophysiology and epidemiology of conduction system arterial dysplasia, .
a rarely reported condition. Autopsy findings and the correlation between hi- After attending this presentation, the audience will learn about an
stopathologic abnormalities and sudden death will be emphasized via a case unusual complication of endocarditis, which could lead to sudden death of
presentation and a review of the literature on this topic. young people.
It is important that the forensic community be aware of this process, its This presentation will impact the forensic science community by
characterisitc histopathology, the distribution and clinical consequences of si- demonstrating how subaortic aneurysms can complicate staphylococcal
milar lesions throughout the body, and its implicatons as a cause of sudden aortic valve endocarditis and cause sudden unexpected deaths in young
death. Pathologic processes involving the conduction system are often con- people.
sidered in the investigation of otherwise healthy persons, and this presenta- Subaortic aortic aneurysms are rare. Initially thought to be of congenital
tion will impact the forensic science community by presenting evidence for origin, they may occur as a complication of aortic valve endocarditis. This
the systematic examination of conduction system histology. report describes a subaortic aneurysm in a 21-year-old patient who had a
A case of the investigation of the sudden death of a previously healthy recent history of staphylococcal endocarditis.
15-year-old male will be presented. The patient had a history of being A 20-year-old Vietnamese male who worked as a machinist presented
overweight (BMI 28.4), mild well-controlled asthma, and Attention Deficit to the Emergency Room of a local hospital with a 4-6 days history of fever,
and Hyperactivity Disorder treated in the past with stimulants. Examination chills, and headache. A cardiology evaluation was requested due to a systolic
revealed an essentially negative autopsy, a negative skeletal survey by ra- murmur on examination. A transesophageal echocardiography revealed
diography, and normal histopathology of the usual microscopic sections abnormal vegetation of the aortic valve and mild aortic, tricuspid and mitral
taken at autopsy. Postmortem toxicology was significant for the presence of regurgitation. Blood cultures drawn at the time of the admission grew
a moderate amount of caffeine. Viral and bacterial cultures grew a likely po- Staphylococcus aureus. Staphylococcus aureus endocarditis was diagnosed.
stmortem contaminant only, and vitreous chemistries were normal. Further The patient was treated with Gentamycin for 14 days, and Nafcillin for seven
examination of the conduction system revealed significant dysplasia of the weeks. The patient was followed by a cardiologist for eight months. The
atrioventricular nodal artery, characterized by irregular fibrointimal thicke- patient refused aortic valve replacement surgery. Ten months after the onset
ning of the vessel wall with marked disruption of the elastic lamina, highli- of the first episode the patient was found down at home with shortness of
ghted by special stains. breath and an altered level of consciousness. He was transported to the
Dysplasia of the atrioventricular nodal artery is a rare entity, described hospital, but suffered cardiac arrest and was pronounced in the Emergency
only in small case reports and series. The morphologic changes are the same Room. At autopsy, the patient weighed 149 pounds and measured 67 inches.
as those found with fibromuscular dysplasia, which is most commonly seen The external examination showed evidence of therapeutic intervention and
in the renal and internal carotid arteries but has been reported in numerous no external trauma was noted. The pericardial cavity was filled with 200
arterial beds and may even be a generalized condition. Fibromuscular dy- mL of clotted blood. The heart weighed 430 grams. There was aneurysmal
splasia is a nonatherosclerotic, noninflam-matory disease of the arterial wall, enlargement at the base of the left ventricle, between the aorta and the left
the exact cause of which is unknown. The lesions may predominantly alter atrium, measuring 3.0 cm in diameter. A ruptured snout measuring 1 cm was
the intima, media, or the adventitia, and the sequelae are dependent upon the located on the superior aspect of the aneurysm. The aortic valve was
degree of vascular wall thickening or destruction and the location of the af- bicuspid. The aneurysm communicated with the left ventricle just below the
fected vessels. right commissure of the two cusps by a triangular opening measuring 1.5 x
Within the forensic literature, there are scattered case reports of dy- 1.0 cm. Death was attributed to cardiac tamponade from spontaneous rupture

of a subaortic aneurysm. on the main bronchi was also detected. Heart was fixed in formalin, cardiac
Subaortic aneurysms can be congenital, infective or traumatic. size was normal, with conical shape. Macroscopic study (cut in cross-section
Congenital weakness of the fibrous annuli could predispose to the 3 mm intervals) of coronary arteries was unremarkable. A well circumscribed
development of such aneurysms. A bicuspid aortic valve is another encapsulated lobulated reddish and brownish suspected lump measuring
contributing condition. The role of aortic regurgitation as a consequence of 3.5x3x3 was attached to the medial aspect of the left kidney; it was soft on
infective endocarditis in the aneurysmal formation needs to be considered in section and presented aspect of necrosis and haemorrhage. Adrenal tissue
our case. It is probable that rupture of the aneurysm resulted from weakness was attenuated over the upper part of the mass; aspect of minimal
and increased tension of the aneurysmal wall. haemorrhage was observed on pancreas examination.
Forensic Pathology, Sudden Death, Subaortic Aneurysm Histological examination revealed polyvisceral stasis, mild cerebral
edema: massive pulmonary edema was recorded. Cardiac myofibers varied
considerably in size with many large fibers and aspect of fibrosis suggesting
for hypertension; the pathological myocardial picture included fragmentation
G87 A Rare Case of Cardiac Failure Due to of the whole myocyte (pancellular lesion) which ranged from early break-
Hypertensive Crisis in Pheocromocytoma: down in pathological band (intense hyperosinophilia of the hypercontracted
A Methodological Approach for Diagnosis myocardial cells with rexis of the myofibrillar apparatus into cross-fiber,
anomalous and irregular) to a total granular disruption (myofibrillar
Stefano Derrico, MD*, Irene Riezzo, MD, and Cristoforo Pomara, MD, degeneration). Histological examination of the suspected lump addressed
Department of Forensic Pathology, University of Foggia, via Luigi Pinto, diagnosis for a benign pheocromocitoma with the presence of well-defined
1, Foggia, Italy 71100, ITALY nests (Zellballen) bound by a delicate fibrovascular stroma, which contain
amyloid. The cells varied considerably in size and shape and had purely
The goal of this presentation is to present a rare case of cardiac failure granular basophilic cytoplasm; the nuclei were round with prominent
due to hypertensive crisis in pheocromocitoma in an asymptomatic 25-year- nucleoli.
old young man is presented. The rarity of pheocromocytoma makes the case An immunoistochemical study was performed and it showed a positive
peculiar and the complete pathologic investigation adopted (autopsy perfor- reaction for chromogranin and synaptophysin.
ming, immunoistochemical staining, and biochemical screening) is strongly Dosage of catecholamines and their metabolites on a blood and urine
recommended to pathologists to confirm diagnosis. samples was performed showing high levels of catecholamines,
This presentation will impact the forensic science community by de- metanephrine and vanillyl-mandelic acid.
monstrating how the rarity of pheocromocytoma makes the case peculiar. It Clinical data, autopsy findings, data collected from immunoisto-
is strongly suggest, in these cases, the relevance for pathologists of a com- chemical staining and biochemical analysis led us to conclude that cardiac
plete methodological approach, integrating clinical data by means of autopsy failure due to hypertensive crisis in adrenal pheocromocytoma was the cause
findings, immunoistochemical staining and biochemical screening to con- of death.
firm diagnosis. In conclusion, the rarity of pheocromocitoma makes the case peculiar.
Pheocromocytomas are rare but clinically important tumours of The authors strongly suggest, in these cases, the relevance for pathologists
chromaffin cells that produce, store, release and metabolize catecholamines. of a complete methodological approach, integrating clinical data by means
Pheocromocytomas usually manifest clinically as hypertension which can of autopsy findings, immunoistochemical staining and biochemical screening
be sustained or paroxysmal. The diagnosis of pheocromocytoma is based on to confirm diagnosis.
measuring excessive amounts of catecholamines and their metabolites on
Pheocromocitoma, Cardiac Failure, Hypertensive Crisis
blood and urine; more than 90% of patients with pheocromocytoma have
elevated levels of catecholamines, metanephrine, and vanillyl-mandelic acid.
Sensitivity and specificity of these measurements are 91%. Failure to
diagnose the tumours can result in sudden, unexpected and potentially lethal
complications; cause of death in these cases is generally a consequence of G88 Arrhythmogenic Right Ventricular
paroxysmal hypertension as well as cerebral vascular accidents, abrupt Dysplasia (ARVD): A Not So Rare Cause
haemorrhage into the tumour or acute left ventricular failure. of Sudden Death in Young Adults
A 25-year-old man, with a past medical history significant for recurrent
episodes of cephalalgia, was transported to the local Hospital at 11:44 p.m.
Frank Braza, MD, PhD*, Juan A. Merayo-Rodriguez, MD, and Jeffrey
complaining of vomiting and headache. A prescription for symptomatic
West, Danbury Hospital, 24 Hospital Avenue, 2 Tower Lab, Danbury,
treatment was issued unsuccessfully. He had high blood pressure (180/80)
CT 06810
and tachycardia (110 bpm). Neurological examination was unremarkable,
abdomen showed no rigidity, peristaltic sounds were normal. Initial The goal of this presentation is to make the forensic community aware
laboratory findings showed hyperglycaemia (177 mg/dl) and high level of of this entity (ARVD) as a sudden cause of death in the young adult popula-
amylase (125 U/L); further findings showed high levels of myoglobin (153 tion.
ng/ml). A 12 lead electrocardiogram on admission was performed showing This presentation will impact the forensic science community by de-
sinus tachycardia, with right bundle branch block and ventricular bigeminy monstrating how routine full autopsies may not detect the subtle pathologic
extra systoles; non specific repolarization change were also described. Few changes that cause Arrhythmogenic Right Ventricular Dysplasia.
hours later, 8:15 a.m. the patient appeared pale and sweating; blood pressure Ten (10) cases of ARVD/Arrhythmogenic Right Ventricular Car-
was unappreciable and hypocontractility of left ventricle with low ejection diomyopathy (ARVC) autopsied at Danbury Hospital, CT, from June 2002
fraction was observed on echocardiography (EF 25-30%). A state of until June 2007 were reviewed. This number represents 3.75% of the total
haemodynamic shock was declared (FC 170, blood pressure was adult full autopsies performed in our institution during the same period.
unappreciable). Pulmonary edema was observed on chest Rx examination Age, sex, and ethnic background were noted. Associated cardiac and
and oro-tracheal intubation was performed substaining ventilation in non cardiac related diseases were reviewed.
intensive care unit. At 9:15 a.m. ECG monitor showed cardiac arrest; Medications, social and family history (sudden death of a sibling) as
resuscitation manoeuvres were attempted unsuccessfully. well as body habitus (obesity) were tabulated.
A complete postmortem examination was performed two days after Prior symptoms (syncopal episodes, palpitations) and pre-terminal cir-
death. External examination was unremarkable except for food residuals in cumstances (place of death, physical activity) were examined. Autopsy fin-
the mouth. Internal examination showed cerebral oedema; food residuals dings (both cardiovascular and systemic) were correlated.
were recorded at oesophagus exploration; heavy lungs presenting white foam The ten patients’ ages ranged from 34 to 65. Sex ratio was 1:1. 8/10
were obese, 5/10 used alcohol frequently, 10/10 were at rest at time of warfarin to prevent thrombus formation and subsequent pulmonary embo-
pre-final event, 1/10 had family history of sibling (brother) sudden death, lism.
10/10 had some degree of Coronary Artery Disease (CAD), 7/10 had car- Implantable cardioverter-defibrillator devices (ICD’s) are the most ef-
diomegaly ( 450g to 650g), 1/10 had coexisting myocarditis, 10/10 were fective prevention against sudden cardiac death.
Caucasian (only 1 with an Italian background), 4/10 had suffered a signifi- Cardiac transplant surgery is only rarely performed in ARVD. It may be
cant traumatic injury and 3/10 used medications for depression or anxiety. In indicated if the arrhythmias associated with the disease are uncontrollable or
patients with ARVD, the most common findings were obesity, CAD. The if there is severe bi-ventricular heart failure that is not manageable with rou-
authors also concluded that Caucasian ethnicity is prevalent, the pre-termi- tine pharmacological therapy.
nal episode happens at rest, the age group is between 4th and 7th decades, and All first degree family members of the affected individual should be
M:F ratio is ~ 1. screened for ARVD. This is used to establish the pattern of inheritance. Scree-
This report helps to increase awareness regarding this congenital car- ning should begin during the teenage years unless otherwise indicated. Scree-
diac disease. It is relevant to the forensic community, because of its high in- ning tests include: Echocardiogram, EKG, holter monitoring, cardiac MRI,
cidence in children, and young adults, and it is a frequent cause of (sudden and exercise stress test.
death) in the North East (New England). ARVD, Sudden Death, Pre and Postmortem Diagnosis
Arrhythmogenic right ventricular dysplasia (ARVD, also known as
arrhythmogenic right ventricular cardiomyopathy or ARVC) is a type of
non-ischemic cardiomyopathy that involves primarily the right ventricle of
the heart. It is characterized by hypokinetic areas involving the free wall of
G89 Cardiac Death in Anabolic Steroid Abuse:
the right ventricle, with fibrofatty replacement of the right ventricular myo- A Pathological and Toxicological Study
cardium, with associated arrhythmias originating in the right ventricle.
ARVD is an important cause of ventricular arrhythmias in children and Claudio Terranova*,and Massimo Montisci, PhD, University of Padova,
young adults. It is seen predominantly in males, and 30-50% of cases have Section of Legal Medicine, via Falloppio n.50, Padova - Italy, Padova,
a familial distribution. It is usually inherited in an autosomal dominant pat- 35121, ITALY; Cristina Basso, and Gaetano Thiene, via Gabelli 61, Pa-
tern, with variable expression. The penetrance is 20-35% in general, but si- dova, 35121, ITALY; and Santo Davide Ferrara, PhD, University of Padua
gnificantly higher in Italy. Seven gene loci have been implicated in ARVD. - Section of Legal Medicine and Forensic Toxicology, Via Falloppio 50,
The incidence of ARVD is about 1/10,000 in the general American popula- Padua, 35121, ITALY
tion, although some studies have suggested that it may be as common as
After this presentation, participants will understand the proposed
1/1,000. It accounts for up to 17% of all sudden cardiac deaths in the young.
methodological approach in analysis of cases of doping-related death. The
In Italy, the incidence is 40/10,000, making it the most common cause of
presentation will cover reports in the scientific literature of doping-related
sudden cardiac death in the young.
deaths due exclusively to the use of anabolic androgenic steroids (AAS).
Up to 80% of individuals with ARVD present with syncope or sudden
This presentation will impact the forensic science community by high-
cardiac death. The remainder frequently present with palpitations or other
lighting the importance of a correct methodological approach in such cases,
symptoms due to right ventricular outflow tract (RVOT) tachycardia.
and the possible cause-effect relation between AAS intake and cardiac death.
Apoptosis (programmed cell death) appears to play a large role in the
The true extent of doping is underestimated. The absence of chemico-
pathogenesis. It is unclear why the right ventricle is predominantly invol-
toxicological findings in biological samples is a limitation in epidemiologi-
ved. The disease process starts in the subepicardial region and works its way
cal studies, conducted as surveys on the living or case histories of the dead.
towards the endocardial surface, leading to transmural involvement. The left
Literature reports of doping-related deaths due exclusively to AAS confirm
ventricle is involved in 50-67% of individuals. If the left ventricle is invol-
that the phenomenon is underestimated and that epidemiological data from
ved, it is usually late in the course of disease, and confers a poor prognosis.
postmortem and intra vitam studies are contradictory.
90% of individuals with ARVD have some EKG abnormality. The most
The present work describes two cases of the death of young athletes
common one seen in ARVD is T wave inversion in leads V1 to V3.
who had taken AAS; cardiopathological evidence is discussed in relation to
Transvenous biopsy of the right ventricle can be highly specific for
studies in the relative literature.
ARVD, but it has low sensitivity. A biopsy sample that is consistent with
The methodological approach is based on the following steps:
ARVD is found to have > 3% fat, >40% fibrous tissue, and <45% myocy-
(1) assessment of circumstances, (2) analysis of medical documentation,
tes.
(3) external examination and autopsy, (4) microbiological analysis,
A postmortem histological demonstration of full thickness substitution
(5) chemico-toxicological analysis, and (6) interpretation of results.
of the RV myocardium by fatty or fibro-fatty tissue is consistent with ARVD.
Case 1 - A body-builder aged 32 was found dead in his home. Medical
There is no pathognomonic feature of ARVD. The diagnosis is based
history: Subject had taken AAS for years. He had recently stopped taking
on a combination of major and minor criteria. The diagnosis is based on a
them, due to unidentified side-effects. Postmortem findings: External
combination of major and minor criteria, and requires either 2 major criteria
examination, excessive muscular development. Cadaveric section:
or 1 major plus 2 minor, or 4 minor criteria.
cardiomegaly, with concentric hypertrophy of the left ventricle (LV).
Many of these patients have symptoms associated with ventricular ta-
Histology: focal lymphocytic myocarditis and adipose distrophy in disarray
chycardia, such as palpitations, light-headedness, or syncope. Others may
at the apex of the right ventricle. Microbiological analysis: Molecular study
have symptoms and signs related to right ventricular failure, such as lower
by Polymerase Chain Reaction (PCR): negative for cardiotropic viruses.
extremity edema, or liver congestion with elevated hepatic enzymes. Unfor-
Toxicological analysis: Screening and confirmatory chromatographic
tunately, sudden death may be the first and sole manifestation of disease.
techniques to search for xenobiotics were negative.
The goal of management of ARVD is to decrease the incidence of sud-
Case 2 - A body-builder aged 31, accustomed to practicing martial arts,
den cardiac death. This raises a clinical dilemma: How to prophylactically
unexpectedly lost consciousness during training. Hospitalized in intensive
treat the asymptomatic patient who was diagnosed during family screening.
care, he died 72 hours later of cardiac failure and acute hepato-renal failure.
Sotalol, a beta blocker and also a class III antiarrhythmic agent, is the
The medical history included astenia, dyspnea, and perimalleolar
most effective antiarrhythmic agent in ARVD. Other antiarrhythmic agents
edema. The clinical picture had worsened ten days before death. Also was
used include Amiodarone and conventional beta blockers (i.e., Metoprolol).
reported long-term intake of AAS (boldenone, dromostanolone, enanthate
If antiarrhythmic agents are used, their efficacy should be guided by series
methenolone, stanozolol, trenbolone). Postmortem external examination:
ambulatory Holter monitoring, to show a reduction in arrhythmic events.
Excessive muscular development. Cadaveric section, dilatative
Individuals with decreased RV ejection fraction and dyskinetic portions
cardiomyopathy, with endocardial thrombosis. Histology: Marked dysmetria
of the right ventricle, may also benefit from long term anticoagulation with
of hypertrophic myocytes, with diameter up to 30 μ; dyschromic and
dysmetric nuclei, evident interstitial fibrosis, and rare inflammatory ischemia secondary to >90% stenosis of multiple coronary arteries. Initial
infiltrates. The subendocardial trabeculae, especially of the right ventricle responders and emergency department personnel proceeded with
(RV), showed extensive areas of colliquative myocytolysis in repair phase. resuscitative procedures/protocols in response to a presumed choking/
Microbiological analysis: Molecular study by PCR positive for Epstein- asphyxia event. Autopsy revealed extensive cholesterol deposition in the
Barr Virus (EBV). Toxicological analysis: Screening (GC-MS) and coronary arteries with additional deposits found throughout the aorta and
chromatographic (GC-MS/MS) confirmatory techniques to reveal within the skin (xanthomas). The decedent’s family history was significant
xenobiotics in hair were positive for AAS (stanozolol). for a father and 12-year-old sister with hypercholesterolemia. A recent visit
A cause-effect relation between AAS and cardiac death can only be to the pediatrician revealed fasting plasma total cholesterol >400 mg/dl. It
demonstrated by applying rigorous methods of investigation. Further clinical is recommended that medicolegal death investigators become familiar with
and experimental studies are needed for further in-depth knowledge of the the possibility of an acute cardiac death in young children with a family
pathogenetic and physiopathological role played by AAS in causing cardiac history of abnormal cholesterol metabolism.
death. In particular, clarification is needed on the possible effects of AAS on Café Coronary, Children, Familial Hypercholesterolemia
sympathetic control of the cardiac function, related to myocardial
contractility and vascularization.
Anabolic Androgenic Steroids, Cardiac Death, Doping
G91 Identification of Twenty Charred Victims
of a Helicopter Accident, Africa
G90 A “Café Coronary” in a 2-Year-Old:
Case Report Laurent Martrille, MS, MD*, Service de Medecine Legale, CHU
Lapeyronie, 191 Avenue, du Doyen Gaston Giraud, Montpellier, CEDEX 5
Jennifer L. Shuttlesworth, MD*, University of Texas Medical Branch, 301 34295, FRANCE; Charles Georget, DMD, Stéphane Chapenoire, MD,
University Boulevard, Route 0743, Galveston, TX 77555; and Stephen M. Jean Paul Tissier, MS, and Laurent Chartier, PhD, CTGN, IRCGN, 1
Pustilnik, MD, Galveston County Medical Examiner’s Office, 6607 Hi- Boulevard T Sueur, Rosny Sous Bois, 93111, FRANCE; Didier Buiret, MS,
ghway 1764, Texas City, TX 77591 SCIJ, 31 av Franklin Roosevelt, Ecully, 69134, FRANCE; Géréard De
Lassus, MS, IJPN, Paris, 75000, FRANCE; and Eric Baccino, MD, 371,
After attending this presentation, attendees will understand the history
av du Doyen Gaston GIRAUD, 34295 Montpellier, Hopital Lapeyronie,
of the term “café coronary” and the mechanisms, genetics, presenting signs
Cedex 5, FRANCE
and symptoms, and pathologic findings of abnormal cholesterol metabolism
involved in familial hypercholesterolemia. This presentation offers a paradigm for the identification of multiple
This presentation will impact the forensic community by reviewing the charred bodies in situations where there is no existing medicolegal
role genetic diseases play in fatal, premature pediatric coronary artery di- infrastructure.
sease. During café coronary events, myocardial ischemia should be consi- This presentation will impact the forensic science community by-
dered as a cause of death, even in the pediatric population, and especially if demonstrating how a rush to immediate autopsy is not always the best first
there is a family history of premature coronary artery disease or familial dy- step. A first triage including sex, size, and personal effects allowed quick
slipidemia. matching with antemortem data.
“Café coronary” is a term used to describe a sudden attack resulting in Since each mass disaster presents unique challenges, the medicolegal
death that occurs during or shortly after eating, often in the elderly, and is sec- response must be tailored to the circumstances at hand. Scientific standards
ondary to choking; however, the death is erroneously attributed to coronary for identification vary from country to country, often in proportion to the
artery disease. In children and adolescents, the opposite scenario, death in a urgency of identification and the country’s scientific capabilities.
suspected choking victim having a final diagnosis of myocardial ischemia On June 11 2007, a helicopter transporting twenty supporters of a soccer
secondary to coronary artery disease, is extremely rare. squad, among them two French nationals, ignited a couple of feet off the
Childhood is a critical period in which dietary and lifestyle patterns ground at an airport in Africa; investigation revealed that the private
have long-term implications for coronary heart disease risk in adult life. helicopter company was not certified to fly. The bodies, unnumbered, had
Smoking, high intake of dietary total fat and saturated fat, low exercise level, been simply repatriated to local morgue. No forensic investigation were per-
and excessive alcohol consumption are correlated with elevated serum formed locally. The French embassy asked the french government to send a
cholesterol, obesity, and hypertension in children, as well as a predisposition team to Africa in order to identify the french bodies and to help local
to premature death from coronary heart disease. government to identify their bodies. As the bodies were charred, the identi-
Children and adolescents can be at an even higher risk of cardiovascular fication procedure might include all the victims.
disease if there is a family history of premature coronary artery disease or A seven member team of French forensic experts, including two
familial dyslipidemia. Of the primary hyperlipidemias, familial
pathologists and an odontologist, were dispatched to the scene, accompanied
hypercholesterolemia (FH) is the most common and the most documented to
by half a ton of equipment; a one week mission was planned.
have important cardiovascular consequences beginning in childhood. FH is
an inherited dominant condition due to a defect in the LDL receptor gene The first step was to petition the local judiciary to confer official status
and is usually discovered when there are increases in plasma total and LDL on the mission. Next, a unit of the team worked with families to organize
cholesterol in the child and in at least one of the parents. More than 600 intake of antemortem data (medical and dental history, descriptions of
different LDL-receptor mutations have been described. Mutations of the personal effects) and exemplars for possible DNA comparison.
LDL-receptor cause significantly elevated LDL levels. This inability for A second unit worked on analyzing the bodies. A decision was made
cholesterol uptake leads to premature atherosclerosis and a very high risk of to do an intake exam to assign the bodies case numbers, determine the sex
early cardiovascular disease and myocardial infarction. Patients with and size, then describe any personal effects. This preliminary triage facilitated
homozygous FH manifest cardiovascular disease within the first two decades more exacting processing with regards to comparison with available
of life, and may present within the first decade of life with physical findings antemortem data (scars, prostheses, dental irregularities). With that goal, an
related to cholesterol deposition, such as tendon xanthomata, cutaneous autopsy (minimal autopsy following the Interpol procedure) with odontologic
xanthelasma, or corneal arcus. FH heterozygotes usually present with evaluation was conducted on each body, and a segment of femur retained
problems in early to mid-adulthood. for possible DNA testing.
A 2-year-old Hispanic male appeared to be suffering from a “café On-site identification was possible for fourteen of the twenty bodies as
coronary” while eating, but was actually suffering from acute myocardial follows: dental charting – eight bodies; radiographic comparison – two

bodies; confirmation of a hip prosthesis - one body; anthropological G93 Cervical Spine Injuries in Fatal Traffic
identification of an old fracture – one body; identification by highly specific
ritual scars – two bodies; fingerprints – one body. Some bodies were
Crash Victims: Microscopy and
identified by multiple modalities. Finally, for six bodies, genetic testing was Diagnostic Imaging Findings
the only possible option, and was accomplished through mitochondrial DNA
extracted from bone specimens sent to France packed in dry ice. Location Lars Uhrenholt, DC*, and Annie Vesterby Charles, DMSc, University of
work took one week, with DNA identification of the final six bodies Aarhus, Institute of Forensic Medicine, Peter Sabroes Gade 15, Aarhus C,
completed in three weeks. Europe 8000, DENMARK; Ellen Hauge, MD, PhD, Research Unit for
All site work was done by the specially french trained team, equipped Rheumatology and Bone Biology, Aarhus University Hospital, Aarhus
to perform postmortem examinations without relying on local infrastructure Sygehus (NBG), Denmark; and Markil Gregersen, DMSc, University of
(with the exception of access to water). This team includes police officers, Aarhus, Institute of Forensic Medicine, Peter Sabroes Gade 15, Aarhus C,
crime scene investigators, forensic odontologists, and forensic pathologists, Europe 8000, DENMARK
all trained in identification methods and technics.
The objective of this presentation is to familiarize the attendees with
The authors experience demonstrates that a rush to immediate autopsy
the presence of discrete lesions in the cervical spine facet joints in fatal traf-
is not always the best first step. In this case, preliminary triage on the basis
fic crash victims based on a large case-control forensic autopsy study utili-
of sex, size and personal effects allowed quick matching. Time for identifi-
zing advanced diagnostic imaging procedures and histological methods.
cation was reduced, and the bodies were rapidly released to families as
This presentation should encourage forensic specialists and researchers
identifications progressed, easing the political pressure.
to include detailed examination of the posterior elements of the spinal column
Forensic, Mass Disaster, Identification in the evaluation of trauma victims. Furthermore, clinical sciences should
consider these findings as potentially relevant in cases of cervical spine
symptomatology after severe road traffic crashes despite negative diagnostic
G92 Risk Factors for Pedestrian Deaths imaging evaluation.
Occult lesions have previously been identified in the cervical spine in
William T. Gormley, MD, PhD*, and Anna Noller, PhD, Office of the Chief case studies on autopsy material using diagnostic imaging procedures and
Medical Examiner, Commonwealth of Virginia, 400 East Jackson Street, microscopy; very few case-control studies have, however, been performed.
Richmond, VA, 23219 The lower cervical spine facet joints from 42 subjects (20 fatalities from
passenger car traffic crashes (cases) and 22 decedents due to non-traumatic
After attending this presentation, attendees will understand some of the causes (controls)) were removed en bloc during autopsy. The specimens
pertinent risk factors associated with pedestrian deaths. were examined with: (1) advanced diagnostic imaging procedures (conven-
This presentation will impact the forensic community and public health tional x-rays, computed tomography and magnetic resonance imaging),
agencies by documenting and highlighting factors which can help focus (2) stereomicroscopy of 3-mm thick anatomical slices, and (3) microscopy
injury prevention strategies. of 10µm thick stained histological sections. Each facet joint was examined
All pedestrian deaths investigated by the Central Virginia District Of- and described systematically with each of the three methods. The diagnos-
fice of the Chief Medical Examiner in the years 2002 through 2006 were re- tic imaging examination included evaluation of fractures and bleeding, the
viewed using police reports, death certificates, and medical examiner stereomicroscopy included evaluation of fractures, bleeding and damage to
investigation and autopsy reports. The decedent information and circum- the synovial folds, and the microscopy included evaluation of fractures,
stances of the death were extracted to analyze factors such as age, sex, race, bleeding in and disruption of the folds and haemarthrosis. Furthermore, age-
manner of death, intoxication, time of day, season, location of death, activity related changes were evaluated microscopically with regard to cartilage
of decedent, and vehicles involved. fibrillation and fissures, vascular invasion of the tidemark and semi-
Approximately 70% of all deaths were adults (21 to 65 years old) and quantitative histomorphometric measurements of the cartilage thickness,
70% of all deaths were males. The rate of pedestrian deaths (per million) was subchondral bone thickness, cartilage length, and percentage overlap of the
21 for males compared with 8.7 for females. Rates were highest for Hispa- anterior and posterior folds. Results from the diagnostic imaging procedures
nics (24.2) followed by African Americans (19.3) then non-Hispanic Cau- and the stereomicroscopy were compared to the microscopical findings.
casians (12.1). Lesions in the lower cervical spine facet joints were common,
Considering individual risk factors in adult pedestrian deaths, the lea- particularly in the soft tissues, including bleeding in the joints spaces and the
ding factor was darkness with approximately 76% of deaths occurring at synovial folds. Among the diagnostic imaging procedures, computed
night. The second most prominent factor was alcohol intoxication (Blood Al- tomography was the most sensitive towards identifying facet fractures,
cohol >= 0.08 % by weight by volume) present in 44% of pedestrian deaths. whereas soft tissue lesions could not be identified reliably in any of the
The next most common factors were crossing a road (41%) or walking along diagnostic imaging procedures. None of the stereomicroscopical findings
or in a road (25%). Almost 8% of the pedestrian deaths were associated correlated significantly with the microscopical findings. Microscopical
with a domestic dispute and 88% of the victims were male. Nearly 7% of the examination was the most sensitive method and identified all facet fractures,
pedestrian deaths occurred in victims of or responders to a previous motor haemarthrosis, and bleeding in the folds. The microscopical findings corre-
vehicle accident. lated well with the exposure to trauma. None of the osseous or soft tissue
Most of the pedestrian deaths were certified as accidents (94%). Only lesions in the cervical spine facet joints were identified during the autopsy.
4% of the pedestrian deaths were certified as suicides but in an additional 6% Furthermore, histomorphometric data were collected for the normal anatomy
of the deaths there were circumstances which were suspicious for but not of the lower cervical spine facet joints.
diagnostic of suicide. Discrete injuries in the lower cervical spine facet joints are common
Education and enforcement focusing of risks of darkness, alcohol use after fatal road traffic crashes. Osseous lesions of the facet joints can be
and pedestrians crossing or walking on roads are focus areas for prevention. reliably identified on computed tomography whereas soft tissue lesions can
Pedestrians and responders on roads after motor vehicle collisions are at great not. Stereomicroscopical examination does not reliably identify lesions in the
risk. Domestic disputes are associated with a surprising number of pedestrian facet joints in comparison to microscopical examination which identifies
deaths. Pedestrian deaths require careful investigation to correctly establish both osseous and soft tissue lesions in great detail.
manner of death. This presentation should encourage forensic specialists and researchers
Pedestrian, Motor Vehicle, Death to include detailed examination of the posterior elements of the spinal column
in the evaluation of trauma victims. Furthermore, clinical sciences should
consider these findings as potentially relevant in cases of cervical spine
symptomatology after severe road traffic crashes despite negative diagnostic 275 yards from the point of impact before coming to rest near the barrier.
imaging evaluation. The driver sustained severe injuries to the head, neck, torso and abdomen.
Fatal Traffic Crash, Cervical Spine Injury, Investigation Some of the injuries that contributed to her death resulted from excessive
lap belt loading.
This case is an example of high severity crash occurring in a unique
vehicle. The severity of the collision is due not only to the high delta-V of
G94 Reconstruction of a Fatal Dragster Crash the crash but also its short time duration. Irrespective of the restraint system
integrity, a fatal outcome was predictable.
Michael J. Shkrum, MD*, London Health Sciences Centre, Department of
Pathology, 339 Windermere Road, London, Ontario, N6A 5A5, CANADA; Dragster, Crash, Reconstruction
Kevin J. McClafferty, BESc*, Multi-Disciplinary Accident Research Team,
Faculty of Engineering, University of Western Ontario, London, Ontario
N6A 5B9, CANADA; and John R. Fernandes, MDCM, Forensic Pathology G95 Death Due to Aquatic Erotic
Unit, Hamilton Health Sciences, 237 Barton Street, East, Hamilton, Onta-
rio L8L 2X2, CANADA
Asphyxia - Accident or Homicide?
After attending this presentation, attendees will understand the basic Andrea Zaferes, BA*, PO Box 211, Hurley, NY 12443; and Kari B. Reiber,
principles in crash reconstruction, vehicle crash dynamics, measures of im- MD, and Dennis J. Chute, MD, Office of the Medical Examiner, Dutchess
pact severity, occupant kinematics, seatbelt overloading, and biomechanics County Department of Health, 387 Main Street, Poughkeepsie, NY 12601
of injury in the context of an unique type of motor vehicle collision.
This presentation will impact the forensic science community by pre- The objective of this presentation is to alert medical examiners, medi-
senting concepts in crash reconstruction vehicle crashworthiness, occupant colegal investigators and other forensic experts to unusual and potentially
protection and human tolerance to impact by an in-depth analysis of an un- deadly forms of erotic asphyxial behavior in an aquatic environment. Our
common type of high-severty collision, this presentation will be of interest concern is that such behavior can be misconstrued as autoerotic and classi-
to all motor vehicle collision investigators. fied “accident” in the event of a death.
This presentation examines a number of different concepts in crash re- This presentation will impact the forensic science community by illu-
construction, vehicle crashworthiness, occupant protection and human tole- strating that aquatic erotic asphyxia is a potentially deadly activity that can
rance to impact through the in-depth analysis of an uncommon type of be a venue for more sinister activities such as aquatic sexual sadism and child
high-severity collision. This illustrative case will be of interest to anyone abuse. Since aquatic erotic asphyxia requires the participation of two or
investigating motor vehicle collisions and consequent injury patterns. more individuals, it should not be confused with autoerotic asphyxia. In the
A 17-year-old female driver lost control of her rail-type dragster at the event of a death, a thorough investigation is needed to assign manner of
finish line during a routine performance run. The vehicle struck a rigid left death.
concrete barrier running parallel to the track. The driver’s seatbelt failed du- Accidental autoerotic deaths generally occur during solitary sexual ac-
ring the crash, and she was ejected and fatally injured. The cause of the seat- tivity involving the use of props or other stimulatory devices, when the vic-
belt failure and its role in the death of the young woman were major tim miscalculates or when a safety mechanism or breathing apparatus fails.
considerations during the in-depth investigation of the crash. Some of the mechanisms used to produce cerebral hypoxia include ligatures,
The light stiff dragster rail was propelled by a jet engine mounted plastic bags, body wrapping and submersion in water. Aquatic erotic
behind the seat and was traveling at a speed of 305 mph when it suddenly asphyxia (AEA) a potentially dangerous but less known form of erotic
veered to the left at the finish line. The driver shut off the jet engine just past asphyxial behavior, may involve more than one participant, whereby the
the finish line, and the vehicle began to decelerate rapidly due to large ae- manner of death is at issue in the event of a death. Illustrative cases and a
rodynamic forces that also put the vehicle into a hard counterclockwise ro- brief review of the literature will be presented.
tation. The “jet car” was traveling at approximately 280 mph and slipping AEA and its many subcategories as advertised on the internet with par-
sideways when it struck the barrier with its front end just 80 yards past the ticular attention to the more pernicious forms of the practice such as aquatic
finish line. At impact, the approach angle of the vehicle’s center of mass sexual sadism and the forceful immersion of children are described. Surpri-
was 9.3 degrees to the barrier as indicated by a single tire mark. The com- singly, references to aquatic pedophilia can be found on some of the websi-
ponent of the vehicle’s velocity directed perpendicular to the barrier was 45 tes catering to “aquaphiles”. AEA can involve more than one participant in
mph. Impact speed is often a poor measure of crash severity, and the velo- various gender combinations, with one dominant figure dunking or drow-
city change (delta-V) and time duration (delta-t) of the impact must be con- ning a submissive figure, or with two individuals wrestling under water for
sidered. The delta-V in this case would be similar in magnitude to the dominance. AEA enthusiasts are careful to avoid injury and even post de-
component of the impact velocity that was directed perpendicular to the bar- tailed medical questionnaires on their websites. AEA activity sometimes in-
rier. A delta-V of 45 mph is indicative of a severe crash. By comparison, full- volves the use of actors wearing underwater makeup and props to ensure a
frontal passenger vehicle crash tests into fixed rigid barriers are conducted safe and controlled environment. Aquatic sadists on the other hand derive
at test speeds of 30 mph by regulatory agencies in North America. While the pleasure from the dunking-related torture and/or actual drowning of another
delta-V sustained by the dragster was very high and well beyond the com- person, and promote more “realistic” scenarios.
pliance limits of passenger vehicles, there are additional considerations when Given that the AEA community is becoming increasingly organized,
evaluating impact severity. Due to the low mass and very stiff construction with personal ad websites, commercially available videos, DVD’s and pho-
of the vehicle it sustained minor front-end crush. As a result of the short tographs, and even conventions and hosted parties, the authors strongly re-
ride-down distance, the delta-t would be much less than a similar severity commend that the practice be taken into consideration when investigating a
crash by a passenger vehicle. Consequently, the resulting decelerations su- death in water. Investigators should search for unusual items such as cin-
stained by the dragster were very large, and the impact extremely severe. derblocks, cut lengths of rope, large clear plastic tarps, diver weight belts,
The occupant compartment remained intact, but the driver’s five-point unusually set-up scuba regulators, large empty fish tanks, and other apparel
restraint harness failed during the crash. The left lap belt, right lap belt latch not usually worn in hot tubs or pools. Evidence suggesting the participation
plate and central crotch strap separated due to occupant loading. The failure of more than one individual should also be carefully looked for, since the
of the left lap belt occurred at the adjuster mechanism and appeared similar death scene may have been altered or sanitized. The concern is that when
to the restraint failure observed after Dale Earnhardt’s fatal NASCAR crash. aquatic erotic asphyxial activity results in the death of a participant, we may
The dragster driver was ejected and slipped out of her helmet, which remai- be dealing with homicidal violence and sexual sadism and not accidental au-
ned tethered to the vehicle. Both driver and vehicle traveled approximately toerotic activity. The fact that death can potentially occur after the person

exits the water further underscores the need for a thorough and thoughtful present. However, there exist rare cases of head injury in which only soft tis-
death investigation whenever a drowning is suspected. sue injury is found and there are no epidural, subdural or subarachnoid he-
Aquatic Erotic Asphyxia, Aquatic Sexual Sadism, Autoerotic Asphyxia morrhages, or gross injuries to the brain, and yet sudden death has occurred.
In these specific rare cases the blood ethanol levels are elevated. The pro-
posed mechanism of death is that the combined effect of concussive brain
injury and elevated blood alcohol produces postinjury apnea, leading to sud-
G96 Bear Facts Alaska: den death. Normally, concussive brain injury rarely causes postinjury apnea.
The Good, The Bad, and the Ugly However, the presence of elevated blood ethanol, a respiratory depressant,
appears to potentiate fatal apnea in even mild concussive injury.
Kathleen Day, MA, MS*, University of Alaska, Anchorage, PO Box A computer search was used to identify all cases in the City of St. Louis
670276, Chugiak, AK 99567; and Franc Fallico, MD, Office of the Chief and four of the adjacent counties in the past ten years. Eight such cases were
Medical Examiner, State of Alaska, 4500 South Boniface Parkway, Ancho- found. The ages ranged from 23 to 64 years. Each of the individuals suffe-
rage, AK 99567 red blunt trauma about the head and/or face and had blood ethanol levels
ranging from 0.18 to 0.40 g/dl. Two of the cases involved women who had
After attending this presentation participants will understand charac-
been sexually assaulted and in which the manner of death was homicide. In
teristic trauma patterns found in fatal bear maulings , how these patterns re-
each of these cases the thorough scene investigations and the circumstances
late to bear etiology in the wild and the latest research about and how to
surrounding their deaths exclude other possible causes of death.
avoid bear attacks. The presentation will include autopsy results from highly
Milovanovic and DiMaio published a series of cases of death due to
publisized attacks, as well as those that are less well known looking at data
concussion and alcohol in 1999. This review of autopsies in the St. Louis me-
from all species of bears.
tropolitan area corroborates the findings of these authors and their descrip-
This presentation will impact the forensic community/humanity by pro-
tion of the pathophysiologic processes that take place in such deaths and
viding the latest information on bear fatality trauma and pathology with data
provides additional cases for review.
accumulated by wildlife biologists in a synthesized fashion. It will provide
This study is of use to the forensic community in supporting the theory
the forensic community with a model of the injury patterns that are found in
that sudden death occurs from concussive injury of the brain in the presence
fatal bear attacks and hopefully help in the prevention of future attacks.
of alcohol. This diagnosis must be seriously considered in any death in which
There has not been much forensic research conducted in the realm of
there is injury to the head without visible injury of the intracranial structures
bear fatal bear maulings and attacks. Because human development continues
and the blood ethanol levels are elevated. Overlooking this cause of death
to encroach on natural habitats the numbers of bear- human encounters ap-
may result in erroneous classifications of manner of death as natural or ac-
pear to be on the increase. A review of the literature consists mainly of brief
cidental, for example, when the manner may indeed be homicide. As such,
case studies or papers that have been written in past decades in the context
consideration of this entity can unquestionably impact the medicolegal in-
of emergency medicine or wildlife biology. Although being fatally mauled
vestigation of some deaths.
by a bear may be at the fringes of popular forensic science, these deaths
usually enter the realm of forensic pathologists either because the death is Blunt Head Trauma, Concussion, Alcohol
unattended, suspicious or gets attention from the media. Because of these
reasons, pathologists should have an understanding of injury patterns and a
general understanding of why they occur. Biologists have contributed a great G98 Preliminary Study and Potential Role of
deal of data to aid pathologists in explaining why particular injuries occur. It
is hoped that when fatal bear injuries are carefully documented and analyzed, CT Imaging Autopsy in the Investigation
pathologists can reciprocate and help biologists better understand bear spe- of Death Due to Accidental Blunt Trauma
cies behavior with the goal of preventing further deaths.
Numerous case studies of bear mauling injury patterns found at auto- Barry Daly, MD*, and Clint W. Sliker, MD, University of Maryland Medi-
psy are presented as well as the most recent scientific data from biologists that cal Center, Diagnostic Imaging Department, 22 South Greene Street, Bal-
examine the specific nature of bear-human interactions and the best way to timore, MD 21201; Zabiullah Ali, MD, Dawn Zulauf, RN, and Jack M.
avoid them. Titus, MD, Office of the Chief Medical Examiner, 111 Penn Street, Balti-
Bear Fatality, Trauma Patterns, Etiology more, MD 21201; Mary G. Ripple, MD, 68 Bluebird Road, Port Deposit,
MD 21904; and David R. Fowler, MD, Office of the Chief Medical Exami-
ner, 111 Penn Street, Baltimore, MD 21201
G97 Concussive Head Injury and Alcohol The goals of this presentation are: (1) to understand the investigational
technique of 2 dimensional and 3 dimensional CT imaging autopsy in the
Jane Willman Turner, PhD, MD*, St. Louis University School of Medicine, medical examiners investigation of death, (2) to review a U.S. medical exa-
1402 South Grand Boulevard, St. Louis, MO 63104 miners office early experience and results of CT imaging autopsy compared
with conventional autopsy for fatal accidental blunt trauma, and (3) to de-
Upon completion of this presentation, attendees will gain an apprecia-
scribe circumstances where CT imaging autopsy may evolve into a triage
tion of the combined effects of ethanol and concussive head injury in causing
tool for the medical examiners investigation of sudden death.
sudden death. A detailed review of autopsies of individuals whose cause of
This presentation will impact the forensic community and humanity by
death was concussive head injury with alcohol will be presented along with
addressing the potential role of non-invasive CT imaging autopsy to replace
outlines of the scene investigations and examination of the toxicology re-
conventional autopsy or enable performance of limited, focused autopsy in
sults.
the U.S. medical examiners investigation of fatal accidental blunt trauma.
This study is of use to the forensic community in supporting the theory
CT imaging autopsy has potential for rapid and cost effective investigation
that sudden death occurs from concussive injry of the brain in the presence
in such circumstances, including mass casualty investigations. It may also
of alcohol. Consideration of this entity can unquestionably impact the me-
provide options in the setting of religious and cultural objections to conven-
dicolegal investigation of some deaths.
tional autopsy.
The spectrum of diffuse brain injury ranges from mild concussive injury
Recent publications have suggested a potential role for high-resolution
to diffuse axonal injury resulting in death. The cases of diffuse axonal injury
CT imaging using 2D and 3D techniques in the forensic investigation of
are often apparent to the forensic pathologist at the time of autopsy as the as-
death. This pilot study evaluated the sensitivity of CT imaging autopsy for
sociated markers of injury are often present. That is to say, in cases of sud-
major injuries and accuracy for the cause of death. The study also evalua-
den death from severe head injury, significant intracranial injuries are often
ted the potential role of CT imaging autopsy as a replacement for or adjunct seven were free of significant injuries.
to conventional autopsy in the investigation of traumatic accidental death Of the eight individuals who were found dead at the bottom of a
within a U.S. state medical examiner system. stairway, but had no significant injuries, six were men and two were women.
Of 40 decedents prospectively investigated with whole body 40-detec- The age range was 48-87 years with an average age of 63 years. Six of the
tor row 2D and 3D CT within 24 hours of death, 27 were identified as vic- eight decedents had cutaneous head injuries. Six of the eight individuals had
tims of suspected accidental blunt trauma. Each CT study acquired cutaneous injuries of the torso and/or the extremities. None of the individuals
approximately 3,000 images in 10 minutes scanning time and required 30 mi- were free of cutaneous injuries. Seven of the eight deaths in this group re-
nutes interpretation time. As this was a new technique, CT was interpreted sulted from atherosclerotic cardiovascular disease and/or hypertensive car-
with consensus reading by 2 radiologists and compared with medical exa- diovascular disease. One death resulted from a mixed drug intoxication with
miners autopsy results for major findings and cause of death in all cases. citalopram and ethanol. Cocaine intoxication was a contributing factor in
CT imaging autopsy correctly identified 217 major traumatic findings one of the deaths due to cardiovascular disease. The drug screens in the re-
(average 8/decedent, sensitivity 93.4%). It correctly identified a specific maining six were negative for significant findings. Four of the eight indivi-
injury or combination of blunt trauma injuries as the cause of death in 25 duals in this subset had a reported significant chronic medical condition,
cases and excluded traumatic death in 2 others. Fourteen major false-nega- known before the autopsy, that might explain a sudden death.
tive CT findings included non-displaced atlanto-occipital subluxation (n=4); Of the nineteen individuals who died from injuries related to a fall, 15
fractures of the ribs or sternum (n=3); lacerations of the aorta (n=3), bronchus were men and 4 were women. The age range of this subset was 30-93 with
(n=1), and liver (n=1); cardiac contusion (n=1); avulsion of the renal pedi- an average age of 63 years. Eighteen of the nineteen deaths in this category
cle (n=1). CT identified 8 major findings not detected at conventional auto- were caused by craniocerebral injuries. The one death in this group not cau-
psy: fractures of sacrum (n=2), mandible (n=2), skull base (n=2), cervical sed by head injuries was a 93-year-old woman whose death resulted from a
spine (n=1); lung lacerations (n=1). Suspected significant air embolism as- left femur fracture and multiple left rib fractures. Thirteen of the eighteen had
sociated with major skull base or thoracic trauma (n=6) and tension pneu- cutaneous head injuries, and three of these thirteen had cutaneous head inju-
mothorax (n=1) were noted on CT but not found at autopsy, likely related to ries and blood draining from the external auditory canal(s). Fifteen of the ni-
the technique used. neteen individuals had cutaneous injuries of the torso and/or the extremities.
This early experience suggests that CT imaging autopsy has promise as There were no cases of individuals without any cutaneous injuries.
a sensitive tool for the detection of major injuries and accurately determines Of the nineteen individuals who died from injuries due to a fall, the
the cause of death after accidental blunt trauma. It may be insensitive for blood drug screens in seven were negative for significant findings. Ethanol
some major findings including non-displaced fracture or subluxation and the was present in the blood of eleven of the twelve with positive findings and
exact site of vascular injury in the setting of obvious major hemorrhage. Air ranged from 0.04 – 0.30% (in six of these eleven, the level was greater than
embolism appears to be more easily detected by CT than conventional auto- 0.20%). THC was present in the twelfth case with significant toxicology
psy and may play a greater role in death due to blunt trauma than previously findings.
recognized. Of the eighteen individuals with lethal craniocerebral injuries, most had
CT Imaging, Autopsy, Accidental Blunt Trauma skull fractures, however, none of the individuals with lethal injuries had de-
pressed skull fractures.
Ten of the nineteen individuals in this subset of individuals who died
from injuries had a reported significant chronic medical condition, known
G99 Stairway Related Deaths: An Analysis of before the autopsy that might explain a sudden death.
Autopsy Findings of Individuals Found Conclusions: The majority of individuals found dead at the bottom of
Dead at the Bottom of a Stairway a stairway have sustained lethal injuries. The factors that were evaluated
(age of decedent, past medical history, presence of cutaneous injuries) are
Joyce L. deJong, DO*, and Michael A. Markey, MD, Sparrow Forensic not predictive of lethal internal injuries identified at autopsy. A very high
Services, Sparrow Hospital, 1215 East Michigan Avenue, Lansing, MI percentage of individuals found dead at the bottom of a set of stairs have po-
48909-7980; and Rudy J. Castellani, MD, University of Maryland, De- sitive postmortem drug screens, primarily alcohol.
partment of Pathology, 22 South Greene Street, Baltimore, MD 21201 Stairway, Autopsy, Fall
After attending this presentation, the attendee can expect to learn the
characteristics of autopsy findings of individuals found dead at the bottom of
a stairway. G100 Discrimination of Falls and Blows in
This presentation will impact the forensic science community by Blunt Head Trauma: Assessment of
showing that it is not possible to predict which individuals found dead at the Predictability Through Combined Criteria
bottom of a stairway died from injuries and which died from non-traumatic
causes based on age, cutaneous injuries, or a past medical history of a di-
Anny Sauvageau, MD*, S. Racette, BSc, and C. Kremer, MSc, Laboratoire
sease that could cause sudden death.
de sciences judiciaires et de médecine légale, 1701 Parthenais Street, 12th
Cases from the Sparrow Health System Forensic Pathology Depart-
Floor, Montreal, Quebec H2K 3S7, CANADA
ment (Lansing, Michigan) database were searched for deaths of individuals
found dead at the bottom of a stairway. Twenty-seven such cases were iden- The goal of this presentation is to propose a criteria tool for the
tified; all of the deaths had full autopsies and twenty-six had blood drug distinction of falls from blows in blunt head trauma.
screens. This presentation will impact the forensic community by providing new
The cases were divided into two groups: those whose deaths were cau- insight into the evaluation of blunt head injuries.
sed by injuries consistent with a fall and those in which no significant inju- The discrimination of falls from homicidal blows in blunt head injuries
ries were identified. The age range, natural diseases, toxicology findings, is a common but difficult problem in forensic pathology. One of the most
and external injuries were compared between the groups. For the group of often used criteria to evaluate this issue is the hat brim line rule. According
individuals who died due to a fall, the types of lethal injuries were characte- to this rule, an injury located above the hat brim line (HBL) is more likely
rized. the result of a blow, while a fall would generally produce a wound at the
Twenty-seven deaths investigated since January 1, 2000 were of indi- level of HBL. The objective of this study was to evaluate the validity of this
viduals who were found dead at the bottom of a set of stairs. Nineteen of the criterion, as long as of two other possible criteria: side lateralization of skull
twenty-seven died from injuries associated with a fall and eight of twenty- fractures and number of lacerations. Furthermore, a combined criteria tool

will be developed. G101 Unusual Death of a Transsexual
Over a 6-year period (2000-2005), all autopsy cases from the Montreal
Laboratoire de sciences judiciaires et de médecine légale were analyzed.
(Identification of Damaging Means
Cases selected consisted of falls downstairs, falls from one’s own height, and and Death Time)
head trauma by a blunt weapon. Upon review of photographs and autopsy
reports, all cranial fractures and lacerations were positioned on figures Alessandro DellErba*, Sandra Cornetta, MD, Fiorenza Zotti, PhD, and
representing the head and the skull in different anatomical views. For the Annalisa Addante, MD, PHD, Section of Legal Medicine, Place G. Cesare,
present study, HBL was defined as the area located between two lines parallel BARI, 70124, ITALY
to a line inspired by the Frankfort horizontal plane (horizontal plane passing
After attending this presentation, the attendees will understand how
through right and left porion points and the left orbitale), the superior margin
scanning electron microscopy and immunohistochemistry can assist the
passing through the glabella (G line) and the inferior margin passing through
forensic investigator and pathologist in correlating the scene, autopsy
the center of the external auditory meatus (EAM line). For each case, the
findings, and cause of death.
following elements were compiled: location of fractures in relation to HBL,
side lateralization of skull fractures and number of lacerations.
illustrating the importance of ancillary studies in the forensic autopsy.
A total of 114 cases were selected: 21 cases of downstairs falls, 29 cases
February 2007 in Puglia, a transsexual homicide victim was discovered
of falls from one’s own height, and 64 cases of head trauma by a blunt
on a suburban road. The body was adjacent to the victim’s automobile.
weapon. The location of a cranial fracture inside HBL was of little interest
The autopsy confirmed that the cause of death was a serious encephalic
in the distinction of falls from blows. On the other hand, fractures located
concussion. There were doubts about the means of trauma, and for such a
above HBL were associated to blows in 75.9% and to falls in only 24.1%.
reason further analysis was conducted with the scanning electron microscope.
Hence, a fracture positioned above HBL was in favour of a blow (α=0.02,
Material that was deposited on the epidermic borders of the scalp was
contingency coefficient=0.25). Side lateralization of fractures was also of
compared with the varnish rests of the automobile. It was suspected that the
interest in the distinction of falls from blows: right skull fractures were more
collision/impact of the victim’s head was to the lower clapper of the right
likely to result from falls whereas left skull fractures were more often
front door.
associated with blows (α=0.007, contingency coefficient=0.36). Even more
The time of death was evaluated by immunohistochemical surveys
interesting was the number of lacerations: cases presenting 3 or less
executed on samples of cerebral parenchyma using the anti-betaAPP
lacerations were mostly falls cases (60,5%), whereas all cases (100%) with
antibody.
more than 3 lacerations were cases of blows (α =0.000, contingency
coefficient=0.48). Transsexual Homicide, Damaging Means, Immunohistochemical
By combining those criteria, a better predicting rate was achieved. Investigation
Indeed, the presence of at least two criteria in favor of a fall was successfully
predicting cases in 65.9%, whereas the presence of at least two criteria in
favor of a blow revealed a perfect score of 100% of successful prediction.
Furthermore, by combining the three criteria altogether, the predictability of
the criteria tool was even better: the presence of a combination of three
criteria in favour of blows still demonstrated a success rate of 100%, while
the success rate for falls reached 83.3% (α=0.001, contingency
coefficient=0.62).
Considering the previous results, the presence of a fracture above HBL,
of a left side lateralization of skull fractures and the presence of more than
three lacerations are criteria in favor of a blow. On the contrary, a typical fall
case is more likely to present with a fracture inside HBL, a right side later-
alization of skull fractures and 3 lacerations or less. A criteria tool based on
combination of those criteria can achieve a predictability rate of 100% for
cases of blows and 83.3% in falls cases.
Blunt Head Trauma, Hat Brim Line, Skull Fracture

Pathology/Biology
G1 Sudden Unexpected Death in a This presentation will impact the forensic community and/or
humanity by demonstrating how the number of cases of assisted suicide is
Case of Human Immunodeficiency growing every year in Switzerland, responding to the requests of very sick
Virus (HIV) and Myocobacterium patients, when palliative care and other alternatives are not efficient
Infection Diagnosed Postmortem enough anymore.
Assisted suicide is permitted in several countries and jurisdictions:
Hydow Park, MD*, Atlantic County Medical Examiner’s Office, Belgium, the Netherlands, the state of Oregon (USA) and Switzerland.
201 Shore Road, Northfield, NJ 08225-2319 The practice of assisted suicide is controversial leading to debates among
doctors, jurists, and ethicists.
After attending this presentation, attendees will learn: 1) Initial In Switzerland, article 115 of the Swiss penal code considers
diagnosis of HIV/AIDS can be made postmortem by performing thorough assistance suicide a crime if and only if the motive is for personal gain. It
histological examination and necessary laboratory tests, 2) Sudden death condones assisting suicide for altruistic reasons. This allows associations
can occur in cases of unsuspected HIV/AIDS cases with non-tuberculous such as EXIT-ADMD (French Switzerland), EXIT German Switzerland,
Myocobacterium infection in spleen and lymph nodes, 3) PCR technique or DIGNITAS to assist severely ill patients under certain conditions in
is available for identifying Mycobacterium species in formalin-fixed their desire to end their lives.
paraffin-embedded tissues. This study takes into consideration 200 cases of assisted suicide
This presentation will impact the forensic community and/or performed by the association EXIT-ADMD between 2001 and 2005. The
humanity by assisting the forensic pathologists in better identifying districts of Vaud and Geneva were the primary focus of this study, with
HIV/AIDS cases at an early stage, so that it will benefit the immediate and the number of cases increasing continually over this time period.
family and the community. Most of the patients were female. The most frequent pathologic
This 35-year-old female was found unresponsive at her residence at conditions were neoplasia, neurological diseases, and cardio-vascular
6:00 pm. She was pronounced dead at emergency room after the usual diseases. The average age of patients was over 70. More than ¾ of
resuscitative measures. She had a full-day work as a clerk stenographer assisted suicides occurred at home; 20 patients died at a nursing home.
and left work at 4:00 pm. She stated to her co-worker that she had chills Due to internal policy restrictions, some of the patients had to leave the
while riding down on the elevator to leave work. She had a history of hospital or nursing home in which they were staying in order to receive
cervical carcinoma-in-situ that was treated with total hysterectomy and assistance with their suicide.
recently had laser vaporization for dysplasia of vaginal wall. She had been The most common lethal substance used by patients, when assisted
otherwise in good health. At autopsy the spleen was slightly enlarged and in their suicide, was sodium pentobarbital (between 11 and 15 grams)
had gray nodules and there were skin ulcers in perineum. Microscopic inducing coma within less than ten minutes, and leading to a painless death
examination of the spleen revealed ill-defined epithelioid cell granulomas within than 30 minutes. At the moment of death, their family or relatives
containing rare acid-fast bacilli (AFB). Sections of mesenteric lymph surrounded most patients.
nodes revealed lymphoid depletion and numerous AFB in ill-defined Legal requirements following such a death are quite simple in
epithelioid cell granulomas. The skin ulcers were microscopically Geneva. As it is a violent death, the forensic physician must examine the
consistent with herpes simplex virus infection. In view of the presence of remains, and completes a death certificate noting the unnatural nature of
cervical carcinoma-situ, vaginal wall dysplasia, Mycobacterium infection, death. Based on these medicolegal observations, the police officer
and herpes simplex skin infection, HIV-1 antibody tests (enzyme-linked completes a document called the “Nihil Obstat.” This permits burial of the
immunosorbent assay and Western blot assay) were performed on a blood remains to take place without any other formality, allowing for full respect
specimen taken at autopsy. Both tests were positive. Further investigation of the deceased and his/her family.
revealed that the decedent’s brother had known that the decedent might
Assisted Suicide, EXIT Association, Switzerland
have had HIV infection, because her ex-boyfriend had told him that she
might have been infected with HIV. To identify Mycobacterium species
the formalin-fixed paraffin-embedded tissues of mesenteric lymph nodes G3 Firearms Injuries:
were sent to Central Arkansas VA Medical Center laboratory, where Beyond Entry and Exit Wounds
Mycobacterium tuberculosis DNA complex was not detected by use of
polymerase chain reaction (PCR) assays. This case was reported as
Rosa Falamingo, MD, PhD, and Francesco Vinci, MD, Section of Legal
HIV/AIDS to NJ State since the diagnosis had not been made antemortem.
Medicine (Di.M.I.M.P.) - University of Bari, Piazza Giulio Cesare,
HIV/AIDS, Sudden Death, Mycobacterium Policlinico, Bari, 70124, Italy; and Carlo P. Campobasso, MD, PhD*,
Department of Health Sciences (Di.S.pe.S), University of Molise, via De
G2 Assisted Suicide as Practiced in After attending this presentation, attendees will learn (1) the
the French Part of Switzerland diagnostic features of pattern injuries made by firearms; and (2) their
relevant role in criminal investigations.
Sandra E. Burkhardt, MD*, Jerome Sobel, MD, and Romano This presentation will impact the forensic community and/or
La Harpe, MD, Institute of Forensic Medicine, 9, Avenue de humanity by showing several case studies in which patterned abrasions
Champel, Geneva, 1206, Switzerland and wounds were useful in the identification of the firearms used and in
the reconstruction of the assaults.
After attending this presentation, attendees will understand the legal Patterned injuries usually occur when the force is applied at or near
aspects of assisted suicide in Switzerland, where the penal code condones a right angle to the skin surface, rather than with the skidding impact of a
this practice for altruistic reasons, even if not performed by a doctor; the graze. If a weapon with a patterned surface strikes the skin, abrasions or
prevalence of this type of death and the way it is treated. bruises and even lacerations follow the ridges of the object if it has a

profile of varying height. Formerly it was often claimed that abrasions included desiccation and brittleness of the skin, which was stretched
retained the pattern of the impacting object more accurately than other tightly across anatomical prominences such as the cheekbones, chin,
injuries such as bruises and lacerations. However, even if abrasions do costal margin, and hips. The skin and the underlying tissues of the body
preserve such patterns well, bruises and lacerations may also follow the were darkened, hard, forming a leathery shell over the body and making
profile of the inflicting object reproducing exactly the imprint of firearm autopsy dissection difficult. The corpse was well preserved through the
weapons and/or its parts. mummification process and no external injuries were observed. There
The plastic grip of a firearm weapon can easily imprint its design on was little evidence of insect activity. The shutters of the entry way were
the skin producing bruises and/or lacerations at the edges of the impact site closed but the windows were open so that there was accessibility to air.
such as heavy objects with firm impacts use to do. The skin between the The carpet on which the body was sitting and the upholstery of the easy
thumb and index finger of the hand holding a pistol may slightly overlap chair on which the head was lying absorbed most of the early putrefactive
the lumen of the barrel so that a graze wound can occur. Shape and size fluids. Several empty pupae of Lucilia sericata and Calliphora vicina,
of pattern injuries are often useful for the identification of the weapon used cast larval skins of Dermestidae (Coleoptera) along with dermestid frass
in the assault. In the literature, there have been many reported cases in (excreta) were found on the floor close to the body suggesting a death
which additional pattern injuries have been found in the area surrounding occurred during the spring season.
the entry wounds produced by shotguns, revolvers, and semiautomatic Mummification often occurs in elderly bodies due to rapid
pistols due to the peculiar firearm muzzle design. These findings have dehydration of the outer surface. The rapidity of dehydration may reduce
been used in shooting reconstruction and also to establish the range of fire. the usual swelling of the body preventing also putrefaction by enteric
It is well known that if the discharge is contact, the muzzle of a firearm microorganisms, soil bacteria, and other decay organisms. The rapid
can imprint an abrasion on the skin surface. Hard and loose-contact drying of soft tissues may also protect the internal organs even from insect
wounds have been described depending on whether the muzzle of the colonization as in this case where after the drying had taken place, the
weapon is jammed “hard” against the skin (so that the skin envelops the corpse remained in that state for many years with no insect activity at all.
muzzle) or held lightly against the skin. Even when there is a gap between Larval infestation for all blow fly species is usually hindered by the rapid
the muzzle and the skin, for example when the barrel of the weapon is held dehydration of the skin surface; female adults recognize dehydrated
at an acute angle to the skin, the muzzle can imprint part of its and/or mummified skin as in hospitable to the larval stages which need
circumference thus producing angled or incomplete-contact wounds. both moisture and accessibility to air. Radiographs of the body disclosed
Difficulties in interpreting such pattern injuries may occur when the injury osteoporosis but no fractures or other evidence of blunt trauma. The
involves a surface not completely flat such as the head. In these cases the internal organs were well preserved. However, the cause of death was
position of the edge that digs in most deeply may give an indication of the undetermined. Based on the antemortem data available the remains were
angle of the blow. rapidly identified by dental comparison. The man had been missing seven
Pattern Injuries, Firearm Wounds, Ballistic years. The neighbors stated they had thought that the man had died a long
time ago. Unpaid electricity bills resulted in termination of electrical
service. The paid condominium bills forced the manager of the
condominium led to the entry of the apartment.
G4 The Mummified Corpse
Mummification, Postmortem Changes, Forensic Taphonomy and
Found in a Domestic Setting Entomology
Carlo P. Campobasso, MD, PhD*, Department of Health Sciences
(Di.S.pe.S.), University of Molise, via De Sanctis, snc, Campobasso, Italy
86100, Italy; and Rosa Falamingo, MD, PhD, Domenica
G5 Acute Hemorrhagic Leukoencephalpathy
Laviola, MD, Claudia Liuzzi, MD, and Francesco Vinci, MD, Section of (Weston-Hurst Disease): A Natural
Legal Medicine (Di.M.I.M.P.) - University of Bari, Piazza Giulio Cesare, Disease Presents as Head Trauma
After attending this presentation, attendees will gain an Kenneth D. Hutchins, MD*, Miami-Dade County Medical Examiner
understanding of the forensic and ethical issues pertaining to lunattended Department, Number 1 Bob Hope Road, Miami, FL 33136; and Lyla E.
deaths of those with little or no contact with society and the mummified Perez, MD, Southern Regional Medical Examiner Office, 1175 DeHirsch
remains found after a significant period of time after death. Avenue, Woodbine, NJ 08270
This presentation will impact the forensic community and/or The goal of this presentation is to describe a case of death due to
humanity by presenting a case of a mummified corpse found several years acute hemorrhagic leukoencephalopathy (AHL), a natural disease
after death. masquerading as head trauma.
Mummification refers to all natural and artificial processes that bring This presentation will impact the forensic community and/or
about preservation of the body or its parts. Such processes include humanity by demonstrating how AHL, a natural occurring brain disease
primarily the drying of the soft tissues instead of liquefying putrefaction. which may mimic brain trauma and must be considered in the differential
The essential requirement for mummification is a dry environment, diagnosis of cerebral hemorrhage.
preferably with a moving air current, which is usually in a warm Naturally occurring neurologic disease may occasionally mimic
environment. The most widely known form of mummification is in hot traumatic injury.
and arid areas like Egypt, Chile, and Peru. It is also likely to occur in A 19-year-old man complained of headache after bouncing a soccer-
temperate climates especially when the body is left undisturbed in warm ball on his head. He was admitted to a hospital where he became lethargic,
dry place such as closed rooms, closets, and attics. then comatose. A computed tomographic (CT) scan revealed dense,
A mummified body of an 86-year-old white male with a history of bilateral, frontal lobe hematomas. Angiography did not demonstrate
coronary atherosclerosis was found in the entryway of his apartment vascular abnormalities. A craniotomy was performed to evacuate the
located in a condominium of the city of Bari (Southern Italy) hematomas; however the patient died after a four day hospitalization.
approximately seven years after death. The body was sitting on the carpet Further history revealed that the patient may have sustained head trauma
in front of an easy chair, clothed in a woolen vest with dark pants and during an altercation in the days previous to the hospital admission.
shoes. The head was lying face down on the easy chair and the scalp with Because of the possibility of a trauma related death, jurisdiction was
long grey hair was still present. The appearances of mummification assumed by the medical examiner and an autopsy was performed. Gross

neuropathologic examination revealed a swollen, soft brain that exhibited centralized office that covers the entire state. All non-natural deaths and
evidence of surgical intervention and transtentorial herniation. The frontal purely natural deaths that are unexpected or unsupervised by a physician,
lobes had dense, confluent hemorrhages, located predominantly in the affecting persons under 50 years of age are transported to the office for
white matter, extending across the genu of the corpus callosum. cause of death investigation.
Additional foci of hemorrhage were in the convolutional white matter of • Each body was measured and weighed upon arrival at the OCME.
the cingulate gyrus and the internal and external capsules. There were no • BMI was calculated following a standard formula (BMI = weight
cortical contusions or other traumatic pathology. Histologic examination in kilograms/squared height in meters)
demonstrated perivascular hemorrhage surrounding necrotic blood vessels • Cases were tabulated by age, gender, manner of death, height,
with fibrinous exudates within the Virchow Robin spaces, perivascular weight, BMI and BMI NIH categories (normal [BMI <25],
inflammation, and demyelination. These findings were diagnostic of AHL. overweight [25<BMI<30], obese [30<BMI<40] and very obese
AHL, or Weston-Hurst disease, is a rare inflammatory, demyelinating [BMI<40)
disease of the brain characterized clinically by an abrupt onset of • Non-natural deaths (Accident, Suicide, Homicide and
neurologic symptoms and signs with rapid progression. Its onset is Undetermined) were analyzed separately and grouped together
frequently associated with an antecedent viral illness. The disease is for comparison
usually fatal, although recovery has been described with medical • Statistical analysis included descriptive statistics and multivariate
treatment. The clinical differential diagnosis includes herpes simplex logistic regression, using likelihood ratio tests of statistical
virus type 1 encephalitis, meningoencephalitis, encephalomyelitis, sagittal significance. Effect sizes were estimated by odds ratios (OR)
sinus thrombosis, central nervous system vasculitis, and in the elderly, • Possible bias (systematic errors impacting the different groups
congophilic angiopathy. Traumatic injuries are usually not entertained in differently) were sought and discussed
the differential diagnosis, although the gross findings are similar to those Results: The study included 6987 individuals, 2097 (30.0%) had
associated with fat embolism following skeletal fractures. In this case, the natural deaths and 4890 had non-natural [1345 (19.3%) were accidents,
unusual CT scan findings and the history of possible antecedent head 1210 (17.3%) were homicides, 642 (9.2%) were suicides and 1693
injuries led to the suspicion that the lesions resulted from head trauma. (24.2%) undetermined.
This case illustrates the importance for forensic pathologists to recognize • The percentage of women in the natural death group was higher
AHL as a natural disease process that may rarely mimic traumatic brain (34.0%) than in the non-natural deaths (21.5%), and the average
injury. age (SD) was higher for the group of natural deaths (41.3 +/-7.0)
Head Trauma, Acute Hemorrhagic Leukoencephalopathy, than the group of non-natural deaths (35.1 +/- 9.0).
Demyelinating Disease • BMI was an independent risk factor (p<0.0001, OR=9.4) for
natural death when adjusted for age (p<0.0001, OR=15.4) and
gender (p<0.0001, OR=1.7 F/M) in a multivariate logistic
G6 Weight That Kills: Adults With Natural regression analysis. Per unit of measure, BMI was a comparable
Deaths are Heavier Than Those Dying risk factor to age.
• The mean (SD) BMI in natural deaths was higher than that of
Non-Naturally — A Cross-Sectional Study non-natural deaths: 29.3 (9.1) vs. 27.5 (6.5).
• The percent of natural deaths among the different BMI levels was
Ana Rubio, MD, PhD*, and David Reisz, BS, State of Maryland Office of 26.9% for people in the normal weight range, 27.9% in the
the Chief Medical Examiner, 111 Penn Street, Baltimore, MD 21201; overweight group, 32.1% in the obese group, and 48.6% among
Christopher Cox, PhD, Bloomberg School of Public Health, Johns the very obese.
Hopkins University, Monument Street, Baltimore, MD 21205; and David Conclusions: In an adult population, the relative frequency of natural
M. Fowler, MD, State of Maryland Office of the Chief Medical Examiner, death increases steadily with increasing levels of obesity. This increase
111 Penn Street, Baltimore, MD 21201 persists when adjusted for both age and gender, indicating that obesity is
After attending this presentation, attendees will understand the an independent risk factor, comparable or greater in its effect to age.
impact of obesity on natural death by applying standard epidemiologic Obesity, Body Mass Index, Natural Deaths
techniques to data obtained at the State of Maryland Medical Examiner
Office.
This presentation will impact the forensic community and/or
humanity by highlighting the problem of obesity and raising awareness of G7 Forensic Science “Case Derived”
how deep and broad the problem is and the need to address it.
Introduction: The morbidity and mortality produced by obesity in Templates Formulated With
the United States and other developed societies has reached epidemic Relational Database Software
proportions. Although the problem starts in childhood and adolescence,
the medical impact takes hold in adult life. Clinical studies have shown Gilbert E. Corrigan, MD, PhD*, East Baton Rouge Coroner’s Office,
the effect of obesity on cardiovascular disease, diabetes, cancer 4030 T.B. Hearndon Drive, Baton Rouge, LA 70807; and Sarah P.
degenerative joint diseases among others, and some autopsy studies have Corrigan, MS, Jefferson Parish Forensic Laboratory, Jefferson Parish
confirmed the clinical findings. Government, Metaire, LA 70001
Aim: To evaluate the magnitude and severity of the impact of
obesity on mortality This presentation demonstrates the forensic science utility of
Hypothesis: Excess weight is a risk factor for mortality; thus Body commercial open-marketed relational databases in template and table
Mass Index (BMI) in individuals with a natural death is higher than in production, report and forms formulations, and query fashioning.
those with non-natural deaths (they would be alive if not for the non- This presentation will impact the forensic community and/or
natural factors). humanity by demonstrating the valuable and available merits of relational
Methods: Cross-sectional study involving young and middle age database use in the forensic sciences as a readily learned, available, and
adults (ages 20 – 50 years) in the state of Maryland whose death during a important tool in the armamentarium of the forensic scientist.
recent three year period (2002-2005) was either unexpected or violent. Using Microsoft Access relational database software, a series of
Cases were selected from the State of Maryland Office of the Chief templates are presented covering forensic science topics, especially those
Medical Examiner (OCME) database. The State of Maryland has a single, arising in forensic pathology and crime laboratory environment.

Templates are important graphic aids in data entry and case analysis; depression and, six month duration of neck and head pain. She was found
in relational databases they are formulated by critically selecting fields for dead in bed under suspicious circumstances so a postmortem examination
data tables. Precise and accurate derivations of essential factors pertaining was performed. The cause of death was due to acute bacterial
to the selected data item are necessary; however, database structures are leptomeningitis at the cervico-medullary junction, acute inflammation of
readily edited, improve with review, making templates dynamic and the adjacent dura mater and the tissue of her upper cervical spinal column
progressive. The ease of template production is emphasized. associated with subluxation and instability of her atlanto axial (AA) joint.
Other dimensions of relational database software are demonstrated The case compares to what is known as Grisel’s syndrome, a subluxation
and include the production of relational tables, the use of queries, and the of the AA joint due to inflammation-induced ligamentous instability
production of forms and reports. Relational database application mastery associated with an infectious/inflammatory process of the head or neck.
is presented as a legitimate forensic science skill. Grisel’s syndrome is more often found in children than adults; it may
Evaluations of the available relational databases on the basis of ease produce spinal and neurologic complications and, rarely, death.
of use, availability of support services and educational courses, Neurocutaneous Melanosis, Lead Encephalopathy, Grisel’s
certifications, personal application, and cost are presented. A summative Syndrome
reference is made available.
Relational Database, Templates, Computer Software
G9 Ruptured Cerebral Artery Aneurysm
Mimicking Home Invasion and Assault
G8 Three Unusual Neuropathologic-Related
Causes of Sudden Death Albert Y. Chu, MD, MHS*, and Luis A. Sanchez, MD, Harris County
Medical Examiner’s Office, 1885 Old Spanish Trail, Houston, TX 77054
Dennis J. Chute, MD*, and Kari Reiber, MD, Dutchess County Medical
After attending this presentation, attendees will understand a case of
Examiner’s Office, 387 Main Street, Poughkeepsie, NY 12601
a 48-year-old white female with blunt force injuries who was found nude
The goal of this presentation is to make the audience familiar with and semi-conscious in her ransacked residence. While the case was
three unusual neuropathologic entities that may contribute to sudden death initially investigated as a possible home invasion and assault, the “victim”
in the medicolegal setting. was ultimately diagnosed with a ruptured left posterior communicating
This presentation will impact the forensic community and/or artery aneurysm before dying.
humanity by demonstrating cases that exemplify the range of This presentation will impact the forensic community and/or
neuropathologic maladies that may contribute to sudden, unexpected or humanity by demonstrating that cases of ruptured cerebral artery
suspicious deaths highlight the asset a neuropathology consultation aneurysm may rarely present with psychotic and/or violent behavior and
provides and emphasize the utility of postmortem examinations in the that this behavior may in turn result in scene findings and injuries that may
elucidation of medical diseases and co-morbidity. initially be confused with criminal activity and awareness of psychotic
The autopsy findings of three medicolegal cases of sudden death and/or violent behavior as an unusual presenting symptom of ruptured
associated with uncommon neuropathologic findings of which the general cerebral artery aneurysm and its potential to mimic assault at the scene.
forensic pathologist may not be familiar are reviewed. Two cases were A 48-year-old white female with a history of hypertension was found
unexpected deaths that involved relatively young patients with histories of at her residence during a welfare check performed by her landlord and her
seizure disorders. Neurologic disorders were suspected but the exact best friend. The decedent was nude, semi-conscious, and “appeared to
relationship to the cause of death was not defined until postmortem have been beaten.” In addition, the house, which according to the landlord
examination. The other patient was elderly, thus, not an unexpected death; was typically kept very clean and tidy, was “trashed.” EMS was activated,
however, because of circumstances surrounding the scene investigation an and the decedent was taken to the hospital.
autopsy was performed and an unexpected rare neuropathologic Police arrived on the scene and investigated the case as an assault.
abnormality was found. The doors to the residence were locked but not secure and showed no signs
Case 1 was a 43-year-old male with a history of congenital nevi of of forced entry. Disarray at the scene was limited to the living room,
his head, torso, and extremities. The patient also suffered from kitchen, dining room, and bathroom; the two bedrooms were tidy. In the
hypertension, chronic alcoholism, and a poorly controlled grand mal living room and dining room, various pieces of furniture and the television
seizure disorder of five years duration prior to death. He was discovered had been overturned, and broken dishes and glassware were strewn about.
unresponsive in a bathroom and autopsy revealed a malignant melanocytic A lampshade had been torn to pieces. In the kitchen, the door of the oven
tumor diffusely infiltrating the leptomeninges and focally the cortex of the had been removed and was located in an adjacent hallway, a bathrobe was
superior gyrus of his left temporal lobe. The cause of death was attributed in the refrigerator, and pieces of chicken were scattered throughout.
to a seizure due to a malignant melanoma of the temporal lobe arising in Vacuum cleaner parts were in the washing machine. In the bathroom,
the context of neurocutaneous melanosis. vomit was on the floor and a can of insect repellent was in the toilet. No
Case 2 was a 57-year-old female with a history of mental retardation, valuables were missing from the house.
clumsiness, incoordination, and a childhood seizure disorder that At the hospital, the decedent was noted to have numerous contusions
developed as a sequel to chronic infantile lead poisoning. She was and abrasions, predominantly on the extremities. Toxicologic screening
discovered unresponsive and asystolic on her bedroom floor. Twelve days for drugs of abuse and alcohol performed the day of admission was
prior to her death she had a witnessed fall down a staircase, and fractured negative. A sexual assault examination was also negative, and ultimately
her left leg. The cause of death was a pulmonary thromboembolism due to no evidence of semen was detected in any of the swabs or clothing
deep venous thrombosis status post left leg fracture. Autopsy also collected. A computed tomography scan detected subarachnoid
revealed profound atrophy and gliosis of her cerebellum consistent with hemorrhage at the base of the brain, and angiography detected a ruptured
residual damage from chronic lead poisoning. Although peripheral left posterior communicating artery aneurysm. Despite a coil
nervous system involvement in chronic lead poisoning is well known, less embolization procedure, the decedent never became coherent and expired
so is marked cerebellar atrophy with subsequent incoordination as nine days after arrival to the hospital. Because the attending physician
occurred in this case. thought that the decedent’s blunt force injuries may have contributed to
Case 3 was a 75-year-old female with a history of chronic osteo- death, the decedent was brought to the Harris County Medical Examiner’s
arthritis, hypertensive atherosclerotic cardiovascular disease, and Office for autopsy.

Autopsy examination confirmed the presence of subarachnoid There were a surprising number of somewhat unusual deaths,
hemorrhage associated with the treated left posterior communicating including cyanide poisoning, a stab wound of the leg (in a paraplegic
artery aneurysm. Injuries were limited to cutaneous injuries of the torso individual), cold exposure, helium inhalation, jumping from a height
and extremities detected externally; no internal evidence of blunt force or (through a skylight into the lobby), and self-immolation.
penetrating trauma was identified. Additional findings included evidence Notes were present in 30% of cases and 18% of cases were
of the decedent’s known hypertensive cardiovascular disease including considered to be highly organized (photographs, wills, insurance policies,
cardiomegaly with concentric left ventricular hypertrophy and myocyte “do-not-resuscitate” statements, Hemlock Society membership, religious
hypertrophy and renal arteriolosclerosis. The cause of death was classified material, etc.). Suicide in a hotel would seem to require at least some
as ruptured cerebral artery aneurysm due to hypertensive cardiovascular degree of planning and organization. Of the six deaths due to incised
disease, and the manner was classified as natural. wounds, only one employed a weapon at hand (broken bottle). Of the five
Cerebral artery aneurysms are relatively common and have been hangings, only two individuals brought a ligature to the scene; the
reported as incidental findings in up to five percent of all autopsies. remainder used linens or clothes hangers, items likely to be found in a
Typically, these aneurysms are asymptomatic unless they rupture, in which hotel setting. In nine cases, there was multiple occupancy of the hotel
case most symptoms are due to the resulting subarachnoid hemorrhage. room, although most of these were not witnessed.
The classic presentation is that of “the worst headache in my life”; other The suicide notes in two cases indicated that the decedents had an
common symptoms include loss of consciousness, seizures, meningeal advanced malignancy. At autopsy, neither case had an identifiable
signs, nausea and vomiting, drowsiness, dizziness, and cranial nerve neoplasm. It is not known if this was a sincere belief on the part of the
deficits. Psychiatric symptoms, while previously reported, are unusual. decedent or an attempt to console the family.
This rare presentation of ruptured cerebral aneurysm resulted in a criminal Cocaine was present in 12% of cases and was related to the cause of
investigation of possible assault. death in only one. It was by far the most common drug of abuse detected.
Cerebral Artery Aneurysm, Psychosis, Assault Alcohol was present in 38% of cases, with 18% of these less than 0.04
mg/dL (possible bracing effect) and 36% greater than 0.2 mg/dL. It
appears that when alcohol is consumed in this setting, the blood
concentration is likely to be high. In three cases where death was
G10 Checking In to Check Out: attributed to illicit drug intoxication, all had suicide notes.
The New Mexico Experience Decedents resided out of state in 28% of cases, almost half of these
of Suicide Occurring in Hotels in states adjacent to New Mexico. Over half of the cases resided less than
100 miles from the scene, with 22% less than ten miles. It is possible that
Rebecca A. Irvine, MD*, University of New Mexico, Office of the a polite question or inquiry by registering personnel regarding nearby
Medical Investigator, MSC 11 6030, 1 University of New Mexico, residence may be a point of intervention.
Albuquerque, NM 87131-0001 There should be concern for the safety and welfare of personnel in
the hospitality industry as these cases included physical domestic violence
After attending this presentation, attendees will have an awareness of (x3), violent felons (x2), law enforcement stand-offs (x2), shooting outside
features of hotel facilities, which may attract individuals contemplating the hotel room (x2) and a prison escapee. The case of self-immolation in
suicide and the characteristic findings of the population that complete the particular could have caused a large-scale tragedy.
act in this setting.
Suicide, Hotel, New Mexico
humanity by delineating findings and behavior, which may assist in the
determination of manner of death as suicide occurring in a hotel as well as
facilitate discussion with the family under these circumstances. Possible G11 Liver Laceration as a Result of
points of intervention by hotel personnel are examined. Safety issues in Resuscitation in an Adult Man
the hospitality industry are underscored.
Hotels offer many advantages to the individual contemplating Ellen G. Moffatt, MD*, Office of the Chief Medical Examiner,
suicide, including but not limited to, privacy, an expected guarantee of 850 Bryant Street, San Francisco, CA 94103
timely discovery which will not traumatize loved ones, a place to stay
when one has traveled to avoid recognition in their own community, After attending this presentation, attendees will understand some of
sanctuary, a place to act out, neutral ground during disputes, or simply a the more obscure complications of resuscitation in adults, in order to
high building with access to the roof. For others, it may be the end of a identify them at autopsy. This case is presented as an example of an injury
long road trip during which suicide was contemplated. Perhaps the that may be mistakenly interpreted as one that caused or contributed to
sterility and depersonalized setting appeals to those with depression. All death.
cases in New Mexico certified as suicide where the death occurred in a This presentation will impact the forensic community and/or
hotel setting or equivalent between 1995 and 2005 were reviewed for humanity by differentiating injuries as the result of trauma and as the result
demographics and unique features (N=74, 2% of suicides certified in the of postmortem (or perimortem) resuscitation and reasons for their
State in this time frame). formation.
This setting is preferred by White (73%) males (74%) between the A 41-year-old male police officer on a nighttime training exercise
ages of 30 and 50 (69%). collapsed suddenly. His fellow police officers immediately began CPR.
Firearm injuries are the method of choice in 42% of cases; no firearm His past medical history included controlled hypercholesterolemia, and
suicides were immediately discovered because of the sound of the complaints of left arm tingling the week prior to his death.
discharge of the weapon. At autopsy, abrasions were on the center of the chest with fractures
Drug intoxications accounted for 22% of the deaths; 22% of the non- of the right fourth and fifth ribs at the sternum and the right fifth rib
illicit drug intoxications had detectable antiemetic substances. Although laterally. An 8.0 centimeter laceration was at the falciform ligament.
Final Exit recommends the use of an antiemetic in cases of contemplated Approximately 750 milliliters of unclotted blood was in the abdominal
overdose, it is also recommended that when death occurs in a hotel, a note cavity.
of apology to the staff and a large tip be left. Neither of these was present Although the total cardiac weight (380 grams) was normal for his
in any of the cases. height and weight, the left ventricle measured 2.0 centimeters and the

septum thickness ranged from 2.0 centimeters to 1.1 centimeters. Decedents whose cause of death was cardiac-related comprised 52%
Histologically the heart showed focal cytomyolysis and fibrosis adjacent of cases presenting to the HCME during the 2002-2004 time period. Of
to the bundle of His. Occasional parenchymal vessels had medial those cases, 20% were under the age of 50, 72% were male and 51% were
hypertrophy with narrowing of their lumens. Toxicology studies were of Caucasian descent. A notable 43% were smokers. Obesity was listed
negative. There was no evidence of head injury. on the death certificate as a contributing factor in 5% of the cases and
Liver lacerations are an uncommon, but recognized, complication in chronic ethanolism contributed in 3%. Atherosclerotic Cardiovascular
resuscitation in children. Liver lacerations as a complication of Disease and Hypertensive Cardiovascular Disease were diagnosed in 54%
resuscitation in adults have been rarely reported, and are usually seen in of those individuals under the age of 20 years. From 2002 to 2004,
patients receiving thrombolytic or anticoagulant therapy (1, 2). Other cardiovascular disease was shown to be the cause of death in 16 children
uncommon complications of resuscitation include tracheal rupture (3), between the ages of 12 and 18, with the majority collapsing while
lung herniation (4), heart rupture (5, 6) and gastric rupture (7,8). Other participating in athletic events. In light of these findings further study has
more common complications of resuscitation in adult include broken ribs, been initiated at the HCME, expanding the study to the five year span of
along with heart and splenic lacerations. 2001-2005, reducing the upper age limit to 40 years, and exploring other
Proposed mechanisms of this injury include disparate size between case history factors for all of the cases such as cardiac enzyme levels, and
rescuer and victim, and over-enthusiastic or incorrect placement of chest prescription and recreational drug use. Body Mass Index was also
compressions. calculated for each decedent. The analyzed results of the expanded
Resuscitation, Complication, Laceration findings are described in the poster presentation.
The important contribution of socio-cultural behaviors to health
status has been documented in the medical and public health literature.
Modifications of these behaviors, combined with the use of basic non-
G12 The Epidemiology of Sudden Cardiac invasive cardiac diagnostic screening tests may greatly reduce the risk of
Death in Young Decedent Medical SCD among younger individuals, such as student athletes. The HCME
Examiner Cases and other medical examiner offices can be instrumental in raising
community awareness of SCD. A key goal of this public health education
Sharon M. Derrick, PhD*, Stacey A. Mitchell, MSN, RN, and Luis A. should be to promote the benefits of screening and prevention measures.
Sanchez, MD, Harris County Medical Examiner’s Office, 1885 Old Cardiac, SCD, Epidemiology
epidemiology of sudden cardiac death cases (SCD) presenting to a large G13 Significance of Blood Neopterine
medical examiner’s office over a five year time span (2001-2005) Measurement in Forensic Autopsy Cases
resulting in increased understanding of the etiology of this cause of death.
This presentation will impact the forensic community and/or Takaki Ishikawa, MD, PhD*, Department of Legal Medicine, Osaka City
humanity by providing detailed medical and social history information University Medical School, Asahi-machi 1-4-3, Abeno, Osaka, 545-8585,
recovered from a population of young individuals who died from sudden Japan; Marianne Hamel, MD, PhD, Thomas Jefferson University
cardiac death. The resulting database is large enough to provide Hospital, Department of Pathology, 132 South 10th Street, Suite 285
statistically significant data that can be used as a basis for further research. Main Building, Philadelphia, PA 19107; and Bao-Li
Dissemination of this information may support an emphasis on innovative Zhu, MD, PhD, and Hitoshi Maeda, MD, PhD, Department of Legal
screening and prevention practices targeting youth, ultimately contributing Medicine, Osaka City University Medical School, Asahi-machi 1-4-3,
to decreased mortality from SCD in this at-risk segment of the United Abeno, Osaka, 545-8585, Japan
States population.
Sudden Cardiac Death (SCD) is the leading cause of natural death After attending this presentation, attendees will understand how
each year in the United States. This poster presentation will inform increased neopterin levels in postmortem blood samples identified with
attendees regarding the epidemiology of SCD cases presenting to a large immunohistochemistry indicate non-specific viral infection.
medical examiner’s office over a five year time span (2001-2005), This presentation will impact the forensic community and/or
resulting in increased understanding of the etiology of this cause of death. humanity by demonstrating how correct interpretation of postmortem
SCD is often the result of untreated rapid ventricular tachycardia or blood neopterin levels can direct the postmortem examination in a cost-
ventricular fibrillation but it may be due to a variety of different effective and efficient manner.
conditions, including but not limited to acute myocardial infarction, Definitive and specific diagnoses regarding infection with fatal viral
coronary artery disease, cardiomyopathies, myocarditis, valvular heart pathogens are often hampered by the significant cost and labor associated
disease, conduction abnormalities and drug toxicity (prescription and with immunohistochemical staining. However, examination of non-
recreational). specific markers for viral infection through high-throughput laboratory
SCD is a significant public health problem, the basis of which will be methods serves to direct the postmortem examination in a cost-effective
more effectively addressed through building a clear and accurate picture and efficient manner. Neopterin, a pteridine released by macrophages, is
of young SCD decedents, thereby broadening innovative intervention a well-established marker of immune system activation. This study
projects to include previously underserved at-risk segments of the analyzes postmortem blood neopterin levels from multiple anatomic sites
population. in an attempt to elucidate their accuracy in diagnosis of fatal viral
A retrospective record review was conducted at the Harris County infection. Medicolegal autopsy cases (n=521, 1-96 years of age, 366
Medical Examiner’s Office in Houston, Texas (HCME) that identified males and 155 females) were examined. Causes of death were blunt injury
natural deaths reported to the HCME from 2002 through 2004. A full case (n=118), sharp injury (n=27), poisoning (n=26), drowning (n=30), fire
review was performed for all of the cases in which cardiac death was listed fatalities (n=85), hypothermia (n=10), asphyxiation (n=30), hyperthermia
as the primary cause of death after autopsy or external exam and in which (n=7), and natural death (n=143). Blood samples were collected at the
the decedent was under the age of 50 years. Socially influenced factors, time of postmortem examination from the subclavian and femoral veins
such as obesity (listed as contributory on the death certificate), tobacco and from the left and right heart. Neopterin levels were measured by high
use, and chronic ethanolism were noted for each case in addition to the performance liquid chromatography. Neopterin levels greater than 500
decedents’ medical histories. pmol/mL correlated with fatal viral infection. Viral infection was

confirmed by histology and PCR. Levels of C-reactive protein, an may contribute to differences in the results of the two groups, are
additional marker of immune system activation, and neopterin were postulated.
compared and a high correlation was observed in right heart blood. The influence of positive viral nasopharyngeal swab culture results on
However, neopterin levels from all sites were significantly higher in cases the cause of death is discussed including correlation of the viral results with
of multiple organ failure that was not associated with viral infection than other autopsy findings such as microscopy. Negative culture results and
in other cases. factors, which may contribute to negative results, are also mentioned. Brief
This study indicates that postmortem blood neopterin levels are both case summaries on several autopsies with positive viral nasopharyngeal
useful and cost-effective as a non-specific marker of viral infection. As culture results are presented as examples of correlation of culture results
the purpose of the postmortem examination is to provide the most specific with other autopsy findings to determine the causes of death.
information regarding cause of death possible, it is appropriate, though Nasopharyngeal Swabs, Infants, Autopsy
expensive, to elucidate the specific pathogen. Increased neopterin levels,
in cases of possible viral infection, should trigger the
immunohistochemical examination of tissue samples for specific viral
antigens. However, neopterin levels may also be elevated in the face of
G15 Succession of Microfungi in Grave Soil
drug use, chronic heart failure, and renal disease and caution should be
used in interpreting blood neopterin content in the presence of these Shari L. Forbes, PhD*, University of Ontario Institute of Technology,
conditions. 2000 Simcoe Street North, Oshawa, Ontario L1H 7K4, Canada; Trevor
Lumley, PhD, Environment Canada, Environment Technology Centre,
Neopterin, C-reactive Protein, Viral Infection 335 River Road, Ottawa, Ontario K1A0H3, Canada; and David
Carter, PhD, University of Nebraska Lincoln, 202 Plant Industry
G14 Evaluation of Nasoharyngeal Viral Swabs After attending this presentation, attendees will understand that soil
in Infants Dying of Natural Causes microfungi possess the potential to act as a tool to estimate extended
postmortem and postburial interval.
Wendy A. Stroh, DO*, and Deborah Kay, MD, Office of the Chief This presentation will impact the forensic community and/or
Medical Examiner, 400 East Jackson Street, Richmond, VA 23219 humanity by providing investigators with a novel method for estimating
time since death in cases involving buried remains.
After attending this presentation, attendees will be more informed on The estimation of postmortem interval (PMI) becomes increasingly
viral nasopharyngeal swabs in the infant population regarding frequency inaccurate as decomposition proceeds. Estimating postmortem period in
of use, results, and their impact on cause of death. cases where a body is buried in soil is particularly difficult because soil
This presentation will impact the forensic community and/or typically prevents forensically important insects from accessing the body.
humanity by elucidating the impact of viral postmortem testing in infants Thus, the development of insect larvae is generally unavailable as a
dying of natural causes. forensic tool in investigations involving burials. Therefore, a need exists
This presentation will acquaint conference attendees with viral to develop new techniques for estimating PMI of buried bodies and
nasopharyngeal culture swabs use in an infant population less than one- postburial interval (PBI). This need is particularly great for bodies
year-old, dying of natural causes as well as the use of positive results in associated with an extended postmortem period (months to years).
determining the cause of death. Information on the viral nasopharyngeal The forensic application of microfungal ecology has the potential to
swab such as appropriate collection and submission techniques, sample improve the estimation of extended postmortem periods. Like the
rejection criteria utilized at the laboratory, and laboratory technology macrofungi, microfungi respond to nutrient amendment. This response
employed in determining results and its limitations of the technology is typically results in fungal proliferation and, as the nutrient source is
also provided. utilized, a succession of microfungal taxa occurs. This phenomenon is
The Office of the Chief Medical Examiner in Richmond, Virginia has similar to insect succession associated with cadaver decomposition on the
used nasopharyngeal swabs to obtain viral culture samples since 2003. soil surface. In addition, some microfungi, primarily from order
Viral nasopharyngeal culture swabs are performed in the vast majority of Onygenales, possess the ability to access keratin as a food source. This
infant autopsies at this institution. They are routinely submitted along might be of particular importance to forensic science, as a body in
with blood and cerebrospinal spinal fluid cultures as part of the extended PMI primarily comprises keratinaceous material such as skin,
postmortem evaluation of all infants in whom Sudden Infant Death hair and nails.
Syndrome is a consideration. A study was carried out to identify fungal species present in grave
Autopsy charts on all infants under the age on one year dying of soil over a period of six months following inhumation. In spring 2006 five
natural causes were reviewed. Data was tabulated on the total number of pig (Sus scrofa) carcasses were placed in separate shallow graves (40-50
autopsies, total number of viral nasopharyngeal cultures obtained, cm) and covered with soil. Carcasses were exhumed at monthly intervals
submitted resulted and rejected or not performed and reasons for rejection, for the 6-month period. Soil was collected from the walls and base of each
total number of positive cultures including virus type detected and total grave. These soils were sprinkled or diluted in water and spread onto
number of negative results (no virus identified). tapwater, cornmeal, or Mycosel® agar plates containing the antibiotic
The viral nasopharyngeal swab kit contents are discussed. chloramphenicol. This antibiotic was used to suppress the growth of
Appropriate procedures for obtaining optimal results in regards to bacteria and rapidly proliferating fungi that can overwhelm the fungi of
sampling, storage of the specimen and proper submission are provided. interest.
Examples of rejection criteria are included as are factors that adversely Following the first exhumation, minimal decomposition had
affect culture results. occurred and the carcass was classified as being in the fresh/bloat stage.
A discussion of the laboratory technology employed to obtain viral As expected, there was no discernable difference between microfungus
nasopharyngeal culture results is included. The limitations of the communities in control soil samples (taken at four depths one meter away
technology are listed. A list of types of viruses detected is included. Other from the cadaver) and soil taken from various microsites in contact with
technologies for obtaining viral culture results are mentioned as well as the the cadaver. Communities were dominated by Trichoderma spp., Mucor
limitations of these methods and factors affecting culture results. spp., Acremonium spp., Sordaria fimicola, and coelomycete spp.; all
Postmortem viral nasopharyngeal swab culture results are compared common soil microfungi. These findings were able to provide a thorough
with antemortem results on infants of a similar age group. Factors, which background of the microfungi community in the soil.

Following the second exhumation, considerable decomposition had automated system such as capillary electrophoresis. This technique
occurred and the carcass was classified as being in the active/advanced exploits the use of separation of the complex fraction isolated followed by
decomposition stage. Discernible differences in the microfungi detection of the fragments.
community were apparent between grave soil and control soil samples, The results show a linear relationship between percent protein
particularly with regard to the soil nematode community. This stage of degraded and the log of postmortem time. A fresh “reference” human
decomposition is associated with an increase in bacterial-feeding heart tissue obtained at time T0 was incubated to obtain a temporal
nematodes that are then succeeded by fungal-feeding nematodes. degradation profile. Comparison of human cardiac tissue samples with
Exhumations will continue for the remainder of the trial and results unknown time of death can be evaluated qualitatively against the
for the six month period will be presented. Based on the preliminary “reference” human heart tissue. The time of death can be estimated by
results, it is anticipated that communities of nematophagous fungi will matching the “degradation fingerprint.” Similarly, a calibration curve (r >
change in response to shifts in nematode community composition. These 0.95) can be obtained with the percent cTnI degraded plotted against the
changes should be predictable over time. As a result, community structure log of the time postmortem using the reference human heart tissue. This
data for nematophagous fungi has the potential to act as an additional curve can be used to estimate the time since death relative to the
forensic tool in estimating PMI and PBI of buried remains. “reference” tissue based on the percent degradation. Data indicates that
Microfungi, Grave Soil, Postburial Interval the degradation of cTnI in heart tissue shows very specific bands during a
postmortem interval of a week. Troponin T is more stable in comparison
to Troponin I so the degradation of cTnT should be longer. Data combined
from cTnI and cTnT could be used for extended PMI estimate. Human
G16 Improved Estimation of Postmortem cardiac tissue samples frozen at known time of death were analyzed by
Interval With Multiple Protein Markers both semi-quantitative and qualitative techniques and both show similar
and Improved Analytical Methods agreement with the known time of death.
Overall, the data demonstrates that this technique represents a major
Behnoush Memari, MS*, Kenneth G. Furton, PhD, and Alberto advance in time of death determination providing a reliable semi-
Sabucedo, PhD, Florida International University, Department of quantitative biochemical marker from a protected organ versus estimates
Chemistry and Biochemistry, 11200 SW 8th Street University Park based on direct temperature measurements. Tissue cardiac Troponin I and
CP-345, Miami, FL 33199 Troponin T shows excellent characteristics as time of death markers in the
extended postmortem interval that is difficult to estimate with current
After attending this presentation, attendees will learn about the methods.
development and utility of cardiac Troponin I (cTnI) and Troponin T
TnI (Troponin I), TnT (TroponinT), Postmortem Interval (PMI)
(cTnT) as time since death markers for PMI Estimation.
humanity by improving the accuracy in postmortem interval estimates.
PMI provides crucial information required in many criminal, civil, and G17 Drowning of a Child With a Cardiac
forensic investigations. Fibroma of the Interventricular Septum
Time since death markers have lagged behind advances in forensics
technology. Knight (1994) explains,” regrettably, the accuracy of
Darshan R. Phatak, MD*, and Luis A Sanchez, MD, Harris County
estimating the postmortem interval (PMI) has by no means kept pace with
Medical Examiner Office, 1885 Old Spanish Trail, Houston, TX 77054
the enormous strides made in technological sophistication.” Early work
on time since death focused on postmortem temperature measurements After attending this presentation, attendees will have a better
and algorithms to model postmortem cooling behavior. Current comprehension of the nature of the presentation of this potentially fatal
technology is still largely based on postmortem temperature methods mesenchymal cardiac tumor, an understanding of the gross and
similar to those described in the 1800’s. Marshall summarized the microscopic pathology and the physiology of potentially fatal disturbances
temperature measurement method as follows, “It would seem that the to cardiac function resulting from the size of the tumor and location in the
timing of death by means of temperature can never be more than an heart.
approximation.” This presentation will impact the forensic community and/or
Biochemical markers for estimating time since death offer the humanity by demonstrating why it is strongly recommended that those
possibility of increased accuracy and reliability in time since death involved in the determination and certification of the cause and manner of
estimates. Cardiac Troponin I (cTnI) and cardiac Troponin T (cTnT) are death familiarize themselves with cardiac tumors” presentation, pathology
heart tissue proteins and selective markers of cardiac muscle damage. and lethal potential and remember to include them in their differential
Investigation of these proteins as a marker for time since death shows diagnosis when confronted by cases such as this one.
great promise in mammalian heart tissue. cTnI and cTnT are found as This presentation will have a positive impact on pathologists,
intact protein in freshly sampled tissue at the onset of death, (T0). These coroners, medical examiners, other autopsy practitioners and humanity at
proteins are good substrates for several enzymes released in cardiac tissue large as it can heighten general awareness towards a potentially treatable
upon death (necrosis). The proteolytic breakdown of these proteins by cardiac tumor that may be found either incidentally or strike down
proteases in postmortem cardiac tissue is exploited to determine the children, a vulnerable population subset, without warning.
postmortem interval. Both bovine and human heart tissue show similar A four-year-old Hispanic female child drowned in a swimming pool
banding patterns upon degradation. This technique takes a small sample at a family gathering and had a past medical history of cardiomegaly and
of cardiac tissue that is homogenized and extracted with magnetic a heart murmur which were diagnosed neonatally, yet reportedly neither
microparticles. The proteins are separated by SDS-PAGE electrophoresis treated nor followed medically since infancy. Prior to death, the decedent
and selectively visualized by Western blot. The Western blot is probed had no health complaints or behavioral changes. At the scene, the
with mouse monoclonal antibodies against cardiac TnI and TnT. This step decedent’s stomach was bloated and clear fluid was reported in the
is followed by an anti-mouse conjugate labeled with alkaline phosphatase respiratory tract.
that is developed with a precipitating colored substrate. The degradation Pertinent autopsy findings included cerebral edema, serous fluid
pattern of cTnI and cTnT is monitored using this bioanalytical protocol. within the pleural cavities, pneumonomegaly, and hepatosplenomegaly.
The area of the bands within a lane is quantitated by scanning and Cardiomegaly and a fibroma of the interventricular septum were also
digitizing the bands. Project methodology will be migrated to more found at autopsy. Toxicological tests were negative.

The majority of primary cardiac tumors are benign, with fibromas This case involves a 19-year-old white female who was a still-life
representing five percent of all cases. In the pediatric population, it is the photography model participating in a pornographic photo shoot in a studio
second most common primary tumor of the heart after rhabdomyomas. in a small rural community. Following a photo shooting session, she
The tumor also has a predilection to form within the interventricular voluntarily, orally took an unknown amount of a proprietary liquid
septum and grows in size rapidly. Despite the lack of aggressive behavior morphine preparation and lay down to take a nap. While she was asleep
or any metastatic potential, fibromas of the heart can interfere with normal on the bed, the photographer took some additional photographs and, later,
physiologic function due to the interdigitation of tumor cells around and by his own admission, performed sodomy on the individual while she was
between cardiomyocytes and cardiac blood vessels and the possibility of asleep. Approximately one hour later, he noticed that she wasn’t breathing
entrapment and disruption of the cardiac conduction system that can result and called the local rescue squad. She was rushed to the hospital, where
in a fatal arrhythmia. In addition to immediate local effects, the physical it was determined that she was pulseless, apneic, cold, and blue. It was
alteration of the cardiac muscle also results in pathologic changes of the determined by postmortem examination and toxicology that she had died
other organ systems that will also impair the health of the individual over from a lethal concentration of morphine, in combination with two other
time. benzodiazepines, dextromethorphan in the presence of a residual
The tumor is often surgically resectable or treatable by heart concentration of cocaine and its metabolite, benzoylecgonine. Questions
transplantation so therefore, proper diagnosis and prompt treatment can be arose during the investigation concerning whether the decedent was alive
lifesaving. Cardiac fibromas may also occur in the setting of the nevoid and/or was capable of consent during the purported act of sodomy by the
basal cell carcinoma syndrome (Gorlin-Goltz syndrome), so it can be photographer.
beneficial for parents and other relatives to know the diagnosis. The most Postmortem police scene photographs and digital photographs taken
important lesion in the differential diagnosis is fibrosarcoma, a at the studio by the photographer while the decedent was asleep on the bed
malignancy that is rare in the heart and in the general pediatric population. were reviewed. It was revealed that numerous patterned lividity markings,
In a primary cardiac tumor, it is also of crucial importance to rule out a made by the decedent’s clothing, had persisted for several hours after the
metastasis from a primary tumor of another location, as the treatment will clothing items had been removed. These photographs were matched up
vary. with the “date and time modified” column on the computer explorer
This case of cardiac fibroma serves as a good example of a primary window. They demonstrated that the decedent had expired at least more
cardiac tumor’s potential for fatal presentation in a child. Sometimes than an hour before the photographer admitted to sodomizing her. This
children with congenital heart abnormalities do not receive close finding was instrumental in showing that charges of non-consensual
monitoring of their health under a physician’s care, and it is strongly sexual assault, to include animate object penetration, were not appropriate
recommended that those involved in the determination and certification of in this case, because the decedent was already dead at the time the act of
the cause and manner of death familiarize themselves with cardiac tumors’ sodomy and digital insertion were performed.
presentation, pathology and lethal potential and remember to include them Time of Death, Livor Mortis, Digital Photography
in their differential diagnosis when confronted by cases such as this one.
Cardiac, Fibroma, Drowning
G19 Dispersion of Hesitation Marks and
Defense Wounds: A New Criterion
G18 Estimating Time of Death From Livor of Differentiation of Sharp Force
Mortis Patterns: A Case Presentation Suicide and Homicide
William Massello III, MD*, Office of the Chief Medical Examiner, 6600 Stéphanie Racette, BSc*, Célia Kremer, MSc, Anne Desjarlais, and Anny
Northside HS Road, Roanoke, VA 24019 Sauvageau, MD, Laboratoire de Sciences Judiciaires et de Médecine
Légale, 1701, Parthenais Street, 12th floor, Montreal, Quebec H2K 3S7,
After attending this presentation, attendees will understand the Canada
forensic importance of recognizing patterns of lividity produced by
articles of clothing and of documenting these patterns of lividity After attending this presentation, attendees will be introduced to a
photographically. Patterns of lividity can be useful in estimating the time new criterion of differentiation of hesitation marks and defense wounds in
of death. Attendees will also come to appreciate how a pains taking sharp force injuries.
analysis of postmortem photographs can have relevance to the application This presentation will impact the forensic community and/or
of the proper criminal charges. humanity by providing new insight in the evaluation of hesitation marks
This presentation will impact the forensic community and/or and defense wounds.
humanity by demonstrating how both scene photography and postmortem In evaluating manner of death, forensic pathologists often rely on
photography of the remains, when used in conjunction with computer widely accepted criteria of differentiation at autopsy. For example, the
resources, can be valuable in estimating the time of death. It also presence of hesitation marks or defense wounds in sharp force injury cases
demonstrates that a careful analysis of patterns of lividity, even in has been accepted as a criterion of differentiation between sharp force
postmortem digital photographs, can be important in providing suicide and homicide.
evidentiary material for use in helping resolve important questions in With this study, the authors wanted to enrich the description of
criminal law. hesitation marks and defense wounds. The authors hypothesize that (1)
Following this case presentation, the attendees will understand the hesitation marks would predominantly be present on inner surface of
forensic importance of recognizing patterns of lividity produced by upper limbs while such predominance would not be found for defense
articles of clothing and of documenting these patterns of lividity wounds, (2) a possible left predominance in hesitation marks could be
photographically. Additionally, it will be shown how these patterns of found, considering the higher proportion in the general population of
lividity can be useful in estimating the time of death. An understanding of right-handed person and finally that (3) hesitation marks and defense
the importance of postmortem photography as a tool in death investigation wounds would show a different pattern of dispersion on upper limbs.
will be underscored. Attendees will also come to appreciate how a pains Over a 5-year period, in the Quebec province (Canada), all cases of
taking analysis of postmortem photographs can have relevance to the suicidal and homicidal sharp force injury presenting hesitation marks
application of the proper criminal charges. (n=43) and defense wounds (n=91) were retrospectively reviewed. For

each case, hesitation marks or defense wounds were drawn on an upper that time, the stepchild reported that the last thing he remembered was
limb chart divided into 12 sections covering the upper arm to the hands. falling into the pool.
The total amount of lesions for each section was compiled as well as the The decedent’s wife last saw him alive 2.5 hours before he was
total amount of wounded sections. For all suicidal victims, a general chart found. She thought he and the three children were going back to their
of upper limbs was done by superimposing every chart with hesitation room to watch television. She did not know why they would go to the
marks. The same was achieved with homicidal victims for defense pool, since he and the children were unable to swim. An investigation by
wounds. law enforcement found no evidence of foul play.
(1) Sharp force victims of suicide presented a significant higher average A “foam cone” was at the mouth and nose of the decedent at the
amount of hesitation marks on inner aspect of upper limbs then on scene. At autopsy, there was marked bilateral scleral hemorrhage. No
exterior surface (p<0.05). In victims of homicide, no difference abrasions or contusions were on the anterior or posterior neck. Internally,
was revealed between inner and exterior average amounts of the lungs were hyperinflated. Frothy fluid filled the airways and exuded
defense wounds. from the cut surfaces of the lungs. The sphenoid sinus contained 3 ml of
(2) In terms of left and right comparison, a left predominance was not bloody fluid. Blood was in the mastoid air cells bilaterally. The right
found for hesitation marks cases or for defense wounds cases. In ventricle of the heart was dilated and the thyroid gland was markedly
fact, in suicide cases, the average amount of hesitation marks was congested. A layered anterior neck dissection revealed hemorrhage on the
the same on each inner side of upper limbs. surface of multiple strap muscles that was confined to the fascial surfaces
(3) Graphical superimposition of hesitation marks/defense wounds for of the muscle; sectioning did not reveal contusion within the substance of
all victims visually revealed low dispersion of hesitation marks the muscle. A comprehensive toxicology screen did not detect alcohol or
and high dispersion of defense wounds. This was statistically drugs within iliac blood. A vitreous electrolyte screen was within normal
confirmed by comparing the average amount of hesitation limits. The cause of death was determined to be drowning. The manner
marks/defense wounds and the average total number of wounded of death was accident.
sections. For both inner and exterior aspects of upper limbs, the Despite the assertion that anterior neck muscle hemorrhage “do not
average total number of wounded sections was significantly higher occur in drowning and should always raise the suspicion of foul play”
for defense wounds compared to hesitation marks (p<0.05), while (Spitz, 2006), others have reported this finding (Carter et al., 1998;
no significant difference was revealed for the comparison of Puschel et al., 1999). This hemorrhage has been attributed to hypostasis
average amount of wounds. In other words, for a similar average (livor mortis), muscular injury due to violent neck movements or an
amount of hesitation marks and defense wounds, the average artifact of decomposition (Carter et al., 1998). Conjunctival and facial
number of wounded sections on upper limbs revealed to be higher petechiae are due to increased cephalic venous pressure; a phenomena that
for defense wounds then for hesitation marks. Thus, defense may be exaggerated by coughing, gagging or a struggle that increases
wounds show higher dispersion on upper limbs compared to cardiac output and blood pressure (Ely and Hirsch, 1999).
hesitation marks. Increased central venous pressure due to coughing and gagging, as
This retrospective study of hesitation marks and defense wounds first well as increased cardiac output and blood pressure during the struggle of
confirmed the initial hypothesis of predominance of hesitation marks on the drowning process, led to the scleral and neck hemorrhages described
inner surface of upper limbs. However, while it is often said that sharp in this case. The elevated central venous pressure would be transmitted
force victims, considering the proportion of right-handed person in the through valveless veins to the neck musculature as well as the head. Such
general population, are more likely to present hesitation marks on their left elevated pressure could also cause right heart dilation and congestion of
upper limb, this five year study failed to confirm such predominance. the thyroid gland.
Consequently, the authors discourage the use of a left-right characteristic Strangulation can result in neck and scleral hemorrhages similar to
in the evaluation of hesitation marks and defense wounds. The pattern of those described in the current case. Direct trauma to the neck during
dispersion of hesitation marks and defense wounds suggests a difference strangulation would typically cause hemorrhage within the substance of the
in the pattern of dispersion as a new criterion for hesitation marks and muscle rather than just fascial hemorrhage. When a body recovered from
defense wounds. water has these findings, it is imperative to consider all scene, autopsy, and
Hesitation Marks, Defense Wounds, Sharp Force Injury toxicology findings to arrive at the proper cause and manner of death.
This case presentation demonstrates that drowning can result in
significant neck and scleral hemorrhage, probably due to increased central
G20 Neck and Scleral Hemorrhage venous pressure during the drowning process.
Due to Drowning Drowning, Hemorrhage, Strangulation
Russell T. Alexander, MD*, and Jeffrey M. Jentzen, MD, Milwaukee

County Medical Examiner’s Office, 933 West Highland Avenue, G21 Papillomacular Folds: Whiplash
Milwaukee, WI 53233 Maculopathy or Postmortem Artifact?
The goal of this presentation is to review a case of drowning
Patrick E. Lantz, MD*, Wake Forest University Health Sciences,
associated with extensive bilateral scleral and neck hemorrhage.
Department of Pathology, Medical Center Boulevard, Winston Salem,
NC 27157
humanity by discussing the occurrence and possible mechanisms for the
creation of scleral and neck hemorrhage in drowning related deaths. After attending this presentation, attendees will understand the
The decedent was a 30-year-old male who was found with his 5-year- usefulness of postmortem monocular indirect ophthalmoscopy in
old stepson at the bottom of a nine foot deep hotel pool after hotel workers differentiating postmortem fundal artifacts from pathologically significant
noted two of the decedent’s other young children playing unattended on retinal folds.
the steps in the shallow end of the pool. The decedent and his stepson This presentation will impact the forensic community and/or
were pulled unresponsive from the pool. Firefighters arrived at the scene humanity by demonstrating that horizontal, hypopigmented, non-
and started CPR after finding the decedent pulseless and not breathing. hemorrhagic retinal folds represent a postmortem artifact and must not be
After 30 minutes of resuscitative efforts, he was declared dead at the misinterpreted as retinal injury from putative vitreoretinal traction
scene. The child was taken in “critical” condition to a nearby children’s associated with whiplash or presumed shaking (Shaken Baby Syndrome
hospital, and was discharged the next day with no neurological deficits. At or Inflicted Childhood Neurotrauma).

Clinically, whiplash maculopathy has been associated with three of postmortem anogenital examination techniques; and increasing in the
subtle macular disturbances following head/neck trauma from diagnostic acumen of the forensic examiner.
hyperextension/flexion. These include mild reduction of central visual Recent studies have focused on the application of a 1% solution of
acuity or paracentral scotoma, grayish swelling of the foveal zone and a toluidine blue dye, a general nuclear stain, as a practice standard for the
small pit or depression in the fovea. The retinal opacity usually resolves medical-legal examination of living sexual assault victims. Specific
and visual acuity most often returns to 20/20 but the foveal depression recommendations, e.g., the sequence of the dye application during the
invariably remains. No specific pathophysiologic mechanism has pelvic examination, have been delineated and advocated. Some authors
explained the development of traumatic retinopathy after this indirect and numerous practitioners recommend application of the nuclear stain
ocular trauma. Some authors favor a mixed mechanism, mechanic and prior to insertion of the speculum. This is based on the assumption that
vascular, to explain these alterations while others postulate that local that the nuclear stain will delineate iatrogenic injury from pre-existing
microcirculatory disturbances are the cause of the retinopathy as opposed traumatic findings due to a sexual assault. In one study of antemortem
to the systemic disturbance associated with Purtscher’s retinopathy. sexual assault cases, Jones, Dunnuck, Rossman, et al described a 3.7%
A recent publication claimed the first account of the macroscopic and incidence (1/27 cases) where one additional genital injury was delineated
microscopic pathologic findings that they believed were the result of via toluidine blue, after speculum insertion and removal by the examiner.
whiplash maculopathy and retinopathy (Forensic Sci Med Pathol This injury was located on the posterior labia minora.
2005;1:19-25). The macular and retinal findings were found at autopsy in In a study by Hochmeister, Whelan, et al., (JFS, 1997), there was no
20-year-old woman who suffered fatal head and neck injuries following a effect on either PCR or RFLP recovery when vaginal swabs were exposed
roller-coaster accident. Both eyes had horizontal folds extending to the dye. However, the sample size was limited to only five women and
temporally from the optic disc just beyond the fovea presumably postcoital swabs were collected within six hours of coitus. In California,
secondary to vitreous traction. the medical-legal protocol recommends that dye application be deferred
However, the horizontal hypopigmented, non-hemorrhagic until after collection of biological specimens.
papillomacular retinal folds depicted in this case report represent A review of the original methodologies from Richart (1963), Collins
postmortem artifacts readily apparent by postmortem monocular indirect (1966), Lauber & Souma (1982), and McCauley (1987) was done by
ophthalmoscopy as evidenced by the following case. A 4-month-old Crowley and Peterson (To Dye or Not to Dye, AAFS, 2005). Variability in
infant presented to the Emergency Department of a regional medical interpretation of results in antemortem patients may be due to many
center apneic and pulseless. Resuscitative efforts re-established cardiac factors. Toluidine blue is specific for zones of parakeratosis; thus positive
activity but mechanical ventilation was required. Direct and indirect results can be due to inflammatory, benign, or malignant vulvovaginal
ophthalmoscopy in the Pediatric Intensive Care unit did not reveal any diseases. Twenty-three different benign vulvovaginal conditions, in
fundal hemorrhages or retinal folds. Death occurred 56 hours after addition to the presence of cervical mucous, will yield false positive
admission. Postmortem monocular indirect ophthalmoscopy performed results with application of this dye in vivo.
four hours after death confirmed clinical funduscopic findings; however, A paucity of data exists on the “normal” appearance of the anogenital
the following morning, 21 hours after death bilateral hypopigmented, non- tissues during the postmortem interval. Detailed observation and baseline
hemorrhagic retinal papillomacular folds had formed that were grossly studies are ideally done with colposcopy and documentation via magnified
and microscopically similar to the retinal folds attributed to whiplash photos, to facilitate peer review. Colposcopy has been thoroughly utilized
maculopathy. by numerous authors to enable the study of both normal and abnormal
Subsequent examination of infants and adults who have died from findings in both child and adult sexual assault victims since the late 1980s.
natural disease processes has demonstrated that these artifactual The protocol for detailed postmortem inspection and the methodology for
papillomacular retinal folds initially form a few hours after death as retinal an evidentiary anogenital examination have been previously described
elevations around the fovea centralis then extend nasally and temporally. (Crowley, JFS, 2004). The correct application and interpretation of
This fairly uniform sequence has been as demonstrated by serial results/findings were thoroughly described by the earlier authors (Richart,
postmortem fundal imaging utilizing monocular indirect ophthalmoscopy. Collins, Lauber & Souma, and McCauley). The intensity of the stain is
It is imperative that this postmortem artifact is not misinterpreted as retinal correlated to the nuclear density of the tissues. Most of the earlier authors
injury from putative vitreoretinal traction associated with whiplash or reiterated that the proper decolorization of the dye was the most important
presumed shaking (Shaken Baby Syndrome or Inflicted Childhood part of the methodology. Conventional methodologies vary widely, as do
Neurotrauma). the post-assault time intervals for application of the dye. Another salient
Whiplash Maculopathy, Postmortem Monocular Indirect factor in any discussion of the efficacy of a nuclear stain vs. colposcopy is
Ophthalmoscopy, Postmortem Artifact the anatomic site to which the dye can be appropriately applied. Although
used by the earliest authors for diagnosis of cervical and vulvar neoplasias,
Lauber and Souma, in 1982, first described its use for evaluation of sexual
assault victims and comparison to a control group of consenting women.
G22 To Dye or Magnify! A Proposal to It is important to remember that at that time, colposcopy was not widely
Study the Efficacy of Toluidine Blue available for examination of this population. These authors also limited
Dye vs. Colposcopy in the Postmortem the application of the dye to the posterior fourchette, an area that is
histologically comprised of skin-like stratified squamous epithelium.
Anogenital Examination As mentioned previously, subtle findings may be an examiner issue
(Slaughter, personal communication, 2004). Many programs do not
Sharon R. Crowley, RN, MN*, 122 Emeline Avenue, Santa Cruz, routinely include follow-up examinations in their protocol. Without
CA 95060 incorporation of follow-up examinations, it may be extremely difficult to
The goals of this presentation is to determine if toluidine blue is a evaluate findings such as localized redness and swelling. In all cases, both
reliable or useful adjunct in the postmortem genital examination; to antemortem and postmortem, it is essential to employ the highest
describe a baseline study protocol that compares results from standards, in order to differentiate traumatic findings from either
photocolposcopy at 7.5X and 15X magnification vs. photocolposcopy preexisting benign vulvovaginal conditions or postmortem artifact. Even
plus the addition of toluidine blue dye; and to better understand the nature experienced sexual assault examiners, whose expertise is confined to
and appearance of the postmortem anogenital anatomy. antemortem cases, may confuse normal postmortem changes or findings
This presentation will impact the forensic community and/or secondary to the cause and manner of death with traumatic lesions that are
humanity by demonstrating an increase in the reliability and consistency consistent with penetrating injury, i.e., sexual assault.

Materials and Methods: Using the mobile system of technology known from clinical radiology and pathology correlating radiological and
described by Crowley (JFS, 2004), the author proposes a baseline study of pathological findings, different forensic morphological findings are
postmortem genital examinations with concomitant application of a 1% presented. Additionally the application of micro CT and Magnetic
solution of toluidine blue dye. Utilizing colposcopy at 15X magnification, Resonance Microscopy is introduced for the forensic use.
no injuries were noted in living sexual assault victims via the nuclear stain The new possibilities that are based on the combined data sets of
that had not already been visualized with colposcopy (Slaughter, Brown, forensic corpses (visible human in forensics) such as real data based
Crowley, & Peck, Amer. J of Ob Gyn., 1997). forensic virtual reconstruction and application of “morphological
Careful scrutiny and photo documentation with colposcopy at 7.5X fingerprints” are demonstrated. The article gives an overview on
and 15X should be done prior to speculum insertion and anoscopy. After postmortem application of 3D surface scanning and radiological cross
the speculum (and anoscopic) examination, the dye can be applied to the sectional scanning using CT and MRI in forensic medicine by correlating
following sites: lateral aspects of the labia majora, posterior fourchette, imaging appearances of essential forensic findings to their appearance in
fossa navicularis, perineum, and the perianal area up to, but not beyond traditional autopsy.
the area of the anal verge. The labia minora are moist and the epithelium This paper presents the newest developments in postmortem biopsy,
is similar to mucous membrane. Only the lateral aspects are covered by postmortem angiography, and the MRI whole body imaging using “Total
skin. Thus, any positive findings at this anatomic site must be interpreted imaging Matrix.”
with caution. Application of the dye and scrupulous decolorization should Virtopsy, Virtual Autopsy, Imaging
then be done in the manner described by the original authors. These
anatomic sites are selected based on histological composition and
applicability to the techniques that were thoroughly described by previous
authors, Richart (1963), Collins (1966), Lauber & Souma (1982), and G24 Female Firearm-Related Suicides:
McCauley (1987). A Reappraisal
Another salient factor that requires further study and comparison to
photocolposcopy is the interval of applicability for both antemortem and Kevin D. Whaley, MD*, Anna Noller, PhD, and William T.
postmortem cases. Currently, a wide variation exists in standards. In non- Gormley, MD, PhD, Central District, Office of the Chief Medical
genital sites, toluidine blue has been shown to yield positive uptake in Examiner, Commonwealth of Virginia, 400 East Jackson Street,
granulation tissue. The great variety of normal artifact often present in Richmond, VA 23219
postmortem cases presents many additional challenges. It is crucial that
examiners avoid working in a vacuum. Often forensic nurse examiners After attending this presentation, attendees will recognize that
are called to examine postmortem cases because of their expertise in living suicides by women using firearms, including shotguns are not rare and
sexual assault cases. It is imperative that they consult and collaborate with may be increasing in incidence.
the forensic pathologist, especially if their expertise has been previously This presentation will impact the forensic community and/or
confined only to the antemortem arena. Normal postmortem artifact has humanity by demonstrating the increasing incidence of self-inflicted
been misinterpreted as trauma and the additional use of toluidine blue will gunshot and shotgun wounds by women.
likely only complicate interpretation until it has been sufficiently studied. After attending this presentation, attendees will appreciate the
In equivocal cases, the forensic pathologist can remove the relevant tissues increasing incidence of female firearm-related suicide. Moreover, they
en bloc for dissection and microscopic evaluation. Prior to this, it is useful will become familiar with the most common risk factors associated with
to have an initial in situ examination via colposcopy of the anogenital these cases.
tissues. When women die from apparently self-inflicted firearm wounds,
The ultimate goal is to better visualize the anogenital tissue in the especially shotgun wounds, many citizens, family members, and death
postmortem patient, in order to improve the understanding of what is investigators are very suspicious that the death is really a homicide. This
normal, and what is not, at various postmortem intervals. It is possible that presentation will impact the forensic community, particularly forensic
the application of toluidine blue dye may then enhance, for pictorial pathologists, and medicolegal death investigators, by facilitating accurate
documentation. and efficient determination of the manner of death in female firearm-
related suicides. Furthermore, proper classification of these deaths as
Colposcopy, Toluidine Blue Dye, Forensic Nurse Death Investigator
suicides will also result in a more efficient expenditure of time and other
resources with regards to law enforcement and the judicial system.
Notwithstanding increasing data to the contrary, female suicides are
G23 Virtopsy - Virtual Autopsy, Where We Go? often stereotypically associated with less violent means (i.e., poisoning,
hanging, carbon monoxide) while their male counterparts are
Michael J. Thali, MD*, University Bern, Centre Forensic Imaging and stereotypically associated with more destructive means (i.e., firearms,
Virtopsy, Buehlstrasse 20, Bern, Bern 3012, Switzerland jumping from heights, motor vehicle accidents).
After attending this presentation, attendees will learn about the Despite being historically associated with male suicide, a
newest imaging technologies for forensic medicine. retrospective review of female suicides occurring in Virginia from 2000 –
This presentation will impact the forensic community and/or 2005 revealed a significant percentage of female decedents utilized a
humanity by discussing the upcoming cutting edge developments and firearm. This study reviewed the case files of all female firearm-related
steps in visual documentation and reconstruction of forensic cases. suicides from 2000 to 2005 at the Richmond District Office of the Chief
Therefore there will be a great impact of the paper. Invasive “body Medical Examiner. Additional data was gathered from the other three
opening” autopsy is today’s state of the art in human postmortem districts with regards to the incidence female firearm-related over this five
investigation. Modern cross section techniques can supplement and may year period. Data collected from each case included the age, race,
replace autopsy to some extent with several improvements for the forensic comorbidities, socioeconomic status, and substance abuse history, type of
workflow. firearm utilized, firearm availability, and whether or not other methods of
A combination of 3D optical and photogrammetric surface scanning self-destruction accompanied the firearm injury. The demographics and
with full body CT scans as well as postmortem MRI investigations to risk factors associated with female firearm-related suicides differ from
correlate the radiological findings with the forensic findings documented those associated with their male counterparts. Appreciating these
in traditional autopsy performed afterwards is discussed. Using the Armed differences will facilitate accurate and efficient medicolegal death
Forces Institute of Pathology (AFIP) design comparison approach, well investigation of female suicides involving a firearm.

Of particular concern is a gradual increase in the incidence of convulsions, pattern of decortication rigidity and respiratory responses.
firearm-related female suicides annually. In Virginia, the incidence of To date, this is a unique study of agonal movements in asphyxia by
firearm-related female suicides has increased by approximately ten hanging. The importance of inter-laboratory collaboration in extending
percent over a four-year period. Moreover, of firearm-related female this project by adding other available filmed hangings is discussed and the
suicides, a significant percentage involves a shotgun rather than a handgun importance of a Working Group of Human Asphyxia (WGHA) is further
or rifle. emphasized.
The presentation will include case examples that illustrate the most Asphyxia, Hanging, Forensic Pathology
common scenarios involving female firearm-related suicide.
Shotgun, Suicide, Women
G26 The Methods of Committing and Alcohol
Intoxication of Suicides in the
G25 Agonal Sequences in Four Filmed
Southwestern Croatia From 1996 to 2005
Hangings: Analysis of Respiratory
and Movement Responses to Asphyxia Alan Bosnar, MD, PhD*, Valter Stemberga, MD, Miran Coklo, MD, and
by Hanging Sanja Dobi Babic, BSc, Department of Forensic Medicine, Rijeka
University School of Medicine, B. Branchetta 20, Rijeka, 51000,
Anny Sauvageau, MD*, and Stéphanie Racette, BSc, Laboratoire de Croatia; and Emina Grgurevic, MD, Public Health Institute of
Sciences Judiciaires et de Médecine Légale, 1701 Parthenais Street, 12th Primorsko-Goranska County, Kresimirova 52a, Rijeka, 51000, Croatia
Floor, Montreal, Quebec H2K 3S7, Canada After attending this presentation, attendees will understand the
The goal of this presentation is to first review the literature on relationship between alcohol intoxication and the choice of suicide
physiological responses to asphyxia by hanging in human and animal method in the Southwestern Croatia from 1996 to 2005.
literature, and then to compare such data to four cases of filmed hanging. This presentation will impact the forensic community and/or
In the conducting of investigations and trials, forensic pathologists are humanity by through the contribution to a better understanding of the
often asked to discuss the body’s responses to hypoxia/anoxia and their relationship between alcohol intoxication and the choice of suicide
temporal relationship to the timing of asphyxial deaths. However, those method, and by pointing towards efficiency of specific suicide prevention
questions are difficult to answer considering the actual paucity of research measures in specific methods of committing suicide.
literature. This study was undertaken to determine if the level of alcohol
This presentation will impact the forensic community and/or intoxication and the choice of specific methods of committing suicide are
humanity by providing new insight into the physiopathology of human related.
asphyxia. Suicides in the Southwestern Croatia in a ten year period, especially
Introduction: The human pathophysiology of asphyxia by hanging regarding the method of committing and alcohol intoxication, were
is still poorly understood, despite great advances in forensic science. Even analyzed. The examined region has an area of 7,993 km² with the
though some studies have been conducted on animals, the extent to which population of 322,964, mostly living in the city of Rijeka, as a regional
those results can be applied to human is uncertain. Since experimental center.
protocols are, of course, out of the question, filmed hangings hold the key In the examined period, 512 suicides were recorded, with 367 male
element to answer questions regarding the sequence of events leading to and 154 female victims. The average age of male victims was 50.81 years,
death in the context of human asphyxia. while female victims were older with the average age of 56.02 years. Ten
Methods: A total of four filmed hangings were analyzed: one suicide various methods of committing suicide were recorded, with hanging as the
filmed by a video camera, two autoerotic deaths and one suicide in most frequent (34%), followed by jumping from height (17%), firearms
custody filmed by a surveillance camera. Those filmed hangings were (15%), poisoning (14%), drowning (10%), jumping under/in front of a
compared in terms of loss of consciousness, convulsions, decortication, train (4%), explosive devices (4%), cutting/stabbing (1.2%), electrocution
and decerebration rigidity, loss of muscle tone, last muscle movement, and (0.4%) and self-immolation (0.4%). The average blood alcohol
respiratory responses. Two independent judges scored the time frame at concentration at the moment of suicide was 0.68 g/kg with male, and 0.29
which each of these responses occurred. g/kg with female victims. The highest blood alcohol levels at the moment
Results: With the time 0 representing the onset of hanging, rapid of suicide were recorded with suicides by explosive device (with the
loss of consciousness was observed (at 13-18s), closely followed by average blood alcohol concentration of 1.71 g/kg), while the lowest
appearance of convulsions (at 15-19s) in all cases. Within the first minute concentrations were recorded with female hanging suicides (with the
(19-21s in most cases, 46s in one case), decerebration rigidity was average blood alcohol concentration of 0.0153 g/kg) and male
observed. Two phases of decortication rigidity was also noted, the first cutting/stabbing suicides (with the average blood alcohol concentration of
one being relatively sudden and quick (onset at around 1min00s -1min 08s 0.103 g/kg).
in most cases, 21s in one case) while the second one (onset between This study suggests that the alcohol consumption before committing
1min04s - 1min32s) extended for about one minute, with an observed suicide is more significant in cases of suicide with an explosive device
climax of rigidity about 20 seconds after its onset. Appearance of loss of than in the other methods of suicide. This especially drastic method of
muscle tone varied between 1min 38s and 2min 47s, with last isolated suicide was rare in Croatia in a period prior to the Croatian Independence
muscle movement occurring between 2min 15s and 4min 10s. Similar War (1991-1995), but its incidence significantly increased during the war
patterns between cases was observed for respiratory responses: onset of and in a post-war period. These victims were not chronic alcoholics, but
very deep respiratory attempts between 20 and 22 seconds, last attempt they consumed excessive alcohol as a result of psychiatric disorders as a
between 2min 00s and 2min 04s for an average interval of 1min 40s to consequence of war stress they suffered. This study showed that increased
1min 42s. Overall, total hanging time before apparent death was between alcohol consumption in Croatia is more closely associated with certain
2min 47s - 4min 10s. methods of suicide over other methods.
Conclusion: Despite differences in the types of hanging, similarities Suicide, Alcohol, Croatia
could be revealed regarding rapid loss of consciousness and onset of

G27 Suicide by Self Immolation in The study confirms that suicide by self-immolation is extremely rare
in Cook County, Illinois, USA with an overall yearly average of 2.54 cases
Cook County, Illinois, USA (0.05%). The majority of cases were male, white, with a history of mental
illness, and immolated themselves at home.
Ponni Arunkumar, MD*, J. Scott Denton, MD, and Edmund R.
Donoghue, MD, Cook County Medical Examiners Office, 2121 West Forensic Science, Self-Immolation, Suicide
G28 Seasonal Incidence of Suicides in
After attending this presentation, attendees will learn of the
prevalence of suicide by self-immolation and conditions leading to self- Crete Island: A Five Year Study
immolation.
This presentation will impact the forensic community and/or Marianna Kalyva, MD*, University of Crete, Department of
humanity by generating awareness of death by self-immolation, discuss, Forensic Sciences, Medical School, Heraklion, 71110, Greece;
and describe the predisposing factors for this rare cause of death. Vasilios Stoukas, Telamonos 25, Anthoupoli, Peristeri, Athens 12135,
Suicide by self-immolation is extremely rare in the United States. Greece; and Anna Mavroforou, PhD, Elena F. Kranioti, MD, Panagiotis
This study aims to describe and determine the prevalence of such deaths Mylonakis, MD, Antonios Papadomanolakis, MD, and Manolis
in Cook County, Illinois, with an ethnically diverse population of 5.5 Michalodimirakis, MD, JD, University of Crete, Medical School,
million people, which includes the city of Chicago and its neighboring Department of Forensic Sciences, Heraklion, 71110, Greece
suburbs. A thirteen year retrospective study from 1993 to 2005 was After attending this presentation, attendees will learn information
conducted to determine whether there were any common factors that lead concerning seasonal peaks of the suicide rates, as well as the reasons for
to death by self-immolation. Computerized records of the Office of the this distribution in Mediterranean countries.
Medical Examiner of Cook County were searched and reviewed for causes This presentation will impact the forensic community and/or
of death from self-immolation. The review identified 33 cases from 1993 humanity by increasing understanding of the suicide incidence during all
to 2005 of such deaths. Seven cases were excluded from the study as one year round in a country with many special factors (religion, weather
was a homicide, four were accident, and two were undetermined. conditions, people’s attitude, Mediterranean temperament etc.).
The age, sex, mental illness history, location of event, yearly Suicide is defined as the intentional act of self-destruction committed
incidence, use of accelerant, and presence of witnesses were studied. by someone who knows what he or she is doing, and who is aware of the
Of the 33 cases, 23 were male and ten were female. The male: female probable consequences of his or her action. The epidemiology of the
ratio was 2.3:1. The ages ranged from 16 to 91 years old. The average suicide phenomenon is always of major interest in contemporary forensic
age was 38.2 years. Most of the cases were in the 30-39 year age group science. Studies have shown that suicide in some countries constitutes the
with the following distribution: three cases (9.1%) were 11-19 years; eight third, or even the second most common cause of death for persons aged
cases (24.2%) were 20-29 years; nine cases (27.3%) were 30-39 years; between 15 and 24 years, including accidents and homicides.
three cases (9.1%) were 40-49 years; eight cases (24.2%) were 50-59 In order to study this phenomenon on the island of Crete, a
years; one case (3.0%) was 60-69 years; one case (3.0%) was 90-99 years. retrospective analysis of all suicide cases for the period 1999 to 2003 was
Of the 33 cases, 22 were white; ten were black, and one Asian. conducted, based on the archive files of the Department of Forensic
Carbon monoxide determination was done in seventeen out of 33 Sciences (Medical School, University of Crete, Greece), which serves the
cases. The carbon monoxide level ranged from negative to 45%. The entire region. Crete is an island (the southernmost island in Europe) with
average blood carbon monoxide level was 11.4%. Twenty-two cases a population of about 750,000 inhabitants with millions of tourists
received medical treatment. annually.
An accelerant was used in 27 cases (81.84%). Gasoline was the most The parameters chosen were the personal data of the subjects (age,
frequently used accelerant. It was used in 21 cases (63.6%). Charcoal sex, and nationality), the information concerning time and location where
lighter fluid was used in two cases. Acetone in nail polish remover was death occurred (date and exact time of the incident, area, and exact
used in one case. An unknown accelerant was used in four cases. location), and the cause of death. In a total of 183 cases, 80.0% of them
The majority of self-immolation cases occurred at home, with nine involved men and 20.0% women. One hundred seventy-two cases
cases. Three cases occurred in the garage adjacent to the home, one case concerned persons of Greek nationality (94.0%) and the rest concerned
in the front lawn of the home, two cases in the driveway of the home, two foreigners. Thirty-six incidents (19.7%) occurred in 1999, 51 (27.9%) in
cases in the backyard of the home, two cases in a forest preserve, two cases 2000, 30 (16.4%) in 2001, 30 (16.4%) in 2002 and 36 (19.7%) in 2003.
in a parking lot, two cases in an alley, two cases near or on railroad tracks, Hanging prevailed as the main cause of death (41.0%), followed by
two cases on a street, and one case each in a church, a college, a grassy chemical substance overdose (drugs and pesticides, 26.8%), and firearm
area near major toll roads, and a shop. injuries (gunshot and shotgun wounds, 21.2%). The age specific suicide
Nine out of the 33 self-immolation cases were witnessed. Six of the rates per year were 20.0%, 16.4%, 13.1%, 15.3%, 12.0%, 12.6%, and
cases had attempted suicide before. One had a prior attempt of self- 7.7% for 21-30, 31-40, 41-50, 51-60, 61-70, 71-80, and 81-90 age groups
immolation. Ten subjects had talked previously about suicide. In only respectively. Four persons were of undetermined age. Seventy-one out of
five cases, a suicide note was left. 183 (39.0%) cases occurred at the region of Heraklion, which corresponds
Twenty-seven cases (81.8%) had a history of mental illness, mostly with the population distribution of Crete.
depression. A history of depression was seen in seventeen cases (51.5%). The bimodal seasonal peak in the suicide rate observed in this study
In ten cases, the cause of death was thermal burns due to self- was in agreement with several other reports, indicating that suicide
immolation. Seven cases were determined as thermal burns due to house follows a seasonal pattern with a dominant peak during the spring or early
fire or fire. Four cases were determined as thermal burns due to gasoline summer (months of maximum day light, 14.2% and 12.0% stand for June
fire. Three cases were closed as thermal burns and two cases as simply and May respectively) and a lesser peak in the autumn. The spring peak
self-immolation. In two cases, the cause of death was carbon monoxide in the suicide rate has been typically observed in Mediterranean countries.
intoxication due to clothing fire. On case was closed as inhalation of It has also been reported that agricultural populations have a longer spring
smoke and soot due to house fire. One case each was closed as thermal peak, while industrial populations have a shorten one. This should be
injury, inhalation injury due to self-immolation, sepsis due to self- considered as a further explanation for the extended spring peak observed,
immolation, and multisystem organ failure due to thermal burns due to since the suicide incidence was higher in rural areas, which were
motor vehicle fire. represented by 61.2%.

The suicide incidence in Crete (3.9 per 100,000 inhabitants) seems to In 78% of cases, the mains circuit in the premises was still live, as
be lower than the reported average in Greece (7.1 per 100,000 was the electrical outlet used to cause electrocution. Timers had been used
inhabitants), but higher compared to other Greek geographical regions, in eight cases, but the remaining 17 bodies were “live” on arrival of
e.g., a suicide incidence rate of about 2.7 stands for Epirus, at the north- witnesses or electricity personnel. In at least one case it was reported that
western coast of Greece. witnesses touched the electrically active body. Notes from the deceased
Suicide, Seasonal incidence, Crete Island warning of potential electrical hazard from touching the body were found
in at least five of the cases. Safety mechanisms were not tripped in any of
the cases, and were only tampered with in one case.
Discussion: While suicide by electrocution is typically described as
G29 Suicidal Electrocution in Australia the activation of electrical appliances while immersed in a body of water,
cases in Sydney appears to have a high proportion of individuals who
Peter Y. Chan, BSc*, and Johan A. Duflou, MBChB, MMed, Department attach themselves to power points via exposed wires. In the majority of
of Forensic Medicine, PO Box 90, Glebe, NSW 2037, Australia cases in this study the body was “live” at the time of discovery, presenting
The goal of this presentation is to describe a series of electrocution a life-threatening risk to initial responders to the death. Investigators and
suicides in Australia. emergency workers should remain vigilant upon discovery of electrical
This presentation will impact the forensic community and/or suicides, due to the fact that most bodies remain electrically active long
humanity by providing details of the typical electrical suicide death scene, after death.
autopsy features, and some specific problems associated with suicidal Electrocution, Suicide, Death Scene Hazards
electrocution.
Introduction: While suicide is a worldwide phenomenon, the
method that is used frequently has a geographic correlation. For instance, G30 Open Fractures in Pedestrians
firearm suicides make up 50% of all suicides in the USA, while intentional Mimicking Gunshot Wounds
poisoning with agricultural pesticides is used in up to 80% of cases in
some Third World countries. While electrocution is not the most common Melissa A. Brassell, MD*, Mary G. Ripple, MD, and David R.
form of suicide in Australia, compared to most parts of the world it appears Fowler, MD, Office of the Chief Medical Examiner, State of Maryland,
to be a relatively frequent mechanism of suicide that warrants further 111 Penn Street, Baltimore, MD 21201
study.
Materials and methods: This retrospective study investigates the After attending this presentation, attendees will understand the
trend of suicide by electrocution in the period from 1996 to 2005 similarities and differences in the appearance of pedestrian injuries and
examined at the Department of Forensic Medicine, Glebe, Sydney. gunshot wounds and the implications of non-forensic trained health care
Reviewed were the common autopsy, histology, and death scene professionals confusing these types of injuries on initial inspection.
characteristics of individuals who commit suicide via electrocution. A This presentation will impact the forensic community and/or
total of 25,675 deaths were investigated at between 1996 and 2005, with humanity by emphasizing the need for continuing education and a close
definite or probable suicide as the manner of death in 2029 cases. Suicidal working relationship between medical examiner/coroner’s offices and
electrocution cases were obtained by searching the Department of forensic health care professionals.
medicine autopsy text database. All cases in this study had a full autopsy, In February and April 2006, autopsies were performed on two
including toxicology and histology, and a detailed death scene pedestrians that were thought to have sustained gunshot wounds. While it
investigation by criminalists and electricians had been performed. was clear that the individuals had been struck by a motor vehicle, there
Results: There were 25 cases of definite suicidal electrocution was concern in both instances based on initial external examination at the
(mean 2.5 cases/annum, 1.2% of all completed suicides), and a further scene by emergency personnel and at the hospital emergency department,
three cases of possible suicidal electrocution in the time period. The latter that they had sustained gunshot wounds prior to being struck.
three cases were not analyzed further. Eighty-one percent of decedents The first case was a 27-year-old male who was struck by a Chrysler
were male, and the mean age was 57 years (range 22 to 90 years). At least 300 as he ran across the intersection of a local street. Information obtained
40% of decedents were either currently working or had worked as from paramedics following a preliminary external examination at the
electricians. Psychological comorbidities, predominantly depression, scene was that the individual sustained a gunshot wound to the right thigh
were observed in 73% of cases. prior to being struck. An investigation was begun by police into the
In 20 of the 25 cases, the mechanism of electrocution was by probable shooting. At autopsy, there was an open right femur fracture with
attachment to a live main electrical power point using electrical flex. The an associated ½” x 5/8” irregular laceration with a surrounding irregular,
flex was typically tied around the wrists, causing a lethal current to pass contiguous abrasion located on the inner right thigh. In addition, there was
through the body. Deep circumferential electrical burn marks on the wrists a curvilinear, 3” x 4” laceration on the lateral thigh with associated
or other extremities were typical, although there were three cases where extension lacerations, abrasions, and protrusion of the quadriceps muscle.
the electrical flex had been placed elsewhere (chest or mouth). The Postmortem radiographs and dissection of the thigh showed no beveling
remaining five cases had electrocuted themselves by dropping an and no bullet fragments or distinct wound path. Thus, the findings were
electrical appliance in the bath. There were histological findings not consistent with a gunshot wound. The second case was a 25-year-old
consistent with electrocution in one of these cases. Two showed no signs female who was struck by a Nissan Maxima as she crossed a busy
of electrocution despite the body being found immersed in water with an expressway at approximately 6:00 a.m. She was taken to the nearest
appliance active or recently turned off, and two others were too badly hospital, where physicians interpreted injuries of the left eyebrow and
decomposed for any further assessment. right temporal region as a possible through and through gunshot wound.
Toxicology was positive in 17 (68%) cases. These included a single Because of suspicion of a gunshot wound, her hands were bagged for
drug in 14 (56%) cases, with alcohol and benzodiazepine use preservation of evidence. A homicide investigation was begun. At
predominating (5 and four cases respectively) Autopsy revealed the autopsy, a 3” curvilinear abrasion and adjacent 1” laceration with skin
presence of significant organic disease in 17 cases, with nine of these avulsion was present on the right temple and a ½” laceration with a
presenting with at least two separate pathological processes. Grossly, contiguous curvilinear abrasion was present lateral to the left eyebrow.
pulmonary congestion or edema was found in 12 cases. Histologically, Autopsy, including radiographs showed linear and diastatic skull fractures,
morphology consistent with electrocution was found in 11 cases. no beveled skull defects, no wound track, and no bullet fragments. Thus,
the findings were not consistent with a gunshot wound.

Open fractures of long bones sustained as a pedestrian struck by a acetate (with a concentration of 4 mmol/ml) was sent to the SICU by the
motor vehicle primarily mimic gunshot wound defects at the skin surface. pharmacy. Apparently 5 ml of the potassium acetate was drawn into a 10
The overlying skin surface can show a full thickness laceration produced cc syringe and injected into a 100 ml buretrol and topped with 95 ml of
by the blunt trauma. Some of these lacerations are roughly circular to normal saline and 5% dextrose. The pump was set to run at 25 ml/hour
irregular with contiguous abrasions similar to that of an atypical entrance beginning at 17:00 hours.
gunshot wound with its surrounding abrasion collar. Closer external E.J.M. was also started on 4 ml of magnesium sulfate (2000 mmol/L)
examination of these wounds shows that the edges can be re- intravenously to run over two hours. At 18:40 hours, as the primary nurse
approximated, unlike that seen in an entrance gunshot wound. In addition, was otherwise occupied, the nurse responsible for the patient in the next
internal dissection and radiography reveal typical compound fractures bed added 4 ml of magnesium sulfate to the same buretrol. This nurse
with distinct linear edges, no bone dust or minute bone fragments, no noted that the buretrol contained 60 ml of fluid and the pump was running
beveling, no wound track and no bullet fragments. at 25 ml/hour.
Since open fractures can mimic gunshot wounds, close inspection of At 19:30 hours a shift change occurred and a third nurse became
the external wound and evaluation of the internal injury both by dissection involved with E.J.M. On taking over the patient’s care, the nurse
and radiography are essential in determining whether the injuries were “eyeballed” the buretrol and noted it contained about 75 ml of fluid and
caused by a gunshot. This presentation emphasizes the need for educating that the fluid was infusing at a rate of 50 ml/hour. Although the patient’s
health care professionals, especially first responders and emergency room chart contained instructions for the pump to run at 25 ml/hour, based on
staff, in injury patterns in order to prevent an unnecessary homicide the volume remaining in the buretrol (75 ml) and that it would take two
investigation. hours to complete the infusion, the nurse apparently, at 20:00 hours,
Gunshot Wound, Pedestrian, Laceration overwrote the order to read 50 ml/hour. Around this time it also became
apparent that E.J.M.’s condition was becoming unstable. Blood was
drawn at 20:30 hours and sent to the hospital laboratory for electrolyte and
hemoglobin levels. At 20:38 hours, E.J.M. went into cardiac arrest. An
emergency code was called and she was pronounced dead after 15 minutes
of resuscitation.
G31 Homicide in a Surgical Intensive Care Unit At 21:13 hours, the SICU was notified by the laboratory of a critical
potassium level of 7.6 mmol/L. The physician was informed of these
A. Thambirajah Balachandra, MBBS*, Johanna Abbott, and Carol results and immediately suspected a medication error. The buretrol was
Youngson, RN, Office of the Chief Medical Examiner, Manitoba Justice, seized and sent to the hospital laboratory for analysis. A search for the
210-1 Wesley Avenue, Winnipeg, Manitoba R3C 4C6, Canada; John used 50 cc vial of potassium acetate, however, was not successful.
Burchill, Hate Crimes Unit Coordinator/Major Crimes Analyst, The death of E.J.M. was reported to the medical examiner’s office on
Winnipeg Police Service, PO Box 1680, 151 Princess Street, Winnipeg, January 4, 2002 at 22:35 hours by the physician due to the possible
Manitoba R3C 2Z7, Canada; and N.D.N. Asela Mendis, MBBS, and medication error. The medical examiner commenced an investigation that
Sholeh Barooni, MD, Office of the Chief Medical Examiner, Manitoba included the results of the medicolegal autopsy (concluded that
Justice, 210-1 Wesley Avenue, Winnipeg, Manitoba R3C 4C6, Canada hyperkalemia was the cause of death), as well as the findings from the
The goals of this presentation will be to increase the forensic internal investigation done concurrently by the hospital. Following
community’s awareness of the potential for potassium overdose to be extensive meetings between the medical examiner’s office, the hospital
intentionally administered to patients in health care facilities; to explore and the police; hours of interviewing physicians, nursing staff and other
the problems and difficulties encountered in the medicolegal investigation health care workers; numerous searches for the missing potassium acetate
of such cases; and, to devise means of preventing hyperkalemic deaths as vial; and repeated testing on the buretrol contents, the medical examiner’s
a result of intentional overdose. office and the hospital jointly concurred that E.J.M.’s death was not an
With the increasing number of frail, elderly patients with multiple accident, but the result of an intentional act. Consequently, detectives
medical complications, it may be tempting for health care workers who are from the Winnipeg Police Service officially took over the investigation on
taking care of these patients to put them “out of their misery.” However February 12, 2002.
logical it may sound, it is unethical and contrary to law. The criminal use Results: Repeated laboratory analyses of the buretrol contents
of intravenous potassium salts on these victims usually will not leave any revealed a potassium concentration ten times higher than what had been
evidence to identify the cause of death or the perpetrator. Investigating prescribed for the patient, an increased amount of chloride, and a trace
these cases is very difficult because the victims have multiple problems amount of diphenhydramine, which had never been prescribed. It was
and police departments, medical examiners, and forensic pathologists are also evident from the investigation that the pump speed had been doubled
reluctant to conduct a homicide investigation in a hospital, especially the and additional fluids had been injected into the buretrol. Lastly, the used
intensive care unit. Publicizing these cases will keep the forensic 50 cc vial of potassium acetate had never been recovered. Thus, it was
community alert. This presentation will impact the forensic community reasonable to conclude that someone, probably a member of staff at the
and/or humanity by discussing the various means of investigating such hospital, had doubled the pump speed and added potassium acetate,
cases. potassium chloride and diphenhydramine to the buretrol to intentionally
Case Background: On January 3, 2002 at 09:30 hours, E.J.M., an cause E.J.M.’s death. Therefore, the manner of death was homicide.
83-year old woman who lived alone, was found by police in a semi- Despite a thorough police investigation, which included an extensive
conscious state in her home. She was taken to the emergency department report by a Major Crimes analyst, there was insufficient evidence to lay
of a tertiary care hospital in Winnipeg, Manitoba. She was diagnosed with charges against any individual or individuals involved.
a fractured left hip, renal failure, myoglobinuria, and pneumonia. She was Conclusion: This death clearly illustrates that administering
admitted at 17:47 hours and transferred to the Surgical Intensive Care Unit excessive amounts of potassium can kill patients in health care facilities.
(SICU). The plan was to stabilize her condition before she underwent However, hyperkalemia as a result of intentional overdose is next to
corrective hip surgery. impossible to diagnose by autopsy alone. Other, thorough investigations,
The following day, at 15:45 hours, her serum electrolytes revealed a including a review of the medical chart, analyses of any remaining fluids,
potassium level of 3.3 mmol/L. As her serum chloride level was elevated, and examination of the pump’s memory system, are vital to the
the physician prescribed potassium acetate – to be infused at a rate of 5 investigator in reaching a conclusion of intentional overdose. Following
mmol/hour for four hours for a total of 20 mmol. A 50 cc vial of potassium the death of E.J.M., it is now the practice in intensive care units in

Manitoba hospitals not to store potassium acetate or potassium chloride on G33 An Exceptional Case of Death
the wards.
In February 2003, in the absence of criminal charges, the Chief
Due to Lesions of Water Nozzle
Medical Examiner directed that an inquest be held into the death of E.J.M.
The findings of the inquest judge were released in September 2005. The Nunzio Di Nunno, MD, PhD*, Università degli Studi di Lecce, Via G.
report can be accessed by visiting website: http://www.manitoba Dorso n. 9, Bari, 70125, Italy; Luigi Viola, MD, Università degli Studi di
courts.mb.ca/inquest_reports.html (Report No. 6 - E.J.M. – September 12, Bari, Sezione di Medicina Legale, DIMIMP, Policlinico di Bari, Piazza
2005). G Cesare 11, Bari, 70124, Italy; Fulvio Costantinides, MD, Università
degli Studi di Trieste, San Pelagio n. 45, Duino-Aurisina, 34100, Italy;
Hyperkalemia, Intensive Care Unit Death, Homicide and Giandomenico Maria Battista, MD, and Cosimo Di Nunno, MD,
Università degli Studi di Bari, Sezione di Medicina Legale, DIMIMP,
Policlinico di Bari, Piazza G. Cesare 11, Bari, 70124, Italy
The goal of this presentation is to describe an exceptional case of
G32 Subdural Hemorrhage, Subarachnoid mortal lesions due to water nozzle, a professional tool used to wash solid
surfaces.
Hemorrhage, and a Healing Tibia This presentation will impact the forensic community and/or
Fracture: Abuse or Complications humanity by describing unusual high pressure water injuries.
of Leukemia? A 28-year-old young worker at a navy yard, died while he was trying
to clean the hold ports of a ship moored at wharf of Arsenale S. Marco in
Trieste (Italy).
Veena D. Singh, MD, MPH*, University of New Mexico Health Sciences
During the investigation, the remains of the man was found laying
Center, Department of Pathology MSC08 4640, 1 University of New
face down on the floor of a little mobile platform raised several meters
Mexico, Albuquerque, NM 87131; and Kurt B. Nolte, MD, and Ross
from the ground, where he was working alone.
Reichard, MD, Office of the Medical Investigator, MSC11 6030, 1
Close to the body there was the water nozzle with the switch in the
off position. There was a wide tear in the overall she was wearing and
The goal of this presentation is to discuss the natural diseases that “homogenized” organic tissues were found on the platform. Skeletal
may mimic inflicted trauma and discuss methods of differentiating natural elements of the remains were exposed where soft tissue had been avulsed.
disease from neglect and inflicted trauma. The postmortem examination showed skin abrasions on the right half of
This presentation will impact the forensic community and/or the face with a fracture of the skull, wide and deep soft tissue injuries of
humanity by highlighting issues related to pediatric autopsy and findings the right upper limb with areas of complete soft tissue avulsion. The soft
that may obscure cause and manner of death. A better understanding of tissue of the right side of the chest was largely absent and perforated with
ways that natural disease can mimic inflicted trauma will better enable laceration of the lung and heart. Technical testing of the tool by an
forensic pathologists to avoid inaccurate diagnoses. engineer showed the equipment for water cleaning was working properly,
Objective: Child fatalities due to natural disease vs. abuse and/or providing of water with a pressure of about 500 bars by an auto-turning
neglect are challenging forensic autopsies. nozzle. However, the safety devices had been altered. Unaltered, the jet
Case Summary: A two-year-old boy was found dead in his foster of water should be stopped automatically if the water release and safety
care bed. He was receiving treatment with L-asparaginase and steroids for buttons (the last one has to be activated by the other hand) are not activated
acute lymphoblastic leukemia. In the weeks prior to his death he became at the same time.
increasingly weak and had several falls witnessed by therapists and family The scene investigation, with particular reference to the remains
members. In the days prior to his death he had marked thrombocytopenia. position, and the water nozzle found close to the body, the nature of the
Autopsy revealed acute small cerebral subdural and subarachnoid injuries, the negative toxicology testing, along with the technical findings
hemorrhage, and superior sagittal sinus and cerebral venous thromboses, a about the functioning of the tool and its altered safety devices provided a
healing tibial compression fracture and extensive bronchopneumonia. clear sequebce of events that led to this death. This accidental death was
There were no retinal or optic nerve sheath hemorrhages. caused by the inappropriate use of a water cleaning device.
Discussion: Although subdural and subarachnoid hemorrhages in Water Nozzle, Crime Scene Investigation, High Pressure Water
children are suggestive of inflicted injury, correlation of the medical Injuries
history with autopsy findings in this case indicated that the
neuropathologic findings were likely a result of minor trauma associated
with underlying leukemia and treatment effects. L- asparaginase has been
associated with abnormal blood clotting. Careful review of a decedent’s
G34 Hanging Deaths in Ontario:
medical history and correlation with autopsy findings is crucial to Retrospective Analysis of 755 Cases
distinguish inflicted trauma from accidental trauma, and from natural
disease processes that mimic trauma. The cause of death in this case was Elena Tugaleva, MD*, and Michael J. Shkrum, MD, Department of
certified as complications of acute lymphoblastic leukemia and the Pathology, London Health Sciences Centre, 339 Windermere Road,
manner of death was certified as natural. London, Ontario N6A 5A5, Canada; Donald R. Gorassini, PhD,
Thrombosis, Neuropathology, Pediatric Department of Psychology, King’s University College at The University
of Western Ontario, 266 Epworth Avenue, London, Ontario N6A 2M3,
Canada; and Barry A. McLellan, MD, Office of the Chief Coroner, 26
Grenville Street, Toronto, Ontario M7A 2G9, Canada
After attending this presentation, attendees will gain an appreciation
of the demographics and pathology of hanging deaths in Ontario. The
findings will be compared to the other series and discussed with regards to
influencing factors and quality assurance standards.
humanity by emphasizing the importance of documenting neck injuries in

hanging deaths, and will discuss factors influencing their frequency. It G35 Maternity and Paternity Testing of a
will address quality assurance issues, such as an importance of recording
of pertinent negatives, use of standardized autopsy reports and dissection
Discarded Dead Neonate Involving a
protocols, and utilization of additional postmortem techniques. Young Girl and Her Father
The frequency of neck injuries in deaths by hanging is controversial.
In the literature, the range is wide, varying from 0 to 76.6% for hyoid and Jian Tie, MD, PhD*, Yuka Serizawa, BS, and Sesaku
laryngeal fractures. Multiple factors account for this variation. Complete Uchigasaki, MD, PhD, Department of Legal Medicine,
neck examination and accurate recording of not only positive but also Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi,
negative findings are important. Tokyo, 173-8610, Japan; Yoshihiro Mitsugi, Criminal Investigation
This study is a retrospective analysis of deaths by hanging that Laboratory, Saitama Prefectural Police Headquarters, 3-10-1 Kizaki
happened in Ontario during a two-year period (January 1998 to December Urawa-ku, Saitama, Saitama 330-0042, Japan; and Shigemi
1999). The main goal of the study was to determine the frequency of Oshida, MD, PhD, Department of Legal Medicine, Nihon
different hanging-related neck injuries. Fractures of the neck structures University School of Medicine, 30-1 Oyaguchi Kamimachi, Tokyo,
and soft tissue injuries were studied. Secondly, factors recognized as 173-8610, Japan
important in the incidence of neck fractures, such as age, sex, and weight
Upon completion of this presentation, participants will know how
of the deceased were evaluated. The third goal was to determine whether
to gather evidence when the case involves a discarded dead neonate
the frequency of hyoid/laryngeal injuries varied depending on autopsy
using DNA identification. In the presented case, the infant’s mother was
location, i.e., forensic pathology unit, teaching hospital, or community
16 years old and the infant’s father was also the infant’s mother’s father.
hospital.
This is a rare paternity testing case. Sixteen Y-plex chromosomal STR
A total of 755 cases were available for evaluation of which 632 had
testing was used to analyze the relationship of the girl’s father and the
a complete autopsy and 68 were limited to external examination only. In
infant.
55 cases, no postmortem examination was conducted. The largest
category was suicidal hanging, at 737 cases (97.6%). Nine cases (1.2%)
humanity by showing that Y-Plex STR is a very useful genetic maker for
were accidents and two cases (0.3%) were homicides. In seven (0.9%)
forensic practice.
cases the manner of death was not determined. The mean age of the
A male neonate was found dead in a paper box, with the umbilical
deceased was 40.58 years (the youngest victim was two and the oldest 94
cord coarsely amputated. Next to the body there were several
years old), and there was a male predominance (82.6%). The following
bloodstains on a pair of sandals marked with the name of a family living
represents a breakdown, by location, of the cases that were examined: 240
near the scene. A 16-year-old girl with the same family name was
(34.3%) in forensic facilities (of which 72.9% were complete autopsies
suspected as the neonate’s mother, as her house was near the scene and
and 27.1% were external examinations); 48 (6.9%) in teaching hospitals
blood was found in the toilette of her home. The girl’s father and mother
(of which all were complete autopsies), and 412 (58.9%) in community
were divorced years ago, and her father was remarried to another
hospitals (of which only three were limited to external examination).
woman. In order to obtain evidence to determine whether the infant was
Of the 632 cases that had complete autopsies, the most common
the girl’s son and to establish the identity of the infant’s father, DNA was
hanging related neck injuries were those of soft tissue. The latter were
extracted from the oral epithelium of the girl and her father. Blood taken
quite variable in severity, ranging from minute soft tissue hemorrhages to
at autopsy provided the source of DNA from the infant. Fifteen
complete transection of the neck structures. Soft tissue injuries not
autosomal STR loci plus the amelogenin locus were investigated using
associated with skeletal trauma were reported in 59 cases (9.3%).
DNA samples of the girl, her father, and the infant. To investigate the
Associated fractures of the hyoid bone and/or laryngeal cartilages were
relationship between the infant and the girl’s father, sixteen Y
present in 46 cases (7.3%) with the most common being hyoid fractures
chromosomal STR loci were analyzed using DNA samples from the
(30 cases). Less common were fractures of thyroid cartilage alone (10
girl’s father and the infant. The probabilities of maternity and paternity
cases), combination of hyoid and thyroid cartilage fractures (3 cases), and
were 0.9999999 and 0.9999999, respectively, for all fifteen autosomal
cricoid cartilage (3 cases). Seven cases of cervical spine injuries (fractures
STR loci analyzed. Furthermore, the sixteen Y chromosomal STR loci
or dislocations) were documented.
were an exact match between the dead infant and the girl’s father. These
A higher incidence of neck fractures occurred among men. There
results conclusively proved that the 16-year-old girl and her father were
was a tendency for the number of fractures to increase with increasing age
the biological parents of the discarded dead neonate.
and weight/BMI of the deceased.
The frequencies of hyoid/laryngeal fractures distributed over Discarded Dead Neonate, Maternity and Paternity Testing, STR
forensic, teaching, and community facilities were as follows: 7.4%, 16.7%
and 6.1%, respectively. The frequency of fractures reported in specialized
forensic facilities reached 10.6% if the Forensic Pathology Unit in Toronto G36 Undetected Polyglandular Autoimmune
was excluded from the analysis. The lower frequency of fractures (2.8%) Syndrome Type II (Schmidt Syndrome)
registered in this unit could be explained by different demographics of
cases that underwent complete postmortem examination, specifically due
as a Cause of Sudden Death
to a higher proportion of complete autopsies performed on female and
younger individuals. Higher frequency of fractures correlated with a Michael S. Lantier*, Villanova University, 800 Lancaster Avenue,
higher percentage of cases in which there was accurate reporting, i.e., Villanova, PA 19085; and Fredric N. Hellman, MD, MBA, Office
definite comments were made upon presence or absence of specific of the Medical Examiner, Delaware County, Route 352-Fair Acres, Lima,
injuries and their site. PA 19037
Hanging, Neck Injuries, Pathology The goals of this presentation are to discuss the clinical features and
disease association characteristics of the Polyglandular Autoimmune
Syndrome Type II, and to increase the recognition of the morbidity and
mortality arising from polyglandular autoimmune disorders.
humanity by demonstrating how polyglandular autoimmune (PGA)
syndromes are associated with a diversity of related diseases. Diabetes
mellitus Type I is a common manifestation of PGA Types II and III. Less

frequently observed is Addisonian crisis arising from co-occurring addressing mechanisms of actions and common routes of administration,
thyroiditis and adrenalitis in the absence of pancreatic involvement and health risks that such ingestions present to responding personnel are also
resulting in sudden, unexpected death. The premorbid clinical and presented. Based upon commonly understood risk factors lending to
laboratory manifestations of this disorder can be subtle and non-specific, insecticide-related suicide from certain areas of Asia, potential parallels to
yet are critical benchmarks to be recognized in order to avoid a potentially certain regions of the United States are reviewed. Additional issues
lethal outcome. explored include assessing the predisposition to insecticide-related suicide
Immunologic syndromes impacting multiple endocrine organs and based on geography, agricultural intensity, accessibility to such poisoning
giving rise to other nonendocrine immune disorders are a rare cause of agent(s), and relative lack of access to medical centers capable of
sudden, unexpected death. Endocrine deficiency due to Polyglandular rendering rapid treatment and antidote(s).
Autoimmune Syndrome can be brought on by infection, infarction, or Propoxur (Baygon) is a potent carbamate insecticide used to control
tumor that results in the destruction of all or a large part of an endocrine cockroaches, flies, mosquitoes, and lawn and turf insects. It is also a
gland. In most cases, however, the activity of an endocrine gland is poison used to complete suicide. Insecticide intoxication is a significant
depressed as a result of an autoimmune reaction that produces method of suicide in some areas of the world. A 55-year-old black male
inflammation, lymphocytic infiltration, and partial or complete destruction was found unresponsive in his garage with a glass of Propoxur adjacent to
of the gland. There are three patterns of Polyglandular Autoimmune him. Upon transport to a suburban Philadelphia hospital emergency
(PGA) Syndrome, referred to as types I, II, and III. PGA Type I usually department, fumes from the insecticide emanated from the victim’s body,
occurs in childhood and is characterized by hyperparathyroidism (79% of sickening 29 hospital workers and 12 hospital patients. As a safety
cases), followed by adrenal cortical failure (72%). Diabetes mellitus Type precaution, the hospital was quarantined and its employees
I seldom occurs. PGA Type II generally occurs in adults and always decontaminated. It is imperative for physicians, emergency medical
involves the adrenal cortex and frequently the thyroid gland (Schmidt service personnel, and investigators to be aware of the risks and
syndrome) and the pancreatic islets. Type II is the most common of the detrimental consequences involving deaths associated with insecticide
syndromes and is characterized by the occurrence of autoimmune ingestion. While proper handling of patients is crucial, healthcare
Addison’s disease in combination with thyroid autoimmune diseases personnel should be aware of the public health risks created by individuals
and/or diabetes mellitus Type I. The most frequent clinical association is who ingest select poisons. Propoxur’s mechanism of action relies upon
between Addison’s disease and Hashimoto’s thyroiditis, while the least the reversible carbamylation of acetylcholinesterase, resulting in a
frequent clinical combination is Addison’s disease, Graves’ disease, and subsequent accumulation of acetylcholine in myoneuronal junctions (i.e.,
diabetes mellitus Type I. PGA Type III occurs in adults and does not both in nicotinic and muscarinic systems). The modes of absorption
involve the adrenal cortex, but includes at least two of the following: include inhalation, ingestion, and dermal penetration, and the pertinent
thyroid deficiency, diabetes mellitus, pernicious anemia, vitiligo, and signs and symptoms include diaphoresis, urination, bradycardia, seizures,
alopecia. and bronchospasm. Insecticide ingestion as a means of suicide is stratified
Following the sudden death of a 38-year-old Caucasian female an by two principal variables, these being availability of the agent(s) utilized
autopsy revealed findings consistent with the diagnosis of Schmidt and the related variable of agricultural intensity within the region of the
syndrome, or Polyglandular Autoimmune Syndrome Type II. While world studied. In rural, agricultural regions of Sri Lanka and China, a high
diabetes mellitus Type I was not diagnosed, as is the case in 50% of PGA incidence of self-poisoning deaths have been attributed to harsh living
Type II presentations, her past medical history included an ill-defined conditions, stressful situations, accessibility to the poisoning agent(s), and
thyroid disorder and recent premorbid history of listlessness to extreme relative lack of access to medical centers capable of rendering rapid
fatigue and non-specific somatic complaints. Her healthcare professional treatment and an antidote(s). Access to lethal means is one principal
failed to make the correct premortem diagnosis. The differential diagnosis variable observed from suicide patterns in the United States, though the
of this disorder is addressed, as is a brief discussion of the polyglandular most common injury associated with completed suicides in this country
autoimmune syndromes, with particular emphasis on the etiology, derives from firearms. The premise proposed is that those regions of the
epidemiology, morbidity, and mortality associated with Polyglandular United States which parallel most closely those conditions predisposing to
Autoimmune Syndrome Type II. suicidality as observed in Sri Lanka and rural China should exhibit higher
Autoimmune, Polyglandular, Endocrine insecticide ingestion-related suicide rates in comparison to other areas of
the country.
Insecticide, Suicide, Healthcare Worker Risks
G37 Suicide by Ingestion of Carbamate
Insecticide: Case Report and
G38 Chemical Asphyxia and Bondage:
Regional Variations
Autoerotic Fatality Induced by
Lucas D. Duke, BS*, Drexel School of Medicine, 2125 Spring Garden Chloroform Inhalation
Street, #3R, Philadelphia, PA 19130; Sepideh Samzadeh, BS, Drexel
University School of Medicine, 135 South 20th Street, Apartment #1506, Heather A. Cannon*, Mercyhurst College, 501 East 38th Street, Erie, PA
Philadelphia, PA 19103; and Fredric N. Hellman, MD, MBA, Office of 16546; and Fredric N. Hellman, MD, MBA, Office of the Medical
the Medical Examiner, Delaware County, Route 352-Fair Acres, Lima, Examiner, Delaware County, Route 352-Fair Acres, Lima, PA 19037
PA 19037
It is important to acknowledge variations from characteristic
After attending this presentation, attendees will understand how autoerotic asphyxial death practices. The use of chemical inhalation, more
insecticide ingestion is a significant method for suicide both globally and specifically chloroform, as a means to create a euphoric autoerotic state
nationally. Attendees will also understand the possible threats to first has rarely been discussed in past literature. After attending this
responders and healthcare personnel attending to victims of insecticide presentation, attendees will learn how autoerotic asphyxia is also rarely
self-ingestion. observed in those older than the sixth decade.
This presentation will impact the forensic community and/or It is well recognized in contemporary literature that autoerotic
humanity by attempting to further increase understanding of suicide asphyxial deaths are most commonly observed among Caucasian males in
patterns, focusing upon a means not commonly observed in the United the third to fourth decade of life. However, there are cases that are distinct
States but frequently employed in select regions of Asia. In addition to from the common pattern of age demographics and the means of attaining

a hypoxic state. This presentation will impact the forensic community affected by this syndrome. The entity is a hematologic and
and/or humanity by demonstrating how it is imperative to acknowledge anatomic/forensic curiosity, with remarkable gross and microscopic
that significant variations from characteristic autoerotic asphyxial findings.
practices do occur. The possibility of autoerotic asphyxial death should be Statement of Methods: This poster will present a case report and
entertained in the aged population when corroborated by appropriate scene literature review of: Sporadic Hemophagocytic Syndrome, and its clinical,
and evidentiary information. laboratory, and histopathologic manifestations, with a focus on its
Autoerotic asphyxia is a paraphilia in which a hypoxic state is sometimes innocuous presentation as a viral illness, leading to rapid
induced in order to enhance orgasm during sexual activity. The medical (within 14 days) death in both young and older patients.
examiner becomes involved in those situations in which the hypoxic state Abstract: The focus of this case report is patient EC, a 77-year-old
becomes irreversible and results in the death of the practitioner. While this male, who was transferred from an outside hospital to the institution with
practice is observed most commonly in Caucasian males whose ages range confusion, ataxia, pancytopenia, diffuse lymphadenopathy/ splenomegaly,
from the third through fourth decades, deviation from these demographic and a flu-like illness with temperature spikes to 103° F. His past medical
variables do occasionally occur. Autoerotic asphyxiation through the use history included CAD s/p MI, dermoid tumors, and hypercholesterolemia.
of a ligature about the neck, with escape mechanism, is the most common He underwent a cervical lymph node biopsy during admission, which
means of this practice. More atypical approaches to reach a euphoric state demonstrated a non-clonal proliferation of T-cells with Ebstein-Barr virus
through oxygen deprivation include rebreathing via the use of a plastic positivity (by in-situ hybridization, consistent with mononucleosis). EC
bag, positional asphyxia through thoracic compression, submersion, and was treated with steroids without improvement of his lymphadenopathy.
chemical inhalation. Chemicals most frequently cited as hypoxic agents Labs during admission: WBC 2.6; Hgb 9.5; Plt 34 Neut: 40.9%; Lymphs:
in available literature documenting autoerotic practices include propane, 51.5 %; Eos: 3.6% Absolute Neutrophil Count: 5650. Serology tests
butane, ether, aerosol glue, tetrachloroethylene, 1-1-1 trichloroethane, and showed EBV IgG positive/Ig negative, CMV IgG positive/IgM negative,
ketamine. Documentation of chloroform use in autoerotic asphyxial RPR negative, HIV negative, toxoplasmosis negative. For his entire
practice is distinctly uncommon. hospital admission, he had no bacterial growth in his blood cultures, but
A 67-year-old Caucasian male was discovered in bed and multiply did have S. aureus positive respiratory cultures.
bound within his suburban Philadelphia, PA residence. The decedent was Within two weeks of admission, EC suffered a non-Q wave
discovered wearing a black rubber gas mask, with a bottle of chloroform myocardial infarction, with an echocardiogram study showing an EF of 25
situated on an end table adjacent to his head. A postmortem interval of at – 30%. Although the work up of his hematologic aberrancies continued,
least two to three days had transpired from the time of death until the time the patient’s medical status deteriorated following his MI.
of discovery. Toxicological assessment demonstrated the presence of The patient developed hypoxic respiratory failure and cardiogenic
chloroform in the blood, liver, brain, and lung of the decedent, consistent shock, and expired on 15 days after admission.
with inhalation of this agent in an effort to induce a hypoxic, reversible At autopsy, the body was that of a cachectic older male with marked
state. Scene investigation disclosed evidence supportive of multiple generalized lymphadenopathy. Histologic findings included a newly
paraphilias engaged in by the decedent, including leather and black rubber diagnosed pleomorphic high-grade large B-cell lymphoma, which showed
fetishism and masochistic acts, including earplugs and genital entrapment. EBV positivity and systemic hemophagocytic lymphohistiocytosis. The
Numerous enema bags were distributed throughout portions of the presence of the stain LMP-1 in most of the lymphoma cells is consistent
otherwise fastidious residence, suggesting klismaphilia. While deaths with an EBV-driven disorder. There was also evidence of a remote
arising from the performance of autoerotic asphyxia characteristically myocardial infarct and pleural fibrosis.
involve young Caucasian males through the use of a neck ligature, it is Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening
important to recognize significant variation from this general pattern. It is condition characterized by uncontrolled hyper-inflammation on the basis
likewise imperative to consider the possibility of additional participants of various inherited or acquired immune deficiencies. It is also
and criminal activity when confronted with such scenarios. characterized by clinical, laboratory and histologic findings. The clinical
Chloroform, Autoerotic, Paraphilia symptoms/signs include: fever, severe constitutional symptoms,
lymphadenopathy, hepatosplenomegaly, icterus/jaundice, neurologic
symptoms (seizures, CN palsies, encephalitis, meningismus) and rash
(maculopapular/nodular eruptions). Laboratory criteria include:
G39 Hemophagocytic Lymphohistiocytosis: A pancytopenia (cytopenia in at least two cell lineages),
Case Report and Review of the Literature hypertriglyceridemia, high ferritin, transaminases, bilirubin, and LDH.
Also, hypofibrinogenemia, high levels of the á chain of the soluble IL-2
Julia M. Braza, MD*, and Meghan Delaney, DO, Beth Israel Deaconess receptor and Impaired function of Natural Killer Cells and cytotoxic T
Medical Center and Harvard Medical School, 330 Brookline Avenue, cells. Histopathologic findings are: reactive and systemic proliferation of
Boston, MA 02215 benign histiocytes that phagocytose blood cells and their precursors in
bone marrow, and or spleen. EC fulfilled the criteria for the acquired form
The goal of this presentation is to discus a case of a rare hematologic
of hemophagocytic syndrome, due either to an EBV infection, lymphoma,
syndrome (Hemophagocytic Lymphohistiocytosis), and a literature
or a combination of both: an EBV-driven high-grade lymphoma.
review. New data has shown, that in the infection associated form of
Familial forms (FHLH) hemophagocytic lymphohistiocytosis is the
hemophagocytic syndrome, a selective loss of cytotoxic function in
entity where HLH is the primary and only manifestation, occurring in
antigen presentation to T cells, creates an imbalance in the immune
approximately in 1/50,000 births. FHLH is associated with immune
system, and promotes abnormal/excessive production of T cell derived
deficiencies such as: Chédiak-Higashi Syndrome, Griscelli Syndrome,
cytokines, such as Interferon gamma (IFNã), which is quite toxic, and
and X-linked lymphoproliferative Syndrome. Secondary (Sporadic) HLH
leads to the characteristic clinical and histopathologic features of HLH.
is associated with the trigger of a benign or neoplastic disease (most
This is a rare entity, yet important, because it has a primary and secondary
patients have no known underlying immune deficiency), such in the
form, which may occur in the young, and in individuals with no known
patient, EC. Various infectious microorganisms, mostly viruses, such as
underlying immune deficiency/lymphoproliferative disorder.
EBV, but also bacteria, protozoa and fungi, induce secondary HLH. In a
review article from 1996 of children with infection-associated
humanity by identifying and discussing the different forms of this
hemophagocytic syndrome (IAHS) EBV was found to be the triggering
syndrome, i.e., primary and secondary; its clinical, laboratory and
event in 74% of cases. HLH may also occur as a complication of
histopathologic findings and its unusual cause of death in those individuals

rheumatologic disorders (macrophage activation syndrome), malignancies These pellets on X-Ray and direct examination were consistent with
(especially T cell lymphomas), also known as Lymphoma associated snake-shot. This ammunition is most frequently used in shotguns. When
Hemophagocytic Syndrome (LAHS). EBV was detected only rarely in it is fired from a handgun, it is typically used to kill reptiles and other thin-
those with B- cell lymphomas, and much more so, 80%, in patients with skinned small animals at short distances, up to approximately five yards.
T/NK lymphomas. The median survival time with pts with LAHS is about Handguns of many calibers including 9 mm, .357 Magnum, .38 Special,
11 days. .40, .44 Special and Magnum, and .45 semi-automatic may accept small
New data about what the possible etiologies are for sporadic pellet-filled projectiles which contain shot of the same size as that used in
hemophagocytic syndrome have shown that uncontrolled secretion of a shotgun, but with a smaller load and charge.
cytokines may stimulate the proliferation and phagocytic activity of The rounds consist of a hollow plastic projectile that contains the
macrophages, and therefore cause widespread inflammation, and the loose shot. If snake-shot is used in a gun without the encapsulating plastic,
severe pancytopenia seen in this entity. More specifically, a selective loss the lead shot may form pits in the rifling of the barrel. The cartridge
of cytotoxic function in antigen presentation to T cells, creates an moves down the barrel of the handgun and opens on leaving the muzzle;
imbalance in the immune system, and promotes abnormal/excessive normally, the shot does not separate until after it has left the barrel. With
production of T cell derived cytokines, such as Interferon gamma (IFNã), shot of size #12, colloquially known as snake-shot, there might be as little
which is quite toxic, and leads to the characteristic clinical and as 1.5 to 3 ft-lb of energy in each pellet as it hits the target. While it might
histopathologic features of HLH. easily penetrate human skin at close ranges (but not contact), it would not
In conclusion, in the presented case, the clinical, laboratory, and be expected to penetrate deeper into the body than muscle tissue, and so
autopsy findings demonstrate case of Secondary Hemophagocytic would not be typically used in a homicide. Some experts report that the
Lymphohistiocytosis. The disease entity has specific clinical, laboratory rounds are not useful for self-defense, especially against a human
and histopathologic findings, and when sporadic, can present as an assailant, as the penetration is minimal and the shot diameter tiny.
innocuous viral illness, as in EC’s case, with fatalities occurring within However, in the case of a direct hard contact gunshot wound this
two weeks of presentation, due to uncontrolled hyper-inflammation and ammunition created a surprising amount of damage that was more than
activated macrophages/histiocytes that kill/ingest all hematopoietic sufficient to kill.
elements, causing widespread pancytopenia. The cause of death in this case was a hard contact gunshot wound of
Hemophagocytic Lymphohistiocytosis, Ebstein Barr Virus (EBV), the head. The manner of death was suicide, based on the autopsy and
Interferon Gamma (IFNã) scene investigation. The use of snake-shot as ammunition was unusual but
just as lethal as a bullet.
Snake-Shot, Handgun, Suicide
G40 Snake-Shot From a Handgun:
An Unusual Gunshot Wound Suicide
G41 Non-Traumatic Homicide Following
Karen B. Looman, DO*, and Wendy M. Gunther, MD, Tidewater Office Assault: 16 Cases - A Review of
of the Chief Medical Examiner, 830 Southampton Avenue, Suite 100, Investigation, Pathology, Toxicology,
Norfolk, VA 23510
and Judicial Outcome
After attending this presentation, attendees will learn about
projectiles for handguns that fire snake-shot and the use of such a Patricia A. Aronica-Pollak, MD*, Jack M. Titus, MD, and David R.
projectile in this case of suicide and be able to recognize the following: Fowler, MD, Office of the Chief Medical Examiner State Of Maryland,
How snake-shot can be fired from a handgun, how such a projectile can 111 Penn Street, Baltimore, MD 21201
create an unusual entrance wound on postmortem examination, how to
reconcile radiologic findings typical of a shotgun with a handgun as the After attending this presentation, attendees will understand some
weapon, and why such findings are not inconsistent with a suicide. principles of the classification of the manner of death as homicide when
This presentation will impact the forensic community and/or death occurs as the result of a physical altercation or a significant implicit
humanity by providing useful information about unusual but not threat in the absence of fatal traumatic injuries, by reviewing the
uncommon ammunition used in a suicide. investigation reports, the pathology reports, the toxicology reports, and the
A 49-year-old man had an argument with his wife at his home. He judicial outcomes of these cases.
got a revolver out of his locked gun cabinet, went out to his car, and was This presentation will impact the forensic community and/or
found dead in the car some time later with a gunshot wound. Scene humanity by discussing how these types of cases can differ from
investigation found the revolver in the deceased man’s hand. There was traditional homicides which most often result from traumatic injuries and
no shotgun present in the house or the car. A suicide note to the son was the classification problems which can arise including a review of the Davis
located in the house. guidelines written in 1978 and the judicial outcome differences.
Initially, the location of the gunshot wound made this suspicious for Homicide is most often defined as death at the hands of another.
a homicide. He was shot behind the right ear. Autopsy procedures When traumatic injuries are the cause of death, the manner of death is
included photography, gunshot residue, X-Ray, toxicology, and visceral usually obvious and clear. However, when the traumatic injuries do not
dissection. The X-Ray of the decedent’s head showed unusually extensive cause death and one must rely on the investigation for the manner of death,
fracturing of the cranium and numerous pellets in the cranial cavity. the case must be critically evaluated. If a physical altercation takes place
Close examination of the gunshot wound revealed a hard contact, immediately prior to death or the development of signs and symptoms
stellate, penetrating wound of the head, of unusual dimension for a such as chest pain begin during or within a short time after the assault, then
handgun, located above and behind the right ear. A muzzle mark was temporal relationship between the assault and the death cannot be ignored
difficult to distinguish because of the numerous stellate tears radiating and a manner of death of homicide must be considered. Likewise, if no
from the entrance perforation. The parietal bone of the skull had a contact between the decedent and the assailant(s) occurs, but there is a
perforation with fouling beneath the periosteum. The right parietal and significant implicit threat to safety (Davis guidelines), one must also
occipital lobes were perforated by multiple pellets, partially dividing the consider homicide, as again, the temporal relationship cannot be ignored.
midbrain from the cerebral hemispheres. The pellets also perforated the Sixteen cases were reviewed from the state of Maryland from the
left cerebral hemisphere, pulpifying the brain parenchyma. years 1990 through 2006 where death was determined to be the direct

result of a struggle/assault or the result of a significant implied threat. All the point of exit. Associated findings include hemorrhagic foci along the
of the cases were classified as homicides on the death certificates. None wound tract, scattered foci of subarachnoid hemorrhage, acute blood
had any traumatic injuries listed on the cause of death line or as throughout the lateral, third, and fourth ventricles, air within the left
contributory to the cause of death although some did have minor temporal horn and a 1 to 2 millimeter thick acute subdural hematoma
lacerations, contusions, and abrasions. Of the 16, three (19%) were along the right fronto-temporal convexity.
female. Eight (50%) were African American. The ages ranged from 15 The decedent was operated on immediately. The retained portion of
years to 89 years with a mean age of 55 years. Most of the causes of death pool cue was 16.8 centimeters in length and 1.4 centimeters in diameter.
were cardiac in nature including cardiac arrhythmias, coronary artery The distal end of the pool cue was intact with a blood stained disrupted
disease, hypertensive changes, congenital anomalies, aortic dissection, white collar, 2.5 centimeters from the distal end. Dried blood and strands
and coronary artery tunneling. In addition, one case of ruptured berry of attached hair were present on the cue up to approximately 4 centimeters
aneurysm was noted. Toxicology was negative for ethanol in 12 of the 15 from the distal end. The proximal end was uneven and broken off. The
cases (80%) cases and negative for illicit drugs in ten out of 13 (77%) remaining portion of the pool cue was obtained from law enforcement and
cases in which drugs were tested. Of the positive cases, cocaine and consisted of a traditional wooden stick with a broken distal end that
morphine were the illicit drugs that were identified. Cocaine was detected matched the removed segment.
in all three cases with morphine additionally detected in one of the three. The findings at autopsy included a surgically altered left parietal
Cocaine was listed as a contributing cause of death on the death certificate scalp defect, and discrete foci of subscalpular hemorrhage at the points of
in all three cases. entry and exit of the object through the skull. The oval left craniotomy
In 15 of 16 cases (94%), there were physical altercations between at window had a central round metal surgical device covering a 2 centimeter
least two individuals. Of these, four (27%) were known to use a blunt round defect with inward beveling. A 2.2 centimeter, somewhat square-
object other than a fist such as a baseball bat (2), walking cane, or walker. shaped, fractured defect with partial outward beveling was within right
In one case a blunt object (plank) was thought to have been used but was temporal bone.
not confirmed through investigation. One individual was held at gunpoint Small round defects are in the frontal bone and dura due to the
but a physical struggle never ensued prior to loss of consciousness. In insertion of pressure monitors. Gel foam and subdural hemorrhage were
three (19%) cases no injuries, even minor, were described. The majority in the left parietal region and associated with a 3.0 centimeter sutured
of cases (69%) involved individuals over 50 years of age. The remaining round dural patch. Approximately 20 milliliters of subdural hemorrhage
younger population could be further subdivided into those with congenital was present over the right cerebral convexity. A circular, punched-out,
abnormalities and those with positive toxicology. round defect involved the dura of the right temporal bone and is associated
The judicial outcomes for these cases varied from no charges filed to with the aforementioned temporal bone defect. The calvarium was 2 to 3
full jury trials. The determination of the extent of prosecution for each millimeters in thickness, diffusely.
case was case dependent because of their complexity and nature. In one The brain weighs 1300 grams. It herniated through the right
case there was a bench trial with a conviction, subsequent appeal and temporal bone defect. A 2.0 centimeter circular defect was in the left
retrial with a jury. parietal convexity, and a 1.5 centimeter defect was in the right lateral
Davis Guidelines, Non-Traumatic Death, Homicide temporal lobe. The cerebral hemispheres were symmetrical with marked
swelling characterized by flattened gyri and narrowed sulci. Patchy
subarachnoid hemorrhage was present over cerebral convexities and at the
base of the brain.
G42 Death by Cue in the Parietal Pocket: Following formalin fixation, sections through the cerebral
An Unusual Injury Pattern Caused hemispheres, cerebellum, and brainstem revealed a hemorrhagic wound
by the Use of a Blunt Object track coursing through the left parietal lobe, midline structures including
the thalami, and the right temporal lobe. Extensive hemorrhage and tissue
Valerie S. Green, MD*, Mary L. Anzalone, MD, Dwayne A. destruction were associated with the wound track. Secondary
Wolf, MD, PhD, and Luis A. Sanchez, MD, Harris County Medical hemorrhages are in the rostral brainstem.
Examiner’s Office, 1885 Old Spanish Trail, Houston, TX 77054 Microscopic examination showed parenchymal hemorrhage in the
brainstem, ischemic neuronal change, and hemorrhage with tissue
The goal of this presentation is to stress the importance of obtaining destruction from the section of the wound track. Iron stains on the sections
accurate and detailed investigative information, and keeping an open mind were negative.
about the findings at autopsy. The injury pattern and the weapon may not
Head Injury, Blunt Object, Unusual Pattern
be what you expect them to be.
humanity by continuing to reiterate the need for excellence in forensic
investigation and by alerting the community as to other potential uses of a G43 Pediatric Malignancies Presenting
seemingly harmless recreational object. as Sudden Death: A Case Series
A 27-year-old man died from a penetrating injury of the head with
perforation of the skull and brain by a pool cue. The decedent was Allison S. Nixdorf-Miller, MD*, Tracey S. Corey, MD, Barbara Weakley-
involved in an altercation with another individual that began with an Jones, MD, and William R. Ralston, MD, Office of the Chief Medical
exchange of punches, and ended with the decedent lying on the floor with Examiner, 810 Barrett Avenue, Louisville, KY 40204
a pool cue in his head. Bystanders reported the decedent being
immediately unresponsive following the altercation. Paramedics arrived After attending this presentation, attendees will learn how pediatric
and used a bolt cutter to cut the pool cue, leaving a portion remaining in malignancies, though rare, may present as sudden death. Careful
the decedent’s head. The decedent was then transferred to a local hospital examination of the history and physical findings will aid in the ultimate
where he remained in critical condition throughout his 8- day hospital stay. cause of death.
Computed tomography of the head revealed a tubular piece of This presentation will impact the forensic community and/or
foreign material embedded into the skull with acute fractures in the left humanity by aiding in better understanding of pediatric malignancies in
parietal bone, at the point of entry. The wound tract extended through the sudden death.
left parietal lobe, crossing the midline and traversing the thalami. Acute The goal of this presentation is to review causes of sudden death due
fractures were seen in the squamosal portion of the right temporal bone at to previously undiagnosed malignancies in the pediatric population from

1994 to 2006 at the Office of the Chief Medical Examiner in Louisville, age group, with cancer being second. Leukemia is the most common
Kentucky. malignancy in children between the ages of 0-19, followed closely by
Five deaths due to malignancies in children between the ages of five central nervous system malignancies. These constitute the two most
months and fourteen years were identified during this time period. Two common causes of cancer deaths in this age group. Most malignancies
Wilm’s tumors, a T-cell mediastinal acute lymphoblastic lymphoma, and are diagnosed by classic signs and symptoms, failure to thrive, weight loss,
two acute myeloblastic leukemias are listed as the causes of death. None fatigue, feeling poorly, and autopsies on these patients, when requested,
of the five cases reported had a previous diagnosis of malignancy prior to are undertaken in the hospital setting with a known or suspected diagnosis.
death. In fact, one case (AML M5) was thought to be a victim of child In the five cases presented, preceding symptoms did not lead to a timely
abuse due to the physical findings of bilateral black eyes. diagnosis. Sudden death is a rare, unfortunate presentation of pediatric
Cases 1 and 2: Unlike death in the case of Wilm’s tumor due to malignancy.
intraperitoneal hemorrhage reported by Somers et al, the children in both Sudden Death, Malignancy, Pediatric
of these WIlm’s tumor cases of died as a result of pulmonary tumor
emboli. A five-year-old girl followed closely by her family physician for
mild developmental delay was participating in class activities and was
thought to have fallen asleep in class. She was unarousable, and
G44 An Experimental Comparison of
subsequently it was determined she had died. At autopsy, a 6.5 cm Wilm’s Bone Wound Ballistics of Non-Lead
tumor was found in the upper pole of the left kidney, with extensive but and Lead Bullets
microscopic pulmonary tumor emboli within all lobes of the lungs. The
second Wilm’s tumor was found in a three-year-old boy who had a three Bryce O. Anderson, PhD*, and Tyler A. Kress, PhD, BEST Engineering,
day history of vague abdominal pain and constipation. He collapsed after 2312 Craig Cove, Knoxville, TN 37919; Anne M. Kroman, MA,
being given antacids for his pain. The 8.0 cm tumor within the left kidney University of Tennessee, Department of Anthropology, Knoxville, TN
caused a large tumor thrombus within the inferior vena cava and a tumor 37996; David J. Porta, PhD, Bellarmine University, Department of
embolus with occlusion of the right ventricular outflow tract and pulmonic Biology, 2001 Newburg Road, Louisville, KY 40205; and John C.
trunk. Hungerford, PhD, University of Tennessee, 208 ESH, Knoxville,
Case 3: A ten-year-old boy presented to his primary care doctor five TN 37996
times in the three months preceding his death with complaints of fever,
cough, wheezing, and neck swelling. He was diagnosed at the last visit as After attending this presentation, attendees will gain an
having pneumonia with a widened mediastinum. That evening he began understanding of how the increasingly prevalent use of non-lead bullets
gasping for air, became cyanotic, and collapsed. At autopsy a 470 gm, affects forensic examination and investigation.
22.0 cm mediastinal mass completely encased the aortic arch and great This presentation will impact the forensic community and/or
vessels, trachea, anterior pericardial sac and hilum. The superior border of humanity by increasing knowledge of wound ballistics extended to the
the mass was the thyroid gland. Immunophenoptying confirmed a T-cell non-lead bullet trajectory through results from experimental impact
mediastinal acute lymphoblastic lymphoma. In this case no other organs biomechanics testing.
were involved. In this work a new type of small arms ammunition is evaluated to
Case 4: A 14-year-old girl with a three week history of headache, determine its capability of producing wound trauma. This new
abdominal pain, extreme fatigue and fevers, was brought to the emergency ammunition dispenses the toxic lead core of conventional bullets in favor
room in full arrest. She had been seen in the ER three times in the week of a non-toxic pressed tungsten and tin powder core. The testing involved
prior to her death with the above listed symptoms and given a clinical firing rifle and pistol caliber tungsten tin and lead core bullets against real
diagnosis of pharyngitis with a suspected etiology of infectious porcine femurs encased in ballistic gelatin. The lead bullets were used to
mononucleosis. At autopsy a large intracerebral hemorrhage was found, establish a benchmark of performance for the tungsten tin bullets to be
with petechiae in all visceral organs. In addition to massively enlarged measured against. Various metrics such as penetration depth and bone
visceral lymph nodes, leukemic infiltrates were found within the spleen, fragment weight were recorded.
liver, heart, adrenals, and brain. Immunohistochemical stains performed The specific cartridge calibers used in the testing were the 9mm x
on the paraffin embedded tissue confirmed the diagnosis of acute 19mm (Luger) and the 5.56mm x 45mm (5.56 NATO). The specific bullet
myeloblastic leukemia. types evaluated were the semi-jacketed soft point with a brass enclosed
Case 5: A five-month-old boy presented to an outlying hospital with base. The bullet weight of the 9mm projectile was 124 grains and the
a two day history of gasping for air, bloody emesis, lethargy, and bullet weight of the 5.56mm projectile was 60 grains. The ratio of
decreased urine output. He rapidly deteriorated in the emergency room, tungsten powder to tin powder was set by weight at 68% W and 32% Sn
and was brought to a local hospital where he was pronounced dead. A for a net density nearly identical to lead. This resulted in the tungsten tin
history of abuse or neglect by the family was suspected due to severe bullets being the same shape, size, and density as the lead bullets.
bilateral periorbital ecchymoses, and multiple additional contusions. After Ordnance gelatin powder was mixed 10% by weight according to
his death, laboratory results revealed his white count to be 269,000. At accepted standards to replicate within 3% the penetration depth measured
autopsy, small bowel intussusception with resultant bowel necrosis was in living swine leg muscle as established by Fackler (1985). The gelatin
identified, with an extensive leukemic infiltrate. Ensuing disseminated was molded into a rectangular block with a rounded front face. The
intravascular coagulation led to petechiae and the large periorbital overall dimensions of the block were 24” long, 8” wide, and 16” high and
ecchymoses, as well as extensive subarachnoid hemorrhages. Leukemic required 36 liters of water and 4 kilograms of gelatin powder to
infiltrates were found within the pericardial sac, liver, kidneys, manufacture. The bones were mounted upright approximately 4” behind
leptomeninges, pancreas, spleen, gastrointestinal tract, and lung leading to the front face. The blocks were maintained at 39º F for at least eight hours
acute pulmonary crisis. Immunophenotyping revealed an acute monocytic prior to and during the shot. The ballistic gelatin block was mounted on a
leukemia (M5). table 10’ away from the muzzle of the firearm in accordance with FBI
These cases correlate with one recent paper in which Wilm’s tumor ballistic testing protocol. Three separate 0.177” BB’s were fired into each
and white cell malignancies were the most common malignancies ballistic gelatin block to verify acceptable block density.
presenting as sudden death in the pediatric age group. These findings Four combinations of bullet type were evaluated and three shots of
differ from another paper, which found that tumors, malignant or benign, each combination were made. The tungsten tin pistol bullets had a mean
involving the central nervous system and heart were most common in their velocity of 1035 ft/s and a total mean penetration depth of about 14.5”
case series. Accidents are the most common cause of death in the pediatric with a mean distance of 9.12” beyond the bone. There were

approximately 180 grains of bone fragments generated by the W-Sn bullet G46 The Role of Postmortem Cardiac Enzymes
impact. The lead pistol bullets had a mean velocity of 1048 ft/s and a total
mean penetration depth of about 13” with a mean distance of 6.78” beyond
in the Diagnosis Acute Cardiac Deaths
the bone. There were approximately 73 grains of bone fragments
Nick I. Batalis, MD*, and Bradley J. Marcus, MD, Christine N.
generated by the Pb pistol bullet impact. The lead rifle bullets had a mean
Papadea, PhD, and Kim A. Collins, MD, Medical University of South
velocity of 2792 ft/s and a total mean penetration depth of about 6” and
Carolina, 165 Ashley Avenue, Main Hospital, Suite 281, PO Box 250108,
went a mean distance of 1.08” beyond the bone. There were
approximately 287 grains of bone fragments generated by the Pb rifle
bullet impact. The tungsten tin rifle bullets had a mean velocity of 2843 After attending this presentation, attendees will have a greater
ft/s and a total mean penetration depth of about 16” with a mean distance understanding of biomarkers of acute myocardial injury and their role, or
of 10.33” beyond the bone. There were approximately 266 grains of bone lack thereof, in the postmortem diagnosis of myocardial infarction. The
fragments created by the W-Sn rifle bullet impact. information presented here will help guide the investigations and autopsies
It was found that the performance of the W-Sn pistol bullets was in cases of suspected acute cardiac deaths.
closely similar to that of the Pb pistol bullets, but the W-Sn bullets created Sudden deaths due to myocardial infarction compose a large
a higher mean collective weight of bone fragments than the Pb pistol percentage of the workload of investigators, coroners, and forensic
bullets did. The W-Sn rifle bullets exhibited much deeper post-bone pathologists and others whose work involves death investigation. This
penetration depth than the Pb rifle bullets, although the mean collective presentation will impact the forensic community and/or humanity by
bone fragment weight was approximately the same. It was concluded that aiding these workers in the approach and workup of suspected acute
there was essentially no difference between the W-Sn and Pb pistol bullets cardiac deaths. While biomarkers of myocardial damage may have some
but that the W-Sn rifle bullets would create a much deeper permanent utility in the diagnosis of acute cardiac deaths, they should not be used
cavity than Pb rifle bullets. The mechanism of this deeper penetration exclusively to make the diagnosis. As deaths certified due to myocardial
depth was attributed to the resistance to fragmentation of the W-Sn bullet infarction occasionally incite legal battles involving employers and
in hard and soft tissue. treating physicians, it is of the utmost importance to correctly classify
Reference: these deaths and not simply rely on a single or series of biological markers.
1 Fackler, M.L., Malinowski, J.A.: The Wound Profile: A Visual Method In addition, performing routine postmortem markers of myocardial
for Quantifying Gunshot Wound Components. J. Trauma, 25 (6) : 522- damage can be costly and may consume resources that could be better
529, 1985. utilized on other testing or equipment.
Sudden cardiac deaths due to myocardial infarction constitute a large
Bone Wound Ballistics, Non-Lead Bullet, Ballistic Gelatin
percentage of the caseload for death investigators, coroners, and forensic
pathologists. While sometimes one has a high level of suspicion of a
myocardial infarction at autopsy, it is only by finding a thrombus or seeing
characteristic gross or microscopic morphological changes in the
myocardium that one can definitively make this diagnosis. Because of this,
researchers continue to seek out a more sensitive method of determining
acute myocardial damage. For years, treating clinicians have been able to
G45 Model Protocol for Forensic Medical measure serum levels of proteins and enzymes normally contained within
Examination of Victims of Trafficking the myocardium. Increased serum levels of these markers have been
in Human Beings shown to be highly sensitive and specific for myocardial damage. The
preferred markers have changed over time, but currently three of the more
reliable markers include troponin (isoforms I and/or T), total creatine
Djordje M. Alempijevic, MD, PhD*, Dragan S. Jecmenica, MD, PhD,
kinase (CK), and CK-MB a more specific isoform of CK.
Snezana Pavlekic, MD, PhD, Slobodan N. Savic, MD, PhD, and
Various authors have investigated the role of postmortem cardiac
Branimir V. Aleksandric, MD, PhD, Institute of Forensic Medicine,
markers at autopsy and have had varying results. Some of the studies
Faculty of Medicine, University of Belgrade, 31a Deligradska Street,
include a correlation of postmortem and antemortem levels of cardiac
Belgrade, 11000, Serbia
markers, a comparison of postmortem serum and pericardial fluid levels,
After attending this presentation, attendees will understand basic and several have attempted to determine if postmortem levels are
health issue related to trafficking in human beings (THB), in particular significantly higher in deaths due to myocardial ischemia than due to other
these related to physical trauma, sexual violence, and substance misuse. causes of death. To date, though, there has not been a standardized study
The attendees should also become familiar with advantages of early determining postmortem levels of cardiac markers from serum of different
medicolegal examination of THB victims. anatomic locations.
This presentation will impact the forensic community and/or The current study included ten decedents, five with histories
humanity by giving arguments and advocate for necessity of medicolegal suspicious for myocardial infarction and confirmed at autopsy, and five
health-care for THB victims that is mostly being neglected in existing control subjects who died of non-cardiac disease. For each decedent, six
local anti-trafficking policies and intervention protocols. A positive different samples (pericardial fluid and serum from the femoral veins,
example of Istanbul Protocol use in evaluation of torture victims would subclavian veins, aorta, left cardiac ventricle, and right cardiac ventricle)
serve as an illustration of good practice in sound related field. were drawn and tested for CK, CK-MB, and troponin-I (TnI). Three main
The presentation will discuss the experience gained through the conclusions were drawn; the levels of cardiac markers from the control
trainings for medical and judiciary professionals in countries of Western group are significantly higher than the reference range for living patients;
Balkans (Serbia, Bosnia and Herzegovina, and Croatia). A protocol there are significant differences in the levels are cardiac markers between
developed for forensic medical examination of victims of THB will be serum samples from different anatomic locations; and only three cardiac
discussed in detail. It is recommended that the agenda of anti-trafficking marker/anatomic site combinations were significantly different between
policies needs to be redrawn to include forensic medical assessment of the control and study groups (femoral/TnI, right ventricle/CK-MB, and
victims for legal purposes. pericardial fluid/CK-MB). These complete findings, a review of the
Human Trafficking, Forensic Medical Examination, Injury literature, and a discussion about the role of postmortem cardiac markers
in detecting acute myocardial damage will be discussed.
Cardiac Enzymes, Acute Myocardial Infarction, Death

G47 Histologic Evidence of Repetitive interaction with the cause of death may reveal recent trends in suicide in
the Maryland population.
Blunt Force Abdominal Trauma Methods: The Office of the Chief Medical Examiner (OCME) for
in Three Pediatric Fatalities the State of Maryland oversees all suicidal deaths occurring in the state.
From January 2003 to December 2005 there were 1477 suicidal deaths in
Daniel W. Dye, MD*, University of Arkansas for Medical Sciences the state. Cases within the time frame were extracted from the OCME
Department of Pathology, 4301 West Markham, Slot #517, Little Rock, database, each case was reviewed, and data were analyzed for age,
AR 72205; and Charles P. Kokes, MD, Arkansas State Crime ethnicity, cause of death, county of residence, history of depression and/ or
Laboratory, 2 Natural Resources Drive, Little Rock, AR 72211 previous suicide attempts, and whether or not there was a suicide note and
of what type. Of all cases, 800 (54.2%) had a complete autopsy, 264
(17.9%) had a partial autopsy, 56 (3.8%) were inspected at the OCME, 300
importance of retaining sections of the retroperteneum for microscopic
(20.3%) scene inspections in respective counties, and 57 (3.9%) were
examination.
approvals (cases were not examined at the office, death certificates were
signed by the certifying physician and co-signed at the OCME office).
humanity by increasing awareness of recognizing certain patterns of
Results: Men were more likely to commit suicide (80% of the cases
fibroblastic proliferation and reactive vasculature encountered if proper
versus 48.4% of the Maryland population), and were slightly younger
sections are taken in cases of repeated child abuse.
(45.7 +/- 18.7 years of age) than women (46.5 +/- 16.9 years). Caucasians
In cases of fatal child abuse, the discovery of external blunt force
were over-represented (79.1% of cases and 59.8% of the population) while
trauma, skull fractures, subdural hematomas, abdominal hemorrhage, as
the remaining racial or ethnic groups had fewer suicides than the overall
well as retinal hemorrhages are all well described in the pediatric and
Maryland rate. The rate of suicide was highest among the elderly. While
forensic literature. The gross findings at autopsy, when taken into
11.4% of the population of Maryland are over 65 years of age, in this study
consideration with scene investigation and interviews with caregivers,
17.4% were in that age group. The three most common causes of death
point to a clear manner and cause of death in many cases. In such cases,
were gunshot wounds (46.7%), asphyxia (26.4%) and drug intoxication
the discovery of changes attributable to older abusive injuries helps
(13.5%). Less common were blunt force injuries (5.5%), carbon
support a conclusion of death due to inflicted trauma. Three cases of fatal
monoxide intoxication (3.8%), sharp force injuries (2.4%), and rarely
child abuse in which acute blunt force abdominal trauma was the cause of
other methods (such as electrocution) or more than one method (such as
death and the manner of death was homicide are presented. In each of
gunshot wound and hanging) were employed. Suicides were fewer than
these cases, careful examination with proper sectioning and microscopy of
expected in Baltimore City per capita and other large metropolitan areas,
select abdominal tissues revealed the presence of fibroblast proliferation,
in part due to the different racial and ethnic mix in urban versus rural
increased vascularity, and hemosiderin laden macrophages indicating
populations. The cause of death was influenced by gender [men were
abdominal injuries older than the acute, fatal blunt force trauma. Iron and
nearly ten times (627 cases men versus 63 cases women) as likely to use
trichrome stains were used to highlight hemosiderin and fibrosis in all
guns, whereas drug intoxication was almost equally distributed between
three cases; however the recognition of a fibroblast proliferation and a
the genders], age (there were no suicides by sharp force injuries in the
reactive vascular pattern was best seen on routine hematoxylin and eosin
adolescent group, where the most common cause of death was asphyxia
stains. These findings at autopsy, along with good investigative evidence,
due to hanging) and racial/ethnic background (asphyxia was the most
were helpful in establishing the diagnosis of chronic physical abuse.
common cause of death among Asian [48.6% of all suicides in this group]
Fibroblast, Proliferation, Child Abuse and Hispanics [45.2%], while gunshot wounds were the most common
cause in African Americans [49.3%} and Caucasians [47.8%]).
Conclusions: A three year cross sectional study of suicide in
G48 Death by Suicide in Maryland: Maryland confirmed known risk factors (male gender, Caucasian race, and
A Cross-Sectional Study, 2002 to 2005 old age) and also found association between these risk factors and the
cause of death (suicide method). These associations may be useful in
targeting efforts at prevention.
Jonrika M. Malone, MD*, Ana Rubio, MD, PhD, Corey Tayman, and
David M. Fowler, MD, State of Maryland Office of the Chief Medical Suicide, Cause of Death, Risk Factors
After attending this presentation, attendees will recognize the impact G49 Can Mandibular Fractures
of suicidal deaths among various age groups, races, and between genders,
allowing them to better understand that suicide as a manner of death is not Occur in Non-Oral Contact
isolated to the young or the old. Shotgun Wounds of the Head?
humanity by bringing to the forefront the significance of suicide in overall Edward L. Mazuchowski, MD, PhD*, Office of the Armed Forces
mortality, detailing the different causes of death in diverse groups, and Medical Examiner, 1413 Research Boulevard, Rockville, MD 20850;
drawing epidemiologic data from the entire state of Maryland, Mary G. Ripple, MD, Office of the Chief Medical Examiner, 111 Penn
representing the population as a whole. Street, Baltimore, MD 21201; Craig T. Mallak, JD, MD, Office of the
Introduction: An estimated 5,600,388 individuals called the state of Armed Forces Medical Examiner, 1413 Research Boulevard, Rockville,
Maryland home in 2005 according to the United States Census Bureau. MD 20850; and David R. Fowler, MD, Office of the Chief Medical
The ratio of men to women is nearly 50-50, with 48.4% and 51.6% Examiner, 111 Penn Street, Baltimore, MD 21201
respectively. With a population increase of 5.7% from 2000, the state is
steadily growing, as is the rest of the country. After attending this presentation, attendees will be aware of the
The overall rate of suicide in the state of Maryland is 8.8 per 100,000 characteristics of contact shotgun wounds of the head that do not directly
populations per year (about 493 deaths per year). Although age (both involve the oral cavity, lower face, or mandible.
extremes of life with adolescents and the very old being at higher risk), This presentation will impact the forensic community and/or
race (Caucasians being overrepresented) and gender (males more likely to humanity by demonstrating how mandibular fractures can occur with non-
complete suicidal deaths) are known risk factors for suicide in the oral contact shotgun wounds of the head and that these fractures do not
literature, a detailed analysis of these and other risk factors and the imply separate blunt force injury to the mandible.

Contact shotgun wounds of the head most commonly involve the oral G50 A Retrospective Review of
cavity, submental region, temple, or frontal scalp. Although these wounds
are usually suicides, homicides do occur. In all cases, autopsy findings
Youth Suicide in New Mexico
should correlate with the investigation. Additional injury, such as a
mandibular fracture in a contact shotgun wound to the temple region, must Veena D. Singh, MD, MPH*, University of New Mexico Health Sciences
be explained in order to rule in or rule out the probability of separate blunt Center, Department of Pathology MSC08 4640, 1 University of New
force injury. Mexico, Albuquerque, NM 87131; and Jeffrey S. Nine, MD, and Sarah
The files of the Office of the Chief Medical Examiner (OCME) for Lathrop, DVM, PhD, Office of the Medical Investigator, MSC11 6030, 1
the state of Maryland were reviewed for shotgun wounds to the head from University of New Mexico, Albuquerque, NM 87131
January 1995 through June 2006. Review showed 215 total shotgun to the The goal of this presentation is to provide a brief overview of youth
head cases with available records. Of those 215 cases, 133 were contact suicide in the United States; discuss one model of suicide and suicidal
shotgun wounds to the head. According to available information, the behavior; provide an overview of youth suicide in New Mexico including
location of the contact shotgun wounds included 26 cases (20%) that were demographics, decedent characteristics, and circumstances of death; and
intraoral, 49 cases (37%) with contact under the chin, 52 cases (39%) with discuss possible interventions to prevent youth suicide, based on the New
contact at the level of the nose or above and 6 cases (4%) with contact at Mexico experience.
the side of the face at the mandible. Of the 52 cases with contact at the This large-scale study on suicide in children and adolescents will
level of the nose or above, ten cases (19%) had mandibular fracture. Three impact the forensic community and/or humanity by demonstrating
of the ten cases (30%) were determined to be homicides and seven of the increasing understanding of this large (and growing) public health
ten cases (70%) were determined to be suicides. Location of the shotgun problem. With a solid understanding of the circumstances surrounding
wounds were right side of the head at the temple (3 cases), middle of youth suicide, it may be possible to predict, and hopefully prevent, future
forehead (2 cases), between the eyes (1 case), right eye (1 case), left eye cases of child and adolescent death.
(1 case), nose (1 case), and back of the head (1 case). Introduction: Although a suicidal behavior in children and
The gauge of the shotgun was known for seven of the ten cases with adolescents is a major public health problem, large-scale research on
mandibular fractures. Six of the shotguns were 12 gauge (60%), one was suicide in this population is uncommon. Analysis of the methods and risk
a 20 gauge (10%), and three were unknown (30%). Of the 42 cases that factors over time may permit more focused planning for suicide
did not produce a mandibular fracture, 21 were 12 gauge (50%), nine were prevention programs.
20 gauge (21.5%), three were .410 (7%) and nine were unknown (21.5%). Methods: All pediatric suicide cases referred to the New Mexico
In a previous study by Harruff comparing the injury produced by Office of the Medical Investigator from 1979 to 2005 were reviewed. For
different gauge shotguns, 20 of 89 cases (22%) of contact shotgun wounds the purpose of this study, pediatric deaths were defined as deaths in the age
of the head were located at the temple, scalp (above the level of the ears) group of one day up to and including 17 years of age. The autopsy, field
or forehead. In these 20 cases, there was no reported difference in the investigator, and police reports were examined in detail regarding age, sex,
internal features of the damage caused. The internal injuries included location, and method of suicide; presence of suicide notes; and any
extensive fractures of the skull and maceration of the brain without injury contributing psychologic factors or stressors.
to the facial structures. In contrast to the internal injuries, 12 gauge Results: There were 433 pediatric suicides during the study period,
shotguns produced extensive external lacerations while larger gauge ranging in age from nine to 17; the age-adjusted suicide rate was 4.8 per
shotguns produced lacerations primarily at the site of contact. In the 100,000 with a male-female ratio of 3.8:1. There was no significant
current study, the 12 gauge shotgun on average caused more extensive change in gender, race, or age over time; however, there was a significant
lacerations when compared to the larger gauge shotguns. However, both increase in the number of suicides per year. Greater numbers of suicides
the 12 gauge and 20 gauge shotguns were able to cause a mandibular were observed during the months of December and February as compared
fracture. to other months. Psychologic stressors were identified in some cases, such
In contact shotgun wounds of the head, fragmentation of the skull is as psychiatric problems (46%) and chronic family problems including
caused by the increase in internal pressure of the skull due to the charge of physical or sexual abuse (32%). There was a history of previous suicide
the shot and the increase in pressure caused by the rapidly expanding gas attempt or suicidal ideation in 28% of the cases. Most of the suicides
from combustion of the propellant. It is postulated that this force is (76%) occurred in the victim’s home or yard, and 25% left a suicide note.
directly transmitted from the temporal bone to the mandible resulting in In 26% of cases alcohol or other drugs were detected postmortem;
fracture. toxicology testing was more often positive in decedents over the age of 15
This report emphasizes that mandibular fractures can occur with and only rarely positive in decedents younger than 15. Gunshot wound
contact shotgun injuries at or above the level of the nose and that these was the most common method overall (58%), followed by hanging (30%),
injuries can occur regardless of the gauge of the shotgun. It is paramount overdose (5%), and other (including drowning, jumping from height, and
not to report separate blunt force injury as the cause of the mandibular blunt force vehicular trauma, 5%). Of note, hanging deaths were
fractures without further investigation and autopsy findings supporting significantly more common among Native Americans as well as those
those conclusions. If there are allegations or concern of blunt force injury, decedents younger than 13. In addition, there has been a statistically
then autopsy should show separate points of impact on the skin of the jaw significant decrease in deaths by firearm and a concurrent significant
area as evidenced by contusion, abrasion, or lacerations. increase in hanging deaths.
Contact Shotgun Wound, Head, Mandibular Fracture Conclusions: Although the age-adjusted suicide rate is markedly
higher in New Mexico than nationally, the trends in the regional
population are similar to those seen nationally. The authors therefore
present their findings in this 26-year retrospective study to increase
understanding of pediatric suicides. With a solid understanding of the
circumstances, it may be possible to predict, and hopefully prevent, future
cases of child and adolescent death.
Adolescent, Death, Suicide

G51 A Homicide Due to a The trigger mechanism of the bomb was connected in turn to an
electric blasting cap; such a setup affords subsequent detonation of the
“Disguised Mail Bomb” device. The package was a typical “disguised bomb” with the explosive
contained in an innocuous appearing container.
Margherita Neri, MD*, Irene Riezzo, MD, and Emanuela According to the autopsy findings and histological data, death was
Turillazzi, MD, PhD, Department of Forensic Pathology attributed to primary blast injury (PBI). The primary blast injury arises
University of Foggia, Viale Pinto 1, Foggia, 71100, Italy from the overpressure of the wave that crushes the body and damages the
Attendees will learn about a case of a homicide due to blast injuries air containing organs directly, and other organs indirectly.
from a bomb disguised as a package in the mail.” The goal of this study The investigation of explosion-related fatalities can be a substantial
is to underline the importance of the cooperation between the forensic challenge in forensic casework. Determining whether the mode of death
pathologists and the forensic laboratory section in cases of death due to is suicide, homicide, or accident in such cases can present an especially
explosion and the importance of the use of confocal microscope to identify difficult task to the forensic pathologist.
the exact origin of the material present in skin samples. Therefore the detailed forensic investigation performed with
This presentation will impact the forensic community and/or autoptical and histological findings, and the study of metal fragments
humanity by demonstrating the importance of histopathology in present in the skin using a confocal type laser profile microscope at the
explosive-related death and the application of confocal microscope to same time the analysis of the bomb package permitted the exact
support investigation to clarify the circumstances surrounding the death. reconstruction of the homicidal explosion.
Explosive-related deaths fall into three types: accident, homicide, Blast Injury, Confocal Microscopy, Disguised Bomb
and suicide. Homicidal explosive deaths, although rare, are often
associated with acts of terrorism.
An explosion following the opening of a mail package addressed to
his father wounded a young Italian man. The boy was quickly taken by G52 Ocular Study in Pediatric Deaths
ambulance, but was declared dead before he arrived at the hospital. At the
crime scene, along with biological material, several small and large pieces Under Two Years of Age With Novel
of yellow mail paper, metal, and glass fragments, and numerous shotgun Findings in the Retina of Children
pellets were collected. Who Died of Sudden Infant Death
Prosecutor arranged the autopsy on the body to clarify the exact
mechanism of death and the correlation with the type of bomb. While Syndrome (1994 – 2004)
undressing the body a gunshot pellet was discovered, but a preliminary
total body radiographic examination exhibited no radiopaque metallic Jorge L. Arredondo Marin, MD*, John R. Fernandes, MD, and Chitra
pellets within the body. A complete autopsy was performed. A large Rao, MBBS, McMaster University, Department of Pathology and
number of abrasions, burns, and contusions were present on the face, the Molecular Medicine, Regional Forensic Pathology Unit, Hamilton
anterior part of trunk, and upper and lower limbs. Additional solid gray Health Sciences Centre, 237 Barton Street East , Hamilton, Ontario L8L
metal fragments and white-gray granular material were deposited 2X2, Canada
throughout the facial and trunk injuries. Eyebrows, eyelashes, head and After attending this presentation, attendees will learn of novel
trunk hair, were singed. Blast injury was present to left hand with skin findings of the retina of children who die with the diagnosis of SIDS.
loss, and to right hand with skin and bone loss. The posterior surface of This presentation will impact the forensic community and/or
the body was not injured. The internal examination showed confluent humanity by presenting novel findings which are easily demonstrated on
bruising of lungs and a band-like pattern related to the overlying ribs, routine histologic processing will aid in the understanding of a component
bruising of the abdominal wall, both the skin and the underlying muscles, of the pathophysiological process in children who die of SIDS.
900 cc of blood in the peritoneal cavity; extensive bruising of the gut and Pediatric autopsies are considered one of the most difficult areas in
the mesentery; and lacerations of liver and spleen were present. Forensic Pathology, due to the small stature, different physiology, and the
Examinations of other organs were unremarkable; no fractures of ribs and increased vulnerability of children to abuse.
sternum were detected. Routine histological investigations, applying Sudden infant death syndrome (SIDS) is defined as the sudden death
hematoxilin and eosin staining, were performed on all organs samples. of an infant less than one year of age that remains unexplained after a
Lungs sections showed alveolar ruptures, thinning of alveolar septae, and thorough case investigation, including performance of a complete autopsy
enlargement of alveolar spaces, subpleural and intraalveolar hemorrhages, with negative results, examination of the death scene, and review of the
venous air embolism and soot aspiration in smaller bronchi. Fat red clinical history. SIDS is the leading cause of infant death beyond the
staining, used to document the occurrence of pulmonary fat embolism, neonatal period, mostly between one month and four months. Although
was negative. The air embolism were confirmed by the positive results to the etiology largely remains unknown, many factors have been associated
the immunohistocemical stain for fibrinogen and CD 61 (platelet including metabolic, cardiac, and prone sleep position.
glycoprotein III a). Liver and spleen sections showed intraparenchimal Differential diagnosis includes Shaken baby syndrome (SBS), subtle
diffuse hemorrhages. Samples of soot collected from the skin of face, and accidents, asphyxias, and inflicted trauma. The retinal findings are a key
trunk showed a detachment of the upper epidermal areas, longitudinal part of the investigation specifically identifying areas of retinal
elongation of the cells and nuclei of the basal cells. The cutaneous heat hemorrhage.
injuries were confirmed by the positive results by the The purpose of the study was to describe ocular findings in children
immunohistochemical dye for HSP 90-70-27. Except for brain edema and under two years of age who died suddenly.
generalized haemostasis, examination of other organs was unremarkable. One hundred two forensic pediatric cases of deaths under two years
The skin samples were also examined with a light microscope, in old were selected from the Regional Forensic Pathology Unit of Hamilton
transmitted bright field illumination and phase contrast mode, and with Ontario, over a period of 11 years (1994 – 2004).
confocal microscope using auto-fluorescence emission of skin and metal Forensic reports were analyzed and data such as age, sex, cause of
deposited on corneum stratum and fixed in lower layers of epidermidis; a death, and postmortem intervals were obtained.
three-dimensional reconstruction of samples was performed. Fragments A grossing and microscopic protocol for eyes was created including
of the mail package were analyzed by Forensic Laboratory Section of description with measurements, fixation, sectioning, photography, and
R.A.C.I.S. (Raggruppamento Carabinieri Investigazioni Scientifiche - systematic histology.
Grouping Scientific Investigations Carabinieri).

Pigs’ eyes were processed with same protocol at different A retrospective search of cases from January 2000 to July 2006 in the
postmortem intervals, as a control for postmortem tissue changes. State of Maryland yielded 24 deaths due to exsanguination from
The majority of the cases (55%) were between one month and six arteriovenous fistulas, arteriovenous grafts, and venous access catheters.
months of age. The most common diagnosis was SIDS (59/102). The age range was from 28 years to 85 years with a mean age of 58 years.
Seventy-two (70.5%) cases showed the presence of cytoid bodies in Fifteen (63%) of the decedents were male. Eighteen (75%) were African
the retina. Cytoid bodies are smooth, rounded, eosinophilic balls that American and six (25%) were Caucasian. Seven access sites (29%) were
measure from 7-15 µm and can mimic red blood cells. They were located arteriovenous fistulas and four (17%) were venous catheters. Ten access
predominantly (90%) at the anterior part of retina involving the internal sites (42%) were arteriovenous grafts. Of these ten grafts, seven (70%)
limiting membrane and nerve fiber layer of retina. Cytoid bodies were were synthetic, two (20%) were made of natural materials, and one (10%)
positive for S100, Synuclein, CD 56, and negative for Glycophorin A (an was comprised both synthetic and natural materials. Exsanguination was
RBC marker). due to erosion of an arteriovenous graft or fistula in 14/24 (58%),
Extramedullary hematopoiesis (EMH) was identified in 35 (34%) dislodgement of a venous catheter in 2/24 (8%), dehiscence of graft site
cases. The most frequent location of EMH was the choroid 29/35 (82%). sutures in 2/24 (8%), infection involving a graft or fistula in 2/24 (8%),
Myeloid and erythroid precursors were confirmed by perforation of an artery following venous catheter insertion in one case
immunohistochemistry (myeloperoxidase and glycophorin A (4%), erosion due to an aneurysm involving a fistula in one case, one
respectively). Electron microscopy verified the presence of neural individual who cut her venous catheter at home presumably with scissors
filaments. for unknown reasons and one individual who pulled out his active dialysis
The changes were not seen with control samples, excluding line from his arteriovenous graft in the dialysis center. The manner of
postmortem artifact as the cause for the findings. death was classified as accident in 11of 24 cases (46%), as natural in nine
This study is the first to demonstrate the presence of extramedullary (38%) and as undetermined in four (17%). Of the 22 of 24 cases tested for
hematopoiesis and cytoid bodies in the retinas of SIDS children. The ethanol, one case tested positive. Of the 13 of the 24 cases tested for
findings suggest a subtle hypoxic component in the natural process in drugs, three (23%) tested positive for illicit drugs. The substances
SIDS. The two cases of victims of Shaken Baby Syndrome did not identified included cocaine and morphine. In addition to these three cases,
demonstrate EMH or cytoid bodies. Other causes of asphyxia show a 60% one decedent had pseudoephedrine intoxication that was considered a
incidence of cytoid bodies and 30% incidence of EMH. SIDS cases did contributing cause of death.
not show retinal hemorrhage. Although the complications related to vascular access sites for
The forensic community may benefit from these observations further hemodialysis are many and varied, the results indicate that death by
aiding in the understanding of the pathogenesis of SIDS. exsanguination is an important risk for patients. Dialysis centers should
SIDS, Ocular Findings, Cytoid Bodies educate patients about this potential and instruct them to periodically look
for signs of fistula/graft compromise including fistula/graft failure,
infection, or aneurysm formation. In addition, dialysis centers should
consider encouraging patients to carry a tourniquet at all times after proper
G53 Exsanguination Associated With Vascular training as to its use. Therefore, if a fistula/graft does erode or perforate,
Access Sites in Hemodialysis Patients one can survive until emergency care can be initiated.
Hemodialysis, Exsanguination, Arteriovenous Fistula/Graft
Donna M. Vincenti, MD*, and Patricia A. Aronica-Pollak, MD, Office of
the Chief Medical Examiner, 111 Penn Street, Baltimore, MD 21201;
Joshua M. Sharfstein, MD, City of Baltimore Health Department, 210
Guilford Avenue, Executive Suite, 3rd Floor, Baltimore, MD 21202; and
G54 Potential Errors in Autopsy Reports of
David R. Fowler, MD, Office of the Chief Medical Examiner, 111 Penn Custodial Deaths Temporally Associated
Street, Baltimore, MD 21201 With Electronic Control Devices:
After attending this presentation, attendees will understand some A Cardiovascular Perspective
principles associated with death secondary to exsanguination from
vascular access sites in hemodialysis patients including the vascular access Mark W. Kroll, PhD*, University of Minnesota, Box 23, Crystal Bay, MN
types, the frequency at which this occurs, associated circumstances under 55323; Dorin Panescu, PhD, St. Jude Medical Cardiac Rhythm
which this occurs, and possible modalities for prevention. Management Division, 705 East Evelyn Avenue, Sunnyvale, CA 94086;
This presentation will impact the forensic community and/or Jeffrey Ho, MD, Department of Emergency Medicine, Hennepin County
humanity by providing a review of exsanguination deaths that are directly Medical Center, 730 8th Street South, Minneapolis, MN 55415; Richard
related to arteriovenous fistulas, arteriovenous grafts and venous catheters M. Luceri, MD, Holy Cross Hospital, 4725 North Federal Highway, Ft.
used for hemodialysis in patients with end stage renal disease. This Lauderdale, FL 33308; Igor R. Efimov, PhD,
information can augment knowledge of this lethal complication associated Washington University, 1 Brookings Drive, St. Louis, MO 63130;
with hemodialysis and thereby reinforce the need for patient, caregiver Hugh Calkins, MD, Johns Hopkins Hospital, 601 North Caroline Street,
and health personnel education and vigilance. Baltimore, MD 21287; and Patrick J. Tchou, MD, Cleveland Clinic
Patients with end stage renal failure requiring hemodialysis have Foundation, 9500 Euclid Avenue, Cleveland, OH 44195
three options for vascular access depending on the severity of their
disease, their vascular anatomy, and their vascular viability. Native After attending this presentation, attendees will have a better
arteriovenous fistulas are the preferred choice for long term dialysis understanding of Electronic Control Devices, such as the TASER®
treatment because of their lower rate of breakdown and infection. device, and how to better perform an autopsy in such cases.
Arteriovenous grafts can also be used for long term dialysis treatment if This presentation will impact the forensic community and/or
the patient’s anatomy is not conducive to the creation of a natural fistula humanity by demonstrating more accurate autopsies where an Electronic
but has a greater risk of infection and clotting. Intravenous catheters are Control Device was associated with a death.
preferably used for a short duration, usually for emergency dialysis or Introduction: Sudden, in-custody death (SICD) events are alarming
while waiting for a fistula to mature. Exsanguination from any of these phenomena that occur numerous times per year in this country. With
vascular access sites is a lethal complication for hemodialysis dependent increasing usage of electronic control devices (ECD), such as TASER®
patients. brand devices by law enforcement, the number of SICD events that are

temporally related to ECD applications is growing. The autopsy in such a G55 Headache and Sudden Death in a Young
case presents a diagnostic challenge to the medical examiner, as there are
no postmortem tests available to detect past electrical applications.
Adult: An Unexpected Finding at Autopsy
As ECD technology is relatively new, medical examiners may not be
fully aware of what these devices are and are not capable of and may, Adrienne Segovia, MD*, and Michelle A. Jorden, MD, Office of the
therefore, be making errors in diagnostic judgment. This study analyzed Cook County Medical Examiner, 2121 West Harrison Street, Chicago,
the probable error rate in assigned causes of death based on a convenience IL 60612
sample population. After attending this presentation, attendees will have gained a basic
Methods: A press search for the years 2001-2005 for cases of an understanding of the different ways humans can contract Taenia solium,
SICD with a temporal ECD association was undertaken and the autopsy the pork tapeworm, and the different diseases that can develop from
reports obtained. infection with this parasite, emphasizing involvement of the central
Sudden death from electrical discharge is caused by the induction of nervous system.
ventricular fibrillation (VF) and generally follows this sequence: (1) pulse A 33-year-old white female presented with a history of severe
disappears immediately, (2) there is loss of physical strength for continued headaches, nausea, vomiting, and dizziness. The headaches, which were
resistance, (3) collapse occurs within 5-20 seconds, (4) a VF rhythm is unassociated with fever, began in February 2006. A work up for
shown on a cardiac monitor, and (5) immediate defibrillation is usually meningitis including examination of cerebral spinal fluid was negative,
successful. Any material failure to appreciate the above facts was scored resulting in a diagnosis of migraine headaches. The headaches and
as an error. accompanying symptoms, however, persisted. Following an episode of
Other errors were counted if the report reflected hypotheses not one of the headaches, she was found unresponsive in bed and was unable
supported by known literature. These included: blaming the ECD for to be resuscitated.
cardiac physical changes, inclusion of a publicity sensitive safe comment Autopsy examination revealed the presence of cerebral edema with
(e.g., “we were unable to eliminate the role” of the ECD), assuming tonsillar herniation. The posterior horns of the lateral ventricles in the
prolonged ECD applications are more dangerous than other restraint temporal region were dilated. The fourth ventricle was dilated and
techniques, claiming that ECDs impair breathing, presumption of a lethal obstructed by a colloidal appearing cystic structure that measured 1 cm in
synergy between stimulant drugs and the ECD, use of the ECD in the maximum dimension. The remainder of the autopsy examination was
“drive stun” mode only since this involves current passing between two unremarkable. Blood cultures were negative, vitreous electrolytes showed
very close electrodes and does not create any major body mass a normal postmortem pattern and were unremarkable, and toxicology
involvement. Finally, the use of the metaphorical “last straw” was scored testing was negative.
as an error. Histologically, the brain showed an intense mononuclear infiltrate
Results: There were 176 SICD events reported over the 60 month composed of lymphocytes and plasma cells that surrounded a
period with a temporal ECD association. Twenty-Seven cases where the homogenous amorphous eosinophilic structure in the ventricle. The
autopsy reports listed the ECD as a contributory or as an “unknown” choroid plexus focally showed a similar intense inflammatory reaction.
factor. As expected, the rate of such reports appears to be growing at 2.6 Ependymitis and mononuclear perivascular cuffing were also present.
per year (r2=.74, p = .06). Autopsy reports were reviewed for these cases The cystic structure seen grossly in the fourth ventricle had a wall that was
and errors were tabulated. The decedents were all male with mean age composed of three layers: an eosinophilic outer cuticle with the grapelike
35.6 ± 10.7 years (median = 32) which is consistent with recently reported appearance, a single layer of subcuticular cells, and a myxoid cytoplasm
SICD data.1 A mean of 3.1 ± 1.2 scored errors per report with a range of containing tubular structures. These findings are consistent with
1-6. This rate was very stable across the study period. A sobering finding intraventricular neurocysticercosis.
was the rate at which “last straw” was mentioned as a linkage in lieu of a Upon further questioning of the family, it was learned that the
scientific mechanism. Scored errors are listed in the following table: decedent had immigrated to the United States from Mexico 12 years ago.
Her family in Mexico owned a restaurant type business where pigs were
Probable Error in Citing the ECD N raised and slaughtered on the property. Prior to her recent complaints of
Time to collapse > 1 minute 21 headache, the decedent had been in good health.
Continued resistance after ECD application 14 Cysticercosis is the most common parasitic disease affecting the
Rhythm other than VF 11 central nervous system. It is endemic in Latin America, India, China,
Southeast Asia, and sub-Saharan Africa. It is estimated that up to 90
Publicity sensitive comments 9
percent of patients with cysticercosis have central nervous system
Failure of immediate defibrillation 7 involvement. Sole involvement of the central nervous system is termed
Drive stun mode 6 neurocysticercosis (NCC). The disease is reported in all age groups, but
Assumed drug-ECD electrocution synergy 6 most cases present in the third and fourth decades. Reliable data regarding
Discharge duration or parity 5 the incubation period are lacking, but it is estimated that months to
“Last straw” metaphor as a mechanism 4 decades can pass between initial infection/exposure and the subsequent
Cardiac damage ascribed to ECD 3 development of neurological symptoms.
Assumed ventilation impairment 2 The pork tapeworm Taenia solium causes the infection. Humans can
be either the definitive host or the intermediate host and thus two different
Conclusions: While uncommon, autopsy reports involving diseases are recognized. Infection with the larval form as would occur
electronic control devices do appear several times per year with material from eating contaminated undercooked meat leads to taeniasis. The larva
errors in the area of cardiogenic etiology. The results of this study suggest hatches in the small intestine and develops into tapeworms. In this
that medical examiners need to familiarize themselves with the time and situation humans are the definitive host because they harbor the adult form
causation elements of electrocution, ventricular fibrillation, and ECD of the parasite – the tapeworm. In contrast, when humans harbor the larval
technology to avoid this in the future. form of the parasite, they are the intermediate host and the disease is called
Reference: cysticercosis. This occurs when T. solium eggs are ingested. Sources of
1 Ho JD, Reardon RF, and WG Heegaard. Deaths in police custody: an eggs include contaminated food and water, fruit, or vegetables fertilized
eight month surveillance study. Annals Emerg Med, 2005;46 (suppl):S94. with contaminated human or pig feces and contact with individuals
harboring the tapeworm and shedding the eggs. The disease may be
Electronic Control Devices, TASER®, Autopsy

contracted from fomites because the eggs are resistant to environmental G56 Sudden Death in Duchenne Muscular
conditions.
In the small intestine the eggs hatch releasing oncospheres. The
Dystrophy With Noncompaction of the
oncosphere penetrates the intestinal mucosa, travels to the pulmonary Ventricular Myocardium: A New
circulation, and is disseminated systemically. The oncosphere, which Cardiomyopathy or a Compensatory
develops into the larval form, may reach several different organ systems,
but seem to have a predilection for the central nervous system, skeletal
muscle, subcutaneous tissue, and eyes. Central nervous system
involvement most commonly involves the parenchyma and may cause Michael J. Caplan, MD*, and Kelly Rose, MD*, Medical University of
seizures. South Carolina, Department of Pathology & Laboratory Medicine, Suite
Involvement in the central nervous system may be extraparenchymal 309, 165 Ashley Avenue, Charleston, SC 29425
affecting the ventricles, subarachnoid space, eyes, and spinal cord. It is The goal of this presentation is to evaluate morphologic changes in
estimated that between ten to 30 percent of patients with NCC have the myocardium critically in order to gain insight into their role in the
intraventricular cysts. Ventricular cysts can be attached to the ependyma pathogenesis of apparent cardiomyopathies. What may appear initially to
or float freely migrating throughout the cerebral spinal fluid pathways. be a primary derangement in cardiac muscle (the definition of
Unlike parenchymal cysts, which are typically multiple, ventricular cysts cardiomyopathy) may in fact be a secondary response to another primary
tend to be solitary and ventricular involvement typically occurs without insult.
accompanying parenchymal cysts. Ventricular cysts are more likely to be This presentation will impact the forensic community and/or
symptomatic than parenchymal cysts. Ventricular cysts can cause humanity by creating an awareness of an abnormal morphologic pattern
hydrocephalus either by blocking the flow of cerebral spinal fluid or by within the myocardium and the spectrum of its association with disease
producing ependymitis with scarring, obstruction, and ventriculitis. states, particularly the muscular dystrophies.
Individuals having involvement of the ventricle most commonly present Noncompaction of the ventricular myocardium (NVM) is a condition
with signs of increased intracranial pressure such as headache, nausea, and describing a rare type of cardiomyopathy believed to be due to an
vomiting. These symptoms are commonly attributed to migraine or interruption in cardiac development. It refers specifically to persistence of
tension headaches. the trabecular network of sponge like cardiac muscle that accompanies
NCC is generally a chronic disease whose natural progression mid- to late embryonic development, during which time the myocardial
includes four stages: vesicular, colloidal, granular/nodular and calcified. blood supply is provided by direct diffusion from the intertrabecular
Symptoms typically develop as the parasite begins to die losing its ability spaces that communicate directly with the cardiac chambers. NVM may
to control host defenses. The ensuing inflammatory response results in occur either as an isolated condition, in association with other structural
degeneration of the larva and the formation of a granuloma. heart derangements, or as part of a syndrome of anomalies. NVM has
Making the diagnosis in a clinical setting can be difficult because the been described as a component of several muscular disorders and
clinical manifestations are variable and nonspecific and depend on the mitochondriopathies, including Barth syndrome, Becker muscular
number and location of cysts and the host’s immune response. Proposed dystrophy, Emery-Dreifuss muscular dystrophy, myoadenylate deaminase
diagnostic criteria incorporate absolute, major, minor, and epidemiological deficiency, myotubular and metabolic myopathies, and with mutations in
criteria. Interpretation of the criteria allows for two degrees of diagnostic the G4.5 and a-dystrobrevin genes (Xq28 chromosome region), with
certainty – definitive and probable. possible X-linked inheritance. However, until quite recently, an
No reliable information is available regarding mortality rates. Large association between NVM and Duchenne muscular dystrophy (DMD) had
autopsy series from endemic areas suggests that the majority of cases are not been realized. This presentation describes a case of sudden death in
asymptomatic making calculation of the true incidence and prevalence the setting of DMD complicated by dilated cardiomyopathy (DCM) in
difficult. It is estimated that 50 million people are infected worldwide. which autopsy revealed a prominent finding of NVM; in doing so, this
The disease carries a high cost in morbidity. In endemic countries NCC study attempts to explore a potential causal relationship between the DCM
may be responsible for 50 percent of adult-onset seizure disorders and and NVM.
those with intraventricular and subarachnoid involvement can develop The deceased was a 21-year-old African-American man with DMD
complications such as vasculitis and hydrocephalus. The annual treatment (wheelchair-bound) and DCM; a recent echocardiogram documented
cost in endemic areas is estimated to be close to $90 million per year. In global hypokinesis with a left ventricular ejection fraction ranging from
the United States, there are more cases of imported NCC than in all other 20-30%. Five days before his death, he presented with an acute
developed countries combined, and the annual treatment cost is estimated exacerbation of congestive heart failure and tricuspid regurgitation. On
at $9 million per year. The disease is generally encountered in the the day of his death, his caregiver called 911 for complaints of profound
southwest United States and among Hispanic immigrants. The increasing weakness; paramedics recorded a mean blood pressure of 65 mm Hg. He
number of reported cases in the United States is most likely due to was transported to the Emergency Department and was administered
increased immigration and travel to endemic areas. The long latent period crystalloid intravenous fluids, which restored his blood pressure to 91/51.
and variable clinical presentations make it go undetected or unrecognized However, despite being stable for the next few hours, he experienced a
clinically. Although autopsy studies suggest that NCC is most commonly witnessed seizure that was followed by a thready carotid pulse, and shortly
an incidental finding, the disease can result in death. NCC should be after, by pulseless electrical activity (PEA). Resuscitative efforts were
considered in the differential diagnosis of calcified, nodular, or cystic initiated and were carried out for approximately 10-15 minutes but were
lesions of the central nervous system. unsuccessful and he was pronounced dead.
Neurocysticercosis, Headache, Central Nervous System At autopsy, the deceased exhibited marked flexion contractures of the
hips and knees and there was extensive fatty replacement of the calf and
psoas muscles. There were unequivocal features of DCM, including a
550-g heart (expected for body weight: 223 g), moderate to marked left
ventricular dilatation and patchy but focally confluent areas of dense white
fibrosis, individually up to 0.6 cm, involving the posterior and lateral left
ventricular walls. In addition, there was marked exaggeration of the
trabeculae carnae within the left ventricular chamber, with numerous
anastomosing trabeculae that imparted a distinctly “spongy” appearance,
particularly at the left ventricular apex. Microscopic cardiac examination

revealed confluent replacement fibrosis and fatty ingrowth within the Occasionally, however, these disorders are associated with sudden death
compact outer myocardial half, while the inner half consisted of an due to pathologic involvement of the heart. These cases are likely to be
anastomosing network of trabeculae forming irregular “staghorn”-like investigated by a forensic pathologist, particularly if the individuals do not
spaces. The cause of death was certified as complications of DCM have antemortem diagnoses. Because of its isolation to the heart and rapid
(associated with NVM) due to DMD. clinical course, giant cell myocarditis is most likely to be diagnosed at the
In late 2005, NVM was described for the first time in a patient with time of autopsy. Indeed, an individual may be asymptomatic and sudden
DMD by a group of investigators in Vienna, Austria. They proposed that death may be the presenting manifestation of the disease.
in the setting of DMD, replacement fibrosis of the compact myocardium This study reports two cases in which sudden death resulted from
following myocyte loss is the principal pathologic finding and accounts giant cell inflammatory processes affecting the myocardium. Both
for the clinical spectrum of ventricular dysfunction in these patients, while individuals lacked antemortem diagnoses. In one case an 18-year-old man
NVM represents a compensatory response generated by a failing heart to who had been asymptomatic except for a 2 ½ month history of vague
regenerate its nonfunctional myocardium. The case presented case abdominal pain was found dead at work. Postmortem examination
represents the second reported association between NVM and DMD. This revealed a semigranulomatous, mixed inflammatory cell process
study proposes that the precise molecular signals governing the events in involving the left ventricle that was associated with giant cells and lacked
embryonic myocardiogenesis may be recapitulated in certain clinical myocardial fiber necrosis and tissue eosinophilia. Numerous well-formed,
settings, such as this one; identification and isolation of such signals would noncaseating granulomas were found in the lungs, pulmonary hilar lymph
corroborate this hypothesis and enhance the understanding of such events. nodes and kidneys. The diagnosis of sarcoidosis was rendered. The
Noncompaction of the Ventricular Myocardium, Dilated second case involved a 43-year-old man with a ten year history of
Cardiomyopathy, Duchenne Muscular Dystrophy intermittent chest pressure and cardiac arrhythmias who collapsed at work.
The heart showed a similar mixed inflammatory cell infiltrate that
included giant cells, although focal myocardial fiber necrosis and
eosinophils were also present. Thorough gross and microscopic
G57 Death By Giant Cells: Report of Two examination revealed no involvement of other visceral organs or lymph
Cases of Sudden Cardiac Death Due nodes and the diagnosis of giant cell myocarditis was rendered.
to Giant Cell Inflammatory Processes Giant, Cell, Myocarditis
Rebecca A. Hamilton, MD*, Office of the District 21 Medical Examiner,

70 Danley Drive, Fort Myers, FL 33907; Linda Sullivan, BS, Wuesthoff
Reference Laboratory, 6800 Spyglass Court, Melbourne, FL 32940; and G58 Sudden Death and Keratoderma
Barbara C. Wolf, MD, Office of the District 21 Medical Examiner, 70
Danley Drive, Fort Myers, FL 33907
Associated Cardiomyopathy:
An “Affray” of the Heart
After attending this presentation, attendees will be familiar with the
differential diagnosis in cases of sudden cardiac death due to giant cell
Christopher M. Milroy, MD, LLB*, and Sacha Kolar, MBChB, Forensic
inflammatory processes involving the myocardium and will understand
Science Service, The Medico-Legal Center, Watery Street, Sheffield,
the roles of histologic examination and immunohistologic studies in
South Yorkshire S3 7ES, United Kingdom; and Kim
arriving at the correct diagnosis.
Survana, MBChB, Sheffield Teaching Hospitals, Northern General
Hospital, Herries Road, Sheffield, South Yorkshire S5 7AU, United
humanity by elucidating the clinical and pathologic issues involved in
Kingdom
distinguishing the subgroup of sudden cardiac deaths resulting from
inflammatory processes with giant cells that affect the heart. After attending this presentation, attendees will have knowledge of
The medical examiner or coroner usually investigates sudden and cardiomyopathy associated sudden death and keratoderma as well as the
unexpected deaths in individuals without documented disease processes law regarding manslaughter in England.
that would provide reasonable explanations for the deaths. These include This presentation will impact the forensic community and/or
the unexpected deaths of individuals who have been diagnosed with a humanity by discussing issues of interaction of sudden “natural” death and
known chronic natural disease that was not expected to cause death at that the law pertaining to homicide in England.
point in time as well as those cases in which the deceased had no known A 15-year-old girl was involved in an incident in which she was
pre-existing natural disease at the time of death. Cardiovascular disorders, subject to threats, then blows before running away from the incident. She
most notably arteriosclerotic and/or hypertensive cardiovascular disease, ran uphill away from the incident, collapsed and died. At autopsy a history
account for the majority of sudden and unexpected natural deaths. Less was given that she suffered from the skin disorder Erythrokeratodermia
commonly documented are disease processes directly affecting the Variabilis or possibly Papillon-Lefèevre syndrome and was on
myocardium. In these cases, histologic examination of the myocardium is antihistamines. At autopsy there was significant thickening of the skin,
often essential in reaching a diagnosis. most obvious of the palms and soles of the feet. The hair was abnormal
Granulomatous inflammation of the myocardium can occur in the as were the teeth. On internal examination the heart was clearly abnormal.
course of a number of systemic disease processes including infectious There was a degree of dilatation of the ventricles and on microscopic
etiologies such as fungal, mycobacterial and parasitic infections, as well as examination there was obvious fibrosis, with no evidence of acute
hypersensitivity reactions and rarely autoimmune disorders. In many of infarction or inflammation. A diagnosis of Plantopalmer Keratosis
these disorders giant cells comprise a component of the inflammatory associated cardiomyopathy was made.
infiltrate. Systemic granulomatous processes of unknown pathogenesis, There are a number of genetic abnormalities associated with
most notably sarcoidosis, may also be associated with involvement of the Plantopalmer keratosis. A number of heart conditions may be found
myocardium. In contrast, giant cell myocarditis, also known as idiopathic including Naxos syndrome and Caravajal syndrome.
myocarditis, a rare, frequently fulminant, and fatal disorder of unknown A charge of manslaughter, with an additional charge of affray was
etiology, is isolated to the heart and lacks systemic involvement. laid against four teenage defendants. The basis of the manslaughter charge
The majority of systemic granulomatous disorders that involve the was the charge of affray. except for brain edema and generalized
heart are diagnosed prior to death due to their protracted clinical course haemostasis Three of the defendants were convicted of manslaughter and
and symptomatolgy related to the involvement of other organs. affray. The fourth defendant was acquitted.

On appeal, the convictions for manslaughter were overturned. The will also point out how important is to know the mechanism of death in
convictions for affray were upheld. As well as the unique pathologic these cases to be able to reconstitute the story.
features, this case has clarified the law of manslaughter in the English This presentation will impact the forensic community and/or
legal system, limiting its extent to an act that is dangerous in the sense that humanity through the familiarization with this particular ritualistic way of
sober and reasonable persons would recognize it as foreseeable. committing homicide – the incaprettamento - practiced not only within the
1 Reference: community where it was originally described. Additionally the
R v Carey, C and F (2006) EWCA Crim 17 presentation will emphasize the importance of the differential diagnose
between the diverse forms of mechanical asphyxia used in a single victim.
Cardiomyopathy, Homicide, Keratoderma
Incaprettamento is a typical homicide ritual used by the Italian Mafia
as an admonitory significance to traitors and considered a form of
vendetta. A rope is tied in a noose around the victim’s neck. The other
G59 Correlations for Expected Heart Weight end of the rope is used to tie both hands and feet behind the back. Death
is attributed to self-strangulation when, by exhaustion, the victim will no
William T. Gormley, MD, PhD*, Deborah Kay, MD, and Anna longer be able to support the legs in that forced position. Some authors
Noller, PhD*, Office of the Chief Medical Examiner, Commonwealth point out that sometimes, the binding is done postmortem, to facilitate
of Virginia, 400 East Jackson Street, Richmond, VA 23219 transportation and disposal of the victim.
After attending this presentation, attendees will understand the use of This research presents a case of a man partially naked, who had been
correlations with height, weight, and Body Mass Index (BMI) to apparently gagged and strangled, with the hands and feet tied at the back,
determine expected normal autopsy heart weight as well as variations in seeming to be a case of incaprettamento. He was found in a forest, some
expected heart weight by sex and appreciates the deviation from expected meters away from the local road, in a prone position with the head lower
heart weight as an indicator of heart disease. than the rest of the body.
This presentation will impact the forensic community and/or The autopsy showed that the victim had been gagged, apart from
humanity helping to define abnormal heart weight in sudden and having two constrictor items around the neck: a ladder belt (which tied
unexpected deaths and will explore the epidemiology of heart disease and simultaneously both hands behind the back, with a twisting device made
the effect of BMI on heart weight. of a metal part of a bicycle inserted between the rope and the skin) and,
After attending this presentation attendees will understand that the underneath it, a synthetic rope. The feet were bound with an electric wire,
correlation of height, weight and Body Mass Estimation with expected separately from the hands. Typical ligature injuries were observed, such
normal heart weight is important to identify subtle hypertrophy, especially as asphyxic exuberant signals, osteo-cartilagenous fractures, intimal tear
in the analysis of sudden and unexpected deaths with minimal disease. of the carotid artery and bleeding into the muscles and mucosa. A sexual
Standard references define normal ranges for heart weight at autopsy and assault was ruled out using a standard protocol for collection and
there are published correlations of autopsy heart weight with body weight evaluation of the usual specimens.
and body length. Body Mass Index (BMI) is commonly used as an Taking into account the autopsy diagnoses – gagging and/or a
indicator of obesity and obesity has been correlated with heart disease. single/double ligature – this paper discusses the real cause of death, and its
This study explores the relationship of heart weight at autopsy to BMI as relation with a case of incappretamento. Finally, this presentation will
calculated from length and body weight data measured as part of the debate whether this could be considered a real incaprettamento, since,
routine autopsy procedure. contrary to the typical procedure involved in this type of homicide; the feet
This study reviewed reports of all autopsies performed in 2004 at the were bind independently, without being attached to the hands and neck.
Richmond District Office of the Chief Medical Examiner. Data collected Incaprettamento, Strangulation, Gagging
from each case included age, sex, race, height, weight, heart weight, and
presence or absence of anatomically identifiable heart disease. Cases were
excluded where there was extensive decomposition, burning, or other
G61 A Case Report of an Unexpected
body destruction that could invalidate the height, body weight or heart Accidental Electrocution
weight data. While the collected data contained decedents of all ages, the
study focused on adults between 18 and 65 years of age. Christopher K. Poulos, MD*, Indiana University Department of
Correlations of heart weight with body weight in patients without Pathology and Laboratory Medicine, 521 West McCarty Street,
identifiable heart disease were generally good and in agreement with Indianapolis, IN 46225; Michele Catellier, MD, Forensic Pathology
previously published data. Similar correlation lines for patients with heart Associates of Indiana, 521 West McCarty Street, Indianapolis, IN 46225;
disease were significantly different with the expected bias toward Elena F. Bishop, MD, Indiana University Department of Pathology and
increased heart weight. Comparison of correlations for men and women Laboratory Medicine, Clarian Pathology Laboratory, 350 West 11th
also produced significant and expected differences. Surprisingly, Street, Indianapolis, IN 46225; and Stephen S.
correlations of heart weight with BMI were much worse than the Radentz, MD, Forensic Pathology Associates of Indiana, 521 West
correlations with body weight. McCarty Street, Indianapolis, IN 46225
Body Mass Index (BMI), Heart Disease, Heart Weight After attending this presentation, attendees will understand basic
principals of investigating accidental electrocutions and will also have an
increased index of suspicion for electrocution in certain cases of sudden,
G60 Gagging, Strangulation By Single/ unexpected death.
Double Ligature …or Incaprettamento? This presentation will impact the forensic community and/or
humanity by increasing awareness of electrocution as a differential
diagnosis in certain circumstances and by emphasizing the importance of
João Pinheiro, MD, MSci*, and Duarte Nuno Vieira, PhD, Instituto
a multidisciplinary approach to complete scene investigation in cases of
Nacional de Medicina Legal, Largo Sé Nova, Coimbra, 3000 213,
possible electrocution. By increasing the detection of cases of
Portugal
electrocution, particularly those taking place in public areas, potentially
After attending this presentation, attendees will learn that some hazardous or fatal electrical malfunctions, and situations can be detected
apparent simple cases of strangulation turn out to be complex ones, with and corrected before causing death or harm to additional individuals,
more than one form of mechanical asphyxia involved. This presentation including the investigators.

Fatal electrocutions are reported to account for a death rate of OSHA regulations and manufacturers’ recommendations for proper tire
approximately 0.54 per 100,000, occur most commonly in men, and are servicing.
mostly accidents (though suicides and homicides by electrocution do Three cases of death from injuries related to truck tire repair and/or
occur). The mechanism of death during electrocution varies, but is often handling were identified between 1995 and 2006 at the King County
due to ventricular fibrillation. Electrocutions can be categorized into Medical Examiner’s Office in Seattle, WA. The decedents, all male,
direct current and alternating current types, and alternating current is ranged in age from 30 years to 40 years old and had no significant medical
generally regarded as more dangerous than direct current. Electrocutions conditions. Injuries ranged from blunt force trauma to the head, torso and
can also be divided into high and low-voltage varieties (based on voltage extremities to blast injuries of the upper airways and lungs.
greater than or less than 1000 volts), and, though the exact ratio of high In the first case, the decedent made an unwitnessed service call to
verses low-voltage electrocution varies with the study, up to 83% of change a tire on a tractor-trailer truck parked in a lot. Evidence suggested
electrocutions are with low-voltage current. While high-voltage the individual had changed the tire and was in inflating the new tire when
electrocutions are often accompanied by characteristic electrical burns, the sidewall blew out. The decedent was struck in the face and fell
nearly 50% of low-voltage electrocutions are not accompanied by these backward. Autopsy showed contusions to the lungs, esophagus, posterior
burns or other physical evidence, which renders postmortem diagnosis pharynx, and superior larynx.
potentially difficult. Indeed, even some characteristic features of high In the second case, a warehouse worker was rolling semi-truck
voltage electrocutions, such as the arborescent patterns seen in fatal wheels and tires onto metal racks. A supervisor witnessed a tire explode
lightening strikes, may be transient. This lack of specific pathologic projecting the wheel upward into the decedent’s head, chest and arms,
findings makes a high index of clinical suspicion very important in certain projecting him backwards. Autopsy showed comminuted skull fractures,
circumstances, such when a person is grounded and near a source of cerebral lacerations, multiple rib fractures, and pulmonary contusions.
electricity. Additionally, examination of the victim’s clothing for burns In the third case, the decedent made an unwitnessed roadside service
and death scene investigation are of critical importance in detecting call to change a dump truck tire on an access road. He was found supine
electrocution. Numerous authors have also stressed both the critical on the ground with the tire and wheel resting across his legs. Examination
importance of scene safety and of a multidisciplinary approach during the of the injuries and scene reconstruction demonstrated tire explosion during
investigations of potential electrocutions. Specifically, electrical inflation and upward projection of the wheel. Autopsy revealed a
engineers or representatives of a local power company are often called depressed frontal skull fracture and parietal and frontal scalp lacerations
upon to examine electrical devices that potentially caused the with associated cortical contusions and subarachnoid hemorrhage.
electrocution. Review of the literature revealed well documented patterns of injury
To illustrate these points, this presentation will describe a case of and death associated with explosions during tire servicing and handling.
accidental low-voltage electrocution that occurred in their practice. In this The vast majority of fatalities from all tire servicing accidents involve
case, a 28-year-old male was found dead in a publicly accessible restroom. service work on truck tires. Blunt force injuries to the head accounted for
The initial report, accompanying the decedent to the county coroner’s the majority of these fatalities, while other common injuries include
office, stated the death was believed to be a natural death; however, broken facial and upper extremity bones. Other documented injuries
examination of the decedent revealed burns on the skin and clothing. included “blast” or concussive injuries to air-filled organs such as bowel,
Based upon these burns, which were believed to be electrical, additional lung, and tympanic membranes. This study reviewed several
scene investigation was requested by the forensic pathologist. This manufacturers’ standard safety procedures as well as OSHA regulations
supplemental investigation disclosed that another individual had and found a general concordance on the proper equipment needed when
complained of receiving a “shock” in that restroom. Also, a changing a truck tire and on the proper procedure. These include using
representative of the local power company went to the scene and protective gear and using safety equipment. Proper tire changing
discovered two separate electrical devices that were defective and could procedure was outlined as a multi-step process with clear check points to
have exposed the decedent, or other users of this restroom to low-voltage be met before proceeding onward. The prevention of these types of
current, a risk that was heightened by a wet floor with a metal drain. A injuries can best be accomplished by adherence to the tire manufacturers’
subsequent report that correlated the scene findings with the pattern of warnings and recommendations as well as to OSHA’s tire service
electrical burns on the victim’s skin, suggest that both pieces of equipment regulations. There is precedent for the levying of fines against businesses
contributed to the death of the decedent. This case serves to illustrate the not in compliance with OSHA workplace safety standards.
potentially occult nature of low-voltage electrocutions and how a When investigating these frequently unwitnessed deaths, particular
multidisciplinary scene investigation as well as expert examination of attention needs to be paid to scene investigation, noting if proper
involved electrical equipment can greatly aid in the detection of such procedures and equipment were being employed. This is important not
electrocutions, which can have an impact on public safety. only to rule out foul play, but for ease of reconstruction of events leading
Electrocution, Fatal, Accidental to death when correlated to injuries found at autopsy.
Blunt and Blast Force Injuries, Truck Tire Servicing Accidents,
OSHA
G62 Death From Truck Tire Servicing:
A Report of Three Cases and G63 A Rare Injuring Tool in a Dyadic Death
Sabina Di Donato, MD*, Giovanni Paolo Di Peri, MD, and Carmina
Patrick Cho, MD*, Aldo Fusaro, DO, and Richard C. Harruff, MD, PhD, Dambra, MD, Institute of Forensic Pathology, University of Foggia -
King County Medical Examiner’s Office, 325 Ninth Avenue, Seattle, Italy, Ospedali Riuniti, Viale L. Pinto n. 1 - 71100 Foggia - Italy, Foggia,
WA 98104 71100, Italy
After attending this presentation, attendees will recognize different After attending this presentation, attendees will have a better
blunt force and blast type injuries associated with truck tire servicing understanding of cases involving a homicide and suicide (HS). Only few
accidents. cases of homicide-suicide by carpenter axe are reported in forensic
This presentation will impact the forensic community and/or literature. Sometimes it may be difficult for the forensic pathologist to
humanity by helping in the recognition of the different blunt force and distinguish between a real HS and a double murder. The importance of a
blast type injury patterns; and helping the attendee to be better aware of thorough forensic investigation, including crime scene evaluation,

analysis of circumstantial data, autopsy findings, toxicological analysis, were performed on the cutaneous specimens collected from the neck
histological and immunohistochemical studies is emphasized. lesions for the determination of the vitality. The evaluation of skin
This presentation will impact the forensic community and/or samples with confocal microscope allowed researchers to observe the
humanity by presenting the case of a homicide-suicide, where the three-dimensional model of the strangulation mark and the chopping
murderer chopped his wife with a carpenter axe, and then he hanged wound. Toxicological analyses were negative.
himself. The unusual injuring tool and the relevant injuries were studied Homicide Suicide, Chopping Wound, Immunohistochemical Study
and analyzed to approach the case of dyadic death. The confocal
microscope was utilized to verify the three dimensional appearance of the
cutaneous lesions
Homicide-suicide (HS) is defined as that lethal event in which an
G64 Independence Day
individual kills another and subsequently commits suicide within one Explosion on Lovers Key
week. International studies report a highly variable proportion of HS in all
homicides (from 1.5% of all recorded homicides in USA, to 42% of Brett E. Harding, MBA*, and Barbara C. Wolf, MD, Office of the
Denmark). Some authors proposed that the higher is the homicide rate in District 21 Medical Examiner, 70 Danley Drive, Fort Myers, FL 33907
a population; the lower is the rate of HS. Per capita rates of HS, instead,
After attending this presentation, attendees will have an
appears quite constant across different countries and through time, in fact
understanding of the unique aspects and hazards involved in the
the annual incidence varies from the 0.2-0.6/100,000 in US, 0.07/100,000
investigation of the scene of a pyrotechnics explosion and in the
in England and Wales, 0.18/100,000 in Finland, and 0.22/100,000 in Hong
postmortem examinations of the victims.
Kong. In Italy, in an observational period of 15 years, 1985 – 1999 it has
been observed that the higher rates concern the Northern Italy
humanity by providing an understanding of the unique considerations and
(0.85/100,000), followed by the Central Italy (0.68) and the Southern
hazards that should be taken into account by medicolegal death
region (0.38). Previous studies have outlined that the HS perpetrators
investigators and forensic pathologists involved in the investigation of
show more similarities with those who commit suicide rather than with
deaths due to fireworks-related incidents.
those who commit homicide. The vast majority of offenders are male (75-
Fireworks, generally recognized as having originated in China, have
97%), aged 35-51 years, while the victims are generally female (60-85%),
been popular in the United States since the mid-19th century. They are
aged 30-35 years. Offenders are often apparently free of mental disorders,
traditionally used in the celebration of Independence Day on Fourth of July,
but some are regarded by relatives and friends as “hot tempered”; a low
as well as other holidays. Because injuries due to recreational fireworks-
percentage have a diagnosis of major depression or psychotic disorder.
related incidents among consumers are relatively common, the sale of
The great majority of HS occurs between intimates (spouses and
fireworks is regulated by federal law and is also limited by state and local
cohabitant) and family members. The largest group comprises the spousal
laws. Most injuries occur in children and in individuals actively handling
or lover killing, followed by the homicide of children, and than of other
the fireworks and most commonly involve the hands, face and eyes. In
family members. Male offenders usually kill spouses, while female
contrast, because fireworks display companies are under tight safety
perpetrators generally commit child homicide. The most frequent trigger
regulations, explosions in the professional pyrotechnics industry are rare.
is represented by the imminent separation or ending of an intimate
This study investigated the scene and postmortem examinations of
relationship. Many modes of killing are described like shooting,
the victims of an explosion and resulting fire that occurred on Lovers Key
strangling, stabbing, chopping, gassing, or poisoning, beating, etc. There
in southwest Florida while a pyrotechnics crew was transferring fireworks
exists a significant difference between male and female offenders in the
from a semitrailer to a smaller truck in preparation for a Fourth of July
method chosen to kill: in fact, while men are more prone to adopt active
display. The company had planned to use 853 fireworks shells ranging 3-
methods, women tend to use passive methods.
to 12-inch in diameter and up to 4 feet long. The scene investigation
Here is a case of HS, where the husband chopped his wife at the back
involved eight teams of 80 people from multiple agencies, including the
of the neck, resulting in a complete transection of the cervical spinal cord,
local fire department, the State Fire Marshall’s Office, the Sheriff’s Office,
and than hanged himself. A boy with a friend came back home and found
the Regional Bomb Squad, the Bureau of Alcohol, Tobacco, Firearms and
the lifeless body of his mother lying face down in a large pool of blood.
Explosives, OSHA and the Medical Examiner’s Office. The 40 hour
At a distance of two m, they saw the body of the father hanged by a strong
investigation of the scene presented unique hazards because of flare-ups of
nylon rope to the banisters of the mezzanine. Immediately they tried to
the fire, a secondary explosion and because the debris included live
help him, releasing his head from the slip knot, and called the ambulance,
firework shells. The potential detonation of live ordnance necessitated
but they were both pronounced dead. In the adjacent room, policemen
leaving the bodies at the scene until a thorough search was performed.
found a carpenter axe on a table, stained with blood and locks of hair. On
The live rounds were marked and left in place until they were later secured
the floor beneath the axe a large pool of blood was evident, with extensive
in wet sand for removal and destruction. The investigation subsequently
blood spatter on the surface of the door and the adjacent wall. This pool
determined that the explosion was due to the accidental ignition of the
of blood started a trail of blood terminating at the woman’s body. The
fireworks, although the exact cause was never identified.
postmortem examination of the female deceased showed a deep linear
Four of the six members of the fireworks crew died at the scene, and
cutaneous wound on the back of the neck, 6.5 cm in length, slightly
later another later succumbed to thermal injuries. Two of the bodies at the
oblique, with clear-cut divergent margins, exposing the underlying
scene were relatively intact, while the other two were fragmented. The
structures, with soft tissue bleeding underneath. A red colored area, 7.5 x
sixth worker, a woman who was the farthest away from the trucks, jumped
2.5 cm in diameter, surrounded this wound. The body of the second
into a nearby body of water and survived although she suffered burn
cervical vertebra showed a transverse fracture, passing underneath the
injuries and smoke inhalation. The identification of the decedents was
dens and the right superior articular facet. The spinal cord was completely
made either by dental comparison and/or the comparison of pre- and
transected at the level of C2. Also a complete section of the left vertebral
postmortem radiographs of the axial skeletons. The autopsies also
artery was visible. No relevant injuries were detected on the remained of involved unique considerations due to the possible presence of
the body. Autopsy of the male revealed a ligature mark on the neck. In unexploded ordnance in the bodies, necessitating total body radiographs
both cases, the histological investigation revealed massive hemorrhages in prior to the examinations, because of the possibility of friction causing the
the cutaneous and subcutaneous tissues. Infiltration of erythrocytes in the detonation of these rounds. Injuries included thermal injuries resulting
dural layers and in the spinal cord was evident, at the level of transaction from the fire as well as blunt force injuries caused by the exploding
of the spinal cord in the female victim. Immunohistochemical studies fireworks and by structural materials from the destroyed vehicles. The

two relatively intact bodies showed penetrating wounds, predominately of missing service members were obtained and compared to the data
superficial, containing fireworks pellets and dark burning soot. There were obtained from the left tibia. Exclusionary results, along with evidence
no characteristic injuries to air-containing hollow viscera due to shock obtained from the site, concluded that the missing individual was Air
wave effects. Cadet Leo Mustonen from Brainerd, Minnesota.
Fireworks, Explosion, Fatality The views expressed herein are those of the authors and not
necessarily those of the Armed Forces Institute of Pathology, the U.S.
Army Surgeon General, nor the U.S. Department of Defense.
G65 Identifying the “Iceman” Identification, mtDNA Analysis, Frozen Remains
Sarah L. Bettinger, MSFS*, Devon R. Pierce, BS, and Suzanne M.

Barritt, MS, Armed Forces DNA Identification Laboratory, 1413
Research Boulevard, Building 101, Rockville, MD 20850; Alexander F. G66 Caddisfly Cases Assist Homicide Case:
Christensen, PhD, Joint POW/MIA Accounting Command, Central Determining a Postmortem Submersion
Identification Laboratory, 310 Worchester Avenue, Hickam AFB, HI
96853; and Louis N. Finelli, DO, Armed Forces DNA Identification
Interval (PMSI) Using Aquatic Insects
Laboratory, 1413 Research Boulevard, Building 101, Rockville,
MD 20850 John R. Wallace, PhD*, Millersville University, Department of
Biology, Millersville, PA 17551; Richard W. Merritt, PhD, Ryan K.
After attending this presentation, attendees will understand how the Kimbaraskas, MS, Mark E. Benbow, PhD, and Mollie McIntosh, PhD,
use of mtDNA can aid in the identification of missing service members Michigan State University, Department of Entomology, 243 Natural
from decades-old skeletal remains. Science, East Lansing, MI 48824-1115; and Joyce DeJong, MD,
This presentation will impact the forensic community and/or Sparrow Hospital, Forensic Pathology Department, Lansing, MI 48824
humanity by providing the attendees with an example of the uses of
mtDNA for the identification of human remains exposed to harsh The goal of this presentation is to discuss a particular case study that
environmental conditions. exemplifies the importance of understanding aquatic insect biology to help
The Armed Forces DNA Identification Laboratory (AFDIL) and the determine a postmortem submersion interval (PMSI) in streams, rivers,
Joint POW/MIA Accounting Command-Central Identification Laboratory and possibly lakes. This study demonstrates how certain aquatic insects,
(JPAC-CIL) work in a combined effort to identify missing or unidentified e.g., caddisflies (Order: Trichoptera, Family: Limnephilidae) can be useful
personnel from past military conflicts. With the use of mitochondrial in estimating the time period from a body is submerged to the point of
DNA (mtDNA) testing, skeletal remains are analyzed and compared to discovery. The attendee will learn that some aspects of aquatic
references from associated family members in order to make entomology can be useful in criminal investigations by learning how to
identifications. The following case study from World War II shows how incorporate life history aspects of aquatic insect biology to estimate a
the use of mtDNA can aid in the identification of missing service members PMSI.
from decades-old skeletal remains. This presentation will impact the forensic community and/or
On November 18, 1942, 2d Lt. William Gamber and student Aviation humanity by demonstrating that there are aspects of aquatic entomology
Cadets John Mortenson, Ernest Munn and Leo Mustonen of the 41st valuable to forensic investigations involving bodies recovered from
School Squadron, departed Mather Field, California, for a 4-hour aquatic systems. To date, very little research exists on the use of aquatic
navigational training flight. Five hours after their departure, and with no organisms to estimate a postmortem submersion interval; this particular
communication from the AT-7 aircraft, search crews were sent out to case illustrates how aquatic insect evidence can augment traditional
locate the flight team. However, with no position reports during the flight, techniques used in criminal investigations to develop a PMSI time line.
search crews did not know where to look in the mountainous terrain of the The determination of a postmortem interval using entomological
flight’s route. After search parties found no remnants of the aircraft or its evidence collected from terrestrial crime scenes has been well
crew, the United States Army Air Forces (USAAF) abandoned it search. documented. A review of the literature found that approximately 85% of
On November 9, 1943, the War Department officially declared all four studies pertained to terrestrial organisms, while only 15% pertained to
men as dead. aquatic organisms. This dichotomy can be explained simply because
Almost five years later, on September 24, 1947, two students found terrestrial insects have evolved to feed on carrion while aquatic insects
portions of an aircraft approximately 120 miles east of Los Banos, have not, Therefore, because the biology of some terrestrial insects is
California. Search parties came upon widely scattered wreckage, intimately tied to decomposing animal flesh, where aquatic insect biology
including two engines, embedded in the ice. A data plate from one of the does not, this biological difference has facilitated the use of terrestrial
engines matched that from the missing AT-7 aircraft. Remains found at the insects in criminal investigations. Consequently, many times aquatic
site could not be identified and were interred in a group burial in the insect evidence is ignored from crime scenes in aqueous environments.
Golden Gate National Cemetery, San Bruno, California. Since remains are often found in aquatic environments, it is important that
Decades later, on October 15, 2005, two hikers came upon a body, forensic scientists and law enforcement personnel visiting such crime
partially encased in ice in Mendel Glacier in Kings Canyon National Park. scenes have an increased knowledge of the aquatic organisms that could
No evidence was found to immediately identify the body, but an un- potentially colonize human remains.
deployed U.S. Army parachute was strapped to the body, indicating that of Although few indicators of time since death for remains found in
a military service member. The National Park Service then contacted the aquatic ecosystems are comparable in precision to the insect indicators
JPAC-CIL to assist in the recovery. JPAC-CIL removed the remains as used in terrestrial cases, there are observations that can be useful in
well as some material evidence from the body. Historical evidence suggesting or ruling out an approximate PMSI. For example, the time
associated with the loss of the AT-7, and evidence recovered in 1947 and intervals needed for certain growth phases of aquatic insects such as
2005, suggested that these remains were likely one of the four men aboard caddisflies that may attach themselves to the remains can be used to
this aircraft when it was reported missing on November 18, 1942. estimate a minimum PMSI. Approximately eight of the 13 orders of
The remains arrived at the CIL in Honolulu, Hawaii where a insects containing species with aquatic or semi-aquatic stages are likely to
thorough anthropological analysis was made. On November 3, 2005, a be associated with carrion or remains in aquatic habitats. The evolution of
small portion of the left tibia was sent to the AFDIL, in Rockville, a vast array of physiological and behavioral adaptations in aquatic insects
Maryland, for mtDNA analysis. Blood references from family members enables these organisms to inhabit virtually all bodies of water.

Portions of a body from an adult male were discovered in a south biotic and abiotic factors that influence entomology-based postmortem
central Michigan stream. The body was dismembered and portions were intervals (PMI), i.e., the time period between insect colonization and body
recovered from plastic bags floating in the stream. Insects specimens discovery. The study proposes that this goal can only be achieved by a
collected from the plastic bags containing body parts consisted of one fly multi-investigator group studying forensically-important (FI) arthropods
larva (Diptera) belonging to the family Muscidae, and caddisfly larvae year-round over several years. Investigators and sites will be chosen from
(Trichoptera) belong to two families, the Limnephilidae or case-makers a subset of active and willing researchers (with established track records)
and the Hydropsychidae, net spinners. Because of case material type, size whose institutions bracket more latitudes than longitudes in order to reflect
of mineral pieces used in the case, and the size of the stream from where the widest range of climates and vegetation types.
they were collected, larvae belonging to the family Limnephilidae were The central features of this protocol, which the authors have
separated into two different species, as well as placed in specific larval embraced in their own research and training programs, include the use of
instars (or larval stage of development) which helped to age them. Based pig carcasses as surrogate corpses, fixed sampling stations as mock crime
on the similarities of the behavior, life histories and occurrence of these scenes, comparative tests of different field methods, and the integration of
two species throughout the year, two caddisfly species belonging to the photographic, climatic, and arthropod records. The domestic pig (Sus
genus Pycnopsyche were present, mainly the last developmental larval scrofa Linnaeus) (of roughly 23-27 kg starting weight) closely resembles
stage of Pycnopsyche lepida and Pycnopsyche guttifer were identified. a human in its fat distribution, chest cavity, lack of heavy fur, and
Unique case-building behaviors of these Limnephilid caddisflies found on omnivorous diet. Advantages to using pigs include ease of procurement,
the remains were used to elucidate a PMSI range consistent with the reasonable cost, and a low propensity to incite public objection. The pig-
disappearance of the victim. It is important for forensic investigators to as-surrogate claim was recently validated in field trials conducted inside
understand that although some precision is lost in estimating a PMSI with the Forensic Anthropology Center (formerly ARF) at the University of
aquatic insects, these organisms should not be ignored in gathering Tennessee, Knoxville, TN, using simultaneously placed human and
evidence from aquatic crime scenes, that in fact, they can provide valuable porcine subjects studied over a 35-day summer period. In that study,
details in estimating a PMSI. exceptionally high overlap in arthropod abundances (>99%) was reported
Aquatic Insects, Caddisflies, Postmortem Submersion Interval from three subjects (one human, two pigs), indicating that only a few very
rare FI taxa were associated with one subject or the other.
Within each site, the initial study design will feature replicated pig
carcasses representing the “background” condition (i.e., surface-exposed,
unclothed, and vertebrate unscavenged) against which other replicated
treatments could be compared in the future (e.g., buried, burned,
G67 A Standardized Field Protocol for submerged, clothed, and/or vertebrate scavenged remains). Recent
Experimentally Investigating Variability in research has shown that when different sampling methods are used to
Entomology-Based Postmortem Intervals inventory the carrion-arthropod fauna (i.e., aerial nets, hand collections,
pitfall traps, sticky traps), results are often species-selective leading to
Over Multiple Sites and Years: A Proposal catches of variable species composition which have the potential for
affecting PMI estimates. Many other studies have established that carrion-
Kenneth G. Schoenly, PhD*, California State University, Stanislaus, arthropod succession and carcass decay rates are affected by season,
Department of Biological Sciences, 801 West Monte Vista Avenue, temperature, elevation, exposure mode (e.g., buried, burned, submersed,
Turlock, CA 95382; Jeffery K. Tomberlin, PhD, Texas A&M University, wrapped), presence/absence of predators, and other factors.
Texas Cooperative Extension, 1229 North U.S. Highway 281, Through this protocol, it is hoped to achieve a better understanding
Stephenville, TX 76401; John R. Wallace, PhD, Millersville University, of variability and uncertainty in PMI estimates by holding constant both
Department of Biology, Millersville, PA 17551; M. Lee Goff, PhD, investigator error and exposure conditions. To further this goal this study
Chaminade University, 3140 Waialae Avenue, Honolulu, HI 96816; will work to disentangle the combined and interactive effects of climate,
Jeffrey D. Wells, PhD, West Virginia University, Biological Sciences, season, and geography on carcass decay rates and arthropod colonization,
Morgantown, WV 26506; and Richard W. Merritt, PhD, Michigan State development, succession, and species composition. To further reduce
University, Department of Entomology, 243 Natural Science Building, inter-investigator error, the study will require that each researcher channel
East Lansing, MI 48824 his/her voucher specimens to the same taxonomic specialists to insure
After attending this presentation, attendees will gain understanding uniformity and accuracy of identifications across sites. Statistical analysis
of the key factors that influence variability of entomology-based PMI will focus on testing whether the order and timing of different species of
estimates and the need for forensic entomologists to devise standardized colonizing insects used in both development and succession-based PMI
field experiments at multiple sites over several years. Such a protocol will estimates are comparable (i.e., repeatable) across different sites, seasons,
disentangle the combined and interactive effects of these key factors on and years. Given the critical need to separate pattern from “noise” in
carcass decay rates and carrion-arthropod colonization, development and forensic entomology and to accurately and precisely estimate time-of-
succession. death, which the Law requires to be ascertained, the need for a
This presentation will impact the forensic community and/or standardized field protocol that can function at multiple sites for several
humanity by through the introduction of this collaborative framework and years becomes clear.
call for a standardized field protocol, the authors will provide the forensic Through the introduction of this collaborative framework and call for
science community several scientific examples, gleaned from the a standardized field protocol, the authors will provide the forensic science
entomological literature, of the need to better understand spatio-temporal community several scientific examples, gleaned from the entomological
variability of entomology-based PMI estimates through the establishment literature, for the need to better understand spatio-temporal variability of
of a small network of field sites. entomology-based PMI estimates through the establishment of a small
A multi-site field protocol, modeled after the U.S. Long-Term network of field sites.
Ecological Research Network, is proposed for investigating the major Forensic Entomology, Postmortem Interval, Field Protocols

G68 Characteristics of Fatal All G69 Using Ninhydrin to Detect Grave Soil
Terrain Vehicle (ATV) Accidents
David O. Carter, PhD*, Department of Entomology, University of
Michele Eichenmiller, MS, James A. Kaplan, MD*, David J. Clay, BA, Nebraska-Lincoln, 202 Plant Industry Building, Lincoln, NE 68583-
Myron A. Gebhardt, MS, Brandon Lewis, BS, Nabila A. Haikal, MD, 0816; David Yellowlees, PhD, School of Pharmacy and Molecular
James C. Kraner, PhD, Office of the Chief Medical Examiner, 619 Sciences, James Cook University, Townsville, QLD 4811, Australia; and
Virginia Street West, Charleston, WV 25302 Mark Tibbett, PhD, Centre for Land Rehabilitation, School of Earth and
Geographical Sciences, University of Western Australia, Crawley, WA
After attending this presentation, attendees will learn of particular 6009, Australia
concerns to be considered when investigating fatal ATV accidents.
This presentation will impact the forensic community and/or After attending this presentation, attendees will understand
humanity by focusing attention on the circumstances of fatal All Terrain fundamental effects of cadaver decomposition on associated soil (grave
Vehicle (ATV) accidents, particularly the role of alcohol impairment. soil) and the methodology required to analyze grave soils for the presence
The goal of this presentation is to highlight some of the forensically of ninhydrin-reactive nitrogen.
relevant circumstances surrounding deaths that result from ATV accidents. This presentation will impact the forensic community and/or
Emphasizing the factors that are common to these cases will enhance the humanity by providing a method to rapidly locate clandestine graves and
attendee’s attention to pertinent issues to be considered when investigating cadaver decomposition sites.
ATV related deaths. After this presentation, attendees will understand fundamental effects
An all–terrain vehicle or “ATV” is defined as any vehicle fifty-two of cadaver decomposition on associated soil (grave soil) and the
inches or less in width, having an unladen weight of 800 pounds or less, methodology required to analyze grave soils for the presence of ninhydrin-
traveling on three or more low pressure tires with a seat designed to be reactive nitrogen. This presentation will impact the forensic community
straddled by the rider, intended for, or capable of travel over unimproved by providing a method to rapidly locate clandestine graves and cadaver
terrain. Using national data from 2002-2004, West Virginia leads the decomposition sites.
nation with an annual average of 1.7 fatalities per 100,000 people; Some death investigations commence without knowledge of the
followed by Kentucky at 0.85. The national average for the same period location of a body and/or decomposition site. In these cases it is necessary
is 0.17 deaths per 100,000 citizens. to locate the remains or the site where the body decomposed prior to
The West Virginia Office of the Chief Medical Examiner investigated relocation. Ideally, the location of these sites would be rapid and require
the fatalities reviewed in this report. Biological samples were obtained little destruction of the scene, such as that achieved with cadaver dogs.
from each of the cases during either internal autopsy or external However, few options remain if cadaver dogs are unavailable or prove
examination of the body. Over a three-year period (2003-2005), a total of unsuccessful.
99 fatal ATV-related accidents occurred in West Virginia. Of the fatalities Ninhydrin is a compound that is readily available to most
reviewed, 85 were male and 14 were female. The decedents ranged from investigative agencies, as it can be used to locate latent fingerprints. This
7-80 years of age, with 36 being the average age. Overall, October was use relies on the color change that occurs when ninhydrin reacts with
the month with the highest incidence (14 cases), followed by May and July protein-, peptide-, amino-, and ammonium-nitrogen (collectively known
with 13 fatalities occurring during each. Toxicological testing included as ninhydrin-reactive nitrogen: NRN) left on a surface contacted by skin.
blood alcohol analysis by direct injection GC-FID using t-butanol as an Similarly, the decomposition of an organic resource results in the release
internal standard. Samples were also tested for drugs of abuse. However, of NRN into the soil. Considering that a cadaver can comprise as much as
only alcohol findings are included in this presentation. Other significant 3% nitrogen, there is great potential for NRN to be detected in grave soils.
observations include the following: As a consequence, this study hypothesizes that the decomposition of a
• Fifty-eight percent of the accidents occurred on unpaved roads, body would result in a significant increase in NRN in soil.
with 28% on paved roads. The road surface was not specified in A field experiment was conducted at two disparate field sites during
the records available for review in the remaining cases. the dry season (March 2003). Site 1 was comprised of a loamy sand soil
• Eighty-four of the fatalities were drivers, while ten were (84% sand, 11.1% silt, 4.9% clay) and was located in Yabulu, Queensland,
passengers. The position of the decedent was not ascertained in Australia. Site 1 receives an average rainfall of 140 mm during the dry
five of the deaths. season (March-October) and average maximum/minimum temperature
• There were ten multi-vehicle and 75 single-vehicle accidents. In equals 22.9 °C/16.7 °C. Site 2 was comprised of a sandy soil (97.7%
fourteen collisions, the number of vehicles involved was not sand, 1.3% silt, 1% clay) and was located in Pallarenda, Queensland,
specified. Australia. On average, site 2 receives 120 mm of rainfall during the dry
• Only thirteen individuals were wearing a helmet whereas 51 were season and the average maximum/minimum temperature is 26.9 °C/16.4
not; and of the latter, seven were under the age of 18. °C. Grasses with scattered trees dominated the resulting vegetation at the
• Excessive speed was documented in the investigative reports of two sites, as is typical of a tropical savanna ecosystem. Juvenile rat (Rattus
14 fatalities and was not named as a factor or unknown in the rattus: ~18 g) cadavers were buried (2.5 cm) in the centre of a 2 m2 plot.
remaining 85 cases. Grave soil was collected at 7, 14, 21, and 28 days following burial.
• Forty-nine percent of the fatalities had blood alcohol To measure NRN, 2 g soil (dry weight) was amended with 8 ml KCl
concentrations exceeding 0.08%. (2 M) and shaken (150 rpm) for 30 minutes. Following shaking, the
• The average blood alcohol concentration was 0.19% + 0.09%. solution was filtered through a filter paper (#42) into a culture tube. To 1
Through the first seven months of 2006, 39 ATV-related deaths had ml of filtrate, 0.5 ml ninhydrin reagent [0.8 g ninhydrin, 0.12 g
already occurred in West Virginia, underscoring the need for addressing hydrindantin, 30 ml dimethyl sulfoxide, 10 ml lithium acetate] was added,
the problem of ATV safety by state government. mixed, and incubated at 100 °C for 25 minutes. The reaction was stopped
In conclusion, high blood alcohol concentration is a frequent factor with 10 ml 50% ethanol-water (v/v) and absorbance was read at 570 nm.
in fatal ATV accidents. It is also important to note that the generally steep The concentration of NRN was calculated against a leucine standard. To
terrain of West Virginia is an additional concern when operating vehicles make leucine standard, 0.469 g leucine was dissolved into 1 l distilled
with a high center of gravity, such as an ATV. Other ATV-specific accident water. This contained 50 mcg nitrogen ml-1. Separate 100 ml volumetric
factors obtained from police and injury-prevention sources will also be flasks were amended with 0, 5, 10, 15, 20 and 30 ml leucine solution, 50
presented. ml of 4 M KCl, and water to make up to 100 ml. These standards
ATV, Fatality, Accident contained 0, 250, 500, 750, 1000 and 1500 mcg nitrogen.

Cadaver burial resulted in a 4-6 fold increase in the concentration of Death due to hypothermia is well known as a significant public health
NRN in grave soil. This increase was observed within seven days of burial problem in cold climates, affecting predominantly homeless people, drug
and remained constant until the end of the experiment (day 28), by which dependent persons, and the elderly. Hypothermia is generally considered
time the cadaver had been skeletonized for a minimum of 14 days. This very rare in more temperate climates and there is a general lack of
rapid and stable increase in NRN has great potential to become a standard awareness of the problem by both the medical fraternity and the general
investigative tool, considering that the analysis of NRN in grave soil can public. This study examines the problem of fatal hypothermia in Sydney
be conducted in less than one hour. Australia, a city with a reputation of having a year round temperate to hot
Forensic Taphonomy, Decomposition, Nitrogen climate.
There were 24 cases of fatal hypothermia in a five-year period
between January 2001 and December 2005. For the purposes of this study,
the diagnosis of hypothermia was made by either a temperature
measurement at hospital (17%), suggestive autopsy findings (33%), a
G70 Insects and Time Since Death: suggestive history (4%), or a combination of autopsy findings and a
What Do We Really Estimate? suggestive history (46%). The majority of the deaths occurred in winter
(46%) as expected, whilst equal numbers occurred in the seasons on either
M. Lee Goff, PhD*, Division of Natural Sciences and Mathematics, side of winter - spring (25%) and fall (25%). Despite generally hot
Chaminade University of Honolulu, 3140 Waialae Avenue, Honolulu, HI summer temperatures, one death occurred during summer. This person
96816-1578 had become lost in bushland and was found in a state of extreme
dehydration.
After attending this presentation, attendees will gain an
The mean age was 76 years (range 56 – 92), with a female
understanding of some of the limitations and constraints of time of death
predominance (63%). Risk factors for hypothermia were identified in
estimates based on entomological evidence
58%, and these included alcoholism mental illness (schizophrenia, bipolar
disorder) and developmental delay. All but two decedents lived alone.
humanity by making attendees aware of the problems and constraints
Nine decedents were underweight (body mass index < 20 kg/m2).
associated with time since death estimates based on entomological
Nineteen cases (79%) were found in a building, a house, apartment,
evidence, the participants will be better able to evaluate the significance of
or other premises. Of those, 46% were dead at the scene, while the
these estimates to their investigations.
remainder died either on the way to or in hospital. In the remaining five
Forensic entomology is a powerful tool for use in the estimation of
cases, the decedent was found outside. Three in this group were dead at
the minimum period of time since death in many cases. There are,
the scene, while two died subsequently in hospital. This indicates that
however, certain constraints in its application that must be kept in mind.
despite rewarming and supportive care, hypothermia past a certain point is
First, what is provided is primarily an estimate of the period of insect
irreversible and fatal.
activity on the body, rather than an estimate of the actual period of time
Four decedents were found naked, four were dressed in minimal
since death. While these periods are frequently quite similar and the
amounts of clothing and the decedent was adequately dressed in a further
estimate provided is close to the actual time since death, they are not
three cases. There was evidence of paradoxical undressing in seven cases.
identical. There also exist a number of confounding factors beyond the
In the remaining six cases, the presence or absence of clothing was not
control of the entomologist and./or crime scene personnel that will further
given.
serve to reduce the similarity between the estimate and the actual
Pathological findings in fatal cases of hypothermia are generally
postmortem interval. These include: concealment of the body, incomplete
considered non-specific. Gastric erosions were found in 79%. There was
collection of relevant materials by scene personnel, presence of chemicals
one case with acute pancreatitis, and a single case with rhabdomyolysis.
on or around remains, seasonal and geographic variations in insect
The characteristic cutaneous lesions in hypothermia, reddening and
distribution, microclimatic factors, and lack of common sense. Additional
abrasion over the large joints of the limbs were present in 16 (75%) cases.
problems lie in approaches to interpretations of data, often resulting in
In four cases (17%), there were no autopsy findings to suggest
estimates produced that can not be supported by the current state of the
hypothermia, although either hospital or environmental features strongly
sciences involved.
supported the diagnosis. Other significant autopsy findings included
Postmortem Interval, Insects, Entomology atherosclerotic cardiovascular disease (50%), pneumonia (17%),
pulmonary congestion and edema (17%), chronic airways limitation
(13%) and single cases of glioblastoma multiforme and metastatic bowel
cancer. With the exception of two cases where only a raised blood alcohol
G71 Dying of the Cold in a Warm Climate - was detected, all cases had significant pre-existing natural disease
Hypothermia Deaths in Sydney, Australia processes. Toxicology was performed in 18 cases – alcohol was detected
in four cases, and other psychotropic agents were present in four deaths.
No illicit drugs were detected.
Johan A. Duflou, MMed*, and Cathy Lim, MBBS, Department of
This study highlights a significant public health problem that is not
Forensic Medicine, 42-50 Parramatta Road, Glebe, NSW 2037,
limited to cold climates. There is little awareness of the hazards of
Australia
hypothermia in the elderly in Australia and probably other temperate parts
The goal of this presentation is to describe the features of of the world. Life-threatening hypothermia does not occur at any one
hypothermia related deaths in Sydney, Australia, a geographic location particular temperature, as other factors such as wind movement, clothing,
generally viewed as having a temperate to hot climate. dampness of the environment, and vulnerability of the individual all play
This presentation will impact the forensic community and/or a role. Forensic pathologists and other death investigators who have the
humanity by highlighting the dangers of hypothermia in the elderly, even good fortune of living in warm climates need to remain vigilant of this
in temperate climates. Attendees will be informed of the social condition, and not misattribute the death to natural disease processes such
circumstances, the death scene and pathological findings at autopsy in this as atherosclerotic cardiovascular disease or pneumonia.
series of cases. Autopsy Pathology, Hypothermia, Environmental Medicine

G72 The Postmortem Picnic Scene photographs are key in order to verify or deny the presence of
RIFA activity. A small number of RIFAs will usually get transported with
Kathryn Haden-Pinneri, MD*, Mary Lynn Anzalone, MD, and Luis the body and/or in the body bag. Without scene photographs to review,
A. Sanchez, MD, Office of the Medical Examiner of Harris County, you may not realize the extent of their involvement in wound alteration.
Joseph A. Jachimiczyk Forensic Center, 1885 Old Spanish Trail, In one case, the edges of a gunshot wound were very irregular, simulating
Houston, TX 77054 an atypical entrance or possible intermediary target. Scattered areas of
postmortem insect activity elsewhere on the body indicated the presence
After attending this presentation, attendees will understand a of RIFAs; however, it wasn’t until the scene photos were reviewed that it
potentially confusing postmortem artifact caused by the Red Imported Fire was apparent to what extent they had altered the gunshot wound. In one
Ant (RIFA) and stress the importance of good photographic scene photo, RIFAs are seen completely filling the wound, something typically
documentation. associated with maggots, not ants. This large concentration of RIFAs
This presentation will impact the forensic community and/or imparted an atypical appearance to the gunshot wound.
humanity by educating forensic scientists about alterations in wounds In addition to the many other variables that cause alterations of
caused by solenopsis invicta, the Red Imported Fire Ant, which may affect wounds in the postmortem setting, changes induced by RIFAs must be
wound interpretation. considered, particularly in bodies found outdoors. RIFAs pose an
Postmortem alteration of wounds by insects is a fairly common additional hazard at the time of autopsy. Care must be taken when
phenomenon, especially in decomposed bodies where maggots are manipulating bodies or clothing containing RIFAs because the ants will
frequently encountered. The destruction they produce can be significant, act aggressively, biting and stinging those that have disturbed them,
even to the point of complete obliteration of the wound and the underlying possibly inciting an allergic reaction in susceptible individuals. As RIFAs
wound track. Without damage to the skeletal elements, the trauma may continue to invade the United States, more and more forensic investigators
not be discernible. Alterations of wounds in the “fresh” state are not as will be left to interpret the trauma they leave behind.
common; however it is being seen with increasing frequency in the
Solenopsis Invicta, Fire Ant, Postmortem Artifact
Southern United States, where fire ants have invaded.
Solenopsis invicta (S. wagneri), the Red Imported Fire Ant (RIFA),
has infested large parts of the United States, concentrating mainly in the
warmer Southern region. States from California to Maryland have G73 Applying Statistical Principles
documented their presence and the destruction they cause. Lacking to the Entomological Estimation
predators and parasites, these ants have become a major pest, destroying of Postmortem Interval
plants, crops, trees, and even small animals. They are also attracted to
electrical currents and subsequently damage electrical boxes, air
Bart J. Harvey, MD, PhD, MEd*, University of Toronto, 407-263
conditioners and other equipment.
McCaul Street, Toronto, Ontario M5T 1W7, Canada; Sherah L.
First introduced into the U.S. from its native South America, the
VanLaerhoven, PhD, University of Windsor, Room 23, Biology Building,
RIFA arrived in cargo from Brazil at the port of Mobile, AL in the 1930s.
401 Sunset Avenue, Windsor, Ontario N9B 3P4, Canada; and Paul N.
This species has spread rapidly throughout the Southeastern United States
Corey, PhD, University of Toronto, Department of Public Health
and has recently been identified in Australia, the Philippines, Taiwan, and
Sciences, 6th Floor, 155 College Street, Toronto, Ontario M5T 3M7,
China.
Canada
Fire ants are omnivores, feeding on almost any plant or animal.
Other insects are their preferred food. Humans become affected by the After attending this presentation, attendees will understand how four
RIFA when it bites and stings. In response to vibration or movement, statistical principles apply to the estimation of ambient temperature
RIFAs react quickly and aggressively to disturbances of their colony or necessary to enable the entomological estimation of postmortem interval.
mound. A single ant will sting repeatedly, even when out of venom. The Specifically, attendees will understand how estimate precision, random
RIFA bites with its mandibles to attach itself to the skin, and then it stings variation, sufficient sample size and sampling breadth, and the choice of
with its abdomen, injecting toxic venom. A pustule forms in 24-48 hours, estimation model (e.g., linear, non-linear) should be considered and taken
which may get secondarily infected. Some individuals are allergic to the into account when postmortem interval ambient temperatures are
venom, and anaphylaxis may ensue. estimated.
For forensic pathologists, RIFAs are creating problems by their rapid This presentation will impact the forensic community and/or
appearance on bodies found outdoors. Within minutes, 10-20 ants will humanity by highlighting how the consideration of four statistical
arrive at the body, and many more will come after that. Rather than biting principles can inform the estimation, accuracy, and precision of the
and stinging in an aggressive manner, the RIFA just bites, gaining postmortem interval, as made through entomological techniques.
sustenance from the body instead of injecting venom. In contrast to After attending this presentation, attendees will understand how four
maggots, which prefer open wounds, moist mucous membranes and dark statistical principles apply to the estimation of ambient temperature, which
environments, RIFAs will readily eat intact exposed skin. They tend to is required for estimation of postmortem interval using entomological
concentrate at clothing/skin interfaces and prefer the outer surface of the evidence. Specifically, attendees will understand how estimate precision,
body, rarely entering the body cavities or altering the wound tracks. random variation, sufficient sample size and sampling breadth, and the
Increasingly, RIFAs are being encountered in open wounds, and the choice of estimation model (e.g., linear, non-linear) should be considered
changes they leave behind can be troublesome. In general, postmortem when postmortem interval ambient temperatures are estimated.
artifacts caused by insects are easily distinguished from antemortem This presentation will impact the forensic sciences community by
trauma. When a wound is involved, however, the changes are not as highlighting how the consideration of four statistical principles can inform
straightforward. The yellowing, seen with postmortem insect activity is the estimation, accuracy, and precision of the postmortem interval, as
usually lacking or is camouflaged by the actual wound characteristics. made through entomological techniques.
Firearm wounds, in particular, can have a very puzzling appearance By examining the type and developmental stage of insects found on
when altered by RIFAs. If only a few bites occur around the wound, it remains, entomological techniques can provide an estimation of the time
may be mistaken for stippling, thereby altering the interpretation of range since death or the postmortem interval. Insect development is highly
of fire. On the other hand, if a large number of RIFAs are present and they dependent on ambient temperature, therefore, estimate using insect
have been there long enough, determination of entrance versus exit may evidence require determination of the temperatures that the remains were
be completely obscured. exposed to following death. While these exposure temperatures can be

readily determined in many cases, in others, when no temperature G74 The Validation of Gene Expression
recordings are available, they must be indirectly estimated, often by
examining the relationship between the temperatures at the site where the
as a Means of Predicting the Age
remains were found and those recorded at a nearby weather station. This of the Blow Fly Lucilia sericata
relationship can be determined by taking temperature recordings at the site
where the remains were found for an extended period of time following Aaron M. Tarone, BS*, Department of Zoology, Michigan State
their recovery and comparing these with the temperatures recorded over University, 203 Natural Sciences, East Lansing, MI 48824; and David R.
the same period of time at the nearby weather station. Using the statistical Foran, PhD, Forensic Science Program, Michigan State University, 560
techniques of regression, the relationship between these two measures can Baker Hall, East Lansing, MI 48824
then be defined by a suitable mathematical equation that, for a given
After attending this presentation, attendees will understand the use of
weather station temperature, can provide an estimate of the corresponding
gene expression in determining the age of forensically useful blow flies.
temperature at the site where the remains were found.
However, because these temperature estimations are obtained by the
humanity by helping the forensic community understand how to use gene
mathematical regression modeling of the relationship between two sets of
expression and statistical analyses to better address the requirements of
measured values, the application of four statistical principles can enhance
Daubert as it pertains to forensic entomology.
the accuracy and precision of the estimated temperatures. First, because
Forensic entomology is an established field, with a relatively good
both sets of temperature measures are affected by random variation, the
track record of predicting a postmortem interval (PMI) through an
resulting regression model will be inherently imprecise—that is, single
understanding of blow fly development. However, in the context of
unique temperature values cannot be precisely predicted but, more
Daubert, all of the forensic sciences will be expected to provide
realistically, a range of compatible temperature values can be determined.
techniques that have been adequately tested, have laboratory standard
This range of compatible values is identified through the calculation of the
operating procedures (SOPs), have undergone publication in the peer-
“confidence interval for an observation” [1: 275-278] for each temperature
reviewed literature, are accepted by the relevant scientific community, and
estimated.
have known potential error rates. Though forensic entomology can meet
Second, because the precision of any given model will improve (i.e.,
most of these criteria, the field will likely be required to establish SOPs
the range of compatible values will narrow) according to the number of
and provide information as to error rates and the precision of its methods.
pairs of measurements available for model development, a sufficient
In addition to not yet fully meeting Daubert requirements, blow fly
number of temperature pairs should be included in the data collection used
based PMI estimates suffer from increasing error as the animal develops
to develop the model. Third, it is also important to ensure that a sufficient
(Wells and Lamotte 1995). This stems from the fact that the durations of
number of comparative temperature pairs are collected over the full range
subsequent developmental stages increase, and the body size traits used by
of expected values (i.e., the range of temperatures that the remains were
entomologists (larval length or weight) that help refine age estimates in the
estimated to be exposed to prior to being found). If this is not done then
feeding stages become far less useful in the later stages of immature
‘outlier’ temperatures will need to be estimated by extrapolating the model
development. Thus, other characteristics that predictably change during
beyond the range of values that were used for its development. Because
these stages are potential sources of information that could be valuable to
such extrapolated estimates assume that the relationship between the two
investigators attempting to age flies. Gene expression profiles are known
sets of temperatures is the same beyond the measured values as it is within
to vary significantly throughout the development of all animals, and have
the measured range, erroneous temperature estimates will result when this
been studied extensively in the dipteran Drosophila melanogaster (e.g.,
assumption is not met. Of course, ensuring that the assumption applies in
Arbeitman et al. 2002). To understand how gene expression might be
a given circumstance requires that actual temperature measures be
utilized for more accurately aging a forensically useful blow fly, a gene
collected across a sufficiently broad range of values.
expression profile data set for nine developmentally variable genes was
Fourth, while a straight line (i.e., linear) relationship is often expected
created for the immature life cycle of ~700 individual Lucilia sericata.
to best model the relationship between two measures, this is not always the
Three regional strains of flies were grown under controlled laboratory
case. As such, to enhance the accuracy of the temperature estimates, the
conditions and regularly sampled for both size and gene expression levels,
type of relationship between the two sets of temperature measures should
creating a high-resolution developmental profile of these cohorts.
be appropriately studied so that the applicable mathematical model (i.e.,
Following this, genetic profiles were used in conjunction with
linear or one of the many non-linear possibilities) for each set of
developmental stage and body size data to estimate the age of individual
temperature data can be accurately determined. In fact, it is possible that
blow flies. However, body size and gene expression levels are not easily
different models may be required for different parts of the same set of data
explained by a simple mathematical function (they are non-parametric)
(e.g., day versus night). For example, because of the characteristics of a
and statistical endeavors that can help investigators (and triers of fact)
setting where remains were found, temperatures at that site might be found
understand such multivariate and non-linear data must be employed to
to be generally higher during the day, but lower at night (in comparison to
make predictions of age. To this end, statistical models of developmental
the corresponding weather station temperatures), thus necessitating the
age in terms of genetic and phenotypic profiles have been produced. The
development of two distinct models to be used to estimate the applicable
two most promising forms are principle component analysis and
temperatures, according to the time of day.
generalized additive models. The former has been used in other forensic
During the presentation, examples illustrating each of these statistical
sciences to make predictions of class evidence and may be useful with
principles, and their applicability and impact upon the entomological
entomological data. With generalized additive models, it is possible to
estimation of postmortem interval will be demonstrated and discussed.
define the percent of development explained by the data, and to deduce the
Reference:
1 Glantz SA. Primer of Biostatistics (Sixth Edition). New York, NY:
usefulness of different models (and variables within models) through a
comparison of generalized cross validation (GCV) scores (Wood 2006).
McGraw-Hill, 2005. Currently, predictions of age incorporating standard data and gene
Postmortem Interval, Statistics, Entomology expression can describe up to 97% of the variation in development, which
is an increase of ~10% compared to using developmental stage and body
size alone.
However, no mathematical model is useful based solely on its
theoretical ability to predict age, thus the models need to be validated on
different data sets. To accomplish this, a blind study was conducted with

flies grown under both experimental (in the laboratory using the same decomposed remains (in either the ‘choice’ or ‘no choice’ scenarios) were
conditions as the original experiment) and natural (out of doors) colonized. This result is not unexpected, but confirms the conventionally
environments. Gene expression and body size profiles of the juvenile flies held understanding of a single generation of blow flies emerging from a
collected were used to predict the age of the individuals employing the single corpse, even under extenuating circumstances. The fact that blow
models generated from the aforementioned data set. The validation of the flies under these conditions die without reproducing indicates the
age models and their importance in helping the field of forensic unsuitable nature of a body that has undergone advanced decomposition
entomology increase precision and meet the requirements of Daubert will as larval substrate.
be discussed. Forensic Entomology, Decomposition, Taphonomy
Forensic Entomology, Postmortem Interval, Generalized Additive
Model
G76 The Investigation of Animal Tissue
as an Analogue for Human Tissue
G75 Have I Eaten Here Before?
in Decomposition Studies in Soil
Considering Multigenerational
Colonization of Remains by Blow Flies Kathryn L. Stokes, BSc*, Centre for Forensic Science, University of
Western Australia, 35 Stirling Highway, Nedlands, Perth, Western
Timothy E. Huntington, MS*, and Leon G. Higley, PhD, University of Australia 6009, Australia; Shari Forbes, PhD, University of Ontario
Nebraska, Department of Entomology, 202 Plant Industry Building, Institute of Technology, Faculty of Science, University of Ontario
Lincoln, NE 68583 Institute of Technology, 2000 Simcoe Street North, Oshawa, ON L1H
7K4, Canada; and Mark Tibbett, PhD, Centre for Land Rehabilitation,
After attending this presentation, attendees will understand that there
School of Earth and Geographical Sciences, Faculty of Natural and
is little potential for multiple generations of blow flies arising from the
Agricultural Sciences, University of Western Australia, 35 Stirling
same corpse.
Highway, Nedlands, Perth, Western Australia 6009, Australia
humanity by demonstrating a substrate limitation to blow fly colonization After attending this presentation, attendees will understand the
of decomposing remains. chemical process of decomposition, the compounds released during the
Forensic (or medicocriminal) entomology, the use of arthropods in decomposition of muscle tissue of different species, and their interaction
legal investigations, is most frequently employed to estimate the with the soil environment. The aim of this presentation is to compare the
postmortem interval (PMI) of victims of violent crimes or suspicious use of animal tissue as an accepted model for human tissue in
deaths. The most commonly used method of PMI estimation employs decomposition trials.
temperature-dependent developmental rates of blow fly larvae (Diptera: This presentation will impact the forensic community and/or
Calliphoridae). Retrospective scene temperatures, those temperatures that humanity by showing direct comparisons between the decomposition
the insects experienced during development, are used in combination with chemistry of human and various animal tissues in a soil environment. The
known developmental rates of the species involved to estimate the age of identification of both similarities and differences between the different
the insects, which often correspond closely with the time of death of the tissue types will help identify the best animal analogue for future
victim. decomposition studies.
One key element entomological analysis is the use of the oldest Pig (Sus scrofa) carcasses are currently accepted as the closest model
insects associated with the body, as these represent the closest estimate of to human decomposition due to their physiological similarities to humans.
the minimum time since death. This facet of forensic entomology For this reason they are commonly used in a range of decomposition
consequently leads to questions by investigators and attorneys regarding studies involving microbial activity and entomology. However from a
the potential for multiple generations of blow flies arising from the same chemical perspective there are limitations with this model due to
corpse. While blow flies continue to be attracted to the carrion well into variations in the decomposition compounds produced by humans and
the later stages of decomposition, the carcass is no longer attractive as an animals. Furthermore, the behavior of these compounds in soil is unknown
oviposition medium after some point, and it is widely held that the with respect to the subsequent nutrient dynamics. The current study was
maggots which fed on a set of remains will not normally eclose as adults therefore conducted to investigate the chemical decomposition of skeletal
and oviposit on the same body. Flies in abnormal conditions, however, muscle tissue in soil and to compare similarities and/or differences
have been known to alter their behavior as a response to their between human and animal tissue. The results will assist in determining
circumstances. The goal of this study was to investigate whether adult the most useful animal model in chemical decomposition studies. The
blow flies eclosing into a situation where there is no carrion source other research may benefit forensic investigations involving decomposed
than their larval host would oviposit on this carcass or die without remains whereby the species determination is in question.
reproducing. A laboratory incubation method was used to monitor chemical
Six freshly killed pig (Sus scrofa L.) cadavers (~53 kg) were placed changes during decomposition. The soil in each microcosm was a sand
on the soil surface and left undisturbed for approximately 45 hours (75 texture adjusted to 50% water holding capacity to provide optimal
ADD-B0) to allow for extensive insect colonization. After this time, conditions for microbial activity. Cuboid pieces of skeletal muscle tissue
Lumite® (18 x 14 mesh) exclusion cages (6 ft3) were erected over each from four different species, namely porcine, bovine, ovine and human,
pig. After placement of the cage, adult blow flies were physically killed were interred at 1 cm depth in the soil and incubated at 25oC for 37 days.
or removed from the cage. Subsequent maggot development into adult Carbon dioxide evolution was used as an index of soil microbial activity.
blow flies occurred within each cage, resulting in high populations of adult Aerobic conditions were maintained by opening the microcosms daily to
flies that represented the first generation of fly development on the replace oxygen depleted air from the container. The microcosms were
cadaver. Following the emergence of adult flies within each cage, a destructively harvested at periods of 2, 4, 6, 8, 12, 16, 23, 30 and 37 days.
‘choice’/ ‘no choice’ study was conducted by placing a freshly killed pig Any remaining skeletal muscle tissue was removed, weighed, and dried to
(~47 kg) in three of the cages and observing for colonization of each ascertain mass loss. The soil immediately surrounding the site of muscle
carcass. tissue decomposition (detritosphere) was collected and analysed. The
In this study, each of the fresh pig cadavers in the ‘choice’ portion of mineralization of nutrients was monitored by analyzing inorganic
the experiment were colonized readily by blow flies, but none of the molecules within the soil using colorimetric methods for ammonium,

nitrate and phosphate, and atomic absorption spectroscopy for potassium were recovered. A complete histological study was performed. Cutaneous
levels. The release of long chain fatty acids into the soil was also gunshot wounds were also studied by means of confocal laser scanning
monitored using GC-MS. microscopy. Few days after the examination, a positive identification was
Results have demonstrated that for all skeletal muscle tissues there is made by fingerprint comparison. The victims were two brothers
an observed increase in pH before a decrease back to the starting pH belonging to the criminal association ‘ndrangheta’ under probation in
measured prior to muscle tissue interment. Electrical conductivity also Tuscan countryside. It is well known all over the world of the existence
increases for all different types of skeletal muscle tissue. Further results of the “four Italian mafias” that are referred to the “Cosa Nostra” in Sicily,
from organic and inorganic chemical analyses will be discussed in the the “Camorra” in Campania, the “Sacra Corona Unita” in Puglia and the
presentation. ‘Ndrangheta’ in Calabria. The last one is estimated to be Italy’s most
Animal models are commonly used for decomposition studies due to powerful organized crime association, surpassing the Sicilian Mafia.
restrictions on the use of human cadavers. The results from this study will Their moneymaking schemes include racketeering, extortion, loan
impact the forensic community by showing direct comparisons between sharking, illegal immigration, money laundering, cigarette smuggling, and
the decomposition chemistry of human and various animal tissues in a soil arms and narcotic trafficking. In homicides committed by criminal
environment. The identification of both similarities and differences organization the method employed as well as the positioning of the body
between the different tissue types will help identify the best animal follow a macabre ritual laden with significance and intending to be a
analogue for future decomposition studies. warning to others who interfere with the activities of these organizations.
Animal Tissue, Human Models, Decomposition Ndrangheta Homicide Execution, Burnt Lime, Confocal Microscopy
G77 ‘Ndrangheta’ Homicide (Executions)! G78 Pig-Mentation: Postmortem Iris

Color Change in the Eyes of Sus Scrofa
Cristoforo Pomara, MD, Department of Forensic Pathology, University
of Foggia, Ospedali Riuniti, via L. Pinto 1, Foggia, 71100, Italy; Elizabeth J. Abraham, MA, MSc*, University Health Network, MedWest,
Floriana Monciotti, MD, Department of Forensic Pathology, University 750 Dundas Street West, 2nd Floor, Suite 279, Toronto, Ontario M6J
of Siena, Policlinico Le Scotte, Siena, 53100, Italy; and Marianna Di 3S3, Canada; Margaret Cox, PhD, Inforce Foundation, Melbury House,
Padua, MD, and Carmela Fiore, MD, Department of Forensic 1-3 Oxford Road, Bournemouth, Dorset BH8 8ES, United Kingdom; and
Pathology, University of Foggia, Ospedali Riuniti, via L.Pinto 1, Foggia, David Quincey, MSc, Bournemouth University, Institute of Health and
71100, Italy Community Studies, Royal London House, 1st Floor, Christchurch Road,
After attending this presentation, attendees will learn about Bournemouth, Dorset BH1 3LH, United Kingdom
‘Ndrangheta,’ one of the famous “four mafias” a criminal organization After attending this presentation, attendees will learn that iris color of
from the southern part of Italy. A unique case of ‘ndrangheta’-related a deceased individual is not reliable for identification, and will have an
homicide/double execution is presented. A detailed scene investigation appreciation of the implications of this phenomenon within the context of
and a complete postmortem examination were performed; the surface victim identification, particularly in mass fatality incidents.
aspects of gunshot wounds were also analyzed by means of confocal laser This presentation will impact the forensic community and/or
scanning microscopy. humanity by demonstrating the protocol for victim description,
This presentation will impact the forensic community and/or particularly in mass fatality incidents, should be modified in order to
humanity by demonstrating the rarity of the modalities of this execution account for the taphonomic phenomenon of eye color change.
makes it peculiar and a complete pathologic investigation (death scene Eye color is one of the physical characteristics recorded in a missing
investigation, autopsy performing, and toxicological screening) is strongly person report and in a victim identification report. Software programs are
recommended to completely investigate this type of homicide. employed, by law enforcement and disaster management agencies, to
This unique case of double simultaneous “‘ndrangheta”-related compare the two sets of data, searching for potential matches and
homicide, or execution was discovered in the Tuscan countryside. In the eliminating individuals if the data are inconsistent.
morning of April 10, a farmer noted the presence of bloodstains near the A thorough review of the literature revealed that postmortem iris
road on his property. The bloodstain course ended in a wooded area where color change is mentioned in only two forensic pathology texts, by the
a gun case was detected. He immediately alerted the authorities. An same author. A study on the preservation of contact lenses using the eyes
unusual arrangement of the leaves next to the road caught the attention of of Sus scrofa (domestic pig) also mentions the phenomenon of blue eyes
those searching the area. A few centimeters under these leaves and soil, changing to brown after death.
hands and feet surfaced; at the end of excavations, 160 cm underground, While experienced forensic pathologists should be familiar with the
two lifeless bodies were present. They were found kneeling, beside each phenomenon of postmortem iris color change, it is not common
other. The two bodies were covered with burnt lime, which was cautiously knowledge among death investigators. Victim identification forms and
removed. They were dressed only underpants and wore a pair of gloves. disaster victim identification software currently in use in the United
Clothes belonging to the deceased were found next to the bodies. Core Kingdom, Canada and internationally contain a field for eye color.
temperature of the remains, measured by means of bulbus thermometer, Moreover, recording eye color is standard routine in the external
was 14°C. The external temperature was 17°C. Rrigor mortis was examination in an autopsy.
partially present and livor mortis was represented by fixed reddish-purple In order to determine whether Knight’s references (2004 and 1997)
coloration localized on anterior part of the bodies. At external are anecdotal and/or whether Jackson (2001) observed an anomaly, a
examination the caustic effect of burnt lime on the face and the trunk was controlled experiment of postmortem changes to isolated Sus scrofa eyes
observed. A round wound on the left occipital region was detected on each was carried out. The eyes (n=137) were observed for three days
body. A second round wound on the right dorsal region was observed in postmortem at three different temperatures. In addition, a Sus scrofa head
one of the deceased. Forty-eight hours after discovery, a complete autopsy with heterochromia iridium (two different colored eyes) was obtained in
was performed. A total body CT study confirmed in one case the presence order to observe decompositional changes of eyes in situ.
of a metallic foreign body in the first cervical segment while in the second All isolated blue eyes in the experiment, at room temperature and
case foreign metallic bodies were observed in the right orbital region and higher, changed to brown/black within 48 hours. The in situ blue eye, at
at the mandibular angle. Postmortem examination of the spinal cord was room temperature, turned brown/black within 72 hours. In fact, the in situ
performed according to the Adam’s technique and the deformed bullets

blue eye was indistinguishable from the in situ brown eye, and the change compared to 39% of female ones) while homicide is more frequent in
occurred prior to decomposition of the eye itself. females (28% of female victims compared to 12% of males). In the 15-19
Blue eyes kept at a cool temperature exhibited signs of iris color age group, accident was once again the most frequent manner of death
change, but all of the eyes were still recognizably blue after 72 hours. (38%), though less predominant in comparison with suicide (25%) and
Drying of the sclerae in isolated eyes also occurred, the result being homicide (24%). In terms of gender, the relative incidences of each
that the entire globe turned black concomitantly with the iris color. The manner of death were more similar in this age group.
sclerae of the in situ eyes with open lids, however, remained white and Homicide Victims: In a total of 54 homicide cases (24 females and 30
fresh-looking, and the blue eye changed to brown/black within 72 hours. males), 13 cases belonged to the 4-9 age group, 8 to the 10-14 age group
The possible role of the vitreous humour, which also turned black and 33 to the 15-19. The two most frequent methods of homicide found
postmortem, is explored. The quantity of free melanin granules in the were firearm and sharp force, each at 27% of cases, followed by asphyxia
vitreous increases with postmortem interval. This is likely a result of the (23%), blunt force (20%) and intoxication (3%). The gender distribution
degradation of melanocytes in the retinal and choroids layers of the of homicide cases in the different age groups shows a strong female
posterior chamber, in a process driven by autolysis. Further histological predominant ratio in the 4-9 and 10-14 age groups (9:4 and 5:3
studies are required, including quantified melanin granule counts of respectively), while the opposite situation was observed in the 15-19 age
vitreous humor samples using scanning electron microscopy. group (10:23). An analysis of homicide methods by age group and gender
Most importantly, further studies are required on human eyes to will be presented. Overall, the results for the 4-9 age group are
explore the reliability of this phenomenon and the conditions driving it. If particularly interesting, clearly demonstrating predominance of sharp
postmortem iris color change occurs consistently in humans, then this force in female victims compared to asphyxia in males.
taphonomic artifact will have to be taken into account when recording eye In conclusion, this five year retrospective study gives new insight in
color in victim identification reports. This is particularly relevant in cases the epidemiology of child and adolescent victims in forensic autopsy as
of mass fatalities, when victims may exposed to the elements for up to well as a better description of homicide cases distribution.
several days, and a discrepancy such as eye color in antemortem and Child Death Investigation, Adolescent Death Investigation, Forensic
postmortem data may delay identification when processed by disaster Pathology
victim identification software.
Iris Color Change, Postmortem, Taphonomy
G80 Hemoglobin SC Disease Presenting
as Sickle Crisis After Outpatient
G79 Child and Adolescent Victims in Forensic
Surgery: A Case Report
Autopsy: A Five Year Retrospective Study
Wendy A. Lavezzi, MD*, and Mitra B. Kalelkar, MD, Cook County
Anny Sauvageau, MD*, and Stéphanie Racette, BSc, Laboratoire de Medical Examiner’s Office, 2121 West Harrison Street, Chicago,
Sciences Judiciaires ET de Médecine Légale, 1701, Parthenais Street, IL 60612
12th Floor, Montreal, Quebec H2K 3S7, Canada
After attending this presentation, attendees will learn the significant
After attending this presentation, attendees will have a better signs, symptoms, and sequelae of Hemoglobin SC disease, and implement
understanding of the epidemiological features of child and adolescent the use of postmortem hemoglobin electrophoresis in indicated cases.
victims in forensic autopsy and of the usual characteristics of homicide in This presentation will impact the forensic community and/or
the four to 19 years of age population. humanity by providing information on the importance of recognizing an
Though literature on child abuse investigation of children less than occult hemoglobinopathy and its possible contribution to the cause of
three years of age is quite extensive, the data on forensic autopsy in the death.
older population from four to 19 years of age is more limited. This Hemoglobin SC (Hb SC) disease is a hemoglobinopathy with
presentation will impact the forensic community and/or humanity by approximately the same incidence as that of Hemoglobin SS (Hb SS)
providing data from a systematic five year retrospective study on this child disease in American blacks. The typical presentation of Hb SC disease
and adolescent victim population in forensic autopsy. includes fatigue, dyspnea on exertion, frequent upper respiratory
In the province of Quebec (Canada), all forensic autopsies are infections, sporadic mild jaundice, and arthralgias. The onset of
performed at a centralized laboratory. During the five year period from complications due to Hb SC disease is usually in childhood, but many do
2000-2004, a total of 233 cases of children and adolescents deaths were not present until the teens or later. Rare reports of autosplenectomy in Hb
autopsied in the four to 19 years of age population. Of those, the large SC disease exist, but most patients with Hb SC disease have
majority of cases belonged to the 15-19 age group (139 cases), with the splenomegaly. Unlike Hb SS disease, painful crises in Hb SC disease
remaining cases equally distributed between the 4-9 and the 10-14 age occur more frequently in the muscles and joints than in the abdomen.
groups (42 cases each). Although Hb SC can present with the same manifestations as sickle cell
Child and Adolescent Victims of Forensic Autopsy: Male victims anemia, it is generally characterized by a milder anemia and fewer
were more frequently encountered than female ones (148 males for 75 vasoocclusive crises, with a severity that is intermediate to those of sickle
females), this male predominance being more obvious in the 15-19 age cell disease or sickle cell trait.
group (male:female ratio of 23:19 in the 4-9 age group, 24:18 in the 10-14 A 33-year-old black male who underwent outpatient surgery for
and 101:38 in the 15-19). In this population, accident was the most arthritis that developed following ankle and foot fractures sustained three
frequent manner of death (44%), followed by homicide (24%), suicide years prior when he jumped off a roof while fleeing from an offender. His
(18%), undetermined (9%) and natural (4%). In the 4-9 age group, manner preoperative medical history and physical were within normal limits, and
of death was mostly accident (57%) or homicide (37%). An important he had a history of sickle cell trait.
gender difference was noted in the manner of death. As a matter of fact, The surgery lasted 2½ hours, with two hours of tourniquet time, and
while male were more prone to die from accident (74%) than from consisted of a right subtalar fusion and arthroplasty of the 2nd-4th right
homicide (17%), the opposite was observed for female (47% homicide toes, with application of a cast. There were no complications during
compared to 37% accident). In the 10-14 age group, accident remained the surgery. Ketorolac and local bupivacaine were given, a dressing was
most frequent manner of death (50%), followed by homicide (19%) and applied, and the tourniquet was removed. His airway device was then
suicide (14%). Accidents are more frequent in males (58% of male victims removed, and on the way to the recovery room he suffered sudden

cardiopulmonary arrest and was intubated, but expired despite The autopsy examination revealed extensive subcutaneous
resuscitative measures. hemorrhages, hematomata and laceration of muscles in the region of the
At autopsy, he had a plaster cast on the right leg, beneath which were head, neck, torso and the limbs. No serious fractures were found in the
intact sutured incisions and orthopedic hardware. The lungs were heavy bodies, except for a linear fracture in the occipital skull bone in one case.
and congested, and the mucosa of the gastrointestinal tract was All internal organs were anatomically intact. There were hemorrhages in
hemorrhagic and appeared ischemic. The heart, liver, kidneys, and brain the respiratory, the gastro-intestinal tracts and in the urinary bladder.
displayed no abnormalities. The spleen weighed 4 grams and had light There was severe pulmonary edema.
tan, fibrotic parenchyma. Based on the appearance of the spleen, the The cause of death in these cases was determined to be due to acute
family was contacted, and they stated that the patient did have sickle cell hemorrhagic shock; with complications resulting from their state of severe
trait, and not sickle cell anemia. Vitamin C deficiency at the time they received the multiple beatings with
Postmortem hemoglobin electrophoresis, however, revealed the a club-like weapon.
presence of Hb SC disease. Microscopy revealed pulmonary congestion The patients in hospital were diagnosed as suffering from acute
with prominent sickling of red blood cells within vessels. Sickling of red traumatic hemorrhagic shock and responded to therapeutic doses of
blood cells was also prominent in the liver, heart, kidneys, meninges, Ascorbic Acid (Vitamin C) and to supportive medical treatment. The
adrenal glands, thyroid gland, and gastrointestinal tract. Sections of the clinical diagnoses showed clearly that the detainees were suffering from
spleen showed prominent fibrosis and calcification, consistent with Vitamin C deficiency or Scurvy when they were subjected to the beatings.
autosplenectomy. It is theorized that release of the tourniquet caused a The important principle as illustrated by these cases is that the
large amount of partially deoxygenated blood to re-enter the circulation forensic scientist must evaluate both the complete clinical syndrome
and cause a sickle crisis. The cause of death was determined as sickle cell presented by the victim of an assault and the autopsy examination
crisis due to hemoglobin SC disease, with ankle surgery following a fall diagnosis as a whole concept.
from height as a significant contributing condition. The manner of death The question arises whether similar blows inflicted on healthy
was accidental. detainees could have produced the acute hemorrhagic shock syndromes
Sickle cell crisis in Hb SC disease is rare. Despite the fact that this that were suffered by the beaten detainees?
patient underwent autosplenectomy, he had previously suffered no This presentation will show that in terms of the above principle, the
symptoms of Hb SC disease and believed throughout his life that he had answer must be negative.
sickle cell trait. The use of postmortem hemoglobin electrophoresis was Hola Camp, Massacre, Kenya
invaluable in the determination of cause of death in this case.
Forensic Science, Hemoglobin SC Disease, Sickle Cell Crisis
G82 Comparison of Wound Severity
Between Center-Fire Rifle
G81 Hola Camp Massacre Kenya 1959
Projectiles and Shotgun Slugs
Maurice G. Rogev, MB ChB, MD*, Zamenhof St.11/1, Tel-Aviv-Jafo,
64373, Israel Jennifer H. Park, DO*, Miami Dade County Medical Examiner
Department, 1851 NW 10th Avenue, Miami, FL 33136-1133; and
The goal of this presentation is to demonstrate where in cases where Richard C. Harruff, MD, PhD, King County Medical Examiner’s Office,
either living victims of violence or the dead resulting from violent acts’ it 325 Ninth Avenue, HMC, Box 359792, Seattle, WA 98104
is important to investigate the medical history of the victim when
conducting the clinical examination or the autopsy. After attending this presentation, attendees will understand how the
This presentation will impact the forensic community and/or kinetic energy and fragmentation properties of a missile affect the extent
humanity by drawing the attention of the forensic community to the fact of firearm wounds in a human body.
that these cases do occur. The complete forensic evaluation that includes This presentation will impact the forensic community and/or
a review of the clinical record for all patients undergoing a full autopsy humanity by contributing to the understanding of the relationship of a
examination should become a routine procedure in such cases. missile’s kinetic energy and its wounding pattern in actual firearm
The “Hola Camp Massacre” occurred on 3 March 1959 in a detention wounds.
camp run by the British Colonial Government of Kenya during the Mau Introduction: Contemporary understanding of wound ballistics
Mau rebellion. The detention camp, established early in the Mau Mau relates the severity of wounds to the temporary cavity that a projectile
Kikuyu rebellion that raged from 1952 to 1960 was situated in a remote creates as it passes through the body tissues. This cavity is felt to be
area of the coastal province of Kenya. proportional to the kinetic energy (KE) possessed by the projectile. KE is
The camp was staffed by Kenyan African warders and commanded related to both the mass (m) and the velocity (v) by the well-known
by British Colonial prison officers with locally recruited Kenya European formula: KE = ½ mv2. This concept generally fits with ballistic
civil servants. experiments using gelatin, and accords well with general practical
The following facts are beyond dispute. experience of forensic pathologists. There is little literature; however, that
The warders were authorized to use reasonable force to induce analyzes this relationship in actual firearm wounds. This study sought to
resisting camp detainees to work against their will. In the incident under explore this hypothesis using scientific methods on examples from
consideration, warders used unauthorized excessive violence with clubs, medical examiner cases. A comparison was made of wounds produced by
sticks and body kicks. high velocity, center-fire rifles projectiles (CFRP) with those produced by
Eleven 11 men were killed and some sixty 60 injured. Of these, 26 shotgun slugs (SGS). The basis for this comparison is that CFRP have a
men were admitted to the camp hospital in a state of surgical shock, with relatively small mass and extremely high velocity while SGS have a large
extensive bruising, subcutaneous hemorrhaging and hematomata in many mass and a relatively low velocity.
areas of the body surfaces. Methods: A search was performed of the records at the King County
Clinical examination revealed signs of severe chronic deficiency of Medical Examiner Office, Washington, for SGS and CFRP wound cases
Vitamin C, (Ascorbic Acid). over the last 12 years – from mid-1993 to mid-2005. For these cases, the
The eleven bodies were flown to the Medical Research Laboratories caliber of the CFRP and gauge of the SGS were obtained from the
in Nairobi, where the author performed autopsy examinations in his investigator reports, along with an examination of the weapon,
capacity as the Police Forensic Pathologist. ammunition, and recovered projectile. Only head wounds were used to

compare wounds produced by CFRP and SGS. A grading scheme was Radiographs were made and the BB was noted to have penetrated just over
developed based on head wounds documented in the autopsy reports, 63 mm into the flesh (after magnification was taken into account). The BB
radiographs, diagrams and photographs. Grade I was limited to a skin was surgically removed under fluoroscopy. The surgeon noted no
laceration at the entry site, with minimal fractures or avulsion injuries. involvement of the radius, ulna or major neurovasculature. However, the
Grade II included complex skull fractures and limited avulsion of the BB did pierce the interosseous membrane. The wound was irrigated and
scalp, skull, or brain. Grade III involved extensive avulsion of the scalp, sutured closed with no significant complications.
skull, or brain. It is an extremely rare case when such precise data is known about an
Results: A total of 80 suicide and homicide SGS and CFR cases actual gunshot wound to a live human being. It afforded the authors an
were evaluated, the majority of which were contact wounds of the head. interesting opportunity to compare the BB penetration in this person to a
In all the SGS cases, the slugs exited the body. Forty-two of 61 CFR cases laboratory-based series of experiments utilizing ballistic gelatins.
showed fragmentation in the body. Overall, 64 cases were suicides and 16 In order to perform better controlled studies on the damaging effects
were homicides. All of the contact head wounds resulted in extensive of various bullets passing through soft tissues, ballistic gelatin was created
destruction of bony and soft tissue structures in the path of the wound with many years ago. The gelatin is said to simulate the density and viscosity
complete or near complete avulsion of the brain. For CFR, both high (e.g., of human and animal muscle tissues. A standard gelatin powder (250
.223, 3030, 30-06 caliber) and intermediate velocity (e.g., .45 caliber) Bloom Type A Ordinance Gelatin) was purchased from Kind & Knox
ammunition were considered. Using the KE equation, it was calculated Gelatine, Inc. (Sioux City, Iowa). There are a variety of methods published
that the extent of the wound of a .223 should be approximately 90% that for the preparation of 10% gelatin blocks. Five were chosen for this study:
of a SGS wound. In the majority of SGS cases, slugs exit the body; 1) The manufacturer’s directions; 2) The Vyse gelatin utilized by the FBI;
therefore not all of the KE is transferred to the tissues. The majority of 3) A technique in which the maximum temperature never exceeds 104
CFR projectiles fragment and remain in the body; however, resulting in degrees F; 4) A technique in which the starting water is at 129 degrees F;
the maximum transfer of KE to the tissues. and 5) A recipe published by Lewis et al. 1982. They appear to have
Conclusion: The results support the general observation that the relatively minor differences (mostly related to various temperatures and
extent of wounds of SGS is similar to that of CFR wounds. The objective standing times).
of this study was not to compare the gauge and manufacturers of the Gels were poured into transparent hard plastic cups. Each cup was
weapons, but to provide the results of a general observation of wounding placed in a protective firing range and subjected to five BB shots from 126
characteristics using scientific methods. CFR bullets fragment because of cm away- using the same Daisy gun. A total of 25 shots were recorded for
their high velocity and not because of hitting bone. The majority of the each of the five gelatin recipes and all penetration distances were
time, SGS do not fragment because of their lower velocities. measured with digital calipers. The data were stored in Microsoft Excel,
Fragmentation allows for the dispersion of kinetic energy to the tissues. then imported to Stata 8.0 (College Station, Texas) for analysis. The mean
CFR projectiles possess approximately 90% of the energy of that of SGS; penetration distance for each recipe was: 1) 62.24 mm; 2) 43.25 mm; 3)
however, because most CFR bullets do not exit, there is more transfer of 56.13 mm; 4) 64.22 mm, and 5) 40.98 mm. ANOVA testing was
kinetic energy to the tissues than that of SGS bullets, where majority exit significant between all groups but the chi-squared analysis results were
the body. <0.05; therefore, variances were not equal and parametric testing was
Firearm Wounds, Shotgun Slugs, High Velocity Center-Fire Rifles dropped. Kruskal-Wallis tests indicated statistically significant differences
between the mean penetration distances for all the recipes. The Mann-
Whitney test indicated significant differences between each recipe except
when comparing one and four. Interestingly, the mean penetration
G83 A Comparison of Penetration Distances distances for those recipes were the closest to the actual penetration depth
for Five Ballistic Gelatins to a BB Gunshot in the live human subject (63 mm).
In summary, a live human subject was accidentally shot in a muscular
Wound to a Live Human Forearm area of his forearm with a BB gun. The penetration distance compared
favorably with two of five ballistic gelatin preparations. Although the live
David J. Porta, PhD*, Drew H. Duerson, and Bill Tietjen, PhD, human data consists of a population (n) of one, it appears to be the only
Bellarmine University, Department of Biology, 2001 Newburg Road, such data in the medical literature. Based on this, it seems the preparation
Louisville, KY 40205; and Tyler A. Kress, PhD, BEST Engineering, 2312 method for ballistic gelatin has significant affects on the penetration
Craig Cove Road, Knoxville, TN 37919 distance for BB gunshots.
After attending this presentation, attendees will see the accidental BB Gunshot, Ballistic Gelatin, Live Human Forearm
result of a BB gunshot and learn how ballistic gelatin preparation
methodology can affect penetration results.
This presentation will impact the forensic community and/or G84 Suicidal and Homicidal Sharp Force
humanity by demonstrating the only documented case where precise BB
gun firing distance is known for a wound to a live human forearm. The Injury: A Five Year Retrospective
penetration distance was determined using X-Rays. This data was then Comparative Study of Hesitation
compared with recreated BB gun firings into five (5) different ballistic Marks and Defense Wounds
gelatins to determine which average penetration distance is the closest to
this single human case.
Stéphanie Racette, BSc*, Célia Kremer, MSc, and Anny Sauvageau, MD,
Misuse of BB guns causes a significant number of injuries each year.
Laboratoire de Sciences Judiciaires et de Médecine Légale, 1701,
One of the authors was subjected to such misuse and the result was a
Parthenais Street, 12th floor, Montreal, Quebec H2K 3S7, Canada
penetrating wound to the proximal anteromedial aspect of the right
forearm. The subject was a healthy, 37-year-old male with fairly well After attending this presentation, attendees will gain better
muscled forearms due to years of baseball playing. Fortunately, this knowledge of hesitation marks and defense wounds pattern in sharp force
accident occurred in a laboratory setting and all parameters were recorded. injury and its correlation to suicidal and homicidal manner of death.
The gun was a Daisy-brand Powerline Model 1200. This carbon dioxide This presentation will impact the forensic community and/or
powered pistol can fire a standard steel BB at up to 420 feet/second. In humanity by providing a systematic evaluation of hesitation marks and
this case, the muzzle was located precisely 126 cm from the subject’s bare defense wounds in sharp force injury in the Quebec province (Canada)
forearm and the gun was equipped with a fresh CO2 cartridge. forensic laboratory from 2000-2004.

In sharp force injury cases, forensic pathologists often have to In medicolegal practice, being able to estimate the time of the death
determine whether the injuries where self-inflicted or not. The presence of is of paramount importance. Particularly in cases of homicides (to accuse
hesitation marks or defense wounds, respectively associated to suicide and or exculpate an alleged criminal), the cases of postmortem manipulation
homicide, has been accepted as useful characteristics in the evaluation of of the remains (occurring especially in the cases of overdose), as well as
manner of death. However, very few studies in the forensic literature have in civil matters (for example succession rights). The interest to perform a
systematically analyzed the features differentiating hesitation marks and technique to specify more precisely the time of the death in the first part
defense wounds. of the postmortem interval lead to the development of a new method,
Over a five year period, in the Quebec province (Canada), all cases based on the bioelectrical impedance of the human body.
of suicidal and homicidal sharp force injury were retrospectively reviewed Human body can be compared to an electrical complex circuit,
for the presence of hesitation marks and defense wounds. For each case, containing water, electrolytes, and cellular membranes. A direct, or
data on incidence, gender, age, hesitation marks/defense wounds alternating low frequency (<5 KHz) current, applied to the body, was used
localization, fatal wound(s) pattern and blood alcohol concentration to measure electrical resistance. The alternating current will reflect both
(BAC) was compiled. Data was statistically analyzed in order to highlight the extracellular compartment (electric resistance) and the intracellular
differences between hesitation marks and defense wounds. compartment (capacitive resistance).
Hesitation marks: A total of 58 sharp force suicides (7 women; 51 Initially, measurements were made on 34 fresh bodies, with a known
men) were found, of which 74% (n=43) were positive for hesitation time of the death, less than five hours postmortem. Electrodes (patches)
marks. Seventy-one percent of women and 74% of men presented were applied on the skin with a distance between patches of 10 cm, on the
hesitation marks and women showed a significantly higher amount of chest, abdomen, arms and thighs. Bodies were placed in a room at
hesitation marks compared to men (p<0.05). Victims were aged from 23 constant ambient temperature (approximately 18 - 20 °C). Measurements
to 83 years with an average age of 43 years for cases with hesitation were performed using an impedance meter that automatically recorded the
marks. The three most frequent locations of hesitation marks were neck values of resistance (R), impedance phase angle (theta), as well as the
area in 46% of cases, followed by left thoracic area (44%) and wrists body temperature (rectal probe) and the ambient temperature.
(39%). A positive correlation was found between the amount of fatal Measurements were recorded every ten minutes during the first 24 hours,
wounds and the amount of hesitation marks (p<0.001). When only one then every 15 minutes. The available time for the measurements was
fatal wound was found, absence of hesitation marks was noted in 39% of dependent on the interval between death and the time of the postmortem
cases. No correlation was found between BAC and presence of hesitation examination.
marks. The reactance (Xc) and the impedance (Z) were calculated using the
Defense wounds: A total of 149 sharp force homicides (59 women; recorded data. These results were compared with the postmortem interval.
60 men) were found, of which 61% (n=91) were positive for defense A variation was observed with the absolute values between the different
wounds. A significant difference between male and female incidence was bodies. On the other hand, with the relative values, a statistically
noted (71% compared to 54%; p<0.05) and women showed a significantly significant arithmetic correlation, was noted between the values of
higher amount of defense wounds compared to men (p<0.001). Victims’ reactance and impedance compared to the postmortem interval.
age ranged from six months to 82 years with an average age of 42 years The method of measurements using cutaneous bioelectrical
for cases with defense wounds. In terms of location, defense wounds were impedance may become a valuable analytic tool for the estimation of the
most frequently found on hands (78%), followed by arms (48%) and time of death in forensic medicine.
forearms (34%). Victims presenting with defense wounds showed a four Forensic Medicine, Postmortem Interval, Bioelectrical Impedance
times higher average amount of non-defense wounds. Absence of defense
wounds was noted in 80% of cases showing only one fatal wound. A
negative correlation was revealed between BAC and amount of defense
wounds (p<0.01). Indeed, the highest amounts of defense wounds were
noted in the absence of BAC, while the highest BACs were associated
G86 Postmortem Skeletal Survey Use
with the absence of defense wounds. in Pediatric Forensic Autopsies:
In conclusion, this retrospective study systematically compares A National Survey
features of hesitation marks and defense wounds and gives new insight on
medicolegal expertise in sharp force injury cases. Antoinette L. Laskey, MD, MPH, Children’s Health Services Research,
Hesitation Marks, Defense Wounds, Sharp Force Injury Indiana University School of Medicine, The Regenstrief Institute for
Health Care, 1001 West 10th Street, Bryce 2112, Indianapolis, IN 46202;
and Michele J. Catellier, MD*, Forensic Pathology Associates of
Indiana, LLC, 521 West McCarty Street, Indianapolis, IN 46225
G85 Estimation of Postmortem Interval
Using Bioelectrical Impedance The goal of this presentation is to summarize a national survey of
postmortem pediatric radiology practice, as reported by forensic
of the Human Body pathologists. This will provide an understanding of current practice
patterns and factors that may influence the type and extent of radiologic
Beat Horisberger, MD*, and Patrice Mangin, MD, PhD, Institute of tools that are utilized in the postmortem evaluation of forensic pediatric
Legal Medicine, University of Lausanne, 21, Rue du Bugnon, Lausanne, cases, and introduce possible consideration for future practice including
CH-1005, Switzerland creative funding sources and community resources.
After attending this presentation, attendees will understand the This presentation will impact the forensic community and/or
principles of a new tool for the estimation of postmortem interval, humanity by assisting the forensic pathology community in analysis of
bioelectrical impedance of the human body, in addition to the traditional how skeletal surveys are defined, and whether the current practices are
methods currently used. providing adequate information in cases of unexpected pediatric death
The method of measurements using cutaneous bioelectrical and/or suspected child abuse. In addition, it is anticipated that the results
impedance may impact the forensic community and/or humanity by will provide suggestions for alternative techniques and resources, as well
becoming a valuable analytic tool for the estimation of the time of death as creative funding sources in the area of postmortem radiography. Future
in forensic medicine. research should include a cost-benefit analysis of various protocols.

Radiography is an essential tool in the evaluation of suspected G87 Near Miss Incidents in Police
physical abuse in the living child. Postmortem radiological evaluation is
often included in the autopsy of a child or infant whose death is
Custody Suites in London, UK:
unexpected or suspicious for abuse. Just as in the living, discovery of A One Year Prospective Study
subtle injury at autopsy may be dependent upon ancillary studies.
Although the pathologist has the advantage of direct examination of the Jason Payne-James, MBBS*, Forensic Healthcare Services Ltd.,
axial skeleton during the postmortem examination, a routine autopsy does 19 Speldhurst Road, London, E97EH, United Kingdom; Rebecca
not allow for examination of the appendicular skeleton. Dissection of Teers, BA, Independent Police Complaints Commission, 90 High
distal extremities, for instance, may not be performed without radiologic Holborn, London, WC1V 6BH, United Kingdom; Stefania
studies that direct the pathologist to the location of potential injury. Menin, MSc, Independent Police Complaints Commission, 90 High
Previous studies have documented injuries such as metaphyseal fractures Holborn, London, WC1V 6BH, United Kingdom; and Margaret
that were unsuspected on external examination. Stark, LLM, MBBS, Forensic Medicine Unit, St. George’s Hospital,
According to the recently approved Forensic Autopsy Performance London, SW12, United Kingdom
Standards of the National Association of Medical Examiners, “…The
After attending this presentation, attendees will be able to identify
Forensic Pathologist or representative shall X-Ray all infants.” In
detainees at higher risk of harm while in police custody.
addition, in June 2004 a joint statement of the Society for Pediatric
Radiology and the National Association of Medical Examiners was
humanity by reducing harm to detainees.
published, advocating the use of high quality radiographs in a postmortem
Background: Every year a number of deaths will occur in police
child abuse investigation. The recommended appendicular postmortem
custody within the UK. Potentially preventable deaths in police custody
survey includes a minimum of frontal views of each arm (two films),
include those that involve illicit drugs, alcohol and deliberate self-harm.
paired hands (one film), paired legs (one film) and paired feet (one film).
This study examined near miss incidents (NMI) that did not result in death
It has been recognized that the use of radiographs as an ancillary
in order to develop a better understanding of risk factors for detainees in
study in postmortem examinations is typically routine. The extent of such
custody. For the purposes of this research NMI have been defined as ‘any
examinations, however, is not known. In the case of live children, recent
incidents which resulted in, or could have resulted in, the serious illness,
studies suggest that in facilities with fewer numbers of pediatric cases,
injury or self-harm of a detainee’.
skeletal surveys are used less frequently and tend to include fewer images
Aims & Methods: A prospective study of NMI was undertaken for
per study.
one year from May 2005 to 2006. Forensic physicians (FP) providing
A mail survey of pathologist members of the American Academy of
forensic medical services for the Metropolitan Police Service in London
Forensic Sciences was distributed throughout the United States and its
were asked to complete questionnaires on any incident that may have been
territories. The target population was pathologists who conduct autopsies
considered an NMI. The questionnaire proforma was developed following
on children <36 months of age. There were a total of three mailings, and
a pilot study. Ethical Committee approval was given for this study. The
a $2 incentive was included with each initial survey sent. The objective of
aim of the study was to identify NMIs and to assess whether such incidents
the survey was to (1) assess adherence to the NAME recommendations for
assisted in identifying indicators of increased risk within the police
postmortem radiography among pathologists conducting forensic
custodial setting. Data about all incidents were anonymised.
autopsies in children <36 months of age, and (2) to describe the spectrum
Results: 89 FPs voluntarily participated in this study. One hundred
of postmortem skeletal survey practices in a national sample of
twenty-four proformas were returned in the 12 months study period.
pathologists. The response rate was 259/470 (55%). Data were analyzed
Ninety-six were returned identifying the FP and 28 were completed
utilizing univariate descriptive statistics.
anonymously. 9 FPs returned > 2 proformas. Incidents were classified
Respondents reported handling one to approximately 2,000 pediatric
according to a) type and b) whether they were very likely or fairly likely
cases per year in a given office. Nearly every respondent (99.96%)
to result in a fatality. Each incident could have more than one type. Of 124
indicated that they obtained at least some imaging. The number of
responses, 36% said that if there had been no intervention, the incident
postmortem images obtained ranged from none to a “babygram” (i.e., one
was very or fairly likely to result in a fatality Of the 124 incidents reported,
or two frontal films of the entire body) to a set of 19-30 individual films
60 (48%) were related to suicide/self harm [28% likely to result in
that include multiple views of the axial and appendicular skeleton, to full
fatality]; 41 (33%) were drug related [49% likely to result in fatality]; 29
body MRI or CT scans. Most commonly, films were traditional X-Ray
(23%) were alcohol related [45% likely to result in fatality]; 23 (19%)
films although fluoroscopy and other techniques were also reported.
related to a medical condition / existing injury [65% likely to result in a
Nearly one third of the surveyed pathologists reported routine use of the
fatality]]; two (2%) were due to injuries sustained during arrest [both
“babygram” as their sole postmortem radiographic tool.
likely to result in a fatality]; eight (6%) were reported as being ‘other’
Most surveys are performed on site, at the location of the autopsy
types of incidents [38% likely to result in a fatality].
laboratory, and most are funded at the expense of the office. Other funding
Conclusion: This is the first prospective study examining risk
sources included state budgets, grants and insurance billing.
factors for NMIs in police custody in the UK. The data will help identify
Respondents reported using skeletal surveys most frequently when
particular groups of detainees at increased risk whilst in custody and will
foul play or abuse is suspected. Not all pathologists utilize postmortem
allow lessons to be learned in ensuring that care for such vulnerable
skeletal surveys in cases of presumed Sudden Infant Death Syndrome, or
individuals in custody is optimised.
when foul play is not initially suspected.
Police, Near-Miss Incidents, Death in Custody
Pediatric, Postmortem, Radiology

G88 Probability and Pathological is described involve a narrow (<2 cm) ligature, and 25-50% are complete
suspensions. It was reasonable conclude that no more than 10, and likely
Findings in Suicidal Versus Homicidal five or less of all of the hangings described in the literature review could
Hanging Deaths: A Case Study in have produced the same type of injuries as those seen in this hanging,
Forensic Epidemiology given the risk factors present. The prevalence of potentially similar cases
in the database ranged from 0-0.7%.
Michael D. Freeman, PhD*, Oregon Health and Science University Based on the forensic epidemiologic review, it was opined that 1)
School of Medicine, 205 Liberty Street, Northeast, Suite B, Salem, contrary to the assertion by the defense, the neck organ injuries observed
OR 97301 in the decedent do not commonly occur in similar circumstances, and 2)
such injuries are rare in suicidal hangings with the predictive variables
After attending this presentation, attendees will be introduced to the present in the subject case, as a reasonable scientific certainty. A Bayesian
application of weighted probabilities to pertinent pathological or other analysis of the evidence will be presented.
evidence to forensic decision making in a criminal matter; in the presented
Hanging, Probability, Homicide
case study, the determination in a hanging death of suicide versus
homicide.
This presentation will impact the forensic community and/or G89 Accuracy of Death Certification
humanity by demonstrating how probability plays an important yet
frequently unrecognized and/or improperly applied role in forensic
and Medical Examiner Notification
decision making. This and other concepts of Forensic Epidemiology will in Nova Scotia
be introduced in this presentation, raising awareness for forensic
pathologists and others who rely upon population-based data from which Kelly A. Dakin Hache, MD, PhD, Anatomical Pathology, Dalhousie
to draw conclusions. University, 5788 University Avenue, Halifax, Nova Scotia B3H 2Y9,
Probability is in constant use in forensic settings as a means of Canada; Petra A. Rahaman*, Forensic Science-Biology, University of
weighing the accuracy of specific conclusions, and it is used nearly as Toronto, 107 Linnsmore Crescent, Toronto, Ontario M4J 4K5, Canada;
often to give weight to conclusions. Opinions that include the terms “risk” and Matthew J. Bowes, MD, Nova Scotia Medical Examiner Service,
or “likelihood,” or the expressions “most often” or “would be expected (or 5670 Spring Garden Road, Suite 701, Halifax, Nova Scotia B3J 1H7,
not expected)” are all variations of probabilistic assessments. Such Canada
opinions imply both an underlying basis in population-based data as well
as a methodologically sound synthesis of such data. When probabilistic
of the spectrum of problems associated with errors in death certification
opinions are proffered in a forensic setting they should be scrutinized
and medical examiner notification.
carefully for their basis in epidemiologic data, as well as how the data has
been interpreted to apply to the case in hand.
humanity by providing the framework for assessing and designing
A case study is presented in which a 26-year-old Aboriginal man was
interventions to improve the accuracy of death certification.
found hanging from a sheet in a jail cell in Darwin, Australia in February
Improvements in the accuracy of death certification have important
of 1986. The postmortem examination revealed evidence of unilateral
implications for accuracy of Vital Statistics, basic science research, public
neck organ fracture (thyroid cartilage) and was ruled a suicide. The
health policy, and civil/criminal law implementation. Most importantly,
decedent’s widow believed that the death was a homicide, and brought
the accuracy of death certification is important for families, in terms of
forth collateral evidence supporting the charge. An international panel of
peace of mind and insurance claims.
eight forensic scientists was convened to re-examine the evidence, and it
Background: Information from Vital Statistics is an important
was concluded that there was sufficient evidence to justify a disinterment
resource utilized by clinical researchers, public health authorities, and
of the decedent, in part due to the fact that the neck organ injury was
officials of the Department of Justice. Major errors in death certification
thought to be unlikely given the circumstances of the hanging.
have been identified among physicians in academic institutions, as well as
In 2004 a civil case was brought against several defendants,
including the forensic pathologist who conducted the postmortem among officials in coroner systems.1,2 At the very least, the accuracy of
examination, charging them with a conspiracy to obscure the murder. One this information has implications for basic medical research, public health
of the theories raised by the defense was that neck organ fractures were policy, and civil/criminal law. Most importantly, the accurate certification
common in suicides resembling the circumstances of the death, a of death has important implications for the families of the decedent in
probabilistic determination. For this reason, a forensic epidemiologic terms of peace of mind and insurance claims. As such, it is important to
review of the case was conducted, including a review and analysis of the assess and to design interventions to improve the accuracy of death
relevant literature. certification on both a regional and national scale.
A comprehensive review of the published literature on observational Hypothesis: The role of the Medical Examiner Service (MES) is to
studies of hanging deaths in which neck organ injury was the independent determine the cause and manner of death in circumstances defined by the
variable revealed four validated predictors for the presence of neck organ Fatality Investigations Act (FIA). Under the terms if the FIA, all citizens
injury of varying strength (in nine studies describing 1342 cases): Age have the obligation to report a death, although most commonly this is a
greater than 30 (strong), duration of suspension (moderate to strong), member of a law enforcement agency or a physician. Despite established
ligature width of 1-2 cm or less (moderate), and suspension type (weak to guidelines for reporting, physicians often miss cases. There are likely two
moderate support for full versus partial suspension). components contributing to the numbers missed cases.
Based on the findings in the literature, the features of the this hanging 1. Non-compliance with the established reporting guidelines
(age 26, brief suspension duration [45 minutes], >4 cm ligature width, (not sure when to report)
partial suspension [feet in contact with the ground]) it was determined that 2. Inaccurate certification of death (not sure how to accurately
the neck organ injuries observed in the postmortem examination were assign cause or manner of death)
unlikely to have arisen from the observed circumstances of the hanging. Objectives: The objectives of this study are threefold: 1) to
Further, out of 1342 cases in the literature, ~180 were in males <30 years determine the proportion of cases missed during a two year period (2004-
of age, and among these there were only ten cases of neck organ fracture. 2005); 2) to determine the mechanisms by which these cases were
Although the ten cases did not describe the presence of the other three risk ultimately identified; and 3) to determine why these cases were originally
factors, approximately 75% of suicidal hangings in which ligature width missed as medical examiner cases.

Methods: All available case files from the Nova Scotia Medical Background and Objective: In the United States, two different
Examiner Service over a two-year period (January 1, 2004 to December types of medicolegal death investigative systems, namely, the Coroner and
31, 2005) were reviewed and those classed as “missed cases” were Medical Examiner, exist, the former, headed by an elected, often lay
included in the study. The nature of the missed cases was documented official, the latter, by an appointed physician, sometimes a pathologist.
with respect to the original certification of cause and manner of death, the The origin of the Coroner system dates back to English common law when
final certification of cause and manner of death, the mechanism by which the “crowner” was purely a political position; not surprisingly, such
the cases are identified as a “missed case,” as well as various political overtones have persisted to the present day. The Medical
epidemiological aspects of the cases. The results were evaluated using Examiner system, on the other hand, is, at its best, led by a physician,
descriptive statistical techniques. preferably a pathologist, who has formal training in medicolegal death
Results: The total number of medical examiner cases for the study investigation and in the performance of forensic autopsies. The
period is 1516 (742 cases in 2004 and 774 cases in 2005). Of these, the fundamental philosophical differences between the Coroner and Medical
“missed cases” made up 11% of the total number of cases investigated Examiner systems exert a substantial influence on the nature of the cases
(total 167 missed cases: 80 cases in 2004 and 87 cases in 2005). The that are selected by the medicolegal official to come to autopsy;
mechanisms by which “missed cases” are identified include cremation specifically, that the Coroner, in an effort to minimize spending and stay
approval 56% (93 cases), Vital Statistics 28% (46 cases), hospital within the budget, is more likely to authorize cases for autopsy that will
personnel 6% (10 cases), Trauma Registry 4% (7 cases), physicians 3% (5 potentially result in a criminal proceeding (or a high-profile civil
cases), family of decedent 1% (2 cases), policing agency 1% (2 cases), and litigation), most frequently violent (non-natural) deaths, while the Medical
other 1% (2 cases). In 22% of cases (37 cases) the physician classified the Examiner will have a greater tendency to pursue sudden unexplained
death as unnatural, yet failed to notify the medical examiner service. In deaths, the majority of which result in certification of a natural manner of
59% of cases (99 cases), the physician misclassified the case as natural death. The objective of this study was to determine whether this
when the manner was accidental. hypothesis was indeed valid by comparing a contemporary Coroner and
Conclusions: Both non-compliance with the established reporting Medical Examiner system.
guidelines (not sure when to report) and inaccurate certification of death Methods: This study reviewed deaths spanning a 14-year period
(not sure how to accurately assign cause or manner of death) contribute to from 1992-2005 that were reported to a coroner’s office (the Charleston
the numbers of “missed cases.” This study shows that 11% of medical County, South Carolina Coroner) and over a 6-year period from 2000-
examiner cases are originally “missed,” and are discovered by a variety of 2005 reported to a medical examiner’s office (the State of Delaware Office
mechanisms. This number represents the “tip of the iceberg” in that a of the Chief Medical Examiner [OCME]). Data were coded and analyzed
significant proportion of “missed” deaths are detected by cremation using the program SPSS for Windows, Version 14.0.
approval. It is worth noting that burial in Nova Scotia does not require Results: The breakdown of cases according to manner of death for
approval by the Nova Scotia Medical Examiner System. the two respective jurisdictions is as follows:
References:
1 Pritt, BS, Hardin NJ, Richmond JA, Shapiro SL. Death Certification Jurisdiction Number Natural Accident Homicide Suicide Undetermined
Error at an Academic Institution. Arch Pathol Lab Med. 2005; 129: 1476- of Deaths
Charleston 2,638 827 940 422 345 104
1479.
2 Parai, JL, Kreiger, N, Tomlinson G, Adlaf EM. The Validity of the
County (31.3%) (35.6%) (16.0%) (13.1%) (3.9%)
Coroner, SC
Certification of Manner of Death by Ontario Coroners. Ann Epidemiol. Delaware 4,608 2,302 1,437 230 529 110
2006 (article in press). OCME (50.0%) (31.2%) (5.0%) (11.5%) (2.4%)
Death Certification, Notification of Medical Examiner Service,
Missed Cases Comparison of the two medicolegal systems showed a negative
correlation (r = -0.046 [P = 0.018]) for 2,638 subjects. The difference
between the means of the two groups was 0.171 (95% CI = 0.107 to 0.235;
student’s t = 5.3; df = 2,637; P < 0.001).
G90 Comparative Analysis of Medical Conclusion: The proportion of natural deaths appears to have been
Examiner and Coroner Systems of substantially greater in the State of Delaware Medical Examiner
Medicolegal Death Investigation: jurisdiction while the percentage of homicides was significantly higher in
the Charleston County, South Carolina Coroner’s Office. While the
Is There a Bias Toward Manner of Death? obviously higher degree of inflicted fatal injury in Charleston County,
South Carolina is beyond the scope of this study, the greater percentage of
Michael J. Caplan, MD*, and Bamidele Adeagbo, MD*, Medical natural deaths in the Delaware OCME supports the hypothesis. More
University of South Carolina, Department of Pathology and Laboratory detailed analyses of these respective trends are necessary in order to create
Medicine, Suite 309, 165 Ashley Avenue, Charleston, the most effective and efficient medicolegal death investigative systems
SC 29425 possible.
After attending this presentation, attendees will become aware of Medicolegal Death Investigation, Manner of Death, Coroner/
some of the differences between a Coroner’s and a Medical Examiner’s Medical Examiner
jurisdiction regarding the relative percentages of natural and violent deaths
that are investigated by the respective jurisdictions.
humanity by encouraging critical examination of the differences between
Coroner- and Medical Examiner-based medicolegal death investigation
systems in order to learn more about the motivating factors behind the
decisions to investigate various types of deaths; to retain the most positive
and beneficial aspects of both systems; and, ultimately, to promote
practices that are sound from an investigative standpoint yet also cost-
effective.

G91 Preliminary Findings of the Bureau of The CMEC provides valuable information on the status and needs of
medical examiner and coroner offices in the United States. Information
Justice Statistics 2005 Census of Medical collected in the 2005 CMEC may emphasize specific funding
Examiner and Coroner Offices requirements or other areas that require further assessment of the nation’s
death investigation systems. These preliminary data represent the
Matthew J. Hickman, PhD, and Kristen A. Hughes, MA, U.S. compiled data that will be available in a comprehensive BJS report on
Department of Justice, Bureau of Justice Statistics, 810 7th Street NW, http://www.ojp.usdoj.gov/bjs. Understanding these issues will inform the
Washington, DC 20531; and Jeri D. Ropero-Miller, PhD*, and Kevin J. development of plans to improve both the efficiency and functionality of
Strom, PhD, RTI International, 3040 Cornwallis Road, Research medical examiner and coroner offices.
Triangle Park, NC 27709 Medical Examiner, Coroner, Census
After attending this presentation, attendees will gain an enhanced
understanding of the nation’s death investigation systems. The
presentation will be based on findings from the Bureau of Justice Statistics G92 Pituitary Macroadenoma Presenting
(BJS)-funded Census of Medical Examiner and Coroner Offices (CMEC). as Hhypothermia: A Case Report
humanity by providing the forensic community with reliable and
Michelle A. Jorden, MD*, Adrienne Segovia, MD, and Edmund R.
previously unavailable information on the personnel, functions, resource
Donoghue, MD, Cook County Medical Examiner’s Office, 2121 West
needs, workload, and specialized death investigations reported by U.S.
medical examiner and coroner offices.
Medical examiner and coroner offices serve the public by conducting The goal of this presentation is to present an uncommon cause of
medicolegal investigations, primarily of unnatural or suspected unnatural hypothermia due to a brain tumor and highlight the importance of central
deaths, throughout the United States. The 2005 Census of Medical nervous system causes that affect body temperature regulation.
Examiner and Coroner Offices (CMEC) represents the first data collection This presentation will impact the forensic community and/or
effort by the Bureau of Justice Statistics (BJS) to focus on medicolegal humanity by demonstrating an unusual cause of hypothermia.
investigations of death. The goal of the census is to provide accurate and Hypothermia is diagnosed when an individual’s body temperature is
timely information on the capabilities and resource needs of medical below 95°F (35°C). In forensic pathology practice, the most common
examiners and coroners. RTI International, a nonprofit research cause of hypothermia is exposure to low temperatures without adequate
organization, administered the census on behalf of BJS. warming measures. It is not uncommon for individuals to present to the
Medical examiner and coroner offices were asked to voluntarily emergency room having been exposed to extremely cold temperatures and
complete the census, which covered a variety of topics, including then subsequently to die. In these cases in particular, forensic pathologists
jurisdictions, budgets, funding sources, staffing, workloads, data and must rely on documentation of body temperature within the medical
database usage, records and evidence processing and retention, and records to assess whether hypothermia may have caused or contributed to
investigations of infant deaths and unidentified decedents. The collection death. In cases in which hypothermia is a cause or contributing factor to
effort began in October 2005, when the census was mailed to 1,920 death, the manner of death is rendered as an accident. The extreme ages
medical examiner and coroner offices. As Hurricane Katrina had recently of life, those encompassing the very old and young, are most vulnerable to
devastated the states of Louisiana, Mississippi, and Alabama, the census hypothermia because of debilitating disease or lack of self-nurturing skills.
was not sent to these states during the first phase of the data collection The body responds to hypothermia by increased heat production through
effort. In February 2006, the census was mailed to 154 medical examiner peripheral vasoconstriction and shivering. Shivering ceases between 85-
and coroner offices in Alabama and Mississippi. The data collection effort 90°F and the loss of hypothalamic function to regulate temperature ceases
will be finalized by August 2006. below 85°F. Once compensatory measures fail to increase heat
A multimodal data collection process enabled the death investigation production, individuals can experience ventricular fibrillation and death.
offices to complete the census by mail, facsimile, or Web Less commonly, and rarely documented in the literature, brain lesions
(https://cmec.rti.org). All offices were mailed a unique access code for can cause hypothermia.
Web access. In a final effort to improve response, RTI and BJS developed A 59-year-old black woman who initially came to clinical attention
a reduced-length survey instrument that collected basic information about in May 2006 after falling out of her wheelchair and hitting her head on a
laboratory operations. Currently, the overall response rate for the CMEC concrete floor in her room at a nursing home. She had a history of a brain
is 85%, and the response rate for offices covering populations of 250,000 tumor and was on warfarin for deep venous thrombosis. The subject was
or more is 92%. Of the 49 states included (Louisiana was omitted), 23 had taken to the emergency room to obtain a brain CT scan, as mandated by
a 100% response rate across their medical examiner and coroner offices. the nursing home protocol. En route to the hospital, the patient became
Overall response rates for medical examiner and coroner offices were hypotensive and was cool to touch. In the emergency room the patient was
similar. hypothermic with a temperature of 29°C (84°F) and continued in a
This presentation will highlight similarities and differences in the hypotensive state. A CT scan of the head was negative for hemorrhage.
nation’s medicolegal death investigation systems. Variables include the Once her blood pressure was stabilized with vasopressors, the patient’s
types of systems found across states, expenditures, caseload measures by hospital course was complicated by administration of antibiotics for a
type of procedures involved, turnaround times for case completion, presumptive diagnosis of sepsis and subsequent development of
investigation protocols, and reporting levels for specialized death anaphylaxis. She was intubated after upper airway swelling and
investigations. For example, the geographical distribution of types of developed adult respiratory distress syndrome, which ultimately led to her
offices, as well as aggregate population and jurisdictional coverage, will demise two days later.
be detailed. In addition, the number of accepted cases for 2004 will be At autopsy, there was diffuse consolidation of all the lung lobes and
presented, with discussion of the various functions performed on a case, microscopic examination revealed diffuse hyaline membranes without
such as death scene investigation, autopsy, toxicology, and crime scene organization. There was minimal laryngeal swelling. The skull showed
processing. This presentation will also summarize the policies for evidence of a prior craniotomy site and an organizing subdural hematoma.
handling unidentified human decedents and infant deaths, as well as the The sella turcica was markedly enlarged and contained a 2.3 X 1.8-cm
related caseloads and resource needs. pituitary macroadenoma containing a small area of hemorrhage. The

macroadenoma grossly compressed and distorted the overlying presence of diatoms, identification, and comparison. Images were
hypothalamic area. Microscopic sections of the hypothalamic area recorded of the different genera observed under the microscope. The
revealed a symmetrical compressive infarct consisting of rarefaction of second experiment consisted of manually transferring some of the samples
glial tissue, numerous axonal spheroids, and collections of parenchymal to different articles of clothing, in a spotted manner. The articles of
hemosiderin. The cause of death rendered in this case was hypothermia clothing examined were a white cotton t-shirt, white socks, and jeans.
due to pituitary macroadenoma and the manner of death was rendered as Each piece of clothing was cut in small pieces measuring three by four
natural. inches. The samples once impregnated with the marine, brackish and
This is an unusual case of a macroadenoma causing overlying freshwater samples were placed in plastic containers (16 oz) used for this
compression of the hypothalamus. It is concluded that compression of the experiment. These samples were treated and processed in the same manner
overlying hypothalamic area by the pituitary macroadenoma caused a as the first experiment.
disruption in the thermoregulatory function of the hypothalamus, thus Diatoms were recovered from all the samples collected, and a
causing hypothermia. The fall may have contributed to focal hemorrhage qualitative analysis was performed. Diatoms were abundant in the
and enlargement of the pituitary macroadenoma with further compression estuarine and freshwater samples. On the other hand, the seaweed sample
of the hypothalamus and subsequent development of symptoms. yielded the least amount of diatoms, and only six different genera were
Hypothermia, Pituitary Macroadenoma, Death observed. To determine if a common habitat or source could be indicated;
comparison of the diatoms from different samples showed a total of 23
genera in all samples collected. For recovering the diatoms of different
fabrics such as pieces of t-shirt, sock, and jean material, results showed
G93 Diatoms and Their Forensic Significance 66% success. These findings prove that diatoms can be recovered,
analyzed and can be categorized as trace evidence.
Ismail M. Sebetan, MD, PhD*, and Irelise C. Clendenin, MFS, National In conclusion, diatoms have proven to be a powerful tool that can be
University, 11255 North Torrey Pines Road, La Jolla, used as evidence in forensic cases. It was concluded that diatoms could be
CA 92037 transferred to different items of clothing, car carpets, sneakers, etc., if an
The goal of this presentation is to demonstrate that diatoms could be individual comes in contact with an area where diatoms are expected to be
critical evidence in criminal investigations when aquatic communities are present. These results can be used to educate crime scene investigators and
involved. This research shows that diatoms are a good example of trace police officers on what kind of valuable evidence should not be
evidence and very valuable investigative tools, which can be used to link overlooked at a crime scene or evidence items that show the presence of
an individual to a crime scene. Additionally, this study findings support soil, mud, or water.
that these microorganisms can be recovered by using a simple Trace Evidence, Diatoms, Crime Scene
methodology; and providing investigators with a reliable and quick
technique that could help them determine the presence of diatoms in
physical evidence recovered from a crime scene and/or individual. G94 Evaluation of NT-proBNP as Marker of
humanity by showing that diatoms could be critical evidence in criminal Heart Failure in Postmortem Examination
investigations when aquatic communities are involved. This study will
provide investigators with a simple, reliable and quick technique that Katarzyna Michaud, MD*, and Marc Augsburger, PhD, Institut
could help them determine the presence of diatoms in physical evidence Universitaire de Médecine Légale, Bugnon 21, Lausanne, 1005,
recovered from a crime scene and/or individual. These results can be used Switzerland; Nicolas Donzé, Consilia, Grand Champsec86, Sion, 1950,
to educate crime scene investigators and police officers on what kind of Switzerland; and Marc Bollmann, MD, Béat Horisberger, MD, Bettina
valuable trace evidence should not be overlooked at a crime scene or Schrag, MD, and Patrice Mangin, PhD, Institut Universitaire de
evidence items that show the presence of soil, mud, or water. Médecine Légale, Bugnon 21, Lausanne, 1005, Switzerland
Diatom analysis could help determine if the person was dead or alive The goal of this study was to evaluate the new biochemical marker
when the body is removed from the water. Because of the diatoms vary NT-proBNP in postmortem examination as a tool for diagnosis of heart
morphologically and taxonomically depending on their habitat, it is failure in cases related to coronary ischemia.
possible to determine the location or site of drowning. Moreover, if there This presentation will impact the forensic community and/or
is a possibility of linking a victim to the site of the drowning, there is also humanity by showing that measurement of NT-proBNP is reliable in
a possibility of linking a suspect to a crime scene. It is imperative to try to postmortem examination and should be considered as a useful tool for
recover as much evidence as possible from a crime scene, especially; the autopsy diagnosis of acute or chronic heart failure, whatever its origin.
type of evidence cannot be seen with naked eye such as trace evidence. Introduction: Natriuretic peptides are synthesized and secreted by
Therefore, recovering diatoms from a crime scene or from articles of cardiomyocytes in response to increases in wall stress and their plasma
clothing of the victim or a suspect can provide an important evidence for levels are elevated in patients suffering from myocardial infarction with
use in criminal investigations. The use of diatoms for forensic purposes in systolic dysfunction. Many publications consider one of these peptides,
the United States is very limited and under-utilized BNP, as an excellent marker of heart failure. Recently, in clinical
Samples used in this study were collected from three different bodies medicine, the amino terminal part of pro-BNP (NT-proBNP) was
of water; marine (beach shore), brackish (estuarine), and from a freshwater introduced which is secreted in equivalent proportion to BNP. According
source (lake). Neutralized buffered formalin (NBF 10%) was added to to the published studies, this new cardiac marker has a longer half-life and
each sample to fix and help in the preservation of the diatoms. The a better stability in comparison to the BNP. Moreover, many authors
temperature and the pH of the water were recorded at the time the samples considered high levels of NT-proBNP as an independent predictor of
were collected, as well as the ambient temperature. Samples were stored mortality.
at 4ºC. The first goal of this study was to measure the levels of NT-proBNP
Under restrict sterile condition; the samples were centrifuged for in patients with coronary syndromes and compare them to a control group.
three minutes at 2982 rpm and then re-suspended in a few drops of As serum is not always available during postmortem examination, the
distilled water. A drop of each sample was placed on a glass slide and a second goal of this study was to evaluate a correlation between NT-
high refractive index mounting medium was used to fix the cover slip to proBNP levels measured in serum, blood, aqueous humor and pericardial
the slide. The samples were observed under the microscope for the fluid.

Material and Methods: This study included 34 cases. 25 patients nodule was identified in the right lower lobe of the lung. The remainder
presented an ischemic heart disease (21 men and four women), in 15 of of the internal organs were unremarkable. Microscopic examination of the
them postmortem examination revealed an acute coronary syndrome. In a breast masses revealed a primary non-epithelial breast neoplasm with
control group were included nine cases (5 men and four women) without involvement of the heart, lung and adrenal glands. Immunohistochemical
cardiac pathology. According to the clinical history and autopsy findings, analysis of the tumor was consistent with a large cell lymphoma of T-cell
the cases were classified into four groups. For each case, an autopsy origin (CD 45 +, CD 3 +, CD 20 -, pancytokeratin -, CD 57 – and ALK1
followed by a histological examination was performed. The examination -). Myocardial involvement included transmural infiltration, as expected
of the heart included a macroscopical examination and the analysis of at from the grossly visualized masses, as well as focal permeation of the
least five slides of the myocardium, stained with haematoxylin and eosin, atrioventricular node, which was not associated with a grossly visible
and with von Gieson trichrome. The putrefied cases were excluded from lesion. The enlarged lymph nodes were negative for lymphoma.
the study. Primary breast lymphoma (PBL) is a rare form of extranodal non-
Postmortem blood samples were centrifuged in order to obtain Hodgkin’slymphoma accounting for less than 1% of all breast
“serum.” The NT-proBNP measurements were performed in serum, blood, malignancies. Of these, the great majority will represent B-cell, rather
aqueous humor, and pericardial fluid using a chemiluminescent than T-cell lymphomas. PBL is bilateral in up to 25% of the cases and the
immunoassay kit (Elecsys 2010 analyzer, Roche Diagnostics). clinical presentation is similar to that of carcinomas of the breast, with the
Results: The highest serum levels were measured in patients with exception of slightly larger masses at the time of diagnosis. The growth is
acute coronary syndrome associated with chronic ischemic disease rapid, and several cases have been reported with recent negative
revealed by a clinical history or detected at autopsy. No significant mammograms, as in this case. Lymphoma has a high predilection to
difference was observed between patients with acute coronary syndrome involve the heart, with an incidence of 25%, second only to lung
and without previous ischemic disease in comparison to a control group. carcinoma. Most cases with cardiac involvement are clinically silent
In this preliminary study, the levels measured in blood, aqueous and/or have non-specific symptoms until they present with sudden death.
humor and pericardial fluid were in accordance with levels obtained from The mechanism of sudden death related to carcinomas and
serum. lymphomas is often not determined, as these deaths generally are not
Conclusions: Measurement of NT-proBNP is reliable in postmortem considered ‘unusual, unnatural or unexpected’ deaths and therefore may
examination. In this study, the results obtained for patients suffering from not fall under the jurisdiction of the medical examiner or coroner. Known
coronary syndromes are compatible with clinical data. NT-proBNP complications such as pulmonary emboli, treatment related problems,
measurement should be considered as a useful tool for autopsy diagnosis such as infection, or overall tumor burden are common enough processes
of acute or chronic heart failure, whatever its origin. that forensic pathologists typically don’t perform autopsies. Even when
Natriuretic Peptides, Coronary Syndrome, Heart Failure performed in a hospital setting, it is unlikely that the hospital pathologist
will examine the conduction system on such a case. As part of a thorough
autopsy in a medical examiners office, the cardiac conduction system (in
particular the atrioventricular node), is being examined more often and is
G95 An Unusual Case of Sudden Death occasionally revealing the underlying cause for the sudden death. Any
foreign cell population, whether neoplastic or inflammatory in origin, in
Luisa F. Florez, MD*, Baylor College of Medicine, One Baylor Plaza, the atrioventricular node can precipitate an arrhythmia which may result
Houston, TX 770303; Mary Anzalone, MD, Harris County Medical in sudden death. In the presented case, not only were the cause and
Examiner’s Office, 1885 Old Spanish Trail, Houston, TX 77054; and manner of death determined, but also the mechanism involved.
Carolina Gutierrez, MD, and Mario Cervantes, MD, Baylor College of
Medicine, One Baylor Plaza, Houston, TX 77030; Kathy Haden-Pinneri, Breast Lymphoma, Atrioventricular Node, Sudden Death
MD, Maximillian Buja, MD, and Luis A. Sanchez, MD,
Harris County Medical Examiner’s Office, 1885 Old Spanish Trail,
Houston, TX 77054 G96 Use of Beta-APP Stain in a
Case of Fatal Dog Attack
After attending this presentation, attendees will learn the importance
of implementing the dissection of the atrio-ventricular node in all Paul L. Morrow, MD*, and Michael Rodriguez, MBBS, Department of
necropsies; but particularly in cases of sudden death. Forensic Medicine, 42-50 Parramatta Road, Glebe, New South Wales
This presentation will impact the forensic community and/or 2037, Australia
humanity by illustrating the utility of conduction system evaluation and its
association with mechanism of death as discovered in conjunction with an After attending this presentation, attendees will understand the use of
unusual breast neoplasm. beta-APP histopathological stain to diagnose early central nervous system
A 49-year-old Asian female was found dead in her residence. Two injuries.
weeks prior to her death, she presented to a local Emergency Room for Documentation of earliest stages of CNS injury is problematical.
pain and swelling of her right breast. Clinical examination revealed This presentation will impact the forensic community and/or humanity by
bilateral breast masses, suggestive of carcinoma. A mammogram was making forensic pathologists aware of the use of beta-APP stain to
ordered, but never performed due to the patient’s demise. Review of document mechanism of death in cases where traditional autopsy
medical records reveal a mammogram performed six months prior, which techniques may be inadequate, and illustrate the use of this technique in a
was interpreted as negative. Evidence of a recent biopsy was identified at specific case with relatively short survival time.
the time of autopsy; however, despite extensive searching the biopsy β-APP is a protein that accumulates in damaged neurons and has
results were never located. The autopsy revealed a 7 cm mass in the right been used to identify certain types of central nervous system injury. This
breast and a 2 cm mass in the left breast, both of which had an appearance study presents a fatal case of a dog attacking a two and one a half-year-old
clinically suggestive of carcinoma. The adrenal glands were completely child who was found unconscious by her mother in the dog’s mouth with
replaced by tumor nodules. The heart weighed 195 gm and the the dog “shaking the child back and forth.” The child’s shirt was described
posterolateral left ventriclular wall and interventricular septum contained as soaked with blood, and there was an undetermined, but “small,” amount
soft, white masses that ranged in size from 0.6 cm to 3.5 cm. There was of blood at the scene. There was no active bleeding from wounds upon the
no pericardial effusion or pericardial thickening. Of note, there were only arrival of first responders. The child survived unconscious, tachycardic
two (right neck and supraclavicular) enlarged lymph nodes but no axillary and hypotensive, with minimal bleeding from the wounds, for about 90
lymph nodes; despite the large tumor burden in the breasts. A small minutes during transport to hospital in the ambulance.

Autopsy confirmed soft tissue injuries (bite marks) to the neck, Both in diabetic coma and in alcoholic ketoacidosis there are high
including ligamentous injuries in the posterior nuchal region, a small levels of fatty acids and a disturbance of the metabolic balance that is
defect in the left jugular vein and a small epidural hemorrhage at the level influencing the citric acid cycle.
of the fifth cervical vertebra. There was no subdural or subarachnoid This study suggest that ketone body analysis should be done in cases
hemorrhage. Likewise, there were no obvious gross or microscopic of “fatty liver deaths” as there are indications that many of these deaths are
injuries to the brain, spinal cord or other internal organs to document the due to the increased fatty acid concentrations following a binge and a
mechanism of death. Positive β-APP staining of axons in the corpus subsequent development of ketoacidosis.
callosum and cerebral white matter was found, often in a perivascular Diabetic Coma, Hyperlipidemia, Cause of Death
distribution, and there was rather diffuse positive staining of many
neuronal bodies. Although axons stained positively in the corpus
callosum, the predominantly perivascular pattern of positive β-APP
staining suggested diffuse hypoxic injury to the central nervous system
G98 Forensic Diaphanoscopy Imaging:
resulting from shock and hypotension. A New Tool in Clinical Forensic Medicine
The β-APP stain documented potentially lethal injury to the central
nervous system in the absence of other specific anatomic findings, and Beat Horisberger, MD*, University of Lausanne, Institute of Legal
gives some indication of the mechanism of death. Generally, it is Medicine, 21 Rue du Bugnon, Lausanne, CH-1005, Switzerland;
considered that β-APP stain is positive as early as approximately two Sebastien Tanniger, School of Business and Engineering Vaud,
hours survival time. The documented survival time of one and a half hours HEIG-VD, 1 Route de Cheseaux, Yverdon-les-Bains, CH-1401,
is consistent with this, although it is somewhat earlier than often reported. Switzerland; and Patrice Mangin, MD, PhD, University of Lausanne,
This case illustrates the use of β-APP stain as an early marker of central Institute of Legal Medicine, 21 Rue du Bugnon, Lausanne, CH-1005,
nervous system injury before more traditional markers of injury may be Switzerland
obvious at autopsy.
Beta-APP, CNS Injury, Dog Attack principles of a new tool, the forensic diaphanoscopy imaging, and the
benefits in comparison with more classical method (forensic
diaphanoscopy), illustrated with practical examples of traumatic diagnosis
G97 The Postmortem Diagnosis in clinical forensic medicine.
of Diabetic Coma This presentation will impact the forensic community and/or
humanity by demonstrating how forensic diaphanoscopy imaging can
facilitate the diagnosis of signs of violence on living adult, victims of
Jørgen L. Thomsen, DMJ*, and Peter M. Leth, PhD, University of
aggression, or abused children.
Southern Denmark, Winsløwparken 17, Odense, DK-5000, Denmark
The classical forensic diaphanoscopy method has been developed
After attending this presentation, attendees can expect to learn about following the observation that there were no valuable methods to diagnose
a histology method that will make it easier to establish the postmortem non visible hematomas on living subjects, such as adults who had been
diagnosis of diabetic coma and with a perspective to the significance of assaulted or abused children. This method has been used in Lausanne for
hyperlipidemia. over ten years in forensic clinical expertise. It is a complementary method
This presentation will impact the forensic community and/or to the clinical examination.
humanity by significantly improving in the postmortem diagnosis of However, the probability of detecting a hematoma with this method
diabetic coma, but it is equally important to focus on the role of the lipids (sensibility) or the probability to diagnose correctly subcutaneous
in the abnormal metabolism of diabetics and alcoholics. hematomas (specificity) depends on the training and the experience of the
The postmortem diagnosis of diabetic coma has always been difficult examiner. An insufficiently trained person should expect false positive or
as one of the key markers of coma is a high glucose concentration, but this false negative results. The classical method of forensic diaphanoscopy is
concentration is rapidly decreasing after death. Only few laboratories are based on a subjective interpretation of the examiner. This is the reason
able to quantitatively detect ketone bodies, and the diagnosis is usually why the forensic diaphanoscopy imaging technique, based on objective
based upon a combination of the history, the glycated hemoglobin data, has been developed.
concentration and a semi-quantitative detection of acetone. Compared to the classical method, forensic imaging diaphanoscopy
It has long been known that in death due to diabetic coma there is a has the following characteristics:
vacuolization of the proximal tubules of the kidneys. This vacuolization 1. Use of an annular light source, aimed to integrate a centered
has until recently been believed to consist of glycogen, but it is now video camera, and to increase the diagnostic reliability.
known that it represents an accumulation of triglycerides. 2. An integrated miniature video camera will help maintaining a
In a consecutive series of fourteen cases of diabetic coma, lipid database of analyzed traumas, and offer a source of pictures to be
staining was performed on cryostat sections of the kidneys. It was processed later by digital systems (computers).
demonstrated in all of the fourteen cases that the vacuolization consisted 3. The digital processing of the acquired picture will improve both
of lipids. The sensitivity was thus 100 percent. sensibility and specificity in detecting non-visible subcutaneous
In alcoholic ketoacidosis, the lipid level in blood is high. So far, the hematomas.
authors have been able to perform lipid staining of one case of fatal 4. Automatic adaptation of the light source intensity, based on
alcoholic ketoacidosis and found the same phenomenon in the proximal subcutaneous tissues thickness (not depending on body mass and
tubules of the kidneys as in diabetic coma. corporal topography) and skin pigmentation.
It is thus likely that the deposition of lipids in the proximal tubules is 5. Automatic exclusion of opaque zones due to intravascular blood.
due to the high concentration per se and not increased permeability of the 6. Hematoma documentation using digital processing.
glomerulus as is seen in diabetics. Forensic diaphanoscopy imaging represents a major advance
There has only been little focus on lipids in forensic medicine. One compared to the classical method to diagnose traumas on living subjects.
reason may be the need to do cryostat sections if lipids are to be The technique is more user friendly and reliable, due to the use of
demonstrated in the tissue. Otherwise they will be disguised as empty technological assistance and computer information processing. Creating
spaces due to dissolving in alcohol during tissue embedding. legal documentation is easier and images from the system can easily be

integrated in reports. This reliable investigation method can easily the local media to warn the public about a deadly heroin product mixed
complete a clinical examination by making or confirming the diagnosis of with fentanyl. Syringes found next to the victims were sent by the
suncutaneous hematomas that are not readily visible. This method is also Chicago Police to the Illinois State Police Crime Laboratory for rapid
useful in excluding this diagnosis. It is a non-invasive and easy to use tool. testing, revealing the presence of fentanyl. The fentanyl was purchased
It is particularly useful when child abuse is suspected, when examining from street corner drug sellers as a white powder, in amount and
dark skinned persons where hematomas can be confused with skin color, consistency similar to heroin. Prior to this epidemic, fentanyl was not
or even among obese persons where deep hematomas do not appear or routinely tested for in the Cook County toxicology laboratory. A fentanyl
only appear after a significant period of time on the skin surface. testing protocol was begun for all suspected drug intoxication deaths after
The aim of forensic diaphanoscopy imaging is to facilitate the the epidemic was discovered, and then tested for retrospectively to
diagnosis of signs of violence on living adult, victims of aggression or September 2005.
abused children. Data of fentanyl intoxication deaths were retrospectively collected
Clinical Forensic Medicine, Diagnostic Imaging of Trauma, Invisible for the years 1995 through early 2006 from the Office’s database. As
Hematoma numbers of fentanyl intoxications accelerated in 2006, data was collected
and analyzed prospectively for entry into a real-time CCME Fentanyl
Intoxication Database. For January 1995 to November 2005, the CCMEO
averaged four cases per year (range 1 (1995, 2000) to ten (2002)). Criteria
G99 “Drop Dead”: An Epidemic of for certification for fentanyl intoxication deaths were similar to the office’s
Intravenous Fentanyl Deaths in criteria for opiate-related deaths. Intravenous fentanyl intoxication deaths
Cook County, Illinois: 2005 to Present from April 2005 through May 2006 are shown:
J. Scott Denton, MD*, Edmund R. Donoghue, MD, Mitra B.

Kalelkar, MD, and Nancy Wu Chen, PhD, Cook County Medical
Examiner’s Office, 2121 West Harrison Street, Chicago, IL 60612-3705
The goal of this presentation is to understand that fentanyl has
suddenly appeared as an intravenous drug of abuse, and that medical
examiners, public health officials, and emergency physicians should
realize that clusters of sudden death may appear as an epidemic of fentanyl
intoxications.
humanity by demonstrating the response of the medical examiners office
to a sudden onset and ongoing epidemic of sudden unexplained death,
subsequently found to be from illicit intravenous fentanyl abuse. This has
implications for public health in monitoring and quickly diagnosing
clusters of sudden unexpected death in an urban population.
In November 2005 in Cook County, Illinois, an epidemic of
intravenous fentanyl deaths began and quickly accelerated, and has not
slowed as of June 2006. This epidemic of fentanyl intoxication in Cook Fentanyl-related deaths initially appeared in November (2),
County has not been previously described. Prior to 2005, fentanyl accelerated in December (12), stabilized in January (10) and February (9),
intoxication fatalities, or fentanyl-related deaths, in Cook County were but then accelerated again through March (12), April (24) and May (44).
almost exclusively from abuse or misuse of fentanyl transdermal delayed- Initial June data shows this upward trend is continuing. Of the fatalities
release patches. Fentanyl is approximately 50 times more potent than from April 2005 through May 2006, 96 were male and 20 female. The
heroin, and is a synthetic opiate used clinically during invasive medical average and median ages were 40 years, with a range of 16 to 61. The
procedures and for outpatient pain control through a transdermal patch average concentration of fentanyl in postmortem peripheral blood was 23
delivery system. Some of the more unusual fentanyl intoxications in Cook ng/ml (median 17; range 0.9 to 134). These 116 fentanyl epidemic deaths
County have been previously presented (Wu Chen, N, et al. Suicide by through May 31, 2006, were further subcategorized as fentanyl
transdermal patch, AAFS abstract K19, Orlando, FL, 1999). intoxication without other drugs (43, 37%); fentanyl and opiate
Cook County, Illinois, is a compact major metropolitan area of intoxication (20, 17%); fentanyl and cocaine intoxication (29, 25%);
approximately 5.5 million people within an area of 950 square miles that fentanyl, opiate and cocaine intoxication (6, 5%); fentanyl, opiate, cocaine
surrounds and includes the city of Chicago. In December 2005 hospital and alcohol intoxication (3, 3%); fentanyl and alcohol intoxication (6,
emergency rooms began to report an increase of tight clusters of overdoses 5%); fentanyl, alcohol and opiate and intoxication (5, 4%); and fentanyl,
initially concentrated in the Near South Side of Chicago. In the cocaine and alcohol intoxication (4, 3%). This data shows that fentanyl is
emergency department setting, some of the survivors’ urine toxicology being sold in Chicago predominately as a single drug, not as a so-called
testing results was positive for opiates from heroin, but some were not, “tainted heroin” product. But it also shows that fentanyl is being abused in
even though all showed clinical signs and symptoms of a rapid acute combination with heroin or cocaine, although less frequently. Other drugs
opiate overdose. At the same time, fatalities occurring in these small detected with fentanyl could either represent the purchase of a combined
clusters of apparent opiate intoxications were brought to the Cook County product, or the concurrent use of each individual drug. The origin of this
Medical Examiners Office for examination. illicit white powder fentanyl and the reason for its rapid and continued
Death scene investigations and histories of these fatalities often influx into the Chicago land area is currently under intense investigation
showed a rapid collapse after the injection and the term “Drop Dead” was by numerous government agencies.
coined on the street to describe this new “tainted heroin.” The police used Fentanyl Intoxication, Sudden Death, Cook County, Illinois

G100 Bidding for Poison: The New Availability likely had cases where relatives alleged poisoning, although no access or
specific substance was implicated.
of Poisons and How to Use Them Medical examiners, previously protected by the obstacle of access to
deadly poisons, need to lower their indices of suspicion for cases of
Rebecca A. Irvine, MD*, University of New Mexico, Office of the poisoning. Courtesy of the Internet, access and knowledge of use are
Medical Investigator, MSC 11 6030, University of New Mexico, widely available. Not only must appropriate toxicological analysis be
Albuquerque, NM 87131-0001 considered and performed but also law enforcement investigators with
After attending this presentation, attendees will have an awareness of computer crime experience must be involved in a timely fashion.
the facilitative role of the Internet in obtaining and using deadly poisons Poison, Access, Internet
and the impact this will have on forensic investigators, pathologists,
toxicologists, and computer criminologists.
This presentation will impact the entire forensic community by G101 Cluster of Fentanyl-Tainted Heroin Deaths
highlighting the ease of access to deadly poisons and guidelines for lethal
use on the Internet. In cases of an apparently negative autopsy and/or in a Three-Week Period in Maryland
vague allegations of poisoning by family, the threshold of suspicion has
been raised by almost universal access through the Internet. Strychnine, Mary G. Ripple, MS, MD*, Barry S. Levine, PhD, and Rebecca Jufer-
the poison inadvertently obtained for this study, should also be considered Phipps, PhD, Office of the Chief Medical Examiner, State of Maryland,
in unexpected death in athletes. 111 Penn Street, Baltimore, MD 21201; Erin Artigiani, Center for Drug
An online bid was placed on a collection of antique pharmaceutical Abuse Research, 4321 Hartwick Road, Suite 501, College Park, MD
bottles, some of which were known to have originally contained strychnine 20742; Suzanne Doyon, MD, Maryland Poison Center, 20 North Pine
sulfate, and which were purchased for an extremely reasonable sum. Street, Baltimore, MD 21201; and David R. Fowler, MD, Office of the
The bottles arrived by UPS Ground, left on the doorstep. While this Chief Medical Examiner, State of Maryland, 111 Penn Street, Baltimore,
seemed unusual at the time, the seller was clearly paying homage to the MD 21201
prohibition of sending toxins through the USPS. There were several After attending this presentation, attendees will understand the public
bottles of strychnine sulfate, most of which unexpectedly contained the health significance of cooperative efforts between the Office of the Chief
pure substance, a fact verified by the Toxicology office associated with the Medical Examiner (OCME), the Maryland Drug Early Warning System
Office. The seller had no knowledge of the author’s occupation or intent (DEWS) at University of Maryland’s Center for Substance Abuse
for the purchase. There was no communicated warning. Research (CESAR), the Maryland Poison Center (MPC), and the
Strychnine has a long and colorful history, becoming available in the Maryland State Police (MSP) in the ability to detect a cluster of fentanyl-
early 19th century as a “tonic” for people and a poison for pests (and, tainted heroin deaths in a short period of time.
arguably, for people). It binds at stimulatory receptors in the central This presentation will impact the forensic community and/or
nervous system as well as the inhibitory receptors, resulting in a massive humanity by presenting the problems of detecting fentanyl by routine
over-transmission of signals. Although caution has always been opiate screens and by emphasizing the importance of drug surveillance
recommended with its use, the therapeutic applications were myriad and systems to detect emerging drug trends.
included impotence, alcoholism, constipation and prolapsed uterus. It may Fentanyl is a fast-acting, highly potent synthetic opioid agonist that
have had a limited clinical role in the treatment of surgical shock and is approximately 50-100 times more potent than morphine. Overdose
congestive heart failure. It is to this day on the list of banned substances effects occur rapidly and death occurs primarily from respiratory
for athletes, having been implicated in the win of the 1904 marathon depression. Regional outbreaks of “super potent heroin” have been
(along with raw egg and brandy, which carry their own risks). Eventually, reported in the past. The outbreak in April and May 2006, of which this
of course, it was recognized that the risk far exceeded the therapeutic presentation is a part, included over 120 deaths in the Midwest, Northeast,
benefit and its use was abandoned. It is currently available to athletes as and Mid-Atlantic regions. The primary markets included Chicago, IL,
the herbal nux vomica. Detroit, MI, Philadelphia, PA, and Camden, NJ. In May 2006, authorities
It is hardly a perfect poison for homicide because of its bitter taste seized a fentanyl laboratory in Toluca, Mexico and this was the suspected
and short delay in causing respiratory muscle paralysis. Acute poisoning source of the tainted heroin. A by-product of illicit fentanyl manufacture
may be treated symptomatically. It is, however, one of the most potent by the “Siegfried Method” is 4-Anilino-N-Phenethyl-Piperidine (4-
poisons known and may be administered through multiple routes, ANPP).
including dermal. The horrific terminal phase of convulsions may be Fentanyl is available by prescription as a transdermal patch, an oral
attractive to those with homicidal intent. lozenge and an injectable form. It is manufactured illicitly as powder or
Strychnine is tightly regulated but widely available as a rodenticide. tablets. Fentanyl is abused in any of the prescribed or illicit forms. More
The latter would be particularly unpalatable in the volume required for creative forms of abuse include, wearing multiple patches, scraping the
homicidal intent. The safety recommendations for underground drug off the patches and snorting or injecting it, and chewing and/or
rodenticide use are comparable to biosafety standards for autopsy. swallowing the patches. Fentanyl is not detected using standard urine
In his classic and arguably still relevant chapter on homicidal opiate immunoassays. As a result, negative tox screen results do not rule
poisoning, Adelson cites both access and knowledge of use as out a fentanyl overdose. Without performing a specific fentanyl
prerequisites for the poisoner. Both are within reach of those immunoassay, the accepted detection methodology for the blood or urine
accomplished in the use of the Internet. is gas chromatography. However, detection can be problematic in that
A disturbing study was conducted by the California Poison Control fentanyl is a late eluter and is usually present in very low concentrations.
System (Look what I found! Poison hunting on eBay, Clin Toxicol (Phila). At the OCME, fentanyl was detected in the biological specimens
2005;43(5):375-9)). Over a 10-month period, 125 individual products too following an alkaline extraction and analysis by gas chromatography-
dangerous for commercial use were identified on online auctions; 24 were nitrogen phosphorus detection. Fentanyl was confirmed by full scan
“supertoxic,” including strychnine. Even a cursory search identifies electron ionization gas chromatography-mass spectrometry (GC-MS).
guides to poisoning, including books in the popular press, some intended Fentanyl was quantitated by GC-MS, selected ion monitoring.
as a reference for crime novelists. There were 15 fentanyl related deaths in the State of Maryland from
All medical examiners have undoubtedly had cases that were 1/1/06 until the writing of this report and most were a result of the abuse
frustratingly negative for a cause of death. In addition, almost all have of the patch. A cluster of five fentanyl-tainted heroin deaths occurred from

4/22/06 to 5/12/06. The MPC and CESAR initially reported to the OCME She accepted PO charcoal while she was still alert, but rapidly
a series of 6-8 possible fentanyl-tainted heroin overdoses from the Eastern became unresponsive and went into respiratory failure, requiring emergent
Shore of Maryland two days after the autopsy of the first suspected death. intubation. In short order, her hypotension became so profound that she
That individual survived for two days in the hospital where opiate required a dopamine drip. Her pupils were symmetrically dilated to 4 to
confirmation was negative. Analysis of evidence from this scene by the 5 mm. An initial episode of pulselessness at 0005 AM resolved with
local MSP crime lab revealed fentanyl and procaine. These results cardiopulmonary resuscitative efforts. Levophed (norepinephrine
provided the first solid evidence that fentanyl was involved in this bitartrate, a sympathomimetic vasoconstrictor) and dopamine were
outbreak. At that time the OCME toxicology lab was alerted to look maximized to maintain a mean arterial pressure of 65 mm Hg. At 0153,
specifically for fentanyl. At a later date, the MSP crime lab also confirmed she became pulseless again, and remained in pulseless electrical activity
4-ANPP in the same evidence. Thus far there are five confirmed fentanyl during resuscitation until 0217. She maintained a pulse for thirteen
related deaths and three other suspected cases are currently under minutes, but became pulselss again at 0230; with the administration of 40
investigation. The age range of the deceased was 22 to 32 years old, four mg of vasopressin, she regained a pulse at 0233. Following this third
of five were Caucasian and four of five were male. Fentanyl cardiac arrest, with her pupils dilated and minimally reactive, the family
concentrations ranged from 0.001 to 0.049 mg/L. One of five cases was requested full resuscitative measures be discontinued, She survived in that
positive for fentanyl only, three of five were positive for heroin, four of condition until her final cardiac arrest at 0726. She was pronounced dead
five had morphine in their system, four of five had cocaine in their system, at 0736.
and five of five scenes had intravenous drug paraphernalia. The areas of At autopsy, she was a well developed, moderately obese (68”, 220 lb)
the state involved included Wicomico (1), Somerset (1), and Howard (1) woman with pale conjunctiva, without congestion of the face and neck.
counties, and Baltimore City (2). Numerous dental caries were visible on limited examination of the oral
Medical Examiner/Coroner’s offices need to be aware of the cavity. An abdominal scar correlated with internal signs of a remote
limitations in detecting fentanyl and in cases where investigation points to cholecystectomy and gastric bypass. There were no external wounds and
a drug death and routine toxicology is negative, the toxicology lab needs no wrist scars. Internal visceral examination was significant only for
to be informed of the possibility of fentanyl. A cooperative effort between diffuse fine renal cortical granulation in the absence of significant heart
the Medical Examiner/Coroner’s offices and state drug surveillance hypertrophy (heart weight 359 gm), and a 3” abdominal fat layer,
systems is critical in order to detect emerging drug trends of public health measured 2” below the umbilicus. Two quarter-inch foci of subgaleal
significance. hemorrhage were identified, and a thin film of subarachnoid hemorrhage
Fentanyl, Heroin, Tainted coated the left cerebral hemisphere and both occiptal lobes.
Histologic examination showed evidence of old ischemic disease in
the form of delicate, ramifying collagenous replacement of subendocardial
myocardium, to a degree surprising for the gross exam of the heart. There
G102 Suicidal Caffeine Overdose was slight emphysematous change of the lungs, sclerotic glomeruli of the
renal cortex, and superficial subarachnoid hemorrhage confirmed in the
Wendy M. Gunther, MD*, Tidewater District Office of the Chief Medical brain, without evidence of any arteriovenous malformation. No etiology
Examiner, 830 Southampton Avenue, Suite 100, Norfolk, VA 23510; for the subarachnoid hemorrhage was determined.
Connie M. Luckie, PhD, Department of Forensic Sciences, Toxicology performed on hospital admission blood was reported
Commonwealth of Virginia, 830 Southampton Avenue, Suite 400, negative for trazodone, quetiapine, methamphetamine or byproducts,
Norfolk, VA 23510; and Karen B. Looman, DO, Tidewater District Office cocaine or byproducts, opiates, or alkaline extractable drugs. Ethanol was
of the Chief Medical Examiner, 830 Southampton Avenue, Suite 100, reported positive at 0.05% by weight by volume. Diazepam was present at
Norfolk, VA 23510 a concentration of 0.07 mg/L without nordiazepam. Caffeine was present
After attending this presentation, attendees will learn of an approach at the extremely high level of greater than 180 mg/L.
to the evaluation of a multi-drug overdose suicide by history and Caffeine poisoning is a rare cause of fatal overdose. Caffeine use is
presentation. Recognition of the symptoms and signs of caffeine extremely widespread, to the degree that many toxicologic laboratories do
poisoning in a case of suicidal overdose. not test for it in routine specimens. Caffeine toxicity without fatal
This presentation will impact the forensic community and/or poisoning is frequently reported. The signs and symptoms of fatal caffeine
humanity by recognizing the existence of the abuse of caffeine in a poisoning in light of this case, and, in comparison to opiates, cocaine, and
suicidal overdose, how to assess the signs and symptoms of caffeine antipsychotic and antidepressant drugs, will be discussed.
overdose, and recognizing the signs and symptoms of other drugs when Discussion: Review of this cases will illustrate the forensic methods
assessing a multi-drug overdose. used to elucidate multiple drug death with overlapping signs and
A 44-year-old woman with a history of eight previous psychiatric symptoms.
hospitalizations and multiple previous suicide attempts was brought to the Suicide, Caffeine, Multi-Drug Overdose
emergency room by her daughter at 9:20 p.m. on the day before her death.
Her daughter related that she had made a suicide attempt by taking a
number of prescription and nonprescription pills. G103 Abuse of Prescription Narcotics: A Look
She was alert when she arrived, but her daughter gave the history for Beyond Prescription Monitoring Programs
her. She said her mother had taken large but unspecified amounts of
Cymbalta (duloxetine, an antidepressant), Vistaril (hydroxyzine, an
Gretchen A. Grisbaum, JD*, Quick & Associates, Inc., 21449 Marion
antihistamine with central nervous system sedative properties), Relacor (a
Lane, Suite 6, Mandeville, LA 70471; and Karen Ross, MD, Jefferson
dietary supplement chiefly composed of water-soluble vitamins and
Parish Forensic Center, 2018 8th Street, Harvey, LA 70058
alleged to regulate fat metabolism and homocysteine production),
Seroquel (quetiapine, an antipsychotic sometimes used as an After attending this presentation, attendees will have a broader
antidepressant), and an over-the-counter diet medicine, Stacker 2 (a diet understanding of the widespread problem of prescription narcotic abuse.
medication composed of camellia sinensis white and yellow leaf Additionally, the attendee will understand the liability of physicians,
polyphenols, yohimbine alkaloids derived from Pausinystalia Yohimbe pharmacists and pharmaceutical companies with regard to the dispensing
bark, 6’, 7’-dihydroxybergamottin, capsaicin, and anhydrous caffeine [150 of schedule II narcotics. Finally, the attendee will be introduced to an
mg per pill]). It was believed that she might also have taken trazodone (an alternative means to prescription monitoring programs for dealing with
antidepressant medication commonly sold under the brand name Desyrel). narcotic abuse.

This presentation will impact the forensic community and/or These experiences may be helpful in future investigations of murder by
humanity by informing the forensic community of the ongoing problem of poisoning.
schedule II narcotic abuse in this country while offering an alternative to Despite the common portrayal of murder by poisoning in movies and
currently utilized prescription monitoring programs used in some states. television, deaths from homicidal poisoning are rare. Since the scene and
This issue affects physicians, attorneys, law enforcement, and the findings can be subtle, the investigation of such deaths may be
community as a whole. challenging. The purpose of this paper is to present the nature and
Prescription narcotics enable individuals to undergo surgery and findings of homicidal poisonings seen in a large Medical Examiner’s
relieve pain for millions of Americans who suffer from legitimate chronic Office over a period of 20 year. The San Diego County Medical
pain. While millions of people suffer legitimately from pain, many others Examiner’s Office covers a population of approximately three million
obtain prescription narcotics for illicit purposes. This non-medical use of people.
prescription medications is a widespread problem and a serious public Poison can be defined as a substance that causes injury, illness or
health concern. In order to combat the illegal use of prescription narcotics, death primarily by chemical means. As such, a poisoning could involve
many states have established prescription monitoring programs (PMPs). any type of chemical, drug or medication and could be ingested, injected,
These programs collect data on the dispensing of certain narcotics from inhaled or even absorbed through the skin. The Medical Examiner’s
physicians and pharmacies and disseminate it to regulatory and law database from 1986 to 2005 was searched to identify all homicides that
enforcement agencies. While these state run PMPs are an asset to the involved some type of poisoning, overdose or intoxication. This was done
investigation of illegal narcotic use, various professional and special in several ways, including homicide queries for key words and visual
interest groups voice concerns about the application of prescription scanning of the causes of death. Cases in which the cause of the death was
monitoring programs. not a direct result of a poison, medication or drug administered by another
This presentation will offer an alternative to the prescription person were excluded. Also excluded were law enforcement restraint
monitoring program after a discussion of the factors involved in deaths and other deaths in which the victim was intoxicated or under the
dispensing prescription narcotic medications. An overview of narcotics influence of a drug or medication at the time they were killed by other
and their potential use and abuse will be addressed, as well as sources of means. In addition, cases of fire related deaths and deaths in hospice
illicit prescription narcotics for abuse. The physician duty of care owed to patients given high doses of medications for end of life care were
patients being treated for pain will be discussed. Included in this section excluded.
will be an overview of the widespread problem of the under-treatment of During this time period, there were a total of 3601 homicides. Only
pain in the United States, as well as the serious consequences of 12 cases were identified that were the result of some type of drug,
prescription drug abuse in this country. medication or chemical overdose or intoxication. This represents 0.33%
Deaths due to the use/abuse of prescription narcotics account for an of the homicides and is consistent with previous reports of 0.14 - 0.5%.
alarming number of deaths in many areas of the country as evidenced by Homicidal poisonings in general will be briefly discussed, and the
the autopsy results from Jefferson Parish, LA where in 2005, 22% of history and circumstances of the 12 cases will be presented along with the
autopsy cases were due to the acute effects of drugs - many involving toxicologic findings. A variety of substances were used, and in some cases
Schedule II narcotics often in combination and usually accidental. more than one agent was administered. The nature of the perpetrators and
Additional data on these cases will be presented. A third component of outcome of the cases will also be reviewed.
this presentation will assess the duty owed to patients by pharmaceutical Homicidal poisonings are rare, but by their very nature tend to grab
companies who manufacture prescription medications. This section will the attention of the public and news media. From an investigative
address the liability of drug manufacturers for failure to warn, as well as standpoint they may be difficult to detect, and one may wonder how many
liability for negligent marketing. The duty of care owed by pharmacists to cases are missed. These cases reveal a variety of circumstances,
patients will also be discussed including the scope of the pharmacist’s substances and perpetrators indicating that there is no stereotype for
duty, in addition to recent developments in the approach to pharmacist murder by poison.
liability. Murder, Poison, Homicidal Poisoning
An overview of current prescription monitoring programs will be
provided with particular attention to issues of privacy and confidentiality
of medical information. This section will also encompass the successes
and limitations of these programs and federal initiatives regarding G105 Vaccine Death: A Rare Case of
prescription monitoring programs. Finally, improvements to the current Anaphylactic Shock After
system of state prescription monitoring programs will be suggested Hexavalent Immunization
including a proposed alternative method of addressing prescription drug
abuse in the United States.
Stefano D’Errico, MD*, Francesco Maria Morreale, MD, and Raffaella
Narcotic, Prescription Monitoring Programs, Abuse Bisceglia, MD, Institute of Legal Medicine, University of Foggia,
Ospedali Riuniti, via L.Pinto 1, Foggia, 71100, Italy; and Rossi
Giuseppina, MD, Institute of Legal Medicine, University of Siena,
G104 Murder By Poison: Experiences of Policlinico Le Scotte, Siena, 53100, Italy
a Medical Examiner’s Office
After attending this presentation, attendees will learn of a rare case of
fatal anaphylactic shock after hexavalent (against diphtheria, tetanus,
Christopher Swalwell, MD*, Office of the Medical Examiner,
pertussis, poliomyelitis, Haemofilus influenzae type B and hepatitis B)
immunization in a three month-old female white infant is presented. The
The goal of this presentation is to review the number and nature of aim of the paper is to alert scientific community on reactogenicity of
homicidal poisonings encountered by the San Diego County Medical recent hexavalent formulation of vaccine.
Examiner’s Office during the last 20 years. The audience should gain a This presentation will impact the forensic community and/or
better appreciation of the complexities of investigating homicides humanity by demonstrating that any death that occurs within a few days
resulting from poisoning and the circumstances and nature of such deaths. of vaccination to be autopsied using immunohistochemical stainings,
This presentation will impact the forensic community and/or toxicological analysis on urine and blood specimens and detection of
humanity through a better understanding of the types and frequencies of femoral blood concentration of mast-cell Beta-tryptase to rule out
homicidal poisonings encountered in a large Medical Examiner’s Office. anaphylactic shock.

This case presentation concerns a first-born child, delivered at the shock because autopsy findings after acute anaphylactic death are generally
41st week of gestation by caesarean delivery, with a birth weight of 3.400 non-specific; a cutoff value of 10 ug/l has been established to be optimal,
g and Apgar scores of 9-10. The mother related no significant family with a sensitivity of 86% and specificity of 88%.
history, an unremarkable pregnancy and good heath of the baby, who was Hexavalent Vaccination, Mast-Cell Beta Tryptase, Anaphylaxis
bottle-fed. At three months of age the female infant received a hexavalent
immunization during a morning clinic visit. The mother stated that a few
hours after the immunization the baby had difficulty feeding. Early in the
afternoon the clinical condition of the baby got worse with the onset of
G106 Pattern of Injury in Child Fatalities
severe dyspnea, so she was immediately taken to the emergency Resulting from Child Abuse
department of the local hospital. A state of shock with critical acute
respiratory failure was diagnosed. The baby appeared pale and Ann H. Ross, PhD, North Carolina State University, Department of
unresponsive. The baby was hypotensive (systolic pressure 50 mmHg) Sociology and Anthropology, CB 8107, Raleigh, NC 27695-8107;
and tachycardic (180 bpm) with an undetectable diastolic pressure. Suzanne M. Abel, PhD, Charleston County Coroner’s Office,
Laryngoscopy was unremarkable. Laboratory tests revealed the presence 4050 Bridgeview Drive, North Charleston, SC 29405; Deborah
of hyper-eosinophylia and metabolic acidosis (pH 7.154) with blood Radisch, MD, MPH, Office of the Chief Medical Examiner, CB 7580,
desaturation (pO2 75.9 mmHg) and compensatory hypocapnia. Repeated Chapel Hill, NC 27599-7580; Beth Murnane, MD, Sunrise Pediatric
administrations of adrenaline by aerosol were given along with Associates, 3909 Sunset Ridge Road, Suite 103, Raleigh, NC 27607; and
intramuscular corticosteroids. Despite the aggressive intervention the Sheena Harris, BA, and Kelsie Ballance, North Carolina State
infant died two hours after arriving at the hospital. University, Department of Sociology and Anthropology, CB 8107,
A complete postmortem examination was performed two days after Raleigh, NC 27695-8107
the death. External examination was unremarkable, except for the
After attending this presentation, attendees will understand some of
immunization puncture site on the left thigh. The body was of a three
the contributing factors and demographic characteristics in child fatalities
month old, well-developed and well-nourished, white infant with a body
due to abuse.
weight of 4930 gr and body length of 55 cm. Internal examination was
unremarkable except for lungs presenting white foam in the main bronchi.
humanity by assisting the forensic community/humanity in identifying key
Histological examination revealed mild cerebral oedema, and a shock
elements in maltreatment child fatalities.
histomorphology of the main organs (lungs, liver and kidneys).
When evaluating injuries in young children, physicians should
Immunohistochemical analysis revealed the presence of numerous
consider nonaccidental trauma as an etiology of trauma. According to the
degranulating mast-cells in the pulmonary parenchyma. Toxicological
U.S. Department of Health and Human Services, in 2002, an estimated
analysis of blood and urine specimens for therapeutic and non-therapeutic
1,500 children died of maltreatment. Of these, 36 percent were as a result
drugs were unremarkable. Postmortem measurement of mast cell b-
of neglect, 28 percent were victims of physical abuse, and 29 percent were
tryptase in femoral blood was determined using the AA5 antibody ELISA;
due to multiple types of maltreatment. In 2003, children younger than four
high concentrations, more than 10 ug/l were recorded (11.3 ug/l).
years old accounted for 79 percent of all maltreatment fatalities, with 44
Adverse events following immunization are defined as medical
percent of these deaths occurring in infants (DHHS 2005). The purpose
incidents that take place after an immunization. Serious adverse events
of this study is to further examine the pattern of bony injuries in child
after vaccination have generally been defined as those adverse events that
maltreatment fatalities, with an emphasis on the prevalence of antemortem
result in permanent disability, hospitalization or prolongation of
fractures and the presence of associated perimortem fractures. The sample
hospitalization, life threatening illness, congenital anomaly or death. They
was 130 male and female children, ages 0 to six years of age. The majority
are generally associated with the inherent properties of the vaccine (vaccine
of the data were collected from the case files of the NC Child Fatality
reaction) or some error in the immunization process (program error). The
Prevention Team at the Office of the Chief Medical Examiner in Chapel
event could also be totally unrelated but only temporally related to
Hill North Carolina (n = 120). An additional ten cases were included from
immunization (coincidental event). The use of combination vaccines is an
the Charleston County Coroner’s Office, Charleston, SC. Six age
ideal way to simplify the simultaneous administration of multiple vaccines,
categories were used in this study: 1 (0 -3 months), 2 (4 – 6 months), 3 (7
reducing the number of injections, and may also be the most effective way
– 9 months), 4 (10 – 16 months), 5 (17 months – 2 years), 6 (2 - 6 years).
of ensuring high compliance rates to complex immunization schedules.
Each individual’s lesions were documented and categorized into one of
Recently, parental concern about polivalent vaccines has become
four general body loci (1 = craniofacial, 2 = thoraco/abdominal, 3 = other,
increasingly prevalent. Hexavalent vaccine has been developed for
4 = multiple). The prevalence of trauma and distribution of injury
primary booster vaccination of infants against diphtheria, pertussis, tetanus,
patterns were tested for independence and significance for biological and
poliomyelitis, Haemophilus influenzae type B and hepatitis B. Post
demographic categories (e.g. age, sex, race, month of death) using simple
marketing study confirmed the safety and immunogenicity of hexavalent
frequencies and Chi-square tests. In this study, the peak age categories of
vaccine as an alternative to other licensed vaccines. Members of the
death were 0-3 months (23 %) and two – six years (21.5 %), with 50
European Agency for the Evaluation of Medical Products in 2003
percent of deaths occurring in infants nine months old or younger. The
investigated whether there might be a link between hexavalent vaccines
two different age categories could reflect newborn stress and coincide
and some cases of sudden infant deaths occurred after immunization. It
developmentally with toddlers seeking independence, respectively. Black
was concluded that there was no significant benefit/risk profile of these
males were the most numerous victims. Deaths occurred most often in the
products, and, therefore, no changes in the present conditions of use were
month of December. The body locus most frequently affected was the
recommended. SIDS, viral infection, metabolic disorders, allergic reactions
craniofacial area, 55 percent, usually the result of blunt force trauma
or airway obstruction were plausible but were not definitely proven to have
(abusive head trauma). Notably, ante- or perimortem fractures were not
been the cause of death. Vaccine associated anaphylaxis is a rare
usually associated with known abuse deaths. In this study, eighty percent
occurrence with only few cases reported despite the million of doses
of the cases did not show any antemortem fractures. Thus in cases of
administered, giving a relative risk of 0.65 cases per million doses. It is not
suspected abuse, radiographic skeletal surveys may not be an effective
always clear which component of vaccine is involved in the anaphylactic
method for identifying or predicting the possibility of abuse, which
reaction (antigens, preservatives, adjuvants, manufacturing residuals).
suggest that current detection techniques need to be reevaluated.
Postmortem measurement of mast cell β-tryptase in serum is the only
possible means of diagnosing or confirming death due to anaphylactic Child Abuse, Fatalities, Injury Pattern

G107 Histopathology of Antemortem G108 The Likelihood of Inflicted Injury
Infant Bone Fractures: Is Better Evaluated by the Use of
Estimation of Time Since Insult Inconsistent Histories With the
Constellation of the Triad of Findings:
Murray K. Marks, PhD*, University of Tennessee, Department of
Anthropology, 250 South Stadium Hall, Knoxville, TN 37996-0720;
Subdural Hemorrhage, Brain Swelling,
and Darinka X. Mileusnic, MD, PhD, Regional Forensic Center, and Retinal Hemorrhages
University of Tennessee Medical Center, 1924 Alcoa Highway, Knoxville,
TN 37920 M.G.F. Gilliland, MD*, Brody SOM at ECU, Department Pathology and
Laboratory Medicine, Brody 7 S 10, Greenville, NC 27858
After attending this presentation, attendees will understand the gross,
radiologic and histological signatures of antemortem (chronic) and After attending this presentation, attendees will learn the value of the
perimortem (acute) infant bone fractures associated with child abuse and use of inconsistent histories obtained by investigation as well as autopsy
apply a general timetable to better estimate “time since insult” for wounds. findings in determining the likelihood of inflicted injury in children.
This presentation will impact the forensic community and/or This presentation will impact the forensic community and/or
humanity by providing a means of accurately dating antemortem fracture humanity by confirming that evaluating histories and autopsy findings is a
times, the pathologist and investigating team serving the pathologist can reliable method of ruling in and ruling out many possibly inflicted injuries
better pinpoint the association of a victim to suspect. This association (or in children.
lack thereof) will provide a date line to when wounds may have been Hypothesis: The reliability of the methods used to identify inflicted
received prior to death and help establish a history and pattern of abuse. injury deaths in children has been called into question in the global
Autopsy protocols that allow only macroscopic and radiological community. Reviewing a series of child deaths can test the use of the
evidence fail to provide adequate information about wound diagnosis and constellation of inconsistent histories with autopsy findings to diagnose
time since insult. The obvious importance of recognizing and evaluating such deaths.
evidence of this violence in cases of suspected child abuse is necessary to Synopsis: Correctly distinguishing inflicted from inadvertent injury
gain an appreciation a clear understanding of vulnerable bone, fracture site and from natural disease is critical to the criminal justice system. Certain
biomechanics and wound healing processes crucial to causation and patterns of injuries found clinically or at autopsy have been proposed to
response. Klotzbach and coworkers (2003) first qualified the radiological identify injuries inflicted on children. An observational study of the
and histological signatures relevant to “time since insult” indicators and neuropathology of inflicted head injury in infants and children by Geddes
this research follows that protocol and the procedures of Marks and et al in 2001 reported the frequent finding of: subdural hemorrhage,
coworkers (2005) by expanding those diagnostic criteria of for increased intracranial pressure, and retinal hemorrhages. Others have
microscopically qualifying and quantifying osseous apposition rates at advocated use of this triad of findings to make the diagnosis of inflicted
various postmortem intervals. The rich cellular osteogenic environment injury. A nursing education website asserts, “The triad of subdural
characteristic of growing bone demonstrates a unique response when hematoma, cerebral edema, and retinal hemorrhage represents a diagnosis
compared with static adult bone, regardless of location. of SBS (Shaken Baby Syndrome)”.
Twenty antemortem “healing” and five perimortem occult (hidden) Histories have been important in identifying inflicted injury. Inquiry
and acute fractures from ribs and various appendicular bones from four into the phenomenon of absent or fluid histories in the presence of
infant victims were radiographically and histologically assessed for degree subdural hemorrhages and extremity fractures led to the original
of bony response. The specimens were seized at autopsy and represent recognition of battered children.
various stages of healing. All were prepared as undecalcified dry thin A study of 169 child deaths compared the patterns of ocular and
sections using normal petrographic methods. Both dissecting and light systemic findings in children dying as the result of inflicted injury with
microscopy and SEM were utilized to document, diagnose/qualify and those found in injuries from motor vehicle collisions, falls, and various
quantify defects. asphyxial deaths and in natural disease. Inflicted injury was distinguished
Longitudinal and cross sections taken through wound sites reveal from accidental injury, undetermined causes, and natural disease by
telltale structural remodeling correlating to chronology. These include the investigation of medical and social history, and circumstances surrounding
location and degree of woven “blastic” bone proliferation during collapse as well as autopsy findings.
conversion and obliteration of the comminuted byproducts of the The validity of using a limited subset of histories and a limited subset
hematoma soon after trauma, subsequent manifestation of the of autopsy findings (the triad) to identify inflicted injury was assessed
transformation of the initial solid callus into bone and finally, full using data from the study. The immediate causes of death included: 76
mineralization and “clastic” remodeling of the callus. Besides recognition (45%) intentional injuries, 36 (21%) inadvertent injuries, 47 (28%) natural
of these qualitative events, the ability to recognize, document and causes, and 10 (6%) undetermined causes.
radiograph the wound at autopsy are described with a method for The triad of findings of subdural hemorrhage, brain edema, and
harvesting, processing for histology and the manner of embedding and retinal hemorrhages was seen in 47 of the total 76 (62%) inflicted injury
sectioning for light and scanning electron microscopy. Finally, while deaths and in eight accidental deaths of the total 36 (22%). The triad was
validation of these results was performed using light and SEM, utilization not seen in any of the 46 natural deaths or any of the 10 classified as
is made by dissecting microscopy. undetermined deaths.
Like previous research, this study demonstrated a detailed continuum The sensitivity of finding inconsistent histories with the presence of
of bone healing in rib and diaphyseal fracture calluses and among the triad was 80%. The negative predictive value of finding a consistent
diaphyseal surface woven bone proliferation. These data may imply one history when the triad was absent was 88%. The relative risk of the triad
of three isolated or correlated scenarios: differential inter-bone response to being found with an inconsistent history was 4.56 with confidence limits
similar forces causing breakage/trauma, differential wounding forces or of 2.53-8.20 and a P-value << 0.01.
chronological specificity in wound appearance. Finding the triad with more than one injury history showed good
Histology, Child Abuse, Bone Fracture sensitivity (85%). The negative predictive value of the finding was 87%.
The relative risk of the presence of the triad with more than one injury
history was 3.49 with confidence limits of 1.77-6.90 and a P-value <<
0.01.

In these subsets, consistent histories included confessions as well as children’s hospital from the local emergency room. She showed no
impartial information about events preceding injury. Specificity in these neurological recovery and was removed from life support approximately
cases was 69% and the positive predictive value was 56%. 50 hours following the restraining incident.
Similarly, certain unusual “multiple histories” became clear when At autopsy a 67 pound, normally developed female child was
further investigated. Since “more than one history” was used in defining examined. A recent abrasion to the left face and healing abrasions to both
the subset, these unusual cases yielded a calculated specificity of only 48% knees were seen. Serosal petechiae of the thymus and hilar visceral pleura
and positive predictive value of 44%. were present. An area of localized intra-abdominal serosal hemorrhage
Summary: Subsets of histories and autopsy findings can be reliably involved the mid transverse colon, distal stomach and pancreas with
used to identify deaths which are more likely to be the result of inflicted intrapancreatic extension. These findings were interpreted as possible
injury - deaths with an inconsistent history and the autopsy findings manifestations of compressional force, but may have resulted from
include the triad of subdural hemorrhage, brain edema, and retinal aggressive or misguided resuscitation. Early bilateral bronchopneumonia
hemorrhages. With a consistent history and no triad, inflicted injury is was also identified.
unlikely. With an inconsistent history, or multiple histories, and the Deaths during prone restraint are generally associated with police
presence of the triad, inflicted injury is likely. Thorough investigation and custody, with elements of excited delirium or illicit drug toxicity as
complete autopsy findings must be used to establish whether or not a potentially contributing factors. The importance of this case lies in the fact
particular child’s death was caused by inflicted injuries. that the restrainee was a child, with significant weight and size disparity
Triad (SDH, Brain Edema, RH), Inflicted Injury, Retinal from the restrainers. This restraint protocol placed significant weight over
Hemorrhages the torso of the child, and did not allow adequate visualization of the face
to monitor breathing and consciousness.
Prone Restraint, Compression, Asphyxia
G109 Compressional Asphyxia Due to
Prone Restraint Hold in a Child
G110 Combined Types of Violence in
Robert F. Corliss, MD*, Andrew M. Baker, MD, and Kathryn K. Child Abuse: Report of Three Cases
Berg, MD, Hennepin County Medical Examiner’s Office, 530 Chicago
Avenue, Minneapolis, MN 55415 Wendy M. Gunther, MD*, Leah L. Bush, MD, Elizabeth L. Kinnison, MD,
Department of Legal Medicine, Virginia Commonwealth University,
After attending this presentation, attendees will learn the dangers of
Medical College of Virginia, Tidewater Office of the Chief Medical
prone restraint with compression, particularly in children, and how to
Examiner, Commonwealth of Virginia, 830 Southampton Avenue, Suite
approach the autopsy and investigation of such cases.
100, Norfolk, VA 23510-1046; and Karen B. Looman, DO, Tidewater
Office of the Chief Medical Examiner, 830 Southampton Avenue, Suite
humanity by helping forensic scientists question the role of prone restraint
for behavior modification in children and consider alternative restraint
procedures and monitoring for combative children. After attending this presentation, attendees will learn how different
This presentation reports a case of compressional asphyxia due to a types of injury and neglect may contribute to child death in abuse, evaluate
prone restraint maneuver that occurred in a day treatment facility for the differential contributions of neglect and battering in child homicides,
children with behavioral problems. The decedent was a 7-year-old female recognize two or more distinct contributing causes to death in child
with a history of aggressive behaviors since the age of two. She was homicide, and evaluate impact of such recognition on courtroom
enrolled in the treatment facility for approximately one month, during testimony.
which time several disciplinary actions, including prone restraint, were This presentation will impact the forensic community and/or
employed for behavior modification. During extended prone restraints, humanity by demonstrating overlapping and concurrent types of injury
staff noticed she would appear to “fall asleep” after calming down, but was contributing to death in cases of child abuse, assessing relative
easily awoken. On the day of the fatal restraint, she was displaying contributions of injury and neglect in child homicide, and considering
improper table manners and reportedly “gargling” her drink during lunch. judicial outcomes and defense strategies in child homicides due to
After repeatedly ignoring staff requests to cease the behavior, she was combined types of injury.
taken for a five minute “cool-down” in a separate room. She became Forensic autopsy on battered children often identifies characteristic
aggressive, and was placed in a prone restraint control hold on the floor. findings such as evidence of head impact with and without shaking,
A small towel was placed under her head and two staff members employed beating with and without patterned injury, fractures of ribs and long bones
the restraint with one laying across the calves and holding the left wrist, in various stages of healing, liver lacerations and other visceral injuries,
with the other staff semi-prone across the back controlling the right arm and burns. Forensic autopsy on neglected children frequently reveals
and torso and monitoring the head. starvation, untreated medical illnesses, growth retardation, and dental
The two staff initiating the restraint were each relieved by another caries. Neglect may also be diagnosed at autopsy when a caretaker has
staff member at different times. The entire restraint was longer than an allowed a child to suffer injury through inattentiveness, such as when an
hour. The second staff controlling the torso was a 240-pound male who unwatched child drowns.
relieved his co-worker 30 minutes into the restraint. He noticed the child The concurrence of neglect and battering is less common. This case
to be combative and resisting when he took over. The child claimed she series presents two children who came to forensic autopsy because of a
needed to use the bathroom, and that she felt like she was going to throw combination of fatal neglect and fatal injury on the part of caretakers, and
up. It was apparently not uncommon for restrained children to make such one child whose fatal injuries were due to two unusual overlapping kinds
claims, and this child had recently vomited during a previous prone of violence, smothering and shaking/impact. Defense strategies and
restraint. The restraint continued uninterrupted, and the child calmed judicial outcomes for these cases are reviewed.
down, apparently falling asleep. It was noticed that she had urinated in her Case 1. Drowning and battering. A 3-year-old girl was left alone in
pants. After a reported period of about 30 minutes of no resistance, the a bathtub filled with water for what the mother described as ten minutes.
staff began processing the release. The child was not responding, and The mother stated that the girl was underneath the water when she
when turned over she appeared blue around the mouth and lips. returned, lifeless. Emergency medical services found the child lying on a
Resuscitative efforts were employed, and the child was air lifted to a couch in the livingroom, with a large amount of water on the couch. The

girl had numerous bruises, lacerations, and abrasions over the back, chest, G111 Brainstem Axonal Injury and Retinal
and extremities. Autopsy showed pulmonary edema with abundant froth
in the tracheobronchial tree, supportive of drowning. There were also
Hemorrhages as a Substrate for Sudden
healing fractures of the left clavicle and of a left rib, and numerous scars Death in Second Impact Syndrome:
of the head, trunk, and extremities; some of the wrist scars were due to A Case Report
ligatures. Malnourishment was diagnosed by the weight (less than 5th
percentile for a normal girl of the same age) and height (less than 25th Rudy J. Castellani, MD*, University of Maryland, Baltimore,
percentile), with a weight-to-height ratio less than the fifth percentile. 22 South Greene Street, NBW-81, Baltimore, MD 21201; and Joyce L.
Death was certified as due to drowning, with the manner homicide. deJong, DO, Division of Forensic Pathology, Sparrow Health System,
The mother was charged with felony second-degree murder in the 1215 East Michigan Avenue, Lansing, MI 48912
setting of felony child abuse and neglect. Defense strategy included the
argument that there was no connection between the abuse and the After attending this presentation, attendees will gain an assessment of
drowning. The mother was convicted. At the time of conviction, she was central nervous system at autopsy for axonal injury, and globes at autopsy
pregnant. The sentence of 16 years reflected the judicial decision to for retinal hemorrhage.
maintain her incarceration until all her five surviving children (including This presentation will impact the forensic community and/or
the fetus) should grow up. humanity by increasing the awareness of the pathology and
Case 2. Smothering and shaken impact. His father found a 23- pathophysiology of so-called second impact syndrome. Moreover, it will
month-old boy dead in his bed, with obvious injury to the face and raise the much needed concept that retinal hemorrhages, while a useful
abdomen. The child had been in the care of his girlfriend before he was put “marker” of abuse, are not diagnostic of abuse, and that a degree of
to bed. Autopsy showed that the child had severe blunt force trauma to the circumspection is required in assessing accidental vs. nonaccidental
head, torso, and extremities. This included bilateral subdural hematomas trauma in children.
with retinal hemorrhages and optic nerve sheath hemorrhages, consistent Second impact syndrome is an ill-defined syndrome in which
with shaking, and multiple subgaleal hemorrhages and a brain contusion presumably trivial head injury, following a concussion or other significant
due to impact. There were multiple contusions and abrasions of the head injury is associated with sudden death. The pathophysiology of this
abdomen, including patterned injury, with contusions of the bowel and process is unclear, although diffuse cerebral swelling has been implicated.
contusions and laceration of the mesentery, and right perirenal An 18-month-old boy who suffered a closed head injury from fall
hemorrhage. There were multiple abrasions and contusions of the from a balcony, following which he underwent a short period of
extremities without fractures. However, there was also evidence of rehabilitation and was discharged with a helmet. The helmet was
smothering, including abrasions and contusions of the face, chin, and lips, prescribed because the child’s motor skills had slightly deteriorated. Four
and petechiae of the conjunctiva, face, scalp, and oral mucosa. Death was weeks following the fall from the balcony, the child suffered a fall from a
certified as due to acute blunt force head injury and asphyxiation from coffee table witnessed by both a parent and another adult, after which he
smothering, with the manner homicide. immediately became unresponsive and expired several days later with
The girlfriend was charged with felony child homicide. Defense cerebral swelling and nonperfusion. He was not wearing the helmet at the
strategies included the allegation that the caretaker was not the batterer, time of the fall from the coffee table. At autopsy, marked edema with
but that the child’s 21-year-old developmentally challenged brother had diffuse bilateral ischemic necrosis was present throughout the cerebrum,
fatally injured him during rough play on the floor; and that if the defendant cerebellum, and brainstem. In addition, the right lateral brainstem as well
had smothered him accidentally against her clothing, she had done so as the corticospinal tract at the pontomedullary junction showed axonal
while holding a fatally battered child. The defendant was found guilty. shear injury, including numerous swollen axons and microglial activation
The brother was not charged. Sentencing is pending at the time of this that were temporally consistent with the initial closed head injury.
abstract. Bilateral retinal hemorrhages and bilateral optic nerve sheath hemorrhages
Case 3. Starvation (neglect) and battering/shaking. An 8-week-old were also present. This case demonstrated that this subject may have been
infant girl was found dead in her crib. A history was given that she had predisposed to sudden decompensation following trivial head injury
not been eating well for three weeks, but there had been no contact with because of pre-existing brainstem axonal injury and a vulnerable
medical professionals since birth. At autopsy, the child was dehydrated brainstem cardiorespiratory center. Close examination of the brainstem
and severely malnourished (autopsy weight 5 lbs; birth weight 7 lbs 10 for evidence of axonal injury is warranted in subjects who expire
oz). The eyes were sunken, and the contour of the ribs was visible through following trivial head injury, especially in the case of previous head injury.
the skin. The thymus had atrophied. The gastric pouch was empty, the This case further highlights the lack of specificity of retinal hemorrhages
duodenum and small bowel were nearly empty of chyme, and there was in terms of accidental vs. non-accidental trauma, and that careful
very little stool in the colon. There were bruises of the right forearm and assessment of individual cases is necessary before concluding injuries
left elbow, and on internal examination, there were multiple rib fractures were inflicted by another.
in varying stages of healing. Examination of the head revealed multiple Second Impact Syndrome, Axonal Injury, Retinal Hemorrhage
subgaleal hemorrhages, a linear right parietal skull fracture, and multifocal
subdural hematomas of varying ages overlying recent and old brain
contusions. Histology showed a dense neutrophilic inflammatory response
in the subdural hematomas and the meninges of the brain and spinal cord,
and multiple autopsy cultures grew out a single organism, Salmonella
arizonae. Death was certified as due to meningitis, due to infected
subdural hematoma, due to inflicted traumatic brain injury, with starvation
contributing; with the manner homicide. The mother pled guilty.
Sentencing is pending at the time of this abstract.
Review of these cases will illustrate the forensic methods used to
elucidate multiple overlapping types of injury and neglect that may
contribute to complex cases of child homicide.
Child Abuse, Child Neglect, Combined Types of Violence and Injury

G112 Sexual Abuse: Hymenal Findings in Girls G113 A Chest Full of Blood: Hemothorax as a
With a History of Vaginal Penetration 26 Year Delayed Consequence of Repair
of Transposition of the Great Vessels
Annie Vesterby, MD, DMsc*, and Lene A. Hansen, MD, Institute of
Forensic Medicine, University of Aarhus, Peter Sabroes Gade 15, Karen B. Looman, DO*, and Wendy M. Gunther, MD, Tidewater Office
Aarhus C, 8000, Denmark; and Svend Sabroe, MD, Institute of Public of the Chief Medical Examiner, 830 Southampton Avenue, Suite 100,
Health, Dept. of Epidemiology, University of Aarhus, Vennelyst Norfolk, VA 23510
Boulevard 6, Aarhus C, 8000, Denmark
After attending this presentation, attendees will learn about an
After attending this presentation, attendees will understand that uncommon consequence they may see long after surgical correction of
hymenal lesions at colposcopic examination are seldom seen in late transposition of the great vessels.
disclosure of sexual abuse in children with vaginal penetration. This presentation will impact the forensic community and/or
This presentation will impact the forensic community and/or humanity by providing useful information about a potentially lethal
humanity by assisting professionals in understanding that hymenal lesions delayed complication of a common surgical procedure to correct a
are seldom seen in sexually abused girls who report vaginal penetration. congenital heart problem; describing newer procedures that do not have
The Institute of Forensic Medicine, University of Aarhus, at the this kind of problem; and illustrating signs and symptoms to look for in a
request of the police, performs colposcopic examination of children similar autopsy case.
suspected of being sexually abused. A 27-year-old woman had been born with transposition of the great
From January 1, 1996, to September 2002, 482 children living in vessels (TGV), a congenital heart disorder that was always fatal before
Jutland, Denmark, were investigated (1.48/10,000 children from birth to corrective surgery was developed. In TGV, blood oxygenated by the lungs
16 years). never reaches the rest of the body, and blood returning from the body
This study focuses on hymenal findings in cases of a history of never reaches the lungs. This occurs because, in TGV, the pulmonary
vaginal penetration given either by the child or by the perpetrator or both. artery is attached to the left side of the heart and the aorta is attached to the
Results: Two hundred twenty-six girls reported vaginal penetration right side of the heart.
at least once, and of these 116 were penile penetration. Twenty seven years ago, a standard treatment for this disorder was
The median age of the girls was 12 years (range 2-14 years). the Mustard procedure, in which the pulmonary veins are detached from
Forty-nine girls (22%) were examined within 24 hours after the last the left atrium and surgically reattached to the right atrium, and the
sexual assault, 27 (12%) less than a week and 116 (51%) more than a week superior and inferior vena cava are detached from the right atrium and
later; and in 34 cases (15%) the time since the alleged penetration was reattached across an “atrial baffle” to the left atrium. This procedure
unknown. allows oxygenated blood to flow to the body, and deoxygenated blood
The hymen was normal in 155 girls (55%), showed erythema in 18 from the body to return to the lungs. It also allows the coronary arteries to
(8%) and lesions in 20 (9%); the rest had other irrelevant findings or were remain in their native position in the aorta. It has the disadvantage that the
unknown. right ventricle is responsible for pumping blood to the body, which causes
Hymenal clefts were found in 50 girls (25%), but only 17 girls (38%) it to hypertrophy, and the left ventricle pumps blood to the lungs, under too
had a complete hymenal cleft and of these 15 were above 12 years of age much pressure.
(median age 14 years). In a nine-year-old girl an anteriorly located cleft The patient’s Mustard procedure was performed at 11 months of life.
was observed. She recovered well and lived for twenty-six more years. Approximately
The incidence of hymenal clefts (both incomplete and complete) in three months prior to her death, she was diagnosed with pneumonia, and
the 426 girls investigated increased with increasing age. Thus, 78% of the was treated with antibiotics. The day before her death, she complained of
clefts were found among the oldest girls (above 11 years). chest pain. The night of her death, while talking on the phone, she had a
Eight of the girls with a hymenal cleft had used tampons on a regular fit of coughing. The expectorant contained blood. She went to the
basis. One hundred and nineteen cases were prosecuted and of those 102 emergency room, and during the initial work-up, collapsed and died.
suspects (86%) were convicted. Eight perpetrators admitted vaginal At autopsy, external examination revealed a slender, gracile and
penetration, and the victims in these cases all had a complete posterior nearly cachectic female who had pallor of the face and body. There was a
hymenal cleft. midline chest scar as evidence of her previous cardiac surgery, but no
No significant correlation was found between hymenal clefts and recent injuries or surgical procedures. Blood for toxicology was hard to
appearing at court or being convicted, nor between complete clefts or obtain by inguinal or subclavian puncture.
conviction at court. Internal examination revealed a right hemothorax with 1700 cc of
There was, however, a relationship, although non-significant, blood and clots, visceral pallor, and depletion of the vascular tree. The
between the age of the girls and the probability of the perpetrators to heart showed evidence of the Mustard procedure, with all anastomoses
appear at court; the age of the girls in cases resulting in a conviction was intact. However, there were bilateral pulmonary artery aneurysms. The
significantly higher than in those resulting in acquittal (p=0.02). right ventricle showed evidence of extreme hypertrophy, with the wall
Conclusion: In cases of late disclosure of sexual abuse, the history measuring up to 1.5 cm thick. The right pulmonary artery showed a 10 cm
from the child and the perpetrator, not physical findings, remains the aneurysm at the hilum that extended into the lung. The left pulmonary
single most important feature in evidence of sexual abuse. artery revealed a 3cm aneurysm. A fresh rupture was found in the right
Child Sexual Abuse, Vaginal Penetration, Hymenal Lesions pulmonary aneurysm near the hilum, creating the hemothorax and causing
the young woman’s death.
Extensive recent and older thrombosis of pulmonary artery branches
leading from the aneurysm into the right lower lobe was noted, suggesting
this might have prompted the diagnosis of pneumonia. Thrombosis of
these vessels might have been responsible for raising the pressure in the
aneurysm, ultimately leading to rupture.
The Mustard procedure has been known to extend victims’ lives for
ten years or more. However, pulmonary artery aneurysms, although rare,
have been reported in the literature as a long term sequela. Commoner

problems with the Mustard procedure include cardiac arrhythmias and Approximately 10% of women develop depression during pregnancy
baffle leaks. Transposition of the great vessels is now treated by a or in the postpartum period, and a previous history of major depression is
different procedure, the arterial switch. a risk factor. The previous held belief that pregnancy offers “protection”
This case report will compare the long term complications and from major depression has been challenged by a recent study showing a
advantages of the arterial switch to the Mustard procedure in light of this significantly higher rate of relapse amongst women who discontinued
catastrophic delayed result. This will aid forensic personnel in the future anti-depressant medication compared with those who continued treatment
when they have a case for forensic autopsy with a history of surgical repair (Cohen et al., 2006). Selective serotonin reuptake inhibitors (such as
of transposition of the great vessels. They will know what to expect on fluoxetine, setraline, and paroxetine) have been recommended for the
heart dissection from these surgeries, and to anticipate the possible long treatment of depression during pregnancy due to their efficacy, as well as
term problems that can accompany these types of techniques. historical data suggesting they are not associated with birth defects (Kahn
Transposition of Great Vessels, Aneurysm, Sudden Death et al., 2001). Although sertraline is the most commonly prescribed anti-
depressant in breastfeeding women, controversy still exists over the
adverse effects it exerts on breastfed infants of mothers taking this
medication (Gentile, 2005; Whitby and Smith, 2005). Concerns of fetal
G114 Suicidal Hanging of a Postpartum teratogenicity and infant toxicity due to intrauterine or breast milk
Woman Who Discontinued Anti- exposure to anti-depressants must be balanced against the documented
Depressant Medication During Pregnancy adverse effects that pregnancy related depression imparts on fetal and
infant outcomes (Bonari et al., 204; Mian, 2005). A rare though dramatic
Gregory L. Hess, MD*, Jeffery M. Jentzen, MD, and Russell T. outcome of pregnancy related psychiatric illness is maternal suicide or
Alexander, MD, Milwaukee County Medical Examiner Office, 933 West infanticide. Postpartum psychosis affects approximately 1% of women
Highland Avenue, Milwaukee, Wisconsin 53233 and may increase the risk of maternal or infant death.
This case presentation highlights the risk of discontinuing anti-
The goal of this presentation is to review a case of postpartum suicide depressant therapy during pregnancy for a woman with a history of major
in a woman with a history of major depression who discontinued her depression and previous suicide attempts. Medical examiners and
psychotropic medications during the first trimester of her pregnancy. The investigators need to seek out a history of discontinuation of psychiatric
current controversies surrounding the treatment of depression during medication in women who kill themselves or their children during
pregnancy and in the postpartum period will be reviewed. pregnancy or postpartum. Only by being aware of the current
This presentation will impact the forensic community and/or controversies surrounding the treatment of depression during pregnancy
humanity by discussing the risks and benefits of treating depression in the and in the postnatal period will medical examiners be able to offer
puerperal period. informed opinions when suicide or infanticide occurs in these settings.
The decedent was a 30-year-old female who hanged herself with a
Pregnancy, Depression, Suicide
dog leash 45 days after the uncomplicated vaginal delivery of her third
child. Three days prior to death she began expressing depressive
symptoms reported as sleep disturbance, restlessness and obsessive
preoccupation with her youngest child. The day before her death she G115 A Simple Model for Teaching Postmortem
sought medical attention at a local walk-in clinic for depression and was Monocular Indirect Ophthalmoscopy
prescribed sertraline (Zoloft). The next evening she fashioned a noose
from a dog leash and using a cut log as a step stool, fully suspended herself Terrill L. Tops, MD*, and Patrick E. Lantz, MD, Wake Forest University
by the neck from a tree in the back yard of her home. Scene investigation Health Sciences, Department of Pathology, Medical Center Boulevard,
revealed copious emesis in the kitchen trash, and an empty bottle of Winston Salem, NC 27157
sertraline.
She had a history of two previous inpatient hospitalizations for major After attending this presentation, attendees will understand the
depression, the first of which was an involuntary hospitalization enhanced potential for skill acquisition in postmortem monocular indirect
manifested by self induced starvation and dehydration. During the first ophthalmoscopy using a simple and inexpensive model simulating the
hospitalization, five years prior to her terminal event, she tried to hang ocular fundus.
herself by her bra strap three times. A second depressive episode, This presentation will impact the forensic community and/or
approximately one year before her suicide, was punctuated by her humanity by demonstrating a teaching model that can be used to enhance
threatening to kill herself with a kitchen knife. Neither of these depressive skill acquisition in postmortem monocular indirect ophthalmoscopy and
episodes appeared related to her prior pregnancies. Her psychiatric be assessed to accurately identify and describe fundal abnormalities of
medications prior to her third pregnancy consisted of sertraline and pathological significance such as retinal hemorrhages.
quetiapine on which her symptoms appeared well controlled. She Postmortem examination of the fundus oculi has relied on direct
discontinued her medications during the first trimester of the last ophthalmoscopy or ocular evisceration, but recently the techniques of
pregnancy in consultation with her obstetrician secondary to the unknown postmortem ophthalmic endoscopy and monocular indirect
teratogenicity of these medications (both are pregnancy category C). She ophthalmoscopy have been delineated. Direct ophthalmoscopy has been
had not restarted her medications immediately after delivery because, used to attempt estimates of postmortem interval and identify retinal
according to her husband, she had not felt depressed and she was abnormalities but its usefulness is hindered by postmortem corneal
breastfeeding. clouding (swelling), inherent limited field of view, an inability to view the
At autopsy a dried ligature abrasion partially encircling the neck peripheral retina and lack of stereopsis. In most medical examiner/coroner
crossed the neck anterior midline over the superior edge of the thyroid jurisdictions ocular enucleation is not a standard autopsy procedure unless
cartilage. No petechiae were identified on the conjunctivae of the eyes, child abuse is suspected, thus invariably inuring observational bias when
facial skin, lips or oral mucosa. A layer-wise anterior neck dissection did citing the prevalence of certain fundal findings (e.g., retinal hemorrhages).
not reveal hemorrhage or injury within the strap muscles of the neck, the Postmortem endoscopic funduscopy permits viewing and documentation
hyoid bone, or the thyroid cartilage. No pill fragments were found in the of retinal abnormalities; however, the equipment is costly and training
stomach. Postmortem toxicology testing revealed an elevated level of necessary to gain expertise in operating the endoscopic equipment and
sertraline (0.24mg/L), but no additional drugs or alcohol in iliac blood. subsequent image acquisition. The material necessary for postmortem
monocular indirect ophthalmoscopy (PMIO) is inexpensive and when

compared to direct ophthalmoscopy the technique is less affected by and on leaving had been “fussy” and may have fallen “onto her bottom”
corneal clouding, cataracts, or vitreous hemorrhage. Other advantages on the way to the car. She had one episode of copious clear emesis.
include a relatively large field of view, high resolution and an ability to Immediately after this she became progressively lethargic and
visualize the peripheral retina. Disadvantages include low magnification unresponsive.
and a projected aerial image that is inverted and laterally reversed. On presentation to the emergency department, her vital signs (HR 67,
A valuable skill for forensic pathologists, the technique of RR 35, O2 saturation 64% on room air, BP 145/84) were consistent with
postmortem monocular indirect ophthalmoscopy can be challenging for Cushing’s triad. She was emergently intubated and her vital signs
pathology residents and forensic pathology fellows to master. Indirect normalized. Neurological exam revealed response only to painful stimuli.
ophthalmoscopy is not routinely taught in most medical schools so with Her pupils were sluggishly reactive. Initial laboratories (prior to
the exception of ophthalmologists-in-training most residents and fellows
administration of any fluids) revealed a serum Na+ 128, Cl- 95, K 3.3, CO 2
have a limited exposure to the technique. Because the projected aerial
image is inverted and laterally reversed precise descriptions or recording 15, BUN 15, Cr 0.2, and Glc 259. A bolus of 400cc of normal saline was
of fundal abnormalities can be challenging. Since the image cannot be ordered and transfer to a tertiary care pediatric hospital was arranged.
viewed simultaneously by the instructor and student, learning PMIO can Inadvertently, a bolus of D5W was reportedly administered instead of
be intimidating because the more experienced forensic pathologist must normal saline.
teach the technique and describe the orientation of any fundal Initial labs at the tertiary care facility revealed a serum Na+ of 120.
abnormalities observed. Her pupils were fixed and dilated and she had no respiratory effort.
To facilitate skill acquisition in PMIO, a simple and inexpensive Physical exam was normal with the exception of her neurological exam
teaching model can be constructed from hinged, cylindrical plastic and specifically did not reveal any evidence of rashes or signs of trauma.
containers having an internal diameter of 35 mm and a depth of 30 mm. Her neurological exam revealed she had no doll’s eye reflex, corneal
A 9-mm hole drilled in the center of the hinged lid from a 1-oz cylindrical response, cough or gag. She did withdraw minimally to painful stimuli.
plastic canister creates an artificial pupil. Fundal images depicting An emergent head CT demonstrated diffuse cerebral edema with
hemorrhagic retinopathy printed on 8 x10-inch matte photographic paper herniation and no radiological evidence of intracranial hemorrhage,
are cropped into 3.5 mm circles with available imaging software. although the differential diagnosis included trauma. She was admitted to
Trimmed images from the photographic paper are fitted into the canister’s the Pediatric Intensive Care Unit and fluid resuscitation was initiated.
base. The lid of the canister marked as to the appropriate eye and correct Within hours she developed central diabetes insipidus, with high urine
orientation completes the model. Using a procedural headlight and an output (8 cc/kg/hr), urine specific gravity or 1.000, and a rapidly
aspherical indirect condensing lens, the resident or fellow can practice increasing serum sodium (maximum Na+ 155), despite changing
viewing the simulated fundal image. Multiple funduscopic abnormalities intravenous fluids to 0.45 normal saline. Vasopressin therapy was
with retinal hemorrhages can be created for teaching with variations in the initiated. Ophthalmologic examination ten hours after initial presentation
number, location (preretinal, intra-retinal, subretinal), distribution and showed splinter retinal hemorrhages in the posterior poles bilaterally.
orientation relative to the optic disc. Using this simple teaching model, the Over the next three days, her neurological exam deteriorated until she no
pathology resident or fellow can be assessed as to his/her ability to longer withdrew to painful stimuli. At that time, her family elected to
accurately identify and describe the number, location, distribution and withdraw life support. A postmortem skeletal survey was negative for
orientation of retinal hemorrhages and various other fundal abnormalities fractures.
of pathological significance. The case fell under the coroner’s jurisdiction and a forensic autopsy
Postmortem Monocular Indirect Ophthalmoscopy, Ocular Fundus, was ordered. At autopsy, no external signs of trauma were identified. Her
Retinal Hemorrhage thoracic and abdominal cavities were normal with the notable exception of
cardiomegaly (76 g) and splenomegaly (90 g), neither of which were noted
premortem. Cranial contents were consistent with diffuse cerebral edema
and uncal herniation without intracranial hemorrhage. Cerebral spinal
G116 A Case of Fatal Water Intoxication fluid collected using sterile technique was noted to be xanthochromic and
in a Toddler somewhat gelatinous but not frankly purulent. Culture of the CSF grew
Klebsiella pneumoniae in the broth only. No organisms were identified on
Nadia L. Krupp, MD, Indiana University School of Medicine, 702 gram stain of the CSF.
Barnhill Drive, Indianapolis, IN 46202; Michele J. Catellier, MD*, Local law enforcement officials conducted an investigation including
Forensic Pathology Associates of Indiana, LLC, 521 West McCarty interviews of all parties who had had contact with the child. Her adult
Street, Indianapolis, IN 46225; and Antoinette L. Laskey, MD, MPh, caregivers on the day of her presentation reported that she had been in a
Indiana University School of Medicine, 702 Barnhill Drive, floating toy in a backyard above ground pool for several hours during the
Indianapolis, IN 46202 day. Both adults present at the time did not recall the child becoming
submerged at any time. One caregiver indicated that the adults and older
After attending this presentation, attendees will have reviewed the
children present at the pool had been jumping in from the edge creating
physical and chemical signs and symptoms of water intoxication, thereby
“tidal waves” repeatedly. Repeated interviews with the caregivers
broadening the differential diagnosis in cases of sudden death particularly
revealed consistent histories of the events of the afternoon.
in pediatric practice.
The cause of death was cerebral edema due to hyponatremia due to
acute accidental water intoxication. The manner of death was determined
humanity by demonstrating the clinical signs and symptom of water
to be accidental.
intoxication as well as the differential diagnosis of this condition so that it
A review of the English language literature on accidental water
might be a consideration in cases of sudden unexpected death particularly
intoxication reveals five cases in the pediatric population with symptoms
when environmental conditions include exposure to water.
similar to this case. With timely, appropriate fluid resuscitation a full
This presentation concerns a case of fatal water intoxication in a
recovery is possible, even when the presentation includes a comatose state.
toddler after a day of swimming and a review of the literature on pediatric
It is most likely that this child swallowed a large volume of pool water,
water intoxication.
which acutely dropped her serum sodium that resulted in her symptoms,
A 2.5-year-old, 12 kg, previously healthy female presented to a
with subsequent irreversible cerebral edema and herniation.
community emergency department with profoundly altered mental status.
Her caregiver reported the child had been at a home pool for several hours Water, Intoxication, Pediatric

Pathology/Biology
G1 Otologic Injury as a Consequence of Blast Sudden unexpected natural deaths of CNS etiology are not an
uncommon finding in many medical examiners offices. The authors per-
Trauma; Evaluated by Postmortem formed a retrospective review of 262 cases of natural deaths attributed to a
Otoscopic and Computed Tomography CNS etiology over a 10-year time period to compare the cause, incidence,
Examination and demographic profiles of such cases. Natural deaths were sorted from
11,152 total autopsies performed at the Pima County Forensic Science
Carol J. Solomon, MS, MD*, Louis N. Finelli, DO, and John M. Getz, BS, Center between 1994 and 2003. These natural deaths were then screened
Office of the Armed Forces Medical Examiner, 1413 Research Boulevard, for a primary CNS cause of death (COD) excluding systemic diseases with
Building 102, Rockville, MD 20850 CNS manifestations if the CNS pathology could not be determined to be
the primary mechanism of death. COD and demographic information on
After attending this presentation, attendees will recognize the pattern each case was then tabulated with particular attention to the top three causes
of middle ear injury from blast trauma and it’s correlation with postmortem of death by year. Primary CNS deaths accounted for an average of 7.2% of
otoscopic findings and computed tomography results. natural deaths in this ten-year review. The majority of these (28% of CNS
This presentation will impact the forensic community and/or totals) were attributed to unexpected death in patients with a clinically doc-
humanity by providing a systematic evaluation of middle ear structures umented seizure disorder with a slight male predominance (1.6:1 male:
injured as a result of primary blast trauma. Techniques evaluated are female ratio) and an average age of 38 years. The second most common
intended to augment the routine gross and microscopic examination of cause of death (27% of CNS totals) was hypertensive stroke. The average
victims of blast injury. The results of these studies will aid in the evaluation age of this population was older as compared to the patients with seizure
of patients status post injury and possibly assist in preventive measures in disorders and with a slight male predominance (average age 59 with a 1.4:1
the appropriate setting. male: female ratio). Ruptured aneurysms in various CNS anatomic loca-
The ear is one of the most frequently injured organs affected in an tions were the third most common cause of death (16% of CNS totals)
explosion. Otologic injury is a far more prevalent problem then has been occurring in middle age with a male predominance (average age 48 with a
previously reported. A more thorough evaluation of victims combined with 1.5:1 male: female ratio). Infectious meningitis, most commonly of bac-
an increase in both the number of civilian and military blast injuries cause terial or viral etiology, was also a frequent cause of CNS death (14% of
us to recognize the extent of the problem. The short and long term sequelae CNS totals with average age 35 years with a 1.3:1 male: female ratio).
of this type of trauma may include findings such as hearing impairment, Infectious etiologies were the most age variable COD ranging from 4
tinnitus, and vertigo and cholesteatoma formation. A clearer understanding months to 69 years of age. Other, less frequent, COD, in order of
of the pattern and etiology of injury should benefit survivors in the planning descending frequency, included primary brain neoplasm, idiopathic
of treatment strategies to optimize outcome. The techniques utilized in this intracerebral hemorrhage, congenital anomalies, progressive neurodegen-
study have enabled us to evaluate the mechanism and extent of injury to erative dementias, and idiopathic encephalopathies. These findings are felt
otologic structures. to be representative of a typical forensic autopsy population with an over
Evaluation of middle ear injuries, postmortem, has been a laborious representation of sudden death (seizure disorder, stroke, and aneurysm) and
process. The current study provides two techniques that will provide addi- under representation of chronic CNS pathology (neurodegenerative
tional information in the assessment of blast trauma. These techniques are dementias, neoplasm) than what would be expected in the general
useful in the evaluation of tympanic membrane perforation, hemorrhage population.
into the middle ear and ossicular damage.
Central Nervous System, Natural Death, Review
A series of cases is presented demonstrating the application of post-
mortem otoscopic examination and computed tomography to evaluate
middle ear structures. These findings are correlated with the results of the G3 Frequency of Cases of Fatal Gunshot
corresponding circumstances of death. Wound Victims With Retained “Old”
Blast Injury, Otologic, Computerized Tomography Scan Projectiles From Previous Penetrating
Gunshot Wounds
G2 Natural Central Nervous System (CNS)
Causes of Death: A Ten Year Retrospective Daniel W. Dye, MD*, University of Arkansas for Medical Sciences, 4301
Review (1994-2003) W Markham, Slot 517, Little Rock, AR 72205; and Charles P. Kokes, MD,
Arkansas State Crime Laboratory, #3 Natural Resources Drive, PO Box
8500, Little Rock, AR 72215
Gregory L. Hess, MD*, University of Arizona Health Sciences Center,
1501 North Campbell Avenue, PO Box 245108, Tucson, AZ 85724-5108; After attending this presentation, attendees will learn the importance
and David C. Winston, MD, PhD, Pima County Forensic Science Center, of considering “old” projectiles in assessing a gunshot wound homicide.
2825 East District Street, Tucson, AZ 85714 This presentation will impact the forensic community and/or
humanity by increasing awareness of the “old” projectile as a possible
The goal of this presentation is to explore the incidence and specific
pitfall in the multiple/complex gunshot wound case.
demographic information (age/sex) for natural CNS deaths in Pima County,
When considering multiple gunshot wound cases, the simple equation
AZ from 1994-2003.
of number of entrance wounds equals the number of exit wounds plus the
number of bullets lodged in the victim is always an excellent starting point
humanity by reviewing the incidence and demographics for natural CNS
in the forensic examination. However, when there are intermediate targets,
deaths in Pima County, AZ from 1994-2003. Forensic pathologists and
atypical entrance wounds or fragmented projectiles the situation can be
other forensic scientists may find this information useful to compare with
more complex. The equation can be further complicated by individuals
the incidence of natural CNS deaths in their own practice.

who have sustained a penetrating gunshot wound in the past, survived the The SCUBA gear was examined by a Diving Safety Officer. All com-
injury, and for medical or personal reasons elected not to have the projectile ponents were in good condition and in working order with adequate
removed. These “old” projectiles can be easily distinguished from acute unadulterated air in the tank. The diving computer was interrogated and a
projectile injuries based on their gross appearance with lack of acute hem- depth/time histogram was produced. At approximately 23 minutes into the
orrhage and usual encasement within an area of fibrosis, but when plain dive the histogram has a spike-like irregularity after which the depth
film radiographs are used in the original accounting process, this old remains steadily at approximately 25 feet until the data terminates.
retained projectile can complicate the equation. Prior to autopsy an anterior-posterior radiograph of the chest in the left
A review of all of the victims of fatal gunshot wounds at the Arkansas lateral decubitus position was obtained. Air fluid levels in the right and left
State Medical Examiner’s office from January 1, 2000-December 31, 2004 sides of the heart, gas in the central vascular structures of the chest and
was performed to determine the frequency of cases in which an “old” bullet neck, and pneumomediastinum were observed. Opening the myocardium
was discovered in addition to the acute, fatal, gunshot wound or wounds. under water produced a gush of bubbles. No gas emboli were grossly
A total of 703 gunshot wound homicides were reviewed; twenty-five of apparent in the coronary or cerebral arteries. There was no substantial heart
which had evidence of remote gunshot injury and retained projectiles or disease.
fragments identified on radiologic exam and internal examination. A 3.0 centimeter white subcarinal mass, histologically confirmed as
Individuals with evidence of remote gunshot injury were further classified small cell carcinoma, extended into the hilum of the left lung. It caused
based on anatomic location of the remote projectile, bullet caliber (large or subtotal obstruction of the left upper lobe bronchus and encased the pul-
small), or bird-shot pellets. This classification allows a discussion of pos- monary artery. The pulmonary parenchyma distal to the obstruction was
sible reasons for leaving the “old” bullet in the patient; either for diffi- hemorrhagic and atelectatic. Metastases were present in the mediastinal
culty/futility of retrieval or the patient’s desire to retain the bullet for show lymph nodes and liver.
as a “souvenir” bullet. Medical records revealed that the decedent had been diagnosed with
In this retrospective study, four percent (4%) of the cases of gunshot metastatic lung cancer approximately six months before his death. He
wound homicides at the Arkansas State Crime Laboratory had retained pro- underwent chemotherapy with shrinkage of his metastatic lesions. Chronic
jectiles from previous gunshot wounds. The frequency of these cases cough caused him to undergo bronchoscopy approximately one month
points out the importance of considering the possibility of old bullets when prior to his death, which revealed partial obstruction of the left upper lobe
approaching complex gunshot wound cases. One should always remember bronchus by the neoplasm. He received two fractions of palliative radiation
that every projectile on the x-ray may not be from acute injury. to that area, the last on the morning of the fatal dive.
Gunshot Wound, Homicide, Old retained Projectiles We hypothesize that 1) the presence of a carcinoma obstructing a
bronchus resulted in fatal barotrauma in an experienced diver, and 2) filling
of the central vascular bed by gas resulted in unconsciousness while
submerged, in the absence of cerebral and coronary artery gas emboli.
Divers would benefit from consulting a qualified medical professional
G4 Small Cell Carcinoma of the Lung about the risks of diving with an intrinsic lung disease prior to engaging in
Contributing to Pulmonary Barotrauma this sport.
With Air Embolism in a Recreational Diver: Scuba Diving, Air Embolism, Postmortem Radiograph
A Case Report
Carl W. Wigren, MD*, and J. Matthew Lacy, MD, King County Medical G5 Serum Levels of Pulmonary Surfactant
Examiner’s Office, 325 Ninth Avenue, HMC Box 359792, Seattle,
WA 98104
Associated Proteins A and D (SP-A & SP-D)
in Some Causes of Death
The goal of this presentation is to review the pathophysiology of pul-
monary barotrauma in the setting of SCUBA diving fatalities and to discuss
M. Essam E. El-Sheikh, MD, PhD*, and Taisseur M. Mostafa, MD, PhD,
the potential contribution of local bronchial obstruction to the development
Farwania, PO Box 1747, Kuwait, 1747, Kuwait
of pulmonary barotrauma.
This presentation will impact the forensic community and/or After attending this presentation, attendees will recognize the
humanity by demonstrating how divers would benefit from consulting a potential benefits of testing for pulmonary surfactant proteins in certain
qualified medical professional about the risks of diving with an intrinsic types of sudden deaths, especially those occurring with an asphyxial or
lung disease prior to engaging in this sport. intoxication mechanism.
SCUBA diving is a popular sport in the United States and approxi- This presentation will impact the forensic community and/or
mately 90 deaths are reported each year, mostly from coastal states. humanity by demonstrating research that may be considered as a step in
Drowning is the leading cause of death in diving related fatalities but a host determining the potential diagnostic role of surfactant proteins in post-
of injuries unique to diving may contribute. This presentation will impact mortem settings.
the forensic community and/or humanity by increasing awareness of the It has been suggested that surfactant proteins A and D (SP-A, SP-D)
potential danger of recreational SCUBA diving in those with obstructive may be useful markers of lung injury in the clinical setting. In this present
pulmonary processes. study, cadaveric serum samples were analyzed by specific enzyme linked
A 45-year-old man was SCUBA diving with a partner in seawater at a immunoassays for the levels of SP-A and SP-D in certain causes of death,
spot familiar to both of them. He was an experienced rescue-certified diver such as mechanical asphyxia, drowning, fire, sudden unexplained deaths,
with over 450 dives. The dive lasted approximately 29 minutes with a carbon monoxide intoxication, narcotics abuse, and organophosphate poi-
maximum depth of 84 feet of seawater. During the decompression stop the soning. Results in these types of cases were compared to the serum levels
divers became separated in murky water. The partner surfaced then resub- in a group of healthy volunteers, which served as the control group. No sig-
merged and recovered the decedent from the bottom approximately 25 feet nificant differences were observed in the median serum SP-A and SP-D
below the surface. The decedent was removed from the water and resusci- concentrations among the groups of volunteers, sudden unexplained death,
tation was attempted in the field prior to the pronouncement of death. No mechanical asphyxia, and carbon monoxide intoxication groups.
central lines or other procedures invasive to the central vascular bed or Significantly increased SP-A levels compared to controls were found in
chest were attempted. deaths caused by fire, drowning, narcotic abuse, and organophosphate poi-

soning. Similarly, increased SP-D levels were observed in fire, drowning, Neuropathologic examination showed changes consistent with acute
organophosphate poisoning, and narcotic related deaths, when compared to transtentorial herniation as a mechanism of death. Subtle mass effects and
controls and cases of natural sudden death. A positive correlation was white matter expansion were noted on gross and cut brain examinations.
found between the levels of SP-A and SP-D. These results suggest that Histologic evaluation revealed malignant glial infiltration diagnostic of
analysis of serum surfactant proteins may be useful in estimating the gliomatosis cerebri. Immunohistochemical staining of lesion tissue
intensity of alveolar functional damage at autopsy. suggests the pathogenesis of sudden death in cases of gliomatosis cerebri
Cause of Death, Autopsy, Surfactant Proteins may be related to catastrophic failure of the blood-brain barrier vis-à-vis its
permeability regulatory function.
References:
1. Eberhart CG, et al. Decreasing incidence of sudden death due to undi-
G6 Gliomatosis Cerebri as a Cause of agnosed primary central nervous system tumors. Arch Pathol Lab Med.
Sudden Death in a Young Woman Aug, 2001; 125: 1024-30.
2. Vates GE, et al. Gliomatosis cerebri: A review of 22 cases.
Timothy L. Williams, MD*, and William F. Hickey, MD, Dartmouth- Neurosurgery. Aug, 2003; 53(2): 261-71.
Hitchcock Medical Center, Department of Pathology, One Medical 3. Chamberlin MC. Gliomatosis cerebri: Better definition, better
Center Drive, Lebanon, NH 03756; and Thomas Andrew, MD, Office of treatment. Neurology. July, 2004; 63: 204-5.
the Chief Medical Examiner, 246 Pleasant Street, Concord, NH 03301
Gliomatosis Cerebri, Tumor, Death
After attending this presentation, attendees will be made aware of
gliomatosis cerebri as a rare yet potential cause of sudden natural death.
This presentation will impact the forensic community and/or G7 Death in a Confined Space
humanity by providing a well-illustrated example of an uncommon disease
entity that can be a cause of sudden death that has not heretofore been well Nunzio Di Nunno, MD, PhD*, Universita’ di Lecce, Via G. Dorso n. 9,
described in the forensic science case literature. Bari, 70125, Italy; Francesco Vimercati, MD, Universita’ di Bari, Sezione
This central nervous system (CNS) neoplasm is briefly reviewed, di Medicina Legale, Piazza G. Cesare n. 11, Bari, 70125, Italy; Fulvio
which follows a typical premortem course, demonstrated in this case. The Costantinides, MD, Universita’ di Trieste, P.zza Ospedale, Trieste, 34100,
report is richly illustrated with premortem neuroradiographic images, post- Italy; and Sandra Cornetta, MD, and Di Nunno Cosimo, MD,
mortem images of whole and cut brain, and photomicrographs. In par- Universita’ di Bari, Sezione di Medicina Legale, Piazza G. Cesare n. 11,
ticular, the gross and microscopic postmortem findings provide an Bari, 70125, Italy
excellent example of the kind of subtle changes one may encounter in the
postmortem neuropathologic evaluation of cases of gliomatosis cerebri. After attending this presentation, attendees will understand the patho-
The pathogenesis of sudden death in the context of gliomatosis cerebri is genesis of confined-space asphyxia through the study of three forensic
discussed vis-à-vis changes in the permeability of the blood-brain barrier. cases. Confined-space asphyxia is a quite rare event, caused by a lack of
Sudden death due to undiagnosed primary intracranial neoplasm is environmental oxygen that becomes inadequate to sustain life. This occurs
uncommonly encountered by the forensic pathologist. In a recent review when individuals find themselves trapped in airtight or relatively airtight
[1] of nearly 55,000 autopsies performed over a twenty year period at the enclosure, causing depletion of the oxygen supply and they asphyxiate.
Chief Medical Examiner of Maryland, undiagnosed primary CNS tumors This presentation will impact the forensic community and/or
comprised 0.02-0.05% of sudden deaths. Glial tumors, particularly astro- humanity by demonstrating the forensic approach in investigating cases of
cytomas and glioblastoma multiforme, were the most frequent tumor types death due to confined-space asphyxia, thereby avoiding confusing this
in these cases, and mechanisms of death included seizure, acute hemor- entity for a natural death.
rhage, and herniation. In all of the reviewed cases, discrete CNS tumor Asphyxia due to a confined space is a quite rare event, caused by a
masses were identified at the time of autopsy. lack of oxygen that becomes insufficient to allow normal respiration. This
Gliomatosis cerebri is a rare brain neoplasm characterized macro- happens when a person is trapped in airtight space without exchange of air,
scopically by enlargement, often subtle, of affected brain regions with as breathing exhausts the available oxygen, beginning the asphyxiation
preservation of native CNS architecture and absence of a discrete tumor process.
mass. Microscopically, the tumor consists of proliferating malignant glial The Department of Health, Education, and Welfare defines a confined
cells which diffusely infiltrate large areas of the CNS, involving more than space as “a space, which, by design, has limited openings for entry and exit
two lobes [2], and often involving both supratentorial and infratentorial combined with unfavorable natural ventilation.” Examples of confined
brain regions. The majority of patients diagnosed with gliomatosis cerebri space are caves, refrigerators, tunnels, pipelines, sewers, silos, tanks, pits,
are relatively young (median age 44 [3]), and experience insidiously pro- mines, trenches, holds, vaults, excavations, manholes, and chimneys. In
gressive symptoms, which can include headaches, alteration of mental the past, this kind of accident usually involved people working in building,
status and cognition, dysphasia, visual deficits, hemiparesis, and seizures. shipyard, and other manufacturing and service industries. As society
Often these cases present significant diagnostic challenges to clinicians, changes, the causes and modalities of confined space deaths are different.
and final diagnoses are not made until postmortem examination. Invariably In fact, the illegal immigration phenomenon and the search of new ways to
the mechanism of death in cases of gliomatosis cerebri is compressive reach Europe have become one of the main causes of these accidents in
sequelae from expanding intracranial mass. these last years. People try to enter a country travelling hidden among the
This presentation describes a case of sudden death in a young woman cargo of trucks. If the trip is long and the space is very narrow, the defi-
due to previously undiagnosed gliomatosis cerebri. The patient, 40 years ciency of oxygen could become serious and fatal for the illegal passengers.
old, had a several month history of intermittent headaches that were grad- This paper presents two cases, occurring in two different Italian
ually increasing in frequency and severity. Over this period the patient regions, describing the deaths of three men by confined space asphyxia
underwent multiple clinical evaluations, which were unremarkable, apart during the travel to reach Italy illegally.
from nonspecific white matter enhancement and mass effects by magnetic The first report concerns the death of two Kurdish men. They were
resonance brain imaging. The patient’s headaches were effectively confound in the refrigerator van of a truck, completely loaded with water-
trolled with mild analgesia and she remained fully active up until her death. melons, coming from Greece by a motor-ship and arrived to the port of
This witnessed event occurred suddenly, shortly after the characteristic Brindisi. The autopsies of the two deceased’s did not show any remarkable
onset of episodic headache. General autopsy was unremarkable. pathology, and histological and toxicological tests were negative. The most

significant anatomic-pathological findings of the autopsy were cyanosis of Case Report: The patient MS, a 24-year-old female with end-stage
the face and fingernails, copious and deep reddish-purple postmortem renal disease, presented to Beth Israel Deaconess Medical Center institution
hypostasis, visceral congestion, brain and lung oedema, conjunctival with gross hematuria of one month duration. She was eight months old when
petechiae (in one of the two corpses) and fragmentation of myocardial diagnosed with a rare metabolic disorder, Primary Hyperoxaluria (PH). The
fibres. All these findings were compatible with the diagnosis of death by patient had two failed renal transplants (one in 1981 at eight months of age,
asphyxia and the discovery of the two bodies in the truck trailer. The and another in 1991). She began hemodialysis in 2000 and continued the
circumstances of the deaths confirmed that they were due to confined space treatment until presenting in January 2005, with gross hematuria. A CT scan
asphyxia. also revealed a mass in the left renal allograft. Therefore, a nephrectomy was
The second report regards a stowaway found in a truck trailer near performed, and pathology ruled out post-transplant lymphoproliferative dis-
Trieste. When he arrived to the local hospital he was in coma, with cuta- order, and revealed chronic allograft nephropathy, with extensive deposition
neous temperature at 43°C and completely dehydrated. He died after few of calcium oxalate crystals. The patient was discharged, with no complica-
hours because of progressive deterioration of general health conditions and tions, and returned to the institution one month later for a combined left
massive bleeding from his stomach and bronchi. kidney/liver transplant. Shortly after the procedure, the patient suffered
On basis of all the clinical symptomatology, the results of laboratory thrombosis of the hepatic artery-aorta conduit, which was repaired the fol-
tests and review of the medical records, and the external examination, it lowing day. During repair, it was noted that the liver allograft was necrotic
was established that the death was due to a “heatstroke”. This diagnosis in vivo, and a liver biopsy showed massive necrosis consistent with ischemic-
was confirmed by the circumstances of the discovery of the body, and the type injury (left lobe). The patient quickly became hemodynamically
high environmental temperature (about 40°C). Also in this case, the con- unstable, developed supra-ventricular tachycardia, and after attempts at
fined space where victim had been in hiding for prolonged time, without resuscitation had failed, was pronounced dead.
any ventilation, had a key role in causing the death. The lack of oxygen in At autopsy, the body was that of a jaundiced female of small build
this confined space, and the overheating within the van of the truck became with kyphosis, and a large abdominal surgical wound, covered by mesh.
a lethal combination for this man. There were many adhesions throughout the peritoneum. The transplanted
These two reports bring to attention the serious problems of clan- liver was partially necrotic (40%), and a hemorrhagic infarct was found in
destine immigration occurring within a confined space. Confined space the left lower lobe of the lung. The left, newly-allografted kidney was ante-
asphyxia has caused trouble in the past with occupational deaths, and now riorly placed, and had a dusky hue. The right, previously (1991) trans-
seems to come back under a different aspect. planted kidney, was significantly atrophic, and could not be identified. The
The contribution of the medical examiner to these investigations heart (280 gms) revealed no acute or remote infarcts. The abdominal aorta
should be to identify the correct cause of death due to confined space had an intact stent in place.
asphyxia. As the few and non-specific anatomic-pathological findings of Histologic findings of the liver revealed necrosis in the majority of the
this kind of diagnosis is difficult to determine without history, it is very left lobe, and marked bile stasis in the remaining tissue. The heart had
important to carry out a careful analysis of the circumstances of the death. abundant polarizeable oxalate crystals in the myocardium, with associated
A correct diagnosis in these types of cases requires scene information fibrosis. The kidney showed pigmented tubular casts, and focal calcium
coming from an “on-the-spot investigation.” oxalate deposition. The final autopsy diagnosis was death due to throm-
Confined Space Asphyxia, Death Investigation bosis of the hepatic artery and aortic conduit that led to massive liver
necrosis/failure, and hemodynamic instability. Pre-mortem cardiac con-
duction defects were most likely due to the diffuse deposition of calcium
oxalate crystals within the myocardium.
Primary hyperoxaluria (PH) is a rare metabolic disorder due to a func-
G8 Primary Hyperoxaluria: A Case tional deficiency of the enzyme alanine:glyoxalate aminotransferase
Report and Review of the Literature (AGT). There are at least 20 documented mutations in the gene encoding
AGT (AGXT), but two mutations are associated with about 30% of the
Julia M. Braza, MD and Karoly Balogh, MD, Beth Israel Deaconess disease alleles in PH. More specifically, these mutations are associated
Medical Center, Pathology Department, 330 Brookline Avenue, Boston, with mitochondrial mistargeting and defective peroxisomal uptake of the
MA 02215 AGT protein. Symptoms develop in 15% of children less than one year of
age, and by five, 50% of patients are symptomatic. Infants may suffer from
The goal of this presentation is to discuss a case of the rare metabolic
chronic renal failure and parenchymal oxalosis, and older children may
syndrome primary hyperoxaluria (PH), with a literature review. The
have symptoms of urolithiasis, or complete ureteral obstruction. The
attendees will learn about the inherited form of the disease, its systemic
kidney is the primary organ of involvement, since one of its functions is to
manifestations, genetic alterations and the potential mechanisms of death.
excrete oxalate. Renal failure ultimately occurs, and subsequently, the
PH is relevant and important to the medico-legal and public health fields to
oxalate crystals deposit in other organs, such as the heart, bone marrow, and
identify such cases, especially because it can lead to sudden death in
soft tissues (systemic oxalosis). Chronic renal failure (uremia) leads to sec-
affected patients, who are mostly children and young adults.
ondary hyperparathyroidism, which in a growing individual can cause
The presentation will impact the forensic community and/or humanity
marked skeletal abnormalities. Possible causes of death are end stage renal
by identifying and discussing the etiologies of the disease, its renal and
failure, cardiac conduction deficits, or a multitude of complications from
extra-renal manifestations, current therapeutic approaches, i.e. combined
surgical intervention. Combined liver-kidney transplant is the recom-
liver-kidney transplantation, and the common causes of death in these indi-
mended treatment for these patients, along with hemodialysis, maintaining
viduals. The entity is a surgical and anatomic/forensic curiosity, with
a high urine output, and thiazide diuresis.
remarkable gross and histological findings.
In conclusion, in the presented case, the clinical picture and autopsy
Primary hyperoxaluria is a rare autosomal recessive metabolic dis-
findings demonstrate a case of primary hyperoxaluria. The disease entity
order, caused by the deficiency of the liver-specific peroxisomal enzyme,
has numerous clinical manifestations, including renal failure and cardiac
alanine: glyoxalate aminotransferase (AGT). AGT normally converts gly-
conduction defects, and has a high-risk management, (combined liver-
oxalate to glycine, but when absent, results in an increase of the glyoxalate
kidney transplant); all of which can lead to early, sudden death in these
pool, which is converted to oxalate.
mostly young patients.
This presentation will discuss the clinico-pathologic features, post-
mortem gross and microscopic findings of a fatal case of primary hyperox- Primary Hyperoxaluria, Calcium-oxalate Deposition, Combined
aluria. Liver-Kidney Transplantation

G9 Planned Complex Suicide: G10 Effect of Toilet Detergent on
Report of Two Cases Morphological Change of Spermatozoa
Cristian Palmiere, MD, Institut Universitaire de Médecine Légale, 9 Jian Tie, MD, PhD*, Yuka Serizawa, BS, and Shigemi Oshida, MD, PhD,
Avenue de Champel, Genève, 1211, Switzerland; Francesco Ventura, MD, Department of Legal Medicine, Nihon University School of Medicine, 30-
and Daniela Picchioni, MD, Dipartimento di Medicina Legale, Via de Toni 1 Oyaguchi Kamimachi, Itabashi-Ku, Tokyo 173-8610, Japan
12, Genova, 16132, Italy; and Maria del Mar Lesta, MD, and Romano La
After attending this presentation, attendees will be able to identify and
Harpe, MD*, Institut Universitaire de Médecine Légale, 9 Avenue de
appreciate the morphological changes that occur to spermatozoa when
Champel, Genève, 1211, Switzerland
exposed to toilet detergent.
Planned complex suicides usually present a challenge to the forensic This presentation will impact the forensic community and/or
pathologist and the police in determining the manner and mechanism of humanity by showing how toilet detergent can affect changes in sperma-
death. After attending this presentation, attendees will learn the importance tozoa, helping the criminalist determine the length of spermatozoa
of a careful evaluation of all elements to reconstruct the lethal chain of exposure to the detergent, and providing further assistance in identifying
events. perpetrators of sexual assault.
This presentation will impact the forensic community and/or Human semen is an important specimen in forensic casework. A girl
humanity by improving knowledge of planned complex suicide in the was killed at her own home and found approximately ten days after death.
forensic practice. Five persons were suspected as the killer. A condom containing human
Case report: Two cases of planned complex suicide are reported. In semen and filled with toilet detergent was found in the toilet chamber pot.
the first case (ingestion of sodium hypochlorite bleach with associated Results of DNA identification matched the specimen to one of the suspects.
razor blade wounds), a 27-year-old unemployed female was found dying in However, the problem was to determine the time when the semen was dis-
the early hours of the day in the bedroom of her apartment, lying in a pool carded. For this reason, the following experiment was designed and per-
of blood. Her forearms had been incised at wrist level. A blood stained formed. Human semen samples were collected from fifteen healthy vol-
razor blade was found near the body. Traces of blood were evident on the unteers, and the samples were confirmed to be normal by routine semen
floor in the hall between bathroom and bedroom. She also presented examination. The semen samples were mixed in two concentrations of the
clinical signs of caustic substance ingestion: the lips were burnt, the interior toilet detergent (0.2 mg/ml and 0.02 mg/ml), or in water as control. All
of the mouth was eroded, and the tongue was swollen. A bleach bottle preparations were kept at room temperature and were examined periodi-
(hypochlorite bleach, 5.25% sodium hypochlorite, pH 11,4) was found in cally under a microscope. The Oppitz method was used for spermatozoa
the bathtub. Upon external examination, numerous recent incised wounds staining. In the first five days, no definite change in shape of spermatozoa
were found on the left forearm, most probably inflicted by the razor blade was observed in all the samples. The major change of spermatozoa was
found near the body. These wounds were parallel and superficial, with separation of the tail and the head, which was clearly observed after ten
deeper wounds appearing on both wrists, which had lead to significant days under 400 × magnifications. In samples mixed with 0.2 mg/ml
blood loss. Autopsy revealed oral, pharyngeal, esophageal, and gastric solution of toilet detergent, dissociation of the tail and head was observed
mucosal erosions. Stomach contents contained blood and had the smell of in approximately 40% of the spermatozoa by ten days, 80% by twenty
bleach. All the internal organs were pale. Toxicologic analysis revealed days, and 98% by thirty days. When mixed with 0.02 mg/ml of toilet
sodium hypochlorite in gastric contents. Death was ascribed to razor blade detergent, the corresponding proportions were approximately 40%, 70%
wounds followed by ingestion of sodium hypochlorite bleach. In the and 95%, respectively. In the water control, only 25% showed separation
second case, an 86-year-old man was found dead in the bedroom of his by 10 days, and the percentage by 20 and 30 days was similar to 0.02
apartment. A blood stained razor blade was found on the bed, next to the mg/ml detergent. Increase in bacteria was observed after 20 days.
left arm. A nylon cord, similar to that used for a clothesline, was found However, when magnification was increased from 400 to 800, approxi-
bound tightly around the neck several times. The left arm and chest showed mately 70% of the spermatozoa in toilet detergent solution were found to
multiple superficial incised wounds. There was marked facial congestion possess a tail up to 30 days, whereas very few spermatozoa in the water
and numerous petechial hemorrhages in the skin of the face. Petechial control maintained a tail. The authors find is that after immersed in toilet
hemorrhages were also prominent in the conjunctivae and oral mucosa. detergent for a long time, many spermatozoa maintain the head and tail, but
Numerous, recent cuts were found on the chest. These cuts were superficial the tail becomes thinner and shorter.
and parallel to each other, indicating tentative or hesitation cuts. Numerous Spermatozoa, Toilet Detergent, Morphological Change
(68) recent cuts were found on the left forearm, inflicted by the razor found
near the body. Most of them were superficial cuts of sizes ranging from 2.5
to 3 cm. Upon autopsy, recent hecatomb was noted to the muscles of the
neck, especially the stern mastoid muscles. The tongue showed a recent
hemorrhage. Fresh blood was found in the larynx and trachea. The lung
showed mild congestion. Toxicological analysis did not detect any drugs
or alcohol. Death was ascribed to asphyxia due to strangulation by ligature
with associated razor blade wounds.
Complex Suicide, Razor Wounds

G11 An Unusual Death of a Child G12 Methadone Treatment and Drug Overdose
at the Obstetrician’s Office in Geneva, Switzerland, From 1994 to 2003
Albert Y. Chu, MD*, and Luis A. Sanchez, MD, Harris County Medical Guillaume Perret, MD*, Institut Universitaire de Medecine Legale de
Examiner’s Office, 1885 Old Spanish Trail, Houston, TX 77054 Geneve, 9 av. de Champel, CMU, Geneva, 1211, Switzerland; Ann Ho, PhD,
and Mary Jeanne Kreek, MD, Laboratory of the Biology of Addictive
After attending this presentation, attendees will be presented with a
Diseases, Rockefeller University, 1320 York Avenue, New York, NY 10021;
case of a 13-month-old child who died after his pregnant mother acciden-
and Romano La Harpe, MD, Institut Universitaire de Medecine Legale de
tally fell on him while she was at her obstetrician’s office. The goal of this
Geneve, CMU, 9 av. de Champel, Geneva,1211, Switzerland
presentation is to illustrate the severity of injuries that may result from such
a seemingly innocuous event. After attending this presentation, attendees will learn how lethal
This presentation will impact the forensic community and/or methadone intoxications while on methadone treatment are very rare and
humanity by increasing awareness of the potential for fatal injuries in a case probably due to a lack of strict medical oversight.
where the severity of injuries was in excess of what might have been This presentation will impact the forensic community and/or
expected given the history and, had the event not been witnessed, might humanity by demonstrating why it is important to collect good information
have been mistaken for child abuse. regarding drug and clinical history when considering lethal methadone
A witnessed case of a 13-month-old child whose mother fell on top of intoxications. In this study, most of the decedents were not enrolled in
him at her obstetrician’s office is presented, resulting in severe head injuries methadone programs. Wide access to methadone treatment with good
that, under different circumstances, might be mistaken for abuse. medical oversight does not lead to an increase of lethal methadone intoxi-
A 31-year-old, 5-foot 8inch, 180-pound woman in her 8th month of cations and may be responsible for a large decrease of overall drug intoxi-
pregnancy was at her obstetrician’s office with her two children, a 3-year- cation deaths.
old girl, and a 13-month-old boy. While the woman was being weighed on This presentation will show that methadone treatment is safe when
a scale, the 13-month-old boy walked behind her. Not noticing her child well controlled medically and that methadone overdoses are in most cases
behind her, the woman stepped backward off the scale and onto her child, due to diverted methadone. It will extend an earlier study reported in 2000,
losing her balance and falling on top of the boy. According to a statement covering the years 1994 to 1998, showing that in Geneva, the wide access
to police, her “tailbone hit her son’s head.” The height of the scale was 4 to methadone treatment did not lead to an increase of lethal methadone
inches from the carpeted floor. The event was witnessed by the doctor’s intoxication and may be responsible for a large decrease of overall drug
nurse; whose statement corroborated that of the mother’s and further indi- intoxication deaths.
cated that the left side of the boy’s face was down against the carpet when It is hypothesized that the decrease in the number of lethal drug intox-
his mother landed on him. ications that started in 1995 had continued through 2004 because of the
The boy, who immediately became unresponsive, was taken to the wide access to methadone treatment, which provides treatment to most of
hospital where his Glasgow coma scale on arrival was 4-5 and he was the heroin addicts in Geneva. In 2000, the estimated number of addicted
exhibiting decerebrate posturing. Computed tomography scans of the head drug users in Geneva, including users of heroin, cocaine, cannabis, and
showed a depressed frontal skull fracture, bilateral subarachnoid hemor- benzodiazepines was 2500. The number of methadone treated patients in
rhage (left greater than right), left subdural hematoma (without midline 2005 is 1356 and the new heroin users asking for methadone treatment is
shift), and elevated intracranial pressure. No funduscopic examination was dropping steadily.From 1 January 1994 to 31 December 2003, the authors
performed. Despite medical intervention, he died the next day and was studied systemically all toxicological data from all cases in which
brought to the Harris County Medical Examiner’s Office for autopsy. methadone and/or morphine was found. Cases were selected on the basis
At autopsy, external examination revealed diffuse, right-sided scalp that the only cause of death was a potentially lethal drug concentration in
hemorrhage and right periorbital ecchymosis. Internally, a gaping 7-1/4” the postmortem blood sample. For each case in which methadone was
linear skull fracture involved the parietal skull bilaterally, anteriorly found, information regarding drug and clinical history was collected from
extending to and involving the coronal suture. Dura and brain matter her- police sources and from the Health Authority for each registered
niated through the fracture. Approximately 20 milliliters of subdural hem- methadone-treated patient.
orrhage were present bilaterally (right greater than left). Bilateral It was discovered that the drop of lethal drug intoxications starting in
parasagittal subarachnoid hemorrhage and bilateral tonsillar herniation 1995 continued until 2003. Methadone lethal intoxications remain stable
were also present. Coronal sections revealed contusions of the right frontal and low - around five cases per year. Most of them are due to illegally
and parasagittal contusions. No other injuries were noted. diverted methadone used by a person not in treatment. Cocaine overdoses
In the United States, an estimated 1,400 deaths due to child neglect have increased since 2002. Most of the lethal overdoses have other drugs
and abuse occurred in 2002; of these, 30% were due purely to physical present in the blood, the commonest being benzodiazepines and alcohol.
abuse. The majority of pediatric homicides occur within the first two years In conclusion, methadone treatment has been very successfully imple-
of life, and the cause of death most commonly involves blunt force injuries mented in Geneva since the 1970s and has been widely available since the
to the head or abdomen. Typically, fatal injuries in children do not occur as 1990’s, with a dramatic decrease of heroin overdoses. This can be
a result of minor mishaps during ordinary activities of daily living. The explained by the fact that almost all heroin addicts have easy access to
discrepancy between the history provided by the caregiver and the severity treatment. The wide access to methadone treatment has not lead to an
of the injuries themselves is often the initial indication of abuse. Such increase of lethal methadone intoxications. The lethal methadone intoxica-
stories may describe the decedent rolling off of a bed, falling from the arms tions while on methadone treatment are very rare and probably due to a lack
of the caregiver, or the caregiver falling while carrying the child. Had the of strict medical oversight. It is important to note that most of the decedents
events described in the case above not taken place at the doctor’s office and were not enrolled in methadone programs.
been witnessed, the “discrepancy” between the story and the severity of the Methadone, Addiction, Overdose
injuries sustained by the decedent would likely have raised serious
suspicions of child abuse.
Fall, Head Injuries, Child Abuse

G13 Pathological Changes Associated Introduction: The authors describe a case of suicide in a workplace.
A 45-year-old man who worked in a vegetable and fruits packaging
With Aortic Valve Stenosis business was found dead in his workplace. Because of the scene circum-
stances, analysis of an arterial blood sample taken with an airtight syringe
Lise A.M. Matzke, MSc*, and Courtney Young, BSc*, James C Hogg at the scene revealed absence of carbon monoxide but high levels of carbon
iCAPTURE Centre, Room 166, 1081 Burrard Street, Vancouver, BC V6Z dioxide (CO2). Autopsy found no significant injury and police investi-
1Y6, Canada gators found a handwritten note of intent, describing a recent personal
After attending this presentation, attendees will understand the crisis. Therefore the authors concluded that the cause of death in this case
pathology of aortic valve stenosis (AVS). Aortic valve stenosis is a cause was a suicide by carbon dioxide intoxication. This means of suicide is rare,
of sudden cardiac death in older individuals and young athletes. with cases previously described in the literature as accidental carbon
As such, this poster will impact the forensic community by high- dioxide intoxications. This is the first case of suicide by CO2 intoxication
lighting major pathological features of degenerative and bicuspid aortic within a closed-space tank in which the atmosphere is modified for the
stenosis as well as the underlying pathogenesis of these diseases. package of fruits and vegetables.
An analysis of the morphological features and pathogenesis of this Case report: A 45-year-old male who worked as a packager of veg-
common heart valve disease will aid pathologists and researchers in under- etables was found dead on the floor in his workplace. The location of the
standing its role in sudden death. As the incidence of aortic stenosis death was a confined room used for packaging vegetables, fruits, and
increases, the rate of sudden death due to this disease does as well. This apples. External examination showed no sign of struggle and the victim
presentation will impact the forensic community and/or humanity by had no history of psychiatric disorders. The rescue team thought that cause
assisting in the understanding of the environmental and genetic determi- of death could be carbon monoxide intoxication. In the residence of the
nants of its pathogenesis, which will aid those conducting pathological deceased, police investigators found a handwritten note of self-destructive
examinations to better understand the underlying features of the morpho- intent, describing a recent personal crisis.
logical changes seen at autopsy. Autopsy findings: An autopsy was performed by a board-certified
Aortic valve stenosis is the most common valvular heart disease forensic pathologist. The external examination of the body was significant
among adults in the western world, and continues to increase in prevalence for an absence of cherry red lividity, which is normally a good indicator of
as the average lifespan of the population increases. As such, AVS has CO intoxication. Autopsy found no significant injury and no traumatic
become a focus of intense investigation at the James Hogg iCAPTURE lesion.
Centre in Vancouver, British Columbia, Canada. Toxicology: Toxicological analysis was carried out, including blood
Aortic valve stenosis may be due to congenital malformation of the ethanol levels and screening for common drugs and illegal substances.
valve, rheumatic fusion of commissures, secondary calcification of a con- Surprisingly, carboxyhemoglobin was positive only at 2% saturation. The
genital bicuspid valve, or primary degenerative calcification of an oth- cause of death was unclear. The forensic pathologists had the idea to
erwise normal three cuspid valve. While the exact pathogenesis of AVS is perform the quantification of PCO2 and PO2 in the arterial blood. An
unknown, several genetic and environmental determinants are most likely analysis of the airtight arterial peripheral blood sample found an oxygen
responsible. saturation of 34.1%. The partial arterial CO2 level was 204 mmHg and the
AVS is characterized by narrowing of the aortic valve due to scarring O2 38.6 mmHg. The normal range of partial arterial CO2 extends from 40
and calcification, changes which create an obstruction to blood flow out of to 60 mmHg; the normal range of partial arterial O2 extends from 95 to 60
the main pumping chamber of the heart into one’s circulation. Symptoms mmHg.
can include chest pain, fainting, or heart failure. If left untreated, the The cause of the death was attributed to asphyxiation caused by CO2
outcome of patients with AVS is poor. Once treated, however, mainly by intoxication and especially the depletion of oxygen in the room. The
valve replacement, the patient survival rates and well being greatly manner of death was determined to be suicide. In spite of a suspected rapid
improve. postmortem increase in PCO2 and because of the context of death,
This poster will demonstrate some of the pathological changes assessment of the PCO2 level was performed in this case. The results of
associated with aortic valve stenosis with a discussion of its possible the PCO2 were elevated to such a degree, that it was possible to conclude
pathogenesis. that the cause of death was CO2 intoxication.
Discussion: the mechanisms of toxicity of CO2 are discussed.
Aortic Stenosis, Cardiovascular Pathology, Sudden Death
Carbon dioxide is produced when organic material decomposes or fer-
ments. Asphyxiation from CO2 exposure has occurred in workers entering
grain elevators (cereal stocking), the holds of cargo ships, and brewery vats.
It occurs accidentally when these spaces are not aerated or ventilated, or
G14 Fatal CO2 Suicidal Poisoning when the ventilation system dysfunctions. Sub acute toxicity may be
caused by the body’s failure to eliminate endogenous CO2, as it occurs in
Gilles Tournel, MD*, Fabrice Dedouit, MD, Anne Becart- hypoalveolar ventilation resulting from chronic obstructive pulmonary
Robert, DDS, PhD, Pierre Dutrieux, MD, Valéry Hedouin, MD, PhD, disease, opioid poisoning, or other causes of respiratory failure. Clinical
and Didier Gosset, MD, PhD, Institut de Médecine Légale, Faculté de signs of CO2 intoxication are presented and compared with the concen-
Médecine, 1, place de Verdun, Lille, 59000, France tration in mmHg found in this case. Other sources of CO2 exposure are
detailed. The most frequently encountered causes of CO2 intoxications are
The goal of this presentation is to recognize that the cause and manner
accidental and occur in the occupational setting. Examples of these types
of death requires deliberate consideration, even when the circumstances
of cases are also presented. Deaths by intentional carbon dioxide intoxi-
may lead to an initial obvious, but misleading, direction. It is important to
cation are rare. Generally, such cases are suicide by intentional inhalation
consider the case, the crime scene, and the autopsy findings, especially if
of automobile exhaust gases with low carbon monoxide emissions within
the death is non-natural.
an enclosed garage.
humanity by demonstrating an interesting case for the forensic pathologist CO2, Occupational Suicide, Asphyxiation
and forensic toxicologist. It is important that these two disciplines work
together and to share the findings to go to the truth.

G15 Case Report – Sudden Death Due to The tumor will be missed if routine sections of the AV node are not
submitted in cases of sudden death, especially those involving young,
Cystic Tumor of the Atrioventricular Node healthy individuals. It should always be considered in cases of sudden
death in the context of congenital heart block and congenital fibrosis of the
Carlos F. Chavez Arias, MD*, Kathyrn Haden-Pinneri, MD, Maximiliam AV node.
Buja, MD, and Luis A. Sanchez, MD, Harris County Medical Examiner’s
Office, Joseph J. Jachimcyzk Forensic Center, 1885 Old Spanish Trail, Cystic Tumor of the AV Node, Sudden Death, Heart Block
Houston, TX 77054
The goal of this presentation is to show the importance of including G16 Sudden Death in a Healthy 37-Year-Old
cystic tumors of the atrioventricular node as one of the main differential
diagnoses in cases of sudden death, especially in the context of congenital Man While Driving: Spontaneous
heart block with the adjunct of performing a thorough examination of the Dissection of the Posterior Segment of
cardiac conduction system. the Right Coronary Artery
humanity by demonstrating how this type of tumor will be missed if routine
Wendy M. Gunther, MD*, Department of Legal Medicine, Virginia
sections of the AV node are not submitted in cases of sudden death, espe-
Commonwealth University, Medical College of Virginia, 1101 E Marshall
cially those involving young, healthy individuals, and it should always be
Street, Richmond, VA 23298-0568; and Jonrika M. Malone, MD, Office of
considered in cases of sudden death in the context of congenital heart block.
the Chief Medical Examiner, Tidewater District, 830 Southampton
Cystic tumor of the atrioventricular (AV) node is a benign, congenital,
cystic mass located at the base of the atria septum in the region of the AV
node. Although cystic tumor of the AV node is the most common After attending this presentation, attendees will recognize sponta-
intracranial tumor causing sudden death it is considered a rare neoplasm neous coronary artery dissection as a cause of sudden death, and as a dis-
with less than 100 cases reported in the literature to date. crimination between auto accident injury and natural cause of death.
A case of a woman in her 30’s who was diagnosed as an infant with Review of the epidemiologic, gross, and histologic features and character-
complete heart block is reported. A permanent pacemaker with epicardial istics of this rare disorder will be presented to forensic pathologists
leads was subsequently placed. She functioned normally with the exception This presentation will impact the forensic community and/or
of exercise related shortness of breath. She underwent several pacemaker humanity by increasing the awareness of the existence, characteristics,
changes throughout her life. She had a very active lifestyle. She was in her gross presentation, and histology of a rare natural disorder which frequently
usual state of good health when she experienced a sudden witnessed collapse presents with sudden death, and which may complicate deaths in motor
at her workplace. Her initial cardiac rhythm at the scene was pulseless vehicle accidents.
electric activity with appropriate pacemaker discharge. She was pronounced A 37-year-old man with no history of heart disease, including no
dead at the hospital after unsuccessful resuscitative measures. family history, was driving down a state highway when his car ran off the
At autopsy, examination of the cardiovascular system disclosed a 550- left side of the road, struck a sign, veered across the median across the
gram heart. The coronary arteries had a normal distribution and were free oncoming traffic lane, and struck a utility pole. There was no attempt to
of atherosclerosis. The pacemaker leads were appropriately positioned. No brake, according to witnesses, and no skid marks. No other cars were
gross lesions were visible on examination of the cardiac conduction system. involved in the accident. The victim was wearing his seat belt and shoulder
Microscopic examination of the myocardium showed hypertrophic belt, and the airbag deployed. A witness said the victim showed signs of
myocytes, focal interstitial fibrosis, and focal contraction band necrosis. life after the car came to rest. Emergency medical personnel who reached
Sections from the region of the AV node showed a proliferation of cells the scene noted there was no visible injury, but the victim was unresponsive
forming nests, cysts, and glands of variable size and shape measuring a and asystolic, and they believed him dead. Attempted cardiopulmonary
minimum of one centimeter. The cell population ranged from those resem- resuscitation at the scene and in a local emergency room was unavailing.
bling transitional cells and those with squamous differentiation to cuboidal At autopsy, the victim measured 68” tall and weighed 198, with a
cells and clear, sebaceous-appearing cells. muscular body habitus with no evidence of obesity. External signs of injury
Cystic Tumor of the Atrioventricular (AV) node has been called one were limited to several small bruises on the left side of the shoulder at the
of the “smallest tumors causing sudden death.” When symptomatic the base of the neck, consistent with a shoulder harness. There were no xan-
majority of patients present with complete heart block. The diagnosis of thomata of the eyelids or elbows. The heart weighed 375 grams, less than
heart block in patients with AV nodal tumors may be made at birth or as late five percent of estimated lean body weight; there were no signs of hyper-
as the ninth decade of life. It has a female predominance. The majority of trophy. The renal cortices were smooth. The coronary arteries had normal
known cases are diagnosed at autopsy although a few reported cases have takeoffs, without atherosclerosis other than proximal fatty streaks. There
been diagnosed during life and treated. Pacemaker is the first line of were no coronary anomalies or previous infarcts. There were no significant
therapy; however they are not always effective, as seen in this case. internal injuries.
Although rare and histologically benign, cystic tumors of the AV node are On sectioning of the ventricles, a “red dot” was noted in the epicardial
the most common intracardiac neoplasms causing sudden death. They are fat over the posterior septum. Examination with a hand-held magnifying
located in the AV nodal region because this is an area of embryologic fusion glass confirmed hemorrhage both inside and around the posterior septal
and therefore prone to accidental incorporation of embryologic structures. segment of the right coronary artery. A delicate layer of coronary wall
The mechanism of death is related to its intracardiac location, which can could be seen creating an S-shape between foci of hemorrhage.
precipitate conductive and hemodynamic abnormalities. Cystic tumors of On histology, the coronary artery had dissected through the outer
the AV node are rarely seen grossly, but when visible it is seen as an ele- plane, and a mixed inflammatory infiltrate including eosinophils sur-
vated nodule above the septal leaflet of the tricuspid valve. Most of the rounded the adventitia, and infiltrated the wall. No other area of the heart
time they are first identified microscopically. This lesion is characterized or coronaries showed eosinophils. There were no foci of lymphocytic
by multiple microcysts, gland like structures, and nests of epithelioid (occa- myocarditis. No myocardial scarring, myocyte hypertrophy, or small
sionally squamoid) cells within a fibrous stroma. Previously thought of as vessel disease was present.
a mesothelioma of the AV node, this lesion has since been shown convinc- Dissection of the coronary arteries as a spontaneous event has been
ingly to represent an endodermal heterotopia. well reported in the literature, with an undetermined but possibly

autoimmune etiology. More than two thirds of patients present at autopsy; (average of 31.6 years) and from 21 to 50 years in the control group
the remaining third often recover with stenting or thrombolysis. Coronary (average of 31.7 years).
artery dissection accounts for approximately 0.5% of sudden deaths in Methods: Samples were collected at the level of the atrioventricular
patients 30-40 years old. The typical victim is female, of childbearing age, junction. Slides were stained with haematoxylin-eosin and Masson’s
frequently in her thirties, occasionally postpartum. The victims do not have trichrome. The extent of fibrosis was determined using a 4-point semi-
a history of hypertension (or hypertension is present as an unrelated factor). quantitative scale. Fibrosis assessment was carried out in the following
Over 90% of cases that come to autopsy involve the left anterior regions of the atrioventricular junction: the atrioventricular node, the pene-
descending coronary artery. Under the microscope, the dissection plane is trating part of the node, the branching bundle and the left and the right
in the outer media, unlike the dissection of atherosclerotic arteries. There bundle branches. In addition, the superior septum was also analysed.
is a striking infiltrate of eosinophils, lymphocytes, neutrophils, and Results: The mean values obtained from the different structures of the
macrophages in the adventitia. Some believe that the inflammatory infil- conduction system and the superior septum were higher for the group of
trate is secondary to the dissection, and not a vasculitis. There is no time drug addicts than for the control group.
of day, drug, or activity, which is correlated with initiation of the dissection. Statistical analysis: The pair wise comparison population test showed
Spontaneous or eosinophil-associated dissection of the coronary significant differences (p<0.01) in the atrioventricular node, in the left
arteries in males is rare. Men comprise about 15% of the victims of this bundle branch and in the myocardium of the superior septum.
unusual disorder. The posterior segment of the right coronary artery is the Conclusion: Fibrosis of the different structures of the conduction
most frequently reported site in men. Researchers were unable to find system and of the superior septum is a degenerative lesion whose severity
information that would answer the family’s questions as to risks for other increases with age. Early occurrence of fibrosis in drug addicts appears to
family members. The etiology and genetics of spontaneous coronary dis- be linked primarily to chronic cocaine consumption. This is not surprising,
section are unknown. The case is discussed in conjunction with a review as cocaine cardiotoxicity has been known for a number of years. At the
of the literature and the sparse information that is available on this rare same time, the hair analyses conducted in this study show that repetitive
disorder. cocaine consumption is almost always associated with chronic abuse of
Spontaneous Coronary Artery Dissection, Males, Motor Vehicle other illicit drugs. Thus, one cannot exclude the role played by these other
Accident substances in the appearance of fibrosis in the studied cases.
Myocardial fibrosis may cause problems in the cardiac rhythm and
even lead to sudden death. Thus, in the context of this study, the early onset
of fibrosis in the cardiac conduction system and the superior septum may
G17 Fibrosis of the Cardiac Conduction explain sudden death in chronic drug users whose measured drug levels in
System as a Possible Cause of Death the bloodstream are relatively low.
in Chronic Cocaine Addicts Conduction System, Hair Analysis, Drug Abuse
Katarzyna Michaud, MD*, Thomas Krompecher, MD, Frank Sporkert, PhD,

Franco Taroni, PhD, Béat Horisberger, MD, Marc Augsburger, PhD, and
Patrice Mangin, MD, PhD, Institut Universitaire de Médecine Légale, G18 Fatal Venous Air Embolism in a
Bugnon 21, Lausanne, 1005, Switzerland
Postmenopausal Female During
The goal of this presentation is to present a study of the fibrosis of the Consensual Sexual Intercourse:
cardiac conduction system in chronic cocaine addicts.
This presentation will impact the forensic community and/or A Case Report and Review of the Literature
humanity by demonstrating and emphasizing that the early onset of fibrosis
in the cardiac conduction system may explain sudden death in chronic Erik D. Christensen, MD*, Office of the Greenville County Medical
cocaine users and especially whose measured drug levels are relatively low Examiner, 890 West Faris Road, Suite 110, Greenville, SC 29605
It is well known that the results of toxicological analyses can be dif- After attending this presentation, attendees should have an under-
ficult to interpret in drug addicts because of their increased drug tolerance. standing of the varied setting in which venous air embolism can occur and
Thus, the forensic pathologist is occasionally faced with death cases in can cause sudden death.
chronic drug addicts that demonstrate relatively low drug concentrations in This presentation will impact the forensic community and/or
their blood. In some cases, autopsy does reveal the anatomic/pathological humanity by presenting a case with an unusual cause of sudden death and
cause of death, but in other cases no lesion can be found at the macroscopic to review the relevant literature for future reference.
or microscopic levels. Case Report: A sixty-year-old female had recently begun an infre-
The goal of the present work is to study fibrosis of the cardiac con- quent sexual relationship with a younger man. Following sexual inter-
duction system in chronic cocaine addicts. Myocardial fibrosis may course on the day of her death, her partner noted blood on his penis. She
provide the morphological substrate in certain arrhythmias and may even denied pain, but stated that she did not feel well and was having some
explain a sudden death. At the same time, a review of the literature shows shortness of breath. She then collapsed and expired despite resuscitative
that the cardiac conduction system is rarely examined in drug addicts, measures, which were delayed, as her partner dressed her prior to sum-
including individuals whose drug consumption is chronic, as revealed by moning help.
hair analysis. Autopsy revealed an atrophic vaginal mucosa with a laceration of the
Materials: The group of cocaine addicts was comprised of 33 cases all right lateral sidewall. Intravenous air was present in the pelvic veins and
known by the police to involve chronic substance abusers. In each case, there was also interstitial emphysema. Aspiration of blood from the
cocaine was detected in the hair. Hair analysis also revealed that for all coronary sinus revealed frothy blood and air bubbles were present in her
cases, cocaine was associated with other illicit drugs, such as opiates, epicardial veins.
methadone, and amphetamines. In the majority of cases (27), the cause of Methods: Autopsy protocol and investigative findings for this patient
death was attributed to an overdose. The control group was comprised of are reviewed. The medical literature was searched using the keywords air
31 cases where death was attributed to trauma, hanging, or a natural cause. embolism, venous air embolism, sudden death, and vaginal laceration for
No illicit substance was detected in the blood, urine, or hair of the control citations relating to venous air embolism. References from citations found
cases. The age ranged from 21 to 45 years in the drug addict group were further reviewed for relevant literature.

Results: Venous air embolism is a well-described phenomenon, asso- The most commonly fractured sites in the hyoid were the midshaft of
ciated with neurosurgical procedures in both the seated and prone position, the greater cornu either unilaterally (18.5% for left side, 25.9% right side)
as well as in pelvic procedures ranging from transurethral prostate resection or bilaterally, 18.5%. This agrees with findings on a much smaller sample
to hysteroscopy. It has also been reported to occur in the pregnant women by Pollanen et al (1995). The most commonly fractured sites in the thyroid
following vaginal insufflation and intercourse, in non-pregnant women fol- cartilage were bilateral fractures of the left and right superior cornua (32%),
lowing intercourse and autoerotic manipulation. Cranial blunt injuries may left superior cornu unilaterally (24%) or right superior cornu unilaterally
result in air embolism. Cases related to central venous catheter use, percu- (30%). The most common location for the superior cornu fracture was at
taneous lithotripsy, endoscopy and intraoperative hydrogen peroxide irri- its juncture with the lamina (18% left; 16% right). Ubelaker’s review of the
gation have also been reported. literature (1992) cites a cohesive fracture rate of 8% hyoid fractures and
Conclusions: Venous air embolism is an unusual cause of sudden and 15% thyroid fractures in hangings, 11% fractures hyoid and 32% fractures
unexpected death and this report documents the first case of this phe- thyroid in ligature strangulations, and 34% hyoid and thyroid fractures in
nomenon occurring in the setting of a vaginal laceration resulting from con- manual strangulations.
sensual sexual intercourse in a post-menopausal woman. The data of the group support earlier contention that the supple nature
Air Embolism, Vaginal Laceration, Sudden Death of these structures in children and young adults does not lend them to easy
fracture (O’Halloran & Lundy, 1987; Pollanen & Chiasson, 1996). The
earliest age of hyoid fracture in this series occurs in the third decade with
19% fractured, all in the mid-portion of the greater cornua. The fourth
G19 Incidence of Laryngeal and Hyoid through seventh decades show fracture rates varying between 14 to 26%.
Fractures in Hangings and Strangulations In the eighth and ninth decades the fracture rates are 100%; however this
Using Enhanced Examination Procedures number is based on a total of five individuals. The earliest age of thyroid
cartilage fracture is the second decade with one 18-year-old individual with
Dana Austin, PhD, and Marc A. Krouse, MD, Tarrant County Medical a fracture of the left superior cornu at the base. Fracture rates of the thyroid
Examiner, 200 Feliks Gwozdz Place, Fort Worth, TX 76104-4919 cartilage range from 32% to 70% in the third through seventh decades and
are at 80% in combined eighth and ninth decades.
After attending this presentation, attendees will understand that In cases where ligature type is known for hangings and ligature stran-
enhanced examination of the larynx and hyoid will reveal subtle injuries of gulations, the frequency of fracture type with ligature type was detailed.
bony and cartilaginous structures that might otherwise not be found Cord type ligatures, which included ropes, electrical cords, telephone cords,
The rate of injury of the larynx and hyoid is significantly higher when shoelaces, and other small diameter strings, resulted in 22% hyoid and 44%
examination of these structures is enhanced by high-resolution radiography thyroid fractures. Strap type ligatures, which included cargo straps and
and maceration and removal of soft tissues followed by macroscopic exam- belts, resulted in 12% hyoid fractures and 53% thyroid fractures. Fabric
ination. This presentation will impact the forensic community and/or type ligatures, which included clothing such as t-shirts, sheets, curtains and
humanity by demonstrating how these simple and inexpensive procedures neckties, resulted in 18% hyoid fractures and 45% thyroid fractures. In
can reveal subtle injuries of bone and cartilage that otherwise might not be three cases where the ligature was not recovered at the scene, all had hyoid
seen and complete the forensic examination of the neck in cases of known fractures and 2 out of 3 had thyroid fractures.
or suspected strangulation, hanging or other neck injury. References:
Between 1996 and 2005 the examination of the larynx and hyoid in Pollanen MS & Chiasson DA (1996) Fracture of the hyoid bone in stran-
cases of suspected or known neck injury was enhanced by the following gulation: comparison of fractured and unfractured hyoids from victims of
methodologies: strangulation. JFS 41:110-113. Pollanen MS, Bullger B and Chiasson DA
1. Visual inspection and palpation of the larynx and hyoid at autopsy, (1995) The location of hyoid fractures in strangulation revealed by xerora-
in situ and after en bloc resection and limited dissection of soft tissues diography. JFS 40:303-305. Ubelaker DH (1992) Hyoid fracture and
2. High-resolution radiography of the fresh en bloc specimen utilizing strangulation. JFS 37:1216-1222. O’Halloran RL and Lundy JK (1987)
mammography film Age and ossification of the hyoid bone: forensic implications. JFS
3. Maceration of soft tissue in water with removal of residual tissue 32:1655-1659.
and macroscopic visual inspection of laryngeal and hyoid bone and
Larynx, Hyoid, Examinations
cartilage
The sample consists of 105 individuals who died of hanging or stran-
gulation or suspected strangulation between 1996 and 2005. The sample
population contains 52 males and 53 females with an age range of 8 to 81
years (mean of 36.32 years). For analytical purposes the ages were divided G20 Agonal Sequences in a Filmed
into decades: the first decade and the ninth decade each represented by one Suicidal Hanging: Analysis of
individual; the second through eighth decades ranged from four individuals Respiratory and Movement Responses
(eighth decade) to 31 individuals (third decade). The ancestry of the
sample was 62% European, 18% African, 18% Hispanic, and 2% Asian. to Asphyxia by Hanging
Examined were 62 hangings, 20 manual strangulations, 10 ligature
strangulations and 13 strangulations not otherwise specified (mechanism Anny Sauvageau, MD, MSc*, Laboratoire de Sciences Judiciaires et de
unknown or evidence of arm lock or combination of manual and ligature). Médecine Légale, 1701 Parthenais Street, 12th Floor, Montreal, Quebec
Sixty-one hangings were ruled suicide or consistent with suicide, one 15- H2K 3S7, Canada; Stéphanie Racette, BSc, Laboratoire de Sciences
year-old was ruled accidental and was consistent with autoerotic asphyxi- Judiciaires et de Médecine Légale, 1701 Parthenais Street, 12th Floor,
ation - this was the only hanging where padding was included with the lig- Montreal, Quebec H2K 3S7, Canada
ature. The strangulations cases were all ruled homicide. After attending this presentation, attendees will gain a better under-
Of the hanging cases (N=62), 19.4% had hyoid fracture and 48.4% standing of the physiological responses of asphyxia by hanging.
had thyroid fracture. Of cases of ligature strangulation (N=10), 20% had This presentation will impact the forensic community and/or
hyoid fracture and 40% had thyroid fracture. Of cases of manual strangu- humanity by demonstrating a unique case that will allow a better under-
lation (N=20), 45% had hyoid fracture and 50% had thyroid fracture. In standing of the respiratory and movement responses of asphyxia by
cases of strangulation, not otherwise specified (N=13), 7.7% had hyoid hanging.
fracture and 46.2% had thyroid fracture.

The goal of this presentation is to first review the literature of physio- G21 Visual Misidentifications of Human
logical responses to asphyxia by hanging in humans and animals, and to
compare such data to a unique case of suicide by hanging that was recorded
Remains: Lessons Learned
by a video-camera.
There is just one report in the literature of an analysis of agonal Joyce L. deJong, DO*, Sparrow Hospital, 1215 East Michigan Avenue,
movement sequences in hanging, published in 1989 in German. In this Lansing, MI 48909-7980
case, a man recorded his autoerotic hanging with a video camera and died After attending this presentation, attendees will learn of two visual
accidentally. Except for this foreign language case, there is very few data misidentifications made by parents after the death of their sons.
on human hanging. A few experimental studies have been conducted on This presentation will impact the forensic community and/or
dogs, but the application of those results to human hanging is limited. Of humanity byexamining the procedures followed after one of the parents
course, there are witnessed reports of judicial execution hangings, but those alerted officials of the possible misidentification and suggests (1) methods
are very different in nature from typical hanging, since death is caused to avoid visual misidentifications, and (2) measures to routinely follow to
mostly by fracture-dislocation of the upper cervical vertebrae with trans- respond to claims of bodies being “mixed-up” in the morgue.
action of the spinal cord, rather than asphyxia by neck structure com- Misidentifications are often reported by the general media and rarely
pression. presented formally in the forensic science literature. This presentation will
A case of a 37-year-old man who filmed his hanging suicide is pre- impact the forensic community and/or humanity by assisting the forensic
sented. The man tied a padded rope to his neck and fixed the other end on community by pointing out the situations that most commonly result in
the rail system of an electric garage door. He used the remote control to misidentifications, the steps needed to prevent the misidentifications, and
close the door, therefore hanging himself. His feet were fixed in ski boots, other measures to take to address where the misidentification occurred.
tied with chains to a metal platform. A camera was previously set to film An automobile driven by a drunk driver, struck two 14-year-old white
his suicide. This film allows a unique analysis of agonal movement males, Child A and Child B, as they walked home from a skateboarding
sequences. park. The mother of one of the boys (Mother A) “claimed” Child A as her
Before the final hanging, the man first hesitated for 23 seconds, testing son at the scene and rode to the hospital in the ambulance with the child. A
the door by moving it up and down with the remote control. Then, he second ambulance transported Child B. Child B died in the emergency
finally closed the door and hanged himself. department; “Mother B” and her husband arrived at the emergency
Considering the time of hanging to be time 0, the agonal sequences department after Child B died and claimed him as their son. Child A died
consisted of the following: loss of consciousness (thirteen seconds), con- hours later in the pediatric intensive care unit with his parents and many
vulsions (fifteen seconds), decortication rigidity (twenty-one seconds), others in attendance at his bed. An autopsy performed the following day
decerebration rigidity (forty-six seconds), second decortication rigidity on both of the boys showed the cause of both deaths to be multiple injuries
(one minute eleven seconds), loss of muscle tone with a few isolated due to pedestrian struck by a motor vehicle. Both children had severe head
muscle movements (one minute thirty-eight seconds) and last isolated injuries. Photographs and fingerprints were obtained during the autopsy.
muscle movement (four minutes ten seconds). Close family members viewed the body of Child A at the funeral home and
Twenty-one seconds after hanging, the body presented decortication then had him buried at a local cemetery. The family who claimed Child B
rigidity, with extension of trunk and lower limbs combined with upper-limb had him cremated after an open-casket visitation and funeral. During the
flexion. This pattern of rigidity is caused by cerebral cortex impairment. open-casket visitation, many students from the school the boys attended
Twenty-five seconds later, the body suddenly moved from this pattern of strongly voiced their opinion that the boy in the casket was Child A and not
rigidity to decerebrate rigidity, with full extension of both upper and lower Child B. The parents denied the claims of the visiting children and the
limbs. Mesencephalon impairment causes this rigidity pattern and is gen- funeral directors believed the parents.
erally accompanied by irreversible coma and unstable vital signs. About one year later, Mother A reported that she believed she had
The amplitude of movement during the initial convulsions, as well as claimed the wrong child; her opinion developed after reading the autopsy
during the rigidity pattern changes, explains the minor traumatic lesions reports and recognizing the report with her son’s name described the other
often seen in hanging in closed areas, such as a wardrobe. child and vice versa. Mother A had antemortem fingerprints available for
The hanging in the present case does not seem to completely occlude comparison with the two sets of postmortem fingerprints obtained at the
the airway and respiratory movements are well seen in the film. Twenty- autopsy; the prints matched the postmortem prints of Child B. Child A was
seconds after the hanging, very deep respiratory attempts with rhythmic exhumed and antemortem dental records were obtained for both children.
respiratory chest and abdominal muscle contraction started. The respi- The forensic odontologist compared the two sets of antemortem dental
ration was loud and wheezing. At one minute eleven seconds, abundant records to the exhumed remains of Child A; the odontologist was blinded
saliva freely flowed from the mouth. Respiratory movements progres- as to the identity of the antemortem records. The antemortem records pro-
sively decreased and completely stopped at two minutes. vided by Mother B matched the postmortem dental features of Child A. By
This case confirmed the well-known occurrence of rapid loss of con- both fingerprint and dental record comparison it was determined that Child
sciousness within seconds. Moreover, it gives a unique opportunity to A was the child of Mother B and Child B was the child of Mother A. In
study the agonal movement sequences in hanging. one photograph of Child B, the name of the child is clearly visible on the
Asphyxia, Hanging, Forensic Pathology hospital identification band with the associated autopsy case number indi-
cating the bodies were not mixed up in the morgue after being banded in
the hospital. The parents visually misidentified the children.
Lessons learned from this case are multiple and include: (1) Visual
identifications are not always accurate – even parents can claim the wrong
individual as their child. (2) Incidents involving victims of the same sex,
race, and approximately the same age, should be identified using a bio-
logical method such as fingerprints, dental record comparison, medical X-
ray comparison, or DNA. (3) Photographs of all identifying tags with the
autopsy case number clearly visible should be routinely obtained.
Human Identification, Forensic Science, Exhumation

G22 Identifying Corpses of Foreigners in G23 Mass Disaster Victim Identification:
the State of Advanced Decomposition: The Tsunami Disaster
Sri Lanka After the Tsunami 2004
Sawait Kanluen, MD*, Chulalongkorn University, Department of
Heike Klotzbach, MD, PhD*, Institute of Legal Medicine, Stiftsplatz 12, Forensic Sciences, 254 Phayathai Road, Patumwan, Bangkok 10330,
Bonn, 53111, Germany; Klaus Benedix, DMD, Dental Services German Thailand; and Tony Kanluen, MD, Henry Ford Hospital, Department of
Air Forces, Dachauer Strasse 128, München, Bavaria 80637, Germany; Emergency Medicine, 2799 W Grand Boulevard, Detroit, MI 48202
Guido Beutler, Embassy of the Federal Republic of Germany, 6/50 After attending this presentation, the attendee will understand how to
Shantipath, Chanakyapuri, New Delhi, 110 021, India; and Thomas organize, implement, and utilize the Interpol Disaster Victim Identification
Lubnau, and Kerstin Schneider, Federal Criminal Police Office, Georg- Protocol in mass disaster. Attendees will learn the various identification tech-
Marshall-Strasse 20, Wiesbaden, 65173, Germany; Stephan Klein, niques used in the tsunami disaster in Thailand.
Federal Criminal Police Office, Georg-Marshall-Strasse 20, Wiesbaden, This presentation will impact the forensic community and/or humanity by
65173, Germany demonstrating the importance of an organized approach to victim identification
After attending this presentation, attendees will gain an understanding in mass disasters.
of disaster victim identification under difficult conditions. The Interpol Disaster Victim Identification Protocol has frequently been
This presentation will impact the forensic community and/or utilized in mass disasters like earthquakes, fires, and hurricanes however, never
humanity by assisting the forensic community in understanding the in a tsunami. The victim identification process in Thailand was challenging due
necessity of cooperation of different nations and individual specialists con- to multiple factors including, rapid decomposition of bodies due to heat, sig-
cerning mass disaster victim identification under difficult conditions (e. g. nificant number of foreigners, unprecedented number of victims, and lack of
foreign country, different mentality, and multinational victims advanced prior fingerprint and dental records. The death toll in Thailand included over
decomposition) 5,395 persons (1,953 foreigners) dead and 2,932 (909 foreigners) missing.
After the tsunami numerous tourists were reported missing in Sri Three sites were established in Southern Thailand for the processing of
Lanka. Main objectives of the German disaster victim identification victims, two in Khao Lak, Thailand, and one in Krabi, Thailand. Victims were
(DVI)-team were sustaining a general survey of the circumstances and to then identified as either Thai or foreigner. All foreigners were processed by the
achieve actual dates concerning foreign victims, German citizens in par- International Disaster Victim Identification (DVI) Team while all Thais were
ticular, and to proceed with their identification. Exceptional conditions processed by the Thai Victim Identification Team. Utilizing the Interpol
consisted in a relatively small percentage of multinational foreigners Disaster Victim Identification Protocol, bodies were numbered and pho-
among a vast amount of local disaster victims and in the enormous area tographed. Forensic pathologists examined victims noting birthmarks, tattoos,
where the deceased were disseminated. Extensive search operations scars, jewelry, clothing, height, weight, and other distinguishing characteristics.
revealed that dead bodies of presumptive foreigners were located in hos- Due to the tropical environment and lack of initial refrigeration, many bodies
pitals, funeral parlours, swamps, or provisional graves. Lead-managed by rapidly decomposed before a forensic pathologist could examine the victim.
local authorities, exhumations could be performed. Major challenges con- Dentition was photographed and documented by forensic dentists for com-
sisted of advanced decomposition, and some of the bodies were almost parison to prior dental records. If possible, fingerprints were obtained from
skeletonized by feeding defects. Moreover several bodies had been victims and recorded in the Automated Fingerprint Identification System
embalmed with formaldehyde. Pre-screening for an assumable foreign (AFIS). In a few countries, fingerprints are part of the national ID card
nationality was performed on the grounds of clothing, items carried along however, in most cases, anti-mortem fingerprints were difficult to obtain.
by the victims and dental work. The final identifications by multinational Molar teeth and femur DNA samples were obtained for DNA profiling.
DVI-teams were mainly based on dental findings and results of DNA- According to the Interpol protocol, victims can be identified utilizing four
examination performed in Austria. Targeted police investigations also methods: 1) Dental Records 2) Fingerprints 3) DNA 4) Property. All post-
revealed that numerous people were alive either in Germany or still in Sri mortem information was forwarded to the Thai Tsunami Victim Identification
Lanka. Information Management Center (TTVI-IMC) and entered into a database.
At February 25th, 2005, the mission was completed successfully and Concurrently, embassy officials were obtaining anti-mortem records such
no more German citizen was reported missing in Sri Lanka. It has to be as DNA, fingerprint, dental, clothing, and victim characteristics from victim’s
emphasized that the complaisant support of the local authorities and the families around the world. The international scope of the disaster initially
notable obligation of each individual specialist appointed by different limited victim identification due to the logistics involved in obtaining dental
nations, comparably contributed to the successful and effective completion and fingerprint records.
of this complex and exceptional task. All anti-mortem information is entered into a database and cross-matched
with postmortem information utilizing PLASDATA, a software database
Identification, Mass Disaster, Tsunami program. Of the 721 victims at the Krabi site, 560 (77.6%) were identified. 357
(63.8%) were of Thai nationality and 203 (36.3%) were foreign citizens.
Utilizing property, location, and distinguishing physical characteristics iden-
tified 511 victims (91.3%). Dental records identified 49 victims (8.8%), pri-
marily foreign citizens. DNA and fingerprints did not identify any of the
victims.
At the Krabi site, identification of Thai nationals proved more successful
than foreign citizens for multiple reasons. Family members physically iden-
tified Thai victims through clothing, property, and tattoos prior to body decom-
position. Dental records, fingerprints, and DNA were rarely used for Thai
victims. Foreign citizens were identified through property, clothing, and dental
records. To date, DNA has not proven effective for Thai victim identification.
The Interpol Disaster Victim Identification System can be utilized in
tsunami disasters where resources, technology, and personnel may be limited
and multiple nationalities are involved.
Mass Disaster, Victim Identification, Tsunami

G24 Victim Trauma as an Identification vidual members of the group can be established more readily. (e.g. aircraft
passenger lists or wedding invitation lists). The identification procedure is
Tool in Mass Disasters obviously much more complex when diverse crowds in public places are
involved.
Maurice G. Rogev, MD, MBChB*, 11/1 Zamenhof Street, Tel-Aviv-Jaffo, Injuries can be due to crushing, fire, gas or smoke inhalation, blast
64373, Israel effects in explosions, penetration of primary or secondary missiles, lacer-
After attending this presentation, attendees will learn that it is ation of soft tissue and the effects of bio-chemical agents. Examples will
important to consider the victim’s injuries in relation to his location at the be shown to illustrate the various injuries and their relevance.
time of a Mass Disaster. This relationship is the basis of further identifi- Victim, Location, Identification
cation procedures.
humanity by demonstrating the need to reinforce its commitment to finance G25 Differential Diagnosis: Antemortem vs.
full identification procedures. There is a need to employ Forensic Science
officers capable of implementing a full identification program. Postmortem Bone Trauma
Ipso facto, “Mass Disasters” involve large numbers of victims. In the
Medical Legal field, dealing with such disasters includes the identification Nermin Sarajlic, MD, PhD*, International Commission on Missing
of victims of trauma in a very wide variety of circumstances. In addition Persons, Alipasina 45A, Sarajevo, 71000, Bosnia and Herzegovina; John
to enabling families of the victims to learn the fate of their loved ones, Clark, MRCPath, University of Glasgow, Joseph Black Building,
results of identification procedures are made available for use by law Glasgow, Scotland G12 8QH, UK; and Eva-Elvira Klonowski, PhD,
enforcement agencies. International Commission on Missing Persons, Alipasina 45A, Sarajevo,
The final identification of the victim is usually confirmed by his/her 71000, Bosnia and Herzegovina
DNA profile, and /or by examination of the dentition of the victim after The goal of this presentation is to evaluate the difficulties in differen-
experiencing the trauma. This identification process is greatly simplified if tiation between antemortem and postmortem bone trauma in human
the victim’s pre-trauma identification characteristics can be located in skeletal remains
existing database of DNA or dental records for comparison purposes. This presentation will impact the forensic community and/or
Difficulties are encountered when no such pre-trauma records of a humanity by demonstrating how antemortem - postmortem bone trauma is
particular victim can be located and the identification procedure needs to always challenging for the forensic pathologists who have to deal with pre-
start ab initio. The aim is to attempt to determine the probable identity of dominantly skeletonised remains. This presentation will have an impact on
a particular individual by a compilation of data such as details of where the forensic sciences by demonstrating a way of judging bone trauma on skele-
individual was found, the trauma suffered and anthropological features, tonised remains.
[gender, age, height and race], for comparison with DNA profiles and/or Four years of the war in Bosnia and Herzegovina from 1992 to 1995
dental records of known missing persons. The DNA profile of a particular has left more then 30,000 missing persons, most of whom are presumed
individual can be determined from the DNA profiles of parents or children. dead. Until now, between 14,000 and 16,000 sets of human remains have
The dental history of an individual obtained from dental records kept by been exhumed from numerous single or mass graves in burials, wells,
dentists can also be used in identification. Other indications may be septic tanks and caverns, or as bodies simply left unburied in fields,
obtained from tattoo marks or moles and in some cases implants such as meadows and forests. The majority of the remains were completely skele-
pacemakers (with serial numbers), artificial joints, and the like. tonized, but occasionally they were saponified or mummified.
Victims may be found in collapsed buildings following natural dis- Variable burial conditions and variable decomposition of the remains
asters such as tidal waves, severe flooding, hurricanes or earthquakes as caused deterioration and injuries to the bones. Also, the transfer of the
well as due to human action. Human action can include direct injury as remains from primary to secondary, or even tertiary, mass graves, and the
well as building collapse due to defective building design or construction different techniques used during the exhumation process, caused post-
or terror explosions. mortem injuries to the bones.
Accidents involving road transport, aircraft and maritime vessels can Postmortem examination of the remains to determinate antemortem
cause large numbers of victims. The injury to each victim is largely deter- injuries revealed a considerable amount of additional postmortem damage.
mined by his location in relation to the area of the damage caused by the Assessment of antemortem injuries is not only important in the legal
disaster. Traumatic injuries inflicted on a group of individuals, who were process in order to determine cause and manner of death, but it is also
in close proximity to one another at the time of the disaster, will cause helpful in the identification process, when considering antemortem infor-
similar pathological changes in each member of the group. Different types mation obtained from family members or witnesses about injuries sus-
of injury may often be associated with different locations at the scene of the tained.
incident e.g. injuries to passengers in the rear of an aircraft are likely to be Cases from the authors’ work on exhumed skeletal remains, discuss
different than those in front seats which are closer to burning fuel. the injuries seen, and consider potential causes will be presented (in par-
Consequently, careful examination of the nature of the traumatic injury ticular, consideration will be given to):
may in some cases enable the investigator to establish where an individual • cases with clear signs of antemortem trauma to the bones
victim had been located at the time the incident occurred and therefore • cases with clear signs of postmortem trauma to the bones
narrow the possible identities to persons who were known to be in that par- • cases with postmortem injury possibly due to the influence of the
ticular locality, e.g. from passenger seating lists or lists of occupants of saponification process during the decomposition
rooms in a hotel. • cases in which it is not possible to determinate whether the trauma is
If the identities of individual members of the group are known from antemortem or postmortem
records compiled before the disaster, the DNA profile comparison search is
limited to a much smaller number of individuals and the identities of indi- Forensic Pathology, Skeletal Remains, Bone Trauma

G26 Personal Identification by Morphometric - The correlation coefficient for heterocorrelations for the absolute
distances was between 0.991 and 0.566
Analyses of Retinal Vascular Pattern - The correlation coefficient for autocorrelations for the triangle
perimeters was between 0.999 and 0.99299
Francesco Introna, MD, PhD*, and Antonio De Donno, MD, Section of - The correlation coefficient for heterocorrelations for the triangle
Legal Medicine (Di.M.I.M.P.), University of Bari, P.zza Giulio Cesare perimeters was between 0.99293 and 0.56651
n.11, Bari, 70124, Italy; Carlo Sborgia, MD, and Francesco Boscia, MD, - The correlation coefficient for autocorrelations for the relative
Section of Ophthalmology, University of Bari, P.zza Giulio Cesare n.11, distances was between 0.99995 and 0.97876
Bari, 70124, Italy; Giuseppe Mastronardi, PhD, Electronic and - The correlation coefficient for heterocorrelations for the relative
Electrotecnic DPT, Via Orabona n.4, Bari, Bari, Italy; and Francesca distances was between 0.99248 and 0.92452
Bellomo, MD, and Domenico Urso, MD, Section of Legal Medicine Our results indicate that:
(Di.M.I.M.P.), University of Bari, P.zza Giulio Cesare n.11, Bari, 70124, • The section point for the output of comparison of the absolute
Italy distances is 0.992; higher correlation coefficients indicate certain
The goal of this presentation is to report the results of a biometric per- identification and lower values certain exclusion.
sonal identification study conducted by comparing retinography samples • The section point for the output of comparison of the triangle
obtained from different subjects perimeters is 0.99299; higher correlation coefficients indicate certain
This presentation will impact the forensic community and/or identification and lower values certain exclusion.
humanity by demonstrating an interesting approach for personal identifi- • The section point for the output of comparison of the relative
cation for security environments distances is 0.97876; higher correlation coefficients indicate positive
MATERIALS AND METHOD: A new method for personal identifi- identification, with a 1% risk of false positives.
cation by morphometric analysis of the retinal vascular pattern is presented. Finally, it should be noted that the cases yielding false positives for
In collaboration with the Ophthalmology Clinic of Bari University comparison of the relative distances presented very negative values for the
Hospital, two sets of color images of the right retinal fundus were acquired correlation coefficients of the absolute distances and the triangle
at two different times in 68 subjects, after instillation of mydriatic and using perimeters. Thus, interpolating the results, it can be concluded that if com-
computerized fluorangiography. The system consists of a scanning laser parison of the two retinal maps yields a higher correlation coefficient than
camera connected to a computer, color monitor and operative software. the minimum threshold for autocorrelation of the absolute distances, rel-
This system enables acquisition of Megaplus 1.6 resolution images with ative distances and triangle perimeters, there is certain identification.
1534x1024 pixels that are immediately digitalized and stored on hard disk. The method is currently being patented.
After making a quality selection of the images, they were submitted to Biometric, Personal Identification, Retinal Vascular Pattern
morphometric analysis at the Electrotechnical and Electronics Department
of Bari Polytechnic, using dedicated software.
Following the operative protocol, 5 reference points of the retinal vas- G27 Laryngeal Nerve Iatrogenic Lesions
cular tree were identified: the origin of the superior temporal artery, the
first bifurcation of the superior temporal artery, the origin of the superior Luigi Viola, MD*, Marina Albano, MD, Francesco Vimercati, MD, and
temporal vein, the first bifurcation of the inferior temporal artery and the Nunzio Di Nunno, MD, PhD, Università di Lecce, Via G. Dorso n. 9, Bari,
origin of the inferior temporal vein. These points were individuated and 70125, Italy
marked by the software on each image of the retinal tree. The program then
After attending this presentation, attendees will deepen their under-
automatically supplies the values for the absolute distances, the relative dis-
standing of the surgical practices most likely responsible for damage con-
tances excluding reciprocals, the perimeter values and the areas of the tri-
cerning the lower laryngeal nerve. For this reason, the authors examined the
angles obtained by joining the points, as well as the independent variable
surgical operating procedures that more frequently involve this nerve.
consisting of the differences, albeit minimal, between similar irregular
Therefore, thanks to the study of the specific international bibliography,
figures. Five numerical sets were thus obtained for each image.
procedures have been highlighted which must be carried out, in order to
Statistical comparison was made of the sets by linear regression, deter-
avoid this complication.
mining the correlation coefficient. Cross-analysis was made of each of the
five numerical sets obtained from the 136 images (68 patients x 2), yielding
humanity by studying the circumstances surrounding medical malpractice
23120 comparisons (5 X 68 X 68) for heterologous correlations and 340
concerning laryngeal nerve lesions.
comparisons for homologous correlations (5 x 68).
The aim of this work is to highlight the surgical practices mostly
RESULTS: Analyses showed that the independent variable and the
responsible for damages concerning the lower laryngeal nerve. Iatrogenic
areas of the triangles did not serve for identification purposes due to over-
lesions of the recurrent laryngeal nerve have always been one of the most
lapping, the maximum values for the correlation coefficient in the heterol-
serious and frequent complications in the field of the thyroid surgery.
ogous comparisons being in the same range as those for the homologous
During a thyroid operation, according to the medical literature, the compli-
comparisons in over 60% of the samples.
cation rate ranges from 0.3 to 4%, but can range up to 17% with an oper-
Instead, cross comparison of the correlation coefficients for the sets of
ation concerning a thyroid neoplasia relapse. The lower laryngeal nerve
absolute distances, relative distances and the perimeters of the triangles
iatrogenic lesions are supported by documentary literature in the field of the
showed that they could potentially be useful, possibly in association with
thoracic surgery, especially in the surgical literature on heart surgery.
other analyses, for identification purposes.
Studying the most specific reliable and recent bibliographical sources,
There was no overlapping between the coefficients for the absolute
one can learn of the different factors which cause the onset of lower
distances, which yielded separate, distant dispersion curves for homol-
laryngeal nerve lesions, so they can be identified in a timely manner, in
ogous and heterologous comparisons. Similarly, there was no overlapping
order to prove any possible medical mistake that has occurred.
for the triangle perimeters, which provided separate, albeit close clusters,
An essential role is played in this case by the fundamental features of
for the correlation coefficients. There was only 1% overlap for the corre-
the main pathology of recurrent laryngeal nerve damage. In particular, it
lation coefficients for the relative distances (46 false positives/4620 com-
depends on whether the pathology concerns primarily the nerve itself (trau-
parisons).
matic, toxinfectious, auto-immune, etc) or is the nerve just secondly
The numerical results were:
involved by another pathological process (thyroid and laryngeal
- The correlation coefficient for autocorrelations for the absolute
pathologies, aortic and carotid aneurysm, pulmonary neoplasia, dilatation
distances was between 0.999 and 0.992

of the left atrium in the mitrals, mediastinum lymph node disease, cervical radiography and CT scan demonstrated fractures of the mandibular sym-
adenopathy, etc). Other factors that need to be considered in a case of physis and condyles, along with the left tubercle of the upper jaw, with no
alleged medical responsibility are the different surgical operating proce- evidence of external wounds. Many teeth were injured, with avulsion of the
dures carried out, especially the nerve isolation techniques, which is the first and second incisors of the upper right jaw (11, 12), the first incisor of
main step during an operation concerning frames adjoining the nerve itself. the upper left jaw (21), the second pre-molar of the lower right jaw (45),
With regard to this study, the authors found a greater number of coronal fractures of the first pre-molar of the upper right jaw (14), the
recurrent nerve lesions occurring during a surgical operation due to thyroid second molar of the lower left jaw (37), and the first pre-molar of the lower
pathologies and malignant neoplasia behind the breastbone that are partic- right jaw (44). At the moment of electrocution, the worker was wearing
ularly widespread. In fact, statistical data shows a higher risk of iatrogenic shoes that were sold as safety footwear, and inspection revealed character-
damage during more drastic operations, such as with a total or subtotal thy- istic burn defects on the sole, which corresponded to the electrical burns of
roidectomy or after a second operation in the same location. By observing the feet. Therefore, the safety shoes did not prove effective.
and analyzing six cases of recurrent nerve paralysis, and after a review of A review of the literature reveals few data or case reports specifically
the pertinent literature, this study attempts to underscore the medico-legal addressing the issue of electrocution by arcing, with no direct contact with
difficulty in assessing the nerve damage, or identifying the professional the wire, especially at so great a distance between the energy source and the
responsibility in causing the damage. The examination of these cases victim. In this case the farmer was standing vertically below the power lines
showed a sharp preponderance of mistakes made by the surgeon. Among in front of the olive tree, grasping the aluminium pole. There was a gap of
the above-mentioned cases under examination, four cases out of six con- about 6-7 metres from the upper end of the pole to the high-voltage power
cerned people undergoing an operation for thyroidectomy (total or lines. It has been reported that a sparking gap larger than 50 cm is sufficient
subtotal), one case of laryngectomy, and one of aortic replacement in a to transmit a voltage of about 30-40000V. However, in the reported case
patient affected by an aortic dissecting aneurysm. The second step of the there were behavioral and environmental factors, equally distributed, that
analysis of the medical practice showed a relevant number of mistakes con- can explain the near fatal accident. Firstly, in high voltage accidents it is
cerning a non-isolation of the lower laryngeal nerve during the surgical known that direct contact with the wire is not necessary because when the
operation, even though there are many intraoperating techniques able to body is near the voltage lines an electric arc may jump from the lines to the
highlight the nerve frames at issue, and preserve them properly. Medico- body. Moreover, the resistance opposed by the skin and the air has an
legal experts consider this negligent practice, able to identify these mistakes important role in electrical conduction. In particular, the humid weather
made by doctors implicated in a similar situation, as a result of not keeping present at the time of the farmer’s electrocution, a cloudy and drizzling
to the therapeutic protocols in the specific literature. morning at the end of November, boosted the electric current discharge.
Among six cases of phonatory deficiency under examination, four Another important environmental factor is the part played by the tree,
cases have been closed with the admission of the surgeon’s responsibility, known to be an excellent energy conductor, which in this case was growing
while in the other two cases any responsibility has been excluded. One case just beneath the cable. This situation allowed the accumulation of energy
involved the surgical repair of an aortic aneurysm, and it was considered on every branch, thus representing a potential risk of electrocution in itself.
more important to save the patient’s life than preserve his nerve. In the other In addition, there were some behavioral aspects to be considered. The tool
case, the damage was linked to the post-operative behavior of the patient used by the victim for thrashing is ideal for the conduction of electric
himself. power. Aluminium or graphite, used in staff or pole manufacture, both have
Laryngeal Nerve, Medical Malpractice, Medical Liability superconductor qualities. The current flowing from the metal staff through
the hands would probably not have been able to electrocute the farmer if he
had been wearing good quality safety shoes. Finally, the great human error
G28 Electrocution by Arcing: was that of working under a tree situated so close beneath the high voltage
A Non Fatal Case Study power lines. This is commonly a great hazard for workers, especially those
in industrial fields, as this is one of the most common reasons for accidents
at the workplace in Italy. Each one of the above described factors likely
Biagio Solarino, MD*, Giancarlo Di Vella, MD, PhD, and Alessandra
contributed to dielectric breakdown and conduction of the current from the
Arpaio, MD, Sezione di Medicina Legale - Di.M.I.M.P., Università degli
high voltage power lines to the end of the metal staff and then through the
farmer’s body. Identification of all behavioral and environmental causative
The goal of this presentation is to report an unusual case of electro- factors may lead to future adjustments in design, to reduce the risk of elec-
cution by “arcing” from overhead high-voltage power lines. trocution in working environments. Photographic documentation illus-
This presentation will impact the forensic community and humanity in trates the results of the case investigation.
general, as it provides information about a case of accidental electrocution Electrocution, Arcing, Accident at Work
during working activities that occurred due to dielectric breakdown, so that
the current from a high-tension overhead cable (30000V) ran down an alu-
minium pole grasped by a farmer who was thrashing an olive tree. G29 Abrasion or Gunshot Wound?
An ancient rural tradition is called “battitura”, whereby farmers in
South Italy thrash the branches of the olive trees with a pole or stick,
The Primary Role of Forensic Pathologist
causing the olives to drop into sheets placed under the trees. This is a case
of a 25-year-old Caucasian male, who suddenly collapsed while he was Giancarlo Di Vella, MD, PhD*, and Biagio Solarino, MD, Sezione di
thrashing an olive tree in front of him, using an aluminium pole 2 metres Medicina Legale - Di.M.I.M.P., Università degli Studi di Bari -
long. The olive tree was dangerously situated underneath (but at no less Policlinico, Bari, 70125, Italy
than 7 meters distance) a high-voltage power cable. These cables transmit After attending this presentation, attendees will learn about two cases
very high voltages (30000-60000V) and in Italy they are built at least 10 of gunshot injuries that were undiagnosed by the physicians in the ER,
metres above ground level, thus it should not be possible to come in contact posing a great risk of compromising both the victims’ health and the Police
with the power lines. The patient underwent loss of consciousness and investigations.
bleeding from the mouth. He was taken to the ER where, on examination This presentation will impact the forensic community and/or
for injuries, he was found to have “electrical burns” with peculiar pits on humanity by illustrating the primary role of the forensic pathologist even in
the hands and on the soles of the feet. He developed cardiac arrhythmia the ER, to prevent misdiagnosis of atypical lesions, especially when caused
with high levels of CPK and CK, requiring electrical defibrillation. Dental by unconventional firearms.

Although the effects of firearms on the human body are well known, the event to the Judicial Authorities without delay, if the lesions were obvi-
in some circumstances the objective picture of the lesions may be so ously voluntarily inflicted (criminal assault) and recovery will take longer
modest and lead to an incorrect diagnosis, unless there is a forensic expert than 20 days (penal code, art. 582-583). This obligation applies even for
present. The present work describes two cases in which the correct diag- shorter recovery times if firearms or other potentially lethal weapons were
nosis of a shotgun entrance wound was formulated only thanks to the help used (penal code, art. 585). Failure to notify the Authorities lays the health
of a forensic pathologist, who was called in to give an opinion of the workers themselves open to criminal charges (penal code, art. 361 and
unusual lesions observed in the patients. On 13 December 2004, at 09.00 362). Photographic documentation of each of the above described cases
a.m., a 35-year-old male subject, of robust build and about 180 cm tall, was will be shown during the presentation.
brought by ambulance to the Emergency Room at Bari Hospital (S. Italy). Forensic Pathologist, Gunshot Wound, Modified Toy Gun
He stated that two robbers had attacked him near his home, and one had
grasped him around the neck to immobilize him. The patient was admitted
to Intensive Care due to the presence of subcutaneous emphysema of the
neck and superior mediastinum, causing severe breathing difficulties. He
G30 Sudden Death in Toddlers Due To
showed digitiform ecchymoses on the face, neck and upper portion of the Influenza B Infection: A Report of
chest. The Intensive Care specialist on duty called in the forensic pathol- Two Cases and a Review of the Literature
ogist for a consultation to confirm the traumatic picture and the compati-
bility of the lesions with the dynamics of the events referred by the patient. Kristen Landi, MD*, and Andrea Coleman, MD, Office of the Chief
The forensic pathologist confirmed the presence of ecchymotic-excoriated Medical Examiner, 520 First Avenue, New York, NY 10016
areas in the referred sites and pointed out scratches and bruising caused by
the robber’s hands. An oval-shaped area appearing to be an abrasion was After attending this presentation, attendees will better appreciate the
seen, with distinct, slightly retracted margins, 0.6 cm in diameter, with a importance of viral testing in pediatric autopsy cases. Attendees will have
small eschar in the lower right semicircle. The lesion was localized in the better understanding that influenza may present with atypical symptoms
chin region, 2 cm to the left of the anterior median line. After pho- such as abdominal pain, vomiting and shock and have a very short duration
tographing the lesion, the forensic pathologist decided to explore it in between onset of symptoms and death.
depth, introducing a needle cannula for use as a probe, which revealed the This presentation will impact the forensic community and/or
presence of an entrance into the body. X-rays of the chest and neck were humanity by bringing attention to the need for specialized testing in pedi-
performed, which demonstrated a foreign body found to be a bullet atric autopsy cases, more specifically the need for viral testing, especially
fragment, retained in the soft tissues of the anterior region of the neck just for influenza. Cases of sudden death among children, especially with
in front of the spine. After two weeks the patient underwent surgical atypical symptoms for influenza, usually do not get viral studies collected
treatment to remove the fragment, a deformed lead bullet core that was at the time of autopsy and if viral infections are not considered the cause of
delivered into the hands of the Police. On the basis of the investigations, it death may remain elusive. The authors recommend viral screening for
was possible to conclude that the victim had been struck in the chin by a cases of sudden death among infants and children in addition to the more
slow-moving bullet, which was partly fragmented by impact with the bone. standard specialized testing such as bacterial cultures.
The bullet had been fired from a small calibre firearm, likely a modified toy Influenza has historically been a cause of considerable mortality
gun, which still had not been found at the time of this contribution. world-wide during pandemics as well as small outbreaks, and continues to
On 5 March 2004, a 17-year-old boy accompanied his parents to a be a significant cause of death today. The very young and very old are
small hospital in the province of Bari. He complained of pain in the especially vulnerable. Influenza typically appears during the winter months
mandible, stating that he had fallen down the stairs in his home. and classic symptoms include fever, sore throat, sweating, nasal
Orthopantomography demonstrated a fracture of the mandible and avulsion obstruction, and cough and maligns. In severe attacks bronchiolitis and
of the lower incisors. Transfer to a clinic with facilities for maxillo-facial pneumonia may be caused directly by the virus or may result from sec-
surgery was advised and the patient was taken to Bari Polyclinic for nec- ondary bacterial invasion of the lungs. Influenza is caused by myxovirus
essary care. On arrival, the forensic pathologist was called in to give an influenzae and there are three distinct serotypes (A, B, and C), each con-
expert opinion. HA circular wound, approximately 0.7 cm in diameter, was taining antigenic strains. Virus A causes pandemics as well as local out-
observed in the chin region with inverted margins and a slight, ecchymotic, breaks. It affects all age groups and is associated with a high mortality in
excoriated border. The wound was surrounded by powder tattooing and the elderly, the very young, and those with pre-existing cardiac and pul-
some soot, and these findings, together with the characteristics of the per- monary disease. Virus B causes sporadic cases and limited epidemics,
foration, suggested a gunshot entrance wound. The available X-rays were especially among institutionalized young people. It tends to cause a milder
reviewed and a foreign body was noted, which had not been referred to in disease with a lower mortality rate. Virus C is occasionally detected in
the radiological diagnosis. The bullet, localized in the submandibular local outbreaks.
region, and surgically removed, was a 7.65 mm caliber (FMJ), deformed at Two cases of relatively sudden deaths with atypical symptoms due to
the apex and with no markings (class characteristics). These elements led influenza type B infection in a 4-year-old girl and a 2-year-old boy with no
the investigators to conclude that, far from falling down the stairs, the past medical history or predisposing risk factors are described. Both
victim had been hit in the face by a bullet from a modified toy gun, shot at children presented with mild abdominal symptoms of vomiting and
intermediate range. abdominal pain starting within two days of death, and were found dead in
Failure to diagnose a gunshot wound is an exceptional event. Clinical their beds by their parents. Scene investigation, medical history, autopsy,
medicine relies more and more on sophisticated diagnostic techniques, and metabolic screening, toxicology, bacterial cultures, and toxicology were all
procedures for quality control. However, the previous histories show that negative. Histology of the lungs showed a viral type pattern with a chronic
when non-conventional firearms are used, and the patient history is not sug- inflammatory infiltrate involving the bronchioles, bronchi, and trachea.
gestive of their use, clinicians may be unfamiliar with the type of wound The girl also had small patchy areas of intra-alveolar mixed inflammation
they produce, because these events are rarely seen. In these circumstances, including macrophages and neutrophils consistent with bronchopneu-
consultation with the forensic expert is needed to make a correct diagnosis monia. Viral testing on the lungs of both cases was strongly positive for
of the wounds. This is very important to further judicial investigation pro- influenza B (by immunohistochemistry in the girl, and RT-PCR in the boy).
cedures related to the case. In accordance with the Italian penal law code These cases illustrate two atypical cases of influenza B infection that
(penal procedure code, art. 331), health workers (physicians, nurses, etc) would not have been suspected based on the presenting symptoms and
treating a wounded patient in a hospital facility are obliged to communicate rapidly fatal outcomes. Influenza may be found to be the cause of death if
viral cultures are done in similar types of cases.

In the literature there are reported cases in adults of influenza A There was overrepresentation of cases in the Baltimore metro area
infection with shock like symptoms and high morbidity and mortality. (60% of the cases; 12% of the State wide population). Girls were slightly
There is ongoing research into the possible role that cytokines play in more prevalent than boys (52 vs. 48%) and African-Americans represented
causing additional injury in a number of infections including influenza 64.5% of the total. Median age was 1.1 years. Brain weight ratio (brain
associated encephalopathy, streptococcal toxic shock syndrome and RSV weight obtained at autopsy divided by standard brain weight for indi-
respiratory infections. Immune mediated injury may result from the vidual’s age) was 1.1. The neuropathologic findings depended on age, sur-
cytokine storm triggered by the initial infection and may spill over into the vival after injury and mechanism of force. The majority of the cases had
systemic circulation and cause devastating consequences in a relatively external (73.7%) signs of blunt force head injuries, either alone (50%) or in
short period of time. There are some studies that suggest that RNA viruses combination with torso injuries (50%), with an average of 4.7 (median 4)
like influenza may be particularly prone to inducing cytokine and head contusions/abrasions identified at autopsy. Injuries included
chemokine up regulation including numerous interleukins (including IL-1, intracranial subarachnoid hemorrhage (61.5%), intracranial subdural hem-
IL-6, IL-8, IL-11, IL-16) and tumor necrosis factor. It has been suggested orrhage (55%), hypoxic injuries (35%), cortical contusions (38.5%), brain
that immunomodulators be used as part of the medical treatment of swelling (21%), intracranial epidural hemorrhage (17%), and gliding (inter-
influenza to help prevent cytokine storm. mediate) contusions (15.4%). White matter tears and diffuse axonal
Influenza, Sudden Death, Toddlers injuries were rare. Spinal cord was obtained and studied in 70 of 95 cases
(73.7%). Intraspinal hemorrhage was seen in 31% (subarachnoid 24.3%,
subdural 23% and epidural 17%). Eye pathology was found in 44 of 60
G31 Neuropathology of Pre-Teen Homicides cases studied (73%), and was bilateral in 95% of them.
in the State of Maryland: 1994-2004 Summary and conclusions: Brain pathology is a common finding in
childhood homicide, especially in cases with a blunt force component. The
Ana Rubio, MD, PhD*, State of Maryland Office of the Chief Medical majority of pre-teen homicides are due to blunt force injuries of the head or
Examiner, 111 Penn Street, Baltimore, MD 21201; Miguel A. Riudavets, MD, head and torso. Age, gender, and race influence specific neuropathologic
Department of Pathology (Neuropathology), Johns Hopkins University findings. Brain weight ratio correlates with survival and is influenced by
School of Medicine, Baltimore, MD 21201; Ling Li, MD, State of Maryland neuropathology. Detailed, systematic study and documentation of the
Office of the Chief Medical Examiner, 111 Penn Street, Baltimore, MD central nervous system and ophthalmic injuries is essential in determining
21201; Christopher Cox, PhD, Department of Epidemiology, Johns the nature and timing of the injuries and ruling out natural diseases or acci-
Hopkins Bloomberg School of Public Health, Baltimore, MD 21201; David dental injuries.
Reisz, BA, and David R. Fowler, MD, State of Maryland Office of the Chief Blunt Force Head Injuries, Pre-Teen Children, Homicides
Medical Examiner, 111 Penn Street, Baltimore, MD 21201; and Juan C.
Troncoso, MD, Department of Pathology (Neuropathology), Johns Hopkins
G32 Transplacental Intrauterine Herpes
After attending this presentation, attendees will appreciate that pre- Simplex Virus Infection Resulting in
teen homicides differ from that of other age groups. Brain pathology is a
common finding in childhood homicide, especially in cases with a blunt Cutaneous Calcifications in an Infant
force component. The majority of pre-teen homicides are due to blunt force
injuries of the head or head and torso. Detailed, systematic study and doc- Sam D. Simmons, MD, MBA*, Ashley O’Bannon, MD, and Subodh
umentation of the central nervous system and ophthalmic injuries is Lele, MD, University of Kentucky, Department of Pathology and Lab
essential in determining the nature and timing of the injuries and ruling out Medicine, 800 Rose Street, MS 117, Lexington, KY 40504
natural diseases or accidental injuries. After attending this presentation, attendees will learn about a unique
This presentation will impact the forensic community and/or pathologic presentation of transplacental neonatal herpes infection, which
humanity by demonstrating; (1) a better understanding of the epidemiology may aid in future clinical diagnoses.
of pre-teen homicides; (2) the necessary role of neuropathologic studies in This presentation will impact the forensic community and/or
childhood homicides; and (3) an understanding of the pattern of injuries in humanity by highlighting a distinctive but rare presentation of Herpes
blunt force head trauma in children Simplex Virus (HSV). By augmenting the relatively scant literature on
Background: The State of Maryland (population below 6 million, transplacental HSV infection, this case may expand the differential diag-
half rural) has a unified medical examiner system that investigates suspi- noses for infant autopsies with similar gross findings, and possibly aid in
cious deaths following standard protocols. Homicides in pre-teens differ earlier detection and treatment of intrauterine HSV infection.
from those in the general population in victim’s characteristics (e.g. gender Neonatal HSV infection is often associated with liver necrosis, micro-
distribution), causes of death (e.g. firearm use), environment of death (e.g. cephaly, intracranial calcifications, and brain necrosis, and clinical signs
home) and patterns of injuries. may not be apparent until several days after birth. In many of these cases,
Method: Cases were reviewed and tabulated for demographic char- transmission occurs during birth. More rarely, transplacental intrauterine
acteristics, cause of death, post-injury survival, systemic and brain injuries. HSV infection can occur, with life-threatening effects due to earlier onset
Cases with a significant central nervous system component were examined in the pregnancy. A literature search reveals some isolated case reports of
by a single neuropathology’s (JCT). The majority of the cases included similar cases, most of which demonstrate unique gross presentations. The
examination of the spinal cord and eyes. Cases were stored in a centralized authors describe the autopsy case of an infant born at 25 weeks gestation
database. Data was retrieved and analyzed by nonparametric statistical with diffuse cutaneous calcifications. There was microscopic evidence of
methods. acute chorioamnionitis and acute funisitis. HSV immunostaining was pos-
Results: From 1994 to 2005 one hundred and eighty five children itive on the tissue sections of placental membranes and umbilical cord.
younger than 13 years of age suffered homicidal deaths in the State of Polymerase chain reaction analysis (PCR) on the same paraffin-embedded
Maryland (7.5 % of all deaths reported to the office for that age group). tissues was positive for HSV. No viral inclusions were identified in any of
Blunt force injuries were the most common cause of death (95 cases, the tissue sections.
51.1%) followed by firearms (16.7%) and asphyxia (16.2%), each prefer- A pregnant 20-year-old female (G1P0) presented to her obstetrician
entially affecting children of specific ages. Most children with blunt force with spontaneous rupture of membranes at 25 weeks gestation. The patient
injuries had significant neuropathology, and this is the focus of the was transferred to a tertiary care center for probable chorioamnionitis,
following study. where she was noted to be febrile with uterine tenderness and an elevated

white blood cell count. The fetus began to show signs of distress with This presentation will impact the forensic community and/or humanity
decelerations in heart rate, and a caesarean section was planned. However, by assisting the forensic community in understanding the important reasons
the infant was delivered vaginally in the operating room, approximately 18 for vigorous investigations of these deaths in bathtub to prevent further injury.
hours after the membranes ruptured. The infant failed to breathe sponta- This case consists of the tragic death of a perfectly healthy 9-year-old
neously and had no heart rate, so resuscitation efforts began, including intu- girl (Proc. N. 2172 / 2004 Court of Trani), with no history of illnesses, con-
bation and 3 doses of epinephrine per endotracheal tube. Resuscitation was genital or otherwise, who was found dead by her mother, in the bathtub filled
discontinued after 15 minutes since the infant could not sustain a heart rate. of water. The parents reported to the Judicial Authority that it was an unex-
Apgar scores were 0 @ 1 minute, 1 @ 5 minutes, and 0 @ 10 minutes. pected death, excluding the possibility of an electrocution. The findings of the
Maternal past medical history was significant for two urinary tract following forensic investigations were unprecedented, both from a legal per-
infections during pregnancy, with urine cultures positive for Escherischia spective, as well as from the point of view of the postmortem and histological
coli. She was also briefly hospitalized for pyelonephritis one week prior to data gathered.
delivery, with urine cultures again positive for E. coli. She was treated with The external examination of the child’s body revealed no traces of trau-
Macrobid and Keflex, and was still taking these medications along with matic or violent wounds, although two small unusual areas of skin were
prenatal vitamins at the time of delivery. Prenatal labs were negative for detected in the lumbar region, which, when substantially enlarged, appeared
chlamydia, gonorrhea, HIV, and Group B Strep. She denied any history of to be pale and irregular compared with the surrounding skin. The internal
sexually transmitted diseases. There was no documentation of prenatal examination revealed only a small myocardial dyschromic area under peri-
HSV testing. cardium, a small area of haemorrhage at the level of the lower part of the
At autopsy, the infant’s skin was light tan with extensive areas of dark uterus and a reddish area in region of the vagina.
red discoloration on the back, chest, and head. Additionally, there were The histological examinations excluded acute or chronic pathology,
irregular, white patchy lesions on the posterior head, back, shoulders, chest, revealing indications for an electrocution on the lumbar skin specimens
inguinal areas, and over the coccyx. These lesions appeared to be intra- where a palisade-type appearance of the malpighian layer was noted.
dermal, were not palpable, and did not scrape off. The remainder of the Furthermore, in the myocardium specimen’s bands of contractions and frag-
gross examination was unremarkable. The body was that of a normally mentation and coagulative haemorrhagic intramyocardial necrosis were
formed male infant, consistent with a 25-week gestational age. No other observed.
dysmorphic features were noted, and the internal organs were located in This suspicion of an electrocution was not related with the historical and
their normal anatomic positions. The placenta was significant for a white circumstantial facts of the case. The authors suggested that the Judicial
area on the maternal surface, grossly consistent with an infarct, and encom- Authority obtain a specialist in electrical engineering to perform an exami-
passing less than ten percent of the maternal surface area. nation of the child’s home.
Microscopically, the skin demonstrated multiple areas of intradermal The survey of the bathroom revealed the presence of a glazed metal bath
calcifications, consistent with the white, patchy lesions seen grossly. and a hairdryer. The examination of the hairdryer revealed that some of
Hyperkeratosis was present, with amorphous debris visible on the skin internal parts oxidized. The electrical plant of the house was protected only
surface. However, only minimal inflammation was observed around the by a thermomagnetic circuit breaker and there was no differential circuit
calcified areas. The lungs contained multiple areas of lymphocytic infil- breaker.
tration with debris-laden macrophages. The infarcted area on the maternal In addition to these findings, suspicion for an electrocution was sup-
side of the placenta showed acute inflammation with neutrophilic extrava- ported by the results obtained by a finite element method simulation, aiming
sation and fibrin deposition. The umbilical cord demonstrated funisitis, at determining the electric current distribution inside a human body immersed
with neutrophils visible in the walls of the cord vessels, and chorioam- in a bathtub when an electrically connected hairdryer came into contact with
nionitis of the placental membranes. Of note, no herpetic viral inclusions the bath water. The simulation showed that when the water came in contact
were identified in any of the tissue sections. with the electrical part of the hairdryer, the current lines permeate the bath
Sections containing the intradermal calcifications and sections of pla- water and go across the human body. The current flows until the thermo-
cental membranes and umbilical cord were sent for special staining. GMS, magnetic circuit breaker intervenes (i.e. when the total current reaches about
gram stain, Steiner stain (for spirochetes) and Toxoplasmosis stain were all 90 A). On the basis of this study, the authors suggest that a lethal fraction of
negative on these sections. However, HSV immunostaining was positive this current went across the little girl body, and therefore across her heart,
on the placental membranes and umbilical cord. HSV infection was con- resulting in a fatal ventricular fibrillation.
firmed by PCR at an outside laboratory (ARUP Laboratories, Salt Lake Our investigation having been completed, the judicial authority sum-
City, Utah). The tissue submitted for HSV PCR was from the formalin- moned the parents of the child. The parents withdrew their previous state-
fixed and paraffin-embedded sections of placental membranes and ments, and replaced them with a circumstantial and specific reconstruction of
umbilical cord. the sequence of events immediately preceding the death, which revealed
Herpes (HSV, Herpes Simplex Virus), Transplacental, Cutaneous strong indications of fault. Indeed, the parents of the little girl confessed that
her one-year-old brother, who had been left alone with his sister in the
bathroom, had thrown the hairdryer into the bath in which his sister was
immersed.
G33 Killer Hairdryer The JA therefore asked us to establish the cause or the contributory
cause of the lack of differential circuit breaker in the electrical plant. The
Francesco Introna, MD, PhD, Section of Legal Medicine (Di.M.I.M.P.), computer simulation allowed us to confirm that the presence of a differential
University of Bari, Policlinico - P.zza Giulio Cesare, 11, Bari, 70124, circuit breaker (i.e. when the electrical plant is in compliance with the law)
Italy; Simona Corrado, MD*, Section of Legal Medicine (Di.M.I.M.P.), would not have prevented the death of the little girl, since she was immersed
Bari University, Policlinico - Piazza G. Cesare, 11, Bari, 70124, Italy; in a highly conductive medium.
and Vitantonio Amoruso, Dipartimento di Elettrotecnica ed Elettronica, In conclusion, the case established a grave ‘negligence in supervision’
Politecnico di Bari, Via Orabona, 4, Bari, 70125, Italy by the parents. The fact that the electrical plant did not meet the Standard
After attending this presentation, attendees will learn about the silent requirements did not account either for the cause and / or contributory cause
and invisible nature of electric current injury that requires a thorough inves- of death. In similar cases the use of hairdryers having a full immersion pro-
tigation of the death scene, to aid in accurately determining the cause of tection plug against contact with water (either in the “on” or “off” position)
death. In a suspected electrocution in water, if the autopsy fails to reveal indi- should be mandatory. The authors also recommend that hairdryers which are
cations for an electrocution, a check of the bathtub or pool’s electrical system not provided with a full immersion protection device be recalled.
is still in order. Electrocution, Death in Bathtub, Electric Mark

G34 Pyelonephritis—Sudden and kidney contained acute and chronic inflammatory cell infiltrates within the
renal interstitium associated with focal tubular abscesses. Postmortem
Unexpected Death in Infancy blood cultures yielded Proteus mirabilis, Citrobacter freundii, and
Enterococcus faecalis. Death was attributed to acute pyelonephritis with
Cristin M. Rolf, MD*, University of Kentucky, Office of the Associate perinephric abscess and urosepsis. The significant contributing cause of
Chief Medical Examiner, 100 Sower Boulevard, Suite 202, Frankfort, KY death was Ectrodactyly-Ectodermal Dysplasia-Clefting Syndrome compli-
40601-8272; and Bonnie Mitchell, MD, University of Kentucky, cated by extrophy of the urinary bladder.
Department of Pathology and Laboratory Medicine, 800 Rose Street, Acute pyelonephritis is an acute suppurative inflammation of the
UKMC MS 117, Lexington, KY 40536-0298 kidney usually caused by a bacterial infection. Routes of bacterial spread
The goal of the presentation of these two separate cases is to demon- to the kidney can be either hematogenous or due to retrograde ascension
strate that acute pyelonephritis, which may not be detected clinically, is an from the infected lower urinary tract. Risk factors for pyelonephritis
unusual cause of sudden and unexpected death in infants. include the following: hematogenous septic spread; congenital obstruction
This presentation will impact the forensic community and/or of the urinary tract; vesicoureteral reflux; pregnancy; instrumentation; age
humanity by informing all of the role acute pyelonephritis plays in sudden, and sex; renal lesions with scar; or immunodeficiency. Papillary necrosis,
unexpected death in infancy, and providing a discussion of the differential pyonephrosis, perinephric abscess, and urosepsis represent complications
diagnosis. This potentially lethal condition can be misdiagnosed clinically of acute pyelonephritis. Both cases involve ascending route of infection.
or masked by other co-morbid infections such as otitis media and viral Although the first infant had no gross anomalies of the urogenital tract,
illnesses. functional vesicoureteral reflux cannot be excluded. An incompetent vesi-
This poster presents two cases of infants dying suddenly and unex- coureteral orifice, which is not detectable on visual inspection, could have
pectedly from acute pyelonephritis. In the first case the infant had no allowed the reflux of urine and bacteria into the ureter and kidney. The
known risk factors, in contrast to the second infant who had significant risk hematogenous route was not deemed likely in either case. The second case
for the development of pyelonephritis. The authors review the patho- involved a physical anomaly of the urinary tract with subsequent chronic
genesis, incidence, and differential diagnosis of pyelonephritis in infants traction and obstruction of the ureters.
dying suddenly and unexpectedly. The clinical diagnosis of pyelonephritis in infancy may be difficult for
The first case is that of a previously healthy 7-month-old white female several reasons. A diagnostic index of suspicion was blunted by the mild
with medical history of asthmatic bronchitis. The infant appeared to be in febrile presentation in the first case. Clinical focus on otitis media masked
her normal state of health, playing before she went to sleep the night before the more serious infection in the second case. This poster presents two
her death. She was fed a bottle around 3:00 AM and placed on top of her cases of pyelonephritis, which were neither suspected by parental care-
mother’s chest, which was the infant’s usual sleeping position at night. At givers nor diagnosed clinically in the presence of a less serious infection.
around 6:00 AM the mother noted the infant to lifelessly fall limp from her Pyelonephritis constitutes a rare cause of sudden and unexpected death in
chest onto the couch. The Coroner’s investigation disclosed no evidence of infancy.
maternal intoxication. No wedging or overlay was suspected. The mother Pyelonephritis, Sudden and Unexpected Death in Infancy, Autopsy
stated the infant had a low-grade fever over the preceding 2-3 days.
Despite emergency care and ACLS protocol, the infant could not be resus-
citated. Gross autopsy findings revealed no evidence of accidental asphyxia G35 Necrotizing Fasciitis: Manifestations,
or trauma. All other findings were negative except for an enlarged left Microbiology and Connection With
kidney demonstrating wedge-shaped foci of pink, soft expanded renal
cortex and medulla. No stigmata of sepsis were present. No congenital
Black Tar Heroin
anomalies of the urogenital tract were grossly evident. Microscopic exam-
ination of the kidneys revealed acute pyelonephritis of the left kidney char- Nancy M. Dunbar, BA*, Carl Wigren, MD, and Richard C.
acterized by acute inflammatory cell infiltrates involving the renal tubules Harruff, MD, PhD, King County Medical Examiner’s Office,
and interstitium. Tubular abscesses were present. Death in this case was HMC Box 359792, 325 Ninth Avenue, Seattle, WA 98104
attributed to acute pyelonephritis. After attending this presentation, attendees will gain knowledge
The second case involved a 10-month-old white male infant diag- regarding the manifestations and microbiology of necrotizing fasciitis and
nosed with Ectrodactyly-Ectodermal Dysplasia-Clefting Syndrome com- how it is related to injection of black tar heroin. The hypothesis is that
plicated by extrophy of the urinary bladder with subsequent necrotizing fasciitis caused by drug injection differs substantially from the
hydronephrosis. The infant had undergone multiple corrective surgical pro- same disease due to other causes.
cedures for extrophy, epispadias, anteriorly placed imperforate anus, and This presentation will impact the forensic community and/or
cleft palate. His course was complicated by bilateral hydroureter and humanity by showing the relationship of necrotizing fasciitis to injection of
hydronephrosis. Prophylactic Cephalexin was prescribed throughout the black tar heroin and the importance of understanding the manifestations,
last months of his life. On the day before death the infant developed recent microbiology, and causes of this infectious disease.
onset of fussiness and low-grade fever, and was diagnosed in the local pedi- Introduction: Black tar heroin use is pervasive in the Seattle area.
atric clinic with otitis media. He was prescribed Amoxicillin clavulanate When intravenous (IV) drug users exhaust their IV sites, they resort to sub-
and discharged to home. The next evening the infant was placed in an cutaneous (SC) and intramuscular (IM) routes. Unfortunately, SC and IM
infant swing to calm his fussiness. He was found unresponsive in the swing injection promotes infection by introducing contaminated material into the
2 hours later. The body was positioned sitting in the seat with his head tissue. Infections are common in heroin users, who often believe that the
extended over the backrest of the seat. Coroner’s investigation revealed no drug rather than the injection method is responsible. From what is known
evidence of swing malfunction or positional compromise of respiratory about black tar heroin, it is likely that either the raw drug or diluents contain
excursion. At autopsy, gross examination revealed the facial and appen- clostridial spores, which are difficult to kill by the brief heating drug users
dicular stigmata of Ectrodactyly-Ectodermal Dysplasia-Clefting Syndrome employ. It is not uncommon for clusters of infections to be associated with
with postnatal operative corrections. The repaired urinary bladder con- a single batch of heroin. Because necrotizing fasciitis is often fatal, this
tained numerous stones, and the mucosa was significant grossly and micro- study was initiated to delineate factors responsible for the disease.
scopically for chronic cystitis. Bilateral hydroureter and hydronephrosis Methods: King County Medical Examiner’s Office assumes juris-
were present. A perinephric acute inflammatory exudate was present diction in all reported cases of necrotizing fasciitis, deaths related to drug
around the right kidney and adjacent right liver lobe. Histopathologically, abuse, and all infections that may represent a public health hazard. For this
both kidneys demonstrated chronic interstitial nephritis, and the right study, a records review over 7 years yielded 87 total deaths due to necro-
tizing fasciitis. Eliminating those that lacked identification of the infecting The paternally inherited Y chromosome contains the largest nonre-
microorganisms left 65 cases in the present study. For these 65 cases, combining block of nucleotides in the human genome (approximately 50
disease manifestations were correlated with the source of infection and the million base pairs) and has much lower levels of polymorphism than any
microorganism(s) identified. other region of the human genome (International SNP Map Working Group
Results: Of 32 cases due to drug injection, 17 grew cultures isolating 2001). It has become an extremely important tool in a variety of areas
a single organism; the remaining 15 were polymicrobial. Of the 17 single including forensics (Jobling et al. 1997), genealogical reconstruction
isolates, 13 were clostridia (4 C. sordellii and 2 C. perfringens). Of the 15 (Jobling 2001), molecular archaeology (Stone et al. 1996), nonhuman
polymicrobial cultures, clostridia were present in 11, with C. sordellii rep- primate genetics (Stone et al. 2002) and human evolutionary studies
resenting 4 cases. Overall, clostridia accounted for 24 of 32 cases of necro- (Hammer and Zegura 1996; Underhill et al. 2000, 2001; Hammer et al.
tizing fasciitis due to black tar heroin injection. 2001). As a direct result of the relatively low mutation rate, 0.23%/STR
All of 13 cases of necrotizing fasciitis developing after other types of locus/generation in human pedigrees, concordance of male-line relation
trauma grew cultures containing at least one species of streptococci; 7 grew can be deduced via direct comparison Y-STRs. This direct comparison of
a single isolate, 4 of which were S. pyogenes. The remaining 6 cases were paternally inherited Y-STRs was utilized to explore a centuries old contro-
polymicrobial with various streptococci predominating. versial legend that contends that the legendary Shawnee War Chief, Blue
In 14 cases developing apparently spontaneously, with no known Jacket, was not of American Indian descent, however, was a white man of
trauma but several with comorbid conditions, 3 had single isolates of Dutch descent, known as Marmaduke Swearingen. The comparison of
clostridia identified, 2 of which were C. septicum. Another 7 grew single twelve Y-chromosome polymorphic markers in six purported male-line
isolates of streptococci, 5 of which were S. pyogenes. Two additional descendants of Chief Blue Jacket and four purported male-line descendants
infections were due to Staphylococcus aureus, and the remaining 2 were of Marmaduke Swearingen, eight generations removed in both families,
polymicrobial. revealed that male line descendants in each of the families shared the same
In 6 cases complicating integument breakdown, such as ulcers and 12 locus Y-STR haplotype. However, the Swearingen haplotype was dis-
percutaneous feeding tube sites, all were infected by streptococci; 2 had tinctly different from that of the Blue Jacket male-line descendants, with
single isolates of S. pyogenes and 4 were polymicrobial. consistency at only five of the 12 tested loci therefore, excluding them from
Conclusions: This study shows convincingly that necrotizing fasciitis an ancestry linked to Chief Blue Jacket.
due to clostridial infections is a potential consequence of IM or SC injection Y-STRs, Genealogical Reconstruction, Mutation Rates
of black tar heroin. This disease has a high mortality rate. Although black
tar heroin is the likely source, clostridia are unlikely to cause infection
unless mechanically introduced into an anaerobic environment. Thus, the
injection method rather than the drug is primarily responsible for the
disease. There is insufficient evidence from this study to say whether
clostridial spores came from the raw black tar heroin, from diluents, or
G37 Using Multiplexed Microsatellite
from contaminated needles. The microbiology of cases of necrotizing Markers of Cannabis sativa to Determine
fasciitis originating from other sources of infection differs from those due Genetic Diversity
to drug injection; in these, streptococcal infections predominate.
Compared to clostridia, group A streptococci (S. Pyogenes) are virulent and Maria Angelica Mendoza, MS*, Heather Erek, BS*, and José R.
can cause fatal disease spontaneously or following superficial trauma. Almirall, PhD, 11200 SW 8th Street, CP194, Miami, FL 33199
Accordingly, the organism itself is often primarily responsible for disease.
This study supports the conclusion that necrotizing fasciitis caused by After attending this presentation, attendees will understand previously
injection of black tar heroin is substantially different from the same disease described microsatellite markers known to discriminate between individual
resulting from other causes. Cases associated with heroin injection are pre- plants were multiplexed into a single reaction and validated in 2 separate
dominantly clostridial infections while the others are predominantly strep- laboratories with over 30 plant individuals.
tococcal infections. While all cases of necrotizing fasciitis are potentially This presentation will impact the forensic community and/or
fatal, this conclusion indicates that different prevention and treatment humanity by providing the forensic community with a genetic test, which
strategies are necessary depending on the underlying cause. they can use to track origin in order to connect samples to each other to
associate distributors.
Necrotizing Fasciitis, Clostridial Bacterial Infections, Black Tar
Cannabis sativa L. (marijuana) plants can be easily identified through
Heroin
morphological examination and chemical analysis; however there is a need
for a DNA test for use as a means of association between individual plants
and even as a method to track distribution networks.
G36 Was the Shawnee War Chief Cannabis sativa L. is the most frequently used illegal drug in the
Blue Jacket a Caucasian? United States. Cannabis has been used throughout history for its stems in
the production of hempen fiber for rope and fabric, for its seed for oil and
Carolyn Rowland, MS*, Forensic Bioinformatic Services, Inc., 2850 food and for its flowers and leaves as a psychoactive drug. Microsatellite
Presidential Drive, Suite 150, Fairborn, OH 45371; Dan E. Krane, PhD, markers have been chosen for a DNA test because these markers have dis-
Wright State University, Department of Biological Sciences, 2640 Colonel tinct advantages over other genetic methods. STRs have multiple alleles at
Glenn Highway, Dayton, OH 43435; Marc S. Taylor, MS, Technical a single locus, can be standardized such that reproducibility between labo-
Associates, Inc., 4125 Market Street, Suite 3, Ventura, CA 93003; and ratories can be easily achieved, have a high discrimination power and can
Robert Van Trees, BA, 589 Westwood Drive, Fairborn, OH 45324 be multiplexed.
In this project, seven Cannabis primers selected from a set of primers
After attending this presentation, attendees will gain an appreciation previously described by the group [1] and four Cannabis primers from a set
for the mutation rate of the paternally inherited Y chromosome with regards previously described by Gilmore’s group [2] were multiplexed into a single
to inquiries of male lineage. reaction. The multiplex reactions were independently analyzed in two sep-
This presentation will impact the forensic community and/or arate labs for 30 different cannabis plants. Both an ABI 3100 and an ABI
humanity by demonstrating the confidence by which male line descent can 310 were used for the analysis. Trinucleotide repeats were chosen to reduce
be ascertained by performing a direct comparison of the Y-STR haplotypes the incidence of artifacts that may affect interpretation. The forward
back eight generations. primers in some of the primer sets were fluorescently tagged with 6-FAM

dye and some of forward primer sets were tagged with HEX dye. Hemp tions from minute and degraded DNA samples. It is suitable for the
DNA extracts were provided by Tariq Mahmood of the Alberta Research analysis of degraded DNA samples in wildlife forensics, food inspection,
Council in Alberta, Canada. The hemp samples were amplified in a single conservation biology and ancient faunal remains analysis.
optimized reaction to determine base pair size for each allele. The primers Species Identification, PCR Amplification, mtDNA
were then combined into a single multiplexed reaction. The samples were
amplified on a 9700 Thermal cycler with the following parameters: a 5-
minute incubation at 94°C then twenty-five cycles of 94°C for 30 seconds, G39 Sternal Shard From Bystander Bullet:
54°C for 30 seconds and 72°C for 30 seconds, eight cycles of 94°C for 30 A Rare Mechanism of Homicide
seconds, 52°C for 30 seconds and 72°C for 30 seconds, a 60 minute
extension time at 60°C and a final 4°C chill. The samples were prepared Wendy M. Gunther, MD*, Office of the Chief Medical Examiner,
and electrokinetically injected for capillary electrophoresis on the ABI Tidewater District, 830 Southampton Avenue, Suite 100, Norfolk,
Prism 3100. The data generated was imported into GeneScan 3.7 and the VA 23510
base pair size analysis performed using Genotyper 3.7.
Previous studies using these microsatellite markers were able to dis- After attending this presentation, attendees will become aware of
tinguish clones from non-clones. Efforts to construct a comprehensive unusual locations a bullet may reach in the in body, and understand how a
genomic map of Cannabis sativa, where the positions of these gunshot wound can cause death without the bullet penetrating into the chest
microsatellite loci on various chromosomes/linkage groups could be cavity, or injuring any vital organ.
defined are presented. Efforts to determine the level of polymorphism and This presentation will impact the forensic community and/or
to measure the genetic relationships between different Cannabis plants are humanity by making the attendee aware of fractured sternal fragments as
also presented. There were a total of 30 individual Cannabis sativa plants possible injuring substances in a death in which a bullet does not penetrate
into the chest cavity, and achieve agreement on whether a death in such a
analyzed, 15 with a low Δ9 tetrahydrocannabinol (THC) content and 15 circumstance can be considered accidental, or whether the manner is more
with a high THC content. appropriately to be deemed a homicide.
This study determined the practicality of multiplexing primers sets to An 18-year-old senior high school student, who was captain of the
differentiate individual plants within the Cannabis sativa species. Using local track team, exited an all-night pancake restaurant after two o’clock on
previously described primer sets the authors were able to produce a a Saturday morning. He passed through the restaurant parking lot at the
working multiplex, which could differentiate fourteen individual Cannabis time that a gun battle was going on between adversaries on the opposite
samples of unique origin. During testing, the authors determined that there side of a busy six-lane surface street. The adversaries, who were
was no significant difference in base pair size between alleles typed using exchanging shots after exchanging words at a nightclub, were unknown to
the single locus amplification and the multiplexed amplification. Each the victim. It is likely that he was not aware of the gun battle on exiting the
cannabis sample gave a unique profile showing clear differences between restaurant.
the generated genotypes. A bullet from the exchanged fire crossed the highway, and struck the
References: young man in the chest. He collapsed in the parking lot. Emergency
1. H. AlGhanim and J.R. Almirall, Development of Microsatellite Markers medical services both en route and at the local trauma center provided
in Cannabis sativa for DNA Typing and Genetic Relatedness Analyses, J. resuscitative efforts for more than an hour, without avail. Emergency tho-
of Analytical and Bioanalytical Chem., 2003, 376: 1225-1233. racotomy revealed a large amount of blood in the chest.
2. S. Gilmore and R. Peakall, Isolation of microsatellite markers in At autopsy, the gunshot wound had a slightly atypical appearance, in
Cannabis sativa L. (marijuana). Molecular Ecology Notes 2003, 3: that it consisted of a ½” oval, with a broader than usual central perforation.
105-107. There were 250 cc of blood remaining in the chest after bilateral thora-
Cannabis, STRs, Multiplex cotomy; all viscera were markedly pale, and the vascular tree was depleted
of blood. In situ thoracic organ dissection revealed the presence of a par-
tially transected right anterior pulmonary vein, with injury to the right atrial
G38 Co-Amplification of Cytochrome B and appendage. However, despite this clear evidence of an injury path, no
D-loop mtDNA Fragments for More bullet could be located for the initial hour of the autopsy.
During the prolonged search for the bullet, a physician, who was
Reliable Species Identifications observing the autopsy, identified the projectile in the chest plate, which had
been set to one side during the dissection, with its undersurface exposed to
Dongya Yang, PhD*, Department of Archaeology, Simon Fraser view. The bullet was clearly visible, impacted in the inner sternum,
University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada; and although it was partially covered by a disrupted shard of fractured bone
Speller Camilla, MA, Department of Archaeology, Simon Fraser from the inner cortex of the sternum. This shard of bone, with a triangular
University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada shape like a knife blade, projecting at close to a right angle from the inner
After attending this presentation, attendees will learn a new method cortex, had lacerated the pulmonary vein and right atrium. The bullet
for the analysis of degraded DNA samples in wildlife forensics, food which caused death had done so without entering the thoracic cavity, and
inspection, conservation biology and ancient faunal remains analysis. without perforating any vital structures, because it dislocated a sternal shard
This presentation will impact the forensic community and/or from the inner cortex of the sternum, at an unfortunate angle which was
humanity by demonstrating the co-amplification method, which is a simple, responsible for death.
cost-efficient and genomic DNA-saving approach for species identifica- The shooter claimed self-defense, in that he was returning fire on a
tions from minute and degraded DNA samples. person who, he stated, was firing at him from within a car across the
This study proposed the simultaneous co-amplification of both parking lot. The mechanism of death supported his contention that he did
cytochrome b and D-loop fragments for more reliable animal species iden- not intend to fire at the victim. Three months later, free on bail, he was
tifications. This method uses a conserved cytochrome b sequence to obtain arrested with three other men after a drug-surveillance related gun battle
a less ambiguous species indication and a hyper-variable D-loop DNA with police.
sequence to obtain other specific information concerning species, popu- The mechanism of this unusual chain of events leading to death will
lation, and even individual specificities. Tests on ancient whale and salmon be discussed, utilizing autopsy photographs, with consideration of the
DNA samples have demonstrated that the co-amplification is a simple, appropriate manner of death.
cost-efficient and genomic DNA-saving approach for species identifica- Sternal Shard, Gunshot Wound, Bystander

G40 False Positive Diagnosis of Subarachnoid described as progressively lethargic. She was intubated in the emergency
department but became profoundly bradycardic during a head CT. She
Hemorrhage and Subdural Hemorrhage received inotropic support but expired four hours after presentation. Head
by Computerized Tomography CT was interpreted as showing a small right frontal SDH with blood at the
posterior aspect of the interhemispheric fissure. No SDH was identified at
Sangeeta Sandhu, MD*, St. Luke’s-Roosevelt Hospital, 515 West 59 autopsy, which revealed bacterial leptomeningitis and this was given as the
Street, #4K, New York, NY 10019; Stephen deRoux, MD, and Beverly cause of death. The father was released from police custody following
Leffers, MD, Office of Chief Medical Examiner (Brooklyn), 520 First autopsy as he had been arrested on suspicion of child abuse (shaken baby
Avenue, New York, NY 10016-6402; and Thomas Gilson, MD, Office of syndrome).
Chief Medical Examiner (Manhattan), 520 First Avenue, New York, NY Forensic Science, Subarachnoid Hemorrhage, Subdural Hemorrhage
10016-6402
The goal of this presentation seeks to raise awareness of the potential
misdiagnosis of subarachnoid hemorrhage and subdural hemorrhage by G41 TASER-Related Fatalities: Case Report
computerized tomography. Attendees should understand possible reasons and Review of the Literature
for misdiagnosis as well as their medicolegal and clinical implications.
Amy T. Sheil, MD*, and Kim A. Collins, MD, Medical University of South
humanity by presenting three cases of misdiagnosed subarachnoid hemor-
Carolina, Department of Medical and Forensic Autopsy, 165 Ashley
rhage and one of subdural hemorrhage.
Avenue, Suite 309, Charleston, SC 29425
Death investigators should be aware of potential discrepancies between
radiologic and autopsy findings. After attending this presentation, attendees will be aware of TASER-
Subarachnoid hemorrhage (SAH) involves bleeding into the space related fatalities, understand the pathophysiological effects of TASER
between the pia and arachnoid membranes and subdural hemorrhage stunning, know common comorbid conditions identified in deaths resulting
(SDH) is characterized by bleeding into the space between the dura and in conjunction with TASER use, and identify important clinical and patho-
arachnoid membranes. SDH is generally associated with trauma while logic information in the assessment of a TASER-related death.
SAH has well-recognized traumatic and non-traumatic (e.g. ruptured This presentation will impact the forensic community and/or
cerebral aneurysm) etiologies. Computerized tomography (CT) is fre- humanity by demonstrating a compilation of information regarding
quently used in the evaluation of cases of suspected head trauma and has a TASER-related deaths and will educate the forensic community (police,
high sensitivity in the diagnosis of SAH and SDH. Misdiagnosis by CT of coroners, medical examiners, and investigators) regarding use and patho-
SAH has been infrequently reported but may have significant clinical and physiological effects of the TASER. Identification of comorbid conditions
medicolegal consequences. Potential sources of misdiagnosis include and risk factors for poor outcomes associated with TASER stunning may
hypoxic encephalopathy, meningitis and reviewer inexperience. This lead to additional studies concerning guidelines for use. Recommendations
report addresses three adult cases where CT misdiagnosis of SAH occurred may inspire the implementation of clinical and histopathological standards
as well as a pediatric case where CT misdiagnosed a SDH. in evaluation of future TASER-associated deaths. Finally, understanding
The first case involved a 25-year-old man who presented to the emer- the need for cautious use may limit the number of TASER-associated fatal-
gency department with vomiting and abdominal pain following an alcohol ities, and therefore support continued utilization of this non-lethal weapon.
binge. He had altered mental status and went into cardiorespiratory arrest A recent rash of TASER-related fatalities has inspired controversy
shortly after presentation. He was resuscitated but remained comatose and regarding the use of the touted non-lethal weapon, as well as the exact role
succumbed to multisystem organ failure three days after admission. A head the TASER (an acronym for “Thomas A. Swift’s Electric Rifle”) has played
CT after resuscitation was interpreted as showing diffuse SAH. No SAH in the deaths of over 100 people since 2001. Most reports have been promi-
was identified at autopsy. Neuropathologic examination revealed changes nently featured by the media. TASER International, Inc. asserts that the
consistent with hypoxic encephalopathy with cerebral edema. Cause of TASER has not been directly responsible for these deaths.
death was acute liver failure due to acute and chronic alcoholism. The TASER is an electric stun gun designed to cause incapacitation
The second case involved a 49-year-old man who presented in car- upon delivery of approximately 50,000 volts of electricity by means of two
diorespiratory arrest to the emergency department after being found unre- metal darts. A cartridge containing two barbed darts is loaded in the gun.
sponsive at home. Past medical history was notable for a high cervical The darts are attached to the cartridge by means of thin wire (some with
spine injury approximately one and half years prior to death. Because of ranges up to 21 feet), and are deployed from the cartridge by pressing a
the injury the decedent was ventilator dependent. After resuscitation he trigger button. One press of the trigger causes a five-second delivery of
remained comatose and died one day later. A CT scan of the head after electricity. A longer duration of delivery may be obtained by continuing to
resuscitation was interpreted as showing diffuse SAH but no SAH was press the trigger. Following deployment of the darts, the gun may be used
identified at autopsy. Neuropathologic evaluation demonstrated hypoxic to deliver electricity by direct contact. Delivery of such an electrical
encephalopathy with cerebral edema. The cause of the decedent’s initial stimulus causes intense, immediate, and painful muscle contraction. Many
cardiopulmonary arrest was related to complications of his remote neck law enforcement agencies throughout the U.S. employ TASER guns; the
injury and this was listed as the proximate cause of death. TASER is also commercially available to civilians. While the TASER
The final adult case involved a 33-year-old man with a history of sub- likely has been useful in preventing lethal use of force in some situations,
stance abuse who collapsed at a fast food restaurant and was taken unre- a concern is that few standards are in place governing the use of the
sponsive to the hospital where he was resuscitated. He regained vital signs TASER. Fatalities have occurred during or following TASER stunning.
but had sustained a hypoxic brain insult and never regained consciousness Many perpetrators on whom the TASER has been deployed have been
before expiring 14 hours later. A head CT after resuscitation was inter- acutely intoxicated by various drugs, including cocaine, methamphetamine,
preted as showing diffuse SAH. This was not present at autopsy and neu- and phencyclidine (PCP). Acute intoxication has generally been ruled as
ropathologic examination again showed only signs of hypoxic the cause of death in these cases, and TASER use indirectly implicated. In
encephalopathy with cerebral edema. Cause of death was related to acute the absence of any evidence of illicit substances, other causes of death have
drug intoxication. included positional asphyxia, excited delirium, or underlying cardiac
The pediatric case involved a 5 week-old infant who was brought to disease.
the hospital in extremis by her father after she developed labored breathing. A case of a 29-year-old schizophrenic inmate who died immediately
She had been previously healthy but over the preceding hours was after being tased approximately six times, subsequent to his attack on cor-

rections officers is reported. He collapsed in a supine position, and his or intra-oral gunshot wounds. Females were significantly more likely to
hands were cuffed in front of his body. Postmortem examination revealed commit suicide by drug intoxication than were males, though hanging was
an anatomically normal heart, normal postmortem vitreous chemistries, the most common method used. While the availability of firearms has sig-
and a negative urine drug screen. No obvious cause of death was revealed nificantly increased over the last decade, there did not seem to be a signif-
by autopsy. Focal interventricular cardiac septum subendocardial icant upward trend in the use of firearms to commit suicide in the youth and
myocardial contraction bands were identified by light microscopy. The teen population. There did appear to be an upward trend in hangings. Drug
authors concluded that the inmate died of a fatal cardiac arrhythmia, and in intoxication and multiple injuries, falls from a height, accounted for an
light of the temporal relationship to delivery of TASER electrical stimulus, additional 10%, with carbon monoxide intoxication and drowning making
the manner of death was deemed homicide. up the remainder.
The pathology findings in this case are reported, with a review of the Regional evaluation of youth and teen suicide occurrence in the state
existing literature concerning TASER-related deaths. showed a preponderance of cases in Baltimore County (16%) and
TASER, Forensic Medicine, Death Baltimore City (15%). Montgomery County and Prince George’s County
comprised an additional 23% of cases. The remaining 20 more rural
Maryland counties had suicide rates ranging from 1-4%. While there has
not been a significant increase in the overall number of youth and teen
G42 A Demographic Analysis of Youth and suicide over the last decade, it may be useful to more closely evaluate those
Teen Suicide in Maryland (1994-2003) counties, which have had a steady rise in suicides in this age group.
Knowledge of risk factors and demographics for suicide in this population,
Melissa A. Brassell, MD*, Carol H. Allan, MD, Mary G. Ripple, MD, and and how they differ according to socioeconomic status will assist in appro-
David R. Fowler, MD, Office of the Chief Medical Examiner, 111 Penn priately placing and developing prevention strategies.
Street, Baltimore, MD 21201 Teen Suicide, Suicide Methods, Suicide Prevention
After attending this presentation, attendees will be briefed on the
analysis of trends regarding youth and teen suicide, which will assist in
properly developing, placing and implementing suicide prevention G43 Effectiveness of Death Investigation
strategies. in Cases of Potential Elder Abuse
humanity by demonstrating the trends regarding age, gender, race and
Diane C. Peterson, MD*, and Richard E. Powers, MD, P220 West
methods of suicide among youth and teen age groups (age 10-19) in
Pavilion, Department of Pathology, 619 19th Street South, Birmingham,
Maryland, which may assist in the application of suicide prevention
AL 35233; James N. Robinson, BA, University of Alabama at
strategies.
Birmingham Medical School, VH P-100, 1530 3rd Avenue South,
Learning Objectives: This is a retrospective epidemiologic survey of
Birmingham, AL 35294; and Gregory G. Davis, MD, Jefferson County
youth and teen suicide, ages 10-19, in the state of Maryland. Analysis of
Coroner/Medical Examiner Office, 1515 Sixth Avenue South, Room 611,
trends regarding age, gender, race and methods of suicide within this pop-
Birmingham, AL 35233-1601
ulation may assist in the application of prevention strategies.
Suicide is the 11th leading cause of death in the United States, com- After attending this presentation, attendees will learn a means to
prising 7% of all deaths. Adolescent suicide rates have continued to examine the effectiveness of a medical examiner system at detecting cases
increase over the last several decades. There have been an increasing of elder abuse.
number of articles focusing on the epidemiology of suicide, showing the This presentation will impact the forensic community and/or
majority of suicide victims to be Caucasian males, followed by African humanity by showing a means for evaluating the effectiveness of a medical
American males, Caucasian females and African American females, in examiner office at investigating cases of elder abuse.
decreasing order of frequency. Fewer studies have focused on the trends of RATIONALE: A primary means of detecting foul play is the exami-
suicide in childhood. This report is a retrospective analysis of suicide in nation by the medical examiner of the bodies of all individuals who die
youth (age 10-14) and teen (age 15-19) age groups. unexpectedly. Death in the elderly, however, is not necessarily unexpected,
Suicide is the third leading cause of death between the ages of 10-19 and it is possible that foul play is more easily hidden in the elderly by a
years, comprising nearly 8% of all deaths, following only unintentional claim that death was expected, thus bypassing the jurisdiction of the
injury and homicide. In the state of Maryland, during the years of 1994- medical examiner. The rate of referral to the medical examiner’s office of
2003, there were 262 deaths between the ages of 10 and 19 in which the suspected lethal abuse or neglect in the elderly by all reporters or first
manner of death was determined to be suicide. The average age was 16.7 responders is unknown. Reasonable conservative estimates exist, however,
years. Youth suicide (age 10-14) accounted for 19.5% of these deaths. of claims of elder abuse substantiated upon investigation. Researches
In this population, 68% of suicide victims were Caucasian and 28% wished to assess the effectiveness of the existing medical examiner system
were African American, a ratio of approximately 2.5:1. This ratio is lower in Jefferson County, Alabama at capturing all cases of physical abuse in the
than that typically seen in the general population. This may be explained elderly. The authors compared the number of cases of suspected elder
by the larger African American population seen in the state of Maryland abuse investigated by the medical examiner office to the number of cases
when compared to the United States as a whole. Other races comprised 4% of elder abuse expected to occur in order to determine whether present
of suicide victims. As in prior studies on suicide, the majority of suicide reporting network and investigative guidelines are sufficient for recog-
victims were male (81%). The order, in decreasing frequency, remains nizing cases involving physical abuse in the elderly.
Caucasian males (55.3%), African American males (24.4%), Caucasian METHODS: The authors conducted a retrospective study of deaths
females (14.1%) and African American females (4.6%). investigated by the Jefferson County Coroner/Medical Examiner Office,
Gunshot wounds and hangings, which steadily increased in frequency Alabama from January 1, 2003 to December 31, 2004 and reviewed the
over the ten-year period, comprised the majority of methods of suicide deaths that occurred in decedents 65 years of age or older, looking for evi-
(83%), consistent with that seen in the general population. A majority of dence of assault or physical abuse. During this time criteria for accepting
fatal self-inflicted gunshot wounds occurred in the male population cases remained unchanged. The findings were compared with an estimate
(41.6%), with 71.6% of these deaths resulting from contact gunshot based on the estimated number of cases of physical abuse that should have
wounds to the head or intra-oral gunshot wounds. 5.7% of female suicides occurred during this time span. The estimate was made using data from the
resulted from gunshot wounds, approximately half of these due to contact Adult Protective Services Division of the Alabama Department of Human

Resources, the United States Census estimates for the state and county pop- G45 Antemortem and Postmortem Toxicological
ulations, and the mortality statistics for Jefferson County. During fiscal
year 2004 Adult Protective Services conducted 4,754 investigations into
Findings in Motor Vehicle Accidents,
allegations of abuse, of which 16% included allegations of physical abuse. Maryland (2003-2004): Does Impairment
Half of these allegations were substantiated upon investigation. Given a Equal Death?
random distribution of cases, use of population and mortality data indicate
that the Jefferson County Office should expect to investigate about six Sunil K. Prashar, MD*, State of Maryland, Office of the Chief Medical
cases with allegations of physical abuse and three cases of substantiated Examiner, 111 Penn Street, Baltimore, MD 21201; Jami L. Grant, PhD,
physical abuse in the elderly per year. University of Baltimore, 1420 North Charles Street, Baltimore, MD
RESULTS: From 2003-2004 the Jefferson County Coroner/Medical 21201; Susan R. Hogan, MD, David R. Fowler, MD, and Mary G.
Examiner Office examined 198 individuals age 65 years or older, and sus- Ripple, MD, State of Maryland, Office of the Chief Medical Examiner, 111
picion of abuse was reported or found in eight cases. In three cases the Penn Street, Baltimore, MD 21201; and Mary E. Kramer, RN, R. Adams
abuse was not substantiated at postmortem examination, and in five cases Cowley Shock Trauma Center, 22 S Greene Street, Baltimore, MD 21201
the death was a homicide. Based on the estimates given above, the
expected number of cases for two years was 12 cases of suspected abuse After attending this presentation, attendees will understand the
and 6 cases of substantiated abuse, so the office investigated roughly the potential utility of adding toxicological screening for drugs to the routine
number of cases that might have been expected over the course of this testing of alcohol levels in individuals involved in motor vehicle accidents.
study. Because a case more or fewer would make such a large difference Furthermore, attendees will better understand the individual, situational and
when dealing with such small numbers, e looked at the number of homi- regional factors associated with motor vehicle related fatalities.
cides in individuals 65 years of age or older by year during the past decade This presentation will impact the forensic community and/or
(1995-2004), during which criteria for accepting jurisdiction were identical humanity by demonstrating a method to assist state officials in setting
to the criteria used for the years of review. It was found that the number of policy for the testing of substances of impairment involved in serious motor
homicides in individuals 65 years of age or older per year ranged from a vehicle accidents. In addition, the presentation will impact the design of
high of 12 (in 1997) to a low of 0 (2004), with a mean of six cases per year. public alcohol and drug prevention programs by identifying at risk popula-
CONCLUSION: Using published reports of the incidence of substan- tions and consumption trends, assist law enforcement in the development
tiated investigations of physical abuse in the elderly, the authors investi- of improved interdiction programs, and serve as a guide for future research
gated about the number of cases of physical abuse that were predicted by a among the forensics community.
model. The number of deaths suspicious for elder abuse investigated by the In the state of Maryland, law enforcement personnel perform alcohol
medical examiner is in keeping with the number of allegations and sub- testing of individuals involved in motor vehicle accidents. The purpose of
stantiations for elder abuse in Alabama. The authors’ approach to case this research is to determine whether alcohol testing alone is a reasonable
selection and assumption of jurisdiction appears to be adequate for the marker of impairment in motor vehicle accidents or whether full toxico-
investigation of physical abuse in the elderly. logical screening should also be required. In addition, this research iden-
tifies factors associated with use of alcohol and/or drugs in the driving
Elder, Abuse, Homicide
fatality population with the goal of improving public policies and
decreasing driving fatalities.
This presentation will assist state officials in setting policy for the
testing of substances of impairment involved in serious motor vehicle acci-
dents. In addition, the presentation will impact the design of public alcohol
G44 Use of CT as an Aid in the Recovery of and drug prevention programs by identifying at risk populations and con-
Metallic Foreign Bodies at Autopsy sumption trends, will assist law enforcement in the development of
improved interdiction programs, and will serve as a guide for future
Edward A. Reedy, PhD, MD*, John M. Getz, PhD, Lisa Pearse, MD, research among the forensics community.
Craig T. Mallak, MD, JD, and James L. Caruso, MD, Armed Forces The research methodology is based on a retrospective study of the
Medical Examiner System, 1413 Research Boulevard, Building 102, motor vehicle accident fatalities that presented to the State of Maryland
Rockville, MD 20850 Office of the Chief Medical Examiner (OCME) and the motor vehicle
accident injured population that presented to the University of Maryland
After attending this presentation, attendees will learn the practical Shock Trauma Center (UMSTC) between July 2003 and June 2004. The
application of a well-established technology to aid in the recovery of evi- study sample included motor vehicle operators, passengers, pedestrians,
dence. motorcyclists and bicyclists. Outcome variables include the presence of
This presentation will impact the forensic community and/or alcohol alone, drugs alone, and both alcohol and drugs. In the fatalities,
humanity by demonstrating the possible introduction of an existing radi- drugs included are those routinely tested for at autopsy at the OCME and
ology method into the forensic autopsy. include illicit drugs, prescription medications and over the counter medica-
The recovery of metallic projectiles at autopsy can be difficult if the tions. In the injured sample, drugs included the 18 drugs tested for at
fragments are small, deeply embedded, very few in number or if the UMSTC.
entrance wound or wound tract is obscured by burns or tissue loss. The Predictor variables include individual factors (e.g., decedent age, race,
recovery of projectiles is essential for evidentiary purposes. Plain radi- and gender), situations factors (e.g., vehicle type, single vs. multiple
ographs frequently prove difficult to interpret, and recovery of metallic vehicles, driver vs. passenger, at fault vs. not at fault, safety equipment, and
foreign objects often requires multiple views. The use of CT at autopsy to road conditions), and regional/geographic factors (e.g., access to trauma
locate metallic objects is not a new concept, but is impractical when there care). This approach is similar to that used in public health research,
are large numbers of foreign bodies to be recovered. Software algorithms focusing on primary (before event), secondary (during event) and tertiary
now provide a means for the subtraction of tissue densities, allowing for: (after event) factors, as they pertain to injury-causing events.
the determination of size, shape, density, and location of metallic foreign Using various descriptive and inferential statistical techniques, the fol-
bodies in relation to anatomical structures. CT was utilized at the time of lowing results were derived (for fatalities n=251; for injured n=2,880). The
autopsy to identify and recover metallic foreign bodies as evidence. fatality sample was predominately male (n=186), constituting 74%.
CT, Radiology, Metallic Caucasians (n=147) and African-Americans (n=78) comprised approxi-

mately 90%. Decedent ages in both populations ranged from 13 to 65 of debilitating illness (17 cases, with 7 cases of schizophrenia or other psy-
years. Of the fatality sample, 50.6% tested positive for alcohol and/or chiatric disorder, 2 cases of mental retardation, and 8 cases due to chronic
drugs, 39.4% tested positive for alcohol alone, 12.4% tested positive for illness such as diabetes mellitus, loss of mobility due to gunshot wounds,
alcohol and drugs, and 11.2% tested positive for drugs alone. Of the injured etc). In six cases the cause for living in a boarding home was unclear from
sample, 22.3% tested positive for alcohol and/or drugs, 16.5% tested pos- the chart. The manners of death were distributed as shown in Table 1.
itive for alcohol alone, 2.6% were positive for both alcohol and drugs, and
5.8% were positive for drugs alone. Table 1. Distribution of deaths by manner in decedents from boarding homes.
The results suggest that alcohol is a good indicator of driving
impairment, as approximately 40% of the fatality sample and 16.5% of the Manner of Death No. (%) (Overall % of office)
injured sample tested positive for its presence. However, nearly half of the Natural 20 (57) (34)
fatality sample and 69% of the injured sample that tested positive for drugs Accident 3 (9) (31)
would have been missed by alcohol screening only. Therefore, the ability Suicide 5 (14) (12)
to determine impairment following motor vehicle accidents may be Homicide 0 (0) (20)
improved by expanded toxicological studies. Undetermined 7 (20) (3)
Toxicology, Alcohol, Motor Vehicle Accidents

The natural deaths were due to ischemic heart disease (7 cases),
hypertension (3 cases), and one case each of pneumonia, cardiomyopathy,
and alcoholism. The remaining seven natural deaths were due to undeter-
G46 Descriptive Study on the Causes of mined natural causes, a situation that most often arises when a physician
Death of Residents of Boarding Homes refuses to sign a death certificate after the body has already been buried or
cremated. The three accidental deaths were due to intoxication related to
Andrea L. Dickens, MD*, and Richard E. Powers, MD, P220 West substance abuse. Two suicides were a gunshot wound of the head, two a
Pavilion, Department of Pathology, 619 19th Street South, Birmingham, hanging, and one an overdose. In the seven cases where the cause of death
AL 35233; James N. Robinson, BA, University of Alabama at was undetermined, four were undetermined in part because the office
Birmingham Medical School, VH P-100, 1530 3rd Avenue South, received the case after a physician refused to sign the death certificate, and
Birmingham, AL 35294; and Gregory G. Davis, MD, Jefferson County three were undetermined following an autopsy. Decedents with a history
Coroner/Medical Examiner Office, 1515 Sixth Avenue South, Room 611, of substance abuse tended to be intoxicated at the time of death; toxicology
Birmingham, AL 35233-1601 testing revealed an intoxicating substance in nine of the 11 decedents with
a history of substance abuse who were tested. Thirty-two of the decedents
After attending this presentation, attendees will gain a better under- were not married, whether because of death of their spouse, divorce, or
standing of the circumstances surrounding death and the causes of death for never having married. The factors that led to the assumption of jurisdiction
disabled residents of boarding homes. of a case were lack of a physician to sign the death certificate, history or
This presentation will impact the forensic community and/or scene evidence to suggest substance abuse, or concern on the part of the
humanity by demonstrating how boarding homes will become an increas- decedent’s family about foul play or poor care. No evidence of physical
ingly common source of cases as disabled individuals are moved from abuse was found in any of these cases.
institutional care to community housing in compliance with the federal CONCLUSION: Federal law requires that states offer community-
Olmstead Decree. based living for individuals with disabilities rather than house these indi-
RATIONALE: In 1999 the Supreme Court issued the Olmstead viduals in institutions. Boarding homes are the community-based housing
Decree, which requires that states offer community-based living for indi- available to these disabled persons. Residents of boarding homes are likely
viduals with disabilities rather than house these individuals in institutions. to be disabled by substance abuse or by a mental disorder. Research indi-
Several options are available to states to satisfy the requirements of the cates that abuse of the elderly is more likely in individuals with short-term
Olmstead Decree. Nursing homes, for example, often house individuals memory problems, any psychiatric diagnosis, substance abuse, or poor
disabled by dementia. Boarding homes also play a critical role in providing social support. Most residents of boarding homes in this study were
housing for disabled individuals, and boarding homes have proliferated in socially isolated and either mentally disabled or prone to substance abuse,
response to the increased demand for such housing since the beginning of leading us to conclude that deaths that occur in boarding homes merit
the movement to deinstitutionalize individuals with disabilities. The forensic investigation.
quality of care given by nursing homes has been a subject of great interest
Group Home, Boarding Home, Disabled
recently, both in the medical and legal communities. The nursing home
industry is tightly regulated by the federal government, and the causes of
death for nursing home patients are recorded as a matter of course.
Boarding homes, in contrast, are under no regulation, and virtually nothing G47 The Death of an Italian Soldier in Iraq:
is known of the outcomes of disabled patients living in boarding homes, Murder or Fatality?
including the circumstances in which these individuals die.
METHODS: The authors conducted a retrospective study of deaths Margherita Neri, MD*, Marianna Di Padua, MD, Cristoforo Pomara, MD,
investigated by the Jefferson County Coroner/Medical Examiner Office, and Emanuela Turillazzi, MD, PhD, Department of Forensic Pathology,
Alabama from January 1, 2000 to December 31, 2004. Review of the case University of Foggia, Viale Pinto 1, Foggia, 71100, Italy
files revealed 35 deaths during that time that occurred in a boarding or
group home. Each case was reviewed, recording the circumstances sur- The death of an Italian soldier in Iraq is presented. The goal of this
rounding death and the cause and manner of death. study is to present a relatively quick and easy method for evaluation of
RESULTS: Researchers found 35 deaths investigated by the office gunshot residues, useful for interpreting gunshot wounds in cases where the
which occurred in a boarding or group home. The mean age of the dece- circumstances of death are not clear. A specific histochemical stain with
dents was 59 years, with a standard deviation of 15 years (minimum age 25 sodium rhodizonate and an analysis using a confocal type laser profile
years, maximum age 91 years). Twenty-one decedents were black and microscope was performed in order to clarify the exact death scenario.
fourteen were white. Twenty-two decedents were male and thirteen were This presentation will impact the forensic community and/or
female. The reasons for living in a boarding home were divided between humanity by providing a relatively quick and easy method for evaluation of
two broad categories – a history of substance abuse (12 cases) or a history gunshot residues, using sodium rhodizonate staining on histological

samples, that may help determine range of fire in cases of death caused by In this reported case, the careful histological investigation of the
firearm, and in this particular case, in order to clarify whether it is an wound skin through specific staining made the circumstances of the death
accident, homicide or a suicide case. This histochemical data may be sup- clear, leading to the assessment of entrance site and firing distance.
ported by the use of a confocal microscope. Furthermore the circumstantial data confirmed the hypothesized death sce-
A young Italian soldier in Iraq, at 01:00 p.m. was discovered wounded nario, that it was an accidental self–inflicted gunshot while the soldier was
in a shooting range, where he was training with his rifle, a “MINIMI” cal. trying to unblock his rifle.
5.56 mm. The rifle was found near the man and was seized. He was Soldier Death, Gunshot Wound, Shooting Range
quickly taken by helicopter to the nearest military hospital in serious
clinical condition, but he continued getting worse, so was transferred and
hospitalized to Kuwait City, and died at 4:27 p.m. The body was trans-
ferred to Italy to the Department of Forensic Pathology of Foggia. A
G48 Prevention of Accidental Strangulation
Military Prosecutor arranged the autopsy on the body because the cir- of Children in Their Sleeping Bags:
cumstances of the wound suggested that the death could be an accident Development of a New Sleeping Bag
or, alternatively, a murder.
A complete autopsy was performed. The head injury was massive Kathrin Gerlach, MD*, Department of Legal Medicine, Pestalozzistrasse
with partial evisceration of the brain. A large gaping tear of the scalp was 22, Basel, 4056, Switzerland; Beat Horisberger, MD, Department of
present. The exact sites of the entrance and the exit of the bullet were not Legal Medicine, Rue du Bugnon 2, CH-1005 Lausanne, Switzerland,
apparent. Careful re – approximation of the scalp and the examination of Walter Bar, MD, Department of Legal Medicine, Winterthurerstrasse 190,
the tear showed an irregularly circular wound with irregular margins, sur- CH-8091 Zürich, Switzerland; and Volker Dittmann, MD, and Daniel
rounded by a wide zone of raw abraded skin in the forehead. A large, V – Wyler, MD, Department of Legal Medicine, Pestalozzistrasse 22, CH-
shaped scalp laceration (18 x15 centimetres) radiated from this circular area 4056 Basel, Switzerland
up to the parietal and occipital bones. Gross identification of the entrance
site was not possible. The brain was edematous, and the bilateral frontal The goal of this presentation is to draw your attention to the dangers
and right parietal regions were lacerated with lost brain parenchyma. of accidental strangulation of children in their sleeping bags. Dr. Gerlach
The brain was sectioned with coronal cuts according to the Adams will also introduce a newly developed model of a sleeping bag, which pre-
technique and showed right to left shift of the midline structure. vents fatal incidents of that kind.
In the bilateral frontal region a small foci of hemorrhage was present This presentation will impact the forensic community and/or
and characteristic petechial hemorrhages continued throughout coronal cuts humanity by aiming to sensitize the audience to the problem, to critically
and affected the corpus callosum. Furthermore, in the right hemisphere, discuss the prototype as well as to show how to avoid such fatalities, which
superficial subcortical hematomas extended into the parenchyma and the should also be accomplished by marketing the new sleeping bag.
right lateral ventricle. In the last few years, researchers analysed several fatalities of children
The cerebellum the subarachnoid space was affected by moderate who had strangled themselves at the neckline of their sleeping bag due to
hemorrhage, and the brainstem showed characteristic petechial hemor- their own movements while sleeping. Those sleeping bags can be pur-
rhages. chased on the market and should be suitable to fix children.
The examination of the other organs was unremarkable. Routine his- Types of sleeping bags currently available on the market with their safety
tological investigation of skin specimens applying hematoxilin and eosin advantages and disadvantages are presented.
staining revealed a detachment of the upper epidermal areas mainly After this analysis, these fatal incidents appear to be avoidable, and it is
extending through the basal cell layers with flattened and stretched epi- possible to adopt measures to prevent these deaths. A simple means to
dermis. The deeper parts of stratum papillare and underlying upper layers resolve the problem would be a revision of the cut patterns in the current
of the corium were homogenized. In these areas wide erythrocyte accu- sleeping bags, which fixes the main hazard of these sleeping bags.
mulation was present in the dermis and sub-epidermic adipose tissue. In A prototype was developed with a cut to prevent these fatal incidents.
superficial and deep layers of skin and dura mater were black foreign This prototype sleeping bag is being tested for its functionality and han-
bodies. Brain sections showed intraparenchymal diffuse haemorrhages. dling and is registered for marketing. This prototype will be presented to
Frontal wound skin and dura mater samples were also stained with an audience of experts.
Rhodizonate dye technique. Rhodizonic acid exists as needle-shaped
Sleeping Bag, Strangulation, Prevention
crystals of a dark orange colour and forms a sodium salt, which reacts with
heavy metal ions (barium, antimony, lead, tin) contained in gunshot
residues (GSR) with a red precipitate. On histological tissue sections,
Rhodizonate reacts with heavy metal particles from the primer by gener- G49 VIRTOPSY (Virtual Autopsy) -
ating a finely granular scarlet red pattern. The specimens were examined Past, Present, and Future
with a light microscope, in transmitted brightfield illumination and phase
contrast mode. Michael J. Thali, MD*, University of Berne, Institut Forensic Science,
In the samples collected from skin of the frontal region the Na- Buehlstrasse 20, Bern, Switzerland; Peter Vock, MD, University of
Rhodizonate reaction was positive for the presence of gunshot residues Berne, Radiology Department, Berne, 3005, Switzerland; and Richard
(GSR), showing dotted, non–contiguous, coarsely granulated deposits of Dirnhofer, MD, University of Berne, Institut of Forensic Medicine, Berne,
rhodizonate, positive not only on the surface of skin, but also appearing Berne 3012, Switzerland
within the gaps between connective tissue fibers. The same findings were
observed in the dura mater specimens. After attending this presentation the attendee will get an upgrade of
The GSR-positive samples were examined with confocal microscope the cutting edge technologies in forensic imaging/radiology.
using fluorescence emission of skin and antimony, a heavy metal contained This presentation will impact the forensic community and/or
in gunshot residues. A three-dimensional reconstruction was performed humanity by providing an actual overview of upcoming imaging tech-
that confirmed the presence of GRS – positive granules on skin and dura nologies in forensic medicine.
mater surface. The aim of the VIRTOPSY project (www.virtopsy.com) is utilizing
Gunshot residue findings, their morphological aspects, and their 3D body-surface documentation and minimal-invasive, image-guided
location were indicative for a shooting distance less 40 centimetres. virtual autopsy utilizing optical and radiological scanning to push low-tech

documentation and autopsy procedures in a world of high-tech medicine in Public, the Politicians, the funders) that high standards in professional
order to improve scientific value, to increase significance and quality in the forensic practice are delivered consistently with accountability. The paper
forensic field. The Institute of Forensic Medicine, University of Berne is, will discuss the experience of the Centre for Forensic Medicine, Health
in collaboration with a well selected national and international research Sciences Authority Singapore, in its journey towards assuring professional
team, evaluating and validating several cutting-edge technologies such as quality.
3D optical and photogrammetric surface scanning, computed tomography Quality, Forensic Medicine, Accreditation
(CT), magnetic resonance imaging (MRI), magnetic resonance (MR) spec-
troscopy, micro-CT, micro-MR, postmortem biopsy, postmortem angiog-
raphy and synthetic body models. The term VIRTOPSY was created from
the terms virtual and autopsy: Virtual is derived from the Latin word G51 Insects of the Grave: A Cold Case History
‘virtus’, which means ‘useful, efficient, and good’. Autopsy is a combi-
nation of the old Greek terms ‘autos’ (=self) and ‘opsomei’ (= I will see). Involving Insects 27 Years After Death
Thus autopsy means ‘to see with ones own eyes’. Because the goal was to
eliminate the subjectivity of “autos”, the two terms virtual and autopsy Richard W. Merritt, PhD*, Michigan State University, Department of
were merged - deleting “autos” - to create VIRTOPSY. Today the project Entomology, 243 National Science Building, East Lansing, MI 48824;
VIRTOPSY combining all the research topics under one scientific Mark E. Benbow, PhD, Department of Biology, DePauw University,
umbrella, is characterized by a trans-disciplinary research approach that Greencastle, IN 46135; Ryan K. Kimbirauskas, MS, Michigan State
combines Forensic Medicine, Pathology, Radiology, Image Processing, University, Department of Entomology, East Lansing, MI 48824; Joyce L.
Physics and Biomechanics to an international scientific network. The deJong, DO, Sparrow Hospital, 1215 East Michigan Avenue, Lansing,
paper will give an overview of the Virtopsy change process in forensic MI 48909; and Richard Snider, PhD, Michigan State University,
medicine. Department of Zoology, East Lansing, MI 48824
Virtopsy, Virtual Autopsy, Forensic Radiology After attending the presentation, attendees will understand the biology
of a relatively small group of insects (Collembola) rarely mentioned as an
insect frequenting decomposing remains, especially following exhumation
G50 Professional Quality in a Forensic Medical 27 years after death. They also will be exposed to the environmental
factors that may have led to this occurrence.
Setting: The Singapore Experience This presentation will impact the forensic community and/or
humanity by presenting case that provides important information to ento-
Paul P.S. Chui, MBBS, DMJ, MBA*, and Clarence T. Tan, MBBS, Health mologists and biologists on the biology of Collembolan as it relates to
Sciences Authority, 11 Outram Road, Singapore, 169078, Singapore human decomposition. The case also will add to the biological information
After attending this presentation, attendees will 1. Understand the of this insect group as to their movement in the soil and apparent niche at
need for Professional Quality in a forensic medical setting; 2. Gain an this soil depth. This is information that will rarely ever be collected in
insight in how CFM, HSA has approached the subject of Professional normal crime scene investigations, and it is a rare occurrence in nature to
Quality; and 3. See the need to implement quality systems suitable to their find insects inhabiting a cadaver 27 years after death.
own operating environment. This presentation will make forensic entomologists and other biolo-
This presentation will impact the forensic community and/or gists aware of insects and other arthropods associated with decomposing
humanity by encouraging implementation of quality systems and pro- bodies far beyond the normal postmortem interval. It also will make
moting more emphasis on assuring quality of services of the forensic med- forensic pathologists aware of what types of arthropods may be encoun-
icine community; and encouraging dialogue between practitioners as to tered during investigations when bodies have been exhumed after several
best practices that would engender the above. years.
In many different industries, including the healthcare sector, the The cadaver of a 28-year-old female was exhumed in January 2005
pursuit of quality has become an essential element in both assuring con- from a cemetery in Battle Creek, Michigan. She had sustained a gunshot
sumers a consistency of standards in the products and services delivered as wound to the head and was found dead in her home on November 15, 1977.
well as delivering a competitive marketing advantage. Indeed, this also An autopsy was performed and the manner of death was termed as a
applies to many public agencies around the world. homicide. The body of the victim was subsequently embalmed and then
Forensic medical practices/consultancies are typically small “enter- buried at a depth of 6 feet in an unsealed casket that was placed inside an
prises” with limited budgets and they operate within a limited legal/geo- unsealed cement vault. Information leading to the perpetrator of the crime
graphical jurisdiction, in a typical single seller (the forensic practice) and became known in 2004 and the investigating agency was unable to locate
single buyer/payer (State/Law Enforcement agency) environment. Some an autopsy report. Therefore, law enforcement officials requested the body
of these “enterprises” are one-man-operations (OMO). be exhumed and a second examination be performed.
Professional accountability is mostly limited to challenge within a The current exhumation yielded thousands of live specimens of a
courtroom environment or is non-existent outside of the courtroom in some single species of Collembola or spring tails, Sinella (Coecobrya) tene-
instances. Peer review is not a norm. The weight placed on personal pro- bricosa. This species is considered to be a “tramp” species, cosmopolitan
fessional independence, expertise and experience creates an milieu in the United States and Canada. It is usually collected in protected areas
amenable to development of a prima donna culture where forensic opinion such as caves, wood piles, and greenhouses. Based on their occurrence in
is no longer largely a question of science but of the weight of persona and soils, small size, and given the damp conditions present in the casket, this
charisma in court and the public eye, where the risk of errant practices and species probably made use of soil pores and tunnels made by worms and
practitioners may remain undetected for a long time. Failure to deliver other burrowing arthropods in searching for food. Over time, some indi-
good quality results can pervert the course of natural justice and damage viduals moved down further into the soil into the moist vault and eventually
public confidence in the law enforcement and judicial systems. the casket where cadaver tissues and clothing provided a suitable substrate
Considering the impact of the professional work in influencing for fungal/yeast/mold growth as a food source. At this site the species had
judicial outcomes, it is important, in the authors’ view that while one cannot ideal conditions and the population exploded. Collected with the
wholesale adopt practices from the industry, efforts nonetheless need to be Collembola were large numbers of Acarina (mites) of the Family
made to identify relevant and appropriate measures for adoption, to assure Glycyphagidae, and phorid fly puparia, known as coffin flies.
the stakeholders (the Prosecution, the Courts, Law Enforcement, the Insects, Burial, Collembola

G52 Seasonal Effects on Blow Fly resistance to organophosphate 1, acetylcholine esterase, ultraspiracle,
ecdysone receptor, wingless, slalom, aminopeptidase 1, bicoid, chitin syn-
Species Composition and Behavior thase, and heat shock proteins 60 and 90) was isolated and sequenced in L.
sericata. The expression levels of these genes were profiled throughout the
Jennifer Y. Rosati, BSc*, and Sherah L. VanLaerhoven, PhD, University of juvenile life cycle at two temperatures. They were also assayed in larvae
Windsor, Rm 119 Bio, 401 Sunset Avenue, Windsor, Ontario N9B 3P4, that failed to pupate.
Canada Gene expression profiles were obtained for replicate time series, as
After attending this presentation, attendees will learn about blowfly were the distributions of gene expression levels. Examples of informative
species and behavior and how it relates to decomposition and PMI deter- transcripts at a specific stage include resistance to organophosphate-1,
mination. which became the most common transcript in mid pupal samples, and scal-
This presentation will impact the forensic community and/or loped wings, which decreased dramatically at the same time. Through
humanity by recognizing the importance regarding the effects of habitat replicate analysis of many individuals from each developmental stage, a
and season on blowfly species composition and behavior. confidence interval could be assigned to the expression level of each gene
Blowfly species composition is an important aspect to consider in the throughout the life cycle. Further, by analyzing the expression levels of a
determination of the postmortem interval (PMI). Presented here are some number of genes, confidence levels could be assigned to the estimate of
preliminary results from the first year of a 2-year decomposition study. The developmental stage of the flies. Finally, expression profiles of larvae that
effect of habitat (sun and shade) and season (spring, summer, and fall) on failed to pupate were examined, which indicated aberrant gene expression
the successional patterns of carrion insects were investigated using the lay at the root of this phenotype.
domestic pig. Each season, 2 freshly killed pigs (approximately 23kg) were Current research in forensic entomology includes investigation of
placed in each habitat type in 6 test sites located throughout Windsor/Essex error rates for PMI estimates, as well as improved use of environmental
County, Ontario (n=12 pigs/season). Insects were sampled using a information, in an attempt to increase the accuracy of PMIs generated in
combination of pitfall and malaise traps as well as direct sampling. Internal this way. The developmental gene expression research presented here
carcass temperatures and ambient temperatures were recorded for each pig addresses the biological side of the same issue. The method allows for a
using Smartbutton data loggers and biomass loss was determined through quantitative analysis of age using many different traits, and represents a
weekly weighing. The effect of habitat and season can play a significant promising approach for improving entomology based PMI estimations.
role in determining the species composition and successional patterns of the This project was supported by Grant Number 2004-DN-BX-K005
blowfly community. Observations and differences concerning maggot awarded by the National Institute of Justice, Office of Justice Programs,
feeding and wandering behavior for each habitat and season were recorded. U.S. Department of Justice. Points of view in this document are those of
The research is currently on going with the second year beginning in the author and do not necessarily represent the official position or policies
April 2006. of the U.S. Department of Justice.
Blowfly Species Composition, Blowfly Behavior, Habitat and Forensic Entomology, DNA Expression Levels, Postmortem Interval
Seasonal Effects
G53 Improving Postmortem Interval Estimates G54 The Developmental Studies of The Green
in Forensic Entomology: Blowfly Gene Bottle Fly, Phaenicia coeruleiviridis
Expression and Development (Diptera: Calliphoridae)
Aaron M. Tarone, BS*, Department of Zoology, 203 Natural Sciences Kc L. Deaver, MS*, 2704 72nd Avenue, SE, Mercer Island, WA 98040;
Building, Michigan State University, East Lansing, MI 48824; and and Jerry Cook, PhD, Sam Houston State University, Department of
Kimberly C. Jennings, BS, and David R. Foran, PhD, School of Biological Sciences, 300 Lee Drain, Box 2116, Huntsville, TX 77341
Criminal Justice, 560 Baker Hall, Michigan State University, East After attending this presentation, attendees will learn the develop-
Lansing, MI 48824 mental growth times of Phaenicia coeruleiviridis in this preliminary study
After attending this presentation, attendees will learn about the use of of this species.
gene expression information to assist in making entomology based PMI Insects collected at crime scenes are often used to estimate PMI
estimates. (Postmortem Interval). Developmental growth curves of individual species
This presentation will impact the forensic community and/or are used in these estimations. To date, there is very little information on the
humanity by improving the precision of entomology based PMI estimates. species Phaenicia coeruleiviridis. This presentation will impact the
Investigators often use the presence and age of blowfly larva on a forensic community and/or humanity by helping in creating a more
carcass to estimate the postmortem interval (PMI). Currently, morpho- accurate PMI estimate when Phaenicia coeruleiviridis is used.
logical traits, including larval instar and length and weight are used to Despite its obvious presence and abundance in the south and south-
approximate larval age. Likewise, pupae can be dissected and morpho- eastern parts of the United States, there is little information on the growth
logical features observed. However, the precision of these estimates is and development of the green bottle fly, Phaenicia coeruleiviridis
always in question, particularly for the longer third instar and pupal stages. (Macquart). Growth curves were determined for the egg, larva, and pupa
The goal of this project was to produce a more objective, genetic- stage of this species under constant temperatures of 21.1, 23.8, and 26.6°C.
based assay of juvenile fly age, and thus PMI, focusing on the widely dis- Development from egg to adult under all temperatures ranged from 608 to
tributed and forensically useful blowfly, Lucilia sericata. The foundation 844h. Length and mass measurements for each development stage at each
for this assay was the wealth of developmental data already available from temperature regime were reported, giving investigators an option for
the model fly system Drosophila melanogaster, as well as from a sericata analysis of age and postmortem interval estimations using P.
sister species, L. cuprina, a sheep parasite that has been studied in Australia coeruleiviridis. Although the genus Phaenicia (=Lucilia) is small and the
and New Zealand. In both systems, a variety of developmentally important species appear similar, developmental data varies greatly within this genus,
genes have been shown to undergo changes in expression levels throughout indicating a need for further study.
the immature stages (egg, larva, and pupa). Using known sequence from Developmental Growth Curve, Forensic Entomology, Phaenicia
D. melanogaster and L. cuprina, a suite of genes (white, scalloped wings, coeruleiviridis

G55 Effects of Fluctuating Temperature and However, it is unknown what components (bacteria, fungi) of the soil
microbial biomass are associated with this increase in microbial abundance.
Larval Density on Calliphora dubia It is well understood that the amendment of soil with an organic resource
(Diptera: Calliphoridae) Implications (such as a cadaver) can result in a shift in the composition of the soil
for Postmortem Interval Estimation microbial community. Furthermore, the composition of microbial commu-
nities can also change as a resource decomposes and these successional
Ian Dadour, PhD*, and Sasha Voss, BSc, University of Western Australia, changes may provide a basis to estimate postmortem interval.
Centre for Forensic Science, 35 Stirling Highway, Nedlands, 6009, The current experiment aims to demonstrate the concentration and
Australia succession of Gram-positive bacteria, Gram-negative bacteria, and fungi
associated with cadaver breakdown. In order to investigate this, a field
After attending this presentation, attendees will be briefed on this part experiment was conducted at two disparate field sites during the dry season
of a series of research papers, which revisits fly life histories and examines (March 2003). Site 1 comprised a loamy sand soil (84% sand, 11.1% silt,
them in the environment lived in, rather than the constancy of the labo- 4.9% clay) and was located in Yabulu, Queensland, Australia. Site 1
ratory. Entomologists involved in case-work need to understand develop- receives an average rainfall of 140 mm during the dry season (March-
mental rates of insects. October) and average maximum/minimum temperature equals 22.9 C/16.7
This presentation will impact the forensic community and/or C. Site 2 comprised a sand soil (97.7% sand, 1.3% silt, 1% clay) and was
humanity by reminding forensic entomologists to be careful in their located in Pallarenda, Queensland, Australia. On average, site 2 receives
assessment of fly life histories and their application in case work. 120 mm of rainfall during the dry season and the average
The accuracy of any entomological estimation of postmortem interval maximum/minimum temperature is 26.9 C/16.4 °C. The resulting vege-
(PMI) depends on the thermal history of the larval samples investigated and tation at the two sites was dominated by grasses with scattered trees. These
the availability of comparative developmental reference data. At present, characteristics are typical of a tropical savanna ecosystem.
there is a paucity of data relating to larval development under geographic- Juvenile rat (Rattus rattus: ~18 g) cadavers were buried (2.5 cm) in the
specific climatic conditions and the influence of micro-environmental center of a 2 m2 plot. Cadaver mass loss and phospholipid fatty acid
temperature produced by larval aggregations on development. (PLFA) concentration of soil directly surrounding each cadaver were mea-
Most entomological PMI estimates are based on reference data com- sured at 7, 14, and 28 days following burial. To measure PLFA concen-
piled from larvae reared at constant temperatures. These estimations have tration soil was amended with a chloroform:methanol:phosphate buffer,
the potential to be erroneous where ambient temperatures at the crime scene shaken and centrifuged. Supernatant was removed, placed in a clean glass
fluctuate over time, or where larval aggregations are present on the cadaver culture tube, and dried under nitrogen (N2). Dried lipids were resuspended
during development. High larval density can alter the temperature of the in chloroform and phospholipids were eluted with methanol through a
microenvironment experienced by the larvae above that of the ambient silicic acid column and dried under N2. Dried phospholipids were
temperature used in the PMI estimation.
amended with acidified methanol, incubated for 12 hours at 60 °C, and
In this study, the rate of larval development of the forensically signif-
amended with purified water and petroleum ether. The ether layer was
icant blowfly, C. dubia, was investigated under both constant and fluctu-
transferred to a clean culture tube and dried under N2. Standard (19:0) and
ating temperature regimes. Temperatures investigated approximated the
summer (24ºC; 19/30ºC) and autumn (19ºC; 13/25ºC) seasonal tempera- hexane were added to the dried ether layer and PLFAs were separated by
tures of southern Western Australia. The influence of larval aggregation on capillary gas chromatography using an automated procedure developed by
the development rate of C. dubia was also investigated using larval den- MIDI (MIDI, Inc. Newark, DE). PLFAs were used as markers of Gram-
sities of between 50 and 5000 larvae. This presentation will discuss the positive bacteria (15:0, i15:0, i16:0, 17:0, i17:0, a17:0), Gram-negative
influence of larval aggregation size and fluctuating temperatures on the bacteria (cy17:0, cy19:0, 16:17c, 16:17t) and fungi (18:26c). This
development rate of C. dubia and the implications of this for PMI experiment was replicated four times and controls (soil without cadaver)
estimation were used.
After one week’s burial cadaver decomposition at Site 2 (1/3 mass
Development, Flies, PMI loss) was greater than at Site 1 (1/4 mass loss). All cadavers lost approxi-
mately ¾ of mass after two weeks at which time the larger soil microbial
community was found at Site 1. At this site, the microbial community was
G56 The Composition and Succession of dominated by bacteria throughout, and Gram-positive and Gram-negative
Soil Microbial Communities Following bacteria comprised equal fractions of the population. Fungal PLFA’s were
detected after two and four weeks only. The microbial community at Site
Cadaver (Rattus rattus L.) Burial 2 was also dominated by bacteria for the first two weeks after burial, and
Gram-positive and Gram-negative bacteria also comprised equal fractions
David O. Carter, PhD*, Department of Plant Pathology, University of of the bacterial population. In contrast to site 1 however, the microbial
Nebraska-Lincoln, 406 Plant Sciences Hall, Lincoln, NE 68583-0722; community was dominated by fungi on day 28.
David Yellowlees, PhD, School of Pharmacy and Molecular Sciences, These findings are not surprising considering the introduction of a
James Cook University, Douglas, QLD 4811, Australia; and Mark high-quality; complex resource (such as a juvenile rat cadaver) tends to
Tibbett, PhD, School of Earth and Geographical Sciences, University of result in the proliferation of bacteria. As these resources are depleted bac-
Western Australia, Crawley, WA 6009, Australia teria are commonly replaced by fungi, which are more tolerant to moisture
After attending this presentation, attendees will understand funda- stress and can be indicators of low soil nutrient status. The difference in
mental principles concerning the composition and population dynamics of succession between soils may be because cadavers buried at Site 2 reached
soil microbial communities associated with cadaver decomposition in soil. skeletonization prior to cadavers buried at Site 2. These successional
This presentation will impact the forensic community and/or sequences may be used as a basis to estimate postmortem interval of
humanity by demonstrating the potential for microbial succession as a basis cadavers that have progressed into the skeletonization stage of decompo-
for estimating postmortem interval. sition. The dynamics of specific PLFAs will be presented in relation to
Recent research has shown that the soil microbial biomass can cadaver decomposition stage.
respond positively to the burial of a juvenile rat (Rattus rattus) cadaver. Taphonomy, Succession, Phospholipid Fatty Acid Analysis

G57 Nematode Community Dynamics activity reached early decomposition by day 3, Advanced Decomposition
by day 21 and had not reached Skeletonization by day 49. Insect activity
Associated With Cadaver (Sus scrofa L.) also had an effect on belowground nematode abundance that was charac-
Decomposition and Insect Activity terized in a delay in peak nematode abundance. In the presence of insects
on the Soil Surface nematode abundance reached peak levels on day 14. Nematode abundance
in the absence of insects reached peak levels on day 21 to day 28 and a
David O. Carter, PhD*, Department of Plant Pathology, University of second peak was observed on day 49. The nematode community in asso-
Nebraska-Lincoln, 406 Plant Sciences Hall, Lincoln, NE 68583-0722; ciation with insect activity could be dominated by phoretic nematodes
Timothy E. Huntington, MSc, and Leon G. Higley, PhD, Department of while the nematode community in exclusion cages could be dominated by
Entomology, University of Nebraska-Lincoln, 202 Plant Industry, Lincoln, native soil-dwelling species. Nematode species identification is currently
NE 68583-0816; and Thomas O. Powers, PhD, Department of Plant underway and results will be presented.
Pathology, University of Nebraska-Lincoln, 406 Plant Sciences Hall, Taphonomy, Nematode, Succession
After attending this presentation, attendees will understand the rela-
tionships between the composition of belowground nematode communities G58 Characterization of Adipocere
and cadaver decomposition as well as how these relationships are influ- Formation in Animal Species
enced by insect activity.
This presentation will impact the forensic community and/or Shari L. Forbes, PhD*, University of Ontario Institute of Technology,
humanity by demonstrating the potential for nematode succession as a basis Faculty of Science, 2000 Simcoe Street, N, Oshawa, Ontario L1H 7K4,
for estimating postmortem interval. Canada; and Barbara H. Stuart, PhD, and Boyd B. Dent, PhD,
Soil-dwelling nematodes are microscopic invertebrates that play a key University of Technology, Sydney, Department of Environmental Sciences,
functional role in soil processes of decomposition and nutrient cycling. PO Box 123, Broadway, NSW 2007, Australia
Nematodes are generally the most abundant and diverse metazoans living
in the soil and respond rapidly to disturbance, such as the decomposition of After attending this presentation, attendees will understand the
a body. The investigation of nematode community structure can reflect chemical process by which adipocere forms, the requirements for its for-
decomposition status because nematodes exhibit a sensitive relationship to mation, the types of animal species it has been observed on, and an example
their environment by responding to the spatial and temporal dynamics of of a case study in which its identification was required.
resources. Thus, a localised succession of nematode trophic groups (bac- This presentation will impact the forensic community and/or
terial-feeder, fungal-feeder, herbivore, omnivore, and predator) occurs as a humanity by discussing the value of adipocere as evidence and the limits
resource decomposes. Nematodes are readily sorted into trophic groups associated with confirming its human origin in cases of homicide or human
because feeding behavior can be deduced from the structure of the mouth rights issues.
cavity and pharynx. This makes nematodes an efficient indicator of decom- The aim of this presentation is to demonstrate the importance of iden-
position status. In addition, nematodes may be transported to a decompo- tifying the species origin of adipocere samples collected as evidence. After
sition site by insects. This may have implications for forensic science attending this presentation, attendees will understand the chemical process
because nematodes can establish phoretic relationships with many insects by which adipocere forms, the requirements for its formation, the types of
associated with cadaver decomposition (Calliphoridae, Coleoptera, and animal species it has been observed on, and an example of a case study in
Silphidae). which its identification was required.
This study was based on the understanding that (1) insects respond Adipocere is a soft white substance formed postmortem from fatty
rapidly to the placement of a cadaver on the soil surface and (2) a prolifer- tissue in a decomposing body. Its formation is characterized by the
ation of soil microorganisms is associated with cadaver decomposition in hydrolysis and hydrogenation of the neutral fats into a mixture of predom-
soil. This work aimed to test the hypothesis that nematode community inantly saturated fatty acids. Under suitable conditions adipocere may form
composition is related to the stage of cadaver decomposition and insect on both human and animal remains. The majority of research investigating
activity. adipocere formation has focused on either human remains or porcine
Six 10-week-old pig (Sus scrofa L.) cadavers (~45 kg) were killed by remains, as a model for human decomposition. However, no studies of the
nature of adipocere formation in other animal species have been reported.
trauma (gunshot) to the head and placed inside a 2 m2 plot on the soil
This study was conducted as a result of two enquiries from independent
surface within 30 minutes of death. Three cadavers were exposed to
forensic laboratories to assist with the identification of adipocere collected
insects, three were excluded from insects using Lumite (18 x 14 mesh)
as evidence in homicide cases. In both instances, the species origin of the
exclusion cages (6 ft3), and controls (plots without cadavers) were used.
adipocere fragments was in question.
Thus, four treatments were used: + cadaver + insects, + cadaver – insects,
Adipocere was formed in a controlled soil environment by burial of
- cadaver + insects, - cadaver – insects. Cadaver decomposition was mea-
fatty tissue samples of several different animal species. Infrared spec-
sured using a decomposition scoring system at intervals of 24 hours for the
troscopy was used to provide a lipid profile of the fatty tissue and adipocere
initial seven days and at intervals of seven days thereafter. Cadaver decom-
samples. Gas chromatography-mass spectrometry was employed as a
position was designated as being in one of four stages: Fresh, Early
method for the identification of fatty acids in the original tissue and
Decomposition, Advanced Decomposition, and Skeletonization. Soil
adipocere. Of the six species investigated, adipocere did not form on two
samples (0 cm -10 cm depth) were collected from soil adjacent to the
of the species due to their reduced fat content. The adipocere that formed
cadavers at intervals of seven days using a soil probe (2.5 cm diameter).
from the other species’ tissue could not be visually discriminated between
Following transportation to the laboratory nematodes were extracted from
species.
soils enumerated and identified morphologically. DNA sequencing was
The chemical characterization demonstrated identifiable differences
used for identification when nematodes could not be identified
in the fatty acid content of the original adipose tissue. Characterization of
morphologically.
the adipocere samples also demonstrated differences in fatty acid content
The exclusion of insects had a significant negative effect on cadaver
however this was determined to be a result of the different rates of for-
decomposition. Cadavers exposed to insect activity reached Early
mation of each species. The results suggested that the fundamental com-
Decomposition by day 2, Advanced Decomposition by day 4 and
position of adipocere is similar regardless of the species on which it
Skeletonization by day 21. In contrast, cadavers excluded from insect
formed. There was no evidence to suggest that the chemical composition

of adipocere is species-dependent. This conclusion highlights the difficulty insect development takes place during pre-autopsy refrigeration, potential
associated with determining the species origin of adipocere, whilst also error rates in PMI estimation of 8.6 – 12.8% occur. The potential for blow
demonstrating the caution, which must be taken when attempting to link fly larvae to undergo significant development, including stadia transitions,
adipocere fragments to human remains. while being stored in the morgue is a real possibility. Forensic entomolo-
Further studies are presently on-going to determine the feasibility of gists must consider this continuing development during the course of an
extracting DNA from adipocere. Extraction of DNA may provide the nec- investigation involving samples collected at autopsy.
essary information for determining species origin, as well as providing Forensic Entomology, Postmortem Interval, Autopsy
further evidentiary value in human identification. This presentation will
impact the forensic community and/or humanity by discussing the value of
adipocere as evidence and the limits associated with confirming its human G60 An Unusual Postmortem Change
origin in cases of homicide or human rights issues. in a Child Homicide—Leaching
Adipocere, Species Origin, Characterization
Paul P.S. Chui, MBBS, DMJ, MBA*, Health Sciences Authority,
G59 Maggot Development During Morgue 11 Outram Road, Singapore, 289160, Singapore
Storage and the Effects on Estimating After attending this presentation, attendees will learn about an unusual
the Postmortem Interval form of decomposition change through leaching (loss of fluid from the
body).
Timothy E. Huntington, MS*, Leon G. Higley, PhD, and Frederick P.
humanity by creating awareness of such a finding and discussion of mech-
Baxendale, PhD, University of Nebraska, Department of Entomology,
anism by which such a change occurred.
202 Plant Industry Building, Lincoln, NE 68583
A child came to Singapore with her mother to study in a primary
The goal of this presentation is to present to the forensic sciences com- school. Her mother went back to China and left her on her own. The child
munity research which demonstrates the potential for insect development went missing and sparked off a nationwide search. In the local hot and
during pre-autopsy morgue storage which may in turn affect estimates of humid climate, bodies outdoors decompose quickly and early putrefaction
postmortem intervals by forensic entomologists. begins within two to three days leading to early skeletonization in a week
This presentation will impact the forensic community and/or when the body is left in the open. Police investigations led to the arrest of
humanity by demonstrating the need to consider insect development during a friend of the mother’s whom the child was familiar with. After 3 weeks,
morgue storage. the child’s body was finally recovered, packed in nine plastic bags within a
Forensic (or medicocriminal) entomology, the use of arthropods in cardboard box in the undergrowth of a local hill-park. The case attracted
legal investigations, is most frequently employed to estimate the post- much media sensation as well as outpouring of public sentiment.
mortem interval (PMI) of victims of violent crimes or suspicious deaths. At autopsy, the body was found to be much better preserved than
The most commonly used method of PMI estimation employs temperature- expected. Bruises were well-defined and internal organs were well pre-
dependent developmental rates of blow fly larvae (Diptera: Calliphoridae). served. The condition of the body permitted better recovery of evidence of
Retrospective scene temperatures, those temperatures, which the insects injury for determination of injuries resulting from allegations of sexual
experienced during development, are used in combination with known assault. It was also noted that after the autopsy was completed, signs of
developmental rates of the species involved to estimate the age of the mummification became evident very quickly.
larvae, which often correspond closely with the time of death of the victim. The presentation will discuss the cause of death, an unusual form of
When insect evidence is obtained during autopsy, forensic entomologists decomposition change, which has not been previously described in the lit-
often need to make decisions regarding the effects of low temperature (-1°C erature, and the mechanism for such a postmortem change.
to 4°C) storage of the body and associated insects when estimating the Decomposition, Child-Homicide, Leaching
PMI. Some have argued that development ceases during refrigeration,
while others suggest that maggot mass temperatures go unchanged.
During the course of a 2003 homicide investigation, temperatures G61 Comparison Study of Various Protocols
experienced by the insects associated with the victim were recorded from to Release Maximal Amounts of
the time the body was removed from the scene until autopsy using an Onset
Hobo H8 data logger. During the intervening time the body was kept in a
Amplifiable DNA From Decomposed
standard morgue cooler and the temperatures which were recorded showed Soft Tissue Exposed to Different
that the insects were able to maintain high enough temperatures to be able Environmental Conditions
to continue development despite the cold storage temperature.
Consequently, subsequent experiments with decomposing pigs were con- Daniel E. Katz, MFS*, Delaware Office of the Chief Medical Examiner,
ducted to confirm observations on maggot development in morgue coolers 200 South Adams Street, Wilmington, DE 19801; Timothy McMahon, PhD,
and to establish the magnitude of temperature differences. Armed Forces DNA Identification Laboratory, 1413 Research Boulevard,
Seven porcine cadavers were used: “small pigs” (approx. 11 kg) and Building #101, 2nd Floor, Rockville, MD 20850; Arthur Young, BS,
“big pigs” (38 kg avg.). Pigs were placed in the field for up to 14 days to National Medical Services, 3701 Welsh Road, Willow Grove, PA 19090;
allow for insect colonization and maggot mass formation, which were Rebecca A. Kennedy, Cedar Crest College, 100 College Drive, Allentown,
defined as aggregations of feeding third stage blow fly larvae. Upon PA 18104; Michelle Malley, MSFS, Armed Forces DNA Identification
removal from the study site, each pig was wrapped in a clean sheet and Laboratory, 1413 Research Boulevard, Building #101, 2nd Floor, Rockville,
placed in a medium-duty body bag, as is standard procedure for human MD 20850; and Rebecca E. Wallman, BS, MS, Delaware Office of the
remains. Thermocouples were attached to each replicate and temperatures Chief Medical Examiner, 200 South Adams Street, Wilmington, DE 19801
inside and outside of body bags were measured during storage in a morgue
cooler. Temperatures remained significantly higher (P<.05) inside of the After attending this presentation, attendees will understand what
body bags relative to the cooler, and remained at levels sufficient for protocols are most suitable for certain decomposed tissue remains based on
maggot activity (feeding and development). Maggot development was type of soft tissue and the environmental conditions from which it came.
slowed, but not enough to discount insect development between removal of This presentation will impact the forensic community and/or
the body from the scene and autopsy. If the assumption is made that no humanity by providing guidance to the pathologist and DNA analyst in

obtaining the maximum quantity and quality of DNA from decomposed idence of the deceased, by neighbors who reported a fowl smell.
soft tissue samples. Investigation of the scene found the deceased lying in her bed clothed.
The protocols investigated were compared using five different tissue Police found no evidence of forced entry into the residence, or other evi-
types (brain, heart, kidney, liver, lung) exposed to three different environ- dence indicative of foul play. Relatives of the deceased reported that she
mental conditions (fire, submersion in water, and bog/swamp). was last seen alive approximately one month prior, during the summer
This presentation will benefit the forensic community by providing months. Examination of the body at the Office of the Chief Medical
guidance to the pathologist and DNA analyst in obtaining the maximum Examiner in Baltimore, Maryland, found it to be in an advanced state of
quantity and quality of DNA from decomposed soft tissue samples. decomposition with partial exposure of the skull and upper thoracic cavity.
At autopsy, questions are often raised regarding what type of tissue to Inspection of the chest and abdominal cavity revealed the absence of the
send off for DNA analysis when the body is in a state of decomposition. internal organs as a result of decomposition. No injuries or notable defects
While the standard answer has routinely been deep muscle tissue, anecdotal were observed on the remains with the exception of an extraordinarily long,
evidence from the Delaware OCME DNA Unit and Armed Forces DNA and irregularly shaped left styloid process of the skull.
Identification Laboratory (AFDIL) have suggested that this is not always The extremely large and lengthy styloid process was recognized as
the case and that in fact, organ tissue is often preferable. Historically, the “Eagle syndrome” which is described as the elongation of the styloid
research regarding decomposed tissue samples and associated DNA yields process and stylohyoid ligament calcification. Eagle syndrome has been
has been somewhat limited because the typical DNA laboratory does not named under several other synonyms including stylohyoid syndrome,
have access to such samples. The fact that Delaware’s forensic DNA lab- hyoid syndrome, styloid elongation syndrome, styloid process syndrome,
oratory is located at the Office of the Chief Medical Examiner and, and carotid artery syndrome. The syndrome is well documented in the
therefore, has access to such samples, allowed for this much needed study dental and otolaryngology literature however it has not been widely
to be performed. Decomposition is a cumulative consequence that natu- reported in radiological and general pathological literature. Multiple
rally occurs over time once a body is no longer living. Decomposition orig- symptoms are associated with Eagle syndrome, which includes cough,
inates from the activity of microorganisms/bacteria and internal dizziness, recurrent throat pain, voice alteration, dysphasia and /or facial
biodegradative enzymes, including DNases that cause autolysis of the pain, and sensation of a foreign body present in the throat. It has also been
body. The concentration levels of bacteria and enzymes vary amongst reported that that approximately 4% of the general population is thought to
organs during decomposition based on the organ’s function and location have elongation of the styloid process, and that only a small percentage of
within the body. This variation results in some organs degrading DNA at a those individuals 4% to 10%, are thought to be symptomatic.
faster rate than other organs. Additionally, decomposition can be altered by Anthropological studies have documented the prevalence of elongated
external stimuli associated with different environmental conditions because styloid process, in particular the high frequency of occurrence among
different conditions have different effects on factors such as temperature, various Mongoloid populations. The average length of the styloid process
moisture, pH, and partial pressure of O2. in adult is approximately 2.5 cm, and in most individuals there is little
Four extraction protocols were investigated in a collaborative effort variation in length between left and right process. Eagle syndrome has
between Delaware OCME, AFDIL, and National Medical Services (NMS) been documented as occurring unilaterally or bilaterally. Recognition of
to develop the most successful extraction procedure from various organ Eagle syndrome is rare among the forensic case population unless it is
tissues exposed to different environmental conditions. The four different noted during detailed radiographic examination of lateral views of the head
extraction protocols were an organic extraction using a non-ionic detergent and neck, or during gross examination of skeletonized remains. Most cases
based digestion buffer, an organic extraction using an ionic detergent based are picked up by dentists or oral surgeons during routine panoramic
digestion buffer, a non-organic extraction using standard columns, and a radiographs, or by physical examination involving palpation of the
non-organic extraction with paramagnetic beads. In addition, variations in elongated styloid process in the tonsillar fossa, of those individuals who are
reagent amount as well as variations in reagent amount plus sample amount symptomatic.
were studied. The tissue sample extracts were then quantitated, amplified, In the case of the elderly Negroid female, the recognition of Eagle
and analyzed. Data and conclusions will be presented and discussed at the syndrome was made during removal mummified and decomposed tissues
meeting. surrounding the skull. The left styloid process measured approximately 8
cm in length, and had an average circumference of approximately of
DNA, Decomposition, Tissue
approximately 2.5 cm. Not only did the left styloid process look extremely
large, but it had the appearance as if three medial phalanges had been fused
G62 Eagles Syndrome: Case of an Elongated together. Examination of the right side of the skull found the right styloid
process to be near non-existent, measuring less than 5 mm in length. Close
and Ossified Stylohyoid Ligament in an inspection of the left carotid foramen revealed evidence of significant nar-
Elderly Female rowing resulting from the enlargement of the base of the styloid process. A
review of the deceased medical records obtained by investigators later in
William C. Rodriguez III, PhD*, Office of the Armed Forces Medical time, provided documentation of Eagle syndrome which had been noted
Examiner, 1413 Research Boulevard, Building 102, Rockville, MD 20850; during a dental panoramic exam in 2003 to access periodontal disease.
and Jack M. Titus, MD, and David R. Fowler, MD, Office of the Chief According to the medical records, the elderly woman was asymptomatic at
Medical Examiner, 111 Penn Street, Baltimore, MD 21201 the time of the exam. Documentation of Eagle syndrome provided a means
of positive identification of the deceased. In regards to cause and manner
After attending this presentation, attendees will be able to recognize of death, the absence of trauma, and documented history of heart disease,
cases involving Eagles Syndrome and have a basic understanding of the and negative toxicology, the case was signed out as hypertensive athero-
mechanisms, which may result in this bony anomaly, and associated sclerotic disease -natural.
symptoms. The cause of the elongation of the styloid process is not well under-
This presentation will impact the forensic community and/or stood. Multiple theories have been forwarded including congenital elon-
humanity by providing death investigators with information to ascertain the gation, growth of osseous tissue at the insertion of the stylohyoid ligament,
presence of the skeletal anomaly Eagle Syndrome and how it may or may and calcification of the stylohyoid ligament by an unknown process.
not be involved in the death of the deceased. Pathophysiological mechanisms of symptoms is also contested which
The case presented is that of a 72-year-old Negroid Female whose include irritation of pharyngeal mucosa by post-tonsillectomy scarring or
badly decomposed and, partially skeletonized remains were recovered from by direct compression, traumatic fracture of the styloid process resulting in
her residence in Baltimore, Maryland. Local police were called to the res-

proliferation of granulation tissue, inflammatory or degenerative changes in showed that the neck was completely cut 3 centimeters above the jugular
the tendon, and impingement of the carotid vessels thus irritating the fossa; the wound margins were clear-cut, which led the examiner to assume
sympathetic nerves of the arterial sheath. that the head had been cut off with a sharp tool. The vertebral column was
Eagle syndrome can be treated by surgical and no surgical disconnected on the level of the seventh cervical-first dorsal vertebra.
intervention. No surgical treatment includes steroid injections and other Numerous superficial linear wounds, of different length, and many excori-
anti-inflammatory medications. Surgical treatment involves removal of the ation zones with soft tissue bleeding underneath were present on the cutis
elongated portion of the styloid process. adjacent to the neck lesion. No relevant injuries were detected in the
Anthropology, Eagles Syndrome, Skeletal Pathology remaining body parts. The lack of the severed head didn’t allow analysis
to injuries in this site. Massive blood aspiration, soft tissue hemorrhage
surrounding the neck lesion and the pallor of inner organs as signs of
bleeding out, were present. Histological investigation applying hema-
G63 Where is the Head? A Case toxilin and eosin staining revealed massive hemorrhages in the cutaneous
of Homicidal Decapitation and subcutaneous tissues. Immunohistochemical studies were performed
on the cutis specimens collected from the neck lesion for the determination
Sabina Di Donato, MD*, Carmela Fiore, MD, and Emanuela of the vitality of the neck wound. The expression of Fibronectin, α1-
Turillazzi, MD, PhD, Department of Forensic Pathology, University antichimotripsin, antitriptase, CD 31, and collagen type IV was analyzed.
of Foggia, Viale Luigi Pinto, n.1, Foggia, 71100, Italy The positive results lead us to conclude that the neck lesion was vital, iden-
The goal of this presentation is to present the case of a complete homi- tifying homicidal decapitation as cause of death. Two months later a coun-
cidal decapitation. Investigation of the scene where the body was dis- tryman discovered the skeletal remains of a human head on the back of his
covered, autopsy findings, and DNA analysis are described. In particular, homestead, about 200 m from the place where the body was discovered.
the primary importance of histological and immunohistochemical study to The skull showed no fractures. DNA analysis established that those skeletal
evaluate the vitality of wounds is underlined. remains belonged to the same woman.
Only a few cases of homicidal decapitation are reported in the forensic Homicidal Decapitation, Vitality, Immunohistochemical Study
literature. Sometimes the forensic pathologist faces the particular case,
which may be difficult to distinguish between a vital or a postmortem
beheading, especially when the circumstantial data is insufficient. This pre- G64 Simple Tissue Preservation Methods
sentation will impact the forensic community and/or humanity by showing
how histological and immunohistochemical investigations play a decisive
That Result in Reliable DNA Analyses
role in forensic medicine.
Cases of complete decapitation have been sporadically reported in the Corinne L. Michaud, BS*, and David R. Foran, PhD, Forensic Science
forensic literature. In spite of high suicide rates all over the world, this par- Program, School of Criminal Justice, 560 Baker Hall, Michigan State
ticular mode of death is a relatively rare finding in violent suicidal deaths. University, East Lansing, MI 48824
Suicides by self decapitation have been reported, like those where indi- The goal of this presentation is to inform attendees of several simple
viduals deliberately put their neck onto the track while a train is tissue preservation methods that are conducive to obtaining a quality DNA
approaching or those where subjects use a ligature tied between the neck sample. The procedures outlined can be applied to many situations, since
and a stationary object while attempting to drive a vehicle away, or even the methods examined were developed for use in situations where time,
cases where individuals use a guillotine. Also unintentional decapitations materials, and facilities are limited.
are possible in suicidal cases, as after hangings. Accidental decapitation This presentation will impact the forensic community and/or
may also occur, for example, in cases of train pedestrian fatalities, indus- humanity by demonstrating providing valuable information on how to suc-
trial accidents, and unusual injuries during road accidents regarding either cessfully preserve tissue samples for subsequent DNA analysis. The
cars or motorcycles. Even more rare is the homicidal decapitation. This methods examined for this study required minimal materials, storage space,
manner of death has been used for centuries for execution all over the and temperature considerations. For these reasons, the results of this
world, and today is still used in some countries to carry out a death penalty. research can be useful to many factions of the forensic community, from
In recent years beheadings have also been registered in those homicides mass disaster response teams, to conservation officers, to crime scene tech-
perpetrated by satanic sects, serial killers, or even in hostage killings. The nicians. By having a simple tissue preservation method available in the
forensic pathologist may meet some difficulties in evaluating cases of field, samples can be preserved immediately, which increases the potential
decapitation. A relevant problem, which the forensic pathologist has to for a successful DNA analysis in the laboratory.
face, may be the differentiation between a real decapitation and post- This presentation provides an evaluation of on-site tissue preservation
mortem mutilation of the body. methods, examining the success of each in yielding high quality DNA. The
Here is presented the case of a 32-year-old Italian woman murdered research examined factors such as availability and portability of materials,
by her Romanian partner and found dead under a bridge in a country of tissue storage life at room temperature, ease of use, ease of subsequent
South Italy. The man himself, who in the meantime had escaped abroad, DNA extraction, and the quantity and quality of DNA obtained from pre-
phoned the police indicating the place where he had left the lifeless body of served samples. Attendees will gain an understanding of the range of tissue
the woman, and he also confessed to having strangled her. When the police preservation methods available, as well as the efficacy of each method in
officers arrived at the suggested place, they found the lifeless body of a preserving DNA. The goal of this study was to develop a rapid, reliable
woman, tidily dressed, with the upper regions of the body completely method for storing tissue samples that can be easily employed in the field.
wrapped in her jacket. When they lifted it they discovered that the body In the event of a mass disaster, where a large number of victims must
was completely decapitated. Numerous locks and shards of the scalp were be located and identified, it becomes difficult to process the site in a timely
scattered all around the body, abundantly stained with dried blood. Some and orderly manner. Due to extensive injury or decomposition, many
locks held her earrings and necklace. On the ground beneath the body there victims may only be identified through DNA analysis; therefore, obtaining
was only a small amount of blood. Notwithstanding the careful exami- viable tissue samples is of great importance. Amidst the rush of locating
nation of the scene where the body was discovered and the adjacent coun- survivors, making anthropological identifications, and gathering other
tries, neither the severed head nor the injuring tool was found. Only a metal information about the victims of the disaster, tissue collection for subse-
bar, 66 cm in length and 2 cm in diameter, was recovered near the body, quent DNA testing is often delayed. Likewise, tissue preservation of
showing on its surface some blood spots. The postmortem examination remains discovered in very remote areas can also be hindered. The goal of

this study was to examine protocols for on-site tissue preservation that mitochondria that are still present in cells. There have been several studies
would undergo later DNA analysis. Through development of simple, on the efficiency of mtDNA extraction from hair. While the consensus
portable, and readily available methods for preserving tissues in the field, among these studies is that adequate amounts of mtDNA can be extracted
robust DNA results are more likely to be obtained. from hair and other types of degraded samples, the quality and quantity of
Testing was conducted on tissues taken from recently killed pig car- the genetic material recovered has not been directly addressed. Within
casses that had been placed in a field during the summer; samples were col- some of these same studies, researchers agreed that damage to hair caused
lected regularly over a one-month period. Six preservation methods were by fire or environmental conditions can significantly affect the amount of
evaluated: storage of tissue in ethanol, isopropanol, RNAlater (Ambion, DNA extracted. However, there has not been any published research that
Inc.), and silica desiccant, as well as hot air drying and freezer storage. examines how normal chemical conditioning of hair affect DNA recovery.
Muscle, skin, and brain samples were collected in triplicate from each With the advent of real time PCR, this DNA can be quantified at the
animal, and ca. 0.25 g placed in each storage medium. DNA extractions picogram level and by examining the effect of amplicon size, the level of
were performed after two weeks and after three months for each storage degradation can be evaluated.
method. DNA quality and quantity were assessed using quantitative PCR In this research project, DNA was extracted from telogen hairs from
of three species-specific single-copy nuclear genes. Results were analyzed volunteers who used chemical treatments and those who did not. Ten to
in order to determine which preservation methods were the most successful fifteen hairs, approximately 2-3 cm long, were extracted from each vol-
in yielding a viable DNA sample after a period of storage. unteer using the published phenol chloroform separation method and
Although DNA quantity and quality were the most significant factors purification of the DNA. The recovered DNA was quantified with real time
in the evaluation, many other issues were addressed. Tissue type and level PCR. Amplification was done using published mtDNA primers and primers
of decomposition, portability of materials, toxicity of the preservative, shelf specifically designed for this research. The primers utilized amplified con-
life of preserved samples, and ease of subsequent DNA extraction were also served areas of the coding region of mtDNA, as these areas have the least
factored into the analysis. By considering all of these interdependent vari- amount of variability. Sequencing was done on selected samples with non-
ables, an optimized, reliable procedure for preserving tissue samples when coding, control region primers for the hypervariable 1 and 2 regions. The
adequate storage and DNA processing facilities are not readily available resulting electropherograms were compared to the known reference
can be developed and implemented. samples to determine if adequate amount of quality mtDNA was amplified
DNA Extraction, Mass Disaster, Tissue Preservation in order to yield a genetic profile.
The amount of mtDNA recovered varied from person to person, but
preliminary results revealed that the quantity and quality of mtDNA
G65 Quantification and Amplification of recovered from individuals without chemical hair treatments exceeds that
MtDNA From Chemically Treated Hair which comes from treated hair. However, those hairs subjected to treat-
ments can undergo successful mtDNA amplification and sequencing which
Rayna L. Hebard, BS*, and Bruce R. McCord, PhD, Florida can then be used to obtain a genetic profile.
International University, International Forensic Research Institute, 11200 Mitochondrial DNA, Real Time PCR, Telogen Hair
SW 8th Street, Miami, FL 33199; and DeEtta K. Mills, PhD, Florida
International University, Forensic DNA Profiling Facility, 11200 SW 8th
Street, Miami, FL 33199 G66 What is Forensic Informatics?
After attending this presentation, attendees will learn of some of the Gilbert E. Corrigan, MD, PhD*, East Baton Rouge Coroner’s Office,
techniques used to extract, quantify, and amplify mtDNA from telogen hair 4030 T.B. Herndon Road, Baton Rouge, LA 70808; and Sarah P.
shafts that have been chemically treated. The attendee will also be aware Corrigan, MS*, Reliagene Technologies, Inc., 5525 Mounes Street, Suite
of how these chemical treatments affect the quantity and quality of DNA 101, New Orleans, LA 70123
amplified.
This presentation will impact the forensic community and/or After attending this presentation, attendees will gain an understanding
humanity by providing knowledge of whether chemical processes cause of the precise meaning of forensic informatics, knowledge of its many
degradation to DNA in hair shafts and to what extent that damage may be. dimensions, its role in the progress of the forensic sciences, and the current
This knowledge can help the forensic community to establish ways in challenges of the discipline.
which to overcome this difficulty so as to enhance mtDNA extraction and This presentation will impact the forensic community and/or
amplification from hair so that genetic profiles can be more sufficiently humanity by demystifying the boundaries and contents of the concept of
attainable, as hair forensics is becoming increasing significant in forensics forensic informatics and allow forensic scientists an understanding of the
and law. dimensions of forensic informatics.
Evidentiary collection at crime scenes and mass disaster typically Forensic Informatics is the systematic application of information and
include hair strands that later undergo DNA typing that can identify victims computer science and technology to forensic practice, research, devel-
and assailants. This presentation will impact the forensic community and/or opment, and learning. It is a major discipline of the forensic sciences and
humanity by demonstrating the effect that various beautification processes encompasses many other scientific disciplines, which have reached
have on the quantity and quality of amplifiable mtDNA extracted from hair maturity at a first generation level. As a major or covering discipline it has
shafts. the responsibility for establishing performance standards and ideological
Millions of people, both men and women, subject their hair to dif- goals for the component parts. The forensic responsibility entitles the
ferent chemical treatments, such as bleaching, coloring, and perming. As application of sound computer engineering and scientific principles in an
such, it is reasonable to assume that hair recovered from a crime scene may open, introspective, and universal manner applicable to the judicial system.
have come from a person who utilizes one or more of these popular The goal of utility in the solution of crimes, the search for the criminal act,
processes. the discovery of the criminal, and the analysis and retention of evidence is
Nuclear DNA extraction is typically done on hair strands with obvious; the boundaries of informatics extends into the civil affairs of gov-
growing root tissue. However telogen hairs, hair strands that are naturally ernment additionally and extends into property, taxation, public health, and
shed, do not contain roots. The shafts of hair are not suitable for nuclear inheritance; the detailed review of the fine details and codes of computers
DNA due to the degradation that occurs because of the keratinization and computer software entitling long hours of study are not easily obtained,
process. However, mitochondria are present in abundance in hair shaft. but required. Forensic informatics has practical utility in the solution of
Therefore, mitochondrial DNA is typically extracted from the myriad of complex problems and the retention for review of the detailed data arising

from the solutions of the problems. Importantly, forensic informatics not in custody were included for analysis. Custodial agencies were opera-
only records the past in its archival function, and solves problems with its tionalized to include law enforcement, correctional, psychiatric and emer-
present capabilities, but necessarily provides a key to the future as gency medical. Study variables include, incident location, decedent demo-
vacancies in disciplinary content and theory are discovered and programs graphics, behavioral, medical and toxicological indicators, and the cause
developed to encompass the missing details. and manner of death.
Current challenges in forensic informatics are immense and include Results indicate that death in custody is a multi-faceted phenomenon,
the development of operational and proficiency standards for all forensic subsuming a variety of qualitative types. All manners of death were iden-
software and information systems including the error rate of the system, tified; however natural deaths and suicides comprised the vast majority of
operator deficiency recording, output errors, logic error detection in cases. Similarly, while all custodial agencies experienced death in custody,
software, security requirements for forensic systems, acceptable decay most cases occurred in correctional and psychiatric facilities, respectively.
rates, the mathematics of the database, specialized forensic informational Results also suggest that there have been substantive, qualitative changes in
databases, data mining of criminal patterns, three dimensional forensic death in custody. For example, during the 1940s and 1950s a significant
images, the schooling of new scientists in forensic informatics with the portion of deaths occurred during police transport. This finding reflects the
development of educational standards and professional employment oppor- unique role of law enforcement during those decades: prior to the estab-
tunities, and dimensions in informatics. Guidance to the judiciary in lishment of a formalized emergency medical system, police transported the
forensic informatics seems of major operational import. sick and injured to local hospitals. “Sudden unexpected death in custody,”
Involvement of the forensic sciences in these initial stages of the especially those occurring after a violent struggle with police, emerged
“computer revolution” is a major activity of the current membership of the during the 1980s and 1990s, concomitant with widespread, recreational
American Academy of Forensic Sciences. stimulant drug abuse.
Formal models of forensic informatics and its dimensions are pre- Generally defined, death in custody is an “umbrella” concept that
sented in relation to the other recognized disciplines of information and subsumes a variety of unrelated manners of death and that occurs in
computer science, including medical informatics, pathology informatics, disparate custodial agencies. To understand deaths that occur in custody,
chemical informatics, public health informatics, digital evidence, and further conceptual specification is required. Such specification would
bioinformatics. allow for better methodological precision and improve theoretical/
Forensic Informatics, Forensic Computer Science, Forensic Science conceptual uniformity.
Models Death in Custody, Sudden Death, Law Enforcement
G68 Simultaneous Diabetic Ketoacidosis

G67 Death in Custody: A Historical Analysis and Neuroleptic Malignant Syndrome
Jami R. Grant, PhD*, University of Baltimore, Forensic Studies, 1420
in a Patient on Olanzapine
North Charles Street, Baltimore, MD 21201; Pamela E. Southall, MD*,
and David R. Fowler, MD, Maryland State Office of the Chief Medical Erik D. Christensen*, Office of the Greenville County Medical Examiner,
Examiner, 111 Penn Street, Baltimore, MD 21201; and Shauna R. Scott, 890 West Faris Road, Suite 110, Greenville, SC 29605
University of Baltimore, Forensic Studies, 1420 N Charles Street, After attending this presentation, attendees will understand how neu-
Baltimore, MD 21201 roleptic malignant syndrome and diabetic ketoacidosis are well-described
After attending this presentation, attendees will understand the his- phenomena in conjunction with the use of antipsychotic medications. They
torical evolution of death in custody, be familiar with the various types of can independently cause sudden death and this case report documents their
and the agencies that experience death in custody, and recognize the need first simultaneous occurrence in a patient taking olanzapine.
for conceptual specification of death in custody. This presentation will impact the forensic community and/or
This presentation will impact the forensic community and/or humanity by documenting and reporting the first simultaneous occurrence
humanity by delineating the historical evolution (both qualitative and quan- of DKA and NMS in the same patient taking olanzapine.
titative) of death in custody. Few analyses have examined death in custody Learning Objectives: To present to the forensic and psychiatric
from a historical perspective. An understanding of the history of death in communities the historical, clinical and laboratory findings in a patient who
custody may provide insight that would enhance the development of inter- was diagnosed postmortem as having concomitant diabetic ketoacidosis
vention protocols. (DKA) and neuroleptic malignant syndrome (NMS) as the cause of his
A substantial amount of controversy generally surrounds deaths that sudden death.
occur in custody, especially in this era of instant media coverage and com- Case Report: A 32-year-old black male taking olanzapine for a long
munication. Often, allegations of brutality are launched and community history of psychiatric illness (variably diagnosed as schizophrenia and
relations are notably compromised. Exacerbating the situation, medical schizotypal personality disorder) was found unresponsive. On arrival at the
examiners are often presented with minimal physical findings at autopsy. hospital he was afebrile with symptoms and lab findings consistent with
To understand the phenomenon and minimize its occurrence, the medical- DKA. During his stay in the emergency room he developed a progressive
legal community has conducted a considerable amount of research. decline in mental and clinical status and subsequently developed clinical
However, few analyses have examined death in custody from a historical and laboratory findings of NMS, which were diagnosed postmortem. His
perspective. The purpose of this research is to delineate the historical evo- condition continued to deteriorate and he expired despite aggressive resus-
lution (both qualitative and quantitative) of death in custody. An under- citative measures approximately 6 hours after being found unresponsive.
standing of the history of death in custody may provide insight that would Body temperature at the time of death was 108 degrees Fahrenheit.
enhance the development of intervention protocols. Methods: Medical records and autopsy protocol with laboratory
To identify the frequency and type of deaths in custody occurring over studies were reviewed for this patient and are presented. The medical lit-
time, a retrospective, exploratory analysis was conducted. Using data from erature was searched using the keywords olanzapine, diabetic ketoacidosis,
Maryland’s Office of the Chief Medical Examiner, a sample of and neuroleptic malignant syndrome for citations relating to NMS and
approximately 15,000 cases, dating from 1939 to 2004, was examined. DKA in the setting of neuroleptic use and relevant citations are reviewed
Employing a general definition of the phenomenon, all deaths that occurred and discussed.

Results: Poor glycemic control is a well-described phenomenon in the The investigators were uncertain whether the hanger was thrown from
setting of neuroleptic use and new-onset DKA has been reported in patients several feet across the room or if it was directly applied to the child’s skull.
taking many different neuroleptics, including olanzapine. Neuroleptic The tool was a large caliber, stainless steel hanger measuring approxi-
malignant syndrome, which was reported with much greater frequency on mately 4 by 4 millimeters in thickness, while the U-Shaped angle measured
older neuroleptics, has also been reported to occur with newer antipsy- approximately 3 centimeters. Experiments conducted by the police using a
chotic agents, including olanzapine. A single case of the simultaneous similar hanger and double-up pieces of cardboard demonstrated the U-
occurrence of NMS and DKA was previously reported in a hospitalized shaped portion of the hanger penetrated the cardboard six inches deep or
patient on Thorazine. This case report is the first reported case of the simul- more, when thrown from the same distance the father stated he was from
taneous occurrence of both conditions in a patient taking olanzapine. the child. The crime scene investigation pointed out that there were other
Conclusions: While both NMS and DKA are well-known occur- hangers on the floor, manufactured of plastic material, and the one used was
rences in patients on neuroleptics and equally well-known causes of death the only stainless steel, large caliber hanger present in the room.
in forensic practice, their simultaneous occurrence has not been previously The findings of the physical examination, the scene investigation with
reported in the era of newer antipsychotics. interviews of the parents, and the reconstruction of the incident support the
Diabetic Ketoacidosis, Neuroleptic Malignant Syndrome, Olanzapine conclusion that the injury to the child was inflicted.
In conclusion, diagnosing child abuse is a complicated issue. When
the injuries are uncommon and involve specific parts of the body, such as
the frontal plane, the examiner has to eliminate the potential of an accident.
G69 An Unusual Case of Child The combined efforts of a multidisciplinary team serve a primary role in the
Head Injury by Coat Hanger management of domestic violence and child abuse cases.
The present case represents a very unusual case of domestic
Biagio Solarino, MD*, Sezione di Medicina Legale - Di.M.I.M.P. violence, with child head injury using a stainless steel hanger.
Universita degli Studi di Bari - Policlinico, Bari, 70125, Italy; Amy M. Unfortunately, this is only another incredible report about how abusers
Burrows-Beckham, MD, Office of the Chief Medical Examiner, 810 carry out their harmful acts.
Barret Avenue, Louisville, KY 40204; and Kathy Recktenwald, RN, Coat Hanger, Child Abuse, Pediatric Head Injury
Clinical Forensic Medicine, University of Louisville, 810 Barret Avenue,
After attending this presentation, attendees will understand the value
of a multidisciplinary team, composed of clinical forensic medicine G70 Adolescent Suicide Trends in the Third
specialists, and law enforcement, in the management of injured children. Largest County in the United States
humanity by demonstrating the value of crime scene reconstruction
Andrea J. Harrison, BSN, RN*, Harris County Medical Examiners Office,
coupled with the evaluation of physical evidence in determining the factors
1885 Old Spanish Trail, Houston, TX 77054; Sharon M. Derrick, PhD,
in equivocal child abuse and neglect investigations.
Harris County Public Health and Environmental Services, 2223 West
The question of natural disease process versus accidental injury versus
Loop South, Houston, TX 77027; and Stacey A. Mitchell, MSN, RN, and
inflicted injury is the central issue involved in a clinical forensic investi-
Luis A. Sanchez, MD, Harris County Medical Examiners Office, 1885
gation. The physical findings in the infant or child must be correlated with
Old Spanish Trail, Houston, TX 77054
the history provided by the caretaker, as well as milestones achieved by the
infant or child. Injuries affecting specific frontal locations, such as the After attending this presentation, attendees will gain knowledge and
forehead, nose, chin, palms, and knees, are often the result of accidental awareness of the epidemiology of suicide and suicidal trends in Harrs
events secondary to children playing or falling. For these kinds of injuries, County, Texas, the third largest county in the United States.
the examiner must have an open mind that the injury could be the result of This presentation will impact the forensic community and/or
an unintentional event, instead of a horrible episode of domestic violence. humanity by providing the audience with an understanding of the scope of
The Clinical Forensic Medicine team in Louisville Kentucky is the adolescent suicide problem and relevant risk characteristics of adoles-
routinely consulted in a variety of cases of presumed child abuse and cents in a large urban setting.
neglect. The authors present a case of a 2-year-old female who was brought Introduction: Harris County accounts for 17% of the adolescent
to the Emergency Department with a large stainless steel hanger embedded population in Texas and has a growing adolescent suicide rate, ranking first
in her left frontal region, between the orbit and the bridge of the nose. She in the number of youth suicides reported to the Texas Department of State
was conscious, alert and moved all extremities. A lateral radiograph of the Health Services. Harris County, the home of the fourth largest city in the
head demonstrated a foreign body embedded in the frontal region of the nation (Houston), is also the third largest county with 3.6 million residents
skull for approximately 2cm. A CT scan of the head demonstrated a U and an area of 1,778 square miles. The Houston/Harris County Child
shaped body entering the frontal bone with probable fractures of the Fatality Review Team (HHCCFRT) recorded a rise in the suicide rate for
cribriform plate and crista galli, a small interhemispheric subdural hemor- children aged 10-17 from 2.1 per 100, 000-population size in 1999 to 3.3
rhage and a left frontal subdural pneumocephalus. There was no injury to in 2003. The Harris County Medical Examiners Office (HCMEO) has
the left globe or nasolacrimal duct. identified adolescent suicide as a public health problem, and has conducted
She was taken to the operating room where the curved part of the a collaborative retrospective study to identify those most at risk for suicidal
hanger was removed and the injured brain was derided. The ethmoid bone injury. The results of this study can be used to drive prevention and inter-
and shredded galea were repaired. After a five-day admission, she was vention programs in Harris County.
discharged to home with a CPS approved caretaker. After examination by Purpose: This collaborative study between the HCMEO, Harris
the Clinical Forensic Medicine team, coupled with home inspection and County Public Health and Environmental Services, the Houston-area
interviews by the local police, it was possible to reconstruct the child’s Suicide Prevention Coalition, and the HHCCFRT was implemented to
injury. identify and describe the number and relevant characteristics of adolescents
The parent’s, who are not married, were reported to be arguing. The who died by suicide from 2000 through 2005.
child’s mother stated that when she had her back turned to the father, he is Results: The Harris County Medical Examiners Office classified the
reported to have thrown a hanger, with the intention of hitting the mother. manner of death as suicide for 154 adolescents aged 10-19 years who were
Instead, the hanger hit his daughter, who was playing on the floor. autopsied in the HCMEO from January 2000-July 2005. The majority of

these adolescents (79%) were male. White teens comprised the majority of G72 Comparison of Early Decomposition
these cases at 52% but a notable 34% were of Hispanic ethnicity, followed
by 13% Black and only 1% Asian teens. Gunshot wounds were the cause
Between Domestic Pig Carcasses
of death in 55% of the cases. Hanging (34%) was the second leading cause Hanging and in Contact With the
of death. The remaining 10% of the cases were comprised of overdose Ground on Oahu Island, Hawaii
deaths, blunt force injuries, and carbon monoxide poisonings. The most
recent HHCCFRT data from 2002-2003 (N=34) cases demonstrates that Reupena Sheck*, and M. Lee Goff, PhD, Chaminade University of
older teens (15-17 years) most often used a gun as the mechanism of injury Honolulu, 3140 Waialae Avenue, Honolulu, HI 96816-1578
but the majority of younger (10-14 years) adolescents used hanging as a
mechanism. A suicide note was recovered in only 21% of the reviewed The goal of this presentation is to document the differences in early
cases. The most common precipitating factors to the injury were prior decompositional changes in carcasses that are in contact with the ground
attempts/suicidal ideation (37%), argument with a parent or and hanging.
girlfriend/boyfriend (19%), documented depression or mental illness The patterns of decomposition observed in hangings are quite dif-
(17%), substance abuse (10%). ferent from those observed for bodies in contact with the ground. This pre-
Implications: The results of this study are an important foundation sentation will impact the forensic community and/or humanity by demon-
for establishing prevention and intervention efforts in Houston and Harris strating how the accurate estimation of the postmortem interval is
County. The rising suicide rate among adolescents makes it imperative that dependent on an understanding of these differences in insect invasions,
the HCMEO and HCPHES mobilize to reduce risk in the adolescent popu- temperature generation, and biomass removal.
lation. The scope of the adolescent suicide problem and the characteristics This study was conducted on the campus of Chaminade University on
of at risk adolescents will be disseminated to area agencies and community the island of Oahu, Hawaii. Carcasses of two domestic pigs, Sus scrofa L.,
organizations for use in obtaining funding for effective, best practice were used. One carcass was placed in contact the ground on a wire mesh
suicide programming. platform and the other suspended from a tree, not in contact with the
ground. Carcasses were observed twice daily for a period of two weeks.
Adolescent Suicide, Epidemiology, Trends Weights were recorded daily using a hand-held scale to determine rate of
biomass removal. Internal temperatures were recorded using telether-
mometer probes of the mouth, abdomen, and anus. Ambient temperatures
were recorded at each visit. During the study period, both carcasses passed
G71 Intraspecific Competition in the through four of the five stages of decomposition established by Goff
Blowfly Chrysomya megacephala (1993): Fresh, Bloated, Decay, and Post decay. The skeletal stage was not
reached during this study. Differences in decomposition patterns were
(Diptera: Calliphoridae) Reared noted between the two carcasses. The hanging carcass demonstrated an
at Different Densities initial rate of biomass loss greater than the carcass on the ground. After the
first week, the rate became more equal. Internal mouth temperatures for the
Sandra Pearson*, Criminal Justice Program, Chaminade University of pig on the ground were uniformly higher than for the hanging carcasses,
Honolulu, 3140 Waialae Avenue, Honolulu, HI 96816-1578; and M. Lee probably due to the mediating effect of the air. Abdominal temperatures, as
Goff, PhD, Chaminade University of Honolulu, 3140 Waialae Avenue, well as anal temperatures were more similar, although still higher for the
Honolulu, HI 96816-1578 carcass on the ground.
After attending this presentation, attendees will learn the effects of Decomposition, Temperature, Biomass Removal
population densities on the rates of development and subsequent effects on
the calculations of postmortem interval estimates using entomological
techniques. G73 A Preliminary and Pilot Study About
This presentation will impact the forensic community and/or Mitochondrial DNA Deletion in Sudden
humanity by demonstrating the calculation of an estimated minimum post- Infant Death Syndrome: An Endemic
mortem interval estimate using entomological techniques depends on
correct developmental data for the species involved. Understanding the Study in Taiwan
effects of density and intraspecies competition will serve to gradually
increase the accuracy of these estimates. Tsun-Ying Huang, MS*, Institute of Forensic Medicine, Ministry of
Larvae of Chrysomya megacephala are major factors in the early Justice, 16, Lane 175, Tong-Hwa Street, Taipei, 106, Taiwan, Republic of
decomposition of remains in tropical habitats. This study was undertaken China; Chia-Tung Shun, AP, National Taiwan University, College of
to determine the effects of larval density on rate of development, larval and Medicine, No. 1, Jen Ai Road Section 1, Taipei, 100, Taiwan, Republic of
puparial mortality and adult size for this species under laboratory condi- China; Jui-Ming Li, BS, Institute of Forensic Medicine, Ministry of
tions. Larvae were collected from a pig (Sus scrofa L.) carcass in a meso- Justice, 16, Lane 175, Tong-Hwa Street, Taipei, 106, Taiwan, Republic of
phytic habitat on the Island of Oahu, Hawaii. Colonies were established China; and Shu-Huei Kao, PhD, Institute of Biomedical Technology,
with limited food resource (15 gms of beef liver) at densities of 1:1, Taipei Medical University, 250, Wu-Xing Street, Taipei, 110, Taiwan,
5:1,10:1, 15:1, and 20:1. All colonies were reared at a constant temperature Republic of China
of 24ºC, with light/dark cycles of 13/11 hours. In one section of the study,
After attending this presentation, attendees will gain an understanding
total lengths of 10 larvae per day were recorded to determine rate of devel-
whether there is a relationship between mitochondrial DNA deletion and
opment based on increase in size. In the other section of the study, colonies
sudden infant death syndrome. This presentation will impact the forensic
were left undisturbed for the duration of larval development. Larval mor-
community and/or humanity by demonstrating how although some change
tality and puparial mortality and total mortality were recorded. Of the den-
of genetic markers in mitochondrial DNA may not be the real etiological
sities studied, the 10:1 ratio appeared most favorable for development.
cause of death in SIDS cases; it could be a contributing factor to an infant’s
Larvae reared in these colonies were significantly larger than those in other
death within a critical medical condition or situation.
colonies, reached the puparial stage 24 h ahead of other colonies and had
Sudden infant death syndrome (SIDS) is a leading cause of post-
the lowest larval mortality.
neonatal infant mortality and a serious and challenging issue confronting
Entomology, Competition, Postmortem Interval Estimation the medical and legal professions. Many hypotheses have been proposed

and studied, however, a consensus on the causes of SIDS is still lacking. the knowledge regarding the complex regulation of these inflammatory
Although a number of coding region mitochondrial DNA (mtDNA) muta- mediators, 18 cases of burn fatalities were evaluated immunohistologically
tions involving SIDS have been reported, the role of mtDNA deletion or after autopsy. Paraffin embedded tissues were investigated for expression
depletion in SIDS victims is still unknown. This study was designed to of hsp 70 on the protein level related to survival time and further compli-
investigate whether mtDNA deletions exert any effect on the etiology of cations, such as pneumonia or sepsis). A tendency toward the early
SIDS. Statistical data have shown that infants dying from SIDS score expression of hsp 70 in respiratory epithelium, inflammatory cells, and in
lower in activity tests and appear to be sleepier and less reactive than the epithelium of renal tubuli was revealed. In the cases with longer sur-
control subjects. These behavioral characteristics may have been the result vival time, hsp was increasingly expressed in other organs.
of ATP depletion attributable to mutations or deletion in mtDNA. Heat Shock Proteins, Burn Fatalities, Inflammatory Response
Seven SIDS and 19 non-SIDS fatalities were included in this study to
determine the relative amount of mtDNA copy number and the occurrence
of mtDNA deletion in blood, skeletal muscle, and cardiac muscle G75 “Coca-Cola Man”: Sudden Death in a
specimens. Analytical approaches included real-time quantitative PCR, Jailed Mentally Retarded Man After
primer-shift PCR analysis and DNA sequencing. Breakpoints of the three
types of mtDNA deletions (4977, 5335, and 7599 bp deletions) observed in
an Altercation Involving Police
the population were identified by sequencing methods.
Only one specimen (cardiac muscle) from a congenital heart malfor- Wendy M. Gunther, MD*, Department of Legal Medicine, Virginia
mation subject was found to have 4977 bp mtDNA deletion. Fisher’s exact Commonwealth University, Medical College of Virginia, 1101 East
probability test and Spearman’s correlation coefficient were applied to the Marshall Street, Richmond, VA 23298-0568
analysis of the observed data on 5335 bp and 7599 bp mtDNA deletions After attending this presentation, attendees will have an increased
and found no statistically significant difference on the occurrence fre- index of suspicion for diabetes insipidus in unsuspected cases, familiarity
quencies of 5335 bp and 7599 bp mtDNA deletions between SIDS and non- with the four types of diabetes insipidus, and gain an understanding of the
SIDS victims. However, the observed data indicate: (a) for blood spec- mechanism of diabetes insipidus in psychogenic polydipsia.
imens, the occurrence frequencies of 5335 and 7599 bp mtDNA deletion This presentation will impact the forensic community and/or
observed in the SIDS were 4- and 2-fold, respectively, higher than the non- humanity by providing recognition, postmortem diagnosis and classifi-
SIDS victims; (b) for skeletal muscle specimens, the occurrence fre- cation of diabetes insipidus, and exploring the medical, legal, and media
quencies of 5335 bp mtDNA deletion in SIDS victims was 1.8-fold of the ramifications of death from dipsogenic diabetes insipidus in a mentally
non-SIDS victims. No significant correlation was observed on the relative retarded inmate.
amount of mtDNA copy number and the occurrence frequencies of mtDNA A 58-year-old inmate of an institution for the mentally retarded, who
deletions between the SIDS and non-SIDS groups; however, the occur- bore a number of additional psychiatric diagnoses including undifferen-
rence frequencies of 5335 bp and 7599 bp deletions and the relative amount tiated schizophrenia, violently assaulted a fellow resident, as well as two
of mtDNA copy number in the skeletal and cardiac muscle specimens from nursing home workers who attempted to restrain him. He was subdued
the SIDS group were much higher than that from the non-SIDS group. with the assistance of police. He was arrested for the assault, and taken
The increase in mtDNA content in mtDNA deletion cases correlates from the group home to jail, where he received a medical evaluation, and
with mitochondrial proliferation that might have been a compensatory was noted to be in good health. He was jailed for ten days, during which
mechanism of defective mitochondria. These defects in mtDNA may result he received ongoing medication with oxcarbazepine. At 0310 hours on the
in impaired production of ATP and bioenergetic crisis. mtDNA deletions in eleventh day, he was found dead on the floor of his cell.
themselves do not cause SIDS but may cause energy deficiency or hypoxia At autopsy, the oral cavity was noted to be full of vomitus. When the
in stressful situation during a vulnerable developmental stage. These pre- vomitus was rinsed away, white foam appeared. An 11” x 8” fading green-
liminary results show that mitochondrial DNA deletion might predispose brown bruise occupied most of the right side of the chest, extending across
an infant to death in a critical medical situation. the midline. Two smaller, more recent-appearing bruises were noted on the
Sudden Infant Death Syndrome, SIDS, Mitochondrial DNA Deletion chest and abdomen. Healing abrasions and almost completely faded
bruises were noted on both sides of the upper back, and on the left side of
the chest. Multiple bilateral rib fractures appeared, by their freshness,
G74 Expression of Heat Shock Protein (hsp) location, and lack of hemorrhage, to have been incurred during cardiopul-
70 in Tissue of Different Human monary resuscitative efforts. Natural disease at gross autopsy was
restricted to pulmonary emphysema, slight heart hypertrophy, and minor
Organs After Burn Fatalities renal changes consistent with hypertension. There was no coronary artery
disease, and no coronary thrombosis or pulmonary embolism. It was noted
Heike Klotzbach, MD, PhD*, and Johanna Preuss, MD, Institute for that the urine was root beer colored.
Legal Medicine, Stiftsplatz 12, Bonn, 53111, Germany; Eberhard Vitreous electrolytes, analyzed the following day, exhibited a severe
Lignitz, MD, PhD, Institute for Legal Medicine, Kuhstrasse 30, deviation from expected values. The BUN was 127 mg/dl, and the
Greifswald, 17489, Germany; and Burkhard Madea, MD, PhD, creatinine, 1.2 mg/dl. The sodium level was 180 mmol/L, and the chloride
Institute for Legal Medicine, Stiftsplatz 12, Bonn, 53111, Germany level, 150 mmol/L. Potassium, CO2, and glucose showed a postmortem
After attending this presentation, attendees will gain some under- pattern.
standing of the regulation of the early inflammatory response in humans, Significant social history included moderate mental retardation, a
specifically regarding the initial response of heat shock proteins (hsp). variety of psychiatric diagnoses, and a noted addiction to soft drink
This presentation will impact the forensic community and/or products. At the hospital where he underwent occasional treatment for
humanity by providing some understanding of the regulation of the early exacerbation of psychiatric symptoms, the inmate was referred to as “Coca-
inflammatory response in the human organism after burning fatalities, and Cola man,” due to his nonstop consumption of as much of this soft drink as
contributing to the clinical understanding of the development of the serious he could obtain. Psychiatric treatment notes had documented a recom-
septic or sepsis-like processes in these cases. mendation that he be switched from caffeinated and sugar-containing soda
Heat shock proteins play an important role in the early response to to decaffeinated and diet soda, to control some of his behavior problems.
various physical or chemical alterations and contribute to the up-regulation Death was due to marked hemoconcentration. Consultation with a
of numerous other stress-related mediators such as cytokines. To enhance local endocrinologist suggested the disorder diabetes insipidus.

Diabetes insipidus is a disorder of excessive urination, which may be cooling from analyses of empirical data collected from the recently
traced to four types of inciting cause. One type, gestagenic, occurs only in deceased and from tests on manikins. In most cases these analyses use
association with pregnancy. Another, neurogenic, is due to a pituitary three or fewer postmortem data points and impose, a priori, a multi-expo-
lesion, which may be acquired or congenital. A third, nephrogenic, may be nential curve fit. Data presented here are a first-order attempt using a ther-
congenital, but may also be drug-associated. Certain commonly adminis- modynamic model and non-linear regression with at least ten postmortem
tered drugs are well known to be associated with diabetes insipidus, data points.
including lithium, foscarnet, and clozapine, as well as many cytostatic We are developing mathematical and curve-fitting techniques to
drugs and antimicrobials. No record of administration of any of these drugs construct an analytical model for which body cooling rate is deduced and
could be found. Trileptal is not associated with diabetes insipidus. from which time-of-death is estimated. Data for this model require
The fourth category of diabetes insipidus is dipsogenic, or caused by measurements of internal body temperature during postmortem cooling at
psychogenic polydipsia. In this disorder, excessive drinking of any fluid, matched clock times, although not necessarily at regular intervals.
over a prolonged period of time, causes excessive urination, which may Inexpensive, portable temperature monitoring and logging devices
become independent of normal feedback mechanisms. What was facilitate making these measures are currently available. An estimate of the
originally a psychological compulsion then becomes an organic condition. person’s body temperature at death and ambient temperature are also
This disorder could be produced by a protracted indulgence in very large required, as are data about body weight and the quality of clothing or other
quantities of soft drinks. body covering. Data about the person’s physical activity immediately prior
As diabetes insipidus was not suspected at autopsy, the opportunity to to death, medication history, environmental conditions, and exposure cir-
examine the pituitary was lost. So it cannot be definitively stated whether cumstances provide useful ancillary, but not essential information. The
this was in origin a neurogenic diabetes insipidus, or dipsogenic. A men- analyses are equally valid for people whose bodies are found in water or in
tally retarded and schizophrenic person with a strong drive to imbibe as air. Data analyses are made either with programmable calculators or with
much soft drinks as possible may not have recognized water available in his standard spread sheet programs. Time-of-death is reported as a range
cell as a source of rehydration. Nor could he likely explain his symptoms depending on the strength of the correlation coefficient revealed by curve-
in terms, which would convey his condition to corrections personnel. fitting data for the fall in multiple postmortem body temperatures.
The postmortem diagnosis and classification of diabetes insipidus, Interpretations of preliminary analyses for people whose postmortem
and the ramifications of dipsogenic diabetes insipidus in a mentally cooling rate is recorded in a monitored environment as well as bodies found
retarded inmate, will be discussed, along with a consideration of how to at crime scenes are providing important information to amend the mathe-
deal with newspaper interest in the cause and manner of death. matical model, increase its validity and improve the precision for esti-
Diabetes Insipidus, Psychogenic Polydipsia, In-Custody Deaths mating time-of-death by temperature.
References:
1. Adams, T., Heat Stress, Chp. 98 in Patty’s Toxicology 5th Ed. E.
Bingham et al. editors, John Wiley, 2001.
G76 Estimating Time-of-Death by Body 2. Henssge, C., Death time estimation in casework, I. The rectal temper-
Temperature Analyses - A New ature time of death nomogram, Forensic Science International, Vol. 38, pp.
Mathematical Strategy 209-236, 1988.
3. Knight, B., The evolution of methods for estimating the time of death
Anthony T. Paganini, PhD*, Michigan State University, A519 East Fee from body temperature, Forensic Science International, Vol. 36, pp. 47-55,
Hall, Division of Anatomy, Department of Radiology, East Lansing, 1988.
MI 48824; and Thomas Adams, PhD, Michigan State University, 4. Lynnerup, N., A computer program for the estimation of time of death,
Department of Physiology, 2240B Biophysical Sciences Building, Journal of Forensic Sciences, Vol. 38 (4), 816-820, 1993.
East Lansing, MI 48824 5. Mall, G. and Eisenmenger W., Estimation of time sine death by heat-flow
Finite-Element model. Part I: method, model, calibration and validation,
After attending this presentation, attendees will learn of a revised Legal Medicine (Tokyo), Vol. 7, pp. 1-14, 2005.
curve-fitting method of postmortem estimation of time-of-death by body 6. Spitz, W., Medicolegal Investigation of Death- Guidelines for the
temperature. Application of Pathology to Crime Investigation, Charles C. Thomas,
This presentation will impact the forensic community and/or Springfield, 1993.
humanity by presenting a new way of analyzing temperature data without
Postmortem, Time-of-Death, Temperature
making a priori assumptions regarding postmortem cooling rates or
involving measurement of complex heat transfer parameters
Accurate determination of a patient’s time-of-death is routine in a hos-
pital, nursing home, hospice, or other well-monitored setting. It is more
difficult when death occurs alone at home, at an isolated hunting site, in a G77 Photography of Abuse:
vehicle in a remote area, at a crime scene or at some other unsupervised Is There a Best Method?
site. Time-of-death (TOD) nonetheless provides crucial information
required in many clinical and forensic investigations. Lynette Landon-Chellemi*, PO Box 523, 59-076 Pupukea Road, Haleiwa,
Numerous techniques have been used for the past fifty years to HI 96712; and Wilson T. Sullivan III, MPA, Chaminade University of
estimate TOD, including quantitative analysis of body tissue and fluids or Honolulu, Forensic Science Department, 3140 Waialae Avenue,
qualitative staging of rigor mortis, postmortem lividity, putrefaction, or Honolulu, HI 96816
mummification of the decedent’s remains (6). Sequential and precise mea-
The goal of this presentation is to discuss methods of recording
surements of the change in deep body temperature during the postmortem
photographically injuries both visible and invisible to the unaided eye.
period have been also been employed by numerous investigators (3). The
amount of postmortem temperature data collected is practically limited by
humanity by demonstrating how there is a need for further research in the
the amount of time the medical examiner is allowed access to the body by
development of a standardized protocol for photographing injuries that are
police and the stability of the environment in which the body was found.
not immediately visualized. A standardized protocol for documentation of
Previous investigators have developed equations (2, 4) or intricate
old injury patterns would be useful in elder and child abuse cases.
finite-element computer simulations (5) to predict postmortem body

Historically, documentation of bruising of abuse victims was Soon after the disaster, the local legal authority engaged a team com-
accomplished using standard film cameras, recording injuries visible to the posed of forensic pathologists and engineers to investigate the causes of
naked eye. Presently documentation of abuse has advanced to include both death and the cause of the building collapse. Engineers’ investigations dis-
infrared and ultraviolet imagery using both fast black and white film and covered that the cause of the collapse was due to the accidental explosion
high-speed infrared film. This research will attempt to establish of a domestic gas cylinder originating from a cave. Scene investigations
standardized parameters and techniques for optimum light source and also revealed irregular gas network connections in spite of standard safety
filtration together with an ideal photographic protocol for documentation of rules.
fresh and older patterned injuries. When developing a photographic Three working areas were designated early as medicolegal facilities.
protocol for this research, specific attention is given to techniques A provisional holding area was used to receive dead bodies coming from
appearing in past literature concerning UV and IR imaging of bite marks site of collapse prior to examination allowing family members to be able to
and bruising. Several methods appearing in the literature on the documen- identify the victim. A second private viewing area was designated to let
tation of pattern injuries are explored and tested. In the research the authors family members and friends see photographs of the bodies, objects per-
are attempting to determine if any one of those selected protocols explored taining to the deceased (jewelry, clothing or identifiable objects found), and
proves more beneficial than the others, ultimately determining a “best finally, the bodies themselves, carried from the holding area. An exami-
method” if one exists. Since this is a time of technological shift from film nation space was designated to conduct a more detailed exterior assessment
to digital media, both types of cameras are examined for compatibility, of the body to provide a careful external examination, and to perform a
advantages, and limitations. Photographs were taken for six weeks at two- complete autopsy in order to determine the cause of death, documenting
day intervals using numerous filters with both digital and film capabilities injuries sustained, and determining activities at the time of the collapse.
in an attempt to discern if the digital camera is comparable for this type of According to the most advanced disaster preparation guidelines,
forensic work. Different alternate light sources are tested during ultraviolet injuries were coded using the Abbreviated Injury Severity Scale and its
and infrared digital photography. The digital camera has advantages and derivative Injury Severity Score (ISS). The AIS is a comprehensive tax-
limitations when working with infrared and ultraviolet photography. onomy of individual injuries, which denoted body region, type of anatomic
Abuse, Ultraviolet, Infrared structure and severity of injury. The severity index ranged from 0 (no
injury) to 6 (unsurvivable injury), the ISS estimated overall body trauma
and was calculated by squaring and summing the single highest AIS score
in each of the three most severely injured body regions. An ISS score of 76
G78 The Cave Man in the 21st Century: was indicative of unsurvivable injury. A complete radiographic study of
Chronicle of an Announced Tragedy: each body was performed.
Preventive Measures and Repeating Risk Cranio-facial injuries, cranial fractures, sternum and multiple ribs
fractures, upper and lower limbs fractures, spine fractures and vertebral
Cristoforo Pomara, MD*, Stefano D’Errico, MD, Sabina Di Donato, MD, subluxations, multiple diaphragm lacerations, multiple lacerations and con-
Marianna Di Padua, MD, Francesco M. Morreale, MD, Irene Riezzo, MD, tusion of internal organs (heart, lungs, kidneys, liver and spleen) were
and Margherita Neri, MD, Institute of Forensic Pathology, Foggia detected in a first group of persons represented from the “cave man” group,
University, V.le Luigi Pinto 1, Foggia, 71100, Italy; and Giulio Zizzo, MD, and the family living immediately above the cave. The second group was
Radiology Department Ospedali Riuniti, V.le Luigi Pinto 1, Foggia, composed of three persons in the family living very close to the source of
71100, Italy explosion, and presented with only mild to no traumatic injury. People
belonging to the first group died quickly, due to the severity of their
The goal of this presentation is to describe a building collapse with injuries. The people in the second group died from mechanical asphyxia.
fatalities in a typical southern Italian location. According to the common
Cave, Building Collapse, Injury Severity Score
definition of a disaster, the authors want to warn against complacency and
the underestimation of the appropriateness of certain environmental struc-
tures, and underscore the social impact of such a dramatic event, that upon G79 Hypothermia-Related Deaths in Cook
review was truly a predictable tragedy. County, Illinois From November 2000
This presentation will impact the forensic community and/or to February 2005
humanity by demonstrating how in spite of the tragic event, people con-
tinue to live in “the caves”, in a condition of absolute poverty and in con-
Wendy A. Lavezzi, MD*, Clare H. Cunliffe, MD, and Edmund R.
trast of every safety rule. In all likelihood, just a few precaution safety mea-
Donoghue, MD, Cook County Medical Examiner’s Office, 2121 West
sures could have avoided the dramatic event and could prevent a repeat col-
lapse of these types of buildings.
A human made, level I disaster, occurred with the collapse of a The goal of this presentation is to identify common risk factors in
building in the historical center of Foggia, a city in the South of Italy. In cases of hypothermia death.
this location, some families still live in small, tall, and rundown buildings This presentation will impact the forensic community and/or
of usually two floors tall. These buildings were built in the very early 20th humanity by presenting epidemiological data on deaths due to hypothermia
century, usually above a basement, three meters underground, named by the in Cook County, Illinois, including scene investigation, medical history,
town citizens as “the caves.” These basements are composed of one or two and toxicological studies.
rooms and a small bathroom, with poor lighting and even worse ventilation, Deaths due to hypothermia are a significant public health problem in
with just a small window for an entrance, accessed by stairs. The “caves” cold climates in the United States. Cook County, IL, has a population of
were generally intended for storage, but have often hosted people, usually over 5 million people, and includes Chicago and 120 surrounding suburbs.
elderly. Winter month temperatures in Illinois can reach below zero degrees
During the night of the 20th of November 2004, at 3:15 a.m., a one- Fahrenheit.
floor building over one a “cave” suddenly collapsed. Of the 14 people Risk factors for death during cold exposure are infancy, advanced age
living in the building at the time, six were found alive within a few hours (? 65 years), inadequate shelter, mental impairment, substance abuse, and
after the collapse and were immediately transported to the local hospital. serious medical conditions. Cold-related deaths have received increased
Eight bodies were recovered lifeless from the building, and none were media attention in recent years in Cook County, Illinois, aimed in part at
missing. increasing public awareness of the deaths in order to decrease future deaths
from hypothermia.

This retrospective study examined 129 cases of death related to This presentation will impact the forensic community and/or
hypothermia from the Office of the Medical Examiner in Cook County humanity by teaching the forensic community that gene expression profiles
from November 2000 through February 2005, encompassing five winter and specific mRNA can be used to identify a large number of body parts
seasons. Data examined included age, race and sex of decedents, location and fluids. Attendees will understand that this can be done with very small
found, concomitant medical conditions, outdoor low temperature when amounts of material and therefore useful in forensic investigations when
found, the presence of paradoxical undressing, the presence of alcohol or sample available is limiting.
other drugs, body temperature (when available), whether or not the This presentation proposes that by screening microarray and SAGE
decedent was homeless, and any other significant conditions that con- based tissue expression data in multiple databases, both public and internal,
tributed to the death. it is possible to identify candidate mRNA species that would show tissue
Three of the 129 cases were excluded from the study. In these three specific expression. Additionally, this would select highly expressed
cases, the decedent suffered low body temperature due to sepsis during pro- messages for use in forensic applications.
longed hospitalization; none were exposed to low ambient temperatures. In this presentation, and from the screening of human tissue and body
Of the 126 remaining cases, 34 occurred in the winter season of 2000- fluids, it is possible to define specific markers that can be used for identifi-
01, 27 from 2001-02, 26 from 2002-03, 20 from 2003-04, and 19 from cation. Identification of tissue parts and body fluids is frequently required
2004-05. Eighty-three cases (66%) listed hypothermia or cold exposure as in crime scene investigations. Conventional methods are often labor-
the primary cause of death, and the remaining cases listed hypothermia or intensive, not confirmatory and employ a diverse range of methodologies.
cold exposure as a contributing factor to death. Manners of death were Several forensic laboratories have pioneered the selection of specific
listed as accident in 123 cases, suicide in two cases, and undetermined in protein or mRNA markers for identification of tissues and body fluids.
one case, which involved an unwitnessed drowning with a high post- Some laboratories have designed and tested real-time PCR based assays
mortem alcohol level. The group consisted of 65 white males (52%), 26 that target the detection of mRNAs encoded by > 20,000 genes in identified
white females (21%), 25 black males (20%), 9 black females (7%), and 1 in the human genome. The presented methods employ proprietary methods
Asian male (<1%). In 52 cases (41%), the decedent was of advanced age. to design assays specific to a target transcript avoiding amplification of
In 31 cases (25%), the decedent was homeless. The youngest decedent was related gene transcripts. It also allowed for the development of methods for
28 years old. Forty-seven cases (37%) involved alcohol, and 12 cases pre-amplification of hundreds of targets present in a single sample pre-
(10%) involved other drugs. In 67 cases (53%), the decedent had one or serving relative quantification information. These methods will be useful
more significant medical problems, including heart disease, diabetes mel- when dealing with heterogeneous mixtures.
litus, dementia, or a seizure disorder. In six cases (5%), a significant injury In this study, the performance of assays targeting saliva specific
contributed to the death. Body temperature was taken in 26 cases (21%), markers was analyzed such as Statherin, Histatin Ge3, PRB1, PRB2,
and ranged from less than 70°F to 94.5°F. Outdoor temperatures ranged PRB3, menstrual blood markers like metalloproteinases, and semen spe-
from -9°F to 49°F on the evening before or day found. Mean temperatures cific markers like protamines. These were targets selected based on liter-
per winter season were: 11°F in 2000-01, 21°F in 2001-02, 18°F in 2002- ature reports. A total of 480 genes from the analysis of microarray data
03, 20°F in 2003-04, and 25°F in 2004-05. Seventy three decedents (58%) from specific tissues were selected. TData was used to further limit this to
were found outdoors, 39 (31%) were found indoors with no heat, 13 (10%) a set of 130 genes. Next, RNA from 48 tissues was selected and converted
were found in various unheated areas, including motor vehicles, porches, to cDNA by reverse transcription reaction using random primers and com-
and garages, and one was dropped off at the hospital with a high alcohol mercially available kits. Initially, cDNA was tested using six endogenous
level and low body temperature by an unknown person. Paradoxical controls (GAPDH, GUSB, 18S RNA and ACTB, HPRT and B2M) for nor-
undressing, often cited as a hallmark of hypothermia, was observed in only malization purposes. Next, assays targeting transcripts from these genes
seven cases (6%). were used to analyze gene expression relative to endogenous controls
Autopsy findings in cases of death due to hypothermia may be absent across 48 tissues. HeatMap views of gene expression patterns were con-
or nonspecific. Correlation with the circumstances surrounding the death structed to identify tissue specific patterns. Based on these expression pro-
and the medical and social history of the subject is important in order to files researchers identified ~20 genes, not reported in the literature as spe-
determine the correct cause of death. cific markers that are highly expressed in single tissues. Additionally, the
Deaths due to hypothermia have decreased in Cook County over the authors identified some genes that were expressed in a few (2 to 3) tissues
last five years, possibly due to milder winters, but still remain a significant and could still serve as specific markers when used in specific combina-
public health problem. The forensic community needs to be aware of the tions. This research also shows that pre-amplification protocols can be used
possibility of a cold-related contribution to cause of death. to detect mRNA when the sample is limiting. Detection of saliva specific
Forensic Sciences, Hypothermia, Cold Exposure markers was demonstrated following pre-amplification.
This study demonstrates that, in many instances, single markers can
be defined as specific for a given tissue. These include SEMG1, SEMG2,
KLK3, and PRB4/HGNC that have not been reported in the literature as
tissue specific markers. In some instances, using a combination of targets
G80 Analysis of Gene Expression Patterns to will provide identification. This research has shown that if the sample is
Identify Tissue and Body Fluid Specific limiting, pre-amplification of a large set of mRNAs in a single reaction is
mRNA Species Using Real Time PCR Assays useful for identification.
Tissue Identification, Gene Expression, Real Time PCR
Rixun Fang, PhD, Christine Shulse, BS, Pius Brzoska, PhD, and
Manohar R. Furtado, PhD*, Applied Biosystems, 850 Lincoln Center Dr.,
Foster City, CA 94404; and Chitra F. Manohar, PhD, Lawrence
Livermore National Laboratory, 7000 East Ave, Livermore, CA 94550
After attending this presentation, attendees will learn that it is possible
to test for specific mRNAs that serve as markers for tissue and body fluid
identification. Attendees will be informed about pre-amplification pro-
tocols that can be employed to simultaneously amplify and detect multiple
targets when the amount of material available is limiting.

G81 Caveat Emptor: A Series of Deaths are sought as an easily accessible, non-surgical cosmetic procedure to
create a more feminine appearance. The materials required for the injec-
Related to Subcutaneous Silicone tions are easily obtained through cosmetic supply companies (non-medical
Injections in Transgender Males grade silicone), medical supply companies (medical grade syringe lubri-
cants) or any supplier of viscous liquid silicone (including brake fluid), and
Morna L. Gonsoulin, MD*, Ashraf Mozayani, PhD, Terry Danielson, PhD, the injections are commonly administered in large veterinary syringes. The
and Luis A Sanchez, MD, Harris County Medical Examiner’s Office, substance is injected into the dermis and superficial subcutaneous fat,
1885 Old Spanish Trail, Houston, TX 77054-2098 usually in a circular cluster of small punctures. There it accumulates as
filler, distending the tissue with the objective of creating a more tense and
After attending this presentation, attendees will learn about the history
rounded outline.
and consequences of the practice of illicit subcutaneous silicone injections
Multiple injections are usually required for contour enhancement of
as well as the circumstances, findings and available methods of testing in
the hips and breasts, in particular. Most individuals require additional
cases involving subcutaneous silicone injections in the forensic setting.
applications to maintain the enhanced appearance over time. No estimates
are available for the number of individuals who have received such injec-
humanity by alerting forensic professionals about the circumstances,
tions or for the effects of cumulative silicone exposure of a given individual
findings and available methods of testing in cases involving subcutaneous
who has been repeatedly injected. The clandestine nature of the practice
silicone injections, as well as informing or increasing awareness of a
and the pervasive social stigma associated with transgender community
largely underground, poorly documented and dangerous trend which may
does not lend itself to obtaining accurate statistics. The persistence of the
be gaining popularity despite the potentially significant morbid and lethal
practice worldwide and anecdotal evidence would suggest, however, that
risks.
the reported incidence of lethal sequelae of subcutaneous silicone injection
This presentation highlights a series of three deaths resulting from
is infrequent relative to the number of individuals who have received these
subcutaneous silicone injections obtained illegally outside the medical
injections.
setting for cosmetic purposes. The goal of this presentation is to review the
Increased public awareness appears to have had a significant effect in
circumstances and findings of the cases in light of the general character-
the Houston area. After the local authorities began publicizing the dangers
istics of the typically utilized silicone-containing compounds, their legal
of subcutaneous silicone injections and prosecuting the individuals admin-
and illegal uses, the methods and procedures used during the injections and
istering them, no more deaths related to the practice have been reported as
the complications of subcutaneous silicone injection as a result of inad-
of July 2005.
vertent systemic siloxane exposure. The presentation will impact the
forensic community and/or humanity by alerting forensic professionals Pulmonary Silicosis, Silicone, Transgender
about the circumstances, findings and available methods of testing in cases
involving subcutaneous silicone injections, as well as informing or
increasing awareness of a largely underground, poorly documented and
dangerous trend which may be gaining popularity despite the potentially G82 Anogenital Anatomy: Colposcopy to
significant morbid and lethal risks. Study the Appearance and Changes
In Houston, Texas, a series of three deaths within a three-month period
in 2003 due to pulmonary silicosis were caused by the illegal practice of During the Postmortem Interval
subcutaneous silicone injection for cosmetic enhancement of the hips and
breasts among local transgender males. Gas chromatographic / mass Sharon R. Crowley, MN, RN*, Forensic Clinical Nurse Specialist,
spectrometric analysis indicated the presence of the cyclic siloxanes, hexa- 122 Emeline Avenue, Santa Cruz, CA 95060
methylcyclotrisiloxane, octamethylcyclotetrasiloxane and decamethylcy- After attending this presentation, attendees will be able to describe the
clopentasiloxane, in fluids collected from hip and breast injection sites, and nature and appearance of the anogenital tissues at various postmortem
from syringes and containers of silicones seized during the investigations. intervals, and evaluate the efficacy of a previously described system of
These low molecular weight siloxanes may serve as chemical marker mobile technology for postmortem genital examinations.
substances in the confirmation of siloxane injection. This presentation will impact the forensic community and/or
This unusual cause of death occurred with alarming frequency over a humanity by increasing the diagnostic acumen of forensic examiners,
relatively brief period of time due to a sporadic surge in popularity of the increasing the reliability and consistency of both examination techniques
practice of subcutaneous siloxane injection among the local transgender and documentation via improved methodology and an efficacious tax-
community. The injections had been administered by two independently onomy, and to eventually allowing reliable comparisons between the
operating agents with no medical training who were soliciting in bars fre- anogenital findings in cases of sexual homicide to normative postmortem
quented by transgender males. Although ethnically diverse, the three indi- controls.
viduals involved were young transgender males who had received several Text/background: A paucity of data exists on the “normal”
injections on at least one previous occasion, and their clinical presentations, appearance of the anogenital anatomy during the postmortem interval.
hospital courses and autopsy findings were similar. Data from scrutiny and photodocumentation of these tissues are lacking.
Siloxanes are used in preparations such as hair conditioners, skin care Detailed observations of the usual anatomic sites, which have been care-
products, and industrial lubricants. While their topical use is common, fully studied in living sexual assault victims, are lacking in postmortem
siloxanes are not intended for internal use. Subcutaneous injection of examples. Thus, the interpretation of genital findings in the deceased
siloxanes (silicone) presents the risk of direct introduction of silicone remains a vital and timely issue. In addition, techniques that are often
compounds into the systemic circulation, where they can accumulate in the employed by some examiners for the medical-legal examination of living
pulmonary macrophages (pulmonary silicosis), resulting in hemorrhage, sexual assault victims, such as the application of the nuclear stain, toluidine
respiratory failure and death. Because of the potentially lethal blue dye, have been insufficiently studied in the postmortem arena.
consequence, injection of siloxanes into subcutaneous tissue is illegal in the In order to accomplish this, postmortem cases presenting from various
United States. causes of death from natural, accidental, suicide, and homicide of non-
Isolated case reports documenting the sequelae of subcutaneous sil- sexual etiology, are the focus of the present discussion. These cases will
icone injections have been presented since the 1970’s due to occasional comprise a normative, core group of baseline cases, and the first study of
trends, particularly in the transgender subculture, where silicone injections “normal” postmortem genital anatomy.

Materials and methods: Baseline examples of genital anatomy G83 Unusual Suicide With Chain Saw:
during the postmortem interval are selected based upon availability and
accessibility. Female cases from the representative causes of death will be
A Case Report
clinically evaluated, using the mobile system of technology described by
Gilles Tournel, MD*, Fabrice Dedouit, MD, Anne Becart-
Crowley (JFS, 2004).1 Colposcopic technique includes inspection at 7.5X, Robert, DDS, PhD, Nicolas Pety, MD, Valéry Hedouin, MD, PhD, and
15X, or both, and photodocumentation via a 35 mm SLR camera. Didier Gosset, MD, PhD, Institut de Médecine Légale, Faculté de
Colposcopy was chosen because it is a well-established technique for the Médecine, 1, place de Verdun, Lille, 59000, France
evaluation of sexual assault in both child and adult victims. The range of
postmortem interval categories are < 24 hours (fresh), 48-72 hours, 73-96 After attending this presentation, attendees will learn the importance of a
hours, > 5 days, and unknown. Reproductive status is categorized as pre- careful observation of the crime scene. This presentation will impact the
pubertal, reproductive age, perimenopausal, and post-menopausal. Some forensic community and/or humanity by reminding the forensic pathologist that
of the variables to be collected and entered into a sexual homicide database a careful analysis of both the death scene and the findings of the autopsy are
include age, ethnicity, race, date/time body found, date/time of exami- essential in reaching the proper conclusion, especially in a very unusual death.
nation, cause of death, past medical history, reproductive status, exam tech- Only a few cases of suicide with a chain saw exist. The reports of these
niques, and any known past medical history, especially gynecological cases are never a complex system, such as presented in this case report. It is
history. Routine inspection, visualization, and photodocumentation of the interesting to know of this type of a complex system.
salient anatomic sites includes the labia majora, peri-clitoral area, peri-ure- A case of suicide using a chain saw is presented. A female suffering from
thral area, labia minora, hymen, vagina, cervix, perineum, fossa navicu- schizophrenia committed suicide through an ingenious system leading to the
laris, posterior fourchette, anus, and rectum. Any concomitant gyneco- sectioning of her upper cervical spine involving the cervical spinal cord. The
logical condition or benign lesions are noted. Examination techniques such findings of the resulting investigation are described and the mechanism of
as labial separation, labial traction, use of vaginal speculum, anoscopy, and suicides with the use of a chainsaw is reviewed. The damages to organs and
the degree of fixed magnification (e.g., 7.5X, 15X), used for colposcopic soft tissues are compared to the kinds of chainsaw used.
documentation, are also documented. Case report: Death scene findings: A 32-year-old woman was found
Discussion: The use of colposcopy is well documented in living dead in her living room. The decedent was a female Asian engineer. She had
sexual assault victims. The obvious benefits of improved visualization via a significant medical psychiatric past history. She was found dead by her
magnification, photodocumentation, and the capacity for peer review are family members ten days after her death. The head was disposed under a
equally germane to the postmortem arena. For living victims, the sexual material of pulleys and bags filled with water bottles. The material and the
assault examiner is asked to determine if the physical examination is con- appliance are detailed. The chain saw had a 1600 W, 220-240 V, 50-60 Hz
sistent or inconsistent with the history as provided by the victim. In the engine, and weighted 3 kg. The length was 50 cm including the projecting
deceased, the lack of a history provided by the victim makes the need for rim of the chain. The chain’s number of revolutions was 9.5 per second. The
reliability and accuracy paramount. The examiner must consider the usual stains of blood were located on the floor without splatter on the walls.
benign factors, gynecological conditions, and concomitant anatomical vari- Postmortem findings: The wound extended 7 cm deep into the neck and
ations often present in antemortem cases. The examiner of postmortem involved the posterior muscles and the posterior side of the third and fourth
cases must have the ability to reliably and accurately assess the nature and cervical vertebrae. A complete section of the spinal cord was noted.
appearance of anogenital tissues at all major anatomic sites and at various A study of the cervical bones was performed to compare with the character-
postmortem intervals, while the normal changes of decomposition are istics of the chain saw and to explain all wounds on the cervical vertebrae.
simultaneously superimposed on the anatomy. For both the normative, Bone injuries were compatible with the use of a large width cutting edge
baseline controls and suspected cases of sexual homicide, it is vital that instrument consistent with known chain saw toolmarks. The edges were
meticulous attention be paid to technique, taxonomy, and interpretation. regular and no hesitation lesion was seen. Because the cadaver was decom-
The most compelling argument for the use of the colposcope in this posed, the dentist performed identification. The dental comparison of ante-
setting is the dearth of information available on what is “normal.” In the mortem records and postmortem examination confirmed her identity.
field of postmortem sexual anatomy, the pivotal issue is that “normal” has Discussion: Suicides or suicidal attempts with saws are rare but sensa-
never been defined. Postmortem changes that are routinely recognized by tional, due to the unusual patterns of injury and sometimes, because of the
the adroit examiner of deceased victims such as mucosal autolysis, skin unusual death scene. Cases reports exist in the forensic literature of this type
slippage, dilatation, and lividity, may be mistaken for traumatic changes by of suicide. The injuries are almost always inflicted to the head or the neck
even experienced sexual assault examiners, whose prior experience is but in some cases are visceral, and tissue damage occurs because of strong
limited to antemortem cases. The entire perineum including the vagina and vibrations of the chain saw applied directly to the body. In this case, the
rectum can be removed en bloc for dissection and microscopic evaluation young female had significant psychiatric disorders, conceived, and com-
by the Forensic Pathologist. However, there may be valuable information pleted a complicate scene of suicide. The wounds inflicted to the neck con-
gleaned by initial in situ examination via colposcopy of the anogenital site. firmed the observation of other authors.
A high degree of photographic detail and careful analysis of related The findings of the scene of death were very important to understand
sample variables will also facilitate categorization of anogenital findings, the mechanism of the additional material used in the complex manner. No
using an expanded version of the taxonomy described by Crowley and typical hesitation injuries were observed in the neck, and these findings were
Peterson (AAFS, Dallas, 2004). Continued study may require that the compatible with the situation of the cadaver and the device. The dry bone
initial taxonomy be modified or expanded. study confirmed the regular and sharp limits of the bones injuries.
Reference: The authors discuss and compare this case to the literature in consider-
1. Crowley, Sharon R. “A mobile system for postmortem genital examina- ation of her occupation with possible cultural influences to explain the
tions with colposcopy: SART-TO-GO,” J. ForensicSci. 2004 (Nov); Vol. invention of this efficient and complex deadly system.
49(6):1299-1307. Initial autopsy study of the decomposed body were not sufficient enough
Colposcopy, Forensic Nurse, Postmortem Anogenital Anatomy to characterize the chain saw wounds on her neck, and therefore a dry bone
analysis was important and subsequently performed in order to objectively
study and understand the mechanism and the physiopathology of her death.
The presentation will illustrate the complex deadly system at her scene
of death, in addition to the autopsy findings and the dry bone study.
Chain Saw, Suicide, Complex System

G84 Suicidal Hangings: A Growing G85 DNA Done Right: Manner of Death
Trend in Northern Virginia Determination, Based on Evidence
Obtained From a Belt at a Complex
Erin E. Falconer, MFS*, Danielle L. McLeod, MFS, and Todd M.
Luckasevic, DO, Northern Virginia Office of the Chief Medical
Scene Involving a Decomposed Body
Examiner, 9797 Braddock Road, Suite 100, Fairfax, VA 22032
Leah L. Bush, MD*, and Wendy M. Gunther, MD, Office of the Chief
The goal of this presentation is to identify trends present in suicidal Medical Examiner, Tidewater District, 830 Southampton Avenue,
hangings. Suite 100, Norfolk, VA 23510
humanity by providing information on the findings associated with suicidal After attending this presentation, attendees will learn the appropriate
hangings with emphasis on injuries to the neck, ligature device, presence of methods for handling of evidence at complex scenes; learn about the use of
a suicide note, and history of mental illness/life event. DNA analysis in cases where manner of death is not evident from forensic
Introduction: Suicide is one of the most important public health issues autopsy; and learn about the value of DNA analysis in cases involving
in the United States. Suicide represents the eleventh leading cause of death decomposed bodies.
in the United States. Nearly 20% of the caseload of the Northern Virginia This presentation will impact the forensic community and/or humanity
Office of the Chief Medical Examiner in Fairfax, Virginia is suicide. by demonstrating an expanding awareness of the usefulness of DNA touch
Suicide rates for this country have been relatively stable over the past preparation analysis on items such as ligatures in scenes involving decom-
decade with approximately 10 suicide deaths per 100,000 people. The most posed bodies, and to influence the collection and handling of relevant items
common method of suicide in the United States for both males and females at scenes where the manner of death appears undetermined.
is the use of a firearm. The second most common method of suicide in A 32-year-old man was found dead in his home at Christmastime, in
males is hanging. a state of moderately advanced decomposition. His car was missing from
Materials and Methods: This is a retrospective review of case files his home, as it had been towed away after an interstate crash days before.
from the Northern Virginia Office of the Chief Medical Examiner in The house was secure. There was no suicide note.
Fairfax, Virginia. Inclusionary data for this pilot study included the cause The body at the scene was face down on the bedroom floor, lying
of death from hanging and the manner of death ruled as suicide for autopsy prone between the bed and a chest of drawers. He was clad only in bikini
cases from the years 2003 thru 2004. A total of 320 suicides were autopsied underwear and socks, with some clothes draped over his lower legs. He
during this 2-year study period. Of these 320 suicides, 52 (16%) were due was partially suspended by a belt ligature tied to a drawer handle. The belt
to hanging. These 52 cases were reviewed for the following information: was looped twice around his neck, with one end of the belt pulled through
injuries to the neck, type of ligature device, history of mental illness/life the buckle behind his left ear. The opposite end of the belt was tied in an
event, the presence of alcohol, the presence of a suicide note, past overhand knot to the brass drawer handle.
ideations/attempts, and the demographics of the decedent. The case infor- Significant social history included homosexuality, with a history of
mation was organized into a spreadsheet and the data was analyzed for any depression over his sexual orientation, as reported by his mother. There
trends or interesting correlations. was no known history of autoerotic asphyxia. He had no significant
Results: Between the years 2003 and 2004, the Northern Virginia medical history.
Office of the Chief Medical Examiner in Fairfax, Virginia investigated 320 Scene investigation included leaving the ligature intact for the autopsy
suicides. Of these 320 suicides, 52 (16%) were reported as hanging. Males pathologist, bagging the hands in clean paper bags, leaving the clothing
comprised 81% (42), while females accounted for the remaining 19% (10) undisturbed to allow for a physical evidence recovery kit at autopsy, and
of all suicidal hangings. Caucasians accounted for 71% (37) of the cases, wrapping the body in a clean white sheet prior to placing it in a body bag.
followed by Asians with 13% (7). Case files will be reviewed for a history Autopsy procedures included photography and close examination of
of depression, mental illness, or life event, and past suicide attempt(s). The the hands, clipping of the fingernails for DNA analysis, physical evidence
presence of alcohol and/or suicide note will be reported. recovery kit for sexual activity, removal of the ligature by division away
Conclusions: This pilot study emphasized the increasing rate of sui- from the buckle, and complete visceral dissection. Autopsy findings
cidal hangings in Northern Virginia. Sixteen percent of the suicides in included a ½” horizontal ligature furrow with no upslope, and the following
Northern Virginia are due to hanging. In 2003, 20 individuals died as the pertinent negative findings of no internal neck injuries, significant blunt
result of suicidal hanging. The rate of suicidal hangings increased to a total force or penetrating injuries, obvious sexual assault, or significant natural
of 32 cases in the year 2004 and the rate continued to rise in the first half disease processes, as far as could be determined in his state of moderate
of 2005. This study will report the correlation between type of ligature used decomposition. Postmortem toxicology on bloody purge fluid yielded only
and pathologic trauma to the neck. A history of depression, mental illness, an ethanol level of 0.07 mg%, which most likely was due to postmortem
or life event, and/or past suicide attempt(s) by the decedent will be ana- bacterial production.
lyzed, and the presence of alcohol and/or suicide note will be reported. The cause of death was evident at autopsy as ligature strangulation.
The manner of death was not evident. Manners considered included either
Suicide, Hanging, Ligature suicide, supported by the Christmas season and history of depression,
accident due to autoerotic asphyxia, or homicide by another person.
Autopsy findings could not distinguish between these manners of death.
After discussion of this fact with the responsible detective, he elected to
submit the entire ligature for touch DNA determination of the tied belt lig-
ature end.
This case report will discuss how the DNA evidence from the end of
the belt determined the manner and solved the case, with examination of
relevant procedures by forensic personnel at scene and forensic
pathologists at autopsy, with recommendations for future similar scene
investigations.
Touch Preparation DNA, Scene Investigation, Manner of Death
Determination

G86 Guns That Fire Themselves: G87 Handgun to the Head:
Report of Three Cases Suicide Trends in Northern Virginia
Elizabeth L. Kinnison, MD*, and Wendy M. Gunther, MD, Department of Erin E. Falconer, MFS, Danielle L. McLeod, MFS, and Todd M.
Legal Medicine, Virginia Commonwealth University, Medical College of Luckasevic, DO*, Northern Virginia Office of the Chief Medical
Virginia, 1101 E Marshall Street, Richmond, VA 23298-0568 Examiner, 9797 Braddock Road, Suite 100, Fairfax, VA 22032
After attending this presentation, attendees will be able to recognize The goal of this presentation is to identify trends present in suicidal
characteristics of unusual gunshot wound fatalities that suggest accidental handgun wounds to the head.
misfires from dropped guns. This presentation will impact the forensic community and/or
This presentation will impact the forensic community and/or humanity by providing information on the findings associated with suicidal
humanity by increasing awareness of gunshot wound fatalities due to acci- handgun wounds to the head. Emphasis will be focused on the location and
dental misfires from dropped guns, recognition of typical characteristics of characteristics of the wound, caliber of the handgun, result of gunshot
such cases, and familiarity with pistol types which are associated with acci- residue (GSR) testing, presence of a suicide note, and history of mental
dental misfires on dropping. illness/life event.
Most unwitnessed deaths due to distant gunshot wounds are homi- Introduction: Suicide is one of the most important public health issues
cides. Most unwitnessed deaths due to close range or hard contact gunshot in the United States. Suicide represents the eleventh leading cause of death
wounds are suicides. This report discusses three cases in which dropped in the United States. Nearly 20% of the cases autopsied at the Northern
guns accidentally took the lives of their owners, in unwitnessed events Virginia Office of the Chief Medical Examiner in Fairfax, Virginia are ruled
which had to be pieced together by the examining forensic pathologist. suicide. Suicide rates for this country have been relatively stable over the
A 21-year-old man was found shot beside his bed, with a .44 caliber past decade with approximately 10 suicide deaths per 100,000 people. The
revolver beside him. He had no history of depression, strife, worries, or most common method of suicide in the United States is with the use of a
alcohol abuse. A trail of blood led to the body from the bathroom, where firearm.
there was a narrow gouge in the vinyl flooring. There was no soot or stip- Materials and Methods: This is a retrospective review of case files
pling on the skin or the clothing. The bullet entered the right chest, and was from the Northern Virginia Office of the Chief Medical Examiner in
retrieved from the soft tissues of the back, with an angled trajectory through Fairfax, Virginia. Inclusionary data for this pilot study included the cause
all three lobes of the right lung. The gouge in the vinyl flooring was mea- of death as gunshot wound to the head with a handgun as the lethal device
sured, and was found to correspond in size to the hammer of the gun. and the manner of death ruled as suicide for autopsy cases from the years
A 30-year-old man was found shot inside a locked residence. Earlier 2003 thru 2004. A total of 320 suicides were autopsied during this 2-year
in the evening, a 911 call had been placed from the residence, but operators study period. Of these 320 suicides, 113 (35%) were due to handgun
only heard an open line, with no talking. Attempts to re-establish commu- wounds to the head. These 113 cases were reviewed for the following infor-
nication were unsuccessful. Police arrived to find him dead inside of his mation: the location and characteristics of gunshot wounds, the caliber of
locked residence. A .22 caliber pistol, knife, and telephone were nearby. weapon, underlying psychiatric illness/depression or life event, GSR
Autopsy revealed a single gunshot wound to the back of the right inner results, the presence of alcohol, the presence of a suicide note or past
thigh. While it had minimal marginal darkening, there was no soot or stip- ideations/attempts, and the demographics of the decedent. The case infor-
pling. Microscopic examination of the entrance showed evidence of a close mation was organized into a spread sheet and the data was analyzed for any
range of fire. Firearms examination of the clothing revealed a range of fire trends or interesting correlations.
estimated between 6 and 30 inches. The bullet had a steep upward tra- Results: Between the years 2003 and 2004, the Northern Virginia
jectory through the body, ending its course anterior to the lumbar vertebrae, Office of the Chief Medical Examiner investigated 320 suicides. Of these
after lethal iliac artery injury. The gun had marks on the hammer spur, and 320 suicides, 113 (35%) were caused by shooting oneself in the head with
could be fired without pulling the trigger if the hammer was resting against a handgun. Males comprised 87% (98), while females accounted for the
the firing pin. remaining 13% (15). Caucasians accounted for 87% of the cases. Ethanol
A 22-year-old man, seated on his front porch with his friend, and in (>.02% by weight by volume) was present in postmortem toxicology
possession of an illegal gun, observed a police cruiser passing by. Deciding samples in a total of 39 (35%) of the decedents. Gunshot residue (GSR)
to return the gun to his house, he left the porch, and entered the small was present in 61 (87%) out of 70 samples analyzed. Suicide notes were
anteroom that led to his apartment, with an additional exit in the form of present in 44 (40%) cases. The location of the gunshot wound in decreasing
stairs to the upstairs apartment. His friend heard a single gunshot report. frequency: right temple 61 (55%), intraoral 34 (31%), left temple 8 (7%),
He was found dead in front of his door, with his keys beside him in a forehead 6 (5%), submandibular 4 (4%), and back of head 1 (<1%). Two
location that suggested he had been about to unlock the door. Autopsy cases involved multiple gunshot wounds to the head. A .38 caliber revolver
showed a single distant (more than 3 feet) gunshot wound of the abdomen, was the most common handgun used. There was no known or documented
with visceral injuries on a sharply rising course, exiting the back of his history of depression, psychiatric illness or life event in only 7 (6%) of the
neck. Significant history included his involvement in an altercation five decedents. Finally, 6 (5%) of the decedents had a previously documented
days previously, resulting in a fracture in his hand, which had been cast at suicide attempt.
a local emergency room. It proved to be important that the gun was a Conclusions: This pilot study emphasized the role handguns play in
Takharov pistol. suicide. In the years 2003 thru 2004, thirty-five percent of the suicides in
Characteristics of these cases include unusual, sharply angled trajec- Northern Virginia were due to handgun wounds to the head with the right
tories, no evidence of hard contact gunshot wounds in victims with any temple region being the most common location. Interestingly, when hand-
documented suicidal ideation, frequent absence of powder soot or stippling, edness of the decedent was known and reported, only 3 gunshot wounds of
and guns which may be known to misfire on impact. Case discussions entry were located on the opposite side of the decedent’s dominant hand.
highlight these and other useful findings in similar cases. Also, 2 cases involved multiple (2) gunshot wounds to the head. There was
Gunshot Wounds, Dropped Guns, Accidental Misfires only 1 case where the gunshot wound of entry was located to the back of
the head. GSR was positive in 87% and a suicide note was present in 40%
of the cases. Finally, only 7% of the cases had no known/reported history
of depression, psychiatric illness, or life event.
Handgun, Head, Suicide

G88 Evaluation of Less-Lethal Impact Munitions jectile of the same type, which had undergone more extensive deformation
after striking and penetrating the tailgate of a truck. Further investigation
Richard T. Wyant, MS*, Washington State Patrol, 2203 Airport Way identified the projectiles as the Brenneke® Super Sabot shotgun slugs.
South, Suite 250, Seattle, WA 98134; and Chris Myers, and Tom Burns, Homicide, Shotgun, Sabot
Seattle Police Department, 810 Virginia Street, Seattle, WA 98101
After attending this presentation, attendees will learn about the types
of less-lethal munition systems available, their relative safety, and forensic
considerations. G90 Death by a Radio-Controlled Helicopter
humanity by providing a further understanding of the relative safety of less- Ana E. Lopez, MD*, Harris County Medical Examiner, 1885 Old Spanish
lethal impact munitions that will assist forensics examiners in the study, Trail, Houston, TX 77054; Luis A. Sanchez, MD, Harris County Medical
analysis, and reconstruction of events associated with serious injury or Examiner, 1885 Old Spanish Trail, Houston, TX 77054
death. The goal of this presentation is to report an unusual death by a radio-
Law Enforcement is embracing the concept of less-lethal weaponry. controlled helicopter and to discuss the safety issues concerning model
Less lethal options are demonstrating their worth in reducing injury to helicopters with the forensic community.
officers, and often suspects while providing alternatives to higher force This presentation will impact the forensic community and/or
options. The function of these less lethal devices is often misunderstood. humanity by providing awareness of the dangers in the recreational use of
When a negative outcome or even death results from the use of a less lethal radio-controlled aviation models by detailing the types of fatal injuries that
option, the forensic examiner is often called upon to analyze and recon- can occur with these aircrafts.
struct the incident. This case involves a 41- year- old, white male who was instructing
There is currently a lack of independent data useful for the comparison another man on how to operate a radio-controlled helicopter. The scene
of the various products available on the market. Police agencies and was a five-acre, grassy field, designated as an area for model aeronautic
trainers often have to rely on manufacturer and marketing data to select recreation. The instructor had five years of experience with flying radio-
munitions and tools for their agencies. controlled helicopters, whereas his student had just three months of expe-
A study was devised in an attempt to develop a more objective rience. The instructor demonstrated to his student how to hover the heli-
standard. copter, an older model PHI Tornado radio-controlled, and then passed the
Six basic types of specialty impact munitions were examined for this controls to his student. The student hovered the helicopter for a few
initial study; 12 Gauge bean bags, 40mm bean bags, 40mm sponge type minutes and was attempting to land it, when it tilted and came straight
rounds, 37mm ARWEN/Sage variants, FN303, and Pepperball products. toward them. The student immediately threw himself to the ground and
The ordinance was fired at 10 feet and 35 feet into bare and covered bal- was uninjured; however, the instructor was struck by the helicopter blades
listic gelatin. The ballistic gelatin was used to observe energy distribution and died at the scene.
and relative injury potential across the spectrum of munitions tested. At autopsy, the decedent had a 7 by 2 inch, gaping chop wound of the
Less-Lethal, Impact, Bean Bag right side of the neck and chin. The wound injured the sternocleidomastoid
muscle, the strap muscles, the salivary gland, and the right jugular vein.
The mandible was exposed, and the transverse processes of the 4th and 5th
G89 A First Time for Everything: cervical vertebrae were palpable through the wound. He also had linear-
Homicide Involving the Brenneke® patterned abrasions on the right shoulder, right upper arm, and right upper
back. Toxicology for alcohol was negative. An examination of the heli-
Super Sabot Shotgun Slug copter showed fragmentation of the main rotor blades with blood spatter on
the frame and on the rotor blades. The rotor blades were made of fiberglass
Amy Tharp, MD*, and Donald Jason, MD, JD, Department of Pathology, composite and had an interior metal wire along the leading edge. The heli-
Wake Forest University Baptist Medical Center, Medical Center copter measured approximately four feet in length, two feet in height, and
Boulevard, Winston-Salem, NC 27157 had a main rotor span of five feet.
After attending this presentation, attendees will understand the Based on the circumstances of death and type of injury in this case,
physical characteristics of the Brenneke SuperSabot shotgun slug as it per- there seems to be an inherent danger in the design and rotational movement
tains to the practice of forensic pathology, including injury patterns and of the blades used in radio-controlled helicopters. The use of radio-con-
scene interpretation. trolled aircraft is restricted to designated flying fields, and a license is not
This presentation will impact the forensic community and/or required to operate them. Flying fields also have designated areas for the
humanity by introducing a novel projectile, including its physical charac- aircraft operator with separate areas for spectators.
teristics that have never before been reported in a homicide. The recreational use of model helicopters and airplanes is guided by
Sabot shotgun slugs are not a new projectile, but the Brenneke® the Academy of Model Aeronautics, which publishes an official national
Super Sabot shotgun slug has never been reported in a homicide. The model aircraft safety code. In addition, there are many local model airplane
authors present the case of a 28-year-old man killed with multiple gunshot clubs that establish their own rules and regulations about the use of radio-
wounds during an alleged “drive-by” shooting. At autopsy, a 496.2 grain controlled aircraft, based on the official national code. Local clubs usually
slightly deformed projectile with a base diameter of 5/8” (1.7 cm) was have their own posted safety guidelines at their flying fields. The Academy
found within the decedent’s clothing. Six distinct bullet tracks were iden- of Model Aeronautics recommends that qualified instructors should teach
tified. An entrance of the anterior right thigh was 3/4 x 5/8” and ovoid, beginners how to use these aircrafts, as was the case in this situation.
having only passed through the decedent’s jeans. This bullet track passed Instructors, however, are not required for beginners, who can instruct them-
through the soft tissue of the right thigh, exiting out the medial aspect and selves on their use. It is also recommended that people learn to fly airplanes
partially transecting the right greater saphenous vein, re-entering the medial before flying helicopters.
left thigh and re-exiting out the posterior left upper thigh. With the This case illustrates an unfortunate accident where the recreational use
exception of an irregular entrance on the sole of the left foot, which passed of a radio-controlled helicopter by an inexperienced person led to the death
through the decedent’s shoe, all other entrances were less than 1/2” in of another individual.
greatest dimension. Investigating officers recovered an additional pro- Accidental Death, Radio-Controlled Helicopter, Safety Issues

G91 A Fatality Due to Atomoxetine - Autopsy findings reveal a well-developed male with pulmonary
edema and no evidence of natural disease. There were a few abrasions on
The First Known Case the face that were consistent with the terminal fall and body position.
Toxicologic examination of postmortem blood from the inferior vena cava,
Kathryn Haden-Pinneri, MD*, 21827 Hollow Field Lane, Katy, TX 77450 just above the iliac bifurcation, revealed an atomoxetine level of 16 mg/L
The goal of this presentation is to alert the forensic community to the and a small amount of paroxetine (less than 0.10 mg/L). The liver level of
first known fatality associated with Atomoxetine, a non-stimulant med- atomoxetine was 240 mg/kg and paroxetine of <5 mg/kg. These levels of
ication utilized for the treatment of Attention Deficit Hyperactivity atomoxetine are markedly higher than any levels published to date.
Disorder (ADHD). The presence of both the atomoxetine and paroxetine complicates the
This presentation will impact the forensic community and/or toxicologic picture, as they are both metabolized by the cytochrome P450
humanity by alerting forensic scientists and the medical community of the 2D6 enzyme. It has been documented that co-administration of other 2D6
potentially deadly combination of atomoxetine and paroxetine and to inhibitors with atomoxetine can increase serum atomoxetine levels three- to
inform them of the first known fatality due to atomoxetine. fourfold. In one documented non-fatal overdose of atomoxetine alone, the
Attention Deficit Hyperactivity Disorder (ADHD) is a diagnosed con- patient developed seizures and a prolonged QTc, but was medically
dition in which a child exhibits symptoms of inattention, hyperactivity, and managed and survived. Because of the co-administration of these two med-
impulsivity. As these behaviors are part of most developing children at one ications and the lack of suicidal ideations or suicide notes, the manner of
time or another, the diagnosis requires that such behavior be demonstrated death is undetermined. The cause of death is atomoxetine and paroxetine
to a degree that is inappropriate for the person’s age. Diagnostic guidelines poisoning.
exist to aid clinicians in determining if the symptoms displayed represent Atomoxetine, Attention Deficit Hyperactivity Disorder, Paroxetine
ADHD or are just part of normal development. This diagnosis can be quite
controversial amongst physicians, with some feeling that the diagnosis is
fictitious and over-used and others who feel that it is a medically justified G92 Methadone Deaths are on the
disorder and have documented improvement in children with treatment. Increase in Maryland (1998-2004)
This paper serves to provide basic information on ADHD, without bias
towards one view or the other. Mary G. Ripple, MD*, Office of the Chief Medical Examiner, State of
Treatment for ADHD includes behavioral therapy and medication Maryland, 111 Penn Street, Baltimore, MD 21201; Cheryl Rinehart*,
management. Stimulants are typically the class of medication used for Margaret Hsu, Erin Artigiani, and Eric Wish, PhD, Center for Drug
ADHD treatment, and include amphetamine, methylphenidate, and dex- Abuse Research, 4321 Hartwick Road, Suite 501, College Park, MD
troamphetamine. These medications work on the dopamine receptor. 20740; and David R. Fowler, MD, Office of the Chief Medical Examiner,
Atomoxetine is the first and only non-stimulant medication approved by State of Maryland, 111 Penn Street, Baltimore, MD 21201
the FDA for the treatment of ADHD in children, adolescents, and adults.
Atomoxetine works differently than the stimulants in that it is a norepi- After attending this presentation, attendees will learn the details about
nephrine reuptake inhibitor. Evidence to date indicates that over 70 percent the increase in methadone related deaths in Maryland and they will realize
of children with ADHD who take Atomoxetine manifest significant the importance of cooperation between state drug research groups and the
improvement in their symptoms. Over 2 million prescriptions have been medical examiner’s office.
filled since the FDA approved it in 2002. It is not a controlled substance This presentation will impact the forensic community and/or
like the amphetamines; therefore refills may be phoned in, rather than humanity by assisting the forensic community in recognizing local and
having to pick up a refill prescription in person. national trends in methadone related deaths and the need to be diligent in
Because it is a relatively new medication, postmortem blood and checking the information that is given to research groups that share data
tissue levels are not well established. Prior to this case, there have been no with medical examiner’s offices. They will also realize that the cooperative
known fatalities associated with the use of the medication. There have been effort between these groups can result in the elucidation of causes for drug
deaths due to other factors (motor vehicle accidents, hanging, etc) where trends that can be of public benefit.
atomoxetine has been identified, but in low levels. One factor in the lack This presentation will review the increase in Methadone deaths in the
of information regarding postmortem levels is that not all the toxicology State of Maryland from 1998-2004 and discuss the cooperative efforts of
laboratories have the atomoxetine standard to run the samples against. the Office of the Chief Medical Examiner (OCME) and the Maryland Drug
This case is a 17-year-old male with a history of ADHD, depression Early Warning System (DEWS) at University of Maryland’s Center for
and one prior suicide attempt with medications. His social history is neg- Substance Abuse Research (CESAR).
ative for alcohol and tobacco use, but positive for prior recreational mari- Methadone is a narcotic used in the treatment of addictive disorders
juana use. At the time of his death, he had not used marijuana in approxi- and chronic pain. Nationally, methadone associated deaths increased
mately one year. He presented to a psychiatrist in January 2004 with com- rapidly in 2001 and 2002. A national report in 2004 showed that the recent
plaints of difficulty sleeping, indifference towards school, anxiety and increases in methadone use and associated mortality were related to its use
depressed mood. At the time of that presentation, he was taking esci- as an analgesic and not to its use in opioid treatment programs. Maryland
talopram, quetiapine, and lamotrigene. He was diagnosed with Bipolar dis- also showed a significant increase in methadone related deaths from 1998
order and ADHD and the plan was to begin a trial of atomoxetine and taper to 2004.
and stop the lamotrigene. He was also placed on zolpidem, 10 mg each The computerized files of the OCME were searched for all cases pos-
evening. Several days later, he attempted suicide with the zolpidem after itive for methadone by toxicology. These cases were then individually
relationship problems. He had not shown any suicidal ideations prior to reviewed to determine the number of cases in which methadone intoxi-
that. His atomoxetine dose was increased from 40 mg to 80 mg three cation was the only cause of death and those in which methadone con-
weeks from the initial visit and he was instructed to stop the lamotrigene. tributed to the cause of death in multiple drug intoxications. The concen-
Three weeks later, the depression was reportedly improved, his aggression tration of methadone, cause and manner of death, and demographics were
reduced and overall affect seemed “more flexible.” At the time of his death, reviewed for those cases.
his medications consisted of atomoxetine, paroxetine, quetiapine, lam- There was over an eight-fold increase in the number of methadone
otrigene, and zolpidem. He was found face down in a wooded area near his intoxication deaths from 1998 to 2004 with a peak 11-fold increase in 2003.
home, approximately 22 hours after last being seen alive. There was over a five-fold increase in the total number of drug deaths

involving methadone, including methadone only and multiple drug deaths of this drug is essential to arrive at the proper designation of the cause of
involving methadone. During this time the commercial distribution of death. The interpretation of blood methadone concentrations alone or in
methadone increased at a much faster rate than the admissions to combination with other psychoactive drugs must include inquiry con-
methadone treatment programs. Most decedents were white males in their cerning the victim’s potential chronic use and tolerance of the drug.
late 30s and early 40s. Over the years, the residents of Baltimore City made Research shows that pharmacogenetics play an equally important role in an
up a decreasing proportion of the deaths. Medical conditions contributing individual’s metabolism of methadone and other opiates. This presentation
to death made up a small percentage of cases. In all cases, the most com- will impact the forensic community and/or humanity by demonstrating
monly found drugs were antidepressants. The most common other lethal why further forensic study should focus on the interplay of drug metab-
drug was morphine in the multiple drug intoxication deaths. The most olism with potential genetic links in individuals who die from opiate drug
common manner of death was undetermined. There was no significant dif- intoxication.
ference in the concentration of methadone in the methadone only vs. mul- Methadone, a synthetic opioid, received approval by the U.S. Food &
tiple drug intoxication deaths. The source of the methadone was unknown Drug Administration (FDA) in 1947 for use as an analgesic. By 1950,
in over 50% of the cases and this spurned a pilot study in which OCME physicians prescribed it for the treatment of withdrawal symptoms asso-
pathologists collected additional information from September 2004 to May ciated with heroin and other opioids. The majority of methadone-asso-
2005 about each decedent’s source of methadone using a specially prepared ciated deaths in this study include at least one other drug, in most cases
CESAR form. Even using the form, information about the source of another opioid or central nervous system depressants such as benzodi-
methadone was still unknown for over 50% of the cases. azepines. The synergistic effects of methadone in combination with
Our review has findings similar to the national review, in that dece- ethanol, benzodiazepines, or other opioids may be lethal. Methadone-asso-
dents most likely obtained methadone through means other than treatment ciated deaths skyrocketed in the early 2000’s: a greater number of these
programs. The increase in methadone deaths appears to be due to the pro- deaths were reported to MedWatch (FDA’s Safety Information and Adverse
curement of legally prescribed drug for chronic pain or illegal diversion and Event Reporting Program) in 2001 alone than in the previous decade; the
street sales and does not appear to be from its use in treatment programs. number doubled once again in 2002. The dramatic increase is likely due to
Investigators were not asking specific enough questions about the source of a rise in consumption attributable to either (a) the rise in prescription of oral
methadone. If additional information was requested on the CESAR form methadone to outpatients for chronic pain management, or (b) the greater
and that information was not needed for the determination of cause and availability of “street” methadone, which may account for overall increases
manner of death, then additional calls were not made and the information in illicit drug diversion tactics and usage.
was listed as unknown. In the future, OCME investigators will be paid by This study reviews 176 methadone-related deaths involving post-
funds from CESAR to collect the desired information for these forms. mortem examination with toxicological analyses at the Office of the Chief
Thus, in the near future, an answer to this question shoul be available. Also, Medical Examiner in Louisville, Kentucky between 2000 and 2004.
as a result of this review, the OCME adopted a new protocol in which each Analysis by the Kentucky Office of Forensic Toxicology revealed that
separate drug is now listed in the cause of death and this will facilitate sta- more than a ten-fold increase in methadone-related fatalities occurred,
tistical research. varying from 6 cases in 2000 to 68 cases in 2003. Sixty percent were
Methadone, Research, Maryland males; all were Caucasian. Individuals ranged between 17 and 60 years
(mean age: 38). The average body mass index (BMI) was 26.2. The
Coroner’s investigation reported methadone use in 95 (54.0%) cases. Of
these, 46 (48.4%) involved prescription by private physician, 19 (20.0%)
obtained the drug illegally, 9 (9.5%) received it through a methadone
G93 Methadone-Related Deaths: A Review of treatment clinic, and 21 (22.1%) acquired methadone by unknown means.
Of the 46 individuals receiving physician-prescribed methadone, 23
Medical Examiner Cases in a Large (50.0%) either initiated or refilled their prescriptions < 10 days prior to
Metropolitan Area death. One-third of these had been undergoing pain management, as sup-
ported by the Coroner’s documented clinical history and, in some cases, in
Lisa B. Shields, MD*, Donna M. Hunsaker, MD, and Tracey S. Corey, MD, conjunction with a lumbar or other significant surgical scar.
Office of the Chief Medical Examiner, Urban Government Center, 810 In view of the broad overlap in blood methadone concentrations in
Barret Avenue, Louisville, KY 40204; John C Hunsaker III, MD, JD, Office cases of toxicity compared to tolerant individuals on maintenance, inter-
of the Associate Chief Medical Examiner, University of Kentucky pretation of the postmortem blood methadone concentration was uniquely
Department of Pathology and Laboratory Medicine, 100 Sower Boulevard, individualized for each subject. Evaluation included consideration of the
Suite 202, Frankfort, KY 40601-8272; and Michael K Ward, MS, Kentucky history of past exposure, including amount, frequency, and duration of con-
Medical Examiner’s Program, Office of Forensic Toxicology, 100 Sower sumption, in an effort to determine whether the subject developed tolerance
Blvd Suite 202, Frankfort, KY 40601 to methadone. With application of this evaluative methodology, a total of
130 (73.9%) individuals had toxic or lethal blood concentrations of
The goals of this presentation are to (1) to present a review of
methadone. The blood alcohol concentration (BAC) was negative in 152
methadone-related fatalities encompassing comprehensive medicolegal
(86.4%) of cases, while 9.1% had a BAC ? 0.1%; 4.0% had a level between
death investigations conducted at the Office of the Chief Medical Examiner
0.1% - 0.2%; and one victim had a level between 0.2% - 0.3%. The fol-
in Kentucky between 2000 and 2004; (2) to offer guidance in the interpre-
lowing psychoactive medications were detected in the blood: benzodi-
tation of toxicological data involving methadone, specifically in the context
azepines (33.0%), antidepressants (39.2%), and other opiates (27.8%). The
(a) of the victim’s use of methadone prior to death and (b) of combinations
P450 metabolizers, promethazine and diphenhydramine, were frequently
with other drugs, particularly benzodiazepines, antidepressants, and other
observed in combination with methadone, at 14.2% and in 10.2%, respec-
opiates.
tively. Urine was collected in 88.1% of cases. In addition to blood con-
The documented rapid rise in methadone-related deaths in Kentucky
centrations of drugs noted above, the urine screen confirmed cannabinoids
and nationally requires a better understanding of its pathophysiology and
in 28.4% and cocaine or its metabolites in 21.9% of all cases.
the ways it contributes to significantly increased morbidity and mortality.
A thorough investigation into the practices of procurement and use/abuse Methadone, Opiates, Pain

G94 The Value of Expanded Postmortem Sudden deaths from the rupture of an arteriovenous malformation
(AVM) are rare in forensic pathology practice. This presentation will
Toxicology Testing Menu impact the forensic community and/or humanity by illustrating the impor-
tance of understanding this entity to avoid confusing an AVM with child
Luis E. Remus III, PhD, MD*, Ashraf Mozayani, PhD, abuse.
Terry Danielson, PhD, and Luis A, Sanchez, MD, Harris County The goal of this presentation is first to differentiate the four major
Medical Examiners Office, 1885 Old Spanish Trail, Houston, TX 77054 groups of vascular malformations of the brain, which are arteriovenous
After attending this presentation, attendees will understand the value malformation (AVM), cavernous angioma, venous angioma and capillary
of retaining alternative tissues for postmortem toxicological analyses. telangiectasia, and secondly, to describe their implications in forensic
This presentation will impact the forensic community and/or pathology.
humanity by demonstrating the utility of alternative postmortem tissue AVMs consist of tangled masses of tortuous arteries and veins devoid
analysis in determining defensible cause of death. of intervening capillaries that frequently extend from brain parenchyma
The objective of this presentation is to relate experiences from the into the subarachnoid space. Cavernous angioma is a tightly packed col-
Harris County Medical Examiner’s Office regarding use of brain tissue, as lection of hyalinized vascular channels most commonly found in the cere-
a supplement to blood, for the postmortem identification of cocaine and its bellum, pons and subcortical regions. Venous angioma is composed of
metabolites. varicose veins generally located in the cerebral white matter. Capillary
First reported by Spiehler and Reed in 1985 (1), and then further clar- telangiectasia appears as a collection of small-caliber, very-thin-walled
ified by Karch in 1998 (2), the concentrations of cocaine (COC) and ben- channels most likely found in the pons. Cavernous hemangioma is the only
zoylecognine (BE) in brain parenchymal tissue are vital components to a malformation lacking intervening brain parenchyma. AVM and cavernous
defensible cause of death due to cocaine intoxication. angioma often cause hemorrhages. On the other hand, venous angioma and
Over a 16-month period, in Harris County, there were 58 cases ini- capillary telangiectasia are typically asymptomatic.
tially designated as undetermined but were suspected of being cocaine- AVM is a rare cause of sudden death. In forensic context, six cases of
associated deaths. Brain tissue from each of these cases had been obtained such deaths have been reported, in three different papers. In five of these
as part of the routine autopsy protocol at the time of necropsy. Due either reported cases, children aged 5 to 10 years old complained of headache and
to insufficient quantity, the complete lack or poor quality, of blood spec- went to lay down, and later found dead from a ruptured AVM within the
imens taken from these cases, the traditional blood analyses did not identify cerebellum. The other one is an 8-year-old boy found dead in a swimming
COC or its metabolites and did not contribute to the determination of cause pool after rupture of an unsuspected brain AVM.
or manner of death. Subsequently, the brain tissue was analyzed for the Presented here is the case of a 14-year-old girl who died from a rup-
presence of COC, BE, and/or cocaethylene (CE). Of the 58 cases analyzed, tured arteriovenous malformation of the brain. The girl was in good health
35 (60%) COC, BE, and/or CE was found in the brain tissue. As a result, except for asthma. The eldest of nine, she lived in a family that was part of
35 cases that would potentially have been classified as undetermined could a marginal community. Her parents were members of a group that allowed
be closed and signed out as cocaine-associated deaths. child beating and refused all vaccination and modern medicine.
While the analysis of brain tissue should not be considered as a routine The girl was found dead in the morning, lying on her bed, her legs
procedure, the collection of parenchymal tissue (e.g., brain) should be hanging off the side. Child brutality was suspected at first sight because of
incorporated as part of the autopsy procedure. Even if not actually ana- a bluish coloration on the side of her face, which was later proven to be
lyzed, this tissue may prove to be invaluable when more routine analyses livor mortis. On the previous morning, she was feeling fine and went to
prove to be non-contributory to the cause of death determination. Other school. At noon, she started to feel sick. She vomited twice and complained
solid tissues or alternative specimens such as hair, nail clippings, maggots, of headache and nausea. Her body temperature was normal. She went home
and other solid organs are proving to be useful in postmortem toxicological and went to bed by 6 pm, and later found dead the next morning.
analyses. External examination of the 60-pound and 4-foot-5 girl revealed
In conclusion, the Harris County Medical Examiner’s Office has nothing worthy of note. At internal examination, the 1580-gram brain
observed the utility of alternative specimens, such as brain, in the determi- showed massive edema with intracerebral hemorrhage and secondary
nation of cause in cocaine-related, or suspected, deaths. necrosis around the left lateral ventricle, extending to the ventricle with
References: widening of the latter. Microscopically, the lesion was composed of
1. Spiehler VR, Reed D, Brain Concentrations of Cocaine and different caliber thick-walled vascular channels surrounded by intervening
Benzoylecognine in Fatal Cases, Jour Foren Sci, 1985, 30(4):1003-1001. reactive cerebral parenchyma, with gliosis and hemosiderin deposits. The
2. Karch SB, Hearn L, Mash D, and Ruttenber J, Postmortem Diagnosis of abnormal vessels extended into the subarachnoid space in some areas. The
Cocaine Toxicity: The Utility of Brain Concentration Measurements, rest of the autopsy was unremarkable except for mild lung congestion.
SOFT-TIAFT Meeting, October 1998, Albuquerque, NM. Toxicological analysis reveals only a therapeutic dose of acetaminophen.
The death was attributed to a rupture of a cerebral AVM and the manner of
Cocaine, Alternative Tissue Testing, Cause of Death
death was ruled natural.
The present case is a reminder that the forensic pathologist should be
able to recognize an AVM and know how to differentiate it from the others
G95 Arteriovenous Malformation and its types of cerebral vascular malformations. Although rare, it can be a cause
Implications in Forensic Pathology: of sudden death, and should be considered in the differential diagnosis of
A Case Report intracerebral hemorrhage, and not confused with trauma, especially in
children.
Anny Sauvageau, MD, MSc*, Laboratoire de Sciences Judiciaires et de Sudden Death, Arteriovenous Malformation, Forensic Pathology
Médecine Légale, 1701 Parthenais Street, 12th Floor, Montreal, Quebec
H2K 3S7, Canada
After attending this presentation, attendees will gain better knowledge
and understanding of the four types of vascular malformations (mor-
phology, usual location, outcome) and their implication in forensic
pathology.

G96 Sudden Death in the Young in Australia among 10- to 20-year-olds in a large urban population, the frequency of
drugs and alcohol in the study group, and the relationship of suicide to other
Johan A. Duflou, MBChB, MMed *, Department of Forensic Medicine, factors studied. This information will further assist in the formation and
PO Box 90, Glebe, NSW 2037, Australia; and Rajesh Puranik, MBBS, implementation of prevention strategies.
Clara K. Chow, MBBS, Michael J. Kilborn, DPhil and Mark A. After steadily increasing during the late 1970s through the early
McGuire, MBBS, PhD, Department of Cardiology, Royal Prince Alfred 1990s, the Centers for Disease Control and Prevention reported that
Hospital, Missenden Road, Camperdown, NSW 2050, Australia between 1992 and 2001 the overall suicide rate for 10 to 19-year-olds in the
United States decreased from 6.2 to 4.6 per 100,000 population. In 2001,
After attending this presentation, attendees will have a good under- suicide was the third leading manner of death behind accidents and homi-
standing of the range of causes of sudden death in young persons, and be cides among 10 to 19-year-olds. In the United States, approximately 2000
able to implement recommendations made from this analysis. adolescents commit suicide annually. Nationwide, 8.5% of students in
This presentation will impact the forensic community and/or grades nine through twelve report that they have attempted suicide. Of
humanity by providing a greater understanding of the range of diseases those attempts, 2.9% required medical attention for their injury or
causing sudden death in the age range 5 to 35 years. overdose. Several major risk factors for adolescent suicide have been iden-
Objective: To determine the causes of sudden natural death in persons tified. Although a history of a previous suicide attempt is a known risk
aged 5-35 years. factor, according to the American Psychiatric Association, many teen
Method: A review of all autopsies conducted at a forensic medicine suicide completers have never made a prior attempt. Other identified risk
facility for the years 1995-2004 (inclusive). This facility serves over 2.5 factors include a history of a psychiatric disorder (most commonly a mood
million people in the eastern part of Sydney, Australia. Data collected disorder either alone or in combination with a conduct disorder or sub-
included the subjects’ age, height, weight, gender, circumstances of death stance abuse), a history of sexual abuse, and a history of parental psychi-
and pathologic findings at autopsy. Deaths caused by trauma, accidental atric disorder. A family history of psychiatric disorder probably increases
causes, drowning and drug toxicity were excluded from the analysis. the risk of suicide in two ways: by bestowing genetic vulnerability and cre-
Results: There were 427 non-traumatic, sudden deaths in the 10-year ating home and living conditions with decreased social support, which
period (70.7% male). Cardiac causes accounted for 56.4%, non-cardiac increases stress at home. Girls are three times more likely to attempt suicide
causes for 39.3% and the cause was not determined in 4.3%. The most when a psychiatric condition is present in association with alcohol use or a
common cardiac cause for sudden death was presumed arrhythmia in those conduct disorder. Peer related violence also appears to increase the level of
with no or minimal structural heart disease (29.0%). Other causes were suicide risk for boys and girls. A recent study found that several of the
acute myocardial infarction (24.5%), myocarditis (11.6%), hypertrophic known risk factors for completed suicide are constant across cultures and
cardiomyopathy (5.8%), aortic dissection and dilated cardiomyopathy countries. The precipitating event, according to one study, occurred from
(5.4% each). Over two-thirds of deaths caused by acute myocardial within 24 hours of death up to one year prior to death. The most frequent
infarction occurred in the 30-35 year age group. Sudden cardiac death precipitants within the week prior to death were difficulties in, or the end
occurred during physical activity in 10.8% of cases. Sudden cardiac death of, a relationship, and arguments with relatives and friends.
had been reported in a first-degree relative in 4.5% of decedents. The most The most common method, identified in numerous studies, is
common non-cardiac causes for sudden death were epilepsy (23.8%), intra- firearms. This is followed by asphyxial deaths - most commonly caused by
cerebral hemorrhage (23.8%), asthma (16.1%), and pulmonary embolism hanging. Beginning in 1997, however, among 10 to 14-year-olds, asphyxia
(12.5%). became the most common method, exceeding deaths caused by firearms.
Conclusion: Presumed cardiac arrhythmia is the most common cause The explanation for this change is unclear. It may in part be due to youth
of sudden natural death in the young. There was no reported history of focused firearm laws which are intended to keep firearms away from
sudden death among the relatives of most decedents. teenagers - such as gun safe storage laws known as child access prevention
Sudden Death, Arrhythmia, Autopsy laws. Many states have adopted laws, which establish a minimum age for
legal possession and purchase of a firearm in response to studies that have
consistently found that the presence of firearms in the home increases the
risk of adolescent suicide. In 1994, a federal law established 18 years as
G97 Suicide Among 10 to 20 Year Olds in Cook the minimum legal age for purchasing and possessing handguns. Illinois
County, Illinois: A Retrospective Review has a minimum age of 21 years for the purchase and possession of a
firearm. Interestingly, a study examining the association of these laws and
Adrienne E. Segovia, MD, Clare H. Cunliffe, MD*, Mitra B. Kalelkar, MD, suicides found that among 14 to 17-year-olds there was no statistically sig-
and Michelle Jorden, MD, Office of the Medical Examiner, County of Cook, nificant association between suicide rates and laws setting minimum ages
2121 West Harrison Street, Chicago, IL 60612 for firearm purchase or possession. This study did find a modest reduction
in suicide rates among the same age group associated with child access pre-
After attending this presentation, attendees will learn the risk factors vention laws. Their model estimates that in the absence of the law the
and most common methods of suicide in this age group. expected suicide rate in this age group would be 6.51 per 100,000 rather
This presentation will impact the forensic community and/or than the observed 5.97 per 100,000.
humanity by identifying the following: the methods used to commit This study examines suicides in children and adolescents who live in
suicide among 10- to 20-year-olds in a large urban population, the fre- Cook County, Illinois, a large culturally and racially diverse, primarily
quency of drugs and alcohol in the study group, and the relationship of urban setting. Cook County, which includes the city of Chicago, has a pop-
suicide to other factors studied. This information will further assist in the ulation of 5,376,741 according to the 2000 census. Caucasians comprise
formation and implementation of prevention strategies. 56.3% of the population, including 19.9% that are of Hispanic ethnicity,
The goal of this presentation is to present a review of the findings of African-Americans comprise 26.1 %, Asians 4.8%, and other racial back-
a retrospective study of suicide deaths among 10- to 20-year-olds in Cook grounds 12.8 %. The same census indicates that the city of Chicago has a
County, Illinois between 1994 and 2004. After attending this presentation population of 2,896,016, and a slightly higher African American population
the attendee will be able to recognize the risk factors and most common — 36.7% — than the county. In the city, Caucasians comprise 42% of the
methods of suicide in this age group. population, Asians 4.3% and other racial backgrounds 17%.
This presentation will impact the forensic community/and or This study explores the demographics, seasons, methods, situational
humanity by identifying the following: the methods used to commit suicide factors, presence of drugs, presence of notes, history of previous suicide

attempts and the identification of known risk factors/stressors when pos- G98 Immunohistochemical Examination
sible. With cases involving gunshot wounds, the location of the injury, the
caliber, and ownership of the weapon, (when available), was noted.
of α-Lactalbumin in SIDS (Sudden
In the time period examined there were 254 cases of suicides: 205 Infant Death Syndrome)
male (81%) and 49 females (19%). The majority involved Caucasians, 120
(47%), followed by African-Americans, 87 (34%). Hispanics accounted for Annalisa Addante, MD, PhD*, Fiorenza Zotti, PhD, Andrea Marzullo, MD,
42 (17%) of the cases. Among Asians, there were 5 (2%) suicide deaths. Alessandro Dell’Erba, MD, PhD, and Massimo Collonna, MD, Section of
The majority of the cases occurred in the 16- to 19-year-old age range, Legal Medicine, University of Bari, Piazza Giulio Cesare, Bari, 70124,
accounting for 74%. Overall, the leading cause of death was from a firearm Italy
injury, 48%, followed by hanging, 38%. Among 10- to 14-year-olds,
however, the leading cause of death was asphyxia (hanging), which
usefulness of semiquantitative comparison of á-lactalbumin immunohisto-
accounted for 65.8%. This is similar to a national trend in this age group,
chemical staining in evaluating cases of suspected SIDS (Sudden Infant
reported by the Centers for Disease Control and Prevention in June 2004,
Death Syndrome).
in which asphyxial deaths surpassed firearm deaths. Three methods tied for
third, each accounting for 3%. The three were pedestrians who stepped in
humanity by demonstrating the use of alpha-lactalbumin in the diagnosis of
front of vehicles, carbon monoxide deaths, and falls from heights. Drug
SIDS. The aim of this study is to evaluate the presence or absence of milk’s
overdoses accounted for 2%. Self-immolation, drowning, and incised/stab
particles within pulmonary histologic sections of 10 infants whose cause of
wounds, each accounted for 1%.
death was suspected to be asphyxia due to human breast milk aspiration.
The number of suicides was fairly uniform throughout the year. There
α-Lactalbumin is a whey protein. Previous immunohistochemical
were slightly more deaths during the spring (29%), compared to autumn
research with this antibody in SIDS deaths has been useful in some cases
(27%), summer (24%), or winter (20%). A history of previous suicide
where aspiration was suspected as a cause of death (Iwadate K. et al.,
attempts was identified in 11%. Depression and/or another psychiatric dis-
2001).
order were found in 23%. Suicide notes were left by 28%.
The authors selected 10 cases of SIDS from the archives of the
Toxicology studies revealed the presence of alcohol, and/or drugs
Section of Legal Medicine and Pathological Anatomy of the University of
(cocaine, benzoylecgonine, opiates, methadone and phencyclidine) in
Bari. All tissues were embedded in paraffin. In order to demonstrate aspi-
19.3%. Blood alcohol levels ranged from 12 mg/dl to 350 mg/dl (mean:
rated milk within the lungs, histological sections stained with Hematoxylin-
109.6 mg/dl).
Eosin (H&E) were initially evaluated. In each case, and when the staining
Although the data from retrospective studies cannot predict who will
was positive or suspected by H&E, immunohistochemical staining using
commit suicide, by identifying risk factors, strategies and intervention, and
commercially available anti-human α-lactalbumin antibodies was
assistance programs can be implemented for those who may be at risk.
performed.
Families, friends, school personnel and healthcare providers need to con-
The authors compared the results of the 10 infants with pulmonary
tinue their vigilance because the complexity of childhood and adolescent
sections from a control group of five infants in which the cause of death
suicide requires multiple strategies to identify and assist those at risk.
was due to a cardiac malformation. In the control group of five deaths,
Childhood and adolescent depression is more common than many adults
none were positive for the antibody, while in the studied group there were
believe. In this study, 23% had a psychiatric history, and/or a history of
two kinds of results. In the experimental group, one pattern showed small
depression. It is estimated that for every completed suicide there are
quantity of protein suggestive for a gastroesophageal reflux or cardiopul-
between 100 to 200 suicide attempts.
monary resuscitation, with both of these factors a cause of terminal
Depression in children and adolescents can be misinterpreted as anger
inhalation. In the second pattern, there was clear positivity of immunohis-
or sullen behavior. The years between ages 10 to 20 can be a difficult time.
tochemical staining. This result was clearly interpreted to mean that aspi-
Warning signs or behaviors can be subtle and may be mistaken as typical
ration was the cause of death.
growing pains. Some signs of depression include: unhappiness, isolated
This method allows the pathologist to evaluate in a semiquantitative
behavior, drop in school performance, loss of interest in activities that were
manner for the possibility of milk aspiration (Iwadate K. et. al., 2001).
formally sources of enjoyment, increase in physical complaints, fatigue,
Using this technique, the authors are able to evaluate in detail cases in
lack of energy or motivation, changes in sleeping and eating habits,
which the circumstances, the autopsy, and the classical histological
increase in drug and alcohol use, outbursts of temper, irritability, rest-
techniques alone do not allow for a definitive diagnosis. It is possible that
lessness and reckless or dangerous behavior. It is important to remember
a re-examination of cases of SIDS using this technique could be useful in
that the traumatic events, which are the triggers or catalysts for suicide in
evaluating for the possibility of breast milk aspiration.
this age group, may seem minor from an adult’s perspective (such as failing
a test/class, getting into an accident, breaking up or being rejected). There Lactalbumin, Breast Milk Aspiration, Immunohistochemistry
is no single theory, which explains why children and teenagers take their
lives in great numbers. Strategies in the home may include restricting
access to medications and firearms. Child firearm access prevention laws
can only go so far because, ultimately, laws cannot protect those intent on
harming themselves.
Suicide, Methods, Children & Adolescents

G99 Forensic Approach in a Case of medical history of the children before death, macroscopic and microscopic
autopsy findings and the results of toxicological examination, exclude any
Simultaneous Sudden Infant traumatic injury, carbon monoxide or drug intoxication, and led us to con-
Death Syndrome clude that acute respiratory failure from interstitial pneumonia was the
cause of the deaths. The presence of environmental risk factors such as the
Francesco M. Morreale, MD*, Irene Riezzo, MD, Stefano D’Errico, MD, ambient air temperature in the infants’ room, number and position of
and Raffaella Bisceglia, MD, Institute of Forensic Pathology Foggia covers, type of bed, prone sleeping position, cosleeping, mother’s cigarettes
University, V.le Luigi Pinto 1, Foggia, 71100, Italy abuse, and recent signs and symptoms of illness, acting at the same pro-
longed time on each baby, had to be considered relevant in justifying the
Simultaneous Sudden Infant Death Syndrome (SSIDS) has received
simultaneity of the lethal event.
limited attention in the medical forensic literature with only a few articles
directly addressing this topic. The goal of this presentation is to present a Simultaneous Sudden Infant Death Syndrome, Acute Respiratory
rare case of simultaneous sudden infant deaths (SSIDS) in twin infants. Failure, Interstitial Pneumonia
The complete multidisciplinary approach from scene investigation, autopsy
examinations, and performance of toxicological testing, satisfies the SIDS
criteria and explains this simultaneous lethal event. G100 Infant Position and the Assessment of
This presentation will impact the forensic community and/or Risk Factors for Asphyxia: A Review
humanity by reporting the simultaneous death of a pair of twins. The rarity
of the event makes it peculiar and the described complete pathologic inves- of 209 Sudden Unexpected Infant Deaths
tigation (death scene investigation, autopsy examination, and toxicological
screening) is strongly recommended in SIDS and is warranted in SSIDS Melissa A. Pasquale-Styles, MD*, Wayne County Medical Examiner
cases. Office, 1300 East Warren Avenue, Detroit, MI 48207; Patricia L.
The case of a simultaneous death in premature, identical male Tackitt, RN, MS, Michigan Public Health Institute, 2438 Woodlake Circle,
monozygotic, 138 days old twins who were found lifeless in their crib three Suite 240, Okemos, MI 48864; and Carl J. Schmidt, MD, Wayne County
or four hours after feeding is presented. In the history given by the mother, Medical Examiner Office, 1300 East Warren Avenue, Detroit, MI 48207
she stated that early in the morning she fed her sons and then put them at After attending this presentation, attendees will understand the impor-
one end of their crib. A few hours later she found the babies in prone tance of a scene investigation, preferably with reenactment using a doll, in
position, cyanotic and breathless. She immediately took each of them out identifying the risk factors for asphyxia in a sudden, unexpected infant
of the crib, wet their faces, and alerted medical rescue, meanwhile trying to death.
unsuccessfully resuscitate them. It was also noted that the babies suffered This presentation will impact the forensic community and/or
from a cough and respiratory difficulties with mucus production for the last humanity by demonstrating how historically, the investigation of an infant
few days, and were seen by a general practitioner who prescribed a cough death has focused predominately on autopsy and microscopic findings with
syrup. The mother also stated that both babies refused feeding before their little understanding or consideration of the risk factors for asphyxia at the
deaths. The extended family had no history of prior SIDS deaths. After scene. Since most infant autopsies are negative for significant disease or
death notification, the authority immediately alerted a forensic pathologist injury, many of these have traditionally been called sudden infant death
and a detailed scene investigation was performed. Upon the death scene syndrome (SIDS). Even in some cases where asphyxia was strongly sus-
investigation, the babies were found lying on the sofa in the restroom of a pected at the scene, such findings have been ignored in favor of a SIDS
small and poorly furnished apartment situated on the ground floor. A diagnosis or cause of death based on some evidence of natural disease at
domestic gas stove was connected to its fuel cylinder and was found cold autopsy such as a respiratory tract infection. By ignoring risk factors for
to the touch in the same room. A technical assessment performed by fire asphyxia in many cases, pathologists have missed emphasizing a major
fighters revealed that the gas supply system was functioning perfectly. The cause of sudden infant death through the years.
mother, except for cigarette abuse, denied risk factors for SIDS, such as At the Wayne County Medical Examiner Office in Detroit, Michigan,
maternal alcohol consumption and legal or illegal drug use during the preg- from 2001 to 2004, scene investigations were performed on 209 sudden
nancy. Internal temperature of the infants measured by means of a bulbus and unexpected infant deaths, ages 1 day to 12 months. This included a
thermometer was 29°C each, and external temperature was 10°C. Rigor follow-up visit, usually performed by a public health nurse. A reenactment
mortis was present and livor mortis was represented by fixed reddish- of the position of the infant’s body when found using a doll took place in
purple coloration localized on anterior part of the body. External exami- all except 7 scenes where parents refused or a doll was unavailable. The
nation was unremarkable, showing no sign of traumatic injuries and/or 209 cases were reviewed to assess the position of the infant at the time of
signs of compression of the nose or mouth or upper airway obstruction. discovery and identify the common risk factors for asphyxia including bed
Only an intense cyanosis on lips and nails was observed. Complete sharing, overlay, wedging, strangulation, and prone position, demonstrated
autopsies two days later were performed. In both cases, cardiac sections obstruction of the nose and mouth and coverage of the head by bedding.
showed a septum secundum atrial septal defect, the lungs were hypoex- Sixty (28.7%) of these infants died in their cribs, 110 (52.6%) died after
panded and heavy with diffuse, firm, red boggy parenchyma, with the being placed to sleep in adult beds, 25 (12.0%) died after being placed to
presence of white fluid in the upper respiratory tracts. Examination of other sleep on couches, 5 (2.4%) died in car seats and 9 (4.3%) died in miscella-
organs showed cerebral edema, epicardial petechiae, and intense vascular neous other locations. Conclusive evidence of asphyxiation including wit-
congestion. Histological examination of the hearts revealed the presence of nessed overlay, wedging, or strangulation was established in 27 cases
multiple foci of myocardial contraction band necrosis, and myofiber break- (12.9%). Bed sharing occurred in 114 deaths (54.5%). An infant position
up. Examination of the sinoatrial (SA) node and the bundle of His revealed with demonstrated complete obstruction of the nose and mouth upon dis-
no abnormalities. The lungs showed subpleural haemorrhages, alveolar covery was shown in 64 cases (30.6%). Prone positions on soft bedding +/-
septa mildly thickened by edema, capillary congestion, alveolar edema, and partial obstruction of the airway, general prone position, and/or coverage of
interstitial infiltrates with leukocytes. No other findings were found except the head by bedding were documented in 30 cases (14.4%). Overall, one
for brain edema and generalized intraparenchymal acute hemostasis. A or more risk factors for asphyxia were identified in 178 out of 209 cases
complete toxicological screening was performed to test for concentrations (85.2%). Nonspecific criteria which may complicate breathing in an infant
of bromexine in blood and urine, and for determination of HbCO in the with airway compromise were identified in 59 out of 178 infants with
blood. Results of the analysis excluded toxic values for drugs, including asphyxia risk factors (33.1%) and included symptoms of the flu or upper
carbon monoxide. Data provided from the death scene investigation,

respiratory infection, medication with sedating decongestants, known res- The stomach contained 300cc of light pink fluid without any food
piratory complications of prematurity and/or a previously diagnosed fragments. The intestinal contents were of a similar consistency to that of
medical condition for which they were not exhibiting acute symptoms. the stomach and light tan in color. The brain had markedly small cerebellar
Thirty-one of 209 infants (14.8%) had no discernible risk factors for hemispheres and atrophic optic nerves. The hippocampi were atrophic and
asphyxia. The information gathered at the scene investigation regarding the the lateral and fourth ventricles were mildly dilated. Microscopic sections
infant’s position at death was completely different from the initial death from the pancreas, heart, lungs, liver, kidney, adrenals, thymus, and trachea
report in 26 of 209 cases (12.4%) and revealed additional information were normal. Vitreous electrolytes included a glucose of598mg/dL, vit-
regarding asphyxia risk factors in 92 cases (44%). Of the 209 infants, the reous osmolality 430mOsm (285-305mOsm), sodium-158mEq/L,
cause of death of 49 (23.4%) was determined to be position-related chloride-140 mEq/L, urea nitrogen-37mg/dL, and creatinine-1.0 mg/dL.
asphyxia, 35 (16.7%) were natural causes (with pneumonia/airway inflam- Acetone was negative. Stool culture was positive for rotavirus. Toxicology
mation and congenital heart disease predominating), 67 (32.1%) were des- was positive for liver acetaminophen with25mcg/gm, and liver salicylate
ignated sudden infant death syndrome (SIDS), 57 (27.3%) died of indeter- of3.5mg/100gm.
minate causes and 1 case was ruled accidental aspiration of food. The Diarrhea illness, world wide, represents a leading or second cause of
increasing awareness in risk factors for asphyxia at the scene has led to a death for children less than five years old. In the United States only about
reduction in the diagnosis of SIDS at the Wayne County Medical Examiner 300 child deaths per year are due to diarrhea.
Office from 38 in 2000 to 2 in 2004 (94.7% decrease). In this same time HHNS is almost always a disorder of Type II diabetes mellitus in
period, the diagnosis of position-related accidental asphyxias in the 1-day elderly, neglected, or debilitated adults. In HHNS, glucose levels are ele-
to 12-month age group increased by 283% from 6 to 17 and indeterminate vated, often as high as 1000 mg/dL or more. Ketones are negative because
causes of death increased by 900% from 3 to 27. This study suggests that lipolysis is inhibited. Serum osmolarity is high, with the measured level
asphyxia plays a greater role in many sudden infant deaths than has been being higher than the calculated level. Acidosis may occur, and is usually
historically recognized, and a thorough scene investigation with doll re- due to lactate from hypoperfusion.
enactment is an effective way to identify the risk factors. A better under-
Fewer than 30 cases of HHNS have been reported in children since
standing of the significance of these risk factors is needed so that the causes
of many sudden infant deaths can be determined and appropriate preventive 1960. In most of these, the children are less than two years old and/or neu-
measures reinforced. rologically impaired. Mortality is as high as seventy five percent, and
occurs from dehydration or from cerebral edema if rehydration occurs too
Sudden Infant Death, Infant Position, Asphyxia rapidly.
HHNS in children represents either the initial presentation of diabetes
mellitus, or it is associated with gastroenteritis, usually rotavirus, as was the
G101 Hyperglycemic Hyperosmolar Nonketotic case with this child. When HHNS is associated with gastroenteritis it is a
Syndrome in a Sixteen-Month Old transient condition and, if the child survives, they have no greater risk of
developing diabetes mellitus than the rest of the population. The mean
Child With Rotaviral Diarrhea glucose level (634 mg/dL) is lower, and the sodium is higher (mean 135
mEq/L), when gastroenteritis is the cause of HHNS.
Mary E. Carr, MD*, and Andrew M. Baker, MD, Hennepin County Suggested laboratory studies needed to make the diagnosis of HHNS,
Medical Examiner’s Office, 530 Chicago Avenue, Minneapolis, MN and to exclude diabetes mellitus, include glucose, osmolarity, HgA1C,
55415 plasma insulin levels, and islet cell antibodies.
The goal of this case study is to present a child death due to severe Although samples to exclude diabetes mellitus did not remain in this
dehydration from hyperglycemic, hyperosmolar, nonketotic syndrome case, this child, who had a severe neurologic disorder and no prior history
(HHNS), with concomitant rotavirus diarrhea. of a hyperglycemic event, and who was hyperosmolar with rotavirus
This presentation will impact the forensic community and/or diarrhea, represents a rare case of HHNS.
humanity by reviewing the rare entity of HHNS in children; and discussing
Hyperglycemic, Hyperosmolar, Nonketotic
the differentiation between stress-induced hyperglycemia, diabetic ketoaci-
dosis (DKA) and HHNS.
A sixteen-month-old male child, born at twenty- five weeks and five G102 Starvation – Interpretation of
days gestation, had several congenital anomalies including serious mental
and neurological deficiencies.
Morphological Findings and Pitfalls
The initial five months of his life were spent in the hospital during
which time he never demonstrated hyperglycemia or showed signs of being Véronique Henn*, and Manfred Kleiber, PhD, Insitute of Forensic
diabetic. Medicine Martin-Luther-University, Franzosenweg 1, Halle, 06112,
Three days prior to his death he developed episodic, profuse watery Germany; and Eberhard Lignitz, PhD, Insitute of Forensic Medicine
diarrhea. He was fed a banana, rice, applesauce, toast, (BRAT) diet, Ernst-Moritz-Arndt-University, Kuhstr. 30, Greifswald, 17489, Germany
without toast. He was also treated with acetaminophen and bismuth sub- After attending this presentation, attendees will learn how to interpret
salicylate. There were no visits to a physician. the morphological findings in cases of starvation.
On the third day of his illness, he was fussing at 0430. His mother This presentation will impact the forensic community and/or
tried to give him cough medicine but he refused. She changed his diaper, humanity by helping to avoid the misinterpretation of the morphological
laid him prone, and rubbed his back. He was notably limp. When she findings in cases of starvation by demonstrating the classifications of mal-
checked on him approximately two hours later, he was unresponsive. nutrition and potential pitfalls in its diagnosis.
Paramedics were called, but death was obvious and no resuscitation was Starvation is still a worldwide and every day problem. A high infant
attempted. mortality exists in many Asian, African and some Central and South
Postmortem examination revealed a slightly dysmorphic male, American states, which is directly explainable by hunger and its after-
weighing 18 pounds and having a crown-heel length of 29.5 inches. The effects. In European and North American countries cases of death from
occipital frontal circumference was 16.8 inches. The eyes appeared starvation are rare, but nonetheless, are not unknown in the forensic
sunken. The organs had dull surfaces and were tacky to touch. There was pathology literature. Actually, illness resulting from wealth and over-
no physical or historical evidence of previous or recent abuse. feeding are much more prevalent.

Nowadays, cases of death due to starvation originate, in general, from G103 Perimacular Circular Folds in
physical or psychical diseases, from food refusal or food deprivation. The
latter cause of intentional food depravation of a child being in most cases a
the Eyes of Injured Children
sign of child neglect punishable by the law.
Starvation due to consumptive illness resulting from serious natural M.G.F. Gillland, MD*, Brody SOM at East Carolina University,
disease, such as cancer, is always related to the original natural disease. Department of Pathology & Laboratory Medicine, Brody 7 South 10,
Deaths caused by malnutrition are cases of unnatural death. Greenville, NC 27834
Under-nutrition can be classified in certain stages. According to the After attending this presentation, attendees will gain an understanding
Gomez-Classification the body weight of a malnourished individual is of how to recognize perimacular folds, will know when to look for them,
compared to the expected weight of an individual of the same age. The cat- and know in what kinds of cases perimacular circular folds have been
egories mild, moderate and severe malnutrition is based on a body weight reported to be present.
of 75 to 89%, 60 to 74% and <60%, respectively, of the expected body This presentation will impact the forensic community and/or
weight. With this classification it is difficult to interpret the correct body- humanity by demonstrating an increasing ability of forensic pathologists to
weight of children. Because of the different growth rates of children, in recognize perimacular circular folds and stimulate interest in looking for
these cases of suspected starvation, the Waterlow classification (Table 1) such folds in a wider variety of death investigations, although most
should be used. The chronic growth retardation of a child can be assessed perimacular circular folds have been seen in abusive head injury deaths.
by comparing the measured height of the body with the expected height. Hypothesis: Examination of the retinas of a group of children would
Then the weight of the individual is compared with the expected weight of allow the identification of perimacular circular folds if present. Review of
the body corresponding to the actual height to assess the actual state of the clinical history, investigative information, and autopsy findings would
under or malnutrition. help establish the significance of such circular folds.
Circular folds have been identified in the eyes of injured children. The
Growth Retardation initial reports described these findings in children described as battered
(Chronic)
babies and in children with head injuries attributed to shaking. Cases were
0 normal 1 mild 2 moderate 3 severe
Height (% of the > 95 95 – 87 87 – 80 < 80
selected to report the presence of circular folds. Another report described
expected height at them in three of ten consecutive cases of child abuse. In all of these reports
a defined age) vitreous traction was the proposed mechanism in the development of cir-
cular folds. In the consecutive series report it was proposed that direct head
Protein-Energy-Malnutrition trauma was sufficient to produce the acceleration deceleration traction.
(Acute) More recently, a report described circular folds in a child with crush head
0 normal 1 mild 2 moderate 3 severe injuries occurring when a television fell from a stand, which was an acci-
Weight (% of the > 90 90 - 80 80 - 70 < 70
dental event.
expected weight at
a defined age dependent
Ocular examinations were a part of a prospective study of child deaths
on the actual height) investigated at the Southwestern Institute of Forensic Sciences. Adequate
material was available for a retrospective evaluation of 33 of the children’s
In this study, cases of starvation were evaluated to point out the diffi- retinas for the presence of circular folds. This group consisted of 25
culties in interpretation of body weight and weight of internal organs and children with abusive injuries, 5 children with accidental head injuries, and
to demonstrate potential pitfalls in this analysis. one each of lethal trunk injuries, brain tumor and drowning. Perimacular
The following conclusions can be drawn from this analysis: circular folds were identified in 11 cases. Review of the clinical histories,
• The suspicion of death through starvation becomes evident at investigations, and autopsy findings revealed that the circular folds were
first sight. only found in children with abusive head injuries.
• The real cause of starvation has to be confirmed by numerous The mechanism of the head injury has previously been reported for a
examinations (autopsy and histology and toxicology). subgroup of head injured children from the entire series from the
• The autopsy of the body includes the determination of all Southwestern Institute of Forensic Sciences. The mechanism of injury for
measurable parameters (height, body weight, organ weight), the 30 head injured children in this group was established independent of
as well as photo documentation. information about the presence or absence of perimacular circular folds.
• Verification of the development of the child at an early age and Circular folds were seen in 3 of 15 deaths attributed to blunt force mecha-
from birth on is necessary. nisms, 7 of 12 deaths with combined shake and blunt force mechanisms,
• Investigation by the police of the responsible caretakers for the and 1 of 3 with the mechanism of injury attributed to shaking.
child, and their responsibility in the starvation, must be carried out. Conclusion: These observations confirm the association of peri-
• Under certain circumstances, such as suspicion of a rare chronic macular circular folds with abusive head injuries in a larger group of child
disease, a pediatrician can be consulted for their expert opinion. deaths than previously reported. The cases were not selected on the basis
of circular folds or abusive head injury. The number of accidental head
Starvation, Waterlow Classification, Malnutrition
injuries and other causes is too small to clarify whether the perimacular cir-
cular folds could be found in other conditions. The mechanism of injury in
8 of the 11 children with circular folds included shaking which supports the
proposed vitreous traction mechanism for the formation of perimacular cir-
cular folds. However, the presence of circular folds in 3 abusive head
injury deaths attributed to blunt force injuries suggests more observations
are needed to clarify this issue.
Perimacular Circular Folds, Abusive Head Injury, Vitreous Traction

G104 Postmortem Detection and Evaluation intra-cerebral hemorrhage/amyloid angiopathy (1), hypertension (1), dia-
betes mellitus (1), pulmonary fibrosis/extra-corporeal membrane oxy-
of Retinal Hemorrhages genation (1).
The manner of death in children under the age of 14 years with RHs
Patrick E. Lantz, MD*, and Constance A. Stanton, MD, Department of (by age group and number of cases) was:
Pathology, Wake Forest University Health Sciences, Medical Center < 1 yr: Natural (7), Accident (2), Homicide (1), Undetermined (1)
Boulevard, Winston-Salem, NC 27157-1072 1-4 yrs: Homicide (2), Accident (1)
After attending this presentation, attendees will gain a better under- 5-9 yrs: Accident (3)
standing of the variety of disease processes associated with retinal hemor- 10-14 yrs: Natural (1), Homicide (1)
rhages in neonates, infants, children, and adults. Histological ocular examination of 28 neonates, infants, children and
This presentation will impact the forensic community and/or adults with retinal hemorrhages from this study demonstrated a variable
humanity by demonstrating how postmortem monocular indirect ophthal- pattern as to the number, character, location and distribution of retinal and
moscopy permits visualization of the fundus after death and can identify optic nerve sheath hemorrhages. Of the 73 individuals with retinal hemor-
retinal hemorrhages associated with a variety of conditions in children and rhages, 75.3% died in the hospital; however, only four children and one
adults. adult had documented clinical fundal examinations. The four children had
Although occurring in about 25% of adults with subarachnoid child abuse consults while the adult experienced a vitreous hemorrhage
hemorrhage, Terson syndrome has been considered rare in children and any from thrombocytopenia during treatment for leukemia. Postmortem
retinal hemorrhages (RHs) not associated with inflicted childhood monocular indirect ophthalmoscopy is a valuable technique for identifying
neurotrauma have been described as few in number and restricted to the retinal hemorrhages associated with a variety of conditions and diseases in
posterior pole. A number of ophthalmologists, pediatricians, and forensic children and adults.
pathologists have asserted that RHs in conjunction with intracranial Retinal Hemorrhages, Postmortem Monocular Indirect
hemorrhages in children can be considered virtually pathognomonic for Ophthalmoscopy, Shaken Baby Syndrome
inflicted childhood neurotrauma or shaken baby syndrome based on the
number, character, location, and distribution of RHs. Unfortunately but
characteristically, most studies to date concerning hemorrhagic retinopathy G105 Examination of Sexually Abused Child:
in non-accidental head injury have lacked specific criteria for case defin- What is the Impact on Judgment?
ition, exhibited observational and selection bias or cases were selected by
the presence or absence of RHs - the clinical or autopsy finding that was Nathalie S. Jousset, MD*, Department of Forensic Medicine, University
being sought as diagnostically valid. Hospital, Angers, 49033, France; and Hubert C. Poirout, MD, Arnaud N.
Since June of 2004 the authors have used postmortem monocular Gaudin, MD, Michel Penneau, MD, PhD, and Clotilde G. Rougé-
indirect ophthalmoscopy to prospectively examine the eyes of 425 Maillart, MD, Department of Forensic Medicine, 4 rue Larrey, Angers,
deceased individuals at the institution (medical examiner and non-medical 49033, France
examiner cases) ranging in age from birth to 96 years. The postmortem
interval ranged from 1 hour to 3 days with 65.9% of examinations After attending this presentation, attendees will know how the
occurring less than 24 hours after death. Slightly over 17% exhibited assumption of the possibility of sexual abuse leads almost systematically to
retinal hemorrhages associated with a variety of diseases and conditions. a forensic examination. This fact has implications on the health of the
The number of decedents with retinal hemorrhages by age group is listed victim and the course of the judicial action. However, it is an examination
in the accompanying Table. often poor in clinical elements that is used as material proof of abuse. The
goal of this study was to try to better understand the contribution of this
Age Range of Decedents and Presence/Absence of Retinal Hemorrhages
examination in the legal process.
< 1 yr 1-4 yrs 5-9 yrs 10-14 yrs > 15 yrs Total
humanity by attempting to better understand the contribution of the forensic
Cases in which 6 0 2 1 5 14 examination when sexual abuse is suspected, and the expected judicial
fundi not follow-up in sexually abused child affairs.
visualized
Assumption of the possibility of sexual abuse leads almost systemati-
Cases with no RHs 43 14 7 4 270 338
cally to a forensic examination. This fact has implications on the health of
the victim and the course of the judicial action. However it is an exami-
Cases with RHs 11 3 3 2 54 73 nation often poor in clinical elements that is used as material proof. The
goal of this study was to try to better understand the contribution of this
Total 60 17 12 7 329 425 examination in the legal process.
A retrospective study on a sample of forensic examinations was
Conditions or causes of death associated with the presence of RHs by carried out on requisition. It concerned 74 children of less than 18 years
age group and number of cases (noted in parenthesis) were: old, examined between June 1998 and June 2000. With the authorisation
< 1 yr: Birth-related (2), asphyxia/suffocation (2), Sudden Infant Death of the court of Angers city, the judicial files were consulted on site.
Syndrome (SIDS)/resuscitation (2), apnea/gastroesophageal reflux (1), in- It concerned 58 girls for 16 boys. The average age of the victims at
utero intracranial hemorrhage (1), blunt trauma of head (1), the time of the medical examination was nine and a half years old. In 15
prematurity/congenital heart disease (1), meningitis (1) cases there was a history of ill-treatment. For nine percent of the victims,
1-4 yrs: Blunt trauma of head (3) the father had been the subject of a penal judgement with prison sentence.
5-9 yrs: Blunt trauma of head (3) Nine cases related to acts of sexual improprieties, 58 cases of sexual
10-14 yrs: Intra-cranial hemorrhage/metastatic cancer (1), blunt trauma of transgressions and 25 cases of rapes or rapes attempts. In 61 percent of the
head (1) cases, the victim revealed the facts. In 70 percents of cases, time between
> 15 yrs: Blunt trauma of head (17), coagulopathy (10), gunshot wound of the facts and revelations was longer than one month.
head (7), ruptured saccular aneurysm (7), intra-cerebral hemorrhage/hyper- The forensic examination did not find any disorder for the great
tension (6), subarachnoid hemorrhage/vascular malformation (1), hypoxic- majority of the children. In four cases, it highlighted hymenal damage of
ischemic brain injury/drug toxicity (1), meningo-encephalitis/leukemia (1), which two were assigned to sexual abuse. Forty-two victims underwent a

psychological or psychiatric consultation. For two children, their remarks However it is not really known how sensitive such procedures are.
were not recognised credible by the experts. Although several studies have been performed, little research has been
The total number authors blamed for abuse was 58. Nineteen had done on the actual sensitivity of radiology, CT scan, and autopsy on control
already been condemned for sexual abuse. In 26 cases, the father was the cases. In order to do this in fact, it is necessary to verify, after radiological
abuser. In 43 percent of the files, the authors acknowledged the facts. The assessment and autopsy, all fractures, which are actually present on the
courts pronounced the culpability of the authors for 42 victims. It was more bone by studying the cleaned skeleton.
frequently pronounced for the female victims (63 %) than for male sex The aim of this study was to compare the sensitivity of three diag-
(21 %). nostic approaches of autopsy, traditional (conventional) radiology, and
Young girls are mainly the victims. In many cases they are abused by computed tomography on “battered” piglets, in order to verify the sensi-
their father or by members of the close family. Forensic examinations did tivity of each method, with respect to the true number of bone fractures
not often reveal cutaneous or genital disorders. The lesions can be fleeting assessed once the piglet was skeletonized (osteological control).
and are often healed. Without bringing material proof, anatomical Four newborn cadaver piglets that had died from natural causes were
description makes it possible to come to a conclusion about the feasibility severely beaten postmortem in every district of the body. Traditional radi-
or not of some denounced sexual abuse. Conclusions of forensic examina- ography, computed tomography (CT) and autopsy were performed. The
tions, when they partly contradict denounced facts do not call into question piglet was then macerated until skeletonized and the number of all fractures
the reality of the sexual abuse. In many cases, the author is condemned present recorded (osteological control).
despite everything. That highlights the importance of investigation and of On the cranium, traditional radiology revealed only 35% circa of
the child’s words. actual fractures, autopsy detected only 31 % (P<0.01 for both comparisons
Sexual Abuse, Child, Forensic Examination vs. osteological control), whereas CT imaging detected all fractures
actually present. For ribs, radiology detected only 47% of all fractures
present, and autopsy 65% circa (P>0.05 for both comparisons vs. osteo-
logical control), while CT scans detected 34% (P<0.01).
G106 Sensitivity of Autopsy and Radiological In suspected cases of fatal child abuse, the authors suggest that the
Examination in Detecting Bone Fractures bones of specific districts be directly analyzed either at autopsy or by col-
in an Animal Model: Implications for the lecting specific diagnostic sites, such as parts of the rib cage, and subjecting
them to maceration. The removed areas could be replaced with artificial
Assessment of Fatal Child Physical Abuse material for cosmetic purposes. These findings stress the importance of
combined radiological, CT scan, autopsy, and osteological survey in the
Cristina Cattaneo, PhD, MD,* and Eloisa Marinelli, MD, Istituto di detection of perimortem bone fractures. This study confirms the possibly
Medicina Legale, Università degli Studi, via Mangiagalli 37, Milano, low sensitivity of autopsy and radiological analysis particularly in the
20133, Italy; Alessia Di Giancamillo, DVM, PhD, Dipartimento di detection of hairline fractures of head and thoracic osseous elements if frac-
Scienze e Tecnologie Veterinarie per la Sicurezza Alimentare, via tures are perimortem and show no healing. According to the authors, in
Celoria 10, Milano, 20133, Italy; Mauro Di Giancamillo, DVM, and cases of suspected fatal child physical abuse, the bones of specific anatomic
Olga Travetti, DVM, Dipartimento di Scienze Cliniche Veterinarie, via regions should be directly analyzed.
Celoria 10, Milano, 20133, Italy; and Laura Viganò, BSc, Pasquale
Child Physical Abuse, Bone Fractures, Radiology
Poppa, BSc, Davide Porta, BSc, Andrea Gentilomo, MD, PhD, and
Marco Grandi, MD, Istituto di Medicina Legale, via Mangiagalli 37,
Milano, 20133, Italy
After attending this presentation, attendees will come to realize the
limits of the radiological CT scan and autopsy assessment in the detection
of antemortem bone fractures in cases of fatal child abuse, and that direct G107 “Homicide by Heart Attack” -
osteological assessment of certain anatomical areas (particularly the rib An Unusual Pediatric Death
cage) is advisable.
Dwayne A. Wolf, MD, PhD*, Harris County Medical Examiner Office,
humanity by demonstrating how the osteological assessment of certain
anatomic areas upon autopsy of infants is advisable, since radiology,
autopsy, and CT scans may miss fractures. The goals of this presentation are to illustrate and discuss applicability
Skeletal injuries are often strong indicators of child abuse and their of previously published criteria for homicide by sudden cardiac death in
detection is crucial. Regardless of whether one is referring to the living or pediatric cases. An unusual case of fatal child abuse will be presented as
the dead, bone fractures are perhaps the most important and problematic an example.
issue as far as detectability is concerned. According to some authors, This presentation will impact the forensic community and/or
skeletal injuries occur in 36-50% of abused children. Whereas external and humanity by demonstrating how the possibility of underlying potentially
internal soft tissue traumatic injuries will eventually show up at a thorough fatal natural disease must be considered in instances where multiple blunt
clinical examination or at the autopsy table, the presence of bone fractures trauma in a deceased child is unassociated with internal injuries of suffi-
whose distribution, number and age are crucial is not easy to detect, partic- cient severity to explain the demise. Although the current example entails
ularly if very recent or if inflicted in the circumstances of a lethal event and obvious natural disease, the presence of more subtle abnormalities should
therefore just barely antemortem. In cases in which the child dies immedi- diligently sought in such cases. If a temporal correlation of abuse (with
ately after infliction of trauma, the signs may consist of very subtle soft non-fatal injuries) with death can be documented by investigation, the
tissue lesions and especially bone fractures – the latter being at times, par- manner of death may be properly classified as homicide.
ticularly difficult to detect when healing processes (and therefore callus for- This 17-month-old Hispanic female child had a history of various
mation) have not taken place. Furthermore, hemorrhaging of soft tissues types of abuse, including blunt trauma as well as neglect. The mother was
may be slight and barely visible upon autopsy, particularly in the paraver- the reported perpetrator, and according to family members, this child was
tebral and posterior vertebral regions, or may be hidden by initial decom- targeted because the mother had doubts as to her maternity (she speculated
position processes. Thus autopsy and radiological assessment are crucial. that the hospital had sent her home postpartum with somebody else’s child).

On the date of death the mother phoned from home to her brother-in-
law and initially indicated that this child had “fallen from the bed.” Over
the next several minutes she phoned her sister as well, made several other
incriminating statements indicating that in fact she had “hit” the child, and
even admitted to her sister “I killed the baby.” The brother-in-law imme-
diately rushed to her house, while simultaneously phoning emergency
medical services. He arrived at the house at nearly the same time as ambu-
lance personnel. Paramedics found the child unresponsive. Aggressive
resuscitative efforts were unsuccessful and the child was pronounced dead
upon arrival to the emergency room. As paramedics were entering the
house the mother rushed out, drove to the local day care, retrieved her other
children and fled to Mexico. The mother and siblings have not been
returned to this country, despite multiple warrants.
The abusive nature of the child’s injuries was undeniable. Contusions
of various ages were distributed widely over all body surfaces, including
the scalp, face, thorax, and extremities. Pressure type contusions were on
the pinna. Multiple contusions were distributed across the mucosa of the
lower lip, and a gaping laceration undermined the upper frenula separating
the upper lip from the alveolar ridge. Internal findings were less
impressive. In fact, no internal injuries were found. Furthermore, no
natural disease was grossly evident. The microscopic appearance of the
heart was strikingly abnormal; myocarditis was florid, with abundant lym-
phocytic inflammation, with intramyocyte edema and myocyte necrosis.
To paraphrase Davis’s criteria for “homicide by heart attack,” 1. the
threat must be severe enough to be considered as a threat to the life of the
victim; 2. the victim should perceive the incident as a threat to their life; 3.
the threat must be an emotionally charged event; 4. death must occur within
the emotional response period during or immediately following the threat;
and 5. cardiac disease associated with predisposition to arrhythmia should
be documented, although no acute cardiac change (ruptured plaque for
example) need be found (J Forensic Sci 23:384; 1978). Although Davis’s
criteria have been applied primarily to instances of a threat without physical
contact, more recent literature (J Forensic Sci 49:598; 2004) expands the
criteria to include threats with actual physical contact, but the inflicted
injuries are insufficient to explain death. Therefore, the investigative and
autopsy findings in this case fit the published criteria for homicide by
sudden cardiac death. Accordingly, the cause of death was classified as
“sudden cardiac death (myocarditis) associated with multiple blunt force
injuries.” The manner of death was classified as homicide. Implications
for similar types of pediatric cases will be described in the presentation.
Child Abuse, Myocarditis, Homicide by Heart Attack

Pathology/Biology
G1 Deaths From Accidental Steam Inhalation Materials: This study is a retrospective study. The authors examined
the epidemiology of firearms injuries presenting to University Hospital of
During African Traditional Therapy Angers from January 1990 to December 2000 (Institute for Legal Medicine
and Unit of Intensive Care). Information was collected from forensic
Bhanwar Lal Bhootra, MD*, Department of Health, PO Box 1944, medical files, police reports, and judicial files.
Polokwane, Limpopo 0700, South Africa Results: One hundred sixty-eight of firearm injuries were analyzed.
The goal of this presentation is to present to the forensic community The mean age was 42 years. Of the cases reviewed eighty percent were
the injurious effects of steam inhalation on the respiratory system, resulting male and 74% died. Of the 90 weapons that could be positively identified,
in the deaths of two children. Death from steam inhalation is a quite rare 20% were handguns. Most often, the shooters used a rifle–especially a
occurrence. In many countries, steam inhalation is practiced to cure cold, shotgun. In many of the cases where a rifle was confirmed as the firearm
cough, or respiratory ailments, etc. used in the shooting, it was a 0.22 calibre low-velocity weapon. One
This presentation will impact the forensic community and/or hundred seventeen (70%) were classified as suicides: victims were often
humanity by highlighting the hazards associated with steam inhalation, if males, about 43 years old and the death rate was high (75%). The head and
done with the whole body covered with a blanket and if necessary precau- neck was the most favored site, accounting for 72% of the wounds; the
tions are not taken. Under these conditions, traditional therapy can be risky. presternal-precordial region of the chest accounted for 17% of the wounds.
Case history: Two children (aged 17 and 6 years) and their mother Twenty-five percent (25%) of cases were homicides: 57% male and 43%
were inhaling steam from boiling water in a pot, while covering their female. The presternal-precordial region of the chest was the most favored
bodies (including the face) with a thick woolen blanket. After steam site (40%). Five cases (3%) were accidents: these injuries were sustained
inhalation of about 5 minutes, the 17-year-old knocked down the pot and during handgun training, cleaning, or carriage of the weapon. Only four
boiling water spilled on the hot plate, producing a considerable amount of cases (2%) were undetermined.
steam. Boiling water also spilled on that child and mother, resulting in Discussion: In France, the deaths from firearms represent 3,100
focal scalds. Within one to two minutes, both children experienced deaths / year (population: about 55 million). This rate is lower than other
difficulty in breathing, collapsed, and died in the home. countries with flexibles laws. Stricter gun control laws were enacted by the
At autopsy, there was oedema of the larynx with blanched white government, prohibiting the ownership of military-style, high-velocity,
tracheal mucosa in the younger child and marked congestion in the older semi-automatic rifles. Indeed, no shooting in this series involved high-
child. Grossly, the lungs, brain, and heart showed hypoxia signs. velocity weapons, and nationally these weapons account for only 1% of all
Microscopically, there was oedema and coagulative necrosis of the tracheal firearm deaths. However, firearms are a frequent means of suicidal death,
mucosa; the lungs showed congestion, oedema, and haemorrhages; and the and the number of homicides committed with a firearm is not insignificant.
brain showed congestion, oedema and focal intra-cerebral haemorrhages. Continued restricted access to firearms is necessary to maintain France’s
Cause of death was attributed to hypoxia from inhalation of steam. relatively low rate of fatal injuries.
It is common practice among the black Africans to use steam Forensic Pathology, Wounds Ballistics, Firearms
inhalation (traditional African therapy) known as ARAMELA in local
Sotho African language) for respiratory problems or congestion or get rid
of unspecified ailments, or for general well-being even when there is no G3 Evaluation of a Novel Tagging and Tissue
evidence of any ailment (superstitious belief).
Moist air has more heat to give up than has an equal volume of dry air. Preservation System for Human Remains
Severe injuries tend to occur with steam inhalation in the form of oedema
of the glottis, severe thermal tracheitis and destruction of bronchial mucosa, Martin Grassberger, MD, PhD*, and Christina Stein, PhD, Department
and haemorrhagic oedema of the centrally located alveoli which can lead to for Forensic Medicine, Medical University of Vienna, Sensengasse 2,
hypoxia and anoxia. Vienna, A-1090, Austria; Stefan Hanslik, PhD, Identilab Forensic
Services, Handelskai 94-96, Vienna, A-1200, Austria; and Manfred
Steam Inhalation, Respiratory Tract, Hypoxia
Hochmeister, MD, Department for Forensic Medicine, Medical University
G2 Firearm Injuries in Angers: 1990 - 2000 The goal of this presentation is to describe a new, easy-to-use,
barcode-based tissue collection, preservation and body tracking system,
Arnaud Gaudin, MD*, and Nathalie Jousset, MD, Service de Médecine which might prove instrumental in the containment of mass fatalities such
Légale, Centre Hospitalier Universitaire - 4 Rue Larrey, Angers, 49100 as aircraft accidents, war-related accidents, environmental disasters
Cedex 01, France; Gilles Tournel, MD, Service de Médecine Légale, (e.g., earthquakes, hurricanes, floods), terrorist bombings, or mass murders.
Institut Médico-Légal - Place Deverdun, Lille, 59000, France; and This presentation will impact the forensic community and/or
Michel Penneau, MD, and Clotilde Rougé-Maillart, MD, Service de humanity by simplifying the use of this tissue collection and body tagging
Médecine Légale, Centre Hospitalier Universitaire - 4 rue Larrey, system, as well as the convenience afforded by working in an ambient
Angers, 49100 Cedex 01, France temperature environment without the requirement of a refrigerator/freezer
or any other additional device, while maintaining DNA integrity for a long
After attending this presentation, attendees will be able to analyze a period of time, representing potential benefits for the forensic community.
series of 168 cases of firearm injuries in a French city. Tissue preservation is a critical issue in forensic investigations where
This presentation will impact the forensic community and/or human remains are collected for DNA analysis. The maintenance of a
humanity by analyzing the rate of firearm injuries and deaths in a French forensically sound chain of custody is also a critical part of field as well as
city and discussing the different governments’ politics. laboratory practice. Low ambient temperatures and rapid recovery of
Firearms are a major cause of injuries and death in many countries, human remains are ideal conditions to ensure successful DNA analysis.
especially in the USA. In France, injuries caused by firearms account for However, such conditions are rarely met in disaster areas, which are often
only a small percentage of trauma admissions and deaths but are frequently encountered in geographically remote regions of the world. The new ear-
the subject of media and public attention. tag system TypiFix™ works simply by pushing a clamp-like applicator. By

operating the loaded applicator a tissue sample is punched out by a G4 Lesch-Nyhan Syndrome and Child Abuse
collection stud and automatically introduced into a self-sealing sample
container. In the tightly sealed sample container, the tissue and its DNA are Andrea M. Berzlanovich, MD*, Institute of Forensic Medicine, University
preserved through desiccation by molecular sieve beads consisting of of Vienna, Sensengasse 2, Vienna, 1090, Austria; Martin Kraupp, MD,
sodium-aluminium-silicate. The ear-tag and sample container are Department of Medical Chemistry, Medical University of Vienna,
preprinted with the same identification number as well as a barcode. They Währinger Straße 10, Vienna, A - 1090, Austria; Johannes A.
are attached to each other until the sample is introduced in the sample Hainfellner, MD, and Herbert Budka, MD, Institute of Neurology,
container. Through this simultaneous barcoding of the remains and the Medical University of Vienna, Währinger Gürtel 18-20, Vienna, A -1090,
tissue sample at the point of recovery, sample switch is excluded. Austria; Wolfgang A. Keil, MD, Institute of Forensic Medicine, University
A feasibility study was conducted to determine the usefulness and the of Munich, Frauenlobstraße 7a, Munich, D -80337, Germany; and
limitations of this device in a forensic setting and to evaluate the effect of Barbara Fazeny-Dörner, MD, Department of Medicine I, Medical
long term storage of tissues in the sealed TypiFix™ container on DNA University Vienna, Währinger Gürtel 18-20, Vienna, A -1090, Austria
analysis using short tandem repeat (STR) methodology. Ten bodies were
selected for this study (time since death 3 - 25 days). Tissue sampling with After attending this presentation, attendees will understand the impor-
simultaneous tagging was performed at the interdigital fold between the tance of distinguishing child abuse from Lesch-Nyhan syndrome (LNS);
thumb and the index finger of either hand using the TypiFix™ applicator. understand the first description of postmotrem verification; and understand
Samples were stored at room temperature and processed at 2 weeks and 6 the diagnostic significance of the absence of the HPRT-enzyme in the
months after collection. Using a special extractor clamp provided by the deceased.
manufacturer of TypiFix™, the bottom of each sealed sample container This presentation will impact the forensic community and/or
was removed and dry tissue samples were transferred to 1.5 ml eppendorf humanity by describing how LNS should be suspected chiefly when self-
cups. The tissue samples were subjected to DNA extraction using the injurious behavior is associated with the typical motor dysfunction and
QIAamp DNA Mini Kit (tissue protocol, Qiagen Inc., Valencia, CA). excessive production of uric acid. This may clearly distinguish it from
Quantification of human genomic DNA was determined using real-time child abuse.
PCR (ABI PRISM® 7000 Sequence Detection System) and the Postmortem analysis of HPRT-enzyme activity is a new and important
Quantifiler™ Human DNA quantification kit (Applied Biosystems). tool for forensic work-up, enabling–especially in cases of doubt–a first and
Autosomal STR analysis was carried out with 1 ng of genomic DNA using guiding diagnostic step before parents are confronted with suspicion of
the AmpFLSTR® SGM Plus® PCR amplification kit. All analyses were child abuse. A confirmation of the HPRT-enzyme deficiency may not
performed in accordance with the manufacturer’s instructions. completely exclude additional child abuse. However, careful forensic
On average 8 ± 5.7 µg DNA (mean ± SD) were purified from each analysis, including enzyme-diagnostics, combined with the presence of
sample. The success rate of STR genotyping after 2 weeks and 6 month injuries typical of self-mutilation, will help to clarify the facts.
was 100%. DNA profiles after six months of storage were identical to LNS is characterized by neurologic dysfunction, cognitive and
those obtained after two weeks. behavioral disturbances, and uric acid overproduction. It results in
Currently, the most commonly used method of preserving tissues for complete deficiency of the enzyme hypoxanthineguanine phosphoribosyl-
subsequent DNA analysis is freezing. Very few alternative approaches transferase (HPRT), which catalyzes the conversion of hypoxanthine to
have been developed to preserve soft-tissue samples at room temperature. inosine monophosphate (IMP) and guanine to guanine monophosphate
Using the described system keeps the collection costs low, provides fast (GMP) in the presence of phosphoribosylpyrophosphate (PPP). Thus, the
and reliable DNA samples from a large number of individuals in a short deficiency of HPRT activity leads to accumulation of PPP resulting in
time, and ensures a forensically solid chain of custody from the point of excessive uric acid production and hyperuricaemia.
recovery in the field to the DNA analysis in the forensic laboratory. The hallmark feature of the disease is persistent self-injurious
The collection of tissue-samples for DNA analyses can easily be behavior with biting the lips, buccal mucosa and/or fingers, often resulting
achieved under field conditions. In case of mass fatalities it enables inves- in partial or total destruction of perioral tissues and amputation of tongue
tigating authorities to collect numerous specimen for DNA analysis and and fingers.
simultaneously label the remains. Barcodes can be manufactured The deceased, a four-year-old boy, was born after uneventful gestation
according to customers’ needs. The system is fail-safe and fraud-proof. and delivery. At the age of six months, he developed marked spasticity,
The specimen container is contamination-proof since only the single-use double hemiparesis and choreoathetosis. Because the neurologic deficits
parts come in contact with biological materials. The tissue sampling for were progressive and the serum level of uric acid elevated, LNS was sus-
DNA analysis is possible without the need to refrigerate or freeze samples. pected. This suspicion was confirmed after evaluation of HPRT-enzyme
According to the manufacturer, tissues stored over 4 years in the TypiFix™ activity, which was almost completely missing. Initial self-mutilation
system are still suitable for amplification of long fragments by PCR. occurred around the age of 18 months, following an accidental, pain-pro-
Therefore the TypiFix™ system provides a new, reliable and useful ducing injury. Feeding was difficult and spasticity developed in upper and
tool for the recovery and simultaneously labeling of human remains and lower extremities; the boy could neither sit, nor stand nor walk without
tissue samples in mass fatalities. help, and he couldn’t speak, only babble. He experienced several respi-
ratory infections. One morning he had an elevated temperature of 101° F,
DNA Analysis, Tissue Preservation, Disaster Identification
without other signs of infection. After breakfast, he fell asleep, and a short
time later, his mother found him lying in bed unconscious after vomiting.
Paramedics performed resuscitation procedures without success. Although
the boy’s mother reported the diagnosis of LNS, suspicion of child abuse
arose because of his injured fingers and his malnutrition. A forensic
autopsy was performed.
Autopsy revealed an undernourhised boy with developmental delay.
His thumbs were scarred from repeated episodes of biting; his tongue, lips,
and buccal mucosa showed abrasions. Both lungs showed pneumonia and
discrete food aspiration; internal and microscopic examinations were oth-
erwise unremarkable.

The formation of 14C-IMP was measured in a radioisotope assay in colonization and succession on mammalian carcasses in brackish or marine
which 14C-labeled hypoxanthine was converted to the labeled nucleotide. environments. The purpose of this presentation is to document how saline
Purine base and nucleotide were separated by thin layer chromatography, environments influence not only the rate that pig carcasses decompose, but
the radioactivity in the nucleotide and base fraction was determined by also characterize the algal/diatom community at each stage of decomposition
liquid scintillation counting, allowing the calculation of the amount of in order to use species diversity and composition indices to estimate a PMSI.
purine base converted to nucleotide. The erythrocytes were extracted. The The objectives of this study include: 1) characterize the physical changes and
assay was carried out by mixing assay buffer, PPP, and 14C-hypoxanthine rate of pig decomposition in saline aquatic systems; 2) compare algal
with the sample. The reaction was stopped by cold perchloric acid. After diversity on pigs to a natural substrate such as ceramic tiles and; 3) determine
centrifugation, the supernates were neutralized with equivalent amounts of if species richness or diversity differs among stages of decomposition. This
KHCO3 and KCLO4 precipitated by centrifugation at 4°C. The supernates study was conducted in two slightly brackish water (brackish is defined as
salinity levels between 5-18% parts per thousand-ppt) ponds near Smyrna,
were spotted on aluminum backed silica-gel-thinlayer sheets containing a
Delaware. The stages of decomposition were identified and characterized by
fluorescence indicator using unlabeled hypoxanthine, inosine and IMP as
physical changes. The duration of each stage was estimated in degree days.
carriers. The spots containing hypoxanthine, inosine, and IMP were iden-
Water temperature was recorded for the duration of each trial. Salinity mea-
tified under UV-light, cut out and the radioactivity quantified by liquid scin-
surements were determined using a refractometer. To examine algal diversity
tillation counting. The controls of the series of postmortem enzyme assays
on pig carcasses vs. a natural substrate, samples were collected every 3 days
demonstrated the HPRT-enzyme to be in the normal range at least up to five
(trial one) and every 2 days (trial two) for approximately 20 days. Algal
days after death. It was thus concluded that the HPRT-enzyme is relatively
samples were preserved in Lugoli solution and glacial acetic acid and stored
stable postmotrem as compared to the boy’s HPRT-enzyme activity of less
in dark conditions until analysis. Algae and diatom species were identified
than 1.5% one day after death, demonstrating the complete deficiency of
using a light microscope and photographed with a Nikon Digital Camera.
the enzyme.
Species diversity and evenness among stages of decomposition were deter-
LNS should be suspected chiefly when self-injurious behavior is
mined using Shannon and Simpson’s diversity indices. The mean diversity
associated with the typical motor dysfunction and excessive production of
indices for pig carcasses and ceramic tiles were compared using a t-test.
uric acid. This may clearly distinguish it from child abuse. Postmortem
Previous studies have revised or suggested that five (not six) stages of decom-
analysis of HPRT-enzyme activity is a new and important tool for forensic
position have been identified for mammalian carcasses in freshwater aquatic
work-up, enabling–especially in cases of doubt–a first and guiding diag-
systems. Five stages are described in this study: Submerged Fresh, Early
nostic step before parents are confronted with suspicion of child abuse. A
Floating, Advanced Floating Decay, Floating Remains, and Sunken Remains.
confirmation of the HPRT-enzyme deficiency may not completely exclude
Ponds in this study maintained a salinity value of 2-4 ppt. Accumulated
additional child abuse. However, careful forensic analysis, including
degree days for trial one of this study was 893 degree days. Pigs began to
enzyme-diagnostics, combined with the presence of injuries typical of self-
float within three days, the duration of the Early Floating stage ranged from
mutilation, will help to clarify the facts.
3-9 days; Floating Decay stage ranged from 6-12 days; Advanced Floating
Autopsy, Child Abuse, Postmortem HPRT-Enzyme Analysis Decay stage ranged from 9-21 days, and pigs sank within 15 – 24 days. The
submerged fresh stage was characterized as the time the body initially entered
the water until it floated to the water surface. Few physical changes were
G5 Determining a Postmortem Submersion observed during this stage. The Early Floating stage was identified as when
Interval (PMSI) Based on Algal/Diatom the pigs floated and began to bloat, forming indentations from the cage on
their skin and with some algal growth. Little to significant disarticulation of
Diversity on Decomposing Mammalian limbs was observed on floating pig carcasses. The Advanced Floating Decay
Carcasses in Brackish Ponds in Delaware stage was characterized as much of the carcass having been removed, with
the skull exposed and the loss of limb bones. The Sunken Remains stage was
John R. Wallace, PhD, Kathryn Zimmerman*, and Erin High, identified when the remains sank to the pond bottom with only bits of bones
Department of Biology, Caputo Hall, Millersville University, remaining. Algal diversity was significantly greater on pig carcasses than
Millersville, PA 17551 ceramic tiles. Diversity increased significantly as decomposition progressed
until pig carcasses had reached the advanced floating decay stage.
The goal of this presentation is to share a new technique to utilize a Mammalian carcasses will support algal/diatom communities and that these
much-neglected biological evidence (aquatic plants) to determine a post- communities experience plant succession similar to terrestrial habitats.
mortem submersion interval. The authors intend to demonstrate how algae However, in terrestrial systems, plant succession/diversity increases over
and diatoms can be used in medicolegal investigations involving brackish time; in aquatic systems, plant succession/diversity will increase and even-
or saline aquatic systems. The attendee will learn how to sample, tually decrease as the substrate (mammalian carcass) decomposes. This study
photograph and identify algae and diatoms useful in forensic science. shows how algal/diatom diversity and taxonomy can be used to determine the
Because very little is known on how bodies decompose in freshwater, duration a submerged victim has been under water.
brackish, and marine environments, and much less is known on how to
determine a postmortem submersion interval (PMSI) (i.e., determine the Brackish Ponds, Diatoms, Postmortem Submerged Interval
time a body has been submerged in an aquatic environment until the point
of discovery), this presentation will impact the forensic community and/or
humanity by adding to a much neglected but growing database on decom-
position in aquatic environments. The authors hope to provide the first G6 Immunocompromised Female, Age 67, With
analysis of mammalian decomposition in brackish ponds using botanical an Angioinvasive Pulmonary Fungal Abcess
evidence to determine a PMSI. This approach has been used in freshwater
systems but not in saline environments such as brackish ponds. It is hoped
Darshan R. Phatak, MD*, Beth Israel Deaconess Medical Center,
using this technique and type of plant evidence will shed new light in deter-
Pathology Department, 330 Brookline Avenue, Boston, MA 02215
mining how long a body may have been submerged in these types of
aquatic systems. After attending this presentation, attendees will understand the
Algae and diatoms have been employed to estimate the location of vulnerability of the immunocompromised person to opportunistic
drowning victims as well as link criminal suspects to specific aquatic crime organisms that may present unexpected autopsy findings and the necessity
scenes. However, little or no evidence exists on documenting algal of a complete medical history.

This presentation will impact the forensic community and/or Attempts by the victim to disguise suicides as homicides are not
humanity by providing an added appreciation for a thorough medical commonly encountered, and the following case study illustrates the
history as an aid to correlate and make sense of unexpected autopsy requirement for a multidisciplinary approach to the investigation.
findings in the immunocompromised. Professionals from the disciplines of documents examination, fingerprint
This poster will present the autopsy of a 67-year-old Caucasian female comparison, odontology, toxicology, forensic pathology, and law
with a longstanding history of hairy cell leukemia (HCL) refractory to enforcement all provided information essential in the determination of
chemotherapy in whom the pertinent autopsy findings included not only manner of death.
residual HCL, but also a large necrotic abcess within the right lung upper The decedent was a 19-year-old male who resided in a small com-
and lower lobes containing thrombus and angioinvasive fungal forms munity in the Midwest. He recently graduated from high school, as class
consistent with Aspergillus species. valedictorian, where he had excelled in sports as well as academics. During
The immunocompromised comprise a subset of the general the early morning hours on a day in July, 2004, the engineer of a train trav-
population who are extremely susceptible to opportunistic organisms eling 60 miles per hour, approximately four miles from the decedent’s res-
whether due to their primary disease process, medicines or therapies used idence, reported that he had struck “something” on the tracks. Upon
to treat their underlying illness, or other medical conditions acting in searching the area, the decedent’s unclothed body was discovered. The
concert with the above to render them extremely vulnerable to viruses, train traffic in the region where the body was discovered was reportedly
bacteria, fungi, and parasites. fairly busy with trains passing through approximately every 30 minutes.
This particular patient presented to the hospital after having low to The identity of the subject remained unknown until later that morning when
moderate grade fever, nonproductive cough, and a sore throat for five days. family members reported the subject missing. Law enforcement investi-
After a workup revealed anemia, thrombocytopenia, leukopenia, and gators examined the decedent’s bedroom, and discovered a handwritten
radiographic evidence of right lower lobe lung infiltrates, she was adminis- note, in block letters, which indicated that the decedent had been abducted.
tered leukoreduced and irradiated packed red blood cells, a course of The note, signed “The Eliminators,” further made mention that the “train
levofloxacin and erythropoetic drugs, and discharged. took care of him” and that investigators “might find a few pieces of him left
She presented again eight days after her initial presentation at the train crossing” at a specific site. Pillows had been placed beneath the
complaining of persistent fevers, chills, an increase of coughing (now with bedding to imitate a body, and the note had been placed on the pillows.
pain), and pain on swallowing. She was admitted and made DNI/DNR. There was no evidence of a struggle, and a sibling had been sleeping
New imaging studies showed a mass lesion bridging the right upper lobe nearby. An exterior door in the residence near the bedroom had been dis-
and superior segment of the right lower lobe suspicious clinically for acute covered ajar. Further evidence recovered from the residence was a journal
infection vs. Leukemic infiltration. Despite administration of Zuosyn and written by the decedent. Additional information provided by family
Ambisone during her inpatient course, there was no improvement in her revealed that the decedent was last seen the previous evening following a
condition. After a bronchoscopy with BAL, which was positive for C. confrontation with his parents concerning his purchase of alcohol for a
albicans, the patient required oxygen via nasal canula to maintain oxygen minor.
saturation above 94%. At autopsy, there were extensive blunt force injuries with multiple
On the morning of her death, the patient had episodes of hemoptysis facial, basilar and calvarial skull fractures; avulsion of the brain and eyes;
with dark blood, then bright red blood. She emergently underwent repeat multiple fractures to the ribs, spine, and extremities; and multiple lacera-
bronchoscopy, where it was noted that there was a right tracheal obstruction tions to internal organs. Also noted at autopsy were strands of baling wire
thought to be clot and tissue. Attempts to remove the obstruction were wrapped loosely around the right wrist, waist and both ankles. Law
unsuccessful and the patient entered asystole. enforcement investigators indicated that baling wire had been noted at the
Even though this particular case occurred in the setting of a tertiary residence, and later discovered beneath the tracks where the impact
care teaching hospital, people having conditions analogous to that of the occurred. Positive identification of the subject was obtained through dental
decedent are often maintained on therapeutic drug regimens in outpatient comparison by an odontologist. A documents examiner analyzed the hand-
settings and can present as cases of sudden unexpected death to medical writing on the note, and it was compared with the subject’s handwriting
examiner offices. It is not only important, therefore, for primary care givers obtained from documents produced as schoolwork. The documents
to be sensitive to changes in the baseline health of their patients as these examiner determined that the handwriting on the note, though efforts had
may be the heralds of opportunistic infection, but also crucial for those per- been made to disguise it, was consistent with the decedents’ previously pro-
forming the postmortem to obtain a complete medical history including duced documents. A latent print was also obtained from the note, and was
medicines used (and if applicable, chemotherapy and radiotherapy) and to identified as the subject’s. The content of the journal was also reviewed,
keep opportunistic infections in their differential as to the mechanism of and revealed the decedent’s increasing despondence and self-doubt.
death. Despite the decedent’s attempts to lead investigators to believe he had
Hairy Cell Leukemia, Aspergillus, Autopsy been a victim of homicide, the manner of death was determined to be
suicide. Staging a homicide may be an effort to gain notoriety, install guilt
or protect family members. Following this investigation, the decedent’s
motive for disguising the suicidal act remains unclear.
G7 Teen Fatality by Train:
Staging, Multidisciplinary, Train Fatality
A Multidisciplinary Approach to
Determination of Manner of Death
G8 A Fatal Case Due to Abdominal
Mary H. Dudley, MD*, Sedgwick County Regional Forensic Science
Center, 1109 North Minneapolis, Wichita, KS 67214
Compartment Syndrome (ACS)
The goal of this case study is to illustrate a multidisciplinary approach Margherita Neri, MD*, Marianna Di Padua, MD, and Emanuela
to the death investigation, and highlight unique elements of staging in an Turillazzi, MD, PhD, Department of Forensic Pathology, University of
attempt to disguise a suicide. Foggia, Viale Pinto 1, Foggia, 71100, Italy
humanity by demonstrating the value of a forensic team approach to the The goal of this presentation is to present to the forensic community a
investigation of the circumstances of death for determination of the manner case of death due to a rare systemic syndrome: abdominal compartment
in complicated or staged death scenes. syndrome (ACS).

This presentation will impact the forensic community and/or According to clinical symptoms and measuring of intra-abdominal
humanity by presenting a case worthy of reporting for the rareness of the pressure, it is possible to make a timely diagnosis of ACS and operate for
syndrome and its great surgical and forensic interest. a prompt abdominal decompression. Clinical studies show a significant
This case has been studied by means of autopsy and histological difference in mortality between ACS patients undergoing abdominal
examinations. decompression and untreated patients (59% vs 100%). Further studies
Abdominal compartment syndrome (ACS) is broadly defined as point out that a timely abdominal decompression and early treatment
organ dysfunction derived from increase in intra-abdominal pressure. reduce both the incidence of ACS (64% vs 43%) and mortality of ACS
Prolonged, unrelieved increased intra-abdominal pressure at more than 20 (44%vs 28%) in patients at risk.
mm Hg can produce pulmonary compromise, renal impairment, cardiac Abdominal Compartment Syndrome, Histological Findings,
failure, shock, and death. This presentation discusses the clinical-patho- Postmortem Diagnosis
logic features, the postmortem findings and microscopic features of a fatal
case due to ACS.
Case Report: A 35-year-old Caucasian female went to the emergency
room with increasing abdominal pain. The woman, admitted to the surgery
G9 Cane Corsos Attack: Two Fatal Cases
unit, underwent a physical examination. It showed a sharply distended and
painful abdomen, no peristalsis, and rebound tenderness. At abdominal Sabina Di Donato, MD*, and Emanuela Turillazzi, MD, PhD, Institute of
ultrasonography, stomach and bowel loops appeared distended with cor- Forensic Medicine, University of Foggia, Viale Luigi Pinto, 1, Foggia,
puscolated liquid material. Abdominal x-ray showed small bowel dis- 71100, Italy; Fernando Panarese, MD, Department of Experimental and
tended with air-fluid levels. Three years before, the woman had undergone Clinical Medicine, University of Magna Grecia, Policlinico Universitario
an appendectomy. She was taken into the operating room for intestinal Catanzaro, Via Tommaso Campanella 115, Catanzaro, 88100, Italy;
occlusion due to adhesions. On the first postoperative day, the patient had Pietrantonio Ricci, MD, Department of Experimental and Clinical
shock with numbness, cutaneous pallor, sweating, cutaneous marbling on Medicine University of Magna Grecia, Policlinico Universitario
upper and lower limbs, tachycardia, tachypnea, peripheral pulselessness, Catanzaro, Via Tommaso Campanella 115, Catanzaro, 88100, Italy
oliguria, and severe metabolic acidosis. After another day of continuous The goal of this presentation is to present the case of two spouses who
deterioration of her clinical condition, she was moved to the Intensive Care were slaughtered by their three pet Cane Corsos. Investigations of the death
Unit. Her abdomen seemed distended, with no peristalsis; CT-scan con- scene and autopsy findings are described.
firmed bowel distention due to fluid and gas, with perihepatic and Although dog bite related fatalities on humans appear to be a breed-
perisplenic fluid collections. Laboratory tests demonstrated leukopenia, specific problem (Rottweiler and Pit Bull), other breeds may bite and cause
neutropenia, and metabolic acidosis. Gynecologic examination revealed a fatalities at higher rates. Here the authors present the cases of spouses
rectocele. On the second day in the Intensive Care Unit the woman con- slaughtered by their own three Cane Corsos, an Italian Molossoid dog
tinued to get worse. She had anuria and hypotension; her intra-abdominal breed. This presentation will impact the forensic community and/or
pressure, measured inside the urinary bladder by means of an ordinary humanity by confirming the inadequacy of breed-specific ordinances.
Foley catheter, was 35 cm H2O. Taken into the operating room for surgical The most common animal bite injuries in the United States are
abdominal decompression, the woman died. A complete autopsy was per- inflicted by dogs, accounting for 80-90% of all bites. It is estimated that
formed 48 h after death. between 1 and 4 million Americans are annually bitten by “man’s best
At autopsy the body was that of a well-developed adult with pale and friend;” approximately 1 in 20 dogs will bite a human being during the
dehydrated skin, ostia, and oral and scleral mucosae. The brain was con- dog’s lifetime. The vast majority of these dog bite wounds produce minor
gested and edematous. The left pleural cavity contained 200 ml of red injuries, and the victims never seek medical attention, but serious sequelae,
liquid; the right pleural cavity contained 400 ml of the same liquid. The and even death, may occur. In 2001, the U.S. Centers for Disease Control
lungs were hypoexpanded and atelectatic. The peritoneal cavity contained and Prevention (CDC) estimated that 368,245 persons were treated in U.S.
1000 ml of red liquid. The intestines appeared distended, with brown liquid hospital emergency departments (EDs) for dog bite-related injuries (rate:
material and pseudomenbranes in the large bowel. Examination of other 129.3 per 100,000 population). Bite wounds, in fact, account for approxi-
organs was unremarkable. mately 1% of all emergency department visits and more than $30 million
The histological findings of the liver revealed necrosis in acinar zone in annual health care costs.
3. The kidney showed characteristics of shock: collapse, swellings of Annual mortality rates from dog attacks are reported at7.2 cases for
endothelial and surface cells, broadening of the basal membrane, and 100 million inhabitants. Many victims of these fatalities, unfortunately, are
impairment of the loops in the glomeruli. The epithelia of tubules were flat- young children (often <1-year-old), and old people (mainly women); in
tened, and their nuclei were enlarged. The bowel wall showed areas of fact, these two groups are made up of weak and defenseless individuals,
epithelial necrosis, fibrinous stratification, and inflammatory infiltration generally unable to protect themselves properly.
spread up to the muscularis mucosae. There is a strict relationship between the victim’s age, severity of
It was concluded that the cause of death was fatal shock due to injuries, and injury site. The majority of dog bites to adults are directed to
Abdominal Compartment Syndrome (ACS). the extremities; conversely, the most frequent targets of dog attacks towards
ACS is a clinical syndrome that occurs as a consequence of intra- children are head and neck. This explains why the highest mortality is seen
abdominal hypertension. ACS is characterized by a tensely distended among children.
abdomen, elevated peak airway pressure, and impairment of cardiac and About 50% of fatal attacks towards human beings involve two or
renal functions, leading to oliguria or anuria. Any insult that causes an more dogs; on the contrary, non fatal bites almost always involve only one
acute increase in intra-abdominal volume can trigger ACS, including dog. In fact, belonging to a pack usually makes dogs behave more
trauma to the abdomen as well as to distant sites, pancreatitis, hemorrhage, aggressive, and increases the probability of causing the victim’s death.
intestinal occlusion, ruptured abdominal aortic aneurysm, massive fluid The most commonly reported breeds are Pit Bull, Rottweiler, German
resuscitation, and burns. The syndrome usually occurs in critically sick Shepherd, Golden Retrievers, Husky, and Akita. Presented the case of a
patients after major abdominal trauma or operations. Several cases were couple slaughtered by their three Cane Corsos, in the garden adjacent to
described where the syndrome developed without direct abdominal insult. their own house. The husband, a 76-year-old man, was found lifeless, lying
These cases, however, were associated with severe hemorrhagic shock, face down in the bloodstained ground, completely covered with blood. He
burns, massive ascites, ileus, ovarian mass, or the use of anti-shock wore trousers and a pair of shoes, but his legs were hidden by leaves. His
trousers. trunk was completely naked, but numerous shards of clothes were scattered

all around the area of aggression, abundantly blood stained. Injuries were head and torso, fracture of the parietal skull, subarachnoid hemorrhage,
localized to head, neck, trunk, and upper limbs, while the genitalia and multiple anterior and posterior rib fractures bilaterally, contusions of the
lower limbs remained intact. The scalp was almost totally absent, so that lungs and heart, and lacerations of the liver.
the frontal, part of the temporal, parietal and occipital bones lay bare. The Case 2: A three-month-old male infant was asleep in a wind-up swing
left lower eyelid and the left zygomatic region showed a stretch laceration when his parents went to bed in a separate bedroom. Three hours later, the
of 4.5 x 3.2 cm, with exposure of the underlying bones; the left external ear mother awoke and, upon checking the infant, found him on the floor
presented a grossly semicircular recision of 3 x 2.5 cm. On the left supra- unresponsive with the swing tipped over. The family dogs that were
clavear region there was a deep oval shaped laceration of 5.4 x 4.7 cm, with present, an eight year-old Chow Chow named “Sandy” and a nine year-old
the exposure of the clavicle, muscles, nerves, and resected vessels. There Dachshund named “CoCo,” were removed by Animal Control. Postmortem
were numerous lacerations on the right side of the neck, the main one was examination revealed multiple injuries consistent with attack by a medium
a deep oval shaped gaping wound of 9.2 x 8 cm, which exposed part of the to large sized dog, including numerous contusions, abrasions, lacerations,
mandible, lacerated musculature and vessels. The left upper arm showed and puncture wounds of the skin; damage to the atlanto-occipital joint;
numerous gaping wounds, in particular the deepest were localised on the fractures of the skull, mandible, clavicle, and ribs; rupture of the spleen and
upper and lower part of the arm, on the elbow, and on the radial face of the left kidney; laceration of the liver; and contusions of the lung.
forearm exposing, respectively, the humerus and the radius, lacerated Dog bite-related fatalities are uncommon events. Children are at
muscles, tendons, nerves and vessels. Similar injuries were on the right particularly high risk, because the majority of dog bites occur in children
upper arm, and in particular in the axillary cavity and on the elbow, where and children are more susceptible to severe injury from dog bites. Other
underlying tissues appeared completely destroyed. All these torn wounds known risk factors for fatal dog attacks include male gender of the victim
presented ragged and irregular margins with adjacent puncture wounds, the and dog breed; a majority of attacks occur on the dog-owner’s property and
so called a-hole-and-a-tear combination. In the vicinity of the bites often without any known provocation.
described, but in particular on the back, were found the typical claw-marks: Canine aggression is a well-described behavioral phenomenon and
narrow, superficial, linear abrasions, parallel to each other, four or five in has been subdivided into various types; of these, predatory aggression
number. The wife, a 70-year-old woman, presented similar wounds over refers to the hard-wired instinctual drive to chase, catch, and kill prey. A
the upper extremities, neck and trunk. The internal examination of both distinguishing feature of predatory aggression is that it is usually triggered
deceased revealed mainly multiple transmural vessels tears. Deaths were by movement, often with little change in the dog’s mood. In each of the
attributed to exsanguination by external bleeding. above cases, infants were left unattended in mobile wind-up swings in the
These represent unique cases, because, there appears to be no pre- presence of trusted household pets. These cases not only underscore the
vious reports of fatal attacks with the involvement of the Cane Corso, an importance of not leaving young children unattended in the presence of pet
Italian breed of Molossoid dog. This confirms that all types of dogs may dogs, but also raise the possibility that mobile swings may trigger a
inflict injuries–even fatal–to people, and reveals the inadequacy of breed- predatory response in dogs and thus may represent an additional risk factor
specific ordinances. for dog attack.
Dog Bite, Fatal Dog Attack, Cane Corso Dog, Infant, Swing
G10 Fatal Dog Maulings Associated G11 Contribution of Burn Injury in a Blunt
With Infant Swings Trauma Case With Incineration
Albert Y. Chu, MD, MHS*, Carol Allan, MD, Mary G. Ripple, MD, John B. Davis, BS*, Eastern Virginia Medical School, 700 West Olney
Tasha Z. Greenberg, MD, and David R. Fowler, MD, Office of the Road, Norfolk, VA 23507-1607; and Leah L. Bush, BS, and Wendy M.
Chief Medical Examiner, State of Maryland, 111 Penn Street, Gunther, MD, Office of the Chief Medical Examiner, Tidewater District,
Baltimore, MD 21201 830 Southampton Avenue, Suite 100, Norfolk, VA 23510-1046
After attending this presentation, attendees will become familiar with The goal of this presentation is to discuss a complex case in which
the phenomenon of dog bite-relatedfatalities involving children left unat- incineration, not the primary cause of death, may have occurred just prior
tended in infant swings. In addition, attendees will become familiar with to death from blunt head trauma, in a homicide. In addition, the authors
the epidemiological, medical, and forensic aspects of fatal dog maulings in review recent literature on significance of carbon monoxide, traces of
children. tracheal soot, and other findings, in determining whether incineration
This presentation will impact the forensic community and/or occurred antemortem or postmortem.
humanity by suggesting an as yet undescribed association between infant This presentation will impact the forensic community and/or
swing use and dog attacks, which may have significant child safety humanity by discussing the issues involved in determing whether inciner-
implications. It will also impact the forensic community by increasing its ation of a body, on which lethal blunt head trauma had been inflicted,
awareness of the general features of dog-bite-related-fatalities. occurred before or after death.
Two cases of fatal dog maulings of children left unattended in wind- Assailants in homicide have often made use of incineration in an
up infant swings are presented, an event not previously described in the attempt to conceal the evidence of the crime. Incineration usually occurs
literature. In addition, a review of dog bite fatalities in children autopsied postmortem. Accelerants are sometimes used. This case illustrates the
in Baltimore over the last ten years and a review of the existing literature questions that arise when autopsy findings suggest that burn injury may
on this topic will be presented. have begun before death.
Case 1: A two-and-a-half-week old male infant was left in a wind-up The Virginia Beach Fire Department responded to a rubbish fire in a
swing by his parents, who went outside to smoke cigarettes. The family field. On extinguishing the blaze, they discovered the unburned shoes and
dog, a one year-old pit bull named “Jigga,” remained in the room with the lower legs of an unidentifiable, partially incinerated decedent, extending
infant. Upon their return, the parents discovered that the swing was over- from the burned rubbish. Local law enforcement was called to the scene,
turned and the infant was on the floor, unresponsive, with bite marks to the and the body was transported to the Medical Examiner’s Office.
body and face. Postmortem examination revealed multiple injuries, The body proved to be that of an adult male, with charring present
including contusions, abrasions, lacerations, and puncture wounds of the over most of the body surface area, but with sparing of both lower legs and

portions of the upper arms. There was exposed muscle, partial skele- In every cage at least some maggots remained on the deteriorating
tonization of the face, and a postmortem epidural hematoma. In addition to food source until it had either been consumed, dried out, or the experiment
the charred body, a distinct odor of accelerant was noted on the debris and was terminated. However, during the late summer experiment of 2003, in
clothing transported with the body. Autopsy revealed blunt impact trauma 6 of 12 test cages, early third instar maggots of Lucilia sp. abandoned a
to the right side of the victim’s head, traces of soot in the trachea, and cherry deteriorating food source (i.e., a nearly consumed and/or rapidly desic-
red discoloration of the muscles. cating piece of liver), and crawled across the bare soil to reach the shelter
Investigation suggested that an assailant had attempted to destroy containing the fresh food source (approx. 40 gm of fresh beef liver) and
evidence of homicide by pouring an accelerant over the victim’s body and began feeding. Similarly, during the late spring experiment of 2004, in 6
igniting it after inflicting blunt trauma to the head. The literature states that of 12 cages, early third instar maggots of Phaenicia sp. exhibited the same
traces of soot in the trachea may occur postmortem. The contribution that foraging behavior. The number of foraging maggots that crawled into the
burning may have made to this blunt trauma homicide, the role of carbon food shelters varied greatly, ranging from 1 – 2 individuals (4 cages) to
monoxide determination in flashover burns, and evidence in general for more than 100 (3 cages). In one cage at least 387 maggots, as confirmed
antemortem vs. postmortem incineration, will be discussed. by rearing the adult flies (Lucilia sp.), had crawled into the food shelter.
Incineration, Antemortem Burn Injury, Blunt Trauma Homicide Although there were 7 cases where maggots crawled into shelters that con-
tained only a moist cloth, the numbers were much lower. In 5 cages where
maggots had crawled into the food shelters, one maggot in each cage
moved in the opposite direction and crawled into the non-food shelter. In
G12 A Field Study of the Foraging two cages where no maggots had crawled into the food shelters, a single
Behavior of Blowfly Maggots maggot in one cage, and two maggots in the second cage, crawled into the
non-food shelters. Finally, in 10 cages no maggots crawled into either
David L. Gibo, PhD*, and Deana Hathout, BSc, University of Toronto at shelter.
Mississauga, 3359 Mississauga Road North, Mississauga, Ontario L5L Blowflies, Maggots, Foraging
1C6, Canada; Brent Walker, BA, Conestoga College, Law and
Security/Police Foundations, School of Health Sciences and Community
Services, 299 Doon Valley Drive, Kitchener, Ontario N2G 4M4, Canada; G13 Cavotricuspid Isthmus Rupture and
and Brian Dixon, PhD, 1645 Howat Crescent, Mississauga, Ontario L5J
4G6, Canada
Hemopericardium: A Delayed
Complication of Cardiac
After attending this presentation, attendees will understand the possi-
bility that the largest blowfly maggots found on a body may be relatively Radiofrequency Catheter Ablation
recent arrivals, having crawled over to the fresh remains when their initial
food source (e.g., a dead mouse) became depleted, resulting in the risk of Ezra Ellis, MD*, and Patrick E. Lantz, MD, Department of Pathology,
significant errors by investigators attempting to calculate postmortem Wake Forest University Health Sciences, Medical Center Boulevard,
interval. Winston-Salem, NC 27157
This presentation will impact the forensic community and/or After attending this presentation, attendees will become aware of
humanity by alerting the forensic community to the possibility that if delayed fatal complications of cardiac radiofrequency ablation.
foraging behavior by food-deprived blowfly maggots is a reasonably This presentation will impact the forensic community and/or
common phenomenon, larger (older) blowfly maggots that have managed humanity by providing heightened awareness of potential complications of
to find their way to a fresh body can be a source of large errors when cardiac radiofrequency ablation that may occur weeks or months following
investigators attempt to calculate postmortem intervals based on published the procedure.
rates of maggot development times. On the other hand, foraging by food- Radiofrequency ablation (RFA) has been used in humans since 1981
deprived blowfly maggots could also provide a possible explanation for the for the treatment of cardiac dysrhythmias. Numerous studies have shown
presence on bodies of anomalous maggots that are larger than expected that it has a high success rate with infrequent complications. The indica-
according to other independent evidence. tions for RFA include atrioventricular (AV) nodal re-entrant tach-
It is generally assumed that the largest, and presumably the oldest, yarrhythmias, accessory pathway dysrhythmias, focal atrial tachycardia,
blowfly maggots (i.e., larvae of Calliphoridae) found on a body initially atrial flutter and idiopathic ventricular tachycardia. Reported complica-
arrived as eggs deposited by flies attracted to the remains. There is the tions include AV block, post-pericardiotomy syndrome, atrio-esophageal
possibility, however, that at least some of the large maggots crawled over fistula, coronary artery stenosis, acute hemopericardium, and delayed right
to the body from some other piece of carrion in the immediate environment. ventricular aneurysm.
For example, if a body is dumped in a field near the remains of a dead A 47-year-old woman had a history of atrial flutter and underwent
mouse, and if the mouse remains had been nearly consumed by blowfly radiofrequency ablation with an 8-mm catheter. The initial ablation line
maggots, at least some of the maggots may abandon the depleted mouse consisted of 17 radiofrequency applications (maximum power 70 watts and
remains and crawl over to the fresh food source, greatly complicating the maximum temperature 70 degrees), most for 60 seconds. The line of block
situation for forensic entomologists. During the late summer of 2003 and extended down from the cavotricuspid region to the inferior vena cava
the late spring of 2004, field studies were conducted of the foraging (IVC). A procedural follow-up study showed unidirectional block with a
response of blowfly maggots feeding on a depleted, or nearly depleted, questionable area near the IVC. An additional 20 RFA applications were
food source. The field studies were conducted in cages that excluded ver- applied superior to the previous line but the applications were also extended
tebrate scavengers but not blowflies and other invertebrates. The experi- into the IVC. A repeat follow-up study showed successful RFA of her atrial
mental situation was manipulated such that the maggots were presented flutter and bidirectional block across the cavotricuspid isthmus at baseline
with three choices: (1) remaining on a low quality and rapidly deteriorating and following an isoproterenol challenge.
food source, (2) abandoning the deteriorating food source and crawling Six weeks following her cardiac RFA she presented to another
approximately 45 cm across bare soil to a shelter containing a moist cloth hospital complaining of chest pain. Troponin levels, a cardiac stress test
and a fresh food source, or (3) abandoning the deteriorating food source and and an echocardiogram were described as normal and she was discharged.
crawling approximately 45 cm across bare soil in the opposite direction to Five days later she had a witnessed collapse at home. Emergency medical
a shelter containing a moist cloth but no food. services responded and found her asystolic. Further resuscitative efforts

were unsuccessful and she was pronounced dead in the emergency to 3%. HbC has a greater tendency to aggregate with HbS that does HbA,
department. and hence those with HbS and HbC (designated HbSC) have a more severe
At autopsy, she had a cavotricuspid isthmus disruption with a 450 mL disease than do whose with HbS and HbA. On deoxygenation, abnormal
hemopericardium. Microscopically, the site of disruption had homoge- hemoglobins undergo aggregation and polymerization. This converts the
nization, necrosis, fibrosis and extravasated blood. Associated with the hemoglobin from freely flowing liquid to viscous gel and results in
fibrosis and necrosis were chronic inflammatory cells and granulation distortion of the red cells, which acquire a sickle shape. Patients have to
tissue. Elastic fibers were disrupted near the site of rupture and hemo- deal with problems ranging from severe anemia, vaso-occlusive compli-
siderin laden macrophages were present. cation, and chronic hyperbilirubinemia to severe infection. In children
The authors were unable to find a previous report of delayed cavotri- painful vaso-occlusive crises are extremely common, as well as hand-foot
cuspid rupture and hemopericardium following cardiac radiofrequency syndrome. An aplastic crisis represents a temporary cessation of bone
ablation; however, in experimental animal studies damage to the tricuspid marrow activity usually induced by parvovirus infection of erythroid cells.
valve and IVC occurred most frequently with high energy pulses and 8-mm Sequestration crisis may occur in children with splenomegaly. With
catheters. modern treatment approximately 90% of patients survive to the age of 20
Radiofrequency Ablation, Cardiac Dysrhythmias, Complications years, and close to 50% survive beyond the fifth decade. No reported case
of rapid death from Hg S-C type sickle cell anemia was found in the
literature.
In this case the child had an acute infection with parvovirus B19,
G14 Sudden Death of a Fourteen-Year-Old which was confirmed by blood serology. It is believed the cause of death
was acute sequestration of blood with an aplastic crisis induced by the
Female With Hb S-C Disease parvovirus, and thus ruled the death as natural. The mother of the deceased
did not promptly call for medical help. She acted such in fearing the
Victor V. Frolov, MD*, Jeffrey M. Jentzen, MD, and John R. Teggatz, MD, discovery of previous child abuse – which does suggest possible medical
Milwaukee County Medical Examiner Office, 933 West Highland Avenue, neglect and, thereby, a potential for other interpretations as to manner of
Milwaukee, WI 53233 death.
The goal of this presentation is to review the sudden death of a child Sickle Cell Anemia, Hb SC Type, Parvovirus B19
with sickle cell anemia – Hb S-C type. The attendees will learn the
different genetic forms of sickle cell disease, their complications, and the
potential mechanisms of death with sickle cell anemia. G15 Interpreting Lesions to the Conduction
This will impact the forensic community and/or humanity by
demonstrating an unusual sudden death in an adolescent with an element of System of the Heart in Case of Death
past physical abuse. Pursant to Cocaine Ingestion
According to her caretakers (mother and a grandmother), this 14-year-
old black female child had been complaining of vague headache and back Katarzyna Michaud, MD*, Thomas Krompecher, MD, Béat
pains for several days. At the morning of her death she had complained of Horisberger, MD, Marc Augsburger, PhD, Frank Sporkert, PhD, and
her “eyes turning color,” increased headache “behind her eyes,” and Patrice Mangin, MD, PhD, Institut Universitaire de Médecine Légale,
difficulty in “straightening out the fingers of her left hand.” Her mother Bugnon 21, Lausanne, 1005, Switzerland
interpreted her daughter’s complaints as predominantly an attempt to avoid
school that day, and dismissed them from having any serious medical The goal of this presentation is to evaluate the potential role of the
implications. At 1:00 p.m. that day, she was found lethargic and pathological lesions of the conduction system in the pathomechanism of
unresponsive. The mother and grandmother attempted to help her stand up, death in cocaine users and to demonstrate the difficulties of forensic
but failed. Of note, despite the grandmother’s wish to immediately call for investigations when death is preceded by cocaine ingestion.
help, the mother rejected such initially, and the 911 call was not placed until This presentation will impact the forensic community and/or
some time later when the mother “could not feel a pulse.” Paramedics humanity by presenting several cases in which it was concluded that
arrived at 3:30 p.m., and she was pronounced dead after resuscitative pathological lesions in the conduction tissue may play a role in the
efforts. occurence of death attributed to intoxication following cocaine ingestion
On initial external examination at the Medical Examiner’s Office Since 2000, there has been a considerable increase in cocaine use and
healed, patterned loop-type scars were noted on the deceased’s torso, cocaine traffic in Switzerland. This trend is matched by an increasing
buttocks, and extremities. No acute injuries were present. Autopsy exam- number of deaths attributed to intoxication in the presence of cocaine and
ination revealed a well-developed, well-nourished young adolescent female of its metabolites. However, it is not always clear whether intoxication is
with scleral icterus and an overall slight jaundice appearance. Internal the sole cause of death.
examination was remarkable for bilateral pulmonary edema, massive Any forensic scientist will agree that death can be attributed to intox-
splenomegaly (spleen weight of 1,190 grams), and evidence of extreme ication only after a complete autopsy, which includes histological analyses.
anemia. No internal injuries were present. Microscopic examination was Potentially lethal levels of a drug must be found and any other cause of
remarkable for extensive sequestering of sickled red blood cells within the death must be excluded. A rigorous approach is especially important in the
spleen and a hypercellular bone marrow with areas of scarring. case of drug users, which may occasionally present very high levels of
Postmortem toxicology was negative for alcohol or drug/medication certain substances without any sign of severe intoxication.
substances other than a small quantity of acetaminophen. Vitreous elec- In the case of death after cocaine ingestion, the interpretation of the
trolytes were unremarkable. Postmortem viral and bacterial cultures were results of toxicological analyses carries an additional difficulty. Some
negative, although a blood sample was positive on immunoassay for victims present pathological lesions, such as cardiovascular lesions, that
parvovirus B 19 antibodies IgM and IgG. may or may not be linked to repetitive cocaine ingestion. The long-term
Sickle cell anemia is an autosomal recessive disease caused by a point and short-term cardiovascular toxicity of cocaine is well established. Some
mutation in beta hemoglobin gene chromosome 11p 15.4 (Hb S; 6 Glu pathologies, caused by cocaine ingestion and which may in fact explain the
leads to Val and Hb C; 6 Glu leads to Lys.). Approximately 8% of black observed death, can be identified through a macroscopic examination.
Americans are heterozygous HbS. The carrier rate for HbC in is about 2% Such is the case for a cerebral hemorrhage or the rupture of an athero-
matous plaque in the coronary artery.

Cocaine use is also known to cause cardiac rhythm disorders, some of family or, after testing is completed, disposition by the coroner needs
which have morphological substrates that can be detected through a micro- family consent. They cannot be reused or refurbished, as U.S. Federal law
scopic examination. A survey of the literature shows that there have been prohibits it. Nuclear pacemaker must be removed to satisfy nuclear
few investigations of the conduction system of the heart in cocaine users regulatory agency requirements for 100% removal of all radioactive
and that no studies have ever examined conduction tissue in chronic users modules. Pacemakers have been used for identifying decedents. Several
whose drug ingestion was confirmed by hair analysis. It thus appeared of case examples from the LA County Coroner will be discussed. A newly
interest to identify pathological lesions in the conduction system of the developed pacemaker policy will be shared.
heart in chronic cocaine users that may explain cardiac rhythm disorders Pacemaker Evaluation, Cardiology Consultation, Defibrillator
and even some deaths. Disposition
This presentation focuses on the different lesions found in the
conduction system of the heart in cocaine addicts. Many authors believe
that such lesions may be the cause of sudden death. The most frequently
observed lesions consist of severe thickening of the atrioventricular node
artery, intranodal and perinodal fibrosis, and microscopic foci of
G17 Traumatic Cardiovascular Complications
myocarditis. of Catheter-Based Procedures: Relevance
Several cases with observable pathological lesions will be presented. to Medicolegal Death Investigation
The victims were young subjects: all were known to the police as long-term
drug users, and some were undergoing a methadone treatment. In each Edward J. Tweedie, MD*, London Health Sciences Centre, 339
case, a forensic autopsy and toxicological analyses were performed, Windermere Road, London, Ontario N6A 5A5, Canada
including hair analysis to establish chronic drug use in general, and cocaine
use in particular. This study included only cases in which toxicological After attending this presentation, attendees will be aware of potential
analyses revealed the presence of cocaine in the blood, in the urine and in traumatic cardiovascular complications of catheter-based procedures and
the hair. will be able to recognize them at autopsy and determine their significance
It was concluded that pathological lesions in the conduction tissue in the context of a medicolegal death investigation.
may play a role in the occurrence of death attributed to intoxication This presentation will impact the forensic community and/or
pursuant to cocaine ingestion. humanity by underscoring the scope and utilization of catheter-based
procedures. The forensic community must be aware of these uncommon
Cocaine, Conduction System, Hair Analyses
but well-recognized adverse events because many of these deaths become
medicolegal death investigations due to their often unexpected nature
related to a medical procedure.
Using several case examples, the audience will become aware of
G16 Defibrillator/Pacemaker Evaluation potentially life-threatening traumatic cardiovascular complications that can
in the Los Angeles County result directly from a wide variety of catheter-based procedures.
Medical Examiner Office There are a wide variety of procedures, both diagnostic and
therapeutic, which involve catheterization of the heart and great vessels.
These include standard, well-established procedures such as central venous
Lakshmanan Sathyavagiswaran, MD*, Daniel Rieders, MD, and Joseph
catheterization for fluid, nutrition or medication administration, and
Muto, Department of Coroner, Los Angeles County, 1104 North Mission
pulmonary artery catheterization for pulmonary pressure monitoring.
Specific cardiac interventions include endomyocardial biopsy, radiofre-
After attending this presentation, attendees will be updated on the quency endocardial ablation for arrhythmia control, cardiac pacemaker and
usefulness of soliciting cardiology consultations on deaths involving implanted defibrillator placement, diagnostic coronary angiography, and
Implantable Cardioverter Defibrillator (ICD)/Implantable Pulse Generator angioplasty procedures. These all carry with them a low but well-
(IPG) (pacemaker) as they relate to determination of cause/manner of recognized risk of traumatic perforation. In addition, more novel
death; and will be provided guidelines on disposition of equipment. procedures, including intravascular ultrasound, and laser and rotational
This presentation will impact the forensic community and/or atherectomy, continue to be developed.
humanity by providing examples of quality evaluation on implanted ICD The following autopsy case examples will be presented: brachio-
and pacemakers. Mortuaries/medical examiners/coroners are provided cephalic vein perforation by a central venous catheter in a dialysis patient
with vital information related to their safety in handling decedents with resulting in fatal hemothorax, right ventricular perforation by a pacemaker
implantable ICD/pacemakers, and disposition of same. electrode in an elderly woman with heart failure, coronary artery dissection
LA County Coroner’s Office uses the services of a cardiologist/ caused by diagnostic coronary angiography, and pulmonary artery
electrophysiologist to conduct forensic evaluations of implanted defibril- perforation by a pulmonary artery catheter after open heart surgery.
lators/pacemakers. In some cases the device is explanted by the medical When perforation occurs, the outcome may be fatal and–due to the
examiner and the cardiologist conducts interrogation with the programmer nature of such deaths–many are investigated in a medicolegal context. The
testing of the pulse generator. This provides information of device function, pathological findings at autopsy must be properly recognized and then
events, and whether the battery is depleted. interpreted. Factors impairing pathological recognition may include a
In other cases the device and lead system is intact in the decedent, in delay from the time of intervention to the time of death, no prior clinical
which case the integrity of the lead system can be verified by the cardiol- awareness of the adverse event, prior removal of the catheters, inadequate
ogist with similar interrogation techniques. The cardiologist also reviews availability of clinical history, and medical examiner or pathologist unfa-
the clinical records and pacemaker tracings, and provides opinions on the miliarity with the nature of the procedure. When such events are identified,
pacing system. it may be difficult to determine the relative contribution of the resultant
Implantable cardioverter defibrillators have to be turned off using a hemorrhage or damage to the cause of death in the presence of other major
programmer to prevent morticians getting a shock. Pacemaker and ICDs co-morbid conditions. Furthermore, it may be difficult to decide upon the
should be removed prior to cremation because of sealing techniques, they manner of death, whether accidental or natural, when other significant
will rupture during cremation due to pressure buildup. disease is present. Proper investigation requires careful review of the
In California, the IPG/ICD is the property of the family. If removed medical record and a complete autopsy. Care must be taken to leave
for evidentiary and cause of death reasons they have to be returned to the catheters and lines in place so that they can be properly inspected in-situ.

Associated hemorrhage should be quantified, and photographs should be Four of the seven natural deaths were cardiac related and three were
taken. Microscopy may aid in dating lesions if healing reaction has non-cardiac related. The structurally normal heart was found in a
developed at the site of injury. 23-month-old child with severe developmental delay and microcephaly. In
Medical examiners and pathologists who perform autopsies in a one case, the cause of death was due to a pulmonary thromboembolus. In
hospital-based setting should familiarize themselves with the ever- the third case, the only cardiac finding was medial hypertrophy of intramy-
expanding array of catheter-based endovascular procedures so that when ocardial arteries. This particular case involved a witnessed arrest 30
adverse complications occur, they will be properly recognized. It is noted minutes after ingestion of sildenafil citrate (Viagara). The cause of death in
that potential complications are not limited to vascular perforations. As new this case was certified as “sudden cardiac death.”
procedures and equipment are introduced, vigilance for adverse events may The practice of utilizing cardiovascular pathologists at a cardiovas-
assist in assessing their overall safety. cular registry for examination of post valve recovery hearts has lead to
significant numbers of heart valve donations at the authors’ institution.
Cardiovascular, Catheter, Complications
This process has not resulted in a delay in death certification and has not
compromised the determination of the cause or manner of death. In fact, it
has been beneficial in several areas. There are some inheritable cardiac
G18 Increasing Heart Valve Donation by conditions that are well known to cause sudden death. Recognition of these
Utilization of a Cardiovascular Registry conditions is sometimes subtle, but the diagnosis may have enormous
implications for family members. Examination of the remnant heart by
Susan J. Roe, MD*, Regina Medical Center, 1175 Nininger Road, cardiovascular pathologists who are accustomed to studying cases of
Hastings, MN 55033; Shannon Mackey-Bojack, MD, and Rachel M. sudden death and working with families also provides the pathologist with
Meuleners, Jesse E. Edwards Cardiovascular Registry, 333 North Smith additional physician resources. Furthermore, as seen by review of these
Avenue, Suite 4625, St. Paul, MN 55102; Lindsey C. Thomas, MD, cases, many cases of non-natural deaths have a significant cardiac abnor-
Regina Medical Center, 1175 Nininger Road, Hastings, MN 55033; and mality. These conditions may not have been evaluated completely without
Jack L. Titus, MD, PhD, Jesse E. Edwards Cardiovascular Registry, 333 donation, if a complete autopsy had not been required. Some of these
North Smith Avenue, Suite 4625, St. Paul, MN 55102 conditions also may have genetic implications for family members.
Tissue Donation, Cardiovascular Pathology, Cause of Death
benefits of utilizing established cardiovascular registries to increase the
number of heart valve donations by medical examiners/coroners.
This presentation will impact the forensic community and/or G19 A Review of Pathologic Findings in
humanity by providing the forensic community details of how an office in Specimens Following Heart Valve Donation
a large metropolitan area was able to allow a significant number of heart
valve donations by requiring that the remnant myocardium be examined by Shannon M. Mackey-Bojack, MD*, Jesse E. Edward’s Registry of
a cardiovascular pathologist. There were no significant delays in time to Cardiovascular Disease, John Nasseff Heart Hospital, 333 North Smith
sign the death certificate nor in determination of the cause of death by Avenue, Suite 4625, St. Paul, MN 55102; Susan J. Roe, MD, Rachel M.
requiring this specialized review. Meuleners, and Lindsey C. Thomas, MD, Regina Medical Center, 1175
The Minnesota Regional Coroner’s Office (MRCO) is the smallest of Nininger Road, Hastings, MN 55033; and Jack L. Titus, MD, PhD, Jesse
four offices covering the greater Minneapolis/St. Paul area, serving a E. Edwards Registry of Cardiovascular Disease, John Nasseff Heart
population of 642,000 persons, the second smallest in the area. The other Hospital, 333 North Smith Avenue, Suite 4625, St. Paul, MN 55102
three offices have a combined jurisdictional population of 2,489,600. Two of
these offices also have large numbers of referral cases from rural Minnesota. After attending this presentation, attendees will understand
MRCO made the decision to allow heart valve donations whenever cardiopathologic examination of hearts following heart valve donation is
possible and to require the tissue services organization to document cardiac beneficial and may yield important information in determining cause of
findings and to send the remnant myocardium to the Jesse E. Edwards death.
Cardiovascular Registry for examination by a cardiac pathologist. This presentation will impact the forensic community and/or
This study examines the result of this change in practice. The number humanity by increasing awareness of the forensic community in the
of heart valve donations was 15 in 2002 and 23 in 2003. The total number nationwide shortage of cardiac tissue grafts and the role of the Medical
of heart valve donations from other offices combined was 11 in 2002 and 6 Examiner in tissue donation.
in 2003. The Cardiovascular Registry was founded in 1960 by Dr. Jesse E.
There was no significant increase in the average number of days until Edwards in St. Paul, MN, for the purpose of studying, classifying, and
death certificate completion (14 vs. 21 days). categorizing heart disease. The Registry, under the direction of Dr.
Heart valves were donated in 21 accidental death cases. The age Edwards, was very involved in describing congenital and acquired heart
range was 15 to 54 years. Significant cardiac findings included: athero- disease. Since its formation, the Cardiovascular Registry has examined
sclerotic coronary artery disease (4), cardiomegaly (3), myocarditis over 27,000 cardiac specimens and cardiovascular surgical specimens.
(2), moderate myxomatous change of mitral and/or tricuspid valves (3), In 2001 the Cardiovascular Registry was approached by one of the
focal subendocardial fibrosis (1), and 80-90% stenosis of a large intramy- nation’s largest tissue donation procurement agencies for the purpose of
ocardial artery (1). Six of the hearts were normal. performing cardiovascular pathologic examinations of post valve recovery
Heart valves were donated in 10 suicidal death cases. The age range hearts. This collaboration began in 2001.
was 16 to 54 years. Significant cardiac findings included atherosclerotic The current study was undertaken to review the type of remnant hearts
coronary artery disease (4), cardiomegaly (2), probable arrhythmogenic received and to tabulate the abnormalities identified. All remnant hearts
right ventricular cardiomyopathy (1), biventricular hypertrophy (1), and received over the period of 33 months were included in the study, for a total
focal subendocardial fibrosis (1). Two of the hearts were normal. of 492 cases.
Heart valves were donated in seven natural death cases. The age The information received for each case includes the body height,
range was 23 months to 58 years. Significant cardiac findings included ath- weight and suspected cause of death. Comprising the 492 cases were 206
erosclerotic heart disease (2) and one case each of possible arrhythmogenic accidents, 75 suicides, 91 natural deaths, 5 homicides, and 116 cases in
right ventricular cardiomyopathy, healing myocarditis, and myocardial which the cause of death was undetermined at the time of heart valve
small vessel disease. One heart was normal. procurement.

Of the suspected natural deaths, 13 were classified as non-cardiac G20 Sudden Death in a Calipatria State Prison
related. The remaining 78 were suspected cardiac deaths. Seventy-seven
of the 78 cases had significant cardiac findings; some had more than one
Inmate With a Single Coronary Artery
major abnormality for a total of 83 significant cardiac findings. Only one
heart was structurally normal. Darryl J. Garber, MD*, Imperial County, California, Los Angeles County
Significant atherosclerotic coronary artery disease with a >75% Coroner’s Office/Department of Medical Examiner, 1104 North Mission
stenotic lesion was identified in 59 cases. One decedent was less than 25 Road, Los Angeles, CA 90033; and Henry Proo, Imperial County,
years of age. Thirty-six of the 59 did not have infarction; 22 had California, 328 Applestill Road, El Centro, CA 92243
myocardial infarction. Other significant cardiac abnormalities in the After attending this presentation, attendees will understand how to
natural group included: myocarditis (6), cardiomegaly (4), bicuspid aortic determine the presence of a “true” single coronary artery and to utilize this
valve with stenosis (3), arrhythmogenic right ventricular cardiomyopathy cardiac malformation as the cause of sudden and unexpected death in the
(2), acute aortic dissection (2), anomalous origin of a coronary artery (1), absence of other pathophysiology.
aneurysmal coronary artery (1), hypertrophic cardiomyopathy (1), dys- This presentation will impact the forensic community and/or
plastic intramyocardial arteries (1), mitral valve prolapse (1), coronary humanity by demonstrating the pathophysiology with a single right
artery thrombo-emboli (1), and prior valvular disease with mechanical coronary artery, and by classifying the finding of a “true” single coronary
valve replacement (1). In the natural death group, 33 incidental cardiac artery as a pathological entity of functional significance potentially leading
findings were identified including: moderate atherosclerotic coronary to sudden death in the absence of other cardiac malformations.
artery disease, myocardial bridge, acute angle of origin of the coronary This presentation is the case of a 31-year-old black man who had been
artery, cardiomegaly, myxomatous change of a valve, patent foramen ovale, incarcerated for approximately six years prior to his death. The decedent
and post inflammatory mitral valve disease. was an inmate at the Calipatria State Prison located in Southern California.
Accidental death constituted the largest group, with 205 cases (42%). He was in the midst of doing exercises in the exercise yard when he
Fifty-one had significant cardiac abnormalities and 107 had incidental suddenly collapsed. He was subsequently taken to the prison infirmary and
cardiac findings, including 9 congenital abnormalities. Twenty-three had transferred to a local hospital for treatment, however, was pronounced dead
traumatic injuries, which were either contusions or lacerations. Injuries despite resuscitative efforts. The decedent had no significant past medical
were found only in this accidental group of cases. One hundred and three history and no history of any drug usage. Postmortem examination
of the remnant hearts were normal. revealed a slightly enlarged heart with a single right coronary artery and
Of the 75 suicides, 22 had significant cardiac abnormalities including complete absence of the left coronary artery and corresponding circulation.
two cases of arrhythmogenic right ventricular cardiomyopathy, an inheri- Gross and microscopic evaluation of the heart revealed subendocardial
table condition. A third case of possible arrhythmogenic right ventricular fibrosis of the anterior and anteroseptal left ventricle characteristic of
cardiomyopathy and one case with focal areas of myocyte disarray were chronic myocardial ischemia. Also grossly and microscopically evident
present in this group. Twenty-three incidental cardiac abnormalities, was superimposed acute myocardial infarction in the same region of the
including congenital abnormalities, were also identified. heart. Changes consistent with poor vascularization, lack of blood flow and
Five remnant hearts were from homicides. Three cases had severe oxygenation of the myocardium of the heart in the distribution of the absent
atherosclerotic coronary artery disease or cardiomegaly. One case had left anterior descending coronary artery were identified.
mitral valve prolapse. Only one heart was structurally normal. A brief review of congenital malformations of the coronary artery
The second largest group of cases, 116, were those in which the circulation will be presented, including criteria for a true single coronary
manner of death was undetermined at the time of heart valve procurement. artery. A single coronary artery without other cardiac malformations
Included in this group were cases in which only the mechanism of death should be considered as a pathological entity potentially leading to sudden
was reported. In 93 of the cases the cause of death was listed as “pending.” death. Training and experience have demonstrated that this entity is usually
In this group were 63 with significant cardiac abnormalities including of no functional significance unless the single artery becomes occluded.
severe atherosclerotic coronary artery disease (33), myocarditis (12), car- This is usually reported as an “incidental” finding, not contributing to
diomegaly (11), and one case each of hypertrophic cardiomyopathy, death. This rare pathological entity may in itself lead to acute and chronic
bicuspid aortic valve with stenosis, non-infective endocarditis, severe myocardial ischemia, myocardial infarction and sudden death. In this
coarctation of the aorta, acute angle of origin of a coronary artery, thrombo- particular case, the decedent had a six-year history of incarceration during
embolus, and dysplastic intramyocardial arteries. Thirty-eight cases had which time he had a history of chronic exercise, which apparently exacer-
normal hearts. In 58 cases, incidental cardiac findings were identified bated the cardiac ischemia and ultimately resulted in acute myocardial
including 5 congenital abnormalities. infarction with sudden death.
The study demonstrates that significant and/or incidental cardiac
Single Coronary Artery, Sudden Death, Myocardial Ischemia and
abnormalities may be identified following heart valve donation.
Infarction
The study also demonstrates that potentially inheritable conditions
such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular
cardiomyopathy may be present when death was due to other causes. The
diagnosis of these conditions is critical, with significant implications for
surviving family members.
In summary, due to the nation wide shortage of bioprosthetic mate-
rials, tissue donation is critically needed. A thorough cardiopathologic
examination remains possible in remnant hearts and may be beneficial in
determining the cause of death.
Tissue Donation, Heart Disease, Sudden Death

G21 An Accident Waiting to Happen: porches. Approximately 1,200 building owners were cited for construction
faults. There are an estimated 300,000 porches within the city of Chicago.
The Chicago Porch Collapse of 2003 At the one-year anniversary of the collapse friends and family held a can-
dlelight vigil for the victims at the collapse site. Nineteen days after the
Aldo J. Fusaro, DO*, J. Scott Denton, MD, Adrienne E. Segovia, MD, one-year anniversary of this deadly porch collapse, another smaller, similar
Edmund R. Donoghue, MD, and Eupil Choi, MD, Cook County Medical wooden porch in the same neighborhood collapsed, causing seven people
Examiner’s Office, 2121 West Harrison Street, Chicago, IL 60612; J. to fall 8 – 10 feet. Fortunately, no one was injured or killed.
Lawrence Cogan, MD, LA County Medical Examiner’s Office, 1104
North Mission Road, Los Angeles, CA 90033; Mitra B. Kalelkar, MD, Traumatic Asphyxia, Porch Collapse, Compressional Asphyxia
Cook County Medical Examiner’s Office, 2121 West Harrison Street,
Chicago, IL 60612
After attending this presentation, attendees will understand the various G22 Forensic Medicine in France
injuries, both traumatic and asphyxial, associated with a structural porch
collapse.
Eric Baccino, MD*, Laurent Martille, MD, and Anne Dorandeu, MD,
Disasters with multiple fatalities are common, and this presentation
Service de Medecine Legale Chu de Montpellier, Hospital Lapeyronie
will impact the forensic community and/or humanity by assisting medical
371 av du Doyen G. Giraud, Montpellier, 34295, France
examiners and forensic pathologists to understand injuries that are
sustained in a porch collapse, the mechanism of the injuries, and how best After attending this presentation, attendees will understand the
to certify the cause of deaths based on autopsy and death scene investi- organization of forensic medicine in France and the interest in clinical
gation findings. forensic medicine.
The authors present a mass casualty during a party in the upscale This presentation will impact the forensic community and/or
Lincoln Park neighborhood of Chicago. On the warm summer evening of humanity by highlighting new fields for forensic doctors.
June 29, 2003, a party was underway within the upper two floors of a Medicolegal activity: Fewteams perform the whole scope of
3-story building that spilled out onto the two attached wooden porches. At medicolegal activity: “classical” forensic pathology, but also “clinical
approximately 12:30 a.m., the 3rd floor porch began to shake. Some forensic medicine.” These teams are based in CHUs (Centre Hospitalier
partygoers exited the porch into the adjacent apartment. Others remained Universitaire, or university hospitals, of which there are 25 in France)
on the porch and began to jump up and down. The porch floor separated where usually forensic toxicology from biological samples, DNA, physical
from the building and the side vertical supports and “pancaked” down onto anthropology, and forensic histology are also available. Entomology and
the second floor porch. The second floor porch floor likewise separated diatom identification are only done in one center for each. Several of these
and collapsed onto the first floor porch, which then collapsed to the ground teams are also in charge of medical care to detainees.
and into a basement stairwell. Approximately 50 people were on the 2nd Around 7,000 forensic autopsies are performed yearly for a
and 3rd floor porches at the time of the collapse; no one was on the first population of more than 60 million people. This low level of autopsy
floor porch or in the basement stairwell. performance is not only due to a low crime rate, but also to French judicial
Emergency medical services responded quickly and extricated victims particularities. Only in four cities is more than one autopsy is performed
from the debris. Fifty-seven people were injured at the time of the collapse, every working day.
and of these, 12 were pronounced dead at the scene. One person died after When possible, a forensic doctor will be called to the death scene;
surviving approximately 19 hours in the hospital. The body positions of the 14,000 to 25,000 scene examinations per year in France seems a reasonable
victims on the two decks when they collapsed are not known. hypothesis.
Five of the victims were female and eight were male. They ranged in Clinical Forensic Medicine includes the examination of people in
age from 19 to 30 years. At autopsy, all subjects had extensive cutaneous custody (around 250,000 per year nationally) and also of living victims:
injuries consisting of abrasions, lacerations and contusions. All subjects child abuse, battered women, assaults, and rapes cases. It is estimated that
also had identifiable petechiae on or over more than one body surfaces, 45,000 living victims are examined each year by forensic physicians.
including face (12/13), conjunctiva (10/13), oral mucosa (2/13), Forensic Doctors: Two hundred fifty physicians are employed full
laryngeal/epiglottic mucosa (3/13), visceral pleura (3/13) and epicardium time in forensic medicine throughout the country. As a result of this
(1/13). High cervical spine fracture/dislocation were found in 5/13. Bony limited number, only in some university hospitals will it be possible to have
fractures were identified in four subjects. Visceral injury was identified in a forensic doctor on duty around the clock every day of the year, for all the
one. The cause of death in 5/13 cases was compressional asphyxia due to types of clinical forensic activities mentioned above. In smaller cities and
porch collapse, with a significant contributing factor of cervical spine rural areas, forensic doctors will focus on serious penal case such as rape,
fracture/dislocation. The cause of death in 6/13 was compressional homicide, and child abuse, the rest being done by general practitioners.
asphyxia due to porch collapse. One of 13 had extensive skull fractures A majority of forensic doctors are now trained through a national
with brain injury and the cause of death was multiple injuries due to porch diploma called “Capacité des Pratiques Medico-Judiciaires.” The
collapse. The one delayed fatality died from anoxic encephalopathy due to diploma requires that during 2 years, the students will have 30 days prac-
compressional asphyxia due to porch collapse. The wooden porch rem- tical instruction per year in an accredited hospital unit. The other possi-
nants were torn down and quickly replaced with a steel porch. Structural bility is D.E.S.C. (Complementary Specialized Study Diploma) reserved
engineering analysis of the porch was performed, with the results to be to the medical interns; after 4 years of internship in any speciality, the can-
summarized during the oral presentation. didate becoming a forensic medicine specialist will need 2 more years of
Traumatic asphyxia, originally described by Ollivier and later refined practical and full time training in a medical forensic unit plus 200 hours of
by Perthes, is currently defined as asphyxia caused by external pressure to lectures. The graduate will be able to perform all types of forensic med-
the thorax, inhibiting respiration. The main anatomic finding is cutaneous, icine activities (including autopsies).
mucosal and serosal petechiae of the head, chest and upper extremities. A recent survey showed that around 750 forensic doctors were needed
The term compressional asphyxia is a more descriptive term, better under- to provide the appropriate and basic emergency forensic medicine services
stood by the lay public as a relatively gradual compression as opposed to a (clinical and crime scene examination) to each local judicial court.
sudden crushing mechanism. Teaching and Research: INSERM (National Institute of Medical
Following the accident, the city of Chicago revised its inspection cri- Research) has no forensic medicine section (nor a forensic science section)
teria for building porches, and in a 2-month sweep, inspected 4,000 and there is no PhD program in forensic medicine.

State funded research programs in forensic medicine are limited to Twenty-seven NMIs involved white Caucasians, 4 involved Asians, and 2
scattered projects (fewer than 10 so far). During the medical curriculum of involved blacks (origin not known). Form 57M (a screening questionnaire
general practitioners, between 20 to 40 hours of lectures will be dedicated used in police custody to identify medical and mental health problems) was
to forensic medicine (medical certificates about living victims and death positive in 12 cases, and the Police National Computer had warnings in 6
certificates, principles of medical liability, and medical confidentiality). cases. Of the main perceived cause of each NMI, illicit drugs were involved
Conclusion: The role of forensic medicine in France is increasing as in 12/38; alcohol in 17/38; deliberate self-harm in 11/38; problems with
the forensic doctors are turning to “Violence Medicine” specialists. The searches, checks or rousing in 8/38; failure of inter-agency communications
relative importance of autopsies is decreasing, a rather positive point with in 5/38; and insufficient resources in 4/38. In a number of cases more than
regard to the (worldwide) difficulties for funding this activity, but has an one factor was involved. Examples of type of NMIs were: illicit drugs –
adverse effect on the experience of practitioners. Concentrating forensic overdose, drug swallowing, drug concealment, theft of drugs from FME;
autopsies in regional hospital-based centers seems to be the only solution, alcohol – self-harm, physical injuries (ruptured spleen, head injury), hypo-
for the sake of quality. glycemia; self-harm – concealed knife, self-hanging on paper suit, drug
Forensic Medicine, France, Organization swallowing).
Summary and Conclusions: Using the figures generated by this
study, the reported rate of NMIs is 0.4 NMI per FME which gives a total
annual rate of 107 NMIs in this setting. These data reflect the incidence of
G23 Near Miss Incidents: Feasibility Studies NMI in one of 43 police forces in England and Wales. These data are
Assessing Forensic Physicians’ Perceptions broadly consistent with documented patterns of deaths in police custody
of Near Misses in Police Custody Suites in that would appear to reinforce the validity of the data. The need for a
prospective study is supported. The next stage is a prospective 6 month
London, United Kingdom study in which NMIs will be recorded around the time of occurrence, with
analysis of each incident subsequently conducted by a research team, in
David Best, PhD, Institute of Psychiatry, King’s College, De Crespigny order to learn lessons which may be utilised to attempt to prevent
Park, London, SE5 8AF, United Kingdom; Siobhan Havis, MSc, Police potentially avoidable deaths in police custody.
Complaints Authority, 10 Great George Street, London, SW1P 3AE,
United Kingdom; and Jason Payne-James, LLM, MB, FRCS, DFM*, Deaths in Custody, Forensic Physicians, Near Miss Incidents
Forensic Healthcare Services, Ltd, 19 Speldhurst Road, Victoria Park,
London, E9 7EH, United Kingdom
G24 Fatal Pulmonary Thromboembolism
After attending this presentation, attendees will gain an understanding
of the causes of near miss incidents and how they may be applied to the care and Hereditary Thrombophilias
of prisoners in custodial settings.
This presentation will impact the forensic community and/or James R. Gill, MD,and Susan F. Ely, MD*, OCME, 520 First Avenue,
humanity by raising awareness of the need for further research into the care New York, NY 10016
of prisoners in custody, in order to try and prevent harm or death occurring.
Background: Deaths of prisoners in police custody are tragedies for The goal of this presentation is to present to the forensic community
all those involved. Potentially preventable deaths in police custody include the role that hereditary thrombophilias may play in deaths due to venous
those which involve illicit drugs, alcohol and deliberate self-harm. Near thromboembolism (VTE). Forensic pathologists will understand the
miss incidents (NMI) that did not result in death have a crucial role in availability and usefulness of postmortem DNA testing for hereditary
understanding risk factors in custody. A program of research has been thrombophilias in deaths due to thromboembolic events.
developed to study near miss incidents. For the purposes of this research This presentation will impact the forensic community and/or
NMI, have been defined as ‘an unplanned and unforeseeable or unforeseen humanity by showing how any and all data generated by increased post-
event that could have resulted, but did not result, in human death or may mortem testing could bring illuminating information to the medical
have resulted in injury or other adverse outcomes.” literature, allowing forensic practice the ability to keep pace with this
Aims & Methods: An initial study was undertaken with pilot inter- important and rapidly developing field, and potentially contribute to the
views of 3 forensic physicians (FP) practising in London, U.K., to create a reduction of morbidity and mortality and the enhancement of public health.
structured questionnaire for all forensic physicians working in London. The autopsy dissection, personal and family medical histories, and
The questionnaire was the basis of a retrospective recall survey of all FPs ancillary studies pertaining to pulmonary embolism (PE) are important
working in London as Forensic Medical Examiners (FME) designed to components in the investigation of these deaths. But, the detection of a PE
assess numbers of NMIs, patterns in occurrence and relevant learning at autopsy and even that of apparent underlying risk factors do not neces-
points within the previous 6 months. A cover letter, background question- sarily signify the end of the investigation. Molecular analysis for genetic
naire (exploring the background of the medical practitioner), copies of NMI risk in selected cases might further explain fatal outcomes in persons in
survey, and reply paid envelopes were sent to each FME (n = 134) in whom causality is inadequately explained. Also, on occasion, no apparent
London, working for the Metropolitan Police Service. Data about all predisposing conditions are identified. Hereditary thrombophilias may
incidents were anonymised. play a causal role in the development of PE in some of these deaths. With
Results: There was an overall response rate of 73% (n=96). Of FME the availability of postmortem molecular testing, their significance in such
respondents, 18% were Principal grade, Senior (24%), Standard (35%) and deaths may be better understood. Most importantly, beyond more accurate
Assistant (23%). 20% of FMEs had specific mental health training and death certification, these tests have the potential to reduce morbidity and
qualification. 52% had forensic qualifications such as the Diploma of mortality for surviving family members.
Medical Jurisprudence, and the Diploma of Forensic Medical Sciences. Pulmonary thromboembolism is commonly diagnosed in forensic
FMEs had been qualified in medicine for a mean of 27 years and had been pathology practice, as it often causes sudden death. It is attributed to a wide
FMEs for a mean of 11 years. Thirty-eight NMIs were reported by 27 variety of predominantly acquired etiologies. Although likely etiologically
FMEs (of all levels) although the retrospective method meant that some multifactorial, some commonly diagnosed proximate causes include:
data are incomplete. The reason for police contact was recorded as alcohol surgery, pregnancy, injury or relative inactivity of any cause, cancer,
(n=8), theft and robbery (n=7), warrants (n=4), violence (n=3), traffic vio- obesity, or serum hyperviscosity. On occasion, no apparent predisposing
lations (n=2) and single cases of drugs, murder and immigration offences. conditions are identified. In these instances, occult hereditary throm-
bophilias may play a contributory causal role.

Currently, there are DNA techniques that allow for the postmortem For example, a gunshot wound to the head which nicks the temporal
diagnosis of some hereditary thrombophilias. These include Factor V artery may be reported as GSW to the head, without listing arterial injury.
Leiden (FVL), Prothrombin (PT), and Methylenetetrahydofolate reductase This omission may limit time and detail in reporting, but can create incon-
(MTHFR) mutations. Less common abnormalities involving antithrombin venience and embarrassment later when investigators attempt to place the
III, protein C and S, plasminogen, dysfibrinogenemia, hyperhomocys- origin of an assault. Without specific information regarding arterial
teinemia, and antiphospholipid antibodies were not tested for, as functional damage, reconstruction conclusions may err. Three less than satisfactory
and serologic diagnostic assays are ill-suited for postmortem blood. ways in which information regarding arterial damage may be obtained after
Resistance to activated protein C, the most potent endogenous antico- the autopsy report:
agulant, is due to a mutation of the factor V gene (i.e., the Leiden mutation) 1. Law enforcement representatives attending the autopsy may ask
which results in decreased control of thrombin generation. The G20210A the pathologists technical questions.
autosomal dominant mutation in the prothrombin gene is associated with an 2. The bloodstain pattern experts may interview the pathologist at a
increased amount of prothrombin, which promotes the formation of later date.
thrombin. Hyperhomocysteinemia (plasma homocysteine concentration 3. Attorneys may bring out the information during direct or cross
>15 ?mol/L) is a risk factor for venous (and arterial) thrombosis. Increased examination at trial.
concentrations of homocysteine are partly determined by enzymes The least desirable consequence may be ignoring the distinct arterial
involved in its metabolism. Some mutations in methylenetetrahydrofolate damage bloodstain patterns because no arterial injury was mentioned in the
reductase (MTHFR) and cystathione-B-reductase (CBS) are associated autopsy. Arterial damage from even minor injury may contribute to rapid
with elevated concentrations of homocysteine. blood loss. In such cases the cause of death may be listed as exsan-
At the Office of Chief Medical Examiner of the City of New York, guination. Identifying where the artery was breached positions the victim
124 deaths (of 15,280 undergoing autopsy) were caused by PE between where the crime emphasis of survival (assault) versus death (homicide)
December 2000 and September 2003. Of those, 34 postmortem blood occurred.
samples from persons having one or more of the selection criteria were ana- Three case examples are shown to emphasize the essential infor-
lyzed by a molecular fluorescence method (FRET) for FVL, PT, and mation possible when arterial damage is recognized.
MTHFR mutations. Characteristics of decedents who were candidates for Case 1: A homicide occurred in a dormitory building. Bloodstain
these tests were based on widely used clinical criteria and included: age < patterns were found at two locations: in the victim’s room and along the
45 years, pregnancy-related deaths, history of recurrent or unexplained hall outside the room. An expert was hired to answer the question of where
stillbirths, oral contraceptive pill use, hormone replacement therapy, the fatal assault began. The identification and position of the injured artery,
treatment with chemotherapy, weak risk factors (long flights, car rides, or and behavior of blood drops distributed best answered the question.
slight obesity), or deep venous thrombosis of undetermined etiology. Case 2: Statements of an assailant placed a victim over a large pool
Heterozygous mutations involving FVL (1 case), PT (3 cases), and of blood when the assailant left the scene. When photographed, the
MTHFR (8 cases), as well as a single homozygous mutation for MTHFR, victim’s body was in an entirely different position with evidence of
were detected, a total of 35% of those tested. Five deaths were clearly considerable arterial rain between positions. Information obtained during
causally related to one or more of these mutations. The possibility of causal the investigation suggested that a second assailant could have committed
relationships in the remaining 29 deaths is discussed. the murder after the first one left. Because no interpretation of the blood-
Venous Thromboembolism, Thrombophilia, Hereditary stains was initially made, and the police took the confession without veri-
fication, it is possible that justice was not served in this case.
Case 3: An alleged drive-by shooting was shown to be a homicide
within the vehicle when the tracking of the blood was aligned with arterial
damage to the carotid artery. Death was by hypovolemic shock 24 hours
G25 An Expert Witness Requests Re-evaluation later.
of SOP in Autopsy Reporting, Supported In conclusion, adding the name and injury of breached arterial blood
With Case Examples vessels to autopsy reports will supply essential information and prevent
later inconvenience and possible reverses of justice.
Anita K.Y. Wonder, MA*, Wonder Institute, PO Box 1051, Carmichael, Arterial Injury, Autopsy Reporting, Bloodstain Patterns
CA 95609-1051
for the importance of listing all breached arteries by name and injury on
autopsy reports. G26 Sudden Death Following Brief
This presentation will impact the forensic community by suggesting a Compression of the Neck
standard operating policy revision in autopsy reporting where arterial injury
is ignored if absent from direct cause and/or manner of death.
John W. Eisele, MD*, Forensic Consultants Medical Group, 2291 March
Medical experts should name all breached arteries and include
Lane, Suite 179E, Stockton, CA 95207; Gerald J. Berry, MD, Stanford
interpretation of injury to facilitate reconstruction of criminal events. This
Pathology Consultants, 300 Pasteur Drive, Room H-2110, Stanford, CA
presentation will illustrate with case examples where knowledge of arterial
94305; and Michael J. Ackerman, MD, PhD, and David J. Tester, BS,
injury, even if not listed in the autopsy report, could have saved time and
Long QT Syndrome Clinic and Sudden Death Genomics Laboratory,
concern for justice and assisted reconstruction of incidents from bloodstain
Mayo Clinic College of Medicine, 200 First Street, SW, Hilton 11,
pattern evidence.
Rochester, MN 55905
Arterial injury is often encountered in casework, yet not all injuries are
mortal. Breach may occur to the carotid, temporal, brachial, and deltoid The goal of this presentation is to present a well-documented case of
arteries, which may project considerable arrays of blood drops without sudden death following brief compression of the neck, and to discuss the
resulting in death. On the other hand, even minor arterial vessel injury may possible mechanisms for this phenomenon and methods to evaluate these
shift results from a survivable assault to death from homicide, suicide, or mechanisms.
accident via hypovolemic shock. When reconstructing crime events, it is This presentation will impact the forensic community and/or
essential to know that arterial blood vessels were breached. The identifi- humanity by providing a well-investigated case of a type of death which
cation and interpretation of arterial injury requires medical expertise. has been poorly documented in the past, and has caused extensive debate

in the forensic pathology community and court system. The presentation G28 Human Wicks: The Almost Complete
will emphasize proper procedures in investigating this type of death.
Nearly all forensic pathology texts make reference to sudden death
Destruction of Major Portions of the
following brief compression of the neck; these deaths are attributed to a Human Body by Fire Fueled at Least
hypersensitive carotid sinus reflex. Review of the medical literature, Partly by the Body Fat of the Victim
however, reveals that reports of death by this mechanism refer to elderly
individuals with significant cardiovascular disease or other factors that Phillip M. Burch, MD*, Office of the Medical Examiner, 1300 Clark
could explain their deaths independent of the neck compression. The vast Avenue, St. Louis, MO 63117
majority of references to a hypersensitive carotid body discuss only fainting
as opposed to sudden death. A case recently investigated in which the death After attending this presentation, attendees will to be able to assess a
of a 14-year-old youth following brief neck compression was witnessed fire scene that involves a human body that provided its own fuel for the fire.
and thoroughly investigated. This presentation will impact the forensic community and/or
Three reliable witnesses reported that there was a brief tussle with humanity by assisting the attendee in the reconstruction of a fire scene to
another youth, during which the decedent attacked the other youth and held establish if a human body was a source of fuel for the fire.
his neck with both hands. The other youth pushed the decedent against a The charred remains of an adult human female were discovered in an
wall and compressed his neck with one hand while he faced the decedent. abandoned house in St. Louis, MO, in early January of 2004. The female
The compression continued for 15 to 30 seconds, at which time the was determined to be the victim of a blunt trauma homicide. Much of the
decedent collapsed. He was pulseless and apneic; cardiopulmonary torso and lower extremities were basically destroyed by the fire, in some
resuscitation by a trained bystander as well as paramedics and emergency places even down to the bones (not even the hot, prolonged fire of the kind
room personnel continued for nearly an hour before he was declared dead. applied at crematoriums totally destroys the bones). Although it is thought
A thorough autopsy was performed. This included a complete gross that the fire occurred where the body was discovered, nothing else at the
examination with layered, in situ dissection of the neck structures, and scene was altered by the fire. How such a fire could occur and go unde-
complete histological and toxicological examination. Multiple microscopic tected by passersby during the fire will be discussed. The remains of this
sections of the heart and serial sections of the conduction system were case, and others like it, resemble those described in cases of so-called
examined during the initial autopsy and re-examined by a cardiac “spontaneous human combustion” and this phenomenon or myth will also
pathology consultant. In addition the carotid bodies and adjacent arteries be discussed.
were serially sectioned and examined by this consultant. None of these pro- Scene Reconstruction, Body Fat, Human Wick
cedures revealed an anatomic cause of death or any significant disease or
injury. Molecular autopsy for long Q-T syndrome is underway.
The presentation will include detailed history and autopsy results, a G29 DNA Extraction and Anthropological
review of the pertinent literature, a discussion of possible mechanisms of
death in this and similar cases, and a discussion of procedures to be Aspects From 6th to 7th Century A.D.
followed in performing a complete investigation of these deaths. Bone Remains
Sudden Death, Neck Compression, Long Q-T Syndrome
Nunzio Di Nunno, MD, PhD*, Sezione di Medicina Legale, Bari University,
Piazza G. Cesare n. 11, Bari, 70125, Italy; Vito Scattarella, BSc, Sandro
Sublimi Saponetti, BSc, and Patrizia Emanuel, BSc, Bari University, Piazza
G. Cesare n. 11, Bari, 70125, Italy; and Stefania Lonero Baldassarra, BSc,
and Cosimo Di Nunno MD, Sezione di Medicina Legale, Bari University,
G27 The Spontaneous Oesophagus Perforation: Piazza G. Cesare n. 11, Bari, 70125, Italy
A Forensic Point of View After attending this presentation, attendees will be able to implement
the knowledge of the DNA extraction.
Renaud Clement*, and Olivier Rodat, PhD, Department of Forensic This presentation will impact the forensic community and/or
Medicine, University of Nantes, 1 Rue Gaston Viel, Cedex, 44 093, humanity by proposing a modified protocol for DNA extraction.
France In the archeological site of the early Christian Episcopal complex of
Saint Peter, in Canosa di Puglia (Bari, Italy), during the operations of
After attending this poster, attendees will understand a case report of archaeological excavations, tombs were discovered. They were dated
forensic autopsy of an unusual cause of death. between the 6th and 7th centuries A.D. with Carbon 14 methodology. Five
This presentation will impact the forensic community and/or skeletons were found in the five tombs:
humanity by demonstrating the contribution of Boerhaave syndrome to 28A: male individual, 43 years old. The height was 170 cm, the
sudden death. biomass was 65.7 kg. The analysis of the bones indicated several note-
An autopsy was performed on a young adult, who apparently died worthy pathologies, such as a number of hypoplasia lines of the enamel, the
during his sleep. Mediastinitis was established and empyema was also presence of Shmorl hernias on the first two lumbar vertebras, the outcome
found in the left pleural cavity. The esophagus examination showed a tear of subacromial impingement syndrome.
in left side. The lesion occurred in the distal esophagus and showed the 28E: male individual, with a biological age of death between 44 and
leak communicating freely with the left pleural space. Esophageal perfo- 60 years. The height was 177 cm. He had a post-traumatic fracture callus
ration was the cause of empyema, and death resulted from barotrauma to of the medial third of the clavicle with an oblique fracture rima.
the lower oesophagus during the effort of vomiting. The disease is 29B: female individual, 44-49 years old. The height was 158.8 cm,
Boerhaave syndrome, a serious and rapidly fatal spontaneous esophagus the biomass was 64.8 kg. There was Wells’ bursite on the ischial tuberosity,
rupture. Forceful ejection of gastric contents in an unrelaxed esophagus on both sides.
against a closed glottis is the mechanism described. The tear thus produced 29E: male individual, 45-50 years old. The height was 169.47 cm,
is vertical, akin to the “Mallory-Weiss” tear. The poster discusses the his- the biomass was 70.8 kg. The third and the fourth vertebrae showed the
torical, statistical, pathophysiological, diagnostic and therapeutic aspects of Baastrup syndrome (compression of the vertebral spine). There were radi-
Boerhaave syndrome. ological signs of deformity on the higher edge of the acetabula and results
Spontaneous Oesophagus Rupture, Autopsy, Death of frequent sprains of the ankles.

31A: male individual, 47-54 years old. The height was 178.65 cm, athletic teams, and nursing homes (JAMA, 2003). Such populations have
the biomass was 81 kg. The vertebral index showed a heavy overloading a higher incidence of sharing common personal objects or facilities that
in the thoracic- lumbar region. There were bony formations under the would make transmission of MRSA (especially via cutaneous and respi-
periosteum on both on the higher and medium facets of the first metatarsus, ratory inoculation) more common. The patient’s history of five years of
and on the higher and lateral facets of the fifth metatarsus on both sides. As incarceration places him within this risk category.
the topographyindicates, these small ossifications coincided with the MRSA was first acquired outside of a hospital setting in the 1980s
contact points between the back of the foot and parts of the upper of the when intravenous drug users in Detroit were reported to have a MRSA bac-
shoes. teremia, according to Collins et al. (Medical Journal of Australia, 2002).
From the osseous remains, in particular from the teeth (central Currently, the Centers for Disease Control (CDC) is conducting an active
incisors), the DNA was extracted and typed in order to identify potential population-based surveillance for community acquired MRSA
family ties among all the subjects. The extraction technique used came (CA-MRSA) in selected regions of the U.S.to help characterize the inci-
from the DNA Promega technique, partially modified by the authors. Stay dence and risk factors for MRSA in the community (JAMA, 2003). Iyer et
times of the sample in the extraction buffer were increased and were al. have studied local outbreaks of CA-MRSA, specifically related to cuta-
increased the PCR cycles. neous presentations, with the finding that cutaneous abscesses were the
Ancient Bone Remains, DNA Extraction, DNA Fingerprint most common presentation, (J Am Acad Dermatol, 2004). This finding is
pertinent to the patient presenting with a cutaneous abscess on his thigh 2
weeks prior to his pulmonary symptoms.
In conclusion, J.V.’s clinical picture and autopsy findings demonstrate
a case of CA-MRSA. MRSA is now emerging as a community based
G30 Risk Factor Analysis and Characteristics agent, and with its varied presentations, such ascutaneous abscesses, shock,
in Community Acquired MRSA and pneumonia, clinicians and pathologists need to include MRSA in the
differential diagnosis.
Julia M. Braza, MD*, Karoly Balogh, MD,; and Anthony Martyniak, MD, MRSA, Risk Factors, Community Acquired Disease
Beth Israel Deaconess Medical Center at Harvard Medical School, 330
The goal of this presentation is to increase awareness of community G31 Commotio Cordis: Sudden Death
acquired methicillin resistant Staphylococcus aureus (MRSA) infections, Among Young People During Sporting
and its shift in epidemiology. It is relevant to the medicolegal and public
health fields to identify such cases, especially in younger individuals, as it and Recreational Activities
is a reportable disease and a cause of sudden death.
This presentation will impact the forensic community and/or Sunil K. Prashar, MD*, and Karoly Balogh, MD, Beth Israel Deaconess
humanity by identifying the risk factors for community acquired MRSA Medical Center, 330 Brookline Avenue, ES-112, Boston, MA 02115
infection in patients without underlying chronic illness, and discussing After attending this presentation, attendees will have an improved
different and atypical presentations, so that the forensic community can understanding of sudden deaths due to commotio cordis including its
better recognize MRSA in individuals who acquire the agent outside of a definition, demographics, mechanisms, treatment, prevention, and potential
hospital setting. medicolegal consequences.
The focus of this case report is patient J.V., a 28-year-old Puerto Rican This presentation will impact the forensic community and/or
man who presented to the Emergency Department with a two day history humanity by improving awareness among the forensic community of
of increasing shortness of breath, chest pain, and bloody sputum. His past sudden deaths due to commotio cordis. Increased understanding of
medical history was significant for previous herpes infection, and a right commotio cordis may lead to more accurate determination of cause of
thigh abscess that was drained two weeks prior to admission. The patient’s death by forensic professionals, improve preventive and safety measures in
social history was significant for incarceration for 5 years (he was released the community, and help avoid inappropriate charges and convictions in the
one year prior to admission) and being a smoker. The patient denied intra- criminal justice system.
venous drug use, and maintained a negative HIV status. J.V.’s hospital A 21-year-old white man with no significant medical history was
course initially manifested as a pulmonary process (consistent with necro- hiking and rock climbing with friends and sustained a 15-foot fall which led
tizing pneumonia), with an almost complete opacification of the left lung to immediate loss of consciousness. A policeman was the first rescuer to
on chest x-ray. On the third day of admission, J.V. deteriorated with sep- the scene. He found the young man to be apneic and pulseless. The
ticemia, shock, acidosis, anuric renal failure, disseminated intravascular policeman administered defibrillation and cardiopulmonary resuscitation.
coagulopathy, paralysis, and a purpuric rash involving his face, anterior The man was airlifted to a local hospital where he was pronounced dead
chest, right arm, lower extremities, and back. Blood cultures revealed gram shortly after admission. The case was referred to the medical examiner’s
positive cocci in pairs and clusters, consistent with the organism office. At autopsy, multiple horizontal abrasions were observed on the face,
Staphylococcus aureus. Histologic findings at autopsy revealed extensive thorax, and legs. There was no intracranial or spinal pathology. There was
bilateral acute pneumonia with multiple pulmonary infarctions, hemor- no evidence of cardiomyopathy and the coronary arteries had normal
rhage, and necrotizing vasculitis. anatomy. There was focal petechial hemorrhage on the posterior
The patient had a rapidly progressive course (6 days) of methicillin epicardium. Blood toxicology was positive for cannibinoids and ethanol
resistant Staphylococcus aureus infection, with no known underlying (0.010 gram %). The cause and manner of death were determined to be
chronic illness or health-care associated risks factors such as recent hospi- commotio cordis and accident, respectively.
talization, recent outpatient visit, recent antibiotic exposure, chronic illness, Commotio cordis is defined as cardiovascular collapse secondary to
diabetes, or malignancy. Therefore, by exclusion, this is a case of com- cardiac arrhythmia caused by low energy impact blunt trauma to the chest
munity acquired MRSA. However, the severity and very rapid progression without structural injury to the sternum, ribs, or heart.
of the infection, which led to his death, raises the question of the possibility Maron et al. (JAMA, 2002) reviewed 128 cases entered into the
of other risk factors, such as intravenous drug use, underlying HIV U.S.Commotio Cordis Registry. The ages ranged from 3 months to 45
infection, or contact with a person or persons with the above-stated risk years with a median age of 14 years. Seventy-eight percent were under 18
factors. There is also an associated chance of increased MRSA years old and 95% were male. Eighty-one percent involved precordial
transmission in certain community clusters such as in correctional facilities, blunt impact from a projectile, most commonly a baseball, softball, or

hockey puck. Twelve percent involved a fight, play fighting, or parental and symptoms and with a Glasgow Coma Score of 15 should not be
discipline. One case involved a fall on playground monkey bars. It is hospitalized.
thought that the narrow, compressible chest of youth increases the risk for This study is aimed at verifying the effective reliability of these
commotio cordis. guidelines in order to make them more complete and to prevent potential
Link et al. (Prog Biophys Mol Biol, 2003) conducted a series of malpractice events.
experiments on a swine model to improve understanding of the For this purpose, 1,035 case histories, representing all the hospitaliza-
mechanisms of commotio cordis. Using projectiles fired at anesthetized tions occurring during the year 2002 in all seven hospitals in a province in
juvenile swine, the researchers found that ventricular fibrillation could be Southern Italy, were examined. Two hundred fifty-eight hospitalized
consistently produced when impact occurred 10-30 milliseconds prior to people (25%) were negative for loss of consciousness, vomiting, amnesia,
the T-wave peak. Impacts led to premature ventricular depolarization. cephalea, and risk factors (clotting pathologies, use of anticoagulant drugs,
Ventricular fibrillation was most consistently produced by impacts at the alcoholism, use of narcotics, previous surgery of the cranium, disabled
center of the left ventricle. The authors found that early defibrillation was elderly people), and the physical examination at admission showed a
a critical factor in survival. Glasgow Coma Score of 15. All of these patients were admitted to the
It has been suggested that soft core baseballs, improved chest hospital contrary to guidelines. In fact, for this kind of patients the
protection, and the presence of defibrillators at organized sporting events guidelines suggest discharge, with an instruction sheet in case of the onset
may decrease commotio cordis events and deaths. of neurological symptoms. An observation period in the hospital and C.T.
Of particular importance to the medicolegal community, Maron et al. scanning by the first six hours would be for the patients with loss of
(American Journal of Cardiology, 2002) described six cases of commotio consciousness only.
cordis which entered the criminal justice system. The cases involved During hospitalization, these patients underwent plain film
parental discipline, domestic dispute, and gang initiation. In all cases, there radiography and/or CT scanning of the head that documented cranial frac-
was no intent to cause death and none of the victims showed sufficient tures in 7 cases and intracranial lesions in another 5.
trauma to cause death. Convictions ranged from reckless homicide to first Conclusions: the study shows that in the 5% of the patients with minor
degree murder, with sentences from 8-20 years. The authors purport that head injury, noanamnesia, and normal neurological examinations–patients
criminally negligent homicide is not the appropriate charge in many cases that should not be submitted to any medical treatment in accordance with
of commotio cordis and that it is the responsibility of the physician the guidelines–performing additional diagnostic tests could reveal the
community to educate the justice system regarding the nature of commotio presence of lesions more serious than initially suspected. The non-
cordis deaths. diagnosis of these lesions could produce forensic-medical problems
Commotio cordis is an important cause of sudden death in young resulting in potential malpractice allegations.
people during sporting and recreational events. It is caused by low energy Guidelines, Medical Malpractice, Minor Head Injuries
impact blunt trauma to the chest which causes fatal cardiac arrhythmia.
Rapid defibrillation is critical to survival. Protective measures may
decrease commotio cordis events and deaths. It is of great importance to
increase awareness of commotio cordis within the medicolegal community
G33 Sudden Death Due to Bilateral Spontaneous
to prevent inappropriate criminal charges and convictions. Pneumothoraces in a Marijuana User
Commotio Cordis, Sudden Death, Cardiac
Joseph A. Felo, DO*, Cuyahoga County Coroner’s Office, 11001 Cedar
Avenue, Cleveland, OH 44106
G32 Guidelines and Medical Malpractice After attending this presentation, attendees will realize the rare, and
in Minor Head Injury Management potentially fatal, complications of chronic marijuana smoking.
To the author’s knowledge, there have been no previous reports in the
medical literature of sudden death due to bilateral spontaneous pneumoth-
Luigi Viola, MD*, Nunzio Di Nunno, MD, PhD, Roberto Quaranta, MD,
oraces in an individual known to use marijuana. This presentation will
Alessandro Dell’Erba, MD, PhD, and Francesco Vimercati, MD, Bari
impact the forensic community and/or humanity by demonstrating the
University, Piazza Giulio Cesare, 11, Bari, 70124, Italy
adverse pulmonary effects of marijuana smoking, and focusing on a rare
This presentation will impact the forensic community and/or complication that may result in sudden death.
humanity by showing the limitations of guidelines used in the management Marijuana remains the most commonly smoked illicit substance in
of minor head injuries. American society. There is a public perception that marijuana smoking has
The use of therapeutic-diagnostic protocols and guidelines is little adverse effect on physical health. However, habitual marijuana
spreading more and more within healthcare systems. The guidelines are smoking may produce lesions in the conducting airways and lung
based upon the latest scientific discoveries of Evidence Based Medicine, parenchyma similar to those lesions caused by repeated inhalation of
and oriented to suggest the most appropriate procedures, optimal recovery tobacco smoke. 9-tetrahydrocannabinol and combustion products of
time, and tools and resources for every patient in order to identify the best Cannabis sativa are respiratory irritants. Compared to tobacco smoke,
clinical practice and the best possible treatment for that patient. marijuana smoke causes a fivefold greater increment of blood carboxyhe-
According to some experts’ opinions, the international standardization moglobin level, a threefold increase in the amount of tar inhaled, and
of the best possible treatment of the most widespread pathologies implies retention of one-third more inhaled tar in the respiratory tract. The
some negative aspects, such as the restriction in being free to make pulmonary effects of chronic marijuana smoking include epithelial remod-
diagnostic and therapeutic decisions by doctors. elling of airways and barotrauma.
Regarding forensic medicine, these guidelines are gaining significant Inhalation of marijuana smoke involves deep, sustained inspiratory
importance: from defensive medicine to medical malpractice. In the effort, often followed by frequent and prolonged Valsalva maneuvers. As
forensic medical field, protocols and guidelines are used as scientific refer- a consequence of increased intraalveolar pressure, there may be rupture of
ences to confirm or contest the doctors’ behavior in the cases in which there alveoli with air leakage into the septal connective tissues. Peripheral
is the suspicion of professional error. dissection of air within the pulmonary interstitium may lead to the for-
As minor head injuries (1.6 million victims per year in U.S.A.) may mation of visceral pleural blebs or bullae.
have grievous disabling consequences, the guidelines on this topic have Rupture of the visceral pleural bullae may result in a pneumothorax,
great importance. They provide that patients without neurological signs which is rarely fatal. The reported case documents the gross and micro-

scopic autopsy findings of a 23-year-old male who was a known habitual emboli usually end up in the right side of the heart or the pulmonary
user of marijuana, whose sudden death was due to bilateral spontaneous arteries, with the origin most commonly being the vena cavae or iliac veins.
pneumothoraces with bilateral apical bullous lung disease. Although giant The literature has documented 76 cases of venous bullet embolism from
bullae and nonfatal pneumothoraces have been documented by chest x-ray 1834 to present. The vast majority of literature describing venous bullet
and CT scan in smokers of marijuana, there have been no known previous emboli has been surgical, and therefore items of forensic importance, such
reports in the medical literature of sudden death due to bilateral sponta- as the caliber of the bullet, tend not to be reported. The largest review of
neous pneumorthoraces in an individual known to use marijuana. 53 cases of venous bullet embolism did not report the calibers of any of the
Marijuana, Pneumothorax, Bullous Lung Disease bullets. Of those cases reviewed, the largest caliber bullet found that
resulted in a venous embolism was a .38 caliber.
This case emphasizes the importance of pre-autopsy radiographs in
G34 Venous Bullet Embolism of a Large the evaluation of gunshot wounds, and points out that one cannot exclude
Caliber Bullet From the Right External the possibility of a venous bullet embolus simply because of the use of a
Iliac Vein to the Heart: Case Report large caliber bullet.
and Review of the Literature Venous, Bullet, Embolism
Mary G. Ripple, MD*, and David R. Fowler, MD, Office of the Chief
Medical Examiner, State of Maryland, 111 Penn Street, Baltimore, G35 Factors Affecting the Formation
MD 21201 of Adipocere in Soils
After attending this presentation, attendees will understand the impor- Shari L. Forbes, BSc, PhD*, Centre for Forensic Science, University of
tance of pre-autopsy radiographs in the evaluation of gunshot wounds, Western Australia, M420, 35 Stirling Highway, Crawley, WA 6009,
become aware of the possibility of large caliber bullets embolizing through Australia; Barbara Stuart, PhD, Department of Chemistry, Materials and
the venous system, and become familiar with the literature on venous bullet Forensic Science, University of Technology, Sydney, PO Box 123,
embolism. Broadway, Australia, 2007; Boyd Dent, PhD, Department of
This presentation will impact the forensic community and/or Environmental Sciences, University of Technology, Sydney, PO Box 123,
humanity by emphasizing the importance of pre-autopsy radiographs in the Broadway, Australia, 2007; and Ian R. Dadour, BSc, PhD, Centre for
evaluation of gunshot wounds, providing the forensic community with a Forensic Science, University of Western Australia, M420, 35 Stirling
recent literature review on venous bullet embolism, and highlighting the Highway, Crawley, WA 6009, Australia
possibility of a large caliber bullet embolizing through the venous system.
This poster will report a case of an unusual venous embolism of a The goal of this presentation is to demonstrate to the forensic community
large (.45) caliber bullet from the right external iliac vein to the right the effect of particular burial factors on the formation of adipocere in a soil
ventricle of the heart, and present a literature review of venous bullet environment.
embolism to better familiarize the forensic pathologist with this rare entity. The presentation will impact the forensic community by promoting the
Arterial embolism of a bullet is rare; however, venous embolism is an significance of adipocere formation in burial environments and encouraging
even more rare occurrence. In both circumstances the bullet is usually a further studies in the field of forensic taphonomy.
low velocity, small caliber bullet. The literature to date has not reported a This presentation will discuss particular factors that are regularly
case of a .45 caliber venous bullet embolus. identified in a burial environment and their effect on the formation of
A 30-year-old African-American male was found lying on the floor in adipocere. The research represents a major component of a three year study
a storage room of a convenience store with a gunshot wound to the left investigating adipocere formation in grave soils.
lower quadrant of the abdomen. The victim had been standing in front of Adipocere refers to a soap-like substance that can form during the
the store when an unknown suspect approached the victim and began decomposition process. It is well known as a later postmortem change,
shooting at the victim. The suspect chased the victim into the store and particularly in burial environments. Adipocere formation occurs by the alter-
fired additional shots at the victim inside the store. The victim was taken ation of the soft, fatty tissue of a cadaver into a greyish-white substance which
to University of Maryland Shock Trauma and surgery was performed, comprises mainly saturated fatty acids. The occurrence of adipocere in a
which revealed a very large hemoperitoneum and retroperitoneal burial environment leads to the inhibition of postmortem changes which
hematoma emanating from the pelvis. Complex vascular injury to the subsequently preserves the human remains. The degree of decomposition and
pelvis was repaired, as were the stomach and small bowel, including differential preservation observed depends on the surrounding environment.
resection of two portions of the small bowel. The victim arrested on the Various conditions associated with the burial environment are believed
operating table two hours into the surgery. A preoperative x-ray revealed a to contribute to the formation of adipocere in soils. Conditions include
large bullet projecting over the right cardiophrenic angle. By report, the temperature, moisture, soil type, soil pH, anaerobic environment and the
victim was supine from the time of the shooting until the autopsy was per- presence of factors such as clothing, coffin, and lime. In the past there have
formed. Autopsy showed a typical gunshot entrance wound on the left side been numerous observational studies commenting on these particular physical
of the front of the abdomen with no soot or gunpowder stippling on the skin factors and methods of burial. However, the literature demonstrates a distinct
surrounding the wound. The bullet traveled front to back, left to right and lack of chemical studies confirming these observations. As a result, a three-
downward, injuring the stomach, multiple loops of small bowel, the year study was conducted to chemically investigate the effect of individual
confluence of the left common and external iliac veins and arteries, the burial factors on adipocere formation in a soil environment.
bifurcationof the aorta, and the right external iliac vein just proximal to its In order to determine the effect of particular burial conditions on
bifurcation. A minimally deformed, .45 caliber, copper-jacketed bullet was adipocere formation, experiments were conducted in a laboratory environment
recovered from the right ventricle of the heart. so that the individual variables could be adequately controlled. The experi-
Bullet embolization should be suspected when there is an entrance ments utilized porcine adipose tissue collected from the abdominal region of
wound and no exit wound and the bullet cannot be located in the suspected pigs (Sus domesticus) reared on identical diets for commercial use. The fatty
region after following its path either by visual or x-ray examination. The tissue samples were buried in soil environments and allowed to decompose for
pattern of bullet embolization depends on body position during and subse- a period of 12 months under individual burial factors. At the completion of
quent to the injur; gravity; muscular and respiratory movements; the this period the samples were analyzed to confirm the formation of adipocere
missile’s size, weight and shape; the diameter of the vessel lumen; blood and compared with control samples to determine the effect of the burial factors
flow; and the blood volume status at the time of injury. Venous bullet on its formation.

This presentation will discuss the results of the chemical study and G37 Establishing a Protocol Between
identify those factors which accelerate and retard adipocere formation.
Adipocere samples collected from grave exhumations and forensic cases were
Clinical and Forensic Institutions
also analysed and the results will be compared with the controlled laboratory to Treat and Investigate Violence
experiment. The research findings will highlight the effects of adipocere Against Women Cases
formation, particularly with regard to overcrowding in cemeteries due to its
regular occurrence in grave sites, and its forensic implications when present in Miguel Lorente, MD, PhD*, and A. Carrasco, Institute of Legal
shallow burials or mass graves. Medicine of Granada (Spain), Av.Sur, 5, Granada, 18071, Spain; José A.
Adipocere, Burial Factors, Grave Soils Lorente, MD, PhD, University of Granada, Department of Forensic
Medicine, Granada, 18012, Spain; Enrique Villanueva, MD, PhD,
Department of Legal Medicine, University of Granada, Avda. Madrid,
G36 Seasonal Distribution and Abundance sn/, Granada, 18071, Spain
of Forensically Important Flies in After attending this presentation, attendees will understand that most
Santa Clara County aggression against women are not treated correctly because they are
unknown, although this does not mean that symptoms are not visible. Only
10% of cases are reported, but 100% of them go to medical institutions
Adrienne Brundage, MS*, 1250 A Edgewood Road, Redwood, CA 94062
asking for assistance for symptoms direct or indirectly related to violence.
The goal of this presentation is to identify any seasonal or This study highlights this situation, and underscores the need to coordinate
geographical patterns among forensically important flies within the county and collaborate through a protocol between forensic and clinical institu-
that may be important to future investigations using a simple and cost- tions to solve medical and forensic issues and to avoid victimization.
effective method. The forensic and clinical medical community must consider violence
Entomologists working with local law enforcement often encounter against women as a global problem. This presentation will impact the
gaps in the collective entomological knowledge due to local variation forensic community and/or humanity by giving an integral answer that
within and among important fly species. This presentation will impact the helps the forensic investigation and the recovery of victims.
forensic community and/or humanity by attempting to help close such a Introduction: Violence against women is not only a crime, but a
gap within Santa Clara County, California. social behavior rooted in cultural values given by a patriarchal conception
Forensic entomology has become relatively common in criminal of society and couple relationships. This means that when a case occurs,
investigations. As insects become more common as indicators of post- any of these cultural values may arise to explain and justify the aggression.
mortem interval, gaps in information at the local level become apparent. Only a small percentage of cases (no more than 10%) are reported, and only
While flies as forensic indicators are well studied, they exhibit great these cases can get social help. However, all these women go to clinical
variation in both successional patterns and seasonal abundance due to institutions with symptoms related direct or indirectly to domestic violence.
microclimates. It is this variation that causes the forensic entomologist the Material and Methods: The study was performed in medical institu-
most difficulty. The entomologist must adapt data from studies that have tions (Emergency Service and General Practitioner Service) using different
taken place miles away or create new, tailored studies to gather data questionnaires about domestic violence (physical and psychological) and
specific to the current case. While the second option is ideal, time and recording social and demographic features of the patients. The sample was
monetary constraints can make it impossible, leaving the scientist to glean all the women that went to the institutions a period of time of two months,
what general information is available in the literature. This does yield and the tests were reviewed by a physician during a regular consultation.
acceptable postmortem interval estimation, but accuracy suffers. These Results and Discussion: There is no significant difference among the
issues were brought to the forefront in the bay area by two cases in which social and demographic features. Of this group of women (patients), 17.9%
general data had to be used due to a lack of local studies. The cases were complained of domestic violence, but paradoxically 51.8% considered their
completed successfully, but the entomologists on the cases identified relationships as “good” or “very good.” Asking all of women if they would
several glaring gaps in the entomological data specific to Santa Clara like doctors to ask regularly about family and couple matters, they
County, California. The existence of these cases led to a two-year study of answered “yes” in 88.5% of cases Asked if they would like doctors to ask
seasonal distribution and abundance of forensically important flies in Santa if they suffer violence and aggression, they answered “yes” in 88.6% of
Clara County, designed to identify and quantify any patterns of fly cases. But at the same time, 35% of women would not confirm domestic
succession that may be useful in future investigations. violence if the doctor reported the case.
Local homicide investigators were consulted, and three areas within Legal regulations on this subject need to be reviewed to try to help
the county were identified as the most common dump sites for human women and solve the cases. In this sense, a global approach needs to be
remains: urban areas (specifically within the city of San Jose, California), introduced that considers not only the legal and forensic implications, but
mountainous areas, and along rivers or streams. Four traps baited with beef also the clinical and the health issues behind this violence. A protocol
liver were placed in each of these areas, one mile apart, and checked for under this global perspective would help women recover, avoid victim-
flies once a week for two years beginning in 2001. The liver was changed ization, assist in answering forensic questions, and ensure appropriate legal
as needed, and temperature data was collected for all corresponding days action against the aggressors.
from the local airport. The insects collected were then pinned and stored Violence Against Women, Domestic Violence, Protocol of Assistance
for identification. The resulting collection consisted of over 16,000 flies
and 3,000 beetles representing several families. In order to expedite the
identification process, only flies belonging to the family Calliphoridae
were identified, although any other insects were preserved in San Jose
State’s Entomology Museum for future reference and study. The identifi-
cation process lasted one year, and the results were entered into a database
where seasonal and geographical patterns were easily recognized. The
results supported the findings in the two cases that prompted the study,
while giving additional insight into current investigations within the county.
Entomology, Calliphoridae, Succession

G38 Analytical Electron Microscopic Detection G39 Evaluation of Clinical Diagnostic
of Aluminum Received Intravenously Accuracy in Post-Coronary Artery
Bypass Graft Surgery Mortality
Sarah M. Colvin, MD*, Carol Allan, MD, Laron Locke, MD, Mary G.
Ripple, MD, and David R. Fowler, MD, Office of the Chief Medical Marianne Hamel, MD, PhD*, Department of Pathology, Anatomy and
Examiner, State of Maryland, 111 Penn Street, Baltimore, MD 21201; Cell Biology, Thomas Jefferson University Hospital, 125 South 11th
and Victor Roggli, MD, Duke University Health Systems, Department of Street, Suite 204 Foerderer Pavilion, Philadelphia, PA 19107-4998;
Pathology, Box 3712, DUMC, Durham, NC 27710 Johan A. Duflou, MMed, Department of Forensic Medicine, Central
The goal of this presentation is for the attendees to realize the Sydney Laboratory Service, 42-50 Parramatta Road, Glebe, NSW 2037,
feasibility of detecting and identifying postmortem heavy metals in Australia
non-environmental exposure cases (i.e., mineral pneumoconioses). The goal of this presentation is to demonstrate the medical and legal
This presentation will impact the forensic community and/or value of autopsy in non-forensic deaths, specifically those occurring after
humanity by illustrating the utility of applying alternative methods, coronary artery bypass graft surgery.
specifically scanning electron microscopy with electron dispersive This presentation will impact the forensic community and/or
spectrometry, for demonstrating the presence of aluminum intravascularly. humanity by examining the value of performing autopsies in post-surgical
This presentation details the postmortem detection of aluminum deaths. The commonly held view amongst clinicians is that autopsies are
inadvertently received intravenously. Careful consideration of inves- of value for plaintiffs in medical malpractice suits. This paper shows that
tigative details can occasionally generate hypotheses that are difficult to the autopsy can answer questions and provide valuable information on
conclusively prove using conventional forensic methods; however, focused surgical technique, thereby decreasing the chances of litigation.
collaboration with specialists from other fields can yield definitive causes This presentation compares the accuracy of clinical diagnoses in
of death as in this case of postmortem detection of aluminum as a result of post-coronary artery bypass grafts (CABG) mortalities to those made via
a therapeutic misadventure. postmotrem diagnosis.
A 77-year-old man with a past medical history of coronary artery In accordance with relevant Australian legislation, all deaths within 24
disease and prior brachytherapy for localized prostate cancer was admitted hours of surgical anesthesia must be reported to the coroner. As part of this
to the hospital for continued urinary bleeding following direct visual notification, detailed medical, surgical and anesthetic information is
internal urethrotomy for urethral stricture. At surgery, a persistent clot in provided, medical charts are perused and a postmortem examination is con-
the bladder and an inflamed prostate were discovered. The clot was ducted. Clinicians who treated the decedent are required to provide an
removed and the prostate resected. opinion on the likely cause of death prior to being informed of the autopsy
Alum bladder irrigation, containing aluminum ammonium sulfate, findings. The autopsy pathologist is therefore in an ideal position to
aluminum potassium sulfate, ammonium alum and potassium alum, was ascertain the accuracy of clinical diagnoses after a comprehensive
ordered, prior to and following the operation. The morning following the postmortem examination is performed.
operation the man was discovered unresponsive. Both a nurse and doctor A total of 140 deaths within 24 hours of CABG surgery were
noted during resuscitative efforts that a bladder irrigation bag was con- identified in the Department of Forensic Medicine in Central Sydney,
nected to the man’s intravenous catheter. In such cases, the involvement of Australia database spanning an 8 year period between 1996 and 2003. Of
hospital risk management is paramount; however, risk management from these, detailed information was available in 134 cases. Comprehensive
the hospital in this case could not conclude whether the Alum solution had autopsies, including histology, and–where relevant–toxicology and a range
infused intravenously, and if so, how much he had received. of other investigations, were conducted in all cases. Deaths were examined
The deceased underwent an autopsy. Gross autopsy findings were from seven hospitals, and all hospitals providing a cardiac surgery service
those of hypertensive and atherosclerotic coronary artery disease. in the Department’s geographic coverage area were represented.
Microscopic findings were most notable for thrombi in pulmonary arte- At autopsy, 23% of cases demonstrated clear discordance between
rioles and capillaries, which stained with periodic acid-Schiff stain. clinical and pathological diagnoses. These deaths occurred despite
Scanning electron microscopy (SEM) with back scattered electronic intensive care monitoring, which presumably supplies exceptional vigi-
imaging (BEI) and energy dispersive spectrometry (EDS) was performed lance in post-surgical care. Commonly misidentified conditions included
on the lung sections. The forensic community is more familiar with the role pump failure, peri-surgical myocardial infarction, aortic dissection, and
of analysis of gunpowder primer residues with SEM/EDS. These arrhythmia. Clinicians were more likely to diagnose acute myocardial
techniques are more often used on lung sections to determine composition infarction than autopsy pathologists. Errors in cause of death formulation
of intrapulmonary materials that cause the different pneumoconioses. were identified in the vast majority of cases on the basis of gross patho-
These same techniques were used in this case to determine if the logical findings, with histologic examination being of assistance in sup-
aluminum-containing bladder irrigation material was present intravascu- porting the diagnosis rather than identifying a different or additional cause
larly. Smudgy material within some of the blood vessels demonstrated of death. Though there is a significant rate of diagnostic error in deter-
distinct peaks for aluminum with energy dispersive spectrometry. mining cause of death in post-CABG deaths, fewer than 1% of study deaths
Nitrogen and sulfur are commonly seen as endogenous tissue were a result of surgical error. The single error identified was a case of
components; aluminum is not. It was concluded that the deceased had iatrogenic rupture of the iliac artery.
received intravenous Alum bladder irrigant solution and that this Hospital autopsy rates have fallen from a high of 30-40% in the 1960s
therapeutic misadventure was his underlying cause of death. This case to single digit rates today. This precipitous decline represents a myriad of lost
demonstrates the benefit of selective use of non-conventional methods to opportunities to improve post-surgical outcomes. A reason frequently given
solve a forensic case by the use of SEM with BEI and EDS in order to for the decline in autopsy rates is a fear that the autopsy could be used as a
demonstrate intravascular aluminum. tool to assist the plaintiff’s attorney in malpractice litigation. Studies like this
Aluminium, Intravascular, SEM/EDS one suggest the opposite. Not only are autopsies an important clinical and
post-surgical audit tool, but helpful in minimizing uncertainty in relation to
possible errors in clinical management and surgical technique. The findings
of this study suggest that the postmotrem examination is far more likely to
shield a clinician from liability than to expose technical mistakes.
Autopsy, CABG Surgery Deaths, Postmortem Diagnosis

G40 Adolescent Death: A 15-Year G41 Heightened Awareness of Bioterrorism:
Retrospective Study Three Cases of Unusual Skin Lesions
Nick I. Batalis, MD*, and Kim A. Collins, MD, Medical University of John A. Stash, DO*, Zabiullah Ali, MD, Carol Allan, MD, Ana Rubio, MD,
South Carolina, 165 Ashley Avenue, Main Hospital, Room 281, Mary G. Ripple, MD, and David R. Fowler, MD, Office of the Chief
Charleston, SC 29425 Medical Examiner, State of Maryland, 111 Penn Street, Baltimore, MD
21201
After attending this presentation, attendees will know the most
common causes and manners of death in the adolescent population; Attendees will learn of the heightened awareness of bioterrorism since
understand the typical victims, perpetrators, and trends in violent deaths; the terrorist attacks in 2001, and how this has raised the suspicion of law
and be aware of the most common drugs of abuse in the adolescent age enforcement and medical personnel in evaluating skin lesions. The attendee
group. will also learn the cutaneous manifistations of several bioterrorist agents.
humanity by providing a thorough classification of adolescent deaths which humanity by providing an increased understanding of how recent historical
could be useful in various ways to coroners, medical examiners, patholo- events involving terrorism and bioterrorism have affected the law
gists, and investigators when confronted with an adolescent death. enforcement and medical communities. They will gain an understanding
Knowing common relationships of perpetrators to victims in violent deaths through the case reports presented of how these events have increased the
could help to find and convict the perpetrators. Also, understanding the suspicion of bioterrorism when evaluating unusual skin lesions. They will
typical victim and circumstances surrounding his or her death could help to increase their understanding of, and ability to recognize, the cutaneous
prevent future violent adolescent deaths. A review of the toxicology in manifestations of bioterrorist agents through the review of those agents.
these cases could help delineate any trends in drugs of use and abuse in the The goal of this presentation is to discuss three cases of unusual skin
adolescent age group, making it possible to prevent some accidental deaths lesions that presented in February of 2004, to the OCME in Baltimore, MD,
through public heath and safety measures. Finally, a review of natural and how the recent heightened awareness of bioterrorism affected the
deaths will demonstrate the most common natural disease processes, which medical community and handling of these cases. In addition, skin lesions
could help in determining the causes of sudden, unexpected deaths in this associated with bioterrorism will be reviewed.
population. Since the terrorist attacks on September 11, 2001, and the anthrax
Adolescents, defined by the World Health Organization (WHO) as attacks that began two weeks later, there has been an increased awareness
children ages 10-19, are a diverse group of people undergoing many of possible terrorist and bioterrorist attacks throughout the United States.
changes in life as they develop, mature, and become adults. Still, pediatric The media, in particular, has elevated this awareness not only with reports
forensic literature is dominated by reports, reviews, and studies of fetal, on the anthrax attack, but with reports of other possible agents that could be
infant, and early childhood death. Previous studies have looked at specific used in a bioterrorist attack, such as smallpox or plague. This increased
aspects of adolescent death, but there remains a paucity of literature awareness has lowered the threshold of the medical community in the
reporting the most common causes and manners of death along with other suspicion of bioterrorist attack in the evaluation of skin lesions. The
pertinent demographics of these victims. following three cases illustrate this heightened awareness and suspicion of
The authors reviewed all cases of pediatric death referred to the bioterrorism, and also reinforce the role of the medical examiner in public
Medical University of South Carolina Forensic Pathology section over the health biosurveillance.
fifteen years between January 1989 and December 2003. In accordance Case Report: A previously healthy 40-year-old Hispanic female had
with the WHO definition, only children 10-19 years of age were included. complained of rash and shortness of breath for one week. Her family found
In all, 542 of 9540 total cases were studied. The authors examined the her on the floor and transported her to the Emergency Department. There
cause and manner of death along with the age, sex, and race of the victim. she was noted to be asystolic, with fixed and dilated pupils and no respira-
The toxicology results, perpetrator identification, death scenario and tions. Numerous crusted and scabbed lesions varying in size and stage of
location, and victim traits were also analyzed. Homicides and suicides healing were noted on her face, torso, and extremities. The Emergency
were due to gunshot wounds, blunt force trauma, sharp force injury, and Department expressed concern about Varicella lesions other than Varicella-
asphyxia. Accidents were subdivided into environmental exposure, zoster (chicken pox), and the body was sent to the medical examiner’s
drug/inhalation toxicity, vehicle collision, and other. Natural deaths were office to rule out smallpox.
classified by organ system. Adolescents comprise an eclectic mix of people Case Report: A previously healthy 46-year-old white male was found
vitally important to society, yet long-term comprehensive studies on the facedown in the hallway of the lower level of his home. The residence was
circumstances of their deaths are lacking in the literature. With a solid secure and the family entered the dwelling after not being able to reach him
understanding of these circumstances it may be possible to predict, and for several days. According to a coworker, several days earlier, the
hopefully prevent, future cases of adolescent death. The authors present decedent said that he would be out of the office for a week after being
their findings in this 15-year retrospective study to better aid forensic diagnosed with a viral infection at a local walk-in clinic. At autopsy,
pathologists, death investigators, law enforcement, and epidemiologists. multiple crusted ulcers on his head, chest, left upper thigh, and anterior
aspect of the right leg were noted. There was also a crusted eschar noted
Adolescent, Death, Forensic Medicine on his abdomen, and multiple non-crusted necrotic ulcers on his right
buttock, right posterior medial thigh, left axilla, back of the neck, lower
lumbar spine, and left upper chest. Law enforcement officials expressed
concern about possible cutaneous anthrax because the deceased was
employed by the National Security Agency.
Case Report: A previously healthy 61-year-old Chinese female that
reportedly arrived from China 20 days earlier collapsed in her bathroom.
Her family, who called 911, heard the fall. Upon EMS arrival she was
found to be asystolic and ACLS was initiated. She was pronounced dead
upon arrival to the Emergency Department. While in China she had con-
tracted a pruritic skin disease of unknown cause, and since her arrival had
also reportedly felt weak and experienced a gradual decline in appetite.
The disease started on her right arm and spread to the rest of her body. For

the three days prior to her death she was bedridden. At the hospital multiple was the most common direction of change (28 DCs), followed by suicide-
skin lesions in various stages of healing ranging from bullae to ruptured to-undetermined (S-U; 14 DCs). The mean TE between the original DC
bullae, raw erosions, dried erosions, crusted lesions, and hypopigmented and amended DC was 3.83 months (SD 6.6 months). DCs amended sec-
scars were noted. The local health department expressed concern about ondary to investigations went the longest between signatures, with a mean
possible bioterrorism. of 8 months. The direction of change was significantly associated with TE
The heightened awareness of bioterrorism has stimulated an increased (P=0.04). The directions most associated with an increasing TE were N-S,
response to unusual and aggressive appearing skin lesions among the U-H, N-U, A-U, S-U and N-A. Toxicology was the most common reason
medical and law enforcement communities. These three cases illustrate for DC amendment (40 DCs) and MOD amendment (28 DCs), followed by
that response, and also provide examples of possible mimickers of bioter- family concerns (23 and 19 DCs, respectively) and investigations (13 and
rorism for comparison to the cutaneous bioterrorist agents reviewed. 12 DCs, respectively). Toxicology was also the most common reason for
Bioterrorism, Skin Lesions, Case Reports amending COD (26 DCs); histology was the second most common reason
for COD amendment (11 DCs), followed by both family concerns and
medical records review (8 DCs each). Of the fourteen DCs that changed
from suicide-to-undetermined, eleven were triggered by family concerns.
G42 Amended Cause and Manner of Death Of the twelve DCs in which MOD was amended secondary to investiga-
Certification: A Six-Year Review of the tions, nine moved to a MOD of undetermined. Twelve of the 109 DCs had
New Mexico Experience “gunshot wound of head” as the COD, all but one of which had suicide as
the MOD. Eight of these eleven suicides were subsequently amended to
Philip R. Croft, MD*, Sarah L. Lathrop, DVM, PhD, and Ross E. undetermined, and in ten the impetus was family concerns.
Zumwalt, MD, Office of the Medical Investigator, MSC11 6030, 1 In conclusion, approximately 1% of death certificates signed by OMI
University of New Mexico, Albuquerque, NM 87131-0001 pathologists had either cause or manner of death amended, with a slightly
higher amendment percentage for external examinations than autopsies.
After attending this presentation, attendees will understand the state ASCVD was the most commonly amended COD, and intoxicant(s) was the
medical examiner office’s experience with the amendment of cause and/or most common ACOD. There was a significant association between MOD
manner of death on death certificates, including frequency of amendment, and number of amended DCs. By percent, natural and suicide DCs were
time between original certification and amendment, reasons for the most frequently amended. Natural-to-accident and suicide-to-undeter-
amendment, and in what way death certification was changed. This mined were the most common directions in which MOD changed.
presentation will impact the forensic community and/or humanity by Toxicology was the most common reason for amendment; family concerns
providing information about how, why, when, and how often the cause were the impetus behind most suicide-to-undetermined amendments, with
and/or manner of death is/are amended on death certificates completed by most of these cases involving gunshot wounds of the head. The average
forensic pathologists. While the answers to these questions are of value to time to amendment was just under 4 months, and direction of change was
the forensic community, little formal study has been undertaken in this area. significantly associated with the time elapsed. This information on how,
At the end of June 2003, the New Mexico Office of the Medical why, when, and how often cause and/or manner of death certification is
Investigator (OMI) computer database was searched for all amended death amended is both interesting and useful to the forensics community.
certificates signed by OMI pathologists from 1997 through 2002. Each
Death Certificate, Manner of Death, Autopsy
case file was reviewed in order to identify only those death certificates
(DCs) with amended cause and/or manner of death fields. Cases that were
initially external examinations only and subsequently became autopsies,
DCs originally signed out by someone other than an OMI pathologist, G43 The Relationship of Drug Abuse
“brain only” research-oriented autopsies, and DCs originally signed out as to Unexplained Sudden Death
“pending” were excluded. Cause of death (COD), amended cause of death
(ACOD), manner of death (MOD), amended manner of death (AMOD), Amy C. Gruszecki, DO*, Jefferson County Coroner Medical Examiner
the time elapsed (TE) between the original and amended DCs, and the Office, 1515 6th Avenue South, Suite 611, Birmingham, AL 35233;
reasons for the changes were recorded for the remaining cases. The reasons Gerald McGwin, Jr., PhD, Department of Epidemiology, School of Public
for the changes were categorized as medical records review, histology, Health, University of Alabama, Birmingham, AL 35233; C. Andrew
investigations, family concerns, microbiology, or error. “Family concerns” Robinson, PhD, Department of Pathology, Forensic Division, University
included any family member, as well as third parties such as friends, of Alabama, Birmingham, AL 35233; and Gregory G. Davis, MD, MSPH,
caretakers, or primary physicians. Statistical analyses were performed Jefferson County Coroner Medical Examiner Office, 1515 6th Avenue
using SAS version 8.02 statistical analysis software for Windows and South, Suite 611, Birmingham, AL 35233
EpiInfo 2002.
The database search identified 108 cases that fit the above criteria, The goal of this presentation is to define the relationship between drug
0.86% of all cases handled at OMI over the study period. This total abuse and deaths where neither anatomical nor toxicological cause for
included 81 autopsies and 27 external examinations. One of the 108 cases death is found.
was amended twice, increasing the total number of amended DCs to 109. This presentation will impact the forensic community and/or
Autopsy DCs from 1997 to 1999 were significantly more likely to be humanity by recommending that decedents with a convincing history of
amended than those from 2000 to 2002 (P=0.02). COD was amended on drug abuse and no other anatomical or toxicological findings at autopsy
62 of these 109 DCs. Twenty-three different CODs were used in these 62 have their cause of death certified as being due to chronic drug abuse.
DCs, with arteriosclerotic cardiovascular disease (ASCVD) accounting for Rationale: Cases of young adults with a history of drug abuse who
almost a quarter. Twenty-nine different ACODs were used on the resulting have died suddenly and unexpectedly in whom neither anatomical nor tox-
62 amended DCs, with intoxicant(s) comprising nearly a third. MOD was icological cause for death is found at autopsy are received regularly. The
amended on 72 of these 109 DCs. Natural deaths had the greatest per- common presence of a history of drug abuse, however, has led researchers
centage of amended DCs (1.39%), followed by suicides (1.22%). Overall, to hypothesize that drug abuse not only induces some change that increases
there was a significant association between manner of death and the the risk of sudden death, but that this change persists after the drug is no
number of DCs amended (P<0.001). For external examinations, natural longer detectable in the body. The first part of this study was presented at
and suicide DCs were significantly more likely to be amended than the 2004 Annual Meeting of the American Academy of Forensic Sciences
accidents (P=0.0002 and P=0.019, respectively). Natural-to-accident (N-A) in Dallas, Texas, where it was shown that deaths certified as undetermined

in cause and manner have an increased likelihood of having a history of G44 Natural Causes of Death Among a
drug abuse when compared to a control group of medical examiner cases.
In this second part of this study was tested the null hypothesis, “There is no
Federal Medical Center Prison Population
difference in the frequency of drug abuse in a study group dying of unde-
termined cause when compared to the frequency of drug abuse in a Peter T. Lin, MD*, and Eric A. Pfeifer, MD, Mayo Clinic, 200 First
matched control group of patients admitted for cholecystectomy,” with the Street, SW, Hilton 11, Rochester, MN 55905
intent of establishing whether a history of drug abuse increases the like- The goal of this presentation is to review the natural causes of death
lihood of sudden death. among federal prisoners treated at a Federal Medical Center during the
Methods: A retrospective case-control study conducted of deaths period 1986-2004, in order to understand the spectrum of complicated
investigated by the Jefferson County Coroner/Medical Examiner Office, natural disease present in the federal prisoner population and to use that
Alabama between 1986 and 2003. The study group consisted of decedents knowledge towards a more accurate determination of manner and cause of
between 10 and 70 years of age whose cause and manner of death remained deaths that occur while in custody.
undetermined following an autopsy and toxicological analysis for ethanol This presentation will impact the forensic community and/or
and drugs of abuse. The control group was chosen from living patients who humanity by adding to the available knowledge base concerning natural
underwent cholecystectomy at the indigent care hospital serving Jefferson causes of death in prisoner populations. Because of the referral medical
County, Alabama, a population similar to that seen in the medical examiner center population studied, particular attention will be paid to complicated
office. Three controls were matched to each study group member to within and severe natural diseases. An understanding of complex disease patterns
5 years of the age of the study decedent and within two calendar years of present in prisoners will assist in accurately determining manner and causes
the date of death of the study decedent (to keep social trends and testing of deaths in custody.
methods comparable). The charts of both the study group (decedents) and Outcome: To understand the spectrum of complicated natural disease
of the control group (patients) were reviewed for evidence of drug abuse. present in the federal prisoner population and to use that knowledge
All toxicology results were noted in the decedents, including the presence towards a more accurate determination of manner and cause of deaths that
of cocaine, any other drugs or medications, and ethanol. Decomposed occur while in custody.
remains were included in the study group. The charts of the living control Deaths that occur while in custody are routinely investigated, and
group were reviewed for a history of drug abuse and hypertension in often require an autopsy to determine the manner and cause of death. A
accordance with the hospital Institutional Review Board. thorough medicolegal investigation protects the interests of the prisoners,
Results: The study group of undetermined deaths consisted of 62 the custodians, and the general public by assisting in the prosecution of
decedents, 24 of whom had some evidence of drug abuse (history, physical prison homicides, documenting natural causes of death when unnatural
signs, positive toxicology for cocaine or its metabolites in urine or bile, causes may be suspected, and identifying contagious diseases that may
opiates, or methamphetamine). In the matched control group 9 of 186 pose a public health risk to prisoners and facility personnel. As in non-
patients had a known history of drug abuse. Cases in the study group were incarcerated populations, the task of determining manner and cause of
seven times (odds ratio 7.0; 95% confidence interval 3.5-14.1; p<0.0001) death in an apparently unnatural death is sometimes complicated by poten-
more likely to have a history of drug abuse than the controls. In other tially lethal natural disease present in the deceased. Therefore, it is
words, given the design of this study, an individual with an undetermined important for forensic pathologists and death investigators to understand
cause of death is seven times more likely to have a history of drug abuse the unique patterns of natural disease that occur in prisoner populations.
than is a living patient chosen from a similar population. Given the small This paper will review natural causes of death among federal
p-value, chance is an unlikely explanation for these results. Heart disease prisoners who were treated at the Rochester Federal Medical Center during
can cause sudden death by dysrhythmia, and should be considered as a the period 1986-2004. The Federal Medical Center system is a network of
cause of death in the decedents, but cases with heart disease sufficient to seven specialized medical centers located throughout the U.S. and operated
account for death were not considered undetermined as to cause of death by the Federal Bureau of Prisons. The Rochester Federal Medical Center
and were thus excluded from the study group. This exclusion is reflected is a major medical and mental health referral center for male prisoners. In
by statistical analysis that showed hypertension was less common in the some instances, consultations are provided through the Mayo Clinic.
study group than in the control group of cholecystectomy patients. Since 1986, the Mayo Clinic has performed 323 autopsies on deaths
Conclusion: This is the second study to show that a history of drug occurring at the Rochester Federal Medical Center. Of the 323 deaths, 320
abuse is far more common in decedents with an undetermined cause of were natural deaths and 3 were suicides, all by hanging. The vast majority
death than it is in a control group chosen to represent a random sample of of natural deaths could be attributed to one of 4 general categories, cancer-
the population. Epidemiological theory indicates that for rare events, such related (148), liver disease-related (63), AIDS-related (57), and cardiovas-
as the death of an individual with a history of drug abuse, the measure of cular disease-related (37). The average age at death for each category was:
the association between the risk (here drug abuse) and the event (here cancer-related, 54.2 years; liver disease-related, 49.6 years; AIDS-related,
death) is a valid and accurate predictor of the incidence of death due to a 39.9 years; and cardiovascular disease-related, 57.0 years. Less common
given risk factor. In other words, individuals who abuse drugs are at natural causes of death included pulmonary embolism (3), stroke (3), sepsis
increased risk of dying suddenly because of their habit of abusing drugs, (2), end stage renal disease (2), aspiration pneumonia (2), chronic
even if not acutely intoxicated at the time of death. Based on these obstructive pulmonary disease (1), warfarin toxicity (1) and sarcoidosis
findings, the authors recommend that decedents with a convincing history involving the heart (1). Among the cancer-related deaths, the five most
of drug abuse and no other anatomical or toxicological findings at autopsy common primary sites were lung (45), hemato-lymphoid (17), colon (16),
have their cause of death certified as being due to chronic drug abuse. pancreas (12) and head and neck (10). In addition, hepatocellular car-
Drug Abuse, Sudden Death, Pathology cinoma was identified in 17 prisoners who died of liver disease. Some of
the more unusual tumors included malignant fibrous histiocytoma (1), gall-
bladder carcinoma (1) and osteosarcoma (1). Among the 37 cardiovascular
causes of death, 34 were due to ischemic heart disease and 3 were due to
idiopathic dilated cardiomyopathy. Among the 63 liver-disease related
deaths, 55 were associated with chronic hepatitis C infection, 3 with
alcohol abuse without evidence of hepatitis C infection, 3 with no known
cause, and 2 due to primary sclerosing cholangitis. The highest number of
liver-related deaths occurred in 1999, accounting for 12 of 29 deaths that

year. AIDS-related deaths peaked in the year 1995, accounting for 11 of 23 have retrospectively investigated a total of 48 forensic autopsy cases. They
deaths that year. have been divided into three main groups: 18 cases of drowning (12 in salt
This study differs from previous studies of prison deaths because the water and 6 cases in fresh water), 20 cases of opiate-related deaths showing
study population consisted only of prisoner deaths occurring at a Federal gross pulmonary edema and, as a control group, 10 cases of rapid deaths
Medical Center. Unnatural and sudden deaths are notably lacking due to by gunshot injuries to the head without pulmonary edema. The study was
the population studied, but the three suicides by hanging corroborate pre- carried out on paraffin tissue blocks from which serial sections (4 ?mthick)
vious reports of an increased risk for suicide while incarcerated; the pre- were used for hematoxylin-eosin and immunostaining. For immunohisto-
ferred modality being hanging. The over-representation of cancer-related chemistry, anti-human SP-A mouse monoclonal antibody (Novo Castra
deaths reflects the referral center population of this study. Previous studies Laboratories Ltd; U.K.) was used at 150-fold dilution, with a 1-hour incu-
have found cardiovascular disease to be the most common natural cause of bation at room temperature, using the universal Avidin-Biotin Complex
death among prisoners. The distribution of cancer types suggests an (ABC). The expression of the SP-A staining was scored semiquantitatively
increased number of deaths from hemato-lymphoid and head and neck based on two staining patterns: membranous or linear staining on the
cancers, and a decreased number of deaths from prostate cancer, compared interior surface of alveolar epithelia, and the interface of intra-alveolar
to the general population. effusion and granular staining showing many prominent massive
Overall, the spectrum of disease present in federal prisoners appears aggregates of SP-A within the intra-alveolar space.
to be as wide as would be expected in a prisoner population numbering over The results show that aggregated granular SP-A staining in the intra-
2 million in 2003. With frequent allegations of prisoner maltreatment alveolar space was frequently observed in drowning victims. A high
bringing increasing scrutiny into deaths occurring while in custody, further intensity of this pattern was frequently found in these victims, suggesting a
studies of natural disease in prisoners will assist in determining manner and molecular alteration caused by a direct effect of aspirated water and/or sub-
cause of deaths in custody. sequent metabolic disturbance in the alveolar type II cells. Granular
Natural, Deaths, Custody deposits of SP-A in the intra-alveolar space were never observed in the
control group of non-asphyxial deaths (10 cases of fatal gunshot injuries).
The group of gross pulmonary edema observed in narcotic deaths showed
a prevalent distribution of membranous or linear pattern staining and only
G45 Distribution Pattern of Pulmonary scattered SP-A aggregates in the intra-alveolar space. The granular SP-A
Surfactant Protein A (SP-A) in staining detected in pulmonary edema is consistent with previous findings
Drowning and Opiate-Related Deaths of SP-A positive staining in lungs with secondary damage such as acute
respiratory distress syndrome (ARDS) or a bronchial lavage causing both
Carlo P. Campobasso, MD, PhD*, Alessandro S. Dell’Erba, MD, PhD, a biochemical alteration of pulmonary surfactant. These results suggest
Annalisa Addante, MD, PhD, Fiorenza Zotti, PhD, Sara Sblano, MD, and some molecular alterations of SP-A due to abnormal surfactant metabolism
Massimo F. Colonna, MD, LLB, Section of Legal Medicine (Di.M.I.M.P.), caused by edema fluid. Based on the comparison of SP-A distribution
University of Bari, Piazza Giulio Cesare, Policlinico di Bari, Bari, 70124, pattern between drowning, agonal changes such as pulmonary edema, and
Italy non-asphyxial deaths, the expression of intra-alveolar SP-A aggregates can
significantly support the final diagnosis of drowning.
Pulmonary Surfactant, Drowning, Opiate-Related Deaths
immunohistochemistry of pulmonary surfactant and the usefulness of
SP-A staining as diagnostic marker of alveolar injury in drowning
compared with agonal changes such as pulmonary edema in opiate-related
deaths. G46 Drowning vs. Trauma and Other Causes
This presentation will impact the forensic community and/or of Asphyxia in Deaths in Water
humanity by demonstrating to the forensic pathology community a finding
supporting the final diagnosis of drowning by routinely using SP-A
Karen B. Looman, DO*, Pathology Residency Program, Eastern Virginia
staining.
Medical School, 700 West Olney Road, Norfolk, VA 23507-1607; Wendy
Pulmonary surfactant covers the surface of the alveoli and prevents
M. Gunther, MD, Office of the Chief Medical Examiner, Tidewater
alveolar collapse by lowering surface tension. It is composed of phospho-
District, 830 Southampton Avenue, Suite 100, Norfolk, VA 23510-1046;
lipids (90%) and proteins (10%). Four surfactant-associated proteins (SPs)
and E.L. Kinnison, Office of the Chief Medical Examiner, Tidewater
have been identified: hydrophilic SP-A and -D, and hydrophobic SP-B and
District, 830 Southampton Avenue, Suite 100, Norfolk, VA 23510-1046
-C. SP-A is the most prevalent form, and is produced in the alveolar type
II cells. Under normal conditions, SP-A is immunohistochemically The goal of this presentation is to review three cases which reveal the
detected in the alveolar type II cells, but also on the alveolar interior surface necessity of looking more closely at cases that involve water. They are
since a small quantity of SP-A is secreted into the alveoli. The immuno- ideal instances where the cause of death appeared obvious, but because a
histochemical distribution pattern of SP-A in the intra-alveolar space has body of water was involved things were not what they seemed. These cases
been previously reported as a useful tool to distinguish mechanical reinforce the need to perform autopsies on any case involved with
asphyxia from other hypoxic cases (Zhu et al., 2000). It can also be submersion in water.
considered a valuable marker of the pulmonary dysfunction in drowning, This presentation will impact the forensic community and/or
showing partial differences in pulmonary pathophysiology depending on humanity by reinforcing the need to closely evaluate violent deaths that
the immersion medium (Zhu et al., 2002). Many prominent, massive involve water.
aggregates of granular SP-A staining observed in the intra-alveolar space Drowning appears to be an easy cause of death to diagnose whenever
have been considered the result of an enhanced secretion caused by strong a person is found not breathing in water. In reverse, drowning is not the
forced breathing that often takes place in the mechanical asphyxia, or by first diagnosis that comes to mind when only a little amount of water is
over-excitement of the autonomic nervous system or, even more, by the present at a scene. These three case histories illustrate some of the diffi-
Ca2+ ions in the edema fluid. The above-mentioned aggregated form may culties in evaluating the role of drowning in complicated cases, particularly
also indicate an early biochemical alteration of SP-A in asphyxial deaths. when autopsy findings are found to be inconsistent with initial impressions
To evaluate the role of plasma components exuded into the alveolar gained from scene investigation. External examination of bodies in such
space and its relationship with the distribution pattern of SP-A, the authors cases may be misleading.

Case One: A 47-year-old male was standing on a dock pier cases, the diagnosis of drowning was based on the presence of autopsy
performing martial arts exercises. He had a history of violence and findings (including overinflated lungs, pulmonary edema, frothy contents
substance abuse. A bystander witnessed this man finish warming up, tuck in the airways) and positive diatom test. The diatom test was performed
a necklace into his shirt, and dive off the pier head first. The man rose to after treatment of the samples with Soluen-350. The test was considered
the surface of the water, and floated as if unconscious. He was rescued positive when a significant number of diatoms were detected in lungs and
within five minutes of the incident, but could not be resuscitated. External other internal organs (liver, kidney, bone marrow) and when concordance
examination revealed a small abrasion along the vertex of his head. His of diatom types recovered from organs and the putative drowning medium
face was congested, and he had some jugular venous distension. There were found. A control population of 12 cases was also selected. For each
were no other obvious external traumatic injuries. Death was initially case, age, sex, manner of death, postmortem interval, and resuscitation
attributed to drowning, with consideration of a cardiac event, possibly attempts were reported from the postmortem records. For each drowning
related to intoxication with cocaine. and control case, blood iron levels were measured in the left ventricle (LV)
Case Two: A 39-year-old male was driving alone in his sports car, and right ventricle (RV) of the heart. The mean difference of iron concen-
without seat belt restraint, along a two-lane road. He lost control of the tration (RVIr-LVIr) between the drowning group and the control group was
vehicle, which went off the roadway, flipped into the air, and landed on its compared. Furthermore, iron measurements were performed in 19
roof in a ditch that contained four inches of water. It is not known how long drowning cases showing advanced putrefaction.
the man was in the car prior to the arrival of the first bystanders who Results and Discussion: The mean age of the drowning cases was
attempted to render aid, but the time interval was less than 10 minutes. The 43.2 years. The mean age of the control population was 36.2 years. In the
first bystanders attempted to pull the man from the passenger window of majority of the drowning cases, manner of death was suicide (n=14). The
the car. When police arrived at 10 minutes from the time of the initial mean difference of iron concentration was significantly higher in the
accident, the man was found face down outside the passenger window of drowning cases compared with age and sex-matched controls (p<0.001).
his car. Emergency medical personnel failed to find a pulse, and he was All drowning cases showed hemodilution. Four control cases showed
pronounced dead. External examination of the body revealed adherent hemoconcentration. No overlap was found in the RVIr-LVIr levels
leaves and mud, with dicing injury to the forehead, left flank, and left thigh. between the two groups. In the control group, the maximal RVIr-LVIr level
Lacerations and bruising were apparent on the chin and lower extremities. was equal to 11 micromol/l. In the drowning group, the difference levels
Conjunctival and intraoral petechiae were identified. No other major ranged from 12 to 387 micromol/l. Resuscitation seemed to have no effect
trauma was obvious on external physical exam. Drowning was not on the results. In cases of drowning showing advanced putrefaction, the
considered among the causes of death at initial examination. Positional or iron test was not reliable because biochemical iron measurement was often
traumatic asphyxia was considered. prevented by inability to obtain postmortem blood.
Case Three: A 46-year-old male with a history of alcohol abuse was Conclusion: According to the results, iron seems to be a good bio-
riding his bicycle at night along a street. He was struck by a motor vehicle, chemical marker for freshwater drowning with a short postmortem interval.
thrown into the air, and landed in a ditch, face down, in 6-7 inches of water. Drowning, Iron, Postmortem Biochemistry
He remained in the water for several minutes, because the woman whose
car had hit him was unable to pull him out unassisted. Ultimately, other
bystanders pulled the man out of the water, but by that time emergency per-
sonnel could not revive him. External exam was remarkable for lack of G48 Elder Abuse and Neglect Death Review:
injury, other than superficial abrasions on his hip and thigh. Cervical Use of an Interagency Team
fracture was considered the likeliest possibility at initial examination.
These three cases underscore the difficulty in identifying what role Christopher Swalwell, MD*, Medical Examiner’s Office, San Diego
drowning may play in death. Evaluation of the scene, the body, and the County, 5555 Overland Avenue, Building 14, San Diego, CA 92123
history may suggest a misleading cause of death. Autopsy may be required
to make an ultimate diagnosis. After attending this presentation, attendees will understand the
organization and implementation of an elder death review team, using the
Drowning, Asphyxia, Violence
San Diego experience as an example.
humanity by providing general awareness of efforts of local governments
G47 Study of the Diagnostic Value of to address the issue of elder abuse and neglect deaths. The experience of
Iron in Freshwater Drowning San Diego County’s elder death review team may be helpful to other
jurisdictions in developing teams.
Geoffroy Lorin de la Grandmaison, MD*, M. Lettereux, PharmD, There is a growing national concern about abuse and neglect of the
K. Lasseguette, MD, J.C. Alvarez, PharmD, Philippe de elderly. San Diego was one of the first counties in California to develop an
Mazancourt, MD, PhD, and Michel Durigon, MD, PhD, Elder Death Review Team in response to legislation enacted in 2001. The
Department of Forensic Pathology, Raymond Poincare Hospital, California law provides for the development of an interagency review team
Garches, 92 380, France “to assist local agencies in identifying and reviewing suspicious elder
deaths and facilitating communication among persons who perform
After attending this presentation, attendees will be able to test the autopsies and the various persons and agencies involved in elder abuse or
diagnostic value of iron (Ir) in freshwater drowning by investigating the neglect cases.” The law lists suggested team membership, including
postmortem levels of hemodilution in drowning cases compared to control experts in the field of forensic pathology, experts in geriatrics, coroners and
cases. medical examiners, district and city attorneys, law enforcement, public
This presentation will impact the forensic community and/or administrators, ombudsmen and representatives from adult protective
humanity by demonstrating the importance of postmortem biochemistry for services.
the diagnosis of freshwater drowning. San Diego County chose to set up the committee through a
Material and Methods: Twenty-six typical freshwater drowning Memorandum of Agreement (MOA) between the District Attorney’s
cases were selected from all immersion cases autopsied in the Department Office, the Sheriff’s Office, the Medical Examiner’s Office, and the Health
of Forensic Pathology between 1998 and 2004 (n=128). The exclusion cri- and Human Services Agency (which includes Aging and Independence
teria were a long postmortem interval (more than one week) and causes of Services). Representatives of these agencies are permanent members of the
death other than drowning (acute intoxication or trauma). For all selected committee and rotate the chairmanship. The MOA provides guidelines for

membership of the committee, objectives, recommendations, and with youths ages 15 to 24, precipitated by either experiencing the suicide
confidentiality. The objectives include identification of risk factors and the of a member of a young individual’s peer group or gaining media exposure
facilitation of communication between agencies in order to reduce the and imitating suicidal behavior.
number of elder deaths due to abuse and neglect. This study presents 466 medical examiner cases of suicide ages 11 to
The Elder Death Review Team borrowed ideas from existing 24 in Kentucky between 1993-2002, with 108 victims ages 11 to 17 and 358
Domestic Violence and Child Fatality review teams. All information is victims ages 18 to 24. The majority of victims in both age groups were
considered confidential, and all members must sign a confidentiality males (88.9% and 87.4%) and Caucasian (88% and 90.8%). A paucity of
agreement. Paperwork is kept to a minimum. The committee has opted to black females committed suicide, consisting of only 0.92% and 0.84% of
discuss only one case per meeting. Discussion goals include determination victims in each group, respectively. The leading causes of death were the
of the nature of the abuse or neglect, if any, whether it played a role in the same for the two age groups, specifically, firearm injury (72.2% and 70.7%),
death, and an assessment of its preventability. A case review-investigative hanging (22.2% and 18.7%), and drug intoxication (2.8% and 5.3%). The
report form was developed to summarize each case. The committee head was the most likely target of the firearm wound for both males and
discussions conclude with recommendations, which can range from females, accounting for 93.6% and 85% of victims in each age group,
changing individual departmental policies to public education to proposing respectively. Suicide peaked in September for group ages 11-17, most likely
legislation. reflecting the tension associated with the initiation of a new school year. The
The committee has had its share of growing pains, and some issues highest percentage of cases for the group ages 18-24 was documented in
have yet to be resolved. However, the authors believe the development of January. Ten (9.2%) subjects ages 11-17 had previously attempted suicide,
a County Elder Death Review Team is one step in raising awareness of in most cases, by incised wounds of the upper extremities; 60% of these
elder abuse and neglect and reducing its prevalence. victims fatally succumbed to a cranial firearm wound. Of the 35 (9.8%)
Elder Abuse, Elder Neglect, Elder Death Review victims ages 18-24 who had previously attempted suicide, 48.6% died as a
result of a firearm injury to the head and 31.4% selected hanging.
Toxicological studies constitute an important component in the
investigation of a suicide. In the suicide group ages 11 to 17, blood and
G49 Adolescent and Young Adult Suicide: urine were collected in 93.5% and 72.2% of cases, respectively.
A Ten-Year Retrospective Review of Approximately 62% of victims in this group had negative blood toxicology,
Kentucky Medical Examiner Cases and 71.2% of urine toxicology screens yielded no drugs. The blood alcohol
concentration (BAC) was negative in 83.2% of cases, while 7.9% had a
Lisa B. Shields, MD*, and Donna M. Hunsaker, MD, Office of the Chief BAC ? 0.1 mg%, and 8.9% < 0.1 mg%. A minority of victims had been
Medical Examiner, 810 Barret Avenue, Louisville, KY 40204; John C. prescribed psychoactive medications as discerned in the blood, specifically,
Hunsaker III, JD, MD, Office of the Associate Chief Medical Examiner, benzodiazepines in 4.9% and antidepressants in 3.9%. Cannabinoids were
Department of Pathology & Laboratory Medicine, 100 Sower Boulevard, detected by urine screen in 23.1% of the decedents. Of the victims ages 18
Suite 202, Frankfort, KY 40601-8272; and Michael K. Ward, BS, to 24, blood and urine were collected in 92.4% and 71.8% subjects, respec-
Kentucky Forensic Toxicology Laboratory, Office of Forensic Toxicology, tively. The blood toxicological results were negative in 40.3% of cases.
100 Sower Blvd, Frankfort, KY 40601 The BAC was negative in 59.2% of cases, ? 0.1 mg% in 26.9%, and < 0.1
mg% in 13.9%. The following prescription psychoactive medications were
The goal of this presentation is to present a comprehensive review of quantitated in the blood: benzodiazepines (8.4%), opiates (6%), and anti-
findings gleaned from postmortem examinations on suicide victims depressants (5.1%). Urine screen revealed cannabinoids in 31.5% and
between the ages of 11 and 24 in Kentucky between 1993 and 2002, and to cocaine in 8.2%.
offer strategies aimed at the prevention of adolescent and young adult This comprehensive analysis incorporates a myriad of factors that
suicide. may have contributed to suicidal behavior, specifically, psychiatric illness,
This presentation will impact the forensic community and/or humanity domestic turmoil, employment unrest, and legal difficulties.
by showing how adolescence represents a tumultuous period in a young
Suicide, Adolescent, Firearm
individual’s life as the youth strives to gain independence and flourish into
a productive member of society. This period of transformation is often asso-
ciated with anxiety and stress, encouraging feelings of hopelessness, per-
sonal failure, and suicidal ideation. The prevalence of youth suicide by
firearm necessitates restricting unsupervised household access to firearms G50 Which Field Method is Best? A
and identifying adolescents and young adults who are at risk for suicide. Comparative Study of Four Entomological
According to the National Vital Statistics Report in 2001, suicide, as a Methods for Sampling Forensically
manner of death, ranked as the third leading cause of death in the United
States between the ages of 15 and 24 and accounted for 3,971 deaths. The Important Arthropods on Human and
rate of completed suicide in this age group has tripled since 1950. The esti- Porcine Remains at the Anthropology
mated ratio of attempted suicides to completed suicides for adolescents is Research Facility in Knoxville, Tennessee
200:1, which is significantly higher than that of the general population,
with an estimated 10-25 attempts for every completed suicide. A host of
Kenneth G. Schoenly, PhD*, Department of Biological Sciences,
biopsychosocial factors contribute to adolescent suicidal behavior. The
California State University, Stanislaus, Turlock, CA 95382; Neal H.
majority of adolescent suicide victims suffer from either single or com-
Haskell, PhD, Department of Biology, Saint Joseph’s College, Rensselaer,
bined psychiatric disorders, including affective and personality disorders,
IN 47978; and Robert D. Hall, PhD, JD, Department of Entomology,
substance abuse, anxiety or conduct disorders, eating disorders, and
1-87 Agriculture Building, University of Missouri, Columbia, MO 65211
aggressive and antisocial tendencies. Youths often display risk-taking
behaviors, including reckless motor vehicular operation, running away The goal of this presentation is to present to the forensic sciences
from home, auto theft, gun carrying, lack of seatbelt use, assault, and community the latest findings from the Anthropology Research Facility
truancy. A lack of a cohesive family unit may provoke suicidal ideation; (ARF) in Knoxville, Tennessee, on the topic of which field sampling
specifically, poor parent-child communication, parental violence, and loss methods, when used singly and in combination, yield the largest fraction of
of a primary caregiver. Suicide clusters are most commonly associated forensically-important insect species from human and porcine remains.

humanity by providing recommendations on which field methods forensic humanity by providing additional information confirming successional
entomologists and crime scene investigators should use when sampling stages of decomposition and allied fauna.
forensically-important arthropods from human remains in medicolegal The decomposition of an exposed pig carcass (Sus scrofa) was moni-
death investigations. tored for approximately 43 days. The carcass progressed through fresh
The obvious constraints imposed on the scientific study of human (2 days), bloat (3 days), decay (5 days), post decay (30 days), and skeletal
corpses speak to the urgency for forensic entomologists to have compar- (2 days) stages and attracted suites of necrophagous species as well as
ative field data on human and surrogate (non-primate) remains to insure predators, parasites and opportunistic feeders. The calliphorid blow flies
that the recommendations offered for one are valid for the other. In 1989, Chrysomya rufifacies and C. megacephala were initial colonizers and made
the on-campus Anthropology Research Facility (ARF) at the University of up the bulk of the initial arthropod abundance; the coleopterans of families
Tennessee, Knoxville, became the site of the first comparative field test of Histeridae, Dermestidae, Trogidae, Staphylinidae, Tenebrionidae and
four arthropod sampling methods used by forensic entomologists. Cleridae appeared in later stages. Most maggot activity occurred during the
Over a 35-day period in summer, aerial sweep nets, pitfall traps, sticky bloat and decay stage, which lasted from day 3 through day 9 of exposure.
traps, and hand collections were taken from one unembalmed, unautopsied By this time only 25% of the carcass remained. During peak maggot
human cadaver and two freshly-euthanized 50-lb pigs. (Due to limitations activity, the difference between internal carcass temperature and ambient
in procurement, replicate human corpses were unavailable in this study.) A air temperature peaked. The greatest number of taxa (22 of 27) and the
third pig, also placed at the site, was not sampled in order to monitor lowest total abundance of arthropods were observed during post decay. A
possible sampling effects on rates of decay and arthropod succession. total of 27 taxa were identified, of which about 64% were dipterans and
Depending on carcass age, the daily sampling schedule included up to four coleopterans combined. The suite of arthropod taxa identified in this study
collections (early morning, noon, afternoon, early evening), for a total of 96 was not significantly different from other outdoor pig decomposition
sampling periods and 1,370 individual samples; by season’s end, the studies done in Hawaii.
corpses at this site became the most intensively sampled remains of any Arthropod Succession, Maggot Masses, Forensic Science
previous study. Where arthropod life stages and taxonomic keys permitted,
specimens were identified to the lowest possible taxon (family, genus or
species). From the arthropod counts, the fraction of forensically-important
arthropods captured by each method and combination of methods was
calculated. Forensically-important taxa include members of the sarcos-
aprophagous fauna (e.g., blow flies, flesh flies, hide beetles) and certain
predators (e.g., rove beetles, clown beetles, ham beetles), both of which
G52 A Comparison of Pig and Human
have been used as forensic indicators in medicolegal death investigations. Tissue in Studies of Decomposition:
Based on analysis of 16 days of samples, different sampling methods Can Flies Tell the Difference?
captured between 35 and 100% of the forensically-important taxa and
between 30 and 100% of the sampled individuals. Hand collection, when Charlotte A. Wacker, MS*, University of California, Davis-Department of
performed by an experienced forensic entomologist, was found to be the Cell Biology and Human Anatomy, One Shields Avenue, Tupper Hall
single best method for sampling forensically important insects at a crime Room 3301, Davis, CA 95616; Lawrence Stutler, MS, University of New
scene, followed by aerial netting, pitfall traps, and sticky traps. Hand Haven, School of Public Safety and Professional Studies, 300 Orange
collection and aerial net sampling were found to offer the best combination Avenue, West Haven, CT 06516; Brandi J. Schmitt, MS, University of
of methods for sampling forensically-important insects. This ranking held California, Davis-Department of Cell Biology and Human Anatomy, One
regardless of whether the remains sampled were human or pig. Human-pig Shields Avenue, Tupper Hall Room 3301, Davis, CA 95616; and Rebecca
comparisons revealed a high degree of similarity in catch statistics, A. Bullard, MS and Robert B. Kimsey, PhD, University of California,
regardless of method, leading researchers to conclude that enough elements Davis, Department of Entomology, One Shields Avenue, Davis, CA 95616
of the forensically-relevant fauna were found on pig carcasses in south-
eastern Tennessee to reflect what crime scene investigators are likely to find The goal of this presentation is to provide preliminary studies that
there on human remains in future death scene investigations. demonstrate how some forensically significant fly species may be attracted
The authors gratefully acknowledge the logistical and field assistance to different types of carrion in varying degrees and to determine if blowflies
of the Anthropology Department of the University of Tennessee, Knoxville, are differentially attracted to human or porcine carrion via olfaction.
and financial support of the National Institute of Justice (Grant #94-IJ-CX- This presentation will impact the forensic community and/or
0039). humanity by providing preliminary studies which indicate that currently
As forensic entomologists they hope to see future field-tests and practiced research methods may not deliver the most accurate results.
eventual adoption of these recommendations by crime scene investigators These studies asked whether adult scavenger insects respond differ-
and other members of the forensic sciences community. ently to volatile compounds emanating from human or porcine remains, in
an effort to determine if porcine surrogates may legitimately be substituted
Forensic Entomology, Anthropology Research Facility (ARF),
for human remains in forensic entomology research. No difference in the
Field Sampling
arthropod fauna attraction to either type of carrion was anticipated.
Natural insect populations were exposed to odors from human or pig
tissue samples contained in traps that bar visual cues. Traps consisted of a
small tub filled with carrion suspended within a covered five-gallon plastic
G51 The Decomposition of a Pig Carcass in bucket or 35-gallon plastic trashcan and above propylene glycol poured
a Mesophytic Biotope, Oahu, Hawaii four centimeters deep. Holes six centimeters in diameter were drilled six
centimeters below the rim of the outer bucket or trashcan to allow insects
Anthony R. Russo, PhD*, Chaminade University of Honolulu, Forensic to have access to the carrion. Once inside the trap, insects drowned in the
Science, 3140 Waialae Avenue, Honolulu, HI 96816 propylene glycol. They were periodically sieved from this preservative
then rinsed and stored in ethanol. For identification to species, forensically
The goal of this presentation is to assist in the understanding of the significant insects were first rinsed in acetone then pinned.
stages of decomposition and the succession fauna on decomposing In a preliminary experiment, equivalent weights of pig or human thigh
carcasses, an aid to estimation of postmortem interval. and forearm tissue in five-gallon bucket traps were used. Eight species of

flies arrived at either carrion. Five were common to both types of carrion. G54 Viral Testing of Adult Mosquitoes
Three species of flies were recovered solely from traps baited with human
carrion, and no species were recovered exclusively from porcine carrion.
Collected in West Virginia for West
In the later experiment, employing 35-gallon trashcan traps, the Nile Virus Using NASBA Assay
plastic tubs were baited with a human or pig cephalic specimen. These
tissues attracted a greater diversity of fly species, totaling 15. Eight of these Justin M. Godby, BS*, Marshall University, 1401 Forensic Science
were common to both types of carrion, three were found associated only Drive, Huntington, WV 25701
with human tissue, and four only with porcine material.
Over both experiments, a total of 16 species of flies were collected
collection methods for mosquitoes, testing of mosquito samples for viral
and identified. Of these, 11 were found on both types of carrion. Two were
RNA, and how forensic equipment and methods can be used for viral
consistently identified only on the human specimens, and four species were
testing.
found solely on the porcine tissue.
Although the results of these experiments remain preliminary, they
humanity by demonstrating the use of forensic methods and procedures that
suggest that adult fly populations on human or porcine carrion may be qual-
can be used to implement viral testing of field collected samples.
itatively different. The impact on current methods of postmortem index
Since its discovery in the United States in 1999, West Nile Virus has
(PMI) can only be determined through the collection of additional data sets.
spread across North America. Though not endemic to the continent,
Olfaction, Forensic Entomology, Carrion mosquitoes of the genera Culex have become vectors of the serocomplex
that causes West Nile. Public health concerns have prompted laboratories
across the nation to develop reliable and rapid tests to detect the virus in
order to initiate surveillance methods. By combining efforts between
public health and forensic agencies, testing protocols can be developed and
performed on not only possible vectors but also infected individuals.
G53 Inter-Observer Variability in Entomology- Current microbial forensic techniques and equipment can be manipulated
Based PMI Estimates: A Single Blind Study to detect viral pathogens using analytical extraction methods. The West
Virginia Department of Health and Human Resources, Division of
Surveillance and Disease Control (WVDHHR/DSDC) in conjunction with
Rebecca A. Bullard, MS*, University of California, Davis, Department of
the West Virginia Office of Laboratory Services (WVOLS), and the
Entomology, One Shields Avenue, Davis, CA 95616; Kenneth G. Schoenly,
Marshall University Forensic Science Center (MUFSC), collected adult
PhD, California State University, Stanislaus, Department of Biological
mosquitoes for viral RNA testing. Viral RNA was isolated and detected by
Sciences, Turlock, CA 95382; and Robert Kimsey, PhD, University of
Nucleic Acid Sequence Based Amplification (NASBA) to ensure
California, Davis, Department of Entomology, One Shields Avenue,
appropriate quality control measures necessary in microbial forensics
Davis, CA 95616
applications.
Attendees will develop an understanding of the variability in current West Nile Virus, TaqMan®, RNA
techniques used to estimate the postmortem interval based on
entomological evidence. The primary goal of this presentation is to open a
dialogue within the forensic entomology community regarding the
development of uniform protocols.
G55 An Instructional DVD on Collecting
This presentation will impact the forensic community and/or Entomological Evidence for Court
humanity by demonstrating a need within the forensic entomology
community to standardize its methods and practices. Ryan K. Kimbirauskas, MS*, Richard W. Merritt, PhD, and Eric M
Although reports of the utility of arthropods in forensic investigation Benbow, PhD, Michigan State University, 243 Natural Science Building,
date as early as 1235 AD, the field of forensic entomology remains in its East Lansing, MI 48824; John R. Wallace, PhD, Millersville University, 1
adolescence, with many avenues of basic research largely unexplored. In South George Street, Millersville, PA 17551; and Jeff K. Tomberlin, PhD,
particular, the method by which the postmortem interval (PMI) is Texas A & M University, 1229 North U.S. Highway 281, Stephenville,
estimated, one of the most important applied methods in forensic ento- TX 76401
mology, remains a highly controversial and problematic process. Indeed, it
After attending this presentation, attendees will learn that there is now
would seem that there might be as many such methods as there are forensic
available a training video on how to properly collect, preserve, and process
entomologists. Herein the authors acknowledge the need for standard-
entomological evidence for court. This training aid will benefit law
ization of this process within the community, investigate the variation in
enforcement agencies, death scene investigators, medical examiners, and
methods employed by forensic entomologists in a single-blind study, and
forensic entomologists.
suggest elements of a uniform protocol. Accordingly, a simulated crime
scene was arranged in which fresh human remains were exposed to insects
humanity by standardizing the practices which are critical to the devel-
at the outdoor decomposition facility operated by the University of
opment of postmortem intervals and the utilization of insects as evidence
California, Davis, Institute for Medicolegal and Surgical Sciences (IMSS).
during criminal investigations.
Following an undisclosed period of exposure (herein referred to as the
This DVD was created by forensic entomologists to fulfill the imme-
PMI), researchers sampled insects from the remains, recorded typical crime
diate need to standardize practices for collecting entomological evidence.
scene and meteorological data, and photographed and videotaped the scene
The material is intended to instruct forensic investigators on how to collect
and data collection efforts. Copies of all materials were sebt to a number
specimen samples and field data in a way that will be scientifically valuable
of practicing forensic entomologists in North America who had previously
and credible in court. The DVD includes an overview of forensic ento-
agreed to participate and render a PMI estimate. The degree to which these
mology and the decomposition of an animal model has been time-lapsed to
estimates vary and bracket the actual PMI will be discussed.
demonstrate the association of insects with various stages of decay. Insects
Forensic Entomology, Postmortem Interval, Standards commonly found with human remains are shown and factors that influence

insect activity and development are described. Crime scene photographs soil moisture during the wet season would result in an increased rate of
and video are used to aid in the recognition of what information should be cadaver decomposition. This experiment was replicated six times and
collected during death investigations. A list of equipment needed to process controls (soil without cadaver) were used.
entomological evidence is given, and the collection and preservation of The soil at Site 1 reached a matric potential of –0.03 megapascals
insect specimens is clearly demonstrated in a step-by-step procedure. The (MPa) (equivalent to 15% moisture content v/v) during the wet season and
main purpose of this DVD is to standardize the practices that are critical to was a constant -1.5 MPa (55% v/v) during the dry season. The soil at Site
the development of postmortem intervals, and demonstrate the utilization 2 reached a matric potential of –0.005 MPa (25% v/v) during the wet
of insects as evidence during criminal investigations. The entire training season and –1.5 MPa (3% v/v) during the dry season. All decomposition
video is 25 minutes; however, the multi-media format provides self-paced processes were greater during the wet season as demonstrated by the
instruction and allows the viewer to select specific modules for quick quantification of cadaver mass loss, microbial activity and nutrient concen-
referencing. tration. This is most likely due to an increase in the activity of soil
Forensic Entomology, Collection, Evidence organisms and the leaching of soluble cadaveric materials as an effect of
rainfall. Some differences were observed between soils within seasons.
Cadaver Decomposition, Soils, Seasonal Effects
G56 How Cadaver Decomposition in Soil is
Affected by Moisture: Part I: A Field G57 How Cadaver Decomposition in Soil is
Experiment to Investigate Seasonal Effects Affected by Moisture: Part II: A Controlled
Mark Tibbett, PhD*, Centre for Land Rehabilitation, School of Earth and Laboratory Experiment
Geographical Sciences, University of Western Australia, Crawley, WA
6009, Australia; and David O. Carter, MSc, and David Yellowlees, PhD, David O. Carter, MSc*, School of Pharmacy and Molecular Sciences,
School of Pharmacy and Molecular Sciences, James Cook University, James Cook University, Douglas, QLD 4811, Australia; Mark Tibbett, PhD,
Douglas, QLD 4811, Australia Centre for Land Rehabilitation, School of Earth and Geographical
Sciences, University of Western Australia, Crawley, WA 6009, Australia;
After attending this presentation, attendees will understand how the and David Yellowlees, PhD, School of Pharmacy and Molecular Sciences,
rate of cadaver decomposition in soils can differ according the soil texture James Cook University, Douglas, QLD 4811, Australia
and season of burial.
This presentation will impact the forensic community and/or After attending this presentation, attendees will understand the
humanity by demonstrating the influence of seasonal variation in moisture interaction between soil moisture and soil texture can have a significant
on decomposition processes associated with cadavers buried in soils of effect on processes associated with cadaver decomposition in soils.
contrasting texture. This presentation will impact the forensic community and/or
Soil moisture resulting from rainfall affects decomposition processes humanity by demonstrating the influence of moisture on processes
by directly influencing the activity of soil organisms and the leaching of associated with cadaver decomposition in soils of contrasting texture.
soluble materials. The amount and distribution of moisture in association Decomposition processes associated with an organic resource, such as
with an organic resource, such as a cadaver, is dependent upon precipi- a cadaver buried in soil, can be affected by the nature of the soil physico-
tation, uptake by vegetation and losses via evapotranspiration and drainage. chemical environment (e.g., soil texture, moisture status) and the activity
These factors are, in part, influenced by soil texture (which is defined by of soil organisms. In a laboratory setting, matric potential (as defined in
the soil particle size distribution). The predominance of large soil particles Part I) can be manipulated in order to test the effect of soil moisture status
(sand) results in greater pore space (the area between soil particles) and on decomposition processes associated with a cadaver buried in soil. Other
increased rates of drainage and aeration. Thus, a soil that is dominated by measurements of soil moisture status, such as a simple gravimetric
small soil particles (clay) may be subject to waterlogging. The most moisture content (g H O g-1 dry soil) and the estimation of moisture
2
accurate assessment of the availability and distribution of moisture is the content in relation to saturation or field capacity (% water holding
measurement of matric potential (the pressure with which moisture is held capacity), do not provide an assessment of the availability of moisture to
between soil particles). This measure can be used to determine the ease soil microorganisms. Hence, the calibration and maintenance of matric
with which soil microorganisms can take up moisture. potential can be used to exclude the activity of larger organisms such as
In order to investigate the effect of soil texture and seasonal moisture protozoa and nematodes. Peak soil microbial activity is typically asso-
variation on cadaver decomposition, a field experiment was conducted at ciated with a matric potential of approximately –0.01 megapascals (MPa).
two disparate field sites. Site 1 comprised a sandy loam soil (84% sand, Soil from the sites described in Part I were sampled (0-10 cm depth)
11.1% silt, 4.9% clay) and was located in Yabulu, Queensland, Australia and sieved (2 mm) field fresh. The soil from Site 1 was a sandy loam soil.
(19°12’S, 146°36’E). Site 1 receives an average rainfall of 995 mm during The soil from Site 2 was a loamy sand soil. Sieved soils (500 g) were
the wet season (November-April) and 140 mm during the dry season weighed into sealable 2 L polyethylene incubation chambers and calibrated
(March-October). The mean maximum/minimum temperature during the to a matric potential of –0.3 MPa (to simulate dry conditions) or –0.01 MPa
wet season is 30.5 °C/27°C. Dry season mean maximum/minimum (to simulate wet conditions). Following an equilibration period of seven
temperature equals 22.9 C/16.7°C. Site 2 comprised a loamy sand soil days, juvenile cadavers (Rattus rattus: ~18 g) were buried at a depth of 2.5
(97.7% sand, 1.3% silt, 1% clay) and was located in Pallarenda, cm and incubated at 22°C. Cadaver mass loss and soil microbial activity
Queensland, Australia (19°11’S, 146°46’E). On average, Site 2 receives were measured over a period of 28 days in order to determine if an increase
1005.1 mm rainfall during the wet season and 120.3 mm rainfall during the in soil moisture would result in an increased rate of cadaver decomposition.
dry season. The mean maximum/minimum temperature during the wet The present experiment also tested the hypothesis that burial in loamy sand
season is 30.7 °C/23.1°C. Dry season mean maximum/minimum temper- soil will result in an increased rate of decomposition. This experiment was
ature equals 26.9 °C/16.4°C. The resulting vegetation at the two sites was replicated 4 times and controls (soil without cadaver) were used.
dominated by grasses with scattered trees. These characteristics are typical In the sandy loam soil a matric potential of –0.3 MPa resulted in an
of a savannah ecosystem. Cadavers (Rattus rattus: ~18 g) were buried at a increase in the rate of all decomposition processes. Conversely, increased
depth of 2.5 cm. Each cadaver was located in the centre of a 2 m2 plot. decomposition was observed in the loamy sand soil calibrated to a matric
Cadaver mass loss, soil microbial activity and nutrient concentration was potential of –0.01 MPa. Significant differences in the rate of decompo-
measured over a period of 28 days in order to determine if an increase in sition processes were observed between soils of similar matric potential.

These contrasting results demonstrate that the rate of cadaver decompo- positive for β-hemolytic Group A Streptococcus. The final autopsy
sition can be affected by an interaction between soil texture and moisture diagnosis was acute bacterial pneumonia due to blood aspiration from blunt
content. Reduced activity in the loamy sand calibrated to –0.3 MPa may force craniocerebral injuries. The facial sinuses were thought to be the
be due to the inability of the soil microbiota to utilize the little water that is source of infection.
tightly bound between soil particles under dry conditions. Reduced activity Review of the literature reveals no data or case reports specifically
in the sandy loam is likely due to a decreased diffusion coefficient of gases addressing the issue of blood aspiration and pneumonia in the head-injured
(e.g., O2, CO2) associated with an abundance of moisture and a high patient, though several studies address the increased risk of pneumonia, and
microbial demand for O2 during the aerobic catabolism of an organic one explores the increased risk of pneumonia in head-injured patients who
resource. These conditions may lead to anaerobiosis. Greater cadaver were carriers of Staphylococcus aureus.4,5 The method of inoculation was
mass loss took place in the field experiment described in Part I. This phe- felt to be aspiration at the time of injury and/or from intubation. The
nomenon may be due to the presence of arthropods in a field setting. patients in this and other studies suffered from severe head injuries and had
Unlike the findings from the field experiment in Part I, cadaver decompo- been intubated, some requiring prolonged ventilator support. This case
sition in soil from Site 1 decreased with an increase in moisture. This might differs, in that the head injury was not severe. The patient experienced no
indicate that the aerobic threshold for the sandy loam soil following loss of consciousness, neurological symptoms, or airway compromise. No
cadaver burial is between –0.005 MPa and –0.001 MPa. information was found regarding studies of the use of prophylactic antibi-
otics in this patient population. Prior to this case, the standard of care at the
Cadaver Decomposition, Soil, Moisture treating medical center for patients with clinically stable maxillofacial and
skull fractures did not include prophylactic antibiotic therapy. This case
suggests that further study in this area is warranted.
G58 Clinically Stable Skull Fracture 1Marion, DW. Complications of head injury and their therapy.
and Fatal Acute Pneumonia: Neurosurgery Clinics of North America 2:April 1991, 411-24.
2Severyn FA, Fenn J. Overwhelming S. pneumonia meningitis after
An Unexpected Combination
basilar skull fracture: A Case Report. Air Medical Journal 19:3, 2000,
102-4.
Christie L. Elliott, MD*, Forensic Pathology Consultants, PO Box 12815,
3Kingsland RC, Guss DA. Actinobacillus ureaea meningitis: Case report
Reno, NV 89510-2815
and review of the literature. The Journal of Emergency Medicine
After attending this presentation, the forensic pathologist and treating 13:5:1995, 623-627.
clinician will be aware of an unexpected and rare complication of head 4Campbell W, Hendrix E, Schwalbe R, et.al. Head-injured patients who are
injuries. nasal carriers of Staphylococcus aureus are at high risk for Staphylococcus
This presentation will impact the forensic community and/or aureus pneumonia. Critical Care Medicine 27:4:1999, 798-801.
humanity by educating the pathologist and the treating clinician about a 5Bronchard R, Albaladejo P, Brezac G, et.al. Early onset pneumonia: Risk
rare but serious complication of clinically mild head injuries, and factors and consequences in head trauma patients. Anesthesiology
stimulating more studies in the area of possible treatments for this 100:2004, 234-9.
complication.
Aspiration pneumonia and acute meningitis are well-recognized Skull Fractures, Pneumonia, Head Injuries
complications in head-injured patients.1-3 Most commonly, the pneumonia
results from aspiration of gastric and oropharyngeal material into the lungs
because of unconsciousness and/or altered gag and swallowing reflexes G59 The Dangers of Dumpster Diving:
from the head injuries. Acute meningitis most often occurs in the presence Deaths Associated With Garbage Collection
of basilar skull fractures, which result in communication between the in the Tidewater Region of Virginia
underlying sinuses and the CSF. Very little information is available in the
medical literature addressing the issue of blood aspiration in head-injured
Leah L. Bush, MD*, Office of the Chief Medical Examiner, Tidewater
patients, particularly those with maxillofacial injuries. The following case
District, Commonwealth of Virginia, 830 Southampton Avenue, Suite 100,
report will illustrate an unexpected complication of such an injury.
Norfolk, VA 23510-1046; and Wendy M. Gunther, MD, Office of the Chief
The patient was a 13-year-old female involved in a single car motor
Medical Examiner, Tidewater District, 830 Southampton Avenue, Suite
vehicle accident. She had epistaxis and abrasions and contusions of the
100, Norfolk, VA 23510-1046
face, but suffered no loss of consciousness or neurological symptoms. A
CT scan showed non-displaced facial fractures, a small basilar skull After attending this presentation, attendees will be able to recognize
fracture, and a right temporal cephalohematoma. She was admitted for characteristics of crush and asphyxial injury inflicted by garbage collection
observation and released the following day. Two days after discharge she machinery on persons within dumpsters. Pertinent considerations in such
returned to the emergency room with complaints of pain, dizziness, and deaths of the contribution of toxicology, natural disease, and history, and
weakness. Repeat CT scan of the head showed no acute changes. Chest the effect on diagnosis of antemortem from frequently seen decomposition
x-ray was normal. She was afebrile, but mildly hypotensive (98/50) and artifact will be reviewed. Public policy consequences of such deaths will
tachycardic. This resolved with a fluid bolus. She was discharged home also be briefly reviewed.
with pain medications. She was found semi-responsive the following This presentation will impact the forensic community and/or
morning and arrested shortly after. She was pronounced dead at the scene. humanity by reviewing an unusual but recurring situation in which
An autopsy was performed the following day. homeless persons or others are crushed to death in garbage dumpsters. The
The postmortem examination revealed a normally developed presentation reviews, autopsy findings, mechanism of death, and role of
adolescent female with soft tissue swelling and resolving contusions and artifacts of decomposition in determining cause of death.
abrasions of the face. Reflection of the scalp showed purulence of the right Four cases accumulated over an 11 year period illustrate an infrequent,
temporal soft tissues. Pertinent intracranial findings included hairline skull but recurring, danger for poor or homeless persons, who die during garbage
fractures across the orbital and ethmoid plates and the anterolateral left collection.
petrous ridge up into the left temporal bone. Grossly, the lungs were heavy, In 1993, the fully clothed body of a 51-year-old man was found by
mottled red/tan, and slightly firm and edematous. Microscopic examination employees of a sewage and trash processing plant when a garbage truck
showed acute pneumonia, edema, and frank blood within the alveolar dumped out the trash collected from a dumpster in Norfolk, Virginia. At
spaces. Cultures of lung tissue, CSF, and right temporal soft tissue were initial examination on scene, a gaping laceration was evident in the lower
abdomen, with exposed bladder wall. At autopsy, diffuse changes of This presentation will impact the forensic community and/or
decomposition did not obscure extensive crush injury, including cervical humanity by assisting the medicolegal experts in learning how to identify
spine, femur, and iliosacral fractures, fragmentation of the liver, diaphrag- terrorist attacks using micro-organisms that are naturally present in animals
matic rent with traumatic herniation of the stomach into the chest, and a and can infect humans. These organisms having undergone weaponization.
ruptured ileocecal junction. These injuries were consistent with death Recent episodes of international unrest raised the danger of the use of
during trash compaction. “weaponized microbiological organisms” in terror attacks. At the same
The decedent proved to be a homeless man with a history of heavy time, the ever-present danger of the transmission of diseases from either
alcohol intake, last seen by his family two to three days before his body was domestic animals or from those who live in natural surroundings creates
found. Although investigation never proved what he was doing in the serious differential diagnostic issues. This presentation will outline an
dumpster, it was possible that he was either looking for recyclable items, or approach to the identification of the infecting microorganism and etiology
may have fallen asleep there. Toxicology showed ethanol at 0.15 mg %. that the forensic practitioner will be expected to make.
In October of 1994, the body of a 48-year-old woman was found in Differential Diagnosis, Zoonoses Terror Exposure, Human Infection
the Hampton, Virginia landfill. At external examination, there were
multiple abrasions and contusions, with areas of confluent contusion; the
face was suffused, with dark purple contusions of the lips, and surrounding
both orbits. At autopsy, there was severe crush injury, with fracture, dislo-
G61 Suicides Among Youth in Geneva,
cation, and transection of the cervical spine at both C1 and C7, and bilateral Switzerland From 1993 to 2002
rib fractures with flail chest. There was also a healed myocardial infarct.
She proved to be a vagrant from the neighboring city of Virginia Beach, Guillaume Perret*, Département de Psychiatrie, Clinique de Psychiatrie
with a history of diabetes and psychiatric problems, who was known to go Adulte, HÙG, Secteur Jonction, Bvd Saint-Georges 16-18, Geneva, 1205,
through trash depots looking for salvageable materials. Toxicology showed Switzerland; Abliz Abudureheman, MD, Institut Universitaire de
a high but not lethal level of carbamazepine, with butalbital and oxazepam. Médecine Légale de Genève, 9 Av de Champel, Geneva, 1211,
It appeared that she might have climbed into a dumpster, collapsed from the Switzerland; Maja Perret-Catipovic, PhD, Département de Psychiatrie,
toxic effects of her drugs or from a cardiac event, was later picked up by Unité, Bd de la Cluse 51, Geneva, 1205, Switzerland; and Romano La
the trash-compacting truck, and was then crushed. Harpe, MD, Institut Universitaire de Médecine Légale de Genève,
In November of 1994, the body of a 37-year-old man was found after C.M.U, 9 av de Champel, Geneva, 1211, Switzerland
a non-compacting trash truck dumped out its load at a sewage and trash
After attending this presentation, attendees will understand the impor-
processing plant. He did not have any crush injuries. Autopsy showed
tance of knowing the circumstances of deaths in suicides among youth to
difuse bilateral scleral and conjunctival hemorrhages, purple suffusion of
help clinicians in their work in youth suicide prevention programs. The effort
the face, marked edema of the face and lips, epiglottal petechiae, contusions
should be made to collect clinical data during medicolegal investigations.
of the neck structure, and further contusions of the chest and back. Death
was ascribed to traumatic asphyxia, which he would have sustained when
humanity by demonstrating how suicides among youth are such a tragic
tons of trash were placed over his body. Toxicology showed numerous
event, and that it is sometimes difficult to collect complete clinical infor-
toluene derivatives. Although investigation did not show how he entered
mation or do a full medicolegal investigation. Sparing the family from too
the dumpster, he may have been seeking a place to inhale glue vapors, and
many questions might be one of the reasons. In Geneva, Switzerland, lack
could have been overcome by the drug.
of crucial information for clinicians who work to prevent suicides among
In 2004, the crushed and decomposing body of a 60-year-old
youth is often observed. This study may help to create a close collaboration
homeless man was found at a dump site near housing debris. Autopsy was
between suicides prevention programs and forensic medicine.
able to show, despite extensive decomposition, that crush injuries had
In Switzerland, suicides represent the leading cause of death in the age
occurred antemortem. He had been known to sleep in an abandoned house
group 20 to 24 years, and the second most common cause of death in the
that was demolished six days previously. Public reaction to the death
15 to 19 year age range. During the 1990s, the number of suicides in those
caused re-evalution of housing demolition policies.
age groups has remained stable, and has even decreased in Geneva between
This discussion will review the mechanism of death, immediate and
1975 and 1996. The aim of this study was to look whether this tendency
underlying causes of death, contribution of natural disease and toxicology,
persisted during the years from 1993 to 2003. The authors analyzed all
and obstacles to determination of cause produced by decomposition, for
cases of suicide among youth less than 25 years of age in Geneva during
persons dying in trash compactors. Review of these cases may heighten
this period. Suicide was defined through police and medicolegal investi-
awareness of the dangers encountered by homeless persons foraging in
gations. Sixty-five suicides were found involving 50 male (77%) and 15
dumpsters.
female (23%) victims. The minimum age was 12 years, and most of the
Garbage Dumpsters, Crush Injury, Traumatic Asphyxia victims were 18 years old or older (89%). No increase in the number of
suicides throughout the years was found in the range being between 1 and
11 cases per year. For males, use of firearms was the most common method
G60 The Differential Diagnosis Between (38%), followed by fall from height (30%), hanging (16%), and drowning
Bioterrorism and Zoonosis and Spread (10%). For females, fall from height was the most frequent (40%), fol-
lowed by use of firearms and medication overdose (20% each), hanging
to Humans: A Patholical Evaluation (13%), and drowning (7%). Only 43% of the cases had toxicological
testing, and the main drugs found were benzodiazepines, cannabis and
Maurice Rogev, MD*, Zamenhof 11, Tel Aviv 64373, Israel cocaine. Blood alcohol concentration was analyzed in 53% of all deaths.
After attending this presentation, attendees will understand how Among them, 32% tested positive, half of them with a concentration below
recent episodes of international unrest have raised the danger of the use of 52.5 mg/dl. Clinical data in medical charts were often incomplete, lacking
“weaponized microbiological organisms” in terror attacks. At the same in more than 70% of the cases. Although this study has brought very useful
time, the ever present danger of the transmission of diseases from either in formation about the circumstances of death, helping to better charac-
domestic animals or from those who live in natural surroundings creates terize suicide in youth, in Geneva, an effort should be made to collect more
serious differential diagnostic issues. This presentation will outline an clinical data during medicolegal investigations. These data would be of
approach to the identification of the infecting microorganism and etiology help to clinicians who work in youth suicide prevention programs.
that the forensic practitioner will be expected to make. Suicides, Youth, Epidemiology

G62 Suffocation by Mistaken Use of a Autopsy demonstrated rib fractures consistent with CPR, a normal
thyroid gland, gastritis, polyvisceral edema, very intensive pulmonary
Biohazard Hood as a “Spit” Hood edema, an enlarged heart, normal coronary arteries, no intravascular
coagulation (pulmonary or other), brain edema, and a tumor in the left
K. Alan Stormo, MD*, Jeffrey M. Jentzen, MD, Mary K. Mainland, MD, adrenal gland (60 g). The fetus and uterus were normal. Histological
John R. Teggatz, MD, and Victor V. Frolov, MD, Milwaukee County examination confirmed the adrenal tumor was a pheochromocytoma.
Medical Examiner, 933 West Highland Avenue, Milwaukee, WI 53233 Toxicology studies were negative.
The goal of this presentation is to document a case of mistaken use of Discussion : Adrenal PC is usually a benign catecholamine-producing
a biohazard hood as a spit hood resulting in suffocation, and show resulting tumor (90%) of the sympathetic nervous system. The incidence is 0.05%
experimental re-enactment of such use including time and oxygen strudies. in all autopsies (McNeil et al., 2000) and sudden death occurred in 8.9% of
This presentation will impact the forensic community and/or the cases (Casanaova et al., 1993). The PC is bilateral in 505% of cases
humanity by demonstrating the danger of the improper use of the device, and left in 635%. The diagnosis is difficult because, generally, PCs develop
and by presenting data related to time necessary to become severely for a long time with non specific symptoms (or without classical
compromised by improper use. constitutional symptoms), until explosive syndromes appear, related to
A 20-year-old male was found to be in possession of drug parapher- catecholamine excess, with severe hypertension, acute pancreatisis,
nalia and was arrested. While being transported to the police station he hyperacute myocardial ischemia, cerebral hemorrhage, cardiogenic shock,
became belligerent, combative, and attempted to spit on the transporting congestive heart failure, and sudden death. Sudden death is the only sign
officer. He was restrained with a car seatbelt with his hands cuffed behind in 1.5% of cases. Several diagnostic methods are available to increase the
him; a biohazard hood was placed over his head to contain the spitting. On detection and the diagnosis (meta- and normetanephrine in urine is one of
arrival at the police department 8-10 minutes later he was found unre- the best sensitive screening tests; abdominal MRI - scintigraphy with
sponsive; resuscitation was unsuccessful and he was pronounced dead in meta-iodo-benzyl-guanidine for visualization). It is important to note that
the local hospital ER. the heart weight is increased in 95% of the patients.
The Quick 2000 is a widely available biohazard escape hood, which Conclusion: Diagnosis is often difficult, and many PCs are not
has a nose clip, a mouthpiece for breathing and a tight neck dam. Breathing recognized during life. Clinicians should be aware of the symptoms of PC,
into the mask without use of the mouthpiece rapidly depletes the oxygen as early diagnosis is very important in order to perform a laparoscopic
and increases CO2. Informal experiments demonstrate severe air hunger in adrenalectomy. In addition, some symptoms are the same as acute drug
two to two and one-half minutes if the mouthpiece is not used. Data from intoxication. PCs are usually curable if diagnosed and treated properly,
more formal experiments with oxygen and CO2 studies will be presented. and, in certain cases, this diagnosis necessitates prompt surgical
intervention.
Asphyxia, Suffocation, Biohazard Hood During autopsy, certain tumors are observed with increased frequency
in patients with PC, including thyroid carcinoma, liver tumor, prostate car-
cinoma, malignant melanoma, carcinoma of the uterine cervix, and breast
carcinoma.
G63 Unsuspected Pheochromocytoma Pheochromocytoma, Sudden Death, Autopsy
Discovered During Autopsy After
Sudden and Unexpected Death in
G64 Modeling Languages in Forensic Pathology
an Expectant Mother
Gilbert E. Corrigan, MD, PhD*, East Baton Rouge Coroner’s Office,
Sophie Gromb, PhD*, Nadia Khaldi, MD, Larbi Benali, MD, Mathurin 4030 T.B. Hearndon Avenue, Baton Rouge, LA 70807
Djodjo, MD, and Alain Miras, PhD, Department of Forensic Medicine -
EA 3676 - IFR 99 of Public Health, CHU Pellegrin - Place Amélie Raba- After attending this presentation, attendees will understand the
Léon, Bordeaux, 33076, France importance and utility of modern modeling computer techniques in forensic
pathology from Microsoft Word® (MS Word), to Microsoft Visio® (MS
The goal of this presentation is to present a case report of sudden death Visio), to Universal Modeling Language Two (UML2).
due to pheochromocytoma (PC), and emphasize the necessity of complete This presentation will impact the forensic community and/or
autopsy and histological analysis in different tissues in which metastases humanity by demonstrating the importance and utility of modeling to
can develop. solving forensic pathology problems.
This presentation will impact the forensic community and/or In forensic informatics, modeling is an underemployed but important
humanity by showing the necessity to perform an autopsy in every case of computer technique. Models illustrate concepts, analyze processes and
sudden death in order to determine the cause of death for medical (respon- relationships, and communicate with efficiency and clarity. Models show
sibility), psychological (family), and epidemiological reasons (prevention the first definitions of processes at their inception; they precede the formal
of disease in the other members of the family); and demonstrating the formulation of the computer application. Current computer applications in
importance of a complete autopsy and the necessity of histological analysis. MS Word®, MS Visio®, and UML2 may be used by forensic scientists to
Case Report: An autopsy case of a PC in a 42-year-old asymptomatic compose models; however, increasing specificity and precision require
and expectant mother is reported, without previously suspected PC. She more study and attention as the applications mature and enlarge.
was pregnant (her last period was 34 weeks ago), and had appointments Models provide computer programmers with the initial structure of
with her obstetrician regularly. Her last visit to a doctor was 15 days before their applications; models also work to provide scientists their first formu-
death, and all had been found normal. She didn’t have abdominal pain or lations of the details of their work. Models act to provide actual represen-
hypertension. Several days before death, she suffered asthenia, dyspnea, tations of concepts and ideas. Referral by scientists to the available models
and chest pain. One morning, during a walk, she felt faint without other allows the definition of objects and relationships valuable to extension of
symptoms (nausea, vomiting, etc.), and this occurred again several minutes their thoughts. Such models teach, communicate, illustrate, standardize,
later. A loss of consciousness occurred and, in spite of the intervention of lead thinking, require attention, precede other actions, require syntax,
intensive care for more than one hour, she died in heart failure and cardio- provide transmission and transfer, and act to standardize operations. The
genic shock. models by structural and behavioral analysis are classified as class

diagrams, package diagrams, object diagrams, use case diagrams, sequence She died with unclear symptoms three days after her collapse. As
diagrams, collaboration diagrams, state charts, activity diagrams, power cause of death, the physicians of the hospital signed “Lung failure in
diagrams, component diagrams, deployment diagrams, engineering pneumonia,” as they suspected an atypical infection of the lungs.
diagrams, flow charts, and brainstorming diagrams. The autopsy showed hemorrhagic lung edema. Weights of the lungs
Current applications providing computer modeling activities have were: right 1085 g, left 1040 g. There was abundant bloody mucus in the
been under formal development by computer scientists for over thirty years respiratory passages, with some coagulated blood in the bronchi. Cultures
and are in their third generation of development. Forensic scientists find of tracheal secretions were negative.
modeling possible with the word processing application MS Word®, and The histological examination revealed an intra- and extra capillary
MS Visio® which is evolving into a more complex, capable and proliferative glomerulonephritis with crescents and focal segmental
inexpensive modeling tool. The more advanced UML2 applications have necrosis of the glomerular loops consistent with rapidly progressive
the capacity to create and manage large models over the expanse of large glomerulonephritis. The lungs showed siderophages indicating older
organizations and corporations with the precision and accuracy needed in bleeding in addition to the fresh bleeding.
sophisticated scientific activities. Many commercial scientific modeling The clinical, laboratory and autopsy findings suggested either
applications are available; however, to date no formal set of forensic Wegener’s disease or microscopic polyarteritis nodosa. The diagnosis was
symbols or diagrams are recognized or developed. made by analysis of autoantibodies; the lack of cANCA indicated the
Little formal recognition has been given to modeling in the forensic or diagnosis polyarteritis nodosa. The differential diagnosis will be critically
pathology literature so that the complexities, multiplicities, and composites discussed.
inherent in the data often are either ignored or not represented. This may be the first reported case of polyarteritis nodosa playing a
Forensic models are limited in number and are without the standard- role within the context of a sudden unexpected death.
ization found in UML2. Note that the development of models is not easy Polyarteritis nodosa, Sudden Unexpected Death,
work and requires analytic time and clear conceptualization of ideas. Immunohistochemistry
Modeling is blocked by poor definitions and is inefficient when topics are
diffuse and poorly understood.
Demonstrations of functional models in forensic scene investigation
and forensic pathology are presented.
G66 Autopsy Findings in Hypothermia:
Forensic Informatics, Modeling Languages, Forensic Death
Investigation
A Five Year Retrospective Study
Patricia A. Aronica-Pollak, MD*, Jack M. Titus, MD, and David R.

G65 Polyarteritis Nodosa as a Rare Case of Fowler, MD, Office of the Chief Medical Examiner, State of Maryland,
111 Penn Street, Baltimore, MD 21201
Sudden Death in Postmortem Diagnosis
Wolfgang A. Keil, MD*, and Felicitas Dahlmann, MD, Institute of anatomic, toxicological, and investigatory findings associated with
Forensic Medicine, Ludwig-Maximilians-University Munich, hypothermia deaths during the past five years in Maryland.
Frauenlobstraße 7a, Munich, D80337, Germany; and Andrea M. This presentation will impact the forensic community and/or
Berzlanovich, MD, Institute of Forensic Medicine, Medical University humanity by providing information on the findings associted with
Vienna, Sensengasse 2, Vienna, A1090, Austria hypothermia deaths with special emphasis on the gross autopsy findings.
To date, there are no recognized pathognomonic findings in
After attending this presentation, attendees will understand that, in the hypothermia-associated deaths. Certain findings have been seen in greater
correct setting, among the common natural disease causes of sudden death frequency in hypothermia. These include paradoxical undressing, gastric
of forensic importance, sometimes very rare diagnoses must be considered. mucosal ulcers, hemorrhagic pancreatitis, and pulmonary edema. It has
In these cases, systemic vasculitis and systemic autoimmune diseases may been suggested that gastric ulcers and pancreatic changes are seen more
play a role. To detect these rare diseases as causes of death, classic frequently following resuscitation. Paradoxical undressing occurs when
histology may need to be supplemented by immunohistochemical and the body temperature is low, presumably causing mental confusion,
serological examination of tissues and other samples. possibly giving the sensation of extreme warmth, and leading to the
This presentation will impact the forensic community by removal of one’s clothing. This confusion may also lead to a characteristic
demonstrating the first reported case of polyarteritis nodosa playing a role pattern of bruising on the extremities (elbows, wrists, hands, knees) as one
within the context of a sudden unexpected death. wanders about in a confused state.
Worldwide, most unexpected sudden deaths of forensic interest by This poster will present the findings from a retrospective review of
natural causes are due to cardiovascular diseases. In these cases, acute 145 cases investigated by the Office of the Chief Medical Examiner for the
myocardial infarction and arteriosclerosis of the coronary arteries are the state of Maryland during the years 1999-2003, in which hypothermia was
leading entities. In contrast to this, sudden deaths due to vasculitis are a the cause of death or a contributory cause of death. The cases were
rarity. Polyarteritis nodosa occurs three times more often in men then in assessed for association with drowning, natural disease, ethanol and drug
women. The diagnosis of the disease is often incorrect. intoxication, appearance of gastric ulcers, gross hemorrhagic changes of the
A 21-year-old old female student from Sweden came to Munich after pancreas, combined lung weights, evidence of paradoxical undressing, and
vacationing in Greece with her parents. She was previously healthy, apart contusions of the extremities.
from a cold with fever a few weeks before her holidays which was treated Of the 145 cases, 19 were not included due to incomplete available
with antibiotics. In Greece she complained of having back pain located data. Of the remaining 126 cases, 13 (9.7%) were associated with
near the right kidney and at a disco at Munich she got dizzy and collapsed. drowning. Only one of the drowning cases showed evidence of gastric
The day after, she became increasingly short of breath. In the afternoon she ulcers. None had pancreatic changes. As expected, average combined lung
was found lifeless in the apartment of a friend with blood around her nose weight was increased at 1067 grams (range 410-2310). Five of the 13
and mouth. She was brought into a hospital immediately. (38.5%) had ethanol levels over 0.08 g/dL. Drug intoxication was not
She remained unconscious and was diagnosed with hypoxic edema of noted in any of the drowning cases. Natural disease contributed in one
the brain. The initial presumption of drug intoxication was disproved by case. Paradoxical undressing and contusion patterns on the extremities
toxicological analysis. were not observed in the drowning cases.

Of the remaining 113 non-drowning cases in which full autopsy Two cases will be presented involving paint transfer onto human bone
examinations had been performed, 83 (73.5%) were male with an average through blunt force: in one case blue paint from a baseball bat and in the
age of 56 years (range 19-91). Natural diseases such as cardiovascular other the black surface (under flaking paint) of an old metal railing. Both
disease, acetonemia, and dementia were associated with 59 (52.2%) of cases involve severe blunt force trauma to the head. This is a phenomenon
cases. Ethanol levels were over 0.08 g/dL in 33 (29.2%) cases. In 17 that had not been noted previously.
(15%) cases, drug intoxication contributed to death. Drugs involved Case 1: In 1995 a 65-year-old male was found dead, the victim of a
included morphine, cocaine, methadone, meperidine, trazadone, severe beating by an assailant who “came in like a raging bull with a
oxycodone and acetaminophen. baseball bat” (according to the Detective). At autopsy, Diane Scala-
Stomach ulcers were seen in 39 (34.5%) of the cases. Of these 39, 11 Barnett, MD, Deputy Coroner of Lucas County, Ohio, requested that Julie
(28.2%) had been resuscitated. Sixteen (14%) of the 113 cases had gross Saul, Director of the Forensic Anthropology Laboratory in that office,
visible changes in the pancreas. Of these 16, 5 (31.3%) had been resusci- reconstruct the fragmented skull and determine what could be learned from
tated. Resuscitation occurred in 14 (12.4%) of the 113 cases in which no the resulting fracture pattern. Blue paint chips and wood splinters were
changes in the pancreas or stomach were noted. The average combined found in the soft tissue at wound edges of the mouth and scalp.
lung weight was 1050 grams, with a range of 400 to 2710 grams. Traces of blue paint were noted on a few small fragments; therefore,
Paradoxical undressing occurred in 6 cases, with an additional 8 more initial cleaning was accomplished using only warm water in order to
potential cases (combined 12%). Pink-brown bruising was noted on the preserve pigment. Ultimately, five fragments were found to have blue paint
upper extremities in 24 (21%) cases and on the lower extremities in 25 embedded in the surface. Other bone fragments were cleaned and
(22%) cases. The contusions were often on the elbows, posterior wrists, the degreased using normal procedures.
backs of the hands, and knees. Of the 14 total cases of potential paradoxical Thirty-six fragments were reassembled. The fracture pattern indicated
undressing, only 4 were associated with these contusions. Therefore, this that the skull had been shattered with one blow, probably administered
pattern of bruising may represent a different type of confusional state while the right side of the victim’s head was against a hard surface – likely
possibly different than the thermoregulatory disturbances. to be the floor. This was confirmed by bloodstain evidence at the scene.
Hypothermia as a cause of death can only be determined through The five bone fragments with embedded blue paint lined up together
thorough investigation, as there are no autopsy findings which are noted in at one edge of the single impact area, located approximately on the left
all cases. However, this study does provide further confidence in the diag- parietal eminence. The force of the blow at that point had driven blue paint
nosis with the presence of other findings. The gastric ulcers were the most from the baseball bat into the fracture edges.
frequently associated finding. The contusions on the upper extremities and Case 2: In 2004 a 40-year-old woman was found dead of severe blunt
lower extremities, especially on the posterior surfaces of the arms, wrists force injuries to the head. At autopsy, several distinctive patterned scalp
and hands, are the next most common findings. Gross changes of the lacerations were noted, along with bruises on the neck, face, chest and
pancreas, visible as hemorrhage, were also noted, but less frequently. The abdomen. A bitemark was present on the left breast. Retraction of the scalp
pulmonary edema was difficult to assess as many of the hypothermia cases revealed distinctive patterns on the skull beneath the scalp lacerations.
also had heart disease and drug and alcohol intoxication contributing to the These contact transfer patterns (not fractures) were formed by embedded
cause of death. Paradoxical undressing, while uncommon, remains a real black pigment, and corresponded well to the overlying scalp lacerations.
phenomenon that is potentially confused with criminal acts. In this case, the instrument was not a broad, smooth object such as the
Hypothermia, Paradoxical Undressing, Gastric Ulcers baseball bat used in the earlier case, but a portion of an old iron fence
railing with shapes that corresponded to both the lacerations and pigment
contact transfer patterns.
In both cases, transfer of color (and/or pattern) onto cranial bone
through blunt force yielded valuable information regarding the instrument
G67 Color Me Guilty: The Role of Paint used.
Transfer in Weapon Linkage Although paint transfer is commonly used for forensic linkage in
vehicle related cases, it may be overlooked in analyzing bone trauma.
Diane Scala-Barnett, MD*, and Julie M. Saul, BA, Lucas County Blunt Force, Paint Transfer, Trace Evidence
Coroner’s Office, 2595 Arlington Avenue, Toledo, OH 43614-2674
After attending this presentation, attendees will be alerted to examine
for the presence of paint transfer onto bone as a means of weapon linkage, G68 The Role of Forensic Insects in
and be prepared to modify their specimen preparation techniques Deposition of Pollen at a Death Scene
accordingly.
Rebecca J. Kirby*, Anita L. Guedea, Phillip L. Watson, PhD, Roger E.
humanity by demonstrating how paint transfer is commonly used for
Mitchell, PhD, and Scott M. Herron, PhD, Ferris State University,
forensic linkage in vehicle related cases, although it may be overlooked in
Department of Biology, Big Rapids, MI 49307
analyzing bone trauma.
Transfer evidence can be an important part of an investigation. The goal of this presentation is to investigate the importance of pollen
Transfer evidence may relate to transfer of blood from one object to transfer by insect visitors to a death scene.
another, often leaving a distinctive contact transfer pattern that may be This presentation will impact the forensic community and/or
linked to a specific weapon. humanity by demonstrating the effect, if any, of forensically important
Paint transfer also yields valuable information. Paint transfer usually insects on the deposition of both anemophilous and zoogamous pollen at a
relates to paint chips/fragments transferred from one vehicle to another (or death scene. The importance of the findings could be critical in showing
onto a victim or structure) during a collision. This information aids in iden- whether pollen evidence is subject to the uncertainty of insect visitors at a
tifying a vehicle model and year based on analysis of the paint. It may even crime scene.
identify a specific vehicle. This poster will present the evidence of pollen deposition at mock
Hair and fibers are transferred from one person or place to another – crime death scenes with and without insect involvement. Pollen can be
evidence of contact. DNA is transferred from a person to an object or transferred to the death scene by wind (anemophilous) and by animals
another person. Fingerprints are transferred from one individual to another (zoogamous), particularly insects. It was the original purpose of the
individual or an object. experiment to document the normal pollen assemblage in mock crime

scenes. This pollen assemblage at these mock crime studies was compared cadaveric rigidity was the result of a weak excitation of the muscular
with the resident pollen on the pigs which were not local. system, and if this excitation really did exist, it was too weak to cause a
For over five years, one of the courses in the forensic biology program visible contraction. To prove this hypothesis, Bierfreund conducted animal
at Ferris State University has used pigs in a mock crime setting to teach experiments that involved weak irritation by the sciatic nerve. The results
students techniques associated with death scenes, including forensic were the very opposite of what he had hoped for.
entomology, botany, and anthropology. These mock crime settings are The experimental results described above and some others are
done under strict animal rights protocols. During these mock crime scenes, partially contradictory. Therefore, it remains unclear what role the nervous
pollen collections have been done for baseline data on the pollen system may play in the development of cadaveric rigidity.
assemblages found during different times of the year. Some years ago, a method to increase understanding of rigor mortis
In a series of insect inclusion and exclusion experiments, the pollen through the objective measurement of the intensity of cadaveric rigidity in
assemblages were collected at the mock crime scene. The original question rats was developed. The principle of the method is to determine the force
attempting to be answered was the effect, if any, of the insects visiting the required to cause a movement of small amplitude (4 mm) in the limb under
mock crime scene and deposition of both anemophilous and zoogamous examination. Since the movement doesn’t break rigor mortis, serial
pollen. The importance of the finding could be critical in showing whether measurements can be conducted. The apparatus used measures the
pollen evidence is local or is subject to the uncertainty of insect visitors at resistance caused by rigor mortis in the knee and hip joints of rats. This
a crime scene. method has been used in the past to evaluate the influence of several
Insect, Pollen, Palynology pre-mortem and postmotrem factors (i.e., body weight, muscular mass,
age, physical exercise, ambient temperature, various causes of death,
electrocution) on the development of rigor mortis.
In present investigations, experiments are performed that at least
G69 Experimental Evaluation of Rigor Mortis - partially clarifies the influence of the central nervous system on the
The Influence of the Central Nervous development of rigor mortis.
System on the Evolution of the Intensity Experimentation: Animals: male albino rats, weighing approx. 300 g.
of Rigor Mortis
Measurement time points: 10 min, 1h, 2h, 3h, 4h, 5h, 6h, 8h, 12h, 16h,
and 24h postmotrem.
Thomas Krompecher, MD*, André Gilles, MD, Conxita Brandt-
Casadevall, MD, Beat Horisberger, MD, and Patrice Mangin, MD, Measurements were made on the hind limbs of the animals.
Institut Universitaire de Médecine Légale, Rue du Bugnon 21, Lausanne,
Group N°1: control
1005, Switzerland
Group N°2: medulla oblongata section
The goal of this presentation is to present the development of the
intensity of rigor mortis after the disconnection of different parts of the Group N°3: destruction of spinal chord with a needle introduced in the
central nervous system. spinal canal
humanity by providing a better understanding of the development of rigor Group N°4: sciatic nerve section
mortis under different conditions. Results: No significant difference was found in the development of the
In 1811, the French physician and chemist P. H. Nysten published the intensity of rigor mortis among the four groups.
first scientific description of rigor mortis. The law named after him states
that “Cadaveric rigidity affects successively the masticatory muscles, those Conclusion: In “normal” conditions, the central nervous system has no
of the face and the neck, those of the trunk and arms and finally those of significant influence on the intensity or on the time course of the rigor
the lower limbs.” It is often added that resolution occurs in the same order. mortis. These experiments do not exclude the possibility of the influence
The development of rigor mortis is thus descending, a finding thought to be of the CNS on the development of cadaveric rigidity in some pathological
related to the varying distances between the different muscles and the conditions.
central nervous system. However, Nysten himself noticed that the Rigor Mortis, Central Nervous System, Rats
destruction of the CNS did not affect the order of the development of
rigidity.
In 1904, Fuchs described the brain as the initial site of death, followed
by the proximal part of the spinal cord, and suggested that the process then G70 β—Phenylethylamine as a Biomarker in
progressed towards the caudal spinal cord: the presumed impulsions
influencing the development of rigor mortis arose from catabolic changes Mechanical Asphyxia-Related Fatalities
in the nerve cells.
In 1819, Busch observed that the removal of the brain and spinal cord Wen-Ling Lin, PhD*, and Kai-Ping Shaw, MD, PhD*, Institute of
resulted in an early onset of rigidity; moreover, rigidity was more Forensic Medicine, Ministry of Justice, Republic of China, 161-1, Section
pronounced and lasted longer. 2, Keelung Road, Taipei, 106, Taiwan, Republic of China
In experiments conducted on animals, Eiselberg (1881) demonstrated The goal of this presentation is to establish β—Phenylethylamine
that when the sciatic nerve was sectioned on one side, in over 70% of cases (PEA) as a biomarker of asphyxia during medicolegal investigation by
rigidity developed later than on the contalateral side. characterizing the rate-limited step of oxygen-dependent monoamine
Gendre (1885) and Aust (1886) confirmed this finding. Aust, in oxidase B (MAOB).
particular, obtained this result in 12 out of a total of 13 experiments. This presentation will impact the forensic community and/or
Having conducted in vivo sectioning of the left side of the spinal cord in humanity by showing how the elevation of PEA concentration in blood
rabbits (underneath the pyramidal crossing), Bierfreund (1888) made the may play a crucial role in asphyxia-related fatalities. A PEA blood level
following statement: “I was very surprised to find that after a few hours fol- higher than 2.7 £gg/ml can play a diagnostic role in the determination of
lowing death, the right half of the body became very rigid, while the left asphyxia during the medicolegal investigation. An endogenous substance,
half remained almost normally mobilisable.” Bierfreund thought that the PEA allows forensic scientists to develop a state-of-the-art biomarker using
“accelerating” effect of the central nervous system on the appearance of the rate-limiting step of MAOB to specify the cause of death in asphyxia.

Identification of asphyxia depends on various non-specific parameters support of the activities of the NICHD Brain and Tissue Bank for
in forensic medicine, such as signs of petechial hemorrhages, cyanosis, Developmental Disorders.
engorgement of right heart chambers, lung congestion, and a variety of This presentation will impact the forensic community and/or
signs in mechanical asphyxia. The cause of death in asphyxia depends on humanity by showing the significant contribution of forensic pathologists
the history and the exclusion of other causes. It is imperative to develop a to medical research involving the use of postmortem human tissues.
quantitative and specific biomarker to interpret the scientific evidence and Medical developments have increased the use of human tissues,
to ensure a precise diagnosis of asphyxia during the medicolegal investi- especially for research purposes. The National Institute of Child Health
gation. PEA, a specific substrate of MAOB, is a biogenic amine and acts and Human Development (NICHD), in 1991, established a Brain and
as a sympathomimetic amine through its release of dopamine. The rate- Tissue Bank at the University of Maryland with a collaborating retrieval
limiting step of the MAOB activity of monoamine deamination is a highly site at the University of Miami. Establishment of the Bank was in response
oxygen-dependent phenomenon. The hypothesis is that reduction of the to requests by family support groups for increased research on develop-
activity of MAOB during the hypoxic status could cause an accumulation mental disorders affecting children and young adults.
of PEA in human body fluids. The Bank obtains donors through efforts by support groups and
A retrospective study consisted of forty-one cases of mechanical forensic pathologists. Through a coordinated outreach effort to support
asphyxia and thirty-seven cases unrelated to asphyxia that were collected groups the Bank has registered over 2400 potential donors. The efforts
from the Institute of Forensic Medicine, Ministry of Justice, during have resulted in donation of autopsy tissue from nearly 1000 donors with
medicolegal investigation in Taiwan. There were sixteen strangulation over 100 different developmental disorders.
fatalities where the causes of death were by manual strangulation (hand or The legal and ethical issues regarding the use of human tissues
ligature) or hanging. In twenty-five cases of suffocation with mostly donated for medical research have received great public attention. To
choking on food, fixing a pad or gag over the face, and drowning were protect the deceased’s body from being used for postmortem research that
concluded to be the causes of death. The control group of fatalities is incompatible with the deceased or their families’ wishes and values,
unrelated to asphyxia included sudden death by cardiac failure, gunshot informed consent is obtained for all tissue donations. The Bank provides
injury, violence, and traffic and falling accidents. In vitro study in human the means for tissue donors to leave a legacy that will benefit future
platelets and in vivo animal models in rats were used to monitor the PEA generations. A partial list of disorders includes adrenoleukodystrophy,
alternation during the hypoxic status. Gas chromatography/mass autism, chromosomal disorders, metabolic disorders, Prader-Willi
spectrometry was performed to determine the PEA concentrations of each syndrome, sudden infant death syndrome, and tuberous sclerosis. Tissue
forensic fatality’s body fluids and of each animal specimen. from an additional 2000 donors has been obtained from local hospitals and
The PEA blood concentrations of strangulation, suffocation and the Office of the Chief Medical Examiner in Maryland. Tissue is stored
control cases were 34.2 ± 7.7 μg/ml (mean ± SEM, n=16), 33.0 ± 6.7 μg/ml formalin fixed and frozen at –80oC. The Bank has collected over 55,000
(n=25) and 0.16 ± 0.03 μg/ml (n=37), respectively. The PEA blood levels tissue samples.
of asphyxia-related fatalities were significantly higher than those of control The availability of normal control tissue is critical to studying
cases (p<0.005). There was no difference in PEA blood levels between suf- developmental disorders. The ONLY source of control tissue is from
focation and strangulation cases. The PEA urine concentrations of stran- accident victims who come under the jurisdiction of medical examiners.
gulation, suffocation and control cases were 1.5 ± 1.1 μg/ml (n=8), 0.3 ± Support by the Office of the Chief Medical Examiner of Maryland has
0.2 μg/ml (n=9) and 0.2 ± 0.1 μg/ml (n=12), respectively. The PEA gastric enabled donation of tissue from normal individuals as well as individuals
content concentrations in strangulation, suffocation and control cases with autism, chromosomal disorders, PraderWilli syndrome, etc. In fact,
ranged from 0.03 to 124.1μg/ml with no statistical difference between disorders that are not inherently life threatening, such as autism, rarely
asphyxia and control group. The postmortem interval for the asphyxia and come to autopsy unless death is accidental. The participation of medical
control groups was 4.3 ± 0.8 days and 5.0 ± 1.0 days, respectively.The examiners throughout the United States has enhanced the collection of
PEA profile was not affected by postmortem alteration up to 13 days. tissues from normal donors (especially under 17 years of age) and donors
Decreasing oxidative activity of MAOB and accumulation of PEA are with rare disorders.
observed during a hypoxic status in human platelets. An animal model to The Bank serves an additional role: making the tissue available to
induce a hypoxic status in rats resulted in elevation of PEA blood levels up qualified researchers. To date the Bank has distributed 12,000 tissue
to two to four times the control value. samples to 360 researchers in 11 countries. These researchers have
In conclusion, elevation of PEA concentration in blood may play a published 150 full-length publications and an equal number of abstracts
crucial role in asphyxia-related fatalities. The PEA blood level higher than based on studies utilizing tissue from the Bank.
2.7 μg/ml can play a diagnostic role in determining asphyxia during the This report focuses on the role of forensic pathologists in medical
medicolegal investigation. An endogenous substance, PEA allows forensic research by support of activities of the Brain and Tissue Bank for develop-
scientists to develop a state-of-the-art biomarker using the rate-limiting step mental disorders. The mechanisms of how to obtain informed consent from
of MAOB to specify the cause of death in asphyxia. the families of the newly dead is also addressed.
β—Phenylethylamine, Asphyxia, Strangulation Forensic Pathologists, Tissue Donation, Medical Research
G71 Forensic Pathologists and the

NICHD Brain and Tissue Bank
G72 Causes of Death Among People in the Prison
for Developmental Disorders
of Loos (Northern France), 1997-2003
Ling Li, MD*, David R. Fowler, MD, and Ana Rubio, MD, Office of the
Gilles Tournel, MD*, Anne A. Bécart-Robert, DDS, PhD, Valéry C.
Chief Medical Examiner, State of Maryland, 111 Penn Street, Baltiomre,
Hédouin, MD, PhD, and Didier Gosset, MD, PhD, Institut de Médecine
MD 21201; and Ronald Zielke, PhD, University of Mayland, Department
Légale, 1, Place de Verdun, Lille, 59 000, France
of Pediatrics, Brain, and Tissue Bank for Developmental Disorders, 655
West Baltimore Street, Baltimore, MD 21201 People in prison are more likely to die prematurely, especially of
violent causes, than people who are not in custody. Some of these deaths
After attending this presentation, attendees will be able to recognize
could be avoided. The goal of this presentation is to study the causes of
the significant contribution of forensic pathologists to medical research by
death (violent and natural) among people in the prison of Loos.

This presentation will impact the forensic community and/or can be yellow and thin, or green or brown thick mucus. It is lined with
humanity by explaining what problems are present in French jails. columnar or cuboidal epithelium in most cases, but mixed cell epithelium
Methods: The authors examined the causes of death in both prisons or pseudostratified squamous epithelium has been found. Ciliated
of Loos for detainees in custody and sentenced detainees, from 1997 to columnar cells and goblet cells are also present in a majority of the cases.
2003. The collected data included age, sex, work, cause of the death, Most Rathke’s cleft cysts are asymptomatic, but they can produce a mass
location of the death, and history of addiction. The causes of death were effect causing headaches, visual changes, and pituitary dysfunction.
categorized as violent (accidental intoxication, suicide, or homicide) or Pituitary histology in this case appeared normal. Rathke’s cleft cysts are
natural (cancer, cardiovascular disease). usually located within the sella turcica. Rarely, they are found in a
Results: Forty-nine persons died in prison during the studied period: suprasellar location, as in this case.
47 male and 2 females ranging in age from 17 to 54 years. The average age Death was due to the complications of chronic cocaine abuse, with
was 30 years. There were 34 suicides, 4 natural deaths, and 11 deaths hypertensive and atherosclerotic cardiovascular disease. The family could
involving the presence of drugs or alcohol. In France, all deaths in prison be assured that the “brain tumor” had been located at autopsy, but had
(natural, homicide, accident, suicide, toxic) are autopsied and findings are nothing to do with her death.
described. Rathke’s Cleft Cyst, Rathke’s Pouch, Forensic Pathology
In this study the cases of suicides are described more precisely.
Among the people who committed suicide, 30% were jailed after
conviction for a sexual assault (34 of the 49 cases). Among them, 17 had
already been sentenced and the others were waiting for a judgment. The
G74 Microscopic Soft Tissue Decomposition
position of the body and the presence of another detainee in the cell was and Time Since Death
studied. The method of suicide was mainly hanging with a large tie
(29/34). Murray K. Marks, PhD*, and Mariateresa A. Tersigni, MA, University of
Discussion: The high number of deaths in custody resulting from self- Tennessee, Department of Anthropology, 250 South Stadium Hall,
harmful behavior has important implications for the criminal justice system Knoxville, TN 37996; and Darinka X. Mileusnic, MD, PhD, University of
and the penitentiary administration. The authorities have a high responsi- Tennessee Medical Center, Knox County Medical Examiner’s Office, 1924
bility to prevent deaths in jail. It is important to develop a preventive health Alcoa Highway, Knoxville, TN 37920
systems inside the jails to prevent suicides. Psychiatric treatments and
therapy must be introduced to reduce the risks. An awareness of these
histological soft tissue demise associated with long-term understanding of
causes might be of assistance in developing mechanisms to further reduce
rigor mortis.
fatalities in this setting.
Prison, Death, Suicide humanity by qualifying the changes that occur at a histological level as a
body decomposes; specifically, the temperatures at which each of the layers
of tissue lyse during this process.
G73 Rathke’s Cleft Cyst: Alleged “Brain Introduction: The stages of human soft tissue decomposition are
Tumor” in a Middle-Aged Cocaine Abuser universally accepted as autolysis and putrefaction with subsequent
macroscopic disfigurement. While the visual signals have been long
recognized and appreciated by pathology, the schedule and precise histo-
Bridget B. Eutenier, BS*, and Karen B. Looman, Pathology Resident
logical deterioration of epidermal, dermal, fat, and muscle tissue have
Program, Eastern Virginia Medical School, 700 West Olney Road,
never been quantified let alone qualified. And, even though biochemistry
Norfolk, VA 23510-1046; Wendy M. Gunther, MD, Office of the Chief
characterizes these events, this study focuses only on structure. This study
Medical Examiner, Tidewater District, 830 Southampton Avenue, Suite
provides a longitudinal histological validation of the process in order to
100, Norfolk, VA 23510-1046
more accurately design future research regarding soft tissue decomposition.
This presentation, will show the histology of a congenital anomaly Materials and Methods: At the outdoor decomposition research
that may present in a forensic case as a history of “brain tumor.” facility at The University of Tennessee, eight identical landmarks on six
A 47-year-old female complained of chest pains at home, but failed to cadavers were biopsied for two weeks following death, and examined with
seek medical treatment. She collapsed at home later that day in the light and electron microscopy for temporal patterning. These sites were the
presence of a family member. She had a history of chronic cocaine use, and ventral chest (pectoral region), shoulder (deltoid region), ventral upper arm
relatives were concerned that she might have used the drug on the day of (biceps), ventral forearm (flexors), lateral hip (gluteal), ventral upper leg
her death. Her only other condition was an unclear history, according to the (rectus femoris), dorsal lower leg (gastrocnemius/soleus), and sole of foot
family, of a “brain tumor.” The tumor had reportedly been present for some (plantar aponeurosis/flexor digitorum brevis). Each site was biopsied once
time, but she had received no recent medical care or treatment for it. each day for the 14 day period. Biopsy sites were paraffin sealed, and
At autopsy, gross inspection of the uncal region revealed an enlarged adjacent puncture sites selected during the decomposition process.
tan-brown mass beneath the pituitary stalk. The stalk itself was fluctuant Biopsies were prepared by routine formalin-fixed histological methods at
to pressure, but did not appear to be enlarged. Sectioning of the brain The University of Tennessee Medical Center and examined using a Leica
revealed a focal 0.4 cm diameter mass, with an apparent necrotic or caseous ZX900 light microscope and an Olympus XNC environmental scanning
center, abutting the optic chiasm on one side, and the mammillary bodies electron microscope.
on the other. Microscopic evaluation revealed the mass to be cystic, with a Results: The cell death associated with decomposition more closely
true wall of squamous epithelium, surrounding a center of amorphous fluid resembles the characteristics of clinically documented cell necrosis as
and squames. This is believed to be a Rathke’s cleft cyst. opposed to the apoptotic events of programmed cell death. That is, the cells
Rathke’s cleft cysts are found in all age groups, but mean occurrence of decomposing tissue go through an expansion and explosion process,
is 40-50 years. They are typically asymptomatic and found incidentally at which causes a breakdown of the cell membrane resulting in the expulsion
autopsy. During embryologic development, Rathke’s pouch is formed of their cytoplasmic contents into the extracellular matrix rather than
from an evagination of oral ectoderm that grows toward the midbrain. simply shriveling into a condensed mass and breaking apart as in apoptosis.
When the anterior lobe of the pituitary gland is formed from this ectoderm, Each of the layers (epidermis, dermis, lipid and muscle fibre) experience
the pouch is reduced to a residual cleft. Cysts are formed when the cleft the same type of cell death, although they do not occur in the same temporal
persists, becomes enlarged, and its secretions accumulate. The cyst fluid period. The loss of muscle fibre structure was observed at 270 degree days.

The epidermis structure was lost at 150 degree days. The dermis cell This case will serve to alert pathologists and investigators to the
structure was maintained until 230 degree days. Fat cell structure was last possible use of a zip gun in likely cases of suicidal gunshot wounds where
to fail at 450 degree days. a weapon is not apparent upon initial inspection of the scene, and an
As part of a recent endeavor to understand the cellular aspect of soft atypical gunshot wound of entrance is present at autopsy.
tissue decomposition, this study provides validation of the cellular death Zip Guns, Atypical Wounds, Scene Investigation
process that is the hallmark of initial decomposition. Thus, this research
provides a baseline for future experimental design.
Time Since Death, Soft Tissue Decomposition, Histology
G76 Suicide or Homicide - The Importance
of Forensic Evidence: A Case Study
G75 An Atypical Gunshot Wound With
Absence of a Weapon? The Value Giancarlo Di Vella, MD, PhD*, Alessandra Arpaio, MD, Claudia
of a Thorough Scene Investigation Liuzzi, MD, and Francesco Vinci, MD, University of Bari, Di.M.I.M.P. -
Sezione di Medicina Legale - Policlinico, Bari, 70125, Italy
Clare H. Cunliffe, MD*, Office of the Medical Examiner, County of Cook, Participants will develop a better understanding of the role and the
2121 West Harrison Street, Chicago, IL 60612 importance of correlating autopsy findings and evidence from scene exam-
ination defining the manner of death.
The goal of this presentation is to increase awareness of zip guns when
investigating scenes in which a weapon is not apparent, and to aid in the
humanity by demonstrating the difficulties in defining a suicide case that
recognition of the atypical wounds they produce.
may be considered unusual with respect to evidence recovered from the
death scene, the background of the deceased, and the connection of the
humanity by alerting the forensic community to the possible use of a zip
suicide to an earlier murder.
gun in likely cases of suicidal gunshot wounds where a weapon is not
Traditionally, the most common method of committing suicide by
initially apparent at scene investigation, and an atypical gunshot wound of
women is via drug overdose. Some statistical reports indicate that since the
entrance is present at autopsy.
mid 1980s there has been a significant increase in the number of female sui-
This presentation will describe the case of a 43-year-old male auto
cides involving the use of a firearm. The most common wound site
mechanic with depression found dead at work. The body was found on the
reported in such suicides is the head, and the handgun is the most common
floor of a washroom stall at the auto body shop where he worked. The
weapon utilized by women to commit suicide. Investigation of suicides in
deceased had sustained a contact gunshot wound of the forehead, and no
most instances tends to be straightforward, however there are some suicides
weapon was found at the scene during initial investigation. A claw hammer
which are very problematic. The determination of the cause and manner of
was present in a pool of blood beneath the victim’s right arm, and blood
death requires proper evaluation of the autopsy findings, in addition to
spatter was present on the hand and arm.
various findings relating to the scene examination. In suicides, the type of
The deceased’s social history strongly suggested that the wound was
weapon used and the existence of a motive or intent are crucial in the recon-
self-inflicted. Two possibilities were considered; firstly, that the gun had
struction of events leading to death. The following report describes a
been removed from the scene prior to the investigator’s arrival, and
suicide case that may be considered unusual with respect to evidence
secondly, that the case actually represented a homicide.
recovered from the death scene, the background of the deceased, and the
Autopsy revealed an atypical lacerated contact gunshot wound of the
connection of the suicide to an earlier murder. In the early morning of
forehead, with a retained medium caliber lead bullet within the posterior
January 17, 2004, the local police in Bari, Italy were alerted to the death of
scalp. The case was pended for police investigation.
a 24-year-old female, by a young man who was fully clothed, with the
Subsequently, a simple zip-gun fashioned from a piece of pipe, a
exception of his pants. The young man informed police that he had wit-
connector and an air-hose nozzle, along with a pin, was found on the floor
nessed a suicide of a woman whose body was located under a local bridge,
at the scene by a co-worker who was cleaning the stall, and the police were
a short distance from the police station. Inspection of the death scene by
notified. On closer examination, a .38 caliber cartridge case was found
police revealed the young woman to be lying on the ground next to the open
embedded in the pipe. The conclusion reached was that the deceased had
door of her automobile. The deceased, who was wearing a very broad
committed suicide using a zip gun constructed from available auto shop
rimmed hat, exhibited a single gunshot wound to the front of the head. A
parts, and fired the weapon using the hammer found adjacent to him. Due
small handgun was recovered next to the deceased by the police. While
to the nature of the scene and the innocuous appearance of the weapon, the
being interviewed at the scene, the informant told police that young woman
mechanism of the injury and the manner of death were not immediately
was his secret mistress, and that he had received numerous calls the pre-
obvious.
vious evening from the woman. During the telephone conversations the
In the United States, zip guns were popular in poor, inner city areas
male informant noted that the young woman was very distraught, and
during the 1950s, since they were easy to manufacture from cheap, com-
insisted that they meet beneath the bridge. Upon arriving beneath the
monly available materials. Frequently, they were constructed from a piece
bridge, the informant approached the woman as she was ranting about their
of wood, a metal barrel such as a car antenna, and a firing pin made from a
past, at which point she placed a handgun against the top of her head and
nail. The simplest zip guns consisted of a piece of metal pipe with a
pulled the trigger. The informant at this point ran to the woman, then held
cartridge inserted at one end. To fire the weapon, the protruding cartridge
her in a desperate attempt to revive her.
base was struck with a hammer. Because the diameter of the bullet was
Examination of the car of the deceased by police led to the recovery
frequently smaller than that of the unrifled barrel, the bullet would be
of a short note which had been written by the woman, and which stated that
unstable and tumble upon leaving the barrel. The resulting low velocity
she wished she could have prevented the murder of her mother. After a
and instability of the bullet made zip guns only suitable for short-range use.
short examination of the scene, the police became very suspicious of the
Today, conventional firearms are less costly and simple to acquire, making
informant and arrested him in connection with the death of the woman.
zip guns almost obsolete.
Further investigation of the suspect revealed that he had recently received
Because zip guns are rarely seen, investigators and pathologists may
several very expensive gifts from the father of the deceased, who was
be unfamiliar with their construction and appearance, and the type of
unaware that the suspect was married. Unknown to the Italian authorities
wounds they produce.
at the time of the suspect’s arrest, the German Police had an arrest warrant

out for the young woman and her boyfriend. Two years prior, the deceased This presentation will impact the forensic community and/or
and her boyfriend murdered her mother in Germany. The mother had been humanity by providing a relatively quick and easy method for evaluation of
bludgeoned, then run over with a motor vehicle to make it appear as if the firearm injuries in skeletal remains.
death was an automobile accident. The goal of this presentation is to introduce forensic scientists to a
The crime scene investigation reported that the body of the deceased technique that can aid in the determination of range of fire in skeletal
was located next to the open door of her BMW. She was in a seated remains found with firearm injuries.
position on the pavement, with legs flexed, and her head and shoulders Introduction: The scenario is not an uncommon one: a person goes
positioned back in the space between the opened door and the driver’s seat. off into a secluded area with the purpose of commiting suicide by shooting
Her clothes exhibited no evidence of tears or rearrangement, with the themself, and is later found in a decomposed or skeletal state. The presence
exception of her hat which exhibited a circular defect in the front with of a weapon would certainly indicate a suicide; however, circumstances are
traces of blood. Located next to the right hand of the deceased was a Baby not always as they appear. Remains can also be scattered and separated
– Browning .25 caliber handgun, model 1932. An empty shell casing of from the weapon, and weapons can be separated from the remains due to
the same caliber was recovered from beneath the body of the deceased. The theft. When remains are decomposed or skeletal, the usual clues to range
postmotrem condition of the deceased as reported by the medical examiner of fire, soot, and stippling are often lost or obscured. The authors present a
at the scene noted a core body temperature of approximately 28° Celsius, technique that can aid in the determination of range of fire in the absence
minimal lividity changes and relatively little evidence of rigor. Inspection of visible soot.
of the car revealed many items of value including jewellery, cash, and an The sodium rhodizonate staining technique is widely employed in
airline ticket for a flight to Paris that was scheduled the same day as the crime laboratories to detect lead residue on clothing. The staining pattern
death. The autopsy confirmed that the muzzle of the handgun was against obtained can then be compared to the implicated weapon and ammunition
the brim of the hat worn by the deceased when it was discharged. Soot, utilized to determine the possible range of fire. This technique employs
primer residue, and spent gunpowder particles were observed in and around spraying the garment with sodium rhodizonate, then sequentially over-
the circular defect site on the hat. Analysis for primer residues were found spraying with buffer and then hydrochloric acid. A pink color with buffer
to be positive on each hand of the victim, in particular on the external and then blue-purple color with acid is indicative of the presence of lead.
metacarpal surface between the first and second digits. A metal jacketed This test has been employed on skin; however the authors demonstrate the
.25 caliber bullet was recovered from within the skull. Considering the technique on human and animal skulls.
cerebral lesions, it was evident that the bullet had passed through the frontal Materials and Methods: Amputated heads from six previously
bone and the right frontal lobe, before crossing the midbrain and ending up slaughtered pigs were purchased for this experiment. Three different
in the left cerebellar lobe. Toxicological analysis was negative; however, weapons and ammunition were utilized: a revolver with a non-jacketed
sperm was identified from the anus of the deceased. DNA analysis of the bullet, a 9mm semi-automatic pistol with a copper-jacketed bullet, and a
sperm found it not to match the DNA profile of the suspect. Ballistic exam- shotgun with 00 buckshot. Hard contact shots were fired with the weapon
ination of the recovered bullet and cartridge revealed them to have been placed between the eyes on the upper portion of the snout. Distant shots
fired by the .25 caliber Baby – Browning recovered next to the deceased. were fired from 3 feet with the handguns and approximately 28 feet with
One point of debate in the investigation was the possibility of positioning the shotgun. The skin from the head was then removed and tested for traces
of the handgun by the deceased to commit suicide. The Baby – Browning, of lead. The skulls were then boiled in water to aid in the removal of the
model 1932, possesses a three-stage safety system to avoid accidental dis- remainder of the soft tissue. Once the soft tissues were removed, the skulls
charge: it cannot be discharged with the magazine removed, even if a car- were re-assembled, if necessary, and tested for lead residue. All skulls were
tridge has been loaded. A manual safety is located on the left side of the examined for visible lead prior to testing with sodium rhodizonate. Color
weapon, along with a secondary safety which is located on the grip which changes were documented and photographed. A test was determined to be
blocks the trigger except when the pistol is held firmly in the hand, ready positive for lead if the color changed from pink with the buffer to purple-
for shooting. Latent fingerprints on the handgun were identified as violet with the acid.
belonging the deceased. The autopsy and ballistic findings strongly sup- Results: The distant gunshot wound from the revolver with the
ported the notion that the deceased had fired the weapon. A reconstruction unjacketed bullet showed faint positive staining of the bone around the
of the incident revealed that the woman held the handgun with both hands, outer surface of the defect, with no staining on the inside of the skull.
with her finger wrapped around the back of the butt, and that she utilized Evaluation of the skin revealed a ¼ inch x ¼ inch area of positive staining
her thumb to depress the trigger. The small amount of gunshot residue with a few positive spots 6 inches from the wound. The distant gunshot
detected on the clothing of the suspect boyfriend was attributed to contam- wound from the semi-automatic weapon revealed no visible residue prior
ination while holding the deceased after the discharge of the weapon. The to testing. After testing, a small rim of lead partially encircled the skin
combined findings of the forensic investigation convinced prosecutors and wound and there were a few positive spots 4, 5, and 6 inches from the
police to reconsider the manner of death as a suicide. The complete details wound edges. There were no traces of lead on the skull. The shotgun
of this investigation will be presented. inflicted multiple buck shot wounds which tested positive for traces of lead
Criminalistics, Handguns, Suicide on the skin, but not the skull. All contact range wounds had visible residue
on the skin prior to testing, and subsequently had brightly positive staining
after testing with sodium rhodizonate. The outer surfaces of the skulls also
showed positive staining, however the inner surfaces of the skulls also
G77 Determination of Range of stained positively. Of note, the brains of the pigs were present at the time
Fire in Skeletal Remains of the shooting. This finding was reproduced on two human skulls, one of
known contact range and the other of presumed contact range.
Kathryn Haden, MD*, Office of the Chief Medical Examiner, Northern Conclusion: Sodium rhodizonate may help determine range of fire in
Virginia District, 9797 Braddock Road, Fairfax, VA 22032; Jill Urban, MD, skeletal remains. Lead residue was detected inside the skulls with inflicted
and Karen Hendley, The Southwestern Institute for Forensic Sciences, 5230 contact range firearm injuries, whereas it was only on the surface of the
Medical Center Drive, Dallas, TX 75235 entrance wound, and in small amounts, of the distant wounds. More studies
are currently underway to further explore these findings.
After attending this presentation, attendees will better understand a
technique that can aid in the determination of range of fire in skeletal Sodium Rhodizonate, Skeletal Remains, Range of Fire
remains found with firearm injuries.

G78 A Modern “Martyr’s Crown”: A Fatal Case This case study involves the death of a 27-year-old male who had
been involved in a physical altercation with his wife on the morning of his
of Multiple Self-Inflicted Nail Gun Shots death. The wife exited the residence and, on hearing a gunshot, re-entered
to find the decedent with a fatal intra-oral gunshot wound. Recovered from
Francesco Maria Morreale, MD*, Christoforo Pomara, MD, and Stefano the scene were a box of .17 HMR rounds.
D’Errico, MD, Institute of Legal Medicine, University of Foggia, At autopsy, the subject had a ¾ inch stellate contact midline intra-oral
Ospedali Riuniti, via L. Pinto 1, Foggia, I-71100, Italy; and Rocco gunshot wound with a surrounding 1½ inch area of soot on the roof of the
Maglietta, MD, Hospital San Carlo, Potenza, I-85100, Italy mouth. The shot fractured the floor of the skull and continued to the left
After attending this presentation, attendees will understand an atypical parietal brain where the projectile was recovered at the brain surface.
case of multiple nail gun shots in a 62-year-old man. The peculiarity of the Typical subarachnoid hemorrhages and cortical contusions were associated
case is represented from the surprising sequence of radiological images. with the wound. Externally, the decedent had an impression on his chest
This presentation will impact the forensic community by underlying corresponding to a spent .17 HMR casing.
the role of a correct and complete radiological store in cases of foreign The .17 HMR TNT cartridge is marketed by CCI as a small varmint
bodies injuries. round with a hollow point tip for “explosive performance.” A follow-up,
The case of a 62-year-old man, who was taken to the emergency room the .17 HMR GamePoint round was introduced in 2004, marketed as a
with multiple head wounds, is presented. He complained only of headache, “dimple-tip bullet [which] mushrooms like a big game bullet instead of
and spontaneously declared that he had shot himself in the head with fragmenting like a varmint bullet. This greatly reduces damage to edible
multiple nails from a nail gun, which he handed over to the physicians. He meat!” A comparison of the .17 HMRs with the various CCI .22 car-
was conscious, oriented to place and time, and had no focal neurological or tridges (http://www.cci-ammunition.com/default.asp) shows velocities for
cognitive defects. Only the finding of a foreign metallic body on the the .17 (2375 & 2525 ft/sec) exceeding the .22 magnum (1875 ft/sec) and
surface of the scalp in the right temporal region alarmed the physicians, energy (250 & 241 ft-lbs) approaching the .22 magnum (312 ft-lbs) – see
who immediately hospitalized the patient. Radiographs of the head demon- below.
strated seven injuries with foreign metallic bodies inside. This reproduced Round Weight (grains) Velocity (ft/sec) Energy (ft-lbs)
the typical appearance of the “Martyr’s Crown.” A CT scan confirmed the .22 short 29 1080 75
presence of multiple nails penetrating the skull in the right (5) and left (2) .22 long rifle 40 1235 135
temporal regions. A subarachnoid hemorrhage was also detected; the ven- .22 magnum 40 1875 312
tricular system was unremarkable. Four days after admission, a surgical .17 HMR GamePoint 20 2375 250
approach was attempted to pull out nails, six of which were pulled out by .17 HMR TNT 17 2525 241
cutting the scalp and temporal muscles; the last one, not on the surface, A potential concern is an attempt (presumably by a novice) to fire such
required a craniotomy. The patient awoke one hour after surgery, but his a .17 caliber from a .22 weapon. The .22 magnum may be able to chamber
clinical condition rapidly worsened. He became comatose, and died after the .17 HMR, however, the 0.05 inch step-down from the casing to the
10 days of hospitalization. bullet would provide for release of much of the propulsive gases. In theory,
Few cases of unsuccessful attempted nail gun suicides are reported in this might create problems for the shooter.
literature, fewer cases of successful suicides are described most frequently In summary, the .17 HMR round has significant velocity and energy.
the head and the left side of chest represent the preferred targets of the body. While causing far more damage than a typical .22 caliber round, the tissue
Nail guns have been used since the 1950s, designed as a powerful destruction is markedly less than that seen with larger calibers.
industrial tool to drive nails into various hard surfaces with ease. Recent Conclusion: Familiarity of the various forensic disciplines with new
years have seen an increased diffusion in the domestic environment, too. rounds should allow recognition of same when encountered in a case–a
The ease of use and speed of these tools enhance productivity at the cost of potential significant benefit in cases where a weapon is recovered at the
increased potential for traumatic injury. The nail gun fires a single nail or scene.
bolt, as projectiles, into wooden or metal surfaces. It could be compared to
conventional firearms, being capable of firing projectiles of up to 10 cm Gunshot Wounds, Suicide, Firearms
into fully stressed concrete at a velocity up to 424 m/sec.
International literature records nail gun related injuries, sometimes G80 A Shot In the Dark? Investigating
lethal, with two categories of forensic interest: industrial accidents and
suicide attempts
Accidental Gunshot Wounds
In conclusion, the case report represents an atypical case of nail gun
suicide; highlights the rarity of the event in the literature, and points out the J.C. Upshaw Downs, MD*, Donelle L. Pyle, MS, Ron Van Fleet, BS,
absence of any clinical sign until surgery. and Shannon Walden, Coastal Regional Laboratory Georgia Bureau of
Nail Gun, Successful Suicide, Cerebral Ischaemia
The goal of this presentation is to provide a general review, using a
case study, of proper investigation of lethal gunshot wounds and, in
G79 .17 HMR – It’s Not Your Father’s .22 particular, recognition of the importance of scene investigation and
firearms function testing in gunshot wound deaths. In addition, attendees
J.C. Upshaw Downs, MD*, Coastal Regional Laboratory Georgia will learn that a particular weapon (Tokarev CZ52) has a tendency, when
Bureau of Investigation, 925A Mohawk Street, Savannah, GA 31419; and dropped, to accidentally discharge due to a defective hammer drop safety.
Ron Van Fleet, BS, Donelle L. Pyle, MS, and Shannon Walden, Georgia This presentation will impact the forensic community and/or
Bureau of Investigation, 925A Mohawk Street, Savannah, GA 31419 humanity by reviewing the overall investigation of a gunshot wound
The goal of this presentation is to present a case study of a suicide fatality with special attention to scene investigation, firearms examination,
employing a .17 HMR to familiarize the forensics community with this and reconstruction to allow for better recognition of manner of death in
round and potential resulting injuries resultant there from. fatal cases. Proper death classification’s societal benefits are obvious,
Familiarity of the various forensic disciplines with new rounds should allowing insurance payments to be made or withheld where appropriate,
impact the forensic community and/or humanity by allowing recognition of and criminal prosectutions to proceed if indicated.
same when encountered in a case, a potential significant benefit in cases Most lethal gunshot wounds are suicides or homicides. True
where o weapon is recovered at the scene. accidental gunshot fatalities are rare, particularly when the misnomer of

“hunting accidents” with firearms is excluded. With such a paucity of have a ten print fingerprint file but may be identified in the latent finger-
actual deaths due to accidental gunshot wounds, an almost imperceptible print files as suspects or perpetrators of crimes. The identification may also
bias against recognition of such cases may develop. potentially uncover perpetrators of identity theft.
Using the case study of the death of a 39-year-old male National Methods and Materials: As a preliminary study, 50 consecutive
Guardsman, the steps of a thorough case investigation, including scene males aged 15-45 are being fingerprinted as part of the medicolegal autopsy
investigation and reconstruction, are reviewed. Through processing of the at the Office of the Chief Medical Examiner (OCME) Central District,
scene in the case study, a gouge was recognized on the floor, near the body. Richmond, Virginia. The fingerprinting method utilizes fingerprint strips
This represented the impact point of the hammer mechanism on the floor, and ink pads. The fingers are cleaned and dried prior to printing. Four
indicating that an accidental discharge was a real possibility. fingerprint strips are labeled with the individual’s personal identification.
The weapon employed should be examined, if possible, in all firearms Two sets of fingerprints are taken. The fingerprints are then entered into
deaths, particularly for function testing. In the presented fatality, the the AFIS database by the fingerprint examiners of the Division of Forensic
weapon employed was a Czech 7.62 mm caliber Tokarev (CZ52) pistol. Sciences (DFS) for a search of the ten print and latent files. The results of
The manufacturer of the pistol, Century International Arms, has issued a the search are reported back to the OCME, and if a match does occur these
recall warning due to a defective hammer drop safety. Inspected weapons, results will be issued to the submitting law enforcement agency.
recognized by a “Z” mark on the left side of the trigger guard, indicate the Fingerprints that are not a match will be archived.
weapon has been “inspected to ensure proper operation in order to avoid The number of decedents that match with the ten print and latent print
grave bodily injury and/or property damage.” files are calculated and assessed for statistical significance with regards to
On function testing, the decedent’s weapon was found to be functional the cost/benefit based on the number of cases closed or solved based on the
with a trigger pull of 7 +/- ¼ pounds in single action mode. The holster was results of this information. The positive predictive value will be calculated
soiled with scattered gunpowder particles. Comparison of the flooring to further define the value of this study.
from the scene and the gun showed the slide and hammer had indeed Fingerprints, Perpetrators, AFIS
caused the gouge. Video recorded re-enactment showed the gun would
regularly discharge when dropped in a similar manner.
Using the location of the decedent’s wounds in combination with the
gouge in the floor at the scene, a reconstruction of the decedent’s death
proved consistent with the history of the victim having accidentally G82 Dead Hits: Matching Decedents’
dropped the gun, resulting in his death. DNA to Unsolved Crime Scenes
Forensic pathology is not limited to the physical examination of a
body. Utilizing available resources, including firearms examination and Todd M. Luckasevic, DO*, Marcella F. Fierro, MD, and Timothy A.
scene investigation, the medical examiner’s analysis of a fatality is Powell, MPH, Office of the Chief Medical Examiner, 400 East Jackson
enhanced, hopefully ensuring proper classification of deaths. Street, Richmond, VA 23219; and George C. Li, MS, Linda Johnston, BS,
Gunshot Wounds, Accident, Safety and Deanne F. Dabbs, MFS, Division of Forensic Science, 700 North 5th
G81 Utilization of Automated Fingerprint The goal of this presentation is to determine the value of comparing
Identification System (AFIS) to Aid DNA samples from decedents to DNA evidence left at unsolved crime
in the Identification of Unknown scenes.
Perpetrators to Close Unsolved Cases humanity by providing closure to cold cases, ultimately impacting the
family and friends of those who were victims of unsolved crimes. The
Kelly L. Hickey, MD*, Marcella F. Fierro, MD, and Timothy A. Powell, forensic and law enforcement community would benefit from determining
MPH, Office of the Chief Medical Examiner, 400 East Jackson Street, DNA matches or hits from unsolved crime scenes and knowing that the
Richmond, VA 23219; andRobin Young, Division of Forensic Science, perpetrators of these violent acts are now deceased.
700 North 5th Street, Richmond, VA 23219 Hypothesis: Submission of DNA samples from cases performed at
Office of the Chief Medical Examiner (OCME) Central District,
The goal of this presentation is to describe the processes and outcomes
Richmond, Virginia, that meet the demographic profile of persons at risk
involved with the implementation and utilization of a fingerprint
for societal maladjustment for comparison with biological evidence left at
comparison system between the central district medical examiner’s office
scenes of unsolved crimes will result in the solving and closing of
and the local law enforcement offices.
outstanding cases.
Introduction: A large percentage of medical examiner cases
humanity by helping law enforcement to close out “cold” case files and find
represent a high-risk group for societal maladjustment (crime) and for
persons involved in identity theft. The law enforcement and forensic
encounters with the legal system as felons. The felon data bank archives
communities will benefit from matching latent and ten print files to the
the DNA profiles of felons. The Division of Forensic Science (DFS) in
deceased individuals, knowing that the case files can be closed and the
Richmond, Virginia, also archives profiles of biologic evidence left at
offenders are permanently off the streets.
scenes of crimes by unknown perpetrators who are not in the data bank.
Hypothesis: Matching the fingerprints of deceased individuals from a
Some perpetrators of crimes who have left biologic evidence profiled by
specific profile with those in the Automated Fingerprint Identification
DFS may die without ever being caught, convicted and entered into the
System (AFIS) database could identify perpetrators who are deceased that
felon data bank or compared with DNA evidence profiles.
may have committed unsolved crimes or have been involved with identity
A pilot study to establish identities among the three groups would
theft.
assist law enforcement by: (1) solving and closing some outstanding cases
Introduction: The highest incidence group of perpetrators of violent
upon identification of a decedent as the perpetrator of a crime where the
crime is males aged 15-45. These individuals are also the highest group to
decedent was not in the data bank but had left biological evidence, and
undergo medicolegal autopsy. By submission of routine fingerprints of
(2) determining whether, in the future, continued comparison of the desig-
deceased males aged 15-45 into AFIS, two questions may be answered
nated group of decedents would assist the law enforcement community by
(1) identification of perpetrators in ten print file should be identified as
saving time, money, and record keeping in a futile search for presently
deceased, so that case files can be closed involving these individuals, and
unidentified, but now deceased, perpetrators of crime.
(2) some of these individuals have not been previously arrested and do not

Materials and Methods: OCME Central pathologists collect and The postcoital swabs were directly exposed to toluidine blue and other
archive blood spots of all medicolegal cases. From these cases, a subset of destaining agents in order to determine if the dye had an adverse effect on
50 consecutive males aged 15 to 45 will be the focus of the pilot study. recovery of DNA. Although there was no effect on either PCR or RFLP
Prior to submitting samples to the data bank, a list of the individuals will be recovery, the sample size consisted of only 5 women and the collection
submitted to the data bank. Data bank staff will check the samples against time was only 6 hours post-coitus.
the listed individuals that already exist in the data bank, and exclude from Rhythm of the Blues: As a general nuclear stain, toluidine blue, when
the study those who match by name. The remaining samples will then be used in vivo, depends on the presence or absence of a nucleated cell popu-
submitted on a specially designed data bank Request for Examination lation at the exposed surface. Because many current protocols stem from
(RFE) form, and will be assigned a unique sample number. The data bank the earlier studies, salient recommendations from those methodologies
profiles those samples utilizing standard DNA-STR profiling kits and should be considered:
enters the results in a specially created database (index), where they remain • Richart (1963), described proper decolorization as the most
for an indefinite period of time for comparison purposes. important part of the method. In very mild dysplasia with very
DNA profiles from these samples are compared against unidentified small lesions, application of the acetic acid destaining agent in
profiles obtained from crime scenes. If a match occurs, a certificate of too liberal or too vigorous a manner might rapidly remove all the
analysis is issued to the submitting law enforcement agency, with a copy to stain, even from areas of dysplasia.
the OCME Central. No certificate of analysis is issued for a search not • Lauber and Souma (1982) used lubricating jelly to decolorize.
resulting in a match. Matches or hits are presented to the police to correlate Like Richart, they stressed that it was essential to ensure that the
with the investigative information. tested area was wiped repeatedly with cotton balls until
Results: The percentage of hits are calculated and assessed statisti- completely dry. They also described the use of finer stroking
cally for cost/benefit for law enforcement based on the number of cases with a dry cotton tip applicator to differentiate lacerations
actually closed/solved as the result of this information. Additionally, the from dye trapped in crevices.
predictive value positive will be calculated to further describe the efficacy • In addition to cervical mucous, columnar epithelium, and areas
of this study. of inflammation, the concomitant presence of 23 categories of
Conclusion: The major observation would be the establishment of benign diseases will cause a false positive dye uptake in living
identities or hits in cold cases. subjects (Collins, 1966).
DNA, Decedents, Cold Cases • Application interval: a great deal of variability exists in the
application of this nuclear stain for documentation of traumatic
intercourse in the living. Original studies were done on subjects
G83 To Dye or Not to Dye: A Tale of the Blues who were examined within 48 hours. The effects of wound
healing on dye application have not been studied. Programs that
Sharon R. Crowley, RN, MN *, 122 Emeline Avenue, Santa Cruz, CA employ toluidine blue during extended intervals after reported
95060; Brian L. Peterson, MD, Forensic Medical Group, 1860 sexual assault must consider the possibility of false positive dye
Pennsylvania Avenue, Fairfield, CA 94533 uptake in areas of granulation tissue.
• Lauber and Souma recommended application of the dye before
After attending this presentation, attendees will be able to evaluate the speculum insertion to avoid the possibility of findings due to
reliability of toluidine blue dye application as part of the postmortem iatrogenic trauma and to circumvent the known spermicidal
genital examination; be able to compare the results from photo-colposcopy effect of the dye in vitro. However, they also recommended
at various magnifications vs. photo-colposcopy plus toluidine blue dye procuring a hanging drop vaginal specimen, prior to application
application; and be able to better understand the nature and appearance of of the dye, in order to compare with a subsequent sample.
postmortem anogenital anatomy at various intervals. Recent protocols do not recommend this step.
This presentation will impact the forensic community and/or • Programs that use this nuclear stain vary significantly in their
humanity by helping to promote consistency and reliability among methodology, i.e., timing of dye application before or after
examiners; improving diagnostic acumen of examiners; and enhancing speculum insertion. The Office of Criminal Justice Planning
both antemortem and postmortem investigations and genital examinations. (OCJP) protocol in California recommends dye application at the
Living with the Blues: Richart (1963) reported the use of 1% conclusion of biological evidence collection.
toluidine blue in more than 200 women as an in vivo staining method to • Early studies were done before colposcopy with magnified
delineate areas of neoplastic epithelium on the cervix. The intensity of the photographs was incorporated into sexual assault examinations.
stain was closely related to the number of nuclei per unit area. Collins et Slaughter, Brown, Crowley, and Peck (1997) saw no injuries
al. (1966) studied 242 patients to determine the efficacy of the dye for out- with toluidine blue that were not already seen via colposcopy.
lining neoplastic areas on the vulva. Lauber and Souma (1982) utilized However, 15X magnification was routinely used for inspection
the dye as an adjunct in the evaluation of traumatic intercourse. Results and photographs. Visualization at lesser magnifications may not
were compared between a group of 22 rape victims and 22 controls that had allow the same level of scrutiny of the anogenital tissues. Photos
engaged in consensual coitus. Both groups were examined < 48 hours. taken prior to speculum insertion can establish the presence or
Further investigation of toluidine blue by McCauley et al. (1987) evaluated absence of pre-existing injury. Likewise, when and if iatrogenic
the influence of race, parity, age, and other factors in 24 rape victims and injury occurs, it can be documented as such.
48 controls, all examined within 48 hours. • Subtle findings are an examiner issue. Follow-up exams are
Dying with the Blues: In 1992, Bays and Lewman described 4 case needed to understand those findings that may mimic trauma and
studies of children, ages 3 months to 4 years, where toluidine blue was used to appreciate changes that occur with healing (Slaughter,
at autopsy to aid in the detection of genital and anal injuries due to child personal communication).
sexual abuse. In 3 of the cases, the dye uptake revealed previously unde- • Antemortem use of the victim as his/her own control: when
tected lacerations and a patterned injury due to a foreign object. Use of col- patients who present with acute genital injury are brought back
poscopy was documented in only one case; magnification was not spec- for a follow-up examination, the resolution of injury and course
ified. This autopsy was done 3 days after the disappearance of the child. of healing can be documented. For the rape-homicide victim,
When DNA does the Blues: One study, by Hochmeister, Whelan, et comparisons are best drawn from a baseline group of cases
al. (1997), studied vaginal swabs from women after consensual intercourse. where the cause of death has a non-sexual etiology.

• Postmortem artifact: in addition to all of the conditions that lens facing the decedent’s eye (position the surface rim of the lens with a
affect dye uptake in the living, factors such as skin slip, mucosal silver ring towards the decedent’s eye). The condensing lens must be
autolysis, blood, and other secretions, may cause a false positive centered in-line and perpendicular to the axis from the examiner’s pupil to
uptake during the postmortem interval. the decedent’s pupil. Resting the examiner’s little finger on the decedent’s
Further study is needed to assess the efficacy and reliability of this forehead is helpful as it helps stabilize the lens. The real inverted, laterally
nuclear stain as an adjunct to the postmortem genital examination. A reversed image is less magnified than that of a direct ophthalmoscope, but
prospective study of postmortem cases drawn from various causes of death the field of view is much larger.
will allow a comparison of toluidine blue and colposcopy. This subgroup Indirect ophthalmoscopy permits viewing of the posterior fundus and
will be part of a larger baseline study on the nature and appearance of the equator even if there is less than perfect anterior segment media; however,
anogenital tissues at various postmortem intervals. When the under- postmortem corneal clouding may cause the fundus to appear hazy. A
standing of what is normal and what is not in the postmortem interval is disadvantage of the technique, as with conventional direct ophthalmoscopy,
improved, the application of any staining adjuncts may then enhance, for is the lack of a stereoscopic view; however, stereopsis can be achieved but
pictorial purposes, what is already known to be present. this depends on the condensing lens, viewing distance, and interpupillary
Colposcopy, Toluidine Blue Dye, Postmortem Genital Examinations distance of the examiner. This technique is about as difficult as direct oph-
thalmoscopy to learn. Presently available aspheric lenses range from +14
to +40 diopters and come in different diameters. Lower power lenses
provide higher magnification but offer a smaller field of view and must be
held farther from the decedent’s eye, making positioning of the lens less
G84 Postmortem Monocular steady. Further investigation is needed to identify techniques that mitigate
Indirect Ophthalmoscopy postmortem corneal clouding.
Postmortem Indirect Ophthalmoscopy, Direct Ophthalmoscopy,
Patrick E. Lantz, MD*, Department of Pathology, Wake Forest University Ocular Fundus
Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157;
and Gill G.W. Adams, BSc, MBChB, Moorfields Eye Hospital, 162 City
After attending this presentation, attendees will become aware of how G85 Multislice Computed Tomography
to perform postmortem indirect ophthalmoscopy and how it differs from In Forensic Pathology
direct ophthalmoscopy.
This presentation will impact the forensic community and/or Klaus Poulsen, MD*, and Jørn Simonsen, MD, Institute of Forensic
humanity by describing an efficient, low cost method to examine the Medicine, Frederik Vs Vej 11, Copenhagen, 2100, Denmark
posterior retina following death that permits a wide field of view compared
with direct ophthalmoscopy. Imaging in forensic pathology has been known for more than one
Postmortem fundal examination can be conducted with a hand held hundred years, but used very little and only in selected cases such as
direct ophthalmoscope, head mounted binocular indirect ophthalmoscope shootings and battered child syndrome, in which cases traditional x-ray
or by monocular indirect ophthalmoscopy. The direct ophthalmoscope technique has been applied. The goal of this presentation is to introduce
provides a detailed monocular retinal inspection with high magnification routine multislice computed tomography (CT) in forensic pathology.
(15x for an emmetrope, less in hyperopia and more in myopia), but a small This presentation will impact the forensic community and/or
field of view (6.5 - 10?). Unfortunately, postmortem corneal changes can humanity by demonstrating how computed tomography can be a useful tool
make fundal examination less than optimal with the direct ophthalmoscope. as a standard examination before autopsies.
Binocular indirect ophthalmoscopy, a technique for evaluating the entire The material consists of more than 1,000 consecutive cases which,
ocular fundus, provides a stereoscopic, low magnification, wide-angle, before traditional postmortem examinations, were scanned in a CT-scanner
moderate to high resolution view of the retina. However, the binocular (Siemens Somatom Plus4Exp). The results were compared with the results
indirect ophthalmoscope is moderately expensive and requires some of the autopsies. The examiner records the results of the scanning and
training to properly use. provides the description and the pictures to the autopsy pathologist, who
Monocular indirect ophthalmoscopy is performed using a bright focal then records his results.
light source (penlight, Finhoff transilluminator, headlamp, otorhinolaryn- All data are stored in optical discs or CD-ROM, and relevant exposi-
gology headlight or light source from direct ophthalmoscope) and a high tions are developed and generated in 3-D images. The scanning procedure
plus condensing lens. The decedent’s eyelid is held open with an eyelid is very short – a few minutes – but the generation of the pictures takes
speculum while glycerin or an ophthalmic irrigating solution is used to approximately 20-40 minutes per case.
keep the cornea moist during the examination. After dimming the room The preliminary evaluation shows that the method is especially
lights, the light source is positioned against the examiner’s lateral valuable to demonstrate foreign bodies such as bullets and artificial joints
canthus/cheek or between the examiner’s eyes. The light source must be etc., fractures of the skeleton and larynx, and also intracranial hemorrhages
directed through the pupil to illuminate the fundus. The image of the retina and hemorrhages from rupture of large vessels such ruptured aneurysms of
is then projected out of the eye, and in an emmetropic eye with no refractive the aorta. In some cases, radiographic calcification of the coronaries is so
error the image of the fundus will be formed at infinity. An aspheric marked that it suggests the cause of death to be coronary insufficiency.
condensing lens is held between the thumb and index finger then placed in In the authors’ opinion, the new method has come to stay in forensic
front of the eye, thus focusing the retinal image in front of the observer. pathology – in the future combined with MR-scanning which covers the
Initially the condensing lens is held to one side of the decedent’s eye until soft tissue examination better. Since the method is non-invasive it is more
the pupillary red reflex is established and moved between the eye and the in accordance with the increasing resistance to classic postmortem exami-
examiner (initially about 1-2 cm from the decedent’s eye) and then slowly nations.
pulled towards the examiner and away from the decedent’s eye until the The new non-invasive technique may also appeal to the hospital
image of the fundus fills the lens, usually about 3–5 cm or equivalent to the pathologist, due to the fact that when it has become routine the technique
focal distance of the lens. Alignment of the condensing lens is critical. It can replace many postmortem examinations in hospitals.
must be held parallel with the plane of the iris, with the flat surface of the Computed Tomography, Virtopsy, CT-Scanning

G86 Murder in the Ancient Castle: A XIV G87 19th Century Autopsy Techniques:
Century Warrior Virtual Autopsy Failing to Meet 21st Century
Forensic Science Needs
Cristoforo Pomara, MD*, Institute of Legal Medicine, University of
Foggia, Viale Pinto 1, Foggia, 71100, Italy; Angelo Marrone, MD,
Diagnostic Immaging Department, ASL Foggia 2, Cerignola (Fg), Via O’Brian C. Smith, MD*, and Teresa A. Campbell, MD, 381 Cherry
Trinitapoli, Foggia, 71042, Italy; Stefano Ricci, MD, PhD, Hollow CV, Cordova, TN 38018; Elayne J. Pope, MA, Department of
Anthropological Laboratory, Department of Environmental Science, Anthropology, University of Arkansas, Fayetteville, AR 72701; Chantal
University of Siena, Via Mattioli n. 4, Siena, 53100, Italy; Irene Ferraro, PhD, C.W. Post Campus, Long Island University, Brookville, NY
Riezzo, MD, Institute of Legal Medicine, University of Foggia, 11548; and Alexandr Senilnikov, MD PhD, Regional Forensic Center,
Viale Luigi Pinto, 1, Foggia, 71100, Italy 1060 Madison AV, Memphis, TN 38104
The goal of this presentation is to present a unique case of the After attending this presentation, attendees will be familiar with
discovery of human skeleton remains of a XIV century “warrior”murdered diagnostic medical procedures applicable to death investigation in lieu of
by a crossbow arrow found in the cervical spine. A virtual autopsy an autopsy.
(“virtopsy”) was conducted with multislice Computed Tomography This presentation will impact the forensic community and/or
(MSCT) and X ray. The results of radiocarbon dating are also presented. humanity by refining the autopsy selection criteria, which will allow
“There was a time, in a Tuscan castle, a brave knight valiantly died greater opportunity for use of advanced clinical techniques and achieve a
fighting a battle to defend the fortress: This is his story.” Thus could begin higher quality of report for use in adjudicated cases.
this exceptional report concerning a discovery in a medieval castle. A The autopsy hit its heyday in the 1880s due to the European masters
medieval murder by a crossbow is presented. In February of 2004, during like Rene Laennec, Rudolf Virchow, and Ambroise August Tardieu to name
restructuring of a medieval castle in a Tuscan country, a burial was a few. Subsequent improvements to the autopsy include use of Roentgen’s
discovered. The burial was found at the base of an ancient keep in the x-ray device, photography replacing artwork, and increased utilization of
highest side of the hill where the castle was built within a rectangular room. laboratory studies including microbiology and immunology. In contrast,
This room was more recently used for animal shelter. some technologies, notably histology, have fallen into decline at many
The burial was placed in a pit dug in barren clay, and contained easily forensic facilities. Currently, Jurgen Ludwig’s multiple editions on autopsy
recognizable human skeletal remains in supine position with the arms bent practices are the most modern compendium of pathology techniques
on the chest and the head protected by two larges stones. derived purely for the purposes of demonstration and diagnosis. Yet the
These skeletal remains constituted a primary sepulture in full space. traditional autopsy still relies upon narrative styles little changed over the
The skeleton appeared completely preserved in each part. Anthropological years, with the exception that comparing lesions to articles of food has been
examination confirmed that the remains belonged to a 30-40-year-old male replaced by standard nomenclature and metrics. The pictorial style of
with a stature of about 170 cm. The anterior surface of the left maxilla had autopsy reporting has been very difficult to incorporate, despite the truth of
a round bone defect with clean-cut outline, 22.10 x 14.65 mm. The alveolar a picture being worth a thousand words. Pre-printed diagrams marked with
processes of the left maxilla had a round bone defect with an irregular short annotations are used by some and in this digital age, many pho-
outline involving the second incisor, canine and first premolar, 17.88 x tographs are still made using film technology, despite the instant feedback
10.64 mm galley dart stile was thrust between the second and the third cer- and proven advantages of digital imaging.
vical vertebrae. A complete x–ray study of the skeleton and an image - A wide variety of disciplines are incorporated at the autopsy table
guided virtual autopsy with multislice computed tomography (MSCT) [anthropology, bloodstain pattern interpretation, trace evidence, and
were made to analyse the correlation between radiologic images, anthropo- clinicians] to provide focal expertise ensuring no stone goes unturned.
logic data and macroscopic findings Expectations of the pathologists include being a physician with clinical
The x-ray study has confirmed the presence of the dart, classified as a skills. Pathologists should be adept at crime scenes, and clinical physical
“verrettone,” a kind of XIV century dart. exams including the ability to read a 12-lead ECG, x-rays and other
The 3-D reconstruction analysis of the maxillary alveolar wound diagnostic images. They also need to be conversant with surgeons
demonstrated the traumatic origin due to the dart entrance wound. The regarding resuscitation and surgical decision making. It is beneficial to
MSCT was able to analyze and reconstruct the internal dart trajectory. The remain current with the latest pharmaceuticals. The majority of continuing
dart penetrated the spinal cord causing an instantaneous death due to a com- education, journals read and textbooks procured are of a clinical nature,
plete section of medulla oblongata. from family practice to the surgicalandmedical specialties, pediatrics and
No other traumatic lesions were found. OB/GYN. Significant additions to autopsy protocols include the
The radiocarbon test (database used: INTC AL 98) was performed to following:
date the remains. It confirmed them as being from the XIV century. • Invasive angiographic studies
In conclusion, the case reported represents a unique case of human • Advanced x-ray protocols for child deaths following AAP guidelines
skeletal remains from a XIV century homicide, killed by a crossbow arrow • Bronchoscopy and endoscopy
in the cervical spine. A complete study with modern techniques has been • Intra-peritoneal lavage
performed, using CT scan and x-ray imaging, DNA analysis and Carbon 14 • Epiluminescence
examination to date remains. • Supra-vital staining
• Cardiac conduction dissections
Crossbow Homicide, Radiocarbon Test, Multi-slice Computed • Cytology of fluids, fine needle aspirates and touch preps
Tomography (MSCT) • Needle biopsy for tissue culture
• Needle biopsy for gross and/or histologic diagnosis
• In situ retinal evaluation
• Retinal recovery and histologic evaluation
• Histologic dating of wounds
• Histologic evaluation of wounds for foreign materials
• Evaluation/interpretation of bloodstain patterns on victims and
clothing

• Excision and retention of bone fractures for fractural analysis and concentrations can rapidly accumulate under many different scenarios. The
toolmarks most common sources of fatal CO intoxication are from inhaled fumes in
• Soft tissue and osseous burn pattern interpretation fires or motor vehicle emissions. Typical accidental poisonings usually
• Digital narrative/pictorial public record autopsy protocol involve unsuspected increased CO levels in enclosed environments, which
• Privileged pictorial autopsy protocol can include secured motor vehicles, closed residential or parking garages,
• Review by cultural anthropology car washes, homes, and even tents. Open air CO intoxication is a well-
known potential hazard in boating-related activities. CO poisoning has
In the practice of pathology, the traditional autopsy tis a quaint
been notoriously attributed to the inhalation of fumes emitted from the
expression of the best technology the 1880s had to offer. As with today’s
gasoline powered motor vehicular exhaust when personal-use automobiles
medicine, the practice of forensics has far more tools in its toolbox now
were involved, even when the engine possessed a catalytic converter. In the
than in the 19th century, mainly borrowed from clinical brethren. By using
U.S., a very small fraction of personal automobiles have a diesel engine.
those tools and refining examinations with diagnostic procedures adopted
While it is known that diesel fuel combustion engines produce much lower
from clinical colleagues, the percentage of persons needing autopsy to
levels of CO than gasoline engines, these CO emissions could certainly rise
attain diagnosis has paralleled hospital autopsy experience and fallen to
to lethal levels given a sufficient amount of time in an enclosed space and
14%. Because the new procedures with fewer autopsies save time, those
under suitable environmental conditions.
most in need of autopsy; primarily homicides, child deaths and those too
The case involves a moderately decomposed 52-year-old male truck
young to die, receive an Engineering Investigation quality autopsy
driver found prone between the sleeper and driver compartments of a
averaging 12 hours of physician time per case. Thus, those cases requiring
secure tractor trailer truck. The initial cause of death attributed to IHD was
the highest standards of proof receive the greatest effort with the latest
amended after the toxicology results from the Kentucky Office of Forensic
technology and the best reporting format.
Toxicology (OFT) showed a blood carboxyhemoglobin saturation of 67%
Autopsy, Forensics, Pathology by differential spectrophotometry. The amended cause of death was
attributed to CO intoxication sustained from inhalation of motor vehicular
exhaust. IHD was considered a significant factor contributing to his death.
G88 Diesel Fumes Do Kill: A Case of Because of the unique source of fatal CO intoxication in this case, the
Fatal Carbon Monoxide Poisoning contributory IHD, and the possible contaminants in the putrefied blood, a
10 year retrospective review was conducted of all non-fire related CO
Directly Attributed to Diesel Fuel Exhaust deaths autopsied at the Office of the Chief Medical Examiner in Louisville,
KY from 1994-2003. The review compared this case to gross autopsy and
Sean M. Griffin, MS*, and Donna M. Hunsaker, MD, Office of the Chief toxicological findings and scene investigation of 116 postmortem cases.
Medical Examiner and the University of Louisville Department of Specifically examined were severity of heart disease, degree of postmortem
Pathology and Laboratory Medicine, 810 Baxter Avenue, Louisville, KY decomposition, and evidence of cherry red skin discoloration present at
40204-1702; Kiran Charturvedi, MD, University of Kentucky Medical autopsy and scene description. In addition, for confirmation of the validity
Center Department of Pathology and Laboratory Medicine, University of of the carboxyhemoglobin detection method used by the Kentucky OFT,
Kentucky, 800 Rose Street, Lexington, KY 40536; Michael K. Ward, BS, blood samples from cases representing varying degrees of decomposition
KY State Forensic Toxicology Laboratory, 100 Sower Boulevard, along with controls were submitted to two different commercial labora-
Frankfort, KY 40601; and Andrea R. Terrell, PhD, American Institute of tories and one federal laboratory. The carboxyhemoglobin concentrations
Toxicology, 2265 Executive Drive, # A, Indianapolis, IN 46241 were measured using three different laboratory methods. The results from
the commercial and federal laboratories were compared to the Kentucky
The goal of this presentation is to present a novel case of fatal carbon
OFT results and were found to show no statistically significant differences
monoxide (CO) poisoning directly attributable to diesel fuel exhaust, a
in measured carboxyhemoglobin concentration. Lastly, an extensive liter-
previously unreported and perhaps under-recognized source of CO.
ature search and personal communication yielded no reported cases of fatal
CO poisoning, accidental or suicidal, attributed to diesel fuel exhaust.
humanity by reporting to the forensic community an under-recognized and
potentially fatal source of CO poisoning. Exhausts emitted from diesel Carbon Monoxide, Diesel Fuel, Poisoning
fuel, although possessing lower levels of CO than exhaust from gasoline
fuel, are nevertheless a conceivably dangerous source of CO. Through this
three-part research project prompted by this single case, the authors aim to G89 Sublingual Tablet Thwarts Opioid Addiction
promote further awareness that CO intoxication can occur from inhalation
of diesel exhausts, similar to open-air intoxication and, most importantly, to William Vilensky, DO, RPh*, Forensic & Educational Consultants, 2113
emphasize that it is preventable. Harbourside Drive, Longboat Key, FL 34228
This presentation will fully examine a case of CO poisoning brought
to autopsy as a possible work-related natural death in Louisville, Kentucky. The goal of this presentation is to offer information regarding a new
The death was initially considered to be caused from complications of tablet, buprenorphine, which when dissolved under the tongue (sublingual)
ischemic heart disease (IHD), pending toxicological analysis that included prevents opiate/opioid withdrawal, craving and continued addiction, and
a CO level. The CO was ordered at the time of autopsy because the victim reduces co-morbid diseases, crime, and healthcare costs.
was found in the secure cab of a running diesel engine semi-trailer truck at This presentation will impact the medical, legal, and forensic
a rest stop. When the toxicology results showed high levels of blood car- community, and/or humanity by demonstrating a high degree of positive
boxyhemoglobin, the death was recertified as CO intoxication secondary to outcome results of maintained sobriety in its first year of use by motivated
inhalation of [diesel] vehicular exhaust fumes. This case will illustrate how patients and private physicians utilizing buprenorphine.
diesel fuel can potentially serve as a source of CO in fatal and nonfatal The Center for Substance Abuse Treatment (CSAT) and The
poisonings. Substance Abuse and Mental Health Services Administration (SAMHSA),
Often called the “silent killer,” CO is the most common fatal divisions of the U.S. Department of Health and Human Services (USHHS),
poisoning in the United States, claiming 1,000 - 3,500 lives every year. have recognized that approximately 980,000 people in the U.S. are addicted
Although suicides constitute the majority of fatalities in CO poisoning, to opioids while only 205%, 180,000, are treated. This innovative treatment
accidents account for approximately 30% of annual deaths. CO is allows the physician to prescribe this drug in the private office setting and
produced by the incomplete combustion of organic material, and high is called Office Based Opioid Treatment (OBOT).

Opiates (morphine and codeine) and semi-synthetic and synthetic This presentation will impact the forensic community and/or humanity
opioids (heroin, oxycodone, hydromorphone, hydrocodone, methadone, by providing realization that homicidal ethylene glycol intoxication is very
fentanyl) are abused by oral ingestion, nasal insufflation, transmucosal rare, with suicidal ingestion by far the most common manner of death.
absorption (oral, nasal, rectal and vaginal) and injection. The amount of Although homicidal poisoning is possible, the determination of the manner of
transmitted diseases from substance abuse, i.e., hepatitis, HIV and sexually death by the medical examiner or forensic pathologist should rely on the cir-
transmitted diseases significantly elevate the cost of medical treatment and cumstances of the death after a thorough investigation, and not based on toxi-
crime. The chemo-therapeutical drug for the past 32 years to detoxify from cology values alone, which overlap with accidental and intentional ingestions.
opioids and maintain sobriety has been methadone. Methadone itself is Introduction: A cluster of alleged and convicted homicidal ethylene
addicting, but enables the addict to live in society, maintain employment, glycol poisoning deaths has recently been reported in the media. In light of
and remain healthy and productive. However, the addicted patients with these reports, the authors sought to retrospectively review the experience of
the primary, chronic, recurrent, neurobiological disorder of the brain (defi- the Cook County Medical Examiner’s Office investigating deaths occurring
nition of addiction by the National Institute of Drug Abuse) must be treated from ethylene glycol intoxication in an 11 year period from 1993 through
daily by reporting to federal and state licensed narcotic treatment programs 2003.
(NTP) each morning for their dose of methadone. This is time consuming Background: Ethylene glycol is a relatively inexpensive and easily
and frequently reduces employability and disrupts the family homeostasis. obtainable liquid used predominately as an antifreeze-antiboil additive in
Buprenorphine is an agonist-antagonist opioid that is used as an anal- motor vehicles, but is also found in detergents, paints, cosmetics, and de-
gesic in small doses by injection but stops opioid craving when given in icing products. It has a sweet taste, and is odorless and colorless, but
high strengths as a sublingual tablet. The Drug Abuse Treatment Act of commonly has fluorescent green or yellow dye added. It is an intoxicant
2000 opened pathways for qualified physicians to prescribe a 30 day supply with properties similar to ethanol when ingested, and is occasionally used
to patients from their offices and filled at pharmacies. This enables the as a substitute for ethanol when ethanol is not available. Several hours after
addicted patient to receive treatment while making them more employable, ingestion, toxic effects of nausea, vomiting, convulsions, stupor, and coma
able to leave welfare subsidies, provides social acceptability, enhances can develop. Death usually occurs 24 to 48 hours later depending on the
mentally and physical health, family acceptability and responsibility. amount ingested, but can be delayed with medical intervention, as ethylene
Two forms of the drug, manufactured under the names of Subutex® glycol causes metabolic acidosis, hyperosmolality, and tissue injury
and Suboxone®, have been available since January 2003. The former, pure through its toxic metabolites.
buprenorphine, induces the drug to a stable maintenance dose. The patient Results and Analysis: During this 11 year period, 35 cases of fatal
is then switched to the latter drug that is combined with a pure opioid antag- ethylene glycol intoxication were found in the Medical Examiner’s Office
onist, naloxone. If a patient tries to pulverize, solubilize, and inject it, the computerized database. Retrospective analysis included review of the
patient will experience rapid withdrawal symptoms. investigation and circumstances of the death; reports of follow-up investi-
The overall purpose is to educate and train physicians to treat gations, including family interviews, autopsy reports, toxicology results;
addiction on the front line of medical practice by the family physician, and any ancillary testing results. Temporally, one case occurred in 1993, no
internist or psychiatrist and thereby treat larger numbers of addicts not cases in 1994 or 1995, seven cases in 1996, eight cases in 1997, two in
currently in treatment and involved in criminal events to support their 1998, four in 1999, one in 2000, two in 2001, four in 2002, and six in 2003.
addiction. Deaths were highest in October, April, and August, with only December
The physician must have a minimum of eight hours of training by having none. The average age was 43 years for both sexes, with a range of
government (CSAT) approved addiction specialty organizations. 25 to 73 years. There were 27 males and 8 females (ratio of 3.4 to 1).
To date, the reports of buprenorphine’s use indicate it is well tolerated Twenty-eight were white and seven were black.
and well accepted. Patients can find certified physicians on a physician Manner of death was determined for the 35 deaths: 29 were suicides, 4
locator web-site. The benefits of these new drugs are to invite untreated accidental, and 1 undetermined. There were no homicides. Of the suicidal
addicts into a less formidable type healing program that eliminates the determinations, ten left suicide notes or phone messages of intent. The four
necessity of reporting to a NTP each morning and raises self-esteem. Since accidental determinations were related to chronic alcoholism and use of eth-
approximately 70% - 80% of inmates in the penal institutions are charged ylene glycol as a substitute intoxicant. The one undetermined case could not
with committing a crime directly or indirectly related to drug abuse or the be resolved between suicide and accident in a setting of chronic alcoholism
disease of addiction, it becomes more cost effective to build better lives and depression. Of the 29 suicide determinations, 14 had history of clinical
rather than bigger prisons. depression, three had psychiatric diagnoses, and ten were going through a
Subutex®, Suboxone®, OBOT breakup in a long-standing relationship. Twenty-one had either commercial
containers or cups of antifreeze at the scene. In examining where death or col-
lapse from intoxication occurred, 28 were at their own home or apartment, 1
at work, 2 at their neighbor’s home, 3 in motels, and one in a large department
G90 An Analysis of 35 Ethylene Glycol store. Of these 28 found at home, 11 were found in their bedroom, 4 in the
Fatalities in Cook County, Illinois basement, 1 in the kitchen, 1 inside a cabinet, 2 in the bathroom, and 7 had
no specific location within the home noted.
From 1993 Through 2003 Autopsy findings were nonspecific and consistent with drug ingestion
with pulmonary and cerebral edema. Calcium oxalate crystals were found
J. Scott Denton, MD*, Valerie Arangelovich, MD, Michel Humilier, MD, in renal tubules if death was not significantly delayed by treatment.
and Edmund R. Donoghue, MD, Cook County Medical Examiner’s Ethylene glycol toxicology analysis was divided into three study
Office, 2121 West Harrison Street, Chicago, IL 60612 groups: (1) those pronounced dead at the scene with postmortem analysis;
After attending this presentation the participant will understand that (2) those found still alive and admitted to the hospital for a short period of
suicide is the most common manner of death from ethylene glycol time with postmortem toxicology; (3) those found still alive and admitted
intoxication in Cook County, Illinois, followed by accident, and rarely to the hospital, but subsequently died with antemortem hospital toxicology
undetermined; understand the common death investigation circumstances analysis only. There were 15 victims in the first group dead at the scene.
surrounding death from ethylene glycol intoxication; and understand that The average blood ethylene glycol concentration on postmortem
toxicology values, although important in determining the cause of death, toxicology testing was 264 mg/dl (range 0 to 849 mg/dl). Average urine
cannot replace a thorough death investigation when determining manner of concentration was 1028 mg/dl (range 151 to 2193 mg/dl). The average
death. ratio of blood to urine compared in individual cases was 0.31 (range 0.12

to 0.50). The manner of death for all members of this first group dead at 95.4% gave their consent to participate in the study and complete the ques-
the scene was suicide. tionnaire. Of those consenting, 82% were male, 18% female. Mean age was
The second group was found alive and admitted to the hospital, but died 28.5y (range 18-49). 80% were unemployed; 29% had no fixed address
after a short period of time, usually in the emergency room, and underwent (1992 – 10%); 65% were Caucasian (1992 – 85%); 18% were Bangladeshi
autopsy with postmortem toxicology testing. All had metabolic acidosis and (1992 – 4%). Significant mental health issues (e.g., schizophrenia) were
hyperosmolality while alive. Examples include two victims who both lived present in 18%; 15% had significant alcohol use; 23% were married or had
nine hours in the ER after a prior ingestion at unknown time. One had eth- long term partners; 56% of partners/spouses used drugs. Heroin remains the
ylene glycol in the blood of 626 mg/dl, bile 529 mg/dl, and vitreous 716 mg/dl. most frequently used drug – in 93% of cases (1992 – 77%); crack cocaine
The second victim had ethylene glycol in the blood of 1141 mg/dl, bile 1134 was used by 87% (1992 –30%); mean daily cost – heroin GBP 76 (range 20-
mg/dl, and urine 561 mg/dl. In these two cases, bile seemed to parallel blood 240), crack GBP 81 (range 20-300). More than 50% of users inject crack and
levels. heroin simultaneously. 56% used the intravenous route (1992 – 72%); 25%
The third group was found alive and admitted to the hospital, but had shared needles at least once (1992- 41.6%); 100% had accessible sources
subsequently died, some after a long hospital course. This group tended to of clean needles; 6.4% were hepatitis B positive (1992 – 25.7%); 42% were
have large variable antemortem blood levels depending when testing was per- aware of hepatitis prophylaxis (1992 – 9.7%); hepatis C positive – 20.2% (not
formed during the hospital course. The range of initial ethylene glycol in the recorded in 1992); 3.6% were HIV positive. The mean total length of time
blood was 143 to 864 mg/dl. All had documented metabolic acidosis and of drug use was 7.5y (range 1 month – 20 years); 82% had served a previous
hyperosmolality, and all progressed to coma and death. Serial determinations prison sentence; 73% of prison sentences were drug-related (drug-defined –
of ethylene glycol blood levels were performed in many of the patients in this 21%, drug-inspired – 74%); 54% had used drugs in prison (1992- 82%); 11%
group and showed variable ethylene glycol metabolism rates. The half-life of had used needles in prison (1992- 30%); 3% of users stated they had started
ethylene glycol appeared to be less than 12 hours in this group where serial using in prison. 38% had been on some form of rehabilitation programs pre-
hospital blood measurements were taken. viously; 11% had been on Drug Treatment & Testing Orders (DTTO); 5.5%
Conclusion: In spite of the recent cluster of alleged and convicted were currently on DTTOs at assessment; 32% had used the services of Drug
ethylene glycol homicides reported in the media, none have been found in Arrest Referral Teams in police stations; 10% were in contact with Drug
Cook County, Illinois, within the past 11 years. The majority of the Cook Teams at the time of assessment.
County deaths were from suicidal ingestion, with a few accidents in people Summary and Conclusions: National drug reduction strategies appear
using it as a substitute for alcohol. The results are similar to a prior reported to have had little beneficial influence on patterns of drug use of the population
cluster of non-fatal intentional ethylene glycol intoxications in Northeastern seen in police custody. In the last decade there appears to be a substantial
Illinois in 1996.1 Toxicology values of ethylene glycol should not be used as increase in the prevalence of drug use – particularly of crack cocaine.
a substitute for a thorough death investigation in determining manner of death. Treatment interventions are either not available, not followed through or not
1 Leikin JB, Toerne T, Burda A, et al. Summertime cluster of intentional needed. In very general terms, the illicit drug use problem appears to have
ethylene glycol ingestions. JAMA, Nov 5, 1997-vol 278, No. 17, p 1406. significantly worsened in the population seen in police custody, although
there is evidence that suggests that within this population health education
Ethylene Glycol, Manner of Death, Toxicology
and harm reduction messages appear to have had some positive effects.
Drugs, Police Custody, Forensic Physicians
G91 Patterns of Illicit Drug Use of Prisoners in
Police Custody in London, United Kingdom
G92 Child Homicides in Hong Kong:
Jason Payne-James, LLM, MB, FRCS, DFM*, Ian Wall, LLM, MRCGP, A Retrospective Review of a Ten-Year
and Caroline Bailey, Forensic Healthcare Services, Ltd., 19 Speldhurst
Road, Victoria Park, London, E9 7EH, United Kingdom
Period From 1989-1998
After attending this presentation, attendees will gain an understanding Philip S.L. Beh, MBBS, DMJ*, Department of Pathology, The University
of the types of illicit drug use seen in prisoners in police custody in the U.K., of Hong Kong, Room 126, University Pathology Building, Queen Mary
and the characteristics of such drugs users. Hospital, Hong Kong, Hong Kong SAR, China; and R.G. Broadhurst,
This presentation will impact the forensic community and/or humanity Department of Sociology, The University of Hong Kong, Room 126, Hong
by allowing understanding of the needs of the drug users and the need for Kong SAR, China
forensic physicians to have a broad general medical background, and thus
assisting in determining the type of training needed by forensic physicians to After attending this presentation, attendees will understand the charac-
manage such patients in the police setting. teristics of child homicide in a predominantly Chinese population and thus be
Various national and local strategies have been formulated and imple- able to compare and contrast with characteristics in their own population.
mented directed at reducing illicit drug use, and crime associated with such This presentation will impact the forensic community and/or
drug use, in England & Wales. A number of these strategies directly involve humanity by providing rare data on child homicide in a predominantly
police (including drug arrest referral workers in all police stations, drug Chinese culture. It also represents a systematic review of all child homi-
testing for trigger offenses, needle exchange schemes), and thus directly or cides for all of Hong Kong in a ten year period. It shows similarities with
indirectly, forensic physicians. other published material but will also highlight differences which may be
Aims and Methods: Studies undertaken in 1992 identified the pro- cultural in nature.
portion of drugs users seen as part of the forensic physician workload and This paper presents the findings of a retrospective review of all child
explored the characteristics of such drug users seen in police custody. The homicide cases seen in Hong Kong in a ten-year period between 1989 and
aim of the current study was to identify changes that have taken place in the 1998. In this period there were a total of 799 homicide incidents, with 948
last decade comparing the number and characteristics of drug users seen in victims and 1666 offenders. Children younger than 4 accounted for 7.3%
police custody. A prospective, anonymised, structured questionnaire survey of victims (n = 69) and between ages 10-15, 8.8% of victims (n = 83).
was undertaken of consecutive, self-admitted illicit drug users seen by However, there was a much lower homicide rate between ages 5 and 10,
forensic physicians in police custody within the Metropolitan Police Service accounting for only 2% (n = 19) of all homicide victims. These results are
in London, U.K. consistent with previous statistics that child homicide had a bimodal
Results: In a separate study 30% of detainees seen had dependence on pattern, peaking in ‘very early childhood’ and ‘late adolescence’
heroin or crack cocaine (1992 – 11%). 113 drug users were studied in 2003. (Christoffel)1

Victim-offender relationships, causes of death and manner of death G94 Breath Holding Spells Associated With
will also be discussed.
i Christoffel, K.K. (1984). Homicide in childhood: A public health
Unexpected Sudden Childhood Death
problem in need of attention. American Journal of Public Health, 74(1), Kathryn K. Berg, MD*, Daniel W. Davis, MD, and Andrew M. Baker, MD,
68-70. Hennepin County Medical Examiner’s Office, 530 Chicago Avenue,
Child Homicide, Hong Kong, Retrospective Review Minneapolis, MN 55415
After attending this presentation, attendees will be able to recognize a
medical condition that may account for sudden death in childhood (greater
G93 Evolution of the Intentional Injury than 12 months old).
Infant Syndrome in Northern France Breath holding spells (BHS) have traditionally been thought to be
benign–“something that the patient will outgrow.” However, clinical
Gilles Tournel, MD*, Institut de Médecine Légale, 1, Place de Verdun, monitoring during some of these “spells” has resulted in the documentation
Lille, 59 000, France; Marie Desurmont, MD, Institut de Médecine of both severe bradycardia and dispersed QT intervals. A recent study
Légale, 10 Rue F Villon, Lille, 59 000, France; Valéry C. Hédouin, MD, reported ten patients with significant bradycardia that required permanent
PhD, Institut de Médecine Légale, 1, Place de Verdun, Lille, 59 000, pacemaker placement.
France; Didier Gosset, MD, PhD, Institut de Médecine Légale, 10 Rue F The authors report the case of a 20-month-old Caucasian male, born
Villon, Lille, 59000, France by induction via membrane rupture and the use of pitocin at the gestational
age of 38 weeks with APGAR scores of 7/8. He was noted to be a “slow
In northern France, child abuse represents a daily preoccupation in starter,” requiring vigorous sternal rubs to facilitate normal vital signs. In
forensic medicine. The goal of this presentation is to retrospectively study addition to this he had temperature instability that required his transfer to
infants hospitalized for subdural hematoma and examined in the forensic the Special Care Nursery for monitoring and isolette placement to maintain
department for suspicion of child abuse. his temperature. He remained in the hospital for six days after his birth.
This presentation will impact the forensic community and/or After discharge he had what his parents described, and his doctor related,
humanity by showing the importance of child abuse and Intentional Injury as “breath holding spells,” occurring two to three times a week. These did
Infant Syndrome (IIIS) in northern France. not alarm his parents because his older sister also suffered from them. His
Patients and Methods: During a 36 month period (January, 1999, to spells were provoked by crying or coughing, and after those activities he
December, 2001), 39 infants aged 1 month to 2 years, hospitalized for sub- occasionally had a quiet period with apparent apnea. These spells were
dural hematoma, were examined or autopsied (eight cases). Clinical and associated with both pallor or cyanosis that could last for five to ten
paraclinical information was collected. seconds. Multiple 911 calls were made when the apneic spells progressed
Results: Intracranial hematoma: 22 subdural hematomas were into seizure activity lasting more than 30 seconds. At the age of seven
bilateral, 5 were interhemispheric and 12 were unilateral. Five infants had weeks, following a coughing episode with an emergency room evaluation,
evidence of different ages of intracranial hematomas and 7 had chronic sub- he was found to have oxygen saturation of 88 to 89 percent. While the
dural hematomas. Some infants had associated skull fractures. Severe phlebotomist was drawing his blood he became apneic. He was given
cerebral edema was present in 8 cases. supplemental oxygen and became more alert. A follow up chest x-ray
Ophtalmoscopic findings: 33/39 cases had abnormal ophtalmoscopic revealed a slightly enlarged cardiac silhouette. A subsequent echocar-
findings. Eighteen cases had retinal hemorrages. Some cases were asso- diogram was normal. He was worked up for gastroesophageal reflux
ciated with retinoschisis (3), with other ocular haemorrages (2), and/or with disease and placed on omeprazole. In the last four months of his life he had
papilledema (3). Retinal haemorrages were absent in six cases. a marked decrease in these episodes.
General examination: 25/39 had evidence of child abuse including On the day of his death, while under the care of his aunt, he was
bruises (12 cases), soft-tissues injuries (5 cases), rib fractures (6 cases), placed in his crib after his lunch meal. No articles of potential respiratory
long bone fractures (2 cases), burns (1 case), bilateral testis injury (1 case), compromise were in the crib. He awoke with a cry after his nap, and when
severe denutrition with growth and psychomotor retardation (6 cases). his caregiver checked on him 20 minutes later, he was found unresponsive
Risk factors: 19 cases had antecedent evidence of child abuse or and a 911 was called. Attempts at resuscitation were unsuccessful.
neglect in their family. Eighteen were first born and the only child. Postmortem exam revealed no anatomic cause of death. Toxicology,
Thirteen infants had previously been abused; in 1 case, the mother was blood cultures, histology, postmortem radiographs, and vitreous
young (less than 18) and in another one she was psychotic. electrolytes were unremarkable. Detailed cardiac pathology was normal.
Facts: In 11 cases, related facts were a history of shaken baby Breath holding spells are a frequently observed event in infancy and
syndrome; in 8 other cases, the history was not correlated with the observed early childhood. Their association with sudden and unexpected death is
injuries. In 18 cases, injury mechanism was not explained by the care- rare. Typical cases begin between six and twelve months of age, and rarely
givers. In two cases, the caregivers have affirmed that they played with last past age four. Breath holding spells have been associated with pallor
their children. and/or cyanosis, and severe cases involving convulsions have been
Neuroimaging: In 27 cases, MRI was performed and was abnormal described. Several causes and explanations have been proposed, but proof
in all cases. They were compared with results obtained in CT imaging, and of etiology is not found in most cases. Autonomic dysfunction and parox-
standard radiography. ysmal vagal overactivity have been felt to play a significant role.
Discussion and Conclusion: Only 33/39 subdural hematomas were The death of this child represents a case of paroxysmal vagal overac-
associated with retinal hemorrages and determined the classical description tivity with a fatal outcome. While rare, when the history is consistent with
of “the shaken baby syndrome.” The absence of a traumatic history or a this premorbid diagnosis, and no alternative explanation is found, this cause
history not correlated with the clinical signs is a major element for the diag- of death should be a consideration.
nosis and is highly suggestive of child abuse. Associated injuries observed
in 50% cases are also pertinent arguments. The use and the utility of Breath Holding Spells, Paroxysmal Vagal Overactivity, Sudden
neuroimaging to determine the time of the lesions and their origin is very Unexpected Death in Childhood
important and discussed. A specific prevention of the IIIS should be
developed in France.
IIIS, Child Abue, Clinical Forensics

G95 An Interdisciplinary Approach for On December 18th, 2002, Baby Cooper’s daycare provider reported
that he didn’t look right as he lay sleeping 45 minutes after being placed
Diagnosis and Age Estimation of Infants’ down for his afternoon nap. Baby Cooper’s “little cheeks were purple.” He
Fractures in the Course of the Autopsy was picked up and it was described that “his little arms went limp.” 911 was
immediately called. Pending emergency personnel arrival, rescue breathing
Heike Klotzbach, MD, PhD*, Institute of Legal Medicine, Hamburg was started as the daycare provider talked to the 911 operator. The para-
University, Butenfeld 34, Hamburg, 22529, Germany; Guenther medics arrived within five minutes. By that time Baby Cooper was
Delling, PhD, Institute of Pathology, Department of Osteo-Pathology, breathing again but had an irregular heart rhythm (bradycardia). Paramedic
Hamburg University, Lottestrasse 2, Hamburg, 22529, Germany; Erich assessment in the field revealed no evidence of trauma. The daycare
Richter, PhD, Institute of Radiology, Department of Pediatric provider denied any intentional or accidental traumatic injury. Baby
Radiology, Martinistrasse 52, Hamburg, 20246, Germany; and Klaus Cooper was quickly transported to San Diego Children’s Hospital. Upon
Pueschel, PhD, Institute of Legal Medicine, Hamburg University arrival, Emergency Department medical staff noted that Baby Cooper’s
Butenfeld 34, Hamburg, 22529, Germany pupils were fixed and dilated, he had no pulse, and could not breathe on his
own. He was intubated and after 45 minutes of resuscitation, including
After attending this presentation, attendees will understand a scheme
CPR, Baby Cooper’s heart began to beat on its own but his respirations had
for diagnosis and age estimation of infants’ fractures during autopsy.
to be maintained on a ventilator. A CT scan two hours after hospital
admission revealed brain swelling consistent with global hypoxic-ischemic
humanity by diagnosing and estimating the age of infants’ fracture as an
injury, including complete obliteration of the sulci and basilar cisterns. The
important contribution to the diagnosis of the battered child syndrome.
admitting pediatrician believed he saw a frontal lobe contusion on the CT
Fractures of different ages are suspicious, and dating the fractures allows
scan. Abdominal and pelvic CT scans were negative. Possible blood was
some scrutiny in assessing whether the ages are in accordance with the
noted in the posterior chamber of baby Cooper’s eyes. A neurological
details given by the accused. Moreover, the implementation of an interdis-
examination concluded that Baby Cooper was probably brain dead. A
ciplinary approach involving forensic pathologists, osteopathologists, and
trauma surgeon examination concluded there was no external evidence of
radiologists allows use all resources and enhances cooperation with other
trauma except for a bruise on Baby Cooper’s chest caused by the CPR done
disciplines.
in the Emergency Department of the hospital. Baby Cooper’s initial blood
Age assessment of infants’ fractures plays an important role in the
studies, done within one hour of hospital arrival, revealed that his blood
diagnosis of the battered child syndrome. In postmotrem cases an interdis-
sugar was 372, his blood gas had a pH of 7.02, his sodium level was ele-
ciplinary scheme involving careful external investigation, skeletal survey,
vated to160 and his potassium was elevated to 11.5. Baby Cooper’s initial
autopsy, radiography, and osteo-histology has proven useful for dating
coagulation studies revealed a severe coagulopathy (a PT of 17, a PPT of
infants’ fractures. Four postmortem cases of infants with multiple fractures
greater than >130, and a low fibrinogen level of 44). Three hours post
of different ages due to child abuse (a total of 48 osseous lesions) were eval-
hospital admission an ophthalmology examination revealed bilateral retinal
uated. Early stages of fracture healing processes were dated histologically
hemorrhages extending out to the periphery. Chest x-ray noted the child’s
by the extent of periosteal thickening, osteoid production and calcification
lungs to be hyperinflated. A complete skeletal survey the following day
of soft callus. In advanced healing processes the osseous apposition rate
was negative. One hour before a blood culture draw, Baby Cooper received
defined by the width of the newly formed trabeculae was measured for age
several IV injections of an antibiotic. Brain death was declared 48 hours
estimation of the fractures. Multiple influencing variables must be con-
after admission. Organ donation took place 64 hours after admission,
sidered. Hence, dating the osseous lesions leads not to one single day, but
preceded by anticoagulant therapy.
to a time-interval when the fracture has occured. The results of the cases
Baby Cooper’s prior medical history included normal birth weight, a
presented indicate the forensic relevance of defining a time interval of the
prolonged vaginal delivery, mild jaundice and significant head molding. At
injury, which often allows some scrutiny in assessing whether the ages are
two weeks Baby Cooper underwent an unremarkable circumcision. At six
in accordance with the details given by the accused. Also, fractures of
weeks Baby Cooper was diagnosed with microcephaly (head circum-
different ages are a strong indicator of child abuse. Further work in this
ference below the 5th percentile). Baby Cooper’s diet consisted of
field will lead to more precise dating of infants’ fractures.
maternal breast milk either via nursing or via bottle. In the month before
Battered Child Syndrom, Infants’ Fractures, Osteo-Histology hospital admission Baby Cooper had sporadic episodes of constipation (up
to four days) and days when he would not eat well.
G96 Are Retinal Hemorrhages Diagnostic At autopsy, anoxic cerebral changes (“respirator brain”) with some
lymphocytic infiltration, questionable “Traumatic Axonal Injury” (“focal
of Shaken Baby Syndrome? What retraction balls”) and superficial hemorrhagic injury of the upper spinal
Really Killed Baby Cooper cord and cerebrum were noted. No frontal lobe contusion, subdural
hematoma, subarachnoid hemorrhage, or other traumatic brain injury was
Christopher J. Plourd, JD*, 1168 Union Street, Suite 303, San Diego, present. Baby Cooper had extensive bilateral retinal hemorrhages, and
CA 92101-3818 unexplained subdural bleeding in the lower thoracic spinal column.
Toxicology was negative. After two months, the medical examiner signed
The goal of this presentation is to discuss the inherent limitations of an amended death certificate and concluded that Baby Cooper was the
the current state of medical knowledge regarding the specificity and causal victim of Shaken Baby Syndrome and ruled the manner of death as
connection of retinal hemorrhages and Shaken Baby Syndrome. homicide.
Bilateral extensive retinal hemorrhages accompanying evidence of The trial of the day care provider was a battle of conflicting medical
childhood head trauma (subdural or subarachnoid hemorrhage) are experts. The prosecution contended that Baby Cooper died of Shaken Baby
considered virtually diagnostic (pathognomonic) of Shaken Baby Syndrome because of the rapid onset of brain swelling, the superficial
Syndrome by most pediatricians and ophthalmologists. The association of spinal cord and cerebral hemorrhagic injury and the bilateral retinal
retinal hemorrhages and Shaken Baby Syndrome, with or without impact, hemorrhages. Defense medical experts concluded that Baby Cooper
is a subject of increasing debate in the forensic medicolegal community. stopped breathing because of a Sudden Infant Death Syndrome event
The purpose of this presentation is to describe the diagnostic dilemma pre- (SIDS) that was resuscitated (known as “ a near-miss SIDS” or a “resusci-
sented by the suspected child abuse death case of 3 month 24 day old Baby tated SIDS” case). All the findings at autopsy were the result of Baby
Cooper, who was alleged to be the victim of Shaken Baby Syndrome (SBS) Cooper being kept alive on a ventilator for more than two days days before
while in the care of his state licensed daycare provider. he was formally declared dead. The retinal hemorrhages were caused by

the child being given vigorous CPR while the lungs were hyperinflated. showed poor gray-white differentiation consistent with severe anoxic brain
The severe anoxic changes with swelling caused the superficial hemor- injury. Clinical brain death was determined about 20 hours after admission.
rhagic and cerebral injury due to crushing against the skull, together with a Major findings at the autopsy included multiple (6) contemporaneous
patient having a severe clotting disorder upon admission to the hospital. acute skull fractures (consistent with a crush injury from quasi-static
At trial, based solely upon the medical findings, the prosecution loading), subscalpular extravasated blood, subgaleal and epidural hemor-
claimed that the daycare provider became increasingly irritated with Baby rhage, subdural hematoma, diffuse subarachnoid hemorrhage, severe
Cooper’s crying, and in a moment of frustration shook him to death. In her anoxic brain injury and a right cortical cerebral contusion. Postmortem
defense the daycare provider testified she did nothing to injure the child and ophthalmologic findings consisted of extensive bilateral retinal hemor-
called numerous character witnesses who testified that, over a fifteen year rhages; intrascleral hemorrhages; retinoschisis and a perimacular retinal
period, they had children in her daycare or were frequent visitors to the fold in the right eye; macular edema of the left eye; and intradural,
daycare. They testified to her love, understanding, and abilities to care for subdural, and subarachnoid hemorrhage of the optic nerves.
the needs of children. Character witnesses also testified that children were Subsequent investigation revealed that the 10-year-old cousin had
always well cared for, and that the daycare provider never lost her temper placed the infant in a baby carriage and taken him and his sister outside
or became frustrated with a child. After two six-week jury trials (the first while the 11-year-old brother played basketball with friends. Investigators
jury trial ended in a deadlock), the daycare provider was acquitted of all doubted her story that when she came back inside she lifted the infant out
charges. The controversial medical evidence along with the character evi- of the stroller with one hand and put the stroller away with her other hand.
dence convinced the jury that the daycare provider was not the type of Subsequent investigation and examination of the stroller showed that if the
person who would be capable of harming an infant child. frame latch was not secure, releasing the latch on the handle would permit
In reviewing a case of suspected Shaken Baby Syndrome death, all the stroller to collapse and lurch forward into the legs of the young
aspects of the case must be integrated before drawing any conclusion babysitter, causing her to fall onto the stroller. Recent evidence-based
regarding cause and manner of death. Attention should be paid to post reports have questioned the diagnostic specificity of certain ocular findings
hospital admission medical treatment and diagnostic tests, along with a in infants/young children with brain injuries. Statements in the medical
careful evaluation of secondary effects of medical care. Extensive literature that retinoschisis and perimacular circular folds are diagnostic of
peripheral retinal hemorrhages are part of a constellation of findings helpful shaken baby syndrome are not supported by objective scientific evidence.
to diagnose some cases of Shaken Baby Syndrome. Retinal hemorrhages It is imperative that ocular findings are not viewed out of context and a
in the absence of specific brain injury (subdural hemorrhage, subarachnoid thorough investigation is conducted before determining whether a fatal
hemorrhage, or contusions) present a diagnostic dilemma. pediatric head injury is intentional or unintentional.
Shaken Baby Syndrome, Retinal Hemorrhages, SIDS Shaken Baby Syndrome, Inflicted Childhood Neurotrauma,
Retinal Hemorrhages
G97 Fatal Craniocerebral Trauma With

Hemorrhagic Retinopathy in an Infant: G98 The Evidence-Based Medicine Paradigm
Abuse or Accident? Shift and Forensic Pathology
M.G.F. Gilliland, MD*, Brody School of Medicine at East Carolina,
Amy M. Tharp, MD*, and Patrick E. Lantz, MD, Department of Department Pathology and Laboratory Medicine, Brody 7 S 10,
Pathology, Wake Forest University Health Sciences, Medical Center Greenville, NC 27834
Boulevard, Winston-Salem, NC 27157
Attendees will learn that the concepts of Evidence-Based Medicine
After attending this presentation, attendees will be aware of the are not being used in forensic pathology writings, although some of the ter-
limitations of certain ocular findings that are considered diagnostic for minology is being applied in polemics about the Shaken Baby Syndrome.
inflicted childhood neurotrauma and remember the importance of a This presentation will impact the forensic community and/or
thorough investiation before determining if a fatal pediatric head injury is humanity by assisting forensic pathologists in being better able to judge the
intentional or unintentional. validity of assertions about Abusive Head Injury and/or Shaken Baby
This presentation will impact the forensic community and/or Syndrome couched in terms of Evidence Based Medicine.
humanity by demonstrating the importance of a thorough investigation for Hypothesis: The term Evidence-Based Medicine (EBM) has, so far,
all cases of fatal pediatric head injury. been utilized in the Forensic Pathology context to gain entry to the current
Severe hemorrhagic retinopathy, retinoschisis and perimacular folds literature for an editorial, an opinion paper, and a single case report, all
have been considered characteristic of inflicted childhood neurotrauma attempting to discredit the concept of Shaken Baby Syndrome. Such papers
(Shaken Baby Syndrome), rarely occurring in children with intracranial might not be given as much consideration without the appearance of
hemorrhage from other causes. Observational reports and evidence-based fluency with the issues raised by EBM.
inquiries have begun to question those assumptions. This is a report of a Synopsis: Evidence-Based Medicine (EBM) is an approach to
case of a 7-month-old infant who was left in the care of his 11-year-old scientific decision-making in selecting treatments for well-defined
brother and 10-year-old cousin for about two hours. When his mother diseases. Prospective, double-blinded, randomized controlled trials (RCTs)
returned from the store she found the infant unresponsive. He was trans- of therapies are given the highest weight, while other forms of comparing
ported to the local hospital where a cranial CT scan showed a non-displaced health interventions are ranked lower in the EBM hierarchy. The term
skull fracture adjacent to the coronal suture with widening of the sagital Evidence-Based as used in the forensic pathology literature to date asserts
suture, an extensive scalp hematoma, and a mixed density left subdural that no evidence exists, or only weak evidence exists, for what is called
hematoma. Cerebral edema was noted, with diffuse effacement of the sulci Shaken Baby Syndrome. EBM nomenclature has not been used in other
over the left cerebral hemisphere and a suggestion of transtenorial contexts to establish or refute other diagnoses in health-related papers,
herniation. After the infant was transferred to a tertiary medical center, a whether in medicine, respiratory care, or dentistry.
pediatric ophthalmology consult reported extensive bilateral retinal hemor- Evidence-Based Medicine (EBM) concepts were introduced to a
rhages with premacular subhyaloid hemorrhage in the right eye and broad readership in a publication in the Journal of the American Medical
macular edema of the left eye consistent with a non-accidental head injury. Association in 1992. The then editor of the JAMA, George Lundberg,
A skeletal survey revealed no fractures other than the parietal skull fracture referred to the JAMA itself as “The Journal of Physician Behavior
described on the initial cranial CT examination. A repeat cranial CT scan

Change.” He was describing his vision for the impact of the articles A stepfather placed his five-month old white female child on a living
presented in the Journal. EBM has rapidly achieved widespread accep- room love seat for a nap at 9:00 a.m.. According to police records, the step-
tance and is achieving “Physician Behavior Change.” Print and electronic father went to sleep across the room on a couch. He awoke a few hours
journals have sprung up to publish articles using the term, and at times even later to find the infant unresponsive. The infant was transported to the
applying the concepts. regional hospital where she was pulseless and apneic with a rectal temper-
Use of the term “Evidence-Based Medicine” has not been uniformly ature of 93.0° F. The initial police investigative report made no mention of
associated with appropriate appreciation of EBM’s goals nor application of syringes or insulin at the scene of death. Little information regarding the
its techniques. Reviewing the actual EBM literature reveals multiple stepfather’s medical history or background was obtained at that time.
articles complaining that others use their terminology but not their At autopsy, the infant was normally developed and well nourished,
concepts. Still other articles discuss the phenomenon of EBM and urge with a length and weight appropriate for age. No contusions, abrasions,
further study of the validity of its assumptions. Much of the literature scars, or other signs of old or recent trauma were noted. Evidence of
dealing with the results from applying EBM describe large studies (called medical intervention included an intraosseous catheter in the right tibia, a
mega-studies) and substitutes for mega-studies by literature analyses single needle puncture wound in the left antecubital fossa, three needle
(called meta-analyses), both seeking to achieve more “Statistical Power” puncture wounds in the right antecubital fossa, and a single needle puncture
(statistical significance) by comparisons of treatment in similar, large wound on the anterior right lower leg. No additional puncture wounds were
groups. Additionally, other articles call for Evidence-Based comparisons of seen. Postmortem x-rays revealed no acute or old skeletal lesions. There
various forms of intervention from toilet-training to cancer treatments. were no petechial hemorrhages in any of the internal thoracic organs, and no
A review of the literature accessed through PubMed congenital organ anomalies were identified. Abundant hemosiderin-laden
(http://www.ncbi.nlm.nih.gov/PubMed) searching for the terms “Evidence- pulmonary macrophages were detected. Additional postmortem micro-
Based Medicine” and “Shaken Baby” reveals only three papers: one is a scopic, microbiologic, and toxicologic studies were unrevealing. Vitreous
literature review, the second is a single case report with a brief literature glucose levels were not obtained due to insufficient sample quantity. The
review, and the third is a comment published in the same issue as the case cause of death was classified as sudden infant death syndrome (SIDS).
report. Both of the literature reviews fail to provide a citation to describe Two years after the first child’s death, the couple had moved to a
the classifications used to assert the weakness(es) of existing “Evidence.” different location, in a different police jurisdiction. A two-month-old male
Determining whether the terminology from EBM is used accurately or sibling was discovered by the father not breathing. Emergency medical
not requires the reader to review the goals and techniques of EBM. Such a personnel arrived to find the child unresponsive and pulseless on the sofa,
review leads one to realize that the terms and techniques of EBM are with the father, again the sole caregiver, pointing toward the child without
misapplied in these three publications. Abusive Head Injury is not a attempting resuscitation. The local hospital documented a rectal
“treatment” applied prospectively and randomly with case-controls (RCTs) temperature of 92.6° F approximately one-hour and ten minutes after the
in a mega-study. father claimed the child was last known to be alive. Autopsy revealed a
The published reports of cases, case series, or studies involving developmentally normal child, with no injuries. Gross and microscopic
Abusive Head Injuries or Shaken Babies are not legitimate subjects for examination did not reveal evidence of natural disease, although abundant
meta-analyses: Those studies which support statistical inference (have hemosiderin-laden macrophages were detected in the lungs. Resuscitative
sufficient “Statistical Power” on their own) gain no benefit from having attempts had been aggressive and puncture marks were in the bilateral
their populations and selection criteria diluted. Those studies which do not femoral areas; however, no other sites suspicious for injection were noted
support statistical inference are too dissimilar both in their populations and at autopsy. Postmortem microbiology and metabolic screening were non-
selection criteria to be legitimately combined. When such heterogeneous contributory. Toxicology for standard drugs of abuse, salicylate and
populations are combined for analysis, the result is at best an admixture, not acetaminophen was negative. Vitreous fluid was not obtained. Because of
the blend meta-analysis seeks. It is a priori apparent that every attempted additional investigative information, a postmortem blood test for insulin
meta-analyses of such disparate groupings must lack all true “Statistical and C-peptide was done. Although the ratio of insulin to C-peptide was
Power,” whether for or against any given hypothesis. suspicious for exogenous insulin injection, the relative postmortem stability
Evidence-Based Medicine, Abusive Head Injury, Shaken Baby of these compounds is not known.
Syndrome After the second case was reported to the medical examiner office, a
coordinated investigation into both of these cases was initiated, with re-
evaluation of the first death. Following a comprehensive investigation,
G99 Sequential SIDS or Double Homicide? utilizing both correlative interpretations and essential interagency cooper-
Challenges of Delayed Investigation ation, the cause and manner of death in the initial case was changed to
undetermined, while the second case was similarly left as undetermined.
of Potential “Subtle” Child Homicides These cases illustrate several points to be considered in sequential child
death investigations. First, multijurisdictional and multiagency
Stacy A. Drake, MSN, RN*, Teresa Royer, MSN, RN, Stephen K. Wilson, MD, coordination was crucial because the family moved into another police
Dwayne A. Wolf, MD, PhD, Ashraf Mozayani, PharmD, PhD, and Luis A. jurisdiction before the second death. Secondly, no suspicious
Sanchez, MD, Harris County Medical Examiner Office, 1885 Old Spanish circumstances came to light during initial investigation of the first child
Trail, Houston, TX 77054 death. In retrospect, some red flags were evident and should have been
detected with current investigative protocols. Third, interpretation and dif-
ferential diagnostic implications of hemosiderin-laden pulmonary
challenges of delayed investigation in sequential infant deaths.
macrophages in infants will be briefly described. Finally, the difficulty of
interpretation of postmortem insulin and C-peptide levels will be described.
humanity by demonstrating successful coordination of investigation of
Limited experimental data obtained during attempted validation of this
sequential childhood deaths. Experience illustrates a truism that needs to
postmortem biochemical test will be presented.
be remembered in all death investigation; namely, that all autopsy,
biochemical and toxicologic data must be considered in the context of a SIDS, Insulin, Sequential Deaths
coordinated investigation.

G100 Case Presentation: Infant Death G101 Child Abuse by Another Child:
Due to Epidermolysis Bullosa Can it Happen?
Eugene L. Hart, MD*, Bonita Fung, MD, Ana Lopez, MD, and Luis A. Darinka Mileusnic-Polchan, MD, PhD*, University of Tennessee Medical
Sanchez, MD, Harris County Medical Examiner’s Office, 1885 Old Center, Knox County Medical Examiner’s Office, 1924 Alcoa Highway,
Spanish Trail, Houston, TX 77054-2098 Knoxville, TN 37920; and Sharon O’Connor, Cook County Office of the
Medical Examiner, 2121 West Harrison Street, Chicago, IL 60612
The goal of this presentation is to acquaint the forensic community with
the manifestations of epidermolysis bullosa, so that they might include this The goal of this presentation is to recognize and appreciate child abuse
disease process in their differential when confronted with similar infant deaths. by another child as a special entity with far reaching professional, ethical,
When confronted with an infant death, this presentation will impact and social consequences.
the forensic community and/or humanity by demonstrating the importance This presentation will impact the forensic community and/or
for the forensic staff to consider the possibility of a natural disease process humanity by demonstrating how child abuse by another child is an
with manifestations that could mimic traumatic injuries. The skin lesions extremely rare occurrence; however, when it happens it should be promptly
of epidermolysis could be mistaken for thermal injuries if a thorough recognized. To assure proper handling of these distressing cases in an
history is not available, and if the possibility of a disease is not considered. efficient and sensible manner, team work of all involved investigators,
This presentation reviews a case of death caused by complications of pathologists, clinicians, and social workers appears to be of paramount
epidermolysis bullosa in a 17-month-old Asian infant.This child began to importance.
form skin bullae in the diaper area days after birth; these soon spread to In this presentation the authors describe a rare and unusual variant of
include the extremities and face. A biopsy-proven diagnosis of epider- child abuse in which the investigation focused on ruling out a preschool
molysis bullosa simplex (Dowling-Meara subtype) was given at age 2 child as the perpetrator. The first part of the presentation outlines the inves-
months. Mucosal involvement became apparent when white plaques were tigative process, highlighting the importance of the alternative approach to
noticed in the oral cavity. Recurrent reflux hindered feeding, and resulted examination and specific methods during the inquiry of the suspects.
in a lack of adequate weight gain. Persistent respiratory difficulties Following that the authors discuss autopsy findings such as the complex
necessitated tracheostomy tube placement at the age of 4 months. The nature of the injuries and particularly the peculiar ocular involvement.
tracheostomy site soon became infected; although treated, a mucoid Correlation between the pathology and proposed mechanism(s) of injury is
discharge, on occasion culture-positive for Staphylococcus aureus and emphasized.
Pseudomonas aeruginosa, continued to drain from the tracheostomy site. Secondly, ethical, social, and professional issues concerning all
A gastrostomy tube was placed at the age of 5 months, due to the child’s involved parties in this daunting and disturbing case are analyzed.
difficulty swallowing. By his seventeenth month of life, the child’s Differing opinions and crucial disagreements among child abuse experts
condition had seemed to stabilize and even slightly improve, when, one regarding workup and findings in this case are disconcerting. These
afternoon, he was found gasping for air; when the father attempted to fundamental differences might reflect to a certain extent doubts and
suction the tracheostomy site, the child stopped breathing. An ambulance emerging crises that are becoming increasingly apparent in the child abuse
transported the child to a nearby hospital, where he was pronounced dead. field. In the end the authors analyze these issues in terms of outcome and
An autopsy was performed by the medical examiner’s office. The follow-up of this tragic event.
small-for-age body had numerous scattered skin lesions, ranging from Blunt Force Injuries, Retinal Hemorrhage, Social Services
unruptured, thin-roofed bullae containing clear fluid, to superficial, red,
weeping erosions, to red-brown, dried erosions with a crusted base. The
teeth were dysplastic. The fingernails and toenails were absent; the nailbeds
had erosions. The oropharyngeal and laryngeal mucosae were markedly
edematous, with multifocal ulceration, scarring, and stenosis. The trachea
G102 Acute Pancreatitis in a 2½-Year-Old Child:
and mainstem bronchi had superficial mucosal erosions as well. A Fatal Therapeutic Complication of
Hematoxylin-eosin stained sections of these mucosal erosions had Polyethylene Glycol (PEG)-L-Asparaginase
extensive chronic inflammation and submucosal fibrosis. Sections of lung
parenchyma had mucus plugs in scattered bronchioles. There was no Cristin M. Rolf, MD*, and Heather Worne, BS, University of Kentucky,
evidence of trauma. The cause of death was listed as: “Complications of Department of Pathology and Laboratory Medicine/ Office of the
epidermolysis bullosa.” Associate Chief Medical Examiner, Kentucky Justice and Public Safety
Epidermolysis bullosa is a group of rare genetic disorders that result Cabinet, 100 Sower Boulevard, Suite 202, Frankfort, KY 40601-8272
in fragile epithelium that splits and blisters when subjected to minor
trauma. Subtypes are classified by the level of the disrupted epithelium or The goal of this presentation is to present to the forensic community a
by genetic basis in newer classifications. Epidermolysis bullosa simplex, case report and review of an unusual cause of acute pancreatitis. The
due to mutations in genes forming keratins, results in splitting within the authors discuss therapeutic effects and complications of the administration
superficial layers of the epidermis. Junctional epidermolysis bullosa is due of PEG-asparaginase as a chemotherapeutic agent.
to mutations in genes forming hemidesmosomes or anchoring filaments, This presentation will impact the forensic community and/or
and results in separation of the basal cell layer from the basement mem- humanity by heightening awareness in the forensic community of an
brane. Dystrophic epidermolysis bullosa is a result of mutation of the gene unusual cause of acute pancreatitis, stressing the importance of gathering
forming type VII collagen, and causes separation of the epidermis from the health history in a patient diagnosed with acute pancreatitis, and informing
underlying dermis. These disorders range from mild to lethal, and can the medical community of this possible complication of the use of PEG-
present at birth or later in life. asparaginase and to raise the index of suspicion so that preventative
When presented with an infant death, it is important for the forensic measures may be applied.
staff to consider the possibility of a natural disease process with manifesta- This presentation consists of a case study of a female toddler who died
tions that could mimic traumatic injuries. The skin lesions of epidermolysis suddenly from acute pancreatitis, a complication of chemotherapeutic
bullosa could be mistaken for thermal injuries if a thorough history is not intervention for Acute Lymphoblastic Leukemia (ALL). The authors
available, and if the possibility of a disease process is not considered. review the pathogenesis, incidence, and diagnostic workup of PEG-L-
asparaginase-induced acute pancreatitis.
Epidermolysis Bullosa, EB, Epidermolysis Bullosa Simplex

A 2 ½-year-old white female was diagnosed with ALL after the onset G103 Increased Risk of Sudden Infant Death
of easy bruising, nosebleeds, and lower leg (shin) pain. Induction therapy
consisted of an antineoplastic and palliative regimen of vincristine, dexam-
Syndrome (SIDS) Among Infants
ethasone, pegaspargase (PEG), cytarabine, and methotrexate. Remission Harboring the Apolipoprotein E-4 Allele:
was induced as the blast counts, which initially ranged from 10 to 14% on Genetic and Pathologic Similarities to
peripheral smear, became essentially absent. The therapy was complicated
by hypertension and sinus bradycardia, which prompted treatment with
Alzheimer’s Disease (AD)
enalapril, an angiotensin-converting enzyme inhibitor. The symptoms
resolved by discharge. For approximately one week thereafter, the patient’s D. Larry Sparks, PhD*, Sun Health Research Institute, 10515 West Santa
blood count remained free of leukemic cells. Approximately two weeks Fe Drive, Sun City, AZ 85351; Rob Friedland, MD, Bob Petersen, PhD,
post induction chemotherapy, the patient developed abdominal pain Ellen Grady, MS, and Sandra Richardson, PhD, Case Western Reserve
without fever. The patient’s mother attributed two episodes of vomiting to University, 10900 Euclid Avenue, Cleveland, OH 44106; and Cristin M.
dexamethasone prescribed to the patient. On the morning of death her Rolf, MD, and John C. Hunsker III, MD, JD, Division of Medical
mother administered an over-the-counter oral stomach remedy and reported Examiner Services, Kentucky Justice and Public Safety Cabinet, 100
that the toddler had difficulty breathing. The emergency medical service Sower Boulevard, Suite 202, Frankfort, KY 40601-8272
was notified and transported the patient to the hospital where, despite After attending this presentation, attendees will learn that there is
aggressive resuscitation attempts she was pronounced dead in the increased apoptotic neurodegeneration in SIDS, which may constitute the
emergency department. proximate cause of death, and that similar to AD, the risk of SIDS may be
Due to the sudden and clinically unexpected nature of the patient’s enhanced among those individuals harboring the Apolipoprotein E-4 allele.
death while in apparent remission, an autopsy was requested by the local Because of the 96% incidence of increased numbers of Alz-50
coroner. At autopsy the body was that of a normal but pale female child immunoreactive neurons in SIDS, this microscopic feature may be useful
with no congenital anomalies. Internal examination exhibited hemorrhagic in establishing the criteria for an objective diagnosis, if convincingly
ascites with petechiae of the small bowel mesentery and omentum. The confirmed. This presentation will impact the forensic community and/or
pancreatic tail was enlarged and violaceous. Microscopical examination humanity by providing direction for future investigation, along the lines of
revealed multifocal necrosis, hemorrhage, and acute inflammatory cellular altered cholesterol metabolism in SIDS, and the relationship between the
infiltrates in the pancreatic parenchyma. Inflammation extended to the severity of Alz-50 pathology and dose of the ApoE-4 allele.
peripancreatic fat, small intestine and appendiceal wall. Other findings Introduction: A number of studies suggest a neuropathologic
included hepatic steatosis and a focal intraluminal thrombus in a pulmonary overlap between Sudden Infant Death Syndrome (SIDS) and the dementing
artery of the right lower lobe. Histopathological examination of the post- disorder Alzheimer’s disease (AD). AD is a neurodegenerative disease
mortem bone marrow confirmed the presence of all three hematopoietic characterized by the pathologic presence of neurofibrillary tangles and
cell lines, but severe autolytic change precluded unequivocal recognition of accumulation of the peptide β-amyloid, predominantly in the temporal
blasts. No gallstones, structural anomalies of the gastrointestinal tract, or cortex and hippocampus. Pre-tangles (early form of the neurofibrillary
other risk factors for pancreatitis were noted. The cause of death was tangle) and degenerating neurons in AD and increased numbers of neurons
ascribed to acute hemorrhagic pancreatitis with the contributing factor of in SIDS medulla and temporal cortex are reactive with Alz-50 antibody
ALL, status post chemotherapeutic intervention (PEG-aspargase). compared to respective control populations. Likewise, increased levels of
Asparaginase is an enzyme manufactured by certain bacteria, plants the neurotoxin β-amyloid are uniformly present in AD brain and have been
and animals. Escherichia coli bacteria supply asparaginase used for observed in the temporal lobe of many SIDS infants. Studies of non-
medical purposes. Asparaginase catalyzes the hydrolysis of the amino acid, demented individuals with coronary artery disease (CAD) suggest that Alz-
asparagine, to aspartic acid. Neoplastic cells, especially those of ALL, have 50 immunoreactive neurons occur in advance of AD-like β-amyloid
low levels of asparagine synthetase. For this reason they fail to produce accumulation. An increased risk of developing AD is associated with
sufficient asparagine to survive and require an exogenous source of the increased frequency of the Apolipoprotein E-4 (ApoE-4) genotype. Three
amino acid. Asparaginase, a chemotherapeutic agent for ALL, eliminates ApoE alleles taken two at a time are possible (2/2, 2/3, 3/3, 2/4, 3/4 and
exogenous asparagine by hydrolyzing serum asparagine into nonfunctional 4/4). Likewise, there is an increased risk of CAD if an individual retains the
aspartic acid and ammonia. Asparagine is needed by ALL cells to build ApoE-4 genotype, reportedly because of associated elevations in circu-
proteins for cellular structure and enzymes. Documented complications of lating cholesterol levels. Elevated circulating cholesterol is prevalent in AD
asparaginase include allergic reactions, chemical hepatotoxicity, thrombo- and cholesterol is emerging as a factor promoting production of β-amyloid
genic coagulopathies, hyperglycemia, and acute pancreatitis. Clinical acute in the disorder. Furthermore, CAD in early life increases the risk of
pancreatitis is noted in about 1% of patients receiving asparaginase, and developing AD.
rarely results in death. Scientific Objectives: (1) Determine if there is increased prevalence
Asparaginase is used in several forms in conjunction with other of the ApoE-4 genotype among infants dying of SIDS compared to age-
chemotherapeutic agents to combat ALL. The L-asparaginase form matched infants dying of known causes; (2) Provide previously published
produced by E. coli has been reported to have a lower rate of acute pancre- data indicating that Alz-50 antibody highlights neurons undergoing
atitis than that of asparaginase alone. In an effort to reduce the incidence apoptosis; (3) Demonstrate that there are significantly increased numbers of
of immunogenicity, polyethylene glycol (PEG) is added to L-asparaginase. Alz-50 immunoreactive neurons throughout the length of the respiratory
PEG-asparaginase therapy is a known cause of acute pancreatitis in nuclei in the medulla of SIDS infants, thus suggesting that neurodegener-
the absence of other risk factors. The implications for the patient can be ation may underlie the cause of SIDS.
serious: in rare instances significant morbidity and, as this case study Methods: The authors investigated 115 infants > 4 weeks of age and
demonstrates, even mortality may occur. Acute pancreatitis must be < 12 months of age (81 SIDS and 34 non-SIDS) for ApoE genotype. The
considered in the differential diagnosis of gastrointestinal symptoms in the cause of death was diagnosed using 1991 NICHD criteria for SIDS and
leukemic patient treated with PEG-asparaginase. standard protocols for known causes (non-SIDS). ApoE-4 genotype was
Fatal Acute Pancreatitis, PEG-asparaginase, Acute Lymphoblastic evaluated in brain tissue using real-time PCR methods. Temporal cortex
Leukemia and medulla from a subset of these infants were evaluated for Alz-50
immunoreactive neurons in 50 μm vibratome sections. Some sections were

counterstained for condensed DNA (apoptotic bodies) with propidium Results: One Hundred sixty-five perpetrators were convicted at
iodide subsequent to Alz-50 immunohistochemistry and RNAase treatment court, involving 149 girls and 11 boys, with a median victim age of 13.5
(to degrade all RNA). years for boys and 10.6 years for girls (range 0-15 years of age). Forty-one
Results: The mean age at death was 94.5 + 7.8 days among infants children reported touching of genitals; 22 attempts of vaginal, anal, or oral
with the E-4 allele and 93.2 + 12.4 days among infants without the E-4 penetration, 21 vaginal penetration; 5 anal penetration; 10 fellatio; and 33
allele. The ApoE-4 allele occurred in 29.95% of the infant population and a combination of the above (the rest were other or unknown). Twelve
was absent in 70.15% of the infants. The ApoE-4 allele frequency was children were examined within 24 hours after the last sexual assault, 36
increased in SIDS (16.75%) compared to infants dying of known causes within a week and the rest more than a week later.
(7.6%); this difference was significant using the Armitage’s trend test Colposcopic findings: Sixty-one girls had normal internal genital
(P < 0.05) and marginally significant (P = 0.086) using a linear-by-linear findings (vagina, hymen, vestibulum, labia minor). Ninety-one had
chi square assessment. There was a 2.2-fold increased risk of SIDS (OR, abnormal findings, all non-specific findings except for 10 who had lesions.
0.76 – 6.46) if an infant harbored the ApoE-4 allele. One hundred thirty-three had normal external genital findings (labia
Ninety-six percent of SIDS infants exhibit significantly greater majora, perineum, perianal area). Fifteen girls had abnormal external
numbers of Alz-50 immunoreactive neurons in temporal lobe and genitals, of which six were lesions of the labia majora or/and perineum.
throughout the extent of, and exclusively in the dorsal and ventral respi- Two boys had abnormal but non-specific findings of the penis and four of
ratory nuclei and the reticular activating nuclei of, the dorsal medulla. the anus. Abnormal findings of the anus were found in 22 girls; of the
Essentially all Alz-50 immunoreactive neurons in SIDS brain exhibit con- abnormal anal findings, seven were lesions. Thirty girls had an incomplete
densed bodies of DNA stained by propidium iodide (apoptotic bodies). cleft of the hymen, but only eight were complete posterior clefts.
Such apoptotic bodies were confined to the nuclear envelope and did not Abnormal ano-genital findings were not significantly correlated to
occur in the absence of an Alz-50 immunoreactive neuron. conviction at court; however, the age of the child was.
Discussion: There is a greater than 2-fold increase in the ApoE-4 Conclusion: The history from the child, not physical findings,
allele frequency among infants dying of SIDS compared to age-matched remains the single most important feature in cases of sexual abuse.
infants dying of known causes. This is similar to the just over 2-fold References:
increase in the ApoE-4 genotype among individuals with AD compared to A.K. Lauritsen, K.Meldgaard, A. Vesterby: "Medical examination of
age-matched non-demented non-heart disease controls. This genetic sexually abused children - medicolegal outcome," AAFS 1998. p.96.
difference in SIDS is concomitant with a marked increase in features A. Vesterby, R. Hagemann-Petersen, A.K. Laurisen: "Sexually trans-
suggestive of early AD neuropathology. Because of the anatomic link mitted disease is rare in sexually abused children." IAFS 1999, 15: p. 95.
between the location of enhanced apoptosis in the medulla and control of Child Sexual Abuse, Colposcopic Examination, Conviction at Court
involuntary respiration and arousal from sleep, SIDS may be a neurode-
generative disorder of infancy. Future multi-site studies will be required to
confirm this possibility. Due to the link between ApoE genotype and
cholesterol metabolism, investigation of cholesterol levels in SIDS brains G105 The Contribution of Computerized
and circulation may be fruitful. Image Analysis to the Diagnosis of
Conclusions: SIDS may be the AD of infancy, and as in AD, the
influence of ApoE genotype may contribute to the severity of
Munchausen Syndrome by Proxy
neuropathology in SIDS.
Beat Horisberger, MD*, and Patrice Mangin, MD, PhD, Institute of
SIDS, Alzheimers-Like Neuropathology, Apolipoprotein E Genotype Legal Medicine, University of Lausanne, Rue du Bugnon 21, Lausanne,
1005, Switzerland
G104 Ano-Genital Findings in Sexually Abused difficulty in diagnosing child abuse, in particular Munchausen syndrome by
Children in Cases With a Conviction proxy, and understand the advantages of computerized image analysis for
child abuse diagnosis.
Lene Aagaard Nielsen, MD, and Soren J. Mikkelsen, MD, Children This presentation will impact the forensic community and/or
and Adolescent Psychiatric Hospital, University Hospital of Aarhus, humanity by demonstrating the use of new technologies, such as comput-
66 H. Selmersvej, Risskov, DK-8000, Denmark; and Annie erized image analysis, when child abuse is suspected
Vesterby, MD, DMSci*, Department of Forensic Medicine, Munchausen syndrome by proxy cannot be diagnosed by objective
University of Aarhus, Children abd Adolescent Psychiatric means unless the perpetrator is caught in flagrante delicto (such as when
Hospital of Aarhus, P. Sabroes Gade 15, Aarhus, DK-8000, Denmark using video surveillance). A psychiatric report on its own does note
constitute sufficient proof for such a diagnosis. The authors present a case
After attending this presentation, attendees will understand that ano- that shows how new diagnostic means may be useful in the practice of
genital findings at colposcopic examination are not major determinants for clinical forensic medicine in general, and in the case of the Munchausen
conviction at court. syndrome by proxy in particular.
This presentation will impact the forensic community and/or The case concerns a female infant with a past history of hematomas
humanity by assisting professionals in understanding that specific physical described as "spontaneous" by the pediatricians. The investigation started
findings of the ano-genital area are seldom found in sexually abused when the infant, aged three months, was admitted to the hospital for a
children; the history told by the child remains paramount in cases of sexual fracture of the skull, thought to be accidental on the basis of the initial
abuse. findings. A clinical forensic examination and forensic diaphanoscopy
The department of Forensic Medicine, Aarhus, Jutland, Denmark, per- casted serious doubt on the accidental version of the fracture of the skull.
forms, at the request of the police, colposcopic examinations of children Multiple hematomas, invisible to the naked eye, were also revealed, leading
suspected to be sexually abused. Included in the research during the period to complementary medical imaging analyses. As investigations proceeded,
from January 1, 1996 to September 1, 2002, were 482 children, giving an evidence supporting the hypothesis of infant abuse was mounting. In spite
incidence of 1,48/ 10,000 children from birth to 16 years of age in Jutland, of the authors' negative recommendation, the hospital physicians allowed
Denmark. This study includes those cases in which the perpetrators were the mother to take the child home for the weekend. On Sunday night, the
convicted at court because of substantial evidence of sexual abuse of the mother brought the child back for emergency hospitalization. The infant
child.

presented with numerous petechiae on her head, with the exception of two
areas: a digitiform zone on the scalp and a triangular zone in the nasobuccal
region. Petechiae were also present on the upper part of the thorax and at
the basis of the upper limbs. A number of hematomas, invisible to the
naked eye, were revealed by forensic diaphanoscopy on the anterior side of
the thorax. The lesional picture was consistent with a thoracic compression
leading to the obstruction of the respiratory tract, in the context of an
attempted asphyxia.
A key issue remained: who was the perpetrator of this child abuse?
The answer was provided using computerized analysis of the images
obtained from the digitiform lesion on the infant's scalp and the mother's
and father's fingers. The mother was identified as the perpetrator of the acts
using objective criteria, in the particular context of Munchausen syndrome
by proxy.
Child Abuse, Computerized Image Analysis, Munchausen Syndrome
by Proxy

j
G1
DALLA
Penetrating Wound of Head by

Slingshot: Medicolegal Aspects
Pathology/Biology
Bhanwar Lal Bhootra, MD*, Forensic Pathology Services, Limpoo

G3 The Effects of Liquid Bleach
on Pig Decomposition in
Southeastern Pennsylvania
j 2004
Province, PO Box 1944, Polokwane, 0700, South Africa Lauren E. Way* and John R. Wallace, PhD, Department of Biology,
After attending this presentation, attendees will understand the Millersville University, PO Box 1002, Millersville, PA 17551
occurence of medicolegal problems when medical doctor conducts incom- After attending this presentation, the participant will understand the
plete/improper examination of head wound; and understand the conse- effect of liquid bleach on carrion decomposition. This poster has two
quences of negligent conduct of doctor during trial. objectives to compare the rate of decomposition in pigs treated with and
This case of slingshot intracranial head injury is very unusual. Attention without bleach; and demonstrate the importance of understanding the
of medical officers is once again drawn to the medicolegal problems that can impact chemicals have on corpses for criminal investigative purposes.
be caused by the improper/incomplete examination of wound. This study demonstrates that an easily accessible and common
The author autopsied an unusual case of penetrating wound of head household chemical such as bleach can significantly influence decom-
by slingshot (piece of stone). position rates and postmortem interval (PMI), leading to the possible
The case was initially discharged from casualty after stitching the incorrect estimate in the time of death of a victim.
head wound. The patient died at home of intracranial infection. Autopsy Suspected use of bleach on the victim in a recent homicide trial in
revealed a skull fracture and intracranial stone piece. San Diego, CA, led the prosecutor to question if bleach on a body would
This case highlights that no head injury should be ignored as trivial affect a flies reproductive cycle. This case not only exemplified how
injury. Careful examination of the wound could have prevented a fatality forensic entomologists were unable to corroborate estimations of a post-
and possible medico-legal problems. mortem interval (PMI), but also how the effect of such chemicals may
Head Injury, Slingshot, Homicide influence arthropod colonization and utilization (if any) of a corpse, thus
affecting PMI estimations.
To date, empirical studies published on the effect of controlled sub-
G2 Suicide by Hanging in Children stances and other chemicals such as pesticides, have examined the effect
on particular insects and provided logical implications of the potential
Ziadi Arbia* and Chadly Ali, MD, Department of Forensic Medicine,
impact on a PMI estimate. However, few field studies exist on how
University Hospital Fattouma Bourguiba, Monastir, 5000, Tunisia
decomposition is influenced by any chemical substance. We hypothe-
After attending this presentation, attendees will consider cases of sized that the topical application via dousing of common household
hanging in children and the consequences of suicide in children. bleach would negatively impact insect colonization of pig carcasses
Death from hanging is common in suicide youth. There’s no large directly, and indirectly slow decomposition.
series dealing with such a death but numbers communicated even though The objective for our first experiment was to determine the effect
small are significant. of bleach on pig decomposition. In two later experiments we are com-
Aim: we aimed to examine the epidemiology and pathology findings paring decomposition rates between habitats, each with and without
of 16 cases of suicide from hanging in children and suggest prevention. bleach treatments, and determining the rate of degradation of bleach
Material and Methods: we considered cases of suicidal death from between habitats. Stillborn pig carcasses were used in this study.
hanging in children referred to the department of forensic medicine of the Control pigs (n=3/habitat), i.e,. not treated with bleach and experimental
university hospital Fattouma Bourguiba of Monastir from 1991 to 2002. pigs (n=3/habitat), i.e., treated topically with a dousing (≈ 4
Sixteen cases of children committed suicide by hanging were liters) of Ultra Clorox® liquid bleach, were placed onto individual
reported. These cases were preceded by age, gender, manner of death, past plastic trays inside separate animal Have-a-Hart® cages. In experiment
history, surrounding circumstances and pathology findings. 1, all cages were placed in an open field exposed to full sunlight. For
Results: the 16 children were found dead. The age range was 11 to experiment 2 and 3, cages will be placed in an open field (full sun light)
17. The greatest share of suicide was found in the age of 17. The majority and a wooded area (complete shade). Temperature probes (Tidbits®)
was males (15 /16). Rope for ligature was more common, string was used were inserted into two pigs, 1 control and 1 doused, to monitor internal
in 2 cases. A previous suicide attempt was reported in 1 case. Two cases temperatures. Daily temperatures were recorded from a local weather
were with a borderline personality and one case was with a medical history station and a max/min thermometer located in the open field.
of juvenile diabetes. In 14 cases, hanging occurred within the decedent’s Temperature data was used to determine degree-day totals for each
home. We couldn’t provide a statistic valid seasonal risk. However habitat. The pigs were observed daily to record physical changes in
afternoon seems to be the most chosen time for hanging (10/16). Complete decomposition. The pigs were weighed to the nearest gram to monitor
suspension was seen in all cases. Most of children were from rural areas. percent weight loss. Dead/live insects were sampled from the pigs on
The autopsy showed usual external injuries of asphyxial death. No days 2, 7, 14, 21, and 28 and preserved for identification.
injuries of the larynx or trachea were reported. Contusion hemorrhage of Five stages of decomposition were easily distinguishable for the
neck muscles was found. Petechial hemorrhage was not seen. control and doused or bleach treated pig: fresh, bloat, decay, post-decay,
Conclusion: death from hanging in children is rare. Our report is a and dry. The use of bleach appeared to affect the physical aspects of
contribution to several series dealing with such a death. Prevention is pos- decomposition. Decomposition in the control pig progressed from the
sible in some cases by parental supervision and by providing education fresh to dry stage in 11 days. Preliminary results showed that bleach
and mental health care to adolescent. It’s important to carry out dousing slowed decomposition of pigs by 7 days. Insect colonization on
prospective studies in order to determine the specific character of such experimental pigs was similar to control pigs, however insect feeding
occurrence, so we can provide a specific prevention measures. was negatively impacted through observations of dead maggots and a
Suicide, Death From Hanging, Children recolonization period on day 10.

The rate of decomposition as a function of weight loss was most G5 Pediatric Homicides Related
rapid for the control pig. Decomposition rates for pigs treated with
bleach tended to be similar initially but slowed overtime possibly due to
to Burn Injury
decreased insect activity. Accumulated degree-days estimates were less
for control pigs and significantly greater for pigs treated with bleach in William F. Zaloga, DO*, Wake Forest University Baptist Medical
full sunlight. Center, Department of Pathology, Medical Center Drive, Winston-
Results from the first experiment focused on the first objective of Salem, NC 27157; Kimberly A. Collins, MD, Medical University of
our study, the effect of bleach on pig decomposition. These results show South Carolina, 171 Ashley Avenue, Charleston, SC 29425
that decomposition was slowed by the presence of bleach on the pigs. After attending this presentation, attendees will be able to assign
Our preliminary evidence suggests that decomposition and lack of insect manner of death with more confidence in pediatric homicides related to
activity may influence PMI estimations when bleach is topically applied burn injury.
to a corpse. We are currently conducting two additional experiments to This presentation will impact the forensic community and/or
examine the effects of habitat on the rate of decomposition, as well as humanity by adding to and supporting the current literature of pediatric
extraction and detection techniques of bleach from carrion flesh. burn related homicides.
Forensic Entomology, Bleach, Postmortem Interval Burn related injuries and fatalities are usually thermal but may be
placed into six categories: fire (including smoke inhalation injuries),
scald, contact with a hot object, electrical, chemical, and ultraviolet radi-
ation (sun). Many injuries are mistakenly referred to as “accidents”
because they occur suddenly and are seen as unpredictable and uncon-
trollable; however, injuries often occur in predictable patterns.
We reviewed all forensic cases referred to the Medical University
of South Carolina Forensic Pathology Section over the 28-year period
G4 The Use of Whole Body Donors from January 1975 through December 2002. All cases with victims 17
in Forensic Research years of age and younger were analyzed and included in the study. We
examined the age, sex, and race of the victims; type of burn injury;
reported location; time of year; cause and manner of death; scene
Charlotte A. Wacker, MS* and Brandi J. Schmitt, MS, University of
history; any perpetrator; injury-death time interval; and the autopsy and
California, One Shields Avenue, 3301 Tupper Hall, Davis, CA 95616
toxicology findings.
After attending this presentation, the attendees will learn how In our study there were 124 cases of pediatric burn related fatalities.
whole body donors can facilitate research in forensic science. The ages ranged from 6 months to 17 years. Categorized, the cases were
Whole body donors are used everyday for the advancement of 121 fire related fatalities (97%, 1 fire due to high voltage electrocution),
medical research and education. These studies include, but are not and 3 scald fatalities. There were no burn related fatalities from contact
limited to, surgical trials, biomechanical research, and emergency pro- with hot objects, chemicals, or ultraviolet radiation. Ninety of the burn
cedures, as well as the academics of anatomy as it is taught through dis- related fatalities were in the 0-5 year age group (73%), with a peak (29
section. On the contrary, research in forensic science is generally cases) in the 2 year age group.
prompted by current casework and is performed as a byproduct of an The manner of the burn related deaths was also analyzed with 108
investigation. It is important to note that the use of whole body donors accidents, 12 homicides, and 4 undetermined. No cases were classified
for studies could help answer questions before cases even occur. Many as suicide. Eleven of 12 burn-related homicides also occurred at the
fields within the realm of forensic science can benefit from these home (9 of 12 fire related and 3 of 12 scalds) with all of the victims in
altruists in our society. Included are the disciplines of forensic ento- the 1-8 year age group. The perpetrator of the arsons was the mother in
mology, odontology, pathology, biology, anthropology, and toxicology 5 cases, the sister in 1 case, and undetermined in 2 cases. Homicide
and can extend into aspects of the physical sciences as well. involved a car fire in 1 case in which the father caused an explosion with
One location has facilitated human donor studies important to the an accelerant. The scald death perpetrators were the father, mother’s
associated fields. However, they are conducted in a manner that is spe- boyfriend, and an aunt.
cific for the climate, flora and fauna of that area. In other areas, decom- This retrospective study and review of the literature may reveal pat-
position studies and the like have been performed with the use of porcine terns useful for evaluation of manner of death. By recognizing scene
materials as a substitute for human materials. These studies are not characteristics, potential perpetrators, and children at risk we can better
reported here as invalid, but in order to apply the most appropriate and classify pediatric burn related fatalities.
applicable science to matters of evidence, it is imperative that the most
Pediatric, Burns, Homicide
realistic methods and materials are used. Recognizably, the diversity of
these United States requires the application of continuous studies to
varied geographical areas and academic disciplines to achieve the best G6 Insect Succession Studies on Pig Carrion
and most accurate results. in Southwest Virginia and the Effects of
Thousands of people each year become donors to the 112 university Antemortem Ethanol Ingestion on Insect
sanctioned whole body donation programs throughout the U.S. The lack
of research is not due to the unavailability of human specimens, but is a Succession and Development
result of low numbers of requests by appropriate researchers. This may
be attributed to the idea that many researchers are just not aware of the Kimberly L. Tabor, BA, MS*, Richard D. Fell, PhD, and Carlyle C.
possibilities that exist for their projects. Questions regarding the ethical Brewster, PhD, Virginia Tech, 216 Price Hall, Blacksburg, VA 24061;
uses of whole bodies for science may further reduce the use of human Kevin Pelzer, DVM, Virginia Tech School of Veterinary Medicine,
remains by forensic researchers. It is the intention of the writers to Blacksburg, VA 24061; George S. Behonick, PhD, Department of
provide a comprehensive presentation of the utilization of whole body Criminal Justice Services, Division of Forensic Sciences, 6600
donors to facilitate forensic research in the most appropriate manner Northside High School Road, Roanoke, VA 24019
possible. The goal of this presentation is to present the results of the effects
Whole Body Donor, Forensic Research, Forensic Science of antemortem ethanol ingestion on insect development patterns on pig

carrion; and to present the results of insect succession studies performed of 0.07% suggest distribution within the pig model similar to that
on pig carcasses during different seasons over a two year period. encountered in the vitreous and skeletal muscle of humans. The experi-
This presentation will impact the forensic community and/or mental paradigm seems to provide a reasonably comparable model to
humanity by presenting research which describes an interdisciplinary human postmortem tissues and fluids for elucidating the influence or
animal model, incorporating the expertise of forensic entomology and effect of antemortem ingestion of ethanol on insect succession and
forensic toxicology, in characterizing factors that may or may not development. The postmortem blood ethanol determinations in animals
influence the succession and development of insect taxa on postmortem 3 and 4 are consistent with postmortem neo-formation encountered in
remains. As a collateral forthcoming project, the model will provide the decomposition. Maggot specimens analyzed as homogenates obtained
means to investigate the feasibility of using biochemical markers of from animals 1 and 2 had higher ethanol concentrations when compared
ethanol consumption (fatty acid ethyl esters) in discerning antemortem to the control, untreated animals (No. 3 and No. 4). The low ethanol
ingestion of ethanol from postmortem neo-formation during concentrations observed in the control animal maggot specimens are
decomposition. possibly the result of postmortem neo-formation during decomposition
Learning Objective: one method of estimating the postmortem or being a metabolic by-product attributed to maggot and bacterial inter-
interval (PMI) uses results from studies on the faunal progression or suc- action. Additional data from a second experiment, derived from serial
cession patterns of carrion arthropods. The pattern of insect succession collection of maggot masses over a period of five days, from ethanol-
is specific to the location and environmental conditions in which a treated and control animals is provided in the poster.
carcass occurs. Because taxa can vary greatly with locale, particularly
at the species level, it is important to identify the forensically important ETHANOL RESULTS-% (WEIGHT BY VOLUME)
insects that are specific to an area. To date, no such data have been pub-
lished for the southwest Virginia region. It is possible that factors such Animal No. Antemortem Postmortem Loin Maggots
as antemortem ingestion of ethanol or drugs can affect succession pat- Blood Blood
terns and insect development rates, thereby rendering a PMI estimation 1 0.14 0.11 0.07 0.06
based on insect evidence inaccurate. 2 0.16 0.10 0.07 0.04
Succession studies were performed over three seasons for two years
3 ND 0.02 ND 0.02
using untreated pig carrion. Over 57 insect taxa were collected and iden-
tified. An occurrence matrix showing dominant species on a seasonal 4 ND 0.01 ND 0.02
basis is presented.
In an additional study, two pigs (weighing 57 and 66 kg) were intra- Animals 1&2 ethanol-treated
venously dosed with a mixture of 95% ethanol and saline using an intra- Animals 3&4 non-treated controls
venous catheter inserted into an ear vein and by oral gavage. Two ND indicates not detected
untreated pigs of similar weight (53 and 49 kg) were used as controls.
The research describes an interdisciplinary animal model, incorpo-
Antemortem blood samples were colleced from both groups 15 minutes
rating the expertise of forensic entomology and forensic toxicology, in
following delivery of ethanol to the treated animals. Euthanasia imme-
characterizing factors that may or may not influence the succession and
diately followed the collection of blood samples. Loin meat was
development of insect taxa on postmortem remains. As a collateral forth-
removed from each carcass to be used as a rearing medium for field
coming project, the model will provide the means to investigate the fea-
development studies of the black blow fly, Phormia regina. The car-
sibility of using biochemical markers of ethanol consumption (fatty acid
casses were placed under cages in a partially wooded field within one
ethyl esters) in discerning antemortem ingestion of ethanol from post-
hour of death. Insects were collected and an occurrence matrix was
mortem neo-formation during decomposition. (The Virginia Tech
developed. Results of the succession studies indicate no differences in
Animal Care Committee approved this study).
the insect taxa collected from ethanol-treated versus control pigs.
Decomposition rates were similar for all animals. Forensic Entomology, Ethanol, Maggots
All four carcasses were necropsied in the field two days post-
mortem. Blood, tissue and maggot homogenate specimens were ana- G7 The Detection of Saliva: Factors Affecting
lyzed for ethanol by headspace gas chromatography (HSGC) utilizing a the Phadebas® Press and Tube Tests
HP 7694 HS Sampler configured to an AgilentGC-6890 Plus™ with a
flame ionization detector (FID). The column was a Restek Rtx-BAC1™ Melissa S Kell, BSc*, Wendy Lalonde, BSc, Roger Frappier, MSc, and
and the internal standard utilized was n-propanol. Total run time was Jonathan Newman, BSc, Centre of Forensic Sciences, 25 Grosvenor
four minutes. The limit of quantitation (LOQ) is 0.01%. Street, Toronto, ON M7A 2G8, Canada
For the development studies, P. regina egg clusters were collected
from carcasses and placed in rearing cups containing pieces of loin meat The goal of this paper is to present to the forensic community, the
from either treated or control pigs (n=6 each). The rearing cups were findings from a study conducted to assess a test employed to detect
kept outdoors to monitor development under natural conditions. saliva in forensic casework samples.
Temperature and relative humidity were recorded at the site using Forensic biologists will learn of the relative merits of the Phadebas
HOBO® data loggers. Following egg hatch, six maggots were removed test for the detection of amylase applied quantitatively as a Tube Test
from each rearing cup every eight hours until pupation. Size and larval and semi-quantitatively as a Press Test.
stage were recorded for each sample interval. The time from pupation It is often necessary for a forensic biologist to locate and identify
saliva stains in casework. Not only is saliva important as a source of
until adult emergence was also determined. Preliminary data indicate no
DNA, its presence in various circumstances can corroborate aspects of
difference in development on meat from ethanol-treated versus control
an account of a crime. Unlike blood, which is usually evident by visible,
animals. However, the concentration of ethanol in the loin meat of
red-brown staining, often saliva does not contain any visible compo-
treated animals (0.07%) was only slightly higher than that of controls
nents, making the “stains” difficult to observe. Therefore, chemical
(ND). Additional in vitro studies using meat fortified with higher con-
methods are used to locate saliva stains.
centrations of ethanol are being conducted to determine if alcohol can
At the Centre of Forensic Sciences, the localization and identifi-
affect maggot development.
An ethanol vitreous humor concentration of 0.14% was obtained cation of saliva is determined using the Phadebas® Amylase Test
for one animal (No. 2) and the loin ethanol concentrations (No. 1 and 2) (Pharmacia and Upjohn Diagnostics AB, Uppsala, Sweden). This assay

is used to detect the digestive enzyme α-amylase, which is found in high tragedy. The forensic community needs to enlighten the broader com-
quantities in saliva. The test can be performed in two ways: the press test munity as part of its public health and public safety missions.
(Willott and Griffiths, 1980) and the tube test (Willott, 1974). In this Deaths attributed to the toxic effects of methadone, alone or in
study, three variables were assessed to determine their effects on both the combination with other drugs, have dramatically increased in the State
press and tube tests: 1) the quantity of amylase in a person’s saliva, of Oklahoma during the study period. Tabulation of these deaths on an
2) the type of substrate on which saliva is deposited, and 3) the mixing annual basis from records of the Office of the Chief Medical Examiner
of saliva with a second body fluid, either blood or semen. A second aim of the State of Oklahoma demonstrates this trend. A comparison of
of the study was to evaluate the effectiveness of both tests to determine deaths in the three-year period 1990–1992 versus 2000–2002 shows 7
if the tube test is always necessary to perform in addition to the press versus 140 respectively. This parallels a dramatic rise in the prescribing
test, and to determine the required duration of the press test. of methadone in the state, particularly for the treatment of chronic pain.
Neat and diluted saliva from thirty individuals was used to stain Possible rationales for this increase including unique aspects of the phar-
cotton. Ninety percent of the neat saliva stains were detected in less than macology of methadone are discussed.
10 minutes using the press test, and all neat saliva stains had amylase Methadone, Deaths, Chronic Pain
activities greater than 0.03 International Units (IU) (Willott, 1974) using
the tube test. Overall, the tube test showed higher sensitivity. Press and
tube tests were then performed on stains made from saliva from indi-
G10 Fatal Botox®-Induced
viduals covering a range of amylase levels on the following substrates: Anaphylaxis? A Case Report
cotton, polyester, a blend of 95% acrylic 5% spandex, silk, satin, cor-
duroy, denim, and white S & S #903 filter paper (Schleicher & Schuell Melissa Li, MD*, University of Florida College of Medicine, PO Box
Bioscience). The press test could detect saliva more readily on thinner, 100275, 1600 SW Archer Road, Gainesville, FL 32610-0275; Bruce A.
less absorbent fabrics, while higher amylase activities were obtained Goldberger, PhD, University of Florida, PO Box 100275, Gainesville,
with thicker fabrics using the tube test. Experimentation was also done FL 32610-0275; Carolyn Hopkins, MD, District 8 Medical Examiner’s
to determine how the deposition of saliva in the presence of semen and Office, 606 SW 3rd Avenue, Gainesville, FL 32601
blood affects the press and tube tests. Stains were made of saliva and After attending this presentation, attendees will learn about autopsy
either blood or semen in three different ways: 1) mixing prior to depo- findings and laboratory diagnosis of anaphylactic reactions and the
sition, 2) depositing saliva, letting it dry then depositing the other body history and uses of Botox®.
fluid on top, and 3) depositing the other body fluid first, letting it dry This presentation will impact the forensic community and/or
then depositing saliva on top. Semen did not interfere with the detection humanity by reporting on the first case of Botox® associated death;
of saliva using the press or tube tests, regardless of the method of depo- describing what kind of conditions Botox® is currently used for, and that
sition. Blood did not interfere with the detection of saliva using the tube it can possibly be a cause for anaphylaxis; and describing how to support
test, but when the press test was performed there were some instances the diagnosis of anaphylaxis.
where the result took longer to appear or did not appear within the 20- Introduction: adverse drug reactions can occur with any therapeutic
minute test period. drug, with anaphylaxis being the most serious event. Botox (botulinum
Overall, the press test is sufficient for detecting saliva stains in most type A, Allergan Inc, Irvine, CA) is a relatively new drug that is FDA-
cases if administered for 40 minutes. The limitations discussed must be approved for blepharospasm, strabismus, cervical dystonia and glabellar
considered when blood is present on the sample to be tested, or if the wrinkles. It is also used ‘off label’ for a variety of disorders such as
substrate fabric is heavy / thick (e.g., denim). chronic pain syndromes, hyperhidrosis, cosmesis, and achalasia. It has
Saliva, Phadebas, Amylase been touted as extremely safe and effective. To date, no deaths asso-
ciated with Botox have been reported. We report the first case of ana-
G8 Places to Commit Suicide phylaxis and death in a woman who received a mixture of Botox and
lidocaine injections.
Istvan F. Szentmariay, MD*, Institute of Forensic Medicine, Semmelweis Case History: a 43-year-old woman who had chronic upper back
University, Ulloi UT 93, Budapest, H-1091, Hungary pain presented at a rehabilitation clinic for a repeat set of Botox and lido-
caine injections. Fourteen months previously, she had received her first
NO ABSTRACT PROVIDED. set of Botox injections and obtained relief from her pain for several
months. However, over the last few months, her back pain returned. A
5 cc solution of 1% Lidocaine and 100 units of Botox was made and 1
Suicide, Place of Death, Methods of Suicides cc was injected into each of the 5 trigger points located in her upper
back. Immediately following the last injection, she experienced a vaso-
vagal reaction, lost consciousness and exhibited seizure activity. She
G9 Dramatic Rise in Methadone-Related was transported to the local hospital emergency room, where despite all
efforts, she died.
Deaths in Oklahoma 1990-2002 Autopsy and Toxicologic Findings: the most significant autopsy
finding was pulmonary edema and hemorrhage. The hypopharynx,
Ronalod F. Distefano, DO*, Office of the Chief Medical Examiner, larynx and trachea showed no evidence of edema or hemorrhage.
State of Oklahoma, 1115 West 17th Street, Tulsa, OK 74107 Postmortem blood toxicology demonstrated a lidocaine level of 1.1
After attending this presentation, attendees will have awareness of ug/mL and a methadone level of 0.12 mg/L. Premortem serum demon-
dramatic increase in methadone-related deaths and potential explanation strated a tryptase level of 37.6 ug/ml (reference range 0.4-10.9 ug/ml)
of why they occur. This trend is evolving nationwide and there is every and an IgE level of 6.7 IU/mL (reference range 0.0-100.0 IU/mL).
expectation that it will continue. Discussion: anaphylaxis can occur quite suddenly, and is often a
This presentation will impact the forensic community and/or clinical diagnosis or a diagnosis of exclusion. It commonly occurs with
humanity by making the forensic community aware of the emerging epi- food allergies and insect stings. An elevated serum tryptase level can
demic of deaths related to this drug and the reasons for it. Unique support the diagnosis of anaphylaxis. Tryptase is a mast cell specific
aspects of its pharmacology interacting with ignorance of this by physi- enzyme that is released in allergic reactions. This patient demonstrated
cians, patients, and substance abusers have resulted in an emerging a greatly elevated tryptase level. Although IgE was not significantly ele-

vated, it does not exclude anaphylaxis, since some drugs may trigger Conclusions: The investigation of work-related deaths is chal-
mast cell degranulation directly. Because the mixture included lidocaine, lenging. It requires broad knowledge of various fields of work, and of
the cause of the anaphylaxis cannot be definitively solely attributed to the dangers inherent in each. Investigation must be both wide-ranging,
Botox, since rare anaphylactic reactions and death have been associated yet focused. All findings must be rigorously documented.
with lidocaine. The patient’s previous injections of Botox may have been Both the general public and forensic scientists will realize that there
the time of sensitization. are hazards inherent in every form of work, whether sedentary, or
Conclusion: both Botox and lidocaine have few reported adverse involving physical labor. Prevention of work-related deaths involves
side effects. This is the first Botox associated anaphylactic reaction and recognition of hazards; personal protective equipment; instilling proper
death. Despite reports of safety and few complications, precautions work practices; and monitoring the workplace. It will be recognized that
should always be taken for an adverse reaction. most important of all is a persistent commitment to safety by both man-
Botox®, Lidocaine, Anaphylaxis agement and labor.
While there has been a significant decrease in work-related deaths
over time, many still occur, and many of these are preventable.
G11 Significant Trends in Work-Related
Work-Related Death, Homicide, Investigation
Deaths — United States
Gordon K. Murphy, MD*, 814 Hathaway Road, Dayton, OH 45419-3555
G12 Over Diagnosis of Low
Voltage Electrocution
with work-related deaths and how to investigate them properly.
Both the general public and forensic scientists will realize that there Ronald K. Wright, BS, MD, JD*, 2101 SW 29th Avenue, Fort
are hazards inherent in every form of work, whether sedentary, or Lauderdale, FL 33312
involving physical labor. Prevention of work-related deaths involves After attending this presentation, attendees will understand the
recognition of hazards; personal protective equipment; instilling proper mechanisms of death in electrocution; be provided easily conducted
work practices; and monitoring the workplace. It will be recognized that analyses to prevent over diagnosis of electrocution; recognize that over
most important of all is a persistent commitment to safety by both man- diagnosis of electrocution is relatively common.
agement and labor. While there has been a significant decrease in work- This presentation will impact the forensic community and/or
related deaths over time, many still occur, and many of these are pre- humanity by understanding the pitfalls which can occur in investigation
ventable. of low voltage electrocutions and techniques to employ to reduce over
In recent years, work-related deaths have ranked second only to diagnosis.
motor vehicle accidents as a category of accidental deaths in the USA. The fact that electrical burns are the only significant finding in low
It is vital that the forensic scientist be familiar with all aspects of work- voltage electrocutions is well known in the forensic pathology com-
related deaths because of their frequency; the often time-consuming and munity. The fact that electrical burns are seen in only approximately
complex nature of a proper investigation; and because these deaths often 50% of low voltage electrocutions is also well known. Further, it is gen-
have implications for the living as well, in the context of prevention. A erally understood that a high index of suspicion is required if there is a
significant number of these deaths result in litigation - civil, criminal, possibility that an electrical circuit may have killed someone, as the
or both. autopsy will not identify the cause of death in approximately 50% of
Investigation of work-related deaths involves thorough exami- cases.
nation and documentation of the scene of death, with expert consultation Unfortunately, the above works to create over diagnosis in some
when indicated; a complete autopsy, including toxicology; and clear cases. The author has encountered eight cases of over diagnosis of low
statement of conclusions of the investigation as warranted by the voltage electrocution in the past eight years in his consultative practice
evidence. of forensic pathology. Of these cases, the author was a consultant to the
Four significant trends in work-related deaths in the USA are defense in seven and to the plaintiff in one. The possibility of bias could
apparent from experience and review of the literature. 1 - A significant thus be argued, but then again, the government-hired death investigator
decrease in the number and incidence of work-related deaths particularly also has a bias to determine a cause of death, and in the majority of these
since the turn of the 20th century, as well as in the past 20 years 2 - cases, if electrocution was not diagnosed, the cause of death was cer-
Mining and quarrying; construction; and agriculture in that order were tainly obscure. Invocation of electrocution made a tidy diagnosis in an
formerly the three industries in which the largest numbers of work- otherwise puzzling case in the majority of cases.
related deaths occurred. Due to significant improvements in safety in The eight cases presented show variable circumstances, with
mining and quarrying, and in agriculture, the three leading industries are varying degrees of certainty that the death could not have been electro-
now construction, transportation, and manufacturing. 3 - Work-related cution.
deaths due to gunshot were formerly infrequent. Since 1990, however, In each case there was a possibility of electrocution because some
homicide has been the second-leading cause of work-related deaths in source of electricity was available to the deceased prior to his or her
the USA. Homicide is the leading cause for females. 4 - Deaths due to demise.
collapses of open-trench excavations in construction, although pre- In each case, the approach will be to show that for there to be an
ventable, continue to rise. electrocution, there must be a circuit of more than 16 mamps through the
Illustrative cases: Construction - a motor-vehicle accident, the person immediately prior to the death. 16 mamps is used a minimal
leading cause of work-related death. Deaths at two construction sites, figure as that is the average “no let go” value for alternating current
one presenting the coroner with an unusual responsibility Open-trench passing from hand to hand. Further, it is necessary to show that the
excavation - a death resulting in both a large fine stemming from OSHA circuit of more than 16 mamps traversed the body through the chest or
citations, and a civil lawsuit. Homicide - While the great majority of the head or both. With low voltage electrocution the mechanism of
work-related homicides are committed by fellow workers, each of these death is either asphyxia (rarely) or ventricular fibrillation (commonly.)
two cases is a law enforcement officer shot and killed by another Asphyxia is produced by prolonged exposure (minutes) of the chest
because of mistaken identity during a crisis. Manufacturing - death in a causing tetanic contractions of the chest musculature during a through-
chocolate candy factory Death from immersion in a vat at a paper mill the-chest circuit or by seizures induced by a through-the-head circuit.
Accidental death of a lawyer at work Ventricular fibrillation requires a through the chest circuit, of probably

more than 100 mamps of current flow, but of very brief duration, as little This presentation will impact the forensic community and/or
as 0.2 seconds. humanity by emphasizing the importance of a multidisciplinary
For there to be a circuit of more than 16 mamps through a person approach to death investigation.
there must be exposure to voltage sufficient to overcome the resistance The goals of this research project are to recognize the importance
to current flow which the human body presents. For contact through the of a multidisciplinary approach to the investigation of parachute deaths,
skin, requiring the skin to be minimally keratinized, moist and flushed, with an emphasis on the importance of scene investigation and
the resistance is greater than 1000 ohms. Thus to achieve 16 mamps of equipment analysis.
current flow requires 16 volts as a minimal voltage to achieve “no let- Skydiving carries a low but significant risk of harm for participants.
go.” As will be shown, one of the cases involved batteries have a voltage Between 1992 and 2002, there have been between 27 and 44 skydiving
below 16 volts, thus making it a case of over diagnosis. deaths per year in the United States, with an average of approximately
Further, low voltage direct current probably requires much higher 35 deaths per year. As compared with other high risk sports, skydiving
current flows than seen with alternating current making the DC current has a relatively low mortality rate (25 deaths per 100,000 participants,
case even more unlikely. versus SCUBA diving, 25 per 100,000 and boxing, 50 per 100,000 par-
In one of the cases, the conduit through which wires passed caused ticipants). Human error is the most important cause of mortality in sky-
the insulation to be cut, causing a short circuit which blew the fuse to the diving. Equipment failure is considered rare.
transformer. Upon replacement of the fuse, the cut wire arced periodi- Case Report: A 47-year-old male with no significant medical
cally. As the conduit was grounded, it was never ever to have a voltage, history began his dive at 13,000 feet. He deployed his main parachute at
and thus insufficient voltage provided a way to determine over 5000 feet. The position of his body at the time of deployment of the para-
diagnosis. chute was head down. Witnesses observed the parachute deploy
In another case, the possibility of ground leakage, producing a force properly, but the subject did not steer. The subject began to spin, thus
field of varying voltages over distance was proposed as the mechanism tangling his lines. The subject was not observed to make an attempt at
of electrocution. Demonstration of shoes with high dielectric (resistance cutting the lines and deploying the reserve parachute, which would have
to the flow of electricity) made the over diagnosis unlikely. been the correct course of action. The subject fell to Earth in a grassy
In four of the eight cases the autopsy demonstrated causes of death field some distance from his designated drop zone. At the time of his
from other causes than electricity. These included traumatic asphyxia, impact, his body was traveling at somewhat less than terminal velocity,
ruptured AV malformation of the lung, aortic stenosis with cardiomegaly since his parachute was deployed, but deployed imperfectly. Fire-rescue
and buried left anterior-descending coronary artery with ischemic was called, but resuscitation was unsuccessful and he was pronounced at
changes new and old in the distribution of the LAD. the scene.
In two of the cases the deaths were witnessed. In both of these cases External examination showed a mildly obese male with several
there was no involuntary movement produced by the flow of electricity. abrasions, lacerations and contusions. In particular, the left neck had a
A circuit through a person sufficient to cause death causes involuntary transverse, linear, patterned mixed abrasion and contusion. Internal
contraction of the muscles in the circuit 0.2 seconds after the initiation examination demonstrated scant subarachnoid hemorrhage without skull
of the circuit. This results in a scream or shouts if the current passes fractures or cerebral contusions. The organs of the neck underlying the
through the chest. In addition, if the circuit passes through the upper transverse abrasion/contusion had extensive acute hemorrhage. The
extremity there is involuntary flexion. If the circuit passes through the atlanto-occipital joint was several dislocated, without transection of the
trunk and lower extremities there is involuntary extension. Both of these brainstem or proximal spinal cord, but with significant impingement on
phenomena should be described by witnesses who could see and hear the the brainstem and spinal cord structures. Several ribs were fractured.
soon to be deceased. In two the presented cases no such movements The heart had a full thickness laceration of the right ventricle with hemo-
were heard or seen. pericardium. The coronary arteries did not have any atherosclerosis. The
However, the most striking and uniform absence in all of the pre- lungs were contused but not lacerated. The liver and spleen were exten-
sented cases is the pathway to ground. In none of the presented cases sively lacerated.
was there a demonstrable pathway to ground. To have an electrical Examination of the parachute harness demonstrated a torn vertical
circuit there must be a source of electrons and something conductive to nylon strap on the left side, which connected the horizontal chest strap
allow them to flow to a place with fewer electrons. In a low voltage to the leg straps. The vertical strap doubles over through a metal ring to
electrocution there must be a circuit of more than 16 mamps from an allow for adjustment to the harness length between the chest strap and
energized source and the person must be grounded to complete the the leg strap. The edges of the nylon strap were frayed in close prox-
circuit. In all eight cases there is complete absence of pathway to imity to the metal ring. The company owned several other similar har-
ground, thus an analysis of pathway to ground which is simple and easy nesses of the same type, which showed significant wear pattern in the
to do, is the most important criteria to employ in the investigation of a same location.
possible electrocution. Integration of data collected from the scene, autopsy and analysis
Autopsy, Electrocution, Cause of Death of the harness allowed us to surmise that the nylon strap had snapped
when the parachute deployed, thus causing the freely mobile chest strap
on the left to be violently pulled caudally by the deploying parachute,
forcefully abrading and contusing the left side of the neck while
snapping the head backward. This caused the atlanto-occipital dislo-
G13 Accidental Parachuting Death cation, disabling the subject and making self-rescue impossible. The dis-
Due to Equipment Failure turbed flight characteristics of the limp and unbalanced human form
caused the parachute to spin and tangle, hastening the subject’s descent.
Martha J. Burt, MD and Matthew J. Bowes, MD*, Miami-Dade County The death was ruled an accident.
Medical Examiner Department, Number One on Bob Hope Road, Equipment failure as a cause of parachute death is rare, but poten-
Miami, FL 33136 tially preventable. This case underscores the critical importance of
After attending this presentation, attendees will understand the equipment evaluation by a competent analyst.
importance of an integrated approach to determining cause and manner Skydiving Death, Parachute Equipment, Scene Investigation
of death in skydiving related fatalities.

G14 The Richard Cory Phenomenon: tionship issues as the predominant stressors, but financial strain, iden-
tified in only 8% of victims, was the least frequent stressor. Those
Suicide and Socioeconomic Status suicide victims identified with financial strain had even higher mean and
in Kansas City, Missouri median house values than the suicide or control groups (mean of
financial strain group, $77,126; median, $74,050).
Thomas W. Young, MD*, Jackson County Medical Examiner, 660 East The data indicate that suicide victims are: 1) more likely to live in
24th Street, Kansas City, MO 64108; Suzanna Wooden, University of houses than other victims rather than in apartments or trailers, 2) more
Missouri, Kansas City School of Medicine, 2411 Holmes, Kansas City, likely to live in more expensive houses than other victims, 3) more likely
MO 64108; Jinwen Cai, MD and Gerald L. Hoff, PhD, Kansas City to kill themselves because of factors other than financial strain, and 4) if
Missouri Health Department, 2400 Troost, Kansas City, MO 64108; financial strain is a factor, more likely to kill themselves after becoming
Paul C. Dew, MD, MPh, University of Health Sciences, 1750 accustomed to a more affluent lifestyle.
Independence Avenue, Kansas City, MO 64106 Suicide, Socioeconomic Status, Retrospective Study
The goal of this presentation is to present findings from a retro-
spective study demonstrating a positive association between suicide and G15 Suicide: A Ten-Year Retrospective Review
socioeconomic status. of Kentucky Medical Examiner Cases
humanity by enabling the design of more effective public health inter- Lisa B. Shields, MD*, Donna M. Hunsaker, MD, and John M.
ventions for people at risk for suicide. The study also illustrates how Hunsaker III, MD, JD, Office of the Associate Chief Medical Examiner,
data obtained from a coroner or medical examiner agency may be useful 100 Sower Boulevard, Frankfort, KY 40601
for the epidemiologic research of violent death.
Edwin Arlington Robinson’s famous poem, “Richard Cory,” tells The goal of this presentation is to present a retrospective analysis of
how a man of refinement and wealth goes home “one calm summer information gleaned from postmortem examinations of all suicides from
night” and inexplicably puts “a bullet through his head.” The poem the medical examiners’ records in Kentucky between 1993 and 2002;
leaves the reader surprised that a wealthy man with all one could seem- and to correlate this data with national trends regarding suicides.
ingly desire in life kills himself. Is a suicide like his unexpected? This comprehensive report aims to dispel the conventional image of
Results of a retrospective study performed in Kansas City, Missouri, the suicide victim as an elderly Caucasian male afflicted by physical
indicate that suicide actually occurs more frequently among those with disease and demonstrate how suicidal trends have been drastically
more of life’s finer things. altered over the years; and to delineate distinguishing characteristics
The Jackson County Medical Examiner receives reports of and present at the scene and revealed in the medical history that may aid
investigates all deaths from injury and many natural deaths in Jackson investigators in ascribing the manner of death as suicide.
County, Missouri, and maintains a database of information from these According to the Center for Disease Control’s Monthly Vital
investigations. The information includes the home address of each Statistics Report in 2000, suicide ranks eleventh in the United States and
victim. Jackson County Government performs house and personal accounts for approximately 30,000 deaths annually. A host of biological
property appraisals for taxation purposes. Appraisal values for real estate and psychosocial components interplay in the investigation of a suicide.
and personal property can be viewed from the Jackson County Precipitating factors may include domestic quarrels, loss of
Government website (www.jacksongov.org) by the parcel address and employment, financial difficulties, substance abuse, chronic disease, or
by the name of each individual owning personal property subject to tax- mental illness. The commonly held belief of the typical suicide victim
ation. These government home and personal property appraisals tend to includes either an elderly Caucasian male with a debilitating disease or
be lower than actual real market value. a female dying from acute drug intoxication commonly referred to as an
The authors studied all suicides reported to the Medical Examiner overdose. Men are more likely to commit suicide than women.
from 1998 to 2002. They compared appraisals of houses where suicide Researchers attribute the lower number of female suicides to a larger
victims used to live to appraisals of houses lived in by victims from a number of women who may attempt, but fail to commit, suicide by drug
control group of non-suicidal deaths. Each non-suicide control victim overdose. Furthermore, women may be prone to ventilate emotional
was randomly selected from the Jackson County Medical Examiner problems with others in an attempt to avert suicide whereas men are less
database and matched by age, race, sex, and year of death with each likely to admit hardships and are more impulsive in their actions.
suicide victim. Where available, appraisals for personal property owned Although a suicide note may illustrate suicidal intent, it is present in less
by each victim, the victim’s spouse, or the victim’s parents were also than one third of cases reported by some authors.
obtained and compared for each group. Additionally, stressors for sui- This study presents all 2,866 medical examiner cases of suicide
cidal intent, such as financial strain, recent loss of a loved one, rela- between 1993-2002 in Kentucky. The majority of victims were males
tionship difficulties, and health, mental or drug problems, were iden- (81.8%) and Caucasian (94.8%). Black females comprised the smallest
tified for each suicide from investigative reports. group of decedents, consisting of only 0.59% of suicides. Individuals
The suicide and control groups each had 426 victims. Significantly ranged between 11 and 96 years of age with an average age of 42.0
more victims in the suicide group lived in houses than victims in the years. The greatest number of suicides occurred in the fourth decade of
control group (suicide: 70% vs. control: 56.8%, p < 0.001 by chi square life followed by the fifth decade and then the third decade. The preferred
analysis). Appraisal values for the houses obtained for 277 members of mode of death was by gunshot (67.6%), followed by hanging (13.7%),
the suicide group had a significantly higher mean and median compared overdose (10.0%), and carbon monoxide poisoning (4.6%). Of the 1,934
to those of 227 members of the control group (mean: $70,143 for suicide gunshot wound fatalities, 79.5% of the wounds involved the head,
vs. $61,513 for control, median: $62,316 for suicide vs. $50,580 for 18.3% the chest, and 2.6% the abdomen. Both males and females chose
control, p = 0.04 for two means by two-tailed t-test). Personal property a firearm as their primary means of committing suicide, 71.4% and
appraisals were available for only 93 members of the suicide group and 50.5%, respectively. The head was the most likely target of the gunshot
90 members of the control group. Although the mean and median wound in all shooting victims, specifically, 80.4% of the men and 72.7%
appraisals were higher for the suicide group (mean: $3,666 for suicide of the women. 65.5% of black victims utilized a firearm to commit
vs. $3,054 for control, median: $2,750 for suicide vs. $2,045 for suicide, and 83.8% of these were head wounds. In men, the second and
control), the differences were not statistically significant. Analysis of third most common causes of death respectively were hanging (14.5%)
stressors within the suicide group identified mental health and rela- and overdose (5.9%). Conversely, this pattern was reversed in women:

the second leading cause of death was overdose (28.1%) and the third, Emergency resuscitation was initiated by the owner of the home.
hanging (10.3%). Emergency medical services responded to a 911 call and transported the
The review analyzes a myriad of factors that may have prompted an victim to the hospital, where work-up and imaging studies revealed
individual to commit suicide: medical and psychiatric history, domestic diffuse basilar subarachnoid hemorrhage and a ruptured berry aneurysm
relationship problems, substance abuse, financial and legal difficulties, in the basilar artery. He died approximately 36 hours after the initial
and seasonality. The presence of a suicide note, previous suicide collapse.
attempts, family history of suicide, dyadic murder-suicide, and suicide Autopsy confirmed the presence of diffuse, basilar subarachnoid
by cop have also been documented. A discussion of “playing” with a hemorrhage, as well as a ruptured, 9 mm basilar artery aneurysm. Brain
gun known in Russian Roulette and issues related to schizophrenic examination was consistent with global ischemia. The remainder of the
patients who commit suicide will also be presented. Furthermore, this autopsy was significant for cardiomegaly (500 gm), with concentric left
study inventories and discusses the variety of disease processes and tox- ventricular hypertrophy, as well as mild to moderate atherosclerotic car-
icological findings uncovered at autopsy. diovascular disease involving the aorta and coronary arteries. There
Forensic Science, Forensic Pathology, Suicide were no facial injuries identified at autopsy. A blood ethanol level from
the time of hospital admission was 153 mg/dL.
Police investigation confirmed the story as presented above. The
G16 Homicidal Cerebral Artery victim’s wife, the homeowner, her daughter, and the boyfriend all related
Aneurysm Rupture similar scenarios as they recalled the events. The cause of death was
ruled “subarachnoid hemorrhage due to ruptured basilar artery aneurysm
Joseph A. Prahlow, MD*, c/o South Bend Medical Foundation and following blunt head trauma.” The manner of death was ruled
Indiana University School of Medicine, 530 North Lafayette Boulevard, “homicide.”
South Bend, IN 46601 Whether or not “minor” head trauma may cause the rupture of a
After attending this presentation, attendees will understand that, in cerebral artery aneurysm (or arteriovenous malformation) remains a
the correct setting, a natural disease cause/mechanism of death may be controversial topic. Some claim that “significant” or “severe” head
considered a homicide, and to learn a set of proposed criteria for such trauma is necessary, with concomitant skull fractures or brain contu-
deaths involving ruptured cerebral artery aneurysms. sions/lacerations. Others feel that minor head injury is sufficient, in
This presentation will impact the forensic community and/or certain instances, to cause aneurysm rupture. A careful review of the lit-
humanity by addressing the difficult question of whether or not minor erature suggests that minor head trauma may, in fact, contribute to or
head trauma, or even the threat of trauma, can be implicated in a death cause the rupture of an intracerebral aneurysm or arteriovenous malfor-
due to ruptured cerebral artery aneurysm. If trauma (or threats of mation. This appears to be true particularly when the traumatic event (or
trauma) can be considered a contributory cause in such deaths, threatened traumatic event) is associated with intense emotion, with a
“homicide” may be a reasonable manner of death, given the proper cir- rise in blood pressure. Another factor that increases a person’s risk for
cumstances. The paper proposes a set of criteria to help forensic pathol- cerebral aneurysm rupture (traumatic or spontaneous) is ethanol intoxi-
ogists determine whether or not a given case represents a “homicide by cation, due most probably to the considerable intracranial blood vessel
ruptured berry aneurysm.” dilatation known to occur in association with ethanol intoxication.
In 1978, Davis published his classic work, “Can sudden cardiac The following represent a proposed set of criteria for ruling a rup-
tured cerebral artery aneurysm (or arteriovenous malformation) as a
death be murder?”1 In Davis’ paper, a logical, well-reasoned argument
homicide: 1) Head trauma (and/or extreme emotional stress) must imme-
is made for certifying certain cardiac deaths as homicides, so long as a
diately precede the onset of symptoms related to ruptured aneurysm (or
set of specific criteria are met. Using Davis’ criteria, a mugging victim
arteriovenous malformation). 2) Autopsy findings must confirm the
who suddenly collapses and dies from underlying severe coronary artery
presence of a ruptured aneurysm (or arteriovenous malformation), with
disease can be appropriately ruled a homicide. While some forensic
no findings indicating that the rupture occurred prior to the trauma/emo-
pathologists may not agree with such a ruling, the phrase “homicide by
tional stress. 3) When head trauma is implicated, autopsy evidence of
heart attack” remains well-known to many within the forensic com-
physical injury of the face/head may or may not be present. 4) Head
munity.
trauma (and/or extreme emotional stress) must have occurred during or
Cardiac disease is not the only natural disease process that can be
as a result of an event that would normally be considered a form of
considered the underlying mechanism of death in homicide.
criminal activity. 5) In order to implicate the emotional stress of an event
Subarachnoid hemorrhage related to traumatic ruptured cerebral artery
as a cause or contributing cause of the intracranial hemorrhage, the
berry aneurysm or arteriovenous malformation has received some
victim should have realized that the threat to personal safety was
attention in the medical and forensic literature. In this paper, we present
implicit, and the circumstances should be of such a nature as to be com-
a case of “minor” head trauma causing the rupture of a cerebral artery
monly accepted as highly emotional.
aneurysm. The MOD was considered “homicide.” The ensuing dis-
It is important to remember that each case must be evaluated on its
cussion will address this controversial topic and present a proposed set
own. Death scene investigation and witness statements are often of
of criteria useful in making such a determination.
paramount importance, particularly when attempting to address criteria
An intoxicated, 46-year-old man, his wife, and their female friend
#1, #4, and #5. If the criteria are not met, it is prudent not to rule such
returned to the friend’s home late one night, after having been out for
a death as a homicide. In such an instance, an “undetermined” ruling is
dinner and drinks. The man was reportedly loud and boistrous. Upon
acceptable, with or without a statement suggesting that the case may rep-
hearing the commotion, the friend’s adult daughter, who had been
resent a homicide. As a corollary, a modified form of the criteria may be
sleeping, got-up, came-out of the bedroom, and asked them to be quiet,
utilized in an attempt to determine whether accidental trauma can be
since her live-in boyfriend needed to get-up early for work. She then
implicated in deaths related to ruptured cerebral aneurysms or arteri-
stated that she was going back to bed. The 46-year-old man then pro-
ovenous malformations; criteria #4 would not apply in such accidental
posed to the daughter that he might join her in bed. The daughter’s live-
trauma cases.
in boyfriend then emerged from the bedroom and confronted the intoxi-
Reference: 1. J.H. Davis. Can sudden cardiac death be murder? Journal
cated man. A short verbal altercation ensued, followed by a single
of Forensic Sciences 23(2):384-7,1978.
punch, thrown by the boyfriend, that landed on the other man’s face.
The man immediately collapsed to the floor, totally unresponsive. Homicide, Natural Disease, Cerebral Aneurysm

G17 Death by Defibrillator: A Unique Two cases have been reported in which defibrillators were used in
suicide attempts. In one a male nurse discharged the defibrillator into his
Homicide by Electrocution head. He survived and recovered fully. The second case involved a hos-
pital employee who discharged a defibrillator into his chest. He was
Kendall V. Crowns, MD* and Adrienne Segovia, MD, Cook County found in ventricular fibrillation and died despite resuscitative efforts.
Medical Examines Office, 2121 W. Harrison Street, Chicago, IL 60612 No reported cases of the homicidal use of external defibrillators
This presentation will review a case in which an external defibril- were found in a review of the literature. This case represents a unique
lator was used as a weapon, discuss the general features of defibrillators, and to date unreported form of homicidal electrocution.
and review the role of defibrillators in accidents and suicides. Defibrillator, Electrocution, Homicide
This presentation will review a case in which an external defibril-
lator was used as a weapon, discuss the general features of defibrillators,
and review the role of defibrillators in accidents and suicides.
A 49-year-old mentally challenged black male worked as part of a
cleaning crew in a suburban dialysis clinic. According to co-workers
while he was mopping the floor he had a seizure and collapsed to the
floor. Upon their arrival paramedics found the subject in ventricular fib-
rillation and despite full advanced cardiac life support measures
including external defibrillation he was pronounced dead at a local
emergency room.
The autopsy examination showed a well developed, well nourished
black male weighing 189 pounds and measuring five feet nine inches in
height. Externally there were two irregular burn marks: one on the upper
G18 The Influence of Violence in the Media on
left chest measuring 0.9 x 0.6 inches and the other on the upper right Unusual Methods of Murder and Suicide
chest measuring 0.5 x 0.4 inches. Internal examination was remarkable
for a 415 gram heart and 90% atherosclerotic occlusion of the right Karin A. Margolius, MD, LLB* and Gerard A. Cadden, MD,
coronary artery. The remaining coronary arteries were free of athero- PathCentre, Locked Bag 2009, Nedlands, Perth, WA 6009, Australia
sclerotic disease. The lungs and brain were remarkable only for the After attending this presentation, forensic pathologists and crime
presence of edema. A scene investigation was performed which dis- scene officers will learn about he difficulties in detecting hidden homi-
closed no irregularities or the presence of electrical equipment in the cides and that knowledge of the latest media releases is vital in crime
room in which the decedent had worked. The cause of death was scene analysis.
attributed to coronary atherosclerosis and the manner of death was This presentation will impact the forensic community and/or
natural. humanity by describing to the forensic community the subtleties in signs
One week later a member of the cleaning crew came forward of murder; addressing the need to be aware of the latest film releases;
stating that the initial story had been a fabrication. The crew member and addressing the need for an integrated scene analysis team.
revealed that an 18-year-old co-worker, who had tormented the mentally There is a wealth of research about the influence of the media on
challenged decedent on multiple occasions, had turned on one of the violence, particularly homicides. Most recent reports show little or no
clinics external defibrillators which had a preset energy level of 200 correlation between crime and viewing habits. This has not stopped the
joules. The 18-year-old then coaxed the decedent over and discharged calls for censorship of the media which may restrict freedom of speech.
the defibrillator into his chest. Following this statement and police inves- The cases to be presented have been linked to a film in which there
tigation, the cause of death was amended to electrocution and the was an unusual method of causing death. The film showed the perpe-
manner of death was changed to homicide. trator encasing the victims in a film of plastic wrap causing asphyxi-
The first experiments using electricity to stop the heart were con- ation. He then removed the wrap and the murders remained unsolved for
ducted in 1775 using chickens. It was not until 1956, however, that the a long period of time. Similarly subsequent concealment of the homicide
first successful external defibrillation was performed on humans. method occurred in one case so that crime scene analysis would have
A defibrillator delivers 60,000 watts of electricity in four to five been difficult if the recent release of the film had noted been identified.
millisecond intervals with a resultant energy level of 300 joules. This A teenage girl was found lying in an undisturbed bed in the
level of energy is analogous to a bolt of lightning. A properly used defib- bedroom of a house occupied by her boyfriend. She had two broken fin-
rillator delivers a current through the chest wall and heart. This causes gernails, a small bruise on the thigh and a few petechiae in her eyes. Not
the heart to stop and allows the pacemaker cells of the heart to repolarize far from her head was a roll of unused plastic cling-type wrap while the
and re-establish a sinus rhythm. remainder of the wrap was found in the garbage bin some distance away.
There are two general types of defibrillators, external and internal. At trial the perpetrator confirmed that he copied the method of mur-
These can be further sub–divided into either manual or automatic/semi- dering his victim after viewing the film.
automatic types depending on whether an individual or machine recog- In another case a woman was found with the plastic wrap around
nizes the ventricular fibrillation. Defibrillators can be further sub- her head requiring intense crime investigation into the circumstances
divided based on charge direction, monophasic or biphasic of the defib- surrounding her death. After seeing the film, she used the method to kill
rillator. Defibrillator energy levels range from 0 to 360 joules for manual herself. In a similar case suicide was thought to be the manner of death
defibrillators and to a preset range of 200 to 350 joules with auto- in a man who was found with wrap around his head and neck.
matic/semiautomatic defibrillators. Each case will demonstrate the difficulty in scene analysis, the
Among paramedics accidents occur at a rate of 1 per 1,700 defib- problems in excluding homicide and the need for an awareness of the
rillator shocks and 1 per 1,000 for EMTs trained in the use of defibril- latest film releases. There are features in each case that suggest that the
lators. The most commonly reported injuries in these groups are acci- deaths were due to homicide. Each case died after seeing the same film,
dental shocks. In patients, the most common accidental injuries are skin utilizing the same method as shown in that film. The media has influ-
burns, and occasionally myocardial muscle damage. Rarely, an auto- enced the deaths in these cases.
matic defibrillator may shock a patient with a normal rhythm and cause
fatal arrhythmias. Homicide, Media, Concealment

G19 Use of the Impact Baton or So-Called The Greek term necrophilia or necrophilism refers to a morbid
fondness of being in the presence of dead bodies and, in a stricter sense,
“Rubber Bullet” as Less Lethal Force to the impulse to have sexual context or the act of such contact with a
in Air vs. Water dead body, usually of males with female corpses (Stedman’s Medical
Dictionary, 24th ed.). Necrophilia is classified as psychiatric disorder
Darryl J. Garber, MD* and Irwin Golden, MD, County of Los Angeles (other disturbance of sexual preference) and the psychopathology of
Department of Coroner/Medical Examiner, 1104 N Mission Road, Los necrophiliacs is an interesting, but largely unknown field of forensic
Angeles, CA 90033; Lakshmanan Sathyavagiswaran, MD, Chief psychiatry based mainly on the work of Krafft-Ebing from 1886
Medical Examiner-Coroner, Los Angeles County, 1104 N Mission (Psychopathia sexualis). However, since this disorder is directly asso-
Road, Los Angeles, CA 90033 ciated with bodies and body parts, forensic pathologists play an
After attending this presentation, attendees will be able to recognize important role in the investigation of such cases. The following case
and differentiate wounds associated with impact baton, versus gunshot series demonstrates that the anatomical and pathological know-how of
wounds associated with handguns and/or high velocity projectiles. forensic pathology is indispensable for the police investigations and the
Comparison will be made between impact baton wounds occurring in air psychiatric examination. Furthermore, forensic science is necessary to
as opposed to water. reunite body parts by morphological and molecular analysis thus
This is a case of an officer involved shooting with a local law ensuring that a dignified funeral finally can take place which is
enforcement SWAT Team intervention using “less lethal” force which extremely important for the next-of-kin as they try to cope with this trau-
recently occurred at our office. The decedent is a 34-year-old white matizing event.
Hispanic man measuring 69 inches in height and weighing 283 pounds. The chronologically last case of this series, which was the most spec-
The decedent had barricaded himself inside his trailer and was armed tacular, illustrates all features of necrophilia in an extreme dimension
with a weapon. He was apparently depressed over his mother’s illness which, to our knowledge, never was reached in previous publications and
and had a history of drug abuse. Less lethal force was used to subdue case reports.
the decedent in the form of a police dog as well as the use of the “Impact In October 1999, the body of a 14-year-old girl, who had been killed
Baton” or so-called “Rubber Bullet.” The Sage Control Ordnance KO1 by a train accident, disappeared from a morgue at a small cemetery located
ammunition in a 37 mm Arwen 37 Mark III was used. This is known as in a rural area in Northern Bavaria, Germany. Extensive investigations
the Sage Less Lethal Launched Ammunition and Ordnance System were started but did not provide any results. Regional and national media
(L3A0S). The less lethal means used to subdue this man were unsuc- reported on the case and considerable public pressure was exerted on the
cessful and he was ultimately subdued with the use of .223 high velocity investigators.
rifle wounds. The Arwen round wounds observed in this case will be Three months later, a forester observed a man who was taking pho-
compared to a second case in which rubber bullets were used to subdue tographs of intestines spread out in front of him. Although this observation
an armed man in the San Gabriel River in Los Angeles County. In the was not reported to the police until 4 weeks later, the man could be iden-
second case the impact batons were fired through water, thus altering the tified and he immediately confessed having taken and sexually abused the
wound characteristics. No fatal bullet wounds were incurred and the body. Because of beginning putrefaction, the 40-year-old engineer had
man ultimately drowned. started to dissect the body after a few days, removing organs and body
parts such as the intestines, liver, uterus, vagina and breasts. Using these
Rubber Bullet, Impact Baton, Less Lethal specimens, he continued with sexual activities in his home bathroom and
documented every detail with a digital camera. More than 7000 images
G20 Dissection, Preservation and Sexual Abuse were found on his computer hard disk showing extreme situations which
are difficult to cope with even for experienced forensic pathologists.
of Bodies and Body Parts – An Exceptional The remains of the girl consisting of the trunk, parts of the extrem-
Case of Necrophilia ities and the skull were found in a hole filled with mud on the property
of the man. Some of the dissected specimens had been treated with an
Martin Bauer, MD* and Thomas Tatschner, MD, University of alcoholic solution to stop decomposition and could be recovered in his
Wuerzburg, Institute of Legal Medicine, Versbacher Str. 3, Wuerzburg home. He also admitted having abused 2 other cadavers of young
97078, Germany; Michael Roesler, MD, Institute of Forensic females: in 1985 he had opened a casket and mutilated a body by
Psychology and Psychiatry, Saarland University, Kirrberger Straße, removing breasts, eyeballs and other body parts and in 1981 he had dis-
Homburg 66421, Germany; Dieter Patzelt, MD, Institute of Legal membered the corpse of a 21-year-old woman and further dissected and
Medicine, University of Wuerzburg, Versbacher Str. 3, Wuerzburg abused the torso at his home leaving the extremities in the casket. This
97078, Germany body-snatching had not been noticed at that time. From this case there
After attending this presentation, attendees will learn that were still some specimens kept in his home such as a carefully prepared
necrophilia is a rare disorder which can reach extreme dimensions with spine column with the pelvis attached by a Velcro fastening. He was sus-
long-term sexual abuse of dissected and partially preserved body parts. pected of being involved in more cases of body-snatching or body-
He will retain that cooperation between police, forensic pathology and stripping that had occurred in the region between 1985 and 2000 but no
forensic psychiatry is essential to deal with such cases. evidence could be found and he denied those accusations.
Necrophilia is rare and only few cases have been published in the lit- According to German criminal law he was convicted to two years
erature. The cases presented here are unique because the crimes were com- and three months of prison because of disturbance of human remains. A
mitted by one individual in a period of 20 years. The stolen bodies were psychiatric examination was ordered by the court and the diagnosis
dissected and the organs and body parts partially preserved. The offender “necrophilia” (ICD 10: F65.8, other disorder of sexual preference) was
abused the corpse and the dissected body parts in a way that is hard to made. According to the forensic psychiatrist, the criminal responsibility
imagine and he documented this abuse on thousands of digital images. of the defendant was diminished and the probability of repeating similar
The objective of this presentation is to demonstrate a cases of crimes with corpses was high. The risk of committing homicides to
necrophilia committed by a 40-year-old man with mutilation, dissection satisfy his sexual urges in the future was considered to be significant and
and sexual abuse of three bodies and with extensive sexual abuse of dis- he was moved to a criminal mental hospital for an indefinite period
sected body parts which, in the last case, was documented by the of time.
offender on thousands of digital images. Necrophilia, Sexual Abuse, Body Parts

G21 Too Many Causes of Death: G22 Postmortem Analysis of Anastomotic
What’s the Manner? Suture Line Disruption Following
Carotid Endarterectomy
Wendy M. Gunther, MD*, Office of the Chief Medical Examiner and
Department of Legal Medicine, Virginia Commonwealth University, Judy Melinek, MD, New York City Office of Chief Medical Examiner,
830 Southampton Avenue, Suite 100, Norfolk, VA 23510 520 First Avenue, New York, NY 10016; Patrick Lento, MD*, Mount
After attending this presentation, attendees will be able to evaluate Sinai Hospital Medical Center, 1190 Fifth Avenue, New York, NY
the importance of competing causes of death discovered at autopsy. 10029; John Moalli, ScD*, Exponent Failure Analysis Associates, 149
Rank causes of death in a hierarchical order depending on importance to Commonwealth Drive, Menlo Park, CA 94025
the mechanism of death. Integrate scene information, gross autopsy dis- The goal of this presentation is to describe a case report of a suture
coveries, histologic findings, and toxicology results to determine the line disruption following surgery and how proper specimen handling and
hierarchy of causes of death. Relate manner of death to the most microscopic analysis allowed us to determine the cause of this thera-
important cause of death. peutic complication.
humanity by recalling and reviewing the importance of integrating scene humanity by providing this first report of its kind in which a postmortem
information, autopsy findings, histology, and toxicology into the deter- analysis of suture material from a failed suture line implicated improper
mination of the most important cause of death, in order to determine an surgical technique in the death of a patient. In cases where an anastomotic
accurate manner of death. Understand the likelihood of multiple con- failure is successfully repaired, a broken suture is often discarded along
verging natural diseases in the homeless and alcoholic population. with any clot and blood-soaked gauze. The failure may be reported in the
Increase awareness of recognizing significant and even predominating surgical literature or to the suture manufacturer but, without photography
natural disease in persons with worrisome but nonfatal injuries, which or an ultrastructural evaluation of the filament, it cannot be confirmed
may affect determination of manner of death. whether surgical technique or defective manufacturing was at fault.
A 53-year-old homeless man, familiar to local storeowners for In the forensic setting there is a singular opportunity to examine the
about 15 years, had been living for the last three months beneath the sutures and resolve these issues. The findings can have both medico-
trailer of an abandoned tractor-trailer behind a strip mall. Nearby store- legal and public health implications. In this study it was clear that tissue
owners said he appeared to be losing weight, and undergoing general debris and formalin fixation did not significantly hinder such an analysis
health degeneration. He had no regular medical care. He had a history of and we, therefore, recommend that in future death investigations of this
admission to local hospitals for peptic ulcer disease and for chronic pan- nature, the medical examiner should refrain from handling the suture
creatitis, with a splenic artery aneurysm recognized at one admission. ends with dissecting implements, and preserve the anastomotic suture
The night before his death, children were observed throwing rocks in his line with the surrounding tissue en-bloc so that a more detailed analysis
direction. The children ran off when adults approached. can be performed.
He was found dead beneath the trailer, surrounded by empty beer The tensile strength of a surgical suture is essential in maintaining
cans and vodka bottles. The scene investigators saw a bruise behind his the integrity of vascular anastomoses. In the surgical literature, there
left ear. At autopsy, he had numerous bruises of different ages on his have been several reports of suture line disruptions due to apparent
shoulders, arms, chest, and legs, although no external bruise was appre- fracture of polypropylene suture, including failure of an atrial septal
ciated in the livor behind his left ear. Small abrasions were noted on his defect repair, a proximal anastomosis of a coronary artery bypass, an
elbow and hand; there was no other evidence of external injury. aortic closure in a patent ductus arteriosus repair, a femoral-popliteal
The following lesions were found on internal examination: a small bypass repair, and a carotid endarterectomy. These previous case reports
subgaleal hemorrhage behind the left ear, with a recent left-sided sub- do not present a detailed analysis of the suture tips and there is no pho-
dural hematoma; fresh injury to the left thoracic wall, without rib tography to document the findings.
fracture; three separate ulcers or tears at the esophageo-gastric junction, While faulty operative technique and the loading strength of indi-
one of which appeared to have perforated, but might have been post- vidual sutures have been implicated in spontaneous suture line disrup-
mortem; an ostium secundum defect of the heart, with right ventricular tions, there has, to date, never been a published post-mortem analysis of
dilatation; slight coronary atherosclerosis, with a left predominance of a suture that has known to have failed. We present the case of suture line
the coronary system, and with a remote infarct of the posterior left ven- disruption leading to fatal exsanguination in a 77-year-old man
tricle, which was surrounded by a faint hyperemic area; micronodular following carotid endarterectomy with a facial vein patch. As part of the
cirrhosis of the liver, with diffuse, prominent fatty change; severe public health role performed by the medical examiner’s office and in
chronic pancreatitis, with a stented splenic artery aneurysm; three peptic compliance with the requests of family, hospital and the suture manu-
ulcers in the first part of the duodenum, without frank bleeding; an intra- facturer, we performed a detailed analysis to address the question of
hepatic aneurysmal dilatation of a large branch of the portal vein, with whether the suture or the surgical technique were at fault.
thrombosis; and moderately severe emphysema with chronic bronchitis. A 77-year-old white man with a history of hypertension, coronary
It was not possible to answer police inquiry, at gross autopsy, as to which artery disease and remote myocardial infarction underwent a carotid
of these had caused his death; or whether his manner of death was endarterectomy for high-grade stenosis of the right carotid artery. Under
natural, accident, or homicide. general anesthesia, the endarterectomy was performed and a right facial
What do you do when you have too many causes of death, without vein patch was placed using a double armed, #6-0 Prolene suture. He
a clear manner? The ramifications of multiple severe illnesses and expired approximately 18 hours after surgery, following a sudden, fatal
injuries in a single case are discussed, particularly in a setting of home- exsanguination from the surgical site. At autopsy, there was a 1 cm
lessness and chronic alcoholism, with relevance to the manner of death. defect of the sutured anastomotic line. At the defect, two suture tips were
Multiple Causes of Death, Manner of Death, Alcoholism identified: a straight cranial end and a tightly coiled caudal end. There
was no knot on either side, nor were any loose suture fragments iden-
tified. The smooth edges of the vein graft and carotid artery confirmed
that the tissue itself didn’t fray or tear.

The carotid specimen was preserved en-bloc in 10% formalin and attempt to delineate the best analytical method, this study involved the
photographed using both dissecting and scanning electron microscopy. collection of easily obtainable blood samples, from normal living
Examination of the specimen under a dissecting microscope demon- donors, which were stored at room temperature, then assayed for DNA
strated that other suture knots from the specimen, some involving vas- content at varying times post collection (0-191.5 hrs) to determine the
cular ligatures and others involving a distant line of interrupted sutures, amount of DNA degradation. This amount of degraded DNA was quan-
were tied in stacked granny or half-hitch configurations. Several of these tified using two different computer programs: CellQuest™ v. 3.11
interrupted sutures were in various stages of untying, with one that had (Becton-Dickinson, San Jose, CA) and Modfit™ v. 3.0 (Verity Software,
completely untied but had not yet pulled through the tissues. Topsham, ME, U.S.A). The first program allows for subjective analysis
For scanning electron microscopy, suture tips from the disrupted of the amount of DNA degradation, while the second program uses a
anastomotic line and from elsewhere on the specimen were carefully computer model which can objectively assign the amount of DNA
removed and oriented. For controls, several #6-0 Prolene control sutures degradation, without user input.
were removed directly from the manufacturing package and were alter- After DNA degradation determination by both computer programs,
nately cut with a scalpel blade, surgical scissors, or were manually the relationship of DNA degradation and sample age was plotted and
broken and “popped off” the suture needle. Ultrastructural photography further analyzed with a random coefficient statistical model to yield a
demonstrated that suture tips cut by a scalpel have a squared-off, straight population regression curve.
edge while ones that have been cut by scissors are flattened or wedge- The validity of this curve was then tested using blood collected
shaped with horizontal linear shear marks along the cut surface. from another group of normal donors and analyzed at varying times in a
The microscopic shape and contour of the disrupted suture tips, and blind study. In 20 of 28 samples, a correct 24 hour period was able to be
the complete absence of a knot or additional suture fragments, indicated assigned (71%). These preliminary results suggest that a mathematical
that surgical technique (an untied knot) was the cause of the suture line model, combined with objective computer analysis, can be applied to the
disruption. The removal of a broken or untied suture at surgery or at monitoring of DNA degradation of cellular material, and can potentially
autopsy should not preclude proper analysis of the failed suture, as the become a tool in determining post-mortem interval.
results can have both medico-legal and public health implications. Post Mortem Interval, Flow Cytometry, DNA Degradation
Forensic Science, Forensic Pathology, Anastomosis
G23 Advanced Flow Cytometric DNA G24 The Impact of Dermatologic Consultation
Degradation Analysis: Utility in in Autopsy Examination: A Case of
Postmortem Interval Estimation Pseudoxanthoma Elasticum
Erica Williams, MD*, Hospital of the University of Pennsylvania, Carrie L. Kovarik, MD*, UT Clay J. Cockerell, MD, Sheila D.
Department of Pathology and Laboratory Medicine, 6 Founder Building, Spotswood, MD, and Jeffrey J. Barnard, MD, University of Texas
3400 Spruce Street, Philadelphia, PA 19104; Andrew Bantly, BS, Southwestern Medical School - Forensic Science, 5323 Harry Hines
Hospital of the University of Pennsylvania, Abramson Cancer Center Boulevard, Dallas, TX 75390
Flow Cytometry and Cell Sorting Shared Resource, 3400 Spruce Street, After attending this presentation, attendees will understand and
Philadelphia, PA 19104; Jesse Chittams, MS, University of Pennsylvania realize the usefulness of dermatologic consultation in autopsy examina-
School of Medicine, Department of Biostatistics and Epidemiology, 3400 tions through a case presentation of pseudoxanthoma elasticum.
Spruce Street, Philadelphia, PA 19104; Jonni Moore, PhD, Hospital of This presentation will impact the forensic community and/or
the University of Pennsylvania, Abramson Cancer Center Flow humanity by demonstrating that a dermatology consultation may be a
Cytometry and Cell Sorting Shared Resource, 3400 Spruce Street, very useful addition to forensic and hospital autopsies. We present an
Philadelphia, PA 19104 example of how this consultation may lead to the diagnosis of systemic
After attending this presentation, attendees will be able to disease and possible cause of death.
determine if application of a statistical model and objective computer Dermatologic consultation in the autopsy examination may be very
modeling to DNA degradation data will yield reproducible, accurate useful in many cases. We present a case of pseudoxanthoma elasticum,
results, and help in post-mortem interval estimation. a genetic disease, that was diagnosed by a thorough external exami-
This presentation will impact the forensic community and/or nation and histologic evaluation of the skin.
humanity by providing preliminary results which indicate that more A forty-nine-year old white female was found unresponsive in an
advanced analysis, including statistical evaluation and computer mod- apartment fire and was taken to the local area hospital. On arrival, the
eling, of DNA degradation data is possible. These methodologies could patient was in asystole and had a carbon monoxide concentration of sixty
be then be applied to forensic autopsy samples to assess their validity in percent. She was also found to have evidence of smoke inhalation and
estimating a post-mortem interval. burns over approximately fourteen percent of the total body surface area.
This poster will show data used to develop a mathematical model The patient was pronounced dead and was transferred to the Dallas
for PMI estimation as well as juxtapose two different flow cytometric County Medical Examiner’s Office.
computer models in an effort to select the most reliable methods of On skin examination, the patient had a large leathery, firm, dark
estimation. brown plaque with surrounding erythema on her back and right flank.
Over the past decade, since the first proposal by Cina that flow On the leading edge of the plaque, there were multiple bullae and skin
cytometry might be useful in post-mortem interval estimation by moni- sloughing. The leathery plaque was clinically consistent with the most
toring DNA degradation, several papers have been published attempting severe burn site and was likely the area closest to the heat source given
to establish a link. Using flow cytometry, previous studies on splenic the intense drying of the skin. The bullae and skin sloughing was clini-
and hepatic tissue have suggested that cellular DNA degradation cally consistent with a third degree, full thickness, burn. On the skin of
increases with time, and could thus potentially be used as a tool for post- her neck, anticubital fossa, and inguinal area, the patient had small
mortem interval estimation. However, much of this previous work has yellow papules and a wrinkly appearance that resembled “plucked
been focused on selecting the best type of sample for analysis, rather chicken skin.” A biopsy was taken of the bullae on the right flank and
than on perfecting the technique and analysis of the data obtained. In an the skin the inguinal area.

The biopsy of the bullae was consistent with a full thickness burn sponsive. Hearing the daughter scream, her fiancée went upstairs. The
and showed a necrotic epidermis and polarization of the nuclei around daughter called 911 while the fiancée started cardiopulmonary resusci-
the hair follicles. The biopsy of the skin taken from the inguinal area was tation. When the paramedics arrived, they continued resuscitation using
characteristic of pseudoxanthoma elasticum and showed degeneration of a mechanical cardiopulmonary resuscitation system. Despite all efforts,
the elastic fibers in the middle and lower dermis. On hematoxylin and the decedent was pronounced dead at the scene.
eosin staining, the elastic fibers were basophilic, irregular, and widely External examination showed an abrasion on the top of the head,
dispersed among the collagen bundles. On von Kossa staining, these abrasions on the right side of the forehead, the right cheek, and the right
elastic fibers were highlighted in a dark brown color. side of the nose, and contusions of the lateral right eyebrow and left
Pseudoxanthoma elasticum is an autosomal recessive disorder due temple. There were petechial hemorrhages on skin of the forehead, the
to a mutation in the ABCC6 gene on chromosome 16. The patients have upper and lower eyelids, and cheeks. There were petechial and con-
clumped, distorted, calcified elastic fibers which manifest as disease in fluent hemorrhages of the conjunctivae and sclerae. There were large
many organ systems. The patients typically have flat, yellowish papules abrasions on the lateral left chest and abdomen. There was a contusion
on the skin of flexural areas that sometimes coalesce to resemble of the left knee. The decedent’s doctor was contacted and reported that
“plucked chicken skin.” Most patients also develop angioid streaks in he considered this death sudden and unexpected.
the eye that may lead to blindness, and many develop progressive calci- This presentation will discuss the autopsy findings of this case and
fication of the medium sized arteries which leads to hypertension and two additional cases in which a mechanical cardiopulmonary resusci-
myocardial infarctions at a much younger age. Patients may also have tation system was used. The City and County of San Francisco Medical
calcification of the cerebral and gastric vessels. Examiner’s Office participated in the development of prototypes of a
Upon further investigation into this patient’s history, she was found mechanical cardiopulmonary resuscitation system (Revivant
to be blind and have severe hypertension. These findings, along with the AutoPulse). Recently, the San Francisco Fire Department emergency
characteristic histologic findings on skin biopsy, lead to a definitive personnel began using this mechanical cardiopulmonary resuscitation
diagnosis of pseudoxanthoma elasticum. This disease has tremendous system in the field. This presentation will discuss the rationale and
implications for the family given that it is inheritable and may cause sig- operation of mechanical cardiopulmonary resuscitation systems and
nificant morbidity and mortality. associated findings at postmortem examination.
Dermatologic consultation was extremely useful in this case, given Forensic Pathology, Resuscitation Artifact, Mechanical
that the skin findings, combined with the knowledge of the patient’s Cardiopulmonary Resuscitation
medical history, provided the diagnosis of a rare, genetic, and life threat-
ening disease.
G26 Screening Items of Evidence for the
Dermatology, Consultation, Autopsy
Presence of Body Fluids/DNA in
G25 Homicidal Injury or Forensic Biology Casework —
Resuscitation Artifact? A Hypothesis-Driven Approach
Amy P. Hart, MD*, Venus J. Azar, MD, and Boyd G. Stephens, MD, Melissa Kell, BSc, Sobia Malik, MSc, Gerry Alderson, MSc*, and
Medical Examiner’s Office, City and County of San Francisco, 850 Andrew Greenfield, MSc, Centre of Forensic Sciences, 25 Grosvenor
Bryant Street, San Francisco, CA 94103 Street, Toronto, Ontario M7A 2G8, Canada
After attending this presentation, attendees will become aware of After attending this presentation, participants will learn how the
resuscitation artifact created by mechanical cardiopulmonary resusci- implementation of various case screening strategies and initiatives
tation systems. developed in response to case hypotheses has assisted in addressing per-
Objectives: to present a case of resuscitation artifact from tinent forensic questions in a timely and efficient manner.
mechanical cardiopulmonary resuscitation system which could be This presentation will impact the forensic community and/or
potentially confused with homicidal injury and two additional cases humanity by adapting processes and undertaking examinations specifi-
involving the use of a mechanical cardiopulmonary resuscitation system; cally in response to hypotheses formulated by information in case his-
and, to discuss the mechanical cardiopulmonary resuscitation system tories has permitted us to work more efficiently while addressing the
used in the City and County of San Francisco. most pertinent questions in cases. Sharing these successes will assist
Evaluation and correct identification of resuscitative artifact is other laboratories in implementing similar measures.
critical in the diagnosis and determination of cause and manner of death This poster will present specific examples of case screening
in certain cases. Resuscitative artifact can emulate inflicted injuries and strategies and initiatives adopted at the Centre of Forensic Sciences
possibly be misinterpreted. Occasionally new technology and/or medical (CFS) designed to facilitate hypothesis-driven examinations. The aim is
procedures will create original and distinctive artifact. This presentation to promote the examination of relevant items only, in a manner that is
discusses one new technology and its related artifact. timely and efficient.
The decedent is a 69-year-old obese white man with a history of Many forensic cases require a small number of items to be
hypertension who is found dead on the floor of the bedroom/office in the examined in order to address the pertinent questions at hand. On the
home that he shared with his daughter and a downstairs tenant. On the other hand, larger and more complex cases require that decisions be
evening of his death, his daughter was out with her fiancée. During the made with respect to which items are to be examined, the order in which
evening, the decedent reportedly engaged in a verbal altercation those items are examined, and, given a particular result, the necessity of
regarding the use of the oven in the kitchen with the downstairs tenant. additional examinations. Information provided though the case history
The tenant reported that the landlord seemed very agitated, angry, and and case conferencing as well as knowledge gained through experience
tense, which was unusual for him. The tenant called the decedent’s and training can be used to formulate a hypothesis in accordance with
daughter, who returned with her fiancée to the residence. While the the scientific method to address these decisions.
daughter’s fiancée was speaking with the tenant he noted an abrasion on Recently, CFS case screening procedures were updated and further
the back of the tenant’s right hand, which the tenant claimed was from aligned with the principles of hypothesis testing. An increased emphasis
striking a wall after the verbal altercation with the landlord. The was placed on assessing the relevance of an examination. The following
daughter went upstairs and found her father lying on the floor, unre- statement from our DNA Case Screening Manual is one example:

“Scientists are required to evaluate the relevance of an examination Ultimately, the hypothesis-based approach promotes representative
using the principle of reasonable expectation and to be mindful of the sampling over exhaustive sampling and leads to more meaningful results
limitations such an examination confers.” for clients in a timely fashion.
The approach is demonstrated through the following examples of Case Screening, Forensic Biology, Hypothesis Testing
classes of cases typically encountered at the CFS:
Sexual Assault Cases
Sex assaults comprise roughly two thirds of the workload of the
Biology Section. Examples of initiatives undertaken to screen items
G27 Fatal Kawasaki Disease Associated With
more quickly in accordance with the case history provided include: Cardiac Rhabdomyomas in an Infant
• The sexual assault examination kit (SAEK) provided to treatment
centres throughout the province has been redesigned such that Erik K. Mont, MD*, Miami-Dade County Medical Examiner
only relevant samples are collected. Furthermore, the design of Department, Number One on Bob Hope Road, Miami, FL 33136; Allen
the kit dovetails with our screening procedures in the laboratory, P. Burke, MD, Armed Forces Institute of Pathology, Department of
and provides samples that can be retained for independent testing. Cardiovascular Pathology, 6825 16th Street, NW, Building 54, Room
• In sexual assault cases, relevancy of item examination is evaluated 2005, Washington, DC 20306
and hypothesis-based flowcharts govern the order in which The purpose of this report is three-fold: to present a hitherto
selected items are examined. When vaginal intercourse is the undescribed association (Kawasaki disease and cardiac rhabdomyoma);
only allegation, oral and rectal samples are not examined. Vaginal to illustrate an extremely rare cause of sudden death in infants
samples are examined beginning with the examination of the (cardiac tamponade due to a ruptured Kawasaki aneurysm); and to
vaginal smear. If semen is identified, DNA testing of the vaginal demonstrate the co-existence of two coronary complications of
swab is immediately initiated and case screening is terminated Kawasaki disease: proximal coronary aneurysm (common) and non-
pending DNA results. In the absence of semen on the vaginal aneurysmal stenosis (rare).
samples, underwear from the complainant is examined for the This presentation will impact the forensic community and/or
presence of semen and/or saliva only if vaginal penetration and/or humanity by presenting a hitherto undescribed association in a rare
cunnilingus is alleged, and if the underwear were worn shortly cause of death (cardiac rhabdomyomas in fatal case of Kawasaki disease
after the alleged assault. Clothing is examined for the presence of due to rupture of a coronary aneurysm in an infant).
semen only if the case history indicates that external ejaculation is The purpose of this report is three-fold: to present a hitherto unde-
suspected or if the complainant cannot reliably describe the scribed association (Kawasaki disease and cardiac rhabdomyoma);
circumstances of the assault. to illustrate an extremely rare cause of sudden death in infants (cardiac
• A process was designed to expedite the examination of micro tamponade due to a ruptured Kawasaki aneurysm); and to demonstrate
scope smears made from internal samples collected during the the co-existence of two coronary complications of Kawasaki disease:
SAEK. The examination provides a rapid screen in order to proximal coronary aneurysm (common) and non-aneurysmal
expedite the processing of positive sexual assault cases while stenosis (rare).
minimizing the consumption of related samples. Introduction: Kawasaki disease (KD), or mucocutaneous lymph
• A Cold Case Program was established through the joint efforts of node syndrome, is an inflammatory disease of infants and children that
the CFS and a major metropolitan police service. This initiative is often associated with a systemic vasculitis preferentially involving the
involves the examination/re-examination of unsolved cases by coronary arteries. Although the acute illness usually resolves sponta-
targeting only those cases and those items that are most likely, neously, 15-30% of untreated children develop cardiovascular complica-
based on case history, to produce a DNA result attributable to the tions, including proximal coronary artery aneurysms and rarely coronary
perpetrator. Strict criteria for submission as well as a hypothesis- stenosis without aneurysm formation. Fatal complications are
based flowchart provided to investigators ensure submission of uncommon, occurring in an estimated 0.5% of cases. Sudden deaths are
only relevant items, which leads to a timely examination and the usually related to myocardial ischemia secondary to thrombosis of
highest chance of success. coronary aneurysms or coronary scarring. Among fatal cases of KD,
Property Crime Cases coronary artery rupture has been reported in approximately 5% of those
The CFS has initiated a “Break and Enter” program to accom- autopsied.
modate the submission of evidence from break and enter cases where no KD usually afflicts children under five years of age, and the diag-
suspect is known. The focus of this program is to produce DNA profiles, nosis is based on a constellation of clinical features. The signs include
in a timely fashion, for upload to the National DNA Databank in cases fever unresponsive to antibiotics, cervical lymphadenopathy, bilateral
where there are no other investigative leads. To control a potentially conjunctival injection, labial and oropharyngeal mucosal erythema and
unmanageable influx of break and enter casework, strict guidelines were fissuring, and cutaneous erythema and exanthema that often involves the
established to target the submission of one item per case that is most palms and soles. Infants under six months of age can present with
likely to be attributed to the perpetrator. Items that are accepted as per aggressive coronary vasculitis with aneurysms in the absence of the
the guidelines include swabs of blood, cigarette butts, and swabs from typical clinical signs.
drink containers. Items such as swabs of doorknobs, where there is a The etiology of KD is unknown. Although a number of toxins and
prior expectation of low levels of DNA having been deposited through infectious agents have been implicated, acting as direct pathogens or via
innocuous means, are not accepted. superantigen mediated autoimmunity, no constant associations have
Blood Cases been identified. Moreover, case reports have described rare cases of KD
The principle of hypothesis testing can also be applied in situations occurring in association with other medical conditions, including con-
where the examination for the presence of blood is required. For genital anomalies of the coronary arteries, Beckwith-Weidemann syn-
example, when processing assault cases where the case history suggests drome, and cystic fibrosis. To our knowledge, KD has not been previ-
only one bleeding person (complainant), and where a large number of ously reported in association with cardiac rhabdomyomas.
items from the suspect are submitted, the examination of a single item is Cardiac rhabdomyomas are rare congenital hamartomatous tumors
sufficient if in fact blood is detected. Item selection is based on the cir- usually discovered in infants and children. Most are multiple, occurring
cumstances of the event (e.g., a shoe, if there was kicking involved, or anywhere in the myocardium. Rhabdomyomas of the heart are strongly
the outermost upper garment if there was punching or an assault with a associated with tuberous sclerosis. The clinical presentation and prog-
weapon). nosis depend on the size and location of the tumors.

Clinical History: The decedent was a four-month-old white male G28 Hmong Cultural Aversion to Forensic
infant who was the product of a 38 week gestation, delivered via
cesarean section for maternal pre-ecclampsia. The early neonatal period
Autopsy: Bridging Communication
was marked only by transient hyperbilirubinemia, which resolved spon- and Cultural Barrier
taneously. The infant was healthy until approximately three months of
age, when he developed a cough and intermittent fevers that reportedly Thomas K. Resk, MD*, PO Box 3215, Chico, CA 95927-3215; Thomas
responded to treatment with acetaminophen. He was seen by his A. Rudd, MD, PO Box 332, Highwood, IL 60040-0332
primary pediatrician several times during the ensuing 2-3 weeks and The goal of this presentation is to share with the forensic com-
diagnosed with otitis media. Despite treatment with antibiotics, fevers munity practical experience in communication methods, including the
and cough persisted, prompting an emergency department visit. At the use of community public radio broadcasting, to both increase under-
time, his temperature was recorded at 102.1. He had no lym- standing of the autopsy and to lessen cultural resistance to forensic
phadenopathy, rash, or oral mucosal abnormalities, although redness of autopsy among the Hmong cultural community in the USA.
the eyes was noted. He was discharged home with continued antibiotics This presentation will impact the forensic community and/or
and symptomatic treatment. Ten days after being examined in the emer- humanity by increasing understanding and acceptance of the forensic
gency department, the infant became suddenly unresponsive while being autopsy by Hmong people as an instrument of “good” for the entire com-
dressed by his mother. Resuscitative efforts were unsuccessful. munity as well as greater sensitivity by the forensic community to the
Autopsy Findings: The body was that of a well-developed, well- culture of the Hmong and their desired treatment of the dead.
nourished white male infant who was large for the age of four months. This poster presents the work of the authors and a dedicated group
The skin was pale and free of exanthema. The oral mucosa was free of of Hmong who addressed a series of cultural problems discovered
lesions, and the conjunctivae were clear. There was no lym- during the course of a routine forensic autopsy performed on an Hmong
phadenopathy. The brain was free of tubers, and the kidneys had no elderly woman, a member of one of the five Hmong clans living in Butte
masses. The pericardial sac was distended with 400 cubic centimeters County, located in northern California. After resolution of the cultural
of partially clotted, bright red blood. The heart was normally formed. issues of this individual clan member, the scope of our work was
The epicardial coronary arteries were markedly thickened and firm, most expanded to examine cultural objections to autopsy by all eighteen clans
with a cord-like appearance. Focally (predominantly in the distal left which compose the some 300,000 Hmong currently residing in the
obtuse marginal branches), the arteries had a beaded appearance, with United States. Over several months a series of meetings to identify
areas of thickening alternating with thin, grossly normal-appearing seg- Hmong cultural/religious objections to autopsy were held among
ments. The proximal right coronary artery had a 0.8 x 0.8 x 0.7 cen- members of the Hmong community, the Butte County Chief Deputy
timeter thin walled aneurysm with a 0.1-0.2 centimeter rupture in the Coroner, and the county forensic pathologist. Given deeper insight,
epicardial surface. Transverse sections of the thickened arterial seg- understanding, and sensitivity to the Hmong cultural aversion to autopsy
ments demonstrated firm, yellow-white, circumferentially thickened examination, a number of mitigating steps were initiated by the Butte
arterial walls surrounding narrow, focally pinpoint residual lumina. The County Sheriff-Coroner and forensic pathologist which assured sur-
cardiac valves and chamber dimensions were normal. The myocardium viving Hmong relatives that the spirit of their deceased family member
was firm, red-brown, and free of gross abnormalities. A 0.2 x 0.2 x 0.2 could enter the after-life with minimal negative cultural consequences
centimeter smooth excrescent nodule was on the right ventricular aspect for the decedent. The risk of the decedent’s spirit returning to haunt sur-
of the septum, just below the right ventricular outflow tract. The endo- viving relatives because of the perceived failure of the relatives to
cardial surfaces were otherwise unremarkable. The pulmonary artery, prevent autopsy, a palpable fear among the relatives, was also elimi-
the aorta, and the major systemic arterial branches were free of thick- nated. At the same time the requirements of the law necessitating
ening or other gross abnormalities. forensic autopsy were also upheld.
Microscopic examination: Histologic sections of the coronary Mitigating steps initiated included:
arteries demonstrated diffuse chronic and mixed inflammatory infiltrates (1) Performing a full autopsy only when absolutely necessary.
involving the intima, media, and adventitia. Focally, the inflammation (2) When a decedent coming to forensic autopsy was known, or
was accompanied by intimal hyperplasia and non-occlusive adherent suspected, to be Hmong, the next-of-kin was contacted by the forensic
luminal surface thrombi. The media was focally disrupted and oblit- pathologist to inform them that an autopsy would be done and for what
erated. Both the media and the adventitia had large areas of sclerosis and purpose. An offer for the family to elect a family member, or family rep-
neovascularization resembling granulation tissue. Sections of the right resentative, to ‘talk’ to the spirit of the dead person prior to autopsy in
coronary aneurysm demonstrated attenuation of the arterial wall with the presence of the body was proffered. Because of the Hmong belief
destruction of the media and transmural mixed inflammation with that the spirit resides in the dead body, it is believed possible to commu-
eosinophils. The thin wall was focally disrupted, with transmural fibrin nicate to the person’s spirit after death. The purpose in talking to the
deposition at the rupture site. Myocardial histologic sections revealed dead body was to relate why an autopsy had to be done for which the
multiple small subendocardial and intramural rhabdomyomas in the left family members bore no responsibility. Currently, a native Hmong-
and right ventricles, characterized by well demarcated foci of large, clear speaking liaison between the Hmong community and the Coroner’s
cells, some with spider cell morphology. Office is being sought to replace the time consuming contact role of the
Discussion: Coronary artery aneurysm rupture due to KD and forensic pathologist.
cardiac rhabdomyomas are both independently rare. To our knowledge, (3) Replace all organs back into the body after autopsy.
they have not been previously reported together. In addition, the coex- (4) Allow no metallic foreign items to be left in the body after
istence of proximal aneurysm with diffuse non-aneurysmal stenosis in autopsy.
the acute phase of KD is described. The relationship, if any, between the Delay performing the autopsy until appropriate family ritual
these entities is not clear, and the rhabdomyomas may represent an inci- arrangements could be made.
dental finding in this case of fatal KD. Recognizing that the Hmong cultural aversion to autopsy affected
Kawasaki Disease, Rhabdomyoma, Coronary Aneurysm not only the local community but also the broader Hmong community
throughout the United States, a one hour long radio program titled,
“Forensic autopsy and the Hmong” was carefully scripted employing
very simple Hmong terms to explain medical terms totally foreign to the
Hmong language. The radio program was broadcast over a local

northern California Community Public Radio station, FM 90.1 KZFR – arrhythmia inducing substances and medications, and/or defibrillator
Chico, with an estimated local listening audience of 4,000 Hmong. The placement. Surviving family members may therefore benefit from coun-
radio program was recorded, burned to CD, and redistributed throughout seling and electrophysiologic screening. These interventions have the
the United States to numerous Hmong Cultural Centers as well as potential to save lives.
forensic pathologists who expressed an interest through the National Long Q-T Syndrome, Molecular Diagnosis, Arrhythmia
Association of Medical Examiners (NAME) intenet-based computer
listserve.
A conservative estimate is that tens of thousands of Hmong lis-
G30 Is Hypertension a Risk Factor for Fatal
teners will ultimately be exposed to this radio program. Rupture of Intracranial Aneurysms?
Hmong Culture, Autopsy Resistance, Radio Broadcast
Ana Rubio, MD, PhD*, Office of the Chief Medical Examiner, 111
Penn Street, Baltimore, MD 21201; Christopher Cox, PhD, Division of
G29 Postmortem Diagnosis of Genetic Epidemiology, Statistics and Prevention, National Institute of Child
Arrhythmia Syndromes Health and Human Development; DHHS, 6100 Executive Boulevard,
Room 7B05, Bethesda, MD 20892; David Fowler, MD, Office of the
Carolyn H. Revercomb, MD*, Northern District Office of the Chief Chief Medical Examiner, 111 Penn Street, Baltimore, MD 21201; Juan
Medical Examiner, Fairfax, Virginia, and Department of Legal Troncoso, MD, Neuropathology Unit; Department of Pathology,
Medicine, Virginia Commonwealth University School of Medicine, Johns Hopkins School of Medicine, 720 Rutland Avenue, Baltimore,
9797 Braddock Road, Fairfax, VA 22032 MD 21205
After attending this presentation, attendees will understand current After attending this presentation, attendees will be able to describe
methods of postmortem diagnosis of genetic arrhythmia syndromes. detail of the characteristics of the subjects dying from ruptured berry
Genetic arrhythmia syndromes, which are almost certainly under- aneurysms, including age, gender, and risk factors, detailed location,
diagnosed by medical examiners, have been theorized to cause some size, and anatomic extension of the subarachnoid hemorrhage depending
deaths from Sudden Infant Death Syndrome and have been implicated in on the location; and describe the risk factors for fatal rupture of berry
the development of fatal arrhythmias during exercise. A presentation by aneurysms.
an M.E. about cases where genetic analysis supported an etiology for This presentation will impact the forensic community and/or
fatal arrhythmia may encourage others to increase their index of sus- humanity by demonstrating a better understanding of the epidemiology
picion for these disorders and to support efforts to develop cost-effective and risk factors of nontraumatic subarachnoid hemorrhage, specifically
screening methods. ruptured berry aneurysms
Genetic disorders predisposing to sudden death from arrhythmia in Background: Berry (saccular) aneurysms of the circle of Willis
the absence of cardiac anatomic abnormalities account for an unknown arteries are the most common cause of fatal subarachnoid hemorrhage in
number of deaths presenting to the medical examiner. Two cases illus- the absence of pre-existing trauma. The incidence of intracranial berry
trate the importance of clinical history in such deaths and the methods aneurysms increases with age, with a 1% prevalence in the overall pop-
by which postmortem diagnosis of these conditions can be accom- ulation, 2% in middle age individuals and 5% in older people. The
plished. annual risk of rupture is estimated as 0.6%, with a very high fatality rate.
A 15-year-old girl collapsed in front of witnesses while swimming Berry aneurysms have a multifactorial etiology. They are most com-
and died despite immediate medical attention. Autopsy revealed no monly found at points of branching. An underlying defect in the wall of
injuries, anomalies or acute disease process, and electrolyte analysis and the vessel where the aneurysm subsequently forms is frequently found.
toxicology were non-contributory. Medical history was significant for They are familial in about 5% of the cases, and multiple in a similar per-
two fainting episodes in the past year under conditions of emotional centage of cases. Besides age, other risk factors for the development and
stress. Review of antemortem EKG’s showed mild prolongation of the rupture of berry aneurysms are smoking, hypertension, heavy alcohol
Q-T interval and increased Q-T with increased heart rate. Molecular use or drugs. The role of hypertension in the development and rupture
studies of frozen myocardium have shown a mutation in a cardiac ryan- of aneurysms is controversial, and there are no previous studies corre-
odine receptor gene associated with catecholaminergic polymorphic lating heart weight (raw or normalized) with the development or rupture
ventricular tachycardia. Also present was a polymorphism in the of berry aneurysms.
KCNE1 potassium subunit gene; mutations in that gene have been asso- Goals: To better define the population affected by fatal rupture of
ciated with Long Q-T Syndrome. The death has been classified as due berry aneurysms and detect and characterize risk factors. A primary
to cardiac arrhythmia; further molecular studies are ongoing. hypothesis of the study is that an increased heart weight represents a risk
A 43-year-old woman was found dead where she had been shov- factor for aneurysmal rupture.
eling snow. A complete autopsy revealed no cause of death. The infor- Subjects and Methods: We designed and performed a case-control
mation that her previously healthy sister had collapsed and died on study. Cases were all individuals autopsied at the Office of the Chief
hearing of her death prompted molecular analysis of a liver specimen Medical Examiner for the State of Maryland in whom subarachnoid
archived for toxicology. A mutation was present in a cardiac potassium hemorrhage secondary to ruptured berry aneurysm was identified.
channel gene known to be associated with congenital Long Q-T Two controls were selected per case in order to increase the power
Syndrome. of the study. In order to minimize bias, controls were matched for age
Genetic sequencing for mutations associated with sudden death from (within five years) and gender; we only selected individuals who died
fatal arrhythmia is expensive, time-consuming and not widely available. accidentally, and had an autopsy performed in our office, prior (one of
Review of the circumstances of death, family history and medical records the controls) or subsequent (the other control) to the matching case.
following a negative autopsy facilitates selection of the rare case appro- Antropometric parameters including age, gender, race, height and
priate for molecular testing. Frozen myocardium is currently the best weight were recorded. We obtained clinical information including
specimen for analysis, and should be retained in suspected cases. history of smoking, alcohol or drug use and hypertension. At autopsy,
Simplification of screening for known mutations or abnormal gene heart weight, presence and severity of coronary atherosclerosis, brain
products wo

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FORENSIC

American Academy of Forensic Sciences

The American Academy of Forensic Sciences (AAFS) is a multi-disciplinary

professional organization created and maintained to provide leadership in the application

objectives are to promote professionalism, integrity, competency and education, and to

foster scientific research, improvements in the practice of forensic science, and

collaboration within the many fields of forensic science.

distinguished and diverse membership. It comprises eleven different sections representing

Included among them are physicians, attorneys, dentists, toxicologists, physical

anthropologists, document examiners, psychiatrists, physicists, engineers, criminalists,

research in the field, producing hundreds of refereed publications and books.

since 1949, and to our section’s directors and chair persons.

2011-2012 Gregory G. Davis, MD Jeffery K. Tomberlin, PhD

Exposition Manager; Phyllis Gilliam, Receptionist; Salena Grant, Assistant Meetings

Manager; Cheryl Hunter, Membership Coordinator; Nancy Jackson, Director of

Membership Assistant; and Kimberly Wrasse, Executive Assistant.

This further acknowledges the excellent work of Pathology/Biology authors

worldwide who are willing to share their work for education.

Victor W. Weedn, MD, JD

Index of Title by Year

Index by Presenting Author ............................................................................ Index 125

After attending this presentation, attendees will understand the

Emily F. Gorman, MD*, University of Alabama at Birmingham,

G63 Homicidal Deaths in the Western Suburbs

After attending this presentation, attendees will better understand

Jeffrey Racette, MD*, Baiyang Xu, MD, Todd M. Luckasevic, DO,

After attending this presentation, attendees will understand the

The goal of this presentation is to describe and discuss a case of

After attending this presentation, attendees will appreciate the

G8 Hanging Deaths in Children: An

G11 Injuries to Abdominal Organs in Fatal Road

After attending this presentation, attendees will have learned about

Biagio Solarino, PhD*, Sezione di Medicina Legale, Università degli

After attending this presentation, attendees will be able to critically

After attending this presentation, attendees will improve their

* Presenting Author 100

103 * Presenting Author

G50 Nocturnal Oviposition of Blow Flies

* Presenting Author 104

107 * Presenting Author

* Presenting Author 108

109 * Presenting Author

* Presenting Author 110

111 * Presenting Author

* Presenting Author 112

113 * Presenting Author

115 * Presenting Author

117 * Presenting Author

* Presenting Author 118

119 * Presenting Author

* Presenting Author 120

121 * Presenting Author

* Presenting Author 122

123 * Presenting Author

* Presenting Author 124

125 * Presenting Author

After attending this presentation, attendees can expect to understand

* Presenting Author 126

G91 Lethal Consequences Arising From the