Dominique Lecomte

An international perspective on the prevalence of the Wernicke-Korsakoff syndrome

In the Western world previous studies have shown that the majority of cases of the Wernicke-Korsakoff syndrome (WKS), which is caused by thiamine deficiency, occur in alcoholics. However, in France, a country with one of the highest per capita consumptions of alcohol, the prevalence of the WKS was found to be only 0.4% in a small retrospective autopsy study. This figure is compared with data sent to the authors by a number of neuropathologists from the U.S.A., Europe, Scandinavia and Australia. There was no obvious correlation between the prevalence rates of the WKS, which were highest in Australia (2.8% - previously published), and per capita consumption of alcohol. Other issues such as diet, National programs for supplementation of foods with thiamine, and drinking habits are considered. The pathological diagnosis of the WKS can often be made on macroscopic examination of the brain after fixation in formalin. The mammillary bodies are smaller than normal in most cases of chronic WKS. However in this study it was found that the most common causes of small mammillary bodies were Alzheimers disease and atrophy due to transneuronal degeneration secondary to lesions in the hippocampus.

Homicide followed by suicide: Paris and its suburbs, 1991-1996

Homicide-suicides (HS) are relatively infrequent events. Yet, they are of great concern because they often result in the death of family members, young children, and cause additional morbidity, family disruption and childhood psychological trauma. The aims of our study were (a) to examine the sociodemographic, clinical, and autopsy characteristics of HS in Paris and its suburbs from 1991 through 1996, and (b) to analyze the psychodynamic determinants leading up to the onset of HS. Our findings are compared with those obtained in other international studies. For the purpose of the present study. HS was defined as a violent event in which an individual committed homicide and subsequently committed suicide within a few hours. The main results are as follows. During the six-year study period, 56 HS involving 133 victims were investigated at the Institute of Forensic Medicine of Paris. Seventeen events occurred in Paris and 39 in its suburbs. Paris has a population of approximately 2,200,000 while its suburbs are home to another 8,5000,000. Of the 56 offenders, 48 (85%) were males. The mean age of offenders was 51 years in males (range, 24 to 83) and 40.5 years in females (range, 33 to 56). In 45 events (80%), the offenders used a gun for both the homicide and suicide. A knife was used in only 4 murders, strangulation in 4 other cases, with poisoning, arson, or beating occurring in one case each. In 9 cases, the offender used a different weapon for homicide and suicide. Among firearms, handguns were more likely to be used (26 cases) than shotguns (6 cases) or rifles (13 cases). In 40 cases the offender killed one victim, in 11 cases 2 victims, and in 5 cases 3 victims. The homicide victims consisted of 34 children (21 boys), mean age 8 years (range, 1 to 16), 29 spouses (26 females), 2 girlfriends, 10 strangers, and 2 relatives. Five pets were killed. HS were most likely to be committed in the home. A suicide note was found near the victims in 29 cases (50% of events). In 42 cases the offender was found to be severely depressed. Familial HS were the most frequent events followed by suicidal pacts. When male sexual proprietariness and amorous jealousy were involved, the HS perpetrators acted often impulsively in carrying out the HS. There had been a chronically chaotic relationship and frequent physical violence and verbal threats. The triggering event was often the female withdrawal or estrangement. Only in a few cases, other motivations such as occupational or money problems were involved. Chronic alcoholism was found in 16 cases. In conclusion, the offender was more likely to be a male, severely depressed, violent and jealous who killed his spouse, and often his children, with impulsiveness, but after numerous threats. Our findings suggest that HS differ from both homicide and suicide and thus occupy a distinct epidemiological domain requiring specific prevention programs.

Pathology of arrhythmogenic right ventricular cardiomyopathy/dysplasia--an autopsy study of 20 forensic cases.

Arrhythmogenic right ventricular dysplasia/ cardiomyopathy (ARVC) is characterized histologically by massive infiltration of the right ventricular wall by fat tissue, with surviving strands of cardiomyocytes bordered by or embedded in fibrosis. ARVC has been recognized as a cause of sudden death, especially in the young. The purpose of our autopsy study was to examine the clinical characteristics and the pathological patterns in the hearts of 20 people who died suddenly of ARVC. In view of our findings and the literature, we discussed the possible causes and pathogenesis of ARVC, as well as the mechanisms by which sudden death occurs in this disease. During the 7-year study period, 20 hearts from 9 men and 11 women fulfilled the criteria for ARVC. The mean age was 41 years (range, 17 to 80). The disease was unknown prior to death in all cases. Fourteen persons died at rest, and six on effort. In 9 of the 20 cases, the trigger of sudden death was an acute emotional stress, sometimes associated with a moderate physical activity. The mean heart weight was 380 g (range, 280 to 520). Both ventricles were involved in 40% of the cases. Inflammatory infiltrates consisting of lymphocytes were present in 60% of the cases, but myocyte necrosis was found in only one case. ARVC is more likely to result from a degenerative process than a congenital disorder. Genetic factors, viral or autoimmune inflammation or both, and apoptosis are also involved in the degenerative disorder.

Suicide among youth and young adults, 15 through 24 years of age. a report of 392 cases from paris, 1989-1996

The aims of our study were (1) to examine the socio-demographic, clinical characteristics, autopsy and toxicological findings in 392 youth suicides in Paris, between 1989 through 1996, and (2) to analyze the psychodynamic determinants leading up to the onset of the suicide. During the eight-year study period 392 suicides involving young people were investigated at the Institute of Forensic Medicine of Paris. Two hundred and sixty victims (66%) were males. The mean age was 22 years in both sexes. Fifteen percent of the victims were below 20 years. Ninety-two percent of the subjects were single. Forty percent of the victims were students, 35% were unemployed. One third of the victims had previously attempted suicide. Thirty-five percent of the subjects used to take psychoactive prescription drugs and some of them had been under the care of a mental health professional at the time of the suicide. In 40% of the cases a suicide note was found near the body. Depression (70% of victims), schizophrenia, (10%), affective disorders, parent-child relational problems, partner relational problems, adolescent antisocial behavior, and borderline personality were found to be the most frequent diseases and stressors involved in the suicides. The suicide was rarely an accidental reaction to stress. It was constantly preceded by situational distress, which led to suicidal ideas if the adolescent failed to cope with problems. Ten percent were known as heroin users. In more than 40% of the cases, the victims parents were divorced or separated. The most frequent method of suicide was poisoning followed by jumping from a height, gunshot, subway death, and hanging/asphyxia. Among firearms, a handgun was more likely to be used than rifles (85/15%). Tranquilizers were the most frequent psychoactive drugs used for suicide followed by antipsychotic drugs, antidepressants, and barbiturates (10%).

Stressful events as a trigger of sudden death: a study of 43 medico-legal autopsy cases

The reports relating emotional stress to sudden death are largely anecdotal. In addition to experimental and electrophysiological studies, an opportunity for a better understanding of possible stress-related sudden death (SSD) may be provided by medicolegal autopsies. The goal of our autopsy study was to analyze cardiovascular pathologic findings in cases of SSD and if possible identify mechanisms by which the stressful event (SE) could be the cause. Forty three cases were studied (29 males and 14 females). In all cases, the SE and the death were witnessed. The age range was 22 to 90 years in males (mean, 52) and 30 to 92 years in females (mean, 64). Death occurred in all cases without premonitory symptoms. In 20 cases, death occurred during the SE and in the other 23 cases occurred within 2 h of the event. SE included fear, 15 cases; altercation, 21 cases; sexual activity, 3 cases; police questioning or arrest, 4 cases. According to police reports, in 40 cases (90%), the victims had no previous clinical history of cardiovascular disease. At autopsy, the heart weight in males ranged from 255 to 1000 g with a mean of 517 g and in females the range was 250-700 g with a mean of 417 g. In only 3 cases, gross and microscopic examination of the heart was normal. In 2 of the remaining 40 cases the subjects died of subarachnoid hemorrhage. In 38 cases, a cardiac cause of death was found as follows: coronary heart disease, 27 cases; cardiomyopathy, 6 cases; aortic valvular stenosis, 2 cases and right ventricular dysplasia, 3 cases. A coronary artery thrombosis was found in 8 cases of sudden coronary death. Post myocardial infarction fibrosis was present in 25 cases (92%) of sudden coronary death. In conclusion, it appears from our autopsy study that SSD occurs primarily in those individuals with severe heart disease, especially coronary heart disease.

Isolated myocardial fibrosis as a cause of sudden cardiac death and its possible relation to myocarditis.

In performing medicolegal autopsies on sudden deaths, there occur a number of cases in which no cause of death can be found. In particular, no evidence of macroscopic cardiac abnormalities can be observed. However, extensive histological screening may reveal isolated areas of myocardial fibrosis. The five cases presented discuss the etiology of this fibrosis and its possible relation to myocarditis. The cases involve white women between the ages of 19 and 25 with no previous medical history. The weight of the heart in all five cases was normal. Macroscopic evidence of fibrosis was visible in four out of five cases. No other macroscopic abnormalities were observed. Histologically, there was evidence of scarring or interstitial fibrosis in all five cases. In four of the cases, additional screening permitted the observation of dispersed inflammatory foci consisting of lymphocytes, plasmocytes and macrophages. Two of the cases demonstrated eosinophil and neutrophil aggregates in the center of necrotic foci. No evidence of vascular inflammatory phenomena was observed in any of the five cases. According to the Dallas criteria, three of the five cases fulfill the requirements for myocarditis and one of the five cases for borderline myocarditis. The Dallas criteria, however, do not take into consideration the possible association between inflammation and myocardial fibrosis since many of the reported series of myocarditis have been from hospital autopsies or endomyocardial biopsies and have not taken into account sudden death from fibrotic sequelae of myocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)

Sudden Out-of-Hospital Coronary Death in Patients with No Previous Cardiac History. An Analysis of 221 Patients Studied at Autopsy

Many epidemiological, clinical, and autopsy studies have demonstrated that the risk of sudden coronary death (SCD) is linked to the severity of coronary atherosclerotic lesions and to their thrombotic potential. However it remains unknown why some individuals manifest no clinical evidence of coronary disease until the onset of sudden death. The aim of this autopsy study has been to analyze the sociodemographic, clinical, and pathological features in case of sudden out-of-hospital coronary death where the death was the first manifestation of coronary disease. The results have been compared with those obtained from victims of SCD with known cardiac history. A total of 377 autopsies of sudden out-of-hospital cardiovascular deaths were performed at the Forensic Institute of Paris between 1989 and 1991. A total of 221 were SCD. A total of 160 of these subjects (72.4%) had no cardiac history (group A). The other 61 victims of SCD had cardiac antecedents (group B). Men account for 63% and 77% of the SCD in groups A and B respectively and are 12 years younger than women at the onset of SCD in both groups (65/77 years). Our study showed that in both groups SCD occurs in 83% of cases at home (and at rest) and in 30% of these cases while sleeping. Autopsy showed that SCD be it with or without antecedent occurs on a background of severe coronary disease with multivessels stenoses but coronary thrombosis was rarely observed (15%). SCD occurred in the context of underlying cardiomegaly.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathology of sudden death during recreational sports activity: an autopsy study of 31 cases.

A growing number of people are involved in recreational physical activity. It is therefore not uncommon for a medical examiner to encounter sports-related sudden deaths and to be faced with the legal implications. The authors examined the clinical and cardiac pathologic patterns in 31 persons who died suddenly during sports activities and underwent autopsy at the Institute of Forensic Medicine of Paris between 1991 and 2001. Twenty-nine male subjects, ranging in age from 7 to 57 years (mean 30 years) and two female subjects, 8 and 60 years old, died suddenly during sports activities. The sports involved were various, with running the most frequent: 13 cases. Cardiomyopathies (10 cases) and coronary artery disease (9 cases) were the most frequent causes of deaths. Despite the severity of lesions, only 4 subjects had a known cardiovascular disease. In conclusion, with regard to prevention, efforts should be continued to improve the sensitivity and specificity of diagnostic tools and screening strategies. In this regard, medicolegal autopsies should be systematically performed in cases of sudden death during sports activities, because they provide accurate and useful information for a better knowledge of sports-related mortality.

Diagnosis of Drowning by Combined Computer-Assisted Histomorphometry of Lungs with Blood Strontium Determination*

The aim of our study was to examine the combined contribution of computer-assisted histomorphometry of lungs with blood strontium (BS) measurement to the diagnosis of drowning in cadavers recovered from fresh water. The study population comprised 116 drowned subjects. The results for this group were compared with those obtained for three non-drowned groups: 22 subjects who died from causes other than asphyxia, 13 subjects who died of asphyxia (strangulation or hanging); and 23 healthy living subjects in whom normal BS level was measured. Samples of water where the bodies had been found were analyzed in order to establish a relation with the BS concentration of the drowned subjects. Histologically, each type of pulmonary lesion (congestion, edema, alveolar macrophages, alveolar hemorrhage, and emphysema aquosum) was evaluated semiquantitatively using a score according to the severity of the pathology. Then, a quantitative histomorphometric study was performed using a computer-assisted image analyzer to measure the length and thickness of the alveolar walls, and the area and density of the alveolar cavities. The mean values of the BS levels in the 116 drowned subjects and of the water strontium concentrations were found to be much higher than in the living individuals. Although the ranges were wide, we found no overlap between values found in drowned subjects and those in non-drowned subjects. Emphysema aquosum and to a lesser extent alveolar hemorrhage were found to be the most significant histologic changes in the drowned and asphyxia groups compared with the nonasphyxia control groups.

Childhood homicide in Paris, 1990-1993: a report of 81 cases.

Homicide represents the most dramatic and heart breaking cause of death in children. Yet, in France, the true incidence and medicolegal data (modes, circumstances of deaths, and perpetrators) have been previously unknown. The goal of our study was to analyze the epidemiological and autopsy data in homicides in children in Paris and its suburbs during the past four years. We have included children from a few days after birth to 14 years of age. We report on 81 cases during the following period (17 in 1990; 14 in 1991; 16 in 1992; and 34 in 1993). Of those, 47 were boys and 34 girls. The mean age in boys was 6 years and in girls, 5 years. Fifteen homicides took place in Paris. The other 66 cases were from its suburbs. Twenty-nine of the murdered children were siblings. Seventy children (86%) were killed in their own homes; the father being responsible in 28 cases, and the mother in 17. In 20 instances, the murderer was unknown initially to the police. In 22 cases, the children were killed by gunshot, by stabbing in 14 cases, by battering in 22 cases. Four children died from drug poisoning, 13 from strangulation, and 6 from drowning. A prior history of child abuse was documented in 82% of fatal batterings.