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.     

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.     

Postmortem urinary catecholamine levels with regard to the cause of death

Previous studies suggested that serum catecholamines are useful for investigating stress responses in the death process. The present study analyzed postmortem urinary adrenaline (Ad), noradrenaline (Nad) and dopamine (DA) in serial forensic autopsy cases (n = 199: 154 males and 45 females; age >9 years; survival time <0.5–168 h; within 10 days postmortem) to investigate the differences among the causes of death with special regard to hyperthermia (heatstroke; n = 11) and hypothermia (cold exposure; n = 10); other cases included fatalities from injury (n = 47), mechanical asphyxiation (n = 18), drowning (n = 14), intoxication (n = 31), fire fatality (n = 33) and natural death (n = 35). Each catecholamine level in urine was independent of the age or gender of the subjects, postmortem interval over 10 days or survival time, and did not correlate with the blood level. Urinary Adr and Nad levels were similar to those of clinical serum reference ranges, while DA was higher in all cases. Adr and Nad were higher in blunt head injury, methamphetamine abuse, hypothermia (cold exposure) and hyperthermia (heat stroke), but were low in mechanical asphyxia, drowning, fire fatality, sedative-hypnotic intoxication and acute cardiac death. DA was higher in injury, drowning, fire fatality, methamphetamine abuse and acute cardiac death, but was lower in mechanical asphyxiation and sedative-hypnotic intoxication. These profiles were quite different from those of serum levels, involving a predominant increase of DA, and may be useful for differentiating hyperthermia (heatstroke) and hypothermia (cold exposure) from drowning, sedative-hypnotic intoxication and sudden cardiac death.     

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.     

Step-rate thresholds for moderate and vigorous-intensity activity in persons with Down syndrome

ObjectivesMonitoring physical activity intensity in persons with Down syndrome (DS) may be affected by an altered relationship between metabolic equivalent units (METs) and step-rate. This study examined whether the relationship between METs and step-rate is altered in persons with DS and developed step-rate thresholds for activity intensity for these persons.DesignCross-sectional.MethodsEighteen persons with DS (25 ± 7 years; 8 women) and 22 persons without DS (26 ± 5 years; 9 women) completed six over-ground walking trials each lasting 6 min at their preferred speed and at 0.5, 0.75, 1.0, 1.25, and 1.5 m s^?1. METs were measured with portable spirometry and step-rate with hand-tally. Random effects models were used to predict METs from step-rate, squared step-rate, height, presence of DS, sex, and body mass index (BMI).ResultsStep-rate, squared step-rate, height, and presence of DS contributed significantly to the model (SE = 0.20 METs; R² = 0.63); sex and BMI did not contribute. As height increased, step-rate thresholds for moderate and vigorous-intensity activity decreased. For a given height, participants with DS had lower step-rate at the moderate-intensity threshold than participants without DS. Across participant heights, the moderate-intensity cut-off ranged between 101 and 76 steps min^?1 in persons with DS and between 103 and 80 steps min^?1 in persons without DS. For persons with DS, step-rate at the vigorous-intensity threshold ranged between 136 and 126 steps min^?1.ConclusionsPersons with DS showed altered relationship between METs and step-rate and had lower step-rate thresholds for moderate-intensity activity than persons without DS.     

The association between multiple sclerosis-related fatigue and balance as a function of central sensory integration

BackgroundFatigue and impaired upright postural control (balance) are the two most common complaints in persons with multiple sclerosis (MS), with limited evidence on how they are related.ObjectiveTo examine the relationship between symptomatic fatigue and balance as a function of central sensory integration in persons with multiple sclerosis.Materials and methodsSeventeen persons with relapsing-remitting MS were enrolled in this cross-sectional study. Primary measurements included fatigue (modified fatigue impact scale – MFIS); balance (dynamic posturography, sensory organization testing – SOT); and walking capacity (six-minute walk test – 6MWT).ResultsFatigue scores were significantly associated with balance: MFIS total (r = ?0.78; p < 0.001), physical subscale (r = ?0.77; p < 0.001), cognitive subscale (r = ?0.75; p = 0.001) and psychosocial subscale (r = ?0.53; p = 0.030) scores. MFIS total score was a significant predictor of balance (p ≤ 0.001), accounting for 62% of the variability in SOT composite scores. Significant differences in fatigue (d = 1.75; p = 0.005) and balance (d = 1.74; p = 0.005) were found for participants who had cerebellar and brainstem involvement compared to those without.ConclusionsSymptomatic fatigue is significantly related to balance and is a significant predictor of balance as a function of central sensory integration in persons with MS. Fatigue and balance are associated with cerebellar and brainstem involvement. This study provides early evidence supporting the theory that for those persons with MS who struggle to maintain steady balance during tasks that stimulate the central sensory integration process, complaints of significant levels of fatigue are probable.     

Pulmonary embolism and sudden–unexpected death: Prospective study on 2477 forensic autopsies performed at the Institute of Legal Medicine in Seville

Pulmonary embolism (PE) and deep venous thrombosis (DVT) are clinical manifestations of the same entity, venous thromboembolic disease (VTD). In approximately 25% of patients, the first manifestation of PE is sudden–unexpected death.We carried out a prospective study at the forensic pathology service of the Institute of Legal Medicine in Seville with the aim to know the incidence of PE as well as to describe the epidemiological, pathological and clinical characteristics of these deaths and associated risk factors.In the study period (32 months) 32 cases of PE were registered from a total of 2447 completed autopsies. Three cases were considered accidental deaths and the remaining 29 cases were sudden natural deaths, which represents 1.3% of the total autopsies, 2.6% of natural deaths and 4.3% of sudden deaths. Nineteen cases (59%) were men (mean age 50.3 ± 13.8, range 22–74 years) and 13 cases (41%) were women (mean age 50.3 ± 13.8, range 18–87 years). In 78% of cases death occurred at home or during transfer to a health care centre, mainly during the fall or winter (69%) and between 8 a.m. and 4 p.m. (47%). Pulmonary infarction was associated only in two cases (6%). Nine cases (28%) had been immobilized but only three (9%) received anticoagulant therapy. Surgical interventions had occurred in seven cases (22%). A history of psychiatric pathology was found in 31%. Overweight or obesity was found in 75%. The most frequent symptoms prior to death were dyspnea (31%) and chest pain (19%), and 19% of patients were examined in an Emergencies Department for symptoms compatible with deep vein thrombosis and/or PE, but this diagnosis was not suspected in any case.PE frequently makes its first appearance as sudden death. In addition to the classic risk factors, this study highlights that 75% of the cases were overweight/obese as well as 31% having had a history of psychiatric disorders and treatment as to support that this association should be considered as a risk factor. PE continues to be under diagnosed in Emergencies Department patients, which hinders the application of adequate therapeutic measures to prevent these deaths.     

Diagnostic implications of urinary liver-type fatty acid-binding protein and 8-hydroxy-2′-deoxyguanosine in forensic autopsy cases

Background/aimLiver-type fatty acid-binding protein (L-FABP) is a clinical biomarker of the progress of kidney disease. 8-Hydroxy-2′-deoxyguanosine (8-OHdG) is known as a biomarker of peroxidative DNA damage. We investigated both urinary L-FABP and 8-OHdG in forensic autopsy cases as biomarkers to elucidate the metabolic changes in survival periods after insults.MethodsIn 196 urinary samples from forensic autopsy cases, we measured L-FABP and 8-OHdG by enzyme-linked immunosorbent assay (ELISA) and creatinine by enzymatic assay. Urinary L-FABP/Cr and 8-OHdG/Cr were obtained.ResultsNo significant correlation was observed between urinary L-FABP/Cr or 8-OHdG/Cr, and gender, age, or postmortem interval. Regarding urinary L-FABP/Cr or 8-OHdG/Cr, there were no significant differences among the causes of death. In the survival/agony period, urinary L-FABP/Cr under the cut-off value 31.3 might show that the survival/agony period was within 1 h. Under the cut-off value of urinary 8-OHdG/Cr, 17.8, might indicate that it is within 24 h.ConclusionUrinary L-FABP/Cr may rise within a relatively short survival/agony period, and urinary 8-OHdG/Cr may increase when the damage continues longer. Measuring the urinary L-FABP/Cr and 8-OHdG/Cr might be useful in elucidating the survival/agony period.     

Cardiothoracic ratio in postmortem chest radiography with regard to the cause of death

It is difficult to examine the intact in situ status of thoracic organs, including the heart and lungs, after opening the chest at autopsy. The present study investigated the pathological diagnostic significance of the cardiothoracic ratio (CTR) with regard to heart and lung weight in postmortem plain chest radiography. The pathological diagnostic significance of the CTR in postmortem plain chest radiography using serial forensic autopsy cases of adults (>19 years of age, n = 367, within 72 h postmortem) was retrospectively investigated. In natural deaths, CTR was larger for heart diseases, and was smaller for pulmonary infection and gastrointestinal bleeding, showing correlations to the heart weight except in cases of hemopericardium. In traumatic deaths, CTR was larger in cases of fire fatality and acute methamphetamine intoxication, and varied in cases of blunt injury, showing correlations to the heart weight. However, CTR was smaller for sharp instrument injury and drowning, independently of the heart weight. These findings suggest that postmortem CTR (median, 55.6%, measured using a mobile X-ray apparatus) primarily depends on the heart weight, but is substantially modified during the process of death: the CTR may be enlarged by cardiac dilatation due to terminal congestive heart failure, but may be reduced by inflated lungs in drowning or hypovolemia due to fatal hemorrhage. CTR showed a mild correlation to the right diaphragm level, which was also related to the cause of death, but was independent of the left diaphragm level. Plain chest radiographic findings may also be helpful in investigating the pathophysiology of death, and are to some extent comparable with clinical findings. This also suggests the potential usefulness of postmortem CT and MRI for analysis of terminal cardiac function.     

“Blind spots” in forensic autopsy: Improved detection of retrobulbar hemorrhage and orbital lesions by postmortem computed tomography (PMCT)

ObjectivesThe purpose of this study was to correlate the occurrence of retrobulbar hemorrhage (RBH) with mechanism of injury, external signs and autopsy findings to postmortem computed tomography (PMCT).MethodsSix-teen subjects presented with RBH and underwent PMCT, external inspection and conventional autopsy. External inspection was evaluated for findings of the bulbs, black eye, raccoon eyes and Battle’s sign. Fractures of the viscerocranium, orbital lesions and RBH were evaluated by PMCT. Autopsy and PMCT was evaluated for orbital roof and basilar skull fracture.ResultsThe leading manner of death was accident with central regulatory failure in cases of RBH (31.25%). Imaging showed a high sensitivity in detection of orbital roof and basilar skull fractures (100%), but was less specific compared to autopsy. Volume of RBH (0.1–2.4 ml) correlated positively to the presence of Battle’s sign (p < 0.06) and the postmortem interval. Ecchymosis on external inspection correlated with RBH. There was a statistical significant correlation between bulbar lesion and RBH. Orbital roof fracture count weakly correlated with the total PMCT derived RBH volume. Maxillary hemosinus correlated to maxillary fractures, but not to RBH.ConclusionsRBH are a specific finding in forensically relevant head trauma. PMCT is an excellent tool in detecting and quantifying morphological trauma findings particularly in the viscerocranium, one of the most relevant “blind spots” of classic autopsy. PMCT was superior in detecting osseous lesions, scrutinizing autopsy as the gold standard.     

Postmortem serum levels of amylase and gamma glutamyl transferase (GGT) as markers of systemic tissue damage in forensic autopsy

Serum amylase (AMY) and gamma glutamyl transferase (GGT) are routine clinical markers for investigating pancreatic and hepatobiliary disorders, respectively, but are also increased in systemic deterioration following critical trauma and diseases. The present study investigated the postmortem levels in bilateral cardiac blood of medicolegal autopsy cases without decomposition (n = 163), excluding those with pancreatic or hepatic injury, or preexisting pathologies, as well as prolonged death cases, to evaluate the changes due to systemic deterioration in the death process after fatal insults with special regard to intoxication, hyperthermia (heatstroke) and hypothermia (cold exposure). Serum AMY and GGT levels were virtually independent of postmortem interval. Serum AMY level was mostly higher than the clinical reference range, predominantly including salivary fractions, but was usually below 1000 U/L except for fatal intoxication, which showed significant increases of total AMY as well as salivary and pancreatic fractions in bilateral cardiac blood. Serum levels of salivary and pancreatic AMY fractions showed tendencies to be related to pancreatic subcapsular and interstitial bleeding, respectively, which were relatively frequent and evident in mechanical asphyxiation, intoxication and hyperthermia (heatstroke). Serum GGT was often elevated (mostly below 300 U/L) in cases other than hypothermia (cold exposure). These findings suggest postmortem serum AMY and GGT as indicators of the severity of systemic organ damage in death processes, especially in intoxication; however, elevated serum AMY and GGT levels over 1000 and 300 U/L might indicate significant pancreatic and hepatobiliary pathologies, respectively, except for an elevated serum AMY level in intoxication.     

Ethanol as a single toxin in non-traumatic deaths – A toxicology perspective

There were 285 autopsy cases in 2010 where ethanol was the only toxin. To try to ascertain the toxicity of ethanol alone, those cases where clinical details stated ‘sudden death’, ‘collapsed’, ‘brought in dead to hospital’, ‘found dead at home’, ‘fell down stairs and dead at end of stairs’, ‘sudden death in alcoholic’ and ‘brought in dead and seizures’ were extracted. There were 55 males aged from 23 to 76 years and 17 females aged from 41 to 71 years who fulfilled these criteria. Blood ethanol ranged from <50 to 556 mg/dl. The median band in males is 200–249 mg/dl and the 31% of male cases are in the 200s mg/dl range, levels conventionally considered benign. The levels found in females were spread relatively evenly across the range 150–600 mg/dl. The urine/blood ethanol ratios ranged from 0.13 to 2.02. The blood/vitreous ratios in 10 cases ranged from 0.76 to 1.24 with a median value of 1.16. Calculated blood ethanol from vitreous levels showed a negative bias when compared to the measured value but not in all cases. This limits the role of calculated values in legal cases. The threshold for lethal alcohol toxicity is indistinct and likely to be lower than conventionally acknowledged.     

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.     

A BMI-adjusted ultra-low-dose CT angiography protocol for the peripheral arteries—Image quality,diagnostic accuracy and radiation exposure

ObjectivesTo investigate radiation exposure, objective image quality, and the diagnostic accuracy of a BMI-adjusted ultra-low-dose CT angiography (CTA) protocol for the assessment of peripheral arterial disease (PAD), with digital subtraction angiography (DSA) as the standard of reference.MethodsIn this prospective, IRB-approved study, 40 PAD patients (30 male, mean age 72 years) underwent CTA on a dual-source CT scanner at 80 kV tube voltage. The reference amplitude for tube current modulation was personalized based on the body mass index (BMI) with 120 mAs for [BMI ≤ 25] or 150 mAs for [25 < BMI ≤ 30]. Iterative image reconstruction was applied. The presence of significant stenoses (>70%) was assessed by two readers independently and compared to subsequent DSA. Radiation exposure was assessed with the computed tomography dose index (CTDIvol) and the dosis-length product (DLP). Objective image quality was assessed via contrast- and signal-to-noise ratio (CNR and SNR) measurements. Radiation exposure and image quality were compared between the BMI groups and between the BMI-adjusted ultra-low-dose protocol and the low-dose institutional standard protocol (ISP).ResultsThe BMI-adjusted ultra-low-dose protocol reached high diagnostic accuracy values of 94% for Reader 1 and 93% for Reader 2. Moreover, in comparison to the ISP, it showed significantly (p < 0.001) lower CTDIvol (1.97 ± 0.55 mGy vs. 4.18 ± 0.62 mGy) and DLP (256 ± 81 mGy x cm vs. 544 ± 83 mGy x cm) but similar image quality (p = 0.37 for CNR). Furthermore, image quality was similar between BMI groups (p = 0.86 for CNR).ConclusionsA CT protocol that incorporates low kV settings with a personalized (BMI-adjusted) reference amplitude for tube current modulation and iterative reconstruction enables very low radiation exposure CTA, while maintaining good image quality and high diagnostic accuracy in the assessment of PAD.     

A study of neutrophil as a morphological marker of death from hemorrhagic shock in forensic practice cases

Excessive autolytic inflammation accompanied by dysfunction of “shock organs” is recognized as arising from hemorrhagic shock due to the promotion of endovascular recruitment of neutrophils. Here, activated neutrophils in the organs of autopsy cases were evaluated as a marker of death from hemorrhagic shock. Morphologically-determined injury to the heart, lung, liver, and kidney was investigated in death from five major causes: hemorrhagic shock, head injury, exsanguination, asphyxia, and drowning. The frequency of activated neutrophils was assessed by immunohistochemical staining. When the antemortem interval was less than 2 h, it was found that neither morphological damage nor neutrophil frequencies were significantly different after death due to any of these 5 causes. In contrast, at longer antemortem intervals up to 8 h, the frequency of neutrophils in hemorrhagic shock was significantly greater than in head injury, whereas the degree of morphological damage was no different. Thus, the appearance of activated neutrophils in the primary organs could be useful to identify death caused by hemorrhagic shock after longer antemortem intervals.     

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.     

A case of the large retroperitoneal solitary fibrous tumor

A rare autopsy case of the extremely large retroperitoneal solitary fibrous tumor is reported. A 52-year-old female with a huge abdominal distention was found dead at home. She showed remarkable emaciation. The autopsy revealed a huge retroperitoneal tumor weighing 11.9 kg (36 × 30 × 20 cm in size), which occupied the entire intraperitoneal cavity. Histologically, the tumor consisted of spindle parenchymal cells with fibrous tissues. Immunohistochemically, CD34 was positively stained, whereas S-100, smooth muscle actin, and factor VIII were negative. Her cause of death was diagnosed as emaciation due to the compression of the entire intestine by the tumor. This is a rare case of the extremely large retroperitoneal solitary fibrous tumor, which caused the occasional intestinal obstruction. This disease should be considered in the differential diagnosis of retroperitoneal large tumors that cause accidental deaths in forensic autopsies.     

Medicolegal death of homeless persons in Tokyo Metropolis over 12 years (1999–2010)

BackgroundRecently, the number of homeless persons in Japan has steadily decreased. However, it is not certain whether unexpected death of the homeless have actually decreased in proportion to decrease in total number of cases.MethodsThe documentation of medicolegal deaths among homeless persons handled in the Tokyo Medical Examiner’s Office during 1999–2010 were reviewed, and we compared the number and manner/cause of death between cases occurring before 2004 and those occurring after 2004. In addition, we compared manner/cause of death between homeless and non-homeless persons.ResultsThe number of medicolegal deaths of homeless persons remained almost the same during the study period in spite of a marked decrease in the total number of homeless persons after 2004. Age distribution shifted to older after 2004, and a higher proportion of the deceased had longer postmortem periods after 2004. Comparison between the manners/causes of death of the cases occurring before 2004 and those occurring after 2004 showed little difference. Disease constituted about 70% of all cases, and causes of death from disease were more various than those of non-homeless persons. Certain specific patterns included a higher proportion of death from circulatory disease in elderly homeless persons and a higher proportion of death from alcohol-related digestive disease and tuberculosis among younger homeless persons. Regarding accidental death, hypothermia was a leading cause of death irrespective of age group.ConclusionAging and isolation among homeless persons might contribute to an unchanged number of medicolegal death of them. In addition to measures to address frequent causes of death in each age group, better intervention for isolated homeless persons might be a key factor to prevent unexpected deaths of homeless persons in the future.     

Measuring postmortem glycated hemoglobin – A comparison of three methods

Glycated hemoglobin (HbA1c) is a glycoprotein formed as a result of the non-enzymatic addition of d-glucose to the hemoglobin β-chain. The amount of HbA1c in the blood is dependent on mean glucose levels present during the 1–2 months preceding measurement, and it is an indicator of long-term glycemic levels. HbA1c is a useful marker in postmortem biochemistry in determining cause of death in acetonemic cases by allowing to distinguish diabetic ketoacidosis (DKA) from starvation or alcoholic ketoacidosis (AKA) and intoxication by acetone or isopropanol. We evaluated three methods for postmortem HbA1c measurement: Mono S cation exchange HPLC, affinity chromatography using point-of-care analyzer and a direct enzymatic method by. Additionally, optimization of sample storage and preservatives was performed and interpretation of the results in autopsy cases is discussed. Our results indicate that the HbA1c levels of postmortem samples can be reliably measured with Mono S HPLC. EDTA is the preferable preservative, as samples can be measured after as long as 4 weeks storage at +4 °C. Our study shows that HbA1c analysis is a valuable tool alongside glucose and ketone body analysis in determining the metabolic state of deceased persons in medicolegal autopsies.     

Repeated surgeries in invasive lobular breast cancer with preoperative MRI: Role of additional carcinoma in situ and background parenchymal enhancement

ObjectivesAnalysing the influence of additional carcinoma in situ (CIS) and background parenchymal enhancement (BPE) in preoperative MRI on repeated surgeries in patients with invasive lobular carcinoma (ILC) of the breast.MethodsRetrospective analysis of 106 patients (mean age 58.6 ± 9.9 years) with 108 ILC. Preoperative tumour size as assessed by MRI, mammography and sonography was recorded and compared to histopathology. In contrast-enhanced MRI, the degree of BPE was categorised by two readers. The influence of additionally detected CIS and BPE on the rate of repeated surgeries was analysed.ResultsAdditional CIS was present in 45.4% of the cases (49/108). The degree of BPE was minimal or mild in 80% of the cases and moderate or marked in 20% of the cases. In 17 cases (15.7%) at least one repeated surgery was performed. In n = 15 of these cases, repeated surgery was performed after BCT (n = 9 re-excisions, n = 6 conversions to mastectomy), in n = 2 cases after initial mastectomy. The initial surgical procedure (p = 0.008) and additional CIS (p = 0.046) significantly influenced the rate of repeated surgeries, while tumour size, patient age and BPE did not (p = ns).ConclusionsAdditional CIS was associated with a higher rate of repeated surgeries, whereas BPE had no influence.