Abstract of the thesis for medical doctor: Assessment the forensically histopathologic characteristics and identification method of drowning victims

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The thesis is an answer for debating question regarding of pathologic characteristics of drowning and proposes the DNA analysis for identification method. The description study concluded the valuable pathologic signs and characteristics for diagnosis. In this study, the DNA analysis was applied for victims identification.

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Nội dung Text: Abstract of the thesis for medical doctor: Assessment the forensically histopathologic characteristics and identification method of drowning victims

MINISTRY OF MINISTRY OF HEALTH EDUCATION AND TRAINING HA NOI MEDICAL UNIVERSITY NGUYEN LE CAT ASSESSMENT THE FORENSICALLY HISTOPATHOLOGIC CHARACTERISTICS AND IDENTIFICATION METHOD OF DROWNING VICTIMS Specialized : Pathology and Forensic Medicine Code : 62720105 ABSTRACT OF THE THESIS FOR MEDICAL DOCTOR HA NOI - 2020
THE THESIS WAS COMPLETED IN HA NOI MEDICAL UNIVERSITY Scientific Supervisor: 1. PhD. Luu Sy Hung 2. Associate Professor Dinh Gia Duc The first Reviewer: Associate Professor Nguyen Phuc Cuong The second Reviewer: PhD. Nguyen Duc Nhu The third Reviewer: PhD. Tran Ngoc Dung The Thesis approved by Council of scientist in Ha Noi Medical University. At: Date: 2020 References theThesis in: 1. Vietnam National Library 2. Library of Ha Noi Medical University
LIST OF PUBLICATIONS This Thesis is based on the following papers: 1. Nguyen Le Cat (2013), Signs and injuries of drowning in forensic identification, Journal of Practical Medicine, 876 (7): 54-57. 2. Nguyen Le Cat, Nguyen Van Hoa, Nguyen Tat Tho (2017), Notes when receiving preserved corps for identification in accidents and disasters, Journal of Military Pharmaco-Medicine, 323 (7-8): 9-11. 3. Nguyen Le Cat, Nguyen Thi Ngoc Anh, Do Thi Xao Mai (2018), DNA analysis results in the victim identification of aircraft accidents at sea, Journal of Military Pharmaco- Medicine, 333 (11-12): 44-48. 4. Nguyen Le Cat, Nguyen Thi Ngoc Anh, Do Thi Xao Mai, Luu Sy Hung (2019), Assess the results of drowning victim identification by DNA test in forensic examination, Journal of Military Pharmaco-Medicine, 335 (3-4): 54-58.
1 INTRODUCTION Drowning is being asphyxiated caused by submersion of noses or mouth. The mechanism is complicated and varied depending on the situation, not only the asphyxia in submersion. It is believed as the first problem of public health, and early studied because of social valuation. In evaluation of WHO, the proportion of drowning is 5.6/100.000 population, two third is accidental, 1/3 suicidal drowning, rarely homicidal drowning. Most of victims are children or young people. Vietnam is a tropical country, there are a large number of lakes and rivers, long beach which are potential for drowning, especially in hurricane season. As others countries, the most common cause is occupational or daily activity. Others are homicidal or suicidal cause. In Military Institute of Forensic Medicine, the proportion of drowning is high. However, there is no research of epidemiology, pathology and victims identification. In forensic examination, there are some problems for solving: - Who is the victim? The cause of death? The cause of death is drowning or not? Which examination or test to confirm the drowning cause? - Could the patient be identified ? Which test for identification?. In order to do so, the forensic examiner has to fully collect the primary evidences, analysis the scene, and forensic results, in combination with proper identification method. Therefore, the study “Assessment the forensically pathologic characteristics and identification method of drowning victims” aims to: 1. Description of the pathologic signs and characteristics of drowning victims. 2. Application of DNA analysis in identification of drowning victims.
2 1. The need of the thesis The thesis is an answer for debating question regarding of pathologic characteristics of drowning and proposes the DNA analysis for identification method. The description study concluded the valuable pathologic signs and characteristics for diagnosis. In this study, the DNA analysis was applied for victims identification. 2. The contribution of the thesis Statistical description of general characteristics of drowning such as: conjunctivitis (100%), lividity pattern (74.6%), rigor mortis (89.4%), froth (66.4%), wrinkle skin (58.1%), exophthalmos (100%), flared mouth (78.8%), peeling skin (72%), fluid and foam in the airway (54.8%), pulmonary edema (88.5%), the foreign body in airway (35.5%), water in stomach (30.8%), the laceration of aveoli (88.5%), rupture RBC in vessels and organs (50%). Diatom test plays an important role in diagnosis confirmation and location of drowning. The application of DNA analysis is an appropriate method to victims identification: there was 18.02% victims need to DNA analysis for identification, successful identification was 100% (31/31); from 1-4 postmortem days, most of victims were identified by the normal method (83.3%-84.2%); 85% victims was required the DNA analysis for identification from 5-9 days postmortem. From 1-4 days postmortem, the nucleus analysis was used for every victim. From 5-15 postmortem, the mitochondrial analysis was more preferred, After 15 days postmortem, most victims was identified by mitochondrial analysis. 3. The structure of the thesis The thesis includes 108 pages. General description (02 pages), Conclusion (02 pages), and proposal (01 page). Four chapters : Chapter 1 : General description (31 pages), Chapter 2 : Objects and Methodology (13 pages), Chapter 3: Results (22 pages), Chapter 4: Discussion (37 pages). It also includes 26 tables, 04 images, 09 charts, 73 reference materials, study form and victims list, the image illustrates.
3 Chapter 1 BACKGROUND 1.1. Definition and classification of drowning 1.1.1. Definition In 2002, the International Congress of Drowning defined drowning as : “The asphyxiated process caused by submersion in liquid”. 1.1.2. Classification It is classified into two categories: intention and un-intention. Intention: homicidal or suicidal, Un-intention: accident, or undefined cause. 1.2. Statistical evidence of drowning 1.2.1. General statistics of drowning According to WHO, there are 372000 death caused by drowning each year; 42 death caused by drowning in average each hour. Drowning is the top cause of death for 1-24 years old population. 1.2.2. The co-factor of drowning 1.2.2.1. Age The most common is in 1-4 years old children, then 5-9 years old. It is one of the most 5 cause of death for 1-14 years old population in 48/85 countries. 1.2.2.2. Gender Most of study showed that the proportion was doubled in male rather than female. 1.2.2.3. Location In the low or average income countries, the scene of drowning is the place of daily activities. In the other hand, in high income countries, the scene is in the recreation park. 1.2.2.4. Time It depends on the victims and seasons. 1.2.2.5. The causes In the international congress, the causes was classified as: Accidental (56.2%), suicidal (23.8%), homicidal (0.28%), unidentified (16.5%).
4 1.2.2.6. Others risk factors Alcohol, smoking, poorness, shortage of safety facility, climate, the treatment approach, rehealibitation are the others risk factors. 1.3. The pathologic mechanism 1.3.1. The history of drowning knowledge It was firstly introduced in Greek 2 AC by Galen. At that time, it was supposed that the water filling in stomach and intestine causes the death. The later studies showed that the water fills in the airway and lung causing death. 1.3.2. The mechanism of drowning There are four main mechanisms: water inhalation, the filtration of water in blood stream, alveolus rupture and nervous reflex. 1.3.2.1. Water inhalation a, Stage 1 (1.5 minutes): Submersion victim, strungling to breath, water fills in the stomach, low blood pressure, low heart beat. b, Stage 2 (1 minute): Because of reflexion, victims drink and inhale a large amount flux of water, till the trachea and alveolus, tachycardia, the water bubles from nose to the water surface. c, Stage 3 (1-1.5 minutes): Epilepsy, coma, low BP, arrythmias, ventricular fibrillation, cardiac arrest 1.3.2.2. The water filtration in blood stream There are two situations: a) Drowning in fresh water: The dilution of blood causing the hypoosmolar natrium and chlorium causing the blood cells ruptures. b) Drowning in salt water: Condensed blood. No rupture of blood cells, the electrolyte equilibration is unchange. 1.3.2.3. The alveolus rupture Water enter the alveolus causing dilation and rupture. Hemorrhage in the lung parenchyma, other alveolus without water would be stressed causing emphysema. 1.3.2.4. The nervous reflexion. Beside the alveolus rupture, water in the airway causing inhibition of respiratory and cardiovascular centers located in the medullar leading to death.
5 1.4. The forensic pathology of drowning 1.4.1. The external signs 1.4.1.1. The foam It is typical sign of drowning. It is different with foam caused by pulmonary edema, this foam is more diluted and fragile. 1.4.1.2. The rapid death in drowning Cold cadaver, the temperature is equal with enviroment in primary 8-24 hours, pale and wrinkle skin, eyes swelling. 1.4.1.3. Signs of body soaked in water Skin spikes, cold corpses, body temperature decreased by the ambient temperature of the autopsy detected in 8-24h, skin of palms and feet pale, wrinkled, eye mucus bulging due to water absorption. 1.4.1.4. The traumas and evidences before and post mortem. a, Traumas and evidences before mortem: water jumping, epilepsy, trauma injuries. b, Trauma and evidences post mortem: Caused by floating cadavers. 1.4.1.5. The decomposition signs In the water, it is pale cadavers. In the early of air exposure, the skin color change from green to black. The cadavers will be decomposed rapidly, especially in summer. 1.4.2. The internal signs 1.4.2.1. New cadavers a) Special signs: - The respiratory system: The trachea is fulfilled with the pink foam. Swelling lungs, motley lung surface. Foregin body in airway. - The circulation system: Congestion organs, diluted blood, and red blood cells ruptures. - The gastrointestinal system: Water in stomach and intestine. Hepatomegaly, pale kidney, pale intestin, submucosal hemorrhage. - Brain: Congesion and edema. b) Others signs: Water infiltrates in the sinus of head and face. Hemorrhage in the middle ear and mastoid bone. Emphysema. Soil, grass ... in the palm. Parasites.
6 1.4.2.2. Decomposed cadavers The importants signs are disappeared: deflated lungs, foam and water in trachea. Water is in the shallow of chest. The foreign body could appear in the airway. 1.4.3. The signs of untypical drowning Inhibition reflexion (cardiac arrest, larynx spasm, dry drowning, death because of drowning complication) 1.4.4. The evolution of signs In general: Self water absorption, decomposition and self movement Floating time: depends on the water temperature and characteristics of cadavers. 1.4.5. The characteristics of forensic organs pathology 1.4.5.1. Lungs Water and foreign bodies in the alveolus, hemorrhaging, alveolus dilation. Micropathology could be suggession, thin alveolus wall, rupture of alveolus. The gold diagnosis is the appearance of water foreign body in small bronchi and alveolus. 1.4.5.2. Liver The dilation hepatic and portal veins are filled with blood and water. The portal areas are dilated, swelling vessel wall, the parenchyma is filled with water and blood. Congestion of organs. 1.4.6. The change of biochemistry Imbalance serum electrolyte caused by water filtration. 1.4.7. The biologic agents. Diatoms test: In 1941, Incze proposed the diatoms test to define location of drowning. 1.5. Some new studies of drowning In 2015, Hosahally J.S et al conclued that: in fresh water drowning victims, the intima of aorta root was darker. In 2005, J.Blanco Pamoin et al showed that 21.58% victims had the rupture of gastric mucosa. Milone A et al also showed that CT scanner could help to define the death before or after asphyxia.
7 1.6. The forensic assessment of drowning 1.6.1. The methods It is much more exact if there is a combination of methods to examine the cadaver. 1.6.2. DNA forensic examination The DNA identification of drowning is exact and efficient. Especially in case of decomposed cadavers. 1.6.3. DNA structure DNA is double chains created by two single nucleotids chain. In DNA, there are a lots of genes in particular order. The location of gene in chromosome is called locus. In nuclear DNA, each locus has two allens, one from dad, the other from mom. Mitochondrial DNA is completely maternally generated. 1.6.4. The DNA analysis 1.6.4.1. The nuclear DNA Nuclear DNA analysis is based on the structure and genetic characteristics. With this method, the individual could be well identified only by small sample. 1.6.4.2. The mitochondrial DNA Beside nuclear, the DNA also exists inside the mitochondrial in the circle form, and maternal heredity. Therefore the mitochondrial DNA analysis gave lots of success 1.6.4.3. The comparison in DNA analysis - Direct comparison: Between the victims DNA and the stored victims DNA - Indirect comparison: Between the victims DNA and the DNA of victims familial members. 1.6.4.4. The comparison of nuclear and mitochondrial DNA - Nuclear DNA analysis: It is unstable in the nature enviroment. It is easy, cheap and rapid analysis. - Mitochondrial DNA analysis: Circle form, stable in nature enviroment. It is more difficle, poorly exact, long time for analysis.
8 Chapter 2 OBJECTS AND METHODOLOGY 2.1. Objects 172 drowning victims was examined from Feb 2005 to Feb 2017 in Military Institute of Forensic Medicine (31), the Departement of Forensic - Hanoi Medical University (22), Forensic center of Vinh Phuc (58), Forensic center of Phu Tho (61). 2.1.1. Inclusion criteria - Fulfilled forensic profile. - According to examination protocol - Identification by DNA analysis. 2.1.2. Exclusion criteria - Unfulfilled profile - Unrespect the protocol - During investigation period. 2.2. Study design - Retrospective, perspective, cross sectional study - Time: From Jun 2014 to Jun 2018 - Location: The Military Institute of Forensic Medicine, Forensic Departement of Hanoi Medical University, Forensic center of Vinh Phuc, Forensic center of Phu Tho. 2.3. The objects of study 2.3.1. General characteristics of objects. Age, gender, time of death, time of examination, location, situation 2.3.2. External signs Statistical, assessing and evaluating common signs 2.3.3. Internal signs Statistical, assessing and evaluating common signs 2.3.4. The test 2.3.4.1. Pathology Evaluation of histopathologic results 2.3.4.2. Diatoms test To identify the location of drowning
9 2.3.4.3. Other complimentary tests For Alcohol, drug, toxic in organs 2.3.5. Statistic of untypical drowning 2.3.6. Victims identification by DNA analysis 2.3.6.1. Nuclear DNA analysis 2.3.6.2. Mitochondrial DNA analysis 2.4. Ethic consideration 2.5. Biostatistic method - Excel 2016 and SPSS 16.0 - Biostatistic analysis with significance in p
10 3.1.2. Time of year Table 3.2. The months of the year Month 1 2 3 4 5 6 7 8 9 10 11 12 n p Group 1-5 0 1 1 0 2 0 0 0 0 0 0 1 5 6-14 0 0 0 5 6 0 0 3 2 1 0 0 17 15-29 0 4 2 9 8 3 10 6 9 2 5 3 61 30-44 0 0 0 9 4 5 5 7 7 4 3 1 45 0.1 45 - 59 2 1 1 1 0 3 5 2 1 1 1 1 19 More 60 0 0 1 1 1 1 2 1 1 0 0 0 8 Undefine 0 2 0 2 2 2 3 4 2 0 0 0 17 Total 2 8 5 27 23 14 25 23 22 8 9 6 172 3.1.3. Time of forensic examination Table 3.3. Post mortem forensic examination st 1 Day Day Day >15 Time Undefine Total day 2-4 5-9 10-15 days n 108 36 20 4 3 1 172 % 62.1 20.9 11.6 2.3 1.7 0.6 100 3.1.4. Place of death Table 3.4. Place of death Well- Sea Location River Lake Sewer Pool Tank Flood Total water water n 69 53 9 24 8 1 5 3 172 % 40.1 30.8 5.2 14.0 4.7 0.6 2.9 1.7 100
11 3.1.5. Manner of death Table 3.5. Manner of death Situation Accident Suicide Homicide Undefine Total n 119 12 1 40 172 % 69.2 7.0 0.6 23.2 100 3.1.6. Others characteristics • Occupation Table 3.6. Occupation Occupation Related Unrelated Undefine Total n 5 150 17 172 % 2.9 87.2 9.9 100 • Educational level of the victim Table 3.7. Educational level of the victim Graduation Educational Non Primary Secondary High Un- of high Total level educated school school school define school n 7 30 87 20 11 17 172 % 4.1 17.4 50.6 11.6 6.4 9.9 100 • Ethnic Table 3.8. Ethnic distribution Ethnic Ethnic Ethnic Undefine Total minority major N 73 82 17 172 % 42.4 47.7 9.9 100
12 3.2. The external signs Table 3.9. Statistical of external signs Yes Signs No Undefine Total n % Froth 42 24.42 130 172 Lividity pattern 128 74.42 44 172 Conjunctivitis 123 71.51 41 8 172 Rigor mortis 137 79.65 35 172 Submersion skin 110 63.95 62 172 Flaring mouth 44 25.58 128 172 Occular change 47 27.32 125 172 Necrosis 52 30.23 120 172 Foreign bodies in palm 15 8.72 157 172 Decomposition 3 1.74 168 172 Trauma by the water flux 35 20.35 137 172 Trauma by the animal 7 4.07 165 172 3.2.1. Froth Table 3.10. Froth Total First Day Day Day >15 Un- Froth p day 2-4 5-9 10-15 days define n % Yes 39 3 0 0 0 0 42 24.42 No 69 33 20 4 3 1 130 75.58 0.001 Total 108 36 20 4 3 1 172 100
13 3.2.2. Lividity pattern Table 3.11. Lividity pattern Lividity Day Day Day >15 Total Day 1 Undefine p pattern 2-4 5-9 10-15 Days n % Yes 107 19 1 0 0 1 128 74.42 0.001 No 1 17 19 4 3 0 44 25.58 Total 108 36 20 4 3 1 172 100 3.2.3. Conjunvitis Table 3.12. Conjuncvitis Day Total Day Day Day >15 Conjucnvitis 10- Undefine p 1 2-4 5-9 Days n % 15 Yes 89 20 10 2 1 1 123 71.51 0.02 No 19 14 5 1 2 8 49 28.49 Total 108 34 15 3 3 1 172 100 3.2.4. Rigor mortis Table 3.13. Rigor mortis Rigor Day Day Day >15 Total Day 1 Undefine p mortis 2-4 5-9 10-15 Days n % Yes 106 28 2 0 0 1 137 79.7 0.001 No 2 8 18 4 3 0 35 20.3 Total 108 36 20 4 3 1 172 100 3.2.5. Submersion skin Table 3.14. Submersion skin characteristics Submersion Day Day Day Day >15 Un- Total p skin 1 2-4 5-9 10-15 Days define n % Slight change 58 4 0 0 0 0 62 36.05 0.001 Pale 49 8 0 0 0 1 58 33.72 Scale off 1 24 20 4 3 0 52 30.23 Total 108 36 20 4 3 1 172 100
14 3.2.6. Flaring mouth Table 3.15. The flaring mouth post mortem Flaring Day Day Day Day >15 Un- Total p mouth 1 2-4 5-9 10-15 days define n % Yes 21 19 3 1 0 44 25.58 0.001 No 108 15 1 1 2 1 128 74.42 Total 108 36 20 4 3 1 172 100 3.2.7. Occular change Table 3.16. Occular change post mortem Total Occular Day Day Day Day >15 Un- p change 1 2-4 5-9 10-15 Days define n % Less change 105 16 3 0 0 1 125 72.67 Exophthalmos 3 20 16 3 1 0 43 25 0.001 Deflated eye 0 0 1 1 2 0 4 2.33 Total 108 36 20 4 3 0 172 100 3.2.8. Decomposition post mortem Table 3.17. Decomposition post mortem Day Day Day Day >15 Un- Total Decomposition p 1 2-4 5-9 10-15 days define n % Yes 1 24 20 4 3 0 52 30.23 0.001 No 107 12 0 0 0 1 120 69.77 Total 108 36 20 4 3 1 172 100 3.2.9. Foreign bodies in palms Table 3.18. Foreign bodies in palms Foreign Day Day 2- Day Day >15 Un- Total p bodies 1 4 5-9 10-15 Days define n % Yes 13 2 0 0 0 0 15 8.72 0.49 No 95 34 20 4 3 1 157 91.28 Total 108 36 20 4 3 1 172 100
15 3.2.10. Injuries caused by floating and animal Table 3.19. Injuries caused by floating and animal Front of Back of Injuries Total p body body Chafing of shallow skin 6 20 26 0.54 Torning skin 3 6 9 Making underwater animal - - 7 3.3. Internal signs In the our research, there were 172 cases in which 48 cases only external examination, 20 cases with external examination and the tracheostomy, 104 cases examinated inside and outside of body. 3.3.1. Signs and lesions in the trachea and bronchi Table 3.20. List of signs and lesions in the trachea and bronchi Foreign Fluid, object in Characteristics air Decomposition Unknown Total airway, bubbles bronchi n 68 44 1 11 124 % 54.8 35.5 0.8 8.9 100 3.3.2. Signs in the organ Table 3.21. Statistics of signs in the organ Yes No Unknown Total Signs p n % n % n % Pulmonary edema 92 88.5 8 7.7 4 8.8 104 Congestive of other organ 95 91.3 9 8.7 0 0 104 0.001 Water in stomach 85 81.7 16 15.4 3 2.9 104 Water in sphenoid sinus 9 8.6 1 0.9 94 90.5 104
16 3.3.2.1. Pulmonary lesions Table 3.22. Characteristics of pulmonary lesions Pulmonary lesions Yes n % Paltauf sign 32 104 30.8 Petechiae (Tardieu sign) 43 104 41.3 Lung stretch and slice with more blood 92 104 88.5 Lung bland and slices with little blood 8 104 7.7 Unknown 4 104 8.8 3.3.2.2. Congestive of organs Table 3.23. Characteristics of congestive in organs Congestive of organs Yes n % Heart 82 104 78.8 Liver 91 104 87.5 Kidney 93 104 89.4 Spleen 67 104 64.4 Brain 56 104 53.8 3.3.2.3. Objects in stomach Table 3.24. Characteristics of objects in stomach Objects in stomach n % Water 32 30.8 Water and food 45 43.2 Food 8 7.7 None of food and water 16 15.4 No information 3 2.9 Total 104 100 3.3.3. Mixed lesions Table 3.25. Characteristics of mixed lesions Yes No Unknown Lesions Total p n % n % n % Injures of soft tissue 4 3.85 100 96.15 0 0 104 Fracture 2 1.92 102 98.08 0 0 104 Brain trauma 2 1.92 102 98.08 0 0 104 Hanging trauma 1 0.96 103 99.04 0 0 104 0.001 Cutting wist 1 0.96 103 99.04 0 0 104 Hematoma around shoulder joint 0 0 0 0 104 100 104 Breaking stomach 0 0 104 100 0 0 104
17 3.4. Atypical drowning Table 3.26. List of atypical drownings Type n Total % Near-downing 0 104 0 Dry-downing 8 104 7,7 Drowning with heart and vessel disease 2 104 1.9 3.5. Other test 3.5.1. Histopathology Table 3.27. Signs and lessions of histopathology Yes No Unknown Signs and lessions Total p n % n % n % Foreign objects in the airway 20 19.2 76 73.1 8 7.7 104 Alveolus rupture and oedema 92 88.5 2 1.9 10 9.6 104 Breaking red blood cells 52 50 52 50 0 0 104 Congestive in liver 79 76.0 4 3.8 6 5.8 104 0.001 Congestive and bleeding in heart 81 77.9 5 4.8 18 17.3 104 Congestive and oedema in brain 56 53.8 3 2.9 45 43.3 104 Congestive and oedema in kidney 71 68.3 3 2.9 30 28.8 104 3.5.2. Diatom test Table 3.28. Results of diatom test Categories of diatom Yes No Total p Bacillary diatom 5 2 7 Stellar diatom 4 3 7 0.154 Polygonal diatom 1 6 7 3.5.3. Other test Table 3.29. Results of other test Yes No Test Positive Negative Total p n % n % n % Alchohol in blood 5 2.9 48 27.9 119 69.2 172 Narcotics in 1 0.6 28 16.3 143 83.1 172 0.08 blood Toxic in organs 0 0 40 23.3 132 76.7 172