Trauma Deaths Research Articles

Abstract 4137646: Transcriptomic Profiling of Human Myocardium at Sudden Death to Define Vulnerable Substrate for Lethal Arrhythmias

Background: While some chronic pathological substrates for sudden cardiac death (SCD) are well-known (e.g., coronary disease and left ventricular [LV] dysfunction), the vulnerable myocardial state predisposing to fatal arrhythmia remains a critical barrier to near-term SCD prevention. Hypothesis: Myocardium of autopsy-defined SCDs exhibit distinct expression profiles vs. non-cardiac sudden deaths and trauma deaths that reflect its acute vulnerable state in the hours to days before SCD, as expression arrests upon death. Goals/Aims: Define the vulnerable myocardial substrate for lethal arrhythmia by targeted RNA profiling. Methods: We used autopsy to adjudicate arrhythmic from non-arrhythmic causes in 1,265 sudden deaths in San Francisco from 2011-2018. We performed a transcriptomic evaluation of LV sampled at the time of SCD from 245 consented cases using a curated panel of 448 genes with known or hypothesized association with SCD. Results: Comparison between Arrhythmic (n=129) and Non-Arrhythmic (n=116) cohorts revealed 31 differentially upregulated and 36 downregulated genes (p-adj<0.05), related to collagen-containing extracellular matrix (upregulation of FAP , FMOD , LTBP2 ), ion transport (upregulation of KCNA5 and KCNN3 , and downregulation of KCNJ8, KCNK1, KCNJ5 ), and contraction (downregulation of MYH6 ). Fibrosis-related genes showed the highest magnitude increased expression in Arrhythmic vs. Non-arrhythmic deaths and vs. published transcriptomes from end-stage heart failure. After molecular stratification by known markers for mature ( COL1A1, COL1A2, COL3A1) and active ( POSTN , MEOX1 ) fibrosis, cases with highest expression of both had the highest proportion of arrhythmic cause of death (27/36 [75%]) vs. cases with low expression of both (87/181 [38%], p=0.006) or vs. mature only (10/14 [71%]) or active only (5/14 [36%]). Activated fibroblast gene expression was enriched in Arrhythmic female vs. Arrhythmic male cases, among other sex-specific differences in ion channel and myosin (upregulation of SCN4B , SCN8A , KCNAB1 in females, KCNJ4 and MYH7B in males) expression. Conclusions: RNA profiling of myocardium at SCD identifies active fibrosis, undetectable by conventional clinical methods, in the presence of fixed scar and selected ion channel dysregulation (more pronounced among female cases) as an acute vulnerable substrate for fatal arrhythmias, and may identify patients at elevated near-term risk for SCD and novel pathways for intervention.

Migrant Deaths in California’s Borderlands, 2018–2023

Executive Summary We examine the deaths of undocumented migrants in southern California (i.e., San Diego and Imperial counties) for fiscal years (FYs) 2018–2023 using data obtained from the San Diego County Medical Examiner’s Office (SDCMEO) and Imperial County Coroner’s Office (ICCO). We recorded 314 deaths of undocumented migrants, with 157 in San Diego County (SDC) and 157 in Imperial County (IC). We describe trend fluctuations in migrant deaths and both the overall and county-specific proportions as they relate to causes of death and demographic characteristics (biological sex and age at death). Additionally, to capture the potential effects of the 2019 border wall expansion and COVID-19 pandemic on migrant deaths, we examined differences in these factors between two periods: FY 2018–2019 and FY 2020–2023. We conclude by comparing migrant deaths reported by the medicolegal authorities to estimates published by US Customs and Border Protection’s (CBP) Border Patrol for southern California. From 2018 to 2020, there were approximately 30 known migrant fatalities annually in California. This increased to about 88 deaths per year in 2021 and 2022 before dropping to 50 in 2023. Across the study period, the leading causes of death were drowning (35.4 percent), environmental exposure (23.6 percent), and blunt force trauma (16.9 percent), with the latter cause being largely associated with falls from the border wall. However, we found significant differences between SDC and IC. For instance, 51.6 percent of migrant deaths in IC were due to drowning, compared to 19.1 percent in SDC. Conversely, 21.7 percent of deaths in SDC were due to blunt force trauma, while just 12.1 percent of deaths in IC occurred in this manner. Overall, we found that 75.2 percent of decedents were male, 20.4 percent were female, and 4.5 percent were of unknown sex. Among cases in which a precise age at death was listed, the average age was 34.6 years. Nevertheless, sex and age differed by county in that SDC had a higher proportion of female decedents (28 percent in SDC vs. 12.7 percent in IC) and a higher average age at death (SDC x¯ = 36.8 vs. IC x¯ = 32.0). We also found significant differences between the two periods examined. Perhaps most striking, deaths due to blunt force trauma increased from 3.4 percent of cases in FY 2018–2019 to 19.9 percent of cases in FY 2020–2023. Decedent characteristics also appear to have changed across time. The share of male decedents decreased from 84.5 percent to 73.0 percent, while the share of females increased from 5.2 percent to 23.8 percent between the two periods, while the proportion of decedents ages 50 to 64 years increased significantly (from 4.7 percent to 12.7 percent). Finally, for FYs 2018–2022, CBP reported 25.6 percent fewer migrant deaths than medicolegal authorities in southern California. High numbers of migrant deaths in 2021 and 2022 can be attributed to circumstances during and following the COVID-19 pandemic, including a Trump Administration policy aimed at blocking access to the US asylum system. The expansion of the border wall during the Trump era may also explain increased migrant mortality in 2021 and 2022. Decreases in deaths in California in 2023 may be because of a novel entry location in the San Judas Break or result from a shift in migration trends toward other border states (i.e., Arizona, New Mexico, and Texas). County differences in drowning and blunt force trauma deaths were likely due to the presence of the All-American Canal in IC (drowning), and greater coverage of the pedestrian border wall in SDC (blunt force trauma), respectively. Although speculatory, the higher percentage of female decedents and older age of decedents in SDC may be because these vulnerable individuals perceive San Diego to be a safer route. Changes between FYs 2018–2019 and FYs 2020–2023 in blunt force trauma deaths (3.4 percent to 19.9 percent) are a result of falls from the newly expanded and constructed border wall. We suggest that after more than 30 years of implementation, the United States should eliminate the use of “deterrence” strategies to prevent further and unnecessary loss of life. Additionally, the following actions could reduce migrant mortality in California: installing buoys or other anti-drowning devices in the All-American Canal, making potentially life-saving resources (e.g., blankets and water) available on known migrant routes, and reducing the height of or removing the border barrier. We call for both CBP and medicolegal authorities to provide disaggregated data on migrant fatalities, which would facilitate an accurate accounting these deaths, increase understanding of where and why deaths occur, and therefore be used to support policy changes.

A forensic overview of deaths in mountainous terrain.

Deaths at high altitudes may arise from a range of quite disparate entities including trauma (e.g. falls), environmental factors (e.g. hypothermia and hypoxia), and pre-existing medical conditions (e.g. coronary artery disease). Unique conditions include high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE) which may contribute to lethal mechanisms or precipitate a traumatic event. Forensic issues that may arise in these cases are logistical problems due to remote locations, sometimes with failure to find a body, delay in discovery and/or repatriation, prior local autopsies being performed with embalming, and the non-specificity of pathology markers. Traumatic deaths involve blunt force impacts, falls, suffocation, crush asphyxia and hypothermia. The assessment of cases requires careful integration of the autopsy findings with the medical history of the decedent and an accurate description of their behaviour in the hours leading up to death.

Measuring the outcomes of support provided to people after a suicide or other sudden bereavement: A scoping review

Systematic collection of outcome measures within suicide bereavement support is vital in building the sector’s evidence base. However, there is currently limited understanding around the appropriate and sensitive use of outcome measures. Following the scoping review methodology, a literature review was undertaken to map how programs and interventions that assist individuals bereaved by suicide or other sudden, traumatic deaths gather outcome measures. The search strategy identified 1145 papers, of which 49 met the inclusion criteria. The review identified many ways that outcomes are captured, with custom tools being commonplace. Among standardized tools, the Grief Experience Questionnaire (GEQ) and Beck Depression Inventory (BDI-II) emerged as frequently used. Most articles provided some form of justification for their chosen outcome measure methodology, often citing psychometric robustness over consideration of the impact on service users. The review underscores the need for careful consideration when selecting outcome measure tools or approaches in sudden death bereavement interventions.

The Grief Networks of Traumatic and Nontraumatic Deaths: Comparing Earthquake- and Illness-Related Losses.

Traumatic death is a risk factor for prolonged grief. Network analysis offers a perspective for understanding traumatic bereavement at a symptom interaction level. This study estimates regularized partial correlation grief networks for bereavement due to earthquake (n = 818) and illness (n = 237), using symptoms from the Inventory of Complicated Grief (ICG) as the nodes. Difficulty in accepting death and loneliness were highly central nodes in both networks. Trust difficulties and longing for the deceased exhibited high centrality in the earthquake-bereaved sample but not in the illness-bereaved sample. The earthquake bereavement network was characterized by high connectivity and a diversity of central symptoms. These results provide insights into understanding the severity of grief after a traumatic loss. Although promoting the integration of the reality of loss and alleviating loneliness is important, it might also be worth considering the role of post-loss interpersonal trust and the distress associated with longing for the deceased for traumatic bereavement.

Alteration of Serum MLKL Levels and Their Association with Severity and Clinical Outcomes in Human Severe Traumatic Brain Injury: A Prospective Cohort Study.

Mixed lineage kinase domain-like protein (MLKL), which modulates necroptosis, has been implicated in pathophysiological processes following acute brain injury. Here, serum MLKL was quantified to determine its prognostic significance in severe traumatic brain injury (sTBI). This prospective cohort study enrolled 155 patients with sTBI and 155healthy volunteers. The severity metrics included the Glasgow Coma Scale (GCS) score and Rotterdam computed tomography (CT) classification. The extended Glasgow outcome scale (GOSE) at posttraumatic 180 days was considered as a prognostic parameter, with a score of 1-4 as indicating poor prognosis. Univariate and subsequent multivariate analyses were used for independent factorial investigation. Compared to controls, patients displayed profoundly elevated serum MLKL levels. In the framework of restricted cubic spline analysis, serum MLKL levels were linearly correlated with the likelihood of mortality, overall survival, and poor prognosis. Serum MLKL levels were not only independently correlated with GCS, Rotterdam CT scores and GOSE scores, but were also independently predictive of death, overall survival, and poor prognosis. Subgroup analysis showed that serum MLKL levels exhibited negligible interactions with age, sex, hypertension, diabetes, smoking habits, and alcohol consumption to distinguish the possibility of death, overall survival, and poor prognosis. Within the context of receiver operating characteristic curve analysis, serum MLKL levels had strong discrimination effectiveness for death and poor prognosis and, in contrast to GCS and Rotterdam CT scores, were considered to have equivalent predictive ability. Extreme elevation of serum MLKL levels is intimately related to trauma severity, death, and neurological outcomes, suggesting that serum MLKL may act as a potential predictor for facilitating severity stratification and prognosis prediction of sTBI.

Diagnostic value of serum thymus and activation-regulated chemokine (TARC) in fatal asthma

ObjectivesAsthma, a chronic inflammatory airway disease, is characterized by airway hyperresponsiveness and structural changes. Accurate postmortem diagnosis is crucial because of legal and insurance implications, necessitating differentiation from other causes of sudden death. Thymus and activation-regulated chemokine (TARC) is a chemokine that potentially acts as a biomarker of asthma. This study evaluated the diagnostic value of serum TARC combined with immunoglobulin E (IgE) levels as biomarkers in forensic settings. ResultsThe subjects were 100 autopsy cases, categorized into fatal asthma (n = 25), acute myocardial infarction (AMI) (n = 37), and traumatic deaths (n = 38). TARC levels were significantly elevated in asthma (525.68 ± 801.87 pg/mL) compared with AMI (180.35 ± 109.37 pg/mL) and trauma (173.26 ± 105.01 pg/mL) cases. Similarly, serum IgE levels were higher in asthma (3363.72 ± 7023.46 KU/L) than in AMI (130.92 ± 260.79 KU/L) and trauma (134.53 ± 195.41 KU/L) cases. ROC curve analysis showed that serum TARC had a sensitivity of 68.0 % and specificity of 73.6 % (AUC 0.763, cut-off value of 225 pg/mL). In comparison, serum IgE had a sensitivity of 80 % and specificity of 86.1 % (AUC 0.881, cut-off value of 307 KU/L). The combined use of TARC and IgE increased the diagnostic specificity to 95.8 %. ConclusionsSerum TARC and IgE are valuable biomarkers for diagnosing fatal asthma in forensic settings. While serum TARC levels correlate with Th2-mediated inflammation, the combined measurement of TARC and IgE enhances the diagnostic accuracy, providing significant specificity for confirming asthma diagnosis.

A longitudinal pre-post study: An evaluation of the Department of the Air Force bundled occupational fall prevention efforts.

Fall injuries are the second leading cause of traumatic injury and death for all US workers and are a leading injury concern for the Department of the Air Force (DAF). Bundled interventions can improve the likelihood of injury reduction, especially in large, heterogeneous working populations. In 2013, the DAF implemented the "Air Force Fall Prevention Focus," a bundled intervention of prevention efforts designed to reduce occupational fall injury events among DAF members. The purpose of this study is to describe the burden and risk factors associated with fall injuries and evaluate the effectiveness of the Fall Prevention Focus in reducing the burden of fall injuries. The National Institute for Occupational Safety and Health (NIOSH) partnered with the US Air Force Safety Center (AFSEC) to examine the impact of the Fall Prevention Focus as a bundled intervention. Injury events included a narrative description of the injury event, demographics, work environment, job tasks, and other structured details. Descriptive statistics and pre-post longitudinal modeling were used to evaluate changes in fall injury rates. The Fall Prevention Focus Implementation (2013-2018) resulted in an annual 10.4% (95% confidence interval [CI]: 8.5%, 12.2%) reduction, and a 6-year cumulative 48.3% (95% CI: 41.4%, 54.3%) reduction in fall injury event rates by 2018. Safety in the DAF involves a comprehensive approach. Documenting the impact of the Fall Prevention Focus may help translate these findings to improve fall prevention efforts in other sectors of the military and high fall-risk industries in the private sector, such as construction.

Plasma treatment is associated with decreased brain lesion and resuscitation requirements after traumatic brain injury in a swine model of prolonged damage-control resuscitation

BACKGROUND Hemorrhage and traumatic brain injury (TBI) are the leading causes of death in trauma. Future military conflicts are likely to be in austere environments, where prolonged damage-control resuscitation (p-DCR) may be required for 72 hours before evacuation. Previous studies showed that early administration of fresh frozen plasma (FFP) during p-DCR can significantly decrease the volume of resuscitation required in models of hemorrhagic shock and also provide neuroprotection after TBI. In the current study, we hypothesized that the addition of FFP to p-DCR would decrease the resuscitation requirements and improve neurological outcomes in a large animal model of combined hemorrhagic shock and TBI. METHODS Yorkshire swine (40–45 kg; n = 10) were subjected to TBI (controlled cortical impact) and 40% blood volume hemorrhage. After 2 hours of shock, they were randomized to either: (1) p-DCR–normal saline or (2) p-DCR–FFP (250 mL). Prolonged damage-control resuscitation targeted a systolic blood pressure of 90% of baseline, in line with Tactical Combat Casualty Care principles. At 72 hours, animals were transfused 1 U of packed red blood cells, simulating evacuation to higher echelons of care. Brain lesion size, physiologic parameters, resuscitation fluid requirements, and neurological severity score were used to compare the clinical outcomes. RESULTS The p-DCR–FFP group required significantly less total volume (4,540.0 ± 151.7 mL vs. 974.0 ± 167.0 mL, p < 0.01) of resuscitation to maintain the target systolic blood pressure. Fresh frozen plasma–treated animals had significantly reduced brain lesion size (4,517.0 ± 180.0 mm3 vs. 2,477.0 ± 1,191.0 mm3, p < 0.01) and showed significantly decreased functional neurologic impairment. CONCLUSION In this exploratory study, treatment with FFP decreased resuscitation requirements, reduced brain lesion size, and improved neurological outcomes when added to prolonged DCR in a porcine model of combined hemorrhagic shock and TBI.

Exploring Research on the Coping Strategies of Black Survivors of Homicide Victims: A Scoping Review

Black communities are disproportionately impacted by homicide, yet research on how surviving family members and friends of murdered victims cope with their violent, traumatic death is limited. This scoping review examines current literature on how Black communities cope with homicide, identifies key concepts, reviews study methods, summarizes findings, and offers implications for future research. A scoping review of empirical studies (2000–2024) consisting of majority Black participants coping with homicide was conducted. Out of 2,932 articles, 35 met the inclusion criteria. An inductive thematic analysis was used to synthesize results. Findings from these studies revealed two domains: the sociocultural context of coping and coping strategies, consisting of eight themes (e.g., racism and social stigma, the impact of homicide, support, spiritual coping, activism, maintaining a connection to the deceased, substance use, avoidance, and concealment). These findings emphasize social and cultural factors that shape Black experiences with homicide, which consequently impact the coping resources and strategies they use to manage the violent, traumatic death of loved ones. Implications for future research should focus on standardized collection of homicide data, contextualization of homicide experiences, and diverse research methods.

Prehospital blood transfusion : Opportunities and challenges for the German emergency medical services

Exsanguination is the leading cause of preventable death in severe trauma. Immediate hemorrhage control and transfusion of blood products are critical to maintain oxygen delivery and address trauma-induced coagulopathy. While prehospital blood product transfusion (PHBT) is established in neighboring countries, the fragmented configuration of Germany's emergency medical service (EMS) infrastructure has delayed the adoption of widespread PHBT programmes. This review aims to provide an updated perspective on the evolution, international practices and research needs of PHBT within the German context. This narrative review is based on aPubMed search using the search terms "prehospital" and "blood*". From an initial 4738 articles, 333 were directly related to PHBT and were subjected to further detailed examination. The literature, including referenced studies, was categorized into areas such as history, rationale, international practices, and evidence, and analyzed for quality. The benefit of early blood transfusion in major trauma has been established since WW1, explaining the efforts to initiate this lifesaving intervention as early as possible in the care pathway, including the prehospital field. Recent randomized trials have faced design and recruitment challenges, reflecting the complexity of the research question. These trials have yielded inconclusive results regarding the survival benefits of PHBT in civilian settings. This scenario raises doubts about the capability of randomized trials to resolve questions concerning survival advantages. Despite these difficulties, there is adiscernible trend indicating potential improvements in patient outcomes. In Germany, the incidence of trauma-associated shock stands at 38per 100,000 individuals per year. It is estimated that between 300 and 1800 patients annually possibly benefit from PHBT. Prehospital Blood Transfusion appears to be promising but identifying patient groups most likely to benefit as well as the most suitable blood products remain unresolved issues. In Germany PHBT programs are not yet widely established. Paradoxically, this situation, paired with the extensive German Trauma Registry, provides aprime opportunity for comprehensive prospective cohort studies, addressing the balance between PHBT benefits, logistical feasibility, and implementation strategies. Such studies are essential for establishing guidelines and integrating PHBT efficiently into German trauma care protocols.

Transcriptomic Profiling of Human Myocardium at Sudden Death to DefineVulnerable Substrate for LethalArrhythmias.

While some chronic pathological substrates for sudden cardiac death (SCD) are well known (eg, coronary artery disease and left ventricular [LV] dysfunction), the acute vulnerable myocardial state predisposing to fatal arrhythmia remains a critical barrier to near-term SCD prevention. This study sought to define the distinct myocardial transcriptomic profile of autopsy-defined arrhythmic sudden deaths, compared to nonarrhythmic sudden deaths and trauma deaths, to determine the acute vulnerable state in the hours to days before SCD. We used autopsy to adjudicate arrhythmic from nonarrhythmic causes in 1,265 sudden deaths in San Francisco County from 2011 to 2018. We performed a degradation-tolerant transcriptomic evaluation of LVs sampled at the time of SCD from 245 consented cases using a curated panel of 448 gene probes with known or hypothesized association with SCD. The targeted transcriptome of arrhythmic (n = 129) vs nonarrhythmic (n=90 nonarrhythmic sudden deaths+ 26 trauma deaths) LV samples revealed 31 differentially up-regulated and 36 down-regulated genes (adjusted P< 0.05) related to the collagen-containing extracellular matrix (up-regulation of FAP, FMOD, and LTBP2), regulation of ion transport (up-regulation of KCNA5 and KCNN3 and down-regulation of KCNJ8, KCNK1, and KCNJ5), and contraction (down-regulation of MYH6). Fibrosis-related genes showed the highest magnitude increased expression in arrhythmic vs nonarrhythmic deaths and vs published transcriptomes from end-stage heart failure. After molecular stratification by known markers for mature (COL1A1, COL1A2, COL3A1) and active (POSTN, MEOX1) fibrosis, cases with the highest expression of both had the largest proportion of arrhythmic cause of death (n=27 of 36 [75%]) vs cases with low expression of both markers (n=87 of 181 [38%]) (P = 0.006) or vs mature only (n=10 of 14 [71%]) or active only (n=5 of 14 [36%]). Activated fibroblast gene expression signature was enriched in arrhythmic female vs arrhythmic male cases, among other sex-specific differences in ion-channel and myosin (up-regulation of SCN4B, SCN8A, and KCNAB1 in females and KCNJ4 and MYH7B in males) expression. RNA profiling of the myocardium at SCD identifies active fibrosis, undetectable by conventional clinical methods, in the presence of fixed scar and selected ion-channel dysregulation (more pronounced among female cases) as an acute vulnerable substrate for fatal arrhythmias. These findings may represent novel directions to identify patients at elevated near-term risk for SCD and critical pathways for intervention to reduce acute lethal arrhythmias.

Using computed tomography to evaluate anatomic landmarks in taiwanese trauma patients for insertion of resuscitative endovascular balloon occlusion of the aorta: A retrospective cohort study.

Hemorrhage, particularly from non-compressible torso hemorrhage (NCTH) in the abdominopelvic region, is a leading cause of preventable trauma deaths. Resuscitative endovascular balloon occlusion of the aorta (REBOA), designed for aortic occlusion, has emerged as a tool for temporary hemorrhage control in recent years. However, attaining optimal REBOA placement in diverse demographic groups, such as Asian populations, may pose challenges owing to unique anatomical and physiological differences. This retrospective study analyzed trauma patients who underwent torso computed tomography (CT) at tertiary hospitals in Taiwan from January 2014 to January 2017. The OsiriX software was used to measure the endovascular lengths in the CT images. Among the 223 patients, the median vascular lengths and body measurements were higher in males. The optimal fixed insertion length was identified as 47.5cm for zone 1 with 99.43% accuracy and 25.5cm with 82.1% accuracy for zone 3. The landmark-guided method showed 100% accuracy for zone 1 when using the mid-sternum and 94.6% for zone 3 with the umbilicus as the guide with the distance between the umbilicus, xiphoid process, and pubic ramus. External validation confirmed the accuracy of the landmark-guided method. For zone 1 occlusions, a range of 44-48cm insertion length cross-referenced with the mid-sternal landmark is recommended. For zone 3 occlusions, using the umbilicus as a guide with the distance between the umbilicus, xiphoid process, and pubic ramus provided the highest accuracy.

Analysis of miRNA Expression Profiles in Traumatic Brain Injury (TBI) and Their Correlation with Survival and Severity of Injury.

Traumatic brain injury (TBI) is the leading cause of traumatic death worldwide and is a public health problem associated with high mortality and morbidity rates, with a significant socioeconomic burden. The diagnosis of brain injury may be difficult in some cases or may leave diagnostic doubts, especially in mild trauma with insignificant pathological brain changes or in cases where instrumental tests are negative. Therefore, in recent years, an important area of research has been directed towards the study of new biomarkers, such as micro-RNAs (miRNAs), which can assist clinicians in the diagnosis, staging, and prognostic evaluation of TBI, as well as forensic pathologists in the assessment of TBI and in the estimation of additional relevant data, such as survival time. The aim of this study is to investigate the expression profiles (down- and upregulation) of a panel of miRNAs in subjects deceased with TBI in order to assess, verify, and define the role played by non-coding RNA molecules in the different pathophysiological mechanisms of brain damage. This study also aims to correlate the detected expression profiles with survival time, defined as the time elapsed between the traumatic event and death, and with the severity of the trauma. This study was conducted on 40 cases of subjects deceased with TBI (study group) and 10 cases of subjects deceased suddenly from non-traumatic causes (control group). The study group was stratified according to the survival time and the severity of the trauma. The selection of miRNAs to be examined was based on a thorough literature review. Analyses were performed on formalin-fixed, paraffin-embedded (FFPE) brain tissue samples, with a first step of total RNA extraction and a second step of quantification of the selected miRNAs of interest. This study showed higher expression levels in cases compared to controls for miR-16, miR-21, miR-130a, and miR-155. In contrast, lower expression levels were found in cases compared to controls for miR-23a-3p. There were no statistically significant differences in the expression levels between cases and controls for miR-19a. In cases with short survival, the expression levels of miR-16-5p and miR-21-5p were significantly higher. In cases with long survival, miR-21-5p was significantly lower. The expression levels of miR-130a were significantly higher in TBI cases with short and middle survival. In relation to TBI severity, miR-16-5p and miR-21-5p expression levels were significantly higher in the critical-fatal TBI subgroup. Conclusions: This study provides evidence for the potential of the investigated miRNAs as predictive biomarkers to discriminate between TBI cases and controls. These miRNAs could improve the postmortem diagnosis of TBI and also offer the possibility to define the survival time and the severity of the trauma. The analysis of miRNAs could become a key tool in forensic investigations, providing more precise and detailed information on the nature and extent of TBI and helping to define the circumstances of death.

Indications du scanner post-mortem à l’Institut médico-légal de Paris en 2021–2022

Objective: Evaluate recent developments of large-scale post-mortem CT (PMCT) in the forensic practice at the Paris Forensic Institute.Methods: All decedents who underwent a PMCT between 2021 and 2022 were included. Variables, extracted from the PMCT information form and report metadata, included: demographic characteristics, context, degree of urgency, identity knowledge, use of CT for comparative identification, time from PMCT to radiology report.Results: 1775 PMCT were performed on request of 5 different courts. Decedents were mostly male (n=1256, 71%) and median age was 58 years (IQR 43-72). The 3 most frequent contexts were: traumatic death (n=618, 35%), unknown cause of death in preserved (n=593, 33%) or putrefied decedents (n=434, 25%). Identity was unknown in 164 (9%) decedents and supposed in 504 (29%) cases, among which a comparative identification was successfully performed using CT in 41/504 (8%) patients. The median delay from PMCT to radiologic report was 6h (IQR 1.8-18.6hrs) and was significantly shorter for urgent as compared to non-urgent reports (2.3 hours [IQR 1.2-6.1] vs. 8.4 hours [IQR 2.4-21.4], p<0.001).Conclusion: Large-scale PMCT usage is possible in forensic setting, in varied indications and contexts. Fast edition of radiologic reports allows its integration into time constraints of the judiciary system.

Stopping the bleed when tourniquets cannot: a technique for Foley catheter balloon compression in trauma.

Hemorrhage is a leading cause of death in trauma. Prehospital hemorrhage control techniques include tourniquet application for extremity wounds and direct compression; however, tourniquets are not effective in anatomic junctions, and direct compression is highly operator dependent. Balloon catheter compression has been employed previously in trauma care, but its use has been confined to the operating room and restricted to specific anatomic injuries. In a single-center retrospective review, we describe a technique for balloon catheter compression for hemorrhage control that can be employed across the continuum of trauma care, from the prehospital setting to the trauma bay, the operating room, and postoperative period. Of 18,303 trauma patients in Venezuela, 45% of the 1757 patients with vascular injuries received Foley catheter compression for hemorrhage control. Of these catheters, the majority (75%) were placed in the emergency department, 5% in the prehospital setting, and 20% in the operating room. Over half (53.2%) of the balloon catheters were placed for hemorrhage control in non-compressible anatomic junctions. Foley catheter balloon compression is a useful addition to a provider's arsenal of hemorrhage control techniques, as it is effective in anatomic junctions, preserves collateral circulation through focused compression, and requires minimal active physical attention to maintain hemostasis.

Development and Validation of a Bayesian Network Predicting Intubation Following Hospital Arrival Among Injured Children

BackgroundInadequate airway management can contribute to preventable trauma deaths. Current machine learning tools for predicting intubation in trauma are limited to adult populations and include predictors not readily available at the time of patient arrival. We developed a Bayesian network to predict intubation in injured children and adolescents using observable data available upon or immediately after patient arrival. MethodsWe obtained patient demographic, injury, resuscitation, and transportation characteristics from trauma registries from four American College of Surgeons-verified level 1 pediatric trauma centers from January 2010 through December 2021. We trained and validated a Bayesian network to predict emergent intubation after pediatric injury. We evaluated model performance using the area under the receiver operating and calibration curves. ResultsThe final model, TITAN (Timing of Intubation in Trauma Analysis Network), incorporated five factors: Glasgow Coma Scale, mechanism of injury, injury type (e.g., penetrating, blunt), systolic blood pressure, and age. The model achieved an area under the receiver operating characteristic curve of 0.83 (95% CI 0.80, 0.85) and had a calibration curve slope of 0.98 (95% CI 0.67, 1.29). TITAN had high specificity (98%), negative predictive value (97%), and accuracy (96%) at a binary probability threshold of 22.6%. ConclusionThe TITAN Bayesian network predicts the risk of intubation in pediatric trauma patients using five factors that are observable early in trauma resuscitation. Prospective validation of the model performance with patient outcomes is needed to assess real-life application benefits and risks. Level of EvidencePrognostic and Epidemiological, Level III.

Enhancing trauma evaluation: Comparative analysis of post-mortem computed tomography and autopsy findings in abdominal stab wounds.

In cases of traumatic deaths, accurate assessment of injuries is essential for both legal and medical purposes. This case report compares the findings of post-mortem computed tomography with conventional autopsy methods in assessing abdominal stab wounds. A 34-year-old woman with multiple stab wounds in the abdomen underwent post-mortem examination, including computed tomography imaging. Computed tomography revealed specific breaches in the skin's continuity and internal injuries, including perforation of the stomach. A conventional autopsy confirmed the presence of multiple stab wounds and associated injuries to internal structures. However, additional injuries to major blood vessels, such as the abdominal aorta and inferior vena cava, were only detected during manual exploration of the peritoneal cavity. This case highlights the complementary roles of post-mortem computed tomography and conventional autopsy in evaluating traumatic injuries. While computed tomography imaging offers non-invasive visualisation of injuries, manual examination remains essential for identifying certain injuries, particularly those affecting major blood vessels. The integration of computed tomography imaging with traditional autopsy methods enhances the accuracy and reliability of forensic assessments in cases of traumatic deaths, particularly in complex cases involving multiple injuries. Understanding the strengths and limitations of these techniques is crucial for improving forensic investigations and ultimately enhancing medico-legal outcomes.

The Effect of Life Stages on the Experience of Those Who Have Received an Unexpected and Violent Death Notification: A Qualitative Study.

How individuals are informed of the traumatic loss of a loved one can influence their grieving process and quality of life. This qualitative study aimed to explore, through thematic analysis, how life stages might influence the experience and feelings of those who have received communication of a traumatic death from police officers or healthcare professionals. Recruited through social networks and word of mouth, 30 people participated in the study. Subjects were divided into three groups according to age (Group 1: ten participants aged between 20 and 35 years; Group 2: ten participants aged between 45 and 55 years; and Group 3: ten participants aged 60 and over). Participants completed an ad hoc questionnaire online. Atlas.ti software 8 was used to perform thematic analysis. The three age groups had the following four key themes in common: (a) emotional reactions; (b) subjective valuation of the notification; (c) support; and (d) needs. Subtle differences emerged between age groups; yet the quality of the reactions and main themes did not vary greatly between the groups considered. The communication of an unexpected and violent death seems to provoke rather similar effects in survivors of different life stages. A few differences were noted in sub-themes (increased need for professional training in younger recipients; absence of suicidal ideation in older adults); perhaps quantitative designs could provide further details in future investigations.

Selective postmortem arterial angiography of head and neck using digital x-ray or computed tomography: A practical and rapid method to identify vascular injuries.

Identification of vascular injuries is crucial for complete postmortem evaluation and understanding of trauma deaths by the Medical Examiner. Some vascular injuries are difficult to evaluate due to challenging anatomic locations, especially in the head and neck. Documenting injuries of the facial and vertebral arteries is challenging and necessitates time-consuming dissections that can create artifacts and disfigurement. In busy medical examiner offices with a significant number of traumatic injuries, finding a creative solution to employ reliable postmortem angiography is desirable. At the Office of the Chief Medical Examiner for the State of Maryland (OCME), we created and effectively implemented a selective angiography procedure using traditional indwelling Foley catheters and water-soluble barium swallow contrast to evaluate arterial injuries using either digital radiography or computed tomography imaging modalities. This technique and imaging interpretation can be performed by a medical examiner or forensic pathology fellow after basic technical training and basic radiology training. This study outlines the technique, methods, and utilization of the procedure and describes the findings of six deaths due to vascular lesions from different injury mechanisms and disease processes and describes the ease of implementation on a broader scale in busy Medical Examiner's offices.