Sudden unexpected neonatal death due to late onset group B streptococcal sepsis—A case report

We report a case of sudden unexpected death due to late onset neonatal group B streptococcal sepsis. A male neonate weighing 2731 g was born at 35 week gestational age, and discharged at the age of 4 days after the birth. At 6 days after the discharge (10 days after the birth), because of consciousness loss and hypothermia, the neonate was conveyed to an emergency hospital, eventually followed by his death. Forensic autopsy revealed neither severe trauma nor cardiac anomaly. Both lungs were edematous. Histopathologically, a lot of bacterial clusters were found in the lungs and intracerebral vessels. Cerebrospinal fluid contained a lot of leukocytes. Streptococcus agalactiae was detected in the specimens from the feces and the blood. Collectively, we diagnosed that the cause of the neonate’s death was late onset group B streptococcal sepsis. In autopsy cases of neonates, careful macroscopic and microscopic observations and bacteriological/virological examination should be performed.     

Retrospective analysis of therapeutic effect and prognostic factors on early glottic carcinoma

ObjectiveTo investigate the therapeutic effect of surgery, radiotherapy and photodynamic therapy on early glottic carcinoma and prognostic factors.MethodsRetrospective analysis of 202 cases with early glottic carcinoma (Tis-T2N0M0) underwent surgery (n = 152), radiotherapy (n = 20) and PDT (n = 30) from 2000 to 2013 The KPS score, the disease-free survival (DFS), overall survival (OS), local control (LC), larynx preservation rate, laryngeal function were evaluated. The methods of χ ²test or Fisher's exact probability method, Kaplan Meier method, log-rank test of Kaplan-Meier method, Cox proportional hazards model were used to analyze the data.ResultsThere was no statistical significance in OS, DFS and LC among the three groups. The laryngeal function preservation rate of RT group, PDT group and Surgery group were 90%, 86.7% and 65.1% respectively, with the former two groups significantly superior to Surgery group. While there is no statistical significance between RT group and PDT group. Single factor analysis showed that KPS score before treatment, vocal fold mobility limitation and differentiation degree could have an effect on prognosis. Multivariate regression analyses indicated that anterior commissure invasion, T stage and KPS score before treatment were independent adverse prognostic factors for OS. T stage and differentiation degree were adverse prognostic factors for DFS. T stage was also an adverse factor of LC. Thirty-three cases experienced local recurrence or cervical lymph node metastasis. Three groups showed no statistical difference in local recurrence or lymph node metastasis, with twenty-two cases in Surgery group, four in RT group and seven in PDT group.ConclusionsThe therapeutic effect was approximate in surgery group, radiotherapy group and photodynamic group, and all three treatment regimens achieved good clinical effect. Radiotherapy and photodynamic therapy may be the first or very important treatment on early stage glottic squamous cell cancer (Tis ∼ T₂N₀M₀). However only 6 patients underwent PDT for T2 disease, making definitive treatment conclusions for this subgroup unclear.     

Causes of death in forensic autopsy cases of malnourished persons

PurposeMedical examiners and forensic pathologists often encounter emaciated bodies in postmortem examinations. However, the main disease that caused death is often not clear and measures to prevent the unexpected death of malnourished persons have not been established. In this study, we examined the underlying causes of death among a large number of forensic autopsy cases that showed emaciation to clarify the features of sudden, unexpected death in malnourished persons.MethodsDocuments of autopsy cases without putrefaction handled during 2007–2010 by the Tokyo Medical Examiner’s Office were reviewed (n = 7227). The body mass index (BMI) was calculated for each case. The causes of death for cases with severe malnutrition (BMI < 16; n = 885) were closely examined.ResultsAbout 70% of all deaths in malnourished cases (BMI < 16) was due to disease, and the causative diseases are more varied than in those with less severe malnutrition and those without malnutrition (BMI ? 16). A higher proportion of malnutrition as the cause of death was observed in younger persons for both sexes, and a higher proportion of having a history of psychiatric diseases was observed in younger deceased women. In addition, a higher proportion of alcohol-related digestive diseases was observed especially in younger men, some of whom had a history of alcohol dependence. On the other hand, the proportion of organic diseases, such as neoplasms and gastroduodenal ulcer, was higher in older deceased persons, especially among men. Around 70% of all respiratory diseases comprised pneumonia in both sexes. Among non-disease-related causes of death, poisoning was the most frequent cause in women under 55 years old (35.3%), with the majority having had a history of psychiatric disease.ConclusionsBecause autopsy cases of malnourished persons show various causes of death, physicians have to pay more attention in making death diagnosis in such cases. From a preventative point of view, early detection of organic diseases, a better approach toward managing psychiatric diseases, and implementation of vaccination for pneumonia will contribute to reduction of future unexpected deaths among malnourished persons.     

An autopsy case of spontaneous esophageal perforation (Boerhaave syndrome)

A 45-year-old male, an alcohol addict with asthma, was found dead in his home, after several days of continued drinking. A forensic autopsy was performed 3 days after the discovery of his death in order to specify the cause of death.A longitudinal perforation penetrating all layers of the esophagus measuring 1.8 cm was present on the left wall approximately 2.0 cm from the gastroesophageal junction. There were 1900 mL of greenish to brownish turbid liquid in the left pleural cavity and 150 mL of greenish viscous liquid in the stomach. Histopathologically, an infiltration of numerous neutrophils was evident in the submucosa layer, proper muscular layer, and serous membrane of the esophagus, corresponding to the esophageal laceration. The serum C-reactive protein (CRP) concentration was determined to be 3.1 mg/dL. The alcohol concentrations were determined to be 1.49 mg/g in the right cardiac blood, 1.31 mg/g in the left cardiac blood, and 2.48 mg/g in urine.Based upon the autopsy and histopathological findings, as well as the biochemical and toxicological analyses, we concluded that the cause of death was respiratory failure by pleural effusion, resulting from spontaneous esophageal perforation. This was the first report of a spontaneous esophageal perforation eventually causing respiratory failure.     

Death due to a bronchus-pulmonary artery fistula developed 19 years after radiotherapy: A forensic autopsy case report

Radiotherapy, one of the standard therapies for lung cancer management, may cause severe late complications. In this case report, we describe the forensic autopsy report of a middle-aged man who died from a massive hemoptysis due to a bronchus-pulmonary artery fistula that developed 19 years after radiotherapy. The man, in his 50 s, suddenly developed hemoptysis at home and collapsed. He was in complete remission with no signs of recurrence. Autopsy revealed massive hemorrhage from the bronchus-pulmonary artery fistula, where radiotherapy had been focused. Histopathological findings showed chondronecrosis of the bronchus, disruption of elastic fibers of the pulmonary artery, and marked thickening of the intima of the small arteries around the fistula, which were compatible with radiation reaction. Neither cancer recurrence nor infection was evident. This case suggests that a late complication of radiotherapy should be considered in the differential diagnosis of a patient who was previously received radiotherapy and presents with massive hemoptysis. In such cases, a detailed history on previous therapies and careful examination of the origin of hemorrhage are necessary to determine the cause of death.     

An autopsy case of cardiac tamponade caused by a ruptured ventricular aneurysm associated with acute myocarditis

We report an autopsy case of hemopericardium caused by rupture of a ventricular aneurysm associated with acute myocarditis in an infant boy aged 2 years and 10 months. Three days before his death, the patient developed fever. On the day of death, he described an urge to defecate and attempted to do so in an upright position. While straining to defecate without success for a prolonged period, he stopped breathing and collapsed. On autopsy, his heart weighed 91.7 g and cardiac tamponade was evident, the pericardial cavity being filled with 140 mL of blood that had come from a 1.5-cm-long rupture in a 2.7 × 1.5 cm ventricular aneurysm in the posterior left ventricular wall. Patchy grayish-white discoloration was noted in the myocardium. Histologically, CD3-positive T lymphocytic infiltration accompanied by pronounced macrophage infiltration was observed in the myocardium. Hemorrhagic necrosis was detected in the area of the ventricular aneurysm. Staining for matrix metalloproteinase (MMP) expression revealed abundant MMP-2, MMP-7, and MMP-9. Polymerase chain reaction to detect viruses failed to identify any specific causative viruses in the myocardium. In this case of lymphocytic (viral) and histiocytic myocarditis with pronounced macrophage infiltration and upregulation of MMP expression, myocardial remodeling and associated wall weakening had resulted in formation and rupture of an aneurysm.     

Interstitial pulsed-dose-rate brachytherapy for head and neck cancer—Single-institution long-term results of 385 patients

PurposeTo assess the long-term results of protocol-based pulsed-dose-rate (PDR) interstitial brachytherapy (iBT) in 385 patients with head and neck cancer who underwent PDR-iBT preferably after minimal, nonmutilating surgery.Methods and MaterialsFrom 1997 to 2009, a total of 385 patients received protocol-based PDR-iBT for head and neck cancer. Brachytherapy was preceded by surgery in most of our patients (326/385, 84.7%). Altogether, 246 of 385 patients (63.9%) received iBT alone and 135 of 385 patients (36.1%) in combination with external beam radiation therapy. The analysis was done after a median followup of 63 months.ResultsThe 5-, 10-, and 15-year local relapse-free survival rates according to Kaplan–Meier test for all analyzed patients were 85.8%, 83.1%, and 80.2%, respectively. The 5-, 10-, and 15-year overall survival and disease-free survival rates were 68.9%, 52.2%, and 44.1%, and 81.3%, 79.3%, and 76.3%, respectively. For N0-/N1- vs. N2-patients, we observed significantly different 5-year local recurrence-free survival rates with values of 92.3% and 73.7%, respectively (p = 0.007). No other patient or treatment-related parameters had a significant influence on treatment results. Serious late side effects, such as soft tissue or bone necrosis, were observed in 39 of 385 patients (10.2%) and 18 of 385 patients (4.9%), respectively.ConclusionsThe PDR-iBT with 0.4–0.7 Gy each hour, 24 h per day for patients with head and neck cancer is a proven, effective, and safe treatment method with excellent long-term data.     

Postmortem diffusion of n-butane and i-butane used for anticontagious plugging spray

Blood and tissue samples from a forensic autopsy of a man in his late 60s, who developed dementia and died of multiple head traumas due to a fall from a moving vehicle, contained certain amounts of n-butane and i-butane. The concentration of n-butane was in the range of 0.48–70.5 μL/g, which would be considered as toxic or lethal levels. We had to distinguish whether the cause of his unexplained behavior was due to his pre-existing condition (dementia), or from a confused state induced by butane abuse. No traces of butane use were found at the scene. Police investigation revealed that a propellant used in an anticontagious plugging spray had been administered to him during a postmortem treatment in the emergency hospital. In order to prove the postmortem butane diffusion had resulted from the spray administration and to estimate the diffused concentration, experimental simulation was conducted by using rats. As a result of postmortem treatment with the spray, n-butane at concentrations of 0.54–15.5 μL/mL or g were found in the rat blood and tissues. In this case, we provided further evidence that the postmortem butane diffusion, caused by using the anticontagious plugging spray containing butane gas as a propellant administered to a cadaver during a postmortem procedure prior to forensic autopsy, should be distinguished from cases of actual butane poisoning.     

An autopsy case of acetyl fentanyl intoxication caused by insufflation of ‘designer drugs’

We present a fatal case of intoxication due to insufflation of acetyl fentanyl. His blood concentration of acetyl fentanyl was 270 ng/mL, and the manner of death was classified as an accident. This is the first report of an autopsy case of acetyl fentanyl delivered by insufflation, rather than intravenous administration. He had been snoring loudly for at least 12 h prior to death, and transport to a hospital during this time and treatment with naloxone may have saved his life. In this sense, it can be said that his death was preventable.This case reemphasizes the risk of death associated with drug overdose and the narrow range of acetyl fentanyl between the effective dose (ED50) and lethal dose (LD50). The case should also raise awareness among medical professionals of the effectiveness of naloxone and the need to establish a comprehensive system for toxicological analysis while keeping the possibility of use of ‘designer drugs’ in mind.     

Comparison of the injury severity and medical history of disease-related versus trauma-related bicyclist fatalities

The objective of this study was to clarify the relationship between injury severity and mechanism of death in bicycle fatalities resulting from trauma compared with those resulting from disease, to propose effective measures to prevent fatal bicyclist accidents.Autopsy and accident records were reviewed for bicyclist fatalities who had undergone forensic autopsy at the Dokkyo Medical University School of Medicine between September 1999 and March 2014. Victims’ health histories, blood alcohol levels, causes of death, mechanisms of injury, Abbreviated Injury Scale (AIS) scores and Injury Severity Scores (ISSs) were determined.Fifty-five bicyclists (43 male and 12 female) with a mean age of 62.5 ± 17.3 years were included in this study. Sixteen victims had driven under the influence of alcohol (mean blood concentration of 1.8 ± 0.7 mg/ml). Mean ISS was 32.4 and the chest had the highest mean AIS score (2.6), followed by the head (2.1) and the neck (1.8). Thirty-nine victims (70.9%) had died of trauma and 16 had died of disease. The disease-death victims had significantly higher prevalence of having diabetes mellitus, hyperlipidemia, hypertension, heart disease or cerebrovascular diseases (50.0% vs. 22.2%, p = 0.03) and a lower rate of drunk driving (6.3% vs. 41.0%, p = 0.01) than the trauma-death group. All victims who were affected by disease, and 33.3% of trauma-death victims, had fallen on the road without a vehicle collision (p < 0.001). The mean ISS of the trauma-death group was significantly higher than that of the disease-death group (44.0 vs. 4.2, p < 0.001). Except for facial injuries, the AIS scores were significantly higher in trauma-death victims than in the disease-death group (p < 0.005).To effectively reduce bicyclist fatalities, the authors strongly advocate efforts that will increase compliance with drunk driving prohibitions. For victims of fatal bicycle accidents with a medical history of diseases, a forensic autopsy should be performed to establish a disease-related death while bicycle riding. We must also put into effect preventative safety measures, which take into consideration the physical condition of bicyclists, to reduce the incidence of these types of accidents.     

Reirradiation of prostate cancer with rectum preservation: eradicative high-dose-rate brachytherapy with natural type hyaluronate injection

IntroductionReirradiation of locally recurrent prostate cancer after radiotherapy is limited because of its toxicity to the rectum that is closely adjacent to the prostate. To solve geometric anatomic constraints, including rectal size and distance from the prostate, we developed a technique that modifies the geometry by noninvasive direct intervention.Methods and MaterialsIn a patient with local recurrence of prostate cancer at 18 months after initial radiotherapy of 61.8 GyE_LQ2,3 (gray equivalent in 2 Gy/fraction at α/β = 3 calculated with linear quadratic [LQ] model) to the prostate, we prescribed 16 Gy (60.8 GyE_LQ2,3 or 78.2 GyE_LQ2,1.6) of reirradiation by high-dose-rate brachytherapy, using a bolus injection of native-type hyaluronate to create and maintain a distance between the prostate and the rectum and decrease rectal size during treatment.ResultsThe procedure was achieved in 10 min, without complications. Rectal D_2cc of the reirradiation was 5.58 Gy (9.58 GyE_LQ2,3). Compared with the initial radiation, the gel injection resulted in an improved therapeutic ratio. The patient was regularly followed up at our clinic; at over 3.5 years after reirradiation, there was no evidence of recurrence or radiation-related toxicities greater than Grade 2, maintaining a nadir prostate-specific antigen level of 0.03 ng/mL without hormonal therapy.ConclusionWe consider that this technique is useful for achieving safe and curative reirradiation of prostate cancer.     

Multiparametric evaluation by simultaneous PET-MRI examination in patients with histologically proven laryngeal cancer

ObjectivesTo evaluate the relationship between metabolic 18Fluoro-Deoxyglucose-Positron Emission Tomography (18FDG/PET) and morpho-functional parameters derived by Magnetic Resonance Imaging (MRI) in patients with histologically proven laryngeal cancer. To assess the clinical impact of PET/MRI examination on patient’s staging and treatment planning.Methods16 patients with histologically proven laryngeal cancer were enrolled and underwent whole body PET/CT followed by a dedicated PET/MRI of the head/neck region. Data were separately evaluated by two blinded groups: metabolic (SUV and MTV), diffusion (ADC) and perfusion (K_trans, V_e, k_ep and iAUC) maps were obtained by positioning regions of interest (ROIs). Tumoral local extension assessed on PET/MRI was compared to endoscopic findings.ResultsA good inter-observer agreement was found in anatomical location and local extension of PET/MRI lesions (Cohen’s kappa 0.9). PET/CT SUV measures highly correlate with ones derived by PET/MRI (e.g., p = 0.96 for measures on VOI). Significant correlations among metabolic, diffusion and perfusion parameters have been detected. PET/MRI had a relevant clinical impact, confirming endoscopic findings (6 cases), helping treatment planning (9 cases), and modifying endoscopic primary staging (1 case).ConclusionsPET/MRI is useful for primary staging of laryngeal cancer, allowing simultaneous collection of metabolic and functional data and conditioning the therapeutic strategies.     

Partial vs. whole breast irradiation in a community hospital: A retrospective cohort analysis of 200 patients

PurposeWe compared patients undergoing partial breast irradiation (PBI) with the MammoSite applicator (Cytyc Corp., Marlborough, MA) to a similar group of patients who underwent whole breast irradiation with external beam radiotherapy.Methods and MaterialsStage 0–IIA breast cancer patients satisfying American Brachytherapy Society selection criteria and receiving accelerated PBI with the MammoSite system (n = 100) were compared for toxicities with similarly staged patients receiving whole breast irradiation using tangential portals (n = 100). The MammoSite applicator treatment was prescribed to a total dose of 34 Gy. External beam doses generally ranged from 60 to 66 Gy.ResultsBased on common toxicity criteria scores for acute toxicities, MammoSite patients experienced less cutaneous toxicity, fatigue, and breast pain and had higher Karnofsky performance status scores during the acute period than external beam patients but experienced more seroma pain during followup. These results were both statistically significant and clinically meaningful.ConclusionsIn our institutional experience, PBI using the MammoSite applicator produces less acute toxicity than external beam radiotherapy of the whole breast but is associated with an increased incidence of seroma pain. The rate of disease recurrence in both cohorts was low.     

Postmortem virtual volumetry of the heart and lung in situ using CT data for investigating terminal cardiopulmonary pathophysiology in forensic autopsy

Postmortem CT (PM–CT) is useful to investigate the viscera in situ before opening the body cavity at autopsy. The present study investigated heart and lung volumes in situ with regard to the cause of death as possible indexes of terminal cardiopulmonary dysfunction by means of PM–CT data analysis of forensic autopsy cases within 3 days postmortem (n = 70). Estimated heart volume was larger in sudden cardiac death (SCD; n = 10) and fatal methamphetamine abuse (n = 5) than in other groups, including mechanical asphyxiation (n = 12), drowning (n = 11), acute alcohol/sedative–hypnotic intoxication (n = 8), fire fatality (n = 12), hyperthermia (heatstroke; n = 6) and fatal hypothermia (cold exposure; n = 6). Estimated combined lung volume was larger in drowning, smaller in fire fatality due to carbon monoxide intoxication and SCD, and intermediate in other groups. Volume ratio of the lung to heart was higher in drowning, lower in SCD, and intermediate or varied in other groups; high and low ratios can indicate predominant/antecedent pulmonary and cardiac dysfunctions, respectively. These findings provide quantitative data that are not available at conventional autopsy or by routine two-dimensional CT morphology to assess three-dimensional gross heart and lung morphologies for interpreting terminal cardiopulmonary pathophysiology, detecting significant difference between SCD and other causes of death, especially mechanical asphyxiation and drowning.     

Photodynamic process induced by chloro-aluminum phthalocyanine nanoemulsion in glioblastoma

BackgroundGlioblastoma multiforme (GBM) is a tumor characterized by rapid cell proliferation and migration. GBM constitutes the most aggressive and deadly type of brain tumor and is classified into several subtypes that show high resistance to conventional therapies. There are currently no curative treatments for malignant glioma despite the numerous advances in surgical techniques, radiotherapy, and chemotherapy. Therefore, alternative approaches are required to improve GBM treatment.MethodsOur study proposes the use of photodynamic therapy (PDT) for GBM treatment, which uses chloro-aluminum phthalocyanine (AlClPc) encapsulated in a new drug delivery system (DDS) and designed as a nanoemulsion (AlClPc/NE). The optimal dark non-cytotoxic AlClPc/NE concentration for the U87 MG glioma cell model and the most suitable laser light intensity for irradiation were determined. Experimental U87 MG cancer cells were analyzed via MTT cell viability assay. Cellular localization of AlClPc, morphological changes, and cell death via the necrotic and apoptotic pathways were also evaluated.ResultsAlClPc remained in the cytoplasmic region at 24 h after administration. Additionally, treatment with 1.0 μmol/L AlClPc under light irradiation at doses lower than 140 mJ/cm resulted in morphological changes with 50 ± 6% cell death (p < 0.05). Moreover, 20 ± 2% of U87 MG cells underwent cell death via the necrotic pathway. Measurement of Caspase-9 and -3 activities also suggested that cells underwent apoptosis. Taken together, these results indicate that AlClPc/NE-PDT can be used in the treatment of glioblastoma by inducing necrotic and apoptotic cell death.ConclusionsOur findings suggest that AlClPc/NE-PDT induces cell death in U87 MG cells in a dose-dependent manner and could thus serve as an effective adjuvant treatment for malignant glioma. AlClPc/NE-PDT utilizes a low dose of visible light and can be used in combination with other classic GBM treatment approaches, such as a combination of chemotherapy and surgery.     

Localized prostate cancer with intermediate- or high-risk features treated with combined external beam radiotherapy and iodine-125 seed brachytherapy

ObjectiveThe aim of the study is to compare the results of the combined external beam radiotherapy (EBRT) with iodine-125 seed brachytherapy vs. brachytherapy alone for prostate cancer treatment in patients with intermediate and high risk of disease recurrence.Methods and MaterialsNinety-six patients were treated from January 1998 to December 2006. Twenty-four patients received combined treatment and 72 patients received brachytherapy alone. Patients were classified into intermediate or high risk of recurrence according to the D’Amico’s classification. The prescribed dose for brachytherapy was 145 Gy as monotherapy and 110 Gy for combined treatment. The dose of EBRT was 45 Gy over 5 weeks, with 1.8 Gy daily fractions. Results were analyzed based on Phoenix definition of biochemical recurrence, that is, nadir plus 2 ng/mL.ResultsBiochemical control was achieved by 96% (23 of 24) of patients receiving combined treatment and by 72% (52 of 72) in the group treated by brachytherapy alone (p < 0.015). The addition of EBRT resulted in a 94% biochemical disease-free survival at 5 years; and in brachytherapy alone group, the rate was 54% (p < 0.011). Mean followup was 96 months (24–132 months; confidence interval 95%: 90–102).ConclusionThis study shows that in patients with localized prostate cancer, with intermediate and high risk of biochemical recurrence, the addition of EBRT can confer a significant biochemical control advantage when added to brachytherapy.     

Pharyngeal airspace of asthmatic individuals and those suffering from obstructive sleep apnea syndrome: Study by CBCT

PurposeThe objective of the present study was to comparatively evaluate the oropharyngeal space of patients with obstructive sleep apnea syndrome (OSA) and asthma by means of Cone Beam Computed Tomography (CBCT) images.Material and methodsThe study included individuals with OSA and asthma (n = 10), with OSA and without asthma (n = 6), asthmatics without OSA (n = 6) and healthy individuals (n = 25). All patients were evaluated by a pneumologist and submitted to a nocturnal polysomnogram. Participants underwent CBCT examinations using an I-CAT^® device (Imaging Sciences International, Hatfield, PA, U.S.A.) and all images were exported to Dolphin Image 3D^® software. Cephalometric measurements were taken, as well as measurements of length (C), volume (VOL), sagittal area (SA) and minimum cross-sectional area (MCA); an evaluation was made of the format and contour of the upper airway in three dimensions, with p < 0.05 considered significant.ResultsIn the results of the present study, a statistically significant difference was found between VOL, SA and MCA (p = 0.011; p = 0.009; p = 0.010) with reduced elevated values among the OSA + Asthma, OSA, Asthma and Control groups. Significant differences were seen between the linear (AP), cross-sectional (TR) and mean transverse area (TA) measurements in the group of patients with OSA and asthma as compared to the control group. In the control group, the greatest narrowing of the airway was observed either in the retroglossal or retropalatal area, while more patients in the experimental groups showed narrowing in the retropalatal area.ConclusionThe condition of OSA + asthma was associated with a substantial reduction in upper airway measurements in comparison to controls.     

Undiagnosed late-onset chylothorax accompanied by fatal acute pulmonary thromboembolism after surgical treatment of lung cancer: An autopsy case and review of the literature

Late-onset chylothorax is a relatively rare and essentially benign postoperative complication. We describe an autopsy case of undiagnosed hemi-chylothorax accompanied by fatal acute pulmonary thromboembolism after pulmonary resection and lymph node dissection for lung cancer, reviewing the literature. The patient was a 60-year-old woman. She complained of dyspnea on the 20th postoperative day, which gradually increased. The patient suddenly died 2 days later. Autopsy demonstrated right chylothorax (1000 ml), and fatal acute pulmonary thromboembolism, mainly on the left side, originating from the lower extremities. Postoperative chylothorax, causing respiratory and pulmonary circulatory disturbance, may provide an important predisposition to ward fatality due to pulmonary thromboembolism even among those showing a milder type; thus careful management is necessary.     

Morphological analysis of astrocytes in the hippocampus in mechanical asphyxiation

The present study investigated the morphology of astrocytes in the hippocampus and serum S100B levels in cases of mechanical asphyxia due to neck compression (n = 23: atypical hanging, n = 7; ligature/manual strangulation, n = 16) with regard to the classical autopsy findings, compared with those of other types of asphyxiation (n = 9) and acute myocardial infarction/ischemia (AMI, n = 20). The decrease in intact astrocyte number, as shown by S100 and GFAP-immunostaining, was larger for asphyxiation due to neck compression compared with that for other asphyxiation and AMI, showing a correlation with the increase in the serum S100B levels. The decrease in intact astrocyte number and increase in serum S100B were closely related to the severity of conjunctival petechial hemorrhage and fracture(s) of the hyoid bone and/or thyroid cartilage in asphyxia due to neck compression. These findings suggest that hippocampal astrocyte injury is caused by cerebral hypoxia accompanied by congestion, especially in mechanical asphyxia due to neck compression.     

A comparison of kV and MV imaging in head and neck image guided radiotherapy

PurposeTo compare and assess kV and MV imaging modalities and their role in image guided radiotherapy (IGRT) for head and neck cancer patients.MethodTwelve patients receiving radical radiotherapy to the head and neck were analysed in this study. Six patients undertook MV daily online intervention and a further six patients undertook kV daily online intervention. Pre-intervention field placement data were collected from three separate observers' image match analysis for each patient. The radiotherapy collective involved in the daily online image match analysis formed the fourth observer in the study. The primary end point was to establish the difference in inter- and intra-observer variance between kV and MV imaging modalities.ResultsThe range of the standard deviations of systematic set-up error for MV imaging calculated was 1.47–2.33 mm (MV) and 1.61–1.64 mm (kV) for the right–left (RL), 2.10–2.17 mm (MV) and 1.53–1.84 mm (kV) for the cranio–caudal (CC) and 1.43–1.63 mm (MV) and 1.02–1.11 mm (kV) for the anterior–posterior (AP). The mean inter-observer variance was 0.21 mm (MV) and 0.41 mm (kV) for the RL, 0.53 mm (MV) and 0.55 mm (kV) for the CC and 0.23 mm (MV) and 0.16 mm (kV) for the AP direction. Intra-observer mean variance was in the order of 0.60 mm (MV) and 0.16 mm (kV) for the RL, 1.41 mm (MV) and 0.05 mm (kV) for the CC and 1.41 mm (MV) and 0.08 mm (kV) for the AP.DiscussionThe data in this study suggest both inter- and intra-observer consistency across kV and MV imaging modalities were comparable. However, it is felt that the improved clarity and quality of kV imaging allows all observers to analyse images in a consistent manner, identifying and acting on potential field placement moves.ConclusionThe introduction of kV imaging has maintained the high levels of inter- and intra-observer consistency achieved with MV imaging. This in turn further enables positive verification outcomes and supports the implementation of potential reductions in action thresholds. The increased quality, clarity and field of view offered by kV imaging have established it as the method of choice for head and neck IGRT at Radiation Oncology Queensland.