Publications by authors named "Silke Grabherr"

84 Publications

Postmortem coronary artery calcium score in cases of myocardial infarction.

Int J Legal Med 2021 Apr 13. Epub 2021 Apr 13.

University Center of Legal Medicine Lausanne-Geneva, Chemin de la Vulliette 4, CH - 1000, Lausanne 25, Switzerland.

Sudden cardiac death (SCD) related to atherosclerotic coronary artery disease (ACAD) resulting in myocardial infarction is the most prevalent cause of death in western countries. In clinical practice, coronary artery calcium score (CACS) is considered an independent predictor of coronary events, closely related to atherosclerotic burden and is quantified radiologically by the Agatston score being calculated through computed tomography. Postmortem computed tomography (PMCT) allows the visualization and quantification of coronary calcifications before the autopsy. However, it was reported that some patients who died from severe ACAD had a zero CACS in PMCT. In this study, a retrospective evaluation of CACS in adult's myocardial infarction cases related to ACAD, with available CACS and histological slides of coronary arteries, was performed in order to gain a deeper understanding of coronary calcifications and their role in myocardial infarction cases. The CACS was calculated by using the software Smartscore 4.0 after the radiological examination on a 64-row CT unit using a specific cardiac protocol. Thirty-six cases were identified out of 582 autopsies, recorded during a 2-year study period (29 men, 7 women; age 56.3 ± 11.7). CACS was 0-10 in 5 cases (5 men, 44.8 ± 13.7), 11-100 in 8 cases (6 men, 2 women, 53.1 ± 7.7), 101-400 in 13 cases (11 men, 2 women, 57.4 ± 9.6), and > 400 in 10 cases (9 men, 1 woman, 63.1 ± 11.9). Coronary thrombosis was found in 28 cases, histologically identified as plaque erosions in 6 cases and as plaque ruptures in 22 cases. Statistical analyses showed that CACS increases significantly with age (p-value < 0.05) and does not show significant correlation with gender, body weight, body mass index, and heart weight. CACS was significantly higher in plaque ruptures than in plaque erosions (p-value < 0.01). Zero or low CACS on unenhanced PMCT cannot exclude the presence of myocardial infarction related to ACAD. This paradoxical discrepancy between imaging and autopsy findings can be explained considering the histological aspect of fatal coronary plaques.
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http://dx.doi.org/10.1007/s00414-021-02586-zDOI Listing
April 2021

DBnorm as an R package for the comparison and selection of appropriate statistical methods for batch effect correction in metabolomic studies.

Sci Rep 2021 Mar 11;11(1):5657. Epub 2021 Mar 11.

Unit of Forensic Toxicology and Chemistry, CURML, Lausanne University Hospital-Geneva University Hospitals, Lausanne-Geneva, Switzerland.

As a powerful phenotyping technology, metabolomics provides new opportunities in biomarker discovery through metabolome-wide association studies (MWAS) and the identification of metabolites having a regulatory effect in various biological processes. While mass spectrometry-based (MS) metabolomics assays are endowed with high throughput and sensitivity, MWAS are doomed to long-term data acquisition generating an overtime-analytical signal drift that can hinder the uncovering of real biologically relevant changes. We developed "dbnorm", a package in the R environment, which allows for an easy comparison of the model performance of advanced statistical tools commonly used in metabolomics to remove batch effects from large metabolomics datasets. "dbnorm" integrates advanced statistical tools to inspect the dataset structure not only at the macroscopic (sample batches) scale, but also at the microscopic (metabolic features) level. To compare the model performance on data correction, "dbnorm" assigns a score that help users identify the best fitting model for each dataset. In this study, we applied "dbnorm" to two large-scale metabolomics datasets as a proof of concept. We demonstrate that "dbnorm" allows for the accurate selection of the most appropriate statistical tool to efficiently remove the overtime signal drift and to focus on the relevant biological components of complex datasets.
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http://dx.doi.org/10.1038/s41598-021-84824-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952378PMC
March 2021

Detecting early myocardial ischemia in rat heart by MALDI imaging mass spectrometry.

Sci Rep 2021 Mar 4;11(1):5135. Epub 2021 Mar 4.

University Centre of Legal Medicine, Lausanne-Geneva, Rue Michel-Servet 1, 1211, Geneva, Switzerland.

Diagnostics of myocardial infarction in human post-mortem hearts can be achieved only if ischemia persisted for at least 6-12 h when certain morphological changes appear in myocardium. The initial 4 h of ischemia is difficult to diagnose due to lack of a standardized method. Developing a panel of molecular tissue markers is a promising approach and can be accelerated by characterization of molecular changes. This study is the first untargeted metabolomic profiling of ischemic myocardium during the initial 4 h directly from tissue section. Ischemic hearts from an ex-vivo Langendorff model were analysed using matrix assisted laser desorption/ionization imaging mass spectrometry (MALDI IMS) at 15 min, 30 min, 1 h, 2 h, and 4 h. Region-specific molecular changes were identified even in absence of evident histological lesions and were segregated by unsupervised cluster analysis. Significantly differentially expressed features were detected by multivariate analysis starting at 15 min while their number increased with prolonged ischemia. The biggest significant increase at 15 min was observed for m/z 682.1294 (likely corresponding to S-NADHX-a damage product of nicotinamide adenine dinucleotide (NADH)). Based on the previously reported role of NAD/NADH ratio in regulating localization of the sodium channel (Na1.5) at the plasma membrane, Na1.5 was evaluated by immunofluorescence. As expected, a fainter signal was observed at the plasma membrane in the predicted ischemic region starting 30 min of ischemia and the change became the most pronounced by 4 h. Metabolomic changes occur early during ischemia, can assist in identifying markers for post-mortem diagnostics and improve understanding of molecular mechanisms.
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http://dx.doi.org/10.1038/s41598-021-84523-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7933419PMC
March 2021

Impact of increasing levels of adaptive statistical iterative reconstruction on image quality in oil-based postmortem CT angiography in coronary arteries.

Int J Legal Med 2021 Feb 24. Epub 2021 Feb 24.

Medical Faculty, Department of Diagnostic and Interventional Radiology, University Dusseldorf, D-40225, Dusseldorf, Germany.

Introduction: Postmortem multi-detector computed tomography (PMCT) has become an important part in forensic imaging. Modern reconstruction techniques such as iterative reconstruction (IR) are frequently used in postmortem CT angiography (PMCTA). The image quality of PMCTA depends on the strength of IR. For this purpose, we aimed to investigate the impact of different advanced IR levels on the objective and subjective PMCTA image quality.

Material And Methods: We retrospectively analyzed the coronary arteries of 27 human cadavers undergoing whole-body postmortem CT angiography between July 2017 and March 2018 in a single center. Iterative reconstructions of the coronary arteries were processed in five different level settings (0%; 30%; 50%; 70%; 100%) by using an adaptive statistical IR method. We evaluated the objective (contrast-to-noise ratio (CNR)) and subjective image quality in several anatomical locations.

Results: Our results demonstrate that the increasing levels of an IR technique have relevant impact on the image quality in PMCTA scans in forensic postmortem examinations. Higher levels of IR have led to a significant reduction of image noise and therefore to a significant improvement of objective image quality (+ 70%). However, subjective image quality is inferior at higher levels of IR due to plasticized image appearance.

Conclusion: Objective image quality in PMCTA progressively improves with increasing level of IR with the best CNR at the highest IR level. However, subjective image quality is best at low to medium levels of IR. To obtain a "classic" image appearance with optimal image quality, PMCTAs should be reconstructed at medium levels of IR.
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http://dx.doi.org/10.1007/s00414-021-02530-1DOI Listing
February 2021

Ultrasonographic assessment of ossification of the distal radial epiphysis for estimating forensic age.

Int J Legal Med 2021 Feb 20. Epub 2021 Feb 20.

University Center of Legal Medicine, Lausanne-Geneva, Switzerland.

Since forensic age estimation is not a valid medical indication, research on the use of nonionizing methods is increasing. Ultrasonography is a radiological approach that protects patients from radiation exposure and offers special convenience to them. In this study, ultrasonography was used for age estimation by investigating the degree of ossification of the distal radial epiphysis. Its applicability on the Turkish population was investigated. The left wrist of 688 (322 males, 366 females) patients between the ages of 9 and 25 years was prospectively evaluated by ultrasonography. The intra- and interobserver reliabilities in evaluating the distal radial epiphysis and Cohen's kappa statistics show that the interobserver error was very low, and the kappa value was found to be 0.919. Stage 3 and 4 ossification of the distal radial epiphysis was first detected at age 14.3 and 15.3 years in males and 12.7 and 14.8 years in females, respectively. The data obtained may help determine legally critical age limits of 14 and 15. Although it does not seem useful for the age of 18, ultrasonography may be recommended in selected cases as a fast, inexpensive, frequently reproducible radiological method without concern about radiation and without a predictable health risk.
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http://dx.doi.org/10.1007/s00414-021-02521-2DOI Listing
February 2021

Virtual morphometric method using seven cervical vertebrae for sex estimation on the Turkish population.

Int J Legal Med 2021 Feb 5. Epub 2021 Feb 5.

University Center of Legal Medicine Lausanne-Geneva, Geneva, Switzerland.

Sex estimation from skeletal remains is crucial for the estimation of the biological profile of an individual. Although the most commonly used bones for means of sex estimation are the pelvis and the skull, research has shown that acceptable accuracy rates might be achieved by using other skeletal elements such as vertebrae. This study aims to contribute to the development of sex estimation standards from a Turkish population through the examination of CT scans from the seven cervical vertebrae. A total of 294 individuals were included in this study. The CT scans were obtained from patients attending the Bakirkoy Training and Research Hospital (Turkey) and the data was collected retrospectively by virtually taking measurements from each cervical vertebrae. The full database was divided into a training set (N = 210) and a validation set (N = 84) to test the fit of the models. Observer error was assessed through technical error of measurement and sex differences were explored using parametric and non-parametric approaches. Logistic regression was applied in order to explore different combinations of vertebral parameters. The results showed low intra- and inter-observer errors. All parameters presented statistically significant differences between the sexes and a total of 15 univariate and multivariate models were generated producing accuracies ranging from a minimum of 83.30% to a maximum of 91.40% for a model including three parameters collected from four vertebrae. This study presents a virtual method using cervical vertebrae for sex estimation on the Turkish population providing error rates comparable to other metric studies conducted on the postcranial skeleton. The presented results contribute not only to the development of population-specific standards but also to the generation of virtual methods that can be tested, validated, and further examined in future forensic cases.
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http://dx.doi.org/10.1007/s00414-021-02510-5DOI Listing
February 2021

Forensic age estimation based on fast spin-echo proton density (FSE PD)-weighted MRI of the distal radial epiphysis.

Int J Legal Med 2021 Jan 28. Epub 2021 Jan 28.

University Center of Legal Medicine Lausanne-Geneva, Lausanne, Switzerland.

Radiation exposure is a crucial factor to consider in forensic age estimation. The various magnetic resonance imaging (MRI) modalities used in forensic age estimation avoid radiation exposure. This study examined the reliability of distal radius ossification using fast spin-echo proton density (FSE PD)-weighted MRI to estimate age. Left wrist MRI findings of 532 patients aged 10-29 years were evaluated retrospectively using the five-stage system of Dedouit et al. The intra- and interobserver reliability values were κ = 0.906 and 0.869, respectively. Based on the results, the respective minimum ages estimated for stages 4 and 5 were 13.4 and 16.1 years for females, and 15.1 and 17.3 years for males; the method could not estimate an age of 18 years in any case. FSE PD MRI analysis of the distal radius epiphysis provides supportive data and can be used when evaluating the distal radius for forensic age estimation.
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http://dx.doi.org/10.1007/s00414-021-02505-2DOI Listing
January 2021

Oleic Acid (OA), A Potential Dual Contrast Agent for Postmortem MR Angiography (PMMRA): A Pilot Study.

Curr Med Sci 2020 Aug 29;40(4):786-794. Epub 2020 Aug 29.

Dian Research Center for Postmortem Imaging & Angiography, Beijing, 100192, China.

Choosing proper perfusates as contrast agents is an important aspect for postmortem magnetic resonance angiography (PMMRA). However, in this emerging field, the number of suitable kinds of liquid is still very limited. The objective of this research is to compare MR images of oleic acid (OA) with paraffin oil (PO) in vitro and in ex situ animal hearts, in order to evaluate the feasibility to use OA as a novel contrast agent for PMMRA. In vitro, OA, PO and water (control) were introduced into three tubes separately and Tweighted-spin echo (Tw-SE) and Tw-SE images were acquired on a 1.5T MR scanner. In the second experiment, OA and PO were injected into left coronary artery (LCA) and left ventricle (LV) of ex situ bovine hearts and their Tw-SE, Tw-SE, Tw-multipoint Dixon (Tw-mDixon) and 3DTw-mDixon images were acquired. The overall results indicate that OA may have a potential to be used as a dual (T and T based) contrast agent for PMMRA when proper sequence parameters are utilized. However, as the pilot study was based on limited number of animal hearts, more researches using OA in cadavers are needed to validate our findings.
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http://dx.doi.org/10.1007/s11596-020-2244-7DOI Listing
August 2020

Forensic age estimation via magnetic resonance imaging of knee in the Turkish population: use of T1-TSE sequence.

Int J Legal Med 2021 Mar 24;135(2):631-637. Epub 2020 Aug 24.

University Center of Legal Medicine, Lausanne - Geneva, Switzerland.

The evaluation of epiphyseal areas by magnetic resonance imaging (MRI) for forensic age estimation is an important supportive diagnostic method to prevent repeated radiation exposure without a valid medical reason. There are still not enough individuals being analyzed with MRI for age estimation. The aim of this study was to investigate the utility of T1-weighted turbo spin echo (T1-TSE) MRI sequences in determining the degree of ossification of the distal femoral and proximal tibial epiphyses in a Turkish population. In this study, images from 649 patients (335 males and 314 females) aged 10-30 years were retrospectively evaluated with sagittal T1-weighted turbo spin echo (T1-TSE) MRI sequences of the knee. Proximal tibial and distal femoral epiphysis were scored by two different observers twice using the combined staging system described by Schmeling and Kellinghaus. Spearman's rank correlation analysis indicated a significant positive relationship between age and ossification stages of the distal femoral and proximal tibial epiphyses (p < 0.001). The intra- and inter-observer reliabilities in evaluating the femur and tibia were separately determined and gave promising results and Cohen's kappa statistics ranged from κ = 0.886 and κ = 0.961. The minimal ages of patients with stage 4 ossification were 15.1 years for females and 15.8 years for males for the distal tibial epiphysis and 15.4 years for females and 17 years for males for the distal femoral epiphysis. This study show that (T1-TSE) MRI and the applicability and Schmeling and Kellinghaus staging method of the knee can be performed for living 14- to 17-year-old individuals in need of a supportive noninvasive method for estimating forensic age.
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http://dx.doi.org/10.1007/s00414-020-02402-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870628PMC
March 2021

Reference values and sex differences in absolute and relative kidney size. A Swiss autopsy study.

BMC Nephrol 2020 07 20;21(1):289. Epub 2020 Jul 20.

Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 17, 1011, Lausanne, Switzerland.

Background: Men have larger kidneys than women, but it is unclear whether gender remains an independent predictor of kidney size (expressed as weight or length) after correction for body size. We analysed autopsy data to assess whether relative renal length and weight (e.g. corrected for body weight, height or body surface area (BSA)) are also larger in men. Assuming that kidney size is associated with nephron number, opposite findings could partly explain why women are less prone to the development and progression of chronic kidney disease than men.

Methods: All forensic autopsies performed between 2009 and 2015 at the local university hospital of Geneva in individuals of European descent aged ≥18 years without a known history of diabetes and/or kidney disease were examined. Individuals with putrefied or severely injured bodies were excluded. Relative renal weight and length were respectively defined as renal weight divided by body weight or BSA and renal length divided by body height or BSA.

Results: A total of 635 autopsies (68.7% men) were included in the analysis. Left kidneys were on average 8 g heavier and 2 mm longer than right kidneys (both: p < 0.05). Absolute renal weight (165 ± 40 vs 122 ± 29 g) and length (12.0 ± 1.3 vs 11.4 ± 1.1 cm) were higher in men. Relative renal weight was also higher in men, but relative renal length was larger in women. In multivariable regression analysis, body height, body weight, the degree of blood congestion or depletion at autopsy and age were determinants of renal weight, whereas arterial hypertension and smoking were not. Percentile curves of renal weight and length according to sex and body height were constructed.

Conclusion: Absolute and relative renal weights were both smaller in women. This is in line with recent studies stating that nephron numbers are also lower in women. Relative renal length was longer in women, suggesting that female kidneys have a more elongated shape. In comparison with older autopsy studies, renal weight appears to be stable over time.
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http://dx.doi.org/10.1186/s12882-020-01946-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372852PMC
July 2020

Revolution in death sciences: body farms and taphonomics blooming. A review investigating the advantages, ethical and legal aspects in a Swiss context.

Int J Legal Med 2020 Sep 21;134(5):1875-1895. Epub 2020 May 21.

Swiss Human Institute of Forensic Taphonomy, University Center of Legal Medicine Lausanne-Geneva, Chemin de la Vulliette 4, 1000, Lausanne, Switzerland.

Taphonomy is the study of decaying organisms over time and their process of fossilization. Taphonomy, originally a branch of palaeontology and anthropology, was developed to understand the ecology of a decomposition site, how site ecology changes upon the introduction of plant or animal remains and, in turn, how site ecology affects the decomposition of these materials. In recent years, these goals were incorporated by forensic science to understand the decomposition of human cadavers, to provide a basis on which to estimate postmortem and/or postburial interval, to assist in the determination of cause and circumstances of death, and to aid in the location of clandestine graves. These goals are achieved through the study of the factors that influence cadaver decomposition (e.g. temperature, moisture, insect activity). These studies have also provided insight into the belowground ecology of cadaver breakdown and allowed to develop useful protocols for mass disaster managements in humanitarian medicine. From the results obtained, new scientific disciplines have arisen, gathered under the word "taphonomics" such as the study of microorganisms living below/on a cadaver (thanatogeomicrobiology), and join the more classical forensic sciences such as anthropology, botany or entomology. Taking into account the specificities of the study object (human cadaver), primordial requirements are needed in terms of security (physical and environmental) as well as ethical and legal concerns which are studied in the Swiss context. The present review aims to present in a first part the concept of human forensic taphonomy facilities (HFTF, also colloquially named "body farm") leading to an enrichment of forensic sciences with new "taphonomics". The second part is focused on the mandatory points that must be addressed for a HFTF approach, especially because it requires a specific place to undertake this research which must be performed in conformity with a country's human ethics and laws.
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http://dx.doi.org/10.1007/s00414-020-02272-6DOI Listing
September 2020

Postmortem imaging as a complementary tool for the investigation of cardiac death.

Forensic Sci Res 2019 19;4(3):211-222. Epub 2019 Aug 19.

Lausanne University Hospital and University of Lausanne, University Center of Legal Medicine Lausanne-Geneva, Lausanne, Switzerland.

In the past 2 decades, modern radiological methods, such as multiple detector computed tomography (MDCT), MDCT-angiography, and cardiac magnetic resonance imaging (MRI) were introduced into postmortem practice for investigation of sudden death (SD), including cases of sudden cardiac death (SCD). In forensic cases, the underlying cause of SD is most frequently cardiovascular with coronary atherosclerotic disease as the leading cause. There are many controversies about the role of postmortem imaging in establishing the cause of death and especially the value of minimally invasive autopsy techniques. This paper discusses the state of the art for postmortem radiological evaluation of the heart compared to classical postmortem examination, especially in cases of SCD. In SCD cases, postmortem CT is helpful to estimate the heart size and to visualize haemopericardium and calcified plaques and valves, as well as to identify and locate cardiovascular devices. Angiographic methods are useful to provide a detailed view of the coronary arteries and to analyse them, especially regarding the extent and location of stenosis and obstruction. In postsurgical cases, it allows verification and documentation of the patency of stents and bypass grafts before opening the body. Postmortem MRI is used to investigate soft tissues such as the myocardium, but images are susceptible to postmortem changes and further work is necessary to increase the understanding of these radiological aspects, especially of the ischemic myocardium. In postsurgery cases, the value of postmortem imaging of the heart is reportedly for the diagnostic and documentation purposes. The implementation of new imaging methods into routine postmortem practice is challenging, as it requires not only an investment in equipment but, more importantly, investment in the expertise of interpreting the images. Once those requirements are implemented, however, they bring great advantages in investigating cases of SCD, as they allow documentation of the body, orientation of sampling for further analyses and gathering of other information that cannot be obtained by conventional autopsy such as a complete visualization of the vascular system using postmortem angiography.Key pointsThere are no established guidelines for the interpretation of postmortem imaging examination of the heartAt present, postmortem imaging methods are considered as less accurate than the autopsy for cardiac deathsPostmortem imaging is useful as a complementary tool for cardiac deathsThere is still a need to validate postmortem imaging in cardiac deaths by comparing with autopsy findings.
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http://dx.doi.org/10.1080/20961790.2019.1630944DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6713140PMC
August 2019

Toward safer thanatopraxy cares: formaldehyde-releasers use.

J Anat 2019 11 11;235(5):863-872. Epub 2019 Jul 11.

Swiss Human Institute of Forensic Taphonomy, University Centre of Legal Medicine Lausanne-Geneva, Lausanne, Switzerland.

Human cadavers constitute very useful educational tools to teach anatomy in medical scholarship and related disciplines such as physiology, for example. However, as biological material, human body is subjected to decay. Thanatopraxy cares such as embalming have been developed to slow down and inhibit this decay, but the formula used for the preservation fluids are mainly formaldehyde (FA)-based. Very recently, other formulas were developed in order to replace FA, and to avoid its toxicity leading to important environmental and professional exposure concerns. However, these alternative FA-free fluids are still not validated or commercialized, and their efficiency is still under discussion. In this context, the use of FA-releasing substances, already used in the cosmetics industry, may offer interesting alternatives in order to reduce professional exposures to FA. Simultaneously, the preservation of the body is still guaranteed by FA generated over time from FA-releasers. The aim of this review is to revaluate the use of FA in thanatopraxy cares, to present its benefits and disadvantages, and finally to propose an alternative to reduce FA professional exposure during thanatopraxy cares thanks to FA-releasers use.
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http://dx.doi.org/10.1111/joa.13047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6794211PMC
November 2019

Identification of the retrotalar pulley of the Flexor Hallucis Longus tendon.

J Anat 2019 10 5;235(4):757-764. Epub 2019 Jul 5.

Plate-forme de Morphologie, Université de Lausanne, Lausanne, Switzerland.

Functional Hallux Limitus is the expression of the gliding restraint of the Flexor Hallucis Longus (Fhl) tendon, resulting in several painful syndromes. This impingement is located along the tract of the Fhl tendon at the level of its retrotalar tunnel sealed posteriorly by a fibrous pulley. This pulley, although poorly anatomically characterized, has been arthroscopically proven that its presence or resection plays a pivotal clinical role in the biomechanics of the lower leg, being the main restraint to the physiological movement of the Fhl tendon. The aim of our study was to identify and characterize this anatomical structure. Eleven cadaveric lower legs were initially assessed by computer tomography (CT) imaging, subsequently plastinated, dissected and histologically evaluated by use of Mayer's and Hematoxylin stain. We have shown that the retrotalar pulley of the Fhl shares the same histological characteristics with the retinaculum of the long fibularis muscle and the retinaculum of flexor digitorum muscle, thus it constitutes a different entity than the adjacent formations.
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http://dx.doi.org/10.1111/joa.13046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6742900PMC
October 2019

Neck-MRI experience for investigation of survived strangulation victims.

Forensic Sci Res 2020 7;5(2):113-118. Epub 2019 May 7.

University Center of Legal Medicine Lausanne - Geneva, University Hospital Lausanne, Lausanne, Switzerland.

For the medicolegal evaluation of victims of survived strangulation, a neck-magnetic resonance imaging (MRI) can be performed for assessing lesions in the inner soft tissues (fat, muscles or lymph nodes, for example). In our institute, such MRI examinations have been performed for a test period of 4 years with the aim of evaluating the use of this tool by forensic pathologists and identifying medicolegal indicators for the performance of neck-MRI in surviving victims of strangulation. We retrospectively reviewed medicolegal reports from all victims examined during the test period. We extracted objective lesions (e.g. petechiae, bruising and abrasions) and reported clinical symptoms (e.g. vision disorder, dysphasia) from the reports. These findings were compared to those reported from the neck-MRI. In total, 112 victims were clinically examined after suspected strangulation. Eleven of these victims underwent an MRI examination of the neck. Eighty-four of the victims presented objective lesions during the clinical examination, with eight showing signs of both petechiae and bruising. Neck-MRI was performed in four of these eight victims and three of them showed lesions visible in MRI. Of 76 victims with bruising as the only objective finding, 66 victims described clinical symptoms. Of those 66 victims, seven were examined by MRI and two demonstrated lesions in MRI. When MRI was performed, relevant findings were detected in 45% of the cases. This leads to the suspicion that many more findings could have been detected in the other victims, if an MRI had been performed in those cases. Our results lead us to the conclusion that an MRI examination of victims of suspected strangulation is useful, and strict indications for its application should be established.
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http://dx.doi.org/10.1080/20961790.2019.1592314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476612PMC
May 2019

Biochemical investigations performed in pericardial fluid in forensic cases that underwent postmortem angiography.

Forensic Sci Int 2019 Apr 2;297:e11-e13. Epub 2019 Feb 2.

CURML, University Center of Legal Medicine, Lausanne University Hospital, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland.

Postmortem biochemical investigations in vitreous humor samples collected before and after performing multiphase postmortem computed tomography angiography were performed in the past and demonstrated that specific contrast material injection allowed perfusion and radiological identification of the main vessels of the eye to be obtained without any changes in vitreous humor composition. In the study presented herein, we aimed to test whether the injection of the same contrast material using the same postmortem angiography protocol might influence pericardial fluid composition. Postmortem biochemical investigations were performed on pericardial fluid samples collected from bodies that underwent postmortem angiography (n = 16) prior to and post angiography. Two pericardial fluid samples were analyzed. No statistically significant differences were noticed among levels of any tested markers (urea nitrogen, creatinine, uric acid, C-reactive protein, procalcitonin, beta-hydroxybutyrate, and total IgE levels) in pericardial fluid samples collected prior to and post angiography, leading to the conclusion that pericardial fluid sampling can be delayed until after postmortem angiography when a specific contrast material injection is used.
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http://dx.doi.org/10.1016/j.forsciint.2019.01.032DOI Listing
April 2019

An exploratory study toward the contribution of 3D surface scanning for association of an injury with its causing instrument.

Int J Legal Med 2019 Jul 1;133(4):1167-1176. Epub 2018 Dec 1.

University Centre for Legal Medicine Lausanne-Geneva, Chemin de la Vulliette 4, 25, 1000, Lausanne, Switzerland.

3D surface scanning is a technique brought forward for wound documentation and analysis in order to identify injury-causing tools in legal medicine and forensic science. Although many case reports have been published, little is known about the methodology employed by the authors. The study reported here is exploratory in nature, and its main purpose was to get a first evaluation of the ability of an operator, by means of 3D surface scanning and following a simple methodology, to correctly exclude or associate an incriminated tool as the source of a mock wound. Based on these results, an assessment of the possibility to define a structured methodology that could be suitable for this use was proposed. Blunt tools were used to produce 'wounds' on watermelons. Both wounds and tools were scanned with a non-contact optical surface 3D digitising system. Analysis of the obtained 3D models of wounds and tools was undertaken separately. This analytical phase was followed by a qualitative and a quantitative comparison. Results showed that in more than half of the cases, we obtained a correct association but the prevalence of wrong association was still high due to mark deformation and other limitations. Even if the findings of this exploratory study cannot be generalised, they suggest that the simple and direct comparison process is not reliable enough for a systematic routine application. The article highlights the importance of an analysis phase preceding the comparison step. Limitations of the technique, ensuring needs and possible paths for improvement are also expounded.
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http://dx.doi.org/10.1007/s00414-018-1973-7DOI Listing
July 2019

Postmortem CT Angiography Compared with Autopsy: A Forensic Multicenter Study.

Radiology 2018 Jul 1;288(1):270-276. Epub 2018 May 1.

From the University Center of Legal Medicine Lausanne-Geneva, Chemin de la Vulliette 4, 1000 Lausanne 25, Switzerland (S.G., F.D., K.M., C.P., C.C., P.M., J.M.G.); Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., H.V.); East Midlands Forensic Pathology Unit, University of Leicester, Leicester, England (G.R.); University of Leicester Imaging Department, University Hospitals of Leicester, Leicester Royal Infirmary, Leicester, England (B.M.); Department of Forensic Medicine, Jagiellonian University Medical College, Krakow, Poland (K.W.); Departments of Legal Medicine and Radiology, Hôpital Rangueil, Toulouse, France (F.D.); Institute of Legal Medicine, Munich, Germany (F.F., S.L.); Institute of Legal Medicine, Basel, Switzerland (H.W.); University of Foggia, Foggia, Italy (G.G.); Institute of Forensic Medicine, University of Leipzig, Leipzig, Germany (F.E.); and Department of Medical Radiology, University Hospital Center and University of Lausanne, Lausanne, Switzerland (J.M.G.).

Purpose To determine if postmortem computed tomography (CT) and postmortem CT angiography help to detect more lesions than autopsy in postmortem examinations, to evaluate the strengths and weaknesses of each method, and to define their indications. Materials and Methods Postmortem CT angiography was performed on 500 human corpses and followed by conventional autopsy. Nine centers were involved. All CT images were read by an experienced team including one forensic pathologist and one radiologist, blinded to the autopsy results. All findings were recorded for each method and categorized by anatomic structure (bone, organ parenchyma, soft tissue, and vascular) and relative importance in the forensic case (essential, useful, and unimportant). Results Among 18 654 findings, autopsies helped to identify 61.3% (11 433 of 18 654), postmortem CT helped to identify 76.0% (14 179 of 18 654), and postmortem CT angiography helped to identify 89.9% (16 780 of 18 654; P < .001). Postmortem CT angiography was superior to autopsy, especially at helping to identify essential skeletal lesions (96.1% [625 of 650] vs 65.4% [425 of 650], respectively; P < .001) and vascular lesions (93.5% [938 of 1003] vs 65.3% [655 of 1003], respectively; P < .001). Among the forensically essential findings, 23.4% (1029 of 4393) were not detected at autopsy, while only 9.7% (428 of 4393) were missed at postmortem CT angiography (P < .001). The best results were obtained when postmortem CT angiography was combined with autopsy. Conclusion Postmortem CT and postmortem CT angiography and autopsy each detect important lesions not detected by the other method. More lesions were identified by combining postmortem CT angiography and autopsy, which may increase the quality of postmortem diagnosis. Online supplemental material is available for this article.
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http://dx.doi.org/10.1148/radiol.2018170559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6027995PMC
July 2018

Multiplex quantitative imaging of human myocardial infarction by mass spectrometry-immunohistochemistry.

Int J Legal Med 2018 Nov 19;132(6):1675-1684. Epub 2018 Mar 19.

University Center of Legal Medicine, Lausanne-Geneva, Rue Michel-Servet, 11211, Geneva, Switzerland.

Simultaneous assessment of a panel of protein markers is becoming essential in order to enhance biomarker research and improve diagnostics. Specifically, postmortem diagnostics of early myocardial ischemia in sudden cardiac death cases could benefit from a multiplex marker assessment in the same tissue section. Current analytical antibody-based techniques (immunohistochemistry and immunofluorescence) limit multiplex analysis usually to not more than three antibodies. In this study, mass spectrometry-immunohistochemistry (MS-IHC) was performed by combining laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS) with rare-metal-isotope-tagged antibodies as a technique for multiplex analysis of human postmortem myocardial tissue samples. Tissue sections with myocardial infarction were simultaneously analyzed for seven primary, rare-metal-isotope-tagged antibodies (troponin T, myoglobin, fibronectin, C5b-9, unphosphorylated connexin 43, VEGF-B, and JunB). Comparison between the MS-IHC approach and chromogenic IHC showed similar patterns in ionic and optical images. In addition, absolute quantification was performed by MS-IHC, providing a proportional relationship between the signal intensity and the local marker concentration in tissue sections. These data demonstrated that LA-ICP-MS combined with rare-metal-isotope-tagged antibodies is an efficient strategy for simultaneous testing of multiple markers and allows not only visualization of molecules within the tissue but also quantification of the signal. Such imaging approach has a great potential in both diagnostics and pathology-related research.
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http://dx.doi.org/10.1007/s00414-018-1813-9DOI Listing
November 2018

Visualization of Myocardial Infarction in Postmortem Multiphase Computed Tomography Angiography: A Feasibility Study.

Am J Forensic Med Pathol 2018 Jun;39(2):106-113

Recent studies have indicated that multiphase postmortem computed tomography angiography (MPMCTA) allows detection of a pathological enhancement of the myocardium in regions that correlate with the localization of the infarction at histology. The aim of this study was to verify this hypothesis by examining MPMCTA images in cases of myocardial infarction. Therefore, we investigated 10 autopsy cases where death was attributed to myocardial infarction or which showed cardiovascular pathology. As a control group, we selected 10 cases of non-natural (namely, not cardiac) death. The MPMCTA was performed in both groups to ascertain whether a pathological enhancement could be observed. We detected a myocardial enhancement in all cardiac death cases, in the same region that showed infarction at histology. No enhancement was observed in control cases. These results have important implications in the routine management of sudden cardiac death cases. In fact, MPMCTA can not only orient about the cause of death before autopsy, but can especially help to identify affected regions for guiding and improving the sampling for microscopic examination.
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http://dx.doi.org/10.1097/PAF.0000000000000372DOI Listing
June 2018

The role of angiography in the congruence of cardiovascular measurements between autopsy and postmortem imaging.

Int J Legal Med 2018 Jan 24;132(1):249-262. Epub 2017 Jul 24.

University Center of Legal Medicine Lausanne-Geneva, Chemin de la Vulliette 4, 1000, 25, Lausanne, Switzerland.

Introduction: Postmortem CT angiography is the method of choice for the postmortem imaging investigations of the cardiovascular (CV) system. However, autopsy still remains the gold standard for CV measurement. Nevertheless, there are not any studies on CV measurements on the multi-phase postmortem angiography (MPMCTA) which includes comparisons with autopsy. Therefore, the aim of this study is to compare CV measurements between the native CT scan and the three phases of the MPMCTA to find out which of these modalities correlate the best with autopsy measurements.

Methods: For this study, we selected retrospectively 50 postmortem cases that underwent both MPMCTA and autopsy. A comparison was carried out between the CV measurements obtained with imaging (aorta; heart cavities and cardiac wall thicknesses; maximum cardiac diameter and cardiothoracic ratio) and at the autopsy (aorta; cardiac valves, ventricular thicknesses, and weight).

Results: Our results show that the dynamic phase displays an advantage for the measurement of the aortas. However, the MPMCTA is not accurate to measure the cardiac wall thicknesses. The measurements of the heart cavities show no correlation with the heart valves. The cardiothoracic ratio measured by the MPMCTA shows no correlation with the heart weight. Nevertheless, the maximum cardiac diameter exhibits a correlation with the latter on the venous and dynamic phase.

Conclusions: These results show that only few CV parameters measured with imaging correlate with measurement obtained at the autopsy. These results indicate that in order to better estimate values obtained at the autopsy, we need to define new reference values for the CV measurement on MPMCTA.
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http://dx.doi.org/10.1007/s00414-017-1652-0DOI Listing
January 2018

Understanding scuba diving fatalities: carbon dioxide concentrations in intra-cardiac gas.

Diving Hyperb Med 2017 Jun;47(2):75-81

Forensic Imaging Unit, University Centre of Legal Medicine Lausanne - Geneva, Switzerland.

Introduction: Important developments in the diagnosis of scuba diving fatalities have been made thanks to forensic imaging tool improvements. Multi-detector computed tomography (MDCT) permits reliable interpretation of the overall gaseous distribution in the cadaver. However, due to post-mortem delay, the radiological interpretation is often doubtful because the distinction between gas related to the dive and post-mortem decomposition artifactual gases becomes less obvious.

Methods: We present six cases of fatal scuba diving showing gas in the heart and other vasculature. Carbon dioxide (CO₂) in cardiac gas measured by gas chromatography coupled to thermal conductivity detection were employed to distinguish decomposition from embolism based on the detection of decomposition gases (hydrogen, hydrogen sulfide and methane) and to confirm arterial gas embolism (AGE) or post-mortem offgasing diagnoses. A Radiological Alteration Index (RAI) was calculated from the scan.

Results: Based on the dive history, the intra-cadaveric gas was diagnosed as deriving from decomposition (one case, minimal RAI of 61), post-mortem decompression artifacts (two cases, intermediate RAI between 60 and 85) and barotrauma/AGE (three cases, maximal RAI between 85 and 100), illustrating a large distribution inside the bodies.

Conclusion: MDCT scans should be interpreted simultaneously with compositional analysis of intra-cadaveric gases. Intra-cadaveric gas sampling and analysis may become useful tools for understanding and diagnosing scuba diving fatalities. In cases with short post-mortem delays, the CO₂ concentration of the cardiac gas provides relevant information about the circumstances and cause of death when this parameter is interpreted in combination with the diving profile.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6147232PMC
http://dx.doi.org/10.28920/dhm47.2.75-81DOI Listing
June 2017

A minimally-invasive method for profiling volatile organic compounds within postmortem internal gas reservoirs.

Int J Legal Med 2017 Sep 15;131(5):1271-1281. Epub 2017 Jun 15.

Organic and Biological Analytical Chemistry Group, University of Liège, Allée du 6 Août, 11, B6c, Quartier Agora (Sart-Tilman), 4000, Liège, Belgium.

In forensic casework, non-invasive and minimally-invasive methods for postmortem examinations are extremely valuable. Whole body postmortem computed tomography (PMCT) is often used to provide visualization of the internal characteristics of a body prior to more invasive procedures and has also been used to locate gas reservoirs inside the body to assist in determining cause of death. Preliminary studies have demonstrated that exploiting the volatile organic compounds (VOCs) located in these gas reservoirs by comprehensive two-dimensional gas chromatography-high-resolution time-of-flight mass spectrometry (GC×GC-HRTOF-MS) may assist in providing information regarding the postmortem interval. The aim of the current study was to further develop the procedures related to solid-phase microextraction (SPME) and GC×GC-HRTOF-MS analysis of gas reservoirs collected from deceased individuals. SPME fiber extraction parameters, internal standard approach, and sample stability were investigated. Altering the SPME parameters increased the selectivity and sensitivity for the VOC profile, and the use of a mixed deuterated internal standard contributed to data quality. Samples were found to be stable up to 6 weeks but were recommended to be analyzed within 4 weeks due to higher variation observed beyond this point. In addition, 29 VOC markers of interest were identified, and heart and/or abdominal cavity samples were suggested as a possible standardized sampling location for future studies. The data presented in this study will contribute to the long-term goal of producing a routine, accredited method for minimally-invasive VOC analysis in postmortem examinations.
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http://dx.doi.org/10.1007/s00414-017-1621-7DOI Listing
September 2017

CT-scan . 3D surface scanning of a skull: first considerations regarding reproducibility issues.

Forensic Sci Res 2017 13;2(2):93-99. Epub 2017 Jun 13.

Department of Forensic Imaging, University Centre for Legal Medicine Lausanne-Geneva, Lausanne, Switzerland.

Three-dimensional surface scanning (3DSS) and multi-detector computed tomography (MDCT) are two techniques that are used in legal medicine for digitalizing objects, a body or body parts such as bones. While these techniques are more and more commonly employed, surprisingly little information is known about the quality rendering of digitalized three-dimensional (3D) models provided by each of them. This paper presents findings related to the measurement precision of 3D models obtained through observation of a study case, where a fractured skull reconstructed by an anthropologist was digitalized using both post-mortem imaging methods. Computed tomography (CT) scans were performed using an 8-row MDCT unit with two different slice thicknesses. The variability of 3D CT models superimposition allowed to assess the reproducibility and robustness of this digitalization technique. Furthermore, two 3D surface scans were done using a professional high resolution 3D digitizer. The comparison of 3D CT-scans with 3D surface scans by superimposition demonstrated several regions with significant differences in topology (average difference between +1.45 and -1.22 mm). When comparing the reproducibility between these two digitalizing techniques, it appeared that MDCT 3D models led in general to greater variability for measurement precision between scanned surfaces. Also, the reproducibility was better achieved with the 3D surface digitizer, showing 3D models with fewer and less pronounced differences (from +0.32 to -0.31 mm). These experiments suggest that MDCT provides less reproducible body models than 3D surface scanning. But further studies must be undertaken in order to corroborate this first impression, and possibly explain the reason for these findings.
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http://dx.doi.org/10.1080/20961790.2017.1334353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197135PMC
June 2017

Modern post-mortem imaging: an update on recent developments.

Forensic Sci Res 2017 7;2(2):52-64. Epub 2017 Jun 7.

University Centre of Legal Medicine Lausanne-Geneva, Lausanne, Switzerland.

Modern post-mortem investigations use an increasing number of digital imaging methods, which can be collected under the term "post-mortem imaging". Most methods of forensic imaging are from the radiology field and are therefore techniques that show the interior of the body with technologies such as X-ray or magnetic resonance imaging. To digitally image the surface of the body, other techniques are regularly applied, e.g. three-dimensional (3D) surface scanning (3DSS) or photogrammetry. Today's most frequently used techniques include post-mortem computed tomography (PMCT), post-mortem magnetic resonance imaging (PMMR), post-mortem computed tomographic angiography (PMCTA) and 3DSS or photogrammetry. Each of these methods has specific advantages and limitations. Therefore, the indications for using each method are different. While PMCT gives a rapid overview of the interior of the body and depicts the skeletal system and radiopaque foreign bodies, PMMR allows investigation of soft tissues and parenchymal organs. PMCTA is the method of choice for viewing the vascular system and detecting sources of bleeding. However, none of those radiological methods allow a detailed digital view of the body's surface, which makes 3DSS the best choice for such a purpose. If 3D surface scanners are not available, photogrammetry is an alternative. This review article gives an overview of different imaging techniques and explains their applications, advantages and limitations. We hope it will improve understanding of the methods.
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http://dx.doi.org/10.1080/20961790.2017.1330738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197109PMC
June 2017

A fatal case of oxygen embolism in a hospital.

Forensic Sci Res 2017 31;2(2):100-106. Epub 2017 May 31.

Unit of Forensic Imaging and Anthropology, University Center of Legal Medicine, CHUV Hospital, Lausanne-Geneva, Switzerland.

This case reports on a 68-year-old man who was found dead in hospital next to his bed. Before this, he had been treated with intravenous antibiotics for pneumonia. The body was found with a peripheral venous catheter connected to a nasal cannula delivering oxygen (O) from the wall. Extensive medico-legal examinations were performed, including post-mortem computed tomography (CT), complete conventional autopsy, histological and immunohistochemistry analysis, toxicological analysis and post-mortem chemistry. Additionally, CT-guided gas sampling was performed at multiple sites to collect samples for gas analysis. During the external examination, massive subcutaneous emphysema was visible over the entire surface of the body. The CT scan revealed the presence of gas throughout the vascular system, and in the subcutaneous and muscular tissues. The autopsy confirmed the presence of lobar pneumonia and multiple gas bubbles in the vascular system. The gas analysis results showed a subnormal concentration of oxygen, confirming the suspected pure O embolism. Moreover, the carbon dioxide (CO) concentration in the gas sample from the heart was elevated to a level similar to those found in scuba diving fatalities. This could come from degassing of dissolved CO that accumulated and was trapped in the cardiac cavity. Based on the results of the different exams performed, and especially the gas analysis results, it was concluded that the cause of death was O embolism.
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http://dx.doi.org/10.1080/20961790.2017.1329695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197113PMC
May 2017

Forensic imaging.

Authors:
Silke Grabherr

Forensic Sci Res 2017 15;2(2):51. Epub 2017 May 15.

University Centre of Legal Medicine Lausanne-Geneva, Lausanne, Switzerland.

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http://dx.doi.org/10.1080/20961790.2017.1317691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197116PMC
May 2017

Back to the Future - Part 2. Post-mortem assessment and evolutionary role of the bio-medicolegal sciences.

Int J Legal Med 2017 Jul 25;131(4):1085-1101. Epub 2017 Apr 25.

Institute of Legal Medicine, University-Hospital Essen, Essen, Germany.

Part 2 of the review "Back to the Future" is dedicated to the evolutionary role of the bio-medicolegal sciences, reporting the historical profiles, the state of the art, and prospects for future development of the main related techniques and methods of the ancillary disciplines that have risen to the role of "autonomous" sciences, namely, Genetics and Genomics, Toxicology, Radiology, and Imaging, involved in historic synergy in the "post-mortem assessment," together with the mother discipline Legal Medicine, by way of its primary fundament, universally denominated as Forensic Pathology. The evolution of the scientific research and the increased accuracy of the various disciplines will be oriented towards the elaboration of an "algorithm," able to weigh the value of "evidence" placed at the disposal of the "justice system" as real truth and proof.
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http://dx.doi.org/10.1007/s00414-017-1585-7DOI Listing
July 2017

Back to the Future - Part 1. The medico-legal autopsy from ancient civilization to the post-genomic era.

Int J Legal Med 2017 Jul 24;131(4):1069-1083. Epub 2017 Apr 24.

Department of Legal and Occupational Medicine, Toxicology and Public Health, University-Hospital of Padova, Padova, Italy.

Part 1 of the review "Back to the Future" examines the historical evolution of the medico-legal autopsy and microscopy techniques, from Ancient Civilization to the Post-Genomic Era. In the section focusing on "The Past", the study of historical sources concerning the origins and development of the medico-legal autopsy, from the Bronze Age until the Middle Ages, shows how, as early as 2000 BC, the performance of autopsies for medico-legal purposes was a known and widespread practice in some ancient civilizations in Egypt, the Far East and later in Europe. In the section focusing on "The Present", the improvement of autopsy techniques by Friedrich Albert Zenker and Rudolf Virchow and the contemporary development of optical microscopy techniques for forensic purposes during the 19th and 20th centuries are reported, emphasizing, the regulation of medico-legal autopsies in diverse nations around the world and the publication of international guidelines or best practices elaborated by International Scientific Societies. Finally, in "The Future" section, innovative robotized and advanced microscopy systems and techniques, including their possible use in the bio-medicolegal field, are reported, which should lead to the improvement and standardization of the autopsy methodology, thereby achieving a more precise identification of natural and traumatic pathologies.
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http://dx.doi.org/10.1007/s00414-017-1584-8DOI Listing
July 2017

Sudden cardiac death and sarcoidosis of the heart in a young patient.

Cardiovasc Pathol 2017 May - Jun;28:18-20. Epub 2017 Jan 25.

Geneva University Hospitals, Geneva, Switzerland.

Sarcoidosis is a granulomatous disease of unknown etiology affecting any organ, microscopically characterized by noncaseating granulomata. Cardiac involvement in sarcoidosis has been reported. It might be symptomatic or not and even revealed by sudden death. Heart conduction system is rarely investigated at autopsy, even in cases of sudden cardiac death. We present a case of a 32-year-old woman who died suddenly. The examination of the heart conduction system revealed a cardiac sarcoidosis that could explain the sudden death. The review of clinical data of the patient revealed some symptoms consistent/in agreement with this hypothesis. Cardiac sarcoidosis remains a diagnostic challenge and can be easily missed, clinically and pathologically. The retrospective analysis of clinical data and autopsy results of fatal and unusual cases might help to better understand sarcoidosis and its clinical presentations. Examination of the cardiac conduction system is crucial in selected cases of sudden cardiac death.
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http://dx.doi.org/10.1016/j.carpath.2017.01.003DOI Listing
December 2017