Diagnosis of drowning: Electrolytes and total protein in sphenoid sinus liquid.

In this study, electrolyte (sodium (Na), chlorine (Cl), and magnesium (Mg)) and total protein (TP) concentrations and volume of liquid in the sphenoid sinus were examined to determine their usefulness to elucidate whether drowning occurred in freshwater or seawater. We examined 68 cases (seawater drowning group: 27 cases, freshwater drowning group: 21 cases, non-drowning group: 20 cases). There was a significant difference in Na, Cl, Mg, and TP concentrations of liquid in the sphenoid sinus among the three groups (seawater drowning, freshwater drowning, and non-drowning groups). To distinguish freshwater drowning from seawater drowning, Na, Cl, and Mg concentrations of liquid in the sphenoid sinus might serve as useful indicators.

Development for the measurement of serum thiosulfate using LC-MS/MS in forensic diagnosis of H2S poisoning.

Thiosulfate measurement is crucial to diagnosis of hydrogen sulfide (H2S) poisoning in forensic toxicology. Although GC-MS method is currently regarded as a standard thiosulfate measurement, it requires complicated sample preparation prior to analysis. This study presents a simple, rapid, and highly sensitive method for the quantitative analysis of serum thiosulfate by using liquid chromatography-tandem mass spectrometry (LC-MS/MS). This method is based on selected reaction monitoring and has high sensitivity with a lower quantification limit of 0.5µM. Precision and accuracy of this method meet the basic requirements for quantitative analysis (intra- and inter-day tests have a relative standard deviation of ⩽10.4%; range of analytical recovery is 94.3-102.6%). On the measurements of serum thiosulfate by our developed method, a thiosulfate concentration as 57.5µM was detected clearly in the H2S poisoning case comparing to the non poisoning case in which only a trace amount of thiosulfate was observed.

Appropriate blood sampling sites for measuring Tg concentrations for forensic diagnosis.

Previous studies have reported that thyroglobulin (Tg) concentrations in heart blood are high in cases of asphyxia caused by neck compression such as hanging, strangulation, and throttling and in those with fatal traumatic brain injuries. However, even in cases without these findings presumed to increase the Tg concentration in the previous studies, we previously reported that in some cases the Tg concentration in right heart blood (RHB) and left heart blood (LHB) exceeded the standard value for diagnosis (200 ng/mL) defined in previous studies and the Tg concentration in RHB was significantly higher than that in LHB. In the present study, in our 46 forensic autopsy cases without findings presumed to increase Tg concentration, we separately collected external iliac venous blood (IVB) and external iliac arterial blood (IAB) in addition to RHB and LHB, measured Tg concentrations in RHB, LHB, IVB, and LAB (TRHB, TLHB, TIVB, and TIAB, respectively), and investigated the appropriate blood sampling site for measuring Tg concentrations for forensic diagnosis. TRHB, TLHB, TIVB, and TIAB were 386.3 ± 674.1, 105.8 ± 179.0, 109.2 ± 166.8, and 43.7 ± 90.9 ng/mL, respectively. There were statistically significant differences between TRHB and TLHB, TIVB and TIAB, TRHB and TIVB, and TLHB and TIAB. Tg is more readily diffused by the venous system (RHB, IVB) than by the arterial system (LHB, IAB) because the venous system retains more blood volume after death. Tg is more readily diffused to heart blood (RHB, LHB) than to peripheral blood (IVB, IAB) because of the proximity of the heart to the thyroid gland. Therefore, we conclude that Tg leaks into the vessels around the thyroid gland because of the influences of postmortem changes and subsequently diffuses through the blood after death, and therefore the Tg concentration increases after death. When Tg concentration values are used for forensic diagnosis, it is appropriate to measure them using peripheral arterial blood situated distant from the thyroid gland.

Unreliability of the use of thyroglobulin concentration in postmortem blood samples in forensic diagnosis.

Previous studies have reported that the concentration of thyroglobulin (Tg) in heart blood is high in cases of asphyxia by neck compression such as hanging, strangulation, and throttling and in those with traumatic injuries to the head. However, we have experienced cases in which we observed high Tg concentrations without such findings. Therefore, we analyzed the influence of postmortem changes on Tg concentration. Of 253 forensic autopsies conducted at our institution, we analyzed 44 cases without the findings presumed to increase Tg concentration. We collected right heart blood (RHB) and left heart blood (LHB) separately and measured Tg concentrations in each. The Tg concentration of the RHB in 19 (43%) cases and that of the LHB in 10 (23%) cases was higher than the standard value (200ng/ml) obtained in previous studies. In some cases, we found large differences between the Tg concentrations of RHB and LHB. We suggest that Tg concentration can increase above the standard value and that a difference between the Tg concentration of RHB and LHB arises as a result of postmortem changes. Consequently, if there is a large difference between the Tg concentration of RHB and LHB, the concentration of Tg should not be used as a basis for forensic diagnosis.

Raising future forensic pathologists (first report): results of a preliminary questionnaire survey.

The shortage of future forensic pathologists is a serious problem both in Japan and overseas. In Japan, however, factors such as government budget cuts and increasing the autopsy rates, make the condition even worse. In an attempt to improve this situation, we implemented a questionnaire survey to investigate the particular features necessary when selecting a career in forensic medicine. As a preliminary study, we sent the questionnaire along with an anonymous answer sheet to all forensic pathologists with a degree in medicine M.D., who were affiliated with universities in Hokkaido and the Tohoku district of Japan as of August 2011. Thirteen physicians in nine universities (response rate 77.8%) returned the answer sheet. Characteristics of participants are listed below: years of experience, board specialty and number of years as board certified specialists, percentage of work effort spent on autopsy practice, the time when they decided to work as a forensic pathologist, the time when to best recommend forensic pathologist as a career, and crucial factors in choosing the specialty of forensic medicine. As a result of this research, we've revealed the importance of undergraduate medical education or the effect on the role models. Furthermore, we've also extracted miscellaneous comments, such as standardization of minimum requirements. In our study, we' ve found some clues to increase future candidates in the field forensic medicine. However, we must collect further samples for our questionnaire survey to validate the study, and, as a future project, we must also address this problem at the congress of forensic medicine.

Raising future forensic pathologists (second report): results of a preliminary interview survey.

Fostering the specialists of forensic pathology has become a worldwide problem. In Japan, factors such as government budget cuts, the introduction of initial postgraduate clinical training system, as well as national policy on increasing autopsy rates, may deter young graduates from entering this specialty. The aim of this study was to look for clues to promote the training of young forensic pathologists. We selected and interviewed five forensic pathologists, with each interview lasting approximately 60 minutes, and picked up common views among them. The interviews topic, based on a prior survey, was: "What do you believe forensic pathologists require to promote the training of their successors." We selected common views on the three themes listed below; 1) standardization of minimum requirements to be independent forensic pathologists, 2) balancing forensic pathologists' time among autopsy practice, research, and education, and 3) preparing positions for younger forensic pathologists. These opinions were the same as those of previous studies conducted overseas and must be discussed at academic conferences in the future, where both junior and senior forensic pathologists participate.

Application of electrolyte analysis of pleural effusion to diagnosis of drowning.

We measured concentrations of sodium (Na), chloride (Cl), calcium (Ca), and magnesium (Mg) in pleural effusion from forensic autopsy cases to examine whether they were useful for a diagnosis of drowning. We analyzed a total of 51 cases (15 seawater drowning, 10 freshwater drowning, and 26 non-drowning), and determined the following reference values. If the concentration of Na or Cl is under 65 mEq/l, a diagnosis of freshwater drowning can be made. If the concentration of Na is higher than 175 mEq/l, or that of Cl is higher than 155 mEq/l, or that of Ca is higher than 16 mg/dl, or that of Mg is higher than 15 mg/dl, a diagnosis of seawater drowning can be made. We recommend that pleural effusion from the left and the right thoracic cavities should be collected and analyzed separately because large differences may be observed between each side in the case of drowning. If one side corresponds to the reference value for seawater or freshwater drowning and the other side does not, a diagnosis of drowning can still be made according to the obtained value.

[Observations on injuries by blunt objects].

Based on my personal experience publishing case reports on blunt injuries, I hereby focus on issues that have recently come to my attention. 1. Abrasions: 1) As to whether they occurred ante-mortem or post-mortem; those reddish in color cannot always have occurred antemortem. When they overlap with reddish (-purple) discoloration, as in hypostasis, post-mortem abrasions look reddish as well. Abrasions larger than the tip of the finger or the palm of the hand are often seen post-mortem and are thought to occur due to the touching of putrefied skin post-mortem. 2) There are cases where the direction in which the epidermis peeled-off is not apparent, when it peels off in many directions or where there is no residual epidermis. 3) The shape and size of an abrasion can indicate the structure of the offending blunt object. When there is an abrasion on the scalp 3 to 4 cm in diameter, with structures 5 mm in diameter at the margins of the abrasion, it can be inferred that the victim fell on a paved gravel road. 2. Bruises: 1) Inferring the nature of a blunt object: (1) Evidence of a fist blow: Co-existence of the following three features indicates a blow by the fist : 1. macular discoloration, 2. within an area of approximately 8 cm by 5 cm, 3. with an abrasion from the thumb nail. (2) Evidence of being grabbed:Try to grab the corpse with your own hand during autopsy to find how the person was grabbed. Bruise-like discoloration can be generated post-mortem on the upper arm, when a body is being drawn out of water, for example. 2) Tram-line bruises: These appear when a victim was struck by a stick. To estimate the diameter of the object, it is useful to measure two parts of the bruising : the width of the pale part between the bruises and the width between the outer margins of the bruises. 3. Intradermal bleeding: There tends to be a grouping of hemorrhagic spots, the interval between which 1 mm or less. It can be generated by both direct and indirect force. Abrasions may be both present or absent. 4. Contused lacerated wounds: First of all, it is necessary to determine the characteristics of the offending blunt object based on the findings of the wound. When the edge of the end of a column works against the skin at an angle, abrasions are mainly generated on the one margin abraded by the edge. When the smooth round surface of a column is applied, abrasions are not likely to occur on or near the margins. To diagnose a wound as being contused, the following findings are considered valuable : the margins of the wound are more irregular than the incision; the margins are contused; the osseous membrane is detached at the bottom of the wound; and abrasions are present at the margins. Abrasions are generated when the surface of the object is rough and when the sharper edge is at an angle. They tend not to occur when the surface of the object is smooth with no angular edge or when the sharper edge works perpendicularly against the skin. 5. Post-mortem mutilation by animals: It is necessary to distinguish wounds caused by animals from those that are man-made. Crows will tear out the eyeballs, open the intercostal muscle and devour the lungs. They pull and rip off the skin, but do not seem to chew on the bones. Dogs and foxes will chew on the bones, leaving traces of their teeth about 5 mm in width. Rats leave round-shaped parts missing from the skin, the margins of which are quite sharp. They do not seem to chew on the bones. 6. One pattern of injuries from an immersed body: A set of abrasions, bruises, pocket formation (décollement) of the head and face, accompanied by dehiscence or fracture of the spine and drowning indicates jumping into the water face first and banging the head against the bottom of the body of the water, followed by drowning. 7. A case of a traffic accident: The details of the accident became apparent from the following findings in and on the autopsied body: contused lacerations on both knees, abrasions and pocket formation (décollement) on the parietal region of the head, characteristically shaped abrasions on the back, acetabula fractures caused by raising of the femoral head, fractured ribs caused by antero-posterior or posteroanterior compression, and an annular fracture at the base of the skull. The abrasions on the back were determined to have been generated by compression of structures on the underside of the car. The contused lacerations on the knees were considered to have been generated upon impact with the bumper, and the posture of the victim was concluded to have been supine with his knees drawn up. Collaboration with police traffic investigators is considered essential. 8. The medico-legal diagnostic capability of young pathologists could be improved if they observed unexplainable findings during autopsy with their own eyes, researched and discussed the findings with their mentor and colleagues, and published case reports.

An autopsy case of sudden death due to acute gastric dilatation without rupture.

We report the first autopsy case of fatal gastric dilatation without rupture. A 31-year-old woman who lived alone was found dead in her living room. Despite being very thin, she showed marked abdominal distention. Autopsy and histological findings revealed that a severely distended stomach, of which walls notably thin and displayed transmural necrosis, occupied the entire abdominal cavity. Severe congestion was observed in the intestine and cecum. Theses findings suggest that bulimia nervosa together with anorexia nervosa resulted in rapid dilation of the stomach. We conclude that the cause of death was acute circulatory failure from hypovolemic shock that occurred following compression of the inferior vena cava and superior mesenteric vein, and by loss of circulatory volume to the third space.

Unusual injuries on the right hand and forearm caused by unidentified wild animals.

An old man was found dead in a rice paddy with his face down in the water. His right forearm and hand were severely injured and the shapes of injuries were unusual. It was initially suspected that the injuries had been caused by a cultivator placed at the site. However, they proved to be postmortem injuries because vital reactions were not observed. The skin was widely torn away. Some edges of the injuries looked like a bite mark and other parts looked like scratches. There were many parallel injuries on the right forearm and hand and footmark-like injuries on the right hand. They were probably caused by wild animals. Judging from the sizes and shapes of the footprint, bite marks and scratches, we estimated that the animal which caused the injuries was weasels.

Estimation of the time of death of decomposed or skeletonized bodies found outdoors in cold season in Sapporo city, located in the northern district of Japan.

In Sapporo city, located in the northern district of Japan, it is very difficult to estimate the time of death of decomposed or skeletonized bodies found outdoors in cold season (November-April) because postmortem changes are markedly retarded in the season compared with warm season (May-October), and the bodies are often damaged and skeletonized by carnivorous animals such as wild dogs and foxes. However, they cannot damage the brain in the cranium. The brain is mainly damaged by fly larvae. In Sapporo city, we can estimate that the time of death of a cadaver found outdoors in the cold season is in the beginning of November or before if fly larvae hatched in autumn exist on the cadaver, and that the time of death is in the beginning of November or after if fly larvae hatched in autumn do not exist and most of the brain remains in the cranium.

Age estimation from quantitative evaluation of atherosclerosis of abdominal aorta in Japanese.

To assess validity of age estimation from the degree of atherosclerosis of abdominal aorta, we quantitatively evaluated the atherosclerotic parameters (surface involvement of atherosclerotic lesions, atherosclerotic index, and aortic width at renal arteries and common iliac bifurcation, which was measured by using digital photographs at autopsy), and collected individual factors (age, sex, body height, body weight and heart weight, and body surface, body mass index and cardiomegaly index) in autopsied 103 bodies (62 males, 41 females) during 2 years. We statistically examined their data by multiple regression analysis to determine the effects of the individual factors on the proceeding parameters of atherosclerosis, and obtained correlation coefficient, regression equation, and standard error of estimate between the atherosclerotic parameters and age. Among the factors, only age was influential on all the atherosclerotic parameters, of which the surface involvement (SI%) and the aortic width at common iliac bifurcation (Wb cm) were acceptable as the parameters for age estimation, and useful in a wide age range, according to the results of the standard errors of estimate. We also recognized predicting formulae for age (Y) by multiple regression analysis; Y = 0.52SI + 9.53Wb - 4.41 in males and Y = 0.34SI + 18.47Wb - 23.32 in females.

An autopsy case of intraoperative death due to pulmonary fat embolism--possibly caused by release of tourniquet after multiple muscle-release and tenotomy of the bilateral lower limbs.

We report a case of a juvenile male with muscle rigidity caused by cerebral palsy who experienced intraoperative sudden death due to pulmonary fat embolism after multiple muscle-release and tenotomy of the bilateral lower limbs. Data were obtained through review of the surgical and anesthesia records, as well as from autopsy and histopathological examination. All surgical procedures were performed within the same operation, beginning with the right lower limb and then proceeding with the left lower limb, with application of a pneumatic tourniquet to avoid intraoperative hemorrhage. Slight changes in the hemodynamics were noticed after release of the right tourniquet. Further, sudden onset of hypotension, severe bradycardia, and a marked decrease in percutaneously monitored oxygen saturation occurred just after release of the left tourniquet when the left limb was raised for casting. The patient died despite immediate and vigorous cardiopulmonary resuscitation. At autopsy performed 20 h after death, examination of the lungs revealed a pale surface, slight edema, and obvious fat droplets in the vessels at the cut surfaces. Histopathological examination with fat staining was notable for the presence of pulmonary fat embolism. These results suggest that restoration of venous return after removal of the tourniquet combined with massive fat embolism from dead spaces was the likely cause of death.

[Problems in applying a rapid assay kit for cardiac troponin T to medico-legal blood samples].

It is difficult to diagnose cardiac-related death only by external examination. However, in the areas where no medical examiner system is established, the diagnosis is made mostly from the findings by external examination. Clinically, cardiac troponin T (cTnT) rapid assay kits are used for the diagnosis of ischemic heart disease. The kits have started being applied to forensic medicine and used for the diagnosis of cardiac-related death without exact evidence. In this study, we collected postmortem blood samples from 110 forensic autopsy cases and evaluated the utility of the kits in the field of forensic medicine. Blood samples collected from the left and the right parts of the hearts showed extremely high positive rates (95.1% each), and peripheral blood samples also showed very high positive rates (71.2%), although cardiac-related deaths were only 7 cases of all 110 cases. Because cTnT concentration of postmortem blood samples is affected by non-cardiac-related natural death, postmortem changes, or cardiopulmonary resuscitation, the results from using the kits are not reliable in determining the cause of death. We conclude that the kits cannot be applied in forensic medicine.

[Estimation of time of death by the use of the overwintering of flies].

We observed whether or not there were eggs, larvae, pupae, and empty pupal shells of flies on cadavers found outdoors in Sapporo, the northern district of Japan (43 degrees N). The temperature has an influence on the oviposition of flies. The average season in which flies lay eggs is from the middle of April to the beginning of November, although there is a little lag year by year. As flies overwinter generally as larvae, we can estimate postmortem interval of a cadaver found in spring on the basis of the size and the mortality of the larvae. If the length of larvae is 1 cm or longer, and many of them are dead, and if there are no empty pupal shells, the time of death of a cadaver found outdoors in spring is between the middle of September and the beginning of November in the previous year.

Age estimation from the degree of osteophyte formation of vertebral columns in Japanese.

To assess the age estimation from the degree of osteophyte formation of vertebral column, we set grading scores from 0 to 3 for the osteophyte formation based on the height of the process of vertebral column, and defined the average of the values at the cervical, thoracic and lumbar parts of the vertebra to be 'osteophyte formation index' for an individual. We evaluated osteophyte formation in autopsied 225 bodies (138 males, 87 females) during 5 years, and statistically analyzed the integrated data. The following were statistically obtained for each sex: correlation coefficient, regression equation, standard error of estimate (SE) between the score at each part of the vertebral column and age, and between 'osteophyte formation index' and age. In all the parts of the vertebra, there was a significant correlation between the score value and age. We recognized a significant correlation between 'osteophyte formation index' (X) and age (Y), and regression lines were Y = 37.90 + 12.07X (SE; 12.6 y.o.) in males and Y = 36.67+18.64X (SE; 11.9 y.o.) in females. It was apparent that to know the degree of the osteophyte formation was useful in age estimation.

[Case of positive identification by digital superimposed comparison between photograph of the thoracic vertebrae front and thorax roentgenograph].

We reported an autopsy case in which an antemortem thorax roentgenograph and a postmortem photograph of thoracic vertebrae front were available for digital superimposed comparison of contour of the vertebral column and provided a positive identification by the characteristic osteophyte formation. In the elderly, the thorax roentgenograph is often stored in medical institution. Osteophyte formation of the vertebral column has individual features with the aging and formed characteristic profiles of the vertebral column. Photographing of a cadaver's thoracic vertebrae front after removing of the thoracic and abdominal organ should be carried out to make a material for future comparison examination in personal identification.