Dissertations / Theses on the topic 'Pathology and Forensic Medicine'

Drug abuse has always been a world problem. Recently people abuse both controlled and prescribed drugs. Opioids, cocaine, cannabis and amphetamines are the most widely abused drugs. The picture of the drug abuse problem in Scotland can be understood by an extensive study of drug prevalence and characteristics of drug use in the region. In drug-related deaths, post-mortem analysis, which includes autopsy and collecting samples for histological and toxicological analysis, is necessary to be carried out to investigate whether any drug has contributed to the cause of death. The samples which are commonly collected for toxicological analysis are blood and urine. However, when those fluids are not available, body tissues may be taken as alternative samples, such as liver and skeletal muscle. In this case, it is necessary to understand how drugs move and diffuse to these tissues after death. This phenomenon, which is known as post-mortem redistribution, may cause difficulties in the interpretation of post-mortem drug concentrations. Several studies have tried to investigate post- mortem redistribution including how drugs diffuse in the body after death. However, post-mortem redistribution is still not completely understood. This study proceeded by interrogating post-mortem data within the period of 2011-2016 held by Forensic Medicine and Science (FMS), University of Glasgow to review trends of drug-related death in the West of Scotland in which amphetamine-type stimulants (ATS), cocaine and opioids were detected. Opioids were most commonly detected (81.9%) in drug-related deaths in the West of Scotland, followed by cocaine (21.6%) and ATS (9.4%). The interrogation of post- mortem data within the period of 2007-2016 was also carried out to understand certain pathological conditions which are caused by drug abuse. From the results, it is clear that in the West of Scotland people tend to abuse multiple drugs. This trend may apply in the other part of the country and around the world. It is also clear that, even though methadone was prescribed to assist users to stop from drug addiction, especially heroin, many methadone users still abuse other drugs, as methadone was found in most of the cases in addition to other drugs. For this reason, it is important to investigate the results of drug addiction therapy and educate potential users. Subsequently, methods were adapted for analysing liver and muscle samples from the FMS in-house methods for analysing ATS and basic drugs in autopsy blood and validated according to the standard practices for method validation in forensic toxicology (SWGTOX, May 2013). All ATS drugs (amphetamine, methamphetamine, MDA, PMA, PMMA, MDMA and MDEA) and basic drugs (amitriptyline, citalopram, methadone, mirtazapine, sertraline and tramadol) gave acceptable bias, precision, linearity, recovery and stability for analysing liver and muscle samples. An experimental model for drug diffusion in tissues was studied to simulate and understand drug diffusion in humans. The diffusion rate that was used in this model is in accordance with the volume of distribution of each drug. This model is easy and simple to be carried out in any small laboratory. Blood, liver and muscle samples were analysed from 10 cases collected during the period from August 2016 to April 2017 after the next of kin signed the informed consent forms. Four basic drugs (amitriptyline, methadone, mirtazapine and sertraline) were found in 9 cases and analysed to investigate the ratios between blood, muscle, right liver and left liver. The ratios of drug concentrations of muscle:blood, left liver:right liver were found to be lower than 2. As a result, drug concentrations in muscle can be reliable for toxicological interpretation when blood is not available. The ratio of drug concentration in liver and blood has been suggested as a marker of post-mortem redistribution(1) and this study has shown that the ratio of drug concentration in liver and muscle can also be diagnostic in cases where blood is not available.

Dialectical Behaviour Therapy (DBT) is a type of “talking therapy”, developed from cognitive behavioural therapy; it has been adapted to help people who experience emotions, often females diagnosed with Borderline Personality Disorder (BPD). With its growth in popularity, DBT has been adapted and used with other populations - not just adult females with BPD – to include forensic populations (i.e. people who are in contact with services due to criminal behaviour) and adolescent populations. This thesis contains a systematic literature review investigating the use of DBT in Forensic Services and an empirical study that utilised a qualitative design to explore adolescents and parents’ experiences of DBT.

This thesis aims to provide a detailed understanding of treatment engagement amongst forensic populations. Following an introduction outlining the current theoretical thinking in the area, Chapter 2 presents a systematic literature review exploring reasons for completion/non-completion of treatment from an offender's perspective. Consensus regarding reasons for treatment completion/non-completion was found. Reasons provided supported the majority of factors outlined in the Multifactor Offender Readiness Model (MORM), a model of treatment readiness. Research in this area was limited; no papers exploring adolescents' perspectives were identified. Implications for practice are discussed and areas for future research highlighted. Furthering existing research, Chapter 3 presents a mixed methods research study exploring the reasons why young people, detained in a secure hospital setting choose to attend/not attend sessions. Using thematic analysis several themes were identified. Factors relating to the young person, treatment and the organisation were identified, supporting the MORM. Chapter 4 presents a critical review of the Corrections Victoria Treatment Readiness Questionnaire (CVTRQ), a measure of treatment readiness developed using the internal factors of the MORM. This chapter explores the overall development and psychometric properties of the CVTRQ, highlighting its strengths and limitations. An overall discussion of the work presented is provided in Chapter 5.

Thesis (MMed (Pathology. Forensic Medicine))--University of Stellenbosch, 2010.
Bibliography
ENGLISH ABSTRACT: Background - The workload of the forensic pathologist and Forensic Pathology Services staff is increased by the referral of potentially unnecessary natural cases to the Forensic Pathology Services. The primary aims of the medico-legal autopsy are limited to establishing a cause of death in presumed unnatural cases, and to exclude criminality or negligence. Objective – To determine the final outcomes of forensic post-mortem examinations in “sudden and unexpected” adult deaths over a 5 year period. Methods - An observational, retrospective, descriptive study was conducted. ”Sudden and unexpected” adult deaths referred to Tygerberg Forensic Pathology Services between 1 January 2001 and 31 December 2005 were reviewed. Data was collected from the autopsy reports, contemporaneous notes and hospital records. Findings – A total of 816 adult cases of sudden and unexpected death were referred to Tygerberg Forensic Pathology Services over the 5 year period studied. Complete autopsies had been performed in 74% (601/816) of cases. The presumed manner of death was natural in 79 % of cases, and an increase in the number of natural cases autopsied per year was noted over the 5-year study period. Diseases of the cardiovascular, respiratory and central nervous systems were responsible for the majority of natural deaths. Infectious diseases were responsible for most deaths in the youngest age group studied (18-29 years). Acute alcohol poisoning was responsible for the deaths of 35 (6%) cases, with an average blood alcohol concentration of 0.38g/100mL in these cases. Eight deaths were drug-/substance related. Waiting times for blood alcohol and toxicology results increased over the 5-year study period. No cause of death was found in 10.6% of cases. Conclusions -The questionnaire and interviewing structure could possibly be improved in order to obtain better pre-autopsy information and to reduce the number of “unnecessary” medicolegal autopsies, thereby reducing the burden of cost on the Forensic Pathology Services.
AFRIKAANSE OPSOMMING: Agtergrond – Die werkslading van die forensiese patoloog en ander personeel van die Forensiese Patologie Dienste word vermeerder deur die verwysing van moontlik onnodige natuurlike gevalle na die Forensiese Patologie Dienste. Die primêre doelwitte van die medies-geregtelike nadoodse ondersoek is beperk tot die bepaling van ‘n oorsaak van dood in vermoedelik onnatuurlike gevalle, en om nalatigheid of kriminele aksies uit te skakel. Doelwit – Om die finale uitkomste van medies-geregtelike nadoodse ondersoeke in “skielike en onverwagte” volwasse sterftes oor ‘n 5-jaar tydperk te bepaal. Metodes – ‘n Observasionele, retrospektiewe, beskrywende studie is uitgevoer. “Skielike en onverwagte” volwasse sterftes wat verwys is na Tygerberg Forensiese Patologie Dienste vanaf 1 Januarie 2001 tot 31 Desember 2005 is hersien. Inligting is versamel vanaf die nadoodse ondersoekverslae, kontemporêre notas en hospitaalnotas. Bevindinge – Agthonderd en sestien volwasse gevalle van skielike en onverwagte sterftes is oor die 5-jaar periode verwys na Tygerberg Forensiese Patologie Dienste. Volledige lykskouings is uitgevoer in 74% (601/816) van die gevalle. Die vermoedelike wyse van die sterfte was natuurlik in 79.04% en ‘n toename in die aantal natuurlike gevalle wat lykskouings ondergaan het, is waargeneem oor die 5-jaar studie tydperk. Siektes van die kardiovaskulêre, respiratoriese en sentrale senuweestelsel was verantwoordelik vir die meerderheid natuurlike sterftes. Infektiewe toestande was verantwoordelik vir die meeste sterftes in die jongste ouderdomsgroep (18-29 jaar) wat bestudeer is. Akute alkoholvergiftiging was verantwoordelik vir die sterftes van 35 (6%) gevalle, met ‘n gemiddelde bloed-alkohol-konsentrasie van 0.38g/100mL in hierdie gevalle. Agt sterftes was dwelm-/middelverwant. Die wagtyd vir bloed-alkohol en toksikologie resultate het vermeerder oof die 5-jaar studie tydperk. Die oorsaak van dood was nie gevind in 10.6% van gevalle. Afleidings – Die vraelys en onderhoud-struktuur kan moontlik verbeter word om sodoende beter inligting te verkry voor die uitvoering van ‘n lykskouing, en om die aantal “onnodige” medies-geregtelike nadoodse ondersoeke te verminder, en sodoende die kostedruk te verminder op die Forensiese Patologie Dienste.

Thesis (MScMedSc)--Stellenbosch University, 2014.
ENGLISH ABSTRACT: Background: Sudden infant death syndrome (SIDS) is considered the second most frequent cause of infant mortality worldwide. Research specifically pertaining to SIDS is limited in the South African setting. Identifiable causes for sudden infant death remain challenging despite full medico-legal investigations inclusive of autopsy, scene visit and ancillary studies. Viral infections could contribute to some sudden unexpected death in infancy (SUDI) cases, especially since a multitude of respiratory viruses have been detected from autopsy specimens. The specific contribution of viruses in the events preceding death, including the subsequent involvement of the immature immune response in infants, still warrants deciphering. Infancy is characterised by marked vulnerability to infections due to immaturities of their immune systems that may only resolve as infants grow older when these sudden deaths rarely still occur. In South Africa there is a lack of a standard protocol for investigations into the causes of SIDS, including the lack of standard guidelines as to which specimens should be taken, which viruses should be investigated and which laboratory assays should be utilised. Objectives: In this prospective descriptive study we aimed to investigate the prevalence of viruses in SUDI and SIDS cases at Tygerberg Forensic Pathology Service (FPS) Mortuary over a one year period. The primary aim was to explore possible respiratory viral infections in SUDI and SIDS cases and to determine the usefulness of molecular techniques to detect viruses from SUDI cases. To determine the significance of viruses, we assessed signs of infection from lung histology. The secondary objectives included collecting demographic data to investigate possible risk factors for SUDI and to look for possible similarities between viruses confirmed in living hospitalised infants at Tygerberg, during the study period compared to viruses detected from SUDI cases. Methods: Between May 2012 and May 2013 samples were collected from 148 SUDI cases presenting at Tygerberg FPS Mortuary. As part of the mandatory routine investigations into SUDI, shell vial culture (SVC) results were collected from lung and liver tissue specimens and bacterial culture results were collected from left and right lung and heart swabs at autopsy. To investigate the possibility of viruses implicated in some of the infant deaths we used the Seeplex® RV15 Ace detection multiplex polymerase chain reaction (PCR) assay to establish the frequency of 13 ribonucleic acid (RNA) respiratory viruses (influenza A and B, human parainfluenza 1-4, human coronavirus [OC43, 229E/NL63], human rhinovirus A, B and C, respiratory syncytial virus A and B, human enterovirus and human metapneumovirus) from RNA extracted from tracheal and lower left and right lung lobe swabs. Tissue from the lower left and right lung lobes were also assessed for histology signs of infection. Results: During our study we confirmed multiple known demographic risk factors for SIDS, such as the age peak around 1-3 months, the male predominance, bed-sharing, sleeping in the prone position, heavy wrapping in warm blankets, prenatal smoke exposure, and socio-economic factors. With the Seeplex® RV15 Ace detection assay between one and three viruses were detected in 59.5% (88/148) of cases. Of the 88 cases that had viruses detected, 75% (66/88) had one virus and 25% (22/88) had co-detections of two to three viruses. The most common viruses detected were HRV in 77% (68/88) of cases, RSV in 18% (16/88) of cases and HCoV in 14% (12/88) of cases. Many of the viruses we detected from our cases are included in the SVC test that forms part of the medico-legal laboratory investigation for all SUDI cases at Tygerberg FPS Mortuary. SVCs were positive in 9.5% (14/148) of all cases only. We showed that the SVC method is potentially missing most of the 13 respiratory viruses we investigated that could contribute to death in some of the SUDI cases. Conclusion: In some cases that had a Cause of Death Classification - SIDS, the PCR viruses detected cannot be ignored, especially when it is supported by histological evidence of infection. We thus propose that the use of PCR could alter a Cause of Death Classification from SIDS to Infection in some of these cases. Further research is needed to determine the significance of detecting viruses from SUDI cases wherein no significant histological evidence of infection was observed. This questions whether PCR may be too sensitive and is detecting past and latent viral infections that do not play any role in the cause of death. The histological picture also requires further characterisation to determine if it accurately predicts infections or lethal events and can truly support virology findings, especially in young infants whose immune systems are still maturing. Without determining the true prevalence of viruses in SUDI cases and the viral-specific immune response, the contribution of virus-specific infections to this syndrome will remain largely undetermined.
AFRIKAANSE OPSOMMING: Agtergrond: Wiegiedood (“SIDS/SUDI”) word beskou as die tweede mees algemene oorsaak van sterftes in kinders jonger as een jaar wêreldwyd. Toegewyde SIDS-spesifieke navorsing in die Suid-Afrikaanse samelewing is beperk. Dit bly steeds „n uitdaging om oorsake te probeer identifiseer vir hierdie onverwagte sterftes in kinders (SUDI) ten spyte van volledige medies-geregtelike ondersoeke, insluitende die lykskouing, ondersoek van die doodstoneel en aanvullende ondersoeke. Virusinfeksies kan aansienlik bydra tot sommige onverwagte sterftes in kinders, aangesien verskeie respiratoriese virusse alreeds aangetoon is in monsters verkry tydens outopsies. Die spesifieke rol wat virusse speel in die prosesse wat die dood voorafgaan, asook die bydraende rol van „n onder-ontwikkelde immuunrespons in babas, regverdig verdere ondersoek. Die eerste jaar van lewe word gekenmerk deur verhoogde vatbaarheid vir infeksies weens die ontwikkelende immuunstelsels soos wat babas ouer word, en die voorkoms van SUDI neem stelselmatig af met „n toename in ouderdom. In Suid-Afrika bestaan daar tans geen standaard protokol vir die ondersoek van wiegiedood nie en daar is ook nie standaard riglyne oor die tipe monsters wat geneem moet word, watter virusse ondersoek moet word en watter laboratorium toetse uitgevoer moet word nie. Doelstellings: In hierdie prospektiewe beskrywende studie is gepoog om die virusse wat in gevalle van wiegiedood of SUDI voorkom te ondersoek. Die studie is uitgevoer by die Tygerberg Geregtelike Patologie Dienste lykshuis oor 'n tydperk van een jaar. Molekulêre tegnieke om virusse aan te toon in hierdie gevalle is gebruik om spesifieke virusinfeksies te ondersoek. Die resultate is met histologiese tekens van infeksie in longweefsel gekorreleer. Demografiese data is verder versamel om moontlike risikofaktore vir wiegiedood te ondersoek. Dit is verder vergelyk met virusse wat met dieselfde diagnostiese tegnieke in babas geïdentifiseer is wat tydens die studieperiode in Tygerberg Hospitaal opgeneem was met lugweginfeksies. Metodes: Monsters van 148 SUDI gevalle wat by die Tygerberg lykshuis opgeneem is, is versamel tussen Mei 2012 en Mei 2013. As deel van die roetine ondersoeke in SUDI gevalle, was selkultuur resultate verkry van long en lewer weefsel, asook bakteriële kulture van deppers wat van beide longe en hart geneem was tydens die lykskouings. „n Seeplex® RV15 Ace polimerase kettingreaksie (PKR) toets is gebruik om die teenwoordigheid van virusse te ondersoek wat moontlik by die babasterftes betrokke kon wees. Trageale- en longdeppers wat tydens die lykskouings versamel was, was getoets vir 13 ribonukleïensure (RNS) respiratoriese virusse (influenza A and B, human parainfluenza 1-4, human coronavirus [OC43, 229E/NL63], human rhinovirus A, B and C, respiratory syncytial virus A and B, human enterovirus and human metapneumovirus). Resultate: Ons studie het verskeie bekende demografiese risikofaktore vir SUDI bevestig, byvoorbeeld „n ouderdomspiek tussen een en drie maande ouderdom, manlike predominansie, deel van „n bed met ander persone, slaap posisie op die maag, styf toedraai in warm komberse, blootstelling aan sigaretrook voor geboorte en sosio-ekonomiese faktore. Die Seeplex® RV15 Ace toets het tussen een en drie virusse geïdentifiseer in 59.5% (88/148) van die gevalle. Uit die 88 gevalle waarin virusse opgespoor was, was selgs een virus in 75% (66/88) van gevalle gevind en twee en drie virusse in 25% (22/88). Die mees algemene virusse was HRV in 77% (68/88) van gevalle, RSV in 18% (16/88) van gevalle en HCoV in 14% (12/88) van gevalle. Baie van die virusse wat tydens hierdie studie ondersoek was, was ingesluit in die roetine selkultuur toets wat deel vorm van die standaard medies-geregtelike laboratoriumondersoeke in alle SUDI gevalle by die Tygerberg lykshuis, alhoewel die selkulture positief was in slegs 9.5% (14/148) van gevalle. Ons het gevind dat baie respiratoriese virusse potensieel gemisdiagnoseer word wat „n rol kon speel in of bydra tot die dood van sommige SUDI gevalle. Gevolgtrekking: In sommige gevalle waarin SIDS geklassifiseer is as die oorsaak van dood, kan die virusse wat met PKR toetse opgespoor is nie geïgnoreer word nie, veral waar die bevinding ondersteun word deur histologiese bewyse van infeksie. Ons stel dus voor dat die gebruik van PKR toetse die oorsaak van dood klassifikasie kan verander van SIDS na Infeksie in sommige van hierdie gevalle. Verdere navorsing is nodig om die waarde van gelyktydige opsporing van virusse in SUDI gevalle te bepaal wanneer daar geen noemenswaardige histologiese bewyse van infeksie gevind word nie. Dit bevraagteken of die PKR toets dalk te sensitief is en gevolglik vorige en latente virusinfeksies identifiseer wat nie noodwendig 'n rol in die oorsaak van dood speel nie. Die diagnostiese en kliniese waarde van die histologiese beeld in terme van die rol van virusinfeksies as bydraende oorsaak van dood moet verder ondersoek word, veral in jong kinders wie se immuunstelsels nog nie volledig ontwikkel is nie. Indien die werklike voorkoms van virusse in SUDI gevalle en die virus-spesifieke immuunrespons nie bepaal word nie, sal die rol van virus-spesifieke infeksies in hierdie sindroom grootliks onbekend bly.
Harry Crossley Foundation
Poliomyelitis Research Foundation (PRF)
National Health Laboratory Services Research Trust

In forensic pathology is of fundamental importance the diagnosis of time of death. If such an investigation is often complex with a well-preserved corpse, it is even more difficult in the case of a fetus dead in-utero affected by macerative post-mortal phenomena. The criteria currently available in pathological and obstetrical literature date back to the '60s and '70s and focus on macro- and microscopic characteristics of fetus and placenta almost never scientifically validated. They can turn to be inappropriate or useless in clinical practice, where the medical examiner often experience a complete mismatch between morphological and clinical data. The present study therefore arises from the necessity to update these thanatological criteria. The actual validity of thanatological criteria proposed in literature has been assessed through a retrospective review of a selected population of 55 fetuses spontaneously dead in utero. The analysis was conducted for each case by applying the criteria previously analyzed in the literature (photographic documentation; histological evaluation of organs and placenta). It was then verified the actual correspondence between the morphological data, clinical data and estimated time of death based on known criteria, identifying the main problems and the possible influence of intrinsic or extrinsic factors. Thereafter it has been developed an experimental prospective phase, focus the to the most critical phases of death-birth time (death within 12-24 hours). A TEM analysis was then conducted on skin and muscle samples from voluntary interruptions of pregnancy underwent an experimental macerative protocol, in order to identify possible stages of cell organelles degeneration positively correlated to the time of death. The main novelty emerged from the TEM study was a progressive vacuolization of cell structures.

Thesis (MMED. (Forensic Medicine)) --University of Limpopo, 2019
Traumatic intracranial haemorrhages are common, carry a high mortality rate and are therefore commonly known in the practice of forensic pathology as unnatural deaths. Studies have demonstrated a significant decrease in mortality rate among patients who received surgical interventions compared to patients who were treated medically. Missed or mis-diagnoses, which may be apparent during an autopsy procedure, present possible missed treatment opportunities. Aim/objective and methods The study investigated the discrepancy rate and discrepancy pattern of diagnosis between antemortem brain computed tomography (CT) scan findings and autopsy findings in deceased patients with traumatic intracranial haemorrhage (TIH). A quantitative retrospective descriptive study was conducted based on bodies presented with TIH at Pietersburg Hospital Forensic Pathology Department. A total of consecutive 85 cases with antemortem CT (ACT) scan findings were compared to autopsy findings using percentage agreement and Cohen’s kappa statistics. Results and conclusion There was a fair overall agreement (k=0.38) with overall discrepancy rate of 24.74%, ranging from 9.41% to 34.12% for individual TIH between ACT scan and autopsy findings. Subarachnoid haemorrhage had the lowest agreement between the ACT scan and autopsy findings for TIH. Patient and doctor factors associated with the discrepancies were assessed. Those associated factors, if addressed, may have a positive impact on patient outcome. As far as the debate on non-invasive autopsy procedure is concerned, as a result of existing discrepancy rate, we conclude that ACT should not be used alone in the determination of cause of death but may be used in conjunction with autopsy findings.

Análise semiquantitativa do parênquima distal de pulmões obtidos em autópsia de vítimas de morte por ação do fogo e por sufocação, foi feita para avaliar as alterações em bronquíolos e tecido alveolar (ductos e alvéolos). A análise discriminante dos parâmetros obtidos permitiu classificação de 74%
A semiquantitative analysis of the distal parenchyma in lung autopsies of victims of death by fire and death by suffocation, was done to evaluate the changes in membranous bronchiolar and alveolar tissue (alveolar ducts and alveoli). The discriminant parameters obtained permitted classification of 74% of cases

Para a execução da etapa inicial da identificação médico-legal de restos humanos (antropometria e exame dos arcos dentários), faz-se necessária uma limpeza prévia da ossada, para a remoção de tecidos moles putrefeitos. Os casos não identificados por esses métodos tradicionais, poderão ser submetidos ao exame de DNA. No entanto, apesar do grande avanço da biologia molecular, utilizando a amplificação de DNA pela PCR, algumas limitações que afetam a habilidade de se obter DNA em restos humanos, permanecem. Dessa forma, o objetivo deste trabalho foi fornecer subsídios morfológicos para os analistas forenses, com ênfase na prática médico-legal, visando uma utilização mais eficiente do DNA obtido de osso compacto de restos humanos em decomposição ou já esqueletizados, sem tecidos moles aderidos. Foi realizado o estudo da microestrutura do tecido ósseo compacto femoral, de restos humanos em decomposição, ainda com tecidos moles, que foram limpos pela fervura em água (n = 7) e ossadas já esqueletizadas pela decomposição natural, que não foram fervidas (n = 8). Destes, seis ossadas foram provenientes de cemitério público regular, após 3 anos de inumação, 1 ossada proveniente da região amazônica, e 1 ossada de origem desconhecida. Estas duas ultimas, apresentado-se porosas ou quebradiças. As análises morfológicas de cortes histológicos foram coradas com hematoxilina e eosina e o DNA amplificado pela PCR para os loci CSF1PO, TPOX, TH01, F13A0, FESFPS, vWA, D16S539, D7S820, D13S317 e amelogenina. Os resultados da análise desses dois grupos foram comparados com os de cadáveres frescos (n = 5) do Serviço de Verificação de Óbitos da Capital. A fervura dos ossos, do modo como é realizada no Instituto Médico Legal de São Paulo, pode aumentar a eosinofilia da matriz óssea e, em alguns casos, pode promover a desagregação dos ósteons. Tal procedimento pode remover células, mas pode também remover possíveis inibidores da PCR, favorecendo a análise do DNA obtido destas amostras. O fator limitante para a obtenção e análise de DNA, em amostras de ossos limpos por fervura, é a quantidade exígua de células. Ossos não submetidos à fervura, após inumação por três anos ou há mais tempo em contato com a terra, podem apresentar alterações da microestrutura. No entanto, a presença de hemácias preservadas e núcleos de osteócitos nestas amostras, indica melhor preservação de células em relação às amostras de ossos fervidos. O fator limitante para a análise de DNA nestas amostras é a presença sugestiva de inibidores da reação de amplificação pela PCR. Restos humanos, sem tecidos moles, macroscópicamente não preservados (porosos e quebradiços), e não submetidos à fervura, apresentam alterações de perda de matriz mineralizada; no entanto, nestas amostras ainda é possível encontrar células preservadas. Os resultados obtidos no neste trabalho permitem traçar algumas estratégias para uma melhor utilização nos protocolos de extração e análise do DNA em osso compacto de restos humanos.
To the first essential step to forensic identification of human remains (anthropological study of race, sex, age, etc) it is necessary a previous cleaning of the bones, to remove decomposing soft tissues. Medico-legal inconclusive or non identified cases, by using these traditional methods, could be subjected to DNA analysis. However, in spite of advances in human identification techniques, specially by PCR amplified DNA, some limitations that affect the ability to obtain DNA in human remains still persist. Therefore, the aim of this study was to provide additional support from morphological analysis, to help forensic analysts personnel to utilise more efficiently the DNA, extracted from compact bones of human remains in decomposition or already skeletonized corpse, it means without soft tissues, with special emphasis in the legal-medicine practice. Femoral compact bones were obtained from: 7 human remains found on the ground, in different degree of decomposition which were cleaned by boiling to remove soft tissues; also studied were collections of bones from 8 corpses having undergone natural decomposition: 6 human remains exhumed after 3 years from a common public cemetery in São Paulo City; 1 case from amazon region and 1 case with no information, both cases remained from long time (more than 3 years) in contact with soil. All eight cases, were not boiled as no soft tissue were adhered. As a control, five cadavers 12 to 16 hours post mortem were also used. The compact bones histological sections were stained by haematoxilin and eosin and the loci CSF1PO, TPOX, TH01, F13A01,FESFPS, vWA, D16S539, D7S820, D13S317 and amelogenin were amplified by PCR.The procedure for boiling the human remains utilised in the Legal Medicine Institute of São Paulo would have increased the eosinophily of bone matrix and, in some cases, promoted the desaggregation of the osteons. In addition these procedures would have removed the cells, but in some cases would have removed possible inhibitors of the PCR, favouring in this way the analysis of DNA obtained from these samples. The limiting factor to obtain successful analysis in bones submitted to boiling seem to be the low quantity of nuclei present in these samples. For the other hand, in bones not cleaned by boiling, the presence of preserved red cells and oscteocyte nuclei inside the lacunae indicates better preservation of cells in relation to those bones cleaned by boiling. The limiting factor to obtain successful DNA analysis in bones exhumed or in contact of soil, is the suggestive presence of inhibitors of PCR. Porous and brittle bones from human remains, without soft tissues that are not processed by boiling, present alterations through loss of mineralised matrix, although it is still possible to found preserved cells in these samples. The results presented in this work clarify concerns about viability of DNA for identification analysis. They also help to establish better strategies for optimisation of DNA extraction and analysis in compact bones of human remains.

Lo scopo del lavoro di tesi è stato quello di valutare l'affidabilità dei metodi entomologici per la stima del PMI, in comparazione con altri approcci investigativi proposti di recente quali: il decadimento delle proteine muscolari unitamente a sistemi di punteggio assegnati alle diverse modificazioni post-mortali. Nella prima parte il progetto di ricerca si è incentrato su alcune fasi critiche dell'indagine entomologica (repertazione, preparazione e conservazione del campione entomologico) per poi proseguire con una indagine in campo aperto con modello animale: • un primo studio ha valutato l’efficacia delle due principali metodiche di repertazione del campione entomologico utilizzato per le stime tanatocronologiche: bollitura degli insetti e loro conservazione in soluzione alcolica vs. conservazione in etanolo senza preventiva bollitura. Tali metodi sono stati testati su due specie di ditteri cadaverici: la Lucilia sericata e la Calliphora vicina. I risultati hanno evidenziato per entrambe le specie che la stima del PMI non è alterata se le misurazioni sono condotte entro una settimana anche in campioni direttamente conservati in etanolo ≥70%, senza preventiva bollitura, privilegiando concentrazioni di etanolo più elevate (es. 96%). Successivamente sono stati confrontati tre diversi metodi di misurazione per la stima della lunghezza larvale di C. vicina. Il confronto tra metodiche ha evidenziato come sia affidabile la misurazione delle larve effettuata mediante un semplice strumento quale un micrometro geometrico; • il secondo studio è stato diretto alla valutazione dei metodi più comuni per la conservazione degli esemplari entomologici nelle 24h che precedono il loro trasferimento in laboratorio. Anche in questo caso, sono state testate due specie di ditteri cadaverici: la L. sericata e la C. vicina. Tutti gli stadi larvali (L1, L2 ed L3) sono stati posti in contenitori privi di un substrato di crescita, con e senza ossigeno per 24h. E’ stato poi esaminato, ogni 24h, il loro grado di sviluppo e il tasso di mortalità (MR). I risultati sono posti a confronto con un gruppo di controllo in cui le larve sono state invece allevate in presenza sia di cibo che di ossigeno ad una temperatura costante di 25°C. L’esito di questo studio ha evidenziato per tutte le larve L3 (72h dopo la schiusa) un alto tasso di mortalità fino al 100%. Questo risultato consente, sulla base di evidenze sperimentali, di raccomandare per la repertazione degli esemplari immaturi di ditteri cadaverici la loro temporanea conservazione, prima del trasferimento in laboratorio, in contenitori aereati al fine di consentire un elevato tasso di sopravvivenza delle larve poi utilizzate nel calcolo del PMI; • un terzo studio è stato caratterizzato da una sperimentazione in “campo aperto” su modello animale. Otto carcasse di maiale di differenti masse corporee sono state lasciate decomporre in condizioni naturali. Durante la decomposizione ogni 24 h sono stati valutati i caratteri di ciascuna modificazione post-mortale mediante l’assegnazione di un punteggio (Total Body Score - TBS) e sono stati raccolti campioni di muscolo scheletrico per l’analisi del decadimento molecolare delle proteine. Contestualmente è stato altresì considerato l’andamento della colonizzazione da parte degli insetti cadaverici. L'obiettivo finale dello studio è stato quello di verificare la potenzialità di un approccio combinato dei diversi metodi (TBS, proteine muscolari scheletriche ed entomologia) nel migliorare l’affidabilità predittiva dei singoli metodi per la stima dell’intervallo post mortale. I dati ottenuti dalla sperimentazione hanno evidenziato come l’affidabilità predittiva delle metodiche utilizzate sia maggiore se utilizzate in associazione. Singolarmente considerate, le proteine muscolari si sono rivelate estremamente utili nei primi 5 giorni di PMI mentre lo studio degli insetti nei primi 15 giorni post-mortem. Il dato morfologico ha fornito importanti informazioni nei cadaveri occultati che presentevano un ritardo nella colonizzazione degli insetti.
The application of the entomological method to the estimation of minimum PMI (PMIm) requires that all the standards recommended by the best practice be satisfied, from collection of the entomological evidence to identification of species, reconstruction of thermal history and developmental analysis. Aim of this research study is to assess the reliability of the entomological methods for PMI in comparison with estimation and its complex investigative procedure. The research project has been represented by different experimental studies. In the beginning the research project has focused on some critical steps of the collection and storage of entomological samples useful in PMI estimation. In particular: - the effects of boiling of entomological samples and their storage in alcohol solution have been compared to storage of samples in ethanol without boiling. Two forensically important blow flies have been used: Lucilia sericata and Calliphora vicina. The results showed for both species that the estimation of a PMI by larval length is not biased when performed after a time lag of about one week if specimens are stored in ≥ 70% ethanol. Higher concentration such as 96% is better. Different measuring methods of larval length were also tested on C. vicina larvae. No significant differences were detected among the methods demonstrating that a simple tool like a geometrical micrometer can give accurate results for age estimation of larvae useful for the PMI assessment. - the effects of different temporary storing methods of entomological samples before the arrival in the laboratory have been tested. Samples of L. sericata and C. vicina larvae at different stage of development (L1, L2 and L3) were stored without food supply and with and without air for 24h. The results were then compared with a control group in which larvae were reared in boxes with air-permeable lid on their food substrate at 25°C. All boxes were checked for mortality rate (MR) every 24h. Results showed a high MR for L3 larvae (72h after hatching), developed without oxygen up to 100% thus demonstrating how important is oxygen supply during transportation of entomological evidence; - a field study on animal model (pigs) was finally set up. Eight pig cadavers of different body weight were left to decompose under natural conditions. Morphological changes during decomposition were assessed using the total body score (TBS), muscle samples were collected to analyze protein degradation, and insect colonization was daily evaluated. The final goal of the research study is to answer the novel question whether the combined approach of different methods (TBS, skeletal muscle proteins and entomology) could empower the single methods accuracy in PMI estimation. The data obtained showed that the predictive reliability of the methods is greater when used in combination. Individually considered, muscle proteins proved to be extremely useful in the first 5 days of PMI while forensic entomological method in the first 15 days of PMI. The morphological data (TBS) provided important information in cadavers with a delay in the colonization of insects.

Study project (M.Med.) -- University of Stellenbosch, 2001.
ENGLISH ABSTRACT: The main purpose in doing forensic post mortems is to supply information to the judicial system. Medical personnel involved in doing post mortems seldom get feedback regarding efficiency. Numerous allegations have been made regarding the work of district surgeons in terms of forensic post mortems, often suggesting that the work is substandard. In South Africa district surgeons do post mortems mostly in the rural areas, and training centre personnel do forensic post mortems in urban areas. Training centre personnel include specialized forensic pathologists, registrars and medical officers working in the Departments of Forensic Medicine, affiliated to universities. The South African Police Service mostly manages government mortuaries. The South African forensic medico-legal system is unique, and does not correspond in with the four main systems used worldwide. Research was done by sending 200 questionnaires to a representative group from the legal fraternity of the Western Cape (including judges / magistrates, state prosecutors, private lawyers) and also the South African Police Service investigating officers. The judiciary, as the users of the information generated through forensic post mortems, are therefore in a suitable position to determine the efficacy of forensic post mortem. The questionnaire was structured to determine the general perception, as well as comments, regarding 9 different aspects involved with doing forensic post mortems. These include the thoroughness and completeness of reports, standard of academic knowledge, efficacy of verbal testimony in court, length of time in releasing the report, general attitude, efficacy of sketches and diagrams, efficacy of photography, sufficient taking of toxicology samples and sufficient utilization of special laboratory investigations. The last question was an open question to allow for general comments and anecdotes. For each aspect it was also determined whether there was a difference in efficacy noted between the two groups. The effect of this, if any, on the judicial criminal justice system was also assessed. A different questionnaire was sent out to all forensic pathologists in the Western Cape. The standard of work of the district surgeons was hereby assessed. General comment regarding academic knowledge, and findings at post mortem made by district surgeons was assessed. The pathologists were also questioned regarding the general attitude of district surgeons, and imput were asked regarding continued medical education programs. An area for general comment was also supplied. The main findings were as follows: a. The legal fraternity in the Western Cape is generally satisfied with the efficiency of forensic post mortems, except the use of laboratory investigations and also the length of time to release reports. b. The legal fraternity could determine a difference in the efficiency of post mortems done by district surgeons and training centre personnel. Training centre personnel were generally regarded as more effective. c. The difference between the two groups, due to ineffective district surgeon post mortems, had a negative effect on the criminal justice system. The following recommendations were made: a. Training centre personnel: Serious consideration should be given to appointing qualified forensic pathologists in the rural areas. Training centre personnel should also be more involved in training the district surgeons. b. District surgeons: The training, re-training and continued medical education of district surgeons in the Western Cape should be prioritized. The service conditions should also be reviewed. c. Administrative: Audit of post mortem reports. The efficiency regarding court appearances should be audited through the Department of Justice. Administrative power will be necessary to oversee the above-mentioned recommendations.
AFRIKAANSE OPSOMMING: Die hoofdoel met die doen van geregtelike post mortems is om inligting te verskaf aan die regsproses. Medici gemoeid met geregtelike post mortems kry baie seide terugvoer oor die effektiwiteit van werk gelewer in die hof. Daar is ook herhaaldelik suggesties gemaak dat die werk van die distriksgeneeshere met betrekking tot geregtelike post mortems soms suboptimaal is. Regsmediese post mortemdienste in Suid Afrika word verskaf deur distriksgeneeshere in die platteland, en deur personeel verbonde aan opleidingshospitale in die stede. Die opleidingssentra-personeel sluit in gespesialiseerde forensiese patoloe, kliniese assistente en mediese beamptes werksaam in 'n Departement van Geregtelike Geneeskunde verbonde aan 'n universiteit. Staats- Iykshuise word bestuur en beheer deur die Suid-Afrikaanse Polisiediens. Daar bestaan geen soortgelyke model vir die voorsiening van regsmediese dienste in die res van die wereld nie. Navorsing is gedoen deur vraelyste uit te stuur aan 200 verteenwoordigende regslui (wat insluit regters/landdroste, staatsaanklaers, privaat regslui) en aan Suid-Afrikaanse Polisiediens-ondersoekbeamptes in die Wes Kaap. Die reg, as verbruikers van regsmediese dienste is gekies om 'n opinie uit te spreek oor die doeltreffendheid van forensiese post mortems. Die vraelyste is gestruktureer om die algemene tevredenheid en opinies en kommentaar te bekom oor nege verskillende aangeleenthede rakend die forensiese post mortem, nl. deeglikheid en volledigheid van verslae, standaard van akademiese kennis, effektiwiteit van verbale getuienisaflegging in die hof, tydsverloop vir lewering van verslae, houding en gesindheid van medici, doeltreffendheid van sketse en diagram me, effektiewe gebruik van fotografie, effektiewe gebruik van toksikologiese ondersoeke, effektiewe gebruik van spesiale ondersoeke, asook 'n algemene oop vraag vir kommentaar oor probleemareas. Daar word vervolgens vir elke aangeleentheid bepaal of daar 'n verskil in effektiwiteit opgelet word tussen twee mediese subgroepe, en indien wei watter groep meer effektief funksioneer. Verder sal nagegaan word of die regsproses geaffekteer word deur enige van bogenoemde bevindinge. 'n Verskillende vraelys is uitgestuur aan aile geregtelike patoloe in die Wes-Kaap. Hiermee word die standaard van die werk van distriksgeneeshere beoordeel. Kommentaar is gevra oor akademiese kennis met betrekking tot geregtelike post mortems en oor bevindinge gemaak deur distriksgeneeshere by post mortems. Daar word ook gevra oor die algemene houding van distriksgeneeshere, asook vir voorstelle vir voortgesette onderrigsprogramme. 'n Oop vraag is gestel vir kommentaar oor probleemareas. Uit die response is die volgende gevolgtrekkings gemaak: a. Die regslui in die Wes-Kaap is oor die algemeen tevrede met die diens gelewer met betrekking tot geregtelike post mortems, met uitsondering van die effektiwiteit van laboratoriumondersoeke, en ook oor die tydsverloop tussen die doen van post mortem en die vrystel van die verslae. b. Die regslui kon 'n verskil bepaal in die graad van effektiwiteit van post mortems gedoen deur distriksgeneeshere en opleidingssentra-personeel. Opleidingssentra-personeel is deur die meerderheid van respondente identifiseer as meer effektief. c. Die verskil tussen die twee groepe, a.g.v. oneffektiewe distriksgeneesheer post mortems, het 'n negatiewe effek op die regsproses. Aanbevelings is gemaak om die sisteem te verbeter: a. Opleidingssentra-personeel: Die uitplasing van gekwalifiseerde forensiese patoloe in die platteland moet oorweeg word. Opleidingssentrapersoneel kan ook meer betrokke wees by opleiding van distriksgeneeshere. b. Distriksgeneeshere: Aandag moet gegee word aan die opleiding, heropleiding en voortgesette geneeskundige onderrig van distriksgeneeshere in die Wes-Kaap. Die werksomstandighede waaronder hulle diens lewer moet ook aangespreek word. C. Administratief: Ouditering van post mortem verslae. Ouditering van effektiwiteit van hofverskynings, in assosiasie met die Departement van Justisie. Admininistratiewe wilskrag sal ook essensieel wees by implementering van bogenoemde voorstelle.

This thesis explores facial affect processing in violent offenders, with a specific focus on how patterns of impairment seen in Intimate Partner Violent (IPV) prisoners differ to those of other violent prisoners. Chapter one introduces IPV as a serious public health concern with inadequate treatment efficacy. It discusses the overlap between IPV and non-IPV violence and highlights the need for further research elucidating how the treatment needs of IPV prisoners differ to those of non-IPV prisoners. The role of facial affect processing is then discussed in relation to empathy and violent offending. Chapter two reviews the literature on facial affect processing in violent offenders. The review found deficits in violent offenders’ recognition of negative affect, with deficits in fear, anger and disgust most reliably reported, across indices of accuracy, sensitivity and response bias. Subtleties in processing patterns were observed between violent offenders and non-violent offenders, and between violent offenders and sexually-violent offenders. The review highlighted a dearth of research exploring facial affect processing in IPV prisoners. Chapter three presents a study investigating facial affect processing among IPV and non-IPV violent prisoners and nonoffending controls. It investigated the role of eye-scan paths as a mechanism underpinning recognition deficits in violent offenders and explored the influence of psychopathology on visual scanning behaviour. Groups did not differ in their recognition accuracy but they did differ in their eye-scan paths as a function of intensity and sex of the expression; with nonoffenders demonstrating different visual scanning behaviour relative to offender groups, who did not differ from each other. There was little evidence to suggest that eye-scan paths were influenced by psychopathological profiles of the groups. Chapter four presents a critique of the revised Conflict Tactics Scales (CTS2, Straus, Hamby, Boney-McCoy & Sugarman, 1996), a widely used measure of IPV. The review highlights the objectivity of the measure as both a strength, in terms of its limiting denial, minimisation and cognitive distortions but also a limitation in its failure to take into consideration the context in which the behaviour occurred. The scales’ psychometric properties are also discussed. The thesis conclusions are presented in Chapter five, alongside recommendations for practice and research.

Human organs are the most valuable gifts of life. Until today, through organ transplantation, thousands of lives have been saved and many more blessed with hope and happiness through a better quality of living. However, rapid developments in transplant technology will be meaningless if supply of the needed organs remains scarce and organ transplantation procedures cannot take place accordingly. This global problem of organ shortage is also faced by Malaysia. Despite campaigns and initiatives introduced by the Malaysian authorities, the problem remains unresolved and the situation is worsening. Malaysia is reported to have less than one donor for every one thousand of the population (Lela Yasmin Mansor, 2007). However, statistics from the National Transplant Registry Malaysia confirm a steady increase in the number of registered potential donors each year. This suggests that certain factors must be preventing potential donors from becoming actual donors. Therefore, this study will not only discuss the current scenario of the organ shortage problem in Malaysia, highlighting its underlying factors, but will also scrutinise legal and social factors causing actual donations to remain relatively small, despite the promising number of potential donors registering each year. The study will suggest practical solutions to help solve organ shortages in Malaysia, particularly by utilising brain-dead patients from serious road traffic accidents as a potential source of cadaveric organs. Clarification on the Islamic perspective concerning organ donation is also included, as Islam is the main religion professed in Malaysia.

It is the purpose of this, then, to investigate the feasibility of using the changes of concentrations of small iconic decomposition products in bile as indicators of time since death. High pressure liquid chromatography was selected for measurement of these changes.

Due to concerns about international differences in treatment effectiveness, many countries are reluctant to extrapolate overseas clinical data to form the basis of guideline recommendations and intervention approval processes. The evidence on which these concerns are based, however, comes from a limited dataset, with few studies directly assessing international differences in treatment effectiveness. This study aims to assess differences in the results of cardiovascular trials between Europe, North America, and Asia using the panoramic meta-analysis approach. All meta-analyses containing randomised control trials for the treatment or prevention of cardiovascular diseases were searched for in The Cochrane Library (2000 to 2008) and Medline (2005-2008). Analysis was then conducted within and over the included meta-analyses by performing pair-wise comparisons of the trial results between Europe and North America, Europe and Asia, and North America and Asia and a universal comparison of all three continents’ trial results together. All analyses were conducted over fatal and non-fatal endpoints. The findings suggested that for both endpoints, interventions performed best in Asian trials. For fatal endpoints, a high proportion of positive trial results were observed for Japan. Further investigation showed that between-continent differences in treatment effect could be explained by between-continent differences in trial quality. However, the types of intervention prone to inter-continental differences could not be identified for fatal or non-fatal endpoints. These findings suggest that those developing guidelines and approving interventions should be cautious when extrapolating overseas data. In particular, this study highlights the importance of taking trial quality into account when extrapolating and interpreting clinical trial data from different regions.

Consent is a concept used frequently and with great significance in a wide array of legal fields. It serves to regulate relationships, legitimize authority, delimit normality, and entrench idealized ways of being in the world. Yet despite the consequence of these functions, there is very little precision within legal scholarship about just what consent is. Few investigations of its definitional content depart from presumptive statements about personal autonomy. These associations are often described as the ‘common sense’ of consent and serve to secure a foundationalist discourse about what consent is, rendering alternative conceptions of its meaning or functions unintelligible. This is perhaps best evidenced in more critical approaches to consent, where despite widespread acknowledgement of the concept as a legal and political fiction, its status as a signifier of autonomy is maintained. This creates an imperative to move beyond the notion of consent as merely an illusion, to an understanding of it as something more operative. Not only does the story of autonomy that is told about consent obscure the social realities of inequality, difference, and subordination that might threaten a notion of a homogenous citizenry (and thus, governmental action made in its name), but it also conceals the historically specific conditions of existence which have brought consent’s ‘common sense’ story of autonomy into being. This thesis explores how this dominant narrative of consent, while producing certain ‘ideal’ subjectivities, also necessarily produces subjectivities which don’t fall within the ambit of consent. Moreover, this project asks what is achieved when the meaning of consent is positioned as a matter of ‘common sense’? What does its apparent transparency keep obscure? In contrast to conventional approaches to consent, this project positions consent as an historical artefact rather than a concept with doctrinal, cognitive, or communicative certainty and seeks to investigate its operations across legal fields rather than strictly within them. This includes an examination of consent to sex, the doctrine of informed consent in medical jurisprudence, and the defence of consent to assault in professional sporting contexts. Further, the project engages in a ‘juridical genealogy’ of consent, studying its use in three vastly different historical periods in search of how it might perform different socio-political functions than understandings of its role within contemporary medical and criminal law suggest it should. How these counter-narratives of consent serve to challenge the dominant autonomy story are investigated for what they reveal about the frames of cultural and legal intelligibility at work in consent law today.

The thesis consists of two volumes. Volume 1: This volume consists of three chapters. The first chapter is a literature review examining whether there is a link between psychopathy and self-harm. The second chapter is a quantitative study investigating whether scores on the HCR-20 and FAM risk assessment tools predict frequency of self-harm in females within a secure psychiatric hospital. The third chapter comprises a public domain briefing document which provides a plain language summary of the literature review and empirical paper. Volume 2: This volume consists of five Forensic Clinical Practice Reports (FCPRs). The first details the case of a 63-year-old man with depression and paranoid schizophrenia, formulated from both cognitive and psychodynamic perspectives. The second is a service evaluation examining whether scores on the HCR-20 and HoNOS decrease over time for patients detained within a secure psychiatric hospital, and whether individuals’ scores on these measures reflect the level of security in which they reside. The third FCPR documents the case of a 34-year-old man experiencing offence-related anxiety, shame and depression. The fourth FCPR is a single-case experimental design investigating the effectiveness of a trauma-focussed cognitive-behavioural intervention for offence-related PTSD. The fifth FCPR is an abstract of an oral case presentation of a 14-year-old girl experiencing school anxiety. Pseudonyms have been used throughout to ensure anonymity.

One of the main aims of the forensic anthropological practice regards the proper identification of human remains. Years of studies and research provided many instruments for the reconstruction of the so-called “biological profile” (e.g. age at death, sex, stature, race); nevertheless, and despite the numerous information that it can provide, the pathological investigation of skeletons still displays many uncertainties. The identification of pathological signs from bones can in fact narrow the field of research in case of the recovery of unknown human remains, and can provide valuable data for the definition of a possible cause of death. However, the difficulties encountered when analyzing skeletal remains, due to taphonomic and environmental variables, non-specificity of the bone reaction and the monotony of bone tissue manifestation to stimuli, make pathological identification of diseases one of the most difficult fields of forensic anthropology. The aim of this research project is that of trying to narrow and clarify some aspects of skeletal pathology and forensic anthropology, by analyzing skeletons from three cemeteries of Milan, which are part of the Milano Cemetery Skeletal Collection. The main feature of this collection regards the availability, for many of its individuals, of ISTAT death certificates that make the observers aware of the main cause of death and related pathological conditions of such subjects. After collecting this information the attention then focused on the macroscopic investigation of specific pathologies, those that were more widespread in the available sample, to include: cancer metastases, diabetes, Cardiovascular Disease (CVD) and Human Immunodeficiency Virus (HIV) related to drug abuse. The skeletons of this research were selected and cleaned in a proper way; subsequently, the specific pathologic investigation was carried on after an accurate literature search, aimed at finding the most characteristic features that permit the correct identification of the pathology from bones. The analyses performed allowed the demonstration of the difficulties encountered in unequivocally describe and identify such diseases, despite the previous studies conducted, mainly due to the aspecific and often altered structures acquired by the stimulated areas on bones. The modifications caused by taphonomy, together with the subjectivity of the responses and the paucity of available reference data made the investigation quite difficult. However, the available causes of death permitted a baseline to better understand the observations in identifying and describing pathologic-related skeletal lesions, and to set the basis for a more detailed and comprehensive macroscopic pathologic investigation. Such macroscopic investigation, however, has it limits, as it can not go over a certain level of certainty; for this reason, additional investigation methods (such as x-rays, biochemistry, histology and so on) or additional antemortem data are necessary for increasing the amount of information we can gain from the examination of bare skeleton.

Complete suicides and parasuicides are a major cause of death and disability in South Africa and the rest of the world. The epidemiology, pathology and toxicology of complete suicides were investigated in this study. All the complete suicide cases, which were presented to Salt River Medicolegal Laboratory over a period of one year (1 January 1997 - 31 December 1997), were analysed. The candidate personally conducted 148 of the alleged 180 suicide cases that presented in this time period (82%). The candidate did all the follow up investigations herself. The main findings were: 1. The male to female ratio was 5: 1. (131: 26) 2. Shooting and hanging were the most commonly used methods. 3. The racial distribution of violent deaths showed a high rate of suicides amongst the White population. 4. Suicides accounted for the Joss of young lives, the average age being 37,8 years. The mean age was 34 years. 5. Most victims committed suicide in and around their own homes. 6. The majority did not leave suicide notes. 7. Psychiatric disorders, poor health, arguments with close family members and friends, financial problems and long-standing relationship problems were the most common reasons for the suicides. 8. Suicides by prisoners accounted for 3,8% of the study (6 cases). 9. Two cases of double suicide (group suicide) were identified. 10. Five cases of homicide-suicide were identified in the study material. 11. One case of an attempted suicide by means of a high-speed motor vehicle accident, followed by the successful suicide by other means, was identified.

Thesis (MPhil)--Stellenbosch University, 2014.
ENGLISH ABSTRACT: This thesis discusses ethical dilemmas faced by district surgeons in South Africa. District surgeons render clinical forensic services, which means that they deal mainly with detainees and victims of crime. The main functions of district surgeons are the collection of forensic evidence from patients and the care of detainees. So the focus is to assist in the administration of justice rather than improvement of patient wellbeing. The district surgeon may therefore find himself in a situation where patients’ interests are in conflict with those of law enforcement agencies. Being a medical practitioner in clinical forensic medicine, the district surgeon has an obligation to assist in the administration of justice, as opposed to the traditional obligation to care for patients and put patient’s interests first. This allegiance to both administration of justice as well as patient wellbeing lead to an ethical dilemma of dual loyalties. A dual obligations presents an ethical dilemma for the district surgeon, especially if they are in conflict and mutually exclusive. I discuss the detention and subsequent death of Steve Biko to illustrate how dual obligations can lead to serious human rights violations and even death. Dual obligations are however not limited to detainees and police custody settings, and I demonstrate this by discussing three other scenarios commonly encountered by district surgeons. There is a lack clear guidance for district surgeons who are faced with a conflict of obligations. I explore several ethical theories including consequentialism, deontology and virtue ethics, in search of an ethical framework suitable for resolving conflicts in clinical forensic medicine. I therefore argue that a duty based ethical framework is central to clinical forensic medicine and the resolution of loyalty conflicts. I recommend the resolution of conflicts by using an approach developed by Benjamin (2006). This approach involves weighing -up the different duties in conflict, applying philosophical reasoning and then amelioration. By adopting a structured and wellreasoned ethical framework, district surgeons will be able to deal with conflicts of obligations better.
AFRIKAANSE OPSOMMING: Hierdie tesis bespreek etiese dilemmas wat in die gesig gestaar word deur distriksgeneeshere in Suid-Afrika. Distriksgeneeshere lewer kliniese forensiese dienste, wat beteken dat hulle handel hoofsaaklik oor die gevangenes en slagoffers van misdaad. Die belangrikste funksies van distriksgeneeshere is die insameling van forensiese getuienis van pasiënte, en die sorg van gevangenes. Met hierdie benadering is die fokus om te help met die administratiewe doeleindes van geregtigheid, eerder as die verbetering van die pasiënt se welstand. Die distriksgeneesheer kan hom dus in 'n situasie vind waarby die pasiënte se belange in konflik is met dié van wetstoepassingsagentskappe. As 'n geneesheer in kliniese forensiese geneeskunde, het die distriksgeneesheer 'n verpligting om te help met die administrasie van geregtigheid, in teenstelling met die tradisionele verpligting om te sorg vir hul pasiënte, en hul welstand eerste te plaas. Hierdie getrouheid gaan gepaard met beide regspleging, sowel as die welstand van die pasiënt, wat kan lei tot 'n etiese dilemma van dubbele lojaliteit. Dubbele verpligtinge bied 'n etiese dilemma vir die distriksgeneesheer, veral as hulle in konflik en wedersyds uitsluitend is. Ek bespreek die aanhouding en die daaropvolgende dood van Steve Biko om te illustreer hoe dubbele verpligtinge kan lei tot ernstige skending van menseregte en selfs die dood. Dubbele verpligtinge is egter nie beperk tot die gevangenes en polisie-aanhouding instellings nie, en ek demonstreer dit deur die bespreking van drie ander “scenario's” wat oor die algemeen eervaar word deur distriksgeneeshere. Daar is 'n gebrek aan duidelike riglyne vir distriksgeneeshere wat 'n botsing van verpligtinge in die gesig staar. Ek verken verskeie etiese teorieë insluitende konsekwensialisme, deontologie en deugde-etiek, op soek na 'n etiese raamwerk geskik vir die oplossing van konflikte in kliniese geregtelike geneeskunde. Ek argumenteer dus dat 'n pligsgebaseerde etiese raamwerk sentraal is tot kliniese forensiese geneeskunde, en die resolusie van lojaliteit konflikte. Ek beveel die oplossing van konflikte deur die gebruik van 'n benadering wat ontwikkel is deur Benjamin (2006). Hierdie benadering behels 'n gewigsoorweging tussen die verskillende pligte in konflik, die toepassing van filosofiese redenasie en verbetering. Deur die aanneming van 'n gestruktureerde en beredeneerde etiese raamwerk, sal distriksgeneeshere dus in staat wees om konflikte van verpligtinge beter te hanteer.

This thesis examines the practice of forensic medicine in Scotland in the period 1914 to 1939. This was a time of significant dynamism for the discipline, in which it enjoyed a high public profile and played an important role in the investigation of crime. The project focuses in particular on medico-legal practice at an elite level, based in specialist departments in the universities of Edinburgh and Glasgow. As well as producing a significant amount of research and textbook material, and thus constituting authorities within the discipline, representatives of these institutions gave expert evidence in a number of high-profile trials. Thus, an examination of their work can show how medico-legal knowledge was constructed, presented and challenged. To this end, four main areas of forensic medical practice are analysed, including the post-mortem examination, the laboratory analysis of trace evidence, the investigation of shootings and the use of photography. The development of the techniques contained within these categories is charted, as is the range of situations to which they were applied and the various ways in which their use was challenged in court by hostile legal counsel. Sources including textbooks and journal articles, medical case reports, photograph albums and trial transcripts are used. A fifth section explores an area of the public face of the discipline, specifically the popular output of two of its most famous practitioners, Sydney Smith and John Glaister Jr. Both produced memoirs and newspaper serials after retirement. These are used to explore the ways they reflected on their careers and spun their legacies, portraying themselves as impartial servants of science and justice. The thesis argues that the place of forensic medicine in wider institutional, investigative and geographical networks was central to its existence. The discipline collaborated extensively, both with representatives of other areas of the medical profession and with external authorities, professions and trades. Means of communication, such as written reports and samples taken at autopsy, allowed experts in the universities to lend their expertise to the non-specialists in peripheries by providing expert opinions based on materials sent to them. The scrutiny of post-mortem reports produced by peripheral generalists allowed medico-legists’ expertise to be spread over a wide geographical area. The thesis also reflects on the ways in which medico-legists guarded against error. Techniques derived from other areas of medicine and science were not adopted for use in court until their reliability could be demonstrated satisfactorily, and controls and standards were built in to procedures.

Includes bibliographical references
Background: The TMNP is one of the more famous of Cape Town's tourist attractions. Stretching across the Peninsula, this conservation site is home to rare indigenous flora and fauna, biodiverse habitats and the spectacular Table Mountain. Despite its seemingly safe infrastructure, there have been media reports of accidents and deaths that have occurred in the TMNP and on Table Mountain. Aim: To determine the number and types of fatalities in the TMNP from 2000-2011. Method: The Salt River Forensic Pathology Laboratory is a state mortuary which serves the Cape Peninsula. Included in its drainage area is the TMNP. Approximately 3000 medico legal investigations are performed per annum, the details of which are stored in databases at the SRFPL and at the Division of Forensic Medicine at the University of Cape Town. These and archival records were retrospectively searched for all deaths that occurred in the National Park between 2000 and 2011. The collected information was categorised and analysed according to the demographic profile of victims, cause and manner of death, blood alcohol levels and activities prior to death. Results: Between 2000 and 2011, there were 98 confirmed deaths in the TMNP. The deaths occurred mostly during the South African summer months and on Fridays and Sundays (weekends). The victims were predominantly Caucasian (59%) and male (90 %) with a mean age of 39.4 years. The majority of victims were local, while 15 % were foreign, European and tourists. Overall accidents contributed to 53% of all unnatural deaths with victims predominantly sustaining head injuries and polytrauma which occurred from falls (71%) during mountain recreational activities. 24% of victims who fell tested positive for alcohol (>0.01g/100ml). Body mass index (BMI) calculations of the 98 victims revealed that 53% had BMI above 25. A p re -existing medical condition (predominantly cardiac) was the cause of the natural deaths. 26 A significant finding of the study was that 22% of deaths were due to suicides that took place on or surrounding Table Mountain. Suicides occurred commonly during summer with Fridays and Mondays being the common suicide days. The victims, all men, in the age range of 30-39 years (mean age of 39 years) were predominantly Caucasian (68%) and used hanging (45%) and jumping (27%) off the mountain as the two most preferred methods of death. 22% of suicide victims tested positive for alcohol at time of death. Conclusion: The TMNP is one of South Africa's most popular tourist attractions, due largely in part to the presence of Table Mountain. A retrospective study of deaths that occurred within the Park and on the mountain range over a 12-year period identified a predominantly Caucasian male victim demographic and found that head and polytrauma sustained from falls while participating in mountain associated activities as the leading cause of death. A significant finding was the high percentage (22%) of suicide deaths that took place. This study has helped to identify Table Mountain as a possible local suicide hotspot and points to a need for TMNP authorities to include in their safety protocols, strategies for suicide prevention. Larger collaborative studies are recommended as this would significantly impact on public health through the improvement of Park and mountain safety.

Pedestrian vehicle injuries are a growing public health threat worldwide. In South Africa, pedestrian accidents are the leading cause of injury related deaths in children younger than 15 years. There is international and national research looking at various aspects of pedestrian vehicle accidents. Previous studies have highlighted the general distribution of injuries sustained in paediatric pedestrian accidents. However, the specific types of injuries sustained by children pedestrians in different age groups have not been widely researched. We conducted a retrospective review of children involved in road traffic accidents as pedestrians in the greater Cape Town area from 2011 to 2015. The study population included patients below the age of 13 years that were admitted to Red Cross Children's Hospital (RCCH), as well as those subjects that died and presented to the Forensic Pathology Laboratory in Salt River also known as Salt River Mortuary (SRM). The age group 0-12 years was selected because RCCH is a referral paediatric hospital that only admits children under the age of 13 years. Data obtained from the study population were analysed according to age, gender, time, date (day of week and month) and area of accident, as well as injuries sustained. Cases were grouped according to age in order to analyse and compare changes in injury patterns for different groups. Age groups 0-4 years, 5-9 years and 10-12 years were selected. Further comparison of the injuries sustained was made between children admitted to RCCH (survivors) and subjects admitted to SRM (deceased). During the 5-year period 552 children were admitted to RCCH and 109 cases were admitted to SRM with 2:1 male to female predominance in both study groups. In our study, the group with the highest number/percentage of deaths was children aged 0 – 4 years, which contrasts with previous research. Most of the accidents (75-80%) occurred in lower socioeconomic areas. Significantly more head injuries occurred in children who died from their injuries than those who survived (96% versus 18%) (p < 0.0001). Out of the children who demised, 27% had spinal injuries, 61% had chest injuries and 43% had abdominal injuries, all of which were significantly higher than children who survived (p < 0.0001 for each). Upper limb injuries were equal between the two groups (12% vs 13%) and lower limb injuries were more common in the survivors (46% vs 24%). These results are the first to be documented in Cape Town and provide insight into the nature of injuries sustained by children involved in pedestrian vehicle accidents.

Background Weighing of organs is a necessary part of every autopsy and provides objective evidence of pathology, especially in forensic cases where histology is not always taken. Reference ranges must be locally applicable, accurate, and regularly defined. Aims The primary aim was generation of post-mortem organ weight reference ranges for use in South African mortuaries. Secondary aims were analysing factors influencing organ weights, and comparison of data to those from international populations. Methods A retrospective study was conducted using autopsy reports from the Salt River medico-legal mortuary in Cape Town, South Africa between 2013 and 2016. Disproportionate randomized stratified sampling was used to obtain sufficient cases from males and females; White, Coloured, and African racial groups; and decedents both older and younger than 50 years. Observations from 1262 decedents >18 years old dying traumatic on-scene deaths were recorded, excluding organs with macroscopic evidence of disease or destructive injury. The organs considered were the brain, heart, both lungs, liver, spleen, and both kidneys, and the variables collected were sex, race, age, height and body weight. This study was approved by the University of Cape Town Human Research Ethics Committee. Results Sampled decedents are described and excluded organs accounted for. Descriptive statistics are presented for each of the stratified subsamples. After assumption testing, multiple linear regression models are built, including interaction terms. Factors influencing organ weights are discussed and results compared to selected studies. Ideal organ weight reference ranges are proposed, based on 95% inclusion data from decedents aged 18-35 years with normal body mass indices. A smartphone application is offered, which calculates prediction intervals for individual decedents based on the multiple linear regression models. Conclusion This is the first study on post-mortem organ weights in South Africa, and despite limitations it provides useful locally derived population estimates.

Violence against women is an important cause of morbidity and mortality in South Africa and indeed the of world. Women and men are equal and must have equal guarantees of economic, social, civil, political cultural rights. Women who are denied basic right security cannot participate equally in society. Violence denies this basic human right. This study is descriptive and a retrospective analysis of rape survivors in Johannesburg from 1992, a prospective analysis of homicide victims from Cape from mid-1996 to end 1998. The results have been analysed into demographic variables and compared to trends from the rest of the world. The epidemiology and pattern of injury violent crimes have specifically targeted. The main findings were: 1. incidence of rape in Johannesburg in 1992 was 165 per 100 000 women. 2. Rape in Johannesburg is seasonable and occur mainly in young African women, by strangers. 3. Approximately one third of survivors sustain non-genital as well as genital injury. 4. Most injuries can be classified as minor or moderate and comprise contusion, abrasions and lacerations. 5. The incidence of rape homicide in Town is 7.2 per 100 000 women, which represents a fatal sexual rate 1.23%. 6. The majority of rape homicide victims were coloured women in the group 26 to 45 years. 6. Of those murdered by people known to them, a current or ex-intimate partner murdered 18.6%. 7. 98.3% of rape victims had non-genital injury, and 55.9% had evidence of genital injury. 9. Most rape homicides have evidence of mechanical asphyxiation included in the mechanism of death. 10. The body areas most targeted by perpetrators in sexual assault are the head, neck and upper limbs. 11. The majority of the minor genital injuries comprise abrasions and lacerations to the posterior fourchette and introitus.

Includes bibliographical references
Deaths in police custody are a global phenomenon which continues to beset policing services worldwide. Research into these deaths has provided insight into the complexity of detention and led to the institution of preventative strategies which have seen a reduction in mortality internationally. An improved understanding of the South African detention milieu may similarly assist in reducing the mortality burden in this country. This study retrospectively reviewed deaths in custody in the Cape Town Western Metropole between 2000 and 2009, with the aim of identifying local, modifiable factors to aid in death prevention. Sixty two (62) cases were reviewed. Males predominated (90.3%) in the sample, with the racial profile mirroring that of the general population. The median age of the detainees was 30.5 years. Unnatural causes of death accounted for 82% (n=51) of cases, with suicidal hanging the commonest cause (n=40). Items of clothing were used as ligatures in 80% of hangings, with gate and window bars the most common points of suspension. Time in detention averaged 863 minutes for the sample. Clinical signs of intoxication at the time of arrest was identified as a statistically significant determinant (p=0.02) of a shorter detention time (446 minutes). Ten (10) detainees were identified as either injured at the time of arrest or physically ill during detention, of which 9 succumbed to their injuries or disease. Only three of these detainees received medical attention. These findings highlight the need for urgent review of local police cell architecture to ensure an environment conducive to safe detention, with particular attention to reducing potential points of suspension for hangings. Further, the healthcare needs of detainees must be prioritised through effective training of police personnel with regard to the assessment and management of ill detainees, particularly those intoxicated at the time of arrest.

Background: Violence against women (VAW) is the most pervasive human rights abuse and a global health threat. The most extreme forms of physical and sexual violence are the intentional killing of a woman (femicide) and rape, or the combination of both in the form of r ape homicide, preferably termed 'sexual homicide' in this study. Motivation: Martin's research in 1999 reported a rape homicide incidence rate of 12.3/1000 female rapes reported to the police in Cape Town while the National study performed by Abrahams et al in 1999 reported an incidence rate of 10.9/1000 female rapes reported to the police in South Africa (SA). These high incidence rates, definitional problems, methodological limitations, changes in the law, and inconsistent management of suspected sexual homicides motivated the author to undertake this follow - up study. Objectives: To describe the epidemiology and pathology of femicides in Cape Town and thereby identify risk factors, magnitude and criteria for suspected sexual homicides. Design and Methodology : This is a retrospective descriptive study. Data was collected from autopsy reports of female bodies admitted at Salt River Forensic Pathology Laboratory in Cape Town from the years 2000 to 2009. A 10 - year period improves the sample size and the validity of the results. Limitations : Time constraints led to inadequate information on perpetrators of femicides and therefore a report on intimate femicide is limited in this study. Main findings and Discussion: Results showed an average femicide incidence rate of 12.4/100,000 female population in Cape Town Western Metropole which is half the South African national incidence for 1999, equates to the 2009 national rate and is almost five times the global average. Sexual homicide was suspected in 19.9% of all femicides, slightly higher than the 16.3% previously reported by Martin for Cape Town. The median age of victims was 32 years. Most femicide victims died from gunshot injuries (35.2%) followed by those who were stabbed (29.6%), while the majority (35.7 %) of victims of suspected sexual homicide died from asphyxial deaths, including strangulation. Taking specimens for the Sexual Assault Evidence Collection Kit correlated significantly with genital (77.7%) and anal injuries (64.5%), and 41% of femicide victims had alcohol levels above 0.05g%. Conclusion: The incidence of femicide and sexual homicide in Cape Town is higher than previously reported. Gun violence and alcohol abuse are persistent problems. Recommendations : Findings should be used to motivate for intersectoral collaboration in the form of female homicidal death review (FHDR) teams. These teams should aim to develop standardised guidelines for the forensic management, prosecution, prevention and monitoring strategies for femicides and sexual homicides in South Africa.

DNA has become a powerful forensic tool for solving cases such as linking a suspect to a crime scene, resolving biological relationship issues and identifying disaster victims. Traditionally, DNA investigations mainly involve two steps; the establishment of DNA profiles from biological samples and the interpreta-tion of the evidential weight given by theses DNA profiles. This thesis deals with the latter, with focus on models for assessing the weight of evidence and the study of parameters affecting these probability figures. In order to calculate the correct representative weight of DNA evidence, prior knowledge about the DNA markers for a relevant population sample is required. Important properties that should be studied are, for example, how frequently certain DNA-variants (i.e. alleles) occur in the population, the differences in such frequencies between subpopulations, expected inheritance patterns of the DNA markers within a family and the forensic efficiency of the DNA markers in casework. In this thesis we aimed to study important population genetic parameters that influence the weight of evidence given by a DNA-analysis, as well as models for proper consideration of such parameters when calculating the weight of evi-dence in relationship testing. We have established a Swedish frequency database for mitochondrial DNA haplotypes and a haplotype frequency database for markers located on the X-chromosome. Furthermore, mtDNA haplotype frequencies were used to study the genetic variation within Sweden, and between Swedish and other European populations. No genetic substructure was found in Sweden, but strong similari-ties with other western European populations were observed. Genetic properties such as linkage and linkage disequilibrium could be im-portant when using X-chromosomal markers in relationship testing. This was true for the set of markers that we studied. In order to account for this, we pro-posed a model for how to take linkage and linkage disequilibrium into account when calculating the weight of evidence provided by X-chromosomal analysis. Finally, we investigated the risk of erroneous decisions when using DNA in-vestigations for family reunification. We showed that the risk is increased due to uncertainties regarding population allele frequencies, consanguinity and compet-ing close relationship between the tested individuals. Additional information and the use of a refined model for the alternative hypotheses reduced the risk of making erroneous decisions. In summary, as a result of the work on this thesis, we can use mitochondrial DNA and X-chromosome markers in order to resolve complex relationship in-vestigations. Moreover, the reliability of likelihood estimates has been increased by the development of models and the study of relevant parameters affecting probability calculations.

Introduction: In South Africa (SA), the forensic sector faces significant challenges including how to meet increasing public expectations for high quality, reliable and valid scientific and medico legal results, whilst dealing with increasing caseloads and restricted resources in a developing country. Internationally, lean six-sigma and/or business-based frameworks have been developed to define, measure and analyse the efficiency, effectiveness and output of forensic laboratories, so as to assess performance to meet such challenges. Aim: This pilot project aimed to investigate the effectiveness and efficiency of forensic pathology practice at Salt River Mortuary (SRM) by applying lean six sigma principles (define, measure, analyse and improve) and FORESIGHT metric analyses to retrospective case and staffing data, as well as prospective observational analyses. Methods: A retrospective analysis of cases admitted to Salt River Mortuary in 2015 was conducted to define and measure a snapshot of forensic pathology practice in Cape Town. In addition, observations of autopsy processes were conducted to identify bottlenecks in the system and provide suggestions for improvement. Results: An analysis of post-mortem report turn-around for 3567 cases admitted to SRM in 2015 showed that approximately 10% of cases were closed (cause of death was determined) on the day of the post-mortem, 65% within 14 days and 80% closed within a 30 day period. Certain requested ancillary investigations delayed the finalisation of cause of death; for example, only 8.33% of carbon monoxide testing and 30.31% of histological examinations were completed within the year. A process map outlining autopsy practices at SRM was generated through observational data, which also identified key bottlenecks in the process (e.g.: equipment issues). Preliminary financial data suggested that it cost on average R16 155.03 per case. Staff data demonstrated a lack of pathologists compared to other staff categories and high case load requirements. Discussion: This pilot study investigates the utilization of metrics and strategic frameworks to assess forensic pathology processes in Cape Town. This study offers a cross-sectional insight into financial performance, efficiency and effectiveness of post-mortem investigations at SRM, highlighting bottlenecks and inefficiencies, and providing suggestions for improvement. The findings will assist in forming a basis for future work into the development of a framework for monitoring performance and progress, and developing benchmark standards for the death investigation system in South Africa

Objectives This thesis is based on 4 papers that were all written with the same intent, which was to describe and demonstrate how epidemiologic concepts and data can serve as a basis for improved validity of probabilistic conclusions in forensic medicine (FM). Conclusions based on probability are common in FM, and the validity of probabilistic conclusions is dependant on their foundation, which is often no more than personal experience. Forensic epidemiology (FE) describes the use and application of epidemiologic methods and data to questions encountered in the practice of FM, as a means of providing an evidence-based foundation, and thus increased validity, for certain types of opinions. The 4 papers comprising this thesis describe 4 unique applications of FE that have the common goal of assessing probabilities associated with evidence gathered during the course of the investigation of traumatic injury and death.   Materials and Methods Paper I used a case study of a fatal traffic crash in which the seat position of the surviving occupant was uncertain as an example for describing a probabilistic approach to the investigation of occupant position in a fatal crash. The methods involved the matching of the occupants’ injuries to the vehicular and crash evidence in order to assess the probability that the surviving occupant was either the driver or passenger of the vehicle at the time of the crash. In the second and third papers, epidemiologic data pertaining to traffic crash-related injuries from the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) was used to assess the utility and strength of evidence, such as vehicle deformation and occupant injury of a particular severity and pattern, as a means of assessing the probability of an uncertain issue of interest. The issue of interest in Paper II was the seat position of the occupant at the time of a rollover crash (similar to Paper I), and the association that was investigated was the relationship between the degree of downward roof deformation and likelihood of a serious head and neck injury in the occupant. The analysis was directed at the circumstance in which a vehicle has sustained roof deformation on one side but not the other, and only one of the occupants has sustained a serious head or neck injury. In Paper III the issue of interest was whether an occupant was using a seat belt prior to being ejected from a passenger vehicle, when there was evidence that the seat belt could have unlatched during a crash, and thus it was uncertain whether the occupant was restrained and then ejected after the seat belt unlatched, or unrestrained. Of particular interest was the relative frequency of injury to the upper extremity closest to the side window (the outboard upper extremity [OUE]), as several prior authors have postulated that during ejection when the seat belt has become unlatched the retracting seat belt would invariably cinch around the OUE and cause serious injury. In Paper IV the focus of the analysis was the predictability of the distribution of skull and cervical spine fractures associated with fatal falls as a function of the fall circumstances. Swedish autopsy data were used as the source material for this study. Results In Paper I the indifferent pre-crash probability that the survivor was the driver (0.5) was modified by the evidence to arrive at a post-test odds of 19 to 1 that he was driving. In Paper II NASS-CDS data for 960 (unweighted) occupants of rollover crashes were included in the analysis. The association between downward roof deformation and head and neck injury severity (as represented by a composite numerical value [HNISS] ranging from 1 to 75) was as follows: for each unit increase of the HNISS there were increased odds of 4% that the occupant was exposed to >8 cm of roof crush versus <8 cm; 6% for >15 cm compared to <8 cm, and 11% for >30 cm of roof crush compared to <8 cm. In Paper III NASS-CDS data for 232,931 (weighted) ejected occupants were included in the analysis, with 497 coded as seat belt failures, and 232,434 coded as unbelted. Of the 7 injury types included in the analysis, only OUE and serious head injury were found to have a significant adjusted association with seat belt failure, (OR=3.87, [95% CI 1.2, 13.0] and 3.1, [95% CI 1.0, 9.7], respectively). The results were used to construct a table of post-test probabilities that combined the derived sensitivity and (1 - specificity) rates with a range of pre-crash seat belt use rates so that the results could be used in an investigation of a suspected case of belt latch failure. In Paper IV, the circumstances of 1,008 fatal falls were grouped in 3 categories of increasing fall height; falls occurring at ground level, falls from a height of <3 meters or down stairs, and falls from ≥3 meters. Logistic regression modeling revealed significantly increased odds of skull base and lower cervical fracture in the middle (<3 m) and upper (≥3 m) fall height groups, relative to ground level falls, as follows: (lower cervical <3 m falls, OR = 2.55 [1.32, 4.92]; lower cervical ≥3 m falls, OR = 2.23 [0.98, 5.08]; skull base <3 m falls, OR = 1.82 [1.32, 2.50]; skull base ≥3 m falls, OR = 2.30 [1.55, 3.40]). Additionally, C0-C1 dislocations were strongly related to fall height, with an OR of 8.3 for the injury in a ≥3 m fall versus ground level. Conclusions In this thesis 4 applications of FE methodology were described. In all of the applications epidemiologic data resulting from prior FM investigations were analyzed in order to draw probabilistic conclusions that could be reliably applied to the circumstances of a specific investigation. It is hoped that this thesis will serve to demonstrate the utility of FE in enhancing evidence-based practice in FM.

Post mortem imaging (PMI) is increasingly being adopted as an alternative to invasive autopsies in forensic pathology. PMI can be used as a sole technique or adjunct to an autopsy. The Lodox Xmplar-dr is an X-ray imaging system that has been adopted for use in PMI. The purpose of this study was to evaluate the perceived usability of this imaging system by focusing on the satisfaction of forensic pathologists in use of the system. Assessment of satisfaction was guided by the subjective satisfaction characteristics of likability, pleasure, comfort and trust. Incorporation of user needs into updated system designs may lead to greater perceived ease of use, acceptance and adoption, resulting in increased device utilisation. The study location was the Lodox Xmplar-dr installation site at the Salt River Forensic Laboratory, Cape Town. Five forensic pathologists were observed using the Xmplar-dr system and four were interviewed on their experience using the system. A qualitative research design which used thematic analysis with the aid of NVIVO11 qualitative data analysis software was used to extract key usability and satisfaction themes emerging from the data, to show the extent of user satisfaction. Two key themes emerged. These were categorised as forensic pathologist-related, which focused on the hedonistic and subjective aspects of their satisfaction with the system, and systemrelated, which centred on the satisfaction users derived from the system’s ability to meet their pragmatic and objective expectations in their use of the system. In general, the forensic pathologists were satisfied with the Xmplar-dr system and it exceeded their expectations. Pleasure was derived from the ability of the system to increase work throughput by reducing the need to perform a dissectional post-mortem unless it was deemed absolutely necessary, i.e. when cause of death could not be determined from the X-ray images generated by the system. Participants felt that the system was an indispensable device when performing post mortems. Likability came from the ease of learning to use the basic functions of the system; the study participants stated that the system aided them in determining cause of death and saved time, in line with the definition of the likability characteristic that is centred on the extent to which a user is satisfied with perceived achievements of pragmatic goals. Trust was derived from participants’ views that the system worked as intended, although there could be improvements in terms of robustness, reliability and the imaging system`s support services. Image manipulation on the human-computer interface (HCI) and image representation were concerns highlighted. Most functions could be performed through the system’s HCI rather than by manipulation of the body being examined; this increased the physical comfort satisfaction characteristic. The need for manual placement of bodies on the system`s table by assistants and the associated health consequences were however raised as a concern that diminished the comfort-in-use characteristic of satisfaction. Understanding the user experience of the forensic pathologists who use the Lodox Xmplar-dr system to perform post mortems enabled the identification of areas for improvement. The improvements may increase user satisfaction resulting in better utilisation of the imaging system. The insights gained may be useful for the design of other imaging systems used in forensic pathology.

Although forensic biology is a powerful tool in criminal investigations, there are a number of capability gaps; namely, the interpretation of low-level DNA mixtures, associating the DNA profile with a body fluid, and the issue of consent in sexual offences. A research strategy was developed that utilises whole genome amplification (WGA), messenger RNA and microRNA analysis, DNA profiling, and clothing damage analysis. An evaluation of a WGA technique – multiple displacement amplification - with and without a macromolecular crowding agent, indicated that this may be of use for DNA samples containing certain mixing ratios; however, for this to be truly of use, knowledge of the nature of the sample preanalysis is required, which is not feasible in a forensic environment. A SYBR Greenbased mRNA gene expression test was developed that was capable of distinguishing between saliva and blood by using relative quantitation on real-time PCR. However, the low specificity of the SYBR Green meant that a higher number of controls were required for this to work at forensic standard. A single channel simultaneous analytical test for DNA and microRNA was also developed, which meant that it could be possible to definitively identify the body fluid origin of a DNA profile. This represented a significant step forward in improving forensic biology capability. Reconstruction studies were carried out in response to a sexual assault case where consent was an issue. This study demonstrated that it was possible to cause significant damage to a bra without causing damage to the hook and eye fastening; thus, negating a hypothesis offered by the defence. A long term research strategy has been developed and significant progress has been made in improving the capability of the operational forensic biologist.

Forensic science is growing rapidly in the world today. During the past decade, medico-legal investigations have been highly expanded to include all areas of forensic science. The present study investigated three important aspects of forensic biology. First, this present project investigated, a total number of 5,703 reported medico-legal cases diagnosed as un-natural deaths by The Forensic Department in Kuwait, during the year 2003-2009. The results show that accidental, homicidal and suicidal deaths accounted for 86%, 8% and 6%, respectively. The results showed that most people who died of unnatural deaths were more predominant in the age group 20-29 years (third decade). Road Traffic Accidents accounted for 65% of accidental deaths, and 4% out of them were related to alcohol consumption. The results also illustrated that the highest rate of homicide in Kuwait was due to stab wound injuries (38%) compared to the lower rate of homicidal pattern for infanticides (3%). Similarly, the study showed that the most common method of suicide in Kuwait was death by hanging and this accounted for (60%). This study further demonstrated the effectiveness of virtual autopsy technique as a new tool in forensic investigations to determine various un-natural death causes. A total of thirty (30) male forensic cadavers were employed in this project. The cases were RTA (11), firearm injuries (10), drowning (4), head injuries (3) and lastly strangulation (2). All these cases were compared to the findings of traditional autopsy. The results show similar findings for virtopsy compared to traditional autopsy. This study clearly revealed that virtopsy could be an effective alternative in certain situation, being noninvasive and rapid. The present project also investigated 28 samples of human blood, saliva or semen. The experiments were done at four different temperatures (55°C, 37°C, 24°C and 4°C) and four different humidity ranges (41%, 55%, 58% and 61%), respectively. The results showed that, DNA quantity in blood, saliva and semen samples remained more or less the same at temperatures of 4°C, 24°C and 37°C compared to values for day one with all other days. In contrast, when the temperature was raised to 55 °C, the DNA started to degrade with time until it reached zero at day 12 for saliva and day 15 for blood, but not for semen. The results clearly show that DNA in saliva and blood samples is extremely sensitive to heat compared to semen. In conclusion, the study reveals the different causes of unnatural deaths, the value of virtual autopsy and the need for early DNA measurement in Kuwait.

Forensic facial reconstruction can assist identification by reconstructing a face of the unknown person with the aim of its recognition by his/her family or friends. In the facial reconstruction approach adopted in this study, a 3D average face template was digitally warped onto a 3D scanned skull image. This study was carried out entirely on an Egyptian population, and was the first of its kind. Aims: This study aimed to demonstrate that 3D facial reconstructions using the novel methodology described could show significant resemblance to the faces corresponding to the persons in question when they were alive. Moreover, using techniques previously validated for facial reconstruction, the aim was to compare them to the method developed, and to assess approaches used to determine the accuracy of 3D facial reconstructions. Methods: Initially, a pilot study was conducted using a database of laser scanned skulls and faces. The faces were reconstructed using an average facial template generated by merging a number of faces of similar population, sex, and age. The applicability, as well as the main components of the facial reconstruction method, the single and average facial templates, and the facial soft tissue thickness measurements, were investigated. Furthermore, in the main study, the faces of computed tomography (CT) scanned heads of an Egyptian population were reconstructed using average facial templates. The accuracy of the reconstructed faces was assessed subjectively by face pool, and face resemblance tests, and objectively by measuring the surface distances between the real and reconstructed faces. In addition, a number of novel subjective and objective assessment methods were developed. These included assessment of individual facial regions using subjective resemblance scores, and objective surface distance comparisons. A new objective method, craniofacial anthropometry, was developed by taking and comparing direct measurements from the skull, and comparing the measurements from the real and reconstructed faces. The studied cases were ranked according to all subjective, and objective, tests, and statistically correlated. Results and Conclusions: The average facial templates showed a higher identification rate than the single face templates. The approach of facial reconstruction used in this thesis showed a comparable accuracy to many other facial reconstruction methods, yet was superior in terms of its applicability, transferability, and ease of use. In the face pool tests, the younger assessors were able to correctly identify the reconstructed faces better than older assessors. Furthermore, the identification rate by the forensic anthropology experts was higher than the non-experts. The former group showed the highest agreement between the observers in giving the resemblance scores. Although there was a significant rank correlation between the subjective and objective assessment tests, the subjective tests are influenced by the assessors' subjective characteristics (e.g., age, professional experience), thus making objective assessment more reliable. However, in situations where subjective tests are used, it is better to use the face resemblance tests and consult forensic anthropologists. Also, Craniofacial Anthropometry, particularly the craniofacial angles, can successfully indicate the accuracy of the facial reconstructions. Importantly, this study shows that certain facial regions, particularly the cheek and the jaw, are more reliable than other areas in the subjective and objective assessment of the facial reconstruction.

South Africa has one of the highest prevalences of drug misuse and abuse in Africa. Salt River Mortuary (Cape Town, South Africa), along with other national Forensic Pathology Service providers, receives many cases of suspected drug-related deaths. In some cases, the traditional autopsy – when viewed together with the decedent's history – is not able to indicate whether a drug-related death is accidental or suicidal in relation to altered drug metabolism. Literature has shown that this can be investigated by sequencing gene(s) encoding the implicated metabolising enzyme(s) in a postmortem genetic analysis. However, as such an analysis would normally be performed following the obtainment of postmortem toxicological results, it is imperative to investigate whether blood samples retrieved back from a toxicology laboratory would be sufficient for the said genetic analysis, despite the handling involved in the process of toxicological investigation. To this end, blood samples from 30 deceased individuals in which drug use/abuse may have contributed to death, were collected into two red-top tubes (plain), two grey-top tubes (containing sodium fluoride and potassium oxalate) and one EDTAcontaining purple-top tube (control). DNA was immediately extracted from one of each colour tube, while the duplicate red-top and grey-top tubes first underwent a process of toxicological analyses, and then underwent DNA extraction. The concentration, degradation, purity, contamination, and quality of DNA were assessed using real-time PCR, spectrophotometry, forensic DNA profiling, and Sanger sequencing. In contrast to the grey-top tubes, the results showed that the red-top tubes were most suitable for the aforementioned genetic analysis. Overall, the study not only demonstrated that postmortem genetic analysis using samples retrieved from a toxicology laboratory is possible in the local context, but also provided guidelines around the pre-analytical phase of the analysis. These results illustrate the opportunity to investigate these toxicogenetic avenues further, particularly in future expansion of services currently provided at Salt River Mortuary, which may provide families more information about circumstances of their relative’s death.

Drug use is a major burden in Cape Town, South Africa, and at times may be fatal. Individuals suspected to have demised from drug intoxication are referred for medico-legal investigation, in order for cause of death to be determined. Sometimes, it remains ambiguous as to whether the drug intoxication was suicidal or accidental, even after a full post-mortem examination. Literature has shown that molecular analysis of genetic variants in genes encoding for drug metabolising enzymes may provide insight into the manner of death. At Cape Town’s Salt River Mortuary, numerous toxicological-related cases yield ambiguous results, which may potentially be resolved with molecular analyses. However, no optimised molecular assay to sequence drug metabolising enzymes currently exists in a local context. The aim of this project was to design and optimise a molecular-based assay to sequence the drug metabolising enzyme, CYP2D6. Subsequent to primer design, exons in CYP2D6 were amplified and sequenced. The optimised assay was then applied to DNA from two decedents suspected to have demised from drug intoxication. Following a toxicological drug screen, certain drugs metabolised by CYP2D6 were reported. The assay revealed genetic variants within CYP2D6; both individuals were heterozygous for 138insT, rendering one allele in each individual defective. While one decedent also exhibited variants with normal and unknown haplotypes, the other decedent was homozygous for *17 (decreased functionality), overall making the former an intermediate (altered) or extensive (normal) metaboliser and the latter, an intermediate metaboliser of specific drugs. Quantitative toxicological results were unavailable; consequently, the contribution of the metabolism phenotype on death in these cases could not be established. However, the genetic variants, combined with the presence of these drugs in each case, suggests altered drug metabolism, which should be investigated further and interpreted within each case context. These findings would also be beneficial to the decedents’ living relatives, who may also carry these variants. Overall, this study demonstrates the value of molecular analyses in forensic investigations of toxicological-related fatalities, and lays the foundation for additional future research, particularly since the molecular assay has now been successfully optimised.

The work described in this thesis deals with three aspects of quality assurance in the field of forensic toxicology: proficiency testing schemes, validation of analytical methods for the piperazine group of abused drugs and validation of the police field impairment test, used at the roadside to test drivers for drug-induced impairment. Proficiency Testing: Long term reviews were performed for two forensic external quality assurance schemes. Rounds 30 (in 2007) to 48 (in 2012) of the UKAS-accredited commercial Quartz Forensic Blood Toxicology Proficiency Testing Scheme (PTS), and a ten year period from 1999 to 2009 of the freely-available United Nations Office on Drugs and Crime (UNODC) International Collaborative Exercises (ICE). Only limited ICE data could be made available as much of the original data had been stored on a database which had become obsolete, hence the data were only available as the original results forms provided to UNODC by the ICE participants. Data was entered to Microsoft Excel® spreadsheets and Microsoft Access® databases from the original forms for the years 1999, 2001 (2 rounds), 2003 (2 rounds) and 2005 (2 rounds), and summary data was extracted from the UNODC round reports for the years 2007, 2008 and 2009. Four methods of scoring quantitative performance were reviewed and the most suitable, a z-score using an assigned ‘true’ value and a percentage of the true value as acceptable deviation, was applied to reanalyse the participants’ results and assess their performance. Methods of scoring proficiency which relied upon participants’ data to determine acceptable variation were found merely to describe the data rather than challenge participants on whether or not they were performing fit-for-purpose analyses. Factors such as participation, analytes tested, participants’ methods of analysis and participants performance were summarised for each scheme before the performance of the two schemes, and that of their participants, were compared. ICE tested more analytes per annum but from a smaller test menu than Quartz. This resulted in more repetitive testing and allowed for some trend analysis and performance monitoring. It was not possible to observe performance trends with Quartz due to the wide variety of analytes tested. The smaller array of potential analytes and more repetitive nature of ICE testing also meant that performance monitoring and detection of bias were easier to perform, and ICE was shown to be more effective as external quality assurance (EQA). Quartz provided a good educational resource as it incorporated the wide range of drugs which a forensic toxicology laboratory could realistically encounter. Following the review, however, it was recommended for QUARTZ that, to provide a safeguard against bias, more repetitive testing was required and this has now been adopted. Piperazines: All piperazine analogues are now illegal in the UK, registered as Class C of the Misuse of Drugs Act (1971) and schedule 2, part III of the Misuse of Drugs Regulations (2001). Piperazines can elicit similar effects to some ATS and methods for their detection should be available in forensic toxicology laboratories. In the present study, methods were developed for the detection of a range of piperazines in blood using LC-MS/MS (p-MeOPP, p-FPP, BZP, o-MeOPP, p-MPP and TFMPP) and GC-MS (p-FPP, BZP, TFMPP, p-MPP, o-MeOPP, m-CPP, p-MeOPP and p-CPP). Quality assurance required both methods to be validated. For all piperazine analytes accuracy was within ±15% (20% at low concentrations) and precision was within 15% (20% at low concentrations). For both methods LLOD of all analytes was 5 ng/ml of blood and upper limit of quantification was 2 µg/ml of blood. For the GC-MS method lower limits of quantification (LLOQs) were in the range 20 to 30 ng/ml of blood. For LC-MS/MS, LLOQs ranged from 50 to 60 ng/ml of blood, although quantification by the LC-MS/MS method was restricted by the lack of availability of appropriate internal standards. There were no apparent significant matrix effects and recovery by both methods was >60 % and, therefore, acceptable. Short term stability of the piperazine analytes was investigated. Piperazines remain sufficiently stable when stored in the fridge for at least one week, and are stable through three freeze-thaw cycles. There was no detectable degradation when blood samples were left on the bench-top or when extracted ‘in-process’ samples were left in the autosampler for up to 72 hours. The LC-MS/MS method could provide a readily applicable screening method. A small aliquot of a basic drug extract could be screened by LC-MS/MS for the presence of piperazines, leaving the majority of the extract for other analyses, for example, piperazines confirmation or amphetamines analysis. The GC-MS method was suitably validated to provide quantification but application to casework samples remains to be evaluated. It is recommended that piperazine testing be performed for all suspected MDMA or ‘club drug’ intoxication cases. The Field Impairment Test: The detection of drugged drivers primarily depends on the current method which is the driver field impairment test (FIT). FIT comprises measurement of pupil diameter and four physical tasks (the Romberg balance test, walk and turn test, one legged stand and finger to nose test) intended to simultaneously test comprehension, short term memory, balance and motor function. Despite FIT having ISO accreditation, it has been recognised that police officers lack confidence with the protocol and do not apply the test as often as is necessary. The main difficulty arises from the requirement to make a subjective judgement of impairment and officers lack confidence in their ability to do so. FIT has never been fully validated. The present study was designed to meet the urgent requirement to develop FIT into an objective measurement, by determining what constitutes “normal” performance in FIT by unimpaired adults of different ages. FIT performance was recorded for 79 individuals, a statistically determined cohort size, confirmed by breath and oral fluid analysis not to be under the influence of impairing substances. Each error made during FIT, as defined by the FIT standard operating procedure, was recorded and collated in a Microsoft Excel® spreadsheet for analysis. It was found that the definition of ‘errors’ was too stringent as many which are required to be recorded are normal physiological or behavioural characteristics, such as body sway, and most subjects would be unable to complete the task without displaying them. A less stringent, evidence-based definition of “error” was developed which allowed statistically more significant analysis to be performed on the FIT results. A statistically significant difference (P=0.00578) was shown to exist between the FIT performance of individuals under the age of forty years and those aged forty and over. Based on the principles of a PTS, robust mean and standard deviation were used to determine what constituted acceptable performance. Those in the younger age group could be considered impaired if the police officer witnessed more than seven errors, or, in the older age group, more than fifteen errors. Using these criteria the frequency of false positives, i.e. unimpaired drivers being assessed as impaired is estimated to be (less than 3%). Also, the ranges of errors observed in both groups was large and overlapped, such that it may be possible for an impaired person to appear unimpaired. This requires further investigation.

The identification and management of individuals with a perceived high risk of future violence is of great priority for mental health professionals and the criminal justice system. The overall aim of this thesis is to examine the validity of the assessment and treatment of violence in forensic populations with a specific focus on the contribution of dynamic risk factors in predicting recidivism. Chapter One presents a conceptual literature review which provides an overview of the development of violence risk assessment approaches, and examines the predictive validity of dynamic factors in predicting violent recidivism. The review demonstrates the ability of dynamic risk factors in predicting future community and institutional violence. Chapter Two provides a critique of the HCR-20 Risk Assessment Scheme and highlights that despite some apparent shortcomings of the HCR-20, the instrument remains the best known and best researched, empirically based guide to violence risk assessment. In Chapter Three a prospective research study examines the predictive validity of the HCR-20 Risk Assessment Scheme in a UK sample of patients under the care of a community forensic mental health service. The study aimed to examine the ability of the HCR-20 total scores and individual sub scale scores to predict future acts of violence. The study demonstrates that the historical factors of the HCR-20 are highly predictive of future re-offending within this population and also highlights the importance of the clinical scale in predicting future violent acts. This work adds to current knowledge and understanding of the risk assessment and management process in UK samples. A case study is presented in chapter Four which evaluates the impact of the ETS programme on the cognitive deficits identified in a violent adult male offender (client A) serving a sentence at HMP Birmingham. By Mariam Azam-Zanganeh.

Endometriosis is a puzzling condition responsible for considerable morbidity. The literature is characterised by a large number of reports but there is surprisingly little agreement on the aetiology and pathophysiology. In particular the relationship between mild endometriosis and subfecundity is uncertain. The aim of the studies described in this thesis was to document the incidence, and symptomatology of endometriosis in the fertile and infertile population, to study the natural history of endometriosis in infertile women and to study folliculogenesis, fertilisation and pathophysiology of periovulatory events in spontaneous menstrual cycles. The relevant literature has been extensively reviewed in the first chapter. By using diagnostic laparoscopy, a large group of fertile and infertile women in the premenopausal age group were studied to document the incidence of endometriosis. Endometriosis was more common in the infertile women. Prolonged usage of combined oral contraceptive pill might have a protective effect against the development of endometriosis. A questionnaire based study of menstrual symptomatology concluded that deep dyspareunia was equally frequent among women harbouring pelvic pathology whether endometriotic or post infective in origin, but congestive dysmenorrhoea was more prevalent among women having mild endometriosis. The study of the natural history of endometriosis suggested that among susceptible women the disease will progress despite treatment with danazol or with diathermy ablation but disease progression was much worse if patients were left untreated. A group of 21 women with primary infertility of more than 3 years duration were extensively studied over two consecutive cycles to study folliculogenesis. The majority of these patients had normal follicular development, and had sonographic evidence of ovulation followed by a normal luteal phase. Furthermore no abnormalities of oocyte maturity and fertilisation were noted in the spontaneous cycles studied. Similarly the endocrine milieu provided by follicular and peritoneal fluids was comparable to a control group. The subfecundity in patients with endometriosis remain essentially unexplained.

This thesis examines the use of nail as an alternative biological specimen in forensic toxicology. Nail is a difficult analytical matrix from which to extract drugs because of its tough physical composition, based on keratin. The initial part of the project investigated the use of a cryogenic grinding method for fingernail clippings. Grinding at liquid nitrogen temperatures was found to be an effective procedure and the conditions were optimised to a two or three cycle programme of freezing and grinding. Small particle sizes were obtained of approximate size 1µm. It was established that drugs could be extracted directly from nail powder with a range of solvents without the need for alkaline hydrolysis. Methanol was found to be the most effective extraction solvent, which also gave the lowest number of co-extracted interfering compounds. This procedure was subsequently used with nail samples from different types of forensic cases, including cannabis, heroin and steroid abusers. Cryogenic grinding of nail was evaluated as an extraction method for cannabinoids in nail clippings from chronic cannabis smokers. This method was also compared to the alkaline hydrolysis method. Fingernail clippings were collected with prior informed consent from volunteers attending the Edinburgh Drug Addiction Study (EDAS) clinic. The collected nail clippings were decontaminated and divided into two groups: the first group was extracted with methanol after pulverisation in a liquid nitrogen cryogenic mill; the second was extracted with ethyl acetate after hydrolysis in sodium hydroxide. In both groups deuterated cannabinoids were used as internal standards. Both sets of extracts were derivatised with BSTFA before being analysed by gas chromatography – mass spectrometry (GC-MS). Cannabidiol, ?9-tetrahydrocannabinol and 11-hydroxy-?9-tetrahydrocannibinol were quantified in both sets of extracts. 11-nor-?9 –tetrahydrocannabinol-9-carboxylic acid was only identified and quantified in the extracts resulting from the cryogenic grinding method. Cannabinoid concentrations were very low, in the range 0-4 ng/mg. These results strongly support the use of nail as a biological specimen for the detection and quantification of past exposure to cannabis, and secondly, they indicate that grinding with a cryogenic mill is a useful procedure, which yields simultaneous results for the primary psychoactive cannabinoid and its metabolites. Cryogenic grinding was then evaluated for the extraction of opioids in nail in comparison with the conventional alkaline hydrolysis method. Finger and toe nails were collected from donors with informed consent.

The aim of this study was to investigate new methods of analysis which might be applied to forensic toxicology problems including those resulting from pesticides, particularly the quaternary ammonium herbicide group, and from drugs, particularly the benzodiazepine group. In the first part of this study, an efficient method for the determination of quaternary ammonium (QA) compounds (pesticides and drugs) in human whole blood was developed. The second part of this study concerned the development of a novel sorbents for solid phase extraction using molecularly imprinted polymers (MIPs). The approach adopted was initially to synthesise a known MIP using diazepam as template then to prepare novel MIPs using other benzodiazepines and analogues of QA compounds as templates. In the first of these stages, an anti-diazepam MIP was synthesized using methacrylate acid (MAA) as the monomer and ethylene glycol dimethacrylate (EGDMA) as the cross-liner and was then ground and prepared for use as an SPE sorbent by packing it into SPE cartridges. These cartridges were used to clean up extracts of diazepam and other benzodiazepine drugs made from hair samples via a molecularly imprinted solid-phase extraction (MISPE) protocol. The MISPE method was also found to be applicable to the analysis of diazepam metabolites and other benzodiazepine drugs in addition to diazepam itself. The application of the extraction method to post-mortem hair samples yielded results that were in good agreement with ELISA data (from blood samples) and data arising from the analysis of the same blood samples using a validated in-house SPE-LC-MS-MS method. The MISPE procedure was also compared with a conventional SPE method for analysis of benzodiazepines in hair samples. The results from MISPE protocol showed better selectivity, specificity and accuracy toward diazepam (template molecule) and other benzodiazepines that display a similar resemblance to diazepam in terms of molecular structure. The MISPE procedure was found to be simpler and to offer cleaner extracts compared to a conventional SPE method.