Natural or Violent Death? Deceptive Crime Scene in a Case of Ruptured Varicose Vein

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors, I am very familiar with the pathological entity you describe in this case report. There is not much literature on this subject, and every report can add something to our knowledge. However, I do not believe that the case in its current form can be published, but if you are willing to make the changes requested, the case report will certainly improve, increasing its chances of being published in this excellent journal. I would therefore like to highlight the points that I believe are worthy of modification and that you can certainly address:

The introduction lacks the purpose of your report: what message do you want to convey to the readers of MDPI Forensic Sciences? Perhaps the difficulties encountered in similar cases in understanding the mechanism of lethal vascular injury? How can we arrive at the correct differential diagnosis between natural death and homicide? Or simply to report the case that came to your attention as it is? I believe the purpose of the study should be clearly stated in the introduction.

The case report is too concise: macroscopically, for example, you do not mention hypostasis (in a similar case, I would expect reduced extent and intensity), and there is no description of the lower limbs to verify whether they showed clear signs of chronic venous disease and skin discoloration.

You say that you did not observe any traumatic lesions on the body... I ask: did you see any defensive wounds in case it could have been a homicide? You do not clarify anything in this regard.

You do not report microscopic images of the skin with the injured venous vessel, even though you claim to have performed the histological examination. It would be necessary to include them together with the epicrisis, also for the purpose of chronological dating of the rupture. I would also like to know what stains you performed.

The toxicological examination should be reported (the woman was taking anticoagulants: were they measured?).

As for the pattern of bloodstains (BPA) that you say you studied, you do not explain at all how you came to determine that it was not arterial bleeding but venous bleeding. I would like you to explain clearly how you interpreted the location of the bloodstains, any projection, splatters, or accumulation, and their forensic significance.

The discussions are redundant in some places and deserve to be restructured, also in light of the requested corrections.

Good luck!

Author Response

RESPONSE TO REVIEWERS

 

Reply to Reviewer 1

 

Dear Authors, I am very familiar with the pathological entity you describe in this case report. There is not much literature on this subject, and every report can add something to our knowledge. However, I do not believe that the case in its current form can be published, but if you are willing to make the changes requested, the case report will certainly improve, increasing its chances of being published in this excellent journal. I would therefore like to highlight the points that I believe are worthy of modification and that you can certainly address:

 

1. We appreciate the reviewer's positive comments and interest in the manuscript.

Thank you for your suggestions. We have made the requested changes and additions to the text (written in red). Below are our responses to some of the questions raised by the reviewer. 

 

The introduction lacks the purpose of your report: what message do you want to convey to the readers of MDPI Forensic Sciences? Perhaps the difficulties encountered in similar cases in understanding the mechanism of lethal vascular injury? How can we arrive at the correct differential diagnosis between natural death and homicide? Or simply to report the case that came to your attention as it is? I believe the purpose of the study should be clearly stated in the introduction.

 

1. Thank you for your questions, in accordance as requested, we have integrated the information into the text (red text).

 

The case report is too concise: macroscopically, for example, you do not mention hypostasis (in a similar case, I would expect reduced extent and intensity), and there is no description of the lower limbs to verify whether they showed clear signs of chronic venous disease and skin discoloration.

You say that you did not observe any traumatic lesions on the body... I ask: did you see any defensive wounds in case it could have been a homicide? You do not clarify anything in this regard.

You do not report microscopic images of the skin with the injured venous vessel, even though you claim to have performed the histological examination. It would be necessary to include them together with the epicrisis, also for the purpose of chronological dating of the rupture. I would also like to know what stains you performed.

The toxicological examination should be reported (the woman was taking anticoagulants: were they measured?).

As for the pattern of bloodstains (BPA) that you say you studied, you do not explain at all how you came to determine that it was not arterial bleeding but venous bleeding. I would like you to explain clearly how you interpreted the location of the bloodstains, any projection, splatters, or accumulation, and their forensic significance.

The discussions are redundant in some places and deserve to be restructured, also in light of the requested corrections.

1. Thank you for your questions and for your suggestions, in accordance as requested, we have integrated the information into the text (red text).

We apologise for not including images of the histology, stained with haematoxylin and eosin, but unfortunately they were not of optimal quality.

For the questions regarding the BPA and the distinction between arterial and venous bleeding was critical in this case. As the reviewer notes, arterial bleeding (or arterial spurting) produces highly characteristic, high-pressure patterns. Due to the blood being forcefully ejected from a breached artery in time with the heartbeat, it typically creates distinctive arc-like, gushing, or wavy patterns on surrounding surfaces (especially vertical ones, like walls). These patterns often show a rhythmic sequence corresponding to the systolic pressure. In the case presented, our analysis of the death scene (documented in Figures 1 and 2) revealed a distribution of bloodstains conspicuously lacking any such projected or spurt patterns.  The discussion has been restructured and some redundant partes has been deleted (written in blue).

Reviewer 2 Report

Comments and Suggestions for Authors

I read the article with great interest. The illustrated case is interesting as it describes a generally benign pathology, varicose veins, which, however, in some cases can be unexpectedly fatal. The paper is also interesting because it raises reflections on the careful analysis of the crime scene and on the collection of as much data as possible in order to avoid developing hasty and therefore incorrect conclusions on the real cause of death. However, I think it would be appropriate to expand the introduction by discussing the topic of varicose pathology in more depth and it would also be appropriate to expand the "discussion" section by better describing the difficulties that can be encountered in studying a crime scene with ambiguous characteristics, such as the one described by the authors. 

Check sentence 103-104: better explain the correlation between varicose veins, rupture of varices and  coronary arterie deseases.

Author Response

Reply to Reviewer 2

 

I read the article with great interest. The illustrated case is interesting as it describes a generally benign pathology, varicose veins, which, however, in some cases can be unexpectedly fatal. The paper is also interesting because it raises reflections on the careful analysis of the crime scene and on the collection of as much data as possible in order to avoid developing hasty and therefore incorrect conclusions on the real cause of death. However, I think it would be appropriate to expand the introduction by discussing the topic of varicose pathology in more depth and it would also be appropriate to expand the "discussion" section by better describing the difficulties that can be encountered in studying a crime scene with ambiguous characteristics, such as the one described by the authors. 

Check sentence 103-104: better explain the correlation between varicose veins, rupture of varices and  coronary arterie deseases.

 

1. We appreciate the reviewer positive comments and their expressed interest in the manuscript.

Thank you for your suggestions. We have made the requested changes and additions to the text (written in red).

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,
I have been given the opportunity to review the manuscript "Natural or violent death? The case report of a decepive crime scene.". The manuscript describes a case report in which an 80-year old woman was found deceased in her own appartment. There was a lot of blood in the appartment. The cause of death was assessed as following massive bleeding due to a ruptured varicose vein on the leg. I find the case report interesting and essetiallt well described. Although it is not novel, it still adds interest to the forensic audience with a description of both forensic pathology and blood stain patterns. However, the manuscript can be inmproved.

1. I suggest the title to be more informative on the cause of death.
2. The authors state that their institution do not require ethical approval for anonymized data. However, the case report is not anonymised as there are picures (figure 1) of the deceased in the surrounding with only masking of the area around the eyes. I suggest the authors either further anonymizes the pictures by not including large parts of the deceased. 
3. The pictures contains colored markings, however these are to som extent hard to see clearly. As an example in figure 1b there should be an orange panel, this I cannot see.
4. Please add information on medication, e.g. anticoagulation or other.
5. Please add information on preexisting disease.
6. It is stated that there we no evidence of recent myocardial infarct or other significant disease. As such it would be relevant to state the status of the vasculature - koronarsclerosis? other?
7. Something is missing in the sentence on page 4, row 104.
8. On page 4, row 110-114 it is stated that large amount of blood on the scene of a deceased due to varicose veins can be misinterpreted by first responders as a "homicidal" scene. I think this is actually good, it means that first responders act accordingly and contacts the police when such a scene is observed. In my opinion first responders should not start to try to explain such a scene, but leave it to the police and the medicolegal examiner.
9. In the start of the discussion it is stated that reamining upright can increae the venous return, could you formulate this more clearly. Do you mean that the body part in which the lesions is located is placed low so that blood will drain following gravity

Author Response

Reply to Reviewer 3

 

Dear Authors,

I have been given the opportunity to review the manuscript "Natural or violent death? The case report of a decepive crime scene.". The manuscript describes a case report in which an 80-year old woman was found deceased in her own appartment. There was a lot of blood in the appartment. The cause of death was assessed as following massive bleeding due to a ruptured varicose vein on the leg. I find the case report interesting and essetiallt well described. Although it is not novel, it still adds interest to the forensic audience with a description of both forensic pathology and blood stain patterns. However, the manuscript can be inmproved.

 

1. We appreciate the reviewer's positive comments and interest in the manuscript. Thank you for your suggestions. We have made the requested changes and additions to the text (written in red). Below are our responses to some of the questions raised by the reviewer.

 

1. I suggest the title to be more informative on the cause of death.

 

R Point 1. Thank you for your kind suggestions. As requested, the title has been restructured and the sentence has been modified to improve clarity (written in red).

 

2. The authors state that their institution do not require ethical approval for anonymized data. However, the case report is not anonymised as there are picures (figure 1) of the deceased in the surrounding with only masking of the area around the eyes. I suggest the authors either further anonymizes the pictures by not including large parts of the deceased.

 

 

R point 2. Thank you for your kind suggestions. Furthermore, at the publisher's request, the point regarding consent has been incorporated into the relevant section of the manuscript.

 

3. The pictures contains colored markings, however these are to som extent hard to see clearly. As an example in figure 1b there should be an orange panel, this I cannot see.

 

1. point 3 Thank you for your kind suggestions.

The reviewer is correct that the orange panel, which identifies the 'pool' in Figure 1a, is not present in Figure 1b. This was an intentional choice.

Figure 1b is a close-up detail of the decedent's foot and slipper, which are located within the large blood pool identified by the orange border in the main, wide-angle image (Figure 1a). We decided to omit the orange border in this specific detail view (1b) because we felt that adding multiple-colored panels to the close-up would clutter the image and make it difficult for the reader to observe the fine details of the slipper and the bloodstains on the ankle itself. The purpose of Figure 1a was to label the overall scene patterns, while 1b was intended to show the specific source area more clearly.

 

4. Please add information on medication, e.g. anticoagulation or other.

 

1. point 4 Thank you for your questions. As requested, we have incorporated the information regarding the specifications of the drugs taken and toxicology into the text (text in red)

 

5. Please add information on preexisting disease.

 

1. point 5 Thanks for the suggestion. We've added the data to the text (written in red).

 

6. It is stated that there we no evidence of recent myocardial infarct or other significant disease. As such it would be relevant to state the status of the vasculature - koronarsclerosis? other?

 

1. point 6 Thank you for your questions, in accordance as requested, we have integrated the information into the text (red text).

 

 

7. Something is missing in the sentence on page 4, row 104.

 

R Point 7. Thank you for your suggestion, the sentence has been restructured (written in red).

 

8. On page 4, row 110-114 it is stated that large amount of blood on the scene of a deceased due to varicose veins can be misinterpreted by first responders as a "homicidal" scene. I think this is actually good, it means that first responders act accordingly and contacts the police when such a scene is observed. In my opinion first responders should not start to try to explain such a scene, but leave it to the police and the medicolegal examiner.

 

 

R Point 8. Thank you, we agree with the reviewer's comment.

 

9. In the start of the discussion it is stated that reamining upright can increae the venous return, could you formulate this more clearly. Do you mean that the body part in which the lesions is located is placed low so that blood will drain following gravity

 

1. point 9 Thank you for your questions. As requested, the sentence has been modified to improve its clarity and coherence (written in red).

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors
I thank you for the amendments.

1. As suggested previously I recommend that the pictures of the deceased are further masked in the regions of the breasts and genitialia.

Author Response

Response to reviewer 3

Comment 1: Dear Authors,  I thank you for the amendments. As suggested previously I recommend that the pictures of the deceased are further masked in the regions of the breasts and genitialia

R.  Sorry. We have modified the pictures as requested. Thank you again.