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Severe bleeding due to various traumatic injuries can cause hemorrhagic shock, which is difficult to diagnose using forensic medicine. Therefore, we defined the difference in color between the renal cortex and medulla observed in hemorrhagic shock deaths as "shock kidney-like appearance (SKLA)" and digitally analyzed the color difference with a digital camera and color analysis software. The aim of this study was to develop and evaluate a method for objectively determining SKLA and improve the accuracy of forensic diagnosis. We examined the kidneys of 122 cases (83 males and 39 females; average age, 64.8 years) autopsied at our facility. Using Image J, we analyzed the color of the cortex and medulla from photographs of bisected kidneys. We defined the color difference between the cortex and medulla in the L*a*b* color space as cortical-medullary color difference and performed a comparative analysis between the hemorrhage and control groups. Significant differences were observed in ΔL* and Δa* values between the two groups (p < 0.05 and p < 0.001, respectively). Analysis of Δa* values showed that the cortex was less reddish than the medulla in the hemorrhage group. The cutoff value for determining SKLA was set at Δa* = -1.33 (sensitivity, 0.79; specificity, 0.81; AUC, 0.859). Traditional evaluations of color rely on subjective assessments, which raise issues of reliability and reproducibility. This study successfully overcame the limitations of subjective evaluation by objectively assessing cortical-medullary color difference in the kidneys. Our results represent an important step towards improving the objectivity of color evaluations.
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We report an autopsy of a death due to a ruptured infected pseudoaneurysm; a man in his 70s was found dead with massive bleeding from the shunt of his right arm. Autopsy and pathological examination revealed that the cause of death was hemorrhagic shock due to rupture of an infected pseudoaneurysm. Ruptured aneurysms and pseudoaneurysm are a complication of dialysis, and death is rare because they are treated immediately on discovery. However, these ruptures often occur in non-medical facilities and could result in death if the patient does not have knowledge of first aid. Thus, patient education is important. Approximately only half of the deaths due to massive bleeding from a shunt are autopsied. In Japan, autopsies or partial autopsies are considered necessary to determine whether a bleeding was traumatic and to prevent medical errors from being overlooked.
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Falso Aneurisma , Humanos , Falso Aneurisma/etiologia , Masculino , Idoso , Autopsia , Aneurisma Roto , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Choque Hemorrágico/etiologia , Diálise Renal/efeitos adversos , Hemorragia/etiologia , Evolução Fatal , Aneurisma InfectadoRESUMO
BACKGROUND: Ocular tension decreases with increasing postmortem interval (PMI) and eyes collapse with extreme progression of postmortem change; however, time-related changes in postmortem computed tomography (PMCT) findings have not been clarified. This study aimed to quantitatively evaluate the vitreous volume and CT values of the vitreous body to clarify time-related changes in PMCT. METHODS: We retrospectively reviewed PMCT images of the eyes of subjects who underwent autopsy at our institution between July 2023 and February 2024. They were classified into four PMI groups: PMI-1: < 1 day, PMI-2: 1-2 days, PMI-3: 3-6 days, PMI-4: ≥ 7 days. The vitreous volumes and mean CT values of the vitreous chambers were measured. Additionally, the presence of intraocular gas and crystalline lens dislocation was observed. RESULTS: The PMCT images of 131 eyes of 66 patients (41 males, 25 females) were analyzed. The mean age was 63.7 (22-99) years. The volume of the vitreous cavity was significantly decreased at PMI-3 and PMI-4, which indicated scleral depression. Intraocular gas appeared in PMI-4. Lens dislocation began at PMI-3 and was more frequently observed at PMI-4 and in the higher-temperature environment group. CONCLUSION: Ocular findings on PMCT are useful for estimating the time of death.
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Mudanças Depois da Morte , Tomografia Computadorizada por Raios X , Corpo Vítreo , Humanos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Estudos Retrospectivos , Adulto , Tomografia Computadorizada por Raios X/métodos , Corpo Vítreo/diagnóstico por imagem , Autopsia/métodos , Adulto Jovem , Olho/diagnóstico por imagem , Olho/patologia , Patologia Legal/métodosRESUMO
The aim of this study was to assess the usefulness of postmortem contrast-enhanced CT (PMeCT) performed via direct large-vessel puncture when routine postmortem CT suggests a vascular lesion as the cause of death. PMeCT was performed in 9 cases (4 male, 5 female) with a mean age of 76 years (range 52-92) at the time of death. The mean time elapsed since death was 29.1 h (12.0-72.0). The location of the target vessel for puncture was determined based on the CT table position and a grid placed on the body surface. An 18-G spinal needle was advanced to the puncture site, and the needle tip was confirmed to have reached the intended blood vessel. Using negative pressure with a 20-ml syringe, the needle tip was advanced until reverse bleeding was confirmed. Diluted contrast medium was injected slowly to ensure its dispersion within the blood vessels. Following confirmation of no extravasation, additional doses of diluted contrast agent were injected in 3-4 divided doses, with CT scans obtained at each step to track the distribution of contrast agent over time. PMeCT was successful in all cases, revealing cardiac tamponade in 7 (ascending aortic dissection, n = 6; cardiac rupture, n = 1), thoracic aortic aneurysm rupture, n = 1, and iliac artery aneurysm rupture, n = 1. There were no cases of procedure-related extravasation (pseudo-lesions). When postmortem CT reveals pericardial hematoma or bleeding in the thoracic or abdominal cavity, PMeCT can identify the source of bleeding.
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Autopsia , Meios de Contraste , Punções , Tomografia Computadorizada por Raios X , Humanos , Masculino , Feminino , Idoso , Meios de Contraste/administração & dosagem , Idoso de 80 Anos ou mais , Tomografia Computadorizada por Raios X/métodos , Autopsia/métodos , Pessoa de Meia-Idade , Punções/métodos , Tamponamento Cardíaco/diagnóstico por imagemRESUMO
Forensic pathologists empirically understand that postmortem changes can decrease serum transparency and change its color. Such changes are potential indicators for estimating postmortem intervals; however, reports on color changes focusing on postmortem changes in serum are scarce. To elucidate the effect of postmortem intervals on serum levels, we quantitatively evaluated and investigated the relationship between serum color and time using venous blood samples obtained from three healthy male volunteers. The serum samples were separated at 0 (1 h), 1, 2, 3, 4, 7, 10, 16, 21, and 28 days of storage. Serum transmittance and color were measured using a portable color digitizer and a custom-made measurement tool, respectively. Additionally, serum sodium (Na) and potassium (K) concentrations were measured. Serum transmittance showed a logistic curve-like decrease from 0.652 ± 0.016 (0 days) to 0.101 ± 0.014 (28 days) over time. The color changed from greenish yellow (dominant wavelength: 574.4 ± 0.63 nm) to reddish orange (603.97 ± 1.31 nm). Serum Na concentration decreased, whereas serum K concentration increased along the logistic curve. Strong (0.89, p < 0.001) and inverse correlations (-0.93, p < 0.001) were observed between the serum transmittance decrease and the Na concentration decrease and the K concentration increase, respectively. Serum transmittance decreased over time, indicating a transition from bright to dark. Moreover, a strong correlation was observed between serum transmittance and electrolytes, indicating a relationship between time course, serum transmittance, and electrolytes. These findings may contribute to the estimation of postmortem intervals in the future.
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Eletrólitos , Mudanças Depois da Morte , Humanos , MasculinoRESUMO
BACKGROUND: Obstructive sleep apnea syndrome (OSAS) can cause sudden death during sleep. Previous findings have suggested that OSAS development is related to maxillofacial morphology. Evaluation of facial morphology can determine the risk of developing the disease, and establishing an objective method to assess the underlying etiology of OSAS-related death would be advantageous. OBJECTIVE: The objective of this study is to determine the key features of obstructive sleep apnea syndrome (OSAS) using postmortem oral and pharyngeal computed tomography (CT). METHODS: We retrospectively assessed autopsy cases of patients with (n=25) and without (n=25) OSAS-related death. We used oral and pharyngeal CT images to compare the oral and pharyngeal cavity volume (OPCV), oral and pharyngeal soft tissue volume (OPSV), oral and pharyngeal air space volume (OPAV), and OPAV to OPCV ratio (%air). Receiver operating curve (ROC) analysis was used to determine the accuracy of OSAS prediction. We assessed participants with body mass index (BMI) values within the normal range. RESULTS: Among the 50 subjects, we observed significant between-group differences in OPSV, OPAV, and % air, whereas there were significant between-group differences in OPSV and %air among 28 subjects with normal BMI values. Both comparisons suggested that OSAS-related death was associated with low %air and high OPSV values. CONCLUSION: The %air and OPSV are useful for assessing postmortem oropharyngeal CT images. OSAS-related sudden death is likely when %air and OPSV values are ≤20.1% and ≥127.2 ml, respectively. Among those with normal BMI values, % air and OPSV values of ≤22.8% and ≥111.5 ml, respectively, predict OSAS-related sudden death.
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Postmortem CT has limitations in identifying cervical spine injuries. Injuries at the level of the intervertebral disc (anterior disc space widening), such as rupture of the anterior longitudinal ligament or intervertebral disc, may be difficult to distinguish from normal images depending on the imaging position. We performed postmortem kinetic CT of the cervical spine in the extended position in addition to CT in the neutral position. The difference in intervertebral angles between the neutral and extended positions was defined as the intervertebral range of motion (ROM), and the utility of postmortem kinetic CT of the cervical spine for the diagnosis of anterior disc space widening and its objective index were examined based on the intervertebral ROM. Of 120 cases, 14 had anterior disc space widening: 11 had one lesion and 3 had two lesions. The intervertebral ROM for the 17 lesions was 11.85° ± 5.25° and that for the normal vertebrae was 3.78° ± 2.81°, with a significant difference between the two. ROC analysis of the intervertebral ROM between vertebrae with anterior disc space widening and the normal vertebral spaces showed an AUC of 0.903 (95 % confidence interval 0.803-1) and a cutoff value of 8.61° (sensitivity 0.96, specificity 0.82). Postmortem kinetic CT of the cervical spine revealed that the intervertebral ROM of the anterior disc space widening was increased, which facilitated identification of the injury. An intervertebral ROM that exceeds 8.61° facilitates a diagnosis of anterior disc space widening.
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Vértebras Cervicais , Disco Intervertebral , Humanos , Estudos Retrospectivos , Vértebras Cervicais/patologia , Autopsia , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: The purpose of this study was to review the findings of computed tomography (CT) performed early postmortem on infants and to clarify the postmortem CT lung findings that occur in the absence of abnormal histopathological findings. MATERIALS AND METHODS: From July 2016 to March 2022, 72 infants were autopsied with postmortem CT (41 boys 31 girls, aged 0-36 (mean 8.2) months). Autopsy and postmortem CT lung findings were compared with the causes of death identified by the autopsies, namely sudden infant death syndrome (n = 37), acute circulatory system disease (18), drowning (7), asphyxia (5), and dehydration/undernutrition (5). RESULTS: The %aerated lung volume (-700 HU or less) ranged from 0 % to 33 % (mean 1.5 %, median 0 %), being <1 % in 61 cases (84.7 %) and >3 % in 3/5 (60 %) of the dehydration/undernutrition group. The dehydration/undernutrition group showed significant preservation of lung field air content compared with the other causes of death groups (p < 0.05). Receiver characteristic curve analysis showed a cut off value of 0.8 % and area under the curve of 0.88806. The drowning group had significantly greater pleural cavity fluid retention than the other causes of death groups (p < 0.05). No correlation was found between postmortem interval and pleural cavity fluid retention. However, resuscitation time and pleural cavity fluid retention were correlated. CONCLUSION: Evaluation of CT values on postmortem lung fields of infants usually reveals a marked decrease in air content. When air content exceeds 0.8% on infant postmortem CT, dehydration/undernutrition should be considered in the differential diagnosis.
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Afogamento , Desnutrição , Masculino , Feminino , Humanos , Lactente , Afogamento/diagnóstico , Desidratação/patologia , Pulmão/diagnóstico por imagem , Pulmão/patologia , Tomografia Computadorizada por Raios X , Desnutrição/patologia , Mudanças Depois da MorteRESUMO
Liquid embolic agents are widely used for the endovascular embolization of vascular conditions. However, embolization based on phase transition is limited by the adhesion of the microcatheter to the embolic agent, use of an organic solvent, unintentional catheter retention, and other complications. By mimicking thrombus formation, a water-soluble polymer that rapidly glues blood into a gel without triggering coagulation was developed. The polymer, which consists of cationic and aromatic residues with adjacent sequences, shows electrostatic adhesion with negatively charged blood substances in a physiological environment, while common polycations cannot. Aqueous polymer solutions are injectable through clinical microcatheters and needles. The formed blood gel neither adhered to the catheter nor blocked the port. Postoperative computed tomography imaging showed that the polymer can block the rat femoral artery in vivo and remain at the injection site without nontarget embolization. This study provides an alternative for the development of waterborne embolic agents.
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Embolização Terapêutica , Água , Animais , Embolização Terapêutica/métodos , Polímeros , Ratos , Solventes , Eletricidade Estática , Água/químicaRESUMO
In forensic medicine, although various alcohols have been reported as indicators of decomposition in collected blood, no studies have examined short-chain fatty acids as indicators. In this study, the blood n-butyric acid concentration was quantified, and the association between n-butyric acid and decomposition was investigated to determine whether the detection of n-butyric acid could be a new indicator of decomposition. Among the forensic autopsies performed from 2016 to 2018 in our laboratory, the cases were divided into decomposed (n = 20) and non-decomposed (n = 20) groups based on macroscopic findings. Blood samples collected at the time of autopsy were derivatized with 3-nitrophenylhydrazine hydrochloride after solid-phase extraction. The n-butyric acid concentration was measured using liquid chromatography-tandem mass spectrometry. In addition, ethanol and n-propanol were measured using a gas chromatography-flame ionization detector. There was a significant difference (p < 0.01) in the concentrations of n-butyric acid between the decomposed and non-decomposed groups (0.343 ± 0.259 [0.030-0.973] and 0.003 ± 0.002 [0.001-0.007] mg/mL, respectively). In the decomposed group, n-butyric acid was detected at high concentrations, even in cases where n-propanol was low. These results suggest that n-butyric acid is more likely to be an indicator of blood decomposition than n-propanol.
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1-Propanol , Medicina Legal , Autopsia , Ácido Butírico , Cromatografia Gasosa-Espectrometria de Massas , Humanos , Mudanças Depois da MorteRESUMO
PURPOSE: We evaluated the usefulness of skull fracture analysis using three-dimensional computed tomography skull fracture scores (3DCT-SFs) in cases of fatal falls. MATERIALS AND METHODS: From April 2016 to September 2020, 46 cases of fatal falls from great heights (33 males, 13 females; mean age: 52.7 (range: 18-89) years) were examined using routine postmortem CT. The 3DCT-SFs were determined as the sum of the fracture line lengths measured on a volume rendering image. Skull fracture severity was classified into four stages according to the 3DCT-SFs. These stages were compared by macroscopic evaluation of skull fracture severity (injury level 0: no fracture; injury level I: fracture without deviation; injury level II: fracture with deviation; injury level III: comminuted open skull fracture). The relationship between 3DCT-SFs values, the fall distance, and the hardness of the landing surface was also examined. RESULTS: Skull fractures occurred in 26 cases (56.5%). The mean 3DCT-SFs of the cases that were classified as stages I, â ¡, and III were 86.6 (5.0-187.0), 832.0 (235.1-1865.8), and 3582.5 (2171.6-4787.6), respectively. Upon macroscopic evaluation of fracture severity, there were 8, 10, and 8 cases of injury levels I, II, and III, respectively. The 3DCT-SFs-based stages correlated significantly with the macroscopic skull fracture severity levels (R2 = 0.936). Solid-surface fall points resulted in significantly higher 3DCT-SFs than soft surfaces. Comminuted open fracture of the skull (stage III) occurred with fall distances ≥ 24 m. CONCLUSION: The 3DCT-SFs correlate well with macroscopic findings and are useful as an objective skull fracture index.
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Fraturas Cranianas , Crânio , Autopsia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas Cranianas/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodosRESUMO
OBJECTIVES: Obstructive sleep apnea syndrome (OSAS) induces upper airway occlusion and may cause sudden death during sleep. This study sought to clarify the relationship between oral air space volume and OSAS onset, which is influenced by multiple factors, such as jawbone, dentition morphology, and oral soft-tissue volume. METHODS: (1) 50 subjects from deceased cases were divided into two groups: OSAS (25 subjects) and controls (25 subjects). (2) 28 subjects from clinical cases were divided into two groups: OSAS (9 subjects) and controls (19 subjects). In all cases, the Computed Tomography (CT) images of the facial region were obtained, and four parameters of oral area volume were analyzed in deceased and clinical cases, and comparisons and analyses were performed between OSAS and control cases. In addition, the efficiency of measurement of these parameters was evaluated using Receiver Operating Characteristic (ROC) curves in OSAS. RESULTS: (1) In deceased cases, oral soft-tissue volume (OSV), oral air-space volume (OAV), and the ratio of OAV to OSV (%air) showed a significant correlation. (2) In clinical cases, OAV and %air showed a significant correlation. In both postmortem and clinical images, a small %air value indicates a high risk of developing OSAS and a high probability of OSAS-related sudden death. CONCLUSIONS: It was shown that the %air is an index to evaluate OSAS by CT imaging of the oral region. OSAS may be indicated when the %air value is ⦠16.0% in deceased cases and ⦠6.6% in clinical cases.
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Apneia Obstrutiva do Sono , Morte Súbita , Humanos , Polissonografia/efeitos adversos , Polissonografia/métodos , Apneia Obstrutiva do Sono/diagnóstico por imagem , Apneia Obstrutiva do Sono/etiologia , Tomografia Computadorizada por Raios X/efeitos adversosRESUMO
This qualitative study aimed to explore medical students' experience of generation gap in their interactions with senior teachers (aged >55) in Japan. Focus group interviews were conducted with 28 medical students (20 to 30 years, mean age 22 ±2 years, classified as millennials, with only one year of studies since starting specialised courses for medicine. The participants were interviewed in groups of four, with each interview lasting 60 minutes. Topics covered included generation gap experienced in daily life and during their studies, and work-life balance issues. The discussions were recorded and transcribed, and content analysis was applied. Four specific influential generation-gap categories were identified - distinctive sociocultural backgrounds, more recent educational media tools and faster information dissemination speed, new-era values, and challenges in communication - that were consistent with findings from previous studies. More senior personnel involved in medical education need to consider these categories to enhance effectiveness of teaching.
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Educação Médica , Estudantes de Medicina , Adulto , Grupos Focais , Humanos , Relação entre Gerações , Pesquisa Qualitativa , Adulto JovemRESUMO
Quantitative analysis of thiosulfate is useful for diagnosing hydrogen sulfide poisoning. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) enables more rapid and sensitive measurements than previous methodologies. As simple measurements of blood thiosulfate concentration are affected by the blood matrix, blood is used as the solvent to prepare the standard solution for calibration curve generation. Thus, a large amount of blood devoid of thiosulfate is required. We developed a preparation method by incorporating an ultrafiltration step to overcome this limitation and generate a calibration curve using a standard solution prepared with pure water. We used this improved method to investigate the stability of thiosulfate in refrigerated samples. To compare the effects of refrigeration, blood samples were prepared using the following two methods: one sample was treated with a 50-kDa exclusion ultrafiltration membrane and the other was not treated. The samples were stored at 4 °C, and then measured at 0, 3, 6, 24, 48, and 96 h. The incorporation of the ultrafiltration step in the measurement procedure enabled the quantification of thiosulfate, by plotting a calibration curve using a standard of pure water; it did not require a blood standard. Additionally, the reduction in whole blood thiosulfate concentration was within 10% during 2 days of refrigeration. Thus, the need for a large amount of blood to prepare the standard solution was resolved by the ultrafiltration step in test sample preparation. This method is useful to measure thiosulfate concentration and is not hindered by sample refrigeration for a few days.
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Toxicologia Forense/métodos , Sulfeto de Hidrogênio/intoxicação , Manejo de Espécimes/métodos , Tiossulfatos/sangue , Ultrafiltração/métodos , Calibragem , Humanos , Refrigeração , Soluções , ÁguaRESUMO
Ground glass attenuation (GGA) of the lungs is a common finding of post-mortem computed tomography (PMCT) that is associated with pulmonary congestion and edema due to cardiac failure during the agonal period, or due to post-mortem hypostasis. However, hypo-attenuation of the lung is an atypical finding of PMCT, and is usually a consequence of hypovolemic states before death or postmortem body posture after death. Previous studies have shown a few differential diagnoses, such as hypothermia, massive hemorrhage, asphyxiation by hanging, and dehydration, for hypo-attenuation of the lung. This report presents the case of a woman who died suddenly because of an asthma attack. Our PMCT analysis demonstrated hypoattenuation of the lung in this case. We suggest fatal asthma as a differential diagnosis for the appearance of hypo-attenuation of lungs on PMCT.
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Postmortem CT for investigating childhood deaths is increasingly utilised as a noninvasive adjunct or alternative to standard autopsy; however there are no standardised published imaging protocols. This article describes a standardised imaging protocol that has been developed based on current practices of international postmortem imaging practitioners and experts. This recommendation is expected to be useful for postmortem imaging centres wishing to update their existing practices and for those starting paediatric postmortem CT as a new service.