J Forensic Sci, July 2014, Vol. 59, No. 4 doi: 10.1111/1556-4029.12451 Available online at: onlinelibrary.wiley.com
PAPER PATHOLOGY/BIOLOGY
Fiona M. Bright,1 B.Hth.Sci. (Hons).; Calle Winskog,1 M.D.; Melissa Walker,1 B.Sc.; and Roger W. Byard,1 M.D.
A Comparison of Hypothermic Deaths in South Australia and Sweden
ABSTRACT: Case files from Forensic Science South Australia and the Swedish National Forensic Database were reviewed over a 6-year
period from 2006 to 2011 for cases where hypothermia either caused, or significantly contributed to, death. Data were analyzed for age, sex, time of year/season, place of discovery, circumstances of death, and underlying medical conditions. Despite the considerable demographic, geographic, and climatological differences, hypothermic deaths occurred at very similar rates in South Australia (3.9/100,000) and Sweden (3.3/ 100,000). Deaths from hypothermia in South Australia occurred predominantly indoors at home addresses, involving elderly females with multiple underlying illnesses and limited outside contacts. In contrast, Swedish hypothermic deaths generally occurred outdoors and involved middle-aged elderly males. These data show that hypothermia may be a risk in warmer climates particularly for elderly, socially isolated individuals.
KEYWORDS: forensic science, hypothermia, temperate climate, social isolation, illness, senile squalor syndrome Hypothermia is defined as a decrease in core body temperature below 35°C. It develops when regulatory mechanisms such as vasoconstriction and heat production fail to compensate for heat loss to the environment (1–3). Deviation in core body temperature below normal levels has significant effects on thermoregulation, with fatal hypothermia occurring at temperatures of 26° to 29°C. Death results from myocardial ischemia and/or hypoxia exacerbated by electrolyte imbalances and increased catecholamine levels (1–3). Although it has been recognized that fatal hypothermia is not limited to cold climates or to winter months (4,5), it is often assumed that the risk increases with decreasing environmental temperatures; that is, death from hypothermia is more likely to occur in colder Scandinavian countries than in the warmer nonAlpine regions of Australia. To test this hypothesis, the following study was undertaken. Materials and Methods Forensic case file information was obtained from Forensic Science South Australia and the Swedish National Forensic database between January 2006 and December 2011 using an electronic search for the terms “hypothermia” and “Wischnewski spots.” Cases in which hypothermia was identified as a primary cause of, or a significant contributing factor to, death, and in which there were positive pathological findings of hypothermia were included in the study. Pathological abnormalities included Wischnewski spots of the gastric mucosa, pancreatitis and skin discoloration
1 Discipline of Anatomy and Pathology, The University of Adelaide, Frome Road, Adelaide, SA 5005, Australia. Received 8 Nov. 2012; and in revised form 4 June 2013; accepted 22 June 2013.
© 2014 American Academy of Forensic Sciences
over joints. Cases where no pathological features were present were excluded from the study unless the circumstances of death were strongly suggestive of lethal hypothermia (e.g., an intoxicated individual with no injuries found under a snow drift—in the Swedish cases). Review and analysis included the following parameters: age, sex, time of year and season, place of discovery, circumstances of death, and underlying medical conditions. Relevant toxicology and photographs were reviewed. All cases were de-identified following review and analysis. Raw data were converted to total, age-specific and sex-specific death rates per 100,000 of the population for both South Australia and Sweden. Statistical analysis was performed using GraphPad Prism 6 (GraphPad Software Inc., La Jolla, USA) with the nonparametric significance test Mann–Whitney U. Population statistics of age and sex from South Australia were obtained from the Australian Bureau of Statistics: (www.abs.gov.au/ausstats/[email protected]/mf/3101.0 and www.abs.gov.au/websitedbs/d33 10114.nsf/home/Population%20Pyramid%20-%20Australia), and Swedish population statistics were obtained from the US Census Bureau International database (www.census.gov/population/ international/data/idb/informationGateway.php) and Statistiska Centralbyr an (Statistics Sweden, SCB) (www.scb.se). Results There were 62 cases of fatal hypothermia in South Australia and 296 cases in Sweden between January 2006 and December 2011 (Table 1). In 2006, 2007, and 2008, South Australia had higher rates of hypothermic deaths per 100,000 population than Sweden (1.02, 0.7, & 0.6 vs. 0.5, 0.45, & 0.45, respectively); in 2009 and 2010, Sweden had the highest rates (0.6 & 0.9 vs. 0.4 0.8); and in 2011, the rates were equal at 0.4/100,000. However, comparison of the overall rates for the 6 years of the study revealed no statistical significance between the two, 983
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JOURNAL OF FORENSIC SCIENCES
TABLE 1––Features of hypothermic deaths in South Australia and Sweden (January 2006–December 2011). South Australia
Parameters Sex Male Female Indoor deaths Outdoor deaths
Sweden
Numbers (n = 62)
Percentage (%)
Numbers (n = 296)
Percentage (%)
26 36 52
42 58 84
195 101 16
66 34 5
10
16
280
95
TABLE 2––Hypothermic death rates per 100,000 per year in South Australia. Year
Population
Hypothermic Deaths
Rate per 100,000
2006 2007 2008 2009 2010 2011
1,567,888 1,582,559 1,597,343 1,614,375 1,629,434 1,638,232 Totals
16 11 9 7 13 6 62
1.02 0.7 0.6 0.4 0.8 0.4 3.9
TABLE 3––Hypothermic death rates per 100,000 per year in Sweden. Year
Population
Hypothermic Deaths
Rate per 100,000
2006 2007 2008 2009 2010 2011
9,016,596 9,031,088 9,045,389 9,059,651 9,074,055 9,088,728 Totals
48 41 41 53 80 33 296
0.5 0.45 0.45 0.6 0.9 0.4 3.3
although the rate in South Australia was slightly higher: South Australia—3.9/100,000 and Sweden—3.3/100,000 (p = 0.6104) (Tables 2 and 3). Of the 62 hypothermic deaths in South Australia, 55% of cases were over the age of 70 years, and 42% cases were in the middle age range of 40–69 years, with no reported deaths below the age of 30 years or above 89 years. Deaths occurred in every age range in the Swedish data, with only 37% of cases aged >70 years, and 50% of cases in the middle age ranges
(40–69 years) (Fig. 1). The age difference between the two populations was particularly evident in 2011 where the death rate in the 70–79 year age range in South Australia was 13.3/100,000 compared with only 1.67/100,000 in Sweden. There were 26 (42%) male and 36 (58%) female hypothermic deaths in South Australia over the 6-year period compared with Sweden with 195 (66%) male and 101 (34%) female decedents. Between 2006 and 2011, South Australia had consistently higher rates of female hypothermic deaths than Sweden. Of the hypothermic deaths in South Australia, 52 (84%) occurred indoors and 10 (16%) were outdoors. Fifty (81%) of the South Australian cases lived alone and 59 (95%) had been dead for at least a day, with seven (11%) dead for weeks to months. Four individuals (6%) lived in conditions of isolated squalor, self-neglect, and hoarding. Nine decedents (15%) had been intoxicated. As descriptions of the type of housing and insulation/heating were not available in any of the cases, the diagnoses of hypothermia were based on: i) the pathological findings of Wischnewski spots of the gastric mucosa, pancreatitis, and skin discoloration over joints, or ii) on the circumstances of death; for example, where a thin, elderly individual living alone was found deceased on an unheated floor with inadequate or no clothing, and where there had been consistently low ambient/environmental temperatures. This was particularly relevant in cases where there was marked decomposition. In the Swedish data, only 16 cases (5%) were found indoors with 280 (95%) discovered outdoors. Seventy-six Swedish decedents (26%) were considered to be intoxicated at the time of death with 30 cases (10%) involving a missing person with “wandering behavior.” Hypothermic deaths in South Australia occurred in all months of the year except for March and December. The majority of deaths occurred in winter (44%) followed by spring (31%) and autumn (21%) with three deaths (5%) in summer. In Sweden, all hypothermic deaths were reported in the winter season. Underlying medical conditions/risk factors were identified in 56 (90%) of the South Australian and in 189 (64%) of Swedish cases. These included cardiovascular disease, mental illness, previous cerebrovascular accidents, diabetes, cancer, arthritis, hepatitis, renal and liver disease, and alcohol/drug use. Many of the South Australian cases had not seen a medical professional for months-years and were self-medicating. Discussion South Australia is a state of Australia that has a temperate-tohot climate (average temperature = 20°C—Bureau of Meterology, www.bom.gov.au/climate/current/annual/sa/summary.shtml),
FIG. 1––Percentage of hypothermic deaths per age range: South Australia versus Sweden 2006–2011.
BRIGHT ET AL.
compared with Sweden where there are much colder temperatures (average temperature = 10°C - World Meterological Organisation, www.worldweather.org/096/c00187f.htm#climate). However, despite the significantly warmer climate in South Australia, in three of the 6 years reviewed, there were higher rates of hypothermic deaths than in Sweden. Although this did not reach statistical significance, these data show that hypothermia may be as much of problem in temperate as in cold climates. Fatal hypothermic cases in South Australia occurred predominantly in elderly females, and in all but six cases, there were significant underlying illnesses or risk factors present (90%). In contrast, hypothermic deaths in Sweden occurred predominantly in males in the middle-aged elderly cohort, outdoors, with underlying illness in just under two-thirds of the cases. Unfortunately, pathological markers for hypothermia may be quite subtle and insensitive, and so it is possible that some cases may not have been identified (6). In previous studies, the extremes of age have been noted to be significant risk factor for fatal hypothermia (4,7–9). In the elderly, this results from failing biological mechanisms of temperature regulation, such as vasoconstriction and shivering, and from abnormal temperature perception and regulation, intercurrent illnesses, social isolation, and inadequate housing or poverty (4,10–12). The present study confirms that increasing age, particularly in the South Australian cases, was a risk factor for these deaths, associated with some degree of social isolation (i.e., 81% lived on their own with most bodies not being found for at least a day). It appears that underlying medical conditions such as a cardiovascular or cerebrovascular event or a fall had rendered these individuals incapacitated. Unfortunately, descriptions of the specific houses were not available and so reasons for the higher rates of indoor deaths in South Australia remain conjectural. A previous case report of an elderly woman who died of hypothermia in a poorly heated and insulated house, that is included in the current series, did draw attention to the possibility of inadequate energy efficiency playing a role (13). For example, only 2.6% of Australian homes have double-glazed windows compared with 100% in Finland and Sweden and 88% in Germany (9). Details of heating arrangements (with ambient temperature measurements) and the energy efficiency of the house, including specific mention of wall, floor, and ceiling insulation/heating, nature of the windows (i.e., double-glazed), and the presence of air leaks around doors and windows may clarify this issue in the evaluation of future possible indoor hypothermic deaths. In contrast, Swedish hypothermic deaths were associated with a higher rate of inebriation and outdoor wandering, and in the majority of cases, death was confidently attributed to hypothermia as in many instances individuals were discovered under snow drifts and bodies had to be thawed out before postmortem examinations could proceed.
.
HYPOTHERMIC DEATHS
985
The study is limited by its retrospective nature; however, the diagnosis of hypothermia in both Sweden and Australia relies on the demonstration of standard features of Wischnewski spots of the gastric mucosa, pancreatitis, and skin discoloration over joints or on particular circumstances (14). Certainly, the higher numbers of deaths outdoors in the Swedish data may have been skewed by dramatic death scene findings of decedents buried in snow drifts (something that does not happen in South Australia). However, the high rate of indoor deaths in South Australia is still notable. This study has shown that in a temperate climate elderly, socially isolated individuals with multiple illnesses are at increased risk of hypothermia that is not limited to winter months or to outdoor exposure. References 1. Turk EE. Hypothermia. Forens Sci Med Pathol 2010;6:106–15. 2. Madea B, Tsokos M, Preub J. Morphological findings, their pathogenesis and diagnostic value. Forensic Pathol Rev 2008;5:3–21. 3. Dettmeyer RB. Hypothermia. Forensic histopathology. Berlin-Heidelberg: Springer, 2011;165–71. 4. Elbaz G, Etzion O, Delgado J, Porath A, Talmor D, Novack V. Hypothermia in a desert climate: severity score and mortality prediction. Am J Emerg Med 2008;26:683–8. 5. Lim C, Duflou J. Hypothermia fatalities in a temperate climate: Sydney, Australia. Pathology 2008;41:46–51. 6. Bright F, Winskog C, Byard RW. Wischnewski spots and hypothermia: sensitive, specific, or serendipitous? Forensic Sci Med Pathol 2013;9:88– 90. 7. Herity B, Daly L, Bourke GJ, Horgan JM. Hypothermia and mortality and morbidity. An epidemiological analysis. J Epidemiol Commun Health 1991;45:19–23. 8. Tanaka M, Tokudome S. Accidental hypothermia and death from cold in urban areas. Int J Biomet 1990;34:42–246. 9. Bright F, Winskog C, Byard RW. Hypothermic deaths in South Australia. Med J Australia 2012;197:622. 10. Taylor AJ, McGwin G, Davis GG, Brissie RM, Holley TD, Rue LW. Hypothermia deaths in Jefferson County, Alabama. Inj Prev 2001;7:141– 5. 11. Megarbane B, Axler O, Chary I, Pompier R, Brivet FG. Hypothermia with indoor occurrence is associated with a worse outcome. J Intens Care Med 2000;26:1843–9. 12. Collins KJ. Low indoor temperatures and morbidity in the elderly. Age Ageing 1986;15:212–20. 13. Bright F, Winskog C, Gilbert JD, Byard RW. Additional risk factors for lethal hypothermia. J Forens Leg Med 2013;20(6):595–7. 14. Prahlow J, Byard RW. An atlas of forensic pathology. New York, NY: Springer Publishers, 2012. Additional information and reprint requests: Roger W. Byard, M.D. Discipline of Anatomy and Pathology The University of Adelaide, Frome Road Level 3 Medical School North Building Adelaide 5005, SA Australia E-mail: [email protected]
PAPER PATHOLOGY/BIOLOGY
Fiona M. Bright,1 B.Hth.Sci. (Hons).; Calle Winskog,1 M.D.; Melissa Walker,1 B.Sc.; and Roger W. Byard,1 M.D.
A Comparison of Hypothermic Deaths in South Australia and Sweden
ABSTRACT: Case files from Forensic Science South Australia and the Swedish National Forensic Database were reviewed over a 6-year
period from 2006 to 2011 for cases where hypothermia either caused, or significantly contributed to, death. Data were analyzed for age, sex, time of year/season, place of discovery, circumstances of death, and underlying medical conditions. Despite the considerable demographic, geographic, and climatological differences, hypothermic deaths occurred at very similar rates in South Australia (3.9/100,000) and Sweden (3.3/ 100,000). Deaths from hypothermia in South Australia occurred predominantly indoors at home addresses, involving elderly females with multiple underlying illnesses and limited outside contacts. In contrast, Swedish hypothermic deaths generally occurred outdoors and involved middle-aged elderly males. These data show that hypothermia may be a risk in warmer climates particularly for elderly, socially isolated individuals.
KEYWORDS: forensic science, hypothermia, temperate climate, social isolation, illness, senile squalor syndrome Hypothermia is defined as a decrease in core body temperature below 35°C. It develops when regulatory mechanisms such as vasoconstriction and heat production fail to compensate for heat loss to the environment (1–3). Deviation in core body temperature below normal levels has significant effects on thermoregulation, with fatal hypothermia occurring at temperatures of 26° to 29°C. Death results from myocardial ischemia and/or hypoxia exacerbated by electrolyte imbalances and increased catecholamine levels (1–3). Although it has been recognized that fatal hypothermia is not limited to cold climates or to winter months (4,5), it is often assumed that the risk increases with decreasing environmental temperatures; that is, death from hypothermia is more likely to occur in colder Scandinavian countries than in the warmer nonAlpine regions of Australia. To test this hypothesis, the following study was undertaken. Materials and Methods Forensic case file information was obtained from Forensic Science South Australia and the Swedish National Forensic database between January 2006 and December 2011 using an electronic search for the terms “hypothermia” and “Wischnewski spots.” Cases in which hypothermia was identified as a primary cause of, or a significant contributing factor to, death, and in which there were positive pathological findings of hypothermia were included in the study. Pathological abnormalities included Wischnewski spots of the gastric mucosa, pancreatitis and skin discoloration
1 Discipline of Anatomy and Pathology, The University of Adelaide, Frome Road, Adelaide, SA 5005, Australia. Received 8 Nov. 2012; and in revised form 4 June 2013; accepted 22 June 2013.
© 2014 American Academy of Forensic Sciences
over joints. Cases where no pathological features were present were excluded from the study unless the circumstances of death were strongly suggestive of lethal hypothermia (e.g., an intoxicated individual with no injuries found under a snow drift—in the Swedish cases). Review and analysis included the following parameters: age, sex, time of year and season, place of discovery, circumstances of death, and underlying medical conditions. Relevant toxicology and photographs were reviewed. All cases were de-identified following review and analysis. Raw data were converted to total, age-specific and sex-specific death rates per 100,000 of the population for both South Australia and Sweden. Statistical analysis was performed using GraphPad Prism 6 (GraphPad Software Inc., La Jolla, USA) with the nonparametric significance test Mann–Whitney U. Population statistics of age and sex from South Australia were obtained from the Australian Bureau of Statistics: (www.abs.gov.au/ausstats/[email protected]/mf/3101.0 and www.abs.gov.au/websitedbs/d33 10114.nsf/home/Population%20Pyramid%20-%20Australia), and Swedish population statistics were obtained from the US Census Bureau International database (www.census.gov/population/ international/data/idb/informationGateway.php) and Statistiska Centralbyr an (Statistics Sweden, SCB) (www.scb.se). Results There were 62 cases of fatal hypothermia in South Australia and 296 cases in Sweden between January 2006 and December 2011 (Table 1). In 2006, 2007, and 2008, South Australia had higher rates of hypothermic deaths per 100,000 population than Sweden (1.02, 0.7, & 0.6 vs. 0.5, 0.45, & 0.45, respectively); in 2009 and 2010, Sweden had the highest rates (0.6 & 0.9 vs. 0.4 0.8); and in 2011, the rates were equal at 0.4/100,000. However, comparison of the overall rates for the 6 years of the study revealed no statistical significance between the two, 983
984
JOURNAL OF FORENSIC SCIENCES
TABLE 1––Features of hypothermic deaths in South Australia and Sweden (January 2006–December 2011). South Australia
Parameters Sex Male Female Indoor deaths Outdoor deaths
Sweden
Numbers (n = 62)
Percentage (%)
Numbers (n = 296)
Percentage (%)
26 36 52
42 58 84
195 101 16
66 34 5
10
16
280
95
TABLE 2––Hypothermic death rates per 100,000 per year in South Australia. Year
Population
Hypothermic Deaths
Rate per 100,000
2006 2007 2008 2009 2010 2011
1,567,888 1,582,559 1,597,343 1,614,375 1,629,434 1,638,232 Totals
16 11 9 7 13 6 62
1.02 0.7 0.6 0.4 0.8 0.4 3.9
TABLE 3––Hypothermic death rates per 100,000 per year in Sweden. Year
Population
Hypothermic Deaths
Rate per 100,000
2006 2007 2008 2009 2010 2011
9,016,596 9,031,088 9,045,389 9,059,651 9,074,055 9,088,728 Totals
48 41 41 53 80 33 296
0.5 0.45 0.45 0.6 0.9 0.4 3.3
although the rate in South Australia was slightly higher: South Australia—3.9/100,000 and Sweden—3.3/100,000 (p = 0.6104) (Tables 2 and 3). Of the 62 hypothermic deaths in South Australia, 55% of cases were over the age of 70 years, and 42% cases were in the middle age range of 40–69 years, with no reported deaths below the age of 30 years or above 89 years. Deaths occurred in every age range in the Swedish data, with only 37% of cases aged >70 years, and 50% of cases in the middle age ranges
(40–69 years) (Fig. 1). The age difference between the two populations was particularly evident in 2011 where the death rate in the 70–79 year age range in South Australia was 13.3/100,000 compared with only 1.67/100,000 in Sweden. There were 26 (42%) male and 36 (58%) female hypothermic deaths in South Australia over the 6-year period compared with Sweden with 195 (66%) male and 101 (34%) female decedents. Between 2006 and 2011, South Australia had consistently higher rates of female hypothermic deaths than Sweden. Of the hypothermic deaths in South Australia, 52 (84%) occurred indoors and 10 (16%) were outdoors. Fifty (81%) of the South Australian cases lived alone and 59 (95%) had been dead for at least a day, with seven (11%) dead for weeks to months. Four individuals (6%) lived in conditions of isolated squalor, self-neglect, and hoarding. Nine decedents (15%) had been intoxicated. As descriptions of the type of housing and insulation/heating were not available in any of the cases, the diagnoses of hypothermia were based on: i) the pathological findings of Wischnewski spots of the gastric mucosa, pancreatitis, and skin discoloration over joints, or ii) on the circumstances of death; for example, where a thin, elderly individual living alone was found deceased on an unheated floor with inadequate or no clothing, and where there had been consistently low ambient/environmental temperatures. This was particularly relevant in cases where there was marked decomposition. In the Swedish data, only 16 cases (5%) were found indoors with 280 (95%) discovered outdoors. Seventy-six Swedish decedents (26%) were considered to be intoxicated at the time of death with 30 cases (10%) involving a missing person with “wandering behavior.” Hypothermic deaths in South Australia occurred in all months of the year except for March and December. The majority of deaths occurred in winter (44%) followed by spring (31%) and autumn (21%) with three deaths (5%) in summer. In Sweden, all hypothermic deaths were reported in the winter season. Underlying medical conditions/risk factors were identified in 56 (90%) of the South Australian and in 189 (64%) of Swedish cases. These included cardiovascular disease, mental illness, previous cerebrovascular accidents, diabetes, cancer, arthritis, hepatitis, renal and liver disease, and alcohol/drug use. Many of the South Australian cases had not seen a medical professional for months-years and were self-medicating. Discussion South Australia is a state of Australia that has a temperate-tohot climate (average temperature = 20°C—Bureau of Meterology, www.bom.gov.au/climate/current/annual/sa/summary.shtml),
FIG. 1––Percentage of hypothermic deaths per age range: South Australia versus Sweden 2006–2011.
BRIGHT ET AL.
compared with Sweden where there are much colder temperatures (average temperature = 10°C - World Meterological Organisation, www.worldweather.org/096/c00187f.htm#climate). However, despite the significantly warmer climate in South Australia, in three of the 6 years reviewed, there were higher rates of hypothermic deaths than in Sweden. Although this did not reach statistical significance, these data show that hypothermia may be as much of problem in temperate as in cold climates. Fatal hypothermic cases in South Australia occurred predominantly in elderly females, and in all but six cases, there were significant underlying illnesses or risk factors present (90%). In contrast, hypothermic deaths in Sweden occurred predominantly in males in the middle-aged elderly cohort, outdoors, with underlying illness in just under two-thirds of the cases. Unfortunately, pathological markers for hypothermia may be quite subtle and insensitive, and so it is possible that some cases may not have been identified (6). In previous studies, the extremes of age have been noted to be significant risk factor for fatal hypothermia (4,7–9). In the elderly, this results from failing biological mechanisms of temperature regulation, such as vasoconstriction and shivering, and from abnormal temperature perception and regulation, intercurrent illnesses, social isolation, and inadequate housing or poverty (4,10–12). The present study confirms that increasing age, particularly in the South Australian cases, was a risk factor for these deaths, associated with some degree of social isolation (i.e., 81% lived on their own with most bodies not being found for at least a day). It appears that underlying medical conditions such as a cardiovascular or cerebrovascular event or a fall had rendered these individuals incapacitated. Unfortunately, descriptions of the specific houses were not available and so reasons for the higher rates of indoor deaths in South Australia remain conjectural. A previous case report of an elderly woman who died of hypothermia in a poorly heated and insulated house, that is included in the current series, did draw attention to the possibility of inadequate energy efficiency playing a role (13). For example, only 2.6% of Australian homes have double-glazed windows compared with 100% in Finland and Sweden and 88% in Germany (9). Details of heating arrangements (with ambient temperature measurements) and the energy efficiency of the house, including specific mention of wall, floor, and ceiling insulation/heating, nature of the windows (i.e., double-glazed), and the presence of air leaks around doors and windows may clarify this issue in the evaluation of future possible indoor hypothermic deaths. In contrast, Swedish hypothermic deaths were associated with a higher rate of inebriation and outdoor wandering, and in the majority of cases, death was confidently attributed to hypothermia as in many instances individuals were discovered under snow drifts and bodies had to be thawed out before postmortem examinations could proceed.
.
HYPOTHERMIC DEATHS
985
The study is limited by its retrospective nature; however, the diagnosis of hypothermia in both Sweden and Australia relies on the demonstration of standard features of Wischnewski spots of the gastric mucosa, pancreatitis, and skin discoloration over joints or on particular circumstances (14). Certainly, the higher numbers of deaths outdoors in the Swedish data may have been skewed by dramatic death scene findings of decedents buried in snow drifts (something that does not happen in South Australia). However, the high rate of indoor deaths in South Australia is still notable. This study has shown that in a temperate climate elderly, socially isolated individuals with multiple illnesses are at increased risk of hypothermia that is not limited to winter months or to outdoor exposure. References 1. Turk EE. Hypothermia. Forens Sci Med Pathol 2010;6:106–15. 2. Madea B, Tsokos M, Preub J. Morphological findings, their pathogenesis and diagnostic value. Forensic Pathol Rev 2008;5:3–21. 3. Dettmeyer RB. Hypothermia. Forensic histopathology. Berlin-Heidelberg: Springer, 2011;165–71. 4. Elbaz G, Etzion O, Delgado J, Porath A, Talmor D, Novack V. Hypothermia in a desert climate: severity score and mortality prediction. Am J Emerg Med 2008;26:683–8. 5. Lim C, Duflou J. Hypothermia fatalities in a temperate climate: Sydney, Australia. Pathology 2008;41:46–51. 6. Bright F, Winskog C, Byard RW. Wischnewski spots and hypothermia: sensitive, specific, or serendipitous? Forensic Sci Med Pathol 2013;9:88– 90. 7. Herity B, Daly L, Bourke GJ, Horgan JM. Hypothermia and mortality and morbidity. An epidemiological analysis. J Epidemiol Commun Health 1991;45:19–23. 8. Tanaka M, Tokudome S. Accidental hypothermia and death from cold in urban areas. Int J Biomet 1990;34:42–246. 9. Bright F, Winskog C, Byard RW. Hypothermic deaths in South Australia. Med J Australia 2012;197:622. 10. Taylor AJ, McGwin G, Davis GG, Brissie RM, Holley TD, Rue LW. Hypothermia deaths in Jefferson County, Alabama. Inj Prev 2001;7:141– 5. 11. Megarbane B, Axler O, Chary I, Pompier R, Brivet FG. Hypothermia with indoor occurrence is associated with a worse outcome. J Intens Care Med 2000;26:1843–9. 12. Collins KJ. Low indoor temperatures and morbidity in the elderly. Age Ageing 1986;15:212–20. 13. Bright F, Winskog C, Gilbert JD, Byard RW. Additional risk factors for lethal hypothermia. J Forens Leg Med 2013;20(6):595–7. 14. Prahlow J, Byard RW. An atlas of forensic pathology. New York, NY: Springer Publishers, 2012. Additional information and reprint requests: Roger W. Byard, M.D. Discipline of Anatomy and Pathology The University of Adelaide, Frome Road Level 3 Medical School North Building Adelaide 5005, SA Australia E-mail: [email protected]
