Major Autopsy Findings Research Articles

A retrospective study of the characteristics and toxicology of cases of lysergic acid diethylamide (LSD)- and psilocybin-related death in Australia.

Lysergic acid diethylamide (LSD) and psilocybin are used as recreational drugs, and there is renewed interest in their clinical use. The current study aimed to (1) determine the circumstances of death and case characteristics of LSD- and psilocybin-related death in Australia, 2000-23; and (2) determine the toxicological profile and major autopsy findings of these cases. This was a retrospective exploratory study of all cases of LSD- and psilocybin-related death in Australia, 2000-23, retrieved from the National Coronial Information System. A total of 43 cases were identified: 33 LSD and 10 psilocybin. The median ages were 24 years [interquartile range (IQR) = 13, range = 16-53] (LSD) and 26 years (IQR = 18.5, range = 20-58) (psilocybin), and fewer than five cases were female. The most common circumstance of death among both groups was traumatic accident (LSD 36.4%, psilocybin 40.0%). There were 12 cases of self-harm, all of which involved LSD, all by physical means. In a fifth, death was attributed to multiple drug toxicity (LSD 18.2%, psilocybin 20.0%). In one case, death was attributed solely to LSD toxicity, while in a further two cases death was attributed to a cardiovascular event following LSD consumption (one LSD only, one multiple drug toxicity). In four psilocybin cases, the cause of death was undetermined. The most common clinical presentation was severe agitation (LSD 27.3%, psilocybin 20.0%). Median blood concentrations were LSD 0.8μg/l (IQR = 1.7, range = 0.1-3), psilocin 20 μg/l (IQR = 53.5, range = 6-83). LSD was the only drug present in 25.0% of LSD cases and psilocybin in 20.0% of psilocybin cases. Pre-existing organ pathology was uncommon. Lysergic acid diethylamide (LSD)- and psilocybin-related death in Australia from 2000 to 2023 was primarily due to traumatic injury, whether through accident or self-harm. Cases of acute toxic reactions that were attributed solely to LSD were rare.

Characteristics, toxicology and major organ pathology of deaths due to acute alcohol toxicity in Australia, 2011-2022.

Acute alcohol toxicity is a significant component of alcohol-related mortality. The study aimed to: (i) determine the circumstances of death and characteristics of fatal alcohol toxicity cases, 2011-2022; (ii) determine their toxicological profile and major autopsy findings; and (iii) determine trends in population mortality rates. Retrospective study of acute alcohol toxicity deaths in Australia, 2011-2022, retrieved from the National Coronial Information System. A total of 891 cases were identified, with a mean age of 49.2 years, 71.0% being male. Alcohol use problems were noted in 71.3%. In 57.5% death was attributed solely to acute alcohol toxicity, and combined acute alcohol toxicity/disease in 42.5%. There was evidence of sudden collapse in 24.9% of cases. The mean BAC was 0.331 g/100 mL (range 0.107-0.936), and spirits were the most commonly reported beverages (35.8%). Cases of combined toxicity/disease had significantly lower BACs than those attributed solely to alcohol toxicity (0.296 vs. 0.358 g/100 mL). Cardiomegaly was diagnosed in 32.5%, and severe coronary artery disease in 22.1%. Aspiration of vomitus was noted in 18.0%, and chronic obstructive pulmonary disease in 19.6%. Severe liver steatosis was present in 33.4% and 13.6% had cirrhosis. There was an average annual percentage increase in deaths of 7.90. The 'typical' case was a long-standing, heavy spirits drinker. BACs showed enormous variation and no arbitrary concentration may be deemed lethal. Clinically significant disease was associated with death at a lower BAC and people with such disease may be at increased risk of alcohol poisoning.

Evaluating the performance of ChatGPT in writing autopsy clinicopathological correlations

Abstract ChatGPT is a chatbot launched by OpenAI in November 2022 that has generated excitement due to its utility in several technical fields including medicine. The application has gained media attention due to concerns of academic plagiarism, including its use by students for writing projects. In scientific writing, a preprint in bioarxiv reports human reviewers failing to identify a portion of ChatGPT generated abstracts. Several articles published in early 2023 list ChatGPT as a coauthor, generating debate. In medicine, Gilson et al found ChatGPT crossed the 60% threshold for the NBME Free Step-1 dataset. Patel and Lam wrote a commentary examining the value of ChatGPT in writing discharge summaries. A literature review in PubMed yielded articles further examining the utility of ChatGPT in scientific writing, however none looking at its use in pathology report writing was found. To examine this, we investigated the capabilities of ChatGPT in writing autopsy clinicopathologic reports. The February 13 version of ChatGPT was used to generate autopsy clinicopathologic correlations using prompts with the same patient demographic, same medical history of hypertension and coronary disease, and varying autopsy findings. These findings include cardiac infarct, saddle emboli, basilar artery thrombus, liver cyst, and leukoplakia. A prompt with no significant autopsy findings was also included. The prompts note a lack of imaging, labs, and toxicology. The generated responses were examined and compared. ChatGPT generated multi-sentence responses incorporating patient information, history, and major autopsy findings per prompt, ranging in length from 8 to 14 sentences. Each output varied in style, with some responses including sections for gross and microscopic findings, while others only consisting of clinicopathologic correlation. Each response was generated between 42 seconds to 1 minute. The application generated plausible correlations between the medical histories and autopsy findings. ChatGPT correlated the findings to the patient’s supplied history in prompts with a cardiovascular autopsy finding. For the liver cyst, ChatGPT linked cyst formation to portal hypertension. For leukoplakia, ChatGPT suggested the presence of an upper GI cancer with cardiovascular history also likely contributing to death. For the prompt without significant findings, ChatGPT noted that the autopsy was inconclusive. ChatGPT debuted with an increasing amount of media attention due to its capability of producing natural language responses and surprising knowledge within multiple technical fields. ChatGPT is currently being used in academic writing at multiple levels within multiple fields. In medicine, ChatGPT has done well in multiple USMLE question banks. This study found that ChatGPT generated coherent clinicopathologic correlations commensurate to the amount of information supplied in the initial prompt. While useful as an initial framework, human review is still necessary to refine the response to make a more coherent report and to review made-up findings and dubious correlations.

A descriptive coronial study of heroin toxicity deaths in Australia, 2020-2022: Characteristics, toxicology and survival times.

Mortality rates among people who use heroin are estimated to be 15 times that of the general population. The study aimed to determine (1) the case characteristics and circumstances of death of heroin-related toxicity deaths in Australia, 2020-2022; (2) their toxicological profile and major autopsy findings; (3) the proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a proxy measure of survival times; and (4) compare 6AM positive and negative cases on toxicology, circumstances of death and acute clinical presentation. Retrospective study of heroin toxicity deaths in Australia, 2020-2022, retrieved from the National Coronial Information System. This study was conducted Australia-wide. There were 610 cases of fatal heroin-related drug toxicity. Information was collected on characteristics, manner of death, toxicology and autopsy results. The mean age was 42.6 years (range 18-73 years), 80.5% were male and 7.5% were enrolled in a drug treatment programme. The circumstances of death were as follows: unintentional drug toxicity (86.2%), combined unintentional drug toxicity/disease (11.3%) and intentional drug toxicity (2.5%). The median free morphine concentration was 0.17 mg/L (range 0.00-4.20 mg/L). Psychoactive drugs other than heroin were present in 95.2% (Confidence Interval 93.1%-96.8%), most commonly hypnosedatives (62.3%, 58.2%-66.4%) and psychostimulants (44.8%, 40.7%-49.1%). Major autopsy findings of clinical significance included acute bronchopneumonia (14.8%, 11.3%-18.8%), emphysema (16.9%, 13.2%-21.1%), cardiomegaly (30.1%, 12.7%-28.2%), coronary artery disease (27.4%, 23.0%-32.3%), coronary replacement fibrosis (13.4%, 10.1%-17.3%), hepatic cirrhosis (8.8%, 6.6%-12.2%) and renal fibrosis (10.3%, 7.3%-14.0%). In 47.0% (42.3%-51.2%), 6AM was present in blood. The 'typical' heroin overdose case in Australia from 2020 to 2022 was a male who injected heroin, aged in the 40s, not enrolled in a treatment programme and had used multiple drugs. In over half of cases, there had been a sufficient survival time for 6-acetyl morphine to have been metabolised, which may indicate times in excess of 20-30 min.

Characteristics and circumstances of volatile solvent misuse-related death in Australia, 2000–2021

Introduction Volatile solvent misuse-related death is associated with neuropsychiatric, cardiovascular, respiratory and renal pathology, as well as sudden death. The study aimed to determine: (1) the circumstances of death and case characteristics of volatile solvent misuse-related death in Australia, 2000–2021; (2) the toxicological profile of cases; and (3) the major autopsy findings. Methods Retrospective study of volatile solvent misuse-related death in Australia, 2000–2021 retrieved from the National Coronial Information System. Findings One hundred and sixty-four cases were identified, 79.9% male, mean age 26.5 years (8.5% aged 40 years or older). Circumstances of death were unintentional toxicity (61.0%), unintentional asphyxia (20.1%), intentional self-harm (12.2%) and traumatic accident (6.7%). The most commonly reported acute presentation prior to death was sudden collapse (22 of 47 witnessed events). The most frequently used solvents at the fatal incident were gas fuels (35.4%), gasoline (petrol) (19.5%) adhesives/paints (19.5%), aerosol propellants (12.8%), and volatile anaesthetics (12.8%). The most commonly detected volatile substances were butane (40.7%), toluene (29.6%), and propane (25.9%). Cannabis was present in 27.6% and alcohol in 24.6%. The prevalence of acute pneumonia amongst autopsied cases was low (5.8%) which, together with reports of sudden collapse, suggests that in many cases, death was extremely rapid. There were low levels of major organ pathology. Conclusions While the average age of volatile solvent misuse-related death was in the mid-twenties, a substantial proportion occurred amongst people aged 40 years or older. Reflecting availability, gas fuels predominated. In many cases, death appeared to have been rapid.

Comparison of Prenatal Ultrasound and Autopsy Findings of Fetuses Terminated in Second Trimester: A Five-Year Experience of a Tertiary Center

Objective: The aim of this study is to compare the prenatal ultrasonography (US) and the autopsy findings of the fetuses of 12–24th gestational weeks. Methods: This retrospective study comprises 84 fetuses autopsied. The correlation between US and autopsy findings was classified into four categories: (A) Compatible, (B) Minor findings added, (C) Major findings added, and (D) Incompatible. Results: Malformations were the most common medical termination indication. The most frequent findings at autopsy were multiple system findings followed by central nervous system. Prenatal US and autopsy findings were completely compatible in 48 fetuses (57.1%), while additional minor and major autopsy findings were found in 26 (31.0%) and 4 (4.8%), respectively. Autopsy and US findings were incompatible in 6 fetuses (7.1%). Conclusion: Prenatal ultrasound and fetal autopsy are complementary tools to obtain detailed and complete diagnosis of fetal anomalies and fetal autopsy is still a valuable tool to obtain further diagnostic information.

Characteristics of fatal ‘novel’ synthetic opioid toxicity in Australia

BackgroundAims: To determine 1. The characteristics of all recorded cases of fatal drug poisoning involving novel synthetic opioids (NSOs) in Australia; 2. The toxicology of cases; and 3. The major autopsy findings. MethodsReview of all fatal poisonings related to NSOs in Australia 2000–2021 identified in the National Coronial Information System. ResultsThirty-one cases were identified, 96.8% due to unintentional drug toxicity. The mean age was 31.9 years and 87.1% were male. Only six were aged over forty. A history of substance use problems was documented in 80.6% and 58.1% had a history of injecting drug use. In 32.3% the final route of administration of a NSO was by non-injecting routes of administration. Ten NSOs were identified. Fentanyl analogues were present in 67.2%, most commonly furanylfenatyl (19.4%). Other NSO types were present in 39.7%, most commonly U-47700 (35.5%). Substances other than NSOs were present in 90.3%, most commonly benzodiazepines (67.7%) and other opioids (51.6%). A CNS depressant in addition to NSOs was present in 90.3%, and a new psychoactive substance other than a NSO in 25.8%. Pulmonary oedema was diagnosed in 82.6%, aspiration of vomitus in 30.4%, and acute bronchopneumonia in 17.4%. ConclusionsTen NSOs were identified. Case characteristics suggest a younger cohort whose profile is more typical of use of other NPS than of the established opioids. A large proportion used NSOs by non-injecting routes of administration.

Characteristics of fatal ‘novel’ benzodiazepine toxicity in Australia

IntroductionThe study aimed to determine: 1. The characteristics of all recorded cases of fatal drug poisoning involving ‘novel’ benzodiazepines (NBZDs) in Australia; 2. The toxicology of cases; and 3. The major autopsy findings. MethodsRetrospective study of all deaths due to drug toxicity in Australia in which NBZDs were present in blood toxicology, retrieved from the National Coronial Information System (2000–2021). Information was collected on case characteristics, toxicology and major organ pathology. ResultsA total of 40 cases were identified, the first occurring in 2015, with a median age of 26.5 years and 87.5% being male. Death was due to accidental toxicity in 92.5% of cases. There were extensive histories of substance use problems (80.0%) and mental health problems (32.5%). Etizolam was the most common NBZD (87.5%), followed by flubromazolam (15.0%), with other NBZDs detected in 20.0% (delorazepam, diclazepam, flualprazolam, flubromazepam, lormetazepam). Multiple NBZDs were present in 27.5%. Other drugs were present in 97.5%, most commonly opioids (70.0%), registered benzodiazepines (62.5%), psychostimulants (45.0%) and gabapentinoids (32.5%). A CNS depressant other than a NBZD was detected in 95.0% (n = 38). Autopsies were conducted and available for 30 cases, with pulmonary oedema (76.7%, n = 23), aspiration of vomitus (46.7%, n = 14) and acute bronchopneumonia (36.7%, n = 11) the most common diagnoses. ConclusionsThe ‘typical’ NBZD-related death was a young male who died due to accidental toxicity. Deaths most frequently involved etizolam and multiple substances, particularly depressants.

Fatal overdose from synthetic cannabinoids and cathinones in Japan: demographics and autopsy findings

ABSTRACTBackground: Sixty-one autopsy cases involving cathinones and/or cannabinoids (synthetic cathinones/cannabinoids) use have been reported. However, little is known about the demographics and autopsy findings in fatal synthetic cathinones/cannabinoids users. Objectives: To elucidate demographic and autopsy findings (i.e. major organ pathology and causes of death) in synthetic cathinones/cannabinoids cases. Methods: We reviewed forensic autopsy reports in Department of Legal Medicine of Tokyo Women’s Medical University (Tokyo, Japan) between 2011 and 2015 (a total of 359). We compared demographic and autopsy findings between synthetic cathinones/cannabinoids and methamphetamine cases (as control subjects). Results: There were 12 synthetic cathinones/cannabinoids cases and 10 methamphetamine cases. Synthetic cathinones/cannabinoids users were significantly younger than methamphetamine users (p < 0.01), and there were no cases that used both synthetic cathinones/cannabinoids and methamphetamine. Acute intoxication and cardiac ischemia were the two most prominent causes of death in both synthetic cathinones/cannabinoids users and methamphetamine users. Excited delirium syndrome and pulmonary aspiration were found only in synthetic cathinones/cannabinoids cases. Conclusions: The populations of synthetic cathinones/cannabinoids and methamphetamine users who died of an overdose are different in Japan. Acute intoxication, cardiac ischemia, excited delirium syndrome, pulmonary aspiration, and drowning are the major autopsy findings in synthetic cathinones/cannabinoids-related death. Clinicians shuld be aware of these potentially fatal complications in the medical management of synthetic cathinones/cannabinoids users.

Autopsy findings and pattern of mortality in undiagnosed sickle cell disease patients

Background: Sickle cell disease (SCD) has a high mortality rate with unexpected sudden death. So, the purpose of the study was to analyze clinical and/or autopsy findings at the time of death among sickle cell disease (SCD) patients. Methods: This is a retrospective study of SCD patients who died between January 2011 to December 2011 and the morphological evidence of the cause of death was studied in a tertiary care hospital of south Gujarat. The clinical data, including the age, gender, symptoms and the major autopsy findings and cause of death were obtained for each patient that included histopathological examination. Results: A total of 472 autopsies were performed, out of which sickled erythrocytes were detected in 40 cases. The mean age at death was 30 years and a male/female ratio of 3:1 and peak mortality was in the 2 nd and 3 rd decades of life. The common causes of death in this study include vaso-occlusive crisis (45%), infection (40%). The terminal infection was heralded by upper respiratory tract (43.7%) and by gastroenteritis (31.2%). Other causes of death included intracranial haemorrhage (2.5%) and cirrhosis (2.5%). Among the cases of SCD, 10% of deaths were non-haemoglobinopathy related such as fall (accidental), organophosphorus poisoning and snake bite. Conclusion: This study is to precise analysis of causes of death is needed to focus and improve morbidity and mortality in sickle cell disease especially in highly prevalent area and will impact on the overall survival of these patients.

Fibromyalgia: Comorbidity or a psychosomatic symptom of depression leading to the abuse of opioids?

Introduction: We conducted a retrospective study at the Wayne County Medical Examiner Office, which examined decedents diagnosed with Fibromyalgia, a disorder of unknown etiology characterized by widespread chronic musculoskeletal pain, concomitant with fatigue, sleep disturbances, and psychological distress. Material & Methods: Over a seventeen year period a total of 54 cases from our database met this criterion. Other criteria in the study included cause and manner of death, post-mortem toxicology results, major autopsy findings, and medical history. Results: Our study revealed that the cause of death in approximately two-thirds of the cases was due to drug intoxication. The most frequent post-mortem toxicology finding was Opioids, such as Morphine, Hydrocodone, Oxycodone, Fentanyl, and Codeine. The most common manner of death was accident. Almost 90% of the decedents were Caucasian females, which contrasted with the demographic diversity of Wayne County, Michigan. Additional findings revealed that the average age was 47 years, and the average Body Mass Index (BMI) could be categorized as obese. Nearly 67% of the cases had a medical history of depression. Conclusion: Our findings suggest that Fibromyalgia might be a psychosomatic symptom of depression rather than comorbidity. Therefore, physicians should further inquire about, and consider treating, depression in patients with chronic musculoskeletal pain while completely avoiding the use of opioids, for opioids have a greater risk of being abused and resulting in death in such patients, as found in our study.

Characteristics of sudden bath-related death investigated by medical examiners in Tokyo, Japan.

BackgroundSudden bath-related deaths occur frequently in Japan, particularly among elderly people. However, the precise mechanism of bath-related death remains uncertain, and effective prevention strategies have not been established.MethodsCases of bath-related deaths (n = 3289) were selected from all cases handled by the Tokyo Medical Examiner’s Office from 2009 to 2011 (N = 41 336). The ages and occurrence dates were examined, and major autopsy findings, including toxicological analysis, were evaluated for the autopsied cases (n = 550).ResultsMost cases occurred in individuals older than 60 years of age during winter. Analysis of autopsy findings revealed water inhalation signs in many cases (n = 435, 79.1%). Circulatory system diseases constituted more than half of the pathological findings regarding factors that may have contributed significantly to death (n = 300, 54.5%), and cardiac lesions were the most common pathological finding (n = 250, 45.5%). However, approximately one-third of the cases exhibited no remarkable pathological findings (n = 198, 36.0%). A quarter of all cases involved blood ethanol levels that exceeded 0.5 mg/mL (n = 140).ConclusionsThe results suggested that drowning plays an important role in the final process of bath-related death. Circulatory system diseases may be the primary underlying pathology; however, there were variations in the medical histories and pathologies of cases of bath-related death. From a preventive perspective, family members should pay attention to elderly people with circulatory system diseases during bathing, particularly in winter. Additionally, the notion that ill or inebriated individuals should not take baths should be reinforced.

Prenatal examination and postmortem findings in fetuses with gastroschisis and omphalocele

This study compares prenatal ultrasound examination and autopsy findings in fetuses and infants with gastroschisis and omphalocele. Criteria for inclusion in the study were an autopsy of fetuses/infants with gastroschisis or omphalocele performed between January 1985 and December 2009 and a prenatal ultrasound examination performed in a tertiary referral center. The results were organized into five categories depending on the degree of agreement. Of 11 cases with gastroschisis, only one was not detected at the prenatal ultrasound examination, and the rest had full agreement. Of 70 fetuses with omphalocele, two were not diagnosed at the prenatal ultrasound examination. Four (15%) had major autopsy findings not detected prenatally. The main diagnosis was correct in 64/70 (91%) and improved from 85% to 95% during this study period. The number of cases with major and minor autopsy findings not detected by ultrasound examination was reduced from 48% to 21%. Full agreement occurred in 46/70 (66%). This study shows that the correlation between prenatal ultrasound findings and postmortem examination is good and has improved over time. Comparing full agreement during the first 10 years with the last 15 years showed an improvement (p = 0.05) for fetuses with omphalocele.

An unusual complete laryngo-tracheal separation in a suicidal hanging with a drop effect

Case report A 48-year-old man was found in a public garage, having committed suicide by hanging. The rope which he used as ligature was fixed to the garage’s iron fence. The hanging was complete, with a recorded drop of 2‐2.5 m. An autopsy was performed the following day. The deceased was 186 cm tall and weighed approximately 90 kg. The 2 cm wide rope had compressed the neck to approximately 9.5 cm in diameter. The fixed ligature knot was on the posterior area of the neck as in a typical hanging (Fig. 1a), while the loop was below the laryngeal protuberance. After removing the noose a deep, wide strangulation mark was clearly visible (Fig. 1b). Subsequent dissection of the layers of skin and soft tissue of the neck revealed slight bilateral symmetrical hemorrhages at the periosteal-clavicular origin of the sternocleidomastoid muscles, a complete separation of the larynx from the trachea to the cricotracheal ligament, where part of the esophagus (Fig. 2) and a partially fractured anterior part of the cricoid cartilage were clearly visible, and Amussat’s sign (bilateral superficial transverse lacerations in the intimal layer of the carotid arteries visible below its bifurcation) (Fig. 3a, b). No fractures of the hyoid bone, thyroid cartilage, or cervical spine were found. In the region of the lumbar spine, Simon’s sign (hemorrhages beneath the anterior longitudinal ligament) was also present. Other major autopsy findings were consistent with a rapid death. The victim’s blood alcohol concentration was found to be 0.63 g/l. The cause of death was attributed to severe air-way injury due to hanging; i.e. a complete laryngo-tracheal separation.

Characteristics, circumstances and toxicology of sudden or unnatural deaths involving very high-range alcohol concentrations

To characterize sudden or unnatural deaths with very high-range blood alcohol concentrations (BACs) presenting to the Department of Forensic Medicine (DOFM) in Sydney between 1 January 1997 and 31 December 2011. Case series. Sydney, Australia. A total of 263 cases of sudden or unnatural death with a BAC of ≥0.300 g/100 ml. Case characteristics, circumstances of death, quantitative toxicology, major autopsy findings and serology. The mean age of decedents was 46.7 years and 74.5% were male. Pre-existing alcohol problems were noted in 78.7%. Deaths were due to alcohol toxicity/chronic alcoholism (35.0%), combined alcohol/other drug toxicity (14.8%), accidents (18.6%), natural disease (13.3%), suicide (11.0%), homicide (6.8%) and one case was undetermined. Alcohol was a direct, or contributory, cause of death in 84.4% of cases. The overwhelming majority (81.4%) occurred in a home environment, and deaths did not vary by day or month. The mean BAC was 0.371 g/100 ml (range 0.300-0.820 g/100 ml), being highest in alcohol toxicity/chronic alcoholism cases (0.410 g/100 ml). The most frequently detected substances, other than alcohol, were benzodiazepines (31.9%) and opioids (12.9%). Alcohol-related disease was diagnosed in 62.9% of cases. Alcohol-related pathology was prevalent across all categories of death: severe steatosis (35.3%), cirrhosis (22.5%), chronic pancreatitis (15.3%), cardiomyopathy (9.4%) and cerebellar atrophy (9.0%). Unnatural deaths with very high-range alcohol concentrations extend well beyond direct toxicity, and alcohol is causal in most cases. Those at greatest risk are middle-aged males, with long histories of alcohol problems.

Fatal Heat Injury Incident in a Private Home for Elderly People

This report presents a case in which an 84-year-old elderly female resident of a private home for the aged was fatally injured by a young male member of staff. The deceased suffered from senile dementia, and died from heat shock due to prolonged exposure to an electric fan heater. The heater had been placed immediately in front of the woman's body for approximately 2.5 hours, and the deceased could not escape from the heat by herself. Major autopsy findings were marked second degree burns (predominantly) and smaller areas of first degree burns observed on the anterior body surface (chiefly the face, lower abdomen, forearm and thigh). The burns area exceeded one-third of the entire body surface. Only a small amount of dark red blood (36g) remained in the heart cavity: this was fluid but remarkably condensed. Petechial bleeding was observed in areas such as the palpebral conjunctivae and renal pelvic mucosae. This case generated great public attention as the assailant, who had been employed exclusively for three nights' duty per week, had been regarded as very diligent and kind; inflicting such a lethal injury appeared out of character. Several important issues related to managing residential care facilities for the elderly (in particular, the stress associated with night duty caring for the aged with senile dementia, and the mental health care of the staff themselves) were disclosed and are discussed herein from a medico-legal viewpoint.

Cocaine-related fatalities in New South Wales, Australia 1993–2002

Aim: To ascertain the demographic characteristics, circumstances of death, toxicological results, and major autopsy findings of cocaine-related fatalities. Design: Inspection of the coronial records of all cocaine-related deaths that occurred in New South Wales, Australia between 1 January 1993 and 31 December 2002. Setting: New South Wales, Australia. Findings: 146 cases were identified. Cocaine was implicated in the direct cause of death in 86% of cases, an antecedent cause in 8% and a significant condition contributing to death in 7%. The mean age of decedents was 34.1years, and 84% were male. Half were employed, and 26% were in professional employment. The predominant route of administration was injection (86%), however nasal (8%), oral (3%), smoking (1%), and anal (1%) administration were all recorded. The most common location of death was a private home (53%). No intervention occurred prior to death in 82% of cases. The median blood benzoylecgonine concentration was 0.40 mg/L (range 0.00–20.00 mg/L). Cases had a mean of 3.5 drugs, with morphine (79%) the most common co-occurring drug. In 5% of cases cocaine was the sole drug detected. Cardiac pathology was noted in 57% of cases, most commonly coronary artery atherosclerosis (39%) and cardiac hypertrophy (14%). In 15% of cases moderate to severe arterial occlusion was noted. Cerebrovascular pathology was noted in 22% of cases, most commonly cerebrovascular atherosclerosis (10%). Conclusions: Cocaine-related deaths are a significant clinical problem in New South Wales.

不整脈原性右室心筋症（ＡＲＶＣ）が疑われた突然死の１例 心肺蘇生に伴う右心室破裂合併例

A 49-year-old woman was found submerged in the bathtub at home. Closed chest compression was performed first by her husband for approximately 10 minutes, and then by ambulance personnel for 37 minutes. She was transported to our hospital's emergency room while cardiopulmonary resuscitation was continued. She received external chest compression for 19 minutes and then open-chest direct cardiac massage for 45 minutes. Major autopsy findings were hemorrhage (approximately 400ml) in the pericardial sac and a large longitudinal 3.5cm laceration of the right ventricle. Histopathological examination of the right ventricle revealed marked fatty infiltrations, which had partially replaced the major cardiac muscle layer. Some of cardiac muscle bundles in the right ventricle were disarrayed with fibrosis and fat. Infiltrations of fat were also seen in the left ventricular wall and septum near the conducting system. These autopsy findings suggest that the major cause of death in this case might have been a lethal arrhythmia due to arrhythmogenic right ventricular cardiomyopathy (ARVC), and that the ruptured right ventricular wall and cardiac tamponade were complications of the vigorous resuscitative efforts. In conclusion, the softened myocardium with massive fatty infiltration in ARVC may be susceptible to CPR-related injuries.

Lethal monointoxication by overdosage of MDEA

A 19-year-old man died after the intake of ten tablets of Ecstasy containing 3,4-methylenedioxy- N-ethylamphetamine (MDEA) as the main active ingredient. According to an eyewitness the symptoms of intoxication were strong sweating, sudden aggressiveness followed by hallucinations, subsequent failure of motoric coordination, severe spasms of arms and back, complete depression of the respiratory system, unconsciousness, and collapse. Resuscitation by an emergency doctor failed. Major autopsy findings were severe vascular congestion of all internal organs, liquid post-mortem blood, numerous subpleural and subepicardial petechial haemorrhages. By GC/MS analysis, MDEA was found in large amounts in serum (12 mg/l in femoral vein, 22 mg/l in heart blood serum), urine (201 mg/l), brain (18 to 28 mg/l) and in other tissue samples. Scalp-hair was highly positive for MDEA (17 ng/mg). Besides MDEA and its metabolites only trace amounts of MDMA could be found in urine and blood; no other drugs were detected. It can be concluded that the cause of death was a monointoxication by overdosage of MDEA.

Case of the Month

A 20-YEAR-OLD MAN who was a college baseball player in excellent health complained of back pain and malaise. His symptoms became progressively worse despite being prescribed several medications. Nausea, bloody diarrhea, submandibular lymphadenopathy, hemoptysis, blurred vision, and dizziness developed. On presentation to an emergency department, the results of laboratory studies showed marked leukocytosis and disseminated intravascular coagulation. The patient was transferred to a university hospital, where the possibility of an unusual viral illness was considered. He appeared stable on admission to the hospital but suddenly became unresponsive and apneic 4 hours later. A cardiac monitor indicated electromechanical dissociation, and the advanced cardiac life support protocol was unsuccessful. An autopsy was requested by the physician primarily to identify the etiologic agent of the presumed fatal viral illness. <h3>AUTOPSY FINDINGS</h3> Major autopsy findings included severe hypersensitivity myocarditis, acute respiratory disease syndrome, interstitial nephritis, and centrilobular hepatic necrosis. All the organs examined showed