Philippe Lunetta

Surveillance of injury-related deaths: medicolegal autopsy rates and trends in Finland

Medicolegal autopsies are a vital tool for obtaining reliable injury mortality data. In Finland, medicolegal autopsies have increased from 13.6% of all deaths in 1970 to 23.8% in 2004. In fact, medicolegal autopsies are performed in 87.2% of all unintentional injury deaths, 98.3% of homicides and 99.5% of suicides. Finland has exceedingly high medicolegal autopsy rates compared with other countries. Autopsy rates should be appropriately considered when performing international comparisons of injury-related deaths.

What is the incidence and significance of "dry-lungs" in bodies found in water?

Background:Drowning without aspiration of liquid, generally attributed to death from asphyxia while submerged and in laryngospasm, has been reported to occur in approximately 10% to 15% of drowning victims. Objectives:The occurrence of “dry-drowning” recently has been questioned and the hypothesis developed that “dry-lungs” in bodies found dead in the water could conceal more natural deaths than previously recognized. Methods:Based on 578 selected adult victims who presumably drowned, we analyzed the correlation between the cases with a low combined lung/pleura liquid weight (< 1000 g and < 750 g) and a wide set of individual, circumstantial, and postmortem (PM) variables, using multivariate logistic regression analysis. Victims with lung weight < 1000 g were screened for long-QT syndrome (LQTS) founder mutations in KCNQ1 and KCNH2 genes. Results:Of the 578 victims, 120 (20.7%) had a lung weight of < 1000 g, and 22 of these (3.8%) of < 750 g. Multivariate analysis showed a significant correlation for women (P < 0.001), for women aged 65 years or older (P < 0.001), and for men with prolonged PM submersion time (P < 0.001). “Normal” lungs were found in only 8 (1.4%) victims. Low-weight (< 1000 g), overdistended lungs with no sign of liquid penetration were seen in 11 (1.9%). No LQTS founder mutations were detected. Conclusions:The actual incidence of death of persons found in water who have normal lungs or do not have penetration of liquid into their airways, based on our study, is much lower (below 2%) than currently assumed.

Macroscopical, Microscopical, and Laboratory Findings in Drowning Victims

The medicolegal investigation of bodies found in water focuses on victim identification, evaluation of postmortem submersion time, and determination of the cause and manner of death. In any given case the circumstances surrounding death, environmental factors, victim’s preexisting diseases, and autopsy findings must be appropriately considered in reaching a diagnosis of the cause and manner of death. In addition to drowning, injuries, intoxications, or natural conditions are all among the potential causes of death in bodies found in water or the factor that may have contributed to the fatal outcome. The interpretation of autopsy findings in putative drowning requires a basic knowledge of the pathophysiology of drowning. Hypoxemia plays a primary role in death by drowning, whereas serum electrolyte changes may be observed in experimental models but have little or no clinical significance in humans. The volume of liquid inhaled depends on factors such as the duration of laryngospasm, the number and depth of respiratory movements before death, and the time of onset of cardiac arrest. Recent studies suggest that the actual incidence of drowning without liquid inhalation is much lower than previously estimated. The most important morphological changes associated with drowning are those related to liquid penetration into the airways: external foam, frothy liquid in airways, and lung overexpansion. However, these changes are not specific to drowning. The diagnostic value given to microscopic pulmonary changes varies significantly and is limited mostly by their heterogeneous distribution within the lung parenchyma. Laboratory methods for the diagnosis of drowning have their rationale in the shift of liquid and electrolytes across the pulmonary air-blood barrier, which may cause blood volume and electrolyte changes. Although some methods have been reappraised recently, their usefulness is greatly hampered by factors such as the variable volume of drowning liquid penetrating the airways, the differing duration of the drowning process, and postmortem biochemical instability. Contributions on the reliability of the diatom method for the diagnosis of drowning have yielded widely divergent opinions, of which the most critical often rely on studies lacking a rigorous methodology. Until standardized protocols and reliable separation values for diatoms between control and drowning cases are established, the diatom method cannot be accepted in definitively proving a diagnosis of drowning in the courtroom, but rather represents a useful supportive tool for the diagnosis of death by drowning.

Scanning and transmission electron microscopical evidence of the capacity of diatoms to penetrate the alveolo-capillary barrier in drowning

Abstract The diagnostic value of diatom analysis for drowning is considered to be one of the most controversial arguments in forensic medicine. However, the theoretical assumption of the method, i.e. the capacity of diatoms to penetrate the alveolo-capillary barrier during drowning, has never been addressed. Using scanning (SEM) and transmission electron microscopy (TEM), we have investigated the interaction of a natural population of diatoms and an unialgal culture of Phaeodactylum tricornutum (PT) with the alveolo-capillary barrier in an experimental model of drowning. The SEM analysis allowed the identification of several diatom species along the whole airways and their close interaction with the alveolar wall, but was poorly informative about the effective penetration of diatoms into pulmonary vessels. The TEM analysis was more informative and allowed a precise identification of the PT cells in alveolar spaces and to detect their phagocytosis by alveolar macrophages. PT penetrated into the pulmonary vessels through the thinnest portions of the alveolo-capillary barrier and through the interstitial spaces and were identified in pulmonary capillaries and venules. The morphological demonstration of the capacity of diatoms to penetrate the alveolo-capillary barrier is a step forward in assessing the potentiality, reliability and limitations of diatom analysis on a new basis as a tool for the diagnosis of drowning.

IMMUNOHISTOCHEMICAL IDENTIFICATION OF SYNCYTIOTROPHOBLASTIC CELLS AND MEGAKARYOCYTES IN PULMONARY VESSELS IN A FATAL CASE OF AMNIOTIC FLUID EMBOLISM

The histological diagnosis of amniotic fluid embolism (AFE) is based on finding amniotic fluid components in the pulmonary microvasculature. In addition to the distinctive constituents of AFE, placental and decidual tissue fragments as well as isolated trophoblastic cells and megakaryocytes are potentially detectable within pulmonary vessels. The identification of single syncytiotrophoblastic cells (STC), and their differentiation from circulating megakaryocytes (MK) within the lumen of small and medium-sized pulmonary vessels is difficult by classical morphological methods. In a fatal case of AFE, we have successfully detected the simultaneous presence of STC and MK in the pulmonary microvasculature by means of a panel of specific monoclonal (CD61-GpIIIa, β-hCG) and polyclonal (FVIII-vW hPL) antibodies. The immunohistochemical analysis for identification of STC and MK should provide more precise data on their incidence and distribution in physiological and pathological conditions as well providing new insights into their physiopathological implications and their correlation with AFE and other gynaecological complications.

Molecular screening of selected long QT syndrome (LQTS) mutations in 165 consecutive bodies found in water.

Abstract. The association of the long QT-syndrome (LQTS) with single accidental drowning or near-drowning cases has been recently emphasised, but no data on the prevalence of LQTS among drowning victims are currently available. In this study, we have retrospectively screened specific founder mutations in KCNQ1 (KVLQT1) and KCNH2 (HERG) genes in 165 consecutive bodies found in water in Finland. We found a KCNH2-Fin mutation in a 44-year-old woman whose death was classified as suicidal drowning, whereas no other carriers of the two LQTS founder mutations were identified among the remaining 164 victims. This study provides the first estimate of the minimum prevalence of LQTS (0.61%, CI95: 0.02–3.33) in such a setting and demonstrates the value of genetic analysis of LQTS in putative drownings. The detection of a LQTS founder mutation in a body found in water is a relatively rare event based on our study sample. This finding is, however, of utmost medico-legal importance, since it broadens the spectrum of potential causes and manners of death.

Blood Levels of 3-methylfentanyl in 3 Fatal Poisoning Cases

Three fatal poisoning cases due to 3-methylfentanyl are described. In each case, the death was accidental and occurred after injection of the opioid combined with amphetamine, heroin, or other drugs. The victims’ ages, ranging from 30 to 41 years, were higher than those typically found in heroin poisonings in Finland. The blood concentrations of cis-3-methylfentanyl, measured here for the first time by a specific tandem mass spectrometric method, ranged from 0.3 to 0.9 μg/L (mean 0.5 μg/L). These values are significantly lower than the levels reported for α-methylfentanyl and fentanyl in fatal poisonings. Repeated seizures of fentanyl and its analogs have been reported in Europe close to the Russian border.

Drowning in Finland: “external cause” and “injury” codes

Background: The International Classification of Diseases (ICD) external codes (E codes) for drowning assist in determining the primary event leading to drowning, but do not alone allow the precise determination of the overall drowning rates. Aims: To analyze the sensitivity of the ICD E codes for drowning. To describe the pattern and trend of drowning deaths that are classified with E codes other than for drowning. Setting: Finland, 1969–2000. Methods: Mortality files of Statistics Finland were searched electronically using the injury codes (I codes) and E codes for drowning. Cross analysis of I and E coded drownings was performed to determine the rate and pattern of drowning cases classified with E codes other than for drowning. Time trends were calculated using the Poisson regression model. Results: Of 13 705 drowning deaths, 644 (4.7%) were not identified with the E codes for drowning. The great majority (n=547, 84.9%) of these cases were traffic accidents resulting in drowning. No significant time trends were found even after the introduction, in 1996, of the ICD 10th revision. Conclusions: In Finland, underestimation of overall drowning rates using the E code alone is less pronounced than in countries where similar studies have been performed. The relatively high rate of transport accidents resulting in drowning indicates a specific target for preventive countermeasures.

How well does a national newspaper reporting system profile drowning

In Finland, the Finnish Association for Swimming Instruction and Life Saving (SUH) and Statistics Finland (SF) both provide nationwide data on unintentional drowning. The SUH database relies on rapid reporting from a newspaper clipping service and additional local police information, whereas the SF database relies on the later release of the death certificate information, which is based on extensive medico-legal investigation. The aim of the study was to explore the main differences between the SUH and SF databases for drowning and to evaluate the capacity of the former to characterize drowning events in Finland from 1998 to 2000. Computerized files of death certificates tabulated by SF were linked with the SUH database by deterministic methods. SF and SUH databases allowed the identification of 704 and 567 unintentional drownings, respectively, giving an unintentional drowning rate of 4.5 and 3.6/100 000 per year. Of the 704 drownings described by SF, 418 (59.4%) were also found in the SUH database. The SUH database markedly underreported drowning fatalities in certain settings, such as bath, ditch and swimming pool drownings; fall- and land-traffic-related drownings; and drownings occurring in South Finland. The narrative text of SUH drownings contributed limited information to characterize the drowning events. It was concluded that the newspaper-based SUH data provide more timely data on individual drownings but are not representative of all drownings. Conversely, the SF vital statistics data are more accurate but may take up to 2 years to become available. Both SUH and SF data provide little detailed information on drowning events. A multidisciplinary national surveillance system for drowning is necessary to provide more accurate and timely drowning data, analyse risk factors and design follow-up studies for developing and monitoring prevention strategies.

Physiology Of Drowning: A Review

Drowning physiology relates to two different events: immersion (upper airway above water) and submersion (upper airway under water). Immersion involves integrated cardiorespiratory responses to skin and deep body temperature, including cold shock, physical incapacitation, and hypovolemia, as precursors of collapse and submersion. The physiology of submersion includes fear of drowning, diving response, autonomic conflict, upper airway reflexes, water aspiration and swallowing, emesis, and electrolyte disorders. Submersion outcome is determined by cardiac, pulmonary, and neurological injury. Knowledge of drowning physiology is scarce. Better understanding may identify methods to improve survival, particularly related to hot-water immersion, cold shock, cold-induced physical incapacitation, and fear of drowning.