Grzegorz Teresiński

The influence of ethanol on the level of ketone bodies in hypothermia

Presently available possibilities of macro- and microscopic diagnosis of death from hypothermia are very limited as the changes observed are either weakly specific (ecchymoses in the mucous membrane of the stomach, histological features of haemorrhagic pancreatic necrosis, cardiomyocyte necrosis or decreased content of glycogen in hepatocytes) or represent only local action of low temperatures (frostbites, violet patches in the region of knees and elbows, red livores) and they may not be present in cases of death from cooling at environmental temperature close to zero or higher. The study evaluated the usefulness of acetoacetic acid (Ac-Ac), beta-hydroxybutyric acid (beta-HBA) and acetone determinations in blood, urine and vitreous humour for diagnosis of death from hypothermia. These three substances called ketone bodies, are easily assimilated energetic substrates that get oxidized preferentially before glucose and fatty acids. In hypoglycaemia (also hypothermia-induced one), the tissues dependent on glucose (e.g. the brain) cover most of their energetic needs from oxidation of these compounds. The analysis of 16 cases of death in circumstances suggesting hypothermia (mainly of the alcohol abusers) showed that the degree of ketosis was inversely proportional to the blood ethanol concentration. This relation may result from stimulation of insulin release and a decrease in the release of its antagonists by ethanol, as well as from inhibition of free fatty acid (FFA) beta-oxidation due to increase in the NADH/NAD ratio. So, the antiketonaemic effects of ethanol (together with its influence on the dilatation of the peripheral vessels and inhibition of shivering thermogenesis by muscle relaxation), explain increased sensitivity of intoxicated persons to low temperatures.

Postmortem diagnosis of hypothermia

The identification of hypothermia as the cause of death has always been somewhat problematic in forensic pathology because of unspecific, inconstant, or even negative macroscopic and microscopic findings. Though the simultaneous presence of frost erythema, Wischnewski spots, hemorrhages into the synovial membrane, bloody discoloration of synovial fluid of the knee, and basal vacuolization of the renal tubular epithelial cells has been indicated as strongly supportive of fatal hypothermia, their absence does not allow the diagnosis of hypothermia to be ruled out. Postmortem biochemical investigations are valuable in detecting adaptation responses to cold stress and metabolic changes that occur following cold exposure. However, ethanol intoxication prevents appearance of adaptation responses to cold, rendering the diagnosis less obvious. Immunohistochemistry, postmortem imaging, and molecular pathology have shown promising results, although at present, they do not provide pathognomonic signs of fatal hypothermia. The aim of this article is to present a review of the literature covering the significance of different postmortem investigations that are associated with hypothermia fatalities.

Neck injuries as a reconstructive parameter in car-to-pedestrian accidents

The study has assessed the usefulness of injuries to the ligamentous, muscular and vascular neck structures for deducing about the presumable location of a pedestrian in relation to a motor vehicle at the moment of collision. The localisation of haemorrhagic suffusions in the lower insertions of the scalene (mainly) and sternocleidomastoid muscles has shown a correlation with the direction of the inertia force. No correlation has been observed between the direction of impact and damages to the cervical vascular bundles and the localisation of haemorrhagic suffusions in the upper insertions of the nape muscles. In some cases, injuries to the ligaments of the cervical vertebrae made up the complex characteristic of the direction of acting forces. The injuries of soft tissues and ligaments can, thus, facilitate the deductions about the direction of impact. However, the type of a car involved in the accident and the possibility that these injuries resulted from direct head or neck trauma should be considered.

Diagnostic performance of urinary metanephrines for the postmortem diagnosis of hypothermia

The purpose of this study was to assess the diagnostic potential of urinary metanephrines and 3-methoxytyramine compared to urinary catecholamine determination in diagnosing antemortem cold exposure and fatal hypothermia. 83 cases of fatal hypothermia and 144 control cases were included in this study. Catecholamines (adrenaline, noradrenaline and dopamine), metanephrines (metanephrine, normetanephrine) and 3-methoxytyramine were measured in urine collected during autopsy. All tested analytes were significantly higher in hypothermia cases compared to control subjects and displayed a generally satisfying discriminative value, thus indicating urinary catecholamines and their metabolites as reliable markers of cold-related stress and hypothermia related-deaths. Metanephrine and adrenaline had the best discriminative value between hypothermia and control cases compared to other tested analytes, though with different sensitivity and specificity. These can therefore be considered the most suitable markers of cold-related stress.

Severity of injuries in different modes of transport, expressed with disability-adjusted life years (DALYs)

BackgroundHealth impact assessment (HIA) studies are increasingly predicting the health effects of mode shifts in traffic. The challenge for such studies is to combine the health effects, caused by injuries, with the disease driven health effects, and to express the change in the health with a common health indicator. Disability-adjusted life year (DALY) combines years lived disabled or injured (YLD) and years of life lost (YLL) providing practical indicator to combine injuries with diseases. In this study, we estimate the average YLDs for one person injured in a transport crash to allow easy to use methods to predict health effects of transport injuries.MethodsWe calculated YLDs and YLLs for transport fatalities and injuries based on the data from the Swedish Traffic Accident Data Acquisition (STRADA). In STRADA, all the fatalities and most of the injuries in Sweden for 2007–2011 were recorded. The type of injury was recorded with the Abbreviated Injury Scale (AIS) codes. In this study these AIS codes were aggregated to injury types, and YLDs were calculated for each victim by multiplying the type of injury with the disability weight and the average duration of that injury. YLLs were calculated by multiplying the age of the victim with life expectancy of that age and gender. YLDs and YLLs were estimated separately for different gender, mode of transport and location of the crash.ResultsThe average YLDs for injured person was 14.7 for lifelong injuries and 0.012 for temporal injuries. The average YLDs per injured person for lifelong injuries for pedestrians, cyclists and car occupants were 9.4, 12.8 and 18.4, YLDs, respectively. Lifelong injuries sustained in rural areas were on average 31% more serious than injuries in urban areas.ConclusionsThe results show that shifting modes of transport will not only change the likelihood of injuries but also the severity of injuries sustained, if injured. The results of this study can be used to predict DALY changes in HIA studies that take into account mode shifts between different transport modes, and in other studies predicting the health effects of traffic injuries.

Free fatty acids as markers of death from hypothermia

The possibilities of using morphological markers of fatal hypothermia are limited; therefore, other diagnostic criteria of deaths from hypothermia are being researched. The initiation of protective mechanisms against adverse effects of low temperatures results in activation of hormonal systems and development of characteristic biochemical changes that can be impaired by alcohol intoxication. The aim of the study was to assess the usefulness of determinations of the profile of free fatty acid concentrations as potential markers of hypothermia-related deaths, particularly in intoxicated victims. The study group consisted of blood samples collected during autopsies of 23 victims of hypothermia. The control group included blood samples collected from 34 victims of sudden, violent deaths at the scene of an incident (hangings and traffic accidents) and 10 victims who died because of post-traumatic subdural hematomas with prolonged agony. The study and control groups were divided into three subgroups according to blood alcohol concentrations: 0.0-0.99; 1.0-2.99 and ≥3.0‰. Statistical analysis in the individual subgroups demonstrated significant increases in concentrations of palmitic, stearic and oleic acids (P<0.05), independent of blood ethanol concentration. Palmitic, stearic and oleic acids can be considered the potential markers of fatal hypothermia, including the cases of intoxicated individuals.

Pelvis and hip joint injuries as a reconstructive factors in car-to-pedestrian accidents

The pelvic girdles of 371 pedestrian victims of road traffic accidents were evaluated during postmortem examinations. Additionally, 144 hip joints were opened. The pelvic injuries were found in 28% of the pedestrians hit exclusively in their upright position and 52% of the victims run over by a vehicle. The side of the body hit by a car was determined on the basis of the location of blood suffusions within the subcutaneous tissues and muscles of lower limbs as well as the character of injuries found in the knee and upper ankle joints. The findings were verified with the data from court records. It was shown that the injuries of the sacroiliac joints or vertical fractures of the posterior parts of iliac bones were useful parameters for determining the side (left or right) of the body hit by a vehicle. Moreover, it was found that a direct impact on the hip region was evidenced by the ipsilaterally localized fractures of the iliac ala, central hip fractures and intraosseous blood suffusions within the greater trochanter of the femur. The external dislocations of the hip joints (always) and bilateral injuries to the sacroiliac joints (usually) were observed in the victims run over by vehicles.

Glucocorticosteroids as markers of death from hypothermia

In the course of hypothermia, biochemical changes occur that are associated with stimulation of protective thermogenic mechanisms as well as mobilization of internal energy resources mediated by the hormone system. The objective of the investigation was the assessment of validity of determinations of cortisol, cortisone and corticosterone as hypothermia markers in cases of fatal hypothermia combined with concomitant insobriety of the victims. The experimental group consisted of blood samples collected in the course of medico-legal autopsies of 23 hypothermia victims. The controls included blood samples originating from 34 victims of violent sudden deaths (deaths by hanging and traffic road accidents at the scene) and from ten individuals deceased after prolonged agony in consequence of post-traumatic subdural hematomas. In both groups, three subgroups were distinguished that included cases with ethanol levels within the following ranges: 0.0-0.99, 1.0-2.99 and ≥3.0‰. The comparison of determination results showed that irrespectively of blood ethanol concentration, cortisol, cortisone and corticosterone levels seen in hypothermia victims were significantly higher as compared to the controls (P<0.001).

Injuries of the Thigh, Knee, and Ankle as Reconstructive Factors in Road Traffic Accidents

Currently, traffic accidents comprise the most common cause of traumatic deaths throughout the world and the most common cause of death and disability in the 15- to 44-yr-old age group in developed countries. In 2002, about 1.2 million people were killed in road traffic accidents, and by the year 2020, according to WHO data (1), this figure is projected to almost double, making traffic accidents the third (from the ninth) leading cause of death and disability worldwide (following ischemic heart disease and mental depression). Despite a large number of cars and accidents in high-income countries, however, the percentage of fatalities is low (Table 1). Agood marker of the motorization progress in a particular country is the percentage of pedestrians among all victims of traffic accidents, e.g., high in the low-income countries and eastern Europe (due primarily to a lack of road infrastructure and the absence of a separation between pedestrian and car streams).

Catecholamines and their O-methylated metabolites in vitreous humor in hypothermia cases

PurposeThe aim of this study was to assess the diagnostic value of catecholamines and their O-methylated metabolites in vitreous humor samples in identifying antemortem cold exposure and fatal hypothermia in the forensic casework.MethodsA total of 80 autopsy cases (40 hypothermia fatalities and 40 cases in which hypothermia as the main or contributory cause of death was excluded) were selected for this study. Catecholamines and their O-methylated metabolites were measured in urine and vitreous humor samples collected at autopsy.ResultsUrine catecholamine and their O-methylated metabolite concentrations were significantly higher in hypothermia-related deaths. On the other hand, measurements in vitreous humor samples did not reveal statistically significant differences between hypothermia-related deaths and controls.ConclusionsGlobally considered, our findings seem to suggest that, contrary to urine catecholamines and their O-methylated metabolites, vitreous levels of these compounds appear to be of limited value in characterizing human antemortem stress reactions due to cold exposure and can hardly be used in the forensic setting to support the diagnosis of hypothermia.