Klára Törő

Evaluation of a fatal propofol intoxication due to self administration

Propofol is a short acting intravenous anaesthetic, active agent of Diprivan. The abuse potential of propofol has not completely defined, but there are anecdotal case reports in the literature about propofol abuse and dependency. This report presents a fatal case of a middle age female victim who died of self-administered propofol intoxication. The propofol level of the blood sample was measured with gas chromatography-mass spectrometry after liquid-liquid extraction. The results of toxicological investigation suggested that death was not directly caused by propofol intoxication, however, based on the pathomorphological changes detected during the medico-legal autopsy we supposed that the fatal outcome was resulted by respiratory depression after rapid injection.

Evaluation of meteorological factors on sudden cardiovascular death

Climatic and seasonal triggering factors have received an increasing attention among risk factors of sudden cardiac death. The relationship between cold weather conditions and ischemic heart disease death is well established. In this study, there were 7450 (4967 males, 2483 females) cardiovascular death cases medico-legally autopsied between 1995 and 2004. In most of the cases (76%) cardiac death occurred at the scene, and 17% had acute ischemic heart disease. In order to examine the relationship between daily maximum, minimum and mean temperature, air humidity, air pressure, wind speed, global radiation and the daily numbers of death cases, statistical analysis were accomplished using correlation coefficients, and Box-Whisker-plot diagrams. A significant negative correlation was detected between daily mean temperature and cardiovascular mortality. A remarkable seasonal variation was found. Cold and dry weather may be an important risk factor in bringing on the onset of sudden cardiac death.

Relationship between suicidal cases and meteorological conditions

Meteorological factors are well known to modulate human health status and the rate of death cases. The suicidal rate might have been influenced by climatic and seasonal triggering factors. In this study 4918 suicidal cases (3099 male, 1819 female) in Budapest were investigated in connection with climatic data, as daily maximum, minimum temperature, and air humidity. The most frequent methods of suicide were intoxication, hanging and jumping. A mild seasonal variation was found, however, the rate of suicidal death was influenced by warm temperatures. Higher frequency of suicidal deaths was detected in warm weather with low relative humidity, which implies dominantly dry anticyclonic meteorological conditions. Our results suggest that the medico-legal investigation may help specific suicide prevention programme regarding to the climate change and meteorological conditions as potential risk factors of suicidal cases.

Incomplete decapitation in suicidal hanging - Report of a case and review of the literature

Complete or incomplete decapitation is an unusual complication of suicidal hanging. We present a case of incomplete decapitation due to hanging with soft tissue injuries, spinal cord dissection between C2 and C3, fracture of the hyoid bone and injuries of cartilages. The 52-year-old male victim with a 95kg body mass used a 1.5cm thick and 3.1m long nylon rope snap-hooked to a rafter. The comprehensive literature review of incomplete or complete decapitation by suicidal hanging emphasises the importance of investigation of biomechanical process. In the presented case we calculated the physical parameters (final speed: 7.8m/s, kinetic energy: 2945J, force: 9500N). The previous observations were confirmed that body weight and falling distance were the most important factors in the pathomechanism of decapitation. In the hanging process energy can be stored by changing the position of the human body in the gravitational field, by changing the shape of the hanging rope and by changing the motion of the hanging body. We concluded that the occurrence of complete or incomplete decapitation can increase by the increasing energy stored as potential energy at the starting position and the characteristics of the rope extended by the hanging body.

Evidence for Infection and Inflammation in Infant Deaths in a Country with Historically Low Incidences of Sudden Infant Death Syndrome

Total infant mortality in Hungary has been higher than other European countries; however, the reported incidence of sudden infant death syndrome (SIDS) has been lower. The low incidence of SIDS in Hungary has been supported by evidence obtained from the high rate of scene of death investigation and medico-legal autopsy mandatory since the 1950s. In this study, we compared the incidence of explained and unexplained infant deaths in Hungary for three periods: 1979–1989 when the incidence of SIDS was high in western Europe; 1990–1999 when the incidence of infant deaths was falling following introduction of the public health campaigns to reduce the risk factors associated with SIDS; and 2000–2012 to determine if introduction of Haemophilus influenzae type b or pneumococcal vaccines or introduction of an earlier immunization schedule during this period had an effect on SIDS. Explained infant deaths fell consistently during this period; however, SIDS rose during the second period when the incidence of SIDS was falling in other European countries. Evidence for infection and/or inflammation was observed for the majority of SIDS during each period. The results are discussed in relation to campaigns to reduce infant mortality in Hungary and the introduction of new vaccines and an earlier immunization schedule in 2006.

Fatal Renal Hemorrhage After Extracorporeal Shock Wave Lithotripsy

Abstract:  Renal hematoma is one of the most severe complications of extracorporeal shock wave lithotripsy (ESWL). ESWL is used in the noninvasive treatment of urinary calculosis. The shock waves can lead to capillary damage, renal parenchymal or subcapsular hemorrhage. We present a case with fatal complication and the result of the medico‐legal evaluation. A 71‐year‐old woman was treated by ESWL, renal hematoma was detected during the clinical observation, and the patient died. The death occurred despite close clinical observation as a consequence of a rare complication of ESWL. The mechanism of death was hemorrhagic hypovolemic shock due to renal hemorrhage complications due to ESWL for treatment of renal calculi. This therapeutic complication is a known complication of appropriate treatment.

Homicides against infants, children and adolescents in Budapest (1960–2005)

INTRODUCTION The objective of this study was to determine the characteristics and trends of fatal child abuse that would assist family doctors in detecting signs of maltreatment. SUBJECTS There were 363 (193 males, 170 females) such cases autopsied at the Department of Forensic and Insurance Medicine at Budapest from 1960 to 2005. Information was collected from forensic autopsy records. Data were analyzed according to age, gender, type of abuse, injured body region, and seasonal distribution. The first detection of fatal injuries and death certification were usually done by GPs or ambulance at the scene of the homicide or hospital paediatricians in cases with survival period between the injuries and death. RESULTS Our results suggest a definitive decrease in fatal child abuse cases during the investigated period. In the first part of study period suffocation of infants represent a great number of cases. Infanticide rapidly dropped after the mid 1970s. In this material 89.3% of fatal cases was detected and reported by family doctors. CONCLUSIONS Rate of homicides against infants, children and adolescents reflect the effectiveness of the preventative strategies, the child protection policy and the unique primary health care system for youth. GPs have an important role in the investigation of infanticides and homicide cases against children and adolescents.

Fatal asphyxia due to laryngomucocele

Laryngocele is a rare benign lesion of the larynx resulting from an abnormal dilation of the laryngeal saccule, however, severe airway obstruction and even asphyxia may occur. We report the case of a 55-year-old woman who presented with a feeling of discomfort and mild asphyxia. There was a smooth, firm swelling, 2 cm in diameter, upon palpation on the right side of the neck. Laryngoscopy revealed a bulging near the ventricular and right aryepiglottic folds. CT scan, MRI investigation and in-hospital observation were suggested, the patient, however, refused acute treatment and hospitalization and died suddenly, a few minutes after leaving. Autopsy revealed combined laryngocele with internal and external components. As the presented case shows, the internal part of the laryngocele may cause rapid and complete obstruction. The examining physician should therefore call the patients attention to this potential life threatening condition.

A common polymorphism of the human cardiac sodium channel alpha subunit (SCN5A) gene is associated with sudden cardiac death in chronic ischemic heart disease

Cardiac death remains one of the leading causes of mortality worldwide. Recent research has shed light on pathophysiological mechanisms underlying cardiac death, and several genetic variants in novel candidate genes have been identified as risk factors. However, the vast majority of studies performed so far investigated genetic associations with specific forms of cardiac death only (sudden, arrhythmogenic, ischemic etc.). The aim of the present investigation was to find a genetic marker that can be used as a general, powerful predictor of cardiac death risk. To this end, a case-control association study was performed on a heterogeneous cohort of cardiac death victims (n=360) and age-matched controls (n=300). Five single nucleotide polymorphisms (SNPs) from five candidate genes (beta2 adrenergic receptor, nitric oxide synthase 1 adaptor protein, ryanodine receptor 2, sodium channel type V alpha subunit and transforming growth factor-beta receptor 2) that had previously been shown to associate with certain forms of cardiac death were genotyped using sequence-specific real-time PCR probes. Logistic regression analysis revealed that the CC genotype of the rs11720524 polymorphism in the SCN5A gene encoding a subunit of the cardiac voltage-gated sodium channel occurred more frequently in the highly heterogeneous cardiac death cohort compared to the control population (p=0.019, odds ratio: 1.351). A detailed subgroup analysis uncovered that this effect was due to an association of this variant with cardiac death in chronic ischemic heart disease (p=0.012, odds ratio = 1.455). None of the other investigated polymorphisms showed association with cardiac death in this context. In conclusion, our results shed light on the role of this non-coding polymorphism in cardiac death in ischemic cardiomyopathy. Functional studies are needed to explore the pathophysiological background of this association.

Alcohol‐Related Mortality Risk in Natural and Non‐Natural Death Cases

Abstract:  Determination of the associations between alcohol influence and sudden natural death represents challenges for medicolegal investigations. The aim of this study was to investigate the prevalence of alcohol influence in medicolegal autopsies. In our study of natural and non‐natural deaths cases (5496 total: 4045 males, 1451 females) were examined. Blood alcohol concentrations (BACs) were detected by headspace gas chromatographic method. We investigated the alcohol‐related mortality using hierarchical log‐linear statistical models. Severe BACs were detected among suicidal victims in the oldest age group (>65 years) (InF = 0.442) and among the homicide victims between the age of 40–65 years (InF = 0.234). Correlations we found between manner‐of‐death and sex suggested that the rate of males in accidents (lnF = 0.140) and the rate of females in homicides (lnF = 0.193) were higher. It was concluded that the accurate statistical mortality database may provide a huge support for the determination of alcohol effects on human health and mortality.